腹腔镜下肝切除术的临床疗效及对细胞免疫功能的影响

目的:分析腹腔镜下肝切除术的临床疗效及对细胞免疫功能的影响。方法:回顾分析97例行肝切除术肝癌患者的临床资料,分为观察组(n=48,行腹腔镜下肝切除术)与对照组(n=49,行开腹肝切除术)。对比两组术中指标、术后近期疗效、远期疗效、并发症发生情况及手术前后不同时间点的外周血淋巴细胞亚群、血清白介素-6(interleukin-6,IL-6)、肿瘤坏死因子-α(tumor necrosis factor-α,TNF-α)表达水平。结果:两组转移率、复发率、死亡率、并发症发生率差异均无统计学意义(P0.05);术后72 h,观察组CD3、CD4、CD8、IL-6、TNF-α表达水平基本恢复至术前水平,对照组CD3、CD4、CD8仍低于术前水平,IL-6、TNF-α仍高于术前水平,差异有统计学意义(P0.05)。结论:腹腔镜下肝切除术治疗肝癌的临床疗效确切,创伤小,安全性较高,近期疗效优于开腹肝切除术,且对患者的细胞免疫功能影响小,术后康复快。     

腹腔镜直肠前切除术对机体和局部免疫应激反应的影响

目的:比较腹腔镜和开腹直肠前切除术对患者机体和局部免疫应激反应的影响.方法:选择同期腹腔镜和开腹直肠前切除术患者各25例,于术前1 d和术后第1、3、5 d测定血清IL-6、IL-8、C反应蛋白、TNF-α.术后第1、2、3 d测定腹腔引流液中IL-6、IL-8、TNF-α.结果:腹腔镜组术后血清IL-6、C反应蛋白水平明显低于开腹组(P<0.05),但腹腔引流液中IL-6、IL-8水平未见明显差别(P>0.05).结论:腹腔镜直肠前切除术相对开腹手术对机体全身的免疫功能影响小,但对患者局部免疫应激反应的影响差异无显著性意义.     

腹腔镜与开腹结直肠癌根治术对机体免疫系统影响的比较研究

目的:比较腹腔镜手术与传统开腹手术对患者免疫机能的影响。方法:2006年12月至2007年7月收治结直肠癌患者60例,分别行腹腔镜手术和开腹手术各30例,于术前1d和术后第3天、第7天抽取外周静脉血,比较两组患者的C反应蛋白,IgA,IgM,IgG,IL-6,CD3+,CD4+,CD8+细胞和NK细胞,比较术前1d和术后第1天、第3天TNF-α细胞活性。结果:术后第3天患者CD3+,CD4+,CD8+细胞活性及CD4+/CD8+差异无显著性,但术后第7天腹腔镜较开腹组明显低。术后第3天IL-6开腹组明显高于腹腔镜组。C反应蛋白于术后第3天开腹组高于腹腔镜组。IgM于术后第3天开腹组高于腹腔镜组,IgA、IgG无显著统计学意义。TNF-α于术后第3天开腹组高于腹腔镜组。结论:腹腔镜结直肠癌根治术较传统开腹手术对机体免疫机能影响较小。     

腹腔镜辅助与开腹进展期胃癌根治术对机体免疫功能影响的比较

目的:腹腔镜辅助下与开腹行进展期胃癌根治术对机体免疫功能的影响.方法:将94例进展期胃癌患者按意愿分为腹腔镜组(n=47)与开腹组(n=47),测定2组术前及术后第3、7、14天患者血清IL-6、CRP、IgG、IgM、IgA、CD3+、CD4+,CD8+,CD4+/CD8+、人类白细胞抗原Ⅱ型(HLA-DR)、中性粒细胞(PMN)的数量.结果:2组术后第3天免疫球蛋白较术前均降低(P<0.05),开腹组术后第7天免疫球蛋白较术前低(P<0.05),腹腔镜组术后第7天免疫球蛋白较术前比较差异无统计学意义(P>0.05),除术后第3、7天IgM腹腔镜组高于开腹组(P<0.05),2组间IgA、IgG术后差异无统计学意义(P>0.05);2组术后第3、7天2组IL-6、CRP较术前明显升高(P<0.01),开腹组升高较腹腔镜组更明显(P<0.01);术后第3、7、14天腹腔镜组HLA-DR较术前明显升高(P<0.01),2组间差异有统计学意义(P<0.01,表5);2组术后第3天PMN较术前明显升高(P<0.01);2组外周血CD3+、CD4+,CD4+/CD8+术后第7、14天较术前均明显下降(P<0.01),术后腹腔镜组明显高于开腹组(P<0.01),且腹腔镜组较早恢复正常.结论:与开腹手术相比,腹腔镜手术对机体术后的免疫功能影响小,术后恢复快.     

