Severe trauma requires the presence of anesthesiologists and other anesthesia personnel, wherein damage control resuscitation (DCR) is the primary focus. In this issue, Livingston and colleagues1 went beyond that and, by retrospective analysis of a large trauma study, examined the effect of no or three different volatile anesthetic agents on several short-term outcomes. Not surprisingly, those patients who were more severely injured and subsequently had a higher mortality received no volatile anesthetic. Patients who were treated with desflurane were less severely injured and had less systemic inflammatory response syndrome (SIRS), although these two factors were unrelated to each other. Since the choice of anesthesia was left to the treating anesthesiologist in this cohort, both refraining from the use of volatile agents and the choice of desflurane may have occurred because of the degree of injury and hemodynamic stability. However, the treating anesthesiologist would not have had any way to predict SIRS. Therefore, the finding that desflurane was associated with less SIRS may indicate that a pharmacological agent could influence trauma outcome beyond the short term. SIRS is known to have long-term effects. 2 Already, there are antiinflammatory monoclonal antibodies in clinical evaluation.3,4 If desflurane or similarly effective small-molecule pharmaceuticals, used at the initial trauma surgery, could limit SIRS, one would hope it would also mitigate long-term outcomes.
Trauma in the US is the leading cause of death of people under the age of 45. The median patient age in this study was about 34 years and about 85% of them were male, documenting once again that trauma in the US affects predominantly those in their prime of potential productivity. The loss of productive years of lives is immense and a blow to the American economy. While the treatment cost of blunt trauma is usually covered by some sort of insurance (motor vehicle, workers comp, health insurance, liability, etc.), penetrating trauma care may present a larger uncompensated burden to the physician and facility. This financial challenge may discourage physician participation in trauma care unless there is cost shifting, which may be feasible only in large health care organizations. Additionally, commercial and federal support for research in trauma, and especially for anesthesia in acute trauma care, is limited.5 Livingston and colleagues’1 exploration in this area is encouraging. Trauma in young people damages not only their personal future but also the American economy. It is therefore of interest to evaluate the effect of anesthesia and perioperative pain management on their reintegration into productive life. I recommend that in future studies the authors make an attempt to measure long-term care costs and return to work. Evidence of desirable outcomes could motivate grant givers to provide financing of trauma anesthesia studies.
—H. A. Tillmann Hein, MD
Metropolitan Anesthesia Consultants, LLP
Dallas, Texas
E-mail: thein@metroanesthesia.com
Disclosure statement/Funding
No funding or potential conflict of interest was reported by the authors.
References
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