MD University of Texas Health Sciences Center San Antonio
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Introduction: Patients with traumatic brain injury (TBI) are at risk for nosocomial infections including ventilator associated pneumonia (VAP). The objective of this study was to identify the risk factors from the initial injury and standard ICU management of TBIs associated with the development VAP in pediatric patients with severe TBI.
Methods: We conducted a retrospective cohort study at a single academic institution. Inclusion criteria included: patients age < 18 years of age with severe TBI who were intubated > 48hrs between 2020 and 2024. Patients with mild or moderate TBI, mechanical ventilation for < 48 hours, progression to brain death, presence of immunosuppressive therapy, and transfer to outside facility were excluded. Demographics, injury characteristics, TBI therapies, and were collected. Variables were initially compared with a univariable analysis and those that approached statistical significance with a p value of < 0.1 were then included in a multivariable survival analysis of the main outcome variable, time to VAP diagnosis. Variables that were not statistically significant in the initial multivariable survival analysis were removed to further simplify the model.
Results: 75 patients met our inclusion criteria. 30 were diagnosed with VAP with 45 remaining VAP free during their hospital stay. Male gender (HR=3.34, p=0.011), evidence of aspiration during intubation (HR=7.85, p< 0.001) and enteral feeds (HR=2.95, p=0.02) were associated with increased risk of VAP. In contrast, treatment with albuterol was protective (HR=0.67, p=0.001). Development of VAP was associated with longer hospital length of stay (HR=1.02, p=0.004). The development of VAP was not significantly different in patients who were enterally fed distal to the pylorus or in the stomach. There was no statistically significant difference between males and females in injury severity scores in this cohort.
Conclusions: Evidence of aspiration and enteral feeds were associated with increased risk of VAP in pediatric patients with severe TBI. Albuterol appears to be protective against VAP, consistent with a previously published study. Further investigation into the enteral feeding patterns, timing, and modalities is needed to provide guidance on nutritional support for pediatric patients who suffered a severe TBI.
