Local Tissue Trauma Research Articles

Safety of rapid intravenous paracetamol infusion in paediatric patients

PurposeParacetamol is recommended as a first-line treatment for pain and fever in paediatric patients. Intravenous (IV) infusions are recommended to be administered as a 15-min infusion to minimize local tissue trauma and related pain. The purpose of this study was to demonstrate that IV paracetamol could be administered during 5 ​min or less in paediatric patients without causing related adverse reactions. MethodsProspective, observational safety study including children aged <18 years who received IV paracetamol. Pain scores before and after the paracetamol infusions were obtained using VAS, FLACC, COMFORT neo, or COMFORT behaviour scales with scores from 0 to 10 representing no pain to worst pain. Further, objective signs of inflammation at the infusion site were registered. FindingsWe included 44 patients (median age 2.8 years, range 0.01–17.0 years) who received paracetamol in a peripheral venous catheter (n ​= ​22) or central venous catheter (n ​= ​22). In total, the 93 paracetamol infusions had a median infusion time of 3:00 ​min, range 0:40 to 5:00 ​min. After infusions, pain scores were lower, compared to before infusions (mean change −0.26, 95% confidence interval −0.45 to −0.07, P ​= ​0.007), and no objective signs of inflammation were reported. ImplicationsThis safety study indicates that IV paracetamol can be administered in paediatric patients with a shorter infusion time than recommended without causing adverse reactions. The results may contribute to a more efficient workflow at paediatric departments.

Customized Thinning of Silicon-based Neural Probes Down to 2 µm.

This paper reports on the customized thinning of neural probes based on silicon (Si) using deep reactive ion etching (DRIE) as a post-processing step. The reduced probe dimensions are expected to minimize local tissue trauma, while guaranteeing probe integrity during implantation. For DRIE, the probes are partially masked by a micromachined Si cover chip comprising tailored cavities enabling any desired thinned length l and probe thickness t by a proper choice of cover chip design and DRIE parameters, respectively. A broad variety of probe designs were realized with shank tip thicknesses ranging from 35 µm down to 2 µm. All probes could successfully be implanted into a brain tissue phantom, demonstrating a pronounced reduction in insertion force from 0.55 mN for unprocessed probes to 0.08 mN for 2-µm-thin shanks. When the dura mater was mimicked by a polyethylene (PE) membrane, forces were reduced from 28.9 mN to 16.6 mN for 15-µm-thin shanks.

Bowel perforation secondary to local tissue injury from intentional iron overdose

We report the case of a 16-year-old who presented after intentional ingestion of elemental iron (approximately 48 mg/kg). Iron levels at presentation were 4388 mcg/dl. The patient demonstrated symptoms of severe toxicity including hypotension, metabolic acidosis, and multiple organ failure. Fourteen days after ingestion, the patient suffered multiple punctate bowel perforations that were not related to ischemia and appeared to have been the result of local tissue injury from ingested iron. The bowel was successfully primarily repaired. However, the patient eventually succumbed due to the severity of multisystem organ failure and a systemic fungal infection. We report this case to highlight the risk of local tissue trauma from ingested iron, resulting in bowel perforation. This case highlights the need to eliminate ingested iron to limit systemic absorption and to prevent local tissue trauma and bowel perforation.

Ilizarov External Fixation: Percutaneous Gigli Saw Versus Multiple Drill-hole Osteotomy Techniques for Distraction Osteogenesis

