De'Ath Hd

The incidence and magnitude of fibrinolytic activation in trauma patients

Summary.  Background: Trauma is a global disease, with over 2.5 million deaths annually from hemorrhage and coagulopathy. Overt hyperfibrinolysis is rare in trauma, and is associated with massive fatal injuries. Paradoxically, clinical trials suggest a much broader indication for antifibrinolytics.

Hemostatic effects of fresh frozen plasma may be maximal at red cell ratios of 1:2.

BACKGROUND Damage control resuscitation targets acute traumatic coagulopathy with the early administration of high-dose fresh frozen plasma (FFP). FFP is administered empirically and as a ratio with the number of packed red blood cells (PRBC). There is controversy over the optimal FFP:PRBC ratio with respect to outcomes, and their hemostatic effects have not been studied. We report preliminary findings on the effects of different FFP:PRBC ratios on coagulation. METHODS This is a prospective observational cohort study of trauma patients requiring >4 U of PRBCs. Blood was drawn before and after each 4-U PRBC interval for prothrombin time and analysis by rotational thromboelastometry. Interval change in coagulation parameters were compared with the FFP:PRBC ratio received during each interval. RESULTS Sixty 4-U PRBC intervals from 50 patients were available for analysis. All measures of coagulation deteriorated with low FFP:PRBC ratios (<1:2). Maximal hemostatic effect was observed in the 1:2 to 3:4 group: 12% decrease in prothrombin time (p=0.006), 56% decrease in clotting time (p=0.047), and 38% increase in maximum clot firmness (p=0.024). Transfusion with ≥1:1 ratio did not confer any additional improvement. There was a marked variability in response to FFP, and hemostatic function deteriorated in some patients exposed to 1:1 ratios. The beneficial effects of plasma were confined to patients with coagulopathy. CONCLUSIONS Interim results from this prospective study suggest that FFP:PRBC ratios of ≥1:1 do not confer any additional advantage over ratios of 1:2 to 3:4. Hemostatic benefits of plasma therapy are limited to patients with coagulopathy.

Factors affecting outcome after traumatic limb amputation

Traumatic leg amputation commonly affects young, active people and leads to poor long‐term outcomes. The aim of this review was to describe common causes of disability and highlight therapeutic interventions that may optimize outcome after traumatic leg amputation.

Clinical and biomarker profile of trauma-induced secondary cardiac injury

Secondary cardiac injury has been demonstrated in critical illness and is associated with worse outcomes. The aim of this study was to establish the existence of trauma‐induced secondary cardiac injury, and investigate its impact on outcomes in injured patients.

Trauma-induced secondary cardiac injury is associated with hyperacute elevations in inflammatory cytokines.

Introduction Clinical evidence supports the existence of a trauma-induced secondary cardiac injury. Experimental research suggests inflammation as a possible mechanism. The study aimed to determine if there was an early association between inflammation and secondary cardiac injury in trauma patients. Methods A cohort study of critically injured patients between January 2008 and January 2010 was undertaken. Levels of the cardiac biomarkers troponin I and heart-specific fatty acid–binding protein and the cytokines tumor necrosis factor &agr; (TNF-&agr;), interleukin (IL)-6, IL-1&bgr;, and IL-8 were measured on admission to hospital, and again at 24 and 72 h. Participants were reviewed for adverse cardiac events (ACEs) and in-hospital mortality. Results Of 135 patients recruited, 18 (13%) had an ACE. Patients with ACEs had higher admission plasma levels of TNF-&agr; (5.4 vs. 3.8 pg/mL; P = 0.03), IL-6 (140 vs. 58.9 pg/mL, P = 0.009), and IL-8 (19.3 vs. 9.1 pg/mL, P = 0.03) compared with those without events. Hour 24 cytokines were not associated with events, but IL-8 (14.5 vs. 5.8 pg/mL; P = 0.01) and IL-1&bgr; (0.55 vs. 0.19 pg/mL; P = 0.04) were higher in patients with ACEs at 72 hours. Admission IL-6 was independently associated with heart-specific fatty acid–binding protein increase (P < 0.05). Patients who presented with an elevated troponin I combined with either an elevated TNF-&agr; (relative risk [RR], 11.0; 95% confidence interval [CI], 1.8–66.9; P = 0.015), elevated IL-6 (RR, 17.3; 95% CI, 2.9–101.4; P = 0.001), or elevated IL-8 (RR, 15.0; 95% CI, 3.1–72.9; P = 0.008) were at the highest risk of in-hospital death when compared with individuals with normal biomarker and cytokine values. Conclusions There is an association between hyperacute elevations in inflammatory cytokines with cardiac injury and ACEs in critically injured patients. Biomarker evidence of cardiac injury and inflammation on admission is associated with a higher risk of in-hospital death.

