改良Judet手术入路治疗复杂肩胛骨骨折

目的探讨改良Judet手术入路治疗复杂肩胛骨骨折的适应证及疗效。方法自1997年1月至2005年10月经改良Judet手术入路治疗肩胛骨骨折21例,其中男性15例,女性6例,平均年龄34岁（18～62岁）。根据Hardegger的分型方法,肩胛体部骨折11处、肩胛颈骨折10处、盂缘骨折8处、盂窝骨折7处、肩胛冈骨折9处、肩峰骨折6处。其中多部位复杂骨折15例,伴有腋神经损伤2例,肩胛上神经损伤4例。通过改良Judet手术入路,对不同类型的肩胛骨骨折使用重建钢板或拉力螺钉等固定。结果18例患者获得随访,随访时间6个月至4年,平均21个月。根据Rowe疗效评价标准,优12例,良3例,可2例,差1例,优良率为83％。结论改良Judet入路操作简单,暴露充分,大多数类型的肩胛骨骨折可通过改良Judet入路完成,尤其适用于肩胛体部骨折,肩胛颈骨折,肩胛冈骨折以及不存在喙突、前部肩胛盂骨折的多部位复杂骨折,经改良Judet入路行骨折复位内固定是肩胛骨骨折手术治疗的一种安全有效方法。     

改良后侧入路治疗肩胛骨骨折

目的 探讨改良的后侧入路治疗肩胛骨骨折的手术疗效.方法 采用改良的后侧入路治疗肩胛骨骨折患者18例.骨折根据Hardegger等分型方法,肩胛冈骨折5处,肩胛体骨折15处,肩胛颈骨折11处,盂缘骨折3处,盂窝骨折4处,通过改良的后侧入路,对不同类型的肩胛骨骨折均采用重建钢板,螺丝钉内固定.结果 18例患者均获得随访,平均随访时间18个月(8～32个月).根据Rowe疗效评价标准,优12例,良3例,可2例,差1例,优良率为83.3%.结论 改良的后侧入路操作简单,暴露充分,可以治疗大部分肩胛骨骨折,是一种安全有效的方法.     

后入路手术治疗肩胛骨骨折14例疗效观察

[目的] 探讨后入路手术治疗肩胛骨骨折的适应证及疗效.[方法] 自2000年5月-2007年11月经后入路手术治疗肩胛骨骨折14例,其中男10例,女4例,平均34.6岁(18～62岁).车祸伤8例,高处坠落伤3例,直接暴力伤2例.刀砍伤1例.闭合性骨折11例,开放性骨折3例.根据Hardegger的分型方法,体部骨折8处,肩胛因骨折9处,肩峰骨折6处,肩胛颈骨折lO处,盂缘骨折6处,盂窝骨折4处.其中混合型骨折10例,合并全身多发伤5例;伴有腋神经损伤1例,肩胛上神经损伤2例.通过后入路手术,对不同类型的肩胛骨骨折使用重建钢板或拉力螺钉和钢丝等固定.[结果] 14例患者获得随访,随访时间6个月～3年,平均18个月.根据Rowe疗效评价标准,优10例,良2例,可2例,差0例,优良率为85.7%.术后并发肩关节不稳1例.[结论] 经后入路内固定肩胛骨骨折操作简单,暴露充分.效果可靠.几乎各种类型的肩胛骨骨折均可通过后入路完成,尤其适用于肩胛骨的体部骨折,外科颈骨折及肩胛因骨折以及多部位复杂骨折,是肩胛骨骨折手术治疗的一种安全有效方法.     

