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PubMed2005

Plasminogen activator inhibitor type 1 gene polymorphism and sepsis.

Plasminogen activator inhibitor type 1 (PAI-1) is a 50-kilodalton glycoprotein of the serine protease inhibitor family. The primary role of PAI-1 in vivo is the inhibition of both tissue- and urokinase-type plasminogen activators. In addition to this function, PAI-1 acts as an acute-phase protein during acute inflammation. PAI-1 is a pivotal player in the pathogenesis of sepsis, a complex clinical syndrome that results from a systemic inflammatory response. In patients with sepsis, the levels of PAI-1 are positively related to poor outcome, increased severity of disease, and increased levels of various cytokines, acute-phase proteins, and coagulation parameters. The 4G/5G insertion/deletion promoter polymorphism, which leads to differences in PAI-1 production, has been demonstrated to affect the risk of developing severe complications and dying from sepsis during meningococcal infection and multiple trauma.

Clinical Trials as Topic↗
PubMed2005

Underlying disorders and their impact on the host response to infection.

Underlying disorders, especially those that chronically impair immune host response (e.g., cancers and hematologic malignancies) but also those that acutely impair this response (e.g., major surgery and multiple trauma), increase the incidence of infection and alter the outcome of patients with sepsis. As a part of innate immunity, inflammatory and coagulation responses are lower in patients with underlying disorders than in patients without such disorders, whereas the need for vasopressors and mechanical ventilation is more frequent. Although these patients are older, age-related defects do not appear to be responsible for this lower response, because innate immunity is usually up-regulated in the elderly. Innate immunity seems to be negligibly affected by the direct consequences of underlying disorders, but underlying disorder-related chronic organ insufficiency certainly participates in the observed organ dysfunction, overestimating the infectious insult by itself. Although innate immunity seems not to be actually blunted in patients with underlying disorders, the underlying disorder itself contributes to the severity of the physiological response to sepsis, thereby resulting in a worse outcome.

Aging↗
PubMed2004

GFAP versus S100B in serum after traumatic brain injury: relationship to brain damage and outcome.

Research indicates that glial fibrillary acidic protein (GFAP), part of the astroglial skeleton, could be a marker of traumatic brain injury (TBI). S100B, an astroglial protein, is an acknowledged marker of TBI. Our goal was to analyze the relationship of GFAP/S100B to brain damage and outcome, and to compare the accuracy of GFAP/S100B for prediction of mortality after TBI. Our prospective study included 92 patients admitted <12 h after TBI (median injury severity score 25, median Glasgow Coma Scale 6). TBI was verfied by computerized tomography. GFAP/S100B were measured immunoluminometrically at admission and daily in the intensive care unit (average 10 days, range 1-21 days). We compared GFAP/S100B in non-survivors versus survivors, accuracy for mortality prediction according to receiver operated characteristic curve analysis, correlation between GFAP and S100B, relationship of GFAP/S100B to computerized tomography, cerebral perfusion pressure (CPP), mean arterial pressure (MAP) and 3-month Glasgow Outcome Score (GOS). GFAP (p < 0.005) and S100B (p < 0.0005) were higher in non-survivors than survivors. Both GFAP and S100B were accurate for mortality prediction (area under curve 0.84 versus 0.78 at <12 h after TBI). GFAP and S100B release correlated better later than 36 h after TBI (r = 0.75) than earlier (r = 0.58). GFAP was lower in focal lesions of <25 mL than in shifts of >0.5 cm (p < 0.0005) and non-evacuated mass lesions of >25 mL (p < 0.005). S100B was lower in focal lesions of <25 mL than in non-evacuated mass lesions (p < 0.0005) and lower in swelling than in shifts of >0.5 cm (p < 0.005). GFAP and S100B were lower in ICP < 25 than ICP > or = 25 (p < 0.0005), in CPP > or = 60 than CPP < 60 (p < 0.0005), in MAP > 70 than MAP < or = 70 mm Hg, and in GOS 4-5 than GOS 1 (p < 0.0005). Both measurement of GFAP and S100B is a useful non-invasive means of identifying brain damage with some differences based on the pattern of TBI and accompanying multiple trauma and/or shock.

