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1.
Artigo em Inglês | MEDLINE | ID: mdl-33605704

RESUMO

INTRODUCTION: Nonoperative management of acute calculous cholecystitis (ACC) in the frail geriatric population is underexplored. The aim of our study was to examine long-term outcomes of frail geriatric patients with ACC treated with cholecystectomy compared to initial nonoperative management. METHODS: We conducted a 2017 analysis of the Nationwide Readmissions Database and included frail geriatric (≥65 years) patients with ACC. Frailty was assessed using the 5-factor modified frailty index (mFI). Patients were stratified into those undergoing cholecystectomy at index admission (OP) vs. those managed with non-operative intervention (NOP). The NOP group was further subdivided into those who received antibiotics only, and those who received percutaneous drainage. Primary outcomes were procedure-related complications in the OP group and 6-month failure of NOP (readmission with cholecystitis). Secondary outcomes were mortality and overall hospital length of stay (LOS). RESULTS: A total of 53,412 geriatric patients with ACC were identified, 51.0% of whom were frail: 16,791 (61.6%) in OP group and 10,472 (38.4%) in NOP group (3,256 had percutaneous drainage, 7,216 received antibiotics only). Patients were comparable in age (76±7 vs. 77±8 years;p=0.082) and mFI (0.47 vs. 0.48;p=0.132). Procedure-related complications in the OP group was 9.3% and 6-month failure of NOP was 18.9%. Median time to failure of NOP management was 36[12-78] days. Mortality was higher in the frail NOP group (5.2 vs. 3.2%;p<0.001). The NOP group had more days of hospitalization (8[4-15] vs. 5[3-10];p<0.001). Both receiving antibiotics only (OR 1.6 [1.3-2.0]; p<0.001) and receiving percutaneous drainage (OR 1.9 [1.7-2.2]; p<0.001) were independently associated with increased mortality. CONCLUSION: One in five patients failed NOP and subsequently had complicated hospital stays. Non-operative management of frail elderly ACC patients may be associated with significant morbidity and mortality. LEVEL OF EVIDENCE: Level III Prognostic.

2.
J Trauma Acute Care Surg ; 90(3): 501-506, 2021 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-33617197

RESUMO

INTRODUCTION: Studies have proposed the use of antibiotics only in cases of acute uncomplicated appendicitis (AUA). However, there remains a paucity of data evaluating this nonoperative approach in the vulnerable frail geriatric population. The aim of this study was to examine long-term outcomes of frail geriatric patients with AUA treated with appendectomy compared with initial nonoperative management (NOP). METHODS: We conducted a 1-year (2017) analysis of the Nationwide Readmissions Database and included all frail geriatric patients(age, ≥65 years) with a diagnosis of AUA. Frailty was assessed using the five-factor modified frailty index. Patients were stratified into those undergoing appendectomy at index admission (operative management) versus those receiving antibiotics only without operative intervention (NOP). Propensity score matching in a 1:1 ratio was performed adjusting for patient- and hospital-related factors. RESULTS: A total of 5,562 frail geriatric patients with AUA were identified from which a matched cohort of 1,320 patients in each group was obtained. Patients in the NOP and operative management were comparable in terms of age (75.5 ± 7.7 vs. 75.5 ± 7.4 years; p = 0.882) and modified frailty index (0.4 [0.4-0.6] vs. 0.4 [0.4-0.6]; p = 0.526). Failure of NOP management was reported in 18% of patients, 95% of which eventually underwent appendectomy. Over the 6-month follow-up period, patients in the NOP group had significantly higher rates of Clostridium difficile enterocolitis (3% vs. 1%; p < 0.001), greater number of overall hospitalized days (5 [3-9] vs. 4 [2-7] days; p < 0.001), and higher overall costs (US $16,000 [12,000-25,000] vs. US $11,000 [8,000-19,000]; p < 0.001). Patients undergoing appendectomy after failed NOP had significantly higher rates of complications (20% vs. 11%; p < 0.001), mortality (4% vs. 2%; p = 0.019), and appendiceal neoplasm (3% vs. 1%; p = 0.027). CONCLUSION: One in six patients failed NOP within 6 months and required appendectomy with subsequent more complications and higher mortality. Appendectomy may offer better outcomes in managing AUA in the frail geriatric population. LEVEL OF EVIDENCE: Therapeutic, level IV.

