主动脉夹层动脉瘤术后低氧血症的危险因素

目的 探讨主动脉夹层动脉瘤术后低氧血症发生的危险因素.方法 2005年8月至2008年5月,175例夹层动脉瘤病人行手术治疗,根据到达监护室6 h后动脉血氧分压(mm Hg)/吸入氧浓度(%)(PaO_2)/FiO_2)分为低氧血症组(PaO_2/FiO_2<200)和非低氧血症组(PaO_2/FiO_2≥200).评估及比较两组的年龄、性别、体重指数、有无吸烟史、症状出现至手术时间、是否行急诊手术、手术方式、体外循环时间、主动脉阻断时间、深低温停循环时间、最低直肠温度、术后24 h内引流量和输血量等因素以及ICU停留时间、呼吸机辅助时间、住院时间和院内病死率.结果 主动脉夹层动脉瘤术后低氧血症发生率为28%(49/175例).低氧血症组平均呼吸机辅助(83.09±123.71)h,非低氧血症组(29.50±29.07)h(P=0.017);低氧血症组平均ICU停留(7.46±5.16)d,非低氧血症组(4.25±6.62)d(P=0.007);低氧血症组平均住院(24.45±17.84) d,非低氧血症组(19.19±10.18)d(P=0.041).术前、术中及术后单因素分析中有统计学意义的因素包括体重指数、吸烟史、发病至手术时间、急诊手术、手术方式、深低温停循环和术后24 h内输血量.多因素回归分析显示,深低温停循环、输血量>5U和体重指数>25ks/m~2为有意义的独立预测因素.结论 低氧血症是主动脉夹层动脉瘤术后常见的并发症,术后低氧血症的危险因素包括体重指数、吸烟史、急诊手术、深低温停循环和术后24 h输血量.加强围术期处理是防治夹层主动脉瘤术后低氧血症的有效方法.     

心脏手术史不是A型主动脉夹层孙氏手术院内死亡的独立危险因素

目的 探讨心脏手术史是否是A型主动脉夹层患者全主动脉弓替换加支架象鼻手术(孙氏手术)后院内死亡的独立危险因素.方法 2009年2月至2012年2月,共384例A型主动脉夹层患者纳入研究.其中36例术前有心脏手术史:Bentall手术16例,升主动脉替换术7例,Wheat手术4例,主动脉瓣置换术4例,Bentall加二尖瓣手术2例,二尖瓣及主动脉瓣双瓣置换术1例,房间隔缺损修补术1例,冠状动脉旁路移植术1例.将可能与术后死亡相关的因素先行单因素分析,单因素分析有意义的变量纳入多因素logistic回归分析.结果 孙氏术后院内死亡共31例,占8.07％.有心脏手术史患者36例中共死亡3例,占8.33％.单因素分析结果显示年龄和发病至手术时间小于1周为术前危险因素;体外循环时间超过300 min,主动脉夹层累及冠状动脉需要行冠状动脉旁路移植术为术中危险因素.将此4种危险因素纳入多因素logistic回归,结果显示,发病至手术时间小于1周(P=0.038,OR=2.43)、体外循环超过300 min(P＜0.001,OR=12.05)为孙氏术后患者院内死亡的独立危险因素.心脏手术史不是A型主动脉夹层行孙氏手术后院内死亡的危险因素.有心脏手术史患者术后住ICU时间(2.09±1.89)天,首次手术患者(2.71±3.01)天,组间差异无统计学意义(P=0.25).有心脏手术史患者术后机械通气(30.09 ±33.42)h,首次手术(33.86±40.98)h,组间差异亦无统计学意义(P=0.61).有心脏手术史患者术后因出血导致二次开胸率3.03％,首次手术1.88％,组间差异无统计学意义(P=0.50).结论 心脏手术史不是A型主动脉夹层孙氏手术后院内死亡的独立危险因素,术后并发症发生率未显著增加.对于有心脏手术史的A型主动脉夹层患者,应该积极外科手术治疗.     

急性主动脉夹层术后低氧血症肥胖患者的逐步肺复张治疗

目的评价逐步肺复张术改善肥胖急性A型主动脉夹层术后低氧血症患者的临床疗效。方法将行深低温停循环A型急性主动脉夹层术后出现低氧血症的66例肥胖患者随机分为两组各33例。观察组行肺复张治疗,采用压力控制模式,逐步增加压力支持和呼气末正压再逐步下调;对照组行常规肺复张治疗。比较两组患者干预前后的呼吸指标(氧分压、二氧化碳分压、氧合指数、SpO_2)、循环指标的变化和呼吸机使用时间、ICU滞留时间。结果观察组肺复张30min后氧分压、氧合指数、SpO_2显著高于对照组(P0.05,P0.01);且肺复张期间两组患者血流动力学平稳;观察组呼吸机使用时间和ICU滞留时间显著短于对照组(均P0.05)。结论肺复张治疗可有效改善肥胖急性A型主动脉夹层术后低氧血症患者的氧合状态,采用逐渐递增后逐渐递减压力支持和呼气末正压的方案能维持患者的血流动力学平稳。     

