连续硬外神经阻滞联合胶原酶溶盘术治疗腰椎间盘突出症围手术期护理

目的探讨连续硬膜外神经阻滞联合胶原酶溶盘术治疗腰椎间盘突出症的护理要点。方法对358例腰椎间盘突出症患者,行连续硬膜外神经阻滞联合胶原酶溶盘术治疗,总结护理措施。结果采用改良Macnab方法评价疗效:术后6个月优良率86.87%%(311/358)。结论连续硬膜外阻滞联合胶原酶溶盘术治疗腰椎间盘突出症,效果满意,加强心理护理及术后护理是手术成功的关键。     

胶原酶溶盘术后早期神经根病损临床与实验研究

[目的]探讨胶原酶溶盘术后早期出现神经根病损原因，寻找胶原酶溶盘术后出现早期神经根病损预防与处理方法。[方法]临床回顾分析本院2000年1月-2004年12月开展的腰椎间盘突出症胶原酶溶盘术1280例，其中早期出现神经根病损病例12例（发生率0．94％）。实验将18只日本大耳兔随机分为A、B、C组，A组为后纵韧带完整＋盘内注射组，B组为后纵韧带破损＋盘内注射组，c组为盘外（硬膜外腔）注射组，大体及光镜下观察不同时间椎间盘及神经根改变。[结果]临床资料表明腰椎间盘突出症胶原酶盘内＋盘外溶盘组胶原酶使用剂量大，出现早期神经根损伤病例明显多于其他组（P〈0．05）；12例早期出现神经根病损病例中，10例约在溶盘术后7d内出现；8例术中均未见明显神经根压迫；随访4—30个月，症状有不同程度好转，但无1例痊愈，且3d内手术治疗病例优良率明显高于8d后手术治疗病例。动物实验显示胶原酶对髓核有明显溶解作用，B组（后纵韧带破损组）神经根出现明显损害，C组（盘外注射组）椎间盘内未见明显溶解，亦未见神经根损害。[结论]（1）胶原酶溶盘中间产物和残余髓核溢人椎管可导致神经根损害症状，大剂量的盘内外联合溶盘可加剧神经根损害的发生率，对后纵韧带、纤维环破裂、髓核突人椎管的腰椎间盘突出症行胶原酶溶盘术应慎用；（2）胶原酶溶盘术后神经根损害预后差，预后与手术早晚明显有关；（3）胶原酶溶盘术后严格卧床，正确翻身，有助于降低神经根损害的发生率。     

单开门与胶原酶溶盘联合治疗颈髓损伤的临床研究

目的探讨颈后路单开门椎管扩大成形术与胶原酶直视下溶盘术联合治疗外伤性无骨折脱位型颈脊髓损伤的疗效。方法对11例外伤性无骨折脱位型颈脊髓损伤患者行颈后路单开门椎管扩大成形术，然后在直视下将胶原酶注入突出的颈椎间盘，术后平均随访时间为24个月，结合症状、体征、影像学资料，观察手术效果。结果联合治疗有效地缓解了患者的症状、体征。影像学资料显示椎管容积明显增加，突出的间盘缩小。术后6个月平均JOA改善率63．7％。结论联合治疗不仅通过后路单开门扩大了椎管的容积，而且通过溶盘术缓解了颈髓前面突出髓核的压迫，从而取得了较好的治疗效果。单开门椎管扩大成形术和胶原酶溶盘术联合治疗Ⅲ型无骨折脱位型颈脊髓损伤是一种可行的手术方法。     

靶位注射胶原酶治疗腰椎间盘突出术后复发

目的：探讨靶位注射胶原酶治疗腰椎间盘突出术后复发的临床意义。方法：27例术后复发患者接受注射胶原酶治疗，早期行侧隐窝注射法5例，后期行CT介入靶位注射法16例，CT介入联合靶位注射法6例。结果：所有患者经6个月～2年随访，优9例，良8例，可5例，差5例，优良率63．0％，有效率81．5％；靶位穿刺37次，首次穿刺失败4次(1／9)；4例于注射胶原酶后6～13个月复查CT，发现突出物缩小80％～90％。结论：靶位注射胶原酶溶盘术可与手术互补，适用于腰椎间盘突出术后复发的治疗。     

青少年腰椎间盘突出症胶原酶溶盘术的疗效

腰椎间盘突出症是腰腿痛的主要病因，青少年发病率虽然不高，但常规治疗效果多不满意，胶原酶溶盘作为新兴的治疗方法，对于青少年腰椎间盘突出症的治疗效果很少报道。本研究拟通过观察34例青少年腰椎间盘突出症溶盘疗法的治疗效果，探讨这种治疗方法的可行性。     

