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INTRODUCTION: The shock index (SI) is a known predictor of unfavorable outcomes in trauma. This study seeks to examine and compare the SI values between geriatric patients and younger adults. METHODS: We conducted a retrospective study of the Trauma Quality Improvement Program database from 2017 to 2019. All patients≥ 25 y with injury severity score ≥ 16 were included. Age groups were defined as 25-44 y (group A), 45-64 y (group B), and ≥65 y (group C). SI was calculated for all patients. The primary outcome was mortality and secondary outcomes were need for blood transfusion and need for major surgical intervention (consisting angiography, exploratory laparotomy, and thoracotomy). RESULTS: A total of 244,943 patients were studied. The SI was highest in group A (0.82 ± 0.33) and lowest in group C (0.62 ± 0.30) (P < 0.001). Mortality rate of group C (17%) was significantly higher than group A (9.7%) and B (11.3%) (P < 0.001). In group A, each 0.1 increase in SI was associated with mortality (odds ratio [OR] = 1.079), need for blood transfusion (OR = 1.225) and need for major surgical intervention (OR = 1.347) (P < 0.001 for all). In group C, each 0.1 increase in SI was associated with mortality (OR = 1.126), need for blood transfusion (OR = 1.318), and need for major surgical intervention (OR = 1.648) (P < 0.001 for all). The area under the curve of SI was significantly higher in group C compared to other groups for needing a major surgical intervention and need for blood transfusion (P < 0.05 for both). CONCLUSIONS: These results highlight the significance of the SI as a valuable indicator in geriatric patients with severe trauma. The findings show that SI predicts outcomes in geriatrics more strongly than in younger counterparts.
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Choque , Humanos , Estudos Retrospectivos , Pessoa de Meia-Idade , Masculino , Feminino , Idoso , Adulto , Fatores Etários , Choque/mortalidade , Choque/diagnóstico , Choque/terapia , Transfusão de Sangue/estatística & dados numéricos , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/terapia , Ferimentos e Lesões/diagnóstico , Escala de Gravidade do Ferimento , PrognósticoRESUMO
Venous thrombosis of pancreas transplant allografts often leads to graft loss. It is an worrisome complication and difficult to treat, forming the most common nonimmunological cause of graft loss. Multiple risk factors have been implicated in the development of venous thrombosis of pancreas transplant. Color Doppler ultrasonography enables early diagnosis of venous thrombosis, thus increasing the possibility of graft-rescue treatments. Endovascular management of pancreatic transplant vascular complications is scant and in the form of case reports. We report a case of early detection of pancreatic graft venous thrombosis that was treated successfully by catheter-directed thrombolysis mechanical thrombectomy, percutaneous transluminal angioplasty, and stenting of portal vein.
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Angioplastia com Balão/instrumentação , Oclusão de Enxerto Vascular/terapia , Sobrevivência de Enxerto , Transplante de Pâncreas/efeitos adversos , Veia Porta , Stents Metálicos Autoexpansíveis , Trombose Venosa/terapia , Adulto , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Masculino , Flebografia , Veia Porta/diagnóstico por imagem , Veia Porta/fisiopatologia , Trombectomia , Terapia Trombolítica , Resultado do Tratamento , Ultrassonografia Doppler em Cores , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/etiologia , Trombose Venosa/fisiopatologiaRESUMO
INTRODUCTION: Reintubation in unplanned scenarios, carries inherent risks and potential complications particularly in vulnerable populations such as geriatric trauma patients. We sought to identify preadmission risk factors for unplanned re-intubation (URI) in geriatric trauma patients and its effects on outcomes. METHODS: Analysis of TQIP (2017-2019) of intubated geriatric trauma patients, classified into two groups, those who were successfully extubated and those who required URI. We used logistic regression to assess for preadmission risk factors of URI. RESULTS: Among 23,572 patients, 20.2 â% underwent URI. URI had higher mortality (13.7%vs.8.1 â%, p â< â0.001), in-hospital complications (p â< â0.05), longer hospital and ICU LOS (p â< â0.001 for both). Higher age (OR â= â1.017), smoking (OR â= â1.418), CRF(OR â= â1.414), COPD (OR â= â1.410), alcohol use (OR â= â1.365), functionally dependent health status (OR â= â1.339), and anticoagulant use (OR â= â1.148), increased the risks of URI (p â< â0.05 for all). CONCLUSION: Geriatric patients with comorbidities including age, smoking, CRF, COPD, alcohol use, dependent status, and anticoagulant use are at higher risks of URI that could in turn, be associated with increased rates of mortality, complications, and longer hospital and ICU length of stay. LEVEL OF EVIDENCE: Level III retrospective study.
