氟比洛芬酯联合吗啡镇痛对胃癌患者术后吗啡用药量及肠功能恢复的影响

目的 观察氟比洛芬酯联合吗啡镇痛对胃癌患者术后吗啡用药量及肠功能恢复的影响.方法 40例择期全麻下行胃癌根治术患者,随机分为氟比洛芬酯组和吗啡组,每组20例,分别于术前0.5 h静注氟比洛芬酯或安慰剂英脱利匹特.术后距第一次给药6 h再次静注氟比洛芬酯或英脱利匹特.两组患者术后均行患者自控静脉镇痛(PCIA).记录两组患者术后12、24、36、48 h的VAS和舒适评分(BCS),记录术后吗啡用量以及术后第一次肛门排气的时间.结果 两组VAS和BCS评分在各相应时间点差异无统计学意义.术后1～12 h氟比洛芬酯组吗啡用量为(16.99±3.51)mg,明显低于吗啡组的(25.09±4.63)mg(P<0.01).氟比洛芬酯组患者术后第一次肛门排气的时间为(69.05±11.20)h,短于吗啡组的(78.05±12.94)h(P<0.05).结论 围术期使用氟比洛芬酯可减少胃癌患者术后静脉镇痛的吗啡用量,促进肠功能恢复.     

加速康复外科在胃癌根治术中临床价值的前瞻性研究

目的 探讨加速康复外科(ERAS)在胃癌根治术中的临床价值.方法 选取2011年4月至2013年6月青岛大学附属医院行胃癌根治术的140例患者进行前瞻性研究,采用随机、双盲对照法,通过随机数字表法将入组患者分为ERAS组(围术期采用ERAS处理方案)和对照组(围术期采用传统处理方案).观察患者炎症指标、营养状况指标变化以及术后恢复情况.ERAS组患者于出院后24 h内进行第1次电话随访,出院2周进行门诊随访,直至术后30 d结束.对照组出院后3周门诊常规复查.正态分布的计量资料采用x±s表示,组间比较采用独立样本t检验;各指标趋势比较采用重复测量方差分析.计数资料采用,检验或Fisher确切概率法.结果 筛选出符合研究条件的患者80例,ERAS组和对照组各40例.两组患者血清TP、Alb、前白蛋白、TNF-α、IL-6、C反应蛋白、静息能量消耗、血糖、胰岛素、胰岛素抵抗指数术后1、3、5d在一定趋势内变化,ERAS组术后1d分别为(61±5)g/L、(34±3)g/L、(160±18) g/L、(12.3±2.3) mmol/L、(101±34) ng/L、(43±11)g/L、(1 336±105) kal/d、(7.6±0.8) mmol/L、(16.8±3.5) mU/L、5.7±1.3;对照组分别为(58 ±4)g/L、(31±4)g/L、(147±18) g/L、(15.3±2.2)mmol/L、(122±37) ng/L、(56±27) g/L、(1 450±164) kal/d、(9.3±1.4) mmol/L、(30.5±6.8)mU/L、12.5±3.2,两组比较,差异有统计学意义(F=31.63,8.03,67.36,147.04,9.63,6.84,16.10,54.85,104.51,139.47,P＜0.05).ERAS组患者术后发热时间、肛门排气时间、住院时间和住院费用、疼痛评分、生命质量评分分别为(2.9 ±0.9)d、(2.9 ±0.6)d、(7.6±2.1)d、(28 495±4 722)元、(1.4±1.0)分、(15.4±0.9)分;对照组分别为(3.8 ±0.6)d、(3.5 ±0.7)d、(8.9 ±2.6)d、(35 318 ±7 610)元、(2.4±1.1)分、(14.4±1.2)分,两组比较,差异有统计学意义(t =-0.91,-3.66,-2.85,-4.82,-4.20,3.92,P＜0.05).ERAS组患者发生呼吸道相关并发症2例,再手术患者1例,术后30 d再入院1例;对照组则分别为3例、1例、2例,两组比较,差异无统计学意义(P＞0.05).结论 ERAS应用于胃癌根治术患者的围术期安全可行.它能减轻手术应激,缩短住院时间,改善患者生命质量,且不增加术后并发症,这可能与减少患者胰岛素抵抗、降低静息能量代谢有关.临床试验注册在中国临床试验注册中心注册,注册号为ChiCTR-TRC-10001611.     

术前服用加巴喷丁对胃癌患者术后曲马多镇痛的影响

目的 评价加巴喷丁对胃癌患者术后曲马多镇痛效果的影响.方法 40例ASA Ⅰ或Ⅱ级择期行胃癌根治术的患者,随机分为观察组和对照组.观察组在术前2.5 h单次口服加巴喷丁1 200 mg,对照组口服安慰剂.两组均以电子镇痛泵行曲马多PCIA.镇痛模式为患者自控镇痛(PCA)剂量20 mg,锁定时间10 min;1 h后若镇痛效果不满意,PCA剂量改为30 mg,每小时用量不超过120 mg.镇痛期间行视觉模拟评分(VAS),记录术后1、4、8、12、16、20、24 h心率(HR)、平均动脉压(MAP)、呼吸次数(RR)和曲马多用量.结果 VAS观察组明显低于对照组(P＜0.05);且观察组24 h内曲马多用药量为(317.5±69.6)mg,明显少于对照组(576.5±106.2)mg(P＜0.01).两组患者不良反应的发生率差异无统计学意义.结论 加巴喷丁明显减轻患者术后疼痛,显著减少PCIA曲马多的用量且并不增加不良反应的发生率,可作为超前镇痛药物的选择.     

