硝普钠对乳猪体外循环中肺损伤的保护作用

目的 探讨硝普钠预处理对乳猪体外循环(CPB)中的肺保护作用.方法 20只幼猪,数字随机分为实验组(A组)及对照组(B组).A组CPB前30min股静脉滴入硝普钠(20μg·kg-1·min-1)至实验结束,B组滴入生理盐水.CPB前(T1)、主动脉开放(T2)、CPB后5 min(T3)、20 min(T4)、40 min(T5)、60 min(T6)时点测定气道峰压(Ppk).T1、T3、T6时点行动脉血气分析、血浆TNF-a、IL-6、IL-8、IL-10检测及肺动脉、左心房血中性粒细胞检测.实验结束后,切取3块肺组织行肺湿干比(W/D)测定、光镜及电镜组织形态学观察.结果 中性粒细胞滞留率T6[A组(0.48±0.21),B组(0.77±0.29)]、血清炎症因子水平:TNF-α浓度T3[A组(45.20±14.00)pg/ml,B组(71.19±11.65)pg/ml]、IL-6浓度T3[A组(33.38±9.72)pg/ml,B组(46.09±12.12)pg/ml]、IL-8浓度T3及T6[A组(27.84±11.96)pg/ml、(24.94±1 4.24)pg/ml,B组(56.73±14.78)pg/ml、(40.99±7.94)pg/ml]和IL-10浓度T3[A组(37.88±7.79)pg/ml,B组(27.62±11.53)pg/ml]、氧合指数(OI)T3[A组(463.05±40.50)%,B组(382.62±80.01)%]及动脉-肺泡氧分压比率(Pao2/PAo2)T3及T6[A组(0.75±0.10)、(0.76±0.07),B组(0.56±0.12)、(0.60±0.07)]、气道峰压(Ppk)T3[A组(16.57±1.51)mmHg,B组(23.00±2.00mmHg]以及肺湿干比(W/D)[A组(0.21±0.03),B组(0.27±0.04)].A组与B组相比,差异均有统计学意义.光镜、电镜检查显示A组肺损伤明显减轻.结论 CPB期间,硝普钠预处理能抑制炎症因子上调,减轻急性炎症反应,改善肺功能.

Abstract：

Objective To investigate the protective effects of sodium nitroprusside on lung injury induced by cardiopulmonary bypass (CPB). Methods Twenty piglets were randomly divided into group A (n = 10) and group B (n = 10). The piglets of the group A were administered with sodium nithe end of the experiment. The piglets of group B were continuously injected with saline. Peak pressure (Ppk) of the airway was measured before CPB (T1), at the time releasing aortic cross-clamp,and 5 min (T3), 20 min (T4), 40 min (T5), 60 min (T6) after CPB. The blood gases, neutrophils count and TNF-α, IL-8, IL-6 and IL-10 levels were measured at T1, T3, and T6. Lung tissue was collected to measure the wet to dry weight ratio (W/D). The morphologic changes of the lung were also studied. Results At T3, TNF-α, IL-6, and IL-8 levels, Ppk and W/D ratios of group A were significantly lower than those of group B 33.38 ± 9. 71 pg/ml vs 46. 09 ± 12. 12 pg/ml, 27. 84 ±11. 96 pg/ml vs 40. 99 ± 7. 94 pg/ml, 16. 57 ± 1.51 mmHg vs 23. 00 ± 2. 00 mmHg, 0. 21 ± 0. 03 vs 0. 27 ± 0. 04,respectively). At T3, IL-10, oxygenation index, and alveolar-arterial oxygen ratio of group A were significantly higher than those of group B (37. 88 ± 7. 79 pg/ml vs 27. 62 ± 11. 53 pg/ml, 463. 05 ±40. 50% vs 382. 62 ± 80. 01 %, 0. 75 ± 0. 10 vs 0. 56 ± 0. 12). At T6, the neutrophil sequestration,IL8 level, and alveolar-arterial oxygen ratio of group A were significantly higher than those of group B (0. 48 ± 0. 21 vs 0. 77 ± 0. 29, 24. 94 ± 14. 24 pg/ml vs 40. 99 ± 7. 94 pg/ml, 0. 76 ± 0. 07 vs 0. 60 ±0. 07). Lung morphology study also showed group A had less injury. Conclusions Sodium nitroprusside protects lung from injury by suppressing inflammation on piglets with cardiopulmonary bypass.     