Adult↗
PubMed1987

The effect of oral non-absorbable antibiotics on the emergence of resistant bacteria in patients in an intensive care unit.

Critically ill patients admitted to the surgical intensive care unit since 1982 have been treated prophylactically with oral non-absorbable antibiotics combined with parenteral cefotaxime. A mixture of polymyxin E, tobramycin and amphotericin B has been administered via a nasogastric tube and also applied topically to the buccal mucosa. This regimen has proven to be highly effective in reducing the infection rate. The present study evaluated the occurrence of resistant bacteria with this regimen during a 30-month period, in 164 patients with multiple trauma. No increase in the percentage of patients with acquired drug-resistant Gram-negative bacilli was found during this period. Colonization of the oral cavity and/or gastro-intestinal canal by polymyxin E-resistant strains (invariably Proteus spp.) occurred in 8% of patients, and by tobramycin-resistant bacilli (Escherichia coli or Acinetobacter or Pseudomonas spp.) in 4%. Intestinal colonization with cefotaxime-resistant strains (e.g. Pseudomonas, Acinetobacter or Enterobacter spp.) was observed in 17 patients (10%). Of these strains 82% were eliminated within one week by the oral non-absorbable antibiotics. Colonization of the respiratory tract, urinary tract or wounds with cefotaxime-resistant Gram-negative bacilli occurred in only three patients (2%).

Adolescent↗
PubMed1988

Teicoplanin compared with vancomycin in methicillin-resistant Staphylococcus aureus infections: preliminary results.

Twenty-one patients were included in an open randomized study comparing vancomycin 1 g bd with teicoplanin 400 mg daily in severe methicillin-resistant Staphylococcus aureus infections. The median duration of therapy was 15 days for vancomycin and 21 days for teicoplanin. Most patients presented with severe underlying conditions, such as major surgery (8), solid tumours (5), multiple trauma (3). The infections treated, included septicaemia, osteomyelitis, bronchopneumonia, cellulitis and acute pyelonephritis. Mean MICs of the strains were 0.39 mg/l for vancomycin and 0.195 mg/l for teicoplanin. Mean trough and peak serum concentrations of vancomycin were 14.3 +/- 5 mg/l and 34.3 +/- 13 mg/l, while the teicoplanin values were 7.5 +/- 4 mg/l and 17 +/- 7 mg/l. The cure rate was seven of 12 in the teicoplanin group and six of nine in the vancomycin group, with four and three cases, respectively, of improvement and one failure in the teicoplanin group. Transient renal impairment occurred in two cases with both regimens; superinfection and colonization in three patients and one patient, respectively, with both regimens.

Adult↗
PubMed1986

Creatinine clearance of early detection of posttraumatic renal dysfunction.

Acute renal failure develops insidiously in the presence of normal urine output and vital signs. A prospective study was carried out to find whether renal impairment can be detected in the immediate postoperative period and to determine the renal function test best predicting the development of renal dysfunction. Forty patients with multiple trauma who required more than 10 units of blood and had a systolic blood pressure less than 80 mmHg on admission were studied. Creatinine clearance (Ccr), free-water clearance (CH2O), fractional excretion of Na+, blood urea nitrogen (BUN), urine flow rate, and vital signs were measured and compared in seven patients who developed renal dysfunction within a week of trauma (Group 1) and 33 patients who maintained normal renal function (Group 2). In all Group 1 patients Ccr remained less than 25 ml/min and CH2O greater than -15 ml/h for 6 h following surgery. None of the Group 2 patients had Ccr less than 25 ml/min for longer than 4 h following surgery. However, CH2O values were greater than -15 ml/h in 15 of the 33 Group 2 patients during the first 24 postoperative hours. Ccr values less than 25 ml/min were present, despite normal urine flow rate and blood pressure, in patients who subsequently developed renal dysfunction. Patients who have Ccr values less than 25 ml/min within 6 h following trauma and surgery may develop renal dysfunction, and some of them may proceed to acute renal failure. CH2O was not as good a predictor of development of renal dysfunction as Ccr.

