Preferences and Predictions Regarding Palliative Care in the Trauma Intensive Care Unit.

INTRODUCTION: In the older intensive care unit (ICU) trauma population, it is common to have to make decisions about end-of-life. We sought to demonstrate uncertainty of patients and providers in this area. METHODS: Our study is a prospective observational study of trauma patients 50 years and older admitted to the ICU. Patients or surrogates completed a survey including questions regarding end-of-life. Team members were surveyed with their expectation for patient outcome and appropriateness of palliative or comfort care. Patients were followed up for 6 months. Chi-square analysis and Fisher's exact test were performed. RESULTS: 100 patients had data available for analysis. Surveys were completed by the patient for 39 while a surrogate completed the survey for 61 patients. There was a significant increase in uncertainty if a surrogate answered or if there had been no prior discussions about end-of-life. Nurse, resident, and attending predictions about hospital survival were similar with all groups predicting survival in 82%. 6-month survivors were only predicted to be alive 75% of the time. Ideas about comfort care were similar but there was more variation regarding a palliative care consult with nurses saying yes in 27% of surveys while physicians only said yes in 18%. CONCLUSIONS: The significantly higher rates of uncertainty for both surrogates or in cases where no prior discussion had been had highlight the importance of having more conversations about end-of-life and documentation of advance directives prior to traumatic events. The difference in team member ideas about palliative care demonstrates a need for improved team communication.

Identification of Sarcopenia in Elderly Trauma Patients: The Value of Clinical Competency and Experience.

INTRODUCTION: There is currently no standard definition of sarcopenia, which has often been associated with frailty. A commonly cited surrogate measure of sarcopenia is psoas muscle size. The purpose of this prospective study is to assess medical providers' capabilities to identify frail elderly trauma patients and consequent impact on outcomes after intensive care unit admission. METHODS: Trauma intensive care unit patients over the age of 50 were enrolled. A preadmission functional status questionnaire was completed on admission. Attendings, residents, and nurses, blinded to their patient's sarcopenic status, completed surveys regarding 6-month prognosis. Chart review included cross-sectional psoas area measurements on computerized tomography scan. Finally, patients received phone calls 3 and 6 months after admission to determine overall health and functional status. RESULTS: Seventy-six participants had an average age of 70 years and a corrected psoas area of 383 ± 101 mm2/m2. Injury Severity Score distribution (17.2 ± 8.9) was similar for both groups. Patients also had similar preinjury activities of daily living. Both groups had similar hospital courses. While sarcopenic patients were less likely to be predicted to survive to 6 months (60% vs. 76%, P = 0.017), their actual 6-month mortality was similar (22% vs. 21%, P = 0.915). CONCLUSION: Despite similar objective measures of preadmission health and trauma injury severity, medical providers were able to recognize frail patients and predicted they would have worse outcomes. Interestingly, sarcopenic patients had similar outcomes to the control group. Additional studies are needed to further delineate factors influencing provider insight into functional reserves of elderly trauma patients.

Long term outcomes in older trauma patients admitted to the ICU: A prospective study.

BACKGROUND: Prior studies have shown an increase in mortality in elderly patients when compared to their younger cohort. METHODS: Level 1 trauma patients ≥50 years old were recruited upon admission to the ICU and prospectively followed. After an initial survey, inpatient data were collected and phone surveys were completed at 3 and 6 months. RESULTS: 100 patients were included. There was an 18% inpatient mortality. At 6 months, the mortality rate was 24%; 73% of surviving patients reported good health. 6-month nonsurvivors had a higher percentage requiring preinjury assistance with ambulation. CONCLUSIONS: Severe trauma in patients ≥50 years of age carries a significant rate of mortality however survivors have good outcomes. Need for assistance with ambulation prior to injury is associated with 6 month mortality and could be used as a screening tool for interventions.

Effects of chronic naltrexone treatment in rats on place preference and locomotor activation after acute administration of cocaethylene or ethanol plus cocaine.

When cocaine and ethanol are taken together a cocaine metabolite called cocaethylene is produced. Investigators have determined that cocaine, ethanol, and cocaethylene all produce a conditioned place preference when administered intraperitoneally. On the basis of the moderate success of naltrexone at attenuating the rewarding effects of ethanol and cocaine administered independently, we examined the ability of chronic naltrexone treatment (administered by means of subcutaneous implant across 6 days) to reduce the preference and motor-stimulating effects resulting from intraperitoneal administration of cocaethylene (Experiment 1) and the co-administration of ethanol with cocaine (Experiment 2) in outbred rats. Results demonstrated naltrexone modestly reduced conditioned place preference for cocaethylene but had no effect on the locomotor stimulation resulting from cocaethylene administration. Naltrexone failed to decrease the preference for the chamber paired with co-administration of ethanol and cocaine and did not change the degree of locomotor activation produced by these drugs. These results support the suggestion that naltrexone as a pharmacotherapy to treat co-abuse of ethanol and cocaine in human beings may have limited benefits.