RESUMEN
CONTEXT: Withdrawal of life-sustaining therapies (WDLST) in young individuals with traumatic brain injury (TBI) is an overwhelming situation often made more stressful by socioeconomic factors that shape health outcomes. Identifying these factors is crucial to developing equitable and goal-concordant care for patients and families. OBJECTIVES: We aimed to identify predictors of WDLST in young patients with 1-TBI. We hypothesized uninsured payment method, race, and co-morbid status are associated with WDLST. METHODS: We queried the 2021 Trauma Quality Improvement Program database for patients <45 years with TBI. Patients with WDLST were compared to patients without WDLST. Multivariable logistic regression (MLR) was performed. RESULTS: 61,115 patients were included, of whom 2,487 (4.1%) underwent WDLST. Patients in the WDLST cohort were older (29 vs 27, P<0.001), more likely to suffer from a penetrating mechanism (29% vs 11%, P<.0001), and have uninsured (22% vs 18%) or other payment method (5% vs 3%) when compared to the non-WDLST cohort. MLR identified age (AOR:1.019, 95% CI 1.014-1.024, P<.0001), non-Hispanic ethnicity (AOR:1.590, 95% CI 1.373-1.841, P<.0001), penetrating mechanism (AOR:3.075, 95% CI 2.727-3.467, P<.0001), systolic blood pressure (AOR: 0.992, 95% CI 0.990-0.993, P<0.0001), advanced directive (AOR:4.987, 95% CI 2.823-8.812, P<.0001), cirrhosis (AOR:3.854, 95% CI 2.641-5.625, P<.0001), disseminated cancer (AOR:6.595, 95% CI 2.370-18.357, P=0.0003), and interfacility transfer (AOR:1.457, 95% CI 1.295-1.640, P<0.0001) as factors associated with WDLST. Black patients were less likely to undergo WDLST when compared to white patients (AOR:0.687, 95% CI 0.603-0.782, P<.0001). CONCLUSION: The decision for WDLST in young patients with severe TBI may be influenced by cultural and socioeconomic factors in addition to clinical considerations.
RESUMEN
OBJECTIVE: This study sought to elucidate clinical and imaging findings predictive for malperfusion syndrome after blunt thoracic aortic injury (BTAI). SUMMARY BACKGROUND DATA: There is limited literature on malperfusion syndrome after BTAI and the timing of thoracic endovascular aortic repair (TEVAR) in patients with this condition has not been defined. METHODS: A retrospective analysis of prospectively collected data of patients with BTAI treated between January 2021 and October 2023. Clinical and thoracic aortic (TA) imaging data, time to TEVAR, in-hospital death, and malperfusion/reperfusion sequelae (paraplegia, renal/visceral/limb ischemia, and compartment syndromes) were assessed. Correlations between clinical and imaging findings, time to TEVAR, and outcomes were evaluated. RESULTS: Of the 19,203 trauma patients evaluated, 13,717 (71%) had blunt injuries and 77 (0.6%) had BTAI. The majority (67.5%) were male with a median age of 40 years (IQR:33-55). TEVAR was performed in 42 (54.5%) patients. Seven (9.1%) patients presented with clinical and TA imaging criteria for traumatic thoracic aortic coarctation (TTAC), including diminished/absent femoral pulses and TA luminal narrowing of 50-99%. The median time to TEVAR was 9 (IQR:5-32), 11, and 4 hours for all non-TTAC and TTAC BTAI patients, respectively (P=0.037). Only TTAC patients presented/developed malperfusion/reperfusion sequelae. In-hospital mortality rates were 7.8%, 5.8%, and 29% for all non-TTAC and TTAC BTAI patients, respectively (P=0.09). Aortic-related mortality occurred in only two (2.6%) TTAC patients.. CONCLUSIONS: Patients with clinical and TA imaging manifestations of TTAC are predisposed to malperfusion/reperfusion sequelae if TEVAR is delayed. We recommend the emergent repair of all BTAIs with TTAC.
