Allogeneic blood transfusions: benefit, risks and clinical indications in countries with a low or high human development index

The risks associated with allogeneic red blood cell (RBC) transfusions differ significantly between countries with low and high human development indexes (HDIs). In countries with a low HDI, the risk of infection (HIV, HBV, HCV and malaria) is elevated. In contrast, in countries with a high HDI, immunological reactions (haemolytic transfusion reactions, alloimmunization and immunosuppression) are predominant. Therefore the overall risk associated with RBC transfusions in low HDI countries is much more significant than that in high HDI countries. In view of these risks, the limited efficacy of RBC transfusion and its high costs, this procedure should be used sparingly and rationally. Therefore RBC transfusion protocols adapted to the local situation are essential. Such protocols should distinguish between physiological and haemoglobin-based transfusion triggers. In countries with a high HDI, relative tachycardia and hypotension, despite normovolaemia, ST-segment changes suggestive of myocardial ischaemia and an Hb level 80 years and those with coronary artery or cerebrovascular disease. In countries with a low HDI, clinical signs of circulatory failure or myocardial ischaemia and an Hb level <5 g/dl can serve as transfusion guideline

Tracheal fluid leakage in benchtop trials: comparison of static versus dynamic ventilation model with and without lubrication

Purpose: Longitudinal folds in tracheal tube (TT) cuffs cause leakage of pooled secretions past the tube cuff, and the most common in vitro method to test the efficacy of a new tube is a benchtop model using an artificial rigid trachea. This study compared the potential of a static and dynamic ventilation benchtop model and cuff lubrication in testing the tracheal sealing properties of a given TT cuff. Methods: Static trial Six brands of 7.5mm internal diameter (ID) cuffed TT (n=8) with high volume-low pressure cuffs were inflated in an artificial trachea (18mm ID) without and with lubrication. Dynamic trial The same tube cuffs, without lubrication, were subjected to positive pressure ventilation (PPV)+positive end-expiratory pressure (PEEP) of 5cmH2O or to PPV alone (without PEEP) or to PEEP alone (without PPV). Clear water (5ml) was placed above the tube cuff, and fluid leakage (ml) was measured up to 60min. Results: Gel lubrication, PEEP alone and PPV+PEEP completely prevented fluid leakage across the tube cuffs in all six TT brands tested within 60min when compared to the static unlubricated model (0% leak versus 100% leak; P<0.01). Fluid leakage in the static unlubricated model and the PPV group was 1.38-4.76ml and 0.23-4.47ml, respectively. Conclusion: Gel lubrication, PEEP alone, and PPV+PEEP in the benchtop model had a much stronger protective effect than PPV alone on fluid leakage. Studies testing the fluid sealing efficiency of tube cuffs might be more conclusive in a static benchtop model without lubrication than in a dynamic mode

Resuscitation and transfusion management in trauma patients: emerging concepts

PURPOSE OF REVIEW: Severe trauma is associated with hemorrhage, coagulopathy and transfusion of blood and blood products, all associated with considerable mortality and morbidity. The aim of this review is to focus on resuscitation, transfusion strategies and the management of bleeding in trauma as well as to emphasize on why coagulation has to be monitored closely and to discuss the rationale of modern and future transfusion strategies. RECENT FINDINGS: Coagulopathy and uncontrolled bleeding remain leading causes of death in trauma, lead to blood transfusions and increased mortality as it has been recently shown that blood transfusion per se results in an adverse outcome. In the last years, damage control resuscitation, a combination of permissive hypotension, hemostatic resuscitation and damage control surgery, has been introduced to treat severely traumatized patients in hemorrhagic shock. Goals of treatment in trauma patients remain avoiding metabolic acidosis, hypothermia, treating coagulopathy and stabilizing the patient as soon as possible. The place of colloids and crystalloids in trauma resuscitation as well as the role of massive transfusion protocols with a certain FFP : RBC ratio and even platelets have to be reevaluated. SUMMARY: Close monitoring of bleeding and coagulation in trauma patients allows goal-directed transfusions and thereby optimizes the patient's coagulation, reduces the exposure to blood products, reduces costs and may improve clinical outcome

