Acute phase protein levels as an index of severity of physical injury

Inflammatory Changes and Coagulopathy in Multiply Injured Patients

Severe tissue trauma leads to an early activation of several danger recognition systems, including the complement and the coagulation system, often resulting in an overwhelming almost synchronic pro- and anti-inflammatory response of the host. Although the immune response is associated with beneficial effects at the site of injury including the elimination of exogenous and endogenous danger molecules as well as the initiation of regenerative processes, an exaggerated systemic inflammatory response significantly contributes to posttraumatic complications such as multiple organ failure (MOF) and early death. Besides pre-existing physical conditions, age, gender, and underlying comorbidities, surgical and anesthesiological management after injury is decisive for outcome. Improvements in surgical intensive care have increased number of patients who survive the initial phase after trauma. However, instead of progressing to normal recovery, patients often pass into persistent inflammation, immunosuppression, and catabolism syndrome (PICS). The characterization and management of PICS will require new strategies for direct monitoring and therapeutic intervention into the patient’s immune function. In this chapter, we describe various factors involved in the inflammatory changes after trauma and aim to understand how these factors interact to progress to systemic inflammation, MOF, and PICS.

Effect of surgeon experience on postoperative plasma cortisol and C-reactive protein concentrations after ovariohysterectomy in the dog: a randomised trial

OBJECTIVE

To determine if postoperative C-reactive protein (CRP) or cortisol concentrations were significantly changed between dogs undergoing ovariohysterectomy by an experienced or inexperienced surgeon. As part of the Charles Sturt University teaching program, 45 bitches from an animal shelter were surgically sterilised between March and October 2010.

METHODS

The dogs were randomly assigned to surgeons, with 37 sterilised by veterinary undergraduates and 8 by experienced surgeons. Blood samples were collected preoperatively and at 2, 4 and 6 h postoperatively. A standard midline ovariohysterectomy was performed and detailed records kept.

RESULTS

The median surgery time for experienced surgeons was 17 min versus 87 min for inexperienced surgeons. Anaesthesia time and blood loss were greater among the inexperienced surgeons. The CRP concentration increased significantly postoperatively for all animals (P < 0.001). Bitches sterilised by inexperienced surgeons had a significantly greater rise in CRP at 4 and 6 h post-surgery (P = 0.046). Serum cortisol concentrations were found to increase significantly over time for all animals (P < 0.001), but were not affected by surgeon experience.

CONCLUSION

The results suggest that inexperienced surgeons affect their patients differently to experienced surgeons, potentially through tissue trauma or anaesthetic duration. The lack of difference in the cortisol concentrations reflects the large number of triggers for cortisol release and, potentially, that there was little difference between the groups in terms of perceived pain in the presence of good analgesia. Serum CRP concentration may be a more sensitive measure than serum cortisol of differences in surgical trauma.

The influence of percutaneous nephrolithotomy on human systemic stress response, SIRS and renal function

The objective of this study is to investigate the influences of percutaneous nephrolithotomy (PNL) and open surgery nephrolithotomy on the systemic stress response, SIRS and renal function. Forty patients with kidney calculi were enrolled in the study. Twenty cases were randomized to the PNL group and the other twenty cases to the open surgery group. Levels of C-reactive protein (CRP), interleukin-6(IL-6), β(2)-microglobulin (β(2)-MG), respiration rate, heart rate, body temperature and white blood cell counts were examined. CRP and IL-6 were measured in all patients pre-operatively and on post-operative days 1, 3 and 6, respectively. There was significant difference in their pre- and post-operation levels (P < 0.05), with the peak of CRP and IL-6 observed at post-operative days 3 and 1, respectively. There was significant difference in both CRP and IL-6 between the two groups (P < 0.05). At post-operative day 1, there were 5 cases of SIRS in PNL group and 12 cases in open surgery group; there was significant difference between the two groups (P < 0.05). Serum β(2)-MG levels were measured as the same time as CRP and no significant changes were observed within or between the groups (P > 0.05). Urine β(2)-MG levels were also measured. There was significant difference between pre- and the first day post-PNL (P < 0.05); there was no significant difference between pre- and the third and sixth day post-PNL (P > 0.05). There was significant difference between pre- and first and third day post-open surgery (P < 0.05); but there was no significant difference between pre- and the sixth day post-open surgery (P > 0.05). There was significant difference between two groups at the first, third and sixth days (P < 0.05).

CONCLUSIONS

The systemic stress response is activated both in PNL group and open surgery group to some extent. The degree of stress response of PNL is lower than that of open surgery, proving the advantages of PNL with reference to serum immunology. There were cases in both the groups with SIRS, but the degree of SIRS in PNL group was lesser than the other group. Both the groups have no obvious effect on glomerular filtration function after operation and have effect on renal tubular reabsorption in the early stage after operation; but the recovery of the PNL group is faster than the open surgery group. It is thus shown that PNL is much safer and more feasible and has lesser effect on renal function.

