Nghiên cứu biến đổi nồng độ IL-6, IL-10 huyết tương và mối liên quan với thời điểm phẫu thuật kết hợp xương ở bệnh nhân đa chấn thương có gãy xương lớn

Nghiên cứu biến đổi nồng độ IL-6, IL-10 huyết tương và mối liên quan với thời điểm phẫu thuật kết hợp xương ở bệnh nhân đa chấn thương có gãy xương lớn.Nghiên cứu biến đổi nồng độ IL-6, IL-10 huyết tương và mối liên quan với thời điểm phẫu thuật kết hợp xương ở bệnh nhân đa chấn thương có gãy xương lớn.Nghiên cứu biến đổi nồng độ IL-6, IL-10 huyết tương và mối liên quan với thời điểm phẫu thuật kết hợp xương ở bệnh nhân đa chấn thương có gãy xương lớn.Nghiên cứu biến đổi nồng độ IL-6, IL-10 huyết tương và mối liên quan với thời điểm phẫu thuật kết hợp xương ở bệnh nhân đa chấn thương có gãy xương lớn.Nghiên cứu biến đổi nồng độ IL-6, IL-10 huyết tương và mối liên quan với thời điểm phẫu thuật kết hợp xương ở bệnh nhân đa chấn thương có gãy xương lớn.Nghiên cứu biến đổi nồng độ IL-6, IL-10 huyết tương và mối liên quan với thời điểm phẫu thuật kết hợp xương ở bệnh nhân đa chấn thương có gãy xương lớn.Nghiên cứu biến đổi nồng độ IL-6, IL-10 huyết tương và mối liên quan với thời điểm phẫu thuật kết hợp xương ở bệnh nhân đa chấn thương có gãy xương lớn.Nghiên cứu biến đổi nồng độ IL-6, IL-10 huyết tương và mối liên quan với thời điểm phẫu thuật kết hợp xương ở bệnh nhân đa chấn thương có gãy xương lớn.Nghiên cứu biến đổi nồng độ IL-6, IL-10 huyết tương và mối liên quan với thời điểm phẫu thuật kết hợp xương ở bệnh nhân đa chấn thương có gãy xương lớn.

1 INTRODUCTION Polytrauma a major public health concern which receives much attention from global health systems health care systems of the world, including Vietnam Management of polytrauma patients with major fracture remains controversial, particularly surgical timing, as well as the optimal techniques of external fixation related to the physiopathological progress of multiple injured patients Systemic inflammation response and immune response occurs due to excessive release of pro-inflammatory cytokines, which, in turn, results in an imbalance among them Interleukin-6 (IL-6) and antiflammation cytokines such as interleukin-10 (IL-10) occur after severe trauma and surgical intervention Globally, there have been numerous reports on assessment of role of plasma IL-6, IL-10 levels in monitoring, prognosis as well as investigation of its relation to injury severity, surgical timing and prognostic value of fixation-attributable complications in patients with multiple trauma In Vietnam, this issue needs further study Thus, the thesis named “Research on changes of plasma IL-6, IL-10 level and their association with timing of external fixation of major fracture in patients with multiple trauma” was conducted aiming: Investigate changes of plasma IL-6, IL-10 level and IL-6/IL-10 ratio; their association with characteristics, severity of injury in multiple trauma patients with major fracture; Identify the correlation of IL-6 and IL-10 level as well as IL6/IL-10 ratio with surgical timing of fracture fixation in polytrauma patients New contributions and practical significance of the thesis Based on two aforementioned objectives, the research has provided further scientific evidence on the changes in plasma levels of IL-10 and IL-6 as well as IL-6/IL-10 ratios post-trauma, also determined their correlation with severity as well as features of injury, surgical timing, prognostic value of these cytokines, complications following fracture fixation With findings reported in the current study, we found that the measurement of IL-6, IL-10 levels in polytrauma patients with major fractures contributes to predict promptly and accurately as well as make treatment decisions among physicians Osteosynthesis should not be performed