Association of low non-invasive near-infrared spectroscopic measurements during initial trauma resuscitation with future development of multiple organ dysfunction

doi:10.5847/wjem.j.1920-8642.2015.02.004

Abstract

Abstract:

BACKGROUND: Near-infrared spectroscopy (NIRS) non-invasively monitors muscle tissue oxygen saturation (StO₂). It may provide a continuous noninvasive measurement to identify occult hypoperfusion, guide resuscitation, and predict the development of multiple organ dysfunction (MOD) after severe trauma. We evaluated the correlation between initial StO₂ and the development of MOD in multi-trauma patients.
METHODS: Patients presenting to our urban, academic, Level I Trauma Center/Emergency Department and meeting standardized trauma-team activation criteria were enrolled in this prospective trial. NIRS monitoring was initiated immediately on arrival with collection of StO₂ at the thenar eminence and continued up to 24 hours for those admitted to the Trauma Intensive Care Unit (TICU). Standardized resuscitation laboratory measures and clinical evaluation tools were collected. The primary outcome was the association between initial StO₂ and the development of MOD within the first 24 hours based on a MOD score of 6 or greater. Descriptive statistical analyses were performed; numeric means, multivariate regression and rank sum comparisons were utilized. Clinicians were blinded from the StO₂ values.
RESULTS: Over a 14 month period, 78 patients were enrolled. Mean age was 40.9 years (SD 18.2), 84.4% were male, 76.9% had a blunt trauma mechanism and mean injury severity score (ISS) was 18.5 (SD 12.9). Of the 78 patients, 26 (33.3%) developed MOD within the first 24 hours. The MOD patients had mean initial StO₂ values of 53.3 (SD 10.3), significantly lower than those of non-MOD patients 61.1 (SD 10.0); P=0.002. The mean ISS among MOD patients was 29.9 (SD 11.5), significantly higher than that of non-MODS patients, 12.1 (SD 9.1) (P<0.0001). The mean shock index (SI) among MOD patients was 0.92 (SD 0.28), also significantly higher than that of non-MODS patients, 0.73 (SD 0.19) (P=0.0007). Lactate values were not significantly different between groups.
CONCLUSION: Non-invasive, continuous StO₂ near-infrared spectroscopy values during initial trauma resuscitation correlate with the later development of multiple organ dysfunction in this patient population.

Key words: Near-infrared spectroscopy, Multiple organ dysfunction, Injury severity score, Shock index, Lactate

Bret A. Nicks, Kevin M. Campos, William P. Bozeman. Association of low non-invasive near-infrared spectroscopic measurements during initial trauma resuscitation with future development of multiple organ dysfunction[J]. World Journal of Emergency Medicine, 2015, 6(2): 105-110.

