Sympathoadrenal Activation is Associated with Acute Traumatic Coagulopathy and Endotheliopathy in Isolated Brain Injury.

BACKGROUND: Acute coagulopathy after traumatic brain injury (TBI) involves a complex multifactorial hemostatic response that is poorly characterized. OBJECTIVES: To examine early posttraumatic alterations in coagulofibrinolytic, endothelial, and inflammatory blood biomarkers in relation to sympathetic nervous system (SNS) activation and 6-month patient outcomes, using multivariate partial least-squares (PLS) analysis. PATIENTS AND METHODS: A multicenter observational study of 159 adult isolated TBI patients admitted to the emergency department at an urban level I trauma center, was performed. Plasma concentrations of 6 coagulofibrinolytic, 10 vascular endothelial, 19 inflammatory, and 2 catecholamine biomarkers were measured by immunoassay on admission and 24 h postinjury. Neurological outcome at 6 months was assessed using the Extended Glasgow Outcome Scale. PLS-discriminant analysis was used to identify salient biomarker contributions to unfavorable outcome, whereas PLS regression analysis was used to evaluate the covariance between SNS correlates (catecholamines) and biomarkers of coagulopathy, endotheliopathy, and inflammation. RESULTS: Biomarker profiles in patients with an unfavorable outcome displayed procoagulation, hyperfibrinolysis, glycocalyx and endothelial damage, vasculature activation, and inflammation. A strong covariant relationship was evident between catecholamines and biomarkers of coagulopathy, endotheliopathy, and inflammation at both admission and 24 h postinjury. CONCLUSIONS: Biomarkers of coagulopathy and endotheliopathy are associated with poor outcome after TBI. Catecholamine levels were highly correlated with endotheliopathy and coagulopathy markers within the first 24 h after injury. Further research is warranted to characterize the pathogenic role of SNS-mediated hemostatic alterations in isolated TBI.

Changes in end of life care 5 years after the introduction of a rapid response team: a multicentre retrospective study.

RATIONALE: Rapid response teams (RRTs) are intended to stabilize deteriorating patients on the ward, but recent studies suggest that RRTs may also improve end-of-life care (EOLC). We sought to study the effect of introducing an RRT on EOLC at our institutions, and compare the EOLC care received by patients who were consulted by the RRT with that of patients who were not consulted by the RRT. METHODS: Retrospective review of 450 consecutive deaths at 3 institutions. We compared demographic factors and EOLC received before (2005) and 5 years after (2010) the introduction of an RRT. We also compared these same factors for patients who died in 2010 with and without RRT consultation. RESULTS: There were no differences in the proportion of patients who had Patient/Family Conferences or orders to limit life support on the ward between 2005 and 2010. Although the RRT was consulted for 30% of patients eligible to be seen by the RRT, the RRT was involved in only 11.1% of Patient/Family Conferences that took place on the ward. The prevalence of palliative care consultation and orders for opioids as needed was higher in 2010 than 2005, but those seen by the RRT were less likely to receive a palliative care consultation (30.2% vs. 55.9%), spiritual care consultation (25.4% vs. 41.3%) or an order for sedatives as needed (44.4% vs. 65.0%) than those who were not seen by the RRT. There was no change in the proportion of patients admitted to the ICU in 2010 compared with 2005, and multivariable logistic regression showed that the year of death did not influence the likelihood of ICU admission based on any comorbid or demographic factors. CONCLUSIONS: The introduction of an RRT was not associated with significant improvements in EOLC at our institutions. However, almost 1/3 of dying patients were consulted by the RRT, suggesting that the RRT could play a role in facilitating improved EOLC for some inpatients.

Rapid response teams, do not resuscitate orders, and potential opportunities to improve end-of-life care: a multicentre retrospective study.

PURPOSE: Rapid response teams (RRTs) were created to stabilize acutely ill patients on the ward, but recent studies suggest that RRTs may improve end-of-life care (EOLC). To learn more about the role of the RRT in EOLC at our institutions, we conducted a retrospective review. METHODS: Retrospective review of 300 RRT consultations at 3 academic hospitals in Toronto, Canada. RESULTS: The typical consultation was for an elderly patient with chronic illness. More than 90% had a "full resuscitation" order at the time of consultation. One third were admitted to the intensive care unit within 48 hours of the RRT consultation, and 24.7% ultimately died. Twenty-seven (9.3%) had a patient/family conference on the ward within 48h of the RRT consultation, 24 (8.3%) of whom changed their resuscitation order as a result. Among those who changed their resuscitation order, fewer than 20% were referred to the palliative care or spiritual care service, or prescribed comfort medications as needed (pro re nata), within 48 h of the RRT consultation; 2 patients died without receiving any common EOLC orders, and 15 (63%) died before discharge. CONCLUSIONS: RRT consultation is an important milestone for many patients approaching EOL. RRTs frequently participate in EOL discussions and decision-making, but they may miss opportunities to facilitate EOLC.