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  1. Article ; Online: Early Vital Sign Thresholds Associated with 24-Hour Mortality among Trauma Patients: A Trauma Quality Improvement Program (TQIP) Study.

    April, Michael D / Fisher, Andrew D / Rizzo, Julie A / Wright, Franklin L / Winkle, Julie M / Schauer, Steven G

    Prehospital and disaster medicine

    2024  Volume 39, Issue 2, Page(s) 151–155

    Abstract: Background: Identifying patients at imminent risk of death is critical in the management of trauma patients. This study measures the vital sign thresholds associated with death among trauma patients.: Methods: This study included data from patients ≥ ... ...

    Abstract Background: Identifying patients at imminent risk of death is critical in the management of trauma patients. This study measures the vital sign thresholds associated with death among trauma patients.
    Methods: This study included data from patients ≥15 years of age in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database. Patients with vital signs of zero were excluded. Documented prehospital and emergency department (ED) vital signs included systolic pressure, heart rate, respiratory rate, and calculated shock index (SI). The area under the receiver operator curves (AUROC) was used to assess the accuracy of these variables for predicting 24-hour survival. Optimal thresholds to predict mortality were identified using Youden's Index, 90% specificity, and 90% sensitivity. Additional analyses examined patients 70+ years of age.
    Results: There were 1,439,221 subjects in the 2019-2020 datasets that met inclusion for this analysis with <0.1% (10,270) who died within 24 hours. The optimal threshold for prehospital systolic pressure was 110, pulse rate was 110, SI was 0.9, and respiratory rate was 15. The optimal threshold for the ED systolic was 112, pulse rate was 107, SI was 0.9, and respiratory rate was 21. Among the elderly sub-analysis, the optimal threshold for prehospital systolic was 116, pulse rate was 100, SI was 0.8, and respiratory rate was 21. The optimal threshold for ED systolic was 121, pulse rate was 95, SI was 0.8, and respiratory rate was 0.8.
    Conclusions: Systolic blood pressure (SBP) and SI offered the best predictor of mortality among trauma patients. The SBP values predictive of mortality were significantly higher than the traditional 90mmHg threshold. This dataset highlights the need for better methods to guide resuscitation as initial vital signs have limited accuracy in predicting subsequent mortality.
    MeSH term(s) Humans ; Vital Signs ; Female ; Male ; Wounds and Injuries/mortality ; Wounds and Injuries/therapy ; Middle Aged ; Quality Improvement ; Adult ; Aged ; Emergency Medical Services ; Retrospective Studies ; Databases, Factual
    Language English
    Publishing date 2024-04-02
    Publishing country United States
    Document type Journal Article
    ZDB-ID 1025975-2
    ISSN 1945-1938 ; 1049-023X
    ISSN (online) 1945-1938
    ISSN 1049-023X
    DOI 10.1017/S1049023X24000207
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    Zs.A 2859: Show issues Location:
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  2. Article ; Online: A survey of low titer O whole blood use within the trauma quality improvement program registry.

    Schauer, Steven G / April, Michael D / Fisher, Andrew D / Wright, Franklin L / Winkle, Julie M / Wright, Angela R / Rizzo, Julie A / Getz, Todd M / Nicholson, Susannah E / Yazer, Mark H / Braverman, Maxwell A

    Transfusion

    2024  

    Abstract: Introduction: The use of low titer O whole blood (LTOWB) has expanded although it remains unclear how many civilian trauma centers are using LTOWB.: Methods: We analyzed data on civilian LTOWB recipients in the American College of Surgeons Trauma ... ...

