Traumatismo abdominal en un hospital de tercer nivel. Análisis de resultados, consideraciones terapéuticas y evaluación con índices pronóstico

Objetivo. Conocer la epidemiología y distribución de los traumatismos abdominales en nuestro medio. Evaluar el comportamiento y fiabilidad de la aplicación de índices pronósticos de gravedad analizando su correlación con las decisiones terapéuticas y los resultados obtenidos Método. Estudio retrospectivo en el que se han incluido todos los pacientes con diagnóstico de traumatismo abdominal grave ingresados en un hospital español de referencia, entre 2009 y 2015. Se registraron variables epidemiológicas, clínicas y de resultados, así como la puntuación de distintos índices pronósticos. Resultados. Muestra 153 pacientes, con mediana de edad de 38 años y predominio masculino (73, 9%). Correspondieron a traumatismos de tipo cerrado (94, 1%) y su etiología principal los accidentes de tráfico (60, 1%). El bazo fue el órgano más frecuentemente afectado (44, 4%), seguido por el hígado (36, 6%). La mediana de la estancia hospitalaria fue de 11 días y la mortalidad global de 13%. Aunque el 62, 7% se manejó con éxito de forma conservadora, se observó una mayor puntuación de Injury Severity Score (ISS) y Trauma and Injury Severity Score (TRISS) en aquellos pacientes que precisaron tratamiento quirúrgico (p = 0, 0001), en los que fallecieron (p = 0, 0001) y en aquellos con mayor estancia hospitalaria (RTS –Reevised Trauma Score– p = 0, 001 y TRISS p = 0, 016). Conclusiones. La etiología de los traumatismos abdominales y los balances lesionales en nuestro medio fueron similares a los observados a nivel nacional. La puntuación en las escalas estudiadas tuvo una asociación directa con la necesidad de tratamiento quirúrgico, los días de estancia hospitalaria, la morbilidad y la mortalidad. Objectives. To describe the abdominal injuries treated in our hospital. We assessed the behavior and reliability of prognostic scales, analyzing the correlations between them and therapeutic decisions and outcomes. Methods. Retrospective study including all patients with major abdominal injuries admitted to our hospital between 2009 and 2015. We gathered epidemiologic and clinical data, outcomes, and scores on several prognostic scales. Results. The median age of the 153 patients we identified from case records was 38 years; 73.9% were males. Most cases involved blunt trauma (94.1%) sustained in traffic accidents (60.1%). The spleen and the liver were the organs most often affected (in 44.4% and 36.6%, respectively). The median length of stay in the hospital was 11 days, and overall mortality was 13%. Although conservative management was successful in 62.7% of the cases, we found that patients who had a higher ISS (Injury Severity Score) or TRISS (Trauma and Injury Severity Score) assessments more often required surgery or died (P=.0001, both comparisons). Those who had longer hospital stays had a higher Revised Trauma Score or TRISS (P=.001 and P=.016, respectively). Conclusions. The causes of abdominal injuries and the types treated in our hospital were similar to those described for the rest of Spain. Punctuation on prognostic severity scales correlated directly with the need for surgery, length of hospital stay, complications, and mortality

Association between preoperative levels of 25-hydroxyvitamin D and hospital-acquired infections after hepatobiliary surgery: A prospective study in a third-level hospital

Introduction Evidence implicates vitamin D deficiency in poorer outcomes and increased susceptibility to hospital-acquired infections (HAIs). This study examined the association between serum vitamin D levels and HAIs in a population of hepatobiliary surgery patients. Methods Participants in this prospective analytical observational study were patients who underwent hepatobiliary surgery in a tertiary hospital in Aragon, Spain, between February 2018 and March 2019. Vitamin D concentrations were measured at admission and all nosocomial infections during hospitalization and after discharge were recorded. Results The mean 25-hydroxyvitamin D concentration of the study population (n = 301) was 38.56 nmol/L, which corresponds to vitamin D deficiency. Higher vitamin D concentrations were associated with a decreased likelihood of developing a HAI in general (p = 0.014), and in particularly surgical site infection (p = 0.026). The risk of HAI decreased by 34% with each 26.2-nmol/L increase in serum vitamin D levels. Conclusions Vitamin D levels may constitute a modifiable risk factor for postoperative nosocomial infections in hepatobiliary surgery patients

