Pedicled double-paddle conjoined medial sural artery perforator flap for popliteal defect coverage after skin tumor excision: A case report.

Defect coverage in the popliteal region represents a challenging task because of its peculiar features. The tissue here has to be thin and pliable, to enable proper function, but also resistant to the high stress forces typical of this region. In addition, the adjacent skin is limited in availability and mobility. Therefore, complex reconstruction procedures are usually required to cover defects in the popliteal region. The medial sural artery perforator (MSAP) flap is a thin and pliable flap, with a long arc of rotation provided by its pedicle length, which makes it a suitable procedure for local and regional defects reconstruction. In the present work, we report the use of a pedicled double-paddle conjoined MSAP flap to reconstruct a 7 cm × 7 cm soft tissue defect after resection of a basal cell carcinoma in the popliteal fossa. The MSAP flap was based on two perforators of the medial sural artery. Therefore, the cutaneous island could be split into two islands, which were rearranged to cover the defect side by side in a so-called "kissing flap" technique. The further postoperative course was uneventful. Despite the complex perforator dissection, which can be challenging because of its intramuscular dissection, we believe that the MSAP flap represents a valid solution for local defect coverage in the popliteal region, providing a sufficient amount of tissue and meeting the "like-with-like" criteria.

A novel capnogram analysis to guide ventilation during cardiopulmonary resuscitation: clinical and experimental observations.

BACKGROUND: Cardiopulmonary resuscitation (CPR) decreases lung volume below the functional residual capacity and can generate intrathoracic airway closure. Conversely, large insufflations can induce thoracic distension and jeopardize circulation. The capnogram (CO2 signal) obtained during continuous chest compressions can reflect intrathoracic airway closure, and we hypothesized here that it can also indicate thoracic distension. OBJECTIVES: To test whether a specific capnogram may identify thoracic distension during CPR and to assess the impact of thoracic distension on gas exchange and hemodynamics. METHODS: (1) In out-of-hospital cardiac arrest patients, we identified on capnograms three patterns: intrathoracic airway closure, thoracic distension or regular pattern. An algorithm was designed to identify them automatically. (2) To link CO2 patterns with ventilation, we conducted three experiments: (i) reproducing the CO2 patterns in human cadavers, (ii) assessing the influence of tidal volume and respiratory mechanics on thoracic distension using a mechanical lung model and (iii) exploring the impact of thoracic distension patterns on different circulation parameters during CPR on a pig model. MEASUREMENTS AND MAIN RESULTS: (1) Clinical data: 202 capnograms were collected. Intrathoracic airway closure was present in 35%, thoracic distension in 22% and regular pattern in 43%. (2) Experiments: (i) Higher insufflated volumes reproduced thoracic distension CO2 patterns in 5 cadavers. (ii) In the mechanical lung model, thoracic distension patterns were associated with higher volumes and longer time constants. (iii) In six pigs during CPR with various tidal volumes, a CO2 pattern of thoracic distension, but not tidal volume per se, was associated with a significant decrease in blood pressure and cerebral perfusion. CONCLUSIONS: During CPR, capnograms reflecting intrathoracic airway closure, thoracic distension or regular pattern can be identified. In the animal experiment, a thoracic distension pattern on the capnogram is associated with a negative impact of ventilation on blood pressure and cerebral perfusion during CPR, not predicted by tidal volume per se.

Pedicled double-paddle vertical posteromedial thigh flap for double-layer closure and reconstruction of upper thigh defect after sarcoma resection: A case report.

Large soft tissue defects in the anterior upper thigh region represent a challenging problem in reconstructive surgery. Sarcomas are rather commonly localized in this area and they may reach extensive dimensions before surgery. The debulking procedures must be radical, which often leads to a displacement of major neurovascular structures. In the present work, we report the use of a pedicled double-paddle vertical posteromedial thigh (vPMT) flap to reconstruct a 16 cm × 8 cm soft tissue defect with exposure of the superficial and deep femoral vessels after resection of a myxoid liposarcoma. The vPMT flap was based on two perforators of the profunda femoris artery. Therefore, the cutaneous island could be split into two islands measuring 12 cm × 6 cm and 9 cm × 6 cm, which were exploited to fill the dead space below and over the vessels, reaching a satisfactory volume restoration and tension-free skin closure. The further post-operative course was uneventful. The perforator dissection might be complex and requires a good experience, however, we believe that in similar cases the pedicled double-paddle vPMT flap can be a valid solution when other options are not feasible. Moreover, this allows avoiding a free microsurgical transfer and fulfills the dictum of replacing "like-with-like tissue". No characterizations of the employment of a pedicled chimeric vPMT flap for locoregional multilayer reconstruction are available so far.

