Vasopressor use following traumatic injury - A single center retrospective study

Objectives

Vasopressors are not recommended by current trauma guidelines, but recent reports indicate that they are commonly used. We aimed to describe the early hemodynamic management of trauma patients outside densely populated urban centers.

Methods

We conducted a single-center retrospective cohort study in a Canadian regional trauma center. All adult patients treated for traumatic injury in 2013 who died within 24 hours of admission or were transferred to the intensive care unit were included. A systolic blood pressure <90 mmHg, a mean arterial pressure <60 mmHg, the use of vasopressors or ≥2 L of intravenous fluids defined hemodynamic instability. Main outcome measures were use of intravenous fluids and vasopressors prior to surgical or endovascular management.

Results

Of 111 eligible patients, 63 met our criteria for hemodynamic instability. Of these, 60 (95%) had sustained blunt injury and 22 (35%) had concomitant severe traumatic brain injury. The subgroup of patients referred from a primary or secondary hospital (20 of 63, 32%) had significantly longer transport times (243 vs. 61 min, p<0.01). Vasopressors, used in 26 patients (41%), were independently associated with severe traumatic brain injury (odds ratio 10.2, 95% CI 2.7–38.5).

Conclusions

In this cohort, most trauma patients had suffered multiple blunt injuries. Patients were likely to receive vasopressors during the early phase of trauma care, particularly if they exhibited signs of neurologic injury. While these results may be context-specific, determining the risk-benefit trade-offs of fluid resuscitation, vasopressors and permissive hypotension in specific patients subgroups constitutes a priority for trauma research going forwards.

The outcomes of the elderly in acute care general surgery

INTRODUCTION

Elderly patients form a growing subset of the acute care surgery (ACS) population. Older age may be associated with poorer outcomes for some elective procedures, but there are few studies focusing on outcomes for the elderly ACS population. Our objective is to characterize differences in mortality and morbidity for acute care surgery patients >80 years old.

METHODS

A retrospective review of all ACS admissions at a large teaching hospital over 1 year was conducted. Patients were classified into non-elderly (<80 years old) and elderly (≥80 years old). In addition to demographic differences, outcomes including care efficiency, mortality, postoperative complications, and length of stay were studied. Data analysis was completed with the Student's t test for continuous variables and Fisher's exact test for categorical variables using STATA 12 (College Station, TX, USA).

RESULTS

We identified 467 non-elderly and 60 elderly patients with a mean age-adjusted Charlson score of 3.2 and 7.2, respectively (p < 0.001) and a mortality risk of 1.9 and 11.7 %, respectively (p < 0.001). The elderly were at risk of longer duration (>4 days) hospital stay (p = 0.05), increased postoperative complications (p = 0.002), admission to the ICU (p = 0.002), and were more likely to receive a non-operative procedure (p = 0.003). No difference was found (p = NS) for patient flow factors such as time to consult general surgery, time to see consult by general surgery, and time to operative management and disposition.

CONCLUSIONS

Compared to younger patients admitted to an acute care surgery service, patients over 80 years old have a higher risk of complications, are more likely to require ICU admission, and stay longer in the hospital.

Predictors of mortality and morbidity for acute care surgery patients

BACKGROUND

As the implementation of exclusive acute care surgery (ACS) services thrives, prognostication for mortality and morbidity will be important to complement clinical management of these diverse and complex patients. Our objective is to investigate prognostic risk factors from patient level characteristics and clinical presentation to predict outcomes including mortality, postoperative complications, intensive care unit (ICU) admission and prolonged duration of hospital stay.

METHODS

Retrospective review of all emergency general surgery admissions over a 1-year period at a large teaching hospital was conducted. Factors collected included history of present illness, physical exam and laboratory parameters at presentation. Univariate analysis was performed to examine the relationship between each variable and our outcomes with chi-square for categorical variables and the Wilcoxon rank-sum statistic for continuous variables. Multivariate analysis was performed using backward stepwise logistic regression to evaluate for independent predictors.

RESULTS

A total of 527 ACS admissions were identified with 8.1% requiring ICU stay and an overall crude mortality rate of 3.04%. Operative management was required in 258 patients with 22% having postoperative complications. Use of anti-coagulants, systolic blood pressure <90, hypothermia and leukopenia were independent predictors of in-hospital mortality. Leukopenia, smoking and tachycardia at presentation were also prognostic for the development of postoperative complications. For ICU admission, use of anti-coagulants, leukopenia, leukocytosis and tachypnea at presentation were all independent predictive factors. A prolonged length of stay was associated with increasing age, higher American Society of Anesthesiologists class, tachycardia and presence of complications on multivariate analysis.

CONCLUSIONS

Factors present at initial presentation can be used to predict morbidity and mortality in ACS patients.