RU2613317C2 - Method for prediction of clinical outcome of traumatic disease acuity of elderly and senile patients with severe combined injury - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopaedics, and can be used for choosing therapeutic approach for elderly and senile patients with severe combined injury (polytrauma). Proposed method provides that a number of erythrocyte count (RBC) is determined in complex, haemoglobin level (HGB), total blood protein level, blood albumins and prothrombin time (PTT), corresponding number of points is assigned for each of the detected value of a blood sample, then points are multiplied by corresponding weight coefficient, derived points are summed, and if total score corresponds to 3÷4, very high degree of fatal outcome risk is determined, when the value is equal to 2÷2.9, high degree of fatal outcome risk is determined, when the value is equal to 1.2÷1.9, - average risk and when the total score of < 1.2 – low risk of fatal outcome risk. Determination of fatal outcome risk allows to optimize the therapeutic approach for a patient in accordance with dynamic control of damages, and namely, on receipt of the poor prognosis should refrain from surgery of the second and next surgical stages of damages dynamic control, and on receipt of the favorable prognosis for life surgeries of the second and next surgical stages can be performed.

EFFECT: such tactics allows to reduce death rate among elderly and senile patients with severe combined injury.

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Description

The proposed method relates to medicine, namely to traumatology and orthopedics, and can be used to select the tactics of treatment of elderly patients with severe combined trauma (polytrauma).

Predicting the outcome of an acute period of traumatic disease (TB) is an important problem in traumatology and orthopedics, allowing you to choose the patient’s treatment tactics and achieve a more successful treatment result and avoid complications that appear in subsequent periods of traumatic disease. Currently, in traumatology and orthopedics, there are several dozen scales for determining the severity of the injury (AIS / NISS, VPH-MT) (Gumanenko E.S., Boyarintsev V.V., Vashchenko V.V. Objective assessment of the severity of injuries. / / Military-medical journal, - 1996, - No. 10. - P. 25-34), as well as assessment of the condition of the victims (APACHE I-II-III, SAPS) (B. Lisenko, V. Sheiko. Assessing the severity of polytrauma with predicting the outcome of a traumatic disease. // Orthopedics and Traumatology 2000, - No. 1. P. 36-40). A large number of proposed scales for assessing the condition indicates the absence of a universal scale that can reliably assess the severity of the condition in patients of different age groups. In the available literature, work has been found to evaluate the effectiveness of the most commonly used scales, the vast majority of which are aimed at young and middle-aged patients, which is due to the greater likelihood of injury in this age due to a more active lifestyle, but in the last decade there has been a tendency to increase the number of patients with injuries of the elderly and senile age. This is due to both the general aging of the population and the increase in the number of elderly people who lead an active lifestyle.

A known method developed in the early 80's by a group of German doctors Oestern H.-J. et al., (Polytrauma Score [Hannover]) - Hannover polytrauma code based on a discriminant analysis of lesions in five anatomical areas (head, chest, abdomen, pelvis, limbs) based on age. Each type of damage (by anatomical areas) is scored. The sum of points in certain regions has four degrees of severity: I degree - 19 points (mortality forecast up to 10%), II degree - 20-34 points (up to 25%), III degree - 35-48 points (up to 50%), IV degree - above 49 points (up to 75%). The severity of polytrauma is determined by the sum of the severity points of individual injuries and the age score of the victim. This is the only way to predict death, which takes into account the age of the victim. This method allows you to make a prediction, based on the severity of the injury, and does not allow you to determine changes in the probability of a fatal outcome in the dynamics. The same scales that allow us to assess the dynamics of changes in state (APACHE II, III, SAPS) do not take into account the age-related characteristics of patients in older age groups. Despite the opinion of a number of authors of the APACHE II, III system they are the best for determining the condition of patients with injuries, it is nevertheless necessary to take into account the cumbersomeness of the ARACNE-II scale, the use of computer technology and special software, it is impossible to take into account all the necessary parameters during the period of dysfunction vital organs in the acute period of TB.

