重症肝炎肝移植围术期应用抑肽酶对血管活性药物和输血输液需求的影响

目的探讨重症肝炎患者肝移植围术期应用抑肽酶对血管活性药物和输血输液需求的影响。方法重症肝炎40例随机分为抑肽酶组:微泵持续输入抑肽酶(4×106)U/h;对照组:输等容量生理盐水。观察两组患者肝移植围术期血流动力学、血液丢失量、输血和输液总量、血管活性药物用量、术后引流量、红细胞压积等临床情况。结果两组患者同一时间点的血流动力学和红细胞压积无显著性差异;抑肽酶组手术各期出血量和总出血量明显低于对照组(P<0.05),红细胞、血浆、血小板和液体输入量明显少于对照组(P<0.05);抑肽酶组无肝期和新肝期多巴胺、新肝期肾上腺素用量均少于对照组(P<0.05);两组去甲肾上腺素用量无显著性差异。结论重症肝炎肝移植围术期应用抑肽酶,可显著减少围术期失血、减少血液和液体的输注量,一定程度减少血管活性药物的需求。     

Arginine vasopressin,but not epinephrine,improves survival in uncontrolled hemorrhagic shock after liver trauma in pigs

OBJECTIVE: Epinephrine is widely used for treatment of life-threatening hypotension, although new vasopressor drugs may merit evaluation. The purpose of this study was to determine the effects of vasopressin vs. epinephrine vs. saline placebo on hemodynamic variables, regional blood flow, and short-term survival in an animal model of uncontrolled hemorrhagic shock and delayed fluid resuscitation. DESIGN: Prospective, randomized, laboratory investigation that used a porcine model for measurement of hemodynamic variables and regional abdominal organ blood flow. SETTING: University hospital laboratory. SUBJECTS: A total of 21 pigs weighing 32 +/- 3 kg. INTERVENTIONS: The anesthetized pigs were subjected to a penetrating liver injury, which resulted in a mean +/- sem loss of 40% +/- 5% of estimated whole blood volume within 30 mins and mean arterial pressures of <20 mm Hg. When heart rate declined progressively, pigs randomly received a bolus dose and continuous infusion of either vasopressin (0.4 units/kg and 0.04 units.kg-1.min-1, n = 7), or epinephrine (45 microg/kg and 5 microg.kg(-1).min(-1), n = 7), or an equal volume of saline placebo (n = 7), respectively. At 30 mins after drug administration, all surviving animals were fluid resuscitated while bleeding was surgically controlled. MEASUREMENTS AND MAIN RESULTS: Mean +/- sem arterial blood pressure at 2.5 and 10 mins was significantly (p <.001) higher after vasopressin vs. epinephrine vs. saline placebo (82 +/- 14 vs. 23 +/- 4 vs. 11 +/- 3 mm Hg, and 42 +/- 4 vs. 10 +/- 5 vs. 6 +/- 3 mm Hg, respectively). Although portal vein blood flow was temporarily impaired by vasopressin, it was subsequently restored and significantly (p <.01) higher when compared with epinephrine or saline placebo (9 +/- 5 vs. 121 +/- 3 vs. 54 +/- 22 mL/min and 150 +/- 20 vs. 31 +/- 17 vs. 0 +/- 0 mL/min, respectively). Hepatic and renal artery blood flow was significantly higher throughout the study in the vasopressin group; however, no further bleeding was observed. Despite a second bolus dose, all epinephrine- and saline placebo-treated animals died within 15 mins after drug administration. By contrast, seven of seven vasopressin-treated animals survived until fluid replacement, and 60 mins thereafter, without further vasopressor therapy (p <.01). Moreover, blood flow to liver, gut, and kidney returned to normal values in the postshock phase. CONCLUSIONS: Vasopressin, but not epinephrine or saline placebo, improved short-term survival in a porcine model of uncontrolled hemorrhagic shock after liver injury when surgical intervention and fluid replacement was delayed.     

