The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Long-term intrathecal morphine and bupivacaine in "refractory" cancer pain. I. Results from the first series of 52 patients

Neither epidural (EDA) or intrathecal (IT) morphine nor EDA opiate + bupivacaine provides acceptable relief of some types of cancer pain, e.g. pain originating from mucocutaneous ulcers, deafferentation pain, continuous and intermittent visceral and ischaemic pain, and that occurring with body movement as a result of a fracture. To improve pain relief in such conditions, we gave combinations of morphine and bupivacaine through open IT-catheters to 52 patients with "refractory", severe (VAS 7-10 out of 10), complex cancer pain (Edmonton Stage-3), for periods of 1-305 (median = 23) days. The efficacy of the treatment was estimated from: 1) daily dosage (intraspinal and total opiates, and intraspinal bupivacaine), and 2) scores of non-opiate analgesic and sedative consumption, gait and daily activities, and amount and pattern of sleep. Forty-four patients obtained continuous and acceptable pain relief (VAS 0-2), 26 of them with daily doses of IT-bupivacaine of less than or equal to 30 mg/day (less than or equal to 1.5 mg/h). Higher IT-bupivacaine doses (greater than 60-305 mg/day), not always giving acceptable pain relief, were necessary in 13 patients with deafferentation pain from the spinal cord or brachial or lumbosacral plexuses or pain from the coeliac plexus, or from large, ulcerated mucocutaneous tumours. By combining IT-bupivacaine with IT-morphine, it was possible to use relatively low IT-morphine doses (10-25 mg/day during the first 2 months of treatment) in more than half of the patients. The IT-treatment significantly decreased the total (all routes) opiate consumption and significantly improved sleep, gait and daily activities. For the whole period of observation (6 months), the IT-treatment was assessed as adequate in 3.8%, good in 23.1%, very good in 59.6% and excellent in 13.5% of the cases. Adverse effects of the IT-bupivacaine (paraesthesiae, paresis, gait impairment, urinary retention, anal sphincter disturbances and orthostatic hypotension) did not occur with doses of 2.5-3.0 mg/h (approx. 60-70 mg/day).     

下肢生物力学矫正联合脊柱区核心肌群训练治疗慢性非特异性下腰痛

目的探讨下肢生物力学矫正联合脊柱区核心肌群训练对慢性非特异性下腰痛患者的治疗效果。方法将符合要求并接受下肢生物力学矫正治疗的32例慢性非特异性下腰痛患者随机分为观察组与对照组,每组各16例,两组患者均配置生物力学矫形鞋垫,并进行常规理疗、手法治疗等,观察组患者联合脊柱区核心肌群训练。记录并比较两组患者治疗前后疼痛视觉模拟量表（VAS）评分和腰腿痛Oswestry功能障碍指数（ODI）评分。结果两组患者治疗前VAS、ODI评分比较,差异无统计学意义（P〉0.05）;治疗后1、6个月VAS评分、ODI评分均有改善,观察组改善较对照组明显,差异有统计学意义（P〈0.05）。结论脊柱区核心肌群训练强化了慢性非特异性下腰痛患者下肢生物力学矫正的治疗效果,减轻腰部疼痛,提高生活质量。     

Mid-to long-term results of total hip arthroplasty after contralateral lower extremity amputation

Objective

There is limited literature concerning the outcomes and role of THA as a surgical option for amputee patients. The aim of this study is to determine the mid-to long-term survival and complication rates of cementless total hip arthroplasty (THA) in patients with contralateral below knee amputations.

利伐沙班预防下肢创伤患者术后静脉血栓栓塞的多中心研究

目的 多中心观察下肢创伤患者术后应用利伐沙班预防静脉血栓栓塞症(VTE)的疗效及安全性.方法 2011年2月至2012年3月全国5家医院共472例下肢创伤(骨盆、髋关节周围、股骨、膝关节和胫腓骨骨折)患者纳入研究,其中男305例(64.6％),女167例(35.4％);年龄18～94岁,平均49.1岁.术后应用利伐沙班抗凝时间至少10d,10 mg,1次/d,口服.分别于术前、手术日、出院日、术后14d和术后30 d进行5次随访,根据双下肢彩色多普勒超声观察VTE的发生情况,同时记录出血事件的发生.结果 所有患者术后口服利伐沙班时间平均为10.9d.随访时根据临床观察及彩色多普勒超声检查发现,9例患者发生VTE(1.9％),均为深静脉血栓形成,未出现肺栓塞.2例患者发生不良事件,均与研究药物无关,未发生出血事件.结论 下肢创伤患者术后应用利伐沙班预防VTE安全、有效.     

