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Intestinal Permeability Correlates with Severity of Injury in Trauma Patients

Faries, Peter L. MD; Simon, Ronald J. MD; Martella, Arthur T. MD; Lee, Martin J. PhD; Machiedo, George W. MD

The Journal of Trauma: Injury, Infection, and Critical Care: June 1998 - Volume 44 - Issue 6 - p 1031-1036
Article: Presented At The 57Th Annual Meeting Of The American Association For The Surgery Of Trauma And The Japanese Association For Acute Medicine, September 24-27, 1997, Waikoloa, Hawaii

Background Increased intestinal permeability (IP) and the release of toxic intraluminal materials have been implicated in the systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) observed in patients after severe trauma. Previous studies of intestinal permeability have failed to demonstrate a correlation between early measurements of IP and indicators of injury severity. This study examines the relationship between standard measures of injury severity and the early (day 1) and delayed (day 4) changes in IP. Associations between IP and the development of SIRS, MOF, and infectious complications were also studied.

Methods The metabolically inactive markers lactulose (L) and mannitol (M) were used to measure IP in 29 consecutive patients who sustained injuries that required admission to the surgical intensive care unit and in 10 healthy control subjects. Measurements were made within 24 hours of admission and on hospital day 4. Severity of injury was assessed by A Severity Characterization of Trauma (ASCOT), Trauma and Injury Severity Score (TRISS), Injury Severity Score (ISS), Revised Trauma Score (RTS), and Acute Physiology and Chronic Health Evaluation (APACHE) II score. Postinjury infections and parameters of SIRS and MOF were recorded.

Results The IP of healthy volunteers (L/M, 0.025 +/- 0.008) was within the normal range (L/M <or=to 0.03), whereas the average IP in injured patients was increased both within 24 hours (L/M, 0.139 +/- 0.172) and on the fourth hospital day (L/M, 0.346 +/- 0.699). No significant correlation between severity of injury and increased IP was seen within 24 hours of injury. A significant correlation was seen on hospital day 4, however, with all severity indices measured (ASCOT: r = 0.93, R2 = 0.87, p < 0.001; TRISS: r = 0.93, R2 = 0.87, p < 0.001; ISS: r = 0.84, R2 = 0.70, p < 0.001; RTS: r = 0.68, R2 = 0.47, p = 0.002; APACHE II score: r = 0.51, R (2) = 0.26, p = 0.04). Patients with markedly increased IP (L/M >or=to 0.100) experienced a significant increase in the development of SIRS (83 vs. 44%; p = 0.03) and subsequent infectious complications (58 vs. 13%; p = 0.01) and showed close correlation with the multiple organ dysfunction scores (r = 0.87, R2 = 0.76, p < 0.001).

Conclusion These observations demonstrate that the increased IP observed after trauma correlates with severity of injury only after 72 to 96 hours and not within the initial 24 hours of injury. A large increase in IP is associated with the development of SIRS, multiple organ dysfunction, and an increased incidence of infectious complications.

From the Department of Surgery (P.L.F., R.J.S., A.T.M., G.W.M.), Montefiore Medical Center/Albert Einstein College of Medicine, Jacobi Medical Center, Bronx, New York; and the Great Smokies Diagnostic Laboratory (M.J.L.), Asheville, North Carolina.

Supported in part by a grant from the Great Smokies Diagnostic Laboratory, Asheville, North Carolina.

Presented at the 57th Annual Meeting of the American Association for the Surgery of Trauma, September 24-27, 1997, Waikoloa, Hawaii.

Address for reprints: Ronald J. Simon, MD, Department of Surgery, Jacobi Medical Center, 1400 Pelham Parkway South, Bronx, NY 10461.

© Williams & Wilkins 1998. All Rights Reserved.