Variation in temperature and exergy metrics with the outlet pressure for a throttling process of air.
\r\n\tThe objective of this book is to provide a state-of-the-art review of the use of timber in building construction from various perspectives, including manufacturing, fabrication, modeling, design, and construction of residential and other types of buildings. Of special interest will be contributions related to new developments in timber technologies, design, construction, testing, sustainability, LCA, building envelope, and the performance of timber buildings in natural and man-made hazard conditions.
",isbn:"978-1-83768-263-8",printIsbn:"978-1-83768-262-1",pdfIsbn:"978-1-83768-264-5",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"356565153fc7e43f1bf0cb7ba5e7b28a",bookSignature:"Prof. Ali M. Memari",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/12057.jpg",keywords:"Wood, Lumber, Timber Industry, Home Building, Glue-Laminated Wood, Cross-Laminated Timber, Plywood, Fire Resistance, Sustainability, Fabrication, Panelized/Modular, Material Properties",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 31st 2022",dateEndSecondStepPublish:"June 28th 2022",dateEndThirdStepPublish:"August 27th 2022",dateEndFourthStepPublish:"November 15th 2022",dateEndFifthStepPublish:"January 14th 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"8 hours",secondStepPassed:!1,areRegistrationsClosed:!1,currentStepOfPublishingProcess:2,editedByType:null,kuFlag:!1,biosketch:"Dr. Memari is a Professor and Bernard and Henrietta Hankin Chair in Residential Building Construction in the Departments of Architectural Engineering and Civil and Environmental Engineering. During his 30 years of teaching in structural engineering, his research focused on the behavior of structural, architectural, and enclosure components of residential and commercial buildings under natural hazard loading and environmental conditions. He has published over 300 publications.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"252670",title:"Prof.",name:"Ali",middleName:null,surname:"M. Memari",slug:"ali-m.-memari",fullName:"Ali M. Memari",profilePictureURL:"https://mts.intechopen.com/storage/users/252670/images/system/252670.jpg",biography:"Dr. Memari is a Professor and Bernard and Henrietta Hankin Chair in Residential Building Construction in the Departments of Architectural Engineering and Civil and Environmental Engineering at Penn State, and Director of The Pennsylvania Housing Research Center. During his 30 years of teaching and research experience, he has taught various courses related to structural\r\nengineering. He has focused his research on full-scale laboratory testing characterization and evaluation of residential and commercial buildings with respect to structural, architectural, and envelope components under gravity and lateral loads that simulate natural hazards (earthquakes/wind-storms), as well as environmental effects involving building science aspects (heat transfer, air leakage and moisture transport) through building enclosure. 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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. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"10198",title:"Response Surface Methodology in Engineering Science",subtitle:null,isOpenForSubmission:!1,hash:"1942bec30d40572f519327ca7a6d7aae",slug:"response-surface-methodology-in-engineering-science",bookSignature:"Palanikumar Kayaroganam",coverURL:"https://cdn.intechopen.com/books/images_new/10198.jpg",editedByType:"Edited by",editors:[{id:"321730",title:"Prof.",name:"Palanikumar",surname:"Kayaroganam",slug:"palanikumar-kayaroganam",fullName:"Palanikumar Kayaroganam"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophile",surname:"Theophanides",slug:"theophile-theophanides",fullName:"Theophile Theophanides"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3092",title:"Anopheles mosquitoes",subtitle:"New insights into malaria vectors",isOpenForSubmission:!1,hash:"c9e622485316d5e296288bf24d2b0d64",slug:"anopheles-mosquitoes-new-insights-into-malaria-vectors",bookSignature:"Sylvie Manguin",coverURL:"https://cdn.intechopen.com/books/images_new/3092.jpg",editedByType:"Edited by",editors:[{id:"50017",title:"Prof.",name:"Sylvie",surname:"Manguin",slug:"sylvie-manguin",fullName:"Sylvie Manguin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. 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"}},{type:"book",id:"57",title:"Physics and Applications of Graphene",subtitle:"Experiments",isOpenForSubmission:!1,hash:"0e6622a71cf4f02f45bfdd5691e1189a",slug:"physics-and-applications-of-graphene-experiments",bookSignature:"Sergey Mikhailov",coverURL:"https://cdn.intechopen.com/books/images_new/57.jpg",editedByType:"Edited by",editors:[{id:"16042",title:"Dr.",name:"Sergey",surname:"Mikhailov",slug:"sergey-mikhailov",fullName:"Sergey Mikhailov"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1373",title:"Ionic Liquids",subtitle:"Applications and Perspectives",isOpenForSubmission:!1,hash:"5e9ae5ae9167cde4b344e499a792c41c",slug:"ionic-liquids-applications-and-perspectives",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/1373.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:"2270",title:"Fourier Transform",subtitle:"Materials Analysis",isOpenForSubmission:!1,hash:"5e094b066da527193e878e160b4772af",slug:"fourier-transform-materials-analysis",bookSignature:"Salih Mohammed Salih",coverURL:"https://cdn.intechopen.com/books/images_new/2270.jpg",editedByType:"Edited by",editors:[{id:"111691",title:"Dr.Ing.",name:"Salih",surname:"Salih",slug:"salih-salih",fullName:"Salih Salih"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"59310",title:"Exergy Flows Inside Expansion and Compression Devices Operating below and across Ambient Temperature",doi:"10.5772/intechopen.74041",slug:"exergy-flows-inside-expansion-and-compression-devices-operating-below-and-across-ambient-temperature",body:'\nCooling is part of twenty-first century life. Air conditioning, food conservation, industries such as steel, chemicals, and plastics depend on cooling. By mid-century people will use more energy for cooling than heating [1]. Almost all cold is produced by vapor-compression refrigeration and requires large amounts of electricity for its production. And since electricity is still overwhelmingly produced by burning fossil fuels, the rise in cold production will inevitably increase both fuels consumption and power plant emissions. A climate-change irony is that cooling makes the planet hotter. Besides the development of new cooling devices using renewable energy, an important way to reduce refrigeration power consumption is through the energy efficiency improvement of vapor-compression cycles and their associated elementary processes. The processes of compression and expansion play a central role in air-conditioning, refrigeration and cryogenics. An important question still remains: How to define the efficiency of these processes by taking into account the constraints of the first and second laws of thermodynamics? The answer will be discussed in this paper.
\nThe introduction of exergy, the thermodynamic function that takes into account the quality as well as the quantity of energy, has paved the way for a unified approach to the concept of efficiency, a subject pioneered by Grassmann [2]. Serious difficulties concerning the practical application of this concept to sub-ambient systems, however, retarded the acceptance of exergy analysis by the air-conditioning and refrigeration engineering profession. One can mention, in particular, the difficulty of formulating a coefficient of exergy efficiency (CEE) for elementary processes such as compression and expansion. The coefficient should evaluate the exergy losses, quantify the extent to which the technical purpose of an elementary process is achieved, as well as quantify the exergy consumption within the process. Finally, a uniquely determined value (not several) should be assigned to the coefficient. This paper examines some important points pertinent to these issues and presents a definition of the CEE for the thermodynamic evaluation of expansion and compression devices operating below and across ambient conditions. The definition is based on the concept of transiting exergy, introduced by Brodyansky et al. [3], that allows non-ambiguous computation of two metrics: exergy produced and exergy consumed.
\nThe maximum amount of work obtained from a given form of energy or a material stream, using the environment as the reference state, is called exergy [4, 5]. Three different types of exergy are important for thermodynamic analysis of the sub-ambient processes: exergy of heat flow, exergy of work (equivalent to work) and thermo-mechanical exergy, also known as physical exergy by some authors [4, 6]. Chemical exergy [7], important for some refrigeration systems based on the mixing of streams of different composition, is not considered in the present paper.
