Severe Polytrauma Research Articles

The Effect of Corticosteroids on the Progression and Outcomes of Polytrauma in Children

Polytrauma in children are among the most common causes of death in the pediatric intensive care unit (ICU).The aim of this study was to evaluate the effect of systemic corticosteroids (SCS) on the progression, laboratory parameters, and outcomes of severe multiple injuries in children requiring ICU.Materials and methods. A retrospective, observational, multicenter (case-control and cross-sectional) study included 203 patients from pediatric ICUs across the Russian Federation. The Abbreviated Injury Scale (AIS) score was 36.81 (25–48), and the Pediatric Trauma Score (PTS) was 5.2 (2–8). SCS were administered to 113 (55.7%) children, 19 (9.36%) of whom died.Results. The most severe changes in laboratory parameters, such as an increase in amylase (35.3 vs. 18.3; P0.001) and activated partial thromboplastin time (APTT) (28.9 vs. 25.8; P0.001), were documented upon admission of children with multiple traumatic injuries to the hospital compared with subsequent days of treatment in the ICU. The average fluid volume (as a percentage of age-related fluid requirements) on the first day of treatment in the ICU was 118.53% and did not exceed 84.42% on subsequent days (P0.001). Higher systolic blood pressure (SBP) during the first three days of ICU treatment was observed in children treated without SCS. SBP tended to decrease by day 5, and then a tendency toward arterial hypertension emerged on days 6–7. In children treated with SCS, blood pressure remained stable during the first seven days in the ICU, contributing to a favorable outcome.Conclusion. The use of SCS in children with severe polytrauma from the first day of ICU treatment contributed to the stabilization of hemodynamic parameters and improved control of shock signs. A positive response to SCS in these patients can be considered a marker for a favorable disease course during ICU treatment.

Pharmacologic or genetic targeting of peripheral nerves prevents peri-articular traumatic heterotopic ossification

Heterotopic ossification (HO) is a pathological process that commonly arises following severe polytrauma, characterized by the anomalous differentiation of mesenchymal progenitor cells and resulting in the formation of ectopic bone in non-skeletal tissues. This abnormal bone growth contributes to pain and reduced mobility, especially when adjacent to a joint. Our prior observations suggested an essential role of NGF (Nerve Growth Factor)-responsive TrkA (Tropomyosin Receptor Kinase A)-expressing peripheral nerves in regulating abnormal osteochondral differentiation following tendon injury. Here, we utilized a recently developed mouse model of hip arthroplasty-induced HO to further validate the role of peripheral nerve regulation of traumatic HO. Nerve ingrowth was either modulated using a knockin transgenic animals with point mutation in TrkA, or local treatment with an FDA-approved formulation of long acting Bupivacaine which prevents peripheral nerve growth. Results demonstrate exuberant sensory and sympathetic nerve growth within the peri-articular HO site, and that both methods to reduce local innervation significantly reduced heterotopic bone formation. TrkA inhibition led to a 34% reduction in bone volume, while bupivacaine treatment resulted in a 50% decrease. Mechanistically, alterations in TGFβ and FGF signaling activation accompanied both methods of local denervation, and a shift in macrophages from M1 to M2 phenotypes was observed. In sum, these studies reinforce the observations that peripheral nerves play a role in the etiopathogenesis of HO, and that targeting local nerves represents a potential therapeutic approach for disease prevention.

Postmortem CT and autopsy findings in an elevator-related death: a case report

AbstractElevator-related fatalities and injuries are rarely discussed. Falls have been identified as the first cause of mortality in the majority of these accidents. Evidence suggests that many elevator accidents may be attributed to inadequate equipment maintenance or malfunctions of the devices. This study examines a case involving an elevator maintenance worker found within an elevator shaft, using postmortem computed tomography (PMCT) along with a full autopsy. The autopsy revealed that the cause of death was severe polytrauma resulting from dragging, compression, and crushing mechanisms, which resulted in a dislocated skull and multiple thoraco-abdominal injuries, including exposed organs and viscera. Detailed examination identified a cranio-encephalic crush, leading to a significant alteration in the physiognomy of the facial structures. Additionally, PMCT revealed complex spinal fractures, such as a Jefferson fracture and a complete Chance fracture at the D6 vertebra, accompanied by spinal deviation proximal to the fracture site. Autopsy findings corroborated these PMCT results. A multidisciplinary approach, including PMCT, is proposed as a strategic method for the comprehensive reconstruction of such accidents, facilitating the collection of extensive data.

