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Masterson M, Hunter K, Egodage T. Clinical Outcomes After Early Palliative Care Evaluations in Geriatric Trauma Intensive Care. J Surg Res 2024; 302:359-363. [PMID: 39153356 DOI: 10.1016/j.jss.2024.07.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 07/02/2024] [Accepted: 07/07/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION Older trauma patients are at risk for worse outcomes compared to younger patients. We hypothesized that early initiation of palliative care (EPC) evaluations, within 72 h of trauma intensive care unit (ICU) admission, would be associated with reduced invasive procedures without a change in hospital mortality. METHODS A retrospective cohort review was performed of all trauma patients aged ≥65 y admitted to the trauma (ICU) from January 1, 2016, to December 31, 2021. Patients who received formal palliative care assessments were included. Patient demographics and injury characteristics were evaluated. The primary outcome was ICU length of stay (LOS). Secondary outcomes included code status change, tracheostomy or percutaneous endoscopic gastrostomy placement, use and length of mechanical ventilation, in-hospital mortality, and withdrawal of life-sustaining care. RESULTS Two hundred twenty-five patients met inclusion. One hundred and six had EPC while 119 had late palliative care. EPC was associated with decreased ICU LOS (3 versus 9 d, P < 0.001), hospital LOS (3 versus 11 d, P < 0.001), and days on mechanical ventilation (P < 0.001), and fewer tracheostomy (P = 0.007) and percutaneous endoscopic gastrostomy tubes (P = 0.049). There was no difference in withdrawal of life-sustaining care (P = 0.581) or in-hospital mortality (P = 0.172). Pre-existing code status or code status clarification early in admission was associated with EPC (P = 0.003) and decreased interventions. CONCLUSIONS EPC is associated with decreased LOS and fewer invasive procedures without a change in hospital mortality. Early discussions regarding code status are helpful in decreasing hospital costs and futile interventions. Further investigation is required to standardize palliative care in this population.
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Affiliation(s)
- Monica Masterson
- Cooper Medical School of Rowan University, Cooper University Health Care, Camden, New Jersey.
| | - Krystal Hunter
- Cooper Medical School of Rowan University, Cooper University Health Care, Camden, New Jersey
| | - Tanya Egodage
- Cooper Medical School of Rowan University, Cooper University Health Care, Camden, New Jersey
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De Simone B, Chouillard E, Podda M, Pararas N, de Carvalho Duarte G, Fugazzola P, Birindelli A, Coccolini F, Polistena A, Sibilla MG, Kruger V, Fraga GP, Montori G, Russo E, Pintar T, Ansaloni L, Avenia N, Di Saverio S, Leppäniemi A, Lauretta A, Sartelli M, Puzziello A, Carcoforo P, Agnoletti V, Bissoni L, Isik A, Kluger Y, Moore EE, Romeo OM, Abu-Zidan FM, Beka SG, Weber DG, Tan ECTH, Paolillo C, Cui Y, Kim F, Picetti E, Di Carlo I, Toro A, Sganga G, Sganga F, Testini M, Di Meo G, Kirkpatrick AW, Marzi I, déAngelis N, Kelly MD, Wani I, Sakakushev B, Bala M, Bonavina L, Galante JM, Shelat VG, Cobianchi L, Mas FD, Pikoulis M, Damaskos D, Coimbra R, Dhesi J, Hoffman MR, Stahel PF, Maier RV, Litvin A, Latifi R, Biffl WL, Catena F. The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg 2024; 19:18. [PMID: 38816766 PMCID: PMC11140935 DOI: 10.1186/s13017-024-00537-8] [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: 01/05/2024] [Accepted: 02/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency Minimally Invasive Surgery, Academic Hospital of Villeneuve St Georges, Villeneuve St Georges, France.
- Department of General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- General Surgery Department, American Hospital of Paris, Paris, France.
