Systemic inflammatory response syndrome score at admission independently predicts mortality and length of stay in trauma patients

Mast cells play a critical role in the systemic inflammatory response and end-organ injury resulting from trauma

BACKGROUND

Much of the morbidity after trauma results from excessive activation of the innate immune system. This is manifested as a systemic inflammatory response and associated end-organ damage. Although mast cells are known to be important in many immune responses, their role in the systemic response to severe trauma is unknown.

STUDY DESIGN

C57BL/6J-KitW-sh/BsmJ (mast cell deficient) and wild type mice were subjected to 1.5 hours of hemorrhagic shock plus bilateral femur fracture and soft tissue injury (HS/T), followed by resuscitation at 4.5 hours. Blood withdrawal volumes, mean arterial pressures, circulating cytokine, chemokine, high mobility group box-1 (HMGB-1), double strain DNA (dsDNA), transaminase levels, and histology in liver and lung were compared between groups.

RESULTS

Mast cell deficient mice exhibited greater hemodynamic stability than wild type mice. At baseline, the mast cell deficient mice exhibited no difference in any of the organ injury or inflammatory markers measured. As expected, wild type mice subjected to HS/T exhibited end-organ damage manifested by marked increases in circulating alanine transaminase, aspartate aminotransferase, and dsDNA levels, as well as histologic evidence of tissue necrosis. In clear contrast, mast cell deficient mice exhibited almost no tissue damage. Similarly, the magnitude of increased circulating cytokine and chemokine induced by HS/T was much less in the mast cell deficient mice than in the wild type group.

CONCLUSIONS

Mast cell deficiency resulted in a damped systemic inflammatory response, greatly attenuated multiple organ injury, and more stable hemodynamics in HS/T. So mast cells appear to be a critical component of the initial host response to severe injury.

Imbalance between macrophage migration inhibitory factor and cortisol induces multiple organ dysfunction in patients with blunt trauma

Migration inhibitory factor (MIF) is associated with multiple organ dysfunction syndrome (MODS) in patients with systemic inflammatory response syndrome (SIRS). Our purposes were to determine the serum MIF, cortisol, and tumor narcosis factor-α (TNF-α) and to investigate the influences of the balance between the levels of MIF and cortisol in patients with blunt trauma. The cortisol levels were identical between the patients with and without MODS. However, the MIF and TNF-α levels in the patients with MODS were statistically higher than those of the patients without MODS. The cortisol/MIF ratios in the patients with MODS were statistically higher than those of the patients without MODS. The results show that MIF and TNF-α play an important role together in posttraumatic inflammatory response. An excessive serum MIF elevation overrides the anti-inflammatory effects of cortisol and leads to persistent SIRS followed by MODS in blunt trauma patients.

Admission hypo- or hyperthermia and survival after trauma in civilian and military environments

Background

In the care of patients with traumatic injuries, focus is placed on hypothermia secondary to its deleterious impact on the coagulation cascade. However, there is scant information on the mortality effect of hyperthermia.

Study objectives

We hypothesized that both hypothermia and hyperthermia are associated with decreased survival in patients with traumatic injuries. Furthermore, we hypothesized that in the military setting, the incidence of hyperthermia would be greater compared to the civilian environment and thus contributing to an increase in mortality.

Methods

Registries compared were the National Trauma Data Bank (NTDB), three civilian Level I trauma centers, and military combat support hospitals. The NTDB was used as a reference to define hypothermia and hyperthermia based upon survival. Admission temperature and outcome were known for 4,093 civilian and 4,394 military records.

Results

Hypothermia was defined as < 36°C and hyperthermia > 38°C as mortality increased outside this range. The overall mortality rates were 3.5% for civilians and 2.5% for military (p < 0.05). Of civilians, 9.3% (382) were hypothermic and 2.2% (92) hyperthermic. The incidence of hypothermia in the military patients was 6.0% (263) and for hyperthermia the incidence was 7.4% (327). Irrespective of group, patients with hypothermia or hyperthermia had an increased mortality compared to those with normal temperatures, ([for civilian:military ] hypothermia 12%:11%; normal 2%:2%; hyperthermia 14%:4%).

Conclusion

Care of the victim with traumatic injuries emphasizes avoidance of hypothermia; however, hyperthermia is also detrimental. The presence of hypothermia or hyperthermia should be considered in the initial treatment of the patient with traumatic injuries.

The Systemic Inflammatory Response Syndrome (SIRS)--number and type of positive criteria predict interventions and outcomes in acute surgical admissions

BACKGROUND

Systemic inflammatory response syndrome (SIRS) is a syndrome that reflects the widespread activation of inflammatory pathways. The goal of this study was to find whether the presence or absence of SIRS on emergency surgical admissions is related to the subsequent clinical outcome in terms of in-hospital interventions, length of stay, and mortality.

METHODS

The presence of SIRS at admission, final diagnosis of the underlying disease, treatments, and clinical outcomes were prospectively recorded for 1 month. Comparisons of interventions and outcomes were performed between SIRS+ vs. SIRS- patients. In patients with SIRS, the contribution of each positive criterion was evaluated with regards to mortality.

RESULTS

A total of 179 patients were recruited. The prevalence of SIRS at admission was 35.2%. SIRS+ patients required less diagnostic procedures compared with SIRS- (28.6% vs. 34.5%) but had more therapeutic interventions (39.7% vs. 16.4%), surgical interventions (33.3% vs. 3.4%), intensive treatments (11.1% vs. 0.9%; p < 0.05), longer hospital stay (median 6 days vs. 2 days), and more frequent deaths (11.1% vs. 2.6%). SIRS+ patients with four positive criteria had more surgical interventions, intensive treatments, and fatal outcomes compared with the others. Of importance the most influent factor was the respiratory rate followed by the white cell count and the heart rate/temperature.

CONCLUSIONS

Patients with SIRS at admission apparently receive more interventions, have longer length of stay, and increased mortality than those patients without SIRS. These findings require separate validation in a larger cohort study.

Systemic inflammatory response syndrome score at admission predicts injury severity, organ damage and serum neutrophil elastase production in trauma patients

BACKGROUND

Systemic inflammatory response syndrome (SIRS) is a clinical condition representing the culmination of the activation of a complex network of acute endogenous mediators.

MATERIALS AND METHODS

We investigated both the relationship between the results of SIRS assessments in 212 trauma patients at the time of hospital arrival and measures of trauma severity determined using the Injury Severity Score (ISS) and the Revised Trauma Score (RTS). We then considered the possibility of whether this assessment could be used to predict the development of organ dysfunction as a complication in trauma patients after admission. The serum neutrophil elastase (SNE) level was also measured in 47 cases.

RESULTS

The cases with SIRS had a significantly higher ISS and a lower RTS. Organ dysfunction occurred in 22 cases, and a significant correlation was noted between the development of organ dysfunction and the presence of SIRS (86.4%; 19 cases/22 cases, p=0.0007) at the time of arrival. The SNE level was significantly higher among the patients who fulfilled the four SIRS criteria than among the other patients (p=0.0301).

CONCLUSION

We concluded that the greater the SIRS score at the time of hospital arrival, the greater the anatomical and physiological severity of the trauma patient's condition.

Is damage control orthopedics essential for the management of bilateral femoral fractures associated or complicated with shock? An animal study

BACKGROUND

The maximum score of a single anatomic system, the Injury Severity Score, may not reflect the overall damage inflicted by bilateral femoral fractures and justify the strategy of damage control orthopedics (DCO). It is necessary to investigate effects of various therapeutic procedures on such fractures with or without shock to facilitate correct decision making on DCO.

