RESUMO
The anaesthetic management of multiple traumatic injuries poses numerous challenges. In this report, we present the cases of two patients with polytrauma including pneumothoraces and multiple rib fractures. The first patient, a 39-year-old man, presented with multiple left upper limb fractures, multiple bilateral rib fractures, bilateral pneumothoraces and fractures of multiple facial and cranial bones. The second patient, a 39-year-old woman, presented with right-sided radial and ulnar fractures, a right-sided pelvic fracture, and multiple right-sided rib fractures with an associated pneumothorax. We used ultrasound-guided superficial cervical plexus, interscalene and supraclavicular blocks in the first case and a combined spinal and epidural after ultrasound-guided fascia iliaca and supraclavicular blocks in the second case. In both cases, the use of multiple regional techniques allowed us to avoid the risks of general anaesthesia in patients with conservatively managed pneumothoraces.
RESUMO
Anthracyclines have been a cornerstone in the cure of diffuse large B-cell lymphoma (DLBCL) and other hematological cancers. The ability of anthracyclines to eliminate DLBCL depends on the presence of topoisomerase-II-alpha (TopIIA), a DNA repair enzyme complex. We identified nucleolin as a novel binding partner of TopIIA. Abrogation of nucleolin sensitized DLBCL cells to TopIIA targeting agents (doxorubicin/etoposide). Silencing nucleolin and challenging DLBCL cells with doxorubicin enhanced the phosphorylation of H2AX (γH2AX-marker of DNA damage) and allowed DNA fragmentation. Reconstitution of nucleolin expression in nucleolin-knockdown DLBCL cells prevented TopIIA targeting agent-induced apoptosis. Nucleolin binding to TopIIA was mapped to RNA-binding domain 3 of nucleolin, and this interaction was essential for blocking DNA damage and apoptosis. Nucleolin silencing decreased TopIIA decatenation activity, but enhanced formation of TopIIA-DNA cleavable complexes in the presence of etoposide. Moreover, combining nucleolin inhibitors: aptamer AS1411 or nucant N6L with doxorubicin reduced DLBCL cell survival. These findings are of clinical importance because low nucleolin levels versus high nucleolin levels in DLBCL predicted 90-month estimated survival of 70% versus 12% (P<0.0001) of patients treated with R-CHOP-based therapy.
Assuntos
Antineoplásicos/farmacologia , Linfoma Difuso de Grandes Células B/metabolismo , Fosfoproteínas/antagonistas & inibidores , Proteínas de Ligação a RNA/antagonistas & inibidores , Antineoplásicos/uso terapêutico , Linhagem Celular Tumoral , Dano ao DNA , DNA Topoisomerases Tipo II/metabolismo , Feminino , Expressão Gênica , Humanos , Linfoma Difuso de Grandes Células B/tratamento farmacológico , Linfoma Difuso de Grandes Células B/genética , Linfoma Difuso de Grandes Células B/mortalidade , Masculino , Terapia de Alvo Molecular , Fosfoproteínas/genética , Fosfoproteínas/metabolismo , Proteínas de Ligação a Poli-ADP-Ribose/antagonistas & inibidores , Proteínas de Ligação a Poli-ADP-Ribose/metabolismo , Proteínas de Ligação a RNA/genética , Proteínas de Ligação a RNA/metabolismo , NucleolinaRESUMO
The risks inherent in the use of homologous blood products have increased efforts toward identifying alternatives to transfusion. We have previously shown that the administration of recombinant human erythropoietin (rhEpo) enhances the erythropoietic response to acute blood loss. Recombinant human interleukin-3 (rh-IL-3) is a hematopoietic growth factor that has been shown to act synergistically with rhEpo in accelerating erythropoiesis in vitro. The purpose of this study in a primate model was to determine if the administration of rhIL-3 in combination with rhEpo could augment the erythropoietic response to acute blood loss more than rhEpo therapy alone. Twenty-four adult male baboons were randomized into four groups. The induction of acute