until at least days after injury Organization of the thesis The thesis is comprised of 127 pages (excluding references and appendices), of which 02 pages for Introduction, 35 pages for Overview, 20 pages for Subjects and Methods, 32 pages for Results, 34 pages for Discussion and 02 pages for Conclusion, 01 page for Recommendation, 01 page for Limitations of thesis Additionally, the thesis also includes 62 tables, figures and 19 charts and 147 references with 20 in Vietnamese and 127 in English Chapter OVERVIEW 1.1 Overview on polytrauma 1.1.1 Definition At a medical conference held by French (1971), Patel A and Trillat A were the first to introduce the definition of polytrauma, where a polytrauma patient was defined as having two or more significant injuries, affecting respiratory and circulatory system 1.1.2 Trauma Severity Classification Scores and prognostic index used as an assessment of multiple trauma patients Benefits of Trauma Severity Classification Scores: The scoring system for the trauma enables the usage of a common language for the trauma classification, convenience in the transport and triage of the patients, irrespective of specific features of each patient: injury mechanism, age, geographical regions, trauma systems They include: Revised Trauma Score established by Champion et al (1989), Abbreviated Injury Scale (AIS) created by the Association for the Advancement of Automotive Medicine and Injury Severity Score (ISS) by Baker S.P et al (1974) RTS, ISS are the scoring systems widely used for the classification of multipletrauma patients globally as well as in Vietnam 1.2 The management of major fracture in patients with multiple trauma 1.2.1 Early total care Early total care is defined by Enninghorst et al (2011) that early radical surgery for extremity injuries is performed with other injuries in the first 24 h post trauma Indications for early osteosynthesis don’t depend on injury severity, minor or major fracture or the need for patient’s resuscitation The technique of fracture fixation provides several advantages It allows a lower complcation rate and a shorter hospital stay (Nicola R., 2013) 1.2.2 Damage control orthopedic surgery Damage control surgery is minimally invasive surgical techniques, shorter operating time, simple-to-perform Damage control emphasizes the stabilization and control of hemorrhagic shock and hemostatic resuscitation as soon as possible; often with use of spanning external fixation, rather than immediate fracture repair In a study by Pape HC et al (2002) on polytraumatized patients (ISS ≥ 18) with femoral shaft fracture, the authors reported a significantly lower complication rate of multiple organ failure (MOF) following damage control orthopedic surgery compared to early total care 1.2.3 Secondary surgery Secondary surgery for major fracture is to stabilize fractured bones The optimal timing of surgical stabilization of fractures is a determinant to the outcomes of treatment and rehabilitation There is an accumulating body of evidence to suggest that one of the key determinants of surgical indication and timing of surgical stabilization of fractures is injury severity 1.3 Inflammatory response in polytrauma 1.3.1 Plasma level of interleukin-6 (IL-6) and interleukin-10 IL10 in polytrauma Interleukin-6 (IL-6): is an important pro-inflammatory cytokine Interleukin-6 release from peripheral blood serves as an early marker of injury severity following major trauma Conventionally, there is an elevated IL-6 level immediately after trauma, surgery and can be detected after as early as 70 minutes after injury IL-6 showed a sharp rise to peak within the first 24 hours, then fell rapidly to the baseline levels The presence and persistence of IL-6 in peripheral