加速康复外科护理在老年骨质疏松性胸腰椎压缩性骨折椎体成形中的疗效分析

目的 探讨加速康复外科（enhanced recovery after surgery, ERAS）护理在老年骨质疏松性胸腰椎压缩性骨折（osteoporotic vertebral compression fracture, OVCF）椎体成形病人中的疗效。方法 回顾性分析2017年1月至2018年12月在我院行椎体成形术的435例OVCF病人的临床资料,其中男89例,女346例;年龄为（71.0±3.5）岁（60~89岁）;T₁₁骨折78例、T₁₂骨折114例、L₁骨折134例、L₂骨折109例。将2017年接受常规护理的214例病人纳入对照组,2018年接受ERAS护理的221例病人纳入观察组。观察两组病人疼痛视觉模拟量表（visual analogue scale, VAS）评分、Barthel指数评定量表（Barthel index, BI）评分、下地时间、住院时间及病人护理满意度。结果 术后第1天,观察组的VAS评分、Barthel评分分别为（1.73±0.75）分、（81.00±2.00）分,优于对照组的（2.21±0.70）分、（75.82±1.85）分,差异均具有统计学意义（P均＜0.05）。观察组的下地时间和住院天数分别为（0.11±0.32） d、（3.31±0.50） d,均明显优于对照组的（1.11±0.33） d、（4.09±0.71） d,差异均有统计学意义（P均＜0.05）。出院时,观察组病人的护理满意度为92.31%（204/221）,明显高于对照组的85.51%（183/214）,差异有统计学意义（P＜0.001）。结论 基于ERAS的护理可加速老年OVCF椎体成形病人的康复,提升病人的护理满意度。     

重度颈椎后凸畸形病人平衡悬吊牵引的护理

目的 总结重度颈椎后凸畸形病人平衡悬吊牵引的护理措施,探讨平衡悬吊牵引的护理经验与体会。方法 回顾性分析2017年3月至2020年7月,术前接受平衡悬吊牵引预矫形的17例重度颈椎后凸畸形病人的临床资料。牵引过程中,对病人采取不良反应的观察与处理、平衡悬吊牵引管理、心理疏导和舒适护理等系统的护理干预措施。观察病人牵引前后后凸Cobb角、颈椎功能障碍指数（NDI）、日本骨科协会（JOA）评分改善情况和牵引期间不良反应发生情况。结果 本组病人顺利完成平衡悬吊牵引,牵引时间为（8.6±7.1） d;牵引前后凸Cobb角为82.5°±39.9°,牵引后后凸Cobb角为41.9°±24.4°,差异有统计学意义（P＜0.05）,后凸矫正率为50.6%±14.9%;牵引前后的NDI（7.1%±4.3% vs. 6.2%±8.0%）和JOA评分［（15.5±4.2）分 vs. （16.1±3.8）分］比较,差异均无统计学意义（P均＞0.05）。牵引过程中,出现重症不良反应1例,轻症不良反应6例,经护理干预后缓解。结论 平衡悬吊牵引可有效地改善重度颈椎后凸畸形病人的颈椎后凸角度,通过系统地护理干预,可以保证牵引安全,改善病人不良反应,提高牵引有效性。     

加速康复外科理念对髋关节置换术病人术后并发症预防效果的观察

目的 分析加速康复外科（enhanced recovery after surgery, ERAS）理念对髋关节置换术（total hip arthroplasty, THA）病人术后并发症的预防效果。方法 回顾性分析我院2014年1月至2018年12月收治的200例行THA病人的临床资料,将术后采用常规护理的病人纳入对照组（100例）,术后采用ERAS理念护理的病人纳入观察组（100例）。观察两组病人术后并发症发生情况、髋关节功能康复情况和功能独立性。结果 术后6个月,观察组并发症发生率为4.00%,明显低于对照组的14.00%,差异有统计学意义（P＜0.05）;观察组Harris髋关节功能评分（Harris hip score, HHS）为（93.86±4.37）分,高于对照组的（77.64±8.74）分,差异有统计学意义（P＜0.05）;观察组功能独立性评定量表（functional independence measure, FIM）评分为（116.78±3.99）分,高于对照组的（94.09±6.82）分,差异有统计学意义（P＜0.05）。结论 ERAS理念可有效预防THA病人术后并发症,并且有助于提升病人髋关节功能康复效果及功能独立性。     

