Predicción de la supervivencia en pacientes traumáticos ancianos: comparación entre la metodología TRISS y el Geriatric Trauma Outcome Score

doi:10.1016/j.ciresp.2018.02.014

Cirugía Española

Volume 96, Issue 6, June–July 2018, Pages 357-362

https://doi.org/10.1016/j.ciresp.2018.02.014 Get rights and content

Resumen

Introducción

Comparamos el Geriatric Trauma Outcome score (GTOS) con la probabilidad de supervivencia empleando la metodología TRISS (PS-TRISS) en pacientes traumáticos ancianos ingresados en las Unidades de Cuidados Intensivos (UCI) participantes en el registro de traumatismo en UCI (RETRAUCI).

Métodos

Análisis retrospectivo del RETRAUCI. Los datos cuantitativos se expresan como mediana (rango intercuartil), los datos categóricos como número (porcentaje). Analizamos la validez del GTOS y la PS-TRISS para la predicción de supervivencia. La discriminación se evaluó mediante curvas receiver operating characteristics. La calibración de los modelos se analizó mediante el test de bondad de ajuste de Hosmer-Lemeshow. Un valor de p < 0,05 se consideró estadísticamente significativo.

Resultados

La cohorte incluyó a 1.417 pacientes ≥ 65 años. Mediana edad 75,5 (70,5-80,5) años, varones 1.003 (68,2%), mediana Injury Severity Score 18 (13-25). Ventilación mecánica, 61%. Las caídas fueron el mecanismo de lesión en 659 pacientes (44,8%). Mortalidad hospitalaria: 18,2%. El área bajo la curva para PS-TRISS fue 0,69 (IC del 95% 0,66-0,73) y para GTOS 0,66 (IC del 95% 0,62-0,70); p < 0,05. Ambos scores sobrestimaron la mortalidad en el rango alto de mortalidad predicha.

Conclusiones

En nuestra muestra de pacientes traumáticos ancianos la precisión de GTOS fue inferior a la de la metodología TRISS en la predicción de la supervivencia hospitalaria. Ambos scores tuvieron una mala calibración en la población anciana.

Abstract

Introduction

We compared the Geriatric Trauma Outcome Score (GTOS) with the probability of survival using the TRISS methodology (PS-TRISS) in geriatric severe trauma patients admitted to Intensive Care Units (ICU) participating in the Spanish trauma ICU registry (RETRAUCI).

Methods

Retrospective analysis from the RETRAUCI. Quantitative data were reported as median (Interquartile Range (IQR)), and categorical data as number (percentage). We analyzed the validity of the GTOS and PS-TRISS to predict survival. Discrimination was analyzed using receiver operating characteristics curves. Calibration was analyzed using the Hosmer-Lemeshow goodness-of-fit test. A P value <.05 was considered statistically significant.

Results

The cohort included 1417 patients aged ≥ 65 years. Median age was 75.5 (70.5-80.5), 1003 patients were male (68.2%) and median Injury Severity Score was 18 (13-25). Mechanical ventilation was required in 61%. Falls were the mechanism of injury in 659 patients (44.8%). In-hospital mortality rate was 18.2%. The areas under the curve were: PS-TRISS 0.69 (95%CI 0.66-0.73), and GTOS 0.66 (95%CI 0.62-0.70); P<.05. Both scores overestimated mortality in the upper range of predicted mortality.

Conclusions

In our sample of geriatric severe trauma patients, the accuracy of GTOS was lower than the accuracy of the PS-TRISS to predict in-hospital survival. The calibration of both scores for the geriatric population was deficient.

Section snippets

Introducción

El progresivo envejecimiento poblacional de los países desarrollados ha llevado a un aumento significativo en el número de pacientes ancianos que son atendidos después de un traumatismo grave y se espera que continúe en aumento en las próximas décadas1, 2. Más del 20% de los pacientes traumáticos ingresados en las Unidades de Cuidados Intensivos (UCI) españolas tienen más de 65 años³, de acuerdo con los resultados de la fase piloto del registro de trauma en UCI (RETRAUCI). Estos pacientes

Métodos

El RETRAUCI incluyó su primer paciente el 23 noviembre del año 2012 y cuenta con la aprobación del comité ético de los hospitales participantes. Se trata de un registro multicéntrico con participación voluntaria e implantación en 49 centros de todo el país promovido por el Grupo de Trabajo de Neurointensivismo y Trauma de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC).