Acute secondary erythermalgia and hypertension in children

We studied the clinical symptoms in nine children (seven females and two males; mean age 11.6 years) with severe but transient acute secondary erythermalgia. The classical symptoms at presentation were episodic attacks of painful burning hands and feet which felt warm with congested appearance of the feet. Each attack lasted for a mean period of 25 days (range from 6 to 56 days). The blood pressure was elevated in seven patients. Intravenous sodium nitroprusside was effective in ameliorating the symptoms with drop in blood pressure to normal in five patients; pizotifene, labetolol, prostaglandin E₁ and hypnotherapy were effective in each of four separate cases. The episodes of acute secondary erythermalgia were transient in all and did not recur after a mean follow up period of 1.6 years. These cases suggest that acute secondary erythermalgia, however transient, is not rare and can be associated with mild to moderate hypertension which may respond to sodium nitroprusside. A greater awareness of this condition is necessary to make an accurate and timely diagnosis and institute appropiate therapy in order to prevent undue complications. Erythermalgia Multidisciplinary Study Group: K. Chakravarty, Warrington Hospital NHS Trust, Department of Rheumatology, Warrington, United Kingdom; J.P.H. Drenth, University Hospital St. Radboud, Department of Medicine, Nijmegen, The Netherlands; J.J. Michiels, University Hospital Dijkzigt, Department of Hematology, Rotterdam, The Netherlands: S. Özsoylu, Turkish Health and Therapy Foundation, Medical Center and Memorial Ahmet Örs Hospital, Ankara, Turkey; B.S. Shapiro, Children's Hospital of Philadelphia, Division of General Pediatrics, United States of America     

Hemodynamic effects of sodium nitroprusside in patients with ventricular septal defect

During routine cardiac catheterization of ten patients with ventricular septal defect, the hemodynamic parameters were measured in the resting state and during sodium nitroprusside infusion at an average rate of 8 g/kg/min. Two distinct hemodynamic groups could be identified. Group I characterised by elevated left ventricular filling pressure showed a consistently favourable response to sodium nitroprusside infusion with a decrease in the left ventricular filling pressure, the pulmonary arterial pressures and the left to right shunt. The favourable effect was most pronounced in patients who had pulmonary arterial hypertension in addition to elevated left ventricular filling pressures. Group II patients characterised by normal left ventricular filling pressures showed a variable response to sodium nitroprusside administration. The left ventricular end-diastolic pressure fell or was unaltered. The pulmonary arterial pressures and pulmonary vascular resistance fell in those with pulmonary arterial hypertension. Patients without pulmonary arterial hypertension showed an increase in the magnitude of left to right shunt. On the basis of our data, we feel that vasodilator drugs have a specific role in the management of congestive heart failure secondary to large left to right shunts. The present study strongly indicates the need for further investigations utilizing orally effective vasodilators in patients with congestive heart failure due to left to right shunts.     

