儿童股骨干骨折继发骨筋膜室综合征1例

<正>患儿,男,4岁,于2018年12月8日摔倒后出现右大腿畸形、疼痛、肿胀、活动受限,9 d后前往当地医院就诊。X线片提示:右股骨上段骨折。入院行双下肢悬吊牵引治疗3 d后,患儿突发右下肢剧烈疼痛,查体见肢端肿胀加重、局部张力高,未触及足背动脉及胫后动脉明显搏动,肢端血运差、感觉麻木。当地医生考虑骨筋膜室综合征,急诊,全身麻醉下行右小腿骨筋膜室切开减压+创面负压封闭引流(VSD)+右股骨髁上骨牵引术,术后患肢远肢端血运恢复良好,但足部感觉未恢复。病情好转后行右小腿创     

封闭负压引流术治疗骨筋膜室综合征

目的 探讨封闭负压引流术(vacuum sealing drainage,VSD)在骨筋膜室综合征中的治疗作用及效果.方法 27例四肢骨折并发骨筋膜室综合征患者手术减压后采用VSD持续治疗7～10d,维持125～450mm Hg负压.消肿后,需行游离植皮时同样使用VSD敷料覆盖.结果 27例骨筋膜室综合征患者全部得到迅速控制,肢体肿胀消退.切开减压创面肉芽生长新鲜,无一例发生创面感染.游离植皮表面再次使用VSD敷料覆盖后,植皮存活率100%,存活面积在95%～100%之间.结论 VSD能迅速彻底对骨筋膜室减压,避免创面污染.有利于创面早期愈合,缩短治疗时间,减少患者痛苦,并减轻医护人员工作量.     

负压封闭引流技术在地震伤骨筋膜室综合征中的应用

目的探讨负压封闭式引流(VSD)技术在"5.12"汶川大地震所致骨筋膜室综合征切开减压中的应用。方法回顾性研究了自2008年5月12日～2008年6月1日,接受VSD治疗的15例汶川地震伤员18个患肢。术后记录引流量,肢体肿胀消退情况以及全身发热等症状。根据肢体肿胀程度及肉芽生长情况,采用延期缝合、植皮或者皮瓣转移覆盖创面。结果 15例术后病情得到迅速控制,负压引流量在520～2360ml之间。术后7d内有10个创面肿胀消退,肉芽组织新鲜。余下8个创面经过第二次更换VSD敷料,5处筋膜室切开减压创面肿胀消退,肉芽新鲜。经第三次更换VSD敷料后余下3处创面肿胀消退,肉芽新鲜,予闭合创口。上述切开减压创面无一例发生感染。结论地震致骨筋膜室综合征经早期切开减压结合VSD治疗能快速覆盖创面,减少污染,防止继发感染;能有效引流分泌物,减少毒素吸收;减轻肢体水肿,促进新鲜肉芽生长,利于创面修复。     

分期治疗合并骨筋膜室综合征的胫骨平台骨折

目的：根据胫骨平台骨折并发骨筋膜室综合征的临床特点,探讨其分期治疗的手术方法及临床疗效。方法：2014年4月至2017年5月,采用分期治疗方法治疗合并骨筋膜室综合征的胫骨平台骨折患者22例,男16例,女6例;年龄22~56岁,平均39岁;左侧15例,右侧7例;开放性骨折2例,闭合性骨折20例。所有患者严密进行临床病情观察,根据其特点,依次分为骨筋膜室综合征窗口期（窗口期）、切开减压期（减压期）、软组织评估期（评估期）及骨折终末固定恢复期（恢复期）。所有患者切开减压。结果：骨折均愈合,愈合时间3~9个月,平均6个月。按照Merchant膝关节功能评分标准评定疗效,优18例,良3例,可1例。结论：分期治疗能够早期发现、早期诊断及早期治疗筋膜间室综合征,并且能够全程观察患肢软组织情况,避免了骨筋膜室综合征的误诊、漏诊及误治、失治,是一种便捷、有效、值得推广的方法。     

手部急性骨筋膜室综合征的分型及治疗

目的探讨手部急性骨筋膜室综合征（osteofascial compartment syndrome OCS）的分型及治疗方法。方法对我院收治的24例手部急性OCS的病例资料进行总结。将手部OCS按病变发生范围分四型。Ⅰ型（3例）：病变发生局限于三个以内骨筋膜间室。Ⅱ型（8例）：病变发生于三个以上骨筋膜间室，累及大部分手内肌。Ⅰ、Ⅱ型均将发生病变的筋膜间室取独立切口切开减压。Ⅲ型（4例）：病变发生于三个以上骨筋膜间室，并发掌中间区内动脉弓等组织损伤，形成区室内高压。必须将发生病变的筋膜间室和掌中间区同时切开减压；Ⅳ型（9例）：病变发生于三个以上骨筋膜间室，甚或有掌中间区内高压，并发急性腕管综合征。在手部筋膜间室、掌中间区切开减压后，同时行腕管减压术。结果随访时间6周～1．5年，按黄悦等手腕部OCS疗效的评定标准评定：优17例，良4例，中2例，差1例，优良率87．5％。结论将手部急性OCS按病变发生范围分型，有利于切开减压术式的选择。     

