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Abstract

Background:

Post-trauma resuscitation has evolved based on civilian and wartime experiences over the last decade. Similarly, data from large multicenter randomized trials have changed the management of critically ill trauma patients in the intensive care unit.

Methods:

This is a review of the literature focusing on areas relevant to the management of trauma patients in the intensive care unit.

Results:

The following topics are included: (1) ventilator management, (2) trauma sepsis, (3) use of vasopressors in hemorrhage, (4) glucose control, (5) nutrition, and (6) hemodynamic monitoring.

Conclusion:

This review demonstrated the most recent data of trauma-related critical care. Further studies will be needed to settle growing controversies in the management of critically injured patients.

Keywords

Trauma critical care ventilator management sepsis vasopressors glucose control nutrition hemodynamic monitoring

Introduction

Trauma patients constitute a large portion of the intensive care unit (ICU) population. Due to unique concerns in this cohort, intensivists are required to approach trauma patients differently from other types of ICU patients. In this review article, we introduce data from the recent critical care literature applicable to the management of trauma patients in the ICU.

Ventilator Management

Sedation in the intensive care setting is used to decrease discomfort secondary to medical interventions, including mechanical ventilation, to prevent accidental removal of devices, and to decrease metabolic demands during cardiorespiratory instability. The main reason to limit the duration of sedation is to avoid adverse effects that range from prolonged ventilation to increased mortality associated with delirium (1). Numerous interventions have been advocated to limit the duration of ventilation, including usage of alternate medication (nonsedatives), sedation protocols, sedation stops, and daily spontaneous breathing trials (1, 2).

Recent Society of Critical Care Medicine Guidelines has addressed these issues (3). The guidelines were established to ensure that critically ill patients are free from pain, agitation, and delirium to allow complicity with ICU management goals. These have been incorporated into the ICU pain, agitation, and delirium care bundle that advocates assessing, treating and preventing pain, delirium, optimizing sedation, and decreasing the duration of ventilation.

Controversy remains regarding the optimal sedative following surgery. Dexmedetomidine, midazolam, and propofol have been used in patients undergoing a variety of surgical procedures, with the goal being to achieve successful postprocedural extubation. Dexmedetomidine, rather than propofol and midazolam, sedation facilitates faster discontinuation of mechanical ventilation and is associated with greater hemodynamic stability and arousability and less delirium (4). Early sedation depth has also been demonstrated to be an independent predictor of delayed extubation and increased mortality (5).

In 2011, the Center for Disease Control (CDC) convened a working group and redefined ventilator-associated pneumonia (VAP) as a subcategory of a ventilator-associated events (VAEs). A VAE is defined as deterioration in respiratory status after a period of stability or improvement on the ventilator, evidence of infection or inflammation, and laboratory evidence of respiratory infection (6). There is no longer a radiographic component to the definition. There are three described tiers within VAEs, the first two of which are proposed to be publicly reported: (1) ventilator-associated condition (VAC), (2) infection-related ventilator-associated complication (IVAC), and (3) possible and probable VAP. VAP is a subtype of hospital-acquired pneumonia (HAP) that occurs in people who are receiving mechanical ventilation. How these changes will alter the rate of a VAE in trauma patients remains to be determined.

There are numerous strategies in place designed to limit the occurrence, often grouped together as a ventilator bundle. Croce et al. (7) recently conducted a study in trauma patients, in which the ventilator bundle (stress ulcer prophylaxis, deep vein thrombosis (DVT) prophylaxis, head-of-bed elevation daily sedation vacation, and daily ventilator wean) was implemented as part of the Institute for Healthcare Improvement plan. Their results demonstrated that in trauma patients, VAP is independently associated with male sex and chest injury severity and not implementation of the ventilator bundle. On the other hand, Morris et al. (8) showed a two-third decrease in VAP rates when the bundle was employed in a recently published before–after study in a mixed population of medical and surgical patients.

