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At least 811 records · Page 45Linked to original sources
PubMed2006

Variable costs of ICU patients: a multicenter prospective study.

OBJECTIVE: To analyze the costs of treating critically ill patients. DESIGN AND SETTING: Multicenter, observational, prospective, cohort, bottom-up study on variable costs in 51 ICUs. PATIENTS AND PARTICIPANTS: A total of 1,034 patients aged over 14 years who either spent less than 48 h in the ICU or had multiple trauma, major abdominal surgery, ischemic stroke, chronic obstructive pulmonary disease, cardiac failure, isolated head injury, acute lung injury/adult respiratory distress syndrome (ALI/ARDS), nontraumatic intracranial hemorrhage or coronary surgery. INTERVENTIONS: Data recorded for each patient: length of ICU stay, and cost in euros of all diagnostic and therapeutic procedures, drugs and equipment used, and consultations by physicians from other units. To express cost-efficiency we calculated for each diagnostic group the cost per surviving patient (expenditure for all patients/number of surviving patients) and money loss per patient (expenditure for patients who died/total number of patients). MEASUREMENTS AND RESULTS: Median costs for a multiple trauma patient were euro 4076 and for coronary surgery patient euro 380. The variability is largely due to different lengths of ICU stay. Cost per surviving patient was higher for ALI/ARDS, nontraumatic intracranial hemorrhage, multiple trauma, and emergency abdominal surgery. Money loss per patient was higher for ALI/ARDS and lower for multiple trauma. Planned coronary and major abdominal surgery and short-stay patients were treated most cost-efficiently. CONCLUSIONS: Cost of treatment in an ICU varies widely for different types of patients. Strategies are needed to contain the major determinants of high costs and low cost-efficiency.

Adolescent↗
PubMed1997

[Intramedullary nailing in polytrauma. Pro and contra early management].

The progress after multiple trauma is influenced by the extent of the initial injury and the resulting inflammatory response as well as by the severity of the thoracic trauma. Primary stabilisation of the femoral fracture is compulsory to ensure adequate intensive and respiratory care, e.g. changing between a supine and prone position. Intramedullary nailing in multiple trauma patients is still controversial. Because of retrospective studies concerning the time of operation in patients with multiple trauma of minor severity, primary intramedullary nailing is the method of choice in the Anglo-American section. In German-speaking areas, however, differentiated management has been established because of knowledge of the shock pathogenesis. Intramedullary nailing leads to an additive trauma in the sense of traumatic haemorrhagic shock. This is due to local pulmonary embolisation and systemic inflammatory reactions. Therefore, in severe injuries (ISS > 29 points) and/or severe thoracic trauma (AIS > 3), primary stabilisation by external fixation should be preferred, whereas intramedullary nailing, especially the less risk unreamed nailing, is to be recommended in patients with minor injuries. Definite fracture healing should be achieved by a change to intramedullary nailing in a secondary operation.

Cause of Death↗
PubMed1993

[Rehabilitation and reintegration of polytraumatized patients].

In this randomized study we attempt to verify treatment results, rehabilitation and social reintegration of multiple trauma patients. Two to 4 years after the accident a clinical follow-up examination was carried out on 104 multiple trauma patients with an average age of 29.5 years who had 7.7 single injuries. Patients with injuries of the central nervous system still showed neurological disorders in 32%. The initially determined Glasgow Coma Scale did not correlate with the long-term prognosis of neurological disorders. Only 4 of 38 thoracic injuries had functional disorders-these patients had required long-term ventilation therapy (> 3 weeks). Former abdominal injuries showed no objective disorders in the follow-up. Most of the injuries to the extremities (79.7%) healed without functional disorder. Only patients with lower limb injuries still had complaints. At the time of the checkup 6.7% had still not been able to work (for more than 24 months) and 26.9% for more than 12 months. The disability rate was less than 20% in 64.3%, 7.2% more than 50% and 9.6% more than 80%. Most of these patients had severe head injuries. There was a relationship between reintegration at work and the age of the patients: 49.2% of patients younger than 25 years were working in their previous profession, 26.9% had here re-educated, and only 7.9% were unemployed. However, in the age group older than 25 years, only 29.2% worked in their previous profession and 12.2% had been re-educated. This follow-up study shows that in multiple trauma patients reintegration at work and in social life is possible.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1998

Decreased soluble adhesion molecule L-selectin plasma concentrations after major trauma.

