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PubMed2004

Temperature changes in superficial and deep tissue layers with respect to time of cold gel pack application in dogs.

Despite the widespread clinical use of cryotherapy, there is only limited and inconsistent data on application times. The aim of this study was to determine the changes in tissue temperature and the duration of this effect. In this experimental study, five adult dogs were used. A cold gel pack (10 x 20 cm) was applied transversally over the right leg femoral region. Temperatures were recorded simultaneously: rectal by a mercury thermometer; right leg skin by probe of Nihon Kohden 6000 polygraph; and right leg subcutaneous, intramuscular, and periosteal, and left leg intramuscular temperatures by a fluorooptic biomedical fiber optic (0.6 mm diameter) thermometer connected to a computer system. Total system accuracy was 0.01 degrees C. Cold gel packs were applied for 10, 15, 20, 25, and 30 minutes duration. The results can be summarized as cooling and rewarming data. 1) The superficial tissues such as skin and subcutaneous demonstrated the most rapid and profound cooling effect. The deeper tissues such as bone and muscle exhibited a smaller and more gradual decline in temperature. 2) There was a prolonged rewarming period in all tissues after the removal of the cold gel pack but this period was longer in deeper tissues. According to cold gel pack application time, the rewarming time in intramuscular layers to baseline or plateau temperatures was about: 60 +/- 3 minutes for 10 minutes application, 100 +/- 4 for 15, 130 +/- 5 for 20, 140 +/- 7 for 25, and 145 +/- 8 for 30. It can be concluded from these results that with increased cold gel pack application time, deep tissue temperature decreased and the duration of cooling effect increased. However, the data indicated that the length of application time and the duration of cooling effect were not linearly related. Especially after 20 minutes of application this ratio decreased progressively. There may be implications of these results for clinical practice.

Anesthesia↗
PubMed2005

Adenosine 5'triphosphate transport and accumulation during the cold preservation of rat hepatocytes in University of Wisconsin solution.

AIM: We used isolated hepatocytes to investigate how different concentrations of ATP in the University of Wisconsin (UW) solution affected both cellular ATP content and cell viability during the cold storage and the rewarming step. The mechanism involved in ATP transport and accumulation in hypothermia was also determined. METHODS: The cells were preserved up to 72 h in different conditions: UW solution without ATP (a-group), UW+5 mmol/L ATP (b-group), and UW+10 mmol/L ATP (c-group). The ATP content and the cell viability (LDH release) were determined during the cold storage and the rewarming step. In the groups a and c, the respiratory function of the cells at rewarming was studied. In addition, the cell volume of hepatocytes and the mechanism involved in ATP transport and accumulation were assessed. The extracellular degradation of exogenous nucleotides during transport experiments was investigated by a HPLC technique. RESULTS: After three days of cold storage a loss of cellular ATP content was observed in hepatocytes preserved either without nucleotides (a-group) or with 5 mmol/L ATP (b-group). In contrast, 10 mmol/L ATP (c-group) was able to maintain a normal ATP cellular content, with only a 6% diminution after 72 h of cold storage. The respiratory function was significantly different in hepatocytes preserved with 10 mmol/L ATP than without ATP. No significant change was detected for the three groups in cellular volume during the cold storage. We also report that the time course accumulation of (3H)-ATP by cold stored hepatocytes is a rapid process that is completed after 180 s with linear dependence on the extracellular ATP concentration (linear fitting results in a slope of 0.5624+/-0.1179 mmol/L ATP intracell/mmol/L ATP extracell). CONCLUSION: Our results show that, during hypothermic storage in UW solution, hepatocytes are permeable to ATP by a diffusive mechanism. Also, we found that it is ATP the main extracellular nucleotide available for transport and it is not the breakdown products.

Adenosine↗
PubMed1993

[Effect of temperature on plasma concentration of FK506].

