Hematological and Chemical Profiles in a Porcine Model of Severe Multiple Trauma.

BACKGROUND: Clinical chemistry and hematological tests are widely used to monitor the clinical course of several diseases. However, these parameters are sparse in large-animal models of multiple trauma (MT). Thus, we aimed to provide these missing data to improve future experimental setups in trauma research. METHODS: Male pigs (German Landrace pigs) were randomized into either an MT group (n = 8) including blunt thoracic trauma, tibial fracture, and controlled hemorrhage or a sham group (n = 8) without any trauma. After trauma induction, all animals received intensive care treatment for 72 h under anesthesia, including mechanical ventilation and volume resuscitation. Blood and urine samples were obtained to measure common hematological and chemical parameters before trauma (0 h), after trauma (1.5 h), during resuscitation (2.5 h), after fracture stabilization (3.5 h), and at 12, 24, 48, and 72 h. Statistical analyses were performed using a linear mixed model (group × time) and Welch's ANOVA. RESULTS: MT led to a perceptible immunological reaction. Between groups, significantly different time courses of leukocyte counts (p = 0.034) and lymphocyte proportions (p = 0.001) were observed. Moreover, MT changed the time course of total protein (p = 0.006). Significantly lower concentrations compared to sham were found in MT at each single time point starting at 1.5 h to the end of the observation period (all p < 0.05). CONCLUSIONS: Our results indicate that a traumatic insult leads to significant alterations in the immune system already shortly after trauma. Together with the additional catabolic reactions observed, these alterations might contribute to the occurrence of later complications. The presented data provide valid references for further experimental setups with prolonged observation times, especially in similar porcine models of MT.

Minute-to-minute urine flow rate variability: a retrospective survey of its ability to provide early warning of acute hypotension in critically ill multiple trauma patients.

PURPOSE: Dynamic changes in urine output and neurological status are the recognized clinical signs of hemodynamically significant hemorrhage. In the present study, we analyzed the dynamic minute-to-minute changes in the UFR and also the changes in its minute-to-minute variability in a group of critically ill multiple trauma patients whose blood pressures were normal on admission to the ICU but who subsequently developed hypotension within the first few hours of their ICU admission. PATIENTS AND METHODS: The study was retrospective and observational. Demographic and clinical data were extracted from the computerized register information systems initially; the clinical and laboratory data of 100 critically ill patients with multiple trauma who were admitted to the ICU during the study period were analyzed. Of this group, ten patients were eventually included in the study on the basis of the inclusion criteria. RESULTS: The minute-to-minute urine flow rate (UFR) and urine flow rate variability (UFRV) both decreased significantly during the periods of hypotension (p values 0.001 and 0.006, respectively). Notably, the decrease in UFRV preceded by at least 30 min a corresponding decline in the systolic and mean arterial blood pressures, which manifested as a flattening of UFRV amplitude which was observed prior to the occurrence of the lowest recorded systolic and mean arterial blood pressures. Statistical analysis by the Pearson method demonstrated a strong direct correlation between the decrease in UFRV and the decrease in the MAP (R = 0.9, p = 0.001), and SBP (R = 0.86, p = 0.001) and the decreasing urine output per hour (R = 0.88, p < 0.001). CONCLUSION: We found that changes in UFRV correlate strongly with systolic and mean arterial blood pressures. We feel that this parameter could potentially serve as an early signal of hemodynamic deterioration due to occult bleeding in critically ill trauma patients, and might also be able to identify the optimal end-point of hemodynamic resuscitative measures in these patients.

[Investigation of serum cysteine concentration to monitor glomerular filtration rate for early diagnosis of acute kidney injury in patients with combined trauma].

