Definitions of hospital-acquired pneumonia in trauma research: a systematic review.

PURPOSE: What are reported definitions of HAP in trauma patient research? METHODS: A systematic review was performed using the PubMed/MEDLINE database. We included all English, Dutch, and German original research papers in adult trauma patients reporting diagnostic criteria for hospital-acquired pneumonia diagnosis. The risk of bias was assessed using the MINORS criteria. RESULTS: Forty-six out of 5749 non-duplicate studies were included. Forty-seven unique criteria were reported and divided into five categories: clinical, laboratory, microbiological, radiologic, and miscellaneous. Eighteen studies used 33 unique guideline criteria; 28 studies used 36 unique non-guideline criteria. CONCLUSION: Clinical criteria for diagnosing HAP-both guideline and non-guideline-are widespread with no clear consensus, leading to restrictions in adequately comparing the available literature on HAP in trauma patients. Studies should at least report how a diagnosis was made, but preferably, they would use pre-defined guideline criteria for pneumonia diagnosis in a research setting. Ideally, one internationally accepted set of criteria is used to diagnose hospital-acquired pneumonia. LEVEL OF EVIDENCE: Level III.

No role for standard imaging workup of patients with clinically evident necrotizing soft tissue infections: a national retrospective multicenter cohort study.

PURPOSE: To assess the diagnostic contribution of different imaging studies to diagnose necrotizing soft tissue infections (NSTIs) and the time to surgery in relation to imaging with the hypothesis that imaging studies may lead to significant delays without being able to sufficiently dismiss or confirm the diagnosis since a NSTI is a surgical diagnosis. METHODS: A retrospective multicenter cohort study of all NSTI patients between 2010 and 2020 was conducted. The primary outcome was the number of cases in which imaging contributed to or led to change in treatment. The secondary outcomes were time to treatment determined by the time from presentation to surgery and patient outcomes (amputation, intensive care unit (ICU) admission, length of ICU stay, hospital stay, and mortality). RESULTS: A total of 181 eligible NSTI patients were included. The overall mortality was 21% (n = 38). Ninety-eight patients (53%) received imaging in the diagnostic workup. In patients with a clinical suspicion of a NSTI, 81% (n = 85) went directly to the operating room and 19% (n = 20) underwent imaging before surgery; imaging was contributing in only 15% (n = 3) by ruling out or determining underlying causes. In patients without a clinical suspicion of a NSTI, the diagnosis of NSTI was considered in 35% and only after imaging was obtained. CONCLUSION: In patients with clinically evident NSTIs, there is no role for standard imaging workup unless it is used to examine underlying diseases (e.g., diverticulitis, pancreatitis). In atypical presenting NSTIs, CT or MRI scans provided the most useful information. To prevent unnecessary imaging and radiation and not delay treatment, the decision to perform imaging studies in patients with a clinical suspicion of a NSTI must be made extremely careful.

Mental health is strongly associated with capability after lower extremity injury treated with free flap limb salvage or amputation.

BACKGROUND: Knowledge about factors associated with long-term outcomes, after severe traumatic injury to the lower extremity, can aid with the difficult decision whether to salvage or amputate the leg and improve outcome. We therefore studied factors independently associated with capability at a minimum of 1 year after amputation or free flap limb salvage. METHODS: We included 135 subjects with a free flap lower extremity reconstruction and 41 subjects with amputation, between 1991 and 2021 at two urban-level 1 trauma centers with a mean follow-up of 11 ± 7 years. Long-term physical functioning was assessed using the Physical Component Score (PCS) of the Short-Form 36 (SF36) and the Lower Extremity Functional Scale (LEFS) questionnaires. Independent variables included demographics, injury characteristics, and the Mental Component Score (MCS) of the SF36. RESULTS: Greater mental health was independently and strongly associated with greater capability, independent of amputation or limb reconstruction. Mental health explained 33% of the variation in PCS and 57% of the variation in LEFS. Injury location at the knee or leg was associated with greater capability, compared to the foot or ankle. Amputation or limb reconstruction was not associated with capability. DISCUSSION: This study adds to the growing body of knowledge that physical health is best regarded through the lens of the bio-psycho-social model in which mental health is a strong determinant. This study supports making mental health an important aspect of rehabilitation after major lower extremity injury, regardless of amputation or limb salvage.

Identification of neutrophil phenotype categories in geriatric hip fracture patients aids in personalized medicine.

