外周血淋巴细胞总数在颈椎术后感染早期诊断中的应用价值

目的 :探讨外周血中淋巴细胞总数在颈椎术后手术部位感染(surgical site infection,SSI)早期诊断中的应用价值。方法:回顾性分析复旦大学附属华山医院脊柱外科2001年1月~2015年10月收治的颈椎术后SSI患者18例(浅表切口感染7例,深部切口感染11例),以及性别、年龄、症状及手术方式相同的术后未感染患者47例。所有研究对象术前及术后3d检测并分析体温、外周血中白细胞总数、中性粒细胞总数、淋巴细胞总数、红细胞沉降率(erythrocyte sedimentation rate,ESR)及C-反应蛋白(C-reactive protein,CRP)等参数。绘制术后3d工作特征曲线(ROC曲线),并计算各项参数曲线下面积(AUC);同时,使用约登指数分析各项参数的最佳临界值。采用SPSS 12.0统计软件对测量数据进行统计分析。结果:术前,仅深部切口感染患者的淋巴细胞总数较非感染患者出现显著减少(P=0.01)。术后3d,浅表切口感染与深部切口感染患者的淋巴细胞总数均较术后未感染患者出现明显下降(P=0.02);除此之外,仅深部切口感染患者的CRP及ESR值较未感染患者出现异常升高(P=0.00)。根据术后3d的ROC曲线,仅淋巴细胞总数(P=0.00)与CRP(P=0.01)对颈椎术后SSI具有诊断价值。相较于CRP(0.71),淋巴细胞总数的AUC值(0.97)明显较大。同时,淋巴细胞总数的约登指数(0.944;临界值1.31×109/L)也明显大于CRP(0.424;临界值14.7mg/L)。结论 :颈椎术后围手术期淋巴细胞总数的异常减少与颈椎术后SSI的产生存在明显的相关性。术后早期,检测外周血中淋巴细胞总数有助于早期诊断颈椎术后SSI,为预防及尽早针对性应用抗生素治疗颈椎术后SSI提供可靠依据。     

临床诊断与病原确诊脊柱术后感染的临床特征对比

[目的]比较临床诊断与病原确诊脊柱术后感染的临床特征,为脊柱术后手术部位感染的临床诊治提供帮助。[方法]回顾性分析2004年7月~2012年12月北京大学第三医院28 778例脊柱手术后发生感染的108例患者的病历资料,分为病原确诊组(67例)和临床诊断组(41例),从一般资料、临床表现、实验室检查等方面对两组资料进行综合分析。[结果]108例患者中男56例,女52例,平均年龄49.7岁,感染率为0.38%。常见的临床表现为切口渗液(69.4%)、体温升高(62.0%)、白细胞升高(49.1%)、中性粒细胞百分数升高(44.4%)、切口红肿(37.0%)和切口疼痛(30.6%)。临床诊断组的体温[(37.45±1.06)℃vs(38.00±1.10)℃,P=0.012]、白细胞[(9.33±3.37)×10~9/L vs(11.38±5.44)×10~9/L,P=0.032]和中性粒细胞百分数[(70.91±10.42)%vs(78.63±13.25)%,P=0.002]均低于病原确诊组。[结论]脊柱术后手术部位感染最主要的临床特征为切口渗液和体温升高。缺乏病原学证据的脊柱术后手术部位感染病例,其感染指标变化程度小于病原确诊病例。     

