Mortality Determinants in Severe Traumatic Brain Injury with Pneumonia: A Retrospective Study
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Introduction: Traumatic brain injury (TBI) is defined as an acute brain injury caused by mechanical forces to the head, excluding those related to drugs, alcohol, medications, or other conditions, such as systemic injuries, psychological trauma, or coexisting medical issues. TBI is a global public health issue responsible for significant disability and mortality, with an estimated global incidence of 69 to over 100 million new cases annually. This burden may be higher due to underreporting, particularly in low- and middle-income countries (LMICs). Several methods have been established to classify TBI, one of them is based on its severity with the Glasgow Coma Score (GCS). Pneumonia is a frequent complication in traumatic brain injury (TBI) patients, especially those on prolonged mechanical ventilation. Pneumonia could be classified based on the source of infection into ventilator-associated pneumonia (VAP), hospital-associated pneumonia (HAP), and community-acquired pneumonia (CAP).
Objective: To evaluate the mortality and risk factors of severe traumatic brain injury (sTBI) with pneumonia.
Methods: This study is a cross-sectional study with observational analytical investigations. The sample of this study is sTBI patients who were treated in Dr. Soetomo General Academic Hospital in 2023. Descriptive statistics were used to summarize the patients' characteristics. Chi-square tests and logistic regression were used to find relationship between factors that increase the risk of death and the development of pneumonia.
Results: In 2023, we documented 832 TBI cases, of these, 479 cases (57.6%) were mild TBI, 273 cases (32.8%) were moderate brain injuries, while severe brain injuries (sTBI) with 80 cases (9.6%). Our study shows that 50% of patients with sTBI have pneumonia, and VAP itself is one of the contributing factors to mortality in this population (p<0.001).
Conclusion: Of all types of pneumonia in this study, there is a statistical correlation between mortality and VAP in sTBI patients.
Lefevre-Dognin C, Cogné M, Perdrieau V, Granger A, Heslot C, Azouvi P. Definition and epidemiology of mild traumatic brain injury. Neurochirurgie. 2021;67(3):218–21.
Maas AIR, Menon DK, Adelson PD, Andelic N, Bell MJ, Belli A, et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017; 16(12): 987–1048.
Dewan MC, Rattani A, Gupta S, Baticulon RE, Hung YC, Punchak M, et al. Estimating the global incidence of traumatic brain injury. J Neurosurg. 2018; 130(4): 1080–97.
Hyder AA, Wunderlich CA, Puvanachandra P, Gururaj G, Kobusingye OC. The impact of traumatic brain injuries: a global perspective. NeuroRehabilitation. 2007; 22(5): 341–53.
Roozenbeek B, Maas AIR, Menon DK. Changing patterns in the epidemiology of traumatic brain injury. Nat Rev Neurol. 2013; 9(4): 231–6.
Rubiano AM, Carney N, Chesnut R, Puyana JC. Global neurotrauma research challenges and opportunities. Nature. 2015; 527(7578): S193–7.
Stocchetti N, Maas AIR. Traumatic intracranial hypertension. New England Journal of Medicine. 2014; 370(22): 2121–30.
Najem D, Rennie K, Ribecco-Lutkiewicz M, Ly D, Haukenfrers J, Liu Q, et al. Traumatic brain injury: classification, models, and markers. Biochemistry and cell biology. 2018; 96(4): 391–406.
Vermeij JD, Aslami H, Fluiter K, Roelofs JJ, van den Bergh WM, Juffermans NP, et al. Traumatic brain injury in rats induces lung injury and systemic immune suppression. J Neurotrauma. 2013; 30(24): 2073–9.
Jovanovic B, Milan Z, Djuric O, Markovic-Denic L, Karamarkovic A, Gregoric P, et al. Twenty-eight-day mortality of blunt traumatic brain injury and co-injuries requiring mechanical ventilation. Medical principles and practice. 2016; 25(5): 435–41.
Marjanović V, Novak V, Veličković L, Marjanović G. The incidence and risk factors of ventilator-associated pneumonia in patients with severe traumatic brain injury. Med Pregl. 2011; 64(7–8): 403–7.
Plurad DS, Kim D, Bricker S, Lemesurier L, Neville A, Bongard F, et al. Ventilator-associated pneumonia in severe traumatic brain injury: the clinical significance of admission chest computed tomography findings. Journal of surgical research. 2013; 183(1): 371–6.
Thal SC, Neuhaus W. The blood–brain barrier as a target in traumatic brain injury treatment. Arch Med Res. 2014; 45(8): 698–710.
Purkayastha S, Stokes M, Bell KR. Autonomic nervous system dysfunction in mild traumatic brain injury: a review of related pathophysiology and symptoms. Brain Inj. 2019; 33(9): 1129–36.
Sribnick EA, Popovich PG, Hall MW. Central nervous system injury–induced immune suppression. Neurosurg Focus. 2022; 52(2): E10.
