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Three Part Question

[In trauma patients,] [from which value of base deficit (BD) at hospital arrival] [the prognosis is worst?]

Clinical Scenario

A 26 years old man presents at the ED after a blunt trauma. His vital signs are normal except for a heart rate at 110. His labs are normal except for an abnormal base deficit. The doctor wonders if the abnormal base deficit means that this patient could be at risk of complications or death.

Search Strategy

No best bet on this topic was found.
Ovid MEDLINE(R) 1950 to March Week 4 2009 : 194
EMBASE 1950 to March week 4 2009 via Elsevier: 0
Cochrane library to march week 4 : 0


Medline search :
#1 ) "acid-base equilibrium"[All Fields] OR "acid-base imbalance"[All Fields] OR "base deficit"[All Fields] OR "base excess"[All Fields]
#2) "multiple trauma"[All Fields] OR "traumatology"[All Fields] OR "trauma"[All Fields]
#3) "prgonosis"[All Fields] OR "outcome"[All Fields] OR "outcome assessment (health care)"[All Fields] OR "treatment outcome"[All Fields] OR "early diagnosis"[All Fields] OR "mortality"[All Fields] OR "death"[All Fields] OR "morbidity"[All Fields]
#1 AND #2 AND #3 = 194 articles

Inclusion criterias:
- Population: Adult trauma patients in-hospital setting, at ED arrival or at hospital admission
- Intervention: Base deficit measurement
- Studies: Meta-analysis, systematic reviews, RCT, observational studies
- Outcomes: Morbidity and mortality

Exclusion criterias: Pediatrics, animal subjects, prehospital setting, single injury or burn

Search Outcome

On the 194 articles founded with the search strategy, 20 articles met the inclusion and exclusion criterias.

Those 20 articles were stating that an abnormal arterial base deficit at ED arrival or at hospital admission is associated with an increased mortality, more blood transfusions and volume requirements, more hemodynamic changes, longer LOS in ICU and in hospital, higher incidence of MODS, MOF and maybe ARDS. Also, for a given base deficit, the mortality was lower in stab wounds and/or severe lacerations patients.

The search was then narrowed to keep only the studies that could help to determine which value of base deficit (BD) at hospital arrival Is associated with a worst outcome.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Davis, Parks, Kaups, Gladen and O’Donnell-Nicol 1996 USA	- 2 954 trauma patients admitted to a Level I trauma center from July 1990 through August 1995 with arterial blood gases performed within 1 hour of admission - Patients under age 5, or with trauma caused by thermal injury, seizure, or diabetic ketoacidosis were excluded.	Retrospective review, cohort study	- Hospital LOS - ICU LOS - Blood transfusion in the first 24 hours - Shock-related complications - Mortality	- Hospital LOS and ICU LOS increased with worsening BD - Transfusion were required in 72% with a BD ≤ -6 versus 18% of patients with BD ≥ -6 and increased significantly with each successive BD category - The frequency of ARDS, renal failure, coagulopathy and MOF all increased with increasingly severe BD - Mortality increased with worsening BD	- Poor description of the sample baseline characteristics and the methods - No adjustment for type of trauma, delay of arrival, prehospital treatment, comorbidities or bicarbonates administration
Kincaid, Miller, Meredith, Rahman and Chang 1998 USA	100 patients admitted to the trauma ICU at a Level I trauma center during a 12 months (October 1994 to October 1995) period who were monitored with a pulmonary artery catheter and serial measurements of lactate and base deficit, and who achieved a normal arterial lactate concentration (< 2,2 mmol/L) with resuscitation	Retrospective analysis of a prospectively collected database in a cohort study	- Oxygen consumption and utilization - Incidence of MOF - Mortality	- Persistently high arterial BD (≥ 4 mmol/L) is associated with altered oxygen utilization, an increased risk of MOF and a higher mortality (AUC 0,71) - The ROC curve desmontrate that the value that maximizes sensitivity and specificity is 4 mmol/L	- 9 eligible patients were excluded because not monitored with serial values - Poor sample description - No adjustment for delay of arrival or prehospital treatment
Rixen, Raum, Bouillon, Lefering and Neugebauer 2001 Germany	2 069 multiple trauma patients recorded in 20 participating hospitals belonging to the trauma DGU from January 1993 through December 1997	Prospective multi-center cohort study	- Hemodynamic changes - Volume and transfusion requirements, lactate and coagulation - Mortality	- Increase in the BD category was associated with a significant decrease in systolic blood pressure and PT time as well as increases in heart rate, lactate level and mortality - BD < -6 was associated with significant increase in mortality - Transfusion requirements increased significantly on hospital admission with a worsening in the BD category - In the multufactorial analysis, the hospital admission BD was one of the five best predictors for the outcome (BD, GCS, age, PTT and ISS)	- No mention of comorbidities of the sample - No adjustment for delay of arrival, prehospital treatment or bicarbonates administration
Rutherford, Morris, Reed and Hall 1992 USA	- 3 791 consecutive trauma patients admitted to a teaching tertiary care center with an arterial blood gas sample taken in the first 24 hours between August 1984 to March 1990 - Burn admissions were excluded (674) - 3791/7312 had an arterial blood gas sample drawn within 24 hours of admission	Retrospective cohort study	- Mortality (using LD25)	- BD, age, injury mechanism, and head injury were associated with mortality using logistic regression - In the presence of shock (SBP <90 mmHg), all factors remained significant, and base deficit was supplemental to blood pressure - The mortality increased around BD -4 (5%) and BD -6 (12%)	- No mention of comorbidities of the sample - No adjustment for delay of arrival, prehospital treatment or bicarbonates administration
Tremblay, Feliciano and Rozycki 2002 USA	- 3275 trauma patients admitted at a Level I trauna center from January 1995 through July 2001 who had a BD recorded at the time of admission - Arterial blood gas were generally drawn on salvageable patients with need for intubation, had sustained major truncal trauma, had a past medical history of cardiorespiratory problems, or were thought to have sustained significant blood loss based on history or physical examination	Retrospective cohort study	- Mortality	- Mortality increased with successive increases in BD but was markedly lower for a given BD in those patients having sustained stab wouds and/or severe lacerations as compared with those with GSW or blunt trauma - Probability of survival decreased in most of the groups around BD -4 and BD -6 for stab wounds	- No mention of comorbidities of the sample - No adjustment for delay of arrival, prehospital treatment or bicarbonates administration

