Minimising blood loss and transfusion requirements in hepatic resection

BackgroundSubstantial blood loss and the requirement for blood transfusion remain major considerations for hepatic surgeons. We analysed the impact of a systematic protocol aimed at reducing intraoperative blood loss and homologous blood (HB) transfusion associated with hepatic resection.MethodsProspective clinical data were collected from 151 elective liver resections performed during the period between 1980 and 1999. Further data directly related to blood loss and anaesthesia were retrospectively collected from the anaesthetic intra-operative record. Strategies implemented in 1991 included preoperative autologous blood donation, low central venous pressure anaesthesia, aprotinin administration, ultrasonic dissection, hepatic vascular inflow occlusion and a Cell Saver. Blood loss and transfusion requirements were studied before and after the implementation of these strategies.ResultsThere was no difference in the patient demographics, indications for operation or the scope of resections in the two time periods evaluated. Blood-saving strategies resulted in decreased estimated blood loss (4500 mL vs. 1000 mL p<0.001). In addition, the number of patients requiring transfusion decreased (91.8% vs. 25.5% respectively, p<0.001) and the mean number of units of HB transfusion was lower (I 3.7 vs. 2.3, p<0.001). Morbidity and mortality were also decreased (57.1% vs. 25.5%, p<0.001 and 10.2% and 4.9% p<0.001, respectively). No complications directly referrable to low CVP anesthesia were identified.ConclusionSystematic implementation of strategies designed to control blood loss are effective and may reduce morbidity and mortality associated with hepatic resections.     

Impaired respiratory sinus arrhythmia with paradoxically normal Valsalva ratio indicates combined cardiovagal and peripheral adrenergic failure

Combined reductions of the heart rate responses to deep breathing (HR_DB) and the Valsalva ratio (VR) are used as a standard test of cardiovagal function. We observed that some patients had marked reduction of HR_DB with a paradoxically normal VR. The mechanism of this paradox was evaluated. We found that these patients had evidence of peripheral adrenergic and postganglionic sudomotor impairment, including an excessive fall in blood pressure on upright tilt. Since VR depends on heart rate responses to blood pressure excursions, we evaluated the phases of the Valsalva manoeuvre and the ensuing heart rate responses in these patients and compared the responses to patients with generalized autonomic failure (Group II) and controls (Group III). Group I patients when compared with controls, had a larger phase II fall in blood pressure and normal phase IV resulting in a significantly enhanced baroreflex stimulus. These patients had a normal heart rate increment but 75% failed to develop reflex bradycardia. We conclude that the paradoxical VR is due to the exaggerated blood pressure swing due in turn to adrenergic failure. When both HR_DB and VR are reduced as in Group II, there may be the additional impairment of cardiac adrenergic failure.     

《席弘赋》针灸学术思想探微

《席弘赋》是针灸名赋之一,作者从临床实用角度,阐述了席弘赋在辨证论治、针刺操作、临症配穴等方面的操作应用和席的学术思想.     

Epley’s manoeuvre for benign paroxysmal positional vertigo: a prospective study 1

The treatment of benign paroxysmal positional vertigo (BPPV) by the Epley, canalith repositioning, manoeuvre was popularized following clinical reports which demonstrated a significant success rate. Benign paroxysmal positional vertigo is considered a self-limiting disease, yet only few authors have analysed the effect of this manoeuvre in randomized, controlled terms. A prospective 3-year, controlled study of patients with BPPV of long duration (mean = 6 months) verified its benefit: the recovery course differed significantly between a group of 31 patients treated with the manoeuvre and a control group of 10 untreated patients. Symptoms subsided within 72 h in 35% and within a week in 74% of patients after one session of treatment. Only two treated patients (6.5%) did not recover versus a 50% failure rate among untreated patients (P = 0.0005). The rate of recovery was not affected by the duration of symptoms before initiation of treatment, or by the patient’s age and gender.     

