Журнал «Травма» Том 15, №4, 2014
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Dynamics of Average Weight Molecules Concentration in Patients with Severe Concomitant Thoracic Injury in the Acute Period of Traumatic Disease
Авторы: Stupnytsky M.A., Zhukov V.I., Gorbatch T.V., Pavlenko A.Yu., Biletsky O.V. - Kharkiv National Medical University, Department of Biochemistry, Kharkiv, Ukraine
Рубрики: Травматология и ортопедия
Разделы: Клинические исследования
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Introduction. Polytauma is the leading cause of death in working-age population. It causes over 2 million deaths worldwide according to WHO data. Up to 93 % cases of thoracic injuries are recorded in patients with polytrauma in case of traffic accidentals. Early posttraumatic period is characterized by the organ disturbances development with followed multiply organ failure as the result of the systemic inflammation response syndrome manifestation caused by endotoxemia. The medium-sized peptides (middle mass molecules) are responsible for endotoxemia in case of different pathophysiological conditions. These substances are products of the protein proteolysis as the result of cell destruction and the catabolic orientation of posttraumatic metabolism. The aim of the study was to investigate the dynamic of the medium-sized peptides fractions concentrations in blood plasma of the severe combined thoracic trauma patients.
Materials and methods. Study was performed on 73 male patients aged from 20 to 68 who were treated at the anesthesiology and intensive care department for patients with combined trauma of the Kharkiv city clinical hospital of emergency aid named by prof. O.I. Meshchaninov. Patients with the severe blunt combined thoracic trauma with pneumothoraxes and hemothoraxes, lung contusions, heart contusions and multiply (> 3) rib fractures were included in this study. Patients’ examinations were performed on 1-2-d day after trauma (10.75-33.5 hours after trauma), 3-4-th day (48-75.2 hours) and 5-6-th day (97-122 hours). All patients were divided in to 2 groups according to outcome – survival (n = 42) and non-survival (n = 31) groups. 15 male healthy volunteers at the same age were comprised in to control group. The medium-sized peptides were spectrophotometrically estimated in blood plasma at 254nm (peptide fraction) and 280nm (aromatic fraction). Statistical analysis was performed using GraphPad Prism 5.03 program. Mann-Whitney test was used to assess differences between groups. Chi-square test for trends was performed to consider differences in nominal data. A p-value < 0,005 was considered statistically significant.
Results and discussion. There were no significant differences in age and types of polytrauma according to anatomical classification between the two groups of patients. Significant difference was observed in trauma severity according to ISS scale between groups of patients (25,48 ± 1,35 in survival group and 34,45 ± 1,99 in non-survival group, p = 0,0006).
Significant increase on 39,15 % of the peptide fraction concentration was observed on 1-2-d day in survival group in comparison with control group (0,295 ± 0,0102 U and 0,212 ± 0,0266 U, p = 0,0046). Further normalization trend was detected in comparison with control group on 3-4-th (0,274 ± 0,0097 U, p = 0,0219) and 5-6-th (0,258 ± 0,0086 U, p = 0,0318) days after trauma. Significant increase on 69,33% was observed on 1-2-d day in non-survival group in comparison with control group (0,359 ± 0,0109 U, p = 0,0001) and on 21,69 % in comparison with survival group (p < 0,0001). Slight decrease of the peptide fraction concentration of the medium-sized peptides was detected on 3-4-th day after trauma up to level 61,79 % higher than in control group (0,343 ± 0,0177 U, p = 0,0009) and significantly higher on 25,18 % than in survival group (p = 0,0008). Further significant increase on 82,07 % was observed on 5-6-th day in comparison with control group (0,386 ± 0,0316 U, p = 0,0002) and on 49,61 % in comparison with survival group (p < 0,0001).
Slight different is situation with the medium-sized peptides’ aromatic fraction. Significant 2,37 times increase was observed on 1-2-d day in survival group in comparison with control group (0,295 ± 0,0176 U and 0,124 ± 0,0245 U, p = 0,0001). Further normalization was detected with no significant levels in comparison with control group on 3-4-th (0,156 ± 0,0147 U, p = 0,2498) and 5-6-th (0,174 ± 0,0154 U, p = 0,0803) days after trauma. Significant 3,22 times increase was observed on 1-2-d day after trauma in non-survival group in comparison with control group (0,399 ± 0,0192 U) and on 35,25 % in comparison with survival group (both p<0,0001). Significant 2,76 times increase was detected on 3-4-th day in comparison with control group (0,342 ± 0,0324 U) and 2,19 times increase in comparison with survival group (both p < 0,0001). Significant 2,35 times increase was detected on 5-6-th day after trauma in comparison with control group (0,291 ± 0,0269 U, p = 0,0004) and on 67,24 % in comparison with survival group (p=0,0004).
The miscellaneous dynamics of the medium-sized peptides’ fractions can be explained by different eliminative pathways. It’s well known that hydrophilic low- and medium-molecular substances are removed by kidneys, skin and digestive system. Hydrophobic low- and medium-molecular substances are transported in to liver and lungs with followed biotransformation by monooxygenase system or conjugation reactions and next removing by hydrophilic elimination pathways. Gradual development of organ dysfunction can be responsible for violation of the elimination processes of toxins from blood plasma. The immune system dysfunction gives another contribution in to the endogenous intoxication development. From the one side the violation of the elimination processes can takes part. From the other – increase of the medium-sized peptides concentration as the result of immune system hyperactivity, the autoaggression processes and development of septic complications. Inability to control the integration of such processes determines conception of endogenous intoxication, presenting it as reflection of violation results of micro- and macrocirculation, gas exchange and oxygen “budget”, immune system and anti-infection defense.
Conclusions. The dynamic of both peptide and aromatic fractions of the medium-sized peptides in group of survival patients is characterized by increasing on 1-2-d day after trauma with following normalization trends. Higher level of endogenous intoxication was observed in non-survival group of patients through early posttraumatic period in comparison to those who survived. Dynamic of the medium-sized peptides aromatic fraction is characterized by greater deviations during early posttraumatic period, especially in non-survival group, probably as he result of more complex mechanisms of their detoxification. The level of the medium-sized peptides fractions concentrations can reflect severity of endotoxemia and can serve as additional markers for outcome prediction in patients with the severe combined thoracic trauma.
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