全髋关节置换术治疗血友病性髋关节炎的进展

晚期血友病关节炎患者往往因严重的关节功能障碍而影响日常生活。凝血因子的问世使人工关节置换术治疗重度血友病性关节炎变为可能。血友病性关节炎较多累及膝、髋关节,与全膝关节置换术相比,全髋关节置换术的文献报道相对较少,缺乏公认的治疗指南。因此,本文总结了全髋关节置换术治疗血友病性髋关节炎的相关文献,对其发病机制、凝血因子替代疗法、手术准备、术中及术后注意事项、术后血栓及凝血因子抗体形成的处理方法进行系统综述。本文旨在为应用全髋关节置换术治疗血友病性髋关节炎的围手术期的处理提供参考。     

凝血因子替代疗法下血友病A患者行THA1例报告

正血友病A是一种以X染色体上凝血因子基因突变导致凝血因子Ⅷ(FⅧ)缺乏为特征的凝血机制障碍性隐性遗传性疾病。男性甲型血友病的发病率为0.2‰~([1])。血友病A患者股骨头损伤后常因出血造成慢性髋关节炎最终导致股骨头坏死。由于血友病患者的特殊性,如肌肉萎缩、韧带及关节囊的挛缩、活动度差、骨性畸形、缺损、骨质疏松等,行全髋关节置换术(total hip arthroplasty,THA)的风险或出现并发     

血友病关节炎人工膝关节置换及围手术期处理

目的探讨对血友病关节炎患者行人工膝关节置换的临床效果及其围手术期处理方法。方法1997年2月至2006年2月在血液内科的配合下,在围手术期行凝血因子Ⅷ和Ⅸ活性水平及抑制性抗体监测,强化凝血因子替代补充,我们对4例血友病关节炎患者共6个膝关节行人工膝关节置换治疗。术后平均随访4．4年,记录关节功能改善程度及并发症处理。结果血友病关节炎患者行人工膝关节置换可以使关节疼痛明显缓解,步行距离、上下楼梯和坐位起立等功能明显改善,关节活动度增加。术后早期3个膝关节出现关节内血肿或肌肉出血,其中1例患者因凝血因子Ⅷ抑制性抗体形成,单侧膝关节出现伤口愈合问题,1例患者一过性腓总神经麻痹,1例患者发生静脉循环危象。术后晚期1例患者出现双肘关节出血,但无晚期感染、假体松动、移位和断裂。结论人工膝关节置换可以为重度血友病性关节炎患者减轻关节疼痛,改善关节功能,但是围手术期并发症较多,需要密切监测凝血因子Ⅷ或Ⅸ活性,监测抑制性抗体形成,防止各种早期和晚期并发症的发生。     

血友病患者人工全髋关节置换术的围术期护理

目的探讨血友病患者人工全髋关节置换术的围术期护理方法。方法对5例因股骨头无菌性坏死行人工全髋关节置换术的血友病患者,术前动态监测血Ⅷ因子水平,及时输注凝血因子,予以有针对性的心理护理,术后严密观察出血情况,预防感染,加强对患肢的位置观察及长度测量以防脱位的发生,指导患者循序渐进做好康复锻炼。结果本组5例患者术中出血量500~600ml,术后无异常出血,切口愈合时间为10~15 d,未出现感染等并发症,髋关节功能恢复良好。结论人工全髋关节置换合并血友病患者的临床治疗风险与护理难度大,在围术期护士应积极配合治疗计划制定严谨的护理措施,配合动态监测血Ⅷ因子水平,加强预防出血的护理措施,正确进行康复锻炼,做好出血的预防是关键。     

血友病患者人工全髋关节置换术的围术期护理

目的探讨血友病患者人工全髋关节置换术的围术期护理方法。方法对5例因股骨头无菌性坏死行人工全髋关节置换术的血友病患者,术前动态监测血Ⅷ因子水平,及时输注凝血因子,予以有针对性的心理护理,术后严密观察出血情况,预防感染,加强对患肢的位置观察及长度测量以防脱位的发生,指导患者循序渐进做好康复锻炼。结果本组5例患者术中出血量500~600ml,术后无异常出血,切口愈合时间为10~15 d,未出现感染等并发症,髋关节功能恢复良好。结论人工全髋关节置换合并血友病患者的临床治疗风险与护理难度大,在围术期护士应积极配合治疗计划制定严谨的护理措施,配合动态监测血Ⅷ因子水平,加强预防出血的护理措施,正确进行康复锻炼,做好出血的预防是关键。     

