Patterns and Effects of Admission Hyperglycemia And Inflammatory Response in Trauma Patients: A Prospective Study

2020 ◽  
Author(s):  
Ayman El-Menyar ◽  
Mohammad Asim ◽  
Fayaz Mir ◽  
Suhail Hakim ◽  
Ahad Kanbar ◽  
...  
Keyword(s):  
Blood Glucose ◽  
Length Of Stay ◽  
Inflammatory Response ◽  
Injury Severity ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Trauma Patients ◽  
Severity Of Injury ◽  
Hs Crp ◽  
Initial Blood

Abstract Background: Hyperglycemia following trauma could be a response to stress. The constellation of the initial hyperglycemia, proinflammatory cytokines and severity of injury among trauma patients is understudied. We aimed to evaluate the patterns and effects of on-admission hyperglycemia and inflammatory response in a level 1 trauma center admissions. Methods: A prospective, observational study was conducted for adult trauma patients who were admitted and tested for on-admission blood glucose, hemoglobin A1c, interleukin (IL)-6 ,Il-18 and hs-CRP. Patients were categorized into 4 groups (non-diabetic normoglycemic, diabetic normoglycemic, diabetic hyperglycemic (DH) and stress-induced hyperglycemic (SIH)). The inflammatory markers were measured on 3 time points (admission, 24 h, and 48 h). Pearson’s correlation test and logistic regression analysis were performed. We hypothesized that higher initial readings of blood glucose and cytokines are associated with severe injuries and worse in-hospital outcomes in trauma patients.Results: During the study period, 250 adult trauma patients were enrolled. Almost 13% of patients presented with hyperglycemia (SIH&DH); of whom 50% had SIH. Compared to the other 3 groups; SIH patients were younger, had significantly higher ISS, higher IL-6 readings, prolonged hospital length of stay and higher mortality. The SIH group had lower Revised Trauma Score (p=0.005), lower Trauma Injury Severity Score (p=0.01) and lower GCS (p=0.001). IL-18 and hs-CRP were comparable among the study groups. Compared to the normoglycemia groups, patients with hyperglycemia had elevated high- sensitive troponin T (p=0.001) and required more blood transfusion (p=0.03). Patients with hyperglycemia had 3-times higher in-hospital mortality than the normoglycemia groups (p=0.02). A significant correlation was identified between initial blood glucose and serum lactate, IL-6, ISS and hospital length of stay. IL-6 correlated well with ISS (r=0.40, p=0.001). On- admission blood glucose had age-sex-GCS adjusted odd ratio 1.20(95% CI 1.06-1.33, p=0.003) for severe injury (ISS≥16).Conclusions: On-admission hyperglycemia is associated with a significant severer injury than normoglycemia patients. Initial blood glucose correlates with serum IL-6 which indicates a potential role of the systemic inflammatory response in the disease pathogenesis among the injured patients. On-admission glucose level could be a useful marker of injury severity, triage and risk assessment in trauma patients.This study was registered at the ClinicalTrials.gov (Identifier: NCT02999386), retrospectively Registered on December 21, 2016 https://clinicaltrials.gov/ct2/show/NCT02999386.

scholarly journals Patterns and Effects of Admission Hyperglycemia and Inflammatory Response in Trauma Patients: A Prospective Clinical Study

2021 ◽  
Author(s):  
Ayman El-Menyar ◽  
Mohammad Asim ◽  
Fayaz Mir ◽  
Suhail Hakim ◽  
Ahad Kanbar ◽  
...  
Keyword(s):  
Blood Glucose ◽  
Length Of Stay ◽  
Inflammatory Response ◽  
Injury Severity Score ◽  
Inflammatory Markers ◽  
Injury Severity ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Trauma Patients ◽  
Severe Injuries

