Performance evaluation results of the CRI harvester.
\r\n\tThis book discusses the anatomy and pathophysiological characteristics of the biliary tract, the latest progress in the treatment of different diseases of the biliary tract, and the management of complications. We hope that this book will provide clinicians with evidence for clinical decision-making and provide scientists with a comprehensive overview of current developments in this vital area.
",isbn:"978-1-80356-699-3",printIsbn:"978-1-80356-698-6",pdfIsbn:"978-1-80356-700-6",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,isNomenclature:!1,hash:"75ea7752fb410b6d399b549bb66e9b58",bookSignature:"Prof. Qiang Yan and Dr. Huaping Shen",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11852.jpg",keywords:"Physiological Anatomy, Pathophysiology, Choledochal Cyst, Bile Duct Stone, Inflammation, Obstructive Jaundice, Gallbladder Carcinoma, Cholangiocarcinoma, Diagnosis, Therapeutics, Surgical Treatment, Management of Complications",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 23rd 2022",dateEndSecondStepPublish:"April 20th 2022",dateEndThirdStepPublish:"June 19th 2022",dateEndFourthStepPublish:"September 7th 2022",dateEndFifthStepPublish:"November 6th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Medical doctor, adjunct professor, and FACS, Chairman of Department of General Surgery at Zhejiang University Huzhou Hospital and Director of Department of Hepatopancreatic and Biliary Surgery and Department of Surgery Teaching and Research.",coeditorOneBiosketch:"Associate chief of the Department of Hepatopancreatic & Biliary (HPB) Surgery, Zhejiang University Huzhou Hospital who has been engaged in hepatobiliary and pancreatic surgery for 9 years, and is an expert in diagnosis and treatments of diseases in hepatobiliary and pancreatic fields.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"247970",title:"Prof.",name:"Qiang",middleName:null,surname:"Yan",slug:"qiang-yan",fullName:"Qiang Yan",profilePictureURL:"https://mts.intechopen.com/storage/users/247970/images/system/247970.png",biography:"Qiang Yan, MD, is a master’s supervisor, adjunct professor, and Fellow of the American College of Surgeons (FACS). He is the chairman of the Department of General Surgery and the director of the Department of Hepatopancreatic and Biliary Surgery and Department of Surgery Teaching and Research, Zhejiang University Huzhou Hospital.\nDr. Yan is a member of the Committees of Biliary Surgeons, Department of Surgeons and Hepatobiliary Minimal of Non-invasive Surgery, Chinese Medical Doctor Association, and many other academic associations. He is also a special member of the editorial committees of the Chinese Journal of General Surgery, Liver Cancer, and Chinese Journal of Clinicians. He is a participant in the High-Level Talents of Zhejiang Medicine and Zhejiang Province 151 Talents. Dr. Yan completed advanced studies in hepatobiliary pancreatic surgery at Stanford University Medical Center, California, and University Hospital Regensburg, Germany. He has more than thirty high-quality papers to his credit.",institutionString:"Huzhou Central Hospital",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"3",institution:{name:"Zhejiang University",institutionURL:null,country:{name:"China"}}}],coeditorOne:{id:"344080",title:"Dr.",name:"Huaping",middleName:null,surname:"Shen",slug:"huaping-shen",fullName:"Huaping Shen",profilePictureURL:"https://mts.intechopen.com/storage/users/344080/images/system/344080.png",biography:"Huaping Shen is an associate chief of the Department of Hepatopancreatic and Biliary (HPB) Surgery, Zhejiang University Huzhou Hospital. He has been engaged in hepatobiliary and pancreatic surgery for 10 years and is an expert in diagnosis and treatment of hepatobiliary and pancreatic diseases. 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From chapter submission and review to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"57918",title:"Review of Various Harvesting Options for Cassava",doi:"10.5772/intechopen.71350",slug:"review-of-various-harvesting-options-for-cassava",body:'\nCassava has become an important food security and the world’s third most important crop. The crop is an essential source of food and income throughout the tropics providing livelihood for countless farmers, processors and traders worldwide. Almost 60 percent of world production is concentrated in five countries Nigeria, Brazil, Thailand, Indonesia and the Congo Democratic Republic [1]. In Africa, cassava is the single most important source of dietary energy for a large proportion of the population living in the tropical areas [2]. According to Tufan [3], no other continent depends on cassava to feed as many people as does Africa, where over 500 million people consume it daily.
\nHarvesting is one of the serious bottlenecks in the cassava production value chain. Manual harvesting is slow and associated with drudgery and high root damage, especially under arid conditions [4]. This situation tends to increase the total cost of production because more farm hands are usually required to harvest in order to meet industrial and local demands coupled with an increase in cassava prices on the market.
\nOver the years, various mechanised harvesting options have been developed for use in different parts of the world to overcome these challenges. Earlier attempts at mechanising cassava harvesting have been challenged mainly by inappropriate method of planting, field topography and scale of cultivation. A review of various harvesting options for cassava is crucial to ensure proper adaption and adoption of improved harvesting methods applicable to farmers from different parts of the globe.
\nThe most difficult operation in cassava production is harvesting [5]. This is so because cassava is a highly perishable crop and begins to deteriorate as early as 1–3 days after harvest. It is therefore important to harvest cassava at the right time and in the proper manner. Harvesting too early results in low yield and poor eating quality; on the other hand, when the roots are left too long in the soil, the central portion becomes woody and inedible. It also ties the land unnecessarily to one crop whilst exposing the roots to pests. Cassava is ready for harvest as soon as there are storage roots large enough to meet the requirements of the consumer, starting from 6 to 7 months after planting (MAP), especially for most of the new cassava cultivars [6]. Matured roots are clustered around the base of the plant and extend about 60 cm on all sides. It is for these roots, which contain from 15–40% starch that the crop is cultivated.
\nUnder the most favourable conditions, yields of fresh roots can reach 90 t/ha while average world yields from mostly subsistence agricultural systems are 10 t/ha [7]. Cassava is traditionally harvested by hand lifting the lower part of stem and pulling the roots out of the ground, then removing them from the base of the plant by hand. The upper parts of the stems with the leaves are usually removed before harvest. Levers and ropes can be used to assist harvesting. A mechanical harvester can also be used. Mechanical harvesters, like those developed in Brazil would grab onto the stem and lift the roots from the ground [8]. Harvesting cassava during relatively dry weather is the best since the soil does not stick to the harvesting implement or roots easily [9].
\nMechanisation in terms of harvesting, like most of the other root crops, is still in the development stage with very few commercial technologies in existence. Development of labour-saving technology for cassava harvesting has become the most critical challenge in the cassava transformation worldwide. Earlier attempts at mechanised harvesting have been affected by constraints such as soil characteristics, nature and size of tubers, depth and width of cluster, and bond between tubers and the soil, leading to high tuber damage. Amponsah et al. [10] stated that farm size and level of root tuber breakage are critical factors that are considered in the selection and adoption of any type of cassava harvesting method. There are basically three cassava harvesting options available to farmers across the globe; manual, semi-manual and mechanised.
