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Borazjani R, Mahmudi-Azer S, Taghrir MH, Homaeifar R, Dabiri G, Paydar S, Fard HA. Adjunctive hemoperfusion with Resin Hemoadsorption (HA) 330 cartridges improves outcomes in patients sustaining multiple Blunt Trauma: a prospective, quasi-experimental study. BMC Surg 2023; 23:148. [PMID: 37270595 DOI: 10.1186/s12893-023-02056-w] [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: 02/06/2023] [Accepted: 05/25/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Multi-organ dysfunction syndrome and multi-organ failure are the leading causes of late death in patients sustaining severe blunt trauma. So far, there is no established protocol to mitigate these sequelae. This study assessed the effect of hemoperfusion using resin-hemoadsorption 330 (HA330) cartridges on mortality and complications such as acute respiratory distress syndrome (ARDS) and systemic inflammatory response syndrome (SIRS) among such patients. METHODS This quasi-experimental study recruited patients ≥ 15 years of age with blunt trauma, injury severity score (ISS) ≥ 15, or initial clinical presentation consistent with SIRS. They were divided into two groups: the Control group received only conventional acute care, while the case group received adjunctive hemoperfusion. P-values less than 0.05 were statistically significant. RESULTS Twenty-five patients were included (Control and Case groups: 13 and 12 patients). The presenting vital signs, demographic and injury-related features (except for thoracic injury severity) were similar (p > 0.05). The Case group experienced significantly more severe thoracic injuries than the Control group (Thoracic AIS, median [IQR]: 3 [2-4] vs. 2 [0-2], p = 0.01). Eleven and twelve patients in the Case group had ARDS and SIRS before the hemoperfusion, respectively, and these complications were decreased considerably after hemoperfusion. Meanwhile, the frequency of ARDS and SIRS did not decrease in the Control group. Hemoperfusion significantly reduced the mortality rate in the Case group compared to the Control group (three vs. nine patients, p = 0.027). CONCLUSIONS Adjunctive Hemoperfusion using an HA330 cartridge decreases morbidity and improves outcomes in patients suffering from severe blunt trauma.
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Affiliation(s)
- Roham Borazjani
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Salahaddin Mahmudi-Azer
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Hossein Taghrir
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Homaeifar
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Gholamreza Dabiri
- Department of Intensive Care Medicine, Trauma Research Center, Shahid Rajaee (Emtiaz) Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahram Paydar
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Abdolrahimzadeh Fard
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
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Mortality in polytrauma patients with moderate to severe TBI on par with isolated TBI patients: TBI as last frontier in polytrauma patients. Injury 2022; 53:1443-1448. [PMID: 35067344 DOI: 10.1016/j.injury.2022.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/07/2021] [Accepted: 01/02/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Mortality caused by Traumatic Brain Injury (TBI) remains high, despite improvements in trauma and critical care. Polytrauma is naturally associated with high mortality. This study compared mortality rates between isolated TBI (ITBI) patients and polytrauma patients with TBI (PTBI) admitted to ICU to investigate if concomitant injuries lead to higher mortality amongst TBI patients. METHODS A 3-year cohort study compared polytrauma patients with TBI (PTBI) with AIS head ≥3 (and AIS of other body regions ≥3) from a prospective collected database to isolated TBI (ITBI) patients from a retrospective collected database with AIS head ≥3 (AIS of other body regions ≤2), both admitted to a single level-I trauma center ICU. Patients <16 years of age, injury caused by asphyxiation, drowning, burns and ICU transfers from and to other hospitals were excluded. Patient demographics, shock and resuscitation parameters, multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), and mortality data were collected and analyzed for group differences. RESULTS 259 patients were included; 111 PTBI and 148 ITBI patients. The median age was 54 [33-67] years, 177 (68%) patients were male, median ISS was 26 [20-33]. Seventy-nine (31%) patients died. Patients with PTBI developed more ARDS (7% vs. 1%, p = 0.041) but had similar MODS rates (18% vs. 10%, p = 0.066). They also stayed longer on the ventilator (7 vs. 3 days, p=<0.001), longer in ICU (9 vs. 4 days, p=<0.001) and longer in hospital (24 vs. 11 days, p=<0.001). TBI was the most prevalent cause of death in polytrauma patients. Patients with PTBI showed no higher in-hospital mortality rate. Moreover, mortality rates were skewed towards ITBI patients (24% vs. 35%, p = 0.06). DISCUSSION There was no difference in mortality rates between PTBI and ITBI patients, suggesting TBI-severity as the predominant factor for ICU mortality in an era of ever improving acute trauma care.
