RESUMO
Acquired hemophilia A in postoperative patients can cause major bleeding and an accurate diagnosis is required for effective treatment. Standard treatment is costly, difficult to obtain, and takes 4 to 6 weeks to be effective. This article describes a patient successfully treated with recombinant factor VIIa, porcine factor VIII, plasmapheresis, rituximab, and high-dose corticosteroids.
Assuntos
Hemofilia A/diagnóstico , Hemofilia A/etiologia , Hemorragia Pós-Operatória/tratamento farmacológico , Hemorragia Pós-Operatória/etiologia , Corticosteroides/administração & dosagem , Animais , Fator VIII/administração & dosagem , Fator VIIa/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Plasmaferese , Proteínas Recombinantes/administração & dosagem , Rituximab/administração & dosagem , Suínos , Resultado do TratamentoRESUMO
BACKGROUND: Thyroid cancer has an overall favorable prognosis, but no pre-operative biochemical marker has been shown to distinguish between low and high-risk disease or predict response to therapy. METHODS: We retrospectively reviewed 162 patients that underwent thyroid surgery for thyroid cancer between 2006 and 2022 in whom a pre-operative thyroglobulin level (Tg) was measured. We subdivided patients into low, intermediate and high-risk thyroid cancer and based on their response to therapy per ATA guidelines. RESULTS: We showed that as pre-operative Tg level increased, patients were more likely to have high-risk disease (p â< â0.01). We found a linear association between the primary tumor size and high-risk histology with pre-operative Tg (p â< â0.01). Pre-operative Tg level was significantly associated with response to therapy following initial surgical management. Specifically, as pre-operative Tg increases, patients were less likely to achieve an excellent response (p â< â0.01). CONCLUSIONS: Our retrospective analysis demonstrated that pre-operative Tg is significantly associated with ATA structural risk of recurrence and response to therapy and may have the potential to guide initial therapy and follow-up management.
RESUMO
Background: Parathyroidectomy remains the only definitive cure for primary hyperparathyroidism (PHPT). In rare cases, ectopic hyperfunctioning glands are located in the mediastinum, necessitating a thoracic surgical approach. The objective of this project was to review a single high-volume institutional experience of this presentation, with specific attention to the use of a robotic-assisted thoracic surgery (RATS) approach. Methods: This was a single-center, 5-year retrospective cohort study. All patients who underwent RATS mediastinal mass resection (MMR) for PHPT at the University of Colorado Anschutz Medical Campus were targeted for inclusion. Patient cases were reviewed for demographics, history, operative data, laboratory values, and postoperative course. Results: Eight patients underwent RATS-MMR for PHPT between 2018-2023. Median [interquartile range] operative time was 178 [138-213] minutes, and length of stay was 2.0 [1.5-2.0] days. One patient experienced post-operative chylothorax requiring dietary modification. There were no other 30-day complications or readmissions. Final pathology confirmed intrathymic parathyroid tissue in all patients. All patients achieved cure of PHPT. Conclusions: The robotic-assisted approach has low morbidity and associated hospital length of stay and can be safely used to cure PHPT. As this is a rare pathology with an infrequently utilized surgical approach, it is important to critically discuss the diagnostic evaluation and operative course, aimed at educating the thoracic surgeon who may encounter and assist in the management of these patients.
RESUMO
INTRODUCTION: Patients with small volume intracranial hemorrhage (ICH) are categorized as modified Brain Injury Guidelines (mBIG) 1 and are managed with a 6-h emergency department (ED) observation period. The current study aimed to describe the mBIG 1 patient population and determine the utility of the ED observation period. METHODS: A retrospective analysis was performed on trauma patients with small volume ICH. Exclusion criteria were Glasgow Coma Scale (GCS) < 13 and penetrating injuries. RESULTS: 359 patients were identified over the 8-year study period. The most common ICH was SDH (52.7%) followed by SAH (50.1%). Two patients (0.56%) had neurologic deterioration, but neither had radiographic progression. Overall, 14.3% of the cohort had radiographic progression; none required neurosurgical intervention. Four patients (1.1%) had readmission related to TBI from the index admission. CONCLUSION: There were no patients with small volume ICH that required neurosurgical intervention despite a small subset of patients having radiographic or clinical deterioration. Patients who meet the mBIG 1 criteria may be managed safely without an ED observation period.