Coagulation system changes associated with susceptibility to infection in trauma patients.

BACKGROUND Infection following trauma is associated with increased morbidity and mortality and is common following severe hemorrhage. There is a strong interaction between the coagulation and immunity. The objective of this study was to establish if there was an association between changes in coagulation status after hemorrhage and the subsequent incidence of infection. METHODS Prospective cohort study of adult injured patients presenting to a major trauma center during a 2-year period. Blood was drawn at 24 hours following admission and analyzed using functional thromboelastography testing and laboratory defined tests of coagulation and blood count. Patients were followed up for infectious episodes while in the hospital using Center for Disease Control definitions. RESULTS A total of 158 patients were recruited; 71 (45%) developed infection and were older (44 years vs. 32 years, p = 0.01) and more severely injured (Injury Severity Score [ISS], 25 vs.10; p < 0.01). White blood cell counts at 24 hours were normal, and there was no difference between groups (both 9.6 × 109/L). Protein C was lower in those with infection (70.2 IU/dL vs. 83.3 IU/dL, p = 0.02), with a dose-dependent increase in infection as levels of protein C decreased. Plasmin activation at 24 hours was also strongly associated with infection plasmin-antiplasmin (infection vs. no infection, 6,156 &mgr;g/L vs. 3,324 &mgr;g/L, p = 0.03). The infection cohort had overall 12% lower procoagulant levels (varied between factor VIII 6.4% and factor II 16.2%). CONCLUSION There is a strong association between the status of the coagulation system after 24 hours and the development of infection following trauma. Improved early coagulation management may decrease infection rates in this patient group. LEVEL OF EVIDENCE Prognostic prospective study, level III.

Endovenous laser ablation for persistent and recurrent venous ulcers after varicose vein surgery

A 75-year-old woman presented with painful recurrent venous ulcers (VU) continuously for the past 33 months on a background of frequent intermittent problems for the last 16 years. She had previously been treated with varicose vein surgery and trials of compression bandaging. Subsequently, she underwent endovenous laser ablation (EVLA) targeting the distal incompetent remnant of her great and small saphenous veins. This resulted in complete healing of her ulcers within four weeks. The dramatic response demonstrated in this case suggests that EVLA may represent an effective intervention in the management of postsurgery refractory VU.

Time course of lactate clearance in trauma and its relevance to outcomes

Serum lactate is raised during haemorrhage of trauma and high admission levels are associated with worse outcomes. The time-course of lactate clearance and the effect of packed red blood cell transfusion (PRBC) has not previously been described. This information is important for clinical trials of novel oxygen therapeutics.

Perforation of a sigmoid diverticulum presenting with a pneumoscrotum and surgical emphysema.

A case of a sigmoid perforation presenting as a pneumoscrotum with progressive surgical emphysema is reported. An elderly patient presented with a grossly swollen scrotum and a distended abdomen. A computed tomography (CT) scan demonstrated sigmoid diverticulitis in conjunction with air and a subdiaphragmatic collection. A laparotomy was performed and revealed a perforated sigmoid diverticulum (Hinchey III). Sadly the patient died on the operating table. Intra-abdominal pathology manifesting as a pneumoscrotum and surgical emphysema is a rare yet reported phenomenon most often associated with colonoscopy, but also described with appendicitis and perforated colonic carcinoma. In previous reports, in contrast to this patient, the individual’s scrotum was inflamed but not erythematous and tender, and the rapid progression of surgical emphysema is not reported.

Obese patients have similar short-term outcomes to non-obese in laparoscopic colorectal surgery

AIM To determine whether obese patients undergoing laparoscopic surgery within an enhanced recovery program had worse short-term outcomes. METHODS A prospective study of consecutive patients undergoing laparoscopic colorectal resection was carried out between 2008 and 2011 in a single institution. Patients were divided in groups based on body mass index (BMI). Short-term outcomes including operative data, length of stay, complications and readmission rates were recorded and compared between the groups. Continuous data were analysed using t-test or one-way Analysis of Variance. χ(2) test was used to compare categorical data. RESULTS Two hundred and fifty four patients were included over the study period. The majority of individuals (41.7%) recruited were of a healthy weight (BMI < 25), whilst 50 patients were classified as obese (19.6%). Patients were matched in terms of the presence of co-morbidities and previous abdominal surgery. Obese patients were found to have a statistically significant difference in The American Society of Anesthesiologists grade. Length of surgery and intra-operative blood loss were no different according to BMI. CONCLUSION Obesity (BMI > 25) does not lead to worse short-term outcomes in laparoscopic colorectal surgery and therefore such patients should not be precluded from laparoscopic surgery.