The Effect of Frailty in Predicting Outcomes of Rib Fractures Among Elderly Patients.

INTRODUCTION: Rib fractures are consequential injuries for geriatric trauma patients. Frailty has been associated with adverse outcomes in this population. The Rib Fracture Frailty Index (RFF) and 5-factor modified Frailty Index (mFI) are 2 validated frailty metrics. Research assessing inclusion of frailty metrics in geriatric rib fractures triage protocols is limited. METHODS: A retrospective cohort study was performed for trauma patients ≥50 years old with rib fractures admitted to a Level I trauma center, which currently uses percent predicted forced vital capacity (FVC%) to triage rib fractures patients. Frailty metrics (RFF & mFI) were calculated retrospectively, stratifying patients as low, moderate, or severe frailty. Unfavorable discharge disposition (UDD) was defined as discharge to facility or death. Unadjusted and adjusted odds ratios were used to assess frailty with outcome variables. RESULTS: In total, 834 patients were included from August 2018 - May 2023, with mean age of 69.1. A majority had low frailty (64.0 vs 40.3%), followed by moderate frailty (21.1 vs 30.7%), then severe frailty (14.9 vs 29.0%) for RFF and mFI, respectively. Age, sex, and ISS differed between groups. For RFF, increased frailty was associated with longer hospital and ICU length of stay. Neither frailty metric was associated with unplanned ICU transfer or intubation. In the adjusted analysis, frail patients were more likely to have UDD (OR 8.9, CI 3.4-23.0, P < .0001). CONCLUSION: While both frailty metrics were predictive of UDD, neither was associated with ICU transfer or intubation, suggesting that frailty does not enhance the accuracy of our current protocol using FVC%.

Evaluation of the Nelson Criteria as an Indicator for Nonsurgical Admission in Trauma Patients.

Geriatric patients with complex medical comorbidities who sustain minor injuries may warrant admission to nonsurgical services. The Nelson score provides an objective scoring system that helps identify patients appropriate for nonsurgical admission (NSA). The purpose of this study is to assess the utility of the Nelson criteria in determining the most appropriate admission service. A retrospective review was performed on patients ≥65 years admitted from 12/2016 to 11/2020. 2410 patients met the inclusion criteria. Patients with Nelson score ≥6 were older with more comorbidities, had a lower injury severity score (7.5 vs 12.5, p<0.0001), and a higher rate of NSA (29.2% vs 12.7%, p<0.0001) compared to patients with Nelson score <6. On the multivariable logistic regression, admission service was not identified as an independent predictor of mortality. Utilizing the Nelson criteria may provide an objective measure to stratify and identify patients who would benefit from NSA.

Time is of the Essence: Impact of a More Aggressive Chemical Venous Thromboembolism Prophylaxis Regimen on Trauma Patients.

BACKGROUND: Trauma patients are at high risk for venous thromboembolism (VTE). Opportunity for chemical VTE prophylaxis improvement was identified and practice was altered to start chemoprophylaxis on admission in most patients. The purpose of this study was to determine if early VTE prophylaxis is safe and reduces VTE. METHODS: The trauma registry was queried over a 12-month period for patients admitted greater than 1 day for traumatic injury. The study spanned 6 months on either side of instituting aggressive chemoprophylaxis. Patients were risk adjusted on demographics, Injury Severity Score, transfusions, procedure type, length of stay, and mortality. Pre-intervention patients were then compared to patients in the aggressive cohort with the primary outcome of VTE. Secondary outcomes included transfusions, mortality, and length of stay (LOS). RESULTS: 1597 patients were identified over the study period with 754 (47%) patients in the aggressive period. There were no differences in age, sex, Injury Severity Score, transfusions, procedures, or LOS between cohorts. Pre-algorithm patients were more likely to have penetrating mechanism (9.3% vs 6.6%; P = .009) and longer time to VTE prophylaxis (23.3 vs 13.9 hours; P < .001). No differences were noted in anticoagulant, VTE rate (2.0% vs 1.2%; P = .195), or mortality. Linear regression analysis identified time to chemical prophylaxis as significant predictor of VTE (ß = 43.9, P < .001). CONCLUSIONS: Early aggressive chemical VTE prophylaxis is safe without increasing transfusions. Venous thromboembolism rates were decreased, but did not reach statistical significance.

