OBJECTIVES/GOALS: Patient reported outcomes (PROs) provide unique insight to the patients experience with their healthcare related quality of life QoL. This study aims to 1. Characterize geriatric ...trauma patients’(GTPs) perceived QoL, at time of injury vs. 3- and 6-months post-injury. 2. Introduce and validate a PROs tool, known as the Five Favorite Activities. METHODS/STUDY POPULATION: This is a prospective cohort study of older adults (≥65) presenting to our trauma center with mild traumatic brain injury and/or mild spine, thoracic or extremity fractures. Participants will be asked to complete the NIH-validated Patient-Reported Outcome Measure Information System (PROMIS)-29, PROMIS Cognitive and Functional Abilities, Life-Space Levels and Five Favorite Activities assessment (a list of the five favorite overall and daily activities) tools. Cognitive function will be measured using Montreal Cognitive Assessment tool. Physical function will be evaluated using the Activity Measure for Post-Acute Care 6-click tool. Patients will be contacted at 3- and 6- months post discharge and asked to complete the assessment tools listed above to evaluate changes in QoL during the recovery process. RESULTS/ANTICIPATED RESULTS: We hypothesize that geriatric trauma patients will experience a decline in QoL, physical and cognitive function post-injury. This decline will be associated with a decrease in return to the ability to participate in their pre-injury Five Favorite Activities . DISCUSSION/SIGNIFICANCE: First, this study is one of the first to evaluate PROMs in GTPs. Second, the Five Favorite Activities PROM, will provide a unique, direct and individualized characterization of what GTPs find important to their recovery post injury compared to the current generic PROMs. This information can be utilized in the future to align goal of care with expectations
A life-threatening complication of coronavirus disease 2019 (COVID-19) is acute respiratory distress syndrome (ARDS) refractory to conventional management. Venovenous (VV) extracorporeal membrane ...oxygenation (ECMO) (VV-ECMO) is used to support patients with ARDS in whom conventional management fails. Scoring systems to predict mortality in VV-ECMO remain unvalidated in COVID-19 ARDS. This report describes a large single-center experience with VV-ECMO in COVID-19 and assesses the utility of standard risk calculators.
A retrospective review of a prospective database of all patients with COVID-19 who underwent VV-ECMO cannulation between March 15 and June 27, 2020 at a single academic center was performed. Demographic, clinical, and ECMO characteristics were collected. The primary outcome was in-hospital mortality; survivor and nonsurvivor cohorts were compared by using univariate and bivariate analyses.
Forty patients who had COVID-19 and underwent ECMO were identified. Of the 33 patients (82.5%) in whom ECMO had been discontinued at the time of analysis, 18 patients (54.5%) survived to hospital discharge, and 15 (45.5%) died during ECMO. Nonsurvivors presented with a statistically significant higher Prediction of Survival on ECMO Therapy (PRESET)-Score (mean ± SD, 8.33 ± 0.8 vs 6.17 ± 1.8; P = .001). The PRESET score demonstrated accurate mortality prediction. All patients with a PRESET-Score of 6 or lowers survived, and a score of 7 or higher was associated with a dramatic increase in mortality.
These results suggest that favorable outcomes are possible in patients with COVID-19 who undergo ECMO at high-volume centers. This study demonstrated an association between the PRESET-Score and survival in patients with COVID-19 who underwent VV-ECMO. Standard risk calculators may aid in appropriate selection of patients with COVID-19 ARDS for ECMO.
Background
Older adults (OAs) ≥ 65 years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures ...(EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA compared to their younger counterparts in the state of Maryland.
Methods
A retrospective review of the Maryland Health Services Cost Review Commission from 2009 to 2018 was undertaken. Patients undergoing urgent or emergent ESGP were divided into 2 groups (18-64 years and ≥65 years). Data collected included demographics, APR-severity of illness (SOI), APR-risk of mortality (ROM), the EGSP (partial colectomy PC, small bowel resection SBR, cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and laparotomy), length of stay (LOS), and hospital charges. P-values (P < .05) were significant.
Results
Of the 181,283 patients included in the study, 55,401 (38.1%) were ≥65 years of age. Older adults presented with greater APR-SOI (major 37.7% vs 21.3%, extreme 5.2% vs 9.3%), greater APR-ROM (major 25.3% vs 8.7%, extreme 22.3% vs 5.3%), underwent PC (24.5% vs 10.9%) and SBR (12.8% vs 7.0%) more frequently, and incurred significantly higher median hospital charges for every EGSP, consistently between 2009 and 2018 due to increased LOS and complications when compared to those ≤65 years of age.
Conclusion
These findings stress the need for validated frailty indices and quality improvement initiatives focused on the care of OAs in emergency general surgery to maximize outcomes and optimize cost.
