安全吗？老年创伤患者钝性脾损伤的非手术治疗
Is It safe? Nonoperative management of blunt splenic injuries in geriatric trauma patients.
作者信息
Trust Marc D, Teixeira Pedro G, Brown Lawrence H, Ali Sadia, Coopwood Ben, Aydelotte Jayson D, Brown Carlos V R
机构信息
From the University of Texas at Austin Dell Medical School Department of Surgery and Perioperative Care, Division of Acute Care Surgery (M.D.T., P.T., B.C., J.A., C.V.R.B.); and Department of Trauma Services (M.D.T., P.T., L.B., S.A., B.C., J.A., C.V.R.B.), Dell Seton Medical Center at The University of Texas, Austin, Texas.
出版信息
J Trauma Acute Care Surg. 2018 Jan;84(1):123-127. doi: 10.1097/TA.0000000000001731.
BACKGROUND
Because of increased failure rates of nonoperative management (NOM) of blunt splenic injuries (BSI) in the geriatric population, dogma dictated that this management was unacceptable. Recently, there has been an increased use of this treatment strategy in the geriatric population. However, published data assessing the safety of NOM of BSI in this population is conflicting, and well-powered multicenter data are lacking.
METHODS
We performed a retrospective analysis of data from the National Trauma Data Bank (NTDB) from 2014 and identified young (age < 65) and geriatric (age ≥ 65) patients with a BSI. Patients who underwent splenectomy within 6 hours of admission were excluded from the analysis. Outcomes were failure of NOM and mortality.
RESULTS
We identified 18,917 total patients with a BSI, 2,240 (12%) geriatric patients and 16,677 (88%) young patients. Geriatric patients failed NOM more often than younger patients (6% vs. 4%, p < 0.0001). On logistic regression analysis, Injury Severity Score of 16 or higher was the only independent risk factor associated with failure of NOM in geriatric patients (odds ratio, 2.778; confidence interval, 1.769-4.363; p < 0.0001). There was no difference in mortality in geriatric patients who had successful vs. failed NOM (11% vs. 15%; p = 0.22). Independent risk factors for mortality in geriatric patients included admission hypotension, Injury Severity Score of 16 or higher, Glasgow Coma Scale score of 8 or less, and cardiac disease. However, failure of NOM was not independently associated with mortality (odds ratio, 1.429; confidence interval, 0.776-2.625; p = 0.25).
CONCLUSION
Compared with younger patients, geriatric patients had a higher but comparable rate of failed NOM of BSI, and failure rates are lower than previously reported. Failure of NOM in geriatric patients is not an independent risk factor for mortality. Based on our results, NOM of BSI in geriatric patients is safe.
LEVEL OF EVIDENCE
Therapeutic, level IV.
背景
由于老年人群钝性脾损伤（BSI）非手术治疗（NOM）的失败率增加，过去的观念认为这种治疗方法不可接受。最近，这种治疗策略在老年人群中的应用有所增加。然而，评估该人群中BSI非手术治疗安全性的已发表数据存在矛盾，且缺乏有力的多中心数据。
方法
我们对2014年国家创伤数据库（NTDB）的数据进行了回顾性分析，确定了患有BSI的年轻（年龄<65岁）和老年（年龄≥65岁）患者。入院6小时内接受脾切除术的患者被排除在分析之外。结局指标为非手术治疗失败和死亡率。
结果
我们共确定了18917例BSI患者，其中老年患者2240例（12%），年轻患者16677例（88%）。老年患者非手术治疗失败的频率高于年轻患者（6%对4%，p<0.0001）。逻辑回归分析显示，损伤严重度评分16分或更高是老年患者非手术治疗失败的唯一独立危险因素（比值比，2.778；置信区间，1.769 - 4.363；p<0.0001）。非手术治疗成功与失败的老年患者死亡率无差异（11%对15%；p = 0.22）。老年患者死亡的独立危险因素包括入院时低血压、损伤严重度评分16分或更高、格拉斯哥昏迷量表评分8分或更低以及心脏病。然而，非手术治疗失败并非死亡率的独立相关因素（比值比，1.429；置信区间，0.776 - 2.625；p = 0.25）。
结论
与年轻患者相比，老年患者BSI非手术治疗失败率更高，但具有可比性，且失败率低于先前报道。老年患者非手术治疗失败并非死亡率的独立危险因素。基于我们的结果，老年患者BSI的非手术治疗是安全的。
证据水平
治疗性，IV级。
Zotero 插件