Biochemical characterization of individual injury pattern and injury severity

Hypocalcaemia upon arrival (HUA) in trauma patients who did and did not receive prehospital blood products: a systematic review and meta-analysis

PURPOSE

Hypocalcaemia upon arrival (HUA) to hospital is associated with morbidity and mortality in the trauma patient. It has been hypothesised that there is an increased incidence of HUA in patients receiving prehospital transfusion as a result of citrated blood products. This research aimed to determine if there was a difference in arrival ionised calcium (iCa) levels in trauma patients who did and did not receive prehospital transfusion.

METHODS

We conducted a systematic review and meta-analysis of patients with an Injury Severity Score (ISS) > / = 15 and an iCa measured on hospital arrival. We then derived mean iCa levels and attempted to compare between-group variables across multiple study cohorts.

RESULTS

Nine studies reported iCa on arrival to ED, with a mean of 1.08 mmol/L (95% CI 1.02-1.13; I2 = 99%; 2087 patients). Subgroup analysis of patients who did not receive prehospital transfusion had a mean iCa of 1.07 mmol/L (95% CI 1.01-1.14; I2 = 99%, 1661 patients). Transfused patients in the 3 comparative studies had a slightly lower iCa on arrival compared to those who did not receive transfusion (mean difference - 0.03 mmol/L, 95% CI - 0.04 to - 0.03, I2 = 0%, p = 0.001, 561 patients).

CONCLUSION

HUA is common amongst trauma patients irrespective of transfusion. Transfused patients had a slightly lower initial iCa than those without transfusion, though the clinical impact of this remains to be clarified. These findings question the paradigm of citrate-induced hypocalcaemia alone in trauma. There is a need for consensus for the definition of hypocalcaemia to provide a basis for future research into the role of calcium supplementation in trauma.

A conceptual time window-based model for the early stratification of trauma patients

Progress in the testing of therapies targeting the immune response following trauma, a leading cause of morbidity and mortality worldwide, has been slow. We propose that the design of interventional trials in trauma would benefit from a scheme or platform that could support the identification and implementation of prognostic strategies for patient stratification. Here, we propose a stratification scheme based on defined time periods or windows following the traumatic event. This 'time-window' model allows for the incorporation of prognostic variables ranging from circulating biomarkers and clinical data to patient-specific information such as gene variants to predict adverse short- or long-term outcomes. A number of circulating biomarkers, including cell injury markers and damage-associated molecular patterns (DAMPs), and inflammatory mediators have been shown to correlate with adverse outcomes after trauma. Likewise, several single nucleotide polymorphisms (SNPs) associate with complications or death in trauma patients. This review summarizes the status of our understanding of the prognostic value of these classes of variables in predicting outcomes in trauma patients. Strategies for the incorporation of these prognostic variables into schemes designed to stratify trauma patients, such as our time-window model, are also discussed.

The association between pro-inflammatory biomarkers and nonspecific low back pain: a systematic review

BACKGROUND CONTEXT

About 85% of the patients with low back pain seeking medical care have nonspecific low back pain (NsLBP), implying that no definitive cause can be identified. Nonspecific low back pain is defined as low back pain and disability which cannot be linked to an underlying pathology, such as cancer, spinal osteomyelitis, fracture, spinal stenosis, cauda equine, ankylosing spondylitis, and visceral-referred pain. Many pain conditions are linked with elevated serum levels of pro-inflammatory biomarkers. Outcomes of interest are NsLBP and the level of pro-inflammatory biomarkers.

PURPOSE

To unravel the etiology and get better insight in the prognosis of NsLBP, the aim of this study was to assess the association between pro-inflammatory biomarkers and the presence and severity of NsLBP.

STUDY DESIGN

A systematic literature search was made in Embase, Medline, Cinahl, Webof-science, and Google scholar up to January 19th 2017.

METHODS

Included were cross-sectional and cohort studies reporting on patients aged over 18 years with NsLBP, in which one or more pro-inflammatory biomarkers were measured in blood plasma. The methodological quality of the included studies was assessed using the Newcastle Ottawa Scale. A best-evidence synthesis was used to summarize the results from the individual studies, meaning that the included studies were ranked according to the consistency of the findings and according to their methodological quality score using the Newcastle Ottawa Scale.

RESULTS

Included were 10 studies which assessed four different pro-inflammatory biomarkers. For the association between the presence of NsLBP and C-reactive protein (CRP), interleukin 6 (IL-6) and tumor necrosis factor (TNF)-α limited, conflicting and moderate evidence, respectively, was found. For the association between the severity of NsLBP and CRP and IL-6, moderate evidence was found. For the association between the severity of NsLBP and TNF-α and RANTES Regulated on Activation, Normal T Cell Expressed and Secreted conflicting and limited evidence, respectively, was found.

CONCLUSIONS

This study found moderate evidence for (i) a positive association between the pro-inflammatory biomarkers CRP and IL-6 and the severity of NsLBP, and (ii) a positive association between TNF-α and the presence of NsLBP. Conflicting and limited evidence was found for the association between TNF-α and Regulated on Activation, Normal T Cell Expressed and Secreted and severity of NsLBP, respectively.

