Epidemiologia de parada cardíaca e de mortalidade perioperatória no Brasil: revisão sistemática

Background and objectivesThe perioperative cardiac arrest (CA) and mortality rates in Brazil, a developing country, are higher than in developed countries. The hypothesis of this review was that knowledge of the epidemiology of perioperative CA and mortality in Brazil enables the comparison with developed countries. The systematic review aimed to verify, in studies conducted in Brazil, the epidemiology of perioperative CA and mortality.Method and resultsA search strategy was carried out on different databases (PubMed, EMBASE, SciELO and LILACS) to identify observational studies that reported perioperative CA and/or mortality up to 48 hours postoperatively in Brazil. The primary outcomes were data on epidemiology of perioperative CA and mortality. In 8 Brazilian studies, there was a higher occurrence of perioperative CA and mortality in males; in extremes of age; in patients in worse physical status according to the American Society of Anesthesiologists (ASA); in emergency surgeries; in general anesthesia; and in cardiac, thoracic, vascular, abdominal and neurological surgeries. The patient's disease/condition was the main triggering factor, with sepsis and trauma as the main causes.ConclusionsThe epidemiology of both perioperative CA and mortality events reported in Brazilian studies does not show important differences and, in general, is similar to studies in developed countries. However, sepsis represents one of the major causes of perioperative CA and mortality in Brazilian studies, contrasting with studies in developed countries in which sepsis is a secondary cause.     

Perioperative mortality in older patients: a systematic review with a meta-regression analysis and meta-analysis of observational studies

Study objectiveOlder patients have a higher probability of developing major complications during the perioperative period than other adult patients. Perioperative mortality depends on not only on a patient condition but also on the quality of perioperative care provided. We tested the hypothesis that the perioperative mortality rate among older patients has decreased over time and is related to a country's Human Development Index (HDI) status.DesignA systematic review with a meta-regression and meta-analysis of observational studies that reported perioperative mortality rates in patients aged ≥60 years was performed. We searched the PubMed, EMBASE, LILACS and SciELO databases from inception to December 30, 2019.SettingMortality rates up to the seventh postoperative day were evaluated.MeasurementsWe evaluated the quality of the included studies. Perioperative mortality rates were analysed by time, country HDI status and baseline American Society of Anesthesiologists (ASA) physical status using meta-regression. Perioperative mortality and ASA status were analysed in low- and high-HDI countries during two time periods using proportion meta-analysis.Main resultsWe included 25 studies, which reported 4,412,100 anaesthesia procedures and 3568 perioperative deaths from 12 countries. Perioperative mortality rates in high-HDI countries decreased over time (P = 0.042). When comparing pre-1990 to 1990–2019, in high-HDI countries, the perioperative mortality rates per 10,000 anaesthesia procedures decreased 7.8-fold from 100.85 (95% CI 43.36 to 181.72) in pre-1990 to 12.98 (95% CI 6.47 to 21.70) in 1990–2019 (P < 0.0001). There were no studies from low-HDI countries pre-1990. In the period from 1990 to 2019, perioperative mortality rates did not differ between low- and high-HDI countries (P = 0.395) but the limited number of patients in low-HDI countries impaired the result. Perioperative mortality rates increased with increasing ASA status (P < 0.0001). There were more ASA III-V patients in high-HDI countries than in low-HDI countries (P < 0.0001), and the perioperative mortality rate increased 24-fold in ASA III-V patients compared with ASA I-II patients (P < 0.0001).ConclusionThe perioperative mortality rates in older patients have declined over the past 60 years in high-DHI countries, highlighting that perioperative safety in this population is increasing in these countries. Since data prior to 1990 were lacking in low-HDI countries, the evolution of their mortality rates could not be analysed. The perioperative mortality rate was similar in low- and high-HDI countries in the post-1990 period, but the low number of patients in the low-HDI countries does not allow a definitive conclusion.     

