Intensive care organisation: should there be a separate intensive care unit for critically injured patients?

In the last two decennia, the mixed population general intensive care unit (ICU) with a “closed format” setting has gained in favour compared to the specialized critical care units with an “open format” setting. However, there are still questions whether surgical patients benefit from a general mixed ICU. Trauma is a significant cause of morbidity and mortality throughout the world. Major or severe trauma requiring immediate surgical intervention and/or intensive care treatment. The role and type of the ICU has received very little attention in the literature when analyzing outcomes from critical injuries. Severely injured patients require the years of experience in complex trauma care that only a surgery/trauma ICU can provide. Should a trauma center have the capability of a separate specialized ICU for trauma patients (“closed format”) next to its standard general mixed IC

Trauma: the role of the innate immune system

<p>Abstract</p> <p>Immune dysfunction can provoke (multiple) organ failure in severely injured patients. This dysfunction manifests in two forms, which follow a biphasic pattern. During the first phase, in addition to the injury by trauma, organ damage is caused by the immune system during a systemic inflammatory response. During the second phase the patient is more susceptible for sepsis due to host defence failure (immune paralysis). The pathophysiological model outlined in this review encompasses etiological factors and the contribution of the innate immune system in the end organ damage. The etiological factors can be divided into intrinsic (genetic predisposition and physiological status) and extrinsic components (type of injury or "traumaload" and surgery or "intervention load"). Of all the factors, the intervention load is the only one which, can be altered by the attending emergency physician. Adjustment of the therapeutic approach and choice of the most appropriate treatment strategy can minimize the damage caused by the immune response and prevent the development of immunological paralysis. This review provides a pathophysiological basis for the damage control concept, in which a staged approach of surgery and post-traumatic immunomonitoring have become important aspects of the treatment protocol. The innate immune system is the main objective of immunomonitoring as it has the most prominent role in organ failure after trauma. Polymorphonuclear phagocytes and monocytes are the main effector-cells of the innate immune system in the processes that lead to organ failure. These cells are controlled by cytokines, chemokines, complement factors and specific tissue signals. The contribution of tissue barrier integrity and its interaction with the innate immune system is further evaluated.</p

The effects of regionalization of pediatric trauma care in the Netherlands: A surveillance-based before-after study

BACKGROUND: System changes in pediatric trauma care may reduce childhood injury mortality. The Dutch system of trauma care has been regionalized in 1999/2000. We evaluated changes in referral behavior and in-hospital mortality before and after regionalization of trauma care in the Netherlands. METHODS: A surveillance-based before-after study was performed on all children aged up to 18 years that were discharged from one of the hospitals of the trauma care region "Central Netherlands" between 1996 and 1998 and between 2001 and 2006. The in-hospital mortality rate and referral behavior was compared before (1996-1998) and after (2001-2006) regionalization of trauma care in the Netherlands. RESULTS: A total of 21,585 children were included, with a mean (SD) age of 9.6 (5.5) years and a mean (SD) Injury Severity Score (ISS) of 4.3 (4.4). After regionalization, the mean ISS was lower (p = 0.000), and the mean length of stay was lower (p = 0.000). The in-hospital mortality rate was significantly lower for the adolescent group (age, 13-18 years; n = 7,846; standardized mortality ratio, 0.64; 95% confidence interval, 0.34-0.93) after correction for the ISS. No changes were found for the CONCLUSION: Regionalization of trauma care in the Netherlands reduced the in-hospital mortality rates for adolescents in the last decade. However, this reduction was not caused by a change in referral behavior. (J Trauma Acute Care Surg. 2012;73: 1284-1287. Copyright (c) 2012 by Lippincott Williams & Wilkins