Charles E. Wiles

Using the SF-36 for characterizing outcome after multiple trauma involving head injury

BACKGROUND The purpose of this study was to evaluate the validity of the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) for examining outcomes after multiple trauma and to investigate whether the addition of items selected to measure cognitive function could improve the sensitivity of the SF-36 for identifying differences in outcomes for patients with and without head injury. METHODS One thousand two hundred thirty patients discharged from 12 trauma centers were interviewed 1 year after injury. The interview included the SF-36 supplemented with four items chosen to assess cognitive function. RESULTS The resulting cognitive function scale is internally consistent and measures a component of health that is independent of the dimensions incorporated in the SF-36. It correlates well with established measures of brain injury severity and discriminates among patients with and without brain injury. CONCLUSION This study underscores the need to supplement the SF-36 with a measure of cognitive function when evaluating outcome from multiple trauma involving head injury. Further studies are needed to validate the specific items chosen for measuring cognitive function.

relationships between resting and total energy expenditure in injured and septic patients

Objective: To quantify resting and total energy expenditure in patients who have suffered severe trauma and sepsis. Design: Prospective, unblinded, observational, nonrandomized study. Setting: Critical care unit of a Level I adult trauma center. Patients: Immediate posttrauma patients or trauma patients exhibiting signs of sepsis with multiple organ dysfunction. Interventions: An indirect calorimeter was used to measure energy expenditure at rest (resting energy expenditure) at 0700 and 1900 hrs. The energy expenditure measurement was then continued for up to 12 hrs (total energy expenditure). Clinical data were collected for computation of an illness severity score. Results: Thirteen trauma and 20 septic patients were studied 240 times. All patients were mechanically ventilated. Morphine or fentanyl was infused during 99% of studies. Neuromuscular blocking agents were used in 42% of septic studies. Both the trauma and septic groups were hypermetabolic (mean trauma resting energy expenditure, 36 ± 6 kcal/kg; mean septic resting energy expenditure, 44 ± 8 kcal/kg; p < .05). Total energy expenditure was similar to resting energy expenditure (trauma total energy expenditure = resting energy expenditure × 1.035 ± 0.078, septic total energy expenditure = resting energy expenditure × 1.039 ± 0.071). Total energy expenditure and resting energy expenditure were linearly related (r2 = .89, p < .0001). Conclusions: Trauma and septic patients are hypermetabolic, even when heavily sedated or medically paralyzed. A measurement of resting energy expenditure is a close approximation of total energy expenditure in most patients. (Crit Care Med 1994; 22:1796–1804)

Correlation Between Measured Energy Expenditure and Clinically Obtained Variables in Trauma and Sepsis Patients

BACKGROUND Indirect calorimetry is the preferred method for determining caloric requirements of patients, but availability of the device is limited by high cost. A study was therefore conducted to determine whether clinically obtainable variables could be used to predict metabolic rate. METHODS Patients with severe trauma or sepsis who required mechanical ventilation were measured by an open-circuit indirect calorimeter. Several clinical variables were obtained simultaneously. Measurements were repeated every 12 hours for up to 10 days. RESULTS Twenty-six trauma and 30 sepsis patients were measured 423 times. Mean resting energy expenditure was 36 +/- 7 kcal/kg (trauma) vs 45 +/- 8 kcal/kg (sepsis) (p < .0001). The single strongest correlate with resting energy expenditure was minute ventilation (R2 = 0.61, p < .0001). Doses of dopamine, dobutamine, morphine, fentanyl, and neuromuscular blocking agents each correlated positively with resting energy expenditure. In the case of the inotropics and neuromuscular blockers, there was a probable covariance with severity of illness. A multiple regression equation was developed using minute ventilation, predicted basal energy expenditure, and the presence or absence of sepsis: resting energy expenditure = -11000 + minute ventilation (100) + basal energy expenditure (1.5) + dobutamine dose (40) + body temperature (250) + diagnosis of sepsis (300) (R2 = 0.77, p < .0001). CONCLUSION Severe trauma and sepsis patients are hypermetabolic, but energy expenditure is predictable from clinical data. The regression equations probably apply only to severe trauma and sepsis. Other studies should be conducted to predict energy expenditure in other patient types.

