Does increased lactate discriminate between survivors and non-survivors after abdominal aortic aneurysm surgery?

Blood lactate levels have been correlated with outcome in sepsis,¹in shock of various causes¹ and following paediatric cardiacsurgery.² Lactate was not included in the APACHE II score becauseof practical difficulties with its determination and consequentinfrequent measurement in the early 1980s.³ Postoperative care following abdominal aortic or iliac aneurysm(AAA) surgery is the commonest reason for admission to UK intensivecare units (ICUs). These patients have a high hospital mortalityof 21.4% reported from the ICNARC Case Mix Programme.⁴ One hundredand forty-four consecutive patients admitted to ICU post-AAAsurgery were studied and four measures of lactate recorded fromthe first 24 h of admission (see Table 21). Four patients hadno values recorded. The Wilcoxon rank sum test was used to testfor a significant difference in each measure between survivorsand non-survivors. The area under the receiver operator characteristic(ROC) curve was calculated for each measure to test discriminationbetween survivors and non-survivors, where 1 represents perfectdiscrimination and 0.5 represents no discrimination. STATA 6.0for Windows 95 was used for all statistical tests. Increases in all measures of lactate were significantly associatedwith hospital mortality (probabilities from <0.0001 to 0.0035)(Table 21). The areas under the ROC curves show that all lactatemeasures discriminated between survivors and non-survivors.The 24-h lactate value provided both the strongest associationand the best discrimination. This may be because it is dependentnot only on the magnitude of physiological insult but also onthe adequacy of, and the response to postoperative treatment.In view of the positive correlation with mortality in this largegroup of critically ill patients and the now widespread clinicaluse of lactate measurements, inclusion of the 24-h lactate valueshould be considered for future scoring systems.     

Agreement between venous and arterial blood gas analysis of acid-base status in critical care and ward patients: a retrospective cohort study

Purpose

To determine whether the use of venous blood gases can be a suitable alternative to arterial sampling to evaluate acid-base status.

Methods

The database of the clinical laboratory in a large academic hospital was searched for records of venous blood gas analysis and an arterial sample taken within ten minutes from the same patient. Bland-Altman analyses of pH, pCO₂, and lactate were performed for samples obtained from patients separately from within and outside the intensive care unit (ICU).

Results

In 2,296 paired arterial-venous samples from 351 ICU patients, the bias was 0.044, ?6.2 mmHg, and ?0.07 mEq·L^?1 for pH, pCO₂, and lactate, respectively. The range of agreement centred on this bias (upper minus lower level of agreement) was 0.134, 16.7 mmHg, and 1.35 mEq·L^?1 for pH, pCO₂, and lactate, respectively. Intraclass correlation coefficients (ICCs) were 0.79, 0.76, and 0.99 for pH, pCO₂, and lactate, respectively, indicating excellent agreement. Multiple samples obtained from the same patient had a median standard deviation of 0.02, 2.77 mmHg, and 0.18 mEq·L^?1 for pH, pCO₂, and lactate, respectively. Similar agreement was observed in samples from patients outside the ICU, although the ICC was only 0.53 for pCO₂.

Conclusions

Venous gases are suitable for initial evaluation of acid-base status in critically ill patients. Based on clinical evaluation, an arterial sample may then be considered for confirmation, and thereafter, venous blood gases could be sufficient for monitoring response to treatment.

     

Effect of dolutegravir on folate,vitamin B12 and mean corpuscular volume levels among children and adolescents with HIV: a sub-study of the ODYSSEY randomized controlled trial

Introduction

Dolutegravir-based antiretroviral therapy (ART) is the preferred antiretroviral treatment for children and adolescents living with HIV. A large surveillance study in Botswana previously raised concerns about an association between pre-conception dolutegravir and neural tube defects. Before these concerns were subsequently resolved, we set up a sub-study to look at the effect of dolutegravir on levels of folate and vitamin B12 in children and adolescents within the randomized ODYSSEY trial, as folate and vitamin B12 are known to play a crucial role in neural tube development.

