Does continuous renal replacement therapy favourably influence the outcome of the patients?

Continuous haemodialysis and continuous haemofiltration areefficient and safe techniques for the treatment of acute renalfailure. Theoretical advantages are improved haemodynamic stabilityand easier fluid removal. All 15 available studies comparingintermittent (522 patients) with continuous (651 patients) renalreplacement therapy have been reviewed. From these studies itcannot be established, whether the use of a continuous insteadof an intermittent treatment modality improves the outcome inpatients with acute renal failure. Reviewing all 67 publishedstudies dealing with continuous renal replacement therapy revealeda trend to a decreasing mortality rate (P<0.08) over thelast 11 years, whereas the mean age and the severity of illnessof the patients, measured by the APACHE II score, did not change.In order to establish whether the quality of treatment has improvedas a function of time, two quality factors (QF) were created,i.e. QF for age (mean age/mean mortality rate of the patientstreated) and QF for severity of diseases (mean APACHE II/meanmortality rate). Both QF improved from 1984 until 1994, whenanalyzed for continuous (P<0.001) or intermittent (P<0.001)treatment modality. Thus the quality of treatment of patientswith acute renal failure improved during the last decade. However,there is no evidence with respect to survival rate that a continuousrenal replacement therapy is superior to an intermittent one.     

Continuous treatment modalities in acute renal failure

Continuous treatment modalities have become well establishedin the treatment of severely ill patients with acute renal failuresince the introduction of continuous arteriovenous haemofiltration.However, this simple blood-pressure-driven treatment often failsto control azotaemia, especially in haemodynamically unstablepatients with hypercatabolism. The common feature of furtherdevelopments in continuous treatment modalities, such as continuousarteriovenous haemodialysis, venovenous haemofiltration, orvenovenous haemodialysis is their higher efficacy in controllingazotaemia. Venovenous forms of treatment involve considerablyhigher technical requirements. The main advantages of continuous forms of treatment as opposedto intermittent haemodialysis are greater haemodynamic stabilityand the possibility of adapting nutrition without restrictionto the needs of the critically ill. The uninterrupted necessityfor anticoagulants is the most important disadvantage. The questionof whether patients may profit from the continuous eliminationof mediators involved in acute renal or multiple organ failureis still open. In retrospective analysis continuous methods appear to reducemortality in acute renal failure, but prospective randomizedstudies are necessary to clearly demon strate a benefit of thesemethods as opposed to intermittent haemodialysis.     

肾移植术后长时间发热原因分析

分析肾移植术后24例长时间发热病例资料,并结合国内外文献对此类患者的发病特点,诊断及治疗体会进行了探讨,认为肾移植术后长时间发热与激素冲击治疗。CsA浓度过高及粒细胞下降有关;感染主要发生在肾移植术后早期(1个月内)及中期(1—6个月),机会感染的发生率较高,CMV感染应引起重视;对肾移植术后长时间发热的病例检查手段应全面,对病因不明的病例应采用多种抗生素联合治疗。     

Aseptic meningitis during combined continuous spinal and epidural analgesia

Continuous spinal analgesia (CSA) offers considerable advantages: (1) it requires 10% of the local anesthetic; (2) it may be instituted after patient positioning, thus minimizing the potential for cardiovascular instability; and (3) with low doses of dilute short-acting local anesthetic, the recovery period is shortened (1). Continuous spinal analgesia has been used for various procedures such as surgery and cancer pain control. However, CSA has not gained wide popularity because of its possible complications, such as headache, nerve injury, infection and accidental removal or migration of the catheter. Although real possibilities, these complications have been rarely documented. We describe an episode of aseptic meningitis during combined CSA and EA.     

Pharmacokinetics of ciprofloxacin and vancomycin in patients with acute renal failure treated by continuous haemodialysis.

To determine appropriate doses of ciprofloxacin and vancomycin for septic patients with acute renal failure (ARF) treated by continuous arteriovenous and venovenous haemodialysis, (CAVHD/CVVHD), we performed pharmacokinetic studies in patients receiving these antibiotics. All patients were treated by CAVHD/CVVHD using Hospal AN69S 0.43 m2 filters and Fresenius 1.5% peritoneal dialysis fluid at dialysate flow rates (Qd) of 1 and 2 l/h. Patients received ciprofloxacin 200 mg i.v. 12-hourly (n = 6) or 8-hourly (n = 5); vancomycin 1 g i.v. was administered to 10 patients approximately every 48 h to maintain therapeutic plasma levels. For ciprofloxacin, volume of distribution (Vdarea) was 136.5 +/- 9.81, terminal elimination half-life (t1/2) 6.4 +/- 0.8 h, and total body clearance (TBC) 264.3 +/- 22.9 ml/min (mean +/- SEM). Mean sieving coefficient (S/C) was 0.76 +/- 0.05 and filter clearances at Qd 1 and 2 l/h were 16.2 +/- 1.9 and 19.9 +/- 1.1 ml/min respectively. For vancomycin, Vdarea was 60.7 +/- 5.11, t1/2 24.7 +/- 2.6 h and TBC 31.0 +/- 4.6 ml/min. Mean S/C was 0.66 +/- 0.08 and filter clearances at Qd 1 and 2 l/h 12.1 +/- 2.0 and 16.6 +/- 2.0 ml/min. These data suggest that patients with ARF treated by CAVHD/CVVHD should be given ciprofloxacin 200 mg i.v. 8-12-hourly and vancomycin every 48 h.     

