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INTRODUCTION: Microvascular free tissue transfer is a technique for reconstruction of large defects in head and neck surgery. Failure due to microvascular thrombosis can lead to microvascular damage or flap loss. Recombinant tissue-type plasminogen activator (Alteplase) is still an off-label use but it can help to rescue free flaps when embedded in a salvage algorithm. PRESENTATION OF CASE: A 39-year-old patient with received a tumor resection and reconstruction by a radial forearm flap of the left palate. Postoperatively a venous flap thrombosis occurred and immediate surgical revision was done. Initially eperfusion of the flap could not be achieved even after mechanical removal of the thrombus. Then a thrombolysis with Alteplase, which was applied directly into the radial artery, was done. The flap was salvaged and is now completely integrated into the mucosa. Flap salvage procedure was performed according to our free flap salvage algorithm. DISCUSSION: Thrombolysis with Alteplase for free flap salvage is not a common method. Pedicle thrombosis cannot be predicted. Important procedures during surgical intervention when thrombosis occurs are careful reopening, removal of thrombus, flushing with heparin. Since these procedures failed, surgeons decided to employ Alteplase to optimally rescue the flap. CONCLUSION: The present case shows that pharmacological thrombolysis with Alteplase is an effective ultima ratio in free flap salvage with venous thrombosis, although it is still considered offlabel use. Early detection of flap failure and a clear salvage algorithm are important for successful surgical revisions.

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The aim of this study was to establish a standardized protocol for drug-induced sleep endoscopy (DISE) to differentiate obstruction patterns in obstructive sleep apnea (OSA). Target-controlled infusion (TCI) of the sedative propofol was combined with real-time monitoring of the depth of sedation using bispectral analysis. In an observational study 57 patients (mean age 44.8 years, ± SD 10.5; mean apnea hypopnea Index (AHI) 30.8/hr, ± SD 21.6, mean BMI 28.2 kg/m2, ± SD 5.3) underwent cardiorespiratory polysomnography followed by DISE with TCI and bispectral analysis. Sleep was induced solely by the intravenous infusion of propofol with a TCI-pump, with an initial target plasma level of 2.0 µg/ml. Under continuous monitoring of the patient's respiration, state of consciousness and value of the bispectral analysis, the target plasma propofol level was raised in steps of 0.2 µg/ml/2 min until the desired depth of sedation was reached. The mean value of the bispectral analysis at the target depth of sedation was determined and the obstruction patterns during DISE-TCI-bispectral analysis then classified according to the VOTE-system. Subsequently the results were analyzed according to polysomnographic and anthropometric data. The occurrence of multilevel obstruction sites across all degrees of severity of OSA clarifies the need for sleep endoscopy prior to upper airway surgery. The advantage of this technique is the reproducibility of the protocol even for heterogeneous groups of patients. In addition, the gradual controlled and standardized increase of the plasma level of propofol with real-time control of the bispectral index leads to a precisely controllable depth of sedation. The DISE-TCI-bispectral analysis procedure is a step towards a required reproducible protocol of sleep endoscopy - capable of standardization. However it is not yet known whether these observed obstruction patterns also correspond to findings in natural sleep.

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Endoscopía/métodos , Propofol/administración & dosificación , Apnea Obstructiva del Sueño/diagnóstico , Sueño , Adulto , Femenino , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Polisomnografía , Reproducibilidad de los Resultados , Análisis Espectral

