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Boskabadi SJ, Heydari F, Mohammadnejad F, Gholipour Baradari A, Moosazadeh M, Dashti A. Effect of erythropoietin on SOFA score, Glasgow Coma Scale and mortality in traumatic brain injury patients: a randomized-double-blind controlled trial. Ann Med Surg (Lond) 2024; 86:3990-3997. [PMID: 38989196 PMCID: PMC11230820 DOI: 10.1097/ms9.0000000000002143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 04/14/2024] [Indexed: 07/12/2024] Open
Abstract
Background Recent studies suggest that erythropoietin has an anti-inflammatory effect on the central nervous system. The authors aimed to investigate the effect of erythropoietin on Glasgow Coma Scale (GCS), Sequential Organ Failure Assessment (SOFA) scores, and the mortality rate of traumatic brain injury (TBI) patients. Methods Sixty-eight patients with available inclusion criteria were randomly allocated to the control or intervention groups. In the intervention group, erythropoietin (4000 units) was administrated on days 1, 3, and 5. In the control group, normal saline on the same days was used. The primary outcomes were the GCS and SOFA score changes during the intervention. The secondary outcomes were the ventilation period during the first 2 weeks and the 3-month mortality rate. Results Erythropoietin administration significantly affected SOFA score over time (P=0.008), but no significant effect on the GCS, and duration of ventilation between the two groups was observed. Finally, erythropoietin had no significant effect on the three-month mortality (23.5% vs. 38.2% in the erythropoietin and control group, respectively). However, the mortality rate in the intervention group was lower than in the control group. Conclusion Our finding showed that erythropoietin administration in TBI may improve SOFA score. Therefore, erythropoietin may have beneficial effects on early morbidity and clinical improvement in TBI patients.
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Affiliation(s)
| | - Fatemeh Heydari
- Department of Anesthesiology, School of Medicine, Sari Imam Khomeini Hospital
| | | | | | - Mahmood Moosazadeh
- Gastrointestinal Cancer Research Center, Non-communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ayat Dashti
- Pharmacology and Toxicology, Faculty of Pharmacy
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Duncan CF, Lonsdale DO, Farrah H, Farnell-Ward S, Ryan C, Watson X, Cecconi M, Fjølner J, Szczeklik W, Moreno R, Artigas A, Joannidis M, de Lange DW, Guidet B, Flaatten H, Jung C, Leaver SK. 30-Day Mortality among Very Old Patients Admitted to European Intensive Care Units for Major Trauma. Gerontology 2024; 70:715-723. [PMID: 38387455 DOI: 10.1159/000537718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/05/2024] [Indexed: 02/24/2024] Open
Abstract
INTRODUCTION Cases of major trauma in the very old (over 80 years) are increasingly common in the intensive care unit (ICU). Predicting outcome is challenging in this group of patients as chronological age is a poor marker of health and poor predictor of outcome. Increasingly, decisions are guided by the use of organ dysfunction scores of both acute conditions (e.g., sequential organ failure assessment [SOFA] score) and chronic health issues (e.g., clinical frailty scale [CFS]). Recent work suggests that increased CFS is associated with a worse outcome in elderly major trauma patients. We aimed to test whether this association held true in the very old (over 80) or whether SOFA had a stronger association with 30-day outcome. METHODS Data from the very elderly intensive care patient (VIP)-1 and VIP-2 studies for patients over 80 years old with major trauma admissions were merged. These participants were recruited from 20 countries across Europe. Baseline characteristics, level of care provided, and outcome (ICU and 30-day mortality) were summarised. Uni- and multivariable regression analyses were undertaken to determine associations between CFS and SOFA score in the first 24 h, type of major trauma, and outcomes. RESULTS Of the 8,062 acute patients recruited to the two VIP studies, 498 patients were admitted to intensive care because of major trauma. Median age was 84 years, median SOFA score was 6 (IQR 3, 9), and median CFS was 3 (IQR 2, 5). Survival for 30 days was 54%. Median and interquartile range of CFS were the same for survivors and non-survivors. In the logistic regression analysis, CFS was not associated with increased mortality. SOFA score (p < 0.001) and trauma with head injury (p < 0.01) were associated with increased mortality. CONCLUSIONS Major trauma admissions in the very old are not uncommon, and 30-day mortality is high. We found that CFS was not a helpful predictor of mortality. SOFA and trauma with head injury were associated with worse outcomes in this patient group.
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Affiliation(s)
- Chris F Duncan
- Department of Critical Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Dagan O Lonsdale
- Department of Critical Care, St George's University Hospitals NHS Foundation Trust, London, UK
- Department of Clinical Pharmacology, University of London, London, UK
| | - Helen Farrah
- Department of Critical Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sarah Farnell-Ward
- Department of Critical Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christine Ryan
- Department of Critical Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Ximena Watson
- Department of Critical Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Anesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Jesper Fjølner
- Department of Anaesthesia and Intensive Care, Viborg Regional Hospital, Vyborg, Denmark
| | - Wojciech Szczeklik
- Intensive Care and Perioperative Medicine Division, Jagiellonian University Medical College, Krakow, Poland
| | - Rui Moreno
- Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Faculdade de Ciências Médicas de Lisboa, Nova Médical School, Lisbon, Portugal
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
| | - Antonio Artigas
- Department of Intensive Care Medicine, Parc Tauli University Hospital, Institut d'Investigació I innovació Parc tauli (I3PT), Autonomous University of Barcelona, Sabadell, Spain
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Dylan W de Lange
- Department of Intensive Care Medicine, Dutch Poisons Information Center (DPIC), University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis D'Epidémiologie Et de Santé Publique, Saint Antoine Hospital, AP-HP, Hôpital Saint-Antoine, Service de Réanimation, Paris, France
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care, Department of Clinical Medicine, Haukeland University Hospital Bergen, Department of Anaesthesia and Intensive Care and University of Bergen, Bergen, Norway
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Susannah K Leaver
- Department of Critical Care, St George's University Hospitals NHS Foundation Trust, London, UK
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King KL, Dewar DC, Briggs GD, Jones M, Balogh ZJ. Postinjury multiple organ failure in polytrauma: more frequent and potentially less deadly with less crystalloid. Eur J Trauma Emerg Surg 2024; 50:131-138. [PMID: 36598541 PMCID: PMC10923957 DOI: 10.1007/s00068-022-02202-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/17/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Recently, retrospective registry-based studies have reported the decreasing incidence and increasing mortality of postinjury multiple organ failure (MOF). We aimed to describe the current epidemiology of MOF following the introduction of haemostatic resuscitation. METHODS A 10-year prospective cohort study was undertaken at a Level-1 Trauma Centre-based ending in December 2015. Inclusion criteria age ≥ 16 years, Injury Severity Score (ISS) > 15, Abbreviated Injury Scale (AIS) Head < 3 and survived > 48 h. Demographics, physiological and shock resuscitation parameters were collected. The primary outcome was MOF defined by a Denver Score > 3. SECONDARY OUTCOMES intensive care unit length of stay (ICU LOS), ventilation days and mortality. RESULTS Three hundred and forty-seven patients met inclusion criteria (age 48 ± 20; ISS 30 ± 11, 248 (71%) were males and 23 (6.6%) patients died. The 74 (21%) MOF patients (maximum Denver Score: 5.5 ± 1.8; Duration; 5.6 ± 5.8 days) had higher ISS (32 ± 11 versus 29 ± 11) and were older (54 ± 19 versus 46 ± 20 years) than non-MOF patients. Mean daily Denver scores adjusted for age, sex, MOF and ISS did not change over time. Crystalloid usage decreased over the 10-year period (p value < 0.01) and PRBC increased (p value < 0.01). Baseline cumulative incidence of MOF at 28 days was 9% and competing risk analyses showed that incidence of MOF increased over time (subdistribution hazard ratio 1.14, 95% CI 1.04 to 1.23, p value < 0.01). Mortality risk showed no temporal change. ICU LOS increased over time (subdistribution hazard ratio 0.95, 95% CI 0.92 to 0.98, p value < 0.01). Ventilator days increased over time (subdistribution hazard ratio 0.94, 95% CI 0.9 to 0.97, p value < 0.01). CONCLUSION The epidemiology of MOF continues to evolve. Our prospective cohort suggests an ageing population with increasing incidence of MOF, particularly in males, with little changes in injury or shock parameters, who are being resuscitated with less crystalloids, stay longer on ICU without improvement in survival.
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Affiliation(s)
- Kate L King
- Department of Traumatology, John Hunter Hospital, HRMC, Locked Bag 1, Newcastle, NSW, 2310, Australia
- University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - David C Dewar
- Department of Traumatology, John Hunter Hospital, HRMC, Locked Bag 1, Newcastle, NSW, 2310, Australia
- University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Gabrielle D Briggs
- Department of Traumatology, John Hunter Hospital, HRMC, Locked Bag 1, Newcastle, NSW, 2310, Australia
| | - Mark Jones
- Hunter Medical Research Institute, Locked Bag 1000, New Lambton, Newcastle, NSW, 2305, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital, HRMC, Locked Bag 1, Newcastle, NSW, 2310, Australia.
- University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
- Department of Traumatology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, 2300, Australia.