Objectives: The number of geriatric hip fracture patients is high and expected to rise in the coming years, and many are frail and at risk for adverse outcomes. Early identification of high-risk patients is crucial to balance treatment and optimize outcome, but remains challenging. Previous research in patients with multitrauma suggested that neutrophil phenotype analysis could aid in early identification of high-risk patients. This pilot study investigated the feasibility and clinical value of neutrophil phenotype analysis in geriatric patients with a hip fracture. Methods: A prospective study was conducted in a regional teaching hospital in the Netherlands. At the emergency department, blood samples were collected from geriatric patients with a hip fracture and analyzed using automated flow cytometry. Flow cytometry data were processed using an automated clustering algorithm. Neutrophil activation data were compared with a healthy control cohort. Neutrophil phenotype categories were assessed based on two-dimensional visual assessment of CD16/CD62L expression. Results: Blood samples from 45 geriatric patients with a hip fracture were included. Neutrophils showed an increased activation profile and decreased responsiveness to formyl peptides when compared to healthy controls. The neutrophil phenotype of all patients was categorized. The incidence of severe adverse outcome was significantly different between the different categories (P = 0.0331). Moreover, patients with neutrophil phenotype category 0 developed no severe adverse outcomes. Conclusions: Using point-of-care fully automated flow cytometry to analyze the neutrophil compartment in geriatric hip fracture patients is feasible and holds clinical value in determining patients at risk for adverse outcome. This study is a first step toward immuno-based precision medicine for identifying geriatric hip fracture patients that are deemed fit for surgery.

Quality of Life After Intensive Care Unit Admittance for Necrotizing Soft Tissue Infections Is Deemed Acceptable for Patients.

Background: Because mortality and amputation rates are declining for necrotizing soft tissue infections (NSTIs), this study aimed to assesses the self-reported one-year quality of life (QoL) of severely ill patients with NSTI who survived beyond the intensive care unit (ICU). Patients and Methods: A retrospective cohort study of patients with NSTI admitted to the ICU between 2010 and 2019 was conducted. A year after ICU discharge, QoL was assessed using the three-level EuroQol five-dimensions (EQ-5D-3L) questionnaire, Impact of Event Scale-Revised (IES-R) questionnaires, and pain scales. Furthermore, willingness to undergo ICU admission again if needed was reviewed. Results: Twenty-nine (of 38) patients with NSTI survived their hospitalization (76%). During the one-year follow-up, three patients died (8%; one-year survival 68%). Nineteen patients filled out the questionnaires (73%). The median EQ-5D-3L index score was 0.775 (interquartile range [IQR], 0.687-0.843). The domains reported most to cause impairment were "usual activity" and "pain/discomfort." Patients had a median pain score of five (of 10; IQR, 1-6) and two patients (15%; of 13) scored "clinical concern for PTSD.". Eighty-five percent of the patients would undergo the ICU treatment again if needed. Conclusions: The one-year QoL of ICU-admitted patients with NSTI varies widely, however, the overall QoL and one-year survival was similar to other ICU patients who underwent acute surgery and the QoL was slightly lower than the general ICU population. Most patients experience problems with daily activity and pain, but this does not mean that patients with NSTI automatically had poor self-reported quality of life or unwillingness to undergo ICU treatment again if needed.

Outcome of severely injured patients in a unique trauma system with 24/7 double trauma surgeon on-call service.

BACKGROUND: The presence of in-house attending trauma surgeons has improved efficiency of processes in the treatment of polytrauma patients. However, literature remains equivocal regarding the influence of the presence of in-house attendings on mortality. In our hospital there is a double trauma surgeon on-call system. In this system an in-house trauma surgeon is 24/7 backed up by a second trauma surgeon to assist with urgent surgery or multiple casualties. The aim of this study was to evaluate outcome in severely injured patients in this unique trauma system. METHODS: From 2014 to 2021, a prospective population-based cohort consisting of consecutive polytrauma patients aged ≥ 15 years requiring both urgent surgery (≤ 24h) and admission to Intensive Care Unit (ICU) was investigated. Demographics, treatment, outcome parameters and pre- and in-hospital transfer times were analyzed. RESULTS: Three hundred thirteen patients with a median age of 44 years (71% male), and median Injury Severity Score (ISS) of 33 were included. Mortality rate was 19% (68% due to traumatic brain injury). All patients stayed ≤ 32 min in ED before transport to either CT or OR. Fifty-one percent of patients who needed damage control surgery (DCS) had a more deranged physiology, needed more blood products, were more quickly in OR with shorter time in OR, than patients with early definitive care (EDC). There was no difference in mortality rate between DCS and EDC patients. Fifty-six percent of patients had surgery during off-hours. There was no difference in outcome between patients who had surgery during daytime and during off-hours. Death could possibly have been prevented in 1 exsanguinating patient (1.7%). CONCLUSION: In this cohort of severely injured patients in need of urgent surgery and ICU support it was demonstrated that surgical decision making was swift and accurate with low preventable death rates. 24/7 Physical presence of a dedicated trauma team has likely contributed to these good outcomes.