Methods

We conducted the sub-study among Ugandan ODYSSEY participants and compared folate and vitamin B12 between children randomized to dolutegravir-based ART (DTG) and non-dolutegravir-based standard-of-care treatment (SOC). Plasma folate was measured at enrolment and week 4 on stored samples; in addition, plasma and red blood cell (RBC) folate and vitamin B12 were assayed at week ≥96 in prospectively collected samples. RBC mean corpuscular volume (MCV) was measured 24-weekly in all ODYSSEY participants. Samples analysed in the sub-study were collected between September 2016 and October 2020.

Results

A total of 229 children aged ≥6 years were included in the sub-study with median age at trial enrolment of 12.3 (interquartile range [IQR] 9.0, 14.7) years, and CD4 count of 501 (IQR 228, 695); 112 (49%) children were male. Most participants (225/229, 98%) had plasma folate results at enrolment and 214 (93%) children had results available for RBC folate, vitamin B12 and plasma folate at week ≥96. MCV results were analysed on 679 children aged ≥6 years enrolled in ODYSSEY. At week 4, mean plasma folate was significantly higher in the dolutegravir arm than in SOC (difference [DTG-SOC] 1.6 ng/ml, 95% CI 0.8, 2.3; p<0.001), and this difference persisted to week ≥96 (2.7 ng/ml, 95% CI 1.7, 3.7; p<0.001). Mean RBC folate at ≥96 weeks was also higher in the DTG arm (difference 73 ng/ml, 95% CI 3, 143; p = 0.041). There was no difference in the treatment arms for vitamin B12 levels at ≥96 weeks or change in MCV through trial follow-up.

Conclusions

Plasma and RBC folate levels were higher in children and adolescents receiving dolutegravir-based ART than on other ART regimens. Further studies are needed to clarify the mechanisms of these interactions and the clinical implications of increased blood folate levels.     

The effect of inhaled nitric oxide in acute respiratory distress syndrome in children and adults: a Cochrane Systematic Review with trial sequential analysis

Acute respiratory distress syndrome is associated with high mortality and morbidity. Inhaled nitric oxide has been used to improve oxygenation but its role remains controversial. Our primary objective in this systematic review was to examine the effects of inhaled nitric oxide administration on mortality in adults and children with acute respiratory distress syndrome. We included all randomised, controlled trials, irrespective of date of publication, blinding status, outcomes reported or language. Our primary outcome measure was all‐cause mortality. We performed several subgroup and sensitivity analyses to assess the effect of inhaled nitric oxide. There was no statistically significant effect of inhaled nitric oxide on longest follow‐up mortality (inhaled nitric oxide group 250/654 deaths (38.2%) vs. control group 221/589 deaths (37.5%; relative risk (95% CI) 1.04 (0.9–1.19)). We found a significant improvement in PaO₂/F_IO₂ ratio at 24 h (mean difference (95% CI) 15.91 (8.25–23.56)), but not at 48 h or 72 h, while four trials indicated improved oxygenation in the inhaled nitric oxide group at 96 h (mean difference (95% CI) 14.51 (3.64–25.38)). There were no statistically significant differences in ventilator‐free days, duration of mechanical ventilation, resolution of multi‐organ failure, quality of life, length of stay in intensive care unit or hospital, cost‐benefit analysis and methaemoglobin and nitrogen dioxide levels. There was an increased risk of renal impairment (risk ratio (95% CI) 1.59 (1.17–2.16)) with inhaled nitric oxide. In conclusion, there is insufficient evidence to support inhaled nitric oxide in any category of critically ill patients with acute respiratory distress syndrome despite a transient improvement in oxygenation, since mortality is not reduced and it may induce renal impairment.     

Serial estimations of blood lactate predict postoperative outcome in cancer patients undergoing head and neck surgeries

