j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5
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ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Mortality after trauma laparotomy in geriatric patients Bellal Joseph, MD, FACS,* Bardiya Zangbar, MD, Viraj Pandit, MD, Narong Kulvatunyou, MD, Ansab Haider, MD, Terence O’Keeffe, MBChB, MSPH, FACS, Mazhar Khalil, MD, Andrew Tang, MD, Gary Vercruysse, MD, Lynn Gries, MD, Randall S. Friese, MD, and Peter Rhee, MD, MPH, FACS Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
article info
abstract
Article history:
Background: Geriatric patients are at higher risk for adverse outcomes after injury because
Received 10 December 2013
of their altered physiological reserve. Mortality after trauma laparotomy remains high;
Received in revised form
however, outcomes in geriatric patients after trauma laparotomy have not been well
13 January 2014
established. The aim of our study was to identify factors predicting mortality in geriatric
Accepted 16 January 2014
trauma patients undergoing laparotomy.
Available online xxx
Methods: A retrospective study was performed of all trauma patients undergoing a laparotomy at our level 1 trauma center over a 6-y period (2006e2012). Patients with age 55 y
Key words:
who underwent a trauma laparotomy were included. Patients with head abbreviated injury
Geriatric trauma
scale (AIS) score 3 or thorax AIS 3 were excluded. Our primary outcome measure was
Trauma laparotomy
mortality. Significant factors in univariate regression model were used in multivariate
Lactate
regression analysis to evaluate the factors predicting mortality.
Age
Results: A total of 1150 patients underwent a trauma laparotomy. Of which 90 patients met
Mortality
inclusion criteria. The mean age was 67 10 y, 63% were male, and median abdominal AIS
Complications
was 3 (2e4). Overall mortality rate was 23.3% (21/90) and progressively increased with age (P ¼ 0.013). Age (P ¼ 0.02) and lactate (P ¼ 0.02) were the independent predictors of mortality in geriatric patients undergoing laparotomy. Conclusions: Mortality rate after trauma laparotomy increases with increasing age. Age and admission lactate were the predictors of mortality in geriatric population undergoing trauma laparotomies. ª 2014 Elsevier Inc. All rights reserved.
1.
Introduction
Trauma laparotomy is the most commonly performed procedure in the acute care setting, and it is associated with complications and mortality [1e4]. Multiple factors such as
coagulopathy, acidosis, injury severity, resuscitation parameters, and hypothermia are known to be associated with worse outcomes after trauma laparotomy [2,3,5e14]. However, the impact of age on outcomes after trauma laparotomy remains unclear.
Oral presentation at the ninth Annual Academic Surgical Congress, February 4e6, 2014, San Diego, California. * Corresponding author. Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Ave, Room.5411, P.O. Box 245063, Tucson, AZ 85727. Tel.: þ1 520 626 5056; fax: þ1 520 626 5016. E-mail address: [email protected] (B. Joseph). 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.01.029
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j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5
Aging population forms a unique cohort of trauma patients with decreased physiological reserve, complex medication history, and altered response to injury, which makes the surgical management of these patients challenging [15e17]. Trauma management guidelines are usually tailored to younger trauma patients and are not well defined in geriatric patient population [18,19]. In addition, the risk factors for morbidity and mortality, which are well known in all trauma patients, may not hold true in geriatric trauma patients. Preoperative optimization or extensively detailed assessment of patients in trauma laparotomy is not possible. Considering the high risk for underestimation of severity of injury in elderly patients undergoing trauma laparotomies [20], identification of independent risk factors for adverse outcomes is necessary in this subgroup of patients. The primary aim of our study was to identify the factors predicting mortality in geriatric trauma patients undergoing laparotomy. Our secondary aim was to identify the postoperative complications in geriatric trauma patients. We hypothesized that increasing age is associated with a higher mortality rate in geriatric patients undergoing trauma laparotomy.
Our primary outcome measure was in-hospital mortality. Our secondary outcome measure was development of complications. For our statistical analysis, we used IBM Statistical Package for Social Sciences software (version 20.0; Chicago, IL). Continuous data are presented as the median and interquartile range or as the mean and standard deviation. Categorical data are presented as proportions and percentages. We categorized our patient population based on their mortality and assessed the outcomes in survived versus nonsurvived population using c2 and t-tests. We also stratified patients in groups of increasing age by 10 y to assess the mortality rate in each group. A univariate analysis was then performed to assess the factors associated with mortality. Factors with P value 0.2 were used in a multivariate logistic regression model to identify independent factors associated with mortality. The estimates of standard errors are evaluated to see whether the inclusion of more covariates causes any instability in estimation. A P value of 0.05 was considered to be statistically significant.
3. 2.