IntroductionMany different methods and variations have been employed to perform osteotomy for deformity correction, bone lengthening, and segmental bone transport. Currently, multiple drill-hole (MDH) and Gigli saw osteotomies are the two most preferred ones, being favoured over other techniques. Our objective is to compare the modified healing index (mHI) of these two commonly used procedures.MethodologyThis retrospective study was conducted at the department of Orthopedics, Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan. The study population consisted of all skeletally mature patients who underwent tibial bone osteotomy for bone lengthening or bone transport using Ilizarov circular fixator from June 2016 to September 2018. We excluded patients with metabolic bone disease and patients who underwent osteotomy for deformity correction. Preoperative and operative patients’ demographics and clinical data were gathered through a review of medical record and mHI was calculated to compare the effectiveness of osteotomy techniques.ResultsA total of 50 patients, 74% males and 26% females 26% with a mean age of 33.14 ± 12 years were included in the study. Of the 50 patients, 23 (27 osteotomies) had undergone MDH osteotomy (group I), whereas 27 patients (37 osteotomies) had a Gigli saw osteotomy (group II). The overall mHI of both groups was 1.60 ± 0.34 month/cm (range 1.0-2.5 month/cm). When we compared the mHI of both techniques, the mean mHI was 1.72 ± 0.33 month/cm (range 1.2 - 2.5 months/cm) in MDH group and 1.54 ± 0.36 month/cm (range 1.0-2.5 month/cm) in the Gigli saw group. The healing index was significantly lower in the Gigli saw group. None of our patients showed nonunion at the osteotomy site. However, the problems of incomplete osteotomy in two cases and bone fractures in four cases were seen in MDH osteotomy.ConclusionAccording to our results, percutaneous Gigli saw osteotomy technique by two small incisions minimizes the local soft tissue trauma and periosteal disruption around the osteotomy more than the multiple drill holes osteotomy, resulting in better consolidation following distraction osteogenesis.

Recycling of residual liquid drug formation following pressurized intra-peritoneal aerosol chemotherapy (PIPAC).

e14215 Background: Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is becoming an increasingly widespread approach in which intra-peritoneal chemotherapy (IPC) is delivered in the shape of a chemoaerosol formed by an aerosol creating device. Disadvantages of current PIPAC applications include nearly instant liquid drug accumulation in the recto-uterine pouch. This study aims to investigate the feasibility of respraying the accumulated liquid to prevent local cytotoxicity and tissue trauma as well as to possibly adjust drug concentrations and improve both distribution patterns and penetration levels. Methods: A well-established, previously described postmortem swine model was used. 200ml of doxorubicin solution were aerosolized within the abdominal cavity at a pressure of 12 mm Hg C02 and 37° degrees Celsius. A suction tube was placed in the recto-uterine pouch and accumulating liquid doxorubicin solution following aerosol formation was collected and recycled in consecutive PIPAC repetitions. PIPAC repetitions were performed by using only the remaining liquid drug within the pouch. Consecutive residual volumes within the recto-uterine pouch were measured, as well as tissue penetration rates at different locations of the peritoneal wall. Results: Liquid formation was continuously reduced with each consecutive spray cycle. Tissue penetration rates were significantly higher following the recycling process (p &lt; 0.05). Drug distribution pattern showed a significant improvement following the recycling process vs. after initial aerosol formation (p &lt; 0.05). Conclusions: Respraying the accumulated liquid drug in the recto-uterine pouch is both feasible and important to eliminate liquid accumulation following PIPAC application. Preliminary data gathered in this study suggest that such a recycling process both improves drug distribution and increases penetration levels. However, recycling might also increase the technical complexity of the entire applicational procedure.

Investigation of biomarkers alterations after an acute tissue trauma in human trapezius muscle, using microdialysis

Alterations in muscle milieu are suggested as important activity of peripheral drive in patients with chronic musculoskeletal pain (CMP). Microdialysis (MD) has been used in monitoring altered metabolic response pattern in muscles. However, the insertion of MD probe causes a local tissue trauma. Whether and how metabolites in trapezius muscle are affected by acute tissue trauma is unknown. Hence, this study investigated the metabolic response and nociceptive reaction of the tissue following MD probe insertion in patients with CMP and healthy individuals. Fifty-nine patients and forty pain-free volunteers were recruited. Pressure pain thresholds (PPTs) were obtained at the trapezius and tibialis muscles. Pain questionnaires determined the levels of pain related aspects. MD (20 kDa cut-off) was performed in the trapezius and samples were collected within 40 min. Interstitial concentration of the metabolites was analyzed by a two-way-mixed-ANOVA. The metabolic response pattern changed over time and alterations in the level of metabolites could be seen in both CMP and healthy controls. Pain questionnaires and pain intensities manifested clinical aspects of pain closely to what CMP patients describe. Analyzing metabolites due to acute tissue trauma by aid of MD may be a useful model to investigate altered metabolic response effect in CMP.

Microsurgical dissection of facial nerve in parotidectomy: a discussion of techniques and long-term results.

