复合磷酸钙骨水泥(CCPC)强化股骨颈空心螺钉扭转刚度的研究

目的评价加压空心螺钉固定时添加复合磷酸钙骨水泥(CCPC)对骨质疏松股骨颈扭转刚度的影响。方法采用16具股骨上段标本,随机分为两组:强化组和非强化组。非强化组进行加压空心螺钉内固定,强化组在进行同样内固定前,先灌入CCPC,置两组标本于NJ-50B型扭转机上,测定扭转10°、30°、90°时的扭转刚度。结果CCPC强化可显著增大空心螺钉扭转刚度,扭转角度为10°时的力矩由灌注前的(5.59±0.27)N·m升至灌注后(5.85±0.26)N·m;扭转角度为30°时的力矩,由灌注前的(6.00±0.15N·m升至(6.20±0.11)N·m,两组有显著性差异(P<0.01)。结论加压空心螺钉固定骨质疏松股骨颈时用CCPC强化能显著提高扭转刚度。     

二种胰肠吻合术吻合口创伤愈合的实验研究

目的　观察比较两种胰肠吻合方法创伤愈合过程。　方法　按吻合方法不同将动物分为捆绑式胰肠吻合组 (Ⅰ组 )和套入式胰肠端端吻合组 (Ⅱ组 ) ,分别在术中、术后 5、10d活体测定吻合口破裂压和离断力 ,并做病理观察。　结果　 (1)破裂压 :Ⅰ组 ,0、5、10d分别为 (139 7± 8 0 )mmHg、(178 7± 9 7)mmHg和 (2 6 8 8± 12 8)mmHg ,Ⅱ组则为 (6 7 3± 7 9)mmHg、(96 2± 10 4 )mmHg和 (130 6± 9 3)mmHg。Ⅰ组和Ⅱ组在 0至 5d和 5至 10d两时间段分别增加 2 7 9%、5 0 5 %和 4 2 9%、35 7% ,两组间在 0、5、10d时差异具有非常显著性 (P <0 0 1)。 (2 )离断力 :Ⅰ组 ,0、5、10d分别为 (4 5± 0 4 )N、(6 6± 0 4 )N和 (10 0± 0 6 )N ;Ⅱ组为 (4 6± 0 6 )N、(5 8± 0 5 )和 (7 1± 0 6 )N。两组在 0天时基本相同 ,但Ⅰ组在 0至 5d和 5至 10d两时间段有较快增长(44 8%和 5 2 9% ) ,两组间在 5、10d时差异具有显著和非常显著性 (P <0 0 5和P <0 0 1)。 (3)组织病理学 :Ⅰ组在 10d时吻合口已由结缔组织基本修复 ,胰腺残端断面已基本由黏膜上皮覆盖。而Ⅱ组则由肉芽组织不完全修复 ,胰腺残端断面尚无上皮再生。　结论　捆绑组 (Ⅰ组 )吻合口强度更强 ,愈合更快。     

卵巢早衰与自然绝经妇女骨密度的对比观察

目的　比较卵巢早衰 (POF)与自然绝经妇女的骨密度 (BMD)。方法　 6 3例经DEXA确诊为骨质疏松的病人分为两组 :2 9例POF为A组 ,年龄 4 8～ 76岁 (6 2 1± 7 0 ) ;34例自然绝经妇女为B组 ,年龄 5 2～ 77岁 (6 3 4± 6 0 )。应用美国Hologic公司QDR4 5 0 0 W型双能X线骨密度仪测定A组和B组腰椎及股骨颈BMD。结果　A、B两组腰椎 2 4、股骨颈BMD相比 ,有显著性差异 (P <0 0 5 )。结论　POF比自然绝经妇女骨量丢失的早并且丢失的多 ,应及早应用HRT。     