Venous thromboembolism chemoprophylaxis after severe polytrauma: timing and type of prophylaxis matter.

In this review, we provide recommendations as well as summarize available data on the optimal time to initiate venous thromboembolism chemoprophylaxis after severe trauma. A general approach to the severe polytrauma patient is provided as well as in-depth reviews of three high-risk injury subgroups: patients with traumatic brain injury, solid organ injury, and pelvic fractures.

Development and validation of a machine learning-based model to assess probability of systemic inflammatory response syndrome in patients with severe multiple traumas

BackgroundSystemic inflammatory response syndrome (SIRS) is a predictor of serious infectious complications, organ failure, and death in patients with severe polytrauma and is one of the reasons for delaying early total surgical treatment. To determine the risk of SIRS within 24 h after hospitalization, we developed six machine learning models.Materials and methodsUsing retrospective data about the patient, the nature of the injury, the results of general and standard biochemical blood tests, and coagulation tests, six models were developed: decision tree, random forest, logistic regression, support vector and gradient boosting classifiers, logistic regressor, and neural network. The effectiveness of the models was assessed through internal and external validation.ResultsAmong the 439 selected patients with severe polytrauma in 230 (52.4%), SIRS was diagnosed within the first 24 h of hospitalization. The SIRS group was more strongly associated with class II bleeding (39.5% vs. 60.5%; OR 1.81 [95% CI: 1.23–2.65]; P = 0.0023), long-term vasopressor use (68.4% vs. 31.6%; OR 5.51 [95% CI: 2.37–5.23]; P < 0.0001), risk of acute coagulopathy (67.8% vs. 32.2%; OR 2.4 [95% CI: 1.55–3.77]; P < 0.0001), and greater risk of pneumonia (59.5% vs. 40.5%; OR 1.74 [95% CI: 1.19–2.54]; P = 0.0042), longer ICU length of stay (5 ± 6.3 vs. 2.7 ± 4.3 days; P < 0.0001) and mortality rate (64.5% vs. 35.5%; OR 10.87 [95% CI: 6.3–19.89]; P = 0.0391). Of all the models, the random forest classifier showed the best predictive ability in the internal (AUROC 0.89; 95% CI: 0.83–0.96) and external validation (AUROC 0.83; 95% CI: 0.75–0.91) datasets.ConclusionsThe developed model made it possible to accurately predict the risk of developing SIRS in the early period after injury, allowing clinical specialists to predict patient management tactics and calculate medication and staffing needs for the patient.Level of evidenceLevel 3.Trial registrationThe study was retrospectively registered in the ClinicalTrials.gov database of the National Library of Medicine (NCT06323096).

Mechanism of injury and disposition of severe polytrauma patients at Kalafong Hospital 2018/2019

Mechanism of injury and disposition of severe polytrauma patients at Kalafong Hospital 2018/2019

Evaluation of the Glasgow Coma Scale-Pupils score for predicting inpatient mortality among patients with traumatic subdural hematoma at United States trauma centers.