Parotidectomy has well-documented post-operative complications. Dissection of the facial nerve branches can be challenging even under loupe magnification, and partial, or complete injury of the nerve branches can occur during surgery. To reduce this risk and the associated complications, we propose a number of microsurgical best practices, which can be performed during parotidectomy. A retrospective survey was conducted on 109 patients (45 males and 64 females, average age 46.2 years, range of 6 to 74 years) who underwent parotidectomy in two different institutions. Our data showed no permanent injury to the facial nerve, and 17% of neuroapraxia that had resolved with time. Post-operative complications have occurred in 33 cases (30% rate). In the superficial parotidectomy cohort (78 patients), the number of complications was 17 (21%). In the total parotidectomy cohort (31 patients), the number of complications was 16 (51%). Based on our results, we believe that the use of microsurgical techniques during parotidectomy may represent a useful tool in improving accuracy and minimising local tissue trauma that can affect nerve recovery. This is particularly true in situations such as tumor recurrence, tissue fibrosis or in case of sizeable tumors around the facial nerve branches. We believe that the decreased risk of facial nerve post-operative symptoms outweigh the disadvantage of increased operative time of this procedure.

Biomarkers alterations in trapezius muscle after an acute tissue trauma: A human microdialysis study

Abstract Aims Alteration in muscle milieu has been proposed as one of the main contributors underlying chronic musculoskeletal pain (CMP). Microdialysis (MD) provides real-time information on release of pain and metabolic biomarkers in muscle. However, insertion of MD probe causes a local tissue trauma, which may affect the tissue milieu. Whether an acute tissue trauma alter pain and metabolite biomarkers in trapezius muscle of patients with CMP is not known. Hence, this study investigated changes in muscle metabolites following MD probe insertion in patients with CMP in comparison with healthy controls. Methods Nineteen patients (11 women and 8 men; 41.4 years) with CMP and 20 pain-free volunteers (10 women and 10 men; 36.5 years) were recruited (project approval number: 2013/151- 31). Baseline pressure pain thresholds (PPT) at trapezius muscle were obtained bilaterally with a reference point at the tibialis muscle. Pain questionnaires were used for determining levels of anxiety and depression and catastrophizing impact. Interstitial samples were collected from trapezius muscles by aid of MD (20 kDa cut-off) during a period of 40 min. Collected dialysates at 2 time-points of 20 and 40 min were stored at −70 °C until analysis. Concentrations of glucose, lactate, pyruvate, glycerol, and glutamate were analyzed by ISCUSSflex. P ≤ 0.05 was considered significant. Results No potential case with respect to anxiety, depression or catastrophizing impact was found. Lower PPTs were found in CMP group (P ≤ 0.05). Significantly lower levels of pyruvate were found in CMP group at both 20 min (P = 0.003) and 40 min (P = 0.006). Gender-based analysis indicated higher concentrations of glutamate in female patients with CMP. Conclusions This study was first to demonstrate metabolite alterations during trauma phase of MD in trapezius muscles of CPM compared with healthy controls. This model proved beneficial for investigating pain and metabolic biomarkers during acute phase of MD.

Nosocomial Jejunal Mucormycosis - an Unusual Cause of Perforation Peritonitis

Mucormycosis is a rare but highly invasive opportunistic fungal infection. Gastrointestinal disease although uncommon is highly fatal. We report a case of jejunal mucormycosis in a 24 year old undernourished female with preceding surgical intervention for acute intestinal obstruction of tubercular etiology. On 8th post-operative day, she developed oozing from suture line, prompting exploratory laparotomy, bowel resection, jejunostomy and ileal mucus fistula. Resected bowel showed one perforation and several areas of impending perforations. Characteristic broad, pauci-septate hyaline, empty looking hyphae with infrequent branching were found transmurally and showing angio-invasion. Local intestinal tissue trauma coupled with her sub-normal immune status permitted this unusual nosocomial infection. Histopathological demonstration of the fungus in surgical specimens remains cornerstone of diagnosis of mucormycosis in view of its non-specific symptoms, low isolation rates of mycological culture and lack of other rapid tests.

