小儿示指旋转撕脱性断指特点及其再植

通过３例小儿示指肇转撕脱性断指的再植，分析了小儿旋转撕脱性离断的损伤特点及机制，小儿组织细嫩，皮肤、静脉、骨骼断裂发生在干骺端，撕脱较成人轻；肌腱、神经撕脱较重，与成人类似。该类损伤再植的难点在于吻合细小血管和伸指装置的修复。术中要保护好骨骺，妥善处理好肌腱、血管及神经。术后适当制动，早期功能锻炼，可使再植指获得满意的外观和功能。     

游离静脉筋膜瓣在再植术中的应用

手指皮肤套状撕脱伤组织损伤特点是：伤指全部皮肤、指神经、血管束，甚至末节指骨经指间关节撕脱，指屈肌腱从前臂肌肉肌腱连结处被拉断，并随撕脱的指皮肤、指骨一起抽出，指动脉及指静脉在较大范围内牵拉，血管内膜受到广泛的损伤，因此不宜应用直接吻合血管的方法将撕脱的皮肤原位缝合后再植。挤压伤组织损伤特点：直接受力，组织挫伤重，血管内膜有不同程度损伤，不能直接吻合，皮肤组织出现不同程度坏死，深部组织外露，单纯静脉移植桥接动脉圆，往往因后期的皮肤坏死、深部组织外露而导致再植失败。笔者利用静脉筋膜瓣桥接动脉在复杂断掌断指再植中获得成功，报道如下。     

废弃上肢全前臂皮瓣移植一例报告

患者，男，３０岁，车祸挤伤右肩部４h。检查：右上肢自肱骨上１／３处完全离断，皮肤自肩关节周围撕脱，创面骨断端及肌肉组织外露，离断上肢断端皮肤及肌肉组织挫灭达１０cm以上，部分神经血管自近端撕出，创面污染。全身情况：贫血貌，血压偏低，意识清楚。诊断：右上臂中上１／３处完全撕脱性离断。治疗：入院后即行输液，输血等抗休克治疗。生命体征平稳后，行右上臂残端清创，在无菌条件下从废弃肢体上切取全前臂皮瓣，移植于右上臂皮肤缺损区。术中将皮瓣肱动脉、静脉与受区肱动脉、静脉行端端吻合，并将头静脉远近端行端端吻合。动、静比例为１∶３。在皮瓣近端吻合臂内侧皮神经、桡神经。松血管夹后，观察到远端桡、尺及骨间动脉有搏动性出血，结扎远端血管及创面出血点，将皮瓣顺血管走行方向完整缝合于受区创面，留置引流条。术后抗感染、解痉、抗凝等治疗，皮瓣顺利成讨论：本例右上臂上１／３处完全离断，皮肤自肩关节周围撕脱，断面有１０cm以上毁损，且有部分神经血管撕出。如采用：①右上肢再植，将造成上肢严重短缩畸形，创面不能覆盖，而再植成活的前臂及手臂又很难恢复功能，造成短肢废用畸形，影响精神生活，故短缩再植不宜施行；②残端缝合。一种方法是行肩关节离断，皮肤缝合...     

毁损性断掌的急诊再植与再造

目的探讨毁损性断掌急诊再植与再造的方法及临床疗效。方法38例毁损性断掌按手掌和手指的毁损程度选择两类方法急诊修复：（1）异位短缩再植：将2～5个离断手指连同部分手掌异位短缩再植于腕部或前臂残端,结合术后系统的康复锻炼,重建部分手功能;（2）前臂残端手再造：从足部切取相应的组织如足趾、第1趾蹼、趾骨、足背皮瓣等移植修复。上述组织都是足背动脉及其分支供应．静脉回流也主要依靠大隐静脉系统,手术时可以整体切取,行一期移植再造手术。结果本组术后平均随访5．5个月（4~12个月）。除1例再植手指部分坏死外,其余全部成活,手的功能和外形均得到较好改善与恢复。按中华医学会手外科学会断指再植功能评定试用标准评定,手指功能优良率85．2％。结论畀位短缩再植和前臂残端手再造,能够使手的功能和外形得到较好地改善与恢复;充分认识毁损性断掌的特点,合理应用解剖关系及残存组织是决定手术成败的关键。     

