RESUMO
BACKGROUND: Acute type A aortic dissection (ATAAD) is a critical cardiovascular emergency that requires prompt surgical intervention for preserving life, particularly in patients with critical preoperative status. This retrospective study aimed to investigate the clinical features, early and late outcomes, and prognostic factors in patients undergoing aortic repair surgery for ATAAD complicated with preoperative shock. METHODS: Between April 2007 and July 2020, 694 consecutive patients underwent emergency ATAAD repair at our institution, including 162 (23.3%) presenting with preoperative shock (systolic blood pressure <90 mm Hg), who were classified into the survivor (n = 125) and non-survivor (n = 37) groups according to whether they survived to hospital discharge. The clinical demographics, surgical information, and postoperative complications were compared. Five-year survival and freedom from reoperation rates of survivors were analyzed using the Kaplan-Meier actuarial method. Multivariate logistic regression analysis was used to identify independent risk factors for in-hospital mortality. RESULTS: The in-hospital surgical mortality rate in patients with ATAAD and shock was 22.8%. The non-survivor group showed higher rates of preoperative cardiopulmonary resuscitation, acute myocardial infarction, and cerebral infarction, and was associated with longer cardiopulmonary bypass time, higher rates of total arch replacement and intraoperative extracorporeal membrane oxygenation implementation. The non-survivor group had higher blood transfusion volumes and rates of malperfusion-related complications. Multivariate analysis revealed that preoperative cardiopulmonary resuscitation, prolonged cardiopulmonary bypass time, and total arch replacement were risk factors for in-hospital mortality. For patients who survived to discharge, the 5-year cumulative survival and freedom from aortic reoperation rates were 75.6% (95% confidence interval, 67.6%-83.6%) and 82.6% (95% confidence interval, 74.2%-91.1%), respectively. CONCLUSIONS: Preoperative shock in ATAAD is associated with a high risk of in-hospital mortality, particularly in patients who undergo cardiopulmonary resuscitation and complex aortic repair procedures with extended cardiopulmonary bypass. However, late outcomes are acceptable for patients who were stabilized through surgical treatment and survived to discharge.
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Dissecção Aórtica , Mortalidade Hospitalar , Choque , Humanos , Feminino , Masculino , Dissecção Aórtica/cirurgia , Dissecção Aórtica/complicações , Dissecção Aórtica/mortalidade , Pessoa de Meia-Idade , Choque/mortalidade , Choque/cirurgia , Estudos Retrospectivos , Prognóstico , Idoso , Fatores de Risco , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento , Período Pré-Operatório , Aneurisma Aórtico/cirurgia , Aneurisma Aórtico/complicações , Aneurisma Aórtico/mortalidade , Doença AgudaRESUMO
BACKGROUND: Timely identification of high-risk pediatric trauma patients and appropriate resource mobilization may lead to improved outcomes. We hypothesized that reverse shock index times the motor component of the Glasgow Coma Scale (GCS) (rSIM) would perform equivalently to reverse shock index times the total GCS (rSIG) in the prediction of mortality and the need for intervention following pediatric trauma. METHODS: The 2017-2020 National Trauma Data Bank data sets were used. We included all patients 16 years or younger who had a documented prehospital and trauma bay systolic blood pressure, heart rate, and total GCS. We excluded all patients who arrived at the trauma center without vital signs and interfacility transport patients. Receiver operating characteristic curves were used to model the performance of each metric as a classifier with respect to our primary and secondary outcomes, and the area under the receiver operating characteristic curve (AUROC) was used for comparison. Our primary outcome was mortality before hospital discharge. Secondary outcomes included blood product administration or hemorrhage control intervention (surgery or angiography) <4 hours following hospital arrival and intensive care unit admission. RESULTS: After application of exclusion criteria, 77,996 patients were included in our analysis. Reverse shock index times GCS-motor and rSIG performed equivalently as predictors of mortality in the 1- to 2- ( p = 0.05) and 3- to 5-year-old categories ( p = 0.28), but rSIM was statistically outperformed by rSIG in the 6- to 12- (AUROC, 0.96 vs. 0.95; p = 0.04) and 13- to 16-year-old age categories (AUROC, 0.96 vs. 0.95; p < 0.01). Reverse shock index times GCS-motor and rSIG also performed similarly with respect to prediction of secondary outcomes. CONCLUSION: Reverse shock index times GCS-total and rSIM are both outstanding predictors of mortality following pediatric trauma. Statistically significant differences in favor of rSIG were noted in some age groups. Because of the simplicity of calculation, rSIM may be a useful tool for pediatric trauma triage. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level III.
