七氟醚对未成熟兔在体心肌缺血/再灌注血清IL-6、TNF-α的影响

目的 研究七氟醚对未成熟兔在体心肌缺血,再灌注血清IL-6、TNF-α水平的影响.方法 1～2周龄未成熟兔随机分为对照组(C组)、缺血,再灌注组(I/R组)和七氟醚预处理组(S组),每组8只.分别于缺血前(T0)、缺血30 min再灌注前(T1)、再灌注120 min后(T2)采取静脉血,ELISA法检测血清中IL-6和TNF-α的水平;再灌注120 min后取心肌组织,HE染色光镜下观察其病理学改变.结果 T2时S组IL-6水平(66.07±24.12) pg/μl,低于I/R组的(200.37±93.07)pg/μl,P<0.05;,INF-α水平(6.56±3.61) pg/μl,略低于I/R组(8.59±2.68)pg/μl,但差异无统计学意义(P>0.05).光镜下S组心肌组织病理改变较I/R组轻.结论 七氟醚可通过降低血浆IL-6、TNF-α水平,减轻机体的炎症反应来对未成熟兔在体心肌缺血/再灌注损伤起保护作用.     

阿片受体在异氟醚延迟预处理减轻兔心肌缺血再灌注损伤中的作用

目的 探讨阿片受体在异氟醚延迟预处理减轻兔心肌缺血再灌注损伤中的作用.方法 健康雄性新西兰大白兔40只,体重2.0～2.5 kg,采用结扎左冠状动脉前降支40 min,再灌注120 min的方法制备心肌缺血再灌注损伤模型,随机分为4组(n=10):假手术组(S组)吸入纯氧2 h,24 h后仅动脉下穿线不结扎;心肌缺血再灌注组(IR组)吸入纯氧2 h,24 h后行心肌缺血再灌注;异氟醚延迟预处理组(I组)吸人2%异氟醚2 h,24 h后行心肌缺血再灌注;阿片受体阻断剂+异氟醚延迟预处理组(N组)静脉注射纳洛酮6 mg/kg后10 min,吸入2%异氟醚2 h,24 h后行心肌缺血再灌注.于再灌注120 min时取心脏,计算心肌缺血面积和梗死面积,测定磷酸化p38MAPK蛋白表达水平,观察心肌细胞超微结构.结果 S组心肌细胞完整,排列整齐,线粒体形态正常,糖原丰富;IR组和N组心肌细胞水肿,心肌纤维排列紊乱,线粒体、内质网膜水肿,空泡化;I组心肌细胞水肿程度减轻,心肌纤维排列较完整,线粒体轻度水肿.与IR组比较,I组心肌梗死面积减小,磷酸化p38MAPK蛋白表达下调(P<0.05),N组上述指标差异无统计学意义(P>0.05).结论 阿片受体参与异氟醚延迟预处理减轻兔心肌缺血再灌注损伤.     

乳化异氟醚预处理对大鼠肾缺血再灌注损伤的影响

目的 评价乳化异氟醚预处理对大鼠肾缺血再灌注损伤的影响.方法 选择雄性SD大鼠32只,体重220～300 g,10～ 13周龄,采用随机数字表法,将其分为4组(n=8):假手术组(S组)、肾缺血再灌注组(I/R组)、乳化异氟醚预处理组(E组)和脂肪乳剂预处理组(I组).I/R组、E组和I组采用夹闭左侧肾蒂45 min后恢复再灌注的方法建立肾缺血再灌注模型.E组和I组分别静脉输注8%乳化异氟醚、30%脂肪乳剂4ml·kg-·h-30 min,洗脱15 min后制备模型.于再灌注3h时采集腹主动脉血样5ml,测定血清肌酐(Cr)、胱抑素C(Cys C)、TNF-α、IL-6、IL-10浓度;取左肾组织,行HE染色,光镜下观察病理学结果,并行肾脏近曲小管坏死程度分级.结果 与S组比较,其余3组血清Cr、Cys C、TNF-α、IL-6、IL-10浓度及肾脏近曲小管坏死程度均升高(P＜0.05);与I/R组和I组比较,E组血清Cr、Cys C、TNF-α、IL-6浓度及肾脏近曲小管坏死程度均降低(P＜0.05),血清IL-10浓度升高(P＜0.05).I/R组和I组上述各指标比较差异无统计学意义(P＞0.05).I/R组和I组肾组织病理学损伤严重,E组肾组织病理学损伤明显减轻.结论 8％乳化异氟醚预处理可减轻大鼠肾缺血再灌注损伤,其机制可能与抑制全身炎性反应有关.     