Background
Older adults (OAs; ≥ 65 years) comprise a growing population in the United States and are anticipated to require an increasing number of emergency general surgery procedures (EGSPs). The ...aims of this study were to identify the frequency of EGSPs and compare cost of care in OAs managed at teaching hospitals (THs) vs nonteaching hospitals (NTHs).
Methods
A retrospective review of data from the Maryland Health Services Cost Review Commission database from 2009 to 2018 for OAs undergoing EGSPs was undertaken. Data collected included demographics, all patient-refined (APR)-severity of illness (SOI), APR-risk of mortality (ROM), Charlson Comorbidity Index (CCI), EGSPs (partial colectomy (PC), small bowel resection, cholecystectomy, operative management of peptic ulcers, lysis of adhesions, appendectomy, and laparotomy, categorized hospital charges, length of stay (LOS), and mortality.
Results
Of the 55,401 OAs undergoing EGSPs in this study, 28,575 (51.6%) were treated at THs and 26,826 (48.4%) at NTHs. OAs at THs presented with greater APR-ROM (major 25.6% vs 24.9%, extreme 22.6% vs 22.0%, P=.01), and CCI (3.1±3 vs 2.7±2.8, P<.001) compared to NTHs. Lysis of adhesions, cholecystectomy, and PC comprised the overall most common EGSPs. Older adults at THs incurred comparatively higher median hospital charges for every EGSP due to increased room charges and LOS. Mortality was higher at THs (6.13% vs 5.33%, P<.001).
Conclusion
While acuity of illness appears similar, cost of undergoing EGSPs for OAs is higher in THs vs NTHs due to increased LOS. Future work is warranted to determine and mitigate factors that increase LOS at THs.
Rib fractures (RFx) remain the most prevalent injury in an elderly population that will increase from 40 to 81 million for the next 30 years. We sought to create an accurate cost-effective algorithm ...to triage elderly patients with RFx that accounted for both frailty and trauma burden.
Retrospective analysis evaluated 400 patients older than 55 years with RFx admitted to a level 1 trauma center from 2007 to 2012. Comorbidities included chronic obstructive pulmonary disease, congestive heart failure, tobacco use, obesity, and nutrition and functional status. Trauma burden included RFx, tube thoracostomy, pulmonary contusions, and spine and extremity fractures. Patients with Glasgow Coma Scale scores lower than 13, thoracoabdominal surgery, or deaths from other causes were excluded. Comparative analysis used bivariate and logistic regression. Variables contributing to intubation (INT) and pneumonia (PNA) were then used to create a scoring system to predict the need for intensive care unit (ICU) admission.
Six variables increased the risk for INT or PNA: chronic obstructive pulmonary disease, low albumin, assisted status, tube thoracostomy, Injury Severity Score, and RFx (p < 0.05). These six variables and congestive heart failure (odds ratio, 1.9; p = 0.06) were used to create a predictive model with the following scores assigned respectively: 1.4, 1.1, 1, 0.9, 0.1(n), 0.1(n), and 0.6. A score lower than 3.7 had a sensitivity and specificity of 78.5% and 78.9%. The negative predictive value was 94.5% for INT or PNA, suggesting a low risk for ICU requirement. Ninety-two ICU admissions had a score lower than 3.7. Forty had no other indication for ICU admission aside from RFx. These patients had an average ICU length of stay of 1.7 days, resulting in an increased cost of $2,200 per patient.
A scoring system combining frailty and trauma burden may provide more accurate and cost-effective triage of the elderly trauma patient with RFx. Further prospective studies are required to verify our scoring system.
Prognostic and epidemiologic study, level III.
Introduction
The PREdiction of Survival on ECMO Therapy Score (PRESET-Score) predicts mortality while on veno-venous extracorporeal membrane oxygenation (VV ECMO) for acute respiratory distress ...syndrome. The aim of our study was to assess the association between PRESET-Score and survival in a large COVID-19 VV ECMO cohort.
Methods
This was a single-center retrospective study of COVID-19 VV ECMO patients from 15 March 2020, to 30 November 2021. Univariable and Multivariable analyses were performed to assess patient survival and score differences.
Results
A total of 105 patients were included in our analysis with a mean PRESET-Score of 6.74. Overall survival was 65.71%. The mean PRESET-Score was significantly lower in the survivor group (6.03 vs 8.11, p < 0.001). Patients with a PRESET-Score less than or equal to six had improved survival compared to those with a PRESET-Score greater than or equal to 8 (97.7% vs. 32.5%, p < 0.001). In a multivariable logistic regression, a lower PRESET-Score was also predictive of survival (OR 2.84, 95% CI 1.75, 4.63, p < 0.001).
Conclusion
We demonstrate that lower PRESET scores are associated with improved survival. The utilization of this validated, quantifiable, and objective scoring system to help identify COVID-19 patients with the greatest potential to benefit from VV-ECMO appears feasible. The incorporation of the PRESET-Score into institutional ECMO candidacy guidelines can help insure and improve access of this limited healthcare resource to all critically ill patients.