RESUMEN
Introduction Computed Tomography (CT) to rule out pulmonary embolus (PE) is often ordered during post-trauma laparotomy clinical decompensation (CD) involving fever, tachycardia, tachypnea, and/or leukocytosis. We hypothesize this diagnostic modality is low-yield in the postoperative period when surgery-related sequelae are more probable. Methods This is a single-center retrospective cohort study of patients who underwent trauma laparotomy and had subsequent CT for CD from March 19, 2019 to June 30, 2022. Descriptive statistics and multiple logistic regression were performed. The primary outcome was saddle and lobar PE incidence. Results 1032 adult patients underwent trauma laparotomy with 434 undergoing CT for CD: 137 CT abdomen and pelvis only, 30 CTPE, 265 both. The majority (80.2 %) was male, age 33[interquartile range (IQR) 24-45], suffered penetrating mechanism (57 %), and had ISS 23[IQR16-30]. Injuries at laparotomy included 47 % solid organ, 62 % GI tract, 7 % biliary, 11 % vascular, and 42 % other. 176 (41 %) required damage control laparotomy. Median time to CT post-laparotomy was 174 h [111-235] with saddle and lobar PE in 3 (1 %), peripheral PE 18 (5 %), and abdominal abscess, leak, fluid, or pseudoaneurysm in 222 (51 %). Clinical management was altered (40 %) by antibiotics, therapeutic anticoagulation, drainage, aspiration, filter, thrombectomy, or surgical operation. Patients for whom CT findings changed management were more likely to have had GI tract surgery (69% vs 57 %, p = 0.021), higher white blood cell (WBC) (16.4 [13.1-20.5] vs 15.1 [9.9-19.5], p = 0.002), more hours between CT and laparotomy (184 [141-245] vs 162 [89-230], p = 0.002), and lower mortality (2% vs 8 %, p = 0.008). In-hospital mortality was 5 %; none were PE-related. Predictors of clinical intervention required based on CT imaging were GI tract injury (AOR: 1.65, p = 0.0182), and elevated WBC (AOR: 1.038, p = 0.010 Conclusion Saddle and lobar PE incidence post-trauma laparotomy is low. SIRS-type symptoms prompting postoperative CT commonly have no procedural or antibiotic requirement. Postoperative decompensation is more likely related post-operative complications, and less likely a PE.
Asunto(s)
Laparotomía , Embolia Pulmonar , Tomografía Computarizada por Rayos X , Humanos , Masculino , Embolia Pulmonar/etiología , Embolia Pulmonar/diagnóstico por imagen , Femenino , Estudios Retrospectivos , Adulto , Persona de Mediana Edad , Complicaciones Posoperatorias , Traumatismos Abdominales/complicaciones , Traumatismos Abdominales/cirugía , Traumatismos Abdominales/diagnóstico por imagen , Incidencia , Taquicardia/etiologíaRESUMEN
INTRODUCTION: Augmented renal clearance (ARC) is prevalent in trauma populations. Identification is underrecognized by calculated creatinine clearance or estimated glomerular filtration rate equations. Predictive scores may assist with ARC identification. The goal of this study was to evaluate validity of the ARCTIC score and ARC Predictor to predict ARC in critically ill trauma patients. METHODS: This single center, retrospective study was performed at an academic level 1 trauma center. Critically ill adult trauma patients undergoing 24-h urine-collection were included. Patients with serum creatinine >1.5 mg/dL, kidney replacement therapy, suspected rhabdomyolysis, chronic kidney disease, or inaccurate urine collection were excluded. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for ARCTIC Score and ARC Predictor were calculated. Receiver operating characteristic curves were created for ARCTIC score and ARC Predictor models. RESULTS: One-hundred and twenty-two patients with ARC and 78 patients without ARC were included. The ARCTIC score sensitivity, specificity, PPV, and NPV were 89%, 54%, 75%, and 75%, respectively. The ARC Predictor demonstrated sensitivity, specificity, PPV, and NPV of 77%, 88%, 91%, and 71%, respectively. Regression analyses revealed both ARCTIC score ≥6 and ARC Predictor threshold >0.5 as significant risk factors for ARC in presence of traumatic brain injury, obesity, injury severity score, and negative nitrogen balance (ARCTIC ≥6: odds ratio 8.59 [95% confidence interval 3.90-18.92], P < 0.001; ARC Predictor >0.5: odds ratio 20.07 [95% confidence interval 8.53-47.19], P < 0.001). CONCLUSIONS: These findings corroborate validity of two pragmatic prediction tools to identify patients at high risk of ARC. Future studies evaluating correlations between ARCTIC score, ARC Predictor, and clinical outcomes are warranted.