Assuntos
Lesões Encefálicas , Humanos , Estudos Retrospectivos , Serviço Hospitalar de Emergência , Hospitalização , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/cirurgia , Escala de Coma de GlasgowRESUMO
BACKGROUND: During the pandemic, hospitals implemented disaster plans to conserve resources while maintaining patient care. It was unclear how these plans impacted injury care and trauma surgeons. STUDY DESIGN: A 16 question survey assessing COVID-related hospital policy and resource allocation pre-COVID-19 peak (March), and a 19 question post-peak (June) survey was distributed to Trauma/Critical Care attending's via social media and the Western Trauma Association member email list. RESULTS: There were 120 pre- and 134 post-peak respondents. Most (95%) altered trauma PPE components, a nd 67% noted changes in their admission population pre-peak while 80% did so post-peak. Penetrating injury increased 56% at Level 1 centers and 27% at Level 2 centers. Altered ICU and transfusion criteria were noted with 25% relocating TBI patients, 17% revised rib fracture admission criteria, and 23% adjusted transfusion practices. Importantly, 12% changed their massive transfusion protocol, with 11% reducing the symptomatic transfusion threshold from 7 g/dL to 6 g/dL. Half (50%) disclosed impediments to patient care including PPE shortages and COVID test-related procedural delay (Fig. 2). While only 14% felt their institution was overwhelmed by COVID, the vast majority (81%) shared durable concerns about personal health and safety. CONCLUSIONS: Disparate approaches to COVID-19 preparedness and response characterize survey respondent facility actions. These disparities, especially between Level 1 and Level 2 centers, represent opportunities for the trauma community to coordinate best-practice planning and implementation in light of future consequence infection or pandemic care.
Assuntos
COVID-19 , COVID-19/epidemiologia , Hospitais , Humanos , Pandemias , Alocação de Recursos , SARS-CoV-2 , Centros de TraumatologiaRESUMO
INTRODUCTION: Neighborhood measures of social vulnerability encompassing multiple sociodemographic factors can be used to quantify disparities in outcomes. We hypothesize patients with high Social Vulnerability Index (SVI) are at increased risk of morbidity following colectomy. METHODS: We used local 2012-2017 National Surgical Quality Improvement Program (NSQIP) data to study colectomy patients, examining associations between SVI and postoperative outcomes. RESULTS: We included 976 patients from five hospitals. High SVI (>75th percentile) was associated with increased postoperative morbidity on unadjusted analysis (OR 1.84, 95% CI 1.35-2.52, p < 0.001); this association persisted after adjusting for demographics and comorbidities (OR 1.63, 95% CI 1.15-2.31, p = 0.005). The association with SVI was not significant after adjusting for perioperative risk modifiers such as emergent presentation (OR 1.37, 95% CI 0.95-1.98, p = 0.10). CONCLUSIONS: High social vulnerability is associated with increased postoperative complications. This effect appears mediated by perioperative risk factors, suggesting potential to improve outcomes by facilitating timely surgical intervention.
Assuntos
Cirurgia Colorretal , Colectomia/efeitos adversos , Humanos , Morbidade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Vulnerabilidade SocialRESUMO
BACKGROUND: Military data demonstrating an improved survival rate with whole blood (WB) have led to a shift toward the use of WB in civilian trauma. The purpose of this study is to compare a low-titer group O WB (LTOWB) massive transfusion protocol (MTP) to conventional blood component therapy (BCT) MTP in civilian trauma patients. METHODS: Trauma patients 15 years or older who had MTP activations from February 2019 to December 2020 were included. Patients with a LTOWB MTP activation were compared to BCT MTP patients from a historic cohort. RESULTS: 299 patients were identified, 169 received LTOWB and 130 received BCT. There were no differences in age, gender, or injury type. The Injury Severity Score was higher in the BCT group (27 vs 25, P = .006). The LTOWB group had a longer transport time (33 min vs 26 min, P < .001) and a lower arrival temperature (35.8 vs 36.1, P < .001). Other hemodynamic parameters were similar between the groups. The LTOWB group had a lower in-hospital mortality rate compared to the BCT group (19.5% vs 30.0%, P = .035). There were no differences in total transfusion volumes at 4 hours and 24 hours. No differences were seen in transfusion reactions or hospital complications. Multivariable logistic regression identified ISS, age, and 24-hour transfusion volume as predictors of mortality. DISCUSSION: Resuscitating severely injured trauma patient with LTOWB is safe and may be associated with an improved survival.