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BACKGROUND: With a sustained increase in the proportion of elderly trauma patients, geriatric traumatic brain injury (TBI) is a significant source of morbidity, mortality and resource utilization. The aim of our study was to assess the predictors of mortality in geriatric TBI patients who underwent craniotomy. METHODS: We performed a 4-year analysis of ACS-TQIP database (2016-2019) and included all geriatric trauma patients (≥65y) with isolated severe TBI who underwent craniotomy. We calculated 11- point modified frailty index (mFI) for patients. Our primary and secondary outcomes were mortality and unfavorable outcome, respectively. Multivariate regression analysis was performed to identify the predictors of outcomes. Patients with mFI ≥ 0.25 were defined as Frail, whereas patient with mFI of 0.08 or higher (<0.25) were identified as pre-frail; Non-frail patients were identified as mFI of <0.08. RESULTS: We analyzed data from 20,303 patients. The mortality rate was 17.7 % (3,587 patients). Having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 2.251, p < 0.001), and pre-hospital anticoagulant use (OR = 1.306, p < 0.001) increased the risks of mortality. Frailty, as a continuous variable, was not considered as a risk factor for mortality (p = 0.058) but after categorization, it was shown that compared to non-frails, patients with pre-frailty (OR = 1.946, p = 0.011) and frailty (OR = 1.786, p = 0.026) had increased risks of mortality. Higher mFI (OR = 4.841), age (OR = 1.034), ISS (OR = 1.052), having ≥ 2 concomitant types of intra-cranial hemorrhage (OR = 1.758), and use of anticoagulants (OR = 1.117) were significant risk factors for unfavorable outcomes (p < 0.001, for all). CONCLUSIONS: Having more than two types of intra-cranial hemorrhage and pre-hospital anticoagulant use were significant risk factors for mortality. The study's findings also suggest that frailty may not be a sufficient predictor of mortality after craniotomy in geriatric patients with TBI. However, frailty still affects the discharge disposition and favorable outcome. LEVEL OF EVIDENCE: Level III retrospective study.
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Minimally invasive surgical techniques have demonstrated superior outcomes across various elective procedures. Laparoscopic surgery (LS) is established in general surgery with laparoscopic operations for acute appendicitis and cholecystitis being the standard of care. Robotic surgery (RS) has been associated with equivalent or improved postoperative outcomes compared with LS. This increasing uptake of RS in emergency general surgery has encouraged the adoption of robotic acute care programs across the world. The key elements required to build a sustainable RS program are an enthusiastic surgical team, intensive training, resources and marketing. This review is a comprehensive layout elaborating the step-by-step process that has helped our high-volume level I trauma center in establishing a successful robotic acute care surgery program.
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The use of prophylactic measures, including perioperative antibiotics, for the prevention of surgical site infections is a standard of care across surgical specialties. Unfortunately, the routine guidelines used for routine procedures do not always account for many of the factors encountered with urgent/emergent operations and critically ill or high-risk patients. This clinical consensus document created by the American Association for the Surgery of Trauma Critical Care Committee is one of a three-part series and reviews surgical and procedural antibiotic prophylaxis in the surgical intensive care unit. The purpose of this clinical consensus document is to provide practical recommendations, based on expert opinion, to assist intensive care providers with decision-making for surgical prophylaxis. We specifically evaluate the current state of periprocedural antibiotic management of external ventricular drains, orthopedic operations (closed and open fractures, silver dressings, local, antimicrobial adjuncts, spine surgery, subfascial drains), abdominal operations (bowel injury and open abdomen), and bedside procedures (thoracostomy tube, gastrostomy tube, tracheostomy).
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The evaluation and workup of fever and the use of antibiotics to treat infections is part of daily practice in the surgical intensive care unit (ICU). Fever can be infectious or non-infectious; it is important to distinguish between the two entities wherever possible. The evidence is growing for shortening the duration of antibiotic treatment of common infections. The purpose of this clinical consensus document, created by the American Association for the Surgery of Trauma Critical Care Committee, is to synthesize the available evidence, and to provide practical recommendations. We discuss the evaluation of fever, the indications to obtain cultures including urine, blood, and respiratory specimens for diagnosis of infections, the use of procalcitonin, and the decision to initiate empiric antibiotics. We then describe the treatment of common infections, specifically ventilator-associated pneumonia, catheter-associated urinary infection, catheter-related bloodstream infection, bacteremia, surgical site infection, intra-abdominal infection, ventriculitis, and necrotizing soft tissue infection.