Hemodynamic and anti-inflammatory effects of early esmolol use in hyperkinetic septic shock: a pilot study.

BACKGROUND: Several studies have shown that heart rate control with selective beta-1 blockers in septic shock is safe. In these trials, esmolol was administered 24 h after onset of septic shock in patients who remained tachycardic. While an earlier use of beta-blockers might be beneficial, such use remains challenging due to the difficulty in distinguishing between compensatory and non-compensatory tachycardia. Therefore, the Esmosepsis study was designed to study the effects of esmolol aimed at reducing the heart rate by 20% after the initial resuscitation process in hyperkinetic septic shock patients on (1) cardiac index and (2) systemic and regional hemodynamics as well as inflammatory patterns. METHODS: Nine consecutive stabilized tachycardic hyperkinetic septic shock patients treated with norepinephrine for a minimum of 6 h were included. Esmolol was infused during 6 h in order to decrease the heart rate by 20%. The following data were recorded at hours H0 (before esmolol administration), H1-H6 (esmolol administration) and 1 h after esmolol cessation (H7): systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, central venous pressure, heart rate, PICCO transpulmonary thermodilution, sublingual and musculo-cutaneous microcirculation, indocyanine green clearance and echocardiographic parameters, diuresis, lactate, and arterial and venous blood gases. RESULTS: Esmolol was infused 9 (6.4-11.6) hours after norepinephrine introduction. Esmolol was ceased early in 3 out of 9 patients due to a marked increase in norepinephrine requirement associated with a picture of persistent cardiac failure at the lowest esmolol dose. For the global group, during esmolol infusion, norepinephrine infusion increased from 0.49 (0.34-0.83) to 0.78 (0.3-1.11) µg/min/kg. The use of esmolol was associated with a significant decrease in heart rate from 115 (110-125) to 100 (92-103) beats/min and a decrease in cardiac index from 4.2 (3.1-4.4) to 2.9 (2.5-3.7) l/min/m-2. Indexed stroke volume remained unchanged. Cardiac function index and global ejection fraction also markedly decreased. Using echocardiography, systolic, diastolic as well as left and right ventricular function parameters worsened. After esmolol cessation, all parameters returned to baseline values. Lactate and microcirculatory parameters did not change while the majority of pro-inflammatory proteins decreased in all patients. CONCLUSION: In the very early phase of septic shock, heart rate reduction using fast esmolol titration is associated with an increased risk of hypotension and decreased cardiac index despite maintained adequate tissue perfusion (NCT02068287).

Free double-paddle posterior tibial artery perforator flap for hypopharynx reconstruction: A case report and literature review.

Microsurgical free tissue transfer is nowadays considered to be one of the main options for head and neck reconstruction. The free posterior tibial artery perforator (PTAP) flap is a well-known reconstructive technique for local defect coverage in the distal leg, and only recently has been employed for head and neck reconstructions. Being a very thin and pliable flap, with low donor site morbidity and constant anatomy, the PTA perforator-based flap could be a great alternative to the more commonly-employed radial forearm free flap (RFFF). The present case report shows a complex head and neck defect coverage by means of a free double-paddle PTA flap, with a concise literature review of previous PTA flap descriptions in this setting. A 59-year-old male patient presented with a hypopharynx leakage after radiotherapy due to hypopharynx carcinoma. Since the patient had an occluded ulnar artery on the left side and an arterial line in the radial artery on the right side, both a RFFF and an ulnar artery perforator (UAP) flap were contraindicated. Moreover, two different cutaneous flaps were needed to reconstruct a 6 × 8 cm2 defect, one for the reconstruction of the hypopharynx and one for the resurfacing of the neck, since previous surgeries and radiotherapy led to severe fibrosis of the neck. The patient had a BMI of 25.4 kg/m2, which led us to exclude the anterolateral thigh (ALT) flap because of its thickness. For the forementioned reasons, an unconventional double-paddle PTAP flap based on two perforator vessels was chosen. Based on two perforators, two skin islands were harvested, building a double-paddle PTA perforator-based flap. The proximal skin island was 6 × 7 cm2 and the distal one was 6 × 4 cm2 . The larger skin flap was set at the leakage of the hypopharynx. The smaller skin island was used to monitor the survival of the whole flap and for resurfacing the outer side of the neck. The postoperative course was uneventful and at 3 months follow up the reconstructive result was good with no functional drawback. In view of the obtained result, we can consider that the PTA flap might be a reliable alternative to the much widely used RFFF, with a minor donor site morbidity, for delicate head and neck reconstructions.

