Anne Craveiro Brøchner

Pathophysiology of the systemic inflammatory response after major accidental trauma

BackgroundThe purpose of the present study was to describe the pathophysiology of the systemic inflammatory response after major trauma and the timing of final reconstructive surgery.MethodsAn unsystematic review of the medical literature was performed and articles pertaining to the inflammatory response to trauma were obtained. The literature selected was based on the preference and clinical expertise of authors.DiscussionThe inflammatory response consists of hormonal metabolic and immunological components and the extent correlates with the magnitude of the tissue injury. After trauma and uncomplicated surgery a delicate balance between pro- and anti-inflammatory mediators is observed. Trauma patients are, however, often exposed, not only to the trauma, but to several events in the form of initial surgery and later final reconstructive surgery. In this case immune paralysis associated with increased risk of infection might develop. The inflammatory response is normalized 3 weeks following trauma. It has been proposed that the final reconstructive surgery should be postponed until the inflammatory response is normalized. This statement is however not based on clinical trials.ConclusionPostponement of final reconstructive surgery until the inflammatory is normalized should be based on prospective randomized trials.

Outcome following physician supervised prehospital resuscitation: a retrospective study

Background Prehospital care provided by specially trained, physician-based emergency services (P-EMS) is an integrated part of the emergency medical systems in many developed countries. To what extent P-EMS increases survival and favourable outcomes is still unclear. The aim of the study was thus to investigate ambulance runs initially assigned ‘life-saving missions’ with emphasis on long-term outcome in patients treated by the Mobile Emergency Care Unit (MECU) in Odense, Denmark Methods All MECU runs are registered in a database by the attending physician, stating, among other parameters, the treatment given, outcome of the treatment and the patients diagnosis. Over a period of 80 months from May 1 2006 to December 31 2012, all missions in which the outcome of the treatment was registered as ‘life saving’ were scrutinised. Initial outcome, level of competence of the caretaker and diagnosis of each patient were manually established in each case in a combined audit of the prehospital database, the discharge summary of the MECU and the medical records from the hospital. Outcome parameters were final outcome, the aetiology of the life-threatening condition and the level of competences necessary to treat the patient. Results Of 25 647 patients treated by the MECU, 701 (2.7%) received prehospital ‘life saving treatment’. In 596 (2.3%) patients this treatment exceeded the competences of the attending emergency medical technician or paramedic. Of these patients, 225 (0.9%) were ultimately discharged to their own home. Conclusions The present study demonstrates that anaesthesiologist administrated prehospital therapy increases the level of treatment modalities leading to an increased survival in relation to a prehospital system consisting of emergency medical technicians and paramedics alone and thus supports the concept of applying specialists in anaesthesiology in the prehospital setting especially when treating patients with cardiac arrest, patients in need of respiratory support and trauma patients.

The inflammatory response in blood and in remote organs following acute kidney injury.

In patients with acute kidney injury (AKI) mortality remains high, despite the fact that the patients are treated with continuous renal replacement therapy. The interaction between the kidney and the immune system might explain the high mortality observed in AKI. In order to elucidate the interaction between the kidney and immune system we developed a two‐hit model of AKI and endotoxemia. Our hypothesis was that ischemia/reperfusion (I/R) of the kidney simultaneously with endotoxemia would generate a more extensive inflammatory response compared to I/R of the hind legs. Our expectation was that elevated levels of cytokines would be found in both blood and in organs distant to the kidneys. Forty mice were divided into five groups. The mice were subjected to the following operations: A: Sham only, no lipopolysaccharide (LPS); B: I/R of both kidneys + LPS; C: LPS only; D: Nephrectomy + LPS; E: I/R of both hind legs + LPS. In groups B and E, I/R times were identical. All mice were kept alive for 24 h and then sacrificed. Levels of interleukin (IL)‐1β, IL‐6, IL‐10, and tumor necrosis factor‐α were measured in the blood. The activity of myeloperoxidase (MPO) in lungs, kidneys, and liver was evaluated as an indirect measurement of accumulation of granulocytes. In this study, significantly higher amount of IL‐6 and IL‐10 in the plasma was observed following renal I/R compared to hind leg I/R. The elevated levels of cytokine in plasma were observed following nephrectomy and endotoxemia. The neutrophil infiltration of distant organs measured by the levels of MPO in the lung and liver also showed a significantly higher level in renal I/R compared to hind leg I/R. Renal I/R is associated with a more pronounced inflammatory response in blood and distant organs. The high cytokine levels measured following nephrectomy might be explained by compromised elimination of cytokines by the kidney in AKI.

The impact of long-term haemofiltration (continuous veno-venous haemofiltration) on cell-mediated immunity during endotoxaemia

Background:  Increased survival with high‐volume continuous veno‐venous haemofiltration (CVVH) has been demonstrated in critically ill patients. This may be the result of intensified blood purification or an effect on the immune system. We hypothesized that CVVH modifies the cell‐mediated immunity. We investigated the effect of high‐volume CVVH for 24 h on the cell‐mediated immunity following endotoxin infusion.

