key: cord-0982079-k8pc9kv5
authors: Santos, Adora Tricia; de Roulet, Amory; Thorson, Teagan; Lee, Benjamin; Khariton, Konstantin
title: Tracheostomy in the Time of COVID: Experience From a High Volume Center
date: 2021-11-30
journal: Journal of the American College of Surgeons
DOI: 10.1016/j.jamcollsurg.2021.08.611
sha: aeefde2d431570fe6f971dcb66c75693aa159bfc
doc_id: 982079
cord_uid: k8pc9kv5

nan

incidence, indication, and efficacy of tourniquet placement in acute trauma resuscitation. METHODS: Regional Level 1 Trauma Centers prospectively enrolled for 12 months adult patients (18yrs) who had a tourniquet placed. Age, gender, mechanism, tourniquet type, indication, applying personnel, and location placed were collected. Occlusion, hemostasis, major vascular injury, imaging and operations performed, and outcomes were assessed.

RESULTS: Nine trauma centers received 156 patients with 163 tourniquets. Patients were most often male (134, 86.5%) with penetrating injuries (132, 85.7%) from gunshots (85, 54.7%). Commercial tourniquets were used most (93.3% windlass, 4.3% improvised). 88.9% were placed in the prehospital setting (by fire/paramedics 49.7%, police 39.9%, bystanders 2.6%). The most common indications were pooling (54.7%) and pulsatile (36.7%) hemorrhage. Tourniquets were placed high proximal extremity (66.9%) with 4% covering and 1.3% distal to the wound. Median application time was 30min (IQR 20-41min). Overall, 45.2% had a named vascular injury. Only 60.8% of applications were arteriovenous occlusive, 78.1% in patients with arterial injury. Tourniquet application failed to achieve hemostasis in 24.3% with a named vascular injury. There was no difference in hemostasis between those with and without vascular injury (p¼0.66) or between agencies placing the tourniquet (p¼0.53). 58 patients (37.7%) required vascular operations including 21 fasciotomies.

CONCLUSION: Discerning which injuries require tourniquets remains elusive. Given trained responders only deployed tourniquets as successfully as untrained laypersons, more emphasis on education, training, and device development is needed. Outcomes and optimal timing of TC are not well studied in patients with COVID-19 associated critical illness. This study reviews the outcomes of patients who underwent TC for COVID-19 respiratory failure.

METHODS: This is a retrospective review of 64 consecutive TCs at a single center. Institutional criteria for TC were intubation >10 days, FiO 2 60%, PEEP 10, and low vasopressors requirements. The primary outcome of interest was mortality. Secondary outcomes included time to tracheostomy, post tracheostomy ICU length of stay (LOS), decannulation rates, ventilator associated pneumonia (VAP) rates and hospital discharge rates.

Of the 64 patients, 64% were male with a mean age of 62.3 years, with Hispanics making up 60.3%. The overall mortality rate was 40.6%. Median time to TC was 15 days with post-TC ICU LOS averaging 15 days. Average time to downsizing was 10 days. 18.8% were decannulated prior to discharge, and 59.4% were discharged from the hospital. Average time to decannulation was 31 days. Post-tracheostomy VAP rates were 15.9%. Factors associated with mortality were P:F ratios, FiO 2 and PEEP settings at time of TC. A nonparametric smoothed graph shows inflection points at P:F ratio <200, PEEP>10 and FiO 2 >70% at which point mortality increased.

The optimal criteria for TC in patients with the novel COVID-19 virus is unclear. At our institution, we noted a relationship between P:F ratios, FiO 2 , and PEEP settings at time of TC and mortality.

44 (81%) underwent angioembolization (AE) and 30d mortality was 24.1%. Survivors were younger (41 vs 50y, p¼0.007), received less blood prior to AE

The only independent predictor of gluteal artery AE was higher ISS (p¼0.027) after controlling for SBP, HR, Hgb, platelets, INR, pRBC, FFP, age, gender, GCS, anticoagulation and mechanism. Independent predictors of mortality were ISS (p¼0.0398), Age (p¼0.0107) and pre-angiogram pRBC (p¼0.0427) after controlling for gender

INTRODUCTION: Significance of gluteal artery injuries has rarely been described in the trauma literature. To fill this gap, we looked at the incidence and management of this injury and its potential significance on morbidity and mortality dependent on patient characteristics and mode of management.METHODS: Retrospective single center study (01/2009-12/2018) including all adult (18yo) trauma patients with gluteal artery injury based on primordial word search of Computed Tomographic Angiography (CTA) or angiogram with confirmed extravasation by report. Demographics, interventions and outcomes were compared with descriptive statistics and multivariate logistic regression.