METHODS

A model of bilateral femoral fractures was made in 36 of 48 male New Zealand White rabbits. A model of bilateral femoral shaft fractures associated with shock was made. After resuscitation, a reamed intramedullary nailing fixation was performed in the first group (IM group), and an external fixation device applied in the second group (EF group), and the fractures in the third group (control group) were supported with splints only. They were divided into four groups: shock with IM nailing (shock-IM), shock with external fixation (shock-EF), shock with conservative method (shock-Cons), and intramedullary nailing without shock (nonshock-IM). Vital signs and inflammatory reactions were recorded. Thirty-six hours after the therapeutic procedures in four groups, the animals were killed for histologic evaluation.

RESULTS

The changes of vital signs were most significant in shock-IM group (p < 0.05). The exaggerated levels of interleukin-6, Interleukin-10, and tumor necrosis factor alpha concentrations demonstrated a significant difference between all the groups-shock-IM and other groups (p < 0.05). As to histologic appearances, the statistical difference varies from organ to organ. There is highly significant difference when the IM group is compared with the other two groups as far as lungs are concerned. As to the liver, there is only significant difference between the IM group and the control group. In terms of kidney and heart, there is no significant difference cross the groups. As to histologic appearances, there is highly significant difference in lungs between shock-IM group and other three groups. There is significant difference in liver between the shock-IM group and the shock-Cons group (p < 0.05). Kidneys and heart were less affected cross the groups.

CONCLUSIONS

In this study, an early reamed intramedullary nailing fixation procedure resulted in more adverse effects on system stress, inflammatory response, and multiple organs. The injuries also cause histologic damages to lungs and liver. Therefore, early reamed intramedullary nailing fixation may pose a potential risk of developing complications and adopting the DCO strategy may be more preferable. Shock and IM combined cause most severe damages, followed by IM without shock, shock plus EF, and shock plus conservative procedure in that order. If IM must be used for some reasons, it is desirable be delayed until shock has been fully controlled and vasculorespiratory stability restored.

Traumatic brain injury and aging: is a combination of progesterone and vitamin D hormone a simple solution to a complex problem?

Although progress is being made in the development of new clinical treatments for traumatic brain injury (TBI), little is known about whether such treatments are effective in older patients, in whom frailty, prior medical conditions, altered metabolism, and changing sensitivity to medications all can affect outcomes following a brain injury. In this review we consider TBI to be a complex, highly variable, and systemic disorder that may require a new pharmacotherapeutic approach, one using combinations or cocktails of drugs to treat the many components of the injury cascade. We review some recent research on the role of vitamin D hormone and vitamin D deficiency in older subjects, and on the interactions of these factors with progesterone, the only treatment for TBI that has shown clinical effectiveness. Progesterone is now in phase III multicenter trial testing in the United States. We also discuss some of the potential mechanisms and pathways through which the combination of hormones may work, singly and in synergy, to enhance survival and recovery after TBI.

Revisiting the validity of APACHE II in the trauma ICU: improved risk stratification in critically injured adults

BACKGROUND

Quality and benchmarking initiatives highlight the need for accurate stratified risk adjustment. The stratification of trauma patients has relied on scores specific to trauma populations. While the Acute Physiologic and Chronic Health Evaluation (APACHE) II score has been considered "invalid" in the trauma population, we hypothesized that APAHCE II would more accurately predict outcomes in critically injured patients in whom commonly used trauma scores have inherent limitations.

METHODS

A prospective cohort of critically injured patients was enrolled. Severity scores and their sub-components were collected, and in-hospital mortality was assessed. The area under the receiver operating characteristic (AUROC) curve was used to determine the predictive value of each score. Logistic regression estimated the odds of death associated with incremental changes in severity scores and their subcomponents.

RESULTS

1019 patients were available for analysis. APACHE II was the best predictor of mortality (AUROC 0.77 versus AUROC 0.54 for ISS and 0.64 for TRISS). A unit increase in APACHE II was associated with an OR of death of 1.18 (95% CI 1.14-1.22). The components of APACHE II that contributed the most to its accuracy included temperature, serum creatinine and the Glasgow Coma Scale (GCS).

CONCLUSION

Critically injured patients have physiologic derangements not accurately accounted for by commonly used trauma scores. In this subset a more general ICU scoring system is useful for risk adjustment for research, administrative and quality improvement purposes.

Delirium in the nursing home patients seen in the emergency department

OBJECTIVES

To determine whether nursing home patients are more likely than non-nursing home patients to present to the emergency department (ED) with delirium and to explore how variations in their delirium risk factor profiles contribute to this relationship.

DESIGN

Prospective cross-sectional study.

SETTING

Tertiary care academic ED.

PARTICIPANTS

Three hundred forty-one English-speaking patients aged 65 and older.

MEASUREMENTS

Delirium status was determined using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) administered by trained research assistants. Multivariable logistic regression was used to determine whether nursing home residence was independently associated with delirium. Adjusted odds ratios (ORs) with their 95% confidence intervals (95% CIs) were reported.

RESULTS

Of the 341 patients enrolled, 58 (17.0%) resided in a nursing home and 38 (11.1%) were considered to have delirium in the ED. Of the 58, (22 (37.9%) nursing home patients and 16 of 283 (5.7%) non-nursing home patients had delirium; unadjusted OR=10.2, 95% CI=4.9-21.2). After adjusting for dementia, a Katz activity of daily living score less than or equal to 4, hearing impairment, and the presence of systemic inflammatory response syndrome, nursing home residence was independently associated with delirium in the ED (adjusted OR=4.2, 95% CI=1.8-9.7).

CONCLUSION

In the ED setting, nursing home patients were more likely to present with delirium, and this relationship persisted after adjusting for delirium risk factors.

The stressed host response to infection: the disruptive signals and rhythms of systemic inflammation

The cognate signals from sterile or pathogen-induced sources converge on the same recognition or response pathways. In the surgical patient, a systemic response to infection most often occurs in the context of ongoing inflammatory stress. Such an inflammatory response is modulated initially by the magnitude of injury and by patient-specific (endogenous) factors, such as confounding illness, age, and genetic variation. Over an extended period of stress, treatmentrelated (exogenous) factors add unpredictability to host responses to subsequent challenges, such as acquired infection. The host response is discussed in the context of how existing sterile stressors may modify the response to acquired infection in surgical patients.

The Severity of Injury and the Extent of Hemorrhagic Shock Predict the Incidence of Infectious Complications in Trauma Patients

BACKGROUND

Trauma patients are at high risk of developing systemic inflammatory response syndrome (SIRS) and infections. The aim of this study was to evaluate the influence of the severity of injury and the extent of hemorrhagic shock at admission on the incidence of SIRS, infection and septic complications.

METHODS

A total of 972 patients who had an injury severity score (ISS) of ≥ 17, survived more than 72 h, and were admitted to a level I trauma center within 24 h after trauma were included in this retrospective analysis. SIRS, sepsis and infection rates were measured in patientswith different severities of injury as assessed by ISS, or with various degrees of hemorrhagic shock according to ATLS(®) guidelines, andwere compared using both uni- and multivariate analysis.

RESULTS

Infection rates and septic complications increase significantly (p < 0.001) with higher ISS. Severe hemorrhagic shock on admission is associated with a higher rate of infection (72.8%) and septic complications (43.2%) compared to mild hemorrhagic shock (43.4%, p < 0.001 and 21.7%, p < 0.001, respectively).

CONCLUSION

The severity of injury and the severity of hemorrhagic shock are risk factors for infectious and septic complications. Early diagnostic and adequate therapeutic work up with planned early "second look" interventions in such high-risk patients may help to reduce these common posttraumatic complications.

The burden of the systemic inflammatory response predicts vasospasm and outcome after subarachnoid hemorrhage

INTRODUCTION

Subarachnoid hemorrhage (SAH) can trigger immune activation sufficient to induce the systemic inflammatory response syndrome (SIRS). This may promote both extra-cerebral organ dysfunction and delayed cerebral ischemia, contributing to worse outcome. We ascertained the frequency and predictors of SIRS after spontaneous SAH, and determined whether degree of early systemic inflammation predicted the occurrence of vasospasm and clinical outcome.