A multicenter,randomized, double-blind,placebo- controlled trial of intravenous ibuprofen 400 and 800 mg every 6 hours in the management of postoperative pain

Background: Although opioids are the mainstay of inpatient postoperative pain management, they do not block inflammation. The NSAID ibuprofen has antiinflammatory and analgesic properties, and a multimodal approach may reduce opioid requirements.Objective: This study was conducted to assess the effects of intravenously administered ibuprofen 400 and 800 mg q6h in postoperative pain management.Methods: This multicenter, randomized, doubleblind, placebo-controlled trial was conducted in 406 patients scheduled to undergo elective, single-site orthopedic or abdominal surgery. All patients received morphine administered by patient-controlled analgesia pump, or by hospital staff at the request of the patient, after surgery and were randomly assigned in a 1:1:1 ratio to receive ibuprofen 400 mg IV, ibuprofen 800 mg IV, or inactive vehicle (placebo). The first dose of study drug was administered intraoperatively at the initiation of wound closure, then every 6 hours for a total of 8 doses over the first 48 hours of the study. After the initial 8 doses, the protocol allowed for continued administration of IV ibuprofen or placebo every 6 hours, at the discretion of the investigator, for control of postoperative pain for a total of up to 120 hours (5 days). The ibuprofen and placebo were administered while patients had access to morphine throughout the duration of the study. The primary outcome measure was morphine use in the first 24 hours after surgery. Secondary measures were patient self-reports of pain scores at rest and with movement. Pain intensity was measured before (baseline) and at 1, 2, 3, 6, 9, 12, 15, 18, 24, 27, 30, 33, 36, 39, 42, 45, and 48 hours after the first administration of study medication, and then once daily through day 5 if the patient continued to receive study medication. Patients were assessed by study personnel for treatment-emergent adverse events (AEs).Results: A total of 406 patients were enrolled (319 women, 87 men; mean [SD] age, 45 [12] years; weight, 83.8 [19.1] kg; ibuprofen 400 mg IV, 134 patients; ibuprofen 800 mg IV, 138; and placebo, 134). In the intent-to-treat population, median morphine use was significantly reduced during the first 24 hours after administration of the study drug in patients who received ibuprofen 800 mg IV q6h (by 22% vs placebo; P = 0.030). The use of ibuprofen 800 mg IV q6h was associated with significant reductions in pain at rest and with movement across 3 time periods (1-24, 6-24, 12- 24 hours) compared with placebo. Ibuprofen 400 mg IV q6h was associated with significant reductions in pain at rest and with movement during the 6- to 24-hour and 12- to 24-hour time periods compared with placebo. The prevalences of AEs and abnormalities in laboratory measurements were not significantly different between patients who received IV ibuprofen and those who received placebo. Treatment-emergent AEs were reported in 368 of 406 patients (91%). With respect to the number of patients who experienced serious AEs, the differences in the 400-mg IV ibuprofen group (118/134 [88%]) and the 800-mg IV ibuprofen group (124/138 [90%]) compared with the placebo group (126/134 [94%]) were not statistically significant. There were significant reductions in the proportions of patients who experienced gastrointestinal disorders in the 400- and 800-mg IV ibuprofen groups compared with the placebo group (99/134 [74%] and 98/138 [71%], respectively, vs 113/134 [84%]; P = 0.05 and P = 0.009). There were significant reductions in the numbers of patients experiencing pyrexia in the 400- and 800-mg IV ibuprofen groups compared with the placebo group (9/134 [7%] and 10/138 [7%] vs 23/134 [17%]; P = 0.013 and P = 0.015). Dizziness occurred in a significantly greater proportion of patients in the ibuprofen 800-mg q6h group compared with the placebo group (P = 0.011).Conclusions: In these patients undergoing postoperative pain management, ibuprofen 800 mg IV q6h was associated with significant reductions in morphine use and pain at rest and with movement compared with placebo. Ibuprofen IV was not associated with significant increases in AEs compared with placebo, with the exception of dizziness with the 800-mg dose. These findings suggest that ibuprofen 800 mg IV q6h was effective for postoperative pain management and was generally well tolerated. ClinicalTrials.gov identifier: NCT00225732.     