Assuntos
Reação Transfusional , Ferimentos e Lesões , Adulto , Transfusão de Componentes Sanguíneos , Transfusão de Sangue/métodos , Humanos , Escala de Gravidade do Ferimento , Ressuscitação/métodos , Estudos Retrospectivos , Reação Transfusional/etiologia , Ferimentos e Lesões/etiologia , Ferimentos e Lesões/terapia , Adulto JovemRESUMO
IMPORTANCE: Despite limited capacity and expensive cost, there are minimal objective data to guide postoperative allocation of intensive care unit (ICU) beds. The Surgical Risk Preoperative Assessment System (SURPAS) uses 8 preoperative variables to predict many common postoperative complications, but it has not yet been evaluated in predicting postoperative ICU admission. OBJECTIVE: To determine if the SURPAS model could accurately predict postoperative ICU admission in a broad surgical population. DESIGN, SETTING, AND PARTICIPANTS: This decision analytical model was a retrospective, observational analysis of prospectively collected patient data from the 2012 to 2018 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, which were merged with individual patients' electronic health record data to capture postoperative ICU use. Multivariable logistic regression modeling was used to determine how the 8 preoperative variables of the SURPAS model predicted ICU use compared with a model inputting all 28 preoperatively available NSQIP variables. Data included in the analysis were collected for the ACS NSQIP at 5 hospitals (1 tertiary academic center, 4 academic affiliated hospitals) within the University of Colorado Health System between January 1, 2012, and December 31, 2018. Included patients were those undergoing surgery in 9 surgical specialties during the 2012 to 2018 period. Data were analyzed from May 29 to July 30, 2021. EXPOSURE: Surgery in 9 surgical specialties, including general, gynecology, orthopedic, otolaryngology, plastic, thoracic, urology, vascular, and neurosurgery. MAIN OUTCOMES AND MEASURES: Use of ICU care up to 30 days after surgery. RESULTS: A total of 34â¯568 patients were included in the analytical data set: 32â¯032 (92.7%) in the cohort without postoperative ICU use and 2545 (7.4%) in the cohort with postoperative ICU use (no ICU use: mean [SD] age, 54.9 [16.6] years; 18 188 women [56.8%]; ICU use: mean [SD] age, 60.3 [15.3] years; 1333 men [52.4%]). For the internal chronologic validation of the 7-variable SURPAS model, data from 2012 to 2016 were used as the training data set (n = 24â¯250, 70.2% of the total sample size of 34â¯568) and data from 2017 to 2018 were used as the test data set (n = 10â¯318, 29.8% of the total sample size of 34â¯568). The C statistic improved in the test data set compared with the training data set (0.933; 95% CI, 0.924-0.941 vs 0.922; 95% CI, 0.917-0.928), whereas the Brier score was slightly worse in the test data set compared with the training data set (0.045; 95% CI, 0.042-0.048 vs 0.045; 95% CI, 0.043-0.047). The SURPAS model compared favorably with the model inputting all 28 NSQIP variables, with both having good calibration between observed and expected outcomes in the Hosmer-Lemeshow graphs and similar Brier scores (model inputting all variables, 0.044; 95% CI, 0.043-0.048; SURPAS model, 0.045; 95% CI, 0.042-0.046) and C statistics (model inputting all variables, 0.929; 95% CI, 0.925-0.934; SURPAS model, 0.925; 95% CI, 0.921-0.930). CONCLUSIONS AND RELEVANCE: Results of this decision analytical model study revealed that the SURPAS prediction model accurately predicted postoperative ICU use across a diverse surgical population. These results suggest that the SURPAS prediction model can be used to help with preoperative planning and resource allocation of limited ICU beds.
