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Predictors of Mortality of Trauma Patients Admitted to the ICU: A Brazilian Journal of Anesthesiology 71 (2021) 23---30 CLINICAL RESEARCH Predictors of mortality of trauma patients admitted to ଝ the ICU: a retrospective observational studyଝ a,b,c,∗ a a Matthaios Papadimitriou-Olivgeris , Eleftheria Panteli , Kyriaki Koutsileou , a a c a Maria Boulovana , Anastasia Zotou , Markos Marangos , Fotini Fligou a University of Patras, School of Medicine, Department of Anaesthesiology and Intensive Care Medicine, Patras, Greece b University Hospital of Lausanne, Department of Infectious Diseases, Lausanne, Switzerland c University of Patras, School of Medicine, Division of Infectious Diseases, Patras, Greece Received 15 June 2019; accepted 27 June 2020 Available online 25 December 2020 KEYWORDS Abstract Background and objectives: Worldwide, trauma is one of the leading causes of morbidity and Road traffic accident; mortality. The aim of the present study is to identify the predictors of mortality of trauma Traumatic brain injury; patients requiring Intensive Care Unit (ICU) admission. Sepsis; Methods: This retrospective study was conducted in the ICU of our institution in Greece during a six-year period (2010---215). New Injury Severity Results: Among 326 patients, trauma was caused by road traffic accidents in .5%, followed by Score (NISS); falls (21.1%) and violence (7.4%). Thirty-day mortality was 27.3%. Multivariate analysis showed Revised Injury Severity that higher New Injury Severity Score (NISS), severe head/neck injury, acute kidney injury, septic shock and hemorrhagic shock were significantly associated with mortality while higher Revised Classification, version Injury Severity Classification, version II (RISC II) and the administration of enteral nutrition II (RISC II) were associated with survival. NISS showed the higher accuracy in predicting 30-day mortality followed by RISC II, while scores based only in physiological variables had lower predictive ability. Conclusions: Increased mortality was strongly associated with the severity of the injury upon admission. Traumatic brain injury, septic shock and acute kidney injury have also been found among the strongest predictors of mortality. NISS can be considered as a statistically superior score in predicting mortality of severely injured patients. © 2020 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). ଝ th A part of this work was presented as a poster presentation at the 27 European Society of Intensive Care Medicine, 27 September–1 October 2014, Barcelona, Spain. ∗ Corresponding author. E-mail: [email protected] (M. Papadimitriou-Olivgeris). https://doi.org/10.1016/j.bjane.2020.12.006 © 2020 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). M. Papadimitriou-Olivgeris, E. Panteli, K. Koutsileou et al. TM Introduction collected from the ICU computerized database (Criticus , University of Patras, Greece) and the patients’ chart reviews. The parameters assessed included demographic Trauma continues to present challenges to healthcare sys- characteristics (age, sex), severity scores of illness on admis- tems around the world and remains one of the leading causes sion [Injury Severity Score (ISS), New ISS (NISS), Trauma of morbidity and mortality in Europe, with road traffic acci- 1 Score and Injury Severity Score (TRISS), Revised Trauma dents accounting for the majority of fatal injuries. More Score (RTS), Revised Injury Severity Classification, versão than 120,000 people die annually in Europe due to road traf- II (RISC II) (Table 1), Acute Physiology and Chronic Health fic injuries. Greek mortality rate from road traffic injuries is Evaluation II (APACHE II) score, Simplified Acute Physiology 14.9 per 100,000 people, while European and the worldwide 2 Score II (SAPS II) and Sequential Organ Failure Assessment ones are 13.4 and 18.8, respectively. 8---13 (SOFA) score], mechanism of trauma, GCS (Glasgow Coma Mortality after trauma usually shows a trimodal pat- Scale), PaO /FiO , area of trauma, Length Of Stay (LOS) and tern, consisting of immediate deaths (within the first hour), 2 2 complications (hemorrhagic shock, infection, acute kidney early deaths (during the first 24 hours) and late deaths 3 injury). Severe trauma injury for each area of trauma was (after the first day). Severe traumatic injuries are life- considered as those with Abbreviated Injury Scale (AIS) ≥ 4 threatening and require admission in the Intensive Care Unit 2,4 points. Infection was categorized as sepsis or septic shock (ICU). In-hospital mortality of trauma patients admitted 14 according to new sepsis definition. Acute kidney injury to the ICU is associated with severe brain