Prediction of massive bleeding. Shock index and modified shock index. / Predicción de hemorragia masiva. Índice de shock e índice de shock modificado.

OBJECTIVE: To determine the predictive value of the Shock Index and Modified Shock Index in patients with massive bleeding due to severe trauma. DESIGN: Retrospective cohort. SETTING: Severe trauma patient's initial attention at the intensive care unit of a tertiary hospital. SUBJECTS: Patients older than 14 years that were admitted to the hospital with severe trauma (Injury Severity Score >15) form January 2014 to December 2015. VARIABLES: We studied the sensitivity (Se), specificity (Sp), positive and negative predictive value (PV+ and PV-), positive and negative likelihood ratio (LR+ and LR-), ROC curves (Receiver Operating Characteristics) and the area under the same (AUROC) for prediction of massive hemorrhage. RESULTS: 287 patients were included, 76.31% (219) were male, mean age was 43,36 (±17.71) years and ISS was 26 (interquartile range [IQR]: 21-34). The overall frequency of massive bleeding was 8.71% (25). For Shock Index: AUROC was 0.89 (95% confidence intervals [CI] 0.84 to 0.94), with an optimal cutoff at 1.11, Se was 91.3% (95% CI: 73.2 to 97.58) and Sp was 79.69% (95% CI: 74.34 to 84.16). For the Modified Shock Index: AUROC was 0.90 (95% CI: 0.86 to 0.95), with an optimal cutoff at 1.46, Se was 95.65% (95% CI: 79.01 to 99.23) and Sp was 75.78% (95% CI: 70.18 to 80.62). CONCLUSION: Shock Index and Modified Shock Index are good predictors of massive bleeding and could be easily incorporated to the initial workup of patients with severe trauma.

Epidemiology of severe trauma in Spain. Registry of trauma in the ICU (RETRAUCI). Pilot phase. / Epidemiología del trauma grave en España. REgistro de TRAuma en UCI (RETRAUCI). Fase piloto.

OBJECTIVE: To describe the characteristics and management of severe trauma disease in Spanish Intensive Care Units (ICUs). Registry of trauma in the ICU (RETRAUCI). Pilot phase. DESIGN: A prospective, multicenter registry. SETTING: Thirteen Spanish ICUs. PATIENTS: Patients with trauma disease admitted to the ICU. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Epidemiology, out-of-hospital attention, registry of injuries, resources utilization, complications and outcome were evaluated. RESULTS: Patients, n=2242. Mean age 47.1±19.02 years. Males 79%. Blunt trauma 93.9%. Injury Severity Score 22.2±12.1, Revised Trauma Score 6.7±1.6. Non-intentional in 84.4% of the cases. The most common causes of trauma were traffic accidents followed by pedestrian and high-energy falls. Up to 12.4% were taking antiplatelet medication or anticoagulants. Almost 28% had a suspected or confirmed toxic influence in trauma. Up to 31.5% required an out-of-hospital artificial airway. The time from trauma to ICU admission was 4.7±5.3hours. At ICU admission, 68.5% were hemodynamically stable. Brain and chest injuries predominated. A large number of complications were documented. Mechanical ventilation was used in 69.5% of the patients (mean 8.2±9.9 days), of which 24.9% finally required a tracheostomy. The median duration of stay in the ICU and in hospital was 5 (range 3-13) and 9 (5-19) days, respectively. The ICU mortality rate was 12.3%, while the in-hospital mortality rate was 16.0%. CONCLUSIONS: The pilot phase of the RETRAUCI offers a first impression of the epidemiology and management of trauma disease in Spanish ICUs.

Analysis of the nutritional management practices in intensive care: Identification of needs for improvement.

