Comparison of direct and intravesical measurement of intraabdominal pressure in children

Purpose

The aim of this study was to compare directly measured intraabdominal pressure with the pressure measured indirectly via urinary catheter using different bladder-filling volumes in children.

Methods

Prospective observational study in pediatric intensive care unit at a university children's hospital. Three simultaneous measurements of intraabdominal pressure were performed in 14 children, mean age 1.6 months (range, 0.2-56), after cardiac surgery requiring cardiopulmonary bypass directly via an intraperitoneal dialysis catheter and indirectly via indwelling urinary catheter with bladder volumes of 1, 1.5, 2, 2.5, and 3 mL/kg of physiological saline. Of the 14 patients, 9 were mechanically ventilated at the time of the intraabdominal pressure measurements.

Results

Directly measured intraabdominal pressure ranged between 0 and 10 mm Hg and showed the highest correlation (r = 0.971, P < .0001) with the pressure measured via urinary catheter using bladder-filling volume of 1 mL/kg. The higher the bladder-filling volume, the higher was the overestimation of the intraabdominal pressure and the weaker was the correlation with the direct measurement. Overestimation of intraabdominal pressure was 1.3, 2.0, and 2.9 mm Hg, with bladder volume of 1, 2, and 3 mL/kg, respectively.

Conclusion

These data suggest that intravesical pressure closely correlates with intraabdominal pressure in children. A bladder-filling volume of 1 mL/kg is recommended for the measurement of intraabdominal pressure in children with a risk of abdominal compartment syndrome.     

Splanchnic perfusion pressure: a better predictor of safe primary closure than intraabdominal pressure in neonatal gastroschisis

Background/Purpose

Both measured intraabdominal pressure (IAP) and calculated splanchnic perfusion pressure (SPP) have been advocated for use in operative management of gastroschisis. We directly compared these 2 clinical indices.

Methods

Institutional review board-approved multi-institutional retrospective review from 3 centers with 112 subjects. Splanchnic perfusion pressure was recorded as mean arterial pressure-IAP. We compared the clinical utility of IAP and SPP using univariate and multivariate regression analyses.

Results

Calculated mean SPP was higher among neonates requiring silo placement compared to those without (39.0 ± 1.9 vs 33.7 mm Hg, P < .01). Measured IAP levels were similar between groups (11.5 ± 1.1 vs 10.0 ± 0.5, mm Hg, P < .4). On a receiver operating characteristic curve, the inflection point for more than 90% specificity for silo placement was at an SPP of 44. In multivariate regression analysis adjusting for all factors below, SPP was independently associated with silo placement (odds ratio 1.2, 95% confidence interval 1.1-1.3, P < .01), and IAP was not (odds ratio 1.2, 95% confidence interval <1.0-1.5, P < .1).

Conclusions

These data suggest that SPP is a stronger predictor than IAP for the ability to achieve primary closure in the management of neonatal gastroschisis. We infer from these data that intraoperative SPP of more than 43 mm Hg may obviate the need for silo placement.     

Decompressive craniectomy in pediatric patients with traumatic brain injury with intractable elevated intracranial pressure

Background

Care of pediatric traumatic brain injury (TBI) has placed emphasis on maximizing cerebral perfusion to prevent ischemia and reperfusion injury. A subset of patients with TBI will continue to have refractory intracranial pressure (ICP) elevation despite aggressive therapy including ventriculostomy, pentobarbital coma, hypertonic saline, and diuretics. Decompressive craniectomy (DC) is a controversial treatment of severe TBI. It is our hypothesis that DC can enhance survival and minimize secondary brain injury in this patient subset.

Methods

Patients younger than 20 years treated at a level I regional trauma center between November 2001 and November 2004, who met inclusion criteria for the Brain Trauma Foundation TBI-trac clinical database were included. All patients with a mechanism of injury consistent with TBI and Glasgow Coma Scale score of less than 9 for at least 6 hours after resuscitation and who did not die in the emergency department are entered into a clinical database. Patients who arrived at the study hospital more than 24 hours after injury are excluded.

Results

There were 30 patients with TBI identified. The mean Glasgow Coma Scale score at presentation was 8 with a range of 3 to 13. Six patients underwent DC for intractable elevated ICP. Of 6 patient's postoperative ICP, 5 were less than 20 mm Hg. One patient required a return to the operating room where further débridement of brain was performed. All patients who received a DC survived and were discharged to a TBI rehabilitation facility.

