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Schieren M, Defosse JM, Annecke T. [Specialised Intensive Care Treatment Concepts for Severe Chest Trauma]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:354-367. [PMID: 38914078 DOI: 10.1055/a-2149-1814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
This review covers key elements of the critical care management of patients with thoracic trauma. Contrast-enhanced chest computertomography remains the diagnostic modality of choice, as it is more sensitive than conventional chest imaging. Regarding risk stratification, special caution is required in older patients with thoracic trauma given their high risk for posttraumatic complications. In the case of respiratory insufficiency, an attempt of non-invasive ventilation techniques is justified in most patients due to potential treatment benefits. Achieving sufficient pain control is a fundamental goal of critical care management. In this regard, erector-spinae-block and paravertebral block present potentially advantageous alternatives to thoracic epidural anaesthesia. In stable patients, the placement of small-calibre chest tubes may be a beneficial approach compared with large-bore tubes. If surgical stabilization of rib fractures is indicated, it should be done as early as possible.
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Dogruyol T, Kahraman S, Dogruyol S, Buz M, Cimenoglu B, Ozdemir A, Dogu Geyik F, Demirhan R. Is intensive care necessary after major thoracic surgery? A propensity score-matched study. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2023; 31:229-238. [PMID: 37484638 PMCID: PMC10357857 DOI: 10.5606/tgkdc.dergisi.2023.23501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/20/2022] [Indexed: 07/25/2023]
Abstract
Background This study aims to compare the surgical results, complications, mortality rates, and inpatient costs in two patient groups followed, whether in the intensive care unit or general ward after a major thoracic procedure and to examine clinical and surgical factors related to the development of complications. Methods Between January 2018 and June 2021, a total of 485 patients (150 males, 335 females; mean age: 58.3±13.2 years; range, 22 to 86 years) who underwent a major thoracic surgery in our clinic were retrospectively analyzed. The patients were divided into two groups as the intensive care unit patients (n=254) and general ward patients (n=231). In the former group, the patients were followed in the intensive care unit for a day, while in the general ward group, the patients were taken directly to the ward. The groups were compared after propensity score matching. All patients were analyzed for risk factors of morbidity development. Results After propensity score matching, 246 patients were enrolled including 123 patients in each group. There was no statistically significant difference between the groups in any features except for late morbidity, and inpatient costs were higher in the intensive care unit group (p<0.05). In the multivariate analysis, age, American Society of Anesthesiologists Class 3, and secondary malignancy were found to be associated with morbidity (p<0.05). Conclusion In experienced centers, it is both safe and costeffective to follow almost all of the major thoracic surgery patients postoperatively in the general ward.
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Affiliation(s)
- Talha Dogruyol
- Department of Thoracic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
| | - Selime Kahraman
- Department of Thoracic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
| | - Sinem Dogruyol
- Emergency Medicine, Haydarpaşa Numune Training and Research Hospital, Istanbul, Türkiye
| | - Mesut Buz
- Department of Thoracic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
| | - Berk Cimenoglu
- Department of Thoracic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
| | - Attila Ozdemir
- Department of Thoracic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
| | - Fatih Dogu Geyik
- Department of Anesthesiology and Reanimation, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
| | - Recep Demirhan
- Department of Thoracic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Türkiye
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Mukherjee K, Schubl SD, Tominaga G, Cantrell S, Kim B, Haines KL, Kaups KL, Barraco R, Staudenmayer K, Knowlton LM, Shiroff AM, Bauman ZM, Brooks SE, Kaafarani H, Crandall M, Nirula R, Agarwal SK, Como JJ, Haut ER, Kasotakis G. Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society. J Trauma Acute Care Surg 2023; 94:398-407. [PMID: 36730672 DOI: 10.1097/ta.0000000000003830] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia. METHODS Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used. RESULTS Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality. CONCLUSION We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia. LEVEL OF EVIDENCE Systematic Review/Meta-analysis; Level IV.
