title: Implications of extubation delay in brain-injured patients meeting standard weaning criteria.
abstract: We hypothesized that variation in extubating brain injured patients would affect the incidence of nosocomial pneumonia, length of stay, and hospital charges. In a prospective cohort of consecutive, intubated brain-injured patients, we evaluated daily: intubation status, spontaneous ventilatory parameters, gas exchange, neurologic status, and specific outcomes listed above. Of 136 patients, 99 (73%) were extubated within 48 h of meeting defined readiness criteria. The other 37 patients (27%) remained intubated for a median 3 d (range, 2 to 19). Patients with delayed extubation developed more pneumonias (38 versus 21%, p < 0.05) and had longer intensive care unit (median, 8.6 versus 3.8 d; p < 0.001) and hospital (median, 19.9 versus 13.2 d; p = 0.009) stays. Practice variation existed after stratifying for differences in Glasgow Coma Scale scores (10 versus 7, p < 0.001) at time of meeting readiness criteria, particularly for comatose patients. There was a similar reintubation rate. Median hospital charges were $29,057.00 higher for extubation delay patients (p < 0.001). This study does not support delaying extubating patients when impaired neurologic status is the only concern prolonging intubation. A randomized trial of extubation at the time brain-injured patients fulfill standard weaning criteria is justifiable.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Department of Neurology, Neurological Surgery, and Respiratory Care, Harborview Medical Center, University of Washington, Seattle, Washington, USA. wcoplin@med.wayne.edu
authors.forename: W M
authors.initials: WM
authors.lastname: Coplin
authors.forename: D J
authors.initials: DJ
authors.lastname: Pierson
authors.forename: K D
authors.initials: KD
authors.lastname: Cooley
authors.forename: D W
authors.initials: DW
authors.lastname: Newell
authors.forename: G D
authors.initials: GD
authors.lastname: Rubenfeld
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001930:Brain Injuries / Q000628:therapy*; D002545:Brain Ischemia / Q000628:therapy; D002648:Child; D015331:Cohort Studies; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D007442:Intubation, Intratracheal; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000209:etiology / Q000517:prevention & control; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000009:adverse effects; D020521:Stroke / Q000628:therapy; D013345:Subarachnoid Hemorrhage / Q000628:therapy; D013997:Time Factors; D015300:Ventilator Weaning