Liver cirrhosis but not alcohol abuse is associated with impaired outcome in trauma patients – A retrospective,multicentre study

IntroductionLiver cirrhosis has been shown to be associated with impaired outcome in patients who underwent elective surgery. We therefore investigated the impact of alcohol abuse and subsequent liver cirrhosis on outcome in multiple trauma patients.Materials and methodsUsing the multi-centre population-based Trauma Registry of the German Society for Trauma Surgery, we retrospectively compared outcome in patients (ISS ≥ 9, ≥18) with pre-existing alcohol abuse and liver cirrhosis with healthy trauma victims in univariate and matched-pair analysis. Means were compared using Student's t-test and analysis of variance (ANOVA) and categorical variables using χ² (p < 0.05 = significant).ResultsOverall 13,527 patients met the inclusion criteria and were, thus, analyzed. 713 (5.3%) patients had a documented alcohol abuse and 91 (0.7%) suffered from liver cirrhosis. Patients abusing alcohol and suffering from cirrhosis differed from controls regarding injury pattern, age and outcome. More specific, liver cirrhotic patients showed significantly higher in-hospital mortality than predicted (35% vs. predicted 19%) and increased single- and multi-organ failure rates. While alcohol abuse increased organ failure rates as well this did not affect in-hospital mortality.ConclusionsPatients suffering from liver cirrhosis presented impaired outcome after multiple injuries. Pre-existing condition such as cirrhosis should be implemented in trauma scores to assess the individual mortality risk profile.     

Trauma centre patient volume and inpatient mortality risk reconsidered

BackgroundSeveral studies have examined the relationship between injury volumes and trauma centre outcomes, with varying results attributable to differences in the measurement of volume's effect on mortality and differences in how characteristics are addressed as potential confounders.MethodsThis analysis includes all trauma cases reported to the NTDB 2012. The effect of trauma centre volume on patient mortality risk was measured in three different contexts: as a linear function of trauma centre volume, as a dichotomous function comparing patients in trauma centres with and without 1200 or more cases, and as a non-linear function of trauma centre volume. Multivariable weighted Hierarchical Generalized Linear Models were used to account for the combined effects of facility level and patient level covariates. Patient level mortality risk was assessed using the ACS Trauma Quality Improvement Programme methodology.ResultsTrauma centre volume was not a statistically significant predictor (at the α = 0.01 level) of patient mortality risk, in any of the three models. Comprehensive adjustments for patient level risk were obtained, with excellent discrimination between survivor and decedent cases. The addition of trauma volume to baseline patient mortality risk yielded no improvement in the accuracy of any model. These results were not sensitive to the inclusion of Level II trauma centres. Equivalent results were obtained by repeating the analysis for the Level I subpopulation only.ConclusionsCase volume may be a reasonable standard for determining whether adequate numbers of injured patients are available to support training needs and experience requirements of a Level I trauma centre. However, case volume is not a useful predictor of patient mortality in individual facilities. Trauma centre volume has no independent effect, after accounting for the patient level characteristics that predominantly influence mortality.     

The impact of the Major Trauma Network: will trauma units continue to treat complex foot and ankle injuries?

IntroductionApril 1st 2012 saw the introduction of National Trauma Networks in England. The aim to optimise the management of major trauma. Patients with an ISS ≥ 16 would be transferred to the regional Major Trauma Centre (level 1). Our premise was that trauma units (level 2) would no longer manage complex foot and ankle injuries thereby obviating the need for a foot and ankle specialist service.MethodsRetrospective analysis of the epidemiology of foot and ankle injuries, using the Gloucestershire trauma database, from a trauma unit with a population of 750,000. Rates of open fractures, complex foot and ankle injuries and requirement for stabilisation with external fixation were reviewed before and after the introduction of the regional Trauma Network. Secondly, using the Trauma Audit & Research Network (TARN) database, all foot and ankle injuries triaged to the regional Major Trauma Centre (MTC) were reviewed.ResultsIncidence of open foot and ankle injuries was 2.9 per 100,000 per year. There were 5.1% open injuries before the network and 3.2% after (p > 0.05). Frequency of complex foot and ankle injuries was 4.2% before and 7.5% after the network commenced, showing no significant change. There was no statistically significant change in the numbers of patients with complex foot and ankle injuries treated by application of external fixators. Analysis of TARN data revealed that only 18% of patients with foot and ankle injuries taken to the MTC had an ISS ≥ 16. The majority of these patients were identified as requiring plastic surgical intervention for open fractures (69%) or were polytrauma patients (43%). Only 4.5% of patients had isolated, closed foot and ankle injuries.ConclusionWe found that at the trauma unit there was no decrease in the numbers of complex foot and ankle injuries, open fractures, or the applications of external fixators, following the introduction of the Trauma Network. These patients will continue to attend trauma units as they usually have an ISS < 16. Our findings suggest that there is still a need for foot and ankle specialists at trauma units, in order to manage patients with complex foot and ankle injuries.     

