[Treatment of postoperative thrombosis]. / Therapie der postoperativen Thrombose.

For the treatment of deep vein thrombosis (DVT), rapid diagnosis and prompt therapy are crucial to minimize the risk of fatal pulmonary embolism and long-term complications, including the postthrombotic syndrome and recurrent thromboembolism. The treatment of acute DVT remains controversial. In this review, treatment options in relation to exposing and predisposing risk factors are discussed. Evidence-based data and recommendations from official guidelines are presented.

Weight-based heparin dosing is more effective in the treatment of postoperative deep vein thrombosis.

Rapid clinical diagnosis and adequate treatment are the major determinants of successful therapy of deep vein thrombosis (DVT). In the initial treatment of DVT, heparin is the anticoagulant of choice. Appropriate heparin dosing is of major interest concerning the onset of therapeutic anticoagulation and, thus, the clinical outcome of the patients. This study was designed to compare a weight-based heparin nomogram with a standard heparin nomogram for the treatment of DVT in orthopaedic patients. Forty patients in two groups were included in the study. In group one (patients treated with the weight-based heparin nomogram) the therapeutic range (partial thromboplastin time 1.5-2.3 times the control) was reached on average within 24 h (75% of the patients); 95% of the patients reached the therapeutic range within 48 h. In group two (patients treated with the standard heparin nomogram) the therapeutic range was reached on average within 48 h (60%; 30% of the patients reached the therapeutic range within 24 h). The used weight-based heparin nomogram has proved to be effective, safe and superior to one based on standard practice concerning the time elapsed between initial heparin therapy and achieving the therapeutic range for intravenous anticoagulation.

[Treatment of chronic acetabular pelvic osteomyelitis after alloprosthetic hip joint replacement with a gluteus maximus flap]. / Behandlung einer chronischen acetabulären Beckenosteomyelitis nach alloprothetischem Hüftgelenkersatz mit einer M.-glutaeus-maximus-Schwenklappenplastik.

We report on a 65-year-old man who was sent to our clinic with osteomyelitis of the hip combined with a chronic external fistula after hip joint replacement followed by several further operations including amputation of the leg. After complete removal of the fistula and repeated vacuum sealing of the wound, we used a vasculated glutaeus maximus muscle flap to close the defect. The course after the operation was without any complications. The method applied led to sufficient treatment of the osteomyelitis without weakening the trunk muscles or rendering the use of crutches more difficult.

Hypothermic versus normothermic cardiopulmonary bypass: influence on circulating adhesion molecules.

OBJECTIVE: Cardiopulmonary bypass (CPB) may result in a whole-body inflammatory response with the risk of subsequent development of organ failure. Leukocyte-endothelial binding followed by neutrophil migration appear to play a central role. This process is markedly influenced by adhesion molecules. Whether plasma levels of circulating adhesion molecules are beneficially influenced by hypothermic CPB was studied in patients undergoing either hypothermic or normothermic CPB. DESIGN: Prospective, randomized study. SETTING: Single-Institutional, clinical investigation in a cardiac anesthesia department of a university hospital. PARTICIPANTS: 30 patients scheduled for elective aortocoronary artery bypass grafting. INTERVENTIONS: The patients were prospectively and randomly divided into two groups: group 1 underwent hypothermic CPB (rectal temperature 27 to 28 degrees C; n = 15) and group 2 normothermic CPB (rectal temperature > 36 degrees C; n = 15). MEASUREMENTS AND MAIN RESULTS: Plasma levels of circulating (soluble) adhesion molecules (endothelial leukocyte adhesion molecules [sELAM-1], vascular cell adhesion molecule-1 [sVCAM-1], intercellular adhesion molecule-1 [sICAM-1], and granule membrane protein 140 [sGMP-140]) were measured from arterial blood samples using enzyme-linked immunosorbent assays (ELISA) after induction of anesthesia (= baseline values), after weaning from bypass, at the end of surgery, 5 hours after the end of CPB, and on the morning of the first postoperative day. Mean rectal temperature of group 1 was 27.2 +/- 0.4 degrees C and 36.7 +/- 0.4 degrees C in group 2. In both groups, plasma levels of sELAM-1 were significantly higher than baseline only 5 hours after CPB. sICAM-1 increased until the first postoperative day (group 1: +35%; group 2: +37%) without, however, exceeding the normal range. sVCAM-1 plasma levels increased after CPB (group 1: +56%; group 2: +40%). At the end of surgery and 5 hours after CPB, sGMP-140 plasma levels were significantly higher in the hypothermic (increase from 301 +/- 34 to 582 +/- 57 ng/mL) than in the normothermic patients (increase from 310 +/- 45 to 480 +/- 32 ng/mL). On the first postoperative day, both groups showed similar, significantly elevated plasma levels of sGMP-140. CONCLUSIONS: Plasma levels of circulating adhesion molecules sELAM-1, sICAM-1, and sVCAM-1 did not differ between hypothermic and normothermic CPB, indicating no differences in endothelial activation between the two groups. Only sGMP-140 plasma levels were increased more after hypothermic CPB. Additional influences of hypothermia on the coagulation system might have contributed to the higher sGMP-140 plasma levels of these patients. The definite role of circulating adhesion molecules in cardiac surgery patients remains to be elucidated.

