Prolonged Mechanical Ventilation in Pediatric Trauma Patients in a Combat Zone

Abstract

Objectives: It is well known that polytrauma can lead to acute lung injury. Respiratory failure has been previously observed in combat trauma, but not reported in children, who account for over 11% of bed days at deployed Military Treatment Facilities (MTFs) using significant resources. We seek to identify risk factors associated with prolonged mechanical ventilation (PMV) which is important in resource planning and allocation in austere environments.

Design: Retrospective review of prospectively collected data within the United States Department of Defense Trauma Registry.

Setting: Deployed U.S. MTFs in Iraq and Afghanistan from 2007 to 2016.

Patients: All pediatric subjects who required at least 1 day of mechanical ventilation, excluding patients who died on day 0.

Interventions: PMV was defined using the Youden index for mortality. A multivariable logistic regression model was then performed to identify factors associated with PMV.

Measurements and main results: The Youden index identified greater than or equal to 6 days as the cutoff for PMV. Of the 859 casualties included in the analysis, 154 (17.9%) had PMV. On univariable analysis, age, severe injury to the thorax and skin, 24-hour volume/kg administration of crystalloids, colloids, platelets, plasma, and packed RBCs was associated with PMV. In the multivariable model, odds ratios (95% CI) associated with PMV were crystalloids 1.04 (1.02-1.07), colloids 1.24 (1.04-1.49), platelets 1.03 (1.01-1.05), severe injury to the thorax 2.24 (1.41-3.48), and severe injury to the skin 4.48 (2.72-7.38). Model goodness-of-fit r2 was 0.14.

Conclusions: In this analysis of factors associated with PMV in pediatric trauma patients in a combat zone, in addition to severe injury to skin and thorax, we found that administration of crystalloids, colloids, and platelets was independently associated with greater odds of PMV. Our findings will help inform resource planning and suggest potential resuscitation strategies for future studies.