Reduction of blood use in surgery for coronary artery disease

Ninety consecutive patients underwent surgery for coronary artery disease. Eighty-one (90%) did not require blood transfusion in the immediate postoperative period; nine patients received 16 units of blood, 6 of whom bled excessively; 2 were re-explored. Twelve had post-operative haemoglobins below 8.5 G/dl during their stay. They were transfused a total of 28 units of blood before discharge. Post-operative blood loss in the 9 transfused early averaged 894 +/- 176 ml (SEM). Loss from the not transfused patients averaged 481 +/- 18 ml (p less than 0.001). Patients transfused later had a mean loss of 510 +/- 36 ml (P NS). Sixty-nine patients were not transfused. Haemoglobin on the first post-operative day was 11.3 +/- 1.3 G/dl (SD). This declined to 10.2 +/- 1.2 G/dl on the fifth day. Discharge haemoglobin was 10.5 +/- 1.2 G/dl. Two patients died, one of myocardial infarction on the third day and the other of pancreatitis on the fourth. Both had had early blood transfusion. Haemoglobins were above 10 G/dl. Of the 69 untransfused patients 17% had supraventricular arrhythmias. Ten percent had serous wound discharges; 3 were infected. There were no sternal dehiscences. It is concluded that bank blood transfusion with its attendant hazards and expense is easily avoidable in most patients. This saving of resources will increase the availability of blood and rare groups for surgery.     

Changes in pulmonary clearance of technetium labelled DTPA during haemodialysis.

An index of pulmonary epithelial permeability has been studied in 12 patients with chronic renal failure during haemodialysis. It was assessed by the half time clearance from lung to blood (t 1/2 LB) of a nebulised solution containing technetium labelled diethylene triamine pentacetic acid (99mTc DTPA). Six patients were cigarette smokers and six were non-smokers. The non-smokers had greater predialysis permeability (mean 37.7, range 24-54 min) than non-smokers without renal disease (mean 60.2, range 38-99 min; p less than 0.025). The t 1/2 LB was measured before dialysis and during the first half hour and the last half hour of dialysis in all 12 patients and also during other periods of dialysis in 10 of them. Dialysis lasted for five hours in 11 patients and four hours in one patient. There was no significant change in the t 1/2 LB of 99mTc DTPA during early dialysis; but as dialysis progressed there was a statistically significant increase in t 1/2 LB, suggesting a reduction of pulmonary epithelial permeability. These results show no increase in an index of pulmonary epithelial permeability in association with the pulmonary sequestration of neutrophils that occurs in early haemodialysis. They also suggest that in chronic renal failure the epithelial permeability is increased and that this can be modified by haemodialysis.     

Pulmonary embolism after hip or knee replacement: postoperative changes on pulmonary scintigrams in asymptomatic patients

Serial pulmonary imaging has proved to be effective in the evaluation of patients undergoing total joint arthroplasty. A clinical dilemma arises in asymptomatic patients whose postoperative pulmonary images differ from the preoperative images. The authors prospectively evaluated 403 patients with serial imaging to determine the significance of changed postoperative images in asymptomatic patients undergoing total hip or knee arthroplasty. Twenty-two (5.5%) patients had significant changes on postoperative images. Seventeen were asymptomatic; all but one underwent pulmonary angiography. Documented pulmonary emboli were demonstrated in 100% of patients whose postoperative images changed to indicate a high probability of pulmonary embolism, 71% whose images changed to a moderate probability, and 0% whose images changed to indeterminate probability. Overall, pulmonary emboli occurred in 76% of all asymptomatic patients with significantly change postoperative images. Asymptomatic pulmonary embolism is a significant occurrence after total hip or knee repair, and a changed lung scan with appropriate clinical evaluation is an accurate indicator of pulmonary emboli in asymptomatic postarthroplasty patients.     

Pain experiences of traumatically injured patients in a critical care setting.

BACKGROUND: Little is known about the acute pain experiences of traumatically injured critically ill patients. OBJECTIVES: To describe pain experiences of traumatically injured adults during the first 72 hours of hospitalization. METHODS: Thirty multiply injured adults at a level I trauma center participated in the study. Pain was measured by using the McGill Pain Questionnaire and a visual analog scale. Subjects completed pain measures while at rest in a supine recumbent position and after a turn onto the side. RESULTS: The typical subject was 37 years old, had 4 major blunt trauma injuries, and had received the equivalent of 55.9 mg of morphine during the 24 hours before data collection. Mean at-rest scores were 26.5 on the pain-rating index, 2 on the present pain intensity index, and 34.6 on the visual analog scale. Immediately after the turn, mean scores on the visual analog scale increased from 25 to 48.1 (P = .002). Other pain scores after the turn did not differ significantly from at-rest values. Subjects who turned had lower scores on the visual analog scale at rest (P = .02) and less anxiety (P = .02) than did those who refused to turn. Ninety-six percent reported pain in the injured areas, and 36% reported pain related to biomedical devices. No relationship was found among reported pain and demographic, treatment, or clinical variables. CONCLUSIONS: Additional research is needed on pain at rest and during commonly performed procedures and on improved methods for pain relief in traumatically injured critically ill patients.     

Ultraviolet radiation increases HIV-long terminal repeat-directed expression in transgenic mice.

Previously described FVB/N mice harboring a human immunodeficiency virus (HIV) long terminal repeat (LTR)/chloramphenicol acetyl transferase (CAT) transgene were treated with varying amounts of 254 nm UV-C radiation or 312 nm UV-B radiation. At optimal exposure periods, a 20-fold increase in HIV-LTR-directed expression was observed in ear specimens collected 24 h following UV-C exposure; a fourfold increase in expression was induced by UV-B exposure. Investigation of the kinetics of UV-C induction in vivo revealed that LTR-directed gene expression began to increase 2 hours after exposure and reached a maximum on Day 3 following exposure (greater than 30-fold induction). In experiments examining the kinetics of UV-B activation, the maximum level of CAT activity in the ears of irradiated transgenic animals was fivefold above levels in unirradiated transgenic controls (Day 5). Furthermore, CAT activity was not induced in fur-bearing skin following UV exposure; however, a fourfold increase in HIV-LTR-directed expression could be elicited when hair was removed by shaving prior to UV-B treatment.