Predictors of mortality in trauma patients

The purpose of this study was to ascertain risk factors for death from trauma. The large cohort allows for simultaneous evaluation of known mortality risk factors along with controlling for factors to assess the influence of each independently. Individually, base deficit, temperature, hypotension, age, and injury severity have been shown to be associated with an increased risk of death. However, in the English literature, there is no data on the independent predictive power and interaction of these risk factors. A review of trauma registry parameters from 1995 to 2000 was used. Demographics, injury severity, physiological and hematological parameters, and time data were evaluated in a univariate analysis. Variables significantly associated with mortality were entered into a stepwise backward multiple logistic regression. There were 1276 deaths (8.9%) with 25 per cent of the deaths within 3 hours. The top four predictors of mortality in this group were partial thromboplastin time (OR 3.37, 95% CI: 2.51-4.52), positive head computed tomography result (OR, 2.47; 95% CI, 1.95-3.04), initial hemoglobin (OR, 1.69; 95% CI, 1.23-2.31), base deficit (OR, 1.62; 95% CI, 1.29-2.04), and trauma resuscitation bay systolic blood pressure (OR, 1.45; 95% CI, 1.11-1.88). We conclude that prognostic indicators of all-cause mortality after trauma, which remain independent in the presence of all other factors and are potentially treatable, included low hemoglobin, elevated prothrombin and partial thromboplastin time, low scene and trauma bay systolic pressure, and elevated base deficit. The independent indicators of mortality, which are untreatable, included head injury, increasing age, and Injury Severity Score.     

Predictors of outcome in patients requiring surgery for liver trauma

INTRODUCTION: Severe bleeding from liver injury is one of the major causes of mortality in patients with abdominal trauma. The study was undertaken to assess factors that influence outcome following liver trauma. PATIENTS AND METHODS: This is a prospective study of patients with liver injury treated in one surgical ward at King Edward VIII Hospital over a 7-year period (from 1998 to 2004). Data collected included demographics, intra-operative findings, operative management and outcome. RESULTS: Of a total of 478 patients with abdominal trauma, 105 (22%) were found to have liver injuries, of whom only 7 were female. Their mean age was 27.81+/-10.33 years. Injuries were due to firearms (70), stabs (26) and blunt trauma (9). Nineteen patients presented with shock (systolic BP6h in 47 patients. Forty patients required ICU management (38%) and the mean ICU stay was 6.55+/-5.65 days. Twenty patients (19%) needed a re-laparotomy for various reasons. The complication rate was 37% and the mortality rate was 20% (23% for firearms, 44% for blunt trauma and 4% for stabs). The mortality rate in patients with shock was 58% compared to 12% in those who were not shocked (p<0.0001). Mortality rate was 2, 23 and 63% for Injury Severity Score (ISS)20, respectively (group 1 versus group 2 p=0.015; group 1 versus group 3 p<0.0001 and group 2 versus group 3 p=0.001). Mortality rates for delay 6h were 28 and 9%, respectively (p=0.008). Associated injuries led to a higher mortality (3% versus 27%; p=0.006). Hospital stay was 11.27+/-12.09 days. CONCLUSIONS: Liver injuries occurred in 22% of abdominal injuries. Injury mechanism, delay before surgery, shock on admission, grade of injury, associated injury and ISS are significantly associated with outcome.     

Injuries associated with serious brachial plexus involvement in polytrauma among patients requiring surgical repair

Background

Brachial plexus injury occurs in up to 5% of polytrauma cases involving motorcycle crashes and in approximately 4% of severe winter sports injuries. One of the conditions for the success of operative therapy is early detection, ideally within three months of injury. The aim of this study was to evaluate associated injuries in patients with severe brachial plexus injury and determine whether there is a characteristic concomitant injury (or injuries), the presence of which, in the polytrauma, could act as a marker for nerve structures involvement and whether there are differences in severity of polytrauma accompanying specific types of brachial plexus injury.

Methods

We evaluated retrospectively 84 surgical patients from our department, from 2008 to 2011, that had undergone brachial plexus reconstruction. For all, an injury severity scale (ISS) score and all major associated injuries were determined.

