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Trauma - logistics and stress response
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Trauma is a major cause of death and disability. Adverse events, such as prolonged prehospital time, hypoxia, hypotension and/or hyperventilation have been reported to correlate to poor outcome.

Adequate cortisol levels are essential for survival after major trauma. In hypotensive critically ill patients, lack of sufficient amount of cortisol can be suspected, and a concept of critical illness related corticosteroid insufficiency has been proposed. Corticosteroid therapy has many adverse effects in critically ill patients and should only be given if life-saving. Correct measurement of serum cortisol levels is important but difficult in critically ill patients with capillary leakage. Estimation of the free and biologically active cortisol is preferable. In serum less than 10% of cortisol is free and biologically active and not possible to measure with routine laboratory methods. Salivary cortisol can be used as a surrogate for free cortisol, but salivary production is reduced in critically ill patients. Liver resection could reduce cortisol levels due to substrate deficiency.

Aims: 1. Evaluate the occurrence of early adverse events in patients with traumatic brain injury and relate them to outcome. 2. Assess cortisol levels over time after trauma and correlate to severity of trauma, sedative/analgesic drugs and cardiovascular function. 3. Evaluate if saliva stimulation could be performed without interfering with salivary cortisol levels. 4. Assess cortisol levels over time after liver resection in comparison to other major surgery.

Results: There was no significant correlation between prehospital time ³60 minutes, hypoxia (saturation <95%), hypotension (systolic blood pressure <90 mmHg), or hyperventilation (ETCO2 <4.5 kPa) and a poor outcome (Glasgow Outcome Scale 1-3) in patients with traumatic brain injury. Cortisol levels decreased significantly over time after trauma, but there was no correlation between low (<200 nmol/L) serum cortisol levels and severity of trauma.

Infusion of sedative/analgesic drugs was the strongest predictor for a low (<200 nmol/L) serum cortisol. The odds ratio for low serum cortisol levels (<200 nmol/L) was 8.0 for patients receiving continuous infusion of sedative/analgesic drugs. There was no significant difference between unstimulated and stimulated salivary cortisol levels (p=0.06) in healthy volunteers. Liver resection was not associated with significantly lower cortisol levels compared to other major surgery.

Conclusion: There was no significant correlation between early adverse events and outcome in patients with traumatic brain injury. Cortisol levels decreased significantly over time in trauma patients. Low cortisol levels (<200 nmol/L) were significantly correlated to continuous infusion of sedative/analgesic drugs. Saliva stimulation could be performed without interfering with salivary cortisol levels. Liver resection was not associated with low cortisol levels compared to other major surgery.

Place, publisher, year, edition, pages
Umeå Universitet , 2014. , 65 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1654
Keyword [en]
traumatic brain injury, multiple trauma, hydrocortisone, adrenal insufficiency, hypnotics and sedatives, citric acid, glycerol, saliva, liver, colorectal surgery
National Category
Anesthesiology and Intensive Care
Identifiers
URN: urn:nbn:se:umu:diva-93324ISBN: 978-91-7601-072-3 (print)OAI: oai:DiVA.org:umu-93324DiVA: diva2:747579
Public defence
2014-10-10, E04 byggnad 6E NUS, Norrlands Universitetssjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2014-09-19 Created: 2014-09-17 Last updated: 2014-09-18Bibliographically approved
List of papers
1. Severe traumatic brain injury: consequences of early adverse events
Open this publication in new window or tab >>Severe traumatic brain injury: consequences of early adverse events
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2011 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 55, no 8, 944-951 p.Article in journal (Refereed) Published
Abstract [en]

Background: Several factors associated with an unfavourable outcome after severe traumatic brain injury (TBI) have been described: prolonged pre-hospital time, secondary referral to a level 1 trauma centre, the occurrence of secondary insults such as hypoxia, hypotension or low end-tidal carbon dioxide (ETCO(2)). To determine whether adverse events were linked to outcome, patients with severe TBI were studied before arrival at a level 1 trauma centre.

