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Andrew B Peitzman

Publications and source records attributed to Andrew B Peitzman.

17 recordsLinked to original sources
PubMed2006

Damage-control laparotomy.

PURPOSE OF REVIEW: This article summarizes the current state of damage-control laparotomy as practiced in trauma surgery. Since the first description of deliberately abbreviated laparotomy 20 years ago, damage-control laparotomy has been widely applied. The purpose of this review is to discuss current concepts in damage-control laparotomy in trauma and general surgery patients. RECENT FINDINGS: The immediate, essential goals of control of surgical bleeding and containment of gastrointestinal soilage are achieved at a truncated laparotomy. Ongoing resuscitation of the injured patient with severe physiologic derangements is continued in the intensive care unit. Only when the lethal triad of hypothermia, metabolic acidosis, and coagulopathy is corrected does the patient subsequently undergo definitive surgery. Recent studies have better defined the subset of patients that benefit from such an approach. SUMMARY: Application of abbreviated laparotomy has been widely applied in the trauma population. Breaking the pathophysiologic cycle of hypothermia, coagulopathy, and acidosis with this approach has improved survivorship in this critically injured group of patients. The extension of the abbreviated laparotomy concept has also been described in the general surgery population, and raises the possibility of extending this concept to broader surgical fields.

Acidosis↗
PubMed2006

Nonoperative management of severe blunt splenic injury: are we getting better?

BACKGROUND: Most minor splenic injuries are readily treated nonoperatively but controversy exists regarding the role of nonoperative management for higher-grade injuries. The infrequency of these injuries has made evaluation of factors critical to their management difficult. METHODS: Through the National Trauma Data Bank, 3,085 adults sustaining severe (Abbreviated Injury Scale score > or = 4) blunt splenic injury from 1997 to 2003 were retrospectively reviewed. Patient management, demographic information, physiologic data, procedures performed, and outcomes were analyzed. RESULTS: Nonoperative management was attempted in 40.5% of patients but ultimately failed in 54.6% of those. Failure of nonoperative management was associated with increased age, low admission systolic blood pressure, higher injury severity score, and increased hospital and intensive care unit length of stay. Mortality associated with failure of nonoperative management (12.3%) and successful observation (13.8%) was similar. CONCLUSIONS: Nonoperative management of higher-grade splenic injuries is associated with a high rate of failure and prolonged hospital stay. Careful judgment must be exercised in applying nonoperative management to patients with severe splenic injuries.

Adult↗
PubMed2006

Failure of nonoperative management of abdominal solid organ injuries.

PURPOSE OF REVIEW: Nonoperative management of the spleen has been the conventional approach for dealing with blunt splenic injury in children for 25 years. Following acceptance in the field of pediatric surgery, nonoperative management of blunt injury to the liver and spleen became the template in adult trauma surgery. It has proven to be of unequivocal benefit to the majority of hemodynamically stable pediatric and adult patients who have suffered blunt liver or splenic trauma. Offsetting these gains, has been the presence of failures. RECENT FINDINGS: The recent literature has focused on factors which may impact the nonoperative management success or failure rate. These factors include initiation of guidelines, risk of overwhelming postsplenectomy infection, character of clinical judgment, role of computed tomography in detecting associated intraabdominal injuries, the presence of more than one solid organ injury, risk of associated hollow viscus injury, and the drawbacks of angioembolization. SUMMARY: Despite the failures of nonoperative management outlined in this review, the approach has been generally successful. Efforts at improving organ salvage rates and diminishing failures with this approach continue. Notwithstanding our enthusiasm to advance this method of patient care, we must avoid imperiling a subpopulation of patients in our attempt to improve nonoperative management success rates.

Abdominal Injuries↗
PubMed2005

Failure of observation of blunt splenic injury in adults: variability in practice and adverse consequences.