Long-term continuous axillary plexus blockade using 0.25% bupivacaine

Three patients, presenting with various traumatic, vasospastic and chronic neuromuscular disorders of the upper body, received continuous axillary block ranging from 4 to 16 days. Intermittent injections of 0.25% bupivacaine were used to provide analgesia, sympathetic blockade and muscle relaxation. No systemic or neurological side-effects were recorded. Nerve function recovered promptly after stopping the injections. It is concluded that continuous brachial plexus blockade is a clinically safe and effective technique for the relief of acute traumatic pain and vasospastic disorders of the upper limb. The technique, its merits and possible complications are discussed.     

连续性血液净化治疗多脏器功能衰竭九例临床观察

目的 探讨连续性血液净化对多脏器功能衰竭的抢救与治疗.方法 在常规治疗基础上给予连续性血液净化治疗.结果 治疗前、后血肌酐、谷丙转氨酶、肌酸磷酸激酶比较差异有学意义(P均<0.05).结论 连续性血液净化治疗对多脏器功能衰竭的抢救有重要作用.     

Trace element removal during in vitro and in vivo continuous haemodialysis.

BACKGROUND: Continuous renal replacement therapy (CRRT) increasingly is being used to treat critically ill patients with renal disease. CRRT removes waste products but also nutrients. Our understanding of trace element CRRT clearance has been limited by poor assay sensitivity. The development of inductively coupled plasma mass spectrometry (ICP-MS) allows for the measurement of CRRT trace element removal. METHODS: Continuous venovenous haemodialysis (CVVHD) transmembrane clearances of trace elements and urea were assessed using a bovine blood-based in vitro model using two different haemodialyser types. These findings were validated in 10 critically ill adult patients receiving continuous venovenous haemodiafiltration (CVVHDF). Calculated daily trace element loss was compared with a typical dose of daily trace element supplementation. RESULTS: The mean +/- SD in vitro CVVHD transmembrane clearances (ml/min) for the polysulfone haemodialyser were chromium 0.97 +/- 0.23, copper 0.47 +/- 0.18, manganese 4.6 +/- 3.6, selenium 1.2 +/- 0.63 and zinc 2.3 +/- 0.32 and for the cellulose diacetate haemodialyser chromium 1.54 +/- 0.91, copper 0.21 +/- 0.07, manganese 7.8 +/- 4.1, selenium 0.76 +/- 0.39 and zinc 2.7 +/- 0.37. The in vivo CVVHDF transmembrane clearances (ml/min) were chromium 5.4 +/- 2.4, copper 0.45 +/- 0.33, manganese 1.9 +/- 4.6, selenium 1.6 +/- 1.2, and zinc 4.0 +/- 1.3. CONCLUSION: ICP-MS assays detected the five trace elements in the effluent of CVVHDF patients. Trace element CVVHD transmembrane clearance estimates for our in vitro model were supported by the in vivo CVVHDF findings. Calculated daily trace element loss attributed to CVVHD and CVVHDF with dialysate flow rates of 33.3 ml/min is less than what is provided in a daily dose of a trace element supplementation product.     

术后持续镇痛对胃肠功能恢复的影响

为探讨术后持续镇痛对胃肠功能恢复的影响,将120例择期大、中型腹部手术后的病人随机分成两组,实验组(60例)采用硬膜外持续镇痛,对照组(60例)采用间断肌内注射镇痛剂,观察并记录肠鸣音恢复时间、肛门排气时间.结果:实验组肠鸣音恢复时间为(50.50±2.48) h,对照组为(43.58±3.86) h;实验组肛门排气时间为(58.54±2.47) h,对照组为(51.27±3.80) h,两组比较,差异无显著性(均P＞0.05).表明术后持续镇痛不影响胃肠功能的恢复.     

Continuous Cyclic Peritoneal Dialysis: A Preliminary Report

Continuous cyclic peritoneal dialysis (CCPD) was designed to reduce the high incidence of peritonitis and eliminate the multiple interruptions created by dialysate exchanges during the day needed for CAPD, while maintaining the quality of dialysis. Three nocturnal cycles with 2 liters of dialysate lasting 3 hours each are provided by an automated cycler while the patient sleeps. Two liters are left in the abdomen in the morning. Only one daily connection and one disconnection are required between the peritoneal catheter and the cycler line. Our 84 patient months experience with 14 patients reveals a low incidence of peritonitis (1 per 42 patient months), satisfactory ultrafiltration rates and clearances that compare favorably with those of CAPD (C_urea 67, C_creatinine 58, and C_B12 45 L/wk). Blood pressure control has been excellent while most patients enjoy liberal diets.
This preliminary study suggests that CCPD may indeed reduce the rate of peritonitis, provide excellent clearance and ultrafiltration, allow more free time to the patient and maintain a steady physiological state.     