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Hafeez MS, Li SR, Reitz KM, Phillips AR, Habib SG, Jano A, Dai Y, Stone A, Tzeng E, Makaroun MS, Liang NL. Characterization of multiple organ failure after ruptured abdominal aortic aneurysm repair. J Vasc Surg 2023; 78:945-953.e3. [PMID: 37385354 PMCID: PMC10698734 DOI: 10.1016/j.jvs.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Multiple organ failure (MOF) is associated with poor outcomes and increased mortality in sepsis and trauma. There are limited data regarding MOF in patients after ruptured abdominal aortic aneurysm (rAAA) repair. We aimed to identify the contemporary prevalence and characteristics of patients with rAAA with MOF. METHODS We retrospectively reviewed patients with rAAA who underwent repair (2010-2020) at our multihospital institution. Patients who died within the first 2 days after repair were excluded. MOF was quantified by modified (excluding hepatic system) Denver, Sequential Organ Failure Assessment (SOFA) score, and Multiple Organ Dysfunction Score (MODS) for postoperative days 3 to 5 to determine the prevalence of MOF. MOF was defined as a Denver score of >3, dysfunction in two or more organ systems by SOFA score, or a MODS score of >8. Kaplan-Meier curves and log-rank testing were used to evaluate differences in 30-day mortality between multiple organ failure and patients without MOF. Logistic regression was used to assess predictors of MOF. RESULTS Of 370 patients with rAAA, 288 survived past two days (mean age, 73±10.1 years; 76.7% male; 44.1% open repair), and 143 had data for MOF calculation recorded. From postoperative days 3 to 5, 41 (14.24%) had MOF by Denver, 26 (9.03%) by SOFA, and 39 (13.54%) by MODS criteria. Among these scoring systems, pulmonary and neurological systems were impacted most commonly. Among patients with MOF, pulmonary derangement occurred in 65.9% (Denver), 57.7% (SOFA), and 56.4% (MODS). Similarly, neurological derangement occurred in 92.3% (SOFA) and 89.7% (MODS), but renal derangement occurred in 26.8% (Denver), 23.1% (SOFA), and 10.3% (MODS). MOF by all three scoring systems was associated with increased 30-day mortality (Denver: 11.3% vs 41.5% [P < .01]; DOFA: 12.6% vs 46.2% [P < .01]; MODS: 12.5% vs 35.9% [P < .01]), as was MOF by any criteria (10.8% vs 35.7 %; P < .01). Patients with MOF were more likely to have a higher body mass index (55.9±26.6 vs 49.0±15.0; P = .011) and to have had a preoperative stroke (17.9% vs 6.0%; P = .016). Patients with MOF were less likely to have undergone endovascular repair (30.4% vs 62.1%; P < .001). Endovascular repair was protective against MOF (any criteria) on multivariate analysis (odds ratio, 0.23; 95% confidence interval, 0.08-0.64; P = .019) after adjusting for age, gender, and presenting systolic blood pressure. CONCLUSIONS MOF occurred in only 9% to 14% of patients after rAAA repair, but was associated with a three-fold increase in mortality. Endovascular repair was associated with a reduced MOF incidence.
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Affiliation(s)
- Muhammad Saad Hafeez
- Division of Vascular Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
| | - Shimena R Li
- Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
| | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
| | - Amanda R Phillips
- Division of Vascular Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
| | - Salim G Habib
- Division of Vascular Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
| | - Antalya Jano
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Yancheng Dai
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Andre Stone
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Edith Tzeng
- Division of Vascular Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
| | - Michel S Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
| | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA.
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Barea-Mendoza JA, Chico-Fernández M, Serviá-Goixart L, Quintana-Díaz M, García-Sáez I, Ballesteros-Sanz MÁ, Iglesias-Santiago A, Molina-Díaz I, González-Robledo J, Fernández-Cuervo A, Pérez-Bárcena J, Llompart-Pou JA. Associated Risk Factors and Impact in Clinical Outcomes of Multiorgan Failure in Patients with TBI. Neurocrit Care 2023; 39:411-418. [PMID: 36869209 DOI: 10.1007/s12028-023-01698-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/10/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Individual extracerebral organ dysfunction is common after severe traumatic brain injury (TBI) and impacts outcomes. However, multiorgan failure (MOF) has received less attention in patients with isolated TBI. Our objective was to analyze the risk factors associated with the development of MOF and its impact in clinical outcomes in patients with TBI. METHODS This was an observational, prospective, multicenter study using data from a nationwide registry that currently includes 52 intensive care units (ICUs) in Spain (RETRAUCI). Isolated significant TBI was defined as Abbreviated Injury Scale (AIS) ≥ 3 in the head area with no AIS ≥ 3 in any other anatomical area. Multiorgan failure was defined using the Sequential-related Organ Failure Assessment as the alteration of two or more organs with a score of ≥ 3. We analyzed the contribution of MOF to crude and adjusted mortality (age and AIS head) by using logistic regression analysis. A multiple logistic regression analysis was performed to analyze the risk factors associated with the development of MOF in patients with isolated TBI. RESULTS A total of 9790 patients with trauma were admitted to the participating ICUs. Of them, 2964 (30.2%) had AIS head ≥ 3 and no AIS ≥ 3 in any other anatomical area, and these patients constituted the study cohort. Mean age was 54.7 (19.5) years, 76% of patients were men, and ground-level falls were the main mechanism of injury (49.1%). In-hospital mortality was 22.2%. Up to 185 patients with TBI (6.2%) developed MOF during their ICU stay. Crude and adjusted (age and AIS head) mortality was higher in patients who developed MOF (odds ratio 6.28 [95% confidence interval 4.58-8.60] and odds ratio 5.20 [95% confidence interval 3.53-7.45]), respectively. The logistic regression analysis showed that age, hemodynamic instability, the need of packed red blood cells concentrates in the initial 24 h, the severity of brain injury, and the need for invasive neuromonitoring were significantly associated with MOF development. CONCLUSIONS MOF occurred in 6.2% of patients with TBI admitted to the ICU and was associated with increased mortality. MOF was associated with age, hemodynamic instability, the need of packed red blood cells concentrates in the initial 24 h, the severity of brain injury, and the need for invasive neuromonitoring.
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Affiliation(s)
| | - Mario Chico-Fernández
- UCI Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Lluís Serviá-Goixart
- Servei de Medicina Intensiva, Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida, Universitat de Lleida, Lleida, Spain
| | | | - Iker García-Sáez
- Servicio de Medicina Intensiva, Hospital Universitario de Donostia, Donostia, Spain
| | | | - Alberto Iglesias-Santiago
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Instituto de Investigación Biosanitaria, Granada, Spain
| | - Ismael Molina-Díaz
- Servicio de Medicina Intensiva, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Spain
| | - Javier González-Robledo
- Servicio de Medicina Intensiva, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Ana Fernández-Cuervo
- Servicio de Medicina Intensiva, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Jon Pérez-Bárcena
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears, Carretera Valldemossa, 79, 07120, Palma, Spain
| | - Juan Antonio Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears, Carretera Valldemossa, 79, 07120, Palma, Spain.
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Richards J, Fedeles BT, Chow JH, Scalea T, Kozar R. Raising the bar on fibrinogen: a retrospective assessment of critical hypofibrinogenemia in severely injured trauma patients. Trauma Surg Acute Care Open 2023; 8:e000937. [PMID: 36726403 PMCID: PMC9884899 DOI: 10.1136/tsaco-2022-000937] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/04/2022] [Indexed: 01/26/2023] Open
Abstract
Objectives Fibrinogen depletion may occur at higher levels than historically referenced. We evaluated hypofibrinogenemia and associated mortality and multiple organ failure (MOF) after severe injury. Methods Retrospective investigation including 417 adult patients with Injury Severity Score (ISS) >15. Demographics and injury characteristics were collected. Fibrinogen within 30 minutes of admission was described: <150 mg/dL, 150 mg/dL to 200 mg/dL and >200 mg/dL. Primary outcome: 28-day mortality. Secondary outcomes: 28-day MOF and blood product transfusion. Multivariable logistic regression model evaluated association of fibrinogen categories on risk of death, after controlling for confounding variables. Results presented as OR and 95% CIs. Results Fibrinogen <150 mg/dL: 4.8%, 150 mg/dL to 200 mg/dL: 18.2%, >200 mg/dL: 77.0%. 28-day mortality: 15.6%. Patients with <150 mg/dL fibrinogen had over fourfold increased 28-day mortality risk (OR: 4.9, 95% CI 1.53 to 15.7) after adjusting for age, ISS and admission Glasgow Coma Scale. Patients with lower fibrinogen were more likely to develop MOF (p=0.04) and receive larger red blood cell transfusion volumes at 3 hours and 24 hours (p<0.01). Conclusions Fibrinogen <150 mg/dL is significantly associated with increased 28-day mortality. Patients with fibrinogen <150 mg/dL were more likely to develop MOF and required increased administration of blood products. The optimal threshold for critically low fibrinogen, the association with MOF and subsequent fibrinogen replacement requires further investigation. Level of evidence Level III.