The Glasgow Coma Scale-Pupils (GCS-P) score has been suggested to better predict patient outcomes compared with GCS alone, while avoiding the need for more complex clinical models. This study aimed to compare the prognostic ability of GCS-P versus GCS in a national cohort of traumatic subdural hematoma (SDH) patients. Patient data were obtained from the National Trauma Data Bank (2017-2019). Inclusion criteria were traumatic SDH diagnosis with available data on presenting GCS score, pupillary reactivity, and discharge disposition. Patients with severe polytrauma or nonsurvivable head injury at presentation were excluded. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of GCS-P versus GCS scores for inpatient mortality prediction were evaluated across the entire cohort, as well as in subgroups based on age and traumatic brain injury (TBI) type (blunt vs penetrating). Calibration curves were plotted based on predicted probabilities and actual outcomes. A total of 196,747 traumatic SDH patients met the study inclusion criteria. Sensitivity (0.707 vs 0.702), specificity (0.821 vs 0.823), and AUC (0.825 vs 0.814, p < 0.001) of GCS-P versus GCS scores for prediction of inpatient mortality were similar. Calibration curve analysis revealed that GCS scores slightly underestimated inpatient mortality risk, whereas GCS-P scores did not. In patients > 65 years of age with blunt TBI (51.9%, n = 102,148), both GCS-P and GCS scores underestimated inpatient mortality risk. In patients with penetrating TBI (2.4%, n = 4,710), the AUC of the GCS-P score was significantly higher (0.902 vs 0.851, p < 0.001). In this subgroup, both GCS-P and GCS scores underestimated inpatient mortality risk among patients with lower rates of observed mortality and overestimated risk among patients with higher rates of observed mortality. This effect was more pronounced in the GCS-P calibration curve. The GCS-P score provides better short-term prognostication compared with the GCS score alone among traumatic SDH patients with penetrating TBI. The GCS-P score overestimates inpatient mortality risk among penetrating TBI patients with higher rates of observed mortality. For penetrating TBI patients, which comprised 2.4% of our SDH cohort, a low GCS-P score should not justify clinical nihilism or forgoing aggressive treatment.

Intra-articular Calcaneal Fractures: A Report of Cases and Comments on Preoperative Management.

To present a review of the clinical characteristics, preoperative and surgical management, and outcomes of patients with intra-articular calcaneal fractures who had open reduction and internal fixation (ORIF) and to offer some comments on and research ideas for the preoperative management of patients with these fractures. We studied consecutive patients who had ORIF performed by a single surgeon for closed, intra-articular calcaneal fractures at our level-1 trauma center between 5/29/2012 and 3/20/2018. All inpatients were treated with a preoperative soft tissue management protocol, whereas outpatients were not. Data were obtained about demographic and clinical characteristics, times from injury to surgery, quality of fracture reductions, and complication rates. Mean follow-up for the 72 patients with 77 calcaneal fractures was 8.5 (range: 1-43) months, and 21 (27.3%) fractures received inpatient preoperative care with a soft tissue management protocol, while 56 (72.7%) received outpatient preoperative management. More of the fractures treated preoperatively as inpatients versus outpatients were classified as Sanders type III (66.7% vs. 32.1%) and type IV (8.9% vs. 4.8%) fractures and were associated with polytrauma (38.1% vs. 7.1%) and diabetes mellitus (9.5% vs. 5.4%), respectively. For all patients, the mean time from injury to surgery was 12.2 (range: 2.7-19.4) days, and the time was 6.3 days for inpatients and 14.4 days for outpatients, but the quality of fracture reductions and complication rates did not differ between these two groups. Patients with intra-articular calcaneal fractures treated as inpatients and receiving a preoperative soft tissue management protocol had outcomes after ORIF that were not inferior to those experienced by patients treated preoperatively as outpatients, despite a greater proportion of the inpatients having severe fractures, polytrauma, and diabetes mellitus. Dedicated preoperative soft tissue management protocols may be beneficial for patients with calcaneal fractures and warrant further study.

A biomarker panel of C-reactive protein, procalcitonin and serum amyloid A is a predictor of sepsis in severe trauma patients

Severe trauma could induce sepsis due to the loss of control of the infection, which may eventually lead to death. Accurate and timely diagnosis of sepsis with severe trauma remains challenging both for clinician and laboratory. Combinations of markers, as opposed to single ones, may improve diagnosis. We compared the diagnostic characteristics of routinely used biomarkers of sepsis alone and in combination, trying to define a biomarker panel to predict sepsis in severe patients. This prospective observational study included patients with severe trauma (Injury severity score, ISS = 16 or more) in the emergency intensive care unit (EICU) at a university hospital. Blood samples were collected and plasma levels of procalcitonin (PCT), C-reactive protein (CRP), interleukin-6 (IL-6) and serum amyloid A (SAA) were measured using commercial enzyme linked immunosorbent assay (ELISA) kits. A total of 100 patients were eligible for analysis. Of these, 52 were diagnosed with sepsis. CRP yielded the highest discriminative value followed by PCT. In multiple logistic regression, SAA, CRP, and PCT were found to be independent predictors of sepsis. Bioscore which was composed of SAA, CRP, and PCT was shown to be far superior to that of each individual biomarker taken individually. Therefore, compared with single markers, the biomarker panel of PCT, CRP, and SAA was more predictive of sepsis in severe polytrauma patients.

