Injury, Int. J. Care Injured 46 (2015) 15–20
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Admission blood glucose predicted haemorrhagic shock in multiple trauma patients§ Janett Kreutziger a,*, Andreas Rafetseder b, Simon Mathis a, Volker Wenzel a, Rene´ El Attal c, Stefan Schmid d a
Department of Anaesthesia and Critical Care Medicine, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria Internship, General Hospital of Linz, Krankenhausstr. 9, 4020 Linz, Austria c Department of Trauma Surgery, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria d Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 17 September 2014
Introduction: Admission blood glucose is known to be a predictor for outcome in several disease patterns, especially in critically ill trauma patients. The underlying mechanisms for the association of hyperglycaemia and poor outcome are still not proven. It was hypothesised that hyperglycaemia upon hospital admission is associated with haemorrhagic shock and in-hospital mortality. Methods: Data was extracted from an observational trauma database of the level 1 trauma centre at Innsbruck Medical University hospital. Trauma patients (18 years) with multiple injuries and an Injury Severity Score 17 were included and analysed. Results: In total, 279 patients were analysed, of which 42 patients (15.1%) died. With increasing blood glucose upon hospital admission, the rate of patients with haemorrhagic shock rose significantly [from 4.4% (glucose 4.1–5.5 mmol/L) to 87.5% (glucose >15 mmol/L), p < 0.0001]. Mortality was also associated with initial blood glucose [5.50 mmol/L 8.3%; 5.51–7.50 mmol/L 10.9%, 7.51–10 mmol/L 12.4%; 10.01–15 mmol/L 32.0%; 15.01 mmol/L 12.5%, p = 0.008]. Admission blood glucose was a better indicator for haemorrhagic shock (cut-off 9.4 mmol/L, sensitivity 67.1%, specificity 83.9%) than haemoglobin, base excess, bicarbonate, pH, lactate, or vital parameters. Regarding haemorrhagic shock, admission blood glucose is more valuable during initial patient assessment than the second best predictive parameter, which was admission haemoglobin (cut-off value 6.5 mmol/L (10.4 g/dL): sensitivity 61.3%, specificity 83.9%). Conclusions: In multiple trauma, non-diabetic patients, admission blood glucose predicted the incidence of haemorrhagic shock. Admission blood glucose is an inexpensive, rapidly and easily available laboratory value that might help to identify patients at risk for haemorrhagic shock during initial evaluation upon hospital admission. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Multiple trauma Admission blood glucose Haemorrhagic shock Outcome
Introduction Admission blood glucose is known to be a predictor for outcome in several disease patterns [1–5]. This phenomenon is well documented in trauma patients [6–10], which seem to be more
§ The study was performed at the Medical University of Innsbruck, Dep. of Anaesthesia and Critical Care Medicine. * Corresponding author. Tel.: +43 512 504 80357; fax: +43 512 504 6780357. E-mail addresses: [email protected] (J. Kreutziger), [email protected] (A. Rafetseder), [email protected] (S. Mathis), [email protected] (V. Wenzel), [email protected] (R. El Attal), [email protected] (S. Schmid).
http://dx.doi.org/10.1016/j.injury.2014.09.018 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
prone to a poor outcome due to hyperglycaemia than other critically ill patients [11]. In a retrospective analysis, it was described that patients who died in haemorrhagic shock had the highest blood glucose levels upon hospital admission [6]. In that case, post-traumatic hyperglycaemia could be a surrogate parameter indicating threatened vital organ blood flow, which could be employed to make emergency medical and hospital personnel aware of life-threatening haemorrhagic shock. Up to now, a possible association of blood glucose and haemorrhagic shock was not analysed in trauma patients. The hypothesis of this study was that admission blood glucose predicts haemorrhagic shock and mortality in multiple trauma patients.