METHODS

Retrospective analysis of prospectively collected data on 276 consecutive patients admitted to a neurosciences intensive care unit with acute, non-traumatic SAH between 2002 and 2005. A daily SIRS score was derived by summing the number of variables meeting standard criteria (HR >90, RR >20, Temperature >38 degrees C, or <36 degrees C, WBC count <4,000 or >12,000). SIRS was considered present if two or more criteria were met, while SIRS burden over the first four days was calculated by averaging daily scores. Regression modeling was used to determine the relationship among SIRS burden (after controlling for confounders including infection, surgery, and corticosteroid use), symptomatic vasospasm, and outcome, determined by hospital disposition.

RESULTS

SIRS was present in over half the patients on admission and developed in 85% within the first four days. Factors associated with SIRS included poor clinical grade, thick cisternal blood, larger aneurysm size, higher admission blood pressure, and surgery for aneurysm clipping. Higher SIRS burden was independently associated with death or discharge to nursing home (OR 2.20/point, 95% CI 1.27-3.81). All of those developing clinical vasospasm had evidence of SIRS, with greater SIRS burden predicting increased risk for delayed ischemic neurological deficits (OR 1.77/point, 95% CI 1.12-2.80).

CONCLUSIONS

Systemic inflammatory activation is common after SAH even in the absence of infection; it is more frequent in those with more severe hemorrhage and in those who undergo surgical clipping. Higher burden of SIRS in the initial four days independently predicts symptomatic vasospasm and is associated with worse outcome.

[Epidemiological analysis of demographic characteristics and type of injuries in patients with multiple trauma with respect to conclusive treatment outcome]

INTRODUCTION

Multiple trauma is one of the leading causes of mortality and morbidity in the population of people under 45 years of age. The consequences of multiple trauma have huge epidemiological, social and economic significance.

OBJECTIVE

The aim of the paper was to analyse the conclusive treatment outcome of multiply traumatized patients with respect to their sex, age, injury mechanism and type.

METHOD

This retrospective study included 100 patients with multiple injuries (ISS > 16) treated in the Emergency Room of the Clinical Centre of Serbia in the course of 2004. Clinical, X-ray, laboratory and numerical presentation methods--scores (ISS and GCS) were used to show the injury severity.

RESULTS

Most of the injured were males (80%), and the average age was 40 +/- 20 (5-83). Out of the total number of patients who died, 23 (82%) were males, and 5 (18%) were females. The average age of the patients with fatal outcomes was 48 +/- 21 (8-86). Traffic accidents were the leading cause of injury (59%). The median GCS was 10 +/- 3 (3-15). The average ISS was 30 (20-66) in the surviving patients, and 53 (27-77) in those who died.

CONCLUSION

With respect to sex, in most cases multiple trauma affects males (p < 0.01), with the average age of about 40. With respect to injury mechanism, the main cause of the occurrence of multiple trauma is traffic accidents (p < 0.01). There is a statistically significant difference in the values of GCS and ISS relative to the definitive outcome (p < 0.01). Statistical data processing indicated that there was a statistically significant correlation between mortality and type of injury in a given organic system (p < 0.01), but that there was no statistically significant correlation between mortality and age.

Assessment of the clinical course with inflammatory parameters

Inflammatory changes after trauma depend on the severity and the distribution of the injury and can be modified by the medical treatment. They precede the development of organ dysfunction and may be used for monitoring purposes. Among these, pro-inflammatory cytokines appear to be the most reliable parameters.

Systemic inflammation and remote organ injury following trauma require HMGB1

High-mobility group box 1 (HMGB1) is a 30-kDa DNA-binding protein that displays proinflammatory cytokine-like properties. HMGB1-dependent inflammatory processes have been demonstrated in models of sterile injury, including ischemia-reperfusion injury and hemorrhagic shock. Here, we tested the hypothesis that the systemic inflammatory response and associated remote organ injury that occur after peripheral tissue injury are highly dependent on HMGB1. Toll-like receptor 4 (TLR4) wild-type (WT) mice subjected to bilateral femur fracture after treatment with neutralizing antibodies to HMGB1 had lower serum IL-6 and IL-10 levels compared with mice treated with nonimmune control IgG. Similarly, compared with injured mice treated with control IgG, anti-HMGB1 antibody-treated mice had lower serum alanine aminotransferase levels and decreased hepatic and gut mucosal NF-κB DNA binding. TLR4 mutant (C3H/HeJ) mice subjected to bilateral femur fracture had less systemic inflammation and liver injury than WT controls. Residual trauma-induced systemic inflammation and hepatocellular injury were not ameliorated by treatment with a polyclonal anti-HMGB1 antibody, even though HMGB1 levels were transiently elevated just 1 h after injury in both WT and C3H/HeJ mice. Collectively, these data demonstrate a critical role for a TLR4-HMGB1 pathway in the initiation of systemic inflammation and end-organ injury following isolated peripheral tissue injury.

Surgical stress response

Recent advances in molecular medicine have allowed the characterization and quantification of inflammatory cascades following surgery and trauma. Activation of immune cells is followed by the release of various cytokines as well as by migration of leukocytes into inflamed tissues. Various methods have been developed in order to modulate the immune-inflammatory system and at the same time to prevent overreaction and unexpected complications. In this context, the magnitude of surgical stress exerted on the patient is of paramount importance. Several factors, either controllable or not, are known to contribute to the development and amplification of the 'surgical stress response'. Therefore, they should be taken into consideration by both surgical practitioners and other medical specialties involved in the management of the traumatised patient.

Systemic inflammation and remote organ damage following bilateral femur fracture requires Toll-like receptor 4

Extensive soft tissue injury and bone fracture are significant contributors to the initial systemic inflammatory response in multiply injured patients. Systemic inflammation can lead to organ dysfunction remote from the site of traumatic injury. The mechanisms underlying the recognition of peripheral injury and the subsequent activation of the immune response are unknown. Toll-like receptors (TLRs) recognize microbial products but also may recognize danger signals released from damaged tissues. Here we report that peripheral tissue trauma initiates systemic inflammation and remote organ dysfunction. Moreover, this systemic response to a sterile local injury requires toll-like receptor 4 (TLR4). Compared with wild-type (C3H/HeOuJ) mice, TLR4 mutant (C3H/HeJ) mice demonstrated reduced systemic and hepatic inflammatory responses to bilateral femur fracture. Trauma-induced nuclear factor (NF)-κB activation in the liver required functional TLR4 signaling. CD14−/− mice failed to demonstrate protection from fracture-induced systemic inflammation and hepatocellular injury. Therefore, our results also argue against a contribution of intestine-derived LPS to this process. These findings identify a critical role for TLR4 in the rapid recognition and response pathway to severe traumatic injury. Application of these findings in an evolutionary context suggests that multicellular organisms have evolved to use the same pattern recognition receptor for surviving traumatic and infectious challenges.

Systemic Inflammatory Response Syndrome and Nosocomial Infection in Trauma

BACKGROUND

Admission systemic inflammatory response syndrome (SIRS) score has been previously reported to be an accurate predictor of infection and outcome in trauma. However, the data were limited to the first 7 days of admission. Our objective in this follow-up study was to prospectively evaluate the utility of daily SIRS scores in the second and third week of admission as compared with the first week in prediction of nosocomial infection and outcome in high-risk trauma patients.

METHODS

Prospective data were collected on 1,277 consecutive trauma patients admitted during a 28-month period to the intensive care unit. SIRS scores were calculated daily for the first week and every other day for the following 2 weeks. Patients were categorized into SIRS occurring "early" (week 1), "middle" (week 2), and "late" (week 3). Centers for Disease Control and Prevention guidelines were used for the diagnosis of infection. Multivariate linear and logistic regression analyses were utilized for statistical analyses, controlling for the covariates of age, Injury Severity Score, and admission Glasgow Coma Scale score.

