Trauma Capillary Leak Syndrome Carries High Mortality

Traumatic-induced capillary leak syndrome is the name being given to a newly described, highly lethal disease process in critically injured trauma patients. As yet, there is no effective treatment, but some studies have been conducted to better understand its characteristics, with an eye toward ultimately finding a way to prevent it.

Traumatic-induced capillary leak syndrome (TICS) is characterized by acute hypotension, hemoconcentration, and shock, but its chief hallmark is hypoalbuminemia within 2 hours of the injury. The lower the serum albumin at that time, the worse the patient’s prognosis – independent of all the standard predictors. The prognosis is somewhat modified, however, if the serum albumin rises during the next 3 days, said Dr. Grant Bochicchio of the University of Maryland, Baltimore.

In a study of more than 1,000 critically injured trauma patients, Dr. Bochicchio reported that a serum albumin level below 2.6 mg/dL was associated with increased morbidity and mortality (Am. Surg. 2004;70:1099-102). His new prospective study, which he presented at the annual meeting of the American Surgical Association, included a different cohort of 2,348 trauma patients admitted to the ICU, all with a serum albumin measurement obtained within 2 hours post-injury and monitored over the next 7 days.

In all, 79% of the patients had blunt trauma injuries. Their mean age was 43 years, with an ISS (Injury Severity Score) of 27 and an APACHE (Acute Physiology and Chronic Health Evaluation) II score of 13. The mean initial serum albumin level was 2.9 mg/dL. TICS was graded on a 1-5 scale, with grade 1 being an initial serum albumin below 1.0 mg/dL, and grade 5 being a normal serum albumin of 3.5 mg/dL or more.

There were 84 patients with grade 1 TICS. They had an overall 70% mortality. Moreover, patients with grade 1 TICS had a 91% mortality rate if their serum albumin failed to improve by more than 50% over the next 72 hours, reported Dr. Bochicchio.

Patients with TICS grade 1 were significantly older and had higher ISS and APACHE II scores than did those with a normal albumin level. This was true as well for the 409 patients with TICS grade 2 (that is, an initial serum albumin of 1.0-1.99 mg/dL).

In a multivariate logistic regression analysis adjusted for age, APACHE II score, ISS, and sex, patients who were TICS grade 1 or 2 spent an average of 9 more days on a ventilator, 11 more days in the ICU, and 12 more days in the hospital, and they had a 10-fold greater risk of mortality than did the 732 grade 5 patients.

The majority of deaths in TICS grade 1 or 2 patients resulted from multisystem organ failure.

In all, 777 infections were diagnosed in the study population during the first week. The infection rate was 62% in patients with grade 1 TICS, 50% with grade 2, and 12% with grade 3 (that is, an initial serum albumin of 2.0-2.6 mg/dL), compared with just 5% in grade 5 patients.

Dr. Bochicchio said that his research focus is shifting to TICS prevention. Toward this end, he’ll be taking a close look at inflammatory markers and seeking a means to reduce the amount of fluid that TICS patients typically require. He hopes that prevention will prove to be more fruitful than the various attempts at treatment to date.

"Every study I’ve seen shows that administering exogenous albumin actually increases mortality," he noted.

Several discussants questioned whether the association Dr. Bochicchio has documented between low serum albumin and increased morbidity and mortality in critically injured trauma patients is actually causal.

"If you’re injured and older, you tend to present with a lower albumin. You’re calling it the traumatic-induced capillary leak syndrome, but my hypothesis would be that those patients are actually getting more fluid and bleeding more: You bleed more, you get more fluid, and you end up with a lower albumin. What this study may really be showing us is [that] aggressive resuscitation may be killing people; it may have nothing to do with the capillary leak syndrome," contended Dr. Martin A. Schreiber, professor of surgery at Oregon Health and Science University, Portland.

Dr. Bochicchio replied that patients with severe TICS didn’t get more fluid before arriving at the hospital than did other trauma patients, although after reaching the hospital, they did.

