Predictors of mortality of trauma patients admitted to the ICU: a retrospective observational study☆

Impact of nutritional screening on mortality and intensive care unit length of stay

Background

Nutritional assessment is a fundamental part of the treatment of patients hospitalized in the ICU, allowing the implementation of interventions appropriate to the identified requirements. Since the risk of malnutrition is a modifiable factor, its correct management can positively influence hospital evolution. This study aims to test the impact of the incorporation of nutritional screening and assessment on mortality and length of stay in patients hospitalized in an Intensive Care Unit in Cali, Colombia, during the years 2019 and 2021-2022.

Methods

This is a historical cohort epidemiological study where one cohort consisted of 114 patients who received a standard nutritional screening (interpretation of body mass index and its clinical impression). The other cohort of 630 patients was those exposed to screening with the Malnutrition Universal Screening Tool (MUST) scale. Hematological, clinical, and nutritional variables were considered and their relationship with adverse events, length of hospital stay, and discharge status.

Results

There were significant differences between the two cohorts (p < 0.001), with increased mortality and length of hospital stay in patients who received standard nutritional screening without MUST. Furthermore, there was a greater presence of enteral support, diarrhea, anemia, leukocytosis, and lymphopenia in this cohort.

Conclusion

Implementing the MUST screening method and specific nutritional interventions resulted in a significant improvement in patient mortality figures. In addition, the predictive mortality model revealed that emesis and leukopenia increased the probability of death.

Management of Patients Suffering Acute Traumatic Brain Injuries

The objective of this literature review was to examine and summarize knowledge of best practices for the management of patients suffering traumatic brain injury based on studies using a variety of practices to improve outcomes published 2018 - 2021. From a clinical perspective, when a patient suffers an acute traumatic brain injury, providers and clinicians ask themselves and each other, "What else could we do? What could we have tried to improve the outcome with this patient?" Astute clinicians spend ample time reviewing contemporary studies to improve their patients' outcomes. This project aimed not to find all studies about a specific treatment, but to review all studies about a topic to evaluate the studies for rigor and results to improve bedside patient care in times of crisis. A quality assessment model was used in four domains: design, bias, synthesis, and dissemination with a Quality Assessment Score assigned for each of the four domains. Ten studies met the rigor of the quality assessment evaluation. The highest ranked studies indicate a common theme of prevention of extension of injury.

Predictors of mortality for blunt trauma patients in intensive care: A retrospective cohort study

Background

Major trauma places substantial demand on critical care services, is a leading cause of death in under 40-year-olds and causes significant morbidity and mortality across all age groups. Various factors influence patient outcome and predefining these could allow prognostication. The aim of this study was to identify predictors of mortality from major trauma in intensive care.

Methods

This was a retrospective study of adult trauma patients admitted to general intensive care between January 2018 and December 2019. We assessed the impact on mortality of patient demographics, patterns of injury, injury scores (Glasgow Coma Score (GCS), Charlson's comorbidity index (CCI), Acute Physiology and Health Evaluation II (APACHE II), Injury Severity Score (ISS) and Probability of Survival Score (Ps19)), number of surgeries and mechanism of injury using logistic regression.

Results

A total of 414 patients were included with a median age of 54 years (IQR 34-72). Overall mortality was 18.6%. The most common mechanism of injury was traffic collision (46%). Non-survivors were older, had higher ISS scores with lower GCS on admission and lower probability of survival scores. Factors independently predictive of mortality were age 70-80 (OR 3.267, p = 0.029), age >80 (OR 27.043, p < 0.001) and GCS < 15 (OR 8.728, p < 0.001). Ps19 was the best predictor of mortality (p <0.001 for each score category), with an AUROC of 0.90.

Conclusions

The significant mortality predictors were age, fall from <2 metres, injury of head or limbs, GCS <15 and Ps19. Contrary to previous studies, CCI and APACHE II did not significantly predict mortality. Although Ps19 was found to be the best current prognostic score, trauma prognostication would benefit from a single validated scoring system incorporating both physiological variables and injury patterns.