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Wu SC, Chen TA, Cheng HT, Chang YJ, Wang YC, Tzeng CW, Hsu CH, Muo CH. Lipid-Free PN is Associated with an Increased Risk of Hyperbilirubinemia in Surgical Critically Ill Patients with Admission Hepatic Disorder: A Retrospective Observational Study. Ther Clin Risk Manag 2021; 17:1001-1010. [PMID: 34548793 PMCID: PMC8449686 DOI: 10.2147/tcrm.s322341] [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: 05/28/2021] [Accepted: 08/26/2021] [Indexed: 11/29/2022] Open
Abstract
Background To evaluate the effect of different PN types on surgical critically ill trauma/acute care surgery patients with hepatic disorders at admission. Methods This is a retrospective study. The PN types included lipid-free, soybean oil/medium-chain triglyceride, olive oil-based, and fish oil-containing PNs. Patients admitted with liver injury or liver surgery, elevated serum AST/ALT level, and elevated serum total bilirubin level were included. The exclusion criteria are as follows: 1) age <18 years, 2) severe liver disease/cirrhosis, 3) received more than one type of PN and 4) serum total bilirubin >4.9 mg/dl at admission. Demographics, severity, comorbidities, blood stream infection, hyperbilirubinemia (total bilirubin > 6.0 mg/dl), and mortality were collected for analysis. We also performed analysis stratified by separated lipid doses (g/kg/day). Results A total of 156 patients were enrolled. There were no demographic differences among groups. The lipid-free group was associated with the highest mortality rate and incidence of hyperbilirubinemia. Compared to the lipid-free group, the olive oil-based group had the lowest risk of hyperbilirubinemia. After being stratified by separated lipid doses, the incidence of hyperbilirubinemia decreased when the lipid dosage increased. Regarding different types of lipids, patients who received more than the median dosage of lipids showed a significantly lower risk of hyperbilirubinemia, except in the fish oil-containing group. Conclusion Our result suggested that lipid-free PN is associated with an increased risk of hyperbilirubinemia in surgical critically ill patients with admission hepatic disorder. Further studies are warranted.
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Affiliation(s)
- Shih-Chi Wu
- School of Medicine, China Medical University, Taichung, Taiwan.,Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan
| | - Te-An Chen
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Han-Tsung Cheng
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Jun Chang
- Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Yu-Chun Wang
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Wei Tzeng
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Hao Hsu
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Hsin Muo
- Management Office for Health Data, China Medical University and Hospital, Taichung, Taiwan
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Lipid-Free Parenteral Nutrition Is Associated with an Increased Risk of Hepatic Dysfunction in Surgical Critically Ill Patients: A Retrospective Observational Study. Healthcare (Basel) 2021; 9:healthcare9091096. [PMID: 34574872 PMCID: PMC8467940 DOI: 10.3390/healthcare9091096] [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: 05/28/2021] [Revised: 07/21/2021] [Accepted: 08/11/2021] [Indexed: 01/03/2023] Open
Abstract
To evaluate the effects of lipid-free parenteral nutrition (PN) and various intravenous fat emulsions (IVFEs) on hepatic function in surgical critically ill trauma/acute care surgery patients. We retrospectively reviewed trauma/acute care surgery patients without admission hepatic disorder that received PN. The PN groups include lipid-free, soybean oil/medium-chain triglyceride, olive oil-based, and fish-oil contained PN. We excluded patients with (1) age <18 years, (2) without surgery, (3) preexisting liver injury/diseases, (4) hyperbilirubinemia at admission, (5) received more than one type of PN, and (6) repeated ICU episodes in the same hospitalization. Hepatic dysfunction was considered as serum total–bilirubin >6.0 mg/dL. The demographics, severity score, comorbidities, blood stream infection, and mortality were collected for analyses. The major outcome is hepatic function. We also performed analyses stratified by separated lipid doses (g/kg/day). A total of 249 patients were enrolled. There were no demographic differences among groups. The lipid-free PN group had a higher incidence of hepatic dysfunction and mortality. Compared to the lipid-free group, the other three IVFEs had significantly lower risks of hepatic dysfunction, while the olive oil-based group had a significantly lower risk of 30 and 90-day mortality. After being stratified by separating lipid doses, the soybean oils showed a decreasing trend of hepatic dysfunction and mortality with increased dosage. Fish oil >0.05 g/kg/day was associated with lower hepatic dysfunction incidences. Our findings suggest that, when compared to IVFEs, surgical critically ill patients with trauma/acute care surgery that received lipid-free PN are associated with an increased risk of hepatic dysfunction. In addition, the olive oil-based group had a significantly lower risk of mortality, while fish oil >0.05 g/kg/day was associated with lower incidences of hepatic dysfunction; however, further studies are warranted.
