脊柱手术后静脉血栓发生率的Meta分析

目的 :利用Meta分析的方法评价脊柱手术后发生静脉血栓的相关影响因素。方法:计算机检索2017年7月31日以前PubMed、Web of Science、EMBASE、the Cochrane Library等英文数据库和万方、知网、维普等中文数据库中关于脊柱手术后静脉血栓自然发生率的相关研究,采用NOS量表对纳入的研究进行质量评价,提取年龄、性别、体重指数(BMI)、手术方式与部位、手术时间、出血量、高血压、糖尿病、心脏病、D-二聚体水平、术前行走障碍等病史信息,将这些信息通过Review Manager 5.3软件进行Meta分析。结果:共纳入22篇文献,包含2841542例脊柱术后患者,其中发生静脉血栓者7557例,纳入文献的NOS评分在5~8分。Meta分析结果示,脊柱手术后静脉血栓发生者年龄[WMD=6.05,95%CI(3.62,8.48),P0.0001]、失血量[SMD=2.22,95%CI(1.03,3.41),P=0.0003]、手术时间[WMD=59.60,95%CI(10.27,108.93),P=0.02]均高于非静脉血栓者;男性患者术后静脉血栓发生率低于女性患者[OR=0.59,95%CI(0.38,0.94),P=0.03];手术方式中脊柱融合术患者术后静脉血栓发生率高于非融合术患者[OR=1.67,95%CI(1.40,1.99),P0.00001];术前有高血压[OR=1.78,95%CI(1.51,2.10),P0.00001]、糖尿病[OR=1.48,95%CI(1.40,1.57),P0.00001]、行走障碍史者[OR=4.47,95%CI(4.47,10.98),P=0.001]均增加了术后静脉血栓发生率;而BMI、手术入路、手术部位、心脏病史和D-二聚体水平对脊柱手术后静脉血栓发生率影响差异无统计学意义(P0.05)。结论:年龄偏高、女性、行脊柱融合术、失血量大、手术时间长者及伴有高血压、糖尿病、行走障碍史者术后易发生静脉血栓,临床应加以防范。     

腰椎后路融合术后急性手术部位感染的危险因素分析

目的探讨腰椎后路融合术后发生急性手术部位感染的相关危险因素。方法回顾性分析2016年1月至2018年12月于我院脊柱外科行腰椎后路融合手术的330例病人的临床资料。病人主要诊断包括腰椎椎管狭窄、腰椎间盘突出症、腰椎骨折、肿瘤等。根据术后是否发生急性手术部位感染将病人分为感染组和非感染组,选择年龄、性别、身体质量指数(body mass index, BMI)、吸烟、高血压、糖尿病、骨质疏松症、手术节段数、手术时间、出血量、切口长度、术后引流时间、尿路感染和脑脊液漏等可能影响术后急性手术部位感染的因素,先后应用单因素分析和二元Logistic回归分析腰椎后路融合术后急性手术部位感染的危险因素。结果共有19例术后发生了急性手术部位感染,发生率为5.76%(19/330)。单因素分析结果显示:两组病人的年龄、BMI、糖尿病、骨质疏松、手术节段、手术时间、出血量、脑脊液漏、尿路感染以及切口长度的差异均有统计学意义(P均<0.05)。二元Logistic回归分析结果显示:BMI[OR=1.429,95%CI(1.059,1.929),P=0.020]、合并糖尿病[OR=9.568,95%CI(2.183,41.935),P=0.003]、手术时间[OR=8.868,95%CI(1.992,39.482),P=0.004]、切口长度[OR=7.257,95%CI(2.937,16.719),P<0.001]为腰椎后路融合术后急性手术部位感染的独立危险因素。结论为了降低腰椎术后急性手术部位感染的发生率,围术期应合理评估控制相关危险因素,以获得更好的治疗效果和病人满意度。     

