严重髋臼骨折全髋置换适应证选择及临床效果观察

目的探讨早期和晚期全髋关节置换术治疗严重髋臼移位骨折的疗效与评价。方法对17例髋臼骨折移位施行了早期全髋置换术,伤后到手术时间平均8d(5～21d),平均年龄53岁(26～69岁)。对髋臼骨折继发性严重的创伤性关节炎5例,股骨头坏死2例,股骨头持续性后脱位2例分别施行了晚期挽救性全髋置换术,伤后到手术时间平均7个月(3～25个月),平均年龄37岁(26～46岁)。结果平均随访时间为4.1年(1～6年)。最后随访根据Harris评分平均为82分(69～100分),其中25例疗效为优良,1例发生异位骨化。无一例发生假体松动,1例发生髋臼杯严重中央移位。结论严重髋臼移位骨折,常规切开复位内固定难以取得良好疗效,施行早期全髋置换术效果肯定。髋臼骨折手术所致的创伤性关节炎、髋关节后方脱位、股骨头坏死等并发症施行晚期挽救性全髋置换术效果亦肯定。手术最好由对髋臼创伤及全髋置换经验丰富的骨科医生施行。     

老年移位髋臼骨折手术治疗策略及疗效

目的探讨切开复位内固定术和一期全髋关节置换术治疗老年髋臼骨折的临床疗效并进行比较研究。方法1998～2005年间共收治45位年龄超过60岁的髋臼骨折患者，其中21例行切开复位内固定，10例行一期全髋关节置换术。手术距受伤时间不到2周，平均7d。术后常规给予抗凝药预防深静脉血栓形成，按康复计划进行恢复性功能锻炼，定期随访行髋关节功能Harris评分。结果本组随访1．5～7年，平均4年；最后随访时，切开复位内固定组Harris评分为69～84分，平均79分，优良率为57％，伴有较高的创伤性关节炎、异位骨化、股骨头骨坏死发生率；全髋关节置换术组患者的Harris评分为75～90分，平均84分，优良率为80％，仅有髋臼杯轻度移动（〈4mm），无假体松动、深部感染等并发症。结论全髋关节置换术治疗老年移位髋臼骨折可以取得比切开复位内固定更好的稳定性，术后恢复快、功能质量高，并发症少，是一种较好的选择。     

陈旧粉碎性髋臼骨折手术重建修复的策略及预后

背景：陈旧粉碎性髋臼骨折多为高动能严重复合损伤,现逐年增加,且无法早期手术。随着早期切开复位内固定手术的经验积累,对陈旧粉碎性髋臼骨折进行切开复位内固定重建手术势在必行。目的：探讨切开复位内固定手术重建修复陈旧粉碎性髋臼骨折的可行性、方法及疗效。方法：回顾性研究2003年10月至2010年6月应用先纠正髋臼周围骨盆骨折移位及股骨头臼关系,再重建修复髋臼关节面的方法治疗24例陈旧粉碎性髋臼骨折。骨折距手术时间3～6周,平均26.1天。分析手术时间、出血量及输血量、合并伤情况等。术后限制髋部活动4～6周,床上逐渐行关节功能锻炼,3月后下床扶拐活动,并逐渐负重。结果：随访10～36个月,平均15.6个月。关节面骨折复位质量采用Matta标准：解剖复位21髋,满意复位2髋,不满意复位1髋。采用改良Mered＇Aubigne-Postel临床结果评分：优21髋,良2髋,差1髋。术后发生股骨头坏死1例（4.17%）,异位骨化11例（45.83%）,坐骨神经一过性麻痹6例（25%）。结论：先行瘢痕切除松解、整体复位固定髋臼关节外骨折、恢复头臼关系,再应用可吸收螺钉固定、植骨、骨软骨骨折块镶嵌挤压等方法修复碎裂关节面的手术方法治疗陈旧粉碎性髋臼骨折,可达到满意复位及关节功能恢复。     

髋臼骨折后创伤性关节炎全髋关节置换疗效研究

[目的]比较髋臼骨折经切开复位内固定治疗和保守治疗后发生创伤性关节炎行全髋关节置换术的远期疗效。[方法]30例（32髋）髋臼骨折患者行保守治疗或切开复位内固定术，髋臼骨折后平均间隔7年5个月（5个月～29年）发生创伤性关节炎，对32髋行全髋关节置换术治疗，手术时平均51岁（25～78岁）。应用非骨水泥人工关节29髋，骨水泥型2髋，混合型1髋。术后平均随访8年9个月（4～17年）。[结果]手术组和保守组在骨移植、翻修率、手术时间和异位骨化发生率方面无显著差异（P〉0．05）；失血量有统计学差异（P〈0．05），保守组失血量较多。手术组和保守组临床疗效无显著性差异。[结论]髋臼骨折行保守治疗和手术治疗后发生创伤性关节炎需行人工关节置换治疗，两者远期疗效相似，非骨水泥型关节置换疗效较好。     

髋臼骨折内固定术后的全髋关节置换

目的探讨髋臼骨折经内固定术后出现并发症而导致疗效不佳,行全髋关节置换(TH R)的方法和疗效。方法总结经切开复位内固定治疗的髋臼骨折患者11例,因术后27～63个月(平均46.5个月)内继发创伤性关节炎或股骨头坏死,继而行全髋关节置换术。其中合并髋臼骨缺损6例,进行颗粒性植骨2例,结构性加颗粒性植骨4例;异位骨化4例,均发生于K-L入路。采用后外侧入路9例,髂股延伸切口2例,其中6例为原手术切口。结果11例患者全部得到随访,随访1年6个月～7年3个月,平均3年5个月。出现感染1例,脱位1例,无菌松动1例。术后再次异位骨化2例,其中1例引起坐骨神经症状,再次行神经松解术。所有随访病例髋关节功能均有改善,H arris评分由术前平均47分,提高到术后88分。结论选择正确的手术入路,适当处理异位骨化组织和内固定物,重建髋臼骨缺损,是髋臼骨折经切开复位内固定术后,再行全髋关节置换成功的关键。     