硝普钠对肠道病毒71型感染手足口病低血压期临床疗效分析

目的 探讨硝普钠在肠道病毒71型(EV71)感染合并心肺功能障碍治疗中的作用和价值.方法 采用病例-对照分析方法,对10例临床确诊为危重症EV71手足口病(低血压期)患儿进行回顾性分析,探讨低血压期应用硝普钠对血压、脉搏、末梢循环及肺水肿的治疗效果.选择既往予米力农/肾上腺素治疗的8例EV71感染肺水肿/肺出血患儿作为对照.结果 10例患儿入院时均出现肺水肿、肺出血、心功能紊乱及低血压症状,均行气管插管、机械通气治疗,2例合并严重室性心律紊乱,2例多次心脏骤停.10例患儿均在出现循环障碍加重、血压下降时行硝普钠试验,并给予硝普钠静脉滴注治疗,硝普钠最大剂量为3.5μg/(kg·min),平均应用硝普钠时间为(29±18)h,于给药30min～1 h后患儿出现面色及末梢循环改善,脉搏有力,30 min～2 h后出现心率逐渐下降,血压回升至正常水平,未见不良反应发生.结论 低血压期是EV71感染手足口病患儿的急危重症,手足口病合并休克综合征与交感神经兴奋导致的急性左心室功能紊乱相关,硝普钠能有效的减轻心、脏后负荷,纠正休克,改善预后.

Abstract：

Objective To investigate the curative effect of sodium nitroprusside in the treatment of EV71-related pneumoedema/pneumorrhagia and hypotension in this study. Methods This was a retrospective study of a total 10 children with EV71-related pneumoedema/pneumorrhagia treated with sodium nitroprusside using case-control methods. The clinical manifestations and outcomes of the 10 children (present cohort) were compared with those of 8 children (past cohort) who had EV71-related pneumoedema/pneumorrhagia without sodium nitroprusside. Results Among these 10 patients,all were at the appearance of pneumoedema/pneumorrhagia, cardiac arrhythmia and hypotension. Two patients showed severe cardiac arrhythmia, two patients showed cardiac arrest for many times. All 10 patients were treated with mechanical ventilation and other conventional treatments. At the first time of the manifest of hypotension,sodium nitroprusside were put into practice in all 10 patients. Ten patients were treated with intravenously sodium nitroprusside in the stage of hypotension by maxi30 min ～ 1 h,the patients showed an improvement in vultus,pulse and peripheral circulation and decrease of heart rate and elevation of blood pressure after 30 min ～2 h,but at least 2～6 h later,the blood pressure tended to stabilize at normal standard. Conclusion Hypotension is the intensive stage in EV71-related hand,foot and mouth disease ,and the shock syndrome caused by acute left ventricular disorder is related to sympathetic nerve activity. Sodium nitroprusside can effectively reduce the cardiac afterload,and correct shock and improve the prognosis.     

Sodium nitroprusside treatment of severe arterial hypertension in children.

Severe arterial hypertension in children constitutes a high-risk situation requiring rapid and effective therapy. We have assessed the clinical value of sodium nitroprusside as a rapidly acting antihypertensive agent. Twenty children admitted with hypertensive crises of renal origin were treated with intravenous infusion of sodium nitroprusside at an average rate of 1.4 mug/kg/min. Desired levels of blood pressure were reached in all patients within one to 20 minutes. Rapid improvement of cardiac failure was observed in all patients, and neurologic signs of distress disappeared in 16 of the 20 children within 24 to 48 hours of treatment, permitting substitution of oral medication. One patient died of cerebral hemorrhage without improvement of encephalopathy. There were no undesirable effects of therapy or deterioration of renal function in any patient.     

Sodium nitroprusside prevents oxygen-free-radical-induced pulmonary vasoconstriction in newborn piglets

The aim of the present study was to test whether hypoxanthine-xanthine oxidase (XO) induced a pulmonary vasoconstriction in newborn piglets, and whether this vasoconstriction could be attenuated or abolished by pretreatment of nitric oxide (NO) donor sodium nitroprusside (SNP). Twenty-five anesthetized newborn piglets (1-3 days old) were randomly assigned to the following four groups: the control group received saline intravenously only; the XO group received 0.1 mmol/kg of hypoxanthine subsequent with XO (1.5 U/kg); the SNP group received the same dosages of hypoxanthine/ XO together with SNP intravenously, allopurinol (ALP) group received ALP intravenously prior to hypoxanthine and XO injection. After giving XO, the pulmonary arterial pressure (PAP) and vascular resistance (PVR) increased, while the cardiac index decreased significantly in the XO group. By contrast, these variables were not significantly modified by XO injection in the SNP and ALP groups. The data suggest that oxygen free radicals induce a pulmonary vasoconstriction in newborn piglets, and this vasoconstriction can be prevented by infusion of the NO donor SNP.     