Systemic inflammatory profiles and their relationships with demographic, behavioural and clinical features in acute low back pain

Systemic inflammation is linked with development and persistence of many pathological pain states. Although chronic phase inflammatory responses are well reported, the acute phase has received limited attention. Here we investigated circulating pro-inflammatory cytokines and C-reactive protein (CRP), and explored their relationships with symptom severity and other factors in acute low back pain (LBP). Ninety-nine individuals within two weeks of onset of acute LBP and 55 pain-free controls completed questionnaires related to their pain (visual analogue scale, VAS) and disability, behaviour, sleep quality and psychological status. CRP, interleukin-6 (IL-6), tumor necrosis factor (TNF) and interleukin-1β (IL-1β) were measured from serum samples. Biomarkers were compared between LBP and control participants, and in a separate analysis, for those with "high-pain" (VAS ⩾4) and "low-pain" (VAS <4). The relationships between biomarkers and all other variables, including other cytokines/CRP were assessed. CRP was higher in LBP than controls and in those with high- than low-pain (p<0.01). IL-6 was higher in those with high- than low-pain (p<0.05), but not controls. Various pain and non-pain factors were associated with each biomarker differently. These findings suggest systemic CRP and IL-6 are important contributors to inflammation in the early post-onset phase of LBP and that various factors can shape these responses.

Optimal Chest Compression Rate and Compression to Ventilation Ratio in Delivery Room Resuscitation: Evidence from Newborn Piglets and Neonatal Manikins

Cardiopulmonary resuscitation (CPR) duration until return of spontaneous circulation (ROSC) influences survival and neurologic outcomes after delivery room (DR) CPR. High quality chest compressions (CC) improve cerebral and myocardial perfusion. Improved myocardial perfusion increases the likelihood of a faster ROSC. Thus, optimizing CC quality may improve outcomes both by preserving cerebral blood flow during CPR and by reducing the recovery time. CC quality is determined by rate, CC to ventilation (C:V) ratio, and applied force, which are influenced by the CC provider. Thus, provider performance should be taken into account. Neonatal resuscitation guidelines recommend a 3:1 C:V ratio. CCs should be delivered at a rate of 90/min synchronized with ventilations at a rate of 30/min to achieve a total of 120 events/min. Despite a lack of scientific evidence supporting this, the investigation of alternative CC interventions in human neonates is ethically challenging. Also, the infrequent occurrence of extensive CPR measures in the DR make randomized controlled trials difficult to perform. Thus, many biomechanical aspects of CC have been investigated in animal and manikin models. Despite mathematical and physiological rationales that higher rates and uninterrupted CC improve CPR hemodynamics, studies indicate that provider fatigue is more pronounced when CC are performed continuously compared to when a pause is inserted after every third CC as currently recommended. A higher rate (e.g., 120/min) is also more fatiguing, which affects CC quality. In post-transitional piglets with asphyxia-induced cardiac arrest, there was no benefit of performing continuous CC at a rate of 90/min. Not only rate but duty cycle, i.e., the duration of CC/total cycle time, is a known determinant of CC effectiveness. However, duty cycle cannot be controlled with manual CC. Mechanical/automated CC in neonatal CPR has not been explored, and feedback systems are under-investigated in this population. Evidence indicates that providers perform CC at rates both higher and lower than recommended. Video recording of DR CRP has been increasingly applied and observational studies of what is actually done in relation to outcomes could be useful. Different CC rates and ratios should also be investigated under controlled experimental conditions in animals during perinatal transition.

Identification of potential biomarkers for post-traumatic complications released after trauma-hemorrhage from murine Kupffer cells and its investigation in lung and liver

CONTEXT

Early diagnosis of complications after severe trauma by specific biomarkers remains difficult.

OBJECTIVE

Identify potential new biomarkers for early diagnosis of post-traumatic complications.

MATERIAL AND METHODS

Mice underwent pressure-controlled hemorrhage or sham procedure. Four hours later, genome-wide expression of isolated Kupffer cells was compared with controls using Affymetrix-Genechip-Expression-Analysis and real-time-PCR.

RESULTS

Expression analysis and real-time-PCR revealed a significant increase of gene expression of Cxcl10, Il4ra, Csf2rb2, Lcn2, and Gbp5.

CONCLUSION

Cxcl10, Il4ra, Csf2rb2, Lcn2, and Gbp5 might represent new biomarkers for early diagnosis of post-traumatic complications, if they are linked to the development of post-traumatic complications.

Association between increased blood interleukin-6 levels on emergency department arrival and prolonged length of intensive care unit stay for blunt trauma

Background

Systemic immune response to injury plays a key role in the pathophysiological mechanism of blunt trauma. We tested the hypothesis that increased blood interleukin-6 (IL-6) levels of blunt trauma patients on emergency department (ED) arrival are associated with poor clinical outcomes, and investigated the utility of rapid measurement of the blood IL-6 level.

Methods

We enrolled 208 consecutive trauma patients who were transferred from the scene of an accident to a level I trauma centre in Japan and admitted to the intensive care unit (ICU). Blood IL-6 levels on ED arrival were measured by using a rapid measurement assay. The primary outcome variable was prolonged ICU stay (length of ICU stay > 7 days). The secondary outcomes were 28-day mortality, probability of survival and Abbreviated Injury Scale (AIS) scores.

Results

Patients with prolonged ICU stay had significantly higher blood IL-6 levels on ED arrival than the patients without prolonged ICU stay (P < 0.0001). The receiver-operating characteristic curves produced an area under the curve of 0.75 (95 % confidence interval [CI], 0.66–0.84; P < 0.0001) for prolonged ICU stay. The patients who had increased blood IL-6 levels on ED arrival had increased 28-day mortality (P = 0.021) and decreased probability of survival (P < 0.0001). The AIS scores for the thorax, abdomen, extremity, and external body regions independently correlated with blood IL-6 levels (unstandardized coefficients [95 % CI] for the thorax: 23.8 [12.6–35.1]; P < 0.0001; abdomen: 42.7 [23.8–61.7]; P < 0.0001; extremity: 19.0 [5.5–32.4]; P = 0.0060; external body regions: 62.9 [13.2–112.7]; P = 0.030); the standardized coefficients for the thorax (0.27) and abdomen (0.28) were larger than those for the extremity (0.18) and external body regions (0.15).

