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Background Major trauma is associated with high incidence of septic complications and multiple organ dysfunction (MOD), which markedly influence the outcome of injured patients. Early identification of patients at risk of developing posttraumatic complications is crucial to provide early treatment and improve outcomes. We sought to evaluate the prognostic value of serum procalcitonin (PCT) levels after trauma as related to severity of injury, sepsis, organ dysfunction, and mortality. Methods We searched PubMed, MEDLINE, EMBASE, the Cochrane Database, and references of included articles. Two investigators independently identified eligible studies and extracted data. We included original studies that assessed the prognostic value of serum PCT levels in predicting severity of injury, sepsis, organ dysfunction, and mortality among critically injured adult patients. Results Among 2015 citations, 19 studies (17 prospective; 2 retrospective) met inclusion criteria. Methodological quality of included studies was moderate. All studies showed a strong correlation between initial PCT levels and Injury Severity Score (ISS). Twelve out of 16 studies demonstrated significant elevation of initial PCT levels in patients who later developed sepsis after trauma. PCT level appeared a strong predictor of MOD in seven out of nine studies. While two studies did not show association between PCT levels and mortality, four studies demonstrated significant elevation of PCT levels in non-survivors versus survivors. One study reported that the PCT level of ≥ 5 ng/mL was associated with significantly increased mortality (OR 3.65; 95% CI 1.03–12.9; p = 0.04). Conclusion PCT appears promising as a surrogate biomarker for trauma. Initial peak PCT level may be used as an early predictor of sepsis, MOD, and mortality in trauma population.

Background: There is increasing interest in the timely administration of concentrated sources of fibrinogen to patients with major traumatic bleeding. Following evaluation of early cryoprecipitate in the CRYOSTAT 1 trial, we explored the use of fibrinogen concentrate, which may have advantages of more rapid administration in acute haemorrhage. The aims of this pragmatic study were to assess the feasibility of fibrinogen concentrate administration within 45 minutes of hospital admission and to quantify efficacy in maintaining fibrinogen levels ≥ 2 g/L during active haemorrhage. Methods: We conducted a blinded, randomised, placebo-controlled trial at five UK major trauma centres with adult trauma patients with active bleeding who required activation of the major haemorrhage protocol. Participants were randomised to standard major haemorrhage therapy plus 6 g of fibrinogen concentrate or placebo. Results: Twenty-seven of 39 participants (69%; 95% CI, 52–83%) across both arms received the study intervention within 45 minutes of admission. There was some evidence of a difference in the proportion of participants with fibrinogen levels ≥ 2 g/L between arms (p = 0.10). Fibrinogen levels in the fibrinogen concentrate (FgC) arm rose by a mean of 0.9 g/L (SD, 0.5) compared with a reduction of 0.2 g/L (SD, 0.5) in the placebo arm and were significantly higher in the FgC arm (p Conclusions: In this trial, early delivery of fibrinogen concentrate within 45 minutes of admission was not feasible. Although evidence points to a key role for fibrinogen in the treatment of major bleeding, researchers need to recognise the challenges of timely delivery in the emergency setting. Future studies must explore barriers to rapid fibrinogen therapy, focusing on methods to reduce time to randomisation, using ‘off-the-shelf’ fibrinogen therapies (such as extended shelf-life cryoprecipitate held in the emergency department or fibrinogen concentrates with very rapid reconstitution times) and limiting the need for coagulation test-based transfusion triggers. Trial Registration: ISRCTN67540073. Registered on 5 August 2015. 5 August 2015.

