长期机械通气后的结局：一项全县创伤登记分析
Outcomes following prolonged mechanical ventilation: analysis of a countywide trauma registry.
作者信息
Rubano Jerry A, Paccione Michael F, Rutigliano Daniel N, Vosswinkel James A, McCormack Jane E, Huang Emily C, Yang Jie, Shapiro Marc J, Jawa Randeep S
机构信息
From the Division of Trauma (J.A.R., M.F.P., D.N.R., J.A.V., J.E.M.M.J.S., and R.S.J), Department of Surgery, Stony Brook University School of Medicine; and Department of Preventive Medicine (J.Y.), Stony Brook University Medical Center, Health Sciences Center, Stony Brook, New York.
出版信息
J Trauma Acute Care Surg. 2015 Feb;78(2):289-94. doi: 10.1097/TA.0000000000000515.
BACKGROUND
The care of mechanically ventilated patients at high-volume centers in select nontrauma populations has variable effects on outcomes. We evaluated outcomes for trauma patients requiring prolonged mechanical ventilation (PMV). We further hypothesized that the higher mechanical ventilator volume trauma center would have better outcomes.
METHODS
A retrospective review of a county's trauma registry was performed for trauma patients who were at least 18 years old admitted from 2006 to 2010. Eleven hospitals serve this suburban county, with a population of approximately 1.5 million people. The state has designated them as nontrauma centers (n = 6), area trauma centers (ATCs, n = 4), or regional trauma center (RTC, n = 1), where the last one provides the highest echelon of care. Patients requiring mechanical ventilation for at least 96 hours following injury were evaluated.
RESULTS
A total of 3,382 trauma patients were admitted to the RTC, and 5,870 were admitted to the other 10 hospitals in the county. Seven hundred seventy-one received mechanical ventilation at the RTC, and 687 at the other 10 hospitals combined. Of these patients, 407 at the RTC and 308 at the remaining facilities (291 at ATCs and 17 at nontrauma centers) required PMV. Median (interquartile range [IQR]) Injury Severity Score (ISS) at the RTC was higher (29 [21-41] vs. 22 [16-29] p < 0.001) than that at ATCs. Hospital length of stay (in days) was comparable between the RTC and ATCs (28 [18-45] vs. 26 [16-44.7]). With regard to complications, rates of renal failure, sepsis, and myocardial infarction were similar. The RTC had higher pneumonia rates (59% vs. 45.4%, p < 0.001) and venous thromboembolic disease rates (20.4% vs. 10.4%, p < 0.001) than did ATCs. In-hospital mortality was 17% at the RTC and 34.4% at ATCs (p < 0.001).
CONCLUSION
A mortality benefit but higher VTE and pneumonia rate for PMV patients at the RTC was noted. Collaborative practice initiatives are warranted to reduce morbidity and mortality across the region.
LEVEL OF EVIDENCE
Epidemiologic study, level IV.
背景
在特定非创伤人群的大容量中心，对机械通气患者的护理对治疗结果有不同影响。我们评估了需要长时间机械通气（PMV）的创伤患者的治疗结果。我们进一步假设，机械通气量较大的创伤中心会有更好的治疗结果。
方法
对2006年至2010年收治的至少18岁的创伤患者进行了一项对某县创伤登记处的回顾性研究。该县有11家医院，服务人口约150万。该州已将它们指定为非创伤中心（n = 6）、区域创伤中心（ATC，n = 4）或区域创伤中心（RTC，n = 1），其中最后一个提供最高级别的护理。对受伤后需要机械通气至少96小时的患者进行了评估。
结果
共有3382名创伤患者被收治到RTC，5870名被收治到该县的其他10家医院。771人在RTC接受了机械通气，其他10家医院共687人。在这些患者中，RTC有407人，其余机构有308人（ATC有291人，非创伤中心有17人）需要PMV。RTC的中位（四分位间距[IQR]）损伤严重程度评分（ISS）高于ATC（29[21 - 41]对22[16 - 29]，p < 0.001）。RTC和ATC的住院天数相当（28[18 - 45]对26[16 - 44.7]）。关于并发症，肾衰竭、败血症和心肌梗死的发生率相似。RTC的肺炎发生率（59%对45.4%，p < 0.001）和静脉血栓栓塞性疾病发生率（20.4%对10.4%，p < 0.001）高于ATC。RTC的院内死亡率为17%，ATC为34.4%（p < 0.001）。
结论
注意到RTC的PMV患者有死亡率获益，但VTE和肺炎发生率较高。有必要开展合作实践倡议以降低该地区的发病率和死亡率。
证据水平
流行病学研究，IV级。
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