Inflammatory biomarkers in combat wound healing.

BACKGROUND: Modern war ballistics and blast injuries inflict devastating extremity injuries, violating soft tissue, bone, and neurovascular structures. Despite advances in complex wound management, appropriate timing of war wound closure remains subjective. In addition, the pathophysiology of acute wound failure is poorly defined. METHODS: Patients with penetrating extremity wounds sustained during combat were prospectively studied and followed for 30 days after definitive wound closure. The primary outcome was wound healing. Wound dehiscence was defined as spontaneous partial or complete wound disruption after closure. Serum, wound effluent, and wound bed tissue biopsy were collected at each surgical wound debridement. Serum and wound effluent were analyzed with a multiplex array of 22 cytokines and chemokines, and wound tissue for corresponding gene transcript expression. RESULTS: Fifty-two penetrating extremity war wounds in 33 male patients were investigated. Nine (17%) wounds dehisced. Concomitant vascular injury, increased wound size, and higher injury severity score correlated with wound dehiscence. Both serum and wound effluent cytokine and chemokine protein profiles were statistically associated with healing outcome at various time points. Wound biopsy gene transcript expression demonstrated increased tissue inflammation associated with wound failure. Multiple protein and gene transcript biomarkers predictive of wound healing were identified. CONCLUSIONS: The cytokine and chemokine protein and gene transcript expression patterns demonstrate a condition of inflammatory dysregulation associated with war wound failure. A molecular biomarker panel may predict combat wound healing outcome and warrants prospective validation.

Transforming an academic military treatment facility into a trauma center: lessons learned from Operation Iraqi Freedom.

BACKGROUND: To manage the influx of patients with predominately extremity injuries from Operation Iraqi Freedom (OIF), our center was required to transform from a nontrauma academic hospital to a trauma hospital by using a multidisciplinary approach. STUDY DESIGN: A retrospective chart review was performed of casualties from OIF who were received over 14 months. RESULTS: A total of 313 casualties were received. The average number of admissions was 16 per month, except during November 2004, when there were 88 admissions over 7 days. The mean ISS for all patients was 14.1 +/- 10.3. A total of 113 patients (36%) required admission to the intensive care unit for an average of 7.5 +/- 5.2 days. The mean interval between injury and arrival in the continental United States was 6.5 +/- 4.6 days. Most casualties suffered multisystem trauma, with extremity injuries predominating. The multidisciplinary approach to casualty care consisted of several meetings a week and included everyone involved in caring for these combat casualties. CONCLUSIONS: A multidisciplinary approach transformed an existing medical center into a trauma receiving hospital capable of managing and maintaining a surge in patient admissions resulting in minimal morbidity and mortality. This model further supports a multidisciplinary approach to trauma care and could serve as a guideline for transforming existing medical centers into trauma receiving hospitals to deal with patient overflow in the event of future civilian mass casualties.

Perioperative blood transfusion in combat casualties: a pilot study.

BACKGROUND: In recent studies, blood transfusion has been shown to increase the rate of wound healing disturbances in orthopedic patients. Furthermore, our group has determined a correlation between delayed wound healing and elevations in inflammatory mediators in combat casualties. Therefore, we sought to determine the effect of blood transfusion on wound healing and inflammatory mediator release in combat casualties. METHODS: Prospective data were collected on 20 severely injured combat casualties sustaining extremity wounds. Patients were admitted to the National Naval Medical Center during a 13-month period from January 2007 to January 2008. Data variables included age, gender, Glasgow coma score (GCS), mechanism of injury, and transfusion history. Injury severity was assessed using the Injury Severity Score (ISS). Serum was collected initially and before each surgical wound debridement and analyzed using a panel of 21 cytokines and chemokines. The association between blood transfusion and wound healing, incidence of perioperative infection, intensive care unit (ICU) admission rate, and ICU and hospital length of stay was assessed. Differences were considered significant when p < 0.05. RESULTS: The study cohort had a mean age of 22 +/- 1, a mean ISS of 15.8 +/- 2.6, and a mean GCS 13.9 +/- 0.6; all were men and suffered penetrating injuries (90% improvised explosive device [IED] and 10% gunshot wound [GSW]). The cohort was divided into two groups. Patients receiving 4 units of blood initially (group 2, n = 9). There was no significant difference in age, ISS, GCS, or mortality between the two groups. However, group 2 patients had significant impairment in wound healing rate (54% vs. 9%, p < 0.05), higher ICU admission rate (78% vs. 9%, p < 0.01), perioperative infection rate (89% vs. 27%, p < 0.01), and a longer hospital length of stay (49.9 +/- 12.8 vs. 23.8 +/- 2.9, p < 0.05) compared with group 1 patients. In addition, there was a significant correlation between the initial mean serum cytokine/chemokine level of interleukin (IL)-10, IL-8, interferon inducible protein (IP)-10, IL-6, and IL-12p40 and the number of units of blood transfused (p < 0.05). CONCLUSION: Allogeneic blood transfusions in combat casualties were associated with impaired wound healing, increased perioperative infection rate, and resource utilization. In addition, the extent of blood transfusion was associated with significant differences in inflammatory chemokine and cytokine release.

