Increasing BMI is associated with higher mortality, worsening outcomes and highly specific injury patterns following trauma: A multi-institutional analysis of 191,274 patients

Evaluation of an Association Between Enoxaparin Dose per Estimated Blood Volume and Clinically Relevant Bleeding in Low-Weight Trauma Patients

BACKGROUND

The optimal dosing for enoxaparin venous thromboembolism (VTE) prophylaxis in low-weight trauma patients is unknown. Estimated blood volume (EBV) has shown promise as a dose modifier.

OBJECTIVE

To characterize the association of enoxaparin dose per EBV with the prevalence of VTE and bleeding in low-weight trauma patients.

METHODS

This was a retrospective study of trauma patients admitted over a 4-year period. Included patients were adults weighing <60 kg who received a minimum of 3 consecutive doses of enoxaparin. The primary endpoint was a comparison of enoxaparin dose per EBV in patients experiencing bleeding and VTE. Secondary endpoints included comparisons of dose per body mass index (BMI) and total body weight (TBW) and the ability of dose per EBV to predict clinical endpoints. Subgroup analyses for patients weighing <50 kg were performed for all endpoints.

RESULTS

A total of 189 patients were included. Statistical comparisons for VTE were not performed because of low prevalence. The dose of enoxaparin per EBV was not statistically different between patients who did and did not bleed in all analyses. Doses per BMI and TBW were also not statistically different between the groups. In patients weighing <50 kg, numerically higher doses per EBV, BMI, and TBW were noted in patients that bled versus those that did not. Enoxaparin dose per EBV was not a statistically significant predictor of bleeding in logistic regression models.

CONCLUSION AND RELEVANCE

No significant associations between enoxaparin dose per EBV, BMI, or TBW and bleeding were noted in the study. Future analyses of EBV and other dose modifiers should consider inclusion of patients weighing <50 kg.

HYPERGLYCEMIA IN NON-DIABETIC ADULT TRAUMA PATIENTS IS ASSOCIATED WITH WORSE OUTCOMES THAN DIABETIC PATIENTS: AN ANALYSIS OF 95,764 PATIENTS

INTRODUCTION

The adverse impact of acute hyperglycemia is well documented but its specific effects on non-diabetic trauma patients are unclear. The purpose of this study was to analyze the differential impact of hyperglycemia on outcomes between diabetic and non-diabetic trauma inpatients.

METHODS

Adults admitted 2018-19 to 46 Level I/II trauma centers with >2 blood glucose tests (BGT) were analyzed. Diabetes status was determined from ICD-10, trauma registry and/or HbA1c >6.5. Patients with and without >1 hyperglycemic result >180 mg/dL were compared. Logistic regression examined the effects of hyperglycemia and diabetes on outcomes, adjusting for age, gender, ISS & BMI.

RESULTS

There were 95,764 patients: male 54%, mean age 61, mean ISS 10, diabetic 21%. Patients with hyperglycemia had higher mortality and worse outcomes compared to those without hyperglycemia. Non-diabetic hyperglycemic patients had the highest odds of mortality (Diabetic: aOR: 3.11, 95% CI: 2.8-3.5, Non-diabetics aOR: 7.5, 95% CI: 6.8-8.4). Hyperglycemic non-diabetics experienced worse outcomes on every measure when compared to non-hyperglycemic non-diabetics, with higher rates of sepsis (1.1 vs 0.1%, P < .001), more SSIs (1.0 vs 0.1%, P < .001), longer mean hospital LOS (11.4 vs. 5.0, P < .001), longer mean ICU LOS (8.5 vs. 4.0, P < .001), higher rates of ICU use (68.6% vs. 35.1), and more ventilator use (42.4% vs. 7.3%).

CONCLUSIONS

Hyperglycemia is associated with increased odds of mortality in both diabetic and non-diabetic patients. Hyperglycemia during hospitalization in non-diabetics was associated with the worst outcomes and represents a potential opportunity for intervention in this high-risk group.

LEVEL OF EVIDENCE

Level II (therapeutic/care management).

The Association of Body Mass Index and Outcomes in Adult Patients with Chest Wall Injuries

BACKGROUND

Thoracic injury secondary to rib fractures following motor vehicle collisions (MVCs) significantly contribute to morbidity and mortality. While obesity has reached epidemic proportions, little is known regarding how BMI impacts outcomes in MVCs. The aim of this study was to examine how BMI impacts outcomes in MVC patients with rib fractures.

METHODS

The ACS-TQIP Database was utilized to evaluate adult MVC patients with ≥3 rib fractures. Patients with a non-thoracic AIS ≥3 were excluded, to focus on chest injuries. Patients were sorted according to the presence or absence of flail chest injuries and BMI into groups with a low (<15), intermediate (15-24), or severe (≥25) ISS.

RESULTS

Overweight and obese patients in the non-flail cohort had decreased odds of pneumothorax in all ISS groups (P < 0.05). Overweight (P = 0.049) and obese (P = 0.011) patients in the low ISS non-flail cohort had decreased odds of splenic laceration. In the non-flail cohort, obese patients with a low and intermediate ISS had decreased odds of pulmonary contusion (P < 0.01). Obese patients in the low and intermediate ISS non-flail cohorts had increased odds of PE (P < 0.05). In both the flail and non-flail cohorts, obese patients with an intermediate ISS had decreased odds of liver laceration (P < 0.05), as well as a longer HLOS, ICU-LOS, and mechanical ventilation time (P < 0.01).

CONCLUSION

Obesity affects associated injuries, complications, and hospital outcomes in a complex way after MVC related chest wall trauma. Thus, the effect of BMI should be taken into consideration when assessing and treating obese MVC trauma patients.