自体挤压致筋膜间室综合征2例报告

自身压迫所致的筋膜间室综合征较为少见,我们曾遇见2例,报告如下.例1男,26岁,因CO中毒昏迷,左胸部持续压迫左前臂达13小时,醒后左前臂肿胀、麻木、手指活动受限,2天后急症入院,检查见左前臂明显肿胀、压痛、感觉减退,左手呈爪状畸形,肢体血运正常,无骨折征象,诊断为前臂筋膜间室综合征,立即于局麻下行左前臂伸、屈侧筋膜间室切开减压术,术中见有大量液体渗出,并有部分肌肉坏死,伤口予以敞开,每日换药,半月后经植皮创面愈合,患肢功能受限.     

胫骨平台骨折并发骨筋膜室综合征的早期处理:切开减压、复位内固定及VSD

目的探讨胫骨平台骨折并发骨筋膜室综合征患者采用早期切开减压、骨折切开复位内固定(open reduction with internal fixation,ORIF)及负压封闭引流(vacuum sealing drainage,VSD)治疗的可行性,为此类患者早期治疗提供新的临床思路。方法 2008年7月～2012年5月对287例胫骨平台骨折患者中并发骨筋膜室综合征的31例患者均采取上述方法治疗,待肿胀消退,皮肤软组织松弛后再行减压伤口二期直接缝合。结果 31例胫骨平台骨折并发骨筋膜室综合征患者经切开减压、复位内固定及VSD处理后恢复良好,均未出现感染、肢体(或皮肤)坏死以及关节功能障碍等并发症。结论胫骨平台骨折并发骨筋膜室综合征早期行切开减压、复位内固定及VSD是一种切实有效的治疗思路,值得在临床上推广。     

骨筋膜间室综合征5例诊治经验教训

本院于1990年10月至1995年3月收治骨筋膜间室综合征5例,其中2例截肢,现报告如下:1 病例介绍例1,男性,28岁,入院诊断为右胫骨中段闭合性骨折,即给骨折部整复夹板固定,处理3h后,患肢疼痛剧烈,继而局部肿胀,给调整固定夹板,症状仍未改善,第二天出现右小腿下段皮肤感觉消失,诊断为骨筋膜室综合征,行切开筋膜减压,并送高压氧舱等治疗.但感觉及运动功能仍未见恢复,后行小腿截肢.例2,女性,3岁,入院诊断左股骨中段闭合性骨折,予垂直悬吊皮牵引,术后患儿哭闹不停,一直诉患肢疼痛加剧,检查后发现患肢小腿肿胀,12h后发现患肢足背明显肿胀,并散在张力水泡,皮肤苍白,考虑骨筋膜室综合征,急行切开筋膜减压,术后第二天见小腿     

腘窝火器伤5例的临床治疗

目的 探讨腘窝火器伤的治疗及效果.方法 采用早期血管神经探查修复、自体血管移植、小腿切开减压、二期减压切口植皮治疗胭窝火器伤5例.结果 5例患者保肢均成功,4例患肢功能恢复良好,1例合并腓总神经损伤致足下垂,功能恢复欠佳.结论 腘窝火器伤患者应争取时间,早期行血管神经探查及小腿筋膜间室预防性切开减压,二期覆盖减压切口创面,保肢成功率高,效果较为满意.     

骨折合并骨筋膜间室综合征的早期诊断和治疗

目的：探讨骨折合并骨筋膜间室综合征的早期诊断和治疗。方法：复习并分析1988年－2001年间48例骨折合并骨筋膜间室综合征的患资料，所有病例均先输入甘露醇及地塞米松，有效Ⅱ期行骨折固定，无效及晚期7例即行切开减压并骨折复位内固定术。结果：14例脱水治疗有效的早期轻型患及27例早期重型患经急诊切开减压骨折内固定的患，疗效优良，占85.4%（41／48），而7例晚期患疗效不佳。结论：早期诊断、早期减压（8h以内）是治疗关键，如超过12h，则疗效不佳；骨折早期复位和固定是减压的重要措施；重视创面处理和晚期康复治疗。     

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.