RESUMO
BACKGROUND: Ketamine and etomidate are commonly used as sedatives in rapid sequence intubation (RSI). However, there is no consensus on which agent should be favored when treating patients with trauma. This study aimed to compare the effects of ketamine and etomidate on first-pass success and outcomes of patients with trauma after RSI-facilitated emergency intubation. METHODS: We retrospectively reviewed 944 patients who underwent endotracheal intubation in a trauma bay at a Korean level 1 trauma center between January 2019 and December 2021. Outcomes were compared between the ketamine and etomidate groups after propensity score matching to balance the overall distribution between the two groups. RESULTS: In total, 620 patients were included in the analysis, of which 118 (19.9%) were administered ketamine and the remaining 502 (80.1%) were treated with etomidate. Patients in the ketamine group showed a significantly faster initial heart rate (105.0 ± 25.7 vs. 97.7 ± 23.6, p = 0.003), were more hypotensive (114.2 ± 32.8 mmHg vs. 139.3 ± 34.4 mmHg, p < 0.001), and had higher Glasgow Coma Scale (9.1 ± 4.0 vs. 8.2 ± 4.0, p = 0.031) and Injury Severity Score (32.5 ± 16.3 vs. 27.0 ± 13.3, p < 0.001) than those in the etomidate group. There were no significant differences in the first-pass success rate (90.7% vs. 90.1%, p > 0.999), final mortality (16.1% vs. 20.6, p = 0.348), length of stay in the intensive care unit (days) (8 [4, 15] (Interquartile range)), vs. 10 [4, 21], p = 0.998), ventilator days (4 [2, 10] vs. 5 [2, 13], p = 0.735), and hospital stay (days) (24.5 [10.25, 38.5] vs. 22 [8, 40], p = 0.322) in the 1:3 propensity score matching analysis. CONCLUSION: In this retrospective study of trauma resuscitation, those receiving intubation with ketamine had greater hemodynamic instability than those receiving etomidate. However, there was no significant difference in clinical outcomes between patients sedated with ketamine and those treated with etomidate.
Assuntos
Etomidato , Ketamina , Humanos , Etomidato/uso terapêutico , Ketamina/uso terapêutico , Estudos Retrospectivos , Anestésicos Intravenosos/efeitos adversos , Indução e Intubação de Sequência Rápida , Centros de Traumatologia , Intubação Intratraqueal , República da CoreiaRESUMO
BACKGROUND: The preventable trauma death rate survey is a basic tool for the quality management of trauma treatment because it is a method that can intuitively evaluate the level of national trauma treatment. We conducted this study as a national biennial follow-up survey project and report the results of the review of the 2019 trauma death data in Korea. METHODS: From January 1, 2019 to December 31, 2019, of a total of 8,482 trauma deaths throughout the country, 1,692 were sampled from 279 emergency medical institutions in Korea. All cases were evaluated for preventability of death and opportunities for improvement using a multidisciplinary panel review approach. RESULTS: The preventable trauma death rate was estimated to be 15.7%. Of these, 3.1% were judged definitive preventable deaths, and 12.7% were potentially preventable deaths. The odds ratio for preventable traumatic death was 2.56 times higher in transferred patients compared to that of patients who visited the final hospital directly. The group that died 1 hour after the accident had a statistically significantly higher probability of preventable death than that of the group that died within 1 hour after the accident. CONCLUSION: The preventable trauma death rate for trauma deaths in 2019 was 15.7%, which was 4.2%p lower than that in 2017. To improve the quality of trauma treatment, the transfer of severe trauma patients to trauma centers should be more focused.