Methods
After obtaining approval from the University of Arizona Institutional Review Board, a retrospective study was performed on all trauma patients undergoing a laparotomy at our level 1 trauma center over an 8-y period (2006e2013). Patients aged 55 y undergoing an emergent trauma laparotomy were included. Patients with head abbreviated injury scale (AIS) score 3, thorax AIS 3, patients who died before the completion of the emergent laparotomy, and patients transferred from other facilities were excluded. Patient’s medical records were reviewed and the following data points were recorded: patient demographics (age and gender), mechanism of injury, vitals on presentation (systolic blood pressure, heart rate, temperature), Glasgow Coma Scale score, comorbidities (obesity, heart disease, and diabetes mellitus), admission laboratory parameters (hemoglobin, lactate, partial thromboplastin time, international normalized ratio, and platelet count), volume of crystalloid and blood products during the first 24 h of admission, hospital and intensive care unit (ICU) length of stay, and in-hospital mortality. The injury severity score (ISS) and abdominal AIS were obtained from the trauma registry. Crystalloid resuscitation was defined as the sum of the volumes of normal saline and lactated ringer administered, per patient, in emergency department, operating room, ICU, and/or hospital room during the first 24 h of admission. The blood product resuscitation was defined as the sum of the volumes of packed red blood cells of fresh frozen plasma, and of platelets administered, per patient, in the emergency department, operating room, ICU, and/or hospital room during the first 24 h of admission. Complications were defined as pneumonia, urinary tract infection (UTI), acute respiratory distress syndrome, acute renal failure, abdominal compartment syndrome, sepsis, and wound infection. Damage control laparotomy was defined as patients who did not have their fascia closed in the initial laparotomy.
Results
A total of 1150 patients underwent a trauma laparotomy. Of which, 90 patients were included in the analysis. The mean age was 67 10 y, 63% were male, median abdominal AIS was 3 (2e4), and median ISS was 17 (9e27). Most of the injuries were due to blunt trauma (75.6%). Patients who died were older (P ¼ 0.004) had higher abdominal AIS (P ¼ 0.01), higher lactate level (P ¼ 0.001), lower platelet counts (P ¼ 0.03), and received more crystalloid (P ¼ 0.03) and blood products (P ¼ 0.003) during resuscitation. Table 1 compares the demographic differences among survived and nonsurvived patients in our population.
Table 1 e Demographics, laboratory data, and comorbidities. Variables Age, y, (mean SD) Male, (%) Blunt trauma, (%) ISS, median (IQR) A-AIS, median (IQR) Temp, (mean SD) SBP, (mean SD) HR, (mean SD) Platelet count, (mean SD) PTT, (mean SD) INR, median (IQR) Lactate, (mean SD) Heart disease, (%) Diabetes mellitus, (%) Obesity, (%) Crystalloids, L, (mean SD) Blood products, L, (mean SD)
Survived (n ¼ 69) 65 8 65 74 18 (9e25) 3 (2e4) 36.0 0.9 116 32 94 20 250 95 30 9 1.3 (1.1e1.5) 3.2 2.3 5 16 2 7.4 4.3 2.2 2.8
Nonsurvived P (n ¼ 21) value 72 12 57 81 23 (15e29) 4 (2e4) 36 0.7 113 26 99 25 192 110 29 7 1.3 (1.1e1.6) 5.8 3.8 5 23 9 12.4 16.4 4.7 4.0
0.004 0.5 0.5 0.04 0.01 0.8 0.6 0.3 0.03 0.7 0.7 0.001 0.9 0.4 0.07 0.03 0.003
A-AIS ¼ abdominal AIS; HR ¼ heart rate; IQR ¼ interquartile range; ISS ¼ injury severity score; SBP ¼ systolic blood pressure; SD ¼ standard deviation; Temp ¼ temperature.
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Table 3 e Univariate and multivariate regressions for mortality. Variables
Univariate OR
Fig e Mortality stratified by age.
Overall rate of complications was 40%. Pneumonia (11.1%) followed by UTI (8.9%) was the most common complication. Overall mortality rate was 23.3% and progressively increased with age (P ¼ 0.013; Fig). Table 2 highlights the complications and outcomes in the study population. Twenty patients were managed by DCL with a higher mortality rate (55% versus 14.3%, P ¼ 0.001). Patients who received massive transfusion (n ¼ 18) had a higher mortality rate (50% versus 16.2%, P ¼ 0.005). There was no significant difference in mortality based on the mechanism of injury (penetrating: 18.2% versus blunt: 25%, P ¼ 0.5). Four patients had abdominal vascular injuries (two patients had hepatic artery injury, one had inferior vena caval injury, and one had portal vein injury), and survival rate was 50% among patients (2/4) with vascular injuries. Table 3 shows the results of univariate and multivariate regression analyses for mortality. On univariate analysis for factors associated with mortality, age (P ¼ 0.006), abdominal AIS (P ¼ 0.16), platelet count (P ¼ 0.02), lactate (P ¼ 0.004), crystalloid resuscitation (P ¼ 0.1), and blood product resuscitation (P ¼ 0.01) were significant. After adjusting for all factors in a multivariate regression model, age (odds ratio ¼ 1.1, 95% confidence interval ¼ 1.01e1.14, P ¼ 0.02) and lactate (odds ratio ¼ 1.3, 95% confidence interval ¼ 1.03e1.67, P ¼ 0.02) were independently associated with mortality.