blood up to 10 days post trauma allows an assessment on the extent of inflammatory response Elevated IL-6 levels can predict MOF-related mortality Human interleukin-10 (IL-10) is a potent antiinflammatory cytokine that canprevent immunopathology during inflammatory responses IL-10 has protective effects under inflammatory conditions Excessive production of IL-10 increases the susceptibility of infection and is prone to developing severe sepsis IL-10 plasma levels reflects severity of injury and are elevated in patients with sepsis, MOF or acute respiratory distress syndrome and mortality IL-10 occurs early within 60 minutes following injury Dekker et al’s study demonstrated that elevated IL10 was correlated with incidence of sepsis and MOF Association of IL-6, IL-10 with the injury severity Numerous studies reveal an early increase of IL6 immediately after trauma This response initially corresponds to the first-hit phenomenon Subsequently, the second hit impact following surgical procedure results in a higher response of plasma IL-6 level According to a report by Svoboda (1994), plasma IL-6 level upon admission was significantly correlated with injury severity as assessed by ISS value An early increase in IL-6 was associated with MOF IL-10 plasma concentrations on day post-trauma and postoperation were equally and significantly elevated (Tschoeke et al, 2007) Role of IL-6, IL-10 and their prognostic value A higher plasma level of IL-6 has been shown to have a high predictive value for the mortality among polytraumatized patients, especially within the first 24 hours post-trauma By contrast, prognostic value of IL-10 concentrations was lower This corresponds to the findings reported by Gebhard F et al (2000), in which 19% of 94 patients died and elevated IL-6 was found among the deaths at 4, 6, 12 hours following injury Lausevic Z et al revealed high level of IL-6 were raised in patients with MOF and were elevated early post-trauma Pape H-C noted that in patients with the most severe injuries, IL-6 plasma levels remained elevated at post-operative day and was strongly associated with MOF Role of IL-6, IL-10 and surgical timing Inflammatory response has been reported to be higher in patients undertaking secondary surgery at days 2-4 than those operated at days - (study by Pape H-C et al) Additionally, the finding revealed the high likelihood of MOF in patients with elevated IL-6 at admission undergoing secondary surgery Stahel P.F et al (2005) suggested that progress of systemic inflammatory response and immune response was the crucial factor for the time of second surgery Starting from 24 hours after trauma, based on systemic inflammatory and immune response, polytrauma can be divided into four stages: phase of increased systemic inflammatory response (days - 4), window period (days - 10), immunodeficiency period (3rd week) and recovery period (after weeks) The author stated that the second surgery should be performed at the window period and the recovery period after trauma In contrast, if surgery performs during the period of increased systemic inflammation and immunodeficiency stage, postoperative complication rate will be so high 1.4 International and domestic researches on IL-6, IL-10 among traumatized patients 1.4.1 International researches Patients with minor injury had elevated concentrations as well but to a far lesser extent Bogener V (2009) found that patients with severe injuries had higher IL-6, IL-8 and IL-10 plasma levels By contrast, those with minor injury had less elevated concentrations Furthermore, excessively elevated IL-10 was strongly associated with major trauma (ISS>35) Svoboda P et al noted that increased IL-6 level following trauma was correlated with MOD and there was a close