BackgroundOrthopedic trauma surgery has multiple, both patient-based and surgeon-based risk factors. Evaluating and modifying certain patient safety factors could mitigate some of these risks. This study investigates the influence that the time of day of surgery has on mortality and complication rates.Question/purposeThis study evaluates whether the time of day of orthopedic trauma surgery influences complication or mortality rates.Patients and methodsA prospective Swiss surgical database developed as a nationwide quality assurance project was reviewed retrospectively. All patients with trauma-coded diagnoses that were surgically treated in Swiss hospitals between 2004 and 2014 were evaluated. Surgery times were stratified into morning, afternoon, evening and night. The primary outcomes were in-hospital mortality and complication rates. Co-factors were sought in bivariate and multivariable analysis.ResultsOf 31,692 patients, 13,969 (44.3%) were operated in the morning, 12,696 (40.3%) in the afternoon, 4,331 (13.7%) in the evening, and 550 (1.7%) at night. Mortality rates were significantly higher in nighttime (2.4%, OR 1.26, p=0.04) and afternoon surgery (1.7%, OR 1.94, p=0.03) vs. surgery in the morning (1.1%). Surgery performed in the afternoon and at night showed significantly increased general complication rates vs. surgery performed in the morning. (OR 1.22, p=0.006 and OR 1.51, p=0.021, respectively).ConclusionThis study observed higher complication and mortality rates for surgery performed after-hours, which correlates with other recent studies. Surgeon fatigue is a potential contributing factor for these increased risks. Other potential factors include surgeon experience, surgery type, and the potential for more severe or emergent injuries occurring after-hours.
BackgroundNonoperative management for blunt splenic injury is the preferred treatment. To improve the outcome of selective nonoperative therapy, the current challenge is to identify factors that predict failure. Little is known about the impact of concomitant injury on outcome. Our study has two goals. First, to determine whether concomitant injury affects the safety of selective nonoperative treatment. Secondly we aimed to identify factors that can predict failure.MethodsFrom our prospective trauma registry we selected all nonoperatively treated adult patients with blunt splenic trauma admitted between 01.01.2000 and 12.21.2013. All concurrent injuries with an AIS ≥ 2 were scored. We grouped and compared patients sustaining solitary splenic injuries and patients with concomitant injuries. To identify specific factors that predict failure we used a multivariable regression analysis.ResultsA total of 79 patients were included. Failure of nonoperative therapy (n = 11) and complications only occurred in patients sustaining concomitant injury. Furthermore, ICU-stay as well as hospitalization time were significantly prolonged in the presence of associated injury (4 versus 13 days,p < 0.05). Mortality was not seen. Multivariable analysis revealed the presence of a femur fracture and higher age as predictors of failure.ConclusionsNonoperative management for hemodynamically normal patients with blunt splenic injury is feasible and safe, even in the presence of concurrent (non-hollow organ) injuries or a contrast blush on CT. However, associated injuries are related to prolonged intensive care unit- and hospital stay, complications, and failure of nonoperative management. Specifically, higher age and the presence of a femur fracture are predictors of failure.
Up to 20% of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) patients develop severe inflammatory complications with diffuse pulmonary inflammation, reflecting acute respiratory distress syndrome (ARDS). A similar clinical profile occurs in severe trauma cases. This review compares pathophysiological and therapeutic principles of severely injured trauma patients and severe coronavirus disease 2019 (COVID-19). The development of sequential organ failure in trauma parallels deterioration seen in severe COVID-19. Based on established pathophysiological models in the field of trauma, two complementary pathways of disease progression into severe COVID-19 have been identified. Furthermore, the transition from local contained disease into systemic and remote inflammation has been addressed. More specifically, the traumatology concept of sequential insults ('hits') resulting in immune dysregulation, is applied to COVID-19 disease progression modelling. Finally, similarities in post-insult humoral and cellular immune responses to severe trauma and severe COVID-19 are described. To minimize additional 'hits' to COVID-19 patients, we suggest postponing all elective surgery in endemic areas. Based on traumatology experience, we propose that immunoprotective protocols including lung protective ventilation, optimal thrombosis prophylaxis, secondary infection prevention and calculated antibiotic therapy are likely also beneficial in the treatment of SARS-CoV-2 infections. Finally, rising SARS-CoV-2 infection and mortality rates mandate exploration of out-of-the box treatment concepts, including experimental therapies designed for trauma care.
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