\nThe exergy of heat flow \n
where Θ = 1 − T0/T is the Carnot factor determined by the temperature T of heat flow, and the ambient temperature T0. Contrary to conditions above ambient, Θ is negative for sub-ambient temperatures. However, according to Eq. (1), \n
Energy (a) and exergy (b) balances of a reversible refrigerator (RR).
The thermo-mechanical exergy equals the maximum amount of work obtainable when the stream of substance is brought from its initial state to the environmental state, defined by pressure P0 and temperature T0, by physical processes involving only thermal interaction with the environment [3, 4]. The specific thermo-mechanical exergy eP,T is calculated according to:
\nThe value of eP,T may be divided by two components: thermal exergy eT due to the temperature difference between T and T0, and mechanical exergy eP due to the pressure difference between P and P0. It is important to emphasize that this division is not unique, because eT depends on pressure conditions and eP in its turn depends on temperature conditions. As a result, the division has no fundamental meaning and leads, as will be illustrated further, to ambiguities for the exergy efficiency definition. By conventional agreement [4], eT and eP are defined as:
\nThe contribution of eT and eP to the value of eP,T can be clearly visualized on the exergy-enthalpy diagram presented in Figure 2. For instance, the thermal exergy for point 1 is illustrated as the segment (eT)1 defined by the intersections of two isotherms T1 and T0 with the isobar P1. The mechanical exergy for point 1 is illustrated as the segment (eP)1 defined by the intersections of two isobars P1 and P0 with the isotherm T0. Whatever the temperature conditions are (T < T0 or T > T0), the thermal exergy is always positive [3], as clearly presented on the e-h diagram. In this sense the eT behavior is similar to that of the exergy of heat flow, that is always positive, as has been discussed. Meanwhile, eP is only positive for conditions P > P0 (see for example point 1), but it is negative for P < P0, as illustrated by point 2 in Figure 2.
\nThermal eT and mechanical eP exergy components on an exergy-enthalpy diagram.
The exergy balance around any process under steady state conditions and without external irreversibilities (the case considered in this paper) may be written as [4]:
\nHere \n
The input-output efficiency ηin-out, first proposed by Grassmann [2], is computed according to Eq. (6):
\nThe shortcomings of this definition, particularly for its application to sub-ambient problems, are well documented [3, 4, 5, 6, 7, 8, 9]. The main one is the fact that often ηin-out does not evaluate the degree to which the technical purpose of a process is realized; the subject will be illustrated in Section 3. The products-fuel efficiency ηpr-f proposed by Tsatsaronis [10] and Bejan et al. [6] in the context of expansion and compression processes is computed as:
\nUnder the terms “products” and “fuel” the authors meant either the differences in exergies of the streams at the inlet and outlet of a process, or the exergies of streams themselves. For example, while evaluating the efficiency of an adiabatic compression operating above ambient conditions, the “fuel” is the supplied work, and the “product” is the increment of thermo-mechanical exergy. The problem with this approach is that it is possible to obtain different values of ηpr-f of the sub-ambient expansion and compression processes due to the fact that different things can be understood under the notions “products” and “fuel”. It should be also mentioned that some authors used a different terminology to express the numerator and denominator of Eq. (7). For example, Kotas [4] used “desired output” vs. “necessary input”; Szargut et al. [5] used “exergy of useful products” vs. “feeding exergy”.
\nBrodyansky et al. [3] proposed a definition of efficiency based on the subtraction of the exergy that has not undergone transformation within an analyzed process. The latter was named “transiting exergy”, \n
where Δ\n
Following the equations proposed by Brodyansky et al. [3], the specific transiting thermo-mechanical exergy etr of an analyzed system is defined as the minimum exergy value that can be assigned to a material stream, considering the pressure P and temperature T at the inlet and outlet, as well as the ambient temperature T0. With this definition, there are three possible combinations of Pin, Tin, Pout, Tout and T0 that determine the value of etr:
\nInspection of these equations shows that for all three cases etr is determined by using the lowest pressure \n
The case of the throttling process operating above T0 is presented on an e-h diagram (see Figure 3a). According to Eq. (9a), the value of etr is:
\nTransiting thermo-mechanical exergy presentation for a throttling process of a real gas operating above (a), below (b), and across (c) ambient temperature (T0).
This value coincides with the value e2 as illustrated in Figure 3a. The specific exergy losses (d) are also presented on the diagram. Following Eq. (8), the values Δ\n
where \n
As a result, the efficiency ηtr = 0, meaning that the exergy consumed is completely lost during the process and there is no produced exergy. It should be mentioned that the input-output efficiency calculated according to Eq. (6) has a negative value in this particular case and has no physical meaning. This is due to the fact that \n
Now, let us analyze the case of throttling at sub-ambient conditions presented in Figure 3b. According to Eq. (9b):
\nThus Δ\n
The term (ΔeT)Pout in Eq. (14) is the increase of the specific thermal exergy due to an isobaric temperature drop under
The values Δ\n
Again, the input-output efficiency is not suitable for the evaluation of the processes presented in Figure 3b and c, given that the outlet exergy e2 = e(Pout, Tout) is negative. Another difficulty is linked to the application of the products-fuel efficiency for these cases. The exergy transfer of the throttling process at sub-ambient conditions consists in the partial transformation of mechanical exergy (“fuel”) into thermal exergy (“product”). The problem stems from the fact that there are multiple possibilities to define “fuel” and “product” in this case; as a result multiple values of ηpr-f may be formulated, leading to the ambiguity in the products-fuel efficiency application. Indeed, the different increments of thermal exergy may be considered as a “product” for the case in Figure 3b, for example, the increase in thermal exergy following the isobar P1 or the isobar P2. In the same way, different decrements of mechanical exergy may be considered as a “fuel” in the same figure, for example, the decrease of mechanical exergy following the isotherms T1 or T2.
\nContrary to “products-fuel”, the transiting exergy approach does not attempt to individually compute the thermal and mechanical exergy component variations. It relies, rather, on the unaffected part of the thermo-mechanical exergy entering and leaving the system.
\nAs illustrated in Figure 3a and c, the transiting exergy may be considered as the introduction of a new reference state to evaluate exergy consumed and produced. Instead of the reference point e = 0 (the intersection of the isobar P0 and the isotherm T0), the new reference point is presented by etr: the intersection of the isobar P2 and the isotherm T2 for the case 3a; of the isobar P2 and the isotherm T1 for the case 3b; and of the isobar P2 and the isotherm T0 for the case 3c. Finally, the transiting exergy approach provides the foundation for the non-ambiguous definition of the terms Δ\n
The initial parameters of air at the inlet of a throttling valve are: \n
The outlet temperature of the air is calculated by using the software Engineering Equation Solver (EES) [11]. Given that the expansion of air takes place at sub-ambient conditions, Eqs. (13)–(15) are used to evaluate \n
The expansion valve of a refrigeration mechanical vapor compression cycle is supplied with the subcooled working fluid R152a at the rate \n
A vapor compression cycle is presented on a Ts-diagram in Figure 4. The subcooling process is represented by the line 3f-3. Given that the expansion of R152a takes place across ambient temperature, Eqs. (16)–(18) are used to evaluate \n
The transiting exergy does not change with the subcooling, because it is the function of constant parameters T0 and P2, meanwhile the exergy produced increases and exergy consumed decreases. The new result is that ηtr is rising with the subcooling. It should be mentioned that increasing the amount of subcooling is well documented as a way to increase the COP (coefficient of performance) of vapor compression cycles [4]. Thus, the rise in ηtr of an expansion device guarantees the COP improvement of the overall cycle, a conclusion that may lead to practical recommendations for optimization of refrigeration cycles.
