小腿穿支血管蒂螺旋桨皮瓣修复足踝部软组织缺损

目的 报道穿支血管蒂螺旋桨皮瓣在小腿下段及足踝部软组织缺损修复中的应用价值. 方法 2008年6月至2011年3月,共收治小腿下段及足踝部软组织缺损6例,缺损范围8 cm ×7 cm～ 18 cm×11 cm.采用VSD覆盖创面,待创面肉芽组织新鲜、感染控制后,应用胫后动脉穿支血管蒂螺旋桨皮瓣修复4例,腓动脉穿支血管蒂螺旋桨皮瓣修复2例,皮瓣范围9cm×8 cm～21 cm×12 cm.结果 术后5例全部成活,1例出现皮瓣小部分坏死;1例出现表浅水泡;1例出现短暂的静脉淤血;在大的螺旋桨皮瓣患者中出现短暂一过性的小腿水肿.获随访7～26个月,皮瓣质地优良,色泽接近正常,局部稍饱满,外观功能恢复良好,患者满意.结论 穿支血管蒂螺旋桨皮瓣血供可靠,手术操作相对容易,供区损伤小,成功率高,应该被考虑作为小腿下段及足踝部软组织缺损修复的适宜方法之一.     

内踝上穿支蒂隐神经营养血管逆行皮瓣的临床应用

目的 探讨应用内踝上穿支蒂隐神经营养血管皮瓣修复足踝部软组织缺损的临床效果.方法 应用内踝上胫后动脉穿支蒂隐神经营养血管皮瓣修复足踝部软组织缺损9例,其中车祸致伤5例,机器挤压伤4例,皮瓣旋转点在内踝上3～8 cm.结果 皮瓣全部成活,皮瓣面积4 cm×4 cm～12 cm × 8 cm.随访6～18个月,平均12个月.9例皮瓣全部顺利成活,皮瓣质地、弹性均正常,感觉获得一定恢复,外观及功能满意.供区创面顺利愈合.结论 该皮瓣血供可靠,不损伤主要血管,切取方便,是修复足踝部软组织缺损的较理想选择.     

小腿穿支血管筋膜蒂皮瓣修复小儿足踝部软组织缺损

目的探讨小腿穿支血管筋膜蒂皮瓣修复小儿足踝部软组织缺损的临床疗效。方法 2012年5月-2015年1月,采用小腿穿支血管筋膜蒂皮瓣修复小儿足踝部软组织缺损12例。足踝部软组织缺损面积3.5 cm×5.0 cm～7.0 cm×15.0 cm,均伴有不同程度的肌腱或骨骼外露。带胫后动脉穿支的小腿内侧筋膜蒂皮瓣7例,带腓动脉外踝后上穿支的筋膜蒂皮瓣4例,带胫后动脉穿支的小腿内侧筋膜蒂皮瓣及带腓动脉外踝后上穿支的筋膜蒂皮瓣1例。结果术后12例皮瓣均成活,其中2例皮瓣皮缘远端少许坏死,经换药后愈合;12例获随访,随访时间3～18个月,平均8.9个月;皮瓣血运良好,无臃肿,外形满意,供区愈合良好;患肢功能良好。结论小腿穿支血管筋膜蒂皮瓣修复小儿足踝部软组织缺损操作简单,疗效可靠,是修复小儿足踝部软组织缺损理想的治疗方法之一。     

内踝上穿支蒂隐神经营养血管逆行皮瓣的临床应用

目的 探讨应用内踝上穿支蒂隐神经营养血管皮瓣修复足踝部软组织缺损的临床效果.方法 应用内踝上胫后动脉穿支蒂隐神经营养血管皮瓣修复足踝部软组织缺损9例,其中车祸致伤5例,机器挤压伤4例,皮瓣旋转点在内踝上3～8 cm.结果 皮瓣全部成活,皮瓣面积4 cm×4 cm～12 cm × 8 cm.随访6～18个月,平均12个月.9例皮瓣全部顺利成活,皮瓣质地、弹性均正常,感觉获得一定恢复,外观及功能满意.供区创面顺利愈合.结论 该皮瓣血供可靠,不损伤主要血管,切取方便,是修复足踝部软组织缺损的较理想选择.     

内踝上穿支蒂隐神经营养血管逆行皮瓣的临床应用

目的 探讨应用内踝上穿支蒂隐神经营养血管皮瓣修复足踝部软组织缺损的临床效果.方法 应用内踝上胫后动脉穿支蒂隐神经营养血管皮瓣修复足踝部软组织缺损9例,其中车祸致伤5例,机器挤压伤4例,皮瓣旋转点在内踝上3～8 cm.结果 皮瓣全部成活,皮瓣面积4 cm×4 cm～12 cm × 8 cm.随访6～18个月,平均12个月.9例皮瓣全部顺利成活,皮瓣质地、弹性均正常,感觉获得一定恢复,外观及功能满意.供区创面顺利愈合.结论 该皮瓣血供可靠,不损伤主要血管,切取方便,是修复足踝部软组织缺损的较理想选择.     

