Jorge I. Cue

Interleukin-10 is associated with the development of sepsis in trauma patients.

Interleukin-10 (IL-10) is a potent regulator of proinflammatory cytokines, including tumor necrosis factor-alpha, IL-1, IL-6, and interferon-gamma. We retrospectively evaluated 66 severely injured patients for detectable plasma IL-10. the presence or absence of IL-10 was correlated with clinical parameters. Forty of 66 patients had detectable levels of IL-10. Plasma IL-10 was associated with admission hypotension (p < 0.01) and the development of sepsis (p < 0.05). There was no difference between IL-10-positive and -negative patients with respect to age, mechanism or severity of injury, blood transfusion, operative interventions, or the subsequent development of ARDS, hepatic dysfunction, or renal insufficiency. We conclude that IL-10 can be detected in the plasma of some severely injured patients and that it is associated with the development of sepsis. Further investigation of the immunoregulatory effects of IL-10 after trauma is indicated.

Penetrating esophageal injuries: Multicenter study of the American Association for the Surgery of Trauma

OBJECTIVE The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay. METHODS This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.5 years. Patients surviving to reach the operating room (OR) were divided into two groups: those that underwent diagnostic studies to identify their injuries (preoperative evaluation group) and those that went immediately to the OR (no preoperative evaluation group). Statistical methods included Fishers exact test, Students T test, and logistic regression analysis. RESULTS The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean Injury Severity Score was 28, and the mean time interval to the OR was 6.5 hours. There were associated injuries in 356 patients (88%), and an overall complication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hundred forty-six patients survived to reach the OR: 171 in the preoperative evaluation group and 175 in the no preoperative evaluation group. No statistically significant differences were noted in the two groups in the following parameters: number of patients, age, Injury Severity Score, admission blood pressure, anatomic location of injury (cervical or thoracic), surgical management (primary repair, resection and anastomosis, resection and diversion, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus 1 hour in the no preoperative evaluation group (p < 0.001). Overall complications occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal related complications occurred in the preoperative evaluation group versus 32 (19%) in the no preoperative evaluation group (p = 0.003). Mean surgical intensive care unit length of stay was 11 days in the preoperative evaluation group versus 7 days in the no preoperative evaluation group (p = 0.012). Logistic regression analysis identified as independent risk factors for the development of esophageal related complications included time delays in preoperative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection and diversion (odds ratio, 4.47). CONCLUSION Esophageal injuries carry a high morbidity and mortality. Increased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, rapid diagnosis and definitive repair should be made a high priority.

DOES BLOOD TRANSFUSION OR HEMORRHAGIC SHOCK INDUCE IMMUNOSUPPRESSION

Blood transfusions have been implicated in predisposing patients to infection by inducing immunosuppression. This study evaluated the effects of syngeneic (ST) and allogeneic (AT) blood transfusion with and without hemorrhagic shock (HS) to determine whether transfusion or the accompanying hemorrhage affected certain components of the immune response. Lewis rats received ST or AT at 10%, 20%, or 30% of blood volume. Hemorrhagic shock was induced in other animals, which were resuscitated with either shed blood or substituted 10%, 20%, or 30% ST or AT. Intradermal staphylococcal abscess size, peritoneal leukocyte elicitation, and peritoneal macrophage Ia receptor expression were selected to measure the immune system response. Hemorrhagic shock increased abscess size significantly (p less than 0.05), but ST or AT alone or in combination with HS had no effect. Both shock and transfusion per se increased macrophage Ia receptor expression (p less than 0.05), but no additive or synergistic effect was observed. Peritoneal leukocyte elicitation was not affected by HS, ST, or AT. These results suggest that HS and not blood transfusion is a major determinant of the risk of infection.

The patient with circulatory shock: To feed or not to feed?

Controversy continues to surround the appropriate form and timing of nutrition support for the patient with circulatory shock. Clinical studies have demonstrated improvements in outcome with the administration of enteral nutrition to critically ill patients; however, the provision of enteral nutrition to critically ill patients with ongoing shock remains controversial. This article reviews gut perfusion during normal states and during circulatory shock as well as alterations in perfusion when enteral feeding is provided. Pharmaconutrients studied during ischemia and reperfusion are discussed.

A prospective, randomized comparison between open and closed peritoneal lavage techniques.