Methods: Prospective, observational study design. Patients with severe TBI (n = 48), admitted to Umea University Hospital between January 2002 to December 2005 were included. All medical records from the site of the accident to arrival at the level 1 trauma centre were collected and evaluated.

Results: A pre-hospital time of >60 min, secondary referral to a level 1 trauma centre, documented hypoxia (oxygen saturation <95%), hypotension (systolic blood pressure <90 mmHg), hyperventilation (ETCO(2) <4.5 kPa) or tachycardia (heart rate >100 beats/min) at any time before arrival at a level 1 trauma centre were not significantly related to an unfavourable outcome (Glasgow Outcome Scale 1-3).

Conclusion: Early adverse events before arrival at a level 1 trauma centre were without significance for outcome after severe TBI in the trauma system studied.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2011
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:umu:diva-47379 (URN)10.1111/j.1399-6576.2011.02451.x (DOI)000294356500006 ()
Available from: 2011-09-26 Created: 2011-09-20 Last updated: 2017-12-08Bibliographically approved
2. Adrenal response after trauma is affected by time after trauma and sedative/analgesic drugs
Open this publication in new window or tab >>Adrenal response after trauma is affected by time after trauma and sedative/analgesic drugs
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2014 (English)In: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 45, no 8, 1149-1155 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The adrenal response in critically ill patients, including trauma victims, has been debated over the last decade. The aim of this study was to assess the early adrenal response after trauma. METHODS: Prospective, observational study of 50 trauma patients admitted to a level-1-trauma centre. Serum and saliva cortisol were followed from the accident site up to five days after trauma. Corticosteroid binding globulin (CBG), dehydroepiandrosterone (DHEA) and sulphated dehydroepiandrosterone (DHEAS) were obtained twice during the first five days after trauma. The effect of time and associations between cortisol levels and; severity of trauma, infusion of sedative/analgesic drugs, cardiovascular dysfunction and other adrenocorticotropic hormone (ACTH) dependent hormones (DHEA/DHEAS) were studied. RESULTS: There was a significant decrease over time in serum cortisol both during the initial 24 h, and from the 2nd to the 5th morning after trauma. A significant decrease over time was also observed in calculated free cortisol, DHEA, and DHEAS. No significant association was found between an injury severity score >/= 16 (severe injury) and a low (< 200 nmol/L) serum cortisol at any time during the study period. The odds for a serum cortisol < 200 nmol/L was eight times higher in patients with continuous infusion of sedative/analgesic drugs compared to patients with no continuous infusion of sedative/analgesic drugs. CONCLUSION: Total serum cortisol, calculated free cortisol, DHEA and DHEAS decreased significantly over time after trauma. Continuous infusion of sedative/analgesic drugs was independently associated with serum cortisol < 200 nmol/L.

Place, publisher, year, edition, pages
Elsevier, 2014
Keyword
Multiple trauma, Adrenal insufficiency, Sedatives
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:umu:diva-91640 (URN)10.1016/j.injury.2014.02.001 (DOI)24975481 (PubMedID)1879-0267 (Electronic) 0020-1383 (Linking) (ISBN)
Available from: 2014-08-13 Created: 2014-08-13 Last updated: 2017-12-05Bibliographically approved
3. Saliva stimulation with glycerine and citric acid does not affect salivary cortisol levels
Open this publication in new window or tab >>Saliva stimulation with glycerine and citric acid does not affect salivary cortisol levels
2014 (English)In: Clinical Endocrinology, ISSN 0300-0664, E-ISSN 1365-2265, Vol. 81, no 2, 244-248 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE:

In critically ill patients with hypotension, who respond poorly to fluids and vasoactive drugs, cortisol insufficiency may be suspected. In serum over 90% of cortisol is protein-bound, thus routine measures of total serum cortisol may yield 'false lows' due to hypoproteinaemia. Thus, the occurrence of cortisol insufficiency could be overestimated in critically ill patients. Salivary cortisol can be used as a surrogate for free serum cortisol, but in critically ill patients saliva production is decreased, and insufficient volume of saliva for analysis is a common problem. The aim of this study was to investigate if a cotton-tipped applicator with glycerine and citric acid could be used for saliva stimulation without affecting salivary cortisol levels.