Conclusion

Although this is a small sample, DC should be considered in patients with TBI with refractory elevated ICP. Long-term follow-up of this patient population should consist of neuropsychiatric evaluation in conjunction with measurement of social function.     

Inhaled prostacyclin is safe, effective, and affordable in patients with pulmonary hypertension, right heart dysfunction, and refractory hypoxemia after cardiothoracic surgery

Background

The purpose of this study was to describe our institutional experience in using inhaled prostacyclin as a selective pulmonary vasodilator in patients with pulmonary hypertension, refractory hypoxemia, and right heart dysfunction after cardiothoracic surgery.

Methods

Between February 2001 and March 2003, cardiothoracic surgical patients with pulmonary hypertension (mean pulmonary artery pressure >30 mm Hg or systolic pulmonary artery pressure >40 mm Hg), hypoxemia (Pao₂/fraction of inspired oxygen <150 mm Hg), or right heart dysfunction (central venous pressure >16 mm Hg and cardiac index <2.2 L · min⁻¹ · m⁻²) were prospectively administered inhaled prostacyclin at an initial concentration of 20,000 ng/mL and then weaned per protocol. Hemodynamic variables were measured before the initiation of inhaled prostacyclin, 30 to 60 minutes after initiation, and again 4 to 6 hours later.

Results

One hundred twenty-six patients were enrolled during the study period. At both time points, inhaled prostacyclin significantly decreased the mean pulmonary artery pressure without altering the mean arterial pressure. The average length of time on inhaled prostacyclin was 45.6 hours. There were no adverse events attributable to inhaled prostacyclin. The average cost for inhaled prostacyclin was $150 per day. Compared with nitric oxide, which costs $3000 per day, the potential cost savings over this period were $681,686.

Conclusions

Inhaled prostacyclin seems to be a safe and effective pulmonary vasodilator for cardiothoracic surgical patients with pulmonary hypertension, refractory hypoxemia, or right heart dysfunction. Overall, inhaled prostacyclin significantly decreases mean pulmonary artery pressures without altering the mean arterial pressure. Compared with nitric oxide, there is no special equipment required for administration or toxicity monitoring, and the cost savings are substantial.     

N-Terminal Brain Natriuretic Peptide as a Diagnostic Test in Cirrhotic Patients With Pulmonary Arterial Hypertension

Background

The aim of this study was to assessed the correlation of N-terminal natriuretic peptide type B (NT-proBNP) with echocardiographic and hemodynamic indexes of right ventricular (RV) function and to evaluate the sensitivity and specificity of Doppler echocardiography in the diagnosis of portopulmonary hypertension.

Methods

All patients underwent liver transplantation for cirrhosis. We obtained clinical data, NT-proBNP levels, echocardiography, and right heart hemodynamic measurements before transplantation.

Results

Patients with pulmonary hypertension displayed significantly higher levels of NT-proBNP. They also showed higher model for End-stage Liver Disease scores and higher indices of RV overload on cardiac hemodynamics. The negative predictive value of echocardiography to identify pulmonary hypertension was 83%. A correlation was not observed between systolic pulmonary artery pressures measured by the two methods; however, NTproBNP showed a trend toward a significant correlation with mean pulmonary pressure as determined by hemodynamics (r = .3; P < .01).

Conclusion

We concluded that NT-proBNP values showed significant correlations with pulmonary hypertension that could assist in a noninvasive diagnoseis for this group of patients.     

High cost of stage IV pressure ulcers

Background

The aim of this study was to calculate and analyze the cost of treatment for stage IV pressure ulcers.

Methods

A retrospective chart analysis of patients with stage IV pressure ulcers was conducted. Hospital records and treatment outcomes of these patients were followed up for a maximum of 29 months and analyzed. Costs directly related to the treatment of pressure ulcers and their associated complications were calculated.

Results

Nineteen patients with stage IV pressure ulcers (11 hospital-acquired and 8 community-acquired) were identified and their charts were reviewed. The average hospital treatment cost associated with stage IV pressure ulcers and related complications was $129,248 for hospital-acquired ulcers during 1 admission, and $124,327 for community-acquired ulcers over an average of 4 admissions.

