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Biomedical subjects

A Trupka

Publications and source records attributed to A Trupka.

At least 19 recordsLinked to original sources
PubMed2001

Minimally invasive video-assisted parathyroidectomy.

BACKGROUND: The standard surgical procedure for parathyroidectomy consists of bilateral cervical exploration and the visualization of all four parathyroid glands. However, improved preoperative localization techniques and the availability of intraoperative intact parathyroid hormone (iPTH) monitoring now allow single adenomas to be treated with minimally invasive techniques. METHODS: Patients with primary hyperthyroidism (pHPT), who were found to have one unequivocally enlarged parathyroid gland on preoperative ultrasound and 99mTc-SestaMIBI scintigraphy underwent minimally invasive video-assisted parathyroidectomy by an anterior approach. Intraoperatively, rapid electrochemiluminescense immunoassay was used to measure iPTH levels shortly before and 5, 10, and 15 mins after excision of the adenoma. The operation was considered successful when a >50% decrease in preexcision iPTH levels was observed after 5 min. RESULTS: Between November 1999 and May 2000, 10 of 22 patients with pHPT were deemed eligible for the minimally invasive approach. In all cases, the adenoma was removed successfully. However, in two cases, intraoperative iPTH monitoring did not show a sufficient decrease in iPTH values. Subsequent cervical exploration revealed a double adenoma in one case and hyperplasia in the other. CONCLUSIONS: Even when high-resolution ultrasound and 99mTc-SestaMIBI scintigraphy are used, the presence of multiple glandular desease cannot be ruled out entirely. When the minimally invasive approach is contemplated, intraoperative iPTH monitoring is indispensible to ensure operative success. However, in selected cases, minimally invasive parathyroidectomy represents an excellent alternative to the conventional technique.

Adenoma↗
PubMed2001

[Intraoperative monitoring of intact parathyroid hormone (iPTH) in surgery of primary hyperparathyroidism with a new rapid test].

OBJECTIVES: Intraoperative differentiation between adenoma and hyperplasia during surgery for primary hyperparathyroidism (pHPT) is sometimes difficult, but essential for good results. The aim of our study was to evaluate a new highly sensitive electrochemiluminescence immunoassay (ECLIA) for intraoperative monitoring of intact parathyroid hormone (iPTH) following parathyroidectomy as an adjunct for identification of solitary adenoma in patients with pHPT. METHODS: Thirty consecutive patients with pHPT (2 with recurrent pHPT) were examined following a standardized protocol: Immediately before and 5, 10 and 15 min following parathyroidectomy of the enlarged gland, iPTH was measured with a new ECLIA (Roche-Diagnostics, Mannheim, Germany). The results were available within 15-20 min. Besides 20 conventional bilateral neck explorations, parathyroidectomy was carried out in a minimally invasive video-assisted technique (MI-VAP) in 10 patients. RESULTS: Among the 30 patients we found 24 with solitary adenoma (80%), 5 with hyperplasia (17%) and one with a double adenoma (3%). Five minutes after removal of a solitary adenoma the level of iPTH had decreased by 65 (12)% [mean (+/- SD)], after 10 min by 76 (8)% and after 15 min by 81 (8)%. All patients with multiple gland disease could be clearly identified, as iPTH after 15 min did not fall below 50% of basal value. Only after removal of all hyperplastic glands did iPTH decrease to the normal range. Sensitivity and specificity for prediction of a solitary adenoma were 92% and 100% (decline of iPTH more than 50% from baseline value 5 min after parathyroidectomy). In one patient with recurrent pHPT intraoperative sampling from different sites in both internal jugular veins could predict the quadrant of the enlarged gland. Correlation (r) between the results of the quick and the conventional assay, which requires 24 h of incubation, was 0.955. All patients had normal or low calcium levels postoperatively. CONCLUSIONS: (1) Intraoperative monitoring of iPTH with this new quick assay allows safe identification of patients with solitary adenoma during surgery for pHPT. (2) It represents a valuable adjunct to surgical skill not only in primary operations for pHPT but especially in cases of recurrent surgery for pHPT. (3) With this test available minimally invasive techniques for parathyroidectomy may be employed in cases of preoperatively localized adenoma (ultrasound, sesta-mibi scan), avoiding bilateral neck exploration with its higher potential for complications.

