脊髓损伤患者62例前瞻性临床研究

目的:通过前瞻性研究设计,对影响脊髓损伤患者功能恢复的各种影响因素进行初步分析.方法:设计前瞻性队列研究方案,在不干涉临床治疗方案前提下,采集2006年12月至2007年12月收治的脊髓损伤患者资料,纳入标准定为:急性脊髓损伤(受伤时间在1周以内),男女不限,年龄限定在18～65岁,根据临床查体结合MRI或CT检查证实为美国脊髓损伤协会(ASIA)分级标准(2000年修订)的A级(完全性脊髓损伤,损伤平面下不存在任何运动和感觉功能)或者B级(不完全性脊髓损伤,损伤平面下不存在运动功能,但存在感觉功能).所有入选病例均获随访,并分别在受伤入院当时及第1次评估后1、3、6个月采用ASIA分级标准、功能独立性评测(FIM)评价脊髓损伤及恢复情况,分析影响脊髓损伤患者功能恢复的因素.结果:共入选62例患者,男性60例,女性2例;年龄18～41岁,平均24岁;A级损伤29例,B级损伤33例.A级损伤中,手术减压患者(手术组)和非手术减压患者(非手术组)的感觉、运动ASIA评分及FIM评分比值在术后各时间点上的差异无统计学意义(P>0.05),B级损伤中,手术组和非手术组在手术前后感觉、运动ASIA评分、FIM评分的比值在各个时间点上差异均具有统计学意义(P<0.05).在手术组患者中,减压手术在伤后8 h以内(≤8 h)进行者,术前和术后感觉、运动ASIA评分、FIM评分比值与在伤后8 h以外(>8 h)进行者相比差异具有统计学意义(P<0.05).结论:对于A级损伤,手术减压时间点的选择对损伤的脊髓功能恢复影响差别不大,考虑到护理的方便和维持脊柱稳定性的要求,可以选择减压内固定手术;对于B级损伤,应该尽早进行减压手术以最大程度地恢复损伤脊髓的功能.     

颈脊髓损伤后外科干预时机的选择

目的探讨颈脊髓损伤后外科干预的时机。方法将53例颈脊髓损伤,按伤后手术时间分24h内手术组(A组)、25～72h组(B组)、3～7d组(C组)、8～14d组(D组);按脊髓损伤严重程度分脊髓严重损伤组、脊髓损伤组,通过ASIA评分评定神经功能。结果各组术后ASIA评分均增高,A组最高,B组在术后1、3个月ASIA评分高于C组,但末次随访两组无差异。脊髓严重损伤组ASIA评分均明显低于脊髓损伤组。结论颈脊髓损伤患者入院后,应充分评估病情,对颈髓不完全损伤者宜3d内手术,24h内手术更好;如为脊髓严重损伤者,宜在7d左右手术。     

单唾液酸神经节苷脂(GM-1)对脊柱脊髓损伤疗效回顾性分析

目的通过对比对急性脊髓损伤患者使用和不使用GM-1的疗效,研究GM-1对急性脊髓损伤的疗效。方法回顾性分析本院2003年以来92例急性脊髓损伤病例,其中分为使用及不使用GM-1,通过对比浅感觉,运动及小便功能诸方面来研究GM-1对急性脊髓损伤的疗效。结果浅感觉,运动及小便功能等方面功能恢复程度的对比均有P0.05,差异有统计学意义。结论GM-1对急性脊髓损伤的功能恢复有促进作用。     

道路交通伤致急性脊髓损伤的临床研究

目的 探讨道路交通伤致急性脊髓损伤的治疗,以期提高救治效果.方法 2005年6月至2008年10月收治64例因交通伤致急性脊髓损伤患者,男57例,女7例;年龄4～65岁,平均43.7岁;受伤至入院时间2.5 h～7 d,平均39.7 h.根据8 h内入院和8 h后入院分为A、B两组.根据美国脊髓损伤协会(ASIA)分级:A级14例,B级23例,C级17例,D级10例.所有患行均接受激素治疗,58例患者采用手术治疗,6例采用非手术治疗.比较A、B两组患行的ASIA分级改善率.结果 64例患者无一例死亡,获6～24个月(平均17.3个月)随访.A组26例患者中,治疗后有22例肢体功能得到不同程度的恢复,根据ASIA分级,平均改善等级为1.5±0.9.B组38例患者中,治疗后有12例肢体功能得到不同程度的恢复,根据ASIA分级:平均改善等级为0.9±0.6,A组改善率高于B组,差异有统计学意义(P＜0.05).总体ASIA改善等级为1.1.结论 交通伤导致的脊髓损伤程度重,治疗效果不理想,转送救治时间长是影响治疗效果的重要原因,有必要改进急救器械和转送方式.     