BACKGROUND: The Eastern Association for the Surgery of Trauma Multiinstitutional Workgroup reported a failure rate for nonoperative management of blunt splenic injury in adults of 10.8%. Sixty percent of the failures occurred within 24 hours of admission. The purpose of this multiinstitutional study by the Eastern Association for the Surgery of Trauma was to determine common variables in failure of nonoperative management of blunt splenic injury in adults. STUDY DESIGN: Medical records were reviewed in a blinded fashion on 78 patients in whom nonoperative management failed. Statistical analysis was performed with ANOVA, extended chi-square, and Fisher's exact test; statistical significance was p<0.05. RESULTS: The 78 patients were categorized based on hemodynamic status. Forty-four percent were stable; 31% had transient hypotension or tachycardia that resolved with fluid infusion (responders); and 25% were unstable. Two-thirds of the unstable patients required laparotomy within 12 hours of admission; all had laparotomy within 72 hours. Mortality was significantly different when comparing the unstable to the stable and responder groups: stable (3%), responders (8%), and unstable (37%), despite similar age and only modest differences in Injury Severity Score. Eight CT scans were misinterpreted initially. Of 26 Focused Abdominal Sonography for Trauma (FAST) studies, 11 (42.3%) were false negative. Abnormal abdominal findings were noted in 67.7% of patients on admission. Ten patients died (12.8%). Sixty percent of the deaths were caused largely by delayed treatment of splenic or other abdominal injuries; one patient died in the responder group and five unstable patients died. CONCLUSIONS: Thirty percent to 40% of the patients who had unsuccessful nonoperative management in this study were selected inappropriately, with hemodynamic instability or initial misinterpretation of diagnostic studies. As a consequence, the majority of the deaths were from delayed treatment of intraabdominal injuries. This article suggests that written protocols, better adherence to sound clinical judgment, and experienced and timely interpretation of radiologic studies would reduce the incidence of failure of nonoperative management of blunt splenic injury in adults.

Adolescent↗
PubMed2005

Cytochrome P-450 activity is differentially altered in severely injured patients.

OBJECTIVE: To assess whether changes in cytochrome P-450 (CYP) activity of specific CYP enzymes occur in severely injured patients and to assess changes in CYP activity during recovery. DESIGN: Prospective clinical study. SETTING: University-affiliated, level I trauma center and trauma critical care unit. PATIENTS: Twenty-three multiply injured patients admitted to a trauma critical care unit were compared with healthy volunteers. INTERVENTIONS: CYP metabolizing activity was assessed using the probe drugs mephenytoin (CYP-2C19), chlorzoxazone (CYP-2E1), dapsone (multiple CYP enzymes), and flurbiprofen (CYP-2C9). MEASUREMENTS AND MAIN RESULTS: Mephenytoin metabolism was profoundly suppressed after injury and increased during postinjury recovery, whereas chlorzoxazone metabolism was suppressed to a lesser degree. Measures of dapsone and flurbiprofen metabolism were elevated throughout the study. Chlorzoxazone and mephenytoin metabolism correlated with the multiple organ dysfunction score and with the multiple organ failure score. CONCLUSIONS: CYP isoform activity is differentially altered by shock and trauma in injured patients. The metabolic activity of selected CYP isoforms may have potential for evaluating acute hepatic dysfunction in critically ill trauma patients.

Biomarkers↗
PubMed2005

Admission hypothermia and outcome after major trauma.

OBJECTIVE: Uncontrolled exposure hypothermia is believed to be deleterious in the setting of major trauma. Prevention of hypothermia in the injured patient is currently practiced in both prehospital and in-hospital settings. However, this standard is based on studies of limited patient series that were not designed to identify the independent relationship between hypothermia and mortality. Recent studies suggest that therapeutically applied hypothermia may benefit selected patient subsets. The goal of this study was to evaluate the independent association between admission hypothermia and mortality after major trauma, with adjustment for clinical confounders. DESIGN: Retrospective analysis of a statewide trauma registry. The primary outcome was death at hospital discharge. The key exposure was hypothermia, defined as body temperature </=35 degrees C at admission. Multivariate regression was used to risk-adjust for age, severity and mechanism of injury, and route of temperature measurement. Additional adjustment for prehospital exposure time and intravenous fluid therapy was also evaluated. SETTING: Trauma centers of the Commonwealth of Pennsylvania. PATIENTS: All trauma patients >/=16 yrs of age for the years 2000-2002. Transferred patients were excluded. Patients were excluded if temperature or route of temperature measurement was not known. Both the full cohort and a subset with isolated severe head injury were evaluated. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 38,520 patients, 1,921 (5.0%) were hypothermic at admission. Admission hypothermia was independently associated with increased odds of death in both the full cohort (odds ratio, 3.03; 95% confidence interval, 2.62-3.51) and the subset with isolated severe head injury (2.21; 1.62-3.03), with adjustment for age, severity and mechanism of injury, and route of temperature measurement. CONCLUSIONS: Admission hypothermia is independently associated with increased adjusted odds of death after major trauma. The increase in mortality is not completely attributable to physiologic presentation or injury pattern or severity.

