肺超声评分评价肺保护性通气策略对老年开腹手术患者肺损伤的影响

目的通过肺超声评分探讨肺保护性通气策略减轻老年开腹手术患者肺损伤的作用。方法选择2019年8月至2020年6月择期开腹手术患者50例,男33例,女17例,年龄65～80岁,BMI 18～25 kg/m~2,ASAⅠ—Ⅲ级。采用随机数字表法将患者分为两组:对照组(C组)和肺保护性通气组(P组),每组25例。所有患者常规麻醉诱导,采用容量控制的通气模式。C组设置V_T 8 ml/kg,不使用呼气末正压(PEEP);P组设置V_T 6 ml/kg, PEEP 6 cmH_2O,每间隔30 min给予手法肺复张。采用床旁超声评估患者双侧共12个区域的肺部超声,各区域分数累积为肺超声评分(LUS)。记录入室时(T_0)、麻醉诱导气管插管后5 min(T_1)、手术开始后2 h(T_2)、手术结束时(T_3)、气管导管拔除后15 min(T_4)、2 h(T_5)、术后1 d(T_6)的LUS评分、HR、MAP、SpO_2、PaO_2和PaCO_2。记录T_1—T_3时的氧合指数(PaO_2/FiO_2)、气道峰压(Ppeak)、吸气末平台压(Pplat)和驱动压力(ΔP)。记录术后7 d内肺部并发症(PPCs)的发生情况。结果与T_0时比较,T_1—T_5时C组和P组LUS评分明显升高(P0.05)。与T_1时比较,T_2—T_3时C组PaO_2/FiO_2明显降低(P0.05),P组ΔP明显降低(P0.05)。与C组比较,P组T_2—T_5时LUS评分明显降低(P0.05),T_2—T_3时PaO_2/FiO_2明显升高(P0.05)、ΔP明显降低(P0.05)。C组术后7 d内PPCs发生率为20%,P组未发生PPCs(P0.05)。结论床旁肺超声监测下,老年开腹手术患者在全麻期间和术后早期LUS评分升高,肺通气丢失。肺保护性通气策略可降低患者围术期的肺超声评分,减少肺通气损失,降低术后7 d的肺部并发症发生率。     

滴定个体化呼气末正压对全麻俯卧位脊柱手术老年患者呼吸功能的影响

目的探讨滴定个体化呼气末正压(PEEP)对全麻俯卧位脊柱手术老年患者术中呼吸和循环的影响。方法选择择期全麻下行俯卧位脊柱手术老年患者80例,男39例,女41例,年龄≥65岁,ASAⅡ或Ⅲ级。根据术中是否滴定获取个体化PEEP将患者随机分为两组:滴定组和对照组,每组40例。滴定组从0 cmH_2O开始递增至20 cmH_2O,PEEP变化梯度为2 cmH_2O获取个体化PEEP;对照组PEEP恒定为5 cmH_2O并通气至手术结束。记录滴定过程中每个PEEP水平持续1 min时动态肺顺应性(Cdyn),将Cdyn最大时的PEEP定为个体化PEEP。记录俯卧位时(T_0)、PEEP通气10 min(T_1)、30 min(T_2)、60 min(T_3)、手术结束(T_4)、拔管后20 min(T_5)的MAP、HR、CVP,记录T_0—T_4时平均气道压(Pmean)和Cdyn。T_0—T_5时行血气分析,计算肺内分流率(Qs/Qt)和氧合指数(OI)。记录机械通气过程中去氧肾上腺素使用和术后肺部并发症情况。结果滴定组所获取的个体化PEEP为(12.38±2.67)cmH_2O。T_0—T_5时两组MAP、HR、CVP差异无统计学意义。T_0—T_4时两组Pmean差异无统计学意义。T_2—T_4时滴定组Cdyn明显高于对照组(P0.05),Qs/Qt明显低于对照组(P0.05)。T_2—T_5时滴定组OI明显高于对照组(P0.05)。滴定组去氧肾上腺素使用率明显高于对照组[10例(25%) vs 3例(8%),P0.05]。滴定组术后肺部并发症发生率明显低于对照组[2例(5%) vs 8例(20%),P0.05]。结论与恒定PEEP 5 cmH_2O比较,俯卧位脊柱手术老年患者术中滴定个体化PEEP,能够更好地改善氧合,降低肺内分流率,减少术后肺部并发症。     

