Current management of large bowel injuries and factors influencing outcome

Background

Colonic and intra-peritoneal rectal injuries may be managed by primary repair and extra-peritoneal rectal injuries by diverting colostomy. This study was undertaken to document our experience with this approach and to identify factors which might impact on outcome.

Patients and methods

Prospective study of all patients treated for colon and rectal injuries in one surgical ward at King Edward VIII hospital, Durban, over a 7-year period (1998-2004). Demographic data, clinical presentation, findings at laparotomy and outcome were documented.

Results

Of 488 patients undergoing laparotomy, 177 (36%) had injuries to the colon and rectum with age 29.8 ± 10.9 years. Injury mechanisms were firearms (118) stabs (54) and blunt trauma (5). Delay before laparotomy was 10 ± 9.3 h. Complication and mortality rates were 36% and 17%, respectively. 68 patients (38%) required ICU management. Shock on admission and increased transfusion requirements were associated with a significantly increased mortality. Patients with delay ≤12 h before laparotomy had a higher mortality rate than those with delay >12 h. The mortality rate increased with the number of associated injuries and it was higher the higher the Injury Severity Score (ISS); it was similar for stabs, firearms and blunt trauma. Hospital stay was 9.5 ± 9.2 days.

Conclusion

We reaffirm that primary repair is appropriate for colonic and intra-peritoneal rectal injuries and that extra-peritoneal rectal injuries require diverting colostomy. Shock on admission, increased blood transfusion requirements, associated organ injury and severity of the injury were associated with high mortality.     

Epidemiology of foot injury in a high-income developing country

Objectives

To study the epidemiology of foot injuries and factors predicting their severity in a high-income developing country so as to define prevention priorities.

Patients and Methods

All patients admitted to Al-Ain Hospital with foot injury between March 2003 and March 2006 were identified from a prospectively collected Trauma Registry. Injuries were scored using foot and ankle severity scale (FASS). Bilateral, multiple or segmental injuries, open fractures or those with FASS score higher than 3 were included in severe foot injury group and compared with simple foot injury group regarding patients’ demography, co-morbidities, trauma mechanism and energy, incident location, number of associated injuries, Injury Severity Score (ISS) and hospital stay using a univariate analysis. A logistic regression model was then used to study factors predicting severity of foot injury.

Results

171 patients (156 males) were studied. The average (range) age was 34 (2-75). 95 had right foot injury, 66 had left, and 10 had both. Fall from height was the most common mechanism. 105 (61%) had work-related injuries. 130 (76%) had isolated foot injury. 151 (88%) had 212 foot fractures. 20 (12%) had soft tissue injuries. 70 (41%) had severe injuries while 101 (59%) had simple ones. The multiple logistic model was highly significant (p = 0.002). Number of associated injuries (p = 0.025) and location of trauma (p = 0.044) were significant while the amount of energy (p = 0.054) showed a strong trend to predict severity.

Conclusions

Fall from height is the most common mechanism of foot injury in United Arab Emirates. The number of associated injuries, high-energy trauma, and being work related are predictors of foot injury severity. Prevention priorities include counteractions against falling from height and falling heavy objects as occupational hazards.     

Femoral nailing during serum bicarbonate-defined hypo-perfusion predicts pulmonary organ dysfunction in multi-system trauma patients

Objective

To assess the value of venous serum bicarbonate as an endpoint of resuscitation and guide to timing of femoral nailing in multi-system trauma patients.

Design

Retrospective cohort study.

Setting

Academic Level 1 Trauma Centre.

Patients

Seventy-two consecutive adult multi-system trauma patients (Injury Severity Score ≥ 15) with femoral shaft fracture (Orthopaedic Trauma Association Class 32-A to 32-C) treated with reamed medullary nail fixation.

Intervention

Femoral nailing in the setting of hypo-perfusion defined by venous serum bicarbonate (SB). Threshold values of SB were determined first by correlating SB and simultaneously drawn arterial base deficit (BD). Then, corresponding values of SB to previously defined thresholds of hypo-perfusion based on BD were identified using regression analysis.