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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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Acute kidney injury in severely injured patients admitted to the intensive care unit. Mil Med Res 2020; 7:47. [PMID: 33036667 PMCID: PMC7547510 DOI: 10.1186/s40779-020-00277-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 09/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Our objective was to identify possible associations between clinical and laboratory variables and the risk of developing acute kidney injury (AKI) in severely injured patients admitted to the intensive care unit (ICU) for whom creatine kinase (CK) levels were available. METHODS For this retrospective observational study, we analyzed adult trauma patients admitted to the ICU from 2011 to 2015 at Fundación Valle del Lili (FVL) University Hospital. Our primary outcome was the incidence of AKI. Multivariate regression analysis was used to assess risk factors for this outcome. RESULTS A total of 315 patients were included. The trauma mechanisms were blunt (n = 130), penetrating (n = 66) and blast (n = 44) trauma. The median (interquartile range, IQR) of injury severity score (ISS) was 21 (16-29). AKI developed in 75 patients (23.8%). Multivariate regression analysis revealed that the thoracic abbreviated injury scale (AIS) value (median (IQR) in the AKI group: 3 (0-4)), Acute Physiology and Chronic Health Evaluation (APACHE II) score (median (IQR) in the AKI group: 18 (10-27)), CK greater than 5000 U/L, lactic acid concentration at admission, and dobutamine administration were independently associated with AKI. CONCLUSION We found that age, APACHE II score, thoracic trauma, lactic acidosis, and dobutamine administration were independently associated with AKI. Trauma surgeons need to be aware of the increased odds of AKI if one of these factors is identified during the evaluation and treatment of injured patients.
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Shock volume: Patient-specific cumulative hypoperfusion predicts organ dysfunction in a prospective cohort of multiply injured patients. J Trauma Acute Care Surg 2019. [PMID: 29521799 DOI: 10.1097/ta.0000000000001871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Multiply injured patients are at risk of developing hemorrhagic shock and organ dysfunction. We determined how cumulative hypoperfusion predicted organ dysfunction by integrating serial Shock Index measurements. METHODS In this study, we calculated shock volume (SHVL) which is a patient-specific index that quantifies cumulative hypoperfusion by integrating abnormally elevated Shock Index (heart rate/systolic blood pressure ≥ 0.9) values acutely after injury. Shock volume was calculated at three hours (3 hr), six hours (6 hr), and twenty-four hours (24 hr) after injury. Organ dysfunction was quantified using Marshall Organ Dysfunction Scores averaged from days 2 through 5 after injury (aMODSD2-D5). Logistic regression was used to determine correspondence of 3hrSHVL, 6hrSHVL, and 24hrSHVL to organ dysfunction. We compared correspondence of SHVL to organ dysfunction with traditional indices of shock including the initial base deficit (BD) and the lowest pH measurement made in the first 24 hr after injury (minimum pH). RESULTS SHVL at all three time intervals demonstrated higher correspondence to organ dysfunction (R = 0.48 to 0.52) compared to initial BD (R = 0.32) and minimum pH (R = 0.32). Additionally, we compared predictive capabilities of SHVL, initial BD and minimum pH to identify patients at risk of developing high-magnitude organ dysfunction by constructing receiver operator characteristic curves. SHVL at six hours and 24 hours had higher area under the curve compared to initial BD and minimum pH. CONCLUSION SHVL is a non-invasive metric that can predict anticipated organ dysfunction and identify patients at risk for high-magnitude organ dysfunction after injury. LEVEL OF EVIDENCE Prognostic study, level III.