Conclusions

Increased blood IL-6 level on ED arrival was significantly associated with prolonged length of ICU stay. Blood IL-6 level on ED arrival independently correlated with the AIS scores for the abdomen and thorax, and, to a lesser extent, those for the extremity and external body regions. The rapid measurement of blood IL-6 level on ED arrival can be utilized as a fast screening tool to improve assessment of injury severity and prediction of clinical outcomes in the initial phase of trauma care.

Inflammatory Changes and Coagulopathy in Multiply Injured Patients

Severe tissue trauma leads to an early activation of several danger recognition systems, including the complement and the coagulation system, often resulting in an overwhelming almost synchronic pro- and anti-inflammatory response of the host. Although the immune response is associated with beneficial effects at the site of injury including the elimination of exogenous and endogenous danger molecules as well as the initiation of regenerative processes, an exaggerated systemic inflammatory response significantly contributes to posttraumatic complications such as multiple organ failure (MOF) and early death. Besides pre-existing physical conditions, age, gender, and underlying comorbidities, surgical and anesthesiological management after injury is decisive for outcome. Improvements in surgical intensive care have increased number of patients who survive the initial phase after trauma. However, instead of progressing to normal recovery, patients often pass into persistent inflammation, immunosuppression, and catabolism syndrome (PICS). The characterization and management of PICS will require new strategies for direct monitoring and therapeutic intervention into the patient’s immune function. In this chapter, we describe various factors involved in the inflammatory changes after trauma and aim to understand how these factors interact to progress to systemic inflammation, MOF, and PICS.

[Cytokines as biomarkers in polytraumatized patients]

BACKGROUND

Multiple trauma can lead to posttraumatic complications such as systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), and sepsis. Currently, these complications are monitored using clinical and organ-specific parameters. The immune system is activated by trauma. Cytokines, which are the messenger molecules of this system, can be determined in serum. Furthermore, they are associated with the intensity of the inflammatory and anti-inflammatory reactions.

AIM

This review describes clinical studies that measured cytokines such as TNF-α, IL-1β, IL-6, IL-8, and IL-10 to prognosticate posttraumatic complications. On the other hand, IL-6 can be helpful in deciding which primary operation to perform, i.e., external fixator or intramedullary nail. Moreover, IL-6 indicates the strength of the immune reaction. Thereby, it may help in determining the optimal time for secondary surgery.

Serum interleukin-6 level as an early marker of injury severity in trauma patients in an urban low-income setting: a cross-sectional study

Background

Trauma is still the leading cause of death in many regions of the world. Severity scores have been developed to assist in management of trauma victims. Immune response to trauma has been known to positively correspond to the severity of trauma. Part of this response involves release of cytokines into blood circulation which promote the acute inflammatory response commonly seen after trauma. Studies have shown that IL-6 levels commonly correlate positively with the Injury Severity Score (ISS). The aim of this cross-sectional study was to determine whether this kind of relationship exists between IL-6 levels and injury severity in trauma patients in Mulago Hospital as defined by the Kampala Trauma Score (KTSII) which is locally developed.

Methods

Trauma patients aged ≥18 years presenting to the Accident and Emergency unit of Mulago National Referral Hospital (MNRH) within 12 h after injury were recruited into the study after obtaining consent. Severity of injury was determined as per the Kampala Trauma Score (KTSII) and venous blood drawn for assay of serum IL-6 levels. Data obtained was entered and analyzed using Stata version 11 software focusing on the association between Serum IL-6 levels with Severity of trauma and duration of injury.

Results

A total of 159 patients were recruited (79 Mild and 80 Severe trauma) with a male to female ratio of 4.7:1. Road traffic crashes (67.92 %) were the commonest cause of injury. Serum IL-6 levels were found to positively correspond with severity of injury (z = 4.718, p < 0.001). There was no significant correlation between serum IL-6 levels and duration of injury in both severe (r = 0.12, p = 0.29) and mild (r = 0.06, p = 0.62) trauma groups of patients. Only 9.43 % of trauma patients were brought in an Ambulance.

Conclusions

Serum IL-6 levels correspond with severity of injury. However, within the first twelve hours after injury, these levels did not vary significantly with duration of injury.

Early inflammatory response in polytraumatized patients: Cytokines and heat shock proteins. A pilot study

INTRODUCTION

In the initial phases after polytrauma there is an hyperinflammatory state that sometimes leads to multiple organ dysfunction syndrome (MODS) and death, and that appears to be responsible for posttraumatic immunosuppression; among the trigger endogenous stimuli, heat shock proteins (HSPs) have been proposed. The objectives of this study were to analyze if some inflammatory mediators can be considered prognostic biomarkers of outcome, and the possible role of HSPA1A in posttraumatic immunosuppression.

HYPOTHESIS

Cytokines and HSPs could be early prognostic biomarkers of inflammatory and immune response in polytrauma patients.

MATERIALS AND METHODS

A prospective observational descriptive pilot study was carried out, evaluating the early inflammatory and stress response of 18 polytraumatized patients (ISS>16) on hospital admission, at 12hours, 24hours, and 48hours posttrauma. Variable means were compared using non-parametric tests; qualitative and quantitative variables were analyzed using a Spearman's correlation test.

