【罂粟摘要】急性创伤性脊髓损伤患者早期与晚期气管切开术的比较:一项系统综述和Meta分析
急性创伤性脊髓损伤患者早期与晚期气管切开术的比较:一项系统综述和Meta分析
贵州医科大学 高鸿教授课题组
翻译：潘志军 编辑：佟睿 审校：曹莹
急性创伤性脊髓损伤(SCIs)通常会导致呼吸障碍，这可能会导致患者肺功能障碍后遗症、感染风险增加和死亡。急性SCI患者气管切开术的最佳时机目前尚不清楚。这项系统综述和Meta分析旨在评估急性SCI患者气管切开术的最佳时机，并比较早期和晚期气管切开术的潜在益处。
我们检索了Medline、PubMed、Embase、Cochrane Central、Cochrane系统综述数据库和PsycINFO中已经发表的研究。纳入对象是接受早期或晚期气管切开术的SCI成人患者，我们对其进行了研究并比较了结果。此外，还排除了伴随创伤性脑损伤的研究。数据由2名评审人员独立提取，并录入到R软件中进行分析。进行随机效应Meta分析以评估汇总优势比(OR)或平均差(MD)。
共八项研究的1220名患者符合纳入标准。早期和晚期气管切开组的平均年龄和性别相似。大多数研究在受伤或气管插管后7天内进行了早期气管切开术。与胸椎SCI患者相比，颈椎SCI患者接受早期气管切开术的可能性是其两倍（OR=2.13；95%置信区间[CI]，1.24～3.64；P= 0.006）。早期气管切开术将重症监护病房(ICU)的平均住院时间缩短了13天(95%CI，-19.18～-7.00；P=0.001），并使机械通气的平均持续时间缩短了18.30天（95% CI，-24.33～−12.28；P=0.001）。尽管与晚期气管切开术相比，早期气管切开术的院内死亡率汇总风险较低，但结果并不显著（OR = 0.56；95% CI，0.32～1.01；P = 0.054）。在亚组分析中，早期气管切开术组的死亡率显著降低（OR=0.27；P=0.006）。最后，早期和晚期气管切开术组之间的肺炎风险无差异。
根据现有数据，与晚期气管切开术相比，在受伤或气管插管的前7天内进行早期气管切开术的颈椎SCI患者更多、ICU住院时间更短且机械通气时间更短。早期气管切开术后院内死亡风险可能较低。然而，由于研究质量和可用的临床数据不足，很难做出结论性的解释。未来需要对更多患者进行前瞻性试验，以全面评估急性SCI后气管切开时机的短期和长期结果。
Talha Mubashir, Abdul A. Arif, Prince Ernest, et al. Early Versus Late Tracheostomy in Patients With Acute Traumatic Spinal Cord Injury: A Systematic Review and Meta-analysis.[J]. (Anesth Analg 2021;132:384–94).
Early Versus Late Tracheostomy in Patients With Acute Traumatic Spinal Cord Injury: A Systematic Review and Meta-analysis
Abstract
Background: Acute traumatic spinal cord injuries (SCIs) often result in impairments in respiration that may lead to a sequelae of pulmonary dysfunction, increased risk of infection, and death. The optimal timing for tracheostomy in patients with acute SCI is currently unknown. This systematic review and meta-analysis aims to assess the optimal timing of tracheostomy in SCI patients and evaluate the potential benefits of early versus late tracheostomy.
Methods: We searched Medline, PubMed, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, and PsycINFO for published studies. We included studies on adults with SCI who underwent early or late tracheostomy and compared outcomes. In addition, studies that reported a concomitant traumatic brain injury were excluded. Data were extracted independently by 2 reviewers and copied into R software for analysis. A random-effects meta-analysis was performed to estimate the pooled odds ratio (OR) or mean difference (MD).
Results: Eight studies with a total of 1220 patients met our inclusion criteria. The mean age and gender between early and late tracheostomy groups were similar. The majority of the studies performed an early tracheostomy within 7 days from either time of injury or tracheal intubation. Patients with a cervical SCI were twice as likely to undergo an early tracheostomy (OR = 2.13; 95% confidence interval [CI], 1.24–3.64; P = .006) compared to patients with a thoracic SCI. Early tracheostomy reduced the mean intensive care unit (ICU) length of stay by 13 days (95% CI, −19.18 to −7.00; P = .001) and the mean duration of mechanical ventilation by 18.30 days (95% CI, −24.33 to −12.28; P = .001). Although the pooled risk of in-hospital mortality was lower with early tracheostomy compared to late tracheostomy, the results were not significant (OR = 0.56; 95% CI, 0.32–1.01; P = .054). In the subgroup analysis, mortality was significantly lower in the early tracheostomy group (OR = 0.27; P = .006). Finally, no differences in pneumonia between early and late tracheostomy groups were noted.
Conclusions: Based on the available data, patients with early tracheostomy within the first 7 days of injury or tracheal intubation had higher cervical SCI, shorter ICU length of stay, and shorter duration of mechanical ventilation compared to late tracheostomy. The risk of in-hospital mortality may be lower following an early tracheostomy. However, due to the quality of studies and insufficient clinical data available, it is challenging to make conclusive interpretations. Future prospective trials with a larger patient population are needed to fully assess short- and long-term
outcomes of tracheostomy timing following acute SCI.