腹腔镜脾切除治疗门脉高压脾功能亢进患者术后血栓相关并发症分析

目的探讨腹腔镜脾切除(LS)治疗门脉高压脾功能亢进患者术后血栓相关并发症发生情况。方法选取2015-02—2016-02间接受脾切除术的66例门脉高压脾功能亢进患者,依据手术方式不同分为2组,每组33例。A组行腹腔镜手术,B组行开腹手术。比较2组手术时间、切口长度、术中出血量、血小板计数(PLT)、PLT变化率及术后血栓相关并发症。结果 A组手术时间、术中出血量明显多于B组,手术切口长度明显短于B组(P0.05);2组术后PLT均较术前明显升高,但组间差异均无统计学意义(P0.05);A组PLT变化率、门脉系统血栓总出现率明显高于B组(P0.05)。结论相对于开腹术,LS术后患者更易产生门脉系统血栓,LS术暂时无法完全替代开腹术治疗门脉高压性脾功能亢进。     

门静脉高压症脾亢脾巨噬细胞数量及其吞噬功能的观察

目的观察门静脉高压症(PH)脾亢脾脏巨噬细胞(MΦ)数量及其吞噬功能的变化,为进一步探讨PH脾功能亢进(脾亢)的发病机制提供依据。方法取20例PH脾亢患者的手术脾脏作为PH组,按脾脏肿大程度的分级标准,再分为中度肿大组(11例)和重度肿大组(9例)。6例正常脾外伤性破裂患者的手术脾脏作为对照组。称重后贴壁法分离培养脾脏MΦ,用细胞计数板在显微镜下计数MΦ的相对数(每g脾脏组织中的MΦ数)并计算MΦ绝对数(整个脾脏内MΦ的总数),鸡红细胞吞噬法计算MΦ的吞噬率和吞噬指数。结果对照组、PH中度和重度脾大组MΦ的相对数分别为(13．13±3．72)×10~5/g、(8．80±0．97)×10~5/g、(7．29±1．33)×10~5/g,PH组比对照组均显著减少(P＜0．01),但PH的两组之间差异无统计学意义(P＞0．05)；PH组脾脏的重量明显增加(P＜0．01),可达正常脾重的3．5～6．0倍(放血后)；各组MΦ的绝对数分别为(1．94±0．55)×10~8、(4．91±1．12)×10~8、(6．86±0．77)×10~8,PH组比对照组均显著增多(P＜0．01),且PH重度肿大组也显著多于中度肿大组(P＜0．01)；各组MΦ的吞噬率和吞噬指数分别为(6,33±0．58)%和(0．07±0．01)、(11．25±2．19)%和(0．14±0．03)、(13．00±2．38)%和(0．16±0．04),PH组比对照组均显著增强(P＜0．01),但PH的两组之间比较差异无统计学意义(P＞0．05)。结论PH脾亢时,脾脏MΦ的相对数虽然减少,但绝对数增多,MΦ的吞噬功能增强。MΦ在PH脾亢的形成中可能扮演着非常重要的角色。进一步支持了脾亢发病中的“脾内阻留学说”。     

部分脾栓塞治疗血吸虫性脾功能亢进17例报告

目的探讨部分脾栓塞治疗血吸虫性脾功能亢进的临床价值。方法对血吸虫性脾功能亢进17例行周围性部分脾栓塞,栓塞剂为医用明胶海绵。结果栓塞范围50% ~75% (平均59 0% )。术后17例随访6 ~29个月,平均16 9月。白细胞计数术后最后一次随访为( 5 74±1 31 )×109 /L,比术前( 2 19±0 73 )×109 /L显著升高(t=11 86,P=0 000);血小板计数术后最后一次随访为(106 18±30 92 )×109 /L,比术前( 31 29±14 09 )×109 /L显著升高(t=8 28,P=0 000)。未出现严重并发症。结论部分脾栓塞治疗血吸虫性脾功能亢进安全、疗效确切,但其远期疗效需进一步观察。     