RESULTS

Seven patients met criteria for MODS. Statistically significant changes were recorded in leukocyte count, C-reactive-protein (CRP), IL-6, TNF-α, and IL-1ß concentrations. HSPA1A levels were significantly higher immediately after the accident followed by gradual lowering. Anti-Hsp70 antibodies showed a significant reduction in all the studied time-points. MODS did not influence either plasma levels of leukocytes, fibrinogen, RCP or anti-Hsp70, but patients with MODS had higher plasma levels of IL-6 and TNF-α and a slower decrease of HSPA1A concentrations.

DISCUSSION

The higher serum concentrations of TNF-α and IL-6 found in patients with MODS, suggests a possible role as potential early predictive markers for systemic inflammatory response and clinical complications. The higher levels of HSPA1A in patients with MODS, allows proposing HSPA1A as a useful prognostic trauma biomarker early after severe injury and to consider a "damage control surgery". The significant reduction in the levels of anti-Hsp70 antibodies could reflect a part of posttraumatic immunosuppression and hydrocortisone treatment might be suggested.

LEVEL III

case-control study.

Impact of haemorrhagic shock intensity on the dynamic of alarmins release in porcine poly-trauma animal model

PURPOSE

Traumatic insults result in an altered inflammatory response, in which alarmins release has a central role. The impact of haemorrhagic shock intensity on the long-term kinetics of alarmins is not yet fully elucidated. We investigated these aspects in a combined trauma (chest, abdominal, and extremities injury) porcine model with different severities and durations of haemorrhagic shock.

METHODS

After induction of combined trauma (tibia fracture, lung contusion, and liver laceration), haemorrhagic shock was induced at different intensities: moderate haemorrhage (MH; n = 15): mean arterial pressure (MAP) <30 ± 5 mmHg [maximum loss of total blood volume (TBVmax): 45 %] for 90 min, and severe haemorrhage (SH; n = 10): MAP <25 ± 5 mmHg (TBVmax 50 %) for 120 min. Resuscitation was performed using a standardized crystalloid infusion protocol. Animals were mechanically ventilated and underwent ICU-monitoring for 48 h (MH) and 48.5 h (SH). Blood samples were collected over the clinical time course, and systemic levels of serum alarmins [High-Mobility Group Protein B-1 (HMGB-1) and Heat Shock Protein 70 (HSP70)] were measured using an ELISA kit.

RESULTS

Heart rate, systemic blood pressure, lactate, and base excess were significantly altered as a function of haemorrhagic shock in both trauma groups (MH and SH). Systemic HMGB-1 levels were significantly elevated in both trauma groups when compared to the sham group. Haemorrhagic shock severity and duration were positively correlated with HMGB-1 levels and compared to baseline values, concentrations remained significantly increased in SH when compared to MH. On the other hand, we observed a significant decrease in the systemic HSP70 levels of trauma groups (MH, and SH) when compared to the sham group, which was significantly decreased compared to baseline values in SH over the entire time course.

CONCLUSION

Our data show that haemorrhagic shock duration and severity affect the systemic levels of HMGB-1 and HSP70. This early alarmins release after trauma can be used to guide the treatment strategies (e.g. surgical procedures) of polytrauma patients.

Differences between blunt and penetrating trauma after resuscitation with hydroxyethyl starch

BACKGROUND

The purpose of this study was to test the hypothesis that a single bolus of 6% hydroxyethyl starch (HES 450/0.7 in lactated electrolyte injection) during initial resuscitation has a differential effect in blunt and penetrating trauma patients.

METHODS

Consecutive admissions to the trauma service were reviewed. Patients who died within 24 hours were excluded. Multivariate analysis defined individual predictors for the primary outcomes, acute kidney injury (AKI) and mortality within 90 days. Data were expressed as mean ± SD, and significance was assessed at p < 0.05.

RESULTS

There were 1,410 patients (76% male; mean ± SD, age 43 ± 18 years; 68% blunt trauma; mean ± SD Injury Severity Score [ISS] 14 ± 11; AKI, 4.4%; and mortality, 3.4%). HES (0.5-1.5 L) was administered to 216 patients (15.3%). After multiple logistic regression, HES remained a significant independent predictor of AKI after blunt trauma (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.24-5.19; area under the receiver operating characteristic curve [AUROC], 0.809) but not penetrating trauma (OR, 0.90; 95% CI, 0.23-3.60; AUROC, 0.849). In separate logistic regression models, HES was a significant predictor of mortality after blunt trauma (OR, 3.77; 95% CI, 0.91-0.97; AUROC, 0.921) but not penetrating trauma (OR, 0.72; 95% CI, 0.13-3.94; AUROC, 0.904).

CONCLUSION

HES is an independent risk factor for AKI and death after blunt, but not penetrating, trauma, which underscores a fundamental difference between these two injury types.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Peripheral cytokines as a chemical mediator for postconcussion like sickness behaviour in trauma and perioperative patients: literature review

Besides brain injury and systemic infection, cognitive and concussion like sickness behaviour is associated with muscular trauma and perioperative patients, which represents a major obstacle to daily activities and rehabilitation. The neuroinflammatory response triggers glial activation and consequently the release of proinflammatory cytokines within the hippocampus. We review clinical studies that have investigated neurocognitive and psychosomatic symptoms related to muscular trauma and in perioperative conditions. These include impaired attention and executive and general cognitive functioning. The purpose of this literature review is to focus on the systemic inflammation and the role of proinflammatory cytokines IL1, IL6,and TNF and other inflammatory mediators which mediates the cognitive impairment and induces sickness behaviour. Moreover, this review will also help to determine if some patients could have long-term cognitive changes associated with musculoskeletal injuries or as a consequence of surgery and thereby will lead to efforts in reducing that risk.

