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Nordham KD, Tatum D, Attia AS, Patel MB, Paramesh A, Duchesne JC, Nahmias J, Maiga AW, Peetz AB, Udekwu PO, Stiles A, Shell C, Stodghill JD, Maghsoudi T, Iacullo E, McLafferty B, Coonan E, Boudreau RM, Zimmerman SA, Shammassian B, Egodage T, Aramento I, Morris P, Metheny J, Farrell MS, Painter MD, McCabe OT, Spadafore P, Wong DTW, Serrano J, Sciarretta JD, Kim P, Hayton R, Gonzales D, Murry J, Meadows K, Jacobson LE, Williams JM, Bernard AC, Smith B, Morrissey SL, Patel N, Tabello D, Teicher E, Chowdhury SM, Ahmad F, Marcos BS, West MA, Jacome TH, Davis G, Marks JA, Rattigan D, Haan JM, Lightwine K, Matsushima K, Park S, Santos A, Shrestha K, Sawyer R, VandenBerg S, Jean RJ, Hicks RC, Lueckel S, Bugaev N, Abosena W, Alvarez C, Lieser MJ, McDonald H, Dumas RP, Fitzgerald CA, Terzian WTH, Tian Y, Mousafeiris V, Mulita F, Berne JD, Mederos DR, Smith AA, Taghavi S. Impact of catastrophic brain injury guidelines on organ donation rates: Results of an EAST multicenter trial. J Trauma Acute Care Surg 2024:01586154-990000000-00812. [PMID: 39327646 DOI: 10.1097/ta.0000000000004386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
BACKGROUND One third of organ donors suffer catastrophic brain injury (CBI). There are no standard guidelines for the management of traumatic CBI prior to brain death, and not all trauma centers have institutional CBI guidelines. In addition, there is high variability in management between institutions with guidelines. Catastrophic brain injury guidelines vary and may include various combinations of hormone therapy, vasopressors, fluid resuscitation, and other practices. We hypothesized that centers with CBI guidelines have higher organ donation rates than those without. METHODS This prospective, observational EAST-sponsored multicenter trial included adult (18+ years old) traumatic-mechanism CBI patients at 33 level I and II trauma centers from January 2022 to May 2023. Catastrophic brain injury was defined as a brain injury causing loss of function above the brain stem and subsequent death. Cluster analysis with linear mixed-effects model including UNOS regions and hospital size by bed count was used to determine whether CBI guidelines are associated with organ donation. RESULTS A total of 790 CBI patients were included in this analysis. In unadjusted comparison, CBI guideline centers had higher rates of organ donation and use of steroids, whole blood, and hormone therapy. In a linear mixed-effects model, CBI guidelines were not associated with organ donation. Registered organ donor status, steroid hormones, and vasopressin were associated with increased relative risk of donation. CONCLUSION There is high variability in management of CBI, even at centers with CBI guidelines in place. While the use of institutional CBI guidelines was not associated with increased organ donation, guidelines in this study were not identical. Hormone replacement with steroids and vasopressin was associated with increased donation. Hormone resuscitation is a common feature of CBI guidelines. Further analysis of individual practices that increase organ donation after CBI may allow for more effective guidelines and an overall increase in donation to decrease the long waiting periods for organ transplant recipients. LEVEL OF EVIDENCE Prognostic; Level III.