Conclusions

The costs incurred from stage IV pressure ulcers are much greater than previously estimated. Halting the progression of early stage pressure ulcers has the potential to eradicate enormous pain and suffering, save thousands of lives, and reduce health care expenditures by millions of dollars.     

Right gastroepiploic artery is the first alternative inflow source for hepatic arterial reconstruction in living donor liver transplantation

Background

Sufficient arterial flow after living donor liver transplantation (LDLT) is closely related to graft survival and prevention of postoperative complications. However, some unfavorable hepatic arterial conditions in recipients preclude reconstruction, requiring alternative stumps. We have used the right gastroepiploic artery (RGEA) as a first alternative for hepatic inflow.

Methods

From January 2006 to December 2008, we performed 754 LDLTs including 28 cases of RGEA among hepatic arterial anastomoses. The arterial anastomosis was performed by an single surgeon under 859 a microscope using an end-to-end interrupted suture technique. RGEA was mobilized over 15 cm from the greater curvature of stomach and greater omentum.

Results

The indications for RGEA use included severe hepatic arterial injury from previous transarterial chemoembolization (n = 14), need for additional arterial flow in dual-grafts LDLT (n = 13), poor blood flow from the recipient hepatic artery (n = 3), and arterial injury during hilar dissection (n = 3). The mean diameter of the isolated RGEA was 2.0 ± 0.2 mm (range: 1.0-2.5). Most hepatic arterial anastomoses were performed with a significant size discrepancy of more than twofold. All reconstructed hepatic arterial flowes showed good; no complication was identified during the mean follow-up period of 56 months to date.

Conclusions

Using RGEA as an alternative arterial inflow is a simple, reliable procedure for situations of inadequate recipient hepatic or multiple graft arteries.     

The positive effect of negative pressure: vacuum-assisted fixation of Integra artificial skin for reconstructive surgery

Background

Integra artificial skin (Integra) (Integra Life Sciences Corporation, Plainsboro, NJ) is increasingly used as a skin substitute in reconstructive surgery. However, reliable fixation to the wound bed, a factor of paramount importance for successful application, is often hard to achieve. The vacuum-assisted closure system (VAC; KCI, Switzerland), a well-established subatmospheric pressure device, might be of interest to overcome these problems because of its ability to conform to almost any surface. The goal of this study was to test whether negative pressure application yields reliable fixation of Integra in children undergoing reconstructive surgery.

Methods

Between 2001 and 2004, VAC was applied in 18 children (n = 18) aged 7 months to 16.5 years. All required reconstructive surgery with implantation of Integra covering 1% to 12% of the total body surface area. After Integra implantation, VAC was installed for 13 to 30 days.

Results

The VAC fixation of Integra was successful in 17 patients (94.5%). The only failure (5.5%) occurred in a patient in whom negative pressure could not be maintained because of a lesion site susceptible to both dislodgement and infection (perianal region). Consequently, infection occurred, and Integra had to be removed.

Conclusions

These results demonstrate that VAC is a valid tool for reliable fixation of Integra in children undergoing even demanding reconstructive surgery.     

The effect of nitrous oxide on intracuff pressure of the size 2 ProSeal Laryngeal Mask Airway

Study Objective

To investigate intracuff pressure changes in the ProSeal Laryngeal Mask Airway (PLMA) during 50% nitrous oxide (N₂O) anesthesia.

Design

Prospective, randomized study.

Setting

Operating room of a university-affiliated hospital.

Patients

40 ASA 1 and 2 children, aged 2 to 6 years, weighing 10-20 kg, undergoing elective inguinal herniorrhaphy with general anesthesia.

Interventions and Measurements

Patients were assigned to two groups (n = 20). Patients in Group A were anesthetized with 50% N₂O in oxygen and sevoflurane, while patients in Group B were anesthetized with 50% air in oxygen and sevoflurane. PLMA cuffs were inflated with air. PLMA intracuff pressures starting from a baseline pressure of 30 mmHg were recorded using a pressure transducer for 30 minutes. The occurrence of postoperative throat discomfort was recorded.

Main Results

In Group A, who inhaled 50% N₂O for 30 minutes, intracuff pressures reached 86.7 ± 10.4 mmHg, while in Group B, who inhaled 50% air for 30 minutes, intracuff pressures were 29.7 ± 1.0 mmHg. The postoperative throat complication rate in Group A was 45%, which was significantly higher than in Group B (5%).