神经节苷脂对大鼠脊髓损伤后微管相关蛋白-2表达的影响及意义

[目的]通过观察单唾液酸四己糖神经节苷脂(monosialotetrahexosyl gangliosides,GM-1)对于大鼠脊髓损伤(spinal cord injury,SCI)后微管相关蛋白-2(microtubule-associated protein 2,MAP-2)表达及运动功能恢复是否能够产生影响来探讨CM-1对大鼠脊髓损伤后神经细胞的保护作用及其机制.[方法]Wistar雌性大鼠66只(体重260～300 g),随机取6只作为正常对照组,余60只采用改良Allen's打击法于T9-11节段椎管制作大鼠急性SCI模型,并随机分为GM-1组(A组)和生理盐水对照组(B组)两组,每组各30只.分别于术后1、7、14、28、56 d采用Rivilin斜扳试验、改良Tarlov评分评价大鼠后肢运动功能恢复程度后处死取材,每组各时相点6只.以组织学和免疫荧光染色观察大鼠脊髓损伤的修复情况.[结果]术后7d起,Rivilin斜扳试验和Tarlov评分在A、B组间比较有显著性差异(P<0.0105),即A组功能恢复明显优于B组.术后56 d:HE染色示A组大鼠脊髓损伤处无明显空洞和瘢痕组织,有各种形态细胞形成,部分细胞有明显分化特征;B组脊髓断端被瘢痕组织填塞,可见大量炎性细胞和成纤维细胞浸润,并有较大脊髓空洞形成.免疫荧光染色发现,A组各时相点MAP-2表达呈阳性细胞数较B组高,差异有统计学意义(P <0.0105).[结论]SCI后,动物神经功能的恢复与MAP-2的表达呈一定的相关性;GM-1可通过增强脊髓损伤后MAP-2的表达来保护大鼠受损后脊髓的神经元.     

单唾液酸四己糖神经节苷脂乳酸/羟基乙酸共聚物微球对大鼠脊髓损伤后神经功能的影响

目的：探讨经蛛网膜下腔注入单唾液酸四己糖神经节苷脂（monosialotetrahexosylgangliosides,GM-1）乳酸/羟基乙酸共聚物（poly lactic-co-glycolic acid,PLGA）微球对大鼠脊髓损伤（spinal cord injury,SCI）后神经功能的影响。方法：94只成年SD大鼠随机分为4组：微球治疗组（A组）、普通GM-1制剂治疗组（B组）和损伤对照组（C组）各30只,正常对照组（D组）4只。A、B、C组大鼠采用Nystrom法制备T10脊髓压迫损伤模型,伤后即刻开始给药,A组大鼠经蛛网膜下腔一次性注入20μlGM-1PLGA微球悬液（含GM-150μg）,B组大鼠伤后至处死前每24h一次经尾静脉注入GM-1普通制剂30mg/kg,C组大鼠经蛛网膜下腔一次性注入20μl生理盐水,D组大鼠不手术、不给药。A、B、C组大鼠于术后1、3、7、14d进行脊髓运动功能（BBB）评分,术后1、7、14d检测运动诱发电位,术后8h、1d、3d、7d、14d检测大鼠脑脊液中GM-1含量;术后8h、1d、3d、7d、14d处死动物（n=6）,取T10节段脊髓并切片,用HE染色观察脊髓组织学变化,用免疫组化染色方法检测SCI后14d时损伤脊髓组织中NF200表达情况。D组上述各指标的检测不分时间点,只进行1次。结果：各时间点A、B、C组大鼠BBB评分均显著低于D组（P〈0.01）,术后3d、7d、14d时A、B组显著高于C组（P〈0.01）,各时间点A组与B组无显著性差异（P〉0.05）。各时间点A、B、C组大鼠运动诱发电位N1波潜伏期较D组明显延长、波幅明显降低（均P〈0.01）,但术后1d和7d时A、B组N1波潜伏期明显较C组短（P〈0.01）,术后7d和14d时A、B组N1波波幅明显较C组高（P〈0.01）,各时间点A组与B组比较无显著性差异（P〉0.05）。各时间点A、B组大鼠脑脊液内GM-1含量均显著高于C组和D组（均P〈0.01）,术后8h、1d、3d时A组明显高于B组（P〈0.01或0.05）,术后7、14d时A组与B组比较无显著性差异,C组和D组比较无显著性差异（P〉0.05）。HE染色,D组正常,术后各时间点A、B组大鼠脊髓损伤区组织形态优于C组,而A组与B组大鼠脊髓损伤区组织形态基本相似。A组、B组和C组大鼠SCI后14d损伤脊髓组织中NF200阳性细胞平均光密度（AOD）值均显著低于D组（P〈0.01）,但A、B组均显著高于C组（P〈0.01）,A组和B组间无显著性差异。结论：经蛛网膜下腔注入GM-1PLGA微球对大鼠脊髓损伤后神经功能具有良好的保护作用,与外周应用普通GM-1制剂比较,能减少药物用量,快速提高局部药物浓度,并较长时间维持稳定,提高生物利用率,且疗效相当。     