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Nikolaos Pararas
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Paola Fugazzola
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
| | | | | | - Andrea Polistena
- Department of Surgery, Policlinico Umberto I Roma, Sapienza University, Rome, Italy
| | - Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vitor Kruger
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Emanuele Russo
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Tadeja Pintar
- UMC Ljubljana and Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Luca Ansaloni
- New Zealand Blood Service, Christchurch, New Zealand
| | - Nicola Avenia
- Endocrine Surgical Unit - University of Perugia, Terni, Italy
| | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Lauretta
- Department of Surgical Oncology, Centro Di Riferimento Oncologico Di Aviano IRCCS, Aviano, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Alessandro Puzziello
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Campus Universitario di Baronissi (SA) - Università di Salerno, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vanni Agnoletti
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Luca Bissoni
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Oreste Marco Romeo
- Bronson Methodist Hospital/Western Michigan University, Kalamazoo, MI, USA
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates
| | | | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital and The University of Western Australia, Perth, Australia
| | - Edward C T H Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ciro Paolillo
- Emergency Department, Ospedale Civile Maggiore, Verona, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Fernando Kim
- University of Colorado Anschutz Medical Campus, Denver, CO, 80246, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Adriana Toro
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Federica Sganga
- Department of Geriatrics, Ospedale Sant'Anna, Ferrara, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Nicola déAngelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | | | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Lorenzo Cobianchi
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Manos Pikoulis
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | | | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melissa Red Hoffman
- Department of Surgery, University of North Carolina, Surgical Palliative Care Society, Asheville, NC, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Rifat Latifi
- University of Arizona, Tucson, AZ, USA
- Abrazo Health West Campus, Goodyear, Tucson, AZ, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
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Duncan AJ, Holkup LM, Sang HI, Sahr SM. Benefits of Early Utilization of Palliative Care Consultation in Trauma Patients. Crit Care Explor 2023; 5:e0963. [PMID: 37649850 PMCID: PMC10465097 DOI: 10.1097/cce.0000000000000963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVES To determine the effects of palliative care consultation if performed within 72 hours of admission on length of stay (LOS), mortality, and invasive procedures. DESIGN Retrospective observational study. SETTING Single-center level 1 trauma center. PATIENTS Trauma patients, admitted to ICU with palliative care consultation. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The ICU LOS was decreased in the early palliative care (EPC) group compared with the late palliative care (LPC) group, by 6 days versus 12 days, respectively. Similarly, the hospital LOS was also shorter in the EPC group by 8 days versus 17 days in the LPC group. In addition, the EPC group had lower rates of tracheostomy (4% vs 14%) and percutaneous gastrostomy tubes (4% vs 15%) compared with the LPC group. There was no difference in mortality or discharge disposition between patients in the EPC versus LPC groups. It is noteworthy that the patients who received EPC were slightly older, but there were no other significant differences in demographics. CONCLUSIONS EPC is associated with fewer procedures and a shorter amount of time spent in the hospital, with no immediate effect on mortality. These outcomes are consistent with studies that show patients' preferences toward the end of life, which typically involve less time in the hospital and fewer invasive procedures.
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Affiliation(s)
- Anthony J Duncan
- Department of Surgery, University of North Dakota, Grand Forks, ND
- Sanford Medical Center Department of Trauma and Acute Care Surgery, Fargo, ND
| | - Lucas M Holkup
- Department of Surgery, University of North Dakota, Grand Forks, ND
- Sanford Medical Center Department of Trauma and Acute Care Surgery, Fargo, ND
| | - Hilla I Sang
- Sanford Medical Center Department of Trauma and Acute Care Surgery, Fargo, ND
| | - Sheryl M Sahr
- Department of Surgery, University of North Dakota, Grand Forks, ND
- Sanford Medical Center Department of Trauma and Acute Care Surgery, Fargo, ND