Acute Kidney Injury↗
PubMed1993

Fenoldopam improves renal hemodynamics impaired by positive end-expiratory pressure.

BACKGROUND: Mechanical ventilation with positive end-expiratory pressure (PEEP) can impair renal hemodynamics. Fenoldopam, a dopamine receptor agonist, has been shown, in animal experiments, to improve renal perfusion. The purpose of the current study was to examine the effects of this agent on altered renal hemodynamics secondary to positive pressure ventilation. METHODS: Twelve patients requiring mechanical ventilation of their lungs and PEEP for the treatment of hypoxemia after multiple trauma or visceral surgery were studied. Hemodynamic variables, renal vascular resistance, urine flow, creatinine, inulin and PAH clearance, and excretion of sodium and potassium (NaE and KE) were measured before and after introduction of a level of PEEP high enough to decrease urine flow rate by 25% or more, and after administration of intravenous fenoldopam. RESULTS: No hemodynamic effect resulted from 0.1 microgram.kg-1.min-1, but 0.2 micrograms.kg-1.min-1 fenoldopam decreased both diastolic and mean arterial blood pressure from 66 +/- 37 (mean +/- SEM) to 57 +/- 21 mmHg, and from 83 +/- 3 to 74 +/- 4 mmHg, respectively. Renal vascular resistance was reduced from 54 +/- 12 to 19 +/- 5 dynes.s.cm-5 at 0.2 micrograms.kg-1.min-1. Fenoldopam produced a dose-related increase in renal blood flow and PAH clearance. With 0.2 micrograms.kg-1.min-1 fenoldopam, urine flow increased from 81 +/- 25 to 116 +/- 29 ml/h, NaE from 28 +/- 7 to 85 +/- 70 microM/min, and KE from 65 +/- 12 to 109 +/- 16 microM/min. CONCLUSIONS: The results of the current study indicate that intravenous fenoldopam at a dose of 0.2 micrograms.kg-1.min-1 improves renal hemodynamics and increases Na and K excretion in patients requiring mechanical ventilation of their lungs and PEEP. These effects are probably caused by an increased kidney perfusion secondary to renal artery vasodilation.

2,3,4,5-Tetrahydro-7,8-dihydroxy-1-phenyl-1H-3-ben↗
PubMed1980

Muscle and plasma amino acids following injury. Influence of intercurrent infection.

The present study was undertaken to determine intracellular amino acid patterns in patients with multiple trauma, whether or not complicated by sepsis and during convalescence. A percutaneous muscle biopsy was performed three to four days following major accidental injury in ten patients and analyzed for muscle free amino acids. Venous blood was drawn at the time of the biopsy and analyzed for plasma free amino acids. Five patients developed sepsis and a repeat biopsy was performed on days 8 to 11. In five of the patients a biopsy was performed during the late convalescent period (anabolic phase). A marked depletion of nonessential amino acids in muscle occurred in both injury and sepsis due to a decrease (50%) in glutamine, which was equally marked in both states. The essential amino acids in muscle increased in injury. During sepsis, a further increase was observed with a return toward normal in the convalescent period. In injury, the most marked rise was in the branched-chain amino acids, phenylalanine, tryosine and methionine. With sepsis, a further rise in muscle branched-chain amino acids, phenylalanine and tryosine occurred, while plasma levels remain unchanged. During convalescence, muscle glutamine, arginine, histidine and plasma branched-chain amino acids were below normal, whereas muscle phenylalanine and methionine were elevated. The muscle free amino acid pattern observed after major trauma was essentially the same as earlier described following elective operation. This suggests a common response of intracellular amino acids irrespective of the degree of injury, and may indicate that the pump settings which regulate amino acid transport follow the "all or none" rule. The high intracellular levels of branched-chain amino acids in sepsis suggest that the energy deficit of this state is due to an impairment of substrate use rather than intracellular availability. The high concentrations of the aromatic amino acids and methionine may be due to altered liver function. During the late convalescent period (anabolic phase) the low levels of certain key amino acids suggests inadequate nutrition. The difficulties in nourishing the injured or septic patient are well recognized. The period following these catabolic states may be an important period for the application of an optimal, aggressive nutritional regimen.