切开复位内固定治疗有移位髋臼骨折的疗效分析

目的观察切开复位内固定治疗有移位髋臼骨折的远期疗效,并分析影响远期疗效的相关因素.方法本组按Letournel-Judet分型简单骨折23例,复杂骨折31例,骨折移位≥3 mm,合并髋关节后脱位16例,中心性脱位13例,股骨头软骨面损伤17例.均采用切开复位钢板螺钉内固定,其中伤后2周内手术42例,3周后手术12例.结果术后平均随访38个月,Matta关节评分＞15分、Liebergall影像学评价A、B的病例43例,优良率79.6%,3年后全髋置换5例,占9.3%.结论切开复位内固定能使髋臼恢复正常解剖形态,有利于关节功能的恢复,远期疗效较好;Letournel-Judet骨折分型、股骨头软骨面是否损伤、骨折后手术时间以及复位质量是主要影响因素,提示髋臼创伤骨折的严重程度直接影响其预后.     

骨盆、髋关节

经骶骨纵向固定融合治疗创伤性腰骶脱位；Chiari截骨术治疗成人髋发育不良的远期随访；强直性脊柱炎的人工全髋关节置换术(附18例／31髋中期随访分析)；髋臼骨折的实用分型与治疗选择；髋关节发育不良患者全髋关节置换术的髋臼中心化；股骨近端缩短及全髋置换术治疗陈旧股骨颈骨折伴严重髋关节脱位；全髋关节置换治疗陈旧性髋臼骨折合并髋关节脱位的临床观察；全髋关节置换治疗髋臼骨折；老年患者髋部骨折治疗方法的选择与预后探讨；强直髋的全髋关节置换术；金属钛网联合颗粒骨打压植骨治疗髋臼骨缺损。     

髋臼骨折后全髋关节置换术的初步临床结果

目的分析髋臼骨折术后全髋关节置换术的早期临床效果。方法2002年1月至2007年12月，共对18例髋臼骨折后创伤性髋关节关节炎的患者进行了全髋关节置换术，其中13例髋臼骨折做过切开复位内固定术，另5例行闭合复位骨牵引治疗；10例因为既往手术的疤痕粘连，关节置换时需行较广泛的软组织松解；9例在全髋关节置换术时仍有固定用的内植入物，5例术中需要取出内固定；12例术中用取下的股骨头行结构性或颗粒植骨；16例用非骨水泥髋臼，2例用金属加强环与骨水泥固定聚乙烯髋臼。术后随访行x线摄片评估，髋关节功能作Harris评分。结果随访时间6—70个月不等，平均38个月。3例术后发生髋关节周围BrookerⅡ度异位骨化，其中2例行异位骨化切除；1例术中股骨骨折，1例深部感染，1例髋臼松动并移位。最后随访时，12例（67％）患髋没有或仅偶有轻微疼痛，4例中度疼痛，2例疼痛需要助行工具；Harris评分由术前平均43．5分到术后平均84分。结论髋臼骨折后髋关节骨关节炎仍可通过全髋关节置换手术得到有效治疗，但其手术复杂程度与款臼骨折的处理有关，且并发症的发生率比一般的全髋关节置换手术高。     

髋臼骨折术后行全髋关节置换术原内固定物的处理要点

目的 探讨髋臼骨折内固定术后因并发症而再次行全髋关节置换术(THA)时对原内固定物的处理方法.方法 对17例由于髋臼骨折行切开复位内固定术后出现相应并发症而二期行THA.结果 本组随访17个月～8年3个月,按Harris评分标准,由术前平均56.4分恢复至术后89.5分,效果良好.结论 髋臼骨折切开复位内固定术后因并发症再次行THA时,原内固定物如果不影响髋关节假体的置入操作和假体置入后关节活动时,可不予以取出,不影响THA疗效.     

H/G非骨水泥人工全髋关节置换术后聚乙烯内杯磨损临床研究

目的 对H/G非骨水泥人工全髋关节置换术后聚乙烯内杯的磨损及髋臼周围骨溶解的情况进行总结.方法 我院1991至1995年共进行58例(65髋)H/G非骨水泥人工全髋关节置换,其中35例(40髋)获得10年以上随访.对这35例(40髋)患者获得随访的病例,采用计算机数字化方法测量髋臼聚乙烯内杯的二维线性磨损.结果 35例40髋均有不同程度的磨损,磨损范围2～8 mm,平均磨损为(0.32±0.31)mm/年.10髋聚乙烯磨损超过6 mm,髋臼假体周围的骨溶解严重,并伴有金属假体的移位,其中5髋聚乙烯内杯完伞磨透,金属股骨头与金属髋臼相接触;5髋聚乙烯内杯磨损严重伴明显骨溶解,内杯松动.2髋聚乙烯内杯脱位.共实施翻修手术12例,包括更换聚乙烯内杯和金属股骨头2例、金属闩杯翻修2例、全髋翻修8例.28髋在髋臼侧发现骨溶解,其中14髋股骨侧亦有骨溶解发生.结论 本组病例所观测到的H/G髋臼聚乙烯内杯的磨损程度超过文献所报道,而且由于磨损产生的大量磨屑,导致假体周围出现明显骨溶解,直接影响到假体的稳定.关节置换术后应定期随访,避免出现严重骨溶解后增加翻修手术的困难.     

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.