微创Chevron合并外侧软组织松解治疗轻中度拇外翻畸形的短期疗效分析

目的:探讨微创Chevron合并外侧软组织松解治疗轻中度拇外翻畸形的短期疗效。方法:自2019年1月至2021年12月,采用微创Chevron截骨加外侧软组织松解术式治疗67例(80足)轻中度拇外翻患者,男5例(6足),女62例(74足);年龄20~60(47.2±9.7)岁;轻度(拇外翻角 ≤ 20°)54例(64足),中度(20°<拇外翻角 ≤ 40°)13例(16足)。比较术前与末次随访时拇外翻角(hallux valugs angle,HVA),Ⅰ-Ⅱ跖骨间角(Ⅰ-Ⅱ intermetatarsal anlge,Ⅰ-Ⅱ IMA),远端跖骨关节角(distal metatarsal articular angle,DMAA),籽骨Hardy评分变化,并采用北美足踝外科协会拇趾-跖趾关节(American Orthopaedic Foot and Ankle Society''s Hallux Metatarsophalanged-Interphalangeal,AOFAS Hallux MTP-IP)评分进行疗效评价。结果:67例患者获得随访,时间6~23(13.7±6.5)个月。术前HVA、Ⅰ-Ⅱ IMA、DMAA、籽骨Hardy评分、AOFAS Hallux MTP-IP评分分别为(27.5±7.0)°,(17.4±4.1)°,(11.4±3.8)°,(4.9±2.6)分,(58.2±9.1)分;末次随访时时分别为(8.3±4.8)°,(6.9±3.0)°,(3.9±2.4)°,(2.7±1.1)分,(91.3±2.2)分;术前与末次随访比较差异有统计学意义(P<0.05)。轻度患足(64足)和中度患足(16足)术前各项影像学指标和AOFAS Hallux MTP-IP评分比较差异有统计学意义(P<0.05);末次随访时,上述指标比较差异无统计学意义(P>0.05);从各指标改善程度来看,中度拇外翻患足HVA、Ⅰ-ⅡIMA、籽骨Hardy评分、AOFAS Hallux MTP-IP评分优于轻度拇外翻患足(P<0.05)。术后4例出现截骨部位切口周围红肿,经局部换药及口服抗生素均治愈。结论:微创Chevron截骨联合外侧软组织松解术对于轻中度拇外翻有良好的矫形效果及功能改善。     

改良微创Chevron截骨整形术治疗足拇外翻的疗效分析

目的观察改良微创Chevron截骨整形术治疗足拇外翻的临床疗效。方法自2016年6月至2017年6月,对收治的36例(46足)足拇外翻患者行改良微创Chevron截骨整形术。通过美国足踝评分系统(aofas ankle hindfoot scale, AOFAS)对手术前后的临床效果进行评价,同时对比术前及术后6周足拇外翻角(HVA)与第一、二跖骨间夹角(IMA)的角度,以及术后瘢痕的临床疗效评价。结果本组共36例患者,随访10～17个月。AOFAS术后评分平均为89.16分;术后6周,患者HVA术后平均为12.18°;IMA术后平均为6.74°。通过影像学比较HVA角度,其差异无统计学意义(P0.05)。对切口瘢痕处行临床疗效评估,总有效率为96%。患者未见临床复发。结论采用改良微创Chevron截骨整形术治疗足拇外翻可以获得良好的临床效果,且近期疗效较满意。     