Psychiatric comorbidity and trauma: impact on inpatient outcomes and implications for future management.

PURPOSE: This study aimed to quantify the impact of pre-existing psychiatric illness on inpatient outcomes after major trauma and to assess acuity of psychiatric presentation as a predictor of outcomes. METHODS: A retrospective single-center cohort study identified adult trauma patients with an Injury Severity Score (ISS) ≥ 16 between January 2018 and December 2019. Bivariate analysis assessed patient characteristics, injury characteristics, and injury outcomes between patients with and without psychiatric comorbidity. A sub-group analysis explored further effects of psychiatric history and need for inpatient psychiatric consultation on outcomes. RESULTS: Of 640 patients meeting inclusion criteria, 99 patients (15.4%) had at least one psychiatric comorbidity. Patients with psychiatric comorbidity sustained distinct mechanisms of injury and higher in-hospital morbidity (44% vs. 26%, OR 1.97, 95% CI 1.17-3.3, p = 0.01), including pulmonary morbidity (31% vs. 21%, p < 0.01), neurologic morbidity (18% vs 7%, p < 0.01), and deep wound infection (8% vs. 2%, p < 0.01) than the control cohort. Psychiatric patients also had significantly greater median intensive care unit (ICU), length of stay (LOS) (1 day vs. 0 days, p = 0.04), median inpatient ward LOS (10 days vs. 7 days, p = 0.02), and median overall hospital LOS (16 days vs. 11 days, p < 0.01). In sub-group analysis, patients with a history of psychiatric illness alone had comparable outcomes to the control group. CONCLUSIONS: Psychiatric comorbidity negatively impacts inpatient morbidity and inpatient LOS. This effect is most pronounced among acute psychiatric episodes with or without a history of mental illness.

The Impact of Resident Involvement on Outcomes and Costs in Elective Hand and Upper Extremity Surgery.

PURPOSE: The purpose of this study was to assess the impact of resident involvement on periprocedural outcomes and costs after common procedures performed at an academic hand surgical practice. METHODS: A retrospective review was performed in all patients undergoing 7 common elective upper extremity procedures between January 2008 and December 2018: carpal tunnel release, distal radius open reduction and internal fixation (ORIF), trigger finger release, thumb carpometacarpal arthroplasty, phalanx closed reduction and percutaneous pinning, cubital tunnel release, and olecranon ORIF. The medical record was reviewed to determine the impact of surgical assistants (resident, fellow, or physician assistant) on periprocedural outcomes, periprocedural costs, and 1-year postoperative outcomes. The involvement of surgical trainees operating under direct supervision was compared with the entire operation performed by the attending surgeon with a physician assistant present. RESULTS: A total of 396 procedures met the inclusion criteria. Analysis of the whole study sample revealed low rates of intraoperative complications, wound complications, medical complications, readmissions, and mortality. Subgroup analysis of carpal tunnel releases revealed significantly greater tourniquet times for residents compared with physician assistants (7 ± 2 min, 6 ± 1 min), as well as longer overall operating room times for residents compared to fellows or physician assistants (17 ± 5 min, 13 ± 3 min, 12 ± 3 min). Operating room times for distal radius ORIF were significantly greater among residents compared to fellows or physician assistants (68 ± 19 min, 57 ± 17 min, 56 ± 14 min). There were no differences in any other perioperative metrics or periprocedural costs for the trigger finger release or cubital tunnel release cohorts. CONCLUSIONS: Resident involvement in select upper extremity procedures can lengthen operative times but does not have an impact on blood loss or operating room costs. CLINICAL RELEVANCE: Surgeons should be aware that having a resident assistant slightly increases operative times in elective hand surgery.

Influence of psychiatric co-morbidity on health-related quality of life among major trauma patients.

