Diaphragm pacing improves respiratory mechanics in acute cervical spinal cord injury. Kerwin AJ, Zuniga YD, Yorkgitis BK, Mull J, Hsu AT, Madbak, FG, et al. J Trauma Acute Care Surg. 2020;89(3):423-428.
Cervical spinal cord injuries (CSCI) frequently lead to respiratory dysfunction, including ineffective cough, decreased vital capacity and chest wall compliance. This respiratory impairment is a frequent cause of morbidity and mortality and a subset of these patients require chronic mechanical ventilation. The authors hypothesize that a diaphragm pacing system (DPS) would improve respiratory mechanics and facilitate ventilator liberation in CSCI.
Acute CSCIs were identified at a single Level 1 trauma center from 2005-2017. Propensity score matching was used to create a comparison group (NO DPS) for patients undergoing DPS based on age, gender, ISS and ED systolic blood pressure. Outcomes included liberation from ventilator prior to discharge, days to liberation, tidal volume (Vt) change before discharge and mortality.
Forty individuals who received DPS were matched to 61 CSCI controls. All patients received tracheostomy and mechanical ventilation for respiratory failure. Thirty-nine of 40 (97%) DPS and 52/61 (82%) of NO DPS survived (p=0.05). Change in Vt was an increase of 88±22mL in the DPS group versus a decrease of 14±32mL in the NO DPS group (p=0.008). Frequency of liberation from mechanical ventilation prior to discharge was not different (DPS 70% vs. 79%). However, mean time to ventilator liberation (10.1 vs. 29.2 days, p<0.001) and hospital length of stay (43 vs. 65 days, p=0.03) were shorter in the DPS group.
In summary, a significant improvement in Vt and time to liberation from mechanical ventilation was observed in patients with CSCI undergoing DPS. Cited limitations include its retrospective nature, small sample size and the overall advancement of SCI care across the study period. This study supports DPS as part of comprehensive spinal cord injury care.
Comparison of direct oral anticoagulant and vitamin K antagonists on outcomes among elderly and nonelderly trauma patients. Nishimura T, Guyette FX, Naito H, Nakao A, Brown JB, Callaway CW. J Trauma Acute Care Surg. 2020;89(3):514-522.
Anticoagulant use is common among the geriatric population, both Vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) as well as antiplatelet use. The use of VKAs results in increased risk of intracranial hemorrhage and mortality in trauma patients. Currently, no study has demonstrated a difference between DOACs and VKAs in fatal hemorrhage or ICH outcomes. This research sought to compare the mortality between anticoagulated trauma patients receiving DOACs and VKAs.
This is a retrospective study of all trauma patients treated with VKAs or DOACs admitted to a single Level 1 center from 2011-2018. Comparison groups were created using propensity score matching and blocking based on age group and enrollment period. The primary outcome was in-hospital mortality, with secondary outcomes of discharge to SNF/rehab vs. home, transfusion volume, and length of stay – hospital, ICU and ventilator days.
From an initial 2237 anticoagulated trauma patients, 334 patients on DOACs (46.1% rivaroxaban, 33.2% apixaban, 20.1% dabigatran, 0.6% edoxaban) were matched to 334 on VKAs. In-hospital mortality was lower in patients receiving DOACs (3.3% vs. 5.7% VKAs, OR 0.56, CI 0.26-1.2, p=0.14), which reached significance in patients over the age of 65 (3.0% vs. 6.6%, OR 0.41, CI 0.17-0.99, p=0.048). The rate of discharge to SNF/rehab, transfusion of products other than FFP and length of stay was not significantly different between patients receiving DOACs and VKAs. DOACs received less FFP; however, this difference was not present when adjusted for PT/INR. Multivariable logistic regression demonstrated that high ISS (OR 1.08, CI 1.01-1.15, p=0.21), SBP<90 (OR 2.77, CI 1.03-7.43, p=0.040) and low GCS (OR 0.84, CI 0.80-0.98, p=0.021) were independently associated with mortality. Conversely, use of DOACs was independently associated with lower in-hospital mortality (OR 0.36, CI 0.41-0.91, p=0.032).
In summary, this research demonstrated decreased in-hospital mortality and administration of FFP for patients over the age of 65 treated with DOACs. The use of DOACs did not have an impact on discharge to SNF, length of stay or other transfusions. Limitations of this study include the retrospective, single-center design and case matching, with only 63% of all DOACs patients included. These interesting finding merit further investigation on the effect of DOACs in the geriatric trauma population.