出入院健康教育软件在骨质疏松性骨折病人术后护理中的应用

目的 探讨骨科病人出入院健康教育软件在骨科病人自我管理和护理能力提高中的应用价值。方法 选择我院骨科2014年2月至2017年1月期间诊治的144例骨质疏松症性骨折的病人,将病人按入院先后顺序随机分为：观察组72例,男40例,女32例,平均年龄为（58.33±3.29）岁;对照组72例,男43例,女29例,平均年龄为（58.13±4.21）岁。两组病人一般资料比较,差异均无统计学意义（均P＞0.05）。对照组给予骨科常规护理,观察组在对照组护理的基础上给予基于出入院健康教育软件的护理,两组护理干预时间为3个月,记录病人自我管理和护理能力情况。结果 护理后,观察组与对照组的自我护理能力评分分别为（114.22±22.19）分、（99.29±14.29）分,均高于护理前的（78.22±15.12）分、（77.92±17.24）分,差异均有统计学意义（均P＜0.05）。护理后,观察组的饮食管理、症状管理、躯体活动管理与社会心理管理各评分均明显高于对照组,差异均有统计学意义（均P＜0.05）。护理后,观察组的生理功能、生理职能、心理健康、总体健康、情感职能、活力、躯体疼痛、社会功能等评分均高于对照组,差异均有统计学意义（均P＜0.05）。结论 出入院健康教育软件对提高骨质疏松性骨折病人的自我管理与护理能力有很好的应用价值,对改善生活质量及提高康复效果有很好的促进作用。     

加速康复外科在关节镜下半月板损伤修复围术期护理中的应用

目的 探讨加速康复外科（enhanced recovery after surgery, ERAS）优化方案在关节镜下半月板损伤修复围术期护理的应用效果。方法 选取2017年1月至6月在北京积水潭医院运动医学科收治的膝关节半月板损伤病人90例,按照随机数字表法分为ERAS组和常规组,每组45例。ERAS组围术期在常规护理方法的基础上,给予改进的ERAS优化护理方案。比较两组病人术后疼痛视觉模拟量表（visual analogue score, VAS）评分、膝关节活动度恢复时间、Lysholm膝关节评分（Lysholm knee score scale, LKSS）、住院时间和费用、术后并发症及术后满意度情况。结果 两组病人术前至术后48 h各时间点的VAS评分均呈下降趋势（F_ERAS组=14.355,F_常规组=5.728,P均＜0.05）,从各个时间点看,ERAS组的VAS评分值显著低于常规组（F_组间=11.937,P_组间=0.001）,不同时间点与分组之间存在交互作用（F_交互=16.571,P_交互＜0.001）;ERAS组术后膝关节活动度恢复至30°、60°、90°及120°时间明显早于常规组（P＜0.001）,且病人住院时间短（t=-5.181,P＜0.001）、住院费用低（t=-3.263,P=0.002）、术后Lysholm膝关节评分更佳（t=10.682,P＜0.001）;ERAS组病人术后恶心、呕吐、尿潴留、关节积液等并发症发生率较常规组低（P＜0.05）,总体满意度明显高于常规组（Z=-2.455,P=0.014）。结论 ERAS优化方案应用于关节镜下半月板损伤修复的围术期护理中效果显著,可明显降低病人术后疼痛程度,缩短住院时间,减少住院总费用和并发症发生率,有效改善病人早期及远期膝关节活动情况,提高病人治疗综合满意度。     

新型加压绷带在腰椎术后脑脊液漏病人中的临床应用

目的 探讨自行设计的新型加压绷带在腰椎术后脑脊液漏病人中的临床应用。方法 选取2021年4月至2022年4月我科腰椎术后脑脊液漏病人42例,应用随机数字表法分为观察组和对照组,每组21例。观察组脑脊液漏病人使用自行设计的新型加压绷带加压包扎治疗,对照组使用普通腹带加压包扎治疗。观察两组病人加压包扎护理耗时、引流管留置时间和加压包扎处的皮肤情况。结果 观察组加压包扎护理耗时和引流管留置时间均较对照组明显缩短［（1.12±0.24）分 vs. （6.74±1.43）分;（5.09±1.12） d vs. （7.18±1.16） d］,差异均有统计学意义（P＜0.001）。观察组加压包扎处皮肤无异常;对照组发生皮肤异常9例（42.86%）,其中红肿4例、水疱1例、破皮4例。结论 新型加压绷带有助于提高加压包扎的护理效果,缩短加压包扎护理耗时和引流管留置的时间,明显改善病人加压包扎处的皮肤状况,极大地降低了护理不良事件的发生,促进了病人术后的康复。     

不同方式延续护理对老年全髋关节置换术后早期康复的影响

目的 探讨老年全髋关节置换术（total hip replacement, THR）后采用电话延续护理和互联网延续护理对其术后早期康复的影响。方法 选取2016年1月至2017年6月在西安市长安区医院骨外科接受THR的108例老年病人进行出院后8周的早期康复延续护理观察,随机分为电话延续护理组和互联网延续护理组,各54例。电话延续护理组采用电话随访形式对病人开展康复训练方法的指导,互联网延续护理组运用移动医疗应用程序（Application, APP）指导病人开展THR术后早期康复训练。采用Harris髋关节功能评分评价两组病人出院前、出院后4周及8周髋关节功能恢复情况,运用简明心境量表（brief profile of mood states, BPOMS）评价病人心境得分,并观察两组病人并发症的发生情况。结果 96例病人完成出院后8周的早期康复延续护理和数据统计,其中电话延续护理组49例,男25例,女24例,年龄为（68.29±8.83）岁;互联网延续护理组47例,男25例,女22例,年龄为（69.73±6.21）岁。出院后8周互联网延续护理组Harris髋关节功能评分为（86.29±8.17）分,优于电话延续护理组的（78.78±10.12）分,两组比较差异有统计学意义（t=6.671,P=0.011）;出院后4周、8周两组心境得分比较,互联网延续护理组均优于电话延续护理组,差异均有统计学意义（t=4.986,P=0.001;t=8.877,P＜0.001）;两组病人并发症发生率比较差异无统计学意义（χ²=1.871,P=0.453）。结论 电话延续护理和互联网延续护理模式对老年病人THR后的早期康复均有积极作用,可促进老年病人疾病控制和症状减轻,并减少并发症,但互联网延续护理模式在老年病人髋关节功能的恢复和病人心境改善方面明显优于电话延续护理模式。     