Circulating adhesion molecules in the critically ill: a comparison between trauma and sepsis patients.

OBJECTIVE: The time course of circulating adhesion molecules was monitored in traumatized and sepsis patients. DESIGN: Prospective, descriptive. SETTING: A surgical intensive care unit of a university hospital. PATIENTS: A total of 30 consecutive critically ill patients suffering either from trauma (n = 15) or postoperative sepsis (n = 15). INTERVENTIONS: All patients were on continuous analgo-sedation and mechanical ventilation. MEASUREMENTS AND RESULTS: From arterial blood samples, plasma levels of soluble adhesion molecules [endothelial leukocyte adhesion molecules (sELAM-1), intercellular adhesion molecule-1 (sICAM-1)], and vascular cell adhesion molecule-1 (sVCAM-1) were measured on the day of admission (trauma patients) or on the day of diagnosis of sepsis (= baseline values), and during the following 5 days. In the trauma group, sELAM-1 (57.9 +/- 11.0 ng/ml) and sVCAM-1 (698 +/- 93 ng/ml) were within normal ranges at baseline, whereas they were markedly elevated in the sepsis group (sELAM-1: 340 +/- 95 ng/ml; sVCAM-1; 1,042 +/- 449 ng/ml). In the sepsis patients, sELAM-1 significantly decreased and sVCAM-1 increased, but remained almost unchanged in the trauma patients. Non-survivors showed markedly elevated plasma levels of sELAM-1 and sVCAM-1. sICAM-1 was elevated in both groups at baseline and was higher in the sepsis group (1,266 +/- 261 ng/ml) than in the trauma group. In the septic patients, sICAM-1 increased further (2,022 +/- 609 ng/ml) and remained unchanged in the trauma group. All non-survivors showed sICAM-1 plasma levels of > 800 ng/ml. CONCLUSIONS: Endothelial damage may result in multiple-organ dysfunction syndrome. Adhesion molecules are considered to be a cornerstone in this process. Trauma patients showed lower plasma levels of circulating adhesion molecules than did sepsis patients indicating more pronounced (inflammatory related) endothelial activation or damage in sepsis. Therapeutic modulation of circulating adhesion molecules may be of benefit to the patients outcome and therefore warrants further study.

Circulating adhesion molecules in pediatric cardiac surgery.

Cardiopulmonary bypass (CPB) may be associated with the risk of a "whole body inflammation." Adhesion molecules, such as endothelial leukocyte adhesion molecule (ELAM-1), intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1), seem to play a pivotal role in the inflammatory response. Soluble forms of these adhesion molecules may serve as markers of endothelial activation or damage. To elucidate whether plasma levels of soluble adhesion molecules differ between pediatric and adult cardiac surgery patients, 15 consecutive children younger than 5 yr undergoing CPB were prospectively studied and compared with adults scheduled for elective coronary artery bypass grafting and valve replacement. Plasma levels of circulating (soluble) adhesion molecules (sELAM-1, sICAM-1, sVCAM-1) were measured from arterial blood samples using enzyme-linked immunosorbent assays after induction of anesthesia (= "baseline"), during CPB, at the end of surgery, and on postoperative days 1 and 2. At baseline, plasma levels of all three soluble adhesion molecules were significantly higher in children than in adults. sELAM-1 and sICAM-1 plasma concentrations were even beyond normal in the children (sELAM-1: 88.8 +/- 13.8 ng/mL; sICAM-1: 349 +/- 27 ng/mL). During CPB and until the end of surgery, plasma levels of all adhesion molecules decreased in the children and remained almost unchanged in the adults. In the children, sELAM-1 remained lower than baseline values until the second postoperative day (45.2 +/- 12.2 ng/mL), whereas sICAM-1 increased in the postbypass period without, however, reaching baseline values (254 +/- 40 ng/mL).(ABSTRACT TRUNCATED AT 250 WORDS)

Do plasma levels of circulating soluble adhesion molecules differ between surviving and nonsurviving critically ill patients?