In 2012, the Berlin Definition of Adult Respiratory Distress Syndrome (ARDS) was published (9). This did away with the acute lung injury (ALI)/ARDS differentiation. It opts instead to classify ARDS as mild, moderate, or severe. Mild ARDS is classified as a PaO₂/FiO₂ ratio of between 200 and 300 mmHg, moderate between 100 and 200 mmHg, and severe less than 100 mmHg. These new break points are associated with different mortalities and suggested therapies.

More recently, a former rescue therapy has been proposed as an empirical respiratory modality in the prevention of ARDS. Airway pressure release ventilation (APRV) is a safe mode of ventilation for hypoxemic or hypercarbic respiratory failure. The improvements in PaO₂ and PaCO₂ are achieved at lower-minute ventilations than with ventilator modes that are volume or pressure-targeted. Although there are proven benefits of APRV, a retrospective review has demonstrated that APRV, as well as male sex, abdominal Abbreviated Injury Scale (AIS) >3, spinal AIS >3, acute renal failure, and sepsis were independent predictors in increasing ventilator days when compared to other methods of ventilation in multiple regression analysis (10). The study was undertaken as a retrospective review of 362 patients. A total of 73 patients received APRV, and 234 patients received assist-control ventilation (ACV). There were no demographic differences between the groups. Patients on APRV did, however, have higher rates of abdominal compartment syndrome and higher chest AIS scores.

There have been two recent articles on high-flow oscillatory ventilation (HFOV), which have both been multicenter studies. Ferguson et al. (11) demonstrated an increase in mortality in the group that received HFOV, whereas Young et al. (12) demonstrated no difference.

Trauma Sepsis

In 2012, the Surviving Sepsis Campaign, which consists of a consensus committee of 68 international experts from 30 institutions, prepared to launch a second update of sepsis guidelines (13). The key recommendations that are distinct from earlier versions of the guidelines include (1) removal of activated protein C from consideration, (2) no recommendation for using a cosyntropin stimulation test for the diagnosis of adrenal insufficiency, and (3) vasopressors to target a mean arterial pressure of 65 mmHg with norepinephrine as a first-line agent instead of dopamine. Unfortunately, there have been no significant changes in the last two decades in the mortality for sepsis post-trauma, resulting in research being undertaken to identify risk factors that can be used as markers for early diagnosis and, hence, decrease septic complications.

Trauma complicated by sepsis carries a mortality that exceeds 50%. A number of inflammatory markers have shown promise as predictors of which patients will suffer sepsis. Gouel-Chéron et al. (14) have demonstrated that early measurement of interleukin-6 (IL-6) and human leukocyte antigen-D related (HLA-DR) have shown potential in predicting patients who will develop sepsis. An increase in IL-6 and persistent decrease in HLA-DR were found to be related to the development of sepsis and had the best predictive value. Nonetheless, although multiorgan failure complicates 29% of cases with severely injured patients with a blunt mechanism of injury, the onset is early and not bimodal, nor associated with a second hit (15). In a real-life clinical setting, implementation of a procalcitonin (PCT)-protocol has demonstrated an association with a reduced duration of antibiotic therapy in septic ICU patients without compromising clinical or economical outcomes (16). However, in ICU patients with the phenotype of severe sepsis or septic shock and without an overt source of infection or a known pathogen, Annane et al. (17) were unable to confirm that a PCT-based algorithm may influence antibiotic exposure.

Vasopressors and Hemorrhage

A study by Lima et al. (18) implies that, in hemorrhagic shock, treatment with low-dose vasopressin (VP), in combination with fluid therapy, improves tissue perfusion when compared to noradrenaline. This is mediated mostly by VP acting upon the V₂ receptors, resulting in vasodilatation and the resulting increase in blood flow through the microcirculation. Arginine vasopressin (AVP) is an important hormone in osmoregulation and blood pressure. During hemorrhage, it has been demonstrated that levels rapidly decrease. There have been numerous studies undertaken on animal models, and the limited studies on humans have shown that circulatory support with AVP is linked to improved outcomes (19). Its effectiveness seems to lie in its ability to increase calcium sensitivity in acidotic environs, thereby allowing for more effective maintenance of vascular tone than catecholamines.

