Clinical implications of fracture-associated vascular damage in extremity and pelvic trauma.

BACKGROUND: Vascular damage in polytrauma patients is associated with high mortality and morbidity. Therefore, specific clinical implications of vascular damage with fractures in major trauma patients are reassessed. METHODS: This comprehensive nine-year retrospective single center cohort study analyzed demography, laboratory, treatment and outcome data from 3689 patients, 64 patients with fracture-associated vascular injuries were identified and were compared to a control group. RESULTS: Vascular damage occurred in 7% of patients with upper and lower limb and pelvic fractures admitted to the trauma room. Overall survival was 80% in pelvic fracture and 97% in extremity fracture patients and comparable to non-vascular trauma patients. Additional arterial damage required substantial fluid administration and was visible as significantly anemia and disturbed coagulation tests upon admission. Open procedures were done in over 80% of peripheral extremity vascular damage. Endovascular procedures were predominant (87%) in pelvic injury. CONCLUSION: Vascular damage is associated with high mortality rates especially in combination with pelvic fractures. Initial anemia, disturbed coagulation tests and the need for extensive pre-clinical fluid substitution were observed in the cohort with vascular damage. Therefore, fast diagnosis and early interventional and surgical procedures are necessary to optimize patient-specific outcome.

[Factor XIII : Pharmacodynamic and pharmacokinetic characteristics]. / Gerinnungsfaktor XIII : Pharmakodynamische und pharmakokinetische Eigenschaften.

Factor XIII (FXIII) plays an important role in the field of blood coagulation. In the last decade, both congenital and acquired deficiencies have been investigated in clinical studies. FXIII is a versatile enzyme that leads to a covalent cross-linking of fibrin fibrils at the end of the clotting cascade and supports platelet adhesion to the damaged sub-endothelium with the result of a mechanically stable clot.Symptoms of FXIII deficiencies vary within a broad spectrum from superficial skin bleeding episodes to severe, sometimes life threatening hemorrhage, requiring prophylactic or therapeutic replacement therapy.Since 1993 purified plasma-derived FXIII concentrate has been available in Germany, large parts of Europe and in the USA and Canada. The administration is conducted intravenously, and FXIII is immediately available in the plasma. The dosage should be determined by measuring actual plasma FXIII-activity. Repetitive application is possible, especially with regard to the mean half-time of 7.9 days.Administration is considered to be safe and effective, but there are some case reports, as with other coagulation factors, describing the appearance of inhibitory antibodies.This summary seeks to provide an insight into the principle pharmacokinetic and pharmacodynamic characteristics of plasma-derived FXIII concentrate, reviewing the current literature. For detailed use in clinical settings, the application of FXIII concentrate or substitution therapy with fresh frozen plasma, we therefore refer to current guidelines and significant studies that have been recently published.

[Bilateral hydrothorax and hydromediastinum after puncture of the right subclavian vein]. / Bilateraler Infusothorax und Infusomediastinum nach Punktion der V. subclavia rechts.

Complications after the percutaneous insertion of central venous catheters are pneumothoraces, catheter-associated infections and thrombosis. In rare cases, late problems occur as a disruption of the main thoracic duct or vascular erosion. The developing pleural effusion must be analysed for other causes such as congestive heart disease, inflammatory or tumorous disease, pancreatitis, low blood protein, or subdiaphragmatic abscess. The following case report describes a rare catheter complication in a 16-year-old polytraumatised patient. The differentiation to a chylothorax and suitable therapy are described.

[Unplanned admission or readmission to the intensive care unit : Avoidable or fateful?] / Ungeplante Aufnahmen oder Rückverlegungen auf die Intensivstation : Vermeidbar oder schicksalhaft?

BACKGROUND: Unplanned admissions or readmissions to the intensive care unit lead to a poorer outcome and present medical, logistic and economic challenges for a clinic. How often and what are the reasons for readmission to the intensive care unit? Which strategies and guidelines to avoid readmission are recommended. MATERIAL AND METHODS: Analysis and discussion of available studies and recommendations of national and international societies. RESULTS: Many studies show that unplanned admissions and readmissions to the intensive care unit represent an independent risk factor for a poor outcome for patients. Different factors that increase the probability of readmission can be identified. Structural changes concerning the normal wards, intensive care unit or the clinic internal emergency service could positively effect readmission rates and/or patient outcome while other studies failed to show any effect of these arrangements. CONCLUSION: Patient transition from the intensive care unit to a lower level of care is a critical point of time and has to be accompanied by a high quality handover. Unstable patients on normal wards have to be identified and treated as soon as possible but effects of standardized medical emergency teams are controversial.