\nThis is the traditional method of harvesting cassava using the bare hands with or without the use of indigenous tools such as hoe, cutlass, mattock, earth chisel etc. Usually, these tools are used to dig round the standing stem to facilitate the pulling of the roots from the soil before detaching the uprooted roots from the base of the plant. Figure 1 shows various manual cassava harvesting options.
\nDifferent manual harvesting options using a hoe (a), bare hands (b), mattock (c), machete (d) and earth chisel (e).
Harvesting cassava manually is laborious especially during the dry season when soil moisture is at lower levels. According to Nweke et al. [11], manual harvesting requires about 22–62 man days per hectare.
\nManual lifting of cassava with the bare hands requires about 23–47 man h/ha as compared to the use of a hoe which requires between 42 to 51 man h/ha [4]. The use of manual harvesting tools is preferable on relatively dryer (hard) soils, whereas manual uprooting technique is best suited for soils with relatively higher moisture content. However, best efficiency of manual harvesting is achieved when the upper cassava plant biomass is removed or coppiced before harvesting.
\nSemi-manual harvesters are harvesting aids that usually adopt the lever principle to ensure that little human effort is used in uprooting the cassava. Various harvesting aids can be found in different cassava growing regions across the globe.
\nThe CRI harvester (Figure 2) was developed at the CSIR-Crops Research Institute (CRI), Kumasi with the intention of decreasing the toil farmers go through as a result of excessive waist bending when using existing manual harvesting tools. The original design, adopted from the International Institute of Tropical Agriculture (IITA) in Nigeria, has undergone several design modifications to ensure best efficiency is achieved using the implement [12].
\nThe CRI harvester in use.
The CRI harvester operates according to the “grip and lift” principle and is made up of a frame with a steel plate to which an immovable griping jaw is fixed. A chisel tip serves as a base which allows for lifting of cassava roots from the soil when using the gripping jaw. It also facilitates the uprooting of cassava especially in hard and dry soils by employing the “dig and lift” principle. This comes in handy where the “grip and lift” principle fails. The harvester has a mechanical advantage of 4.5 when operating under the second class lever principle. With a total weight of 5 kg, even women and children can easily operate and use the tool for harvesting cassava.
\nField assessment of the performance of the CRI harvester showed that it is faster harvesting vertically planted cassava though cassava planted slanted offered the least root tuber breakage and drudgery, regardless of cassava variety. Table 1 presents some performance evaluation results of the CRI harvester according to Amponsah et al. [10].
\nParameter | \nValue | \n
---|---|
Field capacity (man h/ha) | \n49.9–156 | \n
Root tuber breakage (%) | \n4.3–19.6 | \n
Energy expenditure (W) | \n470.3–773.7 | \n
Performance evaluation results of the CRI harvester.
The National Centre for Agricultural Mechanisation (NCAM) in Nigeria also developed and commercialised a semi-mechanised cassava lifter/harvester [13]. The NCAM harvester (Figure 3), consists of a frame to which a footboard and immovable griping jaws are attached and a lever (handle) which is hinged to the frame. Both implements have been tested to harvest up to 200 plants per man-hour and can be classified under semi-manual types of cassava harvesters since they require some degree of human effort to be able to use them effectively for harvesting compared to the mechanised types.
\nThe NCAM harvester.
The CTCRI cassava harvester (Figure 4) was developed at the Central Tuber Crops Research Institute (CTCRI), Kerala, India with the aim of reducing the level of drudgery associated with the use of other manual cassava harvesting tools. The tool, with a mechanical advantage of 3.4 and total weight is 8 kg, operates on the second class lever principle and has a self-tightening mechanism used to grip the cassava stem. The height of the fulcrum at the far end of the lever can be adjusted to facilitate uprooting of cassava plants raised on different land preparation methods (flat, mounds or ridges). The CTCRI harvester requires about 16–40 man h/ha and uses 547–639 W of physical energy during cassava harvesting [4].
\nThe CTCRI semi-manual harvester.
Harvesting cassava mechanically involves the use of a harvesting implement integrally hitched to a tractor to dig out the cassava roots. Manual effort may be needed after cassava uprooting to collect and detach the cassava root tubers. The following field requirements/conditions are also necessary to allow for an optimum mechanical cassava harvesting operation: a field free from hidden obstructions (rocks, roots, stumps etc. down to 40 cm deep) of sizes that can interfere with lifting the tubers; good weed control as weeds block the lifters; Cutting down (coppicing) the cassava plant to a stalk level of about 30 cm prior to harvesting to allow the tractor operator to work in a regular manner. Ridge cultivation of cassava in rows is preferred to facilitate better orientation of stems for tractor operation during harvest.
\nMechanised harvesters can be classified into semi-mechanised and fully mechanised. Whereas all processes from digging of roots, lifting of uprooted roots onto soil surface to transport are mechanically done in fully mechanised harvesters, only the root digging process is mechanised in the case of semi-mechanised harvesters.
\nThe digging, lifting and transport of cassava root cluster into a windrow have been demonstrated under Ghanaian condition using a prototype fully mechanised cassava harvester developed at the Leipzig University, Germany [14]. The harvester reduces the heavy physical work involved in manual cassava harvesting using the hoe and cutlass, especially in the dry season. Design goals for the Leipzig mechanical harvester prototype were, cutting of soil, digging of soil, raising of soil containing the cassava root cluster, transporting the cassava root cluster into windrow behind the tractor to ease manual tuber detachment from stem, reducing the number of moving parts, improvement in the flow of soil and residue to prevent blockade and fuel conservation during seedbed preparation for next cropping. The structural arrangement of the harvester consists of a digging share rising into a conical shaped mouldboard between two legs, a frame of digging tool, a stem guiding device, a frame for stem pulling device and hydraulically operated belt pulling elements. The 1 m wide harvester which is a fully mounted implement operates according to the “dig and pull” principle. It cuts and loosens the growth area of the root cluster by two vertical beams, and a share attached to the base plate.
\nFigure 5 shows the Leipzig mechanical harvester prototype. The cassava root cluster is loosened carefully, lifted to about 20 cm and delivered to the transport unit made of two belts and a set of steel/plastic press rollers. The windrowed root clusters are then detached with hand or cutlass and finally collected. The harvesting process produces a well pulverised field, thus effectively eliminating the tedious and energy intensive conventional primary tillage operation. Additional advantages for using the harvester include, lowering of the total production cost, increase in labour productivity and considerable decrease in harvesting losses and root damage.
\nThe Leipzig mechanical cassava harvester.
The harvester was introduced into Ghana in 1991. However, field testing only started in 1993. As a result, it could not be evaluated extensively and further investigation on the performance of the harvester was expected to be conducted in other agro-ecological zones of the country. Table 2 shows the summarised performance evaluation results after testing the Leipzig mechanical cassava harvester prototype on the TMS 30572 cassava variety for some agro-ecological zones in Ghana according to Bobobee et al. [14].
