Organ Injury In Patients Research Articles

Phosphodiesterase type 4 inhibitor rolipram inhibits activation of monocytes during extracorporeal circulation

Cardiopulmonary bypass is associated with systemic inflammatory response syndrome and risk of multiorgan injury mediated by activated leukocytes. Phosphodiesterase type 4 is the predominant phosphodiesterase isozyme in leukocytes and plays a key role in the regulation of leukocyte activation. The aim of this study was to examine the effect of rolipram, a selective phosphodiesterase type 4 inhibitor, on functional changes of monocytes during simulated extracorporeal circulation. Simulated extracorporeal circulation was established by recirculating heparinized human blood for 120 minutes on a membrane oxygenator with or without 10 micromol/L of rolipram. L-selectin and CD11b expression of monocytes were measured with flow cytometry. C4d fragment, Bb fragment, C5b-9, and interleukin-6 were measured with enzyme immunoassay. Rolipram reduced the increase in CD11b expression and the decrease in L-selectin expression of monocytes in response to simulated extracorporeal circulation. Rolipram inhibited the increase in C4d fragment and interleukin-6, but it did not affect the increase in Bb fragment or C5b-9. Rolipram inhibited changes in adhesion molecule expression and interleukin-6 release by activated monocytes in simulated extracorporeal circulation. This study suggests that phosphodiesterase type 4 inhibition could be feasible therapeutic strategy to prevent exaggerated inflammatory response and organ injury in patients undergoing cardiopulmonary bypass.

Plasma antigen levels of thrombin-activatable fibrinolysis inhibitor did not differ in patients with or without disseminated intravascular coagulation

Thrombin-activatable fibrinolysis inhibitor (TAFI) is a carboxypeptidase that downregulates fibrinolysis and might play some roles in the pathogenesis of disseminated intravascular coagulation (DIC). We prospectively examined the plasma TAFI antigen levels in patients highly suspected to be suffering from DIC. Patients were subdivided into overt DIC and non-DIC groups according to a DIC scoring system. The Sepsis-related Organ Failure Assessment (SOFA) scores were concurrently calculated on patients with sepsis. Overall, there were 23 non-DIC patients and 20 patients with overt DIC. Their baseline characteristics were similar, but patients with overt DIC had much more aberrant coagulation tests and higher lactate dehydrogenase levels. However, there was no significant difference between overt DIC and non-DIC patients regarding their TAFI antigen levels [median/interquartile range (IQR) 74.41/13.98 and 75.29/15.16, respectively, p=0.543]. On regression analysis, TAFI antigen levels were not correlated with either C-reactive protein levels or various coagulation test results. In patients with sepsis (n=31), TAFI levels among three risk groups stratified by low (<or=5), intermediate (6-10), and high (>or=11) SOFA scores were not statistically disparate (median/IQR 65.24/15.14, 74.63/13.79, and 75.29/21.51, respectively, p=0.684), either. Our result indicated that plasma TAFI antigen levels did not vary significantly between patients with or without DIC. Further, they did not possess any correlation with the severity of organ injury in patients with sepsis. The role of TAFI antigen in the pathogenesis of DIC needs further elucidation by future studies.

Blunt abdominal trauma: should US be used to detect both free fluid and organ injuries?

To evaluate abdominal ultrasonography (US) for indirect (with free fluid analysis only) and direct (with free fluid and parenchymal analysis) detection of organ injury in patients with blunt abdominal trauma, with findings at computed tomography (CT) and/or surgery as the standard of diagnosis. Abdominal US was performed at hospital admission in consecutive patients with blunt abdominal trauma. The presence of free peritoneal fluid and organ injury were recorded and compared with results of abdominal CT in all hemodynamically stable patients. When US results were considered false-negative for free fluid or organ injury compared with CT results, repeat US was performed within 6 hours. Admission and second US results were compared with CT and/or surgical results to determine sensitivity, specificity, negative predictive value, and positive predictive value of US with regard to the presence of free intraperitoneal fluid and/or organ injury. Two hundred five hemodynamically stable patients underwent abdominal US and CT. CT revealed free fluid in 83 patients and organ injury in 99. Thirty-one (31%) of 99 patients with organ injury did not have free fluid at CT. Three (10%) of the 31 patients required surgery or angiographic embolization. The sensitivity of admission US was 93% (77 of 83 cases) for the diagnosis of free fluid, 41% (39 of 99) for directly demonstrating organ injury, and 72% (71 of 99) for suggesting organ injury by means of both free fluid and organ analysis. At second US, these sensitivities were 96% (80 of 83 cases), 55% (54 of 99) and 84% (83 of 99), respectively. US is highly sensitive for the detection of free intraperitoneal fluid but not sensitive for the identification of organ injuries. In hemodynamically stable patients, the value of US is mainly limited by the large percentage of organ injuries that are not associated with free fluid.

The relationship between visceral ischemia, proinflammatory cytokines, and organ injury in patients undergoing thoracoabdominal aortic aneurysm repair.

