Obese Trauma Research Articles

A survey of critical care pharmacists on venous thromboembolism prophylaxis dosing practices with enoxaparin in adult trauma patients

AbstractEnoxaparin is the preferred treatment for venous thromboembolism (VTE) prophylaxis in trauma patients, but timing of initiation, optimal dosing, and therapeutic drug monitoring remain controversial. The objective of this study was to evaluate enoxaparin VTE prophylaxis practices in adult trauma patients across trauma centers in the United States and compare results to current guideline recommendations. An online survey designed by the study investigators was sent to pharmacist members of the American College of Clinical Pharmacy (ACCP) Critical Care Practice Research Network (PRN) and residency directors of institutions with accredited Critical Care Pharmacy Residency programs in the fall of 2021. This survey queried pharmacists' self‐reported practices regarding enoxaparin dosing and monitoring in trauma patients. One hundred five responses were collected with an estimated response rate of 5.3%. Most respondents reported using a standard enoxaparin dose of 30 mg subcutaneously (SUBQ) every 12 h (67%; 70/104) in trauma patients with normal renal function and higher initial dosing for obese trauma patients (75%; 78/104). The most common body mass index (BMI) threshold for dose adjustments in obesity was a BMI ≥40 kg/m2; whereas 100 kg or more was commonly reported for a weight threshold. Multiple alternative enoxaparin dosing regimens were reported for obese and overweight patients. Of respondents who monitor anti‐Factor Xa (anti‐Xa) levels, 84% (61/73) reported monitoring peak levels with 47% (29/61) targeting a peak anti‐Xa goal of 0.2–0.4 units/ml. Seventy‐five percent (51/68) of respondents who adjust enoxaparin dosing based on anti‐Xa level monitoring reported adjusting doses by increments of 10 mg SUBQ every 12 h, and 41% (28/68) indicated having a pharmacist‐driven protocol for dose adjustments. Significant variation exists in enoxaparin dosing and monitoring strategies for VTE prophylaxis. Consensus among clinical practice guidelines is needed to standardize practice nationally.

Outcomes of the overweight and obese major trauma patient in the rural setting

PurposeOverweight and obese patients are more prevalent in rural and remote areas and are of major public health concern in Australia. We aimed to evaluate the mortality and morbidity of overweight and obese trauma patients in the rural Australian context. MethodThis was a retrospective cohort study on 207 major trauma patients (injury severity score [ISS] > 12) treated at the Mackay Base Hospital between 2018 and 2021. Data was extracted from the Mackay Base Hospital trauma database and hospital records. Outcomes were compared between body mass index (BMI) groups. ResultsThere were 164 males (79%) and 43 females (21%). The average BMI was 27.09 (standard deviation 5.46). 7 patients (3%) were in the underweight category (BMI < 18.5 kg/m2), 70 (34%) were of normal weight (BMI 18.5–24.9 kg/m2), 79 (38%) were overweight (BMI 25–29.9 kg/m2), and 51 (25%) were obese (BMI > 30 kg/m2). The majority of trauma was blunt (n = 203, 98%). Compared to patients with normal BMI, obese patients were significantly more likely to require intubation, intensive care unit (ICU) admission, and have a longer ICU stay. There were no significant differences in requirement for surgery, duration of surgery, hospital length of stay, ventilator time, or mortality (P > 0.05). However, subgroup analysis of the obese patient group showed an increased rate of complications (sepsis, acute kidney injury, fluid overload and pneumonia), longer ventilation times, hospital and ICU length of stay with increasing BMI in these patients. ConclusionThe majority of trauma presentations in our regional community are in overweight or obese patients. Overweight and obese patients are more likely to require intubation and have a longer intensive care unit admission than normal weight counterparts. Amongst obese patients, those with BMI > 40 (obesity class 3) are at significantly increased risk of complications.

INFLUENCE OF OBESITY ON VASCULAR DYSFUNCTION AFTER TRAUMATIC HEMORRHAGE.