Lactate dehydrogenase can be used for differential diagnosis to identify patients with severe polytrauma with or without chest injury-A retrospective study.

Chest injury is an important factor regarding the prognosis of patients with polytrauma (PT), and the rapid diagnosis of chest injury is of utmost importance. Therefore, the current study focused on patients' physiology and laboratory findings to quickly identify PT patients with chest injury. Data on 64 PT patients treated at a trauma center level I between June 2020 and August 2021 were retrospectively collected. The patients were divided into a PT group without chest injury (Group A) and a PT group including chest injury (Group B). The relationship between chest injury and the patients' baseline characteristics and biochemical markers was analyzed. Heart rate, respiration rate, Sequential Organ Failure Assessment (SOFA) score, glutamate oxaloacetate aminotransferase (GOT), glutamate pyruvate transaminase (GPT), creatine kinase MB (CK-MB), leucocytes, hemoglobin (Hb), platelets, urine output, lactate, and lactate dehydrogenase (LDH) in groups A and B exhibited statistically significant differences at certain time points. Multifactorial analysis showed that blood LDH levels at admission were associated with chest injury (P = 0.039, CI 95% 1.001, 1.022). LDH may be a promising indicator for screening for the presence of chest injury in patients with severe polytrauma.

Endovascular technologies in the treatment of patients with blunt abdominal trauma

Trauma is one of the leading causes of disability and mortality in working-age population. Abdominal injuries comprise 20-30% of traumas. Uncontrolled bleeding is the main cause of death in 30-40% of patients. Among abdominal organs, spleen is most often damaged due to fragile structure and subcostal localization. In the last two decades, therapeutic management has become preferable in patients with abdominal trauma and stable hemodynamic parameters. In addition to clinical examination, standard laboratory tests and ultrasound, as well as contrast-enhanced CT of the abdomen should be included in diagnostic algorithm to identify all traumatic injuries and assess severity of abdominal damage. Development of interventional radiological technologies improved preservation of damaged organs. Endovascular embolization can be performed selectively according to indications (leakage, false aneurysm, arteriovenous anastomosis) and considered for severe damage to the liver and spleen, hemoperitoneum or severe polytrauma. Embolization is essential in complex treatment of traumatic vascular injuries of parenchymal abdominal organs. We reviewed modern principles and methods of intra-arterial embolization for the treatment of patients with traumatic injuries of the liver and spleen.

Emergency medicine: what's new in 2023

Research in prehospital and in-hospital emergency medicine is essential to the development of this discipline. By calling certain practices into question (thrombolysis for minor strokes, use of coagulation factors for patients with severe polytrauma), providing access to new technologies (video-laryngoscopy, POCT troponins in pre-hospital care) or questioning new practices (double defibrillation, pulmonary US in pneumonia), research enables emergency physicians to adapt their day-to-day practice.

Клинический случай оказания экстренной медицинской помощи пациенту с сочетанной травмой после дорожно-транспортного происшествия

Abstract. This research demonstrates a clinical observation of emergency medical care to a patient with associated trauma after a road traffic accident with the diagnosis: “Closed-skull brain injury. Brain concussion. Closed blunt chest trauma. Fracture of the IV–VII ribs on the right and left. Bruise of the right and left lungs. Closed comminuted fracture of the left femur in the middle third with displacement. Paresis of the left oculomotor nerve. Traumatic shock of the III degree”. The description of this case report allows to analyze the clinical and instrumental examination of the victim, tactics of intensive therapy and surgical treatment, clearly demonstrating that the primary task in the management of a victim with severe polytrauma after an accident is diagnosis, anti-shock therapy, pain relief, recovery of impaired vital functions of the body, stabilization of the patient’s condition and surgical treatment of damages and fractures. The research provides a demonstration of successful surgical treatment of a complex closed comminuted diaphyseal fracture of the left femur. A multidisciplinary approach to the treatment of a victim in a road traffic accident with combined trauma is an integrated approach that includes the coordinated action of specialists in various fields, aimed at maximizing the improvement of the victim’s condition. Correctly chosen tactics of diagnostic and treatment measures play a key role in ensuring a positive result and recovery of the victim. Thanks to the coordination of the actions of doctors of various specializations, the victim receives the necessary assistance at each stage of treatment, which contributes to rapid recovery and return to normal life.