Criterios de inclusión y exclusión: existe controversia respecto a qué edad debe

Resultados

La cohorte se compuso de 5.882 pacientes, de los cuales 1.417 pacientes (24,1%) tuvieron una edad ≥ 65 años y constituyeron la población a estudio. La mediana de edad fue de 75,5 (70,5-80,5) años y fueron varones 1.003 (68,2%). La mediana del ISS fue 18 (13-25). Las caídas fueron el principal mecanismo lesional hasta en 659 pacientes (44,8%). Un 71% (1.004 pacientes) presentó traumatismo craneoencefálico (TCE). El 61% de los pacientes recibieron ventilación mecánica. Recibieron procedimientos

Discusión

En enfermedad traumática grave, los scores pueden utilizarse para evaluar la calidad de los cuidados proporcionados y ayudar a establecer el pronóstico de los pacientes y con ello la toma de decisiones. Este hecho es especialmente relevante en el paciente anciano, donde la comorbilidad y el empleo de diferentes tratamientos pueden comprometer todavía más su menor reserva fisiológica1, 2. La compleja metodología TRISS integra información fisiológica y radiológica, y se ha empleado en enfermedad

Financiación

El registro contó con subvención por parte de la Fundación Mutua Madrileña durante los 3 primeros años para el desarrollo de una herramienta de recogida de datos online concedida al investigador principal del proyecto (Dr. Chico-Fernández, N.° referencia AP117892013).

Conflicto de intereses

Los autores declaran no tener conflicto de intereses relacionado con el manuscrito.

Agradecimientos

Los autores agradecen su trabajo en el desarrollo y mantenimiento de la base de datos a Miguel Ángel Ferrero Fernández (ingeniero informático, jefe del Departamento de Informática de la SEMICYUC).

Bibliografía (17)

S.E. Brooks et al.
Evidence-based care of geriatric trauma patients
Surg Clin North Am.
(2017)
M. Chico-Fernández et al.
Epidemiology of severe trauma in Spain. Registry of trauma in the ICU (RETRAUCI). Pilot phase
Med Intensiva.
(2016)
J.A. Llompart-Pou et al.
Age-related injury patterns in spanish trauma ICU patients. Results from the RETRAUCI
Injury.
(2016)
W.K. Utomo et al.
Predictors of inhospital mortality and 6-month functional outcomes in older adults after moderate to severe traumatic brain injury
Injury
(2009)
Y. Peñasco et al.
Limitation of life-sustaining treatment in severe trauma in the elderly after admission to an intensive care unit
Med Intensiva.
(2017)
A.G. Rapsang et al.
Scoring systems of severity in patients with multiple trauma
Cir Esp.
(2015)
R. Ahl et al.
Predicting in-hospital and 1-year mortality in geriatric trauma patients using Geriatric Trauma Outcome Score
J Am Coll Surg.
(2017)
J.A. Llompart-Pou et al.
Severe trauma in the geriatric population
World J Crit Care Med.
(2017)

There are more references available in the full text version of this article.

Cited by (15)