Background: Obesity increases the risk for morbidity and mortality after trauma. These complications are associated with profound vascular damage. Traumatic hemorrhage acutely attenuates vascular responsiveness, but the impact of obesity on this dysfunction is not known. The local inflammatory response in vascular cells is also unknown. We hypothesized that obesity potentiates trauma-induced vascular inflammation and dysfunction. Methods: Male Sprague-Dawley rats (~250 g) were fed normal chow (NC; 13.5% kcal fat, n = 20) or high-fat (HF; 60% kcal fat, n = 20) diets for 6 to 8 weeks. Under anesthesia, hemorrhage was induced by a mesenteric artery laceration, a Grade V splenic injury, and hypotension (MAP = 30-40 mm Hg) for 30 minutes. Vascular responsiveness was assessed ex vivo in isolated mesenteric arteries prehemorrhage and posthemorrhage. Gene expression for IL-1β, and IL-6, prooxidant nicotinamide adenine dinucleotide phosphate oxidase 2 (NOX2), and α-adrenergic receptor were assessed in carotid artery endothelial cells (ECs) and non-ECs (media + adventitia). Results: In NC rats, hemorrhage attenuated norepinephrine-induced vasoconstriction and endothelium-dependent vasodilation to acetylcholine. In HF rats, baseline norepinephrine-induced vasoconstriction was attenuated compared with NC, but vasoconstriction and endothelium-dependent vasodilation did not change prehemorrhage to posthemorrhage. Hemorrhage led to elevated IL-1β gene expression in ECs and elevated IL1β, IL-6, NOX2, and α-adrenergic receptor gene expression in the media + adventitia compared with sham. HF rats had greater EC IL-1 β and NOX2 gene expression compared with NC rats. The hemorrhage-induced elevation of IL-1β in the media + adventitia was greatest in HF rats. Conclusion: Traumatic hemorrhage attenuates vascular responsiveness and induces vascular inflammation. The attenuated vascular responsiveness after hemorrhage is absent in obese rats, while the elevated vascular inflammation persists. A HF diet amplifies the arterial inflammation after hemorrhage. Altered vascular responsiveness and vascular inflammation may contribute to worse outcomes in obese trauma patients.

Effectiveness and Safety of High-Dose Thromboprophylaxis in Morbidly Obese Major Trauma Patients.

Trauma increases risk for venous thromboembolism (VTE) and obesity is a known independent risk factor for VTE development. Currently, no consensus on an optimal prophylactic dosing strategy for morbidly obese trauma patients exists. The objective of this study is to evaluate the effectiveness and safety of a BMI-stratified dosing strategy for VTE prophylaxis in morbidly obese trauma patients. This was a single center, retrospective cohort study of adult major trauma patients with a body mass index (BMI) of ≥40 kg/m2 admitted to the surgical-trauma intensive care unit from April 2014 to July 2020. Patients included were those who received enoxaparin 40 mg subcutaneously (SQ) every 12 hours (Q12H) for BMI of 40 to 49.9 kg/m2 or 60 mg SQ Q12H BMI ≥ 50 kg/m2 (per protocol), or enoxaparin 40 mg SQ Q12H for BMI of 40 to 49.9 kg/m2 (non-protocol). The primary endpoint was confirmed incidence of VTE. Secondary endpoints included occurrence of deep vein thrombosis (DVT) or pulmonary embolism (PE) during hospitalization, bleeding events, intensive care unit (ICU) and hospital length of stay (LOS) and hospital mortality. One hundred forty-five morbidly obese major trauma patients were included, with 123 patients (84.8%) in the per-protocol group. The primary outcome of in-hospital VTE did not occur in any patients in this group. Bleeding events occurred in 3 patients (2.7%) with a BMI of 40 to 49.9 kg/m2 and in 2 patients (16.7%) with a BMI of ≥50 kg/m2 (P = .064). Twenty-two patients in the non-protocol group were reviewed. One VTE event (4.5%) and no bleeding events occurred in this group. Median ICU LOS was 5 days, and hospital LOS was 11 days for the entire study group. Administration of enoxaparin 40 mg SQ Q12H to morbidly obese major trauma patients with a BMI of 40 to 49.9 kg/m2 and enoxaparin 60 mg SQ Q12H in those with a BMI of ≥50 kg/m2 resulted in low rates of VTE and bleeding events in the current study. However, future larger studies using this BMI-stratified dosing strategy are necessary to confirm these findings.