\nParameter | \nValue | \n
---|---|
Draft requirement (kN) | \n11.94–16.2 | \n
Working depth (cm) | \n25 | \n
Soil moisture content (% d.b.) | \n3.5–5.8 | \n
Soil bulk density (g/cm3) | \n1.82 | \n
Cone Index (MPa) | \n0.88–2.5 | \n
Average fuel consumption (l/ha) | \n40.3 | \n
Working speed (km/h) | \n2.4–4.1 | \n
Field capacity (ha/h) | \n0.25–0.38 | \n
Tractor power requirement (kW) | \n55–80 | \n
Performance evaluation results for the Leipzig mechanical cassava harvester.
The Latin American and Caribbean Consortium to Support Cassava Research and Development (CLAYUCA) conducted some research on the adaptation and evaluation of semi-mechanised harvesting systems for cassava in Columbia. This evaluation process became important due to the excessive cost of manual harvesting. A semi-mechanised cassava harvester prototype developed in Brazil was imported and its performance was evaluated under specific conditions in the main cassava growing regions of Columbia [15].
\nThe prototype harvester has a front cutting disk that facilitated the harvesting process and was able to work even on dry soils where manual harvesting was not possible [15]. For a smooth operation, however, it required the cutting of cassava stems prior to harvesting to a height of 20–40 cm. Figure 6 shows the CLAYUCA mechanised harvester model P600.
\nThe CLAYUCA mechanised harvester model P600.
The technical and performance characteristics of the CLAYUCA harvester prototype is presented in Table 3.
\nParameter | \nValue | \n
---|---|
Working width (m) | \n2.4 | \n
Working depth (cm) | \n30–40 | \n
Harvester weight (kg) | \n200 | \n
Average working speed (km/h) | \n7 | \n
Field capacity (ha/h) | \n0.63–1.1 | \n
Tractor power requirement (kW) | \n67 | \n
Performance evaluation results for the CLAYUCA cassava harvester.
The main effect of the use of the harvester is the improvement in the efficiency of labour. Under the traditional system, in which the cassava roots are harvested by hand, a good performance for a worker is around 500 kg roots/day [15]. With the use of the harvester Model P600, CLAYUCA has been able to measure the harvest of around 1100 kg roots/day. In more developed cassava producing systems, such as those found in South Brazil, a good performance using mechanical harvesters is around 1500 kg roots harvested/day. The economic importance of the use of mechanical harvesters is in the reduction in the number of workers that are needed to harvest a cassava field. Ospina et al. [16] reiterated that the introduction of the CLAYUCA harvester prototype allows a reduction of 53% in labour cost for harvesting resulting in a reduction of 43% of the cost of harvest, and a further reduction of 12% of the total production costs.
\nAccording to Oni [17], the National Centre for Agricultural Mechanisation (NCAM) in Nigeria developed a mechanised cassava harvester which was adapted for use in most farming communities in Nigeria. The harvester consists of a combination of a standard chisel plough preceding a serrated disc plough, both mounted on a tractor-drawn toolbar. The harvester has a field capacity of 0.8–1.2 ha/h. Figure 7 shows the NCAM tractor-drawn cassava harvester.
\nNCAM semi-mechanised cassava harvester [
Odigboh and Moreira [18] reported that mechanisation of cassava harvesting has attracted a great deal of research attention but with very modest successes achieved. Catalogues of agricultural machines produced by Brazilian manufacturers contain no cassava harvesters. What exists in Brazil, as elsewhere in the world, are few models of cassava harvesting aids in limited production and on trial use by a few farmers. Also, there are many problems associated with cassava harvesting. Some of these problems are as a result of the serious difficulties created by the random growth patterns of the roots and the equally random branching of the stems. In addition, cassava does not have a specific harvesting season. According to Odigboh and Moreira [18], an effective harvester must therefore be able to operate in the parched hard soils of the dry season, the drenched muddy soils of the tropical rainy season, as well as in soils the consistencies of which vary between those two extremes. Agbetoye et al. (2000) reported that most of the experimental cassava harvesters in literature are based on the elevator digger principle whereby the share cuts through the soil 0.3–0.4 m deep and 0.7–0.8 m wide and handling about 0.23 m3 or about 500 kg of soil to harvest a plant. All these unique characteristics must be appropriately considered to design an effective harvester for cassava.
\nThe TEK mechanical cassava harvester was developed and manufactured at the Department of Agricultural and Biosystems Engineering, Kwame Nkrumah University Science and Technology, Kumasi. This harvester was developed after the Leipzig to suit local prevailing field conditions. However, unlike the Leipzig which was fully mounted with a hydraulic transport system, the TEK harvester did not have that. One thing that was evident during the field evaluation of the Leipzig was that most tractors found on farmer’s fields were not able to support the hydraulic system of the harvester. This necessitated the disabling of the hydraulic transport system in the design of the TEK mechanised harvester. The TEK cassava harvester (Figure 8) basically has the following parts; digger, shakers consisting of a slatted mould conical mouldboard, the linkage points and the vertical support.
\nThe TEK mechanical cassava harvester.
The TEK mechanical harvester, though semi-mechanised, is a fully mounted implement which operates according to the ‘dig and pull’ principle. Having met the necessary field conditions prior to harvest, the implement hitched to the tractor is gently lowered to set the required depth of penetration (depending on root depth of the cassava variety to be harvested). As the digger goes through the soil, the roots are brought onto the surface for collection and detachment facilitated by the inclination of the slatted conical mouldboard (B). Due to the large quantity of soil and trash that is dug out together with the roots, there is often an increase in the resistance behind the tractor leading to increased fuel consumption. When the soil is moist and sticky, the slatted conical mouldboard serves as shakers to sieve the soil clods and reduce adhesion. This helps to accelerate the harvesting process resulting in an increase in the efficiency of the tractor and harvesting implement. Table 4 presents the field evaluation results of the TEK mechanised harvester.
\nParameter | \nValue | \n
---|---|
Working width (m) | \n1 | \n
Working depth (cm) | \n23–29 | \n
Harvester weight (kg) | \n300 | \n
Average working speed (km/h) | \n5 | \n
Field capacity (ha/h) | \n0.4–0.52 | \n
Draft power requirement (kN) | \n10.33 | \n
Performance evaluation results for the TEK cassava harvester.
An added advantage after mechanical harvesting of cassava is that the land is ploughed for subsequent crop establishment. Only harrowing and ridging may be needed, thus total cost of production for the subsequent season is reduced. Careless use of machinery for harvesting however, can damage tubers, resulting in rapid deterioration that will lower the value of the end product.
\nSince 1956 Gibbon’s first ASD closure using a heart-lung machine, cardiac surgery has made great strides. However, bleeding is still the fearful dream of surgeons. According to the World Bank, in upper-middle-income countries as in Turkey, certain restrictions are compulsorily brought to health-care costs. In this case, about 2000 US dollars is paid for open heart surgery in the social security system in Turkey. However, in today’s conditions, the costs have exceeded the fee paid by the social security institution, and in this case, public hospitals continue to provide health-care services despite the loss. On the other hand, the society is aging, and compulsorily, the riskier patients are being operated, but the prolonged length of intensive care and the hospital stay of these patients increase the costs. In this case, the solution is to provide services with serious sacrifices on the basis of health care providers and institutions, especially surgeons. The main principle here should be to evaluate the patient well before the operation and to gain the patient during the operation and to pass through the intensive care period without any problem. This can only be the result of achieving good cardiac functions and hemostasis with a successful operation.
