Associated Risk Factors and Impact in Clinical Outcomes of Multiorgan Failure in Patients with TBI.

BACKGROUND: Individual extracerebral organ dysfunction is common after severe traumatic brain injury (TBI) and impacts outcomes. However, multiorgan failure (MOF) has received less attention in patients with isolated TBI. Our objective was to analyze the risk factors associated with the development of MOF and its impact in clinical outcomes in patients with TBI. METHODS: This was an observational, prospective, multicenter study using data from a nationwide registry that currently includes 52 intensive care units (ICUs) in Spain (RETRAUCI). Isolated significant TBI was defined as Abbreviated Injury Scale (AIS) ≥ 3 in the head area with no AIS ≥ 3 in any other anatomical area. Multiorgan failure was defined using the Sequential-related Organ Failure Assessment as the alteration of two or more organs with a score of ≥ 3. We analyzed the contribution of MOF to crude and adjusted mortality (age and AIS head) by using logistic regression analysis. A multiple logistic regression analysis was performed to analyze the risk factors associated with the development of MOF in patients with isolated TBI. RESULTS: A total of 9790 patients with trauma were admitted to the participating ICUs. Of them, 2964 (30.2%) had AIS head ≥ 3 and no AIS ≥ 3 in any other anatomical area, and these patients constituted the study cohort. Mean age was 54.7 (19.5) years, 76% of patients were men, and ground-level falls were the main mechanism of injury (49.1%). In-hospital mortality was 22.2%. Up to 185 patients with TBI (6.2%) developed MOF during their ICU stay. Crude and adjusted (age and AIS head) mortality was higher in patients who developed MOF (odds ratio 6.28 [95% confidence interval 4.58-8.60] and odds ratio 5.20 [95% confidence interval 3.53-7.45]), respectively. The logistic regression analysis showed that age, hemodynamic instability, the need of packed red blood cells concentrates in the initial 24 h, the severity of brain injury, and the need for invasive neuromonitoring were significantly associated with MOF development. CONCLUSIONS: MOF occurred in 6.2% of patients with TBI admitted to the ICU and was associated with increased mortality. MOF was associated with age, hemodynamic instability, the need of packed red blood cells concentrates in the initial 24 h, the severity of brain injury, and the need for invasive neuromonitoring.

Factors associated with death due to trauma in patients with a Glasgow Coma Scale score of 3 and bilateral fixed dilated pupils. / Factores asociados con la mortalidad en pacientes traumáticos con puntuación de 3 en la escala de coma de Glasgow y midriasis bilateral arreactiva.

OBJECTIVES: To compare patients with a Glasgow Coma Scale (GCS) score of 3 stratified according to pupillary reaction and to explore factors associated with in-hospital death in those with bilateral fixed dilated pupils. MATERIAL AND METHODS: Prospective, observational, multicenter study. We included all patients with trauma and GCS scores of 3 admitted to the intensive care unit from March 2015 to December 2019. Factors associated with in-hospital mortality in the patients with bilateral dilated pupils were explored using multiple regression analysis. RESULTS: Of the 933 patients included, 454 (48.7%) had responsive pupils, 201 (21.5%) had a single fixed dilated pupil, and 278 (29.8%) had bilateral dilation. Hospital mortality was high in all 3 groups: 32.5% in those with normal responsive pupils, 54.6% in those with a single unreactive pupil, and 91.0% in those with bilateral dilation. Factors significantly associated with in-hospital death were age, a score of 3 or more on the Abbreviated Injury Scale for the head, and shock or refractory shock. Types I or II diffuse lesions and evacuated mass lesions were protective in patients with GCS scores of 3 and bilateral dilated pupils. Twelve of the 26 patients (46.1%) with bilateral dilated pupils and GCS scores of 3 had GCS scores of 14 or 15 on discharge from the hospital. CONCLUSION: The in-hospital mortality was 91% in this study of trauma patients with GCS scores of 3 and bilateral dilated pupils. Factors significantly associated with in-hospital death were age, a score of 3 or more on the Abbreviated Injury Scale for the head, and shock or refractory shock. Types I or II diffuse lesions and evacuated mass lesions were protective in patients with GCS scores of 3 and bilateral dilated pupils.

