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Pape HC, Starr AJ, Gueorguiev B, Wanner GA. The role of big data management, data registries, and machine learning algorithms for optimizing safe definitive surgery in trauma: a review. Patient Saf Surg 2024; 18:22. [PMID: 38902828 PMCID: PMC11191186 DOI: 10.1186/s13037-024-00404-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 05/28/2024] [Indexed: 06/22/2024] Open
Abstract
Digital data processing has revolutionized medical documentation and enabled the aggregation of patient data across hospitals. Initiatives such as those from the AO Foundation about fracture treatment (AO Sammelstudie, 1986), the Major Trauma Outcome Study (MTOS) about survival, and the Trauma Audit and Research Network (TARN) pioneered multi-hospital data collection. Large trauma registries, like the German Trauma Registry (TR-DGU) helped improve evidence levels but were still constrained by predefined data sets and limited physiological parameters. The improvement in the understanding of pathophysiological reactions substantiated that decision making about fracture care led to development of patient's tailored dynamic approaches like the Safe Definitive Surgery algorithm. In the future, artificial intelligence (AI) may provide further steps by potentially transforming fracture recognition and/or outcome prediction. The evolution towards flexible decision making and AI-driven innovations may be of further help. The current manuscript summarizes the development of big data from local databases and subsequent trauma registries to AI-based algorithms, such as Parkland Trauma Mortality Index and the IBM Watson Pathway Explorer.
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Affiliation(s)
- Hans-Christoph Pape
- Department of Trauma Surgery, University Hospital of Zurich, Raemistr. 100, Zurich, 8091, Switzerland.
| | - Adam J Starr
- Department of Orthopaedic Surgery, Parkland Memorial Hospital, University of Texas Southwestern, 4900 Harry Hines Blvd, Dallas, TX, 75235, USA
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstr. 8, Davos, 7270, Switzerland
| | - Guido A Wanner
- Department of Spine & Trauma Surgery, Bethanien Hospital, Toberlstr. 51, Zurich, 8044, Switzerland
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Kalbas Y, Heining SM, Kaiser A, Klingebiel FKL, Pfeifer R, Wanner GA, Pape HC. Fracture fixation in polytraumatized patients-From an interdisciplinary early total/appropriate care to the safe definitive surgery concept. Front Med (Lausanne) 2024; 11:1362986. [PMID: 38707191 PMCID: PMC11069308 DOI: 10.3389/fmed.2024.1362986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/18/2024] [Indexed: 05/07/2024] Open
Abstract
The strategies for the timing of fracture fixation in polytrauma patients have changed with improvements in resuscitation and patient assessment. Specifically, the criteria for damage control have been formulated, and more precise parameters have been found to determine those patients who can safely undergo primary definitive fixation of major fractures. Our current recommendations are supported by objective and data-based criteria and development groups. Those were validated and compared to existing scores. This review article introduces the concept of "safe definitive surgery" and provides an update on the parameters used to clear patients for timely fixation of major fractures.
