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1.
Craniomaxillofac Trauma Reconstr ; 14(2): 110-118, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33995831

RESUMO

STUDY DESIGN: Retrospective case series. OBJECTIVE: Speech language pathology (SLP) is an underutilized but important component in rehabilitation after tracheostomy. The purpose of this study was to determine rates of SLP utilization and to streamline tracheostomy decannulation to be more efficient and safer through increased utilization of SLP. METHODS: Adult patients who underwent tracheostomy from April 2016 to December 2018 were evaluated. The primary outcome was completion of any SLP evaluation after tracheostomy, and secondary outcomes were duration from surgery to evaluation, speaking valve and swallow study utilization, downsize and decannulation rates, mean duration of cannulation, and complications. RESULTS: A total of 255 subjects were included, where 197 (77.3%) underwent SLP evaluation. A minority received a speaking valve (33.7%), while approximately half underwent a swallow study (52.9%). There was a delay in SLP evaluation, with mean duration from surgery to SLP evaluation of 5.9 ± 8.0 days. There was consistent improvement in downsize and decannulation rates in all cohorts that utilized SLP services. Tracheostomy indication of head and neck cancer, trauma, completing a successful swallow study conferred increased odds of eventual decannulation, while obesity and tracheostomy history conferred lower odds. An interdisciplinary decannulation pathway was created, based on literature review and results, to assist in decision-making while progressing toward decannulation. CONCLUSION: Speech language pathologists are underutilized for rehabilitation of tracheostomy patients, where they are able to offer many skills to diagnose, treat, manage, and troubleshoot, as patients advance through the decannulation process.

2.
J Trauma Acute Care Surg ; 90(3): 557-564, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33507026

RESUMO

BACKGROUND: The Emergency Surgery Score (ESS) was recently validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively evaluate whether ESS can predict the need for respiratory and/or renal support (RRS) at discharge after emergent laparotomies (EL). METHODS: This is a post hoc analysis of a 19-center prospective observational study. Between April 2018 and June 2019, all adult patients undergoing EL were enrolled. Preoperative, intraoperative, and postoperative variables were systematically collected. In this analysis, patients were excluded if they died during the index hospitalization, were discharged to hospice, or transferred to other hospitals. A composite variable, the need for RRS, was defined as the need for one or more of the following at hospital discharge: tracheostomy, ventilator dependence, or dialysis. Emergency Surgery Score was calculated for all patients, and the correlation between ESS and RRS was examined using the c-statistics method. RESULTS: From a total of 1,649 patients, 1,347 were included. Median age was 60 years, 49.4% were men, and 70.9% were White. The most common diagnoses were hollow viscus organ perforation (28.1%) and small bowel obstruction (24.5%); 87 patients (6.5%) had a need for RRS (4.7% tracheostomy, 2.7% dialysis, and 1.3% ventilator dependence). Emergency Surgery Score predicted the need for RRS in a stepwise fashion; for example, 0.7%, 26.2%, and 85.7% of patients required RRS at an ESS of 2, 12, and 16, respectively. The c-statistics for the need for RRS, the need for tracheostomy, ventilator dependence, or dialysis at discharge were 0.84, 0.82, 0.79, and 0.88, respectively. CONCLUSION: Emergency Surgery Score accurately predicts the need for RRS at discharge in EL patients and could be used for preoperative patient counseling and for quality of care benchmarking. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.


