Immunodeficiency after major trauma and selective surgery.

The posttrauma immunodeficiency syndrome and the related postsurgery immunodeficiency syndrome are essential for the infections often occurring after polytrauma and major surgery. Data are given here showing that after such events the levels of immunoglobulins; the complement factors C3C, C4 and C Factor B; and the numbers of circulating lymphocytes and of the subpopulations CD3, CD4, CD8 and natural killer cells as well as the stimulatory capacity of mononuclear cells to mitogen fall; while the levels of acute phase proteins, neopterin and interleukin 2 receptors and the spontaneous uptake of thymidine by mononuclear cells become augmented. Extent and duration of these changes and the rate of subsequent infections depend on the extent and kind of surgery (minor, major, clean, contaminated). However, crucial factors of the posttrauma and postsurgery immunodeficiency syndromes are not yet elucidated and relevant predictive parameters for infections are not at hand. These are essential prerequisites to initiate future immunomodulatory measures which should be added to the use of intravenous immunoglobulins yielding so far distinct but limited benefits for the prevention of infections after polytrauma and major surgery.

Polyvalent immunoglobulins for prophylaxis of bacterial infections in patients following multiple trauma. A randomized, placebo-controlled study.

One hundred and fifty severely injured patients requiring long-term artificial ventilation were evaluated in a prospective, randomized, double blind study comparing the prophylactic effect of an intravenous immunoglobulin (Sandoglobulin; IGIV) against nosocomial infections with a placebo preparation. The groups were comparable in age, sex, injury pattern, and severity of the trauma. Seventy-six patients received 12 g of Sandoglobulin as a 3% solution on day 0, day 5 and day 12, i.e. a total of 36 g. Sandoglobulin significantly reduced the incidence of pneumonia (28 cases in the IGIV group, 43 cases in the placebo group, p = 0.0111). This resulted in a reduced therapeutic use of antibiotics. For the occurrence of sepsis (IGIV: 14 cases; placebo 19 cases) and other infections (IGIV: 11 cases; placebo: 10 cases) no significant differences were found. No side effects of the administration of IGIV were observed. IGIV prophylaxis neither reduced the overall death rate nor those deaths caused by infection. On day 5 after administration of the first 12 g of IGIV, the IgG serum concentrations were significantly higher in the Sandoglobulin group (8.41 +/- 1.96 mg/ml and 7.42 +/- 2.25 mg/ml respectively, p less than 0.001) whereas later serum samples showed no significant differences.

[The fate of critically injured patients]. / Das spätere Schicksal von Schwerverletzten.

The prognosis of patients with multiple injuries is very favourable once the critically injured have survived the acute life threatening period. Five to six years after the accident 82% of the surviving patients with injuries of three or more body areas who needed intensive care are fully capable of work and are not receiving any financial compensation. In severe head injuries or in paraplegia, lethality during hospitalization is higher and late prognosis worse: nevertheless, five to six years after the accident 55% of these patients are working full time and do not receive any compensation.

[Arthroscopic surgery--current status and perspectives]. / Arthroskopische Chirurgie--heutiger Stellenwert und Perspektiven.

The morbidity after arthroscopic surgery is low; a hospitalization is not necessary in most patients. The possible operations of the knee joint include removal of loose bodies, resections on meniscus, plicae and synovium as well as more complicated procedures as suturing of a meniscus, total synovectomy and operations in patients with osteoarthritis. The advantage of the arthroscopic operation compared with arthrotomy is well documented in meniscal resection (shorter treatment, stay in the hospital and sick leave, reduced costs, and nevertheless excellent results) whereas the indication and clinical value of other arthroscopic procedures (i.e. suturing of a meniscal tear, lateral release, abrasion-arthroplasty) still are discussed. Diagnostic and operative arthroscopy of the shoulder joint has found its place and will certainly improve our knowledge on significance and treatment of disorders and injuries of this joint. In selected cases, an arthroscopy of the elbow, the hip, the ankle, the wrist or the temporomandibular joint offers important diagnostic information and may allow operative treatment. Arthroscopic surgery is technically difficult and not without problems. However, the rate of complications is extremely low (0.56%). Infections occur in significantly less than 1% of the cases. In veterinary medicine, therapeutic arthroscopy is used mainly in horses, but arthroscopies have been performed in the ox, the cow, the pig, the dog, the cat, and the rabbit. Modern joint surgery includes arthroscopic techniques; the training of trauma surgeons and orthopedic surgeons in arthroscopy is therefore mandatory.

