V.A.C.™ Instillation: in vitro model. Part 1

The reproducibility of a V.A.C.™ (Vacuum Assisted Closure) instillation system was investigated by means of an in vitro model. The relation between the volume of a delivered solution and its removal from the system was studied in foams of various size. The relationship of instillation time periods and the volume of delivered solution was determined. Mittels eines in vitro Models wurde die Reproduzierbarkeit der V.A.C.™ (Vacuum Assisted Closure) instillation untersucht. Die Beziehung zwischen den Volumina der infundierten Flüssigkeiten und des Abflusses wurde in Schaumstoffen verschiedener Grösse untersucht. Das Verhältnis zwischen Instillationszeit und Volumen der infundierten Flüssigkeit wurde ermittel

Predictive ability of the ISS, NISS, and APACHE II score for SIRS and sepsis in polytrauma patients

Purpose: Systemic inflammatory response syndrome (SIRS) and sepsis as causes of multiple organ dysfunction syndrome (MODS) remain challenging to treat in polytrauma patients. In this study, the focus was set on widely used scoring systems to assess their diagnostic quality. Methods: A total of 512 patients (mean age: 39.2±16.2, range: 16-88years) who had an Injury Severity Score (ISS) ≥17 were included in this retrospective study. The patients were subdivided into four groups: no SIRS, slight SIRS, severe SIRS, and sepsis. The ISS, New Injury Severity Score (NISS), Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and prothrombin time were collected at admission. The Kruskal-Wallis test and χ2-test, multinomial regression analysis, and kernel density estimates were performed. Receiver operating characteristic (ROC) analysis is reported as the area under the curve (AUC). Data were considered as significant if p<0.05. Results: All variables were significantly different in all groups (p<0.001). The odds ratio increased with increasing SIRS severity for NISS (slight vs. no SIRS, 1.06, p=0.07; severe vs. no SIRS, 1.07, p=0.04; and sepsis vs. no SIRS, 1.11, p=0.0028) and APACHE II score (slight vs. no SIRS, 0.97, p=0.44; severe vs. no SIRS, 1.08, p=0.02; and sepsis vs. no SIRS, 1.12, p=0.0028). ROC analysis revealed that the NISS (slight vs. no SIRS, AUC 0.61; severe vs. no SIRS, AUC 0.67; and sepsis vs. no SIRS, AUC 0.77) and APACHE II score (slight vs. no SIRS, AUC 0.60; severe vs. no SIRS, AUC 0.74; and sepsis vs. no SIRS, AUC 0.82) had the best predictive ability for SIRS and sepsis. Conclusion: Quick assessment with the NISS or APACHE II score could preselect possible candidates for sepsis following polytrauma and provide guidance in trauma surgeons' decision-makin

Entrapment der A.tibialis anterior in einer distalen Tibiafraktur nach intramedullärer Nagelung

Zusammenfassung: Es wird ein Fallbericht über ein Entrapment der A.tibialis anterior im Rahmen der Versorgung einer distalen geschlossenen Tibiafraktur mit Hilfe eines Tibianagels präsentiert. Wegen offenen Metatarsalefrakturen mit einer schwerer Weichteilverletzung der gleichen Seite wurde nach mehreren Débridements eine freie Latissimus-dorsi-Lappenplastik zur Deckung geplant. Die präoperative Angiographie zeigte einen Verschluss der A.tibials anterior auf Frakturhöhe. Der Verschluss wurde als eine sekundäre Gefäßokklusion interpretiert, die durch eine Intimaverletzung des Gefäßes im Rahmen der Verletzung verursacht wurde. Das Entrapment der Arterie im Frakturspalt wurde erst intraoperativ während der Präparation für die Gefäßanstomosierung der Lappenplastik festgestell

Low molecular weight heparin-induced skin necrosis—a systematic review

Background: Low molecular weight heparins (LMWHs) are currently used as a standard for anti-thrombotic therapy. Skin necrosis caused by LMWH is a rare and probably under-reported complication. The aim of our systematic review is to analyse the present literature for cases of LMWH-induced skin necrosis, emphasising the pathogenesis, clinical pattern, and management of this rare side effect. Methods: We performed a Medline literature search (PubMed database) and manual cross-referencing to identify all articles related to LMWH-induced skin necrosis. Data were analysed for type of LMWH used, time until skin necrosis occurred, localisation, size, laboratory findings, switch anticoagulant, complications, and outcome. Additionally, the case of a patient from our hospital is presented. Results: We included a total of 20 articles (21 cases) reporting on LMWH-induced skin necrosis. Skin necrosis occurred locally and distant from the injection site. Heparin-induced antibodies were frequently observed (positive 9/11 articles, negative 2/11). However, severe thrombocytopenia (platelet count <100,000cells/ml) occurred in only four cases, while platelet count remained normal in 50% of the cases. After patients had been switched to other anti-thrombotic drugs, the clinical course was usually benign; however, reconstructive surgery was necessary in two cases. Conclusion: LMWH-induced skin necrosis may occur as part of the heparin-induced thrombocytopenia (HIT) syndrome, but other pathomechanisms, including allergic reactions and local trauma, may also be involved. When HIT is excluded, unfractionated heparin is a safe switch anticoagulant. Otherwise, non-heparin preparations such as hirudin or fondaparinux should be preferre

