key: cord-0935230-7kfooh3e
authors: Adams, Alexandra M.; Laverty, Robert B.; McCarthy, Patrick M.; Marcus, Joseph E.; Boster, Joshua M.; Sattler, Lauren A.; Sobieszczyk, Michal J.; Mason, Phillip E.; Sams, Valerie G.
title: Tracheostomy Placement in Patients with Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation: Did COVID-19 Change Our Practice?
date: 2021-11-30
journal: Journal of the American College of Surgeons
DOI: 10.1016/j.jamcollsurg.2021.08.569
sha: 6b6a2238b7a2acdec167ad9b045d83f0d4e85703
doc_id: 935230
cord_uid: 7kfooh3e

nan

INTRODUCTION: Injury represents a hazardous event that can have long-lasting consequences for both the injured individual and their community. The Social Vulnerability Index (SVI) is a measure used in emergency preparedness to identify need for resources in the event of a disaster or hazardous event, ranking each census tract on 15 demographic/social factors. To inform clinical decision-making for trauma patients, we sought to evaluate SVI as a predictor of long-term trauma outcomes.

METHODS: Moderate-severely injured patients (ISS 9) treated at one of three level-1 trauma centers were asked to complete a phone-based survey to assess outcomes 6-12 months post-injury. These data were matched at the census tract level with overall SVI and with the four SVI themes of socioeconomic status, household composition & disability, minority status & language, and housing type & transportation. Multivariable adjusted regression models were used to assess whether SVI factors were associated with long-term outcomes after injury.

RESULTS: A total of 3,153 patients were included [54% male, mean age 61.6 (SD¼ 21.6) and mean ISS 14.2 (SD¼ 7.4)]. The median overall SVI percentile rank was 35 th (IQR: 16 th -65 th ) with higher values indicating greater community vulnerability. After adjusting for confounders, higher SVI rankings were associated with worse long-term outcomes.

The SVI has potential utility in predicting individuals at higher risk for adverse long-term outcomes after injury. This measure may be a useful needs assessment tool for clinicians and researchers in identifying communities that may benefit most from targeted intervention and prevention efforts.

The Trauma Population and Post-hospital Disposition Across the US Trauma System Mason Sutherland, BS, Adel Elkbuli, MD, MPH, MBA Kendall Regional Medical Center, Miami, FL INTRODUCTION: Investigations detailing predictive measures of hospital disposition after traumatic injury are scarce. We aim to evaluate the hospital disposition of trauma patients to identify factors that best predict discharge location and the likelihood of posthospitalization rehabilitation requirements.

Retrospective cohort analysis of adult and pediatric patients registered in the ACS-TQIP database from 2007-2017. Primary outcome: hospital disposition (acute care facility, longterm care facility (LTC), others). Secondary outcomes: ICU-length of stay (LOS), hospital-LOS, and complications (DVT, PE, CVA/ stroke, acute myocardial infarction, etc.).

: 6,899,538 patients were analyzed. Odds of LTC discharge was significantly higher for black patients (aOR¼1.30, 95% CI:1.24-1.37), those who underwent surgical procedure (aOR¼4.59, 95% CI:4.19-5.03), had abbreviated injury score (AIS) 3 (aOR¼4.22, 95%CI: 4.05-4.39), higher Injury Severity Score (ISS) (aOR¼9.41, 95% CI:9.03-9.80), were critically ill (aOR¼4.09, 95% CI: 3.92-4.27), and were treated at an ACS-verified trauma center (aOR¼1.21, 95% CI:1.17-1.25). Significantly more self-pay patients were discharged home compared to other insurance types (p< 0.0001). Significantly longer hospital-and ICU-LOS were experienced by those who underwent a surgical procedure (p< 0.0001), had an AIS 3 (p< 0.0001), and had a high ISS (p< 0.0001).

CONCLUSION: Patient race, insurance, and injury severity were predictive of post-hospitalization care discharge. Such data has the potential to help refine the in-hospital patient management process and predict discharge secondary care needs, but may suggest that particular groups are at higher risk of insufficient secondary care. Future investigations are needed to better understand how differences in access impacts overall functional status outcomes.

