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For the outbreak of Covid-19 in Wuhan, For the first line anesthesiologists when anesthesia for patients with different conditions will also face a large number of risks, In response of Wuhan medical association anesthesiologist, Haisheng medical will donate the medical device worth about one million yuan to Wuhan. The anesthesia breathing circuit was specially named "new crown special anesthesia breathing circle" by the company. All products are disposable to use, avoid mutual infection among patients sharing anesthesia machine. According to the latest expert consensus of the department of anesthesiology, "work recommendations for the prevention and control of novel coronavirus pneumonia (1st edition)", the inhalation/exhalation end of anesthesia equipment should be provided with a respiratory filter, and the patient end should be provided with one. Apply 3 breath filters at a time. The donated kits come with three FDA-Certified respiratory filters (third party Nielsen laboratory virus filtration rate > 99.993%). Not only to protect the patient, but also to protect the beloved medical staff. Haisheng Donated high quality laryngoscope and disposable laryngoscope blades. On the one hand, the anesthesiologist only needs to observe the laryngoscope display screen during intubation, which does not need to be too close to the patient's face, and can maintain a safer distance from the patient. On the other hand, intubation under visualization can greatly shorten the intubation time and avoid the risk of infection caused by doctors' close contact with patients Haisheng as a medical enterprise with social responsibility to contribute to the outbreak, wish an early end to the epidemic.

Since the end of December 2019, The Epidemic named COVID-19 outbreak in Wuhan, Hubei Province. Wuhan Jinyintan Hospital received the first batch of patients with pneumonia with unknown causes; it has become the focus of the whole country and even the world.With the increase of the concentration of severe patients, the demand for disposable medical consumables such as disposable breathing tubes for ICU is increasing.The shortage of medical supplies has become the biggest problem of the moment. To support the rescue mission, meet the needs of the epidemic prevention, Haisheng production line carry out the production work in advance on January 30th, now work overtime to production. Now The Wuhan Jinyintan Hospital and Wuhan Sixth Hospital and other hospital is using Haisheng medical device in succession. "Producing one more batch of medical supplies may save several more people," one worker said. Not only is the disposable breathing circle, especially the breathing filter is the necessary tool to block bacteria and viruses.The Breathing Filter has been approved by the Nielsen experiment in the United States and obtained the 510K certification from the United States FDA. Connect the ventilator line with a breathing filter to avoid cross-infection between patients, equipment, doctors and other patients (sharing the same equipment).In addition, Haisheng made disposable body temperature transducer, disposable humidified oxygen products and other series can also provide protection in the prevention of virus infection. In the current emergency period, Haisheng medical has made comprehensive preparations for the resumption of production which will pool the potential force to overcome the epidemic prevention and control sniper war.

Booth No.:Pending

Booth No.: Pending

Booth Number:4-111, Hall Blue Sao Paulo - Brazil 21 - 24, May, 2019

A few days ago, Zhejiang Excellent Industrial Product Selection Committee announced the list of "2021 Zhejiang Excellent Industrial Products". Hisern`s "Anesthetic video laryngoscope", "Disposable anesthesia puncture kit (resistance to bending type)", "Disposable Duo-limb Anesthesia Circuit" won the "Zhejiang Excellent Industrial Product Certificate". "Zhejiang Excellent Industrial Products" is a brand and quality "golden card" created by Zhejiang Federation of Industrial Economics and 65 provincial industry associations, prefecture and municipal enterprise associations, entrepreneur associations and industrial Economic associations in order to promote the construction of high-end products and advanced manufacturing collaborative innovation ecosystem. The selection has undergone rigorous preliminary selection, expert review, final selection, publicity and other procedures. Winning this award means that Hisern`s products have been highly recognized by the society in terms of quality, innovation, professionalism, and market prospects, which effectively promotes the corporate brand image, increases corporate visibility and market competitiveness. Hisern Medical has a global sales and service network Understand your problem for the first time and provide product solutions Hisern Medical has been committed to providing quality products and services Welcome your consultation and understanding T: +86-575-88158558 E: info@hisern.com For more details, please visit: www.hisern.com/en

