肋间神经移位修复桡神经肱三头肌肌支的长期随访疗效

目的 分析探讨肋间神经移位修复桡神经肱三头肌肌支的长期随访疗效.方法 回顾性随访2004年至2008年于我院行肋间神经移位修复桡神经肱三头肌肌支的23例患者术后肱三头肌肌力的恢复情况.其中16例患者诊断为全臂丛神经根性撕脱伤,7例患者诊断为C5～G7根性撕脱伤合并下干损伤(非根性撕脱伤).患者受伤至接受肋间神经移位手术的时间间隔为5.7个月;平均随访时间48.7个月.结果 肱三头肌肌力恢复优良率(肌力恢复至M3及以上)为39.1％,肌力恢复至M2的患者占30.4％,肌力恢复至M1及以下占30.5％.G5～C7根性撕脱伤合并下干损伤患者肱三头肌肌力恢复优于全臂丛神经根性撕脱伤患者.使用2根或2根以上的肋间神经移位修复肱三头肌肌支术后疗效未见明显差异.结论 肋间神经移位修复桡神经肱三头肌肌支可使肱三头肌得到一定程度的恢复.     

多组神经移位治疗臂丛上、中干根性撕脱伤重建肩外展及屈肘功能

目的 观察联合应用多组神经移位治疗臂丛上、中干根性撕脱伤的临床效果。方法 我科于2012年4月至2014年4月收治臂丛上、中干根性撕脱伤损伤患者16例,采用副神经斜方肌肌支移位修复肩胛上神经、桡神经肱三头肌长头支移位修复腋神经肌支及Oberlin术式,联合修复臂丛上、中干根性撕脱伤,恢复肩外展及屈肘功能。术后随访采用DASH评分表进行手术疗效评估。结果 术后16例患者中14例得到随访。随访24—28个月(平均25个月),患者肩关节外展恢复至75°-90°,恢复时间9-18个月(平均14个月)。屈肘恢复至100°-160°,恢复时间4-7.5个月（平均5.8个月）。DASH评分8-14分,平均14.6分。结论 臂丛上、中干损伤使用多组神经移位联合治疗,可较好恢复肩外展及屈肘功能,尺神经部分束支移位修复肌皮神经肱二头肌支对手内在肌功能无明显影响。     

臂丛神经根性撕脱伤的治疗

神经移位术是治疗臂丛根性撕脱伤的主要方法。臂丛丛外移位神经包括肋间神经(Tsuyama1969)、副神经(Kotani1970)、颈丛运动支(Brunelli1977)、膈神经(顾玉东1970)、健侧颈7神经根(顾玉东1986)等。其中，健侧颈7根移位神经纤维数量最多，安全有效，已被国内外广泛应用。近年来，胸腔镜下超长切取膈神经，有效缩短了神经再生时间。对颈5、6根性撕脱伤，改良的Oberlin术式——臂丛丛内部分尺神经或正中神经移位修复肌皮神经肱二头肌支，手术简单，屈肘功能疗效肯定；同侧颈7根移位术有效且能恢复多组肌肉功能。对颈8胸1根性撕脱伤，肌皮神经肱肌肌支移位修复正中神经屈指肌束或骨间前神经以恢复屈指功能。对全臂丛根性撕脱伤，改良的Doi术式——双股薄肌移位联合神经移位较好恢复了手握持功能；肢体短缩，健侧颈7移位直接修复正中、尺神经，能恢复屈拇屈指功能，但手内肌功能仍无恢复。如何重建手内肌仍需作进一步探索。     

复合式神经移位术治疗臂丛根性撕脱伤

自１９８８年１１月～１９９４年１２月，应用复合式神经移位术治疗臂丛根性撕脱伤８９例。损伤原因为：摩托车撞击伤６３例，机器牵拉伤２１例，直接损伤５例。损伤类型为：上臂丛型４７例，下臂丛型１３例，全臂丛型２９例。伤后至手术时间为３周～６个月。神经移位方式主要根据不同的损伤类型选用相应的移位方式。术后随访时间为１．５～６年。疗效最佳为膈神经移位，有效率达８２．９％；其次为副神经，达６６．７％；颈丛运动支达５５．２％；肋间神经达４８．３％；健侧Ｃ７神经根移位与患侧尺神经吻合，神经再生率达９６．６％。作者认为，复合式神经移位术治疗臂丛根性撕脱伤，尤其是对上臂丛根性撕脱伤，治疗效果是令人满意的。     

尺神经部分神经束移接肱二头肌运动支术中肌电和疗效观察

目的研究利用尺神经部分神经束移位，治疗臂丛上干根性撕脱伤的临床效果，以及术中应用诱发电位检测供区神经束的经验。方法１９９６年７月～１２月，对６例臂丛上干根性撕脱伤行部分尺神经神经束移接于肌皮神经外侧支手术。术中对尺神经保留部分和切取部分的神经束进行电生理检测。结果尺神经保留部分和切取部分神经束诱发电位的潜伏期和波幅，两者结果均无明显差异。４例术后随访３～７．５个月，肱二头肌肌力恢复到２～３级，供区神经支配区无功能障碍。肌电图检查：神经束移位后的肱二头肌均有新生电位出现。结论采用部分尺神经束移位，治疗臂丛上干根性撕脱伤以恢复屈肘功能，是一个可行的有效的手术方法     