4.
J Surg Res ; 261: 343-350, 2021 Jan 21.
Artigo em Inglês | MEDLINE | ID: mdl-33486416

RESUMO

BACKGROUND: Health literacy (HL) is an important component of national health policy. The aim of our study was to assess the prevalence of low HL (LHL) and determine its impact on outcomes after emergency general surgery (EGS). METHODS: We performed a (2016-2017) prospective cohort analysis of adult EGS patients. HL was assessed using the Short Assessment of HL score. LHL was defined as Short Assessment of HL score <14. Outcomes were the prevalence of LHL, compliance with medications, wound/drain care, 30-d complications, 30-d readmission, and time to resuming activities of daily living. RESULTS: We enrolled 900 patients. The mean age was 43 ± 11 y. Overall, 22% of the patients had LHL. LHL patients were more likely to be Hispanics (59% versus 15%, P < 0.01), uninsured (50% versus 20%, P < 0.01), have lower socioeconomic status (80% versus 40%, P < 0.02), and are less likely to have completed college (5% versus 60%, P < 0.01) compared with HL patients. On regression analysis, LHL was associated with lower medication compliance (OR: 0.81, [0.4-0.9], P = 0.02), inadequate wound/drain care (OR: 0.75, [0.5-0.8], P = 0.01), 30-d complications (OR: 1.95, [1.3-2.5], P < 0.01), and 30-d readmission (OR: 1.51, [1.2-2.6], P = 0.02). The median time of resuming activities of daily living was longer in patients with LHL than HL patients (4 d versus 7 d, P < 0.01). CONCLUSIONS: One in five patients undergoing EGS has LHL. LHL is associated with decreased compliance with discharge instructions, medications, and wound/drain care. Health literacy must be taken into account when discussing the postoperative plan and better instruction is needed for patients with LHL. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Prognostic.

5.
J Surg Res ; 257: 493-500, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32916502

RESUMO

BACKGROUND: Blood pressure alterations in patients with traumatic brain injury (TBI) have been shown to be associated with increased mortality. However, there is paucity of data describing the optimal emergency department (ED) systolic blood pressure (SBP) target during the initial evaluation. The aim of our study was to assess the association between SBP on presentation and mortality in patients with TBI. METHODS: We performed a retrospective (2015-2016) review of the American College of Surgeons Trauma Quality Improvement Program database and included all adult (age ≥18y) trauma patients who had TBI on presentation. The outcome measure was in-hospital mortality at different ED-SBP values. A subanalysis by age and TBI severity in accordance with the Glasgow Coma Scale (GCS) was performed (mild (GCS ≥13), moderate (GCS 9-12), and severe (≤8)). Multivariate logistic regression analysis was performed. RESULTS: A total of 94,411 adult trauma patients with TBI were included. Mean age was 59 ± 21y, 62% were male, and median GCS was 15 [14-15]. Mean SBP was 147 ± 28 mmHg, and overall mortality was 8.6%. The lowest rate of mortality was noticed at ED SBP between 110 and 149 mmHg, whereas the highest mortality was at admission SBP <90 mmHg and SBP >190 mmHg. On regression analysis, SBP between 130 and 149 mmHg (odds ratio = 0.92; P = 0.68) was not associated with increased odds of mortality relative to SBP between 110 and 129 mmHg. On subanalysis based on severity of TBI (mild 80.9%, moderate 5.3%, and severe 13.8%), patients with SBP between 110 and 149 mmHg were less likely to die across all TBI groups. CONCLUSIONS: The optimal ED-SBP range for patients with TBI seems to be age and severity dependent. The optimum range might guide clinicians in developing resuscitation protocols for managing patients with TBI. LEVEL OF EVIDENCE: Level III Prognostic.


Assuntos
Pressão Sanguínea , Lesões Encefálicas Traumáticas/mortalidade , Sistema de Registros , Adulto , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas Traumáticas/fisiopatologia , Serviço Hospitalar de Emergência/normas , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade , Estudos Retrospectivos , Estados Unidos/epidemiologia
6.
J Trauma Acute Care Surg ; 90(1): 177-184, 2021 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-33332783

