fisiopatologia del politrauma gregorio tugnoli chirurgia durgenza e del trauma ospedale...

FISIOPATOLOGIA DEL FISIOPATOLOGIA DEL POLITRAUMAPOLITRAUMAGREGORIO TUGNOLIGREGORIO TUGNOLI

Chirurgia d’Urgenza e del TraumaChirurgia d’Urgenza e del TraumaOspedale Maggiore-BolognaOspedale Maggiore-BolognaDirettore Dr.Franco BaldoniDirettore Dr.Franco Baldoni

XXII

CONGRESSO NAZIONALE S.I.FI.PA.C

SOCIETÀ ITALIANA DI FISIOPATOLOGIA CHIRURGICA

PADOVA 2-3-4 APRILE 2009

PRESIDENTE ONORARIO

DAVIDE D’AMICO

PRESIDENTE MAURO FREGO

SECOND HIT SECOND HIT THEORYTHEORY

““Pathophysiology of polytrauma” Pathophysiology of polytrauma” Keel M, Injury 2005Keel M, Injury 2005

XXII Congresso Nazionale S.I.FI.PA.CXXII Congresso Nazionale S.I.FI.PA.C

INTRODUZIONEINTRODUZIONE• Major trauma is associated with severe Major trauma is associated with severe

hemorrhage, shock, low-flow conditions, hemorrhage, shock, low-flow conditions, impaired oxygen delivery, tissue destruction, impaired oxygen delivery, tissue destruction, and release of debris, as well as gut bacterial and release of debris, as well as gut bacterial translocation. These factors provide the translocation. These factors provide the mechanistic rationale for substantial mechanistic rationale for substantial dyshomeostasis that ultimately leads to organ dyshomeostasis that ultimately leads to organ dysfunction . The subsequent dysfunction of the dysfunction . The subsequent dysfunction of the immune system is characterized by a massive immune system is characterized by a massive inflammatory response. inflammatory response. The magnitude of this The magnitude of this response depends on the type of injury and its response depends on the type of injury and its severity but moreover, it is determined by severity but moreover, it is determined by intrinsic factors such as age, sex, comorbidities, intrinsic factors such as age, sex, comorbidities, and even genetic predisposition. and even genetic predisposition.


INTRODUZIONEINTRODUZIONE

• Comprehension of the Comprehension of the biologic response to injury biologic response to injury however will help to however will help to understand clinical problems understand clinical problems associated with severe associated with severe trauma, like increased trauma, like increased susceptibility to infection, susceptibility to infection, increased risk for sepsis, increased risk for sepsis, and development of multiple and development of multiple organ failure (MOF).organ failure (MOF).


THE “TWO HITS” THEORYTHE “TWO HITS” THEORY


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FIRST HIT: SIRSFIRST HIT: SIRS• Local tissue damage, hypoxia and hypotension induce Local tissue damage, hypoxia and hypotension induce

local and systemic host responses, to preserve the local and systemic host responses, to preserve the immune integrity and stimulate reparative mechanism: immune integrity and stimulate reparative mechanism: Systemic Inflammatory Response Syndrome Systemic Inflammatory Response Syndrome (Acosta JA, (Acosta JA, 1998)1998)

• It is characterized by the local and systemic production It is characterized by the local and systemic production and release of different mediators, such as pro-and release of different mediators, such as pro-inflammatory cytokines, complement factor, proteins of inflammatory cytokines, complement factor, proteins of the contact phase and coagulation systems, acute phase the contact phase and coagulation systems, acute phase proteins, neuroendocrine mediators and an proteins, neuroendocrine mediators and an accumulation of immunocompetent cells at the local site accumulation of immunocompetent cells at the local site of tissue damage of tissue damage (Van Griensen M, 2004)(Van Griensen M, 2004)

• Pro-inflammatory mediators and toxins activate the Pro-inflammatory mediators and toxins activate the plasmatic cascade system, consisting of the plasmatic cascade system, consisting of the complement cascade, the kallikrein-kinin system and the complement cascade, the kallikrein-kinin system and the coagulation cascade coagulation cascade (Keel M, 2004)(Keel M, 2004)


SECOND HITSECOND HIT

• Endogenous second Hit: respiratory distress Endogenous second Hit: respiratory distress with hypoxia, repeated cardiovascular with hypoxia, repeated cardiovascular instability, metabolic acidosis, instability, metabolic acidosis, ischaemia/reperfusion injuries, dead tissue, ischaemia/reperfusion injuries, dead tissue, contaminated catheters or tubes and contaminated catheters or tubes and infection infection (Dunham CM, 1995)(Dunham CM, 1995)