Cardiac surgery is associated with an invasive procedure, serious anticoagulation requirement and perioperative blood loss due to cardiopulmonary bypass and accordingly high-probability allogenic blood transfusion. Risk factors:
Hemodilution (prime of cardiopulmonary bypass, cardioplegia, and perioperative fluids)
Coagulation and fibrinolysis activation
A consumptive coagulopathy
Anticoagulation with unfractionated heparin
Other physiological disorders such as hypothermia, hypocalcemia, academia [1].
In cardiac surgery, patient blood management (PBM) contributes to the maintenance of perioperative hemostasis, which reduces the requirement for blood transfusion [2]. Both the use of high amounts of blood products and the requirement for reoperation are linked to undesirable clinical outcomes [3, 4]. The use of one or two units of packed red blood cells (PRBCs) in coronary artery bypass grafting (CABG) patients is associated with increased cost as well as dramatic mortality and morbidity [5]. However, it is unclear whether these complications are independent predictors of outcome or a sign of the complexity and complications of surgery [2]. In any case, re-exploration due to bleeding and tamponade is a strong predictor of early postoperative mortality and morbidity. It should be kept in mind that not performing re-exploration when it is required brings about more serious consequences. There is, however, no general consensus on when exploration for postoperative bleeding is indicated, and surgical practice varies considerably in this regard [6]. There may be limited resources to achieve hemostasis, as well as to detect cardiac tamponade or when the patient will be re-explored for bleeding. The cardiac surgeon should be skeptical about this and use all arguments in his or her hand. Hemodynamic deterioration, decrease in urine output, decreasing Hb levels while increasing base gap and lactate levels in blood gas analysis, deterioration in general condition of the patient and chest pain, and most importantly enlarged mediastinum on chest radiogram, hematoma accumulation in lung fields are the most important manifestations of cardiac tamponade and bleeding. The patient should be re-explored without hesitation. It should not be compromised on surgical site cleaning and antisepsis in postoperative cardiac tamponade patients, who are usually opened urgently with impaired hemodynamics. After the urgent removal of hematomas, anastomoses and cardiotomies should be checked first. After bleeding control, the patency of drainage tubes should be checked and they should be replaced, if necessary.
Numerous factors such as advanced age, preoperative dual antiplatelet therapy (DAPT), platelet dysfunction, preoperative anemia, small body surface area, female gender, non-elective surgery, non-isolated surgery, non-CABG surgery, and redo surgery are associated with increased bleeding [7, 8, 9].
A group of hemostatic agents including topical hemostats, sealants and adhesives are available to stop these bleedings. Despite these, hemostasis cannot be achieved due to the inappropriate use of hemostatic agents in 40% of surgical patients, as in the surgery of traumatic injuries [10].
Failure to adequately optimize the patient prior to surgery increases the risk of bleeding and anemia during the operation [2]. The use of routine preoperative screenings has been highly discussed in terms of its ability to identify high-risk patients for postoperative bleeding and transfusion requirements. Preoperatively determined prothrombin time or the activated partial thromboplastin time (aPTT) could not be associated with perioperative blood loss or transfusion requirements [11, 12, 13]. The most commonly identified risk factor for postoperative bleeding is a low fibrinogen level [11, 12, 14, 15, 16]. However, despite its association with bleeding, the positive predictive value of a low-fibrinogen level remains poor (positive predictive value <20%) [15]. A low platelet count (<10,010–9/L) has been associated with increased risk of transfusion, and patients with the highest postoperative blood loss volumes show the lowest platelet counts [12]. It has been shown that patients with the highest postoperative blood loss volumes show the lowest thrombin generation rates, but this test is mainly used for research purposes and is not routinely used in everyday practice [12, 17].
In preoperative Hb evaluations of 1388 female and 3265 male patients undergoing elective cardiac surgery, it was found that borderline anemia (defined as the hemoglobin concentration of 120–129 g L−1) was more common in the female group and about one-third of the patients were in this range. These women had increased morbidity, reflected by increased red cell transfusion and prolonged hospital stay compared with non-anemic women (Hb >130 g L−1). It was also found that these women received more erythrocyte transfusion than male patients [18].
Acetylsalicylic acid (ASA) is one of the cornerstones for the treatment of acute and chronic cardiovascular disease. Primary and secondary prevention with ASA has been shown to reduce mortality, myocardial infarction (MI) and stroke but to increase the risk of bleeding complications [19]. All patients requiring emergency or elective CABG are treated with ASA. A meta-analysis showed that ASA reduced the risk of perioperative MI [odds ratio (OR) 0.56, 95% confidence interval (CI) 0.33–0.96] but not the risk of death (OR 1.16, 95% CI 0.42–3.22). Twelve-hour blood loss, PRBC transfusions and surgical re-exploration increased with ASA [20]. A large RCT compared the administration of ASA (100 mg) on the day of surgery versus placebo in patients having CABG [49]. The study showed no effect of treatment with ASA on 24-h bleeding (mean blood loss: 780 vs. 740 mL;
Given all these results, the continuation of ASA treatment in patients undergoing CABG may be reason of increasing postoperative blood loss while reducing ischemic event [2]. In patients with high probability of re-exploration such as those who refuse the blood transfusion, who will undergo non-CABG surgery, complex cases, redo operations, and those who have severe renal failure, hematologic and inherited platelet function disorders, ASA should be discontinued 5 days before surgery. Prevention of thrombotic events outweighs the risk of bleeding in other patients. Current information suggests that ASA-inhibited platelet aggregation can be reversed by platelet transfusion, which supports the continuation of ASA treatment until operation [23, 24]. Mortality rates significantly decrease in patients who are initiated on ASA in the first 48 h after CABG compared to patients who are not initiated on ASA (1.3 vs. 4%
The administration of DAPT, a P2Y12—receptor antagonist (clopidogrel, ticagrelor and prasugrel), in combination with ASA significantly reduces the risk of thrombotic complications in acute coronary syndromes compared to ASA alone [26]. Compared to clopidogrel, the risk of thrombotic complications is significantly reduced by ticagrelor and prasugrel, the second generation P2Y12 antagonists, while the risk of both spontaneous and surgical bleeding increases significantly [27]. Recently, cangrelor, a new reversible intravenous P2Y12 inhibitor with an ultrashort half-life to offset the effect after discontinuation, was introduced [28].
Today, glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors (eptifibatide, tirofiban and abciximab) are almost exclusively used in conjunction with percutaneous coronary interventions, but may also be used for bridging high-risk patients on oral P2Y12 inhibitors to surgery [29, 30]. The discontinuation times of these drugs before surgery are based on pharmacokinetic assumptions. The recovery of platelet functions is obtained within 24–48 h for abciximab and 4–8 h for eptifibatide and tirofiban [31]. In a small retrospective study, tirofiban-treated patients having CABG showed more bleeding than patients who were not treated with tirofiban, but there was no difference between different discontinuation times [32]. Discontinuation of GPIIb/IIIa inhibitor at least 4 h before surgery should be considered to minimize the risk of postoperative bleeding.