    Abstract Introduction: The use of low titer O whole blood (LTOWB) has expanded although it remains unclear how many civilian trauma centers are using LTOWB.
    Methods: We analyzed data on civilian LTOWB recipients in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database 2020-2021. Unique facility keys were used to determine the number of centers that used LTOWB in that period.
    Results: A total of 16,603 patients received LTOWB in the TQIP database between 2020 and 2021; 6600 in 2020, and 10,003 in 2021. The total number of facilities that reported LTOWB use went from 287/779 (37%) in 2020 to 302/795 (38%) in 2021. Between 2020 and 2021, among all level 1-3 designated trauma facilities that report to TQIP LTOWB use increased at level-1 centers (118 to 129), and level-2 centers (81 to 86), but decreased in level-3 facilities (9 to 4). Among pediatric and dual pediatric-adult designated hospitals there was a decrease in the number of pediatric level-1 centers (29 to 28) capable of administering LTOWB. Among centers with either single or dual level-1 trauma center designation with adult centers, the number that administered LTOWB to injured pediatric patients also decreased from 17 to 10, respectively.
    Conclusions: There was an increase in the number of facilities transfusing LTOWB between 2020 and 2021. The use of LTOWB is underutilized in children at centers that have it available. These findings inform the expansion of LTOWB use in trauma.
    Language English
    Publishing date 2024-02-13
    Publishing country United States
    Document type Journal Article
    ZDB-ID 208417-x
    ISSN 1537-2995 ; 0041-1132
    ISSN (online) 1537-2995
    ISSN 0041-1132
    DOI 10.1111/trf.17746
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    Zs.A 284: Show issues Location:
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  3. Article ; Online: Blood consumption in the Role 2 setting: A Department of Defense Trauma Registry analysis.

    McWhirter, Kelly K / April, Michael D / Fisher, Andrew D / Wright, Franklin L / Rizzo, Julie A / Corley, Jason B / Getz, Todd M / Schauer, Steven G

    Transfusion

    2024  

    Abstract: Background: The Role 2 setting represents the most far-forward military treatment facility with limited surgical and holding capabilities. There are limited data to guide recommendations on blood product utilization at the Role 2. We describe the ... ...

    Abstract Background: The Role 2 setting represents the most far-forward military treatment facility with limited surgical and holding capabilities. There are limited data to guide recommendations on blood product utilization at the Role 2. We describe the consumption of blood products in this setting.
    Study design and methods: We analyzed data from 2007 to 2023 from the Department of Defense Trauma Registry (DODTR) that received care at a Role 2. We used descriptive and inferential statistics to characterize the volumes of blood products consumed in this setting. We also performed a secondary analysis of US military, Coalition, and US contractor personnel.
    Results: Within our initial cohort analysis of 15,581 encounters, 17% (2636) received at least one unit of PRBCs or whole blood, of which 11% received a submassive transfusion, 4% received a massive transfusion, and 1% received a supermassive transfusion. There were 6402 encounters that met inclusion for our secondary analysis. With this group, 5% received a submassive transfusion, 2% received a massive transfusion, and 1% received a supermassive transfusion.
    Conclusions: We described volumes of blood products consumed at the Role 2 during recent conflicts. The maximum number of units consumed among survivors exceeds currently recommended available blood supply. Our findings suggest that rapid resupply and cold-stored chain demands may be higher than anticipated in future conflicts.
    Language English
    Publishing date 2024-02-15
    Publishing country United States
    Document type Journal Article
    ZDB-ID 208417-x
    ISSN 1537-2995 ; 0041-1132
    ISSN (online) 1537-2995
    ISSN 0041-1132
    DOI 10.1111/trf.17741
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    Zs.A 284: Show issues Location:
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    Jg. 1995 - 2021: Lesesall (1.OG)
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  4. Article ; Online: Preventable death and interpersonal violence in the United States: Who can be saved?

    Carmichael, Heather / Steward, Lauren / Peltz, Erik D / Wright, Franklin L / Velopulos, Catherine G

    The journal of trauma and acute care surgery

    2019  Volume 87, Issue 1, Page(s) 200–204

    Abstract: Background: Public health initiatives to reduce mortality from penetrating trauma have largely developed from patterns of injury observed in military casualties, with a focus on hemorrhage control and use of tourniquets. Recent efforts show that injury ... ...