normovolemic anemia to a hematocrit of 20% was accomplished via exchange-transfusion with 6% hetastarch. The groups were then treated for 7 consecutive days with the following growth factors: group I (n = 7), no growth factors; group II (n = 5), rhIL-3 alone (100 micrograms/kg/d); group III (n = 6), rhEpo alone (1000 U/kg/d); group IV (n = 6), rhEpo (1000 U/kg/d) plus rhIL-3 (100 micrograms/kg/d). All animals received folate, vitamin B12, and intravenous iron-dextran immediately following the exchange-transfusion. Response to therapy was monitored for 35 days. There were no adverse reactions following growth factor administration. The analysis of erythropoietic rates between study days 1 through 11, as determined via linear regression analysis, revealed that hematocrits increased significantly faster in the groups receiving rhEpo compared to controls. The administration of rhIL-3, however, did not increase the rate of erythropoiesis when compared to controls, nor did it augment response when added to the rhEpo regimen. The results of this study demonstrate that the administration of rhIL-3 alone had no significant effect on erythropoiesis in this setting of acute blood loss. Further, despite promising in vitro data, rhIL-3 provided no additional stimulation of erythropoiesis in animals receiving rhEpo. Nevertheless, the study confirms that the pharmacologic acceleration of erythropoiesis by rhEpo alone remains an attractive alternative to homologous transfusion.
Assuntos
Anemia/sangue , Eritropoese/efeitos dos fármacos , Eritropoetina/farmacologia , Interleucina-3/farmacologia , Doença Aguda , Análise de Variância , Anemia/tratamento farmacológico , Animais , Contagem de Células Sanguíneas/efeitos dos fármacos , Modelos Animais de Doenças , Quimioterapia Combinada , Eritropoetina/uso terapêutico , Interleucina-3/uso terapêutico , Masculino , Papio , Proteínas Recombinantes/farmacologia , Proteínas Recombinantes/uso terapêuticoRESUMO
Polymerization of pyridoxylated stroma free hemoglobin (poly SFH-P) yields a solution with a normal hemoglobin concentration, normal colloid osmotic pressure (COP), and a suitable P50. In the present study we compared its in vivo O2-carrying capacity and intravascular persistence with those of pyridoxylated hemoglobin (SFH-P), following a partial exchange transfusion (900 ml) in adult baboons (n = 4 in each group). Poly SFH-P in plasma had an O2-carrying capacity that was 77% greater than that achieved with SFH-P (8.0 versus 4.5 vol%). Furthermore, poly SFH-P provided 5.0 vol% at the end of 24 hours and 2.5 vol% at the end of 48 hours; in contrast SFH-P provided only 2.2 vol% at the end of 6 hours and none within 24 hours. A normal COP was maintained throughout the postexchange period with poly SFH-P despite a 68% increase in plasma protein concentration (from 7.1 to 11.9 gm/dl). The plasma P50 of poly SFH-P decreased from 16 torr immediately after exchange to 12 torr at the end of 48 hours. The in vivo rate of conversion to methemoglobin was similar with both solutions. Polymerized pyridoxylated hemoglobin is currently the only modification of hemoglobin solution that approximates the O2-carrying capacity of whole blood and can be infused without altering the plasma COP.
Assuntos
Substitutos Sanguíneos , Hemoglobinas/fisiologia , Oxigênio/sangue , Animais , Proteínas Sanguíneas/análise , Transfusão Total , Peso Molecular , Papio , Distribuição Aleatória , Fatores de TempoRESUMO
Efforts to produce a clinically acceptable hemoglobin solution that could function as a temporary oxygen carrier have evolved through several stages. Beginning with the simple tetramer, we have lowered the affinity state by pyridoxylation and then polymerized the modified tetramer. This new substance, polyhemoglobin, has a normal oxygen capacity and a half-life of 38 hours. Issues of nephrotoxicity and immunocompetence after infusion remain to be defined.