单一下肢闭合骨折围手术期深静脉血栓形成的部分影响因素分析

目的 探讨年龄、性别、身体质量指数（body mass index, BMI）及骨折部位对单一下肢闭合骨折围手术期下肢深静脉血栓形成（deep vein thrombosis, DVT）的影响。方法 回顾性分析西安交通大学医学院附属红会医院2015年1月至2017年12月符合纳入条件的325例下肢骨折病人的临床资料,其中男155例,女170例,年龄为（58.41±19.82）岁（19~94岁）,BMI为（23.22±3.71） kg/m²（15.59~35.16 kg/m²）;髋部骨折185例,股骨干骨折12例,膝关节周围骨折66例,胫腓骨干骨折25例,踝关节骨折27例,足部骨折10例。手术前后分别行双下肢静脉彩色多普勒超声检查,根据双下肢静脉超声结果将病人分为术前有血栓组和术前无血栓组、术后血栓组和术后无血栓组,分别对病人的年龄、性别、BMI及骨折部位进行统计分析。先采用单因素分析筛选危险因素,再采用多因素Logistic回归分析确定主要的独立危险因素。结果 术前有100例病人发生DVT,发生率为30.77%,术后有166例病人发生DVT,发生率为51.08%;发病率在前三位的年龄段依次为60~74岁、≥75岁、45~59岁;女性病人更易发生DVT;按BMI分组后,术前术后各个组DVT发生率的差异无统计学意义;骨折部位以髋部以远、膝关节以近骨折（包括膝关节周围骨折）的DVT发生率最高。结论 髋部以远、膝关节以近骨折（包括膝关节周围骨折）及60岁以上的女性病人是下肢单一闭合骨折DVT的主要影响因素,应给予足够预防性抗凝治疗,防止发生致命性肺栓塞。     

内皮祖细胞在治疗下肢缺血性疾病中的研究进展

随着人口老龄化、饮食结构改变及引起血管疾病高危因素的增加,下肢缺血性疾病已成为老年人的多发病,是截肢致残的主要原因.作为21世纪最先进的技术,干细胞移植快速地应用于临床,并被认为可能是根治性治疗下肢缺血性疾病的方法之一,内皮祖细胞由于其独特的生物学特性逐渐成为治疗这一病变的新方向和新研究热点.本文着重介绍内皮祖细胞治疗肢体缺血性病变的理论基础和研究进展.     

教练法在下肢动脉疾病患者疼痛管理中的应用

目的探讨教练法在下肢动脉疾病患者疼痛管理中的作用。方法将160例下肢动脉疾病患者随机分为对照组和教练组各80例。对照组采用常规护理方法,教练组在常规护理的基础上,采用教练法,即通过减少疼痛管理的态度障碍,促进患者行为改变,从而达到减轻疼痛的效果。两组均在干预前后填写简明疼痛问卷及障碍问卷。结果干预后教练组疼痛管理的态度障碍及疼痛程度显著少于或轻于对照组(均P0.05)。结论教练法用于下肢动脉疾病患者的疼痛管理,可改善患者的疼痛障碍,提高疼痛管理水平。     

Late results of coronary bypass in patients presenting with lower extremity ischemia: the cleveland clinic study

Cardiac catheterization was performed in a prospective series of 1000 patients under consideration for elective peripheral vascular reconstruction from 1978–1982. Of these, 381 (mean age 62) presented primarily because of lower extremity ischemia. Severa, surgically correctable coronary artery disease (CAD) was documented in 79 (21 %) of the leg group, and 68 (18 %) received myocardial revascularization, with three fatal complications (4.4 %). In this subset, 39 patients have had uneventful aortoiliac, femoropopliteal or distal extremity procedures, compared to an operative mortality of 23 % for 13 others with uncorrected or inoperable CAD (p=0.015). A total of 286 patients have undergone 407 peripheral vascular operations with eight early daths (2.8 %). An additional 114 patients (30 %) died during the late follow-up interval, including 48 (13 %) with cardiac events. Both the cumulative 5-year survival (72 %) and cardiac mortality (16 %) after coronary bypass are superior to comparable figures (21 % and 56 %, respectively) among 36 other patients with severe, uncorrected or inoperable CAD (p=0.0001). Five-year survival appears to be improved by myocardical revascularization in men (p=0.0027), hypertensives (p=0.0001), nondiabetics (p=0.0002) and those over 60 years of age (p=0.0072).     