Rib fractures in the elderly: physiology trumps anatomy.

INTRODUCTION: Rib fractures in elderly patients are associated with increased morbidity and mortality. Predicting which patients are at risk for complications is an area of debate. Current models use anatomic, physiologic or laboratory parameters in isolation to answer this question. The 'RibScore' is an anatomic model that assesses fracture severity. Given that frailty is a major driver of adverse outcomes in the elderly, we hypothesize that the combined analysis of fracture severity, physiologic reserve and current pulmonary function are better predictors of respiratory compromise in this population. METHODS: This is a retrospective chart review of 263 trauma patients age ≥55 from January 2014 to June 2017. Criteria included blunt mechanism and ≥ 1 rib fracture identified by CT. Variables indicating adverse pulmonary outcomes were defined by: pneumonia, respiratory failure and tracheostomy. Three models were assessed: (1) RibScore, (2) Modified Frailty Index (mFI) and (3) initial partial pressure of carbondioxide (PaCO2). RESULTS: A total of 263 patients met inclusion criteria. 13% developed pulmonary complications. Increased RibScore, mFI and PaCO2 were each statistically associated with risk of complications. Receiver operating characteristics area under the curve analysis of individual models predicted complications with the following concordance statistic (CS): anatomic (RibScore) yielded a CS of 0.79 (95% CI 0.69 to 0.89); physiologic (mFI) yielded a CS of 0.83 (95% CI 0.75 to 0.91) and laboratory (PaCO2) yielded a CS of 0.88 (95% CI 0.80 to 0.95). The PaCO2 had the highest discriminative ability of the three individual models. Combining all three models yielded the best performance with a CS of 0.90 (95% CI 0.81 to 0.97). DISCUSSION: The RibScore maintains discriminative ability in the elderly. However, models based on mFI and PaCO2 individually outperform the RibScore. A combination of all three models yields the highest discriminative ability. This combined approach is best for assessing the severity of rib fractures and prediction of complications in the elderly. LEVEL OF EVIDENCE: Prognostic Study, Level III.

PADUA score as a predictor for pulmonary embolism: a potential strategy for reducing unnecessary imaging.

An objective tool that is easy to integrate with an electronic medical record may help reduce unnecessary imaging for diagnosing a pulmonary embolism (PE). In this study, we assess the PADUA score in stratifying patients based on their risk of a PE. We reviewed charts of patients that underwent a computed tomography pulmonary angiogram (CT-PA) between January 2014 and September 2015 at our institution. Patient demographics including gender, age, race, and variables of the PADUA score were collected. The primary outcome was a positive CT-PA for a PE. Univariate and multivariate analysis was performed to derive predictors for a positive CT-PA. A receiver operator curve was calculated for the PADUA score and an optimal cutoff was calculated. Diagnostic test statistics were performed. Our study included 1067 patients. Of these, 185 (17.3%) had a PE. These patients tended to be older (64.3 SD 15.9 vs. 59.7 years SD 17.4, p < 0.01), have a higher proportion of Black patients (38.9% vs. 31.9%, p = 0.03), have a higher median [IQR] PADUA score (4.0 [3-6] vs. 3.0 [1-4], p < 0.01), and a higher rate of a DVT/PE history (30.3% vs. 5.2%, p < 0.01). Independent predictors included a DVT/PE history (OR: 7.65, 95% CI 4.89-12.0, p < 0.01), limited mobility (OR: 1.47, 95% CI 1.01-2.14, p = 0.046), and age 70 or greater (OR: 1.47, 95% CI 1.03-2.11, p = 0.03). The PADUA score had an AUC of 0.64 (95% CI 0.60-0.69, p = 0.046). The optimal cutoff was 4 and the sensitivity and specificity were 57.3% and 66.8%, respectively. The positive predictive and negative predictive values were 22.6% and 88.2%, respectively. The PADUA is a possible tool to stratify patients prior to performing a CT-PA. By using the score to guide management, we may be able to reduce unnecessary imaging through the implementation of the score in an EMR system. Further prospective research is warranted.