Since the outbreak of the new crown in early 2020, more than 100 million people have been diagnosed globally and more than 3 million people have lost their lives. The global crisis triggered by COVID-19 has penetrated into all aspects of our medical system. In order to prevent the spread of the new coronavirus to patients, medical staff, equipment and the environment, we mainly rely on two important filtration systems: loop filters and masks when using artificial respiration systems in operating rooms and/or intensive care units (ICU) Respirator. However, there are many types of breathing filters on the market. When discussing the level of filtration efficiency of different manufacturers, are their standards the same? During the COVID-19 epidemic, how to choose a high-performance breathing filter? Clinicians should understand the specifications of the respiratory pathway filter. These can be found from the manufacturer's website or hotline, product literature, online and journal articles. Important parameters include: l Bacteria and virus filtration efficiency (%-the higher the better) l NaCl or salt filtration efficiency (%-the higher the better) l Air resistance (pressure drop at a given air velocity (unit: Pa or cmH2O, unit: L/min), the lower the better) It should be noted that when the filter is under humid conditions, will its previous parameters (for example, filtration efficiency and gas resistance) be affected or changed? l Internal volume (the lower the better) l Humidification performance (moisture loss, mgH2O/L air-the lower the better), or (moisture output, mgH2O/L air, the higher the better). The heat and moisture exchange (HME) equipment itself has no filtering performance. HMEF adopts electrostatic membrane or pleated mechanical filter membrane with heat and moisture exchange function and filtering performance. It should be noted that HMEF can only effectively perform the heat and moisture exchange function when it is close to the airway and in the position of the two-way airflow. They retain water during exhalation and release water during inhalation. Hisern Medical`s Disposable breathing filters have the testing report issued by the Nelson Labs from the United States, and it protects patients and medical staff from air and liquid-borne microbial pathogens. Nelson Labs is a clear leader in the microbiology testing industry, offering more than 700 laboratory tests and employing more than 700 scientists and staff in state-of- the-art facilities. They are known for exceptional quality and rigorous testing standards. Heat Moisture Exchanger Filter (HMEF) Introduction: Heat and Moisture Exchanger Filter (HMEF) combines the efficiency of dedicated breathing filters with optimum moisture return. Features: l Low dead space, to minimize dangers associated with re-breathing carbon dioxide. l Lightweight, to reduce additional heavy on the tracheal connection. l Maximizes the humidity of inspired gases. l ISO, CE&FDA 510K Hisern Medical has a global sales and service network Understand your problem for the first time and provide product solutions Hisern Medical has been committed to providing quality products and services Welcome your consultation and understanding T: +86-575-88409031 E: info@hisern.com For more details, please visit: www.hisern.com/en

This technique measures arterial pressure directly by inserting a cannula needle into the appropriate artery. The catheter must be connected to a sterile, fluid-filled system connected to an electronic patient monitor. In order to measure blood pressure correctly using an arterial catheter, the experts propose a systematic 5-step method that assists in (1) selecting the insertion site, (2) selecting the type of arterial catheter, (3) placing the arterial catheter, (4) level and zero sensors, and (5) checking the quality of the BP waveform. During operation, it is necessary to prevent air from entering and causing embolism; Careful selection of suitable vessels and puncture sheath/radial artery sheath is also required. Postoperative effective nursing to prevent the occurrence of complications is very important, these complications include: (1) hematoma, (2) Infection of puncture site, (3) Systemic infection, (4) arterial thrombosis, (5) Distal ischemia, (6) Local skin necrosis, (7) Arterial joint loosening caused blood loss, etc. Which methods can be used to enhance care: 1. After successful catheterization, keep the skin at the puncture site dry, clean and free from oozing blood. Replace 1 times daily apply, there is bleeding at any time disinfection replacement at any time. 2. Strengthen clinical monitoring and monitor body temperature 4 times a day. If the patient has high fever, chills, should be timely search for the source of infection. If necessary, tube culture or blood culture is taken to assist diagnosis, and antibiotics should be properly used. 3. The catheter should not be placed for too long, and the catheter should be removed immediately once there are signs of infection. Under normal circumstances, the blood pressure sensor should be kept for no more than 72 hours and the longest one week. If it is necessary to continue, the pressure measurement site should be replaced. 4. Replace the heparin diluent connecting the tubes every day. Prevent intraductal thrombosis. 5. Closely observe whether the color and temperature of the distal skin of the arterial puncture site are abnormal. If liquid extravasation is found, the puncture site should be pulled out immediately, and 50% magnesium sulfate should be wet applied to the red and swollen area, and infrared therapy can also be irradiated. 6. Local bleeding and hematoma :(1) when the puncture fails and the needle is pulled out, the local area can be covered with gauze ball and wide adhesive tape under pressure. The center of pressure dressing should be placed at the needle point of the blood vessel, and the local area should be removed after 30 minutes of pressure dressing if necessary. According to the vascular anatomy and physiology of radial artery puncture, Yixinda specializes in producing tourniquet with radial artery compression for medical staff to assist in hemostasis after the removal of puncture needle or indentation needle during artery puncture operation. After surgery, the patient was asked to keep the limbs straight on the operative side, and pay attention to local observation if the patient has activities in the short term to prevent bleeding. 7, hematoma can be 50% magnesium sulfate wet compress or spectral instrument local irradiation needle and test tube should be fixed firmly, especially when the patient is agitated, should strictly prevent their own extubation. (3) The connection of the arterial pressure tube must be closely connected to avoid bleeding after disconnection. 7. Distal limb ischemia: (1) the collateral circulation of the intubated artery should be confirmed before surgery, and puncture should be avoided if the artery has lesions. (2) Choose appropriate puncture needles, usually 14-20g catheter for adults and 22-24g catheter for children. Do not be too thick and use them repeatedly. (3) Maintain the good performance of the tee to ensure the dripping of heparin normal saline; In general, every time arterial blood is extracted through the pressure tube, it should be immediately rinsed with heparin saline to prevent clotting. In the process of pressure measurement, blood sample collection or zero adjustment, it is necessary to strictly prevent intravascular air embolism. (4) When the pressure curve on the monitor is abnormal, the cause should be found. If there is blood clot blocked in the pipeline, it should be removed in time. Do not push the blood clot in to prevent arterial embolism. (5) Closely observe the color and temperature of the distal skin of the operative side, and dynamically monitor the blood flow of the hand through the blood oxygen saturation of ipsilateral finger. Extubation should be timely when abnormal changes of ischemia signs such as pale skin, temperature drop, numbness and pain are found. (6) If the limbs are fixed, do not wrap them in a ring or wrap them too tightly. (7) The duration of arterial catheterization is positively correlated with thrombosis. After the patient's circulation function is stable, the catheter should be removed in time, generally no more than 7 days. Disposable pressure transducer Introduction: Provide consistent and accurate readings of arterial and venous blood pressure measurements. Features: l Kit options (3cc or 30cc) for both adult/pediatric patients. l With single, double and triple lumen. l Available with closed blood sampling system. l 6 connectors and various cables match most monitors in he world. l ISO, CE & FDA 510K. Hisern Medical has a global sales and service network Understand your problem for the first time and provide product solutions Hisern Medical has been committed to providing quality products and services Welcome your consultation and understanding T: 0575-88409031 E: info@hisern.com For more details, please visit: www.hisern.com