Table 2 e Complications and outcomes. Outcomes Complications Pneumonia UTI ARDS Sepsis ARF Wound infection ACS Hospital length of stay, (mean SD) ICU length of stay, (mean SD) Mortality
Total (n ¼ 90) 40% (36) 11.1% (10) 8.9% (8) 7.8% (7) 5.6% (5) 5.6% (5) 4.4% (4) 2.2% (2) 15 19 10 13 23.3% (21)
ACS ¼ abdominal compartment syndrome; ARDS ¼ acute respiratory distress syndrome; ARF ¼ acute renal failure; SD ¼ standard deviation.
Age Lactate Abdominal AIS Platelet count Crystalloid* Blood products* Maley Blunt injuryy Systolic BP Temperature PTT INR Obesityy Heart diseasey Diabetes mellitusy
CI 95%
1.1 1.01e1.1 1.3 1.09e1.55 1.2 0.9e1.8 1.002 1.001e1.01 1.1 0.9e1.1 1.2 1.04e1.3 0.7 0.2e1.9 0.8 0.2e2.5 0.9 0.9e1.004 1.001 0.6e1.7 0.7 0.9e1.05 0.7 0.2e2.6 7.1 0.6e83 1.1 0.1e11 1.6 0.5e5.4
Multivariate P 0.006 0.004 0.16 0.02 0.1 0.01 0.5 0.7 0.4 0.9 0.9 0.6 0.3 0.9 0.4
OR
CI 95%
P
1.1 1.01e1.14 0.02 1.3 1.03e1.67 0.02 1.4 0.8e2.4 0.2 1 0.9e1.01 0.5 1 0.9e1.1 0.3 1 0.7e1.3 0.8 e e e e e e e e e e e e e e e e e e e e e e e e e e e
BP ¼ blood pressure; CI ¼ confidence interval; INR ¼ international normalized ratio; OR ¼ odds ratio; PTT ¼ partial thromboplastin time. Bold values are statistically significant in multivariate analysis. * Liters in first 24 h of admission. y Categorical variables.
4.
Discussion
The Impact of age on the outcomes in trauma patients undergoing laparotomy is unknown. We found that elderly patients after trauma laparotomy have a high mortality rate compared with general population [14]. When we looked at 10year increments, there was a direct correlation with mortality with every decade of life after 55. Age and lactate were independent predictors of mortality; however, coagulopathy and resuscitation crystalloid volume were not associated with mortality in geriatric patients after trauma laparotomy. Several studies have shown the effect of age on adverse outcomes in trauma patients [21,22]. Our results confirm that age is an independent predictor of mortality after trauma laparotomy. We found the mortality rate after trauma laparotomy was 23% in geriatric patients, which is higher compared with general trauma population [14]. We also found an incremental increase in rate of mortality with every decade increase in patient age in our study. Patients aged >85 had a 2-, 3-, and 4-fold increase in mortality rate compared with 75e85, 65e75, and 55e65 y old groups, respectively. Blood lactate is a known predictor of worse outcomes in trauma [23e25]. We found that lactate level was the only independent predictor of mortality in elderly patients undergoing trauma laparotomy. Odom et al. [23] reported that trauma patients with an initial lactate level of 4.0 or above has nearly 3-fold increase in mortality. Similarly, Callaway et al. [24] concluded that lactate level and base deficit predicts mortality in geriatric trauma patients. Obtaining lactate level is particularly useful in elderly trauma patients as an accurate estimation of injury severity is often difficult in these patient because of their altered physiology that masks the effects of trauma [7,15e17,25]. Although lactate clearance is shown to be an important factor, compared with lactate clearance,
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j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5
initial lactate level is a value more likely to be available in most trauma centers [23]. We believe that lactate level is a reliable tool that will provide surgeons with information regarding patient’s status post-trauma and thus needs to be recorded in all geriatric trauma patients on admission. Several studies have highlighted the role of crystalloid resuscitation in the development of complications and mortality in trauma patients [2,3,10]. Our study shows that resuscitation crystalloid volume was not independently associated with mortality, although we see a trend toward more volume in nonsurvivors. Ley et al. [26] have shown crystalloid resuscitation of more than 1.5 L in elderly trauma patients is associated with mortality. In our level 1 trauma center, we adapted the principles of damage control resuscitation (DCR), decreased crystalloids, and an increase in blood product resuscitation [4]. A possible explanation for this loss of effect can be a decrease in resuscitation crystalloid volume to a level lower than the threshold for mortality by adapting to DCR. Studies have reported coagulopathy as a component of lethal triad of trauma and an independent predictor of mortality [5,6]. We found that coagulopathy is not associated with increased risk of mortality in elderly trauma patients. Early factor