BACKGROUND: Binding of the leukocyte glycoprotein L-selectin to ligands expressed by activated endothelium directs leukocyte recruitment to areas of acute inflammation. Sequestration by activated microvascular endothelium has been proposed to explain the low plasma concentrations of soluble L-selectin (sCD62L) observed early in patients with acute respiratory distress syndrome. We hypothesized that inflammatory endothelial activation may occur in trauma patients, leading to decreased sCD62L plasma concentrations. METHODS: This study was a prospective analysis of sCD62L plasma concentrations in patients with isolated head injuries and multiple trauma patients without head injuries admitted to two tertiary-level intensive care units. sCD62L plasma concentrations were determined in 18 consecutive adult patients with isolated moderate and severe head injuries and in 13 multiple trauma patients without head injuries immediately upon admission to the intensive care unit and then daily for up to 10 days after trauma. RESULTS: Compared with healthy adult controls (n=22), patient sCD62L plasma concentrations were significantly decreased upon admission (5.7+/-1.6 vs. 11.0+/-1.7 pmol/mL; p < 0.001). In all patients, sCD62L concentrations remained depressed throughout the study period. sCD62L concentrations did not differ significantly between patients with isolated head injuries and multiple trauma patients without head injuries, although repeated-measures analysis of variance showed significantly more depressed sCD62L concentrations associated with severe (n=14) compared with moderate head injuries (n=4) during the study period (p < 0.05). CONCLUSION: Patients with major trauma present with a significant reduction of sCD62L plasma concentrations within the first 12 hours after trauma and during subsequent intensive care. This finding suggests widespread microvascular endothelial activation after trauma, which may be associated with increased neutrophil extravasation.

Adolescent↗
PubMed1997

Patterns of cytokine evolution (tumor necrosis factor-alpha and interleukin-6) after septic shock, hemorrhagic shock, and severe trauma.

OBJECTIVE: To compare the patterns of evolution of two proinflammatory cytokines (tumor necrosis factor [TNF]-alpha and interleukin-6 [IL-6]) in two major clinical entities associated with systemic inflammatory response: septic shock and multiple trauma (with and without hemorrhagic shock). DESIGN: Prospective study of two cohorts of patients. SETTING: Critical care unit and Emergency Center of a university hospital. PATIENTS: Twenty-five nontrauma patients with septic shock and 60 multiple trauma patients (of whom eight patients were resuscitated from hemorrhagic shock). INTERVENTIONS: Serial blood samples were collected in each patient for determination of serum cytokine concentrations. Samples were obtained over 7 days in septic shock patients and 11 days in trauma patients. Standard resuscitation techniques were used in each patient. Clinical and laboratory data were prospectively collected. MEASUREMENTS AND MAIN RESULTS: High concentrations of circulating TNF-alpha and IL-6 were found in patients with septic shock. High IL-6 concentrations, but normal TNF-alpha concentrations were detected in trauma patients. At study entry, TNF-alpha concentrations were higher in nonsurvivor septic shock than in nonsurvivor trauma patients (42 +/- 7 vs 13 +/- 2 pg/mL; p < .001). During the whole study period, nonsurvivor septic shock patients maintained higher TNF-alpha concentrations than nonsurvivor trauma patients (p < .001). In survivors in both groups, normal values for TNF-alpha were detected during the whole study period. At study entry, IL-6 concentrations were significantly higher in nonsurvivor septic shock patients than in nonsurvivor trauma patients (15,627 +/- 4336 vs. 317 +/- 124 pg/mL; p < .0001). During the whole study period, much higher concentrations of IL-6 were detected in septic shock patients than in trauma patients (p < .0001). In survivors, at study entry, IL-6 concentrations were much higher in septic shock patients than in trauma patients (3947 +/- 1410 vs. 247 +/- 41 pg/mL; p < .001). Higher IL-6 concentrations were maintained throughout the study period in septic shock patients than in trauma patients (p < .001). In septic shock patients, changes in both TNF-alpha and IL-6 were correlated with outcome, higher values being found in patients likely to die. Neither TNF-alpha nor IL-6 values were of any significant value in predicting outcome of trauma patients. When septic shock patients were compared with traumatized patients resuscitated from hemorrhagic shock, the former had much higher concentrations of both TNF-alpha and IL-6 throughout the study period (p < .01 to p < .00001). Increased IL-6 values were an indicator of the development of a nosocomial infection in trauma patients. In five trauma patients who developed a nosocomial pneumonia during the study period, the IL-6 concentration was 433 +/- 385 pg/mL before the onset of pneumonia, then peaked at 3970 +/- 1478 pg/mL on day 7, and returned to baseline (219 +/- 58 pg/mL) on day 11. CONCLUSIONS: In septic shock patients, high amounts of circulating TNF-alpha and IL-6 are found and then correlate with fatal outcome. In trauma patients (even those patients resuscitated from hemorrhagic shock), much less increased concentrations of IL-6 are detected while normal TNF-alpha circulating concentrations are measured. In these patients, cytokine concentrations do not correlate with outcome. This finding suggests a much higher degree of activation of the immunoinflammatory cascade in septic shock than in multiple trauma patients. Increased IL-6 values are an indicator of the development of a nosocomial infection in trauma patients.

