RESUMO
COVID-19 has emerged as a global pandemic leading to an increase in hospitalization and intensive care unit (ICU) admissions worldwide. Due to severe acute respiratory distress syndrome (ARDS), many patients require prone positioning, which is associated with increased pressure ulcer/injury (PU/PI) incidence. COVID-19 pathophysiology may favor the occurrence of PU/PI due to hypoxemia, inflammatory status, and vasculopathy. This study aimed to compare the incidence of PU/PI in ICU patients before and during the COVID-19 pandemic. A retrospective cohort study was conducted at a university hospital in Brazil. Data from the medical charts of every adult patient admitted to ICU from March to July 2019 and the same period in 2020 were collected. The group from 2019 included 408 patients admitted due to multiple causes, and the group from 2020 included 229 patients admitted due to COVID-19 infection. The incidence of PU/PI was significantly higher in patients admitted in 2020 compared to 2019 (62,5 vs. 33,8%, respectively). Also, PU/PI location and severity have been different between groups, with the patients with COVID-19 (2020 group) more exposed to stage 3, 4, and non-stageable lesions, as well as more PU/PI on face skin and other less common locations. In conclusion, the COVID-19 pandemic has highlighted a higher PU/PI incidence. ICU patients were older during the pandemic, had higher body mass index and comorbidities, and needed more invasive medical devices and pronation. The occurrence of PU/PI was also associated with prolonged hospitalization and mortality.
Assuntos
COVID-19 , Lesões por Esmagamento , Úlcera por Pressão , Adulto , Humanos , Úlcera por Pressão/epidemiologia , Úlcera por Pressão/etiologia , Pandemias , COVID-19/epidemiologia , Estudos Retrospectivos , Estudos de Coortes , Unidades de Terapia IntensivaRESUMO
Well-vascularized composite tissue offers improved outcomes for complex head and neck reconstruction. Patients with vessel-depleted necks and failed reconstructions require alternative reconstructive options. We describe a pedicled internal mammary artery osteomyocutaneous chimeric flap (PIMOC) for salvage head and neck reconstruction. Bilateral dissections of 35 fresh cadavers were performed to study individual tissue components and vascular pedicles to develop the PIMOC technique. The flap was then utilized in a series of patients with vessel-depleted neck anatomy. The PIMOC was dissected bilaterally in all cadavers and there were no statistical differences in vascular pedicle caliber or length with regards to laterality or gender. Five patients subsequently underwent this procedure. The flaps included a vertical rectus abdominis myocutaneous component and a 6th or 7th rib with adjacent muscle and skin to restore bone defects, internal lining, and external coverage. All donor sites were closed primarily. There were no flap losses and all patients gained improvements in facial contour, speech and swallow. Although technically complex, the PIMOC is reproducible and provides a safe and reliable option for salvage head and neck reconstruction. The harvest of the 6th or 7th rib and rectus abdominis muscle renders an acceptable donor site.
Assuntos
Cabeça/cirurgia , Artéria Torácica Interna/cirurgia , Retalho Miocutâneo/cirurgia , Pescoço/cirurgia , Procedimentos de Cirurgia Plástica , Terapia de Salvação , Adulto , Idoso , Feminino , Humanos , Masculino , Mandíbula/cirurgia , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: This study aims to compare the major anatomical aspects among anterolateral thigh, parascapular and lateral arm flaps. METHODS: Sixty flaps were dissected in 20 human cadavers, comparing their vascular pedicle length, flap thickness and arterial/venous pedicle diameters. RESULTS: The vascular pedicle length (from the origin of the vascular pedicle to its entry into the skin flap) of anterolateral thigh flap (13.43 ± 3.92 cm, lateral circumflex femoral artery) was longer than parascapular (9.07 ± 1.20 cm, circumflex scapular artery) and lateral arm flap (8.90 ± 1.65 cm, posterior collateral radial artery) (P < 0.001). The thickness of lateral arm flap (6.32 ± 2.33 mm) was lesser than parascapular (8.59 ± 2.93 mm) and anterolateral thigh flap (9.30 ± 3.54 mm) (P < 0.001). The arterial/venous pedicle diameters of lateral arm flap (2.37 ± 0.69 mm / 2.61 ± 0.74 mm) were lesser than parascapular (3.46 ± 0.80 mm / 4.07 ± 0.87 mm) and anterolateral thigh flap (3.26 ± 0.74 mm / 3.87 ± 0.70 mm) (P < 0.001). CONCLUSIONS: The vascular pedicle length of anterolateral thigh flap was the longest and that lateral arm flap presented a pedicle with the smallest arterial and venous diameters, in addition to being the thinnest flap.
