Long-term outcome following upper extremity replantation after major traumatic amputation.

BACKGROUND: Amputations in general and amputations of upper extremities, in particular, have a major impact on patients' lives. There are only a few long-term follow-up reports of patients after macro-replantation. We present our findings in contrast with the existing literature. METHODS: Sixteen patients with traumatic macro-amputation of an upper extremity were eligible for inclusion in this study. Altogether, the patients underwent replantation in 3 institutions between 1983 and 2011. RESULTS: Twelve male and four female patients with an average age at injury of 40.6 years (range, 14-61 years) were included in this study. The mean follow-up period was 13.5 years (range, 4.4-32.6 years; SD, 5.7 years). The mean disabilities of the arm, shoulder and hand (DASH) outcome measure was 41 (range, 5.2-94.8; SD, 18.2), functional independence measurement (FIM) was 125 (range, 120-126; SD, 1.8). Chen I representing very good function was accounted in six, Chen II representing good function in eight, Chen III (fair) in one and Chen IV (bad function) in one patient. CONCLUSIONS: We found that while the majority of the included patients exhibited good or very good function of the extremity, none of the replanted appendages regained normal levels of functionality. In addition, all participants were very satisfied with their outcomes. Positive long-term results with high rates of subjective satisfaction are possible after replantation of upper extremities.

[Minimally invasive treatment of intra-articular calcaneal fractures with the 2­point distractor]. / Minimal-invasive Versorgung intraartikulärer Fersenbeinfrakturen mit dem 2­Punkt-Distraktor.

OBJECTIVE: Open treatment of calcaneus fractures often has an increased risk of wound healing. Minimally invasive treatment with small incisions reduces complications. INDICATIONS: Calcaneal fractures with malalignment/comminution >1-2 mm; broadening, varus alignment of the calcaneal length axis or shortening; emergency surgery for open fractures or compartment syndrome. CONTRAINDICATIONS: Local or general contraindications. SURGICAL TECHNIQUE: Standardised positioning; restoration of length/axis with 2­point distractor under fluoroscopic control. Fragment reduction via small incisions. Fixation with 7.3 mm cannulated screws and 4.0 mm sustentaculum screws. POSTOPERATIVE MANAGEMENT: Cast-free and no weight bearing for 6 weeks; then weight bearing in a heel off-loading shoe for another 6 weeks with physiotherapy; if needed postoperative cast until soft tissue consolidation. RESULTS: Of 212 calcaneal fractures, 182 were treated with this technique. Wound healing complication rate was 2.7%; 4.7% of patients required secondary arthrodesis of the subtalar joint.

Haemostatic profile of reconstituted blood in a proposed 1:1:1 ratio of packed red blood cells, platelet concentrate and four different plasma preparations.

The concept of haemostatic resuscitation implies early and high-volume plasma transfusion. We investigated the haemostatic profile of reconstituted whole blood prepared in a 1:1:1 ratio of blood, platelets and plasma. This consisted of packed red blood cells, platelet concentrate and four different plasma variants: fresh frozen; solvent-detergent; lyophilised quarantine; and lyophilised methylene blue-inactivated plasma. Haematocrit, platelet count, endogenous thrombin potential and coagulation factor activity were significantly lower in reconstituted blood compared with citrated whole blood (p < 0.01). Except for lyophilised methylene blue-inactivated plasma, no substantial differences between plasma variants in coagulation factor activity, endogenous thrombin potential and standard coagulation tests were observed. After reconstitution, haematocrit and platelet counts were slightly above recommended transfusion triggers, most thromboelastometry (ROTEM(®)) parameters were within the normal range and fibrinogen concentrations were between 1.57 g.l(-1) and 1.91 g.l(-1). Reconstitution of whole blood in a 1:1:1 ratio resulted in significant dilution of haematocrit and platelet count, but values remained above limits recommended by transfusion guidelines. Fibrinogen concentrations of reconstituted whole blood were also significantly reduced, and these were below the threshold value for supplementation recommended by recent guidelines.

Mortality reduction in cardiac anesthesia and intensive care: results of the first International Consensus Conference.

There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggesting measures for prioritized future investigation we performed the first International Consensus Conference on this topic. The consensus was a continuous international internet-based process with a final meeting on 28 June 2010 in Milan at the Vita-Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons, and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting, and ranking. Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic ß-blockade, early aspirin therapy, the use of pre-operative intra-aortic balloon counterpulsation, and referral to high-volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. This International Consensus Conference has identified the non-surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra-aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic ß-blockade, early aspirin therapy, and referral to high-volume centers. The use of aprotinin and aged red blood cells may result in increased mortality.

Mortality reduction in cardiac anesthesia and intensive care: results of the first International Consensus Conference.

BACKGROUND: There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggesting measures for prioritized future investigation we performed the first international consensus conference on this topic. METHODS: The consensus was a continuous international internet-based process with a final meeting on June 28th 2010 in Milan at the Vita-Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting and ranking. RESULTS: Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic beta-blockade, early aspirin therapy, the use of preoperative intra-aortic balloon counterpulsation and referral to high-volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. CONCLUSION: This international consensus conference has identified the non-surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra-aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic beta-blockade, early aspirin therapy, and referral to high-volume centers. The use of aprotinin and aged red blood cells may result in increased mortality.

Levosimendan infusion improves haemodynamics in elderly heart failure patients undergoing urgent hip fracture repair.

BACKGROUND: Elderly patients with heart failure undergoing urgent major surgery suffer substantial cardiac morbidity and mortality. Levosimendan, a novel calcium sensitizer, enhances myocardial contractility while simultaneously having vasodilatory and cardioprotective properties. This could be advantageous in perioperative management of heart failure patients. METHODS: Ten consecutive patients with symptomatic heart failure and left ventricular ejection fraction <35% undergoing urgent hip fracture repair were studied. Levosimendan was administered with an infusion rate of 0.1 microg kg(-1) min(-1) in a total dose of 12.5 mg starting a minimum of 2 h prior to surgery. Haemodynamic parameters were obtained at baseline and at 4, 8, 12, 16, 20, 24, 28, 36 and 48 h after start of levosimendan. B-type natriuretic peptide was measured on admission and after 48 h. RESULTS: Patients were 86 +/- 7 yr (mean +/- SD) of age. Levosimendan significantly increased cardiac index from 2.4 +/- 0.3 L min(-1) m(-2) at baseline to 3.2 +/- 0.6 L min(-1) m(-2) after 24 h by increases in stroke volume index (baseline 27 +/- 5 mL m(-2), after 24 h 37 +/- 10 mL m(-2), P < 0.05). Systemic vascular resistance index significantly decreased from 2718 +/- 841 to 1964 +/- 385 dyn s cm-5 m(-2) within 24 h. Haemodynamic changes exerted by levosimendan persisted up to 48 h. B-type natriuretic peptide plasma concentrations decreased from 1143 +/- 792 to 935 +/- 724 ng L(-1) after 48 h (P = 0.006). CONCLUSION: In patients with heart failure, preoperative start of levosimendan infusion improves intraoperative and postoperative haemodynamics. These findings suggest that levosimendan is a useful drug for preoperative optimization of cardiac function in high-risk patients undergoing major surgery.