脊柱内固定术后手术部位感染并脊柱结核1例

正手术部位感染(surgical site infection,SSI)是脊柱内固定术后常见并发症之一,指在无内置物材料30d内或有内置物材料手术12个月内发生的与手术相关的感染~([1]),包括表浅切口感染、切口深部感染及邻近器官和组织间隙的感染~([2])。临床上,脊柱术后感染病原菌以金黄色葡萄球菌多见(45.2%),其次是表皮葡萄球菌(31.4%),其他常见的致病菌还有肠球菌、大肠杆菌、消化链球菌等~([3])。笔者所在医     

上颈椎结核外科手术诊疗的研究进展

正近年来,结核病的发生率呈增长趋势,骨关节结核约半数累及脊柱,上颈椎结核占脊柱结核的0.3%~1.0%~([1-2])。发生率虽低,但其部位特殊,造成该区域骨和韧带的广泛破坏,进而导致的压迫和不稳定严重威胁到延髓、脊髓,引起神经和呼吸功能障碍~([3])。但上颈椎漏斗结构对脊髓压迫容忍度较大,早期不易发现,出现严重神经症状时常需要手术治疗~([1-2])。手术治疗的目的主要是清除结核病灶,利于药物渗入,重建上颈椎稳定性,保留和恢复神经功     

保留内置物清创术联合真空负压封闭引流治疗脊柱术后早发性感染

<正>随着脊柱外科技术的发展,融合手术的增加,术后深部感染的发生率为6%,有金属器械置入的复杂手术则感染率可高达20%~([1、2]),脊柱外科术后手术部位感染(surgicalsite infection,SSI)开始成为临床医生面临的一个难题~([1]),如果不及时、有效地处理,则55%~77%的患者可能     

局部使用万古霉素防治脊柱手术后伤口感染的研究进展

正脊柱手术后伤口感染(SSIs)是临床常见并发症之一,可延长患者的住院时间,增加医疗成本,降低生活质量~[1-2]。有研究发现,SSIs占脊柱外科手术感染总人数的22%~[3]。不同文献报道的SSIs发生率差异较大,为0.4%~20.0%~([4-6])。葡萄球菌尤其是耐甲氧西林金黄色葡萄球菌(MRSA)是SSIs的主要致病菌~[7],但引起SSIs的病原菌并不少见,如Zhou等~[8]在破裂的腰椎椎间盘组织中还发现痤     

脊柱结核规范化外科治疗:争议与共识

正人类感染结核分枝杆菌的历史可以追溯到铁器时代,经过数世纪的探索,人类对结核分枝杆菌的控制能力得到了显著的提高~([1])。作为最常见的肺外结核病灶,骨与关节结核占所有结核病例的1%~2%,其中脊柱结核约占骨与关节结核的50%~([2])。脊柱结核常导致寒性脓肿形成、脊柱骨质破坏、脊柱畸形和瘫痪等严重并发症,这也是脊柱结核目前治疗的重点和难点~([3])。从治疗角度,脊柱结核历经抗结核药物治疗、病灶清除术、病灶清除并     

改良封闭式负压引流技术治疗腹部手术切口感染临床研究

正腹部手术切口感染是普外科手术最常见并发症之一,发生率高达4%~([1]),是导致病人住院时间及抗生素使用时间延长、医疗费用增加,甚至医患矛盾的主要原因~([2])。改良封闭式负压引流技术可快速控制腹部切口感染,明显缩短抗生素使用时间~([3])。2014年6月至2017年9月佛山市禅城区中心医院收治57例腹部切口感染病人,其中使用改良封闭式负压引流技术治疗的病人29例,使用普通换药的病人28例。现将其临床疗效对比报告如下。     

心脏大血管术后胸骨纵隔感染外科治疗的麻醉

正心内直视术后胸骨切口感染的发生率并不高,但皮下感染未得到有效治疗进而发展为胸骨感染和纵隔炎,并可能恶化导致败血症、心脏切口感染甚至心脏血管桥破裂,死亡率高达25.7%~52.0%~([1])。外科清创加肌瓣转移重建是治疗该类疾病的重要手段。深部胸骨感染常发生在心脏术后14d左右,病情发展很快,通常需要紧急手术~([2])。由于大多数患者刚经历心血管大手术打击,或处于严重败血症状态,或     

脊柱结核术后复发的治疗方案及临床疗效

正脊柱结核作为常见的肺外结核,占骨关节结核的50%~60%~([1])。严重者可导致脊柱后凸畸形甚至脊髓受压。脊柱结核复发率较低,但复发后常常导致窦道迁延不愈、脊柱畸形及继发性神经损伤。目前脊柱结核的治疗包括非手术治疗与手术治疗,其中手术治疗主要针对存在脊柱畸形、伴严重神经损伤的患者,以达到神经减压、纠正后凸、重建脊柱稳定性的目的~([2])。由于结核病具有难治且易复发的特点,以及手术时机或方法选择不当、术中病灶清     

脊柱感染的诊断与治疗

正脊柱感染(spinal infections)是指特定病原微生物引起的椎体、椎间盘及椎体周围软组织的感染~([1])。文献报道成人脊柱感染的年发病率约为0.83/10万~([2])。脊柱感染通常发病隐匿,严重者会导致神经功能受损、脊柱畸形、瘫痪甚至死亡等。近年来,脊柱感染的发病率呈上升趋势,使脊柱感染的诊断与治疗面临新的挑战。现就脊柱感染的分型、诊断以及治疗相关方面综述如下。     

成人脊柱侧后凸畸形后路矫形术后症状性硬膜外血肿的诊断和治疗

<正>脊柱术后症状性硬膜外血肿(symptomatic spinal epidural hematoma,SSEH)可导致术后神经功能恶化,是脊柱术后少见但会造成严重后果的并发症之一,其发生率为0.1%~1.0%~([1~6])。脊柱术后SSEH的发生与高龄、长节段手术、术中失血量大等因素有关~([4、7、8]),而成人脊柱侧后凸畸形患者常合并上述这些危险因素。因此,对此类患者进行分     

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.     

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.     

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.     

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.     

Immunomodulation in Transplantation with Photopheresis

Abstract: Photopheresis is a technique in which peripheral blood mononuclear cells, in the presence of a photoacti-vatable compound, are exposed extracorporeally to ultraviolet A light and reinfused, inducing a host autoregula-tory immune response. Experimental work and ongoing clinical studies are helping to define the role of this novel, safe, and non-toxic immunomodulating technology in the field of transplantation.