    Abstract Background: Public health initiatives to reduce mortality from penetrating trauma have largely developed from patterns of injury observed in military casualties, with a focus on hemorrhage control and use of tourniquets. Recent efforts show that injury patterns differ between civilian mass casualty events and combat settings, and no studies characterize wounding patterns in all types of civilian homicide. We hypothesize that many homicide deaths are due to nonsurvivable injuries, and that an effective strategy to reduce mortality must focus on both primary prevention as well as improvement in trauma prehospital care.
    Methods: We analyzed homicides from the National Violent Death Reporting System from 2012 to 2015. We excluded deaths due to poisoning, intentional neglect, or unknown weapon. Deaths were classified as "dead on scene" (DOS), "dead on arrival" (DOA), or "dead at or after hospital" (DAH) if the patient was admitted to a hospital. Injury patterns for penetrating weapons (firearms and sharp instruments) were further categorized.
    Results: We included 18,051 homicides, the vast majority of which were due to firearms (n = 12,901 or 71.5%) or sharp instruments (n = 2,265 or 12.5%). The most common injury patterns included wounds to the chest or head, with isolated extremity injuries representing a minority of both firearms deaths (n = 397 of 12,901, 3.1%) and deaths from sharp instruments (n = 50 of 2,265, 2.2%). Furthermore, over half of all deaths occurred prehospital, with only 13.3% of victims admitted prior to death.
    Conclusion: The vast majority of deaths from interpersonal violence are due to firearm injuries. Few deaths appear to be related to extremity hemorrhage alone, and over half of all fatally injured died at the scene. Strategies to decrease mortality from interpersonal violence must go beyond treating injuries that have already occurred, and must address violence prevention directly.
    Level of evidence: Epidemiological study, level IV.
    MeSH term(s) Homicide/statistics & numerical data ; Humans ; Retrospective Studies ; United States/epidemiology ; Violence/statistics & numerical data ; Wounds and Injuries/mortality ; Wounds and Injuries/therapy ; Wounds, Gunshot/mortality ; Wounds, Gunshot/therapy ; Wounds, Penetrating/mortality ; Wounds, Penetrating/therapy
    Language English
    Publishing date 2019-06-10
    Publishing country United States
    Document type Journal Article
    ZDB-ID 2651070-4
    ISSN 2163-0763 ; 2163-0755
    ISSN (online) 2163-0763
    ISSN 2163-0755
    DOI 10.1097/TA.0000000000002336
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    Zs.A 127: Show issues Location:
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  5. Article ; Online: The diamond of death: Hypocalcemia in trauma and resuscitation.

    Wray, Jesse P / Bridwell, Rachel E / Schauer, Steven G / Shackelford, Stacy A / Bebarta, Vikhyat S / Wright, Franklin L / Bynum, James / Long, Brit

    The American journal of emergency medicine

    2020  Volume 41, Page(s) 104–109

    Abstract: Introduction: Early recognition and management of hemorrhage, damage control resuscitation, and blood product administration have optimized management of severe trauma. Recent data suggest hypocalcemia exacerbates the ensuing effects of coagulopathy in ... ...

