More medications, more problems: results from the Sedation Level after Emergent Exlap with Packing for TRAUMA (SLEEP-TRAUMA) study

Abstract

Purpose Sedation management of trauma patients after damage control laparotomy (DCL) has not been optimized. We evaluated if shorter sedation exposure was associated with increased proportion of delirium-free/coma-free (DF/CF-ICU) days and change in time to definitive fascial closure (DFC). Methods We reviewed trauma DCL patients at an ACS-verified level I center over 5 years as shorter (SE) or longer than median (LE) sedation exposure. We compared demographics, injury patterns, hemodynamic parameters, and injury severity between groups. We calculated the propensity for each patient to achieve DFC using age, gender, ISS, red blood cell transfusion, bowel discontinuity, abdominal vascular injury, and time to first takeback; we then determined the effect of sedation exposure on rate of DFC by multivariate Cox regression, adjusted for propensity to achieve DFC. We used linear regression adjusted for age, ISS, head-AIS, bowel discontinuity, and vascular injury to determine the effect of sedation exposure on the proportion of DF/CF-ICU days. Results 65 patients (33.8% penetrating) had mean age 41.8 ± 16.0, ISS 27.1 ± 14.2, Head-AIS 1.2 ± 1.6 and median sedation exposure of 2.2 [IQR 0.78, 7.3] days (35 SE and 30 LE). Pattern and severity of solid organ injuries and proportion of small and large bowel and vascular injuries were similar between groups. LE had more abdominal sepsis (23.3% vs 0%, p = 0.003) and enterocutaneous fistula (16.7% vs 0%, p = 0.016), and more ventilator (17.3 ± 12.7 vs 6.1 ± 6.8, p < 0.001), ICU (20.8 ± 14.2 vs 7.2 ± 7.6, p < 0.001), and hospital days (29.6 ± 19.6 vs 13.9 ± 9.0, p < 0.001). DFC was achieved more rapidly in the SE group (2.0 ± 1.5 days vs 3.9 ± 3.7 days [unadjusted], p = 0.023) and SE had a higher proportion of unadjusted DF/CF-ICU days (33.0 ± 32.0% vs 18.1 ± 16.4%, p = 0.020). SE was associated with an increased proportion of adjusted DF/CF-ICU days by multivariate linear regression (13.1% [95% CI 1.4-24.8%], p = 0.029) and with faster adjusted rate of DFC by multivariate Cox regression (RR 2.28 [95% CI 1.25-4.15, p = 0.007]). Conclusions Shorter sedation exposure is associated with increased proportion of DF/CF-ICU days and more rapid DFC after DCL for trauma.

Dexmedetomidine and paralytic exposure after damage control laparotomy: risk factors for delirium? Results from the EAST SLEEP-TIME multicenter trial

“…In our multivariable linear regression analysis, the only two commonalities identified among those listed above were the use of paralytic and dexmetomidine infusions as risk factors associated with decreased DF/CF-ICU-30. This corroborates single-institution data recently published by Kim et al demonstrating that longer exposure to sedation in trauma patients after DCL was associated with a reduction in DF/CF-ICU-30 [22]. Other studies have shown that deeper levels of sedation and longer exposure to sedation has been linked to worse ICU outcomes, but not specifically to delirium.…”

“…The primary endpoint was DF/CF-ICU-30, defined as the number of ICU days out of the first 30 ICU days during which the RASS was at least -3 and the CAM-ICU score was negative divided by the total number of ICU days for each patient and converted to a percentage. The intent of this measure is to serve as a surrogate marker of freedom from delirium, calculated in a manner that avoids bias from varying lengths of ICU stay, previously published by Kim, et al [22] Furthermore, our measure was censored at 30 days to account for the fact that, for the purposes of our study, it was only feasible to collect ICU data for the first 30 days of the patient's ICU stay [22]. Due to the significant differences in mechanisms, patients were grouped as trauma (T) or nontrauma (NT) for purposes of analysis.…”

“…There are few studies specifically evaluating the effects of sedation in the DCL patient population [21]. One recent study by Kim et al demonstrated that shorter exposure to sedation was actually associated with an increased proportion of delirium-free coma-free ICU days and an increased rate of achieving PFC, thus potentially challenging the previous evidence favoring heavy sedation [22].…”

Trauma and nontrauma damage-control laparotomy: The difference is delirium (data from the Eastern Association for the Surgery of Trauma SLEEP-TIME multicenter trial)

“…A single-center review of delirium in T patients after DCL indicated a very high incidence of delirium in this population, as well as revealing a negative association between the duration of sedation infusion exposure and the proportion of delirium-free/coma-free ICU days. 45 It is interesting to see, therefore, that the incidence of delirium in the T cohort is even higher than in the NT cohort, despite the T cohort being younger and the mortality and ICU utilization being similar. One key factor unique to the T cohort is traumatic brain injury.…”

Time is domain: factors affecting primary fascial closure after trauma and non-trauma damage control laparotomy (data from the EAST SLEEP-TIME multicenter registry)

“…Much has been made of the use of neuromuscular blockade to facilitate more rapid achievement of PFC, although the most recent data do not support this assertion [28]. We previously published singlecenter data indicating that shorter duration of sedation infusions was associated with reduced time to PFC in trauma patients [29]. In this larger multicenter study of both trauma and non-trauma patients, we did not find that the duration of benzodiazepine, propofol, dexmedetomidine, or paralytic infusions was associated with the likelihood of achieving PFC.…”