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Master Thesis

Limitation et arrêt des thérapeutiques chez les patients traumatisés : étude multicentrique, analytique, descriptive, rétrospective à partir de la Traumabase™

Abstract : Background: Traumatology is the first cause of death and handicap under 45 years old in France. Half of the deaths in Intensive care units (ICU) are preceded by a decision of withholding or withdrawal of life-sustaining therapy (WLST). The main objective of our study is to determine the incidence of WLST decisions on severe trauma patients in France using the Traumabase™ data. Our hypothesis is that the proportion of WLST in injured patient is the same as the general population of ICU. We will describe the population of injured patients for whom a WLST decision was made and we will determine the factors associated with this decision. Methods: This descriptive, analytical and retrospective study analyzed data from 14 french centers participating in the Traumabase™ database. Any type of trauma managed for less than 48 hours was recorded. Results: The data from 8569 patients was analyzed over the period of January 2016 to December 2018 included. The median age was 36 years old [25-54]. The ISS and SOFA score were 13 [6-24] and 1 [0-6], respectively. A WLST decision was made in 6% (490/8569) of the cases. ICU mortality was 11% (907/8569). 47% (422/907) of deaths were preceded by WLST decisions. Among the patients with a WLST decision, 86% (422/490) will die before ICU discharge. The WLST group was older, had more comorbidities and severity scores were higher. 74% of the patients presented cerebral lesions on CT-scan associated with bilateral mydriasis in 21% of cases. The factors associated with a WLST decision were : age (OR=1.04 - IC0.95 [1.04-1.05] for each additional year), ASA score >=3 (OR = 1.73 - IC0.95 [1.25-2.38]), ISS score (OR = 1.02- IC0.95 [1.01-1.03] per point), SOFA score (OR=1.15 - IC0.95 [1.11-1.20] per point), pre-hospital cardiopulmonary resuscitation (OR =2.59 - IC0.95 [1.72-3.91], pre-hospital orotracheal intubation (OR=1.52 - IC0.95 [1.10-2.11]), cerebral lesions on CT-scan (OR=2.38 - IC0.95 [1.77-3.20]) and pre-hospital bilateral mydriasis (OR=1.69 - IC0.95 [1.14-2.48]). The management of severe trauma in the Northern and Ile de France regions compared to the Southern region was independently associated with a WLST decision (OR=1.60 - IC0.95 [1.09-2.36] and OR=1.44 - IC0.95 [1.02-2.07], respectively). Conclusion: We carried out the first French epidemiological study concerning the WLST decisions in severe trauma patients using data from the Traumabase ™. The incidence of these decisions is lower than in non-trauma patients admitted in ICU. The pre-existing medical diseases influence the decision of WLST. Trauma severity criteria are the most predictive elements of WLST decision. Neurological status is a major determinant in WLST decisions. Surprisingly, our study highlights an inter-regional variability of WLST practice in France.
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Submitted on : Wednesday, December 11, 2019 - 4:36:15 PM
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Laura Kubacsi. Limitation et arrêt des thérapeutiques chez les patients traumatisés : étude multicentrique, analytique, descriptive, rétrospective à partir de la Traumabase™. Sciences du Vivant [q-bio]. 2019. ⟨dumas-02405173⟩



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