重症急性胰腺炎早期感染的危险因素分析

目的：探讨重症急性胰腺炎（ＳＡＰ）早期胰腺感染的易感因素。方法：将１９９８年１月～２０００年１２目间收治重症急性胰腺炎６８例,根据发病后２局内胰腺是否继发感染．分为感染组和非感染组,并分析其易感因素。结果：胰腺继发感染的总发主率为４１．２％;ＡＰＡＣＨＥ ＩＩ积分与胰腺感染发生之间呈明显的正相关性（ｒ＝０．３１,Ｐ＜０．０１）;放置胃管≥７天、肠切能障碍≥５天、施行腹腔灌洗手术、胰腺有坏死及胆源性胰腺炎等危险因素与 ＳＡＰ患者继发胰腺感染的发生率明显相关（Ｐ＜０．０５）;其余各影响因素与胰腺感染均无明显联系（Ｐ＞０．０５）。结论：胃肠道功能障碍≥５天、胆源性胰腺炎、早期胰腺明显坏死和腹腔灌洗引流等是ＳＡＰ自期胰腺感染的主要易感因素。     

急性胰腺炎胰腺微循环功能障碍的研究

通过动态观察消炎痛，伊曲康唑治疗前后急性胰腺炎模型大鼠血浆血栓素Ａ２水平，胰腺血供，胰腺微循 功能状况与病理改变，探讨其内在联系。结果提示；局部缺血和微血和壁通透性增加是ＡＰ的早期病生改变、介导ＡＰ由水肿型向出血坏死型转变；ＡＰ时大量成ＴＸＡ２是这一病理生理改变的重要介绍。为ＡＰ治疗提供了一定的理论基础。     

非手术治疗重症急性胰腺炎92例

为了探讨重症急性胰腺炎的诊断和选择适当的治疗方法，对９２例重症急性胰腺炎（ＳＡＰ）的临床资料进行了分析。结果发现：Ｒａｎｓｏｎ指标及ＣＴ诊断与临床经过大致相符。两个象限以上的腹膜炎，血性腹水和腹水淀粉酶≥２５６温氏单位同时存在，即可明确胰腺实质有出血坏死，可确诊为ＳＡＰ；结合ＣＴ检查可进一步了解胰腺的病理改变，更有利于临床治疗；ＳＡＰ极易并发成人呼吸窘迫综合症（ＡＰＤＳ），高渗晶胶混合液可防治ＡＲＤＳ，并可迅速纠正休克；在非手术治疗过程中，仍有部分病人需要中转手术。全组治愈７１例（７７．１７％），死亡２１例（２２．８２％）。认为：ＳＡＰ的诊断应以临床表现为主，大部分患者都可经非手术治愈。     

急性胰腺炎实验研究的现状与展望

急性胰腺炎 (ＡＰ)尤其是重症急性胰腺炎 (ＳＡＰ)是急腹症外科迄今唯一尚未满意解决的问题 ,有关对ＳＡＰ的认识目前已在三个方面达成了共识。其一 ,ＳＡＰ是一种以外科治疗为主的疾病 ,即从病理解剖学来看 ,其直接病因或与发病有关的重要因素 80 %以上与胆道结石、胆胰管汇合异常及胰腺分隔症有关。在大多数病理情况下如胰腺及周围组织坏死、感染、液体积聚、假性囊肿等 ,均需要适时外科手术干预 ;其二 ,ＳＡＰ是一种严重的全身多器官损害性疾病 ,即其在发病一开始就表现为严重的全身性炎性反应综合症(ＳＩＲＳ) ,迅速出现多脏器功能不良 …     

重症急性胰腺炎非手术治疗恢复后的转归和结果

目的 探讨重症急性胰腺炎（ＳＡＰ）非手术治疗基本恢复后的转归和后续治疗。方法 回顾性分析４１例ＳＡＰ非手术治疗基本恢复后,继发假性胰腺囊肿,复发胰腺炎,慢性腹痛。胆囊结石。３个月至２年间行ＣＴ,ＥＲＣＰ检查,开腹手术,胰组织活检和随访观察１～１２年的资料。结果 假性胰腺囊肿是ＳＡＰ非手术后的主要继发病,胰腺坏死组织的吸收和纤维组织增生夫代呈现３～６个月的缓慢过程。远期效果优良３０例（７３．２％）,隐痛或消化不良１０例（２４．４％）,死于复发性胰腺炎１例（２．４％）。结论 ＳＡＰ基本恢复后应重视后续治疗假性囊肿,近期切除有结石的胆囊,积极防治复发性胰腺炎。     

