霉酚酸酯预防肾移植术后近期急性排斥反应的观察

目的 :观察霉酚酸酯 (MMF)在预防肾移植术后近期 (3个月 )急性排斥反应 (AR)的情况。方法 :将 112例患者随机分成 2组 ,MMF(2 .0 g/d)组和硫唑嘌呤 (Aza)组。两组患者均同时接受相似剂量的环孢素 A和类固醇激素治疗。结果 :观察 3个月 ,MMF组 6 0例 ,AR发生率为 16 .7% (10 /6 0 ) ,Aza组 5 2例 ,AR发生率为 42 .3%(2 2 /5 2 ) ,两组差异有极显著意义 (P <0 .0 1)。 MMF组 5例出现血白细胞、血小板等不同程度下降 ,3例出现腹泻 ,在 MMF减量或停药后均恢复正常 ,未见有 MMF引起的肝、肾功能异常病例 ;Aza组有 9例出现肝功能损害。结论 :MMF具有预防和减少肾移植术后近期 AR效果 ,MMF的安全性可靠 ,副作用轻且为可逆性。     

两种免疫抑制方案在肾移植中应用的不良反应对比分析

目的 评价免疫抑制剂的不同组合在肾移植中应用的安全性。方法 回顾分析肾移植患者的临床资料，术后采用环孢素A(CsA)、硫唑嘌呤(Aza)及泼尼松(Pred)三联用药预防排斥反应者37例(Aza组)，采用CsA、霉酚酸酯(MMF)及Pred三联用药者35例(MMF组)。比较分析两个组用药后的药物不良反应。结果 在消化道反应、白细胞减少、全血细胞减少以及继发感染发生率等方面，MMF组与Aza组的差异无显著性(P＞0．05)，而肝功能损伤的发生率，Aza组明显高于MMF组(P＜0．05)。结论 在药物性肝损伤方面，以MMF、CsA及Pred组成的免疫抑制方案较CsA、Aza及Pred方案相对安全。     

骁悉对肾移植术后感染的影响

目的观察骁悉(MMF)对肾移植术后感染的影响。方法将90例肾移植术后患者分为两组．1997年以前手术的56例为硫唑嘌呤(Aza)组,免疫抑制剂为环孢素A(CsA)加Aza加泼尼松;1998～1999年1月手术的34例为MMF组,免疫抑制剂为CsA加MMF加泼尼松。Aza组CsA起始用量为6mg/(kg·d-1),MMF组为5mg/(kg·d-1),以后根据血药浓度进行调整。结果90例肾移植患者术后总的感染率为17.8％,其中Aza组为21.4％(12/56),2例死亡;MMF组为11.8％(4/34),无死亡病例。两者之间感染率差异有显著性意义(P＜0.05)。结论用MMF代替Aza可以减少肾移植术后的感染率,并提高移植肾成活率。     

肾移植术后早期排斥反应的处理

目的：探讨。肾移植术后早期排斥反应(AR)的处理方法。方法：对14例。肾移植术后3周内发生AR的患者,应用甲基泼尼松龙(MP)治疗7例,改硫唑嘌呤(Aza)为霉酚酸脂(MMF?)治疗5例,抗CD3治疗6例。结果：应用MP治疗的7例中5例AR逆转,2例无效;改Aza为MMF治疗的5例3例逆转,2例无效(其中包括MP无效的2例改Aza为MMF治疗后1例逆转1例无效)。抗CD3治疗6例4例逆转,2例无效(其中MP治疗无效改Aza为MMF治疗后仍无效的1例逆转,MP治疗无效的基础免疫为CsA加MMF?加Pred的1例无效)。结论：MP可使大部分术后早期AR逆转。应用Aza的患者改用MMP后可使早期AR逆转,MP不能完全逆转的AR改用MMF后也有良好的效果。及时应用抗CD3几乎可使术后早期AR全部逆转。     

血清乙型肝炎病毒标志物不同表现模式及肝功能异常对肾移植受者存活率的影响

目的　探讨血清乙型肝炎病毒标志物不同表现模式对肾移植受者长期存活的影响。方法　对 62例血清乙型肝炎病毒标志物阳性者及 1 96例血清乙型肝炎病毒标志物全阴性者肾移植术后的肝功能、人肾均存活的存活率等指标进行随访和回顾性分析。结果　术后早期血清乙型肝炎病毒标志物阳性组与血清乙型肝炎病毒标志物阴性组比较 ,肝功能异常发生率的差异无显著性 (P >0 .0 5) ;术后中远期 ,HBsAg、HBeAg及抗 HBc阳性者的肝功能受损率明显高于血清乙型肝炎病毒标志物阴性组及HBsAg、抗 HBe、抗 HBc阳性者 (P <0 .0 5) ,其人肾均存活的存活率也最低 (P <0 .0 5)。结论　对HBsAg、抗 HBe及抗 HBc阳性者进行肾移植应慎重 ,而HBsAg、HBeAg及抗 HBc阳性者则不适宜接受肾移植     

硫唑嘌呤或骁悉治疗的肾移植患者术后早期并发症比较

目的:比较硫唑嘌呤(azathioprine,Aza)或霉酚酸酯(mycophenolate mofetil,MMF)联合环孢素 激素两种免疫抑制方案的肾移植患者,在术后并发症方面的差异,探讨较理想的免疫抑制方案。方法:收集两组肾移植患者249例:Aza组(即应用Aza CsA 激素)、MMF组(MMF CsA 激素),统计两组患者在术后1年内各种并发症(包括排斥反应、各种感染、肝损害、白细胞减少等)的发生。结果:Aza组与MMF组术后1年急性排斥反应的发生率差异显著;两组总的感染率、肺部感染率相近,但发生急性呼吸窘迫综合征(ARDS)及肺部感染病死率后者明显高于前者。在肝损害、白细胞减少、糖尿病等方面,两组也无统计学差异。结论:MMF组在减少急性排异方面优于Aza组,但增加重症肺部感染机会,肺部感染的病死率升高,且费用贵,故临床上应根据具体情况选择。     