Assuntos
Serviço Hospitalar de Emergência , Hospitalização , Laparotomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Diálise Renal , Respiração Artificial , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Determinação de Necessidades de Cuidados de Saúde , Complicações Pós-Operatórias/terapia , Valor Preditivo dos Testes , Medição de Risco
3.
Am J Surg ; 221(5): 1069-1075, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-32917366

RESUMO

INTRODUCTION: We sought to evaluate whether the Emergency Surgery Score (ESS) can accurately predict outcomes in elderly patients undergoing emergent laparotomy (EL). METHODS: This is a post-hoc analysis of an EAST multicenter study. Between April 2018 and June 2019, all adult patients undergoing EL in 19 participating hospitals were prospectively enrolled, and ESS was calculated for each patient. Using the c-statistic, the correlation between ESS and mortality, morbidity, and need for ICU admission was assessed in three patient age cohorts (65-74, 75-84, ≥85 years old). RESULTS: 715 patients were included, of which 52% were 65-74, 34% were 75-84, and 14% were ≥85 years old; 51% were female, and 77% were white. ESS strongly correlated with postoperative mortality (c-statistic:0.81). Mortality gradually increased from 0% to 20%-60% at ESS of 2, 10 and 16 points, respectively. ESS predicted mortality, morbidity, and need for ICU best in patients 65-74 years old (c-statistic:0.81, 0.75, 0.83 respectively), but its performance significantly decreased in patients ≥85 years (c-statistic:0.72, 0.64, 0.67 respectively). CONCLUSION: ESS is an accurate predictor of outcome in the elderly EL patient 65-85 years old, but its performance decreases for patients ≥85. Consideration should be given to modify ESS to better predict outcomes in the very elderly patient population.


Assuntos
Tratamento de Emergência/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Tratamento de Emergência/efeitos adversos , Tratamento de Emergência/mortalidade , Feminino , Humanos , Laparotomia/efeitos adversos , Laparotomia/mortalidade , Masculino , Medição de Risco , Índice de Gravidade de Doença , Resultado do Tratamento , Estados Unidos
4.
Trauma Surg Acute Care Open ; 5(1): e000528, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33381653

RESUMO

BACKGROUND: Cervical spinal cord injury (CSCI) is devastating and costly. Previous research has demonstrated that diaphragm pacing (DPS) is safe and improves respiratory mechanics. This may decrease hospital stays, vent days, and costs. We hypothesized DPS implantation would facilitate liberation from ventilation and would impact hospital charges. METHODS: We performed a retrospective review of patients with acute CSCI between January 2005 and May 2017. Routine demographics were collected. Patients underwent propensity matching based on age, injury severity score, ventilator days, hospital length of stay, and need for tracheostomy. We then adjusted total hospital charges by year using US Bureau of Labor Statistics annual adjusted Medical Care Prices. Bivariate and multivariate linear regression statistics were performed using STATA V.15. RESULTS: Between July 2011 and May 2017, all patients with acute CSCI were evaluated for DPS implantation. 40 patients who had laparoscopic DPS implantation (DPS) were matched to 61 who did not (NO DPS). Following DPS implantation, there was a statistically significant increase in spontaneous Vt compared with NO DPS (+88 mL vs -13 mL; 95% CI 46 to 131 vs -78 to 51 mL, respectively; p=0.004). Median time to liberation after DPS was significantly shorter (10 vs 29 days; 95% CI 6.5 to 13.6 vs 23.1 to 35.3 days; p<0.001). Adjusted hospital charges were significantly lower for DPS on multivariate linear regression models controlling for year of injury, sex, race, injury severity, and age (p=0.003). DISCUSSION: DPS implantation in patients with acute CSCI produces significant improvements in spontaneous Vt and reduces time to liberation, which translated into reduced hospital charges on a risk-adjusted, inflation-adjusted model. DPS implantation for patients with acute CSCI should be considered. LEVEL OF EVIDENCE: Level III.

