羟考酮用于血管减压手术术终镇痛衔接的半数有效剂量

目的通过序贯法测定羟考酮用于显微血管减压手术术终镇痛衔接的半数有效剂量(Median effective dose,ED_(50))。方法选择2017年6—10月在全麻下行经乙状窦入路显微血管减压手术的面肌痉挛患者23例,男5例,女18例,年龄18~64岁,BMI 18~24kg/m2,ASAⅠ或Ⅱ级。手术结束前30min给予羟考酮,手术结束后连接相同配方的镇痛泵。根据序贯法设定浓度,当出现第7个交叉点时终止试验。术后30min患者镇痛口述分级(verbal rating score,VRS)评分1分为阴性。结果 Dixon-Mood法计算羟考酮ED_(50)为0.054mg/kg(95%CI 0.053~0.056mg/kg);Probit回归模型计算为0.054mg/kg(95%CI 0.030~0.077mg/kg)。结论羟考酮用于显微血管减压手术术终镇痛衔接的ED50为0.054mg/kg。     

不同剂量羟考酮复合依托咪酯用于老年患者无痛胃镜检查的效果

目的观察不同剂量羟考酮复合依托咪酯用于老年患者无痛胃镜检查的效果。方法选择2017年2—11月全麻下行无痛胃镜检查的老年患者120例,男62例,女58例,年龄65～79岁,体重46～68 kg,ASAⅠ—Ⅲ级,随机分为四组,每组30例:羟考酮1组(O1组)、羟考酮2组(O2组)、羟考酮3组(O3组)及对照组(C组)。O1、O2、O3组分别静脉注射羟考酮0.025、0.05、0.075 mg/kg,C组静脉注射等容量生理盐水,2 min后四组静脉注射依托咪酯0.2 mg/kg。术中出现呛咳或体动反应时,静脉追加依托咪酯0.1 mg/kg。记录胃镜检测时间;追加依托咪酯的情况;记录呛咳、体动、呼吸抑制、头晕、恶心呕吐、肌震颤等不良反应的发生情况。结果 O1、O2和O3组追加依托咪酯例数明显少于C组(P0.05);O2和O3组追加依托咪酯例数明显少于O1组(P0.05)。O1、O2和O3组呛咳、体动、恶心呕吐和肌震颤发生率明显低于C组(P0.05);O2和O3组呛咳、体动、恶心呕吐和肌震颤发生率明显低于O1组(P0.05)。O3组呼吸抑制和头晕发生率明显高于C、O1和O2组(P0.05)。结论羟考酮0.025、0.05、0.075 mg/kg复合依托咪酯用于老年患者无痛胃镜检查,其中羟考酮0.05 mg/kg更为安全有效。     

羟考酮抑制老年患者腹腔镜下胆囊切除术瑞芬太尼静脉复合麻醉苏醒期疼痛的半数有效量

目的 探讨羟考酮抑制老年患者腹腔镜下胆囊切除术瑞芬太尼静脉复合麻醉苏醒期疼痛的药效学. 方法 选择拟在全身麻醉下行腹腔镜胆囊切除术患者32例,年龄65～74岁,ASA分级Ⅰ、Ⅱ级.麻醉诱导:依托咪酯0.3 mg/kg,瑞芬太尼采用Minto模型靶控输注(target controlled infusion,TCI),效应室浓度为3.0μg/L.待BIS值在40～45后,静脉注射顺式阿曲库铵0.2 mg/kg,5 min内完成气管插管行机械通气.术中除瑞芬太尼外,不再追加任何镇痛药物,麻醉维持分别TCI丙泊酚(3.0 μg/L)、瑞芬太尼(2.5～3.0 μg/L).手术结束时停用丙泊酚、瑞芬太尼.手术结束前5 min采用改良序贯法静脉注射羟考酮.拔管后30 min测定患者术后VAS评分,VAS评分≥4分为术后急性疼痛.计算羟考酮ED50及其95％可信区间(confidence interval,CI),并记录手术时间、术后拔管时间及恶心、呕吐等副作用. 结果 羟考酮抑制老年患者腹腔镜下胆囊切除术瑞芬太尼静脉复合麻醉苏醒期疼痛的EDs及其95％CI分别为0.126 mg/kg和0.093～0.181 mg/kg.32例患者术后有1例发生恶心、呕吐,无其他副作用发生. 结论 羟考酮(0.126 mg/kg)可以抑制半数老年患者腹腔镜下胆囊切除术瑞芬太尼静脉复合麻醉苏醒期的疼痛.     

