创伤外科医生能跟上吗？一项前瞻性队列研究，比较在创伤重症监护病房和神经科学重症监护病房接受治疗的创伤性脑损伤患者的预后。
Can trauma surgeons keep up? A prospective cohort study comparing outcomes between patients with traumatic brain injury cared for in a trauma versus neuroscience intensive care unit.
作者信息
Roberts Derek J, Leonard Samuel D, Stein Deborah M, Williams George W, Wade Charles E, Cotton Bryan A
机构信息
Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.
Center for Translational Injury Research, The University of Texas Health Science Center, Houston, Texas, USA.
出版信息
Trauma Surg Acute Care Open. 2019 Feb 15;4(1):e000229. doi: 10.1136/tsaco-2018-000229. eCollection 2019.
BACKGROUND
Although many patients with traumatic brain injury (TBI) are admitted to trauma intensive care units (ICUs), some question whether outcomes would improve if their care was provided in neurocritical care units. We sought to compare characteristics and outcomes of patients with TBI admitted to and cared for in a trauma versus neuroscience ICU.
METHODS
We conducted a prospective cohort study of adult (≥18 years of age) blunt trauma patients with TBI admitted to a trauma versus neuroscience ICU between May 2015 and December 2016. We used multivariable logistic regression to estimate an adjusted odds ratio (OR) comparing 30-day mortality between cohorts.
RESULTS
In total, 548 patients were included in the study, including 207 (38%) who were admitted to the trauma ICU and 341 (62%) to the neuroscience ICU. When compared with neuroscience ICU admissions, patients admitted to the trauma ICU were more likely to have sustained their injuries from a high-speed mechanism (71% vs. 34%) and had a higher Injury Severity Score (ISS) (median 25 vs. 16) despite a similar head Abbreviated Injury Scale score (3 vs. 3, p=0.47) (all p<0.05). Trauma ICU patients also had a lower initial Glasgow Coma Scale score (5 vs. 15) and systolic blood pressure (128 mm Hg vs. 136 mm Hg) and were more likely to have fixed or unequal pupils at admission (13% vs. 8%) (all p<0.05). After adjusting for age, ISS, a high-speed mechanism of injury, fixed or unequal pupils at admission, and field intubation, the odds of 30-day mortality was 70% lower among patients admitted to the trauma versus neuroscience ICU (adjusted OR=0.30, 95% CI 0.11 to 0.82).
CONCLUSIONS
Despite a higher injury burden and worse neurological examination and hemodynamics at presentation, patients admitted to the trauma ICU had a lower adjusted 30-day mortality. This finding may relate to improved care of associated injuries in trauma versus neuroscience ICUs.
LEVEL OF EVIDENCE
Prospective comparative study, level II.
背景
尽管许多创伤性脑损伤（TBI）患者被收治于创伤重症监护病房（ICU），但有些人质疑若在神经重症监护病房对其进行治疗，预后是否会改善。我们试图比较在创伤ICU和神经科学ICU收治并接受治疗的TBI患者的特征和预后。
方法
我们对2015年5月至2016年12月期间收治于创伤ICU和神经科学ICU的成年（≥18岁）钝性创伤性TBI患者进行了一项前瞻性队列研究。我们使用多变量逻辑回归来估计比较两组患者30天死亡率的调整优势比（OR）。
结果
该研究共纳入548例患者，其中207例（38%）被收治于创伤ICU，341例（62%）被收治于神经科学ICU。与收治于神经科学ICU的患者相比，收治于创伤ICU的患者更有可能因高速机制受伤（71%对34%），且损伤严重程度评分（ISS）更高（中位数25对16），尽管头部简明损伤量表评分相似（3对3，p = 0.47）（所有p<0.05）。创伤ICU患者的初始格拉斯哥昏迷量表评分也更低（5对15），收缩压更低（128mmHg对136mmHg），且入院时更有可能出现瞳孔固定或不等大（13%对8%）（所有p<0.05）。在对年龄、ISS、高速损伤机制、入院时瞳孔固定或不等大以及现场插管进行调整后，收治于创伤ICU的患者30天死亡几率比收治于神经科学ICU的患者低70%（调整OR = 0.30，95%CI 0.11至0.82）。
结论
尽管入院时损伤负担更高、神经学检查和血流动力学更差，但收治于创伤ICU的患者调整后的30天死亡率更低。这一发现可能与创伤ICU相比神经科学ICU对相关损伤的治疗改善有关。
证据水平
前瞻性比较研究，二级。
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