Conclusion

PLMA intracuff pressure increased significantly during 50% N₂O anesthesia. The children's postoperative throat complication rate also was increased.     

Gastroschisis revisited: role of intraoperative measurement of abdominal pressure

Background

Animal studies have shown that visceral circulation is well preserved when intraabdominal pressure does not exceed 20 mm Hg. Our aim was to analyze the outcomes of a series of infants with gastroschisis whose surgical management was directed by the intraoperative measurement of bladder pressure.

Methods

Forty-two neonates with gastroschisis were surgically managed using intraoperative measurement of bladder pressure at a tertiary care center between July 31, 1992, and March 20, 2004, and their outcome was evaluated. Primary closure with or without prosthetic material was performed when pressures measured 20 mm Hg or less. Delayed closure using a silon pouch was performed when pressures measured more than 20 mm Hg. Categorical variables were analyzed including mode of delivery, associated anomalies, type of closure, complications, and mortality. Continuous variables were analyzed including gestational age, birth weight, bladder pressure, time to full feeds, and length of hospital stay. Categorical and continuous variables for both groups were compared using Fisher's Exact and Wilcoxon's rank-sum tests, respectively, and a significance level of .05 was used. Preapproval of this study was obtained from the Institutional Review Board (No. 6690).

Results

Thirty-three (79%) neonates with a mean bladder pressure of 16 mm Hg underwent primary closure and 9 neonates with a mean bladder pressure of 27 mm Hg underwent delayed closure with a silon pouch that was not spring loaded (P < .03). Patients treated with primary closure had faster return to full feeds and significantly shorter hospital length of stay compared with patients treated by delayed closure (P = .04). Surgical morbidity and mortality was nil in patients after primary closure. One patient with total abdominal evisceration died during attempted delayed closure and another patient required reoperation for bowel necrosis after delayed closure.

Conclusion

Primary closure was safely accomplished in 100% of neonates with gastroschisis whose bladder pressure measured 20 mm Hg or less. Further, this group of patients had a faster return to full feeds and a significantly shorter hospital length of stay compared with neonates who required delayed closure.     

Traumatic subdural hydroma: Clinical characteristics and classification

Background

Traumatic subdural hydroma (TSH) is a common complication of head injuries. The aim of this study was to examine the clinical characteristics and classification of TSH.

Methods

One hundred and ninety-two patients with TSH were treated in Qilu hospital during a 13-year period (1989-2001). We reviewed each patient's clinical records and radiological findings.

Results

Based on clinical features and dynamic observation of CT scanning, TSHs were classified into four types: resolution, steadiness, development and evolution. The resolution type often occurred in the prime of life, and the patients had normal intracranial pressure and good prognoses after conservative treatment. The elderly made up the majority of the steadiness type. Their main clinical manifestations included headaches, dizziness, nausea, vomiting, abnormal mentality, etc. Generally, no positive nervous systemic sign related to TSH was observed. The prognoses of the steadiness type treated by conservative therapy were also satisfactory. The development type was common in babies and children and mainly manifested as progressively increasing intracranial pressure, mild hemiplegia, aphasia and abnormal mentality. The patients with development type often needed surgical treatment where there was an associated risk of dying from accompanying cerebral parenchymal damage or postoperative complications once in a while. The evolution type with chronic subdural haematoma occurred between 22 and 100 days after TSH and in the cases of small hydromas treated conservatively, with mild accompanying cerebral damage, characterised by the polarised age, and chronic increased intracranial pressure, there was always a good prognosis after surgery.

Conclusions

The mechanism, clinical characteristics, treatment methods and prognoses varied with the different types of TSH.     

Efficacy, safety and cost of sedation with sevoflurane in intensive care unit

Objectives

To study efficacy, systemic and cerebral haemodynamic, and cost of sedation with sevoflurane after midazolam failure.

Study design

Prospective observational study in a mixed intensive care unit.