肝癌切除联全脾切除治疗肝癌全并肝硬化、脾功能亢进

目的探讨肝癌合并肝硬化、脾功能亢进时肝癌切除联合脾切除的意义.方法将204例肝癌合并肝硬化、脾功能亢进患者分为肝癌切除+脾切除组(简称切脾组,n=94)和单纯肝癌切除组(简称不切脾组,n=110),比较两组患者手术后白细胞、血小板、血清总胆红素、免疫功能的变化以及并发症发生和术后5年生存情况.结果 (1)两组患者术前CD4、CD8、CD4/CD8、IL2、IFN-γ、IL-10水平差异无显著性意义.(2)术后2个月,切脾组CD4和CD4/CD8分别为(40.8±4.1)%和(1.8±0.2),高于不切脾组的CD4(33.8±3.6)%和CD4/CD8(1.1±0.3),而切脾组CD8(25.8±3.8)%低于不切脾组CD8(32.9±4.1%),差异均有显著性意义(P＜0.05);切脾组IFN-γ和IL2分别为(102.2±14.8) pg/ml和(98.1±15.5) pg/ml,高于不切脾组的IFN-γ (85.6±14.7) pg/ml和IL2 (77.7±14.2) pg/ml,而切脾组IL10(56.8±10.3)pg/ml低于不切脾组IL-10(72.8±15.4)pg/ml,差异均有显著性意义(P＜0.05).(3)术后14 d,切脾组白细胞和血小板计数分别为(9.1±1.4)×109/L和(310±55)×109/L,明显高于不切脾组的(3.6±1.2)×109/L和(99±36)×109/L,两组差异有显著性意义(P＜0.01).(4)术后第7天,切脾组血清总胆红素为(24±7)μmol/L,低于不切脾组的(37±13)μmol/L,差异有显著性意义(P＜0.05).(5)两组术后并发症发生率分别为15.9%和14.5%,差异无显著性意义.(6)切脾组术后5年累积生存率56.4%,不切脾组为50.9%,差异无显著性意义(P＞0.05);但术后5年无瘤生存率切脾组和不切脾组分别为37.7%和18.9%,差异有显著性意义(P＜0.05).结论对肝细胞肝癌合并肝硬化脾功能亢进患者,行肝癌切除联合脾切除可促进机体T细胞亚群和Th细胞恢复平衡、WBC和PLT计数恢复正常;可减轻术后肝脏胆红素代谢负担,有利于肝功能恢复;术后并发症发生率并不增加,而术后5年无瘤生存率却明显提高;脾切除后对减慢肝硬化的发展和减少术后上消化道大出血的发生可能也有帮助.     

脾破裂与脾功能亢进行脾切除术后发热异同分析

外伤性脾破裂常采取脾切除术以达到彻底止血，防止休克的目的；肝硬化门脉高压引起的脾亢采取脾切除＋门奇断流解除脾功能亢进症状及预防上消化道出血。笔者发现：因不同病因行脾切除术后，出现的发热症状，在持续时间，发热高度上差异有着显著性，现报告如下。１　临床资料１．１　一般资料１９９６～１９９７年，因外伤性脾破裂行脾切除３２例，全部为急诊手术，其中男性２５例，女性７例，年龄２～５７岁，平均３３岁，其中１例２岁患儿行脾切除，部分脾组织大网膜移植术。因肝硬化、门脉高压、脾功能亢进行脾切除＋门奇断流术３２例，其…     

完全腹腔镜脾切除联合贲门周围血管离断术在肝硬化门脉高压症中的应用

目的:探讨完全腹腔镜脾切除联合贲门周围血管离断术治疗肝硬化性门静脉高压症的手术技巧、可行性、安全性及临床价值。方法:分析25例肝硬化门脉高压患者行脾切除联合贲门周围血管离断术的临床资料,患者分为两组,腹腔镜组(n=14)接受完全腹腔镜手术;开腹组(n=11)接受传统开腹手术。对比两组患者手术时间、术中出血量、术后疼痛指数、肠功能恢复时间、并发症发生率及术后住院时间等。结果:腹腔镜组12例成功完成手术,2例中转开腹。腹腔镜组与开腹组平均手术时间分别为(200±19)min、(172±20)min(t=3.361,P=0.511);术中平均出血量分别为(183±45)ml与(308±34)ml(t=-2.157,P=0.043);术后平均住院时间分别为(10.2±2.6)d与(12.9±2.0)d(t=2.788,P=0.011);腹腔镜组术后并发症发生率、术后疼痛指数较开腹组低,术后肠功能恢复较开腹组快,两组差异有统计学意义(P0.05)。结论:与传统开腹手术相比,完全腹腔镜脾切除联合贲门周围血管离断术创伤小、术中出血少,术后并发症发生率低,康复快,住院时间短,治疗门脉高压症是安全、可行、有效的,值得临床进一步推广。     