RESULTS

The trauma cohort included patients with blunt injuries (84%) and penetrating injuries (16%). The mean age was 43 +/- 21 years with an overall mortality of 14.7%. Nosocomial infection developed in 580 (45.4%) of the study patients (respiratory site most common) with a total of 1,001 infections (some patients with multiple infections). SIRS (defined as SIRS score >/=2) was common, with 92.4% of patients manifesting SIRS at admission. SIRS was most prevalent during the first week postinjury (91% of patients manifesting SIRS), decreasing to 69% and 50% during postinjury weeks 2 and 3. SIRS was more common in patients who acquired nosocomial infections compared with noninfected patients. Logistic regression analysis confirmed that patients with "middle" SIRS during week 2 (odds ratio [OR] 17.62, confidence interval [CI] 12.95-23.97, p < 0.0001, receiver operating characteristic [ROC] 0.83) and "late" SIRS during week 3 (OR18.12, CI 12.71-25.84, p < 0.0001, ROC 0.81) had significantly greater risk for nosocomial infection compared with patients with "early" SIRS during week 1 (OR 4.55, CI 2.57-8.06, p < 0.0001, ROC 0.65) postinjury.

CONCLUSION

SIRS is predictive of nosocomial infection in trauma through postinjury day 21. Nosocomial infection should be considered as a treatable cause of SIRS in trauma patients, and early diagnostic interventions should be initiated to evaluate for potential causes.

Trauma Associated Severe Hemorrhage (TASH)-Score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma

BACKGROUND

To develop a simple scoring system that allows an early and reliable estimation for the probability of mass transfusion (MT) as a surrogate for life threatening hemorrhage following multiple trauma.

METHODS

Potential clinical and laboratory variables documented in the Trauma Registry of the German Trauma Society (DGU) (1993-2003; n=17,200) were subjected to univariate and multivariate logistic regression analysis to predict the probability for MT.

RESULTS

Clinical and laboratory variables available from data sets were screened for their association with mass transfusion. MT was defined by transfusion requirement of >or=10 units of packed red blood cells from emergency room (ER) to intensive care unit admission. Seven independent variables were identified to be significantly correlated with an increased probability for MT: systolic blood pressure (<100 mm Hg=4 pts, <120 mm Hg=1 pt), hemoglobin (<7 g/dL=8 pts, <9 g/dL=6 pts, <10 g/dL=4 pts, <11 g/dL=3 pts, and <12 g/dL=2 pts), intra-abdominal fluid (3 pts), complex long bone and/or pelvic fractures (AIS 3/4=3 pts and AIS 5=6 pts), heart rate (>120=2 pts), base excess (<-10 mmol/L=4 pts, <-6 mmol/L=3 pts, and <-2 mmol/L=1 pt), and gender (male=1 pt). These variables were incorporated into a risk score, the Trauma Associated Severe Hemorrhage Score (TASH-Score, 0-28 points). Performance of the score was tested with respect to discrimination, precision, and calibration. Increasing TASH-Score points were associated with an increasing probability for MT.

CONCLUSION

The TASH-Score is an easy-to-use scoring system that reliably predicts the probability for MT after multiple trauma. Taken as a surrogate for life threatening bleeding calculation may focus attention on relevant variables indicative for risk and impact strategies to stop bleeding and stabilize coagulation in acute trauma care.

Serum Lipopolysaccharide-Binding Protein Concentrations in Trauma Victims

BACKGROUND

In low concentrations, lipopolysaccharide-binding protein (LBP), an acute-phase protein recognizing lipopolysaccharide (LPS), catalyzes its transfer to the cellular receptor consisting of CD14 and Toll-like receptor-4. Previous studies have documented increased serum LBP concentrations in patients with sepsis, systemic inflammatory response syndrome (SIRS), or acute pancreatitis and after cardiopulmonary bypass. No prior studies have examined LBP expression in trauma victims. We hypothesized that admission LBP plasma concentrations are predictive of outcome (mortality) in trauma. This study assessed time-dependent changes in serum LBP concentrations in trauma patients soon after injury.

METHODS

A prospective, single-institution, observational cohort study of 121 adult trauma patients (age > or =17 years) with moderate to severe injury who required hospitalization. The trauma patients were male in 79.6% of the cases and had a mean age of 43.0 +/- 20.6 years. The mean injury severity score (ISS) was 23 +/- 12, and the crystalloid resuscitation volume given in the first 24 h averaged 6,640 +/- 3,729 mL. Informed consent was obtained on admission, and blood samples were drawn on admission and at 24 h postadmission. Prospective data were collected for daily SIRS score, multiple organ dysfunction score (MODS), and sequential organ failure assessment (SOFA) score, complications, and outcomes. Plasma concentrations of LBP were measured by enzyme-linked immunosorbent assay.

RESULTS

Sixty patients (48.8% of the study cohort) required emergency surgical intervention and sustained a substantial intraoperative blood loss (mean 1,404 +/- 2,757 mL). The hospital mortality rate was 16.3% (20 patients). The mean intensive care unit stay was 8.9 +/- 16.4 days, and the hospital stay was 14.8 +/- 19.6 days. The patients had a significantly higher serum concentrations of LBP on admission (mean 28.0 +/- 25.3 mg/L; range 2-100 mg/L) than did control subjects (mean 6.2 +/- 2.1 mg/L; range 1.3-12.8 mg/L; p < 0.01), similar to the plasma concentrations previously reported in septic patients. A significant increase in LBP concentration was noted at 24 h (mean 72.3 +/- 45.7 mg/L; range 8-210 mg/L; p < 0.05). The admission LBP concentration was significantly greater in nonsurvivors than in survivors. However, after controlling for age and ISS, the admission LBP concentration did not predict death.

An evaluation of systemic inflammatory response syndrome signs in the Sepsis Occurrence In Acutely Ill Patients (SOAP) study

OBJECTIVE

To define the frequency and prognostic implications of SIRS criteria in critically ill patients hospitalized in European ICUs.

DESIGN AND SETTING

Cohort, multicentre, observational study of 198 ICUs in 24 European countries.

PATIENTS AND INTERVENTIONS

All 3,147 new adult admissions to participating ICUs between 1 and 15 May 2002 were included. Data were collected prospectively, with common SIRS criteria.

RESULTS

During the ICU stay 93% of patients had at least two SIRS criteria [respiratory rate (82%), heart rate (80%)]. The frequency of having three or four SIRS criteria vs. two was higher in infected than non-infected patients (p < 0.01). In non-infected patients having more than two SIRS criteria was associated with a higher risk of subsequent development of severe sepsis (odds ratio 2.6, p < 0.01) and septic shock (odds ratio 3.7, p < 0.01). Organ system failure and mortality increased as the number of SIRS criteria increased.

CONCLUSIONS

Although common in the ICU, SIRS has prognostic importance in predicting infections, severity of disease, organ failure and outcome.

[Intensive medicine criteria for operability]

BACKGROUND

Operability is mainly determined by the interaction between the magnitude of an operation and the patient's tolerance for the procedure. A further factor is the benefit gained by performing the procedure versus the sequelae caused by its omission.

RESULTS

Major operations within the first 3 days after trauma appear to have an increased risk, particularly if they are performed during impaired respiratory function (pO(2)/F(i)O(2) ratio <280 mmHg) or increased inflammatory status. Such interventions are recommended to be postponed until a later time. Surgical interventions after day 3 require an individual decision with respect to the timing of the operation. Criteria that are of value in this decision comprise a pO(2)/F(i)O(2) ratio above 280 mmHg, a stable circulation, a platelet count above 100.000 to 150.000/microl, normal global coagulation tests, only moderate systemic inflammation as indicated by C-reactive protein or interleukin-6 levels, a normal fluid balance and in case of traumatic brain injury there should be no signs of increased intracranial pressure. Whether liver function, level of PEEP, catecholamine therapy and other factors will influence operability remains to be elucidated.