When a patient`s trachea is intubated or a supraglottic airway device is placed in situ, the normal warming, humidifying and filtering functions of the upper airways are bypassed. Hence, gas delivered to the patient needs to be artificially conditioned to replace these lost functions Heat and moisture exchangers (HMEs) are intended to conserve a portion of the patient`s exhaled heat and moisture, and condition inspired gas by warming and humidifying it. Breathing system filters are intended to reduce the transmission of microbes and other particulate matter in breathing systems. Devices that contain both filters and HME are called Heat Moisture Exchanger Filters (HMEFs). It is not ideal to distinguish these two common filters with "static" and "folds", because these two types of filters rely on electrostatic charge to a certain extent to keep the particles in the filter material, two types All materials can be folded. The main difference between the two types is the density of the fibers. For "electrostatic" filter materials, the density of the fibers is relatively low, and the electrostatic charge (fiber or triboelectric charge) on the fibers is high. For "pleated" filters, the density of the fibers is high: this leads to increased resistance to gas flow; the pleated material increases the surface area, thereby reducing the resistance. This type of filter is also called "hydrophobic" (because the surface of the filter material repels water) or "mechanical". In this review, the terms "electrostatic" and "pleat" will be used to distinguish these two types of filters. Heat Moisture Exchanger Filter (HMEF) Introduction: Heat and Moisture Exchanger Filter (HMEF) combines the efficiency of dedicated breathing filters with optimum moisture return. Features: l Low dead space, to minimize dangers associated with re-breathing carbon dioxide. l Lightweight, to reduce additional heavy on the tracheal connection. l Maximizes the humidity of inspired gases. l ISO, CE&FDA 510K Hisern Medical has a global sales and service network Understand your problem for the first time and provide product solutions Hisern Medical has been committed to providing quality products and services Welcome your consultation and understanding T: 0575-88409031 E: info@hisern.com For more details, please visit: www.hisern.com

As one of the common equipment, the anesthesia video laryngoscope has a complete function during use. The stable and clean image can ensure fast intubation. It seems that the overall safety will be very high. If it can be used normally, I believe it can be recognized by many people in the market. The current market price is reasonable and the effect of use is also very good. When using an anesthesia video laryngoscope, you can find that the device itself has a patented design. Therefore, it has the functions of taking photos, recordings and storing data when in use. The entire standard video display is very clear, if it can be fast Recognizing photos can also quickly determine the disease, which also shows that the characteristics of the device during use are obvious and it is worth choosing. Judging from the advantages of the design, it is now the choice of a vertically facing optical imaging system, which can display the intubation situation in time, and can also reduce the occurrence of damage in the process of guiding the intubation. The appearance is solid and solid, and the service life is also long. Very long, judging from this feature, it can attract many people to choose with confidence. Now that the power supply technology is more advanced, it can also make the power supply more stable. Anesthesia video laryngoscope has many characteristics in terms of safety and other aspects. If it can be used normally, the equipment will have a good detection effect and it is very convenient to use, which is very convenient for many doctors. It can be accurately detected, and the video content of the entire laryngoscope is also very clear. Application scope of anesthesia video laryngoscope: l Anesthesiology l Emergency Department l ICU l Ambulance l Clinical intubation l Simulation exercises l Clinical teaching l Difficult airway intubation Advantages of anesthesia video laryngoscope: l Clearly show the structure of the larynx and visualize the airway intubation. l The screen can be rotated for easy viewing by the doctor. l The screen displays the front-end image of the lens in real time, which is convenient for clinical teaching. Video Laryngoscope Introduction: A rigid laryngoscope with camera used for difficult and routine endotracheal tube intubations. Features: l Integrated handle, easy to hold operation. l One click to open, quick start, runs immediately. l 3-inch HD monitor displays vocal cord and glottis images clearly. l Integrated formed and anodized aluminum alloy surface which is firm and wear-resistant. l 90 degrees rotated screen, easy for observation and intubation. Hisern Medical has a global sales and service network Understand your problem for the first time and provide product solutions Hisern Medical has been committed to providing quality products and services Welcome your consultation and understanding T: 0575-88409031 E: info@hisern.com For more details, please visit: www.hisern.com

