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The Epidemiology of Chronic Critical Illness After Severe Traumatic Injury at Two Level–One Trauma Centers*

Mira, Juan C. MD1; Cuschieri, Joseph MD2; Ozrazgat-Baslanti, Tezcan PhD3; Wang, Zhongkai MS4; Ghita, Gabriela L. MPH4; Loftus, Tyler J. MD1; Stortz, Julie A. MD1; Raymond, Steven L. MD1; Lanz, Jennifer D. ARNP1; Hennessy, Laura V. RN2; Brumback, Babette PhD4; Efron, Philip A. MD, FCCM1; Baker, Henry V. PhD5; Moore, Frederick A. MD, MCCM1; Maier, Ronald V. MD2; Moldawer, Lyle L. PhD1; Brakenridge, Scott C. MD1

doi: 10.1097/CCM.0000000000002697
Clinical Investigations
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SDC

Objective: To determine the incidence and risk factors of chronic critical illness after severe blunt trauma.

Design: Prospective observational cohort study (NCT01810328).

Setting: Two level–one trauma centers in the United States.

Patients: One hundred thirty-five adult blunt trauma patients with hemorrhagic shock who survived beyond 48 hours after injury.

Interventions: None.

Measurements and Main Results: Chronic critical illness was defined as an ICU stay lasting 14 days or more with evidence of persistent organ dysfunction. Three subjects (2%) died within the first 7 days, 107 (79%) exhibited rapid recovery and 25 (19%) progressed to chronic critical illness. Patients who developed chronic critical illness were older (55 vs 44-year-old; p = 0.01), had more severe shock (base deficit, –9.2 vs –5.5; p = 0.005), greater organ failure severity (Denver multiple organ failure score, 3.5 ± 2.4 vs 0.8 ± 1.1; p < 0.0001) and developed more infectious complications (84% vs 35%; p < 0.0001). Chronic critical illness patients were more likely to be discharged to a long-term care setting (56% vs 34%; p = 0.008) than to a rehabilitation facility/home. At 4 months, chronic critical illness patients had higher mortality (16.0% vs 1.9%; p < 0.05), with survivors scoring lower in general health measures (p < 0.005). Multivariate analysis revealed age greater than or equal to 55 years, systolic hypotension less than or equal to 70 mm Hg, transfusion greater than or equal to 5 units packed red blood cells within 24 hours, and Denver multiple organ failure score at 72 hours as independent predictors of chronic critical illness (area under the receiver operating curve, 0.87; 95% CI, 0.75–0.95).

Conclusions: Although early mortality is low after severe trauma, chronic critical illness is a common trajectory in survivors and is associated with poor long-term outcomes. Advancing age, shock severity, and persistent organ dysfunction are predictive of chronic critical illness. Early identification may facilitate targeted interventions to change the trajectory of this morbid phenotype.

1Department of Surgery, University of Florida College of Medicine, Gainesville, FL.

2Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA.

3Department of Medicine, University of Florida College of Medicine, Gainesville, FL.

4Department of Biostatistics, University of Florida College of Medicine, Gainesville, FL.

5Department of Molecular Genetics and Microbiology, University of Florida College of Medicine, Gainesville, FL.

*See also p. 2104.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported, in part, by grants: R01 GM-104481 and R01 GM-040586 (LLM), R01 GM-113945 (PAE), and P50 GM-111152 (P.A.E., F.A.M., L.L.M., S.C.B.) awarded by the National Institute of General Medical Sciences (NIGMS), and by a postgraduate training grant T32 GM-008721 (J.C.M., T.J.L., J.A.S.) in burns, trauma, and perioperative injury by the NIGMS. The funding agency had no role in study design, data collection and analysis, decision to publish, or preparation of the article, and the conclusions put forth do not necessarily represent the views of the N.I.H., U.S.P.H.S.

Drs. Mira, Cuschieri, Ozrazgat-Baslanti, Mr. Wang, Drs. Loftus, Stortz, Raymond, Ms. Lanz, Ms. Hennessy, Drs. Brumback, Efron, Moore, Maier, Moldawer, and Brakenridge received support for article research from the National Institutes of Health (NIH). Dr. Ozrazgat-Baslanti’s institution received funding from National Institute of General Medical Sciences (NIGMS). Mr. Wang’s institution received funding from the NIH. Dr. Loftus’s institution received funding from the NIH. Dr. Raymond’s institution received support from the NIGMS. Ms. Lanz’s institution received funding from the NIH. Ms. Hennessy’s institution received funding from the NIH. Dr. Brumback’s institution received funding from the NIH, and she received funding from Biogen. Dr. Moore’s institution received funding from the NIH. Dr. Maier’s institution received funding from the NIH/NIGMS. Dr. Moldawer’s institution received funding from the NIGMS. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: Scott.Brakenridge@surgery.ufl.edu

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