枕颈融合术后吞咽困难评估及预测方法的研究进展

枕颈融合术(occipitocervical fusion, OCF)用于治疗因各种原因(创伤、类风湿关节炎、感染、肿瘤、先天畸形和退化等)导致的颅颈交界不稳定。通过OCF可获得满意的融合率并重建枕颈稳定性。吞咽困难为OCF术后常见的并发症, 严重影响患者术后的生活质量。对吞咽困难的评估主要采用Bazaz吞咽困难评分、吞咽生存质量量表(swallowing quality of life, SWAL-QOL)及进食评估问卷调查表-10(eating assessment tool-10, EAT-10)评分, 而临床主要通过颈椎曲度相关参数(O-C2角、O-EA角、Oc-Ax角、PI角)的变化预测吞咽困难的发生。目前, 临床评估及预测吞咽困难的方法很多, 但最佳评估方法尚不确定。本文对OCF术后吞咽困难的评估及预测方法进行综述, 显示Bazaz吞咽困难评分、SWAL-QOL评分及EAT-10评分量表评估OCF术后吞咽困难具有良好的适用性, 而在OCF术中通过调整使O-C2角>-5°、O-EA角>100°、Oc-Ax角>65°、术后PI角较术前PI角增加(即dPI角)≥...     

混合现实技术引导的经皮内窥镜下腰椎椎间盘切除术的初步探索与应用

经皮内窥镜下腰椎椎间盘切除术（PELD）已经成为治疗腰椎椎间盘突出症（LDH）的首选方法^［1-3］。腰椎椎间盘突出类型多样化,术前须精确定位突出椎间盘的“靶点”位置,确定进针点、深度和角度等相关参数,以便术中可按照术前设计快速准确地穿刺和置入工作通道,这是靶向穿刺技术的核心,也是尽可能减少不必要创伤并发症的基础^［4］。常规手术通道的建立,需要根据椎间盘突出的不同病理类型并结合临床实践确定,且术中需要C形臂X线机透视辅助,存在学习曲线陡峭、辐射量大、手术风险高等问题^［5-6］。混合现实（MR）技术是近年发展起来的一门新兴技术,其将虚拟现实（VR）技术与增强现实（AR）技术相结合,操作者可从MR技术呈现的全息影像中获取相关信息,从而实现虚拟和真实的交互^［7-8］。目前,MR技术在复杂的脑外科手术、髋关节手术中已有应用,并获得良好的临床疗效^［9-11］,但尚无其应用于PELD的报道。本研究组在MR技术引导下,对1例LDH患者行PELD,取得了良好的临床疗效,现报告如下。     

选择性神经根阻滞的价值和争议

选择性神经根阻滞（SNRB）是指对患有脊柱退行性疾病的患者，经查体后在影像学技术（X线，CT和B超）的辅助引导下，对高度怀疑病变的神经根（颈、胸、腰、骶）进行选择性地穿刺、定位、阻滞、治疗的一种微创技术^［1-2］。随着微创精准医疗理念的不断发展，SNRB的临床应用越来越广泛，可定位诊断和治疗病变神经根。当SNRB作为诊断方法时，强调定位的精准性，操作要求神经根定位明确，药物阻滞精准，尽量减小阻滞范围，降低假阳性的发生率。随着微创手术技术的广泛开展，多节段脊柱退行性疾病中责任神经根的术前精准定位至关重要，SNRB在明确责任节段、减少手术节段、预测术后效果方面具有重要意义^［3-5］。当SNRB作为治疗方法时，强调治疗的有效性，操作要求在降低并发症的同时，尽量增加SNRB的效果和持续时间。作为一种简单有效的脊髓硬膜外注射方法，SNRB广泛应用于颈肩腰腿痛的治疗，并取得了良好效果^［6-7］。     

