微RNAs在脊髓缺血再灌注损伤中的研究进展

脊髓缺血再灌注损伤(SCII)是胸、腹主动脉术后最严重的并发症之一,可导致严重的神经功能障碍,甚至瘫痪^[1]。SCII主要包括缺血和再灌注2个阶段,缺血发生在体内大动脉阻断或循环停止期间,再灌注包括活性氧和炎性细胞因子的释放以及细胞凋亡^[2]。SCII的具体发生机制目前尚不清楚,近年来,对SCII的病因和发生机制的研究主要包括氧自由基介导的脂质过氧化损伤、炎性反应^[3-5]、细胞内Ca²⁺超载^[6-7]、以谷氨酸盐为主的兴奋性氨基酸的毒性作用^[8]、细胞凋亡^[9-10]和细胞自噬^[11-12]等。微RNA(miRNA)是一类长度为19~25个核苷酸的非编码单链RNA,可以通过和其靶mRNA的3''非编码区(3''-UTR)上的互补核苷酸配对来抑制mRNA或蛋白质的合成,调控靶基因的表达,从而进一步调节细胞的生长、增殖、分化和凋亡^[13]。靶基因的抑制或降解主要取决于miRNA与其靶基因的互补程度,如miRNA与目标mRNA部分配对,会抑制蛋白质合成;如miRNA与其靶mRNA完美(或接近完美)配对,则会导致mRNA降解。单个miRNA可以靶向数百个mRNA,并影响许多基因的表达。据统计,miRNAs能够调节人类基因组中多达30%的编码基因^[14]。此外,miRNAs的作用机制涉及多种重要过程,包括凋亡、分化、发育、增殖和信号转导等。miRNAs已被证实与许多疾病的发生有关,包括自身免疫性疾病(如哮喘、嗜酸性食管炎、过敏性鼻炎和湿疹)^[15]、癌症^[16]、糖尿病及心血管疾病^[17-18]、骨骼肌肉疾病^[19]。miRNAs因在细胞液中的稳定性、在人类和哺乳动物之间的保守性和组织特异性成为重要的生物标志物,在调节神经系统疾病(包括SCII)中发挥着至关重要的作用^[20-21]。     

单侧双通道内窥镜下椎间盘切除术治疗腰椎术后退行性变1例报告

腰椎术后邻近节段退行性变(ASD)是腰椎后路融合术后的常见远期并发症^[1-2],其发生率为4%~31%^[3-5]。ASD由多种因素引起,继而产生新的神经压迫症状。Kambin等^[6]于1986年提出单侧双通道内窥镜下椎间盘切除术(UBED)治疗腰椎椎间盘突出症(LDH)^[7],其兼具了开放手术与微创手术的优点^[8]。本院采用UBED治疗腰椎术后ASD患者1例,现将诊疗过程报告如下。     

颈椎人工椎间盘置换术与颈椎前路椎间盘切除融合术治疗颈椎病的研究进展

颈椎前路椎间盘切除融合术（ACDF）是治疗颈椎病的经典术式,疗效明确,但因责任节段融合引起相邻节段椎间盘压力及未融合节段活动范围增加,导致术后手术关节活动度（ROM）欠缺、邻近节段退行性变（ASD）加速等。针对融合术式存在的弊端,非融合技术颈椎人工椎间盘置换术（CTDR）应运而生,应用于颈椎病的治疗,疗效可靠,可在完成神经减压后保留手术节段ROM,恢复椎间盘高度,降低邻近节段ASD的发生率,克服了ACDF的固有局限^[1-3]。CTDR有明确的适应证和禁忌证^[4],而ACDF的禁忌证较少,2种术式的优劣目前尚无定论。自2005年开始,多个研究中心围绕CTDR和ACDF的疗效优良率、关节ROM、颈椎功能障碍指数（NDI）等方面展开分析比较,得出2种术式的临床疗效相似的结论^[5-9],甚至有部分研究认为CTDR疗效优于ACDF^[10-12]。但因随访时间短,对于CTDR的疗效和预后仍存在争议^[10,13]。近年来,诸多研究^[14-19]在比较CTDR与ACDF预后的同时,还围绕2种术式的医疗支出、恢复周期、运动功能等展开讨论,为术式的个性化选择提供依据。     

生物相容高分子水凝胶在椎间盘修复再生方面作用的研究进展

椎间盘退行性变为慢性疾病,会导致脊柱承重不稳,进而损伤脊髓、马尾神经和神经根,60%的70岁以上老年人群会发病^[1-2]。由于椎间盘退行性变的病理学、病理生理学及生物力学机制并不完全清楚,目前的治疗手段仅能减轻疼痛症状,不能完全消除疾病^[3-4]。椎间盘切除术和椎间融合术是治疗椎间盘退行性变的常用术式,但易造成脊柱生物力学的改变^[5]。人工椎间盘可应用于椎间盘退行性变的治疗,但因椎间盘的结构和功能复杂,很难设计出理想的椎间盘假体来保持天然组织结构和生物力学特征。理想的生物组织替代物应具有高强度、高柔性和高韧性^[6]。     

斜外侧入路腰椎椎间融合术的应用进展

腰椎椎间融合术（LIF）被广泛应用于腰椎椎间盘退行性疾病^[1-2]。LIF包括前/后路椎间融合术（ALIF/PLIF）、经椎间孔腰椎椎间融合术（TLIF）、极外侧/直接外侧腰椎椎间融合术（XLIF/DLIF）等,这些术式具有一定的临床疗效,亦各有优缺点^[3-4]。Mayer^[5]于1997年首先提出一种微创手术入路,Silvestre等^[6]于2012年将其正式命名为斜外侧腰椎椎间融合术（OLIF）,该术式提供了一条通过腹膜后血管鞘和腰大肌前缘间隙到达腰椎的入路,通过避开固有结构,降低了血管及神经丛的损伤风险,同时有较大的操作空间可更好地清除椎间盘及置入更大的椎间融合器,避免暴露引起术后并发症。近年来,OLIF广泛应用于治疗腰椎退行性疾病,相比传统椎间融合术,OLIF具有创伤小、出血少、恢复快及融合率高等优点^[6]。本文从OLIF的手术技术,适应证及禁忌证,临床应用及并发症等方面进行分析,综述如下。     

