ASA classification and surgical severity grading used to identify a high-risk population, a multicenter prospective cohort study in Swedish tertiary hospitals.

BACKGROUND: Identification of surgical populations at high risk for negative outcomes is needed for clinical and research purposes. We hypothesized that combining two classification systems, ASA (American Society of Anesthesiology physical status) and surgical severity, we could identify a high-risk population before surgery. We aimed to describe postoperative outcomes in a population selected by these two classifications system. METHODS: Data were collected in a Swedish multicentre, time-interrupted prospective, consecutive cohort study. Eligibility criteria were age ≥18 years, ASA ≥3, elective or emergent, major to Xmajor/complex (Specialist Procedure Codes used in United Kingdom), gastrointestinal, urogenital or orthopaedic procedures. Postoperative morbidity was identified by the Postoperative Morbidity Survey on postoperative days 3 ± 1, 7 ± 1, 10 + 5 and graded for severity by the Clavien-Dindo system. Mortality was assessed at 30, 180 and 360 days. RESULTS: Postoperative morbidity was 78/48/47 per cent on postoperative days 3/7/10. Majority of morbidities (67.5 per cent) were graded as >1 by Clavien-Dindo. Any type of postoperative morbidity graded >1 was associated with increased risk for death up to one year. The mortality was 5.7 per cent (61/1063) at 30 days, 13.3 per cent (142/1063) at 6 months and 19.1 per cent (160/1063) at 12 months. CONCLUSION: Severity classification as major to Xmajor/complex and ASA ≥3 could be used to identify a high-risk surgical population concerning postoperative morbidity and mortality before surgery. Combining the two systems future electronic data extraction is possible of a high-risk population in tertiary hospitals.

Characteristics and outcomes of patients with COVID-19 admitted to ICU in a tertiary hospital in Stockholm, Sweden.

BACKGROUND: Information on characteristics and outcomes of intensive care unit (ICU) patients with COVID-19 remains limited. We examined characteristics, clinical course and early outcomes of patients with COVID-19 admitted to ICU. METHODS: We included all 260 patients with COVID-19 admitted to nine ICUs at the Karolinska University Hospital (Stockholm, Sweden) between 9 March and 20 April 2020. Primary outcome was in-hospital mortality among patients with definite outcomes (discharged from ICU or death), as of 30 April 2020 (study end point). Secondary outcomes included ICU length of stay, the proportion of patients receiving mechanical ventilation and renal replacement therapy, and hospital discharge destination. RESULTS: Of 260 ICU patients with COVID-19, 208 (80.0%) were men, the median age was 59 (IQR 51-65) years, 154 (59.2%) had at least one comorbidity, and the median duration of symptoms preceding ICU admission was 11 (IQR 8-14) days. Sixty-two (23.8%) patients remained in ICU at study end point. Among the 198 patients with definite outcomes, ICU length of stay was 12 (IQR, 6-18) days, 163 (82.3%) received mechanical ventilation, 28 (14.1%) received renal replacement therapy, 60 (30.3%) died, 62 (31.3%) were discharged home, 47 (23.7%) were discharged to ward, and 29 (14.6%) were discharged to another health care facility. On multivariable logistic regression analysis, older age and admission from the emergency department was associated with higher mortality. CONCLUSION: This study presents detailed data on clinical characteristics and early outcomes of consecutive patients with COVID-19 admitted to ICU in a large tertiary hospital in Sweden.

Socio-economic status and co-morbidity as risk factors for trauma.

Clinical experience and previous studies indicate that low socioeconomic positions are overrepresented in trauma populations. The reason for this social variation in injury risk is likely to be multifactorial. Both individual and environmental sources of explanation are plausible to contribute. We investigated the impact of the influence of socioeconomic factors and co-morbidity on the risk of becoming a trauma victim in a case-control study including 7,382 trauma patients matched in a one to five ratio with controls matched by age-, gender- and municipality from a level 1 trauma centre. Data from the trauma cohort were linked to national registries. Associations between socioeconomic factors and co-morbidity were estimated by conditional logistic regression. The trauma patients had been treated for psychiatric, substance abuse and somatic diagnoses to a higher extent than the controls. In the conditional logistic regression analysis a low level of education and income as well as co-morbidity (divided into psychiatric, substance abuse and somatic diagnoses) were all independent risk factors for trauma. Analysing patients with an injury severity score >15 separately did not alter the results, except for somatic diagnoses not being a risk factor. Recent treatment for substance abuse significantly increased the risk for trauma. Low level of education and income as well as psychiatric, substance abuse and somatic co-morbidity were all independent risk factors for trauma. Active substance abuse strongly influenced the risk for trauma and had a time dependent pattern. These insights can facilitate future implementation of injury prevention strategies tailored to specific risk groups.

