Chapter 21
Posttraumatic Acute Renal Insufficiency
William J. Stone, M.D., and James H. Knepshield, M.D.
The single largest category of patients with ARI (acute renal insufficiency) seen in the 629th Medical Detachment (Renal) developed this complication following trauma. Posttraumatic ARI usually followed wounding in battle but occasionally was seen in nonbattle injury. This report reviews the clinical courses of 62 consecutive patients with posttraumatic ARI referred to the renal unit between August 1967 and February 1969.
Posttraumatic ARI was first recognized in World War II, first treated with hemodialysis in the Korean war, and probably first prevented on a large scale in the Vietnam conflict by appropriate physician education. In Vietnam, rapid evacuation by helicopter brought casualties with unusually severe injuries to well-equipped facilities within 30 minutes of wounding. Immediate resuscitation by physicians and nurses, with large volumes of plasma expanders and universal donor blood, resulted in the survival of many patients with extensive trauma for varying periods. Undoubtedly ARI was prevented frequently by this rapid resuscitation and the ready availability of sophisticated surgical facilities. A rough estimate is that ARI occurred in only 1 in 600 seriously wounded battle casualties in Vietnam as opposed to 1 in 200 in Korea (Whelton and Donadio 1969). The mortality of posttraumatic ARI has changed very little in the last 30 years despite improvement in methods of treating renal failure, shock, and infection; about two of three patients still die (Whelton and Donadio 1969, pp. 100-101; Teschan et al. 1955; Smith et al. 1955; Lordon and Burton 1972). A consideration of possible reasons and solutions for this perplexing situation was attempted.
MATERIALS AND METHODS
Cases of posttraumatic ARI between 1968 and 1969 were reviewed in detail, and the records of patients treated by the 629th Medical Detachment in 1967 and 1968 were extensively abstracted. Most patients were referred from outlying U.S. military hospitals, although a few cases developed in the 3d Field Hospital (site of the renal unit) and in Saigon community hospitals.
A total of 62 patients with posttraumatic ARI were studied. An additional
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This chapter is a revised version ofthe following article by the authors (1974): Post-traumatic acute renal insufficiency in Vietnam. Clin, Nephrol 2:186-90.
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17 patients were excluded because they presented in irreversible shock.The average age of both fatalities and survivors was 25.7 years, with a range of 10 to 75years. All but one of the patientswere male. Table 93 summarizes the patients by race and civilian ormilitary status. Eight (13percent) were civilian while 54 (87 percent) were in the military. U.S.servicemen made up thelargest group (79 percent).
Patients were admitted to a 6-bed (later expanded to an 11-bed) intensive care area separated by partitions from an adjacent medical ward. Nurses and medical corpsmen trained in hemodialysis and peritoneal dialysis worked a 12-hour shift, 7 days a week. Two internist-nephrologists made up the medical staff. Consultant urologists and surgeons provided additional care to nearly every patient.
All hemodialyses were performed in the same intensive care area using a Travenol Standard twin-coil artificial kidney and a 100-liter tub dialysate delivery system (fig. 88). Dialysate was changed every 2 hours. Patients usually underwent dialysis every other day for 6 hours using regional heparinization. Extremely catabolic patients received dialysis more frequently. External Quinton-Scribner shunts were uniformly employed for vascular access. Peritoneal dialyses were performed at the patient`s bedside. Respiratory assistance was provided with volume-controlled ventilators (Emerson) humidified at room temperature.
The following parameters were determined serially by standard laboratory techniques: (1) blood: urea nitrogen, creatinine, sodium, potassium, chloride, bicarbonate, calcium, phosphorus, osmolality, arterial p02, arterial pC02, arterial pH, hematocrit, white blood cell count, differential, platelet count, and prothrombin time; (2) urine: urea nitrogen, creatinine, sodium, potassium, and osmolality. Cultures of blood, urine, wounds, and other body fluids were performed at frequent intervals when deemed necessary.
