The use of Fibrin Sealants in Reducing Drain Output in Abdominoplasty: Is it Useful?

Background: Abdominoplasty is a common surgical procedure in which excess abdominal skin and fat are reduced to improve body contouring. Fibrin sealant has been proposed to reduce postsurgical bleeding and exudation. In this study, we evaluated whether there was a significant statistical difference in surgical output between the use of fibrin glue and its nonuse in abdominoplasty surgery, specifically in reducing bleeding and exudation. Material and methods: A retrospective chart review of 68 postbariatric abdominoplasty patients (58 females, 10 males) was performed. We divided the patients into Group A (30 cases, 44%), in which we used fibrin sealant, and Group B (38 cases, 56%), in which we did not use fibrin glue. We calculated the total amount of liquid in suction drainages until the day of their removal. Statistical analysis included the independent t-test with a significance level of 0.05. Results: The average drainage output in Group A was 620.0 ± 375.0 mL, whereas in Group B, it was 500.0 ± 290.0 mL. Results indicate an insignificant correlation between the use of fibrin glue and the amount of liquid in the surgical drains (t = 1.52, p = 0.13). The result is not significant at p <.05 according to the independent t-test. Conclusion: The use of fibrin sealant surely has a high value in all surgical branches to reduce postoperative complications, but in our study, we did not find any advantages in its use for reducing surgical drain output in abdominoplasty patients.

Reconstruction of the columella with interposition of nasogenian flaps: A case report.

INTRODUCTION: Reconstructing large defects of the columella and upper lip is an interesting challenge in facial reconstruction due to the high visibility of this aesthetic subunit and the difficulties posed by the unique characteristics of the skin in these areas, which differs from that of the surrounding regions. Among the various techniques proposed, the use of local flaps remains the most commonly used and effective method in this type of reconstruction. PRESENTATION OF THE CASE: A 47-year-old man in good clinical condition presented with a nodular lesion on the columella and upper lip. The lesion was excised (revealing it to be a squamous cell carcinoma) and reconstructed using two opposing nasogenian flaps, resulting in an optimal aesthetic and functional restoration. DISCUSSION: The use of local flaps remains the most effective technique for columella defect reconstruction. However, many described techniques require multiple surgical stages or result in visible scarring. Additionally, they do not guarantee effective reconstruction in cases involving the upper lip. On the other hand, the use of free flaps, while more expensive and requiring expert teams, may not ensure optimal color and skin texture matching. CONCLUSIONS: The use of opposing nasogenian flaps allows for a rapid and effective reconstruction of defects involving the columella and upper lip, leading to a swift return to normal life for the patient.

[Clinical experience in treatment of Amanita phalloides poisoning]. / Trattamento dell'avvelenamento da Amanita falloide.

BACKGROUND: The management of patients suffering from Amanita Phalloides poisoning (APP) may be very challenging. Furthermore, the treatment often includes depurative techniques and Orthotopic Liver Transplantation (OLTx) must be started timely to be effective. We report our experience in severe APP treatment. PATIENTS AND METHODS: We retrospectively evaluated five patients suffering from APP and hospitalized within our Intensive Care Unit, assessing different kinds of treatment: two different dialytic techniques, namely Continuous Renal Replacement Therapy (CRRT), and Charcoal Plasmaperfusion (CRRT+CPP), and OLTx. RESULTS: Two patients treated with CRRT+CPP, one patient treated with CRRT only and the patient treated by OLTx recovered. One patient, undergoing CRRT only, died after 14 days of treatment. During the CRRT+CPP treatment no relevant complication occurred. The transplanted patient received dialytic treatment for 7 days after transplantation in order to support renal function impairment and to enhance liver function recovery. CONCLUSIONS: Clinical management of patients suffering from APP requires multi-disciplinary intervention; therefore it is recommended to treat these patients in an Intensive Care Unit with specialized nephrological and toxicological consultancy, in collaboration with an organ transplantation team. In the near future we wish to associate dialytic treatment with a bioartificial liver device, which could bridge the time gap to liver transplantation.