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INTRODUCTION: To prospectively evaluate the performance of Lipopolysaccharide-Binding Protein (LBP) in prediction of hospital mortality and its correlation to C-reactive Protein (CRP), we studied sixty consecutive, postoperative patients with sepsis admitted to the university hospital intensive care unit. MEASUREMENTS AND METHODS: Plasma LBP and CRP were serially measured from day(d)1 (onset of sepsis) to d14 in parallel with clinical data until d28. Predictive value and correlation of LBP and CRP were analyzed by Receiver Operating Characteristic (ROC) curve analysis and Pearson's test, respectively. MAIN RESULTS: LBP and CRP showed the highest levels on d2 or d3 after the onset of sepsis with no significant difference between survivors and nonsurvivors. Only at d7, nonsurvivors had significantly (p = .03) higher levels of CRP than survivors. Accordingly, in ROC analysis, concentration of CRP and LBP on d7 poorly discriminated survivors from nonsurvivors (area under curve = .62 and .55, respectively) without significant difference between LBP- and CRP-ROC curves for paired comparison. LBP and CRP plasma levels allocated to quartiles correlated well with each other (r(2) = .95; p = .02). Likewise, changes in plasma concentrations of LBP and CRP from one observation to the next showed a marked concordance as both parameters concomitantly increased or decreased in 76% of all cases. CONCLUSIONS: During the first 14 days of postoperative sepsis, LBP plasma concentrations showed a time course that was very similar to CRP with a high concordance in the pattern of day-to-day changes. Furthermore, like CRP, LBP does not provide a reliable clue for outcome in this setting.

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Proteína C-Reactiva/metabolismo , Proteínas Portadoras/sangre , Glicoproteínas de Membrana/sangre , Complicaciones Posoperatorias/sangre , Sepsis/sangre , Proteínas de Fase Aguda , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos

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PURPOSE: To prospectively evaluate the performance of procalcitonin (PCT), interleukin-6 (IL-6), and C-reactive protein (CRP) as percentage of baseline (POB) in predicting hospital survival, we studied 64 consecutive, postoperative patients with severe sepsis. MATERIALS AND METHODS: Plasma PCT, IL-6, and CRP were serially measured from day 1 (onset of sepsis) to day 14 in parallel with clinical data until day 28. Multivariate logistic regression and univariate analysis of predictive accuracy of PCT-, IL-6-, and CRP-POB were performed. Newly derived binary prediction rules were evaluated by calculating sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: In survivors, PCT and IL-6 significantly decreased from days 1 to 14, whereas CRP did not. In nonsurvivors, the inflammation markers mostly increased within the second week. At day 7, logistic regression analysis revealed PCT-POB as an independent determinant for survival. Especially, PCT-POB not exceeding 50% and PCT-POB not exceeding 25% with CRP-POB not exceeding 75% on day 7 indicated a favorable outcome with a positive predictive value/sensitivity of 75%/97% and 92%/67%, respectively. In comparison, pretest likelihood to survive by day 28 and observed survival rate were 60% and 67%, respectively. CONCLUSIONS: Prediction rules of decrease in PCT-POB on day 7 in combination with CRP-POB may serve to monitor efficacy and guide duration of therapy in critically ill patients.

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Proteína C-Reactiva/análisis , Calcitonina/sangre , Interleucina-6/sangre , Precursores de Proteínas/sangre , Sepsis/sangre , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Biomarcadores/análisis , Biomarcadores/sangre , Péptido Relacionado con Gen de Calcitonina , Femenino , Humanos , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sepsis/mortalidad , Análisis de Supervivencia , Factores de Tiempo

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OBJECTIVE: To determine perioperative changes in circulating (BVI) and central blood volume (CBVI) by a new dye dilution technique using pulse dye densitometry. DESIGN AND SETTING: Prospective observational study in the cardiac anesthesia and intensive care unit of a university hospital. PATIENTS: Sixty-six patients undergoing coronary artery bypass surgery. MEASUREMENTS AND RESULTS: Hemodynamic measurements by the dye dilution method using pulse dye densitometry were performed prior to skin incision and 3.3+/-1.4 h and 17+/-2.7 h after surgery. Based on conventional monitoring the therapeutic goals of hemodynamic therapy were achieved in all of the patients of this study. Despite a marked positive fluid balance which developed during surgery mean BVI decreased significantly after surgery while CBVI remained unchanged. Postoperative BVI deficits vs. preoperative values were observed in 78% of patients; these BVI deficits were profound in 29% of the cases. In contrast, 65% of the individual patients showed no or only minor postoperative changes in CBVI vs. preoperative values. CONCLUSIONS: Changes in the intravascular volume compartments affected BVI to a greater extent than CBVI. Therefore measuring circulating in addition to central blood volume may be useful to ensure a normal circulating blood volume that can compensate for any change in the central vascular compartment.