RESUMO

BACKGROUND: Traumatic brain injury (TBI) is associated with sympathetic discharge that leads to posttraumatic hyperthermia (PTH). Beta blockers (ßß) are known to counteract overactive sympathetic discharge. The aim of our study was to evaluate the effect of ßß on PTH in critically-ill TBI patients. METHODS: We performed retrospective cohort analysis of the Medical Information Mart for Intensive Care database. We included all critically ill TBI patients with head Abbreviated Injury Scale (AIS) score of 3 or greater and other body region AIS score less than 2 who developed PTH (at least one febrile episode [T > 38.3°C] with negative microbiological cultures (blood, urine, and bronchoalveolar lavage). Patients on preinjury ßß were excluded. Patients were stratified into (ßß+) and (ßß-) groups. Propensity score matching was performed (1:1 ratio) controlling for patient demographics, injury parameters and other medications that influence temperature. Outcomes were the number of febrile episodes, maximum temperature, and the time interval between febrile episodes. Multivariate linear regression was performed. RESULTS: We analyzed 4,286 critically ill TBI patients. A matched cohort of 1,544 patients was obtained: 772 ßß + (metoprolol, 60%; propranolol, 25%; and atenolol, 15%) and 772 ßß-. Mean age was 63.4 ± 15.4 years, median head AIS score of 3 (3-4), and median Injury Severity Score of 10 (9-16). Patients in the ßß+ group had a lower number of febrile episodes (8 episodes vs. 12 episodes; p = 0.003), lower median maximum temperature (38.0°C vs. 38.5°C; p = 0.025), and a longer median time between febrile episodes (3 hours vs. 1 hour; p = 0.013). On linear regression, propranolol was found to be superior in terms of reducing the number of febrile episodes and the maximum temperature. However, there was no significant difference between the three ßß in terms of reducing the time interval between febrile episodes (p = 0.582). CONCLUSION: Beta blockers attenuate PTH by decreasing the frequency of febrile episodes, increasing the time interval between febrile episodes, and reducing the maximum rise in temperature. ßß may be a potential therapeutic modality in PTH. LEVEL OF EVIDENCE: Therapeutic, level IV.

7.
J Surg Res ; 257: 69-78, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32818786

RESUMO

BACKGROUND: Despite improvements in operative techniques, major abdominal complications (MACs) continue to occur after penetrating abdominal trauma (PAT). This study aimed to evaluate the burden of MAC after PAT. METHODS: The (2012-2015) National Readmission Database was queried for all adult (age ≥18 y) trauma patients with penetrating injuries who underwent exploratory laparotomy and were readmitted within 6 mo of index hospitalization discharge. Patients were stratified by firearm injuries (FIs) and stab injuries (SIs). Primary outcomes were rates of MAC: intra-abdominal abscesses (IAAs), superficial surgical site infection (SSI), and fascial dehiscence within 6 mo after discharge. Secondary outcomes were both nonabdominal complications and mortality, postdischarge, and 6-mo readmission. Regression analysis was performed. RESULTS: A total of 4473 patients (FI, 2326; SI, 2147) were included in the study; the mean age was 32 ± 14 y, the Injury Severity Score was 19 (15-25), and 23% underwent damage control laparotomy (DCL). The rate of MAC within 6 mo was 22% (IAA 19%, SSI 7%, and fascial dehiscence 4%). Patients with FIs had a higher rate of IAA (27% versus 10%; P < 0.01), SSI (11% versus 3%; P < 0.01), fascial dehiscence (5% versus 3%; P = 0.03), nonabdominal complications (54% versus 24%; P < 0.01), and postdischarge mortality (8% versus 6%; P < 0.01) compared with patients with SIs . On regression analysis, DCL (P < 0.01), large bowel perforation (P < 0.01), biliary-pancreatic injury (P < 0.01), hepatic injury (P < 0.01), and blood transfusion (P = 0.02) were predictors of MAC. CONCLUSIONS: MAC developed in one in five patients after PAT. FIs have a higher potential for hollow viscus injury and peritoneal contamination, and are more predictive of MAC and nonabdominal complications, especially after DCL. LEVEL OF EVIDENCE: Level III Prognostic.


Assuntos
Abdome/cirurgia , Traumatismos Abdominais/cirurgia , Laparotomia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Ferimentos Penetrantes/cirurgia , Abscesso Abdominal/epidemiologia , Traumatismos Abdominais/complicações , Traumatismos Abdominais/mortalidade , Adolescente , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Laparotomia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Deiscência da Ferida Operatória/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Ferimentos por Arma de Fogo/complicações , Ferimentos por Arma de Fogo/cirurgia , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/mortalidade , Ferimentos Perfurantes/complicações , Ferimentos Perfurantes/cirurgia , Adulto Jovem
8.
J Surg Res ; 257: 239-245, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32862051