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Escala de Coma de Glasgow , Ferimentos e Lesões , Humanos , Masculino , Feminino , Criança , Adolescente , Pré-Escolar , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia , Lactente , Choque/mortalidade , Choque/diagnóstico , Choque/terapia , Curva ROC , Centros de Traumatologia/estatística & dados numéricos , Estudos Retrospectivos , Valor Preditivo dos Testes , Escala de Gravidade do FerimentoRESUMO
OBJECTIVES: Shock is a life-threatening condition in children in low- and middle-income countries (LMIC), with several controversies. This systematic review summarizes the etiology, pathophysiology and mortality of shock in children in LMIC. METHODS: We searched for studies reporting on children with shock in LMIC in PubMed, Embase and through snowballing (up to 1 October 2019). Studies conducted in LMIC that reported on shock in children (1 month-18 years) were included. We excluded studies only containing data on neonates, cardiac surgery patients or iatrogenic causes. We presented prevalence data, pooled mortality estimates and conducted subgroup analyses per definition, region and disease. Etiology and pathophysiology data were systematically collected. RESULTS: We identified 959 studies and included 59 studies of which six primarily studied shock. Definitions used for shock were classified into five groups. Prevalence of shock ranged from 1.5% in a pediatric hospital population to 44.3% in critically ill children. Pooled mortality estimates ranged between 3.9-33.3% for the five definition groups. Important etiologies included gastroenteritis, sepsis, malaria and severe anemia, which often coincided. The pathophysiology was poorly studied but suggests that in addition to hypovolemia, dissociative and cardiogenic shock are common in LMIC. CONCLUSIONS: Shock is associated with high mortality in hospitalized children in LMIC. Despite the importance few studies investigated shock and as a consequence limited data on etiology and pathophysiology of shock is available. A uniform bedside definition may help boost future studies unravelling shock etiology and pathophysiology in LMIC.
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Países em Desenvolvimento , Sepse , Choque/etiologia , Adolescente , Criança , Pré-Escolar , Humanos , Lactente , Pobreza , Prevalência , Choque/epidemiologia , Choque/mortalidade , Choque/fisiopatologiaRESUMO
INTRODUCTION: Shock index (SI) and delta shock index (∆SI) predict mortality and blood transfusion in trauma patients. This study aimed to evaluate the predictive ability of SI and ∆SI in a rural environment with prolonged transport times and transfers from critical access hospitals or level IV trauma centers. METHODS: We completed a retrospective database review at an American College of Surgeons verified level 1 trauma center for 2 years. Adult subjects analyzed sustained torso trauma. Subjects with missing data or severe head trauma were excluded. For analysis, poisson regression and binomial logistic regression were used to study the effect of time in transport and SI/∆SI on resource utilization and outcomes. p < 0.05 was considered significant. RESULTS: Complete data were available on 549 scene patients and 127 transfers. Mean Injury Severity Score was 11 (interquartile range, 9.0) for scene and 13 (interquartile range, 6.5) for transfers. Initial emergency medical services SI was the most significant predictor for blood transfusion and intensive care unit care in both scene and transferred patients (p < 0.0001) compared with trauma center arrival SI or transferring center SI. A negative ∆SI was significantly associated with the need for transfusion and the number of units transfused. Longer transport time also had a significant relationship with increasing intensive care unit length of stay. Cohorts were analyzed separately. CONCLUSION: Providers must maintain a high level of clinical suspicion for patients who had an initially elevated SI. Emergency medical services SI was the greatest predictor of injury and need for resources. Enroute SI and ∆SI were less predictive as time from injury increased. This highlights the improvements in en route care but does not eliminate the need for high-level trauma intervention. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.
Assuntos
Transfusão de Componentes Sanguíneos/estatística & dados numéricos , Serviços Médicos de Emergência , Choque/classificação , Choque/mortalidade , Traumatismos Torácicos/terapia , Ferimentos não Penetrantes/terapia , Cuidados Críticos/estatística & dados numéricos , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Tempo para o Tratamento , Centros de Traumatologia , Estados UnidosRESUMO
OBJECTIVES: To compare the mortality rate of severe dengue (SD) before and after implementation of a revised SD guideline. METHODS: Medical records of SD patients <15 years of age hospitalized during 1998-2020 were reviewed. The revised SD guidelines were implemented in 2016, including intensive monitoring of vital signs and intra-abdominal pressure, the release of intra-abdominal pressure in cases of abdominal compartment syndrome (ACS) and the use of N-acetyl cysteine in cases of acute liver failure. RESULTS: On initial admission, organ failure including severe bleeding, acute respiratory failure, acute kidney injury and acute liver failure was not significantly different between 78 and 23 patients treated in the pre- and postrevised guideline periods, respectively. After hospitalization, the proportions of patients who developed profound shock (68.8% vs. 41.2%), multiorgan failures (60.4% vs. 73.3%), ACS (37.2% vs. 26.1%) and fatal outcome (33.3% vs. 13.0%) were also not significantly different between the pre- and postrevised guideline periods, respectively. In subgroup analysis, the mortality rates in patients with multiorgan failure (44.1% vs. 15.8%), acute respiratory failure and active bleeding (78.1% vs. 37.5%) and ACS (82.8% vs. 33.3%), respectively, were significantly higher in the pre- than the postrevised guideline periods. The durations of time before the liver function tests returned to normal levels, and the mortality rates in acute liver failure patients treated with and without N-acetyl cysteine were not significantly different. CONCLUSIONS: Although following the revised guidelines could not prevent organ failure, the mortality rates in patients with multiorgan failure and/or ACS decreased significantly when following the revised guidelines.