Because the affinity of FK506 for red blood cells is strong, plasma FK506 levels vary depending upon the temperature at which plasma is separated from whole blood. This study was undertaken to investigate the effects on plasma FK506 of blood temperature at the time of separation and of its rewarming at 37 degrees C, using A) blood samples from rats administered with FK506 at 1 mg/kg for 7 days, and B) human blood samples added with FK506 at 1.0, 3.2 and 10 ng/ml in vitro. 1) Plasma FK506 levels of samples from rats were not affected by storage time, but samples separated at 20 degrees C were significantly lower in FK506 levels than those separated at 37 degrees C. Plasma FK506 level after rewarming blood at 37 degrees C was not significantly different from that of blood stored at 37 degrees C. 2) FK506 levels in human plasma, separated at 30 degrees C and 20 degrees C were 51% and 33%, respectively, of the corresponding value for plasma separated at 37 degrees C. But the level of plasma separated at 0 degrees C was 56%, which was higher than that at 20 degrees C. 3) Rewarming of human blood at 37 degrees C for 5 minutes allowed the plasma FK506 level to return to the initial level. FK506 levels of plasma separated without regard to temperature are less reliable and reproducible.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1999

Impaired oxygen utilization during rapid cooling on cardiopulmonary bypass.

UNLABELLED: Little attention has been paid to oxygen demand/supply balance during the cooling phase of cardiopulmonary bypass (CPB). We examined the changes in systemic oxygen utilization caused by the initiation of deep hypothermic CPB. METHODS: We calculated the changes in systemic oxygen consumption (VO2) and its related parameters in 5 patients who underwent reconstruction of the aortic arch using deep hypothermic CPB. Rectal temperature was decreased to 18 centigrade on average. RESULTS: VO2 decreased immediately after the initiation of hypothermic CPB. VO2 decreased by an average of 50% and 64%, while rectal temperatures decreased from 35 to 34 and 32 centigrade, respectively. Hemoglobin-bound oxygen accounted for 68% of VO2 just before CPB and 28% after the rectal temperature decreased to 32 centigrade. This decrease in VO2 correlated with the maximum temperature gradient between the venous and the arterial blood during the cooling phase. The abrupt decrease in VO2 by initiating CPB was associated with an increase in mixed venous oxygen saturation and a decrease in oxygen extraction ratio. VO2 values during the cooling phase were much lower than those during the rewarming phase at any given rectal temperatures. VO2 values at rectal temperatures of 34 and 32 centigrade during the cooling phase of CPB were 40% and 29% of those during the rewarming phase of CPB, respectively. This difference was caused by the changes in VO2 derived from hemoglobin-bound oxygen, and VO2 derived from dissolved oxygen did not show any significant changes during the cooling and the rewarming phase. Hysteresis of VO2 was also observed as a function of the nasopharyngeal temperature. The arterial lactate concentration showed an insignificant but gradual increase during the cooling phase. CONCLUSION: These observations suggested that an immediate decrease in VO2 and the following low values of VO2 caused by the initiation of deep hypothermic CPB could not be simply due to a decrease in the metabolic rate for oxygen but rather due to disturbances in oxygen utilization, one of which seemed to be caused by the impaired oxygen release from hemoglobin. It was also suggested that an increase in mixed venous oxygen saturation by initiating hypothermic CPB did not necessarily indicate an adequate oxygen/demand supply balance.

Adult↗
PubMed1999

Jugular bulb temperature compared with non-invasive temperatures and cerebral arteriovenous oxygen saturation differences during open heart surgery.

Limited information is available about the correlation between cerebral temperature and routine temperature measurements during cardiopulmonary bypass in infants. Nasopharyngeal, tympanic membrane and rectal temperatures were compared with jugular bulb temperature in ten infants operated on with moderate or deep hypothermia. The cerebral arteriovenous saturation differences were correlated with the temperatures at the four measurement sites. The jugular bulb and nasopharyngeal temperatures showed the most rapid response during cooling and rewarming. The tympanic temperature response varied in an unpredictable way. Rectal temperature, which was the target for rewarming, lagged behind during both cooling and rewarming. Overwarming at the end of cardiopulmonary bypass, seen as jugular bulb and nasopharyngeal temperatures exceeding 38 degrees C, was common after deep hypothermia. A high correlation was found between the cerebral arteriovenous oxygen saturation differences and the jugular bulb temperature (r = 0.81) and the nasopharyngeal and the tympanic temperature (r = 0.79), whereas the correlation with rectal temperature was weaker (0.66).

Body Temperature↗
PubMedDate not supplied

Comparative effects of UW and SLS solutions on concentrative proline uptake in cold preserved rat hepatocytes.