Perioperative hypotension and discharge outcomes in non-critically injured trauma patients,a single centre retrospective cohort study

BackgroundThere is a lack of information on the effect of age on perioperative care and outcomes after minor trauma in the elderly. We examined the association between perioperative hypotension and discharge outcome among non-critically injured adult patients.MethodsWe conducted a retrospective study of non-critically ill patients (ISS <9 or discharged within less than 24 h) who received anaesthesia care for surgery and Recovery Room care at a level-1 trauma centre between 5/1/2012 and 11/30/2013. Perioperative hypotension was defined as systolic blood pressure (SBP) <90 mmHg (traditional measure) for all patients, and SBP <110 mmHg (strict measure) for patients ≥65 years. Poor outcome was defined as death or discharge to skilled nursing facility/hospice.Results1744 patients with mean ISS 4.4 across age groups were included; 169 (10%) were ≥65 years. Among patients ≥ 65 years, intraoperative hypotension occurred in >75% (131/169, traditional measure) and in >95% (162/169, strict measure); recovery room hypotension occurred in 2% (4/169) and 29% (49/169), respectively. Mean age-adjusted anaesthetic agent concentration (MAC) was similar across age groups. Opioid use decreased from 9.3 (SD 5.7) mg/h morphine equivalents in patients <55 years to 6.2 (SD 4.0) mg/h in patients over 85 years. Adjusted for gender, ASA score, anaesthesia duration, morphine equivalent/hr, fluid balance, MAC and surgery type, and using traditional definition, older patients were more likely than patients <55 to experience perioperative hypotension: aRR 1.21, 95% CI 1.11–1.30 for 55–64 and aRR 1.19, 95% CI 1.07–1.32 for ages 65–74. Perioperative hypotension was associated with poor discharge outcome (aRR 1.55; 95% CI 1.04–2.31 and aRR 1.87; 95% CI 1.17–2.98, respectively).ConclusionDespite age related reduction in doses of volatile anaesthetic and opioids administered during anaesthesia care, and regardless of hypotension definition used, non-critically injured patients undergoing surgery experience a large perioperative hypotension burden. This burden is higher for patients 55–74 years and older and is a risk factor for poor discharge outcomes, independent of age and ASA status.     

Perioperative mortality for patients with a hip fracture

IntroductionStudies on mortality following hip fracture surgery have hitherto focused on the 30 day to 1 year period and beyond. This study focuses on the immediate perioperative period. It examines mortality rates, patient characteristics, operative details and post-operative complications.Patients and methodsA retrospective study of a hip fracture database in a large District General Hospital in the United Kingdom, from 1986 to 2015. A dataset of 9393 patients was identified, including patients undergoing surgery for curative and palliative purposes, over fifteen years of age and with no upper age limit imposed. It compared patients who survived the first 48 h from start of surgery with those who died within this perioperative period.Results9393 patients were treated surgically and included within this study, with a mean age of 80.13 and consisting of 7130 female and 2263 male patients. The all cause mortality within 48 h from start of surgery was 0.8% (72 patients). Increased risk of perioperative mortality was associated with increasing age, ASA grade 3 and above, in-hospital falls, impaired mobility prior to the fall and a reduced mental test score on admission. For the patient with a perioperative death, the most common circumstances identified in this study involved being found dead in bed by attending staff within 48 h of surgery.DiscussionThere has been significant attention paid to the optimization of patient management leading up to hip fracture surgery and its attendant impact on medium and longer term survival. The information from this study may be used to identify patients most at risk of death in the 48 h after surgery. The importance of this dataset is that it provides large numbers, which are needed in order to look for associations, given the low 48 h mortality rate found.ConclusionWe are unable to highlight any correctable or alterable factors associated with mortality. Further studies with detailed collection of data on a national scale may be needed to assess the impact of levels of postoperative care for hip fracture patients and perioperative mortality.     