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Affiliation(s)
- Yannik Kalbas
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sandro-Michael Heining
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Anne Kaiser
- Department of Anesthesia, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Roman Pfeifer
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Guido A. Wanner
- Department of Spine and Trauma Surgery, Bethanien Hospital, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Li H, Chen J, Xing X, Lou D. Association of lactate detection with in-hospital mortality in critically ill patients with acute myocardial infarction: a retrospective cohort study. BMJ Open 2023; 13:e069129. [PMID: 37085300 PMCID: PMC10124257 DOI: 10.1136/bmjopen-2022-069129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
Abstract
OBJECTIVES To assess the associations of lactate level or lactate clearance at different time points with in-hospital mortality in critically ill patients with acute myocardial infarction (AMI). DESIGN A cohort study. SETTING The Medical Information Mart for Intensive Care III database. PARTICIPANT 490 AMI patients. INTERVENTION None. PRIMARY AND SECONDARY OUTCOME MEASURES In-hospital mortality of patients. RESULTS In total, 120 (24.49%) patients died at the end of follow-up. After adjusting for confounders, increased risk of in-hospital mortality in patients with AMI was observed in those with high lactate level (24 hours) (HR=1.156, 95%CI: 1.002 to 1.333). Increased lactate clearance (24 hours) was correlated with a decreased risk of in-hospital mortality in patients with AMI (HR=0.995, 95% CI: 0.994 to 0.997). The area under the curves (AUCs) of lactate level (24 hours) and lactate clearance (24 hours) were 0.689 (95% CI: 0.655 to 0.723) and 0.672 (95% CI: 0.637 to 0.706), respectively. The AUC of lactate level (24 hours) and lactate clearance (24 hours) was higher than lactate level (baseline). CONCLUSIONS Increased lactate level (24 hours) was associated with an elevated risk of in-hospital mortality in patients with AMI and increased lactate clearance (24 hours) was correlated with a decreased risk of in-hospital mortality in patients with AMI despite the age and genders.
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Affiliation(s)
- Hongwu Li
- Department of Cardiology, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, China
| | - Jingyi Chen
- Emergency Department, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xinyue Xing
- Emergency Department, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Danfei Lou
- Emergency Department, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Pape HC, Moore EE, McKinley T, Sauaia A. Pathophysiology in patients with polytrauma. Injury 2022; 53:2400-2412. [PMID: 35577600 DOI: 10.1016/j.injury.2022.04.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/13/2022] [Indexed: 02/02/2023]
Abstract
The pathophysiology after polytrauma represents a complex network of interactions. While it was thought for a long time that the direct and indirect effects of hypoperfusion are most relevant due to the endothelial permeability changes, it was discovered that the innate immune response to trauma is equally important in modifying the organ response. Recent multi center studies provided a "genetic storm" theory, according to which certain neutrophil changes are activated at the time of injury. However, a second hit phenomenon can be induced by activation of certain molecules by direct organ injury, or pathogens (damage associated molecular patterns, DAMPS - pathogen associated molecular patterns, PAMPS). The interactions between the four pathogenetic cycles (of shock, coagulopathy, temperature loss and soft tissue injuries) and cross-talk between coagulation and inflammation have also been identified as important modifiers of the clinical status. In a similar fashion, overzealous surgeries and their associated soft tissue injury and blood loss can induce secondary worsening of the patient condition. Therefore, staged surgeries in certain indications represent an important alternative, to allow for performing a "safe definitive surgery" strategy for major fractures. The current review summarizes all these situations in a detailed fashion.
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Affiliation(s)
- H-C Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - E E Moore
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Aurora, CO, USA.
| | - T McKinley
- Department of Orthopaedics, Indiana University, 200 Hawkins Dr, Iowa City, IA 52242, USA.
| | - A Sauaia
- Schools of Public Health and Medicine, University of Colorado, Aurora, Colorado, USA.
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Identification of RAGE and OSM as New Prognosis Biomarkers of Severe Pneumonia. Can Respir J 2022; 2022:3854191. [PMID: 35035643 PMCID: PMC8759921 DOI: 10.1155/2022/3854191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/17/2021] [Indexed: 11/17/2022] Open
Abstract
Objective To investigate efficiency of RAGE and OSM as new prognosis biomarkers of severe pneumonia. Methods Eligible patients were classified into hypoxemia and nonhypoxemia groups. Meanwhile, the same cohort was divided into survival and nonsurvival groups after a post-hospital stay of 30 days. We analyzed risk factors for the hypoxia and death among these patients. Results Compared with nonsurvival group, significant increase was noticed in PH, lymphocyte, albumin and platelet level in survival group, while significant decline was noticed in neutrophils, RBC, hemoglobin, hematocrit, creatinine, total bilirubin, CRP, PCT, OSM, RAGE and neutrophils/lymphocyte level. Oxygenation index level was related to APACHE II, LIS, SOFA, NUTRIC score, WBC, neutrophils, lymphocyte, RAGE, and albumin level (p < 0.05). LIS, SOFA, NUTRIC score, lac, lymphocyte, platelet, BUN, total bilirubin, PCT, and OSM levels were associated with mortality rate (p < 0.05). Conclusions RAGE and OSM may serve as a new biomarker for poor prognosis in pneumonia patients.
