血浆置换联合利妥昔单抗治疗肾移植术后抗体介导的排斥反应1例报告并文献复习

目的探讨血浆置换联合利妥昔单抗治疗肾移植术后抗体介导排斥反应(antibodymediated rejection,AMR)的疗效。方法回顾分析1例发生AMR的肾移植受者的临床资料并复习相关文献。结果 1例女性患者,肾移植术后7年,分娩后移植肾失功,1年后行二次肾移植术。术后予他克莫司(FK506)+麦考酚吗乙酯(MMF)+泼尼松三联免疫抑制治疗,肾功能正常。术后5 d患者出现突发尿少,移植肾区胀痛,群体反应性抗体(PRA)Ⅰ类分子升高至14.29%,供体特异性抗体(donor-specific antibody,DSA)阳性,血清肌酐(Scr)升高达606μmol/L,予血浆置换1次(血浆2 000 ml),置换后给予单剂利妥昔单抗500 mg静脉滴注,治疗18 d后复查PRA及DSA阴性,尿量增加,肾功能恢复正常。患者随访至2011年6月,查PRA及DSA一直维持阴性,肾功能良好。结论血浆置换联合利妥昔单抗用于治疗肾移植术后AMR有一定疗效。     

肾移植术后急性体液性排斥反应的治疗

目的 总结肾移植术后急性体液性排斥反应中针对HLA抗体的检测和处理经验.方法 肾移植受者15例,术前行HLA分型、交叉配型和群体反应性抗体(PRA)的检测,术后采用他克莫司(或环孢素A)、霉酚酸酯和糖皮质激素预防排斥反应.15例于肾移植后1～14 d发生抗体介导的急性排斥反应(AMR),采用抗胸腺细胞球蛋白(100 mg/d,使用5 d)治疗,或将环孢素A转换为他克莫司,当PRA明显升高,且血清中出现供者特异性HLA抗体时,即行血浆置换(PP),共行1～5次,每次PP后静脉输注免疫球蛋白(IVIG)100～150 mg/kg,最后1次PP后给予WIG 200～500mg/kg.结果 术后出现抗供者特异性HLA Ⅰ类抗体者9例,抗HLAⅡ类抗体者4例,同时出现抗Ⅰ、Ⅱ类抗体者2例.14例的AMR逆转,1例术后发生移植肾功能恢复延迟,彩色多普勒超声波显示移植肾血流灌注差,于术后第10天切除移植肾.并行二行肾移植.2例AMR后并发急性肾小管坏死,透析后移植肾功能恢复正常.抗排斥反应治疗期间患者均未发生严重感染.随访12～52个月,1例因慢性移植肾肾病恢复血液透析治疗,1例死于心血管疾病,其余患者移植肾功能稳定.结论 将ATG、PP和IVIG联合应用能有效逆转AMR.     

高度致敏受者肾移植的临床处理

目的 总结高度致敏受者肾移植的临床处理经验.方法 26例群体反应性抗体(PRA)峰值≥50%的高致敏患者行同种异体肾移植术.男8例,女18例.平均年龄(47.6±7.4)岁.首次接受移植者15例,二次移植者10例,三次移植者1例.亲属供肾1例,尸体供肾25例.术前要求交叉配型阴性.术后采用抗CDzs单克隆抗体诱导,他克莫司加吗替麦考酚酯加激素三联维持治疗.结果 18例移植后1周内血肌酐(SCr)降至正常.2例分别于术后第2、3天出现加速性排斥反应,经过血浆置换3次及抗CD3单克隆抗体5 mg/d治疗5 d后,1例3周后移植肾功能逐渐恢复正常,另1例排斥反应未能逆转,最终摘除移植肾.发生急性排斥反应6例,2例经激素冲击治疗后逆转,4例为耐激素排斥反应,经抗CD3单克隆抗体5 mg/d治疗5 d和血浆置换治疗3次后,排斥反应逆转.1年移植肾存活率96%(25/26).结论 高度致敏受者肾移植不仅需要HLA配型良好,并且要求供者HLA抗原避开受者所有预存的抗HLA抗体;术后采用抗CD25单克隆抗体诱导,他克莫司加吗替麦考酚酯加激素三联维持治疗,能有效预防和治疗急性排斥反应.     