Rapid quantitative determination of C-reactive protein at chair side in dental emergency patients

OBJECTIVES

The objective of this study was to quantitatively determine, at chair side, the serum C-reactive protein (CRP) levels in dental emergency patients.

STUDY DESIGN

Quantitative CRP test was performed at chair side in 40 patients with acute alveolar abscess (AAA), acute periodontal abscess (APA), and alveolar osteitis (AO) at the time of dental emergency treatment and 1 week after. CRP levels were compared between groups and before and after treatments using ANOVA and Fisher's Exact tests.

RESULTS

Serum CRP levels were greater than 5 mg/L in 30 (75%) of the 40 patients. At 1-week follow-up, the decline in CRP levels was evident in the AAA group (P < .05), but not statistically significant in the APA and AO groups (P > .05).

CONCLUSION

Serum CRP levels are often elevated in patients with odontogenic infections and postoperative complications. Rapid reduction in serum CRP levels was likely to occur following successful treatment of AAA, but less likely to occur in APA and AO.

Video-assisted thoracic surgery lobectomy reduces the morbidity after surgery for stage I non-small cell lung cancer

OBJECTIVE

We conducted this study to evaluate the surgical invasiveness and the safety of video-assisted thoracic surgery lobectomy for stage I lung cancer.

METHODS

Video-assisted thoracic surgery lobectomies were performed on 43 patients with clinical stage IA non-small cell lung cancer. We compared the surgical invasiveness parameters with 42 patients who underwent lobectomy by conventional thoracotomy.

RESULTS

Intraoperative blood loss was significantly less than that in the conventional thoracotomy group (151+/-149 vs. 362+/-321 g, p<0.01). Chest tube duration (3.0+/-2.1 vs. 3.9+/-1.9 days) was significantly shorter than those in the conventional thoracotomy group (p<0.05). The visual analog scale which was evaluated as postoperative pain level on postoperative day 7, maximum white blood count and C-reactive protein level were significantly lower than those in the conventional thoracotomy group (p<0.05). The morbidity rate was significantly lower than that in the conventional thoracotomy group (25.6% vs. 47.6%, p<0.05). Sputum retention and arrhythmia were significantly less frequent than in the conventional thoracotomy group (p<0.05). We experienced no operative deaths in both groups.

CONCLUSION

We conclude that video-assisted thoracic surgery lobectomy for stage I non-small cell lung cancer patients is a less invasive and safer procedure with a lower morbidity rate compared with lobectomy by thoracotomy.

Evaluation of possible tissue damage in patients undergoing extracorporeal shock wave lithotripsy employing C-reactive protein

Extracorporeal shock wave lithotripsy (ESWL) has become the most common treatment for stones in the upper urinary tract. Tissue injury related to ESWL has been documented. C-reactive protein (CRP) is the classical acute-phase protein most recognized as an early marker in diseases characterized by inflammation and tissue injury. Possible tissue trauma by ESWL was evaluated by serial CRP determinations in 150 patients with kidney stones, whose follow-up was uneventful. The mean CRP-concentration prior to ESWL was 6.34 mg/l. The majority of patients did not show any further elevation of CRP-levels. Mean CRP-levels were 7.62 mg/l on the first, 6.12 mg/l on the third and 5.09 mg/l on the fifth day after ESWL. No correlation was observed between the number of shock waves and CRP levels. Judged by CRP-determinations tissue damage induced by ESWL can be considered to be minimal as no marked CRP-elevations could be observed in patients with an uneventful follow-up after ESWL.

Elevation of plasma interleukin-6 level in patients undergoing oral and maxillofacial surgery

OBJECTIVE

The purpose of this study was to evaluate the response of peripheral interleukin-6 associated with oral and maxillofacial surgery.

STUDY DESIGN

Fifteen patients undergoing elective oral and maxillofacial surgery were studied. We investigated the change in plasma interleukin-6 level during and after surgery and the correlation between plasma interleukin-6 level and surgical procedure. Plasma interleukin-6 levels were measured by enzyme-linked immunosorbent assay. Statistical significance was determined by nonparametric methods.

RESULTS

Elevation of plasma interleukin-6 level was detected at 2 to 6 hours after incision and observed to reach a peak level within 6 hours after the end of surgery. There were significant correlations between plasma interleukin-6 level and duration of surgery or response of C-reactive protein.

CONCLUSION

The results suggested that interleukin-6 would be released by surgical injury and elevation of plasma interleukin-6 level would be associated with magnitude of tissue damage in oral and maxillofacial surgery.

The measurement of injury severity

Severity of injury can now be measured objectively and in a manner relevant to everyday practice. A variety of scales/scores are available which are based either on anatomical or physiological parameters or a combination of these. ASCOT methodology represents the most recent major contribution in this area, and follows AIS and TRISS as an established and reliable means of assessing trauma patients, particularly in relation to survival. These methods have clinical application in terms of triage, directing clinical management, assessing prognosis, assessing cost of management and for measuring outcome. The development of these scoring methods is outlined in this paper.