5.
J Trauma Acute Care Surg ; 89(3): 423-428, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32467474

RESUMO

BACKGROUND: Cervical spinal cord injury (CSCI) is devastating with ventilator-associated pneumonia being a main driver of morbidity and mortality. Laparoscopic diaphragm pacing implantation (DPS) has been used for earlier liberation from mechanical ventilation. We hypothesized that DPS would improve respiratory mechanics and facilitate liberation. METHODS: We performed a retrospective review of acute CSCI patients between January 2005 and May 2017. Routine demographics were collected. Patients underwent propensity score matching based on age, Injury Severity Score, ventilator days, hospital length of stay, and need for tracheostomy. Patients with complete respiratory mechanics data were analyzed and compared. Those who did not have DPS (NO DPS) had spontaneous tidal volume (Vt) recorded at time of intensive care unit admission, at day 7, and at day 14, and patients who had DPS had spontaneous Vt recorded before and after DPS. Time to ventilator liberation and changes in size of spontaneous Vt for patients while on the ventilator were analyzed. Bivariate and multivariate logistic and linear regression statistics were performed using STATA v10. RESULTS: Between July 2011 and May 2017, 37 patients that had DPS were matched to 34 who did not (NO DPS). Following DPS, there was a statistically significant increase in spontaneous Vt compared with NO DPS (+88 mL vs. -13 mL; 95% confidence interval, 46-131 mL vs. -78 to 51 mL, respectively; p = 0.004). Median time to liberation after DPS was significantly shorter (10 days vs. 29 days; 95% CI, 6.5-13.6 days vs. 23.1-35.3 days; p < 0.001). Liberation prior to hospital discharge was not different between the two groups. The DPS placement was found to be associated with a statistically significant decrease in days to liberation and an increase in spontaneous Vt in multivariate linear regression models. CONCLUSION: The DPS implantation in acute CSCI patients produces significant improvements in spontaneous Vt and reduces time to liberation from mechanical ventilation. Prospective comparative studies are needed to define the clinical benefits and potential cost savings of DPS implantation. LEVEL OF EVIDENCE: Therapeutic IV.


Assuntos
Diafragma , Terapia por Estimulação Elétrica , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Insuficiência Respiratória/terapia , Traumatismos da Medula Espinal/complicações , Doença Aguda , Adulto , Vértebras Cervicais , Eletrodos Implantados , Feminino , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva , Tempo de Internação , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Pneumonia Associada à Ventilação Mecânica/etiologia , Respiração , Respiração Artificial/efeitos adversos , Insuficiência Respiratória/etiologia , Mecânica Respiratória , Estudos Retrospectivos , Adulto Jovem
6.
Trauma Surg Acute Care Open ; 5(1): e000446, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32432171

RESUMO

BACKGROUND: Patients who sustain blunt solid organ injury to the liver, spleen, or kidney and are treated nonoperatively frequently undergo serial monitoring of their hemoglobin (Hb). We hypothesized that among initially hemodynamically stable patients with blunt splenic, hepatic, or renal injuries treated without an operation, scheduled monitoring of serum Hb values may be unnecessary as hemodynamic instability, not merely Hb drop, would prompt intervention. METHODS: We performed a retrospective review of patients admitted to our urban Level 1 trauma center following blunt trauma with any grade III, IV, or V liver, spleen, or kidney injury from January 1, 2016 to December 31, 2016. Patients who were hemodynamically unstable and went directly to the operating room or interventional radiology were excluded. Patients who required any urgent or unplanned operative or angiographic intervention were compared with patients who did not require an intervention. Routine demographic and outcome variables were obtained and bivariate and multivariate regression statistics were performed using Stata V.10. RESULTS: A total of 138 patients were included in the study. Age (39.3 vs 41.4, p=0.51), mean injury severity score (26.7 vs 22.1, p=0.12), and admission Hb (11.9 vs 12.8, p=0.06) did not differ significantly between the two groups. The number of Hb draws (9.2 vs 10, p=0.69) and the associated change in Hb (3.7 vs 3.5, p=0.71) did not differ significantly between the two groups. Only splenic grade predicted need for urgent intervention (3.5 vs 2, p<0.001). All patients who required an operative or radiologic intervention did so based on change in hemodynamics or severity of splenic grade, per our institutional protocol, and not Hb trend. DISCUSSION: Among patients with blunt solid organ injury, a need for emergent intervention in the form of laparotomy or angioembolization occurs within the first hours of injury. Routine scheduled Hb measurements did not change management in our cohort. LEVEL OF EVIDENCE: Level III.