The closest method adopted for the closest analogue is the scale of relative stabilization of the state (SCO) (Blazhenko AN Abstract of dissertation for the degree of Doctor of Medical Sciences. - Moscow. - 2012. - P. 151-160), used in GBUZ NII-KKB No. 1 of the city of Krasnodar, for the decision to move from one stage of the dynamic damage control to the next. The scale includes the following clinical and physiological parameters that allow you to objectively assess the condition of the victim in the daily work of a multidisciplinary hospital:

- systolic blood pressure (SBP);

- heart rate (heart rate);

- hemogram (red blood cell count, blood hemoglobin concentration, hematocrit level);

- the level of saturation of arterial and venous blood with oxygen and carbon dioxide;

- blood pH indicators;

- the concentration of K ⁺ , Na ⁺ in blood plasma.

The assessment of the parameters taken into account by the HSS is carried out according to table 1.

Scoring characteristics that determine the patient’s condition in the acute period of polytrauma (the more stable the patient’s condition, the lower the total score scored on this scale):

- less than or equal to 5 points - the state is relatively stable;

- greater than or equal to 6 points - the condition of the victim is unstable.

When using this method, its lack of accuracy was revealed with respect to patients of older age groups, namely, patients died with a relatively favorable prognosis.

Thus, the need was identified for a method for reliably predicting the outcome of an acute period of traumatic disease in patients with polytrauma of the elderly and senile. A retrospective study was conducted of 150 case histories of patients with polytrauma, of which 95 were older patients, the control group consisted of patients with polytrauma aged 20 to 40 years - 55 people. The aim of the study was to determine the complex of laboratory parameters and the degree of their deviation from the norm, the changes of which most accurately correlate with the dynamics of the patients' condition, which make it possible to objectively substantiate the choice of treatment tactics at the stages of dynamic damage control. To analyze various biochemical parameters by the method of comparing hypotheses, two groups of patients were formed. Selection criteria for the first group: age over 60 years and an AIS / NISS indicator in the range from 17 to 57. Selection criteria for the second group: age no more than 60 years and an AIS / NISS indicator in the range 17 to 57. Age and AIS / NISS are shown in table No. 1. All patients were injured and were taken by ambulance within the first hour after receiving the injury.

The average age in group I was 69.2 years and with a high level was significantly (p <0.00001) different from the average age of 35.0 years in group II (distributions in the groups were close to normal and close in value of variances, therefore, the t-student criterion was used) (Fig. 1 - Distribution of age values in the compared groups).

The average value of the AIS / NISS index in group I was 29.9 points and did not differ from the average value of the AIS / NISS index equal to 28.3 points in group II (the distributions in the groups were far from the normal distribution law of numerical values, therefore, non-parametric Whitney-Manni test) (Fig. 2 - Distribution of AIS / NISS index values in the compared groups).

The sexual composition of the first group (n = 95) and the second group (n = 55) were analyzed. The relative shares of men and women in the studied groups were statistically the same (p = 0.8921> 0.05): in group I, the share of men was 51.6%, in group II - 52.7%, for women, respectively 48.4% and 47.3%. The comparison was carried out using the χ ² criterion (table. No. 2).

From the above it follows that the selection criteria (age and AIS / NISS index) in the formed groups correspond to the selection condition, and the gender composition in the groups is the same.

Compared the proportion of surviving patients in the compared groups (table. No. 3).

For group I, the proportion of surviving patients among all patients was 62.1% and with high reliability (p = 0.0004 <0.05) differed from the similar share in group II, equal to 89.0%.

In the first part of the study, an analysis was conducted comparing indicators of only the norm of adult age with detected deviations from the norm in the dead and surviving, elderly and young victims with polytrauma.

The statistical processing of clinical material was carried out using non-parametric methods, since the distributions in the groups of values of clinical analyzes were far from the normal distribution of numerical values, therefore, the non-parametric Z-score criterion proposed by WHO in 1978 was used.