injury and multi- 1,3,5 was defined according to Kidney Disease Improving Global organ failure. Many severity scores have been proposed 15 Guidelines (KDIGO) recommendations. to predict mortality comprising of anatomical variables or 4,6---8 SPSS version 21.0 (SPSS, Chicago, IL) software was used physiological ones or combining both. for data analysis. Categorical variables were analyzed by The aims of this study are to identify the predictors of using the Fisher exact test and continuous variables with mortality of the trauma patients requiring ICU admission Mann---Whitney U test. Multiple logistic regression analysis and assess the ability of different injury severity scores to was used. Odds Ratios (ORs) and 95% Confidence Intervals predict the mortality of critically ill injured patients. (CIs) were calculated to evaluate the strength of any asso- ciation. All statistic tests were 2-tailed and p < 0.05 was Methods considered statistically significant. The ability of the scor- ing systems to predict ICU mortality of trauma patients was investigated using Receiver Ooperating Characteristic (ROC) This single center retrospective study was conducted in the analysis. general ICU (capacity of 13 beds) of our institution, Greece, during a six-year period (2010---215). Our institution serves as the only teaching hospital in the south-west Greece, cover- ing a total population of one-million people with a capacity Results of 700 beds. The study was approved by the Ethics Commit- o tee of our institution (n 571). Among 2094 patients admitted to the ICU during the study All patients older than 18 years of age with traumatic period, 326 (15.6%) were admitted following severe trauma injuries admitted at ICU were included in the study. Pre- (Fig. 1). Most of the trauma cases were due to road traf- hospital care was provided by crews consisted of paramedics fic accidents (233 patients; 71.5%) followed by falls (69; with or without medical doctors. All study patients were 21.1%) and violence (24; 7.4%). Blunt trauma was the leading treated according to ICU protocols. Epidemiologic data were mechanism of traumatism (308 patients: 94.2%). Table 1 Description of different trauma specific severity score. Score Type Parameters assessed Variables included Injury Severity Score (ISS) Anatomical Three worst injured body regions 3 according to AIS New ISS (NISS) Anatomical Three worst injuries according to AIS 3 (even from same body region) Revised Trauma Score (RTS) Physiological GCS, systolic blood pressure, 3 respiratory rate Trauma Score and Injury Combined Based in ISS and RTS 6 Severity Score (TRISS) Revised Injury Severity Combined Mechanism, two worst AIS, TBI 15 Classification, version II (RISC demographic, pupil reactivity/size, II) motor function, American Society of Anesthesiologists score, systolic blood pressure, laboratory values (INR, CRP, hemoglobin, base deficit) AIS, Abbreviated Injury Scale; GCS, Glasgow Coma Scale. 24 Brazilian Journal of Anesthesiology 71 (2021) 23---30 Table 2 Univariate analysis for predictors of 30-day mortality of all trauma patients admitted at Intensive Care Unit (ICU). Characteristics Survivors (237) Non-survivors (89) p Demographics Age (years) 43.3 ± 20.2 48.3 ± 23.7 0.143 a Age ≥ 65 years 46 (19.4%) 32 (36.0%) 0.003 Male gender 196 (82.7%) 74 (83.1%) 1.000 Comorbidities Chronic obstructive pulmonary disease 1 (0.4%) 3 (3.4%) 0.064 Arterial hypertension 31 (13.1%) 23 (25.8%) 0.008 Coronary disease 13 (5.5%) 11 (12.4%) 0.054 Chronic heart failure 1 (0.4%) 3 (3.4%) 0.064 Obesity 28 (11.8%) 13 (14.6%) 0.574 Chronic renal insufficiency 4 (1.7%) 6 (6.7%) 0.028 Diabetes mellitus 11 (4.6%) 6 (6.7%) 0.417 Mechanism of trauma Road traffic accident 176 (74.3%) 57 (64.0%) 0.075 Fall 44 (18.6%) 25 (28.1%) 0.069 Violence 17 (7.2%) 7 (7.9%) 1.000 Penetrating trauma 12 (5.1%) 7 (7.9%) 0.425 Admission data First aid offered in hospital other than our institution 155 (65.4%) 56 (62.9%) 0.698 PaO2/FiO2 (mmHg) 278.8 ± 116.7 249.1 ± 127.5 0.032 a PaO2/FiO2 ≤ 200 mmHg 71 (30.0%) 39 (43.8%) 0.025 -1 Hemoglobin (g.dL ) 11.1 ± 2.2 10.3 ± 2.7 0.017 ≤ -1 Hemoglobin 8 g.dL 9 (3.8%) 19 (21.3%) < 0.001 Alcohol consumption 28 (11.8%) 6 (6.7%) 0.225 Operation before admission 111 (46.8%) 42 (47.2%) 1.000 Injury severity scores (upon admission) GCS 9.7 ± 4.2 6.9 ± 4.0 < 0.001 GCS < 981(34.2%) 60 (67.4%) < 0.001 ISS 24.9 ± 8.8 39.9 ± 14.2 < 0.001 a NISS 30.3 ± 10.1 50.9 ± 12.2 < 0.001 ± RTS 6.3 1.2 5.0 ± 1.4 < 0.001 ± ± TRISS 82.4 18.7 44.8 30.1 < 0.001 − a ± RISC II 1.3 1.6 −4.1 ± 2.0 < 0.001 ± ± APACHE II 13.8 6.3 18.2 5.9 < 0.001 ± ± SAPS II 31.8 11.5 44.3 47.8 < 0.001 SOFA 6.9 ± 3.0 8.9 ± 2.8 < 0.001 Area of trauma
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