Kesinger MR, Kumar RG, Wagner AK, Puyana JC, Peitzman AP, Billiar TR, et al. Hospital-acquired pneumonia is an independent predictor of poor global outcome in severe traumatic brain injury up to 5 years after discharge. Journal of Trauma and Acute Care Surgery. 2015; 78(2): 396–402.
Gao B, Li X, Yang F, Chen W, Zhao Y, Bai G, et al. Molecular epidemiology and risk factors of ventilator-associated pneumonia infection caused by carbapenem-resistant enterobacteriaceae. Front Pharmacol. 2019; 10: 262.
Gu D, Dong N, Zheng Z, Lin D, Huang M, Wang L, et al. A fatal outbreak of ST11 carbapenem-resistant hypervirulent Klebsiella pneumoniae in a Chinese hospital: a molecular epidemiological study. Lancet Infect Dis. 2018; 18(1): 37–46.
Xu H, Huo C, Sun Y, Zhou Y, Xiong Y, Zhao Z, et al. Emergence and molecular characterization of multidrug-resistant Klebsiella pneumoniae isolates harboring bla CTX-M-15 extended-spectrum β-lactamases causing ventilator-associated pneumonia in China. Infect Drug Resist. 2018; 33–43.
Wirtz MR, Moekotte J, Balvers K, Admiraal MM, Pittet JF, Colombo J, et al. Autonomic nervous system activity and the risk of nosocomial infection in critically ill patients with brain injury. Intensive Care Med Exp. 2020; 8: 1–14.
Hasan MJ, Sumi CD, Huq SMR, Anam AM, Rabbani R. Aerosolized plus intravenous polymyxin B versus colistin in the treatment of pandrug-resistant klebsiella pneumonia-mediated ventilator-associated pneumonia: A retrospective cohort study in Bangladesh. The Journal of Critical Care Medicine. 2023; 9(2): 106–15.
Li Y, Liu C, Xiao W, Song T, Wang S. Incidence, Risk Factors, and Outcomes of Ventilator-Associated Pneumonia in Traumatic Brain Injury: A Meta-analysis. Neurocrit Care. 2020; 32(1): 272–85.
Chen S, Gao G, Xia Y, Wu Z. Incidence rate and risk factors of ventilator-associated pneumonia in patients with traumatic brain injury: a systematic review and meta-analysis of observational studies. J Thorac Dis. 2023; 15(4): 2068.
Tsikritsaki K, Koukoulitsios G, Dimakou K, Lavdas K, Tsoulou V, Kalatzis I, et al. A41 Incidence and Outcome of Ventilator Associated Pneumonia in Traumatic Brain Injury Patients. European Journal of Anaesthesiology. 2012; 29: S12.
Eurich DT, Marrie TJ, Minhas-Sandhu JK, Majumdar SR. Ten-Year Mortality after Community-acquired Pneumonia. A Prospective Cohort. Am J Respir Crit Care Med. 2015; 192(5): 597–604.
Morgan A, Glossop A. Severe community-acquired pneumonia. BJA Educ. 2016; 16(5): 167–72.
Torres A, Niederman MS, Chastre J, Ewig S, Fernandez-Vandellos P, Hanberger H, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). European Respiratory Journal. 2017; 50(3).
Kózka M, Sega A, Wojnar-Gruszka K, Tarnawska A, Gniadek A. Risk Factors of Pneumonia Associated with Mechanical Ventilation. Int J Environ Res Public Health. 2020; 17(2): 656.
Blot S, Koulenti D, Dimopoulos G, Martin C, Komnos A, Krueger WA, et al. Prevalence, Risk Factors, and Mortality for Ventilator-Associated Pneumonia in Middle-Aged, Old, and Very Old Critically Ill Patients*. Crit Care Med. 2014; 42(3): 601–9.
Cangemi R, Calvieri C, Falcone M, Bucci T, Bertazzoni G, Scarpellini MG, et al. Relation of Cardiac Complications in the Early Phase of Community-Acquired Pneumonia to Long-Term Mortality and Cardiovascular Events. Am J Cardiol. 2015; 116(4): 647–51.
Cilloniz C, Ferrer M, Liapikou A, Garcia-Vidal C, Gabarrus A, Ceccato A, et al. Acute respiratory distress syndrome in mechanically ventilated patients with community-acquired pneumonia. European Respiratory Journal. 2018; 51(3): 1702215.
Yu Y, Fei A. Atypical pathogen infection in community-acquired pneumonia. Biosci Trends. 2016; 10(1): 7–13.
Lizaur-Utrilla A, Gonzalez-Parreño S, Gil-Guillen V, Lopez-Prats FA. Debridement with prosthesis retention and antibiotherapy vs. two-stage revision for periprosthetic knee infection within 3 months after arthroplasty: a case–control study. Clinical Microbiology and Infection. 2015; 21(9): 851.e11-851.e17.
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