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Martin-Rodriguez F, Sanz-Garcia A, Lopez-Izquierdo R, Delgado Benito JF, Martínez Fernández FT, Otero de la Torre S, Del Pozo Vegas C. Prehospital Lactate Levels Obtained in the Ambulance and Prediction of 2-Day In-Hospital Mortality in Patients With Traumatic Brain Injury. Neurology 2024; 103:e209692. [PMID: 39088773 DOI: 10.1212/wnl.0000000000209692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES To analyze the ability of prehospital lactate levels to predict 2-day in-hospital mortality in patients with traumatic brain injury (TBI), severe TBI (Glasgow Coma Scale (GCS) ≤ 8 points), and mild or moderate TBI (GCS ≥ 9 points). Second, 90-day mortality was also explored. METHODS This was a prospective, multicenter, emergency medical services (EMSs) delivery, ambulance-based, derivation-validation cohort study developed in 5 tertiary hospitals (Spain), from November 1, 2019, to July 31, 2022. Patients were recruited from among all phone requests for emergency assistance among adults who were later evacuated to referral hospitals with acute TBI. The exclusion criteria were minors, pregnancy, trauma patients without TBI, delayed presentations, patients were discharged in situ, participants with cardiac arrest, and unavailability to obtain a blood sample. The primary outcome was all-cause 2-day in-hospital mortality and 90-day mortality in patients with moderate or mild TBI compared with patients with severe TBI. Clinical and analytical parameters (lactate and glucose) were collected. The discriminative power (area under the receiver operating characteristic curve [AUC]) and calibration curve were calculated for 2 geographically separated cohorts. RESULTS A total of 509 patients were ultimately included. The median age was 58 years (interquartile range: 43-75), and 167 patients were female (32.8%). The primary outcome occurred in 9 (2.2%) of 415 patients with moderate or mild TBI and in 42 (44.7%) of 94 patients with severe TBI. The predictive capacity of the lactate concentration was globally validated in our cohort, for which the AUC was 0.874 (95% CI 0.805-0.942) for the validation cohort. The ability of the GCS score to predict lactate concentration was greater in patients with a GCS score ≥9 points, with an AUC of 0.925 (95% CI 0.808-1.000) and a negative predictive value of 99.09 (95% CI 98.55-99.64) in the validation cohort. CONCLUSION Our results show the benefit of using lactate in all patients with TBI, particularly in those with a GCS ≥9 points. Routine incorporation of lactate in the screening of patients with TBI could presumably reduce mortality and deterioration rates because of quicker and better identification of patients at risk.
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Affiliation(s)
- Francisco Martin-Rodriguez
- From the Faculty of Medicine (F.M.-R., R.L.-I., C.D.P.V.), Universidad de Valladolid; Advanced Life Support (F.M.-R., J.F.D.B.), Emergency Medical Services (SACYL); Telemedicine and e-Health Research Group (F.M.-R., R.L.-I., J.F.D.B., F.T.M.F., S.O.T., C.D.P.V.), Valladolid; ; Technological Innovation Applied to Health Research Group (ITAS Group) (A.S.-G.), Faculty of Health Sciences, University of de Castilla-La Mancha, Talavera de la Reina; Evaluación de Cuidados de Salud (ECUSAL) (A.S.-G.), Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM); Emergency Department (R.L.-I.), Hospital Universitario Rio Hortega; and Emergency Department, Hospital Clínico Universitario, Valladolid (C.D.P.V.), Spain
| | - Ancor Sanz-Garcia
- From the Faculty of Medicine (F.M.-R., R.L.-I., C.D.P.V.), Universidad de Valladolid; Advanced Life Support (F.M.-R., J.F.D.B.), Emergency Medical Services (SACYL); Telemedicine and e-Health Research Group (F.M.-R., R.L.-I., J.F.D.B., F.T.M.F., S.O.T., C.D.P.V.), Valladolid; ; Technological Innovation Applied to Health Research Group (ITAS Group) (A.S.-G.), Faculty of Health Sciences, University of de Castilla-La Mancha, Talavera de la Reina; Evaluación de Cuidados de Salud (ECUSAL) (A.S.-G.), Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM); Emergency Department (R.L.-I.), Hospital Universitario Rio Hortega; and Emergency Department, Hospital Clínico Universitario, Valladolid (C.D.P.V.), Spain
| | - Raul Lopez-Izquierdo