乏氏动作对冠心病患者等长收缩运动时中心血流动力学的影响

观察１０名冠心病人在冠状动脉腔内成型术前后，进行等长收缩运动和乏氏动作对中心血流动力学的影响。１０名对象均为男性，平均年龄５２岁，单支血管病变伴劳力性心递交 痛，左心基本正常。运动为极量握力运动。运动中无１例病人发生临床可判断的心肌缺血，所有病人均无症状，附加乏氏动作对中心血流动力学的反应类型无明显影响。肺毛压在附加乏氏动作时增加较明显，但右房压也同时成比例增高。右房压与肺毛压变化的相关系数为０．     

Effect of quadriceps contraction on upper limb position sense errors in humans

Short-length muscle contraction (hold-short conditioning) causes limb position sense errors after the muscle returns to its intermediate length; this is due to intrafusal muscle thixotropy, which raises the muscle spindle sensitivity. In humans, contraction of muscles in the upper body (referred to as the Jendrassik manoeuvre) reinforces tendon reflexes in the lower limbs. However, it is unclear whether such a reinforcement manoeuvre enhances thixotropic position sense errors. We studied the effect of quadriceps contraction on upper limb position sense errors induced by hold-short conditioning of the biceps in 12 healthy men. Quadriceps contraction increased the tonic vibration reflex of the biceps, suggesting that quadriceps contraction has a reinforcing effect similar to that of the Jendrassik manoeuvre. After hold-short conditioning of the right biceps, subjects perceived that the conditioned forearm was placed in a more extended position than it actually was. Such position sense errors were enhanced during quadriceps contraction and the degree of error was increased with the intensity of the quadriceps contraction. These results suggest that limb position sense is affected by remote muscle contraction.     

The exaptation of manual dexterity for articulate speech: an electromyogram investigation

Simple ballistic movements are executed faster in reaction time task paradigms when the imperative signal (IS) is accompanied by a startling auditory stimulus (SAS). We examined whether this effect also occurs in complex movements such as the sit-to-stand manoeuvre (STS). Nine healthy volunteers performed STS to visual IS, either presented alone (control trials) or together with SAS (test trials). Reaction time, measured as the time between IS and take-off (TO), was significantly shortened in test trials when SAS was applied at an interval of 0 ms with respect to IS. The onset latency of EMG bursts recorded from tibialis anterior, lumbar paraspinal, quadriceps and biceps femoris muscles reduced proportionally to the shortening of TO. However, these effects were not observed if SAS was delivered 150 ms after IS, when the manoeuvre had already started. Our results suggest that stimuli acting on subcortical motor structures speed-up but do not otherwise interfere with the execution of the motor programs underlying the STS manoeuvre.     

Guidelines of the French Society of Otorhinolaryngology (SFORL) for teleconsultation in patients with vertigo during the COVID-19 pandemic

ObjectivesIn the context of the SARS-CoV-2 pandemic, patients may have been dissuaded from seeking consultation, thus exposing themselves to a risk of loss of chance. This guide aims to define how teleconsultation can assist in assessing vertiginous adults or children, and to gather the information needed to provide quick medical care.MethodsThese recommendations rely on the authors’ experience as well as on literature. A survey on otoneurologic approach via telemedicine has been conducted based on a literature search until March 2020.ResultsThe first clinical assessment of the vertiginous patient via teleconsultation can only be successful if the following conditions are met: initial contact to verify the feasibility of the assessment at a distance, the presence of a caregiver in order to assist the patient, the possibility of making video recordings. Medical history via telemedicine, as in a face-to-face assessment, allows to assess the characteristics, duration, frequency, and potential triggering factors of the vertigo, in both children and adults. During teleconsultation, the following tests can be carried out: oculomotricity evaluation, assessment of balance, simple neurological tests, checking for positional vertigo/nystagmus and, eventually to perform canalith-repositioning procedures. In children, the following should be searched for: history of hearing or visual impairment, a context of fever or trauma, otorrhea, signs of meningeal irritation.ConclusionThe neurotologic telemedicine relies on the accuracy of the clinical assessment, which is based on history taking and a few simple tests, encouraging the development of a decision-making algorithm adapted for teleconsultation. However, the latter has its limitations during an emergency examination of a new patient presenting vertigo, and, at least in some cases, cannot replace a face-to-face consultation. Teleconsultation is often adapted for follow-up consultations of previously selected vertiginous patients during face-to-face assessment.     

