后路截骨联合椎弓根内固定矫形治疗僵硬性脊柱侧后凸畸形

目的探讨经后路截骨联合椎弓根内固定矫形治疗僵硬性脊柱侧后凸畸形疗效。方法对26例僵硬性脊柱侧后凸畸形患者进行后路截骨、椎弓根内固定矫形。8例行后路Ponte截骨,13例行椎弓根截骨术(PSO)联合Ponte截骨,5例行全椎体切除术(VCR)。比较患者术前、术后和末次随访时Cobb角的变化及C7中垂线与骶骨中垂线距离的变化。结果患者均获得随访,时间12~60个月。侧凸Cobb角:术前30°~135°(90.7°±30.6°),术后12°~30°(18°±5.6°),矫正率为82.5%,末次随访13°~32°(20°±5.8°),丢失4.3%;后凸Cobb角:术前20°~60°(40.6°±18.5°),术后10°~26°(16.8°±6.2°),矫正率为85%,末次随访13°~30°(20.5°±7.0°),丢失3.7%;C7中垂线与骶骨中垂线距离:术前3.8~6.5(5.1±1.3)cm,术后0.3~1.3(0.7±0.3)cm,末次随访0.4~1.7(0.8±0.3)cm。所有患者未发生神经损伤等并发症,仅1例患者术后3个月出现内固定松动,经延长固定节段后骨性融合。结论术前充分的评估,选择合适的后路截骨方式,联合椎弓根内固定矫形治疗僵硬性脊柱侧弯,能有效矫正畸形和恢复脊柱冠、矢状面平衡。     

经椎弓根楔形截骨矫正强直性脊柱炎后凸畸形

目的研究经腰椎椎弓根楔形截骨矫正强直性脊柱炎后凸畸形的手术方法和治疗效果。方法2003年1月~2006年12月收治12例男性强直性脊柱炎后凸畸形患者,平均年龄36岁。手术采用一期后路经L3椎弓根截骨矫形,截骨节段上方和下方至少2个节段椎弓根螺钉矫正固定。测量患者术前和术后颌眉线/垂线夹角和脊柱侧位X线L2~4椎体Cobb角度。结果患者颌眉线/垂线夹角由术前平均76.3°矫正到术后平均17°,而L2~4的Cobb角度由术前平均后凸6.7°矫正到术后平均前凸48.6°。所有患者能够平视行走,矢状面平衡和步态得到明显改善。结论对于严重强直性脊柱炎后凸畸形患者,经腰椎椎弓根楔形截骨矫形是一种安全有效的治疗方法。     

一期后路经椎弓根截骨病灶清除植骨内固定治疗胸腰段脊柱结核

[目的]探讨治疗胸腰段脊柱结核一期完成病灶清除、矫正脊柱后凸畸形、植骨、后路钉棒固定的临床疗效。[方法]自2004年1月~2008年6月收治活动期胸腰段单节段脊柱结核伴后凸畸形患者34例,采用一期后路椎弓根截骨病灶清除(在胸椎段,先切取左右肋骨后段),钛笼植骨,后路矫形系统内固定。根据术前、术后X线分析植骨融合情况以及脊柱后凸畸形矫正效果。[结果]34例患者随访时间9~28个月,平均18个月,X线片示结核病灶清除彻底,脊柱畸形矫正,Cobb角由术前20°~45°矫正到术后3°~5°,植骨块无移位,2例再次行前路补充植骨术。结核无复发。[结论]该手术入路简捷,病灶清除彻底,360°环形解除压迫,畸形矫正满意,三柱固定,植骨融合,后期脊柱稳定,缩短了卧床时间,减少了相应的并发症。     

后路半椎体切除椎弓根螺钉内固定治疗小儿先天性脊柱畸形

目的评价后路半椎体切除、椎弓根螺钉内固定治疗小儿先天性脊柱畸形的临床疗效.方法2003年6月～2005年6月应用后路半椎体切除、椎弓根螺钉内固定和自体骨短节段植骨融合治疗28例小儿先天性脊柱侧凸畸形患者,男10例,女18例,年龄1.6～7岁,平均3.8岁.完全分节半椎体24例,半椎体伴对侧分节障碍4例.术后定期复查脊柱X线片,观察脊柱融合、畸形矫正率及内固定稳定情况.结果术中发生胸膜损伤和脑脊液漏各1例,分别经胸腔和伤口引流痊愈;术后切口浅表感染1例,经抗炎和换药处理治愈;无神经系统损伤.随访23～48个月,平均35个月,术前主弯冠状面Cobb角平均为35.2°±2.2°,术后为5.2°±1.2°,末次随访为7.4°±1.1°,丢失2.2°;后凸角平均为26.2°±3.1°,术后为4.2°±0.8°,末次随访为4.8°±1.0°,丢失0.6°;均获得良好骨融合,融合时间3～6个月,平均4.2个月;无内固定失败及假关节形成.结论后路半椎体切除、椎弓根螺钉内固定植骨融合能安全有效地矫正小儿先天性脊柱侧凸畸形,并能达到稳定的短节段内固定及优良的融合效果.     

