The perfusion index as a noninvasive method for monitoring revascularized and replanted digits

BACKGROUND

Monitoring replanted digits remains a challenging task in microsurgical units. Previous studies have indicated the perfusion index (PI), a parameter directly proportional to the blood flow, might be a useful tool.

OBJECTIVE

The PI is evaluated as a monitoring tool in patients with replanted digits.

METHODS

This prospective, non-interventional study includes 31 patients with revascularized or replanted digits. After successful revascularization or replantation, the PI and peripheral oxygen saturation of the affected finger and its contralateral equivalent were measured simultaneously. The values were detected by the device Radical-97® Pulse CO-Oximeter® (Masimo Corporation, 52 Discovery, Irvine, CA 92618, USA).

RESULTS

The median PI of affected fingers was 3.5±0.56 for revascularized and 2.2±0.8 for replanted fingers. The difference between the PI values of replanted digits and the healthy contralateral side was highly significant (p < 0.0001). The area under the curve in the receiver operating characteristics was 0.92 for a PI difference > 80.49% and predicted a loss of replant with a specificity of 100% and a sensitivity of 75%.

CONCLUSION

The assessment of the PI in patients with reperfusion of a vascular compromised digit is a useful tool to continuously monitor peripheral perfusion. The dynamic behavior of the PI is essential to detect perfusion disturbance.

The LRINEC Score-An Indicator for the Course and Prognosis of Necrotizing Fasciitis?

Background: The Laboratory Risk Indicator for Necrotizing Fasciitis score (LRINEC) is a simple tool used to support early diagnosis of Necrotizing Fasciitis (NF). The aim of this study was to investigate whether the LRINEC is suitable as a progression and prognosis parameter in patients with NF. Methods: In this retrospective study, laboratory data of 70 patients with NF were analyzed. The LRINEC was calculated for every patient at the time of hospital admission and postoperatively after surgical interventions. Furthermore, the LRINEC was examined as a prognostic factor for survival. Results: The overall lethality of our series was 20 out of 70 (28.6%). A highly significant LRINEC decrease was found for serial debridements. The largest decrease was observed after the first debridement. There was a significant difference between the initial LRINEC of deceased and surviving patients. A cut off value of >6.5 (7 LRINEC points) resulted in an optimal constellation of sensitivity (70%) and specificity (60%) to predict lethality in patients with NF. Conclusions: The LRINEC significantly decreases after surgical debridement. An initial LRINEC equal or greater than seven is an independent prognostic marker for lethality and can help to identify high-risk patients.

Improvement of Superficial and Deep Cutaneous Microcirculation Due to Axillary Plexus Anesthesia Impaired by Smoking

Background: Understanding microvascular physiology is key to any reconstructive procedure. Current concepts in anesthesia increasingly involve regional peripheral nerve blockade during microvascular reconstructive procedures. Whereas favorable effects on perfusion due to these techniques have been reported earlier, little evidence focusing on its effects in most peripheral vascular compartments is available. Methods: A total of 30 patients who were to receive axillary plexus blockade (APB) were included. Microcirculatory assessment of the dependent extremity was conducted utilizing combined laser-Doppler flowmetry and white light spectroscopy. Two probes (1–2 and 7–8 mm penetration depth) were used to assess changes in microcirculation. Results: APB resulted in significant changes to both superficial and deep cutaneous microcirculation. Changes in blood flow were most prominent in superficial layers with a maximum increase of +617% compared to baseline values. Significantly lower values of +292% were observed in deep measurements. Consecutively, a significant enhancement in tissue oxygen saturation was observed. Further analysis revealed a significant impairment of perfusion characteristics due to reported nicotine consumption (max Bf: +936% vs. +176%). Conclusion: Cutaneous microcirculation is strongly affected by APB, with significant differences regarding microvascular anatomy and vascular physiology. Smoking significantly diminishes the elicited improvements in perfusion. Our findings could influence reconstructive strategies as well as dependent perioperative anesthetic management.

Diced Cartilage Rhinoplasty for Cleft Nose Deformities: Determining the Flexibility of the Cartilage Framework

BACKGROUND

The objective of this trial is to evaluate the flexibility of the cartilaginous component of the cleft nose after diced cartilage rhinoplasty by determining the degree of possible bending in relation to the vertical nasal dorsum axis and to compare with to a control group of the unaffected population.

