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Wed Jan 30 02:38:40 GMT 2008

Like all retrospective studies, regardless of data quality, it can only be used to frame a hypothesis. Without a prospective, randomized study that is widely reproducible, the hypothesis remains nothing more. It cannot be used to guide clinical decision making (although, unfortunately, a lot of what we do is guided by this sort of non-evidence).
John Schulz

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Subject: trauma-list Digest, Vol 55, Issue 29

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Today's Topics:

   1. RE: [ccm-l] PA catheters in trauma. (Robert F. Smith)
   2. Re: Prehospital Report (vs Triage?) (Mike Smertka)
   3. Rocky Mountain Trauma-Emergency Medicine Conference, June
      2008 (Kashuk, Jeffry)

----------------------------------------------------------------------

Message: 1
Date: Tue, 29 Jan 2008 09:06:35 -0500
From: "Robert F. Smith" <rfsmithmd at comcast.net>
Subject: RE: [ccm-l] PA catheters in trauma.
To: "'Trauma &amp; Critical Care mailing list'"
	<trauma-list at trauma.org>
Message-ID: <003901c86280$29526220$7bf72660$@net>
Content-Type: text/plain;	charset="gb2312"

>From reading only the abstract, it is somewhat amazing that the authors 
>seem
to feel that the presence of a piece of plastic somehow confers an improved survival rate in severely injured patients. No mechanism is suggested. It would be fascinating if in the paper they proposed there was some kind of universally accepted algorithm for how this piece of plastic is to be used. Or even what the plastic truly and accurately does. And I doubt the patients with an ISS of 75 received much benefit from it, lol. 

Rob Smith MD, MPH
Chicago

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Jeffery Hammond
Sent: Monday, January 21, 2008 11:20 AM
To: 'Ivan Hronek'; trauma-list at trauma.org
Cc: ccm-l at ccm-l.org
Subject: RE: [ccm-l] PA catheters in trauma.

This is a totally unsupportable conclusion.

The NTDB is an unaudited data repository. This paper is retrospective, uncontrolled, descriptive epidemiology at best. Throwing a bunch of numbers around and subjecting them to some mathematical manipulation doesn't magically turn them into actionable data.

Jeffrey Hammond MD, MPH
New Brunswick, NJ

  _____  

From: ccm-l-bounces at ccm-l.org [mailto:ccm-l-bounces at ccm-l.org] On Behalf Of Ivan Hronek
Sent: Sunday, January 20, 2008 10:11 PM
To: trauma-list at trauma.org
Cc: ccm-l at ccm-l.org
Subject: [ccm-l] PA catheters in trauma.

Pulmonary artery catheter use is associated with reduced mortality in severely injured patients: A National Trauma Data Bank analysis of 53,312 patients

Critical Care Medicine - Volume 34, Issue 6 (June 2006)  -

<http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/s0090349306611061.pdf> PDF version of article 

Feature Articles
Pulmonary artery catheter use is associated with reduced mortality in severely injured patients: A National Trauma Data Bank analysis of 53,312 patients

Randall S. Friese, MD 
Shahid Shafi, MD 
Larry M. Gentilello, MD 

  _____  

>From Parkland Memorial Hospital, Division of Burn, Trauma, Critical 
>Care
Department of Surgery, University of Texas Southwestern Medical Center at Dallas, TX 
  _____  

The authors do not have any financial interests to disclose.

PII S0090-3493(06)61106-1

  _____  

 Objective: 

To evaluate the association between pulmonary artery catheter (PAC) use and mortality in a large cohort of injured patients. We hypothesized that PAC use is associated with improved survival in critically injured trauma patients.

Design: 

Retrospective database analysis.

Setting: 

A total of 268 level 1 trauma centers from across the United States.

Patients: 

A total of 53,312 patients admitted to the intensive care units of the trauma centers participating in the National Trauma Data Bank maintained by the American College of Surgeons.

Measurements and Main Results: 

The National Trauma Data Bank was queried to identify patients aged 16¨C90 yrs with complete data on base deficit, and Injury Severity Score (n = 53,312). Patients were initially divided into two groups: those managed with a PAC (n = 1,933) and those managed without a PAC (n = 51,379). Chi-square and Student's t-test analysis were utilized to explore group differences in mortality. In a second analysis, groups were stratified by base deficit, Injury Severity Score, and age to further explore the influence of injury severity on PAC use and mortality. In addition, a logistic regression model was developed to assess the relationship between PAC use and mortality after adjusting for differences in age, mechanism, injury severity, injury pattern, and co-morbidities. Overall, patients managed with a PAC were older (45.8 ¡À 21.3 yrs), had higher Injury Severity Score (28.4 ¡À 13.5), worse base deficit (-5.2 ¡À 6.5), and increased mortality (PAC, 29.7%; no PAC, 9.8%; p < .001). However, after stratification for injury severity, PAC use was associated with a survival benefit in four subgroups of patients. Each of these groups had advanced age or increased injury severity. Specifically, patients aged 61¨C90 yrs, with arrival base deficit worse than -11 and Injury Severity Score of 25¨C75, had a decrease in the risk of death with PAC use (odds ratio, 0.33; 95% confidence interval, 0.17¨C0.62). Three additional groups had a similar decrease in the risk of death with PAC use: odds ratio, 0.60 (95% confidence interval, 0.43¨C0.83), 0.82 (95% confidence interval, 0.44¨C1.52), and 0.63 (95% confidence interval, 0.40¨C0.98). Logistic regression analysis demonstrated a decreased mortality when a PAC was used in the management of patients with the following severe injury
characteristics: Injury Severity Score of 25¨C75, base deficit of less than -11, or age of 61¨C90 yrs (odds ratio, 0.593; 95% confidence interval, 0.437 ¨C0.805).

