共查询到20条相似文献,搜索用时 31 毫秒
1.
Lauren Nosanov Kenji Inaba Obi Okoye Shelby Resnick Jeffrey Upperman Ira Shulman Peter Rhee Demetrios Demetriades 《American journal of surgery》2013
Background
Few studies have examined the impact of balanced resuscitation in pediatric trauma patients requiring massive transfusions. Adult data may not be generalizable to children.Methods
Retrospective analysis assessed patients seen at a level I trauma center between 2003 and 2010 aged ≤18 years requiring massive packed red blood cell (PRBC) transfusion, defined as transfusion of ≥50% total blood volume. After excluding mortalities in the first 24 hours, the impact of plasma and platelet ratios on mortality was evaluated.Results
Of 6,675 pediatric trauma patients, 105 were massively transfused (mean age, 12.4 ± 6.3 years; mean Injury Severity Score, 25.8 ± 11.4; mortality rate, 18.1%). All deceased patients sustained severe head injuries. Plasma/PRBC and platelet/PRBC ratios were not significantly associated with mortality.Conclusions
In this study, higher plasma/PRBC and platelet/PRBC ratios were not associated with increased survival in children. The value of aggressive blood product transfusion for injured pediatric patients requires further prospective validation. 相似文献2.
Introduction and aims
The use of intravenous oxygen carriers (packed red blood cells (PRBC), whole blood and synthetic haemoglobins (HBOCs) for selected pre-hospital trauma resuscitation cases has been reported, despite a lack of validated clinical indications. The aim of this study was to retrospectively identify a sub-group of adult major trauma patients most likely to benefit from pre-hospital oxygen carrier administration and determine the predictive relationship between pre-hospital shock index (SI) [pulse rate/systolic blood pressure] and haemorrhagic shock, blood transfusion and mortality.Methods
A retrospective review of adult major trauma patients recorded in The Alfred Trauma Registry was conducted. Patients were included if they received at least 1 L of pre-hospital crystalloid and spent over 30 min in transit. The association of shock index and transfusion was determined. Patients were further sub-grouped by mode of transport to determine the population of trauma patients who could be included into prospective studies of intravenous oxygen carriers.Results
There were 1149 patients included of whom 311 (21.9%) received an acute blood transfusion. The SI correlated well with transfusion practice. A SI ≥ 1.0, calculated after at least 1 L of crystalloid transfusion, identified patients with a high specificity (93.5%; 95% CI: 91.8–94.8) for receiving a blood transfusion within 4 h of hospital arrival. While patients transported by helicopter had higher injury severity and blood transfusion requirement, there were no difference in physiological variables and outcomes when compared to patients transported by road car.Conclusions
A shock index ≥ 1.0 is an easily calculated variable that may identify patients for inclusion into trials for pre-hospital oxygen carriers. Shocked patients have high mortality rates whether transported by road car or by helicopter. The efficacy of pre-hospital intravenous oxygen carriers should be trialled using a shock index ≥ 1.0 despite fluid resuscitation as the clinical trigger for administration. 相似文献3.
Objectives
The purpose of this study was to quantify the incidence, patient profile, and outcomes associated with massive transfusion in paediatric trauma patients prior to establishing a massive transfusion protocol.Methods
We performed a retrospective review of paediatric trauma patients treated at London Heath Sciences Centre between January 1, 2006, and December 31, 2011. Inclusion criteria were Injury Severity Score (ISS) greater than 12 and age less than 18 years.Results
435 patients met the inclusion criteria. Three hundred and fifty-six (82%) did not receive packed red blood cells in the first 24 h, 66 (15%) received a non-massive transfusion (<40 mL/kg), and 13 (3%) received a massive transfusion (>40 mL/kg). Coagulopathy of any kind was more common in massive transfusion (11/13; 85%) than non-massive (32/66; 49%) (p = 0.037). Hyperkalemia (18% versus 23%; p = 0.98) and hypocalcemia (41% versus 46%; p = 1.00) were similar in both groups. Of the 13 massively transfused patients, 9 had multisystem injuries due to a motor vehicle collision, 3 had non-accidental head injuries requiring surgical evacuation, and 1 had multiple stab wounds. In the absence of a massive transfusion protocol, only 8 of the 13 patients received both fresh frozen plasma and platelets in the first 24 h. Massive transfusion occurred in patients from across the age spectrum and was associated with severe injuries (mean ISS = 33), a higher incidence of severe head injuries (92%), longer hospital stay (mean = 36 days), and increased mortality (38%).Conclusions
This study is the first to describe the incidence, complications, and outcomes associated with massive transfusion in paediatric trauma patients prior to a massive transfusion protocol. Massive transfusion occurred in 3% of patients and was associated with coagulopathy and poor outcomes. Protocols are needed to ensure that resuscitation occurs in a coordinated fashion and that patients are given appropriate amounts of fresh frozen plasma, platelets, and cryoprecipitate. 相似文献4.