Selective decontamination of the digestive tract to prevent postoperative infection: a randomized placebo-controlled trial in liver transplant patients

OBJECTIVE: To determine the efficacy of selective decontamination of the digestive tract (SDD) in patients undergoing elective transplantation of the liver. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Two academic teaching hospitals. PATIENTS: Adult patients undergoing elective liver transplantation: 26 patients receiving SDD and 29 patients receiving a placebo. INTERVENTIONS: Patients undergoing SDD were administered 400 mg of norfloxacin once daily as soon as they were accepted for transplantation. Postoperative treatment for this group consisted of 2 mg of colistin, 1.8 mg of tobramycin, and 10 mg of amphotericin B, four times daily, combined with an oral paste containing a 2% solution of the same drugs until postoperative day 30. Prophylactic intravenous administration of antibiotics was not part of the SDD regimen in this study. Control patients were given a similar regimen with placebo drugs. MEASUREMENTS: The mean number of postoperative bacterial and fungal infections in the first 30 days after transplantation was the primary efficacy end point. Days on a ventilator, days spent in the intensive care unit, and medical costs were registered as secondary outcome variables. MAIN RESULTS: Of the 26 patients undergoing SDD, 22 (84.5%) developed an infection in the postoperative study period; in the placebo group (n = 29), these numbers were not significantly different (25 patients, 86%). The mean number of postoperative infectious episodes per patient was also not significantly different: 1.77 (SDD) vs. 1.93 (placebo). Infections involving Gram-negative aerobic bacteria and Candida species were significantly less frequent in patients receiving SDD (p <.001 and p <.05). Total costs were higher in the group receiving SDD. CONCLUSIONS: Selective decontamination of the digestive tract does not prevent infection in patients undergoing elective liver transplantation and increases the cost of their care. It does, however, affect the type of infection. Infections with Gram-negative bacilli and with Candida species are replaced by infections with Gram-positive cocci.     

Presentation and outcomes of end stage liver disease patients presenting with septic shock to the emergency department

BackgroundPatients with end stage liver disease (ESLD) are particularly vulnerable to sepsis. ESLD patients are often excluded from controlled sepsis trials and more data are needed to guide the management of this population.ObjectiveTo describe the clinical factors and outcomes of patients with ESLD presenting to the emergency department (ED) with septic shock.MethodsWe performed a retrospective review of patients registered in our dedicated ED adult septic shock pathway. All patients registered between January 2014 and May 2016 were included. Clinical and treatment variables for ESLD patients were compared with non-ESLD patients. A second analysis assessed ESLD survivors compared to non-survivors.Results2,584 septic shock patients were enrolled. ESLD was present in 6.2% (n = 161) of patients. Patients with ESLD had higher mortality compared to patients without ESLD 36.6% vs 21.2% (p < 0.001). ESLD patients were more likely to be younger, female, obese, and have other comorbidities. ESLD patients exhibited lower temperature, higher lactate, and higher incidence of acute kidney injury. There was no difference in antibiotics or fluid resuscitation between groups. ESLD patients received more ED vasopressor support. Among ESLD septic shock patients, maximum lactate and presence of pneumonia were independently associated with death.ConclusionsPatients with ESLD comprise a small but important subgroup of patients with ED septic shock that experience high mortality compared to patients without ESLD. Maximum ED lactate and pneumonia as the source of sepsis are independently associated with adverse outcome and may be used for early recognition of high-risk ESLD sepsis patients.     

婴儿活体肝移植术后早期的液体管理

目的 探讨婴儿活体肝移植术后早期有效的液体管理方法 .方法 对在2008年1月-2009年3月开展的17例婴儿活体肝移植手术,根据婴儿生理特点及肝移植术后血流动力学特点,手术当日适当控制补液,术后3 d内尽早实现患儿液体负平衡,密切观察病情,监测生命体征、尿量,同时结合实验室检查,及时调整补液的性质和量,维持患儿内环境的稳定.结果有效地维持了17例患儿术后早期血流动力学的稳定,未出现与容量有关的并发症.结论 在保证有效循环血容量和血流动力学稳定的基础上,术后3 d内尽早实现患儿液体负平衡是减少术后并发症和降低病死率的关键.     

Preoperative Low-dose and High-dose Pregabalin and Cardiovascular Response to Endotracheal Intubation: A Prospective,Randomized, Single-blind,Controlled Study in China

Purpose

A prospective, randomized, single-blind, controlled clinical study was designed to evaluate the efficacy and tolerability of preoperative pregabalin on cardiovascular response to laryngoscopy and endotracheal intubation.

Postoperative sore throat: incidence and severity after the use of lidocaine, saline, or air to inflate the endotracheal tube cuff.