Assuntos
Substitutos Sanguíneos , Hemoglobinas , Animais , Substitutos Sanguíneos/efeitos adversos , Fenômenos Químicos , Química , Transfusão Total , Hematócrito , Hemoglobinas/efeitos adversos , Hemoglobinas/análise , Humanos , Imunocompetência , Nefropatias/etiologia , Masculino , Pressão Osmótica , Oxigênio/sangue , Consumo de Oxigênio , Papio , Pressão Parcial , RatosRESUMO
The risk of homologous blood may cause physicians to withhold red cell treatment after acute blood loss. We believe that in the euvolemic patient with acute anemia, the heart is the principal organ at risk. The cardiac compensation to extreme anemia is unknown and is the purpose of this report. Fourteen adult baboons were anesthetized, paralyzed, and ventilated with room air. Left atrial and coronary sinus catheters were inserted surgically. Experimental animals (n = 7) were hemodiluted at constant left atrial pressure with 5% human serum albumin. Control animals (n = 7) underwent similar volume exchanges with fresh, cross-matched, homologous red blood cells resuspended in human serum albumin, also at constant left atrial pressure. Six of seven experimental animals survived until hematocrit levels were 4%. Adequate cardiac compensation was observed until hematocrit levels were less than 10%. Increased flow, without increases in the O2 extraction ratio, was the mechanism of compensation used by the healthy heart with patent coronary vessels.
Assuntos
Anemia/fisiopatologia , Coração/fisiopatologia , Adaptação Fisiológica , Anemia/sangue , Anemia/metabolismo , Anemia/terapia , Animais , Transfusão de Sangue , Débito Cardíaco , Transfusão Total , Hematócrito , Lactatos/metabolismo , Miocárdio/metabolismo , Oxigênio/sangue , Consumo de Oxigênio , Papio , Albumina Sérica/administração & dosagem , Resistência VascularRESUMO
The risks of transfusion-associated infectious disease have made increased efforts to avoid homologous transfusion imperative. Little attention has been focused on efforts to accelerate erythropoiesis as a method of reducing homologous blood use. Recombinant human erythropoietin (rHuEPO) has been shown to enhance erythropoiesis. The purpose of this study was to evaluate the effects of perioperative rHuEPO administration on postoperative erythropoiesis. Fifteen baboons were divided into three groups of five each. Group I received no rHuEPO. Group II received five daily preoperative doses of rHuEPO (1000 U/kg). Group III received five daily preoperative doses and 14 daily postoperative doses of rHuEPO (1000 U/kg). All animals underwent a laparotomy followed by an exchange transfusion to a final hematocrit of 15%. The time in days required to recover to hematocrits of 20% was significantly shorter in both groups that received preoperative doses of rHuEPO when compared with that of controls (3.3 vs 5.7 days, p less than 0.01). The recovery times to hematocrits of 25%, 30%, and baseline levels were all significantly shorter in the group that received both preoperative and postoperative doses of rHuEPO. The data show that perioperative dosage of rHuEPO significantly accelerates postoperative erythropoiesis. Perioperative administration of rHuEPO may reduce the requirements for homologous transfusion.
