影响老年髋部骨折病人术后自理能力恢复的危险因素分析

目的 探讨影响老年髋部骨折病人术后自理能力恢复的危险因素。方法 回顾性分析西安交通大学医学院附属红会医院2017年6月至2018年12月收治的195例老年髋部骨折病人的临床资料,并通过门诊复查、电话询问和社区走访等方式获取病人术后康复信息,根据病人术后1年的Barthel指数将病人分为不能自理组（Barthel指数评分≤60分）和基本自理组（Barthel指数评分＞60分）。先采用单因素分析筛选危险因素,再通过多因素Logistic回归确定独立危险因素。结果 195例病人中,不能自理组65例,基本自理组130例。单因素分析显示年龄、美国麻醉医师协会（America Society of Anesthesiologists,ASA）分级、术前合并内科疾病种类、受伤至手术时间、术前血浆白蛋白、血红蛋白、居住环境、术后是否行抗骨质疏松治疗、术后是否于康复机构康复均与老年髋部骨折术后自理能力恢复有关（P均＜0.05）;多因素Logistic回归分析显示高龄［OR=1.326,95% CI（1.036,1.096）,P=0.025］是老年髋部骨折病人术后自理能力恢复的独立危险因素,术前血浆白蛋白高［OR=0.543,95% CI（0.276,0.895）,P=0.002］、居住环境为农村［OR=0.225,95% CI（0.076,0.462）,P=0.007］、术后抗骨质疏松治疗［OR=0.647,95% CI（0.427,0.947）,P=0.002］、术后在康复机构康复［OR=0.438,95% CI（0.229,0.835）,P＜0.001］是老年髋部骨折病人术后自理能力恢复的保护因素。结论 对高龄、术前白蛋白低的病人应加强干预;术后抗骨质疏松治疗以及在康复机构康复对老年髋部骨折病人术后自理能力的恢复有一定积极作用。     

髋部骨折24小时内及延迟入院的下肢深静脉血栓发生情况分析

目的 探讨髋部骨折病人骨折后24 h内下肢深静脉血栓形成（deep vein thrombosis, DVT）的发生率及危险因素,并对超过24 h住院病人血栓发生率的变化进行分析。方法 回顾性分析西安交通大学医学院附属红会医院2014年10月至2018年3月收治的1 183例髋部骨折病人资料,根据受伤时间至入院时间进行分组。分析24 h内住院的374例髋部骨折病人资料,根据入院时下肢静脉彩超结果分为DVT组和非DVT组,对两组病人的年龄、性别、身体质量指数（body mass index, BMI）、骨折类型、美国麻醉医师协会（America Society of Anesthesiologists, ASA）分级、入院时的实验室检查、是否多发伤、是否合并内科疾病等可能危险因素进行单因素分析;采用多因素Logistic回归分析确定其独立危险因素;对超过24 h住院的病人进行DVT发生率的变化情况分析。结果 在髋部骨折后24 h内入院的374例髋部骨折病人中,未发生DVT有292例,发生DVT有82例,血栓发生率为21.93%（82/374）。分析DVT组和非DVT组之间的数据,年龄（P=0.005）、骨折部位（P＜0.001）、入院时血红蛋白（P=0.002）、入院时红细胞压积（P=0.004）之间的差异有统计学意义;多因素Logistic回归分析结果显示：年龄、骨折部位是髋部骨折24 h内形成DVT的独立危险因素。粗隆间骨折［P=0.002,OR=2.510,95%CI：（1.397,4.510）］和粗隆下骨折［P=0.023,OR=4.798,95%CI：（1.237,18.605）］发生DVT的风险分别是股骨颈骨折发生DVT风险的2.51倍、4.80倍。45~59岁、60~75岁、≥75岁年龄段病人分别是＜45岁病人发生DVT风险的3.12、3.20、6.45倍。24 h内入院的病人DVT发生率最低,延迟住院后DVT发生率逐渐升高,在受伤后8~14 d入院的病人DVT发生率最高,达到48.86%。结论 髋部骨折后24 h内就会发生DVT,DVT的类型以远端血栓为主,也会发生近端血栓,年龄≥75岁、股骨粗隆下骨折的病人发生DVT的风险最高。髋部骨折后,随着入院时间的推迟,DVT的发生率逐渐升高。入院后应当第一时间对DVT进行诊断和预防,防止发生致命性肺栓塞。     