Adhesion molecules appear to play a central role in tissue damage secondary to inflammatory response. Besides various neutrophil- and endothelial-bound adhesion molecules, soluble forms of endothelial-derived adhesion molecules have been detected in the circulating blood in recent years. They seem to be good markers of endothelial damage, but their importance in the critically ill has not been definitely elucidated yet. Plasma levels of circulating (soluble) adhesion molecules (endothelial leucocyte adhesion molecules [sELAM-1], vascular cell adhesion molecule 1 [sVCAM-1], intercellular adhesion molecule 1 [sICAM-1]) were serially measured from arterial blood samples using enzyme-linked immunosorbent assays (ELISA) in 50 consecutive patients suffering from severe trauma (injury severity score [ISS] > 25 points) or postoperative complications. Measurements were carried out on the day of admission on the intensive care unit (ICU) ("baseline" value) and during the next 5 days. Survival was defined as survival throughout the study period. The survivor group (n = 30) consisted of more patients who had sustained trauma (53%), whereas in the nonsurvivors (n = 20) more patients with postoperative complications were found (65%). On admission to ICU, septic shock was more often seen in the nonsurvivors (30%) than in the survivors (13%) and the nonsurvivors showed a slightly higher APACHE II score at baseline. At baseline, plasma levels of all three adhesion molecules were elevated beyond normal range in both groups. The sICAM-1 and sELAM-1 plasma concentrations were significantly higher in the nonsurvivors than in the survivors already at baseline. The sELAM-1 and sICAM-1 values significantly decreased in the survivors without reaching normal values. At the end of the investigation period, sVCAM-1 plasma level was within normal range in the survivors. In the nonsurvivors, all three adhesion molecules increased significantly throughout the study period (sELAM-1, from 115 +/- 31 to 158 +/- 23 ng/mL; sICAM-1, from 830 +/- 210 to 1,536 +/- 199 ng/mL; sVCAM-1, from 861 +/- 168 to 1,249 +/- 151 ng/mL). None of the other hemodynamic or laboratory variables could be correlated with the time course of adhesion molecules, except for PaO2/Pao2 ratio, which was negatively correlated with plasma levels of soluble adhesion molecules in the nonsurvivors (analysis of covariance). It is concluded that plasma levels of soluble adhesion molecules were markedly higher in nonsurviving than in surviving critically ill patients. They may possibly serve as markers of the extent of inflammatory response, of the endothelial damage in patients at risk of multiple-organ failure or both.(ABSTRACT TRUNCATED AT 400 WORDS)

Circulating adhesion molecules in cardiac operations: influence of high-dose aprotinin.

Cardiac operations using cardiopulmonary bypass (CPB) are associated with a systemic inflammatory response most likely attributable to the release of various inflammatory mediators and activation of complement or coagulation cascade. In addition, (circulating) adhesion molecules, such as endothelial leukocyte adhesion molecule (ELAM-1), vascular cell adhesion molecule-1 (VCAM-1), and intercellular adhesion molecule-1 (ICAM-1), appear to be of central importance in the CPB-related inflammatory process. In this situation, antiproteases, such as aprotinin, may help to prevent damage of endothelial integrity. In a prospective study, 40 consecutive patients undergoing elective cardiac operation were randomly divided into two groups (with 20 patients in each group): in group 1 "high-dose" aprotinin was used (2 million IU of aprotinin before CPB, 500,000 IU/h until end of operation, 2 million IU added to the prime) (with aprotinin), and in group 2 no aprotinin was given (without aprotinin). Circulating adhesion molecules (cICAM-1, cELAM-1, and cVCAM-1) were measured from arterial blood samples using ELISA after induction of anesthesia (baseline), during CPB, at the end of the operation, 5 hours after CPB, and on the first postoperative day. The two groups were comparable concerning their biometric profile and CPB data. Baseline values of circulating adhesion molecules were within normal range and similar in both groups. During CPB, hemodilution resulted in a decrease in all circulating adhesion molecules. On the first postoperative day, cICAM-1 (with aprotinin, 215 +/- 32 ng/mL; without aprotinin, 230 +/- 40 ng/mL) and cELAM-1 (with aprotinin, 28 +/- 6 ng/mL; without aprotinin, 31 +/- 6 ng/mL) returned to baseline values.(ABSTRACT TRUNCATED AT 250 WORDS)