RESUMEN
BACKGROUND: Cervical degenerative disc disease is the most common indication for anterior cervical discectomy and fusion. Given the possible complications, patients are stratified before anterior cervical discectomy and fusion by preoperative risk factors to optimize treatment. One preoperative factor is a patient's coagulation profile. METHODS: The American College of Surgeons-National Surgical Quality Improvement Database was used to identify patient preoperative coagulation profile and postoperative complications. By generating binary logistic regression models, each of the 4 abnormal coagulation categories (bleeding disorder, low platelet count, high partial thromboplastin time, and high international normalized ratio [INR]) were analyzed for their independent impact on increased risk for complications compared with the control cohort. RESULTS: A total of 61,977 patients were assessed. The most common abnormal coagulation was abnormal platelet count (n = 2149). The most common postoperative outcome was an extended length of hospital stay among patients with an abnormal coagulation profile relative to the control cohort. After multivariate analysis, patients with an abnormal INR (odds ratio, 2.2 [1.3-3.8]; P = 0.003) or abnormal platelet count (odds ratio, 1.5 [1.2-2.1]; P = 0.003) had a higher chance of having an extended length of hospital stay relative to patients having a normal coagulation profile. Having an abnormal INR was found to be associated with an increased risk for having "Any complication." CONCLUSIONS: Our results show significant differences in the incidence rates of a multitude of complications among the 5 groups based on univariate analysis. Patients with any abnormal coagulation disorder had increased rates of developing any complication or having an extended length of hospital stay.
Asunto(s)
Trastornos de la Coagulación Sanguínea/mortalidad , Coagulación Sanguínea/fisiología , Vértebras Cervicales/cirugía , Discectomía/mortalidad , Complicaciones Posoperatorias/mortalidad , Fusión Vertebral/mortalidad , Trastornos de la Coagulación Sanguínea/sangre , Trastornos de la Coagulación Sanguínea/etiología , Estudios de Cohortes , Bases de Datos Factuales/estadística & datos numéricos , Discectomía/efectos adversos , Femenino , Humanos , Relación Normalizada Internacional/mortalidad , Relación Normalizada Internacional/estadística & datos numéricos , Masculino , Complicaciones Posoperatorias/sangre , Complicaciones Posoperatorias/etiología , Sistema de Registros/estadística & datos numéricos , Estudios Retrospectivos , Factores de Riesgo , Fusión Vertebral/efectos adversosRESUMEN
Guidelines suggest targeting a preoperative international normalized ratio (INR) < 1.5. We examined and compared the predictive value of INR relative to the Model for End-Stage Liver Disease (MELD). We reviewed the American College of Surgeons NSQIP from 2005 to 2016 for adult patients undergoing open or laparoscopic cholecystectomy. Patients with a preoperative INR were stratified into groups: ≤1, >1 to ≤1.5, >1.5 to ≤2, and >2. Thirty day postoperative mortality was the primary outcome. Multivariable logistic regressions controlled for baseline differences. Of 58,177 cholecystectomy patients, 15.2 per cent had INR ≤ 1, 80.4 per cent had INR > 1 to ≤1.5, 3.7 per cent had INR > 1.5 to ≤2, and 0.7 per cent had INR > 2. Patients with INR > 2 were older and more likely to have diabetes and hypertension (P < 0.001). Multivariable regression demonstrated a stepwise increase in mortality for INR > 1 to ≤1.5 (odds ratio (OR) = 1.50 [1.10-2.05]), INR > 1.5 to ≤2 (OR = 2.96 [1.97-4.45]), and INR > 2 (OR = 3.21 [1.64-6.31]) relative to INR ≤ 1. C-statistic for INR (0.910) and MELD (0.906) models indicated a similar value in predicting mortality. INR groups also faced an incremental, increased risk of bleeding. Although unable to track preoperative correction of INR, this analysis identifies that INR remains an excellent predictor of postoperative mortality and bleeding after both open and laparoscopic cholecystectomies and is comparable to MELD.
