Impact of fluid therapy on apoptosis and organ injury during haemorrhagic shock in an oxygen-debt-controlled pig model.

INTRODUCTION: Apoptosis, or programmed cell death, seems to play a role in the physiology of shock. The influence of fluid resuscitation on the occurrence of apoptosis during haemorrhage is still unclear. Using an experimental randomised study, the goal of this investigation was to find a relation between different frequently used resuscitation fluids and evidence of apoptosis. MATERIALS AND METHODS: Sixty female pigs with a mean body weight of 20 kg were randomised into six groups, each receiving a different resuscitation fluid therapy: malated Ringer, lactated Ringer, hypertonic saline, hypertonic saline solution/Dextran 60, carbonate/gelatine and a sham group (no shock, no resuscitation). A haemorrhagic shock with a predefined oxygen debt with high mortality expected was induced for a period of 60 min. Then, the resuscitation fluid therapy within each group was initiated. At the beginning, after 1 h of shock and 1 and 2 h after resuscitation, biopsies from the liver were taken, as one of the most important metabolism organs of shock. Three hours after the beginning of the resuscitation period, the animals were allowed to recover under observation for 3 days. At the end of this period, a state of narcosis was induced and another liver biopsy was taken. Finally, the animals were sacrificed and samples were taken from the liver, kidney, heart and hippocampus. The TUNEL method was used for identifying apoptosis. Impairment of liver function was indicated by the measurement of transaminase levels. RESULTS: There was no observed difference in the rate of apoptosis in all groups and a low number of apoptotic cells were found in all the organs sampled. The sham group also showed a low count of apoptosis. The hypoxia-sensitive neurons within the hippocampus did not show any signs of apoptosis. The high oxygen debt during haemorrhage led to a high mortality. The non-treated animals died very quickly, as an indicator for severe shock. Animals treated with hypertonic saline showed a significant increase in aspartate transaminase (AST) plasma levels on the first day after shock. CONCLUSION: The different resuscitation fluids used in the treatment of haemorrhagic shock in this experimental model showed no evidence of a different apoptosis rate in the end organs.

[Systematic literature searches for clinical guideline development in the field of out-of-hospital and early in-hospital care of multiply injured patients]. / Systematische Literatursuchen in der Erstellung klinischer Leitlinien am Beispiel der prä- und frühklinischen Versorgung polytraumatisierter Patienten.

QUESTION: To what extent does the scientific literature have an impact on current clinical practice guidelines (CPGs) in trauma surgery? METHODS: We searched for CPGs on the initial management of multiply injured patients and assessed the quality of literature search and appraisal within these CPGs. Secondly, we compiled a list of all medical journal with relevance to prehospital trauma care. Lastly, we performed a hand search for randomised controlled trials (RCTs) in some of the German not in Medline indexed traumatological journals. RESULTS: We identified 22 CPGs of varying methodological quality. The American guidelines scored highest. Only 21 of the 38 journals (55%) in the field of prehospital trauma surgery were indexed in Medline, while 6 were covered only by Embase and 11 were indexed in neither of both databases. Hand searching four non-indexed German journals identified nearly 200 RCTs. CONCLUSION: Information flow between clinical research and CPG development remains difficult. Thoroughly performed literature searches have an important role in CPG development.

[Technology assessment of ultrasound in acute diagnosis of blunt abdominal trauma]. / Technologiebewertung des Ultraschalls in der Akutdiagnostik des stumpfen Bauchtraumas.

In this article a systematic technology assessment was used for ultrasound in blunt abdominal trauma. We found sonography to be a simple, fast and complication-free method with high sensitivity and specificity. Ruptures of the small bowel seemed to be extremely difficult to detect, especially in the early phase after blunt abdominal trauma. No basic definitions of significant free fluid and maximal limit for non-operative treatment are found in the international literature. Only the combination of prognostic factors such as mechanism of the accident, clinical examination, and the intuition of the surgeon leads to a decision.

[Compartment syndrome: a complication of lithotomy position]. / Das Kompartmentsyndrom: eine Komplikation der Steinschnittlagerung.

Urological operations are commonly performed in the lithotomy position. A rare, but serious, complication is the compartment syndrome, which can result in neurovascular damage and permanent disability or limb loss. We describe two cases of compartment syndrome. One arose after transurethral resection of the prostate, and the other after an operation to change a transsexual patient from man to woman. The literature is reviewed, and the causes of the syndrome and possible ways of preventing serious consequences to the patients affected are discussed.