Ultrasound guided distal peripheral nerve block of the upper limb: A technical review

Upper extremity surgery is commonly performed under regional anesthesia. The advent of ultrasonography has made performing upper extremity nerve blocks relatively easy with a high degree of reliability. The proximal approaches to brachial plexus block such as supraclavicular plexus block, infraclavicular plexus block, or the axillary block are favored for the most surgical procedures of distal upper extremity. Ultrasound guidance has however made distal nerve blocks of the upper limb a technically feasible, safe and efficacious option. In recent years, there has thus been a resurgence of distal peripheral nerve blocks to facilitate hand and wrist surgery. In this article, we review the technical aspects of performing the distal blocks of the upper extremity and highlight some of the clinical aspects of their usage

Massive aspiration past the tracheal tube cuff caused by closed trachael suction system

Background: Aspiration past the tracheal tube cuff has been recognized to be a risk factor for the development of ventilator-associated pneumonia (VAP). This study investigated the effect of closed tracheal suctioning on aspiration of fluid past the tracheal tube cuff in an in vitro benchtop model. Methods: High-volume low pressure tube cuffs of 7.5 mm internal diameter (ID) were placed in a 22 mm ID artificial trachea connected to a test lung. Positive pressure ventilation (PPV) with 15 cm H(2)O peak inspiratory pressure and 5 cm H(2)O positive end-expiratory pressure (PEEP) was used. A closed tracheal suction system (CTSS) catheter (size 14Fr) was attached to the tracheal tube and suction was performed for 5, 10, 15, or 20 seconds under 200 or 300 cm H(2)O suction pressures. Amount of fluid (mL) aspirated along the tube cuff and the airway pressure changes were recorded for each suction procedure. Fluid aspiration during different suction conditions was compared using Kruskal-Wallis and Mann-Whitney test (Bonferroni correction [α = .01]). Results: During 10, 15, and 20 seconds suction, airway pressure consistently dropped down to -8 to -13 cm H(2)O (P < .001) from the preset level. Fluid aspiration was never observed under PPV + PEEP but occurred always during suctioning. Aspiration along the tube cuff was higher with -300 cm H(2)O than with -200 cm H(2)O suction pressure (P < .001) and was much more during 15 and 20 seconds suction time as compared to 5seconds (P < .001). Conclusion: Massive aspiration of fluid occurs along the tracheal tube cuff during suction with the closed tracheal suction system

Impact of propofol on electrocardiographic alterations during intravascular application of bupivacaine - a study in piglets

BACKGROUND: Intravascular application of a small dose of local anesthetics (LA) with epinephrine as well as larger doses of LA under sevoflurane anesthesia results in increase in T-wave amplitude in the electrocardiogram (ECG). The aim of this study was to elucidate whether propofol anesthesia affects these ECG alterations or not. METHODS: Thirty neonatal pigs were randomized into two groups. Group 1 was anesthetized with sevoflurane, group 2 with sevoflurane plus continuous propofol infusion (10 mg·kg(-1)·h(-1)). A test dose of 0.2 ml·kg(-1) bupivacaine 0.125% + epinephrine 1 : 200,000 was injected intravenously. Arterial pressure was monitored. ECG was analyzed for changes in T-wave amplitude (positive if ≥25% baseline) and heart rate. In another setting, bupivacaine 0.125% was intravenous infused at a rate of 4 mg·kg(-1)·min(-1). ECG was analyzed for alteration in T-wave amplitude and heart rate at 1.25, 2.5, and 5 mg·kg(-1) bupivacaine infused. RESULTS: T-wave elevation after the administration of an epinephrine containing LA test dose was similar between the two groups. Increase in heart rate caused by the test dose were significantly higher in group 2 (P = 0.008). During continuous bupivacaine administration, T-wave elevation occurred in 40% and 71% (group 1 and 2) at 1.25 mg·kg(-1), in 80% and 100% at 2.5 mg·kg(-1), and in 93% and 86% at 5 mg·kg(-1) bupivacaine infused. CONCLUSION: Continuous propofol infusion does not suppress the ECG signs of a systemically administered epinephrine containing LA test dose nor does it suppress the ECG signs caused by high doses of intravenous applied bupivacaine

