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      Trauma de tórax en la unidad de cuidados intensivos: factores de riesgo de ventilación prolongada y de muerte

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          Abstract

          Introducción: el trauma de tórax es una entidad frecuente,70% en el contexto de politraumatismos, 46,5% corresponde a siniestros de tránsito. Involucra a pacientes jóvenes con mortalidad de hasta 30%(¹). Material y método: estudio de cohorte dinámica de pacientes adultos en cuidados críticos, período: marzo de 2014 a junio de 2015. Datos recabados prospectivamente: demográficos, comorbilidades, scores de gravedad, asistencia ventilatoria, tratamiento, complicaciones, evolución. Se buscaron factores de riesgo de: ventilación prolongada (?7 días) y de muerte de forma univariada y multivariada con regresión logística, expresados en Odds Ratio (OR) con intervalos de confianza (IC) de 95%. Se utilizaron test de Student y Mann-Whitney para variables cuantitativas; chi cuadrado y test de Fisher para cualitativas. Nivel de significación < 0,05. Resultados: 66 pacientes, 82% hombres. Edad media 43±17 años (± 1 desvío estándar); 73% accidentes de tránsito; 94% trauma cerrado; 60,6% con asistencia ventilatoria mecánica (AVM) invasiva; factores independientes de riesgo para ventilación prolongada: Injury Severity Score (ISS), y NAV (neumonía del ventilado) tardía. Por cada incremento de ISS existe 1,28 más riesgo de tener AVM ?7días y la NAV tardía lo incrementa por 27,46. Todos los fallecidos (9%) estuvieron en AVM, pero no hubo relación entre muerte y ventilación prolongada. Factores de riesgo univariado de muerte: obesidad, NAV temprana, shock hemorrágico, Apache II ?18. Conclusiones: la NAV tardía fue un factor independiente de riesgo de AVM prolongada, también lo fue cada punto de ascenso del ISS en relación con su valor inferior. Tenían riesgo de morir los obesos, los que tenían NAV temprana, shock hemorrágico y Acute Physiology and Chronic Health Evaluation (APACHE) II ?18.

          Translated abstract

          Abstract Introduction: thoracic trauma is a common condition, 70% of cases lie within the framework of polytrauma and 46.5% correspond to traffic accidents. Trauma involves young patients with mortality rates of 30%. Method: we conducted a cohort study oo adult patients in critical condition from March, 2014 to June, 2015. The following data was collected prospectively: demographic details, comorbilities, injury severity scores, mechanical ventilation, treatment, complications and evolution. Risk factors were studied in connection with prolonged mechanical ventilation (=>7 days) and univariate and multivariate logistic regression analyses were conducted, expressed in odds ratio (OR) with 95% confidence intervals. Student’s t Test and Mann-Whitney U tests were used for quantitative variables; Chi-square test and Fisher exact test were used for qualitative variables. The level of statistical significance was <0,05. Results: the study included 66 patients, 82% of them were male. Average age 43±17years old (±1 standard deviation). 73% accounted for traffic accidents, 94% were cases of closed trauma, 60,6% with invasive mechanical ventilation. Independent risk factors for prolonged ventilation: Injury Severity Score (ISS), and late ventilator-associated pneumonia (VAP). Every time the ISS increases the risk of needing mechanical ventilation assistance ? 7days rises 1.28 more times and the late VAP increases it this need by 27.46%. All patients who died (9%) were on mechanical ventilation, although there was no relationship between death and prolonged ventilation. Univariate risk factors: obesity, early VAP, Hemorrhagic shock, Apache II ?18. Conclusions: late VAP was an independent risk factor for prolonged mechanical ventilation, the same as increase in the value of the ISS score, when compared to the lower levels or scores. Obese patients, those with early mechanical ventilation, Hemorrhagic shock and Apache II ?18 were in risk.

          Translated abstract

          Resumo Introdução: Esta é uma lesão frequente, 70% diagnosticadas em politraumatizados, sendo que 46.5% ocorreram como consequência de acidentes de trânsito. Pacientes jovens apresentam uma mortalidade de até 30%(¹). Material e método: Estudo de coorte dinâmica de pacientes adultos em cuidados críticos, realizado no período março 2014-junio 2015. Foram coletados prospectivamente dados: demográficos, comorbidades, graus de gravidade, assistência ventilatória, tratamento, complicações, evolução. Os fatores de risco ventilação prolongada (?7 dias) e morte foram analisados de forma univariada e multivariada com regressão logística, expressados em Odds Ratio (OR) com intervalos de confiança (IC) a 95%. Para variáveis quantitativas foi utilizado o teste de Student e Mann-Whitney e para as qualitativas Chi quadrado e teste de Fisher. Nível de significância < 0,05. Resultados: foram incluídos 66 pacientes, sendo 82% do sexo masculino. A média de idade foi 43±17 anos (± 1 desvio padrão). 73% correspondiam a acidentes de trânsito. 94% apresentavam trauma cerrado; 60,6% com assistência ventilatória mecânica invasiva (AVM). Fatores independentes de risco para ventilação prolongada: injury severity score (ISS), e NAV (Pneumonia do ventilador) de inicio tardio. Por cada incremento de ISS há um aumento de 1,28 do risco de estar com AVM ?7dias e a NAV de inicio tardio aumenta em 27,46. Todos os falecidos (9%) receberam AVM, porém não se encontrou relação entre morte e ventilação prolongada. Os fatores de risco univariado de morte foram obesidade, NAV de inicio precoce, choque hemorrágico, Apache II ?18. Conclusões: foram fatores independente de risco de AVM prolongada a NAV de inicio tardio e também cada ponto de incremento do ISS em relação ao seu valor inferior. Apresentavam risco de morte os obesos, os que tenham NAV de inicio precoce, choque hemorrágico e Apache II ?18.