寰枢椎脱位伴齿突后假瘤诊疗的研究进展

齿突后假瘤是由寰枢椎脱位或其他病因引起的炎性肉芽肿或反应性肥大导致齿突后软组织增生病变^[1]。其可压迫脊髓，导致疼痛、感觉异常，甚至瘫痪。引起齿突后假瘤较常见的病因有类风湿关节炎（RA）^[2-3]、寰枢椎脱位^[4]、颈椎退行性疾病^[5]，少见的病因有长期透析^[6]、晶体沉积^[7]、滑膜囊肿^[8]等。     

椎间盘源性腰痛合并下位椎间隙塌陷2例报告

腰痛为骨科临床常见症状，其可能源于腰椎椎间盘，而椎间盘源性腰痛（DLBP）最常见节段为L₄/L₅和L₅/S₁^[1-3]。DLBP是椎间盘内各种病变（如退行性变等）刺激椎间盘内疼痛感受器引起的功能丧失的下腰痛，不伴根性症状，无神经受压或节段过度活动的影像学证据^[4]。目前DLBP的诊断、治疗仍存在诸多疑问，特别是椎间隙塌陷且MRI显示塌陷节段为“黑间盘”时容易将塌陷节段臆断为责任节段，造成误诊。海军军医大学附属长征医院收治DLBP合并下位椎间隙塌陷患者2例，联合应用椎间盘造影和椎间盘阻滞确诊后行椎间融合术，术后患者腰痛均缓解。现将诊疗过程报告如下，并对诊断存在的争议进行讨论。     

虚拟现实技术在颈椎外科中的应用研究进展

虚拟现实（VR）技术是以计算机生成的三维图像数据为基础,模拟真实场景,通过输出设备给操作者带来沉浸式体验的数字技术。VR技术具有3“I”特性,即沉浸（immersion）、交互（interaction）和想象（imagination）”^[1],还有多种类的信息（视觉、听觉和触觉）输出形式;同时,借助于VR系统内置的运动传感器可获得使用者运动过程中的运动角度、速度和位移等参数。VR系统通过即时提供多重感官模拟并给予反馈,与用户的感知运动系统建立联系^[2]。此外,基于计算机构建的VR系统可在不同时间及地点重复使用。得益于以上诸多优点,VR技术在医学领域,如临床教学^[3]、术前规划^[4]、术后康复训练^[5]等,展现出独特的优势。     

颈椎椎间盘突出致脊髓半切综合征误诊为脑卒中1例报告

脊髓半切综合征(BSS)由Brown-Sequard于1849年首次提出^[1],是由外部压迫和内部病变等原因引起的一种罕见的脊髓不完全性损伤,通常发生在颈部^[2]。可由创伤(如枪伤、刺伤、骨折及椎体脱位)和非创伤(如肿瘤、硬膜外血肿、多发性硬化症、辐射等)引发^[3-5],因椎间盘突出导致的BSS相对较少^[6-7]。BSS表现为病变侧损伤平面以下深感觉障碍及上运动神经元性瘫痪;对侧损伤平面以下疼痛、温觉丧失^[8-9],有轻度到严重的神经功能受损。BSS占创伤性脊髓损伤的1%~4%^[10],国内外相关文献报道较少,主要为个案报道^[2,11]。本院急诊科于2020年10月22日收治1例因存在类卒中症状,初期被误诊为急性脑梗死,在下级医院进行过溶栓治疗的BSS患者,现对诊疗过程进行梳理分析,报告如下。     

经皮内窥镜技术治疗老年单节段退行性腰椎椎管狭窄症

腰椎椎管狭窄症（LSS）是骨科常见病之一。随着我国老龄化的加速,老年退行性腰椎椎管狭窄症（DLSS）的发生率逐年增加,腰腿痛和间歇性跛行严重影响患者的生活质量^[1]。DLSS往往由椎间盘突出或合并钙化、小关节骨赘增生及黄韧带肥厚等原因引起,部分患者合并发育性椎管狭窄^[2-3]。临床上根据解剖部位将LSS分为中央管狭窄（椎管中央型狭窄）、关节下管狭窄（神经根管的关节下段,包括侧隐窝）和椎间管狭窄（椎弓根及椎间孔段）^[4-5]。老年DLSS患者一般病史较长,影像学资料提示多节段的椎间盘膨出或突出、黄韧带肥厚、小关节增生、侧隐窝狭窄,有时神经根病变的定位诊断也不明确,是否需要将所有狭窄的间隙部位减压,是否需要广泛的融合固定一直是临床争论的问题^[6]。传统腰椎减压融合术治疗DLSS效果明显,但手术创伤较大,术后感染、切口愈合不良、植骨区不融合、内固定松动断裂、邻椎病等手术并发症使得此类技术的应用受到限制^[7]。近年来,经皮内窥镜技术在治疗DLSS方面优势明显,通过术前病史询问、体格检查及相关影像学资料的反复研究,并根据病情需要可结合椎间盘造影,最终精准定位责任椎间隙及椎管狭窄部位行靶向穿刺,达到定点精准减压。2014年5月-2017年8月,本院采用经皮内窥镜下减压术并射频消融术治疗老年单节段DLSS患者40例,现将诊疗过程报告如下。     

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.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

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.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.