\nP2 (MPa) | \nT2 (K) | \n∇\n (kW) | \nΔ\n (kW) | \n\n\n (kW) | \n\n\n (kW) | \nηtr (%) | \n
---|---|---|---|---|---|---|
1.0 | \n118.6 | \n101.8 | \n30.8 | \n71.0 | \n245.9 | \n30.3 | \n
0.9 | \n117.3 | \n110.8 | \n32.4 | \n78.4 | \n236.9 | \n29.2 | \n
0.7 | \n114.7 | \n132.0 | \n35.6 | \n96.4 | \n215.7 | \n26.9 | \n
0.5 | \n111.9 | \n160.1 | \n38.8 | \n121.3 | \n187.6 | \n24.2 | \n
0.3 | \n109.1 | \n202.3 | \n42.1 | \n160.2 | \n145.4 | \n20.8 | \n
0.1 | \n106.0 | \n292.3 | \n45.5 | \n246.8 | \n55.5 | \n15.6 | \n
Variation in temperature and exergy metrics with the outlet pressure for a throttling process of air.
A vapor compression cycle presentation on a Ts-diagram.
ΔTsubC (K) | \n∇\n (kW) | \nΔ\n (kW) | \n\n\n (kW) | \n\n\n (kW) | \nηtr (%) | \n
---|---|---|---|---|---|
275 | \n4.083 | \n3.208 | \n0.875 | \n1.744 | \n78.6 | \n
276 | \n4.066 | \n3.230 | \n0.836 | \n1.744 | \n79.4 | \n
278 | \n4.034 | \n3.274 | \n0.760 | \n1.744 | \n81.2 | \n
279 | \n4.020 | \n3.295 | \n0.725 | \n1.744 | \n82.0 | \n
281 | \n3.994 | \n3.339 | \n0.655 | \n1.744 | \n83.6 | \n
Variation in exergy metrics with subcooling for the expansion process of R152a.
The primary purpose of expansion processes in the sub-ambient region is the production of cooling effect. The power that may be produced can be considered as a useful by-product. This type of expansion takes place in cryo-expanders. There are two types of these devices: adiabatic and non-adiabatic gas expansion machines. The energy and exergy balances around a non-adiabatic expander are presented in Figure 5. It should be emphasized that the directions of heat flow \n
Energy (a) and exergy (b) balances around a non-adiabatic cryo-expander.
The process of gas expansion in a non-adiabatic cryo-expander is presented on an e-h diagram (see Figure 6). Similar to the case of adiabatic throttling (Figure 3b), the transiting exergy in the gas flow is defined according to Eq. (9b). As a result, the exergy efficiency is calculated as:
\nGas expansion in a non-adiabatic cryo-expander on an exergy-enthalpy diagram.
In the case of an adiabatic cryo-expander ηtr is calculated according to Eq. (19), but with the term \n
An adiabatic turbine (ηT = 0.80) is supplied with air at the rate \n
Given that the expansion of air takes place across ambient temperature, Eqs. (16)–(18) are used to evaluate \n
P2 (MPa) | \nT2 (K) | \n∇\n (kW) | \nΔ\n (kW) | \n\n\n (kW) | \n\n\n (kW) | \n\n\n (kW) | \nηtr (kW) | \n
---|---|---|---|---|---|---|---|
3.00 | \n271.8 | \n57.9 | \n0.2 | \n45.6 | \n12.1 | \n274.2 | \n79.1 | \n
2.55 | \n263.8 | \n68.3 | \n0.7 | \n53.0 | \n14.6 | \n263.9 | \n78.7 | \n
2.50 | \n255.1 | \n80.1 | \n1.5 | \n61.2 | \n17.4 | \n252.0 | \n78.2 | \n
1.85 | \n245.4 | \n94.1 | \n2.9 | \n70.3 | \n21.0 | \n238.0 | \n77.7 | \n
1.50 | \n234.3 | \n111.1 | \n4.9 | \n80.7 | \n25.5 | \n221.1 | \n77.1 | \n
1.15 | \n221.2 | \n132.6 | \n8.2 | \n93.1 | \n31.3 | \n199.6 | \n76.4 | \n
0.50 | \n204.9 | \n162.0 | \n13.6 | \n108.4 | \n40.0 | \n170.1 | \n75.3 | \n
0.45 | \n182.4 | \n208.9 | \n24.1 | \n129.7 | \n55.1 | \n123.2 | \n73.6 | \n
0.10 | \n138.9 | \n333.2 | \n57.7 | \n171.6 | \n103.9 | \n−1.05 | \n68.8 | \n
Variation in exergy metrics with the outlet pressure for a turbine expansion process.
Figure 7a illustrates a counter flow vortex tube [12]. High pressure gas enters the tube through a tangential nozzle (point 1). Colder low-pressure gas leaves via an orifice near the centerline adjacent to the plane of the nozzle (point 2), and warmer low-pressure gas leaves near the periphery at the end of the tube opposite to the nozzle (point 3). The vortex tube requires no work or heat interaction with the surroundings to operate. The cold mass fraction is μ; the hot gas mass fraction is (1 − μ). The exergy balance around the vortex tube is:
\nA vortex tube (a) and the presentation of the expansion process on an exergy-enthalpy diagram (b).
The expansion processes taking place within a vortex tube are presented on an e-h diagram (Figure 7b). The cold stream expands across T0, the hot expands at T > T0. By applying Eqs. (9a) and (9c) the transiting exergies may be determined for each mass stream, cold (1–2) and hot (1–3).
\nAs a result, the exergy produced and consumed within the cold and hot streams are:
\nThus Δ\n
An adiabatic vortex tube is supplied with air as ideal gas at the rate \n
The results are shown in Table 4. It is illustrated that \n
μ (–) | \nT2 (K) | \nT3 (K) | \n∇\n (kW) | \nΔ\n (kW) | \n\n\n (kW) | \n∇\n (kW) | \nΔ\n (kW) | \n\n\n (kW) | \n\n\n (kW) | \nηtr (%) | \n
---|---|---|---|---|---|---|---|---|---|---|
0.35 | \n268.0 | \n329.5 | \n61.9 | \n0.6 | \n0.0 | \n93.1 | \n0.9 | \n21.9 | \n153.5 | \n0.97 | \n
0.60 | \n273.0 | \n360.4 | \n106.2 | \n0.7 | \n0.0 | \n57.3 | \n2.3 | \n13.5 | \n160.5 | \n1.83 | \n
0.75 | \n278.0 | \n397.6 | \n132.7 | \n0.5 | \n0.0 | \n35.8 | \n3.4 | \n8.4 | \n164.6 | \n2.32 | \n
Variation in exergy metrics with the cold mass fraction for a vortex tube expansion process.
In most refrigeration plants and heat pumps compression starts at T < T0 and ends at T > T0. The process is presented on an e-h diagram (see Figure 8). According to Eq. (9c), transiting exergy is:
\nCompression process across ambient temperature (T0) on an exergy-enthalpy diagram.
The produced and consumed exergies are:
\nΔ\n
An adiabatic compressor of a refrigeration plant is supplied with the working fluid R152a at the rate \n
The results are shown in Table 5. The transiting exergy does not change with the isentropic efficiency ηC, because is a function of constant parameters T0 and P1. The exergy consumed does not change either. The produced exergy decreases. This drop in Δ\n
ηC (–) | \n\n\n (kW) | \n∇\n (kW) | \nΔ\n (kW) | \n\n\n (kW) | \n\n\n (kW) | \nηtr (kW) | \n
---|---|---|---|---|---|---|
0.75 | \n66.0 | \n2.3 | \n53.3 | \n15.0 | \n12.6 | \n78.0 | \n
0.80 | \n61.9 | \n2.3 | \n52.9 | \n11.3 | \n12.6 | \n82.4 | \n
0.85 | \n58.3 | \n2.3 | \n52.6 | \n8.0 | \n12.6 | \n86.8 | \n
0.90 | \n55.0 | \n2.3 | \n52.3 | \n5.0 | \n12.6 | \n91.3 | \n
Variation in exergy metrics with the isentropic efficiency for a compression process.