Exacerbated Vascular Inflammation Following Traumatic Hemorrhage in Obese Rats

IntroductionObesity increases the risk for morbidity and mortality in trauma patients. These complications are associated with prolonged tissue hypoperfusion, hypercoagulability, and edema that reflect profound vascular damage. Traumatic hemorrhage acutely attenuates vascular responsiveness, but the degree of this dysfunction during the obese state is not known. Traumatic hemorrhage also increases circulating inflammatory cytokines; however, the local inflammatory response in vascular cells is unknown. We hypothesized that obesity potentiates trauma‐induced vascular inflammation and dysfunction.MethodsMale Sprague‐Dawley rats (~250g) fed either normal chow (NC; 13.5% kcal fat, n=20), moderate‐fat (MF; 33% kcal fat, n=20), or high‐fat (HF; 60% kcal fat, n=20) diet for 6‐8 weeks were assigned to a traumatic hemorrhage protocol or sham control. Under anesthesia, hemorrhage was induced by the laceration of a mesenteric artery and a Grade V splenic injury. Hypotension (mean arterial pressure = 30–40 mm Hg) was maintained for 30 minutes. Vasoconstrictor and vasodilator properties were assessed ex vivo in isolated mesenteric arteries pre‐ and post‐ hemorrhage. Carotid arteries collected after hemorrhage or sham control were flushed with trizol to collect endothelial cells (ECs). Gene expression was assessed in ECs and the remaining carotid artery (media + adventitia) cells for pro‐inflammatory interleukin (IL)‐1β, and IL‐6, pro‐oxidant NADPH oxidase 2 (NOX2), and α‐adrenergic receptor.ResultsIn NC rats, hemorrhage attenuated norepinephrine‐induced vasoconstriction and endothelium‐dependent dilation. This was accompanied by elevated IL‐1β expression in carotid artery ECs and elevated IL‐1β, IL‐6, NOX2, and α‐adrenergic receptor expression in the carotid artery media + adventitia post‐hemorrhage versus sham control. In MF and HF rats, norepinephrine‐induced vasoconstriction and endothelium‐dependent dilation did not change pre‐ to post‐hemorrhage. In sham animals, endothelial cell IL‐1β and NOX2 expression were higher in HF compared with NC rats. Similar to NC rats, the MF and HF rats had higher IL‐1β expression in carotid artery ECs, and IL‐1β, IL‐6, NOX2, and α‐adrenergic receptor expression in the carotid artery media + adventitia post‐hemorrhage compared with sham. The hemorrhage‐induced elevation of IL‐1β in carotid artery ECs and media + adventitia was greater in HF rats compared with NC and MF rats.ConclusionOur clinically‐relevant model of traumatic hemorrhage attenuates vascular responsiveness and induces vascular inflammation. The attenuated vascular responsiveness following hemorrhage is absent in MF and HF rats, while the elevated vascular inflammation persists. HF rats have an amplified arterial inflammatory response to hemorrhage, both in ECs and in cells of the media + adventitia. The augmented vascular inflammatory response to hemorrhage in HF rats may explain the worse outcomes in obese trauma patients.

The impact of obesity on Singaporean trauma patients and their venous thromboembolism risk.

The impact of obesity on trauma outcomes had been equivocal and the majority of these studies were conducted in the Western population. The aim of our study is to evaluate the impact of obesity on morbidity and mortality in Singaporean patients after trauma. A retrospective case control study of trauma patients admitted to a tertiary institution was performed. Patients admitted for both blunt and penetrating trauma who are aged 16 years and above were included. Propensity score matching (PSM) was performed to reduce selection bias. A total of 5239 patients were reviewed (obese 648, non-obese 4591). Median age was 76 (IQR 63-83) years. Median BMI was 22.8kg/m2 (IQR 20.4-25.2). The overall median ISS was 10 (IQR 9-14). Median ISS was higher in non-obese patients, 10 (IQR 9-14) as compared to obese patients of ISS 9 (IQR 9-13), p=0.003. Obese patients had more abdominal injuries, n=27/648 (4.2%) than non-obese n=114/4591 (2.5%), p=0.013. Non-obese patients had more head injuries, n=1698/4591 (37%) as compared to the obese n=195/648 (30.1%), p=0.001. In-hospital mortality was comparable in the matched cohort (obese n=11/645 (1.7%), (non-obese, n=39/1290 (3.0%), OR 0.56 [0.28-1.09], p=0.085). ICU admission was shorter for the obese (n=36/645 (5.6%) versus n=108/1290 (8.4%), OR 0.65 [0.44-0.96], p=0.027). Obese patients had higher incidence of venous thromboembolism (n=16/645 (2.5%) versus n=12/1290 (0.9%), OR 2.71 [1.27-5.76], p=0.007). Obese trauma patients had fewer head injuries, fewer ICU admissions but comparable mortality rates. Obesity was also associated with higher incidence of venous thromboembolism in the matched cohort.