Main outcome measurement

Pulmonary organ dysfunction (POD) component of the Denver Multiple Organ Failure scoring system.

Results

Simultaneous admission SB and BD values were correlated (r = −0.43, p = 0.001). Adjusting for age, ISS and baseline POD, patients with SB < 24.7 mequiv./L within 6 h of treatment had a 12-fold increase in POD (OR 12.2, 95% CI 1.5-98.6, p = 0.019). This association was diminished, but still significant with hypo-perfusion present within 12 h prior to treatment (OR 5.6, 95% CI 1.0-29.1, p = 0.042) and 24 h prior to treatment (OR 5.9, 95% CI 1.1-30.7, p = 0.037).

Conclusions

Medullary fixation of femoral shaft fracture in the setting of serum bicarbonate-defined hypo-perfusion is associated with increased morbidity. Appropriate damage-control measures and aggressive resuscitation prior to definitive fracture care are advised and physiologic markers such as serum bicarbonate should guide clinical decision making rather than temporal distinctions.     

Early enteral nutrition reduces mortality in trauma patients requiring intensive care: A meta-analysis of randomised controlled trials

Introduction

To determine whether the provision of early standard enteral nutrition (EN) confers treatment benefits to adult trauma patients who require intensive care.

Materials and methods

MEDLINE and EMBASE were searched. Hand citation review of retrieved guidelines and systematic reviews was undertaken and academic and industry experts were contacted.Methodologically sound randomised controlled trials (RCTs) conducted in adult trauma patients requiring intensive care that compared the delivery of standard EN, provided within 24 h of injury, to standard care were included.The primary analysis was conducted on clinically meaningful patient-oriented outcomes, which included mortality, functional status and quality of life. Secondary analyses considered vomiting/regurgitation, pneumonia, bacteraemia, sepsis and multiple organ dysfunction syndrome. Meta-analysis was conducted using an analytical method known to minimise bias in the presence of sparse events. The impact of heterogeneity was assessed using the I² metric.

Results

Three RCTs with 126 participants were found to be free from major flaws and were included in the primary analysis. The provision of early EN was associated with a significant reduction in mortality (OR = 0.20, 95% confidence interval 0.04-0.91, I² = 0). No other outcomes could be pooled. A sensitivity analysis and a confirmatory analysis conducted using a different analytical method confirmed the presence of a mortality reduction.

Conclusion

Although the detection of a statistically significant reduction in mortality is promising, overall trial quality was low and trial size was small. The results of this meta-analysis should be confirmed by the conduct of a large multi-center trial.     

The impact of fresh frozen plasma vs coagulation factor concentrates on morbidity and mortality in trauma-associated haemorrhage and massive transfusion

Introduction

Clinical observations together with recent research highlighted the role of coagulopathy in acute trauma care and early aggressive treatment has been shown to reduce mortality.

Methods

Datasets from severely injured and bleeding patients with established coagulopathy upon emergency room (ER) arrival from two retrospective trauma databases, (i) TR-DGU (Germany) and (ii) Innsbruck Trauma Databank/ITB (Austria), that had received two different strategies of coagulopathy management during initial resuscitation, (i) fresh frozen plasma (FFP) without coagulation factor concentrates, and (ii) coagulation factor concentrates (fibrinogen and/or prothrombin complex concentrates) without FFP, were compared for morbidity, mortality and transfusion requirements using a matched-pair analysis approach.

Results

There were no major differences in basic characteristics and physiological variables upon ER admission between the two cohorts that were matched. ITB patients had received substantially less packed red blood cell (pRBC) concentrates within the first 6 h after admission (median 1.0 (IQR_25-75 0-3) vs 7.5 (IQR_25-75 4-12) units; p < 0.005) and the first 24 h as compared to TR-DGU patients (median 3 (IQR_25-75 0-5) vs 12.5 (8-20) units; p < 0.005). Overall mortality was comparable between both groups whilst the frequency for multi organ failure was significantly lower within the group that had received coagulation factor concentrates exclusively and no FFP during initial resuscitation (n = 3 vs n = 15; p = 0.015). This translated into trends towards reduced days on ventilator whilst on ICU and shorter overall in-hospital length of stays (LOS).