Conclusions: 

Trauma patients managed with a PAC are more severely injured and have a higher mortality. However, severely injured patients (Injury Severity Score,
25¨C75) who arrive in severe shock, and older patients, have an associated survival benefit when managed with a PAC. This is the first study to demonstrate a benefit of PAC use in trauma patients.

  _____  

Key Words: 

    	 pulmonary artery catheter	     	
    	 complication 	    	
    	 injury	     	
    	 trauma	     	
    	 mortality 	    	
    	 National Trauma Data Bank 	    	

Retrospective analyses of large databases and of several randomized controlled trials have demonstrated either no benefit or an increased risk of death in patients who are managed with a pulmonary artery catheter (PAC) ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061001>  [1] , <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061002> [2] ,  <http://www. mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI&sp=16240415
&sid=664762510/N/535610/1.html#r06611061003> [3] , <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061004> [4] ,  <http://www. mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI&sp=16240415
&sid=664762510/N/535610/1.html#r06611061005> [5] , <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061006> [6] ,  <http://www. mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI&sp=16240415
&sid=664762510/N/535610/1.html#r06611061007> [7] ). For these reasons, several authors have questioned the utility of the PAC, and its use in critically injured patients has been called into question.

However, most studies on PAC use were composed largely or entirely of patients with medical illnesses ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061001>  [1] , <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061003> [3] ,  <http://www. mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI&sp=16240415
&sid=664762510/N/535610/1.html#r06611061004> [4] ). Although PAC trials in surgical patients have been conducted, they evaluated perioperative use in high-risk patients or tested specific management techniques such as supranormal oxygen delivery protocols ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061002>  [2] , <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061006> [6] ,  <http://www. mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI&sp=16240415
&sid=664762510/N/535610/1.html#r06611061007> [7] , <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061008> [8] ,  <http://www. mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI&sp=16240415
&sid=664762510/N/535610/1.html#r06611061009> [9] ). No study has been conducted to determine whether PAC use is associated with an increase in survival after injury.

Trauma patients are different from medical patients. Medical patients typically undergo PAC placement for management of organ failure or sepsis. Trauma patients may receive a PAC for these same reasons, but may also undergo PAC insertion as a means of guiding resuscitation. Therefore, the outcomes associated with PAC use in trauma patients may be different. The purpose of this study was to evaluate the association between PAC use and mortality in a large cohort of injured patients. We hypothesized that PAC use is associated with improved survival in critically injured trauma patients.

MATERIALS AND METHODS 

The National Trauma Data Bank is an on-going project of the American College of Surgeons that collects data from participating trauma centers around the country in a standardized format. For the time period of our analysis, the National Trauma Data Bank contained the records of >450,000 patients from 268 trauma centers, 20% of whom were admitted to the intensive care unit. This provides an opportunity to explore the association between PAC use and outcomes in an age- and severity-adjusted contemporaneous cohort of trauma patients managed with and without a PAC.

Data were obtained for the period of January 1994 through December 2001. Patients were included if they survived for >48 hrs, underwent at least one diagnostic or therapeutic procedure, and were 16¨C90 yrs of age with complete information on survival, Injury Severity Score (ISS), and initial base deficit. These criteria identified 53,312 patients. The study population was divided into two groups: those who underwent insertion of a PAC during hospital stay (n = 1,933) and those who did not (n = 51,379).

Patients were first compared by age, preexisting conditions, injury type, injury severity, and complications using chi-square analysis. Injury severity was estimated by ISS (anatomic measurement) and emergency department (ED) base deficit (physiologic measurement). Stratified analysis was then conducted based on age, ISS, and ED base deficit. The relationship between PAC use and survival was measured within each stratum using chi-square or Fisher's exact test.

We chose ISS, which systematically incorporates injuries from multiple body regions into an overall score, as an anatomic marker of injury severity because it is a well-validated method of stratifying patients after injury and has a strong correlation with mortality ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061010>  [10] , <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061011> [11] ). The strength of this correlation is improved when it is coupled with a physiologic measurement of injury severity, such as the base deficit ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061012>  [12] , <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061013> [13] ).