Obesity Does Not Increase Risk for Mortality in Severe Sepsis Trauma Patients.

The prevalence of obesity in the United States is up to 40% in adults. Obese patients with severe sepsis have a lower mortality rate compared with normal body mass index (BMI) patients. We hypothesized that trauma patients with severe sepsis and obese BMI will have a decreased mortality risk in comparison with normal BMI patients. The Trauma Quality Improvement Program (2017) was queried for adult trauma patients with documented BMI and severe sepsis. Patients were grouped based on BMI: non-obese trauma patients (nOTP) BMI <30kg/m2 and obese trauma patients (OTP) ≥30kg/m2. A multivariable logistic regression model was used for analysis of mortality. From 1246 trauma patients with severe sepsis, 566 (42.4%) were nOTP and 680 (57.6%) were OTP. OTP had increased length of stay (LOS) (19 vs 21 days, P < .001), intensive care unit (ICU) LOS (13 vs 18days, P < .001) and ventilator days (10 vs 11days, P < .001). After adjusting for covariates, when compared to normal BMI patients, patients who were overweight (OR 1.11 CI .875-1.41 P = .390), obese (OR .797 CI .59-1.06 P = .126), severely obese (OR .926 CI .63-1.36 P = .696) and morbidly obese (OR 1.448 CI 1.01-2.07 P = .04) all had a similar associated risk for mortality compared to patients with normal BMI. In adult trauma patients with severe sepsis, this national analysis demonstrated OTP had increased LOS, ICU LOS, and ventilator days compared to nOTP. However, patients with increasing degrees of obesity had similar associated risk of mortality compared to trauma patients with severe sepsis and a normal BMI.

Morbidity and Mortality in the Obese Trauma Intensive Care Unit Patient.

Obesity is an epidemic in the United States, known to be associated with comorbidities. However, some data show that obesity may be a protective factor in some instances. The purpose of this study is to determine if there are differences in morbidity and mortality when comparing the obese and non-obese critically ill trauma patient populations. This was a retrospective study conducted at Prisma Health Upstate in Greenville, South Carolina, an Adult Level 1 Trauma Center. Patients over the age of 18years admitted due to trauma from February 6, 2016 to February 28, 2019 were included in this study. Burn patients were excluded. An online trauma database was used to obtain age, sex, body mass index, Glasgow coma score (GCS), injury severity score (ISS), revised trauma score (RTS), days on mechanical ventilation, hospital length of stay (LOS), and intensive care unit (ICU) LOS. There were 2365 critically ill trauma patients who met inclusion criteria for this study. 1570 patients were men (66.38%) and mean age was 53.2 ± 20.9. Of the patients, 2166 patients had blunt trauma (91.59%). Median GCS was 15 (interquartilerange [IQR]: 12, 15), median RTS was 12 (IQR: 11, 12), and median ISS was 17 (IQR: 9, 22). Obese critically ill trauma patients had significantly lower odds of mortality than nonobese (OR .686, CI 0.473-.977). Penetrating traumas (OR: 4.206, CI: 2.478, 6.990), increased ISS (OR: 1.095, CI: .473, 1.112), and increased age (OR: 1.036, CI: 1.038, 1.045) were associated with significantly increased odds of mortality. The obesity paradox is observed in the obese critically ill trauma patient population.

The effect of perturbations of the glycocalyx on microvascular perfusion in the obese trauma population: an in vitro study

ObjectivesPatients with morbid obesity have impaired responses to resuscitation following severe injury, which may contribute to adverse outcomes. Obesity is associated with microvascular dysfunction and metabolic changes associated with altered...

