THE IMPACT OF SOMATIC PATHOLOGY ON THE LEVEL OF MORTALITY IN ELDERLY PATIENTS WITH POLYTRAUMA
Kuban State Medical University,
Scientific Research Institute – Ochapovsky Regional Clinical Hospital No.1,
Krasnodar, Russia
Individuals of elderly and senile age are one of the rapidly increasing groups of the population [1, 2, 3]. At the same time, the amount of patients with injuries, including polytrauma [4, 5, 6], is increasing as result of active way of life [7].
651 patients with polytrauma, age of 18-59, received treatment in Ochapovsky Regional Clinical Hospital No.1 in 2015. The severity of the injuries was ≥ 17 points according to NISS (the mortality is 8.2 %). Also 17 patients at the age older 60 with NISS ≥ 17 were treated (the mortality is 28.6 %).
According to the data from various authors [1, 7, 8, 9], the physiologic age changes in the body and the concurrent somatic pathology determine the difference in mortality despite of similar injuries and treatment approaches in patients of older age groups and in patients of young and middle age, with sudden failure of compensatory capabilities of the body [9] with possible lethal outcomes [1, 7, 8] in older patients.
We have not found any publications about estimation of the relationship between comorbidity [10], age, severity of polytrauma and mortality in the modern special medical literature. It has determined the relevance of the study.
Objective – to evaluate the impact of somatic pathology on mortality in patients of elderly and senile age with polytrauma.
MATERIALS AND METHODS
For achievement of the objective we conducted the study on the basis of the retrospective analysis of 95 older patients with polytrauma who received treatment in Scientific Research Institute – Ochapovsky Regional Clinical Hospital No.1, Krasnodar, in 2008-2012.
The tasks of the study were:
– estimation of the structure of the concurrent somatic pathology in the examined group;
– estimation of the index of comorbidity in the patients of the examined group and estimation of influence on the mortality.
The conditions for participation in the study:
– polytrauma, NISS ≥ 17 [11, 12];
– duration of the prehospital stage not exceeding 40 min;
– realization of intensive care in the intensive care unit or in the emergency surgery department for all patients;
– monitoring of hemodynamics, hemograms, homeostasis and central venous pressure (CVP) which determine the rate, quality and the volume of infusion therapy.
All patients received the staged surgical treatment with consideration of the requirements of the concept of damage control surgery (DCS) and damage control orthopedics (DCO) [5, 13, 14].
Age distribution in the study group (95 patients) was realized with consideration of the classification from WHO [2]. The results are presented in the table 1.
| Table 1 | |
| Distribution of the group of the examined patients (n = 95) | |
Most patients suffered from high energy injuries: road accidents – 72 patients (75.8 %), falling from height – 9 patients (9.5 %), other causes – 14 (14.7 %). The table 2 demonstrates the distribution of the injuries according to anatomic regions.
The characteristics of the identified injuries in various anatomic regions in the study group (the table 2) are similar with the data from the medical literature [7, 14].
| Table 2 | ||||
| The injuries in the patients of the examined group | ||||
The mortality in the study group (2008-2012) was 37.9 %.
For investigation of the structure of the concurrent pathology we conducted the analysis of the case histories of all patients of the study group. Presence or absence of concurrent pathology was determined according to the results of the clinical examination in 74 patients (77.9 %) and autopsy in 21 patients (22.1 %).
Considering the fact of absence of a special scale for estimating comorbidity in patients with polytrauma, Charlson index was used for complex estimation of concurrent diseases [10, 15]. Charlson index is used for predicting mortality from oncopathology, various chronic diseases and long periods of observation [16], and may be used for patients with polytrauma.
Charlson index is a qualimetric system for estimation of age and concurrent diseases. Calculations are based on summarizing the points, which correspond to concurrent diseases, with addition of 1 point per each 10 years of life for a patient at the age older 40.
The statistical analysis and the analysis of clinical materials were conducted with characteristics of descriptive statistics. Mann-Whitney non-parametric test or χ2 test were used for comparison of the hypotheses. The statistically significant results were p value of 0.05 or lower. Statistica 8.0 was used for the statistical analysis.
RESULTS
Comorbidities were found in 87 (91.6 %) patients of the study group. The table 3 shows the rate of the identified diseases.
| Table 3 | ||||||||
| Concurrent pathologic states and frequency of their identification in the examined group | ||||||||
The analysis of comorbidities found the most common concurrent somatic diseases: arterial hypertension (73.7 %), coronary heart disease (57.9 %), with combination of the above-mentioned diseases in 38.9 % (n = 37).