J. Kreutziger et al. / Injury, Int. J. Care Injured 46 (2015) 15–20
16
1241 patients
Admission to resuscitation area No trauma Monotrauma 9.4 mmol/L (n = 76) haemoglobin >5 mmol/L (8 g/dL) (n = 254) haemoglobin 5 mmol/L (8 g/dL) (n = 20) haemoglobin > 6.2 mmol/L (10 g/dL) (n = 216) haemoglobin 6.2 mmol/L (10 g/dL) (n = 58) haemoglobin > 6.5 mmol/L (10.4 g/dL) (n = 202) haemoglobin 6.5 mmol/L (10.4 g/dL) (n = 72)
Yes
No
21 41 44 16 29 33 24 38
182 35 210 4 187 25 178 34
(10.3%) (53.9%) (17.3%) (80%) (13.7%) (58.2%) (11.9%) (52.8%)
(89.7%) (46.1%) (82.7%) (20%) (86.3%) (41.8%) (88.1%) (47.2%)
Sensitivity 95% CI
Specificity 95% CI
66.1 52.4–77.4.1 26.7% 16.5–39.9 53.3% 40.2–65.8 61.3 48.1–73.1
83.9 78.1–88.4 98.1% 95.0–99.4 88.2 82.9–92.21 83.9 78.2–88.5
18
J. Kreutziger et al. / Injury, Int. J. Care Injured 46 (2015) 15–20
trauma), one due to hypoxic brain oedema following cardiopulmonary resuscitation, and one due to complications following trauma (pulmonary embolism). Table 4 gives an overview of common laboratory values of patients with and without haemorrhagic shock. Discussion
Fig. 3. ROC analysis of the three best predicting laboratory values for haemorrhagic shock.
Fig. 4. Box plot of important laboratory values in patients with and without haemorrhagic shock.
admission blood glucose 9.4 mmol/L had a 10.2 times increased chance (odds ratio, CI 5.4–19.2) of suffering a haemorrhagic shock than patients with an admission blood glucose below that value (Figs. 3 and 4). In addition, of the patients with an admission blood glucose 9.4 mmol/L, only 14.5% (n = 11) had an admission haemoglobin
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Admission blood glucose predicted haemorrhagic shock in multiple trauma patients§ Janett Kreutziger a,*, Andreas Rafetseder b, Simon Mathis a, Volker Wenzel a, Rene´ El Attal c, Stefan Schmid d a
Department of Anaesthesia and Critical Care Medicine, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria Internship, General Hospital of Linz, Krankenhausstr. 9, 4020 Linz, Austria c Department of Trauma Surgery, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria d Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 17 September 2014
Introduction: Admission blood glucose is known to be a predictor for outcome in several disease patterns, especially in critically ill trauma patients. The underlying mechanisms for the association of hyperglycaemia and poor outcome are still not proven. It was hypothesised that hyperglycaemia upon hospital admission is associated with haemorrhagic shock and in-hospital mortality. Methods: Data was extracted from an observational trauma database of the level 1 trauma centre at Innsbruck Medical University hospital. Trauma patients (18 years) with multiple injuries and an Injury Severity Score 17 were included and analysed. Results: In total, 279 patients were analysed, of which 42 patients (15.1%) died. With increasing blood glucose upon hospital admission, the rate of patients with haemorrhagic shock rose significantly [from 4.4% (glucose 4.1–5.5 mmol/L) to 87.5% (glucose >15 mmol/L), p < 0.0001]. Mortality was also associated with initial blood glucose [5.50 mmol/L 8.3%; 5.51–7.50 mmol/L 10.9%, 7.51–10 mmol/L 12.4%; 10.01–15 mmol/L 32.0%; 15.01 mmol/L 12.5%, p = 0.008]. Admission blood glucose was a better indicator for haemorrhagic shock (cut-off 9.4 mmol/L, sensitivity 67.1%, specificity 83.9%) than haemoglobin, base excess, bicarbonate, pH, lactate, or vital parameters. Regarding haemorrhagic shock, admission blood glucose is more valuable during initial patient assessment than the second best predictive parameter, which was admission haemoglobin (cut-off value 6.5 mmol/L (10.4 g/dL): sensitivity 61.3%, specificity 83.9%). Conclusions: In multiple trauma, non-diabetic patients, admission blood glucose predicted the incidence of haemorrhagic shock. Admission blood glucose is an inexpensive, rapidly and easily available laboratory value that might help to identify patients at risk for haemorrhagic shock during initial evaluation upon hospital admission. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Multiple trauma Admission blood glucose Haemorrhagic shock Outcome
Introduction Admission blood glucose is known to be a predictor for outcome in several disease patterns [1–5]. This phenomenon is well documented in trauma patients [6–10], which seem to be more
§ The study was performed at the Medical University of Innsbruck, Dep. of Anaesthesia and Critical Care Medicine. * Corresponding author. Tel.: +43 512 504 80357; fax: +43 512 504 6780357. E-mail addresses: [email protected] (J. Kreutziger), [email protected] (A. Rafetseder), [email protected] (S. Mathis), [email protected] (V. Wenzel), [email protected] (R. El Attal), [email protected] (S. Schmid).