Asunto(s)
Valor Predictivo de las Pruebas , Heridas y Lesiones , Humanos , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Adulto , Heridas y Lesiones/complicaciones , Heridas y Lesiones/diagnóstico , Anciano , Enfermedad Crítica , Tasa de Filtración Glomerular , Medición de Riesgo/métodos , Medición de Riesgo/estadística & datos numéricos , Creatinina/sangre , Creatinina/orinaRESUMEN
The purpose of this study was to evaluate the efficacy and safety of intragastric administration of small volumes of sodium enema solution containing phosphorus as phosphorus replacement therapy in critically ill patients with traumatic injuries who required continuous enteral nutrition. Adult patients (>17 years of age) who had a serum phosphorus concentration <3 mg/dL (0.97 mmol/L) were evaluated. Patients with a serum creatinine concentration >1.4 mg/dL (124 µmol/L) were excluded. Patients were given 20 mL of saline enema solution intragastrically, containing 34 mmol of phosphorus and mixed in 240 mL water. A total of 55% and 73% of patients who received one (n = 22) or two doses (n = 11) had an improvement in the serum phosphorus concentration, respectively. The serum phosphorus concentration increased from 2.5 [2.1, 2.8] mg/dL (0.81 [0.69, 0.90] mmol/L) to 2.9 [2.2, 3.0] mg/dL (0.94 [0.71, 0.97 mmol/L) for those who received two doses (p = 0.222). Excluding two patients with a marked decline in serum phosphorus by 1.3 mg/dL (0.32 mmol/L) resulted in an increase in the serum phosphorus concentration from 2.3 [2.0, 2.8] mg/dL (0.74 [0.65, 0.90] mmol/L) to 2.9 [2.5, 3.2] mg/dL (0.94 [0.81, 1.03] mmol/L; n = 9; p = 0.012). No significant adverse effects were noted. Our data indicated that intragastric phosphate administration using a small volume of saline enema solution improved the serum phosphorus concentrations in most patients.
Asunto(s)
Enfermedad Crítica , Nutrición Enteral , Fosfatos , Fósforo , Humanos , Fosfatos/sangre , Fosfatos/administración & dosificación , Masculino , Femenino , Adulto , Fósforo/sangre , Nutrición Enteral/métodos , Persona de Mediana Edad , Enfermedad Crítica/terapia , Enema/métodos , Anciano , Resultado del TratamientoRESUMEN
INTRODUCTION: Management of penetrating neck injuries (PNIs) has evolved over time, more frequently relying on increased utilization of diagnostic imaging studies. Directed work-up with computed tomography imaging has resulted in increased use of angiography and decreased operative interventions. We sought to evaluate management strategies after directed work-up, hypothesizing increased use of non-operative therapeutic interventions and lower mortality after directed work-up. METHODS: Patients with PNI from 2017 to 2022 were identified from a single-center trauma registry. Demographics, injuries, physical exam findings, diagnostic studies and interventions were collected. Patients were stratified by presence of hard signs and management strategy [directed work-up (DW) and immediate operative intervention (OR)] and compared. Outcomes included therapeutic non-operative intervention [endovascular stent, embolization, dual antiplatelet therapy (DAPT), or anticoagulation (AC)], non-therapeutic neck exploration, length of stay (LOS), and mortality. RESULTS: Of 436 patients with PNI, 143 (33%) patients had vascular and/or aerodigestive injuries. Of these, 115 (80%) patients underwent DW and 28 (20%) patients underwent OR. There were no differences in demographics or injury severity score between groups. Patients in the DW group were more likely to undergo vascular stent or embolization (p = 0.040) and had fewer non-therapeutic neck explorations (p = 0.0009), compared to the OR group. There were no differences in post-intervention stroke, leak, or mortality. Sixty percent of patients with vascular hard signs and 78% of patients with aerodigestive hard signs underwent DW. CONCLUSIONS: Directed work-up in select patients with PNI is associated with fewer non-therapeutic neck explorations. There was no difference in mortality. Selective use of endovascular management, AC and DAPT is safe.