Conclusion

Although there was no difference in overall mortality between both groups, significant differences with regard to morbidity and need for allogenic transfusion provide a signal supporting the management of acute post-traumatic coagulopathy with coagulation factor concentrates rather than with traditional FFP transfusions. Prospective and randomised clinical trials with sufficient patient numbers based upon this strategy are advocated.     

Clinical presentation and outcome of chorioretinitis sclopetaria: A case series study

Purpose

To report the clinical presentation, treatment approach and natural course of a series of chorioretinitis sclopetaria patients.

Methods

Thirteen consecutive patients with clinical diagnosis of chorioretinitis sclopetaria were included in a case series study during 2000-2006. All patients underwent clinical examination, including the best-corrected Snellen visual acuity, slit-lamp examination, applanation tonometry, funduscopy and fundus photography.Three-port standard vitrectomy was performed in two patients due to dense vitreous haemorrhage and suspected retinal detachment in both cases. All patients were followed up at week 4, months 2 and 6 and then every 6 months.

Results

The mean age of the patients was 16 ± 6 (range: 5-27) years and 11 patients (84.6%) were male. The mean follow-up period was 37 ± 18 (range: 17-82) months.Baseline best-corrected visual acuity ranged from no light perception (NLP) to 20/1600, and final visual acuity range was from NLP to 20/1200. Only one patient developed acute retinal detachment, and the retina remained attached in others through follow-up.

Conclusion

In spite of severe retinal and choroidal injuries in chorioretinitis sclopetaria, retinal detachment does not usually occur, probably due to spontaneous retinopexy and scar formation. Whilst dealing with chorioretinitis sclopetaria, it is important to make an accurate diagnosis to prevent unwarranted surgical intervention.     

Trauma does not happen at random. Predictable rhythm pattern of injury occurrence in a cohort of 15,110 children

Background

Several adult chronobiologic studies have shown that accidents do not occur at random. Comparing a large cohort of injured children with uninjured children living in an urban setting, we evaluated the rhythmicity of pediatric injury occurrence.

Methods

A data review of a prospective cohort study of child trauma over an 8-year period was recorded in a Swiss urban setting. Chronological and demographic information of preschool as well as school-aged injured children were compared with a similar sample of children assessed in the emergency department for nontraumatic events.

Results

Statistically significant circadian rhythms of injury occurrence were detected with a peak around 4 pm. No sex- or age-related differences were detected between preschool and school-aged children. Type of activity and place of occurrence revealed statistically significant differences in the circadian rhythm of trauma occurrence. No weekly rhythm was validated. A circannual rhythm was validated with a peak on June 14 (±10 days).

Conclusions

Pediatric trauma did not occur at random. Circadian rhythms of pediatric trauma were not influenced by age, sex, or motor vehicle traffic load. Specific circadian and circannual pattern of injury occurrence in children could influence safety campaigns and prevention programs, as well as optimize workforce distribution in medical facilities.     

Efficacy and safety of once-daily dosing of udenafil in the treatment of erectile dysfunction: results of a multicenter, randomized, double-blind, placebo-controlled trial

Background

A once-daily dosing regimen with a phosphodiesterase type 5 inhibitor is needed for the treatment of erectile dysfunction (ED), in part because of the behavioral complexities associated with sexual intimacy. Many patients prefer spontaneous rather than scheduled sexual activities or they anticipate frequent sexual encounters. The pharmacokinetic profiles of udenafil with a time of maximal concentration of 1.0-1.5 h and a terminal half-life of 11-13 h make udenafil a good candidate for once-daily dosing.

Objective

To evaluate the efficacy and safety of once-daily dosing of udenafil in the treatment of ED.

Design, setting, and participants

This multicenter randomized double-blind, placebo-controlled, fix-dosed clinical trial involved 237 patients with ED. The subjects, who were treated with placebo or udenafil (25 mg, 50 mg, or 75 mg) once daily for 12 wk, were asked to complete the International Index of Erectile Function (IIEF), the Sexual Encounter Profile (SEP) diary, and the Global Assessment Questionnaire (GAQ) during the study.

