Introduction : Around 3.2%-8.4% of patients receive venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support after pediatric cardiac surgery. The desired outcome is "bridgetorecovery" in ...most cases. There is no universally agreed protocol, and given the associated costs and complications rates, the decisions as of when and when not to institute VA ECMO are largely empirical.
Methods : A retrospective review of the ECMO database at the Scottish Pediatric Cardiac Services (SPCS) was undertaken. Inclusion criterion encompassed all children (<16 years of age) who were supported with VA ECMO following cardiac surgery between January 2011 and October 2016. The timing of ECMO support was divided into three distinct phases: "endofcase" or intheatre ECMO for patients unable to effectively wean from cardiopulmonary bypass (CPB), ECMO for cardiopulmonary resuscitation ("ECPR"), and Intensive Care Unit ECMO for "failing maximal medial therapy" following cardiac surgery. The patients were analyzed to identify survival rates, adverse prognostic indicators, and complication rates.
Results : We identified 66 patients who met the inclusion criterion. 30day survival rate was 45% and survival rate to hospital discharge was 44% (the difference represents one patient). On followup (median: 960 days, range: 42-2010 days), all survivors to hospital discharge were alive at review date. "Endofcase" ECMO showed a trend toward better survival of the three subcategories ("end of case," ECPR, and ECMO for "failing maximal medical therapy" survival rates were 47%, 41%, and 37.5%, respectively, P = 0.807). The poorest survival rates were in the younger children (<6 months, P = 0.502), patients who had prolonged CPB (P = 0.314) and aortic crossclamp times (P = 0.146), and longer duration of ECMO (>10 days, P = 0.177).
Conclusions : Allcomers VA ECMO following pediatric cardiac surgery had survival to discharge rate of 44%. Elective "endofcase" ECMO carries better survival rates and therefore ECMO instituted early maybe advantageous. Prolonged ECMO support has a direct correlation with mortality.
Disability and death due to low falls is increasing worldwide and disproportionately affects older adults. Current trauma systems were not designed to suit the needs of these patients. This study ...assessed the association between major trauma centre (MTC) care and outcomes in adult patients injured by low falls.
Data were obtained from the Trauma Audit and Research Network on adult patients injured by falls from <2 m between 2017 and 2019 in England and Wales. 30-day survival, length of hospital stay and discharge destination were compared between MTCs and trauma units or local emergency hospitals (TU/LEHs) using an adjusted multiple logistic regression model.
127 334 patients were included, of whom 27.6% attended an MTC. The median age was 79.4 years (IQR 64.5-87.2 years), and 74.2% of patients were aged >65 years. MTC care was not associated with improved 30-day survival (adjusted OR (AOR) 0.91, 95% CI 0.87 to 0.96, p<0.001). Transferred patients had a significant impact on the results. After excluding transferred patients, MTC care was associated with greater odds of 30-day survival (AOR 1.056, 95% CI 1.001 to 1.113, p=0.044). MTC care was also associated with greater odds of 30-day survival in the most severely injured patients (AOR 1.126, 95% CI 1.04 to 1.22, p=0.002), but not in patients aged >65 years (AOR 1.038, 95% CI 0.982 to 1.097, p=0.184).
MTC care was not associated with improved survival compared with TU/LEH care in the whole cohort. Patients who were transferred had a significant impact on the results. In patients who are not transferred, MTC care is associated with greater odds of 30-day survival in the whole cohort and in the most severely injured patients. Future research must determine the optimum means of identifying patients in need of higher-level care, the components of care which improve patient outcomes, develop patient-focused outcomes which reflect the characteristics and priorities of contemporary trauma patients, and investigate the need for transfer in specific subgroups of patients.
Traumatic brain injury (TBI) remains a leading cause of death and disability. The National Institute for Health and Clinical Excellence (NICE) guidelines recommend transfer of severe TBI cases to ...neurosurgical centres, irrespective of the need for neurosurgery. This observational study investigated the risk-adjusted mortality of isolated TBI admissions in England/Wales, and Victoria, Australia, and the impact of neurosurgical centre management on outcomes.