Interleukin-6 as inflammatory marker referring to multiple organ dysfunction syndrome in severely injured children

Background

Despite the suggestion that the inflammatory response in traumatized children is functionally unique, prognostic markers predicting pediatric multiple organ failure are lacking. We intended to verify whether Interleukin-6 (IL-6) displays a pivotal role in pediatric trauma similar to adults.

Methods

Traumatized children less than 18 years of age with an Injury Severity Score >9 points and consecutive admission to the hospital’s pediatric intensive care unit were included. Organ function was evaluated according to the score by Marshall et al. while IL-6 levels were measured repetitively every morning.

Results

59 traumatized children were included (8.4 ± 4.4 years; 57.6% male gender). Incidence of MODS was 11.9%. No differences were found referring to age, gender, injury distribution or overall injury severity between children with and without MODS. Increased IL-6 levels during hospital admission were associated with injury severity (Spearman correlation: r = 0.522, p < 0.001), while an inconsistent association towards the development of MODS was proven at that time point (Spearman correlation: r = 0.180, p = 0.231; Pearson's correlation: r = 0.297, p = 0.045). However, increased IL-6 levels during the first two days were no longer associated with the injury severity but a significant correlation to MODS was measured.

Conclusions

The presented prospective study is the first providing evidence for a correlation of IL-6 levels with injury severity and the incidence of MODS in traumatized children.

Brain inflammation induced by severe asphyxia in newborn pigs and the impact of alternative resuscitation strategies on the newborn central nervous system

BACKGROUND

We compared the current guidelines for neonatal resuscitation with alternative measures and aimed to find out whether this modulated brain inflammation.

METHODS

Progressive asphyxia was induced in 94 newborn pigs until asystole. With the reference being resuscitation guidelines, 30 s of initial positive-pressure ventilation before compression (C) and ventilation (V) (C:V; 3:1) in 21% oxygen, pigs were randomized to (i) ventilation for 30, 60, or 90 s before chest compressions; (ii) C:V ratios of 3:1, 9:3, or 15:2; or (iii) 21% or 100% oxygen. Concentrations of inflammatory markers in the cerebrospinal fluid (CSF) and gene expression in the hippocampus and frontal cortex were measured for different interventions.

RESULTS

In CSF, S100 was higher with 90 s than with 30 or 60 s of initial positive-pressure ventilation, whereas concentrations of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) were higher with 30 than with 60 s. Matrix metalloproteinase-2 (MMP-2) and intracellular adhesion molecule 1 (ICAM-1) were higher with 30 than with 60 s. No other comparison between ratios and oxygen concentrations used yielded significant results.

CONCLUSION

With respect to signs of brain inflammation, newly born pigs at asystole should be ventilated for longer than 30 s before chest compressions start. C:V ratios of 9:3 and 15:2 as compared with 3:1, or air instead of pure oxygen, did not modulate inflammatory markers.

Lung Injury in Asphyxiated Newborn Pigs Resuscitated from Cardiac Arrest - The Impact of Supplementary Oxygen, Longer Ventilation Intervals and Chest Compressions at Different Compression-to-Ventilation Ratios

Introduction:

Non-specific lung inflammatory events caused by severe asphyxia may be intensified by the way we resuscitate the newly born. Assessing lung injury is potentially important because if alternative resuscitation approaches induces similar inflammatory responses or less lung injury. then we may choose the resuscitation approach that is most gentle, and easiest to perform and learn. We investigated the levels of lung inflammatory markers by comparing different ventilation, chest compression and inhaled oxygen fraction strategies in resuscitation of newly born pigs at cardiac arrest.

Materials and Methodology:

Progressive asphyxia in newborn pigs was induced until asystole occurred. With current resuscitation guidelines as a reference group, pigs were randomized to receive initial ventilation before chest compressions for 30s, 60s or 90s, or to compression-to-ventilation ratios 3:1or 9:3, or to resuscitation using pure oxygen or air. We analysed inflammatory markers in bronchoalveolar lavage fluid (BAL), IL8 and TNFα, and lung tissue qPCR for genes matrix metalloproteinases (MMP)2, MMP9, TNFα and ICAM-1.

Results:

BAL-levels of TNFα and IL8 tended to be higher in the 30s group compared to 60s group (p = 0.028 and p = 0.023, respectively) as was gene expression in lung tissue of ICAM-1 and MMP2 (p=0.012 and p=0.043, respectively). MMP2 expression was slightly higher in the 30s group compared to 90s group (p = 0.020). No differences were found between pigs resuscitated with C:V ratio 9:3 and 3:1 or pure oxygen versus air.

Conclusion:

Compared to current guidelines, with respect to lung injury, resuscitation with longer initial ventilation should be considered. Longer series of chest compressions did not change the lung inflammatory response, neither did the use of air instead of pure oxygen in severely asphyxiated pigs resuscitated from asystole.

CK/CK-MB ratio as an indirect predictor for survival in polytraumatized patients

BACKGROUND

Accurate assessment of injury severity is critical for decision making related to the prevention, triage, and treatment of several injured patients. Early estimation of mortality risk of critically injured patients is mandatory for adequate therapeutic strategies. Current risk stratification relies on clinical diagnosis and scoring systems. In our study, we hypothesized whether a simple laboratory test, the CK/CK-MB ratio, could help improving risk prediction in severely traumatized patients.