正中神经、尺神经部分束支移位术重建屈肘功能

目的 观察正中神经、尺神经部分束支移位术的临床疗效及手术前后供体神经功能的变化,分析影响手术疗效的因素。方法 应用正中神经、尺神经部分束支移接给肱二头肌肌支治疗臂丛神经上千型根性撕脱伤,重建屈肘功能。对施行手术的36例患者进行6个月至5年多的随访,根据肱二头肌肌力和肘关节主动活动范围,将患者术后恢复情况分为三级：优：肱二头肌肌力达4级以上,肘关节屈曲达90度以上;可：肱二头肌肌力达3级,肘关节屈曲达60～90度;差：肱二头肌肌力2级以下,肘关节屈曲60度以下。分析影响疗效的几种因素。结果 手术疗效显著,有效率(肱二头肌肌力3级以上)达94．4％,优良率(肱二头肌肌力4级以上)达63．9％。手术前后供体神经功能没有明显变化。影响手术疗效的主要因素有：损伤类型、损伤原因、手术距损伤的间隔时间、患者年龄、供体神经的选择及术后功能锻炼。准确判断患者的损伤类型,严格掌握手术适应证是手术成功的关键。结论 正中神经、尺神经部分束支移位术是治疗臂丛神经上千型根性撕脱伤的一种安全、可靠、有效的手术方法。     

改良法膈神经移位肌皮神经术的临床疗效分析

神经移位是治疗臂丛神经根性撕脱伤的主要方法，其中隔神经移位术是目前治疗臂丛神经根性撕脱伤最有效的方法之一，据文献报道有效率达84．62％。经典的手术方法是将锁骨后松解，打通肋锁间隙，将移植神经通过该间隙桥接，手术难度和风险较大。我们通过改良，简化了膈神经移位肌皮神经的手术方法，取得了良好的效果。     

多组神经移位治疗臂丛C5~C7根性撕脱伤重建肩外展及屈肘功能

目的观察联合应用多组神经移位治疗臂丛上、中干根性撕脱伤重建肩外展及屈肘功能的临床效果。方法我科于2012年4月至2014年4月收治臂丛上、中干根性撕脱伤患者16例,采用副神经斜方肌肌支移位修复肩胛上神经、桡神经肱三头肌长头支移位修复腋神经肌支及尺神经部分束支移位肌皮神经（Oberlin术式）,联合修复臂丛上、中干根性撕脱伤,以恢复肩外展及屈肘功能。术后随访采用臂肩手功能障碍（the disabilities of the arm, shoulder and hand, DASH）评分表评估疗效。结果16例患者中有14例术后得到随访。随访时间为24~28个月（平均为25个月）,患者肩关节外展恢复至75°~90°,恢复时间为9.0~18.0个月（平均为14.0个月）。屈肘恢复至100°~160°,恢复时间为4.0~7.5个月（平均为5.8个月）。DASH评分为8.0~16.0分,平均为14.6分。结论使用多组神经移位联合治疗臂丛上、中干损伤,可较好恢复肩外展及屈肘功能,尺神经部分束支移位修复肌皮神经肱二头肌支对手内在肌功能无明显影响。     

移植神经长度对膈神经移位肌皮神经疗效的影响

目的 探讨移植神经长度对膈神经移位肌皮神经治疗臂丛神经根性撕脱伤疗效的影响.方法 对2007年至2010年于我院行膈神经移位肌皮神经治疗臂丛损伤的患者进行临床随访,其中17例需要做神经移植.通过检测肱二头肌肌力与体重指数(BMI)评定手术疗效.结果 17例患者的总体有效率82.4％,移植神经长度以及BMI与屈肘功能恢复无明显相关性.结论 臂丛损伤患者尤其是全臂丛损伤患者中,膈神经移位肌皮神经的临床疗效不受移植神经长度以及BMI的影响.     

选择性正中、尺神经部分束联合副神经移位治疗颈5,6根性撕脱伤

目的探讨选择性正中、尺神经部分束联合副神经移位治疗臂丛颈5、6根性撕脱伤的疗效。方法22例臂丛颈5、6根性撕脱伤,行选择性正中神经内侧一神经束移位修复腋神经外侧半、尺神经内侧一神经束移位修复肌皮神经肱二头肌支,联合副神经斜方肌支移位修复肩胛上神经。结果术后时间超过12月随访16例,平均随访24月。15例屈肘100°～150°,肌力M4～M5;肩外展90°～120°,肌力M3～M4。1例屈肘90°;肩外展75°。按中华手外科学会标准,优15例,良1例。结论选择性正中、尺神经部分束联合副神经斜方肌支移位治疗臂丛颈5、6根性撕脱伤,可很好恢复屈肘、肩外展功能,且手术简便、功能恢复时间较短。     

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.     

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.     

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.     

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.