低位直肠癌侧方淋巴结清扫术的Meta分析

目的:探讨低位直肠癌侧方淋巴结清扫的意义。方法:计算机检索The Cochrane library、Pubm e d、EMbas e、CBM、维普数据库、中国知网、万方数据库,检索时间为2000年1月—2015年10月,纳入低位直肠癌侧方淋巴结清扫术的对比研究,用revman5.2处理数据,评价低位直肠癌侧方淋巴结清扫术的意义。结果:纳入公开发表的9篇临床对比研究,以低位直肠癌行侧方淋巴结清扫术患者为观察组,传统手术患者为对照组进行Meta分析。观察组手术时间长于对照组,差异有统计学意义[MD=-42.48,95%CI(32.92,-52.04),P0.00001];观察组术中出血量大于对照组,差异有统计学意义[MD=-18.72,95%CI(5.60,31.83),P0.005];观察组局部复发率低于对照组,差异有统计学意义[OR=-0.52,95%CI(0.38,0.71),P0.0001];观察组3年生存率、5年生存率均高于对照组,差异有统计学意义,其合并OR和95%CI分别为OR=2.65,95%CI(1.76,3.99)(P0.00001)和OR=3.57,95%CI(2.05,6.22)(P0.00001)。结论:低位直肠癌行侧方淋巴结清扫术增加患者手术时间、出血量及术后并发症发生风险,但提高患者生存率。     

补肾健脾活血法治疗绝经后骨质疏松症疗效的Meta分析

目的 系统评价补肾健脾活血法治疗绝经后骨质疏松症的疗效。方法 利用计算机检索各大数据库,如Cochrane图书馆、知网(CNKI)、万方(Wanfang)、荷兰医学文献数据库、维普（VIP）、Web of Science、PubMed、Medline等数据库,检索各库建库时间至2021年2月补肾健脾活血法治疗绝经后骨质疏松症的随机对照试验(randomized controlled trial, RCT),并采用RevMan5.3软件对符合纳入条件的文献进行定量Meta分析。结果 共纳入14篇RCT文献进行定量分析,研究共涉及1 218名患者,分析结果显示,①补肾健脾活血法方药在提高绝经后骨质疏松患者临床有效率[OR=2.57, 95 %CI(1.37~4.83),P=0.003]、血清E2水平[MD=3.15,95 %CI(0.28~6.02),P=0.03]以及降低患者B-ALP水平[MD=?17.63,95 %CI(?26.01~?9.25),P<0.0001]、尿Ca/Cr比值[MD=?0.14, 95 %CI(?0.27~?0.01),P<0.0001]方面明显优于常规西药;补肾健脾活血法方药在提高患者腰椎BMD[MD=0.01,95 %CI(?0.02~0.04),P=0.42]、股骨颈BMD[MD=0.00,95 %CI(?0.06~0.05),P=0.91]、IGF-1水平[MD=31.71,95 %CI(?18.54~81.96),P<0.0001]以及降低患者血清IL-6水平[MD =?5.72,95 %CI(?14.05~2.61),P=0.18]、TNF-α水平[MD=?13.51,95 %CI(?39.89~12.86),P<0.0001]与西药相比无统计学意义,具有相同疗效;②补肾健脾活血方联合西药在提高临床有效率[OR=5.44,95 %CI(2.71~10.89),P<0.00001]、提高患者腰椎BMD[MD=0.07,95 %CI(0.04~0.11),P<0.00001]、股骨颈BMD[MD=0.06,95 %CI(0.02~0.09),P=0.0008]、E2水平[MD=5.20,95 %CI(1.35~9.06),P=0.008]以及降低患者血清B-ALP水平[MD=?4.31,95 %CI(?5.53~?3.09),P<0.00001]、IL-6水平[MD=?18.06,95 %CI(?26.56~?9.57),P<0.0001]与西药相比效果更佳;③根据临床有效率、腰椎BMD、股骨颈BMD、血清E2、IL-6水平各指标亚组间比较结果显示,相比于单纯补肾健脾活血法方药,补肾健脾活血法方药与西药二者具有联合增效之功。结论 补肾健脾活血法方药治疗绝经后骨质疏松症具有显著疗效,并可与西药联合具有增效之功,但仍需更多RCTs加以验证。     