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Mortalidade , Dengue Grave/mortalidade , Dengue Grave/fisiopatologia , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/mortalidade , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Falência Hepática Aguda/epidemiologia , Falência Hepática Aguda/etiologia , Testes de Função Hepática , Masculino , Insuficiência de Múltiplos Órgãos/etiologia , Insuficiência de Múltiplos Órgãos/mortalidade , Síndrome do Desconforto Respiratório/epidemiologia , Síndrome do Desconforto Respiratório/mortalidade , Dengue Grave/complicações , Dengue Grave/diagnóstico , Choque/etiologia , Choque/mortalidadeRESUMO
Hemorrhage, a main cause of mortality in patients with trauma, affects vital signs such as blood pressure and heart rate. Shock index (SI), calculated as heart rate divided by systolic blood pressure, is widely used to estimate the shock status of patients with hemorrhage. The difference in SI between the emergency department and prehospital field can indirectly reflect urgency after trauma. We aimed to determine the association between delta SI (DSI) and in-hospital mortality in patients with torso or extremity trauma. Patients with DSI >0.1 are expected to be associated with high mortality. This retrospective, observational study used data from the Pan-Asian Trauma Outcomes Study. Patients aged 18-85 years with abdomen, chest, upper extremity, lower extremity, or external injury location were included. Patients from China, Indonesia, Japan, Philippines, Thailand, and Vietnam; those who were transferred from another facility; those who were transferred without the use of emergency medical service; those with prehospital cardiac arrest; those with unknown exposure and outcomes were excluded. The exposure and primary outcome were DSI and in-hospital mortality, respectively. The secondary and tertiary outcome was intensive care unit (ICU) admission and massive transfusion, respectively. Multivariate logistic regression analysis was performed to test the association between DSI and outcome. In total, 21,534 patients were enrolled according to the inclusion and exclusion criteria. There were 3,033 patients with DSI >0.1. The in-hospital mortality rate in the DSI >0.1 and ≤0.1 groups was 2.0% and 0.8%, respectively. In multivariate logistic regression analysis, the DSI ≤0.1 group was considered the reference group. The unadjusted and adjusted odds ratios of in-hospital mortality in the DSI >0.1 group were 2.54 (95% confidence interval [CI] 1.88-3.42) and 2.82 (95% CI 2.08-3.84), respectively. The urgency of traumatic hemorrhage can be determined using DSI, which can help hospital staff to provide proper trauma management, such as early trauma surgery or embolization.
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Serviço Hospitalar de Emergência/estatística & dados numéricos , Extremidades/patologia , Mortalidade Hospitalar/tendências , Doenças Musculoesqueléticas/complicações , Choque/mortalidade , Tronco/patologia , Ferimentos e Lesões/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , China , Estudos Transversais , Feminino , Seguimentos , Frequência Cardíaca , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Prognóstico , Curva ROC , Sistema de Registros , Estudos Retrospectivos , Choque/etiologia , Choque/patologia , Taxa de Sobrevida , Adulto JovemRESUMO
BACKGROUND: Pediatric trauma patients are treated at adult trauma centers (ATCs), mixed pediatric and ATCs (MTC), or pediatric trauma centers (PTCs). Shock index, pediatric age-adjusted (SIPA) can prospectively identify severely injured children. This study characterized the differences in mortality and hospital length of stay (LOS) among pediatric trauma patients with elevated SIPA (eSIPA) at different trauma centers types. METHODS: Pediatric patients (1-14 years) were queried from the 2013 to 2016 National Trauma Data Bank. Patients with eSIPA were included for analysis. The primary outcome was mortality. Secondary outcomes included rates of splenectomy, computed tomography chest scans, laparotomy, and hospital LOS. Unadjusted frequencies and multivariable regression analyses were performed. An alpha level of 0.01 was used to determine significance. RESULTS: Out of 189,003 pediatric trauma patients, 15,832 were included for analysis. After controlling for age, race, sex, payment method, Injury Severity Score, Glasgow Coma Scale score, hospital teaching status, and number of hospital beds, there was no significant difference in mortality among eSIPA patients at ATCs (odds ratio [OR], 0.753; p = 0.078) and MTCs (OR, 1.051; p = 0.776) when compared with PTCs. This remained true even among the most severely injured eSIPA patients (Injury Severity Score > 25). Splenectomy rates were higher at ATCs (OR, 3.234; p = 0.005), as were computed tomography chest scan rates (ATC OR, 4.423; p < 0.001; MTC OR, 6.070; p < 0.001) than at PTCs. There was a trend toward higher splenectomy rates at MTCs (OR, 2.910; p = 0.030) compared with PTCs, but this did not reach statistical significance. Laparotomy rates and hospital LOS were not significantly different. CONCLUSION: Among eSIPA pediatric trauma patients, there was no difference in mortality between trauma center types. However, other secondary findings indicate that specialty care at PTCs may help optimize the care of pediatric trauma patients. LEVEL OF EVIDENCE: Retrospective cohort study, level IV.