Eric J. Ley Douglas Z. LiouMatthew B. Singer MD James MirochaNicolas Melo MD Rex ChungMarko Bukur MD Ali Salim MD 《The Journal of surgical research》2013
Introduction
Studies on blood product transfusions after trauma recommend targeting specific ratios to reduce mortality. Although crystalloid volumes as little as 1.5 L predict increased mortality after trauma, little data is available regarding the threshold of red blood cell (RBC) transfusion volume that predicts increased mortality.Materials and methods
Data from a level I trauma center between January 2000 and December 2008 were reviewed. Trauma patients who received at least 100 mL RBC in the emergency department (ED) were included. Each unit of RBC was defined as 300 mL. Demographics, RBC transfusion volume, and mortality were analyzed in the nonelderly (<70 y) and elderly (≥70 y). Multivariate logistic regression was performed at various volume cutoffs to determine whether there was a threshold transfusion volume that independently predicted mortality.Results
A total of 560 patients received ≥100 mL RBC in the ED. Overall mortality was 24.3%, with 22.5% (104 deaths) in the nonelderly and 32.7% (32 deaths) in the elderly. Multivariate logistic regression demonstrated that RBC transfusion of ≥900 mL was associated with increased mortality in both the nonelderly (adjusted odds ratio 2.06, P = 0.008) and elderly (adjusted odds ratio 5.08, P = 0.006).Conclusions
Although transfusion of greater than 2 units in the ED was an independent predictor of mortality, transfusion of 2 units or less was not. Interestingly, unlike crystalloid volume, stepwise increases in blood volume were not associated with stepwise increases in mortality. The underlying etiology for mortality discrepancies, such as transfusion ratios, hypothermia, or immunosuppression, needs to be better delineated. 相似文献5.
Background
The current military paradigm for blood transfusion in major trauma favours high plasma:RBC ratios. This study aimed determine whether high plasma:red blood cell (RBC) ratios during massive transfusion for trauma decrease mortality, using meta-analysis of contemporaneous groups matched for injury severity score.Methods
A systemic review of the published literature for massive blood transfusions in trauma was performed. Patients were categorised into groups based on plasma:RBC transfusion ratios. Meta-analysis was only performed when there were no significant differences in Injury Severity Score (ISS) between ratio groups within studies. The main endpoint was 30-day mortality.Results
Six observational studies reporting outcomes for 1885 patients were included in this meta-analysis. Five studies were from civilian environments and one from a military setting. Ratio cut-offs at 1:2 were the most commonly reported, demonstrating a survival advantage with higher ratios (OR 0.49, 95% CI 0.31–0.80, p = 0.004). Ratios ≥ 1:2 showed a significant reduction in mortality compared to lower ratios (OR 0.56, 95% CI 0.40–0.78, p < 0.001). Reducing the cut-off level was still protective (ratios between 1:2.5 and 1:4, OR 0.41), although the confidence interval was wide (0.16–1.00, p = 0.05) and data heterogenous (I2 = 78%). Ratios of 1:1 were not proven to confer additional benefit beyond ratios of 1:2 (OR 0.50, 95% CI 0.37–0.68, p < 0.001).Conclusions
In groups matched for ISS, there was a survival benefit with high plasma:RBC resuscitation ratios. No additional benefits of 1:1 over 1:2 ratios were identified. 相似文献6.
