Pulmonary Embolism Following Severe Traumatic Brain Injury

Intensive Care Med DOI 10.1007/s00134-017-4815-z

LETTER Pulmonary embolism following severe traumatic brain injury: incidence, risk factors and impact outcome Mabrouk Bahloul1*, Hedi Chelly1, Kais Regaieg1, Nessrine Rekik1, Samar Bellil1, Anis Chaari1, Wajdi Bouaziz2, Imen Chabchoub3, Sondes Haddar4, Chokri Ben Hamida1 and Mounir Bouaziz1

© 2017 Springer-Verlag Berlin Heidelberg and ESICM

Dear Editor, factors and the impact of PE on the prognosis in patients Venous thromboembolism (VTE) is an important pre- admitted to our ICU following a severe traumatic brain ventable cause of morbidity and mortality in critically injury. Te diagnosis of PE was confrmed in 76 patients traumatic brain injury (TBI) patients. Trauma produces (11%), who were all included in this study. Te spiral time-dependent responses from the haemostatic system helical (CT) scan performed for all patients. Tere were that can increase risk of bleeding soon after injury and, 65 males (85.5%) and 11 females (14.5%). Te mean age later, increase the risk of thrombosis [1–3]. Although (±SD) was 42 ± 14.5 years, with a range of 17–73 years efective prophylaxis measurements for thromboembolic (Figure1, Supplementary File). Our studied population disease exist, the most efective ones increase the risk is characterized by its severity of injuries with severe of bleeding [4, 5]. In fact, given the risk of aggravation brain-trauma (with abnormal cerebral CT-scan in 95% of of intracranial bleeding in traumatic brain injury (TBI) patients) requiring invasive mechanical ventilation in all patients, the initiation of pharmacological prophylaxis cases (See Figure 2 and Tables 1–6 Supplementary File). is commonly delayed. Tus, later initiation may increase Tirty two patients (42%) underwent a surgical interven- the risk of VTE and pulmonary embolism (PE) [1, 4, 5]. tion before the development of thromboembolic compli- As consequence, it has been well established that brain- cation (See Tables 1–6 Supplementary File). In our study, trauma patients carry a signifcantly increased risk for the a total of 52 patients (68.4%) patients received some form development of venous thrombo-embolic complications of pharmaceutical prophylaxis during their ICU stay. [1–4]. However, although the high incidence of post- Te median time from ICU admission to diagnosis of PE traumatic venous thromboembolic events is well known was 6 days (Figure 3, Supplementary File). Te mortality [1–4], the incidence of post-traumatic PE in the ICU is rate in the ICU was 32.9% (25 patients) and the in-hos- poorly reported, ranging from 0.13 to 6% [1–4]. In addi- pital mortality rate was 41% (31patients). Multivariate tion, despite that the rate of PE is about four times greater analysis showed that factors associated with PE were: in TBI patients than in general medical and surgical ICU Age > 45 years, the development of nosocomial infection, patients [1, 2], there is a lack of data regarding the accu- hypoxemia, and the presence of shock requiring the use rate incidence of PE following severe traumatic brain of catecholamines. Te comparison between the PE (+) injury requiring ICU admission [1, 2]. So, we have done group and PE (−) group, showed that the development a retrospective study over a 4-year period (2009–2012) of of PE was associated with high mortality rate, a high rate 694 patients with head injuries, admitted to the Intensive of nosocomial infections and a high length of stay in ICU Care Unit (ICU) of a university hospital (Sfax-Tunisia). and in hospital (Table 1). Te aim of this study was to determine the incidence, risk Our fndings show that severe TBI patients carry a signifcantly increased risk for venous thrombo- *Correspondence: [email protected] 1 Department of Intensive Care, Habib Bourguiba University Hospital, embolic (VTE) events (in particular PE). Te increase 3029 Sfax, Tunisia in post-traumatic PE in our study in comparison Full author information is available at the end of the article with previous studies [1, 3], can be explained by a Table 1 Risk Factors and impact outcome of PE development, in univariate analysis Parameters PE ( ) (N:76) PE ( ) (N:618) P + − Age (years) 42 14.5 30 17.5 <0.0001 ± ± Isolated traumatic head injury 24 (31.5%) 218 (35.2%) 0.61 Use of catecholamines 55 (72.3%) 310 (50.1%) <0.0001 Use of mechanical ventilation 76 (100%) 618 (100%) 1 SAPSII score 40 10 37 13 0.088 ± ± ISS Score 35.9 9.8 34.5 9.8 0.24 ± ± Glasgow coma scale score 9 3.4 8.7 3.4 0.23 ± ± Systolic Blood Pressure (mmHg) 123 33 114 29 0.014 ± ± PaO2/FiO2 on ICU admission 248 97 301 110 <0.0001 ± ± Hematocrit (%) on ICU admission 38.2 5 36.2 7 0.02 ± ± Prothrombin levels on ICU admission (%) 72 17 67 18 0.041 ± ± Blood transfusion 49 (64%) 401 (64%) 1 Number of secondary systemic insults (SSIs) 4 1.3 3 1.6 0.004 ± ± Development of nosocomial infection 62 (81.5) 266 (43%) <0.0001 Fracture of the pelvis 13 (17%) 67 (10.8%) 0.12 Fracture of long-bones 21 (27.6%) 191(30.9%) 0.60 Chest trauma 26 (34%) 222 (35.9%) 0.8 Abdominal trauma 12 (16%) 97 (15.6%) 1 Cervical spine injuries 9 (11.8%) 66 (10.6%) 0.69 ICU mortality (%) 25 (32.9%) 162 (26.2%) 0.22 Hospital mortality(%) 31 (40.7%) 185 (30%) 0.06 LOS in the ICU (days) 27 22 14 16.2 <0.001 ± ± LOS in Hospital (days) 35 25.6 20.4 20.3 <0.001 ± ± Nosocomial Infections (%) 62 (81.5) 266 (43%) <0.001 Development of pressure ulcer stage III or IV (%) 19 (25%) 73(11.8%) 0.03