[Specific probelms in the intensive care of patients with multiple injuries (author's transl)]. / 47. Besondere Probleme in der Intensivpflege des Polytraumatisierten

Respiratory problems such as throacic injuries, shock lung, fat embolism aspiration are predominant in a specialized intensive care unit for patients with multiple trauma. The most important pulmonary complications are tension pneumothorax (in which case an immediate diagnosis is essential), atelectasis, lesions of the trachea, and pulmonary infections (12 percent of the patients). With severe head injuries it is often difficult to decide whether intensive care is justified. Unfortunately, there are no clear criteria for an early assessment of the prognosis in many of these cases.

[Diagnostic arthroscopy and arthroscopic surgery: experiences with 500 knee arthroscopies]. / Diagnostische Arthroskopie und arthroskopische Operationen: Erfahrungen bei 500 Kniearthroskopien.

A diagnosis by clinical examination and arthrography was not possible in 160 out of 500 arthroscopically examined patients, most of them with post-traumatic knee disorders. In 157 cases the clinical diagnosis was wrong, and in another 58 cases incomplete. Only in 89 patients (18%) arthroscopy proved the clinical diagnosis to be correct. At arthroscopy, a meniscal injury was found in 156 patients (medial meniscus 57, lateral meniscus 64, both menisci 8). With regard to the menisci a previous arthrography was found correct only in 103 out of 213 cases, i.e. in 48%. Lesions of the articular cartilage were present in 210 patients, although they were expected clinically in only one third of these cases. Normal intraarticular structures were found in 95 examinations. The arthroscopic examination was insufficient three times because of a protruding fat pad, and wrong in 2 patients in whom an arthroscopically diagnosed meniscal tear could not be found at arthrotomy. The morbidity of arthroscopy is small. Only complications: A local allergic reaction because of a wound spray in four cases, bronchial asthma following general anesthesia in two patients. No infection occurred. Several therapeutic procedures may be carried out through the arthroscope. So loose bodies were removed from the joint in 39 and partial meniscectomy performed in 13 patients, all of them being treated as out-patients.

[Arthroscopic partial meniscectomy]. / Arthroskopische partielle Meniskektomie.

Partial closed meniscectomy under arthroscopic control is feasible in bucket handle tears and in some cases of L-shaped or longitudinal meniscal lesions. The operation is performed in general anesthesia but without hospitalization of the patient. Postoperative morbidity in 18 patients was surprisingly low, 16 patients being without disturbances two weeks after surgery. Mean duration of working inability was 6.5 days. For the experienced arthroscopist, low costs and decreased morbidity compared to arthrotomy recommend this procedure in selected cases of meniscal lesions.

[Value of imaging procedures in the diagnosis and therapy of severe thoracic injuries]. / Stellenwert der bildgebenden Verfahren bei Diagnose und Therapie von schweren Thoraxverletzungen.

Plain chest radiographs allow the diagnosis of most intrathoracic injuries. However, they are only momentary pictures and give no information on the respiratory function. A tension pneumothorax, rib fractures and subcutaneous emphysema should be diagnosed clinically before radiographs are taken. Computed tomography is helpful in evaluation of intrapulmonary lesions, hemothorax, rupture of the diaphragm and dislocation of the heart. Further diagnostic tools include aortography in suspected aortic rupture, sonography in cardiac injuries and hemopericardium, bronchoscopy in suspected bronchial or tracheal rupture, ECG and enzyme determinations in cardiac contusion, and eventually pneumoperitoneum in suspected rupture of the diaphragm.

[Knee arthroscopy today]. / Die Kniearthroskopie heute.

