改良椎旁肌间隙入路与传统后正中入路治疗胸腰椎骨折的疗效比较

目的 比较改良椎旁肌间隙入路与传统后正中入路治疗胸腰椎骨折合并脊髓损伤病人的效果。方法 纳入我科2014年1月至2016年1月收治的胸腰椎骨折合并脊髓损伤的病人40例,按随机数字表法分为传统组（采用传统后正中入路手术）和改良组（采用改良的椎旁肌间隙入路手术）,每组20例。传统组：男13例,女7例,平均年龄为（37.3±8.5）岁;改良组：男14例,女6例,平均年龄为（37.5±6.2）岁。两组病人一般资料比较,差异均无统计学意义（均P＞0.05）。记录两组病人手术时间、术中出血量、术后引流量。记录并分析术前、术后1周、术后6个月腰部疼痛视觉模拟量表（visual analogue scale, VAS）评分,术前、术后6个月的Frankel脊髓损伤分级,术前、术后即刻、术后6个月的伤椎Cobb角。结果 病人均获得7~20个月的随访,平均随访时间为14个月。两组病人在手术时间、伤椎Cobb角矫正、Frankel分级改善情况方面比较,差异均无统计学意义（均P＞0.05）。改良组的术中出血量为（150.0±35.8） ml,术后引流量为（82.5±14.5） ml,末次腰痛VAS评分为（1.6±0.5）分,均优于传统组的（269.5±39.9） ml、（151.3±19.2） ml、（2.5±0.5）分,差异均有统计学意义（均P＜0.05）。结论 椎旁肌间隙入路结合棘突旁有限显露治疗有脊髓损伤的胸腰椎骨折,在脊柱畸形矫正及神经功能恢复方面效果满意,且能减轻病人的手术创伤,术后病人腰背痛改善更明显。     

导航辅助下颈椎前路椎弓根置钉技术的临床应用

目的 探讨“O”型臂导航辅助下颈椎前路椎弓根螺钉（anterior transpedicular screw,ATPS）技术的置钉准确性和手术效果。方法 前瞻性收集2016年1月至2019年12月于我院就诊的28例颈椎疾患病人,均在“O”型臂及计算机导航辅助下行颈椎前路病灶切除、植骨及ATPS内固定手术。术后评价ATPS置入的准确率;术前和术后1周、6个月采用疼痛视觉模拟量表（visual analogue scale,VAS）评价病人颈肩疼痛程度;采用日本骨科协会（Japanese Orthopaedic Association,JOA）评估治疗分数评价治疗效果;比较病人术前及末次随访时的Frankel神经功能分级。结果 28例病人共置入螺钉112枚,其中椎弓根螺钉98枚（0级91枚,1级7枚）,椎体螺钉14枚。本组病人术后1周和术后6个月的颈肩痛VAS评分分别为（2.14±0.71）分、（1.18±0.48）分,均显著低于术前的（7.29±1.27）分;术后1周和术后6个月的颈肩JOA评分分别为（13.93±0.98）分、（15.36±0.87）分,均显著高于术前的（9.54±1.32）分;与术前比较,差异均有统计学意义（P均＜0.05）。应用颈椎JOA评分,治疗后的评分改善率为77.0%±2.3%。术前Frankel神经功能分级D+E级的人数占比为39.3%（11/28）,术后提高至67.9%（19/28）,差异有统计学意义（χ²=4.595,P=0.032）。结论 导航辅助下ATPS技术是颈椎传统手术技术的一个有益补充,对颈椎椎体破坏严重、颈椎前路内固定翻修、骨质疏松严重等病例有着重要意义,置钉准确率高,手术效果好。     