We congratulate Perlman et al. [1] for their excellent manuscript offering a comprehensive review of hypothermia in trauma patients and proposing a goal-directed algorithm for warming the severely injured patient that can be directly incorporated into current Advanced Trauma Life Support guidelines. In this well-crafted algorithm, the authors reveal a pragmatic treatment strategy that can be implemented in most major trauma centers, and that will be evaluated for efficacy in an upcoming prospective trial based in Toronto, ON, Canada. Although the warming strategies included in this algorithm include a broad range of available techniques and technologies, one approach was omitted (probably due to the fact that it has only recently become available): esophageal heat transfer using a newly available device. In contrast to more traditional lavage, this new device on the market incorporates a closed system of water flow that provides an effective transfer of heat in the efficient heat transfer environment of the esophagus. Recent data have shown success with this device in preventing inadvertent perioperative hypothermia in challenging burn trauma patients [2], as well as in reversing intentionally-induced hypothermia [3]. Ongoing clinical studies are further elucidating the exact quantities of heat transfer capable via this route (ClinicalTrials.gov NCT02743884). Since existing heat exchangers (water blanket chillers) already present in most hospitals are used to power this device, no additional capital expenditures are necessary, making it a cost-effective option. Although initially used primarily for intentional cooling [4], the utility of this approach in trauma patients to provide core warming in a relatively non-invasive manner may warrant its inclusion in subsequent iterations of this well-thought-out algorithm.

Introduction Severely bleeding trauma patients are a small proportion of the major trauma population but account for 40 % of all trauma deaths. Healthcare resource use and costs are likely to be substantial but have not been fully quantified. Knowledge of costs is essential for developing targeted cost reduction strategies, informing health policy, and ensuring the cost-effectiveness of interventions. Methods In collaboration with the Trauma Audit Research Network (TARN) detailed patient-level data on in-hospital resource use, extended care at hospital discharge, and readmissions up to 12 months post-injury were collected on 441 consecutive adult major trauma patients with severe bleeding presenting at 22 hospitals (21 in England and one in Wales). Resource use data were costed using national unit costs and mean costs estimated for the cohort and for clinically relevant subgroups. Using nationally available data on trauma presentations in England, patient-level cost estimates were up-scaled to a national level. Results The mean (95 % confidence interval) total cost of initial hospital inpatient care was £19,770 (£18,177 to £21,364) per patient, of which 62 % was attributable to ventilation, intensive care, and ward stays, 16 % to surgery, and 12 % to blood component transfusion. Nursing home and rehabilitation unit care and re-admissions to hospital increased the cost to £20,591 (£18,924 to £22,257). Costs were significantly higher for more severely injured trauma patients (Injury Severity Score ≥15) and those with blunt injuries. Cost estimates for England were £148,300,000, with over a third of this cost attributable to patients aged 65 years and over. Conclusions Severely bleeding major trauma patients are a high cost subgroup of all major trauma patients, and the cost burden is projected to rise further as a consequence of an aging population and as evidence continues to emerge on the benefits of early and simultaneous administration of blood products in pre-specified ratios. The findings from this study provide a previously unreported baseline from which the potential impact of changes to service provision and/or treatment practice can begin to be evaluated. Further studies are still required to determine the full costs of post-discharge care requirements, which are also likely to be substantial.

