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1.
Surgery ; 2022 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-35970609

RESUMO

BACKGROUND: Initially used in trauma management, delayed abdominal closure endeavors to decrease operative time during the index operation while still being lifesaving. Its use in emergency general surgery is increasing, but the data evaluating its outcome are sparse. We aimed to study the association between delayed abdominal closure, mortality, morbidity, and length of stay in an emergency surgery cohort. METHODS: The 2013 to 2017 American College of Surgeons National Surgical Quality Improvement Program database was examined for patients undergoing emergency laparotomy. The patients were classified by the timing of abdominal wall closure: delayed fascial closure versus immediate fascial closure. Propensity score matching was performed based on preoperative covariates, wound classification, and performance of bowel resection. The outcomes were then compared by univariable analysis. RESULTS: After matching, both the delayed fascial closure and immediate fascial closure groups consisted of 3,354 patients each. Median age was 65 years, and 52.6% were female. The delayed fascial closure group had a higher in-hospital mortality (35.3% vs 25.0%, P < .001), a higher 30-day mortality (38.6% vs 29.0%, P < .001), a higher proportion of acute kidney injury (9.5% vs 6.6%, P < .001), a lower proportion of postoperative sepsis (11.8% vs 15.6%, P < .001), and a lower proportion of surgical site infection (3.4% vs 7.0%, P < .001). CONCLUSION: Compared with immediate fascial closure, delayed fascial closure is associated with an increased mortality in the patients matched based on comorbidities and surgical site contamination. In emergency general surgery, delaying abdominal closure may not have the presumed overarching benefits, and its indications must be further defined in this population.

2.
J Am Coll Surg ; 235(3): 468-480, 2022 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-35972167

RESUMO

BACKGROUND: Using a large national database, we evaluated the relationship between RBC transfusion volume, RBC transfusion rate, and in-hospital mortality to explore the presence of a futility threshold in trauma patients receiving ultramassive blood transfusion. STUDY DESIGN: The ACS-TQIP 2013 to 2018 database was analyzed. Adult patients who received ultramassive blood transfusion (≥20 units of RBC/24 hours) were included. RBC transfusion volume and rate were captured at the only 2 time points available in TQIP (4 hours and 24 hours), or time of death, whichever came first. RESULTS: Among 5,135 patients analyzed, in-hospital mortality rate was 62.1% (n = 3,190), and 4-hour and 24-hour mortality rates were 17.53% (n = 900) and 42.41% (n = 2,178), respectively. RBC transfusion volumes at 4 hours (area under the receiver operating characteristic curve [AUROC] 0.59 [95% CI 0.57 to 0.60]) and 24 hours (AUROC 0.59 [95% CI 0.57 to 0.60]) had low discriminatory ability for mortality and were inconclusive for futility. Mean RBC transfusion rates calculated within 4 hours (AUROC 0.65 [95% CI 0.63 to 0.66]) and 24 hours (AUROC 0.85 [95% CI 0.84 to 0.86]) had higher discriminatory ability than RBC transfusion volume. A futility threshold was not found for the mean RBC transfusion rate calculated within 4 hours. All patients with a final mean RBC transfusion rate of ≥7 U/h calculated within 24 hours of arrival experienced in-hospital death (n = 1,326); the observed maximum length of survival for these patients during the first 24 hours ranged from 24 hours for a rate of 7 U/h to 4.5 hours for rates ≥21 U/h. CONCLUSION: RBC transfusion volume within 4 or 24 hours and mean RBC transfusion rate within 4 hours were not markers of futility. The observed maximum length of survival per mean RBC transfusion rate could inform resuscitation efforts in trauma patients receiving ongoing transfusion between 4 and 24 hours.


