1
|
Yamaguchi K, Abe T, Matsumoto S, Nakajima K, Shimizu M, Takeuchi I. Laparoscopy for emergency abdominal surgery is associated with reduced physical functional decline in older patients: a cohort study. BMC Geriatr 2024; 24:250. [PMID: 38475701 DOI: 10.1186/s12877-024-04872-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND An increasing number of older patients require emergency abdominal surgery for acute abdomen. They are susceptible to surgical stress and lose their independence in performing daily activities. Laparoscopic surgery is associated with faster recovery, less postoperative pain, and shorter hospital stay. However, few studies have examined the relationship between laparoscopic surgery and physical functional decline. Thus, we aimed to examine the relationship between changes in physical function and the surgical procedure. METHODS In this was a single-center, retrospective cohort study, we enrolled patients who were aged ≥ 65 years and underwent emergency abdominal surgery for acute abdomen between January 1, 2019, and December 31, 2021. We assessed their activities of daily living using the Barthel Index. Functional decline was defined as a decrease of ≥ 20 points in Barthel Index at 28 days postoperatively, compared with the preoperative value. We evaluated an association between functional decline and surgical procedures among older patients, using multiple logistic regression analysis. RESULTS During the study period, 852 patients underwent emergency abdominal surgery. Among these, 280 patients were eligible for the analysis. Among them, 94 underwent laparoscopic surgery, while 186 underwent open surgery. Patients who underwent laparoscopic surgery showed a less functional decline at 28 days postoperatively (6 vs. 49, p < 0.001). After adjustments for other covariates, laparoscopic surgery was an independent preventive factor for postoperative functional decline (OR, 0.22; 95% CI, 0.05-0.83; p < 0.05). CONCLUSIONS In emergency abdominal surgery, laparoscopic surgery reduces postoperative physical functional decline in older patients. Widespread use of laparoscopic surgery can potentially preserve patient quality of life and may be important for the better development of emergency abdominal surgery.
Collapse
Affiliation(s)
- Keishi Yamaguchi
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minamiku, Yokohama, 232-0024, Japan.
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan.
| | - Takeru Abe
- Center for Integrated Science and Humanities, Fukushima Medical University, Fukushima, Japan
| | - Shokei Matsumoto
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Kento Nakajima
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minamiku, Yokohama, 232-0024, Japan
| | - Masayuki Shimizu
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Ichiro Takeuchi
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minamiku, Yokohama, 232-0024, Japan
| |
Collapse
|
2
|
Yamaguchi K, Matsumoto S, Abe T, Nakajima K, Senoo S, Shimizu M, Takeuchi I. Predictive value of total psoas muscle index for postoperative physical functional decline in older patients undergoing emergency abdominal surgery. BMC Surg 2023; 23:171. [PMID: 37355574 DOI: 10.1186/s12893-023-02085-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 06/19/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND Older individuals increasingly require emergency abdominal surgeries. They are susceptible to surgical stress and loss of independence in performing daily activities. We hypothesized that the psoas muscle volume would be significantly associated with postoperative functional decline (FD) in older patients undergoing emergency abdominal surgery and aimed to evaluate the use of the psoas muscle volume on computed tomography (CT) scans. METHODS A retrospective, single-center study of patients aged ≥ 65 years who had undergone emergency abdominal surgery between January 2019 and June 2021 was performed. We assessed patients' activities of daily living using the Barthel Index. FD was defined as a ≥ 5-point decrease between preoperative and 28-day postoperative values. The psoas muscle volume was measured by CT, which was used for diagnosis, and normalized by height to calculate total psoas muscle index (TPI). We evaluated associations between FD and TPI using receiver operating characteristics (ROC) analysis and multiple logistic regression analysis. RESULTS Of 238 eligible patients, 71 (29.8%) had clinical postoperative FD. Compared to the non-FD group, the FD group was significantly older and had a higher proportion of females, higher Charlson Comorbidity Index, lower body mass index, higher American Society of Anesthesiology score, lower serum albumin level, and lower TPI. ROC analyses revealed that TPI had the highest area under the curve (0.802; 95% confidence interval [CI], 0.75-0.86). A multivariable logistic regression model revealed that low TPI was an independent predictor of postoperative FD (odds ratio, 0.14; 95% CI, 0.06-0.32). CONCLUSIONS TPI can predict postoperative FD due to emergency abdominal surgery. Identification of patients who are at high risk of FD before surgery may be useful for enhancing the regionalized system of care for emergency general surgery.
Collapse
Affiliation(s)
- Keishi Yamaguchi
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minami-Ku, Yokohama-Shi, Kanagawa, 232-0024, Japan
| | - Shokei Matsumoto
- Department of Trauma and Emergency Surgery, Saiseikai Yokohama-Shi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-Ku, Yokohama-Shi, Kanagawa, 230-0012, Japan.
| | - Takeru Abe
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minami-Ku, Yokohama-Shi, Kanagawa, 232-0024, Japan
| | - Kento Nakajima
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minami-Ku, Yokohama-Shi, Kanagawa, 232-0024, Japan
| | - Satomi Senoo
- Department of Trauma and Emergency Surgery, Saiseikai Yokohama-Shi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-Ku, Yokohama-Shi, Kanagawa, 230-0012, Japan
| | - Masayuki Shimizu
- Department of Trauma and Emergency Surgery, Saiseikai Yokohama-Shi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-Ku, Yokohama-Shi, Kanagawa, 230-0012, Japan
| | - Ichiro Takeuchi
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minami-Ku, Yokohama-Shi, Kanagawa, 232-0024, Japan
| |
Collapse
|
3
|
Abstract
PURPOSE OF REVIEW Advances in medical care allow patients to live longer, translating into a larger geriatric patient population. Adverse outcomes increase with older age, regardless of injury severity. Age, comorbidities, and physiologic deterioration have been associated with the increased mortality seen in geriatric trauma patients. As such, outcome prediction models are critical to guide clinical decision making and goals of care discussions for this population. The purpose of this review was to evaluate the various outcome prediction models for geriatric trauma patients. RECENT FINDINGS There are several prediction models used for predicting mortality in elderly trauma patients. The Geriatric Trauma Outcome Score (GTOS) is a validated and accurate predictor of mortality in geriatric trauma patients and performs equally if not better to traditional scores such as the Trauma and Injury Severity Score. However, studies recommend medical comorbidities be included in outcome prediction models for geriatric patients to further improve performance. SUMMARY The ideal outcome prediction model for geriatric trauma patients has not been identified. The GTOS demonstrates accurate predictive ability in elderly trauma patients. The addition of medical comorbidities as a variable in outcome prediction tools may result in superior performance; however, additional research is warranted.