肩胛骨骨折的手术治疗

目的探讨肩胛骨骨折的手术适应证与手术复位内固定的临床效果。方法自1998年2月至2003年6月，对一组26例经手术复位内固定治疗的肩胛骨骨折患者进行回顾性分析，骨折按Hardegger分型，肩胛体部骨折14处，肩胛颈部骨折12处，其中解剖颈骨折1处，外科颈骨折11处，肩胛冈骨折5处，肩峰骨折4处，肩胛盂窝骨折5处。手术入路采用肩胛骨外侧缘入路17例，肩关节后方入路9例。术后早期行功能锻炼。结果本组26例均获随访，随访时间为12～56个月，平均30．5个月。X线片显示，所有患者均在8～12周达到骨性愈合，平均9周。根据Hardeg—ger功能评定标准评定，优16例，良7例，可2例，差1例，优良率为88．5％。术后创伤性关节炎2例，异位骨化1例，无伤口感染和骨不连。结论手术治疗肩胛骨骨折恢复了肩关节的动力平衡和稳定性，是一种安全可靠的治疗方法．合理的运用手术入路和内固定方式，早期行功能锻炼，可取得满意的临床疗效。     

改良后侧入路手术治疗肩胛颈盂骨折

目的探讨肩胛颈盂骨折的改良后侧入路的手术治疗方法及疗效。方法对2004年6月以来收治的经改良后侧入路切开复位内固定治疗26例肩胛颈盂骨折患者进行分析。均为男性,左侧17例,右侧9例。肩胛颈骨折21例,肩胛盂骨折5例。手术取后侧改良切口,上肢外展上举,沿肩峰略偏向内至肩胛下角作弧形切口,将三角肌下缘的肌筋膜切开,松解三角肌并将其向上拉开,在冈下肌与小圆肌间隙进入,显露肩胛骨腋缘直至颈盂部。根据情况用重建钢板或拉力螺钉固定。结果随访3个月～4年,平均2.6年。均获得骨性愈合,按Hardegger标准疗效评定:优15例,良5例,中1例,差5例。结论经改良后侧入路治疗肩胛颈盂部骨折是安全可靠疗效肯定的方法。     

肩胛盂骨折的手术治疗

目的 探讨肩胛盂骨折手术治疗的效果。方法 自1997年6月至2003年6月，采用切开复位内固定技术治疗17例肩胛盂骨折患，1例肩盂前唇骨折采用前方入路，其余病例均采用后方入路。结果 17例患中15例获随访。随访时间为9～72个月，甲均骨折愈合时间为16周；无术中及术后并发症。结论 不稳定的肩胛盂骨折应采用手术治疗，后方入路重建钢板内固定适合应用于Ideberg分型Ⅰ型以上的骨折。     

肩胛颈、肩胛盂骨折的手术治疗

1999年 4月～ 2 0 0 2年 10月 ,我院收治肩胛颈、肩胛盂骨折 9例 ,采用切开复位、重建钛钢板塑形固定 ,效果满意。1　材料与方法1.1　病例资料　本组 9例 ,均为男性 ,年龄 2 3～ 4 5岁。交通事故伤 7例 ,坠落伤 2例。肩胛颈骨折 6处 ,骨折块前后移位 10mm并骨折端重叠移位 ;盂缘及盂窝骨折 5处 ,骨折块移位超过 10mm ,肱骨头呈半脱位或不稳定状 ,盂窝关节面高低不平超过 5mm。合并肩胛冈骨折 3例 ,肩胛体骨折 4例。复合同侧肱骨、尺桡骨及第 3肋骨骨折 1例 ,臂丛神经损伤 1例 ,桡骨远端骨折 1例 ,C7椎体骨折 1例。1.2　手术方法　全麻后 ,…     

肩胛盂移位及成角在肩胛颈骨折治疗中的意义

目的探讨肩胛盂移位及成角在肩胛颈骨折治疗中的意义。方法回顾分析自2000年1月～2005年1月收治的9例伴有肩胛盂移位及成角的肩胛颈骨折治疗的临床资料。采用前后位X线片检查,辅以CT检查测量肩胛盂移位及成角畸形。采用Goss等的分型方法:ⅡA型5例,ⅡB型4例。伴有合并损伤者7例。肩肘吊带保守治疗2例,通过Judet入路重建钢板内固定手术治疗7例。结果9例患者7例获得随访,随访5个月～4年,平均28.6个月。根据Constant疗效评价标准,优3例,良3例,差1例,优良率为85.7%。远期主要并发症包括,肩关节疼痛3例,肌力下降及外展活动受限4例,肩关节不稳定1例。结论①肩胛颈骨折多由高能暴力所致,合并损伤发生率很高,容易漏诊。②正确的X线摄片及CT检查有助于明确骨折类型和选择治疗方法。③肩胛颈骨折肩胛盂移位超过1cm或成角超过40°应行手术治疗。④手术治疗是一种安全有效的方法,术后正确的康复训练对肩关节功能恢复至关重要。     

