PI3K/AKT/mTOR信号通路在肝癌细胞自体吞噬中的作用研究

目的探讨在肝癌细胞中PI3K／AKT／mTOR信号通路在氨基酸缺乏诱导的自体吞噬中的作用。方法观察HCCLM3、MHCC97L及SMMC-7721肝癌细胞在氨基酸缺乏情况下及与P13K抑制剂3-MA、Wortmannin及LY294002，mTOR抑制剂雷帕霉素协同作用下细胞活力变化。GFP—LC3荧光法观察细胞内自噬体的形成。Western印迹检测LC3-Ⅱ蛋白的表达。结果经无氨基酸培养液EBSS处理后48h，HCCLM3、MHCC97L及SMMC-7721细胞存活率分别为（78．9±3．8）％、（57．2±13．1）％及（3．4±3．0）％（P〈0．01）。与HCCLM3、MHCC97L相比，细胞中的自噬体在SMMC-7721细胞中明显增多，分别为（13．1±3．5）％、（20．0±1．1）％及（48．9±4．5）％（P〈0．01）。Western印迹显示在EBSS处理后早期即有LC3—Ⅱ蛋白的明显表达。在EBSS基础上雷帕霉素20μmol／L处理24h，3种细胞株活力明显下降。3-MA、Wortmannin及LY294002处理也加速EBSS诱导的细胞死亡。结论高转移潜能肝癌细胞比较耐受自噬样细胞死亡。P13K／AKT／mTOR信号通路对自噬样细胞死亡可能起重要调节作用。     

抑制黏着斑激酶表达对人肝癌细胞转移潜能的作用

目的研究抑制人肝癌细胞MHCC97-H中黏着斑激酶（FAK）表达对细胞黏附、侵袭和骨架重塑的影响。方法利用脂质体转染FAKsiRNA至MHCC97-H细胞内。Western blot法检测RNA干扰前后MHCC97．H细胞中FAK蛋白的表达水平。黏附试验和侵袭试验分别检测MHCC97．H细胞黏附和侵袭能力在干扰前后的变化。明胶酶谱试验检测MHCC97-H细胞分泌MMPs的变化。用激光共聚焦显微镜观察免疫荧光标记细胞的骨架重塑的变化。结果特异性FAKsiRNA明显抑制MHCC97．H细胞中FAK表达。干扰后MHCC97-H细胞与细胞外基质纤维连接蛋白的黏附率为35．8％,低于对照组的57．3％（P〈0．05）。干扰后MHCC97-H细胞穿透Tanswell小室的数目由对照组的（31．3±2．6）个减少至（14．5±3．1）个（P〈0．05）。干扰后MHCC97-H细胞分泌MMPs的量明显减少。FAK表达抑制影响骨架蛋白Vinculin在PDGF—BB诱导细胞骨架重塑中分布,阻碍片状伪足形成,延迟黏着斑形成时间。结论FAK表达受到抑制后,通过减少MMPs分泌和影响细胞骨架重塑可降低MHCC97-H细胞黏附、侵袭能力。     

Ad.mda-7高选择性杀伤不同转移潜能肝癌细胞的研究

目的利用携带人MDA-7／IL-24基因的复制缺陷型腺病毒（Ad．mda7）作为载体，感染不同转移潜能的肝癌细胞MHCC97H，MHCC97L，Hep3B和正常的肝细胞L02，观察该基因对肝癌的选择性杀伤作用和增殖抑制作用。方法将携带人MDA-7／IL-24基因的腺病毒Ad．mda-7感染正常肝细胞L02和肝癌细胞MHCC97H，MHCC97L和Hep3B，通过RT-PCR和ELISA方法观察MDA7基因的表达，通过四甲基偶氮哩蓝染色法（MTT）观察该基因对肝癌细胞的生长抑制，Hoechst染色和流式细胞仪观察MDA-7对肝癌细胞的杀伤作用，流式细胞仪检测细胞周期变化。结果RT-PCR提示复制缺陷型腺病毒能介导外源基因MDA-7／IL-24在肝癌细胞株MHCC97H，MHCC97L，Hep3B和正常细胞L02中高效表达；ELISA方法检测提示细胞培养上清液中MDA-7／IL-24蛋白的表达，而且随着感染时间延长表达量升高；MTT实验结果表明MDA7能明显抑制肝癌细胞的生长，Hoechst染色和流式细胞仪提示MDA7能促进肝癌细的凋亡；细胞周期检测提示肝癌细胞大量被阻滞在G2／M期，正常细胞没有增殖阻滞作用。各项结果提示MDA7对正常的肝细胞没有促进凋亡和增殖阻滞的作用。结论Ad．mda-7选择性的杀伤肝癌细胞，促进细胞增殖阻滞及诱导肿瘤细胞凋亡与肝癌细胞的转移潜能无关。     

