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July 22, 1988, Vol 260, No. 4 >
ARTICLE | July 22, 1988

Posttraumatic Multisystem Organ Failure FREE

Malcolm M. DeCamp, MD; Robert H. Demling, MD
[+] Author Affiliations

Reprint requests to Longwood Area Trauma Center, 75 Francis St, Boston, MA 02115 (Dr Demling).


JAMA. 1988;260(4):530-534. doi:10.1001/jama.1988.03410040102037
Text Size: A A A
Published online
Article
References

THE SYNDROME of multisystem organ failure (MSOF) currently affects a wide variety of critically ill or injured patients. The mortality rate is well in excess of 60%. Its natural course requires long stays in the intensive care unit and consumes excessive monetary, physician, and hospital resources. The emergence of MSOF is directly related to improvements in organ system support and monitoring, which have made it possible to sustain previously lethal critical illness. The syndrome is characterized by a hyperdynamic, hypermetabolic state identical to that seen in sepsis. The term sepsis syndrome also is used to reflect the fact that infection, although frequently present, is not essential for initiating or perpetuating progressive organ failure. A systemic inflammatory response modulated by a cascade of soluble protein and lipid mediators seems to be the final common pathway linking the sepsis syndrome with MSOF. Herein, we review the origin and presentation of MSOF and

REFERENCES

1 +
American College of Surgeons: Early Care of the Injured Patient . Philadelphia, WB Saunders Co, 1982;.
2 +
Jenkins M, Jones R, Wilson B, et al:  Congestive atelectasis: Complications of intravenous infusion of fluid . Ann Surg 1950;;132:327-332.
3 +
Baue AE, Chaudry IH:  Prevention of multiple system failure . Surg Clin North Am 1980;;60:1167-1178.
4 +
Goris R, Te Boekhorst T, Nuytinck J, et al:  Multiple-organ failure: Generalized autodestructive inflammation . Arch Surg 1985;;120:1109-1115.
5 +
Blaisdell R, Lim R, Stallone R:  The mechanism of pulmonary damage following traumatic shock . Surg Gynecol Obstet 1970;;130:15-22.
6 +
Petty T, Ashbaugh D:  The adult respiratory distress syndrome . Chest 1971;;60:233-238.
7 +
Rinaldo J, Rogers R:  Adult respiratory distress syndrome: Changing concepts of lung injury and repair . N Engl J Med 1982;;306:900-909.
8 +
Demling RH:  The pathogenesis of respiratory failure after trauma and sepsis . Surg Clin North Am 1981;;60:1372-1390.
9 +
Polk HC, Shields CL:  Remote organ failure: A valid sign of occult intra-abdominal infection . Surgery 1977;;81:310-313.
10 +
Blair E, Cowley R, Wise A, et al:  Clinical physiology of late gram negative bacteremic shock . Am J Surg 1969;;117:673-679.
11 +
Ferraris VA:  Exploratory laparotomy for potential abdominal sepsis in patients with multiple-organ failure . Arch Surg 1983;;118:1130-1133.
12 +
Filkins JP:  Monokines and the metabolic pathophysiology of septic shock . Fed Proc 1985;; 44:300-304.
13 +
Clowes GHA, O'Donnell T, Ryan N, et al:  Energy metabolism in sepsis: Treatment based upon different patterns in shock and high output state . Ann Surg 1974;;180:684-695.
14 +
Wilmore D, Aulick L, Mason A:  Influence of the burn wound on local and systemic response to injury . Ann Surg 1977;;186:444-450.
15 +
Tilney NL, Bailey GL, Morgan AP:  Sequential system failure after rupture of abdominal aortic aneurysms: An unsolved problem in post operative care . Ann Surg 1973;;179:117-122.
16 +
Baue AE:  Multiple, progressive or sequential systems failure: A syndrome of the 1970s . Arch Surg 1975;;110:779-781.
17 +
Eiseman B, Beart R, Norton L:  Multiple organ failure . Surg Gynecol Obstet 1977;;144:323-326.
18 +
Border JR:  Trauma and sepsis , in Worth MH (ed): Principles and Practice of Trauma Care . Baltimore, Williams & Wilkins, 1982;, pp 330-388.
19 +
Meakins JL, Wicklund B, Forse RA, et al:  The surgical intensive care unit: Current concepts in infection . Surg Clin North Am 1980;;60:117-132.