To determine predictability of serial estimations of blood lactate levels for postoperative outcome of head and neck cancer patients and determine validity of single versus serial estimations for accurate prediction of outcome.The study included 322 cancer patients assigned for major head and neck surgeries and admitted to ICU. Data collection included age, sex, and associated comorbidities, and clinical status was determined using APACHE II score. Arterial lactate was measured at time of admission (T0), and 8-hourly (T8, T16, T24), and percentage of change of blood lactate level was calculated versus T0 level. Patients were categorized as survivor and non-survivors, and among each group, patients were categorized according to estimated level of blood lactate into four categories.The mean of APACHE score at ICU admission was 16.6 ± 3.1, and mean duration of ICU and hospital stay was 3.2 ± 1.2 and 19.3 ± 5.5 days, respectively. Fifty-two patients died for postoperative mortality rate 16.1%. Non-survivors were significantly older and had significantly higher APACHE score and significantly longer ICU and hospital stay. At admission blood lactate level was significantly higher in non-survivors compared to survivors. All patients showed progressive increase of blood lactate level, but non-survivors showed significantly higher frequency of elevated blood lactate strata compared to survivors with significantly higher difference between both groups at T8, T16, and T24. There was positive significant correlation between high at admission blood lactate level and APACHE score. Regression analysis defined % of change of blood lactate at T16, high APACHE score, high at admission blood lactate and old age as specific predictors for postoperative mortality in descending order of specificity. Serial estimations of blood lactate are conclusive test for follow-up of patients undergoing major surgical procedures requiring ICU admission. Combined high APACHE score and percentage of change of blood lactate could discriminate survivors from non-survivors especially 16-h after ICU admission.     

Preoperative serum lactate cannot predict in-hospital mortality after decompressive craniectomy in traumatic brain injury

Purpose

Despite the utility of serum lactate for predicting clinical courses, little information is available on the topic after decompressive craniectomy. This study was conducted to determine the ability of perioperative serum lactate levels to predict in-hospital mortality in traumatic brain-injury patients who received emergency or urgent decompressive craniectomy.

Methods

The medical records of 586 consecutive patients who underwent emergency or urgent decompressive craniectomy due to traumatic brain injuries from January 2007 to December 2014 were retrospectively analyzed. Pre- and intraoperative serum lactate levels and base deficits were obtained from arterial blood gas analysis results.

Results

The overall mortality rate after decompressive craniectomy was 26.1 %. Mean preoperative serum lactate was significantly higher in the non-survivors (P = 0.034) than the survivors but had no significance for predicting in-hospital mortality in the multivariate regression analysis (P = 0.386). Rather, preoperative Glasgow Coma Score was a significant predictor for in-hospital mortality (hazard ratio 0.796, 95 % confidence interval 0.755–0.836, P < 0.001).

Conclusion

Preoperative lactate level is not an independent predictor of in-hospital mortality after decompressive craniectomy in traumatic brain-injury patients.

     

Index complications predict secondary complications after infrainguinal lower extremity bypass for critical limb ischemia

Objective

Patients undergoing lower extremity bypass (LEB) are at high risk of perioperative complications that can lead to a cascade of secondary complications. Our goal was to understand the association of index complications with secondary complications after LEB.

Role of admission gas exchange measurement in predicting congenital diaphragmatic hernia survival in the era of gentle ventilation

Background/Purpose

Neonates with significant congenital diaphragmatic hernia (CDH) require cardiopulmonary support. Management has been characterized by progressive abandonment of hyperventilation. Ability to prognosticate outcomes using measures of ventilation and oxygenation with gentle ventilation remains unclear. We sought to determine whether assessment of gas exchange at the time of NICU admission is predictive of survival in this current era.

Methods

Neonates with CDH admitted to a Children’s Hospital from 1995 to 2006 were evaluated for demographics, blood gas (ABG) measurements and ventilator settings for the first 48 hours, and discharge outcome.

Results

One-hundred-and-nineteen CDH patients were admitted, 88 (74%) survived. Mean admission ABG pCO₂ was higher in infants who died compared to survivors (86 ± 48 versus 49 ± 20, p ≤ 0.001); positive predictive value (PPV) for mortality of pCO₂ ≥ 80 mmHg was 0.71. Mean first hour preductal oxygen saturation (preductalO₂Sat) was lower in infants who died compared to survivors (81 ± 17 versus 97 ± 5, p < 0.001); PPV for mortality of preductalO₂Sat < 85% was 0.82. Eleven patients met both pCO₂ and preductalO₂Sat criteria, and 10 (91%) died, PPV of 0.92. Within hours of admission, pCO₂ and preductalO₂Sat differences between survivors and nonsurvivors lost significance.

Conclusion

Admission pCO₂ and preductalO₂Sat may be useful in predicting survival in neonatal CDH. The differential in gas exchange between survivors and nonsurvivors loses significance with contemporary neonatal care.     

