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Epidemiology and Risk Factors of Sepsis After Multiple Trauma: an Analysis of 29,829 Patients from the Trauma Registry of the German Society for Trauma Surgery*

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Epidemiology and Risk Factors of Sepsis After Multiple Trauma: an Analysis of 29,829 Patients from the Trauma Registry of the German Society for Trauma Surgery* Epidemiology and risk factors of sepsis after multiple trauma: An analysis of 29,829 patients from the Trauma Registry of the German Society for Trauma Surgery* Arasch Wafaisade, PhD; Rolf Lefering, MD; Bertil Bouillon, MD; Samir G. Sakka, MD; Oliver C. Thamm, MD; Thomas Paffrath, MD; Edmund Neugebauer, PhD; Marc Maegele, MD; Trauma Registry of the German Society for Trauma Surgery Objectives: The objectives of this study were 1) to assess spective subperiods (16.9%, 16.0%, 13.7%, and 11.9%; p < potential changes in the incidence and outcome of sepsis after .0001). For the subgroup of patients with sepsis, the mortality -respec ,(054. ؍ multiple trauma in Germany between 1993 and 2008 and 2) to rates were 16.2%, 21.5%, 22.0%, and 18.2% (p evaluate independent risk factors for posttraumatic sepsis. tively. The following independent risk factors for posttraumatic Design: Retrospective analysis of a nationwide, population- sepsis were calculated from a multivariate logistic regression based prospective database, the Trauma Registry of the German analysis: male gender, age, preexisting medical condition, Glas- Society for Trauma Surgery. gow Coma Scale score of <8 at scene, Injury Severity Score, > Setting: A total of 166 voluntarily participating trauma centers Abbreviated Injury ScaleTHORAX score of 3, number of injuries, (levels I–III). number of red blood cell units transfused, number of operative Patients: Patients registered in the Trauma Registry of the procedures, and laparotomy. German Society for Trauma Surgery between 1993 and 2008 with Conclusions: The incidence of sepsis decreased significantly complete data sets who presented with a relevant trauma load over the study period; however, in this decade the incidence (Injury Severity Score of >9) and were admitted to an intensive remained unchanged. Although overall mortality from multiple trauma has declined significantly since 1993, there has been no .(29,829 ؍ care unit (n Interventions: None. significant decrease of mortality in the subgroup of septic trauma Measurements and Main Results: Over the 16-yr study period, patients. Thus, sepsis has remained a challenging complication 10.2% (3,042 of 29,829) of multiply injured patients developed after trauma during the past 2 decades. Recognition of the iden- sepsis during their hospital course. Annual data were summarized tified risk factors may guide early diagnostic workup and help to into four subperiods: 1993–1996, 1997–2000, 2001–2004, and reduce septic complications after multiple trauma. (Crit Care Med 2005–2008. The incidences of sepsis for the four subperiods were 2011; 39:621–628) 14.8%, 12.5%, 9.4%, and 9.7% (p < .0001), respectively. In- KEY WORDS: multiple trauma; sepsis; risk factors; incidence; hospital mortality for all trauma patients decreased for the re- outcome; mortality; multivariate analysis everal factors have been recog- survive initial trauma resuscitation since drome and infection (6–11). In a large nized to substantially contrib- it represents the leading cause of death in trauma study, Osborn et al (12) identified ute to impaired outcomes after noncardiac intensive care units (ICUs) the Injury Severity Score (ISS), the Re- severe injury, but sepsis is one (1, 2). However, while overall mortality vised Trauma Score, the Glasgow Coma Sof the most significant in patients who from multiple trauma has gradually de- Scale (GCS) score, comorbidities, and creased in western countries over the male gender as predictors for posttrau- past few decades (3–5), there is only matic sepsis but were not able to adjust *See also p. 876. limited information on the develop- for transfusion or other therapy-related From the Departments of Trauma and Orthopedic ment of sepsis in injured patients over variables. Furthermore, the predictive Surgery (AW, BB, TP, MM) and Anesthesiology and recent years. Epidemiologic data from value of specific injury patterns and the Intensive Care Medicine (SGS) and Institute for Re- the United States have shown a general role of distinct anatomical regions have search in Operative Medicine (AW, RL, OCT, EN, MM), decrease in the incidence of sepsis (2); not been elucidated. Altogether, indepen- University of Witten/Herdecke, Cologne-Merheim Med- ical Center, Cologne; and Committee on Emergency however, comparable European investi- dent risk factors for postinjury sepsis are Medicine, Intensive and Trauma Care (Sektion NIS), gations do not