胃大部切除术后残胃胃瘫综合征临床分析

目的探讨胃大部切除术后残胃胃瘫综合征(PGS)的病因、诊断及治疗。方法对20例胃大部切除术后发生胃瘫综合征的发病因素、临床表现、诊断方法及治疗手段进行分析。结果术前流出道梗阻和胃肠吻合方式是术后PGS的高危因素。胃镜、X线口服造影对PGS的诊断有价值。经非手术治疗,术后PGS在术后6周内一般可以恢复。结论胃大部切除术后残胃胃瘫综合征在术前流出道梗阻、胃肠毕Ⅱ式吻合的病人中发病率较高,患者经过6周的非手术治疗后,多数可以缓解恢复,从而避免了二次手术的痛苦。     

根治性胃大部切除术后胃瘫综合征的回顾性研究

目的探讨根治性远端胃大部切除术后胃瘫综合征(PGS)发生的病因、诊断方法、治疗手段和疗效。方法根治性远端胃大部切除术患者501例,术后出现PGS20例,分析其临床表现、发生时间、恢复时间和诱发因素。结果术前流出道梗阻和胃肠吻合方式是术后PGS的高危因素。胃镜、X线口服造影和核素标记胃排空测定对PGS的诊断有价值。经非手术治疗,术后PGS在术后6周内一般可以恢复。红霉素对PGS的疗效有明确的个体差异。结论胃镜检查时对残胃予以适度刺激有助于PGS的治疗,应尽量避免再次手术。     

胃大部切除术后胃瘫综合征的相关因素分析

目的　探讨胃大部切除术后胃瘫综合征 (PGS)的诱发因素 ,从而为PGS的预防及治疗提供依据。方法　回顾性分析 167例胃大部切除术后 13例发生PGS患者的临床资料 ,并对多种因素进行Logistic回归分析 ,找出PGS的关联因素。 结果　病人自控性静脉镇痛、硬膜外麻醉联合全身麻醉、术前低钾血症与PGS的发生有显著相关性。结论　PGS是多因素诱发的     

胃大部切除术后并发胃瘫综合征28例的心理因素分析

目的探讨胃大部切除术后并发胃瘫综合征(PGS)的心理因素。方法回顾性分析379例行胃大部分切除术后28例并发PGS患者的临床资料。并对其可能的心理诱发因素进行分析。结果患者的年龄(P<0.01)、文化程度(P<0.05)及焦虑情绪状态(P<0.01)与PGS的发生有关,而性别与PGS发生无关(P>0.05)。结论术前心理治疗对胃大部切除术后并发PGS很重要。     

胃癌根治性胃大部切除术后胃瘫的危险因素分析

目的：探讨根治性胃大部切除术后发生胃瘫的危险因素及防治措施。 方法：回顾性分析2006年6月—2013年6月568例行胃癌根治性胃大部切除术患者的临床资料,其中31例发生术后胃瘫综合征（PGS）;以是否发生胃瘫为因变量,以选取的17项相关指标为自变量,进行非条件Logistic回归分析。 结果：多因素Logistic回归分析结果显示：术前合并幽门梗阻、精神紧张、术中Billroth II式吻合、术中淋巴结清扫范围（D3）、术后使用镇痛泵、术后血糖水平、术后肠内营养开始时间、术后腹腔感染、术后吻合口瘘是PGS发生的危险因素(OR>1,P<0.05),围手术期血红蛋白水平和总蛋白水平是PGS发生的保护因素（OR<1,P<0.05）。 结论：胃癌根治性胃大部切除术PGS的发生与多种因素有关,积极做好相关危险因素的处理工作,对防治PGS的发生意义重大。

     