Asunto(s)
Traumatismos del Cuello , Heridas Penetrantes , Humanos , Traumatismos del Cuello/terapia , Traumatismos del Cuello/cirugía , Traumatismos del Cuello/diagnóstico por imagen , Masculino , Femenino , Adulto , Heridas Penetrantes/terapia , Heridas Penetrantes/mortalidad , Heridas Penetrantes/complicaciones , Heridas Penetrantes/diagnóstico por imagen , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Puntaje de Gravedad del Traumatismo , Embolización Terapéutica/métodos , Sistema de Registros , Persona de Mediana Edad , Tiempo de Internación/estadística & datos numéricos , Procedimientos Endovasculares/métodos , Centros Traumatológicos , StentsRESUMEN
INTRODUCTION: Hospital overcrowding is common and can lead to delays in intensive care unit (ICU) admission, resulting in increased morbidity and mortality in medical and surgical patients. Data on delayed ICU admission are limited in the postsurgical trauma cohort. Damage control laparotomy with temporary abdominal closure (DCL-TAC) for severely injured patients is often followed by an aggressive early resuscitation phase, usually occurring in the ICU. We hypothesized that patients who underwent DCL-TAC with initial postanesthesia care unit (PACU) stay would have worse outcomes than those directly admitted to ICU. METHODS: A retrospective chart review identified all trauma patients who underwent DCL-TAC at a level 1 trauma center over a 5 y period. Demographics, injuries, and resuscitation markers at 12 and 24 h were collected. Patients were stratified by location after index laparotomy (PACU versus ICU) and compared. Outcomes included composite morbidity and mortality. Multivariable logistic regression was performed. RESULTS: Of the 561 patients undergoing DCL-TAC, 134 (24%) patients required PACU stay due to ICU bed shortage, and 427 (76%) patients were admitted directly to ICU. There was no difference in demographics, injury severity score, time to resuscitation, complications, or mortality between PACU and ICU groups. Only 46% of patients were resuscitated at 24 h; 76% underwent eventual primary fascial closure. Under-resuscitation at 24 h (adjusted odds ratio [AOR] 0.55; 95% confidence interval [CI] 0.31-0.95, P = 0.03), increased age (AOR 1.04; 95% CI 1.02-10.55, P < 0.0001), and increased injury severity score (AOR 1.04; 95% CI 1.02-1.07, P < 0.0001) were associated with mortality on multivariable logistic regression. The median time in PACU was 3 h. CONCLUSIONS: PACU hold is not associated with worse outcomes in patients undergoing DCL-TAC. While ICU was designed for the resuscitation of critically ill patients, PACU is an appropriate alternative when an ICU bed is unavailable.
Asunto(s)
Unidades de Cuidados Intensivos , Laparotomía , Tiempo de Internación , Humanos , Masculino , Femenino , Estudios Retrospectivos , Laparotomía/estadística & datos numéricos , Adulto , Persona de Mediana Edad , Tiempo de Internación/estadística & datos numéricos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Resultado del Tratamiento , Centros Traumatológicos/estadística & datos numéricos , Periodo de Recuperación de la Anestesia , Traumatismos Abdominales/cirugía , Traumatismos Abdominales/mortalidad , Traumatismos Abdominales/diagnóstico , Adulto Joven , Puntaje de Gravedad del TraumatismoRESUMEN
INTRODUCTION: Historically, a zone II hematoma mandated exploration after penetrating trauma, but this has been challenged given potentially higher nephrectomy rates and the advent of therapeutic endovascular and endoscopic interventions. We hypothesized penetrating mechanism was not a predictor for delayed intervention in the modern era. METHODS: This single-center, retrospective study included renal trauma patients from 3/2019 to 6/2022. Our institutional practice is selective exploration of zone II hematomas for active bleeding and expanding hematoma only, regardless of mechanism. Descriptive statistics and multivariable logistic regression (MLR) were performed. RESULTS: One-hundred and forty-four patients were identified, with median age 32 years (IQR:23,49), 66% blunt mechanism, and injury severity score 17(IQR:11,26). Forty-three (30%) required operative intervention, and of the 20 that had a zone II exploration, 3 (15%) underwent renorrhaphy and 17 (85%) underwent nephrectomy. Penetrating patients more frequently underwent immediate operative intervention (67%vs10%,P < .0001), required nephrectomy (27%vs5%,P = .0003), and were less likely to undergo pre-intervention CT (51%vs96%,P < .0001) compared to blunt patients. Delayed renal interventions were higher in penetrating (33%vs13%,P = .004) with no difference in mortality or length of stay compared to blunt mechanism. Ureteral stent placement and renal embolization were the most common delayed interventions. On MLR, the only independent predictor for delayed intervention was need for initial operative intervention (OR 3.803;95%CI:1.612-8.975,P = .0023). Four (3%) required delayed nephrectomy, of which only one underwent initial operative intervention without zone 2 exploration. CONCLUSIONS: The most common delayed interventions after renal trauma were renal embolization and ureteral stent. Penetrating mechanism was not a predictor of delayed renal intervention in a trauma center that manages zone II retroperitoneal hematomas similarly regardless of mechanism.
