Relationship between intensive care complications and costs and initial 24 h events of trauma patients with severe haemorrhage.

BACKGROUND: The correlation between the events occurring in the initial 24 h following traumatic injury and the outcome of patients presenting with hypovolaemic shock is not clear. METHODS: 27 patients who presented to a regional trauma centre with severe hypovolaemic shock were prospectively monitored. Evidence of severe hypovolaemia and shock was noted on admission with a mean systolic blood pressure of 73.8 mm Hg and a mean lactate level of 6.6 mM/l. The patients received a mean of 21.7 litres intravenous fluids during the first 24 h to maintain a mean systolic blood pressure >or=110 mm Hg and urine output of >or=50 ml/h. Multiple metabolic and physiological parameters were obtained prospectively and on an almost hourly basis for the first 24 h after admission. Patients were followed throughout their stay in hospital to record outcome, complications, total hospital costs and length of stay. RESULTS: Using regression and multivariate analysis, adult respiratory distress syndrome was correlated with hypothermia and persistent lactic acidosis (R(2) = 0.65, p = 0.005). Coagulopathy was associated with hypothermia (R(2) = 0.43, p = 0.04). Length of stay and cost of hospitalisation were highly related to intensive care unit days, hospital-acquired infections and ventilator days (R(2) = 0.86, p = 0.03). CONCLUSION: The initial 24 h events of trauma patients with haemorrhagic shock may have a significant impact on hospital costs and on complications developing later during hospitalisation.

The effects of recombinant human thrombomodulin on endotoxin-induced multiple-system organ failure in rats.

Activation of the coagulation system is postulated to play an important role in the pathogenesis of endotoxin-induced tissue injury. Thrombomodulin (TM) is an endothelial cell membrane glycoprotein receptor for thrombin. Once bound to TM, thrombin loses its procoagulant activity, which results in decreased clotting. In addition, the binding of thrombin to TM activates the endogenous anticoagulant pathway through protein C. We studied the effect of recombinant human TM (rh-TM) on endotoxin-induced multiple-system organ failure (MSOF) in Sprague-Dawley rats weighing 400 to 450 g: 2 mg/kg of rh-TM was injected (T1/2 = 4.5 h) 30 min prior to intravenous injection of 20 mg/kg of Escherichia coli endotoxin. The study presented here consisted of three separate experiments. Experiment 1: 24-h survival study. Experiment 2: multiple-system organ microthrombi study in which 125I-human fibrinogen was injected 30 min prior to an endotoxin or saline injection and tissue microthrombi formation was assessed by measuring the percentage of organ radioactivity (lung, heart, liver, and kidney) against total injected radioactivity (microthrombi index, MI) 2.25 h after an endotoxin or saline injection. Experiment 3: endotoxin-induced MSOF study in which 125I-rat albumin was injected 5 h after an endotoxin or saline injection, and endotoxin-induced organ injury was evaluated by measuring tissue wet-to-dry ratios (W/D) and tissue-to-plasma 125I-rat albumin concentration ratios (T/P) 8 h after the endotoxin or saline injection. Blood contamination in samples from Experiments 2 and 3 was corrected by using 131I-rat albumin measurements. Pretreatment with rh-TM improved the survival from 12 h through 23 h as compared with that of the endotoxin control group (p < 0.05). However, at 24 h, after essentially all injected rh-TM had been eliminated, there was no difference in survival. Significant reductions in MI, W/D, and T/P in the organs sampled were observed in the rh-TM pretreated groups (p < 0.05). In conclusion, rh-TM improved short-term but not overall survival and decreased MSOF in endotoxemic rats.

Pulmonary mucormycosis presenting as an endobronchial lesion.

A 56-year-old diabetic man presented with left upper lobe collapse and postobstructive pneumonitis. Fiberoptic bronchoscopy revealed an endobronchial mass obstructing the left mainstem bronchus. The lesion resembled a bronchial adenoma; however, cytologic and histologic examination revealed invasive mucormycosis. The patient was treated with intravenous amphotericin B followed by endoscopic laser surgery that relieved the obstruction.

Wegener's granulomatosis presenting as right middle lobe obstruction.

Wegener's granulomatosis may present with a variety of findings and be difficult to diagnose. We report a case of a 55-year-old woman presenting with right middle lobe obstruction who was found to have limited Wegener's granulomatosis. Extensive medical evaluation was nondiagnostic and open lung biopsy specimens were required to establish the diagnosis.