Transfusion service disaster planning.

The Mayo Clinic, in Rochester, Minnesota, recently set forth a directive to develop a Mayo Emergency Incident Command System (MEICS) plan to respond to major disasters. The MEICS plan that was developed interfaces with national response plans to ensure effective communication and coordination between our institution and local, state, and federal agencies to establish a common language and communication structure. The MEICS plan addresses multiple aspects of dealing with resource needs during a crisis, including the need for blood and transfusion medicine services. The MEICS plan was developed to supplement our current local emergency preparedness procedures and provide a mechanism for responding to the escalating severity of an emergency to deal with situations of a magnitude that is outside the normal experience. A plan was developed to interface the existing Transfusion Medicine disaster plan standard operating procedures (SOP) with the institutional and Department of Laboratory Medicine (DLMP) MEICS plans. The first step in developing this interface was defining MEICS. Other major steps were defining the chain of command, developing a method for visually indicating who is "in charge," planning communication, defining the actions to be taken, assessing resource needs, developing flowcharts and updating SOPs, and developing a blood rationing team to deal with anticipated blood shortages. Several key features of the interface and updated disaster plan that were developed are calling trees for response personnel, plans for relocating leadership to alternative command centers, and action sheets to assist with resource assessment. The action sheets also provide documentation of key actions by response personnel.

Type IV hyperlipoproteinemia: effects of a caloric restricted type IV diet versus physical training plus isocaloric type IV diet.

Serum lipids, plasma insulin and glucagon, aerobic capacity, and body composition were examined in middle-aged men (X age = 44.2 years) with type IV hyperlipoproteinemia to determine the relative effectiveness of a caloric restricted type IV hyperlipoproteinemia diet (group A) versus physical training plus an isocaloric type IV diet (group B). After 9 weeks of the above interventions, reductions (P less than 0.01) in mean cholesterol levels from 213 to 186 (12% change) and from 205 to 185 mg/dl (9% change), and in triglyceride levels from 332 to 211 (29% change) and from 263 to 138 mg/dl (42% change) were found for groups A and B, respectively. A small reduction in mean fasting insulin level was found only in group B; this reduction appeared inversely associated with increases in aerobic capacity in group B (r = -0.66). Both interventions were without effect on fasting glucagon levels. The physical training program prescribed resulted in a 12% increase in aerobic capacity (group B). Significant mean body weight reductions of 7.7 lb (P less than 0.01) and 2.9 lb (P less than 0.01) were seen for groups A and B, respectively; these absolute body weight reductions differed significantly (P less than 0.05) between groups. Both groups significantly lost body fatness (P less than 0.01). These reductions in body weight and body fatness appeared independent of changes in lipid levels. These results demonstrate that both interventions reduce serum lipids in men with type IV hyperlipoproteinemia but that physical training plus an isocaloric type IV diet may be the more advantageous of the two regimens, since a greater percentage decrease and a more sustained reduction in serum triglyceride levels, and a greater reduction of fasting hyperinsulinemia were observed in group B.

Simplified enrollment for autologous transfusion: automatic referral of presurgical patients for assessment for autologous blood collections.

We implemented a pilot program at our institution for automatic referral of patients for presurgical assessment for preoperative and intraoperative collection of autologous blood. Although patients and clinicians support the use of autologous transfusion, often a request for collection of autologous blood is not initiated. During 11 months, 269 patients (82%) of three orthopedic surgeons entered the program, and 218 underwent operation and were dismissed from the hospital. A total of 940 units of autologous blood (675 preoperatively and 265 intraoperatively) was collected from these 218 patients, and 84% of the units were transfused. Throughout hospitalization, 86% of the patients received only autologous blood, whereas 14% received various proportions of homologous and autologous blood. In contrast, only 26% of a concomitant control group of 220 consecutive orthopedic surgical patients not participating in the automatic-referral program received only autologous blood. Thus, the automatic-referral program increased the percentage of elective orthopedic surgical patients who received only autologous blood from 26% to 86% (P less than 0.001). This study also showed that the same amount of blood was used for autologous transfusions as was routinely used for homologous transfusions in similar cases. The automatic-referral system was convenient for physicians and patients and offered the benefits of reduction of transfusion-associated risks and amelioration of patient anxieties.