Vasoplegia treatments: the past, the present, and the future.

Vasoplegia is a ubiquitous phenomenon in all advanced shock states, including septic, cardiogenic, hemorrhagic, and anaphylactic shock. Its pathophysiology is complex, involving various mechanisms in vascular smooth muscle cells such as G protein-coupled receptor desensitization (adrenoceptors, vasopressin 1 receptors, angiotensin type 1 receptors), alteration of second messenger pathways, critical illness-related corticosteroid insufficiency, and increased production of nitric oxide. This review, based on a critical appraisal of the literature, discusses the main current treatments and future approaches. Our improved understanding of these mechanisms is progressively changing our therapeutic approach to vasoplegia from a standardized to a personalized multimodal treatment with the prescription of several vasopressors. While norepinephrine is confirmed as first line therapy for the treatment of vasoplegia, the latest Surviving Sepsis Campaign guidelines also consider that the best therapeutic management of vascular hyporesponsiveness to vasopressors could be a combination of multiple vasopressors, including norepinephrine and early prescription of vasopressin. This new approach is seemingly justified by the need to limit adrenoceptor desensitization as well as sympathetic overactivation given its subsequent deleterious impacts on hemodynamics and inflammation. Finally, based on new pathophysiological data, two potential drugs, selepressin and angiotensin II, are currently being evaluated.

Daily Telephone Call During the COVID-19 Pandemic: Perceptions of Families and Providers.

BACKGROUND: In intensive care units (ICUs), the quality of communication with families is a key point in the caregiver-patient-family relationship. During the COVID-19 pandemic, hospital visits were prohibited, and many ICUs implemented a daily telephone call strategy to ensure continuity of communication with patients' families. OBJECTIVE: To assess how family members and health care providers perceived this communication strategy. METHODS: The study was conducted in a 45-bed ICU during the COVID-19 pandemic. Communication with families consisted of a single daily telephone call from the senior physician in charge of the patient to the patient's surrogate decision maker. Satisfaction was qualitatively assessed via an anonymous online questionnaire with open-ended questions. RESULTS: Participants completed 114 questionnaires. Forty-six percent of surrogate decision makers stated that the key medical messages were understandable, but 57% of other family members expressed that the frequency of information delivery was insufficient. Fifty-six percent of the physicians described the practice as functional for the organization of the unit. Among health care providers other than physicians, 55% felt that not having to interact with families decreased their emotional load and 50% mentioned saving time and the absence of task interruptions as positive aspects. CONCLUSION: Fixed-time, daily telephone calls in the ICU allowed satisfactory transmission of information between physicians and surrogate decision makers, as perceived by both parties. However, the telephone-based communication strategy could still be improved.

IMPACT OF DIFFERENT VENTILATION STRATEGIES ON GAS EXCHANGES AND CIRCULATION DURING PROLONGED MECHANICAL CARDIO-PULMONARY RESUSCITATION IN A PORCINE MODEL.

ABSTRACT: Background: Optimal ventilation during cardio-pulmonary resuscitation (CPR) is still controversial. Ventilation is expected to provide sufficient arterial oxygen content and adequate carbon dioxide removal, while minimizing the risk of circulatory impairment. The objective of the present study was to compare three ventilation strategies in a porcine model during mechanical continuous chest compressions (CCC) according to arterial oxygenation and hemodynamic impact. Method: Ventricular fibrillation was induced and followed by five no-flow minutes and thirty low-flow minutes resuscitation with mechanical-CCC without vasopressive drugs administration. Three groups of eight Landras pig were randomized according to the ventilation strategy: 1. Standard nonsynchronized volume-control mode (SD-group); 2. synchronized bilevel pressure-controlled ventilation (CPV-group); 3. continuous insufflation with Boussignac Cardiac-Arrest Device (BC-group). We assessed 1. arterial blood gases, 2. macro hemodynamics, 3. tissular cerebral macro and micro-circulation and 4. airway pressure, minute ventilation at baseline and every 5 minutes during the protocol. Results: Arterial PaO2 level was higher at each measurement time in SD-group (>200 mm Hg) compare to CPV-group and BC-group ( P < 0.01). In BC-group, arterial PaCO2 level was significantly higher (>90mm Hg) than in SD and CPV groups ( P < 0.01). There was no difference between groups concerning hemodynamic parameters, cerebral perfusion and microcirculation. Conclusion: Ventilation modalities in this porcine model of prolonged CPR influence oxygenation and decarboxylation without impairing circulation and cerebral perfusion. Synchronized bi-level pressure-controlled ventilation' use avoid hyperoxia and was as efficient as asynchronized volume ventilation to maintain alveolar ventilation and systemic perfusion during prolonged CPR.