Postoperative sore throat occurs in up to 90% of intubated patients and is the most common complaint of patients after endotracheal intubation. A recent study suggested that the use of lidocaine to inflate the endotracheal tube cuff would decrease the incidence of postoperative sore throat. The purpose of this prospective randomized study was to compare the incidence and severity of sore throat after using lidocaine, saline, or air to inflate the endotracheal tube cuff. Variables typically associated with postoperative sore throat, including endotracheal cuff design, endotracheal tube size, intubation technique, laryngoscopy blade, airway placement, suctioning technique, and anesthetic technique, were controlled. The participants were all ASA physical status I, II, or III, female, adult patients undergoing general endotracheal anesthesia for gynecological procedures. The researcher administered the verbal analogue scale, Melzack's Present Pain Intensity Scale of the McGill Pain Questionnaire, to the 75 participants at two intervals, 1 to 3 hours postoperatively and 22 to 25 hours postoperatively, to assess postoperative sore throat. Analysis using the Kruskal-Wallis test suggested that there was no statistical difference in postoperative sore throat among the 3 groups. Lidocaine, saline, and air had similar effects on postoperative sore throat.     

Should vasopressin replace adrenaline for endotracheal drug administration?

OBJECTIVE: Arginine vasopressin was established recently as a drug of choice in the treatment of cardiac arrest and in retractable ventricular fibrillation; however, the hemodynamic effect of vasopressin following endotracheal drug administration has not been fully elucidated. We compared the effects of endotracheally administered vasopressin vs. adrenaline on hemodynamic variables in a canine model, and we investigated whether vasopressin produces the same deleterious immediate blood pressure decrease as did endotracheal adrenaline in the canine model. DESIGN: Prospective controlled study. SETTING: Animal laboratory in Tel-Aviv University, Israel. SUBJECTS: Five adult mongrel dogs weighing 6.5-20 kg. INTERVENTIONS: Dogs were anesthetized; each dog was intubated orally, and both femoral arteries were cannulated for the measurement of arterial pressure and for sampling blood gases. Each dog was studied four times, 1 wk apart, by using the same protocol for injection and anesthesia: endotracheal placebo (10 mL NaCl 0.9%,), endotracheal vasopressin (1 units/kg), endobronchial adrenaline (0.1 mg/kg), and endotracheal adrenaline (0.1 mg/kg). Following placebo, vasopressin, and adrenaline instillation, five forced manual ventilations were delivered with an Ambu bag. Each dog was its own control. MEASUREMENTS AND MAIN RESULTS: Following placebo or drug administration, heart electrocardiography and arterial pressures were continuously monitored with a polygraph recorder for 1 hr. Endotracheal vasopressin produced an immediate increase of diastolic blood pressure (from 83 +/- 10 mm Hg [baseline] to 110 +/- 5 mm Hg at 1 min postinjection). This response lasted >1 hr. In contrast, both endotracheal and endobronchial administration of adrenaline produced an early and significant (p <.05) decrease in diastolic and mean blood pressures. The diastolic blood pressure increase from 85 +/- 10 mm Hg to 110 +/- 10 mm Hg took an ill-afforded 55 secs following endotracheal adrenaline. Diastolic blood pressure was significantly (p <.05) higher following vasopressin compared with adrenaline administration in both routes. CONCLUSIONS: Vasopressin accomplishes its hemodynamic effect, particularly on diastolic blood pressure, more rapidly, vigorously, and protractedly and to a significant degree compared with both endotracheal and endobronchial adrenaline. Evaluation of the effects of endotracheal vasopressin in a closed chest cardiopulmonary resuscitation model is recommended.     

肝移植术后机械通气患者再次插管的原因及其护理对策

目的探讨肝移植术后机械通气患者再次插管的原因及护理对策。方法回顾性分析2004年1月至2009年12月期间237例肝移植术后机械通气患者的病例资料。结果 30例患者发生再次插管,其中14例存活、16例死亡,病死率为53.3%。术后并发呼吸道阻塞、呼吸功能不全、出血、急性左心功能衰竭是再次插管发生的主要原因。结论再次插管发生与否对患者的预后起关键性作用。通过加强患者呼吸道湿化、保持呼吸道通畅,加强对高危患者的监护、预防突发事件的发生,加强预见性护理、预防并发症的发生,可有效降低再次插管率,降低病死率,利于患者术后康复。     

Stress doses of hydrocortisone reverse hyperdynamic septic shock: a prospective, randomized, double-blind, single-center study.