The effect of bupivacaine and morphine on pain and bowel function after colonic surgery

Sixty patients scheduled for colonic surgery were randomly allocated to four groups according to postoperative pain medication: I. Control group, the patients received oxycodone intramuscularly (0.15 mg kg-1) on request. II. Epidural bupivacaine (0.25%) continuously administered by infusion pump, 4-6 ml h-1, for 48 h. III. Epidural morphine, 2-6 mg, at the end of operation and repeated on the first and second postoperative mornings. IV. Epidural morphine, 2-6 mg per die, administered for 48 h continuously by infusion pump. All patients received a balanced anaesthesia with enflurane, fentanyl and vecuronium. Postoperatively, intramuscular oxycodone was given on request. There were no significant differences between the groups in changes in peak flow, spirometry and blood-gas analyses postoperatively. Pain intensity (visual analogue scale) was lower in Groups II and III at 3 h and in Group IV at 24 h compared to the control Group I. All the epidurally treated groups needed less additional analgesics than the control Group I. Postoperatively bowel movements occurred on the second day in Group II (bupivacaine) as compared to the fourth day in all other groups (P less than 0.05).     

The impact of chronic kidney disease on lower extremity bypass outcomes in patients with critical limb ischemia

Objective

Patient selection for open lower extremity revascularization in patients with chronic kidney disease (CKD) remains a clinical challenge. This study investigates the impact of CKD on early graft failure, postoperative complications, and mortality in patients undergoing lower extremity bypass for critical limb ischemia.

Comparison of continuous epidural infusion of fentanyl and bupivacaine with intermittent epidural administration of morphine for postoperative pain management in children

Background: The aim of this study was to compare epidural infusion of bupivacaine and fentanyl and intermittent epidural morphine with regard to analgesic effect, and incidence and severity of side effects in children undergoing major abdominal or genito-urological surgery in order to improve the postoperative pain management of children. Methods: A double-blind, block-randomised study design was used. Thirty-one children aged 3 months to 6 years undergoing major abdominal or genito-urological surgery were studied. After induction of anaesthesia a lumbar epidural catheter was placed at L_3–4 or L_4–5. Postoperatively, the children received either 30 μg/kg of morphine every 8 h or a continuous infusion of fentanyl 2 μg/ml and bupivacaine 1.0 mg/ml at a rate of 0.25 ml.kg^-1.h^-1. All children additionally received rectal paracetamol in doses of 50–100 mg.kg^-1. d^-1 on a regular basis, and if necessary supplementary intravenous morphine in doses of 50 μg/kg. Postoperatively, pain, administration of supplemental morphine and side effects were recorded 5 times by one observer during the day of surgery and the first postoperative day. All children had an epidural catheter throughout the study period. Results: Both regimens provided effective analgesia, but significantly better pain relief was obtained in children receiving the fentanyl/bupivacaine regimen. Sedation, pruritus, vomiting, and administration of antiemetics were seen in both treatment groups, and even though both the incidence and severity of side effects tended to be higher in children receiving morphine, no statistically significant difference was found. No episodes of respiratory depression or motor blockade were noticed. Conclusion: Continuous epidural infusion of fentanyl and bupivacaine was found to be superior to intermittent epidural morphine. The initial regimen should be fentanyl 2 μg/ml and bupivacaine 1.0 mg/ml infused at a rate of 0.25 ml. kg^-1. h^-1.     

下肢静脉造影在下肢静脉曲张患者中的应用及阻塞性下肢静脉曲张发生的预测因素

目的 探讨下肢静脉造影检查在下肢静脉曲张中应用的临床意义,并分析阻塞性下肢静脉曲张可能相关的预测因素.方法 选取2019年1月至2021年12月因下肢静脉曲张于海军军医大学第二附属医院诊治的74例患者(111条患肢)为研究对象,对所有患肢行下肢静脉造影检查,采用病例报告表形式记录患者相关信息,根据有无深静脉阻塞表现分为...     