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Beni CE, Arbabi S, Robinson BRH, O'Keefe GE. Acute intensive care unit resuscitation of severely injured trauma patients: Do we need a new strategy? J Trauma Acute Care Surg 2021; 91:1010-1017. [PMID: 34347741 PMCID: PMC9009679 DOI: 10.1097/ta.0000000000003373] [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] [Indexed: 11/25/2022]
Abstract
BACKGROUND Unlike recent advances in blood product resuscitation, intravenous crystalloid (IVF) use after intensive care unit (ICU) admission in hemorrhagic shock has received less attention and current recommendations are based on limited evidence. To address this knowledge gap, we aimed to determine associations between IVF administration during acute ICU resuscitation and outcomes. We hypothesized that larger IVF volumes are associated with worse outcomes. METHODS We linked our trauma registry with electronic health record data (2012-2015) to identify adults with an initial lactate level of ≥4 mmol/L and documented lactate normalization (≤2 mmol/L), excluding those with isolated head Abbreviated Injury Scale score ≥3. We focused on the period from ICU admission to lactate normalization, analyzing duration, volume of IVF, and proportion of volume as 1-L boluses. We used linear regression to determine associations with ICU length of stay and duration of mechanical ventilation in survivors, and logistic regression to identify associations with acute kidney injury and home discharge while adjusting for important covariates. RESULTS We included 337 subjects. Median time to lactate normalization was 15 hours (interquartile range, 7-25 hours), and median IVF volume was 3.7 L (interquartile range, 1.5-6.4 L). The fourfold difference between the upper and lower quartiles of both duration and volume remained after stratifying by injury severity. Hourly volumes tapered over time but persistently aggregated at 0.5 and 1 L, with 167 subjects receiving at least one 0.5-L bolus for 6 hours after ICU admission. Administration of larger volumes was associated with longer ICU length of stay and duration of mechanical ventilation, as well as acute kidney injury. CONCLUSION There is substantial variation in volume administered during acute ICU resuscitation, both absolutely and temporally, despite accounting for injury severity. Administration of larger volumes during acute ICU resuscitation is associated with worse outcomes. There is an opportunity to improve outcomes by further investigating and standardizing this important phase of care. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Affiliation(s)
- Catherine E Beni
- From the Department of Surgery (C.E.B., S.A., B.R.H.R., G.E.O.) and Harborview Injury Prevention and Research Center (S.A., B.R.H.R., G.E.O.), Harborview Medical Center, University of Washington, Seattle, Washington
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DSouza D, Sunny A, Sima R, Ashwath G, Rozario AP. Lactate Measurement in Critically Injured—Prognostic Importance. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02551-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Lee SG, Song J, Park DW, Moon S, Cho HJ, Kim JY, Park J, Cha JH. Prognostic value of lactate levels and lactate clearance in sepsis and septic shock with initial hyperlactatemia: A retrospective cohort study according to the Sepsis-3 definitions. Medicine (Baltimore) 2021; 100:e24835. [PMID: 33607851 PMCID: PMC7899836 DOI: 10.1097/md.0000000000024835] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 01/25/2021] [Indexed: 01/05/2023] Open
Abstract