A combination of the processes of vapor expansion and compression takes place within a one-phase ejector presented in Figure 9a. A primary (pr) stream at high pressure P1 and temperature T1 expands and entrains a secondary stream (s) at low pressure P2 and temperature T2 < T0. The ratio \n
One phase ejector (a) and presentation of expansion and the compression processes (b) on an exergy-enthalpy diagram.
The processes of expansion of the primary stream and compression of the secondary stream are presented on an e-h diagram (Figure 9b). The secondary stream is compressed across T0, meaning that Eq. (9c) is applied to calculate (etr)s. As a result, the transiting exergy for secondary and primary streams are:
\nThis means that the exergies produced and consumed may be computed as:
\nΔ\n
An ejector of a refrigeration plant is supplied with the working fluid R141b. The parameters of the secondary stream are: P2 = 22.3 kPa, T2 = 268 K. The pressure of the mixed stream is P3 = 91 kPa. The ambient temperature T0 = 289 K. Calculate the variation of (\n
The calculation results are shown in Table 6. The transiting exergy in the secondary flow is negative because the parameters P2 and T0 define the state of the flow under vacuum conditions. The exergy produced and exergy consumed increase with the entrainment factor. The increase in Δ\n
ω (–) | \n∇\n (kW) | \n∇\n (kW) | \nΔ\n (kW) | \n\n\n (kW) | \n\n\n (kW) | \n\n\n (kW) | \n\n\n (kW) | \nηtr (%) | \nP1 (kPa) | \nT1 (K) | \n
---|---|---|---|---|---|---|---|---|---|---|
0.15 | \n9.99 | \n0.017 | \n1.189 | \n8.818 | \n4.286 | \n−0.546 | \n3.740 | \n11.9 | \n1000 | \n418 | \n
0.17 | \n10.07 | \n0.019 | \n1.334 | \n8.755 | \n4.205 | \n−0.619 | \n3.586 | \n13.2 | \n1000 | \n418 | \n
0.20 | \n10.19 | \n0.023 | \n1.547 | \n8.666 | \n4.090 | \n−0.729 | \n3.361 | \n15.2 | \n1000 | \n418 | \n
0.23 | \n10.29 | \n0.026 | \n1.754 | \n8.562 | \n3.983 | \n−0.838 | \n3.145 | \n17.0 | \n1000 | \n418 | \n
0.25 | \n10.36 | \n0.028 | \n1.890 | \n8.498 | \n3.915 | \n−0.911 | \n3.004 | \n18.2 | \n1000 | \n418 | \n
Variation in exergy metrics with the entrainment factor for compression-expansion processes in an ejector.
Life Cycle Analysis (LCA) is an important tool to analyze environmental problems associated with the production, use, and disposal of products or systems [14]. For every product produced within a system the total inflow and outflow of energy and materials are evaluated. The environmental burdens are associated by quantifying the energy and materials used, as well as the wastes released into the environment. The impact of these uses and releases on the environment is assessed. The multidimensional approach of LCA causes some problems when different substances need to be compared and general agreement is required. This problem may be avoided if exergy is used as a common quantity as proposed by Life Cycle Exergy Analysis [15]. The crucial idea behind this method is the distinction between renewable and non-renewable resources. In order to illustrate the method, let us consider three defined time periods within the life cycle of an ejector refrigeration system driven by solar energy [16]. At first, exergy is required during the construction stage to build the plant and put it into operation. During this period the spent exergy is stored in materials, such as metals, glass etc. For the second period, maintenance required for the system’s operation takes place. Exergy necessary for this maintenance is evaluated. The third period is the clean-up stage, including the plant demolition and the recycling of materials. Exergy used for the clean-up is assessed. The exergy used for the construction, maintenance, and clean-up is assumed to originate from non-renewable resources and is named indirect exergy, \n
The common feature of expansion processes operating below or across ambient temperature is the partial transformation of the mechanical exergy component into the thermal exergy component. Sub-ambient compression processes are characterized by the transformation of work into the mechanical exergy component and the partial destruction of the thermal exergy component below T0. In order to evaluate the efficiency of these transformations the calculations of the variation in mechanical and thermal exergy components are required. These calculations may be done in many different ways, for example the variation in eP depends on the chosen temperature conditions, while the variation in eT depends on the chosen pressure conditions. This multiplicity in the exergy variation evaluation leads to ambiguity in the exergy efficiency definition. The approach based on the exclusion of the “transiting flow” from thermo-mechanical inlet and outlet exergies of an analyzed process overcomes this difficulty. This improvement is possible because the transiting exergy is uniquely defined by a specific combination of the process intensive parameters, namely the inlet and outlet pressures and temperatures, as well as T0. The transiting exergy approach allows non-ambiguous evaluation of two thermodynamic metrics: exergy produced and exergy consumed. Their ratio represents the exergy efficiency; the difference between exergy consumed and exergy produced equals the exergy losses within the process. The phenomenological significance of the transiting exergy and the way in which it can be computed for processes below and across T0 has been illustrated for the cases of an expansion valve, a cryo-expander, a vortex tube, an adiabatic compressor, and a monophasic ejector. The input-output exergy efficiency is not an appropriate criterion for evaluation of these processes.
\nThis project is a part of the Collaborative Research and Development (CRD) Grants Program at “Université de Sherbrooke”. The authors acknowledge the support of the Natural Sciences and Engineering Research Council of Canada, Hydro Québec, Rio Tinto Alcan and CanmetENERGY Research Center of Natural Resources Canada (RDCPJ451917-13).
\n\n\n\n\nD\ṅ\n\n\n\n | Destroyed exergy, (kW) |
d | Specific exergy losses, (kJ/kg) |
e | Specific exergy, (kJ/kg) |
\n\n\n\nE\ṅ\n\n\n\n | Exergy, (kW) |
h | Specific enthalpy, (kJ/kg) |
\n\n\n\nH\ṅ\n\n\n\n | Enthalpy, (kW) |
ṁ | (Total) Mass flowrate, (kg/s) |
P | Pressure, (MPa, kPa) |
\n\n\n\nQ\ṅ\n\n\n\n | Heat rate, (kW) |
s | Specific entropy, (kJ/kg K) |
T | Temperature, (K, °C) |
\n\n\n\nW\ṅ\n\n\n\n | Mechanical power, (kW) |
η | Efficiency, (%) |
∇ | Consumption |
Δ | Production |
μ | Cold mass fraction, μ = ṁC/ṁ |
ω | Entrainment ratio |
0 | Ambient state |
1, 2, 3… | States in a process |
C | Cold, Compressor |
f | Fuel |
H | Hot |
in | Inlet |
ind | Indirect |
int | Internal |
max | Maximal |
min | Minimal |
out | Outlet |
pr | Primary, Product |
S,s | Secondary |
subC | Subcooling |
tr | Transiting |
On August 24, 2012, we started our first endovascular treatment for acute mesenteric ischemia. The patient received diagnosis of acute abdomen in the emergent department, and our general surgeon per- formed laparotomy, which found diffuse mesenteric necrosis. After emergent operation, the interven- tional cardiology team was consulted. Endovascular revascularization was performed by Dr. Mu-Yang Hsieh and Dr. Kuei-Chien Tsai. A coronary bare-metal stent was placed to revascularize SMA (superior mesenteric artery) (Integrity, bare-metal stent, 4.0 x 28 mm, Medtronics) (Figure 1).
The angiography found acute superior mesenteric artery occlusion. The flow was re-established after thrombosuction, balloon angioplasty, and stenting with a bare-metal balloon expandable stent (case 1).