Fibrinogen level at hospital admission after multiple injury correlates with BMI and is negatively associated with the need for transfusion and early multiple organ failure

IntroductionBleeding and coagulopathy are leading causes of morbidity and lethal outcome after multiple injuries. The pathophysiology of traumatic coagulopathy is under extensive investigations and recent results highlighted the central role of fibrinogen and the fibrin polymerisation process. Our goal was to investigate the factors influencing fibrinogen level and the consequences of hypofibrinogenaemia with clinical importance. MethodsWe conducted a retrospective analysis enrolling adult patients admitted to the shock room of a tertiary trauma centre in Hungary. Beside coagulation values, demographic data, injury related, transfusion and outcome parameters were collected from the hospital electronic charts. Only patients with complete e-chart were involved into final analysis. Multivariate linear and proportional odds logistic regression models were used to model outcomes – admission fibrinogen and SOFA score – controlling for age, sex, BMI, ISS and lactic acidosis. Results54 patients were enrolled in final analysis. Among the parameters analysed, BMI was positively associated with fibrinogen level at admission (+0.23 g/l for every 5 unit of increase in BMI, 95% CI: 0.09-0.37, p=0.0021). Increased risk of transfusion was observed, if fibrinogen at admission was about 1.8 g/l or lower. Beside age and ISS, fibrinogen concentration was also a determinant of early organ failures as it negatively correlated with SOFA scores within 24 hours or care (OR=2.42, 95% CI: 1.05-5.62, for 1 g/l decrease, p=0.0388). ConclusionsIn our trauma cohort BMI seems to significantly influence fibrinogen level at admission. This result draws our attention to the possible differences of haemostasis process, and consequently different diagnostic and therapeutic thresholds in the management of obese trauma patients. Moderate hypofibrinogenaemia increases transfusion risk and beside ISS might be a prognostic factor of early MOF after multiple injuries.

Effect of Nursing guidelines on obese trauma patients' outcomes

Obese patients have alterations in respiratory physiology and circulatory physiology that significantly affect their evaluation and resuscitation. Aim: To evaluate effect of nursing guidelines on obese trauma patients’ outcomes. Research design: A quasi experimental research design was utilized. Setting: This study was conducted in trauma emergency unite of Dayrut General Hospital. Tool of data collection: (I): obese trauma patient assessmentand (II): Patient evaluation sheet. Result: There were statistically significant difference between study and control groups regarding patient assessment and distribution of complication as hypoxia and apnea. Conclusion: study group showed reduced in complication and achieved satisfactory level according achieved points regarding patient out come after application of nursing guidelines. Recommendation: study need to conduct in a large number of patient and involved inpatient and ICU obese trauma patients.

Obese trauma patients who sustain orthopaedic fractures experience increased length of stay, ICU admissions and mortality

The rising trend of obesity in the United States has been a growing concern within the healthcare system for decades. Since the early 1960s, the prevalence of obesity has more than doubled among U.S. adults, and one out of every three Americans is now considered obese according to the National Health and Nutrition Examination Survey [1,2]. Significant medical comorbidities have been associated with obesity and increased Body Mass Index (BMI); these include hypertension, dyslipidemia, coronary artery disease, stroke, sleep apnea, type II diabetes mellitus and certain types of cancer.

Obesity associated with increased postoperative pulmonary complications and mortality after trauma laparotomy

BackgroundPatient-related risk factors for the development of postoperative pulmonary complications (PPCs) include age ≥ 60-years, congestive heart failure, hypoalbuminemia and smoking. The effect of obesity is unclear and has not been shown to independently increase the likelihood of PPCs in trauma patients undergoing trauma laparotomy. We hypothesized the likelihood of mortality and PPCs would increase as body mass index (BMI) increases in trauma patients undergoing trauma laparotomy.MethodsThe Trauma Quality Improvement Program (2010–2016) was queried to identify trauma patients ≥ 18-years-old undergoing trauma laparotomy within 6-h of presentation. A multivariable logistic regression analysis was used to determine the likelihood of PPCs and mortality when stratified by BMI.ResultsFrom 8,330 patients, 2,810 (33.7%) were overweight (25–29.9 kg/m2), 1444 (17.3%) obese (30–34.9 kg/m2), 580 (7.0%) severely obese (35–39.9 kg/m2), and 401 (4.8%) morbidly obese (≥ 40 kg/m2). After adjusting for covariates including age, injury severity score, chronic obstructive pulmonary disease, smoking, and rib/lung injury, the likelihood of PPCs increased with increasing BMI: overweight (OR = 1.37, CI 1.07–1.74, p = 0.012), obese (OR = 1.44, CI 1.08–1.92, p = 0.014), severely obese (OR = 2.20, CI 1.55–3.14, p < 0.001), morbidly obese (OR = 2.42, CI 1.67–3.51, p < 0.001), compared to those with normal BMI. In addition, the adjusted likelihood of mortality increased for the morbidly obese (OR = 2.60, CI 1.78–3.80, p < 0.001) compared to those with normal BMI.ConclusionObese trauma patients undergoing emergent trauma laparotomy have a high likelihood for both PPCs and mortality, with morbidly obese trauma patients having the highest likelihood for both. This suggests obesity should be accounted for in risk prediction models of trauma patients undergoing laparotomy.Electronic supplementary materialThe online version of this article (10.1007/s00068-020-01329-w) contains supplementary material, which is available to authorized users.