Prolonged time to recovery and its predictors among trauma patients admitted to the intensive care units in comprehensive specialized hospitals in Northwest Ethiopia: a multicenter retrospective follow-up study, 2022

Introduction

A prolonged time to recovery in the intensive care units has adverse effects on both the patients and the healthcare providers. However, there is limited evidence in African countries, including Ethiopia. Therefore, this study aimed to assess the time to recovery and its predictors among trauma patients admitted to intensive care units.

Methods

An institutional-based retrospective follow-up study was conducted on trauma patients hospitalized in intensive care units between 9 January 2019 and 8 January 2022. The charts of 450 patients were chosen using a simple random sampling technique. Data collection was conducted using smartphones and tablets. The data were then exported into STATA version 16 for analysis. The log-rank test and the Kaplan-Meier survival curve were fitted for analysis. An adjusted hazard ratio with 95% confidence intervals was reported to declare the strength of association between time to recovery and predictors in the multivariable Weibull regression analysis.

Results

The overall incidence density rate of recovery was 6.53 per 100 person-day observations, with a median time to recovery of 10 days. Significant predictors of time to recovery included being on mechanical ventilation (AHR = 0.47, 95% CI: 0.34, 0.64), having a Glasgow Coma Scale (GCS) score between 9-12 and 13-15 (AHR = 1.58, 95% CI: 1.01, 2.47, and AHR = 1.66, 95% CI: 1.09, 2.53, respectively), experiencing polytrauma (AHR = 0.55, 95% CI: 0.39, 0.78), and having complications (AHR = 0.43, 95% CI: 0.31, 0.59).

Conclusion and recommendations

The incidence rate of recovery for trauma patients is lower than the national standard, and the median time to recovery is longer. Being on mechanical ventilation, mild and moderate GCS scores, polytrauma, and the presence of complications were significantly associated with prolonged time to recovery. Therefore, special attention has to be given to trauma patients who had polytrauma, complications, received mechanical ventilation, and had a lower GCS score.

Comparative Evaluation of Mortality Predictors in Trauma Patients: A Prospective Single-center Observational Study Assessing Injury Severity Score Revised Trauma Score Trauma and Injury Severity Score and Acute Physiology and Chronic Health Evaluation II Scores

Aim

This prospective cohort study aimed to compare the predictive accuracy of outcome (survival/death) among trauma patients using various prognostic scores.

Methods

Over 3 months, 240 trauma patients in a tertiary care hospital were assessed for demographic details, trauma characteristics, vital signs, Glasgow coma scale, arterial blood gas values, and lab markers. Injury severity score (ISS), revised trauma score (RTS), trauma and injury severity score (TRISS), and acute physiology and chronic health evaluation II (APACHE II) were applied at admission, 24 hours, and 48 hours post-admission.

Results

Road traffic accidents (55.83%) were the primary cause of trauma, followed by falls (33.75%) and violence (10.41%). The all-cause mortality rate was 23.33%, with 34.16% requiring ICU admission. Head injuries (65.83%) were both the most frequent injury site and cause of mortality.

Conclusion

Analysis indicated that APACHE II outperformed other scores in predicting outcomes, with ISS following closely. The study concludes that trauma severity correlates with ICU admission and mortality, emphasizing APACHE II as a superior predictor, particularly for traumatic brain injuries leading to ICU admission and mortality.

Clinical significance

This study contributes to the existing body of knowledge by addressing the gap in comparing prognostic abilities among scoring systems for trauma patients. The unexpected superiority of APACHE II suggests its potential as a valuable tool in predicting outcomes in this specific patient population.

How to cite this article

Gupta J, Kshirsagar S, Naik S, Pande A. Comparative Evaluation of Mortality Predictors in Trauma Patients: A Prospective Single-center Observational Study Assessing Injury Severity Score Revised Trauma Score Trauma and Injury Severity Score and Acute Physiology and Chronic Health Evaluation II Scores. Indian J Crit Care Med 2024;28(5):475-482.

Time to recovery and its predictors following traumatic injuries among injured victims in Dessie Comprehensive Specialized Hospital, North East of Ethiopia, 2022: a retrospective follow-up study

BACKGROUND

Injuries are an extremely important public health problem worldwide. Despite being largely preventable and despite government efforts, injuries continue to be a major public health issue. Thus, the study tends to evaluate the time to recovery and its predictors for traumatic injuries.