Question 1: Does Video laryngoscope Increase the Success Rate of Tracheal Intubation? With a video laryngoscope, because the image of the glottis is captured near the tip of the blade, only a few centimeters of line of sight will be required. In addition, an assistant can adjust the direction and degree of pressure on the neck by confirming the improvement of the view of the glottis on a video screen. Therefore, theoretically, a video laryngoscope would provide a better view of the glottis, and would increase the success rate of tracheal intubation. Question 2: Are Video laryngoscopes Less Stressful and Less Traumatic? Compared with a conventional laryngoscope, a video laryngoscope would be less stressful to the patient, because the video laryngoscope is less likely to require extension and flexion of the head and neck, pressure on the neck, and distortion of the upper airway. Lauren C. Berkow, MD., Timothy E. Morey, MD., and Felipe Urdaneta, MD. concluded that the ideal intubation device would be safe, efficient, reliable, portable, affordable, cost-effective, usable in all age groups and in any location, and easy to teach and master compared to traditional direct laryngoscope methods. Video laryngoscope is a very recent invention in the quest to find alternatives and overcome the intrinsic limitations of the direct approach to laryngeal exposure and intubation. Video laryngoscope is considered a paradigm shift from conventional laryngoscopy and has changed how intubation is taught, learned, and even supervised. Video laryngoscope systems have been added to most major airway guidelines as a primary or alternate firstline approach to intubation as well as for use as a rescue device. Suggestion: Choose Hisern Medical`s Video Laryngoscope and Disposable Laryngoscope Blade. Video Laryngoscope l Ergonomic Design: Ultra-thin HD monitor; integrated handle; Easy for hold and lower physician impairment to patient. l Anti-maloperation Design: Power button on bottom, shut down with 3 seconds long press to prevent the risk of accidental shut down during use. l One click to open: Quick start, run immediately. l Clear image: 3-inch HD monitor displays vocal cord and glottis images clearly. l Firm and wearable: Integrated formed and anodized aluminum alloy surface which is firm and wear-resistant. l Easy for intubation: For patient with limited mouth opening and head and neck movement, it can provide a wider intubation visual field than ordinary larygoscopes, reducing the risk in difficult intubation. Disposable Laryngoscope Blade l Sterility assurance: Produced and packed in 100,000-level clean room, sterilized with EO to prevent the risk of infection. l HD and anti-fog Design: High-tech nano coating, no need preheating and demisting. l Suitable size: The arc design of the laryngosope meets the physiological curve of human oropharynx. l Reasonable shape: compatible with the Macintosh blade.

Project significance (compared to inflatable mask): 1. Convenient to use (no need for the tedious operation of repeated inflation of the syringe). 2. No leakage (three-dimensional soft cushion, directly attached to the face, no risk of airbag leakage). 3. No peculiar smell (elastomer cushion material, no unpleasant condition that the airbag material is easy to deteriorate and produce peculiar smell). 4. The connection is firm (the cushion and the shell are connected by a physical nesting structure, and there is no risk of degumming). Product advancement: patented, non-inflatable mask Patent No.: CN 213642695 U Product cost: a significant reduction of 56-78%. According to the trial results, Dr. Qin Xuewei of Peking University International Hospital tried 7 anesthesia masks (non-inflatable type) and obtained the following points: 1. The effect of ventilation is satisfactory. 2. The cover is clear and easy to see the face. 3. The edge of the mask is crimped to facilitate vomit or saliva to stay at the crimped edge. 4. It was also suggested that obese patients might leak air during pressurized ventilation. The conclusion is that the product is satisfactory and consistent with existing products. Dr. Anli of Shijiazhuang Hospital of Traditional Chinese Medicine tried anesthesia mask (non-inflatable type) and found that the effect of conventional ventilation was satisfactory. He put forward his opinions: 1. There is no fixed ring and it is inconvenient to fix. 2. The fit is worse than the inflatable mask. 3. Inflatable mask cost and hospital control cost are listed as performance assessment indicators of departments, and cost is also a factor of replacement. In conclusion, Hisern Medical chooses the correct size anesthesia mask for all patients. The steps are as follows: 1. Take out the Hisern anesthesia mask from the package and connect it to the respiratory system. 2. Place the mask on the lower lip so that it covers the mouth and nose. The anatomical shape will conform to the size and shape of various face shapes. Hold the mask with your thumb and index finger. If necessary, use the rest of your fingers to lift your chin. There is no need to press hard. The materials used and the true anatomical shape mean that the seal is achieved with minimal pressure. Hisern Anesthesia Mask is a disposable product and should be discarded according to hospital agreement after use.

Clinical application of Central Venous Catheter Central venous catheterization allows for an adequate therapy of critically ill patients during complex therapeutic interventions, especially in anesthesia, intensive care and emergency. 1. Monitoring the central venous pressure (CVP) : it reflects the right ventricular preload and is an index guiding clinical infusion (normal VALUE of CVP: 5-12cmH2O). CVP BP Clinical significance Approach low low Hypovolemia Adequate fluid replacement high low Cardiac insufficiency or relatively excessive volume Strengthens the heart and relaxes the blood vessels high normal Volume vasoconstriction, high PVR Diastolic blood vessels normal low Low CO, relatively insufficient capacity Rehydration experiment 2. Quickly open the large venous channel and quickly replenish fluid: central venous puncture can provide the fastest infusion speed. Back of the hand and forearm veins < 95 ml/min Elbow and upper arm veins 100 – 300ml/min Subclavian vein 1 - 1.5L/min Superior vena cava 2 - 2.5L/min 3. Infusion of special drugs: Infusion of the following drugs has different degrees of damage and impact on peripheral veins, it is necessary to use a central venous catheter infusion instead. l Extreme osmotic pressure ＞ 500mOsm/Kg l The limit of PH value l ＞ 10% glucose l Stimulating drugs, etc. Hisern Medical`s Central Venous Catheter Features: l Equipped with Guided Syringe or T-Type introducer. l Sterile product and comes with single use. l Contains scalpel, Catheter holder and clamp, indwelling catheter, injection cap, extension line clamp and other necessary consumables. Central Venous Catheter(CVC) can be lifesaving but is associated with complication rates of approximately 15%. Operator experience, familiarity with the advantages and disadvantages of the various catheterization sites, and strict attention to detail during insertion help reduce mechanical complications associated with catheterization. Strict aseptic technique and proper catheter maintenance decrease the frequency of catheter-related infections. Routine scheduled catheter changes are not war- ranted. In all cases, central venous catheters should be removed as soon as they are no longer needed.

