胰十二指肠切除术中连续胰肠吻合和Y形空肠内引流的应用

目的评价连续胰肠吻合和Y形空肠内引流在胰十二指肠切除术中的应用,并与传统的胰十二指肠切除术进行比较。方法本组回顾2004年12月至2006年12月间行胰十二指肠切除患者103例,其中接受连续胰肠吻合和Y形空肠内引流的患者55例作为观察组,传统胰十二指肠切除术后捆绑式胰肠吻合的患者48例作为对照组。对两组的手术时间、术中出血量、术后胰漏、术后并发症和术后住院时间以及住院费用等方面的差异进行前瞻性研究。结果两组在手术中出血量及手术后并发症比较没有统计学意义,但在手术时间、术后胰瘘、术后住院时间等方面有统计学意义(P<0.05)。结论相对于传统的胰十二指肠切除术中捆绑式胰肠吻合重建方式,连续胰肠吻合和Y形空肠内引流手术方式较容易掌握,且在术后管理上具有较为明显的优势。     

胰十二指肠切除术不同胰肠吻合方式的选择与效果评价

目的评价不同胰肠吻合方式在胰十二指肠切除术中的临床疗效,探讨不同胰肠吻合方式的适用性。方法回顾性分析2012年1月至2014年8月收治的117例行胰十二指肠切除术患者临床资料,按吻合方式不同分为胰管空肠黏膜吻合(A组,61例)和捆绑式胰肠吻合(B组,56例),比较两种不同胰肠吻合方式术后胰漏及相关并发症的发生率。结果胰肠黏膜吻合组胰腺残端直径明显大于捆绑式胰肠吻合组(t=7.441,P0.05),捆绑式胰肠吻合组胰肠吻合时间明显小于胰肠黏膜吻合组(t=3.085,P0.05)。两组患者术后胰漏、腹腔出血、腹腔感染、胃潴留、肺部感染、平均住院时间及费用,差异无统计学意义(x2=0.257,0.308,0.737,0.896,1.096;t=1.211,1.477;P0.05)。结论胰管空肠黏膜吻合法和捆绑式胰肠吻合法是胰十二指肠切除术两种主要吻合方法,都能有效降低胰漏的发生率,应根据术中探查结果,合理灵活选择不同吻合方式。     

一种简易胰肠套入捆绑式吻合术式的临床应用观察

目的 探讨胰十二指肠切除术简易的胰肠套入捆绑式吻合方法的临床应用价值.方法 回顾性分析2003年5月至2013年5月在我院行胰十二指肠切除术56例患者的临床资料,其中残胰重建方式为简易胰肠套入捆绑式吻合方式手术者32例（简易组）,胰空肠端端常规套入吻合手术者24例（常规组）;比较两组的胰肠吻合手术时间、术中出血量、术后住院时间等情况;并根据Clavien术后并发症诊断和分级标准分析此两种吻合方式与术后并发症发生率及其严重程度的关系.结果 简易吻合组的术中出血量与常规吻合组比较差异无统计学意义（P＞0.05）,而两组胰肠吻合时间、术后住院时间相比较有统计学意义（P＜0.05）;在术后并发症的严重程度分级中简易吻合组的Ⅱ级和Ⅴ级并发症发生率分别为9.36％ （3/32）和3.13％ （1/32）,显著低于常规吻合组的25.00％ （6/24）和12.5％ （3/24）,两组比较,差异有统计学意义（P＜0.05）.结论 在行胰十二指肠切除术中使用简易胰肠套入捆绑式吻合方式明显降低术后并发症的发生率,缩短胰肠吻合手术时间及术后住院时间,可能更有利于患者术后的恢复,此吻合方式值得在临床工作中推广运用.     

不同胰肠吻合方式在PD术中的临床应用比较

目的探讨并分析胰管-空肠黏膜吻合术和捆绑式胰肠套入吻合术在胰十二指肠切除术中的临床应用效果。方法回顾性研究我院近五年行胰十二指肠术患者57例,其中胰管-空肠黏膜吻合式31例,捆绑式胰肠套入吻合式26例,收集患者术前一般情况及术中术后各项指标,分析两种方式有无差异。结果捆绑式胰肠套入吻合较胰管-空肠黏膜吻合手术时间缩短(358.7±7.8 min vs 307.4±5.8 min,P0.05),术后主要并发症胰瘘、腹腔出血以及住院时间两组无统计学差异。结论胰管-空肠黏膜吻合和捆绑式胰肠套入吻合均具有较好的临床效果,捆绑式胰肠套入吻合较胰管-空肠黏膜吻合节省手术时间,具体吻合方式因根据个人习惯和熟练程度灵活选择。     

空肠浆肌鞘套入双捆绑预防胰肠吻合术后胰瘘的效果观察

目的:通过与传统的胰十二指肠切除术进行比较,探讨空肠浆肌鞘套入双捆绑胰肠吻合对预防胰十二指肠切除术后胰瘘的效果.方法:行胰十二指肠切除患者40例,其中行空肠浆肌鞘套入双捆绑胰肠吻合的患者28例作为观察组,传统胰十二指肠切除术后套入式胰肠吻合的12例作为对照组.对2组的手术时间、术中出血量、术后胰瘘、术后并发症和住院时间以及住院费用等方面进行对比研究.结果:观察组术后胰瘘的发生率明显低于对照组(0 vs2/1 2,P<0.05),2组在手术中出血量及手术后并发症发生率差异无统计学意义(P>0.05),但手术时间、术后住院时间短于对照组(P<0.05).结论:相对于传统的胰十二指肠切除术中套入式胰肠吻合重建方式,空肠浆肌鞘套入双捆绑胰肠吻合方式简化了胰肠吻合过程,固定更牢靠,操作更简单,有双重保险的效果,预防术后胰瘘效果明显.     