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Affiliation(s)
- Kaushik Mukherjee
- From the Division of Acute Care Surgery, Loma Linda University Medical Center (K.M.), Loma Linda; University of California Irvine Medical Center (S.D.S.), Irvine; Scripps Memorial La Jolla (G.T.), San Diego, California; Division of Trauma and Critical Care Surgery, Department of Surgery (S.C., K.L.H., S.K.A., G.K.), Duke University Medical Center, Durham, North Carolina; The Mayo Clinic (B.K.), Rochester, Minnesota; University of California San Francisco-Fresno (K.L.K.), Fresno, California; Lehigh Valley Health Network (R.B.), Allentown, Pennsylvania; Stanford University Medical Center (K.S., L.M.K.), Palo Alto, California; University of Pennsylvania Medical Center (A.M.S.), Philadelphia, Pennsylvania; University of Nebraska Medical Center (Z.M.B.), Omaha, Nevada; Texas Tech University Health Sciences Center (S.E.B.), Lubbock, Texas; Massachusetts General Hospital (H.K.), Boston, Massachusetts; University of Florida College of Medicine (M.C.), Jacksonville, Florida; University of Utah Medical Center (R.N.), Salt Lake City, Utah; MetroHealth Cleveland Medical Center (J.J.C.), Cleveland, Ohio; Johns Hopkins Medical Center (E.R.H.), Baltimore, Maryland
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Ferrah N, Beck B, Ibrahim J, Gabbe B, McLellan MS, Cameron P. Older trauma patients with isolated chest injuries have low rates of complications. Injury 2022; 53:4005-4012. [PMID: 36243582 DOI: 10.1016/j.injury.2022.09.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/24/2022] [Accepted: 09/25/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The number of older adults hospitalised for injury is growing rapidly. The population-adjusted incidence of isolated thoracic injuries in older adults is also growing. While some older adults are at high risk of post-traumatic complications, not all older adults will need treatment in a major trauma service (MTS). The aim of this study was to characterise older patients with isolated chest injuries, determine the rates of post-traumatic complications, including respiratory failure and pneumonia, and the factors associated with the risk of developing these complications. PATIENTS AND METHODS This was a retrospective review of patients aged 65 years and over with isolated chest trauma, from January 2007 to June 2017, using data from the Victorian State Trauma Registry. Patient characteristics and rates of complications were compared between patients with 1. isolated rib fractures, and 2. complex chest injury. Multivariable logistic regression was used to identify predictors of respiratory failure, and pneumonia. RESULTS The study population comprised 5401 patients aged 65 years or more, with isolated chest injuries. Two-thirds (65%) of all patients had isolated rib fractures, and 58% of patients (n = 3156) were directly admitted to a non-major trauma centre. Complications were uncommon, with 5.45% of all patients (n = 295) having pneumonia and 3.2% (n = 175) having respiratory failure. Factors associated with increased risk of pneumonia and respiratory failure included advancing age, smoking, chronic obstructive pulmonary disease, congestive heart failure, and more severe and complex chest injury. The adjusted odds of complications were lowest amongst patients not classified as major trauma and receiving definitive treatment in non-MTS. DISCUSSION Our findings suggest that rates of complications in older patients with isolated chest trauma in this study were low, and that there is a large group of patients with isolated, uncomplicated rib fractures, who may not need to be treated in a major trauma centre. Further work should be undertaken to appropriately risk stratify and manage older adults with isolated chest trauma.
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Affiliation(s)
- Noha Ferrah
- School of Public Health and Preventive Medicine, Monash University, Prahan, VIC 3004, Australia.