Assuntos
Eritropoetina/uso terapêutico , Cuidados Pré-Operatórios , Animais , Análise Química do Sangue , Contagem de Células/efeitos dos fármacos , Eritropoetina/sangue , Transfusão Total , Hematócrito , Humanos , Masculino , Papio , Contagem de Plaquetas/efeitos dos fármacos , Cuidados Pós-Operatórios , Período Pós-Operatório , Proteínas Recombinantes , Reticulócitos/citologiaRESUMO
Risks of transfusion are minimized with autologous blood. However, autologous donation programs require 2 to 5 weeks to yield only 2.2 units per patient. Recombinant human erythropoietin (r-HuEPO) has been shown to increase erythropoiesis. This study evaluated the effects of r-HuEPO on an aggressive autologous donation program. Twelve adult male baboons were randomized into two groups of six. All animals were studied three times per week for 5 weeks. A unit of blood was donated when on any study day the hematocrit was greater than 30%. Animals received intravenously either 750 units/kg of r-HuEPO (n = 6) or placebo (n = 6) on each study day. Iron dextran was given intravenously to replace 150% of shed iron. The r-HuEPO group had an earlier onset of reticulocytosis (2.7 vs 5.5 days, p less than 0.01) and donated 35% more blood (13.5 vs 10.0 units, p = 0.01) than the control group. No adverse reactions to r-HuEPO were observed. The data show that an aggressive autologous donation program can yield 10 units of blood over a 5-week period. Further, r-HuEPO increases that yield by an additional 35%. This aggressive autologous donation program with r-HuEPO may significantly reduce the need for homologous transfusion and its attendant risks.
Assuntos
Transfusão de Sangue Autóloga , Eritropoetina/farmacologia , Hematopoese/efeitos dos fármacos , Animais , Hematócrito , Humanos , Complexo Ferro-Dextran/uso terapêutico , Contagem de Leucócitos , Masculino , Papio , Distribuição Aleatória , Proteínas Recombinantes/farmacologia , ReticulócitosRESUMO
Hemoglobin solutions are undergoing clinical trials as erythrocyte substitutes. Some of these solutions have higher O2 affinities compared with normal erythrocyte hemoglobin. Also, they appear to interact with endothelial-derived smooth muscle relaxation. The purpose of this study was to evaluate the nature and limits of compensation to acute normovolemic anemia in the erythrocyte-free primate maintained with a hemoglobin solution. The experimental group consisted of six anesthetized paralyzed adult baboons (Papio anubis) that were exchange transfused (ET) with a pyridoxylated polymerized hemoglobin solution [hemoglobin concentration [( Hb]) = 14 g/dl, O2 half-saturation pressure of hemoglobin (P50) = 19.6 Torr] until a hematocrit less than 1% was achieved. They underwent a second ET with Dextran-70 until [Hb] = 1 g/dl. A control group (n = 6) underwent an ET with Dextran-70 until [Hb] = 1 g/dl. Both groups maintained O2 consumption (VO2) until [Hb] = 3 g/dl. Both groups were stable until [Hb] less than 1 g/dl, and both groups increased their cardiac output. The relation between VO2 and O2 delivery was similar for both groups. In vivo P50 and mixed venous O2 tension were significantly lower in the experimental group. The nature and limits of compensation to diminished O2 delivery due to anemia were similar in the two groups.
Assuntos
Anemia/terapia , Substitutos Sanguíneos/uso terapêutico , Anemia/sangue , Anemia/fisiopatologia , Animais , Substitutos Sanguíneos/administração & dosagem , Débito Cardíaco , Estudos de Avaliação como Assunto , Transfusão Total , Feminino , Hemoglobinas/administração & dosagem , Hemoglobinas/metabolismo , Oxigênio/sangue , Papio , SoluçõesRESUMO
Erythropoietin is the primary regulator of erythropoiesis. Erythropoietin has been shown to increase exponentially in response to linear decreases in hematocrit in normal, unstressed animals. However, the effect of operation, with its attendant stress, on erythropoietin levels is unknown. The purpose of this study is to evaluate the effect of surgical stress on erythropoietin. Twenty otherwise healthy patients scheduled for elective surgical procedures were studied. The cholecystectomy group included 10 patients who underwent cholecystectomy for documented stone disease. Ten patients who underwent coronary artery bypass procedures constituted the coronary artery bypass grafting group. Patients were studied preoperatively as well as on the first and second postoperative days. The hematocrit and erythropoietin levels were similar in both groups preoperatively. The hematocrit in the coronary artery bypass grafting group was lower than that of the cholecystectomy group on postoperative day 1 (0.31 versus 0.36; p less than 0.003) and postoperative day 2 (0.30 versus 0.36; p less than 0.001). During the first two postoperative days the erythropoietin levels were similar between groups. The data show that postoperative erythropoietin levels are similar after coronary artery bypass grafting, despite more severe anemia, when compared with cholecystectomy. This suggests that after coronary artery bypass grafting there is a relative deficiency of erythropoietin. Administration of recombinant human erythropoietin to patients undergoing surgical procedures could correct the erythropoietin deficiency and accelerate postoperative erythropoiesis.