Abdomen, Acute↗
PubMed1981

The "in vitro skin test": a reliable and repeatable assay of immune competence in the surgical patient.

In vitro blast transformation of human peripheral lymphocytes was tested using standard skin test antigens, the mitogens PHA and Con A, and the mixed lymphocytes reaction. The study group included 15 patients with multiple trauma, 40 with major burns, six following cholecystectomies, six following aortic reconstruction, and 30 normal volunteer controls. Repeated skin testing may sensitive patients to candida and streptokinase-streptodornase (SKSD), and desensitize them to mumps antigen. Blast transformation in response to PPD did not correlate with the clinical status of the patients; similarly, blast transformation in response to stimulation by the mitogens PHA and Con A could not reliably predict the occurrence of septic complications. Reactivity in response to stimulation by the soluble antigens SKSD and mumps and in the one-way mixed lymphocyte reaction accurately predicted the clinical course of patients. This method of "in vitro skin testing" is a reliable and repeatable method of monitoring the immunologic status of patients whose illness or injury requires longitudinal study.

Antigens↗
PubMed1982

Mechanisms of insulin resistance following injury.

To assess the mechanisms of insulin resistance following injury, we examined the relationship between insulin levels and glucose disposal in nine nonseptic, multiple trauma patients (average age 32 years, Injury Severity Score 22) five to 13 days postinjury. Fourteen age-matched normals served as controls. Using a modification of the euglycemic insulin clamp technique, insulin was infused in 35 two-hour studies using at least one of four infusions rates (0.5, 1.0, 2.0 or 5.0 mU/kg min). Basal glucose levels were maintained by a variable infusion of 20% dextrose using bedside glucose monitoring and a servo-control algorithm. The amount of glucose infused reflected glucose disposal (M, mg/kg.min). Tracer doses of (6,6,2D2) glucose were administered in selected subjects to determine endogenous glucose production. At plasma insulin concentrations less than 100 microU/ml, responses in both groups were similar. However, maximal glucose disposal rates were significantly less in the patients than in the controls (9.17 +/- 0.87 mg/kg . min vs. 14.3 +/- 0.78, mean +/- SEM, p less than 0.01). Insulin clearance rates in the patients were almost twice that seen in controls. To further characterize this decrease in insulin responsiveness, we studied six additional patients and 12 controls following the acute elevation of glucose 125 mg/dl above basal (hyperglycemic glucose clamp). In spite of exaggerated endogenous insulin production in the patients (80-200 microU/ml vs. 30--70 in controls), M was significantly lower (6.23 +/- 0.59 vs. 9.46 +/- 0.79, p less than 0.02). In conclusion, this study demonstrated that (1) the maximal rate of glucose disposal is reduced in trauma patients; (2) the metabolic clearance rate of insulin in the injured patients is almost twice normal and; (3) insulin resistance following injury appears to occur in peripheral tissues, probably skeletal muscle, and is consistent with a postreceptor defect.

Adult↗
PubMed2000

Priorities in the treatment of facial fractures for the millennium.

Although certain principles for management of facial fractures have not changed, new avenues reach this goal with greater precision and less morbidity. By reviewing these recent developments one can see the enormous potential for future developments in technology, techniques, and biomaterials. Development of tertiary care centers for the multiple trauma victim has improved management of facial trauma by bringing a large experience to a team of individuals where creativity flourishes. Major leaps in diagnostic skills and technology now allow us to answer some to the controversial treatment issues in facial trauma. This article hopes to review some old concepts and look at new approaches in managing facial fractures.

Facial Bones↗
PubMedDate not supplied

Early experience with a polymethyl pentene oxygenator for adult extracorporeal life support.