Association between ion shift index and prognosis in severe trauma patients without isolated head injury

IntroductionThis study aimed to investigate the ion shift index (ISI) as a prognostic factor of severe trauma. We hypothesized that the initial ISI measured in the emergency department (ED) is associated with discharge survival in severe non-isolated head injury (IHI) patients.Materials and methodsThis retrospective observational study included severe trauma patients with available medical records from January 2017 to December 2018 but excluded those with IHI. Logistic regression analysis was conducted to identify the risk factors for mortality in non-IHI patients, and adjustments were performed for relevant covariates. An area under the receiver operating characteristics curve (AUROC) analysis was performed to examine the primary outcome of our study, which was mortality at hospital discharge in severe non-IHI trauma patients.ResultsOf the 483 severe non-IHI trauma patients included in the study, 86 patients (17.8 %) died. The multiple logistic regression analysis demonstrated ISI (odds ratio [OR], 2.300; 95% CI, 1.183–4.470) was significantly associated with mortality in the non-IHI group. Additionally, trauma and injury severity score (TRISS; OR, 0.538; 95% CI, 0.447–0.649), lactate (OR, 1.410; 95% CI, 1.252–1.588), creatinine (OR, 1.554; 95% CI, 1.221–1.979), and activated partial thromboplastin time (aPTT; OR, 1.050; 95% CI, 1.021–1.080) were independently associated with mortality at hospital discharge. The AUROC values for TRISS, lactate, aPTT, creatinine, and ISI were as follows: 0.892 (95% CI, 0.861–0.918), 0.838 (95% CI, 0.803–0.870), 0.754 (95% CI, 0.712–0.792), 0.650 (95% CI, 0.606–0.693), and 0.848 (95% CI, 0.813–0.879), respectively. The AUROC for the multiple logistic regression model with ISI was 0.942 (95% CI, 0.917–0.962). In a model in which TRISS was omitted, the addition of ISI to other predictors significantly improved the AUROC to 0.900 (95% CI, 0.869-0.925) (p=0.039).ConclusionThe initial ISI in the ED after trauma was associated with mortality in severe non-IHI trauma patients. In conjunction with other prognostic indicators, it could be used as an early prognostic marker, particularly if TRISS is unavailable.     

Changes in blood lactate levels after major elective abdominal surgery and the association with outcomes: a prospective observational study

BackgroundProlonged elevated blood lactate levels strongly correlate with poor outcomes in a variety of critically ill patients. We hypothesized that the dynamic postoperative changes in blood lactate levels during the first 24 h were significantly associated with postoperative morbidity and mortality in patients undergoing elective major abdominal surgery.Materials and methodsWe performed a single-center prospective observational study of 114 consecutive patients undergoing elective major abdominal surgery from September 2009 to December 2010. Blood lactate was determined postoperatively at 6 h intervals during the first 24 h. In-hospital complications and deaths occurring within 30 d of enrollment were included in the data analysis.ResultsA total of 88 postoperative complications were recorded in 51 patients (44.7%). There was a significant difference in blood lactate levels among patients with no, minor, and major complications (ANOVA, Groups, P < 0.001; time, P < 0.001; groups × time interaction, P = 0.014). The accuracy of lactate levels to predict both overall and major complications increased postoperatively from 0 h to 24 h. Using a multivariate analysis, the time-weighted average lactate was independently predictive of both overall (OR 7.108, 95% CI 2.271–22.249, P = 0.001) and major (OR 3.277, 95% CI 1.363–7.877, P = 0.008) postoperative complications, and lactate clearance at 0–24 h (OR 0.217, CI 0.077–0.616, P = 0.004) was independently predictive of major postoperative complications. The optimal time-weighted average lactate cutoff value for complication prediction was 1.46 mmol/L; below this level, both overall and major complication rates were significantly reduced, which was true even after adjusting for potential confounding factors.ConclusionsThe dynamic changes in blood lactate levels during the first 24 postoperative h were significantly associated with complications after major elective abdominal surgery. This result warrants a “golden hour and silver day” perspective of early resuscitation in this patient cohort.     

