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8.14 How effective is acute normovolaemic haemodilution (ANH) in vascular patients?
10 years (1986-1996). 28 patients who met these rigid criteria. There were 24 men and four women, aged 32.4 years at the time of the first clinical symptom of the disease. The cumulative tobacco use averaged 16 pack-years for each patient. The initial symptom was limited gangrene of a toe (n = 9) or a finger (n = 2), foot claudication (n = 6), calf claudication (n = 3), rest pain (n = 3), migratory superficial phlebitis (n = 4), and Raynaud phenomenon (n = 1). Angiography and/or Doppler ultrasound revealed digital, pedal and calf artery involvement in all patients, with proximal extension in 10 patients (femoropopliteal in 10, including three cases with external iliac artery involvement). Seven patents also had evidence of upper limb involvement. Histological proof was only available in seven patients. Only nine patients completely stopped smoking. Treatment was exclusively medical in five cases. Twenty-three underwent sympathectomy (20 at lumbal, and three at thoracic level), with a good immediate result in 15. In 11 patients a vascular reconstruction was carried out (eight femorocrural and three iliofemoral bypasses), with a patency rate of only 36% at 2 years. Amputation was required in 15 patients (a mean of 2.7 amputations per patient) at one or more levels: toe (n = 19), forefoot (n = 5), below knee (n = 8), above knee (n = 2), finger (n = 2). Two patients ended up with bilateral leg amputation. Disease progression was moderately related to continued tobacco use. Buerger’s disease still entails considerable risk of major amputation. Complete abstinence from tobacco use is crucial to expect stabilization of the process. However, in advanced stages of the disease, recurrent episodes of ischemia or tissue loss are not excluded despite cessation of smoking.
8.13 The Utilization of Cold Provocation Thermography Uooer Limb Vasosoastic Conditions l.i-=: CHETTER, ].=I. SPARK, K. MERCER, P.I. KENT, D.C. BERRIDGE, D.I.A. SCOTT and RIG. KES?ER, Leeds, UK
in
Introduction: It is estimated that 20000 workers in the UK suffer Raynaud’s phenomenon (RF’), secondary to occupational vibration exposure, as part of the Hand Arm Vibration Syndrome (HAVS) disease complex. It is a clinical diagnosis and the need for an objective investigation to support the diagnosis and exclude primary RI’ has been highlighted. This study analyses the potential of cold provocation thermography (CPT) to fulfil this role. Base Primary GradlentPrmaq Results: Tfp Primary HAVS‘ FingerTemp(“Cl ControlsRI’ H A @ CO~tKJ~S RP HAL’ScontrolsRP Precoolrn~ 0 m m pot, 1.5m m po5t 3 m m p&t 4.j m m nest 6 m m posr 7.5m m post 9 m m port
34.I Li1.Y 2S i3.6 34.5 34.j 14.9 14.7
xx* io.h*t 34 30: 32:y -0.1 191’ IRA’” 21.4 19.7” 20.2” -0.1 20.4~~ 20.8” 26.X 23.1” 23.7” 0.4 21 1” 21.3” 31 23.8” 24.h”t 1.5 24.2” 2S’t 0.9 2k” 21.6” 33 21.7” 22.Yt33.6 24.4” 26.S”t 0.7 ?2.4* 28”t 34.2 24.5” 27.?*t 0.4 23.1” 3O.l”t34.2 24.9” 2Y+t 0.3
-0.9” -1.3; -0.6” -l.l‘t -2” -2.9y -2.6 -3.2y -2.6” -3* -2.4” -2.5” -1.8’ -0.7* -1.4” -0.1
Mrdmn Values presented. * = significantly different from controls, f = rgnificantly different from primary RI?