肾移植后新发狼疮肾炎一例

患者为男性,年龄为30岁.因慢性肾小球肾炎及慢性肾功能不全(尿毒症期),于2008年在我院行亲属活体肾移植(供者为其母亲).术后3d,移植肾功能恢复正常,术后8d,尿量恢复正常.以他克莫司3 mg/d+吗替麦考酚酯2.25mg/d+泼尼松5 mg/d预防排斥反应.2009年5月复查,发现尿蛋白持续++,隐血+～++,于外院诊断为“慢性排斥反应”,血肌酐呈缓慢进展,最高达996 μmol/L,遂开始行规律血液透析治疗.2011年7月,以“肾移植后3年,肾功能异常2年余,肉眼血尿20d,胸闷、憋气10 d”收入我院.     

他克莫司、霉酚酸酯和血浆置换联合应用治疗肾移植术后急性体液性排斥反应

目的　探讨他克莫司 (FK5 0 6 )、霉酚酸酯和血浆置换联合应用治疗急性体液性排斥反应的效果。方法　 6例肾移植后发生急性体液性排斥反应的患者 ,术后采用环孢素A、霉酚酸酯和激素行免疫抑制治疗 ,发生急性体液性排斥反应时经甲泼尼龙和抗胸腺细胞球蛋白治疗无效 ,行血浆置换 4～ 6次 ,并给予FK5 0 6 (0 .2mg·kg-1·d-1)及霉酚酸酯 (由 2 g/d加至 3g/d)治疗。 结果　经 4～ 6次血浆置换和FK5 0 6、霉酚酸酯治疗 ,排斥反应得到逆转 ,6例患者肾功能均恢复良好 ,随诊 3～ 18个月 ,患者的血肌酐水平为 (12 5 .2± 2 6 .5 ) μmol/L。 结论　FK5 0 6、霉酚酸酯和血浆置换联合应用能有效地逆转急性体液性排斥反应     

预存供体特异性抗体阳性肾移植6例报告并文献复习

为探讨术前预存供体特异性抗体(DSA)受者的肾移植临床效果,回顾性分析2017～2019年郑州大学第一附属医院收治的6例术前DSA阳性肾移植受者的临床资料并复习相关文献。6例受者术前群体反应性抗体(PRA)、DSA均阳性,其中3例为亲属来源受者,围手术期通过利妥昔单抗、血浆置换、丙种球蛋白及大剂量兔抗人胸腺细胞免疫球蛋白、甲泼尼龙等联合用药方案降低受者体内预存DSA。术后密切关注受者尿量、血肌酐及DSA动态变化。3例亲属肾移植受者中,1例受者术后13 d出现尿量减少,血肌酐升高,怀疑亚临床排斥反应,给予甲泼尼龙冲击治疗2 d后尿量恢复,血肌酐降至正常水平;其余2例亲属肾移植受者均于术后2周尿量及血肌酐恢复正常水平,DSA降至低危水平。另3例为公民逝世后器官捐献来源肾移植(中国Ⅱ类)受者,术前常规激素+兔抗人胸腺细胞免疫球蛋白诱导治疗后行肾移植术,术后均发生抗体介导排斥反应(AMR)导致移植肾功能延迟恢复(DGF)。通过血浆置换、利妥昔单抗、人免疫球蛋白、激素冲击等联合脱敏治疗后,受者体内DSA降低、排斥反应减轻,分别于术后15 d、35 d、27 d移植肾功能恢复。随访至今,6例DSA阳性受者肾功能均恢复良好,中位血肌酐值104(80～131)μmol/L。我中心认为,预存DSA阳性肾移植受者经过有效的术前预处理及围手术期加强免疫抑制治疗,可以取得良好的移植效果;预存DSA阳性肾移植具有可行性及安全性。     

移植肾动脉狭窄的诊断与处理一例

移植肾动脉狭窄是肾移植后常见的血管并发症,可引起高血压和移植肾功能不全,根据不同的诊断标准,文献报道其发生率在1％～23％之间[1].2011年我中心收治1例移植肾动脉狭窄,现报道如下.临床资料患者为男性,48岁,于2011年1月在外院行肾移植.移植前血清肌酐超过1000 μmol/L,移植后9d降至160μmol/L,之后出现尿量减少,血清肌酐升高(具体不详),考虑为急性排斥反应,给予甲泼尼龙冲击治疗3d,总量为1100 mg,尿量稍增加,但随后尿量又减少,每天不足1000ml,血清肌酐升至312 μmol/L.     

