Injury
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Observational Study
Impact of high-dose norepinephrine during intra-hospital damage control resuscitation of traumatic haemorrhagic shock: A propensity-score analysis.
The use of norepinephrine (NE) during uncontrolled haemorrhagic shock (HS) has mostly been investigated in experimental studies. Clinical data including norepinephrine dose and its impact on fluid resuscitation and organ function are scarce. We hypothesized that there is great variability in NE use and that high doses of NE could lead to increased organ dysfunction as measured by the sequential organ failure assessment (SOFA). ⋯ We included patients with HS (systolic blood pressure < 90 mmHg in severely injured patients) who required haemostasis surgery and a transfusion of more than 4 packed red blood cells (PRBC) in the first 6 h of admission and the used of norepinephrine infusion to maintain the blood pressure goal, between admission and the end of haemostasis surgery in a prospective trauma database. A ROC curve determined that, using Youden's criterion, a dose of NE ≥ 0.6 µg/kg/min was the optimal threshold associated with intrahospital mortality. Patients were compared according to this threshold in a propensity score (PS) model. In a generalized linear mixed model, we searched for independent factors associated with a SOFA ≥ 9 at 24 h RESULTS: A total of 89 patients were analysed. Fluid infusion rate ranged from 1.43 to 57.9 mL/kg/h and norepinephrine infusion rate from 0.1 to 2.8 µg/kg/min. The HDNE group received significantly less fluid than the LDNE group. This dose is associated with a higher SOFA score at 24h: 9 (7-10) vs. 7 (6-9) (p = 0.003). Factors independently associated with a SOFA score ≥ 9 at 24 h were maximal norepinephrine rate ≥ 0.6 µg/kg/min (OR 6.69, 95% CI 1.82 - 25.54; p = 0.004), non-blood resuscitation volume < 9 mL/kg/h (OR 3.98, 95% CI 1.14 - 13.95; p = 0.031) and lactate at admission ≥ 5 mmol/L (OR 5.27, 95% CI 1.48 - 18.77; p = 0.010) CONCLUSION: High dose of norepinephrine infusion is associated with deleterious effects as attested by a higher SOFA score at 24 h and likely hypovolemia as measured by reduced non-blood resuscitation volume. We did not find any significant difference in mortality over the long term.
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Cardiac complications (CC) after injury are rare but contribute disproportionately to mortality. Variability in rates of CC and failure to rescue (FTR) after CC (FTR-C) within trauma systems may suggest opportunities for improvement, but we have not yet demonstrated the ability to identify high and low performers. We examined center-level rates of CC and FTR-C in a mature trauma system with the hypothesis that high-performing centers for each of these outcomes could be identified. ⋯ Rates of CC and FTR-C vary significantly between hospitals in mature trauma systems but high-performing centers can be identified. Inconsistent performance between metrics suggests unknown institutional factors underlie performance for CC and FTR.
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Patients with hip fractures are typically elderly individuals with several co-morbidities. Upon admission to the hospital, they often present with acute pain, electrolyte disturbances, anaemia, coagulopathy, and delirium. ⋯ The balance between the number of clinical tests and optimisation, which may (i.e., fewer complications and better survival) or may not (i.e., more complications and increased mortality due to unnecessary surgical delay) benefit the patient, has been a preoperative challenge. This summary will review existing clinical guidelines and relevant selected studies to evaluate the extent of preoperative optimisation needed prior to hip fracture surgery.
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In May 2017 the European Medical Device Regulation (MDR) was published to replace the current Medical Device Directive (MDD) and the Active Implantable Medical Device Directive (AIMDD). After a transition period of 3 years (ending May 2020) the MDR will apply in the European Union (EU). With this new legislative framework, the requirements for placing new medical devices and keeping existing medical devices on the EU market will become more stringent. ⋯ Since 2000 there has been a significant increase in the quantity and quality of publications in the fields of orthopaedic and orthopaedic trauma surgery. However, there is still a large number of medical devices without direct clinical data which rely on market experience and the established level of a specific technology or a group of devices. Due to this fact, and the fact that the new MDR is requiring sufficient clinical data for devices which shall stay on the market after May 2020, there is an increasing need for new clinical data sources reflecting the real-world use of medical devices.
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Recent research has identified a high prevalence of psychological illnesses in patients who have sustained orthopaedic trauma. Depressive symptoms in this patient population have been reported to range from 13% to as high as 56%. Moreover, symptoms of depression, catastrophic thinking, and post-traumatic stress disorder (PTSD), have been consistently shown to negatively impact patient outcomes following treatment for their traumatic injuries. ⋯ More research which applies the "biopsychosocial model" of health and evaluates the significant impact of psychological and social factors on recovery from trauma is needed. In particular, investigation which evaluates effective screening strategies and interventions to treat psychosocial dysfunction during recovery from trauma is highly desirable. This article reviews the current state of knowledge in this area and suggests future directions for research.