Discrepancy between heart rate and makers of hypoperfusion is a predictor of mortality in trauma patients.
ABSTRACT Tachycardia is an important early sign of shock in trauma. Although the base deficit (BD) and lactate are indicative of hypoperfusion and known to predict mortality, some cases show a discrepancy between heart rate (HR) and BD or lactate; such cases have poor prognosis. The objective of this study was to examine whether lack of tachycardia after hypoperfusion is associated with increased mortality.
Retrospective data were collected on 1,742 adult trauma patients. Mortality was compared with different levels of BD, lactate, and HR on admission. Multivariate logistic regression was used to identify significant risk factors for mortality.
Significantly increased mortality was observed in patients with hypoperfusion (BD less than -5 mmol/L or lactate more than 5 mmol/L). Among these patients, those with a normal HR (<80 bpm) were associated with a higher mortality rate than those with tachycardia (HR, 80-100 or>100 bpm). However, systolic blood pressure (SBP) was not significantly different between the different HR groups. Logistic regression analysis revealed that discrepancy between HR and indicators of hypoperfusion (Dis BD: BD less than -5 mmol/L and HR less than 80 bpm; or Dis lac: lactate more than 5 mmol/L and HR less than 80 bpm) are independent predictors of mortality after controlling for age, SBP, Injury Severity Score, head Abbreviated Injury Scale, HR, and BD or lactate (Dis BD: odds ratio, 2.67; 95% confidence interval, 1.07-6.61; p<0.05 and Dis lac: odds ratio, 4.11; 95% confidence interval, 1.57-10.74; p<0.01, respectively).
The lack of tachycardia in the presence of hypoperfusion is associated with poor prognosis independent of injury severity, SBP, and head injury. A discrepancy between HR and indicators of hypoperfusion could be considered as a predictor of mortality in trauma patients.
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ABSTRACT: The BIG score (Admission base deficit (B), international normalized ratio (I), and Glasgow Coma Scale (G)) has been shown to predict mortality on admission in pediatric trauma patients. The objective of this study was to assess its performance in predicting mortality in an adult trauma population, and to compare it with the existing Trauma and Injury Severity Score (TRISS) and probability of survival (PS09) score. Materials and method: A retrospective analysis using data collected between 2005-2010 from seven trauma centers and registries in Europe and the United States of America was performed. We compared the BIG score to TRISS and PS09 score in a population of blunt and penetrating trauma patients. We then assessed the discrimination ability of all scores via receiver operating characteristic (ROC) curves and compared the expected mortality rate (precision) of all scores to the observed mortality rate. 12,206 datasets were retrieved to validate the BIG score. The mean ISS was 15 +/- 11 and the mean 30-day mortality rate was 4.8%. With an AUROC of 0.892 (95% CI: 0.879 - 0.906) the BIG score performed well in an adult population. TRISS had an area under ROC (AUROC) of 0.922 (0.913 - 0.932) and the PS09 score of 0.825 (0.915 - 0.934). On a penetrating trauma population the BIG score presented with an AUROC result of 0.920 (0.898 - 0.942) compared to the PS09 score (AUROC of 0.921; 0.902 - 0.939) and TRISS (0.929; 0.912 - 0.947). The BIG score is a good predictor of mortality in the adult trauma population. It performed well compared to TRISS and the PS09 score although it has significantly less discriminative ability. In a penetrating trauma population the BIG score performed better than in a population with blunt trauma. The BIG score has the advantage of being available shortly after admission and may be used to predict clinical prognosis or as a research tool to risk stratify trauma patients into clinical trials.Critical care (London, England) 07/2013; 17(4):R134. · 5.04 Impact Factor
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ABSTRACT: We examined the association of plasma lactate at rest, a marker of oxidative capacity, with incident cardiovascular outcomes in 10,006 participants in the Atherosclerosis Risk in Communities (ARIC) Study visit 4 (1996-1998). We used Cox proportional-hazards models to estimate hazard ratios of incident coronary heart disease, stroke, heart failure, and all-cause mortality by quartiles of plasma lactate (Q1, ≤5.3 mg/dL; Q2, 5.4-6.6; Q3, 6.7-8.6; and Q4 ≥8.7). During a median follow-up time of 10.7 years, there were 1,105 coronary heart disease cases, 379 stroke cases, 820 heart failure cases, and 1,408 deaths. A significant graded relation between lactate level and cardiovascular events was observed in the demographically adjusted model (all P for trend < 0.001). After further adjustment for traditional and other potential confounders, the association remained significant for heart failure (Q4 vs. Q1: hazard ratio (HR) = 1.35, 95% confidence interval (CI): 1.07, 1.71) and all-cause mortality (HR = 1.27, 95% CI: 1.07, 1.51) (P for trend < 0.02 for these outcomes) but not for coronary heart disease (HR = 1.02, 95% CI: 0.84, 1.24) and stroke (HR = 1.26, 95% CI: 0.91, 1.75). The results for heart failure were robust across multiple subgroups, after further adjustment for N-terminal pro-B-type natriuretic peptide and after exclusion of participants with incident heart failure within 3 years. The independent associations of plasma lactate with heart failure and all-cause mortality suggest an important role for low resting oxidative capacity.American journal of epidemiology 06/2013; · 4.98 Impact Factor
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ABSTRACT: BACKGROUND:: Lactate has been shown to be a prognostic biomarker in trauma. Although lactate clearance has already been proposed as an intermediate endpoint in randomized trials, its precise role in trauma patients remains to be determined. METHODS:: Blood lactate levels and lactate clearance (LC) were calculated at admission and 2 and 4 h later in trauma patients. The association of initial blood lactate level and lactate clearance with mortality was tested using receiver-operating characteristics curve, logistic regression using triage scores, Trauma Related Injury Severity Score as a reference standard, and reclassification method. RESULTS:: The authors evaluated 586 trauma patients (mean age 38 ± 16 yr, 84% blunt and 16% penetrating, mortality 13%). Blood lactate levels at admission were elevated in 327 (56%) patients. The lactate clearance should be calculated within the first 2 h after admission as LC0-2 h was correlated with LC0-4 h (R = 0.55, P < 0.001) but not with LC2-4 h (R = 0.04, not significant). The lactate clearance provides additional predictive information to initial blood lactate levels and triage scores and the reference score. This additional information may be summarized using a categorical approach (i.e., less than or equal to -20 %/h) in contrast to initial blood lactate. The results were comparable in patients with high (5 mM/l or more) initial blood lactate. CONCLUSIONS:: Early (0-2 h) lactate clearance is an important and independent prognostic variable that should probably be incorporated in future decision schemes for the resuscitation of trauma patients.Anesthesiology 12/2012; 117(6):1276-1288. · 6.17 Impact Factor