[Value of abdominal CT in surgical intensive care patients].
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Abdomen, Acute↗
Biomedical subjects
C Waydhas
Publications and source records attributed to C Waydhas.
[Is maximum management of polytrauma patients financially assured?].
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Adult↗
Deterioration of respiratory function after intra-hospital transport of critically ill surgical patients.
OBJECTIVE: To evaluate the impact of intra-hospital transport of artificially ventilated patients on respiratory function, and to define predictors that may allow estimation of the risk of post-transport pulmonary deterioration. DESIGN: Prospective observation study. SETTING: Surgical ICU, University Hospital. PATIENTS: 49 intra-hospital transports (median Apache-score before transport 21, of 28 consecutive patients (all intubated and mechanically ventilated) were studied. INTERVENTIONS: 32 transports were destined to the radiology department and 17 to the operating theatre. Patients were ventilated during transportation with a transport ventilator. MEASUREMENTS AND RESULTS: The base-line condition of the patients and any changes of hemodynamic function were noted. Arterial blood gases were determined before transport as well as 0.25, 1, 6, 12, and 24 h after return of the patient to the ICU. Of the transports 41 (83.7%) resulted in a decrease of PO2/FIO2-ratio with a deterioration of more than 20% from baseline in 21 cases (42.8%). The impairment of respiratory function lasted longer than 24 h in 10 subjects (20.4%). Ventilation with positive end-expiratory pressure correlated significantly (r = -0.4) with post-transport change of PO2/FIO2-ratio, whereas initial FIO2, initial PO2/FIO2-ratio, Apache II-score, patients' age or transport time did not distinguish between patients with and without a consecutive decrease of pulmonary function. CONCLUSION: Intra-hospital transport of ventilated critically ill patients may result in a considerable and long-standing deterioration of respiratory function. Patients ventilated with positive end-expiratory pressure are at an increased risk and the indication for procedures away from the ICU has to be weighted carefully in these subjects.
APACHE↗
[Postoperative homeostatic imbalance after trauma surgical interventions of various degrees in polytrauma].
The objective of this study was to evaluate and compare the derangement of body homeostatis and the inflammatory response after different types of traumatological operations in patients with multiple injuries. These were determined in a total of 60 operations. The procedures comprised osteosynthesis of the femur (n = 28), the pelvic girdle (n = 11) the spine (n = 8), and facial and basal skull reconstructions (n = 13). Specific and unspecific parameters of the inflammatory response were determined on the morning of the operation, immediately after the procedure, every 6 h on the 1st day and 48 h after the end of surgery. After all types of operations (pelvis, femur, spine, face/basal skull) significant alterations were observed for neutrophil elastase, C-reactive protein, interleukin 6, interleukin 8, antithrombin III, partial thromboplastin time and other parameters. The degree of postoperative changes differed significantly (Kruskal-Wallis test, P < 0.05) among the four types of operations for lactate, heart rate, PO2/FiO2 ratio and nitrogen excretion and showed a strong discriminating tendency for neutrophil elastase and C-reactive protein. The changes were most pronounced after operations on the pelvic girdle, followed by procedures in the femoral, spinal, and facial/basal skull regions. We conclude that a considerable inflammatory response and pronounced disturbance of body homeostasis follow traumatological operative procedures, varying in severity with the type of surgery. Several parameters allow quantitation of the surgical trauma and differentiation between different operations/regions. Further research should focus on the interrelationship between pre-existing preoperative inflammation and the additional trauma inflicted by surgery in patients with severe injuries.(ABSTRACT TRUNCATED AT 250 WORDS)
Acute-Phase Reaction↗
[Cost analysis of clinical treatment of polytrauma patients].
In order to assess the costs arising from the treatment of polytraumatized patients we analysed the data of 100 prospectively studied multiple trauma patients (ISS 38) calculating all medical expenses during their clinical stay. The average cost per patient in the studied group (n = 100) amounted to 63989.- DM. About 65% of this sum derived from the costs of intensive care, while the expenses for operations covered 19%. The group of primarily deceased patients (n = 25) generated the lowest costs of 8468.- DM (per pat.). The highest costs of 95626.- DM were caused by the treatment of patients (n = 32) that developed one or more complications (organ failure) during their stay in the intensive care unit or died (n = 10) during this therapy (101940.- DM). Since the data concerning medical equipment (i.e. surgical devices, radiological equipment) were not centrally registered in the administration department of our clinic, it was not possible to include these costs into this calculation. Thus the total costs must be presumed higher. A relationship between costs of treatment and injury severity (ISS) appeared in polytrauma only by a cost reduction in early deceased very severely injured patients (ISS > 70). The primary diagnosis (injury pattern and severity) cannot predict the incidence of complications increasing the costs of treatment. In the presented study we did not find a correlation between age and treatment costs.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
[Effect of early intubation on the reduction of post-traumatic organ failure].