Stanford A型主动脉夹层肥胖患者术后低氧血症的护理

目的 总结Stanford A型主动脉夹层肥胖患者术后低氧血症的护理经验，为临床护理提供参考。 方法 对41例Stanford A型主动脉夹层行心脏大血管手术后发生低氧血症的肥胖患者，实施肺保护通气策略及俯卧位通气，密切观察病情，预防谵妄发生，实施低氧血症早期康复护理。 结果 41例患者低氧血症全部改善，36例患者成功转出心外重症监护室且康复出院，5例患者因肢体肌力未完全康复转其他医院继续康复治疗。住院时间5～52（20.7±8.6）d，ICU时间40～851 h（中位时间247 h），机械通气辅助时间16～710 h（中位时间181 h）。 结论 Stanford A型主动脉夹层肥胖患者低氧血症发生率高，术后严密监测病情变化，尽早采取针对性干预措施，对纠正患者低氧血症，尽快脱离呼吸机，改善临床预后具有重要意义。     

妊娠合并主动脉夹层的外科治疗

目的总结妊娠合并主动脉夹层的发病特点、妊娠期管理,探讨合理的诊疗方案。方法回顾性分析2011年1月至2017年6月武汉同济医院收治的10例妊娠合并主动脉夹层患者的临床资料,年龄25.2(21～29)岁。结果 10例患者中,8例为初产妇;5例在孕晚期,4例在产褥期发病,其中1例患者有妊娠期高血压,且左右上肢血压明显异常(初始接诊时:左上肢血压90/60 mm Hg,右上肢血压150/90 mm Hg)。临床表现主要为突发剧烈胸背疼痛,伴D-二聚体、C-反应蛋白(CRP)升高,可能与炎性反应相关;所有患者均经胸腹主动脉CTA确诊,其中5例为Stanford A型夹层,5例为Stanford B型夹层,10例患者中1例患者因拒绝手术,最终夹层破裂死亡、胎死腹中,其余9例均接受手术治疗,3例行胸主动脉覆膜支架腔内隔绝术,2例行Bentall术,1例行Bentall术+全主动脉弓血管置换术+胸主动脉覆膜支架腔内隔绝术,1例行Bentall术+胸主动脉覆膜支架腔内隔绝术,1例行Bentall+冠状动脉旁路移植术,1例行胸腹主动脉血管置换术;其中1例行胸主动脉覆膜支架腔内隔绝术因术后重症感染死亡,其余8例康复出院。9例夹层患者均为单胎分娩,9例新生儿中有5例出现新生儿重度窒息,4例轻度窒息。最终3例新生儿因严重并发症死亡,余6例生存。结论妊娠期合并主动脉夹层发生Stanford A型的比率远高于普通人群,胎儿发生宫内窒息的可能性较大,但经过积极有效的手术及围手术期处理,可以有效挽救母(胎)儿生命。     

胸主动脉夹层术后监护与治疗

目的 总结胸主动脉夹层术后监护与治疗的临床经验.方法 134例行胸主动脉夹层手术患者,术后入重症监护室(ICU)进行系统监护.根据患者的各系统状况和主动脉夹层特点,给予相应的支持对症治疗,尽早积极有效地防治可能出现的并发症.结果 平均ICU停留时间(78±53)h;术后死亡5例;一过性脑功能紊乱19例,延迟苏醒1例,脑血管意外3例,截瘫1例;低氧血症31例;心肌缺血1例,室性心律失常2例;术后肾功能衰竭1例;血管吻合口出血二次开胸止血4例;术后感染3例.结论 术后加强各系统的监护,尽早对高危因素分析与评估,有效预防、积极处理各系统并发症,是胸主动脉夹层患者顺利康复的保障.     

急性Stanford A型主动脉夹层术后ICU监护时间延长的危险因素分析

目的分析急性Stanford A型主动脉夹层术后重症监护室(ICU)监护时间延长的危险因素。方法回顾性分析青岛市市立医院2009年12月至2013年12月间80例Stanford A型主动脉夹层手术患者的临床资料,其中男54例(67.5%)、女26例(32.5%),平均年龄(48.9±12.5)岁,ICU时间延长定义为术后ICU时间≥5 d。按ICU监护时间分为两组,ICU监护时间5 d 67例,ICU监护时间≥5 d 13例。对两组患者围术期多项指标进行单因素和多因素分析。结果 ICU监护时间5 d和≥5 d患者的ICU监护时间分别为(63.2±17.4)h和(206.9±25.4)h,院内死亡率分别为3.0%和15.4%。单因素分析显示,ICU监护时间5 d和≥5 d患者患者年龄、欧洲心血管手术危险因素评分、术前D-二聚体水平、体外循环时间、是否深低温停循环、正性肌力药物、术后是否发生脑卒中、术后是否发生急性肾功能衰竭和呼吸衰竭、ICU滞留时间、住院时间差异均有统计学意义。多因素分析结果显示,体外循环时间、术后是否发生脑卒中、术后是否发生急性肾功能衰竭和呼吸衰竭是ICU监护时间延长的独立危险因素。结论体外循环时间、术后发生脑卒中、急性肾功能衰竭和呼吸衰竭是急性Stanford A型主动脉夹层术后ICU监护时间延长的独立危险因素。临床上可以根据上述危险因素采取相应的预防措施,有助于缩短术后ICU监护时间。     