correlation between higher IL-6 and ISS value (r = 0.73) In a study by Gouel-Cheron A et al in 100 patients of whom 37% developed sepsis, IL-10 was found to be increased in the death group and did not correlate with prognosis Casey LC et al (1993) reported that concentrations of plasma IL-6 and IL-10 were used as marker to predict systemic inflammation response syndrome (SIRS), sepsis and multi-organ dysfunction syndrome (MODS) 1.4.2 Domestic researches In Vietnam, there have been a limited number of investigations on posttraumatic cytokine alterations and their role of in the setting of polytrauma Nguyen Viet Quang’s study revealed a higher IL-6 concentration in the deaths than in the survivors and IL-6 was positively correlated with age but negatively with Glassgow scale Nguyen Truong Giang’s study (2018) found an early increase in IL-6 and IL-10 immediately after trauma; IL-6 and IL-6/IL-10 ratio were positively correlated with the injury severity as assessed by ISS, RTS values and can predict the mortality, MODFand sepsis in traumatized patients In a study by Nguyen Luong Bang et al, the highest IL-6 plasma levels were found in the first day after surgery and fell gradually over time IL-6 levels on the first postoperative day closely correlate positively with the Injury Severity Score (ISS) CHAPTER 2: SUBJECTS AND METHODS OF RESEARCH 2.1 Subjects of the study In the present study, 59 polytrauma patients with major fracture were enrolled These patients were performed emergency surgery and treated at Military Hospital 103 in the period study from July, 2015 to January, 2018 2.1.1 Selection criteria - Patients were diagnosed with multiple trauma according to definition of polytrauma by Patel A (1971) and Trentz O (2000) - Patient underwent emergency surgery at Military Hospital 103 within the first hours since injury and received no treatment at tertiary center prior to hospital admission - Multiple trauma patients were accompanied with major fracture The major bones include pelvis, femur, tibia and humerus Patients underwent fracture fixation at Military Hospital 103 during their hospital stay 2.1.2 Exclusion criteria - Patients died prior to surgery - Patients were definitively treated at other hospital before transfer - Patients were was intubated, had tracheotomy - Patients were sent to other hospital prior to undertaking external fixation or were eligible for discharge - Patients had insufficient sample-based data 2.2 Research methods 2.2.1 Study design: This is a prospective, descriptive clinial study with longitudinal follow-up 2.2.2 Sampling size Convenient sample included 59 patients who fulfiled inclusion criteria 2.2.3 Procedures Buil up medical record for patient registries and collect variables based on sampling health record 2.2.3.1 Patient-related variables - Age, gender, causes of trauma, injury mechanism: (Baker SP et al, 1974) - Incidence of the number of injured regions - Incidence of deaths and survivors caculated from the number of injured regions - Mechanism of combined injuries, rate of major fracture - Mortality rate, traumatic shock and acute respiratroy distress - Mortality rate, traumatic shock and acute respiratroy distress according to injury mechanism - Time from trauma to hospital admission - Survival and death rate 2.2.3.2 Organ function assessment in multiple trauma patients - Timing of assement: During treatment - Organ for assessement: Ciculation, Perception 2.2.3.3 Assessment of trauma severity by scoring system RTS, AIS and ISS - Timing of assessment: Hospital admission - Trauma severity scoring system + Revised Trauma Score (RTS) by Champion HR et al (1989) + Abbreviated Injury Scale (AIS): in 1990 and 1998 version AIS 90 and AIS - 98) created by American Association