Mildly Reduced Doses of Adrenaline Do Not Affect Key Hemodynamic Parameters during Cardio-Pulmonary Resuscitation in a Pig Model of Cardiac Arrest.

Adrenaline is recommended for cardiac arrest resuscitation, but its effectiveness has been questioned recently. Achieving return of spontaneous circulation (ROSC) is essential and is obtained by increasing coronary perfusion pressure (CPP) after adrenaline injection. A threshold as high as 35 mmHg of CPP may be necessary to obtain ROSC, but increasing doses of adrenaline might be harmful to the brain. Our study aimed to compare the increase in CPP with reduced doses of adrenaline to the recommended 1 mg dose in a pig model of cardiac arrest. Fifteen domestic pigs were randomized into three groups according to the adrenaline doses: 1 mg, 0.5 mg, or 0.25 mg administered every 5 min. Cardiac arrest was induced by ventricular fibrillation; after 5 min of no-flow, mechanical chest compression was resumed. The Wilcoxon test and Kruskal-Wallis exact test were used for the comparison of groups. Fisher's exact test was used to compare categorical variables. CPP, EtCO2 level, cerebral, and tissue near-infrared spectroscopy (NIRS) were measured. CPP was significantly lower in the 0.25 mg group 90 s after the first adrenaline injection: 28.9 (21.2; 35.4) vs. 53.8 (37.8; 58.2) in the 1 mg group (p = 0.008), while there was no significant difference with 0.5 mg 39.6 (32.7; 52.5) (p = 0.056). Overall, 0.25 mg did not achieve the threshold of 35 mmHg. EtCO2 levels were higher at T12 and T14 in the 0.5 mg than in the standard group: 32 (23; 35) vs. 19 (16; 26) and 26 (20; 34) vs. 19 (12; 22) (p < 0.05). Cerebral and tissue NIRS did not show a significant difference between the three groups. CPP after 0.5 mg boluses of adrenaline was not significantly different from the recommended 1 mg in our model of cardiac arrest.

Percutaneous cannulation for extracorporeal membrane oxygenation (ECMO): A method for pig experimental models.

Pigs are often used for experimental models of cardiogenic shock, cardiac arrest or acute lung injury with veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO) implementation. Percutaneous (as opposed to surgical) cannulation in experimental models has potential advantages, including, less surgical trauma or stressful stimuli and less bleeding complications when compared to open chest cannulation. However, pig anatomy can also be a challenge because of the deep location and angled anatomy of the femoral artery. The Seldinger technique and the use of a percutaneous cannulation kit is feasible in pigs. Summarized here we present (Graphical Abstract):•Percutaneous ECMO cannulation method for non-cardiac surgeon.•Establishment of this simple and rapid methods for pig experimental models.•Predictable complications of this method.

Gastric insufflation during cardiopulmonary resuscitation: A study in human cadavers.

INTRODUCTION: Bag-valve-mask ventilation is the first-line ventilation method during cardiopulmonary resuscitation (CPR). Risks include excessive volume delivery and gastric insufflation, the latter increasing the risk of pneumonia. The efficacy of ventilation can also be reduced by airway closure. We hypothesized that continuous chest compression (CC) could limit the risk of gastric insufflation compared to the recommended 30:2 interrupted CC strategy. This experimental study was performed in human "Thiel" cadavers to assess the respective impact of discontinuous vs. continuous chest compressions on gastric insufflation and ventilation during CPR. METHODS: The 30:2 interrupted CC technique was compared to continuous CC in 5 non-intubated cadavers over a 6 min-period. Flow and Airway Pressure were measured at the mask. A percutaneous gastrostomy allowed measuring the cumulative gastric insufflated volume. Two additional cadavers were equipped with esophageal and gastric catheters instead of the gastrostomy. RESULTS: For the 7 cadavers studied (4 women) median age of death was 79 [74-84] years. After 6 min of CPR, the cumulative gastric insufflation measured in 5 cadavers was markedly reduced during continuous CC compared to the interrupted CC strategy: (1.0 [0.8-4.1] vs. 5.9 [4.0-5.6] L; p < 0.05) while expired minute ventilation was slightly higher during continuous than interrupted CC (1.9 [1.4-2.8] vs. 1.6 [1.1-2.7] L/min; P < 0.05). In 2 additional cadavers, the progressive rise in baseline gastric pressure was lower during continuous CC than interrupted CC (1 and 2 cmH2O vs. 12 and 5.8 cmH2O). CONCLUSION: Continuous CC significantly reduces the volume of gas insufflated in the stomach compared to the recommended 30:2 interrupted CC strategy. Ventilation actually delivered to the lung is also slightly increased by the strategy.

