Clinical Trajectories in Patients with Severe Acute Brain Injury Requiring Mechanical Ventilation: A Descriptive Analysis of a Single-Center Prospective Observational Cohort Study
Natalie L. Smith1, Adrienne James2, Nassim Matin1, Kasra Sarhadi1, James Town3, Claire Creutzfeldt1, Chiara Robba6, Giuseppe Citerio6, Abhijit V. Lele4, Sarah Wahlster5
1Dept. of Neurology, 2Dept. of Anesthesiology, 3Division of Pulmonary, Critical Care, and Sleep Medicine, Dept. of Medicine, 4Dept. of Anesthesiology; Dept. of Neurological Surgery, 5Dept. of Neurology; Department of Anesthesiology; Department of Neurological Surgery, University of Washington, 6Departments of Anesthesia and Intensive Care, Policlinico San Martino
Objective:
To describe outcomes for patients with severe acute brain injury (SABI) who require mechanical ventilation (MV).
Background:
Patients with SABI often require MV due to impaired consciousness and insufficient airway protection, reflecting a substantial neurological injury. Outcomes for this high-acuity population have been insufficiently explored.
Design/Methods:
In this single-center prospective, observational cohort study at a level-1 trauma and comprehensive stroke center, we included consecutive adult patients with SABI, including traumatic brain injury (TBI), spontaneous intracranial hemorrhage (sICH), acute ischemic stroke (AIS), and subarachnoid hemorrhage (SAH), who required MV on admission between September-November 2021. We assessed in-hospital and 6-12 months mortality, tracheostomy and percutaneous gastrostomy tube (PEG) placement, and Extended Glasgow Outcome Score (GOS-E) at 6-12 months.
Results:
Overall, 90 patients (age 55 [SD 19], 73% male; median Glasgow Coma Scale on admission 7 [IQR 3,11]; 50% TBI, 20% sICH, 18% AIS, 12% SAH) were included. Median duration of MV was 2 days (IQR 1,7), with 40% requiring MV for £ 24 hours (G1), 37% 1-7 days (G2), and 23% >7 days (G3). In-hospital mortality was 47% (n=42), 79% (33/42) died after withdrawal of life-sustaining treatments (30% £24 hours, 24% 1-7 days, 45% >7 days). One third of survivors (30%, n=13) underwent PEG, 16% (n=7) tracheostomy. At 6-12 months, 51% (n=46) had died (51% TBI, 67% sICH, 44% AIS, 36% SAH; 44% G1, 55% G2, 57% G3); 57% of survivors (64% TBI, 50% sICH, 33% AIS, 71% SAH; 60% G1, 67% G2, 22% G3) had a GOS-E of 5-8. Among survivors who underwent PEG and tracheostomy, 54% and 29% had a GOS-E 5-8; all survivors who initially underwent tracheostomy were decannulated at 6-12 months.
Conclusions:
Mortality and long-term disability in patients with SABI who required MV were high and varied based on SABI subtype and duration of MV.