AIM: / To determine the early diagnostic criteria for acute kidney injury in patients with combined trauma using serum cystatin C as a biomarker in the diagnostic work-up of the affected patients. MATERIALS AND METHODS: / The study comprised 42 patients who suffered combined trauma from 2015 to 2016. Cystatin C level was measured in serum. Blood sampling was done on the 1st, 3rd, 7th, 14th day of the injury. The patients were predominantly men (80%). Renal function was tested by measuring the rate of filtration and reabsorption using the Reberg-Tareev test. All patients were tested for the following parameters: serum and urine creatinine, 1-minute, 1-hour and 24-hour urine output, the rate of glomerular filtration and tubular reabsorption. RESULTS AND DISCUSSION: / Forty (95.3%) patients had normal Reberg-Tareev test values. In 2 (4.7%) patients Reberg-Tareev test results were below normal values, which was associated with the development of acute renal failure on the sixth or seventh day after trauma. The overwhelming majority of patients with combined trauma had a normal serum creatinine level (n=38). In 33 (78.6%) patients serum cystatin C level was more than 30 percent above normal values. Moreover, an increase in the cystatin C level was observed in the first 3 days, with a gradual decrease thereafter. The glomerular filtration rate, according to the Reberg-Tareev test was reduced only in 4 patients, but when the Hawk formula was used to calculate GFR, it was reduced in 33 patients. On the 3rd day after trauma, based on the increase in the serum cystatin level, 12 patients were found to have subclinical acute renal damage. At the same time, this group of patients had normal azotemia parameters. These findings suggest that measuring glomerular filtration rate using serum cystatin C has a greater accuracy in detecting latent renal dysfunction.

Quantification of urinary F2-isoprostanes with 4(RS)-F4t-neuroprostane as an internal standard using gas chromatography-mass spectrometry Application to polytraumatized patients.

Isoprostanes are a family of prostaglandin isomers produced from oxidation of polyunsaturated fatty acids through a non-enzymatic free radical-catalyzed mechanism. Quantification of F(2)-isoprostanes (F(2)-IsoPs) provides a good index of oxidative stress and allows non-invasive assessment of lipid peroxidation in vivo. Since "interferences peaks" at m/z 573 co-elute with d(4)-15-F(2t)-IsoP preferentially used, we propose a new GC-NICI-MS approach to quantify urinary F(2)-IsoPs by using 4(RS)-F(4t)-neuroprostane as the internal standard. This method was applied to quantify urinary F(2)-IsoPs excretion in healthy volunteers and polytraumatized patients. Our results showed a significant increase (p<0.0001) in urinary F(2)-IsoPs in polytraumatized patients compared with healthy volunteers (4.73+/-2.75 ng/mg vs. 0.811+/-0.359 ng/mg creatinine).

[Dynamics of changes in the concentrations of selenium in plasma, urine, and erythrocytes in children with severe brain injury].

The role of selenium in man is diverse. In particular, selenium is a cofactor of the major antioxidative enzyme glutathione peroxidase, which inhibits free radical oxidation reactions and restores the normal vital functions of cells and organs. This study deals with selenium metabolism in severe brain injury and its correction modes.

[Microbiological investigation of blood, urine, cerebrospinal fluid, and soft tissue material from corpses with purulent and inflammatory foci].

A microbiological investigation conducted by the author allowed her to formulate differential-diagnostic signs of the time of death in persons who die of pyoinflammatory complications of polytrauma: up to 24 hours ago or more than 24 hours. Differences in the count of the pathogens depending on the time of death are demonstrated.

Evaluation of an artificial neural network to predict urea nitrogen appearance for critically ill multiple-trauma patients.