Venous thromboembolism chemoprophylaxis regimens in trauma and surgery patients with obesity: A systematic review.

Venous thromboembolism (VTE) continues to be a devastating source of morbidity and mortality in obese patients who suffer traumatic injuries or obese surgery patients. High incidence rates in VTE despite adherence to prevention protocols have stirred interest in new dosing regimens. The purpose of this study was to systematically review the literature and present the existing VTE chemoprophylaxis regimens for obese trauma and surgical patients in terms of efficacy and safety as measured by the incidence of VTE, anti-factor Xa levels, and the occurrence of bleeding events. An online search of seven literature databases including PubMed, Excerpta Medica Database, GoogleScholar, JAMA Network, CINAHL, Cochrane, and SAGE Journals was performed for original studies evaluating the safety and efficacy of VTE chemoprophylaxis dosing regimens according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The risk of bias was assessed using the Cochrane Risk of Bias Tool and the quality of evidence was determined using the GRADE Working Group criteria. Of the 5,083 citations identified, 45 studies with 27,717 patients met inclusion criteria. In this group, six studies evaluated weight-based dosing regimens, four used a weight-stratified or weight-tiered strategy, five used a body mass index-stratified approach, 29 assessed fixed-dose regimens, and two used continuous infusions. The majority of the studies evaluated anti-factor Xa levels as their primary outcome rather than reduction in VTE. Weight-based and high fixed-dose chemoprophylaxis regimens achieved target anti-Xa concentrations more frequently than standard fixed-dose regimens but were not associated with a reduction in VTE. Additionally, high fixed-dose approaches are associated with increased bleeding complications. Further evaluation with large randomized trials is warranted in trauma and surgery patients with obesity. Systematic review, level III.

Obesity Associated with Increased Postoperative Pulmonary Complications and Mortality after Trauma Laparotomy

Patient-related risk factors for the development of postoperative pulmonary complications (PPCs) include age ≥ 60-years, congestive heart failure, hypoalbuminemia and smoking. The effect of obesity is unclear and has not been shown to independently increase the likelihood of PPCs in trauma patients undergoing trauma laparotomy. We hypothesized the likelihood of mortality and PPCs would increase as body mass index (BMI) increases in trauma patients undergoing trauma laparotomy. The Trauma Quality Improvement Program (2010–2016) was queried to identify trauma patients ≥ 18-years-old undergoing trauma laparotomy within 6-h of presentation. A multivariable logistic regression analysis was used to determine the likelihood of PPCs and mortality when stratified by BMI. From 8,330 patients, 2,810 (33.7%) were overweight (25–29.9 kg/m2), 1444 (17.3%) obese (30–34.9 kg/m2), 580 (7.0%) severely obese (35–39.9 kg/m2), and 401 (4.8%) morbidly obese (≥ 40 kg/m2). After adjusting for covariates including age, injury severity score, chronic obstructive pulmonary disease, smoking, and rib/lung injury, the likelihood of PPCs increased with increasing BMI: overweight (OR = 1.37, CI 1.07–1.74, p = 0.012), obese (OR = 1.44, CI 1.08–1.92, p = 0.014), severely obese (OR = 2.20, CI 1.55–3.14, p < 0.001), morbidly obese (OR = 2.42, CI 1.67–3.51, p < 0.001), compared to those with normal BMI. In addition, the adjusted likelihood of mortality increased for the morbidly obese (OR = 2.60, CI 1.78–3.80, p < 0.001) compared to those with normal BMI. Obese trauma patients undergoing emergent trauma laparotomy have a high likelihood for both PPCs and mortality, with morbidly obese trauma patients having the highest likelihood for both. This suggests obesity should be accounted for in risk prediction models of trauma patients undergoing laparotomy.

