The skeletal consequences of meningococcal septicaemia

Meningococcal septicaemia and its complication of purpura fulminans has a significant impact upon the extremities as the ischaemic insult caused by the intravascular thrombosis typical of the fulminant infection can lead to gangrene and tissue loss in the acute phase of illness and the late sequelae of growth arrest and deformity. The initial management and long-term assessment and intervention are described in this chapter.

Successful management of ultra short bowel syndrome in an elderly patient

An 83-year-old woman presented emergently with a 1-week history of increasing abdominal pain and vomiting. Imaging confirmed an incarcerated incisional hernia containing viable small bowel. Laparotomy revealed profound ischaemic insult extending beyond the hernial contents, affecting virtually the entire small bowel, consistent with acute superior mesenteric artery thrombosis. The patient underwent resection of the entire small bowel except for 20 cm of the jejunum and 15 cm of the terminal ileum. Her duodenum and large bowel were unaffected. Despite her age, comorbidities and only 35 cm of the remnant small bowel, this patient made a remarkable recovery. She transitioned from total parenteral nutrition dependence in an acute hospital setting to being discharged into the community, relying on partial parenteral nutrition two times per week in a home setting.

Ischaemia, healing and outcomes in proximal humeral fractures

Interfragmental ischaemia is a prerequisite for the initiation of the inflammatory and immunological response to fracturing of bone. Intrafragmental ischaemia is inevitable: the extent of the initial ischaemic insult does not, however, directly relate to the outcome for healing of the fracture zones and avascular necrosis of the humeral head. The survival of distal regions of fragments with critical perfusion may be the result of a type of inosculation (blood vessel contact), which establishes reperfusion before either revascularization or neo-angiogenesis has occurred. Periosteum has a poorly defined role in fracture healing in the proximal humerus. The metaphyseal periosteal perfusion may have a profound effect, as yet undefined, on the healing of most metaphyseal fractures of the proximal humerus, and may be disturbed further by inadvertent surgical manipulation. The metaphysis can be considered as a ‘torus’ or ring of bone, its surface covered by periosteum antero- and posterolaterally, through which the tuberosity segments gain perfusion and capsular reflections antero- and posteromedially, through which the humeral head (articular) fragment gains perfusion. The torus is broken in relatively simple primary patterns: a fracture line at the upper surface of the torus is an anatomical ‘neck’ fracture; a fracture line at the lower surface of the torus is the surgical ‘neck’ fracture. Secondary fragmentation (through compression and/or distraction) of the torus itself creates complexity for analysis (classification), alters the capacity and outcome for healing (by variable interruption of the fragmental blood supply) and influences interfragmental stability. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.180005

Intensive care management in hepatic and other abdominal organ transplantation

Care of the transplant patient post-operatively requires a multidisciplinary approach. The goal of the intensivist is to create an ideal environment for the allograft to recover from its ischaemic insult and return to normal function. An understanding of the recipient’s pretransplant physiology is essential, as the pathological states associated with organ failure may persist for weeks to months after transplant. In particular, cardiac and renal disease may impact care in the immediate post-transplant period. An understanding of immune suppressive strategies will enable the intensivist to mitigate nephrotoxic side effects of these medications and anticipate specific vulnerabilities to infection. Attention to all the details of good critical care will give the allograft and the recipient the best chance for long-term survival. The intensivist must be able anticipate problems related to surgery and early signs of allograft recovery and dysfunction. Common post-operative complications are described in this chapter.