1Division of Neurosurgery, St. Michael's Hospital, Toronto.
2Li Ka Shing Knowledge Institute, Unity Health, Toronto.
J Neurosurg Pediatr. 2023 Sep 29;32(6):701-709. doi: 10.3171/2023.8.PEDS23354. Print 2023 Dec 1.
In this study, the authors aimed to quantify the frequency of in-hospital major adverse events (AEs) in a multicenter cohort of pediatric patients with spinal cord injury (SCI) managed at North American trauma centers. They also sought to identify patient and injury factors associated with the occurrence of major and immobility-related AEs.
Data derived from the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) were used to identify a cohort of pediatric patients (age < 19 years) with traumatic SCI. The authors identified individuals with major and immobility-related AEs following injury. They used mixed-effects multivariable logistic regression to identify clinical variables associated with AEs after injury. This analytical approach allowed them to account for similarities in care delivery between patients managed in the same trauma settings during the study period while also adjusting for patient-level confounders. The adjusted impact of AEs on in-hospital mortality and length of stay (LOS) were also assessed through further multivariable regression analysis. Additional subgroup analyses were performed to reduce bias associated with competing risks and explore the age-specific risk factor associations with AEs.
A total of 1853 pediatric patients who sustained either cervical or thoracic SCI were managed at ACS TQIP trauma centers between 2017 and 2020. The most frequently encountered AE types were pressure ulcer, unplanned intubation, cardiac arrest requiring cardiopulmonary resuscitation, and ventilator-associated pneumonia. The crude rate of major in-hospital and immobility-related AEs significantly differed between subgroups, with higher proportions of AEs in complete injuries compared with incomplete injuries. The adjusted risk for major AE following injury was significantly elevated for cervical complete SCI, patients with severe concomitant abdominal injuries, and for those presenting with depressed Glasgow Coma Scale scores less than 13. These same risk factors were associated with major AEs in children older than 8 years but were not significant for younger children (age ≤ 8 years). Complication occurrence was not associated with difference in risk-adjusted mortality (OR 0.72, 95% CI 0.45-1.14), but did increase LOS by 2.2 days (95% CI 1.4-2.7 days).
The authors outlined the prevalence of in-hospital AEs in a large multicenter cohort of North American pediatric SCI patients. Important risk factors predisposing this population to AEs include cervical complete injuries, simultaneous abdominal trauma, and Glasgow Coma Scale scores < 13 at presentation. Postinjury complications impacted health resource utilization by increased LOS but did not affect postinjury mortality. These findings have important implications for pediatric SCI providers and future care quality benchmarking.
本研究旨在量化北美创伤中心管理的脊髓损伤（SCI）儿科患者多中心队列中院内主要不良事件（AE）的频率。作者还试图确定与主要和活动受限相关 AE 发生相关的患者和损伤因素。
使用美国外科医师学院（ACS）创伤质量改进计划（TQIP）的数据，确定了一组年龄<19 岁的外伤性 SCI 儿科患者。作者确定了受伤后发生主要和与活动受限相关的 AE 的个体。作者使用混合效应多变量逻辑回归来确定与损伤后 AE 相关的临床变量。这种分析方法允许他们在研究期间考虑到在同一创伤环境中管理的患者之间提供护理的相似性，同时调整患者水平的混杂因素。还通过进一步的多变量回归分析评估 AE 对院内死亡率和住院时间（LOS）的影响。进行了额外的亚组分析，以减少与竞争风险相关的偏倚，并探讨与 AE 相关的特定年龄的危险因素关联。
2017 年至 2020 年，共有 1853 名在 ACS TQIP 创伤中心接受治疗的患有颈或胸 SCI 的儿科患者。最常见的 AE 类型是压疮、计划外插管、需要心肺复苏的心脏骤停和呼吸机相关性肺炎。主要院内和活动受限相关 AE 的粗发生率在亚组之间存在显著差异，完全性损伤的 AE 比例高于不完全性损伤。受伤后发生主要 AE 的调整风险显著升高，包括颈完全性 SCI、伴有严重合并腹部损伤的患者以及格拉斯哥昏迷量表评分<13 的患者。这些相同的危险因素与 8 岁以上儿童的主要 AE 相关，但与 8 岁以下儿童无关。并发症的发生与调整后的死亡率无差异（OR 0.72，95%CI 0.45-1.14），但会使 LOS 增加 2.2 天（95%CI 1.4-2.7 天）。
作者概述了北美大型多中心儿科 SCI 患者队列中院内 AE 的发生率。使该人群易发生 AE 的重要危险因素包括颈完全性损伤、同时发生的腹部创伤以及入院时格拉斯哥昏迷量表评分<13。受伤后的并发症通过增加 LOS 影响卫生资源的利用，但不影响受伤后的死亡率。这些发现对儿科 SCI 提供者和未来的医疗质量基准测试具有重要意义。