Patients and methods: CPT was performed on three patient groups: eight controls (five men, three women median age 3.5
CARDIOVASCULAR SURGERY
SEPTEMBER 1997
years, range 24-78) with no history of vibration exposure or symptoms of digital vasospasm; 21 primary RP patients (five men, 16 women, median age 38 years, range 16-76) and 21 patients with RP secondary to HAVS (20 men, one woman median age 45 years range 29-81). A precooling thermal image is taken using an infra red camera. Pauents then put on closely fitting, thin, latex gloves and immerse their hands in water at a temperature of 5°C for 1 min. Foilowing removal of the gloves, further images are taken every 30 set for 10 mins. Finger tip and base temperatures and the digital temperature gradient were analysed on each digit, on each image. ‘The mann-Whitney U test was utilized to :issess statistical significance (P < 0.01) Conclusion: Any of the three temperature measurements analysed at CPT gives very strong support to the clinical diagnosis of upper limb vasospastic disorder. Digital temperature gradient and digital basal temperature in the early and late phases of rewarming, respectively. seem to be the most promising indicators of aetiology.
8.14 How Effective is Acute Normovolaemic Haemodilution ( ANH) in Vascular Patients? ].I. SPARK, I.C. CHETTER, A. LUMB, L. CALDlCOTT, D.C. BERRIDGE, R.C. KESTER and D.J.A. SCOTT Leeds, UK Introduction: Recent guidelines for blood transfusion in the surgical setting have emphasized that autologous blood should be procured preoperatively when possible. Despite published guidelines and consensus conference recommendations, the role of ANH in elective vascular surgery has not been defined. Aims: To analyse the efficacy and efficiency rrt ANH as a blood conservation intervention in patients undergoing femoro-distal vascular surgery for critical limb ischaemia. Fourty patients, 26 men and 14 women, with a median age of 68 years, undergoing elective femoro-distal bypass for chronic critical ischaemia were studied prospectively. The volume of blood collected was: Blood volume removed = patient blood vtriume x (initial haematocrit - final haematocrit)/(average haematocrit). Results: Twenty-five patients (62.S%) were suitable for ANH, 1.5 patients were excluded because of poor ventricular function, anaemia or renal disease. Following the induction of anaesthesia, six of the patients required crystalloid and colloid, reducing their baematocrit to 35% before surgery. Median intraoperative blood loss was I I.50 ml, with the median volume of autologous blood collected being 1040ml (range, 400-1400ml). Eleven of the 2.5 patients (44%) had less than 65Oml of surgical blood loss and would have avoided homologous blood transfusion (HBT) without the use of ANH. Two of the patients lost > 2,SOOml of blood and could not avoid HBT through ANH due to the size of the haemorrhage. In six of the patients there was moderate blood loss (950-1400 ml), with two of these patients requiring transfusion because of mild symptomatic anaemia (haemoglobin 9.3 and 8.8 g/dL). Four patients avoided exposure to HBT, with the volume of intraoperative red blood cefls saved being 11Sml. Conclusion: Acute normovolaemic haemodilutron remains in evolution and as a single blood conservation intervention contributes only modestly to blood conservti~tion
45
8.13 The Utilization of Cold Provocation Thermography Uooer Limb Vasosoastic Conditions l.i-=: CHETTER, ].=I. SPARK, K. MERCER, P.I. KENT, D.C. BERRIDGE, D.I.A. SCOTT and RIG. KES?ER, Leeds, UK
in
Introduction: It is estimated that 20000 workers in the UK suffer Raynaud’s phenomenon (RF’), secondary to occupational vibration exposure, as part of the Hand Arm Vibration Syndrome (HAVS) disease complex. It is a clinical diagnosis and the need for an objective investigation to support the diagnosis and exclude primary RI’ has been highlighted. This study analyses the potential of cold provocation thermography (CPT) to fulfil this role. Base Primary GradlentPrmaq Results: Tfp Primary HAVS‘ FingerTemp(“Cl ControlsRI’ H A @ CO~tKJ~S RP HAL’ScontrolsRP Precoolrn~ 0 m m pot, 1.5m m po5t 3 m m p&t 4.j m m nest 6 m m posr 7.5m m post 9 m m port
34.I Li1.Y 2S i3.6 34.5 34.j 14.9 14.7
xx* io.h*t 34 30: 32:y -0.1 191’ IRA’” 21.4 19.7” 20.2” -0.1 20.4~~ 20.8” 26.X 23.1” 23.7” 0.4 21 1” 21.3” 31 23.8” 24.h”t 1.5 24.2” 2S’t 0.9 2k” 21.6” 33 21.7” 22.Yt33.6 24.4” 26.S”t 0.7 ?2.4* 28”t 34.2 24.5” 27.?*t 0.4 23.1” 3O.l”t34.2 24.9” 2Y+t 0.3
-0.9” -1.3; -0.6” -l.l‘t -2” -2.9y -2.6 -3.2y -2.6” -3* -2.4” -2.5” -1.8’ -0.7* -1.4” -0.1
Mrdmn Values presented. * = significantly different from controls, f = rgnificantly different from primary RI?