RESUMO

BACKGROUND: With an aging population, the number of patients on antiplatelet medications and traumatic brain injury (TBI) is increasing. Our study aimed to evaluate the role of platelet transfusion on outcomes after traumatic intracranial bleeding (IB) in these patients. METHODS: We analyzed our prospectively maintained TBI database from 2014 to 2016. We included all isolated TBI patients with an IB, who were on preinjury antiplatelet agents and excluded patients taking anticoagulants. Outcome measures included the progression of IB, neurosurgical intervention, and mortality. Regression analysis was performed. RESULTS: A total of 343 patients met the inclusion criteria. Mean age was 58 ± 11 y, 58% were men, and median injury severity score was 15 (10-24). Distribution of antiplatelet agents was as follows: aspirin (60%) and clopidogrel (35%). Overall, 74% patients received platelet transfusion after admission with a median number of two platelet units. After controlling for confounders, patients who received one unit of pooled platelets had no difference in progression of IB (odds ratio [OR]: 0.98, [0.6-1.9], P = 0.41), need for neurosurgical intervention (OR: 1.09, [0.7-2.5], P = 0.53), and mortality (OR: 0.84, [0.6-1.8], P = 0.51). However, patients who received two units of pooled platelets had lower rate of progression of IB (OR: 0.69, [0.4-0.8], P = 0.02), the need for neurosurgical intervention (OR: 0.81, [0.3-0.9], P = 0.03), and mortality (OR: 0.84, [0.5-0.9], P = 0.04). Both groups were compared with those who did not receive platelet transfusion. CONCLUSIONS: The use of two units of platelet may decrease the risk of IB progression, neurosurgical intervention, and mortality in patients on preinjury antiplatelet agents and TBI. Further studies should focus on developing protocols for platelet transfusion to improve outcomes in these patients. LEVEL OF EVIDENCE: Level III prognostic.


Assuntos
Hemorragia Intracraniana Traumática/terapia , Procedimentos Neurocirúrgicos/estatística & dados numéricos , Inibidores da Agregação de Plaquetas/efeitos adversos , Transfusão de Plaquetas/estatística & dados numéricos , Idoso , Progressão da Doença , Feminino , Humanos , Escala de Gravidade do Ferimento , Hemorragia Intracraniana Traumática/diagnóstico , Hemorragia Intracraniana Traumática/mortalidade , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Resultado do Tratamento
9.
J Surg Res ; 259: 182-191, 2020 Dec 05.
Artigo em Inglês | MEDLINE | ID: mdl-33290893

RESUMO

INTRODUCTION: Changes in the shock index (ΔSI) can be a predictive tool but is not established among pediatric trauma patients. The aim of our study was to assess the impact of ΔSI on mortality in pediatric trauma patients. METHODS: We performed a 2017 analysis of all pediatric trauma patients (age 0-16 y) from the ACS-TQIP. SI was defined as heart rate(HR)/systolic blood pressure(SBP). We abstracted the SI in the field (EMS), SI in the emergency department (ED) and calculated the change in SI (ΔSI = ED SI-EMS SI). Patients were divided into four age groups: 0-3 y, 4-6 y, 7-12 y, and 13-16 y and substratified into two groups based on the value of the age-group-specific ΔSI cutoff obtained with receiver operating characteristic ROC analysis; +ΔSI and -ΔSI. Our outcome measure was mortality. Multivariable logistic and Cox regression analyses were performed. RESULTS: We included 31,490 patients. Mean age was 10.6 ± 4.6 y, and 65.8% were male. The overall mortality rate was 1.4%. In the age group 0-3 y the cutoff point for ΔSI was 0.29 with an area under the curve (AUC) 0.70 [0.62-0.79], ΔSI cutoff 4-6 y was 0.41 AUC 0.81 [0.70-0.92], ΔSI cutoff 7-12 y was 0.05 AUC 0.83 [0.76-0.90], and ΔSI cutoff 13-16 y was 0.13 AUC 0.75 [0.69-0.81]. On the Cox regression analysis, +ΔSI was independently associated with increased in-hospital mortality and 24-h mortality (P ≤ 0.01). CONCLUSIONS: Vital signs vary by age group in children, but ΔSI inherently accounts for this variation. ΔSI predicts mortality and may be utilized as a predictor to help guide triage of pediatric trauma patients. LEVEL OF EVIDENCE: Level III Prognostic.

10.
Ann Surg ; 2020 Nov 17.
Artigo em Inglês | MEDLINE | ID: mdl-33214470

RESUMO

OBJECTIVE: Compare emergency general surgery (EGS) patient outcomes following index and non-index hospital readmissions, and explore predictive factors for non-index readmission. BACKGROUND: Readmission to a different hospital leads to fragmentation of care. The impact of non-index readmsision on patient outcomes following EGS is not well established. METHODS: The Nationwide Readmissions Database (2017) was queried for adult patients readmitted following an EGS procedure. Patients were stratified and propensity-matched according to readmission destination: index vs. non-index hospital. Outcomes were failure to rescue (FTR), mortality, number of subsequent readmissions, overall hospital LOS, and total costs. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS: A total of 471,570 EGS patients were identified, of which 79,127 (16.8%) were readmitted within 30 days: index hospital (61,472; 77.7%) vs. non-index hospital (17,655; 22.3%). Following 1:1 propensity matching, patients with non-index readmission had higher rates of FTR (5.6% vs. 4.3%; p < 0.001), mortality (2.7% vs. 2.1%; p < 0.001), and overall hospital costs (in $1000; 37 [27-64] vs. 28 [21-48]; p < 0.001). Non-index readmission was independently associated with higher odds of FTR (aOR 1.18 [1.03-1.36]; p < 0.001). Predictors of non-index readmission included top quartile for zip code median household income (1.35 [1.08-1.69]; p < 0.001), fringe county residence (1.08 [1.01-1.16]; p = 0.049), discharge to a skilled nursing facility (1.28 [1.20-1.36]; p < 0.001), and leaving AMA (2.32 [1.81-2.98]; p < 0.001). CONCLUSION: One in five readmissions after EGS occur at a different hospital. Non-index readmission carries a heightened risk of FTR. LEVEL OF EVIDENCE: Level III Prognostic STUDY TYPE:: Prognostic.