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Choque/diagnóstico , Centros de Traumatologia/estatística & dados numéricos , Ferimentos não Penetrantes/mortalidade , Adolescente , Fatores Etários , Criança , Pré-Escolar , Feminino , Mortalidade Hospitalar , Humanos , Lactente , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Masculino , Razão de Chances , Estudos Retrospectivos , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Choque/etiologia , Choque/mortalidade , Choque/terapia , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/terapiaRESUMO
BACKGROUND: The equivalent Injury Severity Score (ISS) cutoffs for severe trauma vary between adult (ISS, >16) and pediatric (ISS, >25) trauma. We hypothesized that a novel injury severity prediction model incorporating age and mechanism of injury would outperform standard ISS cutoffs. METHODS: The 2010 to 2016 National Trauma Data Bank was queried for pediatric trauma patients. Cut point analysis was used to determine the optimal ISS for predicting mortality for age and mechanism of injury. Linear discriminant analysis was implemented to determine prediction accuracy, based on area under the curve (AUC), of ISS cutoff of 25 (ISS, 25), shock index pediatric adjusted (SIPA), an age-adjusted ISS/abbreviated Trauma Composite Score (aTCS), and our novel Trauma Composite Score (TCS) in blunt trauma. The TCS consisted of significant variables (Abbreviated Injury Scale, Glasgow Coma Scale, sex, and SIPA) selected a priori for each age. RESULTS: There were 109,459 blunt trauma and 9,292 penetrating trauma patients studied. There was a significant difference in ISS (blunt trauma, 9.3 ± 8.0 vs. penetrating trauma, 8.0 ± 8.6; p < 0.01) and mortality (blunt trauma, 0.7% vs. penetrating trauma, 2.7%; p < 0.01). Analysis of the entire cohort revealed an optimal ISS cut point of 25 (AUC, 0.95; sensitivity, 0.86; specificity, 0.95); however, the optimal ISS ranged from 18 to 25 when evaluated by age and mechanism. Linear discriminant analysis model AUCs varied significantly for each injury metric when assessed for blunt trauma and penetrating trauma (penetrating trauma-adjusted ISS, 0.94 ± 0.02 vs. ISS 25, 0.88 ± 0.02 vs. SIPA, 0.62 ± 0.03; p < 0.001; blunt trauma-adjusted ISS, 0.96 ± 0.01 vs. ISS 25, 0.89 ± 0.02 vs. SIPA, 0.70 ± 0.02; p < 0.001). When injury metrics were assessed across age groups in blunt trauma, TCS and aTCS performed the best. CONCLUSION: Current use of ISS in pediatric trauma may not accurately reflect injury severity. The TCS and aTCS incorporate both age and mechanism and outperform standard metrics in mortality prediction in blunt trauma. LEVEL OF EVIDENCE: Retrospective review, level IV.
Assuntos
Escala de Gravidade do Ferimento , Choque/diagnóstico , Ferimentos não Penetrantes/mortalidade , Ferimentos Penetrantes/mortalidade , Adolescente , Fatores Etários , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Tempo de Internação/estatística & dados numéricos , Masculino , Curva ROC , Sistema de Registros/estatística & dados numéricos , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Choque/etiologia , Choque/mortalidade , Centros de Traumatologia/estatística & dados numéricos , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/diagnósticoRESUMO
BACKGROUND: Several trauma studies have shown that a "flat" inferior vena cava (IVC) is associated with poor clinical outcomes, including hypovolemic shock, major bleeding, transfusions and mortality. These studies utilize IVC measurements on computed tomography (CT) scans, and rarely include emergency general surgery patients. We examine the association between IVC flatness and clinical outcomes in a series of patients with perforated viscus. MATERIALS AND METHODS: Medical records at an academic hospital were reviewed of adults with perforated viscus. Patients who underwent laparotomy or laparoscopy were included if they underwent CT within 12 h prior to incision time. Perforated appendicitis was excluded. A ratio was calculated of the transverse to anterior-posterior diameter of the IVC at 3 locations, then averaged. Clinical outcomes were analyzed by the average IVC ratio. RESULTS: A total of 83 patients were included. Using binomial regression, the average IVC ratio significantly correlated with ICU admission (OR 3.6, 95% CI 1.2 to 11) and acute kidney injury (OR 2.3, 95% CI 1.0 to 5.3), but not postoperative shock (OR 1.2, 95% CI 0.56 to 2.6). CONCLUSIONS: A flat IVC on CT prior to an operation for perforated viscus was associated with worse outcomes, including increased rate of ICU admission and acute kidney injury. More outcomes research is needed to assess the potential role of IVC assessment in preoperative resuscitation.
