补肾健脾方保护腹膜透析患者残余肾功能的前瞻性随机对照研究

目的探讨我科自拟补肾健脾方是否可保护腹膜透析(peritoneal dialysis,PD)患者残余肾功能(residual renal function,RRF)。方法选择2010年1月1日后开始接受PD治疗的慢性肾衰竭患者70例,随机分为对照组及中药组,每组35例。对照组采用传统方法保护RRF,中药组在对照组治疗基础上加用补肾健脾方。记录2组患者基线、24周及48周时的尿量、透析液用量及腹膜透析超滤量,检测血清、24 h腹膜透析液及尿液肌酐、尿素;计算尿素清除指数(Kt/V)、肌酐清除率(creatinine clearance rate,Ccr)、尿素清除率(urea clearance,UCL)及残肾肾小球滤过率(residual glomerular filtration rate,rGFR),rGFR以残肾Ccr及UCL的算数平均数(Ccr+UCL)/2计算。结果 24周时中药组及对照组的尿量、残肾Kt/V、残肾Ccr及rGFR均较基线水平明显降低(P0.05或P0.01);与中药组相比,对照组残肾Ccr以及rGFR的降低更显著(P0.05),尿量、残肾Kt/V的降低数值更大,但未达到统计学差异(P0.05)。48周时2组的尿量、残肾Kt/V、残肾Ccr及rGFR均较基线水平明显降低(P0.05或P0.01),与中药组相比,对照组尿量、残肾Kt/V、残肾Ccr以及残肾rGFR的降低更显著(P0.05或P0.01)。组间比较,24周及48周时中药组及对照组的总Kt/V、总Ccr均无显著性差异,但24周及48周时中药组的每日腹透液用量均少于对照组,且在48周达到统计学差异(P0.01)。结论补肾健脾方对于维持性腹膜透析患者的RRF具有保护作用,并且可能会减少达到充分透析所需的每日腹透液用量。     

影响腹膜透析患者血清白蛋白的相关因素及中医证型分布规律

目的:研究影响腹膜透析(PD)患者血清白蛋白(Alb)的相关因素和中医证型分布规律,为中西医结合治疗低蛋白血症提供依据。方法:收集2017年7月—2018年7月于温州市中医院、温州市中心医院规律腹膜透析的患者177例,分为正常组93例和低白蛋白组84例,采集每位患者的各项临床指标并进行中医辨证分型,探讨影响PD患者Alb的相关因素和中医证型分布规律。结果:两组血肌酐、血清尿素、C-反应蛋白、腹膜尿素清除指数(腹膜Kt/v)、腹膜肌酐清除率(腹膜Ccr)比较,差异无统计学意义(P0.05);两组透析时间、中医症状积分、超滤量、Alb、血红蛋白、尿量、残肾尿素清除指数(残肾Kt/v)、总尿素清除指数(总Kt/v)、残肾肌酐清除率(残肾Ccr)、总肌酐清除率(总Ccr)比较,差异有统计学意义(P0.01)。逐步回归分析发现,残肾Kt/v、总Kt/v是Alb的独立影响因素。本虚证为脾肾阳虚证和阴阳俱虚证的患者Alb水平最低。结论:腹膜透析患者的血清白蛋白水平和残余肾功能、中医证型有着相关性。     