Adult↗
PubMed2001

Prophylactic hemofiltration in severely traumatized patients: effects on post-traumatic organ dysfunction syndrome.

OBJECTIVE: To evaluate the effects of prophylactic veno-venous hemofiltration (CVVH) in the absence of renal failure on multiple organ dysfunction syndrome after severe multiple trauma. DESIGN: Prospective, randomized study. SETTING: Intensive care unit (ICU) in a university hospital. PATIENTS: Twenty-four patients with severe multiple trauma (injury severity score > or = 27), no renal failure on admission and no contraindication for moderate heparinization. INTERVENTIONS: Twelve patients received conventional treatment while 12 patients were treated additionally with isovolemic CVVH for 5 days starting within 24 h following trauma. Signs of organ dysfunction were assessed daily including monitoring of systemic hemodynamic by means of pulmonary artery catheterization during the first 5 days after trauma. MEASUREMENTS AND MAIN RESULTS: Prophylactic CVVH did not affect the overall severity of organ dysfunction as assessed by MOF or APACHE II scores. However, the pattern of impaired organ systems was influenced by CVVH: while the post-traumatic decrease in platelet count in patients subjected to CVVH was more pronounced than in controls (e.g. day 4: control: 115,080 +/- 15,087, CVVH: 57,383 +/- 4,201 microliters-1; p < 0.05) the development of hyperdynamic circulatory failure was simultaneously attenuated, as reflected by a limited increased in cardiac output and an attenuated decrease in systemic vascular resistance and oxygen extraction ratio (e.g. systemic vascular resistance on day 4: control: 624.3 +/- 46.17, CVVH: 842.7 +/- 79.24 dyn.s.cm-5; p < 0.005). CONCLUSION: CVVH blunts the cardiovascular response to multiple trauma and increases tissue oxygen extraction. However, the concomitant decrease in platelet counts represents a limitation for the use of prophylactic CVVH in surgical patients.

Female↗
PubMed2001

Outcome of foot injuries in multiply injured patients.

In the past, foot injuries in patients with multiple trauma were thought to be of lesser importance than fractures of long bones. In one prospective study from the authors' institutions, however, multiple-trauma patients with foot injuries were shown to have a poorer functional outcome compared with matched controls. To address these concerns, this article has two parts. The first part is an overview of general principles in the treatment of foot injuries in polytrauma patients. The treatment of specific injuries is beyond the scope of this article, but an approach is highlighted that can be remembered when decisions are made regarding these severely injured patients. The second part reviews the findings from the authors' study, focusing on functional outcomes of multiple-trauma patients with foot injuries.

Calcaneus↗
PubMed2002

[Vascular complications after cranio-facial trauma].

Despite recent advances in automobile safety, facial trauma remains a common event. Cranio-facial trauma, which usually occurs within a context of multiple trauma, can, in some patients, lead to serious life-threatening vascular complications. Such injury usually involves the carotid system (hemorrhage, aneurysm, dissection). Management of these vascular injuries must be given the same priority as other multiple trauma injuries. We present few typical cases illustrating carotid-cavernous or vertebro-vertebral fistulae, false aneurysms, arterial dissections or oro-facial bleeding. Bleeding is generally controlled by ligation or compression, other lesions being diagnosed secondarily by arteriography depending on the particular clinical situation. Treatment may involve endovascular procedures to achieve intravascular embolism or vascular occlusion.

Accidents, Traffic↗
PubMed2005

Nonspecific increase of systemic neuron-specific enolase after trauma: clinical and experimental findings.