replacement therapy as a component of DCR may have contributed to the elimination of this factor. Our results show that nonsurgical complications such as pneumonia and UTI are more frequently encountered than surgical wound infection in geriatric trauma patients undergoing laparotomy. Similarly, Choi et al. [14] in a study of complications after trauma laparotomy reports that pulmonary and nonsurgical infectious complications are more frequent. Fukuda et al. [27] reported surgical wound infections as the most common postoperative complication in geriatric patients. However, these patients were nontrauma patients and were operated in acute care surgery settings. Our study comes with the intrinsic limitations of a retrospective study design. We did not assess the effect of frailty in our geriatric population. We also did not measure the effect of the ratio of fresh frozen plasma-to-platelets to packed red blood cells, and we did not have lactate clearance. Although we assessed coagulopathy with admission laboratory test results, we did not evaluate the medication history of our patients. We were not able to control for changes in personnel, postoperative care, and ICU management of patients over the study period. However, despite these limitations, we assessed the complications and mortality in geriatric trauma surgery. Our study will add to the literature and will help in management of geriatric trauma patients undergoing trauma laparotomies.
5.
Conclusions
Trauma laparotomies in elderly patients have a high complication rate with nonsurgical complications being most prevalent. Mortality rate after trauma laparotomy increases with increasing age. Admission lactate should be obtained in all geriatric patients as the only independent predictors of mortality in trauma laparotomy. With adaption of DCR, resuscitation crystalloid volume and coagulopathy are no longer among the risk factors for mortality in geriatric trauma patients.
Acknowledgment The authors have no financial or proprietary interest in the subject matter or materials discussed in the manuscript. Author contributions: B.J., B.Z., V.P., R.S.F., and P.R. designed the study. B.J., B.Z., V.P., G.V., A.H., A.T., and R.F. searched the literature. B.J., B.Z., V.P., A.T., M.K., T.K. and A.H abstracted the data. B.J., B.Z., V.P., L.G., N.K., R.S.F., and P.R. analyzed the data. All other authors participated in data interpretation and manuscript preparation.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
references
[1] Hemmila MR, Wahl WL. Management of the injured patient. In: Doherty GM, editor. Current surgical diagnosis and treatment. 13th Edition. New York: McGraw-Hill Medical; 2010. p. 176. [2] Joseph B, Zangbar B, Pandit V, et al. The conjoint effect of reduced crystalloid administration and decreased damage control laparotomy use in the development of abdominal compartment syndrome. J Trauma Acute Care Surg 2014;76: 457. [3] Duchesne JC, Kimonis K, Marr AB, et al. Damage control resuscitation in combination with damage control laparotomy: a survival advantage. J Trauma 2010;69:46e52. [4] Higa G, Friese R, O’Keeffe T, et al. Damage control laparotomy: a vital tool once overused. J Trauma 2010;69:53. [5] Mikhail J. The trauma triad of death: hypothermia, acidosis, and coagulopathy. AACN Clin Issues 1999;10:85. [6] MacLeod JB, Lynn M, McKenney MG, et al. Early coagulopathy predicts mortality in trauma. J Trauma 2003;55:39. [7] Martin MJ, FitzSullivan E, Salim A, et al. Discordance between lactate and base deficit in the surgical intensive care unit: which one do you trust? Am J Surg 2006;191:625. [8] Gad MA, Saber A, Farrag S, et al. Incidence, patterns, and factors predicting mortality of abdominal injuries in trauma patients. N Am J Med Sci 2012;4:129. [9] Kilgo PD, Osler TM, Meredith W. The worst injury predicts mortality outcome the best: rethinking the role of multiple injuries in trauma outcome scoring. J Trauma 2003;55:599. discussion 606e7. [10] Cotton BA, Reddy N, Hatch QM, et al. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg 2011;254:598. [11] Newell MA, Schlitzkus LL, Waibel BH, et al. “Damage control” in the elderly: futile endeavor or fruitful enterprise? J Trauma 2010;69:1049. [12] Inaba K, Teixeira PG, Rhee P, et al. Mortality impact of hypothermia after cavitary explorations in trauma. World J Surg 2009;33:864. [13] Ringdal KG, Skaga NO, Steen PA, et al. Classification of comorbidity in trauma: the reliability of pre-injury ASA physical status classification. Injury 2013;44:29. [14] Choi KC, Peek-Asa C, Lovell M, et al. Complications after therapeutic trauma laparotomy. J Am Coll Surg 2005; 201:546.