Einfluss der Sakrumfraktur auf das funktionelle Langzeitergebnis von Beckenringverletzungen

Zusammenfassung: In der Akutphase umfasst die Behandlung der Beckenringverletzung mit Beteiligung des iliosakralen Komplexes die effiziente Blutungskontrolle und Stabilisierung des Beckenrings. Für das Langzeitresultat sind jedoch neurologische Ausfälle, Fehlverheilungen des hinteren Beckenrings mit tieflumbalen Schmerzen und urologische Komplikationen entscheidend. Zwischen 1991 und 2000 wurden in unserer Klinik 173Patienten mit Sakrumfrakturen behandelt. Diese wurden im Rahmen einer lateralen Kompressionsfraktur (AO-Klassifikation TypB2) oder einer "vertical-shear-" (Typ-C-)Verletzung mit einer Dislokation von 1cm wurden operativ (n=33, 19%) versorgt. 112Patienten wurden nach durchschnittlich 4,9Jahren nachkontrolliert. Von den 39Patienten mit neurologischen Ausfällen (35%) zeigten lediglich 4 eine vollständige neurologische Erholung. Chronische tieflumbale Schmerzen traten selten (n=8, 7%) und nur bei einer Typ-C-Verletzung auf. Die geringe Inzidenz an lumbalen Schmerzen rechtfertigt die konservative Therapie wenig dislozierter (<1cm) Sakrumfrakturen. Entscheidend für das Langzeitergebnis sind neurologische Defizite, die bei 30% aller Patienten persistiere

Kombinierte dorsale und palmare Plattenosteosynthese bei distalen intraartikulären Radiusfrakturen

Zusammenfassung: Hintergrund: Behandlungsziel bei komplexen distalen intraartikulären Radiusfrakturen ist die anatomische Gelenkrekonstruktion. In seltenen Fällen kann dies nur mit einer kombinierten, dorsalen und palmaren Abstützung erreicht werden, trotz der zunehmenden Erfahrung mit winkelstabilen palmaren Implantaten. Diese retrospektive Qualitätskontrollstudie untersucht das funktionelle, radiologische und subjektive Outcome der mit dieser Technik operierten Patienten. Patienten und Methoden : An der Klinik für Unfallchirurgie des Universitätsspital Zürich wurden zwischen März 1999 und Januar 2003 von 360 Patienten mit instabiler distaler Radiusfraktur 30 Patienten mit komplexer C2-/C3-Fraktur über einen kombinierten dorsopalmaren Zugang mit einer 3,5-mm-T-Platte und dorsal mit zwei 1/4-Rohr-Platten behandelt und in die Studie eingeschlossen (9 Frauen, 21Männer, Mittelwert des Alters 52). Nachkontrolliert werden konnten 25 der 30 Patienten im Mittel 29 Monate nach Unfall. Ergebnisse: Die angestrebte anatomische Rekonstruktion gelang nicht bei allen Patienten: 56% zeigten leichte, 28% schwere Zeichen der Arthrose. Die Flexion erreichte 66%, die Extension 75% der gesunden Seite, Pronation und Supination sogar 98 bzw. 91%. Die Kraft beim Faustschluss betrug 75% der kontralateralen Seite. Zehn Patienten (40%) entwickelten im Verlauf ein komplexes regionales Schmerzsyndrom (CRPS). Die Rückkehr zur Arbeit war nach 120 Tagen möglich. Schlussfolgerung: Die dorsopalmare Plattenosteosynthese komplexer, distaler intraartikulärer Radiusfrakturen erlaubt eine Gelenkrekonstruktion mit gutem subjektivem, funktionellem und radiologischem Resultat, dies trotz des durch den beidseitigen Zugang verursachten zusätzlichen Weichteilschaden. Das hohe CRPS-Risiko, aber auch der lange Arbeitsausfall müssen bei der Patientenaufklärung berücksichtigt werde

