Comparison of the thrombogenicity of internationally available fibrin sealants in an established microsurgical model.

Previous studies comparing the thrombotic complications of cryoprecipitated fibrin sealant containing bovine thrombin on microvascular venous anastomoses in a rat epigastric free flap model revealed deleterious outcomes regarding flap survival with higher concentrations of topical bovine thrombin. This study was designed to compare three internationally available fibrin sealants, one experimental fibrin monomer sealant that does not require thrombin, and human thrombin alone as to their effects on the survival of an established rat epigastric free flap model. Ninety Sprague-Dawley rats (400 to 600 g) were prepared for abdominal surgery, and an epigastric-based skin flap was raised. The single vein draining the flap was clamped, divided, and reconnected using standard microvascular suturing techniques. Before release of the clamps, the chosen additive was applied precisely to the anastomosis. Additional material was then added to the raw surface of the flap. The animals were divided into seven treatment groups, each receiving 1 ml of commercial or investigational fibrin sealant or human thrombin alone: one control group receiving no additive treatment, four fibrin sealant groups receiving treatment with commercial or investigational fibrin sealant preparations, and two groups receiving different concentrations (500 IU/ml and 1000 IU/ml) of human thrombin applied to the anastomoses and the surrounding tissue. Flap survival was assessed at 7 days postoperatively. This study supports the contention that microvascular free flap survival based on microvascular venous anastomotic patency was adversely effected by high concentrations of thrombin. Lower concentrations (500 IU/ml and less) of thrombin did not seem to affect flap survival. One test product was composed of a fibrin monomer sealant, which obviates the need for the thrombin additive. This group's survival rate was not statistically different from that of the control group. Thus, for microvascular anastomoses, lower concentrations of thrombin or a sealant devoid of thrombin seem to be best for microvascular anastomotic patency.

Effects of hypertonic saline-dextran solution on regional blood flow and thrombogenicity in PTFE grafts in the vena cava of the rabbit.

OBJECTIVES: to study the effects of hypervolaemic haemodilution with hypertonic saline-dextran solution (HSD) on regional blood flow and thrombogenicity of small diameter polytetrafluoroethylene (PTFE) grafts. DESIGN: blood flow in rabbit aorta, vena cava and femoral, renal and ear arteries was determined in five groups: controls, isovolaemic haemodilution with dextran-70 (10 ml/kg body weight (b.w. )), hypervolaemic haemodilution (10 ml/kg b.w.) with either dextran-70, 7.5% NaCl or a combination of dextran and NaCl (HSD). In a second series PTFE grafts were inserted into the vena cava of rabbits treated with hypervolaemic haemodilution with dextran, hypertonic saline or HSD and examined after two days. RESULTS: blood flow increased in aorta, vena cava and femoral artery after haemodilution. The increase was transient in animals treated with hypertonic NaCl alone but sustained in the dextran-70 groups. The grafts from animals treated with hypertonic saline alone had a lower thrombus mass and higher blood flow compared to those from rabbits haemodiluted with dextran-70 only, indicating that both dextran and NaCl have antithrombotic effects. Superior results were obtained with HSD solution. CONCLUSIONS: HSD solution has a strong flow-promoting action in several vascular beds and beneficial effects on the patency of small diameter vessel grafts.

A global inventory of hospitals using powder-free gloves: a search for principled medical leadership.

Scientific experimental and clinical studies have demonstrated that cornstarch on surgical and examination gloves promotes disease by acting as a reactive foreign body in tissue and serving as a vector for latex allergy. Consequently, hospitals have selected an innovative glove selection program utilizing only powder-free gloves. Healthcare workers in emergency medical systems are now wearing powder-free, latex-free gloves to care for the growing number of patients sensitized to latex. A global Internet search has now identified 70 hospitals in the United States and three hospitals in Europe that use only powder-free gloves.

Effects of heparin, desmopressin, and isovolemic hemodilution with dextran on thrombus formation in synthetic vessel grafts inserted into the vena cava of the rabbit.

The objective of this study was to investigate the effects of isovolemic hemodilution with dextran-70 on thrombus formation and blood flow in synthetic venous vessel grafts. Polytetrafluoroethylene grafts (length, 11 mm; inner diameter, 3 mm) were inserted into the vena cava of rabbits. Six groups were studied: (1) the control group; (2) animals that underwent isovolemic hemodilution with dextran-70 to a hematocrit of about 30%; (3) animals that underwent isovolemic dextran hemodilution combined with a bolus injection of heparin; (4) animals that underwent heparin treatment only; (5) animals that underwent isovolemic dextran hemodilution combined with infusion of desmopressin; and (6) animals that underwent an identical treatment to group 3 but with a 2-week, instead of a 2-day, follow-up. Vena cava blood flow was measured before and after hemodilution and graft insertion and at the termination of the experiments at 2 days (groups 1 to 5) and 2 weeks (group 6) after surgery. Graft patency and thrombus mass weight were evaluated. In the control group, most of the vessels occluded within 2 days. Hemodilution with dextran improved blood flow and reduced thrombus mass weight significantly. Desmopressin, which increases factor VIII, did not influence the effects of hemodilution with dextran, which suggests that the effects of dextran are not mediated by a reduction in the level of this coagulation factor. A single bolus dose of heparin did not reduce thrombus formation in the grafts but did potentiate the effects of isovolemic hemodilution on thrombus mass and graft blood flow. We conclude that isovolemic dextran hemodilution combined with a single bolus of heparin had beneficial long-lasting effects. The grafts in groups 3 and 6 were all patent.