Asunto(s)
Hematoma , Riñón , Nefrectomía , Tiempo de Tratamiento , Heridas no Penetrantes , Heridas Penetrantes , Humanos , Estudios Retrospectivos , Masculino , Femenino , Adulto , Riñón/lesiones , Persona de Mediana Edad , Nefrectomía/métodos , Heridas no Penetrantes/cirugía , Heridas no Penetrantes/terapia , Heridas no Penetrantes/mortalidad , Heridas Penetrantes/cirugía , Heridas Penetrantes/mortalidad , Heridas Penetrantes/terapia , Hematoma/cirugía , Hematoma/terapia , Hematoma/etiología , Puntaje de Gravedad del Traumatismo , Adulto Joven , Traumatismos Abdominales/cirugía , Traumatismos Abdominales/mortalidad , Traumatismos Abdominales/diagnóstico , Embolización Terapéutica/métodosRESUMEN
BACKGROUND: Need for Trauma Intervention (NFTI) score was proposed to help identify injured trauma patients while minimizing under (UT) and over triage (OT). Using a national database, we aimed to describe UT and OT of NFTI vs standard Cribari method (CM) and hypothesized triage sensitivity remains poor. METHODS: The 2021 Trauma Quality Improvement Program (TQIP) database was queried. Demographics, mechanism, verification level, interfacility transfer (IF), and level of activation were collected. Patients were stratified by both NFTI [+ vs -] and CM [Injury severity score (ISS) < 15 vs > 15]. UT was defined as NFTI + or ISS >15 without full trauma activation. RESULTS: 1,030,526 patients were identified in TQIP. 84,969 were UT and 97,262 were OT using NFTI while 94,020 were UT and 108,823 were OT using CM. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NFTI is 49%, 89%, 45%, and 90%, respectively vs 43%, 87%, 39%, and 89% of CM, respectively. Age was higher in the UT group using both scores (52 vs 42, P < .0001 and 54 vs 42, P < .0001, respectively). Using MLR, level 2 and 3 verification, blunt mechanism, female, IF, and older age were associated with UT in both NFTI and CM. Level 1 verification, penetrating mechanism, male, no IF, and younger age were associated with OT. CONCLUSIONS: Current prehospital triage criteria have poor sensitivity for identifying severely injured trauma patients by both NFTI and CM. UT increases as age of the patient increases. Further studies are needed to improve triage.