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Spencer AL, Nunn AM, Miller PR, Russell GB, Carmichael SP, Neri KE, Marterre B. The value of compassion: Healthcare savings of palliative care consults in trauma. Injury 2023; 54:249-255. [PMID: 36307268 PMCID: PMC11210453 DOI: 10.1016/j.injury.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/03/2022] [Accepted: 10/18/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The effects of palliative care (PC) consultation on patient costs and hospitalization metrics in the adult trauma population are unclear. STUDY DESIGN We interrogated our Level I trauma center databases from 1/1/19 to 3/31/21 for patients age ≥18 admitted to the trauma service. Patients undergoing PC consult were matched using propensity scoring to those without PC consultation based on age, admission Glasgow Coma Scale score, Injury Severity Score and Head Abbreviated Injury Scale. Total costs, total cost per day, hospital length of stay (LOS), ICU LOS, intubation days, discharge disposition, and rates of nephrology consultation and tracheostomy/feeding tube placements were compared. RESULTS 140 unique patients underwent PC consultation and were matched to a group not receiving PC consult during the same period. Median total costs in the PC cohort were $39,532 compared to $70,330 in the controls (p<0.01). Median costs per day in the PC cohort were $3,495 vs $17,970 in the controls (p<0.01). Median costs per ICU day in the PC cohort were $3,774 vs $17,127 in the controls (p<0.01). Mean hospital LOS (15.7 vs 7 days), ICU LOS (7.9 vs 2.9 days), and ventilator days (5.1 vs 1.5) were significantly higher in the PC cohort (all p<0.01). Rates of nephrology consultation (8.6 vs 2.1%, p = 0.03) and tracheostomy/feeding tube placements (12.1 vs 1.4%, p<0.01) were also higher in the PC group. Patients were more likely to discharge to hospice if they received a PC consult (33.6 vs 2.1%, p<0.01). Mean time to PC consult was 7.2 days (range 1 hour to 45 days). LOS post-consult correlated positively with time to PC consultation (r = 0.27, p<0.01). CONCLUSION Expert PC services are known to alleviate suffering and avert patient goal- and value-incongruent care. While trauma patients demand significant resources, PC consultation offered in concordance with life-sustaining interventions is associated with significant savings to patients and the healthcare system. Given the correlation between LOS following PC consult and time to PC consult, savings may be amplified by earlier PC consultation in appropriate patients.
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Affiliation(s)
- Audrey L Spencer
- Department of Surgery, University of Arizona College of Medicine, 1501 North Campbell Avenue, Room 5411, Tower 4, Tucson, AZ 85724, United States of America.
| | - Andrew M Nunn
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Preston R Miller
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Gregory B Russell
- Department of Biostatistics & Data Science, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Samuel P Carmichael
- Department of Surgery, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Kristina E Neri
- Wake Forest University School of Medicine, Bowman Gray Center for Medical Education, 475 Vine Street, Winston-Salem, NC 27101, United States of America.
| | - Buddy Marterre
- Departments of Surgery & Internal Medicine, Atrium Health Wake Forest Baptist, 1 Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
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Yue JK, Kobeissy FH, Jain S, Sun X, Phelps RR, Korley FK, Gardner RC, Ferguson AR, Huie JR, Schneider AL, Yang Z, Xu H, Lynch CE, Deng H, Rabinowitz M, Vassar MJ, Taylor SR, Mukherjee P, Yuh EL, Markowitz AJ, Puccio AM, Okonkwo DO, Diaz-Arrastia R, Manley GT, Wang KK. Neuroinflammatory Biomarkers for Traumatic Brain Injury Diagnosis and Prognosis: A TRACK-TBI Pilot Study. Neurotrauma Rep 2023; 4:171-183. [PMID: 36974122 PMCID: PMC10039275 DOI: 10.1089/neur.2022.0060] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
The relationship between systemic inflammation and secondary injury in traumatic brain injury (TBI) is complex. We investigated associations between inflammatory markers and clinical confirmation of TBI diagnosis and prognosis. The prospective TRACK-TBI Pilot (Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot) study enrolled TBI patients triaged to head computed tomography (CT) and received blood draw within 24 h of injury. Healthy controls (HCs) and orthopedic controls (OCs) were included. Thirty-one inflammatory markers were analyzed from plasma. Area under the receiver operating characteristic curve (AUC) was used to evaluate discriminatory ability. AUC >0.7 was considered acceptable. Criteria included: TBI diagnosis (vs. OC/HC); moderate/severe vs. mild TBI (Glasgow Coma Scale; GCS); radiographic TBI (CT positive vs. CT negative); 3- and 6-month Glasgow Outcome Scale-Extended (GOSE) dichotomized to death/greater relative disability versus less relative disability (GOSE 1-4/5-8); and incomplete versus full recovery (GOSE <8/ = 8). One-hundred sixty TBI subjects, 28 OCs, and 18 HCs were included. Markers discriminating TBI/OC: HMGB-1 (AUC = 0.835), IL-1b (0.795), IL-16 (0.784), IL-7 (0.742), and TARC (0.731). Markers discriminating GCS 3-12/13-15: IL-6 (AUC = 0.747), CRP (0.726), IL-15 (0.720), and SAA (0.716). Markers discriminating CT positive/CT negative: SAA (AUC = 0.767), IL-6 (0.757), CRP (0.733), and IL-15 (0.724). At 3 months, IL-15 (AUC = 0.738) and IL-2 (0.705) discriminated GOSE 5-8/1-4. At 6 months, IL-15 discriminated GOSE 1-4/5-8 (AUC = 0.704) and GOSE <8/ = 8 (0.711); SAA discriminated GOSE 1-4/5-8 (0.704). We identified a profile of acute circulating inflammatory proteins with potential relevance for TBI diagnosis, severity differentiation, and prognosis. IL-15 and serum amyloid A are priority markers with acceptable discrimination across multiple diagnostic and outcome categories. Validation in larger prospective cohorts is needed. ClinicalTrials.gov Registration: NCT01565551.