Metabolic adaptation with physical training: 14C-acetate incorporation into tissue lipids.

Forty-eight rats were fed ad libitum, fasted 24 hr, rested 48 hr,and injected i.p. with 40 muCi of 14C-acetate/100 g body weight. Twenty-four rats had followed a progressive physical training program for 12 wk and 24 rats acted as their controls. Following this injection, the rats were sequentially sacrificed at 5-, 10-, 15-, and 20-min intervals and total cholesterol (TC), free cholesterol (FC), and triglyceride (TG) specific activity and concentrations were measured from serum, liver, triceps, and heart tissue. Curves relating specific activity to the time point data were fitted by the method of least squares. Comparison of these curves revealed that serum, liver, and triceps TC and FC specific activity were significantly higher in the trained rats. In contrast, corresponding TC and FC concentrations for these three tissues varied. Liver TC level was significantly less for the trained group, probably due to a reduction in the esterified moiety, since liver FC measures were unchanged. Training resulted in significantly lower TC concentrations in the selected tissues studied even though specific activity curves appeared similar for both groups. Our conclusions are that lipid metabolic adaptation; studied in vivo, occurs in tissues with training, but that these adaptations are not uniform across tissues, lipid moieties, or measurement parameters.

Exercise as a partial therapy for the extremely obese.

The management of the extremely obese patient is best accomplished by a multidisciplinary approach which includes exercise training as an integral component. While diet alone is a potent factor in improving the metabolic complications associated with obesity, the combination of diet and exercise training can further improve these complications and greatly enhance cardiorespiratory function. Although the fitness of extremely obese people is low, individualized exercise programs can be used to safely and progressively train these patients, reduce fatigue, and greatly increase maximum work tolerance. Additional benefits derived from exercise training include improved insulin-mediated glucose utilization, lower serum lipid concentrations, and improved psychological distress scores and anxiety levels. Thus, exercise training can contribute to the success of a weight reducing program by improving metabolic, cardiorespiratory, and psychological factors. Additional important interventions in a multidisciplinary treatment of severe obesity include psychiatric, psychosocial, and vocational counseling.

A comparison of multiport and uniport epidural catheters in laboring patients.

The relative incidence of technical difficulties associated with multiport (three lateral ports) and uniport (single distal port) epidural catheters remains controversial. As part of a continuing institutional evaluation of epidural catheter insertion, 500 parturients were randomized to have either a multiport or a uniport epidural catheter inserted 6 cm into the epidural space. Multiport epidural catheters were associated with inadequate analgesia less often and required manipulation less often than uniport epidural catheters. The incidences of intravenous cannulation, subsequent catheter dislodgement, and catheter replacement were similar for each catheter type. No multiport epidural catheter was associated with multicompartment placement. We conclude that multiport epidural catheters are preferable for use in laboring patients since they reduce the incidence of inadequate epidural analgesia.

Extremely obese patients: improvements in exercise tolerance with physical training and weight loss.

The relationship between improvements in exercise tolerance and body weight was determined for 11 extremely obese patients (mean entry weight = 189kg) concomitantly participating in progressive physical training (walking-jogging) and severe caloric restriction (600kcal/day) to induce weight loss as part of a residential multidisciplinary rehabilitation program. Two standardized tests (treadmill mile-walk and graded-exhaustive) to quantitatively evaluate exercise performance were administered periodically. Significant weight reductions and improvements in exercise tolerance were observed, with measures of the latter occurring relatively sooner. Correlation coefficients between body weight and performance or physiologic response measures were extremely low, indicating widespread individual responsiveness to training and the probable separateness of training and dietary effects. A moderate inverse correlation was found between body weight and a simple measure of work performance: endurance time to volitional exhaustion (r = -0.45). Training programs of moderate rather than higher intensity, duration, and progression rate were used with this obese group. Such programs can be safely administered and will be well tolerated but therapists should recognize the inability to predict improvements in exercise performance on the basis of the current body weights of individual patients. The major application of results from standardized exercise tests, therefore, resides in direct reinforcement of patient progress.

