Mortality prediction using TRISS methodology in the Spanish ICU Trauma Registry (RETRAUCI) / Predicción de la mortalidad a través de la metodología TRISS en el Registro Español de Trauma en UCI (RETRAUCI)

OBJECTIVES: To validate Trauma and Injury Severity Score (TRISS) methodology as an auditing tool in the Spanish ICU Trauma Registry (RETRAUCI). DESIGN: A prospective, multicenter registry evaluation was carried out. SETTING: Thirteen Spanish Intensive Care Units (ICUs). PATIENTS: Individuals with traumatic disease and available data admitted to the participating ICUs. INTERVENTIONS: Predicted mortality using TRISS methodology was compared with that observed in the pilot phase of the RETRAUCI from November 2012 to January 2015. Discrimination was evaluated using receiver operating characteristic (ROC) curves and the corresponding areas under the curves (AUCs) (95% CI), with calibration using the Hosmer-Lemeshow (HL) goodness-of-fit test. A value of p < 0.05 was considered significant. Main variables of interest: Predicted and observed mortality. RESULTS: A total of 1405 patients were analyzed. The observed mortality rate was 18% (253 patients), while the predicted mortality rate was 16.9%. The area under the ROC curve was 0.889 (95% CI: 0.867-0.911). Patients with blunt trauma (n=1305) had an area under the ROC curve of 0.887 (95% CI: 0.864-0.910), and those with penetrating trauma (n=100) presented an area under the curve of 0.919 (95% CI: 0.859-0.979). In the global sample, the HL test yielded a value of 25.38 (p = 0.001): 27.35 (p < 0.0001) in blunt trauma and 5.91 (p = 0.658) in penetrating trauma. TRISS methodology underestimated mortality in patients with low predicted mortality and overestimated mortality in patients with high predicted mortality. CONCLUSIONS: TRISS methodology in the evaluation of severe trauma in Spanish ICUs showed good discrimination, with inadequate calibration - particularly in blunt trauma

Objetivos: Evaluar el Trauma and Injury Severity Score (TRISS) como instrumento de auditoría en el Registro Español de Trauma en UCI. Diseño: Evaluación prospectiva de un registro multicéntrico. Ámbito: Trece UCI españolas. Pacientes: Individuos con enfermedad traumática y datos completos ingresados en las UCI participantes. Intervenciones: Comparamos la mortalidad predicha por el TRISS con la observada en la fase piloto del Registro Español de Trauma en UCI desde noviembre de 2012 hasta enero de 2015. La discriminación se evaluó mediante curvas receiver operating characteristic y el valor bajo su área (IC 95%), y la calibración, mediante el test de bondad de ajuste de Hosmer-Lemeshow. Un valor de p<0,05 se consideró significativo. Principales variables de interés: Mortalidad observada y predicha. Resultados: Analizamos 1.405 pacientes. La mortalidad observada fue del 18% (253 pacientes), mientras que la predicha fue del 16,9%. El área bajo la curva receiver operating characteristic fue de 0,889 (IC 95% 0,867-0,911). Los pacientes con trauma cerrado (n=1.305) presentaron un área bajo la curva receiver operating characteristic de 0,887 (IC 95% 0,864-0,910), y aquellos con traumatismo penetrante (n=100), de 0,919 (IC 95% 0,859-0,979). En la muestra global, el test de Hosmer-Lemeshow mostró un valor de 25,38 (p=0,001), siendo de 27,35 (p<0,0001) en trauma cerrado y de 5,91 (p=0,658) en trauma penetrante. La metodología TRISS infraestimó la mortalidad en los pacientes con mortalidad predicha baja y la sobreestimó en pacientes con mortalidad predicha elevada. Conclusiones: La aplicación de la metodología TRISS en el trauma grave ingresado en las UCI españolas mostró buenos niveles de discriminación y una calibración inadecuada, especialmente en el traumatismo cerrado (AU)

Mortality prediction using TRISS methodology in the Spanish ICU Trauma Registry (RETRAUCI).