In previous studies, we have shown that the rate of cell swelling induced by concentrative proline uptake in isolated rat hepatocytes decreased by 50 per cent after only 24 h of cold storage in University of Wisconsin (UW) solution, thereby representing a sensitive marker of alterations in hepatocyte functions after cold preservation and rewarming. We have thus used concentrative proline uptake to compare the capacity of UW and sodium-lactobionate-sucrose (SLS) solutions to maintain such differentiated hepatocyte functions. Isolated rat hepatocytes were kept at 4 degrees C for 4, 10, 24 and 48 h in UW or SLS solutions, and subsequently cultured at 37 degrees C for 1-2 h. Viability was measured by Trypan blue exclusion. After rewarming, cells were subjected to a 10 min administration of 10 mM proline and accumulation of the amino acid was assessed by changes in cell volume as measured by digital analysis of single-cell images obtained under bright-field illumination. Cell viability was reduced gradually and significantly after 0 to 48 h of preservation, and rewarming amplified this effect. However, loss of viability was similar in UW- and SLS-stored cells, as were initial steady-state cell volumes. Proline-induced swelling rate was reduced significantly by 13, 46 and by 57 per cent after 10, 24 and 48 h of preservation in UW solution, respectively. There is no significant difference between SLS- and UW-preserved hepatocyte swelling rates after 10 h and 48 h of cold preservation. However, the decline in the swelling rate of SLS-preserved hepatocytes incubated for 24 h is significantly lower than that of their UW-preserved counterparts. These results show that the SLS solution can preserve differentiated hepatic functions as well as the UW solution does.

Adenosine↗
PubMed1999

[Changes in oxygen saturation in the jugular bulb during cardiac surgery].

OBJECTIVE: Heart surgery with cardiopulmonary bypass (CPB) leads to changes in supply and consumption of cerebral oxygen (DO2 and VO2C). Monitoring jugular bulb oxygen saturation (SjO2) detects changes in the DO2C/VO2C ratio that occur in patients undergoing heart surgery. The objective of this study was to determine the evolution of SjO2, of the arteriovenous difference of cerebral oxygen and of cerebral oxygen extraction, as well as the possible relation between those variables and changes in mean arterial pressure, hemoglobin counts and temperature in patients undergoing heart surgery with CPB. PATIENTS AND METHOD: A prospective study carried out in 31 patients who underwent coronary valve surgery. To monitor SjO2, each patient's internal jugular vein was cannulated with an oximetric catheter in a retrograde direction to monitor SjO2. RESULTS: Baseline SjO2 (68 +/- 7.4%), obtained after anesthetic induction, was similar to SjO2 before (65 +/- 6%) and after (67 +/- 8.2%) CPB. However, SjO2 upon starting CPB (60 +/- 8.6%) and during rewarming (63 +/- 3%) were significantly lower than at baseline. SjO2 was significantly higher during hypothermic bypass (78 +/- 5%) than at baseline. SjO2 ranged from a low of 60 +/- 8% as CPB was initiated to a high of 78 +/- 5% during hypothermic CPB. Mean arterial pressure was significantly lower at the start of bypass (44 +/- 6 mmHg) than anesthetic induction (83.5 +/- 13.1 mmHg) and the decrease correlated with a significant decrease in SjO2. Changes in mean arterial pressure were unrelated to significant changes in SjO2 at other moments, however. Nor was there a significant relation between changes in temperature or hemoglobin and the evolution of SjO2. At least one episode of SjO2 desaturation (= 50%) occurred in 29% of the patients, with the lowest values being recorded at the start of CPB and during rewarming. CONCLUSIONS: The greatest risk of cerebral oxygen imbalance between supply and demand occurs at the start of CPB and during rewarming, as shown by decreases in SjO2 levels below baseline at those times.

Blood Pressure↗
PubMed1998

[Effects of propofol and etomidate on cerebral oxygen supply and demand balance during middle hypothermia cardiopulmonary bypass].

UNLABELLED: Effects of propofol(Group P) and etomidate(Group E) on cerebral oxygen supply and demand balance during middle hypothermia cardiopulmonary bypass(CPB) were studied in twenty patients undergoing cardiac valve replacement. Arterial blood and jugular bulb blood were taken to analyse blood gas, and cerebral oxygen content were caculated. RESULT: During hypothermia, jugular bulb oxygen saturation(SjO2), jugular bulb blood oxygen content(CjO2) increased; cerebral oxygen extraction rate(CEO2) decreased significantly in two groups(P < 0.05). During rewarming SjO2, CjO2 were significantly decreased, CEO2 increased compared with that before rewarming and hypothermia in two gbroups (P < 0.05). In Group P, SjO2 and CjO2 were higher, CEO2 lower than those in Group E respectively during rewarming (P < 0.05). CONCULUSION: The activity of propofol reduced cerebral metabolism, cerebral oxygen consumption and CEO2 is better than that of etomidate.