OBJECTIVE: To investigate the effects of stress doses of hydrocortisone on the duration of vasopressor therapy in human septic shock. DESIGN: Prospective, randomized, double-blind, single-center study. SETTING: Twenty-bed multidisciplinary intensive care unit in a 1400-bed university hospital. PATIENTS: Forty consecutive patients who met the ACCP/SCCM criteria for septic shock. An additional criterion for inclusion in the study was vasopressor support and high-output circulatory failure with a cardiac index of >4 L/min/m2 after fluid resuscitation (pulmonary capillary wedge pressure: 12-15 mm Hg) and without the use of positive inotropes such as dobutamine or dopexamine. The primary study end point was the time to cessation of vasopressor support (norepinephrine or epinephrine in any dose, dopamine > or = 6 microg/kg/min). Secondary study end points were the evolution of hemodynamics and the multiple organ dysfunction syndrome (MODS). The severity of illness at recruitment was graded using the Acute Physiology and Chronic Health Evaluation II and the Simplified Acute Physiology Score II scoring systems. MODS was described by the Sepsis-related Organ Failure Assessment score. INTERVENTIONS: All eligible patients were prospectively randomized to receive either stress doses of hydrocortisone or placebo. Hydrocortisone was started with a loading dose of 100 mg given within 30 mins and followed by a continuous infusion of 0.18 mg/ kg/hr. When septic shock had been reversed, the dose of hydrocortisone was reduced to 0.08 mg/kg/hr. This dose was kept constant for 6 days. As soon as the underlying infection had been treated successfully or sodium serum concentrations had increased to >155 mmol/L, the hydrocortisone infusion was tapered in steps of 24 mg/day. Physiologic saline solution was the placebo. MEASUREMENTS AND MAIN RESULTS: Hemodynamic and oxygen-derived variables were measured at previously defined time points over a study period of 5 days. Relevant clinical and laboratory measurements were registered for a study period of 14 days to assess the evolution of organ dysfunction. Baseline data at recruitment did not differ between the two groups. Shock reversal was achieved in 18 of the 20 patients treated with hydrocortisone vs. 16 of the 20 patients treated with placebo. Hydrocortisone significantly reduced the time to cessation of vasopressor support. The median time of vasopressor support was 2 days (1st and 3rd Quartiles, 1 and 6 days) in the hydrocortisone-treated group and 7 days (1st and 3rd Quartiles, 3 and 19 days) in the placebo group (p = .005 Breslow test). There was a trend to earlier resolution of the organ dysfunction syndrome in the hydrocortisone group. CONCLUSIONS: Infusion of stress doses of hydrocortisone reduced the time to cessation of vasopressor therapy in human septic shock. This was associated with a trend to earlier resolution of sepsis-induced organ dysfunctions. Overall shock reversal and mortality were not significantly different between the groups in this low-sized single-center study.     

The effects of intravenous fluids temperature on perioperative hemodynamic situation, post-operative shivering, and recovery in orthopaedic surgery

BACKGROUND: Perioperative hypothermia is physiologically stressful because it elevates blood pressure, heart rate and plasma catecholamine concentration that may increase the risk of cardiac complications, bleeding, wound infection, and post-anaesthesia care unit stay. This study was designed to evaluate the effects of warming intravenous fluids on perioperative hemodynamic situation, post-operative shivering and recovery in orthopaedic surgery patients. METHODS: Perioperative pulse rate, blood pressure, intraoperative esophageal and skin temperature were measured in sixty patients undergoing orthopaedic surgery that were randomly divided into two groups according to intraoperative IV fluids management. In 30 patients (hypothermia group) all IV fluids infused were at room temperature. In the other 30 patients (normothermia group) all IV fluids were warmed using a dry IV fluid warmer. RESULTS: The core and skin temperatures of the hypothermia and normothermia groups decreased significantly between the induction of anesthesia and the end of surgery, but the drop was greater in the hypothermia group (P < 0.005). Postoperative mean arterial blood pressure (non-invasive) increased significantly more in the hypothermia group versus normothermia group (p < 0.005). Shivering was observed in 21 of 30 in the hypothermia group and 11 of 30 in the normothermia group (p < 0.005) and recovery time was significantly lower in the normothermia group (36 +/- 5 vs. 26 +/- 3 min, p < 0.005). CONCLUSION: Intraoperative IV fluid warming reduces perioperative changes to the hemodynamic situation, post-operative shivering, and recovery time.     