Assuntos
Ponte de Artéria Coronária/efeitos adversos , Eritropoetina/deficiência , Adulto , Idoso , Nitrogênio da Ureia Sanguínea , Creatinina/sangue , Feminino , Hematócrito , Humanos , Masculino , Pessoa de Meia-Idade , Contagem de Plaquetas , Estresse Fisiológico/complicaçõesRESUMO
Attempts to develop a hemoglobin-based red cell substitute have spanned many decades, but no clinically useful product has been produced to date. The issues preventing clinical application primarily are ones of safety--not efficacy. Numerous animal studies have documented the efficacy of SFH. Although effective, the solution has limitations that have caused concern. Oncotic considerations limit the concentration of the infusate SFH to 6 to 8 g/dL, or half-normal. Owing to the loss of organic phosphate modulators of P50, such as 2,3-DPG, the P50 of SFH is typically between 12 and 14 mm Hg, which is also half the normal value. And finally, the intravascular half-life of SFH is too short, ranging only from 2 to 6 hr. Polymerization provides a means of correcting these limitations. The high oxygen affinity can be greatly diminished by covalent binding of pyridoxal-5'-phosphate to the N-terminal of the chains. Colloid osmotic pressure exerted by a protein solution is proportional to the number of discrete colloid particles. Through polymerization, the number of colloid particles is reduced, leading to a decrease in COP. Data show that this can be achieved in a reproducible fashion. The rate at which COP diminishes determines the yield of polymeric species, as well as their molecular weight distribution. Polymerization can be controlled to result in a yield of 75% to 85% polymers with a molecular weight distribution of 128 to 400 kd. The number average and the weight average molecular weights indicate that the large proportion of polymers represent the cross linking of two tetramers. The data that reflect the interaction of oxygen with poly-SFH-P indicate that the oxygen carrying function of hemoglobin has not been significantly altered by the chemical modifications. The binding coefficient of oxygen is unchanged. As anticipated, there is a loss of cooperativity (diminished Hill coefficient) between the hemoglobin chains, suggesting structural restrictions in the polymeric species because of cross linking. A reduced alkaline Bohr effect is the expected result, and data confirm this. Finally, some increase in oxygen affinity is to be expected with polymerization. This is indeed the case, although the P50 of poly-SFH-P is comparable to banked blood (18 to 22 mm Hg). To be clinically useful, a modified hemoglobin solution requires a reasonable shelf-life.(ABSTRACT TRUNCATED AT 400 WORDS)
Assuntos
Substitutos Sanguíneos/uso terapêutico , Hemoglobinas/uso terapêutico , Gasometria , Substitutos Sanguíneos/efeitos adversos , Substitutos Sanguíneos/farmacologia , Débito Cardíaco , Hematócrito , Hemoglobinas/efeitos adversos , Hemoglobinas/farmacologia , Humanos , Pressão Osmótica , Consumo de Oxigênio , PolímerosRESUMO
This article defines a rational approach to the treatment of hemorrhagic shock. All patients that are hypovolemic following hemorrhage require fluid resuscitation. Some patients require red cell restoration and very few require correction of any clotting deficiencies. A physiologic approach to these problems will lead to optimal patient care in these circumstances.
