摘要:

IntroductionLow gastric intramucosal pH (pHi) after shock resuscitation is associated with organ dysfunction and death in trauma patients. However, the relationship between hemodynamic performance, global oxygen transport, and pHi is unclear. Our purpose was to evaluate the relationship between intravascular volume status, splanchnic hypoperfusion, and outcome after shock resuscitation in trauma patients.Design/SettingCohort study of 79 consecutive critically ill patients at a Level I trauma center stratified by normal (NORM, < or = to 7.32) or low (LOW, < 7.32) pHi when lactate normalized (< 2.2 mmol/L).Main Outcome MeasuresDifferences during resuscitation in mean values of right ventricular end-diastolic volume index (RVEDVI), pulmonary artery occlusion pressure, cardiac index, oxygen delivery index, and oxygen consumption index. The incidence of multiple organ failure and death in the NORM and LOW groups were analyzed via odds ratio and chi2.ResultsPatients in the NORM group (n = 45) had a lower incidence of multiple organ failure (4 of 45 vs. 11 of 34, odds ratio 5.0, p < 0.01) and death (5 of 45 vs. 11 of 34, odds ratio 3.8, p < 0.05) than patients in the LOW group (n = 34). NORM patients had a higher initial RVEDVI (116 +/- 31 vs. 95 +/- 25 mL/m2, p < 0.001) and maintained a significantly higher RVEDVI (114 +/- 27 vs. 97 +/- 17 mL/m2, p = 0.003) throughout resuscitation than the LOW group did. There were no differences in the other studied variables.ConclusionsSupranormal levels of preload during shock resuscitation are associated with better outcome. Maintaining a RVEDVI higher than 100 mL/m2during shock resuscitation may be of benefit in critically injured patients.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BackgroundCardiac preload is most commonly assessed by pulmonary artery wedge pressure. It was postulated that the right ventricular end-diastolic volume index (RVEDVI) derived by thermodilution would be a better predictor of preload in trauma patients with high airway pressures associated with positive pressure ventilation and positive end-expiratory pressure.MethodsVolumetric thermodilution catheters were placed in 52 mechanically ventilated trauma patients. Regression analysis was performed on 986 sets of hemodynamic data comparing pulmonary artery wedge pressure and RVEDVI to cardiac index (CI) at various airway pressures.Results30%.ConclusionsUnlike the pulmonary artery wedge pressure, RVEDVI is as reliable indicator of preload in the mechanically ventilated trauma patient. This is especially true when the right ventricular ejection fraction is not severely depressed.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BackgroundInitial small-volume hypertonic saline resuscitation of a combined hemorrhagic shock and head injury model was studied.MethodsTwenty-three sheep underwent hemorrhage (20 mL/kg) and parietal freeze injury followed by initial bolus resuscitation with lactated Ringer's solution (40 mL/kg) or 7.5% hypertonic saline (HS) (4 mL/kg). Cardiac index was maintained with lactated Ringer's solution for either 2 or 24 hours. Parietal lobe water content, blood volume, and blood flow were determined. Intracranial pressure (millimeters of mercury) was followed.ResultsOverall fluid requirements (milliliters per kilogram) were less at 2 and 24 hours with HS resuscitation. Early intracranial pressure was less with HS resuscitation. Brain water contents were similar between groups. Blood flow in injured and blood volume in uninjured parietal lobe were less for HS at 2 hours, although not different at 24 hours.ConclusionsLess fluid was needed in the short- and long-term with HS resuscitation. Early intracranial pressure was higher with lactated Ringer's solution resuscitation, possibly in part owing to increased blood volume.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BackgroundWe hypothesized that improvements in cellular immune function after hypertonic saline (HTS) resuscitation will alter the outcome of sepsis after hemorrhage.MethodsTo test this hypothesis, a two-hit model was used. Hemorrhage was induced in BALB/c mice by catheterizing the femoral artery and bleeding until a mean arterial pressure = 35 mm Hg was reached and maintained for 1 hour. Resuscitation was performed with HTS (NaCl 7.5%, 4 mL/kg) or lactated Ringer's (LR, twice the shed blood volume), plus the shed blood. Cecal ligation and puncture (CLP) was performed 24 hours after hemorrhage. Mortality was assessed for 72 hours, comparing HTS (n = 14) and LR (n = 13) resuscitation. Another set of animals (n = 10) in each group at each time point) were killed at 2 and 24 hours after blood collection. Liver and blood were cultured for the presence of bacteria, and lung and liver samples were scored on a scale from 0 (normal) to 4 (most severe) in a blind fashion by a pathologist.Results100,000 colony forming units/g) also showed the same trend (HTS = 30%, LR = 60%). Autopsies revealed a better containment of the infection (abscess formation) in the HTS group. At 2 hours, lung scores were 1.2 +/- 0.25 and 2.6 +/- 0.31 for HTS and LR, respectively (p < 0.002). At 24 hours, HTS treated animals showed marked improvement of lung injury, while the scores in the LR group remained high. A significant difference was also observed regarding liver injury. At 2 hours, scores were 0.4 +/- 0.22 and 2.3 +/- 0.16 for HTS and LR, respectively (p < 0.002). At 24 hours, HTS treated animals showed normal hepatic architecture, although mild injury was still observed in the LR group.ConclusionHTS resuscitation leads to increased survival after hemorrhage and CLP. Marked improvements were observed in lung and liver injury compared with isotonic resuscitation. The better containment of the infection observed with HTS resuscitation corresponds to a marked decreased in bacteremia. HTS resuscitation stands as an alternative resuscitation regimen with immunomodulatory potential.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BackgroundTissue oxygen tension can be measured directly in selected organ beds, and these measurements may be more sensitive in assessing the adequacy of resuscitation than global physiologic parameters. We hypothesized that heart tissue oxygen tension would be an important marker for the severity of ischemic insult to the heart during hemorrhagic shock. We further hypothesized that gut oxygen tension measured in the jejunum would prove to be a better measure of splanchnic hypoperfusion than intramucosal pH (pHi).MethodsTissue oxygen probes were inserted directly into the myocardium of the left ventricle and into the lumen of the proximal jejunum in 10 anesthetized swine. A pHi catheter was introduced into the stomach. The animals were subjected to a controlled hemorrhage of 50% of estimated blood volume. Gut and cardiac oxygen were monitored continuously during hemorrhage and resuscitation, which was performed with shed blood and crystalloid.ResultsWhile gut O2and pHi trended together, we were unable to establish a correlation between changes in these two variables during hemorrhage and resuscitation. Heart Po2decreased significantly during hemorrhage, but surpassed baseline values after resuscitation, a finding not seen in gut Po2. No standard physiologic variables reliably predicted changes in heart Po2during these experiments.ConclusionsTissue oxygen tensions measurements are highly responsive to changes induced during graded hemorrhagic shock and resuscitation. Gut Po2and pHi appear to be measuring different physiologic processes in the gastrointestinal tract. The compensatory ability of the heart far exceeds that of the gut after ischemic insult. This hemorrhagic shock model appears feasible for the study of various methods of resuscitation.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BackgroundFocused abdominal sonography for trauma (FAST) relies on hemoperitoneum to identify patients with injury. Blunt trauma victims (BTVs) with abdominal injury, but without hemoperitoneum, on admission are at risk for missed injury.MethodsClinical, radiologic, and FAST data were collected prospectively on BTVs over a 12-month period. All patients with FAST-negative for hemoperitoneum were further analyzed. Examination findings and associated injuries were evaluated for association with abdominal lesions.ResultsOf 772 BTVs undergoing FAST, 52 (7%) had abdominal injury. Fifteen of 52 (29%) had no hemoperitoneum by admission computed tomographic scan, and all had FAST interpreted as negative. Four patients with splenic injury underwent laparotomy. Six other patients with splenic injury and five patients with hepatic injury were managed nonoperatively. Clinical risk factors significantly associated with abdominal injury in BTVs without hemoperitoneum include: abrasion, contusion, pain, or tenderness in the lower chest or upper abdomen; pulmonary contusion; lower rib fractures; hemo- or pneumothorax; hematuria; pelvic fracture; and thoracolumbar spine fracture.ConclusionsUp to 29% of abdominal injuries may be missed if BTVs are evaluated with admission FAST as the sole diagnostic tool. Consideration of examination findings and associated injuries should reduce the risk of missed abdominal injury in BTVs with negative FAST results.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