经皮椎间孔镜联合胶原酶溶盘术治疗非包容型腰椎间盘突出症的疗效观察

目的观察经皮椎间孔镜联合胶原酶溶盘术治疗非包容型单节段腰椎间盘突出症的疗效。方法纳入自2014-01—2017-01诊治的60例非包容型单节段腰椎间盘突出症,30例采用单纯经皮椎间孔镜手术治疗(对照组),30例采用经皮椎间孔镜手术联合胶原酶溶盘术治疗(观察组)。结果术后所有患者均获得12个月以上随访,腰痛及腿痛症状较术前明显改善。观察组术后1例出现出口根感觉异常症状,经2周中频脉冲电疗后好转;2组各有1例复发,行开放手术治疗。2组术后即刻、术后3个月腰痛VAS评分比较差异无统计学意义(P0.05);但观察组术后6、12个月腰痛VAS评分低于对照组,差异有统计学意义(P 0.05)。2组术后即刻、3个月、6个月、12个月腿痛VAS评分比较差异无统计学意义(P0.05)。术后12个月时观察组疗效优于对照组,差异有统计学意义(P 0.05)。结论经皮椎间孔镜联合胶原酶溶盘术治疗非包容型单节段腰椎间盘突出症效果更佳,患者腰痛缓解明显,复发率低。     

注射胶原酶治疗腰椎间盘突出症术后发热分析

目的　分析注射胶原酶治疗腰椎间盘突出症术后的发热特点及可能原因。方法　回顾378例腰椎间盘突出症患者接受注射胶原酶溶解术的治疗情况 ,按时间先后分为A、B两组 ,A组 2 50例 ,B组 1 2 8例。结果　A组仅有 2例轻微发热 (37 3℃ ) ;B组有 2 4例发热 (37 4～ 40 5℃ ) ,占同期病例的 1 8 75 %。发热间隔时间短 (3～ 32h) ,发热程度与时间间隔呈反比 ,伴随有头痛、恶心、呕吐等症状 ,经对症处理迅速降温。结论　注射胶原酶溶盘术后可发生程度不等的发热 ,预后较好。发热与胶原酶批号有关 ,原因可能为药物热     

复合式神经移位术治疗臂丛根性撕脱伤

自１９８８年１１月～１９９４年１２月，应用复合式神经移位术治疗臂丛根性撕脱伤８９例。损伤原因为：摩托车撞击伤６３例，机器牵拉伤２１例，直接损伤５例。损伤类型为：上臂丛型４７例，下臂丛型１３例，全臂丛型２９例。伤后至手术时间为３周～６个月。神经移位方式主要根据不同的损伤类型选用相应的移位方式。术后随访时间为１．５～６年。疗效最佳为膈神经移位，有效率达８２．９％；其次为副神经，达６６．７％；颈丛运动支达５５．２％；肋间神经达４８．３％；健侧Ｃ７神经根移位与患侧尺神经吻合，神经再生率达９６．６％。作者认为，复合式神经移位术治疗臂丛根性撕脱伤，尤其是对上臂丛根性撕脱伤，治疗效果是令人满意的。     

细针微创注射胶原酶治疗神经根型颈椎病

目的研究细针微创注射胶原酶溶盘治疗神经根型颈椎病的效果。方法选择神经根型颈椎病患者120例,采用7号细针穿刺注射胶原蛋白酶,于治疗后随访疗效。结果120例患者溶盘治疗后1个月、12个月的优良率分别为93．3％和95．8％。结论细针穿刺注射胶原蛋白酶溶盘治疗神经根型颈椎病是一种有效的微创治疗方法。     

CT引导椎间盘内、外联合注射胶原酶-臭氧治疗腰椎间盘突出合并Ⅰ°腰椎滑脱症的临床疗效与安全性

目的 分析CT引导下联合注射胶原酶和臭氧治疗腰椎间盘突出症合并Ⅰ°腰椎滑脱症的临床疗效及安全性.方法 对49例腰椎间盘突出合并Ⅰ°腰椎滑脱的患者采用联合注射胶原酶和臭氧溶盘术治疗,通过比较治疗前、后1周、6个月随访时疼痛视觉模拟评分(visual analogue scale/score,VAS)、止痛药使用情况及滑脱椎体位移距离,并采用改良Macnab法对术后1周、6个月进行疗效评定. 结果 术后1周、6个月患者VAS评分及止痛药使用评分明显下降,与术前比较差异均有统计学意义(P＜0.05);滑脱椎体移位距离术后1周、6个月与术前比较差异均无统计学意义(P＞0.05);术后7 d(近期疗效)与术后6月(远期疗效)比较,总体有效率分别为85.71％和87.76％,差异无统计学意义(P＞ 0.05);优良率分别为65.31％和71.42％,差异有统计学意义(P＜0.05).未见严重副作用与并发症发生. 结论 联合注射臭氧和胶原酶治疗腰椎间盘突出合并Ⅰ°腰椎滑脱取得了较理想的临床疗效,可以明显改善患者疼痛,对滑脱椎体稳定性无影响而根性症状即刻改善明显,是一种较安全的微创治疗方法.     

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.     

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.     

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.