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Affiliation(s)
- Justin Richards
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA,R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Benjamin T Fedeles
- Department of Anesthesiology and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan H Chow
- Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Thomas Scalea
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA,Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rosemary Kozar
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA,Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Liu G, Xu J, Wang C, Yu M, Yuan J, Tian F, Zhang G. A machine learning method for predicting the probability of MODS using only non-invasive parameters. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 227:107236. [PMID: 36384060 DOI: 10.1016/j.cmpb.2022.107236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 10/30/2022] [Accepted: 11/07/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Timely and accurate prediction of multiple organ dysfunction syndrome (MODS) is essential for the rescue and treatment of trauma patients However, existing methods are invasive, easily affected by artifacts and can be difficult to perform in a pre-hospital setting. We aim to develop prediction models for patients with MODS using only non-invasive parameters. METHOD In this study, records from 2319 patients were extracted from the Multiparameter Intelligent Monitoring in Intensive Care Ⅲ database (MIMIC Ⅲ), based on the sequential organ failure assessment (SOFA) score. Seven commonly used machine learning (ML) methods were selected and applied to develop a real-time prediction method for MODS based on full parameters (laboratory parameter. drug and non-invasive parameters, 57 parameters in total) and non-invasive parameters only (17 parameters) and compared with four traditional scoring systems. RESULTS The prediction results using LightGBM (LGBM) and Adaboost based on the full parameter modeling were 0.959 for area under receiver operating characteristic curve (AUC), outperforming four traditional scoring systems. The removal of 40 parameters and retaining of 17 non-invasive parameters decreased the AUC value of LGBM by 0.015, which still outperformed all traditional scoring systems. CONCLUSIONS A real-time and accurate MODS prediction method was developed in this paper based on non-invasive parameters by comparing the performance of four ML methods, which proved to be superior to the traditional scoring systems. This method can help medical staff to diagnose MODS as soon as possible and can improve the survival rate of patients in a pre-hospital setting.
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Affiliation(s)
- Guanjun Liu
- Institute of Medical Support Technology, Academy of Systems Engineering, Academy of Military Sciences, 106 Wandong Road, Tianjin 300161, China
| | - Jiameng Xu
- School of Life Sciences, Tiangong University, 399 Binshui West Road, Tianjin 300387, China
| | - Chengyi Wang
- School of Life Sciences, Tiangong University, 399 Binshui West Road, Tianjin 300387, China
| | - Ming Yu
- Institute of Medical Support Technology, Academy of Systems Engineering, Academy of Military Sciences, 106 Wandong Road, Tianjin 300161, China
| | - Jing Yuan
- Institute of Medical Support Technology, Academy of Systems Engineering, Academy of Military Sciences, 106 Wandong Road, Tianjin 300161, China
| | - Feng Tian
- Institute of Medical Support Technology, Academy of Systems Engineering, Academy of Military Sciences, 106 Wandong Road, Tianjin 300161, China
| | - Guang Zhang
- Institute of Medical Support Technology, Academy of Systems Engineering, Academy of Military Sciences, 106 Wandong Road, Tianjin 300161, China.
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Giles T, Weaver N, Varghese A, Way TL, Abel C, Choi P, Briggs GD, Balogh ZJ. Acute kidney injury development in polytrauma and the safety of early repeated contrast studies: A retrospective cohort study. J Trauma Acute Care Surg 2022; 93:872-881. [PMID: 35801964 PMCID: PMC9671597 DOI: 10.1097/ta.0000000000003735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND The role of repeat intravenous contrast doses beyond initial contrast imaging in the development of acute kidney injury (AKI) for multiple injury patients admitted to the intensive care unit (ICU) is not fully understood. We hypothesized that additional contrast doses are potentially modifiable risk factors for worse outcomes. METHODS An 8-year retrospective study of our institutional prospective postinjury multiple organ failure database was performed. Adult ICU admissions that survived >72 hours with Injury Severity Score (ISS) of >15 were included. Patients were grouped based on number of repeat contrast studies received after initial imaging. Initial vital signs, resuscitation data, and laboratory parameters were collected. Primary outcome was AKI (Kidney Disease: Improving Global Outcomes criteria), and secondary outcomes included contrast-induced acute kidney injury (CI-AKI; >25% or >44 μmol/L increase in creatinine within 72 hours of contrast administration), multiple organ failure, length of stay, and mortality. RESULTS Six-hundred sixty-three multiple injury patients (age, 45.3 years [SD, 9.1 years]; males, 75%; ISS, 25 (interquartile range, 20-34); mortality, 5.4%) met the inclusion criteria. The incidence of AKI was 13.4%, and CI-AKI was 14.5%. Multivariate analysis revealed that receiving additional contrast doses within the first 72 hours was not associated with AKI (odds ratio, 1.33; confidence interval, 0.80-2.21; p = 0.273). Risk factors for AKI included higher ISS ( p < 0.0007), older age ( p = 0.0109), higher heart rate ( p = 0.0327), lower systolic blood pressure ( p = 0.0007), and deranged baseline blood results including base deficit ( p = 0.0042), creatinine ( p < 0.0001), lactate ( p < 0.0001), and hemoglobin ( p = 0.0085). Acute kidney injury was associated with worse outcomes (ICU length of stay: 8 vs. 3 days, p < 0.0001; mortality: 16% vs. 3.8%, p < 0.0001; MOF: 42% vs. 6.6%, p < 0.0001). CONCLUSION There is a limited role of repeat contrast administration in AKI development in ICU-admitted multiple injury patients. The clinical significance of CI-AKI is likely overestimated, and it should not compromise essential secondary imaging from the ICU. Further prospective studies are needed to verify our results. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Suresh K, Dixon JM, Patel C, Beaty B, Del Junco DJ, de Vries S, Lategan HJ, Steyn E, Verster J, Schauer SG, Becker TE, Cunningham C, Keenan S, Moore EE, Wallis LA, Baidwan N, Fosdick BK, Ginde AA, Bebarta VS, Mould-Millman NK. The epidemiology and outcomes of prolonged trauma care (EpiC) study: methodology of a prospective multicenter observational study in the Western Cape of South Africa. Scand J Trauma Resusc Emerg Med 2022; 30:55. [PMID: 36253865 PMCID: PMC9574798 DOI: 10.1186/s13049-022-01041-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/01/2022] [Indexed: 11/16/2022] Open
Abstract
Background Deaths due to injuries exceed 4.4 million annually, with over 90% occurring in low-and middle-income countries. A key contributor to high trauma mortality is prolonged trauma-to-treatment time. Earlier receipt of medical care following an injury is critical to better patient outcomes. Trauma epidemiological studies can identify gaps and opportunities to help strengthen emergency care systems globally, especially in lower income countries, and among military personnel wounded in combat. This paper describes the methodology of the “Epidemiology and Outcomes of Prolonged Trauma Care (EpiC)” study, which aims to investigate how the delivery of resuscitative interventions and their timeliness impacts the morbidity and mortality outcomes of patients with critical injuries in South Africa. Methods The EpiC study is a prospective, multicenter cohort study that will be implemented over a 6-year period in the Western Cape, South Africa. Data collected will link pre- and in-hospital care with mortuary reports through standardized clinical chart abstraction and will provide longitudinal documentation of the patient’s clinical course after injury. The study will enroll an anticipated sample of 14,400 injured adults. Survival and regression analysis will be used to assess the effects of critical early resuscitative interventions (airway, breathing, circulatory, and neurologic) and trauma-to-treatment time on the primary 7-day mortality outcome and secondary mortality (24-h, 30-day) and morbidity outcomes (need for operative interventions, secondary infections, and organ failure). Discussion This study is the first effort in the Western Cape of South Africa to build a standardized, high-quality, multicenter epidemiologic trauma dataset that links pre- and in-hospital care with mortuary data. In high-income countries and the U.S. military, the introduction of trauma databases and registries has led to interventions that significantly reduce post-injury death and disability. The EpiC study will describe epidemiology trends over time, and it will enable assessments of how trauma care and system processes directly impact trauma outcomes to ultimately improve the overall emergency care system. Trial Registration: Not applicable as this study is not a clinical trial.
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Affiliation(s)
- Krithika Suresh
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Julia M Dixon
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Chandni Patel
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Brenda Beaty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Deborah J Del Junco
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Shaheem de Vries
- Emergency Medical Services, Western Cape Government Health, Cape Town, South Africa
| | - Hendrick J Lategan
- Department of Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elmin Steyn
- Department of Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Janette Verster
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Steven G Schauer
- U.S. Army Institute of Surgical Research, San Antonio Medical Center, San Antonio, TX, USA
| | - Tyson E Becker
- Brooke Army Medical Center, Fort Sam Houston, San Antonio, TX, USA
| | - Cord Cunningham
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, San Antonio, TX, USA
| | - Sean Keenan
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, San Antonio, TX, USA.,Department of Emergency Medicine, The Center for COMBAT Research, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Lee A Wallis
- Emergency Medical Services, Western Cape Government Health, Cape Town, South Africa.,Department of Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Navneet Baidwan
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Bailey K Fosdick
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Adit A Ginde
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA.,Department of Emergency Medicine, The Center for COMBAT Research, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Nee-Kofi Mould-Millman
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA.