Hypotension during transsphenoidal pituitary surgery associated with increase in plasma levels of brain injury markers

Background

Patients undergoing pituitary surgery may experience short- and long-term postoperative morbidity. Intraoperative factors such as hypotension might be a contributing factor. Our aim was to investigate the association between intraoperative hypotension and postoperative plasma levels of tau, neurofilament light (NfL), and glial fibrillary acidic protein (GFAP) as markers of perioperative brain injury.

Methods

Between June 2016 and October 2017, 35 patients from the Gothenburg Pituitary Tumor Study were included. For tau, NfL, and GFAP, concentrations were measured in plasma samples collected before and immediately following surgery, and on postoperative days 1 and 5. The difference between the highest postoperative value and the value before surgery was used for analysis (∆tau_peak, ∆NfL_peak, ∆GFAP_peak). Intraoperative hypotension was defined as the area under the curve of an absolute threshold below 70 mmHg (AUC70) and a relative threshold below 20% (AUC20%) of the baseline mean arterial blood pressure.

Results

Plasma tau and GFAP were highest immediately following surgery and on day 1, while NfL was highest on day 5. There was a positive correlation between AUC20% and both ∆tau_peak (r² = .20, p < .001) and ∆NfL_peak (r² = .26, p < .001). No association was found between AUC20% and GFAP or between AUC70 and ∆tau_peak, ∆NfL_peak or ∆GFAP_peak.

Conclusion

Intraoperative relative, but not absolute, hypotension was associated with increased postoperative plasma tau and NfL concentrations. Patients undergoing pituitary surgery may be vulnerable to relative hypotension, but this needs to be validated in future prospective studies.     

Anaesthesia related mortality data at a Tertiary Pediatric Hospital in Western Australia

Background

Anaesthesia related mortality in paediatrics is rare. There are limited data describing paediatric anaesthesia related mortality. This study determined the anaesthesia related mortality at a Tertiary Paediatric Hospital in Western Australia.

Methods

A retrospective cohort study of children under-18 years of age, that died within 30-days of undergoing anaesthesia at Princess Margaret Hospital (PMH), between 01 January 2001 and 31 March 2015. A senior panel of clinicians reviewed each death to determine whether the death was (i) due wholly to the provision of anaesthesia (ii) due partly to the provision of anaesthesia or (iii) if death was related to the underlying pathology of the patient and anaesthesia was not contributory. Anaesthesia related mortality, 24-h and 30-day mortality as well as predictors of mortality were determined.

Results

A total of 154,538 anaesthetic events were recorded. There were 198 deaths within 30-days of anaesthesia. Anaesthesia attributable mortality was 0.19/10,000 with all anaesthesia deaths occuring in patients undergoing cardiothoracic surgery. The 24-h and 30-day all-cause mortality rate was 3.43/10,000 (95% CI 2.57–4.49) and 9.38/10,000 (95% CI 7.92–11.04), respectively. Overall mortality was 12.34/10,000 (95% CI 11.09–14.73) Age less than 1-year, cardiac surgery, emergency surgery and higher ASA score were all significant predictors of mortality.

Conclusion

Paediatric anaesthesia related mortality as reflected in this retrospective cohort study is uncommon. Significant risk factors were determined as predictors of mortality.     

Die präklinische Blutgasanalyse Teil 1: Der Stellenwert der präklinischen Blutgasanalyse