Abstract Background The constellation of the initial hyperglycemia, proinflammatory cytokines and severity of injury among trauma patients is understudied. We aimed to evaluate the patterns and effects of on-admission hyperglycemia and inflammatory response in a level 1 trauma center. We hypothesized that higher initial readings of blood glucose and cytokines are associated with severe injuries and worse in-hospital outcomes in trauma patients. Methods A prospective, observational study was conducted for adult trauma patients who were admitted and tested for on-admission blood glucose, hemoglobin A1c, interleukin (IL)-6, IL-18 and hs-CRP. Patients were categorized into four groups [non-diabetic normoglycemic, diabetic normoglycemic, diabetic hyperglycemic (DH) and stress-induced hyperglycemic (SIH)]. The inflammatory markers were measured on three time points (admission, 24 h and 48 h). Generalized estimating equations (GEE) were used to account for the correlation for the inflammatory markers. Pearson’s correlation test and logistic regression analysis were also performed. Results During the study period, 250 adult trauma patients were enrolled. Almost 13% of patients presented with hyperglycemia (50% had SIH and 50% had DH). Patients with SIH were younger, had significantly higher Injury Severity Score (ISS), higher IL-6 readings, prolonged hospital length of stay and higher mortality. The SIH group had lower Revised Trauma Score (p = 0.005), lower Trauma Injury Severity Score (p = 0.01) and lower GCS (p = 0.001). Patients with hyperglycemia had higher in-hospital mortality than the normoglycemia group (12.5% vs 3.7%; p = 0.02). A significant correlation was identified between the initial blood glucose level and serum lactate, IL-6, ISS and hospital length of stay. Overall rate of change in slope 88.54 (95% CI:-143.39–33.68) points was found more in hyperglycemia than normoglycemia group (p = 0.002) for IL-6 values, whereas there was no statistical significant change in slopes of age, gender and their interaction. The initial IL-6 levels correlated with ISS (r = 0.40, p = 0.001). On-admission hyperglycemia had an adjusted odds ratio 2.42 (95% CI: 1.076–5.447, p = 0.03) for severe injury (ISS > 12) after adjusting for age, shock index and blood transfusion. Conclusions In trauma patients, on-admission hyperglycemia correlates well with the initial serum IL-6 level and is associated with more severe injuries. Therefore, it could be a simple marker of injury severity and useful tool for patient triage and risk assessment. Trial registration This study was registered at the ClinicalTrials.gov (Identifier: NCT02999386), retrospectively Registered on December 21, 2016. https://clinicaltrials.gov/ct2/show/NCT02999386.

scholarly journals Does emergency medicine length of stay predict trauma outcomes at a Level 1 Trauma Center?

2015 ◽  
Vol 4 (5) ◽  
pp. 1 ◽  
Author(s):  
Erin Powers Kinney ◽  
Kamal Gursahani ◽  
Eric Armbrecht ◽  
Preeti Dalawari
Keyword(s):  
Length Of Stay ◽  
Trauma Center ◽  
Injury Severity ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Trauma Patients ◽  
Hospital Capacity ◽  
Significant Difference ◽  
Level 1 ◽  
Level 1 Trauma Center

Objective: Previous studies looking at emergency department (ED) crowding and delays of care on outcome measures for certain medical and surgical patients excluded trauma patients. The objectives of this study were to assess the relationship of trauma patients’ ED length of stay (EDLOS) on hospital length of stay (HLOS) and on mortality; and to examine the association of ED and hospital capacity on EDLOS.Methods: This was a retrospective database review of Level 1 and 2 trauma patients at a single site Level 1 Trauma Center in the Midwest over a one year period. Out of a sample of 1,492, there were 1,207 patients in the analysis after exclusions. The main outcome was the difference in hospital mortality by EDLOS group (short was less than 4 hours vs. long, greater than 4 hours). HLOS was compared by EDLOS group, stratified by Trauma Injury Severity Score (TRISS) category (< 0.5, 0.51-0.89, > 0.9) to describe the association between ED and hospital capacity on EDLOS.Results: There was no significant difference in mortality by EDLOS (4.8% short and 4% long, p = .5). There was no significant difference in HLOS between EDLOS, when adjusted for TRISS. ED census did not affect EDLOS (p = .59), however; EDLOS was longer when the percentage of staffed hospital beds available was lower (p < .001).Conclusions: While hospital overcrowding did increase EDLOS, there was no association between EDLOS and mortality or HLOS in leveled trauma patients at this institution.

Placement of Surgical Feeding Tubes Among Patients With Severe Traumatic Brain Injury Requiring Exploratory Abdominal Surgery

2020 ◽  
Vol 86 (6) ◽  
pp. 635-642
Author(s):  
Peter I. Cha ◽  
Ronald M. Jou ◽  
David A. Spain ◽  
Joseph D. Forrester
Keyword(s):  
Length Of Stay ◽  
Abdominal Surgery ◽  
Injury Severity ◽  
Unit Length ◽  
Feeding Tube ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Fascial Closure ◽  
Trauma Patients ◽  
Percutaneous Endoscopic Gastrostomy Placement