Adenoma↗
PubMed2001

[The use of an underlay polypropylene mesh in complicated incisional hernias: sucessful French surgical technique].

BACKGROUND: Incisional hernia repair with conventional techniques is associated with high recurrence rates of 30-50%. Surgical repair using different prosthetic biomaterials is becoming increasingly popular. On the basis of the favourable results by French surgeons, the results of underlay prosthetic mesh repair using polypropylene mesh in complicated and recurrent incisional hernias have been studied. METHODS: After preparation and excision of the entire hernia sac, the peritoneum and posterior rectus sheath are closed with a continuous looped polyglyconate suture. The prosthesis used for the midline hernias is positioned on the posterior rectus sheath and extends far beyond the borders of the myoaponeurotic defect. The prosthesis for lumbar and subcostal hernias is placed in a prepared space between the transverse and oblique muscles. Intraperitoneal placement of the mesh must be avoided. Between January 1997 and September 1998 a total of 57 incisional hernia repair (25 primary hernias, 32 recurrent hernias) have been performed using this technique (28 women, 29 men, mean age 56+/-13 years). RESULTS: Local complications occurred in 6 patients (11%). One patient suddenly died on the 3rd postoperative day from severe pulmonary embolism (mortality 1,7%). Thirthy-seven patients with a minimum follow-up of 6 months were reexamined clinically (follow up time 6-33 months). Till now one recurrent hernia has been observed. There were only minor complaints like a feeling of tension in the abdominal wall (n = 3) and slight pain under physical stress (n = 9). CONCLUSIONS: The aforementioned technique of underlay prosthetic repair allows an anatomical and consolidated reconstruction of the damaged abdominal wall with excellent results and low complication rates especially in high risk patients and complicated hernias.

Female↗
PubMed2000

Laparoscopic loop colostomy for advanced ovarian cancer, rectal cancer, and rectovaginal fistulas.

OBJECTIVES: The objectives of this study were to present a minimal invasive technique of intestinal diversion for selected cases of advanced inoperable ovarian cancer, rectal cancer, and rectovaginal fistulas, and to discuss indications, pitfalls, and potential complications. METHODS: The technical features of laparoscopic colostomy are described. RESULTS: Between August 1995 and July 1997 laparoscopic colostomy was successfully carried out in 12 patients with advanced ovarian cancer, inoperable carcinoma of the rectum, or rectovaginal fistulas. There were no intraoperative or postoperative complications and postoperative recovery was rapid, with all patients having function of the colostomy within 24 h and regaining their preoperative state of mobility on the second postoperative day. CONCLUSION: The laparoscopic approach allows careful selection of the colostomy site and easy mobilization of the colon, causing only little disruption to intestinal function and, hence, improving postoperative recovery. From our experience, laparoscopic colostomy is in most cases a simple and safe operation and can be used as the preferred technique of intestinal diversion.

Colostomy↗
PubMed1999

Safe creation of pneumoperitoneum using an optical trocar.

The blind insertion of the Veress needle and the first trocar may cause serious complications. Therefore, many surgeons perform a minilaparotomy to safely position the first trocar. However, especially in obese patients, the dissection may be difficult and time consuming. As an alternative, optical trocars can be safely positioned under direct visualization. We report on our experience with the Optiview trocar in 200 patients and describe our preferred insertion technique. In our opinion, optical trocars are safe and easy to handle, offering several advantages over the use of the Veress needle and the minilaparotomy.

Humans↗
PubMed1998

[Open and laparoscopic liver resection with a new ultrasound scalpel].

We report on our experience with a new ultrasonically activated scalpel that has been developed for laparoscopic surgery. It works by means of a longitudinally vibrating blade or scissors and can be used for tissue dissection, coagulation and preparation. The high-frequency vibration causes denaturation of protein and thus allows coagulation of small vessels up to 2-3 mm. The most important advantages compared to electrocautery are very limited heat generation, no production of smoke and the lack of current flow through the patient. Because of this, the ultrasonically activated scalpell is an excellent instrument for different types of laparoscopic surgery, as well as for open liver resection.

Adult↗
PubMed1998

[Abdominal trauma].