三孔法腹腔镜与开腹直肠癌根治术后应激及免疫功能的对比研究

目的:比较三孔法腹腔镜与开腹直肠癌根治术对应激及免疫功能的影响。方法:选取2013年6月至2014年4月收治的直肠癌患者,其中26例行改良三孔法腹腔镜直肠癌根治术(三孔组),47例行开腹直肠癌根治术(开腹组)。两组患者分别于术前1 d及术后第1天、第3天、第7天清晨抽取外周静脉血,测定白细胞介素-6(interleukin-6,IL-6)、肿瘤坏死因子-α(tumor necrosis factor,TNF-α)、C反应蛋白(C-reactive protein,CRP)、免疫球蛋白A(immunoglobulin A,Ig A)、免疫球蛋白G(immunoglobulin G,Ig G)、免疫球蛋白M(immunoglobulin M,Ig M)及CD4+、CD8+水平的变化。结果:术前两组患者血清学检测指标差异均无统计学意义(P0.05)。术后第1天、第3天,IL-6、TNF-α逐渐升高,此后下降,三孔组术后第3天IL-6、TNF-α水平明显低于同期开腹组(P0.05)。术后CRP水平均升高,且术后第3天达到峰值;术后第7天,三孔组明显低于同期开腹组,差异有统计学意义(P0.05)。两组患者术后Ig A、Ig G、Ig M及CD4+、CD8+含量较术前降低;术后第3天,三孔组Ig M含量明显高于同期开腹组,差异有统计学意义(P0.05);术后第7天,CD4+、CD8+水平明显高于同期开腹组,差异有统计学意义(P0.05)。结论:与开腹手术相比,三孔法腹腔镜直肠癌根治术患者的应激反应轻,免疫抑制程度低,进一步体现了腹腔镜手术的优越性。     

腹腔镜和开腹直肠癌全直肠系膜切除对机体免疫功能的影响

目的比较经腹腔镜和开腹行直肠癌全直肠系膜切除保留肛门手术对患者免疫功能的影响。方法将 37例行直肠癌全直肠系膜切除保肛术患者分为开腹组 (n =2 1)和腹腔镜组 (n =16 ) ,于术前 1天、术后第 1天、术后第 5天检测血清IL 2、IL 6、TNFα值。术前 1天和术后第 5天检测全血CD3 CD5 6 T细胞和CD3-CD5 6 NK细胞的百分比 ,血清免疫球蛋白IgG、IgM、IgA值。IL 2、IL 6、TNFα值的检测用酶联免疫吸附法 (ELISA) ,Ig的测定用免疫散射比浊法 ,CD3 CD5 6 T细胞和CD3-CD5 6 NK细胞用流式细胞仪进行检测。结果两组手术对CD3 CD5 6 T细胞、CD3-CD5 6 NK细胞、IL 2、IL 6、TNFα和免疫球蛋白的影响差异无显著性意义 (P >0 0 5 )。结论腹腔镜和开腹直肠癌全直肠系膜切除术对患者免疫功能的影响差异无显著性意义。     

腹腔镜与开腹肝癌左外叶切除术对患者围术期指标、免疫功能及术后康复的影响

目的观察腹腔镜与开腹肝癌左外叶切除术对患者围术期指标、免疫功能及术后康复的影响。方法回顾性分析2014年1月～2019年3月于本院行左外叶肝癌切除术患者临床资料,经倾向性匹配后得到腔镜组(行腹腔镜肝左外叶切除术)与开腹组(行开腹肝左外叶切除术)各46例,比较两组围术期指标,分析两组术前1d、术后第1天、术后第3天细胞免疫淋巴细胞亚群(CD3、CD19、NK、CD4/CD8)及体液免疫免疫球蛋白(IgG、IgA、IgM)变化,同时对比两组术后康复情况及并发症发生情况。结果腔镜组手术切口长度、术中失血量及术后镇痛药使用时间均显著低于开腹组(P0.05);两组术后第1天细胞免疫指标(CD3、CD19、NK、CD4/CD8)、体液免疫指标(IgA、IgM、IgG)均显著低于术前1d(P0.05),术后第3天,两组上述指标均有回升趋势,但腔镜组CD3、CD19、NK、CD4/CD8及血清IgA、IgM、IgG水平均显著高于开腹组(P0.05);腔镜组术后疼痛评分、术后首次排气时间、首次下床活动时间、首次进食流食时间、腹腔引流管拔除时间及术后住院时间均显著低于开腹组(P0.05);腔镜组术后并发症总发生率10.87%,显著低于开腹组的30.43%(P0.05)。结论腹腔镜肝癌左外叶切除术相较传统开腹手术而言,能减轻患者创伤,降低手术对患者免疫功能的影响,利于术后恢复,同时减少并发症发生几率。     