CONCLUSION

The pathophysiological consequences of accidental trauma show a phasic course with respect to the immunomodulatory response. An operative trauma inflicted by a secondary surgical intervention contributes an additional burden. Depending on the inflammatory phase during which this secondary hit is inflicted there may be a disturbance of homoeostasis that may even lead to multiple organ failure. Whether this happens can depend on type and magnitude of the surgical intervention. Minor operations result in smaller systemic effects and will be less critical with respect to operability.

Prediction of Outcomes in Trauma: Anatomic or Physiologic Parameters?

BACKGROUND

Prediction of outcomes after injury has traditionally incorporated measures of injury severity, but recent studies suggest that including physiologic and shock measures can improve accuracy of anatomic-based models. A recent single-institution study described a mortality predictive equation [f(x) = 3.48 - .22 (GCS) - .08 (BE) + .08 (Tx) + .05 (ISS) + .04 (Age)], where GSC is Glasgow Coma Score, BE is base excess, Tx is transfusion requirement, and ISS is Injury Severity Score, which had 63% sensitivity, 94% specificity, (receiver operating characteristic [ROC] 0.96), but did not provide comparative data for other models. We have previously documented that the Physiologic Trauma Score, including only physiologic variables (systemic inflammatory response syndrome, Glasgow Coma Score, age) also accurately predicts mortality in trauma. The objective of this study was to compare the predictive abilities of these statistical models in trauma outcomes.

METHODS

Area under the ROC curve of sensitivity versus 1-specificity was used to assess predictive ability and measured discrimination of the models.

RESULTS

The study cohort consisted of 15,534 trauma patients (80% blunt mechanism) admitted to a Level I trauma center over a 3-year period (mean age 37 +/- 18 years; mean Injury Severity Score 10 +/- 10; mortality 4%). Sensitivity of the new predictive model was 45%, specificity was 96%, ROC was 0.91, validating this new trauma outcomes model in our institution. This was comparable with area under the ROC for Revised Trauma Score (ROC 0.88), Trauma and Injury Severity Score (ROC 0.97), and Physiologic Trauma Score (ROC 0.95), but superior compared with admission Glasgow Coma Score (ROC 0.79), Injury Severity Score (ROC 0.79), and age (ROC 0.60).

CONCLUSIONS

The predictive ability of this new model is superior to anatomic-based models such as Injury Severity Score, but comparable with other physiologic-based models such as Revised Trauma Score, Physiologic Trauma Score and Trauma, and Injury Severity Score.

The immuno-inflammatory response to trauma

The systemic inflammatory response syndrome is a well recognized physiological entity being part of our homeostatic mechanisms. It represents the cascade of inflammatory reactions initiated in the immediate aftermath following trauma reflecting the state of alertness that our body undergoes in order to fight for survival. A variety of inflammatory mediators and cellular elements are involved during this process interacting amongst each other. This allows communication between the different organ systems and thus regulating local and systemic responses. We have just begun to characterize and quantify the immuno-inflammatory response to trauma and this has opened new horizons in the way we understand the pathophysiological response to injury. As our knowledge evolves new therapeutic agents and innovative treatment plans will be developed contributing to increased survival rates in patients with multiple injuries.

Pathophysiology of polytrauma

Immediate and early trauma deaths are determined by primary brain injuries, or significant blood loss (haemorrhagic shock), while late mortality is caused by secondary brain injuries and host defence failure. First hits (hypoxia, hypotension, organ and soft tissue injuries, fractures), as well as second hits (e.g. ischaemia/reperfusion injuries, compartment syndromes, operative interventions, infections), induce a host defence response. This is characterized by local and systemic release of pro-inflammatory cytokines, arachidonic acid metabolites, proteins of the contact phase and coagulation systems, complement factors and acute phase proteins, as well as hormonal mediators: it is defined as systemic inflammatory response syndrome (SIRS), according to clinical parameters. However, in parallel, anti-inflammatory mediators are produced (compensatory anti-inflammatory response syndrome (CARS). An imbalance of these dual immune responses seems to be responsible for organ dysfunction and increased susceptibility to infections. Endothelial cell damage, accumulation of leukocytes, disseminated intravascular coagulation (DIC) and microcirculatory disturbances lead finally to apoptosis and necrosis of parenchymal cells, with the development of multiple organ dysfunction syndrome (MODS), or multiple organ failure (MOF). Whereas most clinical trials with anti-inflammatory, anti-coagulant, or antioxidant strategies failed, the implementation of pre- and in-hospital trauma protocols and the principle of damage control procedures have reduced post-traumatic complications. However, the development of immunomonitoring will help in the selection of patients at risk of post-traumatic complications and, thereby, the choice of the most appropriate treatment protocols for severely injured patients.

Alterations in the Systemic Inflammatory Response after Early Total Care and Damage Control Procedures for Femoral Shaft Fracture in Severely Injured Patients

BACKGROUND

Recently, there has been a move away from early total care in patients with severe, multiple injuries to damage control orthopedics (DCO) in an attempt to limit the physiologic insult resulting from operative treatment after trauma. For femoral shaft fracture, this entails initial external fixation and subsequent conversion to an intramedullary nail (IMN). We sought to quantify the inflammatory response to initial surgery and conversion and link this to subsequent organ dysfunction and complications.

METHODS

Patients with femoral shaft fracture and a New Injury Severity Score of 20 or more were included. Data were retrospectively collected for 4 days at admission and at exchange procedure (external fixation to intramedullary nail), and the Systemic Inflammatory Response Syndrome (SIRS) score and the Marshall multiorgan dysfunction score were calculated.

RESULTS

One hundred seventy-four patients met the inclusion criteria. The DCO group had significantly more severe injuries (New Injury Severity Score of 25.4 vs. 36.2, p < 0.0001) and significantly more head and thoracic injuries (both p < 0.0001). The mean SIRS score was significantly higher in the IMN group, from 12 hours until 72 hours postoperatively (p < 0.05). The mean peak postoperative SIRS score was significantly higher in the IMN group than in the DCO group, at the primary procedure and at conversion, as was the time with an SIRS score greater than 1. At conversion in the DCO group, the preoperative SIRS score correlated with magnitude and duration of elevation in the SIRS and multiorgan dysfunction scores (p < 0.0001).

CONCLUSION

It would appear that despite more severe injuries in the DCO group, patients had a smaller, shorter postoperative SIRS and did not suffer significantly more pronounced organ failure than the IMN group. DCO patients undergoing conversion while their SIRS score was raised suffered the most pronounced subsequent inflammatory response and organ failure. According to these data, DCO treatment was associated with a lesser systemic inflammatory response than early total care for femur fractures. The inflammatory status of the patient may be a useful adjunct in clinical decision making regarding the timing of conversion to an intramedullary device.

Causes and consequences of fever complicating critical surgical illness

BACKGROUND

Fever may have malign consequences in the postoperative period. This study was performed to determine the causes and consequences of fever in critically ill surgical patients. The specific hypothesis tested is that postoperative fever is associated with adverse clinical outcomes, including increased organ dysfunction and risk of death.

METHODS

Inception-cohort study of critically ill surgical patients who manifested a core temperature of >/=38.2 degrees C for the first time. The episode of fever was monitored until resolution, which was defined as a core temperature of <38.2 degrees C for at least 72 consecutive h. Demographic data collected included age, gender, admission diagnosis, admission status (elective/emergency), severity of illness (APACHE III), the systemic inflammatory response syndrome (SIRS) score, the cumulative multiple organ dysfunction score, cause of fever (infectious/non-infectious), ICU and hospital length of stay, and mortality. The day of onset of fever in the ICU, peak temperature, ICU day of peak temperature, and duration of fever episode were recorded. All diagnostic and therapeutic interventions were recorded, including the type and duration of antibiotic therapy. Univariate results of possible significance (alpha < 0.15) were tested in logistic regression models for independence of effect upon mortality after auto-correlation was excluded by matrix correlations and the Durbin-Watson statistic. Cases where both non-infectious and infectious causes of fever were present were analyzed as part of the infectious group, whereas the cumulative MOD score was dichotomized (< 5, >/=5 points) at a value known to be associated with increased mortality.