Assuntos
Centros de Traumatologia , Ferimentos e Lesões , Humanos , Seguimentos , Coreia (Geográfico) , Probabilidade , Causas de Morte , República da Coreia/epidemiologia , Estudos RetrospectivosRESUMO
BACKGROUND AND OBJECTIVES: It is often difficult to assess the nutritional requirements of severely injured patients. In this study, we aimed to determine whether various nutritional assessment formulas are accurate at assessing the nutritional requirements of trauma patients. METHODS AND STUDY DESIGN: We recruited trauma patients who were admitted to a trauma centre in 2018 and were identified as being at high risk for malnutrition. Energy expenditure was calculated using commonly used prediction equations, and the results were compared to resting energy expenditures measured using indirect calorimetry. RESULTS: Sixty-nine patients (78.9% men; mean age, 53.6 years) collectively underwent 95 indirect calorimetry assessments. The average resting energy expenditure was 1761.8±483.8 kcal/day, and the average respiratory quotient was 0.8±0.2. The correlations between the measured resting energy expenditures and nutritional requirements estimated by each formula were significant but weak (i.e., r-values <0.8). The Penn State formula had the highest r-value (0.742; 95% confidence interval [CI], 0.6359-0.8210), followed by the Faisy formula (0.730; 95% CI, 0.620-0.812). CONCLUSIONS: The formulapredicted nutritional requirements did not adequately correlate with the resting energy expenditures measured by indirect calorimetry. Therefore, we recommend using indirect calorimetry to assess the nutritional requirements of severely injured patients.
Assuntos
Metabolismo Basal , Desnutrição , Masculino , Humanos , Pessoa de Meia-Idade , Feminino , Avaliação Nutricional , Metabolismo Energético , Desnutrição/diagnóstico , Necessidades Nutricionais , Calorimetria IndiretaRESUMO
BACKGROUND: This study examined the impact of the performance improvement and patient safety (PIPS) program implemented in 2015 on outcomes for trauma patients in a regional trauma center established by a government-led project for a national trauma system in Korea. METHODS: The PIPS program was based on guidelines by the World Health Organization and American College of Surgeons. The corrective strategies were proceeded according to the loop closure principle: data-gathering and monitoring, identification of preventable trauma deaths (PTDs), evaluation of preventable factors, analysis of findings, and corrective action plans. We established guidelines and protocols for trauma care, conducted targeted education and peer review presentations for problematic cases, and enhanced resources for improvement accordingly. A comparative analysis was performed on trauma outcomes over a four-year period (2015-2018) since implementing the PIPS program, including the number of trauma team activation and admissions, time factors related to resuscitation, ventilator duration, and the rate of PTDs. RESULTS: Human resources in the center significantly increased during the period; attending surgeons responsible for trauma resuscitation from 6 to 11 and trauma nurses from 85 to 218. Trauma admissions (from 2,166 to 2,786), trauma team activations (from 373 to 1,688), and severe cases (from 22.6 to 33.8%) significantly increased (all P < 0.001). Time to initial resuscitation and transfusion significantly decreased from 120 to 36 minutes (P < 0.001) and from 39 to 16 minutes (P < 0.001). Time to surgery for hemorrhage control and decompressive craniotomy improved from 99 to 54 minutes (P < 0.001) and 181 to 135 minutes (P = 0.042). Ventilator duration and rate of PTDs significantly decreased from 6 to 4 days (P = 0.001) and 22.2% to 8.4% (P = 0.008). CONCLUSION: Implementation of the PIPS program resulted in improvements in outcomes at a regional trauma center that has just been opened in Korea. Further establishment of the PIPS program is required for optimal care of trauma patients.
Assuntos
Hospitalização/estatística & dados numéricos , Segurança do Paciente , Melhoria de Qualidade , Centros de Traumatologia/organização & administração , Ferimentos e Lesões/terapia , Humanos , Mortalidade , Avaliação de Programas e Projetos de Saúde , Ressuscitação , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: The likelihood of re-bleeding after damage-control surgery (DCS) and perihepatic packing for high-grade liver injuries is a major concern. Thus, although early re-laparotomy tends to be recommended, we conducted this study to evaluate the feasibility of performing definite laparotomy within ≤ 48 h in this clinical population. METHODS: The subjects of this retrospective study were 65 patients (n = 24, ≤ 48-h group; n = 41, > 48-h group) who underwent DCS and perihepatic packing. The primary outcome was the rate of repacking for bleeding during re-laparotomy and the secondary outcomes were mortality and length of stay in the intensive care unit (ICU). RESULTS: The ≤ 48-h group had a higher rate of angioembolization and transfusion of red blood cells (RBCs), fresh frozen plasma, and platelets, but the rates of repacking and mortality were not significantly different between the groups. However, the incidence of pneumonia and ventilation support requirement were significantly lower in the ≤ 48-h group than in the > 48-h group. CONCLUSION: The re-laparotomy performed within ≤ 48 h after DCS and perihepatic packing is feasible for patients with high grade liver injury, using angioembolization and aggressive transfusion, as required. Early re-laparotomy reduces the need for prolonged ventilator support and the incidence of ventilator-associated pneumonia.
Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Embolização Terapêutica/métodos , Técnicas Hemostáticas , Laparotomia , Fígado/lesões , Fígado/cirurgia , Adulto , Estudos de Viabilidade , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pneumonia/prevenção & controle , Reoperação , Respiração Artificial/efeitos adversos , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Trauma mortality review is the first step in assessing the quality of the trauma treatment system and provides an important basis for establishing a regional inclusive trauma system. This study aimed to obtain a reliable measure of the preventable trauma death rate in a single province in Korea. METHODS: From January to December 2017, a total of 500 sample cases of trauma-related deaths from 64 hospitals in Gyeonggi Province were included. All cases were evaluated for preventability and opportunities for improvement using a multidisciplinary panel review approach. RESULTS: Overall, 337 cases were included in the calculation for the preventable trauma death rate. The preventable trauma death rate was estimated at 17.0%. The odds ratio was 3.97 folds higher for those who arrived within "1-3 hours" than those who arrived within "1 hour." When the final treatment institution was not a regional trauma center, the odds ratio was 2.39 folds higher than that of a regional trauma center. The most significant stage of preventable trauma death was the hospital stage, during which 86.7% of the cases occurred, of which only 10.3% occurred in the regional trauma center, whereas preventable trauma death was more of a problem at emergency medical institutions. CONCLUSION: The preventable trauma death rate was slightly lower in this study than in previous studies, although several problems were noted during inter-hospital transfer; in the hospital stage, more problems were noted at emergency medical care facilities than at regional trauma centers. Further, several opportunities for improvements were discovered regarding bleeding control.
Assuntos
Medicina de Emergência/normas , Mortalidade , Sepse/mortalidade , Ferimentos e Lesões/mortalidade , Adolescente , Adulto , Idoso , Serviços Médicos de Emergência , Medicina de Emergência/tendências , Serviço Hospitalar de Emergência , Tratamento de Emergência , Feminino , Geografia , Hemorragia , Hospitais , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Razão de Chances , Reprodutibilidade dos Testes , República da Coreia , Centros de Traumatologia/estatística & dados numéricos , Adulto JovemRESUMO
The splenic surface can be anatomically divided into the visceral surface connected to major blood vessels and the diaphragmatic surface attached to the diaphragm. This study aimed to investigate differences in future treatment and outcomes according to the anatomical location of splenic injuries following abdominal trauma. Patients who were treated at a single trauma center between January 2011 and April 2018 were included. The presence of lacerations or hematoma on the visceral surface was evaluated via computed tomography. Differences in the location of splenic surgery between a group that underwent surgical or radiologic intervention and a group that received conservative care only were analyzed. Of 355 patients with splenic injury analyzed, the total mortality rate was 15.2%. A total of 167 patients underwent surgery and angiographic embolization, and 168 received conservative care only. Splenic injuries involved the visceral surface in 127 and 105 patients in the respective groups. Significant differences in the incidence of splenic injuries involving the visceral surface were found between the two groups in the univariate and logistic regression analyses. The likelihood of needing surgery and treatments such as embolization was higher for cases of splenic injury involving the visceral surface than for splenic injuries that did not involve the visceral surface. Through additional research, it may become possible to analyze the location of a splenic injury to determine an effective and safe method of treatment and accurately predict a prognosis. Clin. Anat. 33:516-521, 2020. © 2019 Wiley Periodicals, Inc.