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Eguia E, Cobb AN, Baker MS, Joyce C, Gilbert E, Gonzalez R, Afshar M, Churpek MM. Risk factors for infection and evaluation of Sepsis-3 in patients with trauma. Am J Surg 2019; 218:851-857. [PMID: 30885453 DOI: 10.1016/j.amjsurg.2019.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/01/2019] [Accepted: 03/06/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND We aim to examine the risk factors associated with infection in trauma patients and the Sepsis-3 definition. METHODS This was a retrospective cohort study of adult trauma patients admitted to a Level I trauma center between January 2014 and January 2016. RESULTS A total of 1499 trauma patients met inclusion criteria and 15% (n = 232) had an infection. Only 19.8% (n = 46) of infected patients met criteria for Sepsis-3, with the majority (43%) of infected cases having a Sequential Organ Failure Assessment (SOFA) score greater on admission compared to the time of suspected infection. In-hospital death was 7% vs 9% (p = 0.65) between Sepsis-3 and infected patients, respectively. Risk factors associated with infection were female sex, admission SOFA score, Elixhauser score, and severe injury (P < 0.05). CONCLUSION Patients with trauma often arrive with organ dysfunction, which adds complexity and inaccuracy to the operational definition of Sepsis-3 using changes in SOFA scores. Injury severity score, comorbidities, SOFA score, and sex are risk factors associated with developing an infection after trauma.
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Affiliation(s)
- Emanuel Eguia
- Loyola University Chicago Burn Shock Trauma Research Institute, Maywood, IL, USA; Department of Surgery, Acute Care Surgery Division, Loyola University Chicago, Maywood, IL, USA.
| | - Adrienne N Cobb
- Loyola University Chicago Burn Shock Trauma Research Institute, Maywood, IL, USA; Department of Surgery, Acute Care Surgery Division, Loyola University Chicago, Maywood, IL, USA
| | - Marshall S Baker
- Department of Surgery, Acute Care Surgery Division, Loyola University Chicago, Maywood, IL, USA
| | - Cara Joyce
- Department of Public Health Sciences, Loyola University Chicago, Maywood, IL, USA
| | - Emily Gilbert
- Division of Pulmonary and Critical Care Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Richard Gonzalez
- Loyola University Chicago Burn Shock Trauma Research Institute, Maywood, IL, USA; Department of Surgery, Acute Care Surgery Division, Loyola University Chicago, Maywood, IL, USA
| | - Majid Afshar
- Loyola University Chicago Burn Shock Trauma Research Institute, Maywood, IL, USA; Department of Public Health Sciences, Loyola University Chicago, Maywood, IL, USA; Division of Pulmonary and Critical Care Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Matthew M Churpek
- Division of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL, USA
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Gong H, Sheng X, Xue J, Zhu D. Expression and role of TNIP2 in multiple organ dysfunction syndrome following severe trauma. Mol Med Rep 2019; 19:2906-2912. [PMID: 30720079 DOI: 10.3892/mmr.2019.9893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 11/30/2018] [Indexed: 11/05/2022] Open
Abstract
Severe trauma can result in secondary multiple organ dysfunction syndrome (MODS) and death. Inflammation response and oxidative stress promote the occurrence and development of MODS. TNFAIP3‑interacting protein 2 (TNIP2), which can repress the activation of nuclear factor‑κB (NF‑κB) and may be involved in MODS progression, has not been studied in regards to MODS. The present study aimed to investigate the expression, role and mechanism of TNIP2 in MODS following severe trauma. The expression level of TNIP2 was initially detected in the blood of patients with MODS using reverse transcription‑quantitative polymerase chain reaction and western blot assay. Then, to investigate the role of TNIP2 in MODS, a MODS rat model was conducted by trauma and the model rats were treated with TNIP2‑plasmid (intraperitoneal injection). Blood levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LDH), blood urea nitrogen (BUN), creatine (Cr) and creatine kinase (CK); and tumor necrosis factor α (TNF‑α), high‑mobility group box 1 (HMGB‑1), malondialdehyde (MDA) and total antioxidant capacity (TAC) in the different groups were assessed. In addition, activation of NF‑κB was assessed by detecting the level of phospho‑p65. The results showed that TNIP2 was significantly decreased in the blood of patients with MODS. TNIP2 was also significantly downregulated in the blood and the pulmonary, renal and hepatic tissues of MODS rats. The levels of ALT, AST, LDH, BUN, Cr and CK were markedly increased in the blood of MODS rats, and these increases were inhibited by TNIP2‑plasmid administration. Moreover, blood levels of TNF‑α, HMGB‑1 and MDA were significantly increased in MODS rats, while TAC was notably decreased, and these changes were prevented by TNIP2‑plasmid administration. Furthermore, it was found that activation of NF‑κB induced by MODS was eliminated by TNIP2‑plasmid. In conclusion, the data indicated that TNIP2 is significantly decreased in MODS following severe trauma, and it plays a protective role in MODS development by inhibiting the inflammation response and oxidative stress by preventing NF‑κB activation.