Comment(s)

Most of the studies were observational studies done in Level I trauma center in the US with admitted patients. Few studies document patients comorbidities and most don’t consider delay to arrival or prehospital treatment as confounding factors. Those are the references of all the 20 articles first identified: 1) Aslar AK. Kuzu MA. Elhan AH. Tanik A. Hengirmen S., Admission lactate level and the APACHE II score are the most useful predictors of prognosis following torso trauma, Injury. 35(8):746-52, 2004 Aug. 2) Davis JW. Kaups KL., Base deficit in the elderly: a marker of severe injury and death, Journal of Trauma-Injury Infection & Critical Care. 45(5):873-7, 1998 Nov. 3) Davis JW. Kaups KL. Parks SN., Base deficit is superior to pH in evaluating clearance of acidosis after traumatic shock, Journal of Trauma-Injury Infection & Critical Care. 44(1):114-8, 1998 Jan. 4) Davis JW. Parks SN. Kaups KL. Gladen HE. O'Donnell-Nicol S., Admission base deficit predicts transfusion requirements and risk of complications, Journal of Trauma-Injury Infection & Critical Care. 41(5):769-74, 1996 Nov. 5) Dunham CM. Damiano AM. Wiles CE. Cushing BM., Post-traumatic multiple organ dysfunction syndrome--infection is an uncommon antecedent risk factor, Injury. 26(6):373-8, 1995 Jul. 6) Dunne JR. Tracy JK. Scalea TM. Napolitano LM., Lactate and base deficit in trauma: does alcohol or drug use impair their predictive accuracy?, Journal of Trauma-Injury Infection & Critical Care. 58(5):959-66, 2005 May. 7) Eachempati SR. Robb T. Ivatury RR. Hydo LJ. Barie PS., Factors associated with mortality in patients with penetrating abdominal vascular trauma, Journal of Surgical Research. 108(2):222-6, 2002 Dec. 8) Eberhard LW. Morabito DJ. Matthay MA. Mackersie RC. Campbell AR. Marks JD. Alonso JA. Pittet JF., Initial severity of metabolic acidosis predicts the development of acute lung injury in severely traumatized patients, Critical Care Medicine. 28(1):125-31, 2000 Jan. 9) FitzSullivan E. Salim A. Demetriades D. Asensio J. Martin MJ., Serum bicarbonate may replace the arterial base deficit in the trauma intensive care unit, American Journal of Surgery. 190(6):941-6, 2005 Dec. 10) Kaplan LJ. Kellum JA., Initial pH, base deficit, lactate, anion gap, strong ion difference, and strong ion gap predict outcome from major vascular injury, Critical Care Medicine. 32(5):1120-4, 2004 May. 11) Kincaid EH. Miller PR. Meredith JW. Rahman N. Chang MC., Elevated arterial base deficit in trauma patients: a marker of impaired oxygen utilization, Journal of the American College of Surgeons. 187(4):384-92, 1998 Oct. 12) Kroezen F. Bijlsma TS. Liem MS. Meeuwis JD. Leenen LP., Base deficit-based predictive modeling of outcome in trauma patients admitted to intensive care units in Dutch trauma centers, Journal of Trauma-Injury Infection & Critical Care. 63(4):908-13, 2007 Oct. 13) MacLeod J. Lynn M. McKenney MG. Jeroukhimov I. Cohn SM., Predictors of mortality in trauma patients, American Surgeon. 