微血管侵犯对早期肝癌肝切除术切缘选择及患者预后的影响

目的探讨微血管侵犯(MVI)对早期肝癌肝切除术切缘选择及患者预后的影响。方法选取2015年1月至2016年12月我院收治的早期肝癌肝切除术患者60例为研究对象,根据病史资料分为MVI阳性组及MVI阴性组,分析导致肝癌患者发生MVI的单因素及独立危险因素,并对比MVI阳性及阴性患者中不同切缘患者1年复发率、生存率,以Cox等比例风险模型评价肿瘤复发及总体生存的独立预测因子,比较不同切缘患者术后并发症。结果与MVI阴性组比较,MVI阳性组手术切缘(1.05±0.07)cm、病灶大小(6.57±1.23)cm、血清甲胎蛋白(AFP)(213.13±13.58)μg/L及肿瘤边缘不光滑70.00%、包膜不完整90.00%、肿瘤多发比例35.00%明显较高(P0.05);Logistic回归分析显示肿瘤边缘不光滑、肿瘤多发为预测早期肝癌患者微血管侵犯的独立危险因素(P0.05);MVI阳性患者中中宽切缘者1年复发率55.56%高于窄切缘者9.09%(P0.05),1年总体生存率66.67%低于窄切缘者100.00%(P0.05);多因素Cox分析显示AFP≥400μg/L、切缘1cm、肿瘤5cm是MVI阳性患者肿瘤复发及病人总体生存的独立预测因子(P0.05);接受中宽切缘或窄切缘患者术后1年并发症发生率15.63%、14.29%比较无显著差异(P0.05)。结论肿瘤边缘不光滑、肿瘤多发是预测微血管侵犯的独立危险因素,对于发生微血管侵犯患者选择中宽切缘能显著延长生存期,降低复发率,改善预后。     

微血管侵犯对肝癌肝移植受者预后影响的临床研究

目的探讨微血管侵犯(MVI)对原发性肝癌(肝癌)肝移植受者预后的影响。方法回顾性分析177例肝癌肝移植受者的临床资料,根据术后病理学检查结果分为MVI阳性组(64例)和MVI阴性组(113例)。比较MVI阴性组和MVI阳性组受者的临床资料;分析肝癌肝移植受者的预后及危险因素。结果 177例受者中,64例(36.2%)MVI阳性,113例(63.8%)MVI阴性。与MVI阴性受者相比,MVI阳性受者的肿瘤分化程度低、术前甲胎蛋白(AFP)水平高、肿瘤最大直径大、肿瘤数量多、伴卫星灶多、不符合米兰标准的例数多(均为P0.05)。肝癌肝移植受者1、3、5年累积生存率(OS)和无复发生存率(RFS)分别为80.2%、62.1%、58.5%和66.3%、57.5%、51.2%。MVI阳性受者的1、3、5年OS和RFS分别为70%、39%、35%和53%、39%、33%,低于MVI阴性受者的86%、75%、72%和73%、68%、63%,差异均有统计学意义(均为P0.05)。Cox回归分析结果显示,肿瘤最大直径8 cm、术前AFP水平≥20 ng/mL、肿瘤中低分化和MVI阳性是影响肝癌肝移植受者OS的独立危险因素(均为P0.05),MVI阳性、肿瘤中低分化以及术前未降期成功是影响肝癌肝移植受者RFS的独立危险因素(均为P0.05)。结论 MVI对预测肝癌肝移植受者的预后具有重要的临床价值。     

肝癌患者术后生存风险因素分析

目的分析影响肝癌患者术后生存的危险因素。方法对41例肝癌术后复发的患者进行单因素和多因素统计分析,得出影响患者术后生存的相关危险因素和独立危险因素。结果嗜酒史、肿瘤无包膜、AFP〉20ng/mL、有瘤栓、低或中分化以及6个月内复发与患者术后生存时间有关,其中复发肿瘤呈现低或中分化以及在6个月内复发是影响术后生存的独立危险因素,复发后中位生存时间仅为17.3个月。结论术前嗜酒史、原发肿瘤无包膜且辅助检查AFP值〉20ng/mL有瘤栓的低或中分化患者,尤其是在术后6个月内复发的患者其术后生存时间相对较短。     

术前甲胎蛋白水平在热消融治疗肝细胞癌中的预后价值

目的探索术前甲胎蛋白(AFP)水平在热消融治疗肝细胞癌(HCC)病人中的预后价值。方法回顾性分析临床诊断为HCC病人305例,均为单发直径3 cm肿瘤,109例接受射频治疗,196例接受微波治疗,比较两组病人的远期疗效并统计分析病人的预后影响因素。结果 AFP≥400μg/L组和AFP400μg/L组病人1、3、5累积生存率分别为83.6%、66.9%、49.8%和96.2%、90.0%、74.7%(P=0.001),1、3、5累积复发率分别为36.3%、61.2%、75.2%和17.6%、38.9%、59.0%(P=0.003)。COX多因素分析中,AFP≥400μg/L是影响术后生存和复发的独立危险因素。射频组和微波组1、3、5年累积生存率分别为91.7%、79.5%、65.8%和94.8%、82.4%、69.4%(P=0.211)。1、3、5年复发率分别为24.1%、50.6%、61.1%和21.4%、40.1%、59.7%(P=0.424)。结论 AFP≥400μg与肝癌预后的生存和复发密切相关,可作为早期肝癌病人术后预后的指标。早期肝癌射频和微波消融远期疗效无明显差异。     