Dr. Bochicchio declared having no financial conflicts of interest.

Traumatic-induced capillary leak syndrome is the name being given to a newly described, highly lethal disease process in critically injured trauma patients. As yet, there is no effective treatment, but some studies have been conducted to better understand its characteristics, with an eye toward ultimately finding a way to prevent it.

Traumatic-induced capillary leak syndrome (TICS) is characterized by acute hypotension, hemoconcentration, and shock, but its chief hallmark is hypoalbuminemia within 2 hours of the injury. The lower the serum albumin at that time, the worse the patient’s prognosis – independent of all the standard predictors. The prognosis is somewhat modified, however, if the serum albumin rises during the next 3 days, said Dr. Grant Bochicchio of the University of Maryland, Baltimore.

In a study of more than 1,000 critically injured trauma patients, Dr. Bochicchio reported that a serum albumin level below 2.6 mg/dL was associated with increased morbidity and mortality (Am. Surg. 2004;70:1099-102). His new prospective study, which he presented at the annual meeting of the American Surgical Association, included a different cohort of 2,348 trauma patients admitted to the ICU, all with a serum albumin measurement obtained within 2 hours post-injury and monitored over the next 7 days.

In all, 79% of the patients had blunt trauma injuries. Their mean age was 43 years, with an ISS (Injury Severity Score) of 27 and an APACHE (Acute Physiology and Chronic Health Evaluation) II score of 13. The mean initial serum albumin level was 2.9 mg/dL. TICS was graded on a 1-5 scale, with grade 1 being an initial serum albumin below 1.0 mg/dL, and grade 5 being a normal serum albumin of 3.5 mg/dL or more.

There were 84 patients with grade 1 TICS. They had an overall 70% mortality. Moreover, patients with grade 1 TICS had a 91% mortality rate if their serum albumin failed to improve by more than 50% over the next 72 hours, reported Dr. Bochicchio.

Patients with TICS grade 1 were significantly older and had higher ISS and APACHE II scores than did those with a normal albumin level. This was true as well for the 409 patients with TICS grade 2 (that is, an initial serum albumin of 1.0-1.99 mg/dL).

In a multivariate logistic regression analysis adjusted for age, APACHE II score, ISS, and sex, patients who were TICS grade 1 or 2 spent an average of 9 more days on a ventilator, 11 more days in the ICU, and 12 more days in the hospital, and they had a 10-fold greater risk of mortality than did the 732 grade 5 patients.

The majority of deaths in TICS grade 1 or 2 patients resulted from multisystem organ failure.

In all, 777 infections were diagnosed in the study population during the first week. The infection rate was 62% in patients with grade 1 TICS, 50% with grade 2, and 12% with grade 3 (that is, an initial serum albumin of 2.0-2.6 mg/dL), compared with just 5% in grade 5 patients.

Dr. Bochicchio said that his research focus is shifting to TICS prevention. Toward this end, he’ll be taking a close look at inflammatory markers and seeking a means to reduce the amount of fluid that TICS patients typically require. He hopes that prevention will prove to be more fruitful than the various attempts at treatment to date.

"Every study I’ve seen shows that administering exogenous albumin actually increases mortality," he noted.

Several discussants questioned whether the association Dr. Bochicchio has documented between low serum albumin and increased morbidity and mortality in critically injured trauma patients is actually causal.

"If you’re injured and older, you tend to present with a lower albumin. You’re calling it the traumatic-induced capillary leak syndrome, but my hypothesis would be that those patients are actually getting more fluid and bleeding more: You bleed more, you get more fluid, and you end up with a lower albumin. What this study may really be showing us is [that] aggressive resuscitation may be killing people; it may have nothing to do with the capillary leak syndrome," contended Dr. Martin A. Schreiber, professor of surgery at Oregon Health and Science University, Portland.

Dr. Bochicchio replied that patients with severe TICS didn’t get more fluid before arriving at the hospital than did other trauma patients, although after reaching the hospital, they did.

Dr. Bochicchio declared having no financial conflicts of interest.