腹腔镜肝癌切除术对患者术后临床康复和体液免疫影响的临床对照研究

目的探讨腹腔镜与开腹肝癌切除术对患者临床康复和体液免疫功能的影响。方法选取2010年1月至2012年6月期间徐州医学院附属医院、江苏省肿瘤医院及南京中医药大学第二附属医院行腹腔镜及开腹肝癌左外叶切除术患者44例,其中腹腔镜组22例,常规开腹组22例。采用ELISA法测定患者术前1 d以及术后第l天和第5天外周血中IgG、IgA、IgM、C3、C4、C反应蛋白（CRP）、IL-2、IL-6及TNF-α水平的变化,同时比较2组患者的手术时间、术中出血量、住院时间及并发症发生情况。结果腹腔镜组患者术后镇痛剂使用时间为（1.9±0.8）d,首次进食时间为（2.2±0.5）d,住院时间为（6.3±1.3）d,均短于开腹组（P〈0.05）,但2组间的手术时间、术中失血量、并发症发生率及死亡率差异均无统计学意义（P〉0.05）。与术前相比,术后第1天2组患者的C3、C4、lgA、IgG、lgM和IL-2均明显降低（P〈0.05）,CRP、IL-6及TNF-α均明显升高（P〈0.05）;开腹组患者术后第l天的C3、C4、lgA、IgG、lgM和IL-2的下降幅度较腹腔镜组更明显（P〈0.05）。术后第5天,腹腔镜组患者的C3、C4、lgA、IgG、lgM及IL-2水平上升和CRP、IL-6及TNF-α水平下降并均接近术前水平;而开腹组患者的C3、C4、lgA、IgG、lgM及IL-2仍低于术前水平（P〈0.05）,CRP、IL-6及TNF-α仍仍高于术前水平（P〈0.05）。结论腹腔镜肝癌切除术后患者的恢复较快,且对患者机体体液免疫功能的影响小于开腹肝癌切除术。     

腹腔镜与开腹结直肠癌手术对机体应激反应及细胞免疫功能影响的比较

比较腹腔镜与开腹结直肠癌根治术对机体应激反应及细胞免疫功能的影响,为腹腔镜手术在结直肠肿瘤中的优势提供依据。选择同一手术组的结直肠癌患者45例,随机分为腹腔镜手术组21例(LCR组)和开腹手术组24例(OCR组),分别在术前1 d和术后第1、6天取外周静脉血,测定CRP、血清淀粉样蛋白A(SAA)、IL-6水平和CD3+、CD4+、CD8+细胞并进行比较。术后第1、6天LCR组的CRP、SAA、IL-6均明显低于OCR组,2组比较差异均有统计学意义(P0.01);术后第6天OCR组的CD3+、CD4+、CD4+/CD8+明显低于LCR组,2组比较差异有统计学意义(P0.01);2组患者手术前后不同时相点的CRP、SAA、CD3+、CD4+、CD4+/CD8+组内比较,差异均有统计学意义(P0.01),LCR组IL-6在术后第1天明显高于术前(P0.01),第6天接近术前水平(P0.05)。腹腔镜结直肠癌根治术对机体细胞免疫功能和应激反应的影响明显小于开腹手术。     

肝癌腹腔镜肝切除术的临床疗效及其对患者血清MIF、免疫炎症因子水平的影响

目的探讨肝癌腹腔镜肝切除术的临床疗效及其对患者血清MIF、免疫炎症因子水平的影响。方法回顾性分析深圳市人民医院2014年1日至2017年10月收治的原发性肝癌50例,其中行腹腔镜肝切除术24例(腹腔镜组)和开腹肝切除术26例(开腹组),比较两组术中总出血量、手术总时间、镇痛剂使用时间、平均住院时间等临床疗效指标,以及术前第1天和术后第1天、第5天的静脉血清巨噬细胞游走抑制因子(MIF)、白介素-1β(IL-1β)、白介素-8(IL-8)、白介素-10(IL-10)和肿瘤坏死因子-α(TNF-α)的水平。结果两组的手术期总出血量、手术切口长度、镇痛剂使用时间、首次进食时间、平均住院时间比较,均具有统计学差异(P0.05);但两组的手术总时间、肝门阻断时间、术后并发症发生率比较无统计学差异(P均0.05)。术后第5天,腹腔镜组血清IL-1β、IL-8、IL-10和TNF-α水平基本恢复至术前水平,而开腹组仍处于高水平状态(P均0.05);两组MIF水平无明显差异,但腹腔镜组比开腹组能较快地降低MIF水平。结论腹腔镜肝切除术治疗肝癌临床效果可靠,且能较快降低血清恶性肿瘤指标,减少刺激机体的免疫学炎症因子水平。     

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.     

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.     

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.     

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.     

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.