压力控制容量保证通气模式对肺切除术患者术后肺部并发症的影响

目的观察压力控制容量保证(PCV-VG)通气模式对肺切除术患者术后肺部并发症(PPCs)的影响。方法选择择期全麻下行胸腔镜肺切除术患者42例,男19例,女23例,年龄18～65岁,ASAⅠ或Ⅱ级。将患者随机分为两组:自双肺通气开始至手术结束始终使用PCV-VG模式通气组(P组)和始终使用容量控制通气(VCV)模式通气组(V组),每组21例。P组双肺通气期间V_T 8 ml/kg,单肺通气(OLV)期间V_T 6 ml/kg,压力上升时间设置为0.5 s; V组双肺通气期间设置V_T 8 ml/kg, OLV期间设置V_T 6 ml/kg,吸气暂停时间为0 s。记录术后1、2、3 d和出院前PPCs的发生情况。记录OLV前(T_0)、OLV 30 min(T_1)、OLV 60 min(T_2)和OLV结束后(T_3)的吸气峰压(PIP)、驱动压(ΔP)、动态肺顺应性(Cdyn)以及PaO_2、PaCO_2和氧合指数(PaO_2/FiO_2)。结果术后1 d P组PPCs发生率明显低于V组[2例(9%) vs 8例(38%),P0.05]。术后2、3 d和出院前两组PPCs发生率差异无统计学意义。T_0—T_3时P组PIP明显低于V组(P0.05)。与T_0时比较,T_1、T_2时两组PIP和ΔP明显升高(P0.05),Cdyn明显降低(P0.05)。T_0—T_3时两组ΔP、Cdyn、PaO_2、PaCO_2和PaO_2/FiO_2差异无统计学意义。结论 PCV-VG模式优于VCV模式,可明显减少肺切除患者术后1 d肺部并发症的发生,降低术中吸气峰压。     

呼气末正压通气对腹腔镜宫颈癌根治术患者眼压和视神经鞘直径的影响

目的观察腹腔镜下宫颈癌根治术中,5 cmH_2O的呼气末正压通气(PEEP)对患者眼内压(IOP)和颅内压的影响。方法选择我院择期行腹腔镜下宫颈癌根治术的患者60例,年龄45～65岁,BMI 20～25 kg/m~2,ASAⅠ或Ⅱ级。采用随机数字表法分为两组,PEEP为5 cmH_2O组(PEEP组)和无PEEP组(ZEEP组),每组30例。两组均采用静脉麻醉诱导气管插管,诱导完成机械通气后,PEEP组设置呼气末正压为5 cmH_2O,ZEEP组呼气末正压设置为0。记录麻醉诱导前(T_0)、麻醉后气腹前10 min平卧位(T_1)、气腹Trendelenburg体位后5 min(T_2)、30 min(T_3)、恢复平卧位气腹消失后(T_4)和术后30 min(T_5)时的IOP、视神经鞘直径(ONSD)、PaO_2、PaCO_2,同时记录T_1—T_4时肺动态顺应性(Cdyn)、气道峰压(Ppeek)和T_0—T_5时HR和MAP。结果与T_0时比较,T_1时两组IOP明显降低(P0.01),T_2—T_3时IOP明显延长(P0.01),T_2—T_3时ZEEP组ONSD明显延长(P0.01),T_3时PEEP组ONSD明显延长(P0.05)。T_1—T_4时PEEP组PaO_2、Cdyn明显高于ZEEP组(P0.05)。T_1时PEEP组Ppeek明显高于ZEEP组(P0.05)。结论在腹腔镜宫颈癌根治术手术中,气腹和Trendelenburg体位下应用5 cmH_2O的PEEP改善患者氧合的同时不引起IOP和颅内压的增高。     

最佳呼吸末正压肺保护通气策略对腹腔镜下结直肠癌根治术患者氧合功能的影响

目的探讨最佳呼吸末正压(PEEP)肺保护通气策略对腹腔镜下结直肠癌根治术患者围术期氧合功能的影响。方法择期行腹腔镜下结直肠癌根治术患者54例,男36例,女18例,年龄65～85岁,ASAⅡ或Ⅲ级。随机分为两组:传统组(T组)和保护组(P组),每组27例。T组设置V_T 9 ml/kg且无PEEP和肺复张(RMs);P组通过肺动态顺应性(Cdyn)PEEP滴定确定患者最佳PEEP值,设置低V_T 7 ml/kg联合最佳PEEP,每30分钟RMs一次。于麻醉诱导后10 min(T_1)、每次RMs后30 min(T_2、T_3、T_4)记录Cdyn及气道平台压(Pplat)、并在T_1—T_4、拔管后30 min(T_5)及术后第3天(T_6)采集动脉血样本,计算氧合指数(OI),记录术前和T_6时的改良临床肺部感染评分(mCPIS)。结果与T组比较,T_3、T_4时P组Cdyn明显升高(P0.05),T_4—T_6时P组OI明显升高(P0.05),T_6时P组mCPIS明显降低(P0.05)。结论最佳PEEP联合低V_T和RMs的肺保护通气策略可改善腹腔镜结直肠癌根治术患者围术期氧合,降低mCPIS。     