exist. still poorly defined, although they might German Society for Trauma Surgery, Berlin, Germany. In addition, independent predictors be useful adjuncts to identify high-risk The authors have not disclosed any potential con- for sepsis during trauma-associated hos- patients at an early stage. flicts of interest. For information regarding this article, E-mail: pitalization are debated controversially. Therefore, using a large multicenter [email protected] Several authors have reported that the population-based trauma registry, the Copyright © 2011 by the Society of Critical Care transfusion of allogenic blood during aims of the present study were 1) to in- Medicine and Lippincott Williams & Wilkins trauma resuscitation is associated with vestigate the incidence and outcome of DOI: 10.1097/CCM.0b013e318206d3df the systemic inflammatory response syn- sepsis after multiple trauma and potential Crit Care Med 2011 Vol. 39, No. 4 621 temporal changes since the establish- Table 1. Basic demographic/clinical characteristics upon admission and outcomes of multiple trauma ment of the database in 1993 and 2) to patients with and without sepsis (1993–2008) identify independent risk factors for sep- sis after multiple trauma. Sepsis, No Sepsis, Demographic/Clinical Characteristic, Outcome 3,042 (10.2%) 26,787 (89.8%) p PATIENTS AND METHODS Age (yrs; mean Ϯ SD)44Ϯ 19 42 Ϯ 21 Ͻ.0001 Male (%) 80.9 72.1 Ͻ.0001 The Trauma Registry of the Deutsche Ge- Blunt/penetrating trauma (%) 95.9/4.1 95.5/4.5 .356 sellschaft fu¨ r Unfallchirurgie. The Trauma Open fracture (%) 12.7 9.0 Ͻ.0001 Registry of the Deutsche Gesellschaft fu¨ r Un- Injury Severity Score (points; mean Ϯ SD)33Ϯ 13 25 Ϯ 13 Ͻ.0001 Ն Ͻ AISHEAD score of 3 (%) 54.6 50.5 .0001 fallchirurgie (German Society for Trauma Ն Ͻ AISTHORAX score of 3 (%) 67.8 49.5 .0001 Surgery) (TR-DGU) (13) was founded in 1993 Ն Ͻ AISABDOMEN score of 3 (%) 29.8 18.0 .0001 as an initiative for prospective, standardized, Ն Ͻ AISEXTREMITIES score of 3 (%) 49.0 37.5 .0001 and anonymous documentation of severely in- SBP at the scene (mm Hg; mean Ϯ SD) 112 Ϯ 33 120 Ϯ 32 Ͻ.0001 jured patients. At present, 166 trauma centers SBP at the scene of Յ90 mm Hg (%) 26.5 17.4 Ͻ.0001 of all levels are participating voluntarily at the heart rate at the scene (beats per minute; mean Ϯ SD)98Ϯ 25 93 Ϯ 23 Ͻ.0001 TR-DGU, mainly from Germany, but also 17 Glasgow Coma Scale score at the scene 10.0 Ϯ 4.8 11.1 Ϯ 4.6 Ͻ.0001 hospitals from Austria, Switzerland, The Neth- (points; mean Ϯ SD) erlands, Belgium, and Slovenia (http:// Glasgow Coma Scale score at the scene of Յ8 (%) 39.4 29.3 Ͻ.0001 www.traumaregister.de). Recently, Ͼ6,000 pa- Intravenous fluids, prehospital (mL; mean Ϯ SD) 1637 Ϯ 1241 1294 Ϯ 1055 Ͻ.0001 Ϯ Ϯ Ϯ Ͻ tients have been registered annually, and it is SBP at the ER (mm Hg; mean SD) 117 30 124 29 .0001 SBP at the ER of Յ90 mm Hg (%) 20.9 11.2 Ͻ.0001 estimated that the TR-DGU covers about 25% Heart rate at the ER (beats per minute; mean Ϯ SD)95Ϯ 23 90 Ϯ 21 Ͻ.0001 of all severe trauma cases in Germany (5). The Hemoglobin (g/dL; mean Ϯ SD) 10.7 Ϯ 2.8 11.8 Ϯ 2.7 Ͻ.0001 Ϫ data are collected prospectively and are struc- Platelets (nL 1; mean Ϯ SD) 187 Ϯ 82 206 Ϯ 81 Ͻ.0001 tured into four consecutive time phases: 1) Prothrombin time (Quick%; mean Ϯ SD)72Ϯ 23 80 Ϯ 22 Ͻ.0001 prehospital phase, 2) emergency room and Base excess (mmol/L; mean Ϯ SD) Ϫ4.2 Ϯ 5.1 Ϫ2.9 Ϯ 4.6 Ͻ.0001 initial treatment until ICU admission, 3) ICU, Intravenous fluids, ER to intensive care unit 3560 Ϯ 3641 2457 Ϯ 2547 Ͻ.0001 and 4) discharge and list of injuries and inter- (mL; mean Ϯ SD) ventions. The registry contains detailed infor- Preexisting medical condition (%) 35.4 28.3 Ͻ.0001 a mation on the demographics, injury severity pRBC transfusion (%) 45.4 24.9 Ͻ.0001 a Ն Ͻ and pattern, prehospital and in-hospital man- Massive transfusion ( 10 pRBC units) (%) 15.2 5.8 .0001 pRBC unitsa (n; mean Ϯ SD) 4.3 Ϯ 8.1 1.8 Ϯ 5.1 Ͻ.0001 agement, time course, and outcome of each Fresh frozen plasma unitsa (n; mean Ϯ SD) 2.3 Ϯ 6.3 0.9 Ϯ 3.5 Ͻ.0001 patient. In 2002, data collection moved from Operative procedures (n; mean Ϯ SD) 5.9 Ϯ 6.5 3.0 Ϯ 3.4 Ͻ.0001 paper form documentation to a central online Laparotomy (%) 27.3 15.0 Ͻ.0001 registration system via the Internet. The doc- Organ failure (%) 82.9 34.8 Ͻ.0001 umentation includes standardized scoring sys- Cardiovascular (%) 63.5 20.1 Ͻ.0001 tems, e.g., the GCS and the Abbreviated Injury Respiratory (%) 63.5 17.3 Ͻ.0001 Scale (AIS) (14, 15). Central nervous system (%) 35.4 18.4 Ͻ.0001 This study was approved by the ethical Hepatic (%) 21.2 2.4 Ͻ.0001 Ͻ board of our institution and is in accordance Renal (%) 20.9 2.6 .0001 Hematologic (%) 18.5 5.2 Ͻ.0001 with the standards of the Helsinki Declaration Multiple-organ failure (%) 63.2 17.3 Ͻ.0001 of 1975.
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