Objectives: Identify 5-year mortality rates in trauma patients greater than 18 years old who undergo tracheostomy and/or gastrostomy tube placement. Design: Retrospective convenience sample with two cohorts. Setting: Academic level 1 trauma center. Patients: Hospitalized patients admitted to the trauma service from July 2008 to December 2012 who underwent tracheostomy and/or gastrostomy tube placement. Interventions: Patients were placed into two cohorts: adult 18–64 and geriatric greater than or equal to 65; mortality data were obtained from the National Death Index. Measurements and Main Results: The primary outcome was 5-year mortality of both cohorts as well as those admitted who did not receive tracheostomy or gastrostomy. Univariate analysis was performed using Fisher exact and Wilcoxon signed-rank tests. Kaplan-Meier curves were plotted to examine mortality up to 5 years after discharge. Conclusions: Five-year postdischarge mortality is significantly higher in geriatric patients undergoing tracheostomy and/or gastrostomy after traumatic injury. Fifty percent die within the first 28 weeks following discharge and 93% die within 2 years.
Limiting CT imaging in the ED has gained interest recently. After initial trauma workup for consultations in the ED, additional CT imaging is frequently ordered. We assessed the benefits of this additional imaging. Our hypothesis was that additional imaging in lower acuity trauma consults results in the diagnosis of new significant injuries with a change in treatment plan and increased Injury Severity Score (ISS). The registry at our Level I trauma center was queried from November 2015 to November 2016 for trauma consults initially evaluated by ED physicians. Patients with mild to moderate injuries were included. Injury findings before and after additional imaging were determined by chart review and pre- and postimaging ISS were calculated. Blinded trauma surgeons assessed the findings for clinical significance and changes in treatment. Four hundred and twenty-one patients were evaluated, 41 were excluded. One hundred and forty patients (37%) underwent additional CT imaging. Forty-seven patients (34%) had additional injuries found, with 16 (12%) increasing their ISS (mean 0.54, SD 1.66). Ninety-three per cent of cases resulted in at least one physician finding the new injuries clinically significant; however, agreement was low (κ = 0.095). For 70 per cent, at least one physician felt the findings warranted a change in treatment plan (κ = 0.405). Additional imaging in ED trauma consults resulted in the identification of new injuries in 1/3 of our patient sample. This suggests that current efforts to limit the use of CT imaging in trauma patients may result in significant injuries going undiscovered and undertreated. Further research is needed to determine the risk of attempts to limit imaging.
Purpose: Best fitting Tomotherapy treatment planning parameters for nine different lesion sites. Method and Materials: Tomotherapy treatment planning and delivery depends on parameters that are not necessarily familiar to a radiotherapy physicist. It is important for planners to familiarize themselves with these parameters and their impact on the time required for delivery: 51 Prostate plans, 268 lungs, 197 Brain, 21Liver, 38 Head & Neck, 46 Breast, 51Pelvis and 59 Pancreas plans for parameters like Pitch, Gantry period, treatment time, delivery modulation, total dose, calculated treatment length and slice width were analyzed for the best fit. Results: For Prostate average modulation delivery factor of 1.8 with average delivered dose of 51.53Gy and average treatment time of 342.4 seconds was used. Average numbers of fractions were 27. For Lung average dose of 50.70Gy with average modulation of 1.726. Average treatment time was 338.6 seconds and average numbers of fractions was 24. For Brain lesions average dose of 28.42Gy with average modulation of 1.71 was used. Average treatment time was 401.45 seconds. Average numbers of fractions was 11. For liver lesions average dose of 28.42Gy was used. Average modulation factor of 1.71 and average treatment time of 401.45 seconds. Average numbers of fractions was 11. For Head & Neck average dose of 36.08Gy with average modulation factor of 1.81 was used. Average treatment time was 420.64 seconds. Average numbers of fractions was 20. For Breast average dose of 41.44Gy with average modulation of 1.97. Average treatment time of 429.27 seconds with average numbers of fractions of 24. For Pelvis average dose of 38.8Gy with average modulation of 1.95. Average treatment time was 344.91 seconds. Average numbers of fractions was 19. For Pancreas average dose of 46.88Gy with average modulation of 1.78. Average treatment time was 266.64 seconds. Average numbers of fractions of 24.
To reduce the risk of catheter-associated urinary tract infection (CAUTI), limiting use of indwelling catheters is encouraged with alternative collection methods and early removal. Adverse effects associated with such practices have not been described. We also determined if CAUTI preventative measures increase the risk of catheter-related complications. We hypothesized that there are complications associated with early removal of indwelling catheters. We described complications associated with indwelling catheterization and intermittent catheterization, and compared complication rates before and after policy updates changed catheterization practices. We performed retrospective cohort analysis of trauma patients admitted between August 1, 2009, and December 31, 2013 who required indwelling catheter. Associations between catheter days and adverse outcomes such as infection, bladder overdistention injury, recatheterization, urinary retention, and patients discharged with indwelling catheter were evaluated. The incidence of CAUTI and the total number of catheter days pre and post policy change were similar. The incidence rate of urinary retention and associated complications has increased since the policy changed. Practices intended to reduce the CAUTI rate are associated with unintended complications, such as urinary retention. Patient safety and quality improvement programs should monitor all complications associated with urinary catheterization practices, not just those that represent financial penalties.
Choice of empiric antibiotic(s) for early ventilator associated pneumonia (VAP) involves weighing the risks of potential infection with multi-drug resistant (MDR) pathogens against those of over-exposure to broad-spectrum agents. Although early VAP is believed to be rarely caused by MDR pathogens, the overall incidence of all methicillin resistant Staphylococcus aureus (MRSA) infections is increasing. We questioned if MRSA VAP is becoming more common and if these infections were occurring earlier in the patient's hospital course. We hypothesized that 1) early (2-4 d from intubation) VAP caused by MRSA is relatively uncommon and 2) those patients with early VAP because of MRSA had risk factors associated with a MDR organism infection.Bronchoscopies with lavage (BALs) from patients admitted to our SICU from 2010-2013 were reviewed. MRSA VAP was defined as growth of ≥10(5) cfu/mL from BAL. Multi-drug resistant risk factors included a previous MRSA infection or positive nasal swab, antibiotic use within 90 d, hospitalization for >5 d, hemodialysis, homelessness, intravenous drug use, and men having sex with men.In the 3-y period, there were 438 cases of VAP. Forty-seven specimens from 43 patients had quantitative microbiologic confirmation of MRSA VAP for an overall prevalence of 10.7%. Of patients with early VAP, three of 106 (2.8%) were MRSA positive. Culture results were graphed according to ventilator days ( Fig. 1 ). The median days ventilated at the time of MRSA VAP were 8 d (range 2-81). All of the early MRSA VAP patients had identifiable risk factors for MRSA infection. The negative predictive value for patients not having a risk factor was one.These data suggest that the incidence of MRSA VAP is stable. Those patients with early MRSA VAP demonstrated traditional MDR risk factors. Patients without risk factors in the early time period could effectively be ruled out from having MRSA VAP and likely do not require empiric MRSA coverage.