4 multiple-signifcant-factors. First, the severity of our Hospital, Sfax, Tunisia. Department of Radiology, Habib Bourguiba University Hospital, Sfax, Tunisia. studied population with severe brain-trauma. Second, the high delay of preventive anticoagulation, due to the Acknowledgements possible hemorrhagic events, that can be life-threatening, All authors thank Professor Chokri Khalaf for his help in the redaction of this manuscript. particularly in patients with head injuries. Tird, the fail- ure of prophylactic measures. Finally, the improvement Compliance with ethical standards of detection methods and the good experience of our Conflicts of interest medical team. The authors declare that they have no competing interests. Te development of PE is associated with high mor- tality rate, a high rate of nosocomial infections and a Availability of data and materials The datasets were analyzed during the current study available from the cor- high length of stay in ICU and in hospital. Te oppor- responding author on reasonable request. tunity to improve our understanding of this poten- tially lethal posttraumatic complication exists and Ethics approval and consent to participate The study was approved by an Internal Review Board. select more appropriately the prophylactic measures is warranted. Funding This study received no funding. Electronic supplementary material The online version of this article (doi:10.1007/s00134-017-4815-z) contains Consent for publication supplementary material, which is available to authorized users. Not applicable.

Author details 1 Department of Intensive Care, Habib Bourguiba University Hospital, Accepted: 21 April 2017 3029 Sfax, Tunisia. 2 Department of Orthopedics, Habib Bourguiba University Hospital, Sfax, Tunisia. 3 Department of Pediatrics, Hedi Chaker University References 3. Bahloul M, Chaari A, Dammak H, Medhioub F, Abid L, Ksibi H, Haddar S, 1. Skrifvars MB, Bailey M, Presneill J, French C, Nichol A, Little L, Duranteau Kallel H, Chelly H, Hamida CB, Bouaziz M (2011) Post-traumatic pulmonary J, Huet O, Haddad S, Arabi Y, McArthur C, Cooper DJ, Bellomo R, EPO-TBI embolism in the intensive care unit. Ann Thorac Med 6:199–206 investigators and the ANZICS Clinical Trials Group (2017) Venous throm- 4. Holley ADL, Reade MC (2013) The ‘procoagulopathy’ of trauma: too much, boembolic events in critically ill traumatic brain injury patients. Intensive too late? Curr Opin Crit Care 19:578–586 Care Med 43:419–428 5. McCully SPL, Schreiber MA (2013) Traumatic brain injury and its efect on 2. Bahloul M, Regaieg K, Chtara K, Turki O, Baccouch N, Chaari A, Bouaziz coagulopathy. Semin Thromb Hemost 39:896–901 M (2017) Posttraumatic thromboembolic complications: Incidence, risk factors, pathophysiology and prevention. Ann Cardiol Angeiol (Paris) 16:30452–30458 (pii: S0003–3928)