Assuntos
Traumatismos Abdominais/cirurgia , Baço/lesões , Baço/cirurgia , Traumatismos Abdominais/diagnóstico por imagem , Adolescente , Adulto , Tomada de Decisões , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Baço/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
BACKGROUND: Resuscitative thoracotomy (RT) can be a lifesaving treatment, but it has not yet been performed in Korea. In this study, we review our experience of RT after a regional trauma center was constructed. METHODS: This is a retrospective study of RT conducted at a single Korean trauma center from May 2014 to March 2018. The primary outcome was survival, and the secondary outcome was return of spontaneous circulation (ROSC). The clinical characteristics of the patients were compared between the ROSC and non-ROSC groups. Survivors were also reviewed. RESULTS: A total of 62 patients were reviewed, and 60 patients had experienced blunt injury. Thirty-nine patients had ROSC. The ROSC group had short cardiopulmonary resuscitation (CPR) time (6 [2-10] min vs 11 [8-12] min, p < 0.001), the presence of sign of life at the trauma bay [32 (86.5%) vs 7 (28.0%), p < 0.001], and a low Injury Severity Score [26 (25-39) vs 37 (30-75), p = 0.038] compared to the non-ROSC group. On multivariate analysis, only the presence of sign of life was significantly associated with ROSC [11.297 (1.496-85.309) OR (95% CI), p = 0.019]. The 24-h survival rate was 8.1%, and the successful discharge rate was 4.8%. CONCLUSION: The outcome of RT in a Korean trauma center was favorable. ROSC after RT was strongly associated with the presence of sign of life, and RT may be performed in the presence of sign of life regardless of prehospital CPR time.
Assuntos
Circulação Sanguínea , Reanimação Cardiopulmonar , Parada Cardíaca Extra-Hospitalar/terapia , Toracotomia , Adulto , Idoso , Pressão Sanguínea , Feminino , Frequência Cardíaca , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/mortalidade , Reflexo Pupilar , República da Coreia/epidemiologia , Respiração , Estudos Retrospectivos , Centros de Traumatologia , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/terapiaRESUMO
BACKGROUND: This study evaluated the effectiveness and clinical outcomes of the implementation of a trauma center and massive transfusion protocol (TCMTP) in a developing country without a well-established trauma system. METHODS: We included patients (1) aged >15 years, (2) with an Injury Severity Score >15, (3) who received ≥10 units of packed red blood cells (PRBCs) within 24 h, (4) who directly visited our institution from 2010 to 2016, and (5) who survived for ≥24 h. Patients treated during the post-TCMTP period (2015-2016) were compared with historical groups treated pre-TCMTP (2010-2012) and interim-TCMTP (2013-2014). Demographics, transfusion and fluid therapy performance, and clinical outcomes were compared between the three groups. RESULTS: Overall, 190 patients were included: 64, 64, and 62 patients in the pre-TCMTP, interim-TCMTP, and post-TCMTP groups, respectively. Comparison between the three groups revealed significant differences in the fresh-frozen plasma/PRBC ratio (p = 0.001) and crystalloid infusion (p = 0.007); these variables gradually increased from pre- to post-TCMTP. Conversely, colloid infusion showed a reduction post-TCMTP (p < 0.001). Kaplan-Meier curves revealed that the 90-day survival rate was significantly higher in the post-TCMTP group (pre-TCMTP: 45.3 vs. 75.8%, p = 0.001; interim-TCMTP: 56.3 vs. 75.8%, p = 0.027). In Cox regression hierarchical survival analysis, TCMTP showed a hazard ratio for mortality of 0.380 after adjusting for all potentially confounding factors. CONCLUSIONS: Our results suggest that building trauma centers and establishing a massive transfusion protocol according to the specific situations of a country will help improve outcomes for major trauma patients, even in developing countries without a well-established trauma system.