Gut failure : predictor of or contributor to mortality in mechanically ventilated blunt trauma patients ?

UNLABELLED Thirty-seven ventilator-dependent blunt trauma patients (ISS 36 +/- 15) were randomized at 24 hours after injury to receive parenteral (TPN) (n = 15), enteral (TEN) (n = 12), or parenteral plus enteral (PN/EN) (n = 10) nutrition. The TEN and PN/EN patients had endoscopically placed transpyloric feeding tubes. Patients who had nutritional complications were two TPN (13%), three TEN (25%), and five PN/EN (50%). Enteral complications were tube occlusion (two), failed duodenal intubation (one), patient extubation of feeding tube (one), gastric reflux (two), and abdominal distention (two). Mortality rates were not different between the groups, but were significantly related to the nutrition-associated complications (p = 0.01): four deaths in ten (40%) with complications and one death in 27 (3.7%) without complications. All four deaths associated with complications occurred in the four with gastric reflux or abdominal distention. No deaths occurred in the other 18 TEN or PN/EN patients (p = 0.0001). Of the four deaths, three were associated with ARDS and respiratory infection (75%). CONCLUSIONS In mechanically ventilated blunt trauma patients, endoscopic transpyloric tube placement and feeding has a substantial failure rate (36%). Intolerance to duodenal feeding has a remarkably high mortality (100%) in patients in whom gut dysfunction may be a manifestation of injury severity or directly affect survival.

Amino Acid Loss and Plasma Concentration During Continuous Hemodiafiltration

Amino acid loss, plasma concentration, and the relationship between amino acid intake and balance during continuous hemodiafiltration (CHD) were investigated in a prospective, nonrandomized study of trauma patients exhibiting the systemic inflammatory response with acute renal failure. Data were compared with those from a group of similar patients who had maintained renal function (control). Both groups received similar amounts of nonprotein calories (3015 +/- 753 nonprotein calories per day in the control group vs 3077 +/- 1018 nonprotein calories per day in the CHD group) and amino acids (2.24 +/- 0.36 g/kg per day in the control group vs 2.19 +/- 0.48 g/kg per day in the CHD group) via the parenteral route. Amino acid solutions were either 19% or 45% branched-chain amino acid enriched. Studies were performed every 12 hours for a maximum of 6 days. Amino acid loss was 2.5 +/- 2.3 g/12 h in the control group vs 6.6 +/- 2.4 g/12 h in the CHD group (p < .0001). Increasing the dialysate rate from 15 to 30 mL/min increased amino acid loss from 5.7 +/- 1.7 to 7.9 +/- 2.6 g/12 h (p < .0001). Amino acid loss was unrelated to amino acid intake but was directly related to plasma amino acid concentration, CHD effluent volume, and the efficiency of filtration as measured by the ratio of filtered urea nitrogen to blood urea nitrogen (R2 = .69). A linear relationship was found between amino acid intake and balance (R2 = .991). The patterns of plasma amino acid concentrations were consistent with metabolic changes wrought by a combination of sepsis and multiple organ dysfunction and type of amino acid intake but seemed unaffected by increased amino acid loss in CHD effluent. Amino acid losses were 2 to 3 times greater from CHD than from normal kidney. However, CHD amino acid losses may not be clinically significant unless amino acid intake is restricted to levels used typically in traditional hemodialysis.

Efficacy of continuous arteriovenous hemofiltration with dialysis in patients with renal failure

