Small bowel obstruction in older patients: challenges in surgical management
BACKGROUND:Small bowel obstruction (SBO) is a common disease affecting all segments of the population, including the frail elderly. Recent retrospective data suggest that earlier operative intervention may decrease morbidity. However, management decisions are influenced by surgical outcomes. Our goal was to determine the current surgical management of SBO in older patients with particular attention to frailty and the timing of surgery. STUDY DESIGN/METHODS:A retrospective review of patients over the age of 65 with a diagnosis of bowel obstruction (ICD-10 K56*) using the 2016 National Inpatient Sample (NIS). Demographics included age, race, insurance status, medical comorbidities, and median household income by zip code. Elixhauser comorbidities were used to derive a previously published frailty score using the NIS dataset. Outcomes included time to operation, mortality, discharge disposition, and hospital length of stay. Associations between demographics, frailty, timing of surgery, and outcomes were determined. RESULTS:264,670 patients were included. Nine percent of the cohort was frail; overall mortality was 5.7%. Frail had 1.82 increased odds of mortality (95% CI 1.64-2.03). Hospital LOS was 1.6 times as long for frail patients; a quarter of the frail were discharged home. Frail patients waited longer for surgery (3.58Â days vs 2.44Â days; pâ€‰<â€‰0.001). Patients transferred from another facility had increased mortality (aOR 1.58; 95% CI 1.36-1.83). There was an increasing mortality associated with a delay in surgery. CONCLUSION/CONCLUSIONS:Patients with frailty and SBO have higher mortality, more frequent discharge to dependent living, longer hospital length of stay, and longer wait to operative intervention. Mortality is also associated with male gender, black race, transfer status from another facility, self-pay status, and low household income. Every day in delay in surgical intervention for those who underwent operations led to higher mortality. If meeting operative indications, older patients with bowel obstruction have a higher chance of survival if they undergo surgery earlier.
Emergency abdominal surgery in patients presenting from skilled nursing facilities: Opportunities for palliative care
BACKGROUND:Residents of skilled nursing facilities (SNF) with acute abdomen present with more comorbidities and frailty than community-dwelling (CD) counterparts. Outcomes in this population are poorly described. METHODS:We hypothesized that SNF patients have higher mortality and morbidity than CD patients. This retrospective review of the NSQIP database from 2011 to 2015 compared outcomes of SNF and CD patients presenting with bowel obstruction, ischemia and perforation. Primary outcomes were in-hospital and 30-day mortality and failure-to-rescue (FTR). RESULTS:18,326 patients met inclusion criteria. 904 (5%) presented from SNF. In-hospital (26% vs 10%) and 30-day mortality (33% vs 26%) was higher in SNF patients (pâ€¯<â€¯0.001). The FTR rate was 34% for SNF patients and 20% for CD patients (pâ€¯<â€¯0.001). CONCLUSIONS:Presentation from SNF is an independent predictor of mortality and FTR. Presentation from SNF is a potential trigger for early, concurrent palliative care to assist surgeons, patients, and families in decision making and goal-concordant treatment.
Older Patients With Severe Traumatic Brain Injury: National Variability in Palliative Care
BACKGROUND:Older patients with traumatic brain injury (TBI) have higher mortality and morbidity than their younger counterparts. Palliative care (PC) is recommended for all patients with a serious or life-limiting illness. However, its adoption for trauma patients has been variable across the nation. The goal of this study was to assess PC utilization and intensity of care in older patients with severe TBI. We hypothesized that PC is underutilized despite its positive effects. MATERIALS AND METHODS:The National Inpatient Sample database (2009-2013) was queried for patients aged â‰¥55Â y with International Classification of Diseases, Ninth Revision codes for TBI with loss of consciousness â‰¥24Â h. Outcome measures included PC rate, in-hospital mortality, discharge disposition, length of stay (LOS), and intensity of care represented by craniotomy and or craniectomy, ventilator use, tracheostomy, and percutaneous endoscopic gastrostomy. RESULTS:Of 5733 patients, 78% died in hospital with a median LOS of 1Â d, and 85% of the survivors were discharged to facilities. The overall PC rate was 35%. Almost 40% of deaths received PC, with nearly half within 48Â h of admission. PC was used in 26% who had neurosurgical procedures, compared with 35% who were nonoperatively managed (PÂ =Â 0.003). PC was associated with less intensity of care in the entire population. For survivors, those with PC had significantly shorter LOS, compared with those without PC. CONCLUSIONS:Despite high mortality, only one-third of older patients with severe TBI received PC. PC was associated with decreased use of life support and lower intensity of care. Significant efforts need to be made to bridge this quality gap and improve PC in this high-risk population.
