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Isolated Severe Blunt Traumatic Brain Injury: Effect of Obesity on Outcomes

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Isolated Severe Blunt Traumatic Brain Injury: Effect of Obesity on Outcomes CLINICAL ARTICLE J Neurosurg 134:1667–1674, 2021 Isolated severe blunt traumatic brain injury: effect of obesity on outcomes Jennifer T. Cone, MD, MHS,1 Elizabeth R. Benjamin, MD, PhD,2 Daniel B. Alfson, MD,2 and Demetrios Demetriades, MD, PhD2 1Department of Surgery, Section of Trauma and Acute Care Surgery, University of Chicago, Illinois; and 2Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, California OBJECTIVE Obesity has been widely reported to confer significant morbidity and mortality in both medical and surgical patients. However, contemporary data indicate that obesity may confer protection after both critical illness and certain types of major surgery. The authors hypothesized that this “obesity paradox” may apply to patients with isolated severe blunt traumatic brain injuries (TBIs). METHODS The Trauma Quality Improvement Program (TQIP) database was queried for patients with isolated severe blunt TBI (head Abbreviated Injury Scale [AIS] score 3–5, all other body areas AIS < 3). Patient data were divided based on WHO classification levels for BMI: underweight (< 18.5 kg/m2), normal weight (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), obesity class 1 (30.0–34.9 kg/m2), obesity class 2 (35.0–39.9 kg/m2), and obesity class 3 (≥ 40.0 kg/ m2). The role of BMI in patient outcomes was assessed using regression models. RESULTS In total, 103,280 patients were identified with isolated severe blunt TBI. Data were excluded for patients aged < 20 or > 89 years or with BMI < 10 or > 55 kg/m2 and for patients who were transferred from another treatment center or who showed no signs of life upon presentation, leaving data from 38,446 patients for analysis. Obesity was not found to confer a survival advantage on univariate analysis. On multivariate analysis, underweight patients as well as obesity class 1 and 3 patients had a higher rate of mortality (OR 1.86, 95% CI 1.48–2.34; OR 1.18, 95% CI 1.01–1.37; and OR 1.41, 95% CI 1.03–1.93, respectively). Increased obesity class was associated with an increased risk of respiratory com- plications (obesity class 1: OR 1.19, 95% CI 1.03–1.37; obesity class 2: OR 1.30, 95% CI 1.05–1.62; obesity class 3: OR 1.55, 95% CI 1.18–2.05) and thromboembolic complications (overweight: OR 1.43, 95% CI 1.16–1.76; obesity class 1: OR 1.45, 95% CI 1.11–1.88; obesity class 2: OR 1.55, 95% CI 1.05–2.29) despite a decreased risk of overall complica- tions (obesity class 2: OR 0.82, 95% CI 0.73–0.92; obesity class 3: OR 0.83, 95% CI 0.72–0.97). Underweight patients had a significantly increased risk of overall complications (OR 1.39, 95% CI 1.24–1.57). CONCLUSIONS Although there was an obesity-associated decrease in overall complications, the study data did not demonstrate a paradoxical protective effect of obesity on mortality after isolated severe blunt TBI. Obese patients with isolated severe blunt TBI are at increased risk of respiratory and venous thromboembolic complications. However, un- derweight patients appear to be at highest risk after severe blunt TBI, with significantly increased risks of morbidity and mortality. https://thejns.org/doi/abs/10.3171/2020.3.JNS193458 KEYWORDS traumatic brain injury; blunt trauma; body mass index; obesity; TQIP; Trauma Quality Improvement Program BESITY is a significant medical comorbidity that states having an obesity prevalence of at least 20% (https:// has risen dramatically in prevalence in the United www.cdc.gov/obesity/data/index.html). States over the last several decades. The preva- Weight is standardly described by the World Health Olence of obesity has more than doubled in the last 25 years. Organization in reference to a person’s body mass index Currently, 36.5% of the US population is obese, with all (BMI; kg/m2).1 Obesity is a BMI ≥ 30 kg/m2, with the fol- ABBREVIATIONS AIS = Abbreviated Injury Scale; ALI/ARDS = acute lung injury/acute respiratory distress syndrome; AUROC = area under the receiver operating char- acteristic; DVT = deep venous thrombosis; ED = emergency department; GCS = Glasgow Coma Scale; HR = heart rate; LOS = length of stay; PE = pulmonary embolism; SBP = systolic blood pressure; TBI = traumatic brain injury; TQIP = Trauma Quality Improvement Program; UTI = urinary tract infection; VTE = venous thromboembolism. SUBMITTED December 20, 2019. ACCEPTED March 9, 2020. INCLUDE WHEN CITING Published online June 12, 2020; DOI: 10.3171/2020.3.JNS193458. ©AANS 2021, except where prohibited by US copyright law J Neurosurg Volume 134 • May 2021 1667 Unauthenticated | Downloaded 10/04/21 04:10 PM UTC Cone et al. lowing discrete obesity classes for increasing BMI: nor- mal weight, 18.5–24.9 kg/m2; underweight, < 18.5 kg/m2; and overweight, 25.0–29.9 kg/m2. Because BMI is not a measure of body fat, there is