Patients with COVID-19 and acute respiratory distress syndrome (ARDS) requiring venovenous extracorporeal membrane oxygenation (VV ECMO) support frequently require prolonged ventilation and tracheostomy. We sought to determine differences in practices and outcomes between patients with and without COVID-19.

We performed a single institution, retrospective case-control study including all patients requiring VV ECMO for COVID-19 related ARDS, who were matched 1:1 for age and gender to patients requiring VV ECMO for ARDS diagnosis from January 2018-January 2020. The primary outcome was performance of tracheostomy. Secondary measures included tracheostomy placement practices and outcomes.

Twenty-five patients with COVID-19 and 25 non-COVID ARDS on VV ECMO were included. There were no differences in BMI or comorbidities between groups. More COVID-19 patients underwent tracheostomy compared to controls [84% vs 44%, p¼0.003; OR 6.68 (95% CI 1.77-25.25)]. There was no difference in percutaneous vs open technique between the two groups (61.9% vs 63.9%, p¼0.923). Median days to tracheostomy was greater in COVID-19 patients (14 vs 6 days, p¼0.020). COVID-19 patients were more likely to be on anti-platelet therapy at time of tracheostomy (42.8% vs 9.1%, p¼0.050) and less likely to have therapeutic anticoagulation held for the procedure (71.4% vs 100%, p¼0.049). There were no differences in bleeding or thrombotic complications, or rates of tracheostomy downsizing or ventilator liberation.

CONCLUSION: Tracheostomy placement is common but performed later among COVID-19 patients with ARDS requiring ECMO. We observed no difference in placement technique in this group. Continuing anticoagulation and antiplatelet therapy appears to be safe. pandemic have impacted all areas of the medical profession. Several reports have indicated that trauma admissions decreased in high income countries during the pandemic with changing trends in the presenting traumas. The aim of this study was to determine if this was the case for one of the largest public hospitals in a lowand middle-income country.

METHODS: Demographic data and trauma outcomes from the Injury Support Initiative for Trauma (INSIGHT) database was retrospectively analyzed from a prospectively collected trauma registry in the largest public hospital in a LMIC. This facility functions as the main referral trauma hospital for the whole country. Trauma admissions from October 2019 to March 2020 and admissions from September 2020 to February 2021 were analyzed using Z-scores and student s t-distribution for nominal and interval variables respectively.

The trauma-related hospital admissions involving nonintentional injuries decreased from 59.6% to 50.5% (p < 0.05). Penetrating injuries due to violence remained unchanged (22.8 vs 23.8, p ¼ 0.75). Interpersonal assaults decreased from 3.77% to 1% (p < 0.05). Mortality slightly increased from 11.5% to 12.8%, but this was not statistically significant (p ¼ 0.6).

The overall proportion of nonintentional injury related hospital admissions decreased significantly; however, penetrating injuries described as gunshot wounds and stabbings persisted, despite COVID related restrictions in a LMIC. The

Computed tomography (CT) of the chest (CTC), abdomen, and pelvis (CTAP) has become increasingly common when assessing trauma patients in the emergency department (ED). However, excessive imaging can expose patients to unnecessary radiation and increase healthcare costs. Here, we characterize the trends of torso CT imaging for the evaluation of ground level falls (GLF) at our level 1 trauma center. METHODS: Patients 18 presenting to our ED with a GLF (1m or less) in 2018-2019 were included. Data was obtained through chart review. Descriptive statistics were used to summarize the patient demographics, the use of torso CT's, and health outcomes

Multivariate logistic regression demonstrated a significant increase in the use of CTCAP over time when controlling for age, gender, race, primary language, physical exam findings, injury severity score

CONCLUSION: GLF patients evaluated in our ED have had an increase in the use of CTCAP over time even when adjusting for factors that would traditionally prompt CTCAP in this population. Delineation of specific guidelines prompting imaging of this patient population is needed to reduce unnecessary healthcare expenditures and minimize radiation exposure