Damage control orthopaedics in polytraumatized patients- current concepts

The principles of fracture management in patients with multiple injuries continue to be of crucial importance. Early treatment of unstable polytraumatized patients with head, chest, abdomen or pelvic injuries, with blood loss followed by immediate fracture fixation (Early Total Care -ETC) may be associated with secondary life threatening posttraumatic systemic inflammatory response syndrome (SIRS). Development of SIRS is typically a function of the type and severity of the initial injury (the “first hit”). Immediate Fracture fixation, using reamed nails or plates, in such unstable patients with multiple injuries is subsequently defined as the “second hit” and may be associated with development of acute respiratory distress syndrome (ARDS) and multiple organ failure (MOF), with relatively high morbidity and mortality.The other alternative for long bone fracture fixation in unstable polytraumatized patients is based on immediate treatment of life threatening conditions related to the injuries, followed by the initial use of minimally invasive modular external frames for long bone fractures and is called Damage Control Orthopedics (DCO) and is widely accepted. In order to refine the DCO concept and to avoid an overuse of external fixation, the “Safe Definitive Surgery” (SDS) concept has been introduced, which is a dynamic synthesis of both strategies (ETC and DCO). The SDS strategy employs clinical parameters and includes repeated assessment of patients. The following paper is going to summarize historical backgrounds and recent concepts in treatment of polytraumatized patients.     

Septischer Schock und multiples Organversagen in der chirurgischen Intensivmedizin

Zusammenfassung Beschrieben wird ein tierexperimentelles Sepsismodell, das der Problematik chirurgischer Intensivpatienten entspricht. Nach rezidivierender Applikation von E.-coli-Endotoxin W0111:134 unter standardisierten Bedingungen konnten spezifische hämodynamische, biochemische (TNF, TXA₂, PG I₂, IL-6, PAF) und morphologische Veränderungen (pulmonales Endothel) nachgewiesen werden. Die sepsisinduzierten ARDS-Veränderungen werden mit einer Hochfrequenzdruck-und-flowmessung mit 385 Meßpunkten fiber einem Atemzyklus analysiert. Die Rolle des Darms in der Sepsis wurde mit ionenselektivem Kaliummonitoring vergleichend auf der Mukosa and Serosa untersucht. Jede Endotoxingabe wurde vom Dünndarm mit selektiven Anstiegen der Kaliumaktivität als Ausdruck einer Endotoxin-induzierten relativen Ischämie beantwortet. Das Profil der Oberflächenkaliumwerte korreliert sowohl mit dem cardiaco output als auch mit den Prostazyklinspiegeln. Die während der Versuchsdauer kontinuierlich abnehmende Mukosa-Serosa-Kaliumdifferenz kann als Nachweis einer die Sepsis katalysierenden intestinalen Permeabilitätsstörung interpretiert werden.

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Septic shock and multiple organ failure during surgical intensive care. Evaluation of pulmonary and intestinal dysfunction assessment in a porcine model

The study deals with an animal model for the problems of surgical intensive care patients. Following repeated applications of E. coli endotoxin W0111:134 under standard conditions, specific hemodynamic and biochemical (TNF, TXA₂, PGI₂, IL-6, PAF) and morphological (endothelium of the lung) alterations were detected. ARDS patterns induced by the sepsis were analyzed by high-frequency measurement of pressure and flow (385 measurements per breathing cycle). The role of the intestine in sepsis was investigated by ion-selective monitoring of surface potassium activity comparing mucosa and serosa. Every injection of endotoxin was followed by a selective increase of the potassium activity revealing relative ischemia induced by the endotoxin. The profile of the potassium levels on the surface correlates both with the cardiac output and with the prostacyclin levels. The continuous narrowing of the difference between mucosa and serosa, potassium during the period of investigation can be regarded as evidence for pathologic change in permeability fostering the septic course.