PURPOSE: The purpose of this study was to compare 1-year post-discharge health-related quality of life (HRQL) between trauma patients with and without psychiatric co-comorbidity. METHODS: A retrospective single-center cohort study identified all severely injured adult trauma patients admitted to a Level 1 trauma center between 2018 and 2019. Bivariate analysis compared patients with and without psychiatric co-morbidity, which was defined as prior diagnosis by a healthcare provider or acute psychiatric consultation for new or chronic mental illness. HRQL metrics included the EuroQol-5D-5L (EQ-5D) questionnaire, visual analogue scale (EQ-VAS), and overall index score. A multiple linear regression model was utilized to identify predictors of EQ-5D index scores. RESULTS: Analysis of baseline characteristics revealed significantly greater rates of substance abuse, severe extremity injuries, inpatient morbidity, and hospital length-of-stay among patients with psychiatric illness. At 1-year follow-up, patients with psychiatric co-morbidity had lower median EQ-5D index scores compared to the control group (0.71, interquartile range [IQR] 0.32 vs. 0.79, IQR 0.22, p = 0.03). There were no differences between groups in individual EQ-5D dimensions, nor in EQ-VAS scores. Presence of psychiatric co-morbidity was not found to independently predict EQ-5D index scores in the linear regression model. Instead, Injury Severity Score (standardized regression coefficient [SRC] - 0.15, 95% confidence interval [CI] - 0.010 to - 0.001) and American Society of Anesthesiologists Physical Status score (SRC - 0.13, 95% CI - 0.08 to - 0.004) predicted poor HRQL 1-year after injury. CONCLUSIONS: Psychiatric co-morbidity does not independently predict low HRQL 1 year after injury. Instead, lower HRQL scores among patients with psychiatric co-morbidity appear to be mediated by baseline health status and injury severity.

Visualization of the inflammatory response to injury by neutrophil phenotype categories : Neutrophil phenotypes after trauma.

PURPOSE: The risk of infectious complications after trauma is determined by the amount of injury-related tissue damage and the resulting inflammatory response. Recently, it became possible to measure the neutrophil phenotype in a point-of-care setting. The primary goal of this study was to investigate if immunophenotype categories based on visual recognition of neutrophil subsets are applicable to interpret the inflammatory response to trauma. The secondary goal was to correlate these immunophenotype categories with patient characteristics, injury severity and risk of complications. METHODS: A cohort study was conducted with patients presented at a level 1 trauma center with injuries of any severity, who routinely underwent neutrophil phenotyping. Data generated by automated point-of-care flow cytometry were prospectively gathered. Neutrophil phenotypes categories were defined by visual assessment of two-dimensional CD16/CD62L dot plots. All patients were categorized in one of the immunophenotype categories. Thereafter, the categories were validated by multidimensional analysis of neutrophil populations, using FlowSOM. All clinical parameters and endpoints were extracted from the trauma registry. RESULTS: The study population consisted of 380 patients. Seven distinct immunophenotype Categories (0-6) were defined, that consisted of different neutrophil populations as validated by FlowSOM. Injury severity scores and risk of infectious complications increased with ascending immunophenotype Categories 3-6. Injury severity was similarly low in Categories 0-2. CONCLUSION: The distribution of neutrophil subsets that were described in phenotype categories is easily recognizable for clinicians at the bedside. Even more, multidimensional analysis demonstrated these categories to be distinct subsets of neutrophils. Identification of trauma patients at risk for infectious complications by monitoring the immunophenotype category is a further improvement of personalized and point-of-care decision-making in trauma care.

Early correction of base deficit decreases late mortality in polytrauma.

INTRODUCTION: Physiology-driven resuscitation has become the standard of care in severely injured patients. This has resulted in a decrease in acute deaths by hemorrhagic shock. With increased survival from hemorrhage, focus shifts towards death later during hospital stay. This population based cohort study investigated the association of initial physiology derangement correction and (late) mortality. METHODS: Consecutive polytrauma patients aged > 15 years with deranged physiology who were admitted to a level-1 trauma center intensive care unit (ICU) from 2015 to 2021, and requiring surgical intervention < 24 h were included. Patients who acutely (< 48 h) died were excluded. Demographics, treatment, and outcome parameters were analyzed. Physiology was monitored by serial base deficits (BD) during the first 48 h. Correction of physiology was defined as BD return to normal values. Area under the curve (AUC) of BD in time was used as measurement for the correction of physiological derangement and related to mortality 3-6 days (early), and > 7 days (late). RESULTS: Two hundred thirty-five patients were included with a median age of 44 years (70% male), and Injury Severity Score (ISS) of 33. Mortality rate was 16% (71% due to traumatic brain injury (TBI)). Median time to death was 11 (6-17) days; 71% died > 7 days after injury. There was no difference between the single base deficit measurements in the emergency department(ED), operating room (OR), nor ICU between patients who died and those who did not. However, patients who later died were more acidotic at 24 and 48 h after arrival, and had a higher AUC of BD in time. This was independent of time and cause of death. CONCLUSION: Early physiological restoration based on serial BD measurements in the first 48 h after injury decreases late mortality.