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10
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Emadi SA, Baradari AG, Charati JY, Taghavi F, Kiabi FH. SOFA and modified SOFA score for accessing outcomes among trauma patients in intensive care unit. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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11
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Cole E, Aylwin C, Christie R, Dillane B, Farrah H, Hopkins P, Ryan C, Woodgate A, Brohi K. Multiple Organ Dysfunction in Older Major Trauma Critical Care Patients: A Multicenter Prospective Observational Study. ANNALS OF SURGERY OPEN 2022; 3:e174. [PMID: 36936724 PMCID: PMC10013163 DOI: 10.1097/as9.0000000000000174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/09/2022] [Indexed: 11/27/2022] Open
Abstract
The objective was to explore the characteristics and outcomes of multiple organ dysfunction syndrome (MODS) in older trauma patients. Background Severely injured older people present an increasing challenge for trauma systems. Recovery for those who require critical care may be complicated by MODS. In older trauma patients, MODS may not be predictable based on chronological age alone and factors associated with its development and resolution are unclear. Methods Consecutive adult patients (aged ≥16 years) admitted to 4 level 1 major trauma center critical care units were enrolled and reviewed daily until discharge or death. MODS was defined by a daily total sequential organ failure assessment score of >5. Results One thousand three hundred sixteen patients were enrolled over 18 months and one-third (434) were aged ≥65 years. Incidence of MODS was high for both age groups (<65 years: 64%, ≥65 years: 70%). There were few differences in severity, patterns, and duration of MODS between cohorts, except for older traumatic brain injury (TBI) patients who experienced a prolonged course of MODS recovery (TBI: 9 days vs no TBI: 5 days, P < 0.01). Frailty rather than chronological age had a strong association with MODS development (odds ratio [OR], 6.9; 95% confidence intervals [CI], 3.0-12.4; P < 0.001) and MODS mortality (OR, 2.1; 95% CI, 1.31-3.38; P = 0.02). Critical care resource utilization was not increased in older patients, but MODS had a substantial impact on mortality (<65 years: 17%; ≥65 years: 28%). The majority of older patients who did not develop MODS survived and had favorable discharge outcomes (home discharge ≥65 years NoMODS: 50% vs MODS: 15%; P < 0.01). Conclusions Frailty rather than chronological age appears to drive MODS development, recovery, and outcome in older cohorts. Early identification of frailty after trauma may help to predict MODS and plan care in older trauma.
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Affiliation(s)
- Elaine Cole
- From the Centre for Trauma Sciences, Blizard Institute, Queen Mary University, London, United Kingdom
| | - Chris Aylwin
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Robert Christie
- From the Centre for Trauma Sciences, Blizard Institute, Queen Mary University, London, United Kingdom
- Barts Health NHS Trust, London, United Kingdom
| | - Bebhinn Dillane
- From the Centre for Trauma Sciences, Blizard Institute, Queen Mary University, London, United Kingdom
| | - Helen Farrah
- St Georges University Hospital NHS Trust, London, United Kingdom
| | - Phillip Hopkins
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Chris Ryan
- St Georges University Hospital NHS Trust, London, United Kingdom
| | - Adam Woodgate
- St Georges University Hospital NHS Trust, London, United Kingdom
| | - Karim Brohi
- From the Centre for Trauma Sciences, Blizard Institute, Queen Mary University, London, United Kingdom
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12
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Prolonged Casualty Care: Extrapolating Civilian Data to the Military Context. J Trauma Acute Care Surg 2022; 93:S78-S85. [PMID: 35546736 DOI: 10.1097/ta.0000000000003675] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Civilian and military populations alike are increasingly faced with undesirable situations in which prehospital and definitive care times will be delayed. The Western Cape of South Africa has some similarities in capabilities, injury profiles, resource-limitations, and system configuration to U.S. military prolonged casualty care (PCC) settings. This study provides an initial description of civilians in the Western Cape who experience PCC and compares the PCC and non-PCC populations. METHODS We conducted a 6 month analysis of an on-going, prospective, large-scale epidemiologic study of prolonged trauma care in the Western Cape ('EpiC'). We define PCC as ≥10 hours from injury to arrival at definitive care. We describe patient characteristics, critical interventions, key times, and outcomes as they may relate to military PCC and compare these using chi-squared and Wilcoxon tests. We estimated the associations between PCC status and the primary and secondary outcomes using logistic regression models. RESULTS 146 of 995 patients experienced PCC. The PCC group, compared to non-PCC, were more critically injured (66% vs 51%), received more critical interventions (36% vs 29%), had a greater proportionate mortality (5% vs 3%), longer hospital stays (3 vs 1 day), and higher SOFA scores (5 vs 3). The odds of 7-day mortality and a SOFA score ≥ 5 were 1.6 (OR: 1.59; 0.68, 3.74) and 3.6 (OR: 3.69; 2.11, 6.42) times higher, respectively, in PCC versus non-PCC patients. CONCLUSIONS EpiC enrolled critically injured patients with PCC who received resuscitative interventions. PCC patients had worse outcomes than non-PCC. EpiC will be a useful platform to provide on-going data for PCC relevant analyses, for future PCC-focused interventional studies, and to develop PCC protocols and algorithms. Findings will be relevant to the Western Cape, South Africa, other LMICs, and military populations experiencing prolonged care. LEVEL OF EVIDENCE III; prospective comparative study.
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13
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Braasch MC, Halimeh BN, Guidry CA. Availability of Multiple Organ Failure Score Components in Surgical Patients. Surg Infect (Larchmt) 2022; 23:178-182. [PMID: 35076318 DOI: 10.1089/sur.2021.265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Scoring systems are often used describe the degree of multi-system organ failure (MOF), however, the data used to calculate these scores are often missing. Studies utilizing these scoring systems often underreport the frequency of missing data. No study has examined the availability of clinical data needed to calculate Sequential Organ Failure Assessment (SOFA), and other organ failure scores. The primary objective of this study is to observe how often emergency general surgery and trauma patients have missing data needed to calculate MOF scores. Patients and Methods: Patients admitted between June 2017 and September 2019 were evaluated. Data to calculate SOFA, quick SOFA (qSOFA), Marshall Multiple Organ Dysfunction Score (MODS), Denver Post-Injury Multiple Organ Failure, and systemic inflammatory response syndrome (SIRS) criteria, as well as demographic and general admission and discharge data, were collected. Results: Of the 238 patients included in this study, 66.4% were emergency general surgery and 33.6% were trauma patients. For all patients, the median intensive care unit (ICU) length of stay (LOS) was seven days (range, 4-12), the median hospital LOS was 14 days (range, 10-21), and 28 patients (11.8%) did not survive to hospital discharge. Sequential Organ Failure Assessment was calculable in 21.4%-18.1%, whereas MODS was calculable in 6.3%-5.0% on days three and five, respectively. The Denver score was calculable in 32.5%-28.8% of trauma patients on these days. Of the data points needed to calculate these scores, the partial pressure of oxygen (Pao2)/fraction of inspired oxygen (FIo2) ratio, central venous pressure (CVP), and bilirubin were the least available components. Conclusions: Data needed to fully calculate SOFA and other common MOF scores are often not readily available highlighting the degree of imputation required to calculate these scores. We recommend better reporting of the degree of missing data in the literature.
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Affiliation(s)
| | - Bachar N Halimeh
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Christopher A Guidry
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
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14
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Temporal Transitions in Fibrinolysis after Trauma: Adverse Outcome Is Principally Related to Late Hypofibrinolysis. Anesthesiology 2021; 136:148-161. [PMID: 34724559 DOI: 10.1097/aln.0000000000004036] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The relationship between late clinical outcomes after injury and early dynamic changes between fibrinolytic states is not fully understood. The authors hypothesized that temporal transitions in fibrinolysis states using rotational thromboelastometry (ROTEM) would aid stratification of adverse late clinical outcomes and improve understanding of how tranexamic acid modulates the fibrinolytic response and impacts mortality. METHODS The authors conducted a secondary analysis of previously collected data from trauma patients enrolled into an ongoing prospective cohort study (International Standard Randomised Controlled Trial Number [ISRCTN] 12962642) at a major trauma center in the United Kingdom. ROTEM was performed on admission and at 24 h with patients retrospectively grouped into three fibrinolysis categories: tissue factor-activated ROTEM maximum lysis of less than 5% (low); tissue factor-activated ROTEM maximum lysis of 5 to 15% (normal); or tissue factor-activated ROTEM maximum lysis of more than 15% (high). Primary outcomes were multiorgan dysfunction syndrome and 28-day mortality. RESULTS Seven-hundred thirty-one patients were included: 299 (41%) were treated with tranexamic acid and 432 (59%) were untreated. Two different cohorts with low-maximum lysis at 24 h were identified: (1) severe brain injury and (2) admission shock and hemorrhage. Multiple organ dysfunction syndrome was greatest in those with low-maximum lysis on admission and at 24 h, and late mortality was four times higher than in patients who remained normal during the first 24 h (7 of 42 [17%] vs. 9 of 223 [4%]; P = 0.029). Patients that transitioned to or remained in low-maximum lysis had increased odds of organ dysfunction (5.43 [95% CI, 1.43 to 20.61] and 4.85 [95% CI, 1.83 to 12.83], respectively). Tranexamic acid abolished ROTEM hyperfibrinolysis (high) on admission, increased the frequency of persistent low-maximum lysis (67 of 195 [34%]) vs. 8 of 79 [10%]; P = 0.002), and was associated with reduced early mortality (28 of 195 [14%] vs. 23 of 79 [29%]; P = 0.015). No increase in late deaths, regardless of fibrinolysis transition patterns, was observed. CONCLUSIONS Adverse late outcomes are more closely related to 24-h maximum lysis, irrespective of admission levels. Tranexamic acid alters early fibrinolysis transition patterns, but late mortality in patients with low-maximum lysis at 24 h is not increased. EDITOR’S PERSPECTIVE
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15
