血管紧张素Ⅱ受体拮抗剂延缓慢性移植肾肾病肾功能损害的临床研究

目的探讨血管紧张素Ⅱ受体拮抗剂洛沙坦能否延缓慢性移植肾肾病(CAN)肾功能衰退的进程及其机理。方法对病理诊断为CAN(Ⅰ级)肾功能不全的22例肾移植患者(A组)使用洛沙坦治疗1年以上,与同期未使用洛沙坦的24例CAN(Ⅰ级)患者(B组)进行对比,比较2组1年后肾功能、尿TGF-β1浓度;并比较A组患者治疗前后移植肾活检组织中TGF-β1mRNA的表达量和TGF-β1免疫荧光强度等。结果1年后,A组肾功能稳定12例、好转2例,而B组肾功能稳定4例,其他患者肾功能均进行性恶化,2组差异有统计学意义(P<0.01)。A组服用洛沙坦1年后,尿TGF-β1浓度为(273.8±84.1)pg/mg.Cr,明显低于B组(457.2±78.9)pg/mg.Cr(P<0.01);A、B 2组肌酐清除率(Ccr)减损量分别为(6.6±5.4)、(16.2±9.1)m l/m in(P<0.01)。A组服药后肾组织中TGF-β1mRNA表达量由1.58±0.36降为0.96±0.27,TGF-β1免疫荧光强度由(10.83±2.33)×106降为(6.41±1.53)×106,差异均有统计学意义(P<0.01)。使用洛沙坦无不良反应发生。结论洛沙坦对CAN(I级)患者肾功能损害具有延缓作用,其机理可能与降低移植肾内TGF-β1的分泌有关。     

尿TGF--β1与慢性移植物肾病的关系

目的探讨肾移植受者尿转移生长因子β1(TGF-β1)与慢性移植物肾病(CAN)的关系.方法1999年8月～2000年12月期间进行肾移植手术157例,在术后满1年时检测尿TGF-β1,所得相对浓度为172.5～533.1 pg/mg(Cr),分别选出TGF-β1浓度最高和最低的各40例患者构成组Ⅰ和组Ⅱ,进行前瞻性观察.在肾移植达3年时,比较两组肾功能有无差异,分析肾功能与术后1年时的尿TGF-β1有无相关性,对肾功能不全者作移植肾穿剌活检,明确是否为CAN.结果在肾移植达3年时,组Ⅰ肌酐清除率(Ccr)减少了(12.8±10.6) ml/min, 29.6%的患者有肾功能不全,均显著大于组Ⅱ[分别为(6.9±5.7)ml/min和9.4%];患者Ccr与术后1年时的尿TGF-β1之间有显著的相关性;肾功能不全者,移植肾在组织学上均呈CAN病理学改变.结论TGF-β1可能在CAN的发生中起重要作用;CAN患者在肾功能异常前尿TGF-β1已显著升高,肾移植后早期检测尿TGF-β1对远期肾功能具有预测作用.     

尿转化生长因子-β1及Ⅳ型胶原与肾内微癥积的相关性研究

目的:通过无创检测方法早期发现肾内微型癥积.方法:对98例肾活检的患者进行中医辨证分型:检测血/尿TGF-β1、尿ColⅣ、Scr、Ccr、24 h尿蛋白排泄;时肾组织运用CMIAS计算机病理图像分析系统作半定量测定;观察尿TGF一岛、ColIV水平,与肾硬化程度、中医辨证间的相关性.结果:(1)肾病患者尿TGF-β1、ColⅣ明显高于健康人(P<0.01).(2)尿TGF-β1、COlⅣ与肾小球基质基底膜面密度、肾间质纤维化程度、间质浸润细胞数呈正相关(P<0.05),与尿ColⅣ呈负相关(P<0.05).随着硬化程度加重尿TGF-β1、ColⅣ水平逐级增高.(3)尿TGF-β1、COlⅣ分别与Scr正相关,与Ccr负相关(P<0.01);与血TGF-β1、24 h尿蛋白定量无关.(4)在轻度肾硬化组,Scr和Ccr尚正常时尿TGF-β1、ColⅣ已高于正常组(P<0.01),尿ColⅣ敏感程度要高于尿TGF-β1和Ccr.(5)98例肾脏病患者的中医辨证以脾肾气虚型为主,占66.3%,以传统"四诊"辩为兼瘀血证者仅占8例(8.16%),肾硬化均属于重度,肾功能已减退,尿TGF-βColⅣ水平显著高于无瘀血证者.结论:尿TGF-β1、ColⅣ能早于Scr和Ccr的异常反映肾硬化及硬化程度.不受血TGF-β1和24 h尿蛋白定量的影响,可以作为监测肾硬化及其进展的一项无创性早期标志性指标,以尿ColⅣ更为敏感;同时揭示肾微癥积的病因为正虚邪郁,中医传统的宏观辨证加上微观辨证可明显提高辨证的准确性,尿TGF-β1、ColⅣ可以作为中医微观辨证的一项量化指标早期诊断肾内微癥积,监测病情的动态变化,指导早期应用消癥散积中药防治肾硬化.     

