Extension of limb salvage by combined vascular reconstruction and adjunctive free-tissue transfer.

PURPOSE: Vascular reconstruction alone can be insufficient for extremity salvage in some patients with severe soft-tissue wounds. We present our experience in 20 patients with vascular reconstruction for ischemic disease and free-tissue transfer for limb-threatening soft-tissue wounds. METHODS: Nineteen patients underwent autogenous venous bypasses and one patient underwent an aortobifemoral bypass. Ten soft-tissue reconstruction were performed at the time of the vascular reconstruction and 10 were delayed. Free-tissue transferred included muscle, fasciocutaneous flaps, and omentum. Inflow to the flap was from the bypass graft (n = 12) or the distal tibial artery. RESULTS: One free flap and graft failed immediately in the same patient. One successful flap and graft required a below-knee amputation for ongoing infection in the surrounding soft tissues. Eighteen of 20 patients have had free-flap and graft patency during the mean follow-up period of 17 months (range 6 to 33 months). These 18 patients ambulate independently. CONCLUSIONS: In patients with arterial insufficiency and severe soft-tissue wounds, combined vascular reconstruction and free-tissue transfer permits extended limb salvage with excellent functional results.

Mafenide acetate concentrations and bacteriostasis in experimental burn wounds treated with a three-layered laminated mafenide-saline dressing.

A laminated wound dressing was developed to deliver mafenide acetate to granulating wounds. This study, using mafenide acetate cream (11.2%) and isotope dilution of 14C-labeled mafenide, has established the peak concentration and decay time for mafenide in the saline layer over the wound. Pseudomonas inhibition under identical concentrations was studied. Peak concentrations of 1,200 mg per deciliter of saline were observed after 2 hours. These levels decayed to 400 mg after 10 hours. Remoistening the dressing was required to achieve the peak and duration just mentioned. Pseudomonas inhibition of 88% of discs was present at 1,200, 800, and 700 mg concentrations. This dropped to 44% at 550 mg and 0 at 400 mg. The effective anti-Pseudomonas period was, therefore, 6 hours.

The "Sulfamylon sandwich"--a laminated mafenide-saline dressing.

Though commercially available 11.2% mafenide acetate cream (Sulfamylon) has been shown to be very effective in preventing burn wound sepsis, it has several serious drawbacks. Five percent mafenide acetate solution dressings are also effective and do not have the disadvantages of the cream. This preparation, however, is not available for general usage. For these reasons, we have devised a laminated dressing using the 11.2% cream and saline, which delivers an aqueous solution of mafenide acetate to the wound. The dressing has proved both effective and acceptable to patients, and is particularly valuable following the application of split-thickness skin grafts to burns and other chronic open wounds. The technique is described.

Avoidance of vascular complications associated with the use of dopamine.

Dopamine, dihydroxyphenylethylamine has three distinct actions depending on dosage. Low doses in the range of 1-2 mcg/kg/min result in vasodilatation. Medium doses of 2-10 mcg/kg/min increase cardiac output due to beta adrenergic action, while above 10 mcg/kg/min a potent vasoconstrictor effect predominates. Because of this last action great care must be used to avoid extravasation of infusions of dopamine directly into the tissue. Dopamine is a very useful agent but carries great potential to do local damage. Administration through a catheter placed into a large vein is recommended. Should extravasation occur, prompt infiltration of the area with phentolamine and a local anaesthetic, local cooling and regional sympathetic block may reduce the damage. The case is reported of a patient who suffered extensive necrosis in the forearm following local extravasation of dopamine.