OBJECTIVES: To analyze the nutritional management practices in Intensive Care (ICU) to detect the need for improvement actions. Re-evaluate the process after implementation of improvement actions. DESIGN: Prospective observational study in 3 phases: 1) observation; 2) analysis, proposal development and dissemination; 3) analysis of the implementation. SETTING: ICU of a hospital of high complexity. PARTICIPANTS: Adult ICU forecast more than 48h of artificial nutrition. PRIMARY ENDPOINTS: Parenteral nutrition (PN), enteral nutrition (EN) (type, average effective volume, complications) and average nutritional ratio. RESULTS: A total of 229 patients (phase 1: 110, phase 3: 119). After analyzing the initial results, were proposed: increased use and precocity of EN, increased protein intake, nutritional monitoring effectiveness and increased supplementary indication NP. The measures were broadcast at specific meetings. During phase 3 more patients received EN (55.5 vs. 78.2%, P=.001), with no significant difference in the start time (1.66 vs. 2.33 days), duration (6.82 vs. 10,12 days) or complications (37,7 vs. 47,3%).Use of hyperproteic diets was higher in phase 3 (0 vs. 13.01%, P<.05). The use of NP was similar (48.2 vs. 48,7%) with a tendency to a later onset in phase 3 (1.25±1.25 vs. 2.45±3.22 days). There were no significant differences in the average nutritional ratio (0.56±0.28 vs. 0.61±0.27, P=.56). CONCLUSIONS: The use of EN and the protein intake increased, without appreciating effects on other improvement measures. Other methods appear to be necessary for the proper implementation of improvement measures.

[Trauma registries: a health priority, a strategic project for the SEMICYUC]. / Registros de trauma: una prioridad sanitaria, un proyecto estratégico para la SEMICYUC.

The most efficient approach to traumatologic disease is prevention, but physicians also must supervise care of the victims. An operational and effective trauma registry requires financial support, adequate software, a well-defined population, personnel committed to training, and a detailed process for data collection, reporting, validation and the maintenance of confidentiality. Above all, however, motivation is required. Registries can offer many benefits in relation to these highly prevalent disorders, with an impact in terms of health promotion and even advantages in the form of cost reductions, as well as relief from the suffering caused by trauma (mortality, disability)-contributing to improve the efficiency and quality of critical trauma care. The SEMICYUC has demonstrated its ability to establish and maintain records of national interest, and this should become a priority project.

[Development of communication tool for patient safety ("Briefing"). Experience in a trauma and emergency intensive care unit]. / Desarrollo de una herramienta de comunicación para la seguridad del paciente (Briefing). Experiencia en una unidad de cuidados intensivos de trauma y emergencias.

OBJECTIVE: To validate a safety tool used in high-risk sectors (safety briefing) in intensive care medicine. DESIGN: A prospective, observational and analytical study was carried out. SETTING: Trauma and emergency intensive care unit in a tertiary hospital. PATIENTS: Patients with severe trauma (Injury Severity Score ISS≥16). INTERVENTION: Documentation of incidents related to patient safety (PS). VARIABLES: Patients characteristics, state of the Unit, patient safety incidents, aspects of the tool (SP) and safety culture impact. RESULTS: We included 441 patients (75.15% males, mean age 39.9±17.5 years), with blunt trauma in 89% and a 10.5% mortality rate. The tool was applied in 586 out of 798 possible shifts (73.4%), and documented 942 events (2.20 incidents per patient). The incidents were more frequently associated with medication (20.7%), devices (placement 4.03%, and maintenance 17.8%) and airway and mechanical ventilation (MV) (17.09%). A correlation was established between the occurrence of incidents and the characteristics of the patient (higher Injury Severity Score, presence of MV, and continuous renal replacement therapies) and the status of the Unit (more than 6 patients per shift out of 8 possible, and holiday period). The tool significantly influenced different aspects of the safety culture of the unit (communication frequency, number of events, punitive loss and active work in PS). CONCLUSIONS: Safety briefing is a tool for the documentation of incidents that is simple and easy to use, and is useful for implementing improvements and in influencing safety culture.

[Evaluation of the compliance of semirecumbent position between 30-45° in intubated patients]. / Evaluación del cumplimiento de cabeceros elevados entre 30-45° en pacientes intubados.

