第2、4掌背动脉皮瓣的临床应用

目的：报道第2、4掌背动脉皮瓣及肌腱皮瓣修复手指软组织缺损的临床疗效。方法：对1994年5月以来25例手指软组织缺损急诊行第2掌背动脉皮瓣或第4掌背动脉皮瓣修复，其中11例为掌背动脉肌腱皮瓣修复。结果：25例皮瓣均成活，外形满意。11例肌腱皮瓣术后随访5个月～6年，肌腱功能恢复按TAM评定法：优2指、良6指、中3指。结论：第2、4掌背动脉皮瓣及肌腱皮瓣修复手指软组织缺损操作简单易行、疗效满意。     

掌背动脉逆行岛状肌腱皮瓣的临床应用

目的探讨应用掌背动脉逆行岛状肌腱皮瓣修复多个手指皮肤伴指伸肌腱缺损的方法和疗效。方法应用掌背动脉逆行岛状肌腱皮瓣修复手指皮肤伴指伸肌腱缺损21例。结果术后21例47块肌腱皮瓣全部成活,手指外形及功能恢复均较满意。结论掌背动脉逆行岛状肌腱皮瓣易切取、损伤小、不牺牲主干动脉,可同时切取多块皮瓣,是修复多个手指皮肤伴指伸肌腱缺损的较好方法之一。     

应用第2掌背动脉逆行皮瓣修复手指Ⅳ度烧伤8例

目的探讨应用第2掌背动脉修复手指皮肤、软组织缺损,伴深部肌腱、血管神经外露的治疗效果。方法在手背设计不同类型的第2掌背动脉逆行皮瓣进行修复。皮瓣范围2．0cm×1．5cm～9．0cm×3．5cm。结果成功率95％以上。术后随访6-24个月,手指外观及运动、感觉功能均较为满意。结论应用第2掌背动脉修复手指皮肤、软组织缺损,有利于早期功能锻炼,对手指的恢复也较为满意。     

逆行第二掌背动脉复合皮瓣的应用

手指外伤伴有皮肤软组织及肌腱缺损时，治疗尤为困难，术后疤痕形成、肌腱粘连，往往造成手部功能影响。自Earley等于1987年首先报道了第二掌背动脉皮瓣以来，该皮瓣逐渐得到广泛应用，并由单纯顺行皮瓣逐渐增加了逆行皮瓣、岛状推进皮瓣及皮支动脉皮瓣移植等。我们自2009年6月-2013年6月，应用逆行第二掌背动脉复合皮瓣修复食、中指背皮肤软组织及伸肌腱缺损12例，术后手指外观及功能恢复良好，现报道如下。     

邻指侧方岛状皮瓣和逆行掌背筋膜皮瓣联合修复手指软组织缺损

目的介绍一种修复手指较大面积软组织缺损的方法。方法采用邻指固有动脉岛状皮瓣联合逆行掌背岛状皮瓣修复23例手指较大面积软组织缺损，术后随访，了解手指功能恢复情况。结果23例皮瓣均成活，手指功能恢复良好。结论联合邻指固有动脉皮瓣和掌背皮瓣是修复手指较大软组织缺损的良好方法。     

掌背动脉逆行皮瓣在手指软组织缺损修复中的临床应用

目的探讨应用掌背动脉逆行皮瓣修复手指软组织缺损的临床效果。方法对2009至2012年21例手指软组织缺损行掌背动脉逆行皮瓣修复的资料进行回顾分析。结果21例皮瓣全部存活,外形满意。21例术后均或随访6个月～1年。皮瓣色泽、厚度、质地基本与邻近皮肤相同,手指与手掌功能正常。结论掌背动脉逆行皮瓣是修复手指软组织缺损的较理想的方法。     