Assuntos
Braço/irrigação sanguínea , Escápula/irrigação sanguínea , Retalhos Cirúrgicos/irrigação sanguínea , Coxa da Perna/irrigação sanguínea , Adolescente , Adulto , Idoso , Artérias/anatomia & histologia , Humanos , Masculino , Pessoa de Meia-Idade , Veias/anatomia & histologia , Adulto JovemRESUMO
BACKGROUND: We consider the use of dermal matrix associated with a skin graft to cover deep wounds in the extremities when tendon and bone are exposed. The objective of this article was to evaluate the efficacy of covering acute deep wounds through the use of a dermal regeneration template (Integra) associated with vacuum therapy and subsequent skin grafting. METHODS: Twenty patients were evaluated prospectively. All of them had acute (up to 3 weeks) deep wounds in the limbs. We consider a deep wound to be that with exposure of bone, tendon, or joint. RESULTS: The average area of integration of the dermal regeneration template was 86.5%. There was complete integration of the skin graft over the dermal matrix in 14 patients (70%), partial integration in 5 patients (25%), and total loss in 1 case (5%). The wound has completely closed in 95% of patients. CONCLUSIONS: The use of Integra dermal template associated with negative-pressure therapy and skin grafting showed an adequate rate of resolution of deep wounds with low morbidity.
RESUMO
The purpose of this article is to describe a case of an 8-month-old girl who was diagnosed with a melanotic neuroectodermal tumor and was submitted to a right hemimandibulectomy and immediate reconstruction with a fibular osteocutaneous free flap. At 12-year follow-up, the longest reported in a patient this young, the transferred bone had grown much like the native mandible, and the patient had adequate mandibular contour and function. No revisions were needed, although orthopedic surgery was performed to correct an ankle valgus deviation on the donor leg. It is the opinion of the authors that microsurgical mandible reconstruction in very young patients is efficient and that the surrounding structures contribute to the remodeling of the bone segment to achieve characteristics similar to those of the native mandible.
Assuntos
Fíbula/transplante , Retalhos de Tecido Biológico , Reconstrução Mandibular/métodos , Transplante Ósseo , Feminino , Seguimentos , Humanos , Lactente , Transplante de Pele , Fatores de TempoRESUMO
BACKGROUND: Degloving injuries may be a challenge when it comes to deciding the surgical approach to be used. Repositioning of the flap and suturing are faster and more straightforward, but often these procedures often lead to total or partial loss of the avulsed flap. Pharmacological agents with vascular properties that enhance the viability of the reattached flap could be beneficial to patients with degloving injuries. Experimental models with which to test this hypothesis are scarce. An experimental model reproducing a degloving injury of the hind limb of rats was developed in our department, and the effects of pentoxifylline (Ptx) and allopurinol (Alp) were assessed. METHODS: In all, 3 groups of rats were studied (25 rats each). A hind limb degloving model was used in all groups, resulting in a reverse flow flap. The flap was then repositioned and sutured. The control (Ct) group received only saline solution, the Ptx group received pentoxifylline (25 mg/kg), and the Alp group received allopurinol (45 mg/kg). The rats were observed for 7 days, after which they were killed, and the flap was removed. The total area of the avulsed flap and the necrotic area were measured. RESULTS: The median total flap area (cm) was 5.6 for the Ct group, 5.5 for the Ptx group, and 5.8 for the Alp group (P = 0.9465). Thus, the flaps were similar. The median necrotic flap area (cm) was 3.3 for the Ct group, 2.3 for the Ptx group, and 1.9 for the Alp group (P = 0.0001). There was a statistical difference between the Ct and Ptx groups and the Ct and Alp groups (P < 0.05). CONCLUSIONS: The areas of necrosis observed in the degloved flaps of the rats' hind limbs were smaller in the pentoxifylline and allopurinol groups. Although allopurinol seems to be more efficient, the difference was not significant.