On August 17, 2012, Dr. Mu-Yang Hsieh initiated a draft for Acute Mesenteric Ischemia Protocol. Be- tween 2013 and 2014, interventional radiologist Dr. Chih-Hon Wu provided valuable revision sugges- tions. In the following years, another seven patients received emergent endocvascular revascularization for acute mesenteric ischemia.
Initial goals: a definitive invasive angiography become a reasonable options for dignosis improvement. To have an in-hospital monitor program.
Intermediate goals: become a center for emergent treatment for acute mesenteric ischemia.
Longterm goals: to achieve better survival as reported from previous literatures. Make our one-year survival rate approximate 88%.
“Patients only have hours before irreversible gut ischemia ensues, followed by profound distributive shock, and death. (quoted from Moore and Ahn, Chapter 35).”
Bowel ischemia was diagnosed in around 0.1% of hospitalized patients [1]. But the mortality of acute mesenteric ischemia is quite high. In our hospital, about 95%mesenteric ischemia presented with acute abdomen.
Because the diagnosis of acute ischemic bowel is often difficult, we initiated a dedicated diagnosis pro- tocol to improve the patient outcomes. (Figure 2):
Emergent primary surgery with f/u angio: 4 patients, all received angio, with 2 SMA lesions fixed, survival 75% (3/4).
Emergent primary endovascular approach (with second look laparoscopy when indicated): 18 pa- tients, 5 failure, survival 0% (0/5), 13 success, survival 92.3% (12/13), 4 required laparoscopy/laparotomy.
Totally conservative management: 6 patients, survival 0% (0/6).
Our registry 2012–2020, 28 patients in the registry. Survival is categorized by treatment modalities.
A filling defect (clot) was found in the SMA (Figure 3):
Early invasive endovascular approach: 8 patients, survival 75% (6/8).
Conservative medical management: 5 patients, survival 0% (0/5).
The survival categoried by treatment methods after finding clot in the SMA.
Since 2016, there are numerous literature reported that endovascular is better than open surgery [2, 3].
In 2017, a guideline suggested for patients with acute mesenteric ischemia, emergent surgical or endovascular intervention is reasonable.6.
In the absence of RCTs, evidence is based on prospective registries. In the case of embolic occlusion, open and endovascular revascularizations seem to do equally well, whereas, with thrombotic occlusion, endovascular therapy is associated with lower mortality and bowel resection rates. The principles of damage control surgery are important to follow when treating these frail patients. This concept focuses on saving life by restoring normal physiology as quickly as possible, thus avoiding unnecessary time-consuming procedures. Although laparotomy is not mandatory after endovascular therapy in these patients with acute bowel ischaemia, it is often necessary to inspect the bowel. In this setting, second-look laparotomy is also indicated after open revascularization. Intra-arterial catheter thrombolysis of the superior mesenteric artery has been reported with good results. Severe bleeding complications were uncommon, except when intestinal mucosal gangrene was present [4].
The internal research board certification.
Guideline update in 2017 [
Acute mesenteric ischemia is one etiology among many causes of acute abdominal pain (< 1/1000) [5].
In reported literatures, the mortality is around 60–80% among patients with acute mesenteric ischemia [5, 6, 7, 8].
embolism
thrombosis
non-occlusive mesenteric ischemia
venous thrombosis
Current report addresses that non-occlusive mesenteric ischemia will lead to a worse prognosis.
Dr. Erben reported in 2018 that endovascular revascularization for acute mesenteric ischemia is cost-saving, with a lower rate of in-hospital mortality [9].
Similar good endovascular treatment results were also obtained in a cohort of Chinese population. A table comparing endovascular versus open surgery groups offer a good perspective on this topic (Table 1) [10].
Variable | Endovascular group ( | Open surgery group ( | ||
---|---|---|---|---|
Symptom onset to treatment (h) | 20.8 ± 15.2 | 25.8 ± 11.3 | 0.35 | −0.96 |
Laparotomy required (%/ | 33.33 (6) | 58.33 (7) | 0.26 | |
Time to laparotomy (h) | 26.3 ± 16.8 | 18.0 ± 7.7 | 0.26 | 1.18 |
Bowel resection (cm) | 88 ± 44 | 253 ± 103 | 0.01 | 3.85 |
Thirty-day mortality (%/ | 16.7 (3) | 33.3 (4) | 0.68 |
Therapeutic efficacy between endovascular and open surgery groups [10].
Abbreviations: CA, celiac artery; CT; computed tomography; IMA, inferior mesenteric artery; MI, myocardial infarction; SMA, superior mesenteric artery.
Source: From Kirkpatrick ID, et al.: Biphasic CT with mesenteric CT angiography in the evaluation of acute mesenteric ischemia: initial experience.
Dr. Lim et al. reported in 2019 that for acute mesenteric ischemia, both open surgery and endovascular revascularization are viable options in the modern era [11].
Findings | Acute MI, n = 26 | Control, n = 36 | Sensitivity (%) | Specificity (%) |
---|---|---|---|---|
Pneumatosis intestinalis | 11 | 0 | 42 | 100 |
SMA or combined CA and IMA occlusion | 5 | 0 | 19 | 100 |
Arterial embolism | 3 | 0 | 12 | 100 |
SMA or portal venous gas | 3 | 0 | 12 | 100 |
Focal lack of bowel wall enhancement | 11 | 1 | 42 | 97 |
Free intraperitoneal air | 5 | 2 | 19 | 94 |
SMA or portal venous thrombosis | 4 | 2 | 15 | 94 |
Solid organ infarction | 4 | 2 | 15 | 94 |
Bowel obstruction | 3 | 2 | 12 | 94 |
Bowel dilatation | 17 | 6 | 65 | 93 |
Mucosal enhancement | 12 | 7 | 46 | 81 |
Bowel wall thickening | 22 | 10 | 85 | 72 |
Mesenteric stranding | 23 | 14 | 88 | 61 |
Ascites | 19 | 24 | 73 | 33 |
Important CT image findings for acute mesenteric ischemia [11].
Abbreviations: CA, celiac artery; CT; computed tomography; IMA, inferior mesenteric artery; MI, myocardial infarction; SMA, superior mesenteric artery.
Source: From Kirkpatrick ID, et al.: Biphasic CT with mesenteric CT angiography in the evaluation of acute mesenteric ischemia: initial experience.
Author (Year) | Data Source | Morbidity | Mortality |
---|---|---|---|
Schermerhorn et al. (2009) | Nationwide Inpatient Sample | Length of stay: 9 days vs. 14 days | In-hospital: 16% vs. 39% |
Bowel resection: 28% vs. 37% | |||
Acute kidney injury: 11.4% vs. 18.4% | |||
Cardiac complication: 2.1% vs. 7.2% | |||
Respiratory complication: 1.1% vs. 5.7% | |||
Block et al. (2010) | Swedish Vascular Registry | Laparotomy: 55% vs. 100% | 30-day: 28% vs. 42% |
Bowel resection: 19% vs. 63% | |||
Second-look operation: 31% vs. 67% | 1 year: 39% vs. 58% | ||
Short bowel syndrome: 27% vs. 55% | |||
Arthur et al. (2011) | Single-Center Chart Review | Laparotomy: 69% vs. 100% | 36% vs. 50% |
Bowel resection: 52 cm vs. 160 cm | |||
Beaulieu et al. (2014) | Nationwide Inpatient Sample | Length of stay: 12.9 vs. 17.1 days | In-hospital: 24.9% vs. 39.3% |
Bowel resection: 14.4% vs. 33.4% | |||
TPN support: 13.7% vs. 24.4% | |||
Branco et al. (2015) | Nasional Surgical Quality Improvement Program | Transfusion: 3.7% vs. 19.3% | Odds ratio 0.4 (CI 0.2–0.9) |
Pneumonia: 22.2% vs. 27.8% | |||
Sepsis: 25.9% vs. 35.5% | |||
Arya et al. (2016) | Single-Center Chart Review | Bowel resection: 36.4% vs. 43.5% | 30-day: 45.4% vs. 34.8% |
Sepsis: 45.4% vs. 22.7% | |||
Re-exploration: 63.6% vs. 56.5% | |||
Major morbidity: 63.6% vs. 69.6% |
Summary of recent literatures (results are endovascular versus open revascularization, respectively) [ 11].