20 +
Carrico CJ, Meakins JL, Marshall JC, et al:  Multiple organ failure syndrome . Arch Surg 1986;;121:196-208.
21 +
Cerra F:  Hypermetabolism, organ failure, and metabolic support . Surgery 1987;;101:1-14.
22 +
Montgomery A, Stager M, Carrico J, et al:  Causes of mortality in patients with the adult respiratory distress syndrome . Am Rev Respir Dis 1985;;132:485-489.
23 +
Wiles J, Cerra F:  The systemic septic response: Does the organism matter? Crit Care Med 1980;;8:55-60.
24 +
Watters JM, Bessey PQ, Dinarello CA, et al:  Both inflammatory and endocrine mediators stimulate host response to sepsis . Arch Surg 1986;;121:179-190.
25 +
Repine JE, Tate RM:  Oxygen radicals and lung edema . Physiologist 1983;;26:78-82.
26 +
Taylor AE, Martin DJ:  Oxygen radicals and the microcirculation . Physiologist 1983;;26:152-155.
27 +
Jin L-J, LaLonde C, Demling RH:  Lung dysfunction after thermal injury in relation to prostanoid and oxygen radical release . J Appl Physiol 1986;;61:103-112.
28 +
Chang SW, Feddersm CO, Henson PM, et al:  Platelet-activating factor mediates hemodynamic changes and lung injury in endotoxin treated rats . J Clin Invest 1987;;79:1498-1509.
29 +
Reines HD, Halushka PV, Cook JA, et al:  Lack of effect of glucocorticoids upon plasma thromboxane in patients in a state of shock . Surg Gynecol Obstet 1985;;160:320-322.
30 +
Demling RH:  Role of prostaglandins in acute pulmonary microvascular injury . Ann NY Acad Sci 1982;;384:517-534.
31 +
NinnemannJL, Stockland AE:  Participation of prostaglandin E in immunosuppression following thermal injury . J Trauma 1984;;24:201-207.
32 +
Dinarello C, Mier J:  Lymphokines: Current concepts . N Engl J Med 1987;;317:940-945.
33 +
Clowes G, George B, Villar C:  Muscle proteolysis induced by a circulating peptide in patients with sepsis or trauma . N Engl J Med 1983;;308:545-552.
34 +
Beutler B, Cerami A:  Cachectin: More than a tumor necrosis factor . N Engl J Med 1987;;316:379-386.
35 +
Tracey KJ, Lowry SF, Bentler B, et al:  Cachectin/tumor necrosis factor participates in reduction of skeletal muscle plasma membrane potential: Evidence of bioactivity in plasma during critical illness . Surg Forum 1986;;37:13-15.
36 +
Ognibene FP, Rosenberg SA, Skibber J, et al:  Interleukin-2 hemodynamics mimic septic shock , abstracted. Clin Res 1986;;34:413A.
37 +
Christou NV, Mannick JA, West MA, et al:  Lymphocyte-macrophage interactions in the response to surgical infections . Arch Surg 1987;; 122:239-250.
38 +
Kariman K, Burns S:  Regulation of tissue oxygen extraction is disturbed in adult respiratory distress syndrome . Am Rev Respir Dis 1985;; 132:109-114.
39 +
Richardson JD, DeCamp MM, Garrison RN, et al:  Pulmonary infection complicating intra-abdominal sepsis: Clinical and experimental observations . Ann Surg 1982;;195:732-738.
40 +
Cerra F, Eyer S:  Acute lung injury and MSOF in post traumatic patients . Crit Care Med , in press.
41 +
Cerra F, Siegel J, Border J:  The hepatic failure of sepsis: Cellular versus substrate . Surgery 1979;;86:409-422.
42 +
Bell R, Coalson J, Smith J:  Multiple organ system failure and infection in adult respiratory distress syndrome . Ann Intern Med 1983;;99:293-298.
43 +
Jones AL:  The intestinal immune system . Gastroenterology 1984;;87:236.
44 +
Keller GA, West MA, Harty JJ, et al:  Modulation of hepatocyte protein synthesis during co-cultivation with macrophage-rich peritoneal cells in vivo . Arch Surg 1985;;120:180-186.
45 +
Cohler LF, Saba TM, Lewis E, et al:  Plasma fibronectin therapy and lung protein clearance with bacteremia after surgery . J Appl Physiol 1987;; 63:623-633.
