Prognostic value of metabolic parameters measured by first responders attending patients with severe trauma: associations with the New Injury Severity Score and mortality. / Valor pronóstico de los parámetros metabólicos medidos en la asistencia inicial a pacientes con trauma grave: asociación con la puntuación de la escala NISS y la mortalidad.

OBJECTIVES: Patients with severe or potentially severe trauma must be identified early, a challenge in prehospital settings. This study aimed to analyze the possible diagnostic and prognostic usefulness of analytical markers recorded in the early moments of care. MATERIAL AND METHODS: Observational study of information extracted from the prospective multicenter Code Trauma database for 2016-2019, excluding data for isolated head injuries. Using the New Injury Severity Score (NISS), we classified cases into 4 levels of severity. NISS and mortality were considered the dependent variables in inferential analyses. We calculated the areas under receiver operating characteristic curves, identified optimal cutoff points (Youden index), and calculated positive (PPV) and negative predictive values.. RESULTS: Of the 1039 trauma patients in the registry, 709 were included in the study. Their mean (SD) age was 40.4 (17.3) years, and 77.3% were men. Motorcycle accidents were the most common causes of trauma (in 21%), and mortality was 12.1%. Lactate concentration, pH, PCO2, hemoglobin concentration, hematocrit, and blood sugar were significantly associated with severity and mortality. The PPVs corresponding to pH for the 4 NISS score groups (34-41, 42-49, 50-59, and $ 60) and mortality, respectively, were 61.2, 64.1, 70.7, 62.2, and 66.6. The PPVs of traditionally used clinical variables were lower. CONCLUSION: Patients with more severe trauma had lower pH values and higher PCO2, lactate, and base excess values. PCO2, pH, and blood sugar findings were the best predictors of severity. Metabolic variables are better predictors than traditionally recorded hemodynamic variables.

OBJETIVO: En entornos de emergencia prehospitalarios, la detección temprana de un paciente con trauma grave o potencialmente crítico es un desafío. El objetivo es analizar las posibilidades diagnósticas y pronóstico de los parámetros analíticos obtenidos en los primeros momentos de la asistencia inicial. METODO: Estudio observacional multicéntrico de la base de datos prospectiva "Código Trauma" de 2016-2019 excluyendo el trauma craneoencefálico aislado. La evaluación de las lesiones se realizó utilizando el New Injury Severity Score (NISS). Los pacientes fueron clasificados en 4 grupos según nivel de gravedad. Para el análisis inferencial, las puntuaciones NISS y el resultado de mortalidad se consideraron variables dependientes. Se realizó el análisis de la curva ROC, puntos de corte óptimos mediante el índice de Youden y se calcularon los valores predictivos positivo (VPP) y negativo. RESULTADOS: De los 1.039 pacientes traumatizados del registro, 709 fueron incluidos en el estudio, con una edad media de 40,4 años (DE 17,3), 77,3% eran varones, el mecanismo lesional principal accidentes de moto (21%) y la mortalidad del 12,1%. El pH, lactato, pCO2, hemoglobina, hematocrito y glucemia influyeron significativamente en gravedad y mortalidad. El VPP de mortalidad para pH fue 61,2, 64,1, 70,7, 62,2 y 66,6 para los grupos de NISS 34- 41, 42-49, 50-59 y $ 60 puntos la mortalidad, respectivamente. Las variables clínicas clásicas obtuvieron valores más bajos. CONCLUSIONES: Los pacientes con mayor gravedad presentaron menor pH y concentraciones más altas de pCO2, lactato y exceso de bases. El pH, la pCO2 y la glucemia tuvieron la mayor capacidad predictiva de gravedad. La capacidad predictiva de los valores metabólicos es superior a la de los valores hemodinámicos clásicos.

Valor pronóstico de los parámetros metabólicos medidos en la asistencia inicial a pacientes con trauma grave: asociación con la puntuación de la escala NISS y la mortalidad / Prognostic value of metabolic parameters measured by first responders attending patients with severe trauma: associations with the New Injury Severity Score and mortality

