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Tracheostomy Placement in Children Younger Than 2 Years: 30-Day Outcomes Using the National Surgical Quality
Justin B Mahida1, Lindsey Asti2, Emily F Boss3
1Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio2Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.
Insights
Pediatric tracheostomy in children under 2 years old has high complication rates, including pneumonia and sepsis. Neonatal age, intraventricular hemorrhage, and cardiac conditions predict these adverse outcomes.
Area of Science:
- Pediatric Surgery
- Otolaryngology
- Quality Improvement Science
Background:
- Tracheostomy in young children is associated with significant morbidity.
- The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric identifies high composite morbidity in otolaryngology for children under 2 undergoing tracheostomy.
Purpose of the Study:
- To identify predictive factors for complications after tracheostomy in patients younger than 2 years.
- To inform quality initiatives aimed at improving surgical outcomes in this vulnerable population.
Main Methods:
- Analysis of 206 elective tracheostomy cases in children younger than 2 years from the NSQIP Pediatric database (2012-2013).
- Comparison of demographic, clinical, and perioperative characteristics between children with and without major complications.
- Logistic regression modeling to identify independent predictors of major complications.
Main Results:
- 24.3% of children experienced a major complication within 30 days post-tracheostomy.
- Common complications included pneumonia, sepsis, death, and surgical site infections.
- Independent predictors of major complications were neonatal age, intraventricular hemorrhage, and comorbid cardiac risk factors.
Conclusions:
- Tracheostomy in young children carries a high risk of morbidity.
- Improved, procedure-specific outcome variables and definitions are needed for NSQIP Pediatric to enhance targeted quality improvement efforts.
Importance:
Analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric demonstrated that the highest contribution to composite morbidity in otolaryngology is seen in children younger than 2 years undergoing tracheostomy.
Objective:
To determine predictive factors for complications following tracheostomy placement in patients younger than 2 years that, if targeted for reduction in quality initiatives, might result in improved surgical outcomes.
Design, Setting, And Participants:
The NSQIP Pediatric reports predefined 30-day postoperative outcomes for surgical cases from participating institutions for quality improvement. All 206 cases of elective tracheostomy performed in children younger than 2 years from 2012 to 2013 among 61 participating institutions and documented in the NSQIP Pediatric public use file were included. Data analysis was conducted from December 1, 2014, to June 30, 2015.
Interventions:
Surgical placement of tracheostomy in children younger than 2 years.
Main Outcomes And Measures:
Demographics and clinical and perioperative characteristics for children who did and did not experience a major complication from elective tracheostomy were compared. Continuous variables were compared using Wilcoxon rank sum tests and categorical variables were compared using Pearson χ2 tests or Fisher exact tests where appropriate. A logistic regression model was fit to identify adjusted odds ratios (aORs) with 95% CIs of preoperative factors predictive of occurrence of a major complication.
Results:
Of the 206 children younger than 2 years who underwent tracheostomy, 50 (24.3%) experienced a major complication within 30 days. The most common complications were pneumonia (16 [7.8%]), postoperative sepsis (12 [5.8%]), death (12 [5.8%]), and deep or organ space surgical site infections (8 [3.9%]). Neonatal age (aOR, 2.38; 95% CI, 1.06-5.37; P = .04), intraventricular hemorrhage (aOR, 2.72; 95% CI, 1.01-7.32; P = .048), and comorbid cardiac risk factors (relative to none: minor risk factors, aOR, 2.94; 95% CI, 1.19-7.24; major or severe risk factors, aOR, 1.31; 95% CI, 0.44-3.84; P = .04 for all cardiac risk factors) were independently predictive of major complications.
Conclusions And Relevance:
Young children undergoing tracheostomy tube placement have high rates of morbidity. This analysis identifies the need for additional procedure-specific outcome variables and improved variable definitions to incorporate into a detailed module for NSQIP Pediatric that will more effectively promote national, specialty-specific targeted quality improvement efforts.
