Elsevier

Journal of Critical Care

Volume 21, Issue 3, September 2006, Pages 253-258
Journal of Critical Care

Clinical Research—Adult
Early markers of acute respiratory distress syndrome development in severe trauma patients

https://doi.org/10.1016/j.jcrc.2005.12.012Get rights and content

Abstract

Purpose

The aim of the study was to identify early risk factors for development of acute respiratory distress syndrome (ARDS) in severe trauma patients.

Materials and Methods

This was a prospective observational study of 693 severe trauma patients (Injury Severity Score ≥16 and/or Revised Trauma Score ≤11) in 17 hospitals in a Spanish region of 8 million inhabitants from July 2002 to December 2002.

Results

Acute respiratory distress syndrome developed in 6.9% of patients who were more severely ill with higher APACHE II (P < .001) and Injury Severity Score (P = .002) scores vs patients not developing ARDS. Acute respiratory distress syndrome development was associated (P < .001) with fractures of femur (International Classification of Diseases, Ninth Revision [ICD-9] codes 820, 821), tibia (ICD-9 code 823), humerus, and pelvis, with a number (≥2) of long bone fractures, and with chest injuries (rib/sternal fracture [ICD-9 code 807] and hemo/pneumothorax [ICD-9 code 860/861]). Patients with ARDS required more colloids (P = .005) and red blood cell units (P = .02) than patients without ARDS during the first 24 hours. Multivariate analysis showed that ARDS was related to chest trauma diagnosis (ICD-9 code 807) (odds ratio [OR], 3.85), femoral fracture (OR, 3.16), APACHE II score (OR, 1.05), and blood transfusion during resuscitation (OR, 1.32).

Conclusions

Risk of ARDS development is related to the first 24-hour admission variables, including severe physiologic derangements and specific ICD-9–classified injuries. Blood transfusion may play an independent role.

Introduction

Since the first description of the acute respiratory distress syndrome (ARDS) in 7 trauma patients [1], trauma and ARDS have been recognized as faithful but somewhat mysterious partners. Thirty-six years later, we are still asking why ARDS develops after trauma, what the risk factors are, and whether it can be predicted. Important unresolved questions include whether we can prevent ARDS and even whether we create it. Acute respiratory distress syndrome is the result of an enduring pathological process, of lesser duration in the trauma than sepsis setting, combined with a dynamic and complex inflammatory response [2]. The trauma population probably constitutes a more homogeneous ARDS group compared with others, with a greater physiologic reserve because of their lower age and comorbidity [3], although the accuracy of ARDS criteria in this population has recently been challenged [4]. Two forms of ARDS have been described: early, during the first 48 hours after trauma and related to hemorrhagic shock; and late, after 48 hours and more related to multiple organ failure and sepsis [5]. Acute respiratory distress syndrome is a complication of both blunt and penetrating trauma, and the outcomes and mortality rates are similar in both cases [6].

The relationship between severe trauma and acute lung injury or ARDS, its more severe form, is well documented. Acute lung injury and ARDS have been related to severity of injury, measured by different scoring systems; specific trauma type, notably chest trauma; hypotension or metabolic acidosis [7]; major fractures; and delay in certain treatments [8].

The hypothesis of the present study was that it may be possible to identify patients at risk for ARDS on the basis of observations made in the first 24 hours after admission. The objectives were to identify current risk factors for ARDS that can be observed within this period in a specific regional setting of 8 million inhabitants. The study was conducted by the interdisciplinary trauma research group in Andalusia (GITAN), a multicenter project on continuous quality improvement of trauma management in intensive care units (ICUs) and emergency departments in Southern Spain.

Section snippets

Participating hospitals

Study participants were the regional emergency health service (EPES-061) and 17 hospitals, 80.6% of hospitals in the Southern Spanish region of Andalusia and including all 5 trauma referral centers (Spanish level III), 4 level II hospitals, and 8 district hospitals (level I). The 4 hospitals that did not participate were all district hospitals. Approval for the research was obtained from ethics committees of all hospitals, and patients or family members were informed of this noninterventional

Epidemiologic characteristics

During the study period, 693 patients were admitted to ICUs enrolled in the Trauma Registry of the GITAN project; 78.6% were males, and mean age was 36.3 ± 19.5 years.

Cause of injury was blunt trauma in 99.4% of cases. The most frequent injury mechanisms were road traffic accidents (65.3% [motorcycles, 30.4%; automobiles, 24.3%]) and falls from heights (14.1%). The remainder (13.7%) included work- and sports-related injuries, among others (Table 1). Regarding transport, 69.6% of patients were

Discussion

The frequency of ARDS development in our large series of severe trauma patients in Southern Spain was 6.9%. Multivariate analysis showed association between ARDS development and variables observable during the first 24 hours after admission, including APACHE II–measured severity of illness at ICU admission, specific ICD-9–classified diagnoses related to chest injury and long bone (femoral) fracture, and amount of blood transfusion during the first 24 hours. Our results indicate that groups at

Conclusions

Our findings support the importance of early assessment based on first-24-hour physiologic and anatomic scores and presence of high-risk injuries such as chest trauma and bone fractures to identify patients who may be at greater risk of ARDS. Blood transfusion may play an independent role by exacerbating the inflammatory response.

Acknowledgments

The authors are indebted to Dr Maureen McCunn and Dr Amy Sisley of the Shock Trauma Center, University of Maryland, Baltimore, for their advice and help in the study design and data analysis and to Richard Davies, MA, for assistance with the English version.

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    This was a GITAN multicenter project. GITAN is an interdisciplinary group of the Intensive Medical Society of Andalusia devoted to improving the management of severe trauma in Andalusia, Spain.

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