Assuntos
Unidades de Terapia Intensiva , Complicações Pós-Operatórias , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de RiscoRESUMO
BACKGROUND: Geriatric trauma rates are increasing, yet trauma centers often struggle to provide autonomy regarding decision making to these patients. Advance care planning can assist with this process. Currently, there are limited data on the impact of advance directives (ADs) in elderly trauma patients. The purpose of this study was to evaluate the prevalence of preinjury AD in geriatric trauma patients and its impact on outcomes, with the hypothesis that ADs would not be associated with an increase in mortality. METHODS: A multicenter retrospective review was conducted on patients older than 65 years with traumatic injury between 2017 and 2019. Three Level I trauma centers and one Level II trauma center were included. Exclusion criteria were readmission, burn injury, transfer to another facility, discharge from emergency department, and mortality prior to being admitted. RESULTS: There were 6,135 patients identified; 751 (12.2%) had a preinjury AD. Patients in the AD+ group were older (86 vs. 77 years, p < 0.0001), more likely to be women (67.0% vs. 54.8%, p < 0.0001), and had more comorbidities. Hospital length of stay and ventilator days were similar. In-hospital mortality occurred in 236 patients, and 75.4% of them underwent withdrawal of care (WOC). The mortality rate was higher in AD+ group (10.5% vs. 2.9%, p < 0.0001). No difference was seen in the rate of AD between the WOC+ and WOC- group (31.5% vs. 39.6%, p = 0.251). A preinjury AD was identified as an independent predictor of mortality, but not a predictor of WOC. CONCLUSION: Despite a high WOC rate in patients older than 65 years, most patients did not have an AD prior to injury. As the elderly trauma population grows, advance care planning should be better integrated into geriatric care to encourage a patient-centered approach to end-of-life care. LEVEL OF EVIDENCE: Prognostic and epidemiological, level IV.
Assuntos
Diretivas Antecipadas , Ferimentos e Lesões/terapia , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisões , Feminino , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Assistência Terminal , Centros de Traumatologia , Ferimentos e Lesões/mortalidadeRESUMO
BACKGROUND: The modified Brain Injury Guidelines (mBIG) are an algorithm for treating patients with traumatic brain injury and intracranial hemorrhage by which selected patients do not require a repeat head computed tomography, a neurosurgery consult, or even an admission. The mBIG refined the original Brain Injury Guidelines (BIG) to improve safety and reproducibility. The purpose of this study is to assess safety and resource utilization with mBIG implementation. METHODS: The mBIG were implemented at three Level I trauma centers in August 2017. A multicenter retrospective review of prospectively collected data was performed on adult mBIG 1 and 2 patients. The post-mBIG implementation period (August 2017 to February 2021) was compared with a previous BIG retrospective evaluation (January 2014 to December 2016). RESULTS: There were 764 patients in the two study periods. No differences were identified in demographics, Injury Severity Score, or admission Glasgow Coma Scale score. Fewer computed tomography scans (2 [1,2] vs. 2 [2,3], p < 0.0001) and neurosurgery consults (61.9% vs. 95.9%, p < 0.0001) were obtained post-mBIG implementation. Hospital (2 [1,4] vs. 2 [2,4], p = 0.013) and intensive care unit (0 [0,1] vs. 1 [1,2], p < 0.0001) length of stay were shorter after mBIG implementation. No difference was seen in the rate of clinical or radiographic progression, neurosurgery operations, or mortality between the two groups.After mBIG implementation, eight patients (1.6%) worsened clinically. Six patients that clinically progressed were discharged with Glasgow Coma Scale score of 15 without needing neurosurgery intervention. One patient had clinical and radiographic decompensation and required craniotomy. Another patient worsened clinically and radiographically, but due to metastatic cancer, elected to pursue comfort measures and died. CONCLUSION: This prospective validation shows the mBIG are safe, pragmatic, and can dramatically improve resource utilization when implemented. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.