Isovolemic hemodilution and skeletal muscle function during ischemia and reperfusion.

Hemodilution has previously been shown to improve microcirculation in skeletal muscle after ischemia. We have studied the effects of isovolemic hemodilution with dextran on the function of anterior tibial muscle in the rabbit. Hemodiluted (hematocrit 28%) and nonhemodiluted animals were compared. Hemodilution led to an immediate increase in femoral blood flow. Flow normalized within 1-2 h, possibly due to flow redistribution. Hemodilution increased muscle force by 10%, which can reflect alterations in blood chemical composition or an improved microcirculation. Unilateral hindlimb ischemia induced by arterial occlusion inhibited muscle force to less than 15% in 150 min. Force and blood flow recovered almost completely after ischemia. After longer ischemia (170-300 min) when force was <5%, muscles did not recover. Hemodilution did not alter the muscle force or the extent or rate of force recovery after ischemia, which shows that the increased blood flow and improved microcirculation are not directly associated with changes in the sensitivity of muscle function to ischemia.

Effect of isovolemic hemodilution with dextran and albumin on thrombus formation in artificial vessel grafts inserted into the abdominal aorta of the rabbit.

The effects of isovolemic hemodilution with dextran-70 and albumin on thrombus formation in artificial arterial grafts were investigated. A polytetrafluoroethylene graft (PTFE, length 13 mm, inner diameter 3 mm) was inserted into the abdominal aorta of rabbits. Three groups of animals were studied; 1) animals receiving isovolemic hemodilution with dextran-70 (10 ml/kg body weight), 2) animals receiving isovolemic hemodilution with albumin (10 ml/kg body weight), and 3) nonhemodiluted controls. The blood flow increased by about 70% and 60% after the hemodilution with dextran and albumin, respectively, and remained high in the hemodiluted animals, after insertion of the graft. After 2 days, the vessel graft was removed and weighed. The thrombus mass was separately weighed. The results suggest that isovolemic hemodilution with both albumin and dextran is associated with a marked increase in blood flow in the rabbit. Hemodilution with dextran also reduced the amount of thrombus formation on the inner wall of the graft.

Contractile properties of skinned preparations from ischaemic canine myocardium and coronary arteries.

The influence of prolonged ischaemia on the regulation of contraction in the myocardium and in the smooth muscle of coronary arteries was investigated. Chemically skinned preparations were used which enabled the contraction to be studied with the environment of the contractile filaments controlled. Myocardial ischaemia was produced in anesthetized adult beagle dogs by occlusion of the left anterior descending artery for 3 h and followed by 30 min reperfusion. Myocardial tissue and segments from coronary arteries were obtained from the ischaemic infarcted wall region ("in vivo ischaemic") and compared with control preparations from perfused coronary arteries and from the free wall of the left ventricle. Coronary and myocardial preparations were also obtained from the heart after a 3 h period in vitro under anoxic conditions at 37 degrees C ("in vitro ischaemic") simulating a state of extreme ischaemia. Control myocardial fibres were fully relaxed at pCa (-log-[Ca2+]) 9 and developed 24 +/- 5% (n = 7) of maximum force at intermediate calcium concentration (pCa 5.5). In contrast, the in vivo and in vitro ischaemic preparations produced force at pCa 9 (28 +/- 13 and 39 +/- 8%, respectively, n = 5 and 7) and showed an increased force development at pCa 5.5 (53 +/- 11 and 75 +/- 5%). The in vivo and in vitro ischaemic coronary arteries relaxed more slowly following calcium removal than control vessels. The in vitro ischaemic vascular preparations developed active force at pCa 9 and showed increased levels of myosin light chain phosphorylation and reduced phosphatase activity.(ABSTRACT TRUNCATED AT 250 WORDS)

Pneumatocele after removal of squamous cell carcinoma in the scalp--a rare complication? Case reports.

Two patients with squamous cell carcinoma of scalp had the outer table of the skull opened with an osteotome and a drill. Split skin grafts were applied to the defect in one and delayed split skin grafts in the other. In both cases the lesions were on the vertex and resulted in leakage of cerebrospinal fluid and formation of intracranial pneumatoceles. In one case there was serious disturbance of the central nervous system. We conclude that deep resection within the vertex region overlying the lateral lacuna in close proximity to the sagittal sinus must be done with care and the residual defect should preferably be covered with local flaps.

Effects of normovolemic hemodilution on blood flow in the rabbit ear.

The effect of isovolemic hemodilution using dextran-60 on arterial blood flow in the rabbit ear was investigated. The animals were anesthetized and an electromagnetic flow probe was applied around the central artery of the ear. Isovolemic hemodilution was performed during a 15 min exchange period. Two degrees of hemodilution were investigated [8.5 and 17 ml dextran-60/kg body weight (b.w.)] and compared with a nontreated control group. The two levels of hemodilution induced reductions in hematocrit to 29 and 21%, respectively, from the control level of about 40%. In all groups, blood pressure maintained constant levels throughout each experiment, which lasted 240 min. In the controls, ear artery blood flow was unchanged or decreased slightly during the experiment. The lower level of hemodilution caused a slight increase of blood flow after 4 h. In the group treated with 17 ml/kg b.w. dextran, blood flow gradually increased after 90 min following hemodilution. After 240 min, flow rates had increased to two- or threefold the initial rate in this group. Although other possibilities exist, the increased blood flow following hemodilution may be interpreted as reflecting a decreased resistance to flow in the tissue due to the decreased viscosity of the blood.