What trauma patients need: the European dilemma.

There is a need for implementation and maturation of an inclusive trauma system in every country in Europe, with patient centered care by dedicated surgeons. This process should be initiated by physicians and medical societies, based on the best available evidence, and supported and subsequently funded by the government and healthcare authorities. A systematic approach to organizing all aspects of trauma will result in health gain in terms of quality of care provided, higher survival rates, better functional outcomes and quality of life. In addition, it will provide reliable data for both research, quality improvement and prevention programs. Severely injured patients need surgeons with broad technical and non-technical competencies to provide holistic, inclusive and compassionate care. Here we describe the philosophy of the surgical approach and define the necessary skills for trauma, both surgical and other, to improve outcome of severely injured patients. As surgery is an essential part of trauma care, surgeons play an important role for the optimal treatment of trauma patients throughout and after their hospital stay, including the intensive care unit (ICU). However, in most European countries, it might not be obvious to either the general public, patients or even the physicians that the surgeon must assume this responsibility in the ICU to optimize outcomes. The aim of this paper is to define key elements in terms of trauma systems, trauma-specific surgical skills and active critical care involvement, to organize and optimize trauma care in Europe.

Physiology dictated treatment after severe trauma: timing is everything.

INTRODUCTION: Damage control strategies in resuscitation and (fracture) surgery have become standard of care in the treatment of severely injured patients. It is suggested that damage control improves survival and decreases the incidence of organ failure. However, these strategies can possibly increase the risk of complications such as infections. Indication for damage control procedures is guided by physiological parameters, type of injury, and the surgeon's experience. We analyzed outcomes of severely injured patients who underwent emergency surgery. METHODS: Severely injured patients, admitted to a level-1 trauma center ICU from 2016 to 2020 who were in need of ventilator support and required immediate surgical intervention ( ≤24 h) were included. Demographics, treatment, and outcome parameters were analyzed. RESULTS: Hundred ninety-five patients were identified with a median ISS of 33 (IQR 25-38). Ninety-seven patients underwent immediate definitive surgery (ETC group), while 98 patients were first treated according to damage control principles with abbreviated surgery (DCS group). Although ISS was similar in both groups, DCS patients were younger, suffered from more severe truncal injuries, were more frequently in shock with more severe acidosis and coagulopathy, and received more blood products. ETC patients with traumatic brain injury needed more often a craniotomy. Seventy-four percent of DCS patients received definitive surgery in the second surgical procedure. There was no difference in mortality, nor any other outcome including organ failure and infections. CONCLUSIONS: When in severely injured patients treatment is dictated by physiology into either early definitive surgery or damage control with multiple shorter procedures stretched over several days combined with aggressive resuscitation with blood products, outcome is comparable in terms of complications.

Hip Fractures in Patients With Liver Cirrhosis: Worsening Liver Function Is Associated with Increased Mortality.