Performance of the Geriatric Trauma Outcome Score in traumatic brain injury: a call of caution
2022, Injury
Validation of the geriatric trauma outcome scores in predicting outcomes of elderly trauma patients
2021, Injury
Citation Excerpt :
They suggested that prognostic models specifically designed for and derived from the elderly patients may be more accurate and generalisable than a generic trauma model in predicting outcomes of the elderly patients with trauma which seems to be on the rise. Whether these two elderly trauma prognostic models are accurate in an Australian trauma setting is unknown [1–7]. We hypothesised that the GTOS and GTOS II were accurate in predicting mortality and unfavourable discharge, respectively, of elderly trauma patients in Australia.
Using three patient characteristics, including age, Injury Severity Score (ISS) and transfusion within 24 h of admission (yes vs. no), the Geriatric Trauma Outcome Score (GTOS) and Geriatric Trauma Outcome Score II (GTOS II) have been developed to predict mortality and unfavourable discharge (to a nursing home or hospice facility), of those who were ≥65 years old, respectively.
This study aimed to validate the GTOS and GTOS II models. For the nested-cohort requiring intensive care, we compared the GTOS scores with two ICU prognostic scores – the Acute Physiology and Chronic Health Evaluation (APACHE) III and Australian and New Zealand Risk of Death (ANZROD).
All elderly trauma patients admitted to the State Trauma Unit between 2009 and 2019 were included. The discrimination ability and calibration of the GTOS and GTOS II scores were assessed by the area under the receiver-operating-characteristic (AUROC) curve and a calibration plot, respectively.
Of the 57,473 trauma admissions during the study period, 15,034 (26.2%) were ≥65 years-old. The median age and ISS of the cohort were 80 (interquartile range [IQR] 72–87) and 6 (IQR 2–9), respectively; and the average observed mortality was 4.3%. The ability of the GTOS to predict mortality was good (AUROC 0.838, 95% confidence interval [CI] 0.821–0.855), and better than either age (AUROC 0.603, 95%CI 0.581–0.624) or ISS (AUROC 0.799, 95%CI 0.779–0.819) alone. The GTOS II's ability to predict unfavourable discharge was satisfactory (AUROC 0.707, 95%CI 0.696–0.719) but no better than age alone. Both GTOS and GTOS II scores over-estimated risks of the adverse outcome when the predicted risks were high. The GTOS score (AUROC 0.683, 95%CI 0.591–0.775) was also inferior to the APACHE III (AUROC 0.783, 95%CI 0.699–0.867) or ANZROD (AUROC 0.788, 95%CI 0.705–0.870) in predicting mortality for those requiring intensive care.
The GTOS scores had a good ability to discriminate between survivors and non-survivors in the elderly trauma patients, but GTOS II scores were no better than age alone in predicting unfavourable discharge. Both GTOS and GTOS II scores were not well-calibrated when the predicted risks of adverse outcome were high.
Outcomes of very elderly trauma ICU patients. Results from the Spanish trauma ICU registry
2020, Medicina Intensiva
Citation Excerpt :
We did not evaluate predicted mortality using the specific Geriatric Trauma Outcome Score 10 as did Mock et al. We used the conventional TRISS methodology since we previously compared the performance of the TRISS methodology and the Geriatric Trauma Outcome Score in our geriatric trauma ICU population and we found that the prediction ability of TRISS was higher, most likely due to severity of injury and the high percentage of patients with TBI.28 However, it must be considered that TRISS was created for a different population (younger patients with predominant high-energy mechanisms of injury), can be difficult to calculate and requires specific skills in the codification of injuries and continuous coefficient updates.
To analyze outcomes and factors related to mortality among very elderly trauma patients admitted to intensive care units (ICUs) participating in the Spanish trauma ICU registry.
A multicenter nationwide registry. Retrospective analysis. November 2012–May 2017.
Participating ICUs.
Trauma patients aged ≥80 years.
None.
The outcomes and influence of limitation of life sustaining therapy (LLST) were analyzed. Comparisons were established using the Wilcoxon test, Chi-squared test or Fisher's exact test as appropriate. Multiple logistic regression analysis was performed to analyze variables related to mortality. A p-value <0.05 was considered statistically significant.
The mean patient age was 83.4 ± 3.3 years; 281 males (60.4%). Low-energy falls were the mechanisms of injury in 256 patients (55.1%). The mean ISS was 20.5 ± 11.1, with a mean ICU stay of 7.45 ± 9.9 days. The probability of survival based on the TRISS methodology was 69.8 ± 29.7%. The ICU mortality rate was 15.5%, with an in-hospital mortality rate of 19.2%. The main cause of mortality was intracranial hypertension (42.7%). The ISS, the need for first- and second-tier measures to control intracranial pressure, and being admitted to the ICU for organ donation were independent mortality predictors. LLST was applied in 128 patients (27.9%). Patients who received LLST were older, with more severe trauma, and with more severe brain injury.
Very elderly trauma ICU patients presented mortality rates lower than predicted on the basis of the severity of injury.
Analizar el desenlace y los factores relacionados con la mortalidad de los pacientes traumáticos muy ancianos ingresados en las Unidades de Cuidados Intensivos (UCI) participantes en el Registro Español de Trauma en las UCI (RETRAUCI).
Registro multicéntrico nacional. Análisis retrospectivo. Noviembre de 2012-mayo de 2017.
Las UCI participantes.
Pacientes traumáticos con edad ≥80 años.
Ninguna.
