Heparin-induced bleeding treatment in microsurgery

Microsurgery is associated with prolonged surgical times with an increased risk of deep vein thrombosis, pulmonary embolism and myocardial infarction. The use of antithrombotic means is a commonly employed tactic to prevent vascular thrombosis after microvascular free flap surgery. Flap loss is a devastating complication of microsurgical procedures that leads to detrimental outcomes. A 32-year-old male patient has a ruptured calcaneal tendon. He underwent 5 surgical cleanings with multiple failed sequential attempts at wound closure. Traumatology department in its microsurgery division where it is proposed to perform neo-tendon with graft of palmaris longus of the right thoracic extemity and radial antebrachial microvascular flap. The neo tendon was performed in addition to the micro surgical coverage with the radial antebrachial flap.When having vascular control with micro-clamps, 6000 U of unfractionated heparin was initiated, approximately 20 minutes after the end of the microvascular anastomosis, there was incoercible bleeding, which is initially treated with spray fibrin. Continued bleeding after 3 hours, so it was decided to reverse the effect of heparin with transfusion of fresh frozen plasma, 10 mg of vitamin K and fibrinogen. The effect of heparin was reversed without having thrombotic complications of microvascular anastomoses. The flap was not reexplored since they showed no signs of vascular compromise. If anticoagulants have been used and an incoercible hemorrhage is found, the effect of heparin must be reversed. In the transfer of tissues with microsurgery, the recommended and safe anticoagulation are prophylactic doses and not therapeutic doses

Pelvic limb reconstruction failed by propeller flap resolved with microsurgery

Reconstruction of lower limb defects is a constant challenge for surgeons, the etiology of the defect can be very variable from diabetic ulcers, traffic accidents, fall from height, oncological resections and many others. Free flaps have always been an important option because it has great results in complex reconstructions in lower limbs, it is a microvascular technique, so it has a higher level of complexity. This technique is usually reserved for extensive perilesional wide defects. On the other hand, the propeller flap, which is considered less invasive and easier as it does not involve microvascular surgery. An 18-year-old patient who had a fracture of the right tibial pylon due to a 7-meter drop, who after orthopedic treatment had a defect with exposure of ostesynthesis material of 3 cm in circumference in the medial malleolus. This defect was first managed with a propeller flap complicated with necrosis at 48 hours which was treated with sub atmospheric pressure system for 5 days and later with an ultra-thin anterolateral flap of the pelvic limb. Complete pedicled propeller flap failure is very rare but, because necrosis develops distally, even partial necrosis can expose bone, tendons, or other tissue. Some surgeons consider that propeller flap placement is risky in this location, especially the distal third of the lower leg a prefer to use free flaps. Whenever any pelvic member reconstruction plan fails in the distal third, the best and safest is the use of microsurgery even with the failure of a previous micro vascular flap

Use of rivaroxaban and acetylsalicylic acid as a combined treatment for peripheral arterial disease in Central Military Hospital

Background: The objective of this research was to evaluate the behavior of 3 risk indicators for peripheral arterial disease in patients under oral treatment with rivaroxaban 2.5 mg every 12 hours plus, acetylsalicylic acid 100 mg every 24 hours. It was hypothesized that the oral combination of rivaroxaban and acetylsalicylic acid presents a therapeutic advantage over other treatments.Methods: A prospective longitudinal and non-randomized study of a single center was performed. 59 patients with peripheral arterial disease were included and treated with acetylsalicylic acid + rivaroxaban. Peak systolic velocity, ankle-brachial index and C reactive protein index were evaluated.Results: Significant changes were found at month 1 and 3 of follow-up in maximum systolic velocity, ankle-arm index and C-reactive protein index. The baseline peak systolic velocity (PSV) in the anterior tibial artery had significant differences after one month of treatment (p=0.001) and after 3 months (p=0.001). The baseline PSV in the posterior tibial artery had significant differences compared to the values found at the month of treatment (p=0.001) and 3 months (p=0.001). In the ankle-brachial index a baseline median of 0.790 was found, one month after the treatment of 0.795 (p=0.147) and 3 months after 0.800 (p=0.019). The mean baseline C-reactive protein obtained was 73.142 mg/l, at one month 87.233 mg/l (p=0.001) and at 3 months at 79.009 mg/l (p=0.294) with a standard deviation of 67.18, 74.78 and 69.69 respectively.Conclusions: The combined use of acetylsalicylic acid and rivaroxaban allows a clinical improvement in patients with peripheral arterial disease