前列腺素E1对尸体肾移植术后肾功能延迟恢复的影响

目的探讨前列腺素E1(PGE1)应用于尸体肾移植术后肾功能延迟恢复(DGF)患者对移植肾功能恢复的影响.方法回顾性分析因急性排斥(AR)和急性肾小管坏死(ANT)导致DGF的127例临床资料,其中应用PGE1治疗56例(PGE1组),未用PGE1者71例(对照组).比较两组在出现DGF后的透析治疗时间、肾功能恢复情况、彩超的移植肾血流阻力指数(RI)及6个月内AR发生率.结果与对照组比较,PGE1组透析治疗时间明显缩短(P＜0.05),移植肾的血肌酐下降速度快(P＜0.05),RI及6个月内AR发生率低(P＜0.05).结论PGE1有利于尸体肾移植术后DGF患者移植肾功能的早期恢复,并能降低AR的发生率.     

肾移植后早期应用咪唑立宾的有效性及安全性

目的 探讨肾移植后早期应用咪唑立宾( MZR)的有效性和安全性.方法 采用前瞻性临床随机对照研究.将61例首次肾移植受者按随机数字表法分为2组:(1)MZR组:33例,应用他克莫司(Tac)+ MZR+泼尼松(Pred)预防排斥反应;(2)吗替麦考酚酯组(MMF)组:28例,应用Tac+ MMF+ Pred预防排斥反应.MZR的用法为:体重＜50 kg者为150mg/d,早餐后口服;体重≥50kg者为200 mg/d,分早、晚2次口服.MMF、Tac和Pred按常规剂量服用.2组受者均于术前2h和术后4d接受巴利昔单抗(20mg/d)诱导治疗.观察并比较2组受者术后6个月内的急性排斥反应(AR)发生率、移植肾存活率以及高尿酸血症、骨髓抑制、巨细胞病毒感染、胃肠道反应等的发生率.结果 术后6个月内,MZR组AR发生率为15.2％,MMF组AR发生率为10.7％ (P＞0.05);MZR组移植肾存活率为97.0％,MMF组移植肾存活率为89.3％(P＞0.05).MZR组和MMF组间高尿酸血症、骨髓抑制、胃肠道反应和肺部感染的发生率的差异无统计学意义(P＞0.05).其中,MZR组未发生巨细胞病毒感染,而MMF组则发生4例(36.4％),差异有统计学意义(P＜0.05).结论 在严密监测下,MZR可应用于肾移植术后早期抗排斥反应治疗.     

心脏死亡器官捐献供肾与传统尸体供肾肾移植的疗效比较

目的 比较心死亡器官捐赠(DCD)供肾与传统尸体供肾肾移植的疗效.方法 回顾性分析单中心2007年2月至2012年6月的69例DCD供肾肾移植受者的资料,并根据受者年龄(相差10岁以内)、移植次数和免疫抑制剂应用情况,按1∶2的比例匹配同期138例传统尸体肾移植受者,进行资料比较.结果 DCD肾移植组术后移植肾功能恢复延迟(DGF)和原发性移植肾无功能(PNF)的发生率为29.0％和2.9％,而传统尸体肾移植组为13.8％和0,差异有统计学意义(P＜0.05).Kaplar-Meier分析结果表明,DCD肾移植组术后6个月、1年和3年的移植肾存活率分别为95.7％、95.7％和93.3％;而传统尸体肾移植组分别为97.8％、97.8％和96.8％,两组的差异无统计学意义(P＞0.05).两组受者存活率的差异也无统计学意义(P＞0.05).术后7和14d,DCD肾移植组的移植肾肾小球滤过率低于传统尸体肾移植组(P＜0.05),但术后1个月至1年,两组移植肾肾小球滤过率的差异无统计学意义(P＞0.05).结论 虽然术后DGF和PNF发生率较高,但DCD肾移植的长期疗效与传统尸体肾移植相当,DCD供肾可以作为替代传统尸体供肾的良好来源.     

肾移植术后早期主动减少免疫抑制剂用量的前瞻性研究

目的探讨对肾移植术后受者早期主动减少免疫抑制剂用量的临床必要性和安全性。方法随机选择63例尸体肾移植受者为观察组,58例尸体肾移植受者为对照组,两组受者均采用环孢素(CsA)+麦考酚吗乙酯(MMF)+泼尼松三联免疫抑制方案。于术后第6周对观察组63例受者予以主动减少免疫抑制剂用量(将CsA血药谷浓度维持在200～250 ng/ml,MMF按受者体质量主动减药),术后4～6个月开始按个体状况将MMF用量调至减药前水平。对照组按常规免疫抑制方案治疗。观察两组受者术后6周至1年的血清肌酐(Scr)、血尿素氮(BUN)、CsA血药谷浓度、肺部感染发生率、急性排斥反应(AR)发生率。结果随访1年期间,观察组受者Scr、BUN基本稳定在同一水平,且与对照组比较差异无统计学意义(均为P>0.05)。观察组与对照组的AR发生率分别为8%与9%,比较差异无统计学意义(P>0.05)。两组的肺部感染率分别为8%(5/63)和14%(8/58),比较差异有统计学意义(P<0.05),对照组有2例发展为严重的肺部感染。结论肾移植术后早期主动减少免疫抑制剂用量能有效降低此阶段肺部感染发生率,且AR发生率并没有增加。     

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.     

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.     

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.     

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.