经后路L1椎体截骨短节段椎弓根内固定术治疗脊柱后凸畸形

目的探讨L1椎体楔形截骨椎弓根螺钉内固定术矫治胸腰段脊柱后凸畸形的效果。方法56例胸腰段后凸畸形患者,均行经后路L1椎体截骨短节段椎弓根内固定,全部采用单节段截骨。结果本组平均手术时间3．7（2．8～4．6）h,术中平均出血量1980（700—3600）ml。术后后凸角由手术前平均54．5°矫正到16．5°,矫正角度38°。随访6～72个月,其间畸形矫正无明显丢失,除2例出现下肢麻痹外,其余均未出现神经系统并发症。结论L1椎体楔形截骨椎弓根螺钉内固定术矫治脊柱后凸畸形固定可靠,矫形效果满意。     

脊柱陈旧骨折后凸畸形的矢状面重建

目的:介绍脊柱陈旧骨折后凸畸形矢状面重建的手术方法。方法:18例胸腰椎陈旧骨折并后凸畸形患者采用两种手术方式治疗:14例采用经椎弓根椎体截骨短节段内固定,4例采用前后联合入路减压、前路截骨Z-plate钢板内固定。结果:随访6个月~3年,无骨不连等发生,有1例TSRH固定患者2枚螺钉发生松动。无脊髓损伤并发症。神经功能Frankel分级均有1级以上提高,术后矢状指数平均6°。结论:经椎弓根椎体截骨短节段内固定和前后联合入路减压、前路截骨内固定,可有效地矫正胸腰椎陈旧骨折遗留的脊柱矢状面畸形,并重建脊柱的稳定性。     

双椎体截骨术矫正重度强直性脊柱炎后凸畸形

目的:探讨经椎弓根双椎体截骨矫正重度强直性脊柱炎后凸畸形的可行性及其疗效.方法:2003年1月～2007年12月收治15例颌眉角90°以上重度强直性脊柱炎后凸畸形患者,平均年龄34.5岁.手术均采用后路经椎弓根连续或者间隔椎体行双椎体截骨矫形,并采用椎弓根螺钉内固定.测量患者术前和术后身高、颌眉角、矢状面失平衡距离和截骨部位Cobb角评价疗效.结果:手术时间231～420min,平均326min;术中出血950～4600ml,平均2290ml.6例患者硬脊膜与椎板粘连,切除椎板时出现硬脊膜破裂并脑脊液漏,经严密缝合及控制引流后伤口按期愈合;1例患者矫形中已融合的C5/6处发生骨折,术后给予硬颈托固定6个月后融合;1例患者术后出现肺部感染,经积极抗炎治疗痊愈出院.患者身高由术前122.5±10.4cm矫正到术后163.6±10.0cm,颌眉角由术前平均102.6°±9.4°矫正到术后19.5°±11.6°,矢状面失平衡距离由术前43.7±5cm矫正到术后11.3±6.1cm,脊柱侧位X线片上截骨部位Cobb角由术前后凸67.1°±24.5°矫正到术后前凸9.7°±25.1°,经统计学处理各指标术后与术前比较均存在显著性差异(P<0.01).结论:对于颌眉角90°以上重度强直性脊柱炎后凸畸形患者,经椎弓根双椎体截骨可以有效矫正患者后凸畸形,外观和功能均可得到明显改善.     