Clostridium Difficile-Associated Infection in Trauma Patients: Development of the Clostridium Difficile Influencing Factors (CDIF) Score.

CONTEXT: Clostridium difficile-associated infection (CDAI) can result in longer hospitalization, increased morbidity, and higher mortality rates for surgical patients. The impact on trauma patients is unknown, however. OBJECTIVE: To assess the effect of CDAI on trauma patients and develop a scoring system to predict CDAI in that population. METHODS: Records of all trauma patients admitted to a Level I Trauma Center from 2001 to 2014 were retrospectively reviewed. Presence of CDAI was defined as evidence of positive toxin or polymerase chain reaction. Patients with CDAI were matched to patients without CDAI using propensity score matching on a ratio of 1:3. MAIN OUTCOME MEASURES: Primary outcome was inhospital mortality. Secondary outcomes included length of stay and need for mechanical ventilation. A decision-tree analysis was performed to develop a predicting model for CDAI in the study population. RESULTS: During the study period, 11,016 patients were identified. Of these, 50 patients with CDAI were matched to 150 patients without CDAI. There were no differences in admission characteristics and demographics. Patients in whom CDAI developed had significantly higher mortality (12% vs 4%, p < 0.01), need for mechanical ventilation (57% vs 23%, p < 0.01), and mean hospital length of stay (15.3 [standard deviation 1.4]) days vs 2.1 [0.6] days, p < 0.0). CONCLUSION: In trauma patients, CDAI results in significant morbidity and mortality. The C difficile influencing factor score is a useful tool in identifying patients at increased risk of CDAI.

A novel, minimally invasive approach to assure hemostasis for intercostal bleeding after trauma.

Intercostal artery injury can cause large hemothoraces. While many patients with intercostal artery injury present hemodynamically unstable and require emergent thoracotomy for hemostasis, some tamponade spontaneously. They may rebleed later, however, and cause recurrent hemothorax or retained hemothorax. Video-assisted thoracic surgery (VATS) is an effective way to evacuate retained hemothorax. However, assessing and ligating intercostal artery injury during VATS can be difficult, and often, open thoracotomy is pursued. Even with open surgery, ligation of the intercostal artery can be a challenge. We present a minimally invasive method of definitive intercostal artery ligation during VATS or open thoracotomy.

Use of Epidural Analgesia as an Adjunct in Elective Abdominal Wall Reconstruction: A Review of 4983 Cases.

CONTEXT: Use of epidural analgesia in patients undergoing elective abdominal wall reconstruction is common. OBJECTIVE: To assess the impact of epidural analgesia in patients undergoing abdominal wall reconstruction. DESIGN: All patients who underwent elective ventral hernia repair from 2005 to 2014 were retrospectively identified. Patients were divided into two groups by the postoperative use of epidural analgesics as an adjunct analgesic method. Preoperative comorbidities, American Society of Anesthesiologists status, operative findings, postoperative pain management, and venothromboembolic prophylaxis were extracted from the database. Logistic regressions were performed to assess the impact of epidural use. MAIN OUTCOME MEASURES: Severity of pain on postoperative days 1 and 2. RESULTS: During the study period, 4983 patients were identified. Of those, 237 patients (4.8%) had an epidural analgesic placed. After adjustment for differences between groups, use of epidural analgesia was associated with significantly lower rates of 30-day presentation to the Emergency Department (adjusted odds ratio [AOR] = 0.53, 95% confidence interval [CI] = 0.32-0.87, adjusted p = 0.01). Use of epidural analgesia resulted in higher odds of abscess development (AOR = 5.89, CI = 2.00-17.34, adjusted p < 0.01) and transfusion requirement (AOR = 2.92, CI = 1.34-6.40, adjusted p < 0.01). Use of epidural analgesia resulted in a significantly lower pain score on postoperative day 1 (3 vs 4, adjusted p < 0.01). CONCLUSION: Use of epidural analgesia in patients undergoing abdominal wall reconstruction may result in longer hospital stay and higher incidence of complications while having no measurable positive clinical impact on pain control.