BACKGROUND: Computer-based simulated biologic neural network models have made significant strides in clinical medicine. METHODS: To determine the predictive performance of a conventional regression model and an artificial neural network for estimating urea nitrogen appearance (UNA) during critical illness, 125 adult patients admitted to the trauma intensive care unit who required specialized nutrition support were studied. The first 100 consecutive patients were used to develop the 2 models. The first model used stepwise multivariate regression analysis. The second model entailed the use of a feeding-forward, back-propagation, supervised neural network. Bias and precision of both methods were evaluated in 25 separate patients. RESULTS: Multivariate regression analysis revealed a significant highly correlative relationship (r(2) = .918, p < or = .01): Predicted UNA (g/d) = (0.29 x WT) + (1.20 x WBC) + (0.44 x SUN) with WT as current body weight in kg, WBC as white blood cell count in cells/mm(3), and SUN as serum urea nitrogen concentration (mg/dL). The regression method was biased toward overestimating measured UNA, whereas the neural network was unbiased. Precision (95% confidence interval) of the neural network was significantly better than the regression (3.3-7.2 g vs 7.3-11.6 g, respectively, p < .01). Regression analysis successfully predicted UNA within 3 g of measured UNA in 16% (4 of 25) of patients, whereas the neural network successfully predicted UNA in 44% (11 out of 25) of patients (p < .06). CONCLUSIONS: These preliminary data indicate that use of an artificial neural network may be superior to conventional regression modeling techniques for estimating UNA in critically ill adult multiple-trauma patients receiving specialized nutrition support.

Predicting total urinary nitrogen excretion from urinary urea nitrogen excretion in multiple-trauma patients receiving specialized nutritional support.

OBJECTIVE: We investigated the accuracy of methods to estimate total urinary nitrogen (TUN) excretion from urinary urea nitrogen (UUN) excretion for patients who have multiple trauma and receive specialized nutritional support. METHODS: Fifty-five critically ill, adult patients who had multiple trauma and were receiving specialized nutritional support were evaluated. A 24-h urine collection for urea nitrogen and total nitrogen was performed 4.4 +/- 2.6 d after admission to the trauma intensive care unit. Patients with significant renal impairment, liver dysfunction, or obesity (>150% of ideal body weight) were excluded from study entry. Eight publications that examined the relation between TUN and UUN were evaluated for bias and precision in estimating TUN from UUN. RESULTS: TUN was 20.8 +/- 10.8 g/d with an average difference of 3.8 +/- 2.8 g/d between TUN and UUN. Linear regression analysis comparing TUN with UUN indicated a significant correlative relation (TUN = 1.1 x UUN + 2; r = 0.958, P < 0.001). The difference between TUN and UUN varied based on UUN: for UUN lower than 10 g/d, TUN minus UUN was 1.5 +/- 1.0 g/d; for UUN 10 to 20 g/d, TUN minus UUN was 4.1 +/- 3.2 g/d; and for UUN higher than 20 g/d, TUN minus UUN was 5.3 +/- 1.9 g/d (P < 0.001). Six methods were biased toward underpredicting TUN, one method was unbiased, and one was biased toward overpredicting TUN. A practical method for estimating TUN from UUN was developed: TUN = UUN + 2 for those with UUN lower than 10 g/d and TUN = 1.1 x UUN + 2 for those with UUN of at least 10 g/d. CONCLUSIONS: Our method, the modified Velasco method, UUN/0.84, and UUN/0.85 provided reasonable estimates of TUN from UUN in critically ill, adult patients who had multiple trauma and were receiving specialized nutritional support; however, our method requires further validation.

Urinary free cortisol values in children under stress.

Children with adrenocortical insufficiency are commonly instructed to increase their baseline glucocorticoid replacement doses by three to five times during periods of stress such as surgery or febrille illness. We conducted this to determine whether these recommendations reflect the actual change in urinary free cortisol (UFC) output during stress. The 24-hour UFC excretion was determined in 78 children who were admitted to a general pediatric department or intensive care unit with temperature > 38.7 degrees C, after major surgery, or during status epilepticus; we reevaluated 43 of the patients 2 weeks after recovery. In addition, the 24-hour UFC levels were determined in 127 healthy children aged 1.8 to 17 years. The UFC level positively correlated with age (r = 0.254; p < 0.001). The amount of UFC per gram of creatinine was inversely correlated with age (r = 0.255; p < 0.001). The amount of UFC per surface area was independent of age. The mean change in the level of UFC per square meter surface area was highest among children who had cardiothoracic surgery and those with multiple trauma. The increase in UFC level during bacterial infection was significantly greater than that during viral infection. The current recommendation to increase the dose to three to five times the baseline glucocorticoid dose during times of stress may underestimate the changes in UFC found in some patients with major surgery, trauma, or certain serious bacterial infections. Production rate studies are needed to prove this point.