46 +
Fry DE:  Multiple system organ failure . Surg Clin North Am 1988;;68:107-122.
47 +
Lucas CE:  The renal response to acute injury and sepsis . Surg Clin North Am 1976;;56:953-975.
48 +
Border JR, Hasset J, LaDuca J, et al:  The gut origin septic states in blunt multiple trauma (ISS = 40) in the ICU . Ann Surg 1987;;206:427-448.
49 +
Deitch E, Winterlon J, Li M, et al:  The gut as a portal of entry for bacteremia . Ann Surg 1987;; 205:681-692.
50 +
Parker MM, Shelhamer JH, Bacharach SL, et al:  Profound but reversible myocardial depression in patients with septic shock . Ann Intern Med 1984;;100:483-490.
51 +
Parrillo JE, Burch C, Shelhamer JH, et al:  A circulating myocardial depressant substance in humans with septic shock: Septic shock patients with a reduced ejection fraction have a circulating factor that depresses in vitro myocardial cell performance . J Clin Invest 1985;;76:1539-1553.
52 +
Madoff R, Sharpe S, Cerra F:  Prolonged surgical intensive care . Arch Surg 1985;;120:698-702.
53 +
Burke J, Quinby W, Bondoc C:  Primary excision and prompt grafting as routine therapy for the treatment of thermal burns in children . Surg Clin North Am 1976;;56:477-494.
54 +
Jansson I, Eriksson R, Liljedhal SO, et al:  Primary fracture immobilization as a method to prevent post-traumatic pulmonary changes . Acta Chir Scand 1982;;148:329-338.
55 +
Revhaug A, Michie H, Manson J, et al:  Inhibition of cyclo-oxygenase attenuates the metabolic response to endotoxin in humans . Arch Surg 1988;;123:162-170.
56 +
Olson NC, Grizzle MK, Anderson DL:  Effect of polyethylene glycol-superoxide dismutase and catalase on endotoxemia in pigs . J Appl Physiol 1987;;63:1526-1532.
57 +
Beutler B, Milsark JA, Cerami AC:  Passive immunization against cachectin/tumor necrosis factor prevents mice from lethal effect of endotoxin . Science 1985;;229:869-871.
58 +
Tracey KJ, Fong Y, Hesse DG, et al:  Anticachectin/TNF monoclonal antibodies prevent septic shock during lethal bacteremia . Nature 1987;;330:662-664.
59 +
Dunn DL, Ewald DC, Chandon N, et al:  Immunotherapy of gram-negative bacterial sepsis: A single murine monoclonal antibody provides cross-genera protection . Arch Surg 1986;;121:58-62.
60 +
Danner RL, Joiner KA, Parrillo JE:  Inhibition of endotoxin-induced priming of human neutrophils by lipid X and 3-Aza-lipid X . J Clin Invest 1987;;80:605-612.
61 +
Polk HC Jr:  The enhancement of host defenses against infection: Search for the Holy Grail? Surgery 1986;;99:1-6.
62 +
Cerra FB, Shronts EP, Konstantinides NN, et al:  Enteral feeding in sepsis: A prospective randomized, double-blind trial . Surgery 1985;; 98:632-639.
63 +
Stoutenbeck C, Van Saene H, Miranda D, et al:  The effect of selective decontamination of the digestive tract on colonization and infection rate in multiple trauma patients . Intensive Care Med 1984;;10:185-192.
64 +
Guiot H, van den Brock P, van der Meer J, et al:  Selective antimicrobial modulation of the intestinal flora of patients with acute nonlymphocytic leukemia: A double-blind placebo controlled study . J Infect Dis 1983;;147:615-623.
65 +
Fisher M, UpChurch KS, Levine PH, et al:  Effect of dietary fish oil supplementation of polymorphonuclear leukocyte inflammatory potential . Inflammation 1986;;10:387-392.
66 +
Chiarla C, Siegel J, Kidd S, et al:  Inhibition of post traumatic septic proteolysis and ureagenesis and stimulation of hepatic acute phase protein production by branched chain amino acid TPN . J Trauma , in press.
67 +
Taylor A, Hernandez L, Perry M, et al:  Overview of tissue oxygen utilization , in Bryan-Brown C, Ayres S (eds): Oxygen Transport and Utilization . Fullerton, Calif, Society of Critical Care Medicine, 1986;.
