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Correspondence to Author: Bilea Souza Mojueira, 

Department of Epidemiology, Groningen, USA.

Abstract:

Context:   The effectiveness of severity indicators in identifying intensive care and forecasting mortality for trauma patients in the Intensive Care Unit (ICU) is not well understood. The purpose of this study was to assess how well severity indices performed in predicting the ICU admission and death of trauma patients.
Methods:   Techniques a retrospective cohort study that examined the electronic health records of trauma patients receiving treatment at a Brazilian hospital between 2014 and 2017 who were at least 18 years old. Anatomical [Injury Severity Score (ISS) and New Injury Severity Score (NISS)], physiological [Revised Trauma Score (RTS), New Trauma Score (NTS), and modified Rapid Emergency Medicine Score (mREMS)], and mixed indices [Trauma and Injury Severity Score (TRISS), New Trauma and Injury Severity Score (NTRISS), Base-defcit Injury Severity Score (BISS), and Basedefcit and New Injury Severity Score (BNISS)] were contrasted when employing the Area Under the Receiver Operating Characteristics Curves (AUC–ROC) to analyze the outcomes (ICU admission and death).
Outcomes:  106 (14.2%) of the 747 trauma patients (mean age 51.5 years, 52.5% female, and 36.1% fall) who were examined were admitted to the intensive care unit, and 6 (0.8%) of them passed away there. For trauma patient ICU admission, the ISS (AUC 0.919) and NISS (AUC 0.916) demonstrated superior predictive ability. When it came to predicting ICU mortality, the NISS (AUC 0.949), TRISS (AUC 0.909), NTRISS (AUC 0.967), BISS (AUC 0.902), and BNISS (AUC 0.976) performed exceptionally well.

Conclusion:   In conclusion Excellent prediction power was demonstrated by anatomical markers for trauma patients’ ICU admission.When it came to ICU mortality, the NISS and mixed indices performed the best.

Introduction:  Significant mortality and rates of Intensive Care Unit (ICU) admissions are caused by trauma [1, 2]. Within this framework, the trauma registry is an essential component of high-quality programs, aiming to methodically archive information reflecting the true influence of trauma and injuries on victims’ clinical results [3]. Among the information that make up the trauma registry are indexes of trauma severity. These comprise scoring systems that evaluate alterations in physiology, biochemistry, and/or the severity of traumatic injuries in order to determine the trauma’s severity [4, 5]. Among the physiological severity indices, the Revised Trauma Score (RTS) is unique. It has an enhanced version known as the New Trauma Score (NTS) [7], and it has been modified into the modified Rapid Emergency Medicine Score (mREMS) [8]. Moreover, the two anatomical indicators that are used in practice the most are the Injury Severity Score (ISS) and the New Injury Severity Score (NISS) [9, 10]. A mixed index known as the Trauma and Injury Severity Score (TRISS) [11] and its upgraded version known as the New Trauma and Injury Severity Score (NTRISS) [12] were developed as a result of the integration of physiological and anatomical factors. The Basedefcit Injury Severity Score (BISS) [5, 13] and the Base-defcit and New Injury Severity Score (BNISS) [5] are blended indices that evaluate the severity of trauma by taking into account the base excess (BE) marker.

MATERIALS AND PROCEDURES:   The purpose of this retrospective cohort study is to assess how well severity indices predict the ICU admission and death of trauma patients. conducted in the trauma center of the Samaritano Hospital in São Paulo, Brazil. The sample was made up of trauma patients who were at least eighteen years old and who were admitted to the facility within twenty-four hours following a traumatic incident between January 1, 2014, and December 31, 2017. Individuals who experienced cardiac arrest and were not successfully revived in the emergency department, as well as those who suffered burns, poisoning, or drowning, Suffocation and asphyxia were not included in the research. The study’s dependent variables were ICU admission and mortality. The physiological (RTS, NTS, and mREMS), anatomical (ISS and NISS), and combined (TRISS, NTRISS, BISS, and BNISS) indices were the independent variables. Three physiological indicators of the trauma patient are assigned points (ranging from zero to four) by the RTS: the patient’s Systolic Blood Pressure (SBP), Respiratory Rate (RR), and Glasgow Coma Scale (GCS) score. The RTS variables (SBP, RR, and GCS) are multiplied by their corresponding weights in the hospital setting. These weights can vary from zero to 7.8408, where a lower value indicates a more severe patient [6]. The NTS is an RTS modification that takes into account the integer that corresponds to the GCS. Its final score can vary from 1.202 (most severe) to 10.685 (less severe), and it uses changes in peripheral oxygen saturation (SpO2) in place of the RR when calculating the SBP value ranges suggested by the RTS [7]. The most recent physiological index (mREMS), which ranges from zero to 26—the maximum score that represents a higher likelihood of death—is calculated by adding the values assigned to the variables SBP, Heart Rate (HR), RR, SpO2, GCS, and age of the trauma patient [8].

