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

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

Disaster planning for a surgical surge: when mass trauma threatens to overwhelm your operating rooms.

Mass casualty events particularly those requiring multiple simultaneous operating rooms are of increasing concern. Existing literature predominantly focuses on mass casualty care in the emergency department. Hospital disaster plans should include a component focused on preparing for multiple simultaneous operations. When developing this plan, representatives from all segments of the perioperative team should be included. The plan needs to address activation, communication, physical space, staffing, equipment, blood and medications, disposition offloading, special populations, and rehearsal.

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

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

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

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

Tracheostomy in Patients on Venovenous Extracorporeal Membrane Oxygenation: Is It Safe?

BACKGROUND: The anticoagulation and coagulopathy associated with venovenous extracorporeal membrane oxygenation (VV-ECMO) lead to concern for increased risks of tracheostomy. The purpose of this study is to evaluate the safety of tracheostomy in patients on VV-ECMO. METHODS: Patients admitted between November 2015 and January 2019 to a dedicated intensive care unit for VV-ECMO were reviewed retrospectively. RESULTS: 96 patients underwent tracheostomy. Tracheostomy was performed percutaneously in 51 patients, open in 24, and hybrid in 21. 28 patients had postprocedure bleeding which was from the tracheostomy site in 13, the airway in 13, and both in 2. 6 patients had major tracheostomy site bleeding and 3 patients had major airway bleeding. 7 patients had minor tracheostomy site bleeding, 10 patients had minor airway bleeding, and 2 patients had minor bleeding at both. Bleeding complications were more common following percutaneous tracheostomy. Being on anticoagulation prior to tracheostomy was protective. DISCUSSION: Bleeding following tracheostomy in VV-ECMO is common with higher bleeding rates observed for those done percutaneously. Most complications were minor. Tracheostomy in patients on VV-ECMO appears safe.

Readmission after emergency general surgery.

BACKGROUND: Readmission rates are an important metric because they enable an evaluation of care and affect Medicare funding. This study evaluates factors contributing to readmission after emergency general surgery. METHODS: The Virginia Health Information database was used to identify patients who had undergone the most common emergency general surgery procedures from 1/2011-6/2016. Analyses were performed for 30 and 90-day readmission. RESULTS: 121,223 records met initial inclusion criteria and 54,372 remained after exclusions. In 30 days there were 5050 readmissions and 7896 readmissions in 90 days. Factors significant in contributing to 30-day readmission were length of stay, discharge location, and several comorbidities. For 90-day readmission the same factors were significant with the addition of urgent vs emergency admission and insurance status as well as additional comorbidities. Discharge to rehab, SNF, or with home healthcare had particularly high rates of 90 day readmission. CONCLUSIONS: We identified factors that contribute to readmission after emergency general surgery providing targets for future interventions. Improved follow up for patients discharged with rehab or home health needs is our next step.

Early Use of a Chest Trauma Protocol in Elderly Patients with Rib Fractures Improves Pulmonary Outcomes.

Rib fractures are among the most common injuries identified in blunt trauma patients. Morbidity increases with increasing age and increasing number of rib fractures. The use of noninvasive ventilation has been shown to be helpful as a rescue technique avoiding intubation in patients who have become hypoxemic but little data with regard to its use to prophylactically prevent worsening respiratory status are available. We developed a chest trauma protocol for our "elderly" (>45 years) trauma patients and sought to determine whether this would improve pulmonary outcomes. We retrospectively reviewed our elderly chest trauma patients one year before (CTRL) and nine months after implementation (STU) of the chest trauma protocol. The protocol consisted of intravenous narcotics, oral nonsteroidal anti-inflammatory drugs, prophylactic noninvasive ventilation, and measurements of incentive spirometry. In the control year, there were 176 patients meeting study criteria, whereas 140 met the criteria in the STU group. The CTRL group had 11 unplanned ICU admissions (rate 0.063), six unplanned intubations (rate 0.034), and eight patients diagnosed with pneumonia (rate 0.045). These rates decreased in the STU group to two unplanned ICU admissions (0.014, P = 0.044), one unplanned intubation (rate 0.007, P = 0.138), and no patients with pneumonia (0.0, P = 0.010). Our chest trauma protocol has significantly decreased adverse pulmonary events in our older blunt chest trauma population with multiple rib fractures. This protocol has become our standard procedure for patients older than 45 years admitted with rib fractures.