DESIGN:

Prospective, observational study.

PARTICIPANTS:

Thirty-six volunteers (six males, 30 females), age 49 ± 9 years, without known oral mucus membrane rupture in the mouth.

MEASUREMENTS:

Forty-two pairs of saliva samples (22 paired morning samples, 20 paired evening samples) were obtained before and after saliva stimulation with glycerine and citric acid. Salivary cortisol was analysed using Spectria Cortisol RIA (Orion Diagnostica, Finland).

RESULTS:

The paired samples correlated significantly (P < 0·0001) and there was no significant difference between un-stimulated and stimulated salivary cortisol levels.

CONCLUSIONS:

Saliva stimulation with a cotton-tipped applicator containing glycerine and citric acid did not significantly influence salivary cortisol levels in healthy volunteers. This indicates that salivary cortisol measurement after saliva stimulation may be a useful complement when evaluating cortisol status in critically ill patients.

National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:umu:diva-86808 (URN)10.1111/cen.12423 (DOI)000339670500013 ()24521305 (PubMedID)
Available from: 2014-03-11 Created: 2014-03-11 Last updated: 2017-12-05Bibliographically approved
4. Liver resection is not associated with decreased cortisol levels.
Open this publication in new window or tab >>Liver resection is not associated with decreased cortisol levels.
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(English)Article in journal (Refereed) Submitted
Abstract [en]

Background: Adrenal hormones are synthesized from cholesterol, produced and stored in the liver. Liver failure has been reported to be associated with adrenal insufficiency. A possible mechanism could be a limited supply of substrate for cortisol synthesis. The aims of this study was to evaluate the occurrence of total serum cortisol <200 nmol/L after major liver resection (≥ 30%) and other major surgery (hemicolectomy) and to assess associations between cholesterol and corti­sol levels after liver resection.

Methods: Prospective, observational study. 40 patients were included (major liver resection n=15, hemicolectomy n=25). Serum and salivary cortisol were followed from morning before surgery up to five days postoperatively. Sulphated dehy­droepiandrosterone (DHEAS) and lipids (cholesterol, low density lipoproteins, high density lipoproteins and triglycerides) were obtained in liver resection patients.

Results: 8/25 (32%, hemicolectomy patients), and 3/15 (20%, liver resection patients) had serum cortisol <200 nmol/L. Neither hemicolectomy nor liver resec­tion was significantly associated with serum cortisol <200 nmol/L, p=0.49. Serum cortisol <200 nmol/L was not significantly associated with lipids below normal limits, (cholesterol; p=1.0 day 1, p=0.46 day 4, LDL; p=0.56 day 1, p=1.0 day 4, and HDL; p=0.27 day 1, p=1.0 day 4). Serum and salivary cortisol correlated sig­nificantly (rs=0.83, p<0.0001, hemicolectomy, rs=0.80, p<0.0001, liver resection).

Conclusion: Serum cortisol levels <200 nmol/L was found in 32% (hemicolec­tomy) and 20% (liver resection) postoperatively. Compared to after hemicolec­tomy, serum cortisol <200 nmol/L was not significantly more common after liver resection. Lipids below normal limits were not associated with serum cortisol <200 nmol/L after liver resection.

Key words: gastrointestinal surgical procedures, adrenal insufficiency, hydrocortisone

National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:umu:diva-92170 (URN)
Available from: 2014-08-22 Created: 2014-08-22 Last updated: 2014-09-18

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