脊髓灰质炎后遗症下肢不等长外科治疗策略(附1 582例报告)

目的 :探讨脊髓灰质炎后遗症下肢不等长外科治疗策略 ,介绍胫骨延长的新手术方法。方法 :回顾性分析 1985年 9月～ 2 0 0 3年 5月共收治脊髓灰质炎后遗症下肢不等长 15 82例 ,根据患者的年龄和下肢短缩的不同类型 ,应用 10种下肢均衡术 ,研制了复合式小腿延长器。结果 :15 2 9例术后获得了 3个月以上随访 ,下肢均衡最少1cm ,最多 11 3cm。未发生 1例严重手术并发症。结论 :根据下肢短缩的不同类型 ,选择适合的手术方式 ,方能获得优良效果 ,新研制的复合式小腿延长器 ,能一期矫正小腿短缩和足踝畸形。     

复杂髋关节手术中应用电生理监测技术预防下肢周围神经损伤

目的探讨在复杂全髋关节置换手术中采用经颅电刺激运动诱发电位（ transcranialelectrical motor evoked potentials, TCeMEPs）和自发肌电图（spontaneouselectromyography,EMG）联合监测预防下肢周围神经损伤的效果。方法自2012年3月-2013年4月对10例复杂全髋关节置换术患者（9例初次手术,1例翻修;下肢短缩最短3cm,最长6cm,平均4．25cm）术中利用经颅电刺激运动诱发电位和自发肌电图实时监测术侧下肢周围神经包括股神经、坐骨神经及其分支情况。所有患者均采用全静脉麻醉＋少剂量肌松剂泵注（顺阿曲库铵0．1mg／kg／h）。结果术后下肢延长最短3cm,最长4．5cm,平均4．1cm。4例患者坐骨神经支配肌肉产生连续爆发EMG波形;9例患者术中全程均能引出所有靶肌TCeMEPs波形,术后未出现医源性下肢神经损伤;1例初次复位时胫前肌和跨长伸肌波形消失,停止手术操作5min,再脱位等待约10min后波形才逐渐恢复,截骨处理并再次复位,术后术侧下肢麻木1周。结论联合运用经颅电刺激运动诱发电位和自发肌电图实时监测能及时反映复杂全髋关节置换术中下肢周围神经受激惹情况和运动功能状态,预防医源性神经损伤。尤其对于需要延长下肢或翻修的患者,更值得在临床推广应用。     

同期跟腱延长及胫骨延长术治疗合并马蹄足的下肢短缩畸形

目的：介绍应用半环式外固定架渐进性骨牵伸延长并同期行跟腱延长术治疗合并马蹄足的下肢短缩畸形的经验。方法：36例合并马蹄足的下肢短缩患者同期行跟腱延长及胫骨延长术,骨延长采用胫骨上端舌型截骨或胫骨上端骨骺牵开。半环式外固定架缓慢延长。结果：36例患者骨延长4-9cm,平均6.5cm。均达预期长度,马蹄足畸形矫正和功能恢复达到术前设计的矫正效果。结论：本术式能减少合并马蹄足的下肢短缩畸形矫正手术次数和术后畸形发生,并有利于术后功能锻炼。     

先天性短股骨颈人工全髋关节置换时避免下肢延长的临床研究

目的探讨对先天性短股骨颈患者行人工全髋关节置换时避免下肢延长的方法。方法回顾分析2005年4月-2010年12月接受单侧人工全髋关节置换的38例先天性短股骨颈患者临床资料。男26例,女12例;年龄45～78岁,平均62.3岁。股骨头缺血性坏死11例,骨关节炎17例,股骨颈骨折10例。术前29例双下肢不等长,临床测量肢体短缩10～24 mm,平均14.5 mm;X线片测量肢体短缩11～25 mm,平均14.7 mm。术前Harris评分为(44.0±3.6)分。结果术后1 d临床及X线片测量示3例患者下肢延长,其余35例双下肢差异均<10 mm,视为等长;总等长率为92.1%(35/38)。术后患者切口均Ⅰ期愈合,无感染、下肢深静脉血栓形成等并发症发生。1例下肢延长16 mm患者步态异常,经增加足跟垫矫正后仍有轻度跛行;其余2例不等长患者有轻度跛行。其余患者行走正常,髋部疼痛明显缓解。术后36例获随访,随访时间12～68个月,平均43.8个月。术后6个月髋关节Harris评分为(86.7±2.3)分,与术前比较差异有统计学意义(t=3.260,P=0.031)。X线片复查示假体无松动与下沉。结论对先天性短股骨颈患者行人工全髋关节置换术时应注意下肢长度测量和截骨平面确定,并使用带领假体,可有效避免下肢延长。     