淋巴细胞总量及比例变化在脊柱退变性疾病术后伤口感染早期诊断中的应用

目的 探讨外周血淋巴细胞总量及其比例变化在脊柱退变性疾病术后伤口感染早期诊断中的临床应用价值。方法 回顾性分析我院脊柱外科2015年1月至2020年12月脊柱退变性疾病手术后发生伤口感染的病人20例（其中颈椎手术6例,腰椎手术14例;浅表软组织感染9例,深部感染11例）,设为感染组。同时选取同期术后未感染的病人20例纳入对照组。对比分析病人术前及术后3、7、14 d外周血中的白细胞总数、中性粒细胞总数、淋巴细胞总数、淋巴细胞比例、C反应蛋白（CRP）、红细胞沉降率（ESR）等参数变化。结果 感染组术后3、7、14 d的CRP、ESR、白细胞总数、中性粒细胞总数均较术前显著提高,且随着时间推移逐步下降;同一观察时间点,感染组的数值均明显高于对照组,差异有统计学意义（P＜0.05）;但中性粒细胞总数和ESR在术后3 d和7 d的变化比较,差异无统计学意义（P＞0.05）。感染组术后3、7、14 d的外周血淋巴细胞总数及淋巴细胞比例较术前明显下降,且随着时间推移逐步上升;且感染组术后3、7 d的淋巴细胞总数和术后3、7、14 d的淋巴细胞比例均显著低于对照组,差异有统计学意义（P<0.05）。对照组术前及术后3、7、14 d的外周血淋巴细胞总数及淋巴细胞比例两两比较,差异均无统计学意义（P＞0.05）。感染组病人术后3 d淋巴细胞总数及其比例的ROC曲线下面积（AUC）分别为0.980、1.000,约登指数分别为0.900、1.000,最佳临界值分别为1.545×10⁹/L、0.265;术后7天的AUC分别为0.898、1.000,约登指数分别为0.750、1.000,最佳临界值分别为1.670×10⁹/L、0.280。结论 同CRP、白细胞总数变化一样,术后早期分析外周血中淋巴细胞总数及比例变化同样有助于脊柱手术术后感染的早期诊断,为早期针对性治疗提供可靠依据。     

脊柱后路内固定术后迟发性感染的治疗

目的:探讨脊柱后路内固定术后迟发性感染(首次感染发生时间≥术后1个月)病例的治疗方法 ,并进行分析总结。方法:自2005年8月~2013年12月共收治脊柱后路内固定术后迟发性感染病例18例,其中颈后路单开门椎管扩大成形术1例,腰椎后路减压固定融合术17例,单纯切口深部感染9例(组1),单纯椎间隙感染7例(组2),同时合并切口深部及椎间隙感染2例(组3),分析迟发性感染的特点,比较3组迟发性感染在体温、炎症指标(WBC计数、ESR、CRP)、临床表现等方面的差异,并进行相应治疗。结果:发生迟发性感染的平均间隔时间为术后17个月(1~101个月),三组病例间感染在发病时间、体温、WBC、ESR、CRP中,仅组2与组3间的体温存在统计学差异(P0.05),其余检验均无统计学差异(P0.05);组1中8例患者行清创+对口冲洗引流术,其中4例取出内固定,组2中1例合并局部不稳定行手术治疗,组3中1例因明显的深部感染行手术治疗,其余病例单纯应用抗生素治疗。所有病例均获治愈,平均随访18个月(12~40个月),未见感染复发。结论:对迟发性脊柱后路术后切口深部感染病例,清创+对口冲洗引流术是有效治疗,对于手术节段融合满意的患者,可积极取出内固定;迟发性单纯椎间隙感染,首选抗生素保守治疗,对于合并明显的切口深部感染或存在不稳定的病例,可行手术清创治疗。     