Assuntos
Lesões Encefálicas , Adulto , Lesões Encefálicas/terapia , Escala de Coma de Glasgow , Humanos , Reprodutibilidade dos Testes , Estudos Retrospectivos , Centros de TraumatologiaRESUMO
BACKGROUND: Unplanned hospital admission after intended outpatient surgery is an undesirable outcome. We aimed to develop a prediction model that estimates a patient's risk of conversion from outpatient surgery to inpatient hospitalization. METHODS: This was a retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program database, 2005 to 2018. Conversion from outpatient to inpatient surgery was defined as having outpatient surgery and >1 day hospital stay. The Surgical Risk Preoperative Assessment System was developed using multiple logistic regression on a training dataset (2005-2016) and compared to a model using the 26 relevant variables in the American College of Surgeons National Surgical Quality Improvement Program. The Surgical Risk Preoperative Assessment System was validated using a testing dataset (2017-2018). Performance statistics and Hosmer-Lemeshow plots were compared. Two high-risk definitions were compared: (1) the maximum Youden index, and (2) the cohort above the tenth decile of risk on the Hosmer-Lemeshow plot. The sensitivities, specificities, positive predictive values, negative predictive values, and accuracies were compared. RESULTS: In all, 2,822,379 patients were included; 3.6% of patients unexpectedly converted to inpatient. The 6-variable Surgical Risk Preoperative Assessment System model performed comparably to the 26-variable American College of Surgeons National Surgical Quality Improvement Program model (c-indices = 0.818 vs. 0.823; Brier scores = 0.0308 vs 0.0306, respectively). The Surgical Risk Preoperative Assessment System performed well on internal validation (c-index = 0.818, Brier score = 0.0341). The tenth decile of risk definition had higher specificity, positive predictive values, and accuracy than the maximum Youden index definition, while having lower sensitivity. CONCLUSION: The Surgical Risk Preoperative Assessment System accurately predicted a patient's risk of unplanned outpatient-to-inpatient conversion. Patients at higher risk should be considered for inpatient surgery, while lower risk patients could safely undergo operations at ambulatory surgery centers.
Assuntos
Pacientes Internados , Pacientes Ambulatoriais , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Medição de Risco , Fatores de RiscoRESUMO
BACKGROUND: Patients suspected of syncope frequently undergo laboratory and imaging studies to determine the etiology of the syncope. Variability exists in these workups across institutions. The purpose of this study was to evaluate the utilization and diagnostic yield of these workups and the patient characteristics associated with syncopal falls. METHODS: A multi-institutional retrospective review was performed on adult patients admitted after a fall between 1/2017-12/2018. Syncopal falls were compared to non-syncopal falls. RESULTS: 4478 patients were included. There were 795 (18%) patients with a syncopal fall. Electrocardiogram, troponin, echocardiogram, CT angiography (CTA), and carotid ultrasound were more frequently tested in syncope patients compared to non-syncope patients. Syncope patients had higher rates of positive telemetry/Holter monitoring, CTAs, and electroencephalograms. CONCLUSION: Patients who sustain syncopal falls frequently undergo diagnostic testing without a higher yield to determine the etiology of syncope.
Assuntos
Síncope , Telemetria , Adulto , Humanos , Síncope/diagnóstico , Síncope/etiologia , Telemetria/efeitos adversos , Ecocardiografia , Testes Diagnósticos de Rotina/efeitos adversosRESUMO
INTRODUCTION: The Bowel Injury Prediction Score (BIPS) is a tool for identifying patients at risk for blunt bowel and mesenteric injury (BBMI) requiring surgery. BIPS is calculated by assigning one point for each of the following: (1) WBC ≥ 17,000, (2) abdominal tenderness, and (3) injury grade ≥ 4 (mesenteric contusion or hematoma with bowel wall thickening or adjacent interloop fluid collection) on CT scan. A total score ≥ 2 is associated with BBMI requiring surgery. We aimed to validate the BIPS as a predictor for patients with BBMIs requiring operative intervention in a multi-center prospective study. MATERIALS AND METHODS: Patients were prospectively enrolled at 15 U.S. trauma centers following blunt trauma with suspicion of BBMI on CT scan between July 1, 2018 and July 31, 2019. The BIPS was calculated for each patient enrolled in the study. RESULTS: Of 313 patients, 38% had BBMI requiring operative intervention. Patients were significantly more likely to require surgery in the presence of abdominal tenderness (OR, 3.6; 95% CI, 1.6-8.0) and CT grade ≥ 4 (OR, 11.7; 95% CI, 5.7-23.7). Patients with a BIPS ≥ 2 were more than ten times more likely to require laparotomy than those with a BIPS < 2 (OR, 10.1; 95% CI, 5.0-20.4). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a BIPS ≥ 2 for BBMI requiring surgery was 72% (CI 0.6-0.8), 78% (CI 0.7-0.8), 67% (CI 0.6-0.8), and 82% (CI 0.8-0.9), respectively. The AUROC curve for BIPS ≥ 2 was 0.75. The sensitivity, specificity, PPV, and NPV of a BIPS ≥ 2 for BBMI requiring surgery in patients with severe alteration in mental status (GCS 3-8) was 70% (CI 0.5-0.9), 92% (CI 0.8-1.0), 82% (CI 0.6-1.0), and 86% (CI 0.7-1.0), respectively. CONCLUSION: This prospective multi-center trial validates BIPS as a predictor of BBMI requiring surgery. Calculation of BIPS during the initial evaluation of trauma patients is a useful adjunct to help general surgeons taking trauma call determine operative versus non-operative management of patients with BBMI including those with severe alteration in mental status.