Adult↗
PubMed2002

Nailfold capillaroscopy and laser Doppler flowmetry during standardised cold challenge to evaluate capillary pattern and digital flow in idiopathic acrocyanosis.

Quantitative correlation between capillary morphologic patterns and digital pulp flow in idiopathic acrocyanosis (IA) is as yet unexplained. We studied capillary pattern, scored according mainly to capillary dilatation and tortuosity. Digital flow was recorded by laser Doppler flowmetry during a standardised cooling and rewarming thermal challenge in a controlled thermostatic chamber. A negative correlation was found by linear regression analysis between increasing capillary abnormalities and decreasing flow rates both at rest and during cooling, while a positive correlation was observed among the presence and intensity of the flow stop reaction during cold challenge and the decrease of hyperaemic re-flow in the rewarming phase. Further investigations may be justified to assess the nature of these abnormalities, whether constitutional or induced by prolonged cold exposure. For this purpose, a standardised method, as the cooling-rewarming challenge, could verify the several pathophysiological hypotheses proposed for vascular acrosyndromes. We need to use a subjective method such as capillaroscopy-based scoring (as in our study endorsed by an objective technique) to acquire the necessary reliability and reproducibility in the functional diagnosis. In fact IA patients with lower morphologic scores show better flow properties.

Blood Flow Velocity↗
PubMed1999

[Changes in p50 and oxygen metabolism during mild hypothermia cardiopulmonary bypass].

OBJECTIVE: To study the changes of p50 and oxygen metabolism during mild hypothermia cardiopulmonary bypass, arterial blood lactate(ABL) were measured, arterial and venous blood gas were analysed in 21 patients undergoing cardiac valve replacement. RESULTS: p50, oxygen consumption(VO2), and oxygen extract rate(ERO2) were decreased during hypothermia and increased during rewarming, respectively (P < 0.05 or P < 0.01), while the change of SvO2 was adversed. PvO2 was decreased significantly during rewarming(P < 0.01), and ABL was continuously increased. CONCLUSION: Both reduction in oxygen utilization during hypothermia and relative deficiency of oxygen supply during rewarming cause tissue hypoxia.

Adult↗
PubMedDate not supplied

Profiling cryopreservation protocols for Ribes ciliatum using differential scanning calorimetry.

DSC analysis was performed at three points in the cryopreservation process on encapsulated-dehydrated meristems of Ribes ciliatum. Meristems were excised from shoots pre-treated with either sucrose or glucose, encapsulated in alginate beads, dehydrated in sucrose solutions, air dried, and plunged in liquid nitrogen. Thermal analysis revealed glass transitions during cooling of air-desiccated meristems, however, on rewarming a small endothermic event was detected suggesting glass destabilization can occur. Interestingly, this did not occur in alginate beads or meristems when these components were cooled and rewarmed separately. The possibility exists that thermal and moisture gradients may arise within the alginate bead/tissue complex and we propose that the heterogeneous composition of the meristems and the surrounding alginate may promote ice nucleation on rewarming. The significance of this regarding the stabilization of glasses formed in alginate beads and their encapsulated meristems is discussed. This study also reports an approach to Ribes cryopreservation in which the pregrowth of shoots in 0.75M sucrose for 1 week can be used as a substitute for cold acclimation.

Journal Article↗
PubMedDate not supplied

[Circulatory and metabolic disturbances in accidental hypothermia (author's transl)].