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Krishnamoorthy V, Temkin N, Barber J, Foreman B, Komisarow J, Korley FK, Laskowitz DT, Mathew JP, Hernandez A, Sampson J, James ML, Bartz R, Raghunathan K, Goldstein BA, Markowitz AJ, Vavilala MS. Association of Early Multiple Organ Dysfunction With Clinical and Functional Outcomes Over the Year Following Traumatic Brain Injury: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study. Crit Care Med 2021; 49:1769-1778. [PMID: 33935162 PMCID: PMC8448900 DOI: 10.1097/ccm.0000000000005055] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Traumatic brain injury is a leading cause of death and disability in the United States. While the impact of early multiple organ dysfunction syndrome has been studied in many critical care paradigms, the clinical impact of early multiple organ dysfunction syndrome in traumatic brain injury is poorly understood. We examined the incidence and impact of early multiple organ dysfunction syndrome on clinical, functional, and disability outcomes over the year following traumatic brain injury. DESIGN Retrospective cohort study. SETTING Patients enrolled in the Transforming Clinical Research and Knowledge in Traumatic Brain Injury study, an 18-center prospective cohort study of traumatic brain injury patients evaluated in participating level 1 trauma centers. SUBJECTS Adult (age > 17 yr) patients with moderate-severe traumatic brain injury (Glasgow Coma Scale < 13). We excluded patients with major extracranial injury (Abbreviated Injury Scale score ≥ 3). INTERVENTIONS Development of early multiple organ dysfunction syndrome, defined as a maximum modified Sequential Organ Failure Assessment score greater than 7 during the initial 72 hours following admission. MEASUREMENTS AND MAIN RESULTS The main outcomes were: hospital mortality, length of stay, 6-month functional and disability domains (Glasgow Outcome Scale-Extended and Disability Rating Scale), and 1-year mortality. Secondary outcomes included: ICU length of stay, 3-month Glasgow Outcome Scale-Extended, 3-month Disability Rating Scale, 1-year Glasgow Outcome Scale-Extended, and 1-year Disability Rating Scale. We examined 373 subjects with moderate-severe traumatic brain injury. The mean (sd) Glasgow Coma Scale in the emergency department was 5.8 (3.2), with 280 subjects (75%) classified as severe traumatic brain injury (Glasgow Coma Scale 3-8). Among subjects with moderate-severe traumatic brain injury, 252 (68%) developed early multiple organ dysfunction syndrome. Subjects that developed early multiple organ dysfunction syndrome had a 75% decreased odds of a favorable outcome (Glasgow Outcome Scale-Extended 5-8) at 6 months (adjusted odds ratio, 0.25; 95% CI, 0.12-0.51) and increased disability (higher Disability Rating Scale score) at 6 months (adjusted mean difference, 2.04; 95% CI, 0.92-3.17). Subjects that developed early multiple organ dysfunction syndrome experienced an increased hospital length of stay (adjusted mean difference, 11.4 d; 95% CI, 7.1-15.8), with a nonsignificantly decreased survival to hospital discharge (odds ratio, 0.47; 95% CI, 0.18-1.2). CONCLUSIONS Early multiple organ dysfunction following moderate-severe traumatic brain injury is common and independently impacts multiple domains (mortality, function, and disability) over the year following injury. Further research is necessary to understand underlying mechanisms, improve early recognition, and optimize management strategies.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Nancy Temkin
- Department of Neurosurgery, University of Washington, Seattle, WA
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Jason Barber
- Department of Neurosurgery, University of Washington, Seattle, WA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
| | | | - Fred K. Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Daniel T. Laskowitz
- Department of Anesthesiology, Duke University, Durham, NC
- Department of Neurosurgery, Duke University, Durham, NC
- Department of Neurology, Duke University, Durham, NC
| | | | | | - John Sampson
- Department of Neurosurgery, Duke University, Durham, NC
| | - Michael L. James
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Neurology, Duke University, Durham, NC
- Brain and Spinal Injury Center, University of California at San Francisco, San Francisco, CA
| | - Raquel Bartz
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Brain and Spinal Injury Center, University of California at San Francisco, San Francisco, CA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | | | - Amy J. Markowitz
- Brain and Spinal Injury Center, University of California at San Francisco, San Francisco, CA
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
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16
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Krishnamoorthy V, Komisarow JM, Laskowitz DT, Vavilala MS. Multiorgan Dysfunction After Severe Traumatic Brain Injury: Epidemiology, Mechanisms, and Clinical Management. Chest 2021; 160:956-964. [PMID: 33460623 PMCID: PMC8448997 DOI: 10.1016/j.chest.2021.01.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/10/2020] [Accepted: 01/07/2021] [Indexed: 01/20/2023] Open
Abstract
Traumatic brain injury (TBI) is a major global health problem and a major contributor to morbidity and mortality following multisystem trauma. Extracranial organ dysfunction is common after severe TBI and significantly impacts clinical care and outcomes following injury. Despite this, extracranial organ dysfunction remains an understudied topic compared with organ dysfunction in other critical care paradigms. In this review, we will: 1) summarize the epidemiology of extracranial multiorgan dysfunction following severe TBI; 2) examine relevant mechanisms that may be involved in the development of multi-organ dysfunction following severe TBI; and 3) discuss clinical management strategies to care for these complex patients.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University, Chapel Hill, NC; Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Chapel Hill, NC.
| | - Jordan M Komisarow
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Chapel Hill, NC; Department of Neurosurgery, Duke University, Chapel Hill, NC
| | | | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
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17
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Eriksson J, Nelson D, Holst A, Hellgren E, Friman O, Oldner A. Temporal patterns of organ dysfunction after severe trauma. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:165. [PMID: 33952314 PMCID: PMC8101241 DOI: 10.1186/s13054-021-03586-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/27/2021] [Indexed: 11/23/2022]
Abstract
Background Understanding temporal patterns of organ dysfunction (OD) may aid early recognition of complications after trauma and assist timing and modality of treatment strategies. Our aim was to analyse and characterise temporal patterns of OD in intensive care unit-admitted trauma patients.
Methods We used group-based trajectory modelling to identify temporal trajectories of OD after trauma. Modelling was based on the joint development of all six subdomains comprising the sequential organ failure assessment score measured daily during the first two weeks post trauma. Further, the time for trajectories to stabilise and transition to final group assignments were evaluated. Results Six-hundred and sixty patients were included in the final model. Median age was 40 years, and median ISS was 26 (IQR 17–38). We identified five distinct trajectories of OD. Group 1, mild OD (n = 300), median ISS of 20 (IQR 14–27), had an early resolution of OD and a low mortality. Group 2, moderate OD (n = 135), and group 3, severe OD (n = 87), were fairly similar in admission characteristics and initial OD but differed in subsequent OD trajectories, the latter experiencing an extended course and higher mortality. In group 3, 56% of the patients developed sepsis as compared with 19% in group 2. Group 4, extreme OD (n = 40), received most blood transfusions, had the highest proportion of shock at admission and a median ISS of 41 (IQR 29–50). They experienced significant and sustained OD affecting all organ systems and a 28-day mortality of 30%. Group 5, traumatic brain injury with OD (n = 98), had the highest mortality of 35% and the shortest time to death for non-survivors, median 3.5 (IQR 2.4–4.8) days. Groups 1 and 5 reached their final group assignment early, > 80% of the patients within 48 h. In contrast, groups 2 and 3 had a prolonged time to final group assignment. Conclusions We identified five distinct trajectories of OD after severe trauma during the first two weeks post-trauma. Our findings underline the heterogeneous course after trauma and describe some potentially important clinical insights that are suggested by the groupings and temporal trajectories. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03586-6.
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Affiliation(s)
- Jesper Eriksson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden. .,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.
| | - David Nelson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Anders Holst
- KTH, Royal Institute of Technology, Stockholm, Sweden.,RISE, Research Institutes of Sweden, Gothenburg, Sweden
| | - Elisabeth Hellgren
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden
| | - Ola Friman
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden
| | - Anders Oldner
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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18
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van Wessem KJP, Leenen LPH. Process related decisions and in-hospital transport times in polytrauma patients benefit from 24/7 in-house presence of trauma surgeons. Injury 2021; 52:189-194. [PMID: 32958341 DOI: 10.1016/j.injury.2020.09.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/31/2020] [Accepted: 09/15/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Time and cause of death in polytrauma has shifted due to improvements in trauma and critical care. These include logistical improvements with dedicated trauma teams and in-house trauma surgeons. This study investigated in-hospital transport times and influence of process related decisions on mortality in polytrauma patients. STUDY DESIGN A 6.5-year prospective study included consecutive polytrauma patients ≥15 years admitted to a Level-1 Trauma Center ICU with 24/7 in-house trauma surgeons. Demographics, physiologic parameters, pre- and in-hospital transport times were prospectively collected. Data are presented as median(IQR). RESULTS 391 patients were included with median ISS of 29(22-36). 82 patients(21%) had a SBP≤90 mmHg on arrival in ED. 44 patients went from ED directly to OR for urgent surgery, all others had CT prior to OR and/or ICU. Patients who went directly to OR from ED had median transport time of 28(23-37) min. Patients who had CT after ED had median transport time of 31(25-42) min. 74(19%) patients died, majority caused by TBI(70%). Ten patients died <24 h after trauma (4 hemorrhage,3 TBI,2 ischemia,1 cardiac injury), 9 of them went straight to OR from ED. Death could possibly have been prevented in 1 patient (1%) who later died of hemorrhage but went to CT before urgent surgery. CONCLUSION In-hospital transport times from ED were half an hour regardless of the following destination (OR/CT). Decisions for transport order based on clinical signs in primary survey were rapid and accurate. This could be attributed to dedicated trauma teams and 24/7 physical presence of trauma surgeons.