Elderly adults with isolated hip fractures- orthogeriatric care versus standard care: A practice management guideline from the Eastern Association for the Surgery of Trauma
BACKGROUND:Elderly patients commonly suffer isolated hip fractures, causing significant morbidity and mortality. The use of orthogeriatrics (OG) management services, in which geriatric specialists primarily manage or co-manage patients after admission, may improve outcomes. We sought to provide recommendations regarding the role of OG services. METHODS:Using GRADE methodology with meta-analyses, the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review of the literature from January 1, 1900, to August 31, 2017. A single Population, Intervention, Comparator and Outcome (PICO) question was generated with multiple outcomes: Should geriatric trauma patients 65 years or older with isolated hip fracture receive routine OG management, compared with no-routine OG management, to decrease mortality, improve discharge disposition, improve functional outcomes, decrease in-hospital medical complications, and decrease hospital length of stay? RESULTS:Forty-five articles were evaluated. Six randomized controlled trials and seven retrospective case-control studies met the criteria for quantitative analysis. For critical outcomes, retrospective case-control studies demonstrated a 30-day mortality benefit with OG (OR, 0.78 [0.67, 0.90]), but this was not demonstrated prospectively or at 1 year. Functional outcomes were superior with OG, specifically improved score on the Short Physical Performance Battery at 4 months (mean difference [MD], 0.78 [0.28, 1.29]), and improved score on the Mini Mental Status Examination with OG at 12 months (MD, 1.57 [0.40, 2.73]). Execution of activities of daily living was improved with OG as measured by two separate tests at 4 and 12 months. There was no difference in discharge disposition. Among important outcomes, the OG group had fewer hospital-acquired pressure ulcers (OR, 0.30 [0.15, 0.60]). There was no difference in other complications or length of stay. Overall quality of evidence was low. CONCLUSION/CONCLUSIONS:In geriatric patients with isolated hip fracture, we conditionally recommend an OG care model to improve patient outcomes. LEVEL OF EVIDENCE/METHODS:Systematic review/meta-analysis, level III.
Pulmonary complications in trauma patients with obstructive sleep apnea undergoing pelvic or lower limb operation
Background/UNASSIGNED:Obstructive sleep apnea (OSA) is increasingly prevalent in the range of 2% to 24% in the US population. OSA is a well-described predictor of pulmonary complications after elective operation. Yet, data are lacking on its effect after operations for trauma. We hypothesized that OSA is an independent predictor of pulmonary complications in patients undergoing operations for traumatic pelvic/lower limb injuries (PLLI). Methods/UNASSIGNED:Nationwide Inpatient Sample (2009-2013) was queried for International Classification of Diseases, Ninth Revision, Clinical Modification codes for PLLI requiring operation. Elective admissions and those with concurrent traumatic brain injury with moderate to prolonged loss of consciousness were excluded. Outcome measures were pulmonary complications including ventilatory support, ventilator-associated pneumonia, pulmonary embolism (PE), acute respiratory distress syndrome (ARDS), and respiratory failure. Multivariable logistic regression analysis was used, adjusting for OSA, age, sex, race/ethnicity, and specific comorbidities (obesity, chronic lung disease, and pulmonary circulatory disease). P<0.01 was considered statistically significant. Results/UNASSIGNED:Among the 337â€‰333 patients undergoing PLLI operation 3.0% had diagnosed OSA. Patients with OSA had more comorbidities and were more frequently discharged to facilities. Median length of stay was longer in the OSA group (5 vs 4â€‰days, p<0.001). Pulmonary complications were more frequent in those with OSA. Multivariable logistic regression showed that OSA was an independent predictor of ventilatory support (adjusted odds ratio (aOR), 1.37; 95% CI,1.24 to 1.51), PE (aOR 1.40; 95% CI, 1.15 to 1.70), ARDS (aOR 1.36; 95% CI,1.23 to 1.52), and respiratory failure (aOR 1.90; 95% CI, 1.74 to 2.06). Conclusion/UNASSIGNED:OSA is an independent and underappreciated predictor of pulmonary complications in those undergoing emergency surgery for PLLI. More aggressive screening and identification of OSA in trauma patients undergoing operation are necessary to provide closer perioperative monitoring and interventions to reduce pulmonary complications and improve outcomes. Level of evidence/UNASSIGNED:Prognostic Level IV.