Sodium valproate versus phenobarbital in the prophylactic treatment of febrile convulsions in childhood

Phenobarbital has been shown to offer effective prophylaxis against childhood febrile convulsions. However, a high percentage of children do not tolerate phenobarbital, mainly due to behavioral changes. Valproate, due to its low toxicity, appears to be an attractive alternative to phenobarbital treatment. Ninety children admitted with their first febrile convulsion were offered prophylactic treatment with either phenobarbital 3–5 mg/kg/day or valproate 20–30 mg /kg/day. Twenty-five children whose parents refused prophylactic treatment make up an untreated control group. Serum levels of the appropriate drug were measured at each follow-up visit. The three groups appear to be comparable. Twenty-one per cent of the phenobarbital treated children required discontinuation of the drug due to side effects. All the children tolerated valproate therapy.Twelve out of 25 untreated children suffered recurrences. Eight out of 33 children treated with phenobarbital suffered recurrences. Four out of 32 children on valproate therapy had recurrences. The difference between valproate treatment and no therapy at all is highly significant (P<0.0001). Phenobarbital did not reduce the risk of recurrence. We now recommend prophylactic treatment with valproate to children with febrile seizures.     

Sodium chloride deficiency in cystic fibrosis patients

Sodium chloride deficiency (SCD) was observed within the 1st year of life in 12 of 46 cystic fibrosis (CF) patients between July 1989 and September 1992. All patients showed sweating, loss of appetite, fever, vomiting, irritation, dehydration, weakness, and cyanosis during an attack. Mean plasma sodium, potassium and chloride levels were 122.9 (range 106–135), 2.5 (range 1.6–3.5), and 73.3 (range 60–90) mEq/l respectively. Alkalosis and elevated plasma renin activity were detected in all patients. Of the patients, 50% showed microscopic haematuria, and hypercalciuria was detected in two out of four patients. Low urinary sodium and high urinary potassium were observed in the four examined patients. Increased creatinine, BUN and uric acid values returned to normal with treatment. All the patients were treated initially with intravenous fluids and electrolyte solutions. All patients were less than 7 months of age during the first attack, five received only breast milk and the others breast milk with formula milk. Their oral salt supplement was 2–4 mEq/kg per day, which is recommended for CF patients, but could be deficient in excessively sweating infants. The genotype of these patients might be cause of high salt losses. F508 is the most common mutation with the frequency of 38% in our CF patients with SCD, but the frequency of unknown mutations is high (54%).     

Primary erythromelalgia in a child responding to intravenous lidocaine and oral mexiletine treatment

Erythromelalgia is a rare, chronic, debilitating condition characterized by redness, warmth, and severe burning pain of the distal extremities. The feet are more commonly affected than the hands. Pain is precipitated by increases in temperature and by exercise. Patients often obtain relief by immersing the affected extremity in cold water. The pain is often refractory to treatment. For many patients, multiple pain medications have been useless in achieving complete relief of pain symptoms. Previous reports of erythromelalgia among adolescents indicated prolonged relief of pain with sodium nitroprusside infusions, epidural infusions of local anesthetics, or gabapentin treatment. We present a case of an 11-year-old, white, male child with primary erythromelalgia, whose initial symptoms started in his preschool years and whose childhood was marked by escalating episodes of pain with warmth and redness of his feet, precipitated especially by increases in temperature and by activity. All conventional pain management techniques had failed to relieve our patient of his symptoms, and he obtained some relief only by soaking his affected extremities in ice water. He had experienced minimal benefit from seeing a pain psychologist, who helped him develop techniques to cope with the pain. At the time of presentation, the patient's episodes of pain had increased to 15 to 20 per day, and there was evidence of chronic immersion injury to the skin of his feet. Before his most recent hospitalization, the pain had spread to involve his hands as well. The patient was overwhelmed with anxiety and could not participate in school or social activities at the time of admission. During his current hospitalization, he did show some therapeutic response to sodium nitroprusside infusion, which unfortunately had to be discontinued because of side effects and because his family desired to leave the ICU environment, which was stressful to the patient. He also had some response to lumbar epidural infusion of local anesthetics, which could not be continued because he found the motor blockade that accompanied his analgesia intolerable. However, intravenous lidocaine infusion, with subsequent transition to oral mexiletine therapy, proved very effective in reducing the frequency and severity of the pain episodes. The patient was discharged from the hospital with oral mexiletine therapy and has been monitored at the pain management clinic. He returned to and completed school, attended summer camp, and enjoys an active happy life. He walks without precipitating pain in his feet and sleeps 9 to 10 hours every night. He has needed to soak his feet on only 4 occasions in the 6 months since his discharge from the hospital. His quality of life has improved significantly. He has shown no evidence of liver toxicity, and his mexiletine levels have been stable.     

