To consider optimal analgesic strategies for thoracic surgical patients.
Recent studies have consistently suggested analgesic equivalence between paravertebral and thoracic epidural analgesia. ...Complications appear to be significantly less common with paravertebral analgesia.
There is good evidence that paravertebral block can provide acceptable pain relief compared with thoracic epidural analgesia for thoracotomy. Important side-effects such as hypotension, urinary retention, nausea, and vomiting appear to be less frequent with paravertebral block than with thoracic epidural analgesia. Paravertebral block is associated with better pulmonary function and fewer pulmonary complications than thoracic epidural analgesia. Importantly, contraindications to thoracic epidural analgesia do not preclude paravertebral block, which can also be safely performed in anesthetized patients without an apparent increased risk of neurological injury. The place of paravertebral block in video-assisted thoracoscopic surgery is less clear.
Data from the Australian Better Safer Transfusion programme show that about one‐third of patients undergoing hip or knee arthroplasty receive perioperative blood transfusions, placing them at ...increased risk for adverse clinical outcomes. Other concerns associated with allogeneic blood transfusion include the quality of stored red cell concentrates, the cost of provision of blood and the predicted local demographics, which mean that fewer donors will need to support a greater number of recipients. In view of the multiple challenges associated with allogeneic blood transfusion and its provision, we developed practical management recommendations for perioperative bleeding in joint replacement surgery, based on available evidence and expert consensus opinion, that aim to promote a new, responsible approach to transfusion management. Key recommendations are as follows. Patients' medical health, including haemoglobin and iron levels, needs to be evaluated and optimized preoperatively. Anticoagulant and antiplatelet therapy should be stopped if possible, unless indicated for secondary cardiovascular prevention or coronary stent patency, in which case careful consideration is required. If substantial blood loss is anticipated, intraoperative management with antifibrinolytic agents is recommended for bleeding prophylaxis. Normothermia should be maintained. Pharmacological and non‐pharmacological measures are recommended for post‐operative thromboprophylaxis. A blood management programme should be instituted for haemodynamically stable patients.
Background/objective:
Reduction of brain temperature remains the most common method of neuroprotection against ischemic injury employed during cardiac surgery. However, cooling delivered via the ...cardiopulmonary bypass circuit is brief and cooling the body core along with the brain has been associated with a variety of unwanted effects. This study investigated the feasibility and safety of a novel selective brain cooling approach to induce rapid, brain-targeted hypothermia independent of the cardiopulmonary bypass circuit.
Methods:
This first-in-human feasibility study enrolled five adults undergoing aortic valve replacement with cardiopulmonary bypass support. During surgery, the NeuroSave system circulated chilled saline within the pharynx and upper esophagus. Brain and body core temperature were continuously monitored. Adverse effects, cardiopulmonary function, and device function were noted.
Results:
Patient 1 received cooling fluid for an insignificant period, and Patients 2-5 successfully underwent the cooling procedure using the NeuroSave system for 56-89 minutes. Cooling fluid was 12°C for Patients 1-3, 6°C for Patient 4, and 2°C for Patient 5. There were no NeuroSave-related adverse events and no alterations in cardiopulmonary function during NeuroSave use. Brain temperature decreased by 3°C within 15 minutes and remained at least 3.5°C colder than the body core. During a brief episode of hypotension in one patient, the brain cooled an additional 4°C in 2 minutes, briefly reaching 27.4°C.
Conclusion:
The NeuroSave system can induce rapid brain-targeted hypothermia and simultaneously maintain a favorable body–brain temperature gradient, even during hypotension. Further studies are required to evaluate the function of the system during longer periods of use.
Split and secondary fermentation defects in Swiss-type cheese varieties are manifested as undesirable slits or cracks that may lead to downgrading of the cheese. Split defect is associated with an ...excessive production of gas or an unsuitable cheese body that cannot accommodate gas produced, or a combination of both factors. Secondary fermentation is the apparent production of gas after the desired propionic fermentation of the warm room has taken place. No consensus exists as to the definitive causes of the defects, but possible causes are reviewed under factors that are associated with rheological behaviour (including cheese manufacture, acidification, intact protein content and proteolysis, seasonality of milk supply and ripening or storage temperature and duration) or with overproduction of gas (including milk microflora, propionic acid bacteria (PAB) — in particular strains with high aspartase activity and ability to grow at low temperatures, lactic acid bacteria, interactions between starter bacteria, facultatively heterofermentative lactobacilli (FHL) and other sources of gas including butyric acid fermentation). The influence of other parameters such as copper concentration, air incorporation, salt content, rind formation and cheese wrapping materials is also considered. Methods to reduce the prevalence of the split defect and secondary fermentation include addition of water to improve elastic properties by the removal of unfermented carbohydrate and the use of FHL to control PAB activity to prevent the production of excessive gas.