撕脱性断指再植的临床应用

近年来，各种特殊损伤类型的断指再植成功率得到了明显的提高。一般认为撕脱性离断的血管无法使用吻合，而我们在临床中发现，许多非切割性离断手指的血管均存在不同程度的损伤，保留并吻合这些血管后断指再植也获得了成功。因此，我们在各种严重损伤的断指中尝试使用撕脱性离断的血管进行吻合并获得了成功。     

上臂绞轧撕脱性离断再植疗效分析

上臂绞轧撕脱性离断伤伤情严重,离断肢体两断端组织尤其是神经血管损伤严重,断端参差不齐,有时还可能会发生部分或全臂丛神经的根性撕脱,这些给离断肢体再植的成活及术后功能恢复造成了极大的影响。我科自1985年对5例上臂绞轧撕脱性离断肢体进行了再植,就其疗效作一分析。     

拇指撕脱性离断再植的体会

拇指占手动能的40％。因此对指体完整的各类拇指离断,均是再植的适应证。拇指撕脱性离断的再植,因其肌腱、指掌侧固有动脉及神经从近端抽出,与一般指体离断再植有所不同。我院自1995年4月～1998年10月,对42例拇指撕脱性离断施行再植,成活40例,失败2例。再植成活的拇指外形及功能较满意。     

拇指撕脱性离断的显微外科治疗

<正> Pho于1979年对拇指撕脱性断指再植首先报道。国内学者对拇指、食指、环指旋转撕脱性断指再植均有过报道,但文中报道的再植方法及成活率各有不同。我们自1990年以来对79例79指旋转撕脱性拇指离断实施再植,成活76指,成活率762％。23例经2个月～3年随访,再植拇指获得了满意的外形和功能。现报道如下。 1 临床资料 本组79例79指,男55例,女24例,年龄最大59岁,最小6岁。指别:左手拇指27例,右手拇指52例。受伤原因:各种丝绳、绞带伤19例,钻床伤21例,其它机器伤39例。离断平面:指间关节平面23例,掌指关节平面39例,腕掌关节平面17例。伤情及手术情况:79例均为完全性离断。3例动脉从远端撕脱,神经、肌腱从近端撕脱,采用远端静脉动脉化,食指尺侧动脉神经转移,顺利成活。50例动脉、神经肌腱从近端抽出,挫     

前臂旋转撕脱离断伤再植成功一例

男, 40岁, 因传送带绞伤右前臂致完全离断出血、疼痛1 h急诊入院。入院检查:右上肢离断, 皮肤离断平面约为肘上8 cm, 肌肉等软组织离断平面约为肱二头肌腱膜止点平面, 尺桡骨离断平面约为远端1/3平面, 尺骨断端远端缺损。肘部至前臂可见残存肌肉组织挫伤较重, 仅屈伸肌群起点处活性尚可, 尚可见肌组织渗血;屈伸肌群近端存留少量腱性组织, 远端腱性组织呈马尾状撕脱。神经血管束长段抽出, 断端挫伤回缩, "鼠尾征"明显。尺桡骨断端不规整, 尺骨远端毁损。创面重度污染, 指端无血运。诊断:右前臂旋转撕脱离断伤。考虑截肢术, 截肢平面设计在肘关节上方, 但患者再植意愿强烈, 故急诊在全身麻醉下行清创再植术。术中于肉眼及显微镜视下清除较重挫伤的软组织, 标记残存活性腱性组织。显微镜视下清创至神经断面神经纤维束整齐, 血管清创至神经内外膜无挫伤, 断端无血栓形成。尺骨于正常骨质处截骨, 旷置, 桡骨截骨后短缩约5 cm。钛板固定桡骨骨折断端, 术中透视见骨折对位及对线可。尺动脉近端毁损, 桡动脉远端毁损, 显微镜视下以8-0无损伤线吻合桡动脉近端与尺动脉远端、头静脉及前臂肘正中静脉。6-0无损...     

9例拇指旋转撕脱性断指再植的术后护理

拇指旋转性撕脱离断的特点为骨与软组织的离断不在同一平面，肌腱神经血管往往自近端抽出长短不一，缺乏可吻合血管，再植比较困难，护理也有一定的难度。我们自1996年以来救治拇指旋转性撕脱伤9例，采用指掌侧固有动脉逆行桥接于拇指桡掌侧动脉后再植获得成功，现将术后护理及报告如下：     

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.     

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.     

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.