头颈部手术后非计划二次插管危险因素分析

  目的  探讨头颈部手术后非计划二次插管的危险因素。  方法  回顾性分析2014年1月1日至2018年12月31日于北京协和医院行头颈部手术患者的临床资料。以术后非计划二次插管患者为研究组,随机抽取一定量的成功拔管者为对照组,研究组与对照组患者比例为1:4。多因素Logistic回归分析头颈部手术后非计划二次插管的危险因素。  结果  共60例(研究组12例,对照组48例)符合纳入和排除标准的患者入选本研究。多因素Logistic回归分析结果显示,有全身麻醉史(OR=9.17, 95% CI:1.05~83.33, P=0.045)、Cormack-Lehane分级Ⅲ级(OR=18.87, 95% CI:1.53~250.00, P=0.022)、术中液体负荷≥20 mL/kg(OR=27.78, 95% CI:1.94~500.00, P=0.014)是头颈部手术后非计划二次插管的危险因素。研究组术后住院时间[7(3.0,17.0)d比2(2.0,5.0)d,P=0.013]、ICU停留时间[1(0.0,2.8)d比0(0.0,0.0)d,P＜0.001]均长于对照组。  结论  头颈部手术后非计划二次插管与有/无全身麻醉史、Cormack-Lehane分级及术中液体负荷有关,其发生不利于患者术后康复。     

肝移植围手术期液体治疗的对术后肺部并发症影响的临床研究

目的探讨肝移植术中、术后的液体治疗与术后早期肺部并发症的关系,为肝移植围手术期合理的液体治疗提供依据。方法回顾性分析肝移植受者62例,根据术后早期是否有肺部并发症分为有并发症组(并发症包括肺水肿、急性肺损伤、肺炎、ARDS)和无并发症组。比较2组患者术前、术中、术后前3d治疗中的参数20项,筛选出影响早期肺部并发症的一些变量,并比较这些变量对术后恢复情况的影响。结果62例患者中,术后早期有肺部并发症29例(46.77%),其中围手术期死亡3例(4.84%)。应用单因素分析比较有并发症组和无并发症组患者的各项参数,结果发现以下参数有统计意义:术前肺功能、术中入量、术中出血量、术中出入量差和术后前3 d至少有2 d的液体平衡≤-500 mL。将它们作为自变量、术后肺部并发症作为因变量,进行logistic多因素回归分析。筛选影响早期肺部并发症的因素,结果保留在回归方程中的变量有:术前肺功能、术中出血量和术后前3 d至少有2 d的液体平衡≤-500 mL。结论肝移植围手术期液体治疗中,术中、术后维持液体平衡是减少肝移植术后肺部并发症的重要措施,尤其是术后前3d在血液动力学稳定的前提下,适当的液体负平衡有利于受体恢复。     

Comparison of the time to extubation after use of remifentanil or sufentanil in combination with propofol as anesthesia in adults undergoing nonemergency intracranial surgery: a prospective, randomized, double-blind trial