三种不同表面设计的腰椎后路椎间融合器拔出强度的生物力学比较研究

目的　评价不同表面设计的腰椎后路椎间融合器的抗拔出性能。方法　 1 2具男性青壮年新鲜尸体的L3、4节段 ,分 3组模拟后路双侧植入螺纹表面柱状椎间融合器 (Interfix) ,锯齿表面方形融合器 (Prospace)和光滑表面方形融合器 (Syncage)。每组共 4个标本 8枚融合器。在生物力学实验机上通过传感器测定各个融合器的最大拔出力并得出拔出曲线。比较试验结果并进行生物力学评价。结果　三种融合器之间的最大拔出强度分别为 6 95± 1 75N (Interfix) ;2 5 8± 6 5N (Prospace) ;1 30± 34N(Syncage)。三者之间均有统计学差异 (P <0 0 5 )。同时三种融合器的拔出曲线具有不同特征 ,其拔出斜率分别为 1 95 6± 75N/mm、 5 0 4± 2 4N/mm、 1 6 3± 7 4N/mm (按Interfix ,Prospace和Syncage的顺序 ) ,三者之间差异显著 (P <0 0 5 )。 结论　在用于测试的 3种融合器中 ,表面带螺纹的Interfix拔出强度最大 ,表面带连续锯齿的Prospace次之 ,表面光滑的Syncage最差。各融合器的拔出性能与其表面设计有关系     

SU6668抑制结肠癌生长和转移的实验研究

目的研究血管生成抑制剂SU6 6 6 8对结肠癌生长和转移的抑制作用。方法建立人结肠癌裸鼠原位种植转移模型。将荷瘤鼠 4 8只随机分为四组 ,每组 12只。种植 1周后开始 ,分别自腹腔注射生理盐水 (对照组 )、5 氟脲嘧啶 (5 Fu组 )、SU6 6 6 8制剂 (SU6 6 6 8组 )、5 Fu与SU6 6 6 8联合应用(5 Fu +SU6 6 6 8组 ) ,每天 1次 ,共用 5周。种植后第 6周末处死动物 ,测量原位肿瘤瘤重、抑瘤率、肿瘤微血管密度 (MVD)、结肠癌细胞凋亡指数 (AI) ,观察癌细胞转移及腹水出现情况。结果对照组、5 Fu组、SU6 6 6 8组、5 Fu +SU6 6 6 8组抑瘤率分别为 0、4 2 6 %、80 9%、87 2 % ;MVD分别为 (13 8± 5 2 )、(12 3± 4 5 )、(2 4± 1 5 )、(0 9± 0 5 ) ;AI分别为 (3 6± 2 4 ) %、(7 1± 5 7) %、(11 9± 3 9) %、(19 9±8 6 ) % ;腹膜转移率分别为 10 0 %、4 5 5 %、16 7%、0 ;肝转移率分别为 75 0 %、36 4 %、16 7%、0。故SU6 6 6 8组、5 Fu +SU6 6 6 8组结肠癌生长和转移受到明显抑制 (P <0 0 5 ) ,尤以 5 Fu +SU6 6 6 8组最明显(P <0 0 5 )。结论SU6 6 6 8对结肠癌生长和转移具有较强的抑制作用 ,与传统腹腔化疗药物联用可起协同抑制作用。     

腰骶椎弓根螺钉翻修及强化固定后稳定性比较

[目的]从生物力学角度评价腰骶椎弓根螺钉翻修及强化固定的稳定性。[方法]采用7具新鲜成人尸体L5S1椎体标本,于L5椎体首先置入5.5mm/45mm椎弓根螺钉,然后再置入7.0mm/55mm螺钉翻修,最后应用骨水泥强化固定;S1椎弓根置入初始螺钉为6.25mm/35mm、翻修螺钉为8.0mm/45mm、最后同样行骨水泥强化固定。在858MiniMTS生物力学实验机上分别测试各状态轴向最大拔出力及最大扭力矩。[结果](1)在L5,初始、翻修及骨水泥强化固定状态的最大把持力分别为(1680.7±242.8)N、(2410.3±366.1)N、(3273.0±688.5)N(P<0.05),最大扭力矩分别为(1006.1±205.3)N·mm、(1432.6±213.7)N·mm、(590.7±83.5)N·m(P<0.05);(2)在S1,初始、翻修及骨水泥强化的把持力分别为(926.3±274.2)N、(957.5±336.3)N、(1825.3±199.9)N,最大扭力矩分别为(667.6±88.3)N·mm、(681.4±79.4)N·mm、(558.8±97.2)N·mm;其中初始及翻修状态把持力及扭力矩均无明显差别(P>0.05),骨水泥强化固定后把持力明显增加、扭力矩明显减小(P<0.05)。[结论](1)L5椎弓根螺钉翻修时,螺钉直径增加1.5mm、长度增加10mm或骨水泥强化均可达到翻修固定的生物力学要求,增加脊椎稳定性,以骨水泥强化固定更为明显;(2)S1椎弓根螺钉翻修时,单纯增加螺钉直径和长度不能获得理想的稳定性,而骨水泥强化螺钉固定效果明显。     

