Study objective: Determine reintubation rate, identify its cause, and detail adverse outcomes from reintubation.
Design: Retrospective review of extubation failures in the trauma ICU.
Setting: University hospital and regional trauma center.
Patients: Four hundred five patients arriving intubated or requiring intubation during hospitalization after 2,516 traumatic injury admissions over 18 months.
Results: Reintubation incidence was 7% (27 times per 405 patients). Comparative mortality of the reintubated group (2/24=8%) is similar to overall trauma center mortality (224/2516=6.5%), but less than the cohort of patients admitted to the hospital intubated (63/405=16%). Reintubated patients had an increased frequency of stridor than reported previously (33%), and an increased tracheostomy rate (62% vs 30%). Stridor was not predictable from injury severity score, Glasgow coma score, age, sex, length of intubation, or place of intubation. Pulmonary complications (atelectasis, tracheobronchitis, pneumonia) developed in half of reintubated patients; stridorous patients did not have an increased rate of pulmonary complications.
Conclusion: Reintubation in trauma ICU patients does not predict poor outcome.
The use of mechanical ventilation and the length of time ventilated have been well correlated with increased mortality. The safest and most rapid method of weaning mechanical ventilation is controversial. Those patients who fail extubation and require reinstitution of ventilatory support do so from a variety of causes. Regardless of the cause of extubation failure, an increased number of complications and higher mortality rate are reported when compared to those patients who did not require reintubation.2 For these reasons, premature extubation is undesirable, and reintubation has become a national filter in critical care quality improvement. To define and address preventable causes and/or to identify those at risk for extubation failure, we sought to determine both the cause and patient outcome after reinstitution of mechanical ventilation in our trauma ICU population.
Critically ill trauma patients are different from their medical counterparts with regards to chronicity of disease, end-organ dysfunction, functional reserve, in addition to age and cause for the precipitating respiratory failure or need for mechanical support. The population of surgical patients, ie, trauma and elective surgical patients, is also not homogeneous, and there are divergent data on reintubation in patients in the surgical ICU. Demling et al report on 700 patients who were extubated in two surgical ICUs at the same institution. A 40% mortality from progressive cardiopulmonary failure is reported in the elective and nontrauma patients, whereas trauma patients had only a 10% mortality after reintubation. Most of the reintubations in the victims of trauma occurred following smoke inhalation injury or in head injury. A more recent report by Kaups et al showed that mortality was significantly increased in those surgical ICU patients requiring reintubation. In their series, trauma patients requiring reintubation had a significantly increased mortality.