title: Application of the Berlin definition in PROMMTT patients: the impact of resuscitation on the incidence of hypoxemia.
abstract: BACKGROUND
  Acute lung injury following trauma resuscitation remains a concern despite recent advances. With the use of the PROMMTT study population, the risk of hypoxemia and potential modifiable risk factors are studied.
  
  
  METHODS
  Patients with survival for 24 hours or greater with at least one intensive care unit day were included in the analysis. Hypoxemia was categorized using the Berlin definition for adult respiratory distress syndrome: none (PaO₂-to-FIO₂ ratio [P/F] > 300 mm Hg), mild (P/F, 201-300 mm Hg), moderate (P/F, 101-200 mm Hg) or severe (P/F ≤ 100 mm Hg). The cohort was dichotomized into those with none or mild hypoxemia and those with moderate or severe injury. Early resuscitation was defined as that occurring 0 hour to 6 hours from arrival; late resuscitation was defined as that occurring 7 hours to 24 hours. Multivariate logistic regression models were developed controlling for age, sex, mechanisms of injury, arrival physiology, individual Abbreviated Injury Scale (AIS) scores, blood transfusions, and crystalloid administration.
  
  
  RESULTS
  Of the patients 58.7% (731 of 1,245) met inclusion criteria. Hypoxemia occurred in 69% (mild, 24%; moderate, 28%; severe, 17%). Mortality was highest (24%) in the severe group. During early resuscitation (0-6 h), logistic regression revealed age (odd ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.04), chest AIS score (OR, 1.31; 95% CI, 1.10-1.57), and intravenously administered crystalloid fluids given in 500 mL increments (OR, 1.12; 95% CI, 1.01-1.25) as predictive of moderate or severe hypoxemia. During late resuscitation, age (OR, 1.02; 95% CI, 1.00-1.04), chest AIS score (OR, 1.33; 95% CI, 1.11-1.59), and crystalloids given during this period (OR, 1.05; 95% CI, 1.01-1.10) were also predictive of moderate-to-severe hypoxemia. Red blood cell, plasma, and platelet transfusions (whether received during early or late resuscitation) failed to demonstrate an increased risk of developing moderate/severe hypoxemia.
  
  
  CONCLUSIONS
  Severe chest injury, increasing age, and crystalloid-based resuscitation, but not blood transfusions, were associated with increased risk of developing moderate-to-severe hypoxemia following injury.
authors.affiliation: Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio 45267, USA. bryce.robinson@uc.edu
authors.forename: Bryce R H
authors.initials: BR
authors.lastname: Robinson
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Cotton
authors.forename: Timothy A
authors.initials: TA
authors.lastname: Pritts
authors.forename: Richard
authors.initials: R
authors.lastname: Branson
authors.forename: John B
authors.initials: JB
authors.lastname: Holcomb
authors.forename: Peter
authors.initials: P
authors.lastname: Muskat
authors.forename: Erin E
authors.initials: EE
authors.lastname: Fox
authors.forename: Charles E
authors.initials: CE
authors.lastname: Wade
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: del Junco
authors.forename: Eileen M
authors.initials: EM
authors.lastname: Bulger
authors.forename: Mitchell J
authors.initials: MJ
authors.lastname: Cohen
authors.forename: Martin A
authors.initials: MA
authors.lastname: Schreiber
authors.forename: John G
authors.initials: JG
authors.lastname: Myers
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Brasel
authors.forename: Herbert A
authors.initials: HA
authors.lastname: Phelan
authors.forename: Louis H
authors.initials: LH
authors.lastname: Alarcon
authors.forename: Mohammad H
authors.initials: MH
authors.lastname: Rahbar
authors.forename: Rachael A
authors.initials: RA
authors.lastname: Callcut
mesh_terms: D015998:Abbreviated Injury Scale; D000328:Adult; D000367:Age Factors; D001803:Blood Transfusion / Q000379:methods*; D016009:Chi-Square Distribution; D000077324:Crystalloid Solutions; D005260:Female; D005440:Fluid Therapy / Q000379:methods; D006470:Hemorrhage / Q000401:mortality / Q000628:therapy*; D017052:Hospital Mortality; D006801:Humans; D000860:Hypoxia / Q000453:epidemiology*; D015994:Incidence; D007552:Isotonic Solutions / Q000008:administration & dosage; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods*; D012307:Risk Factors; D018709:Statistics, Nonparametric; D013898:Thoracic Injuries / Q000401:mortality / Q000628:therapy*; D014193:Trauma Centers; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014947:Wounds and Injuries / Q000401:mortality / Q000628:therapy*
chemical_list: D000077324:Crystalloid Solutions; D007552:Isotonic Solutions