经皮内镜下经椎间孔腰椎间融合术与传统微创经椎间孔腰椎间融合术治疗腰椎退行性疾病临床疗效与安全性的Meta分析

【摘要】 目的：通过Meta分析评价经皮内镜下经椎间孔腰椎间融合术（percutaneous endoscopic transforaminal lumbar interbody fusion,PE-TLIF）与传统微创经椎间孔腰椎间融合术（minimally invasive transforaminal lumbar interbody fusion,MIS-TLIF）治疗腰椎退行性疾病（lumbar degenerative diseases,LDD）的临床疗效与安全性。方法：检索PubMed、Cochrane Library、Web of science、Embase、Medline、CNKI、万方、维普数据库进行了全面搜索关于PE-TLIF和MIS-TLIF治疗LDD的临床预后和并发症的相关研究。提取纳入研究的结局指标数据,包括视觉模拟评分（visual analogue scale,VAS）、Oswestry功能障碍指数（Oswestry disability index,ODI）、日本骨科协会（Japanese Orthopaedic Association,JOA）评估治疗分数;手术时间、透视时间、术中出血量、术后引流量、下床时间、住院时间、融合率和手术相关并发症。提取数据后通过Review Manager 5．3软件进行Meta分析。结果：共纳入10篇文献,2篇RCT,1篇前瞻性队列研究,7篇回顾性研究,总样本量696例,其中PE-TLIF组患者345例,MIS-TLIF组患者351例。Meta分析结果显示,PE-TLIF组住院时间[MD＝-1.45,95%CI（-2.17,-0.74）,P＜0.0001]、术中失血量[MD＝-56.39,95%CI（-77.50,-35.29）,P＜0.00001]、术后引流量[MD＝-46.27,95%CI（-67.68,-24.85）,P＜0.0001]、下地时间[MD＝-2.84,95%CI（-4.97,-0.71）,P=0.009]方面均优于MIS-TLIF组;MIS-TLIF组手术时间[MD＝35.89,95%CI（16.82,54.95）,P=0.0002]、术中透视时间[MD＝15.42,95%CI（15.28,15.55）,P＜0.00001]及下肢VAS评分[MD＝0.10,95%CI（0.01,0.19）,P=0.02]优于PE-TLIF组;二者在术后背部VAS评分[MD＝-0.02,95%CI（-0.10,0.06）,P=0.68]、ODI[MD＝-0.14,95%CI（-0.71,0.43）,P=0.62]、术后JOA评分[MD＝ -0.11,95%CI（-0.48,0.26）,P=0.55]、并发症发生率[OR＝1.69,95%CI（0.81,3.54）,P=0.16]及融合率[OR＝0.56,95%CI（0.23,1.37）,P=0.20]方面无显著性差异。结论：PE-TLIF和MIS-TLIF作为腰椎退行性疾病的微创手术,都具有明显的临床疗效和安全性,两种术式的中远期临床疗效、手术并发症以及融合率方面无明显差异,PE-TLIF在住院时间、术中失血量、术后引流量、下地时间等方面更占优势,PE-TLIF具有手术创伤小、恢复快、术后早期缓解腰腿部疼痛等优点。     