参苓白术散对尿毒症小剂量腹膜透析临床疗效的影响

目的:探讨参苓白术散对尿毒症小剂量腹膜透析临床疗效的影响。方法:选取符合纳入标准腹膜透析的尿毒症患者60例,随机分为两组,各30例。观察组采用小剂量(4 L/d)腹膜透析,同时每日服用参苓白术散;对照组采用常规剂量(8 L/d)腹膜透析,疗程均为6个月。比较两组血尿素氮(BUN)、肌酐(Scr)、钾、钙、磷、白蛋白(Alb)、血红蛋白(Hb)水平,以及计算尿量、超滤量、残肾Kt/V、腹膜Kt/V评估患者腹膜透析充分性。通过饮食热量(DEI)和蛋白的摄入量、主观综合性营养评估(SGA)、生活质量问卷(ADL)调查,评估患者的营养状况和生活质量。结果:(1)两组治疗前后比较,血Scr、BUN差异无统计学意义(P0.05);血Alb、Hb差异均有统计学意义(P0.05或P0.01)。两组治疗后,血Scr、BUN比较,差异无统计学意义(P0.05);血Alb、Hb比较,差异均有统计学意义(P0.05或P0.01)。(2)两组治疗前后比较,血钾、钙、磷水平差异无统计学意义(P0.05)。两组治疗后比较,血钾、钙、磷水平差异同样差异无统计学意义(P0.05)。(3)观察组治疗前后比较,肾Kt/V差异无统计学意义(P0.05),腹膜Kt/V、尿量、超滤量差异均有统计学意义(P0.01)。对照组治疗前后比较,肾Kt/V、腹膜Kt/V、尿量差异均无统计学意义(P0.05),超滤量差异均有统计学意义(P0.01)。两组治疗后比较,肾Kt/V差异无统计学意义(P0.05);腹膜Kt/V、尿量、超滤量差异均有统计学意义(P0.05或P0.01)。(4)两组治疗前后比较,SGA、ADL、DEI、DPI差异均有统计学意义(P0.01)。两组治疗后比较,SGA、ADL、DEI、DPI差异均有统计学意义(P0.01)。结论:小剂量腹膜透析加用参苓白术散透析更充分,能显著改善尿毒症患者的营养状况和生活质量。     

含黄芪腹透液对高腹膜转运CAPD患者超滤功能的影响

目的:观察含黄芪腹透液对高腹膜转运CAPD患者腹膜超滤功能的影响。方法:高腹膜转运CAPD患者34例,治疗组(含黄芪腹透液)与对照组(市售腹透液)各17例,观察治疗后透析超滤量(UF)、腹膜溶质转运性能(D/P Cr、D/P urea、MTAC urea、MTAC Cr)及葡萄糖吸收率的变化。结果:治疗组治疗后第1透析周期超滤量和24h总超滤量明显增加,治疗观察期高糖透析液使用量减少,葡萄糖吸收率有降低趋势,并能一定程度地提高腹膜对溶质的转运,总有效率76.5%,优于对照组(P<0.05)。结论:腹透液中加入黄芪注射液可有效地提高透析超滤量,对高腹膜转运CAPD患者腹膜的超滤功能具有较好的保护作用。     

维持性腹膜透析患者血红蛋白影响因素分析

目的探讨维持性腹膜透析(PD)患者血红蛋白(Hb)水平的影响因素。方法采用横断面调查研究,调查在2018年1月至2018年6月期间泰兴市人民医院肾内科腹透中心规律随访的126例维持性PD患者的Hb情况,同时收集PD患者人口学资料及相关生化指标;按照是否贫血(Hb110 g/L视为贫血)分为两组,比较两组相关资料,探索Hb的影响因素。结果 126例PD患者平均Hb水平为(108.1±18.6) g/L,贫血62例,Hb正常64例,贫血发生率49.2%;与贫血组相比,Hb正常组男性比例较高,24 h尿量较多,残余肾功能(residual renal function,RRF)较好,重组人促红细胞生成素(erythropoietin,EPO)使用剂量较少,铁蛋白及转铁蛋白饱和度较高(P0.05),但两组患者的年龄、身高、体质量、体质量指数(BMI)、糖尿病比例、血压、白蛋白、前白蛋白、血脂、C反应蛋白、叶酸、维生素B_(12)、甲状旁腺素(parathyroid hormone,PTH)水平、尿素清除指数(Kt/V)无统计学差异。Hb与RRF(r=0.310,P=0.001)、尿量(r=0.312,P=0.001)、白蛋白(r=0.223,P=0.012)、铁蛋白(r=0.288,P=0.001)、转铁蛋白饱和度(r=0.327,P=0.001)呈正相关,与EPO使用剂量(r=-0.707,P=0.001)呈负相关,与身高、体质量、BMI、Kt/V、血压、前白蛋白、血脂、C反应蛋白、叶酸、维生素B_(12)、PTH无相关性。采用逐步线性回归发现,性别、RRF、转铁蛋白饱和度是Hb的独立影响因素。结论 PD患者贫血发生率较高,女性、RRF较差、铁缺乏是PD患者发生贫血的危险因素。     

