RESUMO
Trauma patients admitted to an intensive care unit (ICU) may potentially experience a deficiency of coagulation factor thirteen (FXIII). In this retrospective cohort study conducted at a specialized trauma center, ICU patients were studied to determine the dependency of FXIII activity levels on clinical course and substitution with blood and coagulation products. A total of 189 patients with a median injury severity score (ISS) of 25 (16−36, IQR) were included. Abbreviated injury scores for extremities (r = −0.38, p < 0.0001) but not ISS (r = −0.03, p = 0.45) showed a negative correlation with initial FXIII levels. Patients receiving FXIII concentrate presented with a median initial FXIII level of 54 (48−59)% vs. 88 (74−108)%, p < 0.0001 versus controls; they had fewer ICU-free days: 17 (0−22) vs. 22 (16−24), p = 0.0001; and received higher amounts of red blood cell units: 5 (2−9) vs. 4 (1−7), p < 0.03 before, and 4 (2−7) vs. 1 (0−2), p < 0.0001 after FXIII substitution. Matched-pair analyses based on similar initial FXIII levels did not reveal better outcome endpoints in the FXIII-substituted group. The study showed that a low initial FXIII level correlated with the clinical course in this trauma cohort, but a substitution of FXIII did not improve endpoints within the range of the studied FXIII levels. Future prospective studies should investigate the utility of FXIII measurement and lower threshold values of FXIII, which trigger substitution in trauma patients.
RESUMO
BACKGROUND: Outcome prediction in patients with acute respiratory distress syndrome (ARDS) greatly improves when patients are reclassified based on predefined arterial oxygen partial pressure to fractional inspired oxygen ratios (PaO2/FiO2) and positive end-expiratory pressure (PEEP) cutoffs 24 h after the initial ARDS diagnosis. The aim of this study was to test whether outcome prediction improves when patients are reclassified based on predefined PaO2/FiO2 and PEEP cutoffs 24 h after development of mild hypoxemia while not having ARDS. METHODS: Post hoc analysis of a large prospective, multicenter, observational study that ran in the ICUs of two academic hospitals in the Netherlands between January 2011 and December 2013. Patients were classified into four groups using predefined cutoffs for PaO2/FiO2 (250 mmHg) and PEEP (5 cm H2O), both at onset of hypoxemia and after 24 h: PaO2/FiO2 ≥ 250 mmHg and PEEP < 6 cm H2O (group I), PaO2/FiO2 ≥ 250 mmHg and PEEP ≥ 6 cm H2O (group II), PaO2/FiO2 < 250 mmHg and PEEP < 6 cm H2O (group III), and PaO2/FiO2 < 250 mmHg and PEEP ≥ 6 cm H2O (group IV), to look for trend association with all-cause in-hospital mortality, the primary outcome. Secondary outcome were ICU- and 90-day mortality, and the number of ventilator-free days or ICU-free days and alive at day 28. RESULTS: The analysis included 689 consecutive patients. All-cause in-hospital mortality was 35%. There was minimal variation in mortality between the four groups at onset of hypoxemia (33, 36, 38, and 34% in groups I to IV, respectively; P = 0.65). Reclassification after 24 h resulted in a strong trend with increasing mortality from group I to group IV (31, 31, 37, and 48% in groups I to IV, respectively; P < 0.01). Similar trends were found for the secondary endpoints. CONCLUSIONS: Reclassification using PaO2/FiO2 and PEEP cutoffs after 24 h improved classification for outcome in invasively ventilated ICU patients with hypoxemia not explained by ARDS, compared to classification at onset of hypoxemia. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01905033. Registered on July 11, 2013. Retrospectively registered.