In a prospective multiple trauma study lasting from 1986 to 1991 the influence of early intubation (EI) within 2 h after the accident on posttraumatic (multiple) organ failure (M)OF was compared with that of delayed intubation (DI) in 131 patients with multiple injuries (ISS 37). The indications for intubation were unconsciousness following severe head injury in 45 cases (45 EI, 0 DI), major chest trauma (AIS > or = 3) in 40 (31 EI, 9 DI) and other severe injuries (no head or chest trauma, but ISS > 24) in 40 patients (30 EI, 10 DI). One hundred and six trauma victims (81%) were intubated early and 19 patients (14.5%) required intubation and artificial ventilation in the later course, whereas in 6 subjects (4.5%) spontaneous respiration was adequate. The pattern of injured body regions did not differ substantially between the two groups, but the severity of injury was significantly greater (p < 0.001) in the EI group (ISS 39) than in the DI patients (ISS 29). Among the EI patients, 67% developed at least one OF, 45% respiratory failure (RF), and 28% multiple organ failure (MOF); 15% died. The DI group showed almost the same incidence of RF (42%) and other OF (63%), and even a higher (n.s.) incidence of MOF (37%) and mortality rate (26%). In view of the significantly less severe injuries in the DI group, the observed OF and mortality rates are inappropriately high compared with the incidence of OF and death in the EI group.(ABSTRACT TRUNCATED AT 250 WORDS)
Humans↗
A multicenter study of phospholipase A2 in patients in intensive care units.
BACKGROUND: Multiple organ failure (MOF) is becoming the most common cause of death in patients in surgical intensive care units. In this respect, a multicenter study in four different groups of patients in surgical intensive care units was done to evaluate the role of phospholipase A2 (PLA2) in comparison with C-reactive protein (CRP) and polymorphonuclear (PMN) elastase. STUDY DESIGN: A total of 223 patients entered the study: 73 patients with multiple injuries, 46 patients with diffuse peritonitis, 52 patients with sepsis, and 52 patients in a control group who were at a higher risk for postoperative sepsis after defined surgical interventions. The patients underwent a daily monitoring of PLA2, CRP, and PMN elastase for seven days. RESULTS: Phospholipase A2 activity remained within the normal range in patients with multiple injuries and patients in the control group, indicating that this parameter is not influenced by the postaggression metabolism. In contrast, in patients with peritonitis, high PLA2 values were found from the beginning. The efficiency for predicting a lethal MOF was 85 percent for PLA2 (cut-off 80 U/L) in patients if determined at the day of operation. A comparably favorable efficiency (84 percent) was demonstrated for PMN elastase in patients with multiple injuries (cut-off 205 micrograms/L) measured at day one. CONCLUSIONS: These efficiency rates of PLA2 in peritonitis and PMN elastase in multiple injuries were comparable or even better than multifactorial scoring systems used in the study. C-reactive protein did not contribute to an early estimation of the prognosis in all groups analyzed. Therefore, the measurement of PLA2 in patients with diffuse peritonitis and PMN elastase in patients with multiple injuries, as single parameters, is recommended to estimate the individual risk for the occurrence of lethal MOF.
Adolescent↗
Early intubation in severely injured patients.
In a prospectively studied trauma population from 1986 to 1991 the influence of early intubation (EI) within 2 h after the accident on post-traumatic (multiple) organ failure (M)OF was compared with delayed intubation (DI) in 131 patients with multiple injuries (Injury severity score (ISS) 37). Indications for intubation were unconsciousness following severe head injury in 45 cases (45 EI, 0 DI), major chest trauma (AIS > or = 3) in 40 (31 EI, 9 DI) and the severity of injuries (no head or chest trauma, but ISS > 24) in 40 patients (30 EI, 10 DI). One hundred and six trauma victims (81%) have been intubated early and 19 patients (14.5%) required intubation and artificial ventilation later in the course, whereas 6 subjects (4.5%) could manage spontaneous breathing. The pattern of injured body regions and respiratory parameters on admission showed no remarkable difference in the two groups, but the severity of injury was significantly higher (p < 0.001) in the EI group (ISS 39) compared with the DI patients (ISS 29). Due to a significantly worse haemodynamic condition of the EI patients on admission, they showed significantly higher volume requirements throughout the resuscitation period. All patients were treated to a standard resuscitation protocol. Sixty-seven per cent of the EI patients developed at least one OF, 45% respiratory failure (RF), 28% multiple organ failure (MOF) and 15% died. The DI group showed almost the same incidence of RF (42%) and other OF (63%) and an even higher (n.s.) incidence of MOF (37%) and mortality rate (26%). Corresponding to the significantly lower injury severity of the DI group, the observed OF and mortality rates are inappropriately high in comparison with the incidence of OF and death in the EI group. We conclude that EI of multiple injured patients within 2 h after trauma along with ventilatory support--even in alert patients without major chest trauma or signs of cardiocirculatory or respiratory insufficiency, but a known or suspected ISS > 24--may help to reduce post-traumatic organ failure and improve outcome.