• Exogenous second Hit: surgical Exogenous second Hit: surgical interventions with severe tissue damage, interventions with severe tissue damage, hypothermia or blood loss, inadeguated or hypothermia or blood loss, inadeguated or delayed surgical or intensive care after delayed surgical or intensive care after neglected or missed injuries as well as neglected or missed injuries as well as massive transfusions massive transfusions (Haga Y, 1997)(Haga Y, 1997)


TWO HITS: SIRS, CARSTWO HITS: SIRS, CARS

• Hyperinflammation-SIRS: an overwhelming pro-Hyperinflammation-SIRS: an overwhelming pro-inflammatory response leads to the clinical inflammatory response leads to the clinical manifestation of SIRS and finally to host defence manifestation of SIRS and finally to host defence failure failure (Texerau, 2004)(Texerau, 2004)

• Hypoinflammation-CARS: depending on the severity Hypoinflammation-CARS: depending on the severity of injury of injury and the post traumatic courseand the post traumatic course, , anti-anti-inflammatory mediators are also produced. An inflammatory mediators are also produced. An overwhelming anti-inflammatory response seems to overwhelming anti-inflammatory response seems to be responsible for post-traumatic be responsible for post-traumatic immunosuppression with a high susceptibility to immunosuppression with a high susceptibility to infections and septic complications: Compensatory infections and septic complications: Compensatory Anti-inflammatory Response Syndrome Anti-inflammatory Response Syndrome (Bone RC, (Bone RC, 1996)1996)


SIRS, CARS: MARS!SIRS, CARS: MARS!

• The host defence response tries to The host defence response tries to strike a fine balance between SIRS and strike a fine balance between SIRS and CARS to induce reparative mechanism, CARS to induce reparative mechanism, limit entry or overload of limit entry or overload of microorganism and to avoid microorganism and to avoid autoaggressive inflammation with autoaggressive inflammation with secondary tissue damage and secondary tissue damage and susceptibility to infections: Mixed susceptibility to infections: Mixed Antagonist Response Syndrome Antagonist Response Syndrome (Bone (Bone RC, 1996)RC, 1996)


MARS? MODS & MOF!MARS? MODS & MOF!

• An imbalance between these dual responses An imbalance between these dual responses with an overwhelming release of pro- or anti-with an overwhelming release of pro- or anti-inflammatory mediators seems to be inflammatory mediators seems to be resnponsible for organ dysfunction and and resnponsible for organ dysfunction and and increased susceptibility to infections and increased susceptibility to infections and sepsis sepsis (Malone DL, 2001)(Malone DL, 2001)

• Endothelial cell damage, accumulation of Endothelial cell damage, accumulation of leukocytes, DIC and microcirculatory leukocytes, DIC and microcirculatory dysfunction finally lead to cell death and dysfunction finally lead to cell death and necrosis of parenchymal cells with the necrosis of parenchymal cells with the development of Multiple Organ Dysfunction development of Multiple Organ Dysfunction Syndrome or Multiple Organ Failure Syndrome or Multiple Organ Failure (Keel (Keel 2004)2004)


SIRS, CARS, MARS, MODS, MOF, AND… SIRS, CARS, MARS, MODS, MOF, AND… MORE!!!MORE!!!

• The post-traumatic hoste response is also The post-traumatic hoste response is also influenced by neuroendocrine and metabolic influenced by neuroendocrine and metabolic disorders. The sympathetic nervous system and the disorders. The sympathetic nervous system and the adrenal gland represent the efferent regulators of adrenal gland represent the efferent regulators of cardiovascular, respiratory and metabolic response. cardiovascular, respiratory and metabolic response. Signal in the symapthetic area of the hypothalamus Signal in the symapthetic area of the hypothalamus evoke a release of catecholamines from the adrenal evoke a release of catecholamines from the adrenal medulla medulla (Singer M, 2004)(Singer M, 2004)

• Furthermore, catecholamines influence the post-Furthermore, catecholamines influence the post-traumatic metabolis with an increase in the energy traumatic metabolis with an increase in the energy wxpenditure, hepatic glycogenolysis and wxpenditure, hepatic glycogenolysis and gluconeogenesis as well as release of free fatty gluconeogenesis as well as release of free fatty acid....acid....(Plank LD,2000)(Plank LD,2000)


FISIOPATOLOGIA DEL FISIOPATOLOGIA DEL TRAUMATRAUMA

IL CHIRURGO E LA IL CHIRURGO E LA FISIOPATOLOGIA DEL FISIOPATOLOGIA DEL

TRAUMATRAUMAXXII Congresso Nazionale S.I.FI.PA.CXXII Congresso Nazionale S.I.FI.PA.C

UN ARGOMENTO “DI MODA”?UN ARGOMENTO “DI MODA”?

