Association of antiplatelet or anticoagulant agents with in-hospital mortality among blunt torso trauma patients without severe traumatic brain injury: A retrospective analysis of the Japanese nationwide trauma registry

AimPatients with head trauma who take antiplatelet or anticoagulant (APAC) agents have a higher rate of mortality. However, the association between these agents and mortality among blunt torso trauma patients without severe traumatic brain injury remains unclear.MethodsUsing the Japanese nationwide trauma registry, we conducted a retrospective cohort study including adult patients with blunt torso trauma without severe head trauma between January 2019 and December 2020. Eligible patients were divided into two groups based on whether or not they took any APAC agents. The primary outcome was in-hospital mortality. To adjust for potential confounding factors, we conducted random effects logistic regression to account for patients clustering within the hospitals. The model was adjusted for potential confounders, including age, mechanism of injury, Charlson comorbidity index, systolic blood pressure, and injury severity scale on arrival as potentially confounding factors.ResultsDuring the study period, 16,201 patients were eligible for the analysis. A total of 832 patients (5.1%) were taking antiplatelet or anticoagulant agents. Overall in-hospital mortality was 774 patients (4.8%). APAC group had a higher risk of in-hospital mortality compared with the non-APAC group (6.9% vs. 4.7%; unadjusted OR, 1.51; 95% CI, 1.12–2.00; P < 0.01). After adjusting for potential confounder, there were no significant intergroup difference in a higher in-hospital mortality compared to with the non-APAC group (OR, 1.07; 95%CI, 0.65–1.77; P = 0.79).ConclusionThe use of APAC agents before the injury was not associated with higher in-hospital mortality among blunt torso trauma patients without severe traumatic brain injury.     

Hospital factors associated with higher costs in pediatric blunt abdominal trauma: A national study

Background/PurposeOur objective was to evaluate hospital factors, including children's hospital status, associated with higher costs for blunt solid organ pediatric abdominal trauma.MethodsWe queried the 2012 Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Database (KID) for patients 18 years or younger with low-grade and high-grade blunt abdominal trauma. We calculated total hospital costs and adjusted cost ratios (CR) controlling for patient and hospital-level characteristics.ResultsThe 2012 KID included 882 low-grade and 222 high-grade pediatric abdominal trauma patients. Median (interquartile range) per hospitalization costs were similar at children's and nonchildren's hospitals for both low-grade (children's = $6575 [$4333–$10,862], nonchildren's $7027 [$4230–$12,219] p = 0.47) and high-grade (children's = $10,984 [$6211- $20,007] nonchildren's $10,156 [$5439–$18,404] p = 0.55) groups. Adjusted cost ratios demonstrated higher costs in the West and among investor owned hospitals for low-grade and high-grade injuries, respectively. Costs at rural hospitals were higher in both groups (low-grade CR = 2.35 95% CI 2.02, 2.74, high-grade CR = 2.78 95% CI 2.13, 3.63) compared to urban teaching hospitals. Cost ratios did not differ based on children's hospital status.ConclusionHospital costs were similar for children's and nonchildren's hospitals caring for pediatric abdominal trauma. Costs at rural hospitals are higher and may suggest financial instability or nonstandardized care of pediatric trauma patients.Level of evidenceIII     

Isolated high-grade splenic injury among pediatric patients in Japan: Nationwide descriptive study

BackgroundLimited information exists regarding the clinical characteristics, management practice, and outcomes of pediatric patients with isolated splenic injury in Japan. This study aimed to evaluate the characteristics, management, and outcomes, such as survival and splenic salvage rate of pediatric patients with isolated splenic injury in Japan.MethodThis study was a multicenter retrospective cohort study using patient data from the Japan Trauma Data Bank (JTDB) collected between 2004 and 2018. Pediatric patients with isolated high-grade splenic injury whose abbreviated injury scale ≥ 3 were classified according to management groups: nonoperative management (NOM); NOM with splenic artery embolization (SAE); and operative management (OM). The primary outcome was in-hospital survival and the secondary outcomes were splenic salvage rate, hospital length of stay (LOS), rate of discharging to home, and complications.ResultsThere were 230 pediatric patients with isolated high-grade splenic injury during the study period. Of these, 156 (68%) were managed by NOM, 62 (27%) were managed by NOM with SAE, and 12 (5.2%) were managed by OM. No pediatric patient with isolated high-grade splenic injury died between 2004 and 2018 in Japan, and the splenic salvage rate was 97%.ConclusionWe identified a high survival rate and splenic salvage rate among pediatric patients with isolated high-grade splenic injury in Japan. SAE was often used, in contrast with previous reports.Levels of evidenceLevel IV.     