Introduction
Recent retrospective studies have found high fresh frozen plasma (FFP) to packed red blood cell (PRBC) ratios during trauma resuscitation to be associated with improved mortality. Whilst this association may be related to a mortality bias present in these studies, there has been an overall tendency towards a 1:1 FFP:PRBC ratio in massive transfusion guidelines worldwide. The aim of this study was to retrospectively review the administration of FFP in patients undergoing massive transfusion during trauma resuscitation, to add to the evidence base for massive transfusion guidelines.Materials and methods
Multi-trauma patients who were administered blood transfusions of 5 units or more of packed red blood cells (PRBCs) in the first 4 h were included in this study. Mortality was the primary endpoint with length of hospital stay, ICU hours and mechanically ventilated hours secondary endpoints.Results
There were 331 patients included in this study with a median Injury Severity Score (ISS) of 36 (25-50) and a mortality of 29.9%. There was little change in the ratio of FFP:PRBC transfused per patient from 2005 to 2008. A low FFP:PRBC ratio in the first 4 h of resuscitation, older age, low initial GCS and coagulopathy on presentation were significant independent factors associated with mortality. When deaths in the first 24 h were excluded, the FFP:PRBC ratio had no association with mortality.Discussion
This study has shown increased initial survival in association with higher FFP:PRBC ratios during massive transfusion in a population with a high proportion of blunt injuries. The association is difficult to interpret because of an inherent survival bias. The optimal ratio of FFP:PRBC during massive transfusion may be different to 1:1 and further prospective research is required. There is now an increasing need for well designed randomised controlled trials to determine the best FFP:PRBC ratio for the resuscitation of blunt multi-trauma patients. 相似文献7.
Maria S. Altieri Ibrahim Almasry Tyler Jones Christa McPhee Jane E. McCormack Emily C. Huang Patricia Eckardt Marc J. Shapiro Sarah Eckardt James A. Vosswinkel Randeep S. Jawa 《American journal of surgery》2016,212(5):953-960
Background
The prevalence and outcomes of older trauma patients with implantable cardioverter defibrillators (ICDs) or permanent pacemakers (PPMs) is unknown.Methods
The trauma registry at a regional trauma center was reviewed for blunt trauma patients, aged ≥ 60 years, admitted between 2007 and 2014. Medical records of cardiac devices patients were reviewed.Results
Of 4,193 admissions, there were 146 ICD, 233 PPM, and 3,814 no device patients; median Injury Severity Score was 9. Most cardiac device patients had substantial underlying heart disease. Patients with ICDs (13.0%) and PPMs (8.6%) had higher mortality rates than no device patients (5.6%, P = .0002). Among cardiac device patients who died, the device was functioning properly in all that were interrogated; the most common cause of death was intracranial hemorrhage. On propensity score analysis, cardiac devices were not independent predictors of mortality but rather surrogate variables associated with other predictors of mortality.Conclusions
Approximately 9.0% of admitted older patients had cardiac devices. Their presence identified patients who had higher mortality rates, likely because of their underlying comorbidities, including cardiac dysfunction. 相似文献8.
Bellal Joseph Bardiya ZangbarViraj Pandit MD Narong KulvatunyouAnsab Haider MD Terence O’KeeffeMazhar Khalil MD Andrew TangGary Vercruysse MD Lynn GriesRandall S. Friese MD Peter Rhee MD MPH FACS 《The Journal of surgical research》2014
Background
Geriatric patients are at higher risk for adverse outcomes after injury because of their altered physiological reserve. Mortality after trauma laparotomy remains high; however, outcomes in geriatric patients after trauma laparotomy have not been well established. The aim of our study was to identify factors predicting mortality in geriatric trauma patients undergoing laparotomy.Methods
A retrospective study was performed of all trauma patients undergoing a laparotomy at our level 1 trauma center over a 6-y period (2006–2012). Patients with age ≥55 y who underwent a trauma laparotomy were included. Patients with head abbreviated injury scale (AIS) score ≥ 3 or thorax AIS ≥ 3 were excluded. Our primary outcome measure was mortality. Significant factors in univariate regression model were used in multivariate regression analysis to evaluate the factors predicting mortality.Results
A total of 1150 patients underwent a trauma laparotomy. Of which 90 patients met inclusion criteria. The mean age was 67 ± 10 y, 63% were male, and median abdominal AIS was 3 (2–4). Overall mortality rate was 23.3% (21/90) and progressively increased with age (P = 0.013). Age (P = 0.02) and lactate (P = 0.02) were the independent predictors of mortality in geriatric patients undergoing laparotomy.Conclusions
Mortality rate after trauma laparotomy increases with increasing age. Age and admission lactate were the predictors of mortality in geriatric population undergoing trauma laparotomies. 相似文献9.