Logistic regression analysis was used to develop a parsimonious model that predicted mortality after injury. The factors included in the model were PAC use, age, ED base deficit, ISS, presence of co-morbid conditions (liver, kidney, or heart disease), mechanism of injury (blunt vs. penetrating), and specific injury pattern (head, chest, or abdominal injury) as quantified by the Abbreviated Injury Scale ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061014> [14]). Using the patient characteristics associated with more severe injury (advanced age, elevated ISS, and abnormal ED base deficit), the study population was divided into two groups: those with severe injury characteristics and those without. The model was then applied to each of these two groups to determine the influence of injury severity on the association between PAC use and mortality.

Data are presented as mean ¡À sd for continuous variables and as proportions for categorical variables; p < .05 was considered significant for all analyses. SPSS (SPSS, Chicago, IL) for Windows and SAS (SAS Institute, Cary,
NC) for Windows were used for data management and analysis. This research was approved by the Institutional Review Board at the University of Texas Southwestern Medical Center.

RESULTS 

Overall, patients managed with a PAC were older, had higher ISS, greater ED base deficit ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#tbl1> Table 1), and higher mortality (PAC, 29.7%; no PAC, 9.8%; odds ratio, 3.58; 95% confidence interval, 3.26¨C3.93).

Table 1   --  Demographics, injury, and patient characteristics

 	  	 PAC	 No PAC	 p Value	
Demographics (n = 53,312)	
 	 n	 1,933	 51,379	  	
 	 Age, yrs	 45.8 ¡À21.3	 39.5 ¡À18.3	 <.001	
 	 Injury Severity Score	 28.4 ¡À13.5	 15.9 ¡À12.3	 <.001	
 	 Initial base deficit	 -5.3 ¡À6.5	 -1.4 ¡À8.0	 <.001	
Injury characteristics <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#tbl1fn1> [a] (n = 47,654)	
 	 n	 1,829	 45,825	  	
 	 Spinal Injury,% (n =8,138)	 24.9	 16.8	 <.001	
 	 Abdominal injury,% (n =12,134)	 39.1	 24.9	 <.001	
 	 Head injury,% (n =21,101)	 60.4	 43.6	 <.001	
 	 Chest injury,% (n =18,608)	 65.3	 38.0	 <.001	
 	 At least one AIS of ¡Ý3,% (n =34,702)	 96.9	 71.9	 <.001	
Preexisting conditions <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#tbl1fn2> [b] (n = 16,722)	
 	 n	 1,574	 15,148	  	
 	 Cardiac disease,% (n =13,209)	 96.1	 77.2	 <.001	
 	 Diabetes,% (n =1,252)	 4.8	 7.8	 <.001	
 	 Pulmonary disease,% (n =993)	 4.2	 6.1	 .002	
 	 Obesity,% (n =258)	 1.1	 1.6	 .177	
 	 Hepatic disease,% (n =126)	 0.6	 0.8	 .569	
 	 Renal disease,% (n =46)	 0.2	 0.3	 .501	
Complications <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#tbl1fn3> [c] (n = 8,288)	
 	 n	 1,000	 7,288	  	
 	 Infection,% (n =4,661)	 62.3	 55.4	 <.001	
 	 Pneumonia,% (n =3,760)	 56.9	 43.8	 <.001	
 	 ARDS,% (n =1,089)	 22.3	 11.9	 <.001	
 	 Renal failure,% (n =587)	 13.0	 6.3	 <.001	
 	 MI,% (n =559)	 8.2	 6.5	 .05	
 	 VTE,% (n =507)	 5.4	 6.2	 .313	

PAC, pulmonary artery catheter; AIS, Abbreviated Injury Score; ARDS, acute respiratory distress syndrome; MI, myocardial infarction; VTE, venous thromboembolism.

a    	A total of 5,658 patients with incomplete data for injury
characteristics were excluded;	
b    	36,590 patients with incomplete data for pre-existing conditions
were excluded;	
c    	45,024 patients with incomplete data for complication conditions
were excluded.	

Patients with spine, abdominal, chest, or head injury and those with at least one Abbreviated Injury Scale score of ¡Ý3, were more likely to be managed with a PAC ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#tbl1> Table 1). In those patients with a preexisting condition (n = 16,722), cardiac disease was the most common in both groups ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#tbl1> Table 1). Those patients who developed complications (n = 8,288), such as infection, pneumonia, acute respiratory distress syndrome, acute renal failure, or myocardial infarction, were more likely to have been managed with a PAC ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#tbl1> Table 1).