Infección del sitio quirúrgico en cirugía hepatobiliopancreática y su relación con la concentración sérica de vitamina D

Introducción La relación entre las infecciones nosocomiales en pacientes quirúrgicos y la vitamina D ha sido estudiada por algunos autores. Sin embargo, hasta la fecha no existe ningún estudio realizado sobre pacientes de cirugía hepatobiliar. El objetivo de nuestro trabajo es estudiar la infección del sitio quirúrgico (ISQ) en la unidad de cirugía hepatobiliar, y valorar su relación con la concentración sérica de vitamina D. Métodos Se llevó a cabo un estudio analítico observacional de pacientes sucesivos intervenidos en la unidad de cirugía hepatobiliar de nuestro centro durante un año. Se incluyeron las intervenciones relativas a enfermedad biliar, pancreática y hepática. Se determinaron los niveles de vitamina D al ingreso, así como las ISQ de tipo superficial, profunda y órgano-cavitaria diagnosticadas durante el estudio. El seguimiento del paciente se realizó durante al menos un mes tras la cirugía, dependiendo de la enfermedad. La estadística se realizó mediante el programa estadístico R v.3.1.3. Resultados La muestra quedó constituida por 321 pacientes, de los cuales el 25, 8% presentó ISQ a expensas fundamentalmente de las infecciones órgano-cavitarias que presentaron una incidencia del 24, 3%. Concentraciones séricas superiores a 33, 5 nmol/l demostraron reducir en un 50% el riesgo de ISQ. Conclusiones Las concentraciones elevadas de vitamina D en sangre demostraron ser un factor protector frente a las ISQ (OR: 0, 99). Nuestros resultados sugieren una relación directa entre la concentración sérica de vitamina D y la ISQ, justificando la realización de nuevos estudios prospectivos. Introduction: While several studies have examined the correlation between vitamin D concentrations and post-surgical nosocomial infections, this relationship has yet to be characterized in hepatobiliary surgery patients. We investigated the relationship between serum vitamin D concentration and the incidence of surgical site infection (SSI) in patients in our hepatobiliary surgery unit. Methods: Participants in this observational study were 321 successive patients who underwent the following types of interventions in the hepatobiliary surgery unit of our center over a 1-year period: cholecystectomy, pancreaticoduodenectomy, total pancreatectomy, segmentectomy, hepatectomy, hepaticojejunostomy and exploratory laparotomy. Serum vitamin D levels were measured upon admission and patients were followed up for 1 month. Mean group values were compared using a Student's T-test or Chi-squared test. Statistical analyses were performed using the Student's T-test, the Chi-squared test, or logistic regression models. Results: Serum concentrations >33.5 nmol/l reduced the risk of SSI by 50%. Out of the 321 patients analyzed, 25.8% developed SSI, mainly due to organ-cavity infections (incidence, 24.3%). Serum concentrations of over 33.5 nmol/l reduced the risk of SSI by 50%. Conclusions: High serum levels of vitamin D are a protective factor against SSI (OR, 0.99). Our results suggest a direct relationship between serum vitamin D concentrations and SSI, underscoring the need for prospective studies to assess the potential benefits of vitamin D in SSI prevention

Influence of the length of hospitalisation in post-discharge outcomes in patients with acute heart failure: Results of the LOHRCA study

Objective: To investigate the relationship between length of hospitalisation (LOH) and post-discharge outcomes in acute heart failure (AHF) patients and to ascertain whether there are different patterns according to department of initial hospitalisation. Methods: Consecutive AHF patients hospitalised in 41 Spanish centres were grouped based on the LOH (15 days). Outcomes were defined as 90-day post-discharge all-cause mortality, AHF readmissions, and the combination of both. Hazard ratios (HRs), adjusted by chronic conditions and severity of decompensation, were calculated for groups with LOH >6 days vs. LOH <6 days (reference), and stratified by hospitalisation in cardiology, internal medicine, geriatrics, or short-stay units. Results: We included 8563 patients (mean age: 80 (SD = 10) years, 55.5% women), with a median LOH of 7 days (IQR 4–11): 2934 (34.3%) had a LOH 15 days. The 90-day post-discharge mortality was 11.4%, readmission 32.2%, and combined endpoint 37.4%. Mortality was increased by 36.5% (95%CI = 13.0–64.9) when LOH was 11–15 days, and by 72.0% (95%CI = 42.6–107.5) when >15 days. Conversely, no differences were found in readmission risk, and the combined endpoint only increased 21.6% (95%CI = 8.4–36.4) for LOH >15 days. Stratified analysis by hospitalisation departments rendered similar post-discharge outcomes, with all exhibiting increased mortality for LOH >15 days and no significant increments in readmission risk. Conclusions: Short hospitalisations are not associated with worse outcomes. While post-discharge readmissions are not affected by LOH, mortality risk increases as the LOH lengthens. These findings were similar across hospitalisation departments