Obese trauma patients have increased need for dialysis.

Obesity is a risk factor for the development of acute kidney injury but its effect on the need for dialysis in trauma has not been elucidated. Additionally, the contribution that obesity has towards risk of mortality in trauma is unclear. We hypothesized that patients with a higher body mass index (BMI) will have a higher risk for need of dialysis and mortality after trauma. This is a retrospective analysis using the National Trauma Data Bank. All patients ≥ 8 years old were grouped based on BMI: normal (18.5-24.99kg/m2), obese (30-34.99kg/m2), severely obese (35-39.99kg/m2) and morbidly obese (≥ 40kg/m2). The primary outcome was hemodialysis initiation. The secondary outcome was mortality during the index hospitalization. From 988,988 trauma patients, 571,507 (57.8%) had a normal BMI, 233,340 (23.6%) were obese, 94,708 (9.6%) were severely obese, and 89,433 (9.0%) were morbidly obese. The overall rate of hemodialysis was 0.3%. After adjusting for covariates, we found that obese (OR 1.36, CI 1.22-1.52, p < 0.001), severely obese (OR 1.89, CI 1.66-2.15, p < 0.001) and morbidly obese (OR 2.04, CI 1.82-2.29, p < 0.001) patients had a stepwise increased need for hemodialysis after trauma. Obese patients had decreased (OR 0.92, CI 0.88-0.95, p < 0.001), severely obese had similar (OR 1.02, CI 0.97-1.08, p = 0.50) and morbidly obese patients had increased (OR 1.06, CI 1.01-1.12, p = 0.011) risk of mortality after trauma. Obesity was associated with an increased risk for dialysis after trauma. Mortality risk was reduced in obese, similar in severely obese, and increased in morbidly obese trauma patients suggesting an inflection threshold BMI for risk of mortality in trauma.

Obesity increases the risk of chronic pain development after motor vehicle collision.

Obesity has been found to increase the risk of musculoskeletal pain (MSP) in other settings, but to our knowledge, the influence of increased body mass index on pain outcomes after common trauma exposures such as motor vehicle collision (MVC) has not been assessed. In addition, obesity results in biomechanical changes, as well as physiologic changes including reduced hypothalamic pituitary adrenal axis negative feedback inhibition, but mechanisms by which obesity may result in worse post-traumatic outcomes remain poorly understood. In this study, we evaluated the influence of body mass index on axial and overall MSP severity (0-10 numeric rating scale) 6 weeks, 6 months, and 1 year after MVC among 917 European Americans who presented to the emergency department for initial evaluation. After adjusting for an array of sociodemographic factors, obesity (particularly morbid obesity) was an independent risk factor for worse MSP after MVC (eg, RR 1.41 [95% CI 1.11, 1.80] for moderate or severe MSP 6 months after MVC among morbidly obese vs normal weight MVC survivors). Interestingly, substantial effect modification was observed between obesity risk and a genetic variant known to reduce hypothalamic pituitary adrenal axis negative feedback inhibition (FKBP5 rs9380526). (eg, 41% vs 16% increased risk of moderate or severe MSP at 6 months among obese individuals with and without the risk allele.) Further studies are needed to elucidate mechanisms underlying chronic pain development in obese trauma survivors and to develop interventions that will reduce chronic pain severity among this common, at-risk group.

Complications of pelvic and acetabular fractures in 1331 morbidly obese patients (BMI\u2009\u2265\u200940): a retrospective observational study from the National Trauma Data Bank

BackgroundThere have been no large-scale epidemiological studies of outcomes and perioperative complications in morbidly obese trauma patients who have sustained closed pelvic ring or acetabular fractures. We examined this population and compared their rate of inpatient complications with that of control patients.MethodsWe retrospectively reviewed the records of patients treated for closed pelvic ring or acetabular fracture, aged 16–85 years, with Injury Severity Scores ≤15 from the National Trauma Data Bank Research Dataset for the years 2007 through 2010. The primary outcome of interest was rate of in-hospital complications. Secondary outcomes were length of hospital stay and discharge disposition. Unadjusted differences in complication rates were evaluated using Student t tests and Chi-squared analyses. Multiple logistic and Poisson regression were used to analyze binary outcomes and length of hospital stay, respectively, adjusting for several variables. Statistical significance was defined as p < 0.05.ResultsWe included 46,450 patients in our study. Of these patients, 1331 (3%) were morbidly obese (body mass index ≥40) and 45,119 (97%) were used as controls. Morbidly obese patients had significantly higher odds of complication and longer hospital stay in all groups considered except those with pelvic fractures that were treated operatively. In all groups, morbidly obese patients were more likely to be discharged to a skilled nursing/rehabilitation facility compared with control patients.ConclusionsMorbidly obese patients had higher rates of complications and longer hospital stays and were more likely to be discharged to rehabilitation facilities compared with control patients after pelvic ring or acetabular fracture.

