下颈椎后路3种固定技术的拔出强度研究

目的评价下颈椎后路侧块螺钉、椎弓根螺钉、经关节螺钉3种固定方法的拔出强度。方法6具新鲜颈椎尸体标本（C3～C7）,分别用侧块螺钉Roy-Camille法（LMS）、椎弓根螺钉（TPS）和经关节螺钉植入法（TAS）拧入螺钉,使用万能材料实验机,以100、200、300、400、500、600N分级加载,以18mm/min加载速度进行螺钉拔出实验,测试其最大拔出力、最大拔出能量。结果LMS最大拔出力为（426±38）N,最大拔出能量为（5.26±0.39）J;TPS最大拔出力为（502±42）N,最大拔出能量为（7.18±0.67）J;TAS最大拔出力为（482±40）N,最大拔出能量为（6.68±0.47）J。LMS的最大拔出力和最大拔出能量均小于TPS和TAS（P〈0.05）,而TPS和TAS之间相近,差异无统计学意义（P〉0.05）。结论经关节螺钉拔出强度优于侧块螺钉,而椎弓根螺钉拔出强度最大。     

两种长度的颈椎椎弓根螺钉与侧块螺钉拔出试验比较

目的:比较两种长度的颈椎椎弓根螺钉和侧块螺钉的抗拔出力,探讨颈椎经椎弓根短螺钉固定的可行性。方法:5具C3~C5共15节新鲜颈椎标本,用长度为28mm和20mm的皮质骨螺钉分别置入椎弓根,并用20mm的螺钉行侧块双皮质固定,螺钉进入侧块深度约14mm。行拔出试验,比较螺钉的最大轴向拔出力。结果:椎弓根长螺钉的最大拔出力为650N,椎弓根短螺钉为585N,两者比较无显著性差异(P>0.01);侧块螺钉的最大拔出力为360N,与椎弓根短螺钉比较有显著性差异(P<0.0001)。结论:颈椎椎弓根短螺钉固定可提供足够的稳定性,其安全性相对较高。     

下颈椎前路椎弓根螺钉固定系统与普通前路椎体螺钉固定系统的静力学比较

目的：比较下颈椎前路椎弓根螺钉（ATPS）锁定固定系统和普通前路椎体螺钉（VBS）锁定固定系统的静力学特性。方法：采集新鲜颈椎标本16具,分解为C3.,4,C4,5,C5,6,C6,7共32个运动节段（functionalspinalunit,FSU）,其中C3,4,C4,5,C5,6,C6,7各8个。将其按照不同节段随机分成A、B两组,对所获标本椎间盘切除后模拟植骨,分别植入自行设计生产的下颈椎前路椎弓根螺钉配套钢板系统和普通颈椎前路椎体螺钉钢板系统。在生物力学试验机上行钢板的垂直拔出强度试验。结果：下颈椎前路椎弓根螺钉的最大轴向拔出力为（604．68±48．76）N,椎体螺钉为（488．24±32．42）N,两者比较差异有统计学意义（t=2．147,P〈0．05）,前路椎弓根螺钉固定系统与椎体螺钉固定系统在各FSU间差异无统计学意义（A组和B组的F值分别为2．27、2．05,P〉0．05）。结论：下颈椎前路椎弓根螺钉钢板系统的拔出力明显优于普通前路椎体螺钉钢板系统,从生物力学角度上来看具有应用可行性。     

颈椎椎弓根皮质骨螺钉固定的钉道影像学测量与生物力学研究测试

【摘要】 目的：探讨颈椎椎弓根皮质骨螺钉在临床使用可行性、钉道的参数和置钉后生物力学分析。方法：随机选取我院2014年1月～2018年6月住院行颈椎CT三维重建的住院患者CT资料30例,男性16例,女性14例,年龄30～60岁（48.0±5.6岁）,采集患者颈椎（选取C4～C6）CT连续扫描数据,测量每个椎弓根的形态学数据：椎弓根高度和宽度;并在图像处理系统上模拟皮质骨螺钉的钉道轨迹,测量每个钉道的侧倾角和头倾角,计算各个椎体皮质骨螺钉置入的角度范围。选用18具完整的成人新鲜颈椎标本（选取C4～C6）,将每一节段颈椎标本左右两侧椎弓根各作为一个测试单元进行随机置钉,置入传统椎弓根螺钉为A组,置入皮质骨通道的螺钉为B组。再将置好螺钉的颈椎标本进行CT平扫,测量并记录A、B组螺钉的平均固定长度,根据Grade标准评估置钉等级。将颈椎标本固定在特制的夹具上,生物力学测试前通过旋转夹具底座的方法来调整螺钉与夹具的角度,检测螺钉的最大垂直轴向拔出力,比较两组结果。结果：30例住院患者C4高度为7.3±0.8mm、宽度为5.5±0.3mm;C5高度为7.4±0.6mm、宽度为5.8±0.2mm;C6高度为7.6±0.6mm、宽度为6.2±0.3mm。模拟置钉测量C4侧倾角为39.5°±2.3°、头倾角为10.3°±0.4°;C5侧倾角为39.3°±1.3°、头倾角为10.9°±0.5°;C6侧倾角为37.6°±0.9°、头倾角为11.7°±0.3°。新鲜颈椎标本CT扫描重建,两组螺钉Grade置钉等级,A组1级52枚,2级2枚,B组1级51枚,2级3枚,差异无统计学意义（P>0.05）。A组的平均固定长度C4为34.2±1.8mm,C5为34.3±2.3mm,C6为34.6±1.9mm;B组的平均固定长度C4为23.3±1.4mm,C5为24.3±2.1mm,C6为25.7±1.3mm,差异无统计学意义（P>0.05）。A组最大拔出力为521.2±15.6N;B组最大拔出力为527.4±18.9N;两组的最大拔出力差异无统计学意义（P>0.05）。结论：CT扫描、图像模拟显示颈椎皮质骨螺钉置入安全可行;颈椎皮质骨螺钉的拔出力与传统椎弓根骨螺钉相比,固定长度差异不大,拔出力相当。     

