EP.FRI.309 Rib fractures – an overlooked part of general surgical take? An audit and creation of a local pathway

Abstract Introduction Battle et al devised a validated scoring system to stratify patients with rib fractures (RF) at risk of complications based on age; number of fractures; oxygenation; respiratory illness and anticoagulation use. Risk of complications increases with score e.g. ≤10 and ≥31 give estimated complications risk of 13% and 88% respectively (2). Method We conducted a local retrospective audit of 45 patients admitted with RF over 26 months. Initial and subsequent analgesia was recorded. Four subgroups were created based on Batlle score: ≤10, 11-20, 21-30, ≥31. Outcomes included complications, length of stay (LOS) and mortality. Results Whilst overall median score was 18, we observed 20% (n = 9) scored ≥31. Initially, oral analgesia alone was given to 64% of patients; 66% went on to require lidocaine patch and 15% required patient controlled analgesia. Only 2.2% (n = 1) received regional analgesia. Despite 35.6% (n = 16) scoring ≥21, only four proactive critical care referrals were made. Overall pneumonia rate was 20% (n = 9); 44% (n = 4) in the ≥31 group. There were two deaths overall, both in the ≥31 group. Median LOS was 3 days; however 44% (n = 4) of the ≥31 group required ≥7 days. Conclusion One in five RF cases scored ≥31 and consequently had the worst outcomes. There was initial suboptimal analgesia, inadequate early escalation of higher risk patients to critical care and low rates of regional blocks. Consequently, we have created a local pathway based on Battle score (2) to standardise risk stratification and management of these patients in order to improve outcomes.

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Pre-NELA vs NELA – has anything changed, or is it just an audit exercise?

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2016.0248 ◽

2016 ◽

Vol 98 (8) ◽

pp. 554-559 ◽

Cited By ~ 3

Author(s):

M Mak ◽

AR Hakeem ◽

V Chitre

Keyword(s):

Critical Care ◽

High Risk ◽

Uneventful Recovery ◽

Emergency Laparotomy ◽

Mortality And Morbidity ◽

High Risk Patients ◽

Possum Score ◽

Operative Severity Score ◽

Risk Patients ◽

Set Up

BACKGROUND Following evidence suggestive of high mortality following emergency laparotomies, the National Emergency Laparotomy Audit (NELA) was set up, highlighting key standards in emergency service provision. Our aim was to compare our NHS trust’s adherence to these recommendations immediately prior to, and following, the launch of NELA, and to compare patient outcome. METHODS This was a retrospective study of patients who underwent an emergency laparotomy over the course of 6 months – 3 months either side of the initiation of NELA. RESULTS There were 44 patients before the initiation of NELA (pre-NELA, PN group) and 55 in the first 3 months of NELA (N group). We saw a significant increase in the proportion of patients whose decision to operate was made by the consultant: 75.0% in the PN group vs 100% in N group (subsequent data presented in this order) (P < 0.001). The presence of a consultant surgeon (75.0% vs 83.6%, P = 0.321) and anaesthetist (100.0% vs 90.9%, P = 0.064) in theatres were comparable in both groups. Risk stratification based on Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) score showed no difference in high-risk patients in both groups (47.7% vs 36.4%, P = 0.306). With the NELA initiative, however, significantly more patients were admitted directly from theatres to the critical care unit, when compared with the pre-NELA period (9.1% vs 27.3%, P = 0.038). This also reflected a significant reduction in unexpected escalation to a higher level of care during this period (10.0% vs 0%, P = 0.036). Significantly more patients had uneventful recovery in the NELA period (52.3 vs 76.4%, P = 0.018), although there was no difference in 30-day mortality between the groups (2.3% vs 7.3%, P = 0.378). CONCLUSIONS This study demonstrated a greater degree of consultant involvement in the decision to operate during NELA. More high-risk patients have been identified preoperatively with diligent risk assessment and, hence, have been proactively admitted to critical care units following laparotomy, which may account for the significant reduction in unexpected escalation to level 2 or level 3 care and thus in overall better patient outcomes.

