Article Information

Jan Hambrecht^1†, Philipp Vetter¹, Cedric Niggli¹, Hans-Christoph Pape¹, Ladislav Mica^1*

Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland

^*Corresponding Author: Ladislav Mica, Department of Trauma Surgery, University Hospital Zurich, 8091 Zurich, Switzerland

Received: 27 August 2023; Accepted: 08 September 2023; Published: 03 October 2023

Citation:

Jan Hambrecht, Philipp Vetter, Cédric Niggli, Hans-Christoph Pape, Ladislav Mica. Sepsis in Polytrauma Patients: A Comparative Analysis of Damage Control versus Early Total Care regarding the Injury Severity Score using IBM Watson Pathway Explorer®. Journal of Surgery and Research. 6 (2023): 327-331.

Abstract

Keywords

Damage Control, Early Total Care, Sepsis, Polytrauma, Injury Severity Score, IBM Watson

Article Details

Abbreviations

DCS = Damage control

ETC = Early total care

ISS = Injury severity score

OR = Odds ratio

SD = Standard deviation

ASA = American society of anesthesiology

Introduction

Sepsis continues to be a significant cause of mortality and morbidity in polytrauma patients, posing a challenge to healthcare providers. Polytrauma often necessitates immediate medical intervention [1]. Two contrasting treatment strategies have emerged in recent years for polytrauma patients: Damage Control (DCS) and Early Total Care (ETC), each offering distinct approaches to manage the interplay between maximum treatment and minimal risk of complications such as sepsis. DCS adopts a staged approach in the management of polytrauma patients. It involves immediate addressing of life-threatening injuries by interim measures to minimize surgical load and thereby risk of sepsis. Definitive surgical interventions are then performed at a later stage once physiological stability of the patient is achieved. On the other hand, ETC represents the early implementation of definitive surgical interventions, although associated with a higher surgical load. While both DCS and ETC have been employed in clinical practice, a clear consensus on the optimal management strategy for sepsis in polytrauma patients is yet to be established [2,3]. To quantify the injury severity, the ISS was established, providing insights into the patient's physiological response and predicting outcomes [4]. Understanding the relationship between ISS and the choice of treatment strategy is of utmost importance in optimizing patient outcomes including a minimum risk of complications such as sepsis [3,5]. The Watson Trauma Pathway Explorer® is an outcome prediction tool invented by the University Hospital of Zurich in collaboration with IBM®, representing an artificial intelligence application to predict the most adverse outcome scenarios in polytrauma patients: Systemic Inflammatory Respiratory Syndrome (SIRS), sepsis within 21 days and death within 72 h. We intended to investigate the association of surgical treatment (DCS, ETC)) and injury severity (ISS) with the development of sepsis.

Material and Methods

Patient collective sample

Data from 3653 patients in an internal database, with ongoing implementation (2022), served for analysis (Watson Trauma Pathway Explorer^©). All prospectively enrolled polytrauma patients aged ≥ 16 years with an ISS ≥ 16 were included retrospectively into the data sample. Complete datasets were required. We excluded non-survivors prior to admission and patients referred from external hospitals. Patients were split in two groups according to the type of surgical management (ETC, DCS) and injury severity (ISS<30 vs. ISS>30). Differences between groups were analyzed. The presence of sepsis was evaluated.

Definition of Sepsis

Using the most extreme readings of parameters including leucocyte count, respiratory rate, heart rate, the SIRS score was computed daily (6). This calculation was performed throughout the duration of the patient’s hospital stays. Sepsis was characterized as a SIRS score ≥ 2 with a specific infection focus, and it needed to manifest within the observation period of 21 days (7).

Laboratory analysisMeasurements were conducted using a standardized latex-enhanced immune turbidimetry at the laboratory institute of the University of Zurich.

Statistical analysis

Continuous data are presented with mean and standard deviation (SD), and categorical variables are presented with numbers and percentages. The ggplot2-package was used for data-visualization. Data was visually tested for normality using Kolmogorov-Smirnov. Unpaired student T-tests were used for parametric data. Non-parametric data was tested using Wilcoxon-Mann-Whitney tests. Binary categorical data was assessed using Fisher's exact test, and non-binary categorical data using chi-squared test with Yates` correction for continuity. Odds ratios (OR) were calculated using a logistic regression model. Statistical analysis was performed in R (R Core Team (2018). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL: https://www.R-project.org/). The threshold for statistical significance was determined as a p-value of <0.05.