颈椎经关节椎弓根螺钉固定与标准椎弓根螺钉固定的生物力学比较

目的 比较颈椎经关节椎弓根螺钉固定和标准椎弓根螺钉固定的拔出强度.方法 取10具新鲜尸体颈椎标本(C_3～T_1),游离成三个颈椎运动节段(C_(3,4),C_(5,6),C_7T_1).在椎体两侧随机进行经关节椎弓根螺钉固定或标准椎弓根螺钉固定,置入直径3.5 mm皮质骨螺钉.经关节椎弓根螺钉固定以上位椎骨侧块外下象限中点为进钉点,在直视椎弓根下,螺钉在冠状面内倾约45°、矢状面尾倾约50°.由上位椎骨下关节突经关节突关节、下位椎骨的椎弓根,进入下位椎骨的椎体内.标准椎弓根螺钉固定以侧块外上象限中点为进钉点,在直视椎弓根下,螺钉方向参考CT测量结果 ,尽量与椎弓根倾斜角度保持一致,在横断面上内倾约45°、矢状面上螺钉指向椎体的上1/3.在生物力学试验机上行拔出强度试验,比较两种螺钉固定的最大轴向拔出力.结果 颈椎经关节椎弓根螺钉固定平均最大轴向拨出力为(694±42)N,标准椎弓根螺钉固定为(670±36)N,两者比较差异有统计学意义(P<0.05).结论 颈椎后路经关节椎弓根螺钉固定的拔出强度大干标准椎弓根螺钉固定,从生物力学强度方面考虑经关节椎弓根螺钉固定可以作为标准椎弓根螺钉固定的一种补充方法.     

经骶1-2侧块螺钉固定的最大拔出力测定

【摘要】 目的：测量经骶1-2侧块螺钉固定的最大拔出力,初步探讨该内固定方法的有效性。方法：8具甲醛溶液固定湿润成人骶骨标本,采用双能X线吸收测定仪（dual-energy X-ray absorptiometry, DEXA）测定S1椎体骨密度。在同一骶骨标本上随机置入3种骶骨螺钉：经骶1-2侧块螺钉（A组）、S1椎弓根螺钉（B组）、S1前外骶骨翼螺钉（C组）。将标本固定于858型MTS材料试验机上,对螺钉施加轴向拔出力,根据3种骶骨螺钉轴向拔出实验的数据绘制力（N）-位移（mm）曲线,取曲线的顶点作为最大拔出力数值。应用SPSS 16.0统计软件对3组骶骨螺钉的最大拔出力数值行方差分析。结果：8具骶骨标本S1椎体骨密度为0.43～0.74g/cm3,平均0.641±0.275g/cm3。3种骶骨螺钉固定的螺钉即刻平均最大拔出力：A组为379.62±73.10N,B组为829.12±170.74N,C组为230.62±98.52N,3组之间两两比较差异有统计学意义（P＜0.05）。结论：经骶1-2侧块螺钉固定的最大拔出力低于S1椎弓根螺钉固定,但高于S1前外骶骨翼螺钉固定,当S1椎弓根螺钉固定不能施行时,骶1-2侧块螺钉固定可作为一种有效的选择。     