This work sums up several studies: clinical observation (electrocardiogram, cardiac rhythm, circulatory state), and biology (glycemia, blood oxygenation, acid-base balance) in 24 cases of accidental hypothermia, not related to poisoning by central nervous system depressive agents; haemodynamics in 18 of these cases; pathology of the myocardium in 11 cases; haemodynamics and microscopy of the myocardium in dogs with slowly induced or prolonged hypothermia; finally an electron microscope study in hypothermic rats. Electrocardiographic study and continuous monitoring of cardiac rhythm and tracing show, in addition to well known manifestations (bradycardia, lenghtening of QT, J wave), acute dysrhythmias, particularly circulatory arrests by asystole during or even 72 hours after rewarming. The clinical haemodynamic changes, measurable (cardiac output, mean arterial pressure, central venous pressure), or computable (stroke volume, peripheral resistances) are observed during rewarming. Several haemodynamic developments can be distinguished: --favourable evolution when the initial disturbances (decrease in cardiac output and in stroke volume, increase in peripheral resistances) disappear without any therapeutic support: --haemodynamic developments showing at a certain time evidence of hypovolemia requiring only moderate vascular replacement; --haemodynamic developments showing myocardial damage. In some cases, only hypothermia accounts for these. In circulatory arrests during or after rewarming, these haemodynamic disturbances raise the hypothesis of severe cardiac changes due to hypothermia itself.

Acid-Base Equilibrium↗
PubMed2003

[The intervention of reduced glutathione in neutrophil activation in the process of extracorporeal circulation].

OBJECTIVE: To study the intervention of reduced glutathione for neutrophil activation in the process of extracorporeal circulation. METHOD: 20 congenital heart disease children aged from 6 to 12 years were selected randomly, divided into control group and interventional group, patients of interventional group were added reduced glutathione (30 mg/kg) in priming fluid, then phlebotomized on the time of 24 hours before operation, 20 minutes after CPB, rewarming, the end of CPB, 4 hours after operation, 24 hours after operation. After separated neutrophil, we distilled nuclear protein and mensurated the activation of nuclear factor-kappaB by EMSA, assayed the expression of ICAM-1. by immunohistochemistry. RESULTS: Neutrophil nuclear factor-kappaB has been activated on the time of 20 minutes after CPB, arrives at the top on the time of rewarming, and resumes 24 hours after operation; ICAM-1 expresses on the time of rewarming, arrives at the top 4 hours after operation in control group. The data of interventional group is lower than the control group. CONCLUSION: Neutrophil nuclear factor-kappaB is activated and ICAM-1 is expressed in the process of extracorporeal circulation and play an important role in the inflammatory response happening in extracorporeal circulation, which could be relieved by reduced glutathione.

Cardiopulmonary Bypass↗
PubMed1992

Effect of transient vagal cold blockade upon reflex actions of a polar and nonpolar cardiac glycoside.

To determine the role of vagal afferent fibers in expressing the actions of a polar aminosugar digitalis agent [ASI-222 (4-amino-galactose beta-D-digitoxigenin HCl)] and a nonpolar neutral sugar agent (digoxin) on cardiac sympathetic nerve activity (CSNA), we utilized a period of vagal cooling to block traffic in that nerve. Anesthetized dogs were prepared to measure CSNA in efferent fibers from the right stellate ganglion. Both vagi were exposed midcervically and fitted with water-filled glass coils. The vagi were cooled (approximately 4 degrees C) and then either ASI-222 or digoxin was infused i.v. at dose rates which produce cardiac arrhythmias after about 100 min. Saline was infused in a third group. After 50 min of drug infusion, the vagi were rewarmed. During vagal cooling and infusion of saline or ASI-222, CSNA rose by 25 to 30%. Within 10 min after rewarming, CSNA returned to base line values in the saline group but nerve activity in the ASI-222 group promptly fell about 45% below base line and remained depressed. This dose rate of ASI-222 depresses CSNA in neurally intact dogs within 30 min. In contrast, during vagal cooling digoxin caused a slow but progressive fall in CSNA (approximately 20%); with rewarming and higher doses, CSNA began to rise above base-line levels. This profile of changes in CSNA to digoxin is similar to that observed in neurally intact animals. In other dogs given atropine to block the effects of efferent vagal nerve traffic, ASI-222 produced a prompt decline in CSNA like that observed previously in neurally intact dogs.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMedDate not supplied

Thermal analysis of the plant encapsulation-dehydration cryopreservation protocol using silica gel as the desiccant.