Methods of Infanticide: A Review Article

Infanticide refers to the act of killing of infant under the age of 12 months. It is mostly associated with mental disturbance during and immediately after pregnancy. Infanticide can result either from the act of commission or omission. Violence can be used by application of a blunt force or hard object on the infant leading to fractures or damage to vital organs. Strangulation is cutting off the flow of air by constriction of the air passages. This can be done manually or using a cord that wrap the neck. Drowning is the process of submersion or immersion in a liquid medium leading to respiratory impairment. Exposing the infant into the extremes of temperature is also one of the methods used in infanticide. It eventually results in organ dysfunction such as cardiac and respiratory failure, leading to death. Smothering is a form of asphyxia which is caused by deliberate mechanical blocking of the nose and mouth using hands, pillows, or any other objects. It is one of the favorable methods as the absence of resistance from the weak infant hardly leave any injuries. Stabbing is also one of the rare methods used in infanticide. Defenestration is the act of throwing someone or something out of a window leading to severe polytrauma and damage to vital brain centers. Negligence, which is the deliberate withholding of the infant's normal care, is one of the common methods in which death results from dehydration and starvation.

A role for decorin in improving motor deficits after traumatic brain injury

Traumatic brain injury (TBI) is the leading cause of death and disability due to injury worldwide. Extracellular matrix (ECM) remodeling is known to significantly contribute to TBI pathophysiology. Glycosaminoglycans, which are long-chain, variably sulfated polysaccharides abundant within the ECM, have previously been shown to be substantially altered after TBI. In this study, we sought to delineate the dynamics of glycosaminoglycan alterations after TBI and discover the precise biologic processes responsible for observed glycosaminoglycan changes after injury. We performed state-of-the art mass spectrometry on brain tissues isolated from mice after TBI or craniotomy-alone. We observed dynamic changes in glycosaminoglycans at Day 1 and 7 post-TBI, with heparan sulfate, chondroitin sulfate, and hyaluronan remaining significantly increased after a week vis-à-vis craniotomy-alone tissues. We did not observe appreciable changes in circulating glycosaminoglycans in mice after experimental TBI compared to craniotomy-alone nor in patients with TBI and severe polytrauma compared to control patients with mild injuries, suggesting increases in injury site glycosaminoglycans are driven by local synthesis. We subsequently performed an unbiased whole genome transcriptomics analysis on mouse brain tissues 7 days post-TBI and discovered a significant induction of hyaluronan synthase 2, glypican-3, and decorin. The functional role of decorin after injury was further examined through multimodal behavioral testing comparing wild-type and Dcn−/− mice. We discovered that genetic ablation of Dcn led to an overall negative effect of TBI on function, exacerbating motor impairments after TBI. Collectively, our results provide a spatiotemporal characterization of post-TBI glycosaminoglycan alterations in the brain ECM and support an important adaptive role for decorin upregulation after TBI.

CD4 + T cells ferroptosis is associated with the development of sepsis in severe polytrauma patients

BackgroundImmunological disorder remains a great challenge in severe poly-trauma, in which lymphopenia is an important contributor. The purpose of present study is to explore whether ferroptosis, a new manner of programmed cell death (PCD), is involved in the lymphocyte depletion and predictive to the adverse prognosis of severe injuries. Patients and MethodsSevere polytrauma patients admitted from January 2022 to December 2022 in our trauma center were prospectively investigated. Peripheral blood samples were collected at admission (day 1), day 3 and day 7 from them. Included patients were classified based on whether they developed sepsis or not. Clinical outcomes, systematic inflammatory response, lymphocyte subpopulation, CD4 + T cell ferroptosis were collected, detected and analyzed. ResultsNotable lymphopenia was observed on the first day after severe trauma and failed to normalize on the 7th day if patients were complicated with sepsis, in which CD4 + T cell was the subset of lymphocyte that depleted most pronouncedly. Lymphocyte loss was significantly correlated with the acute and biphasic systemic inflammatory response. Ferroptosis participated in the death of CD4 + T cells, potentially mediated by the downregulation of xCT-GSH-GPX4 pathway. CD4 + T cells ferroptosis had a conducive predicting value for the development of sepsis following severe trauma. ConclusionsCD4 + T cells ferroptosis occurs early in the acute stage of severe polytrauma, which may become a promising biomarker and therapeutic target for post-traumatic sepsis.

