Review
Is arterial base deficit still a useful prognostic marker in trauma? A systematic review,☆☆

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Abstract

Background

Arterial base deficit (BD) has been widely used in trauma patients since 1960. However, trauma management has also evolved significantly in the last 2 decades. The first objective of this study was to systematically review the literature on the relationship between arterial BD as a prognostic marker for trauma outcomes (mortality, significant injuries, and major complications) in the acute setting. The second objective was to evaluate arterial BD as a prognosis marker, specifically, in the elderly and in patients with positive blood alcohol levels.

Methods

MEDLINE, EMBASE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were searched from January 1, 1990, to August 6, 2015. Bibliographies of articles were also hand searched for relevant citations.

Results

Thirty-four studies were included in this review. The studies consistently showed that a higher arterial BD was associated with increased mortality, significant injuries, and major complications. The threshold BD value of 6 mmol/L was also useful in discriminating for poorer outcomes. The presence of alcohol did not affect the ability of arterial BD to discriminate between major and minor injuries. Elderly patients had higher mortality in all arterial BD categories compared to the younger age group.

Conclusions

Despite the advances in trauma care in the last 2 decades, arterial BD remains a useful prognostic marker in trauma patients, even in elderly patients and in patients who had consumed alcohol. The threshold BD value of 6 mmol/L was useful to prognosticate poorer outcomes.

Introduction

Arterial base deficit (BD) was first proposed as a measure of metabolic acidosis in 1960 and is still used widely across the world [1], [2], [3], [4], [5]. In trauma patients, early studies had demonstrated a positive correlation between a high BD with poor outcomes, and an arterial BD of more than 6 mmol/L has been suggested as a threshold level to predict for poorer outcomes [6]. However, trauma management has evolved significantly in the last 2 decades with developments such as focused early diagnosis of hemorrhage; damage control resuscitation and surgery; massive transfusion protocols; and the aggressive prevention and correction of the deadly triad of coagulopathy, acidosis, and hypothermia [7]. With these developments, it is important to assess whether arterial BD remains relevant as a prognostic marker of poor outcomes and if its utility in trauma management has changed. With the high costs of trauma care, the prognostic value of arterial BD may enable clinicians to stratify patients who are at risk for mortality; significant injuries; and developing major complications such as adult respiratory distress syndrome (ARDS), acute lung injury (ALI), and multiorgan failure (MOF) [8]. This may allow for more aggressive initial measures, better care placement, and cost-effective resource allocation.

With an ever increasing elderly population as well as patients with alcohol-related injuries, we were also interested in evaluating how BD, as a prognostic marker, performed in these 2 patient groups. In the United States in 2010, 13% of the population was aged 65 years or older, and this age group was the most rapidly growing part of the population [9]. A recent study also showed the disproportionate growth in inhospital admissions due to major trauma in older patients over the past 20 years, relative to the reported population trends [10]. As for alcohol, the burden of alcohol-related visits to trauma center is understandably high with an aggregate estimate of 32.4% [11]. Hence, an appreciation of the performance of arterial BD in these groups of patients can contribute to more timely and optimized management.

The objectives of this systematic review are 2-fold. First, the available literature was reviewed to describe the relationship between arterial BD as a prognostic marker for trauma outcomes (mortality, significant injuries, and major complications) of trauma patients over the last 25 years. Second, the review assessed arterial BD as a prognostic marker in elderly trauma patients and in trauma patients with positive blood alcohol levels.

Section snippets

Criteria for considering studies for inclusion

Studies were considered for inclusion when they addressed arterial BD in the acute setting (prehospital, emergency department [ED], or trauma center) and with the specific outcome measures of mortality, significant injuries, or major complications (ARDS, ALI, and MOF). In addition, studies that focused on trauma patients with a positive blood alcohol level or elderly patients were considered.

English-language articles of all study types including randomized controlled trials, nonrandomized

Results

A summary of the article selection process is depicted in the Figure. The initial search identified 21 619 studies. After exclusion by abstracts and duplicates, 99 studies were considered potentially relevant, and full texts were obtained. The reference lists were also hand searched for potentially relevant studies. One study by Mackersie et al [15], although published in 1989, was included as we deemed this article important in the very early studies of BD in trauma. In total, 118 full texts

Discussion

To our knowledge, this is the first systematic review that summarizes the evidence for arterial BD in trauma patients over a period where significant advancements in trauma management have occurred. This review found that, in the relevant trauma studies conducted over the last 25 years, a higher arterial BD has been consistently associated with an increased mortality, the presence of significant injuries, and major complications. The OR for inpatient mortality increased by 8% to 14% [25], [26]

Conclusions

Despite the advances in trauma care in the last 25 years, an elevated arterial BD is still a harbinger of poor outcomes. The threshold BD value of 6 mmol/L remains useful in predicting for poorer outcomes. This suggests the need for more systematic investigation, monitoring, and aggressive resuscitation in this group of trauma patients. Arterial BD also remains useful in the evaluation of the elderly trauma patients and in patients who had consumed alcohol.

Acknowledgment

The authors thank A/Prof Malcolm Mahadevan, Chief, Emergency Medicine Department, National University Hospital, for his support.

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      The normal pH is 7.4. Acidosis can be diagnosed using arterial blood gas estimation if the base excess is less than −6 mmol/L.1 Higher mortality and morbidity was observed if the base deficit exceeded −6 mmol/L.13 Serum Lactate >4 mmol/L is an additional indicator of acidosis.14 Coagulopathy is diagnosed if partial thromboplastin time exceeds 40 s or if the INR is greater than or equal to 1.4.1

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    Funding sources/disclosures: No sources of funding and no conflict of interest.

    ☆☆

    Prior presentations: poster presentation, Society of Emergency Medicine Meeting, Singapore, February 2012.

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