Combining early coagulation and inflammatory status improves prediction of mortality in burned and nonburned trauma patients.
BACKGROUND
After injury, there is a synergistic response between inflammation and coagulation systems. We hypothesized that combining markers of these processes and standard clinical indices would improve early prediction of in- hospital mortality in burned and nonburned trauma patients.


METHODS
Patients admitted to the surgical or burn intensive care unit within 24 hours of injury with an anticipated stay >or=3 days were enrolled during a one year period. Upon admission, blood was drawn for thromboelastography, plasma-based clotting assays, and cytokine levels. Clinical indices and multiple organ dysfunction syndrome (MODS) scores were recorded. Candidate variables evaluated included age, percentage third degree burns, inhalation injury, percentage total body surface area burns, interleukin-6, tumor necrosis factor alpha, interleukin-8, prothrombin time, partial thromboplastin time (PTT), maximal amplitude reflective of clot strength, group (burn or nonburn) and admission MODS. Multiple logistic regression with stepwise selection and likelihood ratio test was performed to identify predictors for mortality. A receiver operating characteristic (ROC) curve was constructed to assess the diagnostic performance of identified predictors. Validation of the model with an additional cohort was performed.


RESULTS
For model development, we enrolled 25 burned and 33 nonburned trauma patients (20 blunt and 13 penetrating injuries). Fifteen deaths occurred. Multiple logistic regression analysis identified six independent risk factors for death: age, percentage third degree burns, inhalation injury, tumor necrosis factor alpha level, maximal amplitude, and MODS score with an area under ROC curve of 0.961 (95% confidence interval: 0.891, 1.000, p < 0.05). The area under the ROC curve for the validation cohort (n = 66) was 0.936 (95% confidence interval: 0.875, 0.997, p < 0.001).


CONCLUSIONS
Our model improves prediction of in-hospital mortality in comparison to previous methods for burn and nonburn trauma patients. Furthermore, our model is equally applicable to all patients regardless of type of traumatic injury (nonburn or burn). This improvement is because of the inclusion of patient's early coagulation and inflammatory status in addition to standard clinical indices. These data provide a baseline within which to measure incremental improvements in care.
Park
Myung S
MS
US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA. myung.park@amedd.army.mil
Salinas
Jose
J
Wade
Charles E
CE
Wang
Jingjing
J
Martini
Wenjun
W
Pusateri
Anthony E
AE
Merrill
Gerald A
GA
Chung
Kevin
K
Wolf
Steven E
SE
Holcomb
John B
JB
D000328:Adult; D000367:Age Factors; D000368:Aged; D001779:Blood Coagulation Factors / Q000378:metabolism*; D002056:Burns / Q000097:blood* / Q000150:complications / Q000401:mortality*; D016022:Case-Control Studies; D015331:Cohort Studies; D016207:Cytokines / Q000097:blood*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012372:ROC Curve; D013916:Thrombelastography; D014947:Wounds and Injuries / Q000150:complications* / Q000401:mortality*
D001779:Blood Coagulation Factors; D016207:Cytokines