两种截骨术式治疗中重度拇外翻影像学效果与临床疗效的系统评价

目的：系统评价Chevron截骨术与Scarf截骨术治疗中重度拇外翻的影像学效果和临床疗效。方法：计算机检索PubMed、Embase、Cochrane Library、中国生物医学文献数据库（CBM）、中国期刊全文数据库（CNKI）、万方期刊全文数据库（Wanfang Data）关于Chevron截骨术与Scarf截骨术治疗拇外翻的随机对照研究（RCT）,检索时限从建库至2018年6月。由2名研究者独立按照纳入和排除标准筛选文献,评价纳入文献的偏倚风险和提取相关观察指标后,采用RevMan 5.3.5软件进行Meta分析。比较两种截骨术式术后拇外翻角（HVA）、1-2跖骨间角（IMA）、跖骨远端关节面固有角（DMAA）、美国骨科足踝外科协会评分（AOFAS）、术后切口并发症以及患者满意度。结果：最终纳入6篇随机对照研究文献,共507例（足）患者,92.5%的患者为中重度拇外翻,其中Chevron截骨术261例（足）,Scarf截骨术246例（足）。Meta分析结果显示：Chevron截骨术在矫正HVA方面优于Scarf截骨术[MD=-1.95,95% CI （-2.64,-1.27）,P<0.000 01]。而两种方法在IMA[MD=-0.42,95% CI （-1.04,0.21）,P=0.19],DMAA[MD=0.78,95% CI （-0.72,2.29）,P=0.31],AOFAS评分[MD=2.47,95% CI （-2.38,7.33）,P=0.32],术后切口并发症[RR=1.09,95% CI （0.54,2.20）,P=0.82],患者满意度[RR=1.00,95% CI （0.96,1.05）,P=0.92]方面比较差异无统计学意义。结论：Chevron截骨术操作简单、跖骨短缩少、创伤小,在治疗中重度拇外翻矫正HVA方面优于Scarf截骨术,在IMA、DMAA、AOFAS评分、并发症、患者满意度方面二者效果相似。     

Chevron联合Akin截骨与Scarf联合Akin截骨治疗中度足母外翻的临床疗效对比

目的 比较Chevron联合Akin截骨术与Scarf联合Akin截骨术治疗中度足母外翻的临床疗效。方法 回顾分析江苏省中医院骨伤科2012年9月至2015年9月收治的27例（36足）中度足母外翻病人,Chevron联合Akin截骨组（CA组）14例（19足）,Scarf联合Akin截骨组（SA组）13例（17足）,比较两组术前、术后1个月、1年及末次随访时以下指标：足母外翻角（hallux valgus angle, HVA）;第1、2跖骨间夹角（inter metatarsal angle, IMA）;近端关节面固有角（distal metatarsal articular angle, DMAA）;胫侧籽骨位置;第一跖骨长度;另外,比较两组术前、术后末次随访的美国足踝外科协会（American Orthopaedic Foot and Ankle Society, AOFAS）评分。两组病人性别、年龄、术前HVA、IMA、DMAA、第一跖骨长度、胫侧籽骨位置的差异均无统计学意义（P均＞0.05）。结果 两组病人术中未见明显的并发症,术后均愈合良好,无骨折不愈合、延迟愈合、跖骨头坏死、皮神经损伤、内固定松动、僵直、足母内翻等并发症。术后末次随访CA组AOFAS评分为（93.91±9.03）分,SA组AOFAS评分为（91.83±13.58）分,两组比较,差异无统计学意义（t=0.552,P=0.593）。术后1个月、1年、末次随访时两组的HVA、IMA、DMAA比较,差异均无统计学意义（P均＞0.05）。与SA组比较,术后1个月、1年、末次随访时CA组第一跖骨长度短缩程度更大,第一跖骨疼痛发生率更高,而胫侧籽骨复位更理想（P均＜0.05）。结论 Chevron联合Akin截骨与Scarf联合Akin截骨治疗中度足母外翻均有较好的疗效,临床疗效相近。     

微创Chevron-Akin截骨术治疗轻中度拇外翻的早期疗效分析

目的:探讨微创Chevron-Akin(minimally invasive Chevron-Akin,MICA)截骨术治疗轻中度拇外翻的早期临床疗效。方法:自2019年6月至2021年4月,采用MICA截骨术治疗26例(29足)轻中度拇外翻患者,其中男1例,女25例;年龄19~78(38.3±19.5)岁。观察并比较手术前后拇外翻角(hallux valgus angle,HVA),第1、2跖骨间角(intermetatarsal angle,IMA),第1跖骨短缩。末次随访时采用美国骨科足踝外科协会(American Orthopedic Foot and Ankle Society,AOFAS)前足评分系统及视觉模拟评分(visual analogue scale,VAS)评价治疗效果,并记录相关并发症。结果:26例(29足)均获得随访,时间12~33(19.6±5.1)个月。HVA、IMA分别由术前的(32.3±6.6)°、(11.7±3.2)°矫正为术后的(13.0±5.3)°、(6.1±3.2)°,差异有统计学意义(P<0.01);第1跖骨短缩(2.7±1.1) mm。AOFAS评分由术前的(55.7±7.4)分提高到术后的(88.5±7.9)分(P<0.01),其中优15足,良11足,可3足。VAS由术前的(6.5±1.5)分改善为术后的(0.7±0.4)分(P<0.01)。结论:MICA截骨术创伤小,术后恢复快,并发症率低,并且能有效改善拇外翻畸形,是治疗轻中度拇外翻的安全可靠手术方法。     