Abbreviations: CI, confidence interval; TPN, total parenteral nutrition.
For the suspected case of acute mesenteric ischemia, is following serum lactate level useful to confirm acute mesenteric ischemia?
It is not helpful to wait for evidence of increasing serum lactate levels to proceed with further testing; ideally, in fact, intervention would occur in patients with acute mesenteric ischemia before lactic acidosis develops, with the goal of saving additional intestine from full-thickness injury [5].
When the clinical suspicion of acute mesenteric ischemia is high, we should proceed with CT angiography. And in cases with equivocal CT findings, invasive angiography should be considered.
In the early phase of abdominal pain, is serum amylase or lipase diagnostic? In the first eight patients of our case series, amylase and lipase is not useful.
In the first CT study, for patients with no bowel necrosis but still have equivocal CT findings of acute mesenteric ischemia, the best diagnostic method is invasive angiography.
Only a few report focused on primary stenting for acute mesenteric ischemia. Dr. Forbrig reported in 2017 with a case series of 19 consecutive patients and demonstrated that endovascular revascularization has high clinical success rates [12].
Besides balloon angioplasty and stenting, for large thrombus burden, Dr. Miura reported in 2017 that using a stent retriever achieved rapid and good revascularization in a patient with SMA embolism [13].
Dr. Mendes reported in 2018 that using a distal protection device can redude the event of distal em- bolization [14].
Dr. Morbi reported a patient with acute mesenteric ischemia and the patient received emergent by-pass surgery utilizing an aorto-SMA bypass, with good-quality long saphenous vein and segmental small bowel resection [15].
SMA (superior mesenteric artery) dissection has been reported extensively, and the most common problem is when performing open surgery, it is difficult to perform re-entry into the true lumen. The resolution is retrograde open mesenteric stenting (ROMS). The ROMS is performed by opening distal SMA true lumen with placement of a sheath, then proceeding with retrograde wiring and stenting [16].
The proposed classification of SMA dissection (Figure 6).
The classification of SMA dissection. Slide courtesy to Dr. 李栋林浙江大学医学院附属第一医院血管外科.
For SMA dissection, Dr. Loeffler reported in 2017, that if there was no evidence of bowel necrosis, even in symptomatic SMA dissection, regular medical treatment with follow-up may avoid the necessity of open surgery or endovascular stenting [17].
Gobble et al. reported in 2009, included 9 patients (all isolated spontaneous SMA dissection). The treatment modality was variable, including expectant management (4 patients), anticoagulation (2 patients), and endovascular stent placement (3 patients). Among patients who received stenting, acute luminal gain is better [16].
Conservative management of symptomatic spontaneous isolated dissection of the superior mesenteric artery has been reported to be successful.
Systematic review and meta-analysis for patients with spontaneous isolated superior mesenteric artery dissection also suggested conservative treatment [17, 18, 19].
In our patient treated in December 2016, the patient had diffuse aorta atherosclerosis, with celiac trunk- hepatic artery and SMA ostial occlusion.
For patients with chronic mesenteric ischemia due to occlusion of both celiac trunk and SMA, SMA revascularization alone may be adequate to improve symptoms [20].
Severe reperfusion syndrome after acute mesenteric ischemia revascularization has been reported. But optimal medical treatment has not been established
After successful stenting and salvage for acute mesenteric ischemia, stent fracture has been reported. This issue needs further study to establish the best treatment algorithm. Currently, we suggest following patients with abdominal contrast-enhanced CT to evaluate the patency of the stent
The symptoms of acute mesenteric ischemia are described in most general text of most medical textbooks. We do not repeat the symptoms but wish to address the most common clinical challenges in the initial phase of diagnosis: after performing KUB plain film of CT angiography, it is still frequent to fail to proceed to invasive angiography due to multiple reasons: physicians do not familiar with invasive angiography, lack of staffs to perform emergent angiography, no bowel necrosis and surgeon wish to treat the patient conservatively. Following serum lactate level only detects the patients in irreversible bowel necrosis and is not beneficial providing chances of early salvage.
The axial, coronal, sagittal, and 3D reconstruction in advance is mandatory to be reviewed in the initial diagnostic phases. However, in patients with extensive aortic calcification and ostial calcification, care must be taken to interpret the lumen area and stenosis, because the lumen may be mis-interpretated as patent due to extensive ostial calficaition.
CT findings of bowel necrosis: no enhancement of bowel loop, pneumatosis intestinalis, aeroportia (Figure 7).
The CT found extensive air within the portal venous system.
After our index case, an interventional cardiologist (Mu-Yang Hsieh) wrote a draft. The draft was reviewed and completed by an interventional radiologist (Chih-Horng Wu). The interventional radiologist trained the interventional cardiologist to perform selective bowel angiography to reduce time delay in the emergency scenario. The protocol was revised from the acute coronary syndrome protocol. For patients with evident bowel necrosis and peritoneal signs, direct consultation with a surgical team was mandatory (group 1 patients). The endovascular team was contacted after the surgical procedure. For patients with no evident bowel necrosis by CT, any team members can activate the protocol in the emergency department (group 2 patients). In suspected patients with possible CT findings (group 3 patients), the team votetd if proceeding with diagnostic angiography is beneficial to the patient Figures 8–10.
During operation, direct manual examination after laparotomy confirms acute mesenteric ischemia with bowel necrosis.
During emergent angiography, total occlusion SMA was confirmed. The occlusion was re- canalized with a 0.014-
Severe ostial stenosis of SMA. Treated with bare-metal stenting. The abdominal pain com- pletely resolved.
When the patient developed peritoneal signs or when bowel necrosis was evident by CT, the patient will be sent to the operation room first, and open thrombectomy 及 retrograde open mesenteric stenting (ROMS) should be considered
The flow chart of consultation process according to CT imaging findings.
Since 2016, we performed emergent angiography for case 9 and case 10 before the emergent open laparotomy. Direct stenting was performed on SMA. The potential benefit is to shorten the ischemic time
(Figures 12 and 13).
Case 10: revascularization first! It is better with improved flow to jejunum and proximal ileum than SMA proximal total occlusion. During bowel resection, resect the ileocecal junction to ascending colon for
Case illustration example. This illustration was made to make a thorough explanation to the patient and his family.
Treatment results (historical results) were provided to the patient family at the emergency department.
Angiographic (technical) success rate: 6/8 (75%)
Survival at 30 days: 75%
Survival at 7 days, In angiographic success patients: 100%
Survival at 7 days, In angiographic failure patients: 0%
Long-term follow-up survival at 2-year: 50% (due to multiple comorbidities) (Figure 14).
The drawing of disease explanation. All the drawing was made in the emergency department.
Poster prepared and mounted in the emergency department and at the waiting area of intensive care units (Figure 15).
The poster explaining the endovascular protocol for acute mesenteric ischemia. The poster was written in Chinese.
Abdominal angiography was performed emergently in the cath room (cardiology department) angiography room (radiology department). The vascular access was set with a 6-Fr sheath. To perform diagnostic angiography, a 5-Fr diagnostic catheter (RC-1 or JR) was used. In our protocol, the flow was rated using the coronary grading system: TIMI (thrombolysis in myocardial infarction) flow scale. Mesenteric artery disease was defined if there was diameter stenosis over 50%, and mesenteric artery occlusion was defined if there was 100% stenosis with 0 TIMI flow.
