1. Association of Early Norepinephrine Administration With 24-Hour Mortality Among Patients With Blunt Trauma and Hemorrhagic Shock
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Gauss, Tobias, Richards, Justin, Tortù, Costanza, Ageron, François-Xavier, Hamada, Sophie, Josse, Julie, Husson, François, Harrois, Anatole, Scalea, Thomas, Vivant, Valentin, Meaudre, Eric, Morrison, Jonathan, Galvagno, Samue, Bouzat, Pierre, Albasini, François, Briot, Olivier, Chaboud, Laurent, Chateigner Coelsch, Sophie, Chaumat, Alexandre, Comlar, Thomas, Debas, Olivier, Debaty, Guillaume, Dupré-Nalet, Emmanuelle, Gay, Samuel, Ginestie, Edouard, Girard, Edouard, Grèze, Jules, Haesevoets, Marc, Hallain, Marie, Haller, Etienne, Hoareau, Christophe, Lanaspre, Bernard, Lespinasse, Safia, Levrat, Albrice, Mermillod-Blondin, Romain, Nicoud, Philippe, Rancurel, Elisabeth, Thouret, Jean-Marc, Vallenet, Claire, Vallot, Cécile, Zerr, Bénédicte, Abback, Paér-Sélim, Audibert, Gérard, Boutonnet, Mathieu, Clavier, Thomas, Cook, Fabrice, Eljamri, Mohamed, Floch, Thierry, Gaertner, Elisabeth, Garrigue, Delphine, Geeraerts, Thomas, Gette, Sebastien, Godier, Anne, Gosset, Pierre, Hanouz, Jean-Luc, Moyer, Jean-Denis, Langeron, Olivier, Leone, Marc, Pottecher, Julien, Portaz, Jonathan, Raux, Mathieu, Scotto, Marion, Willig, Mathieu, Hardy, Alexia, French Trauma Research Initiative, Albasini, F., Briot, O., Chaboud, L., Chateigner Coelsch, S., Chaumat, A., Comlar, T., Debas, O., Debaty, G., Dupré-Nalet, E., Gay, S., Ginestie, E., Girard, E., Grèze, J., Haesevoets, M., Hallain, M., Haller, E., Hoareau, C., Lanaspre, B., Lespinasse, S., Levrat, A., Mermillod-Blondin, R., Nicoud, P., Rancurel, E., Thouret, J.M., Vallenet, C., Vallot, C., Zerr, B., Abback, P.S., Audibert, G., Boutonnet, M., Clavier, T., Cook, F., Eljamri, M., Floch, T., Gaertner, E., Garrigue, D., Geeraerts, T., Gette, S., Godier, A., Gosset, P., Hanouz, J.L., Moyer, J.D., Langeron, O., Leone, M., Pottecher, J., Portaz, J., Raux, M., Scotto, M., Willig, M., Hardy, A., Hôpital Beaujon [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Hôpital d'Annecy, Centre de recherche en épidémiologie et santé des populations (CESP), Université de Versailles Saint-Quentin-en-Yvelines (UVSQ)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Paul Brousse-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris-Saclay, Inria-SIC [Sophia Antipolis], Inria Sophia Antipolis - Méditerranée (CRISAM), Institut National de Recherche en Informatique et en Automatique (Inria)-Institut National de Recherche en Informatique et en Automatique (Inria), Institut Desbrest de santé publique (IDESP), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Montpellier (UM), Médecine de précision par intégration de données et inférence causale (PREMEDICAL), Institut National de Recherche en Informatique et en Automatique (Inria)-Institut National de Recherche en Informatique et en Automatique (Inria)-Institut Desbrest de santé publique (IDESP), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Montpellier (UM)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Montpellier (UM), Institut de Recherche Mathématique de Rennes (IRMAR), Université de Rennes (UR)-Institut National des Sciences Appliquées - Rennes (INSA Rennes), Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-École normale supérieure - Rennes (ENS Rennes)-Université de Rennes 2 (UR2)-Centre National de la Recherche Scientifique (CNRS)-Institut Agro Rennes Angers, Institut national d'enseignement supérieur pour l'agriculture, l'alimentation et l'environnement (Institut Agro)-Institut national d'enseignement supérieur pour l'agriculture, l'alimentation et l'environnement (Institut Agro), Hôpital Bicêtre, Université Paris-Saclay, Hôpital d'Instruction des Armées Sainte Anne, Service de Santé des Armées, École du Val de Grâce (EVDG), CHU Grenoble, [GIN] Grenoble Institut des Neurosciences (GIN), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Grenoble Alpes (UGA), Hopital Saint-Jean-de-Maurienne, Laboratoire Charles Coulomb (L2C), Centre National de la Recherche Scientifique (CNRS)-Université de Montpellier (UM), and ANR-11-LABX-0020,LEBESGUE,Centre de Mathématiques Henri Lebesgue : fondements, interactions, applications et Formation(2011)