Management of a ruptured epidural catheter, an anesthesiologist's dilemma: a case report

Epidural anesthesia is a widely used anesthetic technique in lower extremity surgeries although it is a relatively safe procedure, it can have complications, such as rupture of the epidural catheter. This is a 69-year-old male patient with a diagnosis of Wagner IV diabetic foot is presented, which was scheduled for left supracondylar amputation in which after epidural block, retention of the catheter tip in the epidural space at level L2-L3 was seen, so hemi laminectomy was performed in a second surgical stage in L2 and removal of the epidural catheter. Ideally a broken needle should be removed as soon as possible

Thoracic limb salvage by fibular free flap

The treatment of most fractures of the ulna and radius is usually performed by anatomical reduction and internal fixation, when damage is extensive and local soft tissue cannot provide a complete wound coverage, locoregional flaps present a suitable reconstructive benefit. A 35-year-old male patient suffered an exposed diaphysio-metaphyseal fracture with multi-fragmented distal radius. The patient was evaluated during a 10-day period at the National Institute of Rehabilitation, where the osteosynthesis material and a severe infectious process with necrosis were identified. Necrosectomy of the posterior compartment and removal of the osteosynthesis material was performed, a skin defect of approximately 22x16 cm was observed with a bone gap of 6 cm of radius and ulna. a fibula-free flap is placed to correct the skin defect and an external fixative used for bone alignment. The fibular free flap presents an excellent therapeutic alternative in the resolution of bone gaps with extensive skin defect. Whenever a trained microsurgery team is available, current scales of limb injury should be considered but not utilized for therapeutic approach, always trying to shift amputation as the first option, to the very last one of them

Microsurgery in complex trauma of pelvic limb in a pediatric patient: case report

Complex trauma is defined as the condition secondary to the exchange of kinetic energy of two or more tissues in one limb. This entity is a surgical emergency that can have many sequelae and can even result in limb loss. An 11-year-old female patient presents complex pelvic limb trauma secondary to contuse injury caused by a helicopter’s rotor blades.  Pelvic limb reconstruction was performed with iliac crest bone graft, the fracture was stabilized with an external fixator and the skin defect was covered with an anterolateral microvascular thigh flap (ALT). There was an adequate integration of the bone graft with adequate skin coverage thanks to the ALT thigh flap. The patient presented discreet limb shortening as consequence.  Currently, microsurgery is the only medical option that meets the objectives of limb reconstruction. Microsurgical techniques can be used in pediatric and adult patients. The success of any recovery from complex trauma is vigorous surgical cleaning, avoiding sequential and/or multiple washes

A Survey of Intestinal Parasites Including Associated Risk Factors in Humans in Panama

46 páginas, 3 figuras, 5 tablas. -- The definitive version is available at: http://www.elsevier.com. -- Technical assistance, María González (IRNASA; CSIC)Intestinal parasitic infections are among the most common infections worldwide, leading to illness with serious and long lasting implications in children and immunocompromised people. Transmission of intestinal parasites is more frequent in tropical and sub-tropical areas where sanitation is poor and socioeconomic conditions are deficient. Panama is a country where climate and social conditions could be reflected in a high number of people infected with intestinal parasites. The presence, prevalence, and distribution of intestinal parasites in this country have been approached to date only in very restricted areas and population groups, but the impact of intestinal parasite infections at the national level is unknown. Methodology/Principal Findings. We conducted a cross-sectional survey between 2008 and 2010 to determine the prevalence of intestinal parasites across Panama. Overall, 14 municipalities in seven provinces of Panama were surveyed. The presence of eggs, cysts, and larvae was assessed by microscopy in 1,123 human fecal samples using a concentration technique. A questionnaire to identify risk factors associated with the frequency of intestinal parasites in the study population was also prepared and performed. Overall, 47.4% of human samples presented parasites. Variables including community type, age group, occupation, co-presence of commensals and socioeconomic factors (use of shoes and type of sanitation) were significantly associated with intestinal parasites (p<0.05). Conclusions/Significance The preliminary data obtained in the current study, showing a high prevalence of fecaloral transmitted parasites in Panama, place intestinal parasitism as a major health problem in this country. Specific interventions should be planned for the indigenous population, the group most afflicted by intestinal parasites.Peer reviewe