RESULTS

Among 2,419 screened patients, 626 patients (26%) developed fever. Febrile patients were older, sicker, more likely to have undergone emergency surgery, more likely to develop organ dysfunction, and more likely to die (all, p < 0.0001). The mean day of onset of fever was day 1 and the mean peak temperature for the episode was 39.1 +/- 0.1 degrees C. For most patients, it was their only episode of fever, with a mean of 1.4 +/- 0.1 episodes/patient. Forty-six percent of febrile patients were found to have an infectious cause of fever. Nearly all patients had SIRS, and nearly all developed organ dysfunction to some degree. By logistic regression, the presence of SIRS (as opposed to fever in isolation), emergency status, higher APACHE III score and the peak temperature were associated with increased mortality, with peak temperature being the most powerful predictor in the model (OR 2.20, 95% Cl 1.57-3.19). Gender had no bearing on outcome, and there was a trend toward a protective effect from an infectious etiology of fever.

CONCLUSIONS

Postoperative fever is deleterious to critically ill patients. The magnitude of fever is a determinant of mortality, whereas an infectious etiology of fever may not be. The impacts of nosocomial infection and suppression of fever on critically surgical patients deserve further study.

Allogenic Blood Transfusion in the First 24 Hours after Trauma Is Associated with Increased Systemic Inflammatory Response Syndrome (SIRS) and Death

BACKGROUND

Previous studies have documented that blood transfusion incites a substantial inflammatory response with the systemic release of cytokines. Furthermore, blood transfusion is a significant independent predictor of multiple organ failure in trauma. The objective of this study was to assess the risk of systemic inflammatory response syndrome (SIRS) and intensive care unit (ICU) admission, length of stay (LOS), and mortality in trauma patients who require blood transfusion.

METHODS

Prospective data were collected on 9,539 trauma patients admitted to the R. Adams Cowley Shock Trauma Center over a 30-month period from January, 1997 to July, 1999. Complete SIRS data were available on 7,602 patients. Patients were stratified by age, gender, race, Glasgow coma scale (GCS), and injury severity score (ISS). A systemic inflammatory response to a wide variety of severe clinical insults (SIRS) was defined as a SIRS score of > or =2, as calculated on admission. Blood transfusion was assessed as an independent predictor of SIRS, ICU admission and length of stay, and mortality.

RESULTS

The mean age of the study cohort was 37 +/- 17 years; the mean ISS was 9 +/- 9 points. Seventy-one percent of the patients were male, and 85% sustained blunt trauma. Blood transfusion within the first 24 h was administered to 954 patients, comprising 10% of the study cohort. Transfused patients were significantly older (43 +/- 20 vs. 36 +/- 16 years, p < 0.00001), had higher ISS (22 +/- 12 vs. 8 +/- 7 points, p < 0.00001), and lower GCS (12 +/- 4 vs. 14 +/- 2 points, p < 0.00001) than non-transfused patients. Blood transfusion and increased total volume of blood transfusion was associated with SIRS. Blood transfusion was also a significant independent predictor of SIRS, ICU admission, and mortality in trauma patients by multinomial logistic regression analysis. Trauma patients who received blood transfusion had a two- to nearly sixfold increase in SIRS (p < 0.0001) and more than a fourfold increase in ICU admission (OR 4.62, 95% CI 3.84-5.55, p < 0.0001) and mortality (OR 4.23, 95% CI 3.07-5.84, p < 0.0001) compared to those that were not transfused. Linear regression analysis revealed that transfusion was an independent predictor of ICU LOS (Coef. 5.20, SE 0.43, p < 0.0001). Transfused patients had significantly longer ICU LOS (16.8 +/- 14.9 vs. 9.9 +/- 10.6 days, p < 0.00001) and hospital LOS (14.5 +/- 15.5 vs. 2.5 +/- 5.3 days, p < 0.00001) compared to non-transfused patients.

CONCLUSIONS

Blood transfusion within the first 24 h was an independent predictor of mortality, SIRS, ICU admission, and ICU LOS in trauma patients. The use of blood substitutes and alternative agents to increase serum hemoglobin concentration in the post-injury period warrants further investigation.

Acute respiratory distress syndrome criteria in trauma patients: why the definitions do not work

BACKGROUND

The international consensus definitions for acute respiratory distress syndrome (ARDS) have formed the basis for recruitment into randomized, controlled trials and, more recently, standardized the protocols for ventilatory treatment of acute lung injury. Although possibly appropriate for sepsis-induced ARDS, these criteria may not be appropriate for posttraumatic ARDS if the disease patterns are widely divergent. This study tests the hypothesis that standard ARDS criteria applied to the trauma population will capture widely disparate forms of acute lung injury and are too nonspecific to identify a population at risk for prolonged respiratory failure and associated complications.

METHODS

Patients with and Injury Severity Score > or = 16 ventilated for > 12 hours were prospectively enrolled. Clinical data, including elements of cardiovascular, renal, hepatic, hematologic, neurologic, and pulmonary function, were collected daily. Two hundred fifty-four patients were enrolled over a 36-month period, of whom 70 met the consensus definitions of ARDS. Patients from whom support was withdrawn within 48 hours were excluded. The remaining 61 patients were stratified into two groups on the basis of intubation (n = 12) days.

RESULTS

There was considerable disparity in severity and clinical course. A mild, limited form of ARDS was characterized by earlier onset (group 1, 2 days; group 2, 4 days; p = 0.002), fewer intubation days (7 days vs. 28 days; p < 0.001), and less severe derangements in lung mechanics. A significant difference between the two groups was also seen in systemic inflammatory response syndrome score, incidence of sepsis, and incidence of multiple organ failure.

CONCLUSION

The criteria for ARDS, when applied to the trauma population, capture a widely disparate group and has poor specificity for identifying patients at risk. Recruitment of trauma patients for ARDS studies or preemptive ventilatory management based solely on these criteria may be ill-advised.

Male gender is associated with increased risk for postinjury pneumonia

Nosocomial pneumonia in trauma patients is a significant source of resource utilization and mortality. We have previously described increased rates of pneumonia in male trauma patients in a single institution study. In that study, female trauma patients had a lower incidence of postinjury pneumonia but a higher relative risk for mortality when they did develop pneumonia. We sought to investigate the hypothesis that male trauma patients have an increased incidence of postinjury pneumonia in a separate population-based dataset. Prospective data were collected on 30,288 trauma patients (26,231 blunt injuries, 4057 penetrating injuries) admitted to all trauma centers (n = 26) in Pennsylvania over 24 months (January 1996 to December 1997). Gender differences in pneumonia were determined for the entire dataset. A second analysis examined all blunt injury patients and excluded all patients with a hospital length of stay less than 24 h, eliminating patients who expired early after admission. In trauma patients with minor injury (ISS < 15), there was no significant difference between male and female patients in the rate of postinjury pneumonia (male 1.37%, female 1.11%). In the moderate-injury group (ISS > 15), male trauma patients had a significantly increased incidence of postinjury pneumonia (ISS 15-30, male 8.85%, female 6.45%; ISS > 30, male 24.35%, female 17.30%). Logistic regression analysis of blunt trauma patients revealed that gender, ISS, injury type, admission Revised Trauma Score (RTS), admission respiratory rate, history of cardiac disease, and history of cancer were all independent predictors of pneumonia. Trauma patients with nosocomial pneumonia had a significantly higher mortality rate (P < 0.001) than patients without pneumonia. There was no gender-specific difference in mortality among pneumonia patients. Male gender is significantly associated with an increased incidence of postinjury pneumonia. In contrast to our initial study, there was no gender difference in postinjury pneumonia mortality rates identified in this population-based study.