Statistically significant results were recognized in which the value of χ ² calculated using the built-in function "CHI2TEST" was less than or equal to 0.05.

A retrospective analysis of changes in hemograms, indicators of biochemical blood tests, coagulograms, electrolytes and blood gases in surviving and dead patients in the study group (older than 60 years) and in control group No. 1 (adult patients aged 20-40 years without concomitant pathology) was performed .

In the process of analysis, laboratory research indicators were selected that most often and more significantly change the values at the treatment stages in patients older than 60 years.

Based on the analysis, it became possible to conclude that the following laboratory parameters of homeostasis correlate most significantly with treatment outcomes in patients over 60: RBC (the number of red blood cells in peripheral blood), HGB (hemoglobin level), the level of total protein and blood albumin , some indicators of the coagulogram (PTV), for other parameters of significant differences were obtained, the result is presented in table 5.

The values of the indicators presented in table 6 were also determined, which are characteristic for surviving patients, but differing from the norm.

In this way, we determined the intervals characteristic for a favorable and unfavorable prognosis for the lives of patients with severe combined trauma of the elderly and senile, the results are presented in table 7.

Further, the method of factor analysis revealed the mutual influence of both each of the indicators separately, and their combined influence on the forecast. For this, the sample of 95 patients (control group) was divided into subgroups based on the occurrence of the revealed changes in indicators and mortality in each subgroup was assessed. As a result, weights were determined for each of the indicators, the introduction of weights allowed us to comprehensively assess the risk of death, the result is presented in table 8.

Based on the results obtained, in 2014, 11 patients over the age of 60 were treated. When receiving an unfavorable prognosis, we refrained from performing operations of the second and subsequent surgical stages of the dynamic control of injuries, and with a favorable prognosis for life, we performed operations of the second and subsequent surgical stages and compared the mortality rate in the main group and the control group, the comparison result is presented in Table 9.

Testing the principle of objective criteria for assessing the state in the system of medical care for victims with polytrauma showed an improvement in treatment outcomes with a decrease in mortality by 10.6%.

The essence of the method for predicting the outcome of the acute period of traumatic disease in patients with polytrauma of the elderly and senile is that it includes laboratory tests of the patient’s blood and differs in that the complex takes into account the number of red blood cells (RBC), hemoglobin level (HGB), the level of total blood protein blood albumin and prothrombin time (PTV), provided that the RBC values are less than 2.3 × 10 ¹² / l, HGB less than 66 g / l, total blood protein less than 41.3 g / l, blood albumin less than 21.5 g / l, changes in convolutions blood system - an increase in the PTV value above 31.9 sec is assigned to each of the values 4 points, with a RBC value of 2.3 × 10 ¹² / l ÷ 2.47 × 10 ¹² / l, HGB 66 ÷ 77 g / l, total protein blood 41.3 ÷ 48.4 g / l, blood albumin 21.5 ÷ 25.8 g / l, changes in the blood coagulation system, PTV values of 18.4 ÷ 31.9 sec are assigned 3 points to each of the values, with the value RBC 2.48 × 10 ¹² / L ÷ 3.3 × 10 ¹² / L, HGB 78 ÷ 100 g / L, total blood protein 48.4 ÷ 52.0 g / L, blood albumin 25.8 ÷ 29.6 g / l, changes in the blood coagulation system, an increase in the PTV value of 14.1 ÷ 18.3 sec, each of the values is assigned 2 points, and for data values RBC teley above 3,3 × ^{12 October} / l, HGB above 100 g / l, the value of total blood protein levels above 52.0 g / l, albumin blood level value above 29.6 g / L, change PTT within normal range of For 13 to 14 seconds, each of the values is assigned 1 point, and to determine the degree of influence of each indicator on the prognosis, weight coefficients for each of the RBC laboratory indicators are 0.12, HGB are 0.12, the total blood protein is 024, the level of blood albumin is 0.28 and PTV - 0.24, the determination of the risk of death occurs as follows, having received laboratory analysis data, it is necessary to determine divide into the interval with which point each indicator falls, then the point corresponding to the degree of risk is multiplied by the corresponding weight coefficient and the points obtained for each indicator are summed up, the sum of the points corresponds to the degrees of risk of a fatal outcome: a very high risk of 3 ÷ 4 points (probability of lethal outcome - 0.916667), high - 2 ÷ 2.9 (probability of death - 0.636364), medium - 1.2 ÷ 1.9 (probability of death - 0.244444) and a low degree of risk with a total amount of less 1.2 points (probability of death emitsya to zero), thus, are recorded as different combinations of indicators, and each indicator weight to the occurrence of unfavorable outcome acute period of traumatic disease.

