肾移植患者术后早期血浆内皮素的变化

对３２例尸体肾移植患者术前及术后早期３个月的血浆内皮素－１（ＥＴ－１）浓度进行了动态观察，同时行前列腺素Ｅ－２（ＰＧＥ－２）、血栓素Ｂ－２（ＴＸＢ－２）与环孢素Ａ（ＣｓＡ）血浓度的测定及移植肾功能与血压的监测。ＥＴ－１、ＰＧＥ－２及ＴＸＢ－２均采用放射免疫法测定，ＣｓＡ血浓度采用多克隆抗体偏振免疫荧光法（ＴＤＸ）进行。结果显示：移植前患者的血浆ＥＴ－１平均浓度为１０．２７±０．５７ｐｇ／ｍｌ，移植后３个月各阶段的ＥＴ－１值均显著降低，平均浓度为４．６２±０．１４ｐｇ／ｍｌ。与此同时，血浆Ｃｒ和ＢＵＮ值以及收缩压、舒张压也呈现相似的变化，与移植前相比有非常显著性差异（Ｐ＜０．０１），且血浆ＥＴ－１浓度的变化与移植肾功能及血压密切相关。血浆ＥＴ－１浓度可作为肾移植术后的一项监测参考指标。     

血栓调节蛋白与肝细胞癌门静脉癌栓的关系

目的　了解血栓调节蛋白（ｔｈｒｏｍｂｏｍｏｄｕｌｉｎ,ＴＭ） 在肝细胞癌（ＨＣＣ） 病人血浆中的水平,探讨ＴＭ 与ＨＣＣ门静脉癌栓形成及侵袭和转移的关系。方法　采用酶联免疫吸附（ＥＬＩＳＡ） 夹心法,检测４５ 例ＨＣＣ病人和６ 例肝良性占位病人的术前和术后血浆ＴＭ 水平。结果　术前ＨＣＣ组血浆ＴＭ水平（１０±６）ｎｇ／ｍｌ 明显高于肝良性占位组（６．１ ±２．２）ｎｇ／ｍｌ,Ｐ＜ ０．０５;单发肝癌结节组（１２ ±６）ｎｇ／ｍｌ和无门静脉癌栓组（１１±６）ｎｇ／ｍｌ 明显高于多发肝癌结节组（８ ±５）ｎｇ／ｍｌ 和门静脉癌栓组（７ ±５）ｎｇ／ｍｌ,Ｐ＜ ０．０５;而ＴＭ 高低与肝癌大小、包膜是否完整、病理分化程度、ＡＦＰ值及肝癌伴肝硬化程度无关,各组比较Ｐ＞０．０５。肝良性占位组术前ＴＭ（６±２）ｎｇ／ｍｌ 与切除术后（５ ．９ ±１ ．８）ｎｇ／ｍｌ 相比差异无显著性,Ｐ＞０ ．０５ ;肝癌组术前（１０ ±５）ｎｇ／ｍｌ 与切除术后（８ ±４）ｎｇ／ｍｌ 相比差异有显著意义,Ｐ＜０ ．０５。结论　ＨＣＣ病人血浆中ＴＭ 水平可升高,ＴＭ 在抗ＨＣＣ门静脉癌栓形成过程中发挥重要作用。     

体外循环与内皮素和降钙素基因相关肽的临床与实验研究

为探讨心脏灌流及体外循环（ＣＰＢ）心内直视手术期间的内皮素（ＥＴ）和降钙素基因相关肽（ＣＧＲＰ）的变化及其临床意义。用含有ＥＴ和ＥＴ＋ＣＧＲＰ的ＫＨ液分别对离体大鼠心脏进行灌流并观察冠脉流量、乳酸脱氢酶（ＬＤＨ）及脂质过氧化产物丙二醛（ＭＤＡ）含量。对ＣＰＢ心脏手术病人围术期测定ＥＴ和ＣＧＲＰ含量。结果：（１）大鼠心脏在ＥＴ灌流期间冠脉血流明显减少，ＭＤＡ生成和ＬＤＨ漏出显著升高；同时灌流ＣＧＲＰ则为相反结果。（２）ＣＰＢ心脏手术病人术前ＥＴ含量明显高于术中及术后（Ｐ＜０．０１）；心脏复苏后ＥＴ达到最低水平，进入ＩＣＵ后ＥＴ开始回升。（３）ＣＰＢ期间ＣＧＲＰ含量与术前比无差异，术后２４小时ＣＧＲＰ明显高于术前及术中（Ｐ＜０．０５）。结论为心脏停搏液中似无必要添加ＣＧＲＰ去拮抗ＥＴ，术后早期适量应用ＣＧＥＰ会有所裨益。     