Is elevated body mass index protective against cervical spine injury in adults?

Correlate body mass index (BMI) with incidence and type of cervical spine injury seen on CT in adult patients presenting with blunt trauma. Retrospective chart review of all adult blunt trauma patients who had a cervical spine CT performed at our level 1 trauma center during an approximately 3-year period. A statistically significant (p = 0.01) difference in cervical spine injury incidence was present between different BMI groups. Cervical spine injury incidence was 7.7% for underweight (BMI ≤ 18) patients, 7.1% for normal weight (BMI 18-25) patients, 6.2% for overweight/obese (BMI 25-35) patients, and 4.7% for morbidly obese (BMI > 35) patients. Using BMI > 18-25 as a reference group, females with BMI > 25-35 had an adjusted odds ratio (aOR) of 0.56 (CI 0.41-0.75) and females with BMI > 35 had an aOR of 0.42 (CI 0.26-0.70). Males with a BMI ≤ 18 had an aOR of 2.20 (CI 1.12-4.32) and males with BMI > 35 had an aOR of 0.66 (CI 0.46-0.95). A particularly low incidence of cervical spine injury was observed in patients older than 65 in the obese group with a cervical spine injury rate of only 1.4% in this patient population. No statistical significant difference was seen in injury morphology across the BMI groups. An inverse relationship exists between BMI and the overall incidence of cervical spine injury. This protective effect appears to be influenced by gender with elevated BMI having lower relative odds of cervical spine injury in women than in men. A particularly low rate of cervical spine injury was identified in obese patients over the age of 65. Routine imaging of all elderly, obese trauma patients with low energy mechanism of injury may not be warranted.

The effects of cryopreserved red blood cell transfusion on tissue oxygenation in obese trauma patients.

Low tissue oxygenation (StO2) is associated with poor outcomes in obese trauma patients. A novel treatment could be the transfusion of cryopreserved packed red blood cells (CPRBCs), which the in vitro biochemical profile favors red blood cell (RBC) function. We hypothesized that CPRBC transfusion improves StO2 in obese trauma patients. Two hundred forty-three trauma patients at five Level I trauma centers who required RBC transfusion were randomized to receive one to two units of liquid packed RBCs (LPRBCs) or CPRBCs. Demographics, injury severity, StO2, outcomes, and biomarkers of RBC function were compared in nonobese (body mass index [BMI] < 30) and obese (BMI ≥ 30) patients. StO2 was also compared between obese patients with BMI of 30 to 34.9 and BMI ≥ 35. StO2 was normalized and expressed as % change after RBC transfusion. A p value less than 0.05 indicated significance. Patients with BMI less than 30 (n = 141) and BMI of 30 or greater (n = 102) had similar Injury Severity Score, Glasgow Coma Scale, and baseline StO2. Plasma levels of free hemoglobin, an index of RBC lysis, were lower in obese patients after CPRBC (125 [72-259] μg/mL) versus LPRBC transfusion (230 [178-388] μg/mL; p < 0.05). StO2 was similar in nonobese patients regardless of transfusion type, but improved in obese patients who received CPRBCs (104 ± 1%) versus LPRPCs (99 ± 1%, p < 0.05; 8 hours after transfusion). Subanalysis showed improved StO2 after CPRBC transfusion was specific to BMI of 35 or greater, starting 5 hours after transfusion (p < 0.05 vs. LPRBCs). CPRBCs did not improve clinical outcomes in either group. CPRBC transfusion is associated with increased StO2 and lower free hemoglobin levels in obese trauma patients, but did not improve clinical outcomes. Future studies are needed to determine if CPRBC transfusion in obese patients attenuates hemolysis to improve StO2. Therapeutic, level IV.