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The impact of severe traumatic brain injury on a novel base deficit- based classification of hypovolemic shock.

Mutschler M, Nienaber U, Wafaisade A, Brockamp T, Probst C, Paffrath T, Bouillon B, Maegele M, TraumaRegister DG - Scand J Trauma Resusc Emerg Med (2014)

Bottom Line: Simultaneously, injury severity scores increased from 20.8 (±11.9) to 41.6 (±17).Increments in BD paralleled decreasing hemoglobin, platelet counts and Quick's values.The number of blood units transfused correlated with worsening of BD.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University of Witten/Herdecke, Ostmerheimer Str, 200, D-51109 Cologne, Germany. manuelmutschler@web.de.

ABSTRACT

Background: Recently, our group has proposed a new classification of hypovolemic shock based on the physiological shock marker base deficit (BD). The classification consists of four groups of worsening BD and correlates with the extent of hypovolemic shock in severely injured patients. The aim of this study was to test the applicability of our recently proposed classification of hypovolemic shock in the context of severe traumatic brain injury (TBI).

Methods: Between 2002 and 2011, patients ≥16 years in age with an AIShead ≥ 3 have been retrieved from the German TraumaRegister DGU(®) database. Patients were classified into four strata of worsening BD [(class I (BD ≤ 2 mmol/l), class II (BD > 2.0 to 6.0 mmol/l), class III (BD > 6.0 to 10 mmol/l) and class IV (BD > 10 mmol/l)] and assessed for demographic and injury characteristics as well as blood product transfusions and outcomes. The cohort of severely injured patients with TBI was compared to a population of all trauma patients to assess possible differences in the applicability of the BD based classification of hypovolemic shock.

Results: From a total of 23,496 patients, 10,201 multiply injured patients with TBI (AIShead ≥ 3) could be identified. With worsening of BD, a consecutive increase of mortality rate from 15.9% in class I to 61.4% in class IV patients was observed. Simultaneously, injury severity scores increased from 20.8 (±11.9) to 41.6 (±17). Increments in BD paralleled decreasing hemoglobin, platelet counts and Quick's values. The number of blood units transfused correlated with worsening of BD. Massive transfusion rates increased from 5% in class I to 47% in class IV. Between multiply injured patients with TBI and all trauma patients, no clinically relevant differences in transfusion requirement or massive transfusion rates were observed.

Conclusion: The presence of TBI has no relevant impact on the applicability of the recently proposed BD-based classification of hypovolemic shock. This study underlines the role of BD as a relevant clinical indicator of hypovolaemic shock during the initial assessment in respect to haemostatic resuscitation and transfusion requirements.

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Transfusion requirements in multiply injured patients with TBI, all trauma patients and multiply injured trauma patients without TBI. A) Percent of patients with ≥ 1 blood product. (n = 23,496); B) Percent of patients with massive transfusion (≥10 blood units until ICU admission). (n = 23,496). Abbreviations: TBI: traumatic brain injury.
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Figure 1: Transfusion requirements in multiply injured patients with TBI, all trauma patients and multiply injured trauma patients without TBI. A) Percent of patients with ≥ 1 blood product. (n = 23,496); B) Percent of patients with massive transfusion (≥10 blood units until ICU admission). (n = 23,496). Abbreviations: TBI: traumatic brain injury.

Mentions: In multiply injured patients with TBI, an increase in BD category was associated with a progressively increasing transfusion requirement (Figure 1). The percentage of patients who received ≥ 1 blood unit during early ED resuscitation increased from 14% in class I to 64% in class IV (Figure 1A), while simultaneously massive transfusion rates increased stepwise from 5% in class I to 42% in class IV (Figure 1B). However, substantial and clinical relevant differences between patients who sustained TBI and the general trauma population were not observed within the four classes of hypovolemic shock based on BD. Similar results were seen when multiply injured patients with TBI were compared to a cohort of severely injured patients without TBI (Figure 1A and B). Only in group IV, patients without TBI had a slightly higher overall transfusion requirement. However, the clinical relevance of this finding remains questionable.


