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PubMed2002

Immunonutrition in patients after multiple trauma.

Severe trauma threatens the life of the victim, both directly and indirectly via immunological dysregulation during the subsequent clinical course. Inflammatory or infectious episodes may complicate the clinical course and ultimately result in sepsis and multiple organ failure, which have mortality rates of up to 80%. Immunomodulatory intervention aims to ameliorate the early hyperinflammatory phase (systemic inflammatory response syndrome, SIRS) to avoid the development of sepsis. One of the immunomodulation strategies is enteral feeding supplemented with specific nutrients, such as glutamine, n-3-polyunsaturated fatty acids, and nucleotides ('immunonutrition'), because changes in the GALT (gut-associated lymphoid tissue) immune response may contribute to intestinal dysfunction and increase susceptibility to post injury gut-derived sepsis. In a prospective, randomized, double-blind, controlled study in twenty-nine patients suffering severe trauma we were able to show that immunonutrition (arginine, n-3-fatty acids, and nucleotides) significantly reduces the number of SIRS days per patient, and also lowers the multiple organ failure (MOF) score on day 3 and days 8-11 (P<0.05). Other studies have reported a reduction in septic complications and MOF rates, shortened hospital stay, and reduction in the use of antibiotics in patients randomized to the immune-enhancing diet. This improved clinical outcome was reflected in a reduction in hospital costs. In the recovery period after trauma (1-72 h after injury) a limitation of the inflammatory response of immunocompetent cells must be achieved as quickly as possible (<72 h). The only strategy available to clinicians caring for trauma patients is immunonutrition, and this should be strongly considered as a rational approach improving immune function and reducing septic complications in critically ill or injured patients.

Enteral Nutrition↗
PubMed1981

Persistent vegetative state after multiple trauma. A clinicopathologic study.

The clinico-pathological findings are reported in a case with persistent vegetative state after multiple cerebral lesions. The lesions are small in size, and are situated at different levels of the CNS, some of them being important in the maintenance of wakefulness and motor initiative. The differential diagnosis and the isolation of such a syndrome are discussed.

Adult↗
PubMed2004

[Evaluation of costs incurred for patients with multiple trauma particularly from the perspective of the hospital].

The aim of this study was to evaluate the costs involved in treating severely injured patients at the clinic differentiated by several characteristics (injury, age), sectors (emergency room, surgery, intensive and normal care), and kinds of costs (fixed costs, variable costs) and to determine influencing factors regarding costs based on the register of the DGU (Deutsche Gesellschaft für Unfallchirurgie). All patients were taken into account who had an injury severity score (ISS) of at least 16. On this basis costs of 3702 patients were analyzed. They were compared by using analysis of variance for different groups of patients classified according to kind of injury, severity of injury, and age. Moreover, multiple regression was performed to control the common influence of demographic factors and the type of injury on costs. The average ISS of the analyzed patients was 30.6 (+/-11.6) points. The average costs of the clinic were 32,166 (+/-25,404) EUR per patient. More than half of the costs was incurred by intensive care and about one-fourth by surgery. On average 30.6% were variable costs and 69.4% were fixed costs. The analysis of variance revealed that costs increased with advancing age and severity of injury (ISS). Multiple regression confirmed these interrelations indicating that extremities are very cost intensive. Due to the high portion of fixed costs, the overall costs strongly depend on the capacity utilization and less on hospital stay. That is why it may be necessary in the future to create centers for trauma care to maintain economic efficiency for treatment of these patients. Besides large differences of costs within closely defined groups of patients, hospitals carry a high economic risk so that a more complex reimbursement system should be discussed than implemented by the German DRGs.

Adult↗
PubMed1999

[Effects of injury pattern on the predictability of 4 multiple trauma scores. Presentation of a method for identifying artifacts].