Influence of diet with or without amino acids on polyamine excretion in multiple trauma victims.

Elevated levels of urinary polyamines (PA) in severely injured trauma patients are further enhanced by total parenteral nutrition (TPN) that contains both glucose and amino acids (AAs). Since TPN solutions contain arginine, the AA precursor of PA, it is not certain whether the increased urinary PA are due to this substrate. Nutritional factors can evidently modify PA metabolism. We measured the daily excretion of the PA, putrescine (PU) and spermidine (SD) in 18 multiply injured (injury severity score [ISS], 32 +/- 2), hypermetabolic (resting energy expenditure [REE]/basal energy expenditure [BEE], 1.41 +/- 0.06), and highly catabolic (daily N loss, 17.2 +/- 1.8 g N/d) acute trauma patients for 5 days in the early flow phase of injury. The patients were fed only maintenance fluids without calories or nitrogen for the first day 60 to 72 hours after injury, and then were randomized to receive glucose alone ([GLUC] 4.1 mg/kg/min, 80% measured REE, n = 8) or the same amount of glucose with AAs (TPN, 275 mg N/kg/d, n = 10) for the following 4 days. There was no significant difference in the enhanced daily PA excretion either in the free or acetylated form between the two dietary regimens. The addition of AAs in the TPN mixture did not seem to further stimulate PA metabolism in the trauma patients. The source of the nutrient content of the diet appears to be important for enhancing total PA excretion in critically ill patients.

Increased gut permeability after multiple trauma.

Gut permeability was studied in multiply injured patients with respect to the development of multiple organ failure (MOF). Two groups were defined according to MOF score (threshold 10 points) as to whether MOF developed (group 1; n = 11, four deaths) or did not (group 2; n = 21, no death). Gut permeability was determined from the ratio of urinary excretion of enterally administered lactulose and mannitol. Serum elastase concentrations were also determined. Mean(s.e.m.) gut permeability was abnormal during the entire study (day 1: group 1--5.1(2.1) versus group 2--10.6(4.1) (P not significant; P < 0.001 versus normal volunteers, 0.56(0.24)). An increase on days 3 and 5 correlated with serum elastase levels only in patients in group 1 (rs = 0.71, P < 0.01). Severe injury leads to increased intestinal permeability, which is related to a systemic inflammatory response.

Urinary excretion of polyamines in patients with surgical and accidental trauma: effect of total parenteral nutrition.

Excretion of polyamines first increases and then decreases in patients with multiple trauma receiving total parenteral nutrition (TPN). To separate the effects of trauma and TPN on polyamine excretion, we studied 12 patients with multiple trauma and 14 patients after surgery for colorectal malignancy. Patients were randomized to receive either TPN or hypocaloric glucose infusion. Urinary excretion of total and free polyamines, putrescine (PU), spermidine (SPD), and spermine (SP), and their metabolites, N1-acetylspermidine (N1-AcSPD) and N8-acetylspermidine (N8-AcSPD), and energy and nitrogen balance were measured. Polyamine excretion, excluding SP, markedly increased after trauma and surgery, exceeding the normal values by twofold to 10-fold. In patients receiving TPN, the excretion of total polyamines was 48% higher (P < .01), PU was 34% higher (P < .05), SPD was 35% higher (P < .05), and SP was 350% higher (P < .05) than in patients receiving hypocaloric glucose. Urinary excretion of SP was only 17% of the reference value during hypocaloric glucose (P < .05), but was normal during TPN. The difference in polyamine excretion between nutrition groups was more pronounced when normalized for nitrogen or energy balance. Patients receiving TPN were more hypermetabolic than patients receiving hypocaloric glucose (resting energy expenditure, 1.36 +/- 0.06 [SE] and 1.16 +/- 0.04 times predicted values, respectively; P < .025). Statistically, energy expenditure could explain the difference in polyamine excretion between nutrition groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Polyamine excretion in depleted patients with gastrointestinal malignancy: effect of perioperative nutrition and tumor removal.

