1/7. Skeletal muscle reperfusion injury: reversal by controlled limb reperfusion--a case report.Despite successful surgical revascularization of ischemic limbs, a local and systemic reperfusion injury may occur after normal blood reperfusion. Recent experimental and clinical application of controlled limb reperfusion in europe has demonstrated superior results, with lower morbidity and mortality. This new surgical technique includes modification of the reperfusate (calcium, pH, substrates, osmolarity, free radical scavenger) and the circumstances of initial reperfusion (time, temperature, pressure). This report describes the first application of controlled limb reperfusion after reperfusion injury. A 16-year-old boy underwent femoral access cardiopulmonary bypass for repeat cardiac repair with an ischemic time of 245 minutes. Postoperatively, severe ischemia/reperfusion syndrome developed with muscle contracture, immobility, and anesthesia of the right leg with a second ischemic time of about 6 hours. The systemic creatine phosphokinase level was 88,000 U/L; myoglobin was 27,000 ng/mL. He underwent controlled limb reperfusion by withdrawing blood from the aorta and mixing it with a crystalloid solution (calcium-reduced, hyperosmolar, hyperglycemic, alkalotic, glutamate- and aspartate-enriched, and containing a free radical scavenger) under controlled conditions (blood:crystalloid solution 6:1, for 30 minutes, reperfusion pressure < 50 mm Hg, and normothermia) before establishing normal blood reperfusion. Metabolic data from the central and femoral vein demonstrated a significant reduction of all previous elevated enzyme levels, avoidance of hyperkalemia, normalization of acidosis, and avoidance of systemic reperfusion injury with no multiorgan failure. limb salvage was accomplished and functional recovery almost complete. To the authors' knowledge, this is the first application of controlled limb reperfusion reported in north america. With this surgical technique we were able to prevent metabolic local and systemic reperfusion changes after prolonged ischemia and also reduced previous reperfusion changes. This report confirms former experimental data, and further clinical studies are warranted.- - - - - - - - - - ranking = 1keywords = organ (Clic here for more details about this article) |
2/7. Acute respiratory distress syndrome of the contralateral lung after reexpansion pulmonary edema of a collapsed lung.STUDY OBJECTIVE: To report that leukocyte-mediated acute injury may develop in a nonhypoxic lung after hypoxia-reoxygenation injury of the hypoxic lung and in other systemic organs in patients with reexpansion pulmonary edema. DESIGN: Case report analysis with examination of the literature. SETTING: intensive care unit of a university hospital. patients: Three patients who developed leukocyte-mediated acute lung injury in the contralateral lung and systemic organ injury after ipsilateral reexpansion pulmonary edema of a collapsed lung. MEASUREMENTS: To rule out the possibility that the acute lung injury in the contralateral lung was an extension of the hypoxia-reoxygenation injury, we analyzed changes in leukocyte and platelet count in the peripheral blood in relation to the development of pulmonary edema in each lung. Changes in liver enzymes were also analyzed to detect hepatic dysfunction as evidence of systemic organ injury. MAIN RESULTS: Both leukocyte and platelet counts decreased when reexpansion pulmonary edema developed, and decreased further when acute lung injury developed in the contralateral lung (F = 8.42, p = 0.037 for leukocytes, and F = 17.66, p = 0.01 for platelets). Significant hepatic dysfunction developed, as evidenced by increases in both serum bilirubin (p = 0.001) and lactic dehydrogenase, indicating the presence of systemic organ injury. CONCLUSIONS: The hypoxia-reoxygenation injury of one lung can induce acute lung injury in the other lung and systemic organ injury.- - - - - - - - - - ranking = 5keywords = organ (Clic here for more details about this article) |
3/7. Lethal hypercytokinemia following hepatic resection under pringle maneuver: a case report.Clinical implications of acute reactant cytokines remain to be clarified in ischemia/reperfusion injury of humans. We report a lethal case of hypercytokinemia following continuous Pringle maneuver. A 36-year-old man with intrahepatic duct stones underwent left lobectomy under continuous hepatic inflow occlusion for 70 minutes. The postoperative course was stormy with rapid deterioration of liver functions, resulting in death due to multiorgan dysfunction on the 4th postoperative day. Analysis of cytokines demonstrated marked elevation of plasma acute inflammatory cytokines level (interleukin-6 and -8) during surgery and immediate postoperative day. Our experience suggests that excessive production of inflammatory cytokines was detrimentally associated with multiorgan dysfunction including liver. The strategies against such hypercytokinemia should be considered when performing liver resection particularly under continuous Pringle maneuver.- - - - - - - - - - ranking = 2keywords = organ (Clic here for more details about this article) |