Asunto(s)
Colecistectomía/mortalidad , Enfermedad Hepática en Estado Terminal/sangre , Enfermedad Hepática en Estado Terminal/mortalidad , Relación Normalizada Internacional/mortalidad , Adulto , Factores de Edad , Análisis de Varianza , Colecistectomía Laparoscópica/mortalidad , Diabetes Mellitus/tratamiento farmacológico , Enfermedad Hepática en Estado Terminal/diagnóstico , Enfermedad Hepática en Estado Terminal/cirugía , Femenino , Humanos , Hipertensión/tratamiento farmacológico , Relación Normalizada Internacional/estadística & datos numéricos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Hemorragia Posoperatoria/mortalidad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Medición de RiesgoRESUMEN
OBJECTIVES: Acute myocardial infarction is the most common cause of cardiogenic shock. Although the number of patients with acute myocardial infarction complicated by cardiogenic shock who were treated with venoarterial extracorporeal membrane oxygenation increased during the last decade, detailed data on survival are lacking. We sought to analyze covariates that were independently associated with survival in this patient population and to externally validate the newly developed prEdictioN of Cardiogenic shock OUtcome foR Acute myocardial infarction patients salvaGed by venoarterial Extracorporeal membrane oxygenation (ENCOURAGE) score. DESIGN: Retrospective clinical study. SETTING: A single academic teaching hospital. PATIENTS: Adult patients with acute myocardial infarction complicated by cardiogenic shock who were supported by venoarterial extracorporeal membrane oxygenation from June 2008 to September 2016. INTERVENTIONS: Fourteen individual variables were assessed for their association with the primary endpoint. These variables were prespecified by the study team as being the most likely to affect survival. A receiver operating characteristic analysis was also performed to test the ability of the ENCOURAGE score to predict survival in this patient cohort. MEASUREMENTS AND MAIN RESULTS: The primary endpoint of the study was in-hospital survival. A total of 61 patients were included in the analysis. Thirty-seven (60.7%) could be weaned from venoarterial extracorporeal membrane oxygenation and 36 (59.0%) survived. Survival was significantly higher in patients less than 65 years old (odds ratio, 14.6 [CI, 2.5-84.0]; p = 0.003), whose body mass index was less than 32 kg/m (odds ratio, 5.5 [CI, 1.2-25.4]; p = 0.029) and international normalized ratio was less than 2 (odds ratio, 7.3 [CI, 1.3-40.1]; p = 0.022). In patients where the first lactate drawn was less than 3 mmol/L, the survival was not significantly higher (odds ratio, 4.4 [CI, 0.6-32.6]; p = 0.147). The C-statistic for predicting survival using a modified version of the ENCOURAGE score, which replaced prothrombin activity less than 50% with an international normalized ratio greater than 2, was 0.74 (95% CI, 0.61-0.87). CONCLUSIONS: In this single-center study, several important covariates were associated with improved survival in patients with acute myocardial infarction complicated by cardiogenic shock who were supported by venoarterial extracorporeal membrane oxygenation and the ENCOURAGE score was found to be externally valid for predicting survival to hospital discharge.
Asunto(s)
Oxigenación por Membrana Extracorpórea/mortalidad , Infarto del Miocardio/terapia , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Índice de Masa Corporal , Femenino , Humanos , Relación Normalizada Internacional/mortalidad , Ácido Láctico/sangre , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Curva ROC , Estudios Retrospectivos , Factores de Riesgo , Choque Cardiogénico/mortalidad , Choque Cardiogénico/terapiaRESUMEN
The incidence of geriatric traumatic brain injury (TBI) is increasing throughout the United States, with many of these patients taking anticoagulation (AC) medication. The purpose of this investigation was to determine the effect of time to international normalized ratio (INR) reversal on intracranial hemorrhage evolution in TBI patients taking prehospital AC medication. We hypothesized that rapid reversal of INR improves outcomes of head-injured patients taking AC medication. Admissions to a Level II trauma center between February 2011 and December 2013 were reviewed. Patients presenting with an initial INR of 2.0 or more, computed tomographic scan positive for intracranial hemorrhage, and INR reversal to less than 1.5 in hospital were included. Patients with nontraumatic intracranial hemorrhage were excluded. Reversal of INR was achieved using some combination of fresh frozen plasma, prothrombin complex concentrate, and vitamin K. A binary logistic regression model assessed the adjusted impact of rapid INR reversal on intracranial hemorrhage evolution. Significance was defined as p < .05. One hundred subjects were included. Four patients with nontraumatic intracranial hemorrhage were excluded, resulting in a final study population of 96 patients. The most common intracranial hemorrhage in the study population was subarachnoid hemorrhage (71.9%), followed by subdural hemorrhage (35.4%). Reversal of INR of less than 5 hr was not associated with intracranial hemorrhage evolution; however, reversal of less than 10 hr was found to be associated with a decreased odds ratio for intracranial hemorrhage evolution (p = .043). Rapid reversal of elevated INR levels (<10 hr) may decrease intracranial hemorrhage evolution in TBI patients taking prehospital AC medication.