可吸收螺钉在拇外翻畸形微创截骨术中的应用分析

目的:探讨可吸收螺钉在拇外翻畸形微创截骨术中的临床疗效。方法:回顾性分析自2019年1月至2020年1月收治的31例拇外翻患者的临床资料,根据术中使用螺钉不同分为可吸收螺钉组(17例)和钛合金空心螺钉组(14例)。其中可吸收螺钉组男1例,女16例;年龄32~72(54.53±12.12)岁;左侧6例,双侧5例,右侧6例;轻度1例,中度11例,重度5例;采用拇外翻微创截骨术+可吸收螺钉固定进行治疗。钛合金空心螺钉组男2例,女12例;年龄18~71(47.57±15.68)岁;左侧4例,双侧4例,右侧6例;轻度1例,中度9例,重度4例;采用拇外翻微创截骨术+钛合金空心螺钉固定进行治疗。观察两组患者并发症情况,分别于术前和术后12个月在足负重位X线片测量并比较两组患者拇外翻角(hallux valgus angle,HVA)和第1、2跖骨间角(intermetatarsal angle,IMA)变化情况,并比较术前和术后12个月美国足踝外科学会(American Orthopedic Foot and Ankle Society,AOFAS)拇趾关节评分系统和视觉模拟评分(visual analogue scale,VAS)。结果:31例患者获得随访,时间13~20(16.61±2.47)个月;可吸收钉组随访时间14~20(16.88±2.80)个月,钛合金空心钉组随访时间13~19(16.29±2.05)个月;两组随访时间比较差异无统计学意义(P>0.05)。吸收螺钉组1例出现术口周围出现麻木;钛合金空心钉组3例出现并发症,其中术口周围麻木症状1例,内固定物刺激皮肤症状1例,复发1例;两组并发症比较,差异无统计学意义(χ²=1.651,P=0.199)。两组术前和术后12个月HVA、IMA比较,差异无统计学意义(P>0.05)。两组术前和术后12个月AOFAS评分、VAS比较,差异无统计学意义(P>0.05)。结论:与拇外翻微创截骨后使用钛合金空心螺钉进行固定相比,使用可吸收螺钉固定在影像学评价和功能评价上可以达到与钛合金空心螺钉固定水平相当的临床效果。     

改良Chevron截骨手术治疗中重度足拇外翻的近期疗效

目的探讨采用第1跖骨远端改良Chevron截骨手术治疗中重度足拇外翻的临床效果。方法笔者自2014-05—2015-12采用第1跖骨远端改良Chevron截骨手术治疗20例(22足)中重度足拇外翻,分别对手术前后患者AOFAS评分、VAS评分、拇趾外翻角(HVA)、第1跖骨远端关节角(DMAA)和第1、2跖骨间夹角(IMA)的差异进行统计学分析。结果所有患者获得随访6~48(20±8.5)个月。均获得骨性愈合,无一例发生切口并发症、跖骨头坏死、拇内翻等并发症,末次随访时无足拇外翻复发。2足术后出现拇趾背皮肤麻木;7例末次随访跖趾关节活动范围有所减小,但患者无明显不适。AOFAS评分:术前(58±3.1)分,术后(92.5±5.0)分;VAS评分:术前(6.5±3.1)分,术后(1.6±1.4)分。术后AOFAS评分和VAS评分均较术前有明显改善,差异有统计学意义(t=-11.763,P=0.027;t=3.657,P=0.043)。术后HVA角、IMA角、DMAA角较术前均获较大改善,差异有统计学意义(t=15.032,P=0.006;t=8.588,P=0.037;t=5.038,P=0.026)。结论对于中重度足拇外翻或DMAA增大的足拇外翻,应用改良Chevron截骨手术可获得满意效果。     