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Prahan, VIC 3004, Australia; Faculty of Medicine, Laval University, Quebec City, Canada
| | - Joseph Ibrahim
- School of Public Health and Preventive Medicine, Monash University, Prahan, VIC 3004, Australia; Department of Forensic Medicine, Monash University, The Victorian Institute of Forensic Medicine, VIC Australia
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Prahan, VIC 3004, Australia; Health Data Research UK, Swansea University Medical School, United Kingdom
| | - Ms Susan McLellan
- School of Public Health and Preventive Medicine, Monash University, Prahan, VIC 3004, Australia
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Prahan, VIC 3004, Australia; Emergency and Trauma Centre, The Alfred Hospital, VIC, Australia
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Battle C, Carter K, Newey L, Giamello JD, Melchio R, Hutchings H. Risk factors that predict mortality in patients with blunt chest wall trauma: an updated systematic review and meta-analysis. Emerg Med J 2022; 40:369-378. [PMID: 36241371 DOI: 10.1136/emermed-2021-212184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 10/03/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Over the last 10 years, research has highlighted emerging potential risk factors for poor outcomes following blunt chest wall trauma. The aim was to update a previous systematic review and meta-analysis of the risk factors for mortality in blunt chest wall trauma patients. METHODS A systematic review of English and non-English articles using MEDLINE, Embase and Cochrane Library from January 2010 to March 2022 was completed. Broad search terms and inclusion criteria were used. All observational studies were included if they investigated estimates of association between a risk factor and mortality for blunt chest wall trauma patients. Where sufficient data were available, ORs with 95% CIs were calculated using a Mantel-Haenszel method. Heterogeneity was assessed using the I2 statistic. RESULTS 73 studies were identified which were of variable quality (including 29 from original review). Identified risk factors for mortality following blunt chest wall trauma were: age 65 years or more (OR: 2.11; 95% CI 1.85 to 2.41), three or more rib fractures (OR: 1.96; 95% CI 1.69 to 2.26) and presence of pre-existing disease (OR: 2.86; 95% CI 1.34 to 6.09). Other new risk factors identified were: increasing Injury Severity Score, need for mechanical ventilation, extremes of body mass index and smoking status. Meta-analysis was not possible for these variables due to insufficient studies and high levels of heterogeneity. CONCLUSIONS The results of this updated review suggest that despite a change in demographics of trauma patients and subsequent emerging evidence over the last 10 years, the main risk factors for mortality in patients sustaining blunt chest wall trauma remained largely unchanged. A number of new risk factors however have been reported that need consideration when updating current risk prediction models used in the ED. PROSPERO REGISTRATION NUMBER CRD42021242063. Date registered: 29 March 2021. https://www.crd.york.ac.uk/PROSPERO/%23recordDetails.
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Affiliation(s)
- Ceri Battle
- Physiotherapy Department, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Kym Carter
- Swansea Trials Unit, Swansea University, Swansea, UK
| | - Luke Newey
- Physiotherapy Department, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Jacopo Davide Giamello
- School of Emergency Medicine, Università degli Studi di Torino Dipartimento di Scienze Mediche, Torino, Italy.,Department of Emergency Medicine, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Remo Melchio
- Department of Internal Medicine, Santa Croce e Carle Hospital, Cuneo, Italy
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Cull JD, Ewing A, Metcalf A, Kitchens D, Manning B. Isolated Rib Fractures in Elderly Falls: Not As Deadly As We Think. J Trauma Nurs 2022; 29:65-69. [PMID: 35275107 DOI: 10.1097/jtn.0000000000000637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rib fractures in elderly patients have been associated with high morbidity and mortality; however, many of these patients had substantial mechanisms of injury, which may have contributed to these high rates. OBJECTIVE The purpose of this study was to determine the morbidity and mortality of elderly patients with isolated rib fractures who fell from standing. METHODS A single-institution retrospective study was conducted in a Level I trauma center using the trauma registry and a separate elderly fall from standing database. Admitted patients 65 years or older who presented with rib fractures after a fall from January 2013 to June 2017 were included. Patients with a nonthoracic Abbreviated Injury Scale score greater than 2 were excluded from the study. RESULTS Of 129 patients with isolated rib fracture, 94% (n = 121) had comorbidities and 71% (n = 92) had two or more comorbidities. Almost half (41.9%; n = 54) were taking antiplatelet and anticoagulant medications, 78.3% (n = 101) were caused by a mechanical fall, and 7% (n = 9) were caused by syncope. Data showed 72.9% (n = 94) had three or more rib fractures. The mortality rate of patients was 3.9% (n = 5). Three patients had dementia at death, four had do-not-resuscitate order, and only two deaths were directly related to pulmonary status. Patients who developed pneumonia (14.7%; n = 19) and required mechanical ventilation for a median of 11 days (3.9%; n = 5) were fewer than those in in previous studies. CONCLUSION The morbidity and mortality associated with rib fractures are significantly less than reported in the literature when additional injuries are excluded.