When comparing two populations of multiply injured patients differences in patient characteristics must be controlled for. To measure the overall severity of injury, scaling systems are used. If after adjustment for injury severity, the proportion of deaths in the two data sets are still different, the difference is to be considered as due to the quality of care. However, this conclusion is only valid after excluding the possibility that the scale in use fails to adequately reflect certain injuries. The scope of the study is to demonstrate a method for examining this potential interference. As an example, four widely used scales were applied to the data of 418 multiply injured patients. By means of multiple logistic regression analysis, variables were selected which have an influence on prognosis in addition to a scale, thus indicating a subgroup of patients who are underrepresented by the respective scoring system. For the scales examined, these additional variables were: Head and thoracic trauma for the Polytrauma score (Oestern), abdominal and thoracic trauma for the Trauma index (Schreinlechner), thoracic trauma and age for the Trauma score (Champion), head trauma and age for the Injury Severity Score (Baker). We conclude that each score analyzed had its characteristic weak points. Prognostic quality was affected by casemix. Therefore, comparisons between groups of polytraumatized patients may be invalidated. The method outlined here is a useful means for checking a scoring system for these types of interfering variables. Therefore, it is recommended to search routinely for potentially interfering variables before applying a scale. In a given data set of multiply injured patients, appropriate adjustments can then be made for the deficiencies of the scoring system.

Adult↗
PubMed1997

Selective intestinal decontamination in multiple trauma patients: prospective, controlled trial.

BACKGROUND: Reduction of potential pathogens by selective intestinal decontamination has been proposed to improve intensive care. Despite large scientific interest in this method, little is known about its benefit in homogeneous trauma populations. METHODS: In a prospective, controlled study, we enrolled non-infected trauma patients (age over 18 years, mechanical ventilation > or = 48 hours, intensive care for more than 3 days) who primarily were admitted to our university medical center. We randomized patients to be treated with two different topical regimens (polymyxin, tobramycin, and amphotericin (PTA) or polymyxin, ciprofloxin, amphotericin (PCA)) or the carrier only (placebo), administered four times daily both to the oropharynx and to the gastrointestinal tract. All patients received intravenous ciprofloxacin (200 mg, bd) for 4 days. FINDINGS: Of 357 enrolled patients, 310 (age 38.0 +/- 16.5 years, Injury Severity Score 35.2 +/- 12.7) met all inclusion criteria. Selective decontamination successfully reduced intestinal bacterial colonization. However, we did not identify significant differences between groups regarding pneumonia (PTA 47.5%, PCA 39.0%, placebo 45.3%), sepsis (PTA 47.5%, PCA 37.8%, placebo 42.6%), multiple organ failure (PTA 56.3%; PCA 52.4%, placebo 58.1%), and death (PTA 11.3%, PCA 12.2%, placebo 10.8%). Total costs per patient were highest with the PTA regimen. CONCLUSIONS: We found no benefit of selective decontamination in trauma patients. Apparently, bacterial overgrowth in the intestinal tract is not the sole link between trauma, sepsis, and organ failure.

Adult↗
PubMed1986

Comparisons between CK-B and other clinical indicators of cardiac contusion following multiple trauma.

The activity of creatine kinase (CK) and creatine kinase B(CK-B) was measured in 17 patients with injuries to multiple organ systems, including the chest. The patients were closely observed for clinical signs of disturbed cardiac function by means of serial ECG, continuous monitoring of cardiac rhythm, daily cardiac auscultation, serial chest roentgenography and monitoring of central hemodynamic parameters. No statistically significant difference in CK and CK-B activity was found between the group of patients with normal cardiac function and the group with disturbed cardiac function. The CK-B activity was markedly elevated, but CK-B activity relative to CK activity was normal in both groups during the first 7 days after the trauma. The authors conclude that the significance of these enzymes' serum activity, measured with the immunoinhibition method, is diagnostically doubtful not only as regards cardiac contusions, but also in other cardiopathy preceding or following major trauma.