Low versus standard-blood-flow reperfusion strategy in a pig model of refractory cardiac arrest resuscitated with Extra Corporeal Membrane Oxygenation.

OBJECTIVE: This study was designed to assess the effect of two veno-arterial ExtraCorporeal Membrane Oxygenation (ECMO) blood-flow strategies in an experimental model of Extracorporeal Cardio-Pulmonary Resuscitation (ECPR) on macrocirculatory, metabolic and microcirculatory parameters in the first six hours of ECMO initiation. METHODS: Cardiac arrest was induced in 18 pigs by surgical ligature of the left descending coronary artery followed by a low-flow time of 40 min using internal cardiac massage. ECPR was initiated in normothermia with an ECMO blood flow of 30-35 ml.kg-1. min-1 (low-blood-flow group, LBF) or 65-70 ml.kg-1. min-1 (standard-blood-flow group, SBF), with the same mean arterial pressure target of 65 mmHg adjusted with norepinephrine. Macrocirculatory and metabolic parameters were assessed by lactate clearance and carotid blood flow. Microcirculatory parameters were assessed by sublingual microcirculation with Sidestream Dark Field (SDF) imaging and peripheral Near-InfraRed Spectrometry (NIRS). Inflammatory cytokine levels were measured with a multicomplexed ELISA-based array platform. RESULTS: There were no between-group differences at baseline and at ECMO initiation (H0). Lactate clearance at H6 was lower in LBF compared to SBF (6.67[-10.43-18.78] vs. 47.41[19.54-70.69] %, p = 0.04). Carotid blood flow was significantly lower (p<0.005) during the last four hours despite similar mean arterial pressure levels. For microvascular parameters, SDF and NIRS parameters were transitorily impaired at H3 in LBF. IL-6 cytokine level was significantly higher in LBF at the end of the experiment. CONCLUSION: In an experimental porcine model of refractory cardiac arrest treated by ECMO, a low-blood-flow strategy during the first six hours of resuscitation was associated with lower lactate clearance and lower cerebral blood flow with no benefits on ischemia-reperfusion parameters.

High Versus Low Blood-Pressure Target in Experimental Ischemic Prolonged Cardiac Arrest Treated with Extra Corporeal Life Support.

BACKGROUND: There is currently no recommendation for the mean arterial pressure target in the particular setting of Extracorporeal Cardiopulmonary Resuscitation (ECPR) in the first hours following cardiogenic shock complicated by cardiac arrest. This study aimed to assess the effects of two different levels of mean arterial pressure on macrocirculatory, microcirculatory, and metabolic functions. DESIGN: Randomized animal study. SETTING: University research laboratory. INTERVENTION: Ventricular fibrillation was induced in 14 male pigs by surgical ligature of the interventricular coronary artery. After 20 min of cardiopulmonary resuscitation, Extracorporeal Life Support (ECLS) was initiated to restore circulatory flow. Thereafter, animals were randomly allocated to a high mean arterial pressure group (High-MAP, 80-85 mm Hg) or to a standard mean arterial pressure group (Standard-MAP, 65-70 mm Hg). Assessments conducted at baseline, immediately following and 6 h after ECLS initiation were focused on lactate evolution, amount of infused fluid, and microcirculatory parameters. RESULTS: There was no significant difference between the two groups at the time of ECLS initiation and at 6 h with regard to lactate levels (High-MAP vs. Standard-MAP: 8.8 [6.7-12.9] vs. 9.6 [9.1-9.8] mmol·l, P = 0.779 and 8.9 [4.3-11.1] vs. 3.3 [2.4-11] mmol·l, P = 0.603). Infused fluid volume did not significantly differ between the two groups (4,000 [3,500-12,000] vs. 5,000 [2,500-18,000] mL, P = 0.977). There was also no significant difference between the two groups regarding renal and liver functions, and sublingual capillary microvascular flow index assessed by Sidestream Dark Field imaging. CONCLUSION: Compared with a standard mean arterial pressure regimen, targeting a high mean arterial pressure in the first hours of an experimental ECPR model did not result in any hemodynamic improvement nor in a decrease in the amount of infused fluid.