Predictors for Tracheostomy with External Validation of the Stroke-Related Early Tracheostomy Score (SETscore)
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Background and Purpose
Ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) patients often require endotracheal intubation (EI) and mechanical ventilation (MV). Predicting the need for prolonged EI and timing of tracheostomy (TR) is challenging. While TR is performed for about 10–15% of patients in the general intensive care unit (ICU), the rate in the neurological ICU and for stroke patients ranges between 15 and 35%. Thus, we performed an external validation of the recently published SETscore.
This is a retrospective review for all patients with IS, non-traumatic ICH, and SAH who required intubation within 48 h of admission to the neurological ICU. We compared the SETscore between tracheostomized versus successfully extubated patients, and early TR (within 7 days) versus late TR (after 7 days).
Out of 511 intubated patients, 140 tracheostomized and 105 extubated were included. The sensitivity for a SETscore > 10 to predict the need for TR was 81% (95% CI 74–87%) with a specificity of 57% (95% CI 48–67%). The score had moderate accuracy in correctly identifying those requiring TR and those successfully extubated: 71% (95% CI 65–76%). The AUC of the score was 0.74 (95% CI 0.68–0.81). Multivariable logistic regression models were used to identify other independent predictors of TR. After including body mass index (BMI), African American (AA) race, ICH and a positive sputum culture in the SETscore, sensitivity, specificity, overall accuracy, and AUC improved to 90%, 78%, 85%, and 0.89 (95% CI 0.85–0.93), respectively. In our cohort, performing early TR was associated with improvement in the ICU median length of stay (LOS) (15 vs 20.5 days; p = 0.002) and mean ventilator duration (VD) (13.4 vs 18.2 days; p = 0.005) in comparison to late TR.
SETscore is a simple score with a moderate accuracy and with a fair AUC used to predict the need for TR after MV for IS, ICH, and SAH patients. Our study also demonstrates that early TR was associated with a lower ICU LOS and VD in our cohort. The utility of this score may be improved when including additional variables such as BMI, AA race, ICH, and positive sputum cultures.
KeywordsTracheostomy Neuro ICU Mechanical ventilation Scoring Stroke ICH SAH
The preliminary results of this work were presented as an oral presentation at the 15th annual neurocritical care conference in Hawaii, October 2017.
Khalid Alsherbini, MD helped in initial idea and data collection and assisted in data analysis, initial manuscript draft, final editing, and submission. Nitin Goyal, MD contributed to data collection, data analysis, manuscript editing, and review. E Jeffrey Metter, MD contributed to planned data analysis and performed statistics, and helped in methods, figures, and tables creation. Abhi Pandhi, MD involved in data collection, indexing of references, and manuscript review. Georgios Tsivgoulis, MD contributed in reviewed final data analysis and methods, review of final manuscript, and statistics. Tracy Huffstatler, ACNP helped in data collection and reviewed manuscript. Hallie Kelly, ACNP contributed to data collection and reviewed manuscript. Lucas Elijovich, MD helped in critical final review of the manuscript and methods. Marc Malkoff, MD involved in critical final review of the manuscript Andrei Alexandrov, MD helped in critical final review of the manuscript.
Source of Support
No funding source was available for this project.
Compliance with Ethical Standards
Conflict of interest
All the authors declare that they have no conflict of interest.
This is to certify that all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the local institution IRB at the University of Tennessee Health science center under the number 17-05354-XP.
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