for Automotive Medicine + Injury Severity Score (ISS) by Baker SP et al (1974) - Changes in plasma of IL-6, IL-10 levels and their association with injury severity + Investigation of changes in plasma of IL-6, IL-10 levels, IL6/IL-10 ratios at time points + IL-6, IL-10 levels and IL6/IL-10 ratios in the group of death and survivors + Predictive value of IL-6, IL-10 levels and IL6/IL-10 ratios for death + Alterations of plasma of IL-6, IL-10 levels and IL6/IL-10 ratios at time points of study related to scoring systems assessed by RTS, AIS, ISS 2.2.3.4 Association of changes in IL-6 and IL-10 levels with surgical timing of fracture fixation - Timing of external fixation: From day to day after trauma and day onward after trauma - Indications for osteosynthesis: Based on the patient’s health condition (Trentz O., 2000) - Fracture fixation devices: External fixation frames, intramedullary nails, screw-plate fixation 10 - Complications following fracture fixation: Pneumonia, sepsis, MOF, surgical site infection - Surgical results: - The number of survivors and deaths - Association as well as prognostic value of IL-6, IL-10 levels pre-and-post operation with surgical complication - Association between surgical timing and complications - Comparison between IL-6, IL-10 post surgery and timing of fracture fixation 2.2.3.5 Process of treatment Compliance with the process of diagnosis and treatment of Military Hospital 103 - Intensive care - Polytrauma management by Stahel P.F (2005): - External fixation as a second-procedure 2.2.3.6 Quantification of serum IL-6, IL-10 levels Timing of blood collection of determination for serum IL-6, IL-10 levels: T0: Blood samples were collected in the first hours after trauma; T1: 12 hours after trauma; T2: 24 hours after trauma, T3: 48 hours after trauma, T4: 72 hours after trauma, T5: immediately prior to external fixation osteosynthesis; T6: 24 hours after fracture fixation - Location for biochemical test: The Center of Medical Pharmaceutical Research, Vietnam Military Medical University – Quantification methods: IL-6, IL-10 concentration were determined by kit of AviBion - Orgenium company, Finland and ELISA 2.3 Time and location for study: + Study period: From July, 2015 to January, 2018 + Location: Military Hospital 103, The Center of Medical Pharmaceutical Research, Vietnam Military Medical University 14 Table 3.3: IL-6/ IL-10 ratios at all time-points of study IL-6/IL-10 Time-points Lowest Highest Median Total (n) p T0 T1 T2 T3 T4 T5 T6 0,03 0,09 0,07 0,07 0,04 0,04 0,13 2,26 6,48 1,99 1,82 2,11 1,88 1,82 0,58 ± 0,49 0,77 ± 0,92 0,52 ± 0,46 0,52 ± 0,44 0,44 ± 0,47 0,41 ± 0,41 0,48 ± 0,35 59 59 59 56 53 59 55 0,002 0,000 0,000 0,000 0,000 0,000 The ratio of IL-6 to IL-10 was highest at T1, equivalent to early peak of IL-6 3.3 The severity of injury 3.3.1 Clinical assessment of injury severity - Mortality rate, traumatic shock and acute respiratory distress Acute respiratory distress occurred in 61%; traumatic shock in 50.8% and mortality in 25.4% - Mortality rate, traumatic shock and acute respiratory distress according to injury mechanism: There was a high rate of traumatic shock, occurring in patients with pelvic and femoral fractures Mortality and traumatic shock among abdominal trauma patients were found to have the highest rate (40% and 85.0%, respectively) The incidence of acute respiratory distress was the highest in chest trauma patients (88.9%) 3.3.2 Assessment of injury severity by AIS scoring systems The mean AIS was 3.69 ± 0.701; AIS3: 44.1%, AIS4: 42.4%, AIS5:13.5% Table 3.4: Association between AIS and fracture sites (n=59) Fracture Non-fracture Features p Fracture sites n ± SD n ± SD Pelvic 16 3.81 ± 0.750 43 3.65 ± 0.686 0.47 15 Femoral 42 3.57 ± 0.668 