雌激素预防大鼠同种肾移植慢性排斥反应的实验研究

目的 探讨雌激素对移植肾慢性排斥反应的影响。方法 以Fisher大鼠作供者,雌性Lewis大鼠作受者进行同种肾移植,为排除排卵周期及相应的内源性性激素变化的影响,肾移植均在非排卵期进行,后治疗组大鼠隔日给予25μg/kg雌二醇皮下注射。移植后16周作肾功能、移植肾组织学及免疫组化检测,测定肾组织中转化生长因子及β－机动蛋白mRNA的表达。结果 与对照组比较,移植后治疗组24d尿蛋白持续保持较低的水平（P＜0.01）,血清肌酐水平降低（P＜0.01）,肌酐清除率升高（P＜0.01）,移植肾组织管内膜增厚、肾小球硬化和间质纤维化程度减轻（P均＜0.01）,淋巴细胞和单核／巨噬细胞浸润减少（P＜0.01）,细胞间粘附分子（ICAM－1）、转化生长因子（TGF－β1）的mRNA表达减少（P均＜0.01）。结论 雌激素对移植肾功能有保护作用,其机理与影响上述细胞因子在移植肾的表达有关,提示雌激素可能为一类潜在的抗慢性排斥反应药物。     

波生坦及依那普利对糖尿病肾病模型干预的对比研究

目的应用波生坦或依那普利对糖尿病肾病(DN)模型进行干预,比较两药疗效,并探讨其作用机制。方法Wistar大鼠摘除右肾后,静脉注射链脲菌素成DN模型,然后分成模型组、波生坦组、依那普利组。对照组为仅注射缓冲液。每组大鼠6只。20周时测量体重、血压、血糖及24h尿蛋白定量,处死大鼠,用PAS染色及Masson染色观察肾脏病理变化;用RT-PCR及免疫组化方法检测肾组织中Ⅰ型胶原(ColⅠ)、Ⅳ型胶原(ColⅣ)、转化生长因子-β1(TGF-β1)、结缔组织生长因子(CTGF)及骨形成蛋白-7(BMP-7)的mRNA及蛋白质表达。结果与对照组相比,糖尿病模型组大鼠血糖、平均动脉压、尿蛋白定量及肾重/体重比值均显著上升(P<0.05或0.01);肾小球系膜及基膜相对面积及肾间质纤维组织相对面积均显著扩大(P<0.01);肾组织内ColⅠ、ColⅣ、TGF-β1及CTGF的mRNA及蛋白质表达均显著上调(P<0.05或0.01),而BMP-7mRNA及蛋白质表达则下调(P<0.05或0.01)。波生坦或依那普利干预后,上述上调指标除血糖外都被显著抑制(P<0.05或0.01),而抑制的BMP-7表达却被上调(P<0.01)。两种药物之间比较,作用无显著性差异(P>0.05)。结论波生坦或依那普利对DN模型的干预效果相似,此疗效可能与下调肾组织TGF-β1及CTGF表达、及上调BMP-7表达相关。     