Transient Regional Hypothermia Applied to a Traumatic Limb Attenuates Distant Lung Injury Following Blast Limb Trauma

Explosive traumatic injury to an extremity may lead to both local and distant organ injury. Regional traumatic tissue hypothermia has been reported to offer systemic protection; here we investigated the protective effects of regional limb hypothermia on local tissue trauma and the lungs. Furthermore, the optimal duration of regional traumatic limb hypothermic treatment was also evaluated. Prospective, controlled, animal study. University research laboratory. Adult male Sprague-Dawley rats. Anesthetized rats were randomized to sham, blast limb trauma, sham and regional hypothermia for 30 minutes, and blast limb trauma and regional hypothermia for 30 minutes, 60 minutes, and 6 hours. Blast limb trauma was created using chartaceous electricity detonators. Distant lung and local tissue injury following blast limb trauma were attenuated by regional traumatic limb hypothermic treatment for 30 minutes, 60 minutes, and 6 hours reflected by reduced lung histopathological changes and water content. Regional traumatic limb hypothermic treatment for 60 minutes and 6 hours failed to further attenuate distant lung and local tissue injury compared with regional traumatic limb hypothermic treatment for 30 minutes. Inhibition of cystathionine gamma-lyase/hydrogen sulfide was reduced by regional traumatic limb hypothermic treatment for 30 minutes in blast limb trauma rats. A surrogate of neutrophil accumulation, myeloperoxidase activity, and release of tumor necrosis factor-α and interleukin-6 were also attenuated by regional traumatic limb hypothermic treatment for 30 minutes in blast limb trauma rats. Oxidative stress was alleviated by regional traumatic limb hypothermic treatment for 30 minutes evidenced by reduction of hydrogen peroxide and malondialdehyde and an increase of superoxide dismutase and glutathione in blast limb trauma rats. Our data indicate that regional traumatic limb hypothermic treatment for 30 minutes offers both local protection for traumatic tissue and systemic protection for the lungs, which is likely associated with restoration of the cystathionine gamma-lyase/hydrogen sulfide pathway and inhibition of the inflammatory response and oxidative stress.

A Comparison of the Forces Applied to a Manikin during Laryngoscopy with the Glidescope® and Macintosh Laryngoscopes

The force applied during laryngoscopy can cause local tissue trauma and can induce cardiovascular responses and cervical spine movement in susceptible patients. Previous studies have identified numerous operator and patient factors that influence the amount of force applied during intubation. There are few studies evaluating the effect of different laryngoscope blades and no study involving video laryngoscopes. In this study we measured the forces using two laryngoscopic techniques. Three FlexiForce Sensors (A201-25, Tekscan, Boston, MA, USA) were attached to the concave blade surface of a Macintosh and a GlideScope laryngoscope. Experienced anaesthetists performed Macintosh and GlideScope intubations on the Laerdal Airway Management Trainer manikin. Compared to Macintosh intubations, the GlideScope intubations had equal or superior views of the glottis with 55%, 58% and 66% lower median peak, average and impulse forces applied to the tongue base. The distal sensor registered the most force in both devices and the force distribution pattern was similar between the devices. The findings suggest that the GlideScope requires less force for similar or better laryngoscopic views, at least in a manikin model.

Open Reduction Internal Fixation of Displaced Sacral Fractures: Technique and Results

Pelvic ring disruption with an associated sacral fracture is typically a result of high-energy injury. Due to significant local soft tissue trauma and the complex neurovascular anatomy in the region, exposure and reduction of sacral fractures has proven to be difficult, hazardous, and fraught with complications. We describe a modified reduction technique to address displacement in sacral fractures to show that it can be safe and effective through evaluation of radiographic, clinical, and functional outcomes. We retrospectively reviewed the radiographic and clinical results of consecutive patients treated at a single institution by the senior surgeon (K.F.D.) with open reduction for displaced sacral fractures. Radiographic follow-up was available on all patients. Complete clinical follow-up was available on 19 of 20 patients. The average duration of follow-up was 3.7 years. All fractures united with no additional surgery. There were no infections or additional neurologic deficits or vascular injuries. There was 1 asymptomatic hardware failure 2 years postoperatively with no further displacement. Average preoperative displacement on the anteroposterior (AP) radiograph was 14.72 mm with a long-term follow-up displacement of 3.25 mm. Iowa Pelvic Score questionnaires demonstrated an average score of 92.2. Eighty-nine percent of patients returned to full time work or their previous activity level. The technique of open reduction and fixation of displaced sacral fractures described in this review is safe and effective with a low complication rate and clinical results comparable to or exceeding that of previously published series.

