RESUMEN
OBJECTIVE: To determine the utility of thoracic computed tomography (TCT) in the initial assessment of critically ill patients with chest injuries. DESIGN: Prospective observational study of cohorts. SETTING: Trauma intensive care unit (ICU) of a Spanish Level III hospital (US equivalent Level I). PATIENTS: Three hundred seventy-five patients with chest injuries were studied, grouped into two cohorts according to whether they underwent admission TCT (exposed cohort, group I, n = 104) or not (unexposed cohort, group II, n = 271). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data, initial severity scores, and chest radiograph (CXR)-based diagnosis were collected in all patients as independent variables. In patients of group I, we also recorded the TCT-based diagnosis and any incidents, complications, or therapy changes resulting from the TCT. The need for and duration of mechanical ventilation, length of ICU stay, and ICU mortality were gathered in the whole sample as dependent variables. The admission data were similar in the two groups, except for a higher Injury Severity Score (ISS) and thoracic ISS in group I. TCT proved to be more sensitive than CXR in detecting pulmonary contusion, hemothorax, pneumothorax, and vertebral fractures and in identifying the faulty placement of chest drainage tubes. TCT findings induced therapy changes in approximately 30% of patients in group I. In the other dependent variables studied, there were no differences between the two groups. In the multivariate analysis, the TCT screening had no effects on the time on mechanical ventilation, length of ICU stay, or mortality. CONCLUSIONS: TCT detects more chest injuries in trauma patients than does CXR and induces therapy changes in a considerable number of patients. However, this does not translate into an improvement in clinical outcomes.
Asunto(s)
Cuidados Críticos , Traumatismo Múltiple/diagnóstico por imagen , Traumatismos Torácicos/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Heridas no Penetrantes/diagnóstico por imagen , APACHE , Adulto , Estudios de Cohortes , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Traumatismo Múltiple/mortalidad , Admisión del Paciente/estadística & datos numéricos , Respiración Artificial/estadística & datos numéricos , Sensibilidad y Especificidad , Tasa de Supervivencia , Traumatismos Torácicos/mortalidad , Heridas no Penetrantes/mortalidadRESUMEN
OBJECTIVE: To customize the Acute Physiology and Chronic Health Evaluation (APACHE) III mortality equation for Spanish admissions to the intensive care unit (ICU) and evaluate its discrimination and calibration. DESIGN: Prospective multicenter inception cohort study. SETTING: 86 ICUs located in all regions of Spain. PATIENTS: 10,929 adult patients selected by a systematic sampling method. All types of critical care patients were included, including coronary bypass patients, but excluding those with burn injury, those admitted for pacemaker implants, patients under 16 years of age, and patients with length of ICU stay < 6 h. MEASUREMENTS AND RESULTS: Data collection in the first 24 h after patient admission included: APACHE III score, treatment location prior to ICU admission, and main ICU admission diagnosis. Using these variables, a model for predicting hospital mortality was constructed, adapted to Spain, and its discriminating ability was assessed by the area below the ROC curve, which was 0.83. The model was validated using the jacknife method and the area below the receiver operating characteristic (ROC) curve for the cross-validated predictions was 0.82. The percentage of patients correctly classified at 0.50 risk of death was 82.3%. Model calibration was evaluated by analysis of the agreement between the observed and cross-validated predicted mortality using the Hosmer-Lemeshow test, which gave a value of (H) 12.27, with no statistical significance, i.e., good calibration. CONCLUSIONS: We have customized the APACHE III mortality prediction system for the Spanish population. This adapted model has demonstrated the requisite validation, calibration, and discrimination for its use among Spanish critical care patients.