Effect of plasma-to-RBC ratios in trauma patients: a cohort study with time-dependent data*.

BACKGROUND: A widespread approach today is to transfuse bleeding trauma patients with RBC concentrates and plasma at a 1:1 ratio. This regime is supported by a range of observational studies showing lower mortality in bleeding patients receiving equal volumes of plasma and RBCs. The rationale for this practice is still unclear with several studies failing to show any survival benefits of increased plasma use, perhaps due to a failure to account for the timing of transfused units. OBJECTIVE: To study the association between plasma-to-RBC ratios and risk of death in trauma patients, using appropriate methods. DESIGN, SETTINGS, AND PARTICIPANTS: In a retrospective cohort study, we assembled data on 741 transfused trauma patients at a large trauma center. Measures of transfusion therapy were assessed entirely time dependently, and relative risk of death was compared between patients receiving low to high plasma-to-RBC ratio (< 0.85 vs > 0.85). MEASUREMENTS AND RESULTS: In the time-dependent analyses, we saw no significant association between a low plasma ratio and the risk of death. However, age more than 75 years, injury severity score greater than 33, Glasgow Coma Scale less than 8, and systolic blood pressure lower than 90 mm Hg were all significantly associated with increased risk of death. Conversely, when the analyses were conducted with conventional methods, a strong protective effect of high plasma ratios was seen. CONCLUSIONS: The key finding in our study is the strikingly different results produced by time-dependent analyses and the conventional analyses when studying survival and plasma-to-RBC ratio, supporting recent claims that prior studies showing benefit of high plasma ratios might have suffered from survival bias. There is a great need for further studies on the subject to enable improvements in treatment of massively bleeding trauma patients.

Patient and process factors associated with opportunities for improvement in trauma care: a registry-based study.

BACKGROUND: Trauma is one of the leading causes of morbidity and mortality worldwide. Morbidity and mortality review of selected patient cases is used to improve the quality of trauma care by identifying opportunities for improvement (OFI). The aim of this study was to assess how patient and process factors are associated with OFI in trauma care. METHODS: We conducted a registry-based study using all patients between 2017 and 2021 from the Karolinska University Hospital who had been reviewed regarding the presence of OFI as defined by a morbidity and mortality conference. We used bi- and multivariable logistic regression to assess the associations between the following patient and process factors and OFI: age, sex, respiratory rate, systolic blood pressure, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), survival at 30 days, highest hospital care level, arrival on working hours, arrival on weekends, intubation status and time to first computed tomography (CT). RESULTS: OFI was identified in 300 (5.8%) out of 5182 patients. Age, missing Glasgow Coma Scale, time to first CT, highest hospital care level and ISS were statistically significantly associated with OFI. CONCLUSION: Several patient and process factors were found to be associated with OFI, indicating that patients with moderate to severe trauma and those with delays to first CT are at the highest odds of OFI.

Time dependent influence of host factors on outcome after trauma.

The impact of host factors, such as gender and co-morbidity, on mortality after trauma has been debated. Quantification of risk factors is dependent on methodological considerations including follow-up time, definitions and adjustment of potential confounders. Optimal follow-up time of trauma patients remains to be elucidated. We investigated the impact of gender and co-morbidity on short and long term mortality in a cohort including 4,051 patients from a level 1 trauma centre. Data from the trauma cohort were linked to validated national registries. 30 and 360-day survival were analysed with logistic and Cox regression, respectively. Long term survival was also estimated as standardized mortality ratio, which implies a comparison with a matched general population. The influence of host factors on outcome after trauma differed over time. Male gender was an independent risk factor for mortality at 1 year but not at 30-days post-injury, even after adjustment for clinically relevant confounders. This gender difference was also apparent when comparing mortality rates with the general population. Moreover, the effect of gender seems to be restricted to elderly patients. The presence of co-morbidity became a significant risk factor beyond 30 days after trauma, suggesting that this patient group may benefit from a more thorough follow up after hospital discharge. A persistent excess mortality compared to the general population was still seen 1 year after the trauma. Our findings indicate that the effect of trauma is not limited to the early post-injury period but adversely affects the long term outcome.

Long-term follow-up of patients treated for traumatic injury regarding physical and psychological function and health-related quality of life.