As enoxaparin and fondaparinux, LMWH mainly functions by inhibiting factor Xa and reaches plasma peak levels 3–4 h after the administration. In patients with normal renal function, their half-life is 5 h. Their anticoagulant effects can be monitored by measuring plasma anti-FXa activities. LMWH-induced bleeding may be treated with protamine, but this therapy does not completely reverse the anticoagulant effect of LMWH [2].
Vitamin K antagonists (VKAs) are commonly used to prevent and treat thromboembolism in cases of atrial fibrillation, venous thromboembolic disease and mechanical heart valve. They are monitored by the international normalized ratio (INR) and prothrombin time. They should be stopped 3–5 days before surgery to obtain an INR <1.5. For emergency surgeries, their effects are completely reversed by prothrombin complex concentrate. Bridging non-cardiac surgery patients who are taking VKA with a full therapeutic dose of LMWH after surgery are associated with increased risk of bleeding but not with a significant reduction in thrombotic events [33]. Elective cardiac surgery is not recommended unless the INR value falls below 1.5. In cases where surgery cannot be postponed, coagulation factors should be used to antagonize the effects [2].
Direct oral anticoagulants (DOACs) is a group of drugs consisting of dabigatran, a direct thrombin inhibitor, and rivaroxaban, apixaban and edoxaban, oral FXa inhibitors, and novel formulations under development. They are increasingly used as an alternative anticoagulation strategy for VKAs [2]. Since emergency surgery in patients under dabigatran treatment has been associated with severe or even fatal bleeding, it is recommended that these drugs be discontinued 48 h before cardiac surgery [34, 35, 36]. The half-life of DOACs may be prolonged in the case of impaired renal function. For emergency reversal of dabigatran, the newly released antidote (idarucizumab) can be used in the pre- and post-operative settings. Treatment of postoperative FXa-related bleeding includes PCC, activated PCC (FEIBAV R, Shire US Inc., Lexington, MA, USA) and recombinant activated factor VII (rFVIIa), since no specific antidote is approved at the moment [2].
According to the EACTS/EACTA recommendations, ASA should be continued in the preoperative period in patients scheduled for CABG (Class IIa, Level C). ASA should be discontinued 5 days in advance (Class IIa, Level C) in patients with a high risk of bleeding, refusing the blood transfusion, or undergoing cardiac surgery other than CABG. If there is no severe bleeding in the first 24 h postoperatively, ASA should be initiated in isolated CABG patients (Class I, level B). If CABG is not urgent, ticagrelor should be discontinued 3 days, clopidogrel 7 days and prasugrel should be discontinued 5 days before surgery in patients taking DAPT (Class IIa, Level B). GPIIb/IIIa inhibitors should be discontinued 4 h before surgery (Class IIa, Level B). GP IIb/IIIa inhibitors should be discontinued 4 h before surgery (Class I, Level C). In order to reduce the risk of bleeding, oral anticoagulants should be discontinued only in patients with a high risk of thrombosis and it should be continued with UFH/LMWH (Class I, Level B). LMWHs should be discontinued 12 h before and fondaparinux before should be discontinued 24 h before (Class I, Level B). In the use of VKAs, surgery should be performed after the INR value reduces below 1.5 (Class IIa, Level C). DOACs should be discontinued 48 h before cardiac surgery (Class IIa, Level C).
Bleeding is the most important complication of surgery, which increases mortality and morbidity rates [37, 38, 39]. Uncontrolled bleeding results in adverse clinical outcomes including anemia, hemodynamic instability, hypothermia, hypovolemia, reduced oxygen delivery to tissues, impaired visualization of the surgical site, and prolonged operative time. Surgical bleeding requires expensive blood transfusion and re-operation, in which a large amount of clinical and personnel resources is used [39]. Major bleeding is also associated with an increased risk of postoperative mortality reaching 20% in vascular surgery and 30–40% in trauma surgery [39].
Blood transfusion itself involves many risks. Transfusion-related acute lung injury, which occurs one in every 1000–5000 plasma and erythrocyte transfusions, is the leading cause of mortality and morbidity [40]. Bacterial contamination, which occurs one in every 2000–3000 platelet transfusions, is another complication of transfusion [40]. The authors have reported that the length of hospital stay is longer in patients with bleeding-related complications or more blood transfusion requirements than those without bleeding complications (10.4 vs. 4.4 days, respectively) [41].
Uncontrolled bleeding and transfusion requirement are associated with bleeding complications, resulting in a considerable amount of cost [42]. Stokes et al. also compared the total hospitalization costs for patients with bleeding-related complications or blood transfusions with those for patients without any complication and, again, noted a significant increase in costs among those with complications [41]. There are, of course, the costs of bleeding and blood and blood transfusion for all countries. In the country where I work, these costs are not as high as in the US.
It should be kept in mind that although blood transfusion is an indispensable treatment, whether clinical or economic, it is the most dangerous drug we have ever used [43].
The surgical nurse plays an important role in optimizing hemostatic applications throughout the operation. To meet the requirements for hemostasis by questioning the surgeon before and during surgery. To know the material available to meet the requirements for surgical intervention. To adjust the time required for the preparation of the necessary material during the operation and be in constant communication with the surgeon [42]. Working with a nurse experienced in cardiovascular surgery is always a significant advantage for the surgeon. In general, I trained my surgical nurses myself in private hospitals where I worked in my surgical life. Private hospitals try to minimize the number of staff in order to limit input cost due to their commercial concerns. They also prefer less educated staff. At this point, the responsibility of the surgeon increases, s/he has to perform a successful operation while continuing the training activities of the nurse. In this respect, cardiovascular surgery centers in many private, public and universities in my country train their own surgical nurses. Personally, I have also trained many nurses and even made them gain the qualifications to perform proximal anastomosis and connect prolene sutures. After a while, the surgical nurse could follow the operation, know what to be asked in advance and quickly prepare the required instrument and material. In my opinion, the most serious disadvantage of this is that you are on your own in decision making since there is no experienced assistant surgeon assisting you (Figures 1 and 2).
Saphenous vein graft anastomosis to coronary artery. Small bites from epicardial tissue with appropriate size prolene suture.
Saphenous vein graft anastomosis to coronary artery. Small clips for the small branches of the saphenous graft.
Selection of the most appropriate method for achieving hemostasis is based on correctly defining the nature and severity of the patient’s bleeding. If the patient presents with or develops uncontrolled bleeding in the operating room, first and to the extent permitted by time, a group of coagulation laboratory values (prothrombin time/international normalized ratio, activated partial thromboplastin time, complete blood count with differential and platelets, activated clotting time, fibrinogen, d-dimer and thromboelastography) should be examined [42]. In cases of unexpected or complex coagulopathy, it is necessary to get professional help from a subspecialist such as a hematologist and blood bank specialist. (While such aids actually work in intensive care follow-ups, it seems difficult for the specialist to comprehend the situation in the operation room and offer solutions in the complexity of the surgery. Therefore, the responsible surgeon must be able to master these issues and produce urgent solutions.) (Figure 3).