Collapse
Affiliation(s)
- Jarva Chow
- Department of Anesthesiology and Critical Care, University of Chicago, Chicago, Illinois
| | - Catherine M Kuza
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| |
Collapse
|
4
|
Scherer J, Kalbas Y, Ziegenhain F, Neuhaus V, Lefering R, Teuben M, Sprengel K, Pape HC, Jensen KO. The GERtality Score: The Development of a Simple Tool to Help Predict in-Hospital Mortality in Geriatric Trauma Patients. J Clin Med 2021; 10:1362. [PMID: 33806240 DOI: 10.3390/jcm10071362] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/11/2021] [Accepted: 03/22/2021] [Indexed: 12/19/2022] Open
Abstract
Feasible and predictive scoring systems for severely injured geriatric patients are lacking. Therefore, the aim of this study was to develop a scoring system for the prediction of in-hospital mortality in severely injured geriatric trauma patients. The TraumaRegister DGU® (TR-DGU) was utilized. European geriatric patients (≥65 years) admitted between 2008 and 2017 were included. Relevant patient variables were implemented in the GERtality score. By conducting a receiver operating characteristic (ROC) analysis, a comparison with the Geriatric Trauma Outcome Score (GTOS) and the Revised Injury Severity Classification II (RISC-II) Score was performed. A total of 58,055 geriatric trauma patients (mean age: 77 years) were included. Univariable analysis led to the following variables: age ≥ 80 years, need for packed red blood cells (PRBC) transfusion prior to intensive care unit (ICU), American Society of Anesthesiologists (ASA) score ≥ 3, Glasgow Coma Scale (GCS) ≤ 13, Abbreviated Injury Scale (AIS) in any body region ≥ 4. The maximum GERtality score was 5 points. A mortality rate of 72.4% was calculated in patients with the maximum GERtality score. Mortality rates of 65.1 and 47.5% were encountered in patients with GERtality scores of 4 and 3 points, respectively. The area under the curve (AUC) of the novel GERtality score was 0.803 (GTOS: 0.784; RISC-II: 0.879). The novel GERtality score is a simple and feasible score that enables an adequate prediction of the probability of mortality in polytraumatized geriatric patients by using only five specific parameters.
Collapse
|
5
|
Zese M, Finotti E, Cestaro G, Cavallo F, Prando D, Gobbi T, Zese R, Di Saverio S, Agresta F. Emergency Surgery in the Elderly: Could Laparoscopy Be Useful in Frailty? A Single-Center Prospective 2-Year Follow-Up in 120 Consecutive Patients. Surgeries 2021; 2:119-27. [DOI: 10.3390/surgeries2010011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: the general population is aging across the world. Therefore, even surgical interventions in the elderly—in particular those involving emergency surgical admissions—are becoming more frequent. The elderly population is often frail (in multiple physiological systems, this is often defined as age-related cumulative decline). This study involved a 2-year follow-up evaluation of frail elderly patients treated with urgent surgical intervention at Santa Maria Regina della Misericordia Hospital, General Surgery Department, in Adria (Italy). Method: a prospective, single-center, 2-year follow-up study of 120 patients >65 years old, treated at our department for surgical abdominal emergencies. We considered co-morbidities (ASA—American Society of Anesthesiologists Physical Status Classification System—score), type of surgery (laparoscopy, laparotomy or converted), frailty score, mortality, and complications at 30 days and at 2 years. Conclusions: 70 (58.4%) patients had laparoscopy, 49 (40.8) had laparotomy, and in 1 (0.8%) case, surgery was converted from laparoscopy to laparotomy. Mortality strictly depends on the type of surgery (laparotomy vs. laparoscopy), complications during recovery, and a lower Fried frailty criteria score, on average. The long-term follow-up can be a useful tool to highlight a safer surgical approach, such as laparoscopy, in frail elderly patients. We consider the laparoscopic approach feasible in emergency situations, with similar or better outcomes than laparotomy, especially in frail elderly patients.
Collapse
|
6
|
Tang A, Chehab M, Ditillo M, Asmar S, Khurrum M, Douglas M, Bible L, Kulvatunyou N, Joseph B. Regionalization of trauma care by operative experience: Does the volume of emergent laparotomy matter? J Trauma Acute Care Surg 2021; 90:11-20. [PMID: 32925573 DOI: 10.1097/ta.0000000000002911] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The volume-outcome relationship led to the regionalization of trauma care. The relationship between trauma centers' injury-specific laparotomy volume and outcomes has not been explored. The aim of our study was to examine the relationship between a trauma center's injury-specific laparotomy volume and outcomes in blunt and penetrating trauma patients. METHODS We performed a (2017) analysis of the Trauma Quality Improvement Program database. We included adult (age, ≥18 years) blunt and penetrating trauma patients who required emergent laparotomies for hemorrhage control. Trauma centers were stratified based on their blunt and penetrating laparotomy volumes: high volume (HV), ≥25 cases per year; medium volume (MV), 13 to 24 cases per year; and low volume (LV), ≤12 cases per year. Multivariate regression analysis was performed to explore predictors of in-hospital mortality. RESULTS A total of 8,588 patients underwent emergent laparotomy for either blunt (4,936; 57.5%) or penetrating injuries (3,652; 42.5%). Overall, mean ± SD age was 40 ± 17 years, abdomen Abbreviated Injury Scale was 3 (2-4), and Injury Severity Score was 26 (17-35). For American College of Surgeons (ACS) level I centers, 50% were HV; 29%, MV; and 21%, LV. For ACS level II centers, 7% were HV; 23%, MV; and 70%, LV. For ACS level III centers, 100% were LV. On multivariate regression analysis, admission of blunt and penetrating trauma patients to HV blunt and HV penetrating centers, respectively, was independently associated with improved in-hospital mortality. High-volume blunt centers had a significantly lower time to laparotomy (72 [41-144] minutes) versus MV (81 [49-145] minutes) and LV (94 [56-158] minutes) centers (p < 0.001). The same trend was observed for HV penetrating trauma centers (35 [24-52] minutes) versus MV (46 [33-63] minutes) and LV (51 [38-69] minutes) centers (p < 0.001). CONCLUSION Blunt and penetrating injury patients requiring emergent laparotomy had higher survival when admitted to trauma centers with HV operative experience for their particular mechanism of injury. The regionalization of trauma care should be based on a thorough evaluation of trauma centers' injury-specific operative experience. LEVEL OF EVIDENCE Prognostic, Level III; Therapeutic/Care management, Level IV.