Polyamines, synthesized by all mammalian cells, are involved in protein and energy metabolism. We measured urinary excretion of polyamines, putrescine, spermidine, spermine, and their metabolites N1-acetylspermidine and N8-acetylspermidine, resting energy expenditure, and nitrogen excretion in 12 depleted patients with gastrointestinal malignancy during preoperative and postoperative parenteral nutrition and in 7 patients with multiple trauma receiving similar parenteral nutrition. During preoperative nutrition support, the excretion of putrescine (p less than .05) and total polyamines (p less than .01) increased by 420% and 60%, respectively. Increases in energy balance and resting energy expenditure during nutrition could entirely explain the observed changes in polyamine excretion. Preoperatively, the excretion of N1-acetylspermidine (p less than .05), N8-acetylspermidine (p less than .001) and total polyamines (p less than .05) was higher in patients with a surgically noncurable tumor than in those with a surgically curable tumor. The energy balance and resting energy expenditure could also explain the differences in polyamine excretion between patients with surgically curable and noncurable disease, excluding the increased N8-acetylspermidine. Postoperatively, the excretion of N8-acetylspermidine in patients with multiple trauma without malignancy and in patients with palliative operation was similar, and was higher than in patients with a totally resected malignancy (p less than .01). Our results suggest that the excretion of polyamines reflects the activity of energy metabolism in general and that polyamine excretion is not specific for any particular disease.

Analysis of cysteinyl leukotrienes and leukotriene B4 by gas chromatography-(tandem) mass spectrometry.

Gas chromatographic-(tandem) mass spectrometric (GC-MS(-MS)) methods for the analysis of cysteinyl leukotrienes (LTs) and leukotriene B4 (LTB4) in biological fluids were developed. The enzymatic synthesis of the stable-isotope labelled analogues [1,1-18O2] LTE4 and [14,15,17,17,18,18-2H6] LTB4 in high isotopic purity is described. Utilizing [1,1-18O2] LTE4 as an internal standard and GC-MS-MS enhanced cysteinyl LTs synthesis was found in patients with multiple trauma and psoriasis compared to healthy volunteers, respectively. The metabolism of LTB4 by human monocytes was investigated and two novel LTB4 metabolites were structurally identified by GC-MS as 10,11-dihydro-LTB4 and 10,11-dihydro-12-oxo-LTB4.

Released prophospholipase A2 activation peptides in the rapid early prediction of trauma outcome: a preliminary report.

Clinical scores of trauma severity may not be adequate measures of trauma-related systemic pathophysiology to be useful in the early prediction of individual patient outcome. This preliminary study evaluates the role of Prophospholipase A2 Activation Peptide (PLAP), measured in patient urine by modified enzyme-linked immunosorbent assay (ELISA), as an early prognostic in the severely injured. Of nine polytrauma patients requiring intensive care after a major accident, two died and one was permanently severely disabled (group 1), whilst six made a full recovery (group 2). These two groups had different ranges of urine PLAP concentration (P = 0.024). Phospholipase A2 (PLA2) activation may be an early event in tissue damage pathways that lead to multisystem organ failure (MSOF). We believe urine and plasma PLAP concentrations merit further evaluation for the early prediction of individual trauma outcome.

Mild orotic aciduria and uricosuria in severe trauma victims.

