应用外科皮瓣修复手外伤手部皮肤组织缺损

目的报道不同类型外科皮瓣修复手部皮肤缺损的临床效果。方法根据手部皮肤缺损组织性质、选择不同类型外科皮瓣进行修复180例,其中碾压撕脱伤130例,绞轧伤37例,爆炸伤13例。修复创面面积最大20cm×18cm。单纯手部皮肤软组织缺损110例,伴有神经、肌腱、血管缺损70例。结果除10例皮瓣远端边缘小部份表皮坏死,经换药后愈合,其余所有皮瓣的成活良好。结论应用外科皮瓣修复手部皮肤软组织缺损能最大限度恢复手的功能和外形,临床效果较好。     

手多元组织缺损的一期显微修复

手部多元组织缺损的一期修复与功能重建较为困难。采用口止母甲瓣或第二足趾与皮瓣组合移植修复手桡、尺侧手指及皮肤缺损，多指缺失，全手皮肤及手指缺损４８例，应用１０４个游离组织瓣全部成活。经５个月～６年随访，再造手指功能良好，两点辨别觉为４ｍｍ～１２ｍｍ。有１０例二期行皮瓣整形和肌腱松解术。认为，组合组织移植一期修复手部多元组织缺损，有恢复期短、功能恢复快的优点。     

手部桡侧大范围多元组织缺损的显微外科治疗

目的 探讨手部桡侧大范围多元组织缺损显微外科治疗的方法. 方法 对桡侧大面积皮肤缺损合并拇指皮肤缺损及拇指Ⅰ°、Ⅱ°、Ⅲ°缺损者采用皮瓣组合躅甲瓣修复.对桡侧多元组织缺损合并拇指Ⅳ°缺损者采用皮瓣组合第二足趾修复.对桡侧多元组织缺损合并拇指Ⅴ°、Ⅵ°缺损者采用皮瓣组合携带第二跖骨、踇、趾短伸肌的第二足趾修复组织缺损及重建大鱼际肌功能. 结果 临床应用30例,综合评价手部功能,优21例,良6例,可3例.有12例皮瓣臃肿二期行整形术,有9例再造拇指肌腱粘连行肌腱松解术. 结论 手桡侧大范围多元组织缺损应据拇指缺损情况进行皮瓣组合甲瓣、第二足趾或携带第二跖骨、躅、趾短伸肌的第二足趾进行修复与重建.     

足部组织在手部组织缺损中的应用

目的 :总结足部组织修复手部组织缺损的临床应用及疗效观察。方法 :应用足部组织游离移植修复手部组织(皮肤、肌腱、血管、骨关节等 )缺损 3 8例 ,急诊Ⅰ期修复 2 2例 ,择期Ⅱ期修复 16例。①腕部掌侧组织缺损合并主干血管长段损伤 2例。②拇手指组织部分缺损 ,Ⅲ°以下拇指缺损拇趾甲皮瓣修复[1 ] 4例 ,第 2、3足趾部分或全部游离移植再造手第 1、2、3指 14例 ,单纯趾甲瓣移植修复第 2指指甲缺损 2例。③手部掌背侧皮肤缺损 ,虎口及手指处皮肤挛缩或缺损12例 :应用足背皮瓣及其复合组织瓣 3例 ,足背多叶型皮瓣 3例 ,趾蹼皮瓣 4例 ,趾侧方皮瓣 2例。④趾腹皮瓣 2例 ,骨关节移植 2例。结果 :需做血管吻合 3 6例 ,坏死 2例 ,其中因伤口感染坏死 1例 ,1例因为血管栓塞时间过长失去探查机会而坏死 ,成活率 97.2 %。手部功能及外形恢复均较为满意。供区 2例植皮部分坏死瘢痕愈合行走时疼痛。结论 :手部组织缺损选择与其功能及外观相似的足部组织修复 ,术后效果满意。     

手部不同种类岛状皮瓣的临床应用

手外伤所致软组织缺损在临床上较常见，除了皮肤缺损外，常伴有血管神经、骨、关节、肌腱的外露或缺损，处理不当会严重影响手的功能及外形。如选用适当的岛状皮瓣修复，可获得较好的临床效果。1985年以来，我们应用手部不同种类的岛状皮瓣修复手部软组织缺损76例，取得了满意的效果。     