Collapse
Affiliation(s)
- Andrew Tang
- From the Division of Trauma, Acute Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, The University of Arizona, Tucson, Arizona
| | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Eguaras Córdoba I, Herrera Cabezón J, Sánchez Acedo P, Galbete Jiménez A, Guillén Grima F. The Urgent Surgery Elderly Mortality risk score: a simple mortality score. Rev Esp Enferm Dig 2020; 111:677-682. [PMID: 31317752 DOI: 10.17235/reed.2019.6187/2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION an increasing number of elderly patients undergo urgent abdominal surgery and this population has a higher risk of mortality. The main objective of the study was to identify mortality-associated factors in elderly patients undergoing abdominal surgery and to design a mortality scoring tool, the Urgent Surgery Elderly Mortality risk score (the USEM score). PATIENTS AND METHODS this was a retrospective study using a prospective database. Patients > 65 years old that underwent urgent abdominal surgery were included. Risk factors for 30-day mortality were identified using multivariate regression analysis and weights assigned using the odds ratios (OR). A mortality score was derived from the aggregate of weighted scores. Model calibration and discrimination were judged using the receiver operating characteristics curves and the Hosmer-Lemeshow test. RESULTS in the present study, 4,255 patients were included with an 8.5% mortality rate. The risk factors significantly associated with mortality were American Society of Anesthesiologists (ASA) score, age, preoperative diagnosis (OR: 37.82 for intestinal ischemia, OR: 5.01 for colorectal perforation, OR: 6.73 for intestinal obstruction), surgical wound classification and open or laparoscopic surgery. A risk score was devised from these data for the estimation of the probability of survival in each patient. The area under the ROC curve (AUROC) for this score was 0.84 (95% CI: 0.82-0.86) and the AUROC correct was 0.83 (0.81-0.85). CONCLUSIONS a simple score that uses five clinical variables predicts 30-day mortality. This model can assist surgeons in the initial evaluation of an elderly patient undergoing urgent abdominal surgery.
Collapse
Affiliation(s)
| | - Javier Herrera Cabezón
- Cirugía General/ Jefe Unidad Hepatobiliopancreatic, Complejo Hospitalario de Navarra, España
| | | | | | | |
Collapse
|
8
|
Smith A, Onyiego A, Duchesne J, Tatum D, Harris C, Moreno-Ponte OI, Strumwasser A, Inaba K, O'Keeffe T, Black J, Quintana MT, Gupta S, Brocker J, Schreiber M, Pickett ML, Cripps MW, Guidry C. A Multi-Institutional Analysis of Damage Control Laparotomy in Elderly Trauma Patients: Do Geriatric Trauma Protocols Matter? Am Surg 2020; 86:1135-1143. [PMID: 32809869 DOI: 10.1177/0003134820943646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Trauma centers are receiving increasing numbers of older trauma patients. There is a lack of literature on the outcomes for elderly trauma patients who undergo damage control laparotomy (DCL). We hypothesized that trauma centers with geriatric protocols would have better outcomes in elderly patients after DCL. METHODS A retrospective chart review of consecutive adult trauma patients with DCL at 8 level 1 trauma centers was conducted from 2012 to 2018. Patients aged 40 or older were included. Age ≥ 55 years was defined as elderly. Demographics, injury information, clinical outcomes, including mortality, and complications were recorded. Univariate and multivariate analyses were performed. RESULTS A total of 379 patients with DCLs were identified with an average age of 54.8 ± 0.4 years with 39.3% (n = 149/379) of patients aged ≥ 55. Geriatric protocols or a consulting geriatric service was present at 37.5% (n = 3/8) of institutions. Age ≥ 55 was a significant risk factor for in-hospital mortality (OR 2, 95% CI 1.0-4.0, P = .04). Institutions without dedicated geriatric trauma protocols/services had higher overall in-hospital mortality on both univariate (57.9% vs 34.3%, P = .02) and multivariate analyses (OR 2.1, 95% CI 1.3-3.4, P < .001). CONCLUSIONS Surgical management of older trauma patients remains a challenge. Geriatric protocols or dedicated services were found to be associated with improved outcomes. Future efforts should focus on standardizing the availability of these resources at trauma centers.