腹膜透析相关性丝状真菌腹膜炎拔管后重置1例并文献复习

目的报道腹膜透析相关性丝状真菌腹膜炎1例的诊疗过程及其预后,并结合文献复习以加强对该病诊疗方面的认识。方法回顾性分析解放军第117医院收治的1例腹膜透析相关丝状真菌腹膜炎患者资料,并总结复习相关文献。结果持续性不卧床腹膜透析的女性糖尿病患者,在出现腹膜透析相关性腹膜炎症状后,给予头孢他啶联合头孢唑林抗感染治疗15d,症状无明显改善;随后腹膜透析液培养提示丝状真菌,立即停用抗生素,给予氟康唑抗真菌治疗,并行腹膜透析管拔管术,术中腹膜透析管内奶酪样物质送检培养提示丝状真菌生长。患者拔管后行血液透析治疗,半年后重置腹膜透析管,行腹膜透析治疗,1.5%腹膜透析液4次/日;2周后测尿量650 ml,超滤量-490 ml,残肾尿素清除指数(Kt/V)0.811,腹膜Kt/V 1.832,总Kt/V 2.64/周,残肾内生肌酐清除率(endogenous creatinine clearance rate,Ccr)35.7,腹膜Ccr 38.9,总Ccr 74.6/周,氮表现率蛋白相当量1.12,提示透析充分,营养状况良好,PET试验提示高平均转运型。连续随访3年患者腹膜透析充分,后因无菌操作不规范致反复细菌性腹膜炎,最终诊断为腹膜超滤衰竭,退出腹膜透析,改行血液透析至今。结论目前腹膜透析相关丝状真菌性腹膜炎治疗以拔管后退出腹膜透析为主,而在腹膜炎治愈、一般情况良好的条件下,仍可以考虑腹膜透析管重置。     

肝细胞生长因子对维持性腹膜透析患者腹膜微炎症状态及超滤量的影响

目的：观察肝细胞生长因子（HGF）对腹膜透析微炎症状态和超滤量的影响。方法：选择稳定的持续非卧床腹膜透析（CAPD）患者20例,采用双盲交叉对照设计,患者随机腹透液内分别加入HGF或生理盐水治疗3个月,再经1个月的洗脱期后交换处理因素,分别观察患者的腹膜微炎症状态、腹膜通透性和超滤量的变化。结果：与处理前和生理盐水处理后相比,HGF可降低透析液CRP、IL-6、TNF-α和TGF-β的水平（P〈0．05）,降低透析液肌酐／血肌酐（D/PCr）比值,降低透析液尿素／血尿素（D／Purea）比值以及透析液白蛋白／血白蛋白比率。HGF可增加4h、0h透析液葡萄糖比率（D4／D0 glucose）及24h超滤量（P〈0．05）,患者周总KT／V和总Ccr／ml无明显变化（P〉0.05）。结论：PD患者腹透液内使用HGF可改善腹腔微炎症状态,降低腹膜对小分子通透性,增加腹膜的超滤量。     

维持性腹膜透析患者尿素清除指数达标现状及影响因素分析

目的探讨单中心维持性腹膜透析患者尿素清除指数(Kt/V)达标现状以及影响因素。方法在泰兴市人民医院腹膜透析中心采用横断面调查,选择2014年11月至2015年5月份维持透析3个月以上的完成透析充分性及生化评估结果的腹膜透析患者77例。所有的患者均采用持续性不卧床腹膜透析(continuous ambulatory peritoneal dialysis,CAPD)或日间不卧床腹膜透析(daytime ambulatory peritoneal dialysis,DAPD)透析方式,调查其Kt/V达标现状。按照Kt/V是否达标(Kt/V≥1.7视为达标)分为2组,比较2组人口学资料及临床生化指标,探讨Kt/V的影响因素。结果入选患者的平均Kt/V为1.75±0.57,平均肌酐清除率为(57.44±19.58)L·周~(-1)·(1.73 m~2)~(-1),Kt/V达标率为54.54%。与Kt/V未达标组相比,达标组女性比例较高,糖尿病肾病患者比例较低,身高、体质量、体质量指数较小,24h尿量较多,残余肾功能较好(P0.05);2组患者年龄、腹膜透析治疗方式、腹膜透析月龄及每日腹膜膜透析液治疗剂量无统计学差异(P0.05)。Kt/V与身高(r=-0.444,P=0.001)、体质量(r=-0.457,P=0.001)、体质量指数(r=-0.240,P=0.035)呈负相关,与24h尿量(r=0.357,P=0.001)、残余肾功能(r=0.330,P=0.003)呈正相关,与年龄(r=0.118,P=0.305)、24h腹透液治疗剂量(r=-0.022,P=0.857)不相关。采用二元Logistic回归分析,女性、较小的体格、较好的残余肾功能是Kt/V达标的保护因素。结论单中心腹膜透析Kt/V达标率54.54%,性别、体格大小、残余肾功能是腹膜透析患者Kt/V达标的影响因素。     