7.
J Trauma Acute Care Surg ; 89(1): 118-124, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32176177

RESUMO

BACKGROUND: The Emergency Surgery Score (ESS) was recently developed and retrospectively validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively validate ESS, specifically in the high-risk nontrauma emergency laparotomy (EL) patient. METHODS: This is an Eastern Association for the Surgery of Trauma multicenter prospective observational study. Between April 2018 and June 2019, 19 centers enrolled all adults (aged >18 years) undergoing EL. Preoperative, intraoperative, and postoperative variables were prospectively and systematically collected. Emergency Surgery Score was calculated for each patient and validated using c-statistic methodology by correlating it with three postoperative outcomes: (1) 30-day mortality, (2) 30-day complications (e.g., respiratory/renal failure, infection), and (3) postoperative intensive care unit (ICU) admission. RESULTS: A total of 1,649 patients were included. The mean age was 60.5 years, 50.3% were female, and 71.4% were white. The mean ESS was 6, and the most common indication for EL was hollow viscus perforation. The 30-day mortality and complication rates were 14.8% and 53.3%; 57.0% of patients required ICU admission. Emergency Surgery Score gradually and accurately predicted 30-day mortality; 3.5%, 50.0%, and 85.7% of patients with ESS of 3, 12, and 17 died after surgery, respectively, with a c-statistic of 0.84. Similarly, ESS gradually and accurately predicted complications; 21.0%, 57.1%, and 88.9% of patients with ESS of 1, 6, and 13 developed postoperative complications, with a c-statistic of 0.74. Emergency Surgery Score also accurately predicted which patients required intensive care unit admission (c-statistic, 0.80). CONCLUSION: This is the first prospective multicenter study to validate ESS as an accurate predictor of outcome in the EL patient. Emergency Surgery Score can prove useful for (1) perioperative patient and family counseling, (2) triaging patients to the intensive care unit, and (3) benchmarking the quality of emergency general surgery care. LEVEL OF EVIDENCE: Prognostic study, level III.


Assuntos
Emergências , Cirurgia Geral , Medição de Risco/métodos , Ferimentos e Lesões/cirurgia , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Pontuação de Propensão , Estudos Prospectivos , Ferimentos e Lesões/mortalidade
8.
J Trauma Acute Care Surg ; 87(5): 1104-1112, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31299694

RESUMO

BACKGROUND: The optimal time to initiate chemical thromboprophylaxis (CTP) in patients who have undergone nonoperative management (NOM) of blunt solid organ injuries (SOI) remains controversial. The aim of our study was to assess the impact of early initiation of CTP in patients with blunt abdominal SOIs. METHODS: We performed a 2-year (2013-2014) retrospective analysis of American College of Surgeons Trauma Quality Improvement Program. We included all adult trauma patients (age, ≥ 18 years) with blunt SOI who underwent NOM. Patients were stratified into three groups based on timing of CTP (early, ≤48 hours of injury; late, >48 hours of injury,; and no prophylaxis group). Our primary outcomes were rates of failure of NOM, pRBC transfusion, and mortality. Our secondary outcomes were the rate of venous thromboembolic (VTE) events (i.e., deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) and length of stay. RESULTS: A total of 36,187 patients met the inclusion criteria. Mean age was 49.5 ± 19 years and 36% of patients received CTP (early, 37% (n = 4,819) versus late, 63% (n = 8,208)). After controlling for confounders, patients receiving early CTP had lower rates of DVT (p = 0.01) and PE (p = 0.01) compared with the no prophylaxis and late CTP groups. There was no difference between the three groups regarding the postprophylaxis pRBC transfusions, failure of NOM, and mortality. CONCLUSION: Our results suggest that in patients undergoing NOM of blunt abdominal SOI, early initiation of CTP should be considered. It is associated with decreased rates of DVT and PE, with no significant difference in post prophylaxis pRBC transfusion, failure of nonoperative management, and mortality. LEVEL OF EVIDENCE: Therapeutic, level V.


