Citation

Lilley EJ, Williams KJ, Schneider EB, Hammouda K, Salim A, Haider AH, Cooper Z. J. Trauma Acute Care Surg. 2016; 80(6): 998-1004.

Affiliation

1Center for Surgery and Public Health, Brigham and Women's Hospital, 1620 Tremont St, Suite 4-020, Boston, MA 02120, USA 2Department of Surgery, Rutgers - Robert Wood Johnson Medical School, 125 Paterson St, New Brunswick, NJ 08821 3Population Health Management, Department of Clinical Affairs, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI 53226 4Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115 5Surgical ICU Translational Research (STAR) Center, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.

Copyright

(Copyright © 2016, Lippincott Williams and Wilkins)

DOI

10.1097/TA.0000000000001028

PMID

26953761

Abstract

BACKGROUND: The Eastern Association for the Surgery of Trauma (EAST) recommends that clinicians consider limiting further aggressive treatment in geriatric patients with severe TBI who do not improve in 72 hours (non-responders) due to their poor prognosis. However, little is known about how these guidelines are followed in practice. This study compared mortality and patient care among geriatric patients with severe TBI classified as "responders" and "non-responders" 72 hours after injury.

METHODS: Retrospective review of patients ≥65 years old at a Level I Trauma Center with severe TBI (GCS<8) from 2011 to 2014. We compared in-hospital mortality, end-of-life (EOL) decision-making, discharge functional status, and 12-month survival in responders (GCS>8 at 72 hours) and non-responders (GCS>8 at 72 hours).

RESULTS: Of 90 patients, 29 (32%) died within 3 days of injury; 29 (32%) were non-responders; and 32 (34%) were responders. An additional 19 (21%) patients died before hospital discharge, of whom 17 (89%) were non-responders. Non-responders had higher odds of in-hospital death (OR 31.8, 95% CI 3.71-272.9, p=0.002). Family meetings to discuss goals of care were more common in the non-responder group (p<0.001) and fewer non-responders were full code at discharge or death (p<0.001). There were no significant differences in functional status at discharge. Among patients discharged alive, there were no differences in 12-month survival.

CONCLUSION: The responder/non-responder dichotomy identifies patients with higher in-hospital mortality outcomes and is associated with differences in EOL decision-making. However, functional impairment and poor survival were prevalent, irrespective of neurologic status at 72 hours. LEVEL OF EVIDENCE: Level III STUDY TYPE: Prognostic and Epidemiological.

Language: en