Assuntos
Traumatismos Abdominais , Ferimentos não Penetrantes , Traumatismos Abdominais/diagnóstico por imagem , Traumatismos Abdominais/cirurgia , Humanos , Mesentério/diagnóstico por imagem , Mesentério/lesões , Mesentério/cirurgia , Estudos Prospectivos , Estudos Retrospectivos , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/cirurgiaRESUMO
BACKGROUND: Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients. METHODS: This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as >10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused. RESULTS: A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63-0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50-0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53-0.62) (p < 0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64-0.75), SBP (AUROC, 0.75; CI, 0.70-0.81), and SI (AUROC, 0.74; CI, 0.68-0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61-0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47-0.58) or SI (AUROC, 0.56; CI, 0.50-0.62) (p < 0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65-0.84), SBP (AUROC, 0.63; CI, 0.54-0.74), and SI (AUROC, 0.64; CI, 0.54-0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%. CONCLUSION: Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock. LEVEL OF EVIDENCE: Diagnostic test, level III.
Assuntos
Transfusão de Componentes Sanguíneos/estatística & dados numéricos , Dióxido de Carbono/metabolismo , Serviços Médicos de Emergência , Ferimentos e Lesões/mortalidade , Adolescente , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Volume de Ventilação Pulmonar , Estados Unidos , Sinais VitaisRESUMO
BACKGROUND: Pulmonary vascular microthrombi are a proposed mechanism of COVID-19 respiratory failure. We hypothesized that early administration of tissue plasminogen activator (tPA) followed by therapeutic heparin would improve pulmonary function in these patients. RESEARCH QUESTION: Does tPA improve pulmonary function in severe COVID-19 respiratory failure, and is it safe? STUDY DESIGN AND METHODS: Adults with COVID-19-induced respiratory failure were randomized from May14, 2020 through March 3, 2021, in two phases. Phase 1 (n = 36) comprised a control group (standard-of-care treatment) vs a tPA bolus (50-mg tPA IV bolus followed by 7 days of heparin; goal activated partial thromboplastin time [aPTT], 60-80 s) group. Phase 2 (n = 14) comprised a control group vs a tPA drip (50-mg tPA IV bolus, followed by tPA drip 2 mg/h plus heparin 500 units/h over 24 h, then heparin to maintain aPTT of 60-80 s for 7 days) group. Patients were excluded from enrollment if they had not undergone a neurologic examination or cross-sectional brain imaging within the previous 4.5 h to rule out stroke and potential for hemorrhagic conversion. The primary outcome was Pao2 to Fio2 ratio improvement from baseline at 48 h after randomization. Secondary outcomes included Pao2 to Fio2 ratio improvement of > 50% or Pao2 to Fio2 ratio of ≥ 200 at 48 h (composite outcome), ventilator-free days (VFD), and mortality. RESULTS: Fifty patients were randomized: 17 in the control group and 19 in the tPA bolus group in phase 1 and eight in the control group and six in the tPA drip group in phase 2. No severe bleeding events occurred. In the tPA bolus group, the Pao2 to Fio2 ratio values were significantly (P < .017) higher than baseline at 6 through 168 h after randomization; the control group showed no significant improvements. Among patients receiving a tPA bolus, the percent change of Pao2 to Fio2 ratio at 48 h (16.9% control [interquartile range (IQR), -8.3% to 36.8%] vs 29.8% tPA bolus [IQR, 4.5%-88.7%]; P = .11), the composite outcome (11.8% vs 47.4%; P = .03), VFD (0.0 [IQR, 0.0-9.0] vs 12.0 [IQR, 0.0-19.0]; P = .11), and in-hospital mortality (41.2% vs 21.1%; P = .19) did not reach statistically significant differences when compared with those of control participants. The patients who received a tPA drip did not experience benefit. INTERPRETATION: The combination of tPA bolus plus heparin is safe in severe COVID-19 respiratory failure. A phase 3 study is warranted given the improvements in oxygenation and promising observations in VFD and mortality. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT04357730; URL: www. CLINICALTRIALS: gov.