Arthroscopy is not only the most reliable diagnostic tool in disorders of the knee joint but it also allows a one-step procedure of diagnosis and therapy in many cases. Most arthroscopic operations can be performed without hospitalisation. Post-operative morbidity is usually low. An excellent or good result was achieved in 91% of arthroscopic partial meniscectomies. Costs were reduced by sFr 6000 to 7000 for arthroscopic operations compared with arthrotomy. The advantage of most arthroscopic procedures performed today has been proven; however, the clinical value of others (i.e. arthroscopic suture of meniscal tears, repair of cruciate ligaments and abrasion-arthroplasty) is still not clear. The frequency of complications is low (0.56%), and infections occur in less than 1%.

[Diagnostic arthroscopy in injuries of the knee joint]. / Diagnostische Arthroskopie bei Verletzungen des Kniegelenks.

Diagnostic arthroscopy is indicated, if other methods of diagnosis have reached their limits. It has become indispensable to proper assessment of injuries of the menisci, cartilage, synovial folds, and plicae and for suspicion of isolated cruciate knee ligament rupture. The practicability or impracticability of an arthroscopic operation in a given case, of course, has bearings upon indication for diagnostic arthroscopy. Patients are usually examined in general anaesthesia, with the joint filled with liquid, using a 30-degree widle-angle lens and a video system. Probing of intra-articular structures is absolutely necessary. The following two specific groups of indications have gained particular importance in knee injuries: Acute arthroscopy is imperative in any case of hemarthrosis with unknown aetiology (ligament injuries were found in 67 per cent of these patients), and it is the diagnostic and therapeutic procedure of choice in acute locking of the knee. Diagnostic arthroscopy should be followed by re-arthroscopy, if the further clinical course cannot be explained by the findings already recorded or in case of new symptoms or additional symptoms in the wake of arthroscopic operation or if major symptoms persist. In the latter case, re-arthroscopy should be performed not later than four to six months from first treatment. Re-arthroscopy revealed a need for another arthroscopic operation after earlier diagnostic arthroscopy in 48 per cent of all cases and after previous arthroscopic operation in 63 per cent.

[Diagnosis of meniscus damage]. / Diagnostik des Meniscusschadens.

Often, the clinical signs of an injured meniscus are not characteristic. The most reliable diagnostic tool in evaluation of meniscal damage is arthroscopy (diagnostic accuracy greater than 95%). It provides precise information on the nature and extent of a meniscal tear. The advent of arthroscopic surgery has favoured the use of endoscopy even as a diagnostic procedure. Arthrography is abandoned except in cases where arthroscopic meniscectomy is not feasible. As additional non-invasive examinations, magnetic resonance and ultrasound may be used; however, both methods are still not generally accepted and do not allow diagnosis and therapy as a one step procedure as does arthroscopy.

[Current aspects and future developments in infection prevention in intensive care units]. / Neuere Aspekte und zukünftige Entwicklungen in der Infektprophylaxe auf Intensivstationen.

The high frequency of nosocomial infections in intensive care units can be reduced in two different ways. Methods which impede the colonization of the patient with pathogenic microorganisms are of primary interest. Replacement of invasive techniques of monitoring and treatment by alternative non-invasive methods will help to prevent infections caused or favoured by those techniques. The concept of selective decontamination of the digestive tract (SDD) is reported to reduce nosocomial infections considerably but needs further clinical evaluation. Furthermore, there is a danger of selecting highly resistant strains by this regimen. A second approach to prevention of infections is improvement of these patients' severely impaired immune defense. The prophylactic use of intravenous immunoglobulins has produced encouraging results, but the indication, dosage and timing of the medication, and a cost-benefit analysis, need further careful consideration. So far, no conclusive clinical studies have been reported on stimulation of cellular immune defense. Finally, improved information on immunodeficiency induced by drugs frequently used in intensive care is an urgent necessity.

[Drainage and lavage in abdominal trauma]. / Drainage und Lavage beim abdominalen Trauma.