Assuntos
Hidratação/métodos , Ressuscitação/métodos , Choque , Transfusão de Sangue , Ensaios Clínicos como Assunto , Coloides/uso terapêutico , Cuidados Críticos , Soluções Cristaloides , Hemodinâmica , Humanos , Soluções Isotônicas , Consumo de Oxigênio , Substitutos do Plasma/uso terapêutico , Choque/metabolismo , Choque/fisiopatologia , Choque/terapiaRESUMO
BACKGROUND: Even though low molecular weight heparins (LMWHs) have become the standard for venous thromboembolism (VTE) prophylaxis in most European countries and Canada, it was not until recently that LMWHs were approved for use in the United States. The main objective of this study was to assess the current preferences and attitudes of United States surgeons toward the prevention of VTE with particular reference to LMWH. METHODS: A survey with questions relative to VTE awareness, risk factors, and prevention practices was mailed to 10,000 Fellows of the American College of Surgeons. RESULTS: A total of 1,145 (11.45%) usable questionnaires were returned. The vast majority (96%) of respondents use prophylaxis against VTE. Although LMWHs were rated first regarding efficacy and second regarding simplicity of use, conventional unfractionated heparin at fixed doses remains the preferred pharmacological agent for VTE prevention (74%), followed by 2 LMWHs: enoxaparin (34%) and dalteparin (16%). Overall, 52% of surgeons preferred physical methods over pharmacological methods when used separately and 26% of surgeons utilize combined physical-pharmacological modalities. CONCLUSIONS: North American general surgeons have substantially modified their approach to VTE prevention in the last 4 years. Physical methods and unfractionated heparin remain the preferred prophylactic modalities, but LMWHs have gained rapid acceptance since their approval for use for VTE prevention in North America. Even though the results of this survey must be interpreted with caution because of the limited response rate and possible sampling bias, they still reflect the current preferences and attitudes of North American surgeons toward prophylaxis.
Assuntos
Anticoagulantes/uso terapêutico , Cirurgia Geral , Heparina de Baixo Peso Molecular/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Tromboembolia/prevenção & controle , Trombose Venosa/prevenção & controle , Anticoagulantes/economia , Atitude do Pessoal de Saúde , Bandagens/economia , Análise Custo-Benefício/economia , Pesquisas sobre Atenção à Saúde , Heparina de Baixo Peso Molecular/economia , Humanos , Incidência , Complicações Pós-Operatórias/epidemiologia , Guias de Prática Clínica como Assunto , Fatores de Risco , Índice de Gravidade de Doença , Inquéritos e Questionários , Tromboembolia/complicações , Tromboembolia/diagnóstico , Resultado do Tratamento , Ultrassonografia Doppler Dupla , Estados Unidos/epidemiologia , Trombose Venosa/complicações , Trombose Venosa/diagnósticoRESUMO
Impaired Fas-mediated apoptosis is associated with poor clinical outcomes and cancer chemoresistance. Soluble Fas receptor (sFas), produced by skipping of exon 6, inhibits apoptosis by sequestering Fas ligand. Serum sFas is associated with poor prognosis of non-Hodgkin's lymphomas. We found that the alternative splicing of Fas in lymphomas is tightly regulated by a long-noncoding RNA corresponding to an antisense transcript of Fas (FAS-AS1). Levels of FAS-AS1 correlate inversely with production of sFas, and FAS-AS1 binding to the RBM5 inhibits RBM5-mediated exon 6 skipping. EZH2, often mutated or overexpressed in lymphomas, hyper-methylates the FAS-AS1 promoter and represses the FAS-AS1 expression. EZH2-mediated repression of FAS-AS1 promoter can be released by DZNeP (3-Deazaneplanocin A) or overcome by ectopic expression of FAS-AS1, both of which increase levels of FAS-AS1 and correspondingly decrease expression of sFas. Treatment with Bruton's tyrosine kinase inhibitor or EZH2 knockdown decreases the levels of EZH2, RBM5 and sFas, thereby enhancing Fas-mediated apoptosis. This is the first report showing functional regulation of Fas repression by its antisense RNA. Our results reveal new therapeutic targets in lymphomas and provide a rationale for the use of EZH2 inhibitors or ibrutinib in combination with chemotherapeutic agents that recruit Fas for effective cell killing.