Collapse
Affiliation(s)
- Alison Smith
- 57835783 Department of Surgery, Tulane School of Medicine, New Orleans, LA, USA
| | - Alexandra Onyiego
- 57835783 Department of Surgery, Tulane School of Medicine, New Orleans, LA, USA
| | - Juan Duchesne
- 57835783 Department of Surgery, Tulane School of Medicine, New Orleans, LA, USA
| | - Danielle Tatum
- Our Lady of the Lake Trauma Hospital, Baton Rouge, LA, USA
| | - Charles Harris
- 57835783 Department of Surgery, Tulane School of Medicine, New Orleans, LA, USA
| | | | | | - Kenji Inaba
- University of Southern California, Los Angeles, CA, USA
| | | | | | - Megan T Quintana
- 21668 Shock Trauma Center University of Maryland, Baltimore, MD, USA
| | - Shailvi Gupta
- 21668 Shock Trauma Center University of Maryland, Baltimore, MD, USA
| | - Jason Brocker
- 21668 Shock Trauma Center University of Maryland, Baltimore, MD, USA
| | | | | | | | - Chrissy Guidry
- 57835783 Department of Surgery, Tulane School of Medicine, New Orleans, LA, USA
| |
Collapse
|
9
|
Gorman E, Bukur M, Frangos S, DiMaggio C, Kozar R, Klein M, Pachter HL, Berry C. Increasing age is associated with worse outcomes in elderly patients with severe liver injury. Am J Surg 2020; 220:1308-11. [PMID: 32653089 DOI: 10.1016/j.amjsurg.2020.06.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/07/2020] [Accepted: 06/25/2020] [Indexed: 01/15/2023]
Abstract
While the incidence of geriatric trauma continues to increase, outcomes following severe blunt liver injury (BLI) are unknown. We sought to investigate independent predictors of mortality among elderly trauma patients with severe BLI. A retrospective study of the NTDB (2014-15) identified patients with isolated, high-grade BLI. Patients were stratified into two groups, non-elderly (<65 years) and elderly (≥65 years), and then two management groups: operative within 24 h of admission and non-operative. Demographics and outcomes were compared. Multivariable logistic regression was used to estimate association with mortality. A total of 1133 patients met our inclusion criteria. 107 patients required surgery and 1011 patients were managed non-operatively. Age was independently associated with mortality (AOR 1.04, p < .001). For patients <65 years, need for operative intervention was associated with a 55 times greater likelihood of death (AOR 55.1, p < .001). In patients ≥65 years, operative intervention was associated with a 122 times greater likelihood of death (AOR 122.09, p = .005). Age is independently associated with mortality in patients with high grade BLI.
Collapse
|
10
|
Yamamoto M, Ikeda M, Matsumoto T, Takemoto M, Sumimoto R, Kobayashi T, Ohdan H. Hemorrhoidectomy for elderly patients aged 75 years or more, before and after studies. Ann Med Surg (Lond) 2020; 55:88-92. [PMID: 32477502 PMCID: PMC7251490 DOI: 10.1016/j.amsu.2020.04.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 02/07/2023] Open
Abstract
Background The incidence of hemorrhoids requiring hemorrhoidectomy among the elderly has been increasing. Old age is sometimes considered a contraindication for surgery. The relationship between age and complications of hemorrhoidectomy for elderly patients is not well established. This study aimed to compare the clinicopathological features and postoperative outcomes of hemorrhoidectomy in the elderly (≥75 years old) and non-elderly patients (<75 years old). Methods A total of 100 patients who underwent hemorrhoidectomy for hemorrhoids of Goligher classification grades 3 and 4 at our institution between 2014 and 2018 were enrolled. The clinical characteristics were compared between the elderly and non-elderly patients. Pain scores were measured at 6, 12, 24, and 48 h after surgery. The risk factors for postoperative complications were identified. Results A total of 34 patients were classified as elderly patients. In the elderly group, aspartate aminotransferase levels were higher while the albumin levels and cholinesterase levels were lower and the platelet counts were significantly lower. The blood urea nitrogen levels were higher and estimated glomerular filtration rates and hemoglobin levels were significantly lower in the elderly group. The pain scores significantly decreased at 48 h postoperatively compared to those recorded at 6 h postoperatively in both groups. Multivariate analysis identified Goligher classification grade 4 and high neutrophil to lymphocyte ratio at the indicators of complications. Conclusions Hemorrhoids due to impairment of liver function and kidney function were dominant in elderly patients. Aging itself was not a risk factor for postoperative complications. The feasibility of hemorrhoidectomy for the elderly is not remained clear. The incidence of postoperative complications was comparable regardless of age. The risk factor for complication was Goligher classification grade 4 and high NLR.
Collapse
Affiliation(s)
- Masateru Yamamoto
- Department of Surgery, National Hospital Organization Yanai Medical Center, Yamaguchi, Japan.,Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masanobu Ikeda
- Department of Surgery, National Hospital Organization Yanai Medical Center, Yamaguchi, Japan
| | - Tomio Matsumoto
- Department of Surgery, National Hospital Organization Yanai Medical Center, Yamaguchi, Japan
| | - Masahiko Takemoto
- Department of Surgery, National Hospital Organization Yanai Medical Center, Yamaguchi, Japan
| | - Ryo Sumimoto
- Department of Surgery, National Hospital Organization Yanai Medical Center, Yamaguchi, Japan
| | - Tsuyoshi Kobayashi
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| |
Collapse
|
11
|
Hatton GE, McNutt MK, Cotton BA, Hudson JA, Wade CE, Kao LS. Age-Dependent Association of Occult Hypoperfusion and Outcomes in Trauma. J Am Coll Surg 2020; 230:417-425. [PMID: 31954820 DOI: 10.1016/j.jamcollsurg.2019.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Occult hypoperfusion (OH), or global hypoperfusion with normal vital signs, is a risk factor for poor outcomes in elderly trauma patients. We hypothesized that OH is associated with worse outcomes than shock in both young and elderly trauma patients. METHODS We conducted a single-center cohort study of adult (16 years or older) trauma patients from 2016 to 2018 with base excess measured on arrival. Perfusion states were defined as shock if heart rate was >120 beats/min or systolic blood pressure was <90 mmHg; OH if base excess was < -2 mmol/L, heart rate was <120 beats/min, and systolic blood pressure was >90 mmHg; and normal for all others. Patients were stratified as young (younger than 55 years) or elderly (55 years or older). Bayesian regression was used to assess the relationship between arrival perfusion state and mortality or serious complication. RESULTS Of 3,126 included patients, 808 were elderly. Rates of shock (33% and 31%) and OH (25% and 23%) were similar in young and elderly patients, respectively. OH on arrival was associated with higher odds of mortality or serious complication than normal perfusion, regardless of age group. Compared with shock, OH was associated with an odds ratio of 1.21 (95% CI, 0.97 to 1.52, posterior probability 96%) for poor outcomes in elderly patients and an odds ratio of 0.52 (95% CI, 0.42 to 0.65, posterior probability <1%) for poor outcomes in younger patients. Findings were similar on sensitivity analysis, excluding shock patients with base excess ≥ -2 mmol/L. CONCLUSIONS In elderly but not younger patients, OH is associated with worse outcomes than shock. Although shock parameters might need to be redefined in elderly patients, more attention is necessary for the diagnosis and treatment of all hypoperfused states in this age group.
