骨髓源性肝干细胞的确认及定向分化的实验研究

目的 确定骨髓源性肝干细胞的表面标记，体外培养诱导其分化为肝细胞。方法 采用流式细胞仪检测多种大鼠肝损伤模型骨髓中干细胞标记的细胞群体的数量变化，寻找可能的肝干细胞，免疫磁珠分离各骨髓干细胞标记的细胞群体，进行体外培养诱导分化，观察细胞形态的变化，免疫组化技术检测清蛋白(白蛋白)，AFP，CK8／18等肝细胞标记的表达。结果 各模型大鼠骨髓内β2微球蛋白阴性(β2m^-)细胞显著增高，体外培养经诱导后呈多角形细胞表现，清蛋白，AFP，CK8／18表达阳性。其他干细胞类型细胞数量变化小，体外培养未见肝细胞样变化。结论 β2m^-细胞的数量随肝损伤而变化，在体外具有向肝细胞分化的能力，可能成为肝干细胞的标记物。     

骨髓间充质干细胞定向分化肝细胞及肝内移植研究

目的 观察体外诱导骨髓问充质干细胞分化及肝纤维化形成环境中移植情况。方法 首先行骨髓间充质干细胞提取、分离和培养，加入肝细胞生长因子（HGF，20μg／L）和表皮生长因子（EGF，1．5mg／L）诱导定向分化。肝纤维化形成的大鼠随机分成2组，每组10只。使用5-溴脱氧尿苷（BrdU）标记诱导的骨髓间充质干细胞，经门静脉向肝纤维化形成的SD大鼠肝脏移植，对照组用BrdU标记未经诱导的骨髓间充质干细胞。2周后通过免疫组织化学方法检测大鼠肝脏标记细胞的分布及BrdU^＋／ALB^＋细胞数量。结果 体外诱导骨髓间充质干细胞定向分化的细胞CK8及ALB表达阳性。移植2周后大鼠肝脏均可检测到BrdU标记细胞，与对照组相比诱导后骨髓问充质干细胞组BrdU^＋／ALB^＋细胞数较多，差异有统计学意义（P〈0．05）。结论 经体外诱导骨髓间充质干细胞能分化为肝细胞，移植在大鼠肝纤维化形成环境中，白蛋白表达细胞数更多。     

骨髓基质干细胞分化来源肝细胞移植的细胞准备及组织学观察

目的 探讨大鼠骨髓基质干细胞向肝细胞分化后体外标记方法及移植肝细胞的肝内组织学表现。方法 分离大鼠骨髓基质细胞，在体外诱导分化为成熟肝细胞。将5-溴脱氧尿嘧啶核苷（BrdU）掺入后的肝细胞移植入已行部分肝切除大鼠体内，分别应用免疫组织化学和免疫荧光方法观察受体肝脏内移植细胞的形态和功能。结果分化成熟肝细胞在BrdU掺入培养后细胞核染色可见特异性棕褐色标记；肝细胞移植后肝组织切片BrdU染色可定位移植细胞；白蛋白抗体染色显示移植细胞具有功能活性。结论 骨髓基质干细胞分化来源的肝细胞移植后形态功能稳定，是进行肝细胞移植的理想细胞来源。     

骨髓源性肝干细胞的筛选、扩增和分化

目的 探讨采用含淤胆血清的培养体系直接从体外全骨髓细胞培养中筛选、扩增和分化骨髓源性肝干细胞的可行性.方法 制备含不同浓度淤胆血清的条件筛选培养液,常规培养大鼠全骨髓细胞,贴壁后换用条件筛选培养液,根据筛选的结果确定最佳的淤胆血清浓度.筛选到的骨髓源性肝干细胞分别采用扩增培养液和分化培养液进行扩增和诱导分化.传代细胞应用流式细胞仪检测干细胞标记.采用免疫组织化学、RT-PCR和电镜等方法对骨髓源性肝干细胞进行形态学以及表型特征的鉴定.以糖原染色和尿素分析的方法对诱导分化的细胞进行代谢功能的测定.结果 筛选培养结果,含50 ml/L的淤胆血清培养液的筛选效果最佳:骨髓源性肝干细胞能够生存,而其他非肝干细胞因不能适应而凋亡.纯化的肝干细胞能在扩增培养体系中传代6代并且维持稳定的细胞表面特征.更换为分化培养体系后,可形成肝细胞样集落形成单位.肝细胞样集落形成单位的细胞表达胎肝细胞的标志(AFP,白蛋白和细胞角蛋白8/18),胆管细胞的标志(细胞角蛋白19),肝细胞的功能蛋白(甲状腺素转运蛋白和细胞色素P450-2 b1),以及肝细胞核因子(HNF-1α和HNF-3 β).同时具有糖原储存和尿素合成等肝细胞特有功能.结论 含淤胆血清的筛选培养液能从全骨髓细胞培养中有效地筛选骨髓源性肝干细胞,并且纯化的肝干细胞能传代6代.肝干细胞分化后能形成具有肝细胞样的表型和功能.骨髓源性肝干细胞为解决临床肝细胞治疗的肝细胞来源问题提供了一个新的方法.     