改良Chevron截骨术联合Akin截骨术治疗足母中重度外翻的临床分析

目的 探究改良Chevron截骨术联合Akin截骨术治疗中重度足母外翻的临床效果。方法 回顾性分析2015年1月至2017年1月我院收治的50例中重度足母外翻病人的临床资料,依据手术治疗方式的不同将其分为改良Chevron截骨治疗组（20例,36病足）和联合手术治疗组（30例,50病足,改良Chevron截骨术联合Akin截骨术）。应用美国足踝外科医师协会（American Orthopaedic Foot and Ankle Society, AOFAS）踝与后足功能评分系统评价患足功能,采用疼痛视觉模拟量表（visual analogue scale, VAS）评估两组病人患足疼痛情况,测量两组病人手术前后的足母外翻角（hallux valgus angle, HVA）和第1、2跖骨间角（inter-metatarsus angle, IMA）评价手术效果。结果 联合手术治疗组病人的术中出血量为（33.75±5.27） ml,手术时间为（55.14±12.89） min,均高于改良Chevron截骨治疗组［（12.88±4.75） ml,（27.67±10.12） min］,差异均有统计学意义（t=3.293,P=0.018;t=4.293,P=0.012）。联合手术治疗组术后1周、1个月、1年的VAS评分［（3.24±0.98）分、（2.17±0.45）分、（1.31±0.12）分］均优于改良Chevron截骨治疗组［（3.42±0.74）分、（2.57±0.36）分、（1.88±0.45）分］,差异均有统计学意义（t=2.267,P=0.028;t=2.991,P=0.017;t=2.542,P=0.021）。两组病人术后的HVA、IMA、AOFAS评分、满意度评分、AOFAS优良率比较,联合手术治疗组［12.67°±2.13°、8.31°±1.02°、（81.21±9.24）分、（91.67±4.12）分、88.8%］优于Chevron截骨治疗组［10.42°±3.52°、7.59°±1.33°、（62.22±6.42）分、（75.32±5.91）分、60.00%］,差异均有统计学意义（t=2.742,P=0.037;t=2.984,P=0.029;t=3.342,P=0.012;t=3.943,P=0.007;χ²=7.274,P=0.032）。结论 改良Chevron截骨术联合Akin截骨术治疗中重度足母外翻具有更好的术后效果,值得进一步推广应用。     

Akin截骨联合第1跖骨截骨治疗拇外翻的疗效

目的探讨Akin截骨联合第1跖骨截骨治疗拇外翻的疗效。方法采用Akin截骨联合第1跖骨截骨治疗27例拇外翻患者(27足):Akin截骨联合Chevron截骨19例,Akin截骨联合Scarf截骨6例,Akin截骨联合Juvara截骨2例。比较术前及末次随访时的第1、2跖骨间夹角(IMA)与拇外翻角(HVA)的变化。末次随访时采用AOFAS踝-后足评分标准评价疗效。结果患者均获得随访,时间10~16个月。截骨端均骨性愈合,前足疼痛较术前显著减轻,无拇外翻复发、转移性跖骨痛等并发症发生。末次随访时,HVA、IMA较术前显著减小,AOFAS踝-后足评分较术前显著提高,差异均有统计学意义(P<0.001)。结论Akin截骨联合第1跖骨截骨治疗拇外翻,纠正畸形效果满意,可降低拇外翻术后复发率,近期临床效果好。     

Scarf截骨术治疗中、重度拇外翻畸形的疗效

目的 探讨Scarf截骨术治疗中、重度拇外翻畸形的临床疗效.方法 应用Scarf截骨术治疗29例拇外翻畸形患者.记录术后并发症的发生情况.比较手术前后AOFAS踝-后足评分、行走时疼痛VAS评分、拇外翻角(HVA)以及第1、2跖骨间角(IMA).结果 患者均获得随访,时间12～48(26.2±9.7)个月.患足切口均一...     

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.