青少年特发性脊柱侧凸主胸弯融合后未融合上胸弯的变化及其与肩部平衡的关系

【摘要】 目的：探讨青少年特发性脊柱侧凸（AIS）患者主胸弯融合后未融合上胸弯的变化及其与肩部平衡的关系。方法：回顾性分析2008年1月~2010年12月在我院接受手术治疗的AIS患者,选取年龄10～18岁,Lenke分型为Lenke 1、2、3、4型,右胸弯且Cobb角＜80°,采用后路椎弓根螺钉系统固定矫形,固定融合上端椎在T4或T4以下,随访时间2年以上的患者,排除翻修手术和截骨手术患者。术前根据Lenke分型判断上胸弯是否为结构性,分成结构性上胸弯组和非结构性上胸弯组,统计比较两组术前、术后3个月和末次随访时外观肩部平衡以及影像学各项参数的变化。结果：共有62例患者纳入本研究,平均年龄14.4岁,随访时间24~62个月,平均36.4个月,其中结构性上胸弯组17例,非结构性上胸弯组45例。两组患者术后上胸弯均能自发性矫正,末次随访时,上胸弯Cobb角平均由27.9°减小至19.4°,T1倾斜角由-0.21°增加至4.7°,第一肋倾斜角（FRT）由0.4°增加至3.7°,锁骨角（CA）由-1.5°增加至0.8°,双肩高度差（CSH）由-13.0mm增加至5.2mm,改变均有统计学意义（P=0.000）。Pearson相关性分析显示,T1倾斜角的改变（术后T1倾斜角-术前T1倾斜角）与CSH变化（术后CSH-术前CSH）有较强相关性（r=0.624,P=0.000）,术后主胸弯的矫正率和FRT与CSH变化为中等程度相关（r=0.437,0.345,P=0.007,0.006）,术前主胸弯Cobb角与CSH变化为弱相关（r=0.262,P=0.040）。上胸弯Cobb角及柔韧性、主胸弯柔韧性、T1倾斜角等参数与CSH变化无统计学相关性。结论：AIS患者结构性与非结构性上胸弯在主胸弯矫正以后均有自发性矫正现象,但T1倾斜角、第一肋倾斜角和双肩高度差均会增加。右胸弯患者左肩被抬高的程度与T1倾斜角增加的程度、主胸弯的矫正率及术后第一肋倾斜角相关。     