Assuntos
Futilidade Médica , Ferimentos e Lesões , Adulto , Transfusão de Sangue , Mortalidade Hospitalar , Humanos , Curva ROC , Ressuscitação , Estudos Retrospectivos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/terapia
3.
J Surg Res ; 280: 85-93, 2022 Aug 11.
Artigo em Inglês | MEDLINE | ID: mdl-35964486

RESUMO

INTRODUCTION: Preperitoneal pelvic packing (PPP) is an important intervention for control of severe pelvic hemorrhage in blunt trauma patients. We hypothesized that PPP is associated with an increased incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE). METHODS: A retrospective cohort analysis of blunt trauma patients with severe pelvic fractures (AIS ≥4) using the 2015-2017 American College of Surgeons-Trauma Quality Improvement Program database was performed. Patients who underwent PPP within four hours of admission were matched to patients who did not using propensity score matching. Matching was performed based on demographics, comorbidities, injury- and resuscitation-related parameters, vital signs at presentation, and initiation and type of prophylactic anticoagulation. The rates of DVT and PE were compared between the matched groups. RESULTS: Out of 5129 patients with severe pelvic fractures, 157 (3.1%) underwent PPP within four h of presentation and were matched with 157 who did not. No significant differences were detected between the two matched groups in any of the examined baseline variables. Similarly, mortality and end-organ failure rates were not different. However, PPP patients were significantly more likely to develop DVT (12.7% versus 5.1%, P = 0.028) and PE (5.7% versus 0.0%, P = 0.003). CONCLUSIONS: PPP in severe pelvic fractures secondary to blunt trauma is associated with an increased risk of DVT and PE. A high index of suspicion and a low threshold for screening for these conditions should be maintained in patients who undergo PPP.

4.
Artigo em Inglês | MEDLINE | ID: mdl-35538361

RESUMO

BACKGROUND: The education of civilians and first responders in prehospital tourniquet (PT) utilization has spread rapidly. We aimed to describe trends in emergency medical services (EMS) and non-EMS PT utilization, and their ability to identify proper clinical indications and to appropriately apply tourniquets in the field. METHODS: A retrospective cohort study was conducted to evaluate all adult patients with PTs who presented at two Level I trauma centers between January 2015 and December 2019. Data were collected via an electronic patient query tool and cross-referenced with institutional Trauma Registries. Medically trained abstractors determined if PTs were clinically indicated (limb amputation, vascular hard signs, injury requiring hemostasis procedure, or significant documented blood loss). PTs were further designated as appropriately or inappropriately applied (based on tourniquet location, venous tourniquet, greater than 2-h ischemic time). Descriptive statistics and univariate analyses were performed. RESULTS: 146 patients met inclusion criteria. The incidence of yearly PT placements increased between 2015 and 2019, with an increase in placement by non-EMS personnel (police, firefighter, bystander, and patient). Improvised PTs were frequently utilized by bystanders and patients, whereas first responders had high rates of commercial tourniquet use. A high proportion of tourniquets were placed without indication (72/146, 49%); however, the proportion of PTs placed without a proper indication across applier groups was not statistically different (p = 0.99). Rates of inappropriately applied PTs ranged from 21 to 46% across all groups applying PTs. CONCLUSIONS: PT placement was increasingly performed by non-EMS personnel. Present data indicate that non-EMS persons applied PTs at a similar performance level of those applied by EMS. Study LevelLevel III.

5.
Am Surg ; 88(6): 1054-1058, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35465697

RESUMO

As hospital systems plan for health care utilization surges and stress, understanding the necessary resources of a trauma system is essential for planning capacity. We aimed to describe trends in high-intensity resource utilization (operating room [OR] usage and intensive care unit [ICU] admissions) for trauma care during the initial months of the COVID-19 pandemic. Trauma registry data (2019 pre-COVID-19 and 2020 COVID-19) were collected retrospectively from 4 level I trauma centers. Direct emergency department (ED) disposition to the OR or ICU was used as a proxy for high-intensity resource utilization. No change in the incidence of direct ED to ICU or ED to OR utilization was observed (2019: 24%, 2020 23%; P = .62 and 2019: 11%, 2020 10%; P = .71, respectively). These results suggest the need for continued access to ICU space and OR theaters for traumatic injury during national health emergencies, even when levels of trauma appear to be decreasing.