Measurements

The primary outcome parameter was the change from baseline for the IIEF erectile function domain (EFD) score. The secondary outcome parameters were SEP questions 2 and 3, the shift to normal rate (EFD ≥26), and the response to the GAQ.

Results and limitations

Compared with placebo, patients who took 50 mg or 75 mg of udenafil had a significantly improved IIEF-EFD score. Similar results were observed in comparing questions 2 and 3 in the SEP diary and the GAQ. Flushing was the most common treatment-related adverse event, which was transient and mild to moderate in severity.

Conclusions

Udenafil significantly improved erectile function among ED patients when administered in doses of 50 mg or 75 mg once daily for 12 wk. Daily administration of udenafil (50 mg) may be another treatment option for ED.     

Oral antibiotic therapy improves fat absorption in cystic fibrosis patients with small intestine bacterial overgrowth

Background

The aim of the present study was to assess the influence of antibiotic therapy on fat assimilation in cystic fibrosis (CF) patients with small intestine bacterial overgrowth (SIBO).

Materials and methods

Twenty six pancreatic insufficient CF patients with bronchopulmonary exacerbation and diagnosed SIBO (positive hydrogen-methane breath test) entered the study. ¹³C mixed triglyceride breath test was performed before and after antibiotic therapy. Sixteen subjects were treated intravenously (ceftazidime and amikacin), ten patients orally (ciprofloxacin).

Results

Cumulative percentage dose recovery changed significantly in the subgroup receiving antibiotics orally [median (mean ± SEM): 3.6% (4.5 ± 1.3%) vs. 7.2 (6.9 ± 1.6%); p = 0.019]. In the subgroup with intravenous drug administration, the tendency towards improvement was noted [2.7 (4.3 ± 1.5%) vs. 5.2 (5.7 ± 0.8%); p = 0.109].

Conclusions

Antibiotic therapy applied in CF patients with SIBO in the course of pulmonary exacerbation results in a significant improvement of fat digestion and absorption.     

Health and cost consequences of surgical versus conservative treatment for a comminuted proximal humeral fracture in elderly patients

Objective

This study aims to evaluate the costs and health outcome for surgical and conservative treatment of displaced proximal humeral fractures.

Design

This study is a randomised controlled trial.

Participants

This study included 50 patients aged 60 or older admitted to hospital with a severely displaced three- or four-part fracture.

Interventions

The patients were treated surgically with an angular stable interlocking implant (25 patients) or conservative treatment (25 patients).

Main outcome measure

The outcomes measured included quality-adjusted life years (QALYs) and societal costs.

Results

At 12 months’ follow-up, the mean difference in the number of QALYs was 0.027 (95% confidence interval (CI) = −0.025, 0.078) while the mean difference in total health-care costs was €597 in favour of surgery (95% CI = −5291, 3777).

Conclusion

There was no significant difference in QALYs or costs between surgical and conservative treatment of severe displaced proximal humeral fractures.     

Solid organ procurement from donors with carbon monoxide poisoning and/or burn--a systematic review

Introduction

Traditionally, carbon monoxide poisoning and/or burn are considered contraindications to organ procurement. Previously reported cases have shown mixed results and many have been redundantly reported in the literature.

Methods

We performed a systematic review of all reported cases of organ transplantation procured from donors with carbon monoxide poisoning and/or burn to investigate whether these patients are suitable donors for solid organ transplantations.

Results

Organ survival rates of reported organs were high (86%). All organs procured from donors with carbon monoxide poisoning and burn survived during follow-up. Mean donors’ peak carbon monoxide levels were comparable for organs surviving or failing during follow-up (31 ± 2.7 vs. 29 ± 26.8; p = 0.95). Eighty-seven per cent of organs procured from donors supported with inotropes or vasopressors prior to organ procurement and 91% of organs procured from donors who were cardiopulmonary resuscitated prior to organ procurement survived during follow-up.