Results

72% of patients had an upper, 26% had a complete and only 2% had a lower brachial plexus palsy. The main cause was motorcycle crashes (60%) followed by car crashes (15%). The average ISS was 35.2 (SD = 23.3), although, values were significantly higher in cases involving a coma (59.3, SD = 11.0). The lower and complete plexus injuries were significantly associated with coma and fractures of the shoulder girdle and injuries of lower limbs, thoracic organs and head. Upper plexus injuries were associated with somewhat less severe injuries of the upper and lower extremities and less severe injuries of the spine.

Conclusion

Serious brachial plexus injury is usually accompanied by other severe injuries. It occurs in high-energy trauma and it can be stated that patients involved in motorcycle and car crashes with multiple fractures of the shoulder girdle are at high risk of nerve trauma. This is especially true for patients in a primary coma. Lower and complete brachial plexus injuries are associated with higher injury severity scale.     

Differing perceptions of preoperative communication among surgical team members

Background

Although preoperative communication is an emerging means through which surgical teams prepare for cases, little is known regarding its current state. This study investigated this topic in a survey of surgical team members.

Racial disparities in postoperative morbidity and mortality among high-risk pediatric surgical patients.

Study objectiveWith increasing improvement in perioperative care, post-surgical complication and mortality rates have continued to decline in the United States. Nonetheless, not all racial groups have benefitted equally from this transformative improvement in postoperative outcomes. We tested the hypothesis that among a cohort of “sick” (ASA physical status 4 or 5) Black and White children, there would be no systematic difference in the incidence of postoperative morbidity and mortality.DesignRetrospective cohort study.SettingInstitutions participating in the National Surgical Quality Improvement Program-Pediatric (2012–2019).PatientsBlack and White children who underwent inpatient operations and were assigned ASA physical status 4 or 5.Measurementsrisk adjusted odds ratios for 30-day postoperative mortality and complications using multivariable logistic regression models, controlling for various baseline covariates.Main resultsThere were 16,097 children included in the analytic cohort (77.0% White and 23.0% Black). After adjusting for baseline covariates, Black children were estimated to be 20% more likely than their White counterparts to die within 30 days after surgery (9.3% vs. 7.2%, adjusted-OR: 1.20, 95% CI: 1.05–1.38, P = 0.007). Black children were also more likely to develop pulmonary complications compared to their White peers (52.1% vs. 44.6%, adjusted-OR: 1.13, 95%CI: 1.04, 1.23, P = 0.005). Being Black also conferred an estimated 28% relative greater odds of developing cardiovascular complications (4.6% vs. 3.3%, 95%CI: 1.06, 1.54, P = 0.010). Finally, being Black conferred an estimated 33% relative greater odds of requiring an extended LOS compared to Whites (50.7% vs. 38.7%, adjusted-OR: 1.33, 95% CI: 1.22–1.46, P < 0.001).ConclusionIn this cohort of children with high ASA physical status, Black children compared to their White peers experienced significantly higher rates of 30-day postoperative morbidity and mortality. These findings suggest that racial differences in postoperative outcomes among the sickest pediatric surgical patients may not be entirely explained by preoperative health status.     

Predictors of surgical mortality and discharge status after coronary artery bypass grafting in patients 80 years and older

Background

Little is known about the outcomes and predictors of discharge status (DCS) in elderly patients after coronary artery bypass grafting (CABG).

Methods

By using the 2004 Nationwide Inpatient Sample database, we identified 5,731 patients aged 80 years and older who underwent primary isolated CABG. Multivariate logistic regression analyses were used to identify independent predictors of surgical mortality and DCS.

Results

The mean patient age was 82.8 ± 2.5 years. The surgical mortality rate was 7%. Only 21% of patients had a routine hospital discharge; the rest used home health care (27%) or were transferred to a rehabilitation unit or another care facility (45%). Older age, female sex, a higher comorbidity index, and referral from the emergency room were independent predictors of surgical mortality and a nonroutine DCS (P < .05 for all). In addition, DCS was associated with the patients' level of income and the expected payer.