Assuntos
Transfusão de Sangue/normas , Ressuscitação/normas , Centros de Traumatologia/normas , Ferimentos e Lesões/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/métodos , Protocolos Clínicos , Feminino , Hidratação/métodos , Hidratação/normas , Humanos , Masculino , Pessoa de Meia-Idade , República da Coreia , Ressuscitação/métodos , Estudos Retrospectivos , Análise de Sobrevida , Ferimentos e Lesões/mortalidade , Adulto JovemRESUMO
A new blood bank system was established in our trauma bay, which allowed immediate utilization of uncross-matched type O packed red blood cells (UORBCs). We investigated the efficacy of UORBC compared to that of the ABO type-specific packed red blood cells (ABO RBCs) from before the bank was installed. From March 2016 to February 2017, data from trauma patients who received UORBCs in the trauma bay were compared with those of trauma patients who received ABO RBCs from January 2013 to December 2015. Propensity matching was used to overcome retrospective bias. The primary outcome was 24-hour mortality, while the secondary outcomes were in-hospital mortality and intensive care unit (ICU) length of stay (LOS). Data from 252 patients were reviewed and UORBCs were administered to 64 patients. The time to transfusion from emergency room admission was shorter in the UORBC group (11 [7-16] minutes vs. 44 [29-72] minutes, P < 0.001). After propensity matching, 47 patients were included in each group. The 24-hour mortality (4 [8.5%] vs. 9 [13.8%], P = 0.135), in-hospital mortality (14 [29.8%] vs. 18 [38.3%], P = 0.384), and ICU LOS (9 [4-19] days vs. 5 [0-19] days, P = 0.155) did not differ significantly between groups. The utilization of UORBCs resulted in a faster transfusion but did not significantly improve the clinical outcomes in traumatic shock patients in this study. However, the tendency for lower mortality in the UORBC group suggested the need for a large study.
Assuntos
Transfusão de Eritrócitos , Choque Traumático/terapia , Sistema ABO de Grupos Sanguíneos , Adulto , Feminino , Escala de Coma de Glasgow , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos , Choque Traumático/mortalidade , Choque Traumático/patologia , Resultado do TratamentoRESUMO
ABSTRACT: Fat embolism syndrome refers to a systemic condition caused by the circulation of fat droplets in the bloodstream, reaching various target organs typically after major bone fractures or related surgical procedures. Although most cases resolve spontaneously, severe instances can lead to significant respiratory failure, neurological damage, and even mortality. Therefore, appropriate prevention, timely diagnosis, and management are crucial for trauma patients at risk. The objective of this review article is to explore the definition, epidemiology, risk factors, clinical presentation, and pathophysiology of fat embolism syndrome. Furthermore, it aims to examine current recommendations for the accurate diagnosis, prevention, and treatment of it, providing a comprehensive guide for the effective management of patients prone to this condition.
RESUMO
ABSTRACT: There have been numerous changes in resuscitation strategies for severely injured patients over the last several decades. Certain strategies, such as aggressive crystalloid resuscitation, have largely been abandoned because of the high incidence of complications and worsening of trauma-induced coagulopathy. Significant emphasis has been placed on restoring a normal coagulation profile with plasma or whole blood transfusion. In addition, the importance of the lethal consequences of trauma-induced coagulopathy, such as hyperfibrinolysis, has been easily recognized by the use of viscoelastic testing, and its treatment with tranexamic acid has been extensively studied. Furthermore, the critical role of early intravenous calcium administration, even before blood transfusion administration, has been emphasized. Other adjuncts, such as fibrinogen supplementation with fibrinogen concentrate or cryoprecipitate and prothrombin complex concentrate, are being studied and incorporated in some of the institutional massive transfusion protocols. Finally, balanced blood component transfusion (1:1:1 or 1:1:2) and whole blood have become commonplace in trauma centers in North America. This review provides a description of recent developments in resuscitation and a discussion of recent innovations and areas for future investigation.