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Affiliation(s)
- Hui Gong
- Department of Emergency Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Xiaomin Sheng
- Department of Emergency Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Jianhua Xue
- Department of Emergency Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Dongbo Zhu
- Department of Emergency Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
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Akaraborworn O, Chaiwat O, Chatmongkolchart S, Chittawatanarat K, Kitsiripant C, Morakul S, Thawitsri T, Wacharasint P, Poopipatpab S, Chau-In W, Kusumaphanyo C. The intensive care unit admission predicting the factors of late complications in trauma patients: A prospective cohort study. ARCHIVES OF TRAUMA RESEARCH 2019. [DOI: 10.4103/atr.atr_46_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Vogel JA, Gannon Sungar W, Boatright D, Ryan J, Murphy B, Loar J, Adams S, Haukoos JS. Denver ED Trauma Organ Failure Score predicts healthcare resource utilization in adult trauma patients. Am J Emerg Med 2018; 37:1108-1113. [PMID: 30219615 DOI: 10.1016/j.ajem.2018.08.073] [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: 02/12/2018] [Revised: 08/23/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Early identification of trauma patients who need specialized healthcare resources may facilitate goal-directed resuscitation and effective secondary triage. OBJECTIVE To estimate associations between Denver Emergency Department (ED) Trauma Organ Failure (TOF) Score and healthcare resource utilization. METHODS Retrospective study of adult trauma patients at Denver Health Medical Center. The outcome was resource utilization including: intensive care unit (ICU) length of stay (LOS), hospital LOS, procedures, and costs. Multivariable regression analyses were used to estimate associations between moderate- or high-risk patients, as determined by the Denver ED TOF Score, and healthcare resource utilization. RESULTS We included 3000 patients with a median age of 42 (IQR 27-56) years, 71% male, median injury severity score 9 (IQR 5-16), and 83% blunt mechanism. Among the cohort, 1379 patients (46%) were admitted to the ICU and 122 (4%) died. The adjusted relative risk for high- and moderate-risk as compared to low risk for number of procedures performed was 2.31 (95% CI 2.07-2.57) and 1.80 (95% CI 1.59-2.03) respectively; ICU LOS was 2.87 (95% CI 2.70-3.05) and 1.71 (95% CI 1.60-1.83) respectively; hospital LOS was 3.33 (95% CI 3.21-3.45) and 1.97 (95% CI 1.90-2.05) respectively. The adjusted geometric mean for high-, moderate-, and low-risk for costs was $48,881 (95% CI $43,799-$54,552), $27,890 (95% CI $25,460-$30,551), and $12,983 (95% CI $12,493-$13,492), respectively. CONCLUSIONS The Denver ED TOF Score predicts healthcare resource utilization, and is a useful bedside tool to identify patients early after injury that are likely to require significant healthcare resources and specialized trauma care.
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Affiliation(s)
- Jody A Vogel
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - W Gannon Sungar
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Dowin Boatright
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jordan Ryan
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Benjamin Murphy
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Jesse Loar
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Sabrina Adams
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Jason S Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA; Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
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Jayaraman SP, Anand RJ, DeAntonio JH, Mangino M, Aboutanos MB, Kasirajan V, Ivatury RR, Valadka AB, Glushakova O, Hayes RL, Bachmann LM, Brophy GM, Contaifer D, Warncke UO, Brophy DF, Wijesinghe DS. Metabolomics and Precision Medicine in Trauma: The State of the Field. Shock 2018; 50:5-13. [PMID: 29280924 PMCID: PMC5995639 DOI: 10.1097/shk.0000000000001093] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Trauma is a major problem in the United States. Mortality from trauma is the number one cause of death under the age of 45 in the United States and is the third leading cause of death for all age groups. There are approximately 200,000 deaths per year due to trauma in the United States at a cost of over $671 billion in combined healthcare costs and lost productivity. Unsurprisingly, trauma accounts for approximately 30% of all life-years lost in the United States. Due to immense development of trauma systems, a large majority of trauma patients survive the injury, but then go on to die from complications arising from the injury. These complications are marked by early and significant metabolic changes accompanied by inflammatory responses that lead to progressive organ failure and, ultimately, death. Early resuscitative and surgical interventions followed by close monitoring to identify and rescue treatment failures are key to successful outcomes. Currently, the adequacy of resuscitation is measured using vital signs, noninvasive methods such as bedside echocardiography or stroke volume variation, and other laboratory endpoints of resuscitation, such as lactate and base deficit. However, these methods may be too crude to understand cellular and subcellular changes that may be occurring in trauma patients. Better diagnostic and therapeutic markers are needed to assess the adequacy of interventions and monitor responses at a cellular and subcellular level and inform clinical decision-making before complications are clinically apparent. The developing field of metabolomics holds great promise in the identification and application of biochemical markers toward the clinical decision-making process.