Collapse
Affiliation(s)
- Gabrielle E Hatton
- Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, University of Texas Health Science Center at Houston, Houston, TX; McGovern Medical School, and Center for Translational Injury Research, University of Texas Health Science Center at Houston, Houston, TX.
| | - Michelle K McNutt
- Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, University of Texas Health Science Center at Houston, Houston, TX; McGovern Medical School, and Center for Translational Injury Research, University of Texas Health Science Center at Houston, Houston, TX
| | - Bryan A Cotton
- Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX; McGovern Medical School, and Center for Translational Injury Research, University of Texas Health Science Center at Houston, Houston, TX
| | - Jessica A Hudson
- Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX; Department of Emergency Medicine, University of Texas Health Science Center at Houston, Houston, TX; McGovern Medical School, and Center for Translational Injury Research, University of Texas Health Science Center at Houston, Houston, TX
| | - Charles E Wade
- Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX; McGovern Medical School, and Center for Translational Injury Research, University of Texas Health Science Center at Houston, Houston, TX
| | - Lillian S Kao
- Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, University of Texas Health Science Center at Houston, Houston, TX; McGovern Medical School, and Center for Translational Injury Research, University of Texas Health Science Center at Houston, Houston, TX
| |
Collapse
|
12
|
Tan HL, Chia STX, Nadkarni NV, Ang SY, Seow DCC, Wong TH. Frailty and functional decline after emergency abdominal surgery in the elderly: a prospective cohort study. World J Emerg Surg 2019; 14:62. [PMID: 31892937 PMCID: PMC6937965 DOI: 10.1186/s13017-019-0280-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 11/25/2019] [Indexed: 11/10/2022] Open
Abstract
Background Frailty has been associated with an increased risk of adverse postoperative outcomes in elderly patients. We examined the impact of preoperative frailty on loss of functional independence following emergency abdominal surgery in the elderly. Methods This prospective cohort study was performed at a tertiary hospital, enrolling patients 65 years of age and above who underwent emergency abdominal surgery from June 2016 to February 2018. Premorbid variables, perioperative characteristics and outcomes were collected. Two frailty measures were compared in this study-the Modified Fried's Frailty Criteria (mFFC) and Modified Frailty Index-11 (mFI-11). Patients were followed-up for 1 year. Results A total of 109 patients were prospectively recruited. At baseline, 101 (92.7%) were functionally independent, of whom seven (6.9%) had loss of independence at 1 year; 28 (25.7%) and 81 (74.3%) patients were frail and non-frail (by mFFC) respectively. On univariate analysis, age, Charlson Comorbidity Index and frailty (mFFC) (univariate OR 13.00, 95% CI 2.21-76.63, p < 0.01) were significantly associated with loss of functional independence at 1 year. However, frailty, as assessed by mFI-11, showed a weaker correlation than mFFC (univariate OR 4.42, 95% CI 0.84-23.12, p = 0.06). On multivariable analysis, only premorbid frailty (by mFFC) remained statistically significant (OR 15.63, 95% CI 2.12-111.11, p < 0.01). Conclusions The mFFC is useful for frailty screening amongst elderly patients undergoing emergency abdominal surgery and is a predictor for loss of functional independence at 1 year. Including the risk of loss of functional independence in perioperative discussions with patients and caregivers is important for patient-centric emergency surgical care. Early recognition of this at-risk group could help with discharge planning and priority for post-discharge support should be considered.
Collapse
Affiliation(s)
- Hwee Leong Tan
- 1Department of General Surgery, Singapore General Hospital, 20 College Road, Academia Level 5, Singapore, 169856 Singapore
| | - Shermain Theng Xin Chia
- 2SingHealth Internal Medicine Residency, Singapore General Hospital, 20 College Road, Academia Level 3, Singapore, 169856 Singapore
| | - Nivedita Vikas Nadkarni
- 3Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, 8 College Rd, Singapore, 169857 Singapore
| | - Shin Yuh Ang
- 4Nursing Division, Nursing Quality, Research & Transformation, Singapore General Hospital, Outram Road, Singapore, 169608 Singapore
| | - Dennis Chuen Chai Seow
- 5Department of Geriatric Medicine, Singapore General Hospital, 20 College Road, Academia Level 3, Singapore, 169856 Singapore
| | - Ting Hway Wong
- 1Department of General Surgery, Singapore General Hospital, 20 College Road, Academia Level 5, Singapore, 169856 Singapore.,6Duke-NUS Medical School, 8 College Rd, Singapore, 169857 Singapore
| |
Collapse
|
13
|
Abstract
BACKGROUND There have been recommendations for increased non-operative management (NOM) of abdominal trauma in adults. To assess the impact of this trend and changes in the epidemiology of trauma, we examined the management of serious abdominal injuries and mortality, in Victorian major trauma patients 16 years or older, between 2007 and 2016. METHODS Using data from the population-based Victorian Trauma Registry, characteristics of patients who underwent laparotomy, embolisation, laparotomy and embolisation, or NOM, were compared with the Chi-square test. Poisson regression was used to determine whether the incidence of serious abdominal injury changed over time. Temporal trends in the management of abdominal injury and in-hospital mortality were analysed using, respectively, the Chi-square test for trend, and multivariable logistic regression. RESULTS Of 2385 patients with serious abdominal injuries, 69% (n = 1649) had an intervention; predominantly a laparotomy (n = 1166). The proportion undergoing laparotomy decreased from 60% in 2007 to 44% in 2016 (p < 0.001), whilst embolisation increased from 6 to 20% (p < 0.001). Population-adjusted incidence of abdominal injury increased 1.6% per year (IRR 1.016, 95% CI 1.002-1.031; p < 0.024), predominantly in people aged 65 years and over (4.6% per year). Adjusted odds of in-hospital mortality declined 6.0% per year (adjusted odds ratio 0.94; 95% CI 0.89, 1.00; p = 0.04). CONCLUSIONS Whilst the incidence of major abdominal trauma increased during the study period, there was a reduction in the proportion of patients managed with laparotomy and reduction in the adjusted odds of in-hospital mortality. Older patients, for whom management is influenced by the complex interplay of frailty and co-morbidities, had lower laparotomy rates.