Prehospital blood gas analysis is a new method in out-of-hospital emergency care. In a prospective pilot study we evaluated the feasibility of prehospital compensation of severe acidosis relying on different monitoring systems to evaluate patients oxygen, carbon dioxide or acid-base status, respectively. Methods: With the help of arterial blood gas checks taken at the site of the emergency, the acid base status of patients undergoing out of hospital cardiopulmonary resuscitation was analysed. The values derived from the first arterial puncture were used to determine the presence and the type of acidosis. The data of the arterial blood gas checks were set into relation with the time elapsed since the beginning of resuscitation and they were compared with end-tidal CO₂. Results: During the observation period 26 blood gas analyses from patients who had out-of-hospital resuscitation because of cardiac arrest were done. Twenty three patients had severe acidosis (pH range <6.9 to 7.31), one had alkalosis (pH 7.51). Only two had an arterial pH within normal range. The pCO₂ was variable (range: 24 to 97 mm Hg). The correlation of pH with time from the beginning of resuscitation to arterial puncture was poor (r=0.407, p<0.05). There was no correlation between pH and BE (r=0.267) or pH and pCO₂, (r=0.016) respectively. Prehospital capnometry had a poor correlation with arterial pCO₂ in most emergeny patients. Only patients with respiratory disturbances of extrapulmonary origin showed a good correlation between end-tidal CO₂ and the arterial pCO₂. In severely ill patients the arterio-alveolar CO₂-difference was unexpectedly high (>15 mm Hg). In four patients resuscitation was not sucessful until compensation of an unexpectedly severe acidosis based upon the findings from blood-gas analysis had been performed. Conclusions: Arterial blood gas analysis proved to be helpful in the optimal management of out of hospital cardiac arrest. The incidence of severe acidosis in patients undergoing cardiopulmonary resuscitation was 80%. The probability of developing acidosis was found to increase slightly depending on the time elapsed since the beginning of CPR. The application of a calculated buffering of acidosis with sodium bicarbonate showed a good outcome in selected cases. In emergency patients alternative methods fail to detect severe disturbances of the patients oxygen and/or carbon dioxide status and the acid-base balance. Management of prehospital cardiac arrest could be optimized by the routine use of blood gas analysis.     

Long-term outcomes of single-ventricle palliation for unbalanced atrioventricular septal defects: Fontan survivors do better than previously thought

Background

Single-ventricle palliation (SVP) for children with unbalanced atrioventricular septal defect (uAVSD) is thought to carry a poor prognosis, but limited data have been reported.

Defining massive transfusion in civilian pediatric trauma

PurposeThe purpose of this study was to identify an optimal definition of massive transfusion (MT) in civilian pediatric trauma.MethodsSeverely injured children (age ≤ 18 years, injury severity score ≥ 25) in the Trauma Quality Improvement Program research datasets 2014–2015 that received blood products were identified. Children with traumatic brain injury and non-survivable injuries were excluded. Early mortality was defined as death within 24 h and delayed mortality as death after 24 h from hospital admission. Receiver operating curves and sensitivity and specificity analysis identified an MT threshold. Continuous variables are presented as median [IQR].ResultsOf the 270 included children, the overall mortality was 27% (N = 74). There were no differences in demographics or mechanism of injury between children that lived or died. Sensitivity and specificity for early mortality was optimized at a 4-h transfusion volume of 37 ml/kg. After controlling for other significant variables, a threshold of 37 ml/kg/4 h predicted the need for a hemorrhage control procedure (OR 8.60; 95% CI 4.25–17.42; p < 0.01) and early mortality (OR 4.24; 95% CI 1.96–9.16; p < 0.01).ConclusionAn MTP threshold of 37 mL/kg/4 h of transfused blood products predicted the need for hemorrhage control procedures and early mortality. This threshold may provide clinicians with a timely prognostic indicator, improve research methodology, and resource utilization.Type of StudyDiagnostic Test.Level of EvidenceIII.     

Factors predicting the need for hemorrhage control intervention in patients with blunt pelvic trauma: a retrospective study

Background

Blunt pelvic injuries are often associated with pelvic fractures and injuries to the rectum and genitourinary tract. Pelvic fractures can lead to life-threatening hemorrhage, which is a common cause of morbidity and mortality in trauma. Thus, early identification of patients with pelvic fractures at risk severe bleeding requiring urgent hemorrhage control is crucial. This study aimed to investigate early factors predicting the need for hemorrhage control in blunt pelvic trauma.

Methods

The medical records of 1760 trauma patients were reviewed retrospectively between January 2013 and June 2018. We enrolled 187 patients with pelvic fracture due to blunt trauma who were older than 15 years. The pelvic fracture pattern was classified according to the Orthopedic Trauma Association/Arbeitsgemeinschaft fur Osteosynthesefragen (OTA/AO) classification. A multivariate logistic regression model was used to determine independent predictors of the need for pelvic hemorrhage control intervention.