A 21-year-old man with fever and abdominal pain after recent peritonsillar abscess drainage

Lemierre syndrome an extremely rare and unreported disease typically results from oropharyngeal infection and/or local tissue trauma with invasion of the parapharyngeal soft tissue with bacteria. Once local tissue invasion occurs, internal jugular vein septic thrombophlebitis with or without metastatic complications may occur. The etiology of Lemierre syndrome is generally Fusobacterium necrophorum, reported to be present in approximately 80% of the cases. The outcome of Lemierre syndrome in the preantibiotic era was nearly always fatal. The outcome today with the appropriate antibiotic coverage is quite good. The management of a patient with suspected Lemierre syndrome should be aggressive and comprehensive. Blood cultures as well as cultures from infection sites should be obtained. Computed tomography, magnetic resonance imaging, and ultrasound are all appropriate modalities to detect the presence of internal jugular vein thrombophlebitis. Treatment of Lemierre syndrome consists of prolonged antibiotic therapy (4 to 6 weeks) with appropriate anaerobic coverage. Typical antibiotics include penicillins, metronidazole, or clindamycin. Surgical drainage of metastatic abscesses is often needed ensure resolution of this disease process. Persistent sore throat syndrome caused by F necrophorum has been reported in the literature and the General Practitioners should be aware of this entity because they may see this in their practice.

An unusual gangrene of multiple limbs due to tight ligatures in an alcoholic patient

The traditional bone setter's gangrene due tight splints is a well-known entity. Gangrene usually supervenes following prolonged pressure of tight splintage by traditional bone setters in the process of treating fractures. We present an unusual case of gangrene in multiple limbs in a chronic alcoholic due to tight ligatures in a non-traumatic situation. Such a case has not been reported previously in the literature. The authors propose a combined effect of tight constricting ligatures leading to prolonged venous occlusion local tissue trauma, acute alcohol toxicity, altered sensorium, decreased tissue perfusion and peripheral neuropathy as the possible mechanism.

Injury to the Lateral Femoral Cutaneous Nerve During Minimally Invasive Hip Surgery: A Cadaver Study

A smaller skin incision as part of minimally invasive surgery (MIS) for total hip arthroplasty (THA) is thought to reduce local tissue trauma. Preservation of cutaneous nerves may reduce postoperative pain and improve rehabilitation. The standard lateral approach (SLA) and two MIS approaches (anterolateral [ALA] and posterior [PA]) were compared to determine which incision preserved cutaneous nerves. Fifteen cadaveric hip specimens were dissected to establish the course of branches of the lateral femoral cutaneous nerve. The number of branches divided by each of the three incisions was recorded. The MIS incisions resulted in significantly less nerve division compared with the SLA. The mean difference between the SLA and the ALA was 4.4 (P < 0.0001), and between the SLA and the PA was 1.4 (P = 0.0005). The ALA divided significantly fewer nerves compared with the PA (mean difference = 3; P = 0.0001). There is little evidence of the benefit of one MIS approach over another in the literature. The ALA preserved significantly more cutaneous nerves in this study. These results need corroboration with clinical outcomes to determine their significance.

SU-FF-J-75: The Effect of Time On Inter-Transponder Distance Implanted in Lung: An Initial Study in a Canine Model