Tracheal fluid leakage in benchtop trials: comparison of static versus dynamic ventilation model with and without lubrication

PURPOSE: Longitudinal folds in tracheal tube (TT) cuffs cause leakage of pooled secretions past the tube cuff, and the most common in vitro method to test the efficacy of a new tube is a benchtop model using an artificial rigid trachea. This study compared the potential of a static and dynamic ventilation benchtop model and cuff lubrication in testing the tracheal sealing properties of a given TT cuff. METHODS: Static trial Six brands of 7.5 mm internal diameter (ID) cuffed TT (n = 8) with high volume-low pressure cuffs were inflated in an artificial trachea (18 mm ID) without and with lubrication. Dynamic trial The same tube cuffs, without lubrication, were subjected to positive pressure ventilation (PPV) + positive end-expiratory pressure (PEEP) of 5cmH(2)O or to PPV alone (without PEEP) or to PEEP alone (without PPV). Clear water (5 ml) was placed above the tube cuff, and fluid leakage (ml) was measured up to 60 min. RESULTS: Gel lubrication, PEEP alone and PPV + PEEP completely prevented fluid leakage across the tube cuffs in all six TT brands tested within 60 min when compared to the static unlubricated model (0% leak versus 100% leak; P < 0.01). Fluid leakage in the static unlubricated model and the PPV group was 1.38-4.76 ml and 0.23-4.47 ml, respectively. CONCLUSION: Gel lubrication, PEEP alone, and PPV + PEEP in the benchtop model had a much stronger protective effect than PPV alone on fluid leakage. Studies testing the fluid sealing efficiency of tube cuffs might be more conclusive in a static benchtop model without lubrication than in a dynamic model

PDZK1: II. an anchoring site for the PKA-binding protein D-AKAP2 in renal proximal tubular cells

BACKGROUND: PDZK1, a multiple PDZ protein, was recently found to interact with the type IIa Na/Pi cotransporter (NaPi-IIa) in renal proximal tubular cells. In a preceding study, yeast two-hybrid screens using single PDZ domains of PDZK1 as baits were performed. Among the identified proteins, a C-terminal fragment of the dual-specific A-kinase anchoring protein 2 (D-AKAP2) was obtained by screening PDZ domain 4. METHODS: After its molecular cloning by means of RACE, the renal expression of D-AKAP2 was analyzed by real-time polymerase chain reaction (PCR) and immunohistochemistry. Protein interactions were characterized by overlays, pull-downs, and immunoprecipitations from transfected opossum kidney (OK) cells. RESULTS: Based on 5'-RACE and PDZK1 overlays of mouse kidney cortex separated by two-dimensional electrophoresis, it was suggested that the renal isoform of D-AKAP2 in mouse comprises 372 amino acids and exists as a protein of >40 kD. Immunohistochemistry and real-time PCR localized D-AKAP2 only to the subapical pole of proximal tubular cells in mouse kidney. In pull-down experiments, D-AKAP2 tightly bound PDZK1 as well as N+/H+ exchanger regulator factor (NHERF-1), but the latter with an apparent fourfold lower affinity. Similarly, His-tagged D-AKAP2 specifically retained PDZK1 from mouse kidney cortex homogenate. In addition, myc-tagged D-AKAP2 and HA-tagged PDZK1 co-immunoprecipitated from transfected OK cells. CONCLUSION: We conclude that D-AKAP2 anchors protein kinase A (PKA) to PDZK1 and to a lesser extent to NHERF-1. Since PDZK1 and NHERF-1 both sequester NaPi-IIa to the apical membrane, D-AKAP2 may play an important role in the parathyroid hormone (PTH)-mediated regulation of NaPi-IIa by compartmentalization of PKA