RESUMO
BACKGROUND: The direct association between procedure risk and outcomes in elderly patients who undergo emergency general surgery (EGS) has not been analyzed. Studies only highlight the importance of frailty. A comprehensive analysis of relevant risk factors and their association with outcomes in elderly patients who undergo EGS is lacking. We hypothesized that procedure risk has a stronger association with relevant outcomes in elderly patients who undergo EGS compared with frailty. STUDY DESIGN: Elderly patients (age >65 years) undergoing EGS operative procedures were identified in the NSQIP database (2018 to 2020) and stratified based on the presence of frailty calculated by the Modified 5-Item Frailty Index (mFI-5; mFI 0 nonfrail, mFI 1 to 2 frail, and mFI ≥3 severely frail) and based on procedure risk. Multivariable regression models and receiving operative curve analysis were used to determine risk factors associated with outcomes. RESULTS: A total of 59,633 elderly patients who underwent EGS were classified into nonfrail (17,496; 29.3%), frail (39,588; 66.4%), and severely frail (2,549; 4.3%). There were 25,157 patients in the low-risk procedure group and 34,476 in the high-risk group. Frailty and procedure risk were associated with increased mortality, complications, failure to rescue, and readmissions. Differences in outcomes were greater when patients were stratified according to procedure risk compared with frailty stratification alone. Procedure risk had a stronger association with relevant outcomes in elderly patients who underwent EGS compared with frailty. CONCLUSIONS: Assessing frailty in the population of elderly patients who undergo EGS without adjusting for the type of procedure or procedure risk ultimately presents an incomplete representation of how frailty impacts patient-related outcomes.
Assuntos
Cirurgia de Cuidados Críticos , Fragilidade , Avaliação Geriátrica , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Operatórios , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Cirurgia de Cuidados Críticos/estatística & dados numéricos , Idoso Fragilizado/estatística & dados numéricos , Fragilidade/complicações , Fragilidade/diagnóstico , Fragilidade/epidemiologia , Cirurgia Geral , Avaliação Geriátrica/métodos , Avaliação Geriátrica/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Estados Unidos/epidemiologia , Tratamento de Emergência/métodos , Tratamento de Emergência/estatística & dados numéricosRESUMO
INTRODUCTION: We have recently shown that readmission after EGS procedures carries a 4-fold higher mortality rate when compared to those not readmitted. Understanding factors associated with death after readmission is paramount to improving outcomes for EGS patients. We aimed to identify risk factors contributing to failure-to-rescue (FTR) during readmission after EGS. We hypothesized that most post-readmission deaths in EGS are attributable to FTR. METHODS: A retrospective cohort study using the NSQIP database 2013-2019 was performed. Patients who underwent 1 of 9 urgent/emergent surgical procedures representing 80% of EGS burden of disease, who were readmitted within 30 days post-procedure were identified. The procedures were classified as low- and high-risk. Patient characteristics analyzed included age, sex, BMI, ASA score comorbidities, postoperative complications, frailty, and FTR. The population was assessed for risk factors associated with mortality and FTR by uni- and multivariate logistic regression. RESULTS: Of 312,862 EGS cases, 16,306 required readmission. Of those, 10,748 (3.4%) developed a postoperative complication. Overall mortality after readmission was 2.4%, with 90.6% of deaths attributable to FTR. Frailty, high-risk procedures, pulmonary complications, AKI, sepsis, and the need for reoperation increased the risk of FTR. DISCUSSION: Death after a complication is common in EGS readmissions. The impact of FTR could be minimized with the implementation of measures to allow early identification and intervention or prevention of infectious, respiratory, and renal complications.