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Affiliation(s)
- John D Cull
- Prisma Health-Upstate, University of South Carolina School of Medicine, Greenville, South Carolina
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Hassanipour S, Ghaem H, Seif M, Fararouei M, Sabetian G, Paydar S. Which criteria is a better predictor of ICU admission in trauma patients? An artificial neural network approach. Surgeon 2021; 20:e175-e186. [PMID: 34563451 DOI: 10.1016/j.surge.2021.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/02/2021] [Accepted: 08/19/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE One of the most critical concerns in the intensive care unit (ICU) section is identifying the best criteria for entering patients to this part. This study aimed to predict the best compatible criteria for entering trauma patients in the ICU section. METHOD The present study was a historical cohort study. The data were collected from 2448 trauma patients referring to Shahid Rajaee Hospital between January 2015 and January 2017 in Shiraz, Iran. The artificial neural network (ANN) models with cross-validation and logistic regression (LR) with a backward method was used for data analysis. The final analysis was performed on a total of 958 patients who were transferred to the ICU section. RESULTS Based on the present results, the motor component of the GCS score at each cutoff point had the highest importance. The results also showed better performance for the AUC and accuracy rate for ANN compared with LR. CONCLUSION The most critical indicators in predicting the optimal use of ICU services in this study were the Motor component of the GCS. Results revealed that the ANN had a better performance than the LR in predicting the main outcomes of the traumatic patients in both the accuracy and AUC index. Trauma section surgeons and ICU specialists will benefit from this study's results and can assist them in making decisions to predict the patient outcomes before entering the ICU.
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Affiliation(s)
- Soheil Hassanipour
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran; Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Haleh Ghaem
- Research Center for Health Sciences, Institute of Health, Non-communicable Diseases Research Center, Epidemiology Department, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Mozhgan Seif
- Department of Epidemiology, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Fararouei
- Department of Epidemiology, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Golnar Sabetian
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahram Paydar
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Are We Underestimating the Morbidity of Single Rib Fractures? J Surg Res 2021; 268:174-180. [PMID: 34329822 DOI: 10.1016/j.jss.2021.06.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/05/2021] [Accepted: 06/08/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE Previous studies suggest that patients with multiple rib fractures have poor outcomes, but it is unknown how isolated single rib fractures (SRF) are associated with morbidity or mortality. We hypothesized that patients with poor outcomes after SRF can be identified by demographics and comorbidities. The purpose of this study was to model adverse outcome after single rib fractures. MATERIALS AND METHODS We used the 2016 National Inpatient Sample to identify patients with SRF associated with blunt trauma using ICD-10 coding. Comorbidities and abbreviated injury score (AIS) were also extracted. Patients with non-chest trauma were excluded. The primary outcome was an adverse composite outcome of death, pneumonia, tracheostomy, or hospitalization longer than twelve days. One-third of the cohort was reserved for validation. Backward selection multivariable modeling identified factors associated with adverse composite outcome. The model was used to create a nomogram to predict adverse composite outcome. The nomogram was then tested using the validation cohort. RESULTS 2,398 patients with isolated SRF were divided into training (n = 1,598) and validation sets (n = 800). The average age was 69 and the majority were male (66%) and received care at academic institutions (61.6%). The adverse composite outcome occurred in 20.8%: 61 deaths (2.5%), 67 tracheostomies (2.8%), 319 pneumonias (13.3%), and 165 patients with hospital length of stay greater than twelve days (6.9%). Results of stepwise multivariable modeling had a C-statistic of 0.700. The multivariable model was used to create a nomogram which had a c-statistic of 0.672 in the validation cohort. CONCLUSION 20% of isolated SRF patients had an adverse outcome. Demographics and comorbidities can be used to identify and triage high-risk patients for specialized care and proper counseling.