切除与不切除滑膜对人工全膝关节置换术后感染影响的比较

[目的]研究膝骨性关节炎患者行人工全膝关节置换术时进行滑膜切除与否对术后感染的影响。[方法]选择2008年~2012年860例符合原发性膝骨关节炎诊断标准的患者,年龄48~82岁,分为两组:420例关节置换同时进行滑膜切除,440例未进行滑膜切除。随访3~7年,平均4.8年。观察和测定手术时间,引流量,术前和术后1、3 d,2、6、12周和1年血沉(ESR)、C反应蛋白(CRP)、白细胞总数和感染率评价膝关节术后临床效果。采用VAS评分和AKSS评分评价手术效果。[结果]两组患者术前各项临床指标差异均无统计学意义,基线基本相同。手术时间滑膜切除组较长(76±15)min,非切除组(65±12)min,P0.001,伤口引流量滑膜切除组(285±105)ml,未切除组(245±103)ml,P0.001。术后滑膜未切除组患者血液中ESR、CRP水平高于切除组,术后2周CRP恢复到术前水平,而ESR缓慢降低直至术后6周接近正常水平。术后两组患者白细胞总数,未切除组偏高,但差异无统计学意义。术后两组患者VAS评分和AKSS评分差异无统计学意义。在平均4.8年的随访中,切除组出现表浅感染3例,深部感染4例,未切除组表浅感染2例,无深部感染患者。[结论]人工全膝关节置换术滑膜切除组手术时间及伤口引流量均高于未切除组,未切除组术后白细胞总数、ESR,CRP偏高,但感染率低,因此推测膝关节滑膜在抗感染中发挥作用。     

关节镜下前交叉韧带重建术后感染的诊断与治疗要点

目的探讨前交叉韧带（ACL）重建术后关节内感染的诊断标准、预防及治疗关键点。方法回顾性分析2007-01—2012-12关节镜下行ACL重建术后关节内感染5例患者的临床资料。术后关节内感染的诊断标准：膝疼痛在术后再度加重,伴体温升高;膝肿胀、积液或切口红肿;血液白细胞、中性粒细胞比例、ESR、CRP升高;关节液白细胞、中性粒细胞比例升高,葡萄糖浓度降低,以及细菌培养。总结5例感染者诊断、治疗过程及结果并回顾相关文献。结果关节镜下ACL重建术102例中5例术后发生关节内感染（4.9%）,其中仅1例细菌培养阳性（0.98%）。采取清创后持续冲洗引流或间断穿刺冲洗治疗后保留移植韧带4例。结论 ACL重建术后关节内感染的治疗原则：早期干预以提高韧带保留率;清创后持续冲洗引流;使用敏感抗生素足疗程治疗;石膏或支具制动,延迟功能锻炼。     

脊柱内固定手术前后CRP、ESR的动态变化及其临床意义

目的观察CRP及ESR在脊柱内固定手术前后的一般变化规律,并探讨其在感染监测中的临床意义。方法选择行脊柱内固定手术的患者98例,其中并发脊柱深部切口感染7例。在术前1天、术后1、3、7、14、21、28天检测CRP及ESR。对于并发脊柱深部切口感染患者,28天后继续每周检测CRP及ESR,直至感染控制,CRP正常。同时记录患者性别、年龄、疾病类型、手术部位、手术时间、是否输血等可能影响CRP及ESR数值变化的因素。结果 CRP在脊柱内固定术后3日达峰值,为86.80 mg/L,然后快速下降,一般在术后14日降至正常,为6.76 mg/L。ESR在脊柱内固定术后7日达峰值,为64.93 mm/h,然后缓慢下降,但术后28日仍高于正常,为20.46 mm/h。术后不同手术部位的CRP动态变化趋势一致,均在术后3日达峰值,术后14日逐渐降至正常,但同时期在胸椎及胸腰段的CRP均值峰值相应高于颈椎及腰椎部位。脊柱术后早期深部感染患者与一般无感染患者相比,其CRP峰值后移,术后7日峰值(136.5 mg/L)高于术后3日(117.31 mg/L),而且回落至正常时间推迟,术后14日(39.93 mg/L)仍高于正常。随感染控制,在术后42日降至正常(6.02 mg/L)。ESR在脊柱术后早期深部感染患者高峰在术后7日出现,但其峰值更高,达106 mm/h,下降幅度小,持续偏高,在术后42日仍高于正常,为43mm/h。结论动态观察CRP及ESR有助于早期发现脊柱内固定术后感染,从而早期治疗。对于肥胖、老年人及糖尿病患者,为术后感染高危人群,动态检测CRP及ESR尤为必要。     