Cohn et al. (20) hypothesized that a resuscitation regimen that limited the total volume of fluid administered would reduce morbidity and mortality rates in critically ill trauma patients. They randomly assigned 78 patients to the experimental group (n = 38) or the control group (n = 40). The groups were similar in age, sex, preexisting medical illnesses, and mechanism and severity of injury. The experimental group required a significantly lower total volume of resuscitation fluid over 5 days than did the control group (p = 0.04). The rates of adverse events, organ dysfunction, and 30-day mortality were similar.

Glucose Control

Hyperglycemia is often seen in severely injured patients. Both early and persistent hyperglycemia is associated with poor outcomes among the trauma population. Moreover, hyperglycemia in trauma patients has a stronger association with poor outcome than it does in other critically ill patients (21). In 2001, intensive insulin therapy (IIT) to control the glucose level between 80 and 110 mg/dL was initially reported to be associated with significantly decreased morbidity and mortality of critically ill patients in the surgical ICU (22). While this prospective randomized controlled study by Van den Berghe et al. included only 4% of trauma patients, Scalea et al. (23) compared the outcomes of critically injured trauma patients between IIT group and non-IIT group in their prospective study. Mortality, length of hospital and ICU stay, and incidence of infectious complication were significantly lower in the IIT group. Thus, IIT has been the standard of care in trauma ICU since the early 2000s.

However, severe hypoglycemia remained a significant concern, despite the overall benefit of IIT. Furthermore, another randomized controlled study repeated at the same institution in Leuven failed to show any benefit of IIT among medical ICU patients (24). Furthermore, two additional multicenter, randomized controlled studies from Europe also showed no difference in mortality between the IIT and non-IIT groups (25, 26). Severe hypoglycemic events were more often seen in the IIT group in both studies. Finally, Finfer et al. (27) conducted the Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose Algorithm Regulation (NICE-SUGAR) trial, including 6104 medical and surgical ICU patients to evaluate the impact of IIT in Australia, New Zealand, the United States, and Canada. In their study, 90-day mortality of patients in the IIT group was significantly higher than in the non-IIT group (27.5% vs 24.9%, p = 0.02). A post hoc analysis of this study showed that the incidence of moderate hypoglycemia and severe hypoglycemia (41–70 mg/dL and ≤40 mg/dL, respectively) was significantly associated with an increased risk of death.

As a result, it remains unclear what the optimal range of blood glucose levels for critically ill trauma patients should be. It is also unknown how a previous history of diabetes, the variability in glucose measurements, or a computerized protocol for insulin infusion would impact the outcome of patients. The American Diabetes Association recommends a more liberal target glucose range between 144 and 180 mg/dL, which was the target in the control group of the NICE-SUGAR trial (28). Kutcher et al. (29) reviewed their institutional database to identify optimal glucose level in critically injured patients. They showed that hyperglycemic events defined as glucose >180 mg/dL, not hypoglycemic events (<60 mg/dL) were significantly associated with mortality.

