Skip to main content
SpringerLink
Log in

Bedeutung des Lebertraumas für die Inzidenz von Sepsis, Multiorganversagen und Letalität bei Schwerstverletzten

Eine organspezifische Auswertung von 24.771 Patienten des Traumaregisters der DGU

Significance of liver trauma fort the incidence of sepsis, multiple organ failure and lethality of severely injured patients

An organ-specific evaluation of 24,771 patients from the trauma register of the DGU

  • Originalien
  • Published:
Der Unfallchirurg Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Die Lebenserwartung nach einem generalisierten schweren Trauma wird häufig durch den initialen Verlust großer Blutmengen und der sekundären Inzidenz einer Sepsis und eines Multiorganversagens (MOV) limitiert. Die mögliche Bedeutung eines Lebertraumas als unabhängiger Letalitätsfaktor bei polytraumatisierten Patienten ist bisher am großen Patientenkollektiv nicht genau untersucht.

Patienten und Methoden

Die Daten von 24.711 Patienten des Traumaregisters der Deutschen Gesellschaft für Unfallchirurgie (DGU) aus 113 Kliniken (1993-2005) wurden retrospektiv ausgewertet. Alle Patienten mit einem „Injury Severity Score“ (ISS)>16 Punkten, ohne isoliertes Schädel-Hirn-Trauma und primärer Aufnahme wurden eingeschlossen.

Ergebnisse

321 Patienten mit einer Leberverletzung (AISLeber=3–5, AISAbdomen<3, ISS>16) wurden mit 574 am Abdomen verletzten Patienten (AISAbdomen=3–5, AISLeber<3, ISS>16) und 9574 Patienten ohne relevante abdominelle oder Leberverletzung verglichen (AISLeber oder AISAbdomen<3). Patienten mit führender relevanter Leberverletzung zeigten bei ähnlichem ISS einen signifikanten Anstieg der Letalität im Gegensatz zu Patienten mit anderen Abdominalverletzungen (34,9 vs. 11,6%), Sepsisrate nach Überleben von 24 h (19,9 vs. 11,0%) und MOV (32,7 vs. 16,6 %).

Schlussfolgerung

Die hier dargestellten Ergebnisse zeigen, dass das Lebertrauma einen wichtigen Prognosefaktor darstellt und die Möglichkeit bietet Patienten mit einem hohen Risiko für Sepsis, MOV und Letalität frühzeitig zu erkennen.

Abstract

Background

The prognosis of multiple injured patients is mainly limited by initial severe hemorrhage causing hemorrhagic shock, subsequent sepsis and multiple organ failure (MOF). Although mechanisms of altered microcirculation, cytokine release etc. have been intensively investigated, little is known about the relevance of severe liver trauma as an independent predictive outcome factor in these patients. This study aimed to clarify the impact of severe liver trauma in one of the largest trauma databases.

Patients and methods

The study was based on data from the German trauma register within the German Society for Trauma Surgery (DGU) and 24,711 patients from 113 hospitals were collected for retrospective analysis between 1993 and 2005. Patients with an injury severity score (ISS) >16, no isolated head injury and primary admission to a trauma center were included. Data were allocated according to the injury pattern into I liver group (severe damage of the liver, AIS>3 and AIS abdomen <3), II Abdomen group (severe abdominal trauma AIS>3, AIS liver <3) and III Control group (liver and/or abdominal trauma AIS<3, other trauma AIS>3).

Results

Out of 24,771 multiple injured patients from 113 trauma centers, 321 individuals were identified which matched the criteria of the liver group. Another 574 patients were allocated to the abdomen group while the majority of patients formed the trauma group (9574). Severe injury of the liver is associated with excessive demands for volume resuscitation and induces a significantly increased risk for sepis and MOF compared to both other groups (sepsis 19.9% vs 11%; MOF 32.7% vs 16.6%). Furthermore, deleterious outcome is more frequent associated with patients with severe liver trauma (lethality 34.9%) compared to severe abdominal trauma (12%) and the control group (19.5%).