Inflammatory response in patients undergoing uterine artery embolization as compared to patients undergoing conventional hysterectomy

Background: Uterine fibroids are benign tumors seen in 20-40% of women of childbearing age, and these fibroids are usually treated by hysterectomy. During the last decade, embolization of the uterine arteries with polyvinyl alcohol microparticles has become an alternative treatment. Purpose: To investigate whether uterine artery embolization generates a reduced inflammatory response as compared with conventional hysterectomy. Material and Methods: 40 women, 20 in each group, entered this prospective, non-randomized study. The two groups were comparable concerning age, comorbidity, and body-mass index (BMI). Results: We found a significant difference between the inflammatory responses in women undergoing embolization compared with the inflammatory response in women having an abdominal hysterectomy. Women undergoing embolization were subjected to a much smaller inflammatory burden, their total morphine consumption was lower, and their return to work was faster than women subjected to conventional hysterectomy. Conclusion: Uterine artery embolization generates a reduced inflammatory response compared with conventional hysterectomy.

Effect of renal and non‐renal ischemia/reperfusion on cell‐mediated immunity in organs and plasma

Brøchner AC, Dagnæs‐Hansen F, Toft P. Effect of renal and non‐renal ischemia/reperfusion on cell‐mediated immunity in organs and plasma. APMIS 2010; 118: 101–7.

Noise exposure during prehospital emergency physicians work on Mobile Emergency Care Units and Helicopter Emergency Medical Services

BackgroundPrehospital personnel are at risk of occupational hearing loss due to high noise exposure. The aim of the study was to establish an overview of noise exposure during emergency responses in Mobile Emergency Care Units (MECU), ambulances and Helicopter Emergency Medical Services (HEMS). A second objective was to identify any occupational hearing loss amongst prehospital personnel.MethodsNoise exposure during work in the MECU and HEMS was measured using miniature microphones worn laterally to the auditory canals or within the earmuffs of the helmet. All recorded sounds were analysed in proportion to a known tone of 94 dB. Before and after episodes of noise exposure, the physicians underwent a hearing test indicating whether the noise had had any impact on the function of the outer sensory hair cells. This was accomplished by measuring the amplitude level shifts of the Distortion Product Otoacoustic Emissions. Furthermore, the prehospital personnels’ hearing was investigated using pure-tone audiometry to reveal any occupational hearing loss. All prehospital personnel were compared to ten in-hospital controls.ResultsOur results indicate high-noise exposure levels of ≥80 dB(A) during use of sirens on the MECU and during HEMS operations compared to in-hospital controls (70 dB(A)). We measured an exposure up to ≥90 dB(A) under the helmet for HEMS crew. No occupational hearing loss was identified with audiometry. A significant level shift of the Distortion Product Otoacoustic Emissions at 4 kHz for HEMS crew compared to MECU physicians was found indicating that noise affected the outer hair cell function of the inner ear, thus potentially reducing the hearing ability of the HEMS crew.DiscussionFurther initiatives to prevent noise exposure should be taken, such as active noise reduction or custom-made in-ear protection with communication system for HEMS personnel. Furthermore, better insulation of MECU and ambulances is warranted.ConclusionWe found that the exposure levels exceeded the recommendations described in the European Regulative for Noise, which requires further protective initiatives. Although no hearing loss was demonstrated in the personnel of the ground-based units, a reduced function of the outer sensory hair cells was found in the HEMS group following missions.

Prehospital prognosis is difficult in patients with acute exacerbation of chronic obstructive pulmonary disease

BackgroundPatients with acute exacerbation of chronic obstructive pulmonary disease often require prehospital emergency treatment. This enables patients who are less ill to be treated on-site and to avoid hospital admission, while severely ill patients can receive immediate ventilatory support in the form of intubation. The emergency physician faces difficult treatment decisions, however, and prognostic tools that could assist in determining which patients would benefit from intubation and ventilator support would be helpful. The aim of the current study was to identify prehospital clinical variables associated with mortality from acute exacerbation of chronic obstructive pulmonary disease. As part of the study, we estimated the 30-day mortality for patients with this prehospital diagnosis.MethodsA retrospective study was performed using data collected by the mobile emergency care unit in Odense, Denmark, combined with data from the patients’ medical records. Patients with the tentative diagnosis of acute exacerbation of chronic obstructive pulmonary disease between 1st July 2011 and 31st December 2013 were included in the study.ResultsBased on data from 530 patients, we found no statistically significant associations between prehospital clinical variables and mortality, apart from a minor association between older age and higher mortality. The overall 30-day mortality was 10%, while that for patients admitted to the intensive care unit was 30%.ConclusionNo specific prehospital prognostic factors for mortality were identified. Prognostic assessment and the decision to withhold treatment for acute exacerbation of chronic obstructive pulmonary disease seem inadvisable in the prehospital setting.

Patients with chronic obstructive pulmonary disease treated by the mobile emergency care unit - hospitalization and prognostic factors

Chronic Obstructive Pulmonary Disease (COPD) is an important and increasing cause of morbidity and mortality worldwide. Patients with COPD suffer from acute exacerbations (AE), which lead to a reduced quality of life, increased risk of mortality, further and longer hospitalization, and increased healthcare costs.