Winkelmann M, Soechtig W, Macke C, Schroeter C, Clausen J D, Zeckey C, Krettek C, Mommsen P
Trauma Department, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hanover, Germany.
Eur J Trauma Emerg Surg. 2019 Apr;45(2):255-261. doi: 10.1007/s00068-017-0897-0. Epub 2018 Jan 9.
Patients with multiple injuries are particularly susceptible to accidental hypothermia which is correlated with an increased risk of post-traumatic complications and mortality; however, its impact on neurological outcome in cases where there is concomitant traumatic brain injury is underexplored.
We analyzed severely injured patients (ISS ≥ 16) including a moderate-to-severe traumatic brain injury (AIS ≥ 3). The primary endpoint was objective neurological recovery, expressed as Glasgow Outcome Scale (GOS) score at time of discharge. Secondary endpoints were mortality, systemic inflammatory response syndrome (SIRS), sepsis, acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS). Statistical analysis included logistic regression (odds ratio). The significance level in all analyses was p = 0.05.
We analyzed 278 patients (M age = 43 years, SD 19; M ISS = 32.8, SD 10.7). Mortality was 17% (n = 14). 102 patients (37%) were hypothermic on admission. Hypothermic patients were more severely injured (ISS 35.6 ± 11.1 vs. 31.2 ± 10.1, p = 0.001; APACHE II 18.1 ± 7.4 vs. 16.2 ± 7.3, p = 0.045) and had a higher transfusion requirement. Mortality rate in hypothermic patients was increased (23.5 vs. 13.1%, p = 0.03); however, hypothermia was not an independent predictor of mortality. Median GOS at discharge was 3 (IQR 3); in 47% of patients the outcome was favorable (GOS 4 or 5) and 36% it was poor (GOS 2 or 3). There were no differences in post-traumatic complications. Analysis of 73 matched pairs of hypothermic and normothermic patients could not prove hypothermia as an independent predictor of poor neurological outcome (OR 1.7, 95% CI 0.8-3.6, p = 0.1) in the total population. However, older patients (> 41 years) had a 4.2-times higher risk (95% CI 1.4-12.7; p = 0.01) of poor neurological outcome, if they were hypothermic on admission.
Accidental hypothermia seems to have a negative impact on neurological recovery in older patients with multiple injuries including traumatic brain injury which outweighs potential benefits.
多发伤患者特别容易发生意外低温，这与创伤后并发症和死亡率增加相关；然而，其对伴有创伤性脑损伤病例的神经学转归的影响尚未得到充分研究。
我们分析了重伤患者（损伤严重度评分[ISS]≥16），包括中度至重度创伤性脑损伤（简明损伤定级标准[AIS]≥3）。主要终点是客观神经功能恢复，以出院时的格拉斯哥预后评分（GOS）表示。次要终点是死亡率、全身炎症反应综合征（SIRS）、脓毒症、急性呼吸窘迫综合征（ARDS）和多器官功能障碍综合征（MODS）。统计分析包括逻辑回归（比值比）。所有分析中的显著性水平为p = 0.05。
我们分析了278例患者（中位年龄 = 43岁，标准差19；中位ISS = 32.8，标准差10.7）。死亡率为17%（n = 14）。102例患者（37%）入院时体温过低。体温过低的患者受伤更严重（ISS 35.6±11.1对31.2±10.1，p = 0.001；急性生理与慢性健康状况评分系统II[APACHE II] 18.1±7.4对16.2±7.3，p = 0.045），且输血需求量更高。体温过低患者的死亡率增加（23.5%对13.1%，p = 0.03）；然而，低温不是死亡率的独立预测因素。出院时的中位GOS为3（四分位间距3）；47%的患者转归良好（GOS 4或5），36%的患者转归不佳（GOS 2或3）。创伤后并发症无差异。对73对体温过低和体温正常患者的配对分析未能证明低温是总体人群中神经学转归不佳的独立预测因素（比值比1.7，95%置信区间0.8 - 3.6，p = 0.1）。然而，年龄较大（>41岁）的患者，如果入院时体温过低，神经学转归不佳的风险高4.2倍（95%置信区间1.4 - 12.7；p = 0.01）。
意外低温似乎对包括创伤性脑损伤在内的多发伤老年患者的神经功能恢复有负面影响，且这种负面影响超过潜在益处。