We randomized 327 blunt trauma patients to compare the open peritoneal lavage technique with the percutaneous (Seldinger wire) technique. The open and closed lavage groups were similar with respect to accuracy and safety. There were one complication in the percutaneous group and two in patients treated by the open method. The incidence of positive lavage was similar in each group. There was one false positive in the percutaneous group and none in the open method group. False negative results did not occur by either method. The percutaneous lavage method required less time for performance, had better patient tolerance, and only required one surgeon to perform the procedure. Percutaneous diagnostic peritoneal lavage (DPL), in the hands of trauma surgeons, is a safe and acceptable alternative to the open DPL method and actually had several advantages as mentioned above.

Solitary splenic abscess: a new complication of splenic salvage treated by percutaneous drainage.

A patient sustained a gunshot injury to the spleen. The spleen was left intact in an attempt to maintain normal immune function in the patient. The patient developed a splenic abscess as a result of the injury, a complication of splenic salvage that we have not found reported before. The abscess was treated successfully via CT-guided percutaneous drainage.

Pharmacokinetics of reconstituted human high-density lipoprotein in pigs after hemorrhagic shock with resuscitation

OBJECTIVES Reconstituted human high-density lipoprotein (HDL) can inhibit lipopolysaccharide effects in vivo. The major objectives of this study were to characterize the pharmacokinetics of reconstituted HDL in a stressed large-animal model and to provide preclinical tolerance information in support of use of reconstituted HDL in humans. DESIGN A randomized, blinded, placebo-controlled trial where each animal received either reconstituted human HDL at a dose of 100 mg/kg (apolipoprotein A-I) or placebo, immediately after hemorrhagic shock and resuscitation. SETTING Animal laboratory. SUBJECTS Twelve immature female swine (18 to 25 kg) were studied. INTERVENTIONS Six to 8 days before shock and study drug administration, animals were anesthesized and catheters were placed in the external jugular vein and abdominal aorta. These catheters were secured to the dorsal surface. On the day of shock, the animals were sedated (alpha-chloralose) and 50 mL/kg of arterial blood was removed over 0.5 hr. One half hour after blood removal, shed blood was infused, which was immediately followed by study drug (reconstituted HDL or placebo), and then by 1 L of lactated Ringers solution. MEASUREMENTS AND MAIN RESULTS Physiologic (arterial blood pressure, heart rate, respiratory rate) and laboratory (serum chemistries, hematologic and coagulation studies, and blood gases) measurements were determined intermittently for 96 hrs after the induction of shock. Blood was collected intermittently for 48 hrs after shock for assay of apolipoprotein A-I and phosphatidylcholine in plasma. Reconstituted HDL was well tolerated and did not appear to alter the physiologic responses to shock and resuscitation. HDL transient increase in aspartate aminotransferase concentration was noted in the reconstituted group but this increase normalized by 24 hrs after drug administration. Mean apolipoprotein A-I pharmacokinetic parameters were as follows: half-life 24.5+/-5.3 (SD) hrs; clearance 41.9+/-10 mL/hr; and volume of distribution 1.39+/-0.08 L. The apparent mean half-life of phosphatidylcholine was 5.4+/-0.8 hrs. CONCLUSIONS Reconstituted human HDL was well tolerated in animals that had undergone hemorrhagic shock with resuscitation. The apolipoprotein component of reconstituted HDL had a relatively long half-life, with distribution limited to the vascular space. These findings support the investigational use of this product in humans.

Single-agent versus combination antibiotic therapy in the management of intraabdominal infections

For the treatment of intraabdominal infection, single‐agent antimicrobial regimens such as β‐lactams with good antianaerobic activity are frequent alternatives to combination regimens such as aminoglycosides or aztreonam plus an antianaerobic agent such as clindamycin or metronidazole. The major issues in selecting a regimen are relative efficacy, potential for adverse drug effects, and cost. Single agents are clearly equivalent to combinations in preventing infectious complications after penetrating abdominal trauma and in treating established intraabdominal infections of mild to moderate severity or in relatively low‐risk patients. A few trials demonstrated their equivalency in patients at high risk of mortality, although experience is limited. Single‐agent regimens may reduce the risks of adverse drug effects compared with combination regimens, but they are not always less expensive.