青少年特发性脊柱侧凸术后肩部外观可塑性与融合策略

【摘要】 目的：本研究旨在探讨青少年特发性脊柱侧凸（adolescent idiopathic scoliosis,AIS）术后肩部外观可塑性,分析基于该现象的胸弯融合上端椎选择策略。方法：对56例Lenke Ⅰ型AIS患者进行回顾性研究,术后随访2～5年。术前Cobb角主胸弯57.65°±12.28°、上胸弯20.34°±9.52°。根据术前肩部平衡、上胸弯柔韧度情况,主胸弯融合上端椎选择方案为：术前右肩抬高非僵硬性上胸弯（柔韧度＞30%）患者10例,选择端椎下位椎（端椎－1）;僵硬性上胸弯（柔韧度≤30%）患者7例,选择端椎。术前双肩平衡非僵硬性上胸弯患者,7例选择端椎上位椎（端椎＋1）,7例选择T3;僵硬性上胸弯患者,5例选择T4,6例选择T3。术前左肩抬高非僵硬性上胸弯患者4例,选择端椎上位椎（端椎＋1）;僵硬性上胸弯患者,1例选择T4,9例选择T3。配对t检验比较术后即刻、末次随访外观肩高（CSD）,评估术后肩部外观可塑性。并对术后肩部平衡进行主观评价,其中患者和家属一方或双方认为肩部外观未恢复平衡,为主观评价不满意。通过分析外观CSD变化,影像学冠状面平衡及T2～T5后凸角,患者及家属主观评价,总结基于肩部外观可塑性的上端椎选择策略。结果：末次随访Cobb角主胸弯19.16°±10.34°、上胸弯11.83°±8.65°,冠状面平衡0.67±0.56cm,T2～T5后凸角17.23°±7.28°。1例患者2年内随访主观评价左肩抬高,其余患者无并发症发生。术前、术后即刻、末次随访时,CSD值：1.04±0.24cm、0.92±0.22cm、0.63±0.16cm;CSD≥1cm患者例数：31例、23例、5例。术后即刻与末次随访CSD存在显著差异（t=7.98,P＜0.001）,最大肩部外观可塑值ΔCSD为1.69cm。随访中肩部恢复平衡的上端椎选择方案：术前右肩抬高非僵硬性上胸弯患者选择端椎－1,右肩抬高僵硬性上胸弯患者选择端椎,双肩平衡非僵硬性上胸弯患者选择端椎＋1或T3,双肩平衡僵硬性上胸弯患者选择T3后,患者末次随访CSD均＜1cm,主观评价满意;术前左肩抬高非僵硬性上胸弯患者选择端椎＋1后1例末次随访CSD为1.06cm,左肩抬高僵硬性上胸弯患者选择T3后1例末次随访CSD为1.02cm,主观评价满意。随访中肩部未恢复平衡的上端椎选择方案：术前双肩平衡僵硬性上胸弯患者选择T4后,2例CSD分别为1.45cm、1.54cm,其中1例随访2年内主观评价左肩抬高;术前左肩高僵硬性上胸弯患者选择T4,1例CSD较大为1.52cm。结论：AIS患者术后肩部外观存在可塑性,基于该特性Lenke Ⅰ型AIS患者胸弯融合上端椎策略为：术前右肩抬高非僵硬性上胸弯患者选择端椎－1,僵硬性上胸弯患者选择端椎;双肩平衡非僵硬性上胸弯患者选择端椎＋1,僵硬性上胸弯患者选择T3;左肩抬高非僵硬性上胸弯患者选择端椎＋1,僵硬性上胸弯患者选择T3。     

Lenke 1型青少年特发性脊柱侧凸病人矫形术后肩平衡的相关因素分析

目的 探讨术前右肩高Lenke 1型青少年特发性脊柱侧凸（adolescent idiopathic scoliosis,AIS）病人术后的肩关节高度变化,并分析术后肩平衡的影响因素。方法 回顾性分析2015年1月至2017年12月于我院手术治疗的术前右肩高Lenke 1型AIS病人41例,根据术后肩部平衡状态分为双肩平衡组和双肩失衡组。分别测量两组病人术前、术后3个月及术后2年的影像学肩关节高度差（radiographic shoulder height,RSH）、上胸弯Cobb角、主胸弯Cobb角、锁骨角、胸廓锁骨角度差（clavicle chest cage angle difference,CCAD）和T₁倾斜角,并计算主胸弯矫正率、上胸弯矫正率、主胸弯柔韧度、上胸弯柔韧度等;分析双肩失衡组病人末次随访时RSH与术前影像学指标的相关性。结果 双肩失衡组术前的锁骨角和CCAD值均高于双肩平衡组,上胸弯柔韧度低于双肩平衡组（P＜0.05）。Pearson相关分析显示术前锁骨角、CCAD与术后RSH呈正相关（P＜0.05,r＞0）;上胸弯柔韧度与术后RSH呈负相关（P＜0.05,r＜0）;锁骨角变化、主胸弯及上胸弯矫正率、主胸弯角度变化与RSH变化呈正相关（P＜0.05,r＞0）。Logistic回归分析未见双肩失平衡的独立危险因素。结论 术前锁骨角、CCAD及上胸弯柔韧度是Lenke 1型AIS病人术后RSH的预测因素,应避免主胸弯过度矫正导致术后肩失衡的发生。     