Assuntos
COVID-19 , Pandemias , COVID-19/epidemiologia , Serviço Hospitalar de Emergência , Humanos , Unidades de Terapia Intensiva , Estudos Retrospectivos , Centros de Traumatologia
6.
J Intensive Care Med ; : 8850666221094506, 2022 Apr 19.
Artigo em Inglês | MEDLINE | ID: mdl-35437045

RESUMO

Objective: To determine whether the outcomes of postoperative patients admitted directly to an intensive care unit (ICU) differ based on the academic status of the institution and the total operative volume of the unit. Methods: This was a retrospective analysis using the eICU Collaborative Research Database v2.0, a national database from participating ICUs in the United States. All patients admitted directly to the ICU from the operating room were included. Transfer patients and patients readmitted to the ICU were excluded. Patients were stratified based on admission to an ICU in an academic medical center (AMC) versus non-AMC, and to ICUs with different operative volume experience, after stratification in quartiles (high, medium-high, medium-low, and low volume). Primary outcomes were ICU and hospital mortality. Secondary outcomes included the need for continuous renal replacement therapy (CRRT) during ICU stay, ICU length of stay (LOS), and 30-day ventilator free days. Results: Our analysis included 22,180 unique patients; the majority of which (15,085[68%]) were admitted to ICUs in non-AMCs. Cardiac and vascular procedures were the most common types of procedures performed. Patients admitted to AMCs were more likely to be younger and less likely to be Hispanic or Asian. Multivariable logistic regression indicated no meaningful association between academic status and ICU mortality, hospital mortality, initiation of CRRT, duration of ICU LOS, or 30-day ventilator-free-days. Contrarily, medium-high operative volume units had higher ICU mortality (OR = 1.45, 95%CI = 1.10-1.91, p-value = 0.040), higher hospital mortality (OR = 1.33, 95%CI = 1.07-1.66, p-value = 0.033), longer ICU LOS (Coefficient = 0.23, 95%CI = 0.07-0.39, p-value = 0.038), and fewer 30-day ventilator-free-days (Coefficient = -0.30, 95%CI = -0.48 - -0.13, p-value = 0.015) compared to their high operative volume counterparts. Conclusions: This study found that a volume-outcome association in the management of postoperative patients requiring ICU level of care immediately after a surgical procedure may exist. The academic status of the institution did not affect the outcomes of these patients.

7.
J Trauma Acute Care Surg ; 93(1): 21-29, 2022 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-35313325

RESUMO

BACKGROUND: Balanced blood component administration during massive transfusion is standard of care. Most literature focuses on the impact of red blood cell (RBC)/fresh frozen plasma (FFP) ratio, while the value of balanced RBC:platelet (PLT) administration is less established. The aim of this study was to evaluate and quantify the independent impact of RBC:PLT on 24-hour mortality in trauma patients receiving massive transfusion. METHODS: Using the 2013 to 2018 American College of Surgeons Trauma Quality Improvement Program database, adult patients who received massive transfusion (≥10 U of RBC/24 hours) and ≥1 U of RBC, FFP, and PLT within 4 hours of arrival were retrospectively included. To mitigate survival bias, only patients with consistent RBC:PLT and RBC:FFP ratios between 4 and 24 hours were analyzed. Balanced FFP or PLT transfusions were defined as having RBC:PLT and RBC:FFP of ≤2, respectively. Multivariable logistic regression was used to compare the independent relationship between RBC:FFP, RBC:PLT, balanced transfusion, and 24-hour mortality. RESULTS: A total of 9,215 massive transfusion patients were included. The number of patients who received transfusion with RBC:PLT >2 (1,942 [21.1%]) was significantly higher than those with RBC:FFP >2 (1,160 [12.6%]) (p < 0.001). Compared with an RBC:PLT ratio of 1:1, a gradual and consistent risk increase was observed for 24-hour mortality as the RBC:PLT ratio increased (p < 0.001). Patients with both FFP and PLT balanced transfusion had the lowest adjusted risk for 24-hour mortality. Mortality increased as resuscitation became more unbalanced, with higher odds of death for unbalanced PLT (odds ratio, 2.48 [2.18-2.83]) than unbalanced FFP (odds ratio, 1.66 [1.37-1.98]), while patients who received both FFP and PLT unbalanced transfusion had the highest risk of 24-hour mortality (odds ratio, 3.41 [2.74-4.24]). CONCLUSION: Trauma patients receiving massive transfusion significantly more often have unbalanced PLT rather than unbalanced FFP transfusion. The impact of unbalanced PLT transfusion on 24-hour mortality is independent and potentially more pronounced than unbalanced FFP transfusion, warranting serious system-level efforts for improvement. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.