Ethical approval

This study was conducted according to the guidelines for good clinical practice and the Helsinki guidelines. Research was based on the TRIPOD statement, representing a guideline for multivariable prediction model. Ethical approval for analysis of patient data was granted by the ethical committee of the University Hospital Zurich and the government of Zurich upon the development of the database (Nr. StV: 1-2008) and reapproved for development of the Watson Trauma Pathway Explorer® (BASEC 2021-00391).

Results

In total, 3653 patients were included, with a mean age of 45 ± 20.2 year, 73.4% of patients were male. Patients developing sepsis had higher values for the (New) Injury Severity Score (NISS/ISS) and the Acute Physiology and Chronic Health Evaluation (APACHE)-II-Score than patients without sepsis development (Figure 1). Sepsis occurred in 15% of all included cases.

Figure 1: Patient sample characteristics

Overall, 1242 patients presented with an ISS > 30 (34.6%), while 2374 patients showed an ISS of ≤ 30 (65.4%). DCS was performed in 66.3% of cases and ETC was carried out in 33.7%. According to ISS, DCS was performed in in 73.5% of the patients with an ISS > 30 and in 62.5% of the patients with an ISS ≤ 30. ETC was performed in 26.5% of the patients with an ISS > 30 and in 37.5% with an ISS ≤ 30. 50.8% of the patients with sepsis showed an initial ISS > 30. An ISS of 30 or lower was detected in 49.2% of the patients. Overall, ETC was performed in 26.9% of all patients who developed sepsis. In patients with an initial ISS < 30, sepsis tended to be more common in the DCS group (p = 0.054) (Figure 2). In patients with an ISS > 30, there was the same tendency (p = 0.081).

Figure 2: Appearance of sepsis depending on Injury Severity Score and trauma strategy

A significantly higher incidence of sepsis was detected in patients with an ISS >30 (OR 2.21, p <0.001) and when DCS was used (OR 1.45, p<0.001) (Figure 3).

Figure 3: Summary of statistical analyses. Odds rations represent the likelihood of sepsis based on Injury Severity Score and trauma strategy. CI = confidence interval.

Discussion

Sepsis, a life-threatening condition resulting from a dysregulated host response to infection, poses a significant challenge in the management of polytrauma patients. There is still a controversial discussion in trauma surgery when it comes to the treatment strategies of polytraumatized patients. Appropriate surgical management can reduce the appearance of complications significantly [8]. The Watson Trauma Pathway Explorer® opened the relevance for sepsis in polytraumatized patients admitted to our trauma bay [9]. In this study, the Watson Trauma Pathway Explorer® allowed a risk stratification for the incidence of sepsis in polytrauma patients according to ISS and surgical treatment type. The development of sepsis in patients after polytrauma is normally associated with a higher injury severity. Prior studies have detected risk factors beside the initial ISS that can affect the development of sepsis like male gender, a preexisting medical condition, the Glasgow Coma Scale (GCS) ≤ 8 or number of surgeries [10]. Our outcomes are concordant with these results. Multicenter studies form South Africa and Germany detected the appearance of sepsis in 14.4% and 12.4% [11.12]. Our results of patients developing sepsis (15%) showing similar numbers. Only a few studies investigated the connection between the development of sepsis and the ISS. Nevertheless, the ISS is described as a potential predictor of sepsis after trauma [13,14]. In our study, we saw the appearance of sepsis in patients with an ISS between 25 and 41. Other studies detected that Patients with sepsis after polytrauma were injured more severely as indicated by a higher ISS (33 vs 25) [15]. Nevertheless, we were able to show that sepsis can also occur in patients with less severe injuries. Osborn et al. investigated the appearance of sepsis with respect to the initial ISS. Patients with mild injuries (ISS < 15) and moderate injuries (ISS 15-29) developed sepsis in 61% the two groups combined. The appearance of sepsis in patients with ISS > 30 was detected in 39% [16]. The treatment strategy was not described in the mentioned literature. Prior studies investigated cofactors which potentially influence the development of sepsis like pre-existing diseases with a higher risk of respiratory failures, kidney-or liver diseases [17]. With DCS, the risk of complications and the survival rate was improved [18,19]. In our study the occurrence of sepsis was seen in DCS and ETC with a similar frequency. These findings are initially counterintuitive, and are interpreted in light of the general patient health status (e.g. pre-existing diseases as mentioned above) apart from trauma. Although, patient condition could not be specified in this regard, the current study implies that DCS does not generally imply a lower risk for sepsis development, urging clinicians not to underestimate the context this technically risk-minimizing surgical treatment strategy. Yet, since polytrauma and sepsis are heterogenic in their clinical presence and respective treatment, a holistic approach should be taken to maximize treatment effects while minimizing complication for better outcomes in polytrauma patients. There are limitations to be mentioned: During the years of data collection and building this database, preexisting diseases and the patient specific American Society of Anesthesiology-Score (ASA) were not registered. The appearance of sepsis is only documented in binary Information, the beginning or duration is not detected. Additionally, any alterations in treatment guidelines that occurred after the commencement of data collection were not taken to account. 