11.
J Intensive Care Med ; : 885066620968518, 2020 Oct 28.
Artigo em Inglês | MEDLINE | ID: mdl-33111599

RESUMO

Tele-ICU is a technology-based model designed to deliver effective critical care in the intensive care unit (ICU). The tele-ICU system has been developed to address the increasing demand for intensive care services and the shortage of intensivists. A finite number of intensivists from remote locations provide real-time services to multiple ICUs and assist in the treatment of critically ill patients. Risk prediction algorithms, smart alarm systems, and machine learning tools augment conventional coverage and can potentially improve the quality of care. Tele-ICU is associated with substantial improvements in mortality, reduced hospital and ICU length of stay, and decreased health care costs. Although multiple studies show improved outcomes following the implementation of tele-ICU, results are not consistent. Several factors, including the heterogeneity of tele-ICU infrastructure deployed in different facilities and the reluctance of health care workers to accept tele-ICU, could be associated with these varied results. Considerably high installation and ongoing operational costs might also be limiting the widespread utilization of this innovative service. While we believe that the implementation of tele-ICU offers potential advantages and makes critical care delivery more efficient, further research on the impact of this technology in critical care settings is warranted.

12.
J Surg Res ; 258: 119-124, 2020 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-33010556

RESUMO

BACKGROUND: Thromboprophylaxis in patients with spinal trauma is often delayed due to the risk of bleeding and expansion of the intraspinal hematoma (ISH). Our study aimed to assess the safety of early initiation of thromboprophylaxis in patients with operative spinal trauma (OST). METHODS: We performed a 2014-2017 retrospective analysis of our level I trauma registry and included all adult patients with isolated OST who received low-molecular-weight heparin (LMWH). Patients were stratified into early (≤48 h) and late (>48 h) initiation of LMWH groups. Outcomes were a decline in hemoglobin level, packed red blood cell transfusion, and progression of ISH. We performed multivariable logistic regression. RESULTS: We identified a total of 526 patients (early: 332, late: 194). Mean age was 46 ± 22y, and the median spine abbreviated injury scale was 3 [2-4]. After thromboprophylaxis, 1.5% (8) of the patients had progression of ISH and 1% (5) underwent surgical decompression of the spinal canal. There was no difference between the two groups regarding the rate of postprophylaxis ISH progression (1.5% versus 1.6%, P = 0.11) or surgical decompression (0.9% versus 1.1%, P = 0.19). Patients who received LMWH within 48 hrs had a lower incidence of clinically significant deep vein thrombosis (2.4% versus 6.8%, P = 0.02), but no difference in pulmonary embolism (0.6% versus 1.6%, P = 0.33) or mortality (1.2% versus 1.5%, P = 0.41). On regression analysis, there was no difference regarding decline in hemoglobin levels (ß = 0.079, [-0.253 to 1.025]; P = 0.23) or number of packed red blood cell units transfused (ß = -0.011, [-0.298 to 0.471]; P = 0.35). CONCLUSIONS: Thromboprophylaxis with LMWH within the first 48 h in patients with OST is safe and efficacious. Prospective studies are needed to further validate their risk-benefit ratio. LEVEL OF EVIDENCE: Level III therapeutic.