Here is a left mammarian artery graft anastomosis to left anterior descending artery. A small retractor used for easy visualization of the arteriotomy. Again usage of small clips. When you are performing the repair sutures to bleeding side of the anastomoses, you have to be careful and you do not need to pass the whole layers of coronary artery.
Mechanical approaches usually provide hemostasis without the need for any hemostatic product. The most basic practice is to apply compression with finger or fingers to the bleeding site. Especially in bleedings of the tissues with high pressure such as the ascending aorta, compression should absolutely be applied with finger to save time for strategies to create solutions. In fact, it is the most basic approach to be performed in the case of unexpected bleedings during a routine operation. While the surgeon is using the fingers of his/her non-dominant hand to restrict bleeding, s/he should give the surgical nurse order for repair. Here, a few simple maneuvers can be life-saving. The venous return should be reduced for lowering the pressure in the ascending aorta. Tilting the patient’s head up by operating table is simple and effective. If you fail for lowering the arterial pressure, transient inferior caval clamping before neutralization of heparin may be very helpful, especially when pulling out the aortic cannula. Another technique in old textbooks is total inflow occlusion. In this technique, it has been described that repairs are carried out in a few minutes with cross-clamps placed on both cavas. However, when removing the caval cross clamp, it should be absolutely ensured that the clamp is fully opened. Moreover, a simple approach in aortic cannulation is using teflon pledgets for outer purse-string suture.
The most basic hemostasis approach is to create a mechanical barrier. The use of a needle and suture in an appropriate size and supporting it with teflon pledgets is the most effective, simple and accurate approach. The suture material to be selected is usually prolene. In order to reduce tissue injury, the needle should be as small as possible along with fine needles, but of sufficient thickness to withstand the tension in the tissue and appropriate thickness to be securely attached. (The most important issue to be considered here is that the other hand knot should be tied tightly enough to stop bleeding and ensure tissue integrity not to allow non-dominant hand suture to loosen when making a suture. Excessively tight and hard knots may cause more severe tissue injuries and bleedings.) For sutures that will both stop bleeding and provide anastomosis, it is necessary to use stronger fibrous tissues of the patient such as the adventitia and epicardial layer (Figure 4).
Two anastomoses to LAD. There is no bleeding from anastomotic sides.
Sponges are the most commonly used inexpensive materials to stop bleeding in the operation field. They are very effective with mechanical compression, especially in oozing-type bleedings. Sponges should be intensely applied to the mediastinum after the clamps are removed and it should be waited until the end of protamine neutralization. As a result of reapplication of a clean sponge, especially after ending the heparin effect, locally contaminated sponges may give information about the site of bleeding other than providing hemostasis (Figure 5).
No bleeding from proximal anastomotic sides of sapheneous vein grafts. Also adventitial tissue bites performed. Sponges under the retractor compress the cavernous tissue of sternum.
Hemoclips are an effective and fast method especially for harvesting arterial grafts and ligating small vessels. However, it is necessary to pay particular attention to the selection of hemoclips. Especially, large hemoclips may damage a small vessel and increase bleeding as a result of tissue injury. It is important to remember that these hemoclips may drop when applying sponge to the operation site or performing bleeding control. Therefore, ligation or suturing may be more effective in appropriate cases.
Other mechanical solutions include electrosurgery, laser, radio-frequency energy, argon beam coagulation, ultrasonic scalpel or ultrasonic surgical aspirator use. When using electrocautery, it is beneficial to use it at the lowest energy and appropriate program that can do our work. It should be kept in mind that especially high energy will increase tissue injury.
Pharmacological strategies for blood preservation are also an important tool in the arsenal of the surgical team since these agents alleviate the activation of the hemostatic system without the clinical and economic consequences associated with transfusion [44]. Pharmacological agents may be of some benefit in diffuse surgical bleedings or in those with a hemostatic defect. These agents may be used in combination with surgical hemostatic agents. These agents are recombinant factor VIIa, desamino-d-arginine vasopressin, and antifibrinolytics (e.g., epsilon aminocaproic acid (EACA), tranexamic acid (TXA)) [44, 45]. The recombinant factor VIIa activates platelets to increase thrombin production. It is used in trauma and surgical refractory bleeding. It acts quickly and is quite expensive. Although it is not a preferred product in our country, we prefer fresh frozen plasma (FFP) in such cases. Desmopressin acetate (vasopressin) factor VIII is a selective V2 agonist that causes the release of von Willebrand factor and tissue plasminogen activator. It is used in platelet dysfunction. It acts in a short time, tachyphylaxis and repeated doses increase the risk of bleeding. The parenteral form is not available in Turkey, the nasal spray form is not very effective.
Antifibrinolytic therapy reduces bleeding, the use of blood and blood products and reoperations due to bleeding [2]. This group includes tranexamic acid (TXA), aprotinin and EACA. The sale of aprotinin has stopped in some countries, especially because it increases mortality rates.
The Aspirin and Tranexamic Acid for Coronary Artery Surgery (ATACAS) randomized controlled trial compared TXA with placebo in patients undergoing CABG surgery and demonstrated a reduction in the risk for reoperation due to major hemorrhage (RR 0.36, 95% CI 0.21–0.62;
Tranexamic acid is also an antifibrinolytic agent that we use frequently. It inhibits plasmin and plasminogen proteases and reduces surgical bleeding. It may cause thrombosis and hypotension.
These blood products include FFP, platelets, prothrombin complex concentrate, cryoprecipitate, and whole blood. Thrombocytes in plasma are indicated when platelet levels are less than 50 × 109/L. It contains cryoprecipitate factor VIII, von Willebrand factor, fibrinogen and fibronectin, and is indicated when the patient’s fibrinogen is less than 100 mg/mL or when the patient has von Willebrand factor deficiency [49]. FFP contains coagulation factors and fibrinogen in variable amounts, while prothrombin complex concentrate contains factors II, VII, IX, and X and prothrombin, as well as proteins in variable amounts. Both FFP and prothrombin complex concentrate are indicated when a surgical patient who is bleeding has an international normalized ratio greater than 1.5 [49].
FFP is obtained from the plasma of volunteer blood donors containing coagulation factors and other proteins. An increasing number of countries use pooled plasma. Pooled plasma contains plasma from multiple donors and is inactivated for viruses with a lower risk of transfusion-induced lung injury [2]. The largest body of evidence is gathered on the prophylactic administration of FFP to patients without a diagnosed coagulopathy and is summarized in a Cochrane review and three other systematic reviews [50, 51, 52, 53]. In patients undergoing cardiac surgery, there was no difference in blood loss and allogeneic blood transfusion requirement when patients intraoperatively receiving FFP were compared with the control group. The RCTs included were limited by small sample sizes and divergent doses of FFP [51, 52, 53]. It has also been shown that FFP is not effective in 24-h blood loss in patients with diagnosed coagulopathy or in the reversal of oral anticoagulation when it is used at a therapeutic dose [51, 53]. In summary, FFP might be used to reverse the action of oral anticoagulation or in the case of persistent perioperative bleeding, but there is no evidence that prophylactic or therapeutic FFP transfusions reduce blood loss after cardiac surgery [2].