    Abstract Introduction: Early recognition and management of hemorrhage, damage control resuscitation, and blood product administration have optimized management of severe trauma. Recent data suggest hypocalcemia exacerbates the ensuing effects of coagulopathy in trauma.
    Objective: This narrative review of available literature describes the physiology and role of calcium in trauma resuscitation. Authors did not perform a systematic review or meta-analysis.
    Discussion: Calcium is a divalent cation found in various physiologic forms, specifically the bound, inactive state and the unbound, physiologically active state. While calcium plays several important physiologic roles in multiple organ systems, the negative hemodynamic effects of hypocalcemia are crucial to address in trauma patients. The negative ramifications of hypocalcemia are intrinsically linked to components of the lethal triad of acidosis, coagulopathy, and hypothermia. Hypocalcemia has direct and indirect effects on each portion of the lethal triad, supporting calcium's potential position as a fourth component in this proposed lethal diamond. Trauma patients often present hypocalcemic in the setting of severe hemorrhage secondary to trauma, which can be worsened by necessary transfusion and resuscitation. The critical consequences of hypocalcemia in the trauma patient have been repeatedly demonstrated with the associated morbidity and mortality. It remains poorly defined when to administer calcium, though current data suggest that earlier administration may be advantageous.
    Conclusions: Calcium is a key component of trauma resuscitation and the coagulation cascade. Recent data portray the intricate physiologic reverberations of hypocalcemia in the traumatically injured patient; however, future research is needed to further guide the management of these patients.
    MeSH term(s) Calcium/physiology ; Humans ; Hypocalcemia/etiology ; Resuscitation ; Wounds and Injuries/complications ; Wounds and Injuries/mortality ; Wounds and Injuries/therapy
    Chemical Substances Calcium (SY7Q814VUP)
    Language English
    Publishing date 2020-12-28
    Publishing country United States
    Document type Journal Article ; Review
    ZDB-ID 605890-5
    ISSN 1532-8171 ; 0735-6757
    ISSN (online) 1532-8171
    ISSN 0735-6757
    DOI 10.1016/j.ajem.2020.12.065
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    Zs.A 2005: Show issues Location:
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    Jg. 1995 - 2021: Lesesall (1.OG)
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  6. Article ; Online: The Extremity/Mechanism/Shock Index/GCS (EMS-G) score: A novel pre-hospital scoring system for early and appropriate MTP activation.

    Kovar, Alexandra / Carmichael, Heather / McIntyre, Robert C / Mago, Jacob / Gladden, Alicia Heelan / Peltz, Erik D / Wright, Franklin L

    American journal of surgery

    2019  Volume 218, Issue 6, Page(s) 1195–1200

    Abstract: Background: Numerous in-hospital scoring systems to activate massive transfusion protocols (MTP) have been proposed; however, to date, pre-hospital scoring systems have not been robustly validated. Many trauma centers do not have blood or pre-thawed ... ...

    Abstract Background: Numerous in-hospital scoring systems to activate massive transfusion protocols (MTP) have been proposed; however, to date, pre-hospital scoring systems have not been robustly validated. Many trauma centers do not have blood or pre-thawed plasma available in the trauma bay, leading to delays in balanced transfusion. This study aims to assess pre-hospital injury and physiologic parameters to develop a pre-hospital scoring system predictive of need for massive transfusion (MT) prior to patient arrival.
    Methods: A retrospective review of all adult full and partial trauma team activations from July 2014-July 2018 from an urban level 2 trauma center was performed utilizing our trauma registry. Stepwise logistic regression analysis was performed to develop a new scoring system, with point totals assigned proportional to the odds ratios of requiring MT for each variable. Internal validation of the EMS-G score was performed using a subset of the data which was not utilized for development of the scoring system, and sensitivity and specificity were compared to previously validated in-hospital scoring systems applied in the pre-hospital setting.
    Results: 763 patients were included with 94 patients (12.3%) receiving early MT, defined as 4 units pRBC in 4 h or ED death. In-hospital models for predicting MT such as Assessment of Blood Consumption (ABC) or Shock Index (SI) have sensitivities and specificities of 46/85% and 94/79% respectively for early MTP utilization based on pre-hospital data. Pre-hospital variables found to be predictive of MT were used to develop the EMS-G (Extremity, Mechanism, Shock Index, GCS) score. This system assigns obvious extremity injury-1-point, penetrating mechanism -2 points, shock index ≥0.9-2 points, GCS ≤8-3 points. A score of 3 or greater was chosen to maximize sensitivity and specificity for pre-hospital MT activation. EMS-G score based on pre-hospital report is 89% sensitive, 84% specific, with a PPV of 44% and NPV of 98% for early MT. Using this system, 25% of full and partial trauma team activations met criteria for pre-hospital MTP activation.
    Conclusion: The EMS-G Score has increased sensitivity and specificity compared to the ABC Score in the pre-hospital setting and appears more appropriate than shock index alone at predicting massive transfusion. This scoring system allows trauma centers to activate MTP prior to patient arrival to ensure early and appropriate blood product administration without blood product wastage.
    MeSH term(s) Adult ; Blood Transfusion/statistics & numerical data ; Colorado ; Emergency Medical Services ; Extremities/injuries ; Female ; Humans ; Male ; Middle Aged ; Predictive Value of Tests ; Retrospective Studies ; Sensitivity and Specificity ; Shock, Hemorrhagic/diagnosis ; Trauma Centers ; Trauma Severity Indices
    Language English
    Publishing date 2019-09-10
    Publishing country United States
    Document type Journal Article
    ZDB-ID 2953-1
    ISSN 1879-1883 ; 0002-9610
    ISSN (online) 1879-1883
    ISSN 0002-9610
    DOI 10.1016/j.amjsurg.2019.08.019
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    Uk I Zs.42: Show issues Location:
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  7. Article ; Online: Clinical Assessment of Low Calcium In traUMa (CALCIUM).

