促肾上腺皮质激素非依赖性肾上腺皮质大结节样增生的外科治疗

目的 探讨促肾上腺皮质激素(adrenocorticotropic hormone,ACTH)非依赖性肾上腺皮质大结节样增生(ACTH independent macronodular adrenal hyperplasia,AIMAH)的诊治经验. 方法 回顾性分析1972年8月至2010年7月诊治14例AIMAH患者资料.男5例,女9例.年龄26～58岁,平均45岁.临床表现为典型库欣综合征( Cushing syndrome,CS)者10例,表现为体质量增加、高血压或高血糖等非特异性症状者4例.生化检查示皮质醇分泌昼夜节律消失,大、小剂量地塞米松抑制试验均不被抑制.CT检查示双侧肾上腺弥漫性增大伴多发结节.14例均行开放手术治疗,其中单侧肾上腺切除5例;一侧肾上腺全切,对侧肾上腺次全切除6例;双侧肾上腺同时切除3例. 结果 14例病理诊断均为肾上腺大结节样或腺瘤样增生.随访12～120个月,平均69个月,CS症状消失.5例单侧肾上腺切除者术后血、尿皮质醇值恢复正常,对侧肾上腺无明显增大.3例双侧肾上腺切除患者中,1例术后7d发生肾上腺皮质功能危象而死亡,2例术后出现皮质功能减退症状,给予糖皮质激素替代治疗.其他患者病情稳定,无Nelson综合征出现. 结论 AIMAH具有独特的临床症状特点,是CS的一种独立罕见类型.首次手术多行单侧肾上腺切除术,可获较长时间的症状缓解.术后应密切随访患者的皮质醇水平、症状和体征,对症状不缓解或复发者可行对侧肾上腺切除或次全切除.     

ACTH非依赖性肾上腺皮质大结节增生症的诊断与手术处理

目的 总结促肾上腺皮质激素（adrenocorticotrop hichormone，ACTH）非依赖性肾上腺皮质大结节增生症（ACTH independent acronodular drenal yperplasia，AIMAH）的诊治经验。方法 回顾性分析5例AIMAH患者的临床资料。结果 5例患者均具有库欣综合征的临床和生化特点，小剂量、大剂量地塞米松抑制试验均不被抑制，血浆ACTH水平低。4例患者行CT检查示双侧肾上腺大结节样增生改变，所有患者均经病理检查证实为双侧肾上腺大结节样或腺瘤样增生。例1、例2行单侧肾上腺切除后，分别于症状缓解3年和5年后复发，行对侧肾上腺全切除后治愈；例3分期行双侧肾上腺切除后治愈；例4、例5行单侧肾上腺切除后，前者5年症状持续缓解，后者仍在随访中。术后无Nelson综合征。结论 IMAH具有独特的内分泌、CT影像和病理学特点，是一种独立的库欣综合征病因，确诊主要依据病理检查。单侧肾上腺切除可获较长时间的症状缓解，应坚持随访患者的皮质醇水平和症状体征，如有复发可行对侧肾上腺切除。     

ACTH非依赖性双侧肾上腺皮质增生所致库欣综合征的外科治疗

目的探讨促肾上腺皮质激素（adrenocorticotropic hormone,ACTH）非依赖性双侧肾上腺皮质增生的临床特点与诊治经验。方法回顾性分析1980年1月至2011年5月诊治21例ACTH非依赖性双侧肾上腺皮质增生患者资料,包括8例ACTH非依赖性肾上腺皮质大结节样增生（AIMAH）和13例原发性色素性肾上腺结节增生（PPNAD）。男6例,女15例。年龄12～58岁,平均34.3岁。临床表现为典型库欣综合征（Cushings syndrome,CS）者18例,表现为体重增加、高血压等非特异性症状者3例。CT检查提示双侧肾上腺结节样增生改变者14例,2例提示左肾上腺占位;5例肾上腺未见明显异常。双侧肾上腺全切3例;双侧肾上腺次全切除术2例,为初次手术行单侧肾上腺切除,术后库欣症状复发,再次行对侧肾上腺次全切除术;单侧肾上腺切除16例。结果手术标本病理结果报告8例为AIMAH,13例为PPNAD。随访16～120个月,CS症状消失。16例单侧肾上腺切除术后血尿皮质醇、血钾、血糖等均恢复正常,对侧肾上腺无明显增大;3例行双侧肾上腺全切者术后醋酸可的松终身替代治疗,无尼尔森综合征发生;2例肾上腺次全切除者系一侧肾上腺全切术后随访中库欣症状复发,行对侧肾上腺次全切术后症状完全缓解。结论 AIMAH和PPNAD均为库欣综合征中罕见的特殊类型,首次手术可行单侧肾上腺切除术缓解症状。术后应密切随访,对症状不缓解或复发者可行对侧肾上腺切除或次全切除。     

肾上腺手术在治疗皮质醇增多症中的疗效评价(附90例报告)