AIMS: To determine compliance of the standard "semirecumbent position between 30-45° in patients with artificial airway (AA)". To know the opinion of the professionals on this issue. MATERIAL AND METHODS: An observational, prospective study was carried out in December 2009 in the ICU department of a tertiary hospital that excluded the limitation of therapeutic effort, prone position and antitrendelemburg. DATA COLLECTED: headrest angle, professional experience of the nurse, shift, perception of the auditor, diagnostic, type of AA (tracheostomy or endotracheal tube), mechanical ventilation (MV) (yes/no) and enteral nutrition (EN). Nurses were surveyed to verify if they knew the standard, if they complied with it, the method used and their suggestions. We used the Student's t test and ANOVA for multivariable analysis, and Fisher's χ2; p<0.05=significant. RESULTS: A total of 546 valid measurements were obtained from 53 patients, of which 40.9% had the correct semirecumbent position (30-45°). Professionals with <1 year of experience were those who raised the headrest the least, with only 26.4% of these measurements over 30°. The standard was met in only 34.8% of the neurocritical patients (NC) vs non NC (46.7%) (p<0.05). It was <30° in 29.2% of patients with tracheostomy vs 44% measurements performed on patients with TOT (p<0.05). There were no differences between shifts, the use of MV or EN. Diagnostic accuracy of the auditor: sensitivity: 91.6%; specificity: 72.5%; positive predictive value: 70.2%; negative predictive value (NPV): 92.4%. 97.9% of responders know the standard. Visual judgment was used in 97.2% of the cases. CONCLUSIONS: Measured compliance was less than 50% although the standard is well known by the nursing team. Even though the subjective perception has a high NPV, it does not achieve the standard.

[Massive transfusion predictive scores in trauma. Experience of a transfusion registry]. / Escalas predictivas de transfusión masiva en trauma. Experiencia de un registro de transfusiones.

OBJECTIVES: Our purpose is to validate previously described massive transfusion (MT) scoring in our Transfusion Trauma Registry. DESIGN: A retrospective cohort of adult trauma patients. SETTING: Trauma and Emergency Intensive Care Unit of a tertiary hospital. PATIENTS: Patients with severe trauma (injury severity score>15) admitted from October 2006 to July 2009. INTERVENTIONS: None. VARIABLES: The following MT scoring and cutoff points (CP) were evaluated: Trauma-Associated Severe Hemorrhage (TASH) CP: ≥16 and ≥18; Assessment Blood Consumption (ABC) CP: ≥2 and Emergency Transfusion Score (ETS) CP: ≥3, ≥4, ≥6. MT was defined as the transfusion of 10 units or more of packed red blood cells in the first 24 hours. We studied the sensivity (S), specifity (SP), and positive and negative predictive values (PPV, NPV), the positive and negative likehood ratios (LHR +, LHR-) and area under the receiver operating characteristic curve (ROC). RESULTS: A total of 568 patients were available for analysis; 77.6% were men, with a mean age of 41.16 ± 18 years and an ISS of 30 ± 13. 93.8% with blunt trauma. The overall MT rate was 18.8%. The best S was obtained with ETS ≥3 and best SP was obtained with TASH ≥18. ROC for different scores was: ABC: 0.779, ETS: 0. 784, TASH: 0.889. CONCLUSION: These scales can be useful for characterizing the TM population, for excluding low-risk populations, and for attempting to be objective in hematological damage control and in supporting clinical decisions, based on fe1w and easily obtainable data.

[Prediction of the clinical usefulness of routine chest X-rays in a traumatology ICU]. / Predicción de la utilidad clínica de la radiografía de tórax rutinaria en una unidad de cuidados intensivos de traumatología.

BACKGROUND: The clinical value of routine chest X-rays in critical care has been questioned, but has not been studied in the trauma environment to date. The objective of this study was to identify easy to use clinical predictors of utility in this setting. MATERIAL AND METHODS: A prospective observational study was made in an 8-bed traumatology ICU. Severe trauma patients (ISS > 15), aged 15 or older and admitted for 48 h or longer were included. Pregnant women and radiographs obtained during initial care or for reasons other than routine indication were excluded. A staff physician, separated from clinical duties, independently reviewed the films in search of changes, as described in a closed checklist. Following closed criteria, the attending physicians reported previous day clinical events and changes in clinical management after chest X-ray obtainment. Demographic and epidemiological data were also recorded. The associations among variables were studied by univariate and multivariate analysis. RESULTS: A total of 1440 routine chest X-rays were obtained from 138 consecutive patients during one year. Young males prevailed (82%; 39 ± 16 years). The most common process was severe blunt trauma (97%). Fifty-two percent suffered severe chest trauma. The mean length of stay was 12.9 ± 10.1 days. Mechanical ventilation was used in 86.8% of the cases. A median of 10.4 ± 9.3 films were obtained from each patient. A total of 14% of the X-rays showed changes, most commonly malpositioning of an indwelling device (6.8%) or infiltrates (4.9%). Those findings led to a change in care in 84.6% of the cases. Multivariate analysis identified the following significant (p < 0.05) risk factors for radiographic changes: first two days of evolution, mechanical ventilation, worsening of PaO2/FiO2, worsening of lung compliance and changes in respiratory secretions. CONCLUSIONS: Based on the results obtained, the risk of not identifying dangerous conditions by restricting routine chest X-rays prescription to the described conditions is low. Observing this policy would probably mean substantial savings and a reduction in radiation exposure.