Sarcopenia is Predictive of Functional Outcomes in Older Trauma Patients
INTRODUCTION/BACKGROUND:Â Older patients are more vulnerable to poor outcomes after trauma than younger patients. Sarcopenia, loss of skeletal mass, is prevalent in trauma patients admitted to the intensive care unit (ICU), and it has been shown to correlate with adverse outcomes, such as mortality and ICU days. Yet, little is known whether it predicts other outcomes. We hypothesized that sarcopenia independently predicts poor functional outcomes in older trauma patients admitted to the ICU. METHODS:We performed a retrospective review of patients aged >55 admitted to a surgical ICU in a Level I trauma center for two years. Sarcopenic status was determined by measuring total skeletal muscle cross-sectional area at the L3 level on admission computed tomography (CT), normalized for height with sex-specific cutoffs. Primary outcome measures were in-hospital mortality, functional outcomes measured by the Glasgow Outcome Scale (GOS) at discharge, and discharge disposition. Multivariable logistic regression was used to determine predictors of primary outcomes. RESULTS:Out of 230 patients, 32% were sarcopenic. The overall mortality was 20%, and 30% were discharged with poor functional outcomes. A higher proportion of sarcopenic patients among survivors had poor functional outcomes at discharge (55% vs. 30%, p=0.002). Sarcopenia was not predictive of in-hospital mortality but was an independent predictor of poor functional outcomes at discharge (OR 2.6; 95% confidence interval [CI] 1.3-5.5), adjusting for age, Glasgow Coma Scale (GCS) on admission, diagnosis of traumatic brain injury (TBI), Injury Severity Score (ISS), and the number of life-limiting illnesses. CONCLUSIONS:Sarcopenia is prevalent in geriatric trauma ICU patients and is an independent predictor of poor functional outcomes. Assessing for sarcopenia has an important potential as a prognostic tool in older trauma patients.
Palliative Care in trauma: Not just for the dying
BACKGROUND:Palliative Care (PC) is indicated in patients with functional dependency and advanced care needs in addition to those with life-threatening conditions. Older trauma patients have PC needs due to increased risk of mortality and poor long-term outcomes. We hypothesized that older trauma patients discharged alive with poor outcomes are not easily identified nor receive PC interventions. METHODS:Prospective observational study of trauma patients 55 years or older. Patients with poor functional outcomes defined by discharge Glasgow Outcome Scale Extended (GOSE) 1-4 or death at 6-month follow-up were analyzed for rate and timing of PC interventions including goals of care conversation (GOCC), do-not-resuscitate (DNR) order, do not intubate (DNI) order, and withdrawal of life supporting measures. Logistic regression was performed for having and timing of GOCC. RESULTS:Three hundred fifteen (54%) of 585 patients had poor outcomes. Of patients who died, 94% had GOCC compared with 31% of patients who were discharged with GOSE 3 or 4. In patients who died, 85% had DNR order, 18% had DNI order, and 56% had withdrawal of ventilator. Only 24% and 9% of patients with GOSE of 3 or 4, respectively, had DNR orders. Fifty percent of the patients who were dead at 6-month follow-up had GOCC during initial hospitalization. The median time to DNR in patients that died was 2 days compared with 5 days and 1 day in GOSE 3 and 4 (p = 0.046). Age, injury severity scale, and preexisting limited physiological reserve were predictive of having a GOCC. CONCLUSION:The PC utilization was very high for older trauma patients who died in hospital. In contrast, the majority of those who were discharged alive, but with poor outcomes, did not have PC. Development of triggers to identify older trauma patients, who would benefit from PC, could close this gap and improve quality of care and outcomes.