胚胎干细胞源性肝细胞的获得及体内移植研究

目的 探讨体外定向诱导小鼠胚胎干细胞(ES细胞)分化为肝细胞的方法及肝损伤模型肝内移植的可行性.方法 常规培养ES细胞后,继续悬浮培养4 d以形成拟胚体(EBs),转移EBs到铺有明胶的6孔板中贴壁培养,并添加3 mmol/L丁酸钠开始诱导分化,7 d后加入淤胆血清筛选、纯化ES源性肝细胞,分化过程中用光学显微镜和电子显微镜观察细胞形态及超微结构的改变;用逆转录-聚合酶链反应(RT-PCR)方法检测肝细胞特异性标志基因:白蛋白(ALB)、甲胎蛋白(AFP)、甲状腺素运载蛋白(TTR)、α1抗胰蛋白酶(AAT)、葡萄糖6磷酸酶(G6P)、酪氨酸转氨酶(TAT)mRNA水平的表达;以荧光示踪剂CFDA-SE标记诱导获得的肝细胞,并移植到肝损伤小鼠肝内,观察移植细胞在肝内的定居、增殖情况.结果 诱导分化过程中,ES细胞形态逐渐出现肝细胞样改变,其超微结构与小鼠肝细胞超微结构十分相似;RT-PCR结果显示,随着诱导时间的推进,标志肝细胞发育过程的ALB、AFP、TTR、AAT、G6P、TAT mRNA顺序表达;肝内移植实验结果显示:ES源性肝细胞可在肝损伤小鼠肝内定居并增殖.结论 丁酸钠联合淤胆血清可以诱导ES细胞分化为肝细胞,ES源性肝细胞肝损伤模型体内移植是可行的,这有可能为细胞移植治疗难治性肝病提供一种新的细胞来源.     

人骨髓基质干细胞向肝细胞分化过程中白蛋白的表达研究

目的观察在体外诱导人骨髓基质干细胞向肝细胞分化过程中自蛋白的表达特征。方法从手术切除弃置的人肋骨骨髓中分离基质细胞,在含有肝细胞生长因子(HGF)、淋巴细胞抑制因子(UF)、纤维母细胞生长因子(FGF)等条件培养基中培养细胞。应用免疫荧光方法在共聚焦显微镜下观察肝细胞特异性白蛋白染色;同时,于诱导培养后多时间点测定培养细胞产生的白蛋白水平。结果人骨髓来源的基质干细胞在条件培养基中经诱导后,分化为成熟附壁细胞;细胞胞浆内肝细胞特异性标志物白蛋白呈阳性染色;已分化细胞合成并分泌白蛋白,其表达水平随细胞分化显示时间依赖性变化特征。结论人骨髓基质干细胞经诱导培养后可向成熟肝细胞分化并具有合成和分泌白蛋白功能,可以作为临床肝细胞移植及生物人工肝等治疗终末期肝病的重要肝细胞来源。     

小鼠胎肝干细胞的生长和分化模式及鉴定

目的 体外培养小鼠胎肝细胞,探索其生长和分化模式,并进行干细胞特征的表型鉴定.方法 分离培养不同时期小鼠胎肝细胞,动态观察细胞形成的集落数及生长模式;收获集落进行干细胞表面标记物流式检测;传代培养胎肝细胞,探索甲胎蛋白(AFP)变化趋势及细胞分化模式.结果 经体外培养,第15天胎肝细胞形成明显集落.生长状况最好,干细胞的表面标记提示形成的集落具有肝干细胞特性.传代培养中,第15天胎肝干细胞以线性模式生长;分化模式中AFP呈现正态分布变化.结论 随胎龄增加,有干细胞特性的细胞逐渐减少.体外培养中,肝干细胞呈线性模式增殖,逆向线性方式分化.     