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[15] Joseph B, Pandit V, Rhee P, et al. Predicting hospital discharge disposition in geriatric trauma patients: is frailty the answer? J Trauma Acute Care Surg 2014;76:196. [16] Callaway DW, Wolfe R. Geriatric trauma. Emerg Med Clin North Am 2007;25:837. x. [17] Heffernan DS, Thakkar RK, Monaghan SF, et al. Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J Trauma 2010;69:813. [18] Phillips S, Rond PC 3rd, Kelly SM, et al. The failure of triage criteria to identify geriatric patients with trauma: results from the Florida Trauma Triage Study. J Trauma 1996; 40:278. [19] Werman HA, Erskine T, Caterino J, et al. Development of statewide geriatric patients trauma triage criteria. Prehosp Disaster Med 2011;26:170. [20] Haas B, Gomez D, Xiong W, et al. External benchmarking of trauma center performance: have we forgotten our elders? Ann Surg 2011;253:144. [21] Adams SD, Cotton BA, McGuire MF, et al. Unique pattern of complications in elderly trauma patients at a Level I trauma center. J Trauma Acute Care Surg 2012;72:112.
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[22] Bochicchio GV, Joshi M, Bochicchio K, et al. Incidence and impact of risk factors in critically ill trauma patients. World J Surg 2006;30:114. [23] Odom SR, Howell MD, Silva GS, et al. Lactate clearance as a predictor of mortality in trauma patients. J Trauma Acute Care Surg 2013;74:999. [24] Callaway DW, Shapiro NI, Donnino MW, et al. Serum lactate and base deficit as predictors of mortality in normotensive elderly blunt trauma patients. J Trauma 2009; 66:1040. [25] Salottolo KM, Mains CW, Offner PJ, et al. A retrospective analysis of geriatric trauma patients: venous lactate is a better predictor of mortality than traditional vital signs. Scand J Trauma Resusc Emerg Med 2013;21:7. [26] Ley EJ, Clond MA, Srour MK, et al. Emergency department crystalloid resuscitation of 1.5 L or more is associated with increased mortality in elderly and nonelderly trauma patients. J Trauma 2011;70:398. [27] Fukuda N, Wada J, Niki M, et al. Factors predicting mortality in emergency abdominal surgery in the elderly. World J Emerg Surg 2012;7:12.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Mortality after trauma laparotomy in geriatric patients Bellal Joseph, MD, FACS,* Bardiya Zangbar, MD, Viraj Pandit, MD, Narong Kulvatunyou, MD, Ansab Haider, MD, Terence O’Keeffe, MBChB, MSPH, FACS, Mazhar Khalil, MD, Andrew Tang, MD, Gary Vercruysse, MD, Lynn Gries, MD, Randall S. Friese, MD, and Peter Rhee, MD, MPH, FACS Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
article info
abstract
Article history:
Background: Geriatric patients are at higher risk for adverse outcomes after injury because
Received 10 December 2013
of their altered physiological reserve. Mortality after trauma laparotomy remains high;
Received in revised form
however, outcomes in geriatric patients after trauma laparotomy have not been well
13 January 2014
established. The aim of our study was to identify factors predicting mortality in geriatric
Accepted 16 January 2014
trauma patients undergoing laparotomy.
Available online xxx
Methods: A retrospective study was performed of all trauma patients undergoing a laparotomy at our level 1 trauma center over a 6-y period (2006e2012). Patients with age 55 y
Key words:
who underwent a trauma laparotomy were included. Patients with head abbreviated injury
Geriatric trauma
scale (AIS) score 3 or thorax AIS 3 were excluded. Our primary outcome measure was
Trauma laparotomy
mortality. Significant factors in univariate regression model were used in multivariate
Lactate
regression analysis to evaluate the factors predicting mortality.
Age
Results: A total of 1150 patients underwent a trauma laparotomy. Of which 90 patients met
Mortality
inclusion criteria. The mean age was 67 10 y, 63% were male, and median abdominal AIS
Complications
was 3 (2e4). Overall mortality rate was 23.3% (21/90) and progressively increased with age (P ¼ 0.013). Age (P ¼ 0.02) and lactate (P ¼ 0.02) were the independent predictors of mortality in geriatric patients undergoing laparotomy. Conclusions: Mortality rate after trauma laparotomy increases with increasing age. Age and admission lactate were the predictors of mortality in geriatric population undergoing trauma laparotomies. ª 2014 Elsevier Inc. All rights reserved.
1.
Introduction
Trauma laparotomy is the most commonly performed procedure in the acute care setting, and it is associated with complications and mortality [1e4]. Multiple factors such as
coagulopathy, acidosis, injury severity, resuscitation parameters, and hypothermia are known to be associated with worse outcomes after trauma laparotomy [2,3,5e14]. However, the impact of age on outcomes after trauma laparotomy remains unclear.