逆行腓动脉穿支蒂腓浅神经营养血管皮瓣修复足踝软组织缺损

目的评价逆行腓动脉穿支蒂腓浅神经营养血管皮瓣修复足踝软组织缺损的临床效果。方法对25例足踝部软组织缺损的患者采用逆行腓动脉穿支蒂腓浅神经营养血管皮瓣进行修复。其中,以腓动脉终末穿支的升支为蒂19例,以其降支为蒂6例。软组织缺损大小10cm×9cm～4cm×3cm,皮瓣面积11cm×9.5cm～6cm×5cm。结果 23例皮瓣完全存活,另2例皮瓣远端部分坏死,经换药后植皮修复。皮瓣术后轻度肿胀,无瘀血。术后随访6～18个月,皮瓣质地优良,蒂部无臃肿。结论以腓动脉穿支为蒂的腓浅神经营养血管皮瓣血供可靠、质地优良,是修复足、踝软组织缺损的良好选择。     

腓动脉及穿支血管蒂皮瓣逆行转移修复足踝部软组织缺损

目的 探讨应用腓动脉及穿支血管蒂皮瓣逆行转移修复足踝部软组织缺损的手术方法 和临床效果.方法 2007年4月至2008年2月,收治10例足踝部软组织缺损患者.男7例,女3例;年龄8～52岁,平均34.2岁.致伤原因:车祸伤6例,坠落伤2例,慢性溃疡1例,烫伤1例.在患肢小腿外侧区沿腓动脉轴线设计皮瓣,术中游离包含于皮瓣内的1～3支腓动脉穿支,于腓动脉穿支近端结扎切断腓动脉及静脉,向远端游离至外踝尖上约5 cm并以此为旋转点,连同皮瓣向远端逆行转移覆盖足踝软组织缺损区.切取皮瓣范围为10 cm×5 cm～25 cm×15 cm,血管蒂长6～17 cm.结果术后10例皮瓣全部成活.仅1例皮瓣远端局部回流不畅、浅表坏死,经换药及抗感染治疗后愈合.供区均Ⅰ期愈合.全部病例获5～14个月(平均9.5个月)随访,所有患者皮瓣外形及功能满意,行走正常.结论 腓动脉及穿支血管蒂营养皮瓣血管蒂长,蒂部细小易转移而不易受压,血供可靠,切取范围大,皮肤质地良好,用于足踝部皮肤软组织缺损的修复效果满意.     

穿支蒂螺旋桨皮瓣修复足踝部软组织缺损25例临床分析

目的 探讨穿支蒂螺旋桨皮瓣在足踝部软组织缺损创面修复中的应用效果.方法 自2007年7月到2011年12月,对足踝部软组织缺损患者采用穿支蒂螺旋桨皮瓣修复25例,穿支动脉来源分别为腓动脉18例,胫后动脉6例,足背动脉1例.皮瓣面积4cm×10cm～9 cm×33 cm.结果 供区直接缝合9例,游离植皮16例,有3例皮瓣术后出现静脉淤血,2例经滴血疗法最终皮瓣成活,1例皮瓣远端1/3坏死,经清创后游离植皮治愈.所有患者均获随访,随访时间1～26个月,所有皮瓣蒂部平整,外表美观,患者较为满意.结论 穿支螺旋桨皮瓣操作简单、安全有效,在足踝部软组织缺损创面的修复中比其他带蒂皮瓣更具优越性.     

腓肠神经营养血管肌皮瓣修复足踝软组织缺损

目的 探讨腓动脉穿支蒂腓肠神经营养血管肌皮瓣修复足踝软组织缺损及骨髓炎创面的临床疗效。方法采用腓动脉穿支远端蒂腓肠神经营养血管肌皮瓣修复足踝软组织缺损及骨髓炎创面18例。其中,足后跟软组织缺损伴骨感染4例,跟腱部缺损3例,内踝部缺损3例,外踝缺损伴死腔8例,皮肤缺损范围9 cm×4 cm～16 cm×9cm。皮瓣切取面积10 cm×6 cm～18 cm×10 cm,携带的深层腓肠肌肉面积4cm×3 cm～9cm ×6cm。供区直接拉拢缝合7例,游离植皮11例。 结果 术后18例肌皮瓣完全成活,创面Ⅰ期愈合。随访5～14个月,无并发症,皮瓣质地优良,外观满意,行走正常,术后皮瓣感觉恢复欠佳。 结论 腓动脉穿支远端蒂腓肠神经营养血管肌皮瓣,血供可靠,转移方便,是修复足踝部软组织缺损及骨髓炎创面的好方法。     

腓动脉主穿支蒂腓肠神经营养血管皮瓣修复足踝部中小面积软组织缺损

目的 总结不依赖低位穿支的单一腓动脉主穿支蒂腓肠神经营养血管皮瓣修复足踝部中小软组织缺损的手术方法 及临床效果. 方法 2004年7月-2007年2月,收治14例足踝部中小面积软组织缺损忠者.男9例,女5例:年龄19～53岁.跟腱断裂术后皮肤坏死4例,交通伤后软组织缺损3例,重物压砸伤、慢性感染溃疡及跟骨骨折术后皮肤坏死各2例,黑色素瘤切除术后1例.软组织缺损范围4 cm×2 cm～9 cm×5 cm;位于踝周12例,跟底负重区2例.均合并深部肌腱或骨组织外露.急诊入院3例,其余患者于伤后12 d～13个月入院.术中切取以腓动脉主穿支为单一蒂的腓肠神经营养血管皮瓣修复创面,范围为13 cm × 5 cm～36 cm × 6 cm.供区均直接缝合. 结果 术后皮瓣全部成活,创面及供区Ⅰ期愈合.患者均获随访,随访时间7～23个月.皮瓣质地优良,外形、色泽良好,两点辨别觉7～12 mm.踝关节功能恢复满意,可正常穿鞋行走. 结论 不依赖低位穿支的单一腓动脉主穿支蒂腓肠神经营养血管皮瓣血供可靠,操作简便,创面修复平整美观,肢体功能恢复满意,适合未涉及前足的踝周、跟底中小面积软组织缺损修复,尤其适合低位缺乏满意穿支者.     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.