不同远端蒂逆行掌背皮瓣修复手指软组织缺损

目的 探讨不同远端蒂掌背皮瓣修复手指软组织缺损的方法和疗效.方法 2008年6月至2009年5月,利用远端蒂逆行掌背皮瓣修复手指软组织缺损37例共45指,其中29指以指蹼处穿支为蒂逆行掌背皮瓣修复,16指以指背动脉背侧支为蒂的掌背皮瓣修复.结果 41块皮瓣顺利存活,4块皮瓣远端轻微血运障碍,经拆除少部分皮瓣缝线后逐渐愈合.术后37例获得随访时间为10～24个月,皮瓣外观满意,患指功能良好.按中华医学会手外科学会上肢部分功能评定试用标准评定:优30例,良5例,可2例;优良率为94.6％.结论 掌背皮瓣存在掌背动脉远端穿支和掌背皮神经营养血管双重供血系统,可灵活选择不同的远端蒂,有效满足手指不同创面的修复需要.     

静脉动脉化掌背动脉筋膜蒂逆行岛状皮瓣修复手指软组织缺损

目的探讨静脉动脉化掌背动脉筋膜蒂逆行岛状皮瓣修复手指软组织缺损的临床疗效。方法对26例33指软组织缺损患者通过指固有动脉断端与皮瓣的静脉吻合,指固有神经断端与掌背筋膜蒂皮瓣的皮神经接合,形成带感觉的静脉动脉化逆行岛状皮瓣修复创面。结果26例33指皮瓣全部成活,伤口一期愈合,皮瓣供区植皮成活,术后随访3～18个月,平均8个月,手指功能和外观恢复满意,皮瓣质地良好,手指饱满,无压痛,感觉恢复良好,两点辨别觉4-9mm。结论静脉动脉化掌背动脉筋膜蒂逆行岛状皮瓣是修复手指软组织缺损的一种较为理想的方法。     

第2、3掌背动脉皮支筋膜皮瓣修复手指中远节软组织缺损

目的 评价应用第2、3掌背动脉皮支筋膜皮瓣修复手指中、远节软组织缺损的方法及其临床疗效. 方法 对手指中、末节软组织缺损伴指骨或肌腱外露14例患者,分别采用第2、3掌背动脉皮支筋膜皮瓣进行修复,皮瓣切取面积为2.0 cm×4.5 cm～ 3.0cm×7.0 cm. 结果 14例14指皮瓣全部成活.术后随访时间为6 ～ 40个月,皮瓣外形优良,不臃肿,皮瓣两点分辨觉为5～9 mm,手指功能恢复良好.供区不用植皮可直接闭合,供区掌背有线形手术瘢痕,少许色素沉着. 结论 第2、3掌背动脉皮支筋膜皮瓣切取方便,损伤小,不牺牲主干动脉,是修复手指中、远节软组织缺损和功能重建的良好方法.     

带掌长肌腱的改进双干型动脉化静脉皮瓣的应用

目的 探讨手指皮肤软组织伴肌腱同时缺损的修复方法和效果. 方法 根据手指皮肤软组织及肌腱缺损情况,在同侧前臂远端以掌长肌腱为中心设计皮瓣,皮瓣内包含掌长肌腱和2条纵向并行的静脉.将皮瓣的脂肪全部清除,保留皮瓣的真皮下血管网,然后显露并切断2条静脉之间的微小交通支,保护腱周血管网,注意避免掌长肌腱与皮瓣分离.皮瓣顺行放置手指创面,皮瓣的掌长肌腱修复手指的肌腱缺损.在放大10倍的手术显微镜下,皮瓣的1条静脉远端或近端与伤指的指固有动脉吻合,另一端结扎;另1条静脉近端与指背或指腹静脉吻合,远端结扎.应用带掌长肌腱的改进双干型动脉化静脉皮瓣修复手指皮肤软组织及肌腱缺损5例5指. 结果 术后5例皮瓣均成活,经4～22个月随访,皮瓣生长良好,柔软、弹性好,按TAM法疗效评定,优1例,良3例,中1例. 结论 带掌长肌腱的双干型改进动脉化静脉皮瓣移植修复手指皮肤软组织伴肌腱缺损临床效果良好.     

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.