Assuntos
Traumatismos Abdominais/terapia , Anticoagulantes/administração & dosagem , Tratamento Conservador/métodos , Tempo para o Tratamento , Tromboembolia Venosa/epidemiologia , Ferimentos não Penetrantes/terapia , Traumatismos Abdominais/sangue , Traumatismos Abdominais/complicações , Traumatismos Abdominais/mortalidade , Adulto , Idoso , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Heparina de Baixo Peso Molecular/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Falha de Tratamento , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle , Ferimentos não Penetrantes/sangue , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/mortalidade
9.
World Neurosurg ; 128: e552-e555, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31051302

RESUMO

BACKGROUND: Antibiotics after spine instrumentation are often extended while the surgical drain is in place, particularly for traumatic injuries. We sought to study if continuing antibiotics past 24 hours affected outcomes. METHODS: We performed a retrospective observational study of all patients who underwent spine fixation with hardware and surgical drains for trauma at our institution. We compared the effect of perioperative (≤24 hours of antibiotics) versus prolonged (>24 hours) antibiotics on surgical outcomes. Bivariate and multivariable logistic and linear regression statistics were performed. RESULTS: Three hundred and forty-six patients were included in the analysis. On multivariate analysis, antibiotic duration >24 hours did not predict surgical site infection (odds ratio, 2.68; 95% confidence interval, 0.88-8.10, P = 0.08) or mortality (odds ratio, 0.59; 95% confidence interval, 0.10-3.44; P = 0.56). CONCLUSIONS: Continuing antibiotics past 24 hours after traumatic spine instrumentation was not associated with improved outcomes. A prospective study to verify these findings may be warranted.


Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia/métodos , Cuidados Pós-Operatórios/métodos , Traumatismos da Coluna Vertebral/cirurgia , Infecção da Ferida Cirúrgica/prevenção & controle , Adulto , Idoso , Drenagem , Feminino , Humanos , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos , Fatores de Tempo
10.
Cureus ; 11(3): e4237, 2019 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-31131161

RESUMO

A male patient aged 49 years presented to the emergency room after sustaining a nail-gun injury to the left neck (Zone III). Computed tomography (CT) angiogram demonstrated retained nail traversing in close proximity to the left internal carotid artery. Catheter angiogram with three-dimensional (3D) reconstruction revealed partial left internal carotid injury without active extravasation and with preserved flow through the vessel. The nail was removed by gentle traction with the simultaneous deployment of stent-graft across the injured segment. Balloon angioplasty of the stent was performed secondary to endoleak and active extravasation. Complete vessel reconstruction with maintained blood flow was achieved. The patient was extubated the following day and was discharged home on hospital day five without neurological deficits. This case report demonstrates the usefulness of endovascular repair of high cervical arterial injuries with special attention to the unique nature of nail gun injuries.

11.
J Gastrointest Surg ; 23(4): 827-836, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30324402

RESUMO

Nearly 3 million patients are hospitalized every year for emergent gastrointestinal (GI) surgical problems and nearly one third of those will require surgery. This article reviews the scope of GI surgical emergencies within the context of emergency general surgery (EGS), costs of care, overview of several common GI surgical problems, and traditional and emerging treatment modalities. This article also argues for ongoing work in the area of risk assessment for EGS, and describes quality metrics as well as outcomes of care for these patients.