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Affiliation(s)
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Netherlands
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Madurska MJ, McLenithan A, Scalea TM, Kundi R, White JM, Morrison JJ, DuBose JJ. A feasibility study of partial REBOA data in a high-volume trauma center. Eur J Trauma Emerg Surg 2021; 48:299-305. [PMID: 33399878 DOI: 10.1007/s00068-020-01561-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 11/19/2020] [Indexed: 01/31/2023]
Abstract
PURPOSE Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to temporize patients with infradiaphragmatic hemorrhage. Current guidelines advise < 30 min, to avoid ischemia/ reperfusion injury, whenever possible. The technique of partial REBOA (P-REBOA) has been developed to minimize the effects of distal ischemia. This study presents our clinical experience with P-REBOA, comparing outcomes to complete occlusion (C-REBOA). PATIENTS AND METHODS Retrospective analysis of patients' electronic data and local REBOA registry between January 2016 and May 2019. INCLUSION CRITERIA adult trauma patients who received Zone I C-REBOA or P-REBOA for infradiaphragmatic hemorrhage, who underwent attempted exploration in the operating room. Comparison of outcomes based on REBOA technique (P-REBOA vs C-REBOA) and occlusion time (> 30 min, vs ≤ 30 min) RESULTS: 46 patients were included, with 14 treated with P-REBOA. There were no demographic differences between P-REBOA and C-REBOA. Prolonged (> 30 min) REBOA (regardless of type of occlusion) was associated with increased mortality (32% vs 0%, p = 0.044) and organ failure. When comparing prolonged P-REBOA with C-REBOA, there was a trend toward lower ventilator days [19 (11) vs 6 (9); p = 0.483] and dialysis (36.4% vs 16.7%; p = 0.228) with significantly less vasopressor requirement (72.7% vs 33.3%; p = 0.026). CONCLUSION P-REBOA can be delivered in a clinical setting, but is not currently associated with improved survival in prolonged occlusion. In survivors, there is a trend toward lower organ support needs, suggesting that the technique might help to mitigate ischemic organ injury. More clinical data are needed to clarify the benefit of partial occlusion REBOA.
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Affiliation(s)
- Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Ashley McLenithan
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, 19131, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Joseph M White
- Division of Vascular Surgery, The Department of Surgery at the Uniformed Services University of the Health Sciences and The Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA.
| | - Joseph J DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
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Asim M, Amin F, El-Menyar A. Multiple organ dysfunction syndrome: Contemporary insights on the clinicopathological spectrum. Qatar Med J 2020; 2020:22. [PMID: 33628712 PMCID: PMC7884906 DOI: 10.5339/qmj.2020.22] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/03/2020] [Indexed: 12/27/2022] Open
Abstract
Multiorgan dysfunction syndrome (MODS) remains a major complication and challenge to treat patients with critical illness in different intensive care unit settings. The exact mechanism and pathophysiology of MODS is complex and remains unexplored. We reviewed the literature from January 2011 to August 2019 to analyze the underlying mechanisms, prognostic factors, MODS scoring systems, organ systems dysfunctions, and the management of MODS. We used the search engines PubMed, MEDLINE, Scopus, and Google Scholar with the keywords "multiple organ dysfunction syndrome," "intensive care units," "multiorgan failure," "MODS scoring system," and "MODS management." The initial search yielded 3550 abstracts, of which 91 articles were relevant to the scope of the present article. A better understanding of a disease course will help differentiate the signs of an intense inflammatory response from the early onset of sepsis and minimize the inappropriate use of medications. This, in turn, will promote organtargeted therapy and prevent occurrence and progression of MODS.
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Affiliation(s)
- Mohammad Asim
- Department of Surgery, Clinical Research, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Farhana Amin
- Sri Ramaswamy Memorial Medical College Hospital & Research Center, Tamil Nadu, India
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21
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Risk Factors Associated With Early and Late Posttraumatic Multiorgan Failure: An Analysis From RETRAUCI. Shock 2020; 55:326-331. [PMID: 32694393 DOI: 10.1097/shk.0000000000001628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze factors associated with the development of early and late multiorgan failure (MOF) in trauma patients admitted to the intensive care unit (ICU). METHODS Spanish Trauma ICU Registry (RETRAUCI). Data collected from 52 trauma ICU between March 2015 and December 2019. We analyzed the incidence, outcomes, and the risk factors associated with early (< 72 h) or late (beyond 72 h) MOF in trauma ICU patients. Multiple logistic regression analysis was performed to analyze associated factors. RESULTS After excluding patients with incomplete data, 9,598 trauma ICU patients constituted the study population. Up to 965 patients (10.1%) presented with MOF, distributed by early MOF in 780 patients (8.1%) and late MOF in 185 patients (1.9%). The multivariate analysis showed that early MOF was associated with: ISS ≥ 16 (OR 2.80), hemodynamic instability (OR from 2.03 to 43.05), trauma-associated coagulopathy (OR 2.32), and acute kidney injury (OR 4.10). Late MOF was associated with: age > 65 years (OR 1.52), hemodynamic instability (OR from 1.92 to 9.94), acute kidney injury (OR 4.22), and nosocomial infection (OR 17.23). MOF was closely related to mortality (crude OR (95% CI) 4.77 (4.22-5.40)). CONCLUSIONS Multiorgan failure was recorded in 10% of trauma ICU patients, with early MOF being the predominant form. Early and late MOF forms were associated with different risk factors, suggesting different pathophysiological pathways. Early MOF was associated with higher severity of injury and severe bleeding-related complications and late MOF with advanced age and nosocomial infection.
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22
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van Wessem KJP, Hietbrink F, Leenen LPH. Attenuation of MODS-related and ARDS-related mortality makes infectious complications a remaining challenge in the severely injured. Trauma Surg Acute Care Open 2020; 5:e000398. [PMID: 32154377 PMCID: PMC7046953 DOI: 10.1136/tsaco-2019-000398] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 01/11/2020] [Accepted: 01/18/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction The recent decrease in multiple organ dysfunction syndrome (MODS)-associated and adult respiratory distress syndrome (ARDS)-associated mortality could be considered a success of improvements in trauma care. However, the incidence of infections remains high in patients with polytrauma, with high morbidity and hospital resources usage. Infectious complications might be a residual effect of the decrease in MODS-related/ARDS-related mortality. This study investigated the current incidence of infectious complications in polytrauma. Methods A 5.5-year prospective population-based cohort study included consecutive severely injured patients (age >15) admitted to a (Level-1) trauma center intensive care unit (ICU) who survived >48 hours. Demographics, physiologic and resuscitation parameters, multiple organ failure and ARDS scores, and infectious complications (pneumonia, fracture-related infection, meningitis, infections related to blood, wound, and urinary tract) were prospectively collected. Data are presented as median (IQR), p<0.05 was considered significant. Results 297 patients (216 (73%) men) were included with median age of 46 (27–60) years, median Injury Severity Score was 29 (22–35), 96% sustained blunt injuries. 44 patients (15%) died. One patient (2%) died of MODS and 1 died of ARDS. 134 patients (45%) developed 201 infectious complications. Pneumonia was the most common complication (50%). There was no difference in physiologic parameters on arrival in emergency department and ICU between patients with and without infectious complications. Patients who later developed infections underwent more often a laparotomy (32% vs 18%, p=0.009), had more often pelvic fractures (38% vs 25%, p=0.02), and received more blood products <8 hours. They had more often MODS (25% vs 13%, p=0.005), stayed longer on the ventilator (10 (5–15) vs 5 (2–8) days, p<0.001), longer in ICU (11 (6–17) vs 6 (3–10) days, p<0.001), and in hospital (30 (20–44) vs 16 (10–24) days, p<0.001). There was however no difference in mortality (12% vs 17%, p=0.41) between both groups. Conclusion 45% of patients developed infectious complications. These patients had similar mortality rates, but used more hospital resources. With low MODS-related and ARDS-related mortality, infections might be a residual effect, and are one of the remaining challenges in the treatment of patients with polytrauma. Level of evidence Level 3. Study type Population-based cohort study.
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Affiliation(s)
- Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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23
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Wang L, Zhao X, Wang Y. The pivotal role and mechanism of long non-coding RNA B3GALT5-AS1 in the diagnosis of acute pancreatitis. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2019; 47:2307-2315. [PMID: 31177837 DOI: 10.1080/21691401.2019.1623231] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The present study planned to dig the potential impacts of long non-coding RNA B3GALT5-AS1 in acute pancreatitis (AP). A total of 66 patients who were diagnosed with AP using ultrasonic imaging were enrolled in the study. Expression levels of B3GALT5-AS1 in the serum of AP patients were determined. Afterwards, rat pancreatic AR42J acinar cells were disposed with caerulein to produce AP-like injury. The role and molecular mechanisms of B3GALT5-AS1 in AP were explored through in vitro cell experiments. The levels of lncRNA B3GALT5-AS1 were observed to be lessened in patients with AP relative to healthy controls. In addition, caerulein was observed to induce injuries in the AR42J cells (depressed cell viability, enhanced cell apoptosis, cytokines production, and levels of amylase). Overexpression of B3GALT5-AS1 alleviated the caerulein-produced injury in the AR42J cells. Moreover, it was determined that miR-203 showed a downside expression by B3GALT5-AS1 regulation, and the overexpression of B3GALT5-AS1 retrained caerulein-produced injury through the suppression of miR-203. In addition, it was observed that miR-203 lessened the level of nuclear factor interleukin-3 (NFIL3) and that NFIL3 was targeted by miR-203. Lastly, the impacts of B3GALT5-AS1 on caerulein-induced cell injury were manifested through the NF-κB signalling pathway. The data from the present study revealed that in patients with AP, B3GALT5-AS1 is expressed in reduced amounts. Overexpression of B3GALT5-AS1 may alleviate caerulein-induced cell injury in AR42J cells through the regulation of miR-203/NFIL3 axis and by inhibiting the activation of the NF-κB signals.