后路全脊椎截骨矫形联合钛网支撑治疗脊柱结核角状后凸畸形的临床疗效观察

目的 探讨后路全脊椎截骨矫形联合钛网支撑治疗脊柱结核角状后凸畸形的临床疗效及安全性。方法 回顾性分析2012年1月至2015年1月于我科采用后路全脊椎截骨矫形联合钛网支撑治疗的19例胸腰椎脊柱结核角状后凸畸形病人的临床资料,观察术前、术后及末次随访时病人的脊柱后凸Cobb角、矢状面平衡、Frankel分级、疼痛视觉模拟量表（visual analogue score, VAS）评分及并发症。结果 所有病人手术均顺利完成,术后随访24~36个月,平均32个月。术后Cobb角矫正至11.4°±4.4°（5°~20°）;末次随访时为11.8°±4.7°（6°~20°）,均较术前显著改善,差异有统计学意义（P均＜0.05）,但二者间比较,差异无统计学意义（P＞0.05）。术后VAS评分为（2.3±1.1）分（1~4分）,末次随访时VAS评分为（2.5±1.3）分（1~5分）,均较术前显著改善,差异有统计学意义（P均＜0.05）,但二者间比较,差异无统计学意义（P＞0.05）。术后及末次随访的侧位片上C₇铅垂线距S1后上缘的距离均为（9.0±4.2） mm,与术前相比有明显改善（P＜0.05）。术前Frankel B级2例,1例恢复到C级、1例恢复到D级;术前Frankel C级5例,4例恢复到E级、1例恢复到D级;术前Frankel D级12例,9例恢复到E级、3例仍为D级。后凸畸形及局部后背疼痛已明显好转,无其他并发症及病情恶化情况。所有病人在随访期间未见内固定及钛网松动和脱出现象。结论 后路全脊柱截骨术联合钛网支撑治疗脊柱结核角状后凸畸形具有良好的临床效果,但因畸形严重、手术难度高仍伴有神经并发症的风险。     

不同部位胆管癌患者术后生存的影响因素分析

背景与目的 目前,胆管癌（CCA）的首选治疗仍为外科手术,但术后复发率较高,患者生存率低。对CCA患者术后生存影响因素的分析将有助于优化手术策略,从而一定程度上改善患者预后。因此,本研究探讨不同部位CCA患者术后生存的影响因素,为临床提供参考。方法 回顾性分析2011年1月—2020年3月133例行手术治疗的CCA患者临床病理资料,其中,肝内胆管癌（iCCA）58例,肝门胆管癌（hCCA）30例,远端胆管癌（dCCA）45例,分析临床病理特征与患者生存的关系与预后影响因素。结果 iCCA患者术后1、2、3、5年的生存率分别为41.38%、22.41%、8.62%、3.45%,单因素分析显示,iCCA患者的术后生存与合并胆道结石、术前血清白蛋白（ALB）水平、凝血酶时间、CEA、CA125、CA19-9、Child-Pugh分级、肿块最大直径、是否R₀切除、淋巴结转移情况、肿瘤分化程度有关（均P<0.05）;多因素分析显示,术前ALB水平、凝血酶时间、CA19-9、Child-Pugh分级、肿块最大直径及是否R₀切除是iCCA患者术后生存的独立影响因素（均P<0.05）。hCCA患者术后1、2、3、5年的生存率分别为43.33%、20.0%、6.67%、3.33%,单因素分析显示,hCCA患者的术后生存与术前CEA水平、是否R₀切除、淋巴结转移情况、肿瘤分化程度、肿块最大直径、是否侵犯门静脉有关（均P<0.05）;多因素分析显示,是否行R₀切除、淋巴结转移情况、肿瘤分化程度、是否侵犯门静脉及肿块最大直径是hCCA患者术后生存的独立影响因素（均P<0.05）。dCCA患者术后1、2、3、5年的生存率分别为62.22%、31.11%、17.78%、14.29%,单因素分析显示,dCCA患者的术后生存与淋巴结转移情况、肿瘤分化程度有关（均P<0.05）。多因素分析显示,淋巴结转移情况、肿瘤分化程度及是否R₀切除是dCCA患者术后生存的独立影响因素（均P<0.05）。dCCA患者术后生存时间优于iCCA和hCCA患者,但差异无统计学意义（均P>0.05）。结论 不同部位CCA有大致共同的预后影响因素,通过评估这些因素有助于预测CCA预后,完善对CCA患者的分层标准,优化术前和术后治疗方案,延长患者生存时间。     

加速康复外科理念在青少年特发性脊柱侧凸围术期的应用

目的 探讨加速康复外科（ERAS）在手术治疗青少年特发性脊柱侧凸（AIS）病人中的应用效果。方法 收集2016年1月至2020年12月在我院接受AIS手术治疗的138例病人的病例资料。将2016年1月至2018年6月给予常规围术期管理措施的69例病人纳入对照组,2018年7月至2020年12月进行ERAS理念管理的69例病人纳入观察组,进行对照研究。记录两组病人手术时间、出血量、术后输血人数等指标,以及手术前后疼痛程度、心理状况、生活质量和炎症因子变化。结果 观察组手术时间、出血量、术后输血人数、并发症发生率和住院时间均低于对照组（P＜0.05）,观察组护理满意度高于对照组（92.75% vs. 73.91%,P=0.003）。观察组术后24 h、3 d的疼痛视觉模拟量表（VAS）评分低于对照组（P＜0.05）;而术后7 d的VAS评分与对照组比较,差异无统计学意义（P＞0.05）。两组术后7 d的焦虑自评量表、抑郁自评量表、简体中文版脊柱侧凸研究学会22项问卷表评分,以及血清白细胞介素-6、肿瘤坏死因子α水平与术前比较,差异均有统计学意义（P均＜0.05）;两组间比较,观察组明显低于对照组,差异均有统计学意义（P均＜0.05）。结论 ERAS能减少AIS病人围术期失血和不良反应,有利于疼痛的早期控制,降低炎症因子,减轻不良情绪,提高生活质量,进而促进病人早期康复。     