下肢骨折病人术后35天内深静脉血栓的发生情况及危险因素分析

目的 探讨下肢骨折病人出院后35 d内深静脉血栓形成（deep vein thrombosis, DVT）的发生率及危险因素。方法 回顾性分析2014年7月至2017年7月西安交通大学医学院附属红会医院创伤骨科收治的402例住院期间未发生DVT的下肢骨折病人的临床资料。所有病人术前、术后都常规用物理方法和药物抗凝预防DVT,嘱咐病人出院后口服利伐沙班抗凝至术后35 d,记录术后35 d复查时双下肢DVT的发生情况。根据术后35 d门诊复查双下肢超声结果将病人分为DVT组和非DVT组,分析比较两组病人的性别、年龄、骨折部位、身体质量指数、合并其他骨折、合并内科疾病、术后的实验室检查（D-二聚体）、术后住院时间的差异,对上诉结果中差异有统计学意义的变量进一步采用多因素Logistic回归分析,分析病人出院后DVT的危险因素。结果 402例下肢骨折病人出院后发生DVT的有56例（13.9%）,其中2例（0.50%）发生肺栓塞,2例均合并有小腿肌间静脉血栓,1例发生在术后3周,1例在术后4周发生致死性肺栓塞。周围型52例,单纯中央型0例,混合型4例。膝关节以近的骨折病人DVT发生率为15.5%（36/232）,膝关节周围骨折病人DVT发生率为13.8%（8/58）,膝关节以远骨折病人DVT发生率10.7%（12/112）。两组间年龄、合并其他骨折、术后住院时间、冠心病、术后1 d D-二聚体、出院时D-二聚体的差异有统计学意义（P＜0.05）,多因素Logistic回归分析显示年龄＞60岁［OR=3.207,95% CI（2.007,8.553）,P=0.009］、合并其他骨折［OR=7.111,95% CI（2.297,22.011）,P＜0.001］、术后住院时间＜7 d［OR=1.448,95% CI（1.225,1.718）,P=0.020］、出院时D-二聚体偏高［OR=1.355,95% CI（0.892,12.626）,P=0.027］是出院后DVT的独立危险因素。结论 虽然出院前常规使用物理方法和药物抗凝预防DVT,出院后嘱咐病人口服利伐沙班35 d,但是出院时没有DVT的下肢骨折病人术后35 d仍有发生DVT的可能（13.9%）,严重者还会发生肺栓塞,年龄、合并其他骨折、术后住院时间较短、出院时D-二聚体是出院后DVT发生的独立危险因素。     

骨质疏松性髋部骨折一年内死亡的危险因素分析

目的 探讨骨质疏松性髋部骨折1年内死亡的独立危险因素。方法 回顾性分析2012年1月至2016年5月我院收治的226例骨质疏松性髋部骨折病人的临床资料,收集病人的性别、年龄、身体质量指数（body mass index, BMI）、基础疾病情况、是否单独居住、日常生活能力评分、骨密度T值、骨折类型、受伤至手术时间、治疗方式、手术方式、麻醉方式、美国麻醉医师协会（American Society of Anesthesiology, ASA）分级以及术前实验室检查指标等临床资料,先后进行单因素分析和多因素Logistic回归分析。结果 1年随访期内,有33例（14.60%）病人死亡,根据病人是否死亡分为死亡组（33例）和生存组（193例）。单因素分析结果显示年龄、性别、基础疾病种类数、慢性肺病、贫血、痴呆、单独居住、日常生活能力评分、骨折至手术时间、治疗方式、全身麻醉、ASA分级以及入院时淋巴细胞、血清白蛋白、血红蛋白、肌酐和骨密度与骨质疏松性髋部骨折1年内死亡相关（P＜0.05）。多因素Logistic回归分析结果表明高龄（OR=2.48,P=0.006）、男性（OR=1.53,P=0.016）、合并基础病种类数≥3类（OR=2.52,P=0.024）、共患慢性肺病（OR=1.74,P=0.017）、共患痴呆（OR=1.21,P=0.025）、日常生活能力评分低（OR=1.61,P=0.014）、ASA分级为Ⅲ~Ⅳ级（OR=1.36,P=0.033）、血清白蛋白水平低（OR=1.30,P=0.041）以及保守治疗方式（OR=1.21,P=0.012）是骨质疏松性髋部骨折1年内死亡的独立危险因素。结论 对于高龄、男性、合并基础疾病类数≥3类、患慢性肺病、痴呆、日常生活能力评分低、ASA分级为Ⅲ~Ⅳ级、血清白蛋白水平低以及保守治疗方式的骨质疏松性髋部骨折病人应予以重视,全面评估病人的身体机能和健康状况,制定合适的治疗方案。     

