Combination of ECMO and cytokine adsorption therapy for severe sepsis with cardiogenic shock and ARDS due to Panton-Valentine leukocidin-positive Staphylococcus aureus pneumonia and H1N1.

Sepsis-induced cardiogenic shock in combination with severe acute respiratory failure represents a life-threatening combination that is often refractory to the conventional methods of treatment. We describe the case of a 33-year-old patient who developed acute cardiovascular collapse and ARDS secondary to superinfection of Panton-Valentine leukocidin-positive Staphylococcus aureus and H1N1 pneumonia who underwent successful combination therapy for severe sepsis-related cardiomyopathy and respiratory failure using extracorporeal membrane oxygenation and cytokine adsorption therapy.

Hepatic venous outflow obstruction in pediatric liver transplantation: technical considerations in prevention, diagnosis, and management.

HVOO creates significant diagnostic and management dilemmas in pediatric liver transplant recipients, particularly with TVGs (split or reduced-size grafts). Numerous technical variations for the hepatic vein to IVC anastomosis have been described to minimize the incidence of this complication, but no consensus for an optimal anastomotic technique exists. One hundred and thirty-four liver transplants (70 TVGs) were performed in 124 patients between 1994 and 2011. These were divided into two cohorts. Group 1 (95 transplants, 41 TVGs) utilized a continuous running anastomosis. Group 2 (39 transplants, 29 TVGs) implemented a triangulated (three-stitch) anastomosis. All were reviewed for demographics, diagnostics, interventions, and outcome. The overall HVOO incidence was seven of 134 transplants (5.2%) and six of 70 transplants utilizing TVGs (8.6%). Group 1 incidence was five of 41 (12.2%) compared with one of 29 (3.4%; p = 0.20, OR 3.89) in Group 2. Liver Doppler was employed in all patients, and only three suggested HVOO. All patients with HVOO underwent venogram, at a median of 81 days post-transplant. All underwent percutaneous venoplasty and required 1-6 treatments, all resulting in HVOO resolution. Incidence of HVOO has improved since adopting the triangulated anastomosis, although not to a level of statistical significance. US is not adequately sensitive to exclude HVOO. Venogram is recommended in patients with prolonged ascites, and venoplasty has been highly successful in HVOO treatment.

Addition of vardenafil into storage solution protects the endothelium in a hypoxia-reoxygenation model.

OBJECTIVE: Based upon the well known protective effect of intracellular cyclic guanosine monophosphate (cGMP) accumulation, we tested the hypothesis that storage solution enriched with optimal concentration of the phosphodiestherase-5 inhibitor vardenafil could provide better protection of vascular grafts against reperfusion injury after long-term cold ischaemic storage. METHODS: Isolated thoracic aorta obtained from rats underwent 24-h cold ischaemic preservation in physiological saline or vardenafil (10(-11) M)-supplemented saline solution. Reperfusion injury was simulated by hypochlorite (200 µM) exposure for 30 minutes. Endothelium-dependent vasorelaxation was assessed, and histopathological and molecular-biological examination of the aortic tissue were performed. RESULTS: Compared with the control group, the saline group showed significantly attenuated endothelium-dependent maximal relaxation (Rmax) to acetylcholine after hypoxia-reoxygenation, which was significantly improved by vardenafil supplementation (Rmax control: 98 ± 1%; saline: 48 ± 6%; vardenafil: 75 ± 4%; p < .05). Vardenafil treatment significantly reduced DNA strand breaks (control: 10.6 ± 6.2%; saline: 72.5 ± 4.0%; vardenafil: 14.2 ± 5.2%; p < .05) and increased cGMP score in the aortic wall (control: 8.2 ± 0.6; saline: 4.5 ± 0.3; vardenafil: 6.7 ± 0.6; p < .05). CONCLUSIONS: Our results support the view that impairment of intracellular cGMP signalling plays a role in the pathogenesis of the endothelial dysfunction induced by cold storage warm reperfusion, which can be effectively reversed by pharmacological phosphodiesterase-5 inhibition.

Reduction in surgical site infection in patients treated with microbial sealant prior to coronary artery bypass graft surgery: a case-control study.

Surgical site infection (SSI) is a serious complication after cardiac surgery. This case-control study investigated the effect of a cyanoacrylate-based microbial skin sealant (InteguSeal) applied preoperatively on the SSI rate in patients undergoing coronary artery bypass graft (CABG) surgery. Of 676 patients who underwent CABG surgery with or without concomitant procedure(s) between March and November 2007, 545 received standard preoperative care and 131 also received pretreatment with the microbial sealant. Of these, 90 cases pretreated with microbial sealant and 90 controls were matched using established preoperative and intraoperative risk factors for SSI. Preoperative risk scores for SSI were 9.9+/-4.3 and 9.7+/-4.0 (P=0.747) for the microbial sealant and the control group, respectively, and combined preoperative-intraoperative risk scores were 9.7+/-4.1 and 8.7+/-3.5 (P=0.080), respectively. Carotid artery disease (P=0.019), congestive heart failure (P=0.019), acute myocardial infarction (P=0.001) and emergency surgery (P=0.026) were significantly more common in the microbial sealant group. Follow-up was 100% for both groups. Superficial or deep sternal infection 30 days post surgery developed in seven patients (7.8%) in the control group compared with one patient (1.1%) in the microbial sealant group (odds ratio 7.5). In summary, the inclusion of microbial sealant in preoperative patient preparation seems to reduce the incidence of SSI following CABG surgery; further larger studies are needed before firm conclusions can be drawn.