While a great part of the Anglo-American medical literature addresses the topic of penetrating trauma the German speaking countries rather publish on blunt abdominal injury. The presented paper discusses the strategic principles of acute clinical management of abdominal trauma on the combined basis of own research results and a comprehensive review of the literature. Blunt abdominal injuries in most cases from a part in the pattern of multiple trauma. The early, first-hours mortality is most often caused by severe traumatic brain injury or abdominal trauma with massive hemorrhage. The prehospital management of penetrating injuries is characterized rather by the concept of 'load and go', whereas the onscene stabilization of the patient with blunt abdominal injury should precede transport to the adequate hospital. On arrival in the accident and emergency room an immediate blood transfusion is recommended for hemodynamically unstable patients. If then a stabilization is not achieved, an emergency laparotomy should follow. Abdominal stab injuries should be explored by laparoscopy if an intraperitoneal lesion is suspected. If then the possibility of an intestinal lesion is present a laparotomy should be performed directly thereafter. Firearm injuries require open revision in almost all cases. The standard diagnostic technique in blunt abdominal trauma is sonography, assisted by computed tomography and, if indicated, angiography in hemodynamically stable patients. Isolated abdominal injuries without hemodynamic or coagulation disorders allow conservative treatment in the intensive care setting. In severe multiple trauma as well as in manifest shock even the smallest fluid detection should lead to laparotomy. The surgical treatment of splenic rupture is still a matter of discussion. Splenectomy is indicated in patients with severe concomitating injuries or shock whereas in the remainder of cases the total or partial preservation of the spleen should be pursued. Hepatic injuries offer a broad spectrum of operative interventions, ranging from superficial hemostatic measures over compression techniques like 'packing' and 'mesh-wrapping' to atypical and anatomical resections and to liver transplantation in exceptional cases. Lesions of tubular organs and the pancreas pose especially difficult diagnostical problems but regularly allow a rather easy operative treatment.

Abdominal Injuries↗
PubMed1998

[Thoracic trauma].

Blunt chest trauma is the leading cause of thoracic injuries in Germany, penetrating chest injuries are rare. Hereby, single or multiple rib fractures, hemato-pneumothorax and pulmonary contusion represent the most common injuries. The early management of thoracic injuries consists of detection and sufficient therapy of acute life threatening situations like tension pneumothorax, acute respiratory insufficiency or severe intrathoracic bleeding. Most of the isolated thoracic injuries are adequately treated by conservative means, sufficient analgesia, drainage of intrapleural air or blood, physiotherapy and clearance of bronchial secretions provided; operative intervention is rarely indicated. In multiple injured patients however, severe blunt chest trauma and especially pulmonary contusion negatively affects outcome with a significant increase of morbidity and mortality. Hence, patients with this combination of pulmonary injuries, such as lung contusion and associated severe injuries, carry a particular high risk of respiratory failure, ARDS and MOF with a considerable mortality. Therefore, early exact diagnosis of all thoracic injuries is essential and can be achieved by thoracic computed tomography, which becomes more and more popular in this setting. Early intubation and PEEP-ventilation, alternate prone and supine positioning of multiple injured patients with lung contusion and differentiated concepts of volume- and catecholamine therapy represent the basic therapeutic principles. Additionally, the entire early trauma management of multiple injured patients must focus on the presence of pulmonary contusion. Every additional burden on their pulmonary microvascular system like microembolisation during femoral nailing, the trauma burden of extended surgery or mediator release in septic states may cause rapid decompensation and organ failure and therefore, has to be avoided.

Cause of Death↗
PubMed1998

High-dose antithrombin III treatment of severely injured patients: results of a prospective study.

