Are trauma patients better off in a trauma ICU?

The Magnitude of Change in Serum Phosphate Concentration Is Associated with Mortality in Patients with Severe Trauma

PURPOSE

Previous studies have suggested that serum phosphate concentration is a prognostic factor in critically ill patients. However, the association between changes in serum phosphate levels and prognosis of patients with trauma remains unclear.

MATERIALS AND METHODS

This study included patients with severe trauma who were treated at the emergency department. Delta phosphate (Δ phosphate) was defined as the difference between serum phosphate concentrations measured at baseline and after 24 hours from the initial measurement. Patients were divided into five groups according to their Δ phosphate levels: group I (Δ phosphate <-2 mg/dL), group II (Δ phosphate -2 to -0.5 mg/dL), group III (Δ phosphate -0.5 to 0.5 mg/dL), group IV (Δ phosphate 0.5 to 2 mg/dL), and group V (Δ phosphate ≥2 mg/dL).

RESULTS

Overall, 1905 patients with severe trauma were included in the analysis. The 30-day mortality was the lowest in group III and tended to increase in groups with a larger Δ phosphate in both the positive and negative directions (group I: 13.7%, group II: 6.8%, group III: 4.6%, group IV: 6.6%, and group V: 26.8%). In multivariable analysis with group III as the reference group, the odds ratios (ORs) of mortality were statistically significant in group IV [OR, 1.92; 95% confidence interval (CI), 1.05-3.56] and group V (OR, 5.28; 95% CI, 2.47-11.24).

CONCLUSION

An increase in serum phosphate concentrations 24 hours after the initial measurement could be considered as an independent prognostic factor in patients with severe trauma.

The State of Global Trauma and Acute Care Surgery/Surgical Critical Care

Trauma is a leading cause of morbidity and mortality globally, with a significant burden attributable to the low- and middle-income countries (LMICs), where more than 90% of injury-related deaths occur. Road injuries contribute largely to the economic burden from trauma and are prevalent among adolescents and young adults. Trauma systems vary widely across the world in their capacity of providing basic and critical care to injured patients, with delays in treatment being present at multiple levels at LMICs. Strengthening existing systems by providing cost-effective and efficient solutions can help mitigate the injury burden in LMICs.

Trauma ICU Prevalence Project: the diversity of surgical critical care

Background

Surgical critical care is crucial to the care of trauma and surgical patients. This study was designed to provide a contemporary assessment of patient types, injuries, and conditions in intensive care units (ICU) caring for trauma patients.

Methods

This was a multicenter prevalence study of the American Association for the Surgery of Trauma; data were collected on all patients present in participating centers’ trauma ICU (TICU) on November 2, 2017 and April 10, 2018.

Results

Forty-nine centers submitted data on 1416 patients. Median age was 58 years (IQR 41–70). Patient types included trauma (n=665, 46.9%), non-trauma surgical (n=536, 37.8%), medical (n=204, 14.4% overall), or unspecified (n=11). Surgical intensivists managed 73.1% of patients. Of ICU-specific diagnoses, 57% were pulmonary related. Multiple high-intensity diagnoses were represented (septic shock, 10.2%; multiple organ failure, 5.58%; adult respiratory distress syndrome, 4.38%). Hemorrhagic shock was seen in 11.6% of trauma patients and 6.55% of all patients. The most common traumatic injuries were rib fractures (41.6%), brain (38.8%), hemothorax/pneumothorax (30.8%), and facial fractures (23.7%). Forty-four percent were on mechanical ventilation, and 17.6% had a tracheostomy. One-third (33%) had an infection, and over half (54.3%) were on antibiotics. Operations were performed in 70.2%, with 23.7% having abdominal surgery. At 30 days, 5.4% were still in the ICU. Median ICU length of stay was 9 days (IQR 4–20). 30-day mortality was 11.2%.

Conclusions

Patient acuity in TICUs in the USA is very high, as is the breadth of pathology and the interventions provided. Non-trauma patients constitute a significant proportion of TICU care. Further assessment of the global predictors of outcome is needed to inform the education, research, clinical practice, and staffing of surgical critical care providers.

Level of evidence

IV, prospective observational study.

Incidences and factors associated with perioperative cardiac arrest in trauma patients receiving anesthesia

Purpose

The aim of this study was to determine the incidences and factors associated with perioperative cardiac arrest in trauma patients who received anesthesia for emergency surgery.