Lenke 1型青少年特发性脊柱侧弯矫形术中不同近端固定椎的疗效分析

目的探讨近端固定在上端椎上一椎体与上端椎治疗术前右肩高的Lenke 1型青少年特发性脊柱侧弯(adolescent idiopathic scoliosis,AIS)的近期临床疗效。方法回顾分析2010年1月—2015年12月行后路矫形手术治疗的37例Lenke 1型AIS患者临床资料,按照近端固定椎不同分为两组:A组(17例),近端固定至上端椎上一椎体;B组(20例),近端固定至上端椎。两组患者性别、年龄、Risser征、双肩影像学高度差(radiographic shoulder height,RSH)、上胸弯柔韧度、主胸弯柔韧度、胸腰弯/腰弯柔韧度等一般资料比较差异无统计学意义(P0.05)。术前、术后1个月及术后1、2年摄X线片测量主胸弯、上胸弯、胸腰弯/腰弯Cobb角,顶椎偏移距离(apical vertebral translation,AVT)、锁骨角(clavicle angle,CA)、RSH、躯干矢状位偏移、躯干冠状位偏移、胸椎后凸(thoracic kyphosis,TK)、腰椎前凸(lumbar lordosis,LL);并评价术后主胸弯矫正指标,包括术后1个月主胸弯矫正度和矫正率、AVT矫正,术后2年主胸弯矫正丢失度和丢失率。结果 A组手术时间和术中出血量均显著大于B组(P0.05)。两组患者均获随访,A组随访时间2～4年,平均2.8年;B组2～3.5年,平均2.6年。围手术期及随访期间均无神经损伤等严重并发症发生,无融合失败、内固定物松动断裂、邻近节段退变和近端交界性后凸等并发症发生。两组患者术后1个月主胸弯矫正度、主胸弯矫正率及AVT矫正,以及术后2年主胸弯矫正丢失度和主胸弯矫正丢失率比较差异均无统计学意义(P0.05)。两组组内比较:除LL在手术前后各时间点间比较差异无统计学意义(P0.05)外,其余各指标术后各时间点均较术前显著改善(P0.05)。RSH、CA、上胸弯Cobb角、胸腰弯/腰弯Cobb角术后各时间点间比较差异均有统计学意义(P0.05),且在术后随访过程中存在自发性矫正现象;而主胸弯Cobb角、 AVT、TK、躯干矢状位和冠状位偏移在术后各时间点间比较差异均无统计学意义(P0.05),在术后随访过程中无明显丢失。两组组间比较:手术前后各时间点两组各影像学指标比较差异均无统计学意义(P0.05)。结论对于术前右肩高的Lenke 1型AIS患者,近端固定椎选择上端椎即可获得满意的近期矫形效果,还可减少术中出血量和手术时间。     

近端固定椎的选择对Lenke 5型脊柱侧凸前路矫形疗效的影响

  目的 探讨近端固定椎的选择对Lenke 5型脊柱侧凸前路融合术矫形疗效的影响。方法 2002年1月至2006年12月接受前路选择性单棒矫形手术治疗 且获得2年以上随访的女性Lenke 5型青少年特发性脊柱侧凸患者36例,近端固定至上端椎21例、近端固定至上端椎下方椎体15例。两组患者平均年龄为（15.3± 1.8）岁和（15.5±1.9）岁,平均胸腰或腰主弯Cobb角为46.2°和46.7°,近端胸弯为26.3°和29.6°。平均融合节段为5.3和4.8个椎体。结果 两组平均随访 31和33个月。冠状面胸腰或腰主弯矫正率为79%和70%（P=0.062）,近端胸弯自发矫正率为46%和29%（P=0.044）。矢状面上,术前和术后两组患者腰椎前凸角、 骶骨倾斜角差异均无统计学意义。矢状面平衡维持于较小的负平衡。胸椎后凸角分别有4.0°和2.3°的轻度增加,末次随访时近端固定至上端椎组大于近端固定 至上端椎下方椎体组（P=0.029）。胸腰段交界性成角均表现为轻度后凸增加,并最终保持2°~4°后凸角。近端交界性后凸均有轻度增加,融合节段成角均呈前 凸减小甚至出现后凸趋势。结论 Lenke 5型脊柱侧凸行前路选择性融合术中,近端融合至上端椎较固定至端椎下方椎体可获得更好的冠状面主弯矫正和近端胸弯 自发性矫正,矢状面矫形效果相似。     

