Junichiro Yokota

Acceleration of Superoxide Production from Leukocytes in Trauma Patients

Superoxide (O2-) and granulocyte elastase (GE) from neutrophils mediate host defense and tissue injury in inflammation. To determine alterations in leukocyte function after trauma, O2- production and GE secretion from neutrophils were studied in trauma patients (n = 20) and healthy controls (n = 15). The priming effect of tumor necrosis factor (TNF), interleukin-la (IL-la), and lipopolysaccharide (LPS) on O2 or GE release also was evaluated. Superoxide production (nmole/10 minutes) was elevated significantly in trauma patients at days 0 (9.5 ± 4.8), 1 (14.2 ±7.3), and 3 (12.2 ± 5.9) and returned to control levels (4.2 ± 1.6) by day 7. There was no difference in GE secretion between trauma patients and healthy controls. Incubation of neutrophils with TNF induced release of both O2- and GE. Superoxide production was induced by TNF at concentrations at or greater than 10-11 mol/L. Granulocyte elastase secretion was induced in a time- and dose-dependent manner by TNF at concentrations between 10-10 and 10-7 mol/L. In contrast IL-1α and LPS did not potentiate O2- or GE release. These results suggest that neutrophil O2- production increases acutely in trauma. Tumor necrosis factor may mediate this O2- and GE production by neutrophils involved in the inflammatory response.

Long-term physical outcome of patients who suffered crush syndrome after the 1995 Hanshin-Awaji earthquake: prognostic indicators in retrospect.

BACKGROUND The 372 cases of crush syndrome that followed the 1995 Hanshin-Awaji earthquake have provided a unique opportunity to investigate the long-term physical outcomes and to establish indications for specific treatments in such patients. The objectives of this study were to identify independent predictors of physical outcome in patients suffering from crush syndrome and to clarify the influence of fasciotomy on outcomes. METHODS Sensory and motor functions were examined 2 years after the earthquake in 42 patients with a total of 58 compressed lower extremities. The influences of time to rescue, fasciotomy, and radical debridement on lower leg muscle strength were evaluated by stepwise regression analysis. Correlation between the time to fasciotomy and lower leg muscle strength was also analyzed. RESULTS Severe disabilities related to the lower leg compartment were present in 47% (8/17) of patients who underwent fasciotomy and in 16% (4/25) of patients who did not. The anterior compartment was damaged more severely than the posterior compartment. Severe sensory and motor disturbances occurred at a higher rate in relation to anterior and posterior compartments that were treated by fasciotomy than in relation to those that were not. Stepwise regression analysis showed fasciotomy/debridement score to be an independent predictor of long-term lower leg muscle strength (R = 0.67, p < 0.0001) and showed time to rescue to be an independent predictor when debrided compartments were not included in the analysis (R = 0.36, p = 0.009). In all debrided anterior compartments, muscle contractility was completely abolished. There was a significant negative correlation between time to fasciotomy and lower leg muscle strength. CONCLUSION Secondary compartment syndrome affects physical outcome in crush syndrome patients. We obtained no evidence that fasciotomy improves outcome. Delayed rescue, delayed fasciotomy, and radical debridement may worsen the physical prognosis. Indications for fasciotomy in crush syndrome during the acute phase need further deliberation.

Clinical significance of periportal tracking on computed tomographic scan in patients with blunt liver trauma

This study was undertaken to evaluate the clinical significance of periportal tracking on computed tomography (CT) in patients with blunt liver trauma. The clinical records and CT findings of 88 patients were reviewed. Angiographic study revealed potential injury to portal triads in patients with periportal tracking on CT. Extrahepatic injuries beneath the liver were associated in 22 of 28 patients with periportal tracking and in 2 of 17 without periportal tracking (P < 0.01, chi-square = 16.38). Hepatic complications such as bile leak, biloma, hemobilia, and infected hematoma were evaluated separately in 43 patients treated conservatively and 45 patients treated surgically. The incidence of complications in patients with periportal tracking was significantly higher in both groups (nonoperative; P < 0.01, chi-square = 8.46 and operative; P < 0.01, chi-square = 8.48). We conclude that periportal tracking on CT implies injury to the subhepatic region and intrahepatic portal triads and that it requires careful examination for extrahepatic injuries in the initial management and late hepatic complications in the follow-up management.

Assessment of Effective Hepatic Blood Flow in Critically Ill Patients by Noninvasive Pulse Dye-Densitometry

Abstact.Purpose: Effective hepatic blood flow (EHBF) is thought to reflect splanchnic perfusion and the metabolic state of the liver. This study was conducted to examine the relationship between cardiac output (CO) and EHBF using pulse dye-densitometry (PDD) in nonseptic and septic patients, and to assess the prognostic value of this relationship. Methods: The subjects were 33 critically ill patients, 16 of whom met the criteria for sepsis. Indocyanine green (ICG) was given via a central venous catheter to each patient. CO (l/min) and EHBF (l/min) were assessed with PDD. Results: CO and EHBF were significantly correlated in the nonseptic patients (r = 0.92, P < 0.001), but not in the septic patients (r = 0.38, P = 0.15). The ratio of EHBF to CO (EHBF/CO) in the septic patients was significantly lower than that in the nonseptic patients (0.08 ± 0.04 vs 0.22 ± 0.05; P < 0.001). Moreover, in the septic patients, the EHBF/CO ratios of nonsurvivors were significantly lower than those of survivors (0.06 ± 0.04 vs 010 ± 0.02; P < 0.01). Conclusions: In nonseptic patients, the EHBF decreased in relation to the CO. However, the EHBF/CO ratio of septic patients was lower than that of nonseptic patients, suggesting that inadequate splanchnic perfusion or metabolic change occurs in septic patients. Furthermore, the lower EHBF/CO ratio was related with a fatal outcome in septic patients. PDD could be a clinically useful method of assessing splanchnic conditions in critically ill patients.

AN UNUSUAL CASE OF NONCAVITARY HEMORRHAGE REVEALED BY INTRAVENOUS CONTRAST-ENHANCED COMPUTED TOMOGRAPHY

Peripheral arterial injuries after blunt trauma commonly follow injuries to adjacent soft tissue, organ, and bone. We present here a case of blunt injury to the lumbar artery and the deep iliac circumflex artery in which there was no adjacent bone fracture, but in which hemorrhagic shock and persistent anemia ensued. Intravenous contrast-enhanced computed tomography revealed the site of active bleeding, leading us to perform an angiographic embolization for hemostasis.

Volume supplementation with iso-sodium solution prevents hypernatremia after head injury

OBJECTIVE To evaluate our developed volume supplement protocol in preventing hypernatremia after head injury. METHODS Iso-sodium solution was infused to keep the 8-hour water balance positive in 20 head-injured patients with hypotonic urine. RESULTS Serum sodium concentrations moved to within a normal range in 6 patients and were temporarily increased in 12 patients. Seven of the 12 showed a negative cumulative water balance and slightly low creatinine clearance. Mean arterial pressure in the other five patients was lower after supplementation and was positively related to sodium excretion. Hypernatremia could not be prevented in the other two patients and they did not survive. Creatinine clearance was below 40 mL/min/m2 in these two patients before supplementation. CONCLUSION Our protocol worked effectively in patients in whom renal function was preserved. Decreased creatinine clearance because of preexisting dehydration and lower arterial pressure disturbed increase in urinary sodium excretion and temporarily aggravated the hypernatremia.