洛沙坦治疗慢性移植物肾病的临床研究

目的明确血管紧张素Ⅱ受体拮抗剂洛沙坦能否改善慢性移植物肾病患者的肾功能。方法2001年8月至2003年4月期间,对病理诊断为慢性移植物肾病(Ⅰ级)肾功不全的24例患者(组Ⅰ)使用洛沙坦治疗1年以上,与同期内未使用洛沙坦的27例慢性移植物肾病患者(组Ⅱ)进行对比,比较两组的肾功能、血和尿转移生长因子-β1(TGF-β1)浓度及使用洛沙坦的不良反应等。结果治疗1年后,组Ⅰ有15例(62.5%)患者移植肾功能得以好转或不再继续恶化,而组Ⅱ除6例(22.2%)移植肾功能维持在原有水平外,其他患者肾功能均进行性恶化。组Ⅰ血和尿TGF-β1浓度及肾功能损失量均明显低于组Ⅱ,使用洛沙坦无不良反应发生。结论洛沙坦能改善部分慢性移植物肾病患者的肾功能,其药理作用可能与降低移植肾内TGF-β1的分泌有关。     

他克莫司替代环孢素A延缓移植肾早期发生的慢性功能丧失

目的探讨他克莫司(FK506)替代环孢素A(CsA)延缓移植肾早期发生的慢性肾功能衰竭的可行性。方法选取1999年1月至2002年5月间病理诊断为慢性移植肾肾病肾功能不全的肾移植受者93例。随机将受者分为2组,A组(50例):用FK506替换CsA,替换剂量比例约为1∶75,其它免疫抑制剂不变;B组(43例):CsA和其它免疫抑制剂均不作调整。比较两组受者3年后的肾功能、内生肌酐清除率(Ccr)减损量、血浆转化生长因子β1(TGF-β1)浓度和急性排斥反应发生率等。结果替换治疗3年后,A组有31例(62.0%)受者移植肾功能稳定或好转,而B组除4例(9.3%)肾功能稳定外,其他受者肾功能均进行性减退;A、B两组Ccr减损量分别为(0.172±0.164)ml/s和(0.359±0.292)ml/s;A、B两组血浆TGF-β1浓度分别为(17.4±8.8)μg/L和(39.5±11.0)μg/L。两组间各结果相比较,差异均有统计学意义(P<0.01)。两组急性排斥反应发生率分别为14.0%和11.6%,差异无统计学意义(P>0.05)。结论以FK506替代CsA可延缓早期发生的慢性移植肾肾病受者肾功能衰竭的速度。     

养阴活血方药拮抗环孢素慢性肾毒性的大鼠体内实验研究

目的探讨养阴活血方药拮抗环孢素(CsA)慢性肾毒性的作用及机制。方法将50只Sprague-Dawley(SD)大鼠随机分为对照组、依那普利组、中药低剂量组、中药中剂量组、中药高剂量组,每组各10只。采用钠耗竭法制作大鼠CsA肾毒性模型:给予钠缺乏饮食,每日皮下注射CsA12.5mg/(kg·d),连续4周。同时,按组别相应予以蒸馏水、依那普利(依那普利10倍成人剂量)、低剂量中药(养阴活血方药5倍成人剂量)、中剂量中药(养阴活血方药10倍成人剂量)、高剂量中药(养阴活血方药20倍成人剂量)灌胃。建组后14d、28d记录各组大鼠死亡率。建组后7d、14d、21d、28d,测定各组大鼠的血清肌酐(Scr)、尿肌酐、24h尿蛋白定量,计算内生肌酐清除率(Ccr)。建组后28d处死大鼠,取右肾组织进行病理学检查和免疫组织化学染色,观察细胞外基质(extracellular matrix,ECM)成分,包括纤维连接蛋白(fibronectin,FN)、胶原蛋白(collagen,Col)Ⅳ和其调节因子转化生长因子(TGF)-β1的表达;取左肾组织进行逆转录聚合酶链反应(RT-PCR),分别检测FN、ColⅣ、TGF-β1,以及抑制ECM生成基因包括组织型纤溶酶原激活物(tissue-type plasminogen activator,tPA)、尿激酶型纤溶酶原激活物(urokinase-plasminogen activator,uPA)、纤溶酶原激活物抑制剂(plasminogen activator inhibitor,PAI)-1基因的核糖核酸(RNA)表达。结果建组后14d,中药高剂量组的死亡率为20%,依那普利组和对照组各为10%,中药中剂量组、中药低剂量组均无死亡。建组后28d,除中药高剂量组的死亡率为20%、中药低剂量组的死亡率为0外,其余3组死亡率均为10%。建组7d后各组大鼠肾功能逐渐恶化,24h尿蛋白定量增加,于建组后14d达到高峰。建组14d后进入CsA慢性肾毒性期,各治疗组大鼠的肾功能均有所改善、24h尿蛋白定量减少,但对照组仍然继续恶化。建组后28d,中药高剂量组和中药中剂量组的Ccr明显高于对照组(均为P<0.05),中药各剂量组及依那普利组的24h尿蛋白定量均低于对照组(P<0.05或P<0.01)。肾组织病理切片常规苏木素-伊红(HE)染色表现为慢性CsA肾毒性肾间质纤维化,以对照组改变最为严重,依那普利组、中药低剂量组、中药中剂量组及中药高剂量组改变依次减弱。马松(Masson)染色可见肾小管及肾小球周围纤维增生,以对照组最为明显。免疫组织化学染色显示对照组的FN、ColⅣ及TGF-β1表达遍布肾小管皮质和髓质,依那普利组及中药各剂量组表达程度较轻。RT-PCR结果提示,FN基因的信使RNA(messenger RNA,mRNA)表达强度以中药高剂量组最低、对照组最高;ColⅣ基因的mRNA表达强度以中药低剂量组最高,中药高剂量组最低;TGF-β1基因的mRNA表达强度以依那普利组、中药高剂量组最低,中药低剂量组表达最高。作为抑制ECM生成的tPA、uPA和PAI-1基因的mRNA在各组表达强度差异均无统计学意义。结论养阴活血方药有类似依那普利拮抗大鼠CsA慢性肾毒性的作用,但对急性肾毒性无保护作用,其作用机制可能与下调TGF-β1等细胞因子,从而抑制ECM的合成有关。     