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          Predictors of poor outcomes after significant chest trauma in multiply injured patients: a retrospective analysis from the German Trauma Registry (Trauma Register DGU®)

          Background Blunt thoracic trauma is one of the critical injury mechanisms in multiply injured trauma victims. Although these patients present a plethora of potential structural damages to vital organs, it remains debated which injuries actually influence outcome and thereby should be addressed initially. Hence, the aim of this study was to identify the influence of critical structural damages on mortality. Methods All patients in the database of the TraumaRegister DGU® (TR-DGU) from 2002–2011 with AIS Chest ≥ 2, blunt trauma, age of 16 or older and an ISS ≥ 16 were analyzed. Outcome parameters were in-hospital mortality as well as ventilation time in patients surviving the initial 14 days after trauma. Results 22613 Patients were included (mean ISS 30.5 ± 12.6; 74.7% male; Mean Age 46.1 ± 197 years; mortality 17.5%; mean duration of ventilation 7.3 ± 11.5; mean ICU stay 11.7 ± 14.1 days). Only a limited number of specific injuries had a significant impact on survival. Major thoracic vessel injuries (AIS ≥5), bilateral lung contusion, bilateral flail chest, structural heart injury (AIS ≥3) significantly influence mortality in study patients. Several extrathoracic factors (age, blood transfusion, systolic blood pressure and extrathoracic severe injuries) were also predictive of increased mortality. Most injuries of the thoracic wall had no or only a moderate effect on the duration of ventilation. Injuries to the lung (laceration, contusion or pneumothoraces) had a moderate prolonging effect. Cardiac injuries and severe injuries to the thoracic vessels induced a substantially prolonged ventilation interval. Conclusions We demonstrate quantitatively the influence of specific structural damages of the chest on critical outcome parameters. While most injuries of the chest wall have no or only limited impact in the study collective, injuries to the lung overall show adverse outcome. Injuries to the heart or thoracic vessels have a devastating prognosis following blunt chest trauma.
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            The effect of obesity on outcomes in trauma patients: a meta-analysis.

            This study aims to assess the effect of obesity on injury severity score (ISS), mortality and course of hospital stay among trauma patients. A systematic review of the literature was conducted by Internet search. Data were extracted from included studies and analysed using a random-effects model to compare outcomes in the obese (body mass index (BMI)≥30kgm(-2)) with the non-obese (BMI<30kgm(-2)) group. Eventually, 18 studies met our inclusion criteria with 7751 obese patients representing 17% of the pooled study population. The data revealed that obesity was associated with increased risk of mortality, longer stay in the intensive care unit and higher rates of complication. Additionally, obese patients seemed to have longer duration of mechanical ventilation and hospital length of stay but it did not reach statistical significance. No difference was observed in ISS between the two groups. Evidence strongly supports the correlation of obesity with worse prognosis in trauma patients and further studies should target this kind of population for therapy and prevention. Copyright © 2012 Elsevier Ltd. All rights reserved.
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              Noninvasive ventilation in chest trauma: systematic review and meta-analysis.

              Single studies of Noninvasive Ventilation (NIV) in the management of acute respiratory failure in chest trauma patients have produced controversial findings. The aim of this study is to critically review the literature to investigate whether NIV reduces mortality, intubation rate, length of stay and complications in patients with chest trauma, compared to standard therapy. We performed a systematic review and meta-analysis of randomized controlled trials, prospective and retrospective observational studies, by searching PubMed, EMBASE and bibliographies of articles retrieved. We screened for relevance studies that enrolled adults with chest trauma who developed mild to severe acute respiratory failure and were treated with NIV. We included studies reporting at least one clinical outcome of interest to perform a meta-analysis. Ten studies (368 patients) met the inclusion criteria and were included for the meta-analysis. Five studies (219 patients) reported mortality and results were quite homogeneous across studies, with a summary relative risk for patients treated with NIV compared with standard care (oxygen therapy and invasive mechanical ventilation) of 0.26 (95 % confidence interval 0.09-0.71, p = 0.003). There was no advantage in mortality of continuous positive airway pressure over noninvasive pressure support ventilation. NIV significantly increased arterial oxygenation and was associated with a significant reduction in intubation rate, in the incidence of overall complications and infections. These results suggest that NIV could be useful in the management of acute respiratory failure due to chest trauma.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                rmu
                Revista Médica del Uruguay
                Rev. Méd. Urug.
                Sindicato Médico del Uruguay (Montevideo, , Uruguay )
                0303-3295
                1688-0390
                December 2016
                : 32
                : 4
                : 254-267
                Affiliations
                [02] orgnameCírculo Católico Obreros Uruguay orgdiv1Médico Intensivista
                [03] orgnameCírculo Católico Obreros Uruguay orgdiv1Médico Intensivista orgdiv2Coordinador
                [01] orgnameCírculo Católico de Obreros del Uruguay orgdiv1Jefe CTI orgdiv2Médico Intensivista
                Article
                S1688-03902016000400004
                6fd8f577-5001-4360-8003-2866a6446462

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

                History
                : 29 April 2016
                : 12 September 2016
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 23, Pages: 14
                Product

                SciELO Uruguay


                RISK FACTORS,MORTALITY,TRAUMATISMOS TORÁCICOS,RESPIRACIÓN ARTIFICIAL,FACTORES DE RIESGO,MORTALIDAD,THORACIC INJURIES,ARTIFICIAL RESPIRATION

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