BACKGROUND: Anesthetics with a short context-sensitive half-time (ie, the time required for the effect-site concentration of an IV drug to decrease by 50% at steady state), such as the opioids remifentanil and sufentanil, are suitable for anesthesia when early neurologic assessment is desired to detect postoperative complications. OBJECTIVE: This study compared the efficacy and safety profile of remifentanil and sufentanil in combination with propofol for anesthesia in adult patients undergoing nonemergency intracranial surgery. METHODS: This was a prospective, randomized, double-blind study in adults aged 18 to 75 years who were scheduled to undergo a supratentorial neurosurgical procedure with a maximum anticipated duration of 480 minutes. Eligible patients had no incapacitating severe systemic disease (American Society of Anesthesiologists physical status class 1-3), and only those in whom immediate postoperative extubation was planned were included. Anesthesia was induced with propofol and either remifentanil 1 microg/kg or sufentanil 0.25 microg/kg. Propofol was continued using a target-controlled infusion (TCI) system. Maintenance infusion rates for remifentanil and sufentanil were 0.25 and 0.0025 microg.kg-1.min-1, respectively. The opioid and propofol infusions were adjusted based on hemodynamic parameters (mean arterial blood pressure, heart rate). The primary end point was the time to extubation. Secondary end points were hemodynamic stability (defined as the number of anesthetic adjustments required to maintain intraoperative hemodynamic parameters within 20% of preinduction values), postoperative IV morphine requirement, postoperative nausea/vomiting (PONV), and intraoperative anesthetic costs. RESULTS: Sixty adults (29 remifentanil, 31 sufentanil) were included in the study. The 2 groups were similar with respect to sex, weight, indication for surgery, and duration of anesthesia. The sufentanil group was significantly older than the remifentanil group (55.3 vs 45.7 years, respectively; P=0.001). The median extubation time was similar in the remifentanil and sufentanil groups (10 minutes [interquartile range, 5-19 minutes] and 16 minutes [interquartile range, 10-30 minutes], respectively). Remifentanil was associated with the need for significantly fewer adjustments to maintain hemodynamic stability compared with sufentanil (0.8 vs 2.1; P=0.037), greater use of postoperative morphine (44.8% vs 22.6% of patients, P=0.01; mean IV morphine dose per patient: 4 vs 1.3 mg, P=0.016), and higher intraoperative opioid costs per patient euro vs euro P<0.001). The incidence of PONV did not differ significantly between groups. The total cost of intraoperative anesthetics per patient was similar in the 2 groups euro and euro as was the cost of propofol euro vs euro CONCLUSION: In these adults undergoing nonemergency intracranial surgery, there was no significant difference in extubation time between those receiving remifentanil and sufentanil infusions adjusted based on hemodynamic parameters in combination with propofol administered by TCI.     

Changes of salivary alpha amylase activity as an indicator of adrenergic activity in response to laryngoscopy and endotracheal intubation

The goal of the study was to determine the diagnostic value of the salivary alpha amylase (sAA) as an indicator of adrenergic activity in response to laryngoscopy and endotracheal intubation. The research group consisted of 52 patients (ASA 1-2) with the median age of 52 +/- 16, scheduled for elective orotracheal intubation by the means of standard intravenous induction of anesthesia. sAA and cortisol in saliva as well as norepinephrine (NA) and cortisol levels in plasma were determined in two points: immediately before laryngoscopy (point A) and one minute after intubation (point B). The heart rate (HR) and mean arterial pressure (MAP) were recorded in corresponding time points to reveal if any correlation existed between hemodynamic parameters and neuroendocrine response. The results showed that MAP significantly increased in point B compared to point A, p < 0.05. HR did not show any significant increase. sAA considerable increase in point B correlated with the MAP-shown increase in the same time point (r(s) = 0.328, p < 0.05). NA increased in point B compared to point A and correlated with sAA increase (r(s) = 0.456, p < 0.01) and MAP changes (r(s) = 0.469, p < 0.01). Cortisol levels both in saliva and plasma did not change. The research proved the increased level of sAA as an adrenergic activity response to laryngoscopy and endotracheal intubation and shown it resemblance to changes of NA and MAP.     

The effect of a thyroid hormone infusion on vasopressor support in critically ill children with cessation of neurologic function

OBJECTIVE: To determine the impact of a thyroid hormone infusion (T4) on the vasopressor requirements in children with cessation of neurologic function (i.e., brain death) during evaluation for organ recovery DESIGN: Retrospective cohort study. SETTING: The 1998-2002 database of a regional organ recovery program. PATIENTS: Children 相似文献   

A Multicenter,Randomized, Double‐Blind,Placebo‐Controlled Trial of Intravenous Ibuprofen (IV‐Ibuprofen) in the Management of Postoperative Pain Following Abdominal Hysterectomy