Conclusions

Burn, carbon monoxide poisoning, high peak carbon monoxide-levels, use of inotropes or vasopressors or cardiopulmonary resuscitation prior to procurement are not contraindications for organ procurement and transplantation. New guidelines for burn units defining the special requirements for organ procurement from donors with carbon monoxide poisoning and/or burn are needed to raise the awareness for potential organ donors and to ultimately increase the donor pool and save patients’ lives.     

Platelet-rich plasma (PRP) enhances bone healing in non-united critical-sized defects: a preliminary study involving rabbit models

Introduction

The use of bone grafts in treating non- or delayed unions as the result of large bone loss is well established. However, despite good outcomes, the time to achieve complete union is still considerably long. To overcome this problem, the use of platelet-rich plasma (PRP) has been advocated albeit with varying success. To determine the true effectiveness of PRP in treating non-/delayed unions, a study was conducted using (n = 12) rabbit models.

Methods and materials

Critical-sized defects measuring 2 cm created in the midshaft of the right rabbit tibias were stabilised using 2.7-mm small fragment plates. A spacer placed in the defects to create a delay in bone union was replaced at 3 weeks with artificial bone grafts (Coragraft^®), with or without PRP. The operated limbs were radiographed following the defect creation and at 3, 7 and 11 weeks (at sacrifice). Bone healing and histological changes were later assessed and scored using the appropriate grading systems. Four groups were compared for quality of healing: (group-A) control group, that is, no PRP or Coragraft; (group-B) PRP; (group-C) Coragraft; and (group-D) PRP and Coragraft.

Results

Group-D demonstrated the best bone healing based on radiological, histological and gross findings (Kruskall-Wallis: p < 0.05). Group-C had significantly higher scores than group-B, whilst group-A had significantly lower scores than all other groups (Mann-Whitney U: p < 0.05).

Conclusion

The use of PRP with bone graft significantly improves the quality of bone healing. However, the use of PRP without bone substitute does not provide adequate repair tissue and, therefore, provides little benefit when used independently.     

International phase III trial of liprotamase efficacy and safety in pancreatic-insufficient cystic fibrosis patients

Background

Most cystic fibrosis (CF) patients have exocrine pancreatic insufficiency (EPI) and need supplementation with pancreatic enzyme replacement therapy (PERT). Liprotamase, a novel non-porcine PERT containing highly purified biotechnology-derived lipase, protease, and amylase, has successfully undergone initial efficacy and safety testing.

Methods

In this international phase III parallel-group, randomized-withdrawal, double-blind placebo-controlled trial, CF patients with EPI 7 years and older, including nutritionally and functionally compromised individuals, underwent baseline testing for coefficients of fat and nitrogen absorption (CFA and CNA) and stool weight and frequency while off PERT. After an open-label treatment period with liprotamase, subjects were randomized 1:1 to one liprotamase or placebo capsule taken with 3 meals and 2 snacks per day. The dose was fixed and increases were not allowed. The same measurements were obtained again after treatment with double-blind study drug or placebo.

Results

138 subjects were randomized. The adjusted least squares mean (LSM) difference between the treatment and placebo groups for change in CFA was 15.1% (p = 0.001) for the subgroup with baseline CFA < 40%, 8.6% (p = 0.006) for subjects with baseline CFA ≥ 40%, and 10.6% (p < 0.001) for the overall intent-to-treat population. Similar results were seen for change in CNA. Stool weight was significantly decreased although not stool frequency. Liprotamase was well tolerated with no safety concerns identified.

Conclusions

In a CF patient population reflective of that encountered in clinical practice, this trial demonstrated that liprotamase at a fixed dose of one capsule per meal or snack (5 capsules per day) was well tolerated and significantly increased fat absorption as measured by improvement in CFA, significantly increased protein absorption as measured by improvement in CNA, and significantly decreased stool weight.     