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Affiliation(s)
- Kristen D Nordham
- From the Department of Surgery (K.D.N., D. Tatum, A.P., J.C.D., A.S.A., E.I., B.M., E.C., S.T.), Tulane University School of Medicine, New Orleans, Louisiana; Department of Surgery (K.D.N.), Harbor-UCLA Medical Center, Torrance, California; Department of Surgery (M.B.P., A.W.M., A.B.P.), Vanderbilt University Medical Center, Nashville, Tennessee; Department of Surgery (J.N., C.A.), University of California-Irvine, Orange, California; Department of Surgery (P.O.U., A. Stiles, C.S.), Wake Med, Raleigh, North Carolina; Department of Surgery (J.D. Stodghill, T.M.), Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Surgery (R.M.B., S.A.Z., B. Shammassian, A.A.S.), Louisiana State University Health, New Orleans, Louisiana;Department of Surgery (T.E., I.A., P.M., J. Metheny), Cooper Medical School of Rowan University, Camden, New Jersey; Department of Surgery (M.S.F., M.D.P.), Lehigh Valley Health Network, Allentown, Pennsylvania; Department of Surgery (O.T.M., P.S.), Valleywise Health Medical Center, Phoenix, Arizona; Department of Surgery (D.T.-W.W., J.S.), Arrowhead Regional Medical Center, Colton, California; Department of Surgery (J.D. Sciarretta, P.K.), Emory University School of Medicine, Atlanta, Georgia; Department of Surgery (R.H., D.G.), Loma Linda University Medical Center, Loma Linda, California; Department of Surgery (J. Murry, K. Meadows), UT Health Tyler, Tyler, Texas; Department of Surgery (L.E.J., J.M.W.), Ascension St. Vincent Hospital, Indianapolis, Indiana; Department of Surgery (A.C.B.), University of Kentucky Healthcare, Lexington, Kentucky;17 DeBusk College of Osteopathic Medicine (B. Smith), Lincoln Memorial University, Harrogate, Tennessee; Department of Surgery (S.L.M., N.P.), Conemaugh Memorial Medical Center, Johnstown, Pennsylvania; Department of Surgery (D. Tabello, E.T.), Inova Health System, Falls Church, Virginia; Department of Surgery (S.M.C., F.A.), King Saud Medical City, Riyadh, Saudi Arabia;Department of Surgery (B.S.M., M.A.W.), University of Minnesota, Minneapolis, Minnesota;22 Department of Surgery (T.H.J., G.D.), Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana;23 Department of 'Surgery (J.A.M., D.R.), Thomas Jefferson University Hospital, Philadelphia, Pennsylvania;24 Department of Surgery (J.M.H., K.L.), Ascension Via Christi Hospitals Wichita, Wichita, Kansas;25 Department of Surgery (K. Matsushima, S.P.), Los Angeles General Medical Center, Los Angeles, California; Department of Surgery (A. Santos, K.S.), Texas Tech University Health Science Center; Department of Surgery (C.B.), Covenant Medical Center, Lubbock, Texas; Department of Surgery (R.S., S.V.), Bronson Methodist Hospital, Kalamazoo, Michigan; Department of Surgery (R.J.J., R.C.H.), College of Medicine Chattanooga, University of Tennessee, Chattanooga, Tennessee; Department of Surgery (S.L.), Warren Alpert Medical School at Brown University, Providence, Rhode Island; Department of Surgery (N.B., W.A.), Tufts Medical Center, Boston, Massachusetts; Department of Surgery (M.J.L., H.M.), Research Medical Center, Kansas City, Missouri; Department of Surgery (R.P.D., C.A.F.), University of Texas Southwestern Medical Center, Dallas, Texas; Department of Surgery (C.A.F.), Brody School of Medicine at East Carolina, Greenville, North Carolina; Department of Surgery (W.T.H.T., Y.T.), University of Nebraska Medical Center, Omaha, Nevada; Department of Surgery (V.M., F.M.), U General University Hospital of Patras, Pio, Greece; and Department of Surgery (J.D.B., D.R.M.), Broward Health Medical Center, Fort Lauderdale, Florida
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Hu GW, Lang HL, Guo H, Wu L, Zhang P, Kuang W, Zhu XG. A risk score based on admission characteristics to predict progressive hemorrhagic injury from traumatic brain injury in children. Eur J Pediatr 2017; 176:689-696. [PMID: 28343321 DOI: 10.1007/s00431-017-2897-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 03/14/2017] [Accepted: 03/21/2017] [Indexed: 10/19/2022]
Abstract
UNLABELLED Traumatic brain injury (TBI) is one of the leading causes of death and disability in children, and progressive hemorrhagic injury (PHI) post TBI is associated with poor outcomes. Therefore, the objective of this study was to develop and validate a prognostic model that uses the information available at admission to determine the likelihood of PHI occurrence after TBI in children. The identified demographic data, cause of injury, clinical predictors on admission, computed tomography scan characteristics, and routine laboratory parameters were collected and used to develop a PHI prognostic model with logistic regression analysis, and the prediction model was validated in 68 children. Eight independent prognostic factors were identified: lower Glasgow coma scale score (3 ~ 8) (6 points), intra-axial bleeding/brain contusion (4 points), midline shift ≥5 mm (9 points), platelets <100 × 109/L (11 points), prothrombin time >14 s (6 points), international normalized ratio >1.25 (7 points), D-dimer ≥5 mg/L (14 points), and glucose ≧10 mmol/L (11 points). We calculated risk scores for each child and defined three risk groups: low risk (0-16 points), intermediate risk (17-36 points), and high risk (37-68 points). In the development cohort, the PHI rates after TBI for the low-, intermediate-, and high-risk groups were 10.1, 47.9, and 84.2%, respectively. In the validation cohort, the corresponding PHI rates were 10.9, 47.5, and 85.4%, respectively. The C-statistic for the point system was 0.873 (p = 0.586 by the Hosmer-Lemeshow test) in the development cohort and 0.877 (p = 0.524 by the Hosmer-Lemeshow test) in the validation cohort. CONCLUSION Using admission predictors, we developed a relatively simple risk score that accurately predicted the risk of PHI after TBI in children. What is Known: • TBI is one of the leading causes of death and disability in children, and PHI post TBI is associated with poor outcomes. •Prediction of patients at low risk of PHI could help reduce treatment costs, whereas identification of patients at high risk of PHI could direct early medical intervention to improve outcomes. What is New: • This study firstly developed a risk score system by assessing the admission information that could provide an earlier prediction of the occurrence of PHI after acute TBI in children.
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Affiliation(s)
- Guo-Wen Hu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Hai-Li Lang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Hua Guo
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Lei Wu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Pei Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Wei Kuang
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Xin-Gen Zhu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China.
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Folkerson LE, Sloan D, Cotton BA, Holcomb JB, Tomasek JS, Wade CE. Predicting progressive hemorrhagic injury from isolated traumatic brain injury and coagulation. Surgery 2015; 158:655-61. [PMID: 26067457 DOI: 10.1016/j.surg.2015.02.029] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 02/17/2015] [Accepted: 02/19/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Progressive hemorrhagic injury (PHI) in traumatic brain injury (TBI) patients is associated with poor outcomes. Early prediction of PHI is difficult yet vital. We hypothesize that TBI subtype and coagulation would be predictors of PHI. METHODS This was a retrospective analysis of highest level activation adult trauma patients with evidence of TBI (head Abbreviated Injury Scale ≥3). Coagulopathy was determined using rapid thrombelastography (r-TEG), complete blood counts, and conventional coagulation tests obtained on arrival. Patients were dichotomized into PHI and stable groups based on head computerized CT. Subtypes of TBI included subdural hematoma, intraparenchymal contusions (IPC), subarachnoid hemorrhage, epidural hematoma, and combined. Data are reported as median values with interquartile range (IQR). Multivariate logistic regression was used to assess the effect of subtype and coagulation on PHI. RESULTS We included 279 isolated TBI patients who met study criteria. There were 157 patients (56%) who experienced PHI; 122 (44%) were stable on repeat CT. Patients with PHI were older, had fewer hospital-free days, and higher mortality (all P < .001). No differences were noted in r-TEG parameters between groups; however, coagulopathy and age were independent predictors of progression in all subtypes (odds ratio [OR], 1.81; 95% CI, 1.09-3.01 [P = .021]; OR, 1.02, 95% CI, 1.01-1.04 [P = .006]). Controlling for age, Glasgow Coma Scale score, and coagulopathy, patients with IPC were more likely to experience PHI (OR, 4.49; 95% CI, 2.24-8.98; P < .0001). CONCLUSION This study demonstrates that older patients with coagulation abnormalities and IPC on admission are more likely to experience PHI, identifying a target population for earlier therapies.
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Affiliation(s)
- Lindley E Folkerson
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, University of Texas Health Science Center, Houston, TX.
| | - Duncan Sloan
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - Bryan A Cotton
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - John B Holcomb
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - Jeffrey S Tomasek
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, University of Texas Health Science Center, Houston, TX
| | - Charles E Wade
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX; Department of Surgery, University of Texas Health Science Center, Houston, TX
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