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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

Der Unfallchirurg volume 111, pages 232–239 (2008)Cite this article

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.

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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.

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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

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  1. S. Lendemans
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  2. M. Heuer
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  3. D. Nast-Kolb
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  4. C.A. Kühne
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  5. M. Dammann
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  6. R. Lefering
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  7. S. Flohe
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  8. S. Ruchholtz
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  9. G. Taeger
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Correspondence to S. Lendemans.

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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

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Schlüsselwörter

  • Trauma
  • Lebertrauma
  • Prognose
  • Sepsis
  • Multiorganversagen

Keywords

  • Trauma
  • Liver trauma
  • Prognosis
  • Sepsis
  • Multiple organ failure