Assuntos
Gastroenteropatias/cirurgia , Cirurgia Geral , Doença Aguda , Efeitos Psicossociais da Doença , Procedimentos Cirúrgicos do Sistema Digestório , Emergências/economia , Gastroenteropatias/economia , Custos de Cuidados de Saúde , Humanos , Medição de Risco
12.
Am J Surg ; 218(2): 255-260, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30558803

RESUMO

INTRODUCTION: The aim of our study is to analyze the 5 years' trends, mortality rate, and factors that influence mortality after civilian penetrating traumatic brain injury (pTBI). METHODS: We performed a 5-year-analysis of all trauma patients diagnosed with pTBI in the TQIP. Our outcome measures were trends of pTBI. RESULTS: A total of 26,871 had penetrating brain injury over the 5-year period. Mean age was 36.2 ±â€¯18 years. Overall 55% of the patients had severe TBI and mortality rate was 43.8%. There was an increase in the rate of pTBI from 3042/100,000 (2010) to 7578/100,000 trauma admissions (2014) (p < 0.001). The mortality rate has increased from 35% (2010) to 48% (2011) (p < 0.001) followed by a linear decrease in mortality to 40% (2014). Independent predictors of mortality were age, pre-hospital intubation, suicide attempt, and craniotomy/craniectomy. CONCLUSIONS: Incidence and mortality for patients who are brought to hospitals following pTBI have gradually increased over the five-year period. Self-inflicted injury and prehospital intubation were the two most significant predictors of mortality.


Assuntos
Lesões Encefálicas Traumáticas/epidemiologia , Traumatismos Cranianos Penetrantes/epidemiologia , Adolescente , Adulto , Lesões Encefálicas Traumáticas/mortalidade , Feminino , Traumatismos Cranianos Penetrantes/mortalidade , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Adulto Jovem
13.
J Trauma Acute Care Surg ; 85(5): 928-931, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29985232

RESUMO

BACKGROUND: Cervical spinal cord injury (CSCI) is devastating. Respiratory failure, ventilator-associated pneumonia (VAP), sepsis, and death frequently occur. Case reports of diaphragm pacing system (DPS) have suggested earlier liberation from mechanical ventilation in acute CSCI patients. We hypothesized DPS implantation would decrease VAP and facilitate liberation from ventilation. METHODS: We performed a retrospective review of patients with acute CSCI managed at a single Level 1 trauma center between January 2005 and May 2017. Routine demographics were collected. Patients underwent propensity matching based on age, injury severity score, ventilator days, hospital length of stay, and need for tracheostomy. Outcome measures included hospital length of stay, intensive care unit length of stay, ventilator days (vent days), incidence of VAP, and mortality. Bivariate and multivariate logistic and linear regression statistics were performed using STATA Version 10. RESULTS: Between July 2011 and May 2017, all patients with acute CSCI were evaluated for DPS implantation. Forty patients who had laparoscopic DPS implantation (DPS) were matched to 61 who did not (NO DPS). Median time to liberation after DPS implantation was 7 days. Hospital length of stay and mortality were significantly lower on bivariate analysis in DPS patients. Diaphragm pacing system placement was not found to be associated with statistically significant differences in these outcomes on risk-adjusted multivariate models that included admission year. CONCLUSIONS: Diaphragm pacing system implantation in patients with acute CSCI can be one part of a comprehensive critical care program to improve outcomes. However, the association of DPS with the marked improved mortality seen on bivariate analysis may be due solely to improvements in critical care throughout the study period. Further studies to define the benefits of DPS implantation are needed. LEVEL OF EVIDENCE: Therapeutic, level IV.