BACKGROUND: Liver cirrhosis is associated with osteoporosis, imbalance leading to falls, and subsequent fragility fractures. Knowing the prognosis of patients with liver cirrhosis of varying severity at the time of hip fracture would help physicians determine the course of treatment in this complex patient popultaion. QUESTIONS/PURPOSES: (1) Is there an association between liver cirrhosis of varying severity and mortality in patients with hip fractures? (2) Is there an association between liver cirrhosis of varying severity and the in-hospital, 30-day, and 90-day postoperative complications of symptomatic thromboembolism and infections including wound complications, pneumonia, and urinary tract infections? METHODS: Between 2015 and 2019, we identified 128 patients with liver cirrhosis who were treated for hip fractures at one of two Level I trauma centers. Patients younger than 18 years, those with incomplete medical records, fractures other than hip fractures or periprosthetic hip fractures, noncirrhotic liver disease, status after liver transplantation, and metastatic cancer other than hepatocellular carcinoma were excluded. Based on these exclusions, 77% (99 of 128) of patients were eligible; loss to follow-up was 0% within 1 year and 4% (4 of 99) at 2 years. The median follow-up duration was 750 days (interquartile range 232 to 1000). Ninety-four patients were stratified based on Model for End-stage Liver Disease (MELD) score subgroup (MELD scores of 6-9 [MELD6-9], 10-19 [MELD10-19], and 20-40 [MELD20-40]), and 99 were stratified based on compensation or decompensation status, both measures for liver cirrhosis severity. MELD scores combine laboratory parameters related to liver disease and are used to predict cirrhosis-related mortality based on metabolic abnormalities. Decompensation, however, is the clinical finding of acute deterioration in liver function characterized by ascites, hepatic encephalopathy, and variceal hemorrhage, associated with increased mortality. MELD analyses excluded 5% (5 of 99) of patients due to missing laboratory values. Median age at the time of hip fracture was 69 years (IQR 62 to 78), and 55% (54 of 99) of patients were female. The primary outcome of mortality was determined at 90 days, 1 year, and 2 years after surgery. Secondary outcomes were symptomatic thromboembolism and infections, defined as any documented surgical wound complications, pneumonia, or urinary tract infections requiring treatment. These were determined by chart review at three timepoints: in-hospital and within 30 days or 90 days after discharge. The primary outcome was assessed using a Cox proportional hazard analysis for the MELD score and compensation or decompensation classifications; secondary outcomes were analyzed using the Fisher exact test. RESULTS: Patients in the MELD20-40 group had higher 90-day (hazard ratio 3.95 [95% CI 1.39 to 12.46]; p = 0.01), 1-year (HR 4.12 [95% CI 1.52 to 11.21]; p < 0.001), and 2-year (HR 3.65 [95% CI 1.68 to 7.93]; p < 0.001) mortality than those in the MELD6-9 group. Patients with decompensation had higher in-hospital (9% versus 0%; p = 0.04), 90-day (HR 3.35 [95% CI 1.10 to 10.25]; p = 0.03), 1-year (HR 4.39 [95% CI 2.02 to 9.54]; p < 0.001), and 2-year (HR 3.80 [95% CI 2.02 to 7.15]; p < 0.001) mortality than did patients with compensated disease. All in-hospital deaths were related to liver failure and within 30 days of surgery. The 1-year mortality was 55% for MELD20-40 and 53% for patients with decompensated disease, compared with 16% for patients with MELD6-9 and 15% for patients with compensated disease. In both the MELD and (de)compensation analyses, in-hospital and postdischarge 30-day symptomatic thromboembolic and infectious complications were not different among the groups (all p > 0.05). Ninety-day symptomatic thromboembolism was higher in the MELD20-40 group compared with the other two MELD classifications (13% for MELD20-40 and 0% for both MELD6-9 and MELD10-19; p = 0.02). CONCLUSION: The mortality of patients with preexisting liver cirrhosis who sustain a hip fracture is high, and it is associated with the degree of cirrhosis and decline in liver function, especially in those with signs of decompensation, defined as ascites, hepatic encephalopathy, and variceal hemmorrhage. Patients with mild-to-moderate cirrhosis (MELD score < 20) and those with compensated disease may undergo routine fracture treatment based on their prognosis. Those with severe (MELD score > 20) or decompensated liver cirrhosis should receive multidisciplinary, individualized treatment, with consideration given to palliative and nonsurgical treatment given their high risk of death within 1 year after surgery. LEVEL OF EVIDENCE: Level III, therapeutic study.

The impact of operative time on the outcomes of necrotizing soft tissue infections: a multicenter cohort study.

BACKGROUND: The primary aim of this study was to identify if there is an association between the operative time of the initial debridement for necrotizing soft tissue infections (NSTIs) and the mortality corrected for disease severity. METHODS: A retrospective multicenter study was conducted of all patients with NSTIs undergoing surgical debridement. The primary outcome was the 30-day mortality. The secondary outcomes were days until death, length of intensive care unit (ICU) stay, length of hospital stay, number of surgeries within first 30 days, amputations and days until definitive wound closure. RESULTS: A total of 160 patients underwent surgery for NSTIs and were eligible for inclusion. Twenty-two patients (14%) died within 30 days and 21 patients (13%) underwent an amputation. The median operative time of the initial debridement was 59 min (IQR 35-90). In a multivariable analyses, corrected for sepsis just prior to the initial surgery, estimated total body surface (TBSA) area affected and the American Society for Anesthesiologists (ASA) classification, a prolonged operative time (per 20 min) was associated with a prolonged ICU (ß 1.43, 95% CI 0.46-2.40; p = 0.004) and hospital stay (ß 3.25, 95% CI 0.23-6.27; p = 0.035), but not with 30-day mortality. Operative times were significantly prolonged in case of NSTIs of the trunk (p = 0.044), in case of greater estimated TBSA affected (p = 0.006) or if frozen sections and/or Gram stains were assessed intra-operatively (p < 0.001). CONCLUSIONS: Prolonged initial surgery did not result in a higher mortality rate, possible because of a short duration of surgery in most studied patients. However, a prolonged operative time was associated with a prolonged ICU and hospital stay, regardless of the estimated TBSA affected, presence of sepsis prior to surgery and the ASA classification. As such, keeping operative times as limited as possible might be beneficial for NSTI patients.