Preinjury Palliative Performance Scale predicts functional outcomes at 6 months in older trauma patients
BACKGROUND:Older trauma patients have increased risk of adverse in-hospital outcomes. We previously demonstrated that low preinjury Palliative Performance Scale (PPS) independently predicted poor discharge outcomes. We hypothesized that low PPS would predict long-term outcomes in older trauma patients. METHODS:Prospective observational study of trauma patients aged â‰¥55 years admitted between July 2016 and April 2018. Preinjury PPS was assessed at admission; low PPS was defined as 70 or less. Primary outcomes were mortality and functional outcomes, measured by Extended Glasgow Outcome Scale (GOSE), at discharge and 6 months. Poor functional outcomes were defined as GOSE score of 4 or less. Secondary outcomes were patient-reported outcomes at 6 months: EuroQol-5D and 36-Item Short Form Survey. Adjusted relative risks (aRRs) were obtained for each primary outcome using multivariable modified Poisson regression, adjusting for PPS, age, race/ethnicity, sex, and injury severity. RESULTS:In-hospital data were available for 516 patients; mean age was 70 years and median Injury Severity Score was 13. Thirty percent had low PPS. Six percent (n = 32) died in the hospital, and half of the survivors (n = 248) had severe disability at discharge. Low PPS predicted hospital mortality (aRR, 2.6; 95% confidence interval [CI], 1.2-5.3) and poor outcomes at discharge (aRR, 2.0; 95% CI, 1.7-2.3). Six-month data were available for 176 (87%) of 203 patients who were due for follow-up. Functional outcomes improved in 64% at 6 months. However, 63% had moderate to severe pain, and 42% moderate to severe anxiety/depression. Mean GOSE improved less over time in low PPS patients (7% vs. 24%; p < 0.01). Low PPS predicted poor functional outcomes at 6 months (aRR, 3.1; 95% CI, 1.8-5.3) while age and Injury Severity Score did not. CONCLUSION:Preinjury PPS predicts mortality and poor outcomes at discharge and 6 months. Despite improvement in function, persistent pain and anxiety/depression were common. Low PPS patients fail to improve over time compared to high PPS patients. Preinjury PPS can be used on admission for prognostication of short- and long-term outcomes and is a potential trigger for palliative care in older trauma patients. LEVEL OF EVIDENCE:Prognostic study, Therapeutic level IV.
Patients with End-Stage Renal Disease and Acute Surgical Abdomen: Opportunities for Palliative Care
Evidence-based review of trauma center care and routine palliative care processes for geriatric trauma patients; A collaboration from the American Association for the Surgery of Trauma Patient Assessment Committee, the American Association for the Surgery of Trauma Geriatric Trauma Committee, and the Eastern Association for the Surgery of Trauma Guidelines Committee
BACKGROUND:Despite an aging population and increasing number of geriatric trauma patients annually, gaps in our understanding of best practices for geriatric trauma patients persist. We know that trauma center care improves outcomes for injured patients generally, and palliative care processes can improve outcomes for disease-specific conditions, and our goal was to determine effectiveness of these interventions on outcomes for geriatric trauma patients. METHODS:A priori questions were created regarding outcomes for patients 65 years or older with respect to care at trauma centers versus nontrauma centers and use of routine palliative care processes. A query of MEDLINE, PubMed, Cochrane Library, and EMBASE was performed. Letters to the editor, case reports, book chapters, and review articles were excluded. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to perform a systematic review and create recommendations. RESULTS:We reviewed seven articles relevant to trauma center care and nine articles reporting results on palliative care processes as they related to geriatric trauma patients. Given data quality and limitations, we conditionally recommend trauma center care for the severely injured geriatric trauma patients but are unable to make a recommendation on the question of routine palliative care processes for geriatric trauma patients. CONCLUSIONS:As our older adult population increases, injured geriatric patients will continue to pose challenges for care, such as comorbidities or frailty. We found that trauma center care was associated with improved outcomes for geriatric trauma patients in most studies and that utilization of early palliative care consultations was generally associated with improved secondary outcomes, such as length of stay; however, inconsistency and imprecision prevented us from making a clear recommendation for this question. As caregivers, we should ensure adequate support for trauma systems and palliative care processes in our institutions and communities and continue to support robust research to study these and other aspects of geriatric trauma. LEVEL OF EVIDENCE:Systematic review/guideline, level III.