Postoperative Komplikationen in der Unfallchirurgie

[Elective and acute procedures in trauma surgery. Complications requiring revision]

BACKGROUND

Using data between 2010 and 31 March 2012, a cohort study concerning complications of all discharged patients who had undergone surgery was performed.

PATIENTS AND METHODS

In our detailed analysis, we defined two groups out of the 5,248 cases: an acute trauma patient group (n = 3,942) and an elective patient group (n = 1,306). Complications were divided into the following groups: (1) technical complications (failure of the implant, poor indication, instability or non-union), (2) local complication (hematoma or delayed wound healing), and (3) infection.

RESULTS

In 4.4% of patients (n = 233), treatment was delayed because of a complication. In 2.3% (n = 123), a technical complication was observed, followed by local complications in 1.3% [e.g., hematoma 0.6%, other wound healing disturbance (0.6%)]. In the elective surgery group, the percentage of complications needing revision (3.1%) was significantly lower compared to the trauma surgery group (4.9%). The patient's age for the non-complicated surgery group was significantly lower (54 vs. 63 years) and length of hospital stay (6.7 days longer) was significantly higher in patients with complications. Risk factors such as smoking were significantly more frequent in patients with complications (9% vs. 18.5%).

CONCLUSION

Recording and evaluating of complications in surgery plays a major role for quality control. Certain factors (e.g., comorbidity and the age of the patient) cannot be influenced, but complications caused by technical problems could theoretically be avoided. Especially these cases must be analyzed in detail to reduce the percentage of complications requiring revision.

Validation of Complications Selected by Consensus to Evaluate the Acute Phase of Adult Trauma Care: A Multicenter Cohort Study

OBJECTIVE

Evaluate the predictive validity of complications derived using expert consensus methodology to monitor the quality of trauma care. Secondary objectives were to assess the predictive validity of complications not selected by consensus and identify determinants of complications.

BACKGROUND

A list of complications to monitor the quality of trauma care has recently been derived using Delphi consensus methodology. However, the predictive validity of consensus complications has not yet been demonstrated.

METHODS

We conducted a multicenter cohort study of adults admitted to the 57 adult trauma centers of a Canadian integrated trauma system (2007-2012; n = 84,216). Multiple generalized linear models were used to assess the influence of complications on mortality and acute care length of stay (LOS) and to identify determinants of consensus complications.

RESULTS

The presence of at least 1 consensus complication was associated with a 2.7-fold [95% confidence interval (CI): 2.45-2.90] and 2.2-fold (95% CI: 2.11-2.19) increase in the odds of mortality and mean LOS, respectively. Nonselected complications were associated with no increase in mortality (odds ratio = 0.90, 95% CI: 0.80-1.01) and a 60% increase in LOS (geometric mean ratio = 1.60, 95% CI: 1.57-1.62). Patient-related factors and factors related to treatment explained 66% and 34% of the variation in complication rates, respectively.

CONCLUSIONS

In addition to the face and content validity ensured by consensus methodology, this study suggests that consensus complications have good predictive validity. Monitoring these complications as part of quality improvement activities would provide an opportunity to improve outcome and resource use for injury admissions.

[Complication management in implant dislocation]

There are many reasons for an implant malposition. Besides knowlege about prevention of implant dislocation, accurate planning of the osteosynthesis, extensive knowlege of the anatomy of the region in question, using all necessary diagnostic tools, choosing the correct approach and the best implant for fracture fixation are also important factors. Nevertheless, implant complications can still be found and if an intraoperative or postoperative implant dislocation occurs a suitable management is necessary. This article describes the different osteosynthesis implants and possible malpositions and dislocations. Tips and tricks are described in order to facilitate the correct indications for the further procedure.

Complications to evaluate adult trauma care: An expert consensus study

BACKGROUND

Complications affect up to 37% of patients hospitalized for injury and increase mortality, morbidity, and costs. One of the keys to controlling complications for injury admissions is to monitor in-hospital complication rates. However, there is no consensus on which complications should be used to evaluate the quality of trauma care. The objective of this study was to develop a consensus-based list of complications that can be used to assess the acute phase of adult trauma care.

METHODS

We used a three-round Web-based Delphi survey among experts in the field of trauma care quality with a broad range of clinical expertise and geographic diversity. The main outcome measure was median importance rating on a 5-point Likert scale (very low to very high); complications with a median of 4 or greater and no disagreement were retained. A secondary measure was the perceived quality of information on each complication available in patient files.