ObjectiveTo document the efficacy of continuous arteriovenous hemofiltration with dialysis following renal failure, without protein restriction, and to explore the magnitude and clinical applications of total daily urea clearance. DesignA noncomparative, descriptive account of a case series. Data were collected prospectively and analyzed retrospectively. SettingA tertiary care facility in a statewide emergency medical services system. PatientsTwenty-eight patients with renal failure were supported by continuous arteriovenous hemofiltration with dialysis in a critical care unit during a 14-month period (21 patients with multitrauma; three patients with soft tissue infections; and four patients with multisystem organ failure who had been transferred from other hospitals). Renal failure was most commonly due to multisystem organ failure or associated with adult respiratory distress syndrome. ResultsContinuous arteriovenous hemofiltration with dialysis days totaled 308 (mean 10.9). All patients received full protein alimentation (mean protein load 131 g/day). The blood urea nitrogen concentration was controlled, generally to 40 to 75 mg/dL (14.3 to 26.7 mmol/L) within 3 to 5 days. Total daily urea clearance ranged from 15 to 21 g/day. Five (18%) of the 28 patients survived. ConclusionContinuous arteriovenous hemofiltration with dialysis appears to be effective for the control of blood urea nitrogen and clearance of urea. This modality also permits full protein alimentation. Total daily urea clearance can be calculated easily and may have important clinical uses and implications.

Inflammatory markers: superior predictors of adverse outcome in blunt trauma patients?

ObjectiveTo assess whether variables reflective of early metabolic responses to injury are predictors of outcome in critically ill trauma patients. DesignClinical inception cohort study comparing conventional measures of injury severity with early host response markers for the correlation of each with outcome. These data are prospectively collected in a group of patients being evaluated in a nutritional support investigation. SettingIntensive care unit (ICU) of a major Level I trauma center. PatientsSeventeen blunt trauma patients, aged 18 to 60 yrs with an Injury Severity Score of 2:15, requiring early mechanical ventilation. InterventionsBlood and urine samples were routinely obtained from patients undergoing nutritional support by one of three routes. Measurements and Main ResultsConventional assessment was consistent with moderate severity and variation: Injury Severity Score, 41 pL 15; Glasgow Coma Score, 11 pL 4; admission circulating lactate concentration, 4.8 pL 2.2 mmol/L; and first 24-hr transfusion requirement, 3.1 pL 2.9 L. The mean concentrations of inflammatory marker during the first week were: cholesterol, 2.67 pL 0.80 mmol/L (103.2 pL 31 mg/dL); C-reactive protein, 23 pL 11 mg/dL; transferrin, 1.44 pL 0.47 g/L; glucose, 9.21 pL 2.27 mmol/L (166 pL 41 mg/dL); albumin, 26 pL 5 g/L; and nitrogen loss, 24 pL 9 g/d. Hospital outcome variables were: ventilator days, 17 pL 7; ICU days, 26 pL 10; hospital days, 38 pL 15; occurrence rate of adult respiratory distress syndrome (ARDS), 35%; infections, 82%; multiple organ failure, 71%; and total of hospital plus professional charges, 125,000 pL 56,000. A significant (p < .05), but weak, correlation existed between all seven outcome variables and the inflammatory markers: ventilator days with cholesterol and C-reactive protein; ICU days with transferrin; total stay with cholesterol; ARDS with C-reactive protein; infections with glucose, cholesterol, and nitrogen loss; multiple organ failure with albumin and C-reactive protein; and financial charges with glucose. However, a significant correlation existed between only two of seven outcome variables and conventional measures of severity: multiple organ failure with lactate and financial charges with transfusion requirement. ConclusionReadily obtainable inflammatory marker measurements may better reflect the summation effects of the early perfusion deficit and tissue injury in the blunt trauma patient compared with conventional measures of injury severity. (Crit Care Med 1994; 22:667–672)

Prospective evaluation of combined high-frequency ventilation in post-traumatic patients with adult respiratory distress syndrome refractory to optimized conventional ventilatory management