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ARI was defined as a sudden progressive rise in the BUN (blood urea nitrogen) and serum creatinine following an inciting event without evidence of other causes of renal failure such as lower urinary tract obstruction. Oliguria meant a urine volume of less than 500 ml per day. A high output state was defined as a urine volume of greater than 500 ml per day in the presence of renal failure.
Multiple fragment wounds were defined as wounds resulting from the explosion of rockets, grenades, boobytraps, mines, and mortar shells; more than one fragment usually penetrated the body, resulting in injury to many organs. Blunt trauma was defined as trauma resulting from falls or vehicular accidents without penetration of the skin. Blast injury followed an explosion when no fragments penetrated the body.
RESULTS
Table 94 summarizes the types of trauma which initiated ARI. Of the two types of injury studied in significant numbers, gunshot wound causing ARI carried a better prognosis (11 of 27 survived); 22 of 26 patients with ARI following multiple fragment wounds died. This was a statistically significant difference (p < 0.05). The overall mortality from posttraumatic ARI was 69 percent.
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Table 95 lists the organs injured. The two postoperative patients are omitted. Differences in survival depended on the areas wounded. For instance, 17% of patients who died had pancreatic injuries, while none of those who survived did (p< 0.05). There was also a significant difference between percentage of fatalities and of survivors with injuries of the small bowel (43/6), and the large bowel (45/17).
Table 96 contrasts causes of posttraumatic ARI in fatalities and survivors. Hemorrhagic shock was by far the leading antecedent event (66 percent). In 90 percent of these cases, ARI occurred within the first post wounding day. Transfusion of massive amounts of uncrossmatched blood was frequently required in the initial resuscitation (90 percent of patients received more than 5,000 ml of blood). The average amount received by those with hemorrhagic shock was 14,000 ml (fig. 89). Transfusion reactions were common and were believed to have led directly to ARI in 13 percent of cases. ABO (blood group) incompatibility was documented in one-third of these. Nephrotoxic antibiotics (kanamycin sulfate and/or sodium colistimethate) caused ARI in another 13 percent, but the use of these potent drugs was required to treat life-threatening infections. Usually excessive dosage was implicated.
Of the patients who died, a total of 33 were managed with hemodialysis (3.3 dialyses per patient), 3 underwent peritoneal dialysis (1 per patient), and 7 were treated conservatively. Of the survivors, 9 received hemodialysis (4 per patient), 3 underwent peritoneal dialysis, and 7 were treated conservatively with diet and fluid restriction alone.
Complications signifying a poor prognosis were: coagulation defects resulting in a bleeding diathesis, respiratory insufficiency with persistent hypoxemia, significant upper gastrointestinal hemorrhage, jaundice, and a clinical picture of septicemia. Only 19 of 38 patients with clinical septicemia (high spiking fever, shaking chills, hypotension, and cutaneous flushing) had positive blood cultures. All organisms were gram-negative rods. Fourteen patients had only one organism cultured from their blood, while five had two. Pseudomonas aeruginosa predominated, with Klebsiella-Aerobacter species next in incidence. Debilitation and weight loss were also frequently encountered. Acute psychoses were an infrequent but difficult problem to manage.
Causes of death were: septic shock in 28 (65 percent); respiratory insufficiency in 10 (23 percent); uncontrollable bleeding in 3 (7 percent); head injury in 1 (2 percent); and hyperkalemia in 1 (2 percent).
Table 97 shows days survived from injury, days spent in the renal unit until death or evacuation, days of oliguria, and percentages of patients with oliguria or a high output state among both survivors and fatalities. Oliguria occurred equally in both groups. Survivors were not evacuated until their clinical condition had stabilized and dialysis was no longer necessary.
DISCUSSION
The critically ill combat casualty was resuscitated almost immediately and then rapidly transported by helicopter to sophisticated treatment facilities. The
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incidence of ARI in these severely wounded individuals has progressively fallen (Whelton and Donadio 1969, pp. 98-99). However, an inordinately high mortality persists in those who do develop ARI. The mortality of 69 percent in these 62 patients is in agreement with the other studies cited (Whelton and Donadio 1969; Teschan et al. 1955; Smith etal. 1955; Lordon and Burton 1972).