无痛胃镜检查时丙泊酚对羟考酮有效剂量的影响

目的采用保守回归法评价无痛胃镜检查时不同丙泊酚浓度对羟考酮半数有效剂量(ED_(50))的影响。方法无痛胃镜检查患者65例,男35例,女30例,年龄18～60岁,BMI 20～24 kg/m~2,ASAⅠ或Ⅱ级,采用随机数字表法将患者随机分为两组。A组和B组丙泊酚TCI血浆浓度分别为5μg/ml和3μg/ml,首例患者羟考酮初始剂量分别为0.07 mg/kg和0.1 mg/kg。根据前一例患者无痛胃镜置入结果决定次例患者羟考酮剂量。前一例患者体动或呛咳反应阳性,则下一例患者羟考酮剂量增加0.01 mg/kg,反之减少0.01 mg/kg。采用保守回归法计算羟考酮的ED_(50)及其95%可信区间(95%CI),重复样本法计算ED_(95)及其95%CI。记录入镜时吞咽、呛咳、体动发生情况;记录麻醉后低血压和低血氧情况;记录术后恶心、呕吐等不良反应情况。结果 A组羟考酮ED_(50)为0.074 mg/kg(95%CI 0.063～0.086 mg/kg),ED_(95)为0.100 mg/kg(95%CI 0.087～0.194 mg/kg)。B组羟考酮ED_(50)为0.086 mg/kg(95%CI 0.061～0.098 mg/kg),ED_(95)为0.118 mg/kg(95%CI 0.103～0.308 mg/kg)。A组低血压发生率明显高于B组(P0.05)。两组恶心和呕吐发生率差异无统计学意义。结论丙泊酚TCI血浆浓度5.0μg/ml和3.0μg/ml时,羟考酮的ED_(95)分别为0.100 mg/kg和0.118 mg/kg。     

羟考酮对三叉神经微血管减压术患者术后早期恢复质量的影响

目的评价羟考酮在三叉神经微血管减压术患者中应用的安全性和有效性,并比较羟考酮与舒芬太尼对三叉神经微血管减压术患者术后早期恢复质量的影响。方法选择择期行三叉神经微血管减压术患者86例,男38例,女48例,年龄18~65岁,BMI 18~30kg/m2,ASAⅠ或Ⅱ级。采用随机数字表法将其分为两组:羟考酮组(O组)和舒芬太尼组(S组),每组43例。两组均接受静-吸复合麻醉,麻醉诱导时O组静脉注射羟考酮0.3mg/kg,S组静脉注射舒芬太尼0.4μg/kg,在手术进行到关硬膜后即刻,O组静脉注射羟考酮0.07mg/kg,S组静脉注射舒芬太尼0.1μg/kg。于术前1d、术后4、24和48h采用数字评分法(numeric rating scale,NRS)评估患者手术切口疼痛和三叉神经区面部疼痛程度。当NRS评分≥4分时O组静脉注射羟考酮3mg,S组静脉注射舒芬太尼5μg进行补救镇痛。于术前1d和术后3d采用40项恢复质量评分量表(QoR-40量表)评估患者恢复质量。记录术后补救镇痛情况、拔管时间、出院时间以及术后恶心呕吐、心动过缓、排尿困难、头晕和瘙痒的发生情况。结果 O组术后3d的QoR-40量表评分中身体舒适度评分、情绪状态评分、心理支持评分、疼痛评分及总评分明显高于S组(P0.05)。O组术后恶心呕吐发生率明显低于S组(20.9%vs 37.2%)(P0.05)。结论在手术时间短于5h的三叉神经微血管减压术患者中,羟考酮0.3mg/kg可安全用于其麻醉诱导,羟考酮0.07mg/kg及3mg可分别安全有效地用于其预防性镇痛及补救镇痛;与舒芬太尼比较,羟考酮可提高三叉神经微血管减压术患者术后早期恢复质量,减少术后恶心呕吐。     