Traumatic-induced capillary leak syndrome is the name being given to a newly described, highly lethal disease process in critically injured trauma patients. As yet, there is no effective treatment, but some studies have been conducted to better understand its characteristics, with an eye toward ultimately finding a way to prevent it.

Traumatic-induced capillary leak syndrome (TICS) is characterized by acute hypotension, hemoconcentration, and shock, but its chief hallmark is hypoalbuminemia within 2 hours of the injury. The lower the serum albumin at that time, the worse the patient’s prognosis – independent of all the standard predictors. The prognosis is somewhat modified, however, if the serum albumin rises during the next 3 days, said Dr. Grant Bochicchio of the University of Maryland, Baltimore.

In a study of more than 1,000 critically injured trauma patients, Dr. Bochicchio reported that a serum albumin level below 2.6 mg/dL was associated with increased morbidity and mortality (Am. Surg. 2004;70:1099-102). His new prospective study, which he presented at the annual meeting of the American Surgical Association, included a different cohort of 2,348 trauma patients admitted to the ICU, all with a serum albumin measurement obtained within 2 hours post-injury and monitored over the next 7 days.

In all, 79% of the patients had blunt trauma injuries. Their mean age was 43 years, with an ISS (Injury Severity Score) of 27 and an APACHE (Acute Physiology and Chronic Health Evaluation) II score of 13. The mean initial serum albumin level was 2.9 mg/dL. TICS was graded on a 1-5 scale, with grade 1 being an initial serum albumin below 1.0 mg/dL, and grade 5 being a normal serum albumin of 3.5 mg/dL or more.

There were 84 patients with grade 1 TICS. They had an overall 70% mortality. Moreover, patients with grade 1 TICS had a 91% mortality rate if their serum albumin failed to improve by more than 50% over the next 72 hours, reported Dr. Bochicchio.

Patients with TICS grade 1 were significantly older and had higher ISS and APACHE II scores than did those with a normal albumin level. This was true as well for the 409 patients with TICS grade 2 (that is, an initial serum albumin of 1.0-1.99 mg/dL).

In a multivariate logistic regression analysis adjusted for age, APACHE II score, ISS, and sex, patients who were TICS grade 1 or 2 spent an average of 9 more days on a ventilator, 11 more days in the ICU, and 12 more days in the hospital, and they had a 10-fold greater risk of mortality than did the 732 grade 5 patients.

The majority of deaths in TICS grade 1 or 2 patients resulted from multisystem organ failure.

In all, 777 infections were diagnosed in the study population during the first week. The infection rate was 62% in patients with grade 1 TICS, 50% with grade 2, and 12% with grade 3 (that is, an initial serum albumin of 2.0-2.6 mg/dL), compared with just 5% in grade 5 patients.

Dr. Bochicchio said that his research focus is shifting to TICS prevention. Toward this end, he’ll be taking a close look at inflammatory markers and seeking a means to reduce the amount of fluid that TICS patients typically require. He hopes that prevention will prove to be more fruitful than the various attempts at treatment to date.

"Every study I’ve seen shows that administering exogenous albumin actually increases mortality," he noted.

Several discussants questioned whether the association Dr. Bochicchio has documented between low serum albumin and increased morbidity and mortality in critically injured trauma patients is actually causal.

"If you’re injured and older, you tend to present with a lower albumin. You’re calling it the traumatic-induced capillary leak syndrome, but my hypothesis would be that those patients are actually getting more fluid and bleeding more: You bleed more, you get more fluid, and you end up with a lower albumin. What this study may really be showing us is [that] aggressive resuscitation may be killing people; it may have nothing to do with the capillary leak syndrome," contended Dr. Martin A. Schreiber, professor of surgery at Oregon Health and Science University, Portland.

Dr. Bochicchio replied that patients with severe TICS didn’t get more fluid before arriving at the hospital than did other trauma patients, although after reaching the hospital, they did.

Dr. Bochicchio declared having no financial conflicts of interest.