Adolescent↗
PubMed2005

Is outcome after blunt splenic injury in adults better in high-volume trauma centers?

An association between outcome and case volume has been demonstrated for selected complex operations. The relationship between trauma center volume and patient outcome has also been examined, but no clear consensus has been established. The American College of Surgeons (ACS) has published recommendations on optimal trauma center volume for level 1 designation. We examined whether this volume criteria was associated with outcome differences for the treatment of adult blunt splenic injuries. Using a state trauma database, ACS criteria were used to stratify trauma centers into high-volume centers (>240 patients with Injury Severity Score >15 per year) or low-volume centers, and outcome was evaluated. There were 1,829 patients treated at high-volume centers and 1,040 patients treated at low-volume centers. There was no difference in age, gender, emergency department pulse, emergency department systolic blood pressure, or overall mortality between high- and low-volume centers. Patients at low-volume centers were more likely to be treated operatively, but the overall success rate of nonoperative management between high- and low-volume centers was similar. These data suggest that ACS criteria for trauma centers level designation are not associated with differences in outcome in the treatment of adult blunt splenic injuries in this regional trauma system.

Adult↗
PubMed2004

Out-of-hospital endotracheal intubation and outcome after traumatic brain injury.

STUDY OBJECTIVE: Previous studies disagree about the effect of out-of-hospital endotracheal intubation on traumatic brain injury. This study compares the effects of out-of-hospital endotracheal intubation versus emergency department (ED) endotracheal intubation on mortality and neurologic and functional outcome after severe traumatic brain injury. METHODS: From the 2000 to 2002 Pennsylvania Trauma Outcome Study (a registry of all patients treated at trauma centers in the Commonwealth of Pennsylvania), adult patients with head/neck Abbreviated Injury Scale score of 3 or greater and undergoing out-of-hospital endotracheal intubation or ED endotracheal intubation were included. Transferred patients were excluded. The primary outcome was death (on hospital discharge). The secondary outcomes were neurologic (good versus poor, inferred from discharge to home versus long-term care facility) and functional outcome (determined from a Functional Impairment Score). The key exposure was endotracheal intubation (out-of-hospital endotracheal intubation versus ED endotracheal intubation). Using multivariate logistic regression, odds estimates for out-of-hospital endotracheal intubation were adjusted using age, sex, head/neck Abbreviated Injury Scale score, Injury Severity Score, mechanism of injury (penetrating versus blunt), admission systolic blood pressure, mode of transport (ground only versus helicopter or helicopter + ground), and the use of out-of-hospital neuromuscular blocking agents. A propensity score adjustment accounted for the potential effects of preexisting conditions, inhospital complications, and social factors (drug and alcohol use, race, and insurance coverage). RESULTS: There were 4,098 patients with head/neck Abbreviated Injury Scale score of 3 or greater who received either out-of-hospital endotracheal intubation (n=1,797, 43.9%) or ED endotracheal intubation (n=2,301, 56.1%). Adjusted odds of death were higher for out-of-hospital endotracheal intubation than ED endotracheal intubation (odds ratio [OR] 3.99; 95% confidence interval [CI] 3.21 to 4.93). Out-of-hospital endotracheal intubation was associated with an increased adjusted odds of poor neurologic outcome (OR 1.61; 95% CI 1.15 to 2.26), moderate or severe functional impairment (Functional Impairment Score 6 to 15; OR 1.92; 95% CI 1.40 to 2.64), and severe functional impairment (Functional Impairment Score 11 to 15; OR 1.80; 95% CI 1.29 to 2.52). CONCLUSION: Out-of-hospital endotracheal intubation was associated with adverse outcomes after severe traumatic brain injury. The implications for current clinical care remain undefined.

Adolescent↗
PubMed2004

Management of adult blunt splenic injuries: comparison between level I and level II trauma centers.