经皮椎间孔镜下腰椎间盘切除术后效果不佳的相关因素分析

目的 探讨经皮椎间孔镜下腰椎间盘切除术（percutaneous endoscopic lumbar discectomy, PELD）后效果不佳的原因。方法 回顾性分析三峡大学附属仁和医院骨科2014年1月至2018年12月采用PELD手术治疗的346例腰椎间盘突出症病人的临床资料,其中男146例,女200例,年龄为17~68岁。比较术后效果良好和效果不佳病人之间在年龄、性别、术前美国麻醉医师协会（America Society of Anesthesiologists, ASA）分级、是否髓核残留、是否椎间孔减压成型、是否规范康复训练、术中出血与否、是否合并腰椎管狭窄、术后有无并发症、是否椎间盘复发这10个方面的差异,对上述结果中有差异的变量进一步采用二分类Logistic回归分析导致PELD术后效果不佳的危险因素。结果 346例病人平均随访12个月,其中31例术后效果不佳,发生于术后3~30个月,平均为16个月。术后效果良好和效果不佳病人间在年龄、是否髓核残留、是否椎间孔减压成型、是否规范康复训练、是否合并腰椎管狭窄、术后有无并发症以及是否椎间盘复发这7个方面比较,差异均有统计学意义（P均＜0.05）。Logistic回归分析显示：髓核残留［OR=4.008,95% CI（1.643,9.773）,P=0.002］、合并腰椎管狭窄［OR=9.134,95% CI（3.604,23.150）,P＜0.001］、椎间盘复发［OR=2.489,95% CI（0.948,6.533）,P=0.044］及术后有相关并发症［OR=2.031,95% CI（0.912,5.892）,P=0.041］是PELD术后效果不佳的危险因素。椎间孔减压成型［OR=0.483,95% CI（0.280,10.833）,P=0.009］是PELD术后效果的保护因素。结论 突出椎间盘髓核残留、合并腰椎管狭窄、椎间盘复发及术后相关并发症是PELD术后效果不佳的危险因素,需严格把握手术适应证、椎管内及椎间孔彻底减压,可减少术后效果不佳的发生。     

髋部骨折术前双下肢深静脉血栓发生率及其危险因素分析

目的 探讨髋部骨折术前双下肢深静脉血栓形成（deep vein thrombosis, DVT）的发生率及其危险因素。方法 回顾性分析2014年9月至2017年10月西安红会医院收治的997例髋部骨折病人资料,男382例,女615例;平均年龄为72.3（17~102）岁。其中股骨颈骨折493例,股骨转子间骨折470例,股骨转子下骨折34例。根据术前双下肢静脉彩超结果分为双下肢血栓组、非双下肢血栓组。对年龄、性别、骨折类型、受伤至手术的时间、术前的实验室检查（血红蛋白、红细胞比容、纤维蛋白原、D-二聚体）、合并内科疾病（原发性高血压、糖尿病、冠状动脉粥样硬化性心脏病、合并两种以上的内科疾病、无内科疾病）等可能危险因素进行单因素分析,再采用多因素Logistic回归分析确定其独立危险因素。结果 997例髋部骨折病人中66例（6.62%）术前发生双下肢DVT。双下肢血栓组与非双下肢血栓组病人的性别、骨折类型、术前D-二聚体水平、术前纤维蛋白原水平、合并内科疾病比较,差异均无统计学意义（P均＞0.05）;而两组病人年龄、受伤至手术时间、术前血红蛋白水平、术前红细胞比容比较,差异均有统计学意义（P均＜0.05）。多因素Logistic回归分析结果显示：年龄＞60岁［95%CI（1.153,12.367）,P=0.028］、受伤至手术时间＞7 d［95%CI（1.087,3.178）,P=0.023］为髋部骨折术前双下肢DVT的独立危险因素。结论 髋部骨折术前双下肢DVT的发生率约为6.62%;病人的年龄＞60岁、受伤至手术时间＞7 d是髋部骨折术前双下肢DVT的独立危险因素。     