Identifying patients who need damage control resuscitation (DCR) early after trauma is pivotal for adequate management of their critical condition. Several trauma-scoring systems have been developed to identify such patients, but most of them are not simple enough to be used in prehospital settings in the early post-traumatic phase. The Trauma Induced Coagulopathy Clinical Score (TICCS) is an easy-to-measure and strictly clinical trauma score developed to meet this medical need.TICCS is a 3-item clinical score (range: 0 to 18) based on the assessment of general severity, blood pressure and extent of body injury and calculated by paramedics on-site for patients with severe trauma. This non-interventional prospective study was designed to assess the ability of TICCS to discern patients who need DCR. These patients were patients with early acute coagulopathy of trauma (EACT), haemorrhagic shock, massive transfusion and surgical or endovascular haemostasis during hospitalization. Diagnosis of EACT was assessed by both thromboelastometry and conventional coagulation tests.During an 18-month period, 89 severe trauma patients admitted to the general emergency unit at our hospital were enrolled in the study, but 7 were excluded for protocol violations. Of the 82 remaining patients, 8 needed DCR and 74 did not. With receiver operating characteristic curve analysis, TICCS proved to be a powerful discriminant test (area under the curve = 0.98; 95% CI: 0.92 to 1.0). A cutoff of 10 on the TICCS scale provided the best balance between sensitivity (100%; 95% CI: 53.9 to 100) and specificity (95.9%; 95% CI: 88.2 to 99.2). The positive predictive value was 72.7%, and the negative predictive value was 100.0%.TICCS can be easily and rapidly measured by paramedics at the trauma site. In this study of blunt trauma patients, TICCS was able to discriminate between patients with and without need for DCR. TICCS on-site evaluation should allow initiation of optimal care immediately upon hospital admission of patients with severe trauma in need of DCR. However, a larger multicentre prospective study is needed for in-depth validation of TICCS.Clinicaltrials.gov ID: NCT02132208 (registered 6 May 2014).

The use of cardiac output monitoring has been shown to be beneficial in the setting of perioperative medicine and critical illness [1,2]. More recently, its application in the setting of major trauma has been described [3]. Here, we describe our preliminary experience of embedding bioreactance flow monitoring within the major trauma primary survey of severely injured patients and the subsequent effect on patient management.

Acute coagulopathy, hypothermia, and acidosis are known as the lethal triad of major trauma patients. Major trauma patients with hypothermia and acidosis developed clinically significant bleeding despite adequate transfusion [1]. Recent animal experiment studies reported that hypothermia is associated with improved survival in controlled hemorrhagic shock [2,3]. Post-traumatic hypothermia is an unproven therapy unlike hypothermia as a postcardiac arrest care. The objective of this study was to investigate the effect of hypothermia on coagulation function in uncontrolled hemorrhagic shock with major trauma.

Mental illness has been recognised as a potential risk factor both for intentional and unintentional injury. About 50% of patients presenting with self-inflicting injuries in emergency departments had previous known psychiatric disorder (PD) [1,2], whereas individuals with mental illness were admitted for unintentional injury twice as often as those without [3]. We aimed to assess the prevalence of PD in trauma patients being admitted to a major trauma ICU and compare it with the nontrauma population.

The purpose of this study was to assess the visiting restrictions placed on families visiting adult patients on critical care units within trauma hospitals in England. Whilst it is well recognised that high-quality care for patients is of paramount importance, we should also be aware that supporting patients' families offers long-term benefits for patient, family and hospital. In our own unit we are reviewing whether we could adopt a more flexible attitude to visiting times and assessing how to provide a more welcoming environment to relatives. To inform our own review and in order to develop a best practise approach, we surveyed all of the major trauma centres in England.

Introduction We tested two hypotheses that disseminated intravascular coagulation (DIC) and acute coagulopathy of trauma-shock (ACOTS) in the early phase of trauma are similar disease entities and that the DIC score on admission can be used to predict the prognosis of patients with coagulopathy of trauma. Methods We conducted a retrospective study of 562 trauma patients, including 338 patients whose data were obtained immediately after admission to the emergency department. We collected serial data for the platelet counts, global markers of coagulation and fibrinolysis, and antithrombin levels. DIC was diagnosed according to the Japanese Association for Acute Medicine (JAAM) DIC scoring system, and ACOTS was defined as a prothrombin-time ratio of >1.2. Results The higher levels of fibrin/fibrinogen degradation products (FDP) and D-dimer and greater FDP/D-dimer ratios in the DIC patients suggested DIC with the fibrinolytic phenotype. The DIC patients with the fibrinolytic phenotype exhibited persistently lower platelet counts and fibrinogen levels, increased prothrombin time ratios, higher FDP and D-dimer levels, and lower antithrombin levels compared with the non-DIC patients on arrival to the emergency department and during the early stage of trauma. Almost all ACOTS patients met the criteria for a diagnosis of DIC; therefore, the same changes were observed in the platelet counts, global markers of coagulation and fibrinolysis, and antithrombin levels as noted in the DIC patients. The JAAM DIC score obtained immediately after arrival to the emergency department was an independent predictor of massive transfusion and death due to trauma and correlated with the amount of blood transfused. Conclusions Patients who develop DIC with the fibrinolytic phenotype during the early stage of trauma exhibit consumption coagulopathy associated with increased fibrin(ogen)olysis and lower levels of antithrombin. The same is true in patients with ACOTS. The JAAM DIC score can be used to predict the prognosis of patients with coagulopathy of trauma.