OBJECTIVES: To validate Trauma and Injury Severity Score (TRISS) methodology as an auditing tool in the Spanish ICU Trauma Registry (RETRAUCI). DESIGN: A prospective, multicenter registry evaluation was carried out. SETTING: Thirteen Spanish Intensive Care Units (ICUs). PATIENTS: Individuals with traumatic disease and available data admitted to the participating ICUs. INTERVENTIONS: Predicted mortality using TRISS methodology was compared with that observed in the pilot phase of the RETRAUCI from November 2012 to January 2015. Discrimination was evaluated using receiver operating characteristic (ROC) curves and the corresponding areas under the curves (AUCs) (95% CI), with calibration using the Hosmer-Lemeshow (HL) goodness-of-fit test. A value of p<0.05 was considered significant. MAIN VARIABLES OF INTEREST: Predicted and observed mortality. RESULTS: A total of 1405 patients were analyzed. The observed mortality rate was 18% (253 patients), while the predicted mortality rate was 16.9%. The area under the ROC curve was 0.889 (95% CI: 0.867-0.911). Patients with blunt trauma (n=1305) had an area under the ROC curve of 0.887 (95% CI: 0.864-0.910), and those with penetrating trauma (n=100) presented an area under the curve of 0.919 (95% CI: 0.859-0.979). In the global sample, the HL test yielded a value of 25.38 (p=0.001): 27.35 (p<0.0001) in blunt trauma and 5.91 (p=0.658) in penetrating trauma. TRISS methodology underestimated mortality in patients with low predicted mortality and overestimated mortality in patients with high predicted mortality. CONCLUSIONS: TRISS methodology in the evaluation of severe trauma in Spanish ICUs showed good discrimination, with inadequate calibration - particularly in blunt trauma.

Drenaje lumbar exteno como tratamiento de la hipertensión endocraneal refractaria en el paciente con traumatismo craneoencefálico / External lumbar drainage as treatment of refractory endocranial hypertension inpatients with head trauma

La hipertensión endocraneal es una complicación frecuente en el traumatismo craneoencefálico grave apareciendo hasta en el 50%-75% de los casos. En ocasiones no se consigue controlar la hipertensión endocraneal a pesar del tratamiento. En estos casos la mortalidad alcanza el 84%-100%. El drenaje lumbar externo es una opción terapéutica en la hipertensión endocraneal refractaria. Aunque su uso fundamental ha sido en pacientes pediátricos, también existe experiencia en pacientes adultos. En la literatura se refiere que esta técnica frecuentemente controla la presión intracraneal y se asocia a una escasa incidencia de complicaciones graves. Presentamos nuestra experiencia en el uso del drenaje lumbar externo en 4 pacientes ingresados por traumatismo craneoencefálico grave que tuvieron una hipertensión endocraneal refractaria al tratamiento habitual, que se controló con el drenaje lumbar externo

Endocranial hypertension is a frequent complication in severe head trauma appearing up to in 50-75% of cases. At times it is impossible to manage endocranial hypertension despite the treatment, and in these cases mortality reaches 84-100%. External lumbar drainage is a therapeutic option in refractory endocranial hypertension. Although it has been used predominantly in pediatric patients there is also experience in adult patients. The literature shows that this technique frequently controls intracranial pressure and that is associated with a limited incidence of serious complications. We present our experience in the use of external lumbar drainage in four patients admitted because of severe head trauma who showed refractory to the habitual treatment; endocranial hypertension in this case was controlled with external lumbar drainage

[Posttraumatic carotid-cavernous fistula diagnosed by transcranial color-coded duplex sonography]. / Diagnóstico por dúplex transcraneal color de una fístula carótido-cavernosa traumática.

The extracranial carotid duplex is a feasible, non invasive technique that is useful for the diagnosis of some intracranial pathologies. We present the case of a patient who was admitted in our unit with a severe traumatic brain injury. An early transcranial color duplex showed a mosaic color flash with unidirectional turbulent flow that was compatible with a posttraumatic carotid cavernous fistula that was confirmed by angio MRI.

