Posttraumatic inflammatory response, secondary operations, and late multiple organ failure.

The objective of this study was to determine the role of surgical procedures as secondary inflammatory insults in the development of late multiple organ dysfunction syndrome in patients with multiple trauma and to evaluate both specific and nonspecific indicators of the inflammatory response in their ability to indicate the risk of severely injured patients to develop organ failure after secondary operations. In a prospective study of 106 severely injured patients (ISS 40.6) who underwent secondary operations (> 3 days after trauma), we compared the level of preoperative inflammation with the sequelae of surgical trauma. The interventions included facial reconstructions; osteosynthesis of the pelvic girdle, long bones, and spine; and others. Group 1 consisted of 40 patients (38%) who developed respiratory, renal, or hepatic failure, or combinations thereof, within 2 days after the operation or whose preexisting organ dysfunction worsened by more than 20% from baseline. The remaining 66 patients (62%) with an uneventful recovery formed group 2. The preoperative levels of neutrophil elastase (92.2 vs. 61.3 ng/dL), C-reactive protein (12.4 vs. 7.6 mg/dL), and platelet count (118,000 vs. 236,000/microL) were significantly more abnormal in the patients of group 1. PO2/FiO2 ratio was also somewhat lower in group 1 patients (305.5 vs. 351), whereas other parameters (e.g., blood pressure, heart rate, bilirubin, creatinine, urinary output, lactate, pH, and coagulation) did not allow preoperative differentiation between groups 1 and 2. An increased state of inflammation (neutrophil elastase > 85 ng/mL, C-reactive protein > 11 mg/dL, platelet count < 180,000/microL) predicted postoperative organ failure with an accuracy of 79% (sensitivity, 73%; specificity, 83%). We conclude that secondary operations may act as a second insult and may precipitate late multiple organ dysfunction syndrome if they are performed in patients with multiple trauma while they still have an increased level of posttraumatic inflammation. However, future investigations have to show whether postponing surgery until inflammation has subsided or the use of less invasive surgical techniques will decrease the rate of postoperative organ failure in the trauma patient.

[Operation planning of secondary interventions after polytrauma]. / Operationsplanung von sekundären Eingriffen nach Polytrauma.

A prospective study of 135 secondary operations (> 24 h after trauma) in patients with multiple injuries (ISS 40.6 pts) was performed to determine specific and unspecific indicators of the inflammatory response that may indicate the degree of risk of postoperative organ failure in these patients. On the morning of the operation each patients' data were recorded and blood samples were collected. Patients were divided in those in whom respiratory, renal and/or hepatic failure developed or preexisting organ failure worsened by more than 20% from baseline within 2 days after the operation and those who had no complications. In 29 patients who were operated upon between 24 and 72 h after trauma only the pO2/FiO2 ratio allowed discrimination between the two groups. The overall accuracy of this parameter as a predictor of postoperative organ failure was 83%, with a sensitivity of 78% and a specificity of 85%. In 106 patients with secondary operations later than 72 h after trauma, neutrophil elastase, C-reactive protein and platelet count revealed the highest predictive accuracy, with cut-off values of 250 ng/ml, 11 mg/dl and 180 x 10(6)/ml, respectively. The combined accuracy of these three parameters in prediction of postoperative organ failure was 79% (sensitivity 73%, specificity 83%). In this group of patients the pO2/FiO2 ratio was of less value and blood pressure, heart rate, renal function parameters, lactate and coagulation parameters were of no value.(ABSTRACT TRUNCATED AT 250 WORDS)