Assuntos
Diafragma , Terapia por Estimulação Elétrica , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Insuficiência Respiratória/terapia , Traumatismos da Medula Espinal/complicações , Doença Aguda , Adulto , Vértebras Cervicais , Eletrodos Implantados , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pneumonia Associada à Ventilação Mecânica/etiologia , Respiração , Respiração Artificial/efeitos adversos , Insuficiência Respiratória/etiologia , Estudos Retrospectivos , Taxa de Sobrevida , Adulto Jovem
14.
J Trauma Acute Care Surg ; 85(1): 198-207, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29613959

RESUMO

BACKGROUND: Traumatic diaphragm injuries (TDI) pose both diagnostic and therapeutic challenges in both the acute and chronic phases. There are no published practice management guidelines to date for TDI. We aim to formulate a practice management guideline for TDI using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. METHODS: The working group formulated five Patient, Intervention, Comparator, Outcome questions regarding the following topics: (1) diagnostic approach (laparoscopy vs. computed tomography); (2) nonoperative management of penetrating right-sided injuries; (3) surgical approach (abdominal or thoracic) for acute TDI, including (4) the use of laparoscopy; and (5) surgical approach (abdominal or thoracic) for delayed TDI. A systematic review was undertaken and last updated December 2016. RevMan 5 (Cochran Collaboration) and GRADEpro (Grade Working Group) software were used. Recommendations were voted on by working group members. Consensus was obtained for each recommendation. RESULTS: A total of 56 articles were used to formulate the recommendations. Most studies were retrospective case series with variable reporting of outcomes measures and outcomes frequently not stratified to intervention or comparator. The overall quality of the evidence was very low for all Patient, Intervention, Comparator, Outcomes. Therefore, only conditional recommendations could be made. CONCLUSION: Recommendations were made in favor of laparoscopy over computed tomography for diagnosis, nonoperative versus operative approach for right-sided penetrating injuries, abdominal versus thoracic approach for acute TDI, and laparoscopy (with the appropriate skill set and resources) versus open approach for isolated TDI. No recommendation could be made for the preferred operative approach for delayed TDI. Very low-quality evidence precluded any strong recommendations. Further study of the diagnostic and therapeutic approaches to TDI is warranted. LEVEL OF EVIDENCE: Guideline; Systematic review, level IV.


Assuntos
Diafragma/lesões , Traumatismos Torácicos/terapia , Ferimentos Penetrantes/terapia , Humanos , Laparoscopia/métodos , Traumatismos Torácicos/diagnóstico , Tomografia Computadorizada por Raios X/métodos , Ferimentos Penetrantes/complicações , Ferimentos Penetrantes/diagnóstico
15.
J Trauma Acute Care Surg ; 82(1): 185-199, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27787438

RESUMO

BACKGROUND: Traumatic injury to the pancreas is rare but is associated with significant morbidity and mortality, including fistula, sepsis, and death. There are currently no practice management guidelines for the medical and surgical management of traumatic pancreatic injuries. The overall objective of this article is to provide evidence-based recommendations for the physician who is presented with traumatic injury to the pancreas. METHODS: The MEDLINE database using PubMed was searched to identify English language articles published from January 1965 to December 2014 regarding adult patients with pancreatic injuries. A systematic review of the literature was performed, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to formulate evidence-based recommendations. RESULTS: Three hundred nineteen articles were identified. Of these, 52 articles underwent full text review, and 37 were selected for guideline construction. CONCLUSION: Patients with grade I/II injuries tend to have fewer complications; for these, we conditionally recommend nonoperative or nonresectional management. For grade III/IV injuries identified on computed tomography or at operation, we conditionally recommend pancreatic resection. We conditionally recommend against the routine use of octreotide for postoperative pancreatic fistula prophylaxis. No recommendations could be made regarding the following two topics: optimal surgical management of grade V injuries, and the need for routine splenectomy with distal pancreatectomy. LEVEL OF EVIDENCE: Systematic review, level III.