13.
J Am Coll Surg ; 2020 Oct 03.
Artigo em Inglês | MEDLINE | ID: mdl-33022396

RESUMO

BACKGROUND: Pelvic hemorrhage is potentially lethal despite homeostatic interventions such as pre-peritoneal packing (PP), resuscitative endovascular balloon occlusion of the aorta (REBOA), surgery, and/or angioembolization. REBOA may be used as an alternative/adjunct to PP for temporizing bleeding in patients with pelvic fractures. Our study aimed to compare the outcomes of REBOA and/or PP, as temporizing measures, in blunt pelvic fracture patients. We hypothesized that REBOA is associated with worsened outcomes. STUDY DESIGN: We performed a 2017 review of the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) and identified trauma patients with blunt pelvic fractures who underwent REBOA placement and/or PP before laparotomy and/or angioembolization. Propensity score matching was performed, adjusting for demographics, vitals, mechanism of injury, ISS, each body region-AIS, and pelvic fracture type. Outcomes were complication rates and mortality. RESULTS: A total of 156 patients (PP: 52; REBOA: 52; REBOA+PP: 52) were matched and included. Mean age was 43 ± 18 years, Injury Severity Score (ISS) was 28 (range 17-32), and 74% were males. Overall mortality was 42%. The 24-hour mortality (25% vs 14% vs 35%; p = 0.042), in-hospital mortality (44% vs 29% vs 54%; p = 0.034), and 4-hour pRBC units transfused (15 [9-23] vs 10 [4-19] vs 16 [9-27]; p = 0.017) were lower in the REBOA group. The REBOA group had faster times to both laparotomy (p = 0.040) and/or angioembolization (p = 0.012). There was no difference between the groups in acute kidney injury, lower limb amputations, or hospital and ICU length of stay among survivors. CONCLUSIONS: REBOA is a less invasive procedure compared with PP and is associated with improved outcomes. Further clinical trials are needed to define the optimal patient who will benefit from REBOA.

14.
J Trauma Acute Care Surg ; 89(4): 723-729, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33017133

RESUMO

INTRODUCTION: Angioembolization (AE) is an integral component in multidisciplinary algorithms for achieving hemostasis in patients with trauma. The American College of Surgeons Committee on Trauma recommends that interventional radiologists be available within 30 minutes to perform emergent AE. However, the impact of the timing of AE on patient outcomes is still not well known. We hypothesized that a delay in AE would be associated with increased mortality and higher blood transfusion requirements in patients with blunt intra-abdominal solid organ injury. METHODS: A 4-year (2013-2016) retrospective review of the ACS Trauma Quality Improvement Program database was performed. We included adult patients (age, ≥18 years) with blunt intra-abdominal solid organ injury who underwent AE within 4 hours of hospital admission. Patients who underwent operative intervention before AE were excluded. The primary outcome was 24-hour mortality. The secondary outcome was blood product transfusions. Patients were grouped into four 1-hour intervals according to their time from admission to AE. Multivariate regression analysis was performed to accommodate patient differences. RESULTS: We analyzed 1,009,922 trauma patients, of which 924 (1 hour, 76; 1-2 hours, 224; 2-3 hours, 350; 3-4 hours, 274) were deemed eligible. The mean ± SD age was 44 ± 19 years, and 66% were male. The mean ± SD time to AE was 144 ± 54 minutes, and 92% of patients underwent AE more than 1 hour after admission. Overall 24-hour mortality was 5.2%. On univariate analysis, patients receiving earlier AE had decreased 24-hour mortality (p = 0.016), but no decrease in blood products transfused. On regression analysis, every hour delay in AE was significantly associated with increased 24-hour mortality (p < 0.05). CONCLUSION: Delayed AE for hemorrhagic control in blunt trauma patients with an intra-abdominal solid organ injury is associated with increased 24-hour mortality. Trauma centers should ensure timeliness of interventional radiologist availability to prevent a delay in vital AE, and it should be a focus of quality improvement projects. LEVEL OF EVIDENCE: Prognostic, level III.

16.
Artigo em Inglês | MEDLINE | ID: mdl-32925573

RESUMO

INTRODUCTION: The volume-outcome relationship led to the regionalization of trauma care. The relationship between trauma centers' injury-specific laparotomy volume and outcomes has not been explored. The aim of our study was to examine the relationship between a trauma center's injury-specific laparotomy volume and outcomes in blunt and penetrating trauma patients. METHODS: We performed a (2017) analysis of the Trauma Quality Improvement Program (TQIP) database. We included adult (age ≥18 years) blunt and penetrating trauma patients who required emergent laparotomies for hemorrhage control. Trauma centers were stratified based on their blunt and penetrating laparotomy volumes: HV (high volume) ≥25 cases/year; MV (medium volume) 13-24 cases/year; LV (low volume) ≤12 cases/year. Multivariate regression analysis was performed to explore predictors of in-hospital mortality. RESULTS: A total of 8,588 patients underwent emergent laparotomy for either blunt (4,936; 57.5%) or penetrating injuries (3,652; 42.5%). Overall, mean age was 40±17y, abdomen AIS was 3[2-4], and ISS was 26[17-35]. For ACS Level I centers: 50% were HV, 29% MV, and 21% LV. For ACS Level II centers: 7% were HV, 23% MV, and 70% LV. For ACS Level III centers: 100% were LV. On multivariate regression analysis, admission of blunt and penetrating trauma patients to HV blunt and HV penetrating centers, respectively, was independently associated with improved in-hospital mortality. HV blunt centers had a significantly lower time to laparotomy (72[41-144] minutes) vs. MV (81[49-145]) and LV (94[56-158]) centers (p<0.001). The same trend was observed for HV penetrating trauma centers (35[24-52] minutes) vs. MV (46[33-63]) and LV (51[38-69]) centers (p<0.001). CONCLUSION: Blunt and penetrating injury patients requiring emergent laparotomy had higher survival when admitted to trauma centers with HV operative experience for their particular mechanism of injury. The regionalization of trauma care should be based on a thorough evaluation of trauma centers' injury-specific operative experience. LEVEL OF EVIDENCE: Level III PrognosticPrognostic.