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Affiliation(s)
- John K. Yue
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
- Address correspondence to: John K. Yue, MD, Department of Neurosurgery, University of California, San Francisco, 1001 Potrero Avenue, Building 1, Room 101, San Francisco, CA 94143, USA.
| | - Firas H. Kobeissy
- Departments of Emergency Medicine, Psychiatry, Neuroscience, and Chemistry, University of Florida, Gainesville, Florida, USA
- McKnight Brain Institute, University of Florida, Gainesville, Florida, USA
- Center for Neurotrauma, Multiomics and Biomarkers, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Sonia Jain
- Division of Biostatistics and Bioinformatics, Departments of Family Medicine and Public Health, University of California, San Diego, San Diego, California, USA
| | - Xiaoying Sun
- Division of Biostatistics and Bioinformatics, Departments of Family Medicine and Public Health, University of California, San Diego, San Diego, California, USA
| | - Ryan R.L. Phelps
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Frederick K. Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Raquel C. Gardner
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Adam R. Ferguson
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - J. Russell Huie
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Andrea L.C. Schneider
- Department of Neurology, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Zhihui Yang
- Departments of Emergency Medicine, Psychiatry, Neuroscience, and Chemistry, University of Florida, Gainesville, Florida, USA
- McKnight Brain Institute, University of Florida, Gainesville, Florida, USA
| | - Haiyan Xu
- Departments of Emergency Medicine, Psychiatry, Neuroscience, and Chemistry, University of Florida, Gainesville, Florida, USA
- McKnight Brain Institute, University of Florida, Gainesville, Florida, USA
| | - Cillian E. Lynch
- Department of Neurology, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Hansen Deng
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Miri Rabinowitz
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mary J. Vassar
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Sabrina R. Taylor
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Esther L. Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Amy J. Markowitz
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Ava M. Puccio
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David O. Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Geoffrey T. Manley
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Kevin K.W. Wang
- Departments of Emergency Medicine, Psychiatry, Neuroscience, and Chemistry, University of Florida, Gainesville, Florida, USA
- McKnight Brain Institute, University of Florida, Gainesville, Florida, USA
- Center for Neurotrauma, Multiomics and Biomarkers, Morehouse School of Medicine, Atlanta, Georgia, USA
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Retrospective Review of Trauma ICU Patients With and Without Palliative Care Intervention. J Am Coll Surg 2022; 235:278-284. [PMID: 35839403 DOI: 10.1097/xcs.0000000000000220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Older trauma patients present with poor preinjury functional status and more comorbidities. Advances in care have increased the chance of survival from previously fatal injuries with many left debilitated with chronic critical illness and severe disability. Palliative care (PC) is ideally suited to address the goals of care and symptom management in this critically ill population. A retrospective chart review was done to identify the impact of PC consults on hospital length of stay (LOS), ICU LOS, and surgical decisions. STUDY DESIGN A Level 1 Trauma Center Registry was used to identify adult patients who were provided PC consultation in a selected 3-year time period. These PC patients were matched with non-PC trauma patients on the basis of age, sex, race, Glasgow Coma Scale, and Injury Severity Score. Chi-square tests and Student's t-tests were used to analyze categorical and continuous variables, respectively. Any p value >0.05 was considered statistically significant. RESULTS PC patients were less likely to receive a percutaneous endoscopic gastric tube or tracheostomy. PC patients spent less time on ventilator support, spent less time in the ICU, and had a shorter hospital stay. PC consultation was requested 16.48 days into the patient's hospital stay. Approximately 82% of consults were to assist with goals of care. CONCLUSION Specialist PC team involvement in the care of the trauma ICU patients may have a beneficial impact on hospital LOS, ICU LOS, and surgical care rendered. Earlier consultation during hospitalization may lead to higher rates of goal-directed care and improved patient satisfaction.