Objectives The purpose of this study was to identify trauma patients who would benefit from surgical placement of an enteral feeding tube during their index abdominal trauma operation. Methods We performed a retrospective analysis of all patients admitted to 2 level I trauma centers between January 2013 and February 2018 requiring urgent exploratory abdominal surgery. Results Six-hundred and one patients required exploratory abdominal surgery within 24 hours of admission after trauma activation. Nineteen (3% of total) patients underwent placement of a feeding tube after their initial exploratory surgery. On multivariate analysis, an intracranial Abbreviated Injury Scale ≥4 (odds ratio [OR] = 9.24, 95% CI 1.09-78.26, P = .04) and a Glasgow Coma Scale ≤8 (OR = 4.39, 95% CI 1.38-13.95, P = .01) were associated with increased odds of requiring a feeding tube. All patients who required a feeding tube had an Injury Severity Score ≥15. While not statistically significant, patients with an open surgical feeding tube compared with interventional radiology/percutaneous endoscopic gastrostomy placement had lower median intensive care unit length of stay, fewer ventilator days, and shorter median total hospital length of stay. Conclusions Trauma patients with severe intracranial injury already requiring urgent exploratory abdominal surgery may benefit from early, concomitant placement of a feeding tube during the index abdominal operation, or at fascial closure.

Risk for Contrast-Induced Nephropathy in Elderly Trauma Patients

2012 ◽  
Vol 78 (10) ◽  
pp. 1114-1117 ◽  
Author(s):  
Ryan Finigan ◽  
Jacqueline Pham ◽  
Rosemarie Mendoza ◽  
Michael Lekawa ◽  
Matthew Dolich ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Length Of Stay ◽  
Injury Severity ◽  
Unit Length ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Trauma Patients ◽  
Contrast Induced Nephropathy ◽  
History Of ◽  
Elderly Trauma Patients

The objective of this study was to determine if elderly trauma patients are at risk for contrast-induced nephropathy (CIN). A retrospective study was conducted identifying 362 patients 65 years and older in our Level I trauma center who received computerized tomography (CT) scans with intravenous contrast. CIN was defined as a 25 per cent increase in serum creatinine levels or a 0.5 mg/dL increase above baseline after CT. History of diabetes mellitus, hospital length of stay, intensive care unit length of stay, Injury Severity Score (ISS), and age were recorded. Eighteen per cent (21 of 118) of the patients had a peak in creatinine, 12 per cent (14 of 118) peaked and returned to baseline, and 6 per cent (7 of 118) peaked and stayed high. Pre-CT elevated creatinine, diabetes mellitus, increased hospital length of stay, ISS, and age show little association to CIN. The data suggest that CIN in elderly trauma patients is rare, regardless of history of diabetes mellitus, age, creatinine, high ISS, or result in higher length of stay. Therefore, there is little justification for the delay in diagnosis to assess a patient's renal susceptibility.

scholarly journals Association between Insurance Status and Hospital Length of Stay following Trauma

2016 ◽  
Vol 82 (3) ◽  
pp. 281-288 ◽  
Author(s):  
Brian R. Englum ◽  
Xuan Hui ◽  
Cheryl K. Zogg ◽  
Muhammad Ali Chaudhary ◽  
Cassandra Villegas ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Injury Severity ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Insurance Status ◽  
Trauma Patients ◽  
Uninsured Patients ◽  
National Trauma ◽  
Insured Patients ◽  
The Relationship

Previous research has demonstrated that nonclinical factors are associated with differences in clinical care, with uninsured patients receiving decreased resource use. Studies on trauma populations have also shown unclear relationships between insurance status and hospital length of stay (LOS), a commonly used metric for evaluating quality of care. The objective of this study is to define the relationship between insurance status and LOS after trauma using the largest available national trauma dataset and controlling for significant confounders. Data from 2007 to 2010 National Trauma Data Bank were used to compare differences in LOS among three insurance groups: privately insured, publically insured, and uninsured trauma patients. Multivariable regression models adjusted for potential confounding due to baseline differences in injury severity and demographic and clinical factors. A total of 884,493 patients met the inclusion criteria. After adjusting for the influence of covariates, uninsured patients had significantly shorter hospital stays (0.3 days) relative to privately insured patients. Publicly insured patients had longer risk-adjusted LOS (0.9 days). Stratified differences in discharge disposition and injury severity significantly altered the relationship between insurance status and LOS. In conclusion, this study elucidates the association between insurance status and hospital LOS, demonstrating that a patient's ability to pay could alter LOS in acute trauma patients. Additional research is needed to examine causes and outcomes from these differences to increase efficiency in the health care system, decrease costs, and shrink disparities in health outcomes.

Trauma Attending Physician Continuity: Does it Make a Difference?