Sodium found in processed cow milk and estimated intake by infants

ObjectiveTo determine the sodium concentration in cow milk available for sale and to estimate its consumption by infants up to 6 months of age.MethodsSodium level was determined by flame emission spectrophotometry in eight different lots of five brands of liquid ultra-high temperature milk and three brands of powdered milk. To estimate sodium consumption via cow milk, orientations for exceptional situations when neither breastfeeding nor infant formula is possible were considered. Inferential statistics were performed and results were compared with critical parameters at a 5% significance level.ResultsThe mean sodium content per portion found in liquid milk (162.5 ± 16.2) mg/200 mL was higher than that in powdered milk (116.8 ± 3.0) mg/26 g. Estimated sodium consumption by infants through powdered milk varied from 149.8 to 224.7% of adequate intake, and via liquid milk can be more than 500% of the adequate intake, reaching 812.4% of it if dilution is not applied. Seven of the eight brands of milk studied had declared, on their labels, that the sodium content was 13–30% lower than that found in chemical analysis.ConclusionLiquid and powdered whole cow milk have high sodium content, and the content per portion is higher in liquid milk than in powdered milk. The estimated consumption of sodium through these products can far exceed the adequate intake for infants from 0 to 6 months old, even when the recommended dilution and maximum daily volumes are followed.     

Sodium and water homeostasis in children with shigellosis

Studies in Bangladesh have shown that the mortality in shigellosis is significantly higher in hyponatraemic (HN) than in normo- (NN) or hypernatraemic children. The aim of this study was to describe the effect of shigellosis on renal haemodynamics and sodium and water homeostasis before treatment was started. Twenty-one moderately ill children infected with Shigella dysenteriae type 1 were studied. Eight of them had a serum sodium concentration below 130 mmol/L. Renal function was determined by glomerular filtration rate measured by clearances of inulin and iohexol. Effective renal plasma flow was estimated by clearance of paraaminohippuric acid. Plasma renin, aldosterone and anti-diuretic hormone were also studied. The HN children had significantly higher haemoglobin and haematocrit levels than the NN group. There was an inverse correlation between serum sodium and haemoglobin, and a direct correlation between serum sodium and urinary sodium and urinary chloride. Direct correlations were found between serum aldosterone and haemoglobin, plasma renin and systolic blood pressure and an inverse correlation between serum aldosterone and serum sodium. Clearances of inulin and iohexol were normal. Detectable levels of ADH were found in both groups, despite low serum osmolalities.

Conclusion : The HN state seems to be triggered by multiple factors. The normal glomerular filtration rate excludes a volume expansion secondary to reduced renal function. Inappropriate or a physiological increase of anti-diuretic hormone secretion may be of importance. The higher sodium losses in stools of the HN children might also be a factor contributing to the HN.     