PURPOSE: Trauma patients often suffer for long time after their injury with physical and psychological problems. Patient-reported outcome measurements (PROM) help us to understand outcomes beyond mortality. The aim of the study was to describe a sample of Swedish trauma patients, regarding their physical function, psychological morbidity, and quality of life after trauma. METHODS: The study population was sourced from the Swedish Trauma Register: taking 1 month of data from five hospitals, over three consecutive years. 218 patients met the inclusion criteria, 147 data sets were used. Inclusion criteria included: age ≥ 18; New Injury Severity Scale (NISS) ≥ 9; and discharged alive. Data were collected at 3, 6, and 12 months after the trauma. EuroQol-5D (EQ-5D), Posttraumatic Symptom Scale-10 (PTSS-10) questionnaires and Glasgow Outcome Score (GOS) instrument were used with additional questions about pain and return to work. RESULTS: 12 months after the trauma: full functional recovery (GOS 5) was seen in 68% of the patients; 59% reported difficult or moderate pain or discomfort; and 44.5% of the patients had returned to work. In EQ-5D mobility dimension, no recovery was evident between 6 and 12 months. Twenty percent of the patients had significant symptoms for PTSD after 6 months and 16% after 3 months and 12 months. CONCLUSION: Trauma patients had decreased physical function and psychological morbidity up to 1 year after the initial injury. Incorporating PROM in the follow-up after trauma is important to understand the patient's perspective of care and treatment.

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

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.

Predicting prolonged sick leave among trauma survivors.

Many survivors after trauma suffer from long-term morbidity. The aim of this observational cohort study was to develop a prognostic prediction tool for early assessment of full-time sick leave one year after trauma. Potential predictors were assessed combining individuals from a trauma register with national health registers. Two models were developed using logistic regression and stepwise backward elimination. 4458 individuals were included out of which 488 were on sick leave full-time 12 months after the trauma. One comprehensive and one simplified model were developed including nine and seven predictors respectively. Both models showed excellent discrimination (AUC 0.81). The comprehensive model had very good calibration, and the simplified model good calibration. Prediction models can be used to assess post-trauma sick leave using injury-related variables as well as factors not related to the trauma per se. Among included variables, pre-injury sick leave was the single most important predictor for full-time sick leave one year after trauma. These models could facilitate a more efficient use of resources, targeting groups for follow-up interventions to improve outcome. External validation is necessary in order to evaluate generalizability.

Thioredoxin a novel biomarker of post-injury sepsis.

BACKGROUND: Thioredoxin (TRX), an endogenous anti-oxidant protein induced in inflammatory conditions, has been shown to increase in plasma and to be associated with outcome in septic patients. This biomarker has never been studied in a trauma setting. We hypothesized that TRX would be increased after trauma and associated with post-injury sepsis. METHODS: Single-centre prospective observational study conducted at the intensive care unit (ICU) at the Karolinska University Hospital, Stockholm, Sweden, a level-1 trauma centre. Eighty-three severely injured trauma patients, 18 years or older, with an ICU stay of three days or more were included. Plasma samples were obtained on day 1 and 3 after informed consent. Clinical, physiological and outcome data were retrieved from the trauma and ICU research registries. Plasma samples were also obtained from 15 healthy subjects. In addition, a standardized porcine trauma model was conducted where a femur fracture followed by a controlled hemorrhage period were inflicted in four pigs. RESULTS: In pigs, however not significant, there was a continuing increase in plasma-TRX after femur fracture and sequential hemorrhage despite near normalisation of cardiac index and lactate levels. In patients, median injury severity score was 29 and 48 patients developed sepsis during their ICU stay. A three-fold increase in initial TRX was seen in trauma patients when compared to healthy volunteers. Thioredoxin was significantly higher in patients in shock on admission, those subject to massive transfusion and in the most severely injured patients. No difference was seen between survivors and non-survivors. Plasma-TRX on day 1 was significantly increased in patients who later developed post-injury sepsis. In a logistic regression analysis including TRX, C-reactive protein, injury severity, massive transfusion, and admission blood pressure, TRX was the only variable independently associated with post-injury sepsis. CONCLUSIONS: This study demonstrates that TRX is released into plasma in response to severe trauma and independently associated with post-injury sepsis. The use of TRX as a biomarker in trauma patients needs further evaluation in larger studies. LEVEL OF EVIDENCE: Retrospective cohort study, level III.

Post-trauma morbidity, measured as sick leave, is substantial and influenced by factors unrelated to injury: a retrospective matched observational cohort study.