2010 ◽  
Vol 76 (1) ◽  
pp. 48-54
Author(s):  
David G. Jacobs ◽  
Jennifer L. Sarafin ◽  
Karen E. Head ◽  
A Britt Christmas ◽  
Toan Huynh ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Injury Severity ◽  
Standard Of Care ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Trauma Patients ◽  
Trauma Service ◽  
Retrospective Comparison ◽  
Scale Scores ◽  
Attending Physician

Continuity of care is important in achieving optimal outcomes in trauma patients, but the optimal length of the trauma attending (TA) rotation is unknown. We hypothesize that longer TA rotations provide greater continuity, and therefore improve outcomes. We did a retrospective comparison of trauma patient outcomes from two consecutive 6-month periods during which we transitioned from a 1-month TA rotation to a 1-week TA rotation. The Wilcoxon rank sum test, and the χ2 were used for statistical analysis. Over the 12-month study period 1924 patients were admitted to the Trauma Service. The two groups were similar with regard to age, gender, injury mechanism, Injury Severity Score and Glasgow Coma Scale scores, and Abbreviated Injury Scores for the chest, abdomen, and extremities. Although mortality, patient charges, and violations of the standard of care were similar between the two groups, overall morbidity was lower (18.6% vs 23.2%), and hospital length of stay higher (9.07 days vs 8.41 days) in the 1-week TA group compared with the 1-month TA group. A one-week TA rotation was associated with a longer hospital length of stay, but improved morbidity. Longer TA rotations do not necessarily provide improved continuity or improved outcomes.

Propofol Infusion Syndrome: Efficacy of a Prospective Screening Protocol

2018 ◽  
Vol 84 (8) ◽  
pp. 1333-1338 ◽  
Author(s):  
Thomas J. Schroeppel ◽  
L. Paige Clement ◽  
Danielle L. Barnard ◽  
Whitney Guererro ◽  
Margaret D. Ferguson ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Injury Severity ◽  
Unit Length ◽  
Hospital Length ◽  
Serum Lactate ◽  
Hospital Length Of Stay ◽  
Trauma Patients ◽  
Propofol Infusion Syndrome ◽  
Positive Screen ◽  
Screening Protocol

Propofol infusion syndrome (PIS) is a potentially lethal complication of propofol marked by rhabdomyolysis, metabolic acidosis, and cardiac arrhythmias or collapse. The objective of this study was to determine the effectiveness of a prospective screening protocol to prevent PIS. All trauma patients admitted who received propofol as a continuous infusion were prospectively screened from November 1, 2013 to December 31, 2015. Variables studied included demographics, injury severity, laboratory values, infusion rates, and mortality. Serum creatine phosphokinase (CPK) and lactate were drawn daily. Propofol was stopped for a positive screen defined as an increase in CPK to greater than 5000 IU/L or lactate greater than 4 mmol/L. Positive and negative cohorts were compared. Two hundred and twenty-five patients met the inclusion criteria and 12 patients (5.3%) had propofol stopped because of elevated CPK. No differences were identified in demographics, transfusions, injury severity, hospital length of stay, or propofol dose. The positive screened group had longer intensive care unit length of stay (20 vs 13 days; P = 0.002) and increased vent days (14.5 vs 10 days; P = 0.008). Max serum osmolality (334 vs 305 mosm/kg; P = 0.049) and max serum CPK (6782 vs 1058 IU/L; P < 0.0001) were higher in the positive cohort. No cases of PIS occurred, and mortality (16.7 vs 15.5%; P = 0.999) was not different between the cohorts. The screening protocol was effective in eliminating PIS. Serial CPK evaluations provided an effective screening tool and serum lactate can be dropped from screening.

Does the Degree of Platelet Adenosine Diphosphate and Arachidonic Acid Receptor Inhibition Correlate With the Severity of Injury in Non-Brain-Injured Trauma Patients?

2020 ◽  
pp. 000313482095483
Author(s):  
Grant Woodruff ◽  
Dustin Price ◽  
Aparna Sodhi ◽  
Andrew Kerwin ◽  
Marie Crandall
Keyword(s):  
Arachidonic Acid ◽  
Linear Regression ◽  
Length Of Stay ◽  
Injury Severity ◽  
Adenosine Diphosphate ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Bivariate Analysis ◽  
Receptor Inhibition ◽  
Severity Of Injury