Background: Ibuprofen and other nonsteroidal anti‐inflammatory drugs are widely used to block pain and inflammation in a variety of settings. Contrarily, opioid analgesia does not block the inflammatory component of pain and the use of these agents can be accompanied by serious side effects. We conducted a multicenter, randomized, double‐blind, placebo‐controlled trial to evaluate the safety and efficacy of intravenous ibuprofen (IV‐ibuprofen) as a postoperative analgesic. Methods: A total of 319 patients were randomly assigned in a 1:1 ratio to receive 800 IV‐ibuprofen or placebo every 6 hours; in addition patients had access to morphine at a dose of 1–2 mg every 5 minutes. The primary outcome measure was median morphine consumption within the first 24 hours following surgery. Results: During the first 24 hours of treatment, the median morphine requirement was reduced by 19% (P ≤ 0.001) and resulted in a significant reduction in pain at rest (AUC, 6 to 24 hours and 12 to 24 hours, P < 0.001) and pain with movement (AUC, 6 to 24 hours, P = 0.010 and 12 to 24 hours, P ≤ 0.001) as measured by the visual analog scale (VAS) in patients receiving 800 mg IV‐ibuprofen compared to placebo. Time to ambulation was significantly faster (P = 0.018) in the IV‐ibuprofen treated group, as well. Similar treatment‐emergent adverse events occurred across both study groups and there was no difference in the overall incidence of these events. Conclusion: This study demonstrated that IV‐ibuprofen is an effective analgesic medication that is safe and well tolerated when administered as an 800 mg dose every 6 hours in patients undergoing total abdominal hysterectomy surgery.     

彩色多普勒超声检测移植肝血流变化预测胆道并发症发生的可行性

目的探讨肝移植术后彩色多普勒超声检测血流变化预测胆道发生并发症的可行性。 方法超声观察125例肝移植患者术后肝脏动静脉血流变化，主要观测血管内径（D），峰值流速（PS），阻力指数（RI），时间平均流速（TAV）。 结果肝移植术后，发生胆道并发症者49例，各项指标分别与术后未发现并发症的对照组59例相比：（1）术后30d内肝动脉PS减低，RI增高，2项指标差异均有显著性意义；（2）术后15d内并发症组肝静脉D较细，TAV减低，差异均有显著性意义；（3）两组间门静脉TAV差异无显著性意义，但并发症组中，单纯肝动脉供血不足者13例，门静脉TAV增高，与对照组相比，差异有非常显著性意义；单纯出现排异反应者8例，门静脉TAV减低，与对照组相比，差异有显著性意义。 结论超声预测肝移植术后肝动脉供血不足及排异反应导致的胆道并发症是可行的。     

Comparative effects of early versus delayed use of norepinephrine in resuscitated endotoxic shock

OBJECTIVE: To assess hemodynamic, tissue oxygenation, and tissue perfusion changes by comparing traditional therapy (fluid resuscitation followed by vasopressor treatment) and alternative therapy (early vasopressor treatment) in a hyperkinetic and sedated model of endotoxic shock. DESIGN: Prospective controlled experimental study. SETTING: Animal research laboratory. SUBJECTS: Male Wistar rats. INTERVENTIONS: Rats were anesthetized, mechanically ventilated, paralyzed, and instrumented to measure mean arterial pressure, heart rate, pulse pressure variation, aortic and mesenteric blood flow, muscle and liver tissue oxygen pressure, blood gas, and lactate. Rats were randomly divided into five groups (n = 7): endotoxin alone (Endo), endotoxin plus norepinephrine (Endo/NE), endotoxin plus fluid therapy alone (ENDO/Fl), endotoxin plus fluid therapy plus late catecholamine (Endo/Fl/Late NE), and endotoxin plus fluid therapy plus simultaneous norepinephrine administration (Endo/Fl/Early NE). MEASUREMENTS AND MAIN RESULTS: Mean arterial pressure increased to baseline values only in the catecholamine-treated group (p < .05). In ENDO/Fl, Endo/Fl/Late NE, and Endo/Fl/Early NE, aortic blood flow was maintained. Mesenteric blood flow was maintained at baseline values only in the catecholamine-treated groups. Mesenteric/aortic blood flow ratio was higher in the early catecholamine group (p < .05). Endo and ENDO/Fl were associated with a marked decrease in liver PO2, which was maintained in catecholamine-treated groups (p < .01). Plasma lactate was lower in the Endo/Fl/Early NE group. Volume resuscitation was higher in Endo and Endo/Fl/Late NE groups with 28 +/- 6 and 27 +/- 4 mL, respectively, when compared with the Endo/Fl/Early NE group (19 +/- 3 mL) (p < .05). CONCLUSIONS: The use of norepinephrine was associated with improved mean arterial pressure, sustained aortic and mesenteric blood flow, and better tissue oxygenation when compared with fluid resuscitation alone, irrespective of time of administration. The early use of norepinephrine plus volume expansion was associated with a higher proportion of blood flow redistributed to the mesenteric area, lower lactate levels, and less infused volume. Thus, the early use of norepinephrine is safe and may decrease the need for volume resuscitation.