Adolescent↗
[Operation planning of secondary interventions after polytrauma].
A prospective study of 135 secondary operations (> 24 h after trauma) in patients with multiple injuries (ISS 40.6 pts) was performed to determine specific and unspecific indicators of the inflammatory response that may indicate the degree of risk of postoperative organ failure in these patients. On the morning of the operation each patients' data were recorded and blood samples were collected. Patients were divided in those in whom respiratory, renal and/or hepatic failure developed or preexisting organ failure worsened by more than 20% from baseline within 2 days after the operation and those who had no complications. In 29 patients who were operated upon between 24 and 72 h after trauma only the pO2/FiO2 ratio allowed discrimination between the two groups. The overall accuracy of this parameter as a predictor of postoperative organ failure was 83%, with a sensitivity of 78% and a specificity of 85%. In 106 patients with secondary operations later than 72 h after trauma, neutrophil elastase, C-reactive protein and platelet count revealed the highest predictive accuracy, with cut-off values of 250 ng/ml, 11 mg/dl and 180 x 10(6)/ml, respectively. The combined accuracy of these three parameters in prediction of postoperative organ failure was 79% (sensitivity 73%, specificity 83%). In this group of patients the pO2/FiO2 ratio was of less value and blood pressure, heart rate, renal function parameters, lactate and coagulation parameters were of no value.(ABSTRACT TRUNCATED AT 250 WORDS)
Acute-Phase Reaction↗
[Early mortality in polytrauma. A critical analysis of preventable errors].
In order to assess the impact of errors on outcome and to identify the rate of preventable deaths we investigated 40 premature deaths that had occurred among polytraumatized patients (blunt trauma; average ISS 53 points) in a prospective study (years 1986-1992) in a level I trauma centre. On analysing the patients' course on the basis of a complete set of data we detected 41 management and timing errors, 15 mistakes in treatment and 8 diagnostic problems. According to the significance of the errors the patients could be divided into three groups: in group 1 (n = 12; 30%) no errors were found, in group 2 (n = 22; 45%) there were errors but these definitely had no influence on the outcome, and in group 3 (n = 6;15%) we ascertained errors with a possible influence on the deaths. In none of the 40 cases of premature death could it be definitely shown that the adverse outcome could have been avoided. In the care of polytraumatized patients there was a clear predominance of management and timing errors insofar as they accounted for 64% of all errors that occurred and had frequently preceded possibly preventable deaths (88% in group 3). To diminish sources of error in the management of polytraumatized patients we must demand that more accurate clinical standards and algorithms be developed and introduced into the treatment of such patients.
Adolescent↗
[An algorithm for management of shock in polytrauma].
The initial management of patients with multiple trauma requires a well-defined plan of action for immediate and adequate therapy, that ensures fast recognition of life-threatening conditions and injuries. While treatment protocols for specific situations and injuries are fairly well defined, there are few such concepts for the overall management process. Therefore, we designed a comprehensive algorithm for in-hospital trauma care to give priority-based guidelines to the trauma room physician. The full management plan (diagnostic and therapeutic interventions in sequence) is implemented in seven flow charts. The first algorithm starts with the initial assessment of immediate life-threatening disorders of A (airways), B (breathing) and C (circulation) and is followed by the early stabilization and maintenance of vital functions. It is followed by six interrelated flow charts, based on disturbed physiological functions (respiration, circulation) and anatomical injuries (thorax, abdomen, head/brain, spine/pelvic girdle/extremities), which are worked up simultaneously and repeatedly. This algorithm is not only intended as an overall guideline for use the management of severely injured patients, but is also indispensable for quality assurance.
Algorithms↗
[Practical and theoretical limits of score systems].