http://dx.doi.org/10.1016/j.injury.2014.09.018 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
prone to a poor outcome due to hyperglycaemia than other critically ill patients [11]. In a retrospective analysis, it was described that patients who died in haemorrhagic shock had the highest blood glucose levels upon hospital admission [6]. In that case, post-traumatic hyperglycaemia could be a surrogate parameter indicating threatened vital organ blood flow, which could be employed to make emergency medical and hospital personnel aware of life-threatening haemorrhagic shock. Up to now, a possible association of blood glucose and haemorrhagic shock was not analysed in trauma patients. The hypothesis of this study was that admission blood glucose predicts haemorrhagic shock and mortality in multiple trauma patients.
J. Kreutziger et al. / Injury, Int. J. Care Injured 46 (2015) 15–20
16
1241 patients
Admission to resuscitation area No trauma Monotrauma 9.4 mmol/L (n = 76) haemoglobin >5 mmol/L (8 g/dL) (n = 254) haemoglobin 5 mmol/L (8 g/dL) (n = 20) haemoglobin > 6.2 mmol/L (10 g/dL) (n = 216) haemoglobin 6.2 mmol/L (10 g/dL) (n = 58) haemoglobin > 6.5 mmol/L (10.4 g/dL) (n = 202) haemoglobin 6.5 mmol/L (10.4 g/dL) (n = 72)
Yes
No
21 41 44 16 29 33 24 38
182 35 210 4 187 25 178 34
(10.3%) (53.9%) (17.3%) (80%) (13.7%) (58.2%) (11.9%) (52.8%)
(89.7%) (46.1%) (82.7%) (20%) (86.3%) (41.8%) (88.1%) (47.2%)
Sensitivity 95% CI
Specificity 95% CI
66.1 52.4–77.4.1 26.7% 16.5–39.9 53.3% 40.2–65.8 61.3 48.1–73.1
83.9 78.1–88.4 98.1% 95.0–99.4 88.2 82.9–92.21 83.9 78.2–88.5
18
J. Kreutziger et al. / Injury, Int. J. Care Injured 46 (2015) 15–20
trauma), one due to hypoxic brain oedema following cardiopulmonary resuscitation, and one due to complications following trauma (pulmonary embolism). Table 4 gives an overview of common laboratory values of patients with and without haemorrhagic shock. Discussion
Fig. 3. ROC analysis of the three best predicting laboratory values for haemorrhagic shock.
Fig. 4. Box plot of important laboratory values in patients with and without haemorrhagic shock.
admission blood glucose 9.4 mmol/L had a 10.2 times increased chance (odds ratio, CI 5.4–19.2) of suffering a haemorrhagic shock than patients with an admission blood glucose below that value (Figs. 3 and 4). In addition, of the patients with an admission blood glucose 9.4 mmol/L, only 14.5% (n = 11) had an admission haemoglobin
