儿童Ⅲ型肱骨髁上骨折伴桡神经损伤治疗分析

目的探讨一期手术治疗Ⅲ型儿童肱骨髁上骨折伴桡神经损伤的临床疗效。方法自2001年8月至2007年3月，对15例Ⅲ型肱骨髁上骨折伴桡神经损伤的患儿采用一期切开复位内固定并神经探查术。结果本组随访12～18个月，所有患儿桡神经功能均完全恢复，骨折于8～12周全部愈合，2例屈曲受限20°～30°，1例轻度肘内翻（小于5°）。结论采用一期切开复位内固定并神经探查术治疗儿童Ⅲ型肱骨髁上骨折伴桡神经损伤，神经离断或嵌压能得到及时处理，神经功能恢复好。骨折的解剖复位和克氏针的牢固固定，可有效地防止肘内翻畸形的发生。     

小切口穿针术在儿童Gartland Ⅲ型肱骨髁上骨折的应用

目的探讨小切口穿针术治疗儿童Gartland Ⅲ型肱骨髁上骨折的手术方式和治疗效果。方法 2002年9月-2009年7月,收治189例儿童Gartland Ⅲ型肱骨髁上骨折。男137例,女52例;年龄1～13岁,平均6.2岁。运动伤173例,车祸伤9例,高处坠落伤5例,地震伤2例。伴其他部位骨折11例;桡神经损伤36例,正中神经损伤5例,尺神经损伤2例;肱动脉断裂2例。受伤至入院时间1h～10d。采用小切口穿针术治疗骨折,同期行神经、血管探查修复。结果术后切口均Ⅰ期愈合,无相关并发症发生。143例获随访,随访时间5个月～5年,平均12个月。X线片示骨折均愈合,愈合时间2～4个月,平均2.5个月。6例发生肘内翻,但肘关节屈伸功能基本正常;其中2例行肱骨远端楔形截骨矫形术,余继续功能锻炼。肘关节功能评价参照Flynn等临床功能评定标准:优121例,良15例,可7例,优良率95.1%。术后切口未遗留明显瘢痕,神经、血管损伤者术后功能均基本恢复正常。结论小切口穿针术治疗儿童Gartland Ⅲ型肱骨髁上骨折具有创伤小、手术时间短、操作简便、手术并发症少的优点。     

改良手术入路转移植骨内固定治疗儿童肱骨髁上骨折

目的观察改良手术入路转移植骨内固定治疗儿童肱骨髁上骨折的临床疗效及预防肘内翻的作用。方法 2005年1月～2010年12月,采用肘后"S"形正中纵切口改良手术入路,取自肱骨髁上骨折桡侧近断端薄层骨片或骨碎片植于同骨折部尺侧处,克氏针交叉内固定,治疗儿童肱骨髁上骨折GartlandⅢ型15例。结果 15例均获随访,平均时间30(12～48)个月;术后肘关节功能按Flynn等临床功能评定标准:优14例,良1例。无肘内外翻畸形。结论该术式暴露充分,不增加受伤组织的"再损伤",直视下复位、固定、植骨;操作简单,手术风险小,功能恢复好;在预防肘内翻畸形方面,可取得比较满意的临床效果。     

肘内侧有限切开克氏针内固定治疗GartlandⅢ型儿童肱骨髁上骨折

目的观察肘内侧有限切开交叉克氏针内固定治疗GartlandⅢ型儿童肱骨髁上骨折的临床疗效。方法回顾性分析2009年10月-2014年10月采用该入路及内固定方式治疗的GartlandⅢ型儿童肱骨髁上骨折32例的骨折愈合及并发症发生情况。结果 32例中有30例获术后随访,随访时间为3~26个月,平均6个月。手术切口均Ⅰ期愈合,骨折愈合良好,愈合时间2~5个月,平均3.2个月。针道感染2例,肘内翻畸形1例,无医源性血管、神经损伤发生,无异位骨化、缺血性肌挛缩等并发症发生。肘关节功能按Flynn评价标准评定优良率为90%。结论肘内侧有限切开复位交叉克氏针内固定治疗GartlandⅢ型儿童肱骨髁上骨折具有创伤小、骨折固定牢靠、神经损伤风险低、切口隐蔽等优点,是治疗GartlandⅢ型儿童肱骨髁上骨折的一种可行的治疗方法。     

儿童移位型肱骨髁上骨折致神经损伤

目的:探讨儿童移位型肱骨髁上骨折致神经损伤类型、保守治疗时间和损伤机理。方法:对53例伴神经损伤的儿童移位型肱骨髁上骨折进行回顾性分析。结果:53例54条神经损伤涉及桡神经29条、骨间后神经13条、骨间前神经6条、正中神经4条、尺神经2条。46条神经保守治疗,8条神经手术探查连续性完整,呈牵拉和挤压伤,2条伴挫伤,伤后8～12周2条桡神经行松解术。伤后8～12周神经功能恢复48条,超过12周6条,最长时间24周。结论:儿童移位型肱骨髁上骨折所致的神经损伤,多数功能可自然恢复。伤后4～6周对神经恢复情况综合评定,肌电图神经传导速度测定功能无恢复及早手术,观察到伤后8～12周为宜。神经在肘部的临床解剖学特点是损伤的基础。     