Diagnóstico por dúplex transcraneal color de una fístula carótido-cavernosa traumática / Postraumatic carotid-cavernous fistula diagnosed by transcranial color-coded duplex sonography

El "dúplex transcraneal color" (DTCC) es una técnica de imagen no invasiva que está demostrando ser útil tanto en el diagnóstico como en el seguimiento de ciertas patologías de localización intracraneal. Presentamos el caso de un paciente que sufrió un traumatismo craneofacial grave al que se realizó un DTCC en los primeros días del ingreso que evidenció un flujo anómalo compatible con fístula carótido-cavernosa (FCC) confirmada posteriormente por angio-RNM (AU)

[Indirect calorimetry in critical ill patients: validity of measurement for ten minutes]. / Calorimetría indirecta en el enfermo crítico: validez de la medición durante 10 minutos.

GOAL: There are no gold standards on the duration and frequency of the measurement of indirect calorimetry, a fact of importance in daily clinical practice. An assessment of is made of the degree of concordance between energy expenditure at rest (EER) measured over a short interval (10 minutes) versus another prolonged measurement (1 hour). PATIENTS: Sixty critically-ill patients, under sedation and analgesia with connection to mechanical ventilation, were studied. INTERVENTIONS: EER values were determined by means of a metabolic computer analysis (Engström Eliza) at rest. The reproducibility and the degree of concordance were assessed in the measurements made with both periods. RESULTS: The mean values of the EER determinations at 10 and 60 minutes were 1,818 +/- 319 kilocalories/day and 1,815 +/- 318 Kcal/day. The limits of the concordance between both times were -101 and +117 kilocalories/day and the correlation was significant (r = 0.98, p < 0.0001). CONCLUSIONS: In critically-ill patients under sedation and with mechanical ventilation, the measurement of EER may be taken over short periods of time (10 minutes) providing that baseline examination conditions are met, thus giving greater availability of the resources used to study indirect calorimetry.

Calorimetría indirecta en el enfermo crítico: validez de la medición durante 10 minutos / Indirect calorimetry in critical ill patients: validity of measurement for ten minutes

Objetivo: No existen estándares definidos sobre la duración y frecuencia de la medición de la calorimetría indirecta, hecho que tiene importancia en la práctica asistencial diaria. Se valora el grado de concordancia entre el gasto energético en reposo (GER) medido en un espacio de tiempo corto (10 minutos) frente a otro prolongado (1 hora).Pacientes: Se estudiaron 60 pacientes críticos, sedoanalgesiados y conectados a ventilación mecánica. Intervenciones: El GER se determinó mediante un computador metabólico (Engström Eliza) en condiciones de reposo. Se valoró la reproducibilidad y el grado de acuerdo de las mediciones hechas en ambos períodos de tiempo. Resultados: Los valores medios de las determinaciones de GER a 10 y 60 minutos fueron de 1818 ñ 319 Kilocalorías/día y de 1815 ñ 318 Kcal/día. Los límites de acuerdo entre ambos tiempos fueron de -101 a + 117 Kilocalorías/día y la correlación fue significativa (r = 0.98, p < 0,0001).Conclusiones: En los pacientes críticos, sedados y en ventilación mecánica, la medición del GER puede hacerse en períodos de tiempo cortos (10 minutos) siempre que se cumplan unas condiciones basales de exploración, lo que permite una mayor disponibilidad de los recursos usados para el estudio de la calorimetría indirecta. (AU)

Goal: There are no gold standards on the duration and frequency of the measurement of indirect calorimetry, a fact of importance in daily clinical practice. An assessment of is made of the degree of concordance between energy expenditure at rest (EER) measured over a short interval (10 minutes) versus another prolonged measurement (1 hour). Patients: Sixty critically-ill patients, under sedation and analgesia with connection to mechanical ventilation, were studied. Interventions: EER values were determined by means of a metabolic computer analysis (Engström Eliza) at rest. The reproducibility and the degree of concordance were assessed in the measurements made with both periods. Results: The mean values of the EER determinations at 10 and 60 minutes were 1,818 ± 319 kilocalories/day and 1,815 ± 318 Kcal/day. The limits of the concordance between both times were -101 and +117 kilocalories/day and the correlation was significant (r = 0.98, p < 0.0001). Conclusions: In critically-ill patients under sedation and with mechanical ventilation, the measurement of EER may be taken over short periods of time (10 minutes) providing that baseline examination conditions are met, thus giving greater availability of the resources used to study indirect calorimetry (AU)