Patients and methods

This retrospective cohort study was approved by the medical ethical committee, Faculty of Medicine, Maharaj Nakorn Chiang Mai Hospital, Thailand. Data of 19,683 trauma patients who received anesthesia between January 2007 and December 2016, such as patient characteristics, surgery procedures, anesthesia information, anesthetic drugs, and cardiac arrest outcomes, were analyzed. Data of patients receiving local anesthesia by surgeons or monitoring anesthesia care (MAC) and those with much information missing were excluded. Factors associated with perioperative cardiac arrest were identified using univariate analysis and the multiple regression model. A stepwise algorithm was chosen at a P-value of <0.20 which was selected for multivariate analysis. A P-value of <0.05 was concluded as statistically significant.

Results

The perioperative cardiac arrest in trauma patients receiving anesthesia for emergency surgery was 170.04 per 10,000 cases. Factors associated with perioperative cardiac arrest in trauma patients were as follows: age >65 years (risk ratio [RR] =1.41, CI =1.02–1.96, P=0.039), American Society of Anesthesiologist (ASA) physical status 3 or higher (ASA physical status 3–4, RR =4.19, CI =2.09–8.38, P<0.001; ASA physical status 5–6, RR =21.58, CI =10.36–44.94, P<0.001), sites of surgery (intracranial, intrathoracic, upper intra-abdominal, and major vascular, each P<0.001), cardiopulmonary comorbidities (RR =1.55, CI =1.10–2.17, P=0.012), hemodynamic instability with shock prior to receiving anesthesia (RR =1.60, CI =1.21–2.11, P<0.001), and having a history of alcoholism (RR =5.27, CI =4.09–6.79, P<0.001).

Conclusion

The incidence of perioperative cardiac arrest in trauma patients receiving anesthesia for emergency surgery was very high and correlated with patient’s factors, especially old age and cardiopulmonary comorbidities, a history of drinking alcohol, increased ASA physical status, hemodynamic instability with shock prior to surgery, and sites of surgery such as brain, thorax, abdomen, and the major vascular region. Anesthesiologists and surgeons should be aware of a warning system and a well-equipped track to manage the surgical trauma patients.

Neuro, trauma, or med/surg intensive care unit: Does it matter where multiple injuries patients with traumatic brain injury are admitted? Secondary analysis of the American Association for the Surgery of Trauma Multi-Institutional Trials Committee decompressive craniectomy study

INTRODUCTION

Patients with nontraumatic acute intracranial pathology benefit from neurointensivist care. Similarly, trauma patients with and without traumatic brain injury (TBI) fare better when treated by a dedicated trauma team. No study has yet evaluated the role of specialized neurocritical (NICU) and trauma intensive care units (TICU) in the management of TBI patients, and it remains unclear which TBI patients are best served in NICU, TICU, or general (Med/Surg) ICU.

METHODS

This study is a secondary analysis of The American Association for the Surgery of Trauma Multi-Institutional Trials Committee (AAST-MITC) decompressive craniectomy study. Twelve Level 1 trauma centers provided clinical data and head computed tomography (CT) scans of patients with Glasgow Coma Scale score of 13 or less and CT evidence of TBI. Non-ICU admissions were excluded. Multivariate logistic regression was performed to measure the association between ICU type and survival and calculate the probability of death for increasing Injury Severity Score (ISS). Multiple injuries patients (ISS > 15) with TBI and isolated TBI patients (other Abbreviated Injury Scale score < 3) were analyzed separately.

RESULTS

There were 3641 patients with CT evidence of TBI with 2951 admitted to an ICU. Before adjustment, patient demographics, injury severity, and survival differed significantly by unit type. After adjustment, unit type, age, and ISS remained independent predictors of death. Unit type modified the effect of ISS on mortality. TBI multiple injuries patients admitted to a TICU had improved survival across increasing ISS. Survival for isolated TBI patients was similar between TICU and NICU. Med/surg ICU carried the greatest probability of death.

CONCLUSION

Multiple injuries patients with TBI have lower mortality risk when admitted to a trauma ICU. This survival benefit increases with increasing injury severity. Isolated TBI patients have similar mortality risk when admitted to a neuro ICU compared with a trauma ICU. Med/surg ICU admission carries the highest mortality risk.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Intensive care organisation: Should there be a separate intensive care unit for critically injured patients?

In the last two decennia, the mixed population general intensive care unit (ICU) with a “closed format” setting has gained in favour compared to the specialized critical care units with an “open format” setting. However, there are still questions whether surgical patients benefit from a general mixed ICU. Trauma is a significant cause of morbidity and mortality throughout the world. Major or severe trauma requiring immediate surgical intervention and/or intensive care treatment. The role and type of the ICU has received very little attention in the literature when analyzing outcomes from critical injuries. Severely injured patients require the years of experience in complex trauma care that only a surgery/trauma ICU can provide. Should a trauma center have the capability of a separate specialized ICU for trauma patients (“closed format”) next to its standard general mixed ICU

Risk factors for the mortality of trauma victims in the intensive care unit

OBJECTIVE

To identify the risk factors associated with mortality of trauma victims during hospitalisation in the intensive care unit (ICU).