Decreased mortality in patients with isolated severe blunt traumatic brain injury receiving higher plasma to packed red blood cells transfusion ratios

IntroductionHigher transfusion ratios of plasma to packed red blood cells (PRBC) and platelets (PLT) to PRBC have been shown to be associated with decreased mortality in major trauma patients. However, little is known about the effect of transfusion ratios on mortality in patients with isolated severe traumatic brain injury (TBI). The aim of this study was to investigate the effect of transfusion ratios on mortality in patients with isolated severe blunt TBI. We hypothesized that higher transfusion ratios of plasma to PRBC and PLT to PRBC are associated with a lower mortality rate in these patients.MethodsRetrospective observational study. Patients with isolated severe blunt TBI (AIS head ≥ 3, AIS extracranial < 3) admitted to an urban level I trauma centre were included. Clinical data were extracted from the institution’s trauma registry, blood transfusion data from the blood bank database. The effect of higher transfusion ratios on in-hospital mortality was analysed using univariate and multivariable regression analysis.ResultsA total of 385 patients were included. Median age was 32 years (IQR 2–50), 71.4% were male, and 76.6% had an ISS ≥ 16. Plasma:PRBC transfusion ratios ≥ 1 were identified as an independent predictor for decreased in-hospital mortality (adjusted OR 0.43 [CI 0.22–0.81]). PLT:PRBC transfusion ratios ≥ 1 were not significantly associated with mortality (adjusted OR 0.39 [CI 0.08–1.92]).ConclusionThis study revealed plasma to PRBC transfusion ratios ≥ 1 as an independent predictor for decreased in-hospital mortality in patients with isolated severe blunt TBI.     

The effect of transfer status on trauma outcomes in low- and middle-income countries: A systematic review and meta-analysis

IntroductionInjuries are a leading cause of disability and death worldwide, and low- and middle-income countries (LMICs) are disproportionately burdened by trauma. Prior studies have shown that transfer status (direct transfer from injury scene to a referral hospital versus indirect transfer from another facility to a referral hospital) may affect patient outcomes. The purpose of this study is to evaluate the relationship between transfer status and trauma patient outcomes in LMICs by conducting a systematic review and meta-analysis.MethodsWe performed a systematic search to identify studies from LMICs that evaluated the relationship between transfer status and trauma patient outcomes. We extracted data on study country, design, patient characteristics, and outcomes. We report results in the form of a narrative summary stratified by type of outcome. We also performed a meta-analysis of studies that reported mortality by transfer status. We calculated a pooled odds ratio of mortality among indirectly transferred (IT) versus directly transferred (DT) patients using random-effects modeling.ResultsWe included 17 observational studies from 9 LMICs in this systematic review. Outcomes assessed were time from injury to arrival at a referral hospital, post-trauma functional status, hospital length of stay, and mortality. IT patients took between 0.6 and 37.9 h longer to arrive at referral hospitals than DT patients. Hospital length of stay was up to 6 days longer for IT patients than DT patients. The pooled odds ratio of mortality among IT patients compared to DT patients was 1.55 (95% CI 1.12 – 2.15; p = 0.009).ConclusionTrauma patients in LMICs who are indirectly transferred to referral hospitals have significantly higher mortality rates than patients who present directly to referral hospitals. These results conflict with findings from HICs and reflect the relative immaturity of trauma systems in LMICs. Strategies to narrow the mortality gap between IT and DT patients include improving prehospital and primary hospital care and developing more efficient transfer protocols.     

Obesity is Associated with Worse Outcomes Among Abdominal Trauma Patients Undergoing Laparotomy: A Propensity-Matched Nationwide Cohort Study

Introduction

Obesity is associated with increased morbidity and mortality in abdominal trauma patients. The characteristics of abdominal trauma patients with poor outcomes related to obesity require evaluation. We hypothesize that obesity is related to increased mortality and length of stay (LOS) among abdominal trauma patients undergoing laparotomies.