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Affiliation(s)
- Sudha P Jayaraman
- Department of Surgery, Division of Acute Care Surgical Services, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Rahul J Anand
- Department of Surgery, Division of Acute Care Surgical Services, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Jonathan H DeAntonio
- Department of Surgery, Division of Acute Care Surgical Services, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Martin Mangino
- Department of Surgery, Division of Acute Care Surgical Services, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Michel B Aboutanos
- Department of Surgery, Division of Acute Care Surgical Services, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Vigneshwar Kasirajan
- Department of Surgery, Division of Cardiothoracic Surgery, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Rao R Ivatury
- Department of Surgery, Division of Acute Care Surgical Services, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Alex B Valadka
- Department of Neurosurgery, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Olena Glushakova
- Department of Neurosurgery, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Ronald L Hayes
- Department of Neurosurgery, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
- Center of Innovative Research, Banyan Biomarkers, Inc., Alachua, Florida
| | - Lorin M Bachmann
- Department of Pathology, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Daniel Contaifer
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Urszula O Warncke
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Donald F Brophy
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - Dayanjan S Wijesinghe
- Department of Surgery, Division of Acute Care Surgical Services, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
- da Vinci Center, Virginia Commonwealth University, Richmond, Virginia
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13
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Reduction in Mortality Rates of Postinjury Multiple Organ Dysfunction Syndrome: A Shifting Paradigm? A Prospective Population-Based Cohort Study. Shock 2018; 49:33-38. [DOI: 10.1097/shk.0000000000000938] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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WITHDRAWN: Pulse-induced contour cardiac output (PiCCO) combined with passive leg raising test predicting fluid resuscitation in adult patients with septic shock. Kaohsiung J Med Sci 2017. [DOI: 10.1016/j.kjms.2017.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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15
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Rendy L, Sapan HB, Kalesaran LT. Multiple organ dysfunction syndrome (MODS) prediction score in multi-trauma patients. INTERNATIONAL JOURNAL OF SURGERY OPEN 2017. [DOI: 10.1016/j.ijso.2017.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Effects of insulin combined with ethyl pyruvate on inflammatory response and oxidative stress in multiple-organ dysfunction syndrome rats with severe burns. Am J Emerg Med 2016; 34:2154-2158. [DOI: 10.1016/j.ajem.2016.08.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 08/01/2016] [Accepted: 08/06/2016] [Indexed: 01/08/2023] Open
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17
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Gaski G, Frantz T, Steenburg S, Bell T, McKinley T. Large-magnitude Pelvic and Retroperitoneal Tissue Damage Predicts Organ Failure. Clin Orthop Relat Res 2016; 474:1410-6. [PMID: 26762300 PMCID: PMC4868157 DOI: 10.1007/s11999-015-4676-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pelvic and retroperitoneal trauma is a major cause of morbidity and mortality in multiply injured patients. The Injury Severity Score (ISS) has been criticized for underrepresenting and inaccurately defining mechanical injury. The influence of pelvic injury volume on organ dysfunction and multiple organ failure (MOF) has not been described. Through the use of CT, this investigation sought to precisely define volumes of mechanical tissue damage by anatomic region and examine its impact on organ failure. QUESTIONS/PURPOSES (1) Do patients with MOF have a greater volume of pelvic and retroperitoneal tissue damage when compared with those without MOF? (2) In patients who sustained pelvic trauma, does the magnitude of pelvic injury differ in patients with MOF? (3) Does the magnitude of organ dysfunction correlate with pelvic tissue damage volume? METHODS Seventy-four multiply injured patients aged 18 to 65 years with an ISS ≥ 18 admitted to the intensive care unit for a minimum of 6 days with complete admission CT scans were analyzed. Each identifiable injury in the head/neck, chest, abdomen, and pelvis underwent volumetric determination using CT to generate regional tissue damage volume scores. Primary outcomes were the development of MOF as measured by the Denver MOF score and the degree of organ dysfunction by utilization of the Sequential Organ Failure Assessment (SOFA) score. Mean pelvic and retroperitoneal tissue damage volumes were compared in patients who developed