Assuntos
Alopurinol/farmacologia , Pentoxifilina/farmacologia , Lesões dos Tecidos Moles/patologia , Lesões dos Tecidos Moles/cirurgia , Retalhos Cirúrgicos/irrigação sanguínea , Retalhos Cirúrgicos/patologia , Animais , Antioxidantes/farmacologia , Sobrevivência Celular/efeitos dos fármacos , Sobrevivência de Enxerto/efeitos dos fármacos , Membro Posterior/lesões , Membro Posterior/cirurgia , Masculino , Necrose/patologia , Necrose/prevenção & controle , Ratos , Ratos Wistar , Pele/irrigação sanguínea , Pele/efeitos dos fármacos , Pele/lesões , Pele/patologia , Lesões dos Tecidos Moles/tratamento farmacológico , Vasodilatadores/farmacologia , Xantina Oxidase/antagonistas & inibidoresRESUMO
BACKGROUND: The objective of the study was to investigate vancomycin dose adjustment in pediatric burn patients by evaluating trough drug concentrations and the pharmacokinetic and pharmacodynamic (PK/PD) correlation. METHODS: Study subjects included 13 patients who were 6.0 years old, 25 kg (median). with normal renal function. These had at least a 30% total burn surface area and inhalation injury were present in 7/13 patients. The patients were investigated prospectively. Plasma monitoring and PK assessments were performed by serial blood sample collections (30 sets). Only 0.2 mL of each plasma sample was required for our plasma measurements, which were made by high performance liquid chromatography. The vancomycin PK/PD target was set at AUC0-24(ss)/MIC>400. RESULTS: Trough values less than 10 µg/mL were obtained in 16/30 sets (53%) as a consequence of increased plasma clearance and the apparent volume of distribution. The daily dose was subsequently increased from 43.4 ± 9.0mg/kg (mean ± SD) to 98.0 ± 17.9 mg/kg, p<0.05. The PK/PD target was reached for pathogens with 0.5mg/L, 1mg/L, 2mg/L and 4 mg/L MIC in 93.3% (28/30), 66.7% (20/30), 33.3% (10/30) and 3.3% (1/30) of the sets, respectively. CONCLUSIONS: To more rapidly achieve the PK/PD targets in pediatric burn patients with normal renal function, an initial dose of approximately 90-100mg/kg/day is recommended; however, this higher dosage regimen should be further evaluated in this population in terms of efficacy and toxicity as well as in terms of achieving pharmacodynamic goals.
