Erythropoietin measurements in severely traumatized patients

Background: Despite numerous studies in critically ill patients, physiological adaptation to acute anaemia and the pattern of erythropoietin (EPO) secretion has not been well described in severely injured patients. The aim of this study was to describe EPO secretion and its relationship with haemoglobin (Hb) levels in severely injured patients.
Methods: We performed an observational, prospective clinical study in our intensive care unit (ICU). For all patients with severe trauma (Injury Severity Score>15), EPO measurement was obtained on admission, during the first 3 days and then when Hb level was measured. Maximal EPO level (EPOmax) and minimal Hb level (Hbmin) during the ICU stay was determined for all patients.
Results: One hundred and seventy-one consecutives patients were included (440 EPO measurements). Seventy-nine patients (46.2%) showed an increased value (≥25 UI/l) EPOmax value. Most EPOmax values were observed early after the trauma [within 4 days for 63 patients (82.8%)].
Plotting EPOmax to Hbmin values show that a threshold Hbmin value of 105 g/l best discriminated patients with and without an elevated EPO secretion. Less than 10% of the patients with Hbmin<105 g/l did not increase their EPO secretion.
Conclusion: In severely traumatized patients a marked response to acute anaemia is observed in most patients. In our study, Hb threshold for a significant EPO secretion following post-traumatic acute anaemia was 105 g/l. The peak level was achieved early in the course of the anaemia.     

Glucose turnover and recycling in colorectal carcinoma.

Glucose metabolism is affected by various pathologic states including tumors. In this project, glucose turnover and recycling rates in 11 patients with colorectal carcinoma were measured using a double-labelled 3-3H and 1-14C glucose injection technique. Fasting blood glucose, lactate, pyruvate, alanine, glycerol, 3-hydroxybutyrate, acetoacetate, plasma cortisol, and plasma insulin concentrations were also measured. No patient in the study had a history of diabetes mellitus or endocrine disorders, nor any abnormal liver function tests. The findings demonstrated a significantly elevated glucose turnover rate in patients with Dukes C and D lesions in comparison to patients with Dukes B lesions. Cori recycling rates were not significantly different between Dukes B vs. Dukes C and D patients. There were no differences between Dukes B and Dukes C and D patients in any of the metabolites measured. Furthermore, there were no significant differences in glucose turnover or recycling rates as a function of pre-illness weight loss. These data suggest that, when colorectal carcinoma extends beyond the limits of the bowel wall, glucose metabolism is significantly altered.     

A population-based study on pneumothorax in severely traumatized patients

BACKGROUND: Pneumothorax (PNX) is a recognized cause of preventable deaths in trauma patients. Our objective was to determine the incidence of traumatic PNX, the characteristics of its victims, and the treatment they receive. METHODS: The study consisted of data set of a population-based study on major trauma. RESULTS: The incidence of PNX was 81 per 1 million population per year, mostly caused by transport accidents. PNX victims generally had multiple injuries, and they showed on-scene clinical parameters worse than victims of other chest injuries of comparable severity. Fifty-three percent of PNXs were drained during the prehospital and early (< 2 hours) hospital course. There was no uniformity of treatment among different types of rescue facilities, some of them never performing decompression despite clinical need. The z statistic for mortality was -0.63. CONCLUSION: PNX can be expected in one in five major trauma victims found alive. PNX is associated with a peculiar on-scene instability. Early decompression is often required. The effects of wider access to prehospital decompression and the reasons for its uneven availability in our setting need elucidation. Nevertheless, the present mortality follows the international standards.     

Infections in severely traumatized children.

To study the incidence and types of infection among severely traumatized children, we reviewed the medical charts of 212 children, hospitalized following traumatic injury, who received antibiotics at sometime during their hospitalization. Infection occurred in 19%. Eleven children had trauma-related infections, whereas 29 (71% of those infected) had 36 nosocomial infections. Tracheitis, sepsis, and urinary tract infections were the most common nosocomial infections and were diagnosed in the second week (10 +/- 3 days) following injury. Nosocomial infections were more likely to develop in children who were more severely injured and who had a greater number of invasive procedures. Severe head injury (cerebral edema or subarachnoid hemorrhage) was more common in those with nosocomial infection (P < .0002, odds ratio 6.8, 95% confidence interval 2.2 to 21.3). Those without these injuries were much less likely to develop nosocomial infections (specificity 97% and negative predictive value 86%). Finally, the development of any nosocomial infection prolonged the hospitalization by a mean of 16 +/- 6 days when comparing children with the same degree of traumatic injury. Prevention of nosocomial infection in children with severe trauma will significantly reduce length of hospitalization.     

Acute acalculous cholecystitis in severely traumatized patients: a prospective sonographic study

Summary Acute acalculous cholecystitis is a well known complication in severely traumatized patients. Existing data originate from retrospective analyses and episodic case reports. In a prospective ultrasonographic study 25 polytraumatized patients admitted to our intensive care unit between January 1, 1989, and December 31, 1989, were examined in daily intervals for this condition. Trauma scoring was performed according to the injury severity score (ISS) and polytrauma score (PTS). Stress cholecystitis was defined as a combination of hydrops of the gallbladder, an increased mural thickness (>3.5 mm), and the demonstration of sludge. We were able to demonstrate this diagnostic triad in four out of 25 patients (=16%). As a consequence early elective cholecystectomy was done in one patient. The remaining patients were treated conservatively. The incidence of stress cholecystitis in severely traumatized patients is probably higher than figures so far published suggest. Ultrasonography is a reliable method of early detection and follow-up for this complication.     