PAC use was associated with increased mortality in all subgroups of ISS, ED base deficit, and age ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#t0661106102> Table 2). However, as age, base deficit, and ISS increased, the risk of death associated with PAC use decreased, and an apparent benefit of PAC use emerged ( <http://www. mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI&sp=16240415
&sid=664762510/N/535610/1.html#t0661106102> Table 2). As shown in <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#t0661106103> Table 3, severely injured patients (ISS ¡Ý 25) with a large base deficit (less than or equal to -11) had a reduction in mortality if they were managed with a PAC. The reduction in mortality associated with PAC use for severely injured patients in shock persisted across all age groups, although this effect did not reach significance for the age group of 41¨C60 yrs. In addition, PAC use in older patients was associated with improved survival, even if the base deficit was only moderately abnormal ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#f06611061001> Fig. 1, <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#t0661106104> Table 4). In contrast, less severely injured trauma patients (ISS, 16¨C24) and severely injured patients without a high admission base deficit (more than -5) have an increased mortality if they undergo PAC placement, regardless of age ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#f06611061002> Fig. 2, <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#t0661106105> Table 5).

Table 2   --  Patient mortality by Injury Severity Score, base deficit, and
age

 	  	 Mortality With PAC,% (n = 1,933)	 Mortality Without
PAC,% (n = 51,379)	 Odds Ratio	 95% Confidence Interval	
Mortality by Injury Severity Score	
 	 1¨C8 (n = 13,111)	 17.3	 1.0	 19.4	 9.64¨C39.0	
 	 9¨C15 (n = 15,997)	 21.1	 2.8	 8.46	 6.27¨C11.4	
 	 16¨C24 (n = 10,809)	 19.9	 7.9	 2.71	 2.17¨C3.38	
 	 25¨C75 (n = 13,395)	 35.6	 30.0	 1.25	 1.12¨C1.41	
Mortality by initial base deficit	
 	 ¡Ý0 (n = 18,157)	 29.4	 6.0	 6.10	 4.86¨C7.66	
 	 -1 to -5 (n = 23,924)	 27.3	 6.5	 4.88	 4.20¨C5.68	
 	 -6 to -10 (n = 7,682)	 27.1	 15.8	 1.87	 1.56¨C2.24	
 	 -11 or less (n = 3,549)	 40.9	 42.0	 0.96	 0.77¨C
1.19	
Mortality by age, yrs	
 	 16¨C40 (n = 31,431)	 26.3	 7.8	 3.94	 3.42¨C4.54	
 	 41¨C60 (n = 13,441)	 29.3	 9.6	 3.60	 2.97¨C4.36	
 	 61¨C90 (n = 8,440)	 35.5	 18.2	 2.29	 1.95¨C2.70	

PAC, pulmonary artery catheter.

Table 3   --  Subgroup analysis

Stratification	 Mortality With PAC,% (n)	 Mortality Without PAC,%
(n)	 Odds Ratio	 95% Confidence Interval	
Decreased mortality with PAC	
 	 Age, 16¨C40	
 	  	 BD, -11 or less	 42.2	 56.7	 0.60	 0.43¨C
0.83	
 	  	 ISS, 25¨C75	 (132)	 (1,093)	  	  	
 	 Age, 41¨C60	
 	  	 BD, -11 or less	 54.1	 59.4	 0.82	 0.44¨C
1.52	
 	  	 ISS, 25¨C75	 (37)	 (438)	  	  	
 	 Age, 61¨C90	
 	  	 BD, -11 or less	 56.7	 83.5	 0.33	 0.17¨C
0.62	
 	  	 ISS, 25¨C75	 (30)	 (206)	  	  	
 	 Age, 61¨C90	
 	  	 BD, -6 to -10	 39.7	 53.7	 0.63	 0.40¨C0.98	
 	  	 ISS, 25¨C75	 (68)	 (309)	  	  	
Increased mortality with PAC	
 	 Age, 16¨C40	
 	  	 BD, -1 to -5	 15.2	 2.6	 5.98	 3.16¨C11.3	
 	  	 ISS, 16¨C24	 (66)	 (2,968)	  	  	
 	 Age, 16¨C40	
 	  	 BD, -1 to -5	 28.1	 16.6	 1.85	 1.41¨C2.42	
 	  	 ISS, 25¨C75	 (235)	 (2,999)	  	  	
 	 Age, 16¨C40	
 	  	 BD, 0 or BE	 31.1	 19.6	 1.79	 1.11¨C2.88	
 	  	 ISS, 25¨C75	 (74)	 (1,539)	  	  	
 	 Age, 41¨C60	
 	  	 BD, -1 to -5	 32.5	 20.8	 1.73	 1.20¨C2.49	
 	  	 ISS, 25¨C75	 (117)	 (1,218)	  	  	
 	 Age, 61¨C90	
 	  	 BD, -1 to -5	 28.9	 18.2	 1.71	 1.07¨C2.71	
 	  	 ISS, 16¨C24	 (76)	 (692)	  	  	

PAC, pulmonary artery catheter; BD, base deficit; ISS, Injury Severity Score; BE, base excess.