Assuntos
Plaquetas , Transfusão de Eritrócitos , Adulto , Transfusão de Componentes Sanguíneos , Eritrócitos , Humanos , Estudos Retrospectivos
8.
J Surg Res ; 276: 31-36, 2022 08.
Artigo em Inglês | MEDLINE | ID: mdl-35334381

RESUMO

INTRODUCTION: Necrotizing soft tissue infections (NSTIs) are surgical emergencies associated with high morbidity and mortality. Identifying risk factors for poor outcome is a critical part of preoperative decision-making and counseling. Sarcopenia, the loss of lean muscle mass, has been associated with an increased risk of mortality and can be measured using cross-sectional imaging. Our aim was to determine the impact of sarcopenia on mortality in patients with NSTI. We hypothesized that sarcopenia would be associated with an increased risk of mortality in patients with NSTI. METHODS: This is a retrospective cohort study of NSTI patients admitted from 1995 to 2015 to two academic institutions. Operative and pathology reports were reviewed to confirm the diagnosis in all cases. Average bilateral psoas muscle cross-sectional area at L4, normalized for height (Total Psoas Index [TPI]), was calculated using computed tomography (CT). Sarcopenia was defined as TPI in the lowest sex-specific quartile. Primary outcome was in-hospital mortality. Multivariate logistic regression was performed to assess the association between sarcopenia and in-hospital mortality. RESULTS: There were 115 patients with preoperative imaging, 61% male and a median age of 57 y interquartile range (IQR 46.6-67.0). Overall in-hospital mortality was 12.1%. There was no significant difference in sex, body mass index (BMI), comorbidities and American Society of Anesthesiologists classification (Table 1). After multivariate analysis, sarcopenia was independently associated with increased in-hospital mortality (Odds ratio, 3.5; 95% Confidence Interval [CI], 1.05-11.8). CONCLUSIONS: Sarcopenia is associated with increased risk of in-hospital mortality in patients with NSTIs. Sarcopenia identifies patients with higher likelihood of poor outcomes, which can possibly help surgeons in counseling their patients and families.


Assuntos
Sarcopenia , Infecções dos Tecidos Moles , Feminino , Humanos , Masculino , Músculos Psoas/diagnóstico por imagem , Músculos Psoas/patologia , Estudos Retrospectivos , Fatores de Risco , Sarcopenia/complicações , Sarcopenia/diagnóstico por imagem , Infecções dos Tecidos Moles/complicações , Infecções dos Tecidos Moles/patologia
9.
Injury ; 53(6): 1979-1986, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35232568