Question 1: Why use Heat Moisture Exchanger Filters (HMEF)? HMEF is passive humidification with bacterial/viral filtration efficiency. Gases emerging from anesthesia machine are dry and room temperature (cold). Tracheal intubation or use of laryngeal mask airway bypasses upper airway modifying pattern of heat and moisture exchange, lungs need 37° & 100% relative humidity. Cilia can stop beating with impaired mucocilliary function includes sputum retention & increased risk of infection. Warmed humidified air is better than cold, dry gases even in short cases. Question 2: Why use Bacterial Viral Filters (B/V)? If used on both the inspiratory and expiratory limb, eliminates risk of switching the filtration limb at machine. Expert committees recommend the use of filters for control/prevention of infections. Mike Pedro, MD: Filter Consideration in the Covid-19 Era. As the COVID-19 pandemic evolves, filtration of mechanical ventilation, such as used in intensive care and anesthesia settings, has become an essential factor in infection control. Ideally, at least two filters should be changed with every patient use: in the expiratory port limb at the connection to the machine and at the connector between the circuit and the patient. These locations protect against contamination of the machine and thus the potential for cross contamination or transmission of pathogens when sampling gases for analysis. Solution: Choose Hisern Medical`s Disposable breathing filter. (Recommend: 1HMEF+2BV Filter) Filter effects, low airway resistance, product quality assurance(As evidenced by the test report of Nielsen Laboratories). l High-efficiency filter media, bacteria filtration efficiency>99.999%, virus filtration efficiency>99.99%; l (Heat and moisture exchange type) high wet material, maintaining the warmth and humidification of the airway, to reduce the loss of heat and moisture of the patient. l Lightweight, to reduce additional heavy on the tracheal connection. l A variety of specifications to meet the needs of adults and pediatric. l Combined use, effectively avoiding cross-infection of machines, patients, and medical staff, making it safer. l The product obtained FDA marketing approval 510 (k) No: K151498

Blood pressure refers to the lateral pressure in blood in a blood vessel against a unit area of the blood vessel wall. The method of measuring blood pressure can be divided into non-invasive monitoring and invasive monitoring, among which non-invasive detection is indirect pressure measurement, which is relatively easy to grasp and has a wide range of indications. But the drawback is obvious: it is not accurate enough, it can only test blood pressure at a point in time. In invasive monitoring, the catheter is directly connected to the blood vessel and directly touches the blood, the pressure in the blood vessel is converted into an electrical signal by the pressure sensor to be recorded in the monitor, and then the monitor is converted into numbers and waveform. Invasive monitoring can provide continuous and accurate systolic blood pressure, diastolic blood pressure and average blood pressure, draw the arterial pressure curve, find the change of blood pressure at any time, and can conveniently take blood for blood gas analysis, so as to relieve the pain of patients. Which patients need invasive blood pressure monitoring? When blood pressure must be kept within a narrow range, critically ill patients whose blood pressure may fluctuate greatly and rapidly need to be observed in real time, and patients whose blood pressure cannot be monitored without invasiveness and need to repeatedly take arterial blood samples for blood gas analysis. Departments used: operating room, anesthesiology department, ICU, emergency department, PCI surgery for coronary heart disease treatment (interventional department, cardiology department, catheterization laboratory). At present, Hisern Medical has obtained 45 national authorized patents, 27 NMPA certificates from China National Medical Products Administration, and CE certificates from EU for 18 products. Disposable pressure transducer and disposable bacterial and viral filter have been approved by FDA 510K. In year 2017, Hisern Medical has passed FDA`S site audit according to QSR820 quality system. Hisern Medical`s products have been widely used in nearly 600 Grade III Level A hospitals in China and exported to more than 30 countries in the world.