For a better understanding of the method, the claims are given in a more correct form with reference to table 10 and table 11:

Correspondence of intervals of values of indicators to points and weights

The formula for calculating:

Based on the data of a retrospective study, the sensitivity, specificity and general accuracy of the obtained method for predicting the outcome of an acute period of a traumatic disease were calculated (Fig. 3 - Sensitivity, specificity and general accuracy of the forecasting method).

The method is used as follows. After the victim arrives at the clinic’s admission department, he is required to take blood for laboratory tests, including a general blood test, a biochemical blood test and a coagulogram. After obtaining the results of laboratory tests, according to table 10, they find what points correspond to each of the found indicators (the number of red blood cells, the level of hemoglobin, the level of total blood protein and blood albumin, as well as prothrombin time). Then the score of each indicator is multiplied by the corresponding weight coefficient in the same table and the results are added up. The total score corresponds to the degree of risk of death: very high risk of 3 ÷ 4 points (probability of death - 0.916667), high - 2 ÷ 2.9 (probability of death - 0.636364), average - 1.2 ÷ 1 , 9 (the probability of a fatal outcome is 0.244444) and a low degree of risk with a total of less than 1.2 points (the probability of a fatal outcome tends to zero). Thus, when obtaining a score corresponding to a very high and high risk of death, one should refrain from aggressive surgical tactics and not go beyond the first stage of dynamic damage control, which includes only life-saving operations, without which the patient will undoubtedly die. After the first stage of the dynamic control of damage, the patient is transferred to the intensive care unit until the condition stabilizes, namely, until the point total is less than 2. With the total score corresponding to the average risk of death, planned minimally invasive operations can be performed, and at a low degree - the full amount of surgical treatment.

Clinical example 1: patient P., 78 years old, was received on 02/06/2014, diagnosis: Combined injury to the head, chest, abdomen, extremities, brain injury, mild brain injury, fracture of 5, 6 ribs on the left, 7 ribs on the right, bruise lung, blunt abdominal injury, open fracture of the lower third of both forearm bones in the lower third on the left, closed fracture of the tibia in the lower third on the right, fracture of the right talus, dislocation in the joint of Chopar, closed fracture of the tibia in the lower third on the left with the displacement of fragments. AIS / NISS injury severity score is 17 points. Upon receipt, the values of laboratory tests necessary to carry out the forecast according to the proposed method were as follows: RBC 3.2 × 10 ¹² / L - 2 points, HGB 91 g / L - 2 points, total blood protein 52.0 g / L - 2 point, blood albumin 31.0 g / l - 1 point, PTV 13.1 sec - 1 point. Further, multiplying each of the obtained points by the corresponding weight coefficient, we obtained a result of 1.48 points, which corresponds to an average degree of risk of death. As a result, it was decided to fix the fractures by the method of extra focal osteosynthesis. Upon further observation on June 9, 2015, RBC 3.7 × 10 ¹² / L - 1 point, HGB 103 g / L - 1 point, total blood protein 57.8 g / L - 7 points, blood albumin 31.3 g / l - 1 point, PTV 14.0 seconds - 1 point, the sum of points - 1, which corresponds to a low risk of death. It was decided to carry out surgical treatment: closed reposition and fixation in the apparatus of the left forearm and metal osteosynthesis with a plate of fractures of the bones of the left leg. After surgical treatment, the total score remained equal to 1 point. 06/12/2014, another operation was performed - closed reposition, osteosynthesis of the talus on the right, fixation of the Shopar joint with knitting needles on the right. RBC 3.5 × 10 ¹² / L - 1 point, HGB 101 g / L - 1 point, total blood protein 49.6 g / L - 2 points, blood albumin 24.7 g / L - 3 points, PTV 13, 0 sec - 1 point The total score is 1.8 points, which corresponds to the average risk of death. 06/16/2015 - RBC 3.5 × 10 ¹² / L - 1 point, HGB 100 g / L - 1 point, total blood protein 52.4 g / L - 7 points, blood albumin 30.3 g / L - 1 point, PTV 13.5 seconds - 1 point, the total score is 1, a low risk of death. 05/15/2014, the dynamics are positive, the patient was transferred to a hospital at the place of residence for further treatment and rehabilitation.

