创伤骨科病人进入ICU状况分析(附31例报告)

目的:介绍我院创伤骨科进入ICU监护治疗情况。探讨创伤骨科进入ICU的主要疾病及进入途径。方法:收治31例创伤骨科病人进行分析,总结进入ICU的主要疾病是:骨科重大手术后5例,多发骨折血压不稳定9例,多发伤合并创伤性失血性休克9例,多发伤合并ARDS6例,高位脊柱骨折并高位脊髓损伤截瘫2例。进入ICU途径是:从急诊室直接到ICU6例,从骨科到ICU9例,从手术室进入ICU15例,外院转入1例。结果:31例中2例在ICU死亡,29例经过ICU康复稳定后转入骨科治疗。结论:我院创伤骨科需要进入ICU治疗的主要疾病是:①骨科常规重大手术后生命体征不稳定;②多发骨折血压不稳定;③多发伤合并创伤失血性休克;④多发伤合并ARDS;⑤脊髓高位损伤需要呼吸机支持。进入ICU的主要途径是急诊手术后进入、骨科病房进入及急诊室三种途径。     

外固定支架在严重多发伤并胫腓骨开放性骨折中应用的病例对照研究

目的：探讨早期外固定架固定开放性胫腓骨骨折对严重多发伤患者治疗和预后的影响。方法：采用回顾性对比分析，73例严重多发伤（ISS〉16分）患者按胫腓骨骨折手术方法不同分2组。治疗组42例，男31例，女11例；平均年龄40．2岁；均急诊行清创、骨折复位外固定支架固定术。对照组31例，男22例，女9例；平均年龄42．6岁；均急诊行清创、跟骨牵引术或石膏外固定术。比较两组患者急性呼吸窘迫综合征（ARDS）、多器官功能障碍综合征（MODS）发生情况及病死率、小腿创面感染率、创面及骨折愈合时间。结果：两组的并发症（ARDS）发生率差异有统计学意义，行外固定架治疗组低于对照组（P〈0．05），治疗组感染率明显低（P〈0．05），创面愈合时间明显短。结论：外固定架治疗严重多发伤并胫腓骨开放性骨折，明显减少并发症发生率，降低创面感染率。     

急诊严重多发伤合并骨与关节损伤应用损伤控制技术治疗的效果分析

目的探讨损伤控制技术在急诊治疗严重多发伤合并骨与关节损伤中的有效性和可行性。方法回顾性分析本院自2011-01—2013-12急诊抢救并应用损伤控制技术治疗的56例多发伤合并骨与关节损伤(观察组),并与自2006-01—2008-12未应用损伤控制技术治疗的64例(对照组)进行比较。比较2组ICU恢复时间、损伤控制后至确定性手术时间、住院时间、死亡率。结果观察组损伤控制后至确定性手术时间(8.71±2.85)d;4例死亡,死亡率7.1%;其余52例随访4~24个月,骨折复位及愈合满意,ICU恢复时间2~7(4.05±1.65)d,住院时间17~36(19.66±4.33)d。对照组损伤控制后至确定性手术时间(5.76±2.71)d;11例死亡,死亡率17.2%;其余53例ICU恢复时间5~14(8.01±2.71)d;住院时间19~41(25.98±7.46)d。与对照组比较,观察组ICU恢复时间、住院时间更短,损伤控制后至确定性手术时间更长,死亡率明显降低,差异有统计学意义(P0.05)。结论对严重多发伤患者灵活运用损伤控制技术,可为科学确定二期手术时机和方式赢得时间,提高患者的生存率,降低并发症发生率和致残率。     

多发伤并脂肪栓塞综合征中长骨干骨折的内固定治疗

目的探讨多发伤并脂肪栓塞综合征(FES)患者中长骨干骨折的内固定治疗方法与时机。方法回顾性分析1990年1月～2004年8月期间28例多发伤合并FES患者中长骨干骨折的内固定方法及手术时机。FES临床表现消失后5～7d首次手术治疗27例;FES临床表现明显减轻、呈浅昏迷状态及生命体征稳定后5d首次手术治疗1例。采用开放复位不扩髓或轻度扩髓髓内钉内固定11例,钢板内固定27例。结果27例FES缓解5～7d后手术治疗患者中,22例术后恢复良好,5例首次手术后出现不同程度发热、脉搏加快等。1例FES期间手术治疗患者首次手术后出现类FES复发。结论对于多发伤并FES患者中的长骨干骨折,以钢板或非扩髓髓内钉内固定较安全;首次手术时间以FES缓解后5～7d较为安全。     

损伤控制骨科理论在救治严重骨折伴多发伤中的应用

目的探讨严重骨折伴多发伤的防治对策以及损伤控制骨科(DCO)理论在救治严重多发伤中的应用价值、可行性和疗效。方法对2002年1月～2011年10月应用DCO理论指导救治的87例严重骨折伴多发伤患者的临床资料进行回顾性分析。结果创伤早期骨折行简单清创外固定,待ICU复苏治疗后,再择期行确定性骨科内固定手术。本组死亡率6.9%(6/87),死亡病例损伤严重度评分(ISS)平均值41分,主要死于休克和合并伤。52例获随访6~20个月,骨折均顺利愈合,肢体功能恢复理想。结论完善救治体系,合理采用DCO模式治疗严重骨折伴多发伤,能降低死亡率,减少并发症,提高救治成功率。     

多发伤骨折的急诊手术治疗

目的本文报告92例多发伤骨折急诊手术治疗经验.方法对92例多发伤骨折行急诊手术治疗.结果 90例治愈,无并发症.2例死亡,死于严重颅脑损伤.结论多发伤病人骨折急诊手术治疗有利于减少并发症,降低死亡率,是一种积极、有效的治疗方法.     