In this prospective study, 217 children sustaining blunt abdominal trauma were initially evaluated with ultrasonography (US) and those with any abnormal ultrasonographic findings were further evaluated with computed tomography. Results of ultrasonographic examination were normal in 157 children and showed abnormalities such as free intraperitoneal fluid (FIF), intra-abdominal organ injury, and intrapleural fluid in 60 children. Computed tomographic examination of the 42 children with organ injury, the seven children with minimal FIF of no definite source, and the three children with intrapleural fluid revealed findings consistent with ultrasonographic findings. Computed tomographic examination of the eight children with more than minimal FIF of no definite source detected by US showed the source as liver injury in one and spleen injuries in two patients. The source of FIF could not be identified with computed tomography in five patients. After clinic follow-up examination, one of these five patients was operated on for abdominal tenderness, fever, and air-fluid levels detected on plain abdominal radiographs, and duodenal perforation was encountered. Clinical courses of the patients with normal ultrasonographic findings were uneventful. We conclude that US, aside from being a screening tool, is alone sufficient in the evaluation of the majority of the children sustaining blunt abdominal trauma. Although this is a preliminary study with further work needed to be done, we propose that further evaluation with computed tomography should be performed on those children in whom more than minimal FIF of no definite source is detected with US.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BackgroundInhaled nitric oxide (NO) has the potential to improve ventilation/perfusion matching and decrease pulmonary artery pressure in patients with profound respiratory failure.MethodsEight patients, average age of 35 years (range, 2.5-77 years) and burn size 49% (range, 19-80%), with inhalation injury and respiratory failure failing conventional management (average Pao2/FIO2ratio (PFR) 85) were given inhaled NO at 20 ppm.ResultsAn immediate mean increase in PFR of 10% and a decrease in pulmonary artery mean pressure of 7.8% was noted. At 24 hours, the average improvement in PFR was 28% and that in pulmonary artery mean pressure was 7.7%. Although not reaching statistical significance, these changes were more pronounced in those patients who went on to survive. There was no hypotension attributed to NO administration, and maximum methemoglobin levels averaged 0.9%.ConclusionsInhaled NO can be safely administered to selected burn patients with severe respiratory failure who are perceived to be failing conventional support. Although current data are not adequate to support its general use, an immediate and sustained improvement in PFR and pulmonary artery mean pressure may correlate with eventual recovery of pulmonary function. Continued evaluation in controlled settings seems warranted and is in progress.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