Craniotomy during ECMO in a severely traumatized patient

Summary Extracorporeal membrane oxygenation (ECMO) can be a last resort treatment in acute respiratory distress syndrome after thoracic trauma. However, co-existent brain trauma is considered to be a contra-indication for ECMO. This is the first report on successful craniotomy under ECMO treatment in a multiply traumatized patient with severe thoracic and brain injuries. This successful treatment with beneficial neurological outcome suggests that ECMO therapy should not be withheld from severely injured patients with combined brain and thoracic trauma presenting with life-threatening hypoxemia. Moreover, even craniotomy may be performed during ECMO therapy without major bleeding and adverse effects on neurological function.     

Relating micromechanical properties and mineral densities in severely suppressed bone turnover patients, osteoporotic patients, and normal subjects

Mineralization of bone, from the tissue level to whole bones, is associated with mechanical properties. The relationship between bone tissue mineralization and micromechanical properties may be affected by age, disease, and drug treatment. Patients with severely suppressed bone turnover (SSBT) suffered atypical fractures while on bisphosphonate treatment. The role of tissue level mineralization in predicting material level properties of SSBT bone may be different from that of other osteoporotic patients and of normal subjects. The aim of this study was to compare the relationships between mineralization and micromechanical properties of bone biopsies from patients with SSBT, bisphosphonate-naive osteoporotic patients with typical vertebral fracture, and normal young and age-matched subjects. We used nanoindentation and quantitative backscattered electron microscopy to characterize the elastic modulus, contact hardness, plastic deformation resistance, and tissue mineralization of the biopsies at site-matched locations within each biopsy. The linear mineralization-mechanical property relationships were different among the groups with respect to the intercepts for only cortical bone tissue but not the slopes for cortical and trabecular bone tissues. For a given mineral density, there was a trend of greater plastic deformation resistance in SSBT cortical bone compared to young normal bone. Similarly, there was a trend of greater plastic deformation resistance in osteoporotic trabecular bone compared to young normal bone for a given mineral density. The age-matched normal group had higher elastic modulus and a trend of higher contact hardness compared to the young normal group for a given mineral density. However, the mechanical property-mineralization relationships within an individual were weak, and only 21 of 53 biopsies that were analyzed had at least one significant association between mineralization and a mechanical property measurement for either cortical or trabecular bone tissues. The average properties of microstructural regions (deep and superficial remodeling packets in trabecular bone; osteonal and interstitial regions in cortical bone) were consistent with mineral accumulation with tissue age, with the exception of the SSBT group. SSBT trabecular bone deep packets had higher hardness and plastic deformation resistance than superficial packets, but mineralization levels and tissue modulus were not different between packet types. We conclude that relationships between mineral and mechanical properties were different between fracture and normal groups and between young and old normal groups, and that atypical fracture may be associated with changed microstructural material properties and tissue level mineralization compared to osteoporotic patients with vertebral fracture and normal subjects. We hypothesize that tissue level bone quality may be an important determinant in fracture risk, such that tissue mineral density may predict different material properties in different patient groups.     

严重下肢创伤后病理畸形与修复

目的 探讨下肢创伤后病理畸形与修复。方法 对332例严重下肢创伤后患者的病史、体征、x线检查等的分析以及对11种手术方法修复软组织、骨缺损等的评价。结果 主要病理畸形:①软组织缺损或骨缺损、骨髓炎;②大范围骨外露、骨坏死并创面感染;③贴骨瘢痕及慢性溃疡;④肌肉麻痹等。应用皮瓣修复创面284例均成功。骨瓣治疗骨不连、骨缺损均愈合。随访2～5年,下肢功能改善,无1例因病废而截肢。结论 根据下肢不同病理畸形,选择最佳修复方法,能获得良好效果。     

Cultured epithelial autografts in extensive burn coverage of severely traumatized patients: a five year single-center experience with 30 patients

OBJECTIVE: We report recent five-year experience in a large, single center series of severely burned and otherwise traumatized patients given cultured epithelial autografts (CEA) from a single commercial laboratory. SUMMARY BACKGROUND DATA: Initial optimism over CEA application has been tempered by subsequent reports asserting that this modality is unreliable and expensive. Discussion continues over its clinical role. METHODS: From 1991 to 1996, CEA were applied to a mean 37+/-17% of total body surface area (TBSA) of 30 patients. These patients had 78+/-10% average burn size, 65+/-16% average third-degree burn size, 90% prevalence of endoscopically confirmed inhalation injury and 37% prevalence of other serious conditions. RESULTS: CEA achieved permanent coverage of a mean 26+/-15% of TBSA, an area greater than that covered by conventional autografts (a mean 25+/-10% of TBSA). Survival was 90% in these severely burned and otherwise traumatized patients. Final CEA take was a mean 69+/-23%. In subset analyses, only younger age was significantly associated with better CEA take (p = 0.0001 in univariate analysis, p<0.04 in multivariate analysis, Student's t-test). CONCLUSIONS: Epicel CEA successfully provided extensive, permanent burn coverage in severely traumatized patients, proving an important adjunct to achievement of a high survival rate in a patient population whose prognosis previously had been poor. In our experience CEA appear to have a very high beneficial value in the management of bur ns >60% TBSA. In some cases studied it is very likely that CEA was a life-saving treatment.