Large volume autologous plasma predonation and retransfusion in orthopedic surgical patients.

BACKGROUND: Intraoperative washed autologous transfusion of the scavenged blood can reduce the deterioration of anemia, even during the operation with a comparatively large blood loss. On the other hand, plasma level can not be collected by this system. The preoperative donation and perioperative retransfusion of autologous plasma may reduce the plasma dilution. PURPOSE: The influence of a large volume plasma predonation and perioperative retransfusion on the plasma protein level was investigated. METHODS: Thirteen patients (63.2 +/- 13.2 yr, 70.3 +/- 12.1 kg) were examined regarding their serum protein (SP), IgG, coagulation systems, colloid osmotic pressure (COP), blood cell count before, just after, 2 h after and 7 days after the donation of 900 ml plasma by plasmapheresis with a simultaneous volume replacement. Twenty surgical patients (52.8 +/- 17.3 yr, 72.6 +/- 16.6 kg, the mean predonated autologous plasma: 2100 ml) with intra- and postoperative retransfusion of autologous plasma were examined perioperatively for SP, IgG, coagulation systems and COP. These parameters were compared with that of the predonated plasma. RESULTS: All data including SP, coagulation and COP, with the exception of IgG, completely recovered within 7 days after preoperative plasmapheresis. Perioperatively, autologous washed blood transfusion system was used. The retransfused volume of autologous predonated plasma was 1740 ml on average. Although about 41 of blood on average was lost perioperatively, only one patient out of 20 patients had to be administered homologous red blood cell transfusion. The levels of most parameters, except for COP, constantly recovered in accordance with the autologous plasma transfusion. Differences in the patterns of improvement were also observed between the parameters. CONCLUSION: A 900 ml plasma predonation can therefore be safely performed with an interval of not less than a week between the last donation and the operation. Autologous plasma retransfusion is thus considered to improve the protein levels.     

Liquorpheresis (CSF-filtration): An effective treatment in acute and chronic severe autoimmune polyradiculoneuritis (Guillain-Barré syndrome)

Summary In recent years, plasmapheresis has become a well established treatment of acute and chronic polyradiculoneuritis (Guillain-Barré syndrome, GBS). Nervertheless, there are still non-responders and there are particular risks associated with this treatment. Despite all efforts, the duration of severe forms of Guillain-Barré syndrome is still considerable. Inflammation and demyelination start intrathecally. We therefore used liquorpheresis (cerebrospinal fluid filtration) as a new effective therapeutic approach. Our first patient, severely disabled with acute GBS, artificially ventilated, had undergone plasma exchange without effect. Plasma immunoadsorption led only to transient improvement. After several liquorphereses, the patient recovered completely. In three additional patients with acute and two with chronic GBS an improvement of clinical signs in close temporal relation to liquorpheresis was observed. Twice, liquorpheresis was combined with immunoadsorption of cerebrospinal fluid. Liquorpheresis was well tolerated in all cases. This procedure may be effective by eliminating humoral or cell-bound factors responsible for the onset or/and maintenance of inflammation. Further controlled studies are necessary and are in progress.Parts of this paper were presented at the symposium of the German Neurological Society, Bad Nauheim, 29.09.1989     

Bilateral pallidal stimulation in children and adolescents with primary generalized dystonia – Report of six patients and literature-based analysis of predictive outcomes variables

Introduction: Primary generalized dystonia is a rare movement disorder. Medical treatment rarely relieves symptoms. The aim of this study was to investigate the efficacy and safety of bilateral pallidal stimulation in 6 children and adolescents with primary generalized dystonia. In addition, we strived to find predictors for treatment outcome by review and analysis of previously published studies. Methods: Six patients with primary generalized dystonia underwent chronic bilateral stimulation of the globus pallidus internus. A PubMed and MEDLINE search was performed in order to identify children and adolescents who underwent deep brain stimulation for primary generalized dystonia. The primary efficacy endpoint was the relative change of the Burke-Fahn-Marsden-Dystonia-Rating-Scale (movement score) after surgery. Results: Forty-four patients were found to meet the inclusion criteria. The mean age at onset of the disease was 7.8 ± 2.8 years and the mean age at surgery was 14.2 ± 3.5 years. The mean Burke-Fahn-Marsden-Dystonia-Rating-Scale (movement score) was 56.9 ± 22.7 before surgery and 23.7 ± 23.2 at a mean follow up of 13.0 ± 4.8 months (p < 0.001). The improvement in the DYT1-positive group was significantly higher compared to the DYT1-negative group (77% ± 24% and 44% ± 30%, respectively, p < 0.001). A positive correlation between the movement score before and after surgery was found in both the DYT1-positive and DYT1-negative cohort (rs = 0.624, p < 0.001 and rs = 0.734, p < 0.001, respectively). Conclusion: DBS is an effective treatment in children and adolescents with primary generalized dystonia. Predictive factors for a better treatment outcome are DYT1-positive status and minor motor impairment before surgery.     