地舒单抗在骨巨细胞瘤新辅助治疗中的应用研究进展

骨巨细胞瘤（GCTB）是一种具有局部侵袭倾向的原发性良性骨肿瘤,以局部溶骨性病灶为特征。GCTB可发生局部复发和远处转移^［1-2］,占所有原发性骨肿瘤的3% ~ 5%,好发年龄为20 ~ 40岁^［1,3］。好发部位为长骨干骺端,约半数发生于股骨下端与胫骨上端,少数严重者软骨下可受累,出现关节功能障碍［4］;发生在脊柱的病灶以骶骨最为多见,其次为腰椎、胸椎、颈椎^［5］。近年来,GCTB的治疗模式逐渐从外科治疗转变为以外科治疗为主、药物治疗辅助的综合治疗。随着新辅助治疗理念的兴起,地舒单抗被广泛应用于GCTB的治疗,其可延缓肿瘤进展、降低手术分期等^［1］。地舒单抗是一种全人源性单克隆抗体,可与核因子-κB受体活化因子配体（RANKL）特异性结合直接抑制破骨细胞功能。然而,也有部分研究^［6］表明,术前应用地舒单抗可能会增高术后局部复发的风险。地舒单抗术前应用时长存在争议,并有少数报道^［7］提出,地舒单抗可能与肿瘤恶变有关。本文通过查阅相关文献,并重点回顾近5年的相关研究,对地舒单抗作为GCTB新辅助治疗药物的应用作如下综述。     

新型冠状病毒感染者脊柱外科急诊手术的围手术期管理专家共识

自2019年12月以来,已有200余个国家和地区相继报道了新型冠状病毒感染病例,世界卫生组织（WHO）于2020年3月12日宣布新型冠状病毒全球大流行,截至6月18日,全球已累计有824万余人感染,44万余人死亡,对全世界医疗、政治和经济领域影响巨大^［1-2］。WHO将其命名为“2019冠状病毒感染性疾病”（COVID-19）,病原体被命名为重症急性呼吸综合征冠状病毒2（SARS-CoV-2）^［3-6］。按照《中华人民共和国传染病防治法》,COVID-19被纳入乙类传染病,采取甲类传染病的预防控制措施^［7］。     

新枕颈距离测量方法在颅底凹陷症手术中的应用及临床意义

目的:采用C4椎体中心至McGregor线垂直距离(the occiput-C4 distance,OC4D)测量颅底凹陷症(basilar invagination,BI)患者枕颈距离,并探讨其在枕颈融合术(occipitocervical fusion,OCF)中评估患者枕颈区纵向复位程度的可行性及临床意义。方法:回顾性分析2014年1月～2019年1月在我院就诊的82例颅底凹陷症患者的临床资料,男性23例,女性59例,平均年龄50.3±9.6岁,行OCF手术治疗56例,男性17例,女性39例,其中3例患者术后出现发音困难、吞咽困难、咽反射减弱等低位颅神经麻痹症状且无法耐受,考虑与术中患者枕颈区过度纵向撑开有关,行翻修手术以减少患者枕颈区纵向撑开距离。测量82例患者入院后术前自然站立位颈椎侧位中立位片、过伸及过屈位片上OC4D值;56例手术患者(53例OCF术后常规恢复患者和3例OCF术后翻修患者)术后住院期间复查的自然站立位颈椎侧位片上OC4D值及3例OCF术后翻修前自然站立位颈椎侧位片的OC4D值,2名脊柱外科医生不同时间单独进行2次测量。在56例手术患者入院和术后复查的颈椎CT检查中分别测量齿突尖到McRae线的垂直距离(the distance of the tip of odontoid to the McRae line,McRL)。计算53例OCF术后症状改善患者和3例OCF术后翻修患者枕颈区的纵向复位距离(患者术后OC4D值-患者术前OC4D值,d-OC4D);记录手术患者术前及术后12个月随访时日本骨科科协会(Japanese Orthopaedic Association,JOA)评分值(17分法),计算手术患者枕颈区纵向复位率和神经功能改善率。结果:82例患者入院颈椎中立位OC4D值为49.1±7.6mm,过屈位为49.0±7.5mm,过伸位为49.0±7.7mm,三者间差异无统计学意义(P0.05)。颈椎中立位、过伸位及过屈位OC4D测量值在观察者间的ICC分别为0.951、0.963和0.949(P0.05),观察者内的ICC分别为0.977、0.982和0.971(P0.05)。56例手术患者中,3例行翻修手术患者术后低位颅神经麻痹症状明显缓解。56例手术患者(3例患者为翻修术后)McRL值由术前6.3±2.8mm降至术后1.8±1.2mm,颈椎中立位OC4D值由术前48.9±6.0mm增至术后53.5±6.6mm,枕颈区纵向复位距离为4.8±1.2mm,95%参考值范围为2.4～7.2mm。JOA评分由术前11.84±2.70分提高至术后12个月随访时14.88±1.74分,差异有统计学意义(P0.05)。手术患者枕颈区平均纵向复位率为65.8%;神经功能平均改善率为70%。d-OC4D与复位率、神经功能改善率之间相关系数r分别为0.831、0.725(P0.001)。结论 :OC4D测量是一种简单有效的枕颈距离测量方法,在颅底凹陷症经后路枕颈融合术前可用于预估患者枕颈区纵向撑开复位的距离,术中可用于即时评估枕颈区纵向撑开复位情况,保证患者枕颈区获得充分减压复位的同时,可避免枕颈区过度纵向撑开而引起相关术后并发症。     