This study explores the value of combined high-frequency ventilation (CHFV) in a prospective clinical trial of 35 patients suffering from severe post-traumatic and/or septic adult respiratory distress syndrome (ARDS) who were refractory to conventional controlled mechanical ventilatory (CMV) support. The severity of ARDS was quantified by lung mechanics and gas exchange variables and the patients were classified on clinical grounds as well as on the basis of their respiratory index/pulmonary shunt relationship [RI/(Qsp/Qt)]. During the same time period as the CHFV study, data from these patients were compared to those from 88 ARDS patients who had quantitatively similar degrees of respiratory insufficiency, but who were treated only with controlled mechanical ventilation (CMV). The use of CHFV in the 35 CMV refractory patients resulted in an increase in expired tidal volume (VTE) by reducing the CMV inspired tidal volume (VTI) while increasing the volume component derived from high-frequency ventilation (HFV). This procedure appeared to reveal potentially salvageable ARDS patients who were refractory to CMV. In these patients, CHFV significantly reduced pulmonary mean airway pressure (Paw). The RI also decreased significantly and it was possible to reduce significantly the FIO2. In surviving ARDS patients treated with CHFV, an improvement in blood gases at reduced FIO2, without decreased cardiac output, was produced. The CHFV technique was used for less than or equal to 25 days and resulted in 23% survival of patients who were clinically and physiologically indistinguishable from the patients in the ARDS nonsurvivor group who were treated by CMV only. In surviving CHFV patients the decrease in Paw permitted a sustained, or increased, cardiac output with a rise in the oxygen delivery/oxygen consumption ratio, thus allowing for a higher PaO2 for any given level of pulmonary shunt.

Inhibition of post-traumatic septic proteolysis and ureagenesis and stimulation of hepatic acute-phase protein production by branched-chain amino acid TPN.

Previous studies have shown that severe sepsis after major trauma results in the reprioritization of release of hepatic acute-phase proteins (APP). They suggest competition for leucine for nutritional utilization may be responsible. To test this hypothesis, a branched-chain enriched (46.6%) amino acid mixture (BCAA) was administered on a prospective randomized basis with standard TPN therapy to 16 septic post-trauma patients. After sepsis was diagnosed, a randomized therapy (control-TPN or BCAA-TPN) was given for 12 days, or until death occurred. Total calories and amino acid nitrogen (N) administered were not different in the two groups (t-test) and q 8 h (347 study periods) amino acid clearances, urinary urea nitrogen excretion, muscle proteolysis from 3-methyl-histidine (3-MH) excretion, and standard indices of sepsis severity and hepatic function were measured, as well as platelets (PLAT), leucocytes (WBC), albumin (ALB), and six acute-phase proteins: C-reactive protein (CRP), alpha-1-antitrypsin (A1TRIP), fibrinogen (FIBRIN), alpha-2-macroglobulin (AMACRO), ceruloplasmin (CERUL), and transferrin (TRANS). Using Scheffé analysis of all contrasts the data showed: BCAA resulted in a fall in 24-hour urea N excretion (24.0 to 20.0 gm/24 hr) and in proteolysis (138 to 126 gm/24 hr) (p less than 0.0001). Prestudy CRP levels were all elevated, but compared to control where APP reprioritization occurred, over the initial 10 days of therapy BCAA patients had a more rapid fall in CRP with a more rapid rise in FIBRIN, TRANS, CERUL, ALBUMIN, AMACRO, and A1TRIP (all p less than 0.0001) relative to CRP. Also, the sepsis-reduced clearances of glutamine and glutamate, alanine, and proline were increased (p less than 0.0001) during BCAA even though urea nitrogen production was reduced (p less than 0.0001). The increase in leucine clearance with BCAA-enriched TPN was positively correlated (r2 = 0.601; p less than 0.0001) with the increase in the sum of all APP and ALB and was also associated with an increase both in FIBRIN and in platelets (p less than 0.0001). The BCAA-related increase in FIBRIN (9.1 to 11.9 mg/ml) occurred at the same time as a fall in prothrombin time (p less than 0.0001). BCAA-enriched TPN reduced proteolysis and amino acid catabolism and appeared to increase the levels of the more rapidly appearing anti-inflammatory and nutritional hepatic APP and formed coagulation elements in post-traumatic sepsis.

Delayed Embolization of a Shotgun Pellet from the Chest to the Middle Cerebral Artery

Embolization of metallic missiles into the cerebral circulation is a rare occurrence. Most of the cases reported were due to gunshot wounds and shotgun wounds to the neck and face. Embolization from injuries sustained to the chest are extremely rare. We report a case of delayed pellet embolization to the middle cerebral artery resulting from a shotgun injury to the left chest.