Assuntos
Pâncreas/lesões , Ferimentos e Lesões/terapia , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pancreatectomia , Complicações Pós-Operatórias/prevenção & controle , Esplenectomia , Ferimentos e Lesões/diagnóstico por imagem
16.
J Surg Res ; 201(1): 134-40, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26850194

RESUMO

BACKGROUND: In the nonoperative management (NOM) of blunt splenic injuries (BSI), the clinical relevance of age as a risk factor has not been well studied. METHODS: Using the 2011 National Trauma Data Bank data set, age was analyzed both as a continuous variable and a categorical variable (group 1 [13-54 y], group 2 [55-74 y], and group 3 [≥75 y]). BSI severity was stratified by abbreviated injury scale (AIS): group 1 (AIS ≤2), group 2 (AIS 3), and group 3 (AIS ≥4). A semiparametric proportional odds model was used to model NOM outcomes and effects due to age and BSI severity. RESULTS: Of 15,113 subjects, 15.3% failed NOM. The odds of failure increased by a factor of 1.014 for each year of age, or factor of 1.5 for groups 2 and 3 each. BSI severity groups 2 and 3 had increases in the odds of failure by factors of 3.9 and 13, respectively, compared with those of group 1. Most failures occurred by 48 h irrespective of age. The effect of age was most pronounced in age groups 2 and 3 with the most severe BSI, where a NOM failure rate of >50% was seen. Both age and failure of NOM were independent predictors of mortality. CONCLUSIONS: Age is associated with failure of NOM but its effect seems more clinically relevant only in high-grade BSI. Factors that could influence NOM success in elderly patients with high-grade injuries deserve further study.


Assuntos
Traumatismos Abdominais/terapia , Baço/lesões , Adolescente , Adulto , Fatores Etários , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Falha de Tratamento , Adulto Jovem
17.
Surg Infect (Larchmt) ; 16(3): 293-7, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25894664

RESUMO

BACKGROUND: Haemophilus species bacteria (HSB) are known pathogens responsible for early pneumonia in intubated trauma patients. The primary goal of this study was to examine the incidence and extent of hypoxemia in intubated trauma patients who develop early ventilator-associated pneumonia (VAP) secondary to HSB. On the basis of our clinical experiences, we hypothesized that patients with Haemophilus species bacteria pneumonia (HSBP) would have a high rate of hypoxemia but that the effect would be transient. METHODS: Retrospective review of intubated trauma patients from an urban level I trauma center with HSBP diagnosed by deep tracheal aspirate or bronchoalveolar lavage from April 2007 to November 2012. Collected variables included day of HSBP diagnosis; PaO2 to FIO2 ratio (P:F) at HSBP diagnosis as well as HSBP day three and HSBP day seven; injury severity score (ISS) and its component parts; admission Glasgow Coma Scale (GCS) score; and mortality. Hypoxemia was defined as P:F <200. χ(2) Tests were utilized to assess factors that differed between hypoxemic and non-hypoxemic patients; data are presented as median (interquartile range, IQR). RESULTS: Sixty-nine patients were identified (80% male; age, 35 y [range, 24-49]; ISS 27 [9-59]). Diagnosis of HSBP occurred early (hospital day 4 [range, 3-5]). Forty-three percent of patients had acute respiratory distress syndrome (ARDS) on HSBP day 1; this decreased to 26% on day three and to 30% on day seven. Forty patients (77%) had a tracheostomy performed. Patients with hypoxemia were significantly less likely to have a severe head injury (GCS<9), p<0.05. Patients with hypoxemia had similar hospital length of stay and mortality to patients who did not develop hypoxemia. CONCLUSION: Haemophilus species bacteria pneumonia in trauma patients is associated with high rates of transient hypoxemia and a high tracheostomy rate, although subsequent outcomes are not affected. Patients with head injuries had a lower incidence of hypoxemia from pneumonia.


Assuntos
Infecções por Haemophilus/complicações , Infecções por Haemophilus/patologia , Hipóxia/epidemiologia , Hipóxia/patologia , Pneumonia Associada à Ventilação Mecânica/complicações , Pneumonia Associada à Ventilação Mecânica/patologia , Ferimentos e Lesões/complicações , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Centros de Traumatologia , Adulto Jovem
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