METHODS

In a 9-year period, 328 nonselected trauma patients were included in our retrospective study at a Level I Trauma Center up to September 2002. Data for this study were obtained from our computerized trauma database, established in September 1992.

RESULTS

In our study population, we could show a negative correlation between Injury Severity Score (ISS) and leukocytes. A positive correlation was detected for liver enzymes and CK-MB. The correlation between ISS and Na(+) was significant. No correlation between ISS, K(+), and Hb/Ht could be observed. Exitus was associated with ISS, alteration in thrombocytes, CK, CK-MB, CRP, Crea, and Na(+).

CONCLUSION

In our study population, CK-MB levels showed a significant correlation with overall surveillance in polytraumatized patients. In our opinion, this might suggest that CK-MB levels could be taken as an indirect predictor for survival. Our findings need to be proven in further prospective clinical trials.

Biochemical markers comparison of dynamic hip screw and Gamma nail implants in the treatment of stable intertrochanteric fracture: a prospective study of 60 patients

This prospective study compared the extent of surgical trauma following dynamic hip screw (DHS) or Gamma nail (GN) implantation in 60 patients (≥ 60 years old) with stable intertrochanteric fracture. Levels of the biochemical markers creatinine kinase (CK) and C-reactive protein (CRP) were measured pre- and postoperatively. CRP levels were statistically significantly lower on postoperative days 1 and 2 in patients in the DHS versus the GN group; no other differences were observed. Surgical procedures for DHS implantation were considered less invasive than those for GN implantation, although the degree of muscle damage was similar in both groups. The degree of bone and bone marrow damage, rather than muscle tissue damage, may be crucial for determining the CRP response during the operative period. It is concluded that DHS implantation may be described as a more 'systemically' minimally invasive procedure than GN implantation.

Orthopedic trauma-induced pulmonary injury in the obese Zucker rat

OBJECTIVE

Obese subjects with orthopedic trauma exhibit increased inflammation and an increased risk of pulmonary edema. Prostaglandin E(2) (PGE(2) ) production is elevated during inflammation and associated with increased vascular permeability. We hypothesize that pulmonary edema in obesity following orthopedic trauma is due to elevated PGE(2) and resultant increases in pulmonary permeability.

METHODS

Orthopedic trauma was induced in both hindlimbs in lean (LZ) and obese Zucker rats (OZ). On the following day, plasma interleukin-6 (IL-6) and PGE(2) levels, pulmonary edema, and pulmonary gas exchange capability were compared between groups: LZ, OZ, LZ with trauma (LZT), and OZ with trauma (OZT). Vascular permeability in isolated lungs was measured in LZ and OZ before and after application of PGE(2) .

RESULTS

As compared with the other groups, the OZT exhibited elevated plasma IL-6 and PGE(2) levels, increased lung wet/dry weight ratio and bronchoalveolar protein concentration, and an impaired pulmonary gas exchange. Indomethacin treatment normalized plasma PGE(2) levels and pulmonary edema. Basal pulmonary permeability in isolated lungs was higher in OZ than LZ, with a further increase in permeability following treatment with PGE(2) .

CONCLUSIONS

These results suggest that pulmonary edema in OZ following orthopedic trauma is due to an elevated PGE(2) and resultant increases in pulmonary permeability.

Recombinant factor XIII mitigates hemorrhagic shock-induced organ dysfunction

BACKGROUND

Plasma factor XIII (FXIII) is responsible for stabilization of fibrin clot at the final stage of blood coagulation. Since FXIII has also been shown to modulate inflammation, endothelial permeability, as well as diminish multiple organ dysfunction (MOD) after gut ischemia-reperfusion injury, we hypothesized that FXIII would reduce MOD caused by trauma-hemorrhagic shock (THS).

MATERIALS AND METHODS

Rats were subjected to a 90 min THS or trauma sham shock (TSS) and treated with either recombinant human FXIII A(2) subunit (rFXIII) or placebo immediately after resuscitation with shed blood or at the end of the TSS period. Lung permeability, lung and gut myeloperoxidase (MPO) activity, gut histology, neutrophil respiratory burst, microvascular blood flow in the liver and muscles, and cytokine levels were measured 3 h after the THS or TSS. FXIII levels were measured before THS or TSS and after the 3-h post-shock period.

RESULTS

THS-induced lung permeability as well as lung and gut MPO activity was significantly lower in rFXIII-treated than in placebo-treated animals. Similarly, rFXIII-treated rats had lower neutrophil respiratory burst activity and less ileal mucosal injury. rFXIII-treated rats also had a higher liver microvascular blood flow compared with the placebo group. Cytokine response was more favorable in rFXIII-treated animals. Trauma-hemorrhagic shock did not cause a drop in FXIII activity during the study period.

CONCLUSIONS

Administration of rFXIII diminishes THS-induced MOD in rats, presumably by preservation of the gut barrier function, limitation of polymorphonuclear leukocyte (PMN) activation, and modulation of the cytokine response.

Postinjury immune monitoring: can multiple organ failure be predicted?

PURPOSE OF REVIEW

Multiple organ failure is the main cause of late morbidity and mortality after severe injury. This disease state is driven by a dysfunctional immune system. Prediction of multiple organ failure on the basis of clinical parameters appears to be insufficient. A better understanding of immunological pathogenesis underlying multiple organ failure may lead to better prediction and innovation in treatment strategy in order to increase the survival of trauma patients.