Collapse
|
14
|
Abstract
Background Abdominal trauma constitutes a significant cause of potentially preventable mortality. Therefore, knowledge of the determinants of outcome facilitates the development of rational treatment protocols for improving outcome. Objective To identify the determinants of outcome in patients with abdominal trauma managed in a tertiary health center. Patients and Methods This is a prospective study of consecutive patients presenting with abdominal trauma to our tertiary health center over a 12-month period. Data regarding patient demographics, injury mechanisms, type of organ injuries, treatment modalities, injury-to-intervention time, and outcomes were documented. The Injury Severity Scores and Revised Trauma Scores were determined. The data were analyzed using the Statistical Package for the Social Sciences version 20. Results There were 76 patients, 66 males and 10 females, whose ages ranged from 15 to 66 years (mean of 32.9 ± 10 years). Thirty-one (40.2%) patients had blunt abdominal trauma whereas 45 (59.8%) patients had penetrating trauma. There was a mortality rate of 8% predominantly from blunt trauma as compared to penetrating abdominal trauma (12.9% vs. 4.4%). There was a statistically significant difference between survivors and nonsurvivors as regards the means of injury-to-intervention time (25.4 ± 36.4 vs. 67.5 ± 58.2, P = 0.007), the means of Injury Severity Scores (15.1 ± 27.9 vs. 23.7 ± 9.8, P = 0.008), and the presence of brain injury (50.0% vs. 5.6%, P = 0.029). Conclusion This study has shown that delayed intervention, high Injury Severity Score, and associated significant brain injury were determinants of poor outcomes. Prompt intervention and postoperative management in intensive care definitely improve outcome.
Collapse
Affiliation(s)
- Solomon Agbroko
- Department of Surgery, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Idi-Araba, Lagos Nigeria
| | - Adedapo Osinowo
- Department of Surgery, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Idi-Araba, Lagos Nigeria
| | - Emmanuel Jeje
- Department of Surgery, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Idi-Araba, Lagos Nigeria
| | - Oluwole Atoyebi
- Department of Surgery, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Idi-Araba, Lagos Nigeria
| |
Collapse
|
15
|
Oshima K, Murata M, Aoki M, Nakajima J, Sawada Y, Isshiki Y, Ichikawa Y, Fukushima K, Hagiwara S, Hinohara H. Efficacy of the Treatment of Elderly Trauma Patients Requiring Intensive Care. Emerg Med Int 2018; 2018:2137658. [PMID: 30693109 DOI: 10.1155/2018/2137658] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/01/2018] [Accepted: 12/13/2018] [Indexed: 11/18/2022] Open
Abstract
Purpose To evaluate the effectiveness of intensive care for the elderly trauma patients aged 80 years and older. Methods Trauma patients admitted to the intensive care unit (ICU) through the emergency room (ER) at our hospital between January 2013 and December 2016 were analyzed. Patients were divided into two groups: patients aged 80 and older (group E) and <80 years old (group Y). Clinical courses and the total treatment costs were compared between the two groups. Data are shown as median (interquartile range). Results A hundred and seven trauma patients were included in the study. There were 26 patients in group E and 81 patients in group Y. There was no significant difference in Injury Severity Score (ISS) (group E, 19 (13, 32); group Y, 17 (14, 25); p=0.708); however, the probability of survival (Ps) was significantly lower in group E (group E, 0.895 (0.757, 0.950); group Y, 0.955 (0.878, 0.986); p=0.004). The duration of ICU stay (days) was significantly longer in group E (10 (5, 23)) than in group Y (4 (3, 9); p=0.001), and the total hospital stay (days) was longer in group E (33 (13, 57)) than in group Y (22 (12, 42); p=0.179). The hospital mortality was higher in group E (11.5%) than in group Y (6.2%) without a significant difference (p=0.365). The total treatment costs were significantly higher in group E ($23,558 (12,456, 42,790) with $1 = ¥110.57) than in group Y ($16,538 (7,412, 25,422); p=0.023). Conclusions Elderly trauma patients require longer-term treatment including ICU stay and greater cost with higher hospital mortality compared with young trauma patients.
Collapse
|
16
|
Crozier-Shaw G, Joyce WP. Too frail for surgery? A frailty index in major colorectal surgery. ANZ J Surg 2018; 88:1302-1305. [DOI: 10.1111/ans.14792] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/19/2018] [Accepted: 07/04/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Geoff Crozier-Shaw
- Department of Colorectal Surgery; Galway Clinic; Galway Ireland
- Royal College of Surgeons in Ireland; Dublin Ireland
| | | |
Collapse
|
17
|
Giordano S, Schaverien M, Garvey PB, Baumann DP, Liu J, Butler CE. Advanced age does not affect abdominal wall reconstruction outcomes using acellular dermal matrix: A comparative study using propensity score analysis. Am J Surg 2017; 213:1046-1052. [DOI: 10.1016/j.amjsurg.2016.10.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/24/2016] [Accepted: 10/30/2016] [Indexed: 02/06/2023]
|
18
|
Llompart-Pou JA, Pérez-Bárcena J, Chico-Fernández M, Sánchez-Casado M, Raurich JM. Severe trauma in the geriatric population. World J Crit Care Med 2017; 6:99-106. [PMID: 28529911 PMCID: PMC5415855 DOI: 10.5492/wjccm.v6.i2.99] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/03/2017] [Accepted: 03/17/2017] [Indexed: 02/06/2023] Open
Abstract
Geriatric trauma constitutes an increasingly recognized problem. Aging results in a progressive decline in cellular function which leads to a loose of their capacity to respond to injury. Some medications commonly used in this population can mask or blunt the response to injury. Falls constitute the most common cause of trauma and the leading cause of trauma-related deaths in this population. Falls are complicated by the widespread use of antiplatelets and anticoagulants, especially in patients with brain injury. Under-triage is common in this population. Evaluation of frailty could be helpful to solve this issue. Appropriate triaging and early aggressive management with correction of coagulopathy can improve outcome. Limitation of care and palliative measures must be considered in cases with a clear likelihood of poor prognosis.