Trauma-scoring is a measurement of injury severity. Before conclusions can be drawn from their results, their validity, reliability and practicability need to be known. With respect to these factors the following statements may be proposed: some scores do have relatively low inter-rater reliability; retrospective interpretation of findings and diagnoses in the patient records may be equivocal; parameters contributing to the score may be lacking in some records; scoring may be time-consuming; the parameters selected to make up the score may not include all the relevant ones; the influence of time is neglected; different methods of patient selection may confound the interpretation of scoring results; most scores are only evaluated with respect to mortality; the scores are interpreted exclusively on the basis of statistical probabilities. We suggest that such scores as the ISS, PTS, (R)TS, which have been fairly well studied with respect to validity, reliability, and practicability, be prepared.
Humans↗
Increased serum concentrations of procollagen type III peptide in severely injured patients: an indicator of fibrosing activity?
OBJECTIVES: To determine the serum concentrations of procollagen type III peptide in severely injured patients with different outcomes and to evaluate the relationship between serum procollagen type III peptide concentrations, sources of increased posttraumatic fibrotic activity (wounds, lung, liver, kidney), and decreased elimination of procollagen type III peptide (liver). DESIGN: Prospective study. SETTING: Surgical ICU, university hospital. PATIENTS: Fifty-seven patients (mean injury severity score: 38.5 points, range 13 to 75 points), between 16 and 70 yrs of age, treated in our institution within 6 hrs after the accident. MEASUREMENTS: Serial measurements were started on admission and continued on a 6-hr basis. After 48 hrs, the monitoring interval was extended to 24 hrs until recovery (but at least until day 14) or death. At each point of evaluation, pulmonary and circulatory function parameters and chest radiographs (once a day) were evaluated, the results were recorded, and blood samples were drawn to determine procollagen type III peptide, total bilirubin, creatinine, gamma-glutamyl transferase, polymorphonuclear elastase, and other parameters. Statistic evaluation was done with the Wilcoxon test, Spearman rank correlation, and a multiple regression model. RESULTS: Mean procollagen type III peptide serum concentrations (+/- SD) were significantly different in patients who died (8.0 +/- 3.8 U/mL) compared with those patients who survived with organ failure (2.7 +/- 1.3 U/mL) or without complications (1.4 +/- 0.5 U/mL), respectively. Significant correlations of procollagen type III peptide concentrations with the serum bilirubin concentrations (r = .7), days with need of mechanical ventilation (r = .64), PaO2/FIO2 ratio (r = -.6), polymorphonuclear elastase (r = .6), serum creatinine concentrations (r = .55), and injury severity score (r = .33) were observed. There was a tendency toward higher serum procollagen type III peptide concentrations in patients with severe skeletal injuries. CONCLUSIONS: Serum procollagen type III peptide concentrations in severely injured patients may be considerably increased in correlation with injury severity and outcome. Procollagen type III peptide serum concentrations seem to reflect the sum of increased collagen formation from wound healing and fibrogenesis of mediator-related organ damage (especially lung) and decreased procollagen type III peptide excretion due to impaired liver function. Further data are necessary to evaluate the role of hepatic elimination in these patients.
Adolescent↗
[Operative injury in spinal surgery in the management of polytrauma patients].
The release of indicators and mediators of the posttraumatic inflammatory response following spine surgery was measured in patients with multiple injuries. Eight of a group of 113 patients (mean injury severity score 36) who underwent delayed operative stabilization of vertebral fractures (> 24 h after trauma) were studied. The following significant postoperative changes of blood levels (median values, Wilcoxon signed-rank test) compared with the preoperative starting point were found: polymorphonuclear granulocyte elastase rose from 220 to 337 ng/ml, cathepsin B from 84.5 to 135.5 mU/l, C-reactive protein from 9.1 to 11.6 mg/dl, lactate from 9.6 to 15.2 mg/dl and neopterin from 6.9 to 15.2 nmol/l, while antithrombin III fell from 107.5% to 84%, platelet count from 102 to 88 x 10(9)/l and pO2/FiO2-ratio from 361 to 260. The alterations in the blood levels of these parameters following spine surgery showed a pattern similar, albeit of lesser magnitude, to that which can be observed after severe accidental trauma. We conclude that the additional activation of the inflammatory response following surgery for vertebral lesions should be taken into account when planning these operations in patients with multiple injuries.
Acute-Phase Proteins↗
[The role of an abdominal injury in follow-up of polytrauma patients].