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BACKGROUND: Leak following surgical repair of traumatic duodenal injuries results in prolonged hospitalization and oftentimes nil per os(NPO) treatment. Parenteral nutrition(PN) has known morbidity; however, duodenal leak(DL) patients often have complex injuries and hospital courses resulting in barriers to enteral nutrition(EN). We hypothesized EN alone would be associated with 1)shorter duration until leak closure and 2)less infectious complications and shorter hospital length of stay(HLOS) compared to PN. METHODS: This was a post-hoc analysis of a retrospective, multicenter study from 35 Level-1 trauma centers, including patients >14 years-old who underwent surgery for duodenal injuries(1/2010-12/2020) and endured post-operative DL. The study compared nutrition strategies: EN vs PN vs EN + PN using Chi-Square and Kruskal-Wallis tests; if significance was found pairwise comparison or Dunn's test were performed. RESULTS: There were 113 patients with DL: 43 EN, 22 PN, and 48 EN + PN. Patients were young(median age 28 years-old) males(83.2%) with penetrating injuries(81.4%). There was no difference in injury severity or critical illness among the groups, however there were more pancreatic injuries among PN groups. EN patients had less days NPO compared to both PN groups(12 days[IQR23] vs 40[54] vs 33[32],p = <0.001). Time until leak closure was less in EN patients when comparing the three groups(7 days[IQR14.5] vs 15[20.5] vs 25.5[55.8],p = 0.008). EN patients had less intra-abdominal abscesses, bacteremia, and days with drains than the PN groups(all p < 0.05). HLOS was shorter among EN patients vs both PN groups(27 days[24] vs 44[62] vs 45[31],p = 0.001). When controlling for predictors of leak, regression analysis demonstrated EN was associated with shorter HLOS(ß -24.9, 95%CI -39.0 to -10.7,p < 0.001). CONCLUSION: EN was associated with a shorter duration until leak closure, less infectious complications, and shorter length of stay. Contrary to some conventional thought, PN was not associated with decreased time until leak closure. We therefore suggest EN should be the preferred choice of nutrition in patients with duodenal leaks whenever feasible. LEVEL OF EVIDENCE: IV.
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BACKGROUND: Surgical stabilization of rib fractures (SSRF) has gained increasing interest over the past decade, yet few candidates who could benefit from SSRF undergo operative management. We conducted an international survey of institutional SSRF guidelines comparing congruence between practice and contemporary evidence. We hypothesized that few guidelines reflect comprehensive evidence to facilitate standardized patient selection, operation, and postoperative management. METHODS: A request for institutional rib fracture guidelines was distributed from the Chest Wall Injury Society. Surgical stabilization of rib fractures-specific guideline contents were extracted using a priori-designed extraction sheets and compared against 28 SSRF evidence-based recommendations outlined by a panel of 14 international experts. Fisher's exact test compared the proportion of strong and weak evidence-based recommendations specified within a majority of institutional guidelines to evaluate whether strength of evidence is associated with implementation. RESULTS: A total of 36 institutions from 3 countries submitted institutional rib fracture management guidelines, among which 30 had SSRF-specific guidance. Twenty-eight guidelines (93%) listed at least one injury pattern criteria as an indication for SSRF, while 22 (73%) listed pain and 21 (70%) listed impaired respiratory function as other indications. Quantitative pain and respiratory function impairment thresholds that warrant SSRF varied across institutions. Few guidelines specified nonacute indications for SSRF or perioperative considerations. Seven guidelines (23%) detailed postoperative management but recommended timing and interval for follow-up varied. Overall, only 3 of the 28 evidence-based SSRF recommendations were specified within a majority of institutional practice guidelines. There was no statistically significant association ( p = 0.99) between the strength of recommendation and implementation within institutional guidelines. CONCLUSION: Institutional SSRF guidelines do not reflect the totality of evidence available in contemporary literature. Guidelines are especially important for emerging interventions to ensure standardized care delivery and minimize low-value care. Consensus effort is needed to facilitate adoption and dissemination of evidence-based SSRF practices. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
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Fraturas das Costelas , Traumatismos Torácicos , Humanos , Fraturas das Costelas/cirurgia , Fraturas das Costelas/complicações , Traumatismos Torácicos/complicações , Fixação Interna de Fraturas , Inquéritos e Questionários , Dor , Estudos RetrospectivosRESUMO
INTRODUCTION: Nonoperative management (NOM) of acute calculous cholecystitis (ACC) in patients with cirrhosis was proposed. We examined the outcomes of cirrhotic patients with ACC treated with cholecystectomy compared to NOM. METHODS: We analyzed the 2017-Nationwide Readmissions Database including cirrhotic patients with ACC. Patients were stratified: cholecystectomy, percutaneous cholecystostomy (PCT), and antibiotics only. PRIMARY OUTCOMES: complications, failure of NOM. SECONDARY OUTCOMES: mortality, length of stay (LOS), and charges. RESULTS: 3454 patients were identified. 1832 underwent cholecystectomy, 360 PCT, and 1262 were treated with antibiotics. PCT patients had higher mortality 16.9% vs. the antibiotics group 10.9% vs. cholecystectomy group 4.2%. PCT patients had longer LOS, but lower charges compared to the operative group. Failure of NOM was 28.2%. On regression, PCT was associated with mortality. CONCLUSION: ACC remains a morbid disease in cirrhosis patients. One in three failed NOM, had longer LOS, and higher mortality. Further studies are warranted to identify predictors of NOM failure. LEVEL OF EVIDENCE: Level III, prognostic.