筋膜下内镜交通支离断术治疗下肢静脉性溃疡的体会

目的:探讨深筋膜下内镜交通支静脉离断术(subfascial endoscopic perforator surgery,SEPS)治疗下肢静脉性溃疡的可行性及应用价值。方法:回顾分析2008年12月至2011年4月为7例(8条肢体)下肢静脉性溃疡伴下肢静脉交通支瓣膜功能不全患者行大隐静脉剥脱术及SEPS的临床资料。结果:7例(8条肢体)手术均获成功,曲张静脉团块消失,下肢静脉血淤滞得到解决,色素沉着减轻,溃疡愈合。术后随访1～3年,无一例复发。结论:SEPS适于治疗下肢静脉交通支瓣膜功能不全的下肢静脉性溃疡患者,手术创伤小、安全、简单、易行,疗效确切,应用价值较高。     

Perioperative outcomes after lower extremity bypass and peripheral vascular interventions in patients with morbid obesity and superobesity

ObjectiveAlthough the effect of body mass index (BMI) on the treatment of infrainguinal peripheral artery disease has been reported, outcomes of patients on the upper end of the obesity spectrum, including morbid obesity (MO) and superobesity (SO), are unclear. Our goal was to analyze perioperative outcomes after lower extremity bypass (LEB) and peripheral vascular interventions (PVIs) in this population of patients.MethodsThe Vascular Quality Initiative was reviewed for all infrainguinal peripheral artery disease interventions from 2010 to 2017. All patients were categorized into four groups: nonobese (BMI 18.5-29.9 kg/m²), obese (BMI 30-39.9 kg/m²), morbidly obese (BMI 40-49.9 kg/m²), and superobese (BMI ≥50 kg/m²). Patient and case details were recorded. Multivariable analysis was used to analyze outcomes. For statistical analysis, MO and SO groups were combined.ResultsWe identified 29,138 LEB cases (68.5% nonobese, 28.3% obese, 2.9% morbidly obese, 0.3% superobese) and 81,405 PVI cases (66.6% nonobese, 29.2% obese, 3.6% morbidly obese, 0.5% superobese). For both LEB and PVI, patients with MO and SO were more likely to be younger, female, nonsmokers, and ambulatory (P < .05). They also more often had diabetes, end-stage renal disease, congestive heart failure, and fewer previous inflow procedures (P < .05). LEB and PVI interventions in patients with MO and SO were less often elective and more often performed for tissue loss. Multivariable analysis showed that LEB in patients with MO and SO was not significantly associated with increased perioperative cardiac complications, return to the operating room, or mortality. Patients with MO and SO were significantly associated with increased surgical site infection (odds ratio, 1.43; 95% confidence interval, 1.02-1.98; P = .03) and increased respiratory complications (odds ratio, 1.6; 95% confidence interval, 1.11-2.31; P = .01). Multivariable analysis showed that MO and SO were not significantly associated with periprocedural access site hematoma, access site stenosis or occlusion, or mortality after PVI.ConclusionsMO and SO were significantly associated with increased incidence of wound infections and respiratory complications after LEB but were not significantly associated with increased incidence after PVI. Overall, patients with MO and SO have more comorbidities and more advanced presentation of vascular disease at the time of intervention, but MO and SO alone should not deter necessary and appropriate revascularization.     