We have described previously that CD8 sup + CD11b sup + TCRgamma/delta sup + type 2 T cells (BA-type 2 T cells) and suppressor macrophages (Sup-Mphi) are generated in spleens of mice 3 to 5 days (Sup-Mphi) and 4 to 9 days (BA-type 2 T cells) after thermal injury. In the present study, an additional suppressor T cell, characterized as CD3 sup + CD4 sup - CD8 sup - TCRalpha/beta sup + T cells (double negative suppressor T cells, DN Sup-T cells), was demonstrated in mice 1 day after thermal injury. DN Sup-T cells inhibited the proliferation of lymphocytes stimulated with allogeneic cells or a lectin in a mixed lymphocyte reaction, and produced both type 1 and type 2 cytokines (interferon-gamma, interleukin-2, interleukin-4, and interleukin-10) when they were stimulated in vitro with anti-CD3 monoclonal antibody. These results suggest that DN Sup-T cells express phenotypic properties similar to natural suppressor cells and cytokine-producing profiles different from type 1 (Th1 cells and CTLs) and type 2 T cells (Th2 cells and CD8 sup + type 2 T cells). DN Sup-T cells may play a role on the burn-associated immunosuppression appearing in the acute phase of thermally injured individuals.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

BackgroundCrush syndrome is a form of traumatic rhabdomyolysis characterized by systemic involvement, in which acute renal failure is potentially life-threatening.MethodsClinical and laboratory data of 14 crush-syndrome patients transferred to a tertiary emergency department after the Hanshin-Awaji earthquake were analyzed. The patients were buried under collapsed houses for the average of 6.7 +/- 5.7 (SD) hours (range, 1 to 24 hours). They were referred to us 6 to 250 hours after the earthquakeResultsOf those who arrived at our institution within 40 hours, 25% (two of eight) developed renal failure, whereas all six patients who arrived after 40 hours developed renal failure. Peak serum creatine kinase ranged from 6,677 to 134,200 U/L (51,674 +/- 41,776). Renal failure was highly associated with massive muscle damage (serum creatine kinase above 25,000 U/L) and insufficient initial fluid resuscitation (below 10,000 mL/2 days).ConclusionsPrompt and adequate, if not massive, fluid resuscitation is the key to preventing renal failure after such injury.

ISSN:0022-5282    

出版商:OVID    

年代:1997

数据来源: OVID