The 2016 Surviving Sepsis Campaign guidelines suggest guiding resuscitation to normalize lactate levels in patients with sepsis-associated hyperlactatemia as a marker of tissue hypoperfusion. This study evaluated the prognostic value of lactate levels and lactate clearance for 30-day mortality in patients with sepsis and septic shock diagnosed in the emergency department.We performed a retrospective cohort study of sepsis patients with initial lactate levels of ≥2 mmol/L. All patients met the Sepsis-3 definitions. The prognostic value of 6-hour lactate levels, 6-hour lactate clearance, 6-hour lactate metrics (≥2 mmol/L), and lactate clearance metrics (<10%, <20%, and <30%) was evaluated. We compared the sensitivity and specificity between metrics.Of the 363 sepsis and septic shock patients, 148 died (30-day mortality: 40.8%). Nonsurvivors had significantly higher 6-hour lactate levels and lower 6-hour lactate clearance than those of survivors. Six-hour lactate levels and 6-hour lactate clearance were associated with 30-day mortality after adjusting for potential confounders (odds ratio, 1.191 [95% confidence interval (CI), 1.097-1.294] and 0.989 [0.983-0.995], respectively). Six-hour lactate levels had better prognostic value than 6-hour lactate clearance (area under the curve, 0.720 [95% CI, 0.670-0.765] vs 0.656 [0.605-0.705]; P = .02). Six-hour lactate levels of ≥3.5 mmol/L and 6-hour lactate clearance of <24.4% were the optimal cut-off value in predicting the 30-day mortality. The prognostic value of 6-hour lactate metrics and 6-hour lactate clearance metrics did not differ. Six-hour lactate levels (≥2 mmol/L) had the highest sensitivity (89.2%).Six-hour lactate levels proved to be more accurate in predicting 30-day mortality than 6-hour lactate clearance and initial lactate levels.
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Affiliation(s)
| | | | - Dae Won Park
- Division of Infectious Diseases, Department of Internal Medicine
| | | | | | | | | | - Jae Hyung Cha
- Medical Science Research Center, Korea University Ansan Hospital, Ansan, Republic of Korea
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Clinical Utility of Delta Lactate for Predicting Early In-Hospital Mortality in Adult Patients: A Prospective, Multicentric, Cohort Study. Diagnostics (Basel) 2020; 10:diagnostics10110960. [PMID: 33212827 PMCID: PMC7697598 DOI: 10.3390/diagnostics10110960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/12/2020] [Accepted: 11/16/2020] [Indexed: 12/23/2022] Open
Abstract
One of the challenges in the emergency department (ED) is the early identification of patients with a higher risk of clinical deterioration. The objective is to evaluate the prognostic capacity of ΔLA (correlation between prehospital lactate (pLA) and hospital lactate (hLA)) with respect to in-hospital two day mortality. We conducted a pragmatic, multicentric, prospective and blinded-endpoint study in adults who consecutively attended and were transported in advanced life support with high priority from the scene to the ED. The corresponding area under the receiver operating characteristics curve (AUROC) was obtained for each of the outcomes. In total, 1341 cases met the inclusion criteria. The median age was 71 years (interquartile range: 54–83 years), with 38.9% (521 cases) females. The total 2 day mortality included 106 patients (7.9%). The prognostic precision for the 2 day mortality of pLA and hLA was good, with an AUROC of 0.800 (95% CI: 0.74–0.85; p < 0.001) and 0.819 (95% CI: 0.76–0.86; p < 0.001), respectively. Of all patients, 31.5% (422 cases) had an ΔLA with a decrease of <10%, of which a total of 66 patients (15.6%) died. A lactate clearance ≥ 10% is associated with a lower risk of death in the ED, and this value could potentially be used as a guide to determine if a severely injured patient is improving in response to the established treatment.