Development and Validation of a Scoring System to Predict Surgical Site Infection After Ventral Hernia Repair: A Michigan Surgical Quality Collaborative Study.

INTRODUCTION: Surgical site infections (SSIs) are a rare but significant complication following an elective ventral hernia repair. This study aims to develop a risk assessment tool in order to predict the risk of developing SSIs postoperatively. METHODS: All patients undergoing an elective ventral hernia repair were identified using the Michigan Surgical Quality Collaborative (MSQC) database. Patients' demographics, comorbidities and technical aspects of the operations were extracted. Logistic regressions were used to create a predictive scoring system for SSIs. RESULTS: A total of 4983 were included. SSIs occurred in 3.4% of the patient population. A stepwise forward logistic regression identified the need to use drains, BMI, wound classification at the end of the surgery, presence of severe adhesions, a history of CAD, the need for intensive care after surgery, the use of pressors, EtOH abuse and history of PVD as being independently associated with the development of postoperative surgical site infections. CONCLUSION: In patients undergoing an elective hernia repair, the incidence of SSI is low. Several preoperative and perioperative factors can contribute to the development of SSIs.

Association of Unplanned Reintubation with Higher Mortality in Old, Frail Patients: A National Surgical Quality-Improvement Program Analysis.

BACKGROUND: Unplanned postoperative reintubation increases the risk of mortality, but associated factors are unclear. OBJECTIVE: To elucidate factors associated with increased mortality risk in patients with unplanned postoperative reintubation. DESIGN: Retrospective study. Patients older than 40 years who underwent unplanned reintubation from 2005 to 2010 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Multiple regression models were used to examine the impact on mortality of factors that included the modified frailty index (mFI) we developed, American Society of Anesthesiologists (ASA) score, age decile, and days to reintubation. MAIN OUTCOME MEASURE: Mortality. RESULTS: A total of 17,051 postoperative reintubations in adults were analyzed. Overall mortality was 29.4% (n = 5009). On postoperative day 1, 4434 patients were reintubated and 878 (19.8%) died. On postoperative day 7 and beyond, 6329 patients were reintubated and 2215 (35.0%) died. Increasing mFI resulted in increasing incidence of mortality (mFl of 0 = 20.5% mortality vs mFl of 0.37-0.45 = 41.7% mortality). As ASA score increased from 1 to 5, reintubation was associated with a mortality of 12.1% to 41.6%, respectively. Similarly, increasing age decile was associated with increasing incidence of mortality (40-49 years, 17.9% vs 80-89 years, 42.1%). After adjustment for confounding factors, mFI, ASA score, age decile, and increasing number of days to reintubation were independently and significantly associated with increased mortality in the study population. CONCLUSION: Among patients who underwent unplanned reintubation, older and more frail patients had an increased risk of mortality.

Nonoperative Damage Control: The Use of Extracorporeal Membrane Oxygenation in Traumatic Bronchial Avulsion as a Bridge to Definitive Operation.

The conventional treatment for an avulsed bronchus is emergent thoracotomy and repair or lobectomy. The principles of damage control thoracic operations include initial hemorrhage control with delayed definite repair after physiologic resuscitation. We report a multiply injured patient with avulsion of the left lower lobe bronchus. Profound acidosis, hypercarbia, and hypoxia precluded an emergent operation, and venovenous extracorporeal membrane oxygenation (V-V ECMO) was used for organ support during physiologic resuscitation. After the achievement of physiologic repletion, a thoracotomy and lobectomy were performed while the patient was supported by V-V ECMO.