RESULTS

Of 19 experts invited to participate, 17 completed the first (brainstorming) round and 16 (84%) completed all rounds. Of 73 complications generated in Round 1, a total of 25 were retained including adult respiratory distress syndrome, hospital-acquired pneumonia, sepsis, acute renal failure, deep vein thrombosis, pulmonary embolism, wound infection, decubitus ulcers, and delirium. Of these, 19 (76%) were perceived to have high-quality or very high-quality information in patient files by more than 50% of the panel members.

CONCLUSION

This study proposes a consensus-based list of 25 complications that can be used to evaluate the quality of acute adult trauma care. These complications can be used to develop an informative and actionable quality indicator to evaluate trauma care with the goal of decreasing rates of hospital complications and thus improving patient outcomes and resource use. DRG International Classification of Diseases codes are provided.

Extracellular micronutrient levels and pro-/antioxidant status in trauma patients with wound healing disorders: results of a cross-sectional study

Background

Disorders in wound healing (DWH) are common in trauma patients, the reasons being not completely understood. Inadequate nutritional status may favor DWH, partly by means of oxidative stress. Reliable data, however, are lacking. This study should investigate the status of extracellular micronutrients in patients with DWH within routine setting.

Methods

Within a cross-sectional study, the plasma/serum status of several micronutrients (retinol, ascorbic acid, 25-hydroxycholecalciferol, α-tocopherol, β-carotene, selenium, and zinc) were determined in 44 trauma patients with DWH in addition to selected proteins (albumin, prealbumin, and C-reactive protein; CRP) and markers of pro-/antioxidant balance (antioxidant capacity, peroxides, and malondialdehyde). Values were compared to reference values to calculate the prevalence for biochemical deficiency. Correlations between CRP, albumin and prealbumin, and selected micronutrients were analyzed by Pearson’s test. Statistical significance was set at P < 0.05.

Results

Mean concentrations of ascorbic acid (23.1 ± 15.9 μmol/L), 25-hydroxycholecalciferol (46.2±30.6 nmol/L), β-carotene (0.6 ± 0.4 μmol/L), selenium (0.79±0.19 μmol/L), and prealbumin (24.8 ± 8.2 mg/dL) were relatively low. Most patients showed levels of ascorbic acid (<28 μmol/L; 64%), 25-hydroxycholecalciferol (<50 μmol/L; 59%), selenium (≤ 94 μmol/L; 71%) and β-carotene (<0.9 μmol/L; 86%) below the reference range. Albumin and prealbumin were in the lower normal range and CRP was mostly above the reference range. Plasma antioxidant capacity was decreased, whereas peroxides and malondialdehyde were increased compared to normal values. Inverse correlations were found between CRP and albumin (P < 0.05) and between CRP and prealbumin (P < 0.01). Retinol (P < 0.001), ascorbic acid (P < 0.01), zinc (P < 0.001), and selenium (P < 0.001) were negatively correlated with CRP.

Conclusions

Trauma patients with DWH frequently suffer from protein malnutrition and reduced plasma concentrations of several micronutrients probably due to inflammation, increased requirement, and oxidative burden. Thus, adequate nutritional measures are strongly recommended to trauma patients.

Complication rates as a trauma care performance indicator: a systematic review

Introduction

Information on complication rates is essential to trauma quality improvement efforts. However, it is unclear which complications are the most clinically relevant. The objective of this study was to evaluate whether there is consensus on the complications that should be used to evaluate the performance of acute care trauma hospitals.

Methods

We searched the Medline, EMBASE, Cochrane Central, CINAHL, BIOSIS, TRIP and ProQuest databases and included studies using at least one nonfatal outcome to evaluate the performance of acute care trauma hospitals. Data were extracted in duplicate using a piloted electronic data abstraction form. Consensus was considered to be reached if a specific complication was used in ≥ 70% of studies (strong recommendation) or in ≥ 50% of studies (weak recommendation).

Results

Of 14,521 citations identified, 22 were eligible for inclusion. We observed important heterogeneity in the complications used to evaluate trauma care. Seventy-nine specific complications were identified but none were used in ≥ 70% of studies and only three (pulmonary embolism, deep vein thrombosis, and pneumonia) were used in ≥ 50% of studies. Only one study provided evidence for the clinical relevance of complications used and only five studies (23%) were considered of high methodological quality.

Conclusion

Based on the results of this review, we can make a weak recommendation on three complications that should be used to evaluate acute care trauma hospitals; pulmonary embolism, deep vein thrombosis, and pneumonia. However, considering the observed disparity in definitions, the lack of clinical justification for the complications used, and the low methodological quality of studies, further research is needed to develop a valid and reliable performance indicator based on complications that can be used to improve the quality and efficiency of trauma care.