Conclusions

Although patients aged 80 years and older have acceptable CABG-related mortality risk, many of these patients require further specialized care at discharge.     

The 90-day mortality and the subsequent renal recovery in critically ill surgical patients requiring acute renal replacement therapy

Background

Particular attention should be paid to postoperative patients that suffer from severe acute kidney injury (AKI) requiring renal replacement therapy (RRT).

Methods

This multicenter prospective observational study included 342 patients with postoperative AKI requiring RRT from January 2002 to December 2006.

Results

There were 137 (40%) survivors at 90 days after the commencement of RRT. Independent predictors of 90-day mortality were older age, presence of sepsis, status post-cardiopulmonary resuscitation, necessity of continuous renal replacement therapy (CRRT), requirement of total parenteral nutrition, lower body mass index, higher Sequential Organ Failure Assessment score, and higher serum lactate level at the commencement of RRT. Further analysis among the survivors showed that lower serum creatinine at intensive care unit admission, lower Simplified Acute Physiology Score II and inotropic equivalent score at the commencement of RRT, and using CRRT were independent predictors for subsequent renal recovery.

Conclusions

The development of AKI requiring RRT in postoperative critical patients represents a substantial risk for mortality and morbidity.     

Does mortality after trauma team activation peak at shift change?

BackgroundPrior institutional data have demonstrated trauma mortality to be highest between 06:00–07:59 at our center, which is also when providers change shifts (07:00–07:30). The objective was definition of patient, provider, and systems variables associated with trauma mortality at shift change among patients arriving as trauma team activations (TTA).MethodsAll TTA patients at our ACS-verified Level I trauma center were included (01/2008–07/2019), excluding those with undocumented arrival time. Study groups were defined by arrival time: shift change (SC) (06:00–07:59) vs. non-shift change (NSC) (all other times). Univariable/multivariable analyses compared key variables. Propensity score analysis compared outcomes after matching.ResultsAfter exclusions, 6020 patients remained: 229 (4%) SC and 5791 (96%) NSC. SC mortality was 25% vs. 16% during NSC (p < 0.001). More SC patients arrived with SBP <90 (19% vs. 11%, p < 0.001) or GCS <9 (35% vs. 24%, p < 0.001). ISS was higher during SC (43[32–50] vs. 34[27–50], p < 0.001). Time to CT scan (36[23–66] vs. 38[23–61] minutes, p = 0.638) and emergent surgery (94[35–141] vs. 63[34–107] minutes, p = 0.071) were comparable. Older age (p < 0.001), SBP <90 (p < 0.001), GCS <9 (p < 0.001), need for emergent operative intervention (p = 0.044), and higher ISS (p < 0.001) were independently associated with mortality. After propensity score matching, mortality was no different between SC and NSC (p = 0.764).ConclusionsEarly morning is a low-volume, high-mortality time for TTAs. Increased mortality at shift change was independently associated with patient/injury factors but not provider/systems factors. Ensuring ample clinical resource allocation during this high acuity time may be prudent to streamline patient care at shift change.     

Energy and protein requirements of general surgical patients requiring intravenous nutrition

