外科感染常见耐药菌的治疗

在外科感染中常见的耐药菌有两类:耐药革兰阳性(G+)球菌和耐药革兰阴性(G-)杆菌.前者有:耐甲氧西林金黄色葡萄球菌(MRSA);耐甲氧西林凝固酶阴性葡萄球菌(MRCNS);耐甲氧西林表皮葡萄球菌(MRSE);耐甲氧西林溶血性葡萄球菌;耐万古霉素肠球菌(VRE)等.耐药G-杆菌主要有两类:(1)肠杆菌科:产超广谱β-内酰胺酶(ESBL)菌;产染色体介导Ⅰ型β-内酰胺酶(AmpC)菌;产超超广谱β-内酰胺酶(SSBL)菌.(2)非发酵菌包括:铜绿假单胞菌;不动杆菌属包括鲍曼不动杆菌、洛非不动杆菌等;嗜麦芽窄食单胞菌等.     

儿童活体肝移植术后住院期间细菌感染的临床研究

目的 研究儿童活体肝移植术后细菌感染的常见病原菌种类、分布特征及耐药性.方法 回顾性分析41例儿童活体肝移植的临床资料,对受者术后住院期间的细菌感染发生率、感染发生时间、感染部位、病原菌种类和分布以及药敏试验结果进行总结.结果 41例肝移植受者中,有33例受者发生细菌感染69次,细菌感染发生率为80.5％(33/41).主要的感染部位依次是下呼吸道32例次(占46.6％)、腹腔16例次(占23.3％)及胆道11例次(占15.9％).共检出致病菌101株,其中革兰阴性菌(G-菌)占73.3％(74/101),超广谱β-内酰胺酶(ESBL)检出率为81.1％ (60/74);革兰阳性菌(G+菌)占26.7％(27/101),耐甲氧西林凝固酶阴性葡萄球菌(MRCNS)检出率为59.3％(16/27),氨基糖苷类高耐药肠球菌(HLAR)检出率为11.1％(3/27).术后2周内检出致病菌72株(71.3％).常见致病菌为铜绿假单胞菌、表皮葡萄球菌和大肠埃希菌等.致病菌对β-内酰胺类加酶抑制剂和头孢类的耐药率超过60％,主要的产ESBL的G-菌对碳青霉烯类敏感,耐药率＜10％;碳青霉烯类药物亚胺培南/西司他丁、美罗培能对质粒介导的ESBL、染色体及质粒介导的头孢菌素酶(AmpC酶)均具有高度稳定性;铜绿假单胞菌对碳青霉烯类和儿科常用抗生素均高度耐药,仅对喹诺酮类敏感;凝固酶阴性葡萄球菌和肠球菌对万古霉素、利奈唑胺、奎奴普丁/达福普丁高度敏感.结论 肝移植术后细菌感染发生率高,耐药菌株检出率高,且具有多重耐药特点.有效地预防感染,术后早期确诊和合理选用抗生素是控制细菌感染的关键.     

外科感染患者细菌分布及耐药性的单中心研究

目的 分析外科感染患者细菌分布及其对常用抗菌药物的耐药性,为外科感染的规范化治疗提供依据.方法 回顾性调查分析2008年1月至201 1年12月外科感染患者送检标本的细菌鉴定及药物敏感性检测结果.结果 3257份临床标本共分离菌株3829株,革兰阴性杆菌占62.4％(以大肠埃希菌、铜绿假单胞菌和肺炎克雷伯菌为主);革兰阳性球菌占37.6％(以肠球菌、金黄色葡萄球菌及凝固酶阴性葡萄球菌为主),其中金黄色葡萄球菌、粪肠球菌检出率呈升高趋势.大肠埃希菌及肺炎克雷伯菌对亚胺培南、阿米卡星、哌拉西林/他唑巴坦等抗菌药物耐药率较低;铜绿假单胞菌和鲍曼不动杆菌对头孢类、碳青霉烯类及喹诺酮类抗菌药物耐药率较高,呈多药耐药性;所有葡萄球菌、粪肠球菌对万古霉素和替考拉宁敏感(100％),但耐万古霉素屎肠球菌检出率呈上升趋势(1.9％～7.5％).产超广谱β-内酰胺酶(ESBL)大肠埃希菌检出率为45.6％ ～61.5％;产ESBL肺炎克雷伯菌检出率呈波动表现;耐甲氧西林金黄色葡萄球菌检出率较高(21.1％ ～55.8％),耐甲氧西林表皮葡萄球菌检出率明显高于其他阳性球菌.结论 我院外科临床感染病原菌以革兰阴性杆菌为主,临床分离细菌耐药现象较为普遍,铜绿假单胞菌和鲍曼不动杆菌药物耐药率较高.     