经皮椎体后凸成形术治疗骨质疏松性椎体压缩骨折后再骨折的危险因素分析

目的 探讨骨质疏松性椎体压缩骨折（OVCF）病人行经皮椎体后凸成形术（PKP）术后再骨折的危险因素。方法 回顾性分析2005年1月至2021年8月于我院诊断为骨质疏松性椎体压缩骨折并行PKP治疗的病人1 829例,其中女1 412例,男417例。根据PKP术后是否发生再次骨折,将病人分为再发骨折组（224例）和未再发骨折组（1 605例）。统计病人的性别、年龄、身体质量指数（BMI）、骨密度、术后侧（后）凸畸形的度数、椎体高度恢复率、初始骨折椎体数量、术前保守治疗时间、术后抗骨质疏松药物的使用、骨水泥渗漏、疼痛视觉模拟量表（VAS）评分、Oswestry功能障碍指数（ODI）进行单因素分析及多因素Logistic回归分析。结果 单因素分析显示性别、年龄、BMI、骨密度、术后抗骨质疏松药物的使用、骨水泥渗漏及术前保守治疗时间均与再骨折的发生有关（P＜0.05）;病人术后侧（后）凸畸形的度数、初始椎体骨折数量、术后椎体高度的恢复率、手术前后VAS评分和ODI与再骨折无明显相关性（P＞0.05）。通过Logistic回归分析发现女性（OR=4.355,95% CI：1.598~17.908,P=0.006）、65岁及以上（OR=6.431,95% CI：1.756~23.233,P=0.003）、BMI≥23 kg/m²（OR=3.561,95% CI：0.787~12.065,P=0.037）、骨密度T值＜-2.5 SD（OR=10.352,95% CI：2.857~41.761,P＜0.001）、术后未使用抗骨质疏松药物（OR=6.070,95% CI：1.731~21.165,P=0.003）、骨水泥渗漏（OR=6.150,95% CI：1.671~16.177,P=0.004）为PKP术后再发骨折的独立危险因素。结论 PKP术中应仔细操作,尽量避免骨水泥渗漏;对于女性、高龄、BMI高、骨密度过低的病人行PKP术后应重点关注;术后进行规律的抗骨质疏松治疗,避免再骨折的发生。     

抗骨质疏松药物对急性骨质疏松性脊柱骨折后放射学特征和临床结果的影响

目的 探讨不同抗骨质疏松药物治疗对急性骨质疏松性脊柱骨折（osteoporotic spinal fracture, OSF）后放射学特征和临床结果的影响。方法 前瞻性纳入120例拟接受保守治疗的老年OSF病人,根据随机数字表将病人分为对照组（40例）、骨吸收抑制剂组（40例）和甲状旁腺激素（parathyroid hormone, PTH）组（40例）,分别在保守治疗的基础上接受安慰剂、双膦酸盐、特立帕肽治疗3个月。比较三组病人治疗前后的数字分级法（numerical rating scale, NRS）疼痛评分、Oswestry功能障碍指数（Oswestry disability index, ODI）、骨折椎体高度丢失比、后凸角和椎骨隐裂（intravertebral cleft, IVC）发生情况。结果 经过3个月治疗,PTH组的NRS评分、ODI均明显低于对照组和骨吸收抑制剂组,骨吸收抑制剂组的上述指标也显著低于对照组,差异均有统计学意义（P均＜0.05）。PTH组和骨吸收抑制剂组的椎体高度丢失比均低于对照组,差异均有统计学意义（P均＜0.05）;但骨吸收抑制剂组和PTH组比较,差异无统计学意义（P＞0.05）。三组病人治疗后的后凸角比较,差异无统计学意义（P＞0.05）。PTH组的IVC发生率显著低于对照组（P＜0.05）,但骨吸收抑制剂组和对照组比较,差异无统计学意义（P＞0.05）。单因素及多因素Logistic回归分析显示MRI Ⅱ型［OR=3.531,95% CI（2.300,5.628）,P＜0.001］是导致骨折愈合不良的独立危险因素,PTH［OR=0.826,95% CI（0.703,0.966）,P=0.018］和骨吸收抑制剂［OR=0.853,95% CI（0.768,0.962）,P=0.006］是预防骨折愈合不良的独立保护性因素。结论 PTH类合成代谢药物可以有效促进骨折愈合、减少椎体塌陷,并显著减轻病人疼痛和促进脊柱功能恢复。     