经后路顶椎椎弓根全椎体截骨矫正胸腰椎后凸畸形

目的探讨经后路顶椎椎弓根三柱截骨治疗脊柱后凸的临床疗效。方法2003年6月－2006年6月,采用经后路顶椎椎弓根三柱截骨治疗42例脊柱后凸患者,其中陈旧胸腰椎骨折20例、椎体发育不良8例、结核性10例、强直性脊柱炎4例。评定脊柱后凸矫正情况、植骨融合情况、内固定位置、手术并发症、腰痛及Oswestry功能评分的变化。结果术后随访6—21个月,平均15个月。植骨融合满意,无延迟愈合或不愈合。术前后凸Cobb角度平均为霹8．5°术后为20．6°,平均矫正角度为35．3°。术前患者腰痛VAS评分平均为7．5分,术后3．6分。术前ODI平均为57．6％,术后31.7％。结论经后路顶椎椎弓根截骨、椎弓根螺钉固定治疗胸腰椎后凸畸形,矫正角度大,手术视野开阔,手术相对安全,可获得满意的放射学矫形效果和临床疗效。     

经后路椎弓根截骨短节段椎弓根钉内固定治疗脊柱后凸畸形

目的探讨经椎弓根单椎体截骨短节段椎弓根钉内固定治疗脊柱后凸畸形的临床疗效。方法2001年6月~2003年11月,采用经后路椎弓根截骨短节段椎弓根钉内固定治疗16例脊柱后凸畸形患者。其中男11例,女5例,年龄24~51岁。强直性脊柱炎12例,陈旧性胸腰椎骨折脱位伴不完全截瘫2例,椎体发育不良2例。病程7~25年,平均12.8年。手术前、后均行脊柱全长X线片检查,测量胸椎后凸角、腰椎前凸角、骶骨水平角及骶骨后上角至脊柱矢状轴线的距离,评定植骨愈合情况、内固定位置及手术并发症。按Bridwell-Dewald脊柱疾患疼痛及功能评定标准进行手术前后疗效评价。结果术中出血700~2000ml,平均1100ml;术中硬脊膜破裂1例;术后发生麻痹性肠梗阻1例,下肢短暂性麻痹2例。术后获随访18~35个月,平均25.6个月。植骨愈合满意,无延迟愈合或不愈合。最后随访时,腰椎前凸角从术前9.6±16.4°,矫正至术后42.6±14.3°(P<0.05),平均矫正角度为33°;骶骨水平角的改变与此类似。胸椎后凸角手术前后改变不明显,而骶骨后上角至脊柱矢状轴线的距离由术前97.5±45.6mm降至术后10.7±9.6mm(P<0.05)。术后疼痛、工作及社交情况较术前都有明显改善。结论经后路椎弓根椎体截骨短节段椎弓根钉内固定治疗脊柱后凸畸形,矫正度数大,手术相对安全,可取得较理想的放射学矫形效果及临床疗效。     

应用头颅-骨盆环牵引辅助后路截骨治疗重度脊柱侧后凸畸形的临床效果

目的探讨应用头颅-骨盆环牵引辅助后路截骨矫形治疗重度脊柱侧后凸畸形的临床效果。方法回顾分析2014年3月至2018年3月贵州省骨科医院脊柱外科收治的重度脊柱侧后凸畸形患者32例的临床资料。其中男14例,女18例,年龄(17.5±4.8)(14~23)岁。均行Halo骨盆牵引后后路截骨矫形手术治疗。牵引力取患者可承受的极限,牵引时间为(3.2±0.6)(3~4)周,后行后路截骨内固定融合术。对患者治疗前左右侧屈位、牵引后和术后的侧后凸矫正率进行比较。采用SPSS 24.0软件对数据进行统计学处理。结果32例患者均顺利完成手术。行经椎弓根椎体截骨(pedicle subtraction osteotomy,PSO)或邻椎截骨12例、Smith-Petersen截骨(Smith-Petersen osteotomy,SPO)或Ponte截骨20例。未见脊髓与神经损伤并发症发生。治疗前脊柱冠状面Cobb角为(136.8±38.0)°(96°~172°),矢状面Cobb角为(90.4±24.0)°(45°~125°)。患者平卧左右侧屈位侧凸矫正率为(8.9±3.2)%,Halo骨盆牵引后侧凸矫正率为(37.6±4.3)%,后路截骨矫形术后侧凸矫正率为(68.7±4.8)%;牵引后矢状面侧凸矫正率为(30.7±5.6)%,后路矫形术后矢状面侧凸矫正率(60.6±4.3)%;各时间点差异均有统计学意义(均P<0.05)。结论应用Halo头颅-骨盆牵引辅助后路截骨矫形治疗重度脊柱侧后凸畸形患者,可预测矫形效果,简化手术,降低操作难度,提高畸形矫正率,安全有效。     

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.