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Goldstein C, Juthani B, Livingston DH, Glass NE, Sifri Z. Utilizing triage rates to improve ICU admission guidelines of elderly rib fracture patients. Am J Surg 2021; 223:126-130. [PMID: 34373083 DOI: 10.1016/j.amjsurg.2021.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/01/2021] [Accepted: 07/19/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Elderly rib fracture patients are generally admitted to an ICU which may result in overutilization of scarce resources. We hypothesized that this practice results in significant overtriage. METHODS Retrospective study of patients over age 70 with acute rib fracture(s) as sole indication for ICU admission. Primary outcomes were adverse events (intubation, pneumonia, death), which we classified as meriting ICU admission. We utilized Cribari matrices to calculate triage rates. RESULTS 101 patients met study criteria. 12% had adverse events occurring on average at day 5. Our undertriage rate was 6% and overtriage rate 87%. The 72 overtriaged patients utilized 295 total ICU days. Evaluating guideline modification, ≥3 fractures appears optimal. Changing to this would have liberated 50 ICU days with 3% undertriage. CONCLUSION Elderly patients with small numbers of rib fractures are overtriaged to ICUs. Modifying guidelines to ≥3 rib fractures will improve resource utilization and save ICU beds.
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Affiliation(s)
- Carma Goldstein
- Department of Surgery, Rutgers New Jersey Medical School, University Hospital Trauma Mezzanine, 150 Bergen Street, Newark, NJ, 07103, USA
| | - Biren Juthani
- Department of Surgery, Rutgers New Jersey Medical School, University Hospital Trauma Mezzanine, 150 Bergen Street, Newark, NJ, 07103, USA
| | - David H Livingston
- Department of Surgery, Rutgers New Jersey Medical School, University Hospital Trauma Mezzanine, 150 Bergen Street, Newark, NJ, 07103, USA
| | - Nina E Glass
- Department of Surgery, Rutgers New Jersey Medical School, University Hospital Trauma Mezzanine, 150 Bergen Street, Newark, NJ, 07103, USA
| | - Ziad Sifri
- Department of Surgery, Rutgers New Jersey Medical School, University Hospital Trauma Mezzanine, 150 Bergen Street, Newark, NJ, 07103, USA.