The Clinical Value of the Systemic Inflammatory Response Syndrome (SIRS) in Abdominal Aortic Aneurysm Repair

OBJECTIVES

The systemic inflammatory response syndrome (SIRS) is common after major surgery. We examine the dynamics of SIRS in AAA patients, and assess the impact of the number of SIRS criteria on patient outcome.

DESIGN

Prospective study of 151 consecutive patients with AAA, undergoing repair electively, urgently or with rupture.

METHODS

SIRS scores and organ failure scores were recorded prospectively each day for all patients. Outcome measures included length of stay, evidence of organ failure and mortality.

RESULTS

The majority of patients developed SIRS postoperatively. Elective patients with a cumulative SIRS score of > or =10 during postoperative days 1-4 were more likely to die, compared to patients with a SIRS score of <10 (p=0.02). The development of SIRS late in the postoperative period (day 5-10) was associated with adverse outcome (death) in elective patients (p=0.01). The actual number of SIRS criteria present did not significantly correlate with either outcome or the incidence of organ failure.

CONCLUSIONS

SIRS is common in patients undergoing AAA repair. The SIRS score provides useful information regarding a patient's physiological state. High SIRS scores, and the development of SIRS late in the postoperative period are associated with adverse outcome in elective patients, and can therefore be used as an indicator of potential problems.

Early leukocytosis in trauma patients: what difference does it make?

OBJECTIVE

To determine the association of the admission white blood cell count in trauma patients with demographics, severity and mechanism of injury, and need for therapeutic intervention.

METHODS

Evaluation of prospectively collected registry data (admissions to a Level I trauma center in 2001). Differences in mean white blood cell count on admission were evaluated with t tests. Multiple linear regressions were performed with forward stepwise selection of variables.

RESULTS

Of the 882 patients admitted for greater than 24 hours, white blood cell count was available for 786. Variations in white blood cell count were noted on bivariate analysis among different races, injury mechanisms and severities, Glasgow Coma Scores, blood pressures, and between patients requiring early transfusions versus those who did not. No difference was noted between patients who went to the operating room in the first 24 hours versus those who did not, or for patients who died in the hospital. On multiple linear regression analyses, only ISS greater than 15, GCS less than or equal to 8, and white race were associated with increases in white blood cell count. Leukocytosis was found not to be associated with mechanism of injury, specific organ injury, shock on admission, or the need for transfusion or surgery.

CONCLUSION

Variations in white blood cell count in trauma patients are associated with race and injury severity, but they are not beneficial in predicting the need for volume resuscitation, transfusion, or surgery.

Modest protection of early hydrocortisone treatment in a rat model of volume-controlled haemorrhage

BACKGROUND

Major insults may trigger generalized inflammatory responses that contribute to progressive multiple organ dysfunction. The present study was performed to test the potential of early hydrocortisone treatment to influence these responses as well as organ function following an episode of rapid and profound blood loss.

METHODS

In isoflurane anaesthesia, 35 spontaneously breathing male Sprague-Dawley rats were bled 2.5 ml 100 g-1 body weight over 10 min. Immediately following withdrawal of blood, one group (n = 17) was given 2 mg of hydrocortisone, and the other (n = 18) had the same amount of normal saline. Seventy-five minutes after initiation of bleeding, two-thirds of the blood was retransfused, together with a new injection of hydrocortisone or saline. Thereafter the rats were observed for 2 h. Key mediators of systemic inflammation and plasma markers of organ function and integrity were measured. Internal organs were weighed and scored for visible pathology. Leukocyte infiltration of the liver was counted in a light microscope.

RESULTS

Hydrocortisone reduced the plasma levels of IL-6 (P < 0.05); non-significant reductions of TNF-alpha (P = 0.12) and IL-10 (P = 0.44) were noted. The synthesis of reactive oxygen species in peritoneal cells was unaffected. Relative organ weights and organ injury scores tended to be reduced, but only wet organ weight for the lungs reached statistical significance. Leukocyte infiltration of the liver was equal in both groups. Plasma levels of ALT, AST, alpha-GST and creatinine did not differ significantly between groups. Two of the hydrocortisone treated rats died compared with four controls.

CONCLUSION

Early treatment with hydrocortisone had a limited organ protective effect in this model of controlled haemorrhagic shock. Although a general tendency for better outcome in the hydrocortisone group was noted, clear-cut and significant advantages of the treatment were not obtained.

Current concepts of the inflammatory response after major trauma: an update

During the past century explosive developments have taken place in the field of molecular medicine and genetics, vastly expanding our understanding of the normal physiological response to injury. We have been able to characterise specific molecular and cell biological processes and apply some of this knowledge to the treatment of multiply injured patients. Despite the significant steps we have made, there still remains much work to be done in this area. This review article highlights the current concepts of post-traumatic immunological changes and their impact in the management of trauma patients.

Hydrocortisone and the mitogen-activated protein kinase inhibitor U0126 acutely suppress reactive oxygen species generation from circulating granulocytes after gunshot injuries in the pig

OBJECTIVE

Several external stimuli, including trauma, increase the endogenous production of reactive oxygen species that spontaneously attack vital biological molecules. In addition to their direct toxic effects, several secondary messenger systems are induced. To forestall a subsequent organ dysfunction, a short-term posttraumatic down-regulation of granulocyte function has been advocated. Corticosteroids are potent and universal anti-inflammatory agents, but they have well-known side effects. Modulation of the mitogen-activated protein kinase cascade is an alternative approach. The purpose of this study was to investigate how the posttraumatic production of reactive oxygen species can be modulated by hydrocortisone or the extracellular signal-regulated kinase inhibitor U0126.

DESIGN

Prospective randomized trial.

SETTING

Field hospital and research laboratory.

SUBJECTS

Seventeen male pigs.

INTERVENTIONS

In general anesthesia, the pigs were exposed to a standardized insult: one gunshot hitting the right femur from a distance of 25 m, and one pistol shot to the left upper abdomen from close range. Following immediate first aid treatment, the animals were transported to a nearby field hospital. According to randomization, the animals received either hydrocortisone 250 mg intravenously (group 1, n = 9) or a similar amount of saline (group 2, n = 8). The injections were given 5 mins after the last shot. Blood samples were drawn before shooting, immediately before hydrocortisone was given, and 60 mins after shooting. Circulating neutrophils were isolated, and the production of reactive oxygen species was measured fluorometrically. Neutrophils from nine randomly chosen animals (five from group 1 and four from group 2) were treated in vitro with the extracellular signal-regulated kinase inhibitor U0126.

MEASUREMENTS AND MAIN RESULTS

The injuries as evaluated by the abbreviated injury scale did not differ between the animals. All survived the first 60 mins. While the in vivo production of reactive oxygen species tended to increase in the controls, a significant reduction was measured in the hydrocortisone group. Subsequent treatment with U0126 further reduced the synthesis of reactive oxygen species by about two thirds in both groups, independently of time.

CONCLUSIONS

Early injection of hydrocortisone after trauma inhibits the synthesis of reactive oxygen species from circulating neutrophils. Inhibition of the extracellular signal-regulated kinase branch of the mitogen-activated protein kinase signaling cascade is an alternative approach. The powerful in vitro capacity of selective extracellular signal-regulated kinase inhibitors to reduce the posttraumatic reactive oxygen species generation deserves further investigations, and compelling evidence of their in vivo usefulness is still lacking.

Development and use of a new staging system for severe acute pancreatitis based on a nationwide survey in Japan

METHODOLOGY

In 1997, a cooperative nationwide survey of 192 patients diagnosed with severe acute pancreatitis in 1996 was carried out.