Thrombosuction, balloon angioplasty, and stenting were performed sequentially or by the discretion of the interventional cardiologist. First, the femoral sheath was changed to a 7-Fr sheath (10 cm), and a guiding catheter (7-Fr JR4 or IMA) was used according to the angle between of SMA ostium and aorta after reviewing the sagittal view on the CT. For ostial lesion, a guide catheter with side hole was used. We usually give a bolus of heparin (3000–5000 U) to achieve activated clotting time of at least 250 seconds. A workhorse 0.014-inch soft coronary wire was used to cross the lesion. With a dedicated coronary thrombosuction catheter, distal contrast injection can be done to confirm that true lumen was reached in cases with SMA occlusion. Thrombosuction was performed (Thrombuster, Terumo, Tokyo, Japan). Balloon angioplasty was done after successful establishment of antegrade flow. Ifpersistentt recoil or restenosis had been noted, the operator could perform bail-out stenting (usually with a coronary bare-metal stent. Thrombolytic agent was not used in our protocol because it was declined by our team (GI man). Because the National Health Insurance did not cover distal protection device in the treatment of acute mesenteric ischemia, the distal protection device was not used.
A coronary system with 0.014-inch wire, balloon, and stents are used in our protocol. Usually, the vascular access is at the common femoral artery (7 Fr sheath). We used a JR4 diagnostic coronary catheter with 0.035-inch wire (Terumo GlideWire) to perform diagnostic angiography. During the intervention, a 0.014-inch coronary wire with length of 180 cm is used (Sion, BMW-U2).
The angle between SMA ostium and aorta can help to choose the suitable guide sheath or guiding catheter to engage SMA. The choices included angled sheath (6 or 7 Fr), IMA, or JR4 guide catheters.
Thrombosuction: we used coronary system, Thrombuster (6 Fr), or Export catheter.
Most commonly used balloons: Trek, Maverick, and Sapphire, with 6–8 atm.
Bail-out stenting should be considered: when thrombosuction, or balloon angioplasty failed, stenting may still be tried.
Before performing bail-out stenting, we should always use thrombosuction catheter to perform distal injection in order to confirm the adequate distal landing zone.
Rotational Thrombectomy Device can be considered and has reported successful to salvage patients with acute mesenteric ischemia in a single center study [21].
Surgery and revascularization are both mandatory to provide optimal survival chances in patients with extensive bowel necrosis.
For patients who received stenting to SMA before surgery, care must be taken not to manipulate the SMA forcefully to avoid inadvertent crush of the stent.
ICU care after the endovascular procedure is mandatory. The electrolyte, urine output, and arterial pressure are to be monitored. An infection specialist is consulted at the discretion of the critical care specialist. The general surgeon will check the abdominal physical exams to detect changes in peritoneal signs. As- pirin (100 mg) and clopidogrel (75 mg) are initiated if no bleeding is noted after overnight observation. For patients with atrial fibrillation, an oral anticoagulant is started at the discretion of the operator and the caring cardiologist.
Important definition: [22].
Primary clinical success was defined as complete resolution of symptoms.
Partial clinical success was defined as resolution of some or most of the symptoms, but persistence of some symptoms after the procedure.
Primary clinical failure was defined as the lack of any or minimal symptom relief.
Technical success: the successful revascularization of all arteries that were treated in which there was less than a 30% residual diameter stenosis.
Partial technical success per patient (who had multiple mesenteric arteries treated) was defined as at least one mesenteric artery treated successfully.
Technical failure was defined as the inability to treat at least one mesenteric artery per patient
Oral digestive decontamination: PO gentamicin 80 mg/day, PO metronidazole 1.5 g/day [23].
What Is the Role of Empiric Treatment for Suspected Invasive Candidiasis in Nonneutropenic Patients in the Intensive Care Unit?
Preferred empiric therapy for suspected candidiasis in non-neutropenic patients in the intensive care unit (ICU) is an echinocandin (caspofungin: loading dose of 70 mg, then 50 mg daily; micafungin: 100 mg daily; anidulafungin: loading dose of 200 mg, then 100 mg daily) (strong recommendation; moderate-quality evidence) [24].
Mandatory medical protocol: blood volume resuscitation, with mean arterial pressure > 65 mmHg, urine output >0.5 ml/kg/hour.
Curative unfractionated heparin therapy with aPTT 50–70 seconds.
IV proton pump inhibitors: IV pantoprazole 80 mg/day
Oxygen therapy
Food resting, PN if prolonged >5 days.
Antibiotics: empirical, not prophylaxis. Tazocin and possible Candida coverage (no evidence of presence)
No | Age | Sex | Comirbidities | CHADS2-VASc | Shock | Resting dyspnea | Food avoidance | Diarrhea | Nausea/vomiting | Ileus, diffuse | Ileus, localized | Lactate (mmol/L) |
---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 79 | Female | Cirrhosis, gout | 2 | + | + | — | — | — | — | + | 8.8 |
2 | 61 | Male | PAOD, ESRD, DM, dyslipidemia, smoking | 2 | + | — | — | + | + | — | + | 2.5 |
3 | 74 | Female | HTN, dyslipidemia, gout | 2 | — | — | — | + | — | — | + | 1.7 |
4 | 72 | Female | DM, HTN | 3 | −+ | — | — | — | + | — | 7.4 | |
5 | 63 | Female | Afib, VHD, mechanical valve, CVA, DM, HTN, dyslipidemia | 5 | — | + | — | — | — | — | + | 2.4 |
6 | 74 | Female | CAD, old MI, PAOD, ESRD, DM, HTN, dyslipidemia | 4 | + | + | — | — | — | — | + | 5 |
7 | 86 | Male | CAD, Afib, VHD, DM, HTN | 3 | — | — | — | — | — | — | + | 2.6 |
8 | 80 | Female | CAD, ESRD, DM, HTN | 4 | — | — | + | — | — | — | + | 1 |
Demographics, clinical characteristics, and presentation of acute abdominal pain of the study participants.
Category | No | Culprint vessel | Lesion | Diameter (mm) | Length (mm) | Calcification | Time from ER to angiography | Treatment | Stenting | Angio / Clinical success | Laparotomy required | Angio to Discharge (days) | F/U durations (days) | Survival at 30 days | Outcome at 12 montsh |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 1 | SMA | 100% occlusion, main trunk | 4 | 28 | Minimal | 24.5 | Aspiration/stenting | BMS | Yes/Yes | Yes (after stenting) | 45 | 33 | Yes | Moratlity |
1 | 6 | SMA | 50% stenosis, ostium | 4 | 5 | Moderate | 12.1 | Direct stenging | BMS | Yes/Yes | Yes (before stenting) | 21 | 166 | Yes | Moratlity |
2 | 4 | SMA | 100% occlusion, main trunk | 2.5 | 40 | Minimal | 16.3 | Aspiration only | NA | No/No | No | NA | 1 | No | Mortality |
2 | 5 | SMA | 100% occlusion, main trunk | 4 | 30 | Minimal | 3.4 | Aspiration/stenting | BMS | Yes/Yes | No | 2 | 341 | Yes | Survival |
2 | 7 | SMA | 100% occlusion, main trunk | 4.5 | 50 | Minimal | 5.5 | Aspiration/stenting | BMS | Yes/Yes | No | 3 | 187 | Yes | Survival |
3 | 2 | SMA & celiac trunk | 100% occlusion, from ostium | 3 | NA | Severe | 11.9 | Wiring only | NA | No/No | No | NA | 1 | No | Mortality |
3 | 3 | IMA | 80% stenosis, ostium | 3 | 15 | Minimal | 22.2 | Direct stenting | BMS | Yes/Yes | No | 2 | 465 | Yes | Survival |
3 | 8 | SMA | 90% stenosis, ostium | 4.5 | 8 | Moderate | 9 | Direct stenting | BMS | Yes/Yes | No | 2 | 90 | Yes | Survival |
Procedure details and outcomes, by group.
