Waydhas C, Nast-Kolb D, Trupka A, Zettl R, Kick M, Wiesholler J, Schweiberer L, Jochum M
Department of Surgery, Klinikum Innenstadt, Ludwig-Maximilians-University, Munich, Federal Republic of Germany.
J Trauma. 1996 Apr;40(4):624-30; discussion 630-1. doi: 10.1097/00005373-199604000-00018.
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.
本研究的目的是确定外科手术作为继发性炎症损伤在多发伤患者晚期多器官功能障碍综合征发生过程中的作用，并评估炎症反应的特异性和非特异性指标在指示重伤患者二次手术后发生器官衰竭风险方面的能力。在一项对106例接受二次手术（创伤后>3天）的重伤患者（损伤严重度评分40.6）的前瞻性研究中，我们比较了术前炎症水平与手术创伤的后遗症。干预措施包括面部重建；骨盆带、长骨和脊柱的骨合成；以及其他手术。第1组由40例患者（38%）组成，这些患者在术后2天内出现呼吸、肾脏或肝脏衰竭，或多种衰竭合并出现，或者其术前已有的器官功能障碍较基线水平恶化超过20%。其余66例（62%）恢复顺利的患者组成第2组。第1组患者术前中性粒细胞弹性蛋白酶水平（92.2对61.3 ng/dL）、C反应蛋白水平（12.4对7.6 mg/dL）和血小板计数（118,000对236,000/μL）明显更异常。第1组患者的PO2/FiO2比值也略低（305.5对351），而其他参数（如血压、心率、胆红素、肌酐、尿量、乳酸、pH值和凝血指标）在术前无法区分第1组和第2组。炎症状态增加（中性粒细胞弹性蛋白酶>85 ng/mL、C反应蛋白>11 mg/dL、血小板计数<180,000/μL）预测术后器官衰竭的准确率为79%（敏感性73%；特异性83%）。我们得出结论，如果在多发伤患者创伤后炎症水平仍升高时进行二次手术，二次手术可能作为第二次损伤并可能促使晚期多器官功能障碍综合征的发生。然而，未来的研究必须表明，将手术推迟到炎症消退或使用侵入性较小的手术技术是否会降低创伤患者术后器官衰竭的发生率。