<http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/If06611061001.fig#top>  Figure 1 Decreased mortality with pulmonary artery catheter (PAC) use. *p < .05. 

Table 4   --  Subgroups demonstrating improved survival with pulmonary
artery catheter use after injury

Group	 Age, yrs	 Base Deficit	 Injury Severity Score	 p
Value	
1	 16¨C40	 Worse than -11	 25¨C75	 <.002	
2	 41¨C60	 -11	 25¨C75	 .53	
3	 61¨C90	 -11	 25¨C75	 <.001	
4	 61¨C90	 -6 to -10	 25¨C75	 .036	

<http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/If06611061002.fig#top>  Figure 2 Increased mortality with pulmonary artery catheter (PAC) use. *p < .05. 

Table 5   --  Subgroups demonstrating decreased survival with pulmonary
artery catheter use after injury

Group	 Age, yrs	 Base Deficit	 Injury Severity Score	 p
Value	
5	 16¨C40	 -1 to -5	 16¨C24	 <.001	
6	 16¨C40	 -1 to -5	 25¨C75	 <.001	
7	 16¨C40	 0 or base excess	 25¨C75	 .0016	
8	 41¨C60	 -1 to -5	 25¨C75	 .003	
9	 61¨C90	 -1 to -5	 16¨C24	 .024	

Logistic regression analysis identified the following factors as independent predictors of mortality after injury: age, ED base deficit, ISS, use of a PAC, penetrating mechanism, head injury, and chest injury ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#tbl6> Table 6). Hosmer and Lemeshow goodness of fit for this model was 0.47. Odds ratio for PAC use demonstrated an increase in the risk of death after injury (1.294; 95% confidence interval, 1.059¨C1.580). However, when the model was applied to severely injured patients, a benefit to PAC use was uncovered (odds ratio, 0.593; 95% confidence interval, 0.437¨C0.805) ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#tbl6> Table 6).

Table 6   --  Logistic regression analysis

 	  	 Odds Ratio for Mortality	 95% Confidence
Intervals	
Parameter: stepwise analysis (n = 53,312)	
 	 PAC used	 1.294	 1.059¨C1.580	
 	 Age	 1.026	 1.024¨C1.028	
 	 ED base deficit	 0.949	 0.942¨C0.955	
 	 ISS	 1.059	 1.056¨C1.063	
 	 Penetrating injury	 1.474	 1.213¨C1.792	
 	 Head injury	 1.418	 1.213¨C1.656	
 	 Chest injury	 0.642	 0.551¨C0.748	
 	 Abdominal injury	 0.971	 0.831¨C1.135	
 	 Co-morbidity present	 1.408	 0.891¨C2.226	
Patient group: effect of PAC use by injury severity <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#tbl6fn1> [a]	
 	 Severe injury characteristics present (n = 2,313)	 0.593	
0.437¨C0.805	
 	 Severe injury characteristics absent (n = 50,999)	 1.885	
1.478¨C2.404	

PAC, pulmonary artery catheter; ED, emergency department; ISS, Injury Severity Score.

a    	Severe injury characteristics: ISS of 25¨C75, base deficit less than
-11, or age of 61¨C90 yrs.	

DISCUSSION 

This study found that the use of a PAC in the management of critically injured patients presenting to the ED in severe shock is associated with a survival benefit. Conversely, those who are initially stable at arrival, as defined by normal base deficit, have increased mortality when a PAC is required during their hospital course.

One potential explanation for these findings is that severely injured patients who arrive in shock undergo early PAC insertion to guide resuscitation. Conversely, patients who arrive without evidence of shock do not have an immediate indication for PAC use and are more likely to undergo insertion later in their hospital course. This latter group most likely undergoes late PAC placement due to the development of complications from their injuries, such as sepsis or organ failure, and are a different group of patients than those undergoing PAC placement acutely due to the presence of severe shock at arrival to the ED.

Although PAC use was associated with an increase in mortality overall, it was associated with a protective effect in patients with severe shock, regardless of age, and in older patients with moderate shock. We also found that the highest risk of death associated with PAC use was in younger patients who arrived at the ED without a significant base deficit. Moreover, no survival benefit was detected with PAC use in patients arriving at the ED without evidence of shock. Overall, these findings support the hypothesis that PAC use in trauma patients with the presence of severe shock at the time of admission provides a survival benefit.