Asunto(s)
Triaje , Heridas y Lesiones , Humanos , Femenino , Masculino , Adulto , Persona de Mediana Edad , Heridas y Lesiones/terapia , Heridas y Lesiones/diagnóstico , Sensibilidad y Especificidad , Puntaje de Gravedad del Traumatismo , Mejoramiento de la Calidad , Estudios Retrospectivos , Anciano , Bases de Datos Factuales , Centros TraumatológicosRESUMEN
BACKGROUND: The management of extraperitoneal bladder injuries (EBIs) when present with concomitant pelvic fractures is controversial. Current evidence is divided between supporting non-operative management with catheter drainage compared to operative management of bladder injury. The purpose of this study was to evaluate current management of EBI in the setting of pelvic fractures at our institution. We hypothesize there is no difference between operative and non-operative groups. METHODS: Retrospective review of patients with concomitant bladder injuries and pelvic fractures at a level 1 trauma center from 2017 to 2022 was performed. Demographics, injury characteristics, management strategies, and complications were collected. Patients were stratified by management (cystorrhaphy vs non-operative) and compared. RESULTS: Of 90 patients with bladder injuries and pelvic fractures, 50 patients (56%) presented with EBI, 26 patients (29%) presented with only intraperitoneal injuries, and 14 patients (16%) presented with a combined injury. Of patients with EBI, 18 (36%) underwent cystorrhaphy and 32 (64%) underwent non-operative management. There was no difference in demographics, orthopedic pelvic operative intervention, length of stay, or mortality between groups. Patients in the operative cohort had more bladder leaks [7 (39%) vs 4 (13%), P = .0406], compared to those in the non-operative cohort. Composite complications [7 (39%) vs 7 (22%), P = .1984] were similar between groups. CONCLUSIONS: Patients with EBI and pelvic fractures who underwent cystorrhaphy had more bladder leaks on follow-up imaging, although there was no difference in composite complications, when compared to those who underwent non-operative management.
Asunto(s)
Fracturas Óseas , Huesos Pélvicos , Vejiga Urinaria , Humanos , Huesos Pélvicos/lesiones , Fracturas Óseas/complicaciones , Fracturas Óseas/cirugía , Fracturas Óseas/terapia , Femenino , Masculino , Estudios Retrospectivos , Vejiga Urinaria/lesiones , Vejiga Urinaria/cirugía , Adulto , Persona de Mediana EdadRESUMEN
Objectives: There is little evidence guiding the management of grade I-II traumatic splenic injuries with contrast blush (CB). We aimed to analyze the failure rate of nonoperative management (NOM) of grade I-II splenic injuries with CB in hemodynamically stable patients. Methods: A multicenter, retrospective cohort study examining all grade I-II splenic injuries with CB was performed at 21 institutions from January 1, 2014, to October 31, 2019. Patients >18 years old with grade I or II splenic injury due to blunt trauma with CB on CT were included. The primary outcome was the failure of NOM requiring angioembolization/operation. We determined the failure rate of NOM for grade I versus grade II splenic injuries. We then performed bivariate comparisons of patients who failed NOM with those who did not. Results: A total of 145 patients were included. Median Injury Severity Score was 17. The combined rate of failure for grade I-II injuries was 20.0%. There was no statistical difference in failure of NOM between grade I and II injuries with CB (18.2% vs 21.1%, p>0.05). Patients who failed NOM had an increased median hospital length of stay (p=0.024) and increased need for blood transfusion (p=0.004) and massive transfusion (p=0.030). Five patients (3.4%) died and 96 (66.2%) were discharged home, with no differences between those who failed and those who did not fail NOM (both p>0.05). Conclusion: NOM of grade I-II splenic injuries with CB fails in 20% of patients. Level of evidence: IV.
RESUMEN
BACKGROUND: Despite improving understanding of trauma-induced coagulopathy (TIC), mortality and morbidity due to exsanguinating trauma remain high. Increased complications due to hemorrhage have been reported in blood group O, possibly due to reduced levels of von Willebrand factor (vWF). METHODS: An urban level 1 adult trauma center registry was retrospectively queried. Patients receiving ≥6 units of pRBC within 4 âh of presentation were included. Patient demographics, admission labs and outcomes were obtained. Univariate and multiple logistic regression analyses were performed. RESULTS: 562 patients were identified. There were no significant differences in demographics, admission labs, or outcome between different ABO groups. After adjustment, Type A patients were more likely to be hypocoagulable compared to Type O patients (p â= â0.014). No mortality differences were seen between ABO types in multiple regression analysis. CONCLUSIONS: No outcome or mortality differences were seen between ABO types, therefore factors other than vWF expression should be considered to explain coagulopathy in trauma patients.