BACKGROUND: The factors important in determining outcome when managing adult blunt splenic injuries continue to be debated. Whether trauma center level designation (Level I versus Level II) affects patient management has not been evaluated. STUDY DESIGN: We conducted a retrospective analysis of prospectively gathered data from the Pennsylvania Trauma Outcome Study database that collected information from 27 statewide trauma centers (Level I [15], Level II [17]). Adult patients (ages > or = 16 years) with blunt splenic injuries (ICD-9-CM 865) were evaluated. Demographic data, injury data, and trauma center level designation were collected, and patient management, length of stay, and mortality were analyzed. RESULTS: There were 2,138 adult patients who suffered blunt splenic injuries during the study period (1998-2000). Patients treated at Level II trauma centers (n = 772) had a higher rate of operative treatment (38.2% versus 30.7%) (p < 0.001), but a shorter mean length of stay (10.1 +/- 0.4 versus 12.0 +/- 0.4 days) (p < 0.01) compared with patients in Level I trauma centers (n = 1,366). The rate of failure of nonoperative treatment was lower at Level II trauma centers (13.0% versus 17.6%) (p < 0.05), but the mortality for patients managed nonoperatively was higher (8.4% versus 4.5%) (p < 0.05). Splenorrhaphy was performed more frequently in Level I trauma centers. CONCLUSIONS: Management differences exist in the treatment of adult blunt splenic injuries between institutions of different trauma center level designation. Multicenter studies should account for this finding in design and implementation.

Adult↗
PubMed2004

Variability in trauma center outcomes for patients with moderate intracranial injury.

BACKGROUND: The variability of outcome between Trauma Centers has not been extensively studied as a possible avenue for performance improvement. Trauma Center variability in severity-adjusted survival for patients with moderate intracranial injury (MII) was studied in order to determine the association of MII-related process of care variables with outcomes. The analytic results were supplemented with peer review of MII patients with unexpected outcomes and identified potential process of care variables. METHODS: A retrospective cohort study was undertaken based on data submitted to a statewide trauma center database from July '95 through June '98. MII patients had one or more selected ICD-9-CM codes with an AIS-90 severity score of 3 or 4 but no higher. Severity adjustment was done using case matching and a logistic function based New Model that appropriately accounts for patients intubated on Emergency Department arrival. MII-related process of care variables derived from the database were identified and their relationship with outcome were evaluated individually and using multivariate methods. Trauma center personnel conducted standardized peer reviews. RESULTS: The study included data from 6765 patients treated at 26 trauma centers. Two centers (2PZW) had significantly more survivors than expected by both severity adjustment methods. Three had significantly fewer survivors than expected (3NZW). By several measures, patients treated in the 2PZW centers were more seriously injured and older than those in the 3NZW centers. CT of the head performed in the treating hospital was the only process of care variable associated with outcome in multivariate evaluations. Peer review also found little association between process of care variables and patient outcomes. However, peer review reported that 23.7% of unexpected deaths identified by case matching or the New Model were preventable or potentially preventable. Peer review also identified as medically unnecessary significant percentages of patients with unexpectedly long stays in hospital (26.4%) or in ICU (17.3%) identified by case matching. Nearly 45% of unexpected complications were judged preventable or potentially preventable. CONCLUSIONS: Two severity adjustment methods identified significant variability in trauma center outcomes for patients with MII. The difference in outcomes between the centers with better than expected (2PZW) and poorer than expected outcomes (3NZW) was substantial. Peer review identified significant opportunities for reducing unexpected deaths, stays in hospital and in ICU, and the occurrence of complications. Trauma registry data and peer reviews found little relationship between available process of care variables and patient outcomes. This study should stimulate discussions to understand reasons for outcome variability and ways to reduce it.

Adult↗
PubMed2003

Characterization of the expression of inducible nitric oxide synthase in rat and human liver during hemorrhagic shock.

