G. Regel

Pattern of organ failure following severe trauma

Abstract. Multiple organ failure (MOF) is considered to be the leading cause of death after severe trauma. Although there is extensive literature on MOF, little is known about the pattern, sequence, and onset of this clinical syndrome. The first goal of this clinical study was to define MOF; the second was to assess the typical onset, sequence, and pattern of MOF; and the third was to define certain risk factors for the development of MOF in 342 multiple trauma patients. Patients with an Injury Severity Score (ISS): > 20 (mean 35.7) were included. Three well established MOF scoring methods were used to give strict definitions of MOF: 11.4% of the total patient population developed MOF, and 88.6% did not. Respiratory failure was most frequent in patients developing MOF (74.4%), and these patients had the highest mortality rate (65.5%) compared to patients with failure of other organ systems (liver, cardiovascular system). Generally, the lung is the first organ to fail after injury (failure after 3.7 ± 2.8 days). Significant renal failure and the need for dialysis decreased to < 5%; other signs of organ dysfunction (gastric, central nervous system) are difficult to verify. Typical risk factors for the development of MOF after severe trauma are the severity, type, and distribution of injury as well as the indicators of prolonged hemorrhagic shock (elevated lactate levels). The main therapeutic efforts, therefore, should be the effective treatment of traumatic hemorrhagic shock during the initial phase, adequate resuscitation, optimal oxygenation, and early surgical treatment.

Influence of thoracic trauma and primary femoral intramedullary nailing on the incidence of ARDS in multiple trauma patients

In multiple trauma patients the development of pulmonary complications (pneumonia, posttraumatic adult respiratory distress syndrome (ARDS)) represents a major problem and can have a substantial impact on the duration of intensive care treatment as well as on outcome. An association between the timing of stabilisation of long bone fractures and the incidence of pulmonary complications has been discussed. In several studies, primary fracture stabilisation of femoral shaft fractures, preferably by intramedullary stabilisation (Lhowe and Hansen, 1988), was shown to reduce the incidence of pneumonia and ARDS and was therefore advocated (Goris et al., 1982; Tscherne, 1983; Kwasni et al., 1986; Ruedi and Wolff, 1975; Bone et al., 1989; Johnson et al., 1985; Behrmann et al., 1990). Some authors generally recommend primary intramedullary femoral nailing in multiple trauma patients (Bone, 1993).

The effect of kinetic positioning on lung function and pulmonary haemodynamics in posttraumatic ARDS: a clinical study

In the treatment of adult respiratory distress syndrome (ARDS) no breakthrough has been achieved so far. In several cases of severe ARDS in multiply injured patients we have seen improvements of lung function by means of continuous body positioning. We therefore compared the effect of kinetic positioning (KIN) on lung function and haemodynamics in ARDS patients with conventional (CON) supine positioning. Pulmonary and systemic haemodynamics were determined on the basis of pulmonary artery catheter measurements. On a daily basis oxygenation ratio (PaO2/FiO2) and pulmonary shunt (Os/Ot. per cent) were calculated. Extravascular lung water (EVLW, ml/kg BW) was determined by the double indicator thermodilution technique. Twenty-two patients were included: KIN, N = 11, CON, N = 11. Mortality from ARDS in KIN patients was 18.2 per cent (N = 2): in CON patients it was 63.6 per cent (N = 7). The oxygenation ratio (PaO2/FiO2) increased significantly in KIN patients from 140 + 45 (day 0) to 237 + 40 (P < 0.05) (day 5); in CON patients no improvement was seen (143 + 48 (day 0). 133 + 44 (day 5); n.s. between groups at day 0: P < 0.05 between groups at day 5). Pulmonary shunt decreased significantly from 26.6 + 4 per cent (day 0) to 12.5 + 2 per cent (day 5) (P < 0.05) in KIN patients and was 36.6 + 6 per cent at day 0 and 31.4 + 2 per cent at day 5 in CON patients (P < 0.05 between groups at day 5).(ABSTRACT TRUNCATED AT 250 WORDS)

Is early kinetic positioning beneficial for pulmonary function in multiple trauma patients

Body positioning (kinetic therapy) is known to improve oxygenation in patients with impaired pulmonary function and ARDS. We have used body positioning prophylactically in trauma patients whose injury and pattern predispose to ARDS. This retrospective study reports the effects of early prophylactic (group P) versus late (group L) axial rotation on pulmonary function and the incidence of ARDS. Both groups were comparable in age, injury severity and the degree of thoracic injury. Systemic oxygenation was significantly better and the incidence of ARDS significantly lower in group P (group P: 34.3 per cent, group T: 74.1 per cent, P < 0.05). There was a tendency towards a lower incidence of pneumonia and a better survival in group P, which did not reach statistical significance. The duration of kinetic therapy and of ventilation was comparable in both groups. In this retrospective evaluation early prophylactic kinetic therapy was associated with a significantly lower incidence of ARDS compared with that instigated later.

Alveolar cell pattern and chemiluminescence response of blood neutrophils and alveolar macrophages in sheep after endotoxin injection.

In order to study the pathomechanisms of the Adult Respiratory Distress Syndrome in an acute animal model, we monitored the alveolar cell pattern and the stimulatory chemiluminescence responses of blood neutrophils and alveolar macrophages in sheep after Escherichia coli endotoxin injection (2 micrograms/kg of body weight). Using appropriate bronchoalveolar lavage techniques, thereby avoiding local inflammation, it was demonstrated that endotoxin injection did not cause any recruitment of neutrophils into the alveoli for a period of up to 24 hours. Following endotoxin injection, blood neutrophils showed a maximal stimulatory response after 5 minutes, and alveolar macrophages after 4 hours. It is concluded that if neutrophils are responsible for initiating the increase in microvascular permeability, then this action must be purely intravascular.