Patients and methods

Mechanically ventiled patients in whom deep sedation failed (Ramsay score < 5 despite midazolam 10 mg/h and fentanyl 400 μg/h) were enrolled. Sedation with sevoflurane and fentanyl (200 μg/h) was performed during 48 hours. Sevoflurane was administered with a dedicated filter (AnaConDa™) and sevoflurane infusion rate was adjusted in order to achieve a Ramsay score ≥5. Ramsay score, mean arterial blood pressure, norepinephrine dose/24 h, intracranial pressure and cerebral perfusion pressure in patients with brain injury were measured. Directs costs for sedation were calculated. An analysis of variance for repeated measures compared values between D0 (intravenous sedation), D1 and D2 (inhaled sedation).

Results

Twenty-five patients (age = 51 [38-63], SAPS II = 43 [33-49]) were enrolled. Ramsay score was 4 [4,5] at D0 and 6 [6] at D1 and D2 (P < 0.05 vs D0). Mean arterial pressure was significantly lower at D1 (80 [73-86] mmHg) as compared to D0 (84 [77-92] mmHg) and D2 (84 [78-91] mmHg) (P < 0,05). Norepinephrine consumption was lower at D2 as compared to D1 (P < 0,05). Intracranial pressure was lower at D1 (9 [5-13] mmHg) and D2 (11 [7-15] mmHg) as compared to D0 (12 [7-17] mmHg) (P < 0.05). PPC was stable at D1 and increased at D2. Directs costs were significantly increased with sevoflurane.

Conclusion

Sevoflurane is an effective and safe alternative to midazolam in ICU patients associated with a moderate increase in costs.     

Management of early hepatic arterial thrombosis after pediatric living-donor liver transplantation

Purpose

Early hepatic arterial thrombosis after living-donor liver transplantation is a cause of graft loss and patient mortality. We analyzed early hepatic arterial thrombosis after pediatric living-donor liver transplantation.

Materials and Methods

Since September 2001, we performed 122 living-donor liver transplants on 119 children. Ten hepatic arterial thromboses developed in the early postoperative period. The 7 male and 4 female patients of overall mean age of 6.3 ± 6.1 years underwent 5 left lateral segment, 3 right lobe, and 2 left lobe transplantations.

Results

Among 10 children with hepatic arterial thrombosis, 8 diagnoses were made before any elevation of liver function tests. One child displayed fever at the time of the hepatic arterial thrombosis. The median time for diagnosis was 5 days. Hepatic arterial thrombosis was treated with interventional radiologic techniques in 9 children, with 1 undergoing surgical exploration owing to failed radiologic approaches, and a reanastomosis using a polytetrafluoroethylene graft. Successful revascularization was achieved in all children, except 1. Four children died, the remaining 6 are alive with good graft function. During the mean follow-up of 52.7 ± 18.8 months, multiple intrahepatic biliary stenoses were identified in 1 child.

Conclusion

Routine Doppler ultrasonography is effective for the early diagnosis of hepatic arterial thrombosis. Interventional radiologic approaches such as arterial thrombolysis and intraluminal stent placement should be the first therapeutic choices for patients with early hepatic arterial thrombosis; if radiologic methods fail, one must consider surgical exploration or retransplantation.     

Iliac venous pressure estimates central venous pressure after laparotomy

Background

Central venous pressure (CVP) is traditionally obtained through subclavian or internal jugular central catheters; however, many patients who could benefit from CVP monitoring have only femoral lines. The accuracy of illiac venous pressure (IVP) as a measure of CVP is unknown, particularly following laparotomy.

Methods

This was a prospective, observational study. Patients who had both internal jugular or subclavian lines and femoral lines already in place were eligible for the study. Pressure measurements were taken from both lines in addition to measurement of bladder pressure, mean arterial pressure, and peak airway pressure. Data were evaluated using paired t-test, Bland-Altman analysis, and linear regression.

Results

Measurements were obtained from 40 patients, 26 of which had laparotomy. The mean difference between measurements was 2.2 mm Hg. There were no significant differences between patients who had laparotomy and nonsurgical patients (P = 0.93). Bland-Altman analysis revealed a bias of 1.63 ± 2.44 mm Hg. There was no correlation between IVP accuracy and bladder pressure, mean arterial pressure, or peak airway pressure.

Conclusions

IVP is an adequate measure of CVP, even in surgical patients who have had recent laparotomy. Measurement of IVP to guide resuscitation is encouraged in patients who have only femoral venous catheter access.     

Management of ventral hernia after giant exomphalos with external pressure compression using helmet device

Purpose

The aim of this study was to evaluate an alternative technique of reducing a ventral hernia that follows the primary conservative treatment of a giant omphalocoele.