选择性脾动脉栓塞与脾修补术治疗外伤性脾破裂的比较

目的比较选择性脾动脉栓塞术与脾修补术的临床应用。方法回顾性分析1992-2004年我院进行的16例选择性脾动脉栓塞和23例脾修补术。结果2组病人均无死亡病例。选择性脾动脉栓塞组2例有术后并发症,脾修补术组10例有术后并发症(P<0.05)。选择性脾动脉栓塞组病人无输血,脾修补术组16例输血,平均输血(682.6±377.3)ml(P<0.05)。选择性脾动脉栓塞组平均住院日(7.3±1.1)d,脾修术组平均住院日(10.4±4.4)d(P<0.05)。选择性脾动脉栓塞组平均手术时间(1.9±0.6)h,脾修补术组平均手术时间(3.0±0.6)h(P<0.05)。结论选择性脾动脉栓塞与脾修补术的治疗效果相同。选择性脾动脉栓塞比脾修补术输血少,术后并发症少,住院时间短,手术时间短。     

腹腔镜脾切除术55例临床分析

目的 探讨腹腔镜脾切除术在各类脾脏疾病中的安全性及疗效.方法 回顾分析2007年5月至2009年12月完成的55例腹腔镜脾切除术资料.其中特发性血小板减少性紫癜(ITP)11例,自身免疫性溶血性贫血6例,球形红细胞增生症1例,脾淋巴瘤1例,脾囊肿10例,脾血管瘤5例,脾脉管瘤2例,肝硬化门脉高压脾功能亢进(脾亢)患者9例,肝硬化脾亢患者9例,不明原因脾肿大脾亢1例.结果 55例患者均顺利完成腹腔镜脾切除术,无中转手助或中转开腹,平均手术时间(119.7±33.0)min.术中出血量平均(83.8±65.2)ml.术后平均住院时间(5.7±1.1)d.术后腹水1例,腹腔引流液淀粉酶升高7例,无手术死亡.结论 腹腔镜脾切除术能安全有效地适用于多种脾脏疾病的手术治疗.     

门脉高压症合并脾功能亢进施行脾切除术的临床疗效分析

目的：分析门脉高压症合并脾功能亢进（简称门脉高压性脾亢）患者行脾切除术的近远期疗效和切脾对机体的影响。方法收集2004年1月至2014年1月收治的351例门脉高压性脾亢患者,回顾性分析病例资料以及行脾切除术后近期疗效评价,并进行远期随访调查,重点了解术后感染、肝癌、肝功能、血细胞变化以及系统疾病的控制情况等。结果患者行脾切除术后,近期内受损的肝功能和血细胞得以恢复。近期内出现黄疸者42例,腹水31例,发热34例,上消化道再出血者13例,予以积极对症处理后均康复出院。远期随访87例发现,29例在切脾约2~33（中位11.4）个月后出现肝功能下降,血清白蛋白水平下降和转氨酶水平升高;原伴发的糖尿病、高血压病和消化系统疾病切脾后较切脾前病情容易控制;继发肝癌者6例,4例死亡,未见有脾切除后凶险性感染。结论门脉高压症合并脾功能亢进患者进行脾切除术对机体有利有弊,故对于此类脾大患者不能一律予以切除。     

完全腹腔镜下脾切除联合贲门周围血管离断术治疗门静脉高压症的疗效评价

目的 比较完全腹腔镜与开腹巨脾切除联合贲门周围血管离断术治疗肝硬化门静脉高压症的临床疗效. 方法 回顾性分析2004年12月至2006年12月对20例肝硬化门静脉高压症食管静脉曲张患者行完全腹腔镜下二级脾蒂离断法脾切除联合贲门周围血管离断术,另20例患者行传统开腹手术.比较两组的手术时间、术中出血量、术后并发症和术后住院时间等资料.结果 腹腔镜组与开腹组平均手术时间分别为(235±79)min和(230±99)min(P=0.068),平均术中出血量分别为(520±386)ml和(1856±1799)ml(P=0.018).腹腔镜组术后发生胸腔积液3例,膈下脓肿1例,轻度腹水2例;开腹组术后发生胸腔积液2例,腹腔积液2例,切口感染2例,门静脉血栓形成1例.并发症发生率分别为30%和35%,两组之间比较差异无统计学意义(P=0.639).术后两组均无死亡病例.两组术后血小板均升至100×109/L以上.腹腔镜组和开腹组平均住院时间分别为(8.5±2.6)d和(14.5±7.4)d(P=0.018).术后随访6～24个月,未再次发生上消化道出血.结论 完全腹腔镜下脾切除联合贲门周围血管离断术比开腹手术术中出血少,住院时间短,具于微创优势,值得推广应用.     

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.