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Patient-controlled Analgesia With Propacetamol-Fentanyl Mixture for Prevention of Postoperative Nausea and Vomiting in High-risk Patients Undergoing Spine Surgery

Journal of Neurosurgical Anesthesiology ◽

10.1097/ana.0000000000000252 ◽

2016 ◽

Vol 28 (4) ◽

pp. 316-322 ◽

Cited By ~ 3

Author(s):

Eun Jung Kim ◽

Jae-Kwang Shim ◽

Sarah Soh ◽

Jong Wook Song ◽

Se Ryeon Lee ◽

...

Keyword(s):

High Risk ◽

Spine Surgery ◽

Postoperative Nausea ◽

Postoperative Nausea And Vomiting ◽

Nausea And Vomiting ◽

Patient Controlled Analgesia ◽

High Risk Patients ◽

Risk Patients

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Decreased Risk of Delirium With Use of Regional Analgesia in Geriatric Trauma Patients With Multiple Rib Fractures

Annals of Surgery ◽

10.1097/sla.0000000000002929 ◽

2018 ◽

Vol 268 (3) ◽

pp. 534-540 ◽

Cited By ~ 11

Author(s):

Kathleen M. O’Connell ◽

D. Alex Quistberg ◽

Robert Tessler ◽

Bryce R. H. Robinson ◽

Joseph Cuschieri ◽

...

Keyword(s):

Rib Fractures ◽

Geriatric Trauma ◽

Trauma Patients ◽

Regional Analgesia ◽

Multiple Rib Fractures

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Risk Factors for Critical Coronavirus Disease 2019 and Mortality in Hospitalized Young Adults: An Analysis of the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) Coronavirus Disease 2019 Registry

Critical Care Explorations ◽

10.1097/cce.0000000000000514 ◽

2021 ◽

Vol 3 (8) ◽

pp. e0514

Author(s):

Sandeep Tripathi ◽

Imran A. Sayed ◽

Heda Dapul ◽

Jeremy S. McGarvey ◽

Jennifer A. Bandy ◽

...

Keyword(s):

Risk Factors ◽

Young Adults ◽

Critical Care ◽

Viral Infection ◽

Respiratory Illness ◽

Critical Care Medicine

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Multispecialty tracheostomy experience

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2019.0184 ◽

2020 ◽

Vol 102 (5) ◽

pp. 343-347 ◽

Cited By ~ 3

Author(s):

G Lipton ◽

M Stewart ◽

R McDermid ◽

R Docking ◽

C Urquhart ◽

...

Keyword(s):

Critical Care ◽

Case Series ◽

Neck Surgery ◽

Health Board ◽

Percutaneous Procedures ◽

Retrospective Audit ◽

Large Head ◽

Significant Case ◽

The Mean ◽

The Uk

Introduction Tracheostomy is a common surgical procedure used to create a secure airway in patients, now performed by a variety of specialties, with a notable rise in critical care environments. It is unclear whether this rise is seen in units with large head and neck surgery departments, and how practice in such units compares with the rest of the UK. Methods A three-year retrospective audit was carried out between anaesthetic, surgical and critical care departments. All tracheostomy procedures were recorded anonymously. Results A total of 523 tracheostomies were performed, 66% of which were in men. The mean patient age was 60 years. The majority (83%) were elective, performed for various indications, while the remaining 17% were emergency tracheostomies performed for pending airway obstruction. A fifth of the tracheostomies were percutaneous procedures. Most emergency tracheostomies (78%) were performed by otolaryngology. Three cricothyroidotomies were performed within critical care and theatres. Complications related to tracheostomy occurred in 47 cases (9%), most commonly lower respiratory tract infection. The mean time to decannulation was 12.8 days. Conclusions This paper discusses the findings of a comprehensive, multispecialty audit of tracheostomy experience in a large health board, with over 150 tracheostomies performed annually. Elective cases form the majority although there is a significant case series of emergency tracheostomies performed for a range of pathologies. Around a quarter of those requiring tracheostomy ultimately died, mostly as a result of advanced cancer.