青少年运动员腰椎峡部裂的诊治进展

腰椎峡部裂是指腰椎关节突之间的损伤或骨质缺损，部分患者出现椎体结构不稳，可造成椎体滑脱等临床症状^［1］，普通人群发生率为4%~6%^［2］。     

基于枕颈影像参数的枕颈融合术后吞咽困难风险分析

目的 基于枕颈影像参数探讨枕颈融合术后吞咽困难的危险因素.方法 选择2018年8月～2020年8月本科收治的84例枕颈交界区不稳患者,均采用枕颈融合术治疗,调查其术后吞咽困难发生情况,设为吞咽困难组及吞咽正常组;比较两组治疗前后的枕颈影像参数,即治疗前后Oc-Ax角、O-C2角、O-EA角以及nPAS以及变化值,并采用多因素Logistic回归分析调查枕颈融合术后吞咽困难的危险因素.结果 术后25例发生吞咽困难;吞咽困难组与吞咽正常组的术前、术后1年O-C2角以及ΔO-C2角差异有统计学意义(P<0.05);两组术前Oc-Ax角、O-EA角以及nPAS差异无统计学意义(P>0.05),两组术后1年Oc-Ax角、O-EA角、nPAS以及各指标的变化值差异有统计学意义(P<0.05).多因素Logistic回归分析显示,ΔO-C2角≤-5°、术后Oc-Ax角≤65°、术后nPAS≤10 mm、术后O-EA角≤100°是枕颈融合术后吞咽困难的危险因素.结论 枕颈交界区不稳患者采用枕颈融合术治疗后吞咽困难发生率较高,O-C2角变化值较大和术后Oc-Ax角、nPAS、O-EA角过小均会增加吞咽困难的风险.     

经口前路寰枢椎复位钢板系统治疗先天性枕颈交界区畸形

目的探讨经口前路寰枢椎复位钢板（transoral atlantoaxial reduction plate,TARP）系统用于先天性枕颈交界区畸形手术治疗的临床疗效。方法 2007年12月-2011年12月采用TARP系统治疗先天性枕颈交界区畸形患者35例。所有患者术前术后均行颈椎过伸过屈位X线、枕颈交界区CT扫描及MRI以评估局部畸形及颈脊髓腹侧压迫情况;采用日本骨科学会（Japanese Orthopaedic Association,JOA）评分（17分法）评估术前术后脊髓损伤及恢复情况。术后3、6、12个月复查颈椎正侧位X线片及CT,评价内固定效果及融合情况。结果 35例患者均顺利完成手术,术后MRI示颈脊髓腹侧压迫均有明显减轻,延髓脊髓角术后平均增加约29.7°,31例（89%）患者术后神经功能有明显改善,4例术前术后神经功能无变化。术后随访1年未发现寰枢椎再脱位、螺钉松动、断裂或移位等并发症。结论TARP系统可对先天性枕颈交界区畸形合并腹侧颈脊髓压迫进行一期减压、复位及内固定,是枕颈交界区畸形理想的治疗手段之一。     