In this study we determine the impact of a dedicated trauma desk on the identification of patients suffering from major trauma and on time to allocate critical care resources. Trauma is increasingly recognised as a serious global health problem and is the leading cause of death in those under the age of 45, accounting for 1,300 deaths in Scotland each year [1]. In addition, trauma causes considerable short-term and long-term morbidity and has personal, social and financial impact on the population [2]. Evidence and expert opinion strongly support the presence of appropriately trained, clinically active, personnel integrated and fundamental to the command and control structure in order to optimise the right resource being dispatched to the right patient at the right time.

Introduction Fibrinogen plays a key role in hemostasis and is the first coagulation factor to reach critical levels in massively bleeding trauma patients. Consequently, rapid estimation of plasma fibrinogen (FIB) is essential upon emergency room (ER) admission, but is not part of routine coagulation monitoring in many centers. We investigated the predictive ability of the laboratory parameters hemoglobin (Hb) and base excess (BE) upon admission, as well as the Injury Severity Score (ISS), to estimate FIB in major trauma patients. Methods In this retrospective study, major trauma patients (ISS ≥16) with documented FIB analysis upon ER admission were eligible for inclusion. FIB was correlated with Hb, BE and ISS, alone and in combination, using regression analysis. Results A total of 675 patients were enrolled (median ISS 27). FIB upon admission correlated strongly with Hb, BE and ISS. Multiple regression analysis showed that Hb and BE together predicted FIB (adjusted R2 = 0.46; loge(FIB) = 3.567 + 0.223.Hb - 0.007.Hb2 + 0.044.BE), and predictive strength increased when ISS was included (adjusted R2 = 0.51; loge(FIB) = 4.188 + 0.243.Hb - 0.008.Hb2 + 0.036.BE - 0.031.ISS + 0.0003.ISS2). Of all major trauma patients admitted with Hb

There is an emerging body of evidence suggesting that early packed red blood cell transfusion accompanied by fresh frozen plasma, while limiting crystalloids, confers a survival benefit in major trauma [1]. Prehospital blood transfusion has been infrequently described, and concerns over expense, transfusion reactions, risk of disease transmission, short shelf half-life and difficult storage have limited the interest of prehospital providers.

Introduction: Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient. When these recommendations are implemented patient outcomes may be improved.Methods: The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document represents an updated version of the guideline published by the group in 2007 and updated in 2010. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.Results: Key changes encompassed in this version of the guideline include new recommendations on the appropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patients in the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline also includes recommendations and a discussion of thromboprophylactic strategies for all patients following traumatic injury. The most significant addition is a new section that discusses the need for every institution to develop, implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. The remaining recommendations have been re-evaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.Conclusions: A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensure that established protocols are consistently implemented will ensure a uniform and high standard of care across Europe and beyond. © 2013 Spahn et al. licensee BioMed Central Ltd., SCOPUS: ar.j, info:eu-repo/semantics/published