RESUMO

BACKGROUND: Results from single-region studies suggest that stay at home orders (SAHOs) had unforeseen consequences on the volume and patterns of traumatic injury during the initial months of the Coronavirus disease 2019 (COVID-19). The aim of this study was to describe, using a multi-regional approach, the effects of COVID-19 SAHOs on trauma volume and patterns of traumatic injury in the US. METHODS: A retrospective cohort study was performed at four verified Level I trauma centers spanning three geographical regions across the United States (US). The study period spanned from April 1, 2020 - July 31, 2020 including a month-matched 2019 cohort. Patients were categorized into pre-COVID-19 (PCOV19) and first COVID-19 surge (FCOV19S) cohorts. Patient demographic, injury, and outcome data were collected via Trauma Registry queries. Univariate and multivariate analyses were performed. RESULTS: A total 5,616 patients presented to participating study centers during the PCOV19 (2,916) and FCOV19S (2,700) study periods.  Blunt injury volume decreased (p = 0.006) due to a significant reduction in the number of motor vehicle collisions (MVCs) (p = 0.003). Penetrating trauma experienced a significant increase, 8% (246/2916) in 2019 to 11% (285/2,700) in 2020 (p = 0.007), which was associated with study site (p = 0.002), not SAHOs. Finally, study site was significantly associated with changes in nearly all injury mechanisms, whereas SAHOs accounted for observed decreases in calculated weekly averages of blunt injuries (p < 0.02) and MVCs (p = 0.003). CONCLUSION: Results of this study suggest that COVID-19 and initial SAHOs had variable consequences on patterns of traumatic injury, and that region-specific shifts in traumatic injury ensued during initial SAHOs. These results suggest that other factors, potentially socioeconomic or cultural, confound trauma volumes and types arising from SAHOs. Future analyses must consider how regional changes may be obscured with pooled cohorts, and focus on characterizing community-level changes to aid municipal preparation for future similar events.


Assuntos
COVID-19 , Ferimentos Penetrantes , COVID-19/epidemiologia , Humanos , Pandemias , Estudos Retrospectivos , SARS-CoV-2 , Centros de Traumatologia , Estados Unidos/epidemiologia , Ferimentos Penetrantes/epidemiologia
11.
J Intensive Care Med ; 37(6): 728-735, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34231406

RESUMO

BACKGROUND: There is little research evaluating outcomes from sepsis in intensive care units (ICUs) with lower sepsis patient volumes as compared to ICUs with higher sepsis patient volumes. Our objective was to compare the outcomes of septic patients admitted to ICUs with different sepsis patient volumes. MATERIALS AND METHODS: We included all patients from the eICU-CRD database admitted for the management of sepsis with blood lactate ≥ 2mmol/L within 24 hours of admission. Our primary outcome was ICU mortality. Secondary outcomes included hospital mortality, 30-day ventilator free days, and initiation of renal replacement therapy (RRT). ICUs were grouped in quartiles based on the number of septic patients treated at each unit. RESULTS: 10,716 patients were included in our analysis; 272 (2.5%) in low sepsis volume ICUs, 1,078 (10.1%) in medium-low sepsis volume ICUs, 2,608 (24.3%) in medium-high sepsis volume ICUs, and 6,758 (63.1%) in high sepsis volume ICUs. On multivariable analyses, no significant differences were documented regarding ICU and hospital mortality, and ventilator days in patients treated in lower versus higher sepsis volume ICUs. Patients treated at lower sepsis volume ICUs had lower rates of RRT initiation as compared to high volume units (medium-high vs. high: OR = 0.78, 95%CI = 0.66-0.91, P-value = 0.002 and medium-low vs. high: OR = 0.57, 95%CI = 0.44-0.73, P-value < 0.001). CONCLUSION: The previously described volume-outcome association in septic patients was not identified in an intensive care setting.


Assuntos
Unidades de Terapia Intensiva , Sepse , Mortalidade Hospitalar , Humanos , Terapia de Substituição Renal , Estudos Retrospectivos , Sepse/terapia
13.
Am Surg ; 87(12): 1893-1900, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34772281

RESUMO

BACKGROUND: COVID-19 is a deadly multisystemic disease, and bowel ischemia, the most consequential gastrointestinal manifestation, remains poorly described. Our goal is to describe our institution's surgical experience with management of bowel ischemia due to COVID-19 infection over a one-year period. METHODS: All patients admitted to our institution between March 2020 and March 2021 for treatment of COVID-19 infection and who underwent exploratory laparotomy with intra-operative confirmation of bowel ischemia were included. Data from the medical records were analyzed. RESULTS: Twenty patients were included. Eighty percent had a new or increasing vasopressor requirement, 70% had abdominal distension, and 50% had increased gastric residuals. Intra-operatively, ischemia affected the large bowel in 80% of cases, the small bowel in 60%, and both in 40%. Sixty five percent had an initial damage control laparotomy. Most of the resected bowel specimens had a characteristic appearance at the time of surgery, with a yellow discoloration, small areas of antimesenteric necrosis, and very sharp borders. Histologically, the bowel specimens frequently have fibrin thrombi in the small submucosal and mucosal blood vessels in areas of mucosal necrosis. Overall mortality in this cohort was 33%. Forty percent of patients had a thromboembolic complication overall with 88% of these developing a thromboembolic phenomenon despite being on prophylactic pre-operative anticoagulation. CONCLUSION: Bowel ischemia is a potentially lethal complication of COVID-19 infection with typical gross and histologic characteristics. Suspicious clinical features that should trigger surgical evaluation include a new or increasing vasopressor requirement, abdominal distension, and intolerance of gastric feeds.