Silicone oxygenators are the standard devices used for Extracorporeal Life Support (ECLS), but they have some limitations. Microporous polypropylene hollow fiber oxygenators overcome many of these problems but, unfortunately, develop plasma leak. Polymethyl-pentene (PMP) is a novel oxygenator material. We report our initial experience with the Medos Hilite 7000LT, a PMP hollow fiber oxygenator, in six adult respiratory ECLS patients with these characteristics: age, mean 32.2 (+/-13) years; weight, mean 81.2 (+/-17) kg; PaO2/FIO2, mean 62.8 [+/-33] mm Hg; Murray Score, mean 3.4 [+/-0.3]; and sepsis related organ failure assessment score, mean 9.6 [+/-2.3]. One patient was cannulated within 10 hours of multiple trauma and 1 hour after thoracolaparotomy; another patient was cannulated 12 hours after a thoracotomy. All six patients survived. Heparin was infused (7.8-32.5 u/kg/hr) to maintain activated clotting time at 162 to 238 seconds; international normalized ratio was 0.9 to 3.4. Two of the six patients required transfusions of fresh frozen plasma, receiving one and five units, respectively. Fibrinogen was 1.4 to 6 g/dl; no cryoprecipitate was needed. Platelet counts were between 65 and 306, and very little platelet transfusion (mean 2.33; +/-3.03 units per patient) was required to maintain these levels. Two patients did not require any platelet transfusion. Maximum blood flow was 5.3 L/min, sweep was 3 to 10 L/min, and resistance was 11 to 43 Paul Wood Units. There were no oxygenator failures. Mean duration of ECLS was 151.7 hours (+/-75.6). Our initial experience with PMP oxygenators in adults was satisfactory, and platelet consumption and resistance to blood flow seem to be greatly reduced with PMP.

Adult↗
PubMedDate not supplied

Critical rehabilitation of the patient with spinal cord injury.

Most healthcare practitioners have worked with patients with spinal cord injury at some point in their career, for some it is a specialty. The critical care area usually only has patient with spinal cord injury for a brief time before they are transferred. More recently, there are longer intensive care unit stays due to multiple trauma and lack of insurance. Nurses must be cognizant of indications, contraindications, and best practice interventions to contribute positively to patient's long-term outcomes. As part of the multispecialty team, nurses can be pivotal in preventing secondary complications, especially pressure ulcers. Rehabilitation team members can be consulted early to provide expertise in managing this complex diagnostic group.

Activities of Daily Living↗
PubMed1997

Current trends in the treatment of femoral shaft fractures in children and adolescents.

Healthcare cost containment and a desire for early discharge of the pediatric patient to the home environment have become important factors in the treatment of femoral shaft fractures in children. As a result, newer techniques of treatment have become popular. The immediate hip spica cast remains the primary method of treatment for most children 6 years of age and younger. The treatment for children between the ages of 6 and 10 years is the most controversial. Many such patients may be treated successfully with immediate hip spica casts. However, external fixation and flexible intramedullary rod fixation are being used more frequently, particularly in patients with multiple trauma. The initial enthusiasm for rigid intramedullary rod fixation of adolescent femoral fractures has been tempered by recent reports of femoral head avascular necrosis. Avoiding the piriformis fossa during rod insertion may prevent this complication. Most children and adolescents with femoral fractures can be treated successfully with a brief hospital course without compromising care or outcome.

Adolescent↗
PubMed2003

Elastic stable intramedullary nailing of midclavicular fractures with a titanium nail.