Parameters of multiple organ dysfunction fail to predict secondary amputation following limb salvage in multiply traumatized patients

OBJECTIVE The purpose of this retrospective analysis was to evaluate whether systemic parameters that are used to characterize multiple organ dysfunction could also be used to predict the optimal time for amputation in patients failing limb salvage surgery following severe extremity injury. METHODS The principal criterion for the study group was a lower limb amputation following a type IIIb or IIIc open tibial shaft fracture in multiply traumatized patients. This group was then divided into one group of primary amputation (group A) and one group of secondary amputation (group B). Beside these groups a third group of total traumatic lower limb amputation was recruited (group C). Data analysis included demographics, injury severity according to the ISS, evaluation of the limb injury by three different salvage scores (HFS, MESS and NISSSA) and organ function monitoring by the Denver MOD Score over a 14-day period posttrauma or up to 7 days after secondary amputation. RESULTS Within the period 1987-1997 a total of 15 patients were recruited for group A (primary amputation), 10 patients for group B (secondary amputation) and nine patients for group C (traumatic amputation). The MOD score was only positive for pulmonary dysfunction, also reflected by the Horovitz quotient, in those patients that died later in either group. Mortality was higher in group A (three out of 15) compared with group B (one out of 10), which may be due to a higher ISS in group A (mean ISS 28.2 vs. 21.0 of group B). Although the MOD score of all recovered patients revealed no significant difference between group A and B, secondary amputation resulted in significantly longer demand of mechanical ventilation. According to our results secondary amputation may lead to transiently decreased pulmonary function but does not necessarily end in multiple organ dysfunction. The need for amputation in failed limb salvage was not indicated by systemic parameters. CONCLUSION The right time for secondary amputation in order to prevent subsequent pulmonary dysfunction cannot be predicted by parameters otherwise indicating organ dysfunction. As the risk of secondary amputation for developing pulmonary dysfunction apparently cannot be estimated the decision for amputation or limb salvage should be made initially after trauma and should be the definite one.

Nonspecific Immune System, Plasma Proteins and Characteristics of the Erythrocyte Insulin Receptor

Several lines of evidence suggest that the imbalance of the humoral-phagocytic immune system conclusively contributes to the development of the adult respiratory distress syndrome (ARDS) [16, 19, 35]. Furthermore, polymorphonuclear leukocytes (PMNLs) are believed to play an essential role in the initiation and amplification of the lung tissue injury processes leading to increased lung permeability and the onset of ARDS. After being stimulated intravascularly, neutrophils adhere to the capillary endothelium, especially of the lung, and then pass across the capillary-interstitial-alveolar space while releasing inflammatory mediators such as arachidonic acid metabolites, oxygen-derived agents, and lysosomal enzymes [26, 29, 33]. These release reactions are coupled to stimulatory response mechanisihs in which soluble and/or particulate stimulators cause extracellular release of respiratory burst products and lysosomal enzymes which lead to an increase in photon emission [1].

Clinical Definition of ARDS An Index Based on Bedside-Derived Parameters

In the present study one of the major problems was classification of patients into groups with or without adult respiratory distress syndrome (ARDS). The pathomorphologic substrate of ARDS is an interstitial edema showing high protein concentrations, which can be measured as extravascular lung water (EVLW). Therefore the primary parameter for determining ARDS and EVLW. Clinical definitions of ARDS as found in the literature are mostly unspecific, simply requiring “respiratory failure” with ventilation. Some definitions require certain values of respiratory parameters in conjunction with low left atrial filling pressures to exclude left pulmonary insufficiency due to left ventricular failure [1]. But these definitions have shown to be too unspecific for the purpose of the present study, which describes the development of an ARDS index to assess ARDS by clinical parameters and validation of ARDS grouping by EVLW.

Influence of Short- and Long-Term Endotoxin Administration on the Phagocytic Functions of Polymorphonuclear Leukocytes and Reticuloendothelial System in a Sheep Model

The reticuloendothelial system (RES) is thought to ensure the clearance of embolic particulate matter and blood-borne bacterial substances after trauma, burns, and sepsis [14]. It thereby helps to prevent disturbances to organ integrity, for instance, lung capillary injury, and consequently the development of adult respiratory distress syndrome (ARDS) [1, 7, 11, 25]. In cases of RES blockade, an enhanced deposition of debris and bacterial matter is seen in the lung [13]. It has been suggested that polymorphonuclear leukocytes (PMNLs) then become activated, migrate to the lung, and can take on a major phagocytic role [8, 21]. It is unclear what mechanisms lead to the activation of neutrophils [26] and their pooling in the lung [5]. This is important in that stimulated PMNLs, in addition to substituting for a blocked RES, may lead to pulmonary endothelial damage [14, 16]. The relative injury-producing role of activated PMNLs alone, as opposed to activated PMNLs that have subsequently decompensated, is unknown [15]. It is therefore questionable whether toxic degranulation is a sign of appropriately increased PMNL function or rather a sign of dysfunction. To clarify these issues we used two animal models that would cause acute and chronic lung injury [2] and examined the behavior of the PMNLs and the RES following single and multiple endotoxin bolus injection.

Changes in Reticuloendothelial Capacity Associated with Liver Dysfunction in Multiple Trauma

Severe trauma is often complicated by the development of multiple organ system failure. In this context mainly dysfunction syndromes of lung and kidney have been described. Distinct disturbances of hepatic function have frequently been noticed. In some cases, however, severe liver failure is seen mostly in association with posttraumatic sepsis [7]. The pathomechanisms relating disturbances of hepatic blood flow, liver cell integrity, and the function of the reticuloendothelial system (RES) in the liver have so far not been clarified [1, 4, 10].