Bogota-VAC – A Newly Modified Temporary Abdominal Closure Technique

Background: We present Bogota-VAC, a newly modified temporary abdominal closure (TAC) technique for open abdomen condition after abdominal compartment syndrome (ACS). Methods: A thin isolation bag (Bogota bag) and a vacuum assisted closure (VAC) system were combined. A matching bag was tension-free fixed on the abdominal fascia by fascia suture. A ring shaped black polyurethane foam of the VAC system was placed into the gap between Bogota bag, abdominal fascia and the wound edge. A constant negative topic pressure of 50–75 mmHg was used in the VAC system. Results: Intra-abdominal pressure (IAP: 22 ± 2 mmHg)of four patients with ACS after severe traumatic brain injury and one patient with isolated ACS after blunt abdominal trauma decreased significantly (p = 0.01)after decompressive laparotomy and treatment with Bogota-VAC (IAP: 10 ± 2 mmHg) and remained low, measured via urinary bladder pressure. Intracranial pressure (ICP) in the four traumatic brain injury patients decreased from 42 ± 13 mmHg to 15 ± 3 mmHg after abdominal decompression. Cerebral perfusion pressure (57 ± 14 mmHg) increased to 74 ± 2 mmHg. Conclusion: The advantage of the presented Bogota-VAC is leak tightness, wound conditioning (soft tissue/fascia), skin protection and facilitation of nursing in combinationwith highest volume reserve capacity (VRC), thus preventing recurrent increased intra-abdominal and intracranial pressure in the initial phase after decompression of ACS compared to other TAC techniques

Penetration of cefuroxime into the cerebrospinal fluid of patients with traumatic brain injury

Cefuroxime levels were measured in cerebrospinal fluid (CSF) and serum of four patients with traumatic brain injury following the implantation of intraventricular catheters. The levels ranged from 0.15 to 2.03 μg/mL in CSF and from 1.8 to 66.9 μg/mL in serum. No ventriculostomy related infections were detecte

The impact of body mass index and gender on the development of infectious complications in polytrauma patients

Purpose: The aim was to test the impact of body mass index (BMI) and gender on infectious complications after polytrauma. Methods: A total of 651 patients were included in this retrospective study, with an Injury Severity Score (ISS)≥16 and age≥16years. The sample was subdivided into three groups: BMI30kg/m2, and a female and a male group. Infectious complications were observed for 31days after admission. Data are given as mean±standard errors of the means. Analysis of variance, Kruskal-Wallis test, χ2 tests, and Pearson's correlation were used for the analyses and the significance level was set at P30kg/m2 group (P=0.519). The female patients developed significantly fewer infectious complications than the male patients (26.8 vs. 73.2%; P<0.001). The incidence of death was significantly decreased according to the BMI group (8.8 vs. 7.2 vs. 1.5%; P<0.0001) and the female population had a significantly lower mortality rate (4.1 vs. 13.4%; P<0.0001). Pearson's correlations between the Abbreviated Injury Scale (AIS) score and the corresponding infectious foci were not significant. Conclusion: Higher BMI seems to be protective against polytrauma-associated death but not polytrauma-associated infections, and female gender protects against both polytrauma-associated infections and death. Understanding gender-specific immunomodulation could improve the outcome of polytrauma patients

Influence of injury pattern on incidence and severity of posttraumatic inflammatory complications in severely injured patients

BACKGROUND: Severe trauma causes systemic inflammatory response syndrome (SIRS) which may lead to multiple organ dysfunction syndrome (MODS) or multiple organ failure (MOF). The aim of this study was to evaluate the influence of the injury pattern on the incidence and severity of SIRS, sepsis, MODS, and mortality. METHODS: A total of 1,273 patients with an injury severity score (ISS) of ≥ 9 points and survival of more than 3 days were included in this retrospective study. Outcome parameters were various grades of SIRS, sepsis, MODS, and mortality. RESULTS: Severe non-infectious SIRS occurred in 23%, sepsis in 14%, and severe MODS in 14% of the patients. Serious (abbreviated injury scale (AIS) ≥ 3 points) head injury and the ISS represented the most potent risk factors for severe SIRS. As estimated by multivariate logistic regression analysis, the presence of severe extremity and pelvic injuries, the ISS, and the male gender were found to be independent risk factors for sepsis. Severe injuries of the abdomen were associated with an increased risk for sepsis in the univariate analysis. Severe injuries to the head or abdomen, the ISS, and the male gender represented independent risk factors for the development of severe MODS. Regarding the late (> 3 days after trauma) hospital mortality, severe head injury, the ISS, and the patient’s age were independent risk factors. CONCLUSIONS: Head injury predominantly determines the incidence of non-infectious systemic inflammation, MOF, and late hospital mortality of patients with severe trauma. Skeletal or abdominal injuries represent relevant risk factors for septic complications. Thus, the incidence of posttraumatic, life-threatening inflammatory complications is related with certain injury patterns in addition to the gender and the severity of trauma