68 +
Bihari D, Sonithies M, Gimson A, et al:  The effects of vasodilation with prostacyclin on oxygen delivery and uptake in critically ill patients . N Engl J Med 1987;;317:397-403.
69 +
Waymack JP, Gallon L, Barcelli U, et al:  Effect of blood transfusions on immune function: III. Alterations in macrophage arachidonic acid metabolism . Arch Surg 1987;;122:56-60.
70 +
Mason J, Wilmore D:  Positive nitrogen balance with human growth hormone and hypocaloric intravenous feedings . Surgery 1986;;100:188-197.
71 +
Ward H, Holliday D, Sim J:  Protein and energy metabolism with biosynthetic growth hormone after gastrointestinal surgery . Ann Surg 1987;; 206:56-61.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
American College of Surgeons: Early Care of the Injured Patient . Philadelphia, WB Saunders Co, 1982;.
2 +
Jenkins M, Jones R, Wilson B, et al:  Congestive atelectasis: Complications of intravenous infusion of fluid . Ann Surg 1950;;132:327-332.
3 +
Baue AE, Chaudry IH:  Prevention of multiple system failure . Surg Clin North Am 1980;;60:1167-1178.
4 +
Goris R, Te Boekhorst T, Nuytinck J, et al:  Multiple-organ failure: Generalized autodestructive inflammation . Arch Surg 1985;;120:1109-1115.
5 +
Blaisdell R, Lim R, Stallone R:  The mechanism of pulmonary damage following traumatic shock . Surg Gynecol Obstet 1970;;130:15-22.
6 +
Petty T, Ashbaugh D:  The adult respiratory distress syndrome . Chest 1971;;60:233-238.
7 +
Rinaldo J, Rogers R:  Adult respiratory distress syndrome: Changing concepts of lung injury and repair . N Engl J Med 1982;;306:900-909.
8 +
Demling RH:  The pathogenesis of respiratory failure after trauma and sepsis . Surg Clin North Am 1981;;60:1372-1390.
9 +
Polk HC, Shields CL:  Remote organ failure: A valid sign of occult intra-abdominal infection . Surgery 1977;;81:310-313.
10 +
Blair E, Cowley R, Wise A, et al:  Clinical physiology of late gram negative bacteremic shock . Am J Surg 1969;;117:673-679.
11 +
Ferraris VA:  Exploratory laparotomy for potential abdominal sepsis in patients with multiple-organ failure . Arch Surg 1983;;118:1130-1133.
12 +
Filkins JP:  Monokines and the metabolic pathophysiology of septic shock . Fed Proc 1985;; 44:300-304.
13 +
Clowes GHA, O'Donnell T, Ryan N, et al:  Energy metabolism in sepsis: Treatment based upon different patterns in shock and high output state . Ann Surg 1974;;180:684-695.
14 +
Wilmore D, Aulick L, Mason A:  Influence of the burn wound on local and systemic response to injury . Ann Surg 1977;;186:444-450.
15 +
Tilney NL, Bailey GL, Morgan AP:  Sequential system failure after rupture of abdominal aortic aneurysms: An unsolved problem in post operative care . Ann Surg 1973;;179:117-122.
16 +
Baue AE:  Multiple, progressive or sequential systems failure: A syndrome of the 1970s . Arch Surg 1975;;110:779-781.
17 +
Eiseman B, Beart R, Norton L:  Multiple organ failure . Surg Gynecol Obstet 1977;;144:323-326.
18 +
Border JR:  Trauma and sepsis , in Worth MH (ed): Principles and Practice of Trauma Care . Baltimore, Williams & Wilkins, 1982;, pp 330-388.
19 +
Meakins JL, Wicklund B, Forse RA, et al:  The surgical intensive care unit: Current concepts in infection . Surg Clin North Am 1980;;60:117-132.
20 +
Carrico CJ, Meakins JL, Marshall JC, et al:  Multiple organ failure syndrome . Arch Surg 1986;;121:196-208.
21 +
Cerra F:  Hypermetabolism, organ failure, and metabolic support . Surgery 1987;;101:1-14.
22 +
Montgomery A, Stager M, Carrico J, et al:  Causes of mortality in patients with the adult respiratory distress syndrome . Am Rev Respir Dis 1985;;132:485-489.
23 +
Wiles J, Cerra F:  The systemic septic response: Does the organism matter? Crit Care Med 1980;;8:55-60.