Patients with multiple injuries were studied retrospectively (n = 483, ISS = 28 pts) and prospectively (n = 133, ISS = 42 pts) to determine the significance of concomitant intraabdominal lesions in the management and outcome of these subjects. In the retrospective part of the investigation 134 patients with intra-abdominal trauma presented with significantly more severe injuries (ISS = 38) as compared to 349 subjects with bland abdomen (ISS = 25). This resulted in a significantly different mortality rate (27 vs 11%). 119 patients with abdominal trauma were managed operatively, with surgery instituted within 4 hrs after the accident in 104 cases. Delayed abdominal surgery was performed in 18 patients due to complications from the initial laparotomy and in 15 cases because of delayed diagnosis. Delayed operations resulted in an increased rate of local complications (33 vs. 6%). In the prospective part of the study 33 out of 133 patients succumbed during resuscitation. In 14 of these, intractable bleeding from abdominal lesions was identified as the cause. In the 100 primary survivors, there was found no difference between 41 patients with and 59 patients without abdominal pathology with respect to injury severity, mortality, complications, initial hemodynamic parameters or the secondary release of inflammatory mediators. However, the initial requirement for red blood cell substitution was significantly higher in subjects with intra-abdominal trauma. Our results demonstrate that massive intra-abdominal hemorrhage may cause early mortality. In primary survivors, abdominal lesions have not shown to be of prognostic relevance, provided that early resuscitation, early diagnosis and early operative therapy can be instituted.
Abdominal Injuries↗
[Venous thrombosis following severe multiple trauma].
The incidence of thromboembolic complications in patients with multiple injuries was reviewed as well with respect to our own prospective investigation (141 patients with a mean injury severity score of 37 points). The rate of deep venous thrombosis (DVT) in severely injured patients is reported to vary from 20 to 90% if invasive diagnostic procedures are used, whereas the rate of clinically relevant manifestations of DVT seems to be much lower. Although 96% of the patient population in our study were thought to be at high risk of having DVT (applying generally accepted risk factors), only 1.4% of the subjects actually developed clinically relevant DVT. The analysis of several parameters of the coagulation and fibrinolytic systems (platelet count, prothrombin time, partial thromboplastin time, antithrombin III, prothrombin, plasminogen, tissue-plasminogen-activator and its inhibitor) showed simultaneous activation of both systems in these severely injured patients. Thus, increased coagulation seems to be counteracted by increased fibrinolysis. In addition, fluid resuscitation with crystalloid and colloid infusions in the prehospital period (1970 ml and 573 ml, respectively) can be viewed as early prophylaxis of thromboembolic complications. Thus, the low DVT rate in a high-risk patient group with multiple injuries might be at least partially explained.
Adult↗
Inflammatory mediators, infection, sepsis, and multiple organ failure after severe trauma.
The relation of (multiple) organ failure (OF) to the release of inflammatory mediators and the incidence of infection and sepsis was studied prospectively in 100 patients with multiple trauma (injury severity score = 37). Sixteen patients died of OF, 47 patients survived OF, and 37 patients had no OF. Fifteen (24%) of the patients with OF showed no signs of infection. In patients with early onset of OF (n=45), infection followed with a lag of 2 or more days. In 16 (44%) of these patients, infection led to a deterioration in organ function. With late onset of OF (n=18), infection preceded OF in nine patients. Polymorphonuclear leukocyte-elastase, neopterin, C-reactive protein, lactate, antithrombin III, and phospholipase A discriminated significantly among the three outcome groups. Of all factors, only polymorphonuclear leukocyte-elastase showed a difference between patients with and without infection or sepsis, respectively. These data indicate that infection might not play a crucial role in the pathogenesis of posttraumatic OF in a substantial portion of patients with trauma. Early OF, especially, seems to be mainly influenced by the direct sequelae of tissue damage and shock (eg, the release of inflammatory mediators). Since infection and sepsis did not lead to an augmented release of mediators in patients with trauma, the role of both entities remains unclear.
Adult↗
[Biochemical factors as objective parameters for assessing the prognosis in polytrauma].
One hundred patients with multiple injuries (mean ISS 37 patients) were prospectively evaluated over a period of 14 days following trauma. Significant differences in the blood levels of PMN elastase, cathepsin B, lactate, neopterin, C-reactive protein (CRP) and antithrombin III (ATIII) were found in non-survivors and in survivors with and without organ failure. On admission, a prediction of organ failure was possible with an accuracy of 63% to 69% (PMN elastase, cathepsin B, ATIII). Death was predictable with an 80% to 90% accuracy within the first 4 days (PMN elastase, lactate, CRP, neopterin). The prognostic value of these factors was comparable to trauma scores regarding organ failure and better with respect to death. Biochemical parameters may be helpful in estimating the severity of the injury and prognosis and in monitoring the ICU course of such patients.
Acute-Phase Proteins↗