Lenke 1型青少年特发性脊柱侧凸患者术后双肩失平衡的影像学评估

[目的]对行全椎弓根螺钉治疗的Lenke 1型青少年特发性脊柱侧凸患者术后双肩失平衡的影像学危险因素进行分析。[方法]选择长海医院行全椎弓根螺钉治疗的Lenke 1型青少年特发性脊柱侧凸患者80例,随访至少2年。测量T1倾斜(T1 tilt)、锁骨角(clavicle angle,CA)、影像学肩高(radiographic shoulder height,RSH)等影像学参数。根据RSH分级的绝对值术后是否大于术前,将其分为术后平衡组与失平衡组,并对两组患者的影像学参数进行对比分析。[结果]术后双肩失平衡的发生率为22.5%。双肩失平衡组正性T1倾斜、正性锁骨角的比例远高于平衡组(P<0.001)。术前双肩水平的患者术后更易出现双肩失平衡(25.8%vs 83.3%,P<0.001)。25.8%的双肩平衡患者上胸弯Cobb角≥30°,而双肩失平衡患者该比例高达55.6%(P=0.018);50.0%的双肩平衡患者主胸弯与上胸弯的Cobb角差值≥25°,而双肩失平衡患者该比例仅为22.2%(P=0.036)。平衡组30.6%患者随访时主胸弯与上胸弯矫正率的差值≥1.8,失平衡组中该比例达61.1%(P=0.019)。[结论]T1倾斜、锁骨角、术前双肩平衡状态、上胸弯Cobb角、主胸弯与上胸弯的Cobb角差值及主胸弯与上胸弯矫正率的比值是较好的预测Lenke 1型青少年特发性脊柱侧凸患者术后双肩失平衡的影像学参数。     

胸弯为主的青少年特发性脊柱侧凸后路矫形术后肩部失平衡的危险因素分析

【摘要】 目的：观察以胸弯为主的青少年特发性脊柱侧凸（AIS）患者后路矫形术后肩部失平衡的发生情况,探讨其危险因素。方法：回顾性分析96例以胸弯为主的AIS患者的临床资料,Lenke分型为Lenke 1、2、3、4型,均为右胸弯且Cobb角＜80°。男15例,女81例;年龄10～18岁,平均14.5岁。均采用后路椎弓根螺钉系统固定矫形,随访22～68个月,平均42.2个月。根据术后肩部平衡情况,将患者分为肩部平衡组和肩部失平衡组,分析比较两组患者的临床资料和影像学特点。结果：肩部失平衡患者17例,发生率为17.7%。单变量分析和Logistic回归分析的结果发现与术后肩部失平衡相关的3个独立因素为：术前锁骨角（OR=1.873,P=0.018）、术前主胸弯Cobb角（OR=2.222,P=0.028）和术后主胸弯Cobb角（OR=0.483,P=0.039）。其中锁骨角和术前主胸弯Cobb角为危险因素,术前锁骨角的正值越大,主胸弯角度越大,术后肩部失平衡的危险性越大;术后主胸弯Cobb角为保护因素,术后主胸弯残余角度较大时,能相对避免肩部失平衡的发生。结论：术前锁骨角为正性倾斜、主胸弯角度较大和术后主胸弯残余角度过小可能是AIS患者主胸弯矫正后肩部失平衡的独立危险因素。     

特发性胸椎侧凸选择性融合术后远端叠加现象

【摘要】 目的：探讨主胸弯型青少年特发性脊柱侧凸（adolescent idiopathic scoliosis,AIS）单次前或后路胸弯融合术后远端叠加现象的发生率,并对其影响因素进行分析。方法：回顾性分析110例行单次前或后路主胸弯融合术的主胸弯型（Lenke 1A型）AIS患者。其中男20例,女90例;年龄10～18岁,平均14.2±2.0岁;主胸弯Cobb角40°～80°,平均为48.2°±7.8°。所有患者在术前、术后及术后随访时均摄站立位全脊柱正侧位X线片。测量侧凸Cobb角,记录患者的年龄、Risser征、Y软骨形态、手术方式、稳定椎及融合节段,统计术后远端叠加现象的发生率,分析其影响因素。结果：随访时间为12～46个月,平均21±5个月。术后Cobb角平均为16.7°±6.1°,末次随访时Cobb角平均为22.0°±8.5°。共有19例出现远端叠加现象,发生率为17.3%。与非叠加组相比,叠加组患者的Risser征较低（2.1±1.4∶3.1±1.3,P=0.002）,月经来潮后时间较短（11.2±14.2∶21.9±18.9个月,P=0.002）,代偿性腰弯柔软度较高[（97.0±9.1）%∶（90.5±15.5）%,P=0.017],远端融合椎（LIV）的位置约高出0.8个椎体。关于叠加现象发生率,低Risser征患者高于高Risser征患者,Y软骨开放组高于Y软骨闭合组,月经初潮未至和来潮小于1年组高于月经来潮大于1年组,腰弯高柔软度组高于低柔软度组,LIV高位置组[相对于稳定椎（SV）]高于低位置组。经过Logistic回归分析,LIV-SV≤-2、Y软骨开放和腰弯高柔软度是术后发生远端叠加现象的三个独立的危险因素。结论：部分主胸弯型AIS患者前或后路矫形术后可发生远端叠加现象。LIV的选择、患者的生长发育成熟度和代偿性腰弯的柔软度是影响远端叠加现象的重要因素。     

