Central cardiovascular and oxygen variables during haemorrhage in the pig

Background: We evaluated the ability of the standards issued by the Danish Society of Anaesthesiologists to reflect a blood loss.
Methods: In 9 pigs bled (0–24 ml kg^-1) and retransfused (to 28 ml kg^-1) during halothane anaesthesia, central cardiovascular, thoracic electrical impedance (TI), oxygen, acid-base and temperature variables were recorded.
Results: With the recommendation for minor surgery (mean arterial pressure (MAP) and heart rate (HR)), the correlation to the blood loss was 0.74 ( P < 0.001) and with that for major surgery (MAP, HR, central venous pressure (CVP) and rectal temperature (Temp_r)) it was 0.79 ( P < 0.001). With the recommendation for extensive surgery (MAP, HR, CVP, pulmonary artery catheter variables and the central-peripheral temperature difference (ΔTemp_r-t)), the correlation was 0.84 ( P < 0.001). Non-invasive monitoring (MAP, HR, ΔTemp_r-t TI and near-infrared spectroscopy of the brain (S_invosO₂)) was only slightly better than basal monitoring (r=0.76, P < 0.001). However, adding arterial base excess (BE), TI and peripheral temperature (Temp_t) to the recommendation for major surgery resulted in a correlation of 0.87 ( P < 0.001), while adding BE and TI to the recommendation for extensive surgery raised correlation to only 0.88 ( P < 0.001).
Conclusion: When the recommendations were followed the correlation to the blood loss ranged from 0.74–0.84. However, with the recording of MAP, HR, CVP, ΔTemp_r-t, BE and TI a correlation of 0.87 was achieved, indicating that a pulmonary artery catheter may not be in need for patients undergoing surgical procedures with expected haemorrhage.     

PHA胸导管来源诱生的LAK细胞的作用

利用胸导管引流治疗哮喘病的机会,研究了PHA在rIL-2诱导胸导管淋巴细胞成为LAK细胞中的作用。结果表明:PHA和rIL-2共同诱导TDL2周,细胞数量扩增约34倍。同时明显促进了DL的~3H-TdR和~3H-Leucine的参入,较对照组有明显差异(P<0.01)。其中rIL-2 100～1000U/ml和PHA组作用最佳,但PHA和rIL-2的协同作用持续时间短,第6d即开始下降,而且PHA参与诱导的TDL-LAK细胞的杀伤活性有所下降。     

Extension of the “Elephant Trunk” Technique in Complex Aortic Pathology: The “Bidirectional” Option

Background. The “elephant trunk” technique, using a free-floating vascular prosthesis, was originally described to facilitate a subsequent operation on the downstream aorta. We developed an additional refinement of this technique, called the “bidirectional elephant trunk.” This option may represent an interesting tool in more complex aortic operations, especially when the descending aorta has to be replaced first in patients with concomitant pathology of the ascending aorta or of the aortic arch.

Methods. The initial operation is performed through a left thoracotomy. The proximal elephant trunk is created by invaginating the future aortic arch graft into the descending aortic graft. The proximal anastomosis between the doubled graft and the proximal descending aorta is performed first. During construction of the distal anastomosis, a distal elephant trunk may be inserted likewise. If the aortic arch and ascending aorta have to be replaced later, this second step is performed through a median sternotomy. The free-floating arch graft is pulled out of the proximal descending aorta with a nerve hook, unfolded, and used for total arch replacement.

Results. This technique was used successfully in 3 patients without mortality. No major complications were observed excepted persistent hoarseness in a patient with preoperative paresis of the recurrent nerve. No perfusion problems due to the unfolding of the free-floating graft occurred during the second operation.

Conclusions. The bidirectional elephant trunk technique is an interesting option that may be suitable for patients presenting with a complex pathology of the whole thoracic aorta when the descending segment has to be replaced first.     

Bilateral continuous paravertebral block used for postoperative analgesia in an infant having bilateral thoracotomy

We describe the successful postoperative pain management in an 11-month-old infant who underwent bilateral thoracotomy, using continuous infusions of bupivacaine into two directly placed paravertebral catheters. Haemodynamic parameters and pain scores were measured 1–2 h for 60 h while the infusions were continued and, intermittently, blood samples were taken for subsequent measurement of serum bupivacaine concentrations. The technique provided effective pain relief and the infant required no other analgesia postoperatively. There were no adverse haemodynamic consequences or complications relating to either catheter placement or drug infusions. Serum concentrations of bupivacaine remained below toxic levels throughout the study period, though accumulation did occur.     