17.
Ann Surg ; 272(4): 556-561, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32932306

RESUMO

OBJECTIVE: To evaluate racial disparities among White and Black pediatric firearm injury patients on a national level. BACKGROUND: Pediatric firearm-related morbidity and mortality are rising in the United States. There is a paucity of data examining racial disparities in those patients. METHODS: The Pediatric Trauma Quality Improvement Program (2017) was queried for pediatric (age ≤17 years) patients admitted with firearm injuries. Patients were stratified by race: White and Black. Injury characteristics were assessed. Outcomes were mortality, hospital length of stay, and discharge disposition. Hierarchical regression models were performed to determine predictors of mortality and longer hospital stays. RESULTS: A total of 3717 pediatric firearm injury patients were identified: Blacks (67.0%) and Whites (33.0%). The majority of patients were male (84.2%). The most common injury intent in both groups was assault (77.3% in Blacks vs in 45.4% Whites; P<0.001), followed by unintentional (21.1% vs 35.4%; P<0.001), and suicide (1.0% vs 14.0%; P<0.001). The highest fatality rate was in suicide injuries (62.6%). On univariate analysis, White children had higher mortality (17.5% vs 9.8%; P<0.001), longer hospital stay [3 (1-7) vs 2 (1-5) days; P = 0.021], and more psychiatric hospital admissions (1.3% vs 0.1%; P<0.001). On multivariate analysis, suicide intent was found to be an independent predictor of mortality (aOR 2.67; 95% CI 1.35-5.29) and longer hospital stay (ß + 4.13; P<0.001), while White race was not. CONCLUSION: Assault is the leading intent of injury in both Black and White children, but White children suffer more from suicide injuries that are associated with worse outcomes. LEVEL OF EVIDENCE: Level III Prognostic.


Assuntos
Afro-Americanos/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Ferimentos por Arma de Fogo/mortalidade , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Estados Unidos/epidemiologia
18.
J Pediatr Surg ; 2020 Jul 30.
Artigo em Inglês | MEDLINE | ID: mdl-32883505

RESUMO

INTRODUCTION: Venous thromboembolism (VTE) prophylaxis in pediatric patients is controversial and is mainly dependent on protocols derived from adult practices. Our study aimed to compare outcomes among pediatric trauma patients who received low molecular weight heparin (LMWH) compared to those who received unfractionated heparin (UFH). METHODS: We performed 2 years (2015-2016) retrospective analysis of the Pediatrics ACS-TQIP database. Pediatric trauma patients (age ≤17) who received thromboprophylaxis with either LMWH or UFH were included. Patients were stratified into three age groups. Analysis of each subgroup and the entire cohort was performed. Outcome measures included VTE events (deep vein thrombosis [DVT] and pulmonary embolism [PE]), hospital and ICU length of stay (LOS) among survivors, and mortality. Propensity score matching was used to match the two cohorts LMWH vs UFH. RESULTS: A matched cohort of 1,678 pediatric trauma patients was analyzed. A significant difference in survival, DVT events, and in-hospital LOS was seen in the age groups above 9 years. Overall, the patients who received LMWH had lower mortality (1.4% vs 3.6%, p<0.01), DVT (1.7% vs 3.7%, p<0.01), and hospital LOS among survivors (7 days vs 9 days, p<0.01) compared to those who received UFH. There was no significant difference in the ICU LOS among survivors and the incidence of PE between the two groups. CONCLUSION: LMWH is associated with increased survival, lower rates of DVT, and decreased hospital LOS compared to UFH among pediatric trauma patients age 10-17 years. LEVEL OF EVIDENCE: Level III Prophylactic. STUDY TYPE: Prophylactic.