Objective
This study aims to assess the effect of obesity on injury severity score (ISS), mortality and course of hospital stay among trauma patients.Method
A systematic review of the literature was conducted by Internet search. Data were extracted from included studies and analysed using a random-effects model to compare outcomes in the obese (body mass index (BMI) ≥ 30 kg m−2) with the non-obese (BMI < 30 kg m−2) group.Result
Eventually, 18 studies met our inclusion criteria with 7751 obese patients representing 17% of the pooled study population. The data revealed that obesity was associated with increased risk of mortality, longer stay in the intensive care unit and higher rates of complication. Additionally, obese patients seemed to have longer duration of mechanical ventilation and hospital length of stay but it did not reach statistical significance. No difference was observed in ISS between the two groups.Conclusion
Evidence strongly supports the correlation of obesity with worse prognosis in trauma patients and further studies should target this kind of population for therapy and prevention. 相似文献10.
Introduction
A previous meta-analysis has found an association between red blood cell (RBC) transfusions and mortality in critically ill patients, but no review has focused on the trauma population only.Objectives
To determine the association between RBC transfusion and mortality in the trauma population, with secondary outcomes of multiorgan failure (MOF) and acute respiratory distress syndrome (ARDS) or acute lung injury (ALI).Data sources
EMBASE (1947–2012) and MEDLINE (1946–2012).Study eligibility criteria
Randomized controlled trials and observational studies were to be included if they assessed the association between RBC transfusion and either the primary (mortality) or secondary outcomes (MOF, ARDS/ALI).Participants
Trauma patients.Exposure
Red blood cell transfusion.Methods
A literature search was completed and reviewed in duplicate to identify eligible studies. Studies were included in the pooled analyses if an attempt was made to determine the association between RBC and the outcomes, after adjusting for important confounders. A random effects model was used for and heterogeneity was quantified using the I2 statistic. Study quality was assessed using the Newcastle-Ottawa Scale.Results
40 observational studies were included in the qualitative review. Including studies which adjusted for important confounders found the odds of mortality increased with each additional unit of RBC transfused (9 Studies, OR 1.07, 95%CI 1.04–1.10, I2 82.9%). The odds of MOF (3 studies, OR 1.08, 95%CI 1.02–1.14, I2 95.9%) and ARDS/ALI (2 studies, OR 1.06, 95%CI 1.03–1.10, I2 0%) also increased with each additional RBC unit transfused.Conclusions
We have found an association between RBC transfusion and the primary and secondary outcomes, based on observational studies only. This represents the extent of the published literature. Further interventional studies are needed to clarify how limiting transfusion can affect mortality and other outcomes. 相似文献11.
Roshan Givergis Swapna Munnangi Katayoun Fayaz M Fomani Anthony Boutin Luis Carlos Zapat LD George Angus 《中华创伤杂志(英文版)》2018,21(5):261-266
Purpose
To evaluate massive transfusion protocol practices by trauma type at a level I trauma center.Methods
A retrospective analysis was performed on a sample of 76 trauma patients with MTP activation between March 2010 and January 2015 at a regional trauma center. Patient demographics, transfusion practices, and clinical outcomes were compared by type of trauma sustained.Results
Penetrating trauma patients who required MTP activation were significantly younger, had lower injury severity score (ISS), higher probability of survival (POS), decreased mortality, and higher Glasgow Coma scale (GCS) compared to blunt trauma patients. Overall, the mortality rate was 38.16%. The most common injury sustained among blunt trauma patients was head injury (36.21%), whereas the majority of the penetrating trauma patients sustained abdominal injuries (55.56%). Although the admission coagulation parameters and timing of coagulopathy were not significantly different between the two groups of patients, a significantly higher proportion of penetrating trauma patients received high plasma content therapy relative to blunt trauma patients (p < 0.01).Conclusion
Despite the use of the same MTP for all injured patients requiring massive transfusion, significant differences existed between blunt trauma patients and penetrating trauma patients. These differences in transfusion characteristics and outcomes following MTP activation underscore the complexity of implementing MTPs and warrant vigilant transfusion practices to improve outcomes in trauma patients. 相似文献12.