Isolated TBI admissions (>15 years, July 2005-June 2006) were extracted from the hospital discharge datasets for both jurisdictions. Severe isolated TBI (AIS severity >3) admissions were provided by the Trauma Audit and Research Network (TARN) and Victorian State Trauma Registry (VSTR) for England/Wales, and Victoria, respectively. Multivariable logistic regression was used to compare risk-adjusted mortality between jurisdictions.
Mortality was 12% (749/6256) in England/Wales and 9% (91/1048) in Victoria for isolated TBI admissions. Adjusted odds of death in England/Wales were higher compared to Victoria overall (OR 2.0, 95% CI: 1.6, 2.5), and for cases <65 years (OR 2.36, 95% CI: 1.51, 3.69). For severe TBI, mortality was 23% (133/575) for TARN and 20% (68/346) for VSTR, with 72% of TARN and 86% of VSTR cases managed at a neurosurgical centre. The adjusted mortality odds for severe TBI cases in TARN were higher compared to the VSTR (OR 1.45, 95% CI: 0.96, 2.19), but particularly for cases <65 years (OR 2.04, 95% CI: 1.07, 3.90). Neurosurgical centre management modified the effect overall (OR 1.12, 95% CI: 0.73, 1.74) and for cases <65 years (OR 1.53, 95% CI: 0.77, 3.03).
The risk-adjusted odds of mortality for all isolated TBI admissions, and severe TBI cases, were higher in England/Wales when compared to Victoria. The lower percentage of cases managed at neurosurgical centres in England and Wales was an explanatory factor, supporting the changes made to the NICE guidelines.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Ground-level ozone (O3) is an air contaminant and can be harmful to the human health and environment. The objective of this study is to analyze the statistical trend of O3 and the association between ...the daily O3 exposure and mortality in Tehran, and to estimate the short-term health benefits of reducing the concentration of O3 in the ambient air of Tehran.
The statistical parameters such as the mean, coefficient of variation, skewness, and kurtosis of O3 concentration for warm and cold seasons were calculated. The association and temporal relationship between the daily O3 concentration and different causes of mortality were analyzed using the generalized additive model (GAM). We utilized the BenMAP software to estimate the (short-term) avoidable mortality associated with reducing O3 concentration to the US EPA's standard level (70 ppb) for a full year and the warm seasons only.
The statistical analysis of O3 revealed an increase in the 1-h maximum and 8-h maximum concentrations in recent years. The association between O3 exposure and mortality was significant for the warm seasons when the concentration was highest. For every 10 ppb increase in the O3 concentration, there was 1.2% increase in mortality. Furthermore, the association was more significant for cardiovascular than respiratory attributed mortality. The analysis also showed a 3-day lag from the time of O3 exposure and mortality for the total population. The aforementioned scenario (for a full year) run in BenMAP resulted in 508 (90% CI: 69–937) annual all-cause avoidable deaths in Tehran.
The maximum O3 concentration in Tehran has been increasing in the recent years, raising the alarm for potential adverse health impacts. In this study we found a significant association between short-term exposure to O3 and mortality during the warm seasons and a substantial predicted health benefit in reduction of this pollutant. Given the increasing ambient O3 concentration, it is necessary to further explore the aetiology/ies behind this increase and to consider how reductions in O3 precursors can reduce the public health burden in Tehran.
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•The maximum concentration of O3 has risen over the last few years.•O3 concentration is associated with mortality in warm seasons.•10 ppb increase in the O3 concentration, results in 1.2% increase in mortality.•Reducing O3 to its standard limit could prevent 508 deaths annually.