19.
J Trauma Acute Care Surg ; 89(2): 329-335, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32744830

RESUMO

INTRODUCTION: Renewed interest in whole blood (WB) resuscitation in civilians has emerged following its military use. There is a paucity of data on its role in civilians where balanced component therapy (CT) resuscitation is the standard of care. The aim of this study was to assess nationwide outcomes of using WB as an adjunct to CT versus CT alone in resuscitating civilian trauma patients. METHODS: We analyzed the (2015-2016) Trauma Quality Improvement Program. We included adult (age, ≥18 years) trauma patients presenting with hemorrhagic shock and requiring at least 1 U of packed red blood cells (pRBCs) within 4 hours. Patients were stratified into WB-CT versus CT only. Primary outcomes were 24-hour and in-hospital mortality. Secondary outcomes were hospital length of stay and major complications. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS: A total of 8,494 patients were identified, of which 280 received WB-CT (WB, 1 [1-1]; pRBC, 16 [10-23]; FFP, 9 [6-16]; platelets, 3 [2-5]) and 8,214 received CT only (pRBC, 15 [10-24]; FFP, 10 [6-16]; platelets, 2 [1-4]). Mean ± SD age was 34 ± 16 years, 79% were male, Injury Severity Score was 33 (24-43), and 63% had penetrating injuries. Patients who received WB-CT had a lower 24-hour mortality (17% vs. 25%; p = 0.002), in-hospital mortality (29% vs. 40%; p < 0.001), major complications (29% vs. 41%; p < 0.001), and a shorter length of stay (9 [7-12] vs. 15 [10-21]; p = 0.011). On regression analysis, WB was independently associated with reduced 24-hour mortality (odds ratio [OR], 0.78 [0.59-0.89]; p = 0.006), in-hospital mortality (OR, 0.88 [0.81-0.90]; p = 0.011), and major complications (OR, 0.92 [0.87-0.96]; p = 0.013). CONCLUSION: The use of WB as an adjunct to CT is associated with improved outcomes in resuscitation of severely injured civilian trauma patients. Further studies are required to evaluate the role of adding WB to massive transfusion protocols. LEVEL OF EVIDENCE: Therapeutic, level IV.


Assuntos
Transfusão de Componentes Sanguíneos , Transfusão de Sangue , Técnicas Hemostáticas , Choque Hemorrágico/terapia , Ferimentos e Lesões/complicações , Adulto , Terapia Combinada , Serviço Hospitalar de Emergência , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Choque Hemorrágico/etiologia , Resultado do Tratamento , Estados Unidos
20.
J Trauma Acute Care Surg ; 89(2): 405-410, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32744835

RESUMO

INTRODUCTION: Organ dysfunction following traumatic brain injury (TBI) is common and has been associated with unpredictable outcomes. The aim of our study is to describe the incidence of non-neurological organ dysfunction (NNOD) and its impact on outcomes in patients with severe TBI admitted to our intensive care unit (ICU). METHODS: We performed a 3-year (2015-2017) review of our Level 1 trauma center's prospectively maintained TBI database and included all adult (age ≥18y) patients with isolated severe TBI (head abbreviated injury severity (AIS) ≥3 and other AIS <3) and an ICU stay >48 hours. Organ dysfunction (OD) was measured by multiple organ dysfunction scores. Organ system failure was defined as a non-neurological component score of ≥3 on any day during the ICU stay. Outcomes measured were the incidence of NNOD and its effect on outcomes. Multivariate regression analysis was performed. RESULTS: A total of 285 patients were included. The mean age was 48 ± 22 years, 72% were males, median [IQR] Glasgow Coma Scale (GCS) was 8[5-10], and median Injury Severity Score (ISS) was 17[10-26]. Epidural hematoma was the most common intracranial hemorrhage (49%) followed by subdural hematoma (46%). The overall incidence of NNOD was 33%, with the most common dysfunctional organ system being the respiratory (23%) followed by the cardiovascular (12%) and hepatic system (8%). The overall in-hospital mortality rate was 19% (NNOD:36% vs. No-NNOD:9%, p< 0.01). On regression analysis, NNOD was associated with higher in-hospital mortality (aOR: 2.0 [1.6-2.7]), discharge to skilled nursing facility (SNF) (aOR: 1.8 [1.4-2.2]), and Glasgow Outcome Scale-Extended (GOS-E) ≤4 (OR: 1.7 [1.3-2.3]) and p-values <0.01. CONCLUSION: One in every three isolated severe TBI patients develop NNOD. NNOD is independently associated with worse outcomes. Understanding the mechanisms associated with NNOD in the setting of TBI may promote prevention practices and improve outcomes in TBI. LEVEL OF EVIDENCE: Prognostic, level III.


Assuntos
Lesões Encefálicas Traumáticas/complicações , Escores de Disfunção Orgânica , Adulto , Idoso , Cuidados Críticos , Feminino , Hematoma Epidural Craniano/etiologia , Hematoma Subdural/etiologia , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Centros de Traumatologia , Estados Unidos
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