烧伤中心细菌耐药性分析

目的研究烧伤中心广泛应用第三代头孢菌素背景下细菌耐药性。方法采用纸片扩散法。结果２５９株革兰氏阴性杆菌对头孢噻肟、头孢曲松、头孢哌酮和头孢他啶全部耐药的菌株占３１％，头孢哌酮／舒巴坦可使５２％耐药菌株恢复敏感性。伊米配能和环丙沙星对铜绿假单胞菌、无硝不动杆菌、肠杆菌科耐药率分别为２３．８％和５１．２％，２８．６％和２１．４％，９．９％和２０．４％。ＭＲＳＡ对伊米配能和环丙沙星耐药率分别为２６．９％和７３％，未发现去甲万古霉素耐药菌株。粪肠球菌对去甲万古霉素耐药率为２．７％。结论革兰氏阴性杆菌对第三代头孢菌素耐药机理除质粒介导的超广谱β－内酰胺酶外，部分菌株可能产生染色体介导的Ⅰ型β－内酰胺酶     

多药耐药鲍曼不动杆菌22种β-内酰胺酶基因和酶活性的检测研究

目的了解临床分离的多药耐药鲍曼不动杆菌（multi—drug resistant Acirtetobacter baumannii,MDRAB）3-内酰胺酶基因存在状况以及酶活性。方法从浙江大学医学院附属第一医院住院患者中分离62株MDRAB,采用PCR及序列分析方法分析22种β-内酰胺酶基因,同时采用酶提取物改良三维试验检测超广谱β-内酰胺酶（ESBLs）、头孢菌素酶（AmpC酶）和金属β-内酰胺酶活性。结果62株MDRAB中,TEM、OXA-23群和ADC基因阳性株数分别为51株（82．3％）、50株（80．6％）和36株（58．1％）,其余19种基因均为阴性;任选5株TEM基因PCR阳性产物测序比对,显示与GenBank基因库中TEM-1型相同;任选6株OXA-23群基因PCR阳性产物测序比对,显示与OXA-23型碳青霉烯酶基因（登录号：CAB69042．1）相同;任选2株ADC基因测序比对,显示与ADC-like型AmpC酶基因（登录号：EU081908）相同。有32株（51．6％）同时产ESBLs和AmpC酶,19株（30．6％）单独产ESBLs,1株（1．6％）单独产AmpC酶;金属β-内酰胺酶活性检测均为阴性。结论产OXA-23群碳青霉烯酶和ADC型AmpC酶是本组MDRAB对β-内酰胺类药物耐药的主要原因。     

连续三年尿路感染菌谱监测及耐药性分析

目的对近3年来尿路感染的菌谱及细菌耐药性进行调查分析,指导临床合理用药。方法收集从我院尿路感染患者尿液标本中分离的828株病原菌进行细菌鉴定及药敏试验（Kirby-Bauer法）,并对革兰阴性杆菌进行超广谱8内酰胺酶（ESBLs）的检测。结果近3年尿路感染以革兰阴性杆菌为主,占68．24％,列前3位的是大肠埃希菌（56．64％）,粪肠球菌（10．1）2％）、真菌（8．56％）。2004年至2006年超广谱8内酰胺酶大肠埃希氏菌比例呈上升趋势（分别占7．59％、23．2％、22．04％）。产酶大肠埃希菌对亚胺培南的耐药率是1．4％,对呋喃妥因的耐药率是23．21％,对头孢类耐药率59．38％～97．26％,对复方新诺明耐药率是95．31％。非产酶大肠埃希菌对亚胺培南的耐药率是0．3％,对呋喃妥因的耐药率是18．14％,对头孢类耐药率从8．87％～31．1）6％不等,对复方新诺明耐药率是72．62％。细菌对各种抗生素有不同程度的耐药性,表现为多重耐药。结论革兰阴性杆菌为尿路感染的主要病原菌,且产超广谱β内酰胺酶的大肠埃希菌呈上升趋势,定期监测尿路感染细菌谱及耐药性变化对于指导临床合理应用抗生素具有十分重要的意义。     

肝移植术后胆汁培养中的病原菌分布及耐药表型分析

目的 对肝移植受者术后胆汁培养中的病原菌分布和耐药表型进行分析,为肝移植术后病原菌感染的临床预防和治疗提供参考.方法 对274例肝移植受者术后胆汁标本的培养结果以及病原菌的药敏试验进行综合分析.结果 274例胆汁标本培养结果显示,有195例标本的病原菌检验呈阳性,阳性率71.2%.共检出病原菌269株,其中阳性球菌168株,以肠球菌(117株)及凝固酶阴性葡萄球菌(50 株)为主;阴性杆菌99株,以铜绿假单胞菌、不动杆菌和嗜麦芽窄食单胞菌为主;检出烟曲霉菌2株.无论阳性球菌还是阴性杆菌,都具有严重的多重耐药性.结论 肝移植受者术后胆汁培养中病原菌的检出率高,耐药性强,耐药范围广.     

