Closed incision negative pressure therapy:international multidisciplinary consensus recommendations

Surgical site occurrences (SSOs) affect up to or over 25% of patients undergoing operative procedures, with the subset of surgical site infections (SSIs) being the most common. Commercially available closed incision negative pressure therapy (ciNPT) may offer surgeons an additional option to manage clean, closed surgical incisions. We conducted an extensive literature search for studies describing ciNPT use and assembled a diverse panel of experts to create consensus recommendations for when using ciNPT may be appropriate. A literature search of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials using key words \u2018prevention\u2019, \u2018negative pressure wound therapy (NPWT)\u2019, \u2018active incisional management\u2019, \u2018incisional vacuum therapy\u2019, \u2018incisional NPWT\u2019, \u2018incisional wound VAC\u2019, \u2018closed incisional NPWT\u2019, \u2018wound infection\u2019, and \u2018SSIs\u2019 identified peer-reviewed studies published from 2000 to 2015. During a multidisciplinary consensus meeting, the 12 experts reviewed the literature, presented their own ciNPT experiences, identified risk factors for SSOs and developed comprehensive consensus recommendations. A total of 100 publications satisfied the search requirements for ciNPT use. A majority presented data supporting ciNPT use. Numerous publications reported SSI risk factors, with the most common including obesity (body mass index 6530 kg/m2); diabetes mellitus; tobacco use; or prolonged surgical time. We recommend that the surgeon assess the individual patient's risk factors and surgical risks. Surgeons should consider using ciNPT for patients at high risk for developing SSOs or who are undergoing a high-risk procedure or a procedure that would have highly morbid consequences if an SSI occurred

Screening and Assessment of the Donor Heart

Why screening? Thirty years ago most donors suffered from head trauma ("Morbus Kawasaki") and a donor older than 35 years was beyond the pale, i.e. donors were young and healthy, and since these early days of transplantation donor hearts have been regarded as healthy "per definitionem"(1). However, due to the general organ shortage the criteria for the acceptance of donor hearts have been widely liberalized. According to the current quarterly data report of the International Society for Heart and Lung Transplantation (ISHLT) nearly two thirds of donors in Europe (64.3%) were older than 35 years, more than a quarter (26.0%) were even older than 50 years and less than 10% of organ donors suffered from head trauma (2). Meanwhile the average (European) donor is 45 years old and is suffering from intracranial bleeding, i.e. the so-called "donor pool" represents a subpopulation with significantly elevated risk for cardiac diseases such as coronary atherosclerosis and hypertension-related myocardial hypertrophy ( Key words: organ donor, heart donor, donor management, screening, coronary angiography, organ transplantation, heart transplantation Screening und Beurteilung des Spenderherzens Wozu Screening? Noch vor dreißig Jahren starben die meisten Spender an einem Schädeltrauma ("Morbus Kawasaki") und ein über 35-jähriger Spender galt als völlig inakzeptabel, d. h. die Spender waren jung und gesund. Seit diesen Anfängen der Transplantationsmedizin wurden Spenderherzen "per Definition" als gesund angesehen (1). Infolge des allgemeinen Organmangels wurden die Kriterien für die Akzeptanz von Spenderherzen jedoch weitgehend liberalisiert und nach dem aktuellen vierteljähr-lichen Datenbericht der International Society for Heart and Lung Transplantation (ISHLT) sind fast zwei Drittel der Spender in Europa (64.3%) älter als 35 Jahre, mehr als ein Viertel (26.0%) sogar älter als 50 Jahre und weniger als 10 % der Organspender sind an einem Schädeltrauma gestorben (2). Heute ist der typische (europäische) Spender 45 Jahre alt und an einer "spontanen" intracerebralen Blutung verstorben, d. h. der sogenannte "Spenderpool" rekrutiert sich aus einer Gruppe von Menschen, die ein signifikant erhöhtes Risiko für kardiale Erkrankungen aufweisen, wie z. B. für koronare Atherosklerose und Bluthochdruck-bedingte myokardiale Hypertrophie (Abb. 1). Leider zeigt die tägliche Erfahrung, dass das Screening der Spenderherzen an diese Entwicklung nicht angepasst worden ist (3). Die Frage "Wozu Screening?" ist daher keineswegs so trivial, wie es scheinen mag: Die Spender-Koronarangiographie ist immer noch eine Ausnahme (wird nur bei 5 -10 % der Spender durchgeführt), obwohl [1] die Prävalenz einer signifikanten atherosklerotischen Koronararterienerkrankung (KHK) im Spenderpool bei etwa 20 % liegt, [2] das Risiko einer Übertra-gung der KHK ohne Angiographie trotz Inspektion des Organs durch den entnehmenden Operateur bei ungefähr 5 -10 % liegt und [3] das Risiko eines frühen Transplantatversagens bei einer versehentlich mitübertragenen signifikanten KHK dreimal so hoch ist wie mit einem gesunden Graft (4,5)

Electric Impedance Recording - A Noninvasive Method of Rejection Diagnosis

The recording of electric tissue impedance reflects membrane function and changes of volume and electrolytes in intra-and extra-cellular space. The purpose of this study was to determine if acute cardiac allograft rejection can be diagnosed from alteration of electric transmyocardial impedance (ETMI). Nine Beagle dogs received a heterotopic neck heart transplant. The animals were immunosuppressed with cyclosporine and steroids for the first three postoperative days. ETMI was recorded twice daily. Transcutaneous biopsies were performed whenever the impedance varied by more than 10%. All hearts showed a uniform impedance decrease immediately after transplantation, reaching a stable plateau after three days. A subsequent increase of impedance by 12.4 +/-2.9% was accompanied by a histological diagnosis of mild rejection. A further increase of 23.2 +/-2.6% histologically showed acute moderate rejection. After treatment with steroids the impedance reached the basic plateau again. Compared with the biopsy the sensitivity and specificity were 100%. The results indicate that the inflammatory process of cardiac allograft rejection can be detected with this method. This technique will be clinically applicable when an implantable telemetric device for recording the impedance and its transmission will be developed