急性脊髓损伤后手术减压时限的临床研究

目的探讨急性脊髓损伤后在不同时间点行手术减压对患者神经功能恢复的影响。方法回顾2005年1月~2009年12月收治的胸椎骨折合并脊髓不完全损伤的89例,按照手术减压时限分为3组:A组,伤后24 h内手术减压(25例);B组,伤后1～3 d内手术减压(47例);C组,伤后3～7 d内手术减压(17例)。根据ASIA残损分级比较术前和术后1年的神经功能情况,比较3组的神经功能恢复情况,分析不同的减压时间疗效有无统计学差异。结果治疗前3组的ASIA残损分级,差异无统计学意义。治疗后3组ASIA残损分级较治疗前提高,A组高于B组和C组(P<0.05),B组高于C组(P<0.05)。结论脊髓不完全损伤后手术减压可以改善神经功能,且手术越早,神经功能恢复越好。     

促红细胞生成素治疗急性脊髓损伤

目的 观察促红细胞生成素(EPO)对急性脊髓损伤神经功能恢复的疗效.方法 急性脊髓损伤患者65例,根据用药分为EPO治疗组35例和对照组30例;分别于入院时及治疗后末次随访时对脊髓损伤程度按ASIA2000评分标准进行神经功能评定,观察两组差异;同时监测患者用药前后血常规及血清EPO浓度,记录不良反应.结果 65例患者术后随访1～3年,平均1.7年,末次随访时治疗组患者ASIA运动、触觉、痛觉功能评分为58,2±8.2、78.5±11.5、82.6±13.5,显著优于对照组运动、触觉、痛觉功能评分45.6±6.8、65.5±13.4、68.7±14.7,差异有统计学意义(P<0.05),EPO组治疗过程中未见明显不良反应.结论 促红细胞生成素是治疗急性脊髓损伤安全有效的药物,早期应用EPO对促进患者神经功能的改善与恢复具有积极意义.     

中上胸椎骨折的手术治疗

目的 分析中上胸椎骨折的损伤特点、手术时机与手术方法。方法 对一组35例手术治疗的中上胸椎骨折(T1-10)进行回顾性总结，其中脊髓完全性损伤25例，不完全性损伤10例。比较不同手术时间的出血量、手术前后ASIA分级及感觉运动评分变化。结果 骨折合并脊髓不完全损伤10例，随访ASIA分级提高1～2级；骨折合并脊髓完全性损伤，不能改善ASIA分级，但能提高运动感觉评分平均20分。结论 中上胸椎骨折具有损伤累及节段多、脊髓损伤严重、功能恢复差的特点。脊髓不完全性损伤应尽早手术，完全性损伤宜在伤后2周手术。后路减压、融合、内固定术治疗中上胸椎骨折可以取得较好疗效。     

颈部脊髓损伤患者神经丝蛋白与ASIA功能分级的关系

【摘要】目的 探讨颈部脊髓损伤患者神经丝蛋白与美国脊髓损伤学会(ASIA)功能分级的关系。方法 选取2016年2月至2019年3月本院收治234例颈部脊髓损伤患者作为本文研究对象,根据颈髓损伤ASIA分级标准,将患者分成五组,即A组(完全性损伤,n=33),B组(不完全性损伤,n=31),C组(不完全性损伤,n=28),D组(不完全性损伤,n=53)和E组(正常,n=89)。比较不同ASIA功能分级患者血清神经丝蛋白水平,并应用Pearson法分析血清神经丝蛋白与ASIA功能分级的相关性。结果 五组患者血清神经丝蛋白水平差异有统计学意义(P<0.05);A组患者血清神经丝蛋白水平明显高于B组、C组、D组和E组,B组患者血清神经丝蛋白水平明显高于C组、D组和E组(P<0.05),C组患者神经丝蛋白水平明显高于D组和E组,且D组患者血清神经丝蛋白水平明显高于E组(P<0.05);血清神经丝蛋白与脊髓损伤ASIA功能分级呈负相关(r=-0.927, P<0.001)。结论 血清神经丝蛋白水平与ASIA功能分级呈负相关,颈部脊髓损伤的严重程度与血清神经丝蛋白水平的提高有关。     

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.     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

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.     

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.     

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.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

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.