羟考酮抑制中老年患者全身麻醉诱导期依托咪酯所致肌阵挛的半数有效量

目的 观察羟考酮抑制中老年患者全身麻醉诱导期依托咪酯所致肌阵挛的药效学. 方法 择期全身麻醉下手术患者62例,ASA分级Ⅰ、Ⅱ级.分为两组:中年组(45～54岁)30例,老年组(65～74岁)32例.麻醉诱导:患者面罩吸氧(8 L/min)5 min后,采用改良序贯法30 s内静脉注射羟考酮.2 min后30 s内静脉注射依托咪酯0.3 mg/kg,持续观察2 min,评估肌阵挛发生情况及其程度.然后静脉注射顺式阿曲库铵2 mg/kg和芬太尼3μg/kg,5min内完成气管插管行机械通气.麻醉分别以靶控输注(target controlled infusion,TCI)丙白酚(3.0 mg/L)、瑞芬太尼(2.5～3.0 μg/L)维持.采用Probit回归方法分析各组羟考酮的ED50及其95％CI,并记录手术时间、术后拔管时间及恶心、呕吐等副作用. 结果 羟考酮抑制中老年患者全身麻醉诱导期依托咪酯所致肌阵挛的ED.分别为0.077 mg/kg和0.062 mg/kg,95％CI分别为0.045～0.122 mg/kg和0.043～0.101 mg/kg;中年组羟考酮剂量明显高于老年组患者(P＜0.05).两组患者副作用发生率比较,差异无统计学意义(D0.05). 结论 羟考酮抑制中老年患者全身麻醉诱导期依托咪酯所致肌阵挛的ED50分别为0.077 mg/kg与0.062mg/kg;95％CI分别为0.045～0.122 mg/kg与0.043～0.101 mg/kg.     

罗哌卡因切口浸润联合羟考酮静脉输注对剖宫产术后宫缩痛和早期恢复的影响

目的观察罗哌卡因切口浸润联合羟考酮静脉术后镇痛对剖宫产术后宫缩痛和产妇早期恢复的影响。方法择期行剖宫产手术产妇60例,年龄22～35岁,ASAⅠ或Ⅱ级,随机均分为三组:羟考酮组(O组),罗哌卡因组(R组)和羟考酮联合罗哌卡因组(OR组)。O组患者于手术缝皮前静脉注射羟考酮0.1 mg/kg,R组患者于手术缝皮前皮下注射0.5%罗哌卡因15 ml浸润麻醉,OR组患者于手术缝皮前静脉注射羟考酮0.1 mg/kg联合皮下给予0.5%罗哌卡因15 ml浸润麻醉。术后VAS评分4分者静脉注射曲马多50 mg作为补救镇痛。比较三组产妇术后4、8、16、24、48 h的切口痛和宫缩痛的VAS评分和Ramsay镇静评分、术后48 h曲马多补救镇痛例次、术后恢复情况、术后皮肤瘙痒和恶心呕吐等不良反应发生情况。结果术后16、24 h O组和OR组宫缩痛VAS评分明显低于R组(P0.05),O组和R组切口痛VAS评分明显高于OR组(P0.05),术后曲马多补救镇痛例次明显大于OR组(P0.05)。O组和R组恶心呕吐发生率明显高于OR组(P0.05)。三组其他不良反应和术后恢复情况差异无统计学意义。结论剖宫产手术应用羟考酮静脉术后镇痛联合罗哌卡因切口浸润为基础的多模式镇痛,能对产妇的切口痛和宫缩痛达到良好的镇痛效果,其中羟考酮在减轻宫缩痛方面作用明显,且不增加术后不良反应。     