Plasmapheresis and cyclophosphamide in the treatment of humoral rejection after heart transplantation

Background: Clinical reports on humoral rejection after heart transplantation showed that these episodes were often more severe than those mediated through T lymphocytes and that the patient’s prognosis was significantly worsened. To evaluate the impact of plasmapheresis on the course of humoral rejection with hemodynamic compromise (HRHC) episodes, we retrospectively investigated the records of 1,108 heart transplant patients. All patients received triple-drug immunosuppression (cyclosporine a, azathioprine, prednisone) and cytolytic antibodies for induction. Between April 1986 and December 1990, HRHC episodes were treated with cortisone boli and cytolytic antibodies for at least 3 days (Group A). Between January 1991 and April 1999, HRHC episodes were treated with cortisone boli, cytolytic antibodies, and plasmapheresis for at least 3 days (Group B). All patients who survived their first HRHC episode received cyclophosphamide instead of azathioprine as maintenance immunosuppression. Altogether we observed 29 HRHC episodes. In 11 cases, no therapy could be administered or the therapy regimen did not correspond to either Protocol A or B. In the remaining 18 HRHC episodes, 7 episodes in 7 patients were treated without plasmapheresis (Group A), but only 2 patients survived, whereas in 11 HRHC episodes in 6 patients, therapy included plasmapheresis (Group B) and all patients survived ( p = 0.002). Four of 6 patients who received cyclophosphamide after their first HRHC episode experienced at least 1 further HRHC episode. Plasmapheresis seems to improve outcomes in HRHC. However, cyclophosphamide as a maintenance immunosuppressive drug failed to prevent further humoral rejection episodes

Arrhythmia post heart transplantation

Abstract A variety of arrhythmias can occur after heart transplantation (HTx). Hearts selected to be donated for HTx should be in good condition and generally beat in sinus rhythm (SR). Absence or loss of SR after HTx can be due to any reason and can lead to serious hemodynamic problems. Ischemia reperfusion injury, unbalanced serum electrolytes and re-warming of cold myocardial tissue are known to initiate arrhythmia during the period of reperfusion after implantation of the heart graft. An important cause of arrhythmias after HTx is the possible rejection reaction, which often prompts supraventricular arrhythmias. Subsequent to the initial course after HTx operation transplant vasculopathy can cause arrhythmias of all kinds. The post-HTx effects of some antiarrhythmic substances such as amiodarone administered preoperatively are at present under discussion as possibly being associated with an increased risk for mortality. A survey of patients' data from the Deutsches Herzzentrum Berlin (DHZB) showed that continuous SR is accompanied by favorable course after HTx. Absence of SR or its loss predicts organ failure. Significant risk factors for cardiac graft failure were found to be associated with the preoperative condition of recipients and donors as well as with the operative procedures and the respective postoperative courses. Of these risk factors three were prominently associated with cardiac graft failure: absence or loss of SR initially after HTx operation, donor age over 30 years and previous thoracic operation of the recipient. Antiarrhythmic medication regulates cardiac rhythm. We examined the hypothesis whether preoperatively administered antiarrhythmic medication influences post-HTx cardiac rhythm and function due to loading of the recipient's body with an antiarrhythmic substance. The examination of the DHZB data showed that medication for antiarrhythmic purposes in patients waiting for HTx is without influence on the occurrence or continuation of sinus rhythm or on the incidence of arrhythmia after HTx. No preoperatively administered antiarrhythmic substance was associated with postoperative arrhythmia or with cardiac graft failure

Closed incision negative pressure therapy: international multidisciplinary consensus recommendations.

Surgical site occurrences (SSOs) affect up to or over 25% of patients undergoing operative procedures, with the subset of surgical site infections (SSIs) being the most common. Commercially available closed incision negative pressure therapy (ciNPT) may offer surgeons an additional option to manage clean, closed surgical incisions. We conducted an extensive literature search for studies describing ciNPT use and assembled a diverse panel of experts to create consensus recommendations for when using ciNPT may be appropriate. A literature search of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials using key words 'prevention', 'negative pressure wound therapy (NPWT)', 'active incisional management', 'incisional vacuum therapy', 'incisional NPWT', 'incisional wound VAC', 'closed incisional NPWT', 'wound infection', and 'SSIs' identified peer-reviewed studies published from 2000 to 2015. During a multidisciplinary consensus meeting, the 12 experts reviewed the literature, presented their own ciNPT experiences, identified risk factors for SSOs and developed comprehensive consensus recommendations. A total of 100 publications satisfied the search requirements for ciNPT use. A majority presented data supporting ciNPT use. Numerous publications reported SSI risk factors, with the most common including obesity (body mass index ≥30 kg/m2 ); diabetes mellitus; tobacco use; or prolonged surgical time. We recommend that the surgeon assess the individual patient's risk factors and surgical risks. Surgeons should consider using ciNPT for patients at high risk for developing SSOs or who are undergoing a high-risk procedure or a procedure that would have highly morbid consequences if an SSI occurred