some controversy regard- ing its utility, especially in individuals with high muscle mass.2 Despite this, BMI remains a standard variable in the description and study of weight. It is generally believed that obesity carries a substantial risk for increased morbidity and mortality in the general population.3–6 Despite this intuitive assumption, there is recent evidence that obese patients may have improved outcomes in certain clinical scenarios.7–13 This protective effect of obesity has been described as the “obesity para- dox.” This term was first coined in 2002 after Gruberg et al. showed that normal-weight patients fared worse after percutaneous coronary intervention than overweight and obese patients, and since then the obesity paradox has been examined in a wide range of medical and surgical patient populations.14 Studies have documented this phe- nomenon in cases of infection and cancer, as well as after cardiac surgery, general surgery, and vascular surgery.7,8, 1 4 – 1 7 , 1 9 , 2 0 , 3 7 Although the etiology of this paradoxical finding is unclear, it is thought to be based in an antiinflammatory effect conferred by the adipose tissue.21–23 The study of the obesity paradox in the trauma popula- tion has yielded conflicting results, likely due to the het- erogeneity of the population.18,24–31 Patients with isolated FIG. 1. Study design. All patients recorded in the TQIP database with severe blunt traumatic brain injury (TBI) represent a clini- isolated severe blunt TBI indicated by maximum (Max) AIS scores of 3 cally unique subset of the trauma population, and the ef- (n = 37,786), 4 (n = 76,856), or 5 (n = 27,366) were selected, leaving data fect of obesity on outcomes in these patients is unclear. In from 38,446 patients for analysis after exclusion criteria were applied (some patients met multiple exclusion criteria). MOI = mechanism of this study we aimed to determine the effect of patient BMI injury. on outcomes after isolated severe blunt TBI. Methods culated using the standard formula.1 Patients with BMI < This study was a retrospective analysis of patient data 10 or > 55 kg/m2 were excluded. Patients were then strati- obtained from the Trauma Quality Improvement Program fied into 5 groups according to their BMI classification: (TQIP) database. Data for all adult patients with isolated underweight (< 18.5 kg/m2), normal weight (18.5–24.9 kg/ severe blunt TBI were collected (2013–2014). Isolated se- m2), overweight (25.0–29.9 kg/m2), obesity class 1 (30.0– vere blunt TBIs were defined based on a head Abbreviated 34.9 kg/m2), obesity class 2 (35.0–39.9 kg/m2), and obesity Injury Scale (AIS) score of 3–5. Patients with significant class 3 (≥ 40.0 kg/m2). extracranial injuries (AIS > 2) were excluded (Fig. 1). Oth- The primary outcomes were overall mortality and er exclusion criteria included patients aged < 20 years or overall in-hospital complications. Secondary outcomes > 89 years and patients who were dead on arrival. Patients included occurrence of any respiratory complications (in- who were transferred from another hospital were also ex- cluding ALI/ARDS, pneumonia, and unplanned intuba- cluded, as initial data for vital signs and Glasgow Coma tion) and occurrence of any VTE complications (including Scale (GCS) scores recorded at an outside hospital could DVT and PE). not be accurately abstracted. Pertinent demographic and Unknown data points were treated as missing data. clinical data for each patient were extracted, including age, Descriptive and comparative statistical analyses were per- sex, height, weight, comorbidities (including hypertension, formed, with categorical data reported as number (%) and smoking status, diabetes mellitus, alcoholism, and bleed- nonparametric continuous variables reported as medians ing disorder), initial emergency department (ED) vital with interquartile ranges (IQRs), as well as dichotomized signs and GCS scores, hospital length of stay (LOS), ICU into clinically relevant cutoff values. Univariate analysis LOS, presence of and time to venous thromboembolism for categorical variables was performed using the chi- (VTE) prophylaxis, in-hospital complications, and mor- square test or the Fisher exact test and for continuous vari- tality. Data were collected for in-hospital complications, ables the Kruskal-Wallis test. including pneumonia, acute lung injury/acute respiratory To compare outcomes according to BMI group, bino- distress syndrome (ALI/ARDS), unplanned intubation, mial logistic regression models were constructed using deep venous thrombosis (DVT), thrombophlebitis, pul- normal-weight patients as the reference group, with vari- monary embolism (PE), urinary tract infection (UTI), and ables inserted using the enter method. Demographic and myocardial infarction, as well as mortality. BMI was cal- clinical variables—including male sex; age > 55 years; 1668 J Neurosurg Volume 134 • May 2021 Unauthenticated | Downloaded 10/04/21 04:10 PM UTC Cone et al.
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