应用食盐蒜泥穴位外敷解除下肢骨折患者术后尿潴留

目的 探讨食盐蒜泥穴位外敷解除下肢骨折患者术后尿潴留的效果.方法 下肢骨折术后尿潴留患者61例,按住院单双号分为对照组(29例)和观察组(32例).观察组采用食盐蒜泥热敷脐部至膀胱区穴位(包括神阙、阴交、石门、关元、中极、曲骨),宽度5 cm、厚度1 mm;对照组采用听流水声、按摩下腹部、热敷膀胱区、温水冲洗会阴部等传统方法.结果 观察组有效率显著高于对照组,首次排尿时间显著短于对照组(均P<.001).结论 应用食盐蒜泥穴位外敷解除下肢骨折患者术后尿潴留时间短、效果好.     

胫骨上下端骨骺联合牵伸延长术

胫骨上下端骨骺联合牵伸延长术王书平康立新林峰本组１２例，男８例，女４例。年龄最小１２岁，最大１４岁，平均年龄１３．４岁。其中脊髓灰质炎后遗症１０例，左下肢３例，右下肢７例。２例外伤性胫腓骨缺损均为左下肢，系外伤后肢体短缩内固定所致。跛行明显，患肢短缩...     

外科治疗下肢静脉曲张的疗效分析

目的探讨外科治疗下肢静脉曲张外科的方法及临床效果。方法回顾性分析78例下肢静脉曲张患者的临床资料。结果 78例患者术后静脉曲张均临床治愈,症状缓解。术后进行随访,时间为6～18个月,1例复发。结论内翻剥脱术治疗主干静脉病变,皮下连续缝扎、电凝(分支)、硬化剂注射都具备创伤小、手术时间短、恢复快等优点。     

股骨近端外展截骨术治疗股骨颈或股骨粗隆间骨折后髋内翻畸形

目的探讨股骨近端外展截骨术治疗股骨颈或股骨粗隆间骨折后髋内翻畸形的临床疗效。方法回顾性分析自2009-01—2016-12采用股骨近端外展截骨术治疗的11例股骨颈或股骨粗隆间骨折后髋内翻畸形,术前均行髋关节X线片及CT检查,测量患髋颈干角及前倾角。结果 11例均获得随访,随访时间平均3(2～8)年。10例术后颈干角110°,平均126°;1例术后颈干角为103°。8例术后前倾角为10°～15°,平均13.5°;3例术后前倾角为5°～10°,平均8°。术后患肢短缩0.2～2.4 cm,平均1.1 cm。术后下肢短缩畸形获得不同程度矫正,其中4例患肢短缩1 cm,5例患肢短缩1～2 cm,2例患肢短缩2 cm。术后患肢短缩在2 cm以内患者步态于术后1年内得到不同程度改善。术后6～12个月所有患者髋部疼痛症状较术前不同程度缓解。结论股骨近端外展截骨术治疗股骨颈或股骨粗隆间骨折后髋内翻畸形可明显改善股骨颈干角、股骨近端旋转及下肢短缩畸形,能有效缓解患髋疼痛症状,改善患者步态,临床疗效满意。     

应用食盐蒜泥穴位外敷解除下肢骨折患者术后尿潴留

目的探讨食盐蒜泥穴位外敷解除下肢骨折患者术后尿潴留的效果。方法下肢骨折术后尿潴留患者61例，按住院单双号分为对照组（29例）和观察组（32例）。观察组采用食盐蒜泥热敷脐部至膀胱区穴位（包括神阙、阴交、石门、关元、中极、曲骨），宽度5cm、厚度1mm；对照组采用听流水声、按摩下腹部、热敷膀胱区、温水冲洗会阴部等传统方法。结果观察组有效率显著高于对照组．首次排尿时问显著短于对照组（均P〈0．01）。结论应用食盐蒜泥穴位外敷解除下肢骨折患者术后尿潴留时间短、效果好。     

胫骨截骨同时植骨牵伸延长术

笔者１９９０～１９９５年采用“人”字型截骨同时植骨牵伸延长术，治疗下肢短缩畸形１８例，效果满意。１临床资料１１一般资料本组男１１例，女７例；年龄最小１７岁，最大２５岁，平均２１岁。１８例均为儿麻后遗症，下肢短缩３～７ｃｍ。１２手术方法基本操作方法...     

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 comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

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.     

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.