大鼠两种不同供肝对原位肝移植术中和术后影响的比较

目的　比较正常 (HB)和心跳停搏 (NHB)供肝对大鼠原位肝移植术中和术后的影响。方法　雄性SD大鼠随机分成HB和NHB两组 ;NHB组又分别设心跳停搏 30min(HNB - 30 )和 4 5min(NHB - 4 5 )两组。每组各行原位肝移植 5 0、30和 30次。结果　HB和NHB组冷缺血、无肝期、肝下下腔静脉 (IVC)阻断、受体手术时间分别为 (6 9.76± 1.5 2 )min和 (70 .32± 1.5 3)min、(16 .4 6± 0 .96 )min和(16 .4 0± 0 .73)min、(2 2 .5 6± 1.73)min和 (2 2 .75± 1.16 )min、(89.38± 3.75 )min和 (90 .5 8± 3.76 )min ;术后受体苏醒和主动饮水时间分别为 (5 .4 3± 3.88)min和 (5 4 .0 6± 5 .99)min、(43.0 4± 10 .19)min和(12 6 .79± 15 .0 2 )min ;受体术后鼻粘膜出血率分别为 4 .17%和 92 .6 8% ;受体第 1周体重下降幅度分别为 (6 .15± 1.92 ) %和 (9.6 2± 1.80 ) % ;第 2周体重增加幅度分别为 (7.4 4± 2 .5 9) %和 (3.16± 1.0 4 ) %。HB组近期死因分别为原发性移植肝无功能 (PGF)、麻醉过深、肺部感染和肝上下腔静脉 (SVC)吻合口漏 ;而NHB组分别为PNF、麻醉过深、无肝期较长 (>17min)和再灌注后供肝渗血 ;HB和NHB - 30、NHB - 4 5组术后 1周存活率分别为 90 %、5 0 %和 30 %。结论　NHB较HB术中操作更复杂 ,更需     

双加压螺钉治疗股骨颈骨折

我科自 1990年 2月～ 1999年 1月应用电视Ｘ线机下复位 ,空心加压螺钉加折断式加压螺钉固定 ,同时辅助口服复元活血汤治疗股骨颈骨折。通过对84例进行随访 ,疗效满意。1　材料与器械股骨颈空心加压螺钉 ,螺纹直径 6ｍｍ ,螺纹长度 30～ 4 0ｍｍ ,杆长 85～ 12 0ｍｍ(螺距 5ｍｍ) ;折断式加压螺钉 ,螺纹直径 4ｍｍ ,螺纹长度 30～ 35ｍｍ ,杆长 70～ 115ｍｍ(螺距 5ｍｍ)。以上两钉材质相同。与以上固定材料相配套的有套筒旋入器 ,直径 3.5ｍｍ钻头 ,直径 4ｍｍ斯氏针 2枚 ,直径 2ｍｍ等长带刻度的克氏针 2枚等。2　临床资料2 1　一般资料　…     