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Newsome K, Sauder M, Spardy J, Kodadek L, Ang D, Michetti CP, Bilski T, Elkbuli A. Palliative Care in the Trauma and Surgical Critical Care Settings: A Narrative Review. Am Surg 2022:31348221101597. [PMID: 35574733 DOI: 10.1177/00031348221101597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND We aimed to conduct a narrative review of available literature to understand the use of palliative care in the trauma and surgical critical care setting. METHODS PubMed, EMBASE, and Google Scholar databases were searched for studies investigating the use of palliative care in the trauma and surgical critical care setting. The search included all studies published through January 9th, 2022. The risk of bias of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Outcomes were summarized in tables and synthesized qualitatively. RESULTS A total of 22 studies were included in this review. Key elements of successful palliative care include communication, shared decision-making, family involvement, pain control, establishing a patient's prognosis, and end-of-life management. Approaches to implementation based upon these key elements include best-case/worst-case scenarios, consultation trigger systems, and integrated institutional palliative care programs. Palliative care may reduce hospital length of stay, improve symptom management, and increase patient satisfaction, but the impact on mortality is unclear. CONCLUSION The core elements of palliative care have been identified and palliative care has been shown to improve outcomes in trauma and surgical critical care. However, the approaches for implementation still require development. The underutilization of palliative care for trauma patients reveals the need for refining criteria for use of palliative care and improvement in the education of surgical critical care teams to provide primary palliative care services.
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Affiliation(s)
- Kevin Newsome
- Florida International University, 158263Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Matthew Sauder
- NSU NOVA Southeastern University, 2814Dr Kiran, C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Jeffrey Spardy
- Florida International University, 158263Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Lisa Kodadek
- Department of Surgery, 12228Yale School of Medicine, New Haven, CT, USA
| | - Darwin Ang
- Department of Surgery, Division of Trauma and Surgical Critical Care, 23703Ocala Regional Medical Center, Ocala, FL, USA
| | | | - Tracy Bilski
- Department of Surgery, Division of Trauma and Surgical Critical Care, 25105Orlando Regional Medical Center, Orlando, FL, USA.,Department of Surgical Education, 25105Orlando Regional Medical Center, Orlando, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 25105Orlando Regional Medical Center, Orlando, FL, USA.,Department of Surgical Education, 25105Orlando Regional Medical Center, Orlando, FL, USA
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Lin PC, Wu NC, Su HC, Hsu CC, Chen KT. Comprehensive comparison between geriatric and nongeriatric patients with trauma. Medicine (Baltimore) 2022; 101:e28913. [PMID: 35363212 PMCID: PMC9281953 DOI: 10.1097/md.0000000000028913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 12/29/2021] [Indexed: 01/04/2023] Open
Abstract
The incidence of geriatric trauma is increasing due to the growing elderly population. Healthcare providers require a global perspective to differentiate critical factors that might alter patients' prognosis.We retrospectively reviewed all adult patients admitted to a trauma center during a 4-year period. We identified 655 adult trauma patients aged from 18 to 64 (nongeriatric group) and 273 trauma patients ≥65 years (geriatric group). Clinical data were collected and compared between the 2 groups.The geriatric group had a higher incidence of trauma and higher Injury Severity Scores than did the nongeriatric group. Fewer geriatric patients underwent surgical treatment (all patients: geriatric vs nongeriatric: 65.9% vs 70.7%; patients with severe trauma: geriatric vs nongeriatric: 27.6% vs 44.5%). Regarding prognosis, the geriatric group exhibited higher mortality rate and less need for long-term care (geriatric vs nongeriatric: mortality: 5.5% vs 1.8%; long-term care: 2.2% vs 5.0%).We observed that geriatric patients had higher trauma incidence and higher trauma mortality rate. Aging is a definite predictor of poor outcomes for trauma patients. Limited physiological reserves and preference for less aggressive treatment might be the main reasons for poor outcomes in elderly individuals.