Methods

The patient is a full-term male neonate with a giant exomphalos. Initially triple dye was applied as an eschar-inducing agent. This resulted in a ventral hernia after 1 month. It was decided to achieve expansion of the abdominal cavity based on the principle of external pressure compression using a sphygmomanometer cuff over the hernia. The cuff was worn continuously, and manual pressure was applied daily. Care was taken to avoid intraabdominal hypertension using the reading of the manometer that was attached. The external pressure was corroborated with observations of respiration and circulation.

Results

The child did not show any ill effects of raised intraabdominal pressure. Throughout the treatment, the child was on full oral feedings and did not require any ventilator support. Reduction of the ventral hernia was achieved in 9 months. Surgical repair of the residual hernia defect was carried out by double breasting of the fascia.

Conclusions

The application of controlled external pressure using a specially constructed device is a safe, noninvasive, and effective method of achieving reduction of a ventral hernia after primary conservative treatment of a giant omphalocoele.     

Establishment of an Ex Vivo Lung Perfusion Model Using Non-Heart-Beating Large Pigs

Background

Functional evaluation of potentially damaged lungs donated after cardiac death is crucial for widespread clinical transplantation. To date, the mean weight of animals used in studies of ex vivo lung perfusion (EVLP) has been 60 kg; however, in the clinical setting, donor weight may be greater.

Objective

To investigate EVLP using lungs from large pigs (mean weight, 115 kg) to simulate human adult lungs donated after cardiac death.

Materials and Methods

Five heart-lung blocks were obtained at 20 minutes after death at the slaughterhouse. The lungs were flushed and preserved on ice for 6 hours before being connected to an ex vivo lung circuit, and were perfused for at least 2 hours.

Results

In all cases, perfusion was sustained for at least 2 hours. Mean (SEM) final flow rate was 4.9 (0.1) L/min, pulmonary artery pressure was 14.8 (1.7) mm Hg, and oxygen tension/fraction of inspired oxygen was 518.0 (18.0) mm Hg. The shunt fraction was 20.5% (4.0%). Histologic analysis demonstrated no significant pulmonary edema at the end of perfusion.

Conclusion

We successfully completed EVLP using lungs from large pigs.     

Brief pressure overload of the left ventricle preconditions rabbit myocardium against infarction

Background

Several nonischemic stimuli have been shown to precondition myocardium. We investigated cardioprotective effects and underlying mechanisms of brief pressure overload of the left ventricle in this study.

Methods

Brief pressure overload of the left ventricle was achieved by two 10-minute partial snaring of the ascending aorta so that systolic left ventricular pressure was raised 50% above the baseline value. Ischemic preconditioning was elicited by two 10-minute coronary artery occlusions. Ten minutes after different pretreatments, myocardial infarction was induced by a 60-minute coronary artery occlusion followed by 3-hour reperfusion. Area at risk and myocardial infarct was determined by blue dye injection and triphenyl tetrazolium chloride staining.

Results

The myocardial infarct size, expressed as percentage of area at risk, was significantly reduced in the pressure overload group (15.9% ± 2.9%, p < 0.001, n = 9) as well as in the ischemic preconditioning group (14.9% ± 1.9%, p < 0.001, n = 9) versus the control group (30.0% ± 6.9%, n = 10). Pretreatment with a blocker of stretch-activated ion channels (gadolinium, 40 μmol/kg, intravenous) abolished the protection induced by pressure overload and ischemic preconditioning. Gadolinium itself did not alter the extent of infarct. There was no significant difference in hemodynamics, area at risk, and mortality among all groups of animals.

Conclusions

Brief pressure overload of the left ventricle by partial snaring of the ascending aorta preconditioned rabbit myocardium against infarction. The underlying mechanism might be related to activation of stretch-activated ion channels.     

Assessment of viability of the pancreas for transplantation using contrast-enhanced ultrasound

Introduction

The main concern in pancreas transplantation is potential thrombosis of the graft due to poor perfusion.

Aim

To assess the viability of the pancreas before transplantation by using contrast-enhanced ultrasound scan (CEUS).