Assuntos
Perfuração Intestinal/cirurgia , Laparoscopia/estatística & dados numéricos , Ressuscitação/estatística & dados numéricos , Choque/cirurgia , Veia Cava Inferior/diagnóstico por imagem , Adulto , Idoso , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/métodos , Tratamento de Emergência/estatística & dados numéricos , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Perfuração Intestinal/complicações , Perfuração Intestinal/diagnóstico , Perfuração Intestinal/mortalidade , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Ressuscitação/métodos , Estudos Retrospectivos , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Choque/diagnóstico , Choque/etiologia , Choque/mortalidade , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: Primary infected aneurysms of the abdominal aorta and iliac arteries are potentially life-threatening. However, because of the rarity of the disease, its pathogenesis and optimal treatment strategy remain poorly defined. METHODS: A nationwide retrospective cohort study investigated patients who underwent surgical treatment for a primary infected abdominal aortic and/or common iliac artery (CIA) aneurysm between 2011 and 2017 using a Japanese clinical registry. The study evaluated the relationships between preoperative factors and postoperative outcomes including 90-day and 3-year mortality, and persistent or recurrent aneurysm-related infection. Propensity score matching was used to compare survival between patients who underwent in situ prosthetic grafting and those who had endovascular aneurysm repair (EVAR). RESULTS: Some 862 patients were included in the analysis. Preceding infection was identified in 30.2 per cent of the patients. The median duration of postoperative follow-up was 639 days. Cumulative overall survival rates at 30 days, 90 days, 1 year, 3 years and 5 years were 94.0, 89.7, 82.6, 74.9 and 68.5 per cent respectively. Age, preoperative shock and hypoalbuminaemia were independently associated with short-term and late mortality. Compared with open repair, EVAR was more closely associated with persistent or recurrent aneurysm-related infection (odds ratio 2.76, 95 per cent c.i. 1.67 to 4.58; P < 0.001). Propensity score-matched analyses demonstrated no significant differences between EVAR and in situ graft replacement in terms of 3-year all-cause and aorta-related mortality rates (P = 0.093 and P =0.472 respectively). CONCLUSION: In patients undergoing surgical intervention for primary infected abdominal aortic and CIA aneursyms, postoperative survival rates were encouraging. Eradication of infection following EVAR appeared less likely than with open repair, but survival rates were similar in matched patients between EVAR and in situ graft replacement.
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Aneurisma Infectado/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma Ilíaco/cirurgia , Fatores Etários , Idoso , Aneurisma Infectado/mortalidade , Aneurisma da Aorta Abdominal/mortalidade , Prótese Vascular , Estudos de Coortes , Procedimentos Endovasculares , Feminino , Seguimentos , Humanos , Hipoalbuminemia/mortalidade , Aneurisma Ilíaco/mortalidade , Japão/epidemiologia , Masculino , Análise por Pareamento , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Choque/mortalidadeRESUMO
INTRODUCTION: Pediatric adjusted shock index (SIPA) has demonstrated the ability to prospectively identify children at the highest risk for early mortality. The addition of neurological status to shock index has shown promise as a reliable triage tool in adult trauma populations. This study sought to assess the utility of combining SIPA with Glasgow Coma Scale (GCS) for predicting early trauma-related outcomes. METHODS: Retrospective review of the 2017 Trauma Quality Improvement Program Database was performed for all severely injured patients younger than 18 years old. Pediatric adjusted shock index and reverse SIPA × GCS (rSIG) were calculated. Age-specific cutoff values were derived for reverse shock index multiplied by GCS (rSIG) and compared with their SIPA counterparts for early mortality assessment using area under the receiver operating characteristic curve analyses. RESULTS: A total of 10,389 pediatric patients with an average age of 11.4 years, 67% male, average Injury Severity Score of 24.1, and 4% sustaining a major penetrating injury were included in the analysis. The overall mortality was 9.3%. Furthermore, 32.1% of patients displayed an elevated SIPA score, while only 27.5% displayed a positive rSIG. On area under the receiver operating characteristic curve analysis, rSIG was found to be superior to SIPA as a predictor for in hospital mortality with values of 0.854 versus 0.628, respectively. CONCLUSION: Reverse shock index multiplied by GCS more readily predicted in hospital mortality for pediatric trauma patients when compared with SIPA. These findings suggest that neurological status should be an important factor during initial patient assessment. Further study to assess the applicability of rSIG for expanded trauma-related outcomes in pediatric trauma is necessary. LEVEL OF EVIDENCE: Prognostic study, level IV.
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Choque/diagnóstico , Ferimentos e Lesões/mortalidade , Adolescente , Criança , Pré-Escolar , Estudos de Viabilidade , Feminino , Escala de Coma de Glasgow , Mortalidade Hospitalar , Humanos , Lactente , Recém-Nascido , Escala de Gravidade do Ferimento , Masculino , Prognóstico , Melhoria de Qualidade/estatística & dados numéricos , Curva ROC , Valores de Referência , Estudos Retrospectivos , Choque/etiologia , Choque/mortalidade , Washington/epidemiologia , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnósticoRESUMO
The emerging role of BRAF and MEK tyrosine-kinase inhibitors has shown new opportunities of treatment for patients with advanced melanoma and BRAF mutations. Its use is associated with some toxicities, as pyrexia, that clinicians may not be familiarized with. We present the case of a patient diagnosed with stage IV melanoma BRAF Val600E mutated who was started on dabrafenib and trametinib and developed three severe episodes of fever, hypotension and acute phase reactants elevation during the first 3 months of therapy, in the absence of microbiological demonstration of infection. The episodes were initially managed as a septic shock with broad-spectrum antibiotics and vasoactive drugs, while treatment with dabrafenib and trametinib was withheld. After two subsequent dose reduction of dabrafenib, the patient did not experience new episodes of fever.