70(9):805-10, 2004 Sep. 14) Miller PR. Croce MA. Kilgo PD. Scott J. Fabian TC., Acute respiratory distress syndrome in blunt trauma: identification of independent risk factors, American Surgeon. 68(10):845-50; discussion 850-1, 2002 Oct. 15) Rixen D. Raum M. Bouillon B. Lefering R. Neugebauer E. Arbeitsgemeinschaft "Polytrauma" of the Deutsche Gesellschaft fur Unfallchirurgie, Base deficit development and its prognostic significance in posttrauma critical illness: an analysis by the trauma registry of the Deutsche Gesellschaft fur unfallchirurgie, Shock. 15(2):83-9, 2001 Feb. 16) Falcone RE. Santanello SA. Schulz MA. Monk J. Satiani B. Carey LC., Correlation of metabolic acidosis with outcome following injury and its value as a scoring tool, World Journal of Surgery. 17(5):575-9, 1993 Sep-Oct. 17) Rutherford EJ. Morris JA Jr. Reed GW. Hall KS.,Base deficit stratifies mortality and determines therapy, Journal of Trauma-Injury Infection & Critical Care. 33(3):417-23, 1992 Sep. 18) Sauaia A. Moore FA. Moore EE. Haenel JB. Read RA. Lezotte DC., Early predictors of postinjury multiple organ failure,Archives of Surgery. 129(1):39-45, 1994 Jan. 19) Tremblay LN. Feliciano DV. Rozycki GS., Assessment of initial base deficit as a predictor of outcome: mechanism of injury does make a difference, American Surgeon. 68(8):689-93; discussion 693-4, 2002 Aug. 20) Tremblay LN. Feliciano DV. Rozycki GS., Are resuscitation and operation justified in injured patients with extreme base deficits (less than -20)?, American Journal of Surgery. 186(6):597-600; discussion 600-1, 2003 Dec.

Clinical Bottom Line

In blunt trauma patients, BD ≤ -4 or -6 at ED arrival or at hospital admission is associated with worst outcomes, including mortality. Level of evidence 2b Grade of recommendation : B : consistent level 2 or 3 studies

References

1. Davis, Parks, Kaups, Gladen and O’Donnell-Nicol Admission base deficit predicts transfusion requirements and risk of complications Journal of Trauma-Injury Infection & Critical Care 41(5):769-74, 1996 Nov.
2. Kincaid, Miller, Meredith, Rahman and Chang Elevated arterial base deficit in trauma patients: a marker of impaired oxygen utilization Journal of the American College of Surgeons 187(4):384-92, 1998 Oct.
3. Rixen, Raum, Bouillon, Lefering and Neugebauer Base deficit development and its prognostic significance in posttrauma critical illness: an analysis by the trauma registry of the Deutsche Gesellschaft fur unfallchirurgie Shock 15(2):83-9, 2001 Feb
4. Rutherford, Morris, Reed and Hall Base deficit stratifies mortality and determines therapy Journal of Trauma-Injury Infection & Critical Care 33(3):417-23, 1992 Sep.
5. Tremblay, Feliciano and Rozycki Assessment of initial base deficit as a predictor of outcome: mechanism of injury does make a difference American Surgeon . 68(8):689-93; discussion 693-4, 2002 Aug.