目的：提高皮质醇增多症的治疗水平。方法：总结90例皮质醇增多症的临床资料以及随访情况。90例患者均有库欣综合征的临床表现,内分泌检查提示高皮质醇状态。71例患者影像学检查发现肾上腺肿块,其中左侧32例,右侧34例;双侧肾上腺肿块5例。19例患者显示双侧肾上腺结节样增生。结果：90例患者均行肾上腺手术,其中60例行肾上腺肿块切除加同侧肾上腺部分切除;6例行肾上腺肿块切除加同侧肾上腺全切除;4例行同时行双侧肾上腺全切除术,6例行先后双侧肾上腺全切除术;11例行单侧肾上腺全切除术;3例行先后双侧肾上腺次全切除。病理显示6例原发性色素性皮质结节状肾上腺皮质增生（PPNAD）;5例大结节样肾上腺皮质增生（AIMAH）;57例肾上腺皮质腺瘤;5例肾上腺皮质癌;17例肾上腺皮质结节样增生,其中7例考虑异位ACTH综合征所致。结论：肾上腺皮质腺瘤切除术效果最好,库欣症状改善最显著。迁延难愈的库欣病,单侧肾上腺全切除,在短期内能缓解代谢症状。分时分侧行肾上腺全切除术,对治疗AIMAH和PPNAD更安全、稳定;根据异位ACTH综合征患者症状和病程,可同时行双侧肾上腺全切除或单侧肾上腺全切除。     

单侧肾上腺切除治疗原发性醛固酮增多症对侧肾上腺储备功能的评价分析

目的对比分析原发性醛固酮增多症(PHA)患者单侧肾上腺切除前后肾上腺皮质分泌功能变化,评估分析单侧肾上腺切除后对侧肾上腺皮质储备功能。方法选取2006年1月至2013年2月接受单侧肾上腺切除手术的42例患者的临床资料。对患者手术前后早晨空腹血皮质醇、促肾上腺皮质素(ACTH)水平、以及促肾上腺皮质激素兴奋1mg地塞米松抑制试验结果进行了有效的统计学分析。结果 42例患者均无出现肾上腺皮质功能不全。手术前后基础皮质醇水平无明显差异。然而,单侧肾上腺切除术后基础ACTH水平明显提高。促肾上腺皮质激素兴奋1mg地塞米松抑制试验的皮质醇峰值水平明显下降。术后皮质醇峰值水平约为术前82.7%(76.0%~91.4%)。结论不伴有皮质醇增多症或亚临床型皮质醇增多症的PHA患者行单侧肾上腺切除,术后血皮质醇水平可维持在正常范围之内,但肾上腺皮质储备功能出现不同程度的下降,其储备功能不低于术前80%,足以使患者术后不会出现肾上腺皮质功能不全。     

ACTH 非依赖性肾上腺皮质大结节增生症3例报告

目的：提高ACTH非依赖性肾上腺皮质大结节增生症（AIMAH）的评价水平。方法：回顾性分析3例AIMAH患者的临床资料。结果：3例AIMAH患者除具有库兴综合征的临床和生化特点之外，还有如下特点：大剂量地塞米松抑制试验（HDDST）不被抑制，血浆ACTH低水平，CT显示双侧肾上腺大结节样增生改变，病理检查为双侧肾上腺大结节样或腺瘤样增生，单侧肾上腺切除症状可缓解3－4年，双侧肾上腺切除可治愈，术后无Nelson征。结论：AIMAH具有独特的内分泌、CT和病理学特点，是一种独立的库兴综合征病因。     

肾上腺大结节增生的外科治疗

目的探讨肾上腺大结节增生(AIMAH)的临床特点与诊治方法。方法总结17例　AIMAH　患者的临床表现、内分泌检查、影像与病理特点以及治疗和预后。男9例,女8例,年龄15～66岁,平均42岁,双侧15例,左右侧各1例。有典型库欣综合征临床表现者10例,另7例表现为高血压或糖尿病症状;实验室检查显示　ACTH<2.2 pmol/L,血皮质醇325.1～1876.8 nmol/L,24 h　尿游离皮质醇71.7～2332.2 nmol/24 h,皮质醇分泌节律消失,大、小剂量地塞米松抑制试验不被抑制12例。CT或MRI显示双侧或单侧不规则结节或团块样增大,直径最大5 cm。结果16例行手术治疗,病理报告为肾上腺皮质结节样或腺瘤样增生。其中行单侧肾上腺切除术10例,双侧肾上腺全切除术4例,双侧肾上腺次全切除术2例。双侧肾上腺全切及次全切除6例症状完全缓解,未复发,未发生尼尔森综合征;单侧肾上腺切除者,库欣症状缓解4例,1例未缓解;5例亚临床AIM- AH,术后血压均降至正常,但糖尿病症状未缓解。结论AIMAH作为皮质醇症一种独立的临床亚型,具有自主性皮质醇分泌、肾上腺多发大结节、双侧肾上腺切除术后不发生尼尔森综合征等临床特征。单侧肾上腺切除可缓解多数AIMAH症状,对于症状不缓解或复发者可行双侧肾上腺次全切或全切。     