单发大肝癌术后早期复发危险因素分析

目的探讨单发大肝癌(肿瘤直径≥5 cm)早期复发危险因素。方法回顾性分析2015年1月至2020年9月间于宁波大学附属李惠利医院接受根治性切除的135例单发大肝癌患者的临床资料。结果 135例患者复发75例, 其中早期复发42例。多因素分析显示, 甲胎蛋白≥400 ng/ml(OR=3.510, 95%CI:1.528～8.064;P=0.003)和微血管侵犯(microvascular invasion, MVI)阳性(OR=2.769, 95%CI:1.143～6.706;P=0.024)是单发大肝癌早期复发的独立危险因素。生存分析显示, 存在早期复发危险者无复发生存率(甲胎蛋白≥400 ng/ml, χ2=23.038, P<0.001;MVI阳性, χ2=10.554, P=0.001)和总生存率(甲胎蛋白≥400 ng/ml, χ2=14.336, P<0.001;MVI阳性, χ2=10.481, P=0.001)均下降。结论甲胎蛋白≥400 ng/ml和MVI阳性是单发大肝癌早期复发的独立危险因素。     

术前中性粒细胞/淋巴细胞比值对小肝癌患者并发微血管浸润的预测价值

目的:评价术前外周血中性粒细胞/淋巴细胞比值(NLR)对小肝癌患者并发微血管浸润(MVI)的预测价值。方法:回顾性分析确诊的50例小肝癌并发MVI患者与随机选取同期确诊的90例小肝癌未并发MVI患者的临床资料。根据受试者工作特征(ROC)曲线确定NLR诊断MVI的临界值,采用单因素分析及非条件Logistic回归模型分析小肝癌患者并发MVI的危险因素。结果:ROC曲线分析得到NLR诊断MVI的临界值为3.27,对应的敏感度为0.480,特异度为0.767,曲线下面积(AUC)为0.613(95%CI=0.511~0.715,P=0.027)。单因素分析显示,并发MVI患者中,AFP25ng/m L、肿瘤最大直径3cm、NLR3.27的比例明显高于在未并发MVI患者中的比例(均P0.05);非条件Logistic回归模分析显示NLR、AFP、肿瘤最大直径是小肝癌患者并发MVI的独立危险因素(均P0.05)。此外,NLR≤3.27的患者AFP、中性粒细胞、淋巴细胞、血小板、白蛋白及肿瘤最大直径方面均优于NLR3.27患者(均P0.05)。结论:术前NLR值是影响小肝癌患者并发MVI的独立危险因素之一,可作为一种临床上简便易行的预测指标,NLR3.27者发生MVI的可能性大。     

原发性肝癌患者手术切除术后早期复发影响因素分析

目的:探讨原发性肝癌(HCC)患者手术切除后早期复发的影响因素。方法:回顾性分析郑州大学第一附属医院2014年1月—2016年1月期间450例经手术切除的HCC患者的临床与随访资料,通过统计学方法分析HCC术后早期复发的影响因素。结果:450例患者中,2年内复发182例(40.4%)。单因素分析结果显示,HCC术后复发与门脉癌栓、术前血清AFP水平、肿瘤数目、最大直径、肿瘤分化程度有关(均P0.05);Cox比例风险回归分析显示,肿瘤数目(RR=2.148,95%CI=1.175～3.924,P=0.013),肿瘤最大直径(RR=1.591,95%CI=1.006～2.518,P=0.047),门脉有无癌栓(RR=1.835,95%CI=1.242～2.709,P=0.001),血清AFP水平(RR=1.722,95%CI=1.141～2.601,P=0.010),肿瘤分化程度(RR=1.463,95%CI=1.071～1.998,P=0.017)均是HCC术后复发的独立因素。通过以上因素建立函数模型对预测HCC术后早期复发的风险程度有一定价值(似然比检验:χ~2=45.727,P0.001)。结论:HCC患者手术切除术后早期复发的影响因素较多,其中门脉癌栓、肿瘤数目、最大直径、肿瘤分化程度、血清AFP水平可能是造成复发的独立危险因素,术前综合评估这些因素对预防术后复发有一定的指导意义。     