Nutrition

Nutritional support is one of the cornerstones of successful management of critically ill trauma patients. Although the literature shows that early enteral nutrition improves the outcome of ICU patients, it is often challenging to provide an appropriate amount of nutrition though an enteral route. In addition to high caloric and protein requirements of trauma patients, the initiation and maintenance of nutrition can be delayed and interrupted by multiple factors such as injury to the gastrointestinal tract, frequent return to the operating room, or intestinal dysmotility. It is still unclear whether early parenteral nutrition support in addition to enteral nutrition improves or worsens the outcome of ICU patients. Interestingly, the current guideline of the European Society of Parenteral and Enteral Nutrition (ESPEN) and the guidelines from the Northern America are contradictory regarding the timing of parenteral nutrition for the critically ill patients whose caloric target cannot be met by enteral nutrition (30, 31). A multicenter randomized controlled trial from Europe (Early versus Late Parenteral Nutrition in Critically Ill Adults (EPaNIC) trial) showed that patients who were initiated on parenteral nutrition on Day 8 (late initiation group) had a significantly shorter ICU and hospital stay than the early initiation group in which parenteral nutrition was initiated on Day 3 (32). Also, the incidence of infectious complications during the ICU stay was significantly higher in the early initiation group compared with the late initiation group. Another multicenter randomized controlled trial from Australia and New Zealand compared the outcome of patients for whom enteral nutrition was relatively contraindicated in a short period of time in the ICU between two nutritional regimens (33). In the early parenteral nutrition group, parenteral nutrition was initiated within 24 h of ICU admission. In this study, early parenteral nutrition did not improve 60-day mortality rate. Furthermore, neither length of ICU nor duration of hospital stay was shortened in the early parenteral group.

A variety of nutritional supplements has been studied in the critically ill patients. Of these, glutamine supplementation was known to be effective in reducing infectious complications of ICU patients in early literature. However, a recent randomized trial from Canada and the United States failed to demonstrate any outcome benefit of adding glutamine to the nutritional regimen (34). In fact, the administration of glutamine was associated with an increased mortality of patients with multiorgan failure. A recent meta-analysis also concluded that adding omega-3 fatty acid (fish oil) to parenteral nutrition is unlikely to improve the outcome of critically ill adult patients (35).

Hemodynamic Monitoring

The impact of invasive hemodynamic monitoring with a pulmonary artery catheter (PAC) on the outcome of critically ill patients has been extensively studied over the last decade. In the trauma population, Friese et al. (36) analyzed the National Trauma Data Bank to show potential outcome benefit by using PACs in a severely injured patient group (older age, higher injury severity score, lower base deficit). Nonetheless, the most recent Cochrane review concluded that the use of a PAC does not alter mortality of and ICU length of stay in critically ill patients (37). Accordingly, the use of noninvasive hemodynamic monitoring techniques has become more popular to guide the resuscitation of severely injured trauma patients in the ICU.

One of the common modalities for noninvasive hemodynamic monitoring is transthoracic echocardiography (TTE). There are several articles to evaluate the correlation of the hemodynamic data between PAC and TTE (38 –40). Gunst et al. (38) evaluated the accuracy of cardiac function and volume status obtained with bedside echocardiography performed by intensivists in the surgical ICU. Their data suggested a good correlation between estimated cardiac index and central venous pressure between PAC and the Bedside Echocardiographic Assessment in Trauma (BEAT) exam. Similarly, Murthi et al. (39) showed the comparison of hemodynamic data using TTE (FREE: focused rapid echocardiographic evaluation) and a catheter-based monitoring technique (PAC or arterial line waveform) in critically ill trauma patients. In addition to excellent agreement in cardiac index between the two modalities, FREE modified the plan of care in more than half of the patients. Ferrada et al. (40) have shown that a BEAT can be successfully performed by attending trauma surgeons after didactic and hands-on teaching sessions. Currently, it is still unknown whether the use of TTE will improve the outcome of severely injured patients compared to other invasive and noninvasive hemodynamic monitoring techniques.

Footnotes

Declaration of Conflicting Interests

All authors deny any potential conflicts of interest.

Funding

No internal and external financial support was used for this study.

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Trauma-Related Critical Care

Abstract

Background:

Methods:

Results:

Conclusion:

Keywords

Introduction

Ventilator Management

Trauma Sepsis

Vasopressors and Hemorrhage

Glucose Control

Nutrition

Hemodynamic Monitoring

Footnotes

Declaration of Conflicting Interests

Funding

References