脊柱转移瘤患者术后生存期影响因素的多元分析

目的 探讨脊柱转移瘤患者术后生存期的影响因素,为临床手术决策提供参考。方法 回顾分析2000年1月~2013年1月在本院接受手术治疗且有完整随访资料的98例脊柱转移瘤患者的临床资料,应用Cox比例风险模型分析脊柱转移瘤患者术后生存期的影响因素。结果 本组患者术后中位生存期为6.0个月[95%可信区间(credibility interval,CI):4.9~7.1个月]。甲状腺癌术后生存期最长,为43.0个月(95% CI:0~92.2个月);结直肠癌最短,为5.0个月(95% CI:1.6~8.4个月)。Cox比例风险模型分析显示,术前Tomita评分≤5分[比值比(odd ratio,OR)=1.439; 95% CI:1.003~2.065; P<0.05]、术后运动功能良好(Frankel分级D、E级; OR=5.397; 95% CI:3.560~8.181; P<0.01)是患者术后生存期独立预测因素;根据术前Tomita评分和术后运动功能状态绘制生存曲线,结果显示术前Tomita评分≤5分或术后运动功能良好的患者生存期显著延长,差异具有统计学意义(P<0.05)。结论 脊柱转移瘤患者制定手术方案时应综合考虑术前Tomita评分和Frankel分级,术前Tomita评分≤5分者或术后Frankel分级D、E级者手术治疗能够获得较好预后;而且术后运动功能较术前身体状态预测效果更好。     

椎板间入路经皮椎间孔镜下髓核摘除术治疗L4/5腰椎间盘突出症的短期疗效分析

目的 探讨椎板间入路经皮椎间孔镜下髓核摘除术（PEID）治疗L_4/5腰椎间盘突出症的临床疗效。方法 回顾性分析2022年1月至2023年1月武汉市第四医院脊柱外科收治住院的60例L_4/5腰椎间盘突出症病人的临床资料。依照病人手术方式的不同,将病人分为试验组和对照组,每组30例。试验组采用PEID治疗,对照组行开窗下髓核摘除术（FD）。比较两组病人切口长度、手术时间、术中出血量、术后住院时间,记录术前及术后1天、1个月、1年疼痛视觉模拟量表（VAS）评分、Oswestry功能障碍指数（ODI）,记录术前及术后1个月随访日常生活能力量表（ADL）评分。结果 试验组切口长度、手术时间短于对照组,术中出血量、术后住院天数少于对照组,差异有统计学意义（P＜0.05）。两组术后VAS评分、ODI均较术前明显改善,差异有统计学意义（P＜0.05）,试验组术后1天、1个月的VAS评分、ODI优于对照组,差异有统计学意义（P＜0.05）。两组术后1年VAS评分、ODI比较,差异无统计学意义（P＞0.05）。两组术后ADL评分均优于术前,试验组优于对照组,差异有统计学意义（P＜0.05）。结论 PEID治疗腰L_4/5椎间盘突出症与FD比较,创伤小、手术中出血量少、对腰椎组织结构破坏小、术后住院时间短、短期内症状缓解迅速,手术疗效可靠。     

脊柱内窥镜下精准减压治疗有根性症状的高龄脊柱侧凸的临床疗效

目的 评价脊柱内窥镜下精准减压治疗有根性症状的高龄脊柱侧凸病人的临床效果。方法 回顾性分析2018年1月至2018年12月在我院行脊柱内窥镜下精准减压手术治疗的16例有根性症状的高龄脊柱侧凸病人的临床资料,其中男9例,女7例;年龄为（77.13±6.04）岁（71~96岁）;9例行侧方椎间孔入路减压神经根松解术,7例行椎板间单侧入路双侧减压神经根松解术。收集病人的手术时间、术后并发症发生情况,收集并比较病人术前、术后6个月随访时的腰痛及下肢痛疼痛视觉模拟量表（visual analogue scale, VAS）评分和Oswestry功能障碍指数（Oswestry disability index, ODI）。结果 16例病人的手术时间为（138.18±27.16） min,随访时间为（8.31±2.02）个月。术前腰痛、下肢放射痛VAS评分和ODI分别为（6.02±0.77）分、（80.50±5.03）%,术后6个月随访时分别为（2.19±0.98）分、（41.25±7.89）%,手术前后数值比较,差异均有统计学意义（t=12.417,P＜0.001;t=23.453,P＜0.001）。结论 对于有根性症状的高龄脊柱侧凸病人,行脊柱内窥镜下精准减压治疗具有手术效果确切、耐受性好、并发症少等优点,可作为有根性症状的高龄脊柱侧凸病人序贯治疗中一种可选择的方案。     