腹腔镜单侧肾上腺切除术治疗8例原发性双侧肾上腺大结节样增生患者的疗效随访

目的探讨行腹腔镜单侧肾上腺切除术的8例原发性双侧肾上腺大结节样增生(PBMAH)患者的治疗效果。方法回顾性分析香港大学深圳医院2015年1月至2020年12月收治的8例确诊为PBMAH患者的临床资料。其中男性5例,女性3例,平均年龄50(34～61)岁。定性诊断有4例为促肾上腺皮质激素(ACTH)非依赖性库欣综合征(CS),另外4例为ACTH非依赖性亚临床库欣综合征(SCS)。完善内分泌、生物化学、病理及影像学检查。所有患者术前均分别行多学科讨论,手术先切除增生明显或者增生体积较大的一侧肾上腺,围手术期和术后均予以激素替代治疗。术后定期随访患者血常规、肝功能、肾功能、血钾、肾上腺相关激素水平与功能试验、垂体及肾上腺MRI/CT等。结果 8例均行后腹腔途径的腹腔镜单侧肾上腺切除术治疗,右侧5例,左侧3例,手术顺利,均无并发症发生。术前肾上腺增强CT提示7例患者双侧肾上腺弥漫性增大且伴有多发结节,1例患者6年前切除左侧肾上腺故表现为右侧肾上腺弥漫性增大伴结节。病理结果提示肾上腺皮质结节状增生5例,肾上腺皮质腺瘤3例。平均随访30.5个月,2例典型CS临床表现和体征的患者,症状得到缓解。8例患者术后的血压和体重指数(BMI)较术前有明显改善,24h的尿皮质醇水平及血钾均正常,双侧肾上腺均被切除的1例患者术后行终身激素替代治疗。结论腹腔镜单侧肾上腺切除术治疗PBMAH安全有效,能改善患者的CS临床症状,推荐为临床一线治疗方案。若行双侧肾上腺全切术,术后需要终身激素替代治疗。     

原发性色素沉着性结节性肾上腺皮质病的临床诊治（附15例报告）

目的：揭示原发性色素沉着性结节性肾上腺皮质病（PPNAD）的临床特点与诊治.方法：对15例PPNAD患者的临床资料进行分析.15例中典型库欣综合征14例,仅表现高血压者1例.伴Carney综合征者8例.实验室检查显示ACTH〈2.2 pmol/L,血皮质醇分泌节律均消失,其中0点血浆总皮质醇268.27～686.41nmol/L,24 h尿游离皮质醇（UFC）386.4～3 569.51 nmol/24 h,14例小剂量和大剂量地塞米松抑制试验均不被抑制.CT双侧肾上腺增粗或小结节者8例,肾上腺未见明显异常者7例.术前诊断为垂体腺瘤、库欣病3例,诊断为异位ACTH综合征1例.双侧肾上腺全伞切1例.单侧肾上腺切除术11例,肾上腺次全切术3例.结果：单侧肾上腺平均重5.2 g,病理诊断均为PPNAD.随访8个月～17年,肾上腺全切者症状完全缓解,无复发 肾上腺次全切除者症状缓解,无需皮质激素替代 单侧肾上腺切除症状缓解,但仍存在高皮质醇血症.结论：PPNAD罕见,易误诊.库欣综合征、ACTH非依赖性内分泌特点、影像学双侧肾上腺基本＂正常＂或略增粗或小结节等为其临床诊断要点.单侧肾上腺切除不能完全缓解皮质醇症,肾上腺次全切除可能为合理的治疗策略,复发者肾上腺全切.术后密切随诊,监测Carney综合征其他相关病变.     

原发性色素沉着性结节性肾上腺皮质病9例诊治分析

目的:探索原发性色素沉着性结节性肾上腺皮质病(PPNAD)的诊治方案。方法:总结我院2010~2016年9例PPNAD患者的临床资料,包括其临床症状、体征,实验室检查、影像学检查、随访资料等,探讨该种疾病的诊断和治疗。结果:9例患者中8例具备典型库欣综合征体貌,1例患者仅表现为高血压。9例患者均具备促肾上腺皮质激素(ACTH)非依赖性特征,表现为ACTH5pg/ml或大剂量地塞米松抑制试验尿游离皮质醇(UFC)未被抑制。影像学可表现为肾上腺基本正常、双侧肾上腺增粗或小结节改变、单侧肾上腺结节或肿物。7例患者行腹腔镜单侧肾上腺切除,术后随访2例症状复发,遂行腹腔镜对侧肾上腺次全切除术。2例仅表现为单侧肾上腺结节或肿物患者,行腹腔镜肾上腺肿物切除术,术后恢复良好。结论:PPNAD为罕见ACTH非依赖性库欣综合征类型,其可依据高皮质醇血症、ACTH非依赖性、影像学检查等做出诊断,明确诊断需术后病理确定。治疗方式可根据患者的病情程度及术后恢复情况以及实验室指标等进行个体化制定。     

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.