可降解壳聚糖血管外周支持与静脉移植物早期结构的变化

目的　探讨可降解壳聚糖血管外周支持 (CES)对静脉移植物 (VG)早期结构变化的影响 ,为临床提高VG通畅率提供新的治疗方法。　方法　将兔右颈内静脉端 端吻合于同侧颈总动脉建立静脉移植模型 ,以有无CES干预分为支架组与无支架组 (每组 2 4只兔 )。术后 1、2、4周分别切除移植静脉 ,计算机图像分析系统测量和计算内膜、中膜厚度和面积 ,免疫组织化学法检测增殖细胞核抗原 (PCNA)指数观察平滑肌细胞增殖程度。　结果　CES在术后 2周开始降解。支架组VG ,术后 1～ 2周内膜、中膜的厚度和面积、PCNA指数在术后 1周轻度增加 ,1～ 2周维持稳定 ,术后 2周分别为(2 6 3± 3 7) μm、(2 6 0± 1 9) μm、(0 5 6± 0 0 8)mm2 、(0 34± 0 0 5 )mm2 与 (11 5± 2 1) % ,明显低于无支架组的 (5 6 4± 9 4 ) μm、(47 6± 4 9) μm、(1 17± 0 0 8)mm2 、(1 2 0± 0 4 3)mm2 与 (36 6± 2 9) % (P <0 0 1) ;术后 4周虽然又增加 ,分别为 (31 7± 1 6 ) μm、(31 7± 1 6 ) μm、(0 72± 0 12 )mm2 、(0 4 2± 0 0 6 )mm2 与 (13 4± 1 2 ) % ,但仍低于无支架组的 (76 8± 8 0 ) μm、(5 7 4± 9 5 ) μm、(1 2 7± 0 17)mm2 、(1 2 7± 0 0 9)mm2 与 (16 8± 2 2 ) % (P <0 0 5 )。结论　CES     

毒蕈碱受体亚型介导逼尿肌细胞收缩与IP3关系的实验研究

目的　探讨信使分子IP3 在毒蕈碱受体亚型M3 R介导逼尿肌细胞收缩中的作用。　方法　MR非选择性激动剂 (carbachol)、拮抗剂 (atropine)及M2 R拮抗剂 (methoctramine)、M3 R拮抗剂 (4 DAMP)刺激原代培养人逼尿肌细胞 ,通过 [3 H]掺入法 ,检测磷脂酰肌醇 (PI)代谢产物 [3 H] IP含量。　结果　 [3 H] IP含量随carbachol刺激浓度增加而增加 ;10 -9、10 -8、10 -7、10 -6、10 -5、10 -4mmol/L的 4 DAMP抑制carbachol后 ,[3 H] IP含量分别为 392 6 .5 7± 2 73.2 9、2 780 .5 2± 2 11.0 9、2 4 36 .84± 15 3.6 2、1973.2 2± 16 4 .71、1372 .38± 14 1.35及 110 7.98± 92 0 .4 5cpm ,相同浓度的at ropine作用后 ,[3 H] IP含量分别为 36 0 2 .6 9± 2 80 .17、2 891.31± 2 0 7.4 5、1983.97± 14 5 .74、12 6 9.5 7± 10 5 .31、110 6 .37± 75 .2 3、92 7.5 0± 77.36cpm ;而相同浓度的methoctramine作用后 ,[3 H] IP含量分别为 4 4 6 2 .74± 36 0 .6 9、3938.6 1± 32 7.13、3315 .4 5± 2 70 .36、30 6 3.19± 2 4 6 .79、2 92 7.37± 2 2 6 .4 5及 2 836 .5 5± 2 4 1.6 3cpm ,两者之间差异有非常显著性意义 (P <0 .0 1) ,表明 4 DAMP和atropine能显著抑制carbachol诱导的代谢反应 ,而methoctram     

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.     

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.     

Risiko Schlaganfall — Öffentlichkeitsarbeit und Aufklärung dringend erforderlich

Zusammenfassung Das wesentliche — und zugleich noch wenig ausgeschöpfte — Potenzial der Schlaganfallmedizin liegt in der langfristigen Prophylaxe. Durch Beeinflussung von Lifestylefaktoren wie Ernährungsgewohnheiten, Zigarettenkonsum und körperlichem Training durch entsprechende Aufklärung ließe sich ein erheblicher Teil an zerebralen Ereignissen vermeiden. Ein weiterer in Deutschland noch zu wenig beachteter Faktor ist die konsequente Blutdruckeinstellung. Breitgestreute Aufklärung könnte außerdem potenziellen Patienten helfen, bereits auftretende Warnsymptome wie die transiente ischämische Attacke richtig einzuschätzen, um eine rechtzeitige Behandlung zu ermöglichen.