Multiple fragment wounds were more perilous than gunshot wounds. Involvement of large bowel, small bowel, or pancreas signified an even more dismal prognosis. The patients received adequate dialysis; they did not die of the complications of renal failure but succumbed to progressive sepsis and shock. A
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TABLE 97.- Selected statistics, 629th Medical Detachment (Renal), August 1967-February 1969
common sequence of fatal events evolved. Following 24 to 48 hours of septic shock refractory to antibiotics, fluid therapy, and pressor drugs, the patient died in one of three ways: pulmonary hemorrhagic consolidation and hypoxemia, a bleeding diathesis probably due to DIC (disseminated intravascular coagulation), or progressive and irreversible shock. Often all three were present. Stress ulcers of the upper gastrointestinal tract were the usual site of uncontrollable bleeding. Depressed platelet counts and prolonged prothrombin times were almost always seen in the patient with bleeding disorders. More sophisticated tests for DIC were unavailable. Respiratory failure did not respond to volume controlled ventilation, frequent suctioning, oxygen administration, or fluid removal by hemodialysis ultrafiltration.
The clinical picture of gram-negative septicemia preceded the above events. It was seen in 79 percent of deaths but in only 26 percent of survivors. An average of 2.4 major surgical procedures were performed on each patient. The following were implicated in contributing to fatal gram-negative septicemia in some: inadequate initial drainage of contaminated areas, particularly in the abdomen; placement of colostomies in or near incisions or drains; failure to reexplore when intra-abdominal infection was suspected on clinical grounds; use of surgical packs for extended periods; prolonged and inappropriate use of urethral catheters and plastic venous cannulas; withholding or inadequate use of antibiotics because of their potential nephrotoxicity; and poor wound healing possibly related to protein-calorie malnutrition.
Once posttraumatic ARI became associated with respiratory failure and
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prolonged uncontrolled hypotension caused by septicemia, very little could be done to reverse the relentless downhill course of the patient. Meticulous patient care and frequent physical examinations by physicians can address the first five contributing factors listed above. Further attention to administration of aminoglycoside antibiotics at more frequent intervals and in doses appropriate to the level of renal function may be critical in preventing nephrotoxic ARI (Chan, Benner, and Hoeprich 1972).
REFERENCES
Chan, R. A.; Benner, E. J.; and Hoeprich, P.D. 1972. Gentamicin therapy in renal failure: Anomo gram for dosage. Ann. Int. Med 76: 773-78.
Lordon, R. E., and Burton, J. R. 1972.Post-traumatic renal failure in military personnel in Southeast Asia. Am. J. Med 53:137-47.
Smith, L. H., Jr.; Post, R. S.;Teschan, P.E.; Abernathy, R. S.; Davis, J. H.; Gray, D. M.; Howard, J. M.; Johnson, K. E.; Klopp, E.; Mundy, R. L. O`Meara, M. P.; and Rush, B. F., Jr.1955. Posttraumatic renal insufficiency in military casualties. II. Management, use of an artificial kidney, prognosis. Am. J. Med 18:187-98.
Stone, W. H., and Knepshield, J. H.1974.Post-traumatic acute renal insufficiency in Vietnam. Clin. NephroL 2:186-90.
Teschan, P. E.; Post, R. S.; Smith, L.H., Jr.; Abernathy, R. S.; Davis, J. H.; Gray, D. M.; Howard, J. M.; Johnson, K. E.; Klopp, E.; Mundy, R. L.; O`Meara, M. P.; and Rush, B. F., Jr.1955. Posttraumatic renal insufficiency in military casualties. I. Clinical characteristics. Am. J.Med 18: 172-86.
Whelton, A., and Donadio, J. V., Jr.1969.Post-traumatic acute renal failure in Vietnam. A comparison with the Korean war experience Johns Hopkins M.J. 124:95-105.