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Affiliation(s)
- Linlin Wang
- a Department of Ultrasound, China-Japan Union Hospital, Jilin University , Changchun , Jilin , China
| | - Xiaonan Zhao
- b Infectious Department of China-Japan Union Hospital, Jilin University , Changchun , China
| | - Ye Wang
- c Department of Pediatrics, China-Japan Union Hospital, Jilin University , Changchun , Jilin , China
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24
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Cole E, Gillespie S, Vulliamy P, Brohi K. Multiple organ dysfunction after trauma. Br J Surg 2019; 107:402-412. [PMID: 31691956 PMCID: PMC7078999 DOI: 10.1002/bjs.11361] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/02/2019] [Accepted: 08/13/2019] [Indexed: 01/31/2023]
Abstract
Background The nature of multiple organ dysfunction syndrome (MODS) after traumatic injury is evolving as resuscitation practices advance and more patients survive their injuries to reach critical care. The aim of this study was to characterize contemporary MODS subtypes in trauma critical care at a population level. Methods Adult patients admitted to major trauma centre critical care units were enrolled in this 4‐week point‐prevalence study. MODS was defined by a daily total Sequential Organ Failure Assessment (SOFA) score of more than 5. Hierarchical clustering of SOFA scores over time was used to identify MODS subtypes. Results Some 440 patients were enrolled, of whom 245 (55·7 per cent) developed MODS. MODS carried a high mortality rate (22·0 per cent versus 0·5 per cent in those without MODS; P < 0·001) and 24·0 per cent of deaths occurred within the first 48 h after injury. Three patterns of MODS were identified, all present on admission. Cluster 1 MODS resolved early with a median time to recovery of 4 days and a mortality rate of 14·4 per cent. Cluster 2 had a delayed recovery (median 13 days) and a mortality rate of 35 per cent. Cluster 3 had a prolonged recovery (median 25 days) and high associated mortality rate of 46 per cent. Multivariable analysis revealed distinct clinical associations for each form of MODS; 24‐hour crystalloid administration was associated strongly with cluster 1 (P = 0·009), traumatic brain injury with cluster 2 (P = 0·002) and admission shock severity with cluster 3 (P = 0·003). Conclusion Contemporary MODS has at least three distinct types based on patterns of severity and recovery. Further characterization of MODS subtypes and their underlying pathophysiology may lead to future opportunities for early stratification and targeted interventions.
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Affiliation(s)
- E Cole
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - S Gillespie
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - P Vulliamy
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - K Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
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25
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Kleinveld DJ, Tuip-de Boer AM, Hollmann MW, Juffermans NP. Early increase in anti-inflammatory biomarkers is associated with the development of multiple organ dysfunction syndrome in severely injured trauma patients. Trauma Surg Acute Care Open 2019; 4:e000343. [PMID: 31750398 PMCID: PMC6827752 DOI: 10.1136/tsaco-2019-000343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/27/2019] [Accepted: 08/29/2019] [Indexed: 12/17/2022] Open
Abstract
Background As a result of improvements in the early resuscitation phase of trauma, mortality is largely driven by later mortality due to multiple organ dysfunction syndrome (MODS), which may be mediated by an early overdrive in the host immune response. If patients at risk for MODS could be identified early, preventive treatment measures could be taken. The aim of this study is to investigate whether specific biomarkers are associated with MODS. Methods Multiple trauma patients presenting to the Amsterdam University Medical Centers, location Academic Medical Center, between 2012 and 2018 with an Injury Severity Score of 16 or higher were sampled on arrival at the emergency department. A wide variety of inflammatory cytokines, endothelial and lung-specific markers were determined. Comparisons were made between patients with and without MODS. Univariate and multivariate logistic regression was used to determine associations between specific biomarkers and MODS. A p value of 0.05 was considered to be statistically significant. Results In total, 147 multiple trauma patients were included. Of these, 32 patients developed MODS (21.7%). Patients who developed MODS were more severely injured, had more traumatic brain injury and showed more deranged markers of coagulation when compared with patients without MODS. Overall, both proinflammatory and anti-inflammatory cytokines were higher in patients with MODS, indicative of a host immune reaction. In the multivariate analysis, the combination of anti-inflammatory proteins interleukin 1 receptor antagonist (IL-1RA) (OR 1.27 (1.07–1.51), p=0.002) and Clara cell protein 16 (CC-16) (1.06 (1.01–1.05), p=0.031) was most strongly associated with the development MODS. Conclusions In trauma, anti-inflammatory proteins IL-1RA and CC-16 have the potential to early identify patients at risk for development of MODS. Further research is warranted to prospectively validate these results. Level of evidence Prognostic study, level III.
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Affiliation(s)
- Derek Jb Kleinveld
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Intensive Care Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anita M Tuip-de Boer
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Anesthesiology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Intensive Care Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Feasibility and Safety of Intravascular Temperature Management for Severe Heat Stroke: A Prospective Multicenter Pilot Study. Crit Care Med 2019; 46:e670-e676. [PMID: 29624537 DOI: 10.1097/ccm.0000000000003153] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Heat stroke is a life-threatening condition with high mortality and morbidity. Although several cooling methods have been reported, the feasibility and safety of treating heat stroke using intravascular temperature management are unclear. This study evaluated the efficacies of conventional treatment with or without intravascular temperature management for severe heat stroke. DESIGN Prospective multicenter study. SETTING Critical care and emergency medical centers at 10 tertiary hospitals. PATIENTS Patients with severe heat stroke hospitalized during two summers. INTERVENTIONS Conventional cooling with or without intravascular temperature management. MEASUREMENTS AND MAIN RESULTS Cooling efficacy, Sequential Organ Failure Assessment score, occurrence rate of serious adverse events, and prognosis based on the modified Rankin Scale and Cerebral Performance Category. Patient outcomes were compared between five centers that were prospectively assigned to perform conventional cooling (control group: eight patients) and five centers that were assigned to perform conventional cooling plus intravascular temperature management (intravascular temperature management group: 13 patients), based on equipment availability. Despite their higher initial temperatures, all patients in the intravascular temperature management group reached the target temperature of 37°C within 24 hours, although only 50% of the patients in the control group reached 37°C (p < 0.01). The intravascular temperature management group also had a significant decrease in the Sequential Organ Failure Assessment score during the first 24 hours after admission (4.0 vs 1.5; p = 0.04). Furthermore, the intravascular temperature management group experienced fewer serious adverse events during their hospitalization, compared with the control group. The percentages of favorable outcomes at discharge and 30 days after admission were not statistically significant. CONCLUSIONS The combination of intravascular temperature management and conventional cooling was safe and feasible for treating severe heat stroke. The results indicate that better temperature management may help prevent organ failure. A large randomized controlled trial is needed to validate our findings.
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27
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Ferrucci JL, Sassi FC, Medeiros GCD, Andrade CRFD. Comparison between the functional aspects of swallowing and clinical markers in ICU patients with Traumatic Brain Injury (TBI). Codas 2019; 31:e20170278. [PMID: 30942285 DOI: 10.1590/2317-1782/20182017278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 09/19/2018] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To characterize and compare the functional aspects of swallowing and clinical markers in intensive care patients with traumatic brain injury (TBI) in Intensive Care Unit (ICU). METHODS Participants of this study were 113 adults diagnosed with TBI. Data collection stage involved: clinical assessment of the risk for bronchoaspiration performed by a speech-language therapist; assessment of the functional level of swallowing (American Speech-Language-Hearing Association National Outcome Measurement System - ASHA NOMS ); assessment of the patient' health status (Sequential Organ Failure Assessment - SOFA). RESULTS After the inclusion criteria were applied, patients were grouped according to their swallowing functional level: levels 1 and 2 - ASHA1 (n=25); levels 3, 4 and 5 - ASHA2 (n=37); levels 6 and 7 - ASHA3 (n=51). The statistical analyses indicated the following significant results: the ASHA3 group presented lower severity levels of TBI at the clinical assessment of bronchoaspiration, remained less time intubated (approximately um third less than the more severe group), remained fewer days in hospital and needed less therapy sessions to return to safe oral feeding. The clinical predictor signs for bronchoaspiration that best characterized the groups were the presence of altered auscultation and the presence of coughing after swallowing. Patients in the ASHA3 group presented these signs less frequently. CONCLUSION The score obtained on the SOFA and the time of orotracheal intubation were identified as the prognostic indicators of functional swallowing. The presence of altered cervical auscultation and coughing were clinical predictors of dysphagia.