Assuntos
COVID-19/complicações , Enteropatias/cirurgia , Enteropatias/virologia , Isquemia/cirurgia , Isquemia/virologia , Feminino , Humanos , Laparotomia , Masculino , Massachusetts , Pessoa de Meia-Idade , SARS-CoV-2
14.
J Surg Res ; 268: 432-439, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-34416415

RESUMO

BACKGROUND: Several studies have demonstrated that low-molecular weight heparin (LMWH) is superior to unfractionated heparin (UFH) in trauma patients. The superiority of either one has not been established for the elderly. In this study, we compared LMWH to UFH in elderly trauma patients. METHODS: A retrospective analysis of the American College of Surgeons' Trauma Quality Improvement Program database was performed for patients aged ≥65 y. Propensity score matching was performed to minimize confounders between the two groups. Outcomes included venous thromboembolic (VTE) and bleeding events. RESULTS: Overall, 93,987 patients were identified (mean age 77.1 ± 7.3 y, females 55,035 [58.6%]), of which 67,738 (72.1%) patients received LMWH and 26,249 (27.9%) received UFH. After Propensity score matching, LMWH was associated with a lower incidence of deep venous thrombosis (1.7% versus 2.1%, P = 0.007) and pulmonary embolisms (0.6% versus 1%, P< 0.001). LMWH was also associated with fewer bleeding complications (transfusions: 2.8% versus 3.5%, P< 0.001, procedures: 0.7% versus 0.9%, P = 0.007). Sub-analyses showed that differences in VTE rates were identified in patients with mild injuries (Injury Severity Score [ISS] <16, 0.6% versus 1.9%, P< 0.001). Differences in bleeding complications were identified in patients with injuries of mild (ISS <16, transfusions: 3% versus 3.8%, P< 0.001, surgeries: 0.3% versus 0.4%, P= 0.015) and moderate severity (ISS 16-24, transfusions: 1.9% versus 2.7%, P= 0.038, surgeries: 1% versus 1.7%, P= 0.013). CONCLUSION: LMWH prophylaxis is superior to UFH for VTE prevention among elderly trauma patients. LMWH prophylaxis is associated with fewer bleeding complications compared to UFH in patients with injuries of mild or moderate severity.


Assuntos
Heparina de Baixo Peso Molecular , Tromboembolia Venosa , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Feminino , Heparina/efeitos adversos , Heparina de Baixo Peso Molecular/efeitos adversos , Humanos , Peso Molecular , Estudos Retrospectivos , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle
15.
Surgery ; 170(5): 1501-1507, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34176601

