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Risk Factors for Mortality in Severe Multiply Injury Patients with Acute Hypoxemic Respiratory Failure

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Risk Factors for Mortality in Severe Multiply Injury Patients with Acute Hypoxemic Respiratory Failure Eur opean Rev iew for Med ical and Pharmacol ogical Sci ences 2015; 19: 3693-3700 Risk factors for mortality in severe multiply injury patients with acute hypoxemic respiratory failure Y.-D. CHEN, X.-L. FENG, L. DENG, P. ZHOU, J.-D. WANG, B. CAI, H. JIANG, Y. DONG, X.-H. ZHANG Department of Emergency ICU, Metabolomics and Multidisciplinary Laboratory for Trauma Research, Institute for Disaster and Emergency Medicine Research, Sichuan Provincial People’s Hospital, Sichuan Academy of Medical Sciences, Chengdu, Sichuan, China Youdai Chen and Xuanlin Feng contributed equally Abstract. – OBJECTIVE: To investigate the CONCLUSIONS: Traumatic AHRF patients re - risk factors related to mortality in severe poly - quiring ventilation support show a high rate of trauma patients with acute hypoxemic respira - early mortality. Greater vigilance for high tory failure (AHRF). APACHE II score, short time interval between PATIENTS AND METHODS: From December injury and ventilation, low pH in traumatic 2011 to December 2014, we identified and intu - AHRF patients is required. bated 524 traumatic AHRF patients in a level 1 trauma centers. Amongst those, we enrolled Key Words: seventy-six severe traumatic AHRF patients Multiple injury, Mortality, Ventilation, Acute hypoxemic with an injury severity score (ISS) over 16 and respiratory failure. need for over 24 hour intra-tracheal mechanical ventilation for our study. Patients were followed daily to collect data about demographics, injury characteristic, diagnostic, treatment, respirato - Abbreviations ry parameters, major complications, duration of mechanical ventilation, length of stay, preva - MODS = Multiple Organ Dysfunction Syndrome; APACHE lence of major complications and 28-days mor - II = Acute Physiology And Chronic Health Evaluation score tality. II; ECMO = Extracorporeal Membrane Oxygenation; GCS RESULTS: Of the 76 patients in our study, 61 = Glasgow Coma Scale; SBP = Systolic Blood Pressure; IP - patients were male. Patients’ ages were from 15 PV = Intermittent Positive Pressure Ventilation; IQR = Inter to 78 years old (43±17) and the predominant Quartile Range. source of trauma was road traffic accidents. Before ventilation, patients had a mean PaO /FiO2 ratio of 108±63, pH of 7.1±0.3, PaCO 2 2 Introduction of 54±24 mmHg, respectively. The PaO2/FiO2 2 ratios were significantly improved by ventila - tion and the average duration of ventilation was Despite of the recent improvements in ventila - 9.63±8.74 days. There were two peak dying tion methods, extracorporeal life support (ECLS) times and the 28-days ICU mortality rate was and resuscitation strategies for trauma 1-3 , patients 28.9%. Logistic regression analysis revealed with severe multiple injuries in China still have a the mortality rate to be significantly higher in high mortality rate 4, which is approximately patients with higher APACHE II scores (odds ra - tio: 1.60, p=0.002), shorter intervals between in - twice as high as in developed countries in 5 jury and admission (odds ratio: -0.91, p=0.03) Europe . and between admission and ventilation (odds Chengdu is one of the biggest cities in south - ratio: -1.85, p=0.012), and lower pH (odds ratio: - west China with a population of just over 14 mil - 0.692, p=0.044). The receiver operating charac - lion. Considering Chengdu’s demographic scale teristic (ROC) curves showed that best cut off and the fast development it experienced in recent points for mortality predictors were APACHE II scores greater than 25, time interval between years, trauma related deaths have increased injury and admission less than 2h, time interval markedly in this city. In 1992, Sichuan Provincial between admission and ventilation less than People’s Hospital of Sichuan Academy of Med - 0.5h, and pH <7.16. ical Sciences (SAMS) established its level 1 trau - Corresponding Author: Xiaohong Zhang, MD; e-mail: [email protected] 3693 Y.-D. Chen, X.-L. Feng, L. Deng, P. Zhou, J.-D. Wang, B. Cai, H. Jiang, Y. Dong, X.-H. Zhang ma center. In 2009, it established a trauma reg - and at least one threatening life injury in one istry database for collecting information from all anatomic site 10-12 . Hypoxemia was defined as trauma patients admitted to the center. According PaO 2/FIO 2 ratio of 300 or lower. The criteria used to that database, a large proportion of trauma pa - for intubation and ventilation were referred to tients with acute hypoxemic respiratory failure Agle et al 13 . (AHRF) often develop acute respiratory distress To investigate the pattern of admission and syndrome (ARDS) as well. The complexity of in - mortality rate of sever traumatic AHRF patients juries in severe trauma cases often makes the with prolonged mechanical ventilation, the fol - ventilation very challenging. This challenge is lowing inclusion criteria and exclusion criteria due to the fact that medical staff should be able were used. Inclusion criteria: (i) ISS over 16; (ii) to provide an optimal oxygenation for the pa - Intubation and placement on mechanical ventila - tients while protecting the lungs from further tion within the first 24 h of injury; (iii ) survival ventilator-induced injuries 6. Prolonged mechani - for more than 48h post-trauma. Exclusion crite - cal ventilation (PMV) for more than 7 days, has ria: Patients who were readmitted to EICU by been reported to result in a longer length of ICU virtue of non-traffic injuries or transferred to stay and a higher mortality in severe multiple EICU from other hospitals after more than one trauma patient 7. However , a mortality benefit for day of treatment. No burn patients, ECMO pa - PMV patients was also noted in regional trauma tients or patients under 15 years old were includ - centre in New York , USA 8. ed in this study. Mortality was calculated 28 day In this study we attempted to investigate the after the injury. Patients were divided into a sur - clinical characteristic and the mortality rates of vivors group and a non-survivor group and were severe traumatic AHRF patients needing ventila - statistically compared. tion support for more than one day. We also searched for possible correlation to the pattern of Statistical Analysis mechanical ventilation and outcomes of these pa - For our statistical analyses we used the chi- tients. square test for categorical variables and Student’s t-test for continuous variables. Variables present - ing significant differences between groups in Patients and Methods multivariate analysis were entered in logistic re - gression analysis. All of the statistical analyses Study Design and Patient Eligibility were performed using a statistical software pack - From December 2011 to December 2014, we age (SPSS for Windows, version 11.0, Chicago, identified and intubated 524 traumatic AHRF pa - IL, USA). A two-side p value of <0.05 was con - tients in a 26-bed, surgeons-verified Emergency sidered statistically significant. Intensive Care Units (EICU) in Sichuan Provin - cial People’s Hospital. Patients’ informations in - cluding gender, age, chronic disease, injury char - Results acteristic, emergency disposition (e.g. CT scan, blood test, cardiopulmonary resuscitation, intu - Traumatic AHRF Patient Characteristics bation, ventilation, use of total parental nutrition, During the study period, 524 traumatic AHRF transfusion, use of H2 blockers, steroids, and va - patients were intubated within the first day after sopressors/inotrope) were collected. As part of injury in our EICU. Indications for initial intuba - ICU routine, severity of the injury for each trau - tion included airway (5%), breathing (48%), cir - ma victim was quantified using ISS on admis - culation (32%), and neurologic disability (15%). sion, APACHE II scores 24 hours after their ad - Among them, 127 patients with blood gas abnor - 9 mission . Complications such as hypotension, re - mality (PaO 2 < 60 mmHg/PaCO 2 > 60 mmHg nal dysfunction, MODS, gastrointestinal hemor - and SaO 2 <90%) despite oxygen therapy, under - rhage, aspiration of gastric contents, and infec - went ventilation within the first 24h ICU admis - tion were also recorded. These data were docu - sion. Consequently, they were operated and re - mented in the patients’ charts and were accessi - suscitated on an emergency bases, only patients ble for further analysis. who required ventilation for more than one day The commonly accepted definition for severe were included in this study. We excluded 24 pa - multiply injury was consistent with both: several tients who weaned within 1 day or changed to injury sites (from two or more anatomic sites) noninvasive ventilation, we also excluded 12 pa - 3694 Risk factors for mortality in severe trauma patients with acute respiratory failure tients who gave up therapy or could not be con - tory rate over 29 per minute); Eighteen patients tacted. Another 6 patients were excluded from had abdominal trauma which lead to shallow analysis because they suffered from chronic lung breathing and aspiration of gastric contents; diseases and another 4 patients for problems as - Twelve patients were unconsciousness due to sociated with drawing or gas poisoning, which head trauma or high thoracic spinal cord injuries might aggravate pulmonary failure (Figure 1). with GCS < 9. The remaining 18 patients with Thus, we enrolled seventy-six traumatic SBP < 90 mmHg were accepted as shock patient, AHRF patients (61 males) who required over 24 presenting with apnea or a gasping breathing pat - hour intra-tracheal mechanical ventilation. Pa - tern (respiratory rate under 6 per minute). tients’ ages were from 15 to 78 years (average Duration of admission before commencement 43±17). The most common source of their in - of ventilation was 8.5±1.9 hours. Before me - juries was road traffic collision (59.21%) fol - chanical ventilation, the mean respiratory rate, lowed by falls (21.05%). Penetrating trauma oc - arterial oxygen saturation (SaO 2), and PaO 2 were curred in only 6 patients (8%). Overall, those 23±17/min, 53±28%, and 83±47 mmHg, respec - seventy-six patients had 209 injured regions. The tively.
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