腰椎椎体间融合术后cage后移危险因素的Meta分析

【摘要】 目的：通过系统评价的方法分析影响腰椎椎体间融合术后cage后移（cage retropulsion,CR）发生的危险因素。方法：检索PubMed、Embase、Cochrane Library、Web of Science、中国生物医学文献数据库（CBM）、中国知网（CNKI）、万方数据库和维普数据库,收集各数据库建库至2023年4月有关影响腰椎椎体间融合术后CR危险因素的文献,研究类型为队列研究及病例对照研究,采用纽卡斯尔-渥太华质量评估量表（Newcastle-Ottawa scale,NOS）对纳入研究进行质量评价,提取纳入研究的基本信息,包括年龄及性别等以及CR发生相关研究因素,如骨质疏松、终板损伤、螺钉松动、梨形椎间隙、cage形状、cage置入深度及手术时长、出血量等。评价纳入研究的偏倚风险后,使用Stata14.0软件进行Meta分析。结果：共纳入16篇相关文献,其中15篇文献为回顾性病例对照研究,1篇为前瞻性队列研究,均为中等及以上质量研究,NOS评分均≥7分。总样本量12667例,其中发生CR者（CR组）326例,未发生CR者（nCR组）12341例,CR发生率为2.83%。Meta分析结果显示：性别（男性）[比值比（odds ratio,OR）=1.264,95%置信区间（confidence interval,CI）（1.003～1.593）,P=0.047]、年龄[效应量标准化平均差（standardized mean difference,SMD）=0.237,95%CI（0.054～0.419）,P=0.011]、骨质疏松[OR=3.126,95%CI（1.040～9.401）,P=0.042]、骨终板损伤[OR=8.161,95%CI（3.711～17.945）,P=0.000]、螺钉松动[OR=7.978,95%CI（3.487～18.255）,P=0.000]、梨形椎间隙[OR=6.037,95%CI（2.381～15.305）,P=0.000]、cage置入深度不足[OR=5.157,95%CI（1.760～15.111）,P=0.003]是腰椎椎体间融合术后发生CR的危险因素。结论：性别（男性）、高龄、骨质疏松、骨终板损伤、螺钉松动、梨形椎间隙、cage置入深度不足与腰椎椎体间融合术后发生CR密切相关,随访期间应对此类患者密切观察,预防发生严重cage移位的并发症。     

胰腺术后胰瘘发生相关危险因素分析（附303例胰腺手术报告）

目的 探讨影响病人胰腺手术后胰瘘发生率的危险因素。方法 回顾性分析2012年2月至2015年1月中国医科大学附属第一医院收治的303例行胰腺手术病人资料,其中术后发生胰瘘50例。对影响术后胰瘘发生的相关因素进行单因素分析及Logistics回归分析。结果 单因素分析结果显示,影响术后胰瘘发生的因素包括性别、病理类型、胰管扩张、手术时间、术中出血量、术前血红蛋白、术前血清总胆红素、术后血清总胆红素（P<0.05）。非条件Logistic回归分析结果显示,影响术后胰瘘发生的独立危险因素为：性别（OR=12.001,95%CI 3.049~47.230,P<0.05）、病理类型（OR=1.605,95%CI 1.108~2.324,P<0.05）、胰管扩张（OR=1.177,95%CI 0.188~0.468,P<0.05）、手术时间（OR=1.641,95%CI=1.173~2.339,P<0.05）、术中出血量（OR=1.096,95%CI 1.094~1.099,P<0.05）、术前血红蛋白（OR=0.888,95%CI 0.823~0.921,P<0.05）、术前血清总胆红素（OR=1.359,95%CI 1.335~1.381,P=0.010）、术后血清总胆红素（OR=1.030,95%CI 1.064~1.004,P<0.05）。结论 男性、手术前后血清胆红素浓度高、壶腹部癌或十二指肠癌是胰瘘发生的独立危险因素,而胰管扩张则可减少胰腺手术后胰瘘的发生。     

胰十二指肠切除术后感染并发症相关危险因素的Meta分析

目的探讨胰十二指肠切除术后感染并发症发生的危险因素。方法收集2005年1月至2016年9月间Pub Med、中国知网、万方等数据库公开发表的有关胰十二指肠切除术后感染并发症危险因素的文献,运用固定或随机模型对各个因素进行合并分析。结果共纳入9项研究、1 386例胰十二指肠切除术患者。Meta分析结果显示,术后感染组患者血清白蛋白水平低于术后非感染组(WMD=-3.56,95%CI:-6.01,-1.10,P=0.005);术后感染组手术时间长于非感染组(WMD=37.65,95%CI:20.81~54.49,P0.0001);围手术期输血的患者术后感染率高于未输血的患者(OR=1.62,95%CI:1.15~2.28,P=0.006);术后发生胰瘘的患者术后感染率高于无胰瘘的患者(OR=4.96,95%CI:2.68~9.18,P0.00001)。术前胆道引流(OR=1.15,95%CI:0.86~1.55,P=0.34)、术中出血量(WMD=35.34,95%CI:-18.37~89.04,P=0.20)、术前总胆红素水平(WMD=-0.16,95%CI:-1.12~0.81,P=0.75)、是否合并糖尿病(OR=1.06,95%CI:0.59~1.91,P=0.85)等因素在两组间无统计学差异(P0.05)。结论低白蛋白水平、手术时间长、输血以及术后胰瘘是胰十二指肠切除术后感染的危险因素,而术前胆道引流、术中出血量、术前胆红素水平、是否合并糖尿病与术后感染并发症无明显相关性。     