General surgical patients require intravenous nutrition either because their gastrointestinal tract is blocked, too short or inflamed or because it cannot cope. Such patients can be grouped into four nutritional/metabolic categories: normal and unstressed; normal and stressed; depleted and unstressed; depleted and stressed. The energy requirements of patients in each of these groups vary according to their energy expenditure. Normally nourished and stressed patients have the highest energy expenditure and therefore require the highest energy input (45-55 kcal.kg-1day-1). Other groups of patients rarely require more than 40 kcal.kg-1day-1. Energy can be given mainly as dextrose although calories needed above 40 kcal kg-1day-1 should be given as fat (unless lipogenesis is desirable). In very stressed patients high rates of glucose infusion can themselves constitute a metabolic stress and fat may play a bigger role as a calorie source. For long term feeding, 1 litre of 10 per cent fat emulsion should be given weekly to avoid essential fatty acid deficiency. The level of nitrogen intake required to maintain a positive nitrogen balance is a lot higher in surgical patients than the suggested recommended dietary allowances for normal subjects. It is dependent not only on the nutritional and clinical state of the patient but also on the levels of energy and nitrogen intake given. When energy intake is below energy needs, normally nourished patients cannot retain nitrogen, although depleted patients can. When energy intake exceeds energy needs, both normally nourished and depleted patients retain nitrogen at levels of nitrogen intake ranging from 250 mg kg-1day-1 (depleted and unstressed) to over 400 mg kg-1day-1 (stressed). Depleted patients can maintain a positive nitrogen balance at lower levels of calorie and nitrogen intake than normally nourished patients and in this respect are analogous to a growing child. In all surgical patients, energy and nitrogen intakes can be manipulated to provide for a controlled maintenance or restoration of either wet lean tissue and/or fat. There is little place for protein sparing therapy or the use of insulin and anabolic steroids to promote nitrogen retention in surgical patients requiring intravenous feeding.     

Outcome for cardiothoracic surgical patients requiring multidisciplinary intensive care

BACKGROUND AND OBJECTIVE: Patients who require multidisciplinary intensive care after cardiac surgery have a poor prognosis. The aim was to investigate factors in the mortality of this group of patients at 6 months. METHODS: A retrospective analysis was made of the 6-month mortality rate in 301 adults who required admission to a multidisciplinary intensive care unit following cardiac surgery from 1991 to 1997. Mortality was correlated with clinical and patient characteristic variables. RESULTS: The intensive care mortality rate was 34% and at 6 months after patients' discharge from intensive care it was 51%. There were positive correlations with death at 6 months for ventricular failure (odds ratio of death 3.4, P = 0.002), sepsis (odds ratio 3.0, P = 0.004) and age over 80 yr (odds ratio of death 9.2, P = 0.034). Patients who had undergone isolated coronary artery graft surgery (odds ratio of death 0.28, P = 0.036) or thoracic surgery (odds ratio of death 0.22, P = 0.042) had better 6-month outcomes. Patients with respiratory or renal failure in the absence of ventricular failure or sepsis had a 6-month mortality rate of 36%; but the lower mortality rate did not achieve statistical significance. CONCLUSIONS: The 6-month mortality rate of 51% in a group of patients requiring multidisciplinary intensive care after cardiac surgery is consistent with previous studies; mortality was particularly high in extreme old age and in patients referred with sepsis or ventricular failure. Those patients with uncomplicated respiratory or renal failure had a better outcome than the group as a whole.     

Increased mortality with undertriaged patients in a mature trauma center with an aggressive trauma team activation system

Purpose

The American College of Surgeons Committee on Trauma (ACS-COT) has determined that a 5 % pre-hospital undertriage [UT; defined as Injury Severity Score (ISS) > 15 and not sent to a trauma center] is an acceptable rate for pre-hospital transfer to a non-trauma center. We sought to determine if this level of undertriage is acceptable within a mature Level II trauma center as a measure of the adequacy of its trauma activation system.

Methods

Our trauma activation system encompasses anatomic, physiologic, and mechanism of injury criteria. We defined UT as ISS > 15 and no trauma activation. All UT patients during the period 2000–2010 were compared to properly triaged patients (CT). The variables examined were mortality, emergency department (ED) length of stay (LOS), hospital LOS, complications, Coumadin use, and age >64 years.

Results

There were 18,324 patients admitted, with 1,156 (6.3 %) UT. UT is associated with an increase in mortality [odds ratio (OR) 3.0; 95 % confidence interval (CI) 2.4–3.8; p < 0.001), longer ED LOS (OR 54.5; 95 % CI 45.5–63.5; p < 0.001), and longer hospital LOS (OR 1.7; 95 % CI 1.4–2.1; p < 0.001). In addition, UT patients had a two-fold increase in complications (OR 2.0; 95 % CI 1.6–2.5; p < 0.001). When controlling for age ≥65 years, Revised Trauma Score (RTS) > 7.0, and one or more co-morbidities, UT patients had 2.18 times higher odds of mortality than their CT counterparts (OR 2.18; 95 % CI 1.57–3.01; p < 0.001). Patients on pre-hospital Coumadin (OR 3.61; 95 % CI 3.04–4.30; p < 0.001) and age >64 years (OR 4.93; 95 % CI 4.36–5.58; p < 0.001) were significant predictors of being undertriaged. A p-value ≤ 0.05 was considered to be significant.