Assuntos
Antibacterianos/administração & dosagem , Queimaduras/tratamento farmacológico , Vancomicina/administração & dosagem , Antibacterianos/farmacocinética , Área Sob a Curva , Queimaduras/metabolismo , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Taxa de Depuração Metabólica , Estudos Prospectivos , Vancomicina/farmacocinéticaRESUMO
The supraclavicular island flap has been widely used in head and neck reconstruction, providing an alternative to the traditional techniques like regional or free flaps, mainly because of its thin skin island tissue and reliable vascularity. Head and neck patients who require large reconstructions usually present poor clinical and healing conditions. An early experience using this flap for late-stage head and neck tumour treatment is reported. Forty-seven supraclavicular artery flaps were used to treat head and neck oncologic defects after cutaneous, intraoral and pharyngeal tumour resections. Dissection time, complications, donor and reconstructed area outcomes were assessed. The mean time for harvesting the flaps was 50 min by the senior author. All donor sites were closed primarily. Three cases of laryngopharyngectomy reconstruction developed a small controlled (salivary) leak that was resolved with conservative measures. Small or no strictures were detected on radiologic swallowing examinations and all patients regained normal swallowing function. Five patients developed donor site dehiscence. These wounds were treated with regular dressing until healing was complete. There were four distal flap necroses in this series. These necroses were debrided and closed primarily. The supraclavicular flap is pliable for head and neck oncologic reconstruction in late-stage patients. High-risk patients and modified radical neck dissection are not contraindications for its use. The absence of the need to isolate the pedicle offers quick and reliable harvesting. The arc of rotation on the base of the neck provides adequate length for pharyngeal, oral lining and to reconstruct the middle and superior third of the face.
Assuntos
Neoplasias de Cabeça e Pescoço/patologia , Neoplasias de Cabeça e Pescoço/cirurgia , Músculos do Pescoço/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Retalhos Cirúrgicos/irrigação sanguínea , Idoso , Idoso de 80 Anos ou mais , Clavícula , Estudos de Coortes , Estética , Feminino , Rejeição de Enxerto , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Esvaziamento Cervical/métodos , Músculos do Pescoço/transplante , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Posicionamento do Paciente , Qualidade de Vida , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento , Cicatrização/fisiologiaRESUMO
Changes in skin sensibility occur in various postoperative plastic surgeries, especially when they involve major skin and subcutaneous dissection. There were no studies so far that objectively compared changes of ear sensibility. This prospective study was conducted to compare ear sensibility before and after otoplasty. Patients with prominent ears (n = 15) underwent bilateral otoplasty. Ear tactile sensibility was tested preoperatively and 6 and 12 months after surgery by Pressure Specified Sensory Device, an apparatus that quantifies cutaneous pressure sensation (g/mm(2)). Comparison between preoperative and 6-months postoperative results indicated an increment on mean skin pressure thresholds; however, mean thresholds between pre- and 12 months postoperative period were similar. Vibratory and hot/cold sensibility did not present any difference during this period. This is the first comparative assessment of ear tactile sensibility using quantitative methods. After otoplasty, initially there was reduction in an ear tactile sensibility, followed by a return to levels similar to preoperative sensibility.
Assuntos
Técnicas Cosméticas , Orelha Externa/cirurgia , Tato , Adolescente , Adulto , Orelha Externa/anormalidades , Orelha Externa/fisiologia , Feminino , Seguimentos , Humanos , Masculino , Pressão , Estudos Prospectivos , Fenômenos Fisiológicos da Pele , Sensação Térmica , Vibração , Adulto JovemRESUMO
In a prospective study, indices of glucose homeostasis, lipid profile, and systemic inflammation were monitored after an aesthetic abdominoplasty, aiming to scrutinize the possible metabolic benefits for abdominal fat removal. Premenopausal females with substantial weight loss (N=40) undergoing circumferential abdominoplasty (index group, n=20) or augmentation mammoplasty with mastopexy (controls, n=20) were recruited. All of them originally underwent Roux-en-Y gastric bypass. Variables included BMI, white blood cell count, C-reactive protein, hemoglobin, total cholesterol and fractions, triglycerides, glucose, and HbA1c. Follow-up reached 20.3 ± 13.6 months for index cases and 29.5 ± 17.4 months for controls. The metabolic and inflammatory indices improved after the bariatric surgery. Subsequent monitoring indicated a stable body weight and biochemical profile in both groups. The exceptions were HDL cholesterol and C-reactive protein, which respectively increased and diminished after the abdominoplasty, consistent with an inflammatory and metabolic advantage for this operation. This is the first long-term study in a weight-stable population to point out such a pattern after abdominoplasty.