Patients and methods: CPT was performed on three patient groups: eight controls (five men, three women median age 3.5
CARDIOVASCULAR SURGERY
SEPTEMBER 1997
years, range 24-78) with no history of vibration exposure or symptoms of digital vasospasm; 21 primary RP patients (five men, 16 women, median age 38 years, range 16-76) and 21 patients with RP secondary to HAVS (20 men, one woman median age 45 years range 29-81). A precooling thermal image is taken using an infra red camera. Pauents then put on closely fitting, thin, latex gloves and immerse their hands in water at a temperature of 5°C for 1 min. Foilowing removal of the gloves, further images are taken every 30 set for 10 mins. Finger tip and base temperatures and the digital temperature gradient were analysed on each digit, on each image. ‘The mann-Whitney U test was utilized to :issess statistical significance (P < 0.01) Conclusion: Any of the three temperature measurements analysed at CPT gives very strong support to the clinical diagnosis of upper limb vasospastic disorder. Digital temperature gradient and digital basal temperature in the early and late phases of rewarming, respectively. seem to be the most promising indicators of aetiology.
8.14 How Effective is Acute Normovolaemic Haemodilution ( ANH) in Vascular Patients? ].I. SPARK, I.C. CHETTER, A. LUMB, L. CALDlCOTT, D.C. BERRIDGE, R.C. KESTER and D.J.A. SCOTT Leeds, UK Introduction: Recent guidelines for blood transfusion in the surgical setting have emphasized that autologous blood should be procured preoperatively when possible. Despite published guidelines and consensus conference recommendations, the role of ANH in elective vascular surgery has not been defined. Aims: To analyse the efficacy and efficiency rrt ANH as a blood conservation intervention in patients undergoing femoro-distal vascular surgery for critical limb ischaemia. Fourty patients, 26 men and 14 women, with a median age of 68 years, undergoing elective femoro-distal bypass for chronic critical ischaemia were studied prospectively. The volume of blood collected was: Blood volume removed = patient blood vtriume x (initial haematocrit - final haematocrit)/(average haematocrit). Results: Twenty-five patients (62.S%) were suitable for ANH, 1.5 patients were excluded because of poor ventricular function, anaemia or renal disease. Following the induction of anaesthesia, six of the patients required crystalloid and colloid, reducing their baematocrit to 35% before surgery. Median intraoperative blood loss was I I.50 ml, with the median volume of autologous blood collected being 1040ml (range, 400-1400ml). Eleven of the 2.5 patients (44%) had less than 65Oml of surgical blood loss and would have avoided homologous blood transfusion (HBT) without the use of ANH. Two of the patients lost > 2,SOOml of blood and could not avoid HBT through ANH due to the size of the haemorrhage. In six of the patients there was moderate blood loss (950-1400 ml), with two of these patients requiring transfusion because of mild symptomatic anaemia (haemoglobin 9.3 and 8.8 g/dL). Four patients avoided exposure to HBT, with the volume of intraoperative red blood cefls saved being 11Sml. Conclusion: Acute normovolaemic haemodilutron remains in evolution and as a single blood conservation intervention contributes only modestly to blood conservti~tion
45