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Bowman JA, Nuño M, Jurkovich GJ, Utter GH. Association of Hospital-Level Intensive Care Unit Use and Outcomes in Older Patients With Isolated Rib Fractures. JAMA Netw Open 2020; 3:e2026500. [PMID: 33211110 PMCID: PMC7677756 DOI: 10.1001/jamanetworkopen.2020.26500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE The optimal level of care for older patients with rib fractures as an isolated injury is unknown. OBJECTIVES To characterize interhospital variability in intensive care unit (ICU) vs non-ICU admission of older patients with isolated rib fractures and to evaluate whether greater hospital-level use of ICU admission is associated with improved outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study included trauma patients aged 65 years and older with isolated rib fractures who were admitted to US trauma centers participating in the National Trauma Data Bank between January 1, 2015, and December 31, 2016. Patients were excluded if they had other significant injuries, were intubated or had assisted respirations in the emergency department (ED), or had a Glasgow Coma Scale (GCS) score of less than 9 in the ED. Hospitals with fewer than 10 eligible patients were excluded. Data analysis was conducted from May 2019 through September 2020. EXPOSURES Admission to the ICU. MAIN OUTCOMES AND MEASURES Composite of unplanned intubation, pneumonia, or death during hospitalization. RESULTS Among 23 951 patients (11 066 [46.2%] women; mean [SD] age, 77.0 [7.2] years) at 573 hospitals, the median (interquartile range) proportion of ICU use was 16.7% (7.4%-32.0%), but this varied from a low of 0% to a high of 91.9%. The composite outcome occurred in 787 patients (3.3%), with unplanned intubation in 317 (1.3%), pneumonia in 180 (0.8%), and death in 451 (1.9%). Accounting for the hierarchical nature of the data and adjusting for propensity scores reflecting factors associated with ICU admission, receiving care at a hospital with the greatest ICU use (quartile 4), compared with a hospital with the lowest ICU use, was associated with decreased likelihood of the composite outcome (adjusted odds ratio, 0.71; 95% CI, 0.55-0.92). CONCLUSIONS AND RELEVANCE In this study, admission location of older patients with isolated rib fractures was variable across hospitals, but hospitalization at a center with greater ICU use was associated with improved outcomes. It may be warranted for hospitals with low ICU use to admit more such patients to an ICU.
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Affiliation(s)
| | - Miriam Nuño
- Department of Surgery, University of California, Davis
- Department of Public Health Sciences, University of California, Davis
- Department of Surgery Outcomes Research Group, University of California, Davis
| | - Gregory J. Jurkovich
- Department of Surgery, University of California, Davis
- Department of Surgery Outcomes Research Group, University of California, Davis
| | - Garth H. Utter
- Department of Surgery Outcomes Research Group, University of California, Davis
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California, Davis
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11
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Spirometry not pain level predicts outcomes in geriatric patients with isolated rib fractures. J Trauma Acute Care Surg 2020; 89:947-954. [PMID: 32467465 DOI: 10.1097/ta.0000000000002795] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Geriatric patients with rib fractures are at risk for developing complications and are often admitted to a higher level of care (intensive care units [ICUs]) based on existing guidelines. Forced vital capacity (FVC) has been shown to correlate with outcomes in patients with rib fractures. Complete spirometry may quantify pulmonary capacity, predict outcome, and potentially assist with admission triage decisions. METHODS We prospectively enrolled 86 patients, 60 years or older with three or more isolated rib fractures presenting after injury. After informed consent, patients were assessed with respect to pain (visual analog scale), grip strength, FVC, forced expiratory volume 1 second (FEV1), and negative inspiratory force on hospital days 1, 2, and 3. Outcomes included discharge disposition, length of stay (LOS), pneumonia, intubation, and unplanned ICU admission. RESULTS Mean age was 77.4 (SD, 10.2) and 43 (50.0%) were female. Forty-five patients (55.6%) were discharged home, median LOS was 4 days (interquartile range, 3-7). Pneumonias (2), unplanned ICU admissions (3), and intubation (1) were infrequent. Spirometry measures including FVC, FEV1, and grip strength predicted discharge to home and FEV1, and pain level on day 1 moderately correlated with the LOS. Within each subject, FVC, FEV1, and negative inspiratory force did not change for 3 days despite pain at rest and pain after spirometry improving from day 1 to 3 (p = 0.002, p < 0.001 respectively). Change in pain also did not predict outcomes and pain level was not associated with respiratory volumes on any of the 3 days. After adjustment for confounders, FEV1 remained a significant predictor of discharge home (odds ratio, 1.03; 95% confidence interval, 1.01-1.06) and LOS (p = 0.001). CONCLUSION Spirometry measurements early in the hospital stay predict ultimate discharge home, and this may allow immediate or early discharge. The impact of pain control on pulmonary function requires further study. LEVEL OF EVIDENCE Diagnostic test, level IV.
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