RESULTS

Alcoholic pancreatitis was the major etiology (46%), and the male-to-female ratio was 2.6:1. Overall, the mortality rate was 27%, which was similar to the rate (30%) in the first nationwide survey of 1,219 patients diagnosed between 1982 and 1986 that was performed in 1987. A marked difference between the surveys was the early mortality rate within 2 weeks: 52% in the 1987 survey and 29% in the current survey. We devised a new stage classification system for acute pancreatitis. Stages 0 and 1 are equivalent to mild and moderate conditions, respectively, in the conventional classification, and stages 2 and higher correspond to severe acute pancreatitis. Severity scores of 2-8 are regarded as stage 2, scores of 9-14, as stage 3, and scores of > or =15, as stage 4. The mortality rates were as follows: 0, stages 0 and 1 at hospitalization; approximately 10%, stage 2; approximately 30-40%, stage 3; and approximately 70-100%, stage 4.

CONCLUSION

We found that stage at hospitalization reflected the prognosis of acute pancreatitis.

Multiple trauma in children: critical care overview

Multiple trauma is more than the sum of the injuries. Management not only of the physiologic injury but also of the pathophysiologic responses, along with integration of the child's emotional and developmental needs and the child's family, forms the basis of trauma care. Multiple trauma in children also elicits profound psychological responses from the healthcare providers involved with these children. This overview will address the pathophysiology of multiple trauma in children and the general principles of trauma management by an integrated trauma team. Trauma is a systemic disease. Multiple trauma stimulates the release of multiple inflammatory mediators. A lethal triad of hypothermia, acidosis, and coagulopathy is the direct result of trauma and secondary injury from the systemic response to trauma. Controlling and responding to the secondary pathophysiologic sequelae of trauma is the cornerstone of trauma management in the multiply injured, critically ill child. Damage control surgery is a new, rational approach to the child with multiple trauma. The selection of children for damage control surgery depends on the severity of injury. Major abdominal vascular injuries and multiple visceral injuries are best considered for this approach. The effective management of childhood multiple trauma requires a combined team approach, consideration of the child and family, an organized trauma system, and an effective quality assurance and improvement mechanism.

Persistent systemic inflammatory response syndrome is predictive of nosocomial infection in trauma

BACKGROUND

Admission systemic inflammatory response syndrome (SIRS) score has been previously reported to be an accurate predictor of infection and outcome in trauma. However, these data were limited to only one SIRS score at admission. A prior study in surgical intensive care unit (ICU) patients reported that the SIRS score on ICU day 2 declined after completion of resuscitation, and was a more accurate predictor of outcome. Our objective in this follow-up study was to prospectively evaluate the utility of daily SIRS scores in prediction of nosocomial infection and outcome in high-risk trauma patients.

METHODS

Prospective data were collected on 702 consecutive trauma patients admitted over a 12-month period to the ICU. SIRS scores were calculated daily. Centers for Disease Control and Prevention guidelines were used for the diagnosis of infection. Multivariate linear regression was used for statistical analysis.

RESULTS

Five hundred seventy-three (82%) patients sustained blunt injuries and 129 (18%) sustained penetrating injuries. The mean age was 43 +/- 21 years, with an overall mortality of 11.4%. Two hundred ninety (41.3%) of the study patients acquired a nosocomial infection (respiratory site most common), with an associated mortality rate of 12.4%. SIRS (defined as SIRS score >/= 2) on hospital days 3 through 7 was a significant predictor of nosocomial infection and hospital length of stay. Persistent SIRS to hospital day 7 was associated with a significant risk for increased mortality (relative risk, 4.7; 95% confidence interval, 1.41-12.87; p = 0.047).

CONCLUSION

Persistent SIRS is predictive of nosocomial infection in trauma. Daily monitoring of SIRS scores is easily accomplished and should be considered in all high-risk trauma patients. Persistent SIRS in trauma should initiate early diagnostic interventions for determination of source of infection, and consideration of early empiric antimicrobial therapy.

Predictors of mortality in adult trauma patients: the physiologic trauma score is equivalent to the Trauma and Injury Severity Score

BACKGROUND

Several statistical models (Trauma and Injury Severity Score [TRISS], New Injury Severity Score [NISS], and the International Classification of Disease, Ninth Revision-based Injury Severity Score [ICISS]) have been developed over the recent decades in an attempt to accurately predict outcomes in trauma patients. The anatomic portion of these models makes them difficult to use when performing a rapid initial trauma assessment. We sought to determine if a Physiologic Trauma Score, using the systemic inflammatory response syndrome (SIRS) score in combination with other commonly used indices, could accurately predict mortality in trauma.

STUDY DESIGN

Prospective data were analyzed in 9,539 trauma patients evaluated at a Level I Trauma Center over a 30-month period (January 1997 to July 1999). A SIRS score (1 to 4) was calculated on admission (1 point for each: temperature > 38 degrees C or < 36 degrees C, heart rate > 90 beats per minute, respiratory rate > 20 breaths per minute, neutrophil count > 12,000 or < 4,000. SIRS score, Injury Severity Score (ISS), Revised Trauma Score (RTS), TRISS, Glasgow Coma Score, age, gender, and race were used in logistic regression models to predict trauma patients' risk of death. The area under the receiver-operating characteristic curves of sensitivity versus 1-specificity was used to assess the predictive ability of the models.

RESULTS

The study cohort of 9,539 trauma patients (of which 7,602 patients had complete data for trauma score calculations) had a mean ISS of 9 +/- 9 (SD) and mean age of 37 +/- 17 years. SIRS (SIRS score > or = 2) was present in 2,165 of 7,602 patients (28.5%). In single-variable models, TRISS and ISS were most predictive of outcomes. A multiple-variable model, Physiologic Trauma Score combining SIRS score with Glasgow Coma Score and age (Hosmer-Lemenshow chi-square = 4.74) was similar to TRISS and superior to ISS in predicting mortality. The addition of ISS to this model did not significantly improve its predictive ability.

CONCLUSIONS

A new statistical model (Physiologic Trauma Score), including only physiologic variables (admission SIRS score combined with Glasgow Coma Score and age) and easily calculated at the patient bedside, accurately predicts mortality in trauma patients. The predictive ability of this model is comparable to other complex models that use both anatomic and physiologic data (TRISS, ISS, and ICISS).

Back to basics: validation of the admission systemic inflammatory response syndrome score in predicting outcome in trauma

BACKGROUND

We have previously documented that the admission systemic inflammatory response syndrome (SIRS) score, calculated with four variables-temperature, heart rate, neutrophil count, and respiratory rate-is a significant predictor of outcome in trauma (n = 4,887). The objective of this current study was to validate our previous findings in a larger trauma patient population, to analyze the predictive accuracy of the four individual components of the SIRS score (temperature, heart rate, neutrophil count, and respiratory rate), and to assess whether the admission SIRS score is an accurate predictor of intensive care unit (ICU) resource use in trauma.

METHODS

Prospective data were collected on 9,539 patients admitted to a Level I trauma center over a 30-month period (January 1997-July 1999). Patients were stratified by age, sex, race, and Injury Severity Score (ISS). SIRS score was calculated at admission, and SIRS was defined as a SIRS score > or = 2.

RESULTS

SIRS score was validated as a significant independent predictor of outcome in trauma by logistic regression analysis after controlling for age and ISS. Of the four SIRS variables, hypothermia (temperature < 36 degrees C) was the most significant predictor of mortality after controlling for age and ISS. Leukocytosis (neutrophil count > 12,000/mm3) was the most significant predictor of total hospital length of stay. SIRS scores of > or = 2 were increasingly predictive of mortality and ICU admission by logistic regression analysis (p < 0.001).

CONCLUSION

These data provide further validation that an admission SIRS score of > or = 2 is a significant independent predictor of outcome and ICU resource use in trauma. Temperature (hypothermia) is the individual component of the SIRS score with the greatest predictive accuracy. SIRS score should be calculated on all trauma admissions.