Systematic effects of surgical treatment of hip fractures: Gliding screw-plating vs intramedullary nailing

Aim

Numerous studies have been published regarding the comparison between intramedullary nail and the dynamic hip screw and plate for the fixation of intertrochanteric fractures in elderly patients. In this paper we present a comparative study of these two methods regarding their systemic effects on this group of patients.

Materials-methods

This is a randomized trial of 120 consecutive patients with an intertrochanteric fracture treated with either extramedullary fixation (dynamic hip screw and plate; DHS, Synthes-Stratec, Oberdorf, Switzerland) or intramedullary nail (Gamma nail, Stryker Howmedica, Freiburg, Germany and Endovis BA, Citieffe, Bologna, Italy).The parameters that we assessed pre-operatively, in addition to their demographics, included their mental state (MMSE), their nutritional and immune state and their pulmonary function. Intra-operatively we calculated the amount of radiation exposure, the amount of blood loss and the length of operative time for each procedure. Postoperatively we repeated the calculation of the mental and pulmonary state and the blood loss, during days 1, 3, and 10 and related them to the ease of the patient's mobilization.

Results

Decreased bleeding and post-operative pain, reduced post-operative morbidity and faster recovery of function were better but not significant in the group of intramedullary fixation (all p > 0.05). However, in the same group there were slightly more patients in whom the MMSE was falling, together with their pulmonary function, suggesting that this method probably predisposes to higher chances of pulmonary dysfunction and the possibility of pulmonary embolism.

Conclusion

We found no significant differences between the two methods of stabilization of these fractures regarding their systemic effects perioperatively. The classic dynamic hip screw can preserve its position as a safe and effective solution for these already vulnerable patients having sustained a trochanteric fracture against the novel intramedullary techniques.     

Occult pneumomediastinum in blunt chest trauma: Clinical significance

Introduction

Thoracic injuries are potentially responsible for 25% of all trauma deaths. Chest X-ray is commonly used to screen patients with chest injury. However, the use of computed tomography (CT) scan for primary screening is increasing, particularly for blunt trauma. CT scans are more sensitive than chest X-ray in detecting intra-thoracic abnormalities such as pneumothoraces and pneumomediastinums. Pneumomediastinum detected by chest X-ray or “overt pneumomediastinum”, raises the concern of possible aerodigestive tract injuries. In contrast, there is scarce information on the clinical significance of pneumomediastinum diagnosed by CT scan only or “occult pneumomediastinum”. Therefore we investigated the clinical consequences of occult pneumomediastinum in our blunt trauma population.

Methods

A 2-year retrospective chart review of all blunt chest trauma patients with initial chest CT scan admitted to a level I trauma centre. Data extracted from the medical records include; demographics, occult, overt, or no pneumomediastinum, the presence of intra-thoracic aerodigestive tract injuries (trachea, bronchus, and/or esophagus), mechanism and severity of injury, endotracheal intubation, chest thoracostomy, operations and radiological reports by an attending radiologist. All patients with intra-thoracic aerodigestive tract injuries from 1994 to 2004 were also investigated.

Results

Of 897 patients who met the inclusion criteria 839 (93.5%) had no pneumomediastinum. Five patients (0.6%) had overt pneumomediastinum and 53 patients (5.9%) had occult pneumomediastinum. Patients with occult pneumomediastinum had significantly higher ISS and AIS chest (p < 0.0001) than patients with no pneumomediastinum. A chest thoracostomy tube was more common (p < 0.0001) in patients with occult pneumomediastinum (47.2%) than patients with no pneumomediastinum (10.4%), as well as occult pneumothorax. None of the patients with occult pneumomediastinum had aerodigestive tract injuries (95%CI 0-0.06). Follow up CT scan of patients with occult pneumomediastinum showed complete resolution in all cases, in average 3 h after the initial exam.

Conclusion

Occult pneumomediastinum occurred in approximately 6% of all trauma patients with blunt chest injuries in our institution. Patients who had occult pneumomediastinum were more severely injured than those who without. However, none of the patients with occult pneumomediastinum had aerodigestive tract injuries and follow up chest CT scans demonstrated their complete and spontaneous resolution.     

