{"title":"青少年严重创伤性脑损伤在创伤中心类型上的显著差异：气管造口术和胃造口术的差异很大。","authors":"Morihiro Katsura, Shingo Fukuma, Shin Miyata, Tatsuyoshi Ikenoue, Sindhu Daggupati, Matthew J Martin, Kenji Inaba, Kazuhide Matsushima","doi":"10.1097/CCM.0000000000006577","DOIUrl":null,"url":null,"abstract":"<p><strong>Objectives: </strong>To explore practice variations in the rate and timing of tracheostomy and gastrostomy for adolescent with severe traumatic brain injury (TBI) across trauma center types.</p><p><strong>Design: </strong>Retrospective cohort study.</p><p><strong>Setting: </strong>Trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program (2017-2021) included adult (ATC), mixed (MTC), and pediatric trauma centers (PTC).</p><p><strong>Patients: </strong>Adolescent 14-18 years old with severe TBI (Head Abbreviated Injury Scale: 3-5 and Glasgow Coma Scale: 3-8) requiring mechanical ventilation.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>A multilevel mixed-effect Poisson regression model assessed the association between trauma center type and tracheostomy/gastrostomy rates. Effect sizes for fixed effects were reported as adjusted incidence rate ratio (IRR) with 95% CI. Secondary analyses were performed to assess the association between trauma center types and ventilator-associated pneumonia (VAP). Of 6978 patients, tracheostomy and gastrostomy were performed in 22.5% and 21.3% at ATC, 20.8% and 21.3% at MTC, and 6.9% and 11.1% at PTC, respectively. The median time to tracheostomy was 10 days (interquartile range [IQR], 7-13 d) at ATC, 11 days (IQR, 7-15 d) at MTC, and 15 days (IQR, 11-23 d) at PTC, demonstrating a significantly later timing of tracheostomy at PTC. In the regression model adjusting for potential confounders, treatment at PTC was significantly associated with a decreased likelihood of tracheostomy and gastrostomy placement compared with ATC (adjusted IRR, 0.38; 95% CI, 0.28-0.52; p < 0.001 and adjusted IRR, 0.58; 95% CI, 0.44-0.75; p < 0.001, respectively). There was no significant difference in the occurrence rate of VAP between ATC, MTC, and PTC.</p><p><strong>Conclusions: </strong>Our results offer insights into the existing current practice variations between ATC, MTC, and PTC in tracheostomy and gastrostomy placement for adolescent with severe TBI. Further research is warranted to examine the impact of these observed disparities on short- and long-term outcomes and to standardize the care process for adolescent patients.</p>","PeriodicalId":10765,"journal":{"name":"Critical Care Medicine","volume":" ","pages":""},"PeriodicalIF":7.7000,"publicationDate":"2025-01-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Significant Disparities in Adolescents With Severe Traumatic Brain Injury Across Trauma Center Types: Wide Variation of Tracheostomy and Gastrostomy.\",\"authors\":\"Morihiro Katsura, Shingo Fukuma, Shin Miyata, Tatsuyoshi Ikenoue, Sindhu Daggupati, Matthew J Martin, Kenji Inaba, Kazuhide Matsushima\",\"doi\":\"10.1097/CCM.0000000000006577\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Objectives: </strong>To explore practice variations in the rate and timing of tracheostomy and gastrostomy for adolescent with severe traumatic brain injury (TBI) across trauma center types.</p><p><strong>Design: </strong>Retrospective cohort study.</p><p><strong>Setting: </strong>Trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program (2017-2021) included adult (ATC), mixed (MTC), and pediatric trauma centers (PTC).</p><p><strong>Patients: </strong>Adolescent 14-18 years old with severe TBI (Head Abbreviated Injury Scale: 3-5 and Glasgow Coma Scale: 3-8) requiring mechanical ventilation.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>A multilevel mixed-effect Poisson regression model assessed the association between trauma center type and tracheostomy/gastrostomy rates. Effect sizes for fixed effects were reported as adjusted incidence rate ratio (IRR) with 95% CI. Secondary analyses were performed to assess the association between trauma center types and ventilator-associated pneumonia (VAP). Of 6978 patients, tracheostomy and gastrostomy were performed in 22.5% and 21.3% at ATC, 20.8% and 21.3% at MTC, and 6.9% and 11.1% at PTC, respectively. The median time to tracheostomy was 10 days (interquartile range [IQR], 7-13 d) at ATC, 11 days (IQR, 7-15 d) at MTC, and 15 days (IQR, 11-23 d) at PTC, demonstrating a significantly later timing of tracheostomy at PTC. In the regression model adjusting for potential confounders, treatment at PTC was significantly associated with a decreased likelihood of tracheostomy and gastrostomy placement compared with ATC (adjusted IRR, 0.38; 95% CI, 0.28-0.52; p < 0.001 and adjusted IRR, 0.58; 95% CI, 0.44-0.75; p < 0.001, respectively). There was no significant difference in the occurrence rate of VAP between ATC, MTC, and PTC.