BACKGROUND: Antithrombin III (AT III) treatment has been shown to reduce disseminated intravascular coagulation and to inhibit thrombin, which plays a central role in the activation of platelets and other inflammatory systems in conditions with severe inflammation. The objective of this study was to evaluate the influence of early and high-dose administration of AT III to patients with severe multiple injuries on the inflammatory response and outcome. METHODS: In a placebo-controlled, double-blind study, 40 consecutive patients with Injury Severity Scores of 29 or greater who met the inclusion criteria were randomized to receive either AT III or placebo within 360 minutes after trauma. Twenty patients were administered AT III for a period of 4 days, aiming to achieve AT III concentrations of 140% of normal. RESULTS: The AT III and placebo groups were comparable with respect to Injury Severity Score, age, incidence of blood pressure less than 80 mm Hg on admission, initial base deficit, and start of the test drug. The patients in the AT III group received a total of about 20,000 IU during the first 4 days. AT III levels of 130 to 140% could be achieved by this regimen, whereas in the control group the AT III concentration averaged about 70%. In the AT III group prothrombin tended to be elevated and prothrombin fragment F1+2 as well as thrombin-AT III complex tended to be lower on the first day. No differences between groups, however, could be observed with respect to partial thromboplastin time, prothrombin time, platelets, plasminogen activator inhibitor I, soluble tumor necrosis factor receptor II, neutrophil elastase, interleukin (IL)-1 receptor antagonist, IL-6, and IL-8. Mortality (15 vs. 5%), incidence of respiratory failure (55 vs. 55%), duration of mechanical ventilation (13 vs. 12 days), and length of stay in the surgical intensive care unit (19 vs. 21 days) were also similar in both treatment groups. The duration of organ failure, however, was shorter in the patients receiving AT III. CONCLUSION: The early and high-dose administration of AT III to patients with severe blunt trauma appears not to attenuate the posttraumatic inflammatory response or to significantly improve outcome.

Adult↗
PubMed1998

[Laparoscopic colostomy--experiences with inoperable ovarian and rectum carcinomas and rectovaginal fistulas].

Between August 1995 and July 1997 laparoscopic colostomy was successfully carried out in 10 patients with advanced ovarian cancer, inoperable carcinoma of the rectum or rectovaginal fistulae. There were no intraoperative or postoperative complications and postoperative recovery was rapid with all patients having function of the colostomy within 24 h and regaining their preoperative state of mobility on the second postoperative day. The laparoscopic approach allows the careful selection of the colostomy site, easy mobilisation of the colon causing only little disruption to the intestinal function and hence, improving postoperative recovery. From our experience, laparoscopic colostomy is a simple and safe operation in most cases and can be used as the preferred technique of intestinal diversion. The technical features of laparoscopic colostomy are described.

Aged↗
PubMed1997

[Dislocated multiple fragment fractures of the head of the humerus. Does dislocation of the humeral head fragment signify a worse prognosis?].

PROBLEM: The vascularity of the articular fragment is of key importance for the final outcome in three- and four-part fractures of the humeral head. Displacement of the articular segment may compromise the arterial blood supply to the humeral head and result in avascular necrosis. There is still controversy as to whether three-and four-part fracture dislocations (articular fragment outside the glenoid) have an even worse prognosis than displaced three- and four-part fractures. PATIENTS AND METHODS: Between January 1985 and May 1993, 102 patients with three- and four-part fractures of the humeral head were treated by ORIF (mostly tension band wiring) at our institution. In a retrospective study we analysed the functional (Constant 100 point score) and radiological outcome of 67 (66%) of these patients. There were 21 patients with fracture dislocations (FD), n = 5 type B2X, n = 5 type B3X, n = 3 type C2X, n = 8 type C3X, according to the classification of Habermeyer [7]. The "X" represents the dislocation of the articular fragment, whereas the classification to each type is done after reduction of the head. The remaining 46 patients presented with displaced, but not dislocated, three- and four-part fractures (DF), n = 24 type B2, n = 7 type B3, n = 3 type C2, n = 12 type C3. Average follow-up was 25 months (7-72 months). Patients with FD were significantly younger (average age 50 years) than patients with DF (average age 63 years, P < 0.05) and showed a significantly higher incidence of traumatic nerve or plexus lesions (FD 19%, DF 2%, P < 0.05). RESULTS: Concerning the functional results, there was no statistically significant difference between the two groups. The FD patients even showed a slight tendency to better results than patients with DF. This was true for the three-part fractures (average Constant score 78 versus 67 points), as well as for the four-part fractures (average Constant score 62 versus 55 points). The significantly younger age of the FD patients may explain their better results. The entire group of patients with three-part fractures showed a significantly better functional outcome (average Constant score 68 points) than patients with four-part fractures (average Constant score 55 points, P < 0.05). The rate of partial and total avascular necrosis of the humeral head was strongly correlated to the fracture type (number of fragments, fracture of the anatomical or surgical neck, according to the classification of Habermeyer),but again there was no difference between the FD and DF group (B2X: 20%, B3X: 20%, C2X: 33%, C3X: 63%; B2: 25%, B3: 29%, C2: 33%, C3: 67%). Astonishingly, the FD were not associated with an increased rate of avascular necrosis of the humeral head. Three (axillary nerve) out of the five observed primary nerve and plexus lesions had a full neurological recovery after 6-12 months; the two patients with alterations of the brachial plexus showed a slow tendency of improvement at follow-up (12 and 18 months), but still had gross muscular atrophy and impaired sensory function. CONCLUSION: In displaced three-and four-part fractures of the humeral head the dislocation of the articular segment does not seem to increase the risk of avascular necrosis, if treated by timely and careful ORIF with respect to the vascularity. Even with the increased risk of primary nerve and plexus lesions in fracture dislocations, good functional results can be achieved by early operative nerve decompression and fracture stabilization in this middle-aged patient group. However, older patients with displaced or dislocated four-fragment fractures through the anatomical neck (type C3) have a poor chance of a favourable outcome, and therefore primary prosthetic replacement should be considered.