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Determinación del Volumen Sanguíneo/métodos , Procedimientos Quirúrgicos Cardíacos , Densitometría/métodos , Técnica de Dilución de Colorante , Análisis de Varianza , Puente de Arteria Coronaria , Hemodinámica , Humanos , Verde de Indocianina , Atención Perioperativa , Sistemas de Atención de Punto , Estudios Prospectivos

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OBJECTIVE: Binding of bacterial cell wall components to CD14 and co-receptors on myeloid cells results in cellular activation and production of proinflammatory mediators. A recombinant anti-CD14 monoclonal antibody (IC14) has been shown to decrease lipopolysaccharide-induced responses in animal and human models of endotoxemia. This study was performed to evaluate the safety, pharmacokinetics, pharmacodynamics, and clinical pharmacology of IC14 in patients with severe sepsis. DESIGN: Randomized, double-blind, placebo-controlled, dose-ranging, multiple-center trial. SETTING: Six medical and surgical intensive care units located in Germany and The Netherlands. PATIENTS: Forty patients with severe sepsis. INTERVENTIONS: IC14 was administered intravenously to eight patients/cohort as single (1 mg/kg or 4 mg/kg) or multiple doses (4 mg/kg daily for 4 days, or 4 mg/kg on day 1 followed by 2 mg/kg daily for 3 days). A placebo group (two patients/cohort) was also included. MEASUREMENTS AND MAIN RESULTS: The overall incidence and types of adverse events were similar among treatment groups. One patient in the group receiving multiple-dose IC14 4 mg/kg daily for 4 days experienced an anaphylactic reaction after receiving the first dose of study drug. IC14 did not induce antibody formation or increase the incidence of secondary bacterial infection. A mean IC14 serum concentration of approximately 1 microg/mL was required to achieve 50% of maximum membrane-bound CD14 receptor occupancy on peripheral blood monocytes. The pattern of proinflammatory and anti-inflammatory cytokines, chemokine, soluble receptor, soluble E-selectin, and acute phase proteins in response to treatment was highly variable by patient and IC14 treatment group. CONCLUSIONS: Single and multiple doses of IC14 were generally well tolerated and did not induce antibody formation or increase the incidence of secondary bacterial infection. The results suggest that CD14 blockade with IC14 warrants further clinical investigation to determine its ability to attenuate the proinflammatory response due to infection.

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Anticuerpos Monoclonales/uso terapéutico , Infecciones Bacterianas/terapia , Receptores de Lipopolisacáridos/inmunología , Proteínas Recombinantes de Fusión/uso terapéutico , Sepsis/terapia , Proteínas de Fase Aguda/efectos de los fármacos , Proteínas de Fase Aguda/metabolismo , Adulto , Anciano , Anticuerpos Monoclonales/inmunología , Anticuerpos Monoclonales/farmacocinética , Área Bajo la Curva , Infecciones Bacterianas/inmunología , Infecciones Bacterianas/metabolismo , Infecciones Bacterianas/mortalidad , Citocinas/sangre , Citocinas/efectos de los fármacos , Relación Dosis-Respuesta Inmunológica , Método Doble Ciego , Selectina E/sangre , Selectina E/efectos de los fármacos , Femenino , Alemania/epidemiología , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Monocitos/efectos de los fármacos , Monocitos/inmunología , Países Bajos/epidemiología , Proteínas Recombinantes de Fusión/inmunología , Proteínas Recombinantes de Fusión/farmacocinética , Seguridad , Sepsis/inmunología , Sepsis/metabolismo , Sepsis/mortalidad , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del Tratamiento