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Affiliation(s)
- Juliana Lopes Ferrucci
- Divisão de Fonoaudiologia, Instituto Central, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - USP - São Paulo (SP), Brasil
| | - Fernanda Chiarion Sassi
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional, Faculdade de Medicina, Universidade de São Paulo - USP - São Paulo (SP), Brasil
| | - Gisele Chagas de Medeiros
- Divisão de Fonoaudiologia, Instituto Central, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - USP - São Paulo (SP), Brasil
| | - Claudia Regina Furquim de Andrade
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional, Faculdade de Medicina, Universidade de São Paulo - USP - São Paulo (SP), Brasil
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Kong T, Park YS, Lee HS, Kim S, Lee JW, You JS, Chung HS, Park I, Chung SP. The delta neutrophil index predicts development of multiple organ dysfunction syndrome and 30-day mortality in trauma patients admitted to an intensive care unit: a retrospective analysis. Sci Rep 2018; 8:17515. [PMID: 30504778 PMCID: PMC6269472 DOI: 10.1038/s41598-018-35796-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 11/09/2018] [Indexed: 02/08/2023] Open
Abstract
No studies have examined the role of delta neutrophil index (DNI) reflecting on immature granulocytes in determining the severity of multiple organ dysfunction (MODS) and short-term mortality. This study investigated the utility of the automatically calculated DNI as a prognostic marker of severity in trauma patients who were admitted to an intensive care unit (ICU). We retrospectively analysed prospective data of eligible patients. We investigated 366 patients. On multivariable logistic regression analysis, higher DNI values at 12 h (odds ratio [OR], 1.079; 95% confidence interval [CI]: 1.037-1.123; p < 0.001) and 24 h were strong independent predictors of MODS development. Multivariable Cox regression analysis revealed that increased DNI at 12 h (hazard ratio [HR], 1.051; 95% CI, 1.024-1.079; p < 0.001) was a strong independent predictor of short-term mortality. The increased predictability of MODS after trauma was closely associated with a DNI > 3.25% at 12 h (OR, 12.7; 95% CI: 6.12-26.35; p < 0.001). A cut-off of >5.3% at 12 h was significantly associated with an increased risk of 30-day mortality (HR, 18.111; 95% CI, 6.988-46.935; p < 0.001). The DNI is suitable for rapid and simple estimation of the severity of traumatic injury using an automated haematologic analyser without additional cost or time.
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Affiliation(s)
- Taeyoung Kong
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Emergency Medicine, Graduate School of Medicine, Kangwon National University, Chuncheon, Republic of Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sinae Kim
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Wook Lee
- Department of Laboratory Medicine, Konyang University Hospital, Daejeon, Republic of Korea
| | - Je Sung You
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Hyun Soo Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Incheol Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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29
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Zhang Y, Yan L, Han W. Elevated Level of miR-551b-5p is Associated With Inflammation and Disease Progression in Patients With Severe Acute Pancreatitis. Ther Apher Dial 2018; 22:649-655. [PMID: 29989302 DOI: 10.1111/1744-9987.12720] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 05/03/2018] [Accepted: 05/30/2018] [Indexed: 12/30/2022]
Abstract
Circulating microRNAs have the potential to be noninvasive biomarkers for assessing disease progression. MicroRNA-551b-5p (miR-551b-5p) was previously reported to be differentially expressed in pancreatic patients. The serum miR-551b-5p level was measured in patients with mild acute pancreatitis (MAP), severe acute pancreatitis (SAP), and healthy controls using quantitative real-time polymerase chain reaction (RT-PCR) analysis to evaluate its impact on inflammatory response. Acute Physiology and Chronic Health Evaluation II (APACHE II), Multiple Organ Dysfunction Score (MODS), Sequential Organ Assessment Score (SOFA), and Ranson's scores were recorded. Inflammatory cytokines, IL-6, IL-17, IL-1β, and Tumor Necrosis Factor-α (TNF-α), were detected in serum samples obtained from MAP and SAP patients on admission day 1, day 3, and day 5 using Enzyme Linked Immunosorbent Assay (ELISA). Inflammatory cytokines were analyzed in peripheral blood mononuclear cells (PBMCs), which were transfected with miR-551b-5p-negative controls and inhibitors. The serum miR-551b-5p level was significantly higher in MAP and SAP patients compared to controls (P < 0.001). An elevated miR-551b-5p level is positively associated with APACHE II, MODS, SOFA, and Ranson's scores (P < 0.001). Serum cytokines levels were significantly elevated in MAP and SAP patients compared to controls (P < 0.05). In addition, the level of these inflammatory cytokines was increased in PBMCs of SAP patients in comparison with those of healthy controls (P < 0.05), and this rise was significantly reduced with the addition of an miR-551b-5p inhibitor. In conclusion, serum miR-551b-5p is elevated in patients with MAP and SAP and is involved in the regulation of inflammatory response. It may be a useful biomarker for assessing the severity of SAP.
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Affiliation(s)
- Yongpeng Zhang
- Department of Emergency, People's Hospital of Dongying, Dongying, Shandong, China
| | - Liying Yan
- Department of Emergency, People's Hospital of Dongying, Dongying, Shandong, China
| | - Wang Han
- Department of Emergency, People's Hospital of Dongying, Dongying, Shandong, China
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30
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Wang ZK, Chen RJ, Wang SL, Li GW, Zhu ZZ, Huang Q, Chen ZL, Chen FC, Deng L, Lan XP, Hu T. Clinical application of a novel diagnostic scheme including pancreatic β‑cell dysfunction for traumatic multiple organ dysfunction syndrome. Mol Med Rep 2017; 17:683-693. [PMID: 29115473 DOI: 10.3892/mmr.2017.7898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 08/22/2017] [Indexed: 11/06/2022] Open
Abstract
A novel diagnostic scheme that includes pancreatic β‑cell dysfunction analysis for the diagnosis of traumatic multiple organ dysfunction syndrome (MODS) was investigated to assist in the early diagnosis and detection of MODS. Early intervention and treatment of MODS has been associated with a reduced mortality rate. A total of 2,876 trauma patients (including patients post‑major surgery) were admitted to the intensive care unit of the authors' hospital between December 2010 and December 2015 and enrolled in the present study. There were 205 cases where the patient succumbed to their injuries. In addition to the conventional diagnostic scheme for traumatic MODS, indexes of pancreatic β‑cell dysfunction [fasting blood‑glucose (FBG), homeostatic model assessment‑β and (blood insulin concentration 30 min following glucose loading‑fasting insulin concentration)/(blood glucose concentration 30 min following glucose loading‑FBG concentration)] were included to establish an improved diagnostic scheme for traumatic MODS. The novel scheme was subsequently used in clinical practice alongside the conventional scheme and its effect was evaluated. The novel scheme had a significantly higher positive number of MODS diagnoses for all trauma patients compared with the conventional scheme (12.48 vs. 8.87%; P<0.01). No significant difference was identified in the final percentage of positive of MODS diagnoses for trauma‑associated mortality patients between the novel (88.30%) and the conventional scheme (86.34%). The novel scheme had a significantly higher positive number of MODS diagnoses for trauma‑associated mortality patients 3 days prior to patients succumbing to MODS compared with the conventional scheme (80.98 vs. 64.39%; P<0.01). The consensus of the MODS diagnosis of all trauma patients between the novel scheme and the conventional scheme was 100%; however, out of the patients diagnosed as positive by novel scheme 71.03% were positive by the conventional scheme. The consensus between the final MODS diagnosis and the MODS diagnosis 3 days prior to patients succumbing to their injuries between the novel scheme and the conventional scheme was 100%; however, out of the patients diagnosed as positive by novel scheme 97.79 were positive by the conventional scheme of the 205 patients who succumbed to MODS and out of the patients diagnosed as positive for MODS by novel scheme 3 days prior to succumbing, 79.52% were positive by the conventional scheme. The results of the present study demonstrated that the novel diagnostic scheme using the relevant indexes of pancreatic β‑cell dysfunction for diagnosis of traumatic MODS, was able to diagnose MODS early without excessively extending the diagnostic scope. Its clinical application should be promoted.
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Affiliation(s)
- Zhan-Ke Wang
- Department of Clinical Laboratory, The 94th Hospital of People's Liberation Army, Nanchang, Jiangxi 330002, P.R. China
| | - Rong-Jian Chen
- Department of General Surgery, The 94th Hospital of People's Liberation Army, Nanchang, Jiangxi 330002, P.R. China
| | - Shi-Liang Wang
- Department of Burns, Third Military Medical University, Chongqing 400038, P.R. China
| | - Guang-Wei Li
- Department of Endocrinology, China‑Japan Friendship Hospital, Beijing 100029, P.R. China
| | - Zhong-Zhen Zhu
- Department of Clinical Laboratory, The 94th Hospital of People's Liberation Army, Nanchang, Jiangxi 330002, P.R. China
| | - Qiang Huang
- Trauma Emergency Center, The 94th Hospital of People's Liberation Army, Nanchang, Jiangxi 330002, P.R. China
| | - Zi-Li Chen
- Department of Intensive Medicine, The 94th Hospital of People's Liberation Army, Nanchang, Jiangxi 330002, P.R. China
| | - Fan-Chang Chen
- Department of General Surgery, The 94th Hospital of People's Liberation Army, Nanchang, Jiangxi 330002, P.R. China
| | - Lei Deng
- Department of Neurosurgery, The 94th Hospital of People's Liberation Army, Nanchang, Jiangxi 330002, P.R. China
| | - Xiao-Peng Lan
- Department of Clinical Laboratory, Fuzhou General Hospital of Nanjing Military Region, Fuzhou, Fujian 350025, P.R. China
| | - Tian Hu
- Department of Wound Healing and Cell Biology Laboratory, Institute of Basic Medical Science, Trauma Centre of Postgraduate Medical School, Chinese People's Liberation Army General Hospital, Beijing 100853 P.R. China
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