TRAUMA, NONOPERATIVE MANAGEMENT 1384TRAUMA, NONOPERATIVE MANAGEMENT 1384

LIVER INJURY 5436LIVER INJURY 5436

TRAUMA PHYSIOLOGY 167813TRAUMA PHYSIOLOGY 167813


IL CHIRURGO E LA FISIOPATOLOGIA IL CHIRURGO E LA FISIOPATOLOGIA DEL TRAUMADEL TRAUMA

• Nessuna altra patologia provoca Nessuna altra patologia provoca talmente tante alterazioni della normale talmente tante alterazioni della normale fisiologia e in così breve tempo come il fisiologia e in così breve tempo come il trauma gravetrauma grave

• La comprensione, seppure parziale, La comprensione, seppure parziale, della fisiopatologia del trauma ha della fisiopatologia del trauma ha portato-come in nessun altro caso-a portato-come in nessun altro caso-a modificare radicalmente il nostro modificare radicalmente il nostro atteggiamentoatteggiamento



• Una migliore comprensione della Una migliore comprensione della fisiopatologia del trauma ha portato a fisiopatologia del trauma ha portato a modificare il nostro atteggiamento:modificare il nostro atteggiamento:

- nell’affrontare il paziente traumatizzatonell’affrontare il paziente traumatizzato

- nel “misurare” gli effetti del traumanel “misurare” gli effetti del trauma

- nel trattare il paziente traumatizzato nel trattare il paziente traumatizzato



• Dall’infusione massiva di cristalloidi Dall’infusione massiva di cristalloidi all’ipotensione controllata, all’uso all’ipotensione controllata, all’uso precoce di sangue ed emoderivatiprecoce di sangue ed emoderivati

• Let the surgeon sleep! “Changing Let the surgeon sleep! “Changing criteria for Trauma Team Activation criteria for Trauma Team Activation from SPB 90 mmHg to <80 mmHg from SPB 90 mmHg to <80 mmHg preserves personnel without patient preserves personnel without patient harm” harm” Shapiro MJ, J Trauma 2008Shapiro MJ, J Trauma 2008


Hgb, PAHgb, PA LattatiLattatiEccesso basiEccesso basipHpH

Parallel monitoring of pro (e.g. IL-6) and inti-Parallel monitoring of pro (e.g. IL-6) and inti-inflammatory (e.g. IL-10) cytokines, as well as acute inflammatory (e.g. IL-10) cytokines, as well as acute phase proteins (e.g. CRP; procalcitonin) could help phase proteins (e.g. CRP; procalcitonin) could help us in the decision making for optimal secondary us in the decision making for optimal secondary operative interventions to limit the second hit operative interventions to limit the second hit (Giannoudis PV, 2004) (Giannoudis PV, 2004)

IL CHIRURGO E LA FISIOPATOLOGIAIL CHIRURGO E LA FISIOPATOLOGIA DEL TRAUMADEL TRAUMA


IL CHIRURGO E LA FISIOPATOLOGIA IL CHIRURGO E LA FISIOPATOLOGIA DEL TRAUMA DEL TRAUMA

• In nessun altro caso, la In nessun altro caso, la comprensione degli aspetti comprensione degli aspetti fisiopatologici ha portato ad fisiopatologici ha portato ad una trasformazione della una trasformazione della nostra stessa attività nostra stessa attività chirurgica: dall’essere chirurgica: dall’essere chirurghi dell’anatomia chirurghi dell’anatomia all’essere chirurghi della all’essere chirurghi della fisiologia fisiologia

• In nessun altro caso, questo In nessun altro caso, questo ha portato ad una attività di ha portato ad una attività di Team multidisciplinare, Team multidisciplinare, preminennte rispetto preminennte rispetto all’attività del singoloall’attività del singolo



• Oggi sappiamo che un Oggi sappiamo che un paziente non muore per la paziente non muore per la mancata riparazione di una mancata riparazione di una lesione ma se non lesione ma se non correggiamo le alterazioni correggiamo le alterazioni fisiologiche prodotte dal fisiologiche prodotte dal trauma. Se, cioè, trauma. Se, cioè, permettiamo che diventi permettiamo che diventi ipotermico in E.R. o in S.O., ipotermico in E.R. o in S.O., se non provvediamo ad un se non provvediamo ad un “corretto” rimpiazzo “corretto” rimpiazzo volemico, se volemico, se “amplifichiamo” l’insulto “amplifichiamo” l’insulto traumatico con procedure traumatico con procedure chirurgiche lunghe ed chirurgiche lunghe ed elaborate, se non elaborate, se non preveniamo adeguatamente preveniamo adeguatamente MOF, RDS, IAHPMOF, RDS, IAHP