Methods

Abdominal trauma patients were identified from the National Trauma Data Bank between 2013 and 2015. Patients who received laparotomies were analyzed using propensity score matching (PSM) to evaluate the mortality rate and LOS between obese and non-obese patients. Patients without laparotomies were analyzed as a control group using PSM cohort analysis.

Results

A total of 33,798 abdominal trauma patients were evaluated, 10,987 of them received laparotomies. Of these patients, the proportion of obesity in deceased patients was significantly higher when compared to the survivors (33.1% vs. 26.2%, p < 0.001). Elevation of one kg/m² of body mass index independently resulted in 2.5% increased odds of mortality. After a well-balanced PSM, obese patients undergoing laparotomies had significantly higher mortality rates [3.7% vs. 2.4%, standardized difference (SD) = 0.241], longer hospital LOS (11.1 vs. 9.6 days, SD = 0.135), and longer intensive care unit LOS (3.5 vs. 2.3 days, SD = 0.171) than non-obese patients undergoing laparotomies.

Conclusions

Obesity is associated with increased mortality in abdominal trauma patients who received laparotomies versus those who did not. Obesity requires a careful evaluation of alternatives to laparotomy in injured patients.

     

Change in outcomes for trauma patients over time: Two decades of a state trauma system

BackgroundTrauma center mortality rates are benchmarked to expected rates of death based on patient and injury characteristics. The expected mortality rate is recalculated from pooled outcomes across a trauma system each year, obscuring system-level change across years. We hypothesized that risk-adjusted mortality would decrease over time within a state-wide trauma system.MethodsWe identified adult trauma patients presenting to Level I and II Pennsylvania trauma centers, 1999–2018, using the Pennsylvania Trauma Outcomes Study. Multivariable logistic regression generated risk-adjusted models for mortality in all patients, and in key subgroups: penetrating torso injury, blunt multisystem trauma, and patients presenting in shock.ResultsOf 162,646 included patients, 123,518 (76.1%) were white and 108,936 (67.0%) were male. The median age was 49 (interquartile range [IQR] 29–70), median injury severity score was 16 (IQR 10–24), and 87.5% of injuries were blunt. Overall, 9.9% of patients died, and compared to 1999, no year had significantly higher adjusted odds of mortality. Overall mortality was significantly lower in 2007–2009 and 2011–2018. Of patients with blunt, multisystem injuries, 17.7% died, and adjusted mortality improved over time. Mortality rates were 24.9% for penetrating torso injury, and 56.9% for shock, with no significant change. Mortality improved for patients with ISS < 25, but not for the most severely injured.ConclusionsOver 20 years, Pennsylvania trauma centers demonstrated improved risk-adjusted mortality rates overall, but improvement remains lacking in high-risk groups despite numerous innovations and practice changes in this time period. Identifying change over time can help guide focus to these critical gaps.     

Improving early identification of the high-risk elderly trauma patient by emergency medical services

Study objectiveWe sought to (1) define the high-risk elderly trauma patient based on prognostic differences associated with different injury patterns and (2) derive alternative field trauma triage guidelines that mesh with national field triage guidelines to improve identification of high-risk elderly patients.MethodsThis was a retrospective cohort study of injured adults ≥65 years transported by 94 EMS agencies to 122 hospitals in 7 regions from 1/1/2006 through 12/31/2008. We tracked current field triage practices by EMS, patient demographics, out-of-hospital physiology, procedures and mechanism of injury. Outcomes included Injury Severity Score ≥ 16 and specific anatomic patterns of serious injury using abbreviated injury scale score ≥3 and surgical interventions. In-hospital mortality was used as a measure of prognosis for different injury patterns.Results33,298 injured elderly patients were transported by EMS, including 4.5% with ISS ≥ 16, 4.8% with serious brain injury, 3.4% with serious chest injury, 1.6% with serious abdominal-pelvic injury and 29.2% with serious extremity injury. In-hospital mortality ranged from 18.7% (95% CI 16.7–20.7) for ISS ≥ 16 to 2.9% (95% CI 2.6–3.3) for serious extremity injury. The alternative triage guidelines (any positive criterion from the current guidelines, GCS ≤ 14 or abnormal vital signs) outperformed current field triage practices for identifying patients with ISS ≥ 16: sensitivity (92.1% [95% CI 89.6–94.1%] vs. 75.9% [95% CI 72.3–79.2%]), specificity (41.5% [95% CI 40.6–42.4%] vs. 77.8% [95% CI 77.1–78.5%]). Sensitivity decreased for individual injury patterns, but was higher than current triage practices.ConclusionsHigh-risk elderly trauma patients can be defined by ISS ≥ 16 or specific non-extremity injury patterns. The field triage guidelines could be improved to better identify high-risk elderly trauma patients by EMS, with a reduction in triage specificity.     