Efficacy and safety of VEPTR instrumentation for progressive spine deformities in young children without rib fusions

This retrospective study analyses 23 children treated with vertical expandable prosthetic titanium rib (VEPTR) for correction of non-congenital early onset spine deformities. After the index procedure (IP), the device was lengthened at 6-month intervals. The average (av) age at the time of IP was 6.5 years (1.11–10.5). The av follow-up time was 3.6 years (2–5.8). Diagnosis included 1 early onset idiopathic scoliosis, 11 neuromuscular, 2 post-thoracotomy scoliosis, 1 Sprengel deformity, 2 hyperkyphosis, 1 myopathy and 5 syndromic. Surgeries (187) included 23 IPs, av 6.5 (4–10) device expansions per patient (149) and 15 unplanned surgeries. 23 complications (0.13 per surgery) included 10 skin sloughs, 5 implant dislocations, 2 rod breakages and 6 infections. Coronal Cobb angle was av 68° (11°–111°), at follow-up av 54° (0°–105°). Pelvic obliquity was av 33° (13°–60°), at follow-up av 16° (0°–42°). T1 tilt was av 29° (5°–84°), two remained unchanged, the remainder improved 10°–68°. Sagittal plane: All but two had stable profiles, two hyperkyphosis of 110°/124° improved to 56°/86°. Space available for lung ratio was less than 90% in ten before the IP, improved in nine and deteriorated in one. Originally designed for thoracic insufficiency syndromes related to rib and vertebral anomalies, VEPTR proved to be a valuable alternative to dual growing rods for non-congenital early onset spine deformities. The complication rate was lower, the control of the sagittal plane and the pelvic obliquity was as good, but the correction of the coronal plane deformity was less than growing rods. However, VEPTR’s spine-sparing approach might provoke less spontaneous spinal fusion and ease the final correction at maturity.     

Ist die Blockade des N. cutaneus femoris lateralis eine Alternative zu einer klassischen Femoralisblockade bei Kniegelenkarthroskopien?

BACKGROUND: Gaps in the distribution area of the lateral femoral cutaneous nerve (LFCN) are assumed to be the reason for pain caused by a thigh tourniquet when performing a femoral nerve (FN) block according to Winnie. The aim of the study was to evaluate if a direct single blockade of the LFCN in patients undergoing knee surgery resulted in a better tolerance to the tourniquet with equally good analgesic quality during surgery. METHODS: A total of 40 patients undergoing knee arthroscopy received a proximal blockade of the sciatic nerve and randomly either an FN or an LFCN block. Practicability, onset time, quality of sensory and motor block, and clinical effectiveness during tourniquet and surgery were assessed. RESULTS: Stimulation time was significantly longer in the LFCN than in the FN group. Quality of sensory and motor block was worse in the LFCN than the NF group. Of the LFCN patients 65% indicated troublesome paraesthesia or pain when a tourniquet was placed, compared to 35% of the FN patients. Of the LFCN patients 50% had pain during cutaneous incision, compared to none of the FN group. During the course of surgery, 70% of the LFCN patients needed supplemental systemic analgesia, but this was required by only 30% of the FN group. CONCLUSION: An LFCN block is not a suitable alternative to an FN block for regional anaesthesia. For patients with contraindications for an FN block according to Winnie (e.g. vessel surgery in the groin) other more effective methods are available.     

Myocardial redox state during coronary artery bypass grafting assessed with microdialysis

Purpose Microdialysis allows the biochemical analysis of interstitial fluids of nearly every organ as a bedside procedure. This technique could be useful to reveal data about the myocardial metabolism during cardiopulmonary bypass in human coronary artery bypass graft (CABG) surgery.Methods In 17 patients undergoing CABG a myocardial microdialysis catheter (CMA 70, CMA/Microdialysis AB, Sweden) was inserted in the apical region of the beating heart. Microdialysis measurements were performed at timed intervals before, during, and after cardiopulmonary bypass (CPB). The concentrations of lactate and pyruvate were analyzed semi-continuously.Results During CPB the myocardial lactate- pyruvate- ratio (LPR) rose from an initial 11 (8–15) to 33 (29–41) (P<0.01). After CPB the LPR decreased to 4 (3–7) at the end of observation (P<0.05). The pyruvate concentration showed an immediate increase from 34 (30–42) µM at the end of CPB to 181 (147–234) µM after removal of the cross-clamp with subsequent increase during reperfusion (P<0.01). Plasma lactate and pyruvate showed no essential changes during the study.Conclusion Using the microdialysis technique it was possible to analyze myocardial metabolic changes during CABG. The course of myocardial LPR as a sensitive indicator of the myocardial redox state showed profound changes during and after CPB. We propose the microdialysis technique as an additional monitoring tool in CABG.