胃癌术后胃瘫综合征的危险因素分析及其对预后的影响

目的 探讨胃癌根治性胃大部切除术后胃瘫综合征(PGS)的临床危险因素及PGS发生对患者预后的影响.方法 回顾性总结浙江省湖州市中心医院2004年1月至2010年5月间收治的422例行根治性胃大部切除术胃癌患者的临床资料,分析术后PGS的危险因素,并比较出现PGS与未出现PGS患者的术后无复发生存情况.结果 422例患者术后PGS发生率为9.5％(42/442).单因素分析显示,年龄大于65岁、术前合并焦虑症和低蛋白血症、术前存在幽门梗阻、术后血糖升高、毕Ⅱ式吻合、手术时间超过4h、术后使用自控型镇痛泵以及术后日补液量超过3500 ml者PGS发生率较高(均P＜0.05),这9项因素可作为PGS发生的潜在临床危险因素.相关分析显示,合并临床危险因素的个数与PGS发生率呈线性正相关(r=0.967,P＜0.05).术后215例(50.9％)患者获得了3～60个月的随访,其中30例发生PGS患者和185例未发生PGS患者的术后平均无复发生存时间分别为26.1和33.4个月,差异有统计学意义(P=0.029).结论 具有临床危险因素的胃癌患者行胃大部切除术后PGS发生概率增加,且PGS的发生会影响患者预后.     

胃切除术后残胃胃瘫综合征的临床总结

目的探讨胃大部切除术后残胃胃瘫综合征(PGS)的发生原因、机制、诊断及治疗。方法对1972年1月至2002年6月4955例胃大部切除术后出现PGS的46例患者的临床资料进行回顾性总结。结果本组PGS发生率0.92%,均发生于术后5～8d。44例非手术治愈,15d内治愈12例,16d10例,18d15例,21d2例,22d2例,25d2例,27d1例。2例于胃大部切除术后14d和15d再次手术加行胃肠或肠肠吻合仍未缓解,继续内科治疗,分别于术后20d和30d治愈。结论PGS的发生是由多种因素诱发。诊断时必须排除机械性、器质性病变。上消化道造影及胃镜检查是诊断PGS的可靠方法。采用非手术疗法均可治愈,手术治疗应列为禁忌证。     

胃大部切除术后并发胃瘫综合征相关因素的探讨

目的探讨引起胃大部分除术后胃瘫综合征(PGS)相关因素。方法回顾分析收治的PGS患者共48例临床资料,按照1∶2比例选择同期胃大部切除术后无PGS患者作为对照组,对可能影响PGS的因素资料进行单因素分析与Logistic回归分析。结果单因素分析共筛选出11个因素与PGS有关;以PGS为应变量,其他统计量作为自变量赋值后进行非条件多因素分析,结果显示,合并基础疾病,BroⅡ(B-Ⅱ)式胃肠重建方式,存在精神因素,手术时间长与PGS有密切的关系。结论PGS与多种因素有关,加强围手术期基础疾病处理、尽量采取B-I式胃肠吻合、尽量缩短手术时间、给予心理支持可一定程度预防和减少PGS发生。     

胃大部切除术后胃瘫综合征的治疗

回顾性分析2000—2004年421例因胃癌行根治性胃大部切除术后发生胃瘫综合征（PGS）17例的临床资料。结果示PGS患病率为4.04%。术后补液量较多（P﹤0.001）及白蛋白（清蛋白）降低程度较严重（P﹤0.001）是PGS的高危因素。经限制性补液及充分的蛋白补充、适当的营养支持，所有病例均于5周内恢复。提示限制性补液及充分、合理的营养支持是治疗术后PGS的重要手段。     

胃大部切除术后胃瘫综合征相关因素的Logistic回归分析

目的 探讨引起术后胃瘫综合征(PGS)相关因素,为制定针对性预防措施提供客观依据.方法 2002年1月至2009年6月对我院所有胃大部切除术患者280例,以PGS者作为观察组,非PGS者作为对照组,对可能影响PGS因素进行单因素分析与Logistic回归分析.结果 280例患者共发生PGS20例(7.14%).单因素分析与PGS有关因素分别为年龄大、围手术期高血糖、贫血、低蛋白血症、术前有消化道梗阻、术前非肠内营养、毕Ⅱ式、手术时间长、广泛淋巴结清扫、术中出血量多、应用自控镇痛泵、腹腔感染、术后肠内营养时间晚(P<0.05),而PGS的发生与性别无关(P>0.05).非条件多因素分析,选出4个主要的危险因素:围手术期高血糖(OR=3.123).低总蛋白血症(OR=3.098),毕Ⅱ式(OR=2.6543),手术时间长(OR=2.874).结论 PGS发生与多种因素有关,应通过围手术期控制血糖,提高血清白蛋白,条件允许的情况下尽量采取毕I式胃肠吻合,尽量缩短手术时间来预防和减少PGS发生.     

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.