Topical hemostatic agents consisting of mechanical, active, flowable, and fibrin sealants provide hemostasis by forming blood clots [54, 55, 56]. Agents in this class vary greatly with respect to safety, efficacy, usability, and cost. An appropriate agent should be selected for each clinical situation.
It consists of combining hemostatic agent and sponge, foam or pad absorbable material. They create a surface against blood flow where blood clots can form [56]. Common mechanical hemostatic agents include porcine gelatin products (e.g., Gelfoam®, Gelfoam Plus®, Surgifoam®), cellulose products (e.g., Surgicel®, Surgicel Fibrillar™, Surgicel Nu-Knit®), bovine collagen products (e.g., Avitene™ sheets, Avitene Ultrafoam™ collagen sponges), and polysaccharide spheres (e.g., Arísta®, Hemostase MPH®, Vitasure™) [54, 55, 56]. They are effective in minimal bleedings and when the coagulation cascade is normal. They are easy to use since they are ready-to-use packaged products, do not require special preparation, are easy to store and act by direct application to the bleeding site [56]. It is important to slightly irrigate before removal not to take clotting beneath them. These products are relatively inexpensive and well-tolerated, while swelling and increased risk of infection are possible side effects [44]. They are usually used as the initial response to bleeding [56]. Cellulose-containing products such as Surgicel are commonly used since they are cheap and easily accessible. Because these products are absorbable, they are easily applied to the bleeding site. They should be used carefully and practically, as they easily disintegrate by swelling when they get wet or come into contact with blood. Although they can be used directly, we use it by mixing with a small amount of cyanoacrylate in a tablespoon for bleedings of difficult to reach points such as the posterior of the aortic root during the operation. In this application, the most important point to consider is to pay attention to the amount of cyanoacrylate used, as it may cause tissue injury. It quickly hardens in a short time when mixed with the polymerized cyanoacrylate cellulose. Therefore, it should be applied quickly and practically. However, it is not effective in severe bleeding since it does not adhere to the tissue. It can be applied hypotensively or by applying compressed medical air to the point of bleeding while the blood is removed. Cyanoacrylate products prepared for medical purpose can also be used, which should be preferred. In emergency situations, products prepared as adhesive can be used as well.
The tablespoon is a simple but effective tool when necessary that should be included in the open heart surgery set. It can be very helpful ascending aorta bleedings especially in proximal anastomosis after weaning from CPB, it gives repair chance to surgeon by keeping it like a shed 4–5 cm distance above. Also helpful for delivering hemostatic powders to bleeding site. It can be herbal powders sold for this purpose, as well as crystallized vancomycin powder, which we usually use. It can also be helpful in the excision of brittle tissues such as fluid or myxoma.
As a cardiac surgeon, I think the most important side effect of such products is that they offer the surgeon extra confidence. The surgeon must provide the patient with hemostasis during the operation, otherwise the drainage ongoing in the intensive care process brings about serious consequences. For this, the surgeon should repeatedly check anastomoses, cardiotomies, surround tissues, especially the sternotomy and stop bleeding with appropriate sutures and ligations.
By converting fibrinogen to fibrin, active hemostats—namely the three topical thrombin products: bovine thrombin (Thrombin-JMI®), pooled human plasma thrombin (Evithrom®), and recombinant thrombin(Recothrom®)—facilitate clot formation at the bleeding site [55, 56, 57]. Active hemostatic agents are the most commonly used adjunctive hemostatic therapies in the surgical setting and conservative estimates show that more than one million patients are treated with topical thrombin administration annually in the United States [58].
While all three preparations are applied to the locally bleeding area or larger areas in diffuse bleedings in the form of spray, they also require certain preparations before application. For example, bovine and recombinant thrombin are stored in powder form at room temperature and prepared with certain special liquids before use. Pooled human thrombin is available in a liquid form and can be stored in a refrigerator for as long as 1 month [56]. In such cases, it should be used together with active hemostatic agents such as absorbable gelatin sponge or powder, since thrombin administered in the presence of active bleeding can be rapidly irrigated. IV should not be used since it may cause a major anaphylactic reaction [59, 60, 61].
As the results showed similar efficacy in all three products, health care providers canalized their next assessment to select the most appropriate agent for the clinical situation. For example, although there are clinical studies showing similar safe use of all these products, bovine thrombin administration has been associated with antibody formation that can lead to immune-mediated coagulopathy and death, which is why this product carries a black box warning [59, 62]. These preparations are not available in Turkey. Even if they are, social security providers do not cover them since they are very expensive.
These products (e.g., Surgiflo®, Floseal®) contain thrombin along with a mechanical gelatin agent. They work together to obstruct blood flow and convert fibrinogen to fibrin [55, 56]. Although the mechanism of action is similar, Surgiflo is porcine gelatin available for use with bovine, human pooled plasma, or recombinant thrombin, whereas Floseal includes absorbable bovine gelatin particles combined with pooled human thrombin [55, 56]. All these agents are most effective in local bleedings and with the help of a syringe, they are applied downward into the wound, on the wound edges, providing an ultimate mechanical barrier and forming an active clot [55, 56]. The surgeon can spray these agents not only on the upper parts of the wound, but also on large irregular surfaces. The product forms a thick structure in the bleeding site approximately 3 min after administration. At the same time, the surgeon can apply pressure with a sponge soaked with saline [56].
While many fibrin sealants are available as topical hemostat, sealant and adhesive, Tisseel has received FDA approval for use only [56, 63]. This product is also available in our country and is used especially in aortic surgery. Since they contain high concentrations of fibrinogen and thrombin, which are naturally found in the blood, they cause blood clot formation [56]. Fibrin sealants—namely Tisseel™, Evicel®, and Vitagel™—are effective for both local and diffuse bleeding and can be applied using either a syringe for local bleeding or spray with a gas-driven device for diffuse-bleeding areas [55, 56]. These agents act better when applied to a relatively dry surface and can be used with absorbable gelatin sponge as the surgeon can press with the finger [56]. In aortic root surgeries such as Bentall procedure, after the placement of valved conduit in the aortic root and left coronary button anastomosis, Tisseel can be applied to this region providing sealing since this area cannot be re-visualized again.
Bovine albumin and glutaraldehyde (BioGlue®) is a cross-linkage between bovine serum albumin and 10% glutaraldehyde [56]. It has been approved by the FDA for adhering intimal and adventitial layers to each other in aortic dissection. This sealant agent is also available, and we especially use it in aortic surgery dissections. In particular, it is applied between the layers of the media at the distal of the primary intimal tear so the layers are adhered to each other.