原发性肝细胞癌根治术后肿瘤复发的影响因素及预后

目的 探讨原发性肝细胞癌(HCC)根治术后患者肿瘤早、晚期复发的影响因素及预后.方法 回顾性分析2003年1月至2006年12月华中科技大学附属同济医院收治的117例行HCC根治术患者的临床资料,以术后2年为界,≤2年肿瘤复发为早期复发,＞2年为晚期复发.分析AFP、AFP/肿瘤单位体积(AFP/V)、肿瘤直径、肿瘤数目、血管侵犯、肿瘤分化程度、肝硬化程度、肝功能分级、HBsAg、肝切除方式、术中输血等因素与术后肿瘤复发的关系,采用Kaplan-Meier生存分析法计算患者术后总体生存率和无瘤生存率,Log-rank法对生存率进行检验.结果 117例患者中有85例(72.6%)出现肿瘤复发,其中早期复发59例(50.4%)、晚期复发26例(22.2%).AFP、AFP/V、肿瘤直径、肿瘤数目、血管侵犯、肿瘤分化程度、术中输血是术后肿瘤早期复发的影响因素(x2=12.78,13.40,5.79,9.98,10.26,9.48,8.32,P＜0.05);AFP、肝硬化程度是术后肿瘤晚期复发的影响因素(x2=4.46,7.75,P＜0.05).AFP/V、肿瘤数目、血管侵犯是术后肿瘤早期复发的独立危险因素(RR=0.170,0.172,0.064,P＜0.05);肝硬化程度是术后肿瘤晚期复发的独立危险因素(RR=2.809,P＜0.05).本组患者术后1、3、5年总体生存率和无瘤生存率分别为82.6%、60.8%、54.9%和65.0%、38.5%、23.1%.AFP＜20μg/L、AFP/V＜14 μg/(L·cm3)、AFP/V14μg/(L·cm3)的患者总体生存率和无瘤生存率比较,差异有统计学意义(P＜0.05).肿瘤早期复发患者1、3、5年总体生存率分别为64.9%、23.0%、20.5%;肿瘤晚期复发患者1、3、5年总体生存率分别为100.0%、88.5%、72.5%,两者比较,差异有统计学意义(x2=26.918,P＜0.05).结论 AFP/V、肿瘤数目、血管侵犯是肿瘤早期复发的独立危险因素,肝硬化程度是肿瘤晚期复发的独立危险因素.HCC根治术后肿瘤早、晚期复发患者生存率存在差异.     

肝癌肝移植术后复发的危险因素分析

目的探讨原发性肝癌(HCC)肝移植术后肿瘤复发或转移的危险因素。方法回顾性我院2003年4月至2007年11月期间76例HCC患者行肝移植的临床资料,根据随访期间是否有复发分为复发组(n=23)和未复发组(n=53),总结肿瘤复发的特点。结果 76例患者中23例(30.3%)术后复发。单因素分析显示患者性别(P=0.449)、年龄(P=0.091)、术前是否治疗(P=0.958)、肿瘤数目(P=0.212)和是否伴有HBV/HCV感染(P=0.220)与肿瘤的复发无关,而肿瘤包膜完整性(P=0.009)、肿瘤分期(P=0.002)、肿瘤直径(P<0.001)、血管侵犯(P<0.001)以及术前AFP水平(P=0.044)与肿瘤的复发有关,其中肿瘤直径<5.0 cm(P=0.001)和术后2个月AFP水平恢复正常者(P<0.001)1年复发率更低。多因素分析显示肿瘤直径(P=0.001,OR=6.456,95%CI为2.356～17.680)、血管侵犯(P=0.030,OR=10.653,95%CI为1.248～90.910)以及术前AFP水平(P=0.017,OR=2.601,95%CI为2.196～5.658)是肝移植术后肿瘤复发的独立危险因素。结论对于肿瘤直径>5.0 cm、伴有血管侵犯以及术前AFP水平≥400μg/L尤其术后2个月AFP水平仍高于正常者术后需加强监测,必要时尽早给予抗肿瘤治疗。     

复发时甲胎蛋白的不同水平对肝癌预后的影响

目的:观察肝细胞肝癌(简称肝癌)复发时甲胎蛋白(AFP)的不同水平对其预后的影响。方法:回顾性分析我医院821例经根治性手术切除的复发性HCC病人。根据复发时AFP水平分为:A组(阴性组),AFP≤20 ng/mL(n=412);B组(低浓度组),AFP 21～400 ng/mL(n=264);C组(高浓度组),AFP>400 ng/mL(n=145)。分析3组病人的一般临床病理特点、复发后生存率以及影响复发后生存的其他危险因素。结果:相比于A组和B组,C组存在更多的原发肿瘤包膜无/不完整(P<0.001)、更多的微血管侵犯(P<0.001)、更差的肿瘤分级(P5 cm、复发肿瘤直径>3 cm、复发肿瘤数目≥2枚、复发时AFP高水平以及复发后非手术治疗是影响肝癌复发生存率的预后危险因素。其中,B组相比于A组的HR值为1.46(95%CI:1.06～2.01,P=0.021);C组相比于A组的HR值为2.77(95%CI:1.89～4.05,P<0.001)。结论:复发时AFP的血清学水平与肿瘤的侵袭性指标相关;复发时AFP浓度越高,预后越差。AFP是判断HCC根治术复发后生存的重要指标。     

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.