Intraoperative autotransfusion: an underutilized technique

The effect of posture on phase III (alveolar nitrogen plateau) and phase IV (closing capacity) of the single-breath oxygen test was examined in 10 normal people. In part 1 of the study, subjects inspired and expired in the standing, supine, prone, and right lateral decubitus positions; there was no effect of posture on phase IV but slopes of phase III were higher when subjects were in the supine and lateral positions. In part 2, subjects inspired in the standing position and expired in one of the recumbent positions. Phase IV occurred infrequently except in the prone position (6 of 10 subj); slopes of phase III in part 2 were not consistently altered by changing posture. It is difficult to explain the failure of posture to alter phase IV solely on a model requiring a linear gradient of pleural pressure. The slope of phase III appears to depend more on the emptying patterns of small regions with widely varying volume-to-ventilation ratios than on gravity-dependent sequences of emptying. Finally, the data suggest a considerable similarity between the upright and prone positions in terms of lung filling and emptying.     

Intraoperative autotransfusion is associated with modest reduction of allogeneic transfusion in prosthetic hip surgery

BACKGROUND: The efficacy of intraoperative salvage and washing of wound blood and the predictors of allogeneic red cell transfusions in prosthetic hip surgery are insufficiently known. METHODS: In 96 patients, undergoing primary or revision surgery, salvaged and washed red cells and, if necessary, allogeneic blood were used to keep haematocrit not lower than 33%. The bleeding of red cells during hospital stay was calculated from the red cell balance. The preoperative red cell reserve (mililitres of red cells in excess of a haematocrit of 33%) was estimated and the difference between this volume and the total bleeding of red cells was retrospectively used to classify patients with regard to the need for red cells. Stepwise regression analysis was used to define patient-related variables associated with allogeneic blood transfusion. RESULTS: Preoperative knowledge of the type of operation (primary, revision), the preoperative red cell reserve, and the body mass could predict roughly half of the need for banked blood (r2 = 0.45). Only one-third of the total bleeding of red cells was retransfused. For complete avoidance of allogeneic blood, autotransfusion was most effective in patients with a moderate need (0-4 u). However, 32% of such patients required allogeneic blood. CONCLUSIONS: Autotransfusion has a limited efficacy to decrease the need for allogeneic blood, and other blood-saving methods should be added for this purpose. It is difficult to predict the need for allogeneic blood preoperatively.     

Quality assessment of intraoperative blood salvage and autotransfusion

Intraoperative blood salvage and autotransfusion are commonly used to minimize exposure to banked blood. Although this technique has been used widely for years, data vary regarding the quality of autotransfused blood. Salvaged blood may contain plasma, residual heparin, and free hemoglobin released from damaged cells. All of these factors may contribute to the adverse sequelae sometimes seen with autotransfusion. For these reasons, we have monitored autotransfused blood to assess its quality. Intraoperative blood salvage was used during most cardiac procedures and at the discretion of the surgeon in other specialties. Blood was collected through a double lumen catheter that was anticoagulated with heparin, filtered, centrifuged, and washed with saline. A sample of the blood was removed for analysis, which included hematocrit, heparin assay, fibrinogen, and free hemoglobin levels. Over a 6-year period, 1593 patients had intraoperative blood salvage with quality assessment. The majority of patients underwent cardiac operations (941 patients, 59%), whereas 243 had orthopedic (15%) and 208 had vascular (13%) procedures. Additionally, there were 127 pediatric patients (8%) and 74 miscellaneous procedures (5%). The highest average yield of salvaged blood was during vascular procedures (1073 +/- 76 mL), whereas orthopedic cases had the lowest yield (378 +/- 19 mL) and hematocrit (39%). There was minimal residual heparin activity, even in patients requiring systemic anticoagulation (0.3 to 0.5 units/mL). Patients undergoing pediatric procedures had the lowest concentration of free hemoglobin (476 mg/L), whereas all adult patients had higher free hemoglobin levels, especially vascular operations (990 mg/L). Intraoperative salvaged blood has minimal heparin activity, even in procedures requiring systemic anticoagulation. Fibrinogen, a marker of residual plasma, was undetectable in the majority of cases. These data indicate that intraoperative blood salvage generally results in a high-quality product (good hematocrit, low heparin, minimal plasma), although there are significant differences in free hemoglobin levels depending on the operative procedure.     