    Mendez, Jessica / Jonas, Rachelle B / Barry, Lauren / Urban, Shane / Cheng, Alex C / Aden, James K / Bynum, James / Fisher, Andrew D / Shackelford, Stacy A / Jenkins, Donald H / Gurney, Jennifer M / Bebarta, Vikhyat S / Cap, Andrew P / Rizzo, Julie A / Wright, Franklin L / Nicholson, Susannah E / Schauer, Steven G

    Medical journal (Fort Sam Houston, Tex.)

    2022  , Issue Per 23-1/2/3, Page(s) 74–80

    Abstract: Major trauma frequently occurs in the deployed, combat setting and is especially applicable in the recent conflicts with explosives dominating the combat wounded. In future near-peer conflicts, we will likely face even more profound weapons including ... ...

    Abstract Major trauma frequently occurs in the deployed, combat setting and is especially applicable in the recent conflicts with explosives dominating the combat wounded. In future near-peer conflicts, we will likely face even more profound weapons including mortars and artillery. As such, the number of severely wounded will likely increase. Hypocalcemia frequently occurs after blood transfusions, secondary to the preservatives in the blood products; however, recent data suggests major trauma in and of itself is a risk factor for hypocalcemia. Calcium is a major ion involved in heart contractility; thus, hypocalcemia can lead to poor contractility. Smaller studies have linked hypocalcemia to worse outcomes, but it remains unclear what causes hypocalcemia and if intervening could potentially save lives. The objective of this study is to determine the incidence of hypocalcemia on hospital arrival and the association with survival. We are seeking to address the following scientific questions, (1) Is hypocalcemia present following traumatic injury prior to transfusion during resuscitation? (2) Does hypocalcemia influence the amount of blood products transfused? (3) To what extent is hypocalcemia further exacerbated by transfusion? (4) What is the relationship between hypocalcemia following traumatic injury and mortality? We will conduct a multicenter, prospective, observational study. We will gather ionized calcium levels at 0, 3, 6, 12, 18, and 24 hours as part of scheduled calcium measurements. This will ensure we have accurate data to assess the early and late effects of hypocalcemia throughout the course of resuscitation and hemorrhage control. These data will be captured by a trained study team at every site. Our findings will inform clinical practice guidelines and optimize the care delivered in the combat and civilian trauma setting. We are seeking 391 patients with complete data to meet our a priori inclusion criteria. Our study will have major immediate short-term findings including risk prediction modeling to assess who is at risk for hypocalcemia, data assessing interventions associated with the incidence of hypocalcemia, and outcome data including mortality and its link to early hypocalcemia.
    MeSH term(s) Humans ; Calcium ; Hypocalcemia/diagnosis ; Hypocalcemia/epidemiology ; Hypocalcemia/etiology ; Prospective Studies ; Hemorrhage/complications ; Blood Transfusion ; Calcium, Dietary
    Chemical Substances Calcium (SY7Q814VUP) ; Calcium, Dietary
    Language English
    Publishing date 2022-10-26
    Publishing country United States
    Document type Observational Study ; Multicenter Study ; Journal Article
    ISSN 2694-3611
    ISSN (online) 2694-3611
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  8. Article ; Online: Association Between Hyperoxia, Supplemental Oxygen, and Mortality in Critically Injured Patients.