术前焦虑对腹腔镜胆囊切除患者术后疼痛及麻醉后复苏的影响

目的 观察腹腔镜胆囊切除患者术前焦虑对术后疼痛及麻醉后复苏的影响. 方法 选择82例择期行腹腔镜胆囊切除术患者,术前依照贝克焦虑量表(Beck's anxiety inventory,BAI)评测结果将患者分为两组:正常组(50例)和焦虑组(32例).焦虑组患者伴有焦虑症状,正常组患者无焦虑症状.观察记录手术时间、麻醉时间、改良Aldrete评分(modified Aldrete score,MAS)达9分的时间和副作用.术后疼痛控制采用芬太尼患者自控静脉镇痛的方法,记录患者术后VAS评分、芬太尼用量和补充镇痛药物使用情况. 结果 患者术前焦虑症发生率为39％.焦虑组患者改良Aldrete评分达9分的时间为(6.3± 1.5)s,明显长于正常组(5.0±1.4)s(P＜0.05),术后副作用发生率也高于正常组(P＜0.05).术后4、8、12h焦虑组患者VAS评分高于正常组[4 h:(3.5±0.7)分比(2.6±1.0)分;8 h:(3.3±0.9)分比(2.2±0.8)分;12 h:(3.1±0.5)分比(2.4±0.6)分](P＜0.05).患者术前BAI评分与术后8、12 h VAS评分呈正相关(8 h:r=0.422;12 h:r=0.526)(P＜0.05).焦虑组患者术后芬太尼用量和追加氯诺昔康补充镇痛的需求均高于正常组(P＜0.05). 结论 术前焦虑对麻醉后复苏以及术后镇痛有着负面影响,对于焦虑患者需增加术后镇痛力度才能达到良好的止痛效果.     

腹腔镜辅助与开腹远端胃癌D2根治术近期康复的对比研究

目的 探讨腹腔镜辅助远端胃癌根治术患者术后早期的康复情况.方法 回顾性分析2010年1月至2012年12月56例腹腔镜辅助下远端胃癌根治术(腹腔镜组)与同期62例开腹远端胃癌根治术(开腹组)患者的临床资料.结果 两组手术时间、淋巴结清扫数目、pTNM分期、切除长度及术后并发症发生率等比较差异无统计学意义(P＞0.05).腹腔镜组术中出血量明显少于开腹组(120±25 ml VS 165±42 ml,P＜ 0.05),腹腔镜组术后胃肠功能恢复时间、平均住院时间均短于开腹组,分别为(75±9hVS 101±12h,P＜ 0.05)和(8.2±2.5 d VS 10.5±2.9 d,P＜ 0.05).结论 腹腔镜辅助胃癌根治术技术可行,同时具备手术视野清晰、创伤小、出血少等优点,患者近期康复效果优于开腹手术.     

脐疗对剖宫产术后镇痛及产妇恢复的效果观察

目的 观察剖宫产术后中药脐疗镇痛效果及对产妇功能恢复的影响.方法 将我院2006年2月至2007年12月在硬膜外麻醉下行剖宫产的足月初产妇200例,术毕按手术顺序随机等分2组:实验组100例,术后采用中药脐疗镇痛;对照组100例,术后采用硬膜外自控镇痛(patient controlled epidural analgesia,PCEA).观察2组镇痛效果及产妇功能恢复情况.结果 实验组术后12、24、48 h VAS评分与对照组比较差异无统计学意义(P＞0.05);实验组24、48 h宫底高度分别为(-0.78±0.38)cm、(-1.37±0.41)cm,对照组24、48 h宫底高度分别为(-1.15±0.22)cm、(-1.80±0.62)cm,差异有统计学意义;12 h副作用方面比较差异有统计学意义(P＜0.01,P＜0.05),两组患者术后72 h出血量实验组为(151.96±32.33)ml、对照组为(194.94±44.09)ml,差异有统计学意义(P＜0.01);开始床上活动时间实验组和对照组分别为(10.3±3.6)h、(15.6±2.1)h;下床活动时间实验组和对照组分别为(22.7±4.4)h、(31.4±4.0)h;肛门排气时间实验组和对照组分别为(26.1±3.8)h、(47.8±7.2)h,两组比较差异有统计学意义(P＜0.01),自主排尿时间差异无统计学意义(P＞0.05).结论 剖宫产术后使用中药敷脐与采用PCEA相比较,可取得同样满意的镇痛效果,而中药敷脐可使产妇提早起床活动,有利于减少产后出血,促进胃肠功能恢复,值得推广应用.     