Elevated monocyte distribution width in trauma: An early cellular biomarker of organ dysfunction

IntroductionTraumatic injury elicits an inflammatory response such as the one occurring during systemic infection. Monocyte distribution width (MDW) has been found to distinguish sepsis in a pool of patients with suspected infection. We hypothesized that an elevated MDW in trauma patients would be associated with the development of multiple organ dysfunction syndrome (MODS) and an increased mortality.Materials and MethodsObservational study in a dedicated trauma Intensive Care Unit (ICU) in Madrid during 2019–2020. Patients were classified according to their first MDW value on admission, as greater or lesser than 21 U. Clinical data was obtained and univariate and multivariate analysis were realized, as well as a test performance analysis.Results354 patients were studied, with a median age of 46 years, 78% male. Half presented with severe trauma ISS > 15, mostly with a blunt mechanism of injury. A MDW ≥ 21 U on admission was found in 17% of cases. These patients were more likely to present with hemodynamic instability and MODS. They had a higher length of stay (3.8 vs 2 days) and higher mortality (21 vs 5%) compared to the low MDW group. These findings remained statistically significant in the multivariate analysis, with an OR 4.6 (IC 95% 1.7–12) for MODS and 3.1 (IC 95% 1.2–8.3) for mortality.ConclusionsIn trauma patients, a MDW ≥ 21 U on admission was independently associated with a greater risk of MODS, a higher mortality and a higher length of stay. This biomarker could be useful in predicting severity in the initial evaluation of trauma patients.     

The impact of BMI on polytrauma outcome

BackgroundVarying results have been reported concerning the effect of body mass index (BMI) on polytrauma outcome. Although most studies focus on obesity and its associated preexisting medical diseases as a predictor for increased mortality rates, there is evidence that polytrauma patients with underweight also face an inferior outcome.MethodsRecords of 5766 trauma patients (minimum 18 years of age, Injury Severity Score ≥ 16, treated from 2004 to 2008) documented in the Trauma Registry of the German Society for Trauma Surgery were subclassified into 4 BMI groups and analysed to assess the impact of BMI on polytrauma outcome.ResultsUnderweight (BMI Group I) as well as obesity (BMI Group IV) in polytraumatized patients are associated with significantly increased mortality by multivariate logistic regression analysis with hospital mortality as the target variable (adjusted odds ratio for BMI Group I, 2.1 (95% CI 1.2–3.8, p = 0.015); for BMI Group IV, 1.6 (95% CI 1.1–2.3, p = 0.009)). Simple overweight (BMI Group III) does not qualify as a predictor for increased mortality (odds ratio 1.0; 95% CI 0.8–1.3).ConclusionsThere is a significant correlation between obesity, underweight, and increased mortality in polytraumatized patients. Efforts to promote optimal body weight may reduce not only the risk of chronic diseases but also the risk of polytrauma mortality amongst obese and underweight individuals.     

The pelvic fracture – Indicator of injury severity or lethal fracture?