     

利用压力-容积曲线选择呼气末正压治疗急性呼吸窘迫综合征

目的探讨利用压力-容积曲线选择呼气末正压(PEEP)对急性呼吸窘迫综合征(ARDS)患者肺力学、血流动力学及动脉血气参数的影响,并选择最佳PEEP范围.方法选择16例确诊为ARDS患者,根据压力-容积曲线,设下拐点压力为PLIP,设上拐点压力为PUIP.分别选择PEEP为0、PLIP/2、PLIP、(PLIP+PUIP)/2和PUIP,测量肺力学、血流动力学及动脉血气参数的变化.结果当PEEP为PLIP/2时,动脉血氧分压与吸入氧浓度比(PaO2/FiO2)及Cst虽然较未加用PEEP时有改善(P<0.05及P<0.01),但尚未达到正常水平;当PEEP为PLIP时,PaO2/FiO2及Cst较PLIP/2时有显著提高(P<0.01),接近正常范围;当PEEP为PUIP时,PaO2/FiO2较(PLIP+PUIP)/2时显著增高(P<0.01),但Cst较PLIP时反而有所降低(P<0.01),MAP下降(P<0.01),CVP升高(P<0.01),同时Pip增高(P<0.01).结论ARDS患者行呼吸机治疗时,在PLIP～PUIP之间可有效纠正低氧血症,而对血流动力学影响较小,可获得满意疗效.     

防治SARS中药的筛选

SARS在世界范围内流行 ,在紧急阶段 ,由于临床处治方案颇有争议 ,迅速的筛选出有效的中成药供临床急用尤为重要和迫切。利用 9个药理筛选模型交叉验证的方法 ,综合评价了 30个中成药的有效性。 19个药物作为有效的药物筛选出来 ,其中 8个最有效作为控制SARS不同阶段症状的药物由全国防治非典指挥部科技攻关组在 2003年5月22日对全国进行发布。本文就筛选的策略 ,顶层设计和主要研究思路做一介绍 ,具体试验结果将陆续发表。     

外源性肺表面活性物质在ARDS中的治疗作用

Several studies have demonstrated that alterations of pulmonary surfactant system contribute to the lung dysfunction associated with acute respiratory distress syndrome (ARDS). There have been many animal experiments and clinical investigations evaluating exogenous surfactant in ARDS models or patients. Exogenous surfactant administration has proven inconsistent as a therapeutic modality for patients with ARDS. Various factors that may influence a host response to exogenous surfactant, these factots include: the nature and severity of the underlying injury,the surfactant preparation utilized, the amount, frequency, and method of surfactant administration, the mode of ventilation used during and after surfactant delivery, and the timing or surfactant administration over the course of the illness     

大承气汤对急性呼吸窘迫综合征大鼠血小板及凝血系统的作用

[目的]通过观察大承气汤对急性呼吸窘迫综合征(ARDS)大鼠血小板及凝血系统的作用,探讨其防治ARDS的机理,为临床用药提供依据。[方法]清洁级大鼠24只,分为对照组,模型组和治疗组。每天灌胃2次,7日后检测血小板和凝血系统的变化。[结果]三组的平均血小板体积及活化部分凝血酶时间有明显差异(P<0·01)血小板计数,凝血酶时间及凝血酶原时间有明显差异(P<0·05)。[结论]大承气汤可通过影响大鼠血小板和凝血系统而使大鼠肺部微血栓减少。大承气汤可通过影响大鼠血小板和凝血系统从而有效地治疗大鼠急性呼吸窘迫综合征。     

白介素-8与急性呼吸窘迫综合征

白细胞介素8(IL-8)是由多种细胞合成与分泌的一种细胞因子,具有很强的中性粒细胞化学趋化作用.急性呼吸窘迫综合征(ARDS)患者的血清及支气管肺泡灌洗液(BALF)中IL-8水平均明显升高,它参与了肺内白细胞的募集、活化以及黏附分子的表达,在ARDS发病机制中起着重要作用.     

白蛋白输注对重症胰腺炎伴ARDS患者术中影响的研究

目的 观察、比较不同成份液体输注在重症胰腺炎伴ARDS患者术中的应用效果.方法 选取该院行胰腺坏死组织清除术的重症胰腺炎伴ARDS患者60例,随机分为对照组与观察组各30例,对照组术中予林格液输注,观察组予白蛋白输注,比较2组患者输注前后气道峰压、中心静脉压、呼吸参数、胸肺顺应性及多巴胺用量.结果 观察组输注后的气道峰压、中心静脉压、呼吸参数、胸肺顺应性均优于对照组,多巴胺用量低于对照组,2组比较差异有统计学意义（P＜0.05）.结论 白蛋白输注对重症胰腺炎伴ARDS患者术中的效果较佳,对心肺功能的作用更为积极,故价值更高.