Clinical example 2: patient L., 60 years old, was admitted on 10/30/2014, diagnosis: Severe combined trauma, concussion, blunt abdominal trauma, multiple fractures of ribs on both sides, hemothorax on the left, unstable pelvic fracture with impaired pelvic integrity rings, closed fracture of the left ulnar process. Traumatic shock of 3 degrees, hemorrhagic shock of 3 degrees. AIS / NISS injury severity score is 27 points. Upon receipt, the values of laboratory tests necessary to carry out the forecast for the proposed method were as follows: RBC 1.23 × 10 ¹² / L - 4 points, HGB 36 g / L - 4 points, total blood protein 34.0 g / L - 4 point, blood albumin 12.2 g / l - 4 points, PTV 41.0 seconds - 4 points. Further, multiplying each of the obtained points by the corresponding weight coefficient, we obtained a result of 4.0 points, which corresponds to a very high degree of risk of death. As a result, it was decided to perform diagnostic laparoscopy - blood was detected in the abdominal cavity, splenectomy, tomonade of a liver rupture were performed, pelvic fracture fixation was performed by an external fixation device, the elbow process fracture was made using a plaster cast. As a result of resuscitation measures, the values of laboratory tests necessary to carry out the forecast for the proposed method were as follows: RBC 4.21 × 10 ¹² / L - 1 point, HGB 129 g / L - 1 point, total blood protein 42.2 g / L - 3 points, blood albumin 23.4 g / l - 3 points, PTV above 32.0 seconds - 4 points. Further, multiplying each of the obtained points by the corresponding weight coefficient, we obtained a result of 2.76 points, which corresponds to a high degree of risk of death. In the intensive care unit: the patient's condition is extremely serious, mechanical ventilation of the lungs continues, intensive infusion therapy, against the background of continuous infusion of vasopressors, blood circulation stopped, 5 hours 43 minutes after admission.

Clinical example 3: patient S., 66 years old, was admitted 05.22.2014, diagnosis: Combined trauma with leading damage to the musculoskeletal system, brain contusion, subarachnoid hemorrhage, hemosinus, open 1A fracture of the right femur, s / fracture of both bones of the right lower leg with displacement, s / fracture of the left clavicle. IHD, GB 3, CHF 1-2. AIS / NISS injury severity score is 22 points. Upon receipt, the values of laboratory tests necessary to carry out the forecast according to the proposed method were as follows: RBC 2.68 × 10 ¹² / L - 2 points, HGB 79 g / L - 2 points, total blood protein 42.7 g / L - 2 point, blood albumin 25.1 g / l - 3 points, PTV 14.2 sec - 2 points. Further, multiplying each of the obtained points by the corresponding weight coefficient, we obtained a result of 2.28 points, which corresponds to a high degree of risk of death. As a result, it was decided to carry out initial surgical treatment of wounds, to fix fractures of the femur and tibia with external fixation devices, after surgical treatment the patient was transferred to the intensive care unit. On the fifth day: the values of laboratory tests necessary to carry out the forecast for the proposed method were as follows: RBC 4.13 × 10 ¹² / L - 1 point, HGB 112 g / L - 1 point, total blood protein 53.3 g / L - 1 point, blood albumin 29.8 g / l - 1 point, PTV 13.4 seconds - 1 point. Further, multiplying each of the obtained points by the corresponding weight coefficient, we obtained a result of 1 point, which corresponds to a low risk of death. As a result, a decision was made on 05/27/2014 to dismantle the device from the right thigh and perform osteosynthesis with an intramedullary nail. 05/28/2014 - dismantle the external fixation apparatus from the lower leg and perform osteosynthesis with an intramedullary shaft. 06/06/2014 - intramedullary osteosynthesis of the right clavicle. On the twentieth day the patient was discharged in satisfactory condition, moving with crutches.

