Posttraumatic Inflammatory Response, Secondary Operations, and Late Multiple Organ Failure

Abstract

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.

Early Total Care versus Damage Control: Current Concepts in the Orthopedic Care of Polytrauma Patients

“…The posttrauma days 2 to 4 have been reported to be unsuitable for performing definitive osteosynthesis [17]. At this time, sustained immunologic changes are ongoing [18] and fluid shifts, increasing generalized tissue edema, are not yet normalized [19]. In a large survey of over 4000 cases, the effects of the timing of surgery on MODS development were analyzed.…”

The association between the levels of CRP, IL-10, PLA2, Fbg and prognosis in traumatic fracture of lower limb

“…Indicators of C-reactive protein (CRP), interleukin-10 (IL-10), phospholipase A2 (PLA2) and fibrinogen β polypeptide chain gene (Fbg) are critical inflammatory factors or important enzymes of inflammatory response. Investigations on how these indicators are used for predicting progression of lower extremity trauma have been previously conducted (7–9). …”

Predicting lower limb periprosthetic joint infections: A review of risk factors and their classification

“…Cardiac dysfunction[4,16,21], renal failure[4,15], anaemia[4,9,16] and coagulopathy[16] have all been shown to increase the risk of infection. This may be directed through specific cellular pathways[39], but may demonstrate the insult the surgical procedures has in causing a secondary inflammatory insults, worsening multiple organ dysfunction[40,41]. …”