Oral presentation at the ninth Annual Academic Surgical Congress, February 4e6, 2014, San Diego, California. * Corresponding author. Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, University of Arizona, 1501 N. Campbell Ave, Room.5411, P.O. Box 245063, Tucson, AZ 85727. Tel.: þ1 520 626 5056; fax: þ1 520 626 5016. E-mail address: [email protected] (B. Joseph). 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.01.029
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Aging population forms a unique cohort of trauma patients with decreased physiological reserve, complex medication history, and altered response to injury, which makes the surgical management of these patients challenging [15e17]. Trauma management guidelines are usually tailored to younger trauma patients and are not well defined in geriatric patient population [18,19]. In addition, the risk factors for morbidity and mortality, which are well known in all trauma patients, may not hold true in geriatric trauma patients. Preoperative optimization or extensively detailed assessment of patients in trauma laparotomy is not possible. Considering the high risk for underestimation of severity of injury in elderly patients undergoing trauma laparotomies [20], identification of independent risk factors for adverse outcomes is necessary in this subgroup of patients. The primary aim of our study was to identify the factors predicting mortality in geriatric trauma patients undergoing laparotomy. Our secondary aim was to identify the postoperative complications in geriatric trauma patients. We hypothesized that increasing age is associated with a higher mortality rate in geriatric patients undergoing trauma laparotomy.
Our primary outcome measure was in-hospital mortality. Our secondary outcome measure was development of complications. For our statistical analysis, we used IBM Statistical Package for Social Sciences software (version 20.0; Chicago, IL). Continuous data are presented as the median and interquartile range or as the mean and standard deviation. Categorical data are presented as proportions and percentages. We categorized our patient population based on their mortality and assessed the outcomes in survived versus nonsurvived population using c2 and t-tests. We also stratified patients in groups of increasing age by 10 y to assess the mortality rate in each group. A univariate analysis was then performed to assess the factors associated with mortality. Factors with P value 0.2 were used in a multivariate logistic regression model to identify independent factors associated with mortality. The estimates of standard errors are evaluated to see whether the inclusion of more covariates causes any instability in estimation. A P value of 0.05 was considered to be statistically significant.
3. 2.
Methods
After obtaining approval from the University of Arizona Institutional Review Board, a retrospective study was performed on all trauma patients undergoing a laparotomy at our level 1 trauma center over an 8-y period (2006e2013). Patients aged 55 y undergoing an emergent trauma laparotomy were included. Patients with head abbreviated injury scale (AIS) score 3, thorax AIS 3, patients who died before the completion of the emergent laparotomy, and patients transferred from other facilities were excluded. Patient’s medical records were reviewed and the following data points were recorded: patient demographics (age and gender), mechanism of injury, vitals on presentation (systolic blood pressure, heart rate, temperature), Glasgow Coma Scale score, comorbidities (obesity, heart disease, and diabetes mellitus), admission laboratory parameters (hemoglobin, lactate, partial thromboplastin time, international normalized ratio, and platelet count), volume of crystalloid and blood products during the first 24 h of admission, hospital and intensive care unit (ICU) length of stay, and in-hospital mortality. The injury severity score (ISS) and abdominal AIS were obtained from the trauma registry. Crystalloid resuscitation was defined as the sum of the volumes of normal saline and lactated ringer administered, per patient, in emergency department, operating room, ICU, and/or hospital room during the first 24 h of admission. The blood product resuscitation was defined as the sum of the volumes of packed red blood cells of fresh frozen plasma, and of platelets administered, per patient, in the emergency department, operating room, ICU, and/or hospital room during the first 24 h of admission. Complications were defined as pneumonia, urinary tract infection (UTI), acute respiratory distress syndrome, acute renal failure, abdominal compartment syndrome, sepsis, and wound infection. Damage control laparotomy was defined as patients who did not have their fascia closed in the initial laparotomy.
Results
A total of 1150 patients underwent a trauma laparotomy. Of which, 90 patients were included in the analysis. The mean age was 67 10 y, 63% were male, median abdominal AIS was 3 (2e4), and median ISS was 17 (9e27). Most of the injuries were due to blunt trauma (75.6%). Patients who died were older (P ¼ 0.004) had higher abdominal AIS (P ¼ 0.01), higher lactate level (P ¼ 0.001), lower platelet counts (P ¼ 0.03), and received more crystalloid (P ¼ 0.03) and blood products (P ¼ 0.003) during resuscitation. Table 1 compares the demographic differences among survived and nonsurvived patients in our population.