肾移植术后外伤性延迟性脾破裂出血一例

患者为男性,56岁,因慢性肾功能衰竭、尿毒症于2008年11月20日在我院接受肾移植,术前2 h及术后4 d分别给予巴利昔单抗20 mg诱导治疗,术后采用他克莫司+吗替麦考酚酯+泼尼松预防排斥反应.术后第5天,受者的血肌酐(Cr)降至216 μmol/L,自行去厕所不慎滑倒,当时无不适.     

硼替佐米在肾脏移植抗体介导排斥反应中的临床应用(附1例报告)

目的高选择性蛋白酶体抑制剂硼替佐米,可特异性清除体内活化的浆细胞,对肾移植后抗体介导的排斥反应(antibody-mediated rejection,AMR)具有重要治疗作用。总结本院首例硼替佐米(bortezomib)治疗AMR的临床资料,为AMR治疗提供新的思路。方法 1例二次肾移植患者,移植后肌酐恢复到正常值,移植后20天出现急性排斥反应,恢复透析。活检病理证实为细胞性和抗体介导的混合性排斥反应。应用硼替佐米[第1天(1.3mg/m2)、第4天(1.0mg/m2)、第8天(1.0mg/m2)]同时联合甲泼尼龙250mg/次和双膜法血浆置换。观察T淋巴细胞亚群、CD139和CD19表达、二次病理活检,群体反应性抗体及血肌酐等变化。结果硼替佐米应用后随访31个月,各种指标变化:1血肌酐恢复并稳定在140umol/L左右;2PRA由最高66.7%,下降至0;3浆细胞表达在第1剂硼替佐米后先明显下降后反弹升高;4病理穿刺检测:C4D染色由强阳性变为阴性,细胞性排斥反应由ⅡA变为可疑;5出现血小板移抑制、低血压、3级周围神经病变等。结论硼替佐米可清除体内活化的浆细胞,对肾移植术后抗体介导的排斥反应的治疗具有良好的临床疗效。为肾脏移植后抗体介导的排斥反应的治疗提供一种新的治疗思路。     

亲属活体肾移植受者预存抗HLA抗体的处理及临床疗效观察

目的 探讨亲属活体肾移植受者预存抗HLA抗体的处理及效果.方法 移植前预存抗HLA抗体者15例,其中2例为供者特异性抗体(DSA),13例为非供者特异性抗体(NDSA).预存DSA者,术前2周开始每2～3 d行血浆置换1次,共行4～5次,每次血浆置换后静脉输注小剂量免疫球蛋白,移植当天给予利妥昔单抗375 mg/m2.术前10 d起给予他克莫司(Tac,0.1mg· kg-1·d-1)+吗替麦考酚酯(MMF,0.5 g/d).术后静脉注射免疫球蛋白(IVIG)0.2～0.4 g·kg-1·d-1,用2～3 d.预存NDSA者,术前第3天行血浆置换治疗1次,部分病例在血浆置换治疗后每天IVIG 0.6 g/kg.15例受者均采用抗胸腺细胞球蛋白(ATG)+甲泼尼龙进行诱导治疗,免疫抑制维持治疗采用Tac+ MMF+泼尼松.结果 预存DSA者,在去抗体减敏治疗后,群体反应性抗体(PRA)和淋巴细胞毒交叉配合试验(CDC)转为阴性;预存NDSA者,其CDC始终阴性,去抗体减敏治疗后仅有部分患者的PRA有所降低.2例预存DSA的受者分别于术后第14天和1个月时出现急性和交界性体液性排斥反应,抗体反弹,予以血浆置换+大剂量IVIG(1～2 g/kg)后,均能有效控制和逆转.现分别随访1年和10个月,肾功能维持良好.13例预存NDSA的受者,1例发生加速性排斥反应,予ATG治疗后逆转;1例发生急性体液性排斥反应,经大剂量IVIG治疗后逆转;1例发生急性细胞性排斥反应伴慢性化改变,甲泼尼龙冲击治疗的效果不佳,移植肾丧失功能.结论 对于预存DSA的患者,采用血浆置换+IVIG+利妥昔单抗进行去抗体减敏治疗,在其PRA和CDC转阴后再行移植,安全性和短期疗效良好.     

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.     

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.