Use of advanced flap and microsurgery techniques in the resolution of mediastinitis as a complication of cardiac surgery

In the majority of cases, mediastinitis is a potential complication in any cardiac surgical procedure. The objective of this case report is to accurately describe how the combination of microsurgery and soft tissue flaps can be an effective therapeutic alternative in the treatment of mediastinitis as a complication of cardiac valve replacement. Female 63-year-old patient with a background of obesity, hypertension and extense cardiac interventions, she was programmed for necrosectomy with left pectoralis flap technique. Mediastinitis, although a rare complication of the sternotomy performed in cardiac surgery, occurring in 1-2%, carries a high mortality rate.  Early diagnosis of mediastinitis after cardiac surgery requires high clinical suspicion, initially making the diagnosis may be difficult, risk factors should be considered. An early surgical approach can reduce the morbidity and mortality of this condition. The pectoralis flap should be considered as a safe therapeutic option

Estabilidad de rendimiento en genotipos mesoamericanos de frijol de grano negro en México

In Mexico, over 400 000 t of black beans are consumed every year, and the country's production is insufficient, which is why it is also imported. By planting varieties with a higher potential yield tan those used nowadays, greater amounts can be produced, and imports reduced or even avoided. The aim was to establish the yield and adaptability of lines and varieties of Mesoamerican breed of black beans, in different environments in Mexico (one in Chiapas, three in Veracruz, one in Puebla, one in the State of Mexico, two in Guanajuato, one in Tamaulipas, two in Durango, one in Zacatecas, one in Nayarit and two in Sinaloa) in 2008. The experiment was set up in a 4*4 lattice design with four repetitions, in fields of four fivemeter long furrows, separated by 0.76 m. During the trials, diverse agricultural characteristics were determined, including yield. With the yield data, a combined analysis was performed (environments-genotypes) and the stability parameters were estimated using the main additives effect and multiplicative interaction model. Highly significant differences were found (p< 0.01) between environments, genotypes and the interaction of both factors. The environments explained variance (59%) further, in comparison to the environment*genotype (23%) interaction and genotype (7%). The highest yields were obtained in Mazatlán, Sinaloa and Durango, Durango, whereas the lowest was found in Guasave, Sinaloa. The Negro Papaloapan variety displayed the highest average yield of 1.4 t ha-1 and presented a reduced interaction with the test environments.En México se consumen más de 400 000 t de frijol de grano negro y la producción nacional es insuficiente por lo que se recurre a la importación. Con la siembra de variedades de mayor rendimiento potencial que las de uso actual y amplia adaptación, es factible obtener una mayor producción y disminuir o evitar las importaciones. El objetivo fue determinar el rendimiento y adaptabilidad de lí­neas y variedades de frijol negro, raza mesoamericana, en diferentes ambientes de México (uno en Chiapas, tres en Veracruz, uno en Puebla, uno en el Estado de México, dos en Guanajuato, uno en Tamaulipas, dos en Durango, uno en Zacatecas, uno en Nayarit y dos en Sinaloa) en 2008. El experimento se estableció en diseño látice 4â��4 con cuatro repeticiones, en parcelas de cuatro surcos de 5 m de longitud, separados 0.76 m. Durante la conducción de los ensayos se determinaron diversas caracterí­sticas agronómicas, entre ellas el rendimiento. Con los datos de rendimiento se realizó análisis combinado (ambientes-genotipos) y se estimaron los parámetros de estabilidad, con el modelo de efectos principales aditivos e interacción multiplicativa. Se detectaron diferencias altamente significativas (p< 0.01) entre ambientes, genotipos y la interacción de ambos factores. Los ambientes explicaron en mayor proporción la varianza (59%), en comparación con la interacción ambienteâ��genotipo (23%) y genotipo (7%). Los mayores rendimientos se obtuvieron en Mazatlán, Sinaloa y Durango, Durango, mientras que el más bajo se obtuvo en Guasave, Sinaloa. La variedad Negro Papaloapan obtuvo el mayor rendimiento promedio de 1.4 t ha-1 y mostró reducida interacción con los ambientes de prueba