BackgroundPresence of pelvic fractures in trauma patients has previously been related to high mortality. However, there are controversies on whether pelvic fractures are the underlying cause of death or if it is rather an indicator of injury severity. We aimed to assess whether the presence of pelvic fracture increased mortality among a cohort of trauma patients or if it was simply an indicator of severe injury.Material and methodsKarolinska University Hospital is the largest trauma centre in Sweden. The hospital is linked to the Swedish National Trauma Registry, “SweTrau”. Registry data was collected for the period January 2013 until December 2015 with a one year further follow-up regarding mortality. Patients in the pelvic fracture group were compared to the non-pelvic fracture group and regression analysis was performed adjusting for factors that could possibly affect mortality.ResultsUnivariable analysis showed that pelvic fracture was associated with an increased mortality, OR 2.4 (CI 1.3–3.4). Multivariable analysis showed that the presence of a pelvic fracture was not associated with an increased 30-day mortality (OR 0.5, CI 0.2–0.9), while factors as Shock (OR 7.1, CI 4.6–10.9), GCS < 9 (OR 6.2, CI 3.9–9.8), ISS > 15 (OR 12.4, CI 8.1–18.9), Age >60 (OR 3.2, CI 2.1–4,9) and ASA 3–4 (OR 4.7, CI 3.1–7.3) were associated with an increased 30-day mortality. Factors affecting 1-year mortality was analysed in the same way and the results were similar.ConclusionPresence of pelvic fractures in trauma patients is not correlated to increased mortality when adjusted for Age, ISS, ASA, GCS and Shock.     

Risk factors for complications within 30 days of operatively fixed periprosthetic femur fractures

BackgroundWith a rising number of periprosthetic femur fractures (PPFFs) each year, the primary objective of our study was to quantify risk factors that predict complications following operative treatment of PPFFs.MethodsA retrospective cohort study of 231 patients with a periprosthetic femur fracture was conducted at an Academic, Level 1 Trauma Center. The main outcome measurement of interest was complications, as defined by the ACS-NSQIP, within 30 days of surgery.Results56 patients had 96 complications. Bivariate analyses revealed ASA score, preoperative ambulatory status, length of stay, discharge disposition, time from admission to surgery, length of surgery, perioperative change in hemoglobin, Charlson comorbidity index, cerebral vascular accident/transient ischemic attack, chronic obstructive pulmonary disease, diabetes mellitus, and receipt of a blood transfusion were associated with development of a complication (p < 0.1). Multivariate logistic regression showed length of stay (OR 1.11, 95% CI 1.03–1.19; p = 0.006), receipt of a blood transfusion (OR 2.48, 95% CI 1.14–5.42; p = 0.02), and diabetes mellitus (OR 2.17, 95% CI 1.03–4.56; p = 0.04) remained independently predictive of complication.ConclusionsLength of stay, receipt of a blood transfusion, and diabetes were associated with increased perioperative risk for developing a complication following operative treatment of periprosthetic femur fractures. Methods to decrease length of stay or transfusion rates may mitigate complication risk in these patients.Level of EvidencePrognostic, Level III     

Paediatric major trauma in the setting of the Irish trauma network

BackgroundThe construction of a new tertiary children's hospital and reconfiguration of its two satellite centres will become the Irish epicentre for all paediatric care including paediatric trauma. Ireland is also currently establishing a national trauma network although further planning of how to manage paediatric trauma in the context of this system is required. This research defines the unknown epidemiology of paediatric major trauma in Ireland to assist strategic planning of a future paediatric major trauma network.MethodsData from 1068 paediatric trauma cases was extracted from a longitudinal series of annual cross-sectional studies collected by the Trauma Audit and Research Network (TARN). All paediatric patients between the ages of 0-16 suffering AIS ≥2 injuries in Ireland between 2014-2018 were included. Demographics, injury patterns, hospital care processes and outcomes were analysed.ResultsChildren were most commonly injured at home (45.1%) or in public places/roads (40.1%). The most frequent mechanisms of trauma were falls <2 m (36.8%) followed by RTAs (24.3%). Limb injuries followed by head injuries were the most often injured body parts. The proportion of head injuries in those aged <1 year is double that of any other age group. Only 21% of patients present directly to a children's hospital and 46% require transfer. Consultant-led emergency care is currently delivered to 41.5% of paediatric major trauma patients, there were 555 (48.2%) patients who required operative intervention and 22.8% who required critical care admission. A significant number of children in Ireland aged 1-5 years die from asphyxia/drowning. The overall mortality rate was 3.8% and was significantly associated with the presence of head injuries (p < 0.001).ConclusionPaediatric Trauma represents a significant childhood burden of mortality and morbidity in Ireland. There are currently several sub-optimal elements of paediatric trauma service delivery that will benefit from the establishment of a trauma network. This research will help guide prevention strategy, policy-making and workforce planning during the establishment of an Irish paediatric trauma network and will act as a benchmark for future comparison studies after the network is implemented.     