经腹膈肌裂孔途径与经胸腹联合切口用于近端胃癌根治术的比较研究

目的 探讨经腹膈肌裂孔途径对进展期近端胃癌行根治术的安全性和临床疗效.方法 回顾性分析2003年6月至2006年9月间在湖北通城县人民医院接受经腹膈肌裂孔途径手术治疗的40例进展期近端胃癌患者的临床资料.其中男27例,女13例;年龄37～76(平均56.1)岁.选取同期经胸腹联合切口途径行近端胃癌根治术且临床病理资料相匹配的40例近端胃癌患者作为对照.结果 与对照组患者相比,经腹膈肌裂孔途径术中出血量明显减少[(181.3±63.7) ml比(248.8±79.7) ml,P=0.000],手术时间缩短[(4.1±0.6)h比(5.3±0.7)h,P=0.000],ICU治疗时间[(6.5±5.7)d比(19.4±18.0)d,P=0.000]及术后住院治疗时间[(14.0±2.3)d比(18.7±3.0)d,P=0.000]均明显缩短;两组患者并发症发生率分别为7.5％(3/40)和10.0％(4/40),5年生存率分别为51.3％和60.0％,差异均无统计学意义(均D0.05).结论 经腹膈肌裂孔途径对进展期近端胃癌行根治术安全、有效.     

腹腔镜辅助近端胃癌根治术临床近期疗效

目的 探讨腹腔镜辅助近端胃癌根治术近期临床疗效.方法 回顾性分析2011年6月至2013年1月收治的48例腹腔镜近端胃癌根治术患者(腹腔镜组),同时选取临床资料与腹腔镜组相近的,行开腹近端胃癌根治术患者40例(开腹组).比较两组在手术时间、出血量、清扫淋巴结数目、术后胃肠功能恢复时间和住院时间的情况.结果 腹腔镜组手术时间、出血量、清扫淋巴结数目、术后胃肠功能恢复时间、住院时间分别为(164±38)min、(80±33)ml、(27.5±3.1)个、(2.5±0.8)d和(10.0±2.2)d.出血量、术后胃肠恢复时间、住院时间与开腹组比较,差异有统计学意义(P＜0.05).按胃周淋巴结组别观察两组淋巴结数目,腹腔镜组的NO.4、10、11d淋巴结平均清扫数目与开腹组比较,差异有统计学意义(P＜0.05).结论 腹腔镜近端胃癌根治术能够达到与开腹手术相同的根治效果,且具有创伤小、恢复快、安全等优点.     

腹腔镜辅助胃癌根治术在进展期胃癌中的应用研究

探讨腹腔镜辅助胃癌根治术在进展期胃癌中的应用效果。选取行腹腔镜辅助根治术的进展期胃癌患者38例作为观察组,同时选取行传统开腹根治术的进展期胃癌患者36例作为对照组,对比分析两组患者的手术时间、术中出血量、平均清除淋巴结数目、下床活动时间和胃肠功能恢复时间。与对照组患者相比,观察组患者的手术时间(218.54±36.35)min,明显延长(P0.05),术中出血量(116.94±39.56)m L、下床活动时间(73.25±14.86)h、胃肠功能恢复时间(83.24±13.56)h、住院时间(10.45±1.85)d,均明显缩短(P0.05);并发症发生率2.63%,明显降低(P0.05);观察组平均清除淋巴结(14.85±3.95)枚,无明显减少(P0.05)。对于进展期胃癌患者,腹腔镜辅助根治术具有良好的治疗效果,值得临床进一步推广使用。     

3D与2D腹腔镜远端胃癌根治Roux-en-Y吻合术临床对比研究

目的比较3D腹腔镜远端胃癌D2根治术与传统2D腹腔镜远端胃癌D2根治术的临床疗效。方法回顾性分析2014年12月至2016年12月解放军总医院普通外科行远端胃癌D2根治术的135例患者的临床资料。观察组65例,行3D腹腔镜远端胃癌D2根治术;对照组70例,行传统2D腹腔镜远端胃癌D2根术;比较两组的手术时间、进流食时间、术中出血量、术后首次下床时间、住院时间、淋巴结清扫数等,比较3D与传统2D的近期临床效果。结果两组患者的性别及年龄等基本资料比较,差异无统计学意义(P0.05)。手术时间:观察组(212.4±40.2)min,对照组(244.6±30.1)min,差异有统计学意义(P0.001);进流食时间:观察组(43.8±5.3)h,对照组(55.1±7.5)h,差异有统计学意义(P=0.019);术中出血量:观察组(47.9±11.2)ml,对照组(83.4±15.3)ml,差异有统计学意义(P0.001);术后首次下床时间:观察组(1.01±0.42)d,对照组(1.76±0.39)d,差异有统计学意义(P=0.026);住院时间:观察组(7.6±1.7)d,对照组(10.4±1.9)d,差异有统计学意义(P=0.032)。淋巴结清扫数:观察组(34.7±8.2)枚,对照组(24.2±8.1)枚,差异无统计学意义(P=0.083)。两组的术后并发症发生率比较,差异无统计学意义。结论 3D腹腔镜远端胃癌D2根治术具有手术创伤小、术后恢复快的优点,安全可行,近期临床效果显著。     

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.