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Prognostic Value of Serum Lactate Levels in Critically Ill Patients in an Intensive Care Unit. ACTA ACUST UNITED AC 2020; 6:59-64. [PMID: 32104732 PMCID: PMC7029407 DOI: 10.2478/jccm-2020-0005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/29/2020] [Indexed: 12/03/2022]
Abstract
Introduction The patient in critical condition, regardless of the cause of admission, continues to be a challenge for health systems due to the high mortality that it reports. There is a need to identify some marker of early obtaining, easy to interpret and with high relevance in the prognosis of these patients. Objective To determine the prognostic value of serum lactate in an Intensive Care Unit (ICU). Method One hundred and forty-five patients admitted to an ICU were enrolled in the study. The Acute Physiology and Chronic Health Evaluation II (APACHE) prognosis score, Sequential Organ Failure Assessment, hemodynamic support need, mechanical ventilation, cause of admission, stay in ICU, analytical and physiological variables were determined. The probability of survival of patients who had elevated and normal serum lactate levels was calculated. The risk of dying was determined using the Cox regression model. Results Twenty-eight patients died (19%) in the ICU. The serum lactate value was higher in the group of patients with trauma, infections, APACHE II and high creatinine levels; as well as with decreased mean arterial blood pressure, need for hemodynamic support and mechanical ventilation. The survival capacity was higher in patients who had normal serum lactate. Serum lactate was the sole independent predictor of mortality (AHR 1.28 [1.07-1.53], p = 0.008). Conclusions Patient assessment through the determination of serum lactate levels provides useful information in the initial evaluation of the critical patient.
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Halvachizadeh S, Baradaran L, Cinelli P, Pfeifer R, Sprengel K, Pape HC. How to detect a polytrauma patient at risk of complications: A validation and database analysis of four published scales. PLoS One 2020; 15:e0228082. [PMID: 31978109 PMCID: PMC6980592 DOI: 10.1371/journal.pone.0228082] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 01/07/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction Early accurate assessment of the clinical status of severely injured patients is crucial for guiding the surgical treatment strategy. Several scales are available to differentiate between risk categories. They vary between expert recommendations and scores developed on the basis of patient data (level II). We compared four established scoring systems in regard to their predictive abilities for early (e.g., hemorrhage-induced mortality) versus late (Multiple Organ Failure (MOF), sepsis, late death) in-hospital complications. Methods A database from a level I trauma center was used. The inclusion criteria implied an injury severity score (ISS) of ≥16 points, primary admission, and a complete data set from admission to hospital-day 21. The following four scales were tested: the clinical grading scale (CGS; covers acidosis, shock, coagulation, and soft tissue injuries), the modified clinical grading scale (mCGS; covers CGS with modifications), the polytrauma grading score (PTGS; covers shock, coagulation, and ISS), and the early appropriate care protocol (EAC; covers acid–base changes). Admission values were selected from each scale and the following endpoints were compared: mortality, pneumonia, sepsis, death from hemorrhagic shock, and multiple organ failure. Statistics Shapiro-Wilk test for normal distribution, Pearson Chi square, odds ratios (OR) for all endpoints, 95% confidence intervals. Fitted, generalized linear models were used for prediction analysis. Krippendorff was used for comparison of CGS and mCGS. Alpha set at 0.05. Results In total, 3668 severely injured patients were included (mean age, 45.8±20 years; mean ISS, 28.2±15.1 points; incidence of pneumonia, 19.0%; incidence of sepsis, 14.9%; death from hem. shock, 4.1%; death from multiple organ failure (MOF), 1.9%; mortality rate, 26.8%). Our data show distinct differences in the prediction of complications, including mortality, for these scores (OR ranging from 0.5 to 9.1). The PTGS demonstrated the highest predictive value for any late complication (OR = 2.0), sepsis (OR = 2.6, p = 0.05), or pneumonia (OR = 2.0, p = 0.2). The EAC demonstrated good prediction for hemorrhage-induced early mortality (OR = 7.1, p<0.0001), but did not predict late complications (sepsis, OR = 0.8 and p = 0.52; pneumonia, OR = 1.1 and p = 0.7) CGS and mCGS are not comparable and should not be used interchangeably (Krippendorff α = 0.045). Conclusion Our data show that prediction of complications is more precise after using values that covers different physiological systems (coagulation, hemorrhage, acid–base changes, and soft tissue damage) when compared with using values of only one physiological system (e.g., acidosis). When acid–base changes alone were tested in terms of complications, they were predictive of complications within 72 hours but failed to predict late complications. These findings should be considered when performing early assessment of trauma patients or for the development of new scores.