MOF and those who did not develop MOF using Student's t-test. Among patients who sustained pelvic injuries, we compared mean volume of tissue damaged in patients who developed MOF and those who did not. We assessed whether there was a correlation between organ dysfunction, as measured by the SOFA score as a continuous variable, and the volume of pelvic and retroperitoneal tissue damage using the Pearson product-moment correlation coefficient. RESULTS The average volume of tissue damage was greater in patients with MOF when compared with those without (MOF: 685.667 ± 1081.344; non-MOF: 195.511 ± 381.436; mean difference 490.156 cc [95% confidence interval {CI}, 50.076-930.237 cc], p = 0.030). Among patients who sustained pelvic injuries, those with MOF had higher average tissue damage volumes than those without MOF (MOF: 1322.000 ± 1197.050; non-MOF: 382.750 ± 465.005; mean difference 939.250 [95% CI, 229.267-1649.233], p = 0.013). Organ dysfunction (SOFA score) correlated with higher volumes of pelvic tissue damage (r = 0.570, p < 0.001). CONCLUSIONS This investigation demonstrated that greater degrees of pelvic and retroperitoneal tissue damage calculated from injury CT scans in multiply injured patients is associated with more severe organ dysfunction and an increased risk of developing MOF. Early identification of polytrauma patients at risk of MOF allows clinicians to implement appropriate resuscitative strategies early in the disease course. Improved stratification of injury severity and a patient's anticipated clinical course may aid in the planning and execution of staged orthopaedic interventions. Future avenues of study should incorporate the ischemic/hypoperfusion component of pelvic injury in conjunction with the mechanical component presented here for improved stratification of multiply injured patients at higher risk of MOF. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Greg Gaski
- Indiana University Health, Methodist Hospital, Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN USA ,Indiana University Health, Methodist Hospital, Department of Orthopaedic Surgery, Indiana University School of Medicine, 1801 N Senate Boulevard, Suite 535, Indianapolis, IN 46202 USA
| | - Travis Frantz
- Indiana University School of Medicine, Indianapolis, IN USA
| | - Scott Steenburg
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN USA
| | - Teresa Bell
- Department of Surgery, Center for Outcomes Research in Surgery, Indiana School of Medicine, Indianapolis, IN USA
| | - Todd McKinley
- Indiana University Health, Methodist Hospital, Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN USA
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18
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Vogel JA, Newgard CD, Holmes JF, Diercks DB, Arens AM, Boatright DH, Bueso A, Gaona SD, Gee KZ, Nelson A, Voros JJ, Moore EE, Colwell CB, Haukoos JS. Validation of the Denver Emergency Department Trauma Organ Failure Score to Predict Post-Injury Multiple Organ Failure. J Am Coll Surg 2015; 222:73-82. [PMID: 26597706 DOI: 10.1016/j.jamcollsurg.2015.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 10/06/2015] [Accepted: 10/06/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND Early recognition of trauma patients at risk for multiple organ failure (MOF) is important to reduce the morbidity and mortality associated with MOF. The objective of the study was to externally validate the Denver Emergency Department (ED) Trauma Organ Failure (TOF) Score, a 6-item instrument that includes age, intubation, hematocrit, systolic blood pressure, blood urea nitrogen, and white blood cell count, which was designed to predict the development of MOF within 7 days of hospitalization. STUDY DESIGN We performed a prospective multicenter study of adult trauma patients between November, 2011 and March, 2013. The primary outcome was development of MOF within 7 days of hospitalization, assessed using the Sequential Organ Failure Assessment Score. Hierarchical logistic regression analysis was performed to determine associations between the Denver ED TOF Score and MOF. Discrimination was assessed and quantified using a receiver operating characteristics (ROC) curve. The predictive accuracy of the Denver ED TOF score was compared with attending emergency physician estimation of the likelihood of MOF. RESULTS We included 2,072 patients with a median age of 46 years (interquartile range [IQR] 30 to 61 years); 68% were male. The median Injury Severity Score was 9 (IQR 5 to 17), and 88% of patients had blunt mechanism injury. Among participants, 1,024 patients (49%) were admitted to the ICU, and 77 (4%) died. Multiple organ failure occurred in 120 (6%; 95% CI 5% to 7%) patients and of these, 37 (31%; 95% CI 23% to 40%) died. The area under the ROC curve for the Denver ED TOF Score prediction of MOF was 0.89 (95% CI 0.86 to 0.91) and for physician estimation of the likelihood of MOF was 0.78 (95% CI 0.73 to 0.83). CONCLUSIONS The Denver ED TOF Score predicts development of MOF within 7 days of hospitalization. Its predictive accuracy outperformed attending emergency physician estimation of the risk of MOF.