    Douin, David J / Anderson, Erin L / Dylla, Layne / Rice, John D / Jackson, Conner L / Wright, Franklin L / Bebarta, Vikhyat S / Schauer, Steven G / Ginde, Adit A

    Critical care explorations

    2021  Volume 3, Issue 5, Page(s) e0418

    Abstract: Objectives: Hyperoxia is common among critically ill patients and may increase morbidity and mortality. However, limited evidence exists for critically injured patients. The objective of this study was to determine the association between hyperoxia and ... ...

    Abstract Objectives: Hyperoxia is common among critically ill patients and may increase morbidity and mortality. However, limited evidence exists for critically injured patients. The objective of this study was to determine the association between hyperoxia and in-hospital mortality in adult trauma patients requiring ICU admission.
    Design setting and participants: This multicenter, retrospective cohort study was conducted at two level I trauma centers and one level II trauma center in CO between October 2015 and June 2018. All adult trauma patients requiring ICU admission within 24 hours of emergency department arrival were eligible. The primary exposure was oxygenation during the first 7 days of hospitalization.
    Interventions: None.
    Measurements and main results: Primary outcome was in-hospital mortality. Secondary outcomes were hospital-free days and ventilator-free days. We included 3,464 critically injured patients with a mean age of 52.6 years. Sixty-five percent were male, and 66% had blunt trauma mechanism of injury. The primary outcome of in-hospital mortality occurred in 264 patients (7.6%). Of 226,057 patient-hours, 46% were spent in hyperoxia (oxygen saturation > 96%) and 52% in normoxia (oxygen saturation 90-96%). During periods of hyperoxia, the adjusted risk for mortality was higher with greater oxygen administration. At oxygen saturation of 100%, the adjusted risk scores for mortality (95% CI) at Fio
    Conclusions: During hyperoxia, higher oxygen administration was independently associated with a greater risk of mortality among critically injured patients. Level of evidence: Cohort study, level III.
    Language English
    Publishing date 2021-05-14
    Publishing country United States
    Document type Journal Article
    ISSN 2639-8028
    ISSN (online) 2639-8028
    DOI 10.1097/CCE.0000000000000418
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  9. Article ; Online: An Analysis of the Incidence of Hypocalcemia in Wartime Trauma Casualties.

    Escandon, Mireya A / Tapia, Ashley D / Fisher, Andrew D / Shackelford, Stacy A / Bebarta, Vikhyat S / Wright, Franklin L / Nicholson, Susannah E / Hill, Ronnie / Bynum, James A / Schauer, Steven G

    Medical journal (Fort Sam Houston, Tex.)

    2021  , Issue Per 22-04/05/06, Page(s) 17–21

    Abstract: Objective: Background: Massive transfusion protocols implement the use of blood products to restore homeostasis. Citrated blood products are required for massive transfusions and can induce hypocalcemia, resulting in decreased cardiac contractility. ... ...