Regardless of the affected body location, the three most serious injuries identified by the AIS are also taken into account when calculating the NISS [10]. The intensity of the trauma is indicated by the value of the ISS and NISS, which can vary from 1 to 75 points [9, 10]. The victim’s age, the ISS, the RTS value of the patient’s entrance to the emergency department, and the In order to determine the trauma victim’s survival probability using regression statistics, the kind of trauma (blunt or penetrating) is taken into account when calculating the TRISS [11]. With the NTRISS’s introduction, the TRISS also received an upgrade. The NISS value is substituted for the ISS value in the NTRISS computation, which follows the same formula as TRISS [12]. The BISS computation, which replaces the RTS taken into account in TRISS, is likewise based on a mathematical logistic regression formula and yields the trauma patient’s survival probability through an examination of age, ISS, and BE delta (ΔBE) [5, 13]. Lastly, the BNISS [5] modifies the BISS formula by substituting NISS for ISS. The study’s data were gathered through an analysis of trauma patients’ electronic medical records. Medical records from the emergency room were searched for physiological data, and the values noted at the patient’s admission to the facility were taken into account. Arterial blood gas obtained upon the patient’s admission to the intensive care unit (ICU) was used to determine the BE value. Throughout the patient’s hospital stay, all traumatic injuries documented in their medical file and determined by physical examination, surgical procedures, and imaging tests were taken into account. Using the AIS 2008 update 2015 manual, the AIS code for each anatomical lesion was determined [21].

Outcomes:   The study had 747 trauma sufferers in all, with a mean age of 51.5 years and 52.5% of them being female. The most common injuries were falls (n=270; 36.1%) and blunt trauma (n=668; 89.4%). The means and medians of the indices in Table 1 indicate that the sample’s trauma victims were not very severe, as indicated by their proximity to normal values. ICU. Information in Fig. In addition to having satisfactory (above 80%) sensitivity, specificity, NPV, and accuracy results, the ISS and NISS had better predictive capacity for patient admission to the ICU than the other indices (RTS, NTS, mREMS, TRISS, and NTRISS), with AUC values greater than 0.900 (ISS AUC 0.919; NISS AUC 0.916). A total of 106 patients (14.2%) were admitted to the ICU. The NISS’s cutoff point (4.5) was greater than the ISS’s (3.5). The AUC values for ISS and NISS were compared, and the results indicated similar performance between the indices (p=0.380), indicating that both ISS and NISS are reliable indicators of patients who require intensive care.Among patients admitted to the ICU (n = 106), the BNISS had a lower mean (78.8%) and median (83.9%) survival probability than the BISS (82.9% and 87.2%, respectively). Six patients (0.8%) died in the intensive care unit. With AUC values above 0.900, the data in Fig. 2 and Table 3 demonstrate that NISS, TRISS, NTRISS, BISS, and BNISS performed exceptionally well in predicting death in the ICU of these patients. All of these indices showed sensitivity and NPV of 100.0%, with the exception of TRISS. However, TRISS had the best PPV (66.7%) and accuracy (96.2%) of all the others Table 4’s AUC values showed no significant difference (p>0.005), indicating that all of the NISS, TRISS, NTRISS, BISS, and BNISS indices are reliable indicators of trauma patient mortality in the intensive care unit.

Conclusion:   The study’s findings allowed for the determination that the ISS or NISS indices can be useful when deciding whether to send trauma patients to the intensive care unit. It is possible to predict mortality in the intensive care unit (ICU) by using the NISS or any of the mixed indices (TRISS, NTRISS, BISS, and BNISS) that were examined in the study. Notably, the features of the sample under study support the results of previous studies about the average age [8, 22], but they differ with respect to the victims’ sex, primary trauma source, and severity as determined by anatomical indices. Research findings indicate that falls rank as the second most common cause of injuries, after traffic accidents. Men are more likely than women to experience falls.primary trauma patients [14, 15, 17] were determined by the ISS and NISS indices [5, 15, 17] to be moderately to severely severe. Conversely, the RTS and TRISS mean and/or median values found in this study support findings from earlier worldwide studies [14, 17, 23].
The sample’s 14.2% ICU admission rate was comparable to that of a 2014 study conducted in Tunisia [17]. This was a far lower frequency than what other research (30.0–81.0%) found [14, 15, 24, 25]. It is well known that the majority of studies that examine trauma rates concentrate primarily on the patient outcome [14–17, 25], particularly when attempting to determine whether the examined index was assertive in the survival likelihood.However, the frequency of fatalities varies greatly throughout studies [14, 15, 17, 22, which are all better than this research, spanning rates ranging from 4.6% to 15%. The study’s findings demonstrated that, when compared to the other indices, ISS and NISS performed the best in terms of assessing how well the indices predicted patient admission to the intensive care unit. Additional studies [17, 18] that also found strong anatomical indices for this disease as predictors support this finding.

Conclusion:   The ability of the anatomical indices to predict trauma patient admission to the intensive care unit was superior. The NISS and mixed indexes shown superior performance concerning mortality. Professionals may find it helpful to apply the most assertive trauma index when making decisions about how best to allocate resources and enhance patient care when it comes to ICU admission and mortality.

Citation:

Bilea Souza Mojueira. A retrospective cohort research examining the effectiveness of severity indices for trauma patients’ admission and mortality in the critical care unit. The Journal of Hepatology 2024.