24 +
Watters JM, Bessey PQ, Dinarello CA, et al:  Both inflammatory and endocrine mediators stimulate host response to sepsis . Arch Surg 1986;;121:179-190.
25 +
Repine JE, Tate RM:  Oxygen radicals and lung edema . Physiologist 1983;;26:78-82.
26 +
Taylor AE, Martin DJ:  Oxygen radicals and the microcirculation . Physiologist 1983;;26:152-155.
27 +
Jin L-J, LaLonde C, Demling RH:  Lung dysfunction after thermal injury in relation to prostanoid and oxygen radical release . J Appl Physiol 1986;;61:103-112.
28 +
Chang SW, Feddersm CO, Henson PM, et al:  Platelet-activating factor mediates hemodynamic changes and lung injury in endotoxin treated rats . J Clin Invest 1987;;79:1498-1509.
29 +
Reines HD, Halushka PV, Cook JA, et al:  Lack of effect of glucocorticoids upon plasma thromboxane in patients in a state of shock . Surg Gynecol Obstet 1985;;160:320-322.
30 +
Demling RH:  Role of prostaglandins in acute pulmonary microvascular injury . Ann NY Acad Sci 1982;;384:517-534.
31 +
NinnemannJL, Stockland AE:  Participation of prostaglandin E in immunosuppression following thermal injury . J Trauma 1984;;24:201-207.
32 +
Dinarello C, Mier J:  Lymphokines: Current concepts . N Engl J Med 1987;;317:940-945.
33 +
Clowes G, George B, Villar C:  Muscle proteolysis induced by a circulating peptide in patients with sepsis or trauma . N Engl J Med 1983;;308:545-552.
34 +
Beutler B, Cerami A:  Cachectin: More than a tumor necrosis factor . N Engl J Med 1987;;316:379-386.
35 +
Tracey KJ, Lowry SF, Bentler B, et al:  Cachectin/tumor necrosis factor participates in reduction of skeletal muscle plasma membrane potential: Evidence of bioactivity in plasma during critical illness . Surg Forum 1986;;37:13-15.
36 +
Ognibene FP, Rosenberg SA, Skibber J, et al:  Interleukin-2 hemodynamics mimic septic shock , abstracted. Clin Res 1986;;34:413A.
37 +
Christou NV, Mannick JA, West MA, et al:  Lymphocyte-macrophage interactions in the response to surgical infections . Arch Surg 1987;; 122:239-250.
38 +
Kariman K, Burns S:  Regulation of tissue oxygen extraction is disturbed in adult respiratory distress syndrome . Am Rev Respir Dis 1985;; 132:109-114.
39 +
Richardson JD, DeCamp MM, Garrison RN, et al:  Pulmonary infection complicating intra-abdominal sepsis: Clinical and experimental observations . Ann Surg 1982;;195:732-738.
40 +
Cerra F, Eyer S:  Acute lung injury and MSOF in post traumatic patients . Crit Care Med , in press.
41 +
Cerra F, Siegel J, Border J:  The hepatic failure of sepsis: Cellular versus substrate . Surgery 1979;;86:409-422.
42 +
Bell R, Coalson J, Smith J:  Multiple organ system failure and infection in adult respiratory distress syndrome . Ann Intern Med 1983;;99:293-298.
43 +
Jones AL:  The intestinal immune system . Gastroenterology 1984;;87:236.
44 +
Keller GA, West MA, Harty JJ, et al:  Modulation of hepatocyte protein synthesis during co-cultivation with macrophage-rich peritoneal cells in vivo . Arch Surg 1985;;120:180-186.
45 +
Cohler LF, Saba TM, Lewis E, et al:  Plasma fibronectin therapy and lung protein clearance with bacteremia after surgery . J Appl Physiol 1987;; 63:623-633.
46 +
Fry DE:  Multiple system organ failure . Surg Clin North Am 1988;;68:107-122.
47 +
Lucas CE:  The renal response to acute injury and sepsis . Surg Clin North Am 1976;;56:953-975.
48 +
Border JR, Hasset J, LaDuca J, et al:  The gut origin septic states in blunt multiple trauma (ISS = 40) in the ICU . Ann Surg 1987;;206:427-448.
49 +
Deitch E, Winterlon J, Li M, et al:  The gut as a portal of entry for bacteremia . Ann Surg 1987;; 205:681-692.
50 +
Parker MM, Shelhamer JH, Bacharach SL, et al:  Profound but reversible myocardial depression in patients with septic shock . Ann Intern Med 1984;;100:483-490.