Background Direct correlations between platelet adenosine diphosphate (ADP) and arachidonic acid (AA) receptor inhibition have been described in the traumatic brain injury (TBI) population. Our goal was to evaluate the percent inhibition of ADP receptor inhibition (ADPri) and AA receptor inhibition (AAri) receptors in non-TBI patients and correlate injury severity and outcomes. Methods We performed a retrospective review of non-TBI patients admitted to our trauma center, who received thromboelastography with platelet mapping prior to blood transfusion. Exclusion criteria included patients younger than 18 years, current antiplatelet therapy, or history of renal failure. Univariate descriptive statistics and bivariate comparisons were performed on patient demographic and outcomes. Multivariable linear regression models were constructed to quantify any association between ADPri and AAri with injury outcomes. High ADP inhibition was defined >20% and high AA inhibition >7%. Results 117 patients met inclusion criteria. Mean age was 53 years with 61% male. Mean ADPri was 64% and AAri 42%. On bivariate analysis, no statistically significant differences with respect to injury severity measures or outcomes were identified. On multivariable linear regression, AAri was associated with longer hospital length of stay. Discussion There was a high degree of platelet dysfunction in this cohort of severely injured patients without TBI. Despite this, the only correlation identified between injury severity and outcomes was AAri correlating with hospital length of stay. Irrespective of injury severity or outcomes, these patients’ results were far from reported “normal” values. Further, research is needed to determine the significance and clinical implications of thromboelastography with platelet mapping use in trauma care.

Advancing the Use of Laparoscopy in Trauma: Repair of Intraperitoneal Bladder Injuries

2019 ◽  
Vol 85 (12) ◽  
pp. 1402-1404 ◽  
Author(s):  
Michael R. Arnold ◽  
Caroline D. Lu ◽  
Bradley W. Thomas ◽  
Gaurav Sachdev ◽  
Kyle W. Cunningham ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Injury Severity ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Bladder Rupture ◽  
Trauma Patients ◽  
Average Hospital ◽  
Early Return ◽  
Significant Difference ◽  
Intraperitoneal Bladder Rupture

Traumatic intraperitoneal bladder rupture (IBR) requires surgical repair. Traditionally performed via laparotomy, experience with laparoscopic bladder repair (LBR) after blunt trauma is limited. Benefits of laparoscopy include decreased length of stay (LOS), less pain, early return to work, fewer adhesions, and lower risk of incisional hernia. The aim of this series is to demonstrate the potential superiority of LBR in select trauma patients. This is a retrospective review performed of all IBR patients from 2008 to 2016. Demographics, clinical management, outcomes, and follow-up were compared between LBR and open bladder repair (OBR) patients. Twenty patients underwent OBR, and seven underwent LBR. There was no significant difference in gender, age, or Injury Severity Score. There were no deaths or reoperations in either group. Average hospital length of stay and ICU days were similar between groups. There was one patient with UTI and one with readmission in each group. There were two incisional hernias and two bowel obstructions in the OBR group, with one patient requiring operative intervention. No such complications occurred in the LBR group. LBR for traumatic IBR can be safely performed in select patients, even in those with multiple extra-abdominal injuries.

Pain Assessment and Control in the Injured Elderly

2016 ◽  
Vol 82 (10) ◽  
pp. 867-871 ◽  
Author(s):  
Ara Ko ◽  
Megan Y. Harada ◽  
Eric J.T. Smith ◽  
Michael Scheipe ◽  
Rodrigo F. Alban ◽  
...  
Keyword(s):  
Risk Factors ◽  
Length Of Stay ◽  
Injury Severity ◽  
Unit Length ◽  
Patient Characteristics ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Trauma Patients ◽  
Increased Risk ◽  
Elderly Trauma Patients

Elderly trauma patients may be at increased risk for underassessment and inadequate pain control in the emergency department (ED). We sought to characterize risk factors for oligoanalgesia in the ED in elderly trauma patients and determine whether it impacts outcomes in elderly trauma patients. We included elderly patients (age ≥55 years) with Glasgow Coma Scale scores 13 to 15 and Injury Severity Score (ISS) ≥9 admitted through the ED at a Level I trauma center. Patient characteristics and outcomes were compared between those who reported pain and received analgesics medication in the ED (MED) and those who did not (NO MED). A total of 183 elderly trauma patients were identified over a three-year study period, of whom 63 per cent had pain assessed via verbal pain score; of those who reported pain, 73 per cent received analgesics in the ED. The MED and NO MED groups were similar in gender, race, ED vitals, ISS, and hospital length of stay. However, NO MED was older, with higher head Abbreviated Injury Scale score and longer intensive care unit length of stay. Importantly, as patients aged they reported lower pain and were less likely to receive analgesics at similar ISS. Risk factors for oligoanalgesia may include advanced age and head injury.

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