Baseline CharacteristicsBaseline Characteristics

Sex and AgeSex and Age F, 29 yrsF, 29 yrs

Height, Weight, BSAHeight, Weight, BSA 160 cm, 58 kg, 1.59160 cm, 58 kg, 1.59

Mechanism of TraumaMechanism of Trauma Blunt,Blunt,Motorbike accidentMotorbike accident

Previous ComorbiditiesPrevious Comorbidities NoneNone

Pre-hospitalPre-hospital

GCSGCS 1313

Systolic BP (mmHg)Systolic BP (mmHg) 8585

Heart RateHeart Rate 135/min135/min

O2 sat - RRO2 sat - RR 99% - 16/min99% - 16/min

RTSRTS 7.17.1

Prehospital fluids volumePrehospital fluids volume 1000 cc1000 cc

Time elapsed from trauma to E.R. arrivalTime elapsed from trauma to E.R. arrival 70 min70 min


Emergency RoomEmergency Room

GCSGCS 1414

BP (Systolic – Diastolic) (mmHg)BP (Systolic – Diastolic) (mmHg) 80/4080/40

O2 sat - RRO2 sat - RR 99% - 20/min99% - 20/min

Heart Rate Heart Rate 125/min125/min

RTSRTS 7.17.1

ISSISS 3434

TRISSTRISS 0.940.94

AAST grade liver injuryAAST grade liver injury 44

HypothermiaHypothermia 35° Celsius35° Celsius

pHpH 7.37.3

BEBE -5.6-5.6

E.R. fluids volumeE.R. fluids volume 1000 cc1000 cc

FFP transfusedFFP transfused 1000 cc1000 cc

PRBC transfusedPRBC transfused 5 units5 units

FASTFAST Versamento libero in tutti i quadrantiVersamento libero in tutti i quadranti


TICU day 6 Drenaggio eco guidato di 2600cc di sangue

IAP (mmHg) 28-22-10-9-5-10

PRBC 3

TICU day 7

IAP (mmHg) 10-8-11-12-9-7

PRBC -

Totale PRBC trasfuse 16XXII Congresso Nazionale S.I.FI.PA.CXXII Congresso Nazionale S.I.FI.PA.C

CONCLUDENDO...UNA RIFLESSIONECONCLUDENDO...UNA RIFLESSIONE

• Conoscere meglio la Conoscere meglio la fisiopatologia del trauma ha fisiopatologia del trauma ha davvero facilitato la nostra davvero facilitato la nostra attività?attività?

• Doverci oggi “destreggiare” Doverci oggi “destreggiare” tra più precise definizioni tra più precise definizioni dello stato del paziente, dello stato del paziente, strumenti diagnostici strumenti diagnostici sempre più veloci e sempre più veloci e trattamenti “alternativi” trattamenti “alternativi” richiede un’esperienza richiede un’esperienza ancora maggioreancora maggiore

• Non era meglio quando Non era meglio quando avevamo più “paura”?avevamo più “paura”?


CONCLUSIONICONCLUSIONI

• L’ effetto fisiopatologico della risposta L’ effetto fisiopatologico della risposta all’aggressione traumatica è il mantenimento della all’aggressione traumatica è il mantenimento della perfusione e della funzionalità cardiaca e cerebrale. perfusione e della funzionalità cardiaca e cerebrale. Nella fase acuta questo porta ad un vantaggio in Nella fase acuta questo porta ad un vantaggio in termini di sopravvivenza; tuttavia, una prolungata termini di sopravvivenza; tuttavia, una prolungata attivazione della risposta infiammatoria sistemica attivazione della risposta infiammatoria sistemica porta effetti negativi quali SIRS e MODS causa di porta effetti negativi quali SIRS e MODS causa di morti tardive nel traumamorti tardive nel trauma

• La comprensione della fisiopatologia del trauma, La comprensione della fisiopatologia del trauma, molto di più che per altre patologie, deve “guidare” molto di più che per altre patologie, deve “guidare” la nostra attività nei tempi e nei modi , ci obbliga ad la nostra attività nei tempi e nei modi , ci obbliga ad “allargare” la nostra visuale e rende preminente “allargare” la nostra visuale e rende preminente l’attività del Trauma Team rispetto a quella del l’attività del Trauma Team rispetto a quella del singolo professionistasingolo professionista


Grazie per la Vostra Grazie per la Vostra attenzione!attenzione!

fisiopatologia del politrauma gregorio tugnoli chirurgia durgenza e del trauma ospedale...

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