{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,19]],"date-time":"2026-05-19T04:55:37Z","timestamp":1779166537777,"version":"3.51.4"},"reference-count":9,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2024,10,25]],"date-time":"2024-10-25T00:00:00Z","timestamp":1729814400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2024,10,25]],"date-time":"2024-10-25T00:00:00Z","timestamp":1729814400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Scand J Trauma Resusc Emerg Med"],"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>The Advanced Trauma Life Support classification (ATLS) of hypovolemic shock is a widely used teaching and treatment reference in emergency medicine, but oversimplifies clinical reality. A decade ago, a landmark study compared vital parameters to base deficit (BD) in trauma patients. The investigators concluded that BD had higher accuracy to detect the need for early blood product administration. BD was subsequently introduced in the ATLS shock classification and has since been widely accepted as a laboratory standard for hypovolemia. The aim of this study is to investigate whether a methodological bias may have inadvertently contributed to the study\u2019s results and interpretation.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>In the current study, we replicate the original study by simulating a cohort of trauma patients with randomly generated data and applying the same methodological strategies. First, a predefined correlation between all predictor variables (vital parameters and BD) and outcome variable (transfusion) was set at 0.55. Then, in accordance with the methods of the original study we created a composite of ATLS parameters (highest class amongst heart rate, systolic blood pressure, and Glasgow Coma Scale) and compared it with BD for resulting transfusion quantity. Given the preset correlations between predictors and outcome, no predictor should exhibit a stronger association unless influenced by methodological bias.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>Applying the original imbalanced grouping and composite allocation strategies caused a systematic overestimation of shock class for traditional ATLS parameters, favoring the association between BD and transfusion. This effect persisted when the correlation between BD and transfusion was set substantially worse (rho\u2009=\u20090.3) than the correlation between ATLS parameters and transfusion (rho\u2009=\u20090.8).<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusions<\/jats:title>\n                <jats:p>In this fully reproducible simulation, we confirm the inadvertent presence of methodological bias. It is physiologically reasonable to include a metabolic parameter to classify hypovolemic shock, but more evidence is needed to support widespread and preferred use of BD.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s13049-024-01276-0","type":"journal-article","created":{"date-parts":[[2024,10,25]],"date-time":"2024-10-25T17:01:56Z","timestamp":1729875716000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Simulating the methodological bias in the ATLS classification of hypovolemic shock: a critical reappraisal of the base deficit renaissance"],"prefix":"10.1186","volume":"32","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7420-8486","authenticated-orcid":false,"given":"M. L. A.","family":"Heldeweg","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"T. T. R.","family":"Heldeweg","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"J. A. H.","family":"Stohlmann","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"P.","family":"Freire Jorge","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"R.","family":"Boer","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"L. A.","family":"Schwarte","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"P.","family":"Schober","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2024,10,25]]},"reference":[{"key":"1276_CR1","unstructured":"10th Edition of the advanced trauma life support\u00ae (ATLS\u00ae) student course manual. Chicago (IL): American College of Surgeons; 2018."},{"issue":"3","key":"1276_CR2","doi-asserted-by":"publisher","first-page":"309","DOI":"10.1016\/j.resuscitation.2012.07.012","volume":"84","author":"M Mutschler","year":"2013","unstructured":"Mutschler M, Nienaber U, Brockamp T, Wafaisade A, Wyen H, Peiniger S, Paffrath T, Bouillon B, Maegele M, TraumaRegister DGU. A critical reappraisal of the ATLS classification of hypovolaemic shock: does it really reflect clinical reality? Resuscitation. 2013;84(3):309\u201313. https:\/\/doi.org\/10.1016\/j.resuscitation.2012.07.012.","journal-title":"Resuscitation"},{"issue":"2","key":"1276_CR3","doi-asserted-by":"publisher","first-page":"R42","DOI":"10.1186\/cc12555","volume":"17","author":"M Mutschler","year":"2013","unstructured":"Mutschler M, Nienaber U, Brockamp T, Wafaisade A, Fabian T, Paffrath T, Bouillon B, Maegele M, TraumaRegister DGU. Renaissance of base deficit for the initial assessment of trauma patients: a base deficit-based classification for hypovolemic shock developed on data from 16,305 patients derived from the TraumaRegister DGU\u00ae. Crit Care. 2013;17(2):R42. https:\/\/doi.org\/10.1186\/cc12555.","journal-title":"Crit Care"},{"issue":"8","key":"1276_CR4","doi-asserted-by":"publisher","first-page":"610","DOI":"10.1097\/EJA.0000000000001850","volume":"40","author":"MLA Heldeweg","year":"2023","unstructured":"Heldeweg MLA, Stohlmann JAH, Loer SA. Base excess and lactate for guidance of peri-operative fluid management: a survey of anaesthetists, residents and intensive care physicians attending 2022 ESAIC in Milan. 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J Trauma. 1996;41(5):769\u201374. https:\/\/doi.org\/10.1097\/00005373-199611000-00001.","journal-title":"J Trauma"},{"issue":"4","key":"1276_CR7","doi-asserted-by":"publisher","first-page":"685","DOI":"10.1002\/sim.5533","volume":"32","author":"GM D'Angelo","year":"2013","unstructured":"D\u2019Angelo GM, Weissfeld LA. Application of copulas to improve covariance estimation for partial least squares. Stat Med. 2013;32(4):685\u201396. https:\/\/doi.org\/10.1002\/sim.5533.","journal-title":"Stat Med"},{"issue":"5","key":"1276_CR8","doi-asserted-by":"publisher","first-page":"1763","DOI":"10.1213\/ANE.0000000000002864","volume":"126","author":"P Schober","year":"2018","unstructured":"Schober P, Boer C, Schwarte LA. Correlation coefficients: appropriate use and Interpretation. Anesth Analg. 2018;126(5):1763\u20138. https:\/\/doi.org\/10.1213\/ANE.0000000000002864.","journal-title":"Anesth Analg"},{"issue":"1","key":"1276_CR9","doi-asserted-by":"publisher","first-page":"109","DOI":"10.1007\/s00423-013-1143-9","volume":"399","author":"S Di Saverio","year":"2014","unstructured":"Di Saverio S, Gambale G, Coccolini F, Catena F, Giorgini E, Ansaloni L, Amadori N, Coniglio C, Giugni A, Biscardi A, Magnone S, Filicori F, Cavallo P, Villani S, Cinquantini F, Annicchiarico M, Gordini G, Tugnoli G. Changes in the outcomes of severe trauma patients from 15-year experience in a Western European trauma ICU of Emilia Romagna region (1996\u20132010). A population cross-sectional survey study. 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