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Proteínas de Fase Aguda/metabolismo , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Imidazóis/efeitos adversos , Oximas/efeitos adversos , Piridonas/efeitos adversos , Pirimidinonas/efeitos adversos , Choque/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Choque/mortalidade , Análise de SobrevidaRESUMO
Introducción: los cristaloides son medicamentos usados en pacientes críticamente enfermos, con resultados ambiguos cuando se utilizan soluciones balanceadas versus solución salina normal. Objetivo: conocer si existen diferencias al usar solución salina 0.9% vs. lactato de Ringer en pacientes críticamente enfermos con sepsis y choque séptico o hipovolémico, en cuanto a mortalidad, lesión renal aguda y tiempo de estancia hospitalaria. Métodos: estudio observacional de tipo cohorte retrospectiva en mayores de 18 años con diagnóstico de sepsis, choque séptico o hipovolémico. Se excluyeron aquellos con enfermedad renal crónica en diálisis, las hospitalizadas por ginecología/obstetricia y aquellos con diagnóstico de muerte encefálica o donantes de órganos. Se evaluaron los desenlaces primarios de mortalidad, lesión renal aguda y estancia hospitalaria. Resultados y discusión: se incluyeron 314 pacientes, 158 en el grupo expuesto a solución salina al 0.9% y 156 con lactato de Ringer. Se presentó lesión renal aguda en 22.7% con solución salina y 25.8% con lactato de Ringer (OR 1.18 IC 95%:0.7-2). La mortalidad con solución salina fue de 49%, y en lactato 49% (OR 1.01 IC 95%:0.63-1.63). Los factores de riesgo identificados para mortalidad fueron uso de soporte vasopresor (OR 35 IC 95% 12-83) y lesión renal aguda (1.3 IC 95% 1.01-1.69). Conclusiones: en el paciente críticamente enfermo con sepsis, choque séptico o hipovolémico el uso desolución salina 0.9% no representa diferencias al compararlo con lactato de Ringer en cuanto a mortalidad, lesión renal aguda o estancia hospitalaria. La elección de un cristaloide debe ser individualizada, teniendo en cuenta las comorbilidades, la presencia de hipercloremia o hiperpotasemia.
Objective: crystalloids are drugs used in critically ill patients, with ambiguous results when balanced solutions versus normal saline solution (NS) are used. The objective of this study is to determine if there are differences when NS (0.9%) vs. lactated Ringer Ìs (LR) solution are given to critically ill patients in sepsis or septic or hypovolemic shock, in terms of mortality, acute renal injury and length of hospital stay. Methods: a retrospective observational cohort study in patients over 18 years old with sepsis or septic or hypovolemic shock. Patients with chronic renal disease on dialysis, those hospitalized by gynecology/obstetrics and those diagnosed with brain death or organ donors were excluded. The primary mortality outcomes, acute renal injury and hospital stay were evaluated. Results: 314 patients were included, 158 in the NS group and 156 in the LR group. Acute renal injury occurred in 22.7% in the NS group and 25.8% in the LR group (OR 1.18 IC 95%:0.7-2). Mortality rate was 49% in the NS group and 49% in the LR group (OR 1.01 95%: CI 0.63-1.63). Mortality risk factors included the use of vasopressor support (OR 35 95% CI 12-83) and acute renal injury (1.3 95% CI 1.01-1.69). Conclusions: no difference was found with the use of NS in critically ill patients with sepsis or septic or hypovolemic shock when compared with LR in terms of mortality, acute renal injury or hospital stay. The choice of which crystalloid to administer should be individualized, based on the comorbidities and the presence of hyperchloremia or hyperkalemia.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Choque/terapia , Sepse/terapia , Lactato de Ringer/uso terapêutico , Solução Salina/uso terapêutico , Choque/mortalidade , Choque Séptico/mortalidade , Choque Séptico/terapia , Análise Multivariada , Estudos Retrospectivos , Resultado do Tratamento , Sepse/mortalidade , Injúria Renal Aguda/induzido quimicamente , Lactato de Ringer/efeitos adversos , Solução Salina/efeitos adversos , Tempo de InternaçãoRESUMO
BACKGROUND: Base Deficit (BD) and lactate have been used as indicators of shock and resuscitation. This study was done to evaluate the utility of BD and lactate in identifying shock and resuscitative needs in trauma patients. METHODS: A prospective observational study was performed from 3/2014-12/2018. Data included demographics, admission systolic BP, ISS, BD, lactate, blood transfusion, and outcomes. BD and lactate were modeled continuously and categorically and compared. RESULTS: 2271 patients were included. BD and lactate were moderately correlated (r2 = 0.63 p < 0.001). On univariate regression, BD and lactate were associated with transfusion requirement and mortality (p < 0.001), but on multivariate regression, only BD was associated with transfusion requirement and mortality (OR = 1.2, p < 0.001; OR = 1.1, p < 0.001, respectively). BD discriminated better than lactate for hypotension, higher ISS, increased transfusion requirements and mortality. CONCLUSIONS: Admission BD and lactate levels are correlated following injury, but BD is superior to lactate in identifying shock, resuscitative needs and mortality in severely injured trauma patients.
