Prediction of sepsis in the burn intensive care unit patient

Sepsis is a significant cause for multiple organ failure and death in the burn patient, yet identification in this population is confounded by chronic hypermetabolism and impaired immune function. The purpose of this study was twofold: 1) determine the ability of the systemic inflammatory response syndrome (SIRS) and American Burn Association (ABA) criteria to predict sepsis in the burn patient; and 2) develop a model representing the best combination of clinical predictors associated with sepsis in the same population. A retrospective, case-controlled, within-patient comparison of burn patients admitted to a single intensive care unit (ICU) was conducted for the period January 2005 to September 2010. Blood culture results were paired with clinical condition: positive-sick ; negative-sick , and screening-not sick . Data were collected for the 72 hours prior to each blood culture. The most significant predictors were evaluated using logistic regression, Generalized Estimating Equations (GEE) and ROC area under the curve (AUC) analyses to assess model predictive ability. Bootstrapping methods were employed to evaluate potential model over-fitting. Fifty-nine subjects were included, representing 177 culture periods. SIRS criteria were not found to be associated with culture type, with an average of 98% of subjects meeting criteria in the 3 days prior. ABA sepsis criteria were significantly different among culture type only on the day prior (p = 0.004). The variables identified for the model included: heart rate\u3e130 beats/min, mean blood pressure\u3c60 mmHg, base deficit\u3c-6 mEq/L, temperature\u3e36°C, use of vasoactive medications, and glucose\u3e150 mg/d1. The model was significant in predicting positive culture-sick and sepsis state, with AUC of 0.775 (p \u3c 0.001) and 0.714 (p \u3c .001), respectively; comparatively, the ABA criteria AUC was 0.619 (p = 0.028) and 0.597 (p = .035), respectively. SIRS criteria are not appropriate for identifying sepsis in the burn population. The ABA criteria perform better, but only for the day prior to positive blood culture results. The time period useful to diagnose sepsis using clinical criteria may be limited to 24 hours. A combination of predictors is superior to individual variable trends, yet algorithms or computer support will be necessary for the clinician to find such models useful

A US military Role 2 forward surgical team database study of combat mortality in Afghanistan.

BACKGROUND: Timely and optimal care can reduce mortality among critically injured combat casualties. US military Role 2 surgical teams were deployed to forward positions in Afghanistan on behalf of the battlefield trauma system. They received prehospital casualties, provided early damage control resuscitation and surgery, and rapidly transferred casualties to Role 3 hospitals for definitive care. A database was developed to capture Role 2 data. METHODS: A retrospective review and descriptive analysis were conducted of battle-injured casualties transported to US Role 2 surgical facilities in Afghanistan from February 2008 to September 2014. Casualties were analyzed by mortality status and location of death (pretransport, intratransport, or posttransport), military affiliation, transport time, injury type and mechanism, combat mortality index-prehospital (CMI-PH), and documented prehospital treatment. RESULTS: Of 9,557 casualties (median age, 25.0 years; male, 97.4%), most (95.1%) survived to transfer from Role 2 facility care. Military affiliation included US coalition forces (37.4%), Afghanistan National Security Forces (23.8%), civilian/other forces (21.3%), Afghanistan National Police (13.5%), and non-US coalition forces (4.0%). Mortality differed by military affiliation (p \u3c 0.001). Among fatalities, most were Afghanistan National Security Forces (30.5%) civilian/other forces (26.0%), or US coalition forces (25.2%). Of those categorized by CMI-PH, 40.0% of critical, 11.2% of severe, 0.8% of moderate, and less than 0.1% of mild casualties died. Most fatalities with CMI-PH were categorized as critical (66.3%) or severe (25.9%), whereas most who lived were mild (56.9%) or moderate (25.4%). Of all fatalities, 14.0% died prehospital (pretransport, 5.8%; intratransport, 8.2%), and 86.0% died at a Role 2 facility (posttransport). Of fatalities with documented transport times (median, 53.0 minutes), most (61.7%) were evacuated within 60 minutes. CONCLUSIONS: Role 2 surgical team care has been an important early component of the battlefield trauma system in Afghanistan. Combat casualty care must be documented, collected, and analyzed for outcomes and trends to improve performance. LEVEL OF EVIDENCE: Therapeutic/Care Management, level IV