RECENT FINDINGS

Immune monitoring has increased the knowledge of the pathogenesis of multiple organ failure, but many mechanisms underlying its cause and development remain to be elucidated. Consequently, adequate predictive markers for diagnosis and monitoring still need to be developed.

SUMMARY

General markers of inflammation including cytokines are correlated with posttraumatic complications with a low sensitivity and specificity and are, therefore, of little use as prognostic markers. Current findings regarding the functionality of immune cells are promising and might be of prognostic value in the near future.

A systems-theoretical framework for health and disease: inflammation and preconditioning from an abstract modeling point of view

Modern advances in molecular biology have produced enormous amounts of data characterizing physiological and disease states in cells and organisms. While bioinformatics has facilitated the organizing and mining of these data, it is the task of systems biology to merge the available information into dynamic, explanatory and predictive models. This article takes a step into this direction. It proposes a conceptual approach toward formalizing health and disease and illustrates it in the context of inflammation and preconditioning. Instead of defining health and disease states, the emphasis is on simplexes in a high-dimensional biomarker space. These simplexes are bounded by physiological constraints and permit the quantitative characterization of personalized health trajectories, health risk profiles that change with age, and the efficacy of different treatment options. The article mainly focuses on concepts but also briefly describes how the proposed concepts might be formulated rigorously within a mathematical framework.

The prognostic importance of serum IL-1beta, IL-6, IL-8 and TNF-alpha levels compared to trauma scoring systems for early mortality in children with blunt trauma

The purpose of the present study was to determine whether a correlation exits between the main trauma scoring systems and the activation of inflammatory cells and mediators such as interleukin-(IL-) 1beta, IL-6, IL-8 and tumor necrosis factor alpha (TNF-alpha) after trauma, and moreover to assess if any of these can be used to predict the outcome in patients under care at a trauma center. Forty-seven children (37 boys, 10 girls) presenting with blunt trauma, were evaluated by an analysis of the relationship between overall mortality and potential risk factors. Admission data, including serum IL-1beta, IL-6, IL-8, TNF-alpha, pediatric trauma score (PTS), and injury severity score (ISS), were collected and analyzed. In descriptive statistics for independent variables, some prognostic factors such as IL-8 (P = 0.04), and ISS (P = 0.004) were significant in their relationship to mortality. In the univariate statistical analysis some other risk factors such as IL-8 (P = 0.004), >20 TNF-alpha (P = 0.04), and ISS (P = 0.007) were significant in their relationship to mortality. The relative risk of developing mortality was higher than two for each of the following risk factors: >10 ages, >25 IL-6, 10-20 TNF-alpha, >20 TNF-alpha, PTS <or= 8, and ISS > 15. There was a positive correlation between IL-8 (r = 0.31, P = 0.33), ISS (r = 0.31, P = 0.0001), and mortality. There was also a correlation with ISS and IL-8 (r = 0.32, P = 0.02). ISS, and the serum IL-8 level are the most important determinants of clinical outcome in critically injured patients. A correlation exits between IL-8 and mortality and between ISS and IL-8.

Significance of levels of IL-6 and IL-8 after trauma: a study of 11 cytokines post-mortem using multiplex immunoassay

PURPOSE

To identify cytokines useful for diagnosis of traumatic death.

METHODS

Post-mortem serum levels of 11 cytokines were assayed for 43 people who died of traumatic injury or from non-traumatic causes. Levels of granulocyte-macrophage colony stimulating factor, gamma interferon, interleukin IL-1beta, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-13, and tumour necrosis factor-alpha were measured using multiplex immunoassay.

RESULTS

Levels of granulocyte-macrophage colony stimulating factor (p<0.01), IL-6 (p<0.001), and IL-8 (p<0.01) among the traumatic group were significantly higher than those among the non-traumatic group. Anatomical trauma severity was also estimated using the total abbreviated injury scale and injury severity score, revealing significant positive correlations between the former and IL-6 (rs=0.6523, p<0.01) and IL-8 levels (rs=0.6584, p<0.01).

CONCLUSIONS

Levels of IL-6 and IL-8 assist differentiation between traumatic and non-traumatic death, are useful objective indices of trauma severity and can support a diagnosis of traumatic death.

Inflammatory biomarkers increase with severity of upper-extremity overuse disorders

MSDs (musculoskeletal disorders) from overuse are common occupational health problems that cause pain, functional loss and loss of work time. The aim of the present study was to determine whether a relationship exists between the severity of early-onset overuse-related MSDs of the upper extremity and serum levels of IL-1beta (interleukin-1beta), TNF-alpha (tumour necrosis factor-alpha), IL-6 (interleukin-6) and CRP (C-reactive protein). Twenty-two subjects with upper-extremity MSDs due to overuse for no longer that 12 weeks were stratified according to the severity of upper-extremity signs and symptoms as determined by a UBMA (upper-body musculoskeletal assessment). Nine asymptomatic subjects also participated. Serum cytokines were analysed using ELISA, and CRP was analysed using a laser nephelometry technique. CRP was strongly correlated, and TNF-alpha, IL-1beta and IL-6 were moderately correlated, with UBMA scores. Only CRP and TNFalpha were significantly associated with UBMA scores in an ordinal logistic regression analysis in which age and BMI (body mass index) were covariates. These results are of clinical importance as they suggest that early-onset overuse-related MSDs may have an inflammatory component. The possibility of using a combination of serum biomarkers to follow the progression of overuse-related MSDs or their response to therapeutic intervention may be of interest to clinical practitioners and should be the focus of future research.