医院获得性肺血栓栓塞症的临床特征与危险因素分析

背景与目的 有关医院获得性肺血栓栓塞症（HA-PTE）的流行病学数据大多来自单一病种的调查研究,对于全院范围内HA-PTE的调查研究尚少。因此,本研究对全院范围内HA-PTE患者流行病学及临床特征等进行分析,以期为HA-PTE防治与管理提供参考依据。 方法 收集中南大学湘雅医院2018年1月1日—12月31日确诊HA-PTE患者（病例组）的临床资料和实验室检验数据,并根据性别、年龄、入院Caprini血栓风险评分等级、是否接受外科手术及手术等级,按1∶1匹配同期非HA-PTE患者作为对照组。分析HA-PTE患者的发病率、病死率、相关临床病理因素、危险因素及有价值的预测指标等。 结果 2018年度122 942例住院患者中确诊新发HA-PTE患者68例（0.55‰）,无HA-PTE相关死亡病例。42.65%（29/68）的HA-PTE患者同时合并有深静脉血栓形成。HA-PTE患者主要分布在神经内科（14/68,20.59%）、普通外科（11/68,16.18%）和呼吸内科（8/68,11.76%）。单因素分析结果显示,病例组呼吸系统疾病、肺部感染及入住ICU的比例高于较对照组（OR=4.60,95% CI=1.75~12.10,P=0.002;OR=2.38,95% CI=1.04~5.43,P=0.040;OR=11.00,95% CI=1.42~85.20,P=0.022）,总住院时长与住院总费用高于对照组（OR=1.11,95% CI=1.05~1.18,P<0.005;OR=1.01,95% CI=1.00~1.03,P=0.005）,纤维蛋白原降解产物（FDP）水平高于对照组（OR=1.11,95% CI=1.03~1.20,P=0.004）。多因素分析结果显示,呼吸系统疾病（校正OR=3.58,95% CI=1.32~9.71,P=0.012）和入住ICU（校正OR=11.38,95% CI=1.38~93.54,P=0.024）是HA-PTE的独立危险因素。 结论 患有呼吸系统疾病和入住过ICU的患者为HA-PTE的高危人群,神经内科、普通外科和呼吸内科是HA-PTE的高危科室,HA-PTE会导致患者的住院时长和医疗费用显著增高。FDP水平对于HA-PTE可能有一定的预测价值。     

肌肉减少症对胰十二指肠切除术后临床结局影响的Meta分析

背景与目的 肌肉减少症可导致机体四肢功能障碍、生活质量下降、死亡等不良事件风险增加。关于肌肉减少症对胰十二指肠切除术（PD）患者影响的研究较少,结论也不一致。本研究系统评价肌肉减少症对接受PD术患者术后临床结局的影响,以期通过有效干预来改善临床结局。方法 利用PubMed、Embase、Cochrane Library、CNKI、维普、万方数据库检索相关文献,检索时间为建库至2022年6月1日。由2名研究者独立筛选文献、提取资料并评价纳入研究的质量和偏倚风险后,采用RevMan 5.3软件对数据进行分析。结果 纳入14项研究,共计2 198例患者,其中肌肉减少症组737例,非肌肉减少症组1 461例,均为队列研究。Meta分析结果显示,两组的手术时间和伤口感染、尿路感染、胆汁漏、术后出血等并发症发生率均无明显差异（均P>0.05）;与非肌肉减少症组患者比较,肌肉减少症组患者术前BMI（WMD=-1.22,95% CI=-1.82~0.62,P<0.001）、术前白蛋白水平（WMD=-0.30,95% CI=-0.41~0.19,P<0.001）均较低;术中出血量较多（WMD=88.12,95% CI=6.94~169.31,P<0.05）;术后总体并发症（OR=3.53,95% CI=2.52~4.94,P<0.001）、Clavien-Dindo ≥3级并发症（OR=1.57,95% CI=1.17~2.12,P=0.003）、菌血症（OR=4.46,95% CI=1.42~13.98,P=0.01）、肺炎（OR=2.07,95% CI=1.31~3.25,P=0.002）、胰瘘（OR=1.34,95% CI=1.05~1.72,P=0.02）发生率较高;住院时间延长（OR=3.18,95% CI=1.97~4.39,P<0.001）,病死率增加（OR=3.17,95% CI=1.55~6.50,P=0.002）。结论 PD术患者术前合并肌肉减少症的比例较高。合并肌肉减少症对患者的临床结局有不利影响,并发症发生率和病死率增加,住院时间延长。     

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.     

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.     

Risiko Schlaganfall — Öffentlichkeitsarbeit und Aufklärung dringend erforderlich

Zusammenfassung Das wesentliche — und zugleich noch wenig ausgeschöpfte — Potenzial der Schlaganfallmedizin liegt in der langfristigen Prophylaxe. Durch Beeinflussung von Lifestylefaktoren wie Ernährungsgewohnheiten, Zigarettenkonsum und körperlichem Training durch entsprechende Aufklärung ließe sich ein erheblicher Teil an zerebralen Ereignissen vermeiden. Ein weiterer in Deutschland noch zu wenig beachteter Faktor ist die konsequente Blutdruckeinstellung. Breitgestreute Aufklärung könnte außerdem potenziellen Patienten helfen, bereits auftretende Warnsymptome wie die transiente ischämische Attacke richtig einzuschätzen, um eine rechtzeitige Behandlung zu ermöglichen.