Asunto(s)
Sistema del Grupo Sanguíneo ABO , Trastornos de la Coagulación Sanguínea , Exsanguinación , Heridas y Lesiones , Humanos , Masculino , Femenino , Estudios Retrospectivos , Trastornos de la Coagulación Sanguínea/etiología , Adulto , Persona de Mediana Edad , Heridas y Lesiones/complicaciones , Heridas y Lesiones/sangre , Heridas y Lesiones/mortalidad , Exsanguinación/mortalidad , Exsanguinación/etiología , Centros Traumatológicos/estadística & datos numéricos , Sistema de RegistrosRESUMEN
BACKGROUND: Iliac and femoral venous injuries represent a challenging dilemma in trauma surgery with mixed results. Venous restoration of outflow (via repair or bypass) has been previously identified as having higher rates of VTE (venous thromboembolism) compared to ligation. We hypothesized that rates of VTE and eventual amputation were similar whether restoration of venous outflow vs ligation was performed at initial operation. METHODS: Patients in the 2019-2021 National Trauma Data Bank with iliac and femoral vein injuries were abstracted and analyzed. The primary outcomes of interest were in-hospital lower extremity amputation and VTE. RESULTS: A total of 2642 patients with operatively managed iliac and femoral vein injuries were identified VTE was found in 10.8% of patients. Multivariable logistic regression was performed and identified bowel injury, higher ISS, older age, open repair, and longer time to VTE prophylaxis initiation as independent predictors of VTE. Amputation was required in 4.2% of patients. Multivariable logistic regression identified arterial or nerve injury, femur or tibia fracture, venous ligation, percutaneous intervention, fasciotomy, bowel injury, and higher ISS as independent factors of amputation. CONCLUSION: Venous restoration was not an independent predictor of VTE. Venous ligation on index operation was the only modifiable independent predictor of amputation identified on regression analysis.
Asunto(s)
Amputación Quirúrgica , Vena Femoral , Vena Ilíaca , Mejoramiento de la Calidad , Lesiones del Sistema Vascular , Tromboembolia Venosa , Humanos , Femenino , Masculino , Tromboembolia Venosa/etiología , Tromboembolia Venosa/prevención & control , Tromboembolia Venosa/epidemiología , Adulto , Vena Femoral/lesiones , Vena Femoral/cirugía , Persona de Mediana Edad , Factores de Riesgo , Amputación Quirúrgica/estadística & datos numéricos , Vena Ilíaca/lesiones , Vena Ilíaca/cirugía , Lesiones del Sistema Vascular/cirugía , Estudios Retrospectivos , Ligadura/métodosRESUMEN
BACKGROUND: Given the acuity of patients who receive MTPs and the resources they require, MTPs are a compelling target for performance improvement. This study evaluated adherence with our MTP's plasma:red blood cell ratio (FFPR) of 1:2 and platelet:red blood cell ratio (PLTR) of 1:12, to test the hypothesis that ratio adherence is associated with lower inpatient mortality. MATERIALS AND METHODS: The registry of an urban level I trauma center was queried for adult patients who received at least 6 units of packed red blood cells within 4 hours of presentation. Patients were excluded for interfacility transfer, cardiac arrest during the prehospital phase or within one hour of arrival, or for head AIS ≥5. Univariate analysis and multiple logistic regressions were performed to identify variables associated with early transfusion protocol noncompliance and the effect on inpatient mortality. RESULTS: Three hundred and eighty-three patients were included, with mean ISS of 25.9 ± 13.3 and inpatient mortality of 28.5%. Increasing age, ISS, INR, and total units of blood product transfused were associated with increased odds of mortality, while an increase in revised trauma score was associated with a decreased odds ratio of mortality. Achieving our goal ratios were protective against mortality, with OR of .451 (P = .013) and .402 (P=.003), respectively. DISCUSSION: Large proportions of critically injured patients were transfused fewer units of plasma and platelets than our MTP dictated; failure to achieve intended ratios at 4 hours was strongly associated with inpatient mortality. MTP processes and outcomes should be critically assessed on a regular basis as part of a mature performance improvement program to ensure protocol adherence and optimal patient outcome.
