Prophylactic diclofenac infusions in major orthopedic surgery: effects on analgesia and acute phase proteins

The influence of diclofenac, given by continuous i.v. infusion starting preoperatively, on postoperative pain and inflammation was assessed in a double-blind, randomized, placebo-controlled study in 40 patients scheduled for major orthopedic surgery. Starting 30 min before induction the patients received either diclofenac (0.35 mg.kg-1 bolus followed by a constant-rate infusion of 90 micrograms.min-1) or placebo for 24 h. The pain intensity (VAS) and the amount of rescue narcotic (piritramide on demand) were significantly lower in the diclofenac group from 4 and 6 h postsurgery, respectively, till end of infusion. Acute phase proteins used as inflammation markers (C-reactive protein, alpha 1-chymotrypsin, alpha 1-acid glycoprotein, haptoglobin and coeruloplasmin) showed similar variations in both groups for 24 h. The diclofenac treatment had no influence on hematological and coagulation profiles, nor on muscle and liver enzymes in comparison with placebo. Both patients and observer rated the diclofenac treatment as significantly superior to the placebo treatment.     

Interpleural or thoracic epidural analgesia for pain after thoracotomy. A double blind study

The analgetic effect of bupivacaine given epidurally or interpleurally after thoracotomy was investigated in a randomized, double blind, placebo controlled study. 32 patients with both an epidural and an interpleural catheter, were randomized to receive either interpleural or epidural analgesia. The interpleural group was given bupivacaine 5 mg ml^-1 with 5 microgram epinephrine as a 30 ml interpleural bolus, followed by a continuous infusion starting at a rate of 7 ml per hour and epidurally a bolus of 0.9% NaCl followed by a continuous infusion of 0.9% NaCl. The epidural group was given bupivacaine 3.75 mg–ml^-1 with 5 microgram epinephrine as a 5 ml epidural bolus, followed by a continuous infusion starting at a rate of 5 ml per hour and interpleurally a bolus of 0.9% NaCl followed by a continuous infusion of 0.9% NaCl. The draining tubes were clamped during the injection of the interpleural bolus and 15 min afterwards. Adequacy of pain relief was evaluated with the Prins–Henry pain scale. Morphine requirement was registered, there was no difference between the groups in painscores or need for additional morphine.     

Postoperative pain treatment after cholecystectomy with epidural sufentanil at lumbar or thoracic level

The difference in analgesic activity following lumbar (group I) or thoracic (group II) epidural administration of 50 ug sufentanil was studied after cholecystectomy. Fifteen patients in each group were evaluated for pain relief using a linear analog scale (LAS), heart rate (HR), mean arterial pressure (MAP), respiratory rate (RR), peak expiratory flow (PEF), forced vital capacity (FVC), forced expiratory volume (FEV,) and arterial CO₂ tension (Paco₂). In five additional patients in each group 75 μg sufentanil was injected for determination of serum levels. Pain scores were lower than three in both groups after 10 min, while mean pain scores remained below one from 20 min until 2 h following injection in both groups. Satisfactory pain relief lasted for 4 h. RR was significantly decreased from two until 360 min. in the lumbar group and from five until 120 min in the thoracic group. Paco₂ was raised in both groups only during the first hour. PEF and FVC were significantly improved compared to control 1, 2 and 4 h following injection. Serum sufentanil levels reached a maximum of 0.299 ±0.052 ng.ml^-1 in the lumbar group and 0.377 ± 0.076 ng–ml^-1 in the thoracic group after 5 min. There were no significant differences between the two groups in the variables studied.     