Purpose: The Calypso 4D Localization® system uses non‐ionizing AC electromagnetic technology to localize implanted Beacon® transponders. The system is capable of real‐time measurement of internal motion. Effective use of this technology in the lung requires placing the transponders in fixed positions that will not change over time. This study compares inter‐transponder distance over an implantation time period of 0–57 days in canine lung.Method and Materials: A pulmonologist bronchoscopically implanted three transponders in a single lung lobe of five canines under an institutionally approved protocol. Distances between transponder pairs were measured over 0–57 days using the Calypso system. The positions were measured both when the dogs were breathing freely and during varied ventilatory amplitudes and frequencies, variable ventilation. In animals with at least two transponders, inter‐transponder distances were calculated. Results: The mean inter‐transponder distances during breathing patterns were stable on the same day, at 2.32cm (free breathing) and 2.40cm (variable ventilation). One animal retained all 3 transponders at 57 days and exhibited significant change in inter‐transponder distance from day 1–9. Changes in mean inter‐transponder distance from day 9–29 ranged from 0.2–1.9mm. For reasons not understood, transponder distances on day 57 for one animal were larger at 2.0–6.5mm. Conclusion: The inter‐fiducial distance was stable regardless of breathing pattern on the same day. Measurements taken on the first day post‐implant varied significantly from later measurements, probably due to local tissuetrauma. Up to 30 days post‐implant, the inter‐transponder distances were stable. However, in one animal after 30 days, the relationship between transponder positions changed. More work is required to improve implant retention and to understand optimal transponder placement relative to a lungtumor target. Future studies will acquire more frequent transponder positions to be a more representative model of clinical patient data. This work was supported by Calypso Medical Technologies.

Effect of systemic hypothermia on local soft tissue trauma-induced microcirculatory and cellular dysfunction in mice*

Changes in body temperature occur as a systemic reaction to severe trauma; however, its role in the manifestation of injury remains unclear. Thermoregulatory responses vary considerably from fever to hypothermia. Although hypothermic trauma patients seem to have a worse prognosis, there is the question whether hypothermia per se or the severity of trauma producing the hypothermia is responsible for aggravated injury and increased mortality rate. The present study unravels how moderate to severe systemic hypothermia modulates local microcirculatory dysfunction and cellular injury in local soft tissue trauma. Prospective, experimental study. Research laboratory at a university. C57BL/6J mice. A model involving standardized drop weight device-induced tissue trauma and high-resolution multifluorescence microscopy in the dorsal skinfold chamber was used to show arteriolar vasoconstriction, reduction of blood flow, nutritive perfusion failure, and apoptotic cell death at 1 hr after trauma. During the 8-hr posttrauma observation period, microcirculation, but not apoptosis, restituted to almost baseline level. Concomitant systemic hypothermia of either 34 degrees C or 30 degrees C did not affect late manifestation of apoptotic cell death but aggravated initial microcirculatory dysfunction and inhibited recovery during the 8-hr follow-up period. Our study provides evidence that systemic hypothermia may aggravate soft tissue trauma-associated microcirculatory dysfunction. These experimental results clearly support clinical efforts to prevent hypothermia in the acutely traumatized patient.

Antibiotics After Rattlesnake Envenomation? Don't Bite!

Rattlesnakes have a high concentration of oral bacterial flora, so empiric antibiotics are often prescribed for bites, even though the local tissue trauma is minimal and the reported incidence of infection is low. Researchers in Arizona conducted a prospective …

Metastatic calcification

Calciphylaxis is a rare, painful, and debilitating disease of widespread metastatic calcification that progresses to ischemic tissue necrosis. It occurs almost exclusively in patients with end-stage renal disease and secondary hyperparathyroidism. Reticulated, violaceous, mottled patches commonly appear on the lower extremities and progress to cordlike nodules and necrotic ulcers with overlying eschars. Septicemia, which may occur after secondary infection of the ulcers, is the most common cause of death. Treatment with phosphate-binding antacids, total or partial parathyroidectomy, and avoidance of local tissue trauma remain the mainstays of therapy, although a uniform cure for calciphylaxis remains elusive. Prognosis for patients with calciphylaxis is dismal, even after surgical intervention. Early diagnosis and treatment is critical to prevent progression of the disease process.

Necrotizing Fasciitis of the Eyelids

Necrotizing fasciitis is a destructive soft tissue infection that rarely involves the eyelids. Three cases of necrotizing fasciitis of the eyelids are described. Necrotizing fasciitis was preceded by minor forehead soft tissue trauma in two cases and occurred spontaneously in one. In two patients necrotizing fasciitis was bilateral and involved both the upper and lower eyelids. Review of these cases, in addition to 18 cases previously reported in the English literature, reveals a predominance in females, preceding minor local soft tissue trauma, frequent bilateral involvement, and an association with alcohol abuse and diabetes. In all of the patients, group A beta-hemolytic streptococci were cultured from the wound. Early recognition of the disease process, prompt surgical debridement of the necrotic tissue, aggressive antimicrobial therapy, and delayed skin grafting combine to minimize morbidity.