For solving the assigned tasks the study group was distributed into 2 subgroups according to the selection criteria – survival or death:
– the patients with favorable outcomes who were discharged or transferred to other medical facilities (n = 59), the mean age was 67.9 ± 6.5, NISS – 29.4 ± 9.1;
– the lost patients (n = 36), mean age of 71.2 ± 7, NISS – 30.8 ± 10.8.
The patients were statistically similar in age (p = 0.09) and severity of the injuries (p = 0.41) in the subgroups of the survived and lost individuals. Distribution of numerical values did not correspond to the normal law; as result, Mann-Whitney non-parametric test was applied [17].
Charlson index was used for complex estimation of comorbidities. The analysis showed the higher values of Charlson index in the lost patients with polytrauma in comparison with the survivors. Charlson index was 4.7 ± 1.4 in the survivors, and 5.8 ± 2.1 in the lost patients (p = 0.001). It means that Charlson index influences on mortality.
For further analysis the patients of the study group (n = 95) were distributed according to severity of polytrauma (a favorable outcome, NISS = 17÷24 (n = 37), unclear or unfavorable outcome, NISS > 24 (n = 58) [18]). The influence of somatic comorbidity and severity of the injuries on the treatment outcomes was examined. The results are presented in the table 4.
| Table 4 | ||||||||
| Charlson index (Ì ± STD)* and mortality for the groups with different values of NISS | ||||||||
The table 4 shows the absence of any statistically significant differences in Charlson index in the compared groups. The higher values of NISS correspond to the statistically significant increase (almost two times) of the proportion of lethal outcomes. The patients with unclear and poor predicted outcomes were included into the single group because of absence of any statistically significant differences in comorbidities.
The groups with different values of NISS were distributed into the subgroups with different outcomes of treatment (lost and survivors). Charlson index was estimated (the table 5).
The received results (the table 5) showed that the highest influence on mortality was associated with somatic comorbidity in polytrauma with relatively favorable predicted outcome for life (NISS – 17-24) [18]. Charlson index was 6.2 ± 1.8 in the lost patients and 4.8 ± 1.3 in the survivors (p = 0.048).
| Table 5 | |||||||||||
| Charlson index for the groups with different points according to NISS in the subgroups with different outcomes of treatment | |||||||||||
The influence of somatic comorbidity was similar, but less intense, for the individuals with relatively unclear and unfavorable predicted outcomes: NISS > 24, Charlson index – 5.6 ± 1.5 in the lost patients and 4.6 ± 1.4 in the survivors (p = 0.009).
The figure shows the levels of mortality for different values of Charlson index in the group with relatively favorable predicted outcomes on the basis of estimation of severity of the injuries.
Figure
The levels of mortality for different values of Charlson index in the group with relatively favorable prognosis for life (NISS 17÷24)
Therefore, comorbidity was found to influence on mortality in the patients with relatively favorable predicted outcomes for life with NISS < 25: the mortality was 21 % for Charlson index of 3-4, more than 40 % – for 5-6, > 50 % – for 7 and higher, 100 % – for 9.
Comorbidity is one of the factors influencing on treatment outcomes in the patients at the age of 60 and older. Charlson index ≥ 5 was associated with the highest amount of unfavorable outcomes regardless of age and severity of the injuries (the mortality was 51.7 % for 60 patients with Charlson index ≥ 5).
DISCUSSION
The approaches to treating older patients with polytrauma should be different from similar approaches for patients of young and middle age, as well as the following moments are considered: age and comorbidity. Timely diagnostics of comorbidity is significant. It allows correcting the treatment with consideration of comorbidity, as well as subsequent correction of homeostasis.
Charlson index ≥ 5 is unfavorable for life. Therefore, one may suppose that amount of comorbidities plays a significant role for older age and physiologic changes for senile age.
The patients with NISS ≥ 25 demonstrated lower influence of comorbidity. The lethal outcomes were mainly conditioned by severity of the injuries.
Use of comorbidity index for estimation of outcomes of polytrauma in combination with the scale for prediction of polytrauma outcome allows objectifying a possibility of realization of stages of surgical treatment for patient with polytrauma, considering damage control concept.
CONCLUSION
1. Estimation of comorbidity by means of comorbidity index allows clarifying predicted outcomes for life in older and senile patients with polytrauma.
2. Mortality is mainly influenced by somatic comorbidity with polytrauma with relatively favorable predicted outcome for life; with NISS 17÷24, Charlson index was 6.2 ± 1.8 in the lost patients and 4.8 ± 1.3 in the survivors.
3. Charlson index > 5 presents unfavorable predicted outcomes in older patients.