Fat elimination during intraoperative autotransfusion: an in vitro investigation

Intraoperative autotransfusion of scavenged blood is an established method to reduce the need for perioperative homologous blood transfusion. However, if fat particles contaminate blood suctioned from the wound site, no reliable method is available to remove them during the washing and concentration of the recycled blood. A new generation of autotransfusion devices (e.g., continuous autotransfusion system [CATS]), based on separation chambers used in cell separators or plasmapheresis devices, allows continuous procession of the collected blood, in contrast with the discontinuous process used in conventional autotransfusion devices such as the Cell Saver 5. Theoretically, the continuous system should be more efficient than the discontinuous system in eliminating fat. Outdated, 36-day-old packed red blood cells, 600 mL, were mixed with 500 mL of lactated Ringer's solution and 200 mL of soya oil. Soya oil was used because it has a fatty acid composition similar to that of fat found in bone marrow. The blood mixture was then washed and concentrated by using either the CATS or the Cell Saver 5. Six samples were processed by each device. The CATS eliminated the soya oil (200 mL) completely, whereas the Cell Saver 5 delivered 30.3 +/- 7.8 mL soya oil into the retransfusion bag. The new generation of autotransfusion devices allows complete removal of fat particles. IMPLICATIONS: Autotransfusion devices serve to wash and retransfuse blood scavenged from the wound site. However, they cannot completely remove fat particles. This in vitro investigation showed that a new device completely removes fat particles and thus prevents retransfusion of fat.     

Intraoperative irradiation: current and future status

Intraoperative radiation therapy (IORT) in its broadest sense refers to the delivery of irradiation at the time of an operation. This article will discusses the rationale for and results of both intraoperative electron radiation therapy and intraoperative high dose rate brachytherapy when used in conjunction with surgical exploration and resection and external beam radiation therapy and chemotherapy. Both IORT methods evolved with similar philosophies as an attempt to achieve higher effective doses of irradiation while dose limiting structures are surgically displaced.     

Treatment guidelines: The good, the bad, and the ugly.

Treatment guidelines for psychotherapy describe a set of best practices based in part on scientific evidence. There have been several sets of such guidelines published recently by governmental, professional, and health services organizations. The adequacy of such guidelines, which perforce reduce the variability of professional services, depends on the adequacy of the scientific evidence with respect to both efficacy and clinical utility. The American Psychological Association formed a Task Force to develop a Template for Developing Guidelines in order to evaluate the scientific evidence for these guidelines. This article describes the Template and then applies it to a set of recently promulgated guidelines. The Template was able to demonstrate the strengths and weaknesses of the various documents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Kidney transplantation in highly sensitized patients: reappraisal of etiology, evaluation, and management protocols

Transplant recipient sensitization to major histocompatibility complex (MHC) antigens is a major problem in clinical organ transplantation in terms of both magnitude and implication. Highly sensitized patients (HSPs) waiting for renal transplantation constitute a high-risk group with difficult management problems. In this review the factors involved in sensitization, detection of sensitization in the pretransplant period, various strategies tried in its prevention, and the current therapeutic approach to management of HSPs are discussed. Although prevention of sensitization is ideal, in practice a certain percentage of transplant recipients continue to exhibit hypersensitization despite all measures. Methods to remove preformed antibodies are effective but are expensive and not freely available. Aggressive immunosuppression based on cyclosporine (CsA) induction protocols constitute the mainstay in the management of HSPs. The availability of newer, potent, and more specific immunosuppressive agents, particularly those suppressing antibody synthesis, has opened a new avenue for more specific immunosuppression and better graft and patient survival following transplantation. Their clinical utility in improving patient and graft survival in HSPs needs to be evaluated.     

Internship training in behavioral medicine: Program description, issues, and guidelines.