Author: Dai Ziyi Huang Yuguang This article is transferred from: J Clin Anesthesia, May 2021, Vol. 37, No. 5, Volume 37, Issue 5 of the Journal of Clinical Anesthesiology, May 2021 The normal body temperature regulation system is composed of three parts: temperature sensor, body temperature regulation center and effector. The core body temperature is tightly regulated and maintained at about 37 ℃, and the peripheral body temperature is 2 ℃ to 4 ℃ lower than the core body temperature. Different from purposeful therapeutic hypothermia, perioperative core body temperature lower than 36.0 ℃ caused by non-medical plan is called perioperative accidental hypothermia (IPH), also known as perioperative hypothermia. The incidence of IPH in various operations is 7% to 90%, which can lead to cardiovascular events, postoperative infections, and increased risk of blood transfusion. The occurrence of IPH is affected by many factors such as anesthesia, surgery, and the patient's own condition. Therefore, prevention and treatment of IPH has become an important part of accelerated rehabilitation surgery (ERAS). There are guidelines that recommend the prevention of IPH, but do not clarify the specific best practices for perioperative temperature management. Although a large number of active thermal insulation measures have been put into clinical use, the incidence of IPH is still high, and there is an urgent need for more efficient methods to prevent IPH. In this paper, the effectiveness of existing IPH prevention strategies will be compared and discussed based on the latest research progress. IPH overview Adverse outcome: IPH is a common intraoperative complication. The intraoperative body temperature of patients decreased by 2 ℃, the risk of infection at the surgical site increased to three times that of patients with normal body temperature, and the wound suture removal time was delayed by 1 day compared with patients with normal body temperature. The incidence of postoperative cardiovascular events (including unstable angina or myocardial ischemia, cardiac arrest, and myocardial infarction) in IPH patients was significantly higher than that in patients with normal body temperature (6.3% vs 1.4%, P=0.02). The risk of intraoperative blood transfusion increased with the degree of hypothermia and duration of hypothermia. Research by Allen et al. have shown that IPH of maternal cesarean section under subarachnoid block may affect the body temperature of the fetus, leading to an increase in the incidence and mortality of neonatal respiratory distress syndrome, hypoglycemia. In addition, IPH can also lead to complications such as increased demand for mechanical ventilation, increased incidence of pressure ulcers, impaired metabolism of anesthetic drugs, increased incidence of chills, and decreased thermal comfort, thereby prolonging the observation time in the post-anaesthesia monitoring and treatment room (PACU). Intensive care unit (ICU) observation time and hospital stay. Mechanism and risk factors: Perioperative core body temperature drops through 3 periods: rapid decline period, anesthetics damage the body temperature regulation center, reduce vasoconstriction and chills threshold, cause vasodilation, so that body heat within 1 hour after induction of anesthesia The core is redistributed to the periphery. During the slow linear decline period, the intraoperative heat loss mainly caused by radiation and convection exceeds the metabolic heat production, resulting in a slow decline in body temperature for 2 hours. In a plateau, hypothermia eventually triggers vasoconstriction, limiting further loss of core heat and balancing the body's heat production and dissipation. The risk of IPH is related to multiple factors such as the patient's own condition, anesthesia, surgery, environmental temperature, perioperative medication, and insulation state. The risk of IPH was directly increased by anaesthesia related factors, such as anesthesia time >2 h, anesthetic drugs, intraoperative infusion of unwarmed fluid >1 000 ml, and combined anesthesia. Patients with age ≥60 years, BMI<25 kg/m2, ASA class ⅱ or above, low basal body temperature before surgery, and history of impaired thermoregulation. Operation-related factors such as operation time >2 h, open surgery, high surgical grade, intraoperative use of unheated rinsing fluid >500 mL, and low operating room temperature indirectly increased the risk of IPH. Research by Miyazaki et al. showed that in the process of establishing pneumoperitoneum during laparoscopic surgery, cold and dry CO2 gas can directly contact the entire inner surface of the abdominal cavity and take away a lot of heat, but the heat insulation of visceral fat prevents the temperature of internal organs under the pneumoperitoneum from falling. Thus reducing the risk of intraoperative hypothermia. Therefore, the researchers suggest that the waist-to-hip ratio reflecting visceral obesity should be included as a predictor of core body temperature during laparoscopic surgery to effectively assess the risk of intraoperative hypothermia. Perioperative temperature management Assess IPH risk: Clinical guidelines recommend continuous assessment of IPH risk throughout the perioperative period based on the patient's IPH risk factors, body temperature monitoring, thermal comfort, and signs and symptoms of hypothermia. A domestic multi-center study included major risk factors for IPH such as patient BMI, preoperative basal body temperature, surgery scale, and anesthesia time to construct a predictive model of IPH probability for general anesthesia patients to assist the surgical team in predicting the risk of hypothermia during surgery. Analyzing the necessity and effectiveness of body temperature protection measures, and effectively preventing IPH based on risk stratification management. The actual clinical application effect of this model is being further tested by multi-center and large samples. Temperature monitoring: Perioperative patient temperature monitoring should be as much as possible to maintain the same position and method as before entering the operating room. Temperature monitoring starts 1 hour before anesthesia, and continuous monitoring during the operation or at least once every 15 to 30 minutes, from the end of the operation to leaving Body temperature monitoring is still required during PACU. The core body temperature can best reflect the body's heat status. The monitoring sites include the pulmonary artery, distal esophagus, nasopharynx and tympanic membrane, but most of these sites are inconvenient to measure. Among the other monitoring parts, the oral cavity is closest to the core body temperature and is suitable for awake patients, followed by the armpits, bladder, and rectum. The measurement results of infrared ear temperature and temporal artery temperature are inaccurate. The core body temperature of children is higher than that of adults (36.5~38.0 ℃) and the temperature drops faster. The guidelines recommend rectal temperature measurement for children under 2 years of age. The new sensor derived from the new zero heat flow technology can provide non-invasive, hygienic, and continuous monitoring of core body temperature, which is more suitable for patients with intraspinal anesthesia. Given that various temperature measurement technologies are sufficiently accurate, the current accuracy of body temperature monitoring depends more on the measurement site. Non-pharmaceutical insulation measures: including passive insulation, active insulation and increasing the ambient temperature. 