Pleural effusion following blunt splenic injury in the pediatric trauma population

Background

Pleural effusion is a potential complication following blunt splenic injury. The incidence, risk factors, and clinical management are not well described in children.

Methods

Ten-year retrospective review (January 2000–December 2010) of an institutional pediatric trauma registry identified 318 children with blunt splenic injury.

Results

Of 274 evaluable nonoperatively managed pediatric blunt splenic injures, 12 patients (4.4%) developed left-sided pleural effusions. Seven (58%) of 12 patients required left-sided tube thoracostomy for worsening pleural effusion and respiratory insufficiency. Median time from injury to diagnosis of pleural effusion was 1.5 days. Median time from diagnosis to tube thoracostomy was 2 days. Median length of stay was 4 days for those without and 7.5 days for those with pleural effusions (p < 0.001) and 6 and 8 days for those pleural effusions managed medically or with tube thoracostomy (p = 0.006), respectively. In multivariate analysis, high-grade splenic injury (IV–V) (OR 16.5, p = 0.001) was associated with higher odds of developing a pleural effusion compared to low-grade splenic injury (I–III).

Conclusions

Pleural effusion following pediatric blunt splenic injury has an incidence of 4.4% and is associated with high-grade splenic injuries and longer lengths of stay. While some symptomatic patients may be successfully managed medically, many require tube thoracostomy for progressive respiratory symptoms.     

Protocol-driven nonoperative management in patients with blunt splenic trauma and minimal associated injury decreases length of stay

BACKGROUND: The purpose of this study was to analyze the impact of more selective use of admission angiography combined with protocolized nonoperative management for blunt splenic injury. METHODS: This was a retrospective chart review of all patients with splenic injuries and Injury Severity Score < 20 managed by protocol and comparison with a prior matched group managed with admission angiography. RESULTS: Forty-three patients were managed under the protocol, with 22 patients treated with admission angiography and the remainder undergoing observation only. Nonoperative salvage was 100% in this group, with a length of stay of 3.3 days. The matched, nonprotocol group had a nonoperative salvage rate of 95%, with a length of stay of 6.8 days. CONCLUSION: Protocol-driven management of splenic injury using admission angiography selectively for higher grade splenic injuries led to a decreased length of stay, higher therapeutic yield, and decreased use of hospital resources without any increase in the failure rate of nonoperative management in a selected group of patients with isolated splenic injuries.     

Predicting inpatient mortality for pediatric trauma patients with blunt injuries: a better alternative

PURPOSE: The aim of this study was to identify significant independent predictors of inpatient mortality rates for pediatric victims of blunt trauma and to develop a formula for predicting the probability of inpatient mortality for these patients. METHODS: Emergency department and inpatient data from 2,923 pediatric victims of blunt injury in the New York State Trauma Registry in 1994 and 1995 were used to explore the relationship between patient risk factors and mortality rate. A stepwise logistic regression model with P<.05 was developed using survival status asthe dependent variable. Independent variables included are elements of the Pediatric Trauma Score (PTS), additional elements from the Revised Trauma Score (RTS), the motor response and eye opening components of the Glasgow Coma Scale (GCS), age-specific systolic blood pressure, the AVPU score, and 2 measures of anatomic injury severity (the Injury Severity Score [ISS] and the International Classification of Disease, Ninth Revision-based Injury Severity Score [ICISS]). RESULTS: The only significant independent predictors of severity that emerged were the ICISS, no motor response (best motor response = 1) from the GCS, and the unresponsive component from the AVPU score. The statistical model exhibited an excellent fit (C statistic = .964). The specificity associated with the prediction of inpatient mortality rate based on the presence of 1 or more of these risk factors was .926, and the sensitivity was .944. CONCLUSION: The best independent predictors of inpatient mortality rate for pediatric trauma patients with blunt injuries include variables not specifically contained in the PTS or the RTS: ICISS, no motor response (best motor response = 1) from the GCS, and the unresponsive component of the AVPU score.     