Assuntos
Desequilíbrio Ácido-Base/sangue , Ácido Láctico/sangue , Ressuscitação , Choque/sangue , Choque/terapia , Ferimentos e Lesões/sangue , Ferimentos e Lesões/terapia , Biomarcadores/sangue , Transfusão de Sangue , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Estudos Prospectivos , Choque/mortalidade , Índices de Gravidade do Trauma , Ferimentos e Lesões/mortalidadeRESUMO
Deciding between palliative and overly aggressive therapies for advanced cancer patients who present to the emergency department (ED) with acute issues requires a prediction of their short-term survival. Various scoring systems have previously been studied in hospices or intensive care units, though they are unsuitable for use in the ED. We aim to examine the use of a shock index (SI) in predicting the 60-day survival of advanced cancer patients presenting to the ED. Identified high-risk patients and their families can then be counseled accordingly. Three hundred and five advanced cancer patients who presented to the EDs of three tertiary hospitals were recruited, and their data retrospectively analyzed. Relevant data regarding medical history and clinical presentation were extracted, and respective shock indices calculated. Multivariate logistic regression analyses were performed. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive performance of the SI. Nonsurvivors within 60 days had significantly lower body temperatures and blood pressure, as well as higher pulse rates, respiratory rates, and SI. Each 0.1 SI increment had an odds ratio of 1.39 with respect to 60-day mortality. The area under the ROC curve was 0.7511. At the optimal cut-off point of 0.94, the SI had 81.38% sensitivity and 73.11% accuracy. This makes the SI an ideal evaluation tool for rapidly predicting the 60-day mortality risk of advanced cancer patients presenting to the ED. Identified patients can be counseled accordingly, and they can be assisted in making informed decisions on the appropriate treatment goals reflective of their prognoses.
Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Mortalidade Hospitalar , Neoplasias Nasofaríngeas/mortalidade , Neoplasias Nasofaríngeas/patologia , Choque/mortalidade , Humanos , Masculino , Curva ROC , Estudos Retrospectivos , Índice de Gravidade de Doença , Choque/fisiopatologia , Fatores de TempoRESUMO
BACKGROUND: Hepatic portal venous gas (HPVG) generally indicates poor prognoses in patients with serious intestinal damage. Although surgical removal of the damaged portion is effective, some patients can recover with conservative treatments. AIM: To establish an optimal treatment strategy for HPVG, we attempted to generate computed tomography (CT)-based criteria for determining surgical indication, and explored reliable prognostic factors in non-surgical cases. METHODS: Thirty-four cases of HPVG (patients aged 34-99 years) were included. Necessity for surgery had been determined mainly by CT findings (i.e. free-air, embolism, lack of contrast enhancement of the intestinal wall, and intestinal pneumatosis). The clinical data, including treatment outcomes, were analyzed separately for the surgical cases and non-surgical cases. RESULTS: Laparotomy was performed in eight cases (surgical cases). Seven patients (87.5%) survived but one (12.5%) died. In each case, severe intestinal damage was confirmed during surgery, and the necrotic portion, if present, was removed. Non-occlusive mesenteric ischemia was the most common cause (n = 4). Twenty-six cases were treated conservatively (non-surgical cases). Surgical treatments had been required for twelve but were abandoned because of the patients' poor general conditions. Surprisingly, however, three (25%) of the twelve inoperable patients survived. The remaining 14 of the 26 cases were diagnosed originally as being sufficiently cured by conservative treatments, and only one patient (7%) died. Comparative analyses of the fatal (n = 10) and recovery (n = 16) cases revealed that ascites, peritoneal irritation signs, and shock were significantly more frequent in the fatal cases. The mortality was 90% if two or all of these three clinical findings were detected. CONCLUSION: HPVG related to intestinal necrosis requires surgery, and our CT-based criteria are probably useful to determine the surgical indication. In non-surgical cases, ascites, peritoneal irritation signs and shock were closely associated with poor prognoses, and are applicable as predictors of patients' prognoses.