1. Passive insulation: Passive insulation should run through the entire perioperative period, including conventional care such as cotton blankets and surgical drapes, and thermal insulation measures such as reflective blankets. Passive insulation can reduce heat loss by 30%, and its insulation effect is related to the coverage area and the number of layers. A prospectie study into line (elective surgical procedures operation time < 1 h) in adult patients with 328 cases, preoperative application of reflective blanket or routine care for thermal insulation cotton blanket, the patients were randomly divided into two groups. The results showed that reflective blankets can be significant The preoperative temperature difference between the temporal artery and the foot was reduced, and the temperature of the foot was increased. There was no significant difference in the minimum core body temperature between the two groups during the operation, indicating that the reflective blanket can increase the body's peripheral heat reserve more than the conventional nursing blanket. Research by Smith et al. have shown that the new Orve+wrap insulation blanket can absorb heat and transfer heat to the patient after preheating, and can achieve the same effect as the inflatable heating device in the short-term postoperative heat preservation (<60 min). 2. Active heat preservation: Active heat preservation includes body surface warming, warming infusion, warming washing fluid, etc. (1) Single active heat preservation: Forced-air warming (FAW) is currently the most commonly used active heat preservation method, and its heat preservation effect is related to the heat preservation part and the heat preservation temperature. Min et al. selected 123 patients undergoing thoracoscopic surgery for a randomized controlled trial (RCT). The patients were in a lateral position during the operation. The results showed that the incidence of intraoperative hypothermia in the upper body air-inflation heating group was significantly lower than that of the lower body air-inflation heating group ( 34% vs 57%, P=0.011). Zhou Yanrong et al. selected 60 children undergoing fracture surgery. The children were randomly divided into three groups according to the different temperatures (32, 38, and 43℃) given during the operation. The results showed that the temperature of children in the 38℃ inflating and heating group was the most stable and the level of inflammatory factors was the lowest. Patients of different ages have different optimal inflation and heating temperatures. Xu et al. study selected 243 elderly patients undergoing arthroplasty. According to postoperative rewarming measures for patients with hypothermia, the patients were randomly divided into group C (conventional blanket) and group F1 (38℃ inflatable heating), F2 group (42℃ inflatable heating), the results showed that the shortest F2 group after temperature, highest efficiency, The incidence of arrhythmia and chills was the lowest, so 42 ℃ may be the optimal inflating temperature for the elderly. Studies by Gosling et al. showed that the incidence of postoperative hypothermia was 29.9% in patients who used air-filled heating during coronary artery bypass grafting, and 7.6% in patients who used circulating water heating. The postoperative body temperature of the patient was 0.5℃ higher than that of the patient who used air-filled heating, indicating that during thoracotomy, the circulating water device may be more effective in preventing and treating IPH than air-filled heating. Laparoscopic surgery also has the risk of IPH. Research by Dean et al. showed that compared with cold and dry CO2, the intraoperative establishment of warming and humidification CO2 pneumoperitoneum could effectively increase the intraoperative core body temperature by 0.3 ℃ (95%CI 0.1-0.6, P<0.001). A Meta analysis showed that, compared with passive thermal insulation, intraoperative active thermal insulation can effectively reduce the incidence of IPH in patients with spinal anesthesia (RR=0.71, 95%CI 0.61~0.83, P<0.001), but even if active thermal insulation is used, IPH may still occur in some patients, so the combined effects of different insulation strategies need to be further studied. (2) Pre-heat preservation: Pre-heat preservation can effectively reduce heat redistribution, make patients rewarming faster during surgery, and reduce the incidence of IPH and adverse outcomes. A systematic review of 14 RCTS showed that inflating and pre-heat preservation can effectively reduce the incidence of IPH in patients undergoing general anesthesia and intraspinal anesthesia, while the application of other heating systems in preinsulation needs further study. Studies have shown that the pre-heat preservation time is generally 15 min to 2h, and the recommended average pre-heat preservation time is 30 min. At least 10 min preheat preservation time is needed to effectively maintain the normal body temperature during surgery. Research by Alfonsi et al. showed that pre-thermal insulation combined with intraoperative thermal insulation can effectively prevent IPH (OR=0.48, 95%CI 0.24~0.96, P=0.025). Therefore, clinical measures of prethermal insulation combined with intraoperative thermal insulation should be further studied to increase the effectiveness of thermal insulation strategy. Munday and other studies have shown that for women undergoing cesarean section under intraspinal anesthesia, intraoperative conventional heating and infusion combined with short-term preheat preservation (20 min) cannot prevent intraoperative hypothermia. Grote et al. showed that the interruption of thermal insulation between the end of pre-thermal insulation and the start of intraoperative thermal insulation could reduce the effect of pre-thermal insulation, and the interruption time was significantly positively correlated with the incidence of intraoperative hypothermia (P<0.001). (3) Composite insulation: The guidelines suggest that the use of composite insulation to enhance active insulation. Zhang et al. compared the effects of different heat preservation methods on IPH in patients undergoing transurethral resection of the prostate under