烧伤中心细菌耐药性分析

目的研究烧伤中心广泛应用第三代头孢菌素背景下细菌耐药性。方法采用纸片扩散法。结果 259株革兰氏阴性杆菌对头孢噻肟、头孢曲松、头孢哌酮和头孢他啶全部耐药的菌株占31％,头孢哌酮/舒巴坦可使52％耐药菌株恢复敏感性,伊米配能和环丙沙星对铜绿假单胞菌、无硝不动杆菌、肠杆菌科耐药率分别为23.8％和51.2％,28.6％和21.4％,9.9％和20.4％。MRSA对伊米配能和环丙沙星耐药率分别为26.9％和73％,未发现去甲万古霉素耐药菌株。粪肠球菌对去甲万古霉素耐药率为2.7％。结论革兰氏阴性杆菌对第三代头孢菌素耐药机理除质粒介导的超广谱β-内酰胺酶外,部分菌株可能产生染色体介导的Ⅰ型β-内酰胺酶。     

肝切除术后腹腔感染的病原菌及耐药性分析

目的:探讨肝切除术后腹腔感染患者的病原菌分布及耐药性、患者临床病理特征与感染类型的关系。方法:回顾性分析2013年1月—2017年12月收治的95例行肝切除术后继发腹腔感染的患者的临床资料及病原菌结果。单因素和多因素Logistic回归分析患者临床资料与感染类型的相关性。结果:95例患者共培养得到非重复菌株170株,单独感染55例(57.9%),混合感染40例(42.1%);其中革兰氏阴性菌80株(47.1%),革兰氏阳性菌83株(48.8%),真菌7株(4.1%)。排名前5的病原菌依次是大肠埃希菌(15.3%),屎肠球菌(14.7%),肺炎克雷伯菌(12.4%),粪肠球菌(11.2%),表面凝固酶阴性葡萄球菌(8.2%)。耐药分析显示,大肠埃希菌和克雷伯菌属产超广谱β-内酰胺酶(ESBLs)菌株检出率分别为76.9%、37.5%,两者对头孢哌酮/舒巴坦的敏感度分别为66.7%、70.0%,对亚胺培南的敏感度分别为100.0%、79.2%。鲍曼不动杆菌除对替加环素保持100.0%敏感外,其余主要抗生素敏感度均在30.0%以下。44株屎/粪肠球菌中未发现万古霉素耐药株,其对万古霉素的敏感度分别为92.0%、89.5%。14株表面凝固酶阴性葡萄球菌全部表现为耐甲氧西林菌株,对万古霉素和利奈唑胺保持100.0%敏感度。Logistic回归分析显示,术后腹腔内并发症是混合感染的独立危险因素(P=0.006)。结论:肝切除术后腹腔感染中革兰氏阳性菌比例较高,以肠球菌属为主。革兰氏阴性菌中耐碳青霉烯类药物肠杆菌比例有增加趋势,多重耐药现象严重。术后腹腔内并发症是混合感染的独立危险因素。     

966株尿路感染病原菌的分布

目的分析尿路感染的病原菌分布及耐药性特点,为临床选用抗菌药物提供依据。方法采用VITEK-32细菌鉴定仪鉴定菌种,对尿路感染患者的1978份尿液标本中分离的966株泌尿系感染病原菌进行鉴定及药物敏感试验。结果在分离的966株病原菌中,革兰阴性菌675株（占69．9％）,主要为大肠埃希菌;革兰阳性菌183株（占18．9％）,主要为粪肠球菌;真菌108株（占11．2％）,主要为白色念珠菌。分离数在前5位的病原菌依次为大肠埃希菌（占49．0％）、粪肠球菌（占9．6％）、肺炎克雷伯菌（占7．ooA）、白色念珠菌（占6．8％）、奇异变形杆菌（占3．9％）。大肠埃希菌产超广谱争内酰胺酶（ESBLs）检出率为47．3％,肺炎克雷伯菌产ESBLs检出率为33．8％。甲氧西林凝固酶阴性葡萄球菌（MRCNS）的检出率为44．8％,耐甲氧西林金黄色葡萄球菌（MRSA）的检出率为50％。结论引起尿路感染病原菌的分布广泛,大肠埃希菌为尿路感染的主要病原菌。有些菌株产生多重耐药性,大肠埃希菌产ESBLs检出率较高。应尽量根据药物敏感试验选用抗菌药物,减少耐药菌株的产生和医院感染的爆发流行。     

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.     

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.     

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.