Inhibition of focal adhesion kinase 2 results in a macrophage polarization shift to M2 which attenuates local and systemic inflammation and reduces heterotopic ossification after polysystem extremity trauma.

Heterotopic ossification (HO) is a complex pathology often observed in combat injured casualties who have sustained severe, high energy polytraumatic extremity injuries. Once HO has developed, prophylactic therapies are limited outside of surgical excision. Tourniquet-induced ischemia injury (IR) exacerbates trauma-mediated musculoskeletal tissue injury, inflammation, osteogenic progenitor cell development and HO formation. Others have shown that focal adhesion kinase-2 (FAK2) plays a key role in regulating early inflammatory signaling events. Therefore, we hypothesized that targeting FAK2 prophylactically would mitigate extremity trauma induced IR inflammation and HO formation. We tested whether the continuous infusion of a FAK2 inhibitor (Defactinib, PF-573228; 6.94 µg/kg/min for 14 days) can mitigate ectopic bone formation (HO) using an established blast-related extremity injury model involving femoral fracture, quadriceps crush injury, three hours of tourniquet-induced limb ischemia, and hindlimb amputation through the fracture site. Tissue inflammation, infiltrating cells, osteogenic progenitor cell content were assessed at POD-7. Micro-computed tomography imaging was used to quantify mature HO at POD-56. In comparison to vehicle control-treated rats, FAK2 administration resulted in no marked wound healing complications or weight loss. FAK2 treatment decreased HO by 43%. At POD-7, marked reductions in tissue proinflammatory gene expression and assayable osteogenic progenitor cells were measured, albeit no significant changes in expression patterns of angiogenic, chondrogenic and osteogenic genes. At the same timepoint, injured tissue from FAK-treated rats had fewer infiltrating cells. Additionally, gene expression analyses of tissue infiltrating cells resulted in a more measurable shift from an M1 inflammatory to an M2 anti-inflammatory macrophage phenotype in the FAK2 inhibitor-treated group. Our findings suggest that FAK2 inhibition may be a novel strategy to dampen trauma-induced inflammation and attenuate HO in patients at high risk as a consequence of severe musculoskeletal polytrauma.

Glomerular hyperfiltration in patients with severe trauma

Background and objectiveAugmented renal clearance or glomerular hyperfiltration (GHF) can significantly affect the clinical outcomes of renally eliminated drugs by promoting subtherapeutic drug exposure. The aggression suffered in patients who suffer severe trauma is a predisposition to manifest GHF and the identification of these patients remains a clinical challenge. The main objective of this study was to describe the prevalence of GHF in a cohort of critically ill trauma patients. Materials and methodsProspective observational study of a cohort of adult patients admitted after suffering severe trauma or polytrauma in the Anesthesiology ICU of the University Hospital of Albacete (Spain). Creatinine clearance (ClCr) was calculated in a 4-h urine collection sample at 24, 72 and 168 h after admission applying the formula; CrCl: [Diuresis in ml (urine/4 h) × Creatinine in urine (mg/dl)] ÷ [240 (minutes) × Creatinine in plasma (mg/dl)]. A CrCl above 130 mL/min was considered GHF. The analyses were performed with the statistical software R version 4.0.4. Results85 patients were included. The median age of the patients was 51 years (IQR 26), 78.82% male. 68 patients were male (78.82%). 75.29% of the patients were polytraumatized. 61 patients (71.76%) presented GHF at some point in the CrCl determination. At 24 h of admission, 56.34% of the patients presented GHF with a mean CrCl of 195.8 ml/min, 61.11% of the patients presented it at 72 h with a mean CrCl of /min and 56.52% presented GHF at 168 h of admission with a mean CrCl of 207 ml/min. A significant positive relationship (p = 0.07) was found between GHF manifested at 72 h and at 168 h. We observed a statistically significant relationship between this phenomenon with younger ages, lower ISS scores and lower plasma creatinines. ConclusionsGHF are a common condition in critically ill patients admitted for severe trauma. We recommend the use of CrCl to assess renal function and make dosage adjustments. Studies are required to understand the clinical impact of these phenomena on drug elimination and to be able to establish the ideal dosage in those cases.

