Implications of Extubation Delay in Brain-Injured Patients Meeting Standard Weaning Criteria

TLDR

The study hypothesizes that delayed extubation in brain‑injured patients increases pneumonia, length of stay, and costs, and argues that a randomized trial of extubation at standard weaning criteria is justified. The authors prospectively followed consecutive intubated brain‑injured patients, recording daily ventilatory, gas exchange, neurologic status, and outcomes to assess extubation timing. Among 136 patients, 73 % were extubated within 48 h, while delayed extubation (median 3 days) was linked to higher pneumonia rates, longer ICU and hospital stays, and $29 k higher charges, yet reintubation rates were similar, indicating that delaying extubation for impaired neurologic status alone is not warranted.

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.