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OBJECTIVE: To determine the time course of histocompatibility leukocyte antigen (HLA)-DR expression in peripheral blood mononuclear cells and their relationship to markers of inflammation, organ function, and outcome during severe sepsis. DESIGN: Prospective, longitudinal study. SETTING: University hospital intensive care unit. PATIENTS: Twenty-three postoperative patients with severe sepsis and 26 patients with uneventful postoperative course as well as 24 healthy, age-matched subjects. INTERVENTIONS: Serum procalcitonin was determined by using an immunochemiluminescence assay, and C-reactive protein and leukocyte antigens were determined by using flow cytometry over 14 days in parallel with clinical data collection. MEASUREMENTS AND MAIN RESULTS: Despite a relative lymphopenia, absolute lymphocyte counts and CD4+/CD8+ T-cell ratio in septic patients were significantly elevated above normal. Particularly, CD4+ and CD8+ T-cell counts in nonsurvivors of sepsis were approximately twice as high as those of survivors. Significantly decreased monocytic HLA-DR expression was observed in both survivors and nonsurvivors at the onset of severe sepsis. Percentages of HLA-DR+ lymphocytes, however, were significantly increased during sepsis, especially in nonsurvivors. Whereas survivors of sepsis showed a continuous recovery of monocytic HLA-DR expression to >or=70% within 10 days, nonsurvivors were characterized by a second decrease in monocytic HLA-DR expression after day 7 or a permanent suppression (<40%). Peak of systemic inflammatory reaction, documented by maximum serum concentrations of procalcitonin and C-reactive protein, coincided with the nadir of monocytic HLA-DR expression. Moreover, procalcitonin and C-reactive protein as well as scores on the Acute Physiology and Chronic Health Evaluation II and Sepsis Organ Failure Assessment were inversely correlated with the monocytic HLA-DR expression. CONCLUSIONS: Decreases in monocytic HLA-DR expression occurred simultaneously with signs of hyperinflammation as early as the onset of severe sepsis and usually developed in opposite directions than inflammatory markers and sepsis severity scores.

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Proteína C-Reactiva/análisis , Calcitonina/sangre , Antígenos HLA-DR/análisis , Inflamación/sangre , Inflamación/inmunología , Monocitos/inmunología , Precursores de Proteínas/sangre , Sepsis/sangre , Sepsis/inmunología , Subgrupos de Linfocitos T , Anciano , Péptido Relacionado con Gen de Calcitonina , Femenino , Citometría de Flujo , Humanos , Estudios Longitudinales , Masculino , Periodo Posoperatorio , Estudios Prospectivos

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OBJECTIVE: To evaluate the agreement between cardiac output (CO) measurements obtained by a new dye dilution technique using pulse dye densitometry (PDD) and thermodilution (TD) and the direct Fick method (F). DESIGN AND SETTING: Prospective clinical study in a university hospital, cardiac surgery intensive care unit. PATIENTS: Fifty-eight cardiac surgery patients after admission to the intensive care unit (six were excluded due to a low pulse signal quality using the PDD method). MEASUREMENTS AND RESULTS: Mean CO was 5.3+/-1.8 l/min for PDD, 5.7+/-1.68 l/min for TD, and 6.16+/-1.66 l/min for F. There was a good correlation between PDD and TD ( r(2)=0.93) and between PDD and F ( r(2)=0.77). Bias and precision between PDD and TD were -0.39+/-0.5 l/min and -0.69+/-0.85 l/min between PDD and F. In general, PDD determined lower CO values than TD and F. Especially in patients with CO below 5 l/min PDD underestimated CO in comparison to TD and F (bias and precision: -0.51+/-0.40 l/min and -0.83+/-1.0 l/min). CONCLUSION: Comparison between PDD and TD showed good agreement for the normal to high CO range. However, agreement was poor in patients with low CO. In the latter patient group PDD showed relevant underestimation of CO compared to TD and F. Due to these limitations PDD cannot entirely replace the pulmonary artery catheter for CO determination.

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Gasto Cardíaco , Técnica de Dilución de Colorante , Termodilución/métodos , Adulto , Anciano , Algoritmos , Análisis de Varianza , Procedimientos Quirúrgicos Cardíacos , Densitometría/métodos , Humanos , Estudios Prospectivos