DESIGN

Prospective cohort.

SETTING

Brazilian ICU specialising in the care of trauma victims.

METHODS

The subjects were divided into two groups: survivors and non-survivors. The variables used to compare the groups included demographic and clinical characteristics and illness/injury severity (Acute Physiology and Chronic Health Evaluation [APACHE II], Simplified Acute Physiology Score [SAPS II], Logistic Organ Dysfunction System [LODS], Injury Severity Score [ISS] and New Injury Severity Score [NISS]). The data were analysed using descriptive and inferential statistics and multiple logistic regression analysis.

RESULTS

The sample consisted of 200 patients (164 males) with a mean age of 40.7 years. The predominant causes of injury were traffic accidents (57.5%) followed by falls (31.0%). The ICU mortality was 19.0%. Logistic regression analysis revealed that one point on the NISS and SAPS II scores increased the risk of death by 6% and 7%, respectively. In contrast, the risk of dying decreased 4% for each day of ICU hospitalisation.

CONCLUSION

Professionals must use the SAPS II and NISS for the early identification of trauma victims at high risk for death especially during the first days of ICU hospitalisation.

Assessing the immune status of critically ill trauma patients by flow cytometry

BACKGROUND

Unintentional injury or trauma remains the leading cause of death among young adults. About one fifth of these trauma patients require care in an intensive care unit (ICU) because of severity of injuries and comorbidities. Patients hospitalized in an ICU are at increased risk for nosocomial infections, such as urinary tract infections, pneumonia, bacteremia, and wound infections. Many of these patients will develop sepsis or septic shock, and some will progress to multiple organ failure and death. The balance between the proinflammatory and counterinflammatory immune response appears to be a driving factor in this progression. At present, there is no proposed method for the timely detection of the immune status in trauma patients, making rational decisions to use immune-altering therapies difficult.

OBJECTIVE

We demonstrate that flow cytometry, with its capabilities to characterize and/or enumerate (a) leukocyte subtypes, (b) leukocyte activation markers, (c) leukocyte-derived cytokines and microvesicles, and (d) leukocyte function is well suited to monitor the immune status of critically ill trauma patients.

METHODS

Information for the review was obtained from the extant literature.

DISCUSSION

We suggest that flow cytometry is a research method that might aid nurse scientists in investigating the immune status of critically ill patients, the recovery status of conditions such as hemorrhagic shock and tissue injury and the relationship between cancer disease progression and symptoms. Therefore, flow cytometry has the potential to broaden nursing research priority areas so that a comprehensive approach to understanding the cellular response is attained.

Medicine versus surgery/anesthesiology intensivists: a retrospective review and comparison of outcomes in a mixed medical-surgical-trauma ICU

BACKGROUND

With various types of complex patients being treated in a mixed medical- surgical- trauma intensive care unit (ICU), we hypothesized that there should be no difference in patient mortality with respect to the core training of the intensivist.

METHODS

We reviewed the cases of all patients admitted to a mixed medical-surgical-trauma ICU at a Canadian university teaching hospital in 2007. Patients were assigned to 1 of 2 treatment groups (internal medicine, surgery/anesthesiology) based on the treating intensivist's training. Our primary outcome was to compare patient mortality in the ICU between the groups. We used generalized estimating equations to determine 10-day mortality after admission to the ICU. A multivariate Cox hazard model was used to determine statistical significance and 95% confidence intervals (CIs) for 11- to 60-day mortality in the ICU.

RESULTS

A total of 961 patients were admitted from January to December, 2007. We found no significant difference between the groups in 10-day mortality (odds ratio 0.73, 95% CI 0.46-1.18, p = 0.20) and 11- to 60-day mortality (hazard ratio 1.43, 95% CI 0.62-3.30, p = 0.40) after admission to the ICU.

CONCLUSION

In a large university trauma centre that operates a mixed medicine- surgical-trauma ICU, there was no significant difference in mortality between patients managed by intensivists with core training in internal medicine and those managed by intensivists with training in surgery/anesthesiology.

Implementation of a protocol facilitates evidence-based physiotherapy practice in intensive care units

OBJECTIVES

To compare the physiotherapy service provided when therapists' decisions are guided by an evidence-based protocol with usual care (i.e. patient management based on therapists' clinical decisions).

DESIGN

Exploratory, controlled, pragmatic sequential time block clinical trial.

SETTING

Level 3 surgical unit in a tertiary hospital in South Africa.

PARTICIPANTS

All patients admitted consecutively to the surgical unit over a 3-month period were allocated to usual or protocol care based on date of admission.

