Severe Head Trauma: Pathophysiology and Management

A randomized, blinded trial of the antioxidant pegorgotein: no reduction in neuropsychological deficits, inotropic drug support, or myocardial ischemia after coronary artery bypass surgery

OBJECTIVE

To determine whether patients receiving pegorgotein preoperatively would be less likely than patients receiving placebo to demonstrate postoperative cerebral or myocardial dysfunction and thus would be less likely to (1) demonstrate a decline in neuropsychologic testing after cardiopulmonary bypass, (2) receive inotropic drug support, or (3) demonstrate electrocardiographic signs of ischemia or infarction.

DESIGN

Prospective, randomized, blinded clinical trial.

SETTING

University teaching hospital and clinics.

PARTICIPANTS

Sixty-seven patients with normal left ventricular function undergoing elective, primary coronary artery bypass surgery.

INTERVENTIONS

Six to 18 hours before aortic cross-clamping, patients received a single dose of placebo (n = 22); pegorgotein, 2,000 IU/kg intravenously (n = 23); or pegorgotein, 5,000 IU/kg intravenously (n = 22).

MEASUREMENTS AND MAIN RESULTS

Patients in the three groups were similar; the mean ages were 65, 66, and 67 years, and there were seven, eight, and seven women in the placebo; pegorgotein, 2,000 IU/kg; and pegorgotein, 5,000 IU/kg groups. Fifty-one of 67 patients demonstrated neuropsychologic deficit 5 to 7 days postoperatively (n = 17, 19, and 15 for placebo, 2,000 IU/kg, and 5,000 IU/kg; p = NS). Median duration of cardiopulmonary bypass was longer in patients with two or more deficits at 4 to 6 weeks than in those with fewer than two deficits (121 v. 98 minutes; p = 0.04). No patient demonstrated a perioperative stroke. Twenty-seven patients required inotropic drug support after cardiopulmonary bypass (n = 8, 11, and 8 for placebo, 2,000 IU/kg, and 5,000 IU/kg; p = NS). Inotropic drug support was associated with history of angina (p = 0.01) and increasing weight (p = 0.03). Nine patients demonstrated early postoperative ischemia or infarction (n = 1, 7, and 1 for placebo, 2,000 IU/kg, and 5,000 IU/kg; p = 0.07).

CONCLUSIONS

This study showed no positive influence of pegorgotein on the incidence of any of the findings and showed a trend toward an increased incidence of myocardial ischemia or infarction.

Nosocomial respiratory tract infections in multiple trauma patients. Influence of level of consciousness with implications for therapy

A prospective study of 161 multiple trauma patients was carried out to determine the incidence, the causative agents, and the outcome of nosocomial respiratory tract infections in this highly selected population. Thirty-eight (23.6 percent) patients developed a nosocomial pneumonia (NP). In addition, there were four superinfections in three patients, representing an incidence of 26 percent (42 of 161). Incidence of NP was significantly greater among comatose patients (42.2 vs 13.3 percent, p less than 0.05). Furthermore, purulent tracheobronchitis was diagnosed in six patients. The causative agent of NP was identified in 36 (85.7 percent) episodes by means of fiberoptic bronchoscopies with protected specimen brush sampling. Staphylococcus aureus (55.8 percent) was the predominant pathogen isolated in multiple trauma patients in coma (Glasgow coma score [GCS] below 9 during a period greater than 24 h), while aerobic Gram-negative bacilli were responsible for the majority of cases in the remaining population studied. The overall mortality rate was 19.8 percent, but only five deaths were related to NP. We conclude that nosocomial respiratory tract infections are a frequent problem in multiple trauma patients, especially in those with GCS below 9, although this complication is associated with a relatively low mortality. Among patients with GCS below 9, S aureus was a frequent finding; consequently, antimicrobial therapy in this population needs to be different than that for the remaining multiple trauma patients with NP.