肩胛骨骨折手术治疗的临床体会

目的:探讨肩胛骨骨折的手术治疗。方法:回顾分析自2001年3月～2004年9月收治的经手术治疗的11例肩胛骨骨折的临床资料。其中体部骨折11处,肩胛颈骨折2处,盂缘骨折1处,肩胛冈骨折3处,锁骨骨折1处。11例肩胛骨骨折损伤共涉及18处,其中2处或2处以上复杂骨折8例(87.6%)。通过后侧入路对不同类型的肩胛骨骨折使用重建AO钢板或(和)异形跟骨钢板固定。结果:11例术后随访6～18个月,根据Rowe的疗效评价标准优8例,良2例,可1例,优良率为73%。结论:①肩胛骨骨折多由高能暴力所致,常见合并损伤,漏诊率高。②手术治疗是一种安全有效的方法。合适的内固定材料选择将有助于手术的成功率。     

肩胛骨外侧切口入路治疗肩胛骨骨折

目的 探讨肩胛骨外侧切口人路治疗严重移位肩胛骨骨折的手术适应证和方法.方法 应用肩胛骨外侧切口人路对11例严重移位的肩胛骨骨折行切开复位内固定术(体部骨折5例,外科颈骨折3例,关节盂缘骨折2例,关节盂窝骨折1例).术后均获随访,随访时间6～16个月.平均为12个月.结果 患者各阶段X线片复查骨折对位对线良好,骨折愈合时间7～22周,平均9周.肩关节功能采用Hardegger功能评分标准:优9例,良2例.结论 肩胛骨外侧切口入路比较适合于肩胛骨体部、肩胛骨颈部、关节盂缘、关节盂窝骨折的复位和内固定手术.但由于该切口偏于肩胛骨外侧,用于肩胛冈骨折时须延长切口.该切口不适合用于肩峰骨折及喙突骨折.肩胛骨外侧切口配合应用多孔重建钢板,可取得肩胛骨体部和颈部骨折的良好复位和固定.     

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.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.     

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.     

Anesthésie générale chez l’enfant : quid des pratiques en 2010 ?

Introduction

The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France.

Material and methods

One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated.

Results

There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N₂O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7–8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL).

Discussion

This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.     

Intérêt d’une rééducation précoce pour les patients neurologiques

Rehabilitation improves the functional prognosis of patients after a neurologic lesion, and tendency is to begin rehabilitation as soon as possible. This review focuses on the interest and the feasibility of very early rehabilitation, initiated from critical care units. It is necessary to precisely assess patients’ impairments and disabilities in order to define rehabilitation objectives. Valid and simple tools must support this evaluation. Rehabilitation will be directed to preventing decubitus complications and active rehabilitation. The sooner rehabilitation is started; the better functional prognosis seems to be.     

Risiko Schlaganfall — Öffentlichkeitsarbeit und Aufklärung dringend erforderlich

Zusammenfassung Das wesentliche — und zugleich noch wenig ausgeschöpfte — Potenzial der Schlaganfallmedizin liegt in der langfristigen Prophylaxe. Durch Beeinflussung von Lifestylefaktoren wie Ernährungsgewohnheiten, Zigarettenkonsum und körperlichem Training durch entsprechende Aufklärung ließe sich ein erheblicher Teil an zerebralen Ereignissen vermeiden. Ein weiterer in Deutschland noch zu wenig beachteter Faktor ist die konsequente Blutdruckeinstellung. Breitgestreute Aufklärung könnte außerdem potenziellen Patienten helfen, bereits auftretende Warnsymptome wie die transiente ischämische Attacke richtig einzuschätzen, um eine rechtzeitige Behandlung zu ermöglichen.