Sara Fonseca

Measurement of Cytokines and Adhesion Molecules in the First 72 Hours after Severe Trauma: Association with Severity and Outcome

Introduction. Severity and outcome assessments are crucial in trauma. Our aim was to describe the role of a group of cytokines (TNFα, IL-6, IL-10, and HMGB-1) and ICAM-1 as severity and outcome assessment tools and their kinetics in the first 72 h after severe trauma. Materials and Methods. Authors designed a prospective cohort study of severe polytrauma patients (ISS > 15) in a level 1 Trauma Centre. Cytokines and ICAM-1 levels and Th1/Th2 ratios were assessed at admission, 24, 48, and 72 h. SIRS, SIRS with hypoperfusion, and shock were identified. Outcomes considered were ICU admission, ARDS, MODS, and death. Results. Ninety-nine patients were enrolled (median ISS: 29 and age 31). There was an early release of pro- and anti-inflammatory mediators with higher values at admission (except for ICAM-1). On admission, IL-6 was associated with ISS, IL-10 with SIRS with hypoperfusion, and HMGB-1 with shock. Several cytokines were associated with outcomes, especially IL-6 and IL-10 at 72 h with MODS and death. Low TNFα/IL-10 and IL-6/IL-10 ratios at 24 and 72 h were associated with MODS and death. Conclusions. Pro- and anti-inflammatory responses occur simultaneously and earlier after injury. Cytokines may be useful for outcome assessment, especially IL-6 and IL-10. Low Th1/Th2 ratio at 24 to 72 h is associated with MODS and death.

Aphonia after shoulder surgery: case report

In this case report we highlight the uniqueness of aphonia as, to the best of our knowledge, cases of aphonia related to interscalene brachial plexus block (IBPB) are not described in the literature. Although hoarseness is a common complication of IBPB, aphonia is not. Therefore, we think it is important to publicize the first case of aphonia after IBPB, which may have arisen only because of a recurrent laryngeal nerve chronic injury contralateral to the IBPB site.

HMGB-1 Levels May be Markers of Haematological Dysfunction after Severe Trauma

Introduction: HMGB-1 is a nuclear protein that acts as an alarmin to tissue repair in sepsis and is one of multiple mediators in the systemic inflammatory response (SIRS). Its role in clinical models of severe trauma is less well studied. Objectives: The aim of this study was to study the release pattern of HMGB-1 in the first 72 hours after severe trauma and the association of HMGB-1 levels with tissue damage, shock, coagulation disorders and thrombocytopenia. Materials and methods: A prospective cohort study enrolling all adult trauma patients with injury severity score (ISS)>15 admitted to a Trauma Room. Analytical variables assessed were: creatine kinase (CK), myoglobin (MIO) lactate, coagulation times and platelets at admission; HMGB-1 levels were measured at admission 24, 48 and 72h. Results: Ninety-nine patients were enrolled with median ISS of 29, age 31 (18-60) years and 83% were male. Shock was found in 17%, hyperlactacidemia in 46%, coagulopathy in 26%, and thrombocytopenia in 19%. Outcomes were ICU admission-66%, MODS-34%, and Death-28%. The HMGB-1 highest level was found at admission. The study showed correlations between HMGB-1 and shock at admission (p<0,047), coagulopathy at 24h (p<0,01), and thrombocytopenia at 48h (p<0,026). Coagulopathy was associated with death and thrombocytopenia with ICU admission and death. HMGB-1 did not show correlation with ISS, CK or MIO or with any of the outcomes. Conclusions: In this group of patients HMGB-1 levels at admission, at 24 h and at 48 h after severe trauma were respectively associated with the existence of shock, coagulopathy and thrombocytopenia.

Impact and Weight of Trauma Load and Inflammation Load Variables on the Severity and Outcome of Major Trauma Patients

Background: Several conditions related to injury severity (trauma load) and systemic inflammatory response (SIRS) after major trauma could affect the outcome. The aim of this study was to assess the influence in the outcome of variables related to trauma and to systemic inflammation after major trauma. Materials and Methods: Prospective cohort study involving patients admitted to the trauma room of a level 1 trauma center. Variables related to the trauma load and to the inflammation load were collected in the first six hours after trauma. IL-6 was measured on admission and at 24, 48 and 72 hours. All variables were correlated with negative outcomes, namely ICU admission, ARDS development, MODS development and death. Univariate and multivariate analysis were performed. Results: Ninety nine patients (aged 31 years;, ISS-29) were enrolled. Regarding trauma load variables, in univariate analysis, severity scores were correlated with all the negative outcome variables, TBI severity with ICU admission and death and CT severity with development of ARDS. Regarding inflammation variables, hypothermia and lethal triad were correlated with MODS; SIRS with hypoperfusion, shock, hypothermia, hyperlactacidemia, coagulopathy and lethal triad with death. IL-6 and IL-10 also correlated with negative outcomes. In multivariate analysis, TRISS, hypothermia and shock in the first six hours and IL- 6 at 48 and 72 hours correlated either with MODS development or death. Conclusions: TRISS, shock and hypothermia in the first six hours and IL-6 level at 48 and 72 hours were independently and significantly associated with MODS development or with death. Avoidance or swift resolution of shock and hypothermia may well be the most important goal in the first six hours after major trauma.