Extracorporeal support for trauma: A trauma quality improvement project (TQIP) analysis in patients with acute respiratory distress syndrome

Trauma Quality Improvement Program: A Retrospective Analysis from A Middle Eastern National Trauma Center

BACKGROUND

The Trauma Quality Improvement Program (American College of Surgery (ACS-TQIP)) uses the existing infrastructure of the Committee on Trauma programs and provides feedback to participating hospitals on risk-adjusted outcomes. This study aimed to analyze and compare the performance of the Level I Hamad Trauma Centre (HTC) with other TQIP participating centers by comparing TQIP aggregate database reports. The primary goal was to pinpoint the variations in adult trauma outcomes and quality measures, identify areas that need improvement, and leverage existing resources to facilitate quality improvement.

METHODS

A retrospective analysis was performed for the TQIP data from April 2019-March 2020 to April 2020-March 2021. We used the TQIP methodology, inclusion and exclusion criteria, and outcomes.

RESULTS

There were 915 patients from Fall 2020 and 884 patients from Fall 2021 that qualified for the TQIP database. The HTC patients' demographics differed from the TQIP's aggregate data; they were younger, more predominantly male, and had significantly different mechanisms of injury (MOI) with more traffic-related blunt trauma. Penetrating injuries were more severe in the other centers. During the TQIP Fall 2020 report, the HTC was a low outlier (good performer) in one cohort (all patients) and an average performer in the remaining cohorts. However, during Fall 2021, the HTC showed an improvement and was a low outlier in two cohorts (all patients and severe TBI patients). Overall, the HTC remained an average performer during the report cycles.

CONCLUSIONS

There was an improvement over time in the risk-adjusted mortality, which reflects the continuous and demanding effort put together by the trauma team. The ACS-TQIP for the external benchmarking of quality improvement could be a contributor to better monitored patient care. Evaluating the TQIP data with emphases on appropriate methodologies, quality measurements, corrective measures, and accurate reporting is warranted.

ECMO in adult patients with severe trauma: a systematic review and meta-analysis

BACKGROUND

Severe trauma can result in cardiorespiratory failure, and when conventional treatment is ineffective, extracorporeal membrane oxygenation (ECMO) can serve as an adjunctive therapy. However, the indications for ECMO in trauma cases are uncertain and clinical outcomes are variable. This study sought to describe the prognosis of adult trauma patients requiring ECMO, aiming to inform clinical decision-making and future research.

METHODS

A comprehensive search was conducted on Pubmed, Embase, Cochrane, and Scopus databases until March 13, 2023, encompassing relevant studies involving over 5 trauma patients (aged ≥ 16 years) requiring ECMO support. The primary outcome measure was survival until discharge, with secondary measures including length of stay in the ICU and hospital, ECMO duration, and complications during ECMO. Random-effects meta-analyses were conducted to analyze these outcomes. The study quality was assessed using the Joanna Briggs Institute checklist, while the certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

The meta-analysis comprised 36 observational studies encompassing 1822 patients. The pooled survival rate was 65.9% (95% CI 61.3-70.5%). Specifically, studies focusing on traumatic brain injury (TBI) (16 studies, 383 patients) reported a survival rate of 66.1% (95% CI 55.4-76.2%), while studies non-TBI (15 studies, 262 patients) reported a survival rate of 68.1% (95% CI 56.9-78.5%). No significant difference was observed between these two survival comparisons (p = 0.623). Notably, studies utilizing venoarterial extracorporeal membrane oxygenation (VA ECMO) (15 studies, 39.0%, 95% CI 23.3-55.6%) demonstrated significantly lower survival rates than those using venovenous extracorporeal membrane oxygenation (VV ECMO) (23 studies, 72.3%, 95% CI 63.2-80.7%, p < 0.001). The graded assessment of evidence provided a high degree of certainty regarding the pooled survival.

CONCLUSIONS

ECMO is now considered beneficial for severely traumatized patients, improving prognosis and serving as a valuable tool in managing trauma-related severe cardiorespiratory failure, haemorrhagic shock, and cardiac arrest.

American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for management of acute respiratory distress syndrome and severe hypoxemia

LEVEL OF EVIDENCE

Therapeutic/Care Management: Level V.

Clinical study of rhGM-CSF for the treatment of pulmonary exogenous acute respiratory distress syndrome by modulating alveolar macrophage subtypes: A randomized controlled trial

BACKGROUND

By modulating the oxygen partial pressure of alveolar epithelial cells, the granulocyte-macrophage colony-stimulating factor (GM-CSF) can stimulate and enhance the innate immune response in the lungs. This study aimed to investigate the therapeutic efficacy of rhGM-CSF in patients suffering from extrapulmonary-induced acute respiratory distress syndrome (ARDS).

METHODS

A randomized, double-blind, placebo-controlled clinical trial was conducted between February 2018 to July 2019, in which 66 sepsis patients with ARDS were recruited. The study randomly allocated the patients into 2 groups: an experimental group (34 cases receiving rhGM-CSF) and a control group (32 cases receiving placebo). The changes in lung function were assessed using the scores of PaO2/FIO2 ratio, acute physiology and chronic health evaluation II, sequential organ failure assessment, and lung injury. Additionally, the study analyzed the levels of inflammatory cells, HLA-DR (%), high mobility group protein B1 (HMGB-1) (ng/mL), tumor necrosis factor-alpha (pg/mL), IL-6 (pg/mL), and GM-CSF (pg/mL) in both blood and bronchoalveolar lavage fluid.

RESULTS

The study results revealed that the experimental group significantly enhanced their pulmonary function compared to the control group. Moreover, the experimental group demonstrated higher levels of inflammatory cells and HLA-DR, whereas levels of HMGB-1 and tumor necrosis factor-alpha were lower in blood (P < .05, respectively). In addition, the experimental group displayed a higher alternatively activated cell ratio and GM-CSF levels in bronchoalveolar lavage fluid (both P < .05); while HMGB-1 levels were significantly reduced (P < .05). However, no notable difference observed in mortality between the 2 groups (P > .05).

CONCLUSIONS

Administering rhGM-CSF to ARDS patients improves lung function and decreases blood inflammation. Nonetheless, while this treatment demonstrates efficacy in reducing these parameters, it does not significantly impact the incidence of ventilator-associated pneumonia or 28-day mortality in ARDS patients.

Practice of Multidisciplinary Collaborative Chain Management Model in Constructing Nursing Path for Acute Trauma Treatment

Prompt and effective treatment is the key to improve the prognosis of patients with acute trauma, and nursing plays an important role. However, conventional nursing has many limitations. Some studies have pointed out that the multidisciplinary collaborative chain management model can optimize the emergency procedures, ensure the continuity of the emergency treatment process, and optimize the treatment details. This study analyzed the practice of constructing an acute trauma care pathway based on a multidisciplinary collaborative chain management model. The results showed that the application of the multidisciplinary collaborative chain management model in the construction of acute trauma treatment nursing paths can enhance the emergency efficiency and nursing treatment, prevent the occurrence of adverse events, and improve the prognosis of patients.