Assuntos
Falha da Terapia de Resgate , Readmissão do Paciente , Complicações Pós-Operatórias , Humanos , Masculino , Feminino , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Pessoa de Meia-Idade , Idoso , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Fatores de Risco , Falha da Terapia de Resgate/estatística & dados numéricos , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/mortalidade , AdultoRESUMO
We aimed to evaluate the effectiveness of an intensive care unit (ICU) round checklist, FAST HUGS BID (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, Ulcer prophylaxis, Glycemic control, Spontaneous breathing trial, Bowel regimen, Indwelling catheter removal, and De-escalation of antibiotics-abbreviated as FD hereafter), in improving clinical outcomes in patients with severe trauma. We included patients admitted to our trauma ICU from 2016 to 2020 and divided them into two groups: before (before-FD, 2016-2017) and after (after-FD, 2019-2020) implementation of the checklist. We compared patient characteristics and clinical outcomes, including ICU and hospital length of stay (LOS) and in-hospital mortality. Survival analysis was performed using Kaplan-Meier curves and multivariable logistic regression models; furthermore, multiple linear regression analysis was used to identify independent factors associated with ICU and hospital LOS. Compared with the before-FD group, the after-FD group had significantly lower in-hospital mortality and complication rates, shorter ICU and hospital LOS, and reduced duration of mechanical ventilation. Moreover, implementation of the checklist was a significant independent factor in reducing ICU and hospital LOS and in-hospital mortality. Implementation of the FD checklist is associated with decreased ICU and hospital LOS and in-hospital mortality.
RESUMO
Trauma is a significant public health issue worldwide, particularly affecting economically active age groups. Quality management of trauma care at the national level is crucial to improve outcomes of major trauma. In Korea, a biennial nationwide survey on preventable trauma death rate is conducted. Based on the survey results, we analyzed opportunities for improving the trauma treatment process. Expert panels reviewed records of 8282 and 8482 trauma-related deaths in 2017 and 2019, respectively, identifying 258 and 160 cases in each year as preventable deaths. Opportunities for improvement were categorized into prehospital, interhospital, and hospital stages. Hemorrhage was the primary cause of death, followed by sepsis/multiorgan failure and central nervous system injury. Delayed hemostatic procedures and transfusions were common areas for improvement in hospital stage. Interhospital transfers experienced significant delays in arrival time. This study emphasizes the need to enhance trauma care by refining treatment techniques, centralizing patients in specialized facilities, and implementing comprehensive reviews and performance improvements throughout the patient transfer system. The findings offer valuable insights for addressing trauma care improvement from both clinical and systemic perspectives.
RESUMO
The Korean government initiated a plan to designate and establish Regional Trauma Centers to reduce the preventable trauma death rate to <20% so as to be on par with advanced countries by 2020. This initiative was undertaken because the reported preventable trauma death rate was close to 40% in South Korea from 1997 to 2009. This review aimed to provide an overview of these Regional Trauma Centers and discuss further development of the trauma care system to assess its performance. As of September 2021, 15 Regional Trauma Centers had been established through a metropolitan-based designation process. Each center has been equipped with Level-I facilities. These Regional Trauma Centers have had 2 positive effects; namely, an increase in the number of severely injured patients attending these centers and a decrease in the national preventable trauma death rate from 30.5% in 2015 to 19.9% in 2017. The establishment of Regional Trauma Centers can lead to improved performance, maximal efficiency, and reduction of preventable deaths in trauma patients. They can also play a key role in prehospital triage and transportation in the trauma care system.
RESUMO
AIMS: Major trauma patients need adequate nutrition for recovery. This study aimed to evaluate the adequacy of nutritional supply and the correlation between nutritional supply and clinical outcome. METHODS: A single-centre retrospective observational study was undertaken, describing the amounts of energy and proteins provided to 320 critically ill trauma patients during the first 10 days after admission. The data were collected from the electronic medical records of patients admitted to the trauma intensive care unit during the study period and descriptive statistical analyses were performed with the SPSS software. RESULTS: The mean proportion of supplied energy to recommended energy during the first 10 days after admission was 57.5%, and the mean percentage of supplied protein to recommended protein intake was 51.3%. The patients were divided into those who received ≥70% (isocaloric nutrition group) and those who received <70% (hypocaloric nutrition group) of their estimated requirements. Both the duration of ventilator use (12.7 ± 10.5 vs. 16.0 ± 15.8 days, respectively, p = 0.009) and duration of parenteral nutrition (1.1 ± 1.4 vs. 2.0 ± 2.0 days, respectively, p = 0.001) were shorter in the isocaloric nutrition group (n = 83) than in the hypocaloric nutrition group (n = 237). CONCLUSION: Total energy and the amount of protein supplied were insufficient compared to the recommended amount. The duration of ventilator use was shorter in the isocaloric nutrition group than in the hypocaloric nutrition group. The association between shortened ventilator use and isocaloric nutrition requires further investigation as a potential intervention to reduce the risk of complications such as ventilator-related pneumonia.