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References 32

1	Parks JK, Elliott AC, Gentilello LM, Shafi S. Systemic hypotension is a late marker of shock after trauma: a validation study of Advanced Trauma Life Support principles in a large national sample. Am J Surg 2006; 192:727-731. doi: 10.1016/j.amjsurg.2006.08.034 pmid: 17161083
2	Millham FH, LaMorte WW. Factors associated with mortality in trauma: re-evaulation of the TRISS method using the National Trauma Data Bank. J Trauma 2004; 56:1090-1096. pmid: 15179251
3	Vassar MJ, Lewis FR Jr, Chambers JA, Mullins RJ, O'Brien PE, Weigelt JA, et al. Prediction of outcome in intensive care unit trauma patients: a multicenter study of Acute Physiology and Chronic Health Evaluation (APACHE), Trauma and Injury Severity Score (TRISS), and a 24-hour intensive care unit (ICU) point system. J Trauma 1999; 47:324-329. doi: 10.1097/00005373-199908000-00017 pmid: 10452468
4	Gando S, Nanzaki S, Kemmotsu O. Disseminated intravascular coagulation and sustained systemic inflammatory response syndrome predict organ dysfunctions after trauma: application of clinical decision analysis. Ann Surg 1999; 229:121-127.
5	Graham CA, Parke TR. Critical care in the emergency department: shock and circulatory support. Emerg Med J 2005; 22:17-21. pmid: 15611535
6	Siegel JH, Fabian M, Smith JA, Kingston EP, Steele KA, Wells MR, et al. Oxygen debt criteria quantify the effectiveness of early partial resuscitation after hypovolemic hemorrhagic shock. J Trauma 2003; 54:862-880. doi: 10.1097/01.TA.0000066186.97206.39
7	Tuhay G, Pein MC, Masevicius FD, Kutscherauer DO, Dubin A. Severe hyperlactatemia with normal base excess: a quantitative analysis using conventional and Stewart approaches. Crit Care 2008; 12:R66. pmid: 18466618
8	Puyana JC, Pinsky MR. Searching for non-invasive markers of tissue hypoxia. Crit Care 2007; 11:R6. doi: 10.1186/cc5153 pmid: 17227587
9	The ProCESS Investigators. A Randomized Trial of Protocol-Based Care for Early Septic Shock. N Engl J Med 2014; 370:1683-1693. pmid: 24635773
10	Marshall JC, Cook DJ, Christou NV, Bernard GR, Sprung CL, Sibbald WJ. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med 1995; 23:1638-1652. doi: 10.1097/00003246-199510000-00007 pmid: 7587228
11	Hirano Y, Omura K, Yoshiba H, Ohta N, Hiranuma C, Nitta K, et al. Near-infrared spectroscopy for assessment of tissue oxygen saturation of transplanted jejuna autografts in cervical esophageal reconstruction. Surg Today 2005; 35:67-72.
12	Rapez A, Oroszy D, Amez ZM. Continuous postoperative monitoring of cutaneous free flaps using near infrared spectroscopy. J Plast Reconstr Aesthet Surg 2008; 61:71-77. pmid: 17532278
13	Arbabi S, Brundage SI, Gentilello LM. Near-infrared spectroscopy: a potential method for continuous, trancutaneous monitoring for compartmental syndrome in critically injured patients. J Trauma 1999; 47:829-833.
14	Creteur J. Muscle StO₂ in critically ill patients. Curr Opin Crit Care 2008; 14:361-366. pmid: 18467900
15	Uilkema RJ, Groeneveld AB. Correlates of thenar near-infrared spectroscopy-derived tissue O₂ saturation after cardiac surgery. Interact Cardiovasc Thorac Surg 2007; 6:265-269. pmid: 17669839
16	Ikossi DG, Knudson MM, Morabito DJ, Cohen MJ, Wan JJ, Khaw L, et al. Continuous muscle tissue oxygenation in critically injured patients: a prospective observational study. J Trauma 2006; 61:780-788. pmid: 17033541
17	Cohn SM, Crookes BA, Procter KG. Near-infrared spectroscopy in resuscitation. J Trauma 2003; 54:S199-S202. pmid: 12768125
18	Smith J, Bricker S, Putnam B. Tissue oxygen saturation predicts the need for early blood transfusion in trauma patients. Am Surg 2008; 74:1006-1011. pmid: 18942633
19	Cohn SM, Nathens AB, Moore FA, Rhee P, Puyana JC, Moore EE, et al. Tissue oxygen saturation predicts development of organ dysfunction during traumatic shock resuscitation. J Trauma 2007; 62:44-55. doi: 10.1097/TA.0b013e31802eb817 pmid: 17215732
20	Crookes BA, Cohn SM, Bloch S, Amortegui J, Manning R, Li P, et al. Can near-infrared spectroscopy identify the severity of shock in trauma patients? J Trauma 2005; 58:806-813. doi: 10.1097/01.ta.0000158269.68409.1c pmid: 15824660
21	Miner J, Nelson R, Hayden L. The effect of near infrared spectroscopy monitoring on the treatment of patients presenting to the emergency department in shock. Crit Care Med 2010; 38:S861.
22	Lima A, van Bommel J, Jansen TC, Ince C, Bakker J. Low tissue oxygen saturation at the end of early goal-directed therapy is associated with worse outcome in critically ill patients. Crit Care 2009; 13 Suppl 5: S13.
23	Iyegha UP, Conway T, Pokorney K, Mulier KE, Nelson TR, Beilman GJ. Low StO₂ measurement in surgical intensive care unit patients is associated with poor outcomes. J Trauma Acute Care Surg 2014; 76:809-816.
24	Jeger V, Jakob SM, Fontana S, Wolf M, Zimmermann H, Exadaktylos AK. 500 ml of blood loss does not decrease non-invasive tissue oxygen saturation (StO₂) as measured by near infrared spectroscopy - A hypothesis generating pilot study in healthy adult women. J Trauma Manag Outcomes 2010; 4:5. pmid: 20465822
25	Marshall JC. Organ dysfunction as a measure of outcome in clinical trials. Eur J Surg Suppl 1999; 584:62-67.
26	Buckley TA, Gomersall CD, Ramsay SJ. Validation of the multiple organ dysfunction (MOD) score in critically ill medical and surgical patients. Intensive Care Med 2003; 29:2216-2222. doi: 10.1007/s00134-003-2037-z pmid: 14566459
27	Ulvik A, Kvåle R, Wentzel-Larsen T, Flaatten H. Multiple organ failure after trauma affects even long-term survival and functional status. Crit Care 2007; 11:R95. pmid: 17784940
28	Santora RJ, Moore FA. Monitoring trauma and intensive care unit resuscitation with tissue hemoglobin oxygen saturation. Crit Care 2009; 13 Suppl 5: S10. Epub 2009 Nov 30.
29	Paladino L, Sinert R, Wallace D, Anderson T, Yadav K, Zehtabchi S. The utility of base deficit and arterial lactate in differentiating major from minor injury in trauma patients with normal vital signs. Resuscitation 2008; 77:363-368. doi: 10.1016/j.resuscitation.2008.01.022 pmid: 18367305
30	Callaway DW, Shapiro NI, Donnino MW, Baker C, Rosen CL. Serum lactate and base deficit as predictors of mortality in normotensive elderly blunt trauma patients. J Trauma 2009; 66:1040-1044. doi: 10.1097/TA.0b013e3181895e9e pmid: 19359912
31	Beekley AC, Martin MJ, Nelson T, Grathwohl KW, Griffith M, Beilman G, et al. Continuous noninvasive tissue oximetry in the early evaluation of the combat casualty: a prospective study. J Trauma 2010; 69 Suppl 1: S14-25.
32	Guyette FX, Gomez H, Suffoletto B, Quintero J, Mesquida J, Kim HK, et al. Prehospital dynamic tissue oxygen saturation response predicts in-hospital lifesaving interventions in trauma patients. J Trauma Acute Care Surg 2012; 72:930-935. pmid: 22491607