Conclusion

Sepsis after trauma remains a substantial challenge and further efforts to reduce the occurrence of complications are necessary. The development of sepsis is significantly more likely in patients with ISS > 30 and the use of DCS. Nevertheless, sepsis can occur in patients with less severe injuries, a lower ISS but potential preexisting diseases. On the other hand, DCS does not generally imply a lower risk for this complication.

Remark:

Watson Trauma Pathway Explorer © by Ladislav Mica and IBM

References

1. Ticlea M, Bratu LM, Bodog F, et al. The Use of Exosomes as Biomarkers for Evaluating and Monitoring Critically Ill Polytrauma Patients with Sepsis. Biochem Genet 55 (2017):1-9.
2. Von Rüden C, Bühren V, Perl M. Polytrauma Management - Treatment of Severely Injured Patients in ER and OR. Z Orthop Unfall 155 (2017): 603-622.
3. Nast-Kolb D, Ruchholtz S, Waydhas C, et al. Management of polytrauma. Chirurg 77 (2006): 861-872.
4. Dehouche N. The injury severity score: an operations perspective. BMC Med Res Methodol 20 (2022) 22-48.
5. Linn S. The injury severity score--importance and uses. Ann Epidemiol 5 (1995): 440-446.
6. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 20 (1992): 864-874.
7. Levy MM, Fink MP, Marshall JC, et al. SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 31 (2003): 1250-1256.
8. Pfeifer R, Pape HC. [Diagnostics and treatment strategies for multiple trauma patients]. Chirurg 87 (2016): 165-713
9. Bone RC. Sir Isaac Newton, sepsis, SIRS, and CARS. Crit Care Med 24 (1996): 1125-1128.
10. Herasevich V, Afessa B, Pickering BW. Sepsis in critically ill patients with trauma. Crit Care Med 39 (2011): 876-878.
11. Muckart DJ, Bhagwanjee S. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference definitions of the systemic inflammatory response syndrome and allied disorders in relation to critically injured patients. Crit Care Med 25 (1997): 1789-1795.
12. Engel C, Brunkhorst FM, Bone HG, et al. Epidemiology of sepsis in Germany: results from a national prospective multicenter study. Intensive Care Med 33 (2007): 606-618.
13. Baker SP, O’Neill B, Haddon W, et al. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14 (1974): 187-196.
14. Brouckaert P, Spriggs DR, Demetri G, et al. Circulating interleukin 6 during a continuous infusion of tumor necrosis factor and interferon gamma. J Exp Med 169 (1989): 2257-2262.
15. Wafaisade A, Lefering R, Bouillon B, et al. Epidemiology and risk factors of sepsis after multiple trauma: An analysis of 29,829 patients from the Trauma Registry of the German Society for Trauma Surgery. Crit Care Med 39 (2011): 621-628.
16. Osborn TM, Tracy JK, Dunne JR, et al. Epidemiology of sepsis in patients with traumatic injury. Crit Care Med 32 (2004): 2234-2240.
17. Labib A. Sepsis Care Pathway 2019. Qatar Med J 19 (2019): 4.
18. Pape HC, Hildebrand F, Krettek C. Decision making and and priorities for surgical treatment during and after shock trauma room treatment. Unfallchirurg 107 (2004): 927-936.
19. Bates P, Parker P, McFadyen I, et al. Demystifying damage control in musculoskeletal trauma. Ann R Coll Surg Engl 98 (2016): 291-294.