严重骨盆骨折为主的多发伤45例救治体会

目的总结严重骨盆骨折合并多发伤的救治经验,进一步提高其救治水平。方法2006年11月至2010年12月收治的45例严重骨盆骨折为主的多发伤患者的诊断、抗休克治疗、骨盆外固定器固定、腹膜外填塞、重症监护室（ICU）监护和稳定后骨盆切开复位内崮定。结果45例死亡3例,截瘫2例。结论严重骨盆骨折为主的多发伤患者的早期积极抗休克,早期输血,骨盆外固定器固定,并行腹膜外填塞,多学科合作处理合并伤,是救治严重骨盆骨折合并多发伤的关键。     

严重多发伤连枷胸患者急诊手术治疗探讨

目的总结分析对严重多发伤连枷胸患者实施急诊肋骨内固定术的优势和局限性。方法收集我科2013年1月~2014年12月严重多发伤合并连枷胸患者的临床资料,根据是否有急诊剖胸探查手术指征,将患者分为手术组与非手术组,手术组患者在实施剖胸探查术同时行肋骨内固定术。比较两组患者损伤严重度(ISS)评分、入院24小时输血量、呼吸机治疗时间、ICU住院时间、肺部感染发生率及死亡率等。结果共47例患者纳入本研究,有急诊开胸探查手术指征的患者11例,与非手术组比较,手术组患者ISS评分、24小时输血量明显高于非手术组,而呼吸机治疗时间及ICU监护时间小于非手术组,差异具有统计学意义(P0.05),两组患者肺部感染发生率以及死亡率比较差异无统计学意义(P0.05)。结论对合并连枷胸的严重多发伤患者,实施急诊肋骨内固定术,可以减少患者呼吸机治疗时间及ICU住院时间,在治疗过程中可酌情实施。     

外固定支架在严重多发伤合并肢体骨折损伤控制中的应用

目的介绍应用外支架治疗严重多发伤合并肢体骨折的方法并评价疗效。方法2009年1月至2012年12月,作者应用外支架对28例严重多发伤合并肢体骨折进行早期临时固定,心肺复苏、ICU监护和Ⅱ期确定性手术治疗,患者中男19例,女9例;年龄25～61岁,平均40．5岁。骨折部位：骨盆骨折5例,骨盆合并四肢骨折3例,四肢骨折15例,脊柱骨折3例,脊柱合并四肢骨折2例。闭合性骨折16例,开放性骨折12例。28例患者均合并其他多部位损伤,创伤严重程度评分平均35分。结果本组患者治愈26例（92％）,死亡2例（8％）,其中1例死于多器官功能衰竭,1例死于颅脑外伤,ICU治疗平均5．6d。发生各种并发症共7例。25例患者获得随访,时间8—36个月,平均16个月。22例骨折正常愈合,平均愈合时间18．4周。2例发生骨折延迟愈合,1例发生骨不连,经二期手术并植骨后愈合。结论外支架可用于严重多发伤合并肢体骨折的早期损伤控制,具有操作简单、效果可靠、并发症少等优点,可有效提高严重多发伤合并肢体骨折的救治效果,值得临床推荐使用。     

损伤控制手术在严重多发伤合并胰十二指肠损伤中的应用

目的探讨损伤控制手术在严重多发伤合并胰十二指肠损伤中的应用。方法回顾近5年来我院收治的4例严重多发伤合并胰十二指肠损伤的病例资料,总结在4例严重多发伤合并胰十二指肠损伤患者中主动采用损伤控制手术的具体应用方法及效果。结果4例多发伤情较重且合并胰十二指肠损伤的损伤严重度(ISS)评分均>16,并处于生理极限状态,应用损伤控制手术首先进行止血和制止肠内容物的外溢、行消化道未重建的胰十二指肠切除术、胰管及胆管外引流、临时关腹等简化手术,随后送到外科ICU待血液动力学稳定,在监护48h后再次行彻底性手术,均痊愈。结论运用损伤控制手术并分阶段重建消化道,对严重多发伤合并胰十二指肠损伤并处于生命极限的患者是有益的,并可显著地降低胰十二指肠损伤患者的死亡率。     

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.     

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.     

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.     

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.     

Immunomodulation in Transplantation with Photopheresis

Abstract: Photopheresis is a technique in which peripheral blood mononuclear cells, in the presence of a photoacti-vatable compound, are exposed extracorporeally to ultraviolet A light and reinfused, inducing a host autoregula-tory immune response. Experimental work and ongoing clinical studies are helping to define the role of this novel, safe, and non-toxic immunomodulating technology in the field of transplantation.