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Affiliation(s)
- Jody A Vogel
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Craig D Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - James F Holmes
- Department of Emergency Medicine, University of California School of Medicine, Sacramento, CA
| | - Deborah B Diercks
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ann M Arens
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO
| | - Dowin H Boatright
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO
| | - Antonio Bueso
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - Samuel D Gaona
- Department of Emergency Medicine, University of California School of Medicine, Sacramento, CA
| | - Kaitlin Z Gee
- Department of Emergency Medicine, University of California School of Medicine, Sacramento, CA
| | - Anna Nelson
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - Jeremy J Voros
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, Denver, CO; Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Christopher B Colwell
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Jason S Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Department of Epidemiology, Colorado School of Public Health, Aurora, CO
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19
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Vogel JA, Seleno N, Hopkins E, Colwell CB, Gravitz C, Haukoos JS. Denver ED Trauma Organ Failure Score outperforms traditional methods of risk stratification in trauma. Am J Emerg Med 2015; 33:1440-4. [PMID: 26254505 DOI: 10.1016/j.ajem.2015.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/01/2015] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Early identification of trauma patients at risk for inhospital mortality may facilitate goal-directed resuscitation and secondary triage to improve outcomes. The objective of this study was to compare prognostic accuracies of the Denver Emergency Department (ED) Trauma Organ Failure (TOF) Score, ED Sequential Organ Failure Assessment (SOFA) score, and ED base deficit and ED lactate for inhospital mortality in adult trauma patients. METHODS Consecutive adult trauma patients from 2005 to 2008 from the Denver Health Trauma Registry were included. Prognostic accuracies of the Denver ED TOF Score, ED SOFA score, ED base deficit, and ED lactate for inhospital mortality were evaluated with receiver operating characteristic curves. RESULTS Of the 4355 patients, the median age was 37 years (interquartile range [IQR], 26-51 years), median Injury Severity Score was 9 (IQR, 4-16), and 81% had blunt mechanisms. In addition, 38% (1670 patients) were admitted to the intensive care unit with a median intensive care unit length of stay of 2.5 days (IQR, 1-8 days), and 3% (138 patients) died. The areas under the receiver operating characteristic curves for the Denver ED TOF, ED lactate, ED base deficit, and ED SOFA were 0.94 (95% confidence interval [CI], 0.94-0.96), 0.88 (95% CI, 0.85-0.91), 0.82 (95% CI, 0.78-0.86), and 0.78 (95% CI, 0.73-0.82), respectively. CONCLUSIONS The Denver ED TOF Score more accurately predicts inhospital mortality in adult trauma patients compared to the ED SOFA score, ED base deficit, or ED lactate. The Denver ED TOF Score may help identify patients early who are at risk for mortality, allowing for targeted resuscitation and secondary triage to improve outcomes.
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Affiliation(s)
- Jody A Vogel
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Nicole Seleno
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO
| | - Emily Hopkins
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO
| | - Christopher B Colwell
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Craig Gravitz
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO
| | - Jason S Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Department of Epidemiology, Colorado School of Public Health, Aurora, CO
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20
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Llompart-Pou J, Talayero M, Homar J, Royo C. Fallo multiorgánico en el paciente con trauma grave. Med Intensiva 2014; 38:455-62. [DOI: 10.1016/j.medin.2014.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 04/27/2014] [Accepted: 05/07/2014] [Indexed: 12/17/2022]
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