Intensivists may provide initial management to patients with major burns, despite lacking extensive knowledge and experience. Burnsurgery.org is a free website "designed to provide comprehensive, up-to-date educational tools for burn care professionals throughout the world". The site is operated by a nonprofit educational group, with editors from Brigham and Women's Hospital in Boston, MA, USA. Potential conflicts of interest are not disclosed, although the site is linked to some commercial sites promoting anabolic and wound care products. Like many health information websites, this site does not report certification by any quality rating organization or adherence to any of the available quality codes of conduct [1]. The site is divided into educational modules, beginning with burn prevention. The most useful sections discuss initial management priorities, including airway assessment, fluid resuscitation, and burn wound size and depth assessment. Overall, the information focuses on resuscitation issues relevant to intensivists and is consistent with current practice. The sample admission order set, which is presented with the rationale for specific orders, is a useful reminder of important initial therapies. Two significant content errors are the failure to caution against cutting the endotracheal tube prior to intubation (in order to prevent disappearance of the tube into the mouth when facial edema becomes massive) and the recommendation to administer intravenous fluids via peripheral veins (which are often impossible to access in a major burn injury and are prone to dislodgement during patient transfer). This section also includes special issues in initial wound management, chemical burns, electrical burns, comanagement of burns and major trauma, and indications for transfer to a burn facility. The site has some limitations. The authors should acknowledge the limited contribution of methodologically robust clinical evidence to most treatment recommendations and the extensive interinstitutional variation in some aspects of care (e.g. wound management). Most of the resuscitation information is not referenced, except for that in the section on burn orders. The discussion of pulmonary issues, such as acute respiratory distress syndrome, is limited and does not incorporate current evidence from the critical care literature. Multiple errors of grammar and spelling distract from the information presented. Although the site appears to be recent, with content posted between 2000 and 2002, the authors do not state the frequency of updating. Finally, it would be very useful to review management recommendations in the context of 'best practices', such as the American Burn Association's practice guidelines for burn care. The website is reasonably functional. Navigation within the site starts from a detailed table of contents on the home page. Similar pages are unfortunately not linked (e.g. initial management to orders), thus requiring a return to the home page to transfer between different sections. This process often entails using the browser's back button because some pages are not linked to the home page. There are no irritating pop-up advertisements or requests for personal information. Most links to other sites are functional. Overall, this site provides an excellent starting point for intensivists involved in the resuscitation and stabilization of burn patients, especially in situations where immediate consultation and transfer to a major burn center is not possible.

This prospective study assessed the efficacy of the predicting power for mortality of two different prehospital scoring systems in trauma patients. We present an improved Mainz Emergency Evaluation Scoring (MEES) in combination with capnometry (MEESc). MEESc is a new scoring system. We compared the prognostic role of outcome of these two prehospital descriptive scoring systems with the prognostic scoring system APACHE II.

This study describes 5.5 years of retrospective data examining hospital and 6-month outcome of patients following decompressive craniectomy (DC). The effectiveness of DC remains uncertain with conflicting results in patients with TBI and stroke [1,2].

Seventy-five percent of ICU mortality after the first 72 hours following major trauma is due to multiple organ dysfunction syndrome (MODS) [1]. How to follow this evolution is not completely understood yet and new parameters are still needed. The aim of this study was to evaluate the effects of polytrauma on sublingual microcirculation and to search correlations among it, Sequential Organ Failure Assessment (SOFA) score and biochemical markers and to use these factors for monitoring patients [2].

Correction After the publication of this abstract [1], we found some mistakes in the text. In details: Introduction section: the correct sentence is “The aim of our study was to assess the rate of complications (deep venous thrombosis, DVT; infections) in patients discharged from Intensive Care Unit (ICU) with a PICC or a ST-CVC.” Methods section: the study period is “Jan 2008 to Aug 2008”. Results section: the sentence with correct data is “Admission diagnosis in PICC and ST-CVC groups were also similar: major trauma (38.6% vs 44.8%), sepsis (40.3% vs 34.4%), post-surgical complications (21.1% vs 20.8%). Total PICCs catheter day were 4024, whereas total ST-CVC catheter days were 2764. Despite similar demographic and clinical caractheristics, PICC group showed a significantly higher rate of DVT than ST-CVC group (27.2% vs 9.6%; P < 0.01).” We regret any inconvenience that this inaccuracy may have caused.