Adult↗
PubMed1997

[Shock room diagnosis in polytrauma. Value of thoracic CT].

OBJECTIVE: The aim of this prospective study was to evaluate whether early thoracic computed tomography (TCT) is superior to routine chest X-ray (CXR) in the diagnostic work-up of blunt thoracic trauma and whether the additional information obtained influences subsequent decisions on therapy in the early management of severely injured patients. PATIENTS AND METHODS: In a prospective study of 103 consecutive patients with clinical or radiological signs of chest trauma (94 multiply injured patients with chest trauma, 9 patients with isolated chest trauma) who had an average ISS of 30 and an average AIS thorax of 3, initial CXR and TCT were compared after the first assessment in our emergency department (a level I trauma center). Mortality in this group was 10% (n = 10). RESULTS: In 67 patients (65%) TCT revealed major complications of chest trauma that had been missed on CXR: lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax ((n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1); in 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT; and in 14 patients CXR and TCT showed identical pathologic results. In 11 patients neither CXR nor TCT revealed pathologic findings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (P < 0.001), pneumothorax (P < 0.005) and hemothorax (P < 0.05). In 42 patients (41%) the additional TCT findings did affect, the therapy selected: chest tube placement or chest tube correction in mostly anteriorly located pneumothoraces or large hemothoraces (n = 31), influence on ventilation mode and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), pericardiocentesis (n = 1). CONCLUSIONS: TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualizing lung contusions and pneumo- and hemothorax. Early TCT influences therapeutic management in a considerable subset of patients. We therefore recommend TCT in the primary diagnostic work-up of multiple injured patients with suspected chest trauma, because early and accurate diagnosis of all thoracic injuries along with acceptance of the implications for therapy may reduce complications and improve the outcome in polytraumatized patients with blunt chest trauma.

Adolescent↗
PubMed1997

Indicators of the posttraumatic inflammatory response correlate with organ failure in patients with multiple injuries.

BACKGROUND: Most prognostic indices for severely injured patients are based on anatomical findings and the vital signs. The posttraumatic organ failure, however, is thought to be triggered by the initial inflammatory response. The objective of this study was to evaluate the correlation between the early activation of inflammation and the rate of organ failure and death. METHODS: Sixty-six patients with multiple injuries (Injury Severity Score > 18, age 18-70 years, admission within 6 hours after accident, survival > 48 hours) were included in this prospective study. During a 14-day observation period, serial blood samples were collected starting within 30 minutes after admission. Plasma levels of neutrophil elastase, lactate, antithrombin III, and interleukin-6 and -8 were determined. The clinical course and the degree of organ failure were recorded daily until death or transfer to a general ward. RESULTS: The 66 severely injured patients had a mean Injury Severity Score of 40 points. Eleven patients died from multiple organ failure (group 1), 38 subjects survived a single or multiple organ failure (group 2), and 17 patients had an uneventful recovery (group 3). The initial plasma concentrations for neutrophil elastase (650 vs. 355 ng/mL), lactate (5.0 vs. 3.1 mmol/L), antithrombin III (48 vs. 62% from normal), interleukin-6 (703 vs. 177 pg/mL), and interleukin-8 (1,101 vs. 301 pg/mL) were significantly different between groups 2 and 3 already in the initial posttraumatic period. Patients from group 1 presented with significantly higher levels of these parameters as early as 24 hours after trauma compared with group 2. Different patterns were identified with respect to early versus late posttraumatic organ failure. CONCLUSIONS: These data show that the degree of the initial inflammatory response corresponds with the development of posttraumatic organ failure. Besides anatomically and physiologically based trauma scores, these parameters might be used as indicators for the injury severity.

