“死亡率上升”：二级创伤中心与一级创伤中心血流动力学不稳定创伤患者的每小时死亡风险。
The "mortality ascent": Hourly risk of death for hemodynamically unstable trauma patients at Level II versus Level I trauma centers.
作者信息
Herrera-Escobar Juan Pablo, Rios-Diaz Arturo J, Zogg Cheryl K, Wolf Lindsey L, Harlow Alyssa, Schneider Eric B, Cooper Zara, Ordonez Carlos Alberto, Salim Ali, Haider Adil H
机构信息
From the Center for Surgery and Public Health (J.P.H-E., A.J.R-D., C.Z., L.L.W., A.H., E.B.S., Z.C., A.S., A.H.H.), Brigham and Women's Hospital, Harvard Medical School; Harvard T.H Chan School of Public Health (J.P.H-E., A.J.R-D., C.Z., L.L.W., A.H., E.B.S., Z.C., A.S., A.H.H.); Division of Trauma, Burn and Surgical Critical Care, Department of Surgery (Z.C., A.S., A.H.H.), Brigham and Women's Hospital, Harvard Medical School Boston, Massachusetts; and Division of Trauma and Acute Care Surgery, Department of Surgery (C.A.O.), Fundacion Valle del Lili, Universidad del Valle, Cali, Colombia.
出版信息
J Trauma Acute Care Surg. 2018 Jan;84(1):139-145. doi: 10.1097/TA.0000000000001706.
BACKGROUND
Severely injured trauma patients have higher in-hospital mortality at Level II versus Level I trauma centers (TCs). To better understand these differences, we sought to determine if there were any periods during which hemodynamically unstable trauma patients are at higher risk of death at Level II versus Level I TCs within the first 24 hours postadmission.
STUDY DESIGN
Trauma patients aged 18 years to 64 years, with Injury Severity Score of 15 or greater, systolic blood pressure less than 90 mm Hg at admission, and treated at Level II or Level I TCs, were identified using the 2007 to 2012 National Trauma Data Bank. Burn patients, transfers, and patients dead on arrival were excluded. Log-binomial regression models, adjusted for patient- and hospital-level confounders, were used to compare mortality at Level II versus Level I TCs over the first 24 hours postadmission.
RESULTS
Of 13,846 hemodynamically unstable patients, 4,212 (30.4%) were treated at 149 Level II TCs, and 9,634 (69.6%) at 116 Level I TCs. Within the first 24 hours, 3,059 (22.1%) patients died. In risk-adjusted models, mortality risk was significantly elevated at Level II versus Level I TCs during the 24 hours postadmission (relative risk, 1.08; 95% confidence interval, 1.01-1.16). Hourly mortality risk was significantly different between Level II and Level I TCs during 4 hours to 7 hours postadmission, with a maximal difference at 7 hours (relative risk, 1.70; 95% confidence interval, 1.23-2.36) and comparable mortality risk beyond 7 hours postadmission.
CONCLUSION
The 4-hour to 7-hour time window postadmission is critical for hemodynamically unstable trauma patients. Variations in available treatment modalities may account for higher relative mortality at Level II TCs during this time. Further investigation to elucidate specific risk factors for mortality during this period may lead to reductions in in-hospital mortality among hemodynamically unstable trauma patients.
LEVEL OF EVIDENCE
Therapeutic/care management, level IV.
背景
与一级创伤中心相比，二级创伤中心的重伤患者院内死亡率更高。为了更好地理解这些差异，我们试图确定在入院后24小时内，血流动力学不稳定的创伤患者在二级创伤中心与一级创伤中心相比，是否存在死亡风险更高的时期。
研究设计
使用2007年至2012年国家创伤数据库，确定年龄在18岁至64岁之间、损伤严重程度评分15分或更高、入院时收缩压低于90mmHg且在二级或一级创伤中心接受治疗的创伤患者。烧伤患者、转院患者和入院时死亡的患者被排除在外。采用对数二项回归模型，对患者和医院层面的混杂因素进行调整，以比较入院后24小时内二级创伤中心与一级创伤中心的死亡率。
结果
在13846例血流动力学不稳定的患者中，4212例（30.4%）在149家二级创伤中心接受治疗，9634例（69.6%）在116家一级创伤中心接受治疗。在最初的24小时内有3059例（22.1%）患者死亡。在风险调整模型中，入院后24小时内二级创伤中心的死亡风险显著高于一级创伤中心（相对风险，1.08；95%置信区间，1.01-1.16）。入院后4小时至7小时内，二级和一级创伤中心的每小时死亡风险存在显著差异，7小时时差异最大（相对风险，1.70；95%置信区间，1.23-2.36），入院后7小时后死亡风险相当。
结论
入院后4小时至7小时的时间窗对血流动力学不稳定的创伤患者至关重要。在此期间，二级创伤中心相对死亡率较高可能是由于可用治疗方式的差异。进一步研究以阐明这一时期死亡的具体危险因素，可能会降低血流动力学不稳定创伤患者群体的院内死亡率。
证据级别
治疗/护理管理，四级。
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