BACKGROUND: Mortality as an endpoint has been the focus of trauma research whereas few studies investigate long-term outcomes in terms of morbidity. An adequate analysis of post-injury morbidity includes several dimensions, for this reason sick leave has been used as a proxy for morbidity in the current study. The aim of this retrospective matched observational cohort study was to investigate sick leave before and after trauma and factors associated with prolonged sick leave. METHODS: Patients from a level one trauma centre 2005-2010 were matched in a 1:5 ratio with uninjured controls. By linkage to national registries, sick leave rates were compared. The association between potential risk factors and full-time sick leave at twelve months post injury, the primary end-point, was examined in trauma patients by logistic regression. RESULTS: Four thousand seven hundred twelve patients and 25,013 controls aged 20-63 were included. Trauma patients had more sick leave both before and after trauma. Age, psychiatric disease, low level of education, serious injury, spinal injury, reduced consciousness at admission, discharge destination other than home, and hospital length of stay >7 days were all associated with the primary end-point. The strongest risk factor was sick leave before trauma; this was also noted in the most seriously injured patients. DISCUSSION: In this retrospective matched observational cohort study we found a significant long-term morbidity, measured as sick leave, among trauma patients. Compared to controls the difference was maximal early after trauma and sustained throughout the follow up period. In the logistic regression, factors associated with the traumatic injury as well as host factors increased the probability of not returning to work. Full sick leavemonth twelve post injury was strongly associated with pre-injury sick leave but also with age, psychiatric comorbidity, level of education, injury severity, spinal injury, low GCS at admission, length of stay at hospital and discharge to other destination than home. CONCLUSIONS: Trauma patients suffer from significant long-term morbidity. The sustained post-trauma morbidity is largely influenced by factors not related to injury per se. These insights enable identification of patients at risk for prolonged sick leave after trauma.

Acute kidney injury following severe trauma: Risk factors and long-term outcome.

BACKGROUND: The trauma patient sustains numerous potentially harmful insults that may contribute to a notable risk of acute kidney injury (AKI). The aim of this study was to investigate the incidence of and to identify risk factors for AKI in severely injured trauma patients admitted to the intensive care unit (ICU). The patients were followed up for 1 year with respect to survival and end-stage renal disease. METHODS: Trauma patients admitted to the ICU for more than 24 hours at a Level I trauma center were included. The outcome measure was AKI diagnosed Days 2 to 7 of ICU treatment. Regression analysis was performed to identify factors associated with AKI development. RESULTS: A quarter of the patients (103 of 413) developed AKI within the first week of ICU admission. AKI was associated with increased 30-day (17.5% vs. 5.8%) and 1-year (26.2% vs. 7.1%) mortality. Risk factors for AKI were male sex, age, nondiabetic comorbidity, diabetes mellitus, Injury Severity Score (ISS) greater than 40, massive transfusion, and volume loading with hydroxyethyl starch (HES) within the first 24 hours. Unexpectedly, sepsis before AKI onset, admission hypotension, and extensive contrast loading (>150 mL) were not associated with AKI development. None of the surviving AKI patients had developed end-stage renal disease 1 year after injury. CONCLUSION: AKI in ICU-admitted trauma patients is a common complication with substantial mortality. Diabetes, male sex, and severe injury were strong risk factors, but age, nondiabetic comorbidity, massive transfusion, and resuscitation with HES were also associated with postinjury AKI. Based on the results of the current study, volume resuscitation with HES cannot be recommended in trauma patients. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic study, level IV.

Screening and treatment of problems after intensive care: a descriptive study of multidisciplinary follow-up.

OBJECTIVES: To describe a multidisciplinary intensive care follow-up and the methods used for identifying and managing physical and psychological problems in ICU survivors. METHODS: Patients treated>four days in an intensive care unit (ICU) were invited three, six and 12 months after intensive care for screening of physical problems with function tests and psychological problems with the Impact of Event Scale (IES) and the Hospital Anxiety and Depression Scale (HADS). RESULTS: 40 of 61 patients had clinically impaired physical function, with no ongoing physical rehabilitation at three months. Twenty-two patients received specific training instructions and 18 patients were referred for physiotherapy. 34 of 61 patients had symptoms of moderate to severe posttraumatic stress and/or symptoms of clinically significant anxiety or depression. Twelve patients accepted referral for psychiatric evaluation and treatment. CONCLUSION: Multidisciplinary follow-up after intensive care can be of value in identifying untreated physical and psychological problems in ICU survivors. Liaison with specialists enables referral for identified problems. Patients screened and treated in the first six months appear to have little need for further follow-up after intensive care.