Abstract Background Damage-control surgery frequently results in open abdomen. The objective of this study was to determine whether resuscitation with goal-directed fluid therapy (GDT) using ...“dynamic” hemodynamic indices via modern pulse contour analysis devices such as the FloTrac Vigileo monitor leads to lower fluid requirements, subsequent quicker abdominal closure, and overall improved outcomes in these patients. Methods Patients admitted to the surgical intensive care unit with open abdomen were retrospectively reviewed. Those resuscitated with Vigileo-guided GDT were matched to those resuscitated by static clinical parameters. Results Total fluid intake and vasopressor requirements were similar in both groups. GDT with the Vigileo allowed earlier lactate clearance and reduced the number of days until abdominal wall closure by an average of .99 days. Conclusions Vigileo-mediated GDT did not affect fluid volume or vasopressor use in open abdomen patients, but facilitated more effective resuscitation and decreased the number of days to fascial closure, leading to shorter hospital stays. Vigileo-mediated GDT, therefore, may improve overall outcomes in open abdomen patients.
Despite increasing diversity in research recruitment, research finding reporting by gender, race, ethnicity, and sex has remained up to the discretion of authors. This study developped and piloted ...tools to standardize the inclusive reporting of gender, race, ethnicity, and sex in health research. A modified Delphi approach was used to develop standardized tools for the inclusive reporting of gender, race, ethnicity, and sex in health research. Health research, social epidemiology, sociology, and medical anthropology experts from 11 different universities participated in the Delphi process. The tools were pilot tested on 85 health research manuscripts in top health research journals to determine inter-rater reliability of the tools. The tools each spanned five dimensions for both sex and gender as well as race and ethnicity: Author inclusiveness, Participant inclusiveness, Nomenclature reporting, Descriptive reporting, and Outcomes reporting for each subpopulation. The sex and gender tool had a median score of 6 and a range of 1–15 out of 16 possible points. The percent agreement between reviewers piloting the sex and gender tool was 82%. The interrater reliability or average Cohen’s Kappa was 0
.
54 with a standard deviation of 0
.
33 demonstrating moderate agreement. The race and ethnicity tool had a median score of 1 and a range of 0–15 out of 16 possible points. Race and ethnicity were both reported in only 25
.
8% of studies evaluated. Most studies that reported race reported only the largest subgroups; White, Black, and Latinx. The percent agreement between reviewers piloting the race and ethnicity tool was 84 and average Cohen’s Kappa was 0
.
61 with a standard deviation of 0
.
38 demonstrating substantial agreement. While the overall dimension scores were low (indicating low inclusivity), the interrater reliability measures indicated moderate to substantial agreement for the respective tools. Efforts in recruitment alone will not provide more inclusive literature without improving reporting.
Acute portal vein thrombosis complicated by mesenteric ischemia requires emergent treatment to address the compromised bowel as well as the portal vein thrombus. We report a novel hybrid approach to ...managing this disease process. The procedure we discuss entails exploratory laparotomy and small bowel resection by the acute care emergency surgery team. Following this, the vascular surgery team performs a portal venogram through a branch mesenteric vein accessed through the laparotomy incision and then places a thrombolysis catheter. This technique and approach allows us to provide initial management efficiently and effectively under one operation.
In trauma patients with cirrhosis who require laparotomy, little data exists to establish clinical predictors of the outcome. We sought to determine the prognosticators of mortality in this ...population.
We performed a 10-year review at four, busy Level I trauma centers of patients with cirrhosis identified during trauma laparotomy. We compared vital signs, laboratory values, and transfusion requirements for those who survived versus those who died. A linear regression was then conducted to determine the variables associated with death in this population.
A total of 66 patients were included and 47% (31/66) died. The model for end-stage liver disease (MELD) score was low (7.8 in Lived, 10.2 in Died). Packed red blood cell (PRBC) transfusion at six hours was greater in those who died; those receiving > 6 units of PRBCs at 6 hours had an increased likelihood of death (odds ratio OR 5.8 (95% CI 1.9, 17.4)). All patients receiving ≥ 17 units of PRBCs died. We found an association between lower preoperative platelets (PLTs), higher preoperative international normalized ratio (INR) and partial thromboplastin time (PTT), lower preoperative pH (presence of profound acidemia), increased intraoperative crystalloid use, and increased intraoperative blood product administration to be associated with death (p < 0.05).
Cirrhotic trauma patients requiring laparotomy should be considered to have a high chance of mortality if they receive six or more PRBCs, are acidotic (pH ≤ 7.25) at the time of hospital arrival, or have coagulopathy at the time of admission (INR > 1.2, PTT > 40).
PDF