瑞马唑仑复合瑞芬太尼用于支撑喉镜下声带手术的效果

目的 观察瑞马唑仑复合瑞芬太尼用于支撑喉镜下声带手术的临床效果。
方法 选择2022年1—8月在全麻下行支撑喉镜声带手术患者180例,男77例,女103例,年龄18～64岁,BMI 18～30 kg/m²,ASA Ⅰ—Ⅲ级。采用随机数字表法将患者分为四组：丙泊酚组（C组）、瑞马唑仑1.0 mg·kg^-1·h^-1组（R1组）、瑞马唑仑1.5 mg·kg^-1·h^-1组（R2组）和瑞马唑仑2.0 mg·kg^-1·h^-1组（R3组）,每组45例。C组麻醉维持采用静脉泵注丙泊酚5 mg·kg^-1·h^-1,R1组麻醉维持采用静脉泵注瑞马唑仑1.0 mg·kg^-1·h^-1,R2组麻醉维持采用静脉泵注瑞马唑仑1.5 mg·kg^-1·h^-1,R3组麻醉维持采用静脉泵注瑞马唑仑2.0 mg·kg^-1·h^-1,所有患者麻醉维持复合瑞芬太尼0.2 μg·kg^-1·min^-1。记录麻醉诱导前（T₁）、支撑喉镜置入即刻（T₂）、麻醉维持结束即刻（T₃）、气管拔管时（T₄）的HR、MAP和BIS。记录镇静起效时间、苏醒时间、拔管时的镇静-躁动评分、拔管后5 min的Ramsay评分。记录术中麻黄碱、硝酸甘油使用情况。记录注射痛、补救镇静例数,拔管后1 h内恶心呕吐、呼吸抑制等不良反应、术中知晓的发生情况。
结果 与C组比较,R1组T₃时MAP、T₂、T₃时BIS明显升高,T₄时MAP明显降低,镇静起效时间明显延长,麻黄碱使用率、注射痛发生率明显降低（P<0.05）;R2组T₂、T₄时HR明显减慢、MAP明显降低,T₃时MAP明显升高,镇静起效时间、苏醒时间、拔管时间明显延长,麻黄碱使用率、注射痛发生率明显降低（P<0.05）;R3组T₂、T₄时HR明显减慢、MAP明显降低,镇静起效时间、苏醒时间、拔管时间明显延长,Ramsay评分明显升高（P<0.05）。与R1组比较,R2组T₂、T₄时HR明显减慢、MAP明显降低,T₂、T₃时BIS明显降低,苏醒时间、拔管时间明显延长（P<0.05）;R3组T₂、T₄时HR明显减慢,T₂—T₄时MAP、T₂、T₃时BIS明显降低,苏醒时间、拔管时间明显延长,Ramsay评分明显升高（P<0.05）。与R2组比较,R3组T₃时MAP明显降低,Ramsay评分明显升高（P<0.05）。四组硝酸甘油使用率、补救镇静、恶心呕吐、呼吸抑制发生率差异均无统计学意义。
结论 瑞马唑仑可以安全用于支撑喉镜下声带手术的麻醉诱导和麻醉维持,与瑞马唑仑1.0、2.0 mg·kg^-1·h^-1比较,瑞马唑仑1.5 mg·kg^-1·h^-1复合瑞芬太尼麻醉维持能更好地维持术中患者血流动力学稳定。     

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.     

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.     

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.     

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.     

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.