The encapsulation-dehydration cryopreservation protocol is critically dependent upon the evaporative desiccation step, which must optimise survival with the retention of glass stability on sample cooling and rewarming. Desiccation is usually achieved evaporatively by drying in a sterile airflow. However, chemical desiccation using silica gel has advantages for laboratories that do not have environmental control and/or which are exposed to high relative humidities and risks of microbial contamination. This study characterised thermal profiles of silica gel-desiccated encapsulated shoot-tips of two Ribes species using Differential Scanning Calorimetry. For both species silica gel-desiccation at 16 degrees C for 5 h decreased bead water content from ca. 75 to 28% fresh weight (3.8 to 0.4 g x g(-1) dry weight); further desiccation (for 6 and 7 h) reduced the bead water content to 21% (0.3 g x g(-1) dry weight). These changes in water status altered the thermal properties of beads for both species. After 7 h desiccation over silica gel stable glass transitions were observed on both cooling and rewarming of beads containing meristems. Tg mid-point temperatures ranged from -78 to -51 degrees C (cooling) and from -88 to -54 degrees C (warming) [at cooling and warming rates of 10 and 5 degrees C min(-1), respectively] after 5 to 7 h silica gel-desiccation. Post-cryopreservation viability of both species was ca. 63%. Thermal analysis studies revealed that an encapsulation/dehydration protocol using silica gel as a desiccant should comprise a minimum 5 h drying (at 16 degrees C). This reduces bead moisture content to a critical point (ca. 0.4 g x g(-1) dry weight) at which stable glasses are formed on cooling and rewarming. It is concluded that silica gel has advantages for use as a desiccant for alginate-encapsulated plant meristems by promoting stable vitrification and is useful in laboratories and/or geographical locations where environmental conditions are not under stringent control.

Cell Survival↗
PubMed1991

[Comparison of various cryopreservation media for vitrification of 7-day bovine embryos].

A vitrification medium, attested for cryopreservation of mouse eight-blastomere embryos (6.85 mol/l glycerol as a cryoprotective agent), was checked up with respect to preservation of bovine seven-day morulas and blastocysts. As this medium was not found to be convenient either as to its technical parameters or the reached embryo survival, its composition was modified. The glycerol content was complemented or partly replaced by other cryoprotectives (methanol, saccharose, L-proline). A comparison of technical parameters and viability of rewarmed embryos shows that our requirements (technically simple technique of freezing and rewarming and good survival) are met in the best way by a cryoprotective combination of 4.11 mol/l glycerol and 1.0 mol/l saccharose. The total of 54.5% embryos developed in-vitro conditions following vitrification in the medium of this composition and after rewarming.

Animals↗
PubMed1991

An experimental model for the study of transcapillary fluid balance in hypothermia.

Disturbed fluid balance is a significant clinical problem in hypothermia and rewarming. We have therefore investigated whether the transcapillary fluid balance in rats exposed to hypothermia and rewarming could be studied with the use of a wick method. Double nylon wicks were sewn into the abdominal skin and left there for one hour, then removed to double-bottomed conic vials and centrifuged. Wick fluid was collected and colloid osmotic pressure measured. Blood samples were taken simultaneously for measurement of hematocrit, hemoglobin, red cell count and plasma colloid osmotic pressure. This was done at 37 degrees C (prehypothermic), 13 degrees C (hypothermic) and at 30 degrees C (during rewarming). Blood pressure was also recorded. The model provides a good method to investigate the colloid osmotic changes of both plasma and interstitium during hypothermic situations.

Animals↗
PubMed1991

[Cold-induced pathology at high altitude].

Cold injury is an objective danger in mountain climbing as well as in many outdoor and recreational sports such as skiing, fishing, etc. Symptoms are easily recognizable by the experienced, and prevention is mostly possible. Cold injury should be divided by pathological means in general hypothermia and local frostbite injuries. Life-threatening deep hypothermia with coma and insufficient circulation or cardiac arrest is reversible under the condition of sufficient core rewarming, for instance by CEC. Because of the big tolerance of hypothermic patients to hypoxia, clinical death is not like biological death and therefore reversible. Local frostbite is not life-threatening, but has often deleterious effects. Rapid rewarming in warm water of 37 to 42 degrees C is mandatory. After rewarming, the difference between superficial and deep frostbite can be established. Scintigraphy seems to be of great help in setting early prognosis. Daily sterile treatment of the injury, whirlpool bath and prevention of infections belong to standard treatment. There are little objective informations about the role of vasodilators, anticoagulants, antibiotics, sympathectomy and others. Early experience with Prostavasine seems to bee encouraging.

Adult↗