AT THE COMBINED SECTIONS WINTER MEETING
CORONADO, CALIF. (FRONTLINE MEDICAL NEWS) – The use of neuromuscular blockade agents in pediatric patients after tracheostomy was not an independent predictor of longer hospital length of stay, results from a 3-year, single-center study suggest. Factors which portended a longer length of stay including having a longer preoperative length of stay and being cared for in the neonatal intensive care unit.
“Across the country there are widespread initiatives to improve quality of care,” study coauthor Eric Bauer said at the Triological Society’s Combined Sections Meeting.
“Tracheostomy has been identified as a contributor to prolonged length of stay. Additionally, it’s a procedure associated with increased rates of pediatric otolaryngology infections and major adverse events including accidental decannulation. However, the factors which increase prolonged hospital stay have not been determined.”
Mr. Bauer, a fourth-year medical student at the Ohio State University, Columbus, noted that some published studies in the medical literature that focus on the use of neuromuscular blockade agents (NMBAs) following pediatric single-stage laryngeal or tracheal reconstruction suggest that these medications may prolong hospital stay and increase complication risk. “Therefore, the goal of our study was to determine if the use of NMBAs in pediatric patients following tracheostomy is associated with a prolonged length of stay,” he said at the meeting jointly sponsored by the Triological Society and the American College of Surgeons..
Mr. Bauer and his fellow researchers performed a retrospective chart review from 2010 to 2013 for all tracheostomies performed and cared for in the neonatal and pediatric intensive care units of Nationwide Children’s Hospital, Columbus . In all, 114 patients were included, 26 of whom received neuromuscular blockade agents in the postoperative period. Patients cared for in the cardiothoracic ICU were excluded from the analysis.
After collecting demographic, clinical, and 30-day outcome characteristics for all patients, the researchers observed no significant differences between those who received NMBAs and those who did not with respect to patient median age, gender, and baseline medical condition differences. “Patients who received NMBAs did have more cardiac illness (50% vs. 22% among those who did not receive NMBAs; P = .005), while patients who did not receive NMBAs had more neurologic disease (81% vs. 54%; P = .006),” Mr. Bauer said. “Overall, it was a medically complex patient group with a vast array of illnesses.”
Upper-airway obstruction was the most common indication for surgery, followed by cardiopulmonary and neurologic conditions. The researchers found that patients who did not receive NMBAs had more neurologic indications for tracheostomy, compared with their counterparts who did receive the agents (38% vs. 8%; P = .003), while patients who ultimately received NMBA had more cardiopulmonary indications for surgery (54% vs. 18%; P< .001).
In an analysis of preoperative factors, patients who ultimately received NMBA, compared with those who did not, had longer preoperative length of stay (LOS) (28-93 days vs. 59-224 days; P = .002), more respiratory failure 3 days prior to surgery (96% vs. 74%; P = .014), and prolonged intubation periods prior to surgery (0-24 days vs. 6-45 days; P = .009). However, location of care (NICU vs. PICU) was similar throughout. In addition, the physiologic status on the day of surgery as indicated by the Pediatric Risk of Mortality score was similar in both groups.
Mr. Bauer went on to report that preoperative interventions including 30-day use of glucocorticoids, inotropes, and aminoglycosides were similar between the two groups, as was the use of blood transfusions 48 hours prior to surgery. As for postoperative sedation, opioid use and pediatric daily dosing was similar between groups. However, the rate of dexmedetomidine use was twice as high in patients who ultimately received NMBAs, compared with those who did not (46% vs. 26%; P = .026).
In terms of outcomes, the rate of pressure ulcers, pneumonia, urinary tract infections, and other complications did not differ between the two groups, while the rate of mortality at the time of data collection was also similar (12% among those who received NMBAs and 15% among those who did not). This “mirrors the national average of 13%-20%,” Mr. Bauer said. “In addition, there were no mortalities related to the procedure itself.”
On univariate analysis, postoperative LOS was a median of 10 days longer in patients who received NMBAs, compared with those who did not (23 vs. 33 days, respectively; P = .043). After multivariate analysis, however, that association was no longer significant (P = .91). Multivariable analysis also found that patients with traumatic indications for tracheostomy placement had a 44% shorter LOS (P = .002), while those with upper-airway obstruction indications for tracheostomy placement had a 27% shorter LOS (P = .02). A similar association was observed in patients who tolerated oral nutrition prior to surgery, as compared with enteral nutrition (a 48% reduction in LOS; P< .001).
Factors which portended a longer postoperative LOS were preoperative lengths of stay that lasted 10 days or more (P less than .001) and being cared for in the neonatal vs. the pediatric ICU (P = .002).
“The use of paralytic agents in this complex cohort was not an independent predictor of longer LOS,” Mr. Bauer concluded. “Instead, factors such as preoperative LOS along with [certain] indications ultimately affected the LOS. Finally, the ideal sedative protocol following tracheostomy has not been determined and requires additional investigation.”
Mr. Bauer reported that neither he nor his associates had relevant financial conflicts to disclose.
On Twitter @dougbrunk