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Affiliation(s)
- Sascha Halvachizadeh
- Department of Trauma, UniversitätsSpital Zürich, Zürich, Switzerland
- Harald Tscherne Laboratory, Department of Trauma, University Zurich, University Hospital Zurich, Zurich, Switzerland
- * E-mail:
| | - Larissa Baradaran
- Department of Trauma, UniversitätsSpital Zürich, Zürich, Switzerland
| | - Paolo Cinelli
- Department of Trauma, UniversitätsSpital Zürich, Zürich, Switzerland
- Harald Tscherne Laboratory, Department of Trauma, University Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, UniversitätsSpital Zürich, Zürich, Switzerland
- Harald Tscherne Laboratory, Department of Trauma, University Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Kai Sprengel
- Department of Trauma, UniversitätsSpital Zürich, Zürich, Switzerland
- Harald Tscherne Laboratory, Department of Trauma, University Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, UniversitätsSpital Zürich, Zürich, Switzerland
- Harald Tscherne Laboratory, Department of Trauma, University Zurich, University Hospital Zurich, Zurich, Switzerland
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Pape HC, Halvachizadeh S, Leenen L, Velmahos GD, Buckley R, Giannoudis PV. Timing of major fracture care in polytrauma patients - An update on principles, parameters and strategies for 2020. Injury 2019; 50:1656-1670. [PMID: 31558277 DOI: 10.1016/j.injury.2019.09.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Sustained changes in resuscitation and transfusion management have been observed since the turn of the millennium, along with an ongoing discussion of surgical management strategies. The aims of this study are threefold: a) to evaluate the objective changes in resuscitation and mass transfusion protocols undertaken in major level I trauma centers; b) to summarize the improvements in diagnostic options for early risk profiling in multiply injured patients and c) to assess the improvements in surgical treatment for acute major fractures in the multiply injured patient. METHODS I. A systematic review of the literature (comprehensive search of the MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases) and a concomitant data base (from a single Level I center) analysis were performed. Two authors independently extracted data using a pre-designed form. A pooled analysis was performed to determine the changes in the management of polytraumatized patients after the change of the millennium. II. A data base from a level I trauma center was utilized to test any effects of treatment changes on outcome. INCLUSION CRITERIA adult patients, ISS > 16, admission < less than 24 h post trauma. Exclusion: Oncological diseases, genetic disorders that affect the musculoskeletal system. Parameters evaluated were mortality, ICU stay, ICU complications (Sepsis, Pneumonia, Multiple organ failure). RESULTS I. From the electronic databases, 5141 articles were deemed to be relevant. 169 articles met the inclusion criteria and a manual review of reference lists of key articles identified an additional 22 articles. II. Out of 3668 patients, 2694 (73.4%) were male, the mean ISS was 28.2 (SD 15.1), mean NISS was 37.2 points (SD 17.4 points) and the average length of stay was 17.0 days (SD 18.7 days) with a mean length of ICU stay of 8.2 days (SD 10.5 days), and a mean ventilation time of 5.1 days (SD 8.1 days). Both surgical management and nonsurgical strategies have changed over time. Damage control resuscitation, dynamic analyses of coagulopathy and lactate clearance proved to sharpen the view of the worsening trauma patient and facilitated the prevention of further complications. The subsequent surgical care has become safer and more balanced, avoiding overzealous initial surgeries, while performing early fixation, when patients are physiologically stable or rapidly improving. Severe chest trauma and soft tissue injuries require further evaluation. CONCLUSIONS Multiple changes in management (resuscitation, transfusion protocols and balanced surgical care) have taken place. Moreover, improvement in mortality rates and complications associated with several factors were also observed. These findings support the view that the management of polytrauma patients has been substantially improved over the past 3 decades.