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Although typical biological treatments of water offer some advantages such as low cost and operability, many investigations referring to the removal of pesticides have suggested that in many cases they have low effectiveness due to the limited biodegradability of many agrochemicals. In recent years, research for new techniques for water detoxification to avoid these disadvantages has led to processes that involve light, which are called advanced oxidation processes (AOPs). Among the different semiconductor (SC) materials tested as potential photocatalysts, titanium dioxide (TiO2) is the most popular because of its photochemical stability, commercial availability, non-toxic nature and low cost, high photoactivity, ease of preparation in the laboratory, possibility of doping with metals and non-metals and coating on solid support. Thus, in the present review, we provide an overview of the recent research being developed to photodegrade pesticide residues in water using TiO2 as photocatalyst.",book:{id:"6407",slug:"application-of-titanium-dioxide",title:"Application of Titanium Dioxide",fullTitle:"Application of Titanium Dioxide"},signatures:"Nuria Vela, Gabriel Pérez-Lucas, José Fenoll and Simón Navarro",authors:[{id:"202983",title:"Dr.",name:"Simón",middleName:null,surname:"Navarro",slug:"simon-navarro",fullName:"Simón Navarro"},{id:"202988",title:"Dr.",name:"Nuria",middleName:null,surname:"Vela",slug:"nuria-vela",fullName:"Nuria Vela"},{id:"202989",title:"Dr.",name:"José",middleName:null,surname:"Fenoll",slug:"jose-fenoll",fullName:"José Fenoll"},{id:"206059",title:"Dr.",name:"Gabriel",middleName:null,surname:"Pérez-Lucas",slug:"gabriel-perez-lucas",fullName:"Gabriel Pérez-Lucas"}]}],mostDownloadedChaptersLast30Days:[{id:"55440",title:"Solubility Products and Solubility Concepts",slug:"solubility-products-and-solubility-concepts",totalDownloads:3051,totalCrossrefCites:6,totalDimensionsCites:7,abstract:"The chapter refers to a general concept of solubility product Ksp of sparingly soluble hydroxides and different salts and calculation of solubility of some hydroxides, oxides, and different salts in aqueous media. A (criticized) conventional approach, based on stoichiometry of a reaction notation and the solubility product of a precipitate, is compared with the unconventional/correct approach based on charge and concentration balances and a detailed physicochemical knowledge on the system considered, and calculations realized according to generalized approach to electrolytic systems (GATES) principles. 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The PA industry is spread out worldwide in Europe, Asia and America, including countries that operate phosphate rock (PR) mines and produce PA, phosphatic fertilizers and phosphate-based products.",book:{id:"5595",slug:"phosphoric-acid-industry-problems-and-solutions",title:"Phosphoric Acid Industry",fullTitle:"Phosphoric Acid Industry - Problems and Solutions"},signatures:"Benjamín Valdez Salas, Michael Schorr Wiener and Juan Ricardo\nSalinas Martinez",authors:[{id:"16436",title:"Dr.",name:"Michael",middleName:null,surname:"Schorr",slug:"michael-schorr",fullName:"Michael Schorr"}]},{id:"62941",title:"Inorganic Coordination Chemistry: Where We Stand in Cancer Treatment?",slug:"inorganic-coordination-chemistry-where-we-stand-in-cancer-treatment-",totalDownloads:2113,totalCrossrefCites:5,totalDimensionsCites:10,abstract:"Metals have unique characteristics such as variable coordination modes, redox activity, and reactivity being indispensable for several biochemical processes in cells. Due to their reactivity, their concentration is tightly regulated inside the cells, and abnormal concentrations are associated with many disorders, such as cancer. As such metal complexes turned out to be very attractive as potential anticancer agents. The discovery of cisplatin was a crucial moment, which prompted the interest in Pt(II) and other metal complexes as potential anticancer agents. This chapter highlights the state of the art on metal complexes in cancer therapy, highlighting their uptake mechanisms, biological targets, toxicity, and drug resistance. Finally, based on the importance of selective target of cancer cells, drug delivery systems will also be discussed.",book:{id:"7549",slug:"basic-concepts-viewed-from-frontier-in-inorganic-coordination-chemistry",title:"Basic Concepts Viewed from Frontier in Inorganic Coordination Chemistry",fullTitle:"Basic Concepts Viewed from Frontier in Inorganic Coordination Chemistry"},signatures:"Pedro Pedrosa, Andreia Carvalho, Pedro V. Baptista and Alexandra R. Fernandes",authors:[{id:"253664",title:"Prof.",name:"Alexandra R",middleName:null,surname:"Fernandes",slug:"alexandra-r-fernandes",fullName:"Alexandra R Fernandes"}]},{id:"57464",title:"General Aspects of the Cobalt Chemistry",slug:"general-aspects-of-the-cobalt-chemistry",totalDownloads:2271,totalCrossrefCites:1,totalDimensionsCites:2,abstract:"This chapter aims to collect and summarize the chemical properties of cobalt and some new cobalt compounds. It deals with the progress of cobalt chemistry. Cobalt has been substantial in both chemical reactions and within many compounds. Some of them are heterocyclic reactions, cobalt-based catalyst and cobalamin. Also, it discusses variety of applications of cobalt in a wide range of areas and toxicity of cobalt. The studies carried out in this area so far have enabled and will be continued to be responsible for producing unknown and difficult reactions. This survey of the recent literature illustrates the fact that many different approaches on cobalt and new cobalt compounds are being used in many different areas.",book:{id:"6133",slug:"cobalt",title:"Cobalt",fullTitle:"Cobalt"},signatures:"Yasemin Yildiz",authors:[{id:"208129",title:"Dr.",name:"Yasemin",middleName:null,surname:"Yıldız",slug:"yasemin-yildiz",fullName:"Yasemin Yıldız"}]},{id:"55301",title:"Recent Overview on the Abatement of Pesticide Residues in Water by Photocatalytic Treatment Using TiO2",slug:"recent-overview-on-the-abatement-of-pesticide-residues-in-water-by-photocatalytic-treatment-using-ti",totalDownloads:1982,totalCrossrefCites:9,totalDimensionsCites:26,abstract:"The water bodies’ pollution with phytosanitary products can pose a serious threat to aquatic ecosystems and drinking water resources. The usual appearance of pesticides in surface water, waste water and groundwater has driven the search for proper methods to remove persistent pesticides. Although typical biological treatments of water offer some advantages such as low cost and operability, many investigations referring to the removal of pesticides have suggested that in many cases they have low effectiveness due to the limited biodegradability of many agrochemicals. In recent years, research for new techniques for water detoxification to avoid these disadvantages has led to processes that involve light, which are called advanced oxidation processes (AOPs). Among the different semiconductor (SC) materials tested as potential photocatalysts, titanium dioxide (TiO2) is the most popular because of its photochemical stability, commercial availability, non-toxic nature and low cost, high photoactivity, ease of preparation in the laboratory, possibility of doping with metals and non-metals and coating on solid support. 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He obtained a Master’s degree in Public Health and PhD in Public Health and Epidemiology. He has a background in Clinical Medicine and has taken courses at higher diploma levels in public health from University of Transkei, Republic of South Africa, and African Medical and Research Foundation (AMREF) in Nairobi, Kenya. Dr. Kasenga worked in different places in and outside Malawi, and has held various positions, such as Licensed Medical Officer, HIV/AIDS Programme Officer, HIV/AIDS resource person in the International Department of Diakonhjemet College, Oslo, Norway. He also managed an Integrated HIV/AIDS Prevention programme for over 5 years. He is currently working as a Director for the Health Ministries Department of Malawi Union of the Seventh Day Adventist Church. Dr. Kasenga has published over 5 articles on HIV/AIDS issues focusing on Prevention of Mother to Child Transmission of HIV (PMTCT), including a book chapter on HIV testing counseling (currently in press). 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