肺保护性通气在老年患者腹腔镜子宫内膜癌根治术中的应用

目的探讨肺保护性通气在老年患者腹腔镜子宫内膜癌根治术中的应用效果。方法选择2019年6月至2020年6月择期行腹腔镜子宫内膜癌根治术的老年女性患者60例,年龄65～80岁,BMI 20～28 kg/m~2,ASAⅠ或Ⅱ级。采用随机数字表法将患者分为两组:肺保护性通气组(P组)和常规机械通气组(R组),每组30例。P组设置V_T 7 ml/kg、呼气末正压通气(PEEP) 7 cmH_2O、每30分钟规律手法肺复张一次;R组仅设置V_T 9 ml/kg,未采用PEEP和肺复张。记录气腹前即刻、气腹后2 h、手术结束即刻的气道峰压(Ppeak)、气道平台压(Pplat)、肺动态顺应性(Cdyn)及血清IL-6、IL-8、TNF-α浓度。记录气腹前即刻和出复苏室即刻的氧合指数(PaO_2/FiO_2)。结果与气腹前即刻比较,气腹后2 h、手术结束即刻两组Pplat、Ppeak及血清IL-6、IL-8、TNF-α浓度均明显升高(P0.05),Cdyn明显降低(P0.05);出复苏室即刻两组PaO_2/FiO_2明显降低(P0.05)。与R组比较,P组气腹后2 h、手术结束即刻Pplat、Ppeak及血清IL-6、IL-8、TNF-α浓度明显降低(P0.05),Cdyn明显升高(P0.05);出复苏室即刻PaO_2/FiO_2明显升高(P0.05)。结论肺保护性通气可以减轻老年患者腹腔镜子宫内膜癌根治术围术期呼吸功能损伤和炎症反应,可安全用于老年患者腹腔镜子宫内膜癌根治术。     

肺保护性通气策略对腹腔镜胃癌根治手术老年患者肺氧合功能及术后肺部并发症的影响

目的探讨肺保护性通气策略(lung protective ventilation strategy,LPVS)对腹腔镜胃癌根治手术老年患者肺氧合功能及术后肺部并发症(postoperative pulmonary complications,PPCs)的影响。方法选择接受腹腔镜胃癌根治手术的老年患者115例,男69例,女46例,年龄≥65岁,ASAⅠ—Ⅲ级,随机分为两组:常规容量控制通气组(CV组,n=57)和肺保护性通气组(PV组,n=58)。记录插管后10 min(T_1)、气腹后10 min(T_2)、气腹后60 min(T_3)、气腹结束10 min(T_4)时的气道峰压(Ppeak),计算肺顺应性(Cdyn),并在T_1—T_4时抽取动脉血进行血气分析,计算氧合指数(OI)、肺泡动脉血氧分压差(A-aDO_2);记录术后第2天改良肺部感染评分(mCPIS);记录术后7 d内PPCs发生情况。结果与T_1时比较,T_2时两组Cdyn均明显降低(P0.05);T_3—T_4时PV组Cdyn明显高于CV组(P0.05);T_3—T_4时PV组OI明显高于CV组、A-aDO_2明显低于CV组(P0.05)。术后第2天PV组mCPIS明显低于CV组(P0.05)。术后7 d内PV组PPCs发生率明显低于CV组(P0.05)。结论肺保护性通气策略能明显改善老年腹腔镜胃癌根治手术老年患者的肺氧合功能,降低术后肺部并发症,具有一定的肺保护作用。     

小潮气量联合低PEEP对老年腹腔镜胆囊切除术患者术中氧合功能及肺功能的影响

目的探讨小潮气量联合低呼气末正压通气(PEEP)对老年腹腔镜胆囊切除术患者术中氧合功能及肺功能的影响。方法择期行腹腔镜胆囊切除术的老年患者共计100例,年龄65～74岁,ASA分级Ⅰ～Ⅱ级,体重指数(BMI)30kg/m~2。采用随机软件将纳入患者随机分为小潮气量联合低PEEP组(T组)和常规容量控制通气组(C组),每组各50例。记录两组患者手术开始即刻(T_0)、气腹后15分钟(T_1)、撤除气腹后15分钟(T_2)、拔除气管导管前(T_3)气道峰压(Ppeak)、平均气道压(Pmean)并计算动态肺顺应性(Cdyn)。于T_0、T_1、T_3时点进行血气分析记录动脉氧分压(PaO_2)、动脉CO_2分压(PaCO_2)并计算氧合指数(OI)。结果 T组患者T_1、T_2时点Ppeak、Pmean显著低于C组患者,但Cdyn显著高于C组患者,差异有统计学意义(P0.05)。两组患者T_0、T_1、T_3时点PaO_2、PaCO_2和OI差异均无统计学意义(P0.05)。结论小潮气量联合低PEEP有助于维持老年腹腔镜胆囊切除术患者术中肺功能及氧合功能。     