The impact of severe traumatic brain injury on a novel base deficit- based classification of hypovolemic shock.

Mutschler M, Nienaber U, Wafaisade A, Brockamp T, Probst C, Paffrath T, Bouillon B, Maegele M, TraumaRegister DG - Scand J Trauma Resusc Emerg Med (2014)

Transfusion requirements in multiply injured patients with TBI, all trauma patients and multiply injured trauma patients without TBI. A) Percent of patients with ≥ 1 blood product. (n = 23,496); B) Percent of patients with massive transfusion (≥10 blood units until ICU admission). (n = 23,496). Abbreviations: TBI: traumatic brain injury.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4016623&req=5

Figure 1: Transfusion requirements in multiply injured patients with TBI, all trauma patients and multiply injured trauma patients without TBI. A) Percent of patients with ≥ 1 blood product. (n = 23,496); B) Percent of patients with massive transfusion (≥10 blood units until ICU admission). (n = 23,496). Abbreviations: TBI: traumatic brain injury.
Mentions: In multiply injured patients with TBI, an increase in BD category was associated with a progressively increasing transfusion requirement (Figure 1). The percentage of patients who received ≥ 1 blood unit during early ED resuscitation increased from 14% in class I to 64% in class IV (Figure 1A), while simultaneously massive transfusion rates increased stepwise from 5% in class I to 42% in class IV (Figure 1B). However, substantial and clinical relevant differences between patients who sustained TBI and the general trauma population were not observed within the four classes of hypovolemic shock based on BD. Similar results were seen when multiply injured patients with TBI were compared to a cohort of severely injured patients without TBI (Figure 1A and B). Only in group IV, patients without TBI had a slightly higher overall transfusion requirement. However, the clinical relevance of this finding remains questionable.

Bottom Line: Simultaneously, injury severity scores increased from 20.8 (±11.9) to 41.6 (±17).Increments in BD paralleled decreasing hemoglobin, platelet counts and Quick's values.The number of blood units transfused correlated with worsening of BD.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University of Witten/Herdecke, Ostmerheimer Str, 200, D-51109 Cologne, Germany. manuelmutschler@web.de.

ABSTRACT

Background: Recently, our group has proposed a new classification of hypovolemic shock based on the physiological shock marker base deficit (BD). The classification consists of four groups of worsening BD and correlates with the extent of hypovolemic shock in severely injured patients. The aim of this study was to test the applicability of our recently proposed classification of hypovolemic shock in the context of severe traumatic brain injury (TBI).

Methods: Between 2002 and 2011, patients ≥16 years in age with an AIShead ≥ 3 have been retrieved from the German TraumaRegister DGU(®) database. Patients were classified into four strata of worsening BD [(class I (BD ≤ 2 mmol/l), class II (BD > 2.0 to 6.0 mmol/l), class III (BD > 6.0 to 10 mmol/l) and class IV (BD > 10 mmol/l)] and assessed for demographic and injury characteristics as well as blood product transfusions and outcomes. The cohort of severely injured patients with TBI was compared to a population of all trauma patients to assess possible differences in the applicability of the BD based classification of hypovolemic shock.

Results: From a total of 23,496 patients, 10,201 multiply injured patients with TBI (AIShead ≥ 3) could be identified. With worsening of BD, a consecutive increase of mortality rate from 15.9% in class I to 61.4% in class IV patients was observed. Simultaneously, injury severity scores increased from 20.8 (±11.9) to 41.6 (±17). Increments in BD paralleled decreasing hemoglobin, platelet counts and Quick's values. The number of blood units transfused correlated with worsening of BD. Massive transfusion rates increased from 5% in class I to 47% in class IV. Between multiply injured patients with TBI and all trauma patients, no clinically relevant differences in transfusion requirement or massive transfusion rates were observed.

Conclusion: The presence of TBI has no relevant impact on the applicability of the recently proposed BD-based classification of hypovolemic shock. This study underlines the role of BD as a relevant clinical indicator of hypovolaemic shock during the initial assessment in respect to haemostatic resuscitation and transfusion requirements.

Show MeSH
Related in: MedlinePlus