茵陈蒿合承气汤对急腹症时内毒素血症的影响

目的：观察茵陈蒿合承气汤对急腹症时内毒素血症的影响。方法：选择具有内毒素血症的３０例急腹症患者,随机分为常规组和中西组,每组１５ 例。常规组给予抗感染补液治疗,中西组除常规治疗外,并给予茵陈蒿合承气汤口服。定量测定外周血内毒素（ＥＴ） 、肿瘤坏死因子α（ＴＮＦα） 、血栓素Ｂ２（ＴＳＢ２）／６酮前列腺素Ｆ１α（６ｋｅｔｏＰＧＦ１ α） 的水平,并观察每日大便次数的变化。结果：两组患者入院时外周血ＥＴ含量分别为９１．３０ ±３９．５０ ｐｇ／ｍｌ、８９．２１ ±２８．９０ ｐｇ／ｍｌ（ Ｐ＞ ０．０５） ,均明显高于正常对照组３３．２４ ±１０．８４ ｐｇ／ｍｌ（ Ｐ＜ ０．０１） 。两组患者外周血ＴＮＦα、ＴＸＢ２／６ｋｅｔｏＰＧＦ１α值明显高于正常人（ Ｐ＜０．０１） ,每日大便次数则明显少于正常人（ Ｐ＜ ０．０１） 。接受治疗后,中西组在降低外周血ＥＴ、ＴＸＢ２／６ｋｅｔｏＰＧＦ１α、ＴＮＦα含量和促进肠道功能恢复方面明显优于常规组。结论：茵陈蒿合承气汤通过通里攻下、清热解毒能降低急腹症患者外周血内毒素含量,减少内毒素血症的发生,抑制炎症介质的产生,维持机体内环境稳定,从而改善预后。     

心脏手术对甲状腺功能的影响

目的观察心脏手术前后甲状腺激素的变化，研究心脏手术对甲状腺功能的影响。方法用放射免疫法测定心脏手术前后患者血中甲状腺激素的含量，观察心脏手术中体外循环（ＣＰＢ）时间的长短对甲状腺激素变化的影响。结果从ＣＰＢ开始至术后Ｔ３、Ｔ４、ＦＴ３均明显降低，Ｔ３、Ｔ４在转流至最低温度时达到极点，分别降至０．３８±０．０４ｎｍｏｌ／Ｌ与５３．０±３．３ｎｍｏｌ／Ｌ，而术后５天仍明显低于术前水平（Ｐ＜０．０５）。ｒＴ３在ＣＰＢ期间稍下降，术后即迅速上升，２天后达到高峰，较术前上升了约３倍（Ｐ＜０．０１），并持续保持在较高水平。ＴＳＨ与ＦＴ４于手术前后均无差别。分组研究表明，手术时间，尤其是ＣＰＢ时间的长短对甲状腺功能的影响并不重要。结论心脏手术可对甲状腺功能造成严重的影响，使患者术后处于低Ｔ３综合征状态；而异常的甲状腺功能对术后心脏功能可能产生不利的影响     

体外循环与内皮素和降钙素基因相关肽的临床与实验研究

本文对离体大鼠心脏灌流及体外循环心内直视手术期间的内皮素和降钙素基因相关肽水平进行了动态观察，结果提示：（１）ＥＴ灌流离体大鼠心脏时冠脉血流明显减少，心脏组织ＭＤＡ生成，ＬＤＨ漏出显著升高。同时灌流ＣＧＲＰ时冠脉血流显著增加，ＭＤＡ生成和ＬＤＨ漏出量显著降低。（２）ＣＰＢ病人术前ＥＴ水平明显高于术中与术后（Ｐ＜０．０１）心脏复苏后，体内ＥＴ含量达到了最低水平。回ＩＣＵ及术后２４小时体内ＥＴ开始回升。（３）ＣＰＢ期间ＣＧＲＰ无明显变化，术后２４小时，体内ＣＧＲＰ含量明显较术前及术中升高（Ｐ＜０．０５）。文章对上述变化的原因及临床意义进行了简要本文作者单位：１０００３７海军总医院胸心外科、心脏内科讨论分析     