压力控制容量保证通气模式改善创伤性脑损伤患者早期预后

目的分析不同通气模式下创伤性脑损伤(TBI)患者的呼吸指标、脑组织炎症指标、肺部感染评分,评价压力控制容量保证通气(PCV-VG)模式对创伤性脑损伤患者早期预后的作用。方法选择2017年4月至2020年4月急诊行仰卧位脑血肿清除术的TBI患者100例,男55例,女45例,年龄40～65岁,BMI 18～28 kg/m~2,ASAⅢ或Ⅳ级,术前格拉斯哥昏迷评分(GCS)5～12分。采用随机数字表法将患者分为两组:压力控制容量保证通气组(P组)和容量控制通气组(V组),每组50例。P组采用PCV-VG模式,V组采用VCV模式。于机械通气即刻(T_1)、机械通气后60 min(T_2)、手术结束即刻(T_3)采集桡动脉血进行血气分析,记录T_1—T_3时HR、MAP、PaO_2、PaCO_2、肺部动态顺应性(Cdyn)、气道峰压(Ppeak)及气道平台压(Pplat)。于T_1—T_3时采集颈内静脉血样,采用ELISA法测定血清纤维胶质酸性蛋白(GFAP)、TNF-α、泛素羧基化水解酶1(UCH-L1)浓度;记录术后3 d和7 d的临床肺部感染评分(CPIS)评估肺部感染情况。结果与T_1时比较,T_2时V组PaO_2、Cdyn明显下降(P0.05),Ppeak、Pplat明显升高(P0.05);T_3时两组PaO_2、Cdyn明显下降(P0.05),Ppeak、Pplat明显升高(P0.05);T_2、T_3时两组血清GFAP、TNF-α、UCH-L1浓度均明显升高(P0.05)。与V组比较,T_2、T_3时P组PaO_2、Cdyn明显升高(P0.05),Ppeak、Pplat明显降低(P0.05),血清GFAP、TNF-α、UCH-L1浓度均明显降低(P0.05);术后3 d和7 d P组CPIS明显降低(P0.05)。结论 PCV-VG模式可以改善TBI患者呼吸指标,减轻脑组织炎症反应及肺部感染,从而改善患者早期预后。     

呼气末正压通气对腹腔热灌注化疗患者呼吸力学及肺功能的影响

目的探讨不同呼气末正压通气对腹腔热灌注化疗患者呼吸力学及肺功能的影响。方法选择择期行腹膜癌热灌注化疗的患者90例,男55例,女35例,年龄40~70岁,ASAⅠ~Ⅲ级。随机分为三组,每组30例。A组为容量控制通气(VCV)组,VT10 ml/kg;B组为VCV+低PEEP组,VT6ml/kg,PEEP 5cm H_2O;C组为VCV+高PEEP组,VT6ml/kg,PEEP 10cm H_2O;术中调整RR维持PETCO2 35~45 mm Hg。于气管插管后5 min(T_1)、腹腔热灌注化疗开始前(T2)、化疗结束时(T_3)、气管拔管前(T4)记录气道峰压(Ppeak)、气道平台压(Pplat)和平均气道压(Pmean),计算动态肺顺应性(C_(dyn))。并取桡动脉血进行血气分析,计算氧合指数(OI)、呼吸指数(RI)、肺泡-动脉血氧分压差(A-aDO_2)及死腔率(VD/VT)。记录术后7d内肺部相关并发症情况。结果与A组比较,T_1~T_4时B、C组Ppeak、Pplat、A-aDO_2和RI明显降低,OI和VD/VT明显升高(P0.05);T_2~T_4时B、C组Pmean明显降低,Cdyn和PaO_2明显升高(P0.05)。与T_1比较,T_2~T_4时A组Ppeak、Pplat和Pmean明显升高,C_(dyn)明显降低(P0.05);T_3时B组Ppeak和Pplat明显升高(P0.05),T_2~T_4 Pmean明显升高(P0.05),T3、T4时C_(dyn)明显降低(P0.05);T_2~T_4时C组Ppeak、Pplat和Pmean明显升高(P0.05),T_3、T_4时Cdyn明显降低(P0.05)。与T0时比较,T2~T4时三组PaO_2和OI明显降低,A-aDO_2、RI和VD/VT明显升高(P0.05)。术后7d内B、C组肺部感染、低氧血症和肺不张的发生率明显低于A组(P0.05)。结论小潮气量(6ml/kg)联合PEEP(5cm H_2O)通气可以显著改善腹膜癌患者术中热灌注期间肺功能,降低围术期肺部并发症的发生风险。     

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.