下肢深静脉血栓并发急性肺栓塞的肺内血栓分布特点及血管腔内治疗的临床效果

目的探讨下肢深静脉血栓并发急性肺栓塞的肺内血栓分布特点及血管腔内治疗的临床效果。方法对8例患者首先行下腔静脉滤器置入术以防止下肢深静脉血栓再次脱落,在此基础上行肺动脉造影,观察肺动脉血栓分布情况,利用导丝导管迅速开通栓塞血管,恢复栓塞血管内血流,每24h给予50万U尿激酶,连续72h肺动脉小剂量置管溶栓,24h后行肺动脉造影,观察残留血栓分布,及时调整溶栓导管位置。72h时再行肺动脉造影,观察肺动脉血流恢复情况并拔管,根据DSA图像应用血管造影机自带容量测量软件工具计算血栓残留量;对下肢深静脉血栓有症状者利用导丝导管对栓塞血管迅速开通,观察血栓开通后下肢症状缓解变化。治疗期间每隔24h抽血行血凝分析1次,观察患者术后是否有渗血、出血增加的现象。结果对8例患者共栓塞肺动脉分支24支,其中双肺动脉4个大分支栓塞患者1例,双肺动脉3个大分支栓塞者6例,双肺动脉2个大分支栓塞者1例。治疗后72h肺动脉造影显示血栓残留量20%者20支,20%~50%者2支,50%者2支。患侧下肢深静脉血栓经血管腔内治疗后下肢肿胀、疼痛均有不同程度缓解,72h后症状基本缓解。治疗期间8例患者的活化部分凝血活酶时间、国际标准化比率均在正常范围之内,未出现渗血、出血增加的现象。结论下肢深静脉血栓并发急性肺栓塞得到及时治疗的患者血栓分布以肺动脉3支分支血栓多见,血管腔内治疗及小剂量置管溶栓治疗是一种安全有效的治疗方法。     

The risk of child abuse in infants and toddlers with lower extremity injuries

Purpose

The aim of this study was to assess the risk of child abuse in children younger than 18 months admitted to a pediatric trauma service with lower extremity injuries.

Methods

An Institutional Review Board-approved retrospective case series of children admitted to a regional pediatric trauma center with lower extremity injuries from 1998 to 2002 (n = 5497) was performed. Factors analyzed included age, injuries, and injury mechanism.

Results

Among 5497 trauma patients, the incidence of abuse was 104 (2%) of 4942 children 18 months or older and 175(32%) of 555 children younger than 18 months (odds ratio [OR], 21.4 ± 2.9, P < .001). There were 1252 (23%) patients with lower extremity injuries in the entire sample, and 66 of these were younger than 18 months. In the extremity trauma group, for patients 18 months or older, 16 (1%) of 1186 were abused compared with 44 (67%) of 66 patients younger than 18 months (OR, 146 ± 53, P < .001). Among all trauma patients younger than 18 months, 41 of 55 lower extremity fractures were linked to abuse, whereas 134 of 500 other injuries were caused by abuse (OR, 8.0 ± 2.6, P < .001). Among the 41 abuse-related fractures, femur fracture was the most common (22), followed by tibia fracture (14).

Conclusions

Among children 18 months or older, abuse is an uncommon cause of lower extremity trauma. In children younger than 18 months, lower extremity injuries, particularly fractures, are highly associated with child abuse. Clinicians must thoroughly investigate lower extremity injuries in this age group.     

No additional analgesic effect of intra-articular morphine or bupivacaine compared with placebo after elective knee arthroscopy

Background: Intra-articular pain prophylaxis is a controversial measure, adding costs although the benefits are still disputed. We wanted to evaluate the effects of intra-articular opioid or local anaesthesia or a combination of the two on postoperative analgesia and analgesic consumption after elective knee arthroscopy.
Methods: 107 patients with little or no preoperative pain and a minor surgical procedure were studied in a prospective, randomized double-blind design. The patients received midazolam 0.03 mg/kg intravenously before induction of general anaesthesia with fentanyl 1–2 μg/kg and propofol 2.0 mg/kg intravenously. Anaesthesia was maintained by a total intravenous technique with propofol infusion supplemented with alfentanil 10 μg/kg when needed. The patients breathed oxygen/air through a laryngeal mask. By the end of the surgery they received 20 ml of test drug into the knee-joint: Group I (BM): 20 ml of bupivacaine 2.5 mg/ml with 3 mg of morphine; Group II (B): 20 ml of bupivacaine 2.5 mg/ml; Group III (M): 20 ml isotonic saline with 3 mg morphine; Group IV (P): 20 ml of isotonic saline (placebo).
Results: There were no significant differences between the groups in: time to first analgesic administered, analgesic consumption during the pre-or post-discharge period, nausea, somnolence, side-effects or postoperative pain perception during the first week.
Conclusions: Intra-articular administration of morphine or bupivacaine is not indicated after elective knee-arthroscopy in patients with minor pre-operative pain and a small surgical trauma.     

“损伤控制骨科”救治严重下肢多发伤合并休克患者的护理

不恰当的骨折治疗,会对严重创伤患者构成二次伤害,引发过度全身炎症反应综合征,增加病死率[1]。损伤控制骨科（damage control orthopedics,DCO）,强调严重多发骨折早期采用快速临时控制措施,