[Diagnostic blood losses in severe trauma patients]. / Pérdidas sanguíneas diagnósticas en pacientes con trauma grave.

OBJECTIVE: To analyze diagnostic (blood drawings) and iatrogenic (Continuous Renal Replacement Therapy, CRRT) blood losses (BL) in severe trauma patients. METHOD: A one-year descriptive, prospective and observational study. We included patients over 15 years of age, admitted with severe trauma and who had a score of > or =16 on the Injury Severity Index (ISS). Those patients in whom limitation of therapeutic effort had been indicated were excluded. A total of 225 patients with 1619 days of evolution were analyzed for volume of BL/day/patient, type of diagnostic test, clinical outcome and utilization of CRRT. The variables were described as mean +/- standard deviation with the Student's T test. RESULTS: Average blood loss of patient per day was 55.5+/-32.2 cc. Statistically significant differences were found between the blood volume drawn when the first day was compared to the second day, 73.5+/-32.2 vs. 56.3+/-21.9 (p<0.001); clinical outcome (alive vs death) 54.8+/-33 vs. 60.7+/-24.9 (p<0.05); severity (ISS<31 or > or =31) 54.65+/-20 vs. 61.5+/-28.5 (p<0.001), No RRT vs RRT: 50.9+/-18.9 vs. 97.2+/-72.6 (p<0.001). CONCLUSIONS: The greatest diagnostic BL occurs during the resuscitation phase, in the patients who die, in those with greater severity and those undergoing CRRT.

Evaluation of quality of care in trauma patients using international scoring systems. / Valoración de la calidad asistencial al traumatismo grave mediante comparación con estándares internacionales.

OBJECTIVE: To evaluate the ability of the TRISS and PS14 models to predict mortality rates in our medical system and population. DESIGN: A retrospective observational study was carried out over a 66-month period. BACKGROUND: The study was conducted in the Trauma Intensive Care Unit (ICU) of a third level hospital. PATIENTS: All severe trauma patients (Injury Severity Score≥16 and/or Revised Trauma Score <12) aged> 14 years were included. VARIABLES OF INTEREST: Medical care data were prospectively recorded. The "W" statistic (difference between expected and observed mortality for every 100 patients) and its significance were calculated for each model. Discrimination and calibration were evaluated by means of receiver operating characteristic (ROC) curves, and the Hosmer-Lemeshow test and GiViTI calibration belt, respectively. RESULTS: A total of 1240 patients were included. Survival at hospital discharge was 81.9%. The "W" scores for the TRISS, TRISS 2010 and PS14 models were+6.72 (P<.01), +1.48 (P=.08) and +2.74 (P<.01) respectively. Subgroup analysis revealed significant favorable results for some populations. The areas under the ROC curve for the TRISS, TRISS 2010 and PS14 models were 0.915, 0.919 and 0.914, respectively. There were no significant differences among them (P>.05). Both the Hosmer-Lemeshow test and GiViTI calibration belt demonstrated poor calibration for the three models. CONCLUSIONS: These models are suitable tools for assessing quality of care in a Trauma ICU, affording excellent discrimination but poor calibration. In our institution, survival rates higher than expected were observed.

Prediction of massive bleeding in a prehospital setting: validation of six scoring systems. / Predicción de hemorragia masiva a nivel extrahospitalario: validación de seis escalas.