RESUMO

BACKGROUND: The Emergency Surgery Score was recently validated in a prospective multicenter study as an accurate predictor of mortality in emergency general surgery patients. The Emergency Surgery Score is easily calculated using multiple demographic, comorbidity, laboratory, and acuity of disease variables. We aimed to investigate whether the Emergency Surgery Score can predict 30-day postoperative mortality across patients undergoing emergency surgery in multiple surgical specialties. METHODS: Our study is a retrospective cohort study using data from the national American College of Surgeons National Surgical Quality Improvement Program database (2007-2017). We included patients that underwent emergency gynecologic, urologic, thoracic, neurosurgical, orthopedic, vascular, cardiac, and general surgical procedures. The Emergency Surgery Score was calculated for each patient, and the correlation between the Emergency Surgery Score and 30-day mortality was assessed for each specialty using the c-statistics methodology. RESULTS: Of 6,485,915 patients, 173,890 patients were included. The mean age was 60 years, 50.6% were female patients, and the overall mortality was 9.7%. The Emergency Surgery Score predicted mortality best in emergency gynecologic, general, and urologic surgery (c-statistics: 0.97, 0.87, 0.81, respectively). The Emergency Surgery Score predicted mortality moderately well in emergency thoracic, neurosurgical, orthopedic, and vascular surgery (c-statistics 0.73-0.79). For example, the mortality of gynecology patients with an Emergency Surgery Score of 5, 9, and 13 was 2%, 27%, and 50%, respectively. The Emergency Surgery Score performed poorly in cardiac surgery. CONCLUSION: The Emergency Surgery Score accurately predicts mortality across patients undergoing emergency surgery in multiple surgical specialties, especially general, gynecologic, and urologic surgery. The Emergency Surgery Score can prove useful for perioperative patient counseling and for benchmarking the quality of surgical care.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Cirurgia Geral/estatística & dados numéricos , Indicadores Básicos de Saúde , Procedimentos Cirúrgicos Operatórios/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Estados Unidos/epidemiologia
17.
Injury ; 52(5): 1204-1209, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33455811

RESUMO

INTRODUCTION: We sought to determine the impact of the indication for shunt placement on shunt-related outcomes after major arterial injuries. We hypothesized that a shunt placed for damage control indications would be associated with an increase in shunt-related complications including shunt dislodgement, thrombosis, or distal ischemia. PATIENTS & METHODS: A prospective, multicenter study (eleven level one US trauma centers) of all adult trauma patients undergoing temporary intravascular shunts (TIVS) after arterial injury was undertaken (January 2017-May 2019). Exclusion criteria included age <15years, shunt placement distal to popliteal/brachial arteries, isolated venous shunts, and death before shunt removal. Clinical variables were compared by indication and shunt-related complications. The primary endpoint was TIVS complications (thrombosis, migration, distal ischemia). RESULTS: The 66 patients who underwent TIVS were primarily young (30years [IQR 22-36]) men (85%), severely injured (ISS 17 [10-25]) by penetrating mechanisms (59%), and had their shunts placed for damage control (41%). After a median SDT of 198min [89-622], 9% experienced shunt-related complications. Compared by shunt placement indication (damage control shunts [n=27] compared to non-damage control shunts [n=39]), there were no differences in gender, mechanism, extremity AIS, MESS score, fractures, or surgeon specialty between the two groups (all p>0.05). Patients with shunts placed for damage control indications had more severe injuries (ISS 23.5 compared to 13; SBP 100 compared to 129; GCS 11 compared to 15; lactate 11.5 compared to 3.6; all p<0.05), and had more frequent shunt complication predictors, but damage control shunts did not have significantly more TIVS complications (11.1% compared to 7.7%, p=0.658). Shunt complication patients were discharged home less often (33% vs 65%; p<0.05) but all survived. CONCLUSION: Shunts placed for damage control indications were not associated with shunt complications in this prospective, multicenter study.


Assuntos
Lesões do Sistema Vascular , Adolescente , Humanos , Masculino , Artéria Poplítea , Estudos Prospectivos , Estudos Retrospectivos , Centros de Traumatologia , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/cirurgia
18.
J Trauma Acute Care Surg ; 90(3): 471-476, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33055577