羟考酮复合布托啡诺用于二次剖宫产术后静脉自控镇痛的效果

目的评估羟考酮复合布托啡诺用于二次剖宫产术后静脉自控镇痛的效果。方法选择择期硬膜外麻醉下行二次剖宫产产妇60例,年龄25～40岁,孕周37～40周,体重65～85 kg,ASAⅠ或Ⅱ级。按随机数字表分为两组:羟考酮复合布托啡诺组(OB组)和布托啡诺组(B组),每组各30例。胎儿娩出后,OB组静脉缓慢注射0.1 mg/kg羟考酮注射液,B组静脉缓慢注射0.02 mg/kg布托啡诺注射液,关腹时连接静脉自控镇痛泵。记录产妇术后2、4、8、12、24 h切口痛以及宫缩痛的VAS疼痛评分;评估术后镇痛满意度;记录术后24 h内PCIA按压次数,初乳时间及0～4 h、4～12 h和12～24 h各时间段哺乳次数;记录恶心呕吐、皮肤瘙痒、头晕、嗜睡、呼吸抑制等不良反应的发生情况。结果与B组比较,术后2、4、8、12、24 h OB组切口痛以及宫缩痛的VAS评分明显降低(P0.05),镇痛期间PCIA按压次数明显减少(P0.05); OB组镇痛满意度2分的产妇比例明显少于B组,OB组镇痛满意度4分的产妇比例明显多于B组(P0.05);OB组术后初乳时间明显早于B组(P0.05)。两组恶心呕吐、头晕、嗜睡等术后不良反应的发生情况差异无统计学意义。结论羟考酮复合布托啡诺用于二次剖宫产术后静脉自控镇痛效果好,产妇满意度高,不良反应发生少,并可促进产后早期泌乳。     

复合不同剂量丙泊酚时羟考酮抑制新辅助化疗乳腺癌患者喉罩置入反应的有效剂量

目的评价新辅助化疗乳腺癌患者复合不同浓度丙泊酚时羟考酮的半数有效剂量(median effective dose,ED50)和95%有效剂量(95%effective dose,ED95)。方法纳入新辅助化疗乳腺癌女性患者62例,年龄18~55岁,BMI 20~25kg/m2,ASAⅠ或Ⅱ级,采用随机数字表法分为两组,分别给予丙泊酚TCI血浆浓度3.0μg/ml(A组)和5.0μg/ml(B组),首例患者羟考酮剂量分别为0.13mg/kg和0.10mg/kg。根据上一例置入喉罩时情况,决定下一例羟考酮剂量。根据最终观察结果,分析计算羟考酮的ED50和ED95及其95%可信区间(CI)。结果A组和B组羟考酮抑制新辅助化疗乳腺癌患者喉罩置入反应的ED50分别为0.131(0.127~0.137)mg/kg和0.085(0.078~0.093)mg/kg。A组和B组羟考酮抑制新辅助化疗乳腺癌患者喉罩置入反应的ED95分别为0.136(0.127~0.186)mg/kg和0.115(0.101~0.241)mg/kg。结论新辅助化疗乳腺癌患者给予丙泊酚TCI血浆浓度3.0μg/ml和5.0μg/ml后,羟考酮抑制喉罩置入反应的ED50分别为0.131(0.127~0.137)mg/kg和0.085(0.078~0.093)mg/kg,ED95分别为0.136(0.127~0.186)mg/kg和0.115(0.101~0.241)mg/kg。     

盐酸羟考酮注射液复合丙泊酚麻醉用于内镜下食管胃底静脉曲张套扎术的疗效和安全性

【摘要】〓目的〓评价盐酸羟考酮注射液与舒芬太尼复合丙泊酚用于肝硬化食管胃底静脉曲张患者内镜下套扎治疗的效果及安全性。方法〓48例肝硬化食管胃底静脉曲张拟行内镜下套扎治疗的患者,分为羟考酮注射液复合丙泊酚组(A组)和舒芬太尼复合丙泊酚组(B组),每组24例。A组静脉注射羟考酮注射液0.1 mg/kg,丙泊酚2 mg/kg诱导,后以丙泊酚4~7 mg·kg-1·h-1维持;B组注射舒芬太尼1 μg/kg,丙泊酚2 mg/kg诱导,后以丙泊酚4~7 mg·kg-1·h-1维持。观察两组患者不同时间点的平均动脉压(MAP)、心率(HR)、呼吸频率(RR)、血氧饱和度(SpO2)和麻醉深度(BIS);记录呛咳、体动次数、丙泊酚总用量、呼吸抑制及术后30 min疼痛评分。结果〓两组各时间段MAP、HR、RR及SpO2差异无统计学意义(P>0.05),A组发生呛咳、体动、呼吸抑制发生的总例数少于B组(P<0.05),同时,A组中丙泊酚用量及术后30 min疼痛评分的概率明显低于B组。结论〓盐酸羟考酮注射液复合丙泊酚麻醉下行内镜食管胃底曲张静脉套扎,对循环和呼吸系统影响小,不良反应较少,镇痛作用持久,麻醉效果好。     

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.