Our results are similar to those reported by Chittock et al. ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061015> [15]) in an observational study of >7,000 critically ill patients in which the highest risk of death associated with PAC use occurred in those with the lowest Acute Physiology and Chronic Health Evaluation (APACHE) II scores, but a survival benefit was associated with PAC use when APACHE II scores were very high. Our results contrast with those of Connors et al. ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061001> [1]), who reported an increase in 30-day mortality for critically ill patients managed with a PAC. In the latter study, a propensity score was developed to determine the likelihood of PAC placement. Patients managed with a PAC were compared with a control group of patients with similar propensity scores who did not undergo PAC insertion. However, the propensity score has never been validated as a predictor of PAC use. Moreover, this study did not stratify patients by severity of illness, as did our study and the study reported by Chittock et al ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061015> [15]).

In addition, we found that patients with preexisting cardiac disease and those patients developing complications after injury ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#tbl1> Table 1) were more likely to be managed with a PAC. The more frequent use of a PAC in patients with underlying co-morbidities or complications may account for the increase in overall mortality in patients managed with a PAC after admission for injury.

Another potential reason why the PAC has been associated with higher mortality is that most previous studies were conducted in hospitals with open intensive care units, where any physician on the medical staff could admit a patient to the unit and place a PAC. Most trauma surgeons caring for critically injured patients are experts in intensive care management and have added qualifications in surgical critical care. Lack of knowledge about appropriate PAC use and misinterpretation of PAC data may offset any potential benefit associated with PAC use ( <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061016>  [16] , <http://www.mdconsult.com/das/article/body/86122664-5/jorg=journal&source=MI
&sp=16240415&sid=664762510/N/535610/1.html#r06611061017> [17] ).

The findings of our study must be interpreted within the context of its limitations. The first limitation is that although the National Trauma Data Bank contained >450,000 patients at the time of this analysis, only 53,000 patients met inclusion criteria. Most were excluded due to missing data points. Those patients surviving for <48 hrs were excluded to eliminate patients with nonsurvivable injuries. This raises the possibility of survivor bias. In addition, although this analysis contained >50,000 patients, its retrospective design and subgroup analysis is not best suited for hypothesis testing and is more appropriate for the generation of new hypotheses. Lastly, neither the timing of PAC placement nor cause of death could be ascertained with certainty by analysis of the National Trauma Data Bank. Therefore, we cannot be certain that patients with signs of severe shock and high injury severity had better survival with a PAC as a result of early insertion.

Despite these limitations, we believe the findings of this study have important implications for trauma care. Unlike general medical patients who typically undergo PAC insertion to manage complications, injured patients may derive benefit from PAC-guided resuscitation to avert complications related to persistent perfusion deficits. This analysis is consistent with this hypothesis and suggests that guidelines and consensus documents that question the utility of the PAC may not apply to critically injured patients.

CONCLUSIONS 

In summary, mortality was greater in trauma patients managed with a PAC. However, when other factors that may influence injury severity were considered, such as age, severity of shock, and anatomic injury scoring, PAC use was associated with a decrease in mortality. The results of our study suggest that PAC insertion is associated with improved outcome in critically injured patients with severe shock at admission and in elderly patients with moderate shock. A prospective randomized, controlled trial of immediate PAC insertion to guide fluid resuscitation in severely injured or elderly trauma patients requiring intensive care unit admission is needed to confirm these findings.

  _____  

REFERENCES:

1  Connors , Jr , JrAF, Speroff T, Dawson NV, et al:  The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA 276. 889-897.1996; <http://www.mdconsult.com/das/journal/view/N/865850?PAGE=1.html&source=MI&AN
CHOR=abs> Abstract 
2  Sandham JD, Hull RD, Brant RF, et al:  A randomized, controlled trial of
the use of pulmonary-artery catheters in high-risk surgical patients.   N
Engl J Med 348. 5-14.2003; <http://www.mdconsult.com/das/journal/view/N/12709316?PAGE=1.html&source=MI&
ANCHOR=abs> Abstract 
3  Rhodes A, Cusack RJ, Newman PJ, et al:  A randomized, controlled trial of
the pulmonary artery catheter in critically ill patients.   Intensive Care
Med 28. 256-264.2002; <http://www.mdconsult.com/das/journal/view/N/12363808?PAGE=1.html&source=MI&
ANCHOR=abs> Abstract 
4  Richard C, Warszawski J, Anguel N, et al:  Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: A randomized controlled trial. French Pulmonary Artery
Catheter Study Group.   JAMA 290. 2713-2720.2003;
<http://www.mdconsult.com/das/journal/view/N/14212738?PAGE=1.html&source=MI&
ANCHOR=abs> Abstract 
5  Yu DT, Platt R, Lanken PN, et al:  Relationship of pulmonary artery catheter use to mortality and resource utilization in patients with severe sepsis.  Crit Care Med 31. 2734-2741.2003; <http://www.mdconsult.com/das/journal/view/N/14206741?ja=393088&PAGE=1.html&
source=MI> Full Text 
6  Barone JE, Tucker JB, Rassias D, et al:  Routine perioperative pulmonary artery catheterization has no effect on rate of complications in vascular
surgery: A meta-analysis.   Am Surg 67. 674-679.2001;
<http://www.mdconsult.com/das/journal/view/N/11918762?PAGE=1.html&source=MI&
ANCHOR=abs> Abstract 
7  Polanczyk CA, Rohde LE, Goldman L, et al:  Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery: An observational study.  JAMA 286. 309-314.2001; <http://www.mdconsult.com/das/journal/view/N/11929660?PAGE=1.html&source=MI&
ANCHOR=abs> Abstract 
8  Velmahos GC, Demetriades D, Shoemaker WC, et al:  Endpoints of resuscitation of critically injured patients: Normal or supranormal? A prospective randomized trial.  Ann Surg 232. 409-418.2000; <http://www.mdconsult.com/das/journal/view/N/11491128?PAGE=1.html&source=MI&
ANCHOR=abs> Abstract 
9  Bishop MH, Shoemaker WC, Appel PL, et al:  Prospective, randomized trial of survivor values of cardiac index, oxygen delivery, and oxygen consumption
as resuscitation endpoints in severe trauma.   J Trauma 38. 780-787.1995;
<http://www.mdconsult.com/das/journal/view/N/391994?PAGE=1.html&source=MI&AN
CHOR=abs> Abstract 
10  Baker SP, O'Neill B, Haddon , Jr , JrW, et al:  The injury severity
score: A method for describing patients with multiple injuries and
evaluating emergency care.   J Trauma 14. 187-196.1974;
<http://www.mdconsult.com/das/journal/view/N/4023267?PAGE=1.html&source=MI>
Citation 
11  Baker SP, O'Neill B:  The injury severity score: An update.   J Trauma
16. 882-885.1976; <http://www.mdconsult.com/das/journal/view/N/4923199?PAGE=1.html&source=MI>
Citation 
12  Davis JW, Shackford SR, Mackersie RC, et al:  Base deficit as a guide to
volume resuscitation.   J Trauma 28. 1464-1467.1988;
<http://www.mdconsult.com/das/journal/view/N/13175495?PAGE=1.html&source=MI&
ANCHOR=abs> Abstract 
13  Davis JW, Parks SN, Kaups KL, et al:  Admission base deficit predicts
transfusion requirements and risk of complications.   J Trauma 41.
769-774.1996;   <http://www.mdconsult.com/das/journal/view/N/1004879?PAGE=1.
html&source=MI&ANCHOR=abs> Abstract 
14  Greenspan L, McLellan BA, Greig H:  Abbreviated Injury Scale and Injury
Severity Score: A scoring chart.   J Trauma 25. 60-64.1985;
<http://www.mdconsult.com/das/journal/view/N/7363238?PAGE=1.html&source=MI&A
NCHOR=abs> Abstract 
15  Chittock DR, Dhingra VK, Ronco JJ, et al:  Severity of illness and risk
of death associated with pulmonary artery catheter use.   Crit Care Med 32.
911-915.2004; <http://www.mdconsult.com/das/journal/view/N/14604239?ja=410451&PAGE=1.html&
source=MI> Full Text 
16  Iberti TJ, Fischer EP, Leibowitz AB, et al:  A multicenter study of physicians' knowledge of the pulmonary artery catheter: Pulmonary Artery Catheter Study Group.  JAMA 264. 2928-2932.1990; <http://www.mdconsult.com/das/journal/view/N/1356052?PAGE=1.html&source=MI&A
NCHOR=abs> Abstract 
17  Reynolds HN, Haupt MT, Thill-Baharozian MC, et al:  Impact of critical care physician staffing on patients with septic shock in a university
hospital medical intensive care unit.   JAMA 260. 3446-3450.1988;
<http://www.mdconsult.com/das/journal/view/N/8190866?PAGE=1.html&source=MI&A
NCHOR=abs> Abstract 

Ivan Hronek MD 

SFMC, Los Angeles

cell: 310 487-3288

ivanhronek at yahoo.com

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http://health.groups.yahoo.com/group/Anesthideas/

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Message: 2
Date: Tue, 29 Jan 2008 06:38:13 -0800 (PST)
From: Mike Smertka <medic0947969 at yahoo.com>
Subject: Re: Prehospital Report (vs Triage?)
To: "Trauma &amp, Critical Care mailing list" <trauma-list at trauma.org>
Message-ID: <773719.55184.qm at web61123.mail.yahoo.com>
Content-Type: text/plain; charset=iso-8859-1

>From my prehospital experience those tags are a waste of time and 
>money. Were it up to me, we would have a big cookout that was triage tag powered.

  Having said that and reading the other responses  have encountered a prehospital agency in the states that uses them on every patient. The logic being they then become familiar and commonly used, so both the hospital and prehospital staff are comfortable with them. 

  But here are my issues with them.

  1. They usually are not someplace that is handy. In a disaster looking for things not relating to patient care is not going to happen due to the already high demands on providers. 