细针单次硬膜外阻滞混合用药术后止痛临床应用

[目的] 观察细针单次硬膜外阻滞，混合用药术后止痛疗效。[方法] 选择ASAⅠ-Ⅱ级，下腹部、下肢急诊或择期手术300例，随机分为A、B两组。均采用7号或9号腰麻针的细针，单次硬膜外阻滞，A组用药1％利多卡因和0．375％布此卡因混合液；B组用A组药的同时加芬太尼50μg观察比较两组效果。[结果] 两组术后止痛良好，手术成功率100％，B组止痛时间优于A组。两组病例围术期未见尿潴留。[结论] 细针单次硬膜外阻滞混合用药，术后止痛，疗效满意，3种药混合优于两种药。优点：本组采用细针可减轻穿刺部位损伤，对年龄较大的骨质增生者、间隙狭窄的病例容易进入。其方法简便，疗效好，经济、安全。     

手术后早期炎性肠梗阻的综合治疗

目的 :探讨对症处理、营养支持、生长抑素及肾上腺皮质激素等药物的综合措施对术后早期炎性肠梗阻(EPII)的治疗作用。　方法 :2 0 0 1年 5～ 12月收治 10例EPII病人 ,在一般对症处理的基础上给予早期肠外营养支持加施他宁及肾上腺皮质激素 ,并逐渐过渡到肠内营养支持 ,观察临床症状改善情况、胃液量、营养支持时间、住院时间、血常规、血生化及营养指标。　结果 :治疗后第 2天病人胃液量即显著减少 (P <0 .0 5 ) ,腹痛、腹胀等症状很快缓解 ,营养指标及肝、肾功能无明显变化 ,肠外营养支持时间平均为 2 1天 ,肠内营养支持平均为 9天 ,平均住院32天 ,所有病人均治愈 ,未行手术治疗。　结论 :EPII是一种特殊类型的肠梗阻 ,采用胃肠减压、维持内稳态、肠内及肠外营养支持、给予生长抑素及肾上腺皮质激素等的综合治疗 ,能明显改善症状、维持病人的营养状况及内环境稳定 ,促进肠功能的恢复 ,有效地治疗EPII。     

Oral vancomycin hydrochloride therapy for postoperative methicillin-cephem-resistantStaphylococcus aureus enteritis

The postoperative development of methicillincephem-resistantStaphylococcus aureus (MRSA) enteritis can be fatal unless it is detected at an early stage and treated with effective antibacterial agents. We report herein a Japanese multicenter collaborative clinical study on the efficacy and safety of oral vancomycin hydrochloride (VCM) in the treatment of MRSA enteritis. A total of 49 patients who had been diagnosed as having, or were strongly suspected of having, MRSA enteritis during the early postoperative period, were given oral VCM as four standard doses of 0.5g per day. The VCM concentrations in the blood, urine, and feces were then measured. No side effects were observed and the clinical efficacy of oral VCM in the 31 evaluable patients was excellent. There was a 100% clinical response rate and a 95.8% bacterial elimination rate in the feces. The clinical complete response (CR) rate to oral VCM differed significantly between patients in whom MRSA was detected only in the feces (100%) and those in whom MRSA was isolated from an additional source (57%) (P<0.01). Although VCM concentrations in the stools were extremely high, the levels in the blood and urine were very low. These results demonstrate that oral VCM should be the treatment of choice for postoperative MRSA enteritis due to its safety and efficacy.     

Combination of cold and compression after knee surgery

The objective of this study was to investigate the effect of continuous long-term application of a combined cooling and compression system (Cryo/Cuff, Aircast Inc., Summit. New Jersey, USA) on postoperative swelling, range of motion (ROM), pain, consumption of analgesics, and return of function after anterior cruciated ligament (ACL) reconstruction. We compared the cold-compression system with traditional ice therapy. There were 44 patients in the series (aged 15–40 year_ who were randomly assigned to a control group (ICE) or a study group (CC). The ICE group consisted of 23 patients (aged 24.2±4.5 years); the CC group consisted of 21 patients (aged 24.8±5.6 years). The ICE group received ice bags postoperatively; the CC group was provided with the Cryo/Cuff during the 14-day hospital stay. Girth, ROM, pain score (visual analog scale), and consumption of analgesics were determined on postoperative days 1, 2, 3, 6, 14, and 28. Twelve weeks after surgery, isokinetic testing was performed, and the functional knee score was determined. In the CC group, significantly less swelling was observed (P<0.035). These patients also reported less pain and had a significantly reduced consumption of analgesics (P<0.04). On all examination days, ROM in the CC group was up to 17° greater than in the ICE group (P<0.02). The functional knee score was singificantly increased in the CC group (P=0.025). The results from our study document the advantages of conitnous cold-compression therapy over cold alone following ACL reconstructionThe study was conducted at the Kreiskrankenhaus Bopfingen, Germany     