糖肾康对糖尿病肾病患者尿转化生长因子-β1的影响

目的:观察糖肾康对糖尿病肾病患者尿转化生长因子-β1的影响,进一步证实糖肾康对DN的治疗作用,并探讨其作用机制.方法:治疗组73例采用糖肾康和卡托普利联合治疗,对照组75例单服卡托普利,两组其他治疗相同,治疗时间为6个月,观察治疗前后尿TGF-β1 的变化.结果:治疗后尿TGF-β1显著下降(P<0.01),与对照组治疗后比较有统计学差异(P<0.05),同时血糖、血脂、胰岛素抵抗(IR)、血流动力学和肾功能明显改善.结论:糖肾康通过改善血糖、血脂、IR、血流动力学和直接抑制TGF-β1功能及分泌达到保护肾脏,使尿TGF-β1产生减少.     

肾移植受者巨细胞病毒感染与慢性移植物肾病

目的　探讨肾移植术后早期巨细胞病毒 (CMV)感染与慢性移植物肾病 (CAN)的关系。　方法　 1999年 8月至 2 0 0 0年 12月行肾移植并随访 3年的患者 77例 ,根据术后 6个月内外周血CMV pp6 5 ( )白细胞计数的数量和持续时间 ,将其分为 :非活动性 (A组 ,n =15 )、低活动性 (B组 ,n=32 )、短期高活动性 (C组 ,n =18)和长期高活动性 (D组 ,n =12 )CMV感染 4组。 6个月后行移植肾穿剌活检 ,通过免疫荧光和逆转录聚合酶链反应 (RT PCR)比较 4组患者肾组织中转移生长因子β1(TGF β1)蛋白和mRNA的表达量 ;3年后比较 4组患者肾功能不全 (血肌酐持续 >114 μmol/L)的发生率和肌酐清除率 (Ccr)减损量 ;对肾功能不全的患者通过活检明确是否为CAN。　结果　肾移植 6个月后A、B、C组TGF β1蛋白表达量分别为 :( 5 .82± 1.32 )× 10 6、( 6 .34± 1.4 7)× 10 6和 ( 6 .5 8± 1.4 4 )× 10 6,TGF β1mRNA分别为 :0 .84± 0 .17、0 .78± 0 .15和 0 .82± 0 .16 ;D组TGF β1蛋白和mRNA表达量分别为 ( 10 .4 7± 2 .12 )× 10 6和 1.37± 0 .2 5 ,均明显高于前 3组 (P <0 .0 1)。前 3组 3年内Ccr减损量分别为 :( 5 .6± 5 .2 )、( 6 .2± 6 .4 )和 ( 5 .9± 4 .7)ml/min ;D组为 ( 15 .8± 9.6 )ml/min ,明显高于前 3组     

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.     

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.     

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.