老年结肠癌患者择期结肠切除术后吻合口漏的影响因素分析及预测模型构建

目的 确定老年结肠癌患者择期结肠切除术后吻合口漏发生的危险因素，并建立术后吻合口漏发生风险的预测模型。方法 回顾性分析2018年1月至2021年12月期间在兰州大学第一医院择期接受结肠癌手术治疗的122例65岁以上老年患者的临床资料。采用单因素分析和多因素logistic回归分析吻合口漏发生的潜在危险因素，根据确定的独立危险因素建立列线图预测模型，并通过受试者工作特征曲线评价模型的预测效能。结果 本研究纳入的122例患者中术后发生吻合口漏10例，未发生吻合口漏112例。单因素分析结果显示：吻合口漏的发生与体质量指数、吸烟、合并糖尿病、年龄校正Charlson合并症指数、术中及术后2 d内输血、术前血红蛋白、术前白蛋白和术前预后营养指数有关（P<0.05）；多因素logistic回归分析结果显示：吸烟[OR=15.529,95%CI为（1.529,157.690）,P=0.020]、年龄校正Charlson合并症指数[OR=1.742,95%CI为（1.024,2.966）,P=0.041]和术中及术后2 d内输血[OR=82.223,95%CI为（1.265,5 343.025）...     

肺癌术后并发症Clavien-Dindo分级≥Ⅱ级危险因素分析的多中心前瞻性队列研究

目的 分析肺癌术后并发症Clavien-Dindo分级≥Ⅱ级的危险因素。方法 纳入2017年11月—2020年1月多中心肺癌手术患者，分析其术后并发症的Clavien-Dindo分级，并采用logistic回归分析确定≥Ⅱ级并发症的危险因素。结果 共纳入388例患者，其中男203例、女185例，平均年龄（56.14±10.36）岁。肺癌术后并发症发生率为25.52%(99/388)，≥Ⅱ级并发症的发生率为20.10%(78/388)。术后最常见的5个并发症分别为：肺炎（6.96%）、持续性肺漏气（>7 d,5.67%）、切口裂开（4.64%）、心律失常（3.87%）和手术后胸腔积液（3.35%）。多因素分析结果显示：开放手术[参照为单孔胸腔镜，OR=2.18,95%CI(1.01,4.70),P=0.047]、扩大切除[参照为亚肺叶切除，OR=2.86,95%CI(1.11,7.19),P=0.030；参照为肺叶切除，OR=2.20,95%CI(1.10,4.40),P=0.026]和手术时间≥3 h[OR=2.07,95%CI(1.12,3.85),P=0.021]是肺癌术后并...     

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.     

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.     

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.     

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.     

Anesthésie générale chez l’enfant : quid des pratiques en 2010 ?

Introduction

The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France.

Material and methods

One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated.

Results

There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N₂O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7–8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL).

Discussion

This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.     

Intérêt d’une rééducation précoce pour les patients neurologiques

Rehabilitation improves the functional prognosis of patients after a neurologic lesion, and tendency is to begin rehabilitation as soon as possible. This review focuses on the interest and the feasibility of very early rehabilitation, initiated from critical care units. It is necessary to precisely assess patients’ impairments and disabilities in order to define rehabilitation objectives. Valid and simple tools must support this evaluation. Rehabilitation will be directed to preventing decubitus complications and active rehabilitation. The sooner rehabilitation is started; the better functional prognosis seems to be.