当前重症急性胰腺炎手术指征及术式选择

近年来在重症急性胰腺炎 (ｓｅｖｅｒｅａｃｕｔｅｐａｎｃｒｅａｔｉｔｉｓ ,ＳＡＰ)的治疗中早期采用非手术治疗原则已趋于明确 ,但对于胆源性ＳＡＰ、某些非胆源性ＳＡＰ(多为暴发性急性胰腺炎 )及ＳＡＰ保守治疗后期有严重并发症的患者 ,手术可能仍是一个重要的治疗手段 ,现就有关手术治疗中手术指征及其术式选择综述如下。1　手术指征及手术时机选择手术指征随着对ＳＡＰ病程和发病转归的认识而改变。过去认为胰腺坏死必然感染 ,感染产生并发症 ,导致死亡率增高 ,故而有胰腺坏死应该越早手术越好 ,切除越彻底越好。通过多年的临床实践 …     

重症急性胰腺炎的早期手术治疗——附21例病例分析

目的 探讨重症急性胰腺炎（ＳＡＰ）早期手术治疗的可行性，方法 ２１例患者分成３组，发病１天内手术者Ｉ组，２～３天为Ⅱ期，４～７天为Ⅲ期，胰腺被膜切开减压，胰床充分引流，适当清除胰腺坏死组织。结果 早期手术２１例，死亡２例，死亡率９．５％，结论 １．ＳＡＰ早期手术是可行的，２．手术疗效与手术方式的改进，手术适应症的选择及手术时机有关。     

重症急性胰腺炎的手术与非手术治疗

为提高重症急性胰腺炎（ＳＡＰ）的疗效，作者总结了９３例ＳＡＰ患者的治疗经验。９３例中，治愈７３例（７８．５％）、死亡２０例（２１．５％）。手术治疗组５３例，死亡１５例（２８．３％）；非手术治疗组４０例，死亡５例（１２．５％）。１９９２年以前早期手术为主，死亡率２３％；１９９２年以后非手术或延期手术为主，死亡率１９．５％。作者认为本病的死亡原因与病情、胰腺坏死范围、有无继发感染及器官衰竭的处理方法有关。早期手术未能改善初期休克、胰腺广泛坏死、器官衰竭等并发症的预后，而非手术方法可以治愈大多数ＳＡＰ病例。胰腺组织坏死继发严重感染者应行手术治疗。手术方法以坏死组织清除和充分引流为主。     

重症急性胰腺炎非手术治疗临床经验

目的 观察重症急性胰腺炎的非手术的治疗效果。临床资料 ３９例ＳＡＰ患者，其中非手术治疗１７例，病情Ｉ级１１例，Ⅱ级６例，死亡１例，手术治疗２２例，Ⅰ级９例，Ⅱ级１３例，死亡４例，结论多数ＳＡＰ可经非手术治疗治愈，对有胰腺组织坏死继发严重感染者则以引流为宜；经早期保守治疗而行延期手术者可简化手术方法，以减少术后并发症，提高手术耐受性     

非手术治疗重症急性胰腺炎

非手术治疗重症急性胰腺炎（ＳＡＰ）是针对过去常规采取早期手术治疗而提出的一种内科治疗方式。它的优点是并发症少,病死率低,并可使大部分病人免于手术。本文参阅国内外文献,结合我们的临床实践和实验研究,对非手术治疗ＳＡＰ的机理、适应证、方法和手术指征作一综合论述。１　非手术治疗ＳＡＰ的机理１１　ＳＡＰ是一种全身炎症反应ＳＡＰ是以胰腺弥漫性出血和组织坏死为特征的急性胰腺炎。它发病急骤,病情凶险。过去对它的发病机理缺乏认识,认为ＳＡＰ仅为胰腺自身消化的局部病变,采取早期手术可以阻止病变的发展,但结果不能…     

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.