The pulmonary and hepatic immune microenvironment and its contribution to the early systemic inflammation following blunt chest trauma

OBJECTIVE

Blunt chest trauma is accompanied by an early increase in plasma cytokine concentrations. However, the local sources of these mediators are poorly defined. We investigated the impact of blunt chest trauma on the inflammatory mediator milieu in different compartments (lung tissue, bronchoalveolar lavage, liver tissue, Kupffer cells, plasma) along with the time course of trauma-induced pulmonary endothelial barrier dysfunction to elucidate potential relationships. In addition, the correlation between intratracheally instilled interleukin-6 and its systemic release were studied.

DESIGN

Prospective, randomized, controlled animal study.

SETTING

Basic science laboratory of a university affiliated level 1 trauma center.

SUBJECTS

Male C3H/HeN mice, 8-9 wks old, n = 141.

INTERVENTIONS

Blunt chest trauma induced by a focused blast wave, intravenous injection of Evans blue, and intratracheal instillation of recombinant human interleukin-6.

MEASUREMENTS AND MAIN RESULTS

Two hours after blunt chest trauma, plasma interleukin-6 was markedly increased. Simultaneously, interleukin-6, tumor necrosis factor-alpha, macrophage inflammatory protein-2, monocyte chemotactic polypeptide-1 and neutrophil/monocyte accumulation in bronchoalveolar lavage and interleukin-6, monocyte chemotactic polypeptide-1, and myeloperoxidase activity in lung tissue were significantly increased. This was accompanied by a coinciding elevation in the Evans blue lung-plasma ratio. Recombinant human interleukin-6, instilled intratracheally before blunt chest trauma, was detected in a dose-dependent manner in the plasma of the mice. Additionally, Kupffer cell interleukin-6, tumor necrosis factor-alpha, and interleukin-10 production was significantly augmented as early as 30 mins after the insult.

CONCLUSIONS

These results indicate that early increased cytokine concentrations in the lung, particularly interleukin-6, are important mediator sources as their local peak coincides with the systemic inflammatory response and is accompanied by a simultaneous impaired function of the pulmonary endothelial barrier. A direct relationship between their local and systemic concentrations can be established. Furthermore, this is the first study to show that Kupffer cells are activated early after blunt chest trauma.

Supernatant of traumatized muscle induces inflammation and pain, but not microcirculatory perfusion failure and apoptotic cell death

Soft tissue trauma induces an inflammatory response locally and in remote organs. Although remote organ failure is attributed to the systemic action of locally released mediators, it is so far unclear to what extent a direct cell injury and the consequences of ischemia or a secondary injury due to locally released mediators contribute to the manifestation of tissue damage at the primary site of trauma. Soft tissue trauma was induced by means of a controlled impact injury technique in the hind limb of pentobarbital-anesthetized rats. Additional animals received a femoral arterial infusion of supernatant of traumatized muscle tissue, of nontraumatized muscle, or 0.9% NaCl. Tissue injury was assessed by determining microcirculatory perfusion failure, inflammatory response, apoptotic cell death, and nociceptive pain behavior. Muscle tissue of traumatized animals revealed perfusion failure, tissue hypoxia, and inflammation. Nociceptive testing showed a decrease in mechanical pain thresholds of the affected hind paw. Infusion of supernatant of traumatized tissue induced local inflammation and pain comparable with that of directly traumatized tissue; however, it failed to cause nutritive perfusion failure. Supernatant of nontraumatized muscle did not affect muscle microcirculation and integrity. Only animals that underwent direct trauma presented with apoptotic cell death, as given by in vivo fluorescence microscopy, caspase 3 protein cleavage, and transferase-mediated dUTP nick-end labeling histology. Trauma-associated humoral factors cause post-traumatic hyperalgesia and inflammation, but not microvascular perfusion failure and apoptotic cell death. This finding may prompt future efforts in the therapy of closed soft tissue trauma to focus not only on antimediator strategies, but to add regimens targeting perfusion failure and tissue apoptosis.

N-Acetylcysteine administered as part of the immediate post-traumatic resuscitation regimen does not significantly influence initiation of inflammatory responses or subsequent endotoxin hyporesponsiveness

Polytrauma and resuscitative efforts induce extensive alterations in the host's internal environment and cellular responses that may be a serious threat to these patients. Administration of exogenous thiols has been recommended to modulate the post-traumatic inflammatory responses. In this study, we have investigated the effect of N-acetylcysteine (NAC) on the early markers of leukocyte activation and subsequent endotoxin hyporesponsiveness. Twenty-eight pigs were exposed to a standardized gunshot injury. First aid treatment and initial life saving surgery was started without delay. One group (n = 14) was randomised to receive NAC 200 mg kg(-1) over 20 min, the remaining group was given the same volume of vehicle. Blood samples drawn at time points 0 and 75 min were also studied in vitro and stimulated with LPS or LPS plus NAC. Selected physiologic variables and degree of organ injury were equal in both groups. TNF-alpha, IL-1beta, and reactive oxygen species (ROS) tended to be lower in the NAC-group (NS). In vitro, NAC significantly reduced the release of the same cytokines after the LPS challenge in blood drawn before injury. NAC did not influence post-traumatic endotoxin tolerance. Adding NAC to the immediate resuscitation fluid did not influence the early post-traumatic organ injury, and initiation of inflammatory responses significantly, or endotoxin tolerance. In vitro, NAC significantly reduced proinflammatory cytokine release, but only in normal blood. The clinical value of this treatment regimen is probably restricted, both due to the unfavourable post-traumatic internal environment and imposed dosing limitations.