Long-term outcomes after trauma and intensive care

Sammanfattning: The goals of trauma and critical care are twofold: to prevent short- and long-term mortality and to return the patient to an independent life. With the development of modern trauma care including technical advancements and generalized concepts, outcome has been improving steadily. However, trauma is still a major cause of mortality in the 1–45 years old age groups and treating these patients is a challenging task consuming significant resources. In strive for improved results in trauma care it is highly important to study factors that may influence outcomes. Apparent determinants such as injury severity, shock and bleeding have been intensively studied over the last decades. There are, however, several less apparent factors including socioeconomic factors, that may influence long-term outcomes. Management of trauma patients continue to evolve, and many previous open surgical procedures are being replaced by nonoperative approaches shifting part of the trauma management to the ICU. Hence, trauma and intensive care are closely connected and improvement on either depends on improvement on both. The aim with this thesis was to increase knowledge of long-term morbidity and outcomes of trauma patients and patients surviving intensive care using national and regional registers in four epidemiological studies. Significant morbidity can be measured as delayed return to work, an entity that causes considerable suffering for trauma victims and significant costs for society. In study I we explored the extent of, and risk factors for delayed return to work after major trauma in a cohort study with matched controls using sick leave as a proxy for long-term morbidity. Compared with controls, trauma patients had more sick leave both before and after trauma. High age, psychiatric disorders, low educational level, serious injury, spinal injury, reduced consciousness at admission, not being discharged directly home, and hospital length of stay for more than seven days were associated with full time sick leave one year after trauma. In study II two separate prediction models, one comprehensive and one simplified, were developed to predict trauma patients at risk of long-term sick leave. Factors related both to the trauma per se as well as host factors were important predictors. Both models were internally validated, accurate and showed high precision. Sick leave after trauma might serve to quantify long-term morbidity and predictive modelling could be valuable when targeting use of scarce follow-up resources. Severe trauma and treatment in the intensive care unit typically involves significant pain rendering treatment with potent analgesics. Commonly the situation resolves, and the drugs can be tapered. It is, however, noted in pain clinics that subgroups of patients become dependent on chronic opioid-treatment for a long time after trauma. This prolonged use or misuse of opioids is obviously influenced by the nature of the injury per se but also by several less well characterized factors. The precise magnitude of this problem is not known, neither are all the associated factors. The wide-spread use of opioids is currently questioned, and prolonged use of opioids is associated with worse outcomes. In study III and IV opioid use before and after trauma and intensive care were investigated. Trauma patients used more opioids compared to matched controls both before and after trauma and among patients admitted to critical care opioid use was also substantial before and after admission. In the trauma cohort, exposure to trauma was associated with long-term opioid usage. High age, comorbidities, increasing injury severity and pre-injury opioid use were some of the factors associated with chronic post-traumatic opioid use. Among patients admitted to critical care, increasing age, female sex, comorbidities, ICU length of stay and pre-admission opioid use were among the factors associated with long-term opioid use. Both among trauma patients and ICU patients, long-term opioid use was associated with increased risk of death 6-18 months after trauma and ICU admission respectively. In both studies the same results applied for patients not using opioids before trauma or admission to critical care. These studies highlight the risks with long-term opioid treatment following trauma or intensive care. To conclude, trauma patients suffer from significant long-term morbidity influenced by nontrauma related factors. Sick leave might be used as a proxy for post-trauma morbidity and prediction models may identify groups of patients at risk of sick leave following trauma and useful when allocating resources for rehabilitation. Furthermore, chronic opioid use is substantial both before and after trauma and intensive care and is associated with an increased risk of death.