Peritoneal lavage is a reliable procedure in diagnosis of posttraumatic intra-abdominal bleeding. The method is extremely sensitive. If the return is found weakly positive, the lavage catheter should be left in position until the situation is cleared. Insufflation of air through the catheter may be used in diagnosis of a ruptured diaphragm. In the first days after trauma, peritoneal lavage may as well be helpful to detect secondary bleeding (for example in delayed rupture of the spleen) in unconscious patients or during mechanical ventilation. Postoperative drainage of the abdomen, too, is of considerable diagnostic value: for assessment of postoperative bleeding and in diagnosis of delayed intestinal perforation or insufficiency of a sutured bowel lesion. In pancreatic trauma, adequate drainage of pancreatic secretions prevents arterial arrosion or the formation of a pseudocyst. Determination of amylase in the drained fluid guides the further therapy: duration of total parenteral nutrition, suppression of pancreatic activity by drugs, removal o the drains. Tactics in draining the abdominal cavity after trauma should take into consideration an optimal removal of blood and secretions as well as the mentioned diagnostic value. In specially indicated cases the drainage system also should allow to perform peritoneal dialysis.

[Diagnosis of chondral injury in trauma of the knee joint (author's transl)]. / Diagnostik der frischen Knorpelverletzung des Kniegelenkes.

Diagnosis of chondral lesions as the only injury in knee trauma is difficult: Lesions of the cartilage were found by arthroscopy, months or years after trauma, in 153 patients; the diagnosis was never suspected immediately after injury. Chondral lesions may be suspected from clinical examination but never proved. Contrast arthography may reveal the injury in exceptional cases. Only arthroscopy or arthrotomy can really prove or exclude injury to the cartilage. Arthoscopy is to he preferred because of the far lower morbidity and is more reliable because of a better view of the articular surfaces.

Problems caused by the unstable thoracic wall and by cardiac injury due to blunt injury.

The treatment of flail chest remains highly controversial. In the literature convincing arguments can be found to support any therapeutic procedure. Newer concepts of mechanical ventilation such as SIMV and CPAP, as well as the use of epidural analgesia, have resulted in a significant reduction in the duration of artificial ventilation. Although the mechanical problems are generally overestimated in this situation, the use of a ventilator is indicated in many cases because of the associated lung damage. Internal fixation of the unstable thoracic wall is restricted to special, selected cases which would otherwise require artificial ventilation, without severe lung injury and without head injury. We found stabilization of bilateral parasternal rib fractures with a retrosternal Sulamaa bar most helpful. Cardiac injuries were present in 16 per cent of our patients admitted after severe blunt thoracic injury. Most of these had myocardial contusion. The analysis of 108 cases of cardiac contusion revealed that every possible variation of ECG can be observed. Repolarization disturbances and impairment of the cardiac rhythm and the conduction system were found most frequently. A ratio of CPK-MB: total CPK of over 6 per cent provides a very significant suspicion of myocardial contusion. The clinical course is characterized by cardiac rhythm disturbances, which required treatment in 40 out of 108 patients, and to a minor extent by heart failure for which treatment was required in 17 patients. Prognosis is generally good with adequate treatment.

Priorities in diagnosis and treatment of blunt chest injuries.

The evaluation of thoracic injuries is only one aspect of the total assessment of a severely injured patient. In a series of 675 hospitalized patients, blunt chest injury was associated with craniocerebral injury in 55 per cent, with abdominal injuries in 20 per cent and with fractures of the extremities in 38 per cent. Both diagnostic and therapeutic procedures go hand in hand. Immediately life-threatening situations (hypovolaemia, respiratory insufficiency, tension pneumothorax and cardiac tamponade) should be diagnosed by clinical signs and treated before radiographs are taken. The chest radiograph is the basic tool for diagnosis of thoracic injuries, although it will not reveal a possible impairment of lung function. Special attention should be paid, and further evaluation is necessary, in suspected rupture of the diaphragm (present in 4 per cent), rupture of the aorta (2 per cent), bronchial rupture (0.5 per cent) and cardiac contusion (16 per cent). Most blunt thoracic injuries can be treated adequately by intercostal tube drainage. Operative intervention has been found necessary in 8 per cent of cases. Indications for thoracotomy are clearly defined.