  2. Many of the tags I used the triage person tore off the color that the patient was not. So since you could only tear off more, the patient could only worsen or you needed a new tag. (As if I didn't have enough to do, copying down info and making a new tag)

  3. There is never enough room to write on those tags, or the font is so small you a lense to read it.

  4. No matter what they are laminated with, they do not hold up to the wet and adverse conditions of the prehospital environment

  5. Patients always become seperated from the tags. Which creates an identification nightmare.  especially the ones that use bar codes or other such patient identifiers. Because when you make a new tag you have to reconcile what proceedures, tests, etc were done under the old one. there is confusion about identifying how many patients you have as well as who is where and did you lose somebody?

  what I have found works best is a 12 inch long piece of 2" diameter cloth tape. (sorry metric types, don't know if it converts or if you have somehting similar) It seems to stick well enough, doesn't become seperated as easy as the tags do. Ball point pen writes on it well. You can always add more tape. record times, as well as vitals and other notes. If the patient deteriorates or imrpoves you don't have to change the tape, just make a note on it. in one glance at the tape you can read the full story. granted it is not as pleasing to the eye as the nice color coded tags. But it is something readily available where I have worked, easy to use, and reliable. In addition the hospital staff doesn't need any special training to make it work for them.( I have been in one MCI/Disaster while working in hospital and countless while working in EMS)  A priority with a set of vitals, identifiers, and notes stuck to a patient seems to be friendly to all providers. Since it is tape it  can also be easily replaced on the patient. for example, if it is stuck to his pants, you just peel it off real fast cut the pants, and stick it to the leg. (obviously as long as it doesn't cover the injury site) If it was, stick it to another part or even to the stretcher/bed they are on. Doesn't even interfere with any radiology. (thought somebody would find the humor in that) 

  I am not saying it is the best end all be all, just that it has worked when I have relied upon it. I haven't seen one marketed premade triage tag, system, clip, etc that I would pay for or suggest paying for. Color coded tape just as worthless because if you wrote all kinds of stuff on it, you need to copy it again everytime the patient priority changes. which may include having to track down the triage officer who has all the different color tape while you are tryng to treat multiple patients. 

  Mike 

Ruy Cabello-Pasini <ruycabello at yahoo.com> wrote:
  Just finished a loooong discussion with the director
of prehospital services at my institution (Mexican
Army), we are implementing a new prehospital report
but he insisted in using the triage tags (cards) but I
insisted on using those only for multiple victims. Is
anybody on the list aware of using just one report
for all patients including disasters? My opinion on
the matter is that if we put a lot of information on
the triage tags then the purpose of rapid filling of
the form is lost. Being in the army I could have
ended the discussion with a: look this is the way we
are going to do it! but I really want to have some
data or input from you experts on the matter, thanks a
lot in advance.

Ruy Cabello-Pasini MD, LTC
Trauma Surgeon

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Message: 3
Date: Mon, 28 Jan 2008 15:39:01 -0700
From: "Kashuk, Jeffry" <Jeffry.Kashuk at dhha.org>
Subject: Rocky Mountain Trauma-Emergency Medicine Conference, June
	2008
To: trauma-list at trauma.org
Message-ID:
	<57788D840D0C394D8C411E7C8C2F66B20191A866 at dhdcwexc02.hosp.dhha.org>
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Dear Fellow Trauma-list members,
On behalf of my colleagues Ernest E."Gene" Moore and Chris Colwell, I invite you to please consider joining us for the 35th annual Rocky Mountain Trauma and Emergency Medicine Conference June 24-27, 2008 in the beautiful mountain setting of Breckenridge, Colorado, about an hour and a half outside of Denver.  This year, we will start the conference on Tuesday, June 24 with a special day long session dedicated to " The Hospital response to Terrorist Bombing Events: International Experiences and Lessons Learned" For those of you who will not be able to make Dr.Mattox's Las Vegas extravaganza, this is a wonderful opportunity to hear  the list's own Karim Brohi, as well as Israelis Yoram Kluger, Pinny Halperin, and Doron Kotler of Israel's Red Cross- (MDA). Our national faculty also includes our own Rick Frykberg as well as LTC John McManus from Fort Sam Houston, along with Bill Mallon from LA and Alice Gervasini from Boston. We will finish the session with an interactive session and scenario management. 
Following our Mass Casualty Day, please consider staying for interesting and provocative sessions on various topics on Surgery, Trauma, Emergency Medicine, and pre-hospital care.. For further details, please visit: www.rockymtntraumaconf.org 
or feel free to contact me at :Jeffry.Kashuk at dhha.org  

Jeffry L. Kashuk, M.D, FACS
Surgery, Trauma, Surgical Critical Care
Denver Health Medical Center
777 Bannock St, MC 0206
Denver, CO 80204
Ph 303-436-6558
Fax 303-436-6572
Cell 303-653-5700

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