Dialytic treatment of rhabdomyolysis-induced acute renal failure: our experience.

Acute renal failure is the most common complication of rhabdomyolysis, with an 8-20% reported incidence. In particular, rhabdomyolysis associated with acute renal failure is frequently observed in critically ill patients, with a 6-16% reported incidence in Intensive Care Units. Dialytic treatment is necessary to correct hydroelectrolytic imbalance and renal function alterations and it may be a pathogenetic therapy by myoglobin removal. In the present study we evaluated our experience on patients suffering from rhabdomyolysis and acute renal failure subjected to dialytic treatment. We retrospectively studied 28 patients, 17 admitted in our Intensive Care Unit (ICU-patients) and treated by continuous renal replacement therapy (particularly by continuous venovenous hemofiltration, continuous venovenous hemodialysis and continuous venovenous hemodiafiltration) and 11 admitted in our Nephrology Department (NICU-patients) and treated by high-efficiency daily hemodialysis. We excluded one ICU-patient from the study because she was affected with lung end-stage neoplasia and it would have been difficult to evaluate the effects of the dialytic treatment on RML biochemical index and on her final outcome. ICU-patients were older, with a mean age of 64 +/- 10 yrs, and were suffering from MODS and typical elderly diseases, such as cardiac and respiratory chronic failure, except from 3 patients with acute liver failure resulting from poisoning, who were relatively younger. In NICU-patients, instead, the mean age was 36 +/- 16 yrs and the causes of RML were narcotic drugs abuse, repetitive seizures and vigorous exercise, more frequently observed in young people. In three relatively older NICU-patients RML was due to lipid lowering drugs assumption. Before starting the dialytic treatment, in ICU-patients CPK plasma level was 2615 +/- 3586, while K+ was 5.10 +/- 1.08 and sCr was 5.69 +/- 4.06 In NICU-patients, on the other hand, CPK was 14273 +/- 9266, while K+ was 5.75 +/- 0.92 and sCr was 5.9 +/- 0.4. ICU-patients mortality rate was 50% (8/16 patients) in spite of the good recovery of renal function and the biochemical RML indexes improvement. In NICU-patients, instead, only one patient died for septic complications (he was a heroin-addict and suffered from overdose syndrome). Early dialytic treatment of RML allows not only to avoid life-threatening complications (first of all the acute renal failure) but moreover it's a pathogenetic treatment because it removes great amount of myoglobin from the plasma. Beside this, continuous renal replacement therapy allows a successful management of critically ill patients with severe hemodynamic conditions. Nevertheless, the final outcome may be very different between ICU- and NICU-patients, with a higher mortality rate in ICU-patients, suffering from MODS.

Continuous renal replacement therapy: our experience in intensive care unit.

Continuous Renal Replacement Therapy (CRRT) indication is still discussed. We report our experience on 98 patients affected with Multiple Organ System Failure (MOSF) and renal failure (acute or chronic) requiring dialysis and timely treated by CRRT. Mortality after 5 days of ICU permanence was 60.2%; the remaining 39 patients were discharged within 21 days and received CRRT treatment for 6.36 +/- 5.59 days. APACHE II score was not able to predict the outcome of patients suffering from acute renal failure (ARF). On the contrary, Systemic Inflammatory Response Syndrome (SIRS) incidence was significantly higher in deceased patients compared to recovered patients. In conclusion, it is important to start dialytic treatment immediately when patients affected with MOSF show renal function damage, even if at an initial stage, in order to improve patients' survival. Moreover a multidisciplinary approach is preferable in ICU patients treatment for not underestimating the management of metabolic and infective complications, the nursing care, and nutritional support.

[Oxidative stress in kidney failure: an experimental study]. / Stress ossidativo nell'insufficienza renale: uno studio sperimentale.