Recent changes in the management of blunt splenic injury: effect on splenic trauma patients and hospital implications

INTRODUCTION

Management of blunt splenic injury has been controversial with an increasing trend towards splenic conservation. A retrospective study was performed to identify the effect of this changed policy on splenic trauma patients and its implications.

PATIENTS AND METHODS

Data regarding patient demography, mode of splenic injury, CT grading, blood transfusion requirement, operative findings hospital stay and follow-up were collected. Statistical analysis of the data was performed using non-parametric Mann–Whitney tests

RESULTS

Over an 8-year period, only 21 patients were admitted with blunt splenic injury. Ten patients were managed operatively and 11 non-operatively. Non-operative management failed in one patient due to continued bleeding. Using Buntain''s CT grading, the majority of grades I and II splenic injuries were managed non-operatively and grades III and IV were managed operatively (P = 0.008). Blood transfusion requirement was significantly higher among the operative group (P = 0.004) but the non-operative group had a significantly longer hospital stay (P = 0.029). Among those managed non-operatively (median age, 24.5 years), a number of patients were followed up with CT scans with significant radiation exposure and unknown long-term consequences.

CONCLUSIONS

Non-operative management of blunt splenic trauma in adults can be performed with an acceptable outcome. Although CT is classed as the ‘gold standard’, initial imaging for detection and evaluation of blunt splenic injury, ultrasound can play a major role in follow-up imaging and potentially avoids major radiation exposure.     

Female sex is independently associated with reduced inpatient mortality after endovascular repair of blunt thoracic aortic injury

BackgroundFemale sex has been associated with decreased mortality after blunt trauma, but whether sex influences the outcomes of thoracic endovascular aortic repair (TEVAR) for traumatic blunt thoracic aortic injury (BTAI) is unknown.MethodsIn this retrospective study of a prospectively maintained database, the Vascular Quality Initiative registry was queried from 2013 to 2020 for patients undergoing TEVAR for BTAI. Univariate Student’s t-tests and χ² tests were performed, followed by multivariate logistic regression for variables associated with inpatient mortality.ResultsOf 806 eligible patients, 211 (26.2%) were female. Female patients were older (47.9 vs 41.8 years, P < .0001) and less likely to smoke (38.3% vs 48.2%, P = .044). Most patients presented with grade III BTAI (54.5% female, 53.6% male), followed by grade IV (19.0% female, 19.5% male). Mean Injury Severity Scores (30.9 + 20.3 female, 30.5 + 18.8 male) and regional Abbreviated Injury Score did not vary by sex. Postoperatively, female patients were less likely to die as inpatients (3.8% vs 7.9%, P = .042) and to be discharged home (41.4% vs 52.2%, P = .008). On multivariate logistic regression, female sex (odds ratio [OR]: 0.05, P = .002) was associated with reduced inpatient mortality. Advanced age (OR: 1.06, P < .001), postoperative transfusion (OR: 1.05, P = .043), increased Injury Severity Score (OR: 1.03, P = .039), postoperative stroke (OR: 9.09, P = .016), postoperative myocardial infarction (OR: 9.9, P = .017), and left subclavian coverage (OR: 2.7, P = .029) were associated with inpatient death.ConclusionsFemale sex is associated with lower odds of inpatient mortality after TEVAR for BTAI, independent of age, injury severity, BTAI grade, and postoperative complications. Further study of the influence of sex on postdischarge outcomes is needed.     

Serum lactate dehydrogenase level is associated with in-hospital mortality in critically Ill patients with acute kidney injury

International Urology and Nephrology - Sixty percent of critically ill patients suffer from acute kidney injury (AKI) and 12% of them require renal replacement therapy during their ICU stay....     