Results

The most common pelvic fracture pattern was type A (54.5%), followed by types B (36.9%) and C (8.6%). Of 187 patients, 48 (25.7%) required pelvic hemorrhage control intervention. Hemorrhage control interventions were most frequently performed in patients with type B fractures (54.2%). Multivariate logistic regression analysis revealed that type B (odds ratio [OR] = 4.024, 95% confidence interval [CI] = 1.666–9.720, p = 0.002) and C (OR = 7.077, 95% CI = 1.781–28.129, p = 0.005) fracture patterns, decreased body temperature (OR = 2.275, 95% CI = 0.134–0.567, p < 0.001), and elevated serum lactate level (OR = 1.234, 95% CI = 1.061–1.435, p = 0.006) were factors predicting the need for hemorrhage control intervention in patients with blunt pelvic trauma.

Conclusion

Patients with type B and C fracture patterns on the OTA/AO classification, hypothermia, or an elevated serum lactate level are at risk for bleeding and require pelvic hemorrhage control intervention.

     

Comparison of cystatin C- and creatinine-based estimated glomerular filtration rates for predicting all-cause mortality in Japanese patients with type 2 diabetes: the Fukuoka Diabetes Registry

Background

There is little information about the predictive ability of cystatin C-based estimated glomerular filtration rates (eGFR_Cys) for all-cause mortality in Asian populations. We compared the discriminatory ability of eGFR_Cys for all-cause mortality with that of creatinine-based estimated glomerular filtration rates (eGFR_Cr) in Japanese patients with type 2 diabetes.

Methods

A total of 4869 participants were classified into four categories (eGFR ≤29, 30–59, 60–89, and ≥90 ml/min/1.73 m²) by eGFR_Cr and eGFR_Cys, and followed up for a median of 3.3 years.

Results

150 deaths were identified. The multivariable-adjusted risk of all-cause mortality was significantly increased in eGFR_Cr ≤29 ml/min/1.73 m² compared with eGFR_Cr ≥90 ml/min/1.73 m² [hazard ratio (HR) 2.4 (95 % confidence interval (95 % CI) 1.2–5.0)], whereas it was significantly increased in eGFR_Cys 59 ml/min/1.73 m² or lower [30–59 ml/min/1.73 m², HR 1.9 (95 % CI 1.1–3.5); ≤29 ml/min/1.73 m², HR 5.8 (95 % CI 2.8–12.0)]. Comparing eGFR_Cys with eGFR_Cr, the proportions of participants reclassified to lower and higher eGFR stages were 6.3 and 28.8 %, respectively. The multivariable-adjusted HRs for all-cause mortality were 1.8 (95 % CI 1.1–2.9) and 0.7 (95 % CI 0.4–1.1), respectively. The C statistic of the model including eGFR_Cys and other risk factors was significantly increased compared with the model including eGFR_Cr. The net reclassification improvement and the integrated discrimination improvement were significantly positive.

Conclusions

Our findings suggest that eGFR_Cys has a stronger association with all-cause mortality and is superior to eGFR_Cr for predicting all-cause mortality in Japanese patients with type 2 diabetes.

     

Serum estradiol concentration as a predictor of death in critically ill and injured adults

BACKGROUND: Whereas animal models of sepsis demonstrate survival benefits for the pro-estrus state, human observational studies have failed to demonstrate a consistent survival advantage among female patients. Estrogen biosynthesis differs substantially in primate and non-primate animals, and estrogens have diverse immunologic actions. Estrogen concentrations are elevated in response to critical illness and injury (regardless of sex), and elevated concentrations of serum estradiol are associated with a higher mortality rate. Our objective was to determine the predictive ability and test characteristics of the serum estradiol concentration at 48 h in critically ill patients. METHODS: A prospective cohort study of surgical and trauma adult intensive care unit patients at two academic tertiary-care centers. Sex hormones (estradiol, progesterone, testosterone, prolactin, and dehydroepiandrosterone) and cytokines were assayed at 48 h, and the 28-day all-cause mortality rate was assessed. RESULTS: There was no difference in mortality rates between the sexes (survivors being male in 75.2% of cases vs. 76.0% in non-survivors; p = 0.43). The serum estradiol concentration was significantly elevated in non-survivors regardless of sex (median 18.7 pg/mL [interquartile range {IRQ} 9.99-43.6] in survivors and 40.7 pg/mL [IQR 9.99-94.8] in non-survivors; p < 0.001). The area under the receiver-operating characteristic (ROC) curve for serum estradiol was 0.64 (95% confidence interval [CI] 0.55, 0.72). The parameter with the largest ROC curve was the Acute Physiology and Chronic Health Evaluation (APACHE) II score (0.75; 95% CI 0.68, 0.82). A serum estradiol cut-point of 50 pg/mL was 48% sensitive and 80% specific in predicting death and classified the outcome of 76% of patients correctly. CONCLUSIONS: Serum estradiol concentration is a valuable prognostic tool and potential contributor to adverse outcomes of critically ill or injured surgical patients.     