Adolescent↗
PubMed1997

Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study.

OBJECTIVE: The aim of this prospective study was to evaluate whether early thoracic computed tomography (TCT) is superior to routine chest x-ray (CXR) in the diagnostic work-up of blunt thoracic trauma and whether the additional information influences subsequent therapeutic decisions on the early management of severely injured patients. PATIENTS AND METHODS: In a prospective study of 103 consecutive patients with clinical or radiologic signs of chest trauma (94 multiple injured patients with chest trauma, nine patients with isolated chest trauma), an average Injury Severity Score of 30 and an average Abbreviated Injury Scale thorax score of 3, initial CXR and TCT were compared after initial assessment in our emergency department of a Level I trauma center. RESULTS: In 67 patients (65%) TCT detected major chest trauma complications that have been missed on CXR (lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax (n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1)). In 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT, and in 14 patients CXR and TCT showed the same pathologic results. Eleven patients underwent both CXR and TCT without pathologic fundings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (p < 0.001), pneumothorax (p < 0.005), and hemothorax (p < 0.05). In 42 patients (41%) the additional TCT findings resulted in a change of therapy: chest tube placement, chest tube correction of pneumothoraces or large hemothoraces (n = 31), change in mode of ventilation and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), and pericardiocentesis (n = 1). To evaluate the efficacy of all those therapeutic changes after TCT the rates of respiratory failure, adult respiratory distress syndrome, and mortality in the subgroup of patients with Abbreviated Injury Scale thorax score of > 2 were compared with a historical control group, consisting of 84 patients with multiple trauma and with blunt chest trauma Abbreviated Injury Scale thorax score of > 2, prospectively studied between 1986 and 1992. Age (38 vs. 39 years), average Injury Severity Score (33 vs. 38), and the rate of respiratory failure (36 vs. 56%) were not statistically different between the two groups, but the rates of adult respiratory distress syndrome (8 vs. 20%; p < 0.05) and mortality (10 vs. 21%; p < 0.05) were significantly reduced in the TCT group. CONCLUSIONS: TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualzing lung contusions, pneumothorax, and hemothorax. Early TCT influences therapeutic management in a significant number of patients. We therefore recommend TCT in the initial diagnostic work-up of patients with multiple injuries and with suspected chest trauma because early and exact diagnosis of all thoracic injuries along with sufficient therapeutic consequences may reduce complications and improve outcome of severely injured patients with blunt chest trauma.

Adolescent↗
PubMed1996

Posttraumatic inflammatory response, secondary operations, and late multiple organ failure.