微型皮瓣修复手指皮肤软组织缺损

目的 探讨对不同类型的手指皮肤软组织缺损，选用不同类型的微型皮瓣游离修复的方式和效果。方法 根据损伤部位和特点，将手指皮肤软组织缺损分成9类，选用9种不同类型的微型皮瓣对170例手外伤进行游离移植修复。结果 术后皮瓣存活168例，坏死2例。术后随访2个月～3年，皮瓣质地、外形及功能均较满意，两点分辨觉为6～10mm。手功能恢复满意。结论 不同类型的手指皮肤软组织缺损应选用不同类型的微型皮瓣游离修复，皮瓣具有良好的血供，供区隐蔽，外形及功能恢复满意等优点，是修复手部皮肤软组织缺损较为理想的方法。     

桡神经浅支营养动脉岛状皮瓣在手外科的应用

创伤或爆炸伤所致手部皮肤软组织严重缺损修复比较困难。我们采用以桡神经浅支营养动脉为蒂的前臂逆行岛状皮瓣修复７例，随访６个月～１年，效果满意，报告如下：资料与方法１．一般资料：本组共７例，男６例，女１例，年龄１０～５３岁。皮瓣面积最大１２cm×１０cm，最小８cm×５cm。５例因爆炸伤致虎口皮肤软组织严重缺损，２例因冲床伤致手背软组织缺损，掌指关节、掌骨外露，伸肌腱缺损。采用以桡神经浅支营养动脉为蒂的逆行岛状皮瓣转移修复。结果术后皮瓣全部成活，经６个月～１年随访，手外形美观、功能、皮瓣感觉恢复良好。２．方…     

前臂及手部岛状皮瓣修复手部皮肤软组织缺损

目的探讨如何选用前臂及手部岛状皮瓣修复手部皮肤软组织缺损并报道其疗效。方法根据手部皮肤软组织缺损的部位、大小及修复要求等有选择的应用前臂及手部6种岛状皮瓣修复手部皮肤软组织缺损102例。结果3例皮瓣远端部分坏死，99例皮瓣完全成活。术后随访6～26个月，皮瓣、弹性、质地良好，伤手功能满意。结论前臂及手部岛状皮瓣是修复手部皮肤软组织缺损的较好方法，应根据手部皮肤软组织缺损部位、大小、修复要求等选用上述皮瓣才能获得理想的修复效果。     

吻合血管的皮瓣及肌皮瓣移植临床应用

目的：报道应用皮瓣及肌皮瓣移植修复四肢肤软组织缺损的临床效果。方法：应用吻合血管股前外侧皮瓣、背阔肌皮瓣及阔筋膜张肌皮瓣移植修复四肢皮肤软组织缺损合并肌腱或骨关节外露12例。结果：术后皮瓣及肌皮瓣均成活，随访1-2年，外观及功能良好。结论：吻合血管皮瓣及肌皮瓣移植是修复四肢皮肤软组织缺损合并肌腱或骨关节外露的有效方法。     

手部骨缺损的修复与重建

目的研究因手指、掌骨缺损而导致手的外形和功能受限,通过显微外科技术重建的手术方法。方法采用自体游离或带血管髂骨与皮瓣组合、带血管跖趾关节或游离足趾与皮瓣组合等方法一期或分期再造残缺手或手指。用局部皮瓣游离皮瓣或串联皮瓣修复缺损的软组织,同时修复关节囊及肌腱缺损。根据重建类型,术后1～3周予以康复训练。结果本组19例,术后1例因严重感染导致手术失败并截指,2例部分皮肤创面予以二期覆盖,其余16例经8月～2．5年随访,按照中华医学会手外科学会断指再植功能评定试用标准评价结果,运动功能：优3例,良7例;感觉功能：优（S5）11例,良（S4）2例;外观评价：优5例,良6例。结论采用自体骨与皮瓣组合、自体足趾及关节移植与皮瓣组合等方法重建手与手指骨缺损,能最大程度地恢复手部外形及功能,降低手和手指残缺率。     

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.