Lenke 5C型脊柱侧凸后路选择性矫形术下端融合椎影像学改变对冠状面平衡的影响

【摘要】 目的：探讨下端融合椎（lowest instrumented vertebra,LIV）相关影像学指标对Lenke 5C型特发性脊柱侧凸（adolescent idiopathic scoliosis,AIS）患者术后冠状面平衡的影响。方法：本研究包括30例行后路选择性融合的Lenke 5C型AIS患者,所有患者于术前、术后即刻及末次随访时拍摄站立前后位像及术前仰卧位拍摄左右Bending像。对术前、术后和末次随访时的冠状面平衡与LIV相关影像学指标（LIV偏移、LIV旋转、LIV倾斜度、LIV尾侧椎间盘开角）进行分析。结果：所有患者平均随访33个月（24~50个月）,其中LIV为L3者20例,L4者10例。30例Lenke 5C型AIS患者术前冠状面胸腰弯/腰弯Cobb角平均为49.8°±5.1°,术前冠状面胸弯Cobb角平均为25.6°±7.1°。相关性检验发现以下3个指标与术后即刻冠状面平衡（coronal trunk balance,CTB）有显著相关性：（1）术前CTB（r=0.69,r2=0.48,P<0.01）;（2）术前LIV倾斜度（r=0.63,r2=0.40,P<0.01）;（3）术后即刻LIV倾斜度（r=0.60,r2=0.36,P<0.01）。在末次随访时,不管是术前还是术后的LIV相关影像学指标均与末次随访时CTB无显著相关（P>0.05）。结论：对行后路选择性融合术的Lenke 5C型AIS患者而言,术前冠状面平衡与否及术前LIV倾斜度大小对预测术后即刻冠状面平衡有重要的作用。术前LIV倾斜大于25°的患者容易发生术后即刻冠状面失平衡。然而,LIV倾斜度对Lenke 5C型AIS患者术后冠状面平衡无显著影响。     

Lenke 1型特发性脊柱侧凸患者术后顶椎区残留旋转的危险因素分析

[目的]探讨影响Lenke 1型青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)患者术后顶椎区残留旋转的危险因素。[方法]选取2010年1月~2014年10月在本院行后路融合术的26例Lenke 1型AIS患者,其中男5例,女21例。按照术后顶椎区残留旋转的严重程度将AIS患者分为两组:A组(顶椎区椎体残留旋转比率70%)15例,B组(顶椎区椎体残留旋转比率70%)11例。分析两组患者的性别、年龄、Risser征、术前主胸弯Cobb角、主胸弯柔韧度、术前顶椎区椎体旋转角度、术前及术后的顶椎偏移距离和躯干偏移距离、胸椎矢状位Cobb角改善率、主胸弯矫正率以及顶椎区置钉密度。单因素分析对比两组患者在上述指标的差异性,并进行Logistic多因素回归分析。[结果]两组间患者的主胸弯柔韧度、术前顶椎偏移距离、主胸弯矫正率、顶椎区置钉密度差异具有统计学意义(P0.05);多因素回归分析显示导致术后顶椎区残留旋转的独立危险因素包括主胸弯矫正率、顶椎区置钉密度(P0.05)。[结论]Lenke 1型AIS患者主胸弯矫正率、顶椎区置钉密度是影响术后顶椎区残留旋转的危险因素。     

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.