Limitation of life support techniques at admission to the intensive care unit: a multicenter prospective cohort study.

PURPOSE: To determine the frequency of limitations on life support techniques (LLSTs) on admission to intensive care units (ICU), factors associated, and 30-day survival in patients with LLST on ICU admission. METHODS: This prospective observational study included all patients admitted to 39 ICUs in a 45-day period in 2011. We recorded hospitals' characteristics (availability of intermediate care units, usual availability of ICU beds, and financial model) and patients' characteristics (demographics, reason for admission, functional status, risk of death, and LLST on ICU admission (withholding/withdrawing; specific techniques affected)). The primary outcome was 30-day survival for patients with LLST on ICU admission. Statistical analysis included multilevel logistic regression models. RESULTS: We recruited 3042 patients (age 62.5 ± 16.1 years). Most ICUs (94.8%) admitted patients with LLST, but only 238 (7.8% [95% CI 7.0-8.8]) patients had LLST on ICU admission; this group had higher ICU mortality (44.5 vs. 9.4% in patients without LLST; p < 0.001). Multilevel logistic regression showed a contextual effect of the hospital in LLST on ICU admission (median OR = 2.30 [95% CI 1.59-2.96]) and identified the following patient-related variables as independent factors associated with LLST on ICU admission: age, reason for admission, risk of death, and functional status. In patients with LLST on ICU admission, 30-day survival was 38% (95% CI 31.7-44.5). Factors associated with survival were age, reason for admission, risk of death, and number of reasons for LLST on ICU admission. CONCLUSIONS: The frequency of ICU admission with LLST is low but probably increasing; nearly one third of these patients survive for ≥ 30 days.

[Missed injuries in patients with multiple trauma: analysis of a trauma registry]. / Lesiones inadvertidas en el politraumatizado: análisis de un registro de trauma.

INTRODUCTION: The frequency of missed injuries (MI) in patients with trauma oscillates between 0.5 and 38%, depending on the distinct studies and their inclusion criteria. In the present study, we evaluated the incidence, contributory factors and clinical relevance of these lesions, based on the Severe Trauma Registry of our center. PATIENTS AND METHODS: We retrospectively analyzed a registry of 912 cases of severe trauma, which were prospectively gathered. Of these, 19 patients had a MI (2%). Demographic (age and sex) and clinical variables (severity scales and mechanism of injury) were compared and avoidable contributory factors and clinically relevant MI were evaluated. RESULTS: Of the 19 patients with a MI, 58% had closed injuries. No statistically significant differences were found in any of the variables studied, although penetrating injuries were clearly more frequent in patients with MI than in those without. Forty-seven percent of MI were musculoskeletal, 26% were visceral and 21% were vascular. Sixty-three percent of contributory factors were potentially avoidable and the most frequent reason for MI was incorrect clinical evaluation. Mortality due to lesions with a delayed diagnosis was 21%. CONCLUSIONS: Incorrect clinical evaluation was the avoidable factor that would have the greatest impact on reducing the number of MI. Another factor that clearly contributes to reduction of MI is appropriate interpretation of radiological images in the context of a tertiary survey. All teams treating these patients should periodically evaluate their results and intervene in the factors contributing to missed diagnoses.

Lesiones inadvertidas en el politraumatizado: análisis de un registro de trauma / Missed injuries in patients with multiple trauma: analysis of a trauma registry

Introducción. La frecuencia de lesiones inadvertidas en pacientes con traumatismos oscila entre el 0,5 y el 38%, según los diferentes estudios y sus criterios de inclusión. En nuestro trabajo hemos evaluado la incidencia, los factores contribuyentes y la relevancia clínica de estas lesiones a partir del Registro de Trauma grave de nuestro centro. Pacientes y métodos. Se analiza de manera retrospectiva un registro de 912 traumatizados graves, recogidos de forma prospectiva. De éstos, 19 pacientes presentaron una lesión inadvertida (2%). Se comparan variables demográficas (edad y sexo) y clínicas (escalas de gravedad y mecanismo lesivo), y se evalúan los factores contribuyentes evitables, así como las lesiones inadvertidas clínicamente relevantes. Resultados. De los 19 pacientes con lesiones inadvertidas, el 58% sufrió traumatismos cerrados. En ninguna de las variables estudiadas se encontró diferencia estadística, aunque las lesiones penetrantes fueron claramente más frecuentes en los pacientes con lesiones inadvertidas que en el grupo sin ellas. El 47% fueron osteoarticulares, el 26% viscerales y el 21% vasculares. Las lesiones potencialmente evitables fueron el 63%, y el motivo más frecuente fue una incorrecta evaluación clínica. La mortalidad por lesiones diagnosticadas de manera tardía alcanzó el 21%. Conclusiones. Una incorrecta evaluación clínica es el factor evitable que más impacto tiene a la hora de disminuir el número de lesiones inadvertidas. Otro factor que claramente contribuye a la reducción es la adecuada interpretación de las imágenes radiológicas, en el contexto de una revisión terciaria. Todos los equipos que tratan a estos pacientes deberían conocer sus resultados e incidir en las fases diagnósticas donde reside el error (AU)

Introduction. The frequency of missed injuries (MI) in patients with trauma oscillates between 0.5 and 38%, depending on the distinct studies and their inclusion criteria. In the present study, we evaluated the incidence, contributory factors and clinical relevance of these lesions, based on the Severe Trauma Registry of our center. Patients and methods. We retrospectively analyzed a registry of 912 cases of severe trauma, which were prospectively gathered. Of these, 19 patients had a MI (2%). Demographic (age and sex) and clinical variables (severity scales and mechanism of injury) were compared and avoidable contributory factors and clinically relevant MI were evaluated. Results. Of the 19 patients with a MI, 58% had closed injuries. No statistically significant differences were found in any of the variables studied, although penetrating injuries were clearly more frequent in patients with MI than in those without. Forty-seven percent of MI were musculoskeletal, 26% were visceral and 21% were vascular. Sixty-three percent of contributory factors were potentially avoidable and the most frequent reason for MI was incorrect clinical evaluation. Mortality due to lesions with a delayed diagnosis was 21%.Conclusions. Incorrect clinical evaluation was the avoidable factor that would have the greatest impact on reducing the number of MI. Another factor that clearly contributes to reduction of MI is appropriate interpretation of radiological images in the context of a tertiary survey. All teams treating these patients should periodically evaluate their results and intervene in the factors contributing to missed diagnoses (AU)