It has been previously shown that the inducible nitric oxide (NO) synthase (iNOS; NOS-2) is elevated after hemorrhage, and that iNOS-derived NO participates in the upregulation of inflammation as well as lung and liver injury postresuscitation from shock. The purpose of this study was to elucidate the time course of iNOS mRNA expression, as well as the cellular and subcellular localization of iNOS protein in the liver posthemorrhage in rats subjected to varying durations of hemorrhagic shock (HS; mean arterial blood pressure [MAP] = 40 mmHg) with or without resuscitation. Expression of iNOS mRNA in rat liver by real-time reverse transcriptase (RT)-PCR demonstrated iNOS upregulation in shocked animals as compared with their sham counterparts as early as 60 min after the initiation of hemorrhage. By 1 h of HS, iNOS protein was detectable in rat liver by immunofluorescence, and this expression increased with time. Immunofluorescence localized iNOS primarily to the hepatocytes, and in particular to hepatocytes in the centrilobular regions. This analysis, confirmed by immunoelectron microscopy, revealed that iNOS colocalizes with catalase, a peroxisomal marker. Furthermore, we determined that iNOS mRNA is detectable by RT-PCR in liver biopsies from human subjects with HS (MAP < 90 mmHg) associated with trauma (n = 18). In contrast, none of the seven nontrauma surgical patients studied had detectable iNOS mRNA in their livers. Collectively, these results suggest that hepatic iNOS expression, associated with peroxisomal localization, is an early molecular response to HS in experimental animals and possibly in human patients with trauma with HS.

Animals↗
PubMed2003

Physical medicine and rehabilitation consultation: relationships with acute functional outcome, length of stay, and discharge planning after traumatic brain injury.

OBJECTIVE: Patients hospitalized with traumatic brain injury comprise a large portion of the population treated at trauma centers, and physiatry consultants evaluate many traumatic brain injury patients in this setting. The purpose of this study was to delineate relationships between physical medicine and rehabilitation consultation in this population and acute functional outcome, length of stay, and discharge planning. DESIGN: Data were obtained for 1866 adult patients hospitalized with nonfatal traumatic brain injury. Functional outcome was determined using a modification of the FIM trade mark. Descriptive and regression analyses were used to determine the relationship of physical medicine and rehabilitation consultation to acute discharge FIM score, length of stay, and discharge disposition. RESULTS: Patients receiving physical medicine and rehabilitation consultation had more severe injuries, lower acute discharge FIM scores, and longer length of stay. However, multivariate analysis showed that earlier (<48 hr after admission) physical medicine and rehabilitation consultation resulted in significantly better FIM scores with transfers (odds ratio, 2.61; 95% confidence interval, 1.06-6.40) and locomotion (odds ratio, 3.54; 95% confidence interval, 1.34-9.32) and a significantly shorter acute length of stay (P = 0.001). CONCLUSIONS: Early physical medicine and rehabilitation consultation may positively impact functional status and length of stay for patients with traumatic brain injury during acute hospitalization. Additional work is needed to determine how physical medicine and rehabilitation consultation impacts rehabilitation-specific medical issues, long-term functional outcome, and healthcare costs.

Adult↗
PubMed2002

TRISS unexpected survivors: an outdated standard?

BACKGROUND: Performance improvement is an essential component of the trauma center. TRISS methodology has been applied as a national standard against which trauma centers can compare their outcomes. Earlier reviews of TRISS unexpected survivors sustained the classification of unexpected survivor in the vast majority of cases. Our hypothesis was that the level of care that is currently expected has made the TRISS unexpected survivors a statistical phenomenon only. METHODS: Two hundred seventy TRISS unexpected survivors at a Level I trauma center from 1991 to 1995 were reviewed. Each case was reviewed as a blinded abstract by six reviewers (three of whom are directors at other facilities) and classified as clinically unexpected survivor (confirmed TRISS classification) or clinically expected survivor (did not sustain TRISS classification as unexpected survivor). Data are expressed as mean +/- SD. Statistical significance was achieved at p < 0.05. RESULTS: Among the 270 patients categorized by TRISS as unexpected survivors, only 10.7% were corroborated as clinically unexpected survivors by this peer review process and 89.3% were reclassified as clinically expected survivors. Confirmed clinically unexpected survivors were more likely to go directly from the emergency department to the operating room (82 vs. 46%; p < 0.05). Age (32 +/- 12 years vs. 40 +/- 19 years; p < 0.05), Injury Severity Score (46 +/- 20 vs. 32 +/- 14; p < 0.05), Revised Trauma Score (2.46 +/- 1.89 vs. 3.11 +/- 1.21; p < 0.05), probability of survival (0.13 +/- 0.13 vs. 0.24 +/- 0.15; p < 0.05), systolic blood pressure in the emergency department (60 +/- 51 mm Hg vs. 109 +/- 33 mm Hg; p < 0.05), hospital length of stay (39.6 +/- 30.3 days vs. 24.0 +/- 23.0 days; p < 0.05), and intensive care unit length of stay (19.5 +/- 20.6 days vs. 9.6 +/- 10.1 days; p < 0.05) were significantly different comparing confirmed versus unsustained classification as unexpected survivors. CONCLUSION: Only 10.7% of survivors classified as unexpected by TRISS were corroborated as unexpected by a blinded, peer-review process. TRISS needs to be updated for meaningful interpretation; modifications need to be made and coefficients need to be revised.