Parameters	Grade 0	Grade 1	Grade 2	Grade 3	Grade 4
Pulmonary PaO₂/FiO₂	>300	226-300	151-225	76-150	<75
Creatinine (μmol/L)	<100	101-200	201-350	351-500	>500
Total Bili (μmol/L)	<20	21-60	61-120	121-240	>240
CV (HR*CVP)/MAP	<10.0	10.1-15.0	15.1-20.0	20.1-30.0	>30.0
GCS	15	13-14	10-12	7-9	<6
Platelt count	>120	81-120	51-80	21-50	<20

Parameters	MOD	Non-MOD	Pvalue
Number	26	52
Age (years)	43±21 (18-92)	40±16 (18-82)	NS
Male gender	20 (77%)	46 (88%)	NS
Mechanism
Blunt	20 (77%)	42 (80%)	NS
Penetrating	6 (23%)	10 (22%)	NS
ISS	29.9±11.5	12.1±9.1	0.0001
Physio/Lab
Shock index	0.92±0.28	0.73±0.19	0.0007
Initial StO₂	53.3±10.3	61.1±10.0	0.002
Lactate (mmol/L)	3.5±1.6	2.8±2.3	0.168

Variables	Included	Excluded	Pvalue
Number	78	41
Age (years)	41±18 (18-92)	39±17 (18-83)	NS
Male gender	66 (85%)	33 (81%)	NS
EMS arrival	72 (92%)	38 (93%)	NS
Level 1 trauma	19 (24%)	11 (27%)
Mechanism
Blunt	62 (79%)	32 (78%)	NS
Penetrating	16 (21%)	9 (22%)	NS
ISS	18.3±9.9	19.2±9.1	NS
Physio/Lab
Shock index	0.79±0.22	0.80±0.17	NS
Initial StO₂	53.3±10.3	-	-
Lactate (mmol/L)	3.0±2.0	3.1±2.1	NS

Variables	StO₂	P value
Lactate (mmol/L)		0.001
<2.0	65.8±7.2
>4.0	51.4±11.2
Shock index		0.0001
≥1.0	48.1±10.9
<1.0	60.2±9.2

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