Comparison of the sepsis-2 and sepsis-3 definitions in severely injured trauma patients

This research by Eriksson et al was published online in the Journal of Critical Care during August 2019.
Purpose:  To evaluate the performance of the new SOFA-based sepsis definition in trauma patients.
Materials and methods:  A single-centre, retrospective, observational study. Primary outcome was 30-day mortality including a censoring analysis for early deaths. The primary outcome was evaluated with logistic regression, receiver operating characteristics (ROC) curves and Kaplan-Meier survival analyses.
Results:  722 severely injured patients were included between 2007 and 2016. 315 patients fulfilled the sepsis-2 criteria and 148 fulfilled the sepsis-3 criteria during the first ten days in the ICU. The odds ratios for 30-day mortality were 0.7 (CI 0.4–1.2) for sepsis-2 and 1.5 (CI 0.8–2.6) for sepsis-3. When censoring patients dying at day 1, sepsis-3 became associated with 30-day mortality whereas sepsis-2 did not. This finding was persistent and enhanced through continuing day-by-day censoring of early deaths. The same pattern was seen for the ROC curves analyses, censoring of early deaths resulted in significant discriminatory properties for sepsis-3 but not for sepsis-2.
Conclusions:  The sepsis-3 definition identifies much fewer patients and is more strongly associated with adverse outcomes than the sepsis-2 definition. The sepsis-3 definition seems to be useful in the post trauma setting.
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Identification and internal validation of models for predicting survival and ICU admission following a traumatic injury

This article by Mitchell and colleagues was published in the November issue of Scandinavian journal of trauma, resuscitation and emergency medicine
Background:  Measures to improve the accuracy of determining survival and intensive care unit (ICU) admission using the International Classification of Injury Severity Score (ICISS) are not often conducted on a population-wide basis. The aim is to determine if the predictiveability of survival and ICU admission using ICISS can be improved depending on the method used to derive ICISS and incremental inclusion of co-variates.
Method:  A retrospective analysis of linked injury hospitalisation and mortality data during 1 January 2010 to 30 June 2014 in New South Wales, Australia was conducted. Both multiplicative-injury and single-worst-injury ICISS were calculated. Logistic regression examined 90-day mortality and ICU admission with a range of predictor variables. The models were assessed in terms of their ability to discriminate survivors and non-survivors, model fit, and variation explained.
Results:  There were 735,961 index injury admissions,13,744 (1.9%) deaths within 90-days and 23,054 (3.1%) ICU admissions. The best predictive model for 90-day mortality was single-worst-injury ICISS includingage group, gender, all comorbidities, trauma centre type, injury mechanism, and nature of injury as covariates. The multiplicative-injury ICISS with age group,gender, all comorbidities, injury mechanism, and nature of injury was the best predictive model for ICU admission.
Conclusions:  The inclusion of comorbid conditions, injury mechanism and nature of injury, improved discrimination for both 90-day mortality and ICU admission. Moves to routinely use ICD-based injury severity measures, such as ICISS, should be considered for hospitalisation data replacing more resource-intensive injury severity classification measures.

The full text of this article is freely available via this link

Incidence of Adult Respiratory Distress Syndrome in trauma patients

In trauma patients, acute respiratory distress syndrome (ARDS) is associated with high morbidity and mortality. Changes in diagnostics, management and treatment may have influenced the incidence of ARDS | Journal of Trauma and Acute Care Surgery

Background: The purpose of this manuscript is to evaluate whether there is a difference in the incidence of posttraumatic ARDS 1) over time, 2) attributable to geographic distribution, and 3) related to admitting surgical subspecialities.

Methods: A comprehensive search of articles published in English and German language was conducted using PubMed, MEDLINE, and the ISI Web of Science. Search terms included ARDS, acute respiratory distress syndrome, multiple trauma, polytrauma, and surgery. A meta-regression was performed to analyse differences between several decades of patient recruitment (decade 1: 1981-90; decade 2: 1991-2000; decade 3: 2001-2010), geographic location (North America and Europe), and the type of admitting surgical service (general vs orthopaedic trauma), respectively. Statistical analyses were performed with R (version 3.1.2, metafor package).

Conclusion: The results of this meta-analysis discard the assumption that the following factors have influenced the incidence of postraumatic ARDS: There was neither a change in the incidence over the last decades, nor a geographical difference within western societies, nor associated with the admitting surgical subspeciality.

Full reference: Pfeifer, R. et al. Incidence of Adult Respiratory Distress Syndrome (ARDS) in trauma patients: A systematic review and meta-analysis over a period of three decades. Journal of Trauma and Acute Care Surgery. Post Acceptance: June 6, 2017

The role of total cell-free DNA in predicting outcomes among trauma patients in the intensive care unit: a systematic review

This systematic review by Gogenur et al was published in the journal Critical Care in early 2017.  The full text of the article is fully available via this link

Background:  Cell-free DNA has been proposed as a means of predicting complications among severely injured patients. The purpose of this systematic review was to assess whether cell-free DNA was useful as a prognostic biomarker for outcomes in trauma patients in the intensive care unit.

