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Prediction of Prolonged Ventilatory Support in Blunt Thoracic Trauma

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Prediction of Prolonged Ventilatory Support in Blunt Thoracic Trauma Intensive Care Med (2003) 29:1101–1105 DOI 10.1007/s00134-003-1813-0 ORIGINAL Ioanna Dimopoulou Prediction of prolonged ventilatory support Anastasia Anthi Michalis Lignos in blunt thoracic trauma patients Efstratios Boukouvalas Evangelos Evangelou Christina Routsi Konstantinos Mandragos Charis Roussos Received: 27 August 2002 Abstract Objective: To identify p=0.04), severity of head injury Accepted: 17 April 2003 predictors of prolonged (>7 days) (odds ratio=1.92, p=0.008), and Published online: 12 June 2003 mechanical ventilation (MV) in pa- bilateral thoracic injuries (odds © Springer-Verlag 2003 tients with blunt thoracic trauma. ratio=12.80, p<0.0001) were signifi- Design: Prospective analysis of con- cant and independent predictors of secutive patients. Setting: Adult in- long-lasting MV. In contrast, gender, tensive care unit (ICU) in a teaching, injuries affecting the other body tertiary-care hospital. Patients and regions (face, abdomen–pelvis, ex- participants: Sixty-nine patients tremities, and external), laparotomy (53 men, 16 women) with thoracic in patients with abdominal injury, or I. Dimopoulou · M. Lignos trauma having a median age of PaO2/FIO2 on admission in the ICU, E. Evangelou · C. Routsi · C. Roussos 35 (range 17–85) years and a median were unrelated to prolonged MV. Department of Critical Care Medicine, injury severity score (ISS) of 29 Conclusions: In thoracic trauma Evangelismos Hospital, (range 14–41) were enrolled in patients admitted in the ICU, pro- Athens, Greece the present study. Associated injuries longed mechanical ventilation was A. Anthi · E. Boukouvalas · K. Mandragos included head–neck (77%), extremi- primarily determined by presence Intensive Care Unit, Hellenic Red Cross Hospital, ties (72%), external (67%), abdo- of bilateral chest injuries, age, and Medical School, men–pelvis (67%), and face (55%). degree of neurotrauma. This infor- National and Kapodistrian University Interventions: Patient surveillance mation may help in planning the of Athens, and data collection. Measurements long-term care of such patients. Athens, Greece and results: Thirty-three (48%) of I. Dimopoulou (✉) the 69 patients required prolonged Keywords Thoracic trauma · 2 Pesmazoglou Street, ventilatory support, ranging in dura- Mechanical ventilation · Duration · 14 561 Kifissia, Athens, Greece e-mail: [email protected] tion from 8 to 38 (median 18) days. Prediction · Bilateral chest injuries · Tel.: +32-10-6200663 Logistic regression analysis revealed Severe head trauma · Aging Fax: +32-10-6202939 that advancing age (odds ratio=1.04, Introduction Clinical experience suggests that a subset of these pa- tients require prolonged ventilatory support. Predictive The importance of thoracic injury is well recognized. It criteria for long-lasting mechanical ventilation (MV) in is involved in nearly one third of acute admissions to the polytraumatized critically ill have been extensively trauma centers and is the second most common cause of investigated [2, 3, 4, 5], but no study has specifically ad- death after head injury, accounting for approximately dressed this issue in thoracic trauma patients. 25% of all trauma-related deaths. In the civilian popula- Early identification of patients who may stay for lon- tion, blunt chest trauma largely exceeds penetrating trau- ger periods under artificial ventilation can be useful in ma [1]. many ways. Important therapeutic decisions can be Mechanical ventilation remains the mainstay of live- made, including earlier placement of tracheostomy, saving therapy in patients with severe thoracic trauma. which has been proven beneficial in trauma patients [6, 1102 7]. Some studies have inferred that prolonged intensive were used, and results are presented as medians and ranges. Com- care unit (ICU) stay is associated with a substantial in- parisons between groups were performed using Mann-Whitney ranked sum test, chi square analysis, or Fisher exact test, where hospital death rate [8, 9] and with poor functional out- appropriate. Logistic regression analysis was carried out to exam- comes in many patients who do survive [9]. Further- ine the association between prolonged MV and the following pos- more, such patients consume a disproportionate amount sible risk factors: gender, age, PaO2/FIO2 on admission to the of nursing and financial resources [10]. Thus, prediction ICU, AIS for five anatomic regions of the body (head–neck, face, abdomen–pelvis, extremities, external), performance of laparoto- of patients requiring long-lasting MV early after the ini- my in patients with abdominal trauma, and thoracic injuries classi- tiation of ventilatory support also has important conse- fied