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Affiliation(s)
- H-C Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - S Halvachizadeh
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - L Leenen
- Department of Trauma, University Medical Centre Utrecht, Suite G04.228, Heidelberglaan 100, 3585 GA, Utrecht, the Netherlands.
| | - G D Velmahos
- Dept. of Trauma, Emergency Surgery and Critical Care, Harvard University, Mass. General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - R Buckley
- Section of Orthopedic Trauma, University of Calgary, Foothills Medical Center, 0490 McCaig Tower, 3134 University Drive NW Calgary, Alberta, T2N 5A1, Canada.
| | - P V Giannoudis
- Trauma & Orthopaedic Surgery, Clarendon Wing, A Floor, Great George Street, Leeds General Infirmary University Hospital, University of Leeds, Leeds, LS1 3EX, UK.
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Martín-Rodríguez F, López-Izquierdo R, Castro Villamor MA, Mangas IM, Del Brío Ibáñez P, Delgado Benito JF, Martín Conty JL, Manzanares JÁ, Mayo-Iscar A, Del Pozo Vegas C. Prognostic value of lactate in prehospital care as a predictor of early mortality. Am J Emerg Med 2018; 37:1627-1632. [PMID: 30471934 DOI: 10.1016/j.ajem.2018.11.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/25/2018] [Accepted: 11/18/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Prehospital Emergency Medical Services must attend to patients with complex physiopathological situations with little data and in the shortest possible time. The objective of this work was to study lactic acid values and their usefulness in the prehospital setting to help in clinical decision-making. STUDY DESIGN We conducted a longitudinal prospective, observational study on patients over 18 years of age who, after being evaluated by the Advanced Life Support Unit, were taken to the hospital between April and June 2018. We analyzed demographic variables, prehospital lactic acid values and early mortality (<30 days). The area under the curve of the receiver operating characteristic was calculated for the prehospital value of lactic acid. RESULTS A total of 279 patients were included in our study. The median age was 68 years (interquartile range: 54-80 years). Overall 30-day mortality was 9% (25 patients). The area under the curve for lactic acid to predict overall mortality at 30 days of care was 0.82 (95% CI: 0.76-0.89). The lactate value with the best sensitivity and specificity overall was 4.25 mmol/L with a sensitivity of 84% (95% CI: 65.3-93.6) and specificity of 70% (95% CI: 65.0-76.1). CONCLUSIONS The level of lactic acid can be a complementary tool in the field of prehospital emergencies that will guide us early in the detection of critical patients.
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Affiliation(s)
- Francisco Martín-Rodríguez
- Advanced Clinical Simulation Center, Department of Medicine, Dermatology and Toxicology, Faculty of Medicine, University of Valladolid, Avda. Ramón y Cajal, 7, 47005 Valladolid, Spain; Prehospital Emergency Medical Services, Advanced Medical Life Support, SACYL, Castilla y León, Spain.
| | - Raúl López-Izquierdo
- Emergency Department, Rio Hortega University Hospital of Valladolid, SACYL, Spain.
| | - Miguel A Castro Villamor
- Advanced Clinical Simulation Center, Department of Medicine, Dermatology and Toxicology, Faculty of Medicine, University of Valladolid, Avda. Ramón y Cajal, 7, 47005 Valladolid, Spain
| | | | | | - Juan F Delgado Benito
- Prehospital Emergency Medical Services, Advanced Medical Life Support, SACYL, Castilla y León, Spain
| | - José L Martín Conty
- Faculty of Occupational Therapy, Speech Therapy and Nursing, University of Castilla la Mancha, Talavera de la Reina, Toledo, Spain
| | | | - Agustín Mayo-Iscar
- Department of Statistics and Operative Research, Faculty of Medicine, University of Valladolid, Spain
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