The effect of a tyrosyl-D-alanyl-glycyl-phenylalanyl-leucyl-arginine diacetate (Dalargin) on oxidative stress in patients with severe combined trauma: a prospective clinical study

INTRODUCTION: Severe combined trauma remains the leading cause of mortality and disability of the workable population. Under damaging factor influence, a whole cascade of pathological processes is triggered, leading to development of multiple organ failure. OBJECTIVE: Exploration of the effects synthetic analogue of tyrosyl-D-alanyl-glycyl-phenylalanyl-leucyl-arginine diacetate (Dalargin) on the dynamics of oxidative stress markers in patients with severe polytrauma and the development of organ dysfunction. MATERIALS AND METHODS: 104 patients with severe combined trauma were included in study. There were 38 patients in the Dalargin group and 66 patients in the control group. Patients from main group received Dalargin in the form of a constant infusion through a syringe dispenser at the dose of 10 mcg/kg/hour at first 12 hours of hospitalization and 5 mcg/kg/hour up to 72 hours from the moment of admission. The control group received standard treatment. Indicators of oxidative stress were evaluated at the time of admission (0 days), 1, 3, 5, 7, 10 and 14 days from the therapy onset. RESULTS: In the main group, there was a significant decrease in oxidative stress markers such as malondialdehyde from the first day of treatment (p &lt; 0.05), normalization of stable nitric oxide metabolites at day 10, and a decrease in total antioxidant activity below normal throughout the observation period. Mortality was comparable in both groups (p &gt; 0.05), but the length of hospital stay was lower in surviving patients in the Dalargin group (p &lt; 0.05). The development of organ dysfunction (acute respiratory distress syndrome, acute kidney injury) was less frequent in the Dalargine group (p &lt; 0.05), but infectious complications (pneumonia, meningitis, wound suppuration) were comparable. CONCLUSIONS: Dalargin leads to a decrease of oxidative stress markers and normalization of endothelial function indicators, which contributes to a decrease of organ dysfunction frequency.

Safety and Metabolic Tolerance of Citrate Anticoagulation in Critically Ill Polytrauma Patients with Acute Kidney Injury Requiring an Early Continuous Kidney Replacement Therapy.

For severe polytrauma patients with an early AKI requiring renal replacement therapy, anticoagulation remains a great challenge. Due to a high bleeding risk, hemodynamic instability, and increased lactate levels, continuous modality (CKRT) and citrate anticoagulation seem to be the most appropriate. However, their safety with regard to the potential risk of impaired citrate metabolism is not documented. A retrospective study of 60 severe polytrauma patients admitted to the emergency department between January 2000 and December 2021 was conducted; the patients requiring CKRT during the first 72 h were treated with citrate (n. 46, group Citrate) or with heparin (n. 14, group Heparin). Out of 60 patients, 31 survived (51.7%). According to logistic regression analysis, age and SOFA score were significant predictors of mortality. The incidence of rhabdomyolysis was more common in the survivors (77.4 vs. 51.7%), and Kaplan-Meyer analysis showed a better trend towards survival at 90 days for the group Citrate than the group Heparin (p 0.0956). In the group Citrate, hemorrhagic episodes were significantly less common (0.045 vs. 0.273 episodes/day, p < 0.001); the effective duration (h/day) of CKRT was longer; and the effective net ultrafiltration rate (mL/kg/h) and blood flow rate were lower. For severe polytrauma patients, early, soft CKRT with citrate anticoagulation at a low blood flow rate and circuit citratemia showed a better safety and hemodynamic stability, suggesting that citrate should be the first choice anticoagulant in this subset of patients.