Asunto(s)
Transfusión Sanguínea , Heridas y Lesiones , Adulto , Humanos , Plaquetas , Transfusión Sanguínea/métodos , Mortalidad Hospitalaria , Plasma , Estudios Retrospectivos , Centros Traumatológicos , Heridas y Lesiones/terapiaRESUMEN
BACKGROUND: The management of acute necrotizing pancreatitis (ANP) has changed dramatically over the past 20 years including the use of less invasive techniques, the timing of interventions, nutritional management, and antimicrobial management. This study sought to create a core outcome set (COS) to help shape future research by establishing a minimal set of essential outcomes that will facilitate future comparisons and pooling of data while minimizing reporting bias. METHODS: A modified Delphi process was performed through involvement of ANP content experts. Each expert proposed a list of outcomes for consideration, and the panel anonymously scored the outcomes on a 9-point Likert scale. Core outcome consensus defined a priori as >70% of scores receiving 7 to 9 points and <15% of scores receiving 1 to 3 points. Feedback and aggregate data were shared between rounds with interclass correlation trends used to determine the end of the study. RESULTS: A total of 19 experts agreed to participate in the study with 16 (84%) participating through study completion. Forty-three outcomes were initially considered with 16 reaching consensuses after four rounds of the modified Delphi process. The final COS included outcomes related to mortality, organ failure, complications, interventions/management, and social factors. CONCLUSION: Through an iterative consensus process, content experts agreed on a COS for the management of ANP. This will help shape future research to generate data suitable for pooling and other statistical analyses that may guide clinical practice. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.
Asunto(s)
Consenso , Técnica Delphi , Pancreatitis Aguda Necrotizante , Pancreatitis Aguda Necrotizante/cirugía , Pancreatitis Aguda Necrotizante/mortalidad , Humanos , Evaluación de Resultado en la Atención de SaludRESUMEN
BACKGROUND: Trauma surgical dogma teaches that patients should have intraoperative angiography (IA) if the surgeon cannot identify a pulse in the injured extremity following a vascular repair. This study was undertaken to assess the utility of IA in trauma patients who underwent open brachial or femoral artery revascularization. METHODS: Retrospective analysis of the Prospective Observational Vascular Injury Trial (PROOVIT) database from 2013 to 2021 evaluated patients >15 years with penetrating or blunt injuries requiring operative intervention of the brachial, superficial femoral, or common femoral arteries. Prospective Observational Vascular Injury Trial data evaluated included documented pulse in the injured extremity at revascularization completion, adjunctive IA, immediate revision, and vascular reintervention during the hospitalization. RESULTS: Of the 5057 patients with vascular injury, 185 patients met our inclusion criteria. The majority were male (86.5%) with a median age, injury severity score, and systolic blood pressure of 29, 12, and 117, respectively. Of the study patients, 39% underwent IA, 14% had immediate revision, and 8% required vascular reoperation during their admission. Patients who underwent IA and with no documented palpable pulse after repair were significantly more likely to require immediate revision before leaving the operating room (22% vs 9%, P = .013) and were not more likely to require reoperation, than those who did not undergo IA (7% vs 9%, P = .613). CONCLUSIONS: Intraoperative angiography is a valuable tool for surgeons for vascular extremity trauma and is associated with a greater rate of immediate revision. Familiarity with angiographic technique is essential for vascular trauma and should be a focal point of training.
Asunto(s)
Lesiones del Sistema Vascular , Humanos , Masculino , Femenino , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/cirugía , Estudios Retrospectivos , Angiografía , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/cirugía , Extremidad Inferior/irrigación sanguínea , Resultado del TratamientoRESUMEN
BACKGROUND: American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines recommend gastrostomy for patients suspected to require enteral access device for 4-6 weeks. Our hypothesis was that traumatic brain injury (TBI) patients undergoing synchronous tracheostomy/gastrostomy (SYNC) compared to tracheostomy first (DELAY) have shorter length of stay (LOS) but higher rates of unnecessary gastrostomy. METHODS: Retrospective review of TBI patients requiring tracheostomy in 2017-2022 âat a Level 1 trauma center was conducted. SYNC and DELAY patients were compared, and CoxPH analysis was performed for LOS. RESULTS: 394 patients were included [mean age: 42 (SD:18); mortality: 9 â%]. The DELAY group had longer LOS (39 vs 32 days, p â< â0.001). There was no significant difference in unnecessary gastrostomy rate between groups (p â= â0.1331). In adjusted hazard analysis, SYNC predicted shorter LOS (HR:1.54; 95 â% CI:1.20-1.98, p â< â0.001). CONCLUSIONS: Synchronous gastrostomy was associated with shorter length of stay and similar rates of unnecessary gastrostomy in TBI patients.