Adult↗
PubMed2002

A brief episode of hypotension increases mortality in critically ill trauma patients.

OBJECTIVE: Hypotension is associated with increased mortality, however previous studies have failed to account for the depth and duration of hypotension. We evaluated the effect of the duration of hypotension on outcome in injured patients. METHODS: Trauma patients admitted to the intensive care unit (ICU) from 1999 to 2000 were prospectively evaluated. Patients transferred to a ward </= 48 hours after admission were excluded. The lowest systolic blood pressure and duration of all episodes of systolic blood pressure below 90 mm Hg were recorded along with the total ICU length of stay and discharge status. The Kruskal-Wallis test, Pearson chi2, and test for trend were used for analysis. RESULTS: Patients with hypotension during the first 24 hours of ICU care had an increased mortality rate. A brief (</= 10 minutes) episode of hypotension was associated with increased mortality that increased with duration of hypotension (p = 0.0001). ICU length of stay also increased with duration of hypotension (p = 0.0001). CONCLUSION: Brief episodes of hypotension are associated with an increased risk of death in patients requiring admission to the ICU after injury and a longer ICU recovery for those who survive.

Adult↗
PubMed2002

Hepatic dysfunction increases length of stay and risk of death after injury.

BACKGROUND: The relative importance of dysfunction or failure of different organ systems to recovery from critical illness is unclear. The purpose of this study was to evaluate the contribution of hepatic dysfunction to outcome after injury. METHODS: We retrospectively evaluated patients admitted to our trauma center from 1994 to 1998 for the development of hepatic dysfunction, defined as serum bilirubin > or = 2.0 mg/dL. Additional variables on patient demographics, injuries, hospital course, and development of other organ system dysfunction were collected from the trauma registry and hospital records. RESULTS: Using logistic regression analysis, hepatic dysfunction was significantly associated with increased intensive care unit length of stay (LOS) and death. The added development of hepatic dysfunction significantly increased LOS in patients with no other organ dysfunction, those with renal dysfunction, and those with respiratory dysfunction. CONCLUSION: Hepatic dysfunction influences recovery after injury independent of the dysfunction of other organ systems. The development of hepatic dysfunction prolongs LOS and increases mortality.

Adult↗
PubMed2002

The modulation of hepatic injury and heat shock expression by inhibition of inducible nitric oxide synthase after hemorrhagic shock.

The role of nitric oxide (NO) in maintaining homeostasis and regulating organ function during hemorrhagic shock is complex. The inducible NO synthase (iNOS) has been hypothesized to play a critical role in the pathophysiologic consequences of severe hemorrhage. Heat shock protein (HSP) expression is increased by hemorrhage and is a marker of the magnitude of ischemic injury in the liver. HSP induction is protective against injury in animal models of inflammation and is regulated by NO in hepatocytes. To clarify the role of iNOS in hepatic injury and its relationship to HSP expression in hemorrhagic shock, NOS was inhibited with L-N-6-(1-iminoethyl) lysine (L-NIL), which is reported to be a selective inhibitor of the inducible NOS isoform. Doses of 50 microg/kg or 150 microg/kg were infused over 1 h at the end of compensated shock. Plasma ornithine carbamoyltransferase (OCT), a specific marker of liver injury, was significantly reduced after hemorrhage with low-dose L-NIL (7.1+/-1.5 IU/L) compared to saline-treated control rats (13.0+/-1.5 IU/L, P < 0.005), while high-dose L-NIL significantly increased OCT release (35.9+/-7.2 IU/L, P< 0.05 versus shock alone) despite a greater MAP after resuscitation. HSP expression (HSP-72 and HSP-32) after hemorrhage was increased by L-NIL treatment at the highest dose. We conclude that excessive NO production from iNOS contributes to shock-induced hepatic injury. Our data suggest HSP expression may reflect the degree of ischemic injury after hemorrhage.

Animals↗