人工关节置换术治疗晚期血友病性关节炎

目的评价人工关节置换术治疗髋、膝关节晚期血友病性关节炎的临床疗效,探讨围手术期凝血因子替代治疗方法、手术方式及术后并发症的处理。方法回顾性分析自2010-06—2017-04采用人工关节置换术治疗的血友病性关节炎12例,髋关节3例(4髋)行全髋关节置换术,膝关节9例(11膝)行全膝关节置换术。围手术期10例甲型血友病凝血因子替代治疗首选基因重组FⅧ制剂,2例乙型血友病凝血因子替代治疗选用冻干人凝血酶原复合物康舒宁。结果 12例均获得随访,随访时间平均32(6~60)个月。所有患者随访期间未发生关节感染,未出现假体脱位及松动,假体位置及力线满意。末次随访时全髋关节置换者髋关节功能Harris评分由术前平均42分提高至平均88分,疼痛VAS评分由术前平均7.5分降低至2.8分,关节活动度明显改善。末次随访时全膝关节置换者膝关节功能HSS评分由术前平均46分提高至平均83分,疼痛VAS评分由术前平均8.5分降低至2.5分,关节活动度由术前平均45.0°改善至86.2°,屈曲畸形由术前平均20.5°改善至5.0°。结论在足够的凝血因子替代治疗的前提下,人工关节置换术是治疗晚期血友病性关节炎的有效手段,可以显著减轻关节疼痛、改善关节功能,大大提高患者的生存质量。     

膝关节置换术治疗晚期血友病性膝关节炎

目的探讨膝关节置换术治疗晚期血友病性膝关节炎的临床疗效、手术特点及围手术期凝血因子替代治疗方法。方法自2010年9月至2014年3月我科共对6例A型血友病性晚期膝关节炎患者行单侧全膝关节置换术,Amold分期Ⅳ期5例,Ⅴ期1例。观察围手术期凝血因子Ⅷ替代治疗过程、效果及膝关节置换术特点,对手术前及术后2年时患膝美国膝关节协会评分(the American knee society score,AKS)系统中的膝评分及功能评分进行比较。结果随访时间2~5年,平均3.6年。全膝关节置换术后早期无关节内出血、皮肤裂开,晚期无关节出血、假体松动、下沉,AKS膝评分从术前(57.7±5.6)分上升至术后2年时(97.0±1.4)分,功能评分从(65.0±6.3)分升至(92.5±4.2)分。结论全膝关节置换术治疗晚期血友病性膝关节炎需在确保凝血因子理想活性的前提下进行,手术难度较大,但效果满意,是治疗晚期血友病性膝关节炎安全、理想的措施。     

血友病性关节炎治疗进展

目前临床上治疗血友病性关节炎有多种方法,如预防性补充缺失的凝血因子或激素、开放性或关节镜下滑膜切除术、放射性滑膜切除术、关节周围截骨术、人工关节置换术等,晚期还可口服D-盐酸青霉胺作为辅助治疗。不同的治疗方法对于不同患者的效果不同,选择治疗方法时需综合考虑多种因素如患者关节炎所处时期、关节受累程度、疼痛、活动度、凝血因子Ⅷ需求量、激素及镇痛药用量等。该文就血友病性关节炎治疗进展作一综述。     

血友病性关节炎治疗进展

目前临床上治疗血友病性关节炎有多种方法,如预防性生补充缺失的凝血因子或激素、开放性或关节镜下滑膜切除术、放射性滑膜切除术、关节周围截骨术、人工关节置换术等,晚期还可口服D-盐酸青霉胺作为辅助治疗.不同的治疗方法对于不同患者的效果不同,选择治疗方法时需综合考虑多种因素如患者关节炎所处时期、关节受累程度、疼痛、活动度、凝血因子Ⅷ需求量、激素及镇痛药用量等.该文就血友病性关节炎治疗进展作一综述.     

~(32)P胶体放射性滑膜切除术在血友病性关节炎治疗中的应用进展

正血友病是一组因为缺乏凝血因子而导致凝血功能障碍的性联隐性遗传性出血性疾病。由于凝血因子缺乏,患者自幼年起关节、肌肉等部位反复因轻微外伤或自发出血,其中以关节出血最为常见。血友病性关节炎是血友病患者关节腔频繁出血引起滑膜炎症、肿胀,软骨退行性变,继而关节出现纤维化损害,导致关节挛缩,关节变形及关节炎,并依次出现肌肉萎缩、运动受限、骨质疏松和残疾。最常见的受累关     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.