INTERVENTIONS

Usual care was provided by clinicians from the hospital department, and non-specialised physiotherapists were appointed as locum tenens to provide evidence-based protocol care.

MAIN OUTCOME MEASURES

Patient waiting time, frequency of treatment sessions, tasks performed and adverse events.

RESULTS

During protocol-care periods, treatment sessions were provided more frequently (P<0.001) and with a shorter waiting period (P<0.001). It was more likely for a rehabilitation management option to be included in a treatment session during protocol-care periods (odds ratio 2.34, 95% confidence interval 1.66 to 3.43; P<0.001). No difference in the risk of an adverse event was found between protocol-care and usual-care periods (P=0.34).

CONCLUSIONS

Physiotherapy services provided in intensive care units (ICUs) when the decisions of non-specialised therapists are guided by an evidence-based protocol are safe, differ from usual care, and reflect international consensus on current best evidence for physiotherapy in ICUs. Non-specialised therapists can use this protocol to provide evidence-based physiotherapy services to their patients. Future trials are needed to establish whether or not this will improve patient outcome.

The role of neurocritical care: a brief report on the survey results of neurosciences and critical care specialists

BACKGROUND

Neurocritical care is a new subspecialty field in medicine that intersects with many of the neuroscience and critical care specialties, and continues to evolve in its scope of practice and practitioners. The objective of this study was to assess the perceived need for and roles of neurocritical care intensivists and neurointensive care units among physicians involved with intensive care and the neurosciences.

METHODS

An online survey of physicians practicing critical care medicine, and neurology was performed during the 2008 Leapfrog initiative to formally recognize neurocritical care training.

RESULTS

The survey closed in July 2009 and achieved a 13% response rate (980/7524 physicians surveyed). Survey respondents (mostly from North America) included 362 (41.4%) neurologists, 164 (18.8%) internists, 104 (11.9%) pediatric intensivists, 82 (9.4%) anesthesiologists, and 162 (18.5%) from other specialties. Over 70% of respondents reported that the availability of neurocritical care units staffed with neurointensivists would improve the quality of care of critically ill neurological/neurosurgical patients. Neurologists were reported as the most appropriate specialty for training in neurointensive care by 53.3%, and 57% of respondents responded positively that neurology residency programs should offer a separate training track for those interested in neurocritical care.

CONCLUSION

Broad level of support exists among the survey respondents (mostly neurologists and intensivists) for the establishment of neurological critical care units. Since neurology remains the predominant career path from which to draw neurointensivists, there may be a role for more comprehensive neurointensive care training within neurology residencies or an alternative training track for interested residents.

Trauma admissions to the intensive care unit at a reference hospital in Northwestern Tanzania

Background

Major trauma has been reported to be a major cause of hospitalization and intensive care utilization worldwide and consumes a significant amount of the health care budget. The aim of this study was to describe the characteristics and treatment outcome of major trauma patients admitted into our ICU and to identify predictors of outcome.

Methods

Between January 2008 and December 2010, a descriptive prospective study of all trauma admissions to a multidisciplinary intensive care unit (ICU) of Bugando Medical Centre in Northwestern Tanzania was conducted.

Results

A total of 312 cases of major trauma were admitted in the ICU, representing 37.1% of the total ICU admissions. Males outnumbered females by a ratio of 5.5:1. Their median age was 27 years. Trauma admissions were almost exclusively emergencies (95.2%) and came mainly from the Accident and Emergency (60.6%) and Operating room (23.4%). Road traffic crash (RTC) was the most common cause of injuries affecting 70.8% of patients. Two hundred fourteen patients (68.6%) required surgical intervention. The overall ICU length of stay (LOS) for all trauma patients ranged from 1 to 59 days (median = 8 days). The median ICU length of hospital stay (LOS) for survivors and non-survivors were 8 and 5 days respectively. (P = 0.002). Mortality rate was 32.7%. Mortality rate of trauma patients was significantly higher than that of all ICU admissions (32.7% vs. 18.8%, P = 0.0012). According to multivariate logistic regression analysis, multiple injuries, severe head injuries and burns were responsible for a longer mean ICU stay (P < 0.001) whereas admission Glasgow Coma Score < 9, systolic blood pressure < 90 mmHg, injury severity core >16, prolonged duration of loss of consciousness, delayed ICU admission (0.028), the need for ventilatory support and finding of space occupying lesion on computed tomography scan significantly influenced mortality (P < 0.001).

Conclusion

Trauma resulting from road traffic crashes is a leading cause of intensive care utilization in our hospital. Urgent preventive measures targeting at reducing the occurrence of RTCs is necessary to reduce ICU trauma admissions in this region. Improved pre- and in-hospital care of trauma victims will improve the outcome of trauma patients admitted to our ICU.