Persistent pneumothorax treated with continuous positive airway pressure

A patient who presented with persistent pneumothorax after blunt chest trauma is described. The lung re-expanded partially in response to chest drain suction but some areas remained collapsed. The institution of continuous positive airway pressure on an intermittent basis, was followed by complete re-expansion of the lung and resolution of the pneumothorax.     

Clinical signs of infection during continuous postoperative epidural analgesia in children: the value of catheter tip culture

BACKGROUND: Infection arising from the use of epidural catheters for postoperative analgesia is a major source of anxiety. METHODS: The routine culture of epidural catheter tips were studied in 100 consecutive children aged 1 day to 15 years. Epidural catheters were inserted aseptically in accordance with an agreed protocol. The catheter site was inspected regularly and the tip sent for microbiological culture following removal. RESULTS: Local signs of inflammation at the epidural site were seen in 16% of children, and bacteria were isolated from catheter tip culture in 32%. Positive catheter tip culture was found in 43% of children with local signs of inflammation and of the remaining children with no local signs, organisms were isolated from the catheter tip in 30%. Culture of skin swabs and catheter tips in two patients with purulent discharge at the epidural site yielded the same organism. No correlation between the number of attempts at catheter insertion and either local signs of inflammation or positive catheter tip cultures were found. CONCLUSIONS: Minor local signs of inflammation and infection are common in pediatric patients during continuous epidural infusion. Epidural catheter tips are also frequently culture positive in patients with and without local signs and who may not go on to develop further signs or symptoms of infection. Routine culture of catheter tips is unnecessary as it is not a good predictor of epidural space infection.     

Continuous passive motion after total knee arthroplasty

Sixty-two patients undergoing primary total knee arthroplasty were studied prospectively. There were 42 patients in whom continuous passive motion (CPM) was used after surgery and 20 controls. The two groups were comparable with respect to age, diagnosis, sex, weight, and preoperative deformity and motion. The mean length of time required for CPM patients to achieve 90 degrees of flexion (9.1 days) was shorter than that for the control group (13.8 days). At the time of discharge from the hospital, however, there was no significant difference between the groups in amount of either flexion or extension. All patients had venograms performed after arthroplasty; the incidence of positive studies indicating thrombophlebitis was 45% in CPM patients and 75% in controls. These data demonstrate that CPM after knee arthroplasty enables patients to recover motion more quickly and affords some protection against deep vein thrombosis.     

连续Z形切口在跟腱断裂术中的应用

正2010年1月~2014年5月,我科采用跟腱连续Z形切口、V-Y成形减张缝合治疗18例急性跟腱闭合性断裂患者,疗效满意,报道如下。1材料与方法1.1病例资料本组18例,男14例,女4例,年龄21~53岁。均为新鲜闭合损伤。受伤至手术时间为1~8 d。1.2治疗方法硬膜外麻醉。以跟腱     

A national survey of propofol infusion use by paediatric anaesthetists in Great Britain and Ireland

Background:  Since the introduction of propofol in 1977, it has been widely used for the induction and maintenance of anaesthesia and for sedation on the intensive care unit. Recently, case reports of suspected propofol infusion syndrome (PRIS) following short term infusions have been published. We set out to obtain a picture of the current use of propofol infusions by paediatric anaesthetists in Great Britain and Ireland.
Methods:  A questionnaire concerning the use of propofol infusions was sent to 388 paediatric anaesthetists.
Results:  A total of 242 (62%) replies were received. 26% of anaesthetists used propofol infusions with at least a monthly frequency. 136 (56%) anaesthetists thought that propofol infusions were of benefit in reducing postoperative nausea and vomiting. The majority of anaesthetists did not state a maximum infusion rate or length of infusion. Of those anaesthetists who answered the questions the maximum rate used was 30 mg·kg⁻¹·h⁻¹ and the longest time considered for an infusion was 72 h. Only 5 (2%) anaesthetists regularly used BIS monitoring, although 106 (44%) expressed a desire to use it if it was freely available in their hospitals. Modifications to infusions from 1% to 2% propofol were used by 38 (16%) anaesthetists and 28 (12%) used glucose infusions intra-operatively.
Conclusions:  There is a wide variety in the use of propofol infusions by paediatric anaesthetists. The mechanisms underlying PRIS are poorly understood and require further work to ensure propofol infusions are used appropriately for anaesthesia in children.