Conclusions

Standard trauma activation criteria may not be adequate to identify the at-risk severely injured trauma patient. Further refinement of in-house trauma triage protocols is necessary if trauma centers are to improve outcomes following trauma.     

Predictors of hospital mortality in type A aortic dissections: a retrospective analysis of 148 consecutive surgical patients

Reports in the literature frequently concern miscellaneous types of dissections. This makes correct interpretation of data difficult. In order to assess the determinants of hospital mortality, the results of 148 consecutive patients over a 23-year period, all operated on for a type A dissection, were reviewed. Mean(s.d.) age was 56(13.1) years, 64% were male. An acute dissection (surgery within 14 days after onset of symptoms) was performed in 139 patients. Stigmata of the Marfan syndrome were present in 6.1% (n=9). Peripheral vascular ischaemic complications were observed in 27.7%. Nowadays, diagnosis is primarily confirmed using transoesophageal echocardiography (75 correct diagnoses among 76 performed). Operation consisted of repair or replacement of the ascending aorta. Resuspension of the aortic valve was performed in 74 patients, and arch replacement in 25. In 74 patients, distal repair was done under deep hypothermic circulatory arrest. Hospital mortality rate was 23.6% (35 patients), though mortality rate calculated over the period 1990-1993 was 17.4% (P=n.s.). Univariate analysis revealed the following variables to be statistically significant predictors of hospital mortality (P<0.05): preoperative ischaemic complications, preoperative resuscitation, haemopericardium, postoperative neurological complications, rethoracotomy, renal insufficiency and intestinal ischaemia. Multivariate stepwise logistic regression indicated preoperative resuscitation, postoperative haemodialysis and postoperative neurological complications as the only independent predictors of hospital death. Dissections arising from a primary intimal tear in the descending aorta had a more favourable outcome (P=0.06, odds ratio 0.1). Although hospital mortality has declined over the past few years, no decline was seen in operative mortality since gelatine-resourcine-formol (GRF) glue is used as a routine. Transoesophageal echocardiography is the first choice in confirming diagnosis. Early operation is advocated, with careful haemostasis, before the development of cardiac tamponade or end-organ ischaemia, as the cornerstone of a successful treatment of a type A dissection. Reduction of neurological complications will further improve the results     

Predictors of outcome in patients with congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation

Background

The role of extracorporeal membrane oxygenation (ECMO) in patients with congenital diaphragmatic hernia is still evolving. The use of ECMO is invasive with potential complications during instrumentation for cannulation and heparinization. There are no reliable predictors of outcome in patients requiring ECMO. We aimed to identify (a) the factors that could predict outcome and (b) the incidence and relation of complications during ECMO to outcome.

Methods

“Pre” ECMO (age, sex, birth weight, blood gasses, and ventilator settings) and “on” ECMO variables (mode of ECMO, use of nitric oxide, surfactant, liquid ventilation, inotropes, timing of repair, and complications on ECMO) were analyzed to identify predictors of outcome.

Results

Fifty-two patients were included. The overall survival was 58%. Mean duration of ECMO (181 ± 120 vs 317 ± 156 hours, P = .001), use of nitric oxide (6 vs 10, P = .049), and renal complications (4 vs 14; P < .001) differed between survivors and nonsurvivors. The survival of patients requiring ECMO support for more than 2 weeks is significantly lower than that of patients requiring ECMO support for less than 2 weeks (18% vs 68%, P = .005). Multiple logistic regression revealed ECMO duration of 2 weeks or more and renal complications to be associated with mortality.

Conclusion

No pre-ECMO variable could be identified as predictor of mortality. Prolonged duration of ECMO and renal complications on ECMO were independently associated with mortality.