OBJECTIVE: To validate the diagnostic ability of six different scores to predict massive bleeding in a prehospital setting. DESIGN: Retrospective cohort. SETTING: Prehospital attention of patients with severe trauma. SUBJECTS: Subjects with more than 15 years, a history of severe trauma (defined by code 15 criteria), that were initially assisted in a prehospital setting by the emergency services between January 2010 and December 2015 and were then transferred to a level one trauma center in Madrid. VARIABLES: To validate: 1. Trauma Associated Severe Haemorrhage Score. 2. Assessment of Blood Consumption Score. 3. Emergency Transfusión Score. 4. Índice de Shock. 5. Prince of Wales Hospital/Rainer Score. 6. Larson Score. RESULTS: 548 subjects were studied, 76,8% (420) were male, median age was 38 (interquartile range [IQR]: 27-50). Injury Severity Score was 18 (IQR: 9-29). Blunt trauma represented 82,5% (452) of the cases. Overall, frequency of MB was 9,2% (48), median intensive care unit admission days was 2,1 (IQR: 0,8 - 6,2) and hospital mortality rate was 11,2% (59). Emergency Transfusión Score had the highest precisions (AUC 0,85), followed by Trauma Associated Severe Haemorrhage score and Prince of Wales Hospital/Rainer Score (AUC 0,82); Assessment of Blood Consumption Score was the less precise (AUC 0,68). CONCLUSION: In the prehospital setting the application of any the six scoring systems predicts the presence of massive hemorrhage and allows the activation of massive transfusion protocols while the patient is transferred to a hospital.

Rotational thromboelastometry (ROTEM) profile in a cohort of asystole donors. / Perfil de tromboelastometría rotacional (ROTEM) en una cohorte de asistolia no controlada.

BACKGROUND: Hypoperfusion plays a central role in shock states, and has been proposed as a coagulopathy trigger. The study of the rotational thromboelastometry (ROTEM) profile during cardiac arrest could offer new insights to the role of hypoperfusion in coagulation during shock states. OUTCOME: To describe the ROTEM profile in a cohort of asystole donors and elucidate the incidence of hyperfibrinolysis. DESIGN: A prospective observational study was carried out in 18 patients consecutively admitted to the ICU after out-of-hospital non-recovered cardiac arrest (CA). Initial rhythm and time between CA and admission were recorded. Conventional coagulation and ROTEM (EXTEM, APTEM, FIBTEM) tests were performed within 30minutes after blood sample collection. SCOPE: An asystole donor reference hospital. PARTICIPANTS: Patients admitted to the ICU after out-of-hospital non-recovered CA. RESULTS: The median age was 50years, and 14 of the patients were men (77.8%). The time from CA to hospital admission expressed as the median (interquartile range) was 91minutes (75-104). The results of the routine tests were: INR 1.25 (1.19-1.34), aPTT 55s (45-73) and fibrinogen 161mg/dl (95-295). For the ROTEM APTEM assay the results were: CT 126s (104-191), CFT 247s (203-694). Hyperfibrinolysis criteria were recorded in 15 patients (83.3%). In addition, MCF improved in APTEM versus EXTEM. Prolonged CA times were associated to lower fibrinogen levels and lower values for MCF FIBTEM (P<.05). CONCLUSIONS: The ROTEM assays revealed severe alterations of the clot formation parameters and a high incidence of hyperfibrinolysis.

Valoración de la calidad asistencial al traumatismo grave mediante comparación con estándares internacionales / Evaluation of quality of care in trauma patients using international scoring systems