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Affiliation(s)
- Pei-Chen Lin
- Graduate Institute of Biomedical Informatics, College of Medicine Science and Technology, Taipei Medical University, Taipei, Taiwan
- Emergency Department, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Nan-Chun Wu
- Division of Traumatology, Department of Surgery, Chi-Mei Medical Center, Tainan, Taiwan
| | - Hsiu-Chen Su
- Division of Traumatology, Department of Surgery, Chi-Mei Medical Center, Tainan, Taiwan
| | - Chien-Chin Hsu
- Emergency Department, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Biotechnology, Southern Tainan University of Technology, Tainan, Taiwan
| | - Kuo-Tai Chen
- Emergency Department, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Abstract
BACKGROUND Similar to the significant rise in the geriatric population in the United States, trauma centers have seen an increase in geriatric trauma patients. These patients present with additional challenges such as a higher likelihood of undertriage, mortality, and frailty. In addition, the varying presence of advanced directive documentation increases the importance of early palliative care consultations for geriatric trauma patients. OBJECTIVE In 2018, a Level I trauma center in the Midwest reviewed the American College of Surgeons Trauma Quality Improvement Program's Palliative Care Best Practice Guideline to identify opportunities for improvement to strengthen the collaboration between the palliative care consult service and trauma program. METHODS The guideline drove improvements, which included documentation changes (i.e., expansion of palliative care consultation triggers, frailty assessment, advanced directives questions, depression screening, and addition of palliative care consultation section on the performance improvement program form) and training (1-hr lecture on palliative care and 5-hr palliative care simulation training) opportunities. RESULTS A 3-month manual chart review (March 2019 through May 2019) revealed that by May 2019, 87.2% of admitted geriatric trauma patients received frailty assessments, which surpassed the benchmark (≥85%). In addition, advanced care planning questions (i.e., health care power of attorney, do not resuscitate order, or living will) exceeded the benchmarks set forth by the guideline (≥90%), with all of the questions being asked and documented in 95.7% of those same patient charts by May 2019. CONCLUSION This quality improvement project has applicability for trauma centers that treat geriatric trauma patients; using the guidelines can drive changes to meet individual institution needs.
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Doppmann P, Meuli L, Sollid SJM, Filipovic M, Knapp J, Exadaktylos A, Albrecht R, Pietsch U. End-tidal to arterial carbon dioxide gradient is associated with increased mortality in patients with traumatic brain injury: a retrospective observational study. Sci Rep 2021; 11:10391. [PMID: 34001982 PMCID: PMC8129079 DOI: 10.1038/s41598-021-89913-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/26/2021] [Indexed: 11/16/2022] Open
Abstract
Early definitive airway protection and normoventilation are key principles in the treatment of severe traumatic brain injury. These are currently guided by end tidal CO2 as a proxy for PaCO2. We assessed whether the difference between end tidal CO2 and PaCO2 at hospital admission is associated with in-hospital mortality. We conducted a retrospective observational cohort study of consecutive patients with traumatic brain injury who were intubated and transported by Helicopter Emergency Medical Services to a Level 1 trauma center between January 2014 and December 2019. We assessed the association between the CO2 gap-defined as the difference between end tidal CO2 and PaCO2-and in-hospital mortality using multivariate logistic regression models. 105 patients were included in this study. The mean ± SD CO2 gap at admission was 1.64 ± 1.09 kPa and significantly greater in non-survivors than survivors (2.26 ± 1.30 kPa vs. 1.42 ± 0.92 kPa, p < .001). The correlation between EtCO2 and PaCO2 at admission was low (Pearson's r = .287). The mean CO2 gap after 24 h was only 0.64 ± 0.82 kPa, and no longer significantly different between non-survivors and survivors. The multivariate logistic regression model showed that the CO2 gap was independently associated with increased mortality in this cohort and associated with a 2.7-fold increased mortality for every 1 kPa increase in the CO2 gap (OR 2.692, 95% CI 1.293 to 5.646, p = .009). This study demonstrates that the difference between EtCO2 and PaCO2 is significantly associated with in-hospital mortality in patients with traumatic brain injury. EtCO2 was significantly lower than PaCO2, making it an unreliable proxy for PaCO2 when aiming for normocapnic ventilation. The CO2 gap can lead to iatrogenic hypoventilation when normocapnic ventilation is aimed and might thereby increase in-hospital mortality.