</p><p><strong>Conclusions: </strong>Our results offer insights into the existing current practice variations between ATC, MTC, and PTC in tracheostomy and gastrostomy placement for adolescent with severe TBI. Further research is warranted to examine the impact of these observed disparities on short- and long-term outcomes and to standardize the care process for adolescent patients.</p>\",\"PeriodicalId\":10765,\"journal\":{\"name\":\"Critical Care Medicine\",\"volume\":\" \",\"pages\":\"\"},\"PeriodicalIF\":7.7000,\"publicationDate\":\"2025-01-13\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Critical Care Medicine\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.1097/CCM.0000000000006577\",\"RegionNum\":1,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q1\",\"JCRName\":\"CRITICAL CARE MEDICINE\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Critical Care Medicine","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1097/CCM.0000000000006577","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"CRITICAL CARE MEDICINE","Score":null,"Total":0}
Significant Disparities in Adolescents With Severe Traumatic Brain Injury Across Trauma Center Types: Wide Variation of Tracheostomy and Gastrostomy.
Objectives: To explore practice variations in the rate and timing of tracheostomy and gastrostomy for adolescent with severe traumatic brain injury (TBI) across trauma center types.
Design: Retrospective cohort study.
Setting: Trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program (2017-2021) included adult (ATC), mixed (MTC), and pediatric trauma centers (PTC).
Patients: Adolescent 14-18 years old with severe TBI (Head Abbreviated Injury Scale: 3-5 and Glasgow Coma Scale: 3-8) requiring mechanical ventilation.
Interventions: None.
Measurements and main results: A multilevel mixed-effect Poisson regression model assessed the association between trauma center type and tracheostomy/gastrostomy rates. Effect sizes for fixed effects were reported as adjusted incidence rate ratio (IRR) with 95% CI. Secondary analyses were performed to assess the association between trauma center types and ventilator-associated pneumonia (VAP). Of 6978 patients, tracheostomy and gastrostomy were performed in 22.5% and 21.3% at ATC, 20.8% and 21.3% at MTC, and 6.9% and 11.1% at PTC, respectively. The median time to tracheostomy was 10 days (interquartile range [IQR], 7-13 d) at ATC, 11 days (IQR, 7-15 d) at MTC, and 15 days (IQR, 11-23 d) at PTC, demonstrating a significantly later timing of tracheostomy at PTC. In the regression model adjusting for potential confounders, treatment at PTC was significantly associated with a decreased likelihood of tracheostomy and gastrostomy placement compared with ATC (adjusted IRR, 0.38; 95% CI, 0.28-0.52; p < 0.001 and adjusted IRR, 0.58; 95% CI, 0.44-0.75; p < 0.001, respectively). There was no significant difference in the occurrence rate of VAP between ATC, MTC, and PTC.
Conclusions: Our results offer insights into the existing current practice variations between ATC, MTC, and PTC in tracheostomy and gastrostomy placement for adolescent with severe TBI. Further research is warranted to examine the impact of these observed disparities on short- and long-term outcomes and to standardize the care process for adolescent patients.
期刊介绍：
Critical Care Medicine is the premier peer-reviewed, scientific publication in critical care medicine. Directed to those specialists who treat patients in the ICU and CCU, including chest physicians, surgeons, pediatricians, pharmacists/pharmacologists, anesthesiologists, critical care nurses, and other healthcare professionals, Critical Care Medicine covers all aspects of acute and emergency care for the critically ill or injured patient.
Each issue presents critical care practitioners with clinical breakthroughs that lead to better patient care, the latest news on promising research, and advances in equipment and techniques.
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