OBJETIVO: Evaluar la capacidad de los modelos TRISS y PS14 para predecir la probabilidad de supervivencia en nuestro sistema de salud y población. DISEÑO: Desarrollamos un estudio observacional retrospectivo durante un periodo de 66 meses. ÁMBITO: El estudio se llevó a cabo en una UCI especializada en traumatología en un hospital urbano de alta complejidad. PACIENTES: Se incluyeron en el estudio los pacientes mayores de 14 años con traumatismo grave (definido como ISS ≥ 16 y/o RTS < 12). VARIABLES DE INTERÉS: Se calculó el estadístico W (diferencia entre la mortalidad -hospitalaria o a los 30 días para los modelos TRISS o PS14 respectivamente- calculada y observada por cada 100 pacientes) y su nivel de significación para cada modelo. Se realizó un análisis por subgrupos. La calibración y discriminación se evaluaron por medio del test de Hosmer-Lemeshoy y cinturón GiViTI y curvas ROC respectivamente. RESULTADOS: Se incluyeron 1.240 pacientes. La supervivencia global al alta fue de 81,9%. El estadístico W para los modelos TRISS, TRISS2010 y PS14 fue respectivamente +6,72 (p < 0,01), +1,48 (p = 0,08) y +2,74 (p < 0,01). El AUROC para los citados modelos fue respectivamente 0,915, 0,919 y 0,914, sin que se encontraran diferencias significativas entre ellos. Tanto el test de Hosmer-Lemeshow como el cinturón de calibración GiViTI mostraron escasa calibración en los 3 modelos. CONCLUSIONES: Estos modelos son una herramienta adecuada para la evaluación de la calidad asistencial en una UCI de traumatismo. En nuestro centro las tasas de supervivencia fueron mayores de lo predicho por los modelos

OBJECTIVE: To evaluate the ability of the TRISS and PS14 models to predict mortality rates in our medical system and population. DESIGN: A retrospective observational study was carried out over a 66-month period. BACKGROUND: The study was conducted in the Trauma Intensive Care Unit (ICU) of a third level hospital. PATIENTS: All severe trauma patients (Injury Severity Score ≥ 16 and/or Revised Trauma Score < 12) aged > 14 years were included. Variables of interest: Medical care data were prospectively recorded. The "W" statistic (difference between expected and observed mortality for every 100 patients) and its significance were calculated for each model. Discrimination and calibration were evaluated by means of receiver operating characteristic (ROC) curves, and the Hosmer-Lemeshow test and GiViTI calibration belt, respectively. RESULTS: A total of 1240 patients were included. Survival at hospital discharge was 81.9%. The "W" scores for the TRISS, TRISS 2010 and PS14 models were +6.72 (P < .01), +1.48 (P = .08) and +2.74 (P < .01) respectively. Subgroup analysis revealed significant favorable results for some populations. The areas under the ROC curve for the TRISS, TRISS 2010 and PS14 models were 0.915, 0.919 and 0.914, respectively. There were no significant differences among them (P > .05). Both the Hosmer-Lemeshow test and GiViTI calibration belt demonstrated poor calibration for the three models. CONCLUSIONS: These models are suitable tools for assessing quality of care in a Trauma ICU, affording excellent discrimination but poor calibration. In our institution, survival rates higher than expected were observed

[An evaluation of a protocol of postoperative nutritional support in patients who have had a liver transplant]. / Valoración de un protocolo de soporte nutricional postoperatorio en pacientes sometidos a trasplante hepático (TxH).

Despite the fact that the incidence of malnutrition in patients subjected to liver transplants is high, there are no definite criteria on the most appropriate postoperative nutritional support characteristics. The present study is a review of our experience with the administering of a diet base on: 1) proteic saving techniques up to enteral nutrition tolerance, and 2) total parenteral nutrition in the event of intolerance (foreseen or proven) to enteral nutrition. The type of nutritional support used and nutritional evaluation data, both during hospitalization in intensive care, were studied over a period of 557 days, in a series of 70 patients subjected to liver transplants. In 61.9% of the study days, parenteral nutritional support techniques had to be used. Enteral nutrition was possible during 18.9% of the study period in patients who had been discharged, compared to 1.8% in patients who needed further transplants or died (p less than 0.001). The elimination of nitrogen gradually increased up to day 9, and then fell. No positive nitrogenated balance was observed until day 13. Glucemia levels remained high during the whole evolutive phase. Seric albumin and transferrin levels were normal at first, and fell during week two. Seric prealbumin levels were within normal limits. Seric Mg and Cu were lower that the reference values during the first 15 days of evolution, where as Zn reached normal levels on day 15. Normal cholesterol values were only observed on day 8. Our results show the level of intolerance to enteral nutrition during the evolution of the patients and the need for using a more aggressive nutritional support.