The impact of prehospital time intervals on mortality in moderately and severely injured patients.

BACKGROUND: Modern trauma systems and emergency medical services aim to reduce prehospital time intervals to achieve optimal outcomes. However, current literature remains inconclusive on the relationship between time to definitive treatment and mortality. The aim of this study was to investigate the association between prehospital time and mortality. METHODS: All moderately and severely injured trauma patients (i.e., patients with an Injury Severity Score of 9 or greater) who were transported from the scene of injury to a trauma center by ground ambulances of the participating emergency medical services between 2015 and 2017 were included. Exposures of interest were total prehospital time, on-scene time, and transport time. Outcomes were 24-hour and 30-day mortality. Generalized linear models including inverse probability weights for several potential confounders were constructed. A generalized additive model was constructed to enable visual inspection of the association. RESULTS: We included 22,525 moderately and severely injured patients. Twenty-four-hour and 30-day mortality were 1.3% and 7.3%, respectively. On-scene time per minute was significantly associated with 24-hour (relative risk [RR], 1.029; 95% confidence interval, 1.018-1.040) and 30-day mortality (RR, 1.013; 1.008-1.017). We found that this association was also present in patients with severe injuries, traumatic brain injury, severe abdominal injury, and stab or gunshot wound. An on-scene time of 20 minutes or longer demonstrated a strong association with 24-hour (RR, 1.797; 1.406-2.296) and 30-day mortality (RR, 1.298; 1.180-1.428). Total prehospital (24-hour: RR, 0.998; 0.990-1.007; 30-day: RR, 1.000, 0.997-1.004) and transport (24-hour: RR, 0.996; 0.982-1.010; 30-day: RR, 0.995; 0.989-1.001) time were not associated with mortality. CONCLUSION: A prolonged on-scene time is associated with mortality in moderately and severely injured patients, which suggests that a reduced on-scene time may be favorable for these patients. In addition, transport time was found not to be associated with mortality. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; level III.

Epidemiology and outcome of rib fractures: a nationwide study in the Netherlands.

PURPOSE: Rib fractures following thoracic trauma are frequently encountered injuries and associated with a significant morbidity and mortality. The aim of this study was to provide current data on the epidemiology, in-hospital outcomes and 30-day mortality of rib fractures, and to evaluate these results for different subgroups. METHODS: A nationwide retrospective cohort study was performed with the use of the Dutch Trauma Registry which covers 99% of the acutely admitted Dutch trauma population. All patients aged 18 years and older admitted to the hospital between January 2015 and December 2017 with one or more rib fractures were included. Incidence rates were calculated using demographic data from the Dutch Population Register. Subgroup analyses were performed for flail chest, polytrauma, primary thoracic trauma, and elderly patients. RESULTS: A total of 14,850 patients were admitted between 2015 and 2017 with one or more rib fractures, which was 6.0% of all trauma patients. Of these, 573 (3.9%) patients had a flail chest, 4438 (29.9%) were polytrauma patients, 9273 (63.4%) were patients with primary thoracic trauma, and 6663 (44.9%) were elderly patients. The incidence rate of patients with rib fractures for the entire cohort was 29 per 100.000 person-years. The overall 30-day mortality was 6.9% (n = 1208) with higher rates observed in flail chest (11.9%), polytrauma (14.8%), and elderly patients (11.7%). The median hospital length of stay was 6 days (IQR, 3-11) and 37.3% were admitted to the intensive care unit (ICU). CONCLUSIONS: Rib fractures are a relevant and frequently occurring problem among the trauma population. Subgroup analyses showed that there is a substantial heterogeneity among patients with rib fractures with considerable differences regarding the epidemiology, in-hospital outcomes, and 30-day mortality.

Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life.