Objetivos. En entornos de emergencia prehospitalarios, la detección temprana de un paciente con trauma grave o potencialmente crítico es un desafío. El objetivo es analizar las posibilidades diagnósticas y pronóstico de los parámetros analíticos obtenidos en los primeros momentos de la asistencia inicial. Métodos. Estudio observacional multicéntrico de la base de datos prospectiva “Código Trauma” de 2016-2019 excluyendo el trauma craneoencefálico aislado. La evaluación de las lesiones se realizó utilizando el New Injury Severity Score (NISS). Los pacientes fueron clasificados en 4 grupos según nivel de gravedad. Para el análisis inferencial, las puntuaciones NISS y el resultado de mortalidad se consideraron variables dependientes. Se realizó el análisis de la curva ROC, puntos de corte óptimos mediante el índice de Youden y se calcularon los valores predictivos positivo (VPP) y negativo. Resultados. De los 1.039 pacientes traumatizados del registro, 709 fueron incluidos en el estudio, con una edad media de 40,4 años (DE 17,3), 77,3% eran varones, el mecanismo lesional principal accidentes de moto (21%) y la mortalidad del 12,1%. El pH, lactato, pCO2, hemoglobina, hematocrito y glucemia influyeron significativamente en gravedad y mortalidad. El VPP de mortalidad para pH fue 61,2, 64,1, 70,7, 62,2 y 66,6 para los grupos de NISS 34-41, 42-49, 50-59 y $ 60 puntos la mortalidad, respectivamente. Las variables clínicas clásicas obtuvieron valores más bajos. Conclusiones. Los pacientes con mayor gravedad presentaron menor pH y concentraciones más altas de pCO2, lactato y exceso de bases. El pH, la pCO2 y la glucemia tuvieron la mayor capacidad predictiva de gravedad. La capacidad predictiva de los valores metabólicos es superior a la de los valores hemodinámicos clásicos. (AU)

Background and objective: Patients with severe or potentially severe trauma must be identified early, a challenge in prehospital settings. This study aimed to analyze the possible diagnostic and prognostic usefulness of analytical markers recorded in the early moments of care. Methods: Observational study of information extracted from the prospective multicenter Code Trauma database for 2016-2019, excluding data for isolated head injuries. Using the New Injury Severity Score (NISS), we classified cases into 4 levels of severity. NISS and mortality were considered the dependent variables in inferential analyses. We calculated the areas under receiver operating characteristic curves, identified optimal cutoff points (Youden index), and calculated positive (PPV) and negative predictive values. Results: Of the 1039 trauma patients in the registry, 709 were included in the study. Their mean (SD) age was 40.4 (17.3) years, and 77.3% were men. Motorcycle accidents were the most common causes of trauma (in 21%), and mortality was 12.1%. Lactate concentration, pH, PCO2, hemoglobin concentration, hematocrit, and blood sugar were significantly associated with severity and mortality. The PPVs corresponding to pH for the 4 NISS score groups (34-41, 42-49, 50-59, and $ 60) and mortality, respectively, were 61.2, 64.1, 70.7, 62.2, and 66.6. The PPVs of traditionally used clinical variables were lower. Conclusions: Patients with more severe trauma had lower pH values and higher PCO2, lactate, and base excess values. PCO2, pH, and blood sugar findings were the best predictors of severity. Metabolic variables are better predictors than traditionally recorded hemodynamic variables. (AU)

Lactate and lactate clearance in critically burned patients: usefulness and limitations as a resuscitation guide and as a prognostic factor.

OBJECTIVE: Lactate levels to guide resuscitation in critically burned patients are controversial. The purpose of our study was to determine whether absolute lactate values or lower lactate clearance predict mortality, and whether these are useful tools in the resuscitation phase. METHODS: We conducted a prospective, unicentric, observational study of a cohort of 214 burn patients admitted in the Burn Intensive Care Unit. We collected demographic and laboratory data, complications, absolute lactate levels and lactate clearance every 8 h since admission to 72 h. In critical patients we monitored hemodynamic parameters with transpulmonary thermodilution. We used Student's t-test or nonparametric tests, mixed models and Pearson and Spearman methods, Fisher's exact and chi-squared test. RESULTS: Of the 214 patients, 76.6% were male, mean age were 46 ± 15 years and 23.0 ± 19.5% of Total Basal Surface Area (TBSA) burned. Initial mean absolute levels of lactate were 2.02 ± 1.62 mmol/L in survivors vs. 4.05 ± 3.90 mmol/L in nonsurvivors. Initial elevated lactate levels increased mortality (p < .001), length of ICU stay, mechanical ventilation and shock. In the subgroup of burned TBSA < 20%, lowering the lactate cut-off point from 2.0 to 1.8 mmol/L improved the mortality prediction (OR:9.3). We found no relationship between lactate clearance in the first 24 h and mortality. In more severe patients (> 20% TBSA burned and initial lactate levels > 2), a good correlation was found between lactate and cardiac index; but not with intrathoracic blood volume index (ITBVI). Patients with low ITBVI preload (< 600 mL/m2) did not show significant differences in lactate clearance compared with those with ITBVI > 600. CONCLUSIONS: Initial elevated lactate levels are a factor of poor prognosis and the cut-off point that best predicts mortality should be adjusted in the patients with TBSA burned < 20%. The global clearance of lactate in the first 24 h, unlike what occurs in other injuries, does not correlate with mortality. Monitoring lactate can ensure adequate peripheral perfusion during resuscitation with lower than normal fluid preload values.