The objective of this study was to determine the role of surgical procedures as secondary inflammatory insults in the development of late multiple organ dysfunction syndrome in patients with multiple trauma and to evaluate both specific and nonspecific indicators of the inflammatory response in their ability to indicate the risk of severely injured patients to develop organ failure after secondary operations. In a prospective study of 106 severely injured patients (ISS 40.6) who underwent secondary operations (> 3 days after trauma), we compared the level of preoperative inflammation with the sequelae of surgical trauma. The interventions included facial reconstructions; osteosynthesis of the pelvic girdle, long bones, and spine; and others. Group 1 consisted of 40 patients (38%) who developed respiratory, renal, or hepatic failure, or combinations thereof, within 2 days after the operation or whose preexisting organ dysfunction worsened by more than 20% from baseline. The remaining 66 patients (62%) with an uneventful recovery formed group 2. The preoperative levels of neutrophil elastase (92.2 vs. 61.3 ng/dL), C-reactive protein (12.4 vs. 7.6 mg/dL), and platelet count (118,000 vs. 236,000/microL) were significantly more abnormal in the patients of group 1. PO2/FiO2 ratio was also somewhat lower in group 1 patients (305.5 vs. 351), whereas other parameters (e.g., blood pressure, heart rate, bilirubin, creatinine, urinary output, lactate, pH, and coagulation) did not allow preoperative differentiation between groups 1 and 2. An increased state of inflammation (neutrophil elastase > 85 ng/mL, C-reactive protein > 11 mg/dL, platelet count < 180,000/microL) predicted postoperative organ failure with an accuracy of 79% (sensitivity, 73%; specificity, 83%). We conclude that secondary operations may act as a second insult and may precipitate late multiple organ dysfunction syndrome if they are performed in patients with multiple trauma while they still have an increased level of posttraumatic inflammation. However, future investigations have to show whether postponing surgery until inflammation has subsided or the use of less invasive surgical techniques will decrease the rate of postoperative organ failure in the trauma patient.

Adult↗
PubMed1995

[Postoperative homeostatic imbalance after trauma surgical interventions of various degrees in polytrauma].

The objective of this study was to evaluate and compare the derangement of body homeostatis and the inflammatory response after different types of traumatological operations in patients with multiple injuries. These were determined in a total of 60 operations. The procedures comprised osteosynthesis of the femur (n = 28), the pelvic girdle (n = 11) the spine (n = 8), and facial and basal skull reconstructions (n = 13). Specific and unspecific parameters of the inflammatory response were determined on the morning of the operation, immediately after the procedure, every 6 h on the 1st day and 48 h after the end of surgery. After all types of operations (pelvis, femur, spine, face/basal skull) significant alterations were observed for neutrophil elastase, C-reactive protein, interleukin 6, interleukin 8, antithrombin III, partial thromboplastin time and other parameters. The degree of postoperative changes differed significantly (Kruskal-Wallis test, P < 0.05) among the four types of operations for lactate, heart rate, PO2/FiO2 ratio and nitrogen excretion and showed a strong discriminating tendency for neutrophil elastase and C-reactive protein. The changes were most pronounced after operations on the pelvic girdle, followed by procedures in the femoral, spinal, and facial/basal skull regions. We conclude that a considerable inflammatory response and pronounced disturbance of body homeostasis follow traumatological operative procedures, varying in severity with the type of surgery. Several parameters allow quantitation of the surgical trauma and differentiation between different operations/regions. Further research should focus on the interrelationship between pre-existing preoperative inflammation and the additional trauma inflicted by surgery in patients with severe injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute-Phase Reaction↗
PubMed1995

[Effect of early intubation on the reduction of post-traumatic organ failure].

In a prospective multiple trauma study lasting from 1986 to 1991 the influence of early intubation (EI) within 2 h after the accident on posttraumatic (multiple) organ failure (M)OF was compared with that of delayed intubation (DI) in 131 patients with multiple injuries (ISS 37). The indications for intubation were unconsciousness following severe head injury in 45 cases (45 EI, 0 DI), major chest trauma (AIS > or = 3) in 40 (31 EI, 9 DI) and other severe injuries (no head or chest trauma, but ISS > 24) in 40 patients (30 EI, 10 DI). One hundred and six trauma victims (81%) were intubated early and 19 patients (14.5%) required intubation and artificial ventilation in the later course, whereas in 6 subjects (4.5%) spontaneous respiration was adequate. The pattern of injured body regions did not differ substantially between the two groups, but the severity of injury was significantly greater (p < 0.001) in the EI group (ISS 39) than in the DI patients (ISS 29). Among the EI patients, 67% developed at least one OF, 45% respiratory failure (RF), and 28% multiple organ failure (MOF); 15% died. The DI group showed almost the same incidence of RF (42%) and other OF (63%), and even a higher (n.s.) incidence of MOF (37%) and mortality rate (26%). In view of the significantly less severe injuries in the DI group, the observed OF and mortality rates are inappropriately high compared with the incidence of OF and death in the EI group.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