The aim of this clinical and experimental study was to determine whether systemic neuron-specific enolase (NSE) is a useful early marker of traumatic brain injury (TBI) and whether NSE is affected by ischemia/reperfusion damage of abdominal organs. Our study included patients with and without TBI (verified by computerized tomography) admitted within 6 h after trauma and male Sprague-Dawley rats with ischemia and reperfusion of the abdominal organs liver, gut, or kidney. Thirty-eight study patients included 13 with isolated TBI and 18 patients with multiple trauma and TBI. Seven patients had multiple trauma but no TBI. Fifteen rats were anaesthetized and subjected to isolated ischemia of the liver, gut, or kidney (n = 5 each) for 1 h, followed by reperfusion for 3 h. In patients, NSE increased over 2-fold versus the upper normal limit (10 microg/L) within 6 h after trauma, regardless of whether TBI had occurred or not. In rats, NSE increased over 3-fold versus laboratory controls during ischemia of the liver and kidney (both P < 0.0005), but not of the gut. NSE increased over 2-fold after onset of reperfusion of the liver and kidney (both P < 0.05), but not of the gut and increased over 3-fold after 3 h of reperfusion of the liver, gut (both P < 0.005), and kidney (P < 0.0005). Our data show that systemic NSE increases to similar degrees with and without TBI. Therefore, NSE is not a useful early marker of TBI in multiple trauma.

Adult↗
PubMed2000

[Determinants of the global quality of life after polytrauma].

This study investigated multiple trauma patients, who were injured between 1991 and 1995 and treated in our department. The aim of this study was to identify the determinants of quality of life after multiple trauma. From a total of 186 patients 173 (93%) were examined. The patients were asked to rate their quality of life according to the Nottingham Health Profile (NHP) and to a visual analogue scale (VAS). The VAS and the NHP isolated the age of the patients, the duration of artificial respiration, and the duration of rehabilitation as the predictors for a reduced overall quality of life. These results show that quality of life after multiple trauma not only depends on the severity of injury but also on demographic and psychosocial factors.

Adolescent↗
PubMed2005

Relationship of taurine and other amino acids in plasma and in neutrophils of septic trauma patients.

Recently, an interdependency of plasma taurine and other amino acids as well as metabolic and clinical variables implicating therapeutic options was reported. This result may be an indication that plasma taurine levels are directly related to intracellular levels. Therefore, the aim of this study was to analyse the possible relationship between taurine levels in plasma and in neutrophils, the relationship to other amino acids, and variables quantifying metabolic impairment and severity of sepsis in multiple trauma patients developing sepsis. After multiple trauma taurine decreased significantly in plasma in thirty-two patients as well as within the neutrophil and does not recover in sepsis. Lower individual levels in the neutrophil did not follow lower individual levels in plasma and no correlation of taurine in plasma and in the neutrophils could be observed. In sepsis, only plasma showed an interdependency of taurine, aspartate, and glutamate. No association between taurine plasma or intracellular levels and SOFA score as indicator for severity of sepsis or metabolic variables was observed. After multiple trauma and in sepsis, taurine uptake in cells (which is regulated in different ways), and intracellular taurine (which serves e.g. as an osmolyte) can be influenced. Therefore a prediction of the neutrophil taurine pool seems not fully possible from taurine plasma levels. Intracellular taurine has some unique properties explaining the missing interdependency despite some similarities in osmoregulation and metabolic interactions to other amino acids. The association of taurine, aspartate, and glutamate in plasma cannot be simply transferred to the neutrophils intracellular level. The clinical meaning of the plasma correlation remains unclear. A dependency of plasma and neutrophil taurine to severity of sepsis and to metabolic variables seems not possible because of the multifactorial pathophysiology of sepsis.

Adult↗
PubMed2000

Practice Management Guidelines for Prophylactic Antibiotic Use in Tube Thoracostomy for Traumatic Hemopneumothorax: the EAST Practice Management Guidelines Work Group. Eastern Association for Trauma.

Multiple factors contribute to the development of posttraumatic empyema. These factors include the conditions under which the tube is inserted (emergent or urgent), the mechanism of injury, retained hemothorax, and ventilator care. The incidence of empyema in placebo groups ranges between 0 and 18%. The administration of antibiotics for longer than 24 hours did not seem to significantly reduce this risk compared with a shorter duration, although the numbers in each series were small. Most reports found a significant reduction in pneumonitis when patients received prolonged prophylactic antibiotics. This use of antibiotics might possibly be better described as presumptive therapy rather than prophylactic.

Antibiotic Prophylaxis↗
PubMed2003

[The long-term course of psychological trauma: a multiplicity of outcomes].

The evolving severity of psychical trauma is measured on a scale of many years. It is assessed in relation to the upheaval that the traumatic event introduces in the life of a subject: in terms of the prior organization of his psychical life as in the relationships that he maintains with his social circle.

Comorbidity↗
PubMed1993

Cytokine patterns in patients after major vascular surgery, hemorrhagic shock, and severe blunt trauma. Relation with subsequent adult respiratory distress syndrome and multiple organ failure.