Assuntos
COVID-19/complicações , Pandemias , Insuficiência Respiratória/tratamento farmacológico , SARS-CoV-2 , Trombose/complicações , Ativador de Plasminogênio Tecidual/administração & dosagem , Adolescente , Adulto , Idoso , COVID-19/sangue , COVID-19/epidemiologia , Estudos Transversais , Feminino , Fibrinolíticos/administração & dosagem , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Tempo de Tromboplastina Parcial , Insuficiência Respiratória/sangue , Insuficiência Respiratória/etiologia , Estudos Retrospectivos , Trombose/sangue , Trombose/tratamento farmacológico , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: The role of resuscitative thoracotomy in the emergency department (ED) for patients that have suffered severe thoracoabdominal trauma has been the subject of much debate. Most studies that characterize emergency thoracotomy are from urban, academic, and trauma centers. We sought to describe patient and hospital characteristics of a nationally representative sample of ED thoracotomy (EDT). METHODS: The health-care cost and utilization project 2013 National ED Sample (NEDS) and the 2013 National Inpatient Sample (NIS) maintained by the agency for health-care research and quality were used to generate a nationally representative estimate of resuscitative thoracotomies performed in the ED. We obtained patient demographics and clinical characteristics and compared the descriptive statistics of the two datasets. RESULTS: The NEDS dataset identified 124 unsuccessful EDTs, whereas the NIS dataset identified 77 admissions for thoracotomy. When weighted to create a national estimate, these represent 952 emergency thoracotomies performed in the US in 2013. Most were male (82.5% and 88.2% in NEDS and NIS, respectively). In addition, 32.9% and 36.4% in NEDS and NIS, respectively, were between the ages of 20 and 29. The majority of thoracotomies were performed at metropolitan teaching hospitals (64.2% and 75.3%, NEDS and NIS, respectively). The mean total ED charges for patients who had an unsuccessful thoracotomy were $32,664 and the mean total inpatient charges were $141,215. CONCLUSION: Nearly 1000 thoracotomies are performed annually on the day of presentation to U. S. hospitals. Although emergency thoracotomy for trauma is an infrequently performed procedure, it almost always occurs at an urban, high volume, and level I or level II trauma centers.
RESUMO
BACKGROUND: Since the outset of the coronavirus disease 2019 (COVID-19) pandemic, published tracheostomy guidelines have generally recommended deferral of the procedure beyond the initial weeks of intubation given high mortality as well as concerns about transmission of the infection to providers. It is unclear whether tracheostomy in patients with COVID-19 infection facilitates ventilator weaning, and long-term outcomes are not yet reported in the literature. METHODS: This is a retrospective study of tracheostomy outcomes in patients with COVID-19 infection at a single-center academic tertiary referral intensive care unit. Patients underwent percutaneous tracheostomy at the bedside; the procedure was performed with limited staffing to reduce risk of disease transmission. RESULTS: Between March 1 and June 30, 2020, a total of 206 patients with COVID-19 infection required mechanical ventilation and 26 underwent tracheostomy at a mean of 25±5 days after initial intubation. Overall, 81% of tracheostomy patients were liberated from the ventilator at a mean of 9±6 days postprocedure, and 54% were decannulated prior to hospital discharge at a mean of 21±10 days postprocedure. Sedation and pain medication requirements decreased significantly in the week after the procedure. In-hospital mortality was 15%. Among tracheostomy survivors, 68% were discharged to a facility. DISCUSSION: The management of patients with COVID-19 related respiratory failure can be challenging due to prolonged ventilator dependency. In our initial experience, outcomes post-tracheostomy in this population are encouraging, with short time to liberation from the ventilator, a high rate of decannulation prior to hospital discharge, and similar mortality to tracheostomy performed for other indications. Barriers to weaning ventilation in this cohort may be high sedation needs and ventilator dyssynchrony. LEVEL OF EVIDENCE: Level V-Therapeutic/care management.