Physical training program for rehabilitating extremely obese patients.

Performance records of 22 extremely obese adult patients undergoing physical rehabilitation in a multi-disciplinary program were used to devise three progressive training protocols to which patients can be individually assigned. These protocols include "fastest pace" walking and jogging and are designed to rehabilitate patients to a two-mile continuous walk within three, five or seven weeks. Specific definition of progressions in distance/work session units are given and criteria for assigning patients to each protocol are discussed. The program allows time for psychological as well as physiological adaptation and improves the rehabilitative process by eliminating much of the variability and regression previously attributed to patient manipulation.

Dose-response effects of anti-inflammatory steroid injections on mechanical properties of rat tail tendons.

It has been suggested that glucocorticoid drug therapy or usage may be a contributing factor in the occurrence of tendon ruptures among athletes. Our earlier findings (7) did not support this position but may have been dependent on the small quantity of drug injected. We subsequently tested selected biomechanical properties of healthy, non-traumatized tail tendons from sixty 90-day-old Sprague-Dawley rats previously injected weekly for six weeks with 0.1 ml saline (controls) or low (0.03 mg/0.1 ml), medium (0.30 mg/0.1 ml) or high doses (0.60 mg/0.1 ml) of betamethasone. Results indicate the biological effectiveness of the medium and high dose treatments through reductions in body and adrenal weights, but we found no statistically significant change in dry tendon weight, yield load or relative yield load, although there was a suggestive trend toward lessened dry tendon weights and greater relative yield loads. The hypothesis that repeated local injections of an anti-inflammatory steroid deleteriously effects mechanical properties of healthy, non-traumatized rat tendons is not supported by our data, even considering that some dosages were 10 to 20 times greater than recommended therapeutic quantities for humans.

Initial work tolerance of extremely obese patients.

Initial work tolerance (walking) of 16 extremely obese (133 to 238 kg) patients entering a multidisciplinary rehabilitation program was low, as previously reported, but also highly variable. Some were capable of walking one mile nonstop while others required as much as eight weeks of progressive exercise training to reach this goal. Treadmill test - indirect calorimetry results indicate that patients required approximately 20 minutes to walk one mile at their fastest pace (3 mph), displayed near steady state aerobic metabolism and expended approximately 150 to 200 net kcal/mile. Patients were screened for abnormal cardiac responses to work using graded exercise test procedures with electrocardiography and there were no apparent hazardous episodes during rehabilitative training.

Establishing an industrial strength testing program.

This study was performed to develop and evaluate a scheme for matching the strength of workers to the strength demands of their jobs. Biomechanical analyses were performed on production jobs in an aluminum reduction plant to identify and quantify strength demands. These data were used to design a set of nine strength tests which simulated job activities with the greatest strength requirements. A cross section of plant employees assigned to these jobs was strength tested and monitored for medical incidents for a period of over two years. Significant relationships were found among job strength requirements, worker strengths, and medical incidents. Workers with strength abilities (as determined by the tests) less than job strength requirements suffered a higher rate of medical incidents than workers whose strength abilities matched or exceeded job demands. It was concluded that strength testing can be used to identify workers who would be at increased risk of suffering medical incidents if placed on jobs which exceeded their strength abilities.

Intrathecal neostigmine and sufentanil for early labor analgesia.