Management of colorectal injuries during operation iraqi freedom: patterns of stoma usage.

BACKGROUND: Management of penetrating colorectal injuries in the civilian trauma population has evolved away from diversionary stoma into primary repair or resection and primary anastomosis. With this in mind, we evaluated how injuries to the colon and rectum were managed in the ongoing war in Iraq. METHODS: The records of Operation Iraqi Freedom patients evacuated to National Naval Medical Center (NNMC) from March 2004 until November 2005 were retrospectively reviewed. Patients with colorectal injuries were identified and characterized by the following: (1) injury type; (2) mechanism; (3) associated injuries; (4) Injury Severity Score; (5) levels of medical care involved in patient treatment; (6) time interval(s) between levels of care; (7) management; and (8) outcomes. RESULTS: Twenty-three patients were identified as having either colon or rectal injury. The average ISS was 24.4 (range, 9-54; median 24). On average, patients were evaluated and treated at 2.5 levels of surgically capable medical care (range, 2-3; median 2) between time of injury and arrival at NNMC, with a median of 6 days from initial injury until presentation at NNMC (range, 3-11). Management of colorectal injuries included 7 primary repairs (30.4%), 3 resections with anastomoses (13.0%), and 13 colostomies (56.6%). There was one death (4.3%) and three anastomotic leaks (30%). Total complication rate was 48%. CONCLUSIONS: Based upon injury severity, the complex nature of triage and medical evacuation, and the multiple levels of care involved for injured military personnel, temporary stoma usage should play a greater role in military casualties than in the civilian environment for penetrating colorectal injuries.

Benign pneumoperitoneum after colonoscopy: a prospective pilot study.

Benign pneumoperitoneum is asymptomatic free intraabdominal air and is reported to occur occasionally with colonoscopy. Management of benign pneumoperitoneum after colonoscopy is controversial and may depend on incidence or etiology. No previous studies prospectively investigated the incidence or inciting factors of benign pneumoperitoneum resulting from colonoscopy. In this study, 100 patients underwent colonoscopy and then radiography of the chest and abdomen to detect free air. The average age was 58 +/- 6.2 years, and 48 of the colonoscopies were therapeutic. No cases of benign pneumoperitoneum were detected, estimating the incidence at 0% to 3% for diagnostic and therapeutic colonoscopy. These data indicate that benign pneumoperitoneum attributable to colonoscopy is rare and possibly nonexistent. Given the paucity of data favoring the occurrence of benign pneumoperitoneum after colonoscopy, we advocate treating all cases of free intraabdominal air after colonoscopy as perforations.

Colonoscopic diagnosis of appendiceal intussusception: case report and review of the literature.

Intussusception of the appendix is an extremely rare condition. Although approximately 200 cases of appendiceal intussusception have been reported in the literature, very few have ever been diagnosed preoperatively. We report a case of appendiceal intussusception secondary to endometriosis in an otherwise healthy female. The case was diagnosed preoperatively by colonoscopy and treated surgically at laparoscopy. We review the literature of appendiceal intussusception and discuss the associated conditions, diagnosis, and a classification scheme for this unusual finding.