Describes an experimental, behavioral medicine training program in the clinical psychology internship of the Palo Alto VA Medical Center. Aspects of program development, clinical and research training experiences, and issues for training are discussed. Guidelines for future training are presented. (16 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Educating APNs for implementing the guidelines for adolescents in Bright futures: guidelines of health supervision of infants, children, and adolescents

As the scope of what constitutes health and the range of determinants of health-promoting and compromising behaviors among adolescents are expanded, APNs must be well prepared to be powerful influences in the lives of all adolescents. The guidelines offered by Bright Futures challenge nurse educators to prepare APNs who possess the core competencies to knowledgeably address the health issues and concerns of all adolescents in multiple settings. The American Academy of Nursing Expert Panel's recommendations contained herein, if implemented, will further enhance the capabilities of graduate programs to prepare APNs to provide developmentally and culturally relevant disease prevention and health promotion care to adolescents and their families.     

Clinical guidelines and the law: advice, guidance or regulation?

A broth microdilution assay was performed to determine the minimal inhibitory concentrations (MICs) of 25 antimicrobial agents for two strains of Borrelia (B.) burgdorferi sensu lato and one strain of B. hermsii. The method comprised BSK II medium lacking gelatin and an incubation period of 72 hours. To investigate the influence of reading mode and density of inoculum on MIC values, microscopical as well as macroscopical MIC reading was performed using standardized final inocula of 10(6) and 10(7) borreliae/ml. Data were processed by two-way analysis of variance. In the microdilution assay, MIC values were significantly influenced either by the inoculum density or reading mode. However, using clearly defined criteria for macroscopical endpoint determination, MICs from macroscopical and microscopical reading were found to be in close agreement. B. burgdorferi sensu lato strains tested were highly susceptible to azithromycin, erythromycin, mezlocillin, piperacillin as well as ceftriaxone, with MICs ranging from < or = 0.016 to 0.125 microgram/ml. B. hermsii was highly susceptible to azithromycin and erythromycin. In comparison to B. hermsii, the beta-lactam antibiotics revealed a significantly higher activity and gentamicin, ofloxacin, and rifampin revealed a significantly lower activity against B. burgdorferi sensu lato strains. To further investigate interactions between BSK II medium, incubation time, and antibiotic efficacy, an agar diffusion bioassay was performed. Out of seven antibiotics tested, the activities of mezlocillin, penicillin G, and piperacillin were significantly influenced by BSK II medium and incubation period and showed a marked decrease of on average 84.0% within 72 hours of incubation.     

Review of Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures.

Reviews the book, Eye movement desensitization and reprocessing: Bask principles, protocols, and procedures by Francine Shapiro (1995). This text is a carefully crafted, almost 400 page book on the theory, mechanisms and workings of eye movement desensitization and reprocessing (EMDR). Francine Shapiro espouses much of what is important in psychotherapy and puts aside much of what has been controversial as she describes EMDR. Simply put, this work is the best representation of the procedure to date. For the clinician who uses this procedure, this book is a must. It outlines its necessary ingredients, standard problems, newer uses, typical mistakes, and changes (over its six year oddessy). Several strengths are noteworthy, including EMDR's painstaking assessment of the client, client safety factors, client preparation, as well as the importance of identifying the moving goalpost of "best" targets, needed cognitions, emotions, and sensations. Importantly too, the focus of EMDR is targets and not disorders. Implied but important to underscore, EMDR applies an essential rubric of psychotherapy, the nondirective unfolding of the client according to a least restrictive principle of intervention (by the therapist). EMDR seems to have this down well. If movement is present, the therapist remains truly nondirective, and uses simple rules; if not, a more active "therapeutic intervention" is called for. A procedure that can perform these tasks and do this in a user-friendly manner is not easy to find. This book highlights this unfolding dynamic. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Intraoperative and laparoscopic ultrasound

The instruments, techniques, clinical applications and results, advantages and limitations of intraoperative ultrasound (IOUS) and laparoscopic ultrasound (LUS) in general surgical oncology are presented based on our experiences and review of publications. IOUS provides remarkable benefits in acquisition of accurate diagnostic information, particularly in tumor staging and resectability, and thereby in intraoperative decision making during hepatobiliary, pancreatic, and endocrine surgery. In addition, various surgical procedures are guided or assisted by IOUS. A latest modality of IOUS is LUS, which can provide similar valuable information and compensate for the limitation of laparoscopy. LUS will demonstrate great promise as an adjunct to laparoscopic exploration or surgery.