51 +
Parrillo JE, Burch C, Shelhamer JH, et al:  A circulating myocardial depressant substance in humans with septic shock: Septic shock patients with a reduced ejection fraction have a circulating factor that depresses in vitro myocardial cell performance . J Clin Invest 1985;;76:1539-1553.
52 +
Madoff R, Sharpe S, Cerra F:  Prolonged surgical intensive care . Arch Surg 1985;;120:698-702.
53 +
Burke J, Quinby W, Bondoc C:  Primary excision and prompt grafting as routine therapy for the treatment of thermal burns in children . Surg Clin North Am 1976;;56:477-494.
54 +
Jansson I, Eriksson R, Liljedhal SO, et al:  Primary fracture immobilization as a method to prevent post-traumatic pulmonary changes . Acta Chir Scand 1982;;148:329-338.
55 +
Revhaug A, Michie H, Manson J, et al:  Inhibition of cyclo-oxygenase attenuates the metabolic response to endotoxin in humans . Arch Surg 1988;;123:162-170.
56 +
Olson NC, Grizzle MK, Anderson DL:  Effect of polyethylene glycol-superoxide dismutase and catalase on endotoxemia in pigs . J Appl Physiol 1987;;63:1526-1532.
57 +
Beutler B, Milsark JA, Cerami AC:  Passive immunization against cachectin/tumor necrosis factor prevents mice from lethal effect of endotoxin . Science 1985;;229:869-871.
58 +
Tracey KJ, Fong Y, Hesse DG, et al:  Anticachectin/TNF monoclonal antibodies prevent septic shock during lethal bacteremia . Nature 1987;;330:662-664.
59 +
Dunn DL, Ewald DC, Chandon N, et al:  Immunotherapy of gram-negative bacterial sepsis: A single murine monoclonal antibody provides cross-genera protection . Arch Surg 1986;;121:58-62.
60 +
Danner RL, Joiner KA, Parrillo JE:  Inhibition of endotoxin-induced priming of human neutrophils by lipid X and 3-Aza-lipid X . J Clin Invest 1987;;80:605-612.
61 +
Polk HC Jr:  The enhancement of host defenses against infection: Search for the Holy Grail? Surgery 1986;;99:1-6.
62 +
Cerra FB, Shronts EP, Konstantinides NN, et al:  Enteral feeding in sepsis: A prospective randomized, double-blind trial . Surgery 1985;; 98:632-639.
63 +
Stoutenbeck C, Van Saene H, Miranda D, et al:  The effect of selective decontamination of the digestive tract on colonization and infection rate in multiple trauma patients . Intensive Care Med 1984;;10:185-192.
64 +
Guiot H, van den Brock P, van der Meer J, et al:  Selective antimicrobial modulation of the intestinal flora of patients with acute nonlymphocytic leukemia: A double-blind placebo controlled study . J Infect Dis 1983;;147:615-623.
65 +
Fisher M, UpChurch KS, Levine PH, et al:  Effect of dietary fish oil supplementation of polymorphonuclear leukocyte inflammatory potential . Inflammation 1986;;10:387-392.
66 +
Chiarla C, Siegel J, Kidd S, et al:  Inhibition of post traumatic septic proteolysis and ureagenesis and stimulation of hepatic acute phase protein production by branched chain amino acid TPN . J Trauma , in press.
67 +
Taylor A, Hernandez L, Perry M, et al:  Overview of tissue oxygen utilization , in Bryan-Brown C, Ayres S (eds): Oxygen Transport and Utilization . Fullerton, Calif, Society of Critical Care Medicine, 1986;.
68 +
Bihari D, Sonithies M, Gimson A, et al:  The effects of vasodilation with prostacyclin on oxygen delivery and uptake in critically ill patients . N Engl J Med 1987;;317:397-403.
69 +
Waymack JP, Gallon L, Barcelli U, et al:  Effect of blood transfusions on immune function: III. Alterations in macrophage arachidonic acid metabolism . Arch Surg 1987;;122:56-60.
70 +
Mason J, Wilmore D:  Positive nitrogen balance with human growth hormone and hypocaloric intravenous feedings . Surgery 1986;;100:188-197.
71 +
Ward H, Holliday D, Sim J:  Protein and energy metabolism with biosynthetic growth hormone after gastrointestinal surgery . Ann Surg 1987;; 206:56-61.

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