Octyl cyanoacrylate (e.g., Dermabond™) and butyl cyanoacrylate (e.g., Indermil®, Histoacryl®, Histoacryl® Blue) are for topical use only. While these agents hold the edges of the skin together, they also form a barrier against bacteria [55, 56]. Cyanoacrylates are quick and easy to use, are stored at room temperature, and are relatively inexpensive. However, they have an exothermic reaction when applied to the skin and thus can cause some discomfort in patients. Safety concerns include potential eye injury, and its use on infected, wet, or poorly healing wounds should be avoided [55, 56]. N-butyl cyanoacrylate is currently used for endovenous ablation of varicose saphenous veins. It is a rapidly polymerizing agent in contact with blood. In special cases, it can be applied directly on the tissue and adhered to topical hemostatic agents with cellulose content. It is a simple but effective application.
What are the limited resources in health care delivery? In underdeveloped and developing countries, both the social insurance provider and the delivery of healthcare services substantially belong to the state. This has advantages as well as disadvantages. These limited resources inevitably create limitations in the delivery of healthcare services. If you cannot produce your technology and buy it from outside, these products cost too much, and even if they are used, serious limitations are required. In this case, the surgical team creates solutions to the current situation; the basic rule of being a surgeon is to make the right decision at the right time. At this point, from patient admission to surgical planning, the right assessment, the right strategy and the right indication should be established for the patient. The surgeon should be skeptical, question and investigate. Beginning a cardiac surgery is an irreversible process. Detection and solution of the problems in the preoperative approach will absolutely increase the surgical success in the preoperative and postoperative periods.
Right indication and correct surgical planning are absolutely necessary. Your nick names have to be patience during surgery. The surgeon’s overconfidence, hastiness and misapplication may lead to serious problems. The surgeon and his/her team should determine all materials required for hemostasis in their hands in the preoperative planning and make their preparations accordingly. The blood bank is an essential concept in cardiac surgery. It is essential to use blood products by determining the patient’s need. Hemostasis should be provided during the operation and this should not be left to the intensive care process. Creating a solution is the basic principle of the surgeon and surgery (Figures 6 and 7).
Me and my colleague performing a mitral valve operation with classical sternotomy.
To be a team can figure the problems out in cardiac surgery.
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Although this type of a numerical model typically requires long calculation times, we have developed a very efficient parallelization strategy on the graphics processing unit (GPU). This simulation approach allows the determination of temperature evolution, elastic and plastic deformation, defect formation, residual stresses, and material flow all within the same model. More importantly, the large plastic deformation and material mixing common to FSW are well captured by the mesh-free method. The parallel strategy on the GPU provides a means to obtain meaningful simulation results within hours as opposed to many days or even weeks with conventional FSW simulation codes.",book:{id:"5257",slug:"joining-technologies",title:"Joining Technologies",fullTitle:"Joining Technologies"},signatures:"Kirk Fraser, Lyne St-Georges and Laszlo I. 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Behind these definitions are hidden all the aspects of normal and pathological functioning of all processes that the topic ‘Metabolism’ will cover within the Biochemistry Series. Thus all studies on metabolism will be considered for publication.",annualVolume:11413,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/17.jpg",editor:{id:"138626",title:"Dr.",name:"Yannis",middleName:null,surname:"Karamanos",fullName:"Yannis Karamanos",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002g6Jv2QAE/Profile_Picture_1629356660984",institutionString:null,institution:{name:"Artois University",institutionURL:null,country:{name:"France"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"243049",title:"Dr.",name:"Anca",middleName:null,surname:"Pantea Stoian",fullName:"Anca Pantea Stoian",profilePictureURL:"https://mts.intechopen.com/storage/users/243049/images/system/243049.jpg",institutionString:null,institution:{name:"Carol Davila University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"203824",title:"Dr.",name:"Attilio",middleName:null,surname:"Rigotti",fullName:"Attilio Rigotti",profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institutionString:null,institution:{name:"Pontifical Catholic University of Chile",institutionURL:null,country:{name:"Chile"}}},{id:"300470",title:"Dr.",name:"Yanfei (Jacob)",middleName:null,surname:"Qi",fullName:"Yanfei (Jacob) Qi",profilePictureURL:"https://mts.intechopen.com/storage/users/300470/images/system/300470.jpg",institutionString:null,institution:{name:"Centenary Institute of Cancer Medicine and Cell Biology",institutionURL:null,country:{name:"Australia"}}}]},{id:"18",title:"Proteomics",keywords:"Mono- and Two-Dimensional Gel Electrophoresis (1-and 2-DE), Liquid Chromatography (LC), Mass Spectrometry/Tandem Mass Spectrometry (MS; MS/MS), Proteins",scope:"With the recognition that the human genome cannot provide answers to the etiology of a disorder, changes in the proteins expressed by a genome became a focus in research. Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. Currently, proteomics relies mainly on mass spectrometry (MS) combined with electrophoretic (1 or 2-DE-MS) and/or chromatographic techniques (LC-MS/MS). MS is an excellent tool that has gained popularity in proteomics because of its ability to gather a complex body of information such as cataloging protein expression, identifying protein modification sites, and defining protein interactions. The Proteomics topic aims to attract contributions on all aspects of MS-based proteomics that, by pushing the boundaries of MS capabilities, may address biological problems that have not been resolved yet.",annualVolume:11414,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/18.jpg",editor:{id:"200689",title:"Prof.",name:"Paolo",middleName:null,surname:"Iadarola",fullName:"Paolo Iadarola",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSCl8QAG/Profile_Picture_1623568118342",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorTwo:{id:"201414",title:"Dr.",name:"Simona",middleName:null,surname:"Viglio",fullName:"Simona Viglio",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRKDHQA4/Profile_Picture_1630402531487",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorThree:null,editorialBoard:[{id:"72288",title:"Dr.",name:"Arli Aditya",middleName:null,surname:"Parikesit",fullName:"Arli Aditya Parikesit",profilePictureURL:"https://mts.intechopen.com/storage/users/72288/images/system/72288.jpg",institutionString:null,institution:{name:"Indonesia International Institute for Life Sciences",institutionURL:null,country:{name:"Indonesia"}}},{id:"40928",title:"Dr.",name:"Cesar",middleName:null,surname:"Lopez-Camarillo",fullName:"Cesar Lopez-Camarillo",profilePictureURL:"https://mts.intechopen.com/storage/users/40928/images/3884_n.png",institutionString:null,institution:{name:"Universidad Autónoma de la Ciudad de México",institutionURL:null,country:{name:"Mexico"}}},{id:"81926",title:"Dr.",name:"Shymaa",middleName:null,surname:"Enany",fullName:"Shymaa Enany",profilePictureURL:"https://mts.intechopen.com/storage/users/81926/images/system/81926.png",institutionString:"Suez Canal University",institution:{name:"Suez Canal University",institutionURL:null,country:{name:"Egypt"}}}]}]}},libraryRecommendation:{success:null,errors:{},institutions:[]},route:{name:"profile.detail",path:"/profiles/154897",hash:"",query:{},params:{id:"154897"},fullPath:"/profiles/154897",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var e;(e=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(e)}()