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Prevalence of Delayed Hemothorax in Blunt Thoracic Trauma

The American Surgeon ◽

10.1177/000313480507100606 ◽

2005 ◽

Vol 71 (6) ◽

pp. 481-486 ◽

Cited By ~ 16

Author(s):

Om P. Sharma ◽

Sara Hagler ◽

Michael F. Oswanski

Keyword(s):

Critical Care ◽

Mortality Rate ◽

Thoracic Trauma ◽

Injury Severity ◽

Age Groups ◽

Rib Fractures ◽

P Value ◽

Blunt Thoracic Trauma ◽

Younger Patients ◽

Current Report

Delayed hemothorax (DHTX) is rarely seen. On an 8-year retrospective analysis of blunt thoracic trauma (BTT), hemothorax (HTX) was diagnosed in 167 patients: 18 children, 113 adults, and 36 elderly. No statistical differences were seen in any age groups regarding Injury Severity Score (mean ISS, 30.54), critical care length of stay (CLOS, 9.0), and hospital LOS (HLOS, 11.21). Mortality rate was 18 per cent in adults and 28 per cent in elderly ( P value < 0.0001). HTX was acute in 160 and delayed in 7 patients. Two-thirds of HTX patients were males and 75 per cent had rib fractures. All of our DHTX patients were males (5 adults and 2 elderly) and had rib fractures. Acute HTX was seen in younger patients (43.3 vs 56.1 years, P value 0.46), with higher ISS (31.44 vs 14.43, P value < 0.001), CLOS (7.19 vs 3.0 days, P value 0.511) and HLOS (11.9 vs 11.6, P value 0.468). Mortality was 22.5 per cent in AHTX and none in DHTX. Eighty-six per cent of DHTX and 49 per cent of AHTX patients went home on discharge. DHTX was rare (5%) in the current report with lower ISS, HLOS, and no mortality. Patients with rib fractures should be watched for development of DHTX as timely diagnosis and treatment is essential for favorable outcome.

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Multicenter longitudinal cross-sectional study comparing effectiveness of serratus anterior plane, paravertebral and thoracic epidural for the analgesia of multiple rib fractures

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2019-101119 ◽

2020 ◽

Vol 45 (5) ◽

pp. 351-356 ◽

Cited By ~ 3

Author(s):

Laura Beard ◽

Carl Hillermann ◽

Emma Beard ◽

Sue Millerchip ◽

Rajneesh Sachdeva ◽

...

Keyword(s):

Hospital Mortality ◽

Negative Binomial ◽

Rib Fractures ◽

Serratus Anterior ◽

Regional Analgesia ◽

Cross Sectional ◽

Thoracic Epidural ◽

Pain Scores ◽

Significant Difference ◽

Anterior Plane

BackgroundThere is a paucity of data comparing effectiveness of various techniques for pain management of traumatic rib fractures. This study compared the quality of analgesia provided by serratus anterior plane (SAP) catheters against thoracic epidural (TEA) or paravertebral catheters (PA) in patients with multiple traumatic rib fractures (MRFs).Methods354 patients who received either SAP, TEA or PA at two tertiary referral major trauma centers in the UK were included (2016–2018). Primary outcome were change in inspiratory volumes and pain scores. Secondary outcomes included in-hospital mortality, along with the length of stay in hospital and critical care. Data were analyzed using linear, log-binomial and negative binomial regression models.Main resultsAcross all blocks, there was a mean (SD) increase in inspiratory volume postblock of 789.4 mL (479.7). Ninety-eight per cent of all participants reported moderate/severe pain prior to regional analgesia, which was reduced to 34% postblock. There was no significant difference in the change in inspiratory volume or pain scores between the TEA, PA or SAP groups. Overall crude mortality was 13.2% (95% CI 7.8% to 18.7%). In an adjusted analysis and compared with TEA, in-hospital mortality was similar between groups (relative risk (RR) 0.4, 95% CI 0.1 to 1.0) and (RR 0.5, 95% CI 0.2 to 1.6) for SAP and PA, respectively.ConclusionSAP, TEA and PA all appear to offer the ability to reduce pain scores and improve respiratory function.

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