We studied the activity of some enzymes directly involved in the endogenous antioxidative defense system: glutathione-peroxidase (GPX), glutathione s-transferase (GST) and superoxide dismutase (SOD). We have investigated the effects of selenium and vitamin E diet supplementation, in form of selenium-vitamin E enriched yeast, in Wistar rats that were undergone to surgical right nephrectomy and 30 minutes of hypoxia. Blood samples were tested for several parameters as glucose, cholesterol, etc. to assess the general health conditions. The protocol consisted of 3 groups of 25 Wistar rats: a control group, a pre-fed group and a post-fed group. The results showed a significative difference in the behaviour of azotemia, proteins and cholesterol. In the control group the activity rapidly increased, then the values decreased slowly and differently for each substance. The pre and post-fed group showed a pronounced increase after 48 h but the normal values are reached more rapidly. We observed an increase in the activity of the GPX and GST after surgical operation and ischemia, but the GPX in pre-fed group reached the normal value before the other groups.

Acute renal failure caused by nontraumatic rhabdomyolysis.

Nontraumatic rhabdomyolysis may be associated with severe metabolic disturbances. In particular, previous literature has described a 8-20% incidence of acute renal failure in rhabdomyolysis. The aim of this study was to evaluate our experience on 11 patients with acute renal failure treated by high-efficiency daily hemodialysis.

Autologous protein reinfusion in severe ovary hyperstimulation syndrome.

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) is one of the most serious complications of ovulation induction by exogenous gonadotropins. The pathophysiologic factors of this syndrome are not well known. Increased capillary permeability causes third space fluid shift, which is responsible for ascites, pleural fluid, and edemas. Severe OHSS may result in renal failure, hypovolemic shock, thromboembolic disease, respiratory distress, and may cause death. It has been observed that paracentesis is efficacious, provided that care is taken to reinfuse protein lost in the peritoneal exudate. For this reason, in three patients with severe OHSS we have used a dialytic technique of reinfusion of concentrated ascitic fluid. STUDY DESIGN: We treated three patients with severe OHSS (grade 6). Through sonography-guided paracentesis, the ascitic fluid was concentrated by ultrafiltration and reinfused. This treatment was instituted and performed once only. Ultrafiltration was obtained with a common high-flow dialyzer (polyacrylonitryle membrane). The concentrated fluid was returned to the patient in a peripheral vein. We have limited further treatment to restoration of fluid and electrolyte balance, avoiding in particular potentially teratogenic drugs. RESULTS: In all three patients, a progressive increase of diuresis was evident during treatment and subjective improvement was almost immediate. Fifteen days after treatment, hematologic and biochemical parameters had returned within normal limits. CONCLUSIONS: In treating severe OHSS, we have used the technique of reinfusion of concentrated ascitic fluid to avoid protein depletion induced by paracentesis. We have been able to successfully restore to normal the hematologic and biochemical imbalance with one treatment. Use of the technique described herein should be limited to carefully selected instances and treatment should be performed in an intensive care unit.

Renal function in patients undergoing cardiopulmonary bypass operations.

We evaluate short- and long-term effects on renal functional reserve of cardiopulmonary bypass in 11 patients. A selected group (persistence of renal functional reserve before operation) of 11 adult patients undergoing cardiopulmonary bypass for aorta-coronary bypass were studied. Renal functional reserve tests were performed in all patients before the operation, at postoperative day 9, and at 6 months after operation. Basal glomerular filtration rate did not show significant changes at 9 days and at 6 months after operation. On the contrary, renal functional reserve was absent at 9 days, but it was restored to preoperative levels at 6 months after operation. In conclusion, our data indicate that cardiopulmonary bypass probably causes renal damage that is not sufficient to influence routine renal function parameters.

Tissue plasminogen activator plus glutamate antagonist improves outcome after embolic stroke.

Thrombolytic therapy is likely to be effective in some patients with stroke, but further improvements may require combination treatment with neuroprotective agents that can be given rapidly with relative safety. We tested the effects of tissue plasminogen activator (t-PA) with the glutamate antagonist MK-801 or the calcium channel blocker nimodipine in an embolic stroke model. We found that MK-801, followed by t-PA, was more effective than t-PA alone in reducing neurologic damage. Nimodipine plus t-PA was not better than t-PA alone. Combined glutamate antagonist and thrombolytic therapy may provide increased efficacy and safety for stroke treatment.