Plasma proinflammatory, anti-inflammatory cytokine, and soluble tumor necrosis factor (TNF) receptor concentrations were examined in hospitalized patients after abdominal and thoracoabdominal aortic aneurysm (TAAA) repair, with and without left atrial femoral bypass. Changes in plasma cytokine concentrations were related to the duration of visceral ischemia and the frequency rate of postoperative, single, or multiple system organ dysfunction (MSOD). Prospective, observational study. Two academic referral centers in the United States and The Netherlands. We included 16 patients undergoing TAAA repair without left atrial femoral bypass, 12 patients undergoing TAAA repair with left atrial femoral bypass, and nine patients undergoing infrarenal aortic aneurysm repair. Timed, arterial blood sampling for proinflammatory and anti-inflammatory cytokine and soluble TNF receptor concentrations (p55 and p75), and prospective assessment of postoperative single and MSOD. Plasma appearance of TNF-alpha, interleukin (IL)-6, IL-8, and IL-10 peaked 1 to 4 hrs after TAAA repair, and concentrations were significantly elevated compared with infrarenal abdominal aortic aneurysm repair (p < .05). Left atrial femoral bypass significantly reduced the duration of visceral ischemia (p < .05) and the systemic TNF-alpha, p75, and IL-10 responses (p < .05). Plasma TNF-alpha concentrations >150 pg/mL were more common in patients with extended visceral ischemia times (>40 mins). Additionally, patients with early peak TNF-alpha concentrations >150 pg/mL and IL-6 levels >1,000 pg/mL developed MSOD more frequently than patients without these elevated plasma cytokine levels (both p < .05). Thoracoabdominal aortic aneurysm repair results in the increased plasma appearance of TNF-alpha, IL-6, IL-8, IL-10, and shed TNF receptors. The frequency and magnitude of postoperative organ dysfunction after TAAA repair is associated with an increased concentration of the cytokines, TNF-alpha, and IL-6 and the increased plasma levels of these cytokines appear to require extended visceral ischemia times.

Nonsurgical Management of Solid Abdominal Organ Injury in Patients over 55 Years of Age

Age greater than 55 is often stated to be a contraindication to nonoperative management of intraperitoneal solid organ injury, based upon failures in early experiences of nonoperative therapy. Refinements in the criteria for nonoperative management of hepatic and splenic injuries have yielded improved success rates compared with those in initial reports, raising questions as to the validity of an age-related contraindication. A retrospective chart review of patients more than 55 years of age sustaining blunt hepatic and/or splenic injury at two urban Level I trauma centers was performed. Patients were stratified into three groups in which selection criteria could not consistently be determined: those managed nonoperatively, those managed operatively, and those who died within 24 hours. The purpose of this review is to identify whether age is a determinant for nonoperative management of abdominal solid organ injury. Eighty-eight patients were identified (mean age, 68.7 +/- 9.8), 17 of whom died in the emergency department or after operative intervention. Of the remaining 71 patients, 37 were originally managed nonoperatively (mean age 69.9 +/- 9.1, mean Injury Severity Score 19.9), 24 sustained hepatic injuries (grades I-IV), 12 sustained splenic injuries (grades I-III), and one patient sustained both organ injuries. Three patients with multisystem trauma died from complications unrelated to their solid organ injury (one brain death, one septic death, and one respiratory arrest). A single patient, with a grade I liver injury, required delayed exploration (for a persistent, unexplained metabolic acidosis) and underwent a nontherapeutic celiotomy. All but one of the 37 patients were successfully treated nonoperatively, for a 97 per cent success rate. We conclude that hemodynamically stable patients more than 55 years of age sustaining intra-abdominal injury can be observed safely. Age alone should no longer be considered an exclusion criterion for nonoperative management of intra-abdominal solid organ injury.

Incidence and significance of free fluid on abdominal computed tomographic scan in blunt trauma.

To determine the incidence and significance of free fluid on abdominal CT in blunt trauma. Retrospective chart review. All blunt trauma patients with an abdominal computed tomographic scan from August of 1993 to December of 1995 were identified from the trauma registry at a Level 1 trauma center. A total of 1,159 computed tomographic scans were performed; records of 18 patients were excluded for incomplete records. Official reports of computed tomographic scans were reviewed for free fluid, solid organ injury, bladder injury, and pelvic fracture. Free fluid without solid organ injury was found in 3% (34 of 1141). Laparotomy was performed because of free fluid in 13 patients. There were six small bowel injuries and one diaphragm injury for a therapeutic laparotomy rate of 54%. Ten patients had trace free fluid and did not undergo laparotomy; none had a missed small bowel injury. The presence of more than trace amounts of free fluid without solid organ injury in patients with blunt trauma is a strong indication for exploratory laparotomy. Patients with isolated trace amounts of free fluid can be safely observed.

Significance of traumatology in abdominal and vascular surgery.

Frequency of polytrauma accounts for the numerous abdominal traumas. Abdominal injuries should be treated by an abdominal surgeon. Three hundred and seventy traumas of the abdomen were checked regarding other injuries and their percentages given. Mortality rate was 16.6 percent. The different steps of diagnosis are shown with special reference to intraperitoneal lavage and sonography. Frequency of possible organ injuries in patients at Göttingen Medical Center is noted and the special surgical care is explained. The importance and urgency of vascular injuries are discussed with reference to different types of arterial and venous injuries in the abdominal cavity and in retroperitoneal spaces.