绿色荧光高/低转移人肝癌细胞株MHCC97-HG/LG的建立及鉴定

目的建立稳定自发绿色荧光的高、低转移人肝癌细胞株并明确鉴定。方法脂质体转染法将绿色荧光蛋白(GFP)基因分别转染至高、低转移人肝癌细胞株MHCC97-H／L内,经 G418反复筛选并单克隆化,得到两株新细胞株MHCC97-HG／LG,对新细胞株GFP表达稳定性、生物学特性、体内外侵袭转移能力及肿瘤血管生成等进行鉴定。结果 MHCC97-HG／LG在体外培养或裸鼠体内接种36 d后均能稳定表达绿色荧光。MHCC97-HG肝、肺转移率均为100％,较 MHCC97-LG及其父系体内外侵袭转移能力显著增强(P<0．01),其原位肿瘤微血管密度较 MHCC97-LG显著增加[(121．0±15．9)／HP vs(87．0±14．2)／HP,P<0．01]。体视荧光显微镜可实时观察裸鼠体内MHCC97-HG／LG种植瘤生长、转移及血管形成情况。结论 MHCC97-HG／LG及其动物模型在肝癌转移机制、肿瘤血管生成等诸多研究领域可能有较广阔的应用前景。     

雄激素对前列腺癌细胞PAR基因表达的影响及其机制

目的观察在前列腺癌特异性高表达的癌基因前列腺雄激素调节基因（PAR）对雄激素的反应及其机制，探讨通过抑制PAR基因治疗雄激素非依赖性前列腺癌的可能性。方法用细胞计数检测双氢睾酮对LNCaP、PC3细胞增殖的刺激效应，以逆转录-聚合酶链反应（RT-PCR）分别检测双氢睾酮对LNCaP、PC3细胞PAR基因mRNA表达水平的影响及双氢睾酮和其拮抗剂联合作用对LNCaP细胞PAR基因mRNA表达水平的影响。结果低浓度（0．001～1nmol／L）双氢睾酮刺激可促进LNCaP细胞增殖，且刺激效应随双氢睾酮浓度升高而增强，在0．1nmol／L浓度时达最大，细胞计数为（27、54±0．71）×10。爪／孔，为对照组（16．13±1．03）×10。爪／孔的（170．74±0．78）％；同时使PAR基因mRNA表达水平上调在0．1nmol／L浓度时最高，为对照组的（272．42±8．24）％，P〈0．05）；高浓度（10、100nmol／L）双氢睾酮则抑制其增殖和PAR基因表达，在10nmol／L和100nmol／L浓度，细胞计数分别为（12．02±0．41）×10。／孔、（11．13±1．92）×10^4／孔（P〈0．05）；PAR基因mRNA表达水平分别为对照组的（76．64±2．47）％和（52．97±1．07）％，（P〈0．05）。这一调节效应可以为氟他胺所阻断。双氢睾酮对PC3细胞生长及PAR基因mRNA表达无明显影响（P〉0．05）。结论PAR可能是雄激素．雄激素受体通路下游的前列腺癌特异性癌基因，有望成为雄激素非依赖性前列腺癌基因和药物治疗的潜在靶点。     

粘着斑激酶在PDGF-BB诱导MHCC-97H细胞黏附侵袭中的作用

目的观察不同浓度血小板衍生生长因子（PDGF-BB）诱导MHCC-97H细胞中粘着斑激酶（focal adhesion kinase，FAK）mRNA的动态变化及FAK在细胞黏附、侵袭的作用。方法不同浓度（1，2．5，5，10，25ng／m1）PDGF-BB诱导MHCC-97H人肝癌细胞，Real-time PCR方法检测FAK及MMP-2的mRNA动态变化，黏附实验、侵袭实验分别检测诱导后MHCC-97H细胞的黏附、侵袭能力的变化。结果诱导后MHCC-97H细胞FAKmRNA水平上调，在10ng／ml浓度时达到最高，为对照组的112．6倍；MMP-2mRNA水平上调并与FAKmRNA水平上调呈一致性，在10ng／ml浓度时达到最高，为对照组的56．9倍。诱导后各组黏附率分别为（66±1．84）%、（69±1．41）％、（69±2．42）％、（71±1．37）%和（66±3．28）%，与对照组的（54±2．08）％比较均有统计学意义（P〈0．001）；诱导后5ng／ml和10ng／ml组侵袭细胞数分别为（26．63±4．5）、（28．75±4．2）个，与对照组（21．5±4．0）个比较有显著性差异（P〈0．05，P〈0．001）。诱导后黏附率与侵袭细胞数变化在10ng／ml浓度时都达到高峰。结论PDGF-BB上调MHCC-97H细胞中FAK表达，上调FAK促进MHCC-97H细胞的黏附和侵袭能力。     