PURPOSE: Treatment of blunt thoracic aortic injuries (BTAIs) has shifted from the open surgical approach to the use of thoracic endovascular aortic repair (TEVAR), of which early outcomes appear promising but controversy regarding long-term outcomes remains. The goal of this study was to determine the long-term TEVAR outcomes for BTAI, particularly radiographic outcomes, complications and health-related quality of life (HRQoL). METHODS: Retrospectively, all patients with BTAIs presented at a single level 1 trauma center between January 2008 and December 2018 were included. Radiographic and clinical outcomes were determined (early and long term). In addition, HRQoL scores using EuroQOL-5-Dimensions-3-Level (EQ-5D-3L) and Visual Analog Scale (EQ-VAS) questionnaires were assessed, and compared to an age-adjusted reference and trauma population. RESULTS: Thirty-one BTAI patients met the inclusion criteria. Of these, 19/31 received TEVAR of which three died in hospital due to aorta-unrelated causes. In total, 10/31 patients died due to severe (associated) injuries before TEVAR could be attempted. The remaining 2/31 had BTAIs that did not require TEVAR. Stent graft implantation was successful in all 19 patients (100%). At a median radiographic follow-up of 3 years, no stent graft-related problems (endoleaks/fractures) were observed. However, one patient experienced acute stent graft occlusion approximately 2 years after TEVAR, successfully treated with open repair. Twelve patients required complete stent graft coverage of the left subclavian artery (LSCA) (63%), which did not result in ischemic complaints or re-interventions. Of fourteen surviving TEVAR patients, ten were available for questionnaire follow-up (follow-up rate 71%). At a median follow-up of 5.7 years, significant HRQoL impairment was found (p < 0.01). CONCLUSION: This study shows good long(er)-term radiographic outcomes of TEVAR for BTAIs. LSCA coverage did not result in complications. Patients experienced HRQoL impairment and were unable to return to an age-adjusted level of daily-life functioning, presumably due to concomitant orthopedic and neurological injuries.

Blunt popliteal artery injury following tibiofemoral trauma: vessel-first and bone-first strategy.

PURPOSE: Blunt popliteal artery injury (BPAI) is a potentially limb-threatening sequela of tibiofemoral (knee) dislocations and fractures. Associated amputation rates for all popliteal artery (PA) injuries range between 10 and 50%. It is unclear whether PA repair or bone stabilization should be performed first. We analyzed (long-term) clinical outcomes of BPAI patients that received initial PA repair (vessel-first, VF) versus initial external stabilization (bone-first, BF). METHODS: Retrospectively, all surgically treated BPAI patients between January 2000 and January 2019, admitted to two level 1 trauma centers were included. Clinical outcomes were determined, stratified by initial management strategy (VF and BF). Treatment strategy was determined by surgeon preference, based on associated injuries and ischemia duration. Primary outcomes (amputation and mortality) and secondary outcomes (claudication and complications) were determined. RESULTS: Of 27 included BPAI patients, 15 were treated according to the VF strategy (56%) and 12 according to the BF strategy (44%). Occlusion was the most frequently encountered BPAI in 18/27 patients (67%). Total delay and in-hospital delay were comparable between groups (p = 1.00 and p = 0.82). Revascularization was most frequently performed by PA bypass (59%). All patients had primary limb salvage during admission (100%). One secondary amputation due to knee pain was performed in the BF group (4%). During a median clinical follow-up period of 2.7 years, three PA re-interventions were performed, two in the BF group and one in the VF group. None suffered from (intermittent) claudication. CONCLUSION: Blunt popliteal artery injury (BPAI) is a rare surgical emergency. Long-term outcomes of early revascularization for BPAI appear to be good, independent of initial management strategy. The BF strategy may be preferred in case of severe orthopedic injury, if allowed by total ischemia duration.

Necrotizing Soft Tissue Infections, the Challenge Remains.

Background: Necrotizing Soft Tissue Infections (NSTIs) are uncommon rapidly spreading infection of the soft tissues for which prompt surgical treatment is vital for survival. Currently, even with sufficient awareness and facilities available, ambiguous symptoms frequently result in treatment delay. Objectives: To illustrate the heterogeneity in presentation of NSTIs and the pitfalls entailing from this heterogeneity. Discussion: NSTI symptoms appear on a spectrum with on one side the typical critically ill patient with fast onset and progression of symptoms combined with severe systemic toxicity resulting in severe physical derangement and sepsis. In these cases, the suspicion of a NSTI rises quickly. On the other far side of the spectrum is the less evident type of presentation of the patient with gradual but slow progression of non-specific symptoms over the past couple of days without clear signs of sepsis initially. This side of the spectrum is under represented in current literature and some physicians involved in the care for NSTI patients are still unaware of this heterogeneity in presentation. Conclusion: The presentation of a critically ill patient with evident pain out of proportion, erythema, necrotic skin and bullae is the classical presentation of NSTIs. On the other hand, non-specific symptoms without systemic toxicity at presentation frequently result in a battery of diagnostics tests and imaging before the treatment strategy is determined. This may result in a delay in presentation, delay in diagnosis and delay in definitive treatment. This failure to perform an adequate exploration expeditiously can result in a preventable mortality.