The analysis of hepatic microcirculation after ischemia and reperfusion during human liver transplantation

GesamtdissertationOrthogonal Polarization Spectral Imaging (OPSI) ermöglicht die Visualisierung und quantitative Analyse der hepatischen Mikrozirkulation unter physiologischen und Ischämie/Reperfusions-Bedingungen am Menschen. Erstmalig konnten die physiologischen Normalparameter der humanen hepatischen Mikrozirkulation quantitativ ermittelt werden. Im Lebertransplantationsprozess kann direkt während der Operation die initiale Mikrozirkulation nach Reperfusion evaluiert und anschließend computergestützt quantitativ exakt gemessen werden. Die Korrelation der gemessenen Mikrozirkulationsparameter und transplantationsspezifischen Daten ermöglicht die Untersuchung von Ischämie /Reperfusions-Schäden. Die gemessenen Parameter der humanen physiologischen Mikrozirkulation waren mit Ausnahme der Erythrozytenflussgeschwindigkeit normalverteilt. Bei der orthotopen Lebertransplantation ist eine ausgeprägte postischämische reaktive Hyperämie festzustellen, die sich durch eine Zunahme des volumetrischen Blutflusses auszeichnet. Die Steigerung des volumetrischen Blutflusses ist ein bedeutender Faktor zur Sicherstellung einer adäquaten Gewebeperfusion nach Reperfusion. In dieser Arbeit werden die beiden Reperfusionsverfahren simultane und sequentielle Rearterialisierung in Bezug auf die Mikrozirkulationsstörung und Transplantatfunktion bei der Leberlebendtransplantation gegenübergestellt. Die alleinige portale Reperfusion führt nicht zu einer ausreichenden nutritiven Perfusion, wodurch das Transplantat initial geschädigt wird. Die folgende Rearterialisierung führte zu einer zügigen Wiederherstellung einer adäquaten Perfusion mit sich einstellender postischämischer Hyperämie. Es zeigte sich eine signifikante Korrelation zwischen dem Zeitintervall portale-arterielle Reperfusion und den gemessenen mikrozirkulatorischen Parametern. Die Messergebnisse dieser Studie unterstützen die simultane Reperfusion als geeignetes Standardprotokoll für die Reperfusion bei der humanen Lebertransplantation.Orthogonal Polarization Spectral Imaging (OPSI) enables the visualization and quantitative analyses of hepatic microcirculation under physiologic and ischemia/reperfusion conditions in humans. For the first time the physiologic parameters of the human hepatic microcirculation were measured. During liver transplantation the initial microcirculation after reperfusion can be evaluated intraoperatively. Subsequent computer assisted measurements can be performed. Correlation between microcirculatory parameters and transplant specific data enables the analyses of ischemia/reperfusion injury. The measured parameters of the human physiologic microcirculation were with exception of the red blood cell velocity normal distributed. A distinct postischemic hyperemia is observed in ortotopic liver transplantation which is based on an increase of volumetric intrasinusoidal blood flow. The increase in volumetric blood flow is an important factor in securing adequate tissue perfusion after reperfusion. In this paper the two reperfusion strategies simultaneous versus sequential were compared in respect to microcirculatory disturbance and graft function during liver transplantation. Isolated portal reperfusion does not result in adequate nutritive tissue perfusion which leads to initial graft damage. Rearterialization restores adequate perfusion accompanied by postischemic hyperemia. A correlation between the time interval portal-arterial reperfusion and measured postreperfusion microcirculatory parameters was observed. The results of this study support simultaneous reperfusion in human liver transplantation

Resuscitative thoracotomy

Resuscitative thoracotomy is often performed on trauma patients with thoracoabdominal penetrating or blunt injuries arriving in cardiac arrest. The goal of this procedure is to immediately restore cardiac output and to control major hemorrhage within the thorax and abdominal cavity. Only surgeons with experience in the management of cardiac and thoracic injuries should perform this procedure

Disasters and mass casualty incidents the nuts and bolts of preparedness and response to protracted and sudden onset emergencies

This book is designed to provide simplified operational blueprint for health care professionals and emergency managers who plan the response and medical management during events with large numbers of sick and injured patience. In addition to discussing the management of sudden mass casualty incidents, the book expands its focus from the first edition by including preparations and responses for insidious and protracted disasters. Much of the material is derived from Israeli experience in managing mass casualty events and was adapted to emergency medical services and medical centers in the United States and other countries. Written by experts in the fields of MCI management, Disasters and Mass Casualty Incidents: The Nuts and Bolts of Preparedness and Response to Protracted and Sudden Onset Emergencies provides health care professionals and institutions, as well as allied organizations, which respond to disasters and mass casualty incidents with the skills and knowledge in planning and responding to catastrophic events

Complex And Simple Appendicitis: REstrictive or Liberal postoperative Antibiotic eXposure (CASA RELAX) using Desirability of Outcome Ranking (DOOR) and Response Adjusted for Duration of Antibiotic Risk (RADAR): study protocol for a randomized controlled trial

ObjectivesAfter appendectomy for simple or complicated appendicitis, the optimal duration of postoperative antibiotics (postop abx) is unclear and great practice variability exists. We propose to compare restrictive versus liberal postop abx using a hierarchical composite endpoint which includes patient-centered outcomes and accounts for duration of antibiotic exposure.Methods/DesignParticipants with simple or complicated appendicitis undergoing appendectomy are randomly assigned to either restricted or liberal strategy. Eligible subjects declining randomization will be recruited to enroll in an observation only cohort. The primary endpoint is an ordinal scale of mutually exclusive clinical outcomes with within-category rankings determined by duration of antibiotic exposure. Subjects in both randomized and observation only cohorts will be analyzed as intention-to-treat, per-protocol, and as-treated. Exploratory Bayesian analyses will be performed.ConclusionThe complex and simple appendicitis: restrictive or liberal postoperative antibiotic exposure multicenter randomized controlled trial will enroll surgical appendectomy patients and seeks to analyze if a strategy of restricted (compared with liberal) postoperative antibiotics results in similar clinical outcomes with the benefit of reduced antibiotic exposure.Trial registration numberNCT05002829