腹膜溶质转运特性对腹膜透析患者营养指标的影响

目的探讨腹膜溶质转运特性对腹膜透析患者营养指标的影响.方法按照腹膜平衡试验(PET)计算结果,将68例稳定的连续性不卧床性腹膜透析(CAPD)患者分为高转运组(37例)和低转运组(31例).检测患者血浆和腹透透出液中的总蛋白、白蛋白及氨基酸量,同步计算蛋白质摄入量(DPI)和蛋白质分解率(nPCR).比较两组营养状态及进行相关因素分析.结果两组的残余肾功能、CAPD治疗时间、每日透析液剂量、超滤量、葡萄糖吸收量、血糖、尿素氮(BUN)、血清肌酐(Scr)和尿素清除指数(Kt/V)比较,差异无显著性意义(均P>0.05).高转运组每日经腹透透出液丢失的总蛋白质和多种氨基酸量显著高于低转运组(均P<0.05);各项营养指标均低于低转运组;两组体重及血清白蛋白比较,差异有显著性意义(均P<0.05).每日经腹透液丢失的Alb量和TAA与D/P4Scr呈正相关关系(均P<0.05).结论腹膜透析高转运患者营养指标较低转运者差,应加强对高转运患者的营养护理和指导;每日透析液量及超滤量能达到TCcr与DPI平衡即可,不宜盲目增加腹透液的剂量、浓度和存留时间,导致过度透析,引起蛋白质和氨基酸经腹透液大量丢失及吸收大量的葡萄糖,加重患者蛋白质缺乏性营养不良.     

肾疏宁抑制腹膜透析腹膜纤维化大鼠基质及新生血管的实验研究

目的:观察中药肾疏宁对腹膜纤维化大鼠腹膜功能、腹膜组织基质积聚、新生血管、结缔组织生长因子(CT-GF)、血管内皮生长因子(VEGF)、肝细胞生长因子(HGF)及骨形态蛋白-7(BMP-7)表达的影响。方法:腹膜透析液+阿霉素注射法诱发SD大鼠腹膜透析腹膜纤维化模型,依体重随机分为4组,1.5%腹膜透析液模型组、4.25%腹膜透析液模型组、1.5%腹膜透析液+肾疏宁干预组及4.25%腹膜透析液+肾疏宁干预组,每组各15只,另设空白对照组(对照组,15只)。1.5%腹膜透析液+肾疏宁干预组及4.25%腹膜透析液+肾疏宁干预组予肾疏宁(按43.93g.kg-1.d-1)灌胃,对照组和模型组予等量生理盐水灌胃。检测腹透液葡萄糖浓度,计算超滤量(UF)及葡萄糖转运量(MGT)。观察腹膜病理形态学改变,分析腹膜厚度、腹膜血管计数、腹膜纤维连接蛋白(FN)及CTGF、VEGF、HGF、BMP-7表达。结果:治疗第6周末,1.5%腹膜透析液+肾疏宁干预组及4.25%腹膜透析液+肾疏宁干预组腹膜透析腹膜纤维化大鼠超滤量(-3.26±14.17)ml及(-2.04±10.74)ml、葡萄糖转运量(18.12±0.81)mmol/kg及(16.14±1.20)mmol/kg、腹膜厚度(74.68±15.33)μm及(211.75±58.23)μm、腹膜血管计数(8.21±2.66)个/mm2及(13.70±4.71)个/mm2、FN(152.47±36.94)%及(231.49±53.49)%、CTGF(708.67±127.22)%及(791.20±126.37)%、VEGF(0.42±0.08)%及(0.50±0.09)%、HGF(245.71±24.38)%及(222.05±23.43)%、BMP-7(351.27±31.99)%及(284.43±26.82)%,与同浓度透析液组比较,差异有统计学意义(P<0.05,P<0.01)。结论:肾疏宁可能通过调控CTGF、VEGF、HGF、BMP-7表达,阻抑基质过度积聚及新生血管生成,进而延缓腹膜透析大鼠腹膜纤维化进展。     

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.