Pharmacologic studies of the neuroprotective actions of a glutamate antagonist in ischemia.

Ischemia may increase glutamate release, which can lead to neuronal damage. The therapeutic value of drugs that antagonize glutamate's effects are being investigated in CNS ischemia. This study examined the efficacy of a noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist, MK-801 [(+)-5-methyl-10,11-dihydro-5H-dibenzo[a,d]cyclohepten- 5,10-imine hydrogen maleate], in reducing ischemic injury. We explored the limits of this therapy and different properties of MK-801 that might be involved in its neuroprotective actions. Two focal CNS ischemia models were used, a multiple cerebral embolic model (MCEM) and a rabbit spinal cord ischemia model (RSCIM). When animals were treated 5 minutes after the onset of injury, MK-801 was effective in reducing ischemic damage in both models. However, when treatment was delayed 10 minutes after the ischemic insult in the MCEM, no neuroprotection was observed even when the MK-801 dose was increased eightfold. We also did not find a beneficial effect of MK-801 pretreatment with a dose that was one tenth of the effective dose in the RSCIM. Studies using the (-) MK-801 isomer showed that MK-801 neuroprotection exhibited stereoselectivity. The contribution of anticonvulsant activity and sedation to MK-801's neuroprotective actions was examined indirectly using phenytoin and midazolam, respectively. Neither drug was effective in reducing ischemic injury in the MCEM. This suggests that MK-801's neuroprotective efficacy in ischemia is mediated through its NMDA receptor antagonist activity independent of its anticonvulsant or sedative properties. These results support the hypothesis that excessive NMDA receptor excitation may be involved in ischemic neuronal damage.

Lack of oxidative damage in serum polyunsaturated fatty acids before and after dialysis in chronic uremic patients.

We described previously that in the erythrocytes and mononuclear blood cells from uremic patients on chronic hemodialysis, the membrane concentrations of malonyldialdehyde (MDA), resulting from peroxidation of polyunsaturated fatty acids (PUFA) in the membrane itself increased, and the concentrations of vitamin E (VIT E), the major antioxidizing agent, were lower. In the present study we analysed whether similar oxidative damage is seen in the serum from hemodialysis patients and whether the serum fatty acid pattern is affected. No evidence was found of oxidative damage in the serum during hemodialysis, serum concentrations of MDA and VIT E remaining constant before and after dialysis. No change was observed in serum pattern of PUFA, particularly linoleic acid. We therefore assume that the oxidative damage described in uremic patients is mainly intracellular.

Tissue plasminogen activator-mediated thrombolysis of cerebral emboli and its effect on hemorrhagic infarction in rabbits.

Tissue plasminogen activator (tPA) dissolves intravascular thrombus and restores blood flow after thromboembolic vascular occlusion. The utility of this agent for treatment of stroke in humans may be limited by post-reperfusion hemorrhagic complications. We studied tPA-mediated thrombolysis in an animal model of cerebrovascular occlusion in order to determine what factors, if any, predispose tPA-treated animals to suffer hemorrhage. Small blood clot emboli were injected into the internal carotid arteries of rabbits. Angiograms confirmed occlusion of the middle cerebral artery or internal carotid artery in 100% of subjects. tPA or saline was administered as a 30-minute infusion at various times after embolization. Hemorrhage rates were similar in all groups regardless of treatment. tPA increased the prothrombin time and the thrombin time but not the partial thromboplastin time. There was no correlation between these changes in blood coagulation and the finding of cerebral hemorrhage. We observed a significant association between stroke severity and cerebral hemorrhage. We conclude that tPA treatment successfully causes thrombolysis of cerebral emboli without causing an increase in the incidence of cerebral hemorrhage in rabbits.