Digital payments are booming, yet many people still prefer the simplicity of using cash. Worldline payments expert David Daly examines whether new forms of biometric authentication can enable more ...people to ‘go digital’ by providing the kind of tech-free ease of use they get from banknotes.
Objective: The first goal of our study was to investigate major determinants of aortic stiffness in postmenopausal women using an echocardiographic method to calculate global pulse wave velocity ...(PWVg) rather than the less accurate carotid–femoral pulse wave velocity (PWVc). The second goal was to relate PWVg to the absolute risk of major cardiovascular (CV) events estimated by CV risk factors. Patients and methods: Two hundred forty‐four consecutive women who presented to our heart station were screened. One hundred twenty‐two were postmenopausal, either natural or surgical, whereas 122 were premenopausal. The mean age of the patients was 54 ± 13 years. Individuals were categorized as current smokers, former smokers, or nonsmokers and hypertensive or not. Hypercholesterolemia and diabetes mellitus were defined. Aortic stiffness was assessed by PWVg measured with pulsed Doppler, the interval between the beginning of QRS complex and the foot of the systolic upstroke in the Doppler spectral envelope was calculated at the aortic valve site and at the right common femoral artery. PWVg was calculated between the aortic valve and right common femoral artery by dividing the straight line distance between the two by the transit time. Results: There was a highly significant statistical difference (P < 0.0012) in PWVg between menstruating women and postmenopausal women. Similarly, this difference in PWVg was also noted among the menstruating population (P < 0.0014) when comparing normotensive women and hypertensive women. In postmenopausal women, PWVg was 6.8 m/sec in normotensive women and 7.56 m/sec in hypertensive women (P < 0.007). Conclusion: PWVg was increased in postmenopausal women compared with menstruating women. Systemic hypertension has an independent, but additive effect on aortic stiffness assessed by PWVg. Our study supports the usefulness of the assessment of aortic stiffness as a marker of CV disease and to identify subjects at risk at an early age.
Tranexamic acid (TXA) is an antifibrinolytic agent frequently used in elective surgery to reduce blood loss. We recently found it also acts as a potent immune-modulator in patients undergoing cardiac ...surgery.
Patients undergoing lower limb surgery were enrolled into the "Tranexamic Acid in Lower Limb Arthroplasty" (TALLAS) pilot study. The cellular immune response was characterised longitudinally pre- and post-operatively using full blood examination (FBE) and comprehensive immune cell phenotyping by flowcytometry. Red blood cells and platelets were determined in the FBE and levels of T cell cytokines and the plasmin-antiplasmin complex determined using ELISA.
TXA administration increased the proportion of circulating CD141+ conventional dendritic cells (cDC) on post-operative day (POD) 3. It also reduced the expression of CD83 and TNFR2 on classical monocytes and levels of circulating IL-10 at the end of surgery (EOS) time point, whilst increasing the expression of CCR4 on natural killer (NK) cells at EOS, and reducing TNFR2 on POD-3 on NK cells. Red blood cells and platelets were decreased to a lower extent at POD-1 in the TXA group, representing reduced blood loss.
In this investigation we have extended our examination on the immunomodulatory effects of TXA in surgery by also characterising the end of surgery time point and including B cells and neutrophils in our immune analysis, elucidating new immunophenotypic changes in phagocytes as well as NK cells. This study enhances our understanding of TXA-mediated effects on the haemostatic and immune response in surgery, validating changes in important functional immune cell subsets in orthopaedic patients.
Percutaneous closure of secundum atrial defects has become an accepted treatment in part because it is minimally invasive and relatively low risk. Despite recent advances in implantation technique ...and device improvements, complications occur. Here, we report a case of device embolization during percutaneous repair of an atrial septal defect (ASD) with multiple fenestrations. We highlight the value of using live/real time three‐dimensional transesophageal echocardiography to help plan the percutaneous procedure and detect complications.
Pericardial cysts are rare anomalies of the pericardium that are usually asymptomatic and followed by two‐dimensional (2D) echocardiography. Here we report a large pericardial cyst that could not be ...measured accurately by 2D echocardiography but three‐dimensional (3D) echocardiography enabled measurements of the cyst that correlated well with computed tomography measurements. In addition, 3D echocardiography demonstrated the mono‐trabeculated nature of the cyst further suggesting the incremental value of 3D echocardiography in the evaluation of pericardial cysts. The cyst was subsequently resected surgically.
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