Conclusions

Severe liver trauma is an independent predictor for severe hemorrhage with a substantial increased risk of sepsis, MOF and trauma-related death. While conservative treatment of patients with severe liver trauma but no hemorrhage is effective, patients with hemodynamic instability seem to form a subgroup where contemporary treatment modalities are not yet sufficient.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Literatur

  1. Pachter HL, Feliciano DV (1996) Complex hepatic injuries. Surg Clin North Am 76: 763–782

    Article  PubMed  CAS  Google Scholar 

  2. Verney M, Becker H, Röher H (1990) Prognose und Therapie der Leberverletzungen beim polytraumatisierten Patienten. Chirurg 61: 711–716

    Google Scholar 

  3. Malhotra AK, Fabian TC, Croce MA et al. (2000) Blunt hepatic injury: a paradigm shift from operative to nonoperative management in the 1990s. Ann Surg 231: 804–813

    Article  PubMed  CAS  Google Scholar 

  4. Pachter HL, Feliciano DV (1995) The current status of nonoperative management of adult blunt hepatic injuries. Am J Surg 169: 442–454

    Article  PubMed  CAS  Google Scholar 

  5. Matthes G, Stengel D, Seifert J et al. (2003) Blunt liver injuries in polytrauma: results from a cohort study with the regular use of whole-body helical computed tomography. World J Surg 27: 1124–1130

    Article  PubMed  Google Scholar 

  6. Velmahos GC, Toutouzas KG, Radin R et al. (2003) High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ. Arch Surg 138: 475–481

    Article  PubMed  Google Scholar 

  7. Bone RC, Balk RA, Cerra FB (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 101: 1644–1655

    Article  PubMed  CAS  Google Scholar 

  8. Vincent JL, Moreno R, Takala J et al. (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 22: 707–710

    Article  PubMed  CAS  Google Scholar 

  9. Tinkoff G, Rhodes M, Diamond D, Lucke J (1990) Cirrhosis in the trauma victim. Effect on mortality rates. Ann Surg 211: 172–177

    Article  PubMed  CAS  Google Scholar 

  10. Dangleben DA, Jazaeri O, Wasser T, Cipolle M (2006) Pasquale M. Impact of cirrhosis on outcomes in trauma. J Am Coll Surg 203: 908–913

    Article  PubMed  Google Scholar 

  11. Christmas AB, Wilson AK, Franklin GA et al. (2005) Cirrhosis and trauma: a deadly duo. Am Surg 71: 996–1000

    PubMed  Google Scholar 

  12. Meijer C, Wiezer MJ, Hack CE et al. (2001) Coagulopathy following major liver resection: the effect of rBPI21 and the role of decreased synthesis of regulating proteins by the liver. Shock 15: 261–271

    PubMed  CAS  Google Scholar 

  13. Blair SL, Karpoff HM, Hodyl C, Fong Y (1998) Pretreatment with IFN-gamma decreases infectious complications after partial hepatectomy in the rat. J Interferon Cytokine Res 18: 175–180

    PubMed  CAS  Google Scholar 

  14. Schroder J, Gallati H, Kremer B (1998) Increased serum levels of soluble tumor necrosis factor a-receptors in patients undergoing partial liver resection. Hepatogastroenterology 45: 1807–1812

    PubMed  CAS  Google Scholar 

  15. Vo NM, Chi DS (1988) Effect of hepatectomy on the reticuloendothelial system of septic rats. J Trauma 28: 852–854

    PubMed  CAS  Google Scholar 

  16. Fukushima H, Ikeuchi J, Tohkin M et al. (1998) Lethal shock in partially hepatectomized rats administered tumor necrosis serum. Circ Shock 26: 1–14

    Google Scholar 

  17. Perdrizet GA, Giles DL, Dring R et al. (2006) Major hepatic trauma: warm ischemic tolerance of the liver after hemorrhagic shock. J Surg Res 136: 70–77

    Article  PubMed  Google Scholar 

  18. Perl M, Gebhard F, Braumuller S et al. (2006) The pulmonary and hepatic immune microenvironment and its contribution to the early systemic inflammation following blunt chest trauma. Crit Care Med 34: 1152–1159

    Article  PubMed  Google Scholar 

  19. Robinson WP 3rd, Ahn J, Stiffler A et al. (2005) Blood transfusion is an independent predictor of increased mortality in nonoperatively managed blunt hepatic and splenic injuries. J Trauma 58: 437–444

    PubMed  Google Scholar 

  20. Moore FA, Moore EE, Sauaia A (1997) Blood transfusion. An independent risk factor for postinjury multiple organ failure. Arch Surg 132: 620–624

    PubMed  CAS  Google Scholar 

  21. Malone D, Napolitano LM, Genuit T et al. (2001) Total cytokine immunoassay: a more accurate method of cytokine measurement? J Trauma 50: 821–825