The purpose of this study is to describe a single institutional experience in diagnosis and management of patients with blunt cerebrovascular injury (BCVI) after severe traumatic brain injury (TBI).

Gastric emptying is often delayed in major trauma patients. These patients are at risk of regurgitation and aspiration during rapid sequence induction or during coma. We hypothesized that an early naso-gastric tube (NGT) would reduce the gastric residuals. We also checked whether gastric volume at admission was associated with aspiration pneumonia.

Venous thromboembolism (VTE) is a common complication after major trauma, and has a high rate of morbidity and mortality. However, racial disparities in incidence of as well as risk factors for VTE exist between Asian and western populations. The risks for VTE after major trauma in Japanese patients remain unknown. Our objective was to identify risk factors for VTE after severe blunt trauma in Japanese patients.

International guidelines for trauma care still recommend the traditional advanced trauma life support investigations for the primary survey: plain radiographs of the chest, cervical spine and pelvis with FAST ultrasounds. However, an increasing amount of data suggest that plain X-rays have excessively low sensitivity. Cervical X-ray may miss up to 35% of the spine injuries, chest X-ray may miss as many as many as 50% of traumatic pneumothorax and a significant percentage of pelvic fractures may not be detected on the pelvis X-ray. CT scan and extended emergency ultrasound (EUs) have a much higher sensitivity if compared with plain X-rays. Moreover, EUs is even less time consuming. Therefore since 2004 we have adopted EUs and/or total body CT scan as the first-line diagnostic tools for major trauma (MT) victims. In a benchmarking analysis of Italian trauma centers (TCs), our hospital ranked first for patient mortality and long-term disability [1]. These results were associated with the shortest diagnostic time. The aim of this study is to assess whether these results were associated with a real change in the diagnostic process.

The aim of the study was to relate the health-related quality of life (HRQL) evaluated 6 months after major trauma and traumatic brain injury with the initial parameters of clinical picture and with the length of ICU stay and sedation. HQRL is reduced in ICU patients, admitted for any reason, after 6 months from discharge [1,2]. The summarized Short-Form 36 (SF-36), comprehending physical functioning, general health, and social functioning, is useful to evaluate HQRL after major trauma [3].

The aim of the present study was to evaluate the mortality prediction power of central venous oxygen saturation (ScVO2) in critically ill patients suffering from major trauma and head trauma.

ICU injured patients often experience a condition of tissue hypoperfusion due to low cardiac output and oxygen delivery (DO2). The imbalance between oxygen demand and DO2 could be responsible for an anaerobic metabolism that is correlated with poor outcome. Several authors demonstrated that traditional (that is, serum lactate, base deficit) and oxygen-derived and carbon dioxide-derived parameters of anaerobiosis are helpful indicators of bad outcome in trauma patients. We aimed to identify predictors of morbidity in our ICU trauma patients.

Early identification of patients who are not fully resuscitated following major trauma improves outcome. However, current markers of clinically occult hypoperfusion, such as lactate and base deficit, have serious limitations, and our aim was to establish a new endpoint of resuscitation.

Current markers of occult hypoperfusion following major trauma have serious limitations. Our aim was to evaluate oxygen extraction as a resuscitation endpoint, and predictor of organ failure and mortality following trauma.

Damage control orthopedics (DCO) is a reviewed concept used in major trauma. Advances in critical care management enable surgical stabilization in the early phase of trauma care. Logistical organization and accessibility to several therapeutic solutions can influence a physician's decisions regarding a trauma patient. The aim of this study is to investigate whether the timing of surgery and method of stabilization in trauma patients with femoral fracture can influence the incidence of pulmonary complication, MOF and the length of stay in the ICU.

