低危老年创伤患者的并发症：病例对照研究。
Complications in low-risk older adult trauma patients: A case-control study.
机构信息
From the Harborview Injury Prevention and Research Center (R.A.T., F.P.R., E.B., M.S.V., S.A.), Seattle, Washington; School of Medicine (M.M.R., M.L.R.), University of Washington, Seattle, Washington; Department of Pediatrics (F.P.R.), University of Washington, Seattle, Washington; Department of Surgery (E.B., S.A), University of Washington, Seattle, Washington; Department of Anesthesiology and Pain Medicine (M.S.V.), University of Washington, Seattle, Washington; and Division of Gerontology and Geriatric Medicine (M.J.R.), University of Washington, Seattle, Washington.
出版信息
J Trauma Acute Care Surg. 2019 May;86(5):858-863. doi: 10.1097/TA.0000000000002204.
BACKGROUND
Although some geriatric trauma patients may be at low risk of complications, poor outcomes are pronounced if complications do occur. Prevention in this group decreases the risk of excess morbidity and mortality.
METHODS
We performed a case-control study of trauma patients 65 years or older treated from January 2015 to August 2016 at a Level I trauma center with a Trauma Quality Improvement Program-predicted probability of complication of less than 20%. Cases had one of the following complications: unplanned admission to the intensive care unit (ICU), unplanned intubation, pneumonia, or unplanned return to the operating room. Two age-matched controls were randomly selected for each case. We collected information on comorbidities, home medications, and early medical care and calculated odds ratios using multivariable conditional logistic regression.
RESULTS
Ninety-four patients experienced unplanned admission to ICU (n = 51), unplanned intubation (n = 14), pneumonia (n = 21), and unplanned return to the operating room (n = 8). The 188 controls were more frequently intubated and had higher median ISS but were otherwise similar to cases. The adjusted odds of complication were higher for patients on a home β-blocker (adjusted odds ratio [aOR], 2.2; 95% confidence interval [CI], 1.2-4.0) and home anticoagulation (aOR, 2.2; 95% CI, 1.2-4.1). Patients with diabetes (aOR 2.0; 95% CI, 1.1-3.7) and dementia (aOR, 2.0; 95% CI, 1.0-4.3) also had higher odds of complication. The adjusted odds of complication for patients receiving geriatrics consultation was 0.4 (95% CI, 0.2-1.0; p = 0.05). Pain service consultation and indwelling pain catheter placement may be protective, but CIs included 1. There was no association between opiates, benzodiazepines, fluid administration, or blood products in the first 24 hours and odds of complication.
CONCLUSIONS
Geriatrics consultation was associated with lower odds of unplanned admission to the ICU, unplanned intubation, pneumonia, and unplanned return to the operating room in low-risk older adult trauma patients. Pathways that support expanding comanagement strategies with geriatricians are needed.
LEVEL OF EVIDENCE
Therapeutic/Care management, Level IV.
背景
尽管一些老年创伤患者并发症风险较低，但如果发生并发症，其预后较差。该人群的预防措施可降低发病率和死亡率。
方法
我们对 2015 年 1 月至 2016 年 8 月在 1 级创伤中心接受治疗且创伤质量改进计划预测并发症概率<20%的 65 岁及以上老年创伤患者进行病例对照研究。病例组发生以下一种并发症：计划外入住重症监护病房（ICU）、计划外插管、肺炎或计划外返回手术室。每个病例随机选择 2 个年龄匹配的对照组。我们收集了合并症、家庭用药和早期医疗信息，并使用多变量条件逻辑回归计算了比值比。
结果
94 例患者发生计划外入住 ICU（n=51）、计划外插管（n=14）、肺炎（n=21）和计划外返回手术室（n=8）。188 名对照者插管的频率更高，损伤严重度评分中位数更高，但与病例相比无其他差异。使用家庭β受体阻滞剂（调整后比值比 [aOR]，2.2；95%置信区间 [CI]，1.2-4.0）和家庭抗凝药物（aOR，2.2；95% CI，1.2-4.1）的患者并发症发生的调整后比值更高。患有糖尿病（aOR，2.0；95% CI，1.1-3.7）和痴呆（aOR，2.0；95% CI，1.0-4.3）的患者并发症发生的调整后比值也更高。接受老年科会诊的患者并发症发生的调整后比值为 0.4（95% CI，0.2-1.0；p=0.05）。疼痛服务会诊和留置疼痛导管可能具有保护作用，但 CI 包括 1。在最初 24 小时内使用阿片类药物、苯二氮䓬类药物、液体管理或血液制品与并发症发生的比值无关。
结论
老年科会诊与低危老年创伤患者计划外入住 ICU、计划外插管、肺炎和计划外返回手术室的风险降低相关。需要制定支持扩大老年医生共同管理策略的途径。
证据水平
治疗/护理管理，IV 级。
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