Clinical predictors of occult pneumothoraces in severely injured blunt polytrauma patients: A prospective observational study

Introduction

The supine antero-posterior (AP) chest radiograph (CXR) is an insensitive test for detecting post-traumatic pneumothoraces (PTXs). Computed tomography (CT) often identifies occult pneumothoraces (OPTXs) that were not diagnosed on CXR. The purpose of this study was to prospectively determine the incidence, and validate previously identified clinical predictors, of OPTXs after blunt trauma.

Methods

All severe blunt injured patients (injury severity score (ISS) ≥ 12) presenting to a level 1 trauma centre over a 17-month period were prospectively evaluated. Thoracoabdominal CT scans and corresponding CXRs were reviewed at the time of admission. Patients with OPTXs were compared to those with overt PTXs regarding incidence and previously identified predictive risk factors (subcutaneous emphysema, rib fractures, female sex and pulmonary contusion).

Results

CT imaging was performed concurrent to CXR in 405 blunt trauma patients (ISS ≥ 12) during the study period. PTXs were identified in 107 (26%) of the 405 patients. Eighty-one (76%) of these were occult when CXRs were interpreted by the trauma team. Concurrent chest trauma predictive of OPTXs was limited to subcutaneous emphysema (p = 0.003). Rib fractures, pulmonary contusions and female sex were not predictive.

Conclusions

OPTXs were missed in up to 76% of all seriously injured patients when CXRs were interpreted by the trauma team. This is higher than previously reported in retrospective studies and is likely based on the difficult conditions in which the trauma team functions. Subcutaneous emphysema remains a strong clinical predictor for concurrent OPTXs.     

Amylase and lipase measurements in paediatric patients with traumatic pancreatic injuries

Introduction

Pancreatic injuries occur in up to 10% of paediatric patients who suffer blunt trauma. Initial amylase and lipase measurements have not been helpful as a screening tool to detect pancreatic injuries. However, one primarily adult study suggests that a delayed measurement may be useful.

Materials and methods

A retrospective chart review was conducted of patients admitted to a Level I paediatric trauma centre from April 1996 to November 2006 with traumatic pancreatic injuries.

Results

The trauma database identified 51 patients with traumatic pancreatic injuries. Inclusion and exclusion criteria were met by 26 patients.Patients with initial amylase and lipase levels measured greater than 2 h post-injury were more consistently elevated compared to those patients who had levels measured at 2 h or less post-injury. There was a significant association between time of measurement and an increased amylase level (p = 0.012). No significant association was found for lipase measurements (p = 0.178).

Discussion and conclusions

In children with blunt pancreatic injury, elevated serum amylase levels were seen in a significantly higher percentage of patients with initial measurements at greater than 2 h post-injury compared to those measured at 2 h or less. Lipase measurements demonstrated a similar trend. Delayed amylase and lipase measurements may be helpful to detect pancreatic injuries, but further study is needed.     

Improved trauma patient outcomes after implementation of a dedicated trauma admitting service

Background

Regionalised trauma systems have been shown to improve the outcome of seriously injured patients. However, it is not clear which components of these systems have the most impact on patient outcomes. The study evaluates the association between implementation of a single, dedicated trauma admitting service at an urban trauma centre and subsequent patient outcomes.

Methods

This was a retrospective review of prospectively collected trauma registry data at the St George Public Hospital, a level I urban trauma centre in Sydney, Australia. Two concurrent 18-month periods, before and after implementation of a full-time trauma service, were compared for differences in patient mortality, complication rates, and ED, ICU and hospital lengths of stay.

Results

There were 962 patients admitted to the hospital in the 18 months immediately preceding the implementation of the trauma service (the PRE group) and 990 patients in the subsequent 18 months (the POST group). There were no significant differences between groups with respect to patient demographics or mechanism of injury, although a higher proportion of patients in the POST group had injury severity scores (ISS) above 15 (30.6% versus 24.8%, p = 0.02). There was an 8% reduction in death rate among the most severely injured patients (ISS > 15), in the POST group as compared to the PRE group (12.2% and 20.2% respectively, p = 0.007).