OBJECTIVE: This study investigates the course of serum cytokine levels in patients with multiple trauma, patients with a ruptured abdominal aortic aneurysm (AAA), and patients undergoing elective AAA repair and the relationship of these cytokines to the development of adult respiratory distress syndrome (ARDS) and multiple organ failure (MOF). SUMMARY BACKGROUND DATA: Severe tissue trauma, hemorrhagic shock, and ischemia-reperfusion injury are pathophysiologic mechanisms that may result in an excessive uncontrolled activation of inflammatory cells and mediators. This inflammatory response is thought to play a key role in the development of (remote) cell and organ dysfunction, which is the basis of ARDS and MOF. METHODS: The study concerns 28 patients with multiple trauma, 20 patients admitted in shock because of a ruptured AAA, and 18 patients undergoing elective AAA repair. Arterial blood was serially sampled from admission (or at the start of elective operation) to day 13 in the intensive care unit, and the serum concentrations of tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-1 beta, and IL-6 were determined. RESULTS: Twenty-two patients died, 15 within 48 hours and 7 after several weeks, as a result of ARDS/MOF. At hospital admission and after 6 hours, these nonsurvivors had significantly higher plasma TNF-alpha and IL-1 beta levels than did the survivors. At the same measuring points, TNF-alpha and IL-1 beta were significantly more elevated in patients with ruptured AAA than in traumatized patients. However, IL-6 was significantly higher in the traumatized patients. In 10 patients, ARDS/MOF developed, and 41 had an uncomplicated course in this respect. Those with ARDS/MOF exhibited significantly different cytokine patterns in the early postinjury phase. TNF-alpha and IL-1 beta levels were higher mainly on the first day of admission; IL-6 concentrations were significantly elevated in patients with ARDS/MOF from the second day onward. The latter cytokine showed a good correlation with the daily MOF score during the whole 2-week observation period. CONCLUSIONS: In the early postinjury phase, higher concentrations of these cytokines are associated, not only with an increased mortality rate, but also with an increased risk for subsequent ARDS and MOF. These data therefore support the concept that these syndromes are caused by an overwhelming autodestructive inflammatory response.

Aged↗
PubMed2001

Gaze dwell times on acute trauma injuries missed because of satisfaction of search.

RATIONALE AND OBJECTIVES: The authors performed this study to determine whether satisfaction of search (SOS) errors in patients with multiple traumas are caused by faulty visual scanning, faulty recognition, or faulty decision making. MATERIALS AND METHODS: A series of radiographs were obtained in patients with multiple traumas. Radiologists interpreted each series under two experimental conditions: when the first radiograph in the series included a fracture, and when it did not. In the first experiment, the initial radiographs showed nondisplaced fractures of the extremities (minor fractures); in the second experiment, the initial radiographs showed abnormalities of greater clinical importance (major fractures). Each series also included a radiograph with a subtle (test) fracture and a normal radiograph on which detection accuracy was measured. In each experiment, gaze dwell time was recorded as 10 radiologists reviewed images from 10 simulated cases of multiple trauma. RESULTS: An SOS effect could be demonstrated only in the second experiment. Analysis of dwell times showed that search on subsequent radiographs was shortened when the initial radiograph contained a fracture; however, the errors were not based on faulty scanning. CONCLUSION: The SOS effect in musculoskeletal trauma is not caused by faulty scanning. Demonstration of an SOS effect on test fractures with major but not minor additional fractures suggests that detection of other fractures is inversely related to the severity of the detected fracture.

Fractures, Bone↗
PubMed2002

Early intensive care unit intervention for trauma care: what alters the outcome?

This review focuses on early management of multiple trauma patients with traumatic brain injury. Early usage of multislice computed tomography can substantially shorten the time spent on diagnostic workup in the emergency room and, therefore, speeds the initiation of lifesaving interventions for the control of hemorrhage. The important role of hemostatic angiographic embolization and its timing, in addition to surgical control of bleeding in patients suffering from pelvic fracture or organ lesions, is emphasized. The ongoing controversy regarding the strategy of fluid resuscitation is discussed. The concept of permissive hypotension seems to be promising but is absolutely contraindicated in patients with traumatic brain injury. Coagulation management should be guided by coagulation monitoring, including thromboelastography. A novel approach to reduce major bleeding is the application of recombinant factor VIIa. Strong effort should be directed toward the management of traumatic brain injury and the maintenance of cerebral perfusion pressure. The optimization of treatment of patients with multiple trauma, including brain injury, is a multidisciplinary task.

Algorithms↗