胸主动脉夹层的再次手术治疗

目的分析胸主动脉夹层术后复发的原因,总结其外科治疗经验。方法回顾分析4例主动脉夹层术后复发患者行手术治疗的临床资料,其中行Bentall手术2例,胸主动脉置换术2例。结果全组无手术死亡,术后并发呼吸及肾功能不全1例,声音嘶哑1例。结论胸主动脉夹层术后再发与原发病、血压控制不良、第1次手术适应证的选择有关,急性DeBakey、型患者应行急诊手术治疗。     

孙氏手术治疗急、慢性Stanford A型主动脉夹层疗效的病例对照研究

目的分析孙氏手术治疗急、慢性Stanford A型主动脉夹层的疗效,探讨累及弓部的Stanford A型主动脉夹层的手术时机。方法回顾性分析2010年6月至2014年6月广东省心血管病研究所327例累及主动脉弓行孙氏手术治疗的急、慢性Stanford A型主动脉夹层患者的临床资料。根据发病至手术的时间是否2周,将患者分为急性组[≤2周,229例,男186例、女43例,年龄(47.47±11.19)岁,发病至手术的时间为(5.70±3.50)d]和慢性组[2周,98例,男76例、女22例,年龄(45.62±12.92)岁,发病至手术的时间为(21.60±15.70)d]。随访出院患者至术后一年。结果急、慢性组术前资料差异无统计学意义。与慢性组相比,急性组同期冠状动脉旁路移植术比例高、体外循环时间及主动脉阻断时间长、术中及术后24 h输红细胞量多,差异有统计学意义(P0.05);急性组病死率、脑神经功能障碍、低心排血量综合征、依赖连续性肾脏替代疗法的急性肾功能衰竭、肝功能不全及伤口愈合不良发生率较慢性组高,住ICU时间、呼吸机使用时间较慢性组长,差异有统计学意义(P0.05)。存活患者术后1年随访,急性组和慢性组生存率分别为97.0%和97.6%,差异无统计学意义。两组皆未有新的并发症。两组术后遗留的不可逆脑神经功能障碍、截瘫、肾功能衰竭差异无统计学意义。结论孙氏手术治疗累及主动脉弓的急性Stanford A主动脉夹层术后短期病死率和并发症显著高于慢性Stanford A型主动脉夹层,急性期手术治疗风险高。     

EuroSCORE Ⅱ预测A型主动脉夹层患者孙氏手术后院内死亡及住ICU时间延长的有效性研究

目的评估欧洲心脏手术风险评估系统Ⅱ(European System for Cardiac Operative Risk EvaluationⅡ,Euro SCOREⅡ)预测A型主动脉夹层患者孙氏手术(全主动脉弓置换+支架象鼻手术)后院内死亡及住ICU时间延长的有效性。方法回顾性分析2009年2月至2012年2月北京安贞医院384例A型主动脉夹层患者的临床资料。急性主动脉夹层228例(59.38%)。根据Euro SCOREⅡ预测术后死亡率将患者分为低危、中危、高危、极高危组。低危组296例(女52例),平均年龄(45.39±10.75)岁;中危组70例(女19例),平均年龄(47.67±11.26)岁;高危组13例(女5例),平均年龄(53.08±4.94)岁;极高危组5例(女1例),平均年龄(41.60±11.08)岁。手术方式均为中度低温停循环+选择性脑灌注下行孙氏手术。采用Euro SCOREⅡ预测患者术后死亡率及住ICU时间延长。结果院内死亡率为8.07%(31/384)。平均住ICU时间为3.06 d,42例住ICU时间≥7 d。对于低危组,Euro SCOREⅡ预测死亡率低于实际死亡率;对于中危、高危、极高危组,预测死亡率高于实际死亡率。Euro SCOREⅡ预测术后死亡、住ICU时间延长的区分度不佳,ROC曲线下面积分别为0.49和0.52,预测术后死亡、住ICU时间延长校正能力亦不佳(P0.001)。结论 Euro SCOREⅡ对A型主动脉夹层患者孙氏手术后院内死亡及住ICU时间延长的预测效能不佳。目前亟需专门针对A型主动脉夹层手术的风险评估系统。     

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.