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Colecistite Aguda , Colecistostomia , Humanos , Estudos Retrospectivos , Resultado do Tratamento , Cirrose Hepática/cirurgia , Colecistite Aguda/complicações , Colecistite Aguda/cirurgia , Antibacterianos/uso terapêuticoRESUMO
BACKGROUND: Duodenal leak is a feared complication of repair, and innovative complex repairs with adjunctive measures (CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak are sparse, and its impact on duodenal leak outcomes is nonexistent. We hypothesized that primary repair alone (PRA) would be associated with decreased duodenal leak rates; however, CRAM would be associated with improved recovery and outcomes when leaks do occur. METHODS: A retrospective, multicenter analysis from 35 Level 1 trauma centers included patients older than 14 years with operative, traumatic duodenal injuries (January 2010 to December 2020). The study sample compared duodenal operative repair strategy: PRA versus CRAM (any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy). RESULTS: The sample (N = 861) was primarily young (33 years) men (84%) with penetrating injuries (77%); 523 underwent PRA and 338 underwent CRAM. Complex repairs with adjunctive measures were more critically injured than PRA and had higher leak rates (CRAM 21% vs. PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more interventional radiology drains, prolonged nothing by mouth and length of stay, greater mortality, and more readmissions than PRA (all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, nothing by mouth duration, need for interventional radiology drainage, hospital length of stay, or mortality between PRA leak versus CRAM leak patients (all p > 0.05). Furthermore, CRAM leaks had longer antibiotic duration, more gastrointestinal complications, and longer duration until leak resolution (all p < 0.05). Primary repair alone was associated with 60% lower odds of leak, whereas injury grades II to IV, damage control, and body mass index had higher odds of leak (all p < 0.05). There were no leaks among patients with grades IV and V injuries repaired by PRA. CONCLUSION: Complex repairs with adjunctive measures did not prevent duodenal leaks and, moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest that CRAM is not a protective operative duodenal repair strategy, and PRA should be pursued for all injury grades when feasible. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
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Traumatismos Abdominais , Ferimentos Penetrantes , Masculino , Humanos , Estudos Retrospectivos , Complicações Pós-Operatórias , Ferimentos Penetrantes/cirurgia , Traumatismos Abdominais/cirurgia , Anastomose Cirúrgica/métodosRESUMO
BACKGROUND: Publications investigating the efficacy of surgical stabilization of rib fractures (SSRF) have increased exponentially. However, there is currently no standardized reporting structure for these studies, rendering both comparisons and extrapolation problematic. METHODS: A subject matter expert group was formed by the Chest Wall Injury Society. This group conducted a review of the SSRF investigational literature and identified variable reporting within several general categories of relevant parameters. A compliment of guidelines was then generated. RESULTS: The reporting guidelines consist of 26 recommendations in the categories of: (1) study type, (2) patient and injury characteristics, (3) patient treatments, (4) outcomes, and (5) statistical considerations. CONCLUSION: Our review identified inconsistencies in reporting within the investigational SSRF literature. In response to these inconsistencies, we propose a set of recommendations to standardize reporting of original investigations into the efficacy of SSRF.
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Fraturas das Costelas , Traumatismos Torácicos , Parede Torácica , Fixação de Fratura , Humanos , Fraturas das Costelas/cirurgia , Parede Torácica/cirurgiaRESUMO
BACKGROUND: Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS: An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS: The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION: Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication. LEVEL OF EVIDENCE: Prognostic, level III.