E. Bui K. Inaba A. Ebadat E. Karamanos S. Byerly O. Okoye I. Shulman P. Rhee D. Demetriades 《European journal of trauma and emergency surgery》2016,42(4):519-525
Purpose
Transfusion ratios approaching 1:1 FFP:PRBC for trauma resuscitation have become the de facto standard of care. The aim of this study was to prospectively evaluate the effect of increasing ratios of FFP:PRBC transfusion on survival for massively transfused civilian trauma patients as well as determine if time to reach the target ratio had any effect on outcomes.Methods
This is a prospective, observational study of all trauma patients requiring a massive transfusion (≥10 PRBC in ≤24 h) at a level 1 trauma center over a 2.5-year period. The ratio of FFP:PRBC was tracked hourly up to 24 h post-initiation of massive transfusion. A logistic regression model was utilized to identify the ideal ratio associated with mortality prediction. A stepwise logistic regression was performed to identify independent predictors of mortality.Results
The study population was predominantly male (89 %) with a mean age of 34.8 ± 16. On admission, 22 % had a systolic blood pressure ≤90 mmHg, 47 % had a heart rate ≥120, and 25 % had a GCS ≤8. The overall mortality was 33 %. The ratio of FFP:PRBC ≥ 1:1.5 was the second most important independent predictor of mortality for this population (R 2 = 0.59). Survivors had a higher FFP:PRBC ratio at all times during the first 24 h of resuscitation.Conclusions
Achieving a ratio of FFP:PRBC ≥ 1:1.5 after the initial 24 h of resuscitation significantly improves survival in massively transfused trauma patients compared to patients that achieved a ratio <1:1.5.13.
Background
Injury sustained in rural areas has been shown to carry higher mortality rates than trauma in urban settings. This disparity is partially attributed to increased distance from definitive care and underscores the importance of proper primary trauma management prior to transfer to a trauma facility. The purpose of this study was to assess Advanced Trauma Life Support (ATLS) guideline adherence in the management of adult trauma patients transferred from rural hospitals to a level I facility.Methods
We performed a retrospective analysis of all adult major trauma patients transferred ≥50 km from an outlying hospital to a level I trauma centre from 2007 through 2009. Transfer practices were evaluated using ATLS guidelines.Results
646 patients were analyzed. Mean age was 40.5 years and 94% sustained blunt injuries with a median Injury Severity Score (ISS) of 22. Median transport distance was 253 km. Among all patients, there were notable deficiencies (<80% adherence) in 8 of 11 ATLS recommended interventions, including patient rewarming (8% adherence), chest tube insertion (53%), adequate IV access (53%), and motor/sensory exam (72%). Patients with higher ISS scores, and those transferred by air were more likely to receive ATLS recommended interventions.Conclusions
Key aspects of ATLS resuscitation guidelines are frequently missed during transfer of trauma patients from the periphery to level I trauma centres. Comprehensive quality improvement initiatives, including targeted education, telemedicine and trauma team training programmes could improve quality of care. 相似文献14.
Kevin B. Laupland Lawrence W. Svenson Vincent Grant Chad G. Ball Michelle Mercado Andrew W. Kirkpatrick 《Injury》2010,41(1):69-72
Introduction
Although trauma is associated with major acute morbidity and mortality, its long-term outcome is less well defined. We sought to define the rate of readmission to hospital and long-term mortality of victims of major trauma.Patients and Methods
All Calgary Health Region residents presenting to the regional trauma program with an injury severity score (ISS) ≥12 between April 1, 2002 and March 31, 2006 were included. Readmission to hospital within one-year and deaths occurring on or before September 30, 2008 were identified using regional and provincial databases.Results
A total of 2652 incident major trauma episodes occurred among 2630 residents; the median age was 41.3 [interquartile range (IQR); 23.1-59.2] years, 1,915 (72%) were male, the median ISS was 19 (IQR; 16-25), and 717 (27%) required intensive care unit admission. Among 2350 survivors to hospital discharge, 537 readmissions occurred (median length of stay 4.0; IQR; 1.6-7.5 days) among 386 patients within one-year of the incident trauma episode, and 323 (60%) required surgery. Re-admitted patients were older, had higher ISS, had longer initial admission length of stay, and were less likely to have sports related injuries. Two hundred and fifteen (8%) of 2350 survivors to hospital discharge died during the median study follow-up duration of 1543 (IQR; 1181-1934) days. Case-fatality rates for 28 days, 90 days, and 365 days were 304 (11%), 327 (12%), and 370 (14%), respectively. Among survivors to 28 days (n = 2348), 66 (3%) suffered delayed one-year mortality (i.e. death occurred between 28 days and 365 days post-trauma). Age ≥65 years of age, initial hospitalisation for ≥28 days, and unintentional falls were independently associated with delayed one-year mortality.Conclusions
Patients with major trauma are at risk for both acute and delayed adverse outcomes. 相似文献15.