METHODS

A hospital-based retrospective follow-up study was used. A total of 329 medical charts were actually reviewed. Traumatic injury victims from January 1, 2018-December 31, 2022 were included, and a simple random sampling technique was utilized. The data was gathered by reviewing medical charts. Data was coded and entered into Epi-Data Manager version 4.6.0.4 statistical software and further analyzed using STATA version 17. Descriptive statistics were performed to see the frequency distribution of variables. A Kaplan-Meier survival estimate and log rank test were performed to plot the overall survival curve and compare the difference in recovery among predictor categories, respectively. A model fitness test was done by using the Cox-Snell residual test and Harrell's C concordance statistic. Finally, a Cox proportional hazard model was fitted to determine the effect of predictors on recovery time from traumatic injuries.

RESULTS

The median time to recovery of traumatic injuries was 5 days (IQR: 3-10 days), with an overall incidence density of 8.77 per 100 person-days of observation. In the multivariable cox proportional regression model, variables such as being male (AHR: 0.384, 95%CI: 0.190-0.776, P-value: 0.008), the Glasgow coma scale of 13-15 (AHR: 2.563, 95%CI: 1.070-6.139, P-value: 0.035), intentional injury (AHR: 1.934, 95%CI: 1.03-3.632, P-value: 0.040), mild traumatic brain injury (AHR: 2.708, 95%CI: 1.095-6.698, P-value: 0.031), and moderate traumatic brain injury (AHR: 2.253, 95%CI: (1.033-4.911, P-value: 0.041) were statistically significant variables.

CONCLUSIONS

The median recovery time for traumatically injured respondents was 5 days. Independent predictors such as the Glasgow coma scale, time taken for surgical management, intent of injury, and traumatic brain injury were statistically significant with time to recovery from trauma.

[Therapeutic and diagnostic complex in intestinal failure syndrome in patients with closed abdominal trauma]

Currently, severe combined abdominal trauma ranks third among all causes of mortality In Russia, second only to cardiovascular and oncologic diseases. In the period from 2019 to 2020 in our country, a slight decrease in traumatism is noted due to a decrease in the number of traffic accidents as the main cause of combined and multiple trauma. The number of abdominal injuries from the total number of injuries In Russian regions ranges from 1.5 to 36.5% and is accompanied by a high level of disability (25-80% in combined trauma and 5-8% in isolated trauma). Despite modern medical advances, lethality in combined trauma of abdominal organs varies from 10.7 to 69.7%, with closed abdominal trauma accounting for up to 6% of fatal outcomes.

OBJECTIVE

Improving treatment outcomes in patients with closed abdominal trauma through comprehensive diagnosis of SCN and optimization of enteral therapy in patients with closed abdominal trauma.

MATERIAL AND METHODS

The study included 40 patients (29 (72.5%) men and 11 (27.5%) women), who underwent examination and treatment at the State Budgetary Institution "Research Institute of SP. Im. N.V. Sklifosovsky Research Institute of St. Petersburg State Medical Center with the diagnosis: Closed abdominal trauma. The age of the patients varied from 25 to 81 years (Mean age was 49.6±13.1). To evaluate the effectiveness of intensive therapy, the patients were divided into 2 groups: the comparison group (n=26) included patients who were treated with complex conservative therapy. Patients of the main group (n=14) conservative therapy was supplemented with the use of ER to restore the functional activity of the intestine under the control of ultrasound and assessment of the degree of intra-abdominal hypertension, as well as with Intestamine to stimulate the intestinal trauma.

RESULTS

In the course of the study it was found that, as a result of complex enteral therapy in the patients of the main group, starting from the 7th day of stay in the ORIT, positive dynamics was observed, consisting in a statistically significant decrease in the levels of lactate, ALT, AST, LDH, and CRP. By the 14th day there was also a statistically significant decrease in leukocyte and PCT levels. The lethality in the main group amounted to 7.2%, n=1. At the same time, in patients of the comparison group only by the 7th day there was a decrease in concentration of CRP (p=0.065), by the 10th day - ALT (<0.001) and by the 14th day there was a decrease in leukocytes level (p=0.038). Lethality in this group amounted to 23.1%, n=6.

CONCLUSION

Timely initiation of pathogenetic enteral therapy contributes to faster normalization of clinical and laboratory parameters, protection of intestinal barrier function, prevention of complications associated with bacterial translocation and bacterial overgrowth syndrome, increase in immunoresistance of the organism.