Methods:  We searched Pubmed, Embase, Scopus and the Cochrane Central Register for Controlled Trials and reference lists of relevant articles for studies that assessed the prognostic value of cell-free DNA detection in trauma patients in the intensive care unit. Outcomes of interest included survival, posttraumatic complications and severity of trauma. Due to considerable heterogeneity between the included studies, a checklist was formed to assess quality of cell-free DNA measurement.

Results:  A total of 14 observational studies, including 904 patients, were eligible for analysis. Ten studies were designed as prospective cohort studies; three studies included selected patients from a cohort while one study was of a retrospective design. We found a significant correlation between higher values of cell-free DNA and higher mortality. This significant correlation was evident as early as on intensive care unit admission. Likewise, cell-free DNA predicted the severity of trauma and posttraumatic complications in a majority of patients.

Conclusion:  The amount of cell-free DNA can function as a prognostic tool for mortality and to a lesser extent severity of trauma and posttraumatic complications. Standardizing cell-free DNA measurement is paramount to ensure further research in cell-free DNA as a prognostic tool.

Advanced extracorporeal therapy in trauma

Zonies, D. & Merkel, M.Current Opinion in Critical Care22(6) pp. 578–583

Purpose of review: The purpose is to review the current application of extracorporeal life support (ECLS) in trauma patients. In addition, programmatic development is described.

Recent findings: ECLS use is increasing among trauma patients. Several recent studies among trauma patients report survival rates of 65–79%. Despite the high bleeding risk, extracorporeal membrane oxygenation (ECMO) may be safely implemented in trauma patients based on a strict protocol-driven policy. Early implementation may improve overall outcomes. Alternative anticoagulants and heparin free periods may be well tolerated in trauma patients at high risk of hemorrhage.

Summary: ECMO is becoming a more routine option in severely injured trauma patients that develop severe respiratory failure. Well tolerated implementation and program development is possible among regional trauma centers. Although clinical knowledge gaps exist, ECMO is a promising treatment in this high-risk population.

Palliative care in the trauma ICU

O’Connell, K. & Maier, R. Current Opinion in Critical Care. Published online: September 21 2016

Purpose of review: The benefits of palliative care for critically ill patients are well recognized, yet acceptance into surgical culture is lagging. With the increasing proportion of geriatric trauma patients, integration of palliative medicine within daily intensive care services to facilitate goal-concordant care is imperative.

Recent findings: Misconceptions of palliative medicine as it applies to trauma patients linger among trauma surgeons and many continue to practice without routine consultation of a palliative care service. Aggressive end-of-life care does not correlate with an improved family perception of medical care received near death. Additionally, elderly patients near the end of life often prefer palliative treatments over life-extending therapy, and their treatment preferences are often not achieved. A new geriatric-specific prognosis calculator estimates the risk of mortality after trauma, which is useful in starting goals of care discussions with older patients and their families.

Summary: Shifting our quality focus from 30-day mortality rates to measurements of symptom control and achievement of patient treatment preferences will prioritize patient beneficence and autonomy. Ownership of surgical palliative care as a service provided by acute care surgeons will ensure that our patients with incurable injury and illness will receive optimal patient-centered care.

Read the abstract here

Therapeutic hypothermia in patients following traumatic brain injury: a systematic review

Dunkley, S. et al. Nursing in Critical Care. Published online: 6 May 2016

Background: The efficacy of therapeutic hypothermia in adult patients with traumatic brain injury is not fully understood. The historical use of therapeutic hypothermia at extreme temperatures was associated with severe complications and led to it being discredited. Positive results from animal studies using milder temperatures led to renewed interest. However, recent studies have not convincingly demonstrated the beneficial effects of therapeutic hypothermia in practice.

Aim: This review aims to answer the question: in adults with a severe traumatic brain injury (TBI), does the use of therapeutic hypothermia compared with normothermia affect neurological outcome?

Design: Systematic review.

Method: Four major electronic databases were searched, and a hand search was undertaken using selected key search terms. Inclusion and exclusion criteria were applied. The studies were appraised using a systematic approach, and four themes addressing the research question were identified and critically evaluated.

Results: A total of eight peer-reviewed studies were found, and the results show there is some evidence that therapeutic hypothermia may be effective in improving neurological outcome in adult patients with traumatic brain injury. However, the majority of the trials report conflicting results. Therapeutic hypothermia is reported to be effective at lowering intracranial pressure; however, its efficacy in improving neurological outcome is not fully demonstrated. This review suggests that therapeutic hypothermia had increased benefits in patients with haematoma-type injuries as opposed to those with diffuse injury and contusions. It also suggests that cooling should recommence if rebound intracranial hypertension is observed.

Conclusion: Although the data indicates a trend towards better neurological outcome and reduced mortality rates, higher quality multi-centred randomized controlled trials are required before therapeutic hypothermia is implemented as a standard adjuvant therapy for treating traumatic brain injury.

Relevance to clinical practice: Therapeutic hypothermia can have a positive impact on patient outcome, but more research is required.

Read the abstract here

Nice Guideline update – Major Trauma: Assessment and Initial Management

This guideline covers the rapid identification and early management of major trauma in pre‑hospital and hospital settings, including ambulance services, emergency departments, major trauma centres and trauma units. It aims to reduce deaths and disabilities in people with serious injuries by improving the quality of their immediate care. It does not cover care for people with burns.

This guideline includes recommendations on:

Read the full guideline here