Background and objectives
Acute traumatic coagulopathy (ATC) has been reported in the setting of isolated traumatic brain injury (iTBI) and associated with high mortality and poor outcomes. The aim of this systematic review was to examine the incidence and outcome of patients with ATC in the setting of iTBI.Methods
We conducted a search of the MEDLINE database and Cochrane library, focused on subject headings and keywords involving coagulopathy and TBI. Design and results of each study were described. Studies were assessed for heterogeneity and the pooled incidence of ATC in the setting of iTBI determined. Reported outcomes were described.Results
There were 22 studies selected for analysis. A statistically significant heterogeneity among the studies was observed (p < 0.01). Using the random effects model the pooled proportion of patients with ATC in the setting of iTBI was 35.2% (95% CI: 29.0–41.4). Mortality of patients with ATC and iTBI ranged between 17% and 86%. Higher blood transfusion rates, longer hospital stays, longer ICU stays, decreased ventilator free days, higher rates of single and multiple organ failure and higher incidence of delayed injury and disability at discharge were reported among patients with ATC.Conclusions
ATC is commonly associated with iTBI and almost uniformly associated with worse outcomes. Any disorder of coagulation above the normal range appears to be associated with worse outcomes and therefore a clinically important target for management. Earlier identification of patients with ATC and iTBI, for recruitment into prospective trials, presents avenues for further research. 相似文献16.
Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation
Chrissy Guidry Elizabeth Gleeson Eric R. Simms Lance Stuke Peter Meade Norman E. McSwain Jr Juan C. Duchesne 《The Journal of surgical research》2013
Background
High ratios of fresh frozen plasma:packed red blood cells in damage control resuscitation (DCR) are associated with increased survival. The impact of volume and type of resuscitative fluid used during high ratio transfusion has not been analyzed. We hypothesize a difference in outcomes based on the type and quantity of resuscitative fluid used in patients that received high ratio DCR.Methods
A matched case control study of patients who received transfusions of ≥ four units of PRBC during damage control surgery over 4 1/2 y, was conducted at a Level I Trauma Center. All patients received a high ratio DCR, >1:2 of fresh frozen plasma:packed red blood cells. Demographics and outcomes of the type and quantity of resuscitative fluids used in combination with high ratio DCR were compared and analyzed. A Kaplan-Meier survival analysis was computed among four groups: colloid (median quantity = 1.0 L), <3 L crystalloid, 3–6 L crystalloid, and >6 L crystalloid.Results
There were 56 patients included in the analysis (28 in the crystalloid group and 28 in the colloid group). Demographics were statistically similar. Intraoperative median units of PRBC: crystalloid versus colloid groups was 13 (IQR 8-21) versus 16 (IQR 12–19), P = 0.135; median units of FFP: 12 (IQR 7–18) versus 12 (IQR 10–18), P = 0.440. OR for 10-d mortality in the crystalloid group was 8.41 [95% CI 1.65–42.76 (P = 0.01)]. Kaplan-Meier survival analysis demonstrated lowest mortality in the colloid group and higher mortality with increasing amounts of crystalloid (P = 0.029).Conclusions
During high ratio DCR, resuscitation with higher volumes of crystalloids was associated with an overall decreased survival, whereas low volumes of colloid use were associated with increased survival. In order to improve outcomes without diluting the survival benefit of hemostatic resuscitation, guidelines should focus on effective low volume resuscitation when high ratio DCR is used. A multi-institutional analysis is needed in order to validate these results. 相似文献17.
