Department of Anesthesiology, Duke University, Durham, NC.
Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA.
Crit Care Med. 2018 Jun;46(6):965-971. doi: 10.1097/CCM.0000000000003052.
To examine the impact of early myocardial workload on in-hospital mortality following isolated severe traumatic brain injury.
Retrospective cohort study.
Data from the National Trauma Databank, a multicenter trauma registry operated by the American College of Surgeons, from 2007 to 2014.
Adult patients with isolated severe traumatic brain injury (defined as admission Glasgow Coma Scale < 8 and head Abbreviated Injury Score ≥ 4).
Admission rate-pressure product, categorized into five levels based on published low, normal, and submaximal human thresholds: less than 5,000; 5,000-9,999; 10,000-14,999; 15,000-19,999; and greater than 20,000.
Data from 26,412 patients were analyzed. Most patients had a normal rate-pressure product (43%), 35% had elevated rate-pressure product, and 22% had depressed rate-pressure product at hospital admission. Compared with the normal rate-pressure product group, in-hospital mortality was 22 percentage points higher in the lowest rate-pressure product group (cumulative mortality, 50.2%; 95% CI, 43.6-56.9%) and 11 percentage points higher in the highest rate-pressure product group (cumulative mortality, 39.2%; 95% CI, 37.4-40.9%). The lowest rate-pressure product group was associated with a 50% increased risk of mortality, compared with the normal rate-pressure product group (adjusted relative risk, 1.50; 95% CI, 1.31-1.76%; p < 0.0001), and the highest rate-pressure product group was associated with a 25% increased risk of mortality, compared with the normal rate-pressure product group (adjusted relative risk, 1.25; 95% CI, 1.18-1.92%; p < 0.0001). This relationship was blunted with increasing age. Among patients with normotension, those with depressed and elevated rate-pressure products experienced increased mortality.
Adults with severe traumatic brain injury experience heterogeneous myocardial workload profiles that have a "U-shaped" relationship with mortality, even in the presence of a normal blood pressure. Our findings are novel and suggest that cardiac performance is important following severe traumatic brain injury.
探讨孤立性重度创伤性脑损伤患者入院时心肌做功对院内死亡率的影响。
回顾性队列研究。
美国外科医师学会运营的多中心创伤登记处——国家创伤数据库的数据，时间为 2007 年至 2014 年。
入选标准为入院格拉斯哥昏迷量表评分<8 分和头部简明损伤评分≥4 分的单纯性重度创伤性脑损伤成年患者。
入院时的心率-压力乘积，根据已发表的低值、正常和亚最大人类阈值分为五个水平：<5000；5000-9999；10000-14999；15000-19999；>20000。
共分析了 26412 例患者的数据。大多数患者的心率-压力乘积处于正常范围（43%），35%的患者出现心率-压力乘积升高，22%的患者出现心率-压力乘积降低。与正常心率-压力乘积组相比，最低心率-压力乘积组的院内死亡率高 22 个百分点（累积死亡率为 50.2%；95%CI，43.6%-56.9%），最高心率-压力乘积组高 11 个百分点（累积死亡率为 39.2%；95%CI，37.4%-40.9%）。与正常心率-压力乘积组相比，最低心率-压力乘积组的死亡率风险增加了 50%（校正后相对风险，1.50；95%CI，1.31-1.76%；p<0.0001），最高心率-压力乘积组的死亡率风险增加了 25%（校正后相对风险，1.25；95%CI，1.18-1.92%；p<0.0001）。这种关系随着年龄的增长而减弱。在血压正常的患者中，心率-压力乘积降低和升高的患者死亡率增加。
重度创伤性脑损伤患者的心肌做功表现出异质性，与死亡率呈“U 形”关系，即使血压正常也是如此。我们的发现是新颖的，表明心脏功能在重度创伤性脑损伤后很重要。