脊柱内固定术后感染的治疗

[目的]探讨脊柱内固定术后感染的治疗方法。[方法]对2005年1月~2014年5月本院收治的21例脊柱内固定术后感染患者的临床表现、诊断及治疗经过进行回顾性分析,男10例,女11例,平均年龄(58±2.3)岁(17~76岁)。早期感染17例,迟发性感染4例;其中浅部感染8例,深部感染13例。在抗生素治疗的同时,浅部感染采用搔刮、冲洗、引流等换药措施;深部感染采用彻底清创、对流冲洗术治疗。对上述治疗前、治疗后1、2个月的白细胞计数、ESR、CRP指标进行统计学分析。[结果]平均随访(44.95±24.83)个月(16~128个月)。病原菌以革兰阳性球菌为多,占66.67%,其中金黄色葡萄球菌最为常见。8例浅部感染,切口平均(14.15±5.60)d愈合;13例深部感染者,12例经一次清创治愈、1例经二次清创治愈,11例保留内置物、2例去除内置物,平均治愈时间为(35.12±18.10)d。所有患者白细胞计数、ESR、CRP在治疗后2个月均恢复正常。[结论]脊柱内固定术后感染,在敏感抗生素治疗的同时,浅部感染经局部换药、深部感染经及时彻底清创及对流冲洗术治疗可获得良好的效果。     

一期清创治疗腰椎内固定术后早期感染

[目的]介绍腰椎内固定术后早期感染保留内置物的彻底清创技术。[方法]2010年1月~2017年1月腰椎内固定术患者692例,术后早期感染患者14例,其中男3例,女11例,平均年龄65岁(58~80岁)。引流管或伤口引流液培养均阳性,金黄色葡萄球菌4例,其中MRSA 2例,表皮葡萄球菌8例,肠杆菌1例,肠球菌1例。获得细菌学证据后,采用亚甲蓝标记后彻底清创、内置物取出高压灭菌回植、伤口放置敏感抗生素、单纯负压引流和抗感染治疗,观察治疗效果。[结果]全部14例患者清创后切口引流液培养均阴性,切口均Ⅰ期愈合,14 d拆除切口缝线。清创术后3 d CRP明显下降,术后1个月ESR及CRP均持续下降,术后3个月ESR及CRP均降至正常范围,所有患者均无感染复发征象。[结论]采用亚甲蓝标记清创、内置物取出高压灭菌回植、伤口放置敏感抗生素、单纯负压引流和抗感染治疗,腰椎内固定术后早期感染可获得Ⅰ期治愈。     

脊柱术后感染血清指标水平变化及临床意义

目的研究脊柱术后感染血清降钙素原(PCT)、C反应蛋白(CRP)、可溶性白细胞(Presepsin)、红细胞沉降率(ESR)水平变化及临床意义。方法选取本院2018年1月到2020年1月期间实施脊柱开放手术患者300例作为研究对象。将术后291例未感染患者作为对照组,9例感染患者作为研究组。在术前及术后分别检测并记录两组患者血清中PCT、CRP、ESR、Presepsin水平。结果术前,两组患者血清PCT、CRP、ESR、Presepsin水平相比,差异无统计学意义(P0.05),术后,两组患者血清PCT、CRP、ESR、Presepsin水平均有明显升高,且研究组患者血清PCT、CRP、ESR、Presepsin水平明显高于对照组,差异有统计学意义(P0.05)。各项指标对于脊柱术后感染均具有很高的诊断价值,联合诊断符合率高达97.8%,四项指标中PCT单独诊断符合率最高,为95.4%。结论血清PCT、CRP、ESR、Presepsin水平可作为诊断脊柱术后感染的监测指标,对疾病的早期诊断和及早治疗有重要意义,具有临床应用价值,值得推广。     

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.