Michael M. Dinh Kendall J. Bein Belinda J. Gabbe Christopher M. Byrne Jeffrey Petchell Serigne Lo Rebecca Ivers 《Injury》2014
Introduction
Quality improvement programmes are an important part of care delivery in trauma centres. The objective was to describe the effect of a comprehensive quality improvement programme on long term patient outcome trends at a low volume major trauma centre in Australia.Methods
All patients aged 15 years and over with major trauma (Injury Severity Score > 15) admitted to a single inner city major trauma centre between 1992 and 2012 were studied. The outcomes of interest were in-hospital mortality and transfer to rehabilitation. Time series analysis using integer valued autoregressive Poisson models was used to determine the reduction in adjusted monthly count data associated with the intervention period (2007–2012). Risk adjusted odds ratios for mortality over three yearly intervals was also obtained using multivariable logistic regression. Crude and risk adjusted mortality was compared before and after the implementation period.Results
3856 patients were analysed. Crude in-hospital mortality fell from 16% to 10% after implementation (p < 0.001). The intervention period was associated with a 25% decrease in monthly mortality counts. Risk adjusted mortality remained stable from 1992 to 2006 and did not fall until the intervention period. Crude and risk adjusted transfer to in-patient rehabilitation after major trauma also declined during the intervention period.Conclusion
In this low volume major trauma centre, the implementation of a comprehensive quality improvement programme was associated with a reduction in crude and risk adjusted mortality and risk adjusted discharge to rehabilitation in severely injured patients. 相似文献18.
Background
Shortage of beds in intensive care units (ICUs) is an increasing common phenomenon worldwide. Consequently, many critically ill patients have to be cared for in other hospital areas without specialized staff, such as general wards, emergency department, post anesthesia care unit (PACU). However, boarding critically ill patients in general wards or emergency department has been associated with higher mortality. The purpose of this study was to evaluate if a delay in ICU admission, waiting in PACU and managed by anesthesiologists, affects their ICU outcomes for critically surgical patients.Methods
A retrospective cohort of adult critically surgical patients admitted to our ICU between January 2010 and June 2012 were analyzed. ICU admission was classified as either immediate or delayed (waiting in PACU). A general estimation equation was used to examine the relationship of PACU waiting hours before ICU admission with ICU outcomes by adjusting for age, patient sex, comorbidities, surgical categories, end time of operation, operation hours, and clinical conditions.Results
A total of 2,279 critically surgical patients were evaluated. Two thousand ninety-four (91.9%) patients were immediately admitted and 185 (8.1%) patients had delayed ICU admission. There was a significant increase in ICU mortality rates with a delay in ICU admission (P < .001). Prolonged waiting hours in PACU (≥6 hours) was associated with higher ICU mortality (adjusted odds ratio 5.32; 95% confidence interval 1.25 to 22.60, P = .024). However, longer PACU waiting times was not associated with mechanical ventilation days, ICU length of stay, and ICU cost.Conclusion
Prolonged waiting hours in PACU because of ICU bed shortage was associated with higher ICU mortality for critically surgical patients. 相似文献19.
Caitlin A. FitzgeraldBryan C. Morse M.D. Christopher J. Dente 《American journal of surgery》2014,208(6):1083-1090
Background
Over the last 10 years, the paradigm of damage control resuscitation (DCR) has been associated with improved patient outcomes. This study investigates the outcomes of both closed and open pelvic ring fractures at a single institution before and after the formal implementation of DCR principles.Methods
A retrospective chart review was performed in an urban level I trauma center of all patients who sustained open or closed pelvic ring fractures between 2002 and 2012.Results
Two thousand two hundred forty-seven patients presented with pelvic fractures between 2002 and 2012. Overall mortality was 10% (n = 212). Only 8% of all patients with closed fractures required DCR compared with 28% of patients with open fractures. There was no difference in mortality when comparing DCR and pre-DCR cohorts for either open or closed pelvic fractures.Conclusions
Interestingly, although DCR seems to lead to more efficient initial resuscitations, further improvements in patient mortality were not realized with formal implementation of DCR principles. 相似文献20.
Andrew Nguyen David S. Plurad Scott Bricker Angela Neville Fred Bongard Brant Putnam Dennis Y. Kim 《The Journal of surgical research》2014