Pinless calcaneus traction: a preliminary report.

Calcaneus traction with a Steinmann-pin or K-wire inserted into the dorsal aspect of the calcaneus is a common temporary procedure in fractures of the lower leg when internal fixation has to be delayed. Infection due to this simple manoeuvre is rare, but is a very serious complication. In 1991, a so-called pinless external fixator was introduced in clinical trials, based on the idea of external fixation without transosseus pins, thus preserving local blood supply and lowering the risk of pin track infection. This pinless clamp also represents a handy tool for calcaneus traction. We have used this pinless clamp for calcaneus traction in 39 patients without any major problems or complications. Of these, 29 patients were scheduled for delayed internal fixation, and in 10 patients this clamp was used intraoperatively in closed tibial nailing for traction on the fracture table. Tips and tricks for the use of this pinless clamp, and its advantages and disadvantages are discussed.

[Epidemiology of winter sport injuries]. / Epidemiologie der Wintersportunfälle.

The region Davos/Klosters is a big wintersport area in Switzerland, where more than 5 million kilometers of vertical drop are skied per year. Over the last 20 years 28,777 patients with wintersport accidents have been treated in the 100-bed hospital of Davos, 85% of these patients have sustained their accident while skiing. An analysis of these datas show an increase of ski accidents as well as an increase of the distance skied. Especially an increase in snowboard accidents is noted over the last few years with a preponderance of lesions of the upper extremity. Injuries of the head, the trunk and simple skin lacerations remain stable over that period. Injuries of the upper extremity are increasing, whereas lower extremity lesions are slightly decreasing. There is a significant decrease of fractures of the leg, while at the same time an important increase of knee injuries is noted. Young patients below 20 years and those between 31 and 40 years of age sustained less accidents over the last 20 years, while the rest of the alpine skiers remain more or less stable in their accident incidence.

[Traumatic hip dislocations. Epidemiologic data at Davos Hospital and a multicenter study in Graubünden Canton]. / Traumatische Hüftluxationen. Epidemiologische Daten aus dem Spital Davos und aus einer multizentrischen Studie im Kanton Graubünden.

We report about 86 patients with traumatic dislocation of the hip. Group 1 consisted of 26 patients of the hospital of Davos, group 2 of 60 patients of a multi-center evaluation of 7 hospitals in the Kanton Graubünden. 53 were males and 33 females. 13 patients were 16 years old or younger, of these 5 below 10 years. 69% are injuries in sports, 66% in alpine skiing. 78 had a posterior, 5 an anterior and 3 central dislocation with a fracture of the floor of the acetabulum. Concomitant local injuries were seen in 76.9% of traffic accidents and only in 22% of skiing injuries. Closed reduction was performed in 81 patients on the average less than two hours after injury, in 5 cases an open reduction was necessary. The subsequent treatment was in 15 cases operative, consisting in reconstruction of the concomitant injuries.

[Calcaneus extension with the pinless external fixator]. / Calcaneusextension mit dem pinless fixateur externe.

Calcaneus traction is a common temporary procedure in fractures of the lower leg, when an internal fixation is not permitted for soft tissue reasons. Usually a Steinmann-pin or a K-wire is driven across the calcaneus, which is a simple manoeuvre performed in local anaesthesia. Infection due to this perforation of the calcaneus are rare, but signify for the patient a catastrophic complication. With the introduction of the pinless external fixateur in 1991 in clinical trials a very handy pinless-clamp exists, which can safely be anchored in the heel and thus permits safe calcaneus traction without any transosseous fixation. We have used this pinless clamp in 39 patients for various reasons and haven't stated any major complications. The clamp has proved to be very useful for temporary traction as well as for the fixation of the leg during closed intramedullary nailing using the fracture table.

[Penetrating injury]. / Pfählungsverletzung.

Penetrating trauma is an uncommon injury in downhill skiing. We have observed only two cases at our clinic. 15 years ago a skier collided with a trail marker. The post entered the patient's right inguinal region and left the pelvis at buttock. The patient removed the foreign body on the slope without assistance. Remarkably, the only vital structure involved was a small puncture of the duodenum. The patient had an uncomplicated postoperative course with a transient impotence lasting six months. At a follow up 15 years later the patient complained of sequelae. This season 1992/93 an English woman collided while skiing with a tree. She sustained a penetrating injury of her left thigh. We performed a careful extraction of the foreign body with a debridement and drainage of the wound. The patient had an uncomplicated postoperative course.