Abstract
Background
Trauma places a significant burden on healthcare services, and its management impacts greatly on the injured patient. The demographic of major trauma is changing as the population ...ages, increasingly unveiling gaps in processes of managing older patients. Key to improving patient care is the ability to characterise current patient distribution.
Objectives
There is no contemporary evidence available to characterise how age impacts on trauma patient distribution at a national level. Through an analysis of the Trauma Audit Research Network (TARN) database, we describe the nature of Major Trauma in England since the configuration of regional trauma networks, with focus on injury distribution, ultimate treating institution and any transfer in-between.
Methods
The TARN database was analysed for all patients presenting from April 2012 to the end of October 2017 in NHS England.
Results
About 307,307 patients were included, of which 63.8% presented directly to a non-specialist hospital (trauma unit (TU)). Fall from standing height in older patients, presenting and largely remaining in TUs, dominates the English trauma caseload. Contrary to perception, major trauma patients currently are being cared for in both specialist (major trauma centres (MTCs)) and non-specialist (TU) hospitals. Paediatric trauma accounts for <5% of trauma cases and is focussed on paediatric MTCs.
Conclusions
Within adult major trauma patients in England, mechanism of injury is dominated by low level falls, particularly in older people. These patients are predominately cared for in TUs. This work illustrates the reality of current care pathways for major trauma patients in England in the recently configured regional trauma networks.
BackgroundThe preparation for critically ill children involves calculating drug and fluid volumes using the commonly taught WETFLAG (weight, energy, endotracheal tube, fluids, lorazepam, adrenaline, ...glucose) acronym. While smartphone applications (apps) are increasingly used for these calculations in clinical practice, limited studies have explored their accuracy and safety.AimTo assess the accuracy of three calculation methods for paediatric emergency drug doses and fluid volumes: a smartphone app, reference charts and traditional calculation methods. The secondary aims were to investigate the effect on the time taken and self-reported stress levels.MethodsA convenience sample of healthcare professionals from four hospitals contributed. Participants calculated drug and fluid doses for fictional patients using the three different methods. The method and case order were randomised centrally. The study recorded the number of errors made during the calculations, healthcare professionals’ self-reported stress levels on a scale of 0 (no stress) to 10 (maximum stress) and the time taken for each case. The app was developed at the direct request of the study team.ResultsNinety-six participants calculated values for six fictional cases, resulting in 576 calculations. Traditional calculation methods showed a statistically significant higher rate of error compared with the use of a smartphone app or reference charts (mean=1, 0, 0, respectively). The smartphone app outperformed both traditional calculation methods and reference charts for time taken and user-reported stress levels.ConclusionsTraditional methods of ‘WETFLAG’ drug and fluid calculations are associated with a statistically significant increased risk of error compared with the use of reference charts or smartphone app. The smartphone app proved significantly faster and less stressful to use compared with traditional calculation methods or reference charts.
Management of patients with head injury Mendelow, A David, Prof; Timothy, Jake, FRCS; Steers, James W, FRCS ...
The Lancet (British edition),
08/2008, Letnik:
372, Številka:
9639
Journal Article
Recenzirano
Revised UK guidelines from the National Institute for Health and Clinical Excellence (NICE) for the management of acute head injury address the initial management and triage/ Evidence has also shown ...that even patients who have sustained a minor head injury have difficulty reintegrating into society.5 Thus, management of head injury is an important topic. The principles for the triage of patients with head injuries were set out in the Royal College of Surgeons' report in 2005.11 This report and the Scottish Intercollegiate Guidelines Network6 were largely based on clinical risk factors and the presence of a skull fracture radiograph.15 This approach resulted in about 5% of patients (about 50000 patients per year in the UK) with head injury proceeding to a CT scan.
•Older patients are the majority of trauma victims in England and Wales.•Marked variations exist in the older trauma population structure and in their management across regional networks.•Older ...patients are not routinely cared for by senior clinicians, including patients with significant brain injury.•Change is needed to optimise care of this numerous and vulnerable trauma population.