Hypermetabolic responses with respect to pyrimidine and purine kinetics in trauma victims were investigated during the catabolic phase before and after nutritional support. Orotic acid and uric acid excretions were measured in 32 adult, severely traumatized, hypermetabolic, and highly catabolic patients while they were receiving fluids with no calories or nitrogen. Patients were then fed intravenously amino acids and glucose or glucose alone or fed enterally for 5-6 d. Daily excretions of orotic acid, uric acid, urea, nitrogen, and creatinine were monitored. Mild orotic aciduria and uricosuria with hypouricemia were the basal-trauma responses. The significant (P = 0.001, r = 0.70) positive correlation between orotic and uric acid excretion demonstrates the parallelism between pyrimidine and purine metabolism. Feeding for 5-6 d could decrease but not readily abolish the injury-induced metabolic changes in nitrogen, pyrimidine, and purine metabolism. Glucose infusion alone may be sufficient to counteract the metabolic effects of trauma in the early flow phase of injury.

Enhanced urinary excretion of leukotriene E4 by patients with multiple trauma with or without adult respiratory distress syndrome.

1. The aim of the present study was to evaluate the systemic synthesis of cysteinyl leukotrienes in patients with multiple trauma. In order to do this, the urinary excretion of leukotriene E4 was assessed in the first 10 days after trauma. 2. Leukotriene E4 was unequivocally identified by g.c.-m.s. in the urine of healthy subjects and patients with multiple trauma after its conversion to 5-hydroxyeicosanoic acid. Leukotriene E4 was routinely isolated from 24 h urine samples by solid-phase extraction followed by reverse-phase h.p.l.c. and was subsequently quantified by r.i.a. 3. Healthy subjects excreted daily 10 +/- 3 nmol of leukotriene E4/mol of creatinine (mean +/- SEM, n = 16) into urine. 4. Patients with multiple trauma who did not develop adult respiratory distress syndrome (n = 7) excreted 76.8 +/- 6.7 nmol of leukotriene E4/mol of creatinine (mean +/- SEM) daily during the first 10 days after trauma, which was significantly (P less than 0.01) more than did healthy subjects. 5. Excretion of leukotriene E4 was even more enhanced in three patients with multiple trauma who developed adult respiratory distress syndrome. Maximal amounts of 593 +/- 185 nmol of leukotriene E4/mol of creatinine (mean +/- SEM) were excreted on day 9 after trauma by these three patients, which corresponds to a 7.7- and a 59-fold increase in excretion of leukotriene E4 compared with patients with multiple trauma who did not develop adult respiratory distress syndrome and healthy subjects, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Elevated urinary C-peptide excretion in multiple trauma patients.

A simple, indirect method of estimating integrated insulin secretion is the measurement of C-peptide, a byproduct of insulin biosynthesis, in plasma and in 24-hr urine samples. We determined, in 29 severely injured hypermetabolic and highly catabolic multiple trauma patients, the plasma level and daily excretion rate of C-peptide, 48-72 hrs postinjury. Data from a set of eight patients who underwent glucose-based total parenteral feeding for 6 days were analyzed for the course of changes in the excretory pattern of C-peptide and catecholamines. The molar ratio of plasma C-peptide to insulin in the trauma patients was similar to that in unstressed controls, indicating that the rate of hepatic insulin extraction is not appreciably altered due to trauma. This is also evident from a significant correlation (p = 0.001) between the plasma C-peptide and insulin levels. The excretion of C-peptide was elevated to three times the normal both in absolute terms and when normalized to creatinine excretion. This was also accompanied by a twofold increase in the plasma levels, indicating an enhanced secretion rate of C-peptide and hence of insulin in response to trauma. Injury-induced insulin resistance does not seem to be due to a decreased insulin secretion. An increase in insulin output would appear to be a significant and desirable response for a continued anabolic stimulus coexistent with the net catabolic phase. Parenteral feeding augmented the excretion of C-peptide and catecholamines and this effect peaked on the fourth day of nutritional therapy.