Gordon Fuller1, Rebecca M Hasler2, Nicole Mealing3, Thomas Lawrence4, Maralyn Woodford4, Peter Juni3, Fiona Lecky5. 1. Trauma Audit and Research Network, Health Sciences Research Group, Manchester Academic Health Sciences Centre, Mayo Building, Salford Royal Hospital, Eccles Old Road, Salford M6 8HD, UK. Electronic address: gordonwfuller@doctors.net.uk. 2. Department of Emergency Medicine, University Hospital Bern, Freiburgstr, 3010 Bern, Switzerland. 3. Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland. 4. Trauma Audit and Research Network, Health Sciences Research Group, Manchester Academic Health Sciences Centre, Mayo Building, Salford Royal Hospital, Eccles Old Road, Salford M6 8HD, UK. 5. School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
Abstract
INTRODUCTION: Low systolic blood pressure (SBP) is an important secondary insult following traumatic brain injury (TBI), but its exact relationship with outcome is not well characterised. Although a SBP of <90 mmHg represents the threshold for hypotension in consensus TBI treatment guidelines, recent studies suggest redefining hypotension at higher levels. This study therefore aimed to fully characterise the association between admission SBP and mortality to further inform resuscitation endpoints. METHODS: We conducted a multicentre cohort study using data from the largest European trauma registry. Consecutive adult patients with AIS head scores >2 admitted directly to specialist neuroscience centres between 2005 and July 2012 were studied. Multilevel logistic regression models were developed to examine the association between admission SBP and 30 day inpatient mortality. Models were adjusted for confounders including age, severity of injury, and to account for differential quality of hospital care. RESULTS: 5057 patients were included in complete case analyses. Admission SBP demonstrated a smooth u-shaped association with outcome in a bivariate analysis, with increasing mortality at both lower and higher values, and no evidence of any threshold effect. Adjusting for confounding slightly attenuated the association between mortality and SBP at levels <120 mmHg, and abolished the relationship for higher SBP values. Case-mix adjusted odds of death were 1.5 times greater at <120 mmHg, doubled at <100 mmHg, tripled at <90 mmHg, and six times greater at SBP<70 mmHg, p<0.01. CONCLUSIONS: These findings indicate that TBI studies should model SBP as a continuous variable and may suggest that current TBI treatment guidelines, using a cut-off for hypotension at SBP<90 mmHg, should be reconsidered.
INTRODUCTION: Low systolic blood pressure (SBP) is an important secondary insult following traumatic brain injury (TBI), but its exact relationship with outcome is not well characterised. Although a SBP of <90 mmHg represents the threshold for hypotension in consensus TBI treatment guidelines, recent studies suggest redefining hypotension at higher levels. This study therefore aimed to fully characterise the association between admission SBP and mortality to further inform resuscitation endpoints. METHODS: We conducted a multicentre cohort study using data from the largest European trauma registry. Consecutive adult patients with AIS head scores >2 admitted directly to specialist neuroscience centres between 2005 and July 2012 were studied. Multilevel logistic regression models were developed to examine the association between admission SBP and 30 day inpatient mortality. Models were adjusted for confounders including age, severity of injury, and to account for differential quality of hospital care. RESULTS: 5057 patients were included in complete case analyses. Admission SBP demonstrated a smooth u-shaped association with outcome in a bivariate analysis, with increasing mortality at both lower and higher values, and no evidence of any threshold effect. Adjusting for confounding slightly attenuated the association between mortality and SBP at levels <120 mmHg, and abolished the relationship for higher SBP values. Case-mix adjusted odds of death were 1.5 times greater at <120 mmHg, doubled at <100 mmHg, tripled at <90 mmHg, and six times greater at SBP<70 mmHg, p<0.01. CONCLUSIONS: These findings indicate that TBI studies should model SBP as a continuous variable and may suggest that current TBI treatment guidelines, using a cut-off for hypotension at SBP<90 mmHg, should be reconsidered.
Authors: M Austin Johnson; Timothy K Williams; Sarah-Ashley E Ferencz; Anders J Davidson; Rachel M Russo; William T O'Brien; Joseph M Galante; J Kevin Grayson; Lucas P Neff Journal: J Trauma Acute Care Surg Date: 2017-07 Impact factor: 3.313
Authors: Jonathan Marehbian; Susanne Muehlschlegel; Brian L Edlow; Holly E Hinson; David Y Hwang Journal: Neurocrit Care Date: 2017-12 Impact factor: 3.210
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