Legion工具在Genesis Ⅱ膝关节假体置换术中的应用

目的 探讨在初次人工全膝关节置换术（total knee arthroplasty, TKA）中应用Legion工具完成Genesis Ⅱ膝关节假体置换术的可行性及临床意义。方法 将中国人民解放军总医院第一医学中心收治的60例单侧内翻型初次TKA病人按随机数字表法分成Legion工具组及Genesis工具组,所有病人均采用Genesis Ⅱ假体,分别采用对应的工具为两组病人完成手术。对病人术前及术后的美国膝关节协会评分（Knee Society Scores, KSS）、最大屈曲角度、术后人工关节被遗忘指数（Forgotten Joint Scores, FJS）及影像学指标进行对比分析。结果 两组病人均获得1年随访,未出现切口相关并发症;术后3个月Legion工具组KSS临床评分及功能评分均高于Genesis工具组［（81.55±4.81）分 vs. （79.05±4.10）分,t=2.165,P=0.035;（84.89±4.60）分 vs. （81.33±5.14）分,t=2.820,P=0.007）］,术后12个月两组KSS评分的差异无统计学意义;术后12个月Legion工具组FJS评分优于Genesis工具组［（94.03±6.50）分 vs. （89.62±6.10）分,t=2.706,P=0.009）］,病人膝关节最大屈曲角度较Genesis工具组大（123.48°±7.63° vs. 108.19°±9.12°,t=2.436,P=0.018）。结论 使用Legion工具行Genesis Ⅱ置换术,可以发挥其简单、精准、微创、个性化的特点,获得更好的临床疗效。     

出院准备服务在全膝关节置换术病人中的应用

目的 探讨出院准备服务在全膝关节置换术（total knee arthroplasty, TKA）病人中的临床护理效果及意义。方法 将2018年1月至6月我科收治的58例单侧TKA病人纳入对照组,采用常规护理和健康教育;将2018年7月至12月收治的64例单侧TKA病人纳入观察组,在常规护理和健康教育的基础上提供出院准备服务。术前和术后3个月采用美国特种外科医院（Hospital for Special Surgery, HSS）膝关节功能评分标准和健康调查简表（the MOS item short form health survey, SF-36）评价病人膝关节功能和生活质量,出院时调查病人护理服务满意度。结果 术后3个月,观察组HSS膝关节功能评分为（89.56±7.17）分,优于对照组的（77.59±6.03）分,差异有统计学意义（t=9.030,P=0.007）;观察组SF-36评分为（68.29±8.68）分,优于对照组的（51.29±3.55）分,差异有统计学意义（t=5.060,P=0.014）。出院时,观察组护理服务满意度为96.88%（62/64）,明显高于对照组的86.21%（50/58）,差异有统计学意义（χ²=3.920,P=0.012）。结论 实施出院准备服务全面、有效地保证了TKA病人出院后康复训练的连续性,使病人及时、准确地获得膝关节功能锻炼指导,提升了TKA病人的膝关节功能、生活质量和护理服务满意度。     

护理流程再造在老年髋部骨折救治绿色通道中的实施及效果评价

目的 评价护理流程再造在老年髋部骨折救治绿色通道建设中的应用效果。方法 回顾性分析2016年1月至2017年6月我院创伤中心收治的60岁以上髋部骨折（排除病理性骨折、双侧骨折及多发伤）并获得12个月随访的128例病人的临床资料,男52例,女76例。按护理流程分为再造后护理流程组（观察组）和常规护理流程组（对照组）,各64例。记录两组病人的手术等待时间、术后首次下床活动时间和住院时间,观察两组病人出院时及术后6、12个月Harris髋关节功能评分,并进行组间统计学分析。结果 观察组手术等待时间（中位数44.3 h）明显短于对照组（中位数137.6 h）,差异具有统计学意义（P＜0.001）;观察组术后首次下床活动时间为（2.24±0.48） d,对照组为（3.51±0.31） d,差异具有统计学意义（P＜0.001）;观察组住院时间为（12.78±1.51） d,对照组为（15.25±1.31） d,差异具有统计学意义（P＜0.001）;术后6、12个月,观察组Harris髋关节功能评分均明显优于对照组,差异均有统计学意义（P均＜0.001）。结论 在老年髋部骨折救治绿色通道建设中优化护理流程能减少病人手术等待时间和缩短住院时间,有利于病人早期下床进行功能锻炼及髋关节功能的恢复,再造后护理流程具有临床推广的意义。     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

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.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.