胰肠吻合与双荷包胰胃吻合近期临床疗效比较

目的 比较胰十二指肠切除术中运用胰肠吻合与双荷包胰胃吻合的近期疗效,探讨胰肠吻合和双荷包胰胃吻合在胰十二指肠切除术中的合理性选择.方法 回顾性该院2010年1月至2012年12月间38例行胰十二指肠切除术患者的临床资料.其中采用胰肠吻合12例,双荷包胰胃吻合26例.结果 38例患者手术均顺利完成.双荷包胰胃吻合组胰瘘发生率(0％)、手术时间[(327.50±32.56) min]、术后住院天数[(10.31±2.44) d]显著少于胰肠吻合组[分别为3/12、(425.83±33.77) min和(14.33±4.14)d],差异有统计学意义(P＜0.05).胆漏、术后腹腔出血、胃排空延迟、切口感染、肺部感染发生率以及术中出血量虽然亦低于胰肠吻合组,但差异无统计学意义.结论 双荷包胰胃吻合是较胰肠吻合相对安全合理的消化道重建方式.前者操作简便,手术时间短,在近期疗效上对预防术后胰瘘等并发症具有很大优越性.     

胰十二指肠切除术中放置与不放置胰管支撑管的比较

目的评价不同胰肠吻合方式在胰十二指肠切除术中的临床疗效,探讨不放置胰管支撑管的胰肠吻合的适用性。方法我院自2012年1月~2015年12月收治的87例可行胰十二指肠切除术患者,按随机分配方式分为胰管-空肠黏膜对黏膜端侧吻合+胰管支撑管外引流组(A组,43例)和胰腺-空肠端侧吻合不放置胰管支撑管组(B组,44例),比较两种不同胰肠吻合方式行胰肠吻合术的时间及术后住院时间、术后并发症的发生率。结果术中未放入胰管支撑管组的胰肠吻合时间(平均15.4min)明显小于术中放入胰管支撑管组(平均21.1min),差异有统计学意义(t=7.137,P0.05)。B组患者术后住院时间小于A组(t=2.408,P0.05,差异有统计学意义)。两组患者术后胰漏、腹腔出血、腹腔感染、胃潴留,差异无统计学意义(χ~2=0.181,0.322,0.603,0.001;P0.05)。结论胰十二指肠切除术不放置胰管支撑管可减少手术时间,降低术后住院天数,且术后并发症的发生率无显著差异,是安全可靠的。     

捆绑式胰肠吻合术在预防胰十二指肠切除术后胰瘘发生中的临床应用

目的 探讨捆绑式胰肠吻合术在预防胰十二指肠切除术后胰肠吻合口漏的可行性及临床应用价值. 方法我院在2002年3月至2006年10月期间对32例胰十二指肠切除术患者采用捆绑式胰肠吻合术.结果 32例患者手术均顺利,无一例发生胰瘘,无手术死亡病例. 术后发生胆瘘2例,经腹腔引流治愈.结论 捆绑式胰肠吻合术操作简便,预防胰瘘效果可靠,值得推广.     

胰胃吻合术治疗胰十二指肠切除术后胰肠吻合口狭窄3例疗效分析

目的 观察胰胃吻合术治疗胰十二指肠切除术后胰肠吻合口狭窄的临床疗效。方法 回顾性分析2010年5月至2017年12月收治的3例内镜治疗失败的胰十二指肠切除术后胰肠吻合口狭窄病人的临床资料。通过开腹探查、切除胰肠吻合口,采用单层捆绑式胰管胃黏膜吻合术进行残胰消化道重建。观察术中和术后情况。结果 从胰肠吻合至诊断胰肠吻合口狭窄的时间分别为72、37 和21个月。3例病人手术均顺利完成,手术时间为137、210、120 min,出血量为 210、350、180 mL。术后未出现胰瘘、出血、感染等并发症。术后症状缓解,术后随访23、58和15个月未再发作。结论 对于内镜治疗失败的胰十二指肠切除术后胰肠吻合口狭窄病人,胰胃吻合术特别是单层捆绑式胰管胃黏膜吻合术是可考虑采取的手术方案。     

腹腔镜与开腹胰十二指肠切除术临床疗效比较

目的 比较腹腔镜与开腹胰十二指肠切除术的临床疗效。方法 回顾性分析南充市中心医院2014 年6 月至2019 年8 月期间完成的104 例胰十二指肠切除术患者资料，其中包含胰头癌47 例，十二指肠乳头癌31 例，胆管下段癌26 例，根据已行的手术方式分为腹腔镜胰十二指肠切除组（A组，n=40）和开腹胰十二指肠切除组（B组，n=64）。比较两组的手术时间、术中出血量、平均排气时间、术后下床活动时间、住院时间及术后并发症发生情况。结果 两组手术时间和术中出血量无统计学差异（P＞0．05），平均排气时间、术后下床活动时间及住院时间A组小于B组（P＜0．05）。其中A组术后发生胰瘘5 例，胆漏4 例，腹腔内出血1 例，胃瘫综合征3 例；B组术后发生胰瘘9 例，胆漏5 例，腹腔内出血1 例，胃瘫综合征4 例，余无明显严重并发症发生；两组术后总并发症发生率无明显差异（P＞0．05）。结论 腹腔镜和开腹胰十二指肠切除术均安全有效，但腹腔镜胰十二指肠切除术后恢复优于开腹胰十二指肠切除术。     

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.