Analizamos el desenlace y la influencia de la limitación de los tratamientos de soporte vital (LLST). Las comparaciones entre grupos se realizaron mediante la prueba de Wilcoxon, la prueba de Chi-cuadrado y la prueba exacta de Fisher según estuviera indicado. Se realizó un análisis multivariante mediante regresión logística para analizar las variables asociadas a la mortalidad. Un valor de p < 0,05 se consideró el límite de la significación estadística.
La edad media fue de 83,4 ± 3,3 años. Varones 281 (60,4%). La causa principal del traumatismo fueron las caídas de baja energía en 256 pacientes (55,1%). El Injury Severity Score (ISS) medio fue de 20,5 ± 11,1. La estancia media en las UCI fue de 7,45 ± 9,9 días. La probabilidad de supervivencia, de acuerdo con la metodología TRISS fue de 69,8 ± 29,7%. La mortalidad en las UCI fue del 15,5%. La mortalidad hospitalaria fue del 19,2%. La causa principal fue la hipertensión intracraneal (42,7%). El ISS, la necesidad de medidas de primer o segundo nivel para controlar la presión intracraneal y el ingreso en las UCI orientado a la donación de órganos fueron predictores independientes de mortalidad. Se documentó la LLST en 128 pacientes (27,9%). Los pacientes con LLST fueron mayores, con una mayor gravedad lesional y un traumatismo craneoencefálico más grave.
Los pacientes traumáticos muy ancianos en las UCI presentaron menor mortalidad de la predicha por la gravedad del traumatismo.
Timing and methods of frailty assessments in geriatric trauma patients: A systematic review
2019, Injury
Citation Excerpt :
Twenty-four were excluded for surrogate measures of frailty such as functional assessments (activities of daily living, modified Rankin Scale [34–39]), malnutrition [40,41], albumin [42], low falls [43], and sarcopenia [44–48], or where outcomes weren’t consistent with the systematic review [49–51]. Studies using The Frailty Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA or STTGMAFRAILTY) and the Geriatric Trauma Outcome Score (GTOS) were excluded on consensus that they did not meet frailty assessment requirements [52–57]. GTOS calculates age+(2.5 × ISS), +22 if packed red blood cells are transfused, and STTGMAFRAILTY adds mobility (preinjury ambulatory capacity, assistive device use), albumin and anticoagulation use to STTGMA parameters of mechanism and severity of injury (low or high energy, mechanism of injury MOI, Abbreviated Injury Scale AIS), age, Glasgow coma score (GCS) and comorbidity (Charlson Comorbidity Index, CCI).
The trauma population is aging and better prognostic measures for geriatric trauma patients are required. Frailty rather than age appears to be associated with poor outcomes. This systematic review aimed to identify the optimum frailty assessment instrument and timing of assessment in patients aged over 65 years admitted to hospital after traumatic injury. The secondary aim was to evaluate outcomes associated with frailty in elderly trauma populations.
This systematic review was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42018090620). A MEDLINE and EMBASE literature search was conducted from inception to June 2019 combining the concepts of injury, geriatric, frailty, assessment and prognosis. Included studies were in patients 65 years or older hospitalised after injury and exposed to an instrument meeting consensus definition for frailty assessment. Study quality was assessed using criteria for review of prognostic studies combined with a GRADE approach.
Twenty-eight papers met inclusion criteria. Twenty-eight frailty or component instruments were reported, and assessments of pre-injury frailty were made up to 1-year post injury. Pre-injury frailty prevalence varied from 13% (13/100) to 94% (17/18), with in-hospital mortality rates from 2% (5/250) to 33% (6/18). Eleven studies found an association between frailty and mortality. Eleven studies reported an association between frailty and a composite outcome of mortality and adverse discharge destination. Generalisability and assessment of strength of associations was limited by single centre studies with inconsistent findings and overlapping cohorts.
Associations between frailty and adverse outcomes including mortality in geriatric trauma patients were demonstrated despite a range of frailty instruments, administering clinicians, time of assessment and data sources. Although evidence gaps remain, incorporating frailty assessment into trauma systems is likely to identify geriatric patients at risk of adverse outcomes. Consistency in frailty instruments and long-term geriatric specific outcome measures will improve research relevance.
: Level III prognostic.
The etiology of trauma in geriatric traumatic patients refer to an academic trauma center: a cross sectional study
2024, Research Square
Performance of trauma scoring systems in predicting mortality in geriatric trauma patients: comparison of the ISS, TRISS, and GTOS based on a systemic review and meta-analysis
2024, European Journal of Trauma and Emergency Surgery

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OriginalPredicción de la supervivencia en pacientes traumáticos ancianos: comparación entre la metodología TRISS y el Geriatric Trauma Outcome ScorePredicting survival in geriatric trauma patients: A comparison between the TRISS methodology and the Geriatric Trauma Outcome Score

Resumen

Introducción

Métodos

Resultados

Conclusiones

Abstract

Introduction

Methods

Results

Conclusions

Section snippets

Introducción

Métodos

Resultados

Discusión

Financiación

Conflicto de intereses

Agradecimientos

Surg Clin North Am.

Med Intensiva.

Injury.

Injury

Med Intensiva.

Cir Esp.

J Am Coll Surg.

Severe trauma in the geriatric population

World J Crit Care Med.

Original
Predicción de la supervivencia en pacientes traumáticos ancianos: comparación entre la metodología TRISS y el Geriatric Trauma Outcome ScorePredicting survival in geriatric trauma patients: A comparison between the TRISS methodology and the Geriatric Trauma Outcome Score