Collapse
|
19
|
Ahl R, Phelan HA, Dogan S, Cao Y, Cook AC, Mohseni S. Predicting In-Hospital and 1-Year Mortality in Geriatric Trauma Patients Using Geriatric Trauma Outcome Score. J Am Coll Surg. 2017;224:264-269. [PMID: 28017806 DOI: 10.1016/j.jamcollsurg.2016.12.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 12/06/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Geriatric Trauma Outcome Score (GTOS; [age] + [2.5 × Injury Severity Score] + 22 [if packed RBC transfused within ≤24 hours of admission]), was developed and validated as a prognostic indicator for in-hospital mortality in elderly trauma patients. However, GTOS neither provides information about post-discharge outcomes nor discriminates between patients dying with and without care restrictions. Isolating the latter, GTOS prediction performance was examined during admission and 1-year post discharge in a mature European trauma registry. STUDY DESIGN All trauma admissions 65 years of age and older in a university hospital during 2007 to 2011 were considered. Data on age, Injury Severity Score, packed RBC transfusion within ≤24 hours, therapy restrictions, discharge disposition, and mortality were collected. In-hospital deaths with therapy restrictions and patients discharged to hospice were excluded. The GTOS was the sole predictor in a logistic regression model estimating mortality probabilities. Performance of the model was assessed by misclassification rate, Brier score, Tjur R2, and area under the curve. RESULTS The study population was 1,080 patients with a median age of 75 years, mean Injury Severity Score of 10, and packed RBCs transfused in 8.2%. In-hospital mortality was 14.9% and 7.7% after exclusions. Misclassification rate fell from 14% to 6.5% and Brier score from 0.09 to 0.05, and area under the curve increased from 0.87 to 0.88. Equivalent values for the original GTOS sample were 9.8%, 0.07, and 0.82, respectively. One-year mortality follow-up showed a misclassification rate of 17.6% and Brier score of 0.13. CONCLUSIONS Excluding patients with care restrictions and discharged to hospice improved GTOS performance for in-hospital mortality prediction. The GTOS is not adept at predicting 1-year mortality.
Collapse
|
20
|
Joseph B, Zangbar B, Pandit V, Fain M, Mohler MJ, Kulvatunyou N, Jokar TO, O'Keeffe T, Friese RS, Rhee P. Emergency General Surgery in the Elderly: Too Old or Too Frail? J Am Coll Surg 2016; 222:805-13. [PMID: 27113515 DOI: 10.1016/j.jamcollsurg.2016.01.063] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/26/2016] [Accepted: 01/26/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Assessment of operative risk in geriatric patients undergoing emergency general surgery (EGS) is challenging. Frailty is an established measure for risk assessment in elective surgical cases. Emerging literature suggests the superiority of frailty measurements to chronological age in predicting outcomes. The aim of this study was to assess the outcomes in elderly patients undergoing EGS using an established Rockwood frailty index. STUDY DESIGN We prospectively measured preadmission frailty in all geriatric (aged 65 years and older) patients undergoing EGS at our institution during a 2-year period. Frailty index (FI) was calculated using the modified 50-variable Rockwood Preadmission FI. Frail patients were defined by FI ≥ 0.25. Outcomes measures were in-hospital complications, development of major complications, and mortality. Multivariate regression analysis was performed. RESULTS A total of 220 patients were enrolled, of which 82 (37%) were frail. Frailty index score did not correlate with age (R = 0.64; R(2) = 0.53; p = 0.1) and poorly correlated with American Society of Anesthesiologists score (R = 0.51; R(2) = 0.44; p = 0.045). Thirty-five percent (n = 77) of patients had postoperative complications and 19% (n = 42) had major complications. Frailty index was an independent predictor for development of in-hospital complications (odds ratio = 2.13; 95% CI, 1.09-4.16; p = 0.02) and major complications (odds ratio = 3.87; 95% CI, 1.69-8.84; p = 0.001). Age and American Society of Anesthesiologists score were not predictive of postoperative and major complications. Our FI model had 80% sensitivity, 72% specificity, and area under the curve of 0.75 in predicting complications in geriatric patients undergoing EGS. The overall mortality rate was 3.2% (n = 7) and all patients who died were frail. CONCLUSIONS Frailty index independently predicts postoperative complications, major complications, and hospital length of stay in elderly patients undergoing emergency general surgery. Use of FI will provide insight into the hospital course of elderly patients, allowing for identification of patients in need and more efficient allocation of hospital resources.
Collapse
|
21
|
|
22
|
Hildebrand F, Pape HC, Horst K, Andruszkow H, Kobbe P, Simon TP, Marx G, Schürholz T. Impact of age on the clinical outcomes of major trauma. Eur J Trauma Emerg Surg 2015; 42:317-32. [PMID: 26253883 DOI: 10.1007/s00068-015-0557-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 07/31/2015] [Indexed: 12/20/2022]
Abstract
PURPOSE In view of demographic changes over the past few decades, the average age of trauma patients is progressively increasing. We therefore aimed to summarize the specific characteristics of geriatric trauma and to identify potential fields for further research to improve the care of elderly trauma patients. METHODS Review of the literature. RESULTS Due to the diverse risk factors (e.g., pre-existing conditions, limited physiological reserve), geriatric patients are prone to developing severe complications, even after less severe trauma. Yet, age is not considered as the only predictor of worse outcomes, and it should not be considered the only criterion for limiting care in those patients. It is crucial that age-specific treatment guidelines are developed to optimize the outcomes for senior trauma patients. Based on the current literature, these guidelines should emphasize the importance of field triage directly to a trauma center, along with the activation of the trauma team. Furthermore, early intensive monitoring, aggressive resuscitation, and time of surgical intervention are of upmost importance to reduce mortality. CONCLUSION The impact of several factors [age, premedical conditions (PMC), decreased physiological reserves, and impaired immune function] on the post-traumatic course of elderly trauma patients needs to be clarified in future experimental and clinical studies for the early identification of geriatric high-risk patients and for the development of age-adapted therapeutic strategies.