Assuntos
Ingestão de Energia , Nutrição Enteral , Humanos , Apoio Nutricional , Estado Nutricional , Ventiladores MecânicosRESUMO
Several reports indicate that early plasma transfusion may promote survival and reduce the incidence of traumatic coagulopathy in situations of massive bleeding. Consequently, it is recommended to maintain a plasma and RBC transfusion ratio between 1 : 1 and 1 : 2 at the start of admission. This retrospective study examined the effect of an early high plasma : RBC ratio on mortality rates by adopting a massive transfusion protocol (MTP) that forced an early and rapid issue of plasma products. Patients who received massive transfusions at a single trauma center between January 2014 and May 2020 were included in the study. A new protocol was established in January 2020, wherein a fixed amount of plasma was issued following MTP activation. Patients who underwent massive transfusions before and after the adoption of the new protocol were compared. In total, 1059 patients met the inclusion criteria. Fifty-one patients who underwent MTP were propensity score-matched with the patients who received a nonprotocolized massive transfusion. The MTP group had a higher plasma : RBC ratio at 1 h (0.8 vs. 0.2) and 4 h of hospitalization (1.1 vs. 0.6), with no significant between-group difference in the plasma : RBC ratio at 24 h of hospitalization. The MTP group had a lower 24 h mortality rate than the control group. There was no significant difference in the 30-day mortality. Using MTP to achieve a high plasma : RBC ratio in the early period of hospitalization appeared to affect 24-hour mortality; however, 30-day mortality did not change.
RESUMO
INTRODUCTION: Open pelvic fractures are commonly associated with life-threatening, uncontrollable haemorrhages. Although management methods for pelvic injury-associated haemorrhage have been established, the early mortality rate associated with open pelvic fractures remains high. This study aimed to identify predictors of mortality and effective treatment methods for open pelvic fractures. METHODS: We defined open pelvic fractures as pelvic fractures with an open wound directly connected to the adjacent soft tissue, genitals, perineum, or anorectal structures, resulting in soft tissue injuries. This study was performed on trauma patients (age ≥15 years) injured by a blunt mechanism between 2011 and 2021 at a single trauma centre. We collected and analysed the data on the Injury Severity Score (ISS), the Revised Trauma Score (RTS), the Trauma and Injury Severity Score (TRISS), length of hospital stay, length of intensive care unit stay, transfusion, preperitoneal pelvic packing (PPP), resuscitative endovascular balloon occlusion of the aorta (REBOA), therapeutic angio-embolisation, laparotomy, faecal diversion, and mortality. RESULTS: Forty-seven patients with blunt open pelvic fractures were included. The median age was 45 years (interquartile range, 27-57 years) and median ISS was 34 (24-43). The most frequently performed treatment methods were laparotomy (53%) and pelvic binder (53%), followed by faecal diversion (40%) and PPP (38%). PPP was the only method performed at a higher rate in the survival group for haemorrhagic control (41% vs. 30%). Haemorrhagic mortality was present in one case that received PPP. The overall mortality was 21%. In the univariate logistic regression analysis, initial systolic blood pressure (SBP), TRISS, RTS, packed red blood cell transfusion for the first 24 h, and base excess showed statistical significance (p<0.05). In the multivariate logistic regression model, initial SBP was identified as an independent risk factor for mortality (odds ratio, 0.943; 95% confidence interval, 0.907-0.980; p = 0.003). CONCLUSION: A low initial SPB may be an independent predictor of mortality in patients with open pelvic fractures. Our findings suggest that PPP might be a feasible method to decrease haemorrhagic mortality from open pelvic fractures, especially for haemodynamically unstable patients with low initial SBP. Further studies are required to validate these clinical findings.