PATIENTS AND METHODS

Fifteen cleft nose patients with diced cartilage rhinoplasty were included in this study, as well as a control group of 15 unaffected individuals. The angle of maximum nasal bending is measured between the basic and maximum bending axis and performed by the same rater twice at least 2 weeks apart to account for intrarater reliability. Study groups were compared with Fisher and independent t test.

RESULTS

The maximum bending to the left side was 16.10 ± 5.03 degrees for the study group and 23.95 ± 6.54 degrees for the control group (P = 0.001). The maximum bending to the right side were 16.54 ± 6.73 degrees for the study group and 23.00 ± 8.88 degrees for the control group (P = 0.034).

CONCLUSION

Diced cartilage graft injection for dorsal augmentation yields reproducible and esthetically pleasing outcomes with good flexibility and natural feel of the nasal tip. Although there is a significant difference compared with a nonaffected control group in maximum bending capacity, all patients in this study were satisfied with the results.

Is major burn injury associated with coagulopathy? The value of thrombelastometry in the detection of coagulopathy in major burn injury: A prospective observational study

BACKGRUND

The coagulation status of burn patients is generally impaired and is a major factor of the deteriorating burn patients' overall situation. In trauma and other patient groups, the differential diagnosis of coagulation impairment has been largely improved by the use of rotational thromboelastometry (ROTEM®). The aim of this prospective observational study was the differentiated observation of coagulopathy in severely burned patients using standard parameters and ROTEM® thrombelastometry during the relevant stages of burn disease.

PATIENTS AND METHODS

Twelve patients that sustained at least 20% third degree burns of total body surface area (TBSA) were included in the study. Standard and ROTEM® coagulation analyses were performed on admission and then twice daily during the first 14 days following burn trauma.

RESULTS

Although the initial assessment of DIC was similar for both standard labs and ROTEM® measurements, more patients were detected to be in a state of worsening coagulation status for a longer time in ROTEM® than in standard measurements. In addition, one patient was rated in to be in decompensated DIC for 3 days according to ROTEM® measurements, while no patient was rated to be in a decompensated DIC based on standard parameters.

CONCLUSION

This study points towards a more complex picture and higher occurrence of DIC in burn patients when thrombelastometric measurements like ROTEM® are taken into account in addition to standard coagulation parameters.

Feasibility study of preoperative microvessel evaluation and characterization in perforator flaps using various modes of color-coded duplex sonography (CCDS)

BACKGROUND

Color-coded duplex sonography (CCDS) is useful for perforator flap design showing the highest sensitivity in identifying microvessels. This prospective study evaluates the feasibility of different ultrasound (US) modes applied by the microsurgeon in daily practice suggesting quantifiable reference values.

METHODS

Twenty-four patients aged between 17 and 68 years (mean 43.3 ± 14.2 years) with 18 anterolateral thigh (ALT) and 6 superficial circumflex iliac artery (SCIP) flaps were included. Indications were traumatic (n = 12), infectious (n = 6), ischemic (n = 4), or tumor-associated defects (n = 2). Different US modes were evaluated regarding applicability using multifrequency linear probes (5-15 MHz). Vessels diameter, peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) were measured. Preoperative results were correlated to intraoperative findings.

RESULTS

In the examined patient group with 24 perforator flaps a 100% correlation was seen when comparing perforators detected with CCDS/PD with intraoperative findings using optimized US settings. Sensitivity, PPV, and accuracy of CCDS were 100% respectively. Mean PSV of 16.99 ± 6.07 cm/s, mean EDV of 5.01 ± 1.84 cm/s and RI of 0.7 ± 0.07 were measured in microvessels (PW-mode). CCDS proved to be superior compared to PD in correct diameter assessment showing a mean diameter of 1.65 ± 0.45 mm, compared to PD-mode 1.31 ± 0.24 mm. Mean PSV and EDV were higher in ALT than in SCIP flaps, RI was slightly higher in SCIP flaps (p > .05). There were no significant differences in size of different flaps' perforators (p > .05).

CONCLUSION

CCDS represents a highly valuable tool in the daily practice of free flap reconstructions using optimized low flow US settings and multifrequency linear probes.