Conclusions

The implementation of a full-time trauma service in this hospital was associated with a reduction in death rate among the most severely injured patients, and a decrease in LOS in patients with an ISS < 15.     

Venous thromboembolism after severe trauma: Incidence, risk factors and outcome

Background

Venous thromboembolic events (VTEs) are common life-threatening complications after trauma, but epidemiology and reported risk factors still vary. The purpose of this investigation was to determine the incidence of VTEs among hospitalised trauma patients, to identify potential risk factors and to assess whether their presence was associated with: (a) the magnitude and pattern of injury, (b) therapeutic interventions and (c) outcome, all by using a large population-based registry.

Patients and methods

Patient data from the Trauma Registry of the German Society for Trauma Surgery (TR-DGU) including datasets from more than 35,000 trauma patients were screened for all clinically relevant VTEs, i.e. deep vein thrombosis (DVT) and pulmonary embolism (PE). A total of 7937 patients were identified for further investigation and multivariate logistic regression analyses were performed to assess potential risk factors for VTEs and to evaluate the effect of VTEs on outcome.

Results

One hundred forty-six of 7937 patients developed clinically relevant VTEs during post-traumatic hospitalisation corresponding to an overall incidence rate of 1.8%. Two-thirds (97/146) of all VTEs occurred during the first 3 weeks after admission.At the time point of the event 118/146 (80.8%) patients were under either mechanical or chemical prophylaxis. Multivariate analysis with VTE as dependent variable identified injury severity score, the number of operative procedures, pelvic injury (abbreviated injury scale ≥ 2) and concomitant diseases (i.e. diabetes, renal failure, malignancies and congenital or acquired coagulation disorders) as independent risk factors. The presence of VTEs was associated with higher frequencies of sepsis (25% vs. 9.1%), single (63.6% vs. 41.3%) and multiple organ failure (49% vs. 25%) and prolonged in-hospital length of stay (52 ± 34 days vs. 29 ± 30 days; all p < 0.001). The mortality in the VTE group totaled 13.7% vs. 7.4% in the non-VTE group (p = 0.004). The presence of PE was associated with a mortality rate of 25.7%. The adjusted odds ratio of post-traumatic VTEs for hospital mortality was 2.08 (CI₉₅ 1.15-3.78; p = 0.016).

Conclusion

The occurrence of clinically apparent VTEs during post-traumatic hospitalisation is low but associated with increased morbidity and mortality. Conclusions about the effectiveness of different thromboprophylactic measures could not be drawn, since detailed information was not recorded. However, 80.8% of VTE patients had received thromboprophylaxis at the time point of the event.     

Bosentan reduces oxidative burst in acid aspiration-induced lung injury in rats

Background

Acid aspiration induces lung injury by causing an intense inflammatory reaction. Neutrophils are attracted by various cytokines, such as TNFβ, and release reactive oxygen species, which then cause acute lung injury. Endothelin antagonists, such as bosentan, have been found to possess anti-inflammatory properties.

Materials and methods

We performed a prospective, randomised, controlled study to evaluate the effects of bosentan in a rat model of acid-induced lung injury. Sprague-Dawley rats underwent sevoflurane anaesthesia; lung injury was then induced by instillation of 1.2 mL/kg, 0.1 M hydrochloric acid. The lungs were ventilated for 6 h and then randomised into three groups: bosentan 30 mg/kg body weight, 90 mg/kg body weight or sodium chloride, each applied immediately after acid aspiration via a gastric tube.

Results

After induction of acute lung inflammation, the production of reactive oxygen species by PMN following stimulation with FMLP increased significantly. Comparison of pre-treatment and post-treatment in the 90 mg/kg bosentan treatment group did not show a significant increase of reactive oxygen species following stimulation with FMLP. A comparison of the absolute difference of the MESF demonstrated a significant difference between the control group and the group treated with 90 mg/kg bosentan.

Conclusions

Bosentan administration at 90 mg/kg body weight reduced the release of reactive oxygen species after 360 min in acid aspiration-induced lung injury in rats.