Methods

Ten harvested pancreatas were studied using an iU22 (Philips, Bothell, USA) scanner together with an L9-3 linear probe for the CEUS. The ultrasound contrast agent SonoVue (Bracco spa, Milan), which is a commercially available second-generation microbubble-based agent, can be visualized in real time at low acoustic pressure (mechanical Index of 0.06). Prior to transplantation, the pancreas is placed in Via Span solution (Bristol-Mayer Squibb AB, Bromma, Sverige). Baseline conventional scale sonography is first performed to assess the parenchyma, which appears as homogenous soft tissue. The donor pancreas arterial supply is cannulated (16 gauge) and infused with Via Span solution. Two milliliters of SonoVue is slowly injected and the pancreas is scanned using the low MI nonlinear imaging mode to visualize the microbubbles enhancement of the pancreas to ensure uniform perfusion of the whole organ. Perfusion was scored visually (0 to 5) subjectively by two observers.

Results

Four grafts were not transplanted for different reasons. Lack of a recipient was the cause in one case with a high score (case 1). Cases 4 and 5 were turned down based on clinical evaluation, and arterial thrombosis was the cause in case 7. The last three cases showed a low mean perfusion score of 1.2. Of the six transplanted pancreatas, the four, that were successfully transplanted displayed a mean perfusion score of 4, compared with a mean score of 1.5 for the two cases who suffered rejection following transplantation.

Conclusion

CEUS offers the potential to assess the perfusion of the pancreas transplant preoperatively, which may improve the selection criteria and potentially impact the outcomes of transplantation.     

The effect of haematoma aspiration on intra-articular pressure and pain relief following Mason I radial head fractures

Background

The aspiration of the accompanying haematoma by Mason type I radial head fractures is advocated by several authors to achieve an analgesic effect. The purpose of this study was to investigate the effect of haematoma aspiration on intra-articular pressure and on pain relief after Mason I radial head fractures.

Materials and methods

A total of 16 patients (10 men and six women, age 23-47 years) with an isolated Mason I radial head fracture were subjected to haematoma paracentesis. Initially, intra-articular pressure was measured by using the Stryker Intra-Compartmental Pressure Monitor System. After haematoma aspiration, a new pressure measurement without moving the needle was performed. Pain before and after haematoma aspiration was evaluated by using an analogue 10-point pain scale.

Results

Intra-articular elbow pressure prior to haematoma aspiration varied from 49 to 120 mmHg (median, 76.5 mmHg), while following aspiration, it ranged from 9 to 25 mmHg (median, 17 mmHg). The median quantity of the aspired blood was 2.75 ml (range, 0.5-8.5 ml). Patients reported a decrease in the visual analogue score (VAS) for pain from 5.5 (4-8) before to 2.5 (1-4) after aspiration. Decrease for both pressure and pain was statistically significant (p = 0.005).

Conclusion

The formation of an intra-articular haematoma in the elbow joint following an undisplaced Mason I radial head fracture leads to a pronounced increase of the intra-articular pressure accompanied by intense pain for the patient. The aspiration of the haematoma results in an acute pressure decrease and an immediate patient relief.     

Sympathetic Nerves Do Not Affect Experimental Ischemia-Reperfusion Injury of Rat Liver

Background

We investigated whether sympathetic, noradrenergic nerves participate in experimental acute ischemia-reperfusion injury of the rat liver.

Methods

Female Wistar rats (200-250 g body weight) were anesthetized with pentobarbital. After tracheotomy, we cannulated a carotid artery and jugular vein. The rats were divided in 2 groups (n = 8 per group). The control group received NaCl IV and the test group received the sympatholytic agent, guanethidine (3 mg/kg, IV). After 30 minutes of drug equilibration, laparotomy was performed to arrange the liver for temporary occlusion (by a ligature) of its vascular supply, corresponding with 70% reduction in hepatic blood flow. The rats were then allowed 60 minutes of equilibration. Thereafter, regional ischemia was induced for 30 minutes. The animals were then monitored for 2 hours of reperfusion. Blood samples for alanine aminotransferase (ALT) estimation (as a measure of injury to the parenchyma) were drawn immediately before ischemia, as well as 60 and 120 minutes after reperfusion. Readings of mean arterial pressure were taken during these times.

Results

After 2 hours of reperfusion, there were no significant differences between the groups with regard to ALT or mean arterial pressure.

Conclusion

Sympathetic, noradrenergic nerves did not affect experimental ischemia-reperfusion injury of rat liver in the current model.