Abdominal Injuries↗
PubMed1983

Head injury in multiple trauma.

Head injury is a major contemporary health problem. Obviously, the best solution is the avoidance and prevention of accidents. The physician who treats patients with multiple injuries must be prepared to make an intelligent assessment of the neurologic injuries, to undertake the initial resuscitation and, when necessary, to do the definitive surgery.

Accidents↗
PubMed1984

Visual abnormalities with multiple trauma.

The diversity of pathogenetic mechanisms involved in posttraumatic visual impairment was reviewed in a study of the hospital records of 24 patients admitted with multiple injuries. Most major visual abnormalities occurred in young people (average age 33 years) who presented with a wide range of overall severity of injury (injury severity score 13-47) and involvement of the central nervous system (Glasgow coma scale 5-15). Bilateral or monocular blindness developed in 63% of patients. Seventy percent of the injuries involved the anterior visual pathways with damage to the optic nerve alone accounting for 35%. Fractures of the sphenoid bone, particularly of the body, accompanied optic nerve and chiasmal injuries and some cases of traumatic carotid-cavernous fistulas. Pathogenetic mechanisms varied according to the site of injury and included vitreous hemorrhage and optic atrophy secondary to raised intracranial pressure, retinal hypoxia from carotid-cavernous fistulas, shearing and compression injuries of the optic nerve, traumatic chiasmal syndrome, temporoparietal and occipital contusions, and transtentorial herniation with occipital infarction. Visual abnormalities varied in severity from moderately reduced visual acuity and diverse hemianopias and scotomas to blindness. The incidence of posttraumatic residual visual abnormalities is likely to increase in the wake of improved acute care of the traumatized victim.

Adolescent↗
PubMedDate not supplied

The multiple trauma victim: a nutritional cripple.

Major trauma often precipitates major malnutrition. In many patients, this malnutrition underlies the morbidity and mortality associated with major injury, often leading to multiple organ failure and refractory sepsis. The clinical challenge is to anticipate these potential nutritional problems and intervene early and appropriately, recognizing that it is far easier to prevent malnutrition than it is to reverse it.

Humans↗
PubMed1986

Multiple trauma associated with vertebral injury.

Three hundred twenty-two vertebral fractures in multiply injured patients are reviewed. Associated general trauma was usually found to be regionalized to the same area of the body as the spinal injury. The exceptions were pelvic and sacral fractures, which were associated with more diffuse organ injury and multiple vertebral fractures.

Adolescent↗
PubMed1984

Mortality amongst multiple trauma patients admitted to an intensive therapy unit.

A retrospective review of 428 severely injured patients admitted to an intensive therapy unit between 1969 and 1982 was performed. The patients' primary injuries were assessed using the injury severity score (ISS), and subsequent complications using the complications impact index and sepsis score. Between 1969 and 1980 mortality fluctuated between 19% and 29% but rose to 47% (p less than 0.05) during 1981-82 in spite of an unchanged ISS. The increased mortality was confined to ventilated patients surviving more than 5 days from injury and was associated with multiple organ failure and severe infection. The rapid and sustained increase in mortality could not be explained by any obvious change in severity of injury or referral pattern. The only deliberate change in management related to the combination of analgesic/sedative drugs used in ventilated patients. During 1979 to 1982 mortality was 28% in patients given morphine with or without benzodiazepines and 77% in those given morphine and etomidate (p less than 0.0005). After discontinuation of the latter regimen (May 1983) and resumption of the former analgesic/sedative combination, mortality fell to 25% (p less than 0.005). Possible mechanisms leading to increased mortality include adrenocortical insufficiency or depth of anaesthesia.

Adolescent↗
PubMed1979

Cardiopulmonary parameters and prognosis after severe multiple trauma.