OBJETIVO: Comparar los pacientes traumáticos con una puntuación de 3 en la escala de coma de Glasgow (Glasgow Coma Scale, GCS) en función de la reactividad pupilar e investigar los factores asociados a la mortalidad hospitalaria en los pacientes con GCS 3 y midriasis bilateral arreactiva. METODO: Estudio observacional, prospectivo y multicéntrico. Se incluyeron todos los pacientes traumáticos recogidos con GCS 3 ingresados en las unidades de cuidados intensivos (UCI) participantes desde marzo 2015 hasta diciembre 2019. Se realizó un análisis de regresión logística para el estudio de los factores asociados a la mortalidad hospitalaria en pacientes con GCS 3 puntos y midriasis bilateral arreactiva. RESULTADOS: De los 933 pacientes con GCS 3 puntos, 454 (48,7%) presentaron pupilas simétricas y reactivas, 201 (21,5%) anisocoria arreactiva y 278 (29,8%) midriasis bilateral arreactiva. La mortalidad hospitalaria fue elevada en los 3 grupos: 32,5% con pupilas normales, 54,6% con anisocoria arreactiva y 91,0% con midriasis bilateral arreactiva. La edad, la puntación de 3 o más en el Abbreviated Injury Scale (cabeza) y el shock o shock refractario se asociaron de forma significativa con la mortalidad hospitalaria, siendo la lesión difusa tipo I y II y la lesión masa evacuada factores protectores en los pacientes con 3 puntos en la GCS y midriasis bilateral arreactiva. De los 26 pacientes que sobrevivieron con GCS 3 y midriasis bilateral arreactiva, 12 (46,1%) tuvieron un GCS de 14-15 al alta hospitalaria. CONCLUSIONES: La mortalidad hospitalaria de los pacientes traumáticos con 3 puntos en la GCS y midriasis bilateral arreactiva fue del 91%. La edad, la puntación de 3 o más en el Abbreviated Injury Scale (cabeza) y el shock o shock refractario se asociaron de forma significativa con la mortalidad hospitalaria, siendo la lesión difusa tipo I y II, y la lesión masa evacuada factores protectores en este grupo de pacientes.

Associated risk factors and outcomes of acute kidney injury in severe trauma: Results from the Spanish trauma ICU registry (RETRAUCI).

INTRODUCTION: Acute kidney injury (AKI) constitutes a common complication after severe trauma. Our objective was to analyse the associated risk factors and outcomes of AKI in a large, multicentre sample of trauma ICU patients. MATERIALS AND METHODS: Observational, prospective and multicentre nationwide registry (RETRAUCI). We included all patients admitted to the participating ICUs from November 2013 to May 2017. We analysed the impact of AKI evaluated by the Risk, Injury, Failure, Loss of kidney function and End-stage kidney disease (RIFLE) definition. Comparison of groups was performed using Wilcoxon test, Chi-Square Test or Fisher's exact test as appropriate. A multiple logistic regression analysis was performed to analyse associated factors to the development of AKI. Logistic regression was used to calculate AKI-related mortality. A P value<0.05 was considered significant. RESULTS: During the study period, 5882 trauma patients were admitted. Complete data were available for 5740 patients. Among them, 871 had AKI (15.17%), distributed by RIFLE R 458 (7.98%), RIFLE I 234 (4.08%) and RIFLE F 179 (3.12%). Associated risk factors were: age (OR 3.05), haemodynamic instability (OR 2.90 to OR 8.34 depending on the severity of hypotension), coagulopathy (OR 1.82), rhabdomyolysis (OR 4.67) and AIS abdomen (OR 1.54). AKI was associated with mortality (crude OR 1.93 (1.59-2.36)), even after adjusting by potential confounders (adjusted OR 1.40 (1.13-1.73)). CONCLUSION: In our large sample of trauma ICU patients we found an incidence of AKI of 15%, which was associated with an increased mortality.