    PubMed  CAS  Google Scholar 

  22. Lendemans S, Kreuzfelder E, Waydhas C et al. (2007) Differential immunostimulating effect of granulocyte-macrophage colony-stimulating factor (GM-CSF), granulocyte colony-stimulating factor (G-CSF) and interferon gamma (IFNgamma) after severe trauma. Inflamm Res 56: 38–44

    Article  PubMed  CAS  Google Scholar 

  23. Flohé S, Lendemans S, Selbach C et al. (2003) Effect of granulocyte-macrophage colony-stimulating factor on the immune response of circulating monocytes after severe trauma. Crit Care Med 31: 2462–2469

    Article  PubMed  CAS  Google Scholar 

  24. Croce MA, Fabian TC, Menke PG et al. (1995) Nonoperative management of blunt hepatic trauma ist the treatment of choice for hemodynamically stable patients. Results of a prospective trial. Ann Surg 221: 744–753

    Article  PubMed  CAS  Google Scholar 

  25. Pachter HL, Knudson MM, Esrig B et al. (1996) Status of nonoperative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients. J Trauma 40: 31–38

    Article  PubMed  CAS  Google Scholar 

  26. Ott R, Schön MR, Seidel S et al. (2005) Surgical management, prognostic factors, and outcome in hepatic trauma. Unfallchirurg 108: 127–134

    Article  PubMed  CAS  Google Scholar 

  27. Clarke JR, Trooskin SZ, Doshi PJ et al. (2002) Surgical management, prognostic factors, and outcome in hepatic trauma. J Trauma 52: 420–425

    PubMed  Google Scholar 

Download references

Danksagung

Abschließend soll den Mitgliedern der Arbeitsgemeinschaft Polytrauma der DGU für die jahrelange, intensive Mitarbeit am Traumaregister gedankt werden. Die AG Polytrauma ist seit Beginn dieses Jahres in die Sektion Notfall, Intensivmedizin und Schwerverletztenversorgung der DGU integriert. Folgende Mitglieder haben einen entscheidenden Anteil am Erfolg des Traumaregisters der DGU: F. Barth, A. Bonk, B. Bouillon, K. Grimme, S. Grote, M. Grotz, M. Hering, S. Huber-Wagner, U. Krehmeier, G. Kanz, M. Kleiner, C. Krettek, C. Kühne, L. Kumpf, K. Ledendecker, I. Marzi, H. Meyer, S. Müller, W. Mutschler, C. Lackner, R. Lefering, D. Nast-Kolb, E. Neugebauer, U. Obertacke, H.J. Oestern, H.-C. Pape, T. Paffrath, Ch. Probst, M. Qvick, M. Raum, D. Rixen, S. Ruchholtz, S. Sauerland, U. Schweigkofler, A. Seekamp, R. Simon, O. Steitz, B. Strohecker, T. Tjardes, F. Walcher, C. Waydhas, M. Wittke, J. Westhoff.

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. Klinik für Unfallchirurgie, Universitätsklinikum, Hufelandstraße 55, 45122, Essen, Deutschland

    S. Lendemans, D. Nast-Kolb, S. Flohe & G. Taeger

  2. Klinik und Poliklinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum, Essen, Deutschland

    M. Heuer & M. Dammann

  3. Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Giessen und Marburg, Standort Marburg, Marburg, Deutschland

    C.A. Kühne & S. Ruchholtz

  4. IFOM-Institut für Forschung in der Operativen Medizin, Lehrstuhl für Chirurgische Forschung, Fakultät für Medizin, Private Universität Witten/Herdecke gGmbH, Klinikum Köln Mehrheim, Köln, Deutschland

    R. Lefering

Authors
  1. S. Lendemans
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. Heuer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. D. Nast-Kolb
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. C.A. Kühne
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. M. Dammann
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. R. Lefering
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. S. Flohe
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. S. Ruchholtz
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. G. Taeger
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to S. Lendemans.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lendemans, S., Heuer, M., Nast-Kolb, D. et al. Bedeutung des Lebertraumas für die Inzidenz von Sepsis, Multiorganversagen und Letalität bei Schwerstverletzten. Unfallchirurg 111, 232–239 (2008). https://doi.org/10.1007/s00113-008-1409-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00113-008-1409-9

Schlüsselwörter

Keywords

Search

Navigation