- From the Faculty of Medicine (F.M.-R., R.L.-I., C.D.P.V.), Universidad de Valladolid; Advanced Life Support (F.M.-R., J.F.D.B.), Emergency Medical Services (SACYL); Telemedicine and e-Health Research Group (F.M.-R., R.L.-I., J.F.D.B., F.T.M.F., S.O.T., C.D.P.V.), Valladolid; ; Technological Innovation Applied to Health Research Group (ITAS Group) (A.S.-G.), Faculty of Health Sciences, University of de Castilla-La Mancha, Talavera de la Reina; Evaluación de Cuidados de Salud (ECUSAL) (A.S.-G.), Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM); Emergency Department (R.L.-I.), Hospital Universitario Rio Hortega; and Emergency Department, Hospital Clínico Universitario, Valladolid (C.D.P.V.), Spain
| | - Juan F Delgado Benito
- From the Faculty of Medicine (F.M.-R., R.L.-I., C.D.P.V.), Universidad de Valladolid; Advanced Life Support (F.M.-R., J.F.D.B.), Emergency Medical Services (SACYL); Telemedicine and e-Health Research Group (F.M.-R., R.L.-I., J.F.D.B., F.T.M.F., S.O.T., C.D.P.V.), Valladolid; ; Technological Innovation Applied to Health Research Group (ITAS Group) (A.S.-G.), Faculty of Health Sciences, University of de Castilla-La Mancha, Talavera de la Reina; Evaluación de Cuidados de Salud (ECUSAL) (A.S.-G.), Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM); Emergency Department (R.L.-I.), Hospital Universitario Rio Hortega; and Emergency Department, Hospital Clínico Universitario, Valladolid (C.D.P.V.), Spain
| | - Francisco T Martínez Fernández
- From the Faculty of Medicine (F.M.-R., R.L.-I., C.D.P.V.), Universidad de Valladolid; Advanced Life Support (F.M.-R., J.F.D.B.), Emergency Medical Services (SACYL); Telemedicine and e-Health Research Group (F.M.-R., R.L.-I., J.F.D.B., F.T.M.F., S.O.T., C.D.P.V.), Valladolid; ; Technological Innovation Applied to Health Research Group (ITAS Group) (A.S.-G.), Faculty of Health Sciences, University of de Castilla-La Mancha, Talavera de la Reina; Evaluación de Cuidados de Salud (ECUSAL) (A.S.-G.), Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM); Emergency Department (R.L.-I.), Hospital Universitario Rio Hortega; and Emergency Department, Hospital Clínico Universitario, Valladolid (C.D.P.V.), Spain
| | - Santiago Otero de la Torre
- From the Faculty of Medicine (F.M.-R., R.L.-I., C.D.P.V.), Universidad de Valladolid; Advanced Life Support (F.M.-R., J.F.D.B.), Emergency Medical Services (SACYL); Telemedicine and e-Health Research Group (F.M.-R., R.L.-I., J.F.D.B., F.T.M.F., S.O.T., C.D.P.V.), Valladolid; ; Technological Innovation Applied to Health Research Group (ITAS Group) (A.S.-G.), Faculty of Health Sciences, University of de Castilla-La Mancha, Talavera de la Reina; Evaluación de Cuidados de Salud (ECUSAL) (A.S.-G.), Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM); Emergency Department (R.L.-I.), Hospital Universitario Rio Hortega; and Emergency Department, Hospital Clínico Universitario, Valladolid (C.D.P.V.), Spain
| | - Carlos Del Pozo Vegas
- From the Faculty of Medicine (F.M.-R., R.L.-I., C.D.P.V.), Universidad de Valladolid; Advanced Life Support (F.M.-R., J.F.D.B.), Emergency Medical Services (SACYL); Telemedicine and e-Health Research Group (F.M.-R., R.L.-I., J.F.D.B., F.T.M.F., S.O.T., C.D.P.V.), Valladolid; ; Technological Innovation Applied to Health Research Group (ITAS Group) (A.S.-G.), Faculty of Health Sciences, University of de Castilla-La Mancha, Talavera de la Reina; Evaluación de Cuidados de Salud (ECUSAL) (A.S.-G.), Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM); Emergency Department (R.L.-I.), Hospital Universitario Rio Hortega; and Emergency Department, Hospital Clínico Universitario, Valladolid (C.D.P.V.), Spain
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Seo D, Heo I, Park J, Kwon J, Sohn HM, Jung K. Predictors of massive transfusion protocols activation in patients with trauma in Korea: a systematic review. JOURNAL OF TRAUMA AND INJURY 2024; 37:97-105. [PMID: 39380617 PMCID: PMC11309178 DOI: 10.20408/jti.2024.0015] [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: 03/05/2024] [Revised: 04/16/2024] [Accepted: 04/24/2024] [Indexed: 10/10/2024] Open
Abstract