肱三头肌两侧开窗入路手术治疗儿童肱骨髁上骨折

目的介绍一种治疗儿童肱骨髁上骨折的新手术入路,即肱三头肌两侧开窗入路。方法对儿童肱骨髁上骨折16例采用肘后正中切口,从肱三头肌的两侧作2个开窗入路显露骨折端,行骨折复位交叉克氏针内固定。结果此入路术中显露骨折端充分。方便骨折复位内固定,术后随访3个月以年,所有骨折均愈合,肘关节功能恢复理想。结论采用肱三头肌两侧开窗入路手术治疗儿童肱骨髁上骨折,对肱三头肌伸肌装置损伤小,显露骨折端容易,可有效防止桡神经损伤和肘肌失神经支配,肘关节功能恢复佳,是儿童肱骨髁上骨折的理想入路选择。     

早期与延迟手术治疗儿童Gartland Ⅲ型肱骨髁上骨折的疗效比较

目的 比较早期与延迟手术治疗儿童Gartland Ⅲ型肱骨髁七骨折的疗效.方法 对2001年1月至2007年6月收治的86例闭合性、无血管神经损伤的GartlandⅢ肱骨髁上骨折患儿资料进行回顾性分析,根据受伤至手术时间分为早期手术组(<8 h)和延迟手术组(>8 h),其中34例早期手术(伤后平均7.2 h手术),52例延迟手术(伤后平均49.5 h手术).对两组患儿开放复位率、手术时间、医源性神经损伤发生率、针道与切口感染率、骨折愈合时间及肘关节功能恢复情况进行比较.结果 早期手术组和延期手术组在开放复位率、手术时间、医源性尺神经损伤发生率、针道与切口感染率、骨折愈合时间及肘关节功能恢复情况等方面差异均尢统计学意义(P>0.05).结论 早期手术和延期手术对儿童Gartland Ⅲ型肱骨髁上骨折的疗效尤明显影响,因此临床上应尽量在术前准备充分、患肘肿胀相对消退时进行手术.     

儿童严重移位肱骨髁上骨折伴神经损伤的治疗策略

目的：探讨儿童肱骨髁上骨折伴神经损伤的临床特点及治疗策略。方法：对2000年6月至2006年12月收治的28例肱骨髁上骨折伴神经损伤的患儿进行总结分析,所有骨折均为GartlandⅢ型,其中闭合性损伤24例,开放性损伤4例。16例（A组）行闭合复位穿针固定,12例（B组）行骨折切开复位并神经探查。切开手术者发现8例神经为挫伤,3例为嵌顿伤,1例为断裂伤。结果：28例神经功能均完全恢复,其中闭合复位穿针者4～6周内恢复13例,8～10周2例,12周1例;切开手术者神经功能恢复4～6周6例,8～10周3例,12～16周3例。结论：儿童肱骨髁上骨折伴神经损伤者,大部分损伤的神经功能可以在骨折闭合复位后逐步恢复,但必要时切开复位、神经探查、修复,同样有重要的现实意义。     

张力带钢丝固定治疗肱骨远端骨折

我们于１９９２年４月至１９９８年３月应用张力带钢丝克氏针固定治疗肱骨远端骨折２４例,结果报道如下。一、临床资料１．对象男１９例,女５例,年龄５～４岁,平均８．６３岁。肱骨髁上骨折１４例,肱骨外髁骨折８例,肱骨内髁骨折２例。手术距受伤时间最长７天,最短者３小时,平均６７小时。２手术方法肱骨髁上骨折采取肘后正中切口,内、外髁骨折取肘内、外侧切口。整复骨折后,肱骨髁上骨折在内、外髁取４５°角各穿入一枚直径１．５ｃｍ的克氏针交叉固定骨折,近端穿出骨皮质０．４ｃｍ,钢丝在两枚克氏针头尾部卧“”字固定于骨断…     

闭合复位经皮穿针固定治疗儿童肱骨髁上GartlandⅢ型骨折

目的：评价闭合夏位后经皮克氏针交叉固定治疗儿童肱骨髁上GartlandⅢ型骨折的临床疗效。方法：16例GartlandⅢ型儿童肱骨髁上骨折,其中男9例,女7例;年龄2—12岁,平均7．2岁。术前有桡神经损伤症状的例2例：有肘前青淤斑的5例;术前呈明显的S状畸形有6例。受伤至接受复位时间48～72小时,平均为38小时;手术治疗在全麻或臂丛阻滞麻醉下进行,持续纵向牵引患肢,手法纠正肱骨髁上骨折的侧方、前后移位,C型臂透视下证实骨折复位满意后克氏针从内外髁交叉打入,且交叉点位于鹰嘴窝顶上;术后屈肘700～80。石膏固定,术后3-4周拆除石膏进行肢体功能锻炼。结果：平均随访5个月（2—12月）,所有骨折术后3-4周骨痂愈合良好,拔除克氏针。术后8周肘关节功能恢复。2例术后有尺神经症状,3个月内恢复。针道感染2例,对症处理后治愈。术后轻型肘内翻1例,明显肘内翻需手术1例。结论：闭合复位经皮克氏针交卫内固定是治疗儿童肱骨髁上GartlandⅢ型骨折的理想选择方法。     

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.