Assuntos
Ascite/terapia , Embolia Aérea/terapia , Isquemia Mesentérica/terapia , Pneumatose Cistoide Intestinal/terapia , Veia Porta/cirurgia , Choque/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Ascite/diagnóstico , Ascite/etiologia , Ascite/mortalidade , Tratamento Conservador/estatística & dados numéricos , Embolia Aérea/diagnóstico , Embolia Aérea/etiologia , Embolia Aérea/mortalidade , Feminino , Gases , Humanos , Mucosa Intestinal/diagnóstico por imagem , Mucosa Intestinal/patologia , Mucosa Intestinal/cirurgia , Masculino , Isquemia Mesentérica/complicações , Isquemia Mesentérica/diagnóstico , Isquemia Mesentérica/mortalidade , Necrose/complicações , Necrose/diagnóstico , Necrose/mortalidade , Necrose/cirurgia , Pneumatose Cistoide Intestinal/diagnóstico , Pneumatose Cistoide Intestinal/etiologia , Pneumatose Cistoide Intestinal/mortalidade , Veia Porta/diagnóstico por imagem , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Choque/diagnóstico , Choque/etiologia , Choque/mortalidade , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
Injury severity scores (ISS) and shock index (SI) are popular trauma scoring systems. We assessed ISS and SI in combat trauma to determine the optimal cut-off values for mortality and trauma outcomes. Retrospective analysis of the Department of Defense Trauma Registry, 2008-2016, was performed. Areas under receiver operating characteristic curves (AUROCs) were calculated for ISS and SI on mortality, massive volume transfusion (MVT), and emergent surgical procedure (ESP). Optimal cut-off values were defined using the Youden index (YI). 22,218 patients (97.1% male), median ages 25-29 years, ISS 9.4 ± 0.07, with 58.1% penetrating injury were studied. Overall mortality was 3.4%. AUROCs for ISS on mortality, MVT, and ESP were 0.882, 0.898, and 0.846, while AUROCs for SI were 0.727, 0.864, and 0.711 respectively. The optimal cut-off values for ISS on mortality, MVT, and ESP were 12.5 (YI = 0.634), 12.5 (YI = 0.666), and 12.5 (YI = 0.819), with optimal values for SI being 0.94 (YI = 0.402), 0.88 (YI = 0.608), and 0.81 (YI = 0.345) respectively. Classic values for severe ISS underrepresent combat injury while the SI values defined in this study are consistent with civilian data.
Assuntos
Escala de Gravidade do Ferimento , Choque/classificação , Guerra , Ferimentos e Lesões/classificação , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Choque/mortalidade , Ferimentos e Lesões/mortalidadeRESUMO
BACKGROUND: Hemorrhage control for pelvic fractures remains challenging. There are several kinds of hemostatic interventions, including angiography/angioembolization (AG/AE), external fixation (EF), and resuscitative endovascular balloon occlusion of the aorta (REBOA). However, no large studies have been conducted for the comparative review of each intervention. In this study, we examined the usage trend of therapeutic interventions in Japan for patients with pelvic fractures in shock and the influence of these interventions on mortality. METHODS: Data of adult patients with pelvic fracture who were in shock were obtained from the Japanese Trauma Data Bank (2004-2014). The primary endpoint was the influence of each intervention (AG/AE, EF, and REBOA) on in-hospital mortality. We also investigated the frequency of each intervention. RESULTS: A total of 3149 patients met all our inclusion criteria. Specifically, 1131 (35.9%), 496 (15.8%), and 256 (8.1%) patients underwent AG, EF, and REBOA interventions, respectively. Therapeutic AE was performed in 690 patients who underwent AG (61.0%). The overall mortality rate was 31.4%. Multiple regression analysis identified that AG/AE (OR 0.64, 95% CI 0.52-0.80) and EF (OR 0.75, 95% CI 0.58-0.98) were significantly associated with survival, whereas REBOA (OR 4.17, 95% CI 3.00-5.82) was significantly associated with worse outcomes. CONCLUSIONS: In Japan, patients with pelvic fracture who were in shock had high mortality rates. AG/AE and EF were associated with decreased mortality. AG may benefit from the early detection of arterial bleeding, leading to decreased mortality of patients with pelvic fracture in shock.
Assuntos
Fraturas Ósseas/complicações , Hemorragia/terapia , Ossos Pélvicos/lesões , Choque/terapia , Adulto , Idoso , Oclusão com Balão , Embolização Terapêutica , Feminino , Fraturas Ósseas/mortalidade , Fraturas Ósseas/terapia , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Choque/mortalidadeAssuntos
Seleção do Doador , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Choque/mortalidade , Doadores de Tecidos/provisão & distribuição , Listas de Espera , Adulto , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Transplante de Coração/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Listas de Espera/mortalidadeRESUMO
BACKGROUND: Damage control laparotomy has increased survival for critically injured patient with penetrating abdominal trauma. There has been a slower adoption of a damage control strategy for thoracic trauma despite the considerable mortality associated with emergent thoracotomy for patients in profound shock. We postulated admission physiology, not blood pressure or shock index, would identify patients who would benefit from thoracic damage control. STUDY DESIGN: Retrospective trauma registry review from 2002 to 2017 at a busy, urban trauma center. Three hundred one patients with penetrating thoracic trauma operated on within 6âh of admission were identified. Of those 66 (21.9%) required thoracic damage control and comprise the study population. RESULTS: Compared with the non-damage control group, the 66 damage control patients had significantly higher Injury Severity Score, chest Abbreviated Injury Scale, lactate and base deficit, and lower pH and temperature. In addition, the damage control thoracic surgery group had significantly more gunshot wounds, transfusions, concomitant laparotomies, vasoactive infusions, and shorter time to the operating room. Notably, however, there were no significant differences in admission systolic blood pressure or shock index between the groups. Once normal physiology was restored, chest closure was performed 1.7 (0.7) days after the index operation. Mortality for thoracic damage was 15.2%, significantly higher than the 4.3% in the non-damage control group. Over two-thirds of damage control deaths occurred prior to chest closure. CONCLUSIONS: Mortality in this series of severely injured, profoundly physiologically altered patients undergoing thoracic damage control is substantially lower than previously reported. Rather than relying on blood pressure and shock index, early recognition of shock identifies patients in whom thoracic damage control is beneficial.