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Male ,Norepinephrine ,[MATH.MATH-ST]Mathematics [math]/Statistics [math.ST] ,Humans ,Hemorrhage ,General Medicine ,Middle Aged ,Shock, Hemorrhagic ,Wounds, Nonpenetrating ,Hemorrhage/drug therapy ,Norepinephrine/therapeutic use ,Retrospective Studies ,Shock, Hemorrhagic/drug therapy ,Wounds, Nonpenetrating/complications ,Wounds, Nonpenetrating/drug therapy - Abstract
ImportanceHemorrhagic shock is a common cause of preventable death after injury. Vasopressor administration for patients with blunt trauma and hemorrhagic shock is often discouraged.ObjectiveTo evaluate the association of early norepinephrine administration with 24-hour mortality among patients with blunt trauma and hemorrhagic shock.Design, Setting, and ParticipantsThis retrospective, multicenter, observational cohort study used data from 3 registries in the US and France on all consecutive patients with blunt trauma from January 1, 2013, to December 31, 2018. Patients were alive on admission with hemorrhagic shock, defined by prehospital or admission systolic blood pressure less than 100 mm Hg and evidence of hemorrhage (ie, prehospital or resuscitation room transfusion of packed red blood cells, receipt of emergency treatment for hemorrhage control, transfusion of >10 units of packed red blood cells in the first 24 hours, or death from hemorrhage). Blunt trauma was defined as any exposure to nonpenetrating kinetic energy, collision, or deceleration. Statistical analysis was performed from January 15, 2021, to February 22, 2022.ExposureContinuous administration of norepinephrine in the prehospital environment or resuscitation room prior to hemorrhage control, according to European guidelines.Main Outcomes and MeasuresThe primary outcome was 24-hour mortality, and the secondary outcome was in-hospital mortality. The average treatment effect (ATE) of early norepinephrine administration on 24-hour mortality was estimated according to the Rubin causal model. Inverse propensity score weighting and the doubly robust approach with 5 distinct analytical strategies were used to determine the ATE.ResultsA total of 52 568 patients were screened for inclusion, and 2164 patients (1508 men [70%]; mean [SD] age, 46 [19] years; median Injury Severity Score, 29 [IQR, 17-36]) presented with acute hemorrhage and were included. A total of 1497 patients (69.1%) required emergency hemorrhage control, 128 (5.9%) received a prehospital transfusion of packed red blood cells, and 543 (25.0%) received a massive transfusion. Norepinephrine was administered to 1498 patients (69.2%). The 24-hour mortality rate was 17.8% (385 of 2164), and the in-hospital mortality rate was 35.6% (770 of 2164). None of the 5 analytical strategies suggested any statistically significant association between norepinephrine administration and 24-hour mortality, with ATEs ranging from –4.6 (95% CI, –11.9 to 2.7) to 2.1 (95% CI, –2.1 to 6.3), or between norepinephrine administration and in-hospital mortality, with ATEs ranging from –1.3 (95% CI, –9.5 to 6.9) to 5.3 (95% CI, –2.1 to 12.8).Conclusions and RelevanceThe findings of this study suggest that early norepinephrine infusion was not associated with 24-hour or in-hospital mortality among patients with blunt trauma and hemorrhagic shock. Randomized clinical trials that study the effect of early norepinephrine administration among patients with trauma and hypotension are warranted to further assess whether norepinephrine is safe for patients with hemorrhagic shock.
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- 2022