人肝癌细胞系MHCC97H中侧群细胞初探

目的 从人肝癌细胞系MHCC97H中分选侧群细胞,探索其形态、表型和功能特征.方法 利用流式细胞仪从MHCC97H中分选得到侧群细胞,用相差显微镜和透射电镜观察其形态学特点;Western blotting观察其ABCG2表达;用流式细胞仪评估侧群细胞与干细胞基因CD133、CD117的关系;用克隆形成实验和NOD/SCID接种实验分别观察侧群细胞体外增殖和体内成瘤情况.结果 侧群细胞体积较小,呈圆形或短梭形;侧群细胞的细胞器如线粒体、内质网等明显少于非侧群细胞;流式检测显示侧群细胞中含有CD133、CD117阳性细胞;Western blotting显示侧群细胞和非侧群细胞中均有ABCG2表达,两者无明显差异;平板克隆形成实验显示SP具有较强的克隆形成能力;体内移植实验显示2000个SP细胞即能在体内形成肿瘤.结论 肝癌细胞系MHCC97H中侧群细胞具有肿瘤干细胞样细胞的表型和特性;ABCG2可能不是决定肝癌侧群细胞表型的主要因素.     

不同转移潜能肝癌细胞株中自体吞噬样细胞死亡的研究

目的 探讨不同转移潜能肝癌细胞株中自噬样细胞死亡的差异。方法 观察不同转移潜能的肝癌细胞株在氨基酸缺乏情况下细胞活力变化，caspases的活化，细胞内自噬体的形成。Western blot检测LC3-Ⅱ蛋白的表达。结果 经无氨基酸培养液EBSS处理后48h，HCCLM3、MHCC97L及SMMC-7721细胞存活率分别为78.95±3.8%、57.25±13.1%及3.4%±3.0%（F= 68.93，P〈0.01）。加入正常培养液，HCCLM3及MHCC97L细胞可以获得再增殖的能力。EBSS处理后3种细胞株中caspases并没有明显活化，6h后自噬体在SMMC-7721细胞中明显增多，分别为13.1%±3.5%、20.0%±1.1%及48.9%±4.5%（F=98.13，P〈0.01）。Western blot显示在EBSS处理后早期即有LC3-Ⅱ蛋白的明显表达。结论 氨基酸缺乏可以诱导肝癌细胞自噬样细胞死亡，高转移潜能肝癌细胞株相对比较耐受。     

干扰素-α诱导肾癌细胞胸苷磷酸化酶表达对5-FU化疗敏感性的影响

目的 探讨干扰素-α诱导肾癌细胞胸苷磷酸化酶（thymidine phosphorylase，TP）表达对5-氟尿嘧啶（5-FU）化疗敏感性的影响。方法采用不同浓度的干扰素-α2b处理肾癌细胞株786—0，应用RT—PCR和免疫印迹方法分别检测TP mRNA和TP蛋白水平变化。MTT法检测不同处理组786—0细胞中5-FU的半数抑制浓度（IC50）。建立肾透明细胞癌移植瘤动物模型，观察干扰素-α2b联合5-FU化疗对移植瘤生长的影响，免疫组化检测移植瘤中TP的表达，TUNEL检测肿瘤细胞的凋亡。结果 干扰素-α2b3000和6000IU／ml处理组，TP mRNA表达量（灰度峰值）分别为0．5733±0．0231和0．8233±0．0404，TP蛋白表达量分别为0．6347±0．0719和0．8735±0．0640。干扰素-α对TP的表达有剂量依赖性增强作用（P〈0．01）。在干扰素-α2b作用下，5-FU对786—0半数抑制浓度由（13．9467±3．7140）μmol／L下降至（5．3200±0．1039）μmol／L，化疗敏感性增加（P〈0．01）。联合用药组移植瘤体积为（0．0940±0．0492）cm^3，小于单纯5-FU组的（0．5424±0．1591）cm^3（P〈0．05）。单纯5-FU组和联合用药组移植瘤中肿瘤细胞凋亡指数差异无统计学意义（P〉0．05）。结论 干扰素-α2b诱导的TP增强表达参与了干扰素-α联合5-FU化疗增效作用，TP是干扰素-α2b的靶基因之。     

MHCC97中肝癌干细胞的分离及其特性

目的 分离肝癌细胞系MHCC97中肝癌干细胞并观察其干细胞特性.方法 利用流式分选法从MHCC97中分离出边缘群(SP)和主群(MP).分别采用软琼脂克隆形成和裸鼠成瘤实验观察SP和MP细胞体内、外成瘤能力;羟基喜树碱(HCPT)体外诱导,逆转录-聚合酶链反应(RT-PCR)分析其分化潜能.结果 SP细胞克隆形成率为57%,MP细胞仅为13%;1×103SP细胞可成瘤(2/8),MP细胞则需1×105才能成瘤(2/8).诱导3 d后,约15%SP细胞出现双核;诱导后SP细胞甲胎蛋白和r-谷氨酰转肽酶的表达降低,白蛋白表达增强,葡萄糖磷酸酶仅诱导后表达.结论 MHCC97中SP亚群富集具有干细胞特性的癌细胞,即肝癌干细胞.     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

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.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

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.