17 4.0 ± 0.707 Tibial 13 3.62 ± 0.650 46 3.72 ± 0.720 Distal radius 3.78 ± 0.667 50 3.68 ± 0.713 0.03 0.67 0.70 3.3.3 Assessment of injury severity by RTS scoring system The mean RTS was 8.24 ± 1.92, the lowest score was and the highest was 12 RTS score from 8-10 was seen in 49.1% Table 3.5: Injury severity by RTS score (n=59) Survival RTS score Mortality n = 44 Rate (%) n = 15 Rate (%) Moderate or minor (>10) (1) 85.71 14.29 Serious (8-10) (2) 27 93.1 6.9 Severe (≤ 7) (3) 11 47.83 12 52.17 p p2-3 = 0.01 p3-2 = 0.01 Table 3.6: RTS score in the survival and death group Group RTS score Mean Mortality (n=15) Survival n=44 p 6.80 ± 1.521 8.73 ± 1.796 0.000 Mean RTS score was lower in the death than in the survival group (p 40) (3) 46.7 53.3 15 100 (p2-3= 0.009) Table 3.8: Mean ISS score in the survival and death group Groups ISS score ISS score (points) Mortality n=15 Survival n=44 p 38.80 ± 11.85 29.70 ±11.14 0.009 3.4 Association between changes in IL-6, IL-10 concentration and the injury severity 3.4.1 Concentration of IL-6 and IL-10 and ratio of IL-6/IL-10 in the mortality group Table 3.9: Concentration of IL-6 in the survival and death group Death Group Time points n T0 T1 T2 T3 T4 T5 T6 15 15 15 12 15 11 ± SD 136,81 ±53,00 155,38 ±48,22 136,20 ±49,15 138,21 ±48,41 120,66 ± 71,25 128,44 ± 79,33 191,43 ± 83,94 Survival n 44 44 44 44 44 44 44 ± SD Total (n) p 45,60 ± 41,24 75,63 ± 64,38 60,71 ± 55,38 53,81 ± 51,61 59,56 ± 48,93 55,75 ± 45,10 95,79 ± 57,37 59 59 59 56 53 59 55 0,000 0,000 0,000 0,000 0,000 0,000 0,000 Table 3.10: Concentration of IL-10 in the survival and death group Group Time points T0 T1 T2 T3 n 15 15 15 12 Death ± SD 149,20 ± 83,44 175,33 ± 81,20 192,81 ± 99,02 199,46 ± 93,81 n 44 44 44 44 Survival ± SD 120,79 ± 69,88 140,28 ± 79,75 175,75 ± 126,95 159,87 ± 96,16 Total (n) 59 59 59 56 p 0,201 0,149 0,638 0,171 17 T4 T5 T6 15 11 240,20 ± 132,51 44 243,69 ± 87,62 44 315,39 ± 99,56 44 207,47 ± 132,61 190,70 ± 97,23 246,64 ± 120,96 53 59 55 0,412 0,067 0,052 Table 3.11: Ratio of IL-6/IL10 in the survival and death group Groups Time points T0 T1 T2 T3 T4 T5 T6 n 15 15 15 12 15 11 Death ± SD 1.07 ± 0.46 1.04 ± 0.44 0.88 ± 0.50 0.85 ± 0.47 0.66 ± 0.57 0.66 ± 0.57 0.71 ± 0.50 Survival ± SD 0.41 ± 0.38 0.68 ± 1.02 0.40 ± 0.38 0.40 ± 0.37 0.36 ± 0.41 0.32 ± 0.30 0.40 ± 0.24 n 44 44 44 44 44 44 44 Total (n) 59 59 59 56 53 59 55 p 0.000 0.200 0.000 0.000 0.03 0.05 0.003 There was a disparity between ratios of IL-6/IL-10 and two groups of death and survivors at all timepoints but T1 (p < 0.05) Table 3.12: Prognostic value of IL-6, IL-10 and ratios of IL-6/IL10 at all time-points AUC Time points T0 T1 T2 T3 T4 T5 T6 IL-6 AUC p IL-10 AUC p IL-6/IL-10 AUC p 0,920 0,836 0,848 0,894 0,772 0.818 0.848 0,607 0,628 0,588 0,609 0,579 0,648 0,694 0,903 0,798 0,839 0,826 0,752 0,736 0,729 0,000 0,000 0,000 0,000 0,002 0,000 0,000 0,220 0,141 0,313 0,210 0,365 0,088 0,026 Total (n) 0,000 0,001 0,000 0,000 0,004 0,007 0,009 59 59 59 56 53 59 55 3.4.2 Association of IL-6, IL-10, IL-6/IL-10 ratios with RTS and ISS Table 3.132: Correlation coefficiency between IL-6 and RTS, ISS Time points T0 T1 T2 T3 RTS score -0,378 -0,412 -0,338 -0,386 p 0,003 0,001 0,009 0,003 ISS score 0,171 0,087 0,161 0,245 p 0,195 0,511 0,223 0,062 Total(n) 59 59 59 56 18 T4 T5 T6 -0,272 -0,268 -0,331 0,037 0,040 0,011 0,203 0,338 0,277 0,123 0,009 0,033 53 59 55 IL-6 was negatively correlated with RTS score (p 0.8, p < 0.05) - IL-10 level pre-operation and post-operative day may exhibit prognostic significance of MOD (area under ROC curve > 0.7, p < 0.05) - There is a higher rate of early complication in patients undergoing fracture fixation on days 2-4 than those operated on day onward, with a statistically significant difference (p