[Enteral therapy in patients with blunt abdominal trauma]

OBJECTIVE

To improve the outcomes in ICU patients with blunt abdominal trauma via enteral therapy by saline enteral solution.

MATERIAL AND METHODS

A retrospective and prospective study included 24 patients (18 (75%) men and 6 (25%) women) with blunt abdominal trauma who underwent examination and treatment at the Sklifosovsky Research Institute for Emergency Care. Age of patients ranged from 38 to 81 years (mean 50.1±13.6).

RESULTS

Enteral therapy was followed by normalization of serum lactate, alanine aminotransferase and aspartate aminotransferase after 3 days. There were significant differences in decrease of lactate dehydrogenase, alanine aminotransferase and C-reactive protein. In the control group, these parameters decreased only by the 10th day.

CONCLUSION

Inclusion of saline enteral solution into the complex therapy contributes to earlier recovery of gastrointestinal function and prevents compartment syndrome. These aspects reduced the number of patients with multiple organ failure.

Glasgow Coma Scale Versus Physiologic Scoring Systems in Predicting the Outcome of ICU admitted Trauma Patients; a Diagnostic Accuracy Study

Introduction

There is no consensus on the performance of decision rules in predicting the prognosis of trauma patients. Therefore, the present study aimed to compare the value of Glasgow coma scale (GCS) and physiologic scoring systems in predicting mortality and poor outcome of trauma patients.

Methods

This diagnostic accuracy study was conducted on multiple trauma patients admitted to the intensive care units of two hospitals in Tehran, Iran, from 21 November 2020 to 22 May 2021. The patients' demographic characteristics, length of stay in the intensive care unit (ICU), the vital signs, and the GCS on admission were recorded. Finally, the mortality, disability, and complete recovery of patients at the time of discharge were evaluated and receiver operating characteristics (ROC) curve analysis was used to compare the performance of physiologic scoring systems with GCS.

Results

200 trauma patients with the mean age of 43.53±19.84 years were evaluated (74% male). The area under the ROC curve for New Trauma Score (NTS), Revised Trauma Score (RTS), Worthing Physiological Scoring System (WPSS), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), Glasgow Coma Scale, Age, and Systolic Blood Pressure score (GAPS) ,Glasgow coma scale (GCS) in prediction of mortality were 0.95, 0.95, 0.83, 0.89, 0.91, 0.84, 0.77, 0.97, and 0.98 respectively. The performance of GCS was statistically superior to RTS (P=0.005), WPSS (P=0.0001), RAPS (P=0.0002), REMS (P=0.002), MEWS (P<0.0001), and NEWS (P<0.0001). However, the performance of GCS, NTS (P=0.146), and GAPS (P=0.513) were not significantly different. Also, in prediction of poor outcomes, the AUC of GCS (0.98) was significantly higher than RTS (0.95), RAPS (0.85), REMS (0.85), MEWS (0.84), NEWS (0.77), and WPSS (0.75).

Conclusion

The GCS score seems to be a better instrument to predict mortality and poor outcome in trauma patients compared to other tools due to its high accuracy, wide application, and easy calculation.

Estimating the time point for nutritional failure in patients suffering from acute brain attacks in the intensive care unit

BACKGROUND

Severe brain attack patients demonstrate hypermetabolic state and gastrointestinal dysfunction, leading to faster onset of nutritional failure.

AIM

To estimate the time point where the development of nutritional failure is more probable among patients with acute brain attacks in the intensive care unit (ICU).

METHODS

Direct bedside observation for selected nutritional parameters was performed. When enteral nutrition was initiated, observation was performed at five points over 9 days.

FINDINGS

84 patients with 55% mortality risk and on mechanical ventilation were included. Over the observation period, gastric residual volume increased (144 ml vs 196 ml), body weight decreased (79.4 kg vs 74.3 kg), and serum albumin reduced (3.6 g/dl to 3.1 g/dl). Caloric attainment and malnutrition score deteriorated, and feeding-related complications increased. Nutritional failure was evidently prevalent between the third and fifth day of observation.

CONCLUSION

An earlier period of enteral nutrition entails higher probability of nutritional failure among severe brain attack patients in the ICU.