RESUMO
BACKGROUND: The Surgical Risk Preoperative Assessment System (SURPAS) uses eight variables to accurately predict postoperative complications but has not been sufficiently studied in emergency surgery. We evaluated SURPAS in emergency surgery, comparing it to the Emergency Surgery Score (ESS). METHODS: SURPAS and ESS estimates of 30-day mortality and overall morbidity were calculated for emergency operations in the 2009-2018 ACS-NSQIP database and compared using observed-to-expected plots and rates, c-indices, and Brier scores. Cases with incomplete data were excluded. RESULTS: In 205,318 emergency patients, SURPAS underestimated (8.1%; 35.9%) while ESS overestimated (10.1%; 43.8%) observed mortality and morbidity (8.9%; 38.8%). Each showed good calibration on observed-to-expected plots. SURPAS had better c-indices (0.855 vs 0.848 mortality; 0.802 vs 0.755 morbidity), while the Brier score was better for ESS for mortality (0.0666 vs. 0.0684) and for SURPAS for morbidity (0.1772 vs. 0.1950). CONCLUSIONS: SURPAS accurately predicted mortality and morbidity in emergency surgery using eight predictor variables.
Assuntos
Tratamento de Emergência/mortalidade , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/mortalidade , Fatores Etários , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos , Emergências , Tratamento de Emergência/estatística & dados numéricos , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Avaliação de Resultados em Cuidados de Saúde , Cuidados Pré-Operatórios , Medição de Risco/métodos , Especialidades Cirúrgicas , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Angioembolization (AE) is recommended for extravasation from liver injury on CT. Data supporting AE are limited to retrospective series that have found low mortality but high morbidity. These studies did not focus on stable patients. We hypothesized that AE is associated with increased complications without improving mortality in stable patients. STUDY DESIGN: We queried the 2016 Trauma Quality Improvement Project database for patients with grade III or higher liver injury (Organ Injury Score ≥ 3), blunt mechanism, with stable vitals (systolic blood pressure ≥ 90 mmHg and heart rate of 50 to 110 beats/min). Exclusion criteria were nonhepatic intra-abdominal or pelvic injury (Organ Injury Score ≥ 3), laparotomy less than 6 hours, and AE implementation more than 24 hours. Patients were matched 1:2 (AE to non-AE) on age, sex, Injury Severity Score, liver Organ Injury Score, arrival systolic blood pressure and heart rate, and transfusion in the first 4 hours using propensity score logistic modeling. Primary outcomes were in-hospital mortality, length of stay, transfusion, hepatic resection, interventional radiology drainage, and endoscopic procedure. RESULTS: There were 1,939 patients who met criteria, with 116 (6%) undergoing hepatic AE. Median time to embolization was 3.3 hours. After successfully matching on all variables, groups did not differ with respect to mortality (5.4% vs 3.2%; p = 0.5, AE vs non-AE, respectively) or transfusion at 4 to 24 hours (4.4% vs 7.5%; p = 0.4). A larger percentage of the AE group underwent interventional radiology drainage (13.3% vs 2.2%; p < 0.001), with more ICU days (4 vs 3 days; p = 0.005) and longer length of stay (10 vs 6 days; p < 0.001). CONCLUSIONS: Hepatic AE was associated with increased morbidity without improving mortality, suggesting the benefits of AE do not outweigh the risks in stable liver injury. Observing these patients is likely a more prudent approach.
Assuntos
Traumatismos Abdominais/terapia , Embolização Terapêutica/métodos , Fígado/lesões , Ferimentos não Penetrantes/terapia , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/mortalidade , Adulto , Angiografia , Feminino , Mortalidade Hospitalar/tendências , Humanos , Escala de Gravidade do Ferimento , Fígado/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tempo para o Tratamento , Estados Unidos/epidemiologia , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/mortalidade , Adulto JovemRESUMO
BACKGROUND: Indications for angioembolization (AE) following liver injury are not clearly defined. This study evaluated the outcomes and complications of hepatic AE. We hypothesize hepatic angioembolization is a useful adjunct to non-operative management of liver injury but with significant morbidity. METHODS: Subjects were identified utilizing trauma registries from centers in a regional trauma network from 2010 to 2017 with an Abbreviated Injury Scale (AIS) coded hepatic injury and an ICD9/10 for hepatic angiography (HA). RESULTS: 1319 patients with liver injuries were identified, with 30 (2.3%) patients undergoing HA: median ISS was 26, and median liver AIS was 4. Twenty-three subjects required AE. 81% had extravasation on CT from a liver injury. 63% underwent HA as initial intervention. 43% of AE subjects had liver-related complications with 35% 30-day readmission but with zero 30-day mortality. CONCLUSIONS: While there were zero reported deaths, a high rate of morbidity and readmission was found. This may be due to the angioembolization or the liver injury itself.