Table 1 e Demographics, laboratory data, and comorbidities. Variables Age, y, (mean SD) Male, (%) Blunt trauma, (%) ISS, median (IQR) A-AIS, median (IQR) Temp, (mean SD) SBP, (mean SD) HR, (mean SD) Platelet count, (mean SD) PTT, (mean SD) INR, median (IQR) Lactate, (mean SD) Heart disease, (%) Diabetes mellitus, (%) Obesity, (%) Crystalloids, L, (mean SD) Blood products, L, (mean SD)
Survived (n ¼ 69) 65 8 65 74 18 (9e25) 3 (2e4) 36.0 0.9 116 32 94 20 250 95 30 9 1.3 (1.1e1.5) 3.2 2.3 5 16 2 7.4 4.3 2.2 2.8
Nonsurvived P (n ¼ 21) value 72 12 57 81 23 (15e29) 4 (2e4) 36 0.7 113 26 99 25 192 110 29 7 1.3 (1.1e1.6) 5.8 3.8 5 23 9 12.4 16.4 4.7 4.0
0.004 0.5 0.5 0.04 0.01 0.8 0.6 0.3 0.03 0.7 0.7 0.001 0.9 0.4 0.07 0.03 0.003
A-AIS ¼ abdominal AIS; HR ¼ heart rate; IQR ¼ interquartile range; ISS ¼ injury severity score; SBP ¼ systolic blood pressure; SD ¼ standard deviation; Temp ¼ temperature.
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Table 3 e Univariate and multivariate regressions for mortality. Variables
Univariate OR
Fig e Mortality stratified by age.
Overall rate of complications was 40%. Pneumonia (11.1%) followed by UTI (8.9%) was the most common complication. Overall mortality rate was 23.3% and progressively increased with age (P ¼ 0.013; Fig). Table 2 highlights the complications and outcomes in the study population. Twenty patients were managed by DCL with a higher mortality rate (55% versus 14.3%, P ¼ 0.001). Patients who received massive transfusion (n ¼ 18) had a higher mortality rate (50% versus 16.2%, P ¼ 0.005). There was no significant difference in mortality based on the mechanism of injury (penetrating: 18.2% versus blunt: 25%, P ¼ 0.5). Four patients had abdominal vascular injuries (two patients had hepatic artery injury, one had inferior vena caval injury, and one had portal vein injury), and survival rate was 50% among patients (2/4) with vascular injuries. Table 3 shows the results of univariate and multivariate regression analyses for mortality. On univariate analysis for factors associated with mortality, age (P ¼ 0.006), abdominal AIS (P ¼ 0.16), platelet count (P ¼ 0.02), lactate (P ¼ 0.004), crystalloid resuscitation (P ¼ 0.1), and blood product resuscitation (P ¼ 0.01) were significant. After adjusting for all factors in a multivariate regression model, age (odds ratio ¼ 1.1, 95% confidence interval ¼ 1.01e1.14, P ¼ 0.02) and lactate (odds ratio ¼ 1.3, 95% confidence interval ¼ 1.03e1.67, P ¼ 0.02) were independently associated with mortality.
Table 2 e Complications and outcomes. Outcomes Complications Pneumonia UTI ARDS Sepsis ARF Wound infection ACS Hospital length of stay, (mean SD) ICU length of stay, (mean SD) Mortality
Total (n ¼ 90) 40% (36) 11.1% (10) 8.9% (8) 7.8% (7) 5.6% (5) 5.6% (5) 4.4% (4) 2.2% (2) 15 19 10 13 23.3% (21)
ACS ¼ abdominal compartment syndrome; ARDS ¼ acute respiratory distress syndrome; ARF ¼ acute renal failure; SD ¼ standard deviation.
Age Lactate Abdominal AIS Platelet count Crystalloid* Blood products* Maley Blunt injuryy Systolic BP Temperature PTT INR Obesityy Heart diseasey Diabetes mellitusy
CI 95%
1.1 1.01e1.1 1.3 1.09e1.55 1.2 0.9e1.8 1.002 1.001e1.01 1.1 0.9e1.1 1.2 1.04e1.3 0.7 0.2e1.9 0.8 0.2e2.5 0.9 0.9e1.004 1.001 0.6e1.7 0.7 0.9e1.05 0.7 0.2e2.6 7.1 0.6e83 1.1 0.1e11 1.6 0.5e5.4
Multivariate P 0.006 0.004 0.16 0.02 0.1 0.01 0.5 0.7 0.4 0.9 0.9 0.6 0.3 0.9 0.4
OR
CI 95%
P
1.1 1.01e1.14 0.02 1.3 1.03e1.67 0.02 1.4 0.8e2.4 0.2 1 0.9e1.01 0.5 1 0.9e1.1 0.3 1 0.7e1.3 0.8 e e e e e e e e e e e e e e e e e e e e e e e e e e e
BP ¼ blood pressure; CI ¼ confidence interval; INR ¼ international normalized ratio; OR ¼ odds ratio; PTT ¼ partial thromboplastin time. Bold values are statistically significant in multivariate analysis. * Liters in first 24 h of admission. y Categorical variables.