subarachnoid block. The study selected 443 elderly patients and randomly divided them into group F (intraoperative inflation heating) , E group (using electric blanket during the operation) and FE group (using inflatable heating and electric blanket during the operation), the device temperature is set to 38℃, the results showed that, compared with the FE group, the heart rate and average artery of the F group and the E group The blood pressure increased significantly, the temperature of the esophagus decreased significantly, the incidence of chills and arrhythmia increased significantly, and patient satisfaction decreased significantly. Chebbout et al. selected 132 women who had undergone cesarean section with subarachnoid block. All women received warming and infusion. According to the absence of other active heat preservation, intraoperative air heating, and intraoperative mattress heating In the three groups, the results showed that there was no statistically significant difference in the average core body temperature between the mothers and the newborns in the three groups. Therefore, the researchers believe that only the use of warming infusions during the operation can prevent maternal IPH, and the addition of other active warmth does not increase the benefit. Rao Yuquan et al. selected 80 patients undergoing spinal surgery under general anesthesia, and they were randomly divided into four groups: intraoperative heating and infusion group (FW group), intraoperative inflatable heating blanket group (AW group), intraoperative heating and infusion + inflatable heating Blanket group (FA group) and pre-operation inflatable heating blanket pre-warm for 30 min + intraoperative heating infusion + inflatable heating blanket group (PFA group), the results showed that compared with FW group, AW group, FA group and PFA group cut Body temperature increased significantly after 60 minutes after skin and 10 minutes after entering PACU, the incidence of postoperative chills was significantly reduced, and patient satisfaction increased significantly, suggesting that the effect of inflatable heating is better than heating infusion, but at different points in the AW group and FA group The difference in core body temperature between the PFA group and the PFA group was not statistically significant. 3. Increase the ambient temperature: It is generally recommended at home and abroad that the temperature in the operating room for adults should not be lower than 21℃. A 3 x 2 factorial experiment according to different environmental temperature in (19, 21, 23 ℃) and passive insulation or gas heating to randomly assigned 292 patients, the results showed that the environmental temperature on the gas heating temperature had no obvious effect on the patient, the use of passive insulation core body temperature can have an impact on patients, 1 ℃ ambient temperature increase, The core body temperature at the end of surgery was increased by 0.13 ℃ (95%CI 0.07-0.20, P<0.01). For children with surgery, the operating room temperature should not be lower than 24℃. A single-center RCT divided the cesarean women who received intraoperative warming and infusion into two groups according to the temperature of the operating room (20 ℃ and 23℃). The study showed that moderately increasing the ambient temperature to 23℃ can significantly reduce the newborn ( 35% vs 50%, P<0.001) and maternal (69% vs 77%, P=0.008) incidence of postoperative hypothermia, no effect on the incidence of neonatal complications such as hypoglycemia and metabolic acidosis. Drug intervention: Studies have shown that effective drug mechanisms for preventing IPH are mainly divided into reducing calorie redistribution (such as: phenylephrine) and increasing metabolic heat production (such as: fructose, amino acids). A single blind RCT study to investigate the effect of different general anesthesia induction methods on reducing heat redistribution showed that both sevoflurane inhalation induction and prophylactic administration of phenylephrine before intravenous induction of propofol were effective in reducing redistributive hypothermia between 0.4 and 0.5℃. Aoki et al. compiled 14 RCT analyses and showed that amino acid infusion can increase body temperature by 0.46℃ (95% CI 0.31~0.62, P<0.001), reduce the occurrence of chills, and shorten the time of extubation and hospitalization. Summary IPH is a common perioperative complication. At present, evidence-based guidelines for the prevention of IPH have been formulated internationally. Future research should comprehensively consider factors such as clinical benefits and potential risks, starting from the incidence of IPH and its complications, and comparing different insulation strategies from multiple angles. In clinical practice, the perioperative temperature management strategies of different types of surgery should be combined with their characteristics and have their own focus, and at the same time, individualized management of patients with different underlying diseases should be implemented. In addition, factors such as the degree of attention of medical staff, multidisciplinary collaboration, and policy support may be important factors in promoting the temperature protection of clinical patients. Disclaimer: The picture comes from the Internet and literature, and the copyright belongs to the Journal of Clinical Anesthesiology The original or reprinted content on this website does not represent the views or positions of Hisern Medical. The contents of drug use and disease diagnosis and treatment mentioned in the article are for medical professionals' reference only. Disposable SpO₂Sensor Product Usage Used to collect the patient's temperature signal to the monitor, real-time, continuous, non-invasive display of the patient's temperature information Applicable departments Used in anesthesiology department, operating room, intensive care unit, burn department, etc. Features l Body cavity type Fully enclosed insulation and waterproof design, monitoring is safer The PVC casing sheath conducts heat quickly, and the monitoring is more accurate The arc-shaped top design is soft and smooth, and the tube placement is smoother Can monitor the temperature of the oropharynx, nasopharynx, esophagus, and rectum l Body phenotype Reflective silver paper foam can effectively reduce the interference of ambient temperature and light source heat source Low-viscosity foam material, fixed temperature measurement position, while reducing skin irritation Hisern Medical has a global sales and service network Understand your problem for the first time and provide product solutions Hisern Medical has been committed to providing quality products and services Welcome your consultation and understanding T: 0575-88409031 E: info@hisern.com For more details, please visit: www.hisern.com

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