A case-control study of risk factors for survival after laparotomy in patients with pancreatic trauma

BackgroundPancreatic trauma results in significant morbidity and mortality. However, few studies have investigated the postoperative prognostic factors in patients with pancreatic trauma.Material and methodsA retrospective study was conducted on consecutive patients with pancreatic trauma who underwent surgery in a national referral trauma center. Clinical data were retrieved from the electronic medical system. Univariate and binary logistic regression analyses were performed to identify the perioperative clinical parameters that may predict the factors of mortality of the patients.ResultsA total of 150 patients underwent laparotomy due to pancreatic trauma during the study period. 128(85.4%) patients survived and 22 (14.6%) patients died due to pancreatic injury (10 patients died of recurrent intra-abdominal active hemorrhage and 12 died of multiple organ failure). Univariate analysis showed that age, hemodynamic status, and injury severe score (ISS) as well as postoperative serum levels of C-reactive protein (CRP), procalcitonin, albumin, creatinine and the volume of intraoperative blood transfusion remained strongly predictive of mortality (P < 0.05). Binary logistic regression analysis showed that the independent risk factors for prognosis after pancreatic trauma were age (P = 0.010), preoperative hemodynamic instability (P = 0.015), postoperative CRP ≥154 mg/L (P = 0.014), and postoperative serum creatinine ≥177 μmol/L (P = 0.027).ConclusionsIn this single-center retrospective study, we demonstrated that preoperative hemodynamic instability, severe postoperative inflammation (CRP ≥154 mg/L) and acute renal failure (creatinine ≥177 μmol/L) were associated with a significant risk of mortality after pancreatic trauma.     

Outcomes of severely injured adult trauma patients in an Australian health service: does trauma center level make a difference?

Background  

Trauma centers are designated to provide systematized multidisciplinary care to injured patients. Effective trauma systems reduce patient mortality by facilitating the treatment of injured patients at appropriately resourced hospitals. Several U.S. studies report reduced mortality among patients admitted directly to a level I trauma center compared with those admitted to hospitals with less resources. It has yet to be shown whether there is an outcome benefit associated with the “level of hospital” initially treating severely injured trauma patients in Australia. This study was designed to determine whether the level of trauma center providing treatment impacts mortality and/or hospital length of stay.     

Predictive factors of morbidity and mortality in grade IV and V liver trauma undergoing perihepatic packing: Single institution 14 years experience at European trauma centre

PurposeMajor liver trauma in polytraumatic patients accounts for significant morbidity and mortality. We aimed to assess prognostic factors for morbidity and mortality in patients with severe liver trauma undergoing perihepatic packing.MethodsProspectively collected records of 293 consecutive polytrauma patients with liver injury admitted at a level I trauma centre between 1996 and 2008 were reviewed. 39 patients with grade IV–V AAST liver injury and treated with peri-hepatic packing were identified and included for analysis. Univariate and multivariate analyses were performed to assess prognostic factors for morbidity and mortality.ResultsMean age of patients was 41 years. 34 patients were haemodynamically unstable at initial presentation. Ten of 39 patients were treated with angiographic embolization in addition to perihepatic packing. The overall mortality rate was 51.3%. Liver-related death occurred in 23.1%. Overall and liver-related morbidity rates were 90% and 28%, respectively. Glasgow Coma Scale (GCS), respiratory rate, packed red blood cells (PRBC) transfusion, pH and Base Excess (BE), Revised Trauma Score (RTS) and Trauma Injury Severity Score (TRISS), need for angiographic embolization as well as early OR and ICU admission were associated with significant decrease of early mortality.ConclusionsRevised Trauma Score, haemodynamic instability, blood pH and BE are important prognostic factors influencing morbidity and mortality in polytrauma patients with grade IV/V liver injury. Furthermore, fast and effective surgical damage control procedure with perihepatic packing, followed by early ICU admission is associated with lower complication rate and shorter ICU stays in this patient population.