短节段椎弓根钉内固定联合高压氧治疗急性脊柱损伤对脊柱形态和功能的影响

目的：探讨短节段椎弓根钉内固定联合高压氧治疗急性脊柱骨折的效果及对脊髓功能恢复的影响。方法：将2017年2月至2020年3月收治的96例急性脊柱骨折患者分为联合组与对照组,每组48例。两组患者均采用短节段椎弓根钉内固定治疗,其中联合组术后给予高压氧治疗。记录两组患者手术时间、手术出血量、切口长度等一般手术情况,观察手术前后脊柱形态功能,美国脊柱损伤协会（Ameraican Spinal Injury Assiciation,ASIA）神经功能分级,血清炎症因子,日常生活活动能力的差异。结果：两组患者的手术时间、手术出血量、切口长度比较差异无统计学意义（P>0.05）。术前及术后1周、6个月患者的伤椎前缘高度比和Cobb角组间比较差异无统计学意义（P>0.05）;两组术后1、6个月的伤椎前缘高度比较术前明显改善（P<0.05）,Cobb角较术前明显减小（P<0.05）。术后1 d两组患者的血清白细胞介素-6（interleukin-6,IL-6）,白细胞介素-8（interleukin-8,IL-8）和肿瘤坏死因子（tumor necrosis factor-α,TNF-α）水平比较差异无统计学意义（P>0.05）;术后1周联合组的血清IL-6、IL-8、TNF-α水平均低于对照组（P<0.05）。术后6个月联合组的ASIA神经功能分级C级2例、D级23例、E级22例,对照组C级7例、D级26例、E级13例,两组比较差异有统计学意义（P<0.05）。术后1、3个月联合组日常生活活动能力的Barthel评分均高于对照组（P<0.05）;术后6个月两组患者的Barthel评分比较差异无统计学意义（P>0.05）。结论 短节段椎弓根钉内固定联合高压氧治疗急性脊柱骨折有利于患者术后脊髓神经功能恢复,对于早期改善患者日常生活活动能力有一定的作用。     

颈椎双侧关节突关节脱位合并呼吸障碍病人的手术治疗

目的 分析颈椎双侧关节突关节脱位（bilateral cervical facet dislocations, BCFDs）合并呼吸障碍病人行手术治疗的临床疗效。方法 回顾性分析2001年1月至2014年1月华中科技大学同济医学院附属协和医院骨科采用围手术期多学科合作的呼吸道管理并行手术治疗的56例BCFDs合并呼吸障碍病人的临床资料,其中全瘫16例,不全瘫40例。行后路复位加植骨融合内固定手术42例,行前后联合入路椎体复位植骨融合内固定术12例,行颈前路复位植骨融合内固定术2例。结果 本组病人随访时间为（68.4±18.6）个月（12~120个月）;病人呼吸功能最终均获得明显改善,15例病人因呼吸障碍术后行气管切开（8例全瘫,7例不全瘫）;植骨融合时间为（7.5±4.5）个月（3~12个月）,融合率为100%。术后2周和末次随访时,40例不全瘫病人的美国脊柱损伤协会（American Spinal Injury Association, ASIA）运动功能评分由术前的（44.36±27.46）分分别改善为（56.04±30.48）分和（61.36±25.12）分,差异均有统计学意义（t=1.801,P＜0.05;t=2.889,P＜0.05）;ASIA感觉评分由术前的（56.24±33.86）分分别改善为（67.64±28.36）分和（68.56±12.72）,差异均有统计学意义（t=1.632,P＜0.05;t=2.154,P＜0.05）;神经功能较术前均获得不同程度的改善。16例全瘫病人术后均无明显神经功能改善,ASIA评分手术前后差异无统计学意义（P＞0.05）。本组病人发生肺炎14例,压力性损伤3例,尿道感染9例,并发症发生率为46.43%（26/56）。结论 对于BCFDs合并呼吸障碍病人选择合适的手术治疗方案,同时采用围手术期多学科合作的呼吸道管理,可提高BCFDs合并呼吸障碍病人的临床救治水平。     

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.     

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.     

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.     

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.