RESUMO

BACKGROUND: The Emergency Surgery Score (ESS) is a point-based scoring system validated to predict mortality and morbidity in emergency general surgery (EGS). In addition to demographics and comorbidities, ESS accounts for the acuity of disease at presentation. We sought to examine whether ESS can predict the destination of discharge of EGS patients, as a proxy for quality of life at discharge. METHODS: Using the 2007 to 2017 American College of Surgeons National Surgical Quality Improvement Program database, we identified all EGS patients. EGS cases were defined as per American College of Surgeons National Surgical Quality Improvement Program as those performed by a general surgeon within a short interval from diagnosis or the onset of related symptomatology, when the patient's well-being and outcome may be threatened by unnecessary delay and patient's status could deteriorate unpredictably or rapidly. Emergency Surgery Score patients were then categorized by their discharge disposition to home versus rehabilitation or nursing facilities. All patients with missing ESS or discharge disposition and those discharged to hospice, senior communities, or separate acute care facilities were excluded. Emergency Surgery Score was calculated for each patient. C statistics were used to study the correlation between ESS and the destination of discharge. RESULTS: Of 6,485,915 patients, 84,694 were included. The mean age was 57 years, 51% were female, and 79.6% were discharged home. The mean ESS was 5. Emergency Surgery Score accurately and reliably predicted the discharge destination with a C statistic of 0.83. For example, ESS of 1, 10, and 20 were associated with 0.9%, 56.5%, and 100% rates of discharge to a rehabilitation or nursing facility instead of home. CONCLUSION: Emergency Surgery Score accurately predicts which EGS patients require discharge to rehabilitation or nursing facilities and can thus be used for preoperatively counseling patients and families and for improving early discharge preparations, when appropriate. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.


Assuntos
Serviço Hospitalar de Emergência , Gravidade do Paciente , Alta do Paciente , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Idoso , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Melhoria de Qualidade , Qualidade de Vida , Estudos Retrospectivos , Medição de Risco , Estados Unidos
19.
J Neurotrauma ; 38(7): 879-885, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33107386

RESUMO

Hypotension is a known risk factor for poor neurologic outcomes after traumatic brain injury (TBI). Current guidelines suggest that higher systolic blood pressure (SBP) thresholds likely confer a mortality benefit. However, there is no consensus on the ideal perfusion pressure among different age groups (i.e., recommended SBP ≥100 mm Hg for patients age 50-69 years; ≥ 110 mm Hg for all other adults). We hypothesize that admission SBP ≥110 mm Hg will be associated with improved outcomes regardless of age group. A retrospective database review of the 2010-2016 Trauma Quality Improvement Program database was performed for adults (≥ 18 years) with isolated moderate-to-severe TBIs (head Abbreviated Injury Scale [AIS] ≥3; all other AIS <3). Sub-analyses were performed after dividing patients by SBP and age; comparison groups were matched with propensity score matching. Primary outcomes were early (6 h, 12 h, and 1 day) and overall in-hospital mortality. Overall, 154,725 patients met the inclusion criteria (mean age 62.8 ± 19.8 years, 89,431 [57.8%] males, Injury Severity Score13.9 ± 6.8). Multi-variate logistic regression showed that the risk of in-hospital mortality decreased with increasing SBP, plateauing at 110 mm Hg. Among patients of all ages, SBP ≥110 mm Hg was associated with improved mortality (SBP 110-129 vs. 90-109 mm Hg: 12 h 0.4% vs. 0.8%, p = 0.001; 1 day 0.8% vs. 1.4%, p = 0.004; overall 3.2% vs. 4.9%, p < 0.001). Among patients age 50-69 years, SBP ≥110 mm Hg was associated with improved mortality (SBP 110-119 vs. 100-109 mm Hg: 12 h 0.3% vs. 0.9%, p = 0.018; 1 day 0.5% vs. 1.5%, p = 0.007; overall 2.7% vs. 4.3%, p = 0.015). In conclusion, SBP ≥110 mm Hg is associated with lower in-hospital mortality in adult patients with isolated TBIs, including patients age 50-69 years. SBP <110 mm Hg should be used to define hypotension in adult patients of all ages.


Assuntos
Pressão Sanguínea/fisiologia , Lesões Encefálicas Traumáticas/mortalidade , Lesões Encefálicas Traumáticas/fisiopatologia , Bases de Dados Factuais/tendências , Hipotensão/mortalidade , Hipotensão/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas Traumáticas/diagnóstico , Feminino , Mortalidade Hospitalar/tendências , Humanos , Hipotensão/diagnóstico , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Admissão do Paciente/tendências , Estudos Retrospectivos
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