Purpose Massive transfusion protocols (MTPs) implementation improves clinical outcomes of the patient's resuscitation with hemorrhagic trauma. Various predictive scoring system have been used and studied worldwide to improve clinical decision. However, such research has not yet been studied in Korea. This systematic review aimed to assess the predictors of MTPs activation in patients with trauma in Korea. Methods The PubMed, Embase, Cochrane Library, Research Information Sharing Service databases, KoreaMed, and KMbase were searched from November 2022. All studies conducted in Korea that utilized predictors of MTPs activation in adult patients with trauma were included. Results Ten articles were eligible for analysis, and the predictors were assessed. Clinical assessments such as systolic and diastolic blood pressure, shock index (SI), prehospital modified SI, modified early warning system (MEWS) and reverse SI multiplied by the Glasgow Coma Scale (rSIG) were used. Laboratory values such as lactate level, fibrinogen degradation product/fibrinogen ratio, and rotational thromboelastometry (ROTEM) were used. Imaging examinations such as pelvic bleeding score were used as predictors of MTPs activation. Conclusions Our systematic review identified predictors of MTPs activation in patients with trauma in Korea; predictions were performed using tools that requires clinical assessments, laboratory values or imaging examinations only. Among them, ROTEM, rSIG, MEWS, SI, and lactate level showed good effects for predictions of MTPs activation. The application of predictors for MTP's activation should be individualized based on hospital resource and skill set, also should be performed as a clinical decision supporting tools.
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Affiliation(s)
- Dongmin Seo
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Inhae Heo
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Juhong Park
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Junsik Kwon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Hye-min Sohn
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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Kosaki Y, Hongo T, Hayakawa M, Kudo D, Kushimoto S, Tagami T, Naito H, Nakao A, Yumoto T. Association of initial lactate levels and red blood cell transfusion strategy with outcomes after severe trauma: a post hoc analysis of the RESTRIC trial. World J Emerg Surg 2024; 19:1. [PMID: 38167057 PMCID: PMC10763143 DOI: 10.1186/s13017-023-00530-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The appropriateness of a restrictive transfusion strategy for those with active bleeding after traumatic injury remains uncertain. Given the association between tissue hypoxia and lactate levels, we hypothesized that the optimal transfusion strategy may differ based on lactate levels. This post hoc analysis of the RESTRIC trial sought to investigate the association between transfusion strategies and patient outcomes based on initial lactate levels. METHODS We performed a post hoc analysis of the RESTRIC trial, a cluster-randomized, crossover, non-inferiority multicenter trials, comparing a restrictive and liberal red blood cell transfusion strategy for adult trauma patients at risk of major bleeding. This was conducted during the initial phase of trauma resuscitation; from emergency department arrival up to 7 days after hospital admission or intensive care unit (ICU) discharge. Patients were grouped by lactate levels at emergency department arrival: low (< 2.5 mmol/L), middle (≥ 2.5 and < 4.0 mmol/L), and high (≥ 4.0 mmol/L). We compared 28 days mortality and ICU-free and ventilator-free days using multiple linear regression among groups. RESULTS Of the 422 RESTRIC trial participants, 396 were analyzed, with low (n = 131), middle (n = 113), and high (n = 152) lactate. Across all lactate groups, 28 days mortality was similar between strategies. However, in the low lactate group, the restrictive approach correlated with more ICU-free (β coefficient 3.16; 95% CI 0.45 to 5.86) and ventilator-free days (β coefficient 2.72; 95% CI 0.18 to 5.26) compared to the liberal strategy. These findings persisted even after excluding patients with severe traumatic brain injury. CONCLUSIONS Our results suggest that restrictive transfusion strategy might not have a significant impact on 28-day survival rates, regardless of lactate levels. However, the liberal transfusion strategy may lead to shorter ICU- and ventilator-free days for patients with low initial blood lactate levels.
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Affiliation(s)
- Yoshinori Kosaki
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Takashi Hongo
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8648, Japan
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashi Kosugi Hospital, 1-396 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
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