不同移植途径对大鼠骨髓干细胞迁移至肝脏及分化的影响

目的 探讨门静脉、尾静脉和肝动脉3种移植途径下大鼠骨髓干细胞迁移至肝脏及向肝细胞分化的情况.方法 取30只正常SD大鼠,采用2-乙酰氨基芴和四氯化碳溶液灌胃,制成急性肝损伤模型,取其骨髓,以淋巴细胞分离液分离出干细胞,再用荧光染料(PKH26)进行标记.将此30只急性肝损伤大鼠分为3组,每组10只,门静脉输注组大鼠麻醉后,取腹部正中切口,经门静脉注入自体骨髓干细胞悬液0.4 ml(4×106个,下同);尾静脉输注组大鼠经尾静脉注人自体骨髓干细胞悬液0.4 ml;肝动脉输注组大鼠麻醉后,取腹部正中切口,将胃十二指肠动脉远端结扎,用动脉夹阻断肝总动脉血流,迅速在胃十二指肠动脉结扎点前方进针,注入自体骨髓干细胞悬液0.4 ml.骨髓干细胞移植后2周,取各组肝脏组织,制成冰冻切片,再以用异硫氰基荧光素标记的抗体进行免疫组织化学染色,检测其PKH26标记阳性细胞以及自蛋白和CK18的表达情况.结果 各组大鼠肝脏切片中均可见散在的PKH26染色阳性的红色荧光,门静脉输注组、尾静脉输注组及肝动脉输注组PKH26染色阳性细胞数分别为(58.0±2.67)个、(57.8±3.04)个及(58.3±3.52)个,三组间的差异无统计学意K(P>0.05).各组肝组织切片均广泛表达白蛋白及CK18(绿色荧光),荧光显微镜下可见同时发绿色荧光和红色荧光的细胞(绿色荧光与红色荧光相叠加而成的黄色荧光).结论 经门静脉、尾静脉和肝动脉注入的骨髓干细胞均能定植于肝脏,并在损伤的肝脏中分化为肝细胞,3种途径的效果相当.     

人源性细胞大鼠体内移植的实验研究

骨髓内存在能够向肝细胞分化的干细胞的事实已被广泛接受。然而,骨髓源性肝干细胞还不能作为生物人工肝以及肝细胞移植的细胞来源进行临床应用。主要的原因是难以通过骨髓源性干细胞获取足够数量的肝细胞。本实验通过建立肝损伤的大鼠体内微环境,将人骨髓干细胞和人肝细胞系CL-1细胞移植到大鼠肝脏内,试图实现动物肝脏人肝细胞化,获取足够的人源化肝细胞,为临床肝脏移植和生物人工肝治疗提供新的思路。材料和方法采集成人骨髓10 ml,梯度密度离心法获取单个核细胞,Percoll分离液分离含有核细胞的中间层,裂解红细胞后调整细胞浓度为2×105/m…     

PKH26标记单核细胞衍生的肝样细胞体内示踪研究

目的 探讨人外周血单核细胞向肝样细胞潜能及单核细胞衍生的肝样细胞移植的有效示踪剂,并进一步观察受体鼠移植后肝样细胞存活、分布与转归情况.方法 分别设立A、B两组.A组为阴性对照组,在细胞培养过程中不添加诱导细胞分化肝细胞生长因子(HGF)和成纤维细胞生长因子-4 (FGF-4);B组应用HGF和FGF-4体外联合诱导人外周血单核细胞向肝干细胞分化.鉴定和判断细胞分化的变化,采用免疫荧光细胞化学染色法检测细胞甲胎蛋白(alpha fetoprotein,AFP)和细胞角蛋白19(cytokeratin 19,CK19)表达.以红色荧光染料PKH26标记单核细胞衍生的肝样细胞,尾静脉注入受体鼠体内作为实验组.对照组注射等量生理盐水.分别于移植2周后取肝组织,通过荧光显微镜观察实验组肝样细胞向肝脏迁移与转归的情况.采用免疫荧光细胞化学染色法检测移植的肝样细胞白蛋白(albumin,ALB)的表达.结果 A组细胞随培养时间延长,单核细胞由刚分离出的较均一的圆形逐渐变得不规则,呈条索状、纤维样改变,少部分细胞呈圆形,细胞发生凋亡,裂解.B组细胞随诱导分化培养时间延长,细胞变大、变圆,呈集落生长,增殖活性强.B组有AFP和CK19阳性表达,而A组则没有表达.动物实验组受体鼠肝组织冰冻切片可见大量PKH26标记阳性的肝样细胞,对照组未发现PKH26标记阳性的肝样细胞.移植2周后行免疫荧光细胞化学染色法检测实验组肝样细胞ALB表达阳性.结论 在HGF和FGF-4体外联合诱导条件下,人外周血单核细胞具有向肝样细胞分化的潜能.并且,PKH26可作为肝样细胞移植的一种有效示踪剂.移居肝组织的肝样细胞2周后开始向成熟肝细胞分化,发挥肝细胞功能,表达白蛋白.     

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.