This study presents the results of a minimally invasive operative treatment for markedly displaced midclavicular fractures. In all patients a flexible titanium nail was inserted in an unreamed technique from the sternal end of the clavicle. The result of surgery was determined with clinical and radiographic controls. The clinical outcome was evaluated 12 months after hardware removal using the scoring system of Constant and Murley. Fifty-eight fractures in 55 patients were treated with intramedullary fixation. Postoperatively on Day 3, the mean subjective pain was significantly lower and range of motion was improved compared with the day before surgery. One nonunion occurred. There was no infection and no implant displacement or refracture. Intramedullary nailing of midclavicular fractures with a flexible titanium nail is a safe minimally invasive surgical technique with excellent functional and cosmetic results compared with plate fixation or conservative treatment. Marked pain reduction along with early restoration of shoulder function and early mobilization are advantageous for patients. This technique can be used as an alternative treatment to conservative procedures or plate fixation in patients with markedly displaced midclavicular fractures, multiple trauma, fractures of the lower extremities, or associated shoulder girdle injuries.

Adolescent↗
PubMed1985

Intragastric prostaglandin E2 and the prevention of gastrointestinal hemorrhage in ICU patients.

The effects of intragastric prostaglandin E2 (PGE2) on the occurrence of acute GI hemorrhage in intensive care patients were investigated in a prospective, double-blind, placebo-controlled study. Ninety patients with two or more risk factors (major surgery, multiple trauma, respiratory insufficiency, renal insufficiency, jaundice, hypotension, peritonitis, sepsis) were randomized for treatment with either PGE2 (0.5 mg) or placebo, administered every 4 h via a nasogastric tube. Blood loss in gastric aspirates was measured by 51Cr-erythrocyte labeling and a peroxidase test (orthotolidine). Of 57 patients who could be evaluated, 29 received PGE2 and 28 received placebo. Hemorrhage occurred in nine PGE2 patients and 13 placebo-treated patients, not a significant difference. The occurrence of hemorrhage was related to the number of risk factors, and GI hemorrhage was rarely the major factor determining mortality. Results of the orthotolidine test were not positively correlated with those of erythrocyte labeling, indicating that peroxidase tests should not be relied upon to detect blood in gastric aspirates.

Adolescent↗
PubMed1987

Evaluation of prognostic indices based on hemodynamic and oxygen transport variables in shock patients with adult respiratory distress syndrome.

We tested prospectively 30 hypotensive shock patients using a continuous, on-line, real-time hemodynamic and oxygen transport monitoring system with a previously described predictive index, modified for the clinical conditions in our ICU. Continuous monitoring and display of cardiac output and 20 or more derived variables, together with the predictive index, were a feasible and useful approach. Unlike previously documented series of elective postoperative general surgical patients, our series consisted of patients with multiple trauma, myocardial infarction, sepsis, and other medical emergencies as well as postoperative cardiac and general surgical patients, all of whom had respiratory failure (acute respiratory distress syndrome). In addition to these differences, our patients were invariably admitted to the ICU after the nadir of their hypotensive crisis. To compare the continuous recorded values with previous studies that used intermittent measurements, three comparable time intervals were selected; data at these time intervals and the predictions derived from them were in satisfactory agreement with prior studies. Moreover, therapeutic goals based on the median values of survivors of the present series were similar, but not identical, to prior series despite differences in the clinical mix and the later postresuscitation ICU admissions of our series.

Adult↗
PubMed1987

Nosocomial infections in a respiratory intensive care unit.

A total of 250 consecutive admissions to an open-plan respiratory ICU were analyzed prospectively to identify the incidence of secondary hospital-acquired infections and possible predisposing factors. Despite preventative measures and a restricted antibiotic policy, 23.6% of patients developed secondary infections. Patients admitted after multiple trauma were the only diagnostic category of patients who showed a significantly increased incidence of secondary infections. The length of hospitalization and number of patients who had intubations or tracheostomies was higher in the group with secondary infection; the causal relationship was difficult to establish. Patients who were not intubated or tracheostomized did not develop secondary infection. Prior administration of antibiotics did not appear to influence the incidence of secondary infection. There was a significant increase in secondary infections in patients with a higher therapeutic intervention scoring system score. The predominant pathogens cultured were highly resistant Gram-negative organisms, particularly Acinetobacter sp. and Pseudomonas sp. Staphylococcus aureus was the most common Gram-positive pathogen. The ICU course was probably prolonged by the complication of nosocomial infection, which may have contributed to the deaths.

Adolescent↗