4.
Discussion
The Impact of age on the outcomes in trauma patients undergoing laparotomy is unknown. We found that elderly patients after trauma laparotomy have a high mortality rate compared with general population [14]. When we looked at 10year increments, there was a direct correlation with mortality with every decade of life after 55. Age and lactate were independent predictors of mortality; however, coagulopathy and resuscitation crystalloid volume were not associated with mortality in geriatric patients after trauma laparotomy. Several studies have shown the effect of age on adverse outcomes in trauma patients [21,22]. Our results confirm that age is an independent predictor of mortality after trauma laparotomy. We found the mortality rate after trauma laparotomy was 23% in geriatric patients, which is higher compared with general trauma population [14]. We also found an incremental increase in rate of mortality with every decade increase in patient age in our study. Patients aged >85 had a 2-, 3-, and 4-fold increase in mortality rate compared with 75e85, 65e75, and 55e65 y old groups, respectively. Blood lactate is a known predictor of worse outcomes in trauma [23e25]. We found that lactate level was the only independent predictor of mortality in elderly patients undergoing trauma laparotomy. Odom et al. [23] reported that trauma patients with an initial lactate level of 4.0 or above has nearly 3-fold increase in mortality. Similarly, Callaway et al. [24] concluded that lactate level and base deficit predicts mortality in geriatric trauma patients. Obtaining lactate level is particularly useful in elderly trauma patients as an accurate estimation of injury severity is often difficult in these patient because of their altered physiology that masks the effects of trauma [7,15e17,25]. Although lactate clearance is shown to be an important factor, compared with lactate clearance,
4
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initial lactate level is a value more likely to be available in most trauma centers [23]. We believe that lactate level is a reliable tool that will provide surgeons with information regarding patient’s status post-trauma and thus needs to be recorded in all geriatric trauma patients on admission. Several studies have highlighted the role of crystalloid resuscitation in the development of complications and mortality in trauma patients [2,3,10]. Our study shows that resuscitation crystalloid volume was not independently associated with mortality, although we see a trend toward more volume in nonsurvivors. Ley et al. [26] have shown crystalloid resuscitation of more than 1.5 L in elderly trauma patients is associated with mortality. In our level 1 trauma center, we adapted the principles of damage control resuscitation (DCR), decreased crystalloids, and an increase in blood product resuscitation [4]. A possible explanation for this loss of effect can be a decrease in resuscitation crystalloid volume to a level lower than the threshold for mortality by adapting to DCR. Studies have reported coagulopathy as a component of lethal triad of trauma and an independent predictor of mortality [5,6]. We found that coagulopathy is not associated with increased risk of mortality in elderly trauma patients. Early factor replacement therapy as a component of DCR may have contributed to the elimination of this factor. Our results show that nonsurgical complications such as pneumonia and UTI are more frequently encountered than surgical wound infection in geriatric trauma patients undergoing laparotomy. Similarly, Choi et al. [14] in a study of complications after trauma laparotomy reports that pulmonary and nonsurgical infectious complications are more frequent. Fukuda et al. [27] reported surgical wound infections as the most common postoperative complication in geriatric patients. However, these patients were nontrauma patients and were operated in acute care surgery settings. Our study comes with the intrinsic limitations of a retrospective study design. We did not assess the effect of frailty in our geriatric population. We also did not measure the effect of the ratio of fresh frozen plasma-to-platelets to packed red blood cells, and we did not have lactate clearance. Although we assessed coagulopathy with admission laboratory test results, we did not evaluate the medication history of our patients. We were not able to control for changes in personnel, postoperative care, and ICU management of patients over the study period. However, despite these limitations, we assessed the complications and mortality in geriatric trauma surgery. Our study will add to the literature and will help in management of geriatric trauma patients undergoing trauma laparotomies.
5.
Conclusions
Trauma laparotomies in elderly patients have a high complication rate with nonsurgical complications being most prevalent. Mortality rate after trauma laparotomy increases with increasing age. Admission lactate should be obtained in all geriatric patients as the only independent predictors of mortality in trauma laparotomy. With adaption of DCR, resuscitation crystalloid volume and coagulopathy are no longer among the risk factors for mortality in geriatric trauma patients.
Acknowledgment The authors have no financial or proprietary interest in the subject matter or materials discussed in the manuscript. Author contributions: B.J., B.Z., V.P., R.S.F., and P.R. designed the study. B.J., B.Z., V.P., G.V., A.H., A.T., and R.F. searched the literature. B.J., B.Z., V.P., A.T., M.K., T.K. and A.H abstracted the data. B.J., B.Z., V.P., L.G., N.K., R.S.F., and P.R. analyzed the data. All other authors participated in data interpretation and manuscript preparation.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
references
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