Major trauma is accompanied by a marked inflammatory reaction that involves infiltration of blood polymorphonuclear leucocytes (PMNs) into the injured area. This process is dynamic and evolves rapidly over the first 24–72 hours after injury. Activated PMNs can contribute to tissue damage by release of oxygen radicals, proteolytic enzymes and proinflammatory cytokines. The acute respiratory distress syndrome (ARDS) that occurs early after major trauma is characterized by a neutrophil infiltrate within the lungs. Also the inflammation, in response to brain injury, involves infiltration of neutrophils into the injured brain parenchyma.

Trauma is the major cause of death for people younger than 40 years in developed counties. In Italy an incidence of 120 deaths per 100,000 inhabitants for trauma is reported. An efficient emergency medical response system (EMRS) must therefore be assured in order to provide adequate treatment on the scene and allow a quick rescue to a referral hospital centre.

This prospective study examines the efficacy of the predicting power for mortality of two different prehospital scoring systems in major trauma. We present an improved MEES in combination with capnometry. MEES combined with capnometry (MEESc) is a new scoring system.

Uncontrolled abdominal abscess after major trauma or surgery easily makes a patient septic condition. It is important but difficult to aspirate mucinous purulent abdominal fluid effectively and to keep the abscess cavity dry for prevention of abdominal sepsis. Formerly, we use double luminal tube, which we use usually as nasogastric tube with low negative pressure. However we could not keep the condition of the infectious space dry by this technique.

Road accidents are the leading cause of death for young people, 50% being represented by vulnerable road users (VRU) (pedestrians, cyclists). In-depth accident studies assess the consequences of lack of use of safety devices and the need to develop new ones. Since 2009 a permanent team (physicians and engineers) has performed in-depth studies on road trauma admitted to our ICU [1].

Introduction: Major trauma is characterized by an overwhelming pro-inflammatory response and an accompanying anti-inflammatory response that lead to a state of immunosuppression, as observed after septic shock. Diminished monocyte Human Leukocyte Antigen DR (mHLA-DR) is a reliable marker of monocyte dysfunction and immunosuppression. The main objective of this study was to determine the relation between mHLA-DR expression in severe trauma patients and the development of sepsis. Methods: We conducted a prospective observational study over 23 months in a trauma intensive care unit at a university hospital. Patients with an Injury Severity Score (ISS) over 25 and age over 18 were included. mHLA-DR was assessed by flow cytometry protocol according to standardized protocol. Mann-Whitney U-test for continuous non-parametric variables, independent paired t test for continuous parametric variables and chi-square test for categorical data were used. Results: mHLA-DR was measured three times a week during the first 14 days. One hundred five consecutive severely injured patients were monitored (ISS 38 ± 17, SAPS II 37 ± 16). Thirty-seven patients (35%) developed sepsis over the 14 days post-trauma. At days 1-2, mHLA-DR was diminished in the whole patient population, with no difference with the development of sepsis. At days 3-4, a highly significant difference appeared between septic and non-septic patients. Non- septic patients showed an increase in mHLA-DR levels, whereas septic patients did not (13,723 ± 7,766 versus 9,271 ± 6,029 antibodies per cell, p = .004). Most importantly, multivariate logistic regression analysis, after adjustment for usual clinical confounders (adjusted OR 5.41, 95% CI 1.42-20.52), revealed that a slope of mHLA-DR expression between days1-2 and days 3-4 below 1.2 remained associated with the development of sepsis. Conclusions: Major trauma induced an immunosuppression, characterized by a decrease in mHLA-DR expression. Importantly, after multivariate regression logistic analysis, persistent decreased expression was assessed to be in relation with the development of sepsis. This is the first study in trauma patients showing a link between the lack of immune recovery and the development of sepsis on the basis of the standardized protocol. Monitoring immune function by mHLA-DR measurement could be useful to identify trauma patients at a high risk of infection.

SCOPUS: re.j, info:eu-repo/semantics/published