Patient and nurse evaluation of paient-controlled analgesia delivery systems for postoperative pian management

Five different patient-controlled analgesia (PCA) delivery systems were evaluated for the treatment of acute postoperative pain in 423 patients undergoing elective operations at a large tertiary care hospital The PCA trial was conducted on four different postsurgical wards over a 5-mo period. All five devices were utilized on each ward for a 1-mo period. According to the nurses, the mean time (± SD) required to become comfortable using the Pharmacia Deltec CADD-PCA was significantly longer (50 ± 37 min) than that using the Abbott Lifecare Plus (19 ± 17 min), Bard PCA I (17 ± 14 min), IVAC PCA (17 ± 14 min), or Baxter PCA Infusor (7 ± 8 min). With respect to ease of documentation by the nursing staff, the Baxter device was superior to the Pharmacia device. Similarly, mechanical problems were less frequent with the Baxter (6%) compared with the Pharmacia device (71%). The patients felt that the nurses were more comfortable using the Baxter device than the Pharmacia device. The patients also found the Baxter device easier to use, especially at night, and the least likely to interfere with ambulation. In conclusion, 80% of the nurses at this teaching center preferred the Baxter PCA Infusor over four widely used electronic PCA devices for the management of acute postoperative pain. The Pharmacia device was felt by the nurses to be less user friendly than She other programmable PCA devices used in this trial. Of the electronic devices we studied, the Bard and IVAC devices were the most cost-effective.     

Factors affecting leakage following esophageal anastomosis

Esophageal anastomotic leaks remain the most serious problem following extirpative procedures for esophageal carcinoma. We conducted a retrospective analysis of 352 patients with carcinoma in the thoracic esophagus who had undergone esophageal anastomosis following esophagectomy at the Kurume University Hospital between 1981 and 1990. Of these, 94 patients (27%) developed anastomotic leaks, and out of this subgroup, 21 (6%) died as a direct result of the leak. A further 20 patients (6%) underwent repair of the leak, after which they were able to tolerate oral intake. The anastomotic leak healed spontaneously in the other 53 patients (15%). The risk factors predisposing to leaks from esophageal anastomoses were determined as: (1) the anastomosis being performed via a retrosternal or subcutaneous route as opposed to an intrathoracic route, (2) the use of colonic interposition as opposed to a gastric pedicle, (3) performing a manual anastomosis as opposed to a mechanical anastomosis, and (4) employing an end-to-end anastomosis, as opposed to an end-to-side anastomosis, using a mechanical method. By introducing an anastomotic stapling device, a microvascular technique, a staged operation based on the preoperative risk analysis, and improvement in pre- and postoperative management, the incidence of anastomotic leakage could be decreased from 35% to 14%, and that of consequent hospital mortality, from 9% to 2%.     

The Relation of the Location of Haptics of Posterior Chamber Intraocular Lenses and Peripheral Anterior Synechia

Purpose:To investigate the occurrence,outcome and influencial factors of the peripheral anterior synechia (PAS) following implantation of posterior chamber intraocular lenses for finding a way to reduce the PAS.Subjects : 40 eyes of 38 senile cataract patients with normal chamber angle and intraocular pressue (IOP) preoperatively were examined.Methods: Extracapsular cataract extraction was performed under microscope with insertion of a posterior chamber lens implant vaulted anteriorly by 10°. Go-nioscopy and slit-lamp examination and photography of the operated eyes were performed 3 to 6 months postoperatively.Results:PAS were found in 20 (50%) of the 40 eyes. Among the 20 eyes with PAS the locations of 23 haptics in 17 eyes corresponded with those of the PAS. PAS were seen more frequently with vertically sulcus-fixated haptics than with the horizontally capsular-fixated haptics , showing a significant difference ( P< 0. 05 ). 88% of the eyes with PAS had pupillary deformation, but their visual acuitie