[Dos and don'ts for crystalloids in intensive care medicine. Can too much water be bad?]. / Dos and Don'ts für Kristalloide in der Intensivmedizin. Kann zu viel Wasser schlecht sein?

Notwithstanding the use of colloids, crystalloids have a firm position in today's intensive care: In addition to the substitution as a basic requirement of the human organism or drug carriers, they are primarily used for volume replacement. A common complication is the development of interstitial edema, which is due to the composition of these solutions and the permeability of the glycocalyx.With the large variety available on the market, bicarbonate-based precursor isotonic-balanced full electrolyte solutions have become established in the meantime. The use of 0.9% saline solution is regarded as obsolete. With low cost and a good safety profile, a few relevant aspects, e.g., the risk of hypervolemia and electrolyte imbalance, must be taken into account in the use of crystalloids.

Early repair of open abdomen with a tailored two-component mesh and conditioning vacuum packing: a safe alternative to the planned giant ventral hernia.

PURPOSE: Once open abdomen therapy has succeeded, the problem of closing the abdominal wall must be addressed. We present a new four-stage procedure involving the application of a two-component mesh and vacuum conditioning for abdominal wall closure of even large defects. The aim is to prevent the development of a giant ventral hernia and the eventual need for the repair of the abdominal wall. METHODS: Nineteen of 62 patients treated by open abdomen over a two-year period could not receive primary abdominal wall closure. To achieve closure in these patients, we applied the following four-stage procedure: stage 1: abdominal damage control and conditioning of the abdominal wall; stage 2: attachment of a tailored two-component mesh of polyglycolic acid (PGA) and large pore polypropylene (PP) in intraperitoneal position (IPOM) plus placement of a vacuum bandage; stage 3: vacuum therapy for 3-4 weeks to allow granulation of the mesh and optimization of dermatotraction; stage 4: final skin suture. During stage 3, eligible patients were weaned from respirator and mobilized. RESULTS: The abdominal wall gap in the 19 patients ranged in size from 240 cm(2) to more than 900 cm(2). An average of 3.44 vacuum dressing changes over 19 days were required to achieve 60-100 % granulation of the surface area, so final skin suture could be made. Already in stage 3, 14 patients (73.68 %) could be weaned from respirator an average of 6.78 days after placement of the two-component mesh; 6 patients (31.57 %) could be mobilized on the edge of the bed and/or to a bedside chair after an average of 13 days. No mesh-related hematomas, seromas, or intestinal fistulas were observed. CONCLUSION: The four-stage procedure presented here is a viable option for achieving abdominal wall closure in patients treated with open abdomen, enabling us to avoid the development of planned giant ventral hernias. It has few complications and has the special advantage of allowing mobilization of the patients before final skin closure. Long-term course in a large number of patients must still confirm this result.

Pyoderma gangraenosum as rare complication of incisional hernia repair in a patient with Werlhof's disease.

On the 3rd day following surgery to repair an incisional hernia, a 67-year-old male patient with Werlhof's disease (idiopathic thrombocytopenic purpura) was diagnosed with a histologically confirmed pyoderma gangraenosum (PG), a rare complication of wound healing. Dexamethasone pulse therapy resulted in rapid remission of the skin lesions. Further improvement was slowed when the patient suffered multiple organ failure in the intensive care unit, delaying his transfer to rehabilitation for 8 weeks. Postoperative PG is always a differential diagnostic possibility in patients with sterile, progressive, painful, ulcerative skin lesions at or near the surgical wound. Unlike most wound healing complications, which are treated by debridement or antibiotics, the treatment of choice for PG is high-dose steroid therapy.

[Cytomegalovirus colitis in an elderly polytraumatised patient]. / Cytomegalievirus-Kolitis bei einer polytraumatisierten älteren Patientin.

HISTORY AND CLINICAL FINDINGS: During a long-term stay on a intensive-care unit a polytraumatised elderly patient developed hematochezia, which was refractory to blood transfusion. INVESTIGATIONS AND DIAGNOSIS: During colonoscopy, multiple ulcers were found in the right colon and rectum, and right hemicolectomy was performed after another massive anal blood loss. Histological findings showed characteristic intranuclear inclusions, positive Cytomegalovirus (CMV)-IgM titer and positive polymerase chain reaction (PCR) in blood. TREATMENT AND COURSE: After hemicolectomy, antiviral therapy with ganciclovir was initiated for two weeks intravenously, and no more gastrointestinal symptoms occurred. In the following days, enteral alimentation was continued without problems. CONCLUSIONS: CMV colitis should be considered in immunoincompetent patients after more common etiologies for severe diarrhea have been excluded. Timely diagnosis is essential to improve the outcome for elderly patients or patients with severe co-morbidities.