腰骶椎隐裂并膀胱功能障碍38例临床分析

目的探讨腰骶椎隐裂对膀胱功能的影响。方法回顾分析38例腰骶椎隐裂致膀胱功能障碍患者的临床表现、治疗方法及疗效。结果38例中12例遗尿患儿给予口服普鲁本辛和电针治疗，8例症状减轻（有效率67％）；12例尿频、尿急患者，经口服舍尼亭、泌尿灵和电针治疗，症状缓解（有效率100％）；6例脊髓栓系综合征（TCS）患者，2例行脊髓神经黏连松解术排尿困难改善，2例膀胱造瘘，2例终身自我清洁导尿。结论腰骶椎隐裂可引起遗尿、尿频、尿急和排尿困难等膀胱功能障碍，通过药物、电针或手术治疗可减轻症状。     

比较奥昔布宁和去氨加压素联合应用及单独应用去氨加压素或丙咪嗪治疗原发性夜间遗尿的效果：一项随机对照临床试验

作者前瞻性评价奥昔布宁和去氨加压素联合应用治疗儿童夜间遗尿的效果,比较联合用药与去氨加压素或丙咪嗪单独应用的疗效差别。2003-2004年,共有158例儿童入组,排除13例不同意研究协议的患儿,余145例随机分配为3组,应用奥昔布宁联合去氨加压素以及去氨加压素、丙咪嗪进行治疗。145例患儿中男100例,女45例,平均年龄(7.8±2.5)岁(5~15岁),随访时间>6个月。在治疗第1,3和6个月评价疗效,评价指标包括平均遗尿频率、治疗后夜尿频率变化和治疗后夜尿频率与治疗前基线频率的比值。按照白天排尿症状将疗效进行分类。采用χ2检验和单因素方差分析进行…     

夜间遗尿症研究的进展

夜间遗尿症可影响患儿的自尊心与自信心 ,引起心理异常 ,进而可使体质下降 ,积极治疗可消除这些不良影响。此病是多因素引起的综合征。治疗也宜采取综合措施 ,才能取得优良效果 ,具体对策是 :唤醒大脑、建立条件反射、抑制不稳定膀胱、减少夜晚尿量以适应功能性膀胱容量 ,所用的方法是 :各种遗尿报警器 ,结合选用丙咪嗪、羟丁宁、desmo pressin等药物 ,坚持治疗一段时间 ,可取得良好效果     

患儿术前焦虑的研究进展

患儿由于认知水平有限、对父母依赖性高等特点,术前焦虑发生率高于成人.术前焦虑不仅对父母及医务人员造成显著困扰,且对患儿术后恢复产生消极影响,可引起伤口愈合延迟、疼痛、睡眠障碍、遗尿及性格负向改变等.影响患儿术前焦虑的因素包括气质、年龄、既往就医经历、父母术前焦虑状态、手术室和就医环境以及麻醉诱导方式等.目前临床上评估患...     

便秘——一种常见而未被认识的遗尿原因

作者对25例无肾脏病理性疾病儿童的遗尿原因进行了研究、评价和治疗,其中22例有持续性便秘史,检查时采用气囊注气测得直肠膨胀感觉降低(正常10～20ml;患儿>40ml),对直肠气囊大剂量注气的耐受性增加(正常30～40ml感不适.患儿>80ml,内多数患儿可耐受110ml,此量象征直肠内有一直径6.5厘米的球体,患儿无不适感。3例无便秘史,直肠感觉正常,测压试验示直肠耐压性无异常。     

骶后孔阻滞治疗遗尿症

多年来,我们采用骶后孔阻滞法治疗遗尿症46例,取得较满意效果,报告如下.1 临床资料46例中,男16例,女30例;年龄7～23岁.其中11～15岁22例.遗尿病史3～20年,其中10年以上者18例.每夜遗尿2次以上者9例,1～2次25例,每周遗尿3次以上者12例.本组病例均无明显病因如炎症、畸形等.2 治疗方法     

夜间遗尿症研究的进展

夜间遗尿症可影响患儿的自尊心和自信心，引起心理异常，进而可使体质下降，积极治疗可消除这些不良影响，此病是多因素引起的综合征。治疗也宜采取综合措施，才能取得优良效果，具体对策是：唤醒大脑，建立条件反射，抑制不稳定膀胱，减少夜晚尿量以适应功能性膀胱容量，所用的方法是：各种遗尿报警器，结合选用丙咪嗪，羟丁宁、ｄｅｓｍｏ－ｐｒｅｓｓｉｎ等药物，坚持治疗一段时间，可取得良好效果。     

遗尿症的诊断和治疗

正遗尿症(Enuresis)俗称尿床,通常指熟睡时不自主地漏尿。如何诊断和精准治疗遗尿症是临床面临的问题。本文就遗尿症的诊断和治疗进展进行综述。一、定义和病因国际小儿尿控协会(international children's continence society,ICCS)将遗尿定义为儿童5岁以后在睡眠中出现漏尿~([1])。世界卫生组织最新国际疾病分类推荐的遗尿症诊断标准为:患儿年龄5岁,每月至少     

膀胱训练治疗成人遗尿症

15岁以上无器质性病变、睡眠时遗尿,每月至少发生一次的可定为成人遗尿症,成人发病率可达1.2％。抗胆碱药物及镇定药也没特效。并有副作用,膀胱横断去神经法为损伤性治疗,治愈率只为50％,本文作者对成年妇女遗尿症的治疗进行了前瞻性研究,以确定膀胱训练的治疗效果。1978～1980年间有26例遗尿的女病人,年龄为20～69岁,平均年龄49岁,最少每周夜间遗尿一次,住院进行膀胱训练。其中1     

小儿遗尿症的诊治现状

小儿遗尿症 (ｅｎｕｒｅｓｉｓｉｎｃｈｉｌｄｒｅｎ)是指小儿≥ 5岁、睡眠状态下不自主排尿≥ 2次 /周〔1 ,2〕。可分为原发性与继发性遗尿〔3〕、或单纯性与症状性遗尿(症状性遗尿又分为功能性与器质性遗尿 ) 〔1〕。根据小儿遗尿的特点 ,小儿夜间遗尿有以下几个亚型 :原发性夜间遗尿、发作性夜间遗尿、家族性夜间遗尿和夜间多尿性遗尿〔2〕。其中属原发性遗尿为6 9 % ,继发性为 3 1 % ,男多于女〔4〕。夜间遗尿症发病率随年龄增长而下降 :3岁为 5 0 % 〔5〕,5～ 7岁为1 1 .2 % 〔4〕、～ 1 1岁为 1 3 .7% 〔6〕。学龄前时男占2 7.8% ,女 …     

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.     

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.