BACKGROUND: Recent efforts to improve the combined spinal epidural (CSE) technique have focused on adding opioids to other classes of analgesics. In this study, the authors used intrathecal neostigmine in combination with intrathecal sufentanil to investigate the usefulness of neostigmine for reducing side effects and prolonging the duration of sufentanil. METHODS: One hundred six healthy pregnant women in labor were enrolled in this study, which was divided into four phases. In all phases, patients received a CSE anesthetic while in the lateral position. In phase I, three groups of six women each received intrathecal neostigmine, 5, 10, or 20 microg, in an open-label, dose-escalating safety assessment. In phase II, 24 women received intrathecal sufentanil alone to establish an ED50 (dose that produces > 60 min of labor analgesia in 50% of patients). In phase III, an ED50 was established for sufentanil combined with a fixed dose of neostigmine (10 microg). In phase IV, 40 women received either twice the ED50 of sufentanil alone or twice the ED50 of sufentanil plus neostigmine, 10 microg. RESULTS: Neostigmine alone had no adverse effects on maternal vital signs, fetal heart rate, or Apgar scores. Neostigmine, 20 microg, produced analgesia in one patient and severe nausea and vomiting in another. The ED50 for intrathecal sufentanil alone was 4.1 +/- 0.31 microg, and the ED50 for intrathecal sufentanil combined with neostigmine, 10 microg, was 3.0 +/- 0.28 microg. The duration of analgesia and side effects from double these ED50s (sufentanil, 9 microg, or sufentanil, 6 microg, plus neostigmine, 10 microg) were similar between groups. CONCLUSIONS: The 10-microg intrathecal neostigmine dose alone produced no analgesia or side effects, but reduced the ED50 of intrathecal sufentanil by approximately 25%. Additionally, doses approximately double these ED50s each produced a similar duration of analgesia and side effects, indicating intrathecal neostigmine shifts the dose-response curve for intrathecal sufentanil to the left.

0.125% ropivacaine is similar to 0.125% bupivacaine for labor analgesia using patient-controlled epidural infusion.

UNLABELLED: We compared the effects of 0.125% ropivacaine with 0.125% bupivacaine in laboring patients using patient-controlled epidural analgesia (PCEA). Fifty-one ASA physical status I or II term parturients with functioning epidural catheters were randomized to receive ropivacaine or bupivacaine using a prospective, double-blind design. Basal infusions (6 mL/h) were supplemented with patient-controlled boluses (5 mL) every 10 min as required. For inadequate analgesia, patients were administered 10-mL boluses of study solution until comfortable. There were no differences in verbal pain scores, amount of local anesthetics used, sensory levels, motor blockade, labor duration, mode of delivery, side effects, or patient satisfaction between the two local anesthetics. We conclude that 0.125% ropivacaine and bupivacaine are clinically indistinguishable and are both highly effective for labor analgesia using PCEA. IMPLICATIONS: This study compared labor analgesia from 0.125% ropivacaine and 0.125% bupivacaine using patient-controlled epidural analgesia. We found no significant differences in local anesthetic use, analgesic characteristics, or side effects between 0.125% ropivacaine and 0.125% bupivacaine. We conclude that these two drugs are clinically indistinguishable at this concentration.

Effectiveness of unsupervised and supervised high intensity physical training in normalizing serum lipids in men with type iv hyperlipoproteinemia.

The effect of high intensity physical training (HIPT), conducted in an unsupervised (group A) or supervised (group B) setting, was studied in 23 middle-aged men with Type IV hyperlipoproteinemia (HLP). Following 10 weeks of HIPT intervention, significant metabolic changes were observed such as reductions in both fasting triglyceride and insulin levels, but no changes in fasting serum cholesterol or glucagon levels were found. Other favorable results noted included a significant improvement in physical fitness, as measured by increases in aerobic power, and a decrease in body fatness with only minimal weight losses. There were no significant differences in the results when groups A and B were compared. It was concluded that HIPT is an effective means of lowering fasting triglyceride and insulin levels in Type IV HLP individuals. In addition, such physical training programs can be conducted in either an unsupervised or supervised setting, provided the subjects are highly motivated.