Comprehensive cardiopulmonary and metabolic monitoring of severely traumatized patients for 7 days from the time of injury has allowed us to determine parematers which correlate with survival and nonsurvival. The earliest and most persistent change is an increased pulmonary vascular resistance which results in right heart overload and failure. Left heart "failure" which has been previously described with acute respiratory failure and shock is shown to be a mathematical artifact caused by dilatation of the right heart and encroachment on left ventricular filling volume. Causes of death in most patients were not directly referable to right heart dysfunction but we postulate that hypercoagulability and microembolism could independently produce the observed pulmonary vascular changes as well as the multiple organ failure which usually was responsible for death. Resolution of this question will require more sophisticated hematologic evaluation.

Adolescent↗
PubMedDate not supplied

Investigation of neutrophil--endothelial cell interaction in multiple trauma by chemiluminescence.

The trauma-induced activation of neutrophils and their functional alterations, i.e., increase in adherence and release of oxygen derived metabolites, is considered to play a central role in the initiation and amplification of capillary endothelial cell damage and following organ failure. In the present study neutrophil-endothelial cell interaction was studied using an in vitro model of human umbilical cord vein endothelial cells and human neutrophils. Production of oxygen-derived metabolites was determined by comparing mean peak chemiluminescence of neutrophils from multiply traumatized patients (n = 40) and mean peak chemiluminescence of neutrophils from blood donors (n = 160). Adherence and endothelial injury by neutrophils of multiply traumatized patients were compared with data of healthy blood donors. Chemiluminescence response of 70,000 neutrophils isolated from healthy control individuals was 699 +/- 98 x 10(3) cpm and could be increased significantly by endothelial cells to 1410 +/- 135 x 10(3) cpm (p < 0.05). Chemiluminescence response to neutrophils of polytraumatized patients was 1174 +/- 94 x 10(3) cpm and could not be significantly increased by endothelial cells (1419 +/- 120 x 10(3) cpm). Adherence of neutrophils of blood donors to endothelial cells was 12.31 +/- 0.77%. Adherence of neutrophils of polytraumatized patients was significantly increased to values of 24.83 +/- 2.03%. Injury of endothelial cells was not detectable with neutrophils from blood donors (1.11 +/- 1.09% 111in-release). Significantly increased 111in-release was apparent upon incubation with neutrophils of polytraumatized patients (5.76 +/- 1.28%). The data shows evidence of in vivo preactivation of neutrophils of polytraumatized patients, and supports the hypothesis that endothelial cells play an active role in neutrophil-endothelial cell interactions by modulating production of oxygen-derived metabolites.

Abdominal Injuries↗
PubMed1985

Polyvalent immunoglobulins for prophylaxis of bacterial infections in patients following multiple trauma. A randomized, placebo-controlled study.

One hundred and fifty severely injured patients requiring long-term artificial ventilation were evaluated in a prospective, randomized, double blind study comparing the prophylactic effect of an intravenous immunoglobulin (Sandoglobulin; IGIV) against nosocomial infections with a placebo preparation. The groups were comparable in age, sex, injury pattern, and severity of the trauma. Seventy-six patients received 12 g of Sandoglobulin as a 3% solution on day 0, day 5 and day 12, i.e. a total of 36 g. Sandoglobulin significantly reduced the incidence of pneumonia (28 cases in the IGIV group, 43 cases in the placebo group, p = 0.0111). This resulted in a reduced therapeutic use of antibiotics. For the occurrence of sepsis (IGIV: 14 cases; placebo 19 cases) and other infections (IGIV: 11 cases; placebo: 10 cases) no significant differences were found. No side effects of the administration of IGIV were observed. IGIV prophylaxis neither reduced the overall death rate nor those deaths caused by infection. On day 5 after administration of the first 12 g of IGIV, the IgG serum concentrations were significantly higher in the Sandoglobulin group (8.41 +/- 1.96 mg/ml and 7.42 +/- 2.25 mg/ml respectively, p less than 0.001) whereas later serum samples showed no significant differences.

Adolescent↗