Methylsuccinate and Mesaconate in Urine of Patients Treated with Sodium Benzoate

Two unusual peaks were found on gas chromatography of urine from four hyperammonemic patients treated with sodium benzoate. These peaks were identified by gas chromatography/ mas spectrometric analyses as methylsuccinate and mesaconate. Of the two unusual substances, methylsuccinate was found to be a contaminant of sodium benzoate administered for the treatment of hyperammonemia. However, mesaconate was not a contaminant of sodium benzoate, though it could be detected in all urine samples from hyperammonemic patients treated with sodium benzoate. Mesaconate can be produced from methylsuccmate in viva Considering that mesaconate is an inhibitor of fumarase, the toxic effects of sodium benzoate may be attributable to the mesaconate. It is recommended that methylsuccinate-free sodium benzoate should be used for the treatment of hyperammonemia.     

A Report of a Case with Pure Red Cell Aplasia Induced by Sodium Valproate

A 5-year-old girl developed pure red cell aplasia (PRCA) during sodium valproate (VPA) administration. Only four cases of VPA induced PRCA have been reported in the literature. Furthermore no precise report concerning the underlying mechanisms is available. Using a system for the clonal growth of autologous bone marrow committed erythroid stem cells (CFU-E, BFU-E) WA itself was not inhibitory for colony formation at a physiological concentration. Patient's serum and peripheral mononuclear cells collected at admission showed no inhibitory effects on erythroid progenitor cell growth. Rapid recovery from PRCA was observed after discontinuation of VPA, without immunosuppressive therapy. Our observation suggests that VPA may induce PRCA through the inhibitory effect beyond the differentiation stage of BFU-E and CFU-E in some cases.     

Use of sodium nitroprusside in neonates: efficacy and safety

Sodium nitroprusside was administered to 58 neonates, including 11 with severe respiratory distress syndrome, 15 with persistent pulmonary hypertension of the newborn, 28 with clinical shock, three with systemic hypertension, and two with pulmonary hypoplasia, all refractory to conventional intensive therapy. Nitroprusside was infused at 0.2 to 6.0 micrograms/kg/min for periods of 10 minutes to 126 hours. Infants with severe respiratory distress syndrome had increased PaO2 and decreased PaCO2 or peak inspiratory pressure, and nearly all (82%) survived. Infants with persistent pulmonary hypertension of the newborn had variable responses; improvement did not correlate with survival, but survival (47%) was identical to that in an earlier series of infants given tolazoline. Infants in shock had improved perfusion, urine output, and serum bicarbonate levels, and these responses were significantly related to survival. Hypertension was controlled in all three hypertensive infants. Adverse effects were very uncommon. Toxic effects were not observed. Sodium nitroprusside is effective and can be used safely in circulatory disorders in the neonate.     

Teratogenic Effects of Sodium Valproate in the Jcl: ICR Mouse Fetus

Sodium valproate was administered to Jc1:ICR mice in order to evaluate its teratogenicity. A single dose of 600 mg/kg of sodium valproate was injected intrapentoneally on gestational day 6, 7, 8 or 9. On day 18 of gestation, dams were laparotomized, and live fetuses were inspected for the presence of external and internal abnormalities. Exencephaly and urogenital abnormalities showed the highest frequency in the group treated on day 8, being recognized in about 60% and 10% of live fetuses, respectively. Cardiovascular abnormalities were found in the highest frequency in the group treated on day 7 (in about 30% of live fetuses). Incidence of tail abnormality was found to increase with delay in day of drug administration. Other abnormalities observed were cleft palate and digital malformation. Our study showed that a constellation of major abnormalities similar to the congenital valproate syndrome suspected in humans could be produced in the Jc1:ICR mouse fetus.     

Sodium glycerophosphate in the treatment of neonatal hypophosphataemia.

Nineteen very low birthweight (mean (SD) gestational age 28 (3) weeks) were parenterally fed nutrition solutions containing inorganic calcium and phosphorus salts. All infants had hypophosphataemia. Plasma concentrations were maintained between 1.5 mmol/l and 2.2 mmol/l. Plasma phosphorus concentrations reached 1.5 mmol/l or greater in three patients after 12 hours, in a further nine patients after 36 hours, and in all patients by 60 hours. Changes in plasma calcium concentrations were not significant.