Prognostic value of arterial blood gas disturbances for in-hospital mortality in pediatric patients with severe traumatic brain injury

Background

The aim of this study was to evaluate the changes of arterial blood gas as a secondary insult in children and young adults suffering from severe traumatic brain injury, and to assess the correlation, if any, with their in-hospital mortality.

Method

In this cross-sectional study, the medical data of all children and adolescents with severe head trauma admitted to the Rasht Poursina Hospital were reviewed between April 2006 and September 2011. Data including age, gender, GCS upon admission, arrival and daily ABG values for the first 3 days, results of brain CT scan, as well as in-hospital mortality rate were collected. A logistic regression model was used to determine the association between acid–base disturbance and in-hospital mortality after adjustment for potential confounding factors.

Result

Of the 108 patients, 75 % were male and 25 % were female; and 31.5 % of them died in the hospital. Univariate analysis showed a significantly higher risk of mortality in patients who developed mixed metabolic acidosis plus respiratory acidosis on their admission day (OR?=?3.94, p?=?0.012). Multiple logistic regression analysis demonstrated that mixed metabolic acidosis plus respiratory acidosis (OR?=?3.81, 95 % CI?=?1.18–12.27, p-value?=?0.025) and GCS (OR?=?0.457, 95 % CI?=?0.31–0.65, p-value?<?0.001) were two significant predictors of mortality, regardless of other confounding variables.

Conclusion

The results of present study show that, in pediatric patients with severe head injuries, initial mixed metabolic acidosis plus respiratory acidosis and GCS are significant predictors of mortality, but other factors after adjustment for potential confounding factors had no prognostic effect.     

Poor glycemic control is associated with increased mortality in critically ill trauma patients

Glycemic control improves outcome in cardiac surgical patients and after myocardial infarction or stroke. Hyperglycemic predicts poor outcome in trauma, but currently no data exist on the effect of glycemic control in critically ill trauma patients. In our intensive care unit (ICU), we use a subcutaneous sliding scale insulin protocol to achieve glucose levels <140 mg/dL. We hypothesized that aggressive glycemic control would be associated with improved outcome in critically ill trauma patients. At our urban Level 1 trauma center, a retrospective study was conducted of all injured patients admitted to the surgical ICU >48 hours during a 6-month period. Data were collected for mechanism of injury, age, diabetic history, Injury Severity Score (ISS), and APACHE II score. All blood glucose levels, by laboratory serum measurement or by point-of-care finger stick, were collected for the entire ICU stay. Outcome data (mortality, ICU and hospital length of stay, ventilator days, and complications) were collected and analyzed. Patients were stratified by their preinjury diabetic history and their level of glucose control (controlled <140 mg/dL vs non-controlled > or =141 mg/dL) and these groups were compared. During the study period, 103 trauma patients were admitted to the surgical ICU >48 hours. Ninety (87.4%) were nondiabetic. Most (83.5%) sustained blunt trauma. The average age was 50 +/- 21 years, the average ISS was 22 +/- 12, and the average APACHE II was 16 +/- 9. The average glucose for the population was 128 +/-25 mg/dL. Glycemic control was not attained in 27 (26.2%) patients; 19 (70.4%) of these were nondiabetic. There were no differences in ISS or APACHE II for controlled versus non-controlled patients. However, non-controlled patients were older. Mortality was 9.09 per cent for the controlled group and was 22.22 per cent for the non-controlled group. Diabetic patients were older and less severely injured than nondiabetics. For nondiabetic patients, mortality was 9.86 per cent in controlled patients and 31.58 per cent in non-controlled patients (P < 0.05). Also, urinary tract infections were more prevalent and complication rates overall were higher in nondiabetic patients with noncontrolled glucose levels. Nonsurvivors had higher average glucose than survivors (P < 0.03). Poor glycemic control is associated with increased morbidity and mortality in critically ill trauma patients; this is more pronounced in nondiabetic patients. Age may be a factor in these findings. Subcutaneous sliding scale insulin alone may be inadequate to maintain glycemic control in older critically ill injured patients and in patients with greater physiologic insult. Prospective assessment is needed to further clarify the benefits of aggressive glycemic control, to assess the optimal mode of insulin delivery, and to better define therapeutic goals in critically ill, injured patients.