Assuntos
Linfoma de Células B/sangue , Linfoma de Células B/genética , RNA Antissenso/genética , RNA Longo não Codificante/genética , Receptor fas/sangue , Receptor fas/genética , Adenina/análogos & derivados , Processamento Alternativo , Apoptose/genética , Proteínas de Ciclo Celular/genética , Proteínas de Ciclo Celular/metabolismo , Linhagem Celular Tumoral , Metilação de DNA , Proteínas de Ligação a DNA/genética , Proteínas de Ligação a DNA/metabolismo , Proteína Potenciadora do Homólogo 2 de Zeste , Proteína Ligante Fas/metabolismo , Regulação Neoplásica da Expressão Gênica/efeitos dos fármacos , Técnicas de Silenciamento de Genes , Histonas/metabolismo , Humanos , Íntrons , Linfoma de Células B/metabolismo , Modelos Biológicos , Piperidinas , Complexo Repressor Polycomb 2/genética , Complexo Repressor Polycomb 2/metabolismo , Ligação Proteica , Pirazóis/farmacologia , Pirimidinas/farmacologia , Proteínas de Ligação a RNA/genética , Proteínas de Ligação a RNA/metabolismo , Proteínas Supressoras de Tumor/genética , Proteínas Supressoras de Tumor/metabolismoRESUMO
A five-year-old child with severe arthrogryposis multiplex congenita and malnutrition underwent surgery for chronic osteomyelitis of the head of the left humerus. The child had typical features of arthrogryposis multiplex congenita, including a difficult airway. Propofol was used for induction and maintenance. Spontaneous respiration was maintained with a nasal airway. Analgesia was provided with an interscalene brachial plexus block placed using a nerve stimulator. No opioid was given. The child had an uneventful recovery with good postoperative analgesia. The anaesthetic implications of arthrogryposis multiplex congenita are discussed.
Assuntos
Artrogripose/cirurgia , Plexo Braquial , Bloqueio Nervoso , Articulação do Ombro/cirurgia , Pré-Escolar , Humanos , MasculinoRESUMO
PURPOSE: The use of intermittent pneumatic compression, in addition to elastic bandages or stockings, accelerates the healing of leg ulcers in patients with severe chronic venous insufficiency (CVI). There is recent evidence that impulse compression of the plantar venous plexus reduces post-traumatic ankle swelling and prevents postoperative venous thromboembolism. The purpose of this study was to evaluate the clinical and hemodynamic responses after home use of impulse foot compression for 3 months in patients already using therapeutic compression stockings for the management of CVI. METHODS: Twelve extremities from 9 patients with documented CVI, class 4 to 5 according to the Clinical, Etiology, Anatomy, Pathophysiology classification system, were included in this prospective cohort study. All patients were instructed to use a foot pump device at home for 2 hours a day for 3 months in addition to therapeutic compression stockings (30-40 mm Hg) worn during the day. The device was set to three cycles (3 seconds) of compression (120 mm Hg) per minute. A clinical scoring system was completed before foot compression and 1, 2, and 3 months thereafter. In addition, all patients underwent air plethysmography studies at the same time intervals, including venous volume, venous filling index, ejection fraction, and residual volume fraction. RESULTS: Patients reported significant improvement in their scores for swelling (P <.05) and pain (P <.04). Air plethysmography showed a reduction in venous volume and venous filling index, although these differences were not significant. Ejection fraction remained unchanged and residual volume fraction was significantly reduced (P <.05) compared with baseline. The foot compression devices were well tolerated by all the patients in the study. CONCLUSIONS: The use of home foot impulse compression plus elastic stockings significantly reduced the residual volume fraction as measured by air-plethysmography in a group of patients with severe CVI. This favorable hemodynamic response could, in part, explain the clinical improvement achieved by this combined treatment. However, this represents a preliminary pilot study that needs to be confirmed in future randomized controlled studies with more patients included.