下颈椎后路经关节螺钉内固定的解剖学研究

目的明确下颈椎后路经关节螺钉固定的技术参数，为临床应用提供参考。方法取20具（男14具、女6具）尸体颈椎标本，仔细解剖颈部的后侧和侧前方，以清晰地暴露颈椎侧块，保护好脊神经前、后支（C2-7）及其与周围结构的关系。确定安全的进、出钉点，从C2.3-C5.6直视下置人经关节螺钉。通过CT重建，测量经关节固定螺钉的角度、长度、螺钉尖与椎动脉的距离，并确定经关节螺钉矢状面的安全进钉角度（sagittal safety angle，SSA）。结果经关节固定螺钉方向在矢状面呈尾倾，冠状面呈外倾，各固定节段间略有不同，但差异无统计学意义（P〉0．05）。下颈椎后路经关节螺钉固定的理想角度为在矢状面尾倾平均37.3^o±5．0^o，在冠状面外倾平均16．6^o±4．6^o。经关节螺钉钉道长度平均为（18．7±1.4）mm，在C2.3，水平螺钉钉道长度与C3.4C4.5C5.6比较差异有统计学意义（P〈0．05）。后路经关节螺钉矢状面安全进钉角度为41．9^o±5．6^o，螺钉钉尖与椎动脉的距离平均为（5．8＋1．5）mm，各固定节段间略有不同，但差异无统计学意义（P〉0．05）。结论下颈椎后路经关节螺钉置钉时要求一定的准确性，可以作为颈椎侧块螺钉和椎弓根螺钉固定的一种补充内固定方法。     

椎弓根螺钉把持椎弓根皮质骨对其固定强度的影响

目的：了解椎弓根螺钉把持椎弓根皮质骨对椎弓根螺钉固定强度的影响。方法：将成年羊腰椎椎弓根48个依据椎弓根皮质骨内径和椎弓根螺钉直径（6．25mm）的相对关系分为三组：A组，螺钉直径小于椎弓根皮质骨内径：B组．螺钉直径超出椎弓根皮质骨内径0.01～0．50mm；C组，螺钉直径超出椎弓根皮质骨内径0.51～1．00mm。每组再根据进钉深度与椎弓根长度（平均约8mm）的相对关系分为Ⅰ（进钉深度为16mm）、Ⅱ（进钉深度为8mm）两组。将椎弓根螺钉置入椎弓根中，观察钉道结构、膨胀情况，测量椎弓根螺钉最大轴向拔出力。结果：椎弓根螺钉置入后，椎弓根发生不同程度膨胀；椎弓根螺纹能够切入皮质骨中；C Ⅰ组最大轴向拔出力比A Ⅰ组和B Ⅰ组大（P〈0．05），C Ⅱ组最大轴向拔出力比A Ⅱ组和B Ⅱ组大（P〈0．05），B Ⅱ组比A Ⅱ组大（P〈0.05）。结论：椎弓根螺钉把持椎弓根皮质骨能够增加椎弓根螺钉的固定强度；且椎弓根螺钉把持椎弓根皮质骨量越大，固定强度越大。     

寰椎后路单或双层皮质骨螺钉固定强度的生物力学评价

目的:测量单层皮质骨和双层皮质骨寰椎侧块螺钉固定与寰椎椎弓根螺钉固定的强度,为临床选择寰椎后路螺钉固定的方式提供生物力学依据。方法:利用12例新鲜的寰椎和第三颈椎标本,进行单层皮质骨和双层皮质骨的椎弓根螺钉或侧块螺钉固定,测试并比较其螺钉拔出强度。结果:双层皮质骨寰椎椎弓根螺钉固定的拔出力最大,为1757.0±318.7N;单层皮质骨寰椎椎弓根螺钉固定(1192.5±172.6N)与双层皮质骨寰椎侧块螺钉固定(1243.8±350.0N)及单层皮质骨C3椎弓根螺钉固定(1121.6±224.6N)的拔出力之间均无明显差异。结论:应用寰椎侧块螺钉固定时宜选用双层皮质骨螺钉固定,而寰椎椎弓根螺钉固定选用单层皮质骨螺钉即可。     

下颈椎经关节螺钉钉棒系统固定的生物力学研究

目的：比较下颈椎三柱损伤后单独经关节螺钉固定（TAS）、经关节钉棒系统同定（TRS）和侧块螺钉钉棒系统固定（LRS）的三维稳定性。方法：12具新鲜颈椎标本．制成C4／5、C5／6节段三柱损伤模型，分别进行单独经关节螺钉（TAS组）、经关节螺钉钉棒系统（TRS组）和侧块螺钉钉棒系统（LRS组）三种方法固定，在非限制性和非破坏性的实验条件下测试其前屈、后伸、左右侧弯和轴向旋转运动状态的稳定性。结果：TAS组和TRS组在各方向的运动范同（ROM）和中性区（NZ）的均数均显著小于完整标本组，差异有统计学意义（P〈0．05）；LRS组在前屈、后伸、侧弯运动中的ROM和NZ与完整标本组比较有显著降低，差异有统计学意义（P〈0．05）；LRS组在旋转运动中的ROM和NZ与完整标本组比较有不同程度的降低，但差异无统计学意义（P〉0．05）。TAS、TRS在各个方向稳定性明显优于LRS组（P〈0．05）。TRS在前屈运动中的ROM和NZ与TAS组比较有所减小，但无统计学意义（P〉0．05）；在后伸、侧弯和旋转运动中，TRS组稳定性明显优于TAS组，有统计学意义（P〉0．05）。结论：在下颈椎三柱损伤选择经关节固定技术时以钉棒形式同定稳定性更好。     

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.