in two groups—one group with any unilateral thoracic injury quences for informing families on a realistic basis about (lung contusion, hemothorax, pneumothorax, or rib fractures), and expectations and evaluating ICU resources. a second group having any bilateral thoracic injury. All factors Given these considerations, this prospective, descrip- were included in the model, and nonsignificant variables were de- leted by backward elimination (deletion criterion; p>0.05). The tive study was designed to isolate risk factors that might odds ratios and the 95% confidence intervals were calculated. Sta- predict long-term mechanical ventilation in adult blunt tistical significance was determined at the p<0.05 level. The SAS thoracic trauma patients. statistical package was used for all analyses (SAS Institute Inc., Cary, NC, USA). Materials and methods Results Patients All consecutive patients with blunt thoracic trauma admitted to the During the study period, 79 patients with thoracic trauma ICU of the Hellenic Red Cross Hospital between January 2000 and other associated injuries were admitted to the ICU of and December 2001 were prospectively evaluated. Patients meet- the Hellenic Red Cross Hospital. Of these, 15 patients ing the following criteria were included in this study: (1) intuba- (19%) died in the ICU. Early deaths (within 48 h postin- tion and placement on mechanical ventilation within the first 24 h jury) were recorded in ten patients and were related to of injury; (2) survival for more than 48 h posttrauma. The Institutional Review Board approved the study, and in- head trauma (n=6), major thoracic aorta injury (n=2), or formed consent was obtained from next-of-kin. massive bleeding (n=2). These patients were excluded from further analysis. Late deaths (4–28 days after inju- ry) occurred in five patients due to sepsis/multiple organ Study protocol failure (n=3) or severe brain injury (n=2). Thus, 69 pa- The following data were collected for each patient: age, sex, tients were included in the current study. mechanism of injury, thoracic along with extrathoracic injuries, All injuries were caused by blunt trauma related to total time spent on MV, length of ICU stay, surgical therapy in- motor vehicle crashes. Demographic and clinical charac- cluding laparotomy in patients with abdominal trauma, ratio of ar- terial blood oxygen tension to the concentration of inspired oxy- teristics of the 69 patients are shown in Table 1. No pa- tient had isolated thoracic trauma, and the most common gen (PaO2/FIO2) on admission to the ICU, and mortality. The ab- breviated injury scale (AIS) was evaluated as the measure of ana- concomitant injuries were brain trauma along with bone tomic injury for six body regions: (1) head–neck, (2) face, (3) tho- fractures, occurring in more than 70% of patients. Sixty- rax, (4) abdomen–pelvis, (5) extremities, and (6) external [11]. five patients (94%) were severely injured (ISS >16). The The injury severity score (ISS) was calculated as the sum of the squares of the highest AIS grade in each of the three most severely most common thoracic injuries were lung contusions, rib injured body regions [12]. Brain, neck, thoracic, and abdominal fractures, and hemothorax (in more than 60% of pa- injuries were assessed by computed tomography scanning (CT tients), while pneumothorax and flail chest were less scan) on admission. common (Table 2). No patient sustained sternal fracture, Certain complications, including pneumonia and adult respira- tory distress syndrome (ARDS), were recorded. Pneumonia was myocardial contusion, or rupture of the diaphragm, great diagnosed by a new and persistent infiltration on chest X-ray, a vessels, or tracheobronchial tree. No patient underwent body-core temperature >38°C, and purulent tracheal secretions thoracotomy, whereas in 15 patients with abdominal in- with evidence of many neutrophils and bacteria. ARDS was de- jury laparotomy was performed. Analgesia was common fined according to the American-European Consensus Conference in all patients and included the continuous intravenous on ARDS as PaO2/FIO2 ratio <200 with bilateral infiltrates on chest X-ray with no evidence of congestive heart failure [13]. infusion of fentanyl. In the entire patient population, me- Prolonged MV was defined as the need for MV support of dian PaO2/FIO2 on admission in the ICU was 200, rang- more than 7 days [5, 8]. For analysis, patients were subdivided in ing from 80 to 460. Median duration of MV and ICU two groups based solely on duration of MV. Group 1 included pa- stay were 7 (range 1–40) days and 18 (range 3–50 ) days tients who remained on the ventilator for up to 7 days, and group 2 comprised all patients who required MV for more than 8 days. respectively. Overall, duration of MV lasted from 1 to 7 days in 36 patients (group 1), whereas 33 patients remained on the Statistical
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