Testing the principle of objective criteria for assessing the state in the system of providing medical care to elderly and senile victims with severe combined trauma (polytrauma) showed an improvement in treatment outcomes with a 10.6% reduction in mortality.

Claims (1)

A method for predicting the outcome of an acute period of traumatic disease in patients with severe combined injuries of the elderly and senile, including laboratory tests of a patient’s venous blood sample, characterized in that the complex determines the number of red blood cells (RBC), hemoglobin level (HGB), the level of total blood protein, blood albumin and prothrombin time (PTT), with an RBC of more than 3.3 × 10 ¹² / l, 1 point and a weight coefficient of 0.12, with an RBC of more than 2.48 × 10 ¹² / l ÷ 3.3 × 10 ¹² / l assign 2 points and a weight coefficient of 0.12, with an RBC of more than 2.3 × 10 ¹² / l ÷ 2.47 × 10 ¹² / l assign 3 points and a weight coefficient of 0.12, with RBC less than 2.3 × 10 ¹² / l assign 4 points and a weight coefficient of 0.12; with an HGB of more than 100 g / l, 1 point is assigned and a weight coefficient of 0.12, with an HGB of more than 78 ÷ 100 g / l, 2 points are assigned and a weight of 0.12, with an HGB of more than 66 ÷ 77 g / l, 3 points and weight coefficient 0.12, with an HGB of less than 66 g / l, 4 points are assigned and a weight coefficient of 0.12; with a total blood protein of more than 52.0 g / l, 1 point and a weight coefficient of 0.24 are assigned, with a total blood protein of 48.4 ÷ 52.0 g / l, 2 points and a weight coefficient of 0.24 are assigned, with a total blood protein of 41 , 3 ÷ 48.4 g / l assign 3 points and a weight coefficient of 0.24, with a total blood protein of less than 41.3 g / l assign 4 points and a weight coefficient of 0.24; when the number of blood albumin is more than 29.6 g / l, 1 point and a weight coefficient of 0.28 are assigned; when the number of blood albumin is 25.8 ÷ 29.6 g / l, 2 points and a weight coefficient of 0.28 are assigned, with the number of blood albumin , 5 ÷ 25.8 g / l assign 3 points and a weight coefficient of 0.28, with the number of blood albumin less than 21.5 g / l assign 4 points and a weight coefficient of 0.28; with a PTV of 13-14 seconds, 1 point and a weight coefficient of 0.24 are assigned; with a PTV of 14.1-18.3 seconds, 2 points and a weight coefficient of 0.24 are assigned, with a PTV of 18.4-31.9 seconds, 3 points are assigned and a weighting factor of 0.24, with a PTV of more than 31.9 seconds, 4 points are assigned and a weighting factor of 0.24, then the points assigned to each of the parameters are multiplied by the corresponding weighting factor and the obtained points are summarized provided that the total score is 3 ÷ 4, determine a very high risk of death, with a value of 2 ÷ 2.9, you determine the highest risk of death, with a value of 1.2 ÷ 1.9, is average risk, and with a score of less than 1.2, a low risk of death.

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