Asunto(s)
Anticoagulantes/efectos adversos , Lesiones Traumáticas del Encéfalo/complicaciones , Lesiones Traumáticas del Encéfalo/diagnóstico , Causas de Muerte , Relación Normalizada Internacional/mortalidad , Hemorragias Intracraneales/etiología , Anciano , Anciano de 80 o más Años , Anticoagulantes/uso terapéutico , Lesiones Traumáticas del Encéfalo/tratamiento farmacológico , Lesiones Traumáticas del Encéfalo/mortalidad , Estudios de Cohortes , Bases de Datos Factuales , Femenino , Evaluación Geriátrica , Humanos , Hemorragias Intracraneales/mortalidad , Hemorragias Intracraneales/fisiopatología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Tasa de Supervivencia , Factores de Tiempo , Centros TraumatológicosRESUMEN
OBJECTIVE: To develop a validated mortality prediction score for children with traumatic injuries. PATIENTS AND METHODS: We identified all children (<18 years of age) in the US military established Joint Theater Trauma Registry from 2002 to 2009 who were admitted to combat-support hospitals with traumatic injuries in Iraq and Afghanistan. We identified factors associated with mortality using univariate and then multivariate regression modeling. The developed mortality prediction score was then validated on a data set of pediatric patients (≤ 18 years of age) from the German Trauma Registry, 2002-2007. RESULTS: Admission base deficit, international normalized ratio, and Glasgow Coma Scale were independently associated with mortality in 707 patients from the derivation set and 1101 patients in the validation set. These variables were combined into the pediatric "BIG" score (base deficit + [2.5 × international normalized ratio] + [15 - Glasgow Coma Scale), which were each calculated to have an area under the curve of 0.89 (95% confidence interval: 0.83-0.95) and 0.89 (95% confidence interval: 0.87-0.92) on the derivation and validation sets, respectively. CONCLUSIONS: The pediatric trauma BIG score is a simple method that can be performed rapidly on admission to evaluate severity of illness and predict mortality in children with traumatic injuries. The score has been shown to be accurate in both penetrating-injury and blunt-injury populations and may have significant utility in comparing severity of injury in future pediatric trauma research and quality-assurance studies. In addition, this score may be used to determine inclusion criteria on admission for prospective studies when accurately estimating the mortality for sample size calculation is required.
Asunto(s)
Campaña Afgana 2001- , Guerra de Irak 2003-2011 , Índices de Gravedad del Trauma , Heridas y Lesiones/mortalidad , Desequilibrio Ácido-Base/diagnóstico , Desequilibrio Ácido-Base/mortalidad , Adolescente , Traumatismos por Explosión/diagnóstico , Traumatismos por Explosión/mortalidad , Quemaduras/diagnóstico , Quemaduras/mortalidad , Causas de Muerte , Niño , Preescolar , Femenino , Alemania , Escala de Coma de Glasgow/estadística & datos numéricos , Hospitales Militares , Humanos , Puntaje de Gravedad del Traumatismo , Relación Normalizada Internacional/mortalidad , Masculino , Pronóstico , Curva ROC , Sistema de Registros/estadística & datos numéricos , Estudios Retrospectivos , Tasa de Supervivencia , Estados Unidos , Heridas no Penetrantes/diagnóstico , Heridas no Penetrantes/mortalidad , Heridas Penetrantes/diagnóstico , Heridas Penetrantes/mortalidadRESUMEN
INTRODUCTION: We have shown the usefulness of global haemostatic tests International Normalized Ratio (INR) and Activated Partial Thromboplastin Time (APTT) for predicting survival in critically ill patients. Ability to analyse inhibitors protein C and antithrombin is limited to a small number of laboratories and often only during office hours. We therefore studied the usefulness of global haemostatic tests to predict levels of protein C and antithrombin and investigated value of these latter tests in predicting outcome. PATIENTS/METHODS: Blood samples were collected within 6 h of admission to intensive care unit (ICU) and tested regarding platelet count, INR, and APTT. If platelet count was <100x10(9) L(-1), INR >1.36 and/or APTT >45 s, a second sampling was done within 6 h after the first one for analysis of protein C and antithrombin. Ninety-two patients were included; length of stay at ICU and hospital, survival when leaving ICU and hospital and up to 5 years were recorded. RESULTS: Using univariate analysis of variance, INR and APTT separately predicted levels of protein C and to some extent antithrombin. Neither platelet count nor any combinations of global haemostatic tests were predictive. Utilising Cox regression, decreased protein C, but not antithrombin, predicted lower survival rate. CONCLUSIONS: Global haemostatic tests INR and APTT can predict levels of protein C and, though less so, antithrombin. A low protein C level indicated a sinister prognosis in the ICU setting, at the hospital, and after up to 5 years.