4/7. Long current impulses may be required for nerve stimulation in patients with ischemic pain.PURPOSE: To report on the efficacy of peripheral plexus catheters in the treatment of ischemic pain in spite of nerve stimulation with long current impulses. CLINICAL FEATURES: Two patients with severe neuropathic ischemic foot pain are described. A 56-yr-old man with diabetes, renal failure, and autonomic neuropathy presented with severe ischemic foot pain. Opioids produced excess sedation and hypotension. A 62-yr-old woman was admitted after femoral-popliteal bypass and developed a reperfusion pain syndrome not relieved with opioids, gabapentin, amitryptiline, and clonidine. In both patients, a sciatic plexus catheter was placed with resolution of pain. Conventional nerve stimulation, which uses a pulse duration of 0.1 msec, did not result in muscle contraction. However, by using a nerve stimulator capable of delivering a 1.0 msec impulse duration, a muscle twitch or paresthesia endpoint ensued allowing for successful catheter placement. CONCLUSION: Peripheral plexus catheters provide a safe alter-native to systemic analgesics for pain relief in patients with ischemic foot pain. However, conventional nerve stimulation techniques may not elicit a motor response in patients with underlying neuropathy, and the use of nerve stimulators capable of delivering long current impulses is recommended.- - - - - - - - - - ranking = 1.9766030601169keywords = nerve (Clic here for more details about this article) |
5/7. Pulmonary failure following lower torso ischemia: clinical evidence for a remote effect of reperfusion injury.acute lung injury as a remote sequela of severe lower torso ischemia-reperfusion has been demonstrated experimentally, in a process involving leukosequestration and generation of the arachidonate derivatives thromboxane and leukotriene b4. However, contemporary clinical reports have been limited to development of transient, subclinical "reperfusion pulmonary edema" several hours after declamping in patients undergoing elective abdominal aortic aneurysm repair. This report refocuses attention on the clinical syndrome of severe, acute deterioration in pulmonary function occurring several hours after restoration of perfusion to an ischemic lower torso in two patients. The lung injury is characterized by progressive hypoxemia, pulmonary hypertension, decreased lung compliance, and non-hydrostatic pulmonary edema, consistent with adult respiratory distress syndrome (ARDS). This report reinforces the concept that humoral mediators generated at reflow may induce end-organ injury at a site remote from the focus of ischemia-reperfusion, and that the lung is a target organ.- - - - - - - - - - ranking = 2keywords = organ (Clic here for more details about this article) |
6/7. Simplified, controlled limb reperfusion and simultaneous revascularization for acute aortic occlusion.A 62-year old patient was admitted with a 24-hour history of ischemia in both legs caused by acute distal aortic occlusion and had had a total loss of sensitivity and motor function for 8 hours. Preoperative serum creatine phosphokinase level was 10,900 IU/ml. During aortofemoral reconstruction, both limbs were reperfused with a potassium-free, blood-cardioplegia-like perfusate. Fasciotomies were not necessary. After operation, maximal serum creatine phosphokinase levels remained below 10,000 IU/ml. Limb sensitivity and motor function were normal. Even for prolonged acute aortoiliac occlusion, a simplified controlled limb-reperfusion may preserve skeletal muscle and nerve function and prevent local and systemic complications caused by reperfusion damage.- - - - - - - - - - ranking = 0.21962256223522keywords = nerve (Clic here for more details about this article) |
7/7. Intraoperative continuous hemofiltration for metabolic management in acute aortoiliac occlusion.Acute aortoiliac occlusion, or Leriche's syndrome, carries a risk of the development of severe ischemia-reperfusion injury, characterized by electrolyte and acid-base balance disturbances. These injuries are often fatal, because of the rapid deterioration of multiple organ systems. We present a case in which we intraoperatively and postoperatively treated hyperkalemia and metabolic acidosis by high-volume, continuous, veno-venous hemofiltration, which is a recently developed form of continuous renal replacement therapy.- - - - - - - - - - ranking = 1keywords = organ (Clic here for more details about this article) |