距骨的血液供应及其临床意义

本文观察了２４侧尸体足标本，均无已知临床血管疾病。在死后３６～４８小时之间行动脉灌注ＡＢＳ填充剂，以化学腐蚀和手工剔除的方法清除软组织。距骨的血供来自小腿下部三根主要动脉的分支，即跗骨管动脉和三角支、近端和远端跗骨窦动脉、颈上支及后结节血管丛。跗骨管动脉常发自足底内侧动脉，而三角支多单独自胫后动脉发出；跗骨管动脉通常比三角支和跗骨窦动脉都来得细小。以上的这些动脉相互吻合，形成了一个骨膜血管网，覆盖于全部的距骨非关节面上。而且，环绕着跗骨管、跗骨窦、距骨颈的上面和距骨体部的内侧面，由三角支、跗骨管动脉、跗骨窦动脉、颈上支及其相互之间的吻合血管网形成了一个不定形的距骨动脉环。本文还讨论了距骨缺血性坏死与动脉环的可能关系，距骨骨折脱位或手术后的缺血性坏死是由于距骨动脉环的毁损或功能受影响所致。三角支在距骨骨折脱位时具有重要意义，手术或手法复位时应注意保护。     

Bilateral subclavian steal associated with severe coarctation of the thoracic aorta and an aberrant right subclavian artery

A 10-year-old girl having bilateral subclavian steal associated with severe coarctation of the thoracic aorta and an aberrant right subclavian artery was found, on admission, to have no difference between upper and lower extremity blood pressure, but echocardiography revealed severe thoracic aorta coarctation and systolic blood pressure in the carotid arteries exceeding 200 mmHg estimated by Doppler ultrasonography. Magnetic resonance imaging and angiography demonstrated bilateral subclavian steal without esophageal compression. We reconstructed the aortic arch using the left subclavian artery and a reversed Blalock-Park procedure, then repaired the coarctation with a 14 mm woven double velor vascular graft. The girl was symptom-free following uncomplicated recovery from surgery. Doppler ultrasonography 2 weeks after surgery showed the pressure gradient across the aortic arch had decreased from 180 mmHg to 60 mmHg. This residual gradient at the anastomosis between the ascending aorta and left subclavian artery may improve as native vessels grow.     

Aortic regurgitation secondary to diastolic prolapse of a tubular intimal flap into the left ventricle in a patient with anuloaortic ectasia

A 32-year-old man with distal skeletal manifestations of Marfan's syndrome had experienced shortness of breath and orthopnea for one month. Physical examination showed the presence of severe aortic regurgitation. Both noninvasive and invasive studies revealed that the aortic regurgitation was induced by previously undescribed peculiar and unusual etiology: diastolic prolapse of a circumferentially dissected tubular intimal flap into the left ventricle. The patient underwent surgical repair with striking clinical improvement.     

Advantages of using the midline incision right retroperitoneal approach for abdominal aortic aneurysm repair

This study was conducted to compare the midline incision right retroperitoneal approach for repairing abdominal aortic aneurysms (AAA) with the transperitoneal approach. The intra- and postoperative course of 15 patients who underwent AAA repair using the transperitoneal approach between 1987 and 1991 and another 15 patients who underwent AAA repair using the retroperitoneal approach between 1991 and 1994 were evaluated. The incidence of postoperative wound complications was also assessed. There was no operative or hospital death in either group. Although a significantly longer interval was required from the incision to the aortic clamp using the extraperitoneal method, there were no statistical differences in the aortic clamping time, total operation time, or blood loss between the two groups. On the other hand, there was a statistically significant improvement in bowel function and a significant reduction in the length of postoperative hospitalization following the extraperitoneal procedure. Furthermore, no wound complications such as those associated with the left flank incision developed after the extraperitoneal procedure. Thus, we recommend the midline incision right retroperitoneal approach for AAA as it does not involve muscle division and is associated with fewer complications.     

3-D echocardiographic imaging of double aortic arch.

Delineation of arch abnormalities is difficult by conventional 2-D echocardiography and MRI has been the investigation of choice. 3-D echocardiography is increasingly used in congenital heart disease for both functional anatomy and morphology. This case report demonstrates that 3-D echocardiography can be used in delineating arch anomalies, which can avoid further imaging that needs a general anaesthetic.     

鸡胚第一对弓动脉的发生

用印地安墨汁注入活体鸡胚心脏，在体现显微镜下观察１１２例第１０～２０期鸡胚第一对弓动脉的发生。第一对弓动脉于第１０期出现，至第２０期退化消失。第一对弓动脉出现时尚无相应的第一咽弓，随着第一咽弓的出现，第一对弓动脉的起始端形成一个突入第一咽弓内的动脉瘤样隆起，此隆起随着第一咽弓的增大逐渐发育成一对贯穿第一咽弓的弓状血管。第一对弓动脉可以分为位于第一咽弓内的近侧段和位于此咽弓之外，与背主动脉相连的远侧段。