    Abstract Objective: Background: Massive transfusion protocols implement the use of blood products to restore homeostasis. Citrated blood products are required for massive transfusions and can induce hypocalcemia, resulting in decreased cardiac contractility. Recent data suggests that major trauma alone is associated with hypocalcemia. This phenomenon remains poorly described. We seek to characterize the incidence and risk factors for early hypocalcemia in the setting of combat trauma.
    Materials and methods: This is a secondary analysis of previously described data from the Department of Defense Trauma Registry from January 2007 to March 2020. In this sub-analysis, we selected only casualties that had at least one ionized calcium measurement. We defined hypocalcemia as an ionized calcium level of less than 1.2mmol/L.
    Results: Within our study database, there were 142 adult casualties that met inclusion with at least one calcium value documented. We found 72 (51%) experienced at least one episode of hypocalcemia. Median composite injury severity score (ISS) was significantly lower in the control cohort compared to those with hypocalcemia (9 versus 15, p=0.010). Survival was similar between the two groups (97% versus 90%, p=0.166). On multivariable analysis when evaluating serious injuries by body region, only serious injuries to the extremities were significantly associated with developing hypocalcemia (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.00-2.21). When comparing prehospital interventions, only intravenous (IV) fluid administration was associated with high proportions experiencing hypocalcemia (25% versus 43%, p=0.029). In the multivariable model adjusted for ISS, mechanism of injury, and patient category, IV fluids were associated with the development of hypocalcemia (OR 2.48, 95% CI 1.03-5.94). When comparing vital signs, only respiratory rates were noted to be higher in the hypocalcemia cohort (18.6 versus 20.4, p=0.048).
    Conclusions: Approximately half of combat casualties with available ionized calcium (iCa) level were hypocalcemic. Prehospital IV fluid use was associated with the development of hypocalcemia. Our study has implications for forward-staged medical teams with limited laboratory analysis capabilities. Additional research is needed to determine whether calcium replacement improves survival from traumatic injury and to identify the specific indications and timing for calcium replacement. This study will help inform a clinical study intended to aid in the development of clinical practice guidelines for deployed medical personnel.
    MeSH term(s) Adult ; Blood Transfusion ; Humans ; Hypocalcemia/epidemiology ; Hypocalcemia/etiology ; Incidence ; Injury Severity Score ; Registries
    Language English
    Publishing date 2021-07-17
    Publishing country United States
    Document type Journal Article
    ISSN 2694-3611
    ISSN (online) 2694-3611
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  10. Article ; Online: Early ventilator liberation and decreased sedation needs after tracheostomy in patients with COVID-19 infection.

    Carmichael, Heather / Wright, Franklin L / McIntyre, Robert C / Vogler, Thomas / Urban, Shane / Jolley, Sarah E / Burnham, Ellen L / Firth, Whitney / Velopulos, Catherine G / Idrovo, Juan Pablo

    Trauma surgery & acute care open

    2021  Volume 6, Issue 1, Page(s) e000591

    Abstract: Background: Since the outset of the coronavirus disease 2019 (COVID-19) pandemic, published tracheostomy guidelines have generally recommended deferral of the procedure beyond the initial weeks of intubation given high mortality as well as concerns ... ...

    Abstract Background: Since the outset of the coronavirus disease 2019 (COVID-19) pandemic, published tracheostomy guidelines have generally recommended deferral of the procedure beyond the initial weeks of intubation given high mortality as well as concerns about transmission of the infection to providers. It is unclear whether tracheostomy in patients with COVID-19 infection facilitates ventilator weaning, and long-term outcomes are not yet reported in the literature.
    Methods: This is a retrospective study of tracheostomy outcomes in patients with COVID-19 infection at a single-center academic tertiary referral intensive care unit. Patients underwent percutaneous tracheostomy at the bedside; the procedure was performed with limited staffing to reduce risk of disease transmission.
    Results: Between March 1 and June 30, 2020, a total of 206 patients with COVID-19 infection required mechanical ventilation and 26 underwent tracheostomy at a mean of 25±5 days after initial intubation. Overall, 81% of tracheostomy patients were liberated from the ventilator at a mean of 9±6 days postprocedure, and 54% were decannulated prior to hospital discharge at a mean of 21±10 days postprocedure. Sedation and pain medication requirements decreased significantly in the week after the procedure. In-hospital mortality was 15%. Among tracheostomy survivors, 68% were discharged to a facility.
    Discussion: The management of patients with COVID-19 related respiratory failure can be challenging due to prolonged ventilator dependency. In our initial experience, outcomes post-tracheostomy in this population are encouraging, with short time to liberation from the ventilator, a high rate of decannulation prior to hospital discharge, and similar mortality to tracheostomy performed for other indications. Barriers to weaning ventilation in this cohort may be high sedation needs and ventilator dyssynchrony.
    Level of evidence: Level V-Therapeutic/care management.
    Language English
    Publishing date 2021-01-19
    Publishing country England
    Document type Journal Article
    ISSN 2397-5776
    ISSN (online) 2397-5776
    DOI 10.1136/tsaco-2020-000591
    Database MEDical Literature Analysis and Retrieval System OnLINE

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