Collapse
Affiliation(s)
- F Hildebrand
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany. .,Harald Tscherne Research Laboratory for Orthopaedic Trauma, Aachen University, Aachen, Germany.
| | - H-C Pape
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - K Horst
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.,Harald Tscherne Research Laboratory for Orthopaedic Trauma, Aachen University, Aachen, Germany
| | - H Andruszkow
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.,Harald Tscherne Research Laboratory for Orthopaedic Trauma, Aachen University, Aachen, Germany
| | - P Kobbe
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - T-P Simon
- Department of Intensive Care Medicine, Aachen University, Aachen, Germany
| | - G Marx
- Department of Intensive Care Medicine, Aachen University, Aachen, Germany
| | - T Schürholz
- Department of Intensive Care Medicine, Aachen University, Aachen, Germany
| |
Collapse
|
23
|
Joseph B, Zangbar B, Khalil M, Kulvatunyou N, Haider AA, O'Keeffe T, Tang A, Vercruysse G, Friese RS, Rhee P. Factors associated with failure-to-rescue in patients undergoing trauma laparotomy. Surgery 2015; 158:393-8. [PMID: 26013985 DOI: 10.1016/j.surg.2015.03.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 03/02/2015] [Accepted: 03/04/2015] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Quality improvement initiatives have focused primarily on preventing in-hospital complications. Patients developing complications are at a greater risk of mortality; however, factors associated with failure-to-rescue (death after major complication) in trauma patients remain undefined. The aim of this study was to identify risk factors associated with failure-to-rescue in patients undergoing trauma laparotomy. METHODS An -8-year, retrospective analysis of patients undergoing trauma laparotomy was performed. Patients who developed major in-hospital complications were included. Major complications were defined as respiratory, infectious, cardiac, renal, or development of compartment syndrome. Regression analysis was performed to identify independent factors associated with failure-to-rescue after we adjusted for demographics, mechanism of injury, abdominal abbreviated injury scale, initial vital signs, damage control laparotomy, and volume of crystalloids and blood products administered. RESULTS A total of 1,029 patients were reviewed, of which 21% (n = 217) patients who developed major complications were included. The mean age was 39 ± 18 years, 82% were male, 61% had blunt trauma, and median abdominal abbreviated injury scale was 25 [16-34, interquartile range]. Respiratory complications (n = 77) followed by infectious complications (n = 75) were the most common complications. The failure-to-rescue rate was 15.7% (n = 34/217). Age, blunt trauma, severe head injury, uninsured status, and blood products administered on the second day were independent predictor for failure-to-rescue. CONCLUSION When major complications develop, age, uninsured status, severity of head injury, and prolonged resuscitation are associated independently with failure-to-rescue, whereas initial resuscitation, coagulopathy, and acidosis did not predict failure to rescue. Quality-of-care programs focus in patient level should be on improving the patient's insurance status, preventing secondary brain injury, and further development of resuscitation guidelines.
Collapse
Affiliation(s)
- Bellal Joseph
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ.
| | - Bardiya Zangbar
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Mazhar Khalil
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Narong Kulvatunyou
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Ansab A Haider
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Terence O'Keeffe
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Andrew Tang
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Gary Vercruysse
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Randall S Friese
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Peter Rhee
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| |
Collapse
|
24
|
Zhao FZ, Wolf SE, Nakonezny PA, Minhajuddin A, Rhodes RL, Paulk ME, Phelan HA. Estimating Geriatric Mortality after Injury Using Age, Injury Severity, and Performance of a Transfusion: The Geriatric Trauma Outcome Score. J Palliat Med 2015; 18:677-81. [PMID: 25974408 PMCID: PMC4522950 DOI: 10.1089/jpm.2015.0027] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A tool to determine the probability of mortality for severely injured geriatric patients is needed. OBJECTIVE We sought to create an easily calculated geriatric trauma prognostic score based on parameters available at the bedside to aid in mortality probability determination. METHODS All patients ≥ 65 years of age were identified from our Level I trauma center's registry between January 1, 2000 and December 31, 2013. Measurements included age, Injury Severity score (ISS), units of packed red blood cells (PRBCs) transfused in the first 24 hours, and patients' mortality status at the end of their index hospitalization. As a first step, a logistic regression model with maximum likelihood estimation and robust standard errors was used to estimate the odds of mortality from age, ISS, and PRBCs after dichotomizing PRBCs as yes/no. We then constructed a Geriatric Trauma Outcome (GTO) score that became the sole predictor in the re-specified logistic regression model. RESULTS The sample (n = 3841) mean age was 76.5 ± 8.1 years and the mean ISS was 12.4 ± 9.8. In-hospital mortality was 10.8%, and 11.9% received a transfusion by 24 hours. Based on the logistic regression model, the equation with the highest discriminatory ability to estimate probability of mortality was GTO Score = age + (2.5 × ISS) + 22 (if given PRBCs). The area under the receiver operating characteristic curve (AUC) for this model was 0.82. Selected GTO scores and their related probability of dying were: 205 = 75%, 233 = 90%, 252 = 95%, 310 = 99%. The range of GTO scores was 67.5 (survivor) to 275.1 (died). CONCLUSION The GTO model accurately estimates the probability of dying, and can be calculated at bedside by those possessing a working knowledge of ISS calculation.
Collapse
Affiliation(s)
- Frank Z Zhao
- 1 Department of General Surgery, UT Southwestern Medical Center, Parkland Memorial Hospital , Dallas, Texas
| | - Steven E Wolf
- 2 Division of Burns/Trauma/Critical Care, Department of Surgery, UT Southwestern Medical Center, Parkland Memorial Hospital , Dallas, Texas
| | - Paul A Nakonezny
- 3 Division of Biostatistics, Department of Clinical Sciences, UT Southwestern Medical Center , Dallas, Texas
| | - Abu Minhajuddin
- 3 Division of Biostatistics, Department of Clinical Sciences, UT Southwestern Medical Center , Dallas, Texas
| | - Ramona L Rhodes
- 4 Division of Geriatrics and Palliative Care, Department of Internal Medicine, UT Southwestern Medical Center, Parkland Memorial Hospital , Dallas, Texas
| | - M Elizabeth Paulk
- 5 Division of Palliative Care, Department of Internal Medicine, UT Southwestern Medical Center, Parkland Memorial Hospital , Dallas, Texas
| | - Herb A Phelan
- 2 Division of Burns/Trauma/Critical Care, Department of Surgery, UT Southwestern Medical Center, Parkland Memorial Hospital , Dallas, Texas
| |
Collapse
|