Immunocompromised patients with acute respiratory distress syndrome : Secondary analysis of the LUNG SAFE database

The aim of this study was to describe data on epidemiology, ventilatory management, and outcome of acute respiratory distress syndrome (ARDS) in immunocompromised patients. Methods: We performed a post hoc analysis on the cohort of immunocompromised patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study. The LUNG SAFE study was an international, prospective study including hypoxemic patients in 459 ICUs from 50 countries across 5 continents. Results: Of 2813 patients with ARDS, 584 (20.8%) were immunocompromised, 38.9% of whom had an unspecified cause. Pneumonia, nonpulmonary sepsis, and noncardiogenic shock were their most common risk factors for ARDS. Hospital mortality was higher in immunocompromised than in immunocompetent patients (52.4% vs 36.2%; p < 0.0001), despite similar severity of ARDS. Decisions regarding limiting life-sustaining measures were significantly more frequent in immunocompromised patients (27.1% vs 18.6%; p < 0.0001). Use of noninvasive ventilation (NIV) as first-line treatment was higher in immunocompromised patients (20.9% vs 15.9%; p = 0.0048), and immunodeficiency remained independently associated with the use of NIV after adjustment for confounders. Forty-eight percent of the patients treated with NIV were intubated, and their mortality was not different from that of the patients invasively ventilated ab initio. Conclusions: Immunosuppression is frequent in patients with ARDS, and infections are the main risk factors for ARDS in these immunocompromised patients. Their management differs from that of immunocompetent patients, particularly the greater use of NIV as first-line ventilation strategy. Compared with immunocompetent subjects, they have higher mortality regardless of ARDS severity as well as a higher frequency of limitation of life-sustaining measures. Nonetheless, nearly half of these patients survive to hospital discharge. Trial registration: ClinicalTrials.gov, NCT02010073. Registered on 12 December 2013

Mechanical ventilation in patients with cardiogenic pulmonary edema : a sub-analysis of the LUNG SAFE study

Patients with acute respiratory failure caused by cardiogenic pulmonary edema (CPE) may require mechanical ventilation that can cause further lung damage. Our aim was to determine the impact of ventilatory settings on CPE mortality. Patients from the LUNG SAFE cohort, a multicenter prospective cohort study of patients undergoing mechanical ventilation, were studied. Relationships between ventilatory parameters and outcomes (ICU discharge/hospital mortality) were assessed using latent mixture analysis and a marginal structural model. From 4499 patients, 391 meeting CPE criteria (median age 70 [interquartile range 59-78], 40% female) were included. ICU and hospital mortality were 34% and 40%, respectively. ICU survivors were younger (67 [57-77] vs 74 [64-80] years, p < 0.001) and had lower driving (12 [8-16] vs 15 [11-17] cmHO, p < 0.001), plateau (20 [15-23] vs 22 [19-26] cmHO, p < 0.001) and peak (21 [17-27] vs 26 [20-32] cmHO, p < 0.001) pressures. Latent mixture analysis of patients receiving invasive mechanical ventilation on ICU day 1 revealed a subgroup ventilated with high pressures with lower probability of being discharged alive from the ICU (hazard ratio [HR] 0.79 [95% confidence interval 0.60-1.05], p = 0.103) and increased hospital mortality (HR 1.65 [1.16-2.36], p = 0.005). In a marginal structural model, driving pressures in the first week (HR 1.12 [1.06-1.18], p < 0.001) and tidal volume after day 7 (HR 0.69 [0.52-0.93], p = 0.015) were related to survival. Higher airway pressures in invasively ventilated patients with CPE are related to mortality. These patients may be exposed to an increased risk of ventilator-induced lung injury. Trial registration Clinicaltrials.gov NCT02010073