The establishment of national trauma networks have resulted in significant benefits to injured patients. Older people are the majority of major trauma patients and there is need to study variations in care and performance against clinical metrics for them. We aim to describe this patient group in terms of injury, demographics, episode of care assessment and variation between component regions of the Major Trauma Network of England and Wales.
The Trauma Audit and Research Network (TARN) database was analysed from April 2017 to March 2019. Patients aged 65 years and above with injury severity score (ISS) greater than eight were selected for analysis. Patients were compared by care pathway in terms of first and second treating hospitals and by demographics, injury mechanism, severity, physiology at arrival to hospital (including Glasgow Coma Score (GCS)) and mortality, where known, at discharge.
Fifty-three thousand three hundred and forty-seven older injured patients (median age 82.5 years and 58.2% female), were treated in 165 hospitals within the 17 regional trauma networks over the two-year study period. Aside from GCS and gender, all other patient characteristics were significantly different between networks and specifically, a large variation between the network with the highest proportion of older patients (60.4%) and that with a preponderance of younger patients (40.2%) is seen. 84% of cases were due to a fall <2 m and 36.7% of cases had a brain injury. 73.5% of cases had one or more comorbidities.
We have increased the understanding of how older patients contribute to and are managed by a national trauma service. We have demonstrated variation in numbers and patient characteristics throughout regional trauma networks. We have detailed the whole patient episode, allowing us to comment on disparities in management such as senior review and access to specialist clinical care settings. Older patients dominate United Kingdom major trauma and considerable variations and shortfalls have been identified. Work is needed to focus on the whole clinical episode for these patients both to improve outcome and patient experience but to also to ensure sustainable clinical care in a resource deplete era.
AimsAdolescent trauma patients transition through services and dependent on age, may be managed in either paediatric, adult or mixed trauma departments. Clinicians are posed with a dilemma whether to ...follow adult or paediatric trauma guidelines. There is currently little in the way of published studies which compare adolescent (10-24) trauma patterns and interventions to adult (³25) or paediatric (<10) data.MethodsData were collected from the national Trauma and Audit Research Network (TARN) database for all adolescent trauma episodes in England, Wales and Northern Ireland over a 10-year period (January 2010 to December 2019). The aim is to compare adolescent trauma patterns and interventions to adult and paediatric cases. We performed direct comparison of demographics and analysis of continuous variables with Mood’s test.ResultsA total of 505,162 TARN cases were included. A number of trauma descriptors or outcomes were more prevalent in adolescent group. Road traffic accidents are the most common mechanism of injury in the adolescent group, in contrast to both the paediatric and adult group where falls <2m were most common. Violence related injury (shootings and stabbings) were also more common in the adolescent group; 9.4% compared with 0.3% and 1.5% in the paediatric and adult groups respectively. The adolescent grouping had the highest median injury severity score and the highest proportion of interventions (blood products, chest drain insertion, thoracotomy and cricothyroidotomy).The adolescent group also often encapsulated trends occurring due to increasing age. The proportion of cases due to stabbing peaks at 17 (11.8%), becoming the second most common MOI. The median ISS remains at 9 until aged 15, peaking at 13 in 18-year-olds. The percentage of cases that fulfil the definition of polytrauma enters double figures (11.8%) at 15 reaching a peak of 17.6% at age 18. The use of blood products within the first 6 hours remains around 2% (1.6-2.8%) until 15 (3.4%), increasing to 4.7% at age 16. Chest drain insertion peaks at 9.6% at age 17.ConclusionTrauma patterns are more closely aligned between adult and paediatric cohorts, than adolescence with our results suggesting they are a unique entity. However, there is considerable change during adolescence meaning the common division of paediatric to adult trauma care at 16 years to be an imperfect but not unreasonable service model. Training, trauma resources and responses need to be implemented with the adolescent group in mind with specific consideration for targeted prevention given the different predominant mechanisms of injury in this group.
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