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Affiliation(s)
- Pascal Doppmann
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St, Rorschacher Strasse 95, 9007, GallenSt. Gallen, Switzerland
| | - Lorenz Meuli
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Miodrag Filipovic
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St, Rorschacher Strasse 95, 9007, GallenSt. Gallen, Switzerland
| | - Jürgen Knapp
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Aristomenis Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, FreiburgstrasseBern, Switzerland
| | - Roland Albrecht
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St, Rorschacher Strasse 95, 9007, GallenSt. Gallen, Switzerland
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, FreiburgstrasseBern, Switzerland
- Swiss Air-Ambulance, Rega (RettungsFlugwacht/Guarde Aérienne), Postfach 1414, 8058, Zurich, Switzerland
| | - Urs Pietsch
- Department of Anaesthesiology and Intensive Care Medicine, Cantonal Hospital St, Rorschacher Strasse 95, 9007, GallenSt. Gallen, Switzerland.
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, FreiburgstrasseBern, Switzerland.
- Swiss Air-Ambulance, Rega (RettungsFlugwacht/Guarde Aérienne), Postfach 1414, 8058, Zurich, Switzerland.
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12
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Maurer LR, Sakran JV, Kaafarani HM. Predicting and Communicating Geriatric Trauma Outcomes. CURRENT TRAUMA REPORTS 2021. [DOI: 10.1007/s40719-020-00209-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Esquibel BM, Waller CJ, Borgert AJ, Kallies KJ, Harter TD, Cogbill TH. The role of palliative care in acute trauma: When is it appropriate? Am J Surg 2020; 220:1456-1461. [PMID: 33051066 DOI: 10.1016/j.amjsurg.2020.10.002] [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: 03/27/2020] [Revised: 08/21/2020] [Accepted: 10/04/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION We hypothesized that trauma providers are reticent to consider palliative measures in acute trauma care. METHODS An electronic survey based on four patient scenarios with identical vital signs and serious blunt injuries, but differing ages and frailty scores was sent to WTA and EAST members. RESULTS 509 (24%) providers completed the survey. Providers supported early transition to comfort care in 85% old-frail, 53% old-fit, 77% young-frail, and 30% young-fit patients. Providers were more likely to transition frail vs. fit patients with (OR = 4.8 [3.8-6.3], p < 0.001) or without (OR = 16.7 [12.5-25.0], p < 0.001) an advanced directive (AD) and more likely to transition old vs. young patients with (OR = 2.0 [1.6-2.6], p < 0.001) or without (OR = 4.2 [2.8-5.0], p < 0.001) an AD. CONCLUSIONS In specific clinical situations, there was wide acceptance among trauma providers for the early institution of palliative measures. Provider decision-making was primarily based on patient frailty and age. ADs were helpful for fit or young patients. Provider demographics did not impact decision-making.
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Affiliation(s)
- Brendon M Esquibel
- General Surgery Residency, Department of Medical Education, Gundersen Health System, La Crosse, WI, USA
| | - Christine J Waller
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA.
| | - Andrew J Borgert
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA
| | - Kara J Kallies
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA
| | - Thomas D Harter
- Department of Bioethics and Humanities, Gundersen Health System, La Crosse, WI, USA
| | - Thomas H Cogbill
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA
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Surgery and Palliative Care: A Shared History and Integrated Future. Jt Comm J Qual Patient Saf 2020; 46:491-492. [PMID: 32682693 DOI: 10.1016/j.jcjq.2020.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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