Influence of pleural pressure variations on cardiovascular system dynamics: a model study

A mathematical model of the human cardiovascular system (CVS) is used to study the effect of different respiratory manoeuvres on the circulation. The model simulates the normal CVS and the interaction between the heart and the intrathoracic pressure. The vascular system is represented by resistive, capacitive and inertial elements whereas the ventricles are assumed to function according to the time-varying elastance concept based on their transmural pressures. The model predicts that normal inspiratory effeort effects an increase in the venous return, an increase in the pulmonary flow and a slight decrease in the left ventricular stroke volume (LVSV), which represents a decrease in ejection due to the increased LV transmural pressure. A step decrease in pleural pressure to −40 mm Hg, representing the Müller manoeuvre (MM), accentuates these findings, showing a decrease in LVSV in spite of an increase in the LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV) and the LV filling pressure, expressed as the mean left atrial transmural pressure. Simulating intermittent positive pressure ventilation (IPPV) with added positive end expiratory pressure (PEEP) shows an 18·6 per cent decrease in the cardiac output compared with quiet respiration. The calculated results of the model are in good agreement with available experimental data, suggesting that most of these findings may be explained by basic haemodynamic principles in the uncontrolled CVS.     

盐酸戊乙奎醚联合深呼吸法抑制麻醉诱导时芬太尼诱发咳嗽反应的有效性和安全性

目的探讨盐酸戊乙奎醚（PHC）联合深呼吸法抑制麻醉诱导时芬太尼诱发的咳嗽反应（FIC）的有效性和安全性。方法选取2015 年9 月-2016 年9 月该院行手术治疗的220 例患者的临床资料,随机分为4 组,每组55例。H组：于静脉注射芬太尼前10 min给予PHC 0.01 mg/kg,用生理盐水稀释成10 ml静脉注射。P组：芬太尼静脉注射前,患者完成3 次深呼吸后立刻静脉注射芬太尼。M 组：静脉推注芬太尼前10 min给予PHC0.01 mg/kg用生理盐水稀释成10 ml 静脉注射,完成3 次深呼吸后立即给予患者静脉注射芬太尼。N 组：按照一定诱导顺序给予静脉快速诱导。记录患者静脉注射芬太尼后2 min 内咳嗽出现的时间及严重程度,并计算咳嗽发生率;记录静脉注射芬太尼前10 min 或静脉注射PHC（T0）、静注芬太尼后1 min（T1）、2 min（T2）的心率（HR）、收缩压（SBP）、舒张压（DBP）和脉搏血氧饱和度（SpO2）;并分别计算平均动脉压（MAP）。结果4组患者咳嗽程度比较差异有统计学意义（χ2=153.424,p =0.001）;4组咳嗽发生时间比较差异有统计学意义（χ2 =26.509,p=0.019）。4 组患者FIC发生率差异有统计学意义（χ2=12.488, p=0.006）。H 组、P 组、M组和N组FIC 发生率分别为8 例（14.5%）、7 例（12.7%）、4 例（7.3%）和17 例（30.9%）,将H 组、P 组和M 组合并后,并与N 组比较,差异有统计学意义（χ2=11.337,p =0.001）;4 组患者HR、SpO2及MAP 在T0、T1和T2时逐渐降低;T2时HR和MAP 比T0时降低,差异有统计学意义（p <0.05）,T0、T1 和T2 时间的SpO2差异无统计学意义（p >0.05）。4 组不良反应发生率及不良反应比较无统计学意义（p >0.05）。结论PHC 联合深呼吸法能有效抑制FIC 的发生,优 于单独使用PHC 和深呼吸法,且对患者血流动力学影响小,不良反应少,安全性高。