Der simultane distal gestielte Suralislappen

Exposed bradytrophic tissue in regions with high mechanical loading is an indication for defect coverage with (myo-, adipo-) fasciocutaneous flaps. In this case, distally based sural flaps were used for bilateral coverage of defects in weight-bearing areas of feet after fourth-degree frostbite. Residual defects can be covered with a split skin mesh graft. The definitive prosthetic supply of the foot assumes a stabilized plantar soft tissue situation. Among its advantages in comparison to free microvascular flaps, the locally based fasciocutaneous flap can be harvested with less donor site morbidity after elevation and does not require secondary debulking. It has been shown that the reduced stability at the border zone between flap and mesh graft has an adverse effect.     

Langzeitergebnisse nach operativer Versorgung von Pilon-tibial-Frakturen Eine retrospektive Untersuchung

Background: While Pilon fractures of the tibia have been treated for decades by primary open reduction and internal fixation by plate osteosynthesis, during the last 10 years differential treatment was developped: After primary open reduction nowadays patients are treated with (according to type of fracture and tissue damage). As well as primary open reduction and internal fixation a two-step treatment (primary external fixator and delayed ORIF) or consolidation by external fixator combined with minimal invasive osteosynthesis (cannulated screws and K-wires) has been implemented. Furthermore, the significance of primary bone grafting in comminuted fractures to prevent aseptic pseudarthrosis has been acknowledged. Methods: Of 151 patients with 160 pilon fractures treated from January 1979 to May 1995, 107 patients (113 fractures) were evaluated. Only the results of C2 and C3 fractures could be compared, as only in these groups were all three types of treatment used. Results: Over 75% of the treated fractures were closed fractures, most of them being fractures with a soft tissue damage grade 2 of the Oestern and Tscherne classification. In the open fractures we found mainly grade 3 fractures according to the Gustilo and Anderson classification. In 54.9% of all pilon tibial fractures we observed an uncomplicated course of healing. Early complications (25.7%) were mainly soft tissue infections, whereas we found pseudarthrosis to be the most frequent late complication. Highest infection rate (55.5%) was in the two-step treatment group (primary external fixator and delayed ORIF) and lowest in the primary internal stabilization group, although especially in the C2 and C3 fractures best clinical late results were obtained with the two-step procedure. Conclusion: The complication rate in the treatment of pilon fractures depends mainly on the type of fracture, the soft tissue damage and the type of treatment. The results of primary ORIF varied. In the case of low-grade soft tissue damage, good to excellent results were accomplished. In the case of higher-grade soft tissue damage, the problem of soft tissue coverage and reconstruction of the joint surface could be solved with good results by the two-step treatment. Herewith it is important to use limited open reduction of displaced fragments and fixation by cannulated screws and K-wires. We consider ORIF of the fibula necessary as stabilization of the second column of the ankle joint.     

Risk factors in nosocomial pneumonia in intensive care patients. A prospective study to identify high-risk patients

Sixteen risk factors for nosocomial pneumonia were prospectively studied in 582 intubated patients in a surgical intensive care unit (ICU) to identify patients at particularly high risk. Overall, pneumonias developed in 94 of the patients (16%). Significant risk factors for pneumonia were mechanical ventilation for more than 72 h, impaired consciousness or co-operation, specific therapeutic interventions as a marker of severe underlying diseases (dopamine/dobutamine greater than or equal to 5 micrograms/kg.min, barbiturate therapy for treatment of elevated intracranial pressure, continuous i.v. antiarrhythmic or antihypertensive drugs), and pre-existing pulmonary abnormalities (P less than 0.001). The acquisition of postoperative pneumonia was further associated with male sex, ASA class IV and a history of smoking, but statistical significance was lost after stepwise logistic regression. Longer operative procedures, thoracic or upper abdominal surgery, longer preoperative hospital stay, low serum albumin concentration on admission, prior antibiotics, old age, obesity, low weight, malignant disease, and steroid treatment did not influence the incidence of pneumonia. In this study we were able to identify a subpopulation of intensive care patients at particularly high risk for pneumonia.     

Untersuchungen über die Brauchbarkeit der Blutvolumenbestimmung mit dem Volemetron

Ohne ZusammenfassungVortragender:M. Schmolke-Freiburg i. Br.     

Frequency of colonization and pneumonia and development of resistance in long-term ventilated intensive-care patients subjected to selective decontamination of the digestive tract

Colonization of the oropharynx with potentially pathogenic microorganisms (PPM) is a highly significant factor in the pathogenesis of bacterial pneumonia in intensive care patients. Via colonization of the oropharynx, bacteria pass into the tracheobronchial tree, where they can give rise to pneumonia after overcoming pulmonary resistance mechanisms. By a new, prophylactic antibiotic treatment schedule consisting in selective decontamination of the digestive tract (SDD) with locally applied nonabsorbable antibiotics, Stoutenbeek achieved drastic lowering of the colonization and infection rate in trauma patients. In the present study, we wanted to check whether this new prophylactic antibiotic schedule can be applied on a surgical intensive care ward in all patients with long-term ventilation, irrespective of the diagnosis, and whether it affords advantages over a conventional antibiotic schedule. MATERIALS AND METHODS. All patients on a surgical intensive care ward in whom it was expected that mechanical ventilation would be necessary for more than 4 days were included in the study. During the first 6 months 83 patients were investigated, in whom antibiotics were only administered when the presence of infection had been confirmed, in accordance with generally accepted guidelines (control group). In the second 6-month period, 82 patients were selectively decontaminated with 4 x 100 mg polymyxin E, 4 x 80 mg tobramycin and 4 x 500 mg amphotericin B, administered through the gastric tube and in an antimicrobial paste in the oropharynx (SDD group). The SDD schedule entailed systemic administration of cefotaxime in the first 3-4 days. RESULTS. In the control group, enterobacteria/Pseudomonas spp. were isolated significantly more frequently than in the SDD group (P less than 0.001): in the pharyngeal smear in up to 53%, in the tracheal secretion up to 36%, and in the rectal smear in up to 93% of the patients In the SDD group in the 1 week the frequency of gram-negative aerobic bacteria in the pharynx decreased from 33% to 5%, in the tracheal secretion from 23% to 14% and in the rectum from 86% to 52% (24% in the second week). However, the decrease in gram-negative microorganisms was accompanied by significant increase in the frequency of Staphylococcus epidermidis and enterococci. The SDD schedule proved to be effective with regard to the rate of infection. In the control group, 35 patients developed pneumonia (42%) as against 5 patients receiving SDD prophylaxis (6%). The duration of mechanical ventilation in the patients with pneumonia was 5 days longer than in patients without pneumonia.(ABSTRACT TRUNCATED AT 400 WORDS)     

Haemophili and related bacteria in the human oral cavity

The occurrence of haemophili and related bacteria in saliva and dental plaque has been studied using a selective medium. Haemophili were isolated from all samples studied. The mean salivary count for 57 saliva specimens was 3.9 × 10⁷, whereas the relative numbers found in 15 specimens of dental plaques were about three to five times lower. More than 1000 isolates were subjected to a high number of biochemical tests. Several species of Haemophilus were encountered, but H. influenzae was practically absent from all samples studied. Haemophilus parainfluenzae comprised the overwhelming majority of the isolates from saliva, whereas H. segnis constituted a significant proportion of the population of haemophili in dental plaques. H. paraphrophilus was present in a minority of the samples. Haemophilus aphrophilus, Actinobacillus actinomycetemcomitans and Eikenella corrodens were isolated from dental plaques only, and the former species only from 27 per cent of the samples. A practical scheme for the identification of oral haemophili and related bacteria is provided.