经尿道前列腺电汽化与经尿道前列腺电切对BPH的疗效比较

对２４０例有症状的前列腺增生症（ＢＰＨ）患者分别行经尿道前列腺电汽化术（ＴＶＰ）和经尿道前列腺电切术（ＴＵＲＰ）。结果显示：１２０例ＴＶＰ手术者，前列腺症状评分（ＩＰＳＳ）从术前的２０．９下降至术后３个月的５．１（Ｐ＜０．００１），最大尿流率由１０．６ｍｌ／ｓ上升至１９．２ｍｌ／ｓ（Ｐ＜０．０１）。ＴＵＲＰ组１２０例，ＩＰＳＳ从术前的２１．２下降至术后３个月的５．２（Ｐ＜０．００１），最大尿流率由１０．２ｍｌ／ｓ上升至１９．４ｍｌ／ｓ（Ｐ＜０．０１），两组比较无显著差异性（Ｐ＞０．０５）。平均留置导尿管时间：ＴＶＰ组２６．５小时，ＴＵＲＰ组５０．７小时，有显著性差异（Ｐ＜０．０１）。术后阳萎发生率：ＴＶＰ组２．４％，ＴＵＲＰ组１４．５％（Ｐ＜０．０５）。ＴＶＰ组术中无大出血及经尿道前列腺电切综合征（ＴＵＲＳ）发生，需输血者仅１例。ＴＵＲＰ组３例发生ＴＵＲＳ，输血１４例。比较结果：ＴＶＰ能达到与ＴＵＲＰ完全相同的治疗效果，且并发症少，价格相对较低，近期效果满意。     

体外循环心内直视手术对心血管调节肽影响的初步临床研究

作者对１５例体外循环心内直视手术病人的内皮素（ＥＴ）、降钙素基因相关肽（ＣＧＲＰ）、神经降压素（ＮＴ）和Ｐ物质（ＳＰ）进行测定，结果提示：（１）ＣＰＢ手术病人术前ＥＴ含量明显高于术中及术后（Ｐ＜０．０１），开放循环心脏复苏后，体内ＥＴ含量达到了最低水平，回ＩＣＵ及术后２４小时，ＥＴ含量回升，但仍明显低于术前；（２）ＣＰＢ期间ＣＧＲＰ无明显变化，术后２４小时体内ＣＧＲＰ水平明显较术前及术中升高（Ｐ＜     

心内直视手术对甲状腺激素代谢的影响及其临床意义

为了解体外循环心脏直视手术对甲状腺激素代谢的影响并探讨其临床意义。作者选择２１例心脏直视手术病人，用放免法分别于术前、术中、术后２、２４小时测定其血浆Ｔ３、Ｔ４、游离Ｔ３（ＦＴ３）、游离Ｔ４（ＦＴ４）、反Ｔ３（ｒＴ３）及促甲状腺激素ＴＳＨ的含量。结果发现Ｔ４、ＦＴ４术中降低，术后２小时恢复正常（Ｐ＜０．０５）。Ｔ３、ＦＴ３呈下降趋势，术后２４小时降至最低（Ｐ＜０．０１）。ｒＴ３进行性升高。ＴＳＨ术中一过性升高。结论：甲状腺激素在ＣＰＢ时变化为术中低Ｔ３、Ｔ４综合征，术后为低Ｔ３综合征。提示ＣＰＢ后Ｔ３补充治疗有利于病人康复及某些术后难治性心功能不全的处理。     

体外循环心脏手术期间降钙素基因相关肽的变化

为探讨体外循环（ＣＰＢ）心脏手术病人降钙素基因相关肽（ＣＧＲＰ）的变化和临床意义，对１５例先天性心脏病和１１例风湿性心脏病（男１９例，女７例；年龄６～５６岁；体重１３～６８ｋｇ）行ＣＰＢ心脏手术的病人，采血用放免法测定ＣＧＲＰ含量。结果麻醉后转流前、阻断主动脉２０、４０分钟、开放主动脉即刻、开放后２０、４０分钟、术后６小时和术后１０天共８个时点ＣＧＲＰ含量分别为２．３９２±１．３７５、７．４８２±６．７９３、４．６６６±２．７１２、６．５４０±４．５００、７．８２６±７．２６９、９．２８９±４．９７６、５．２４２±４．０１４、３．９８３±２．８８７ｐｍｏｌ／Ｌ。与转流前比较，ＣＧＲＰ含量在阻断主动脉至开放主动脉明显升高，开放主动脉４０分钟达高峰（Ｐ＜０．００１），术后６小时稍有回落，但仍高于转流前（Ｐ＜０．００５），术后１０天虽显著回落，但仍显著高于转流前水平（Ｐ＜０．０５）。结论：ＣＰＢ期间ＣＧＲＰ升高对心肌有重要保护作用     

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.