Increased incidence of postoperative infections during prophylaxis with cephalothin compared to doxycycline in intestinal surgery

Background

The Acute Physiology and Chronic Health Evaluation (APACHE) III prognostic system has not been previously validated in patients admitted to the intensive care unit (ICU) after orthotopic liver transplantation (OLT). We hypothesized that APACHE III would perform satisfactorily in patients after OLT

Methods

A retrospective cohort study was performed. Patients admitted to the ICU after OLT between July 1996 and May 2008 were identified. Data were abstracted from the institutional APACHE III and liver transplantation databases and individual patient medical records. Standardized mortality ratios (with 95% confidence intervals) were calculated by dividing the observed mortality rates by the rates predicted by APACHE III. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow C statistic were used to assess, respectively, discrimination and calibration of APACHE III.

Results

APACHE III data were available for 918 admissions after OLT. Mean (standard deviation [SD]) APACHE III (APIII) and Acute Physiology (APS) scores on the day of transplant were 60.5 (25.8) and 50.8 (23.6), respectively. Mean (SD) predicted ICU and hospital mortality rates were 7.3% (15.4) and 10.6% (18.9), respectively. The observed ICU and hospital mortality rates were 1.1% and 3.4%, respectively. The standardized ICU and hospital mortality ratios with their 95% C.I. were 0.15 (0.07 to 0.27) and 0.32 (0.22 to 0.45), respectively. There were statistically significant differences in APS, APIII, predicted ICU and predicted hospital mortality between survivors and non-survivors. In predicting mortality, the AUC of APACHE III prediction of hospital death was 0.65 (95% CI, 0.62 to 0.68). The Hosmer-Lemeshow C statistic was 5.288 with a p value of 0.871 (10 degrees of freedom).

Conclusion

APACHE III discriminates poorly between survivors and non-survivors of patients admitted to the ICU after OLT. Though APACHE III has been shown to be valid in heterogenous populations and in certain groups of patients with specific diagnoses, it should be used with caution – if used at all – in recipients of liver transplantation.     

Serial lactate and admission SOFA scores in trauma: an analysis of predictive value in 724 patients with and without traumatic brain injury

Objective

Arterial lactate, base excess (BE), lactate clearance, and Sequential Organ Failure Assessment (SOFA) score have been shown to correlate with outcome in severely injured patients. The goal of the present study was to separately assess their predictive value in patients suffering from traumatic brain injury (TBI) as opposed to patients suffering from injuries not related to the brain.

Materials and methods

A total of 724 adult trauma patients with an Injury Severity Score (ISS) ≥ 16 were grouped into patients without TBI (non-TBI), patients with isolated TBI (isolated TBI), and patients with a combination of TBI and non-TBI injuries (combined injuries). The predictive value of the above parameters was then analyzed using both uni- and multivariate analyses.

Results

The mean age of the patients was 39 years (77 % males), with a mean ISS of 32 (range 16–75). Mortality ranged from 14 % (non-TBI) to 24 % (combined injuries). Admission and serial lactate/BE values were higher in non-survivors of all groups (all p < 0.01), but not in patients with isolated TBI. Admission SOFA scores were highest in non-survivors of all groups (p = 0.023); subsequently septic patients also showed elevated SOFA scores (p < 0.01), except those with isolated TBI. In this group, SOFA score was the only parameter which showed significant differences between survivors and non-survivors. Receiver operating characteristic (ROC) analysis revealed lactate to be the best overall predictor for increased mortality and further septic complications, irrespective of the leading injury.

Conclusion

Lactate showed the best performance in predicting sepsis or death in all trauma patients except those with isolated TBI, and the differences were greatest in patients with substantial bleeding. Following isolated TBI, SOFA score was the only parameter which could differentiate survivors from non-survivors on admission, although the SOFA score, too, was not an independent predictor of death following multivariate analysis.