七氟醚后处理对大鼠脑缺血-再灌注损伤的抗炎作用

目的观察七氟醚后处理对大鼠脑缺血-再灌注(IR)炎症反应的作用。方法 40只Wistar大鼠被随机分为五组:S组大鼠分离血管但不阻断大脑中动脉,术后90min给予1.0MAC的七氟醚30min。IR组阻断大脑中动脉90min,在再灌注初期给予氧气30min。PS1、PS2、PS3组均阻断大脑中动脉90min,在再灌注初期分别给予0.5、1.0、1.5MAC的七氟醚30min。再灌注24h时采集股动脉血样,测定血清TNF-α、IL-10、IL-1β浓度。结果与S组比较,IR组大鼠的血清TNF-α和IL-1β浓度明显升高,而IL-10浓度明显降低(P0.05)。与IR组比较,PS1、PS2和PS3组血清TNF-α和IL-1β浓度明显降低,IL-10浓度明显升高(P0.05),并且随着七氟醚吸入浓度的增加,其作用不同程度地增强(P0.05)。结论七氟醚后处理对于缺血-再灌注大鼠可实现脑保护作用,并缓解血清炎症因子的变化。     

异氟醚预处理对兔局灶性脑缺血再灌注时降钙素基因相关肽和NF-κB的影响

目的 探讨异氟醚预处理对兔局灶性脑缺血再灌注时降钙素基因相关肽( CGPP)和NF-κB水平的影响.方法 新西兰纯系家兔54只,雌雄不拘,体重2.0～2.5 kg,采用随机数字表法,将其随机分为3组(n＝18):假手术组(S组)、脑缺血再灌注组(I/R组)和异氟醚预处理(I组).麻醉下气管内插管,机械通气,S组和I/R组静脉输注咪达唑仑维持麻醉;I组吸人1.4％异氟醚30 min后洗脱10 min进行异氟醚预处理,然后制备脑缺血再灌注损伤模型,在脑缺血再灌注损伤过程中静脉输注咪达唑仑,3组静脉输注芬太尼和维库溴铵.I/R组和I组采用线栓法制备局灶性脑缺血再灌注损伤模型,于缺血2h时进行再灌注.分别于麻醉前和再灌注即刻、1h、2h、3h、4h、5h时取耳中央动脉血样,测定血浆CGRP浓度,各时点取完血样后立即处死动物,测定脑组织神经元NF-κB活性及其表达.结果 与S组比较,I/R组血浆CGRP浓度、脑组织神经元NF-κB活性升高,脑组织NF-κB表达上调(P<0.05);与I/R组比较,I组血浆CGRP浓度升高,脑组织神经元NF-κB活性降低,脑组织NF-κB表达下调(P<0.05).结论 异氟醚预处理减轻兔脑缺血再灌注损伤的机制与促进CGRP释放及抑制神经元NF-κB功能有关.     

异氟醚延迟预处理对兔心肌缺血再灌注时αB-晶状体蛋白表达的影响

目的 探讨异氟醚延迟预处理对兔心肌缺血再灌注时αB-晶状体蛋白表达的影响.方法 健康雄性新西兰大白兔30只,体重2.0～2.5 kg,随机分为3组(n=10):假手术组(S组)吸入纯氧2 h,24 h后仅动脉下穿线不结扎;心肌缺血再灌注组(IR组)吸入纯氧2 h,24 h后行心肌缺血再灌注;异氟醚延迟预处理组(Ⅰ组)吸入2%异氟醚2 h,24 h后行心肌缺血再灌注.采用结扎左冠状动脉前降支40min,再灌注120 min的方法制备心肌缺血再灌注模型.于再灌注120 min时采集动脉血样测定血清超氧化物歧化酶(SOD)活性,取心肌组织测定αB-晶状体蛋白及caspase-3的表达水平,计算心肌缺血面积和梗死面积,观察心肌细胞超微结构.结果 S组心肌细胞完整,排列整齐,线粒体形态正常,糖原丰富;IR组心肌细胞水肿,心肌纤维排列紊乱,线粒体、内质网膜肿胀,空泡化;Ⅰ组心肌细胞水肿程度减轻,心肌纤维排列较完整,线粒体轻度肿胀.与IR组比较,Ⅰ组心肌梗死面积减小,血清SOD活性升高,心肌caspase-3表达下调,αB-晶状体蛋白表达上调(P<0.05).结论 异氟醚延迟预处理减轻兔心肌缺血再灌注损伤的机制可能与上调心肌αB-晶状体蛋白表达有关.     

线粒体通透性转换孔在七氟醚延迟预处理减轻大鼠心肌缺血再灌注损伤中的作用

目的 探讨线粒体通透性转换孔(mPTP)在七氟醚延迟预处理减轻大鼠心肌缺血再灌注损伤中的作用.方法 雄性SD大鼠80只,体重250～300 g,随机分为5组(n=16):假手术组(S组)、缺血再灌注组(IR组)、七氟醚延迟预处理组(SP组)、mPTP开放剂苍术苷+七氟醚延迟预处理组(A+SP组)和苍术苷组(A组).IR组、SP组、A+SP组和A组采用结扎左冠状动脉前降支30 min后进行再灌注的方法制备心肌缺血再灌注模型.SP组和A+SP组吸入2.5%七氟醚l h,其余组吸入纯氧1 h,停止吸入后24 h进行心肌缺血.A+SP组和A组在缺血前15 min经尾静脉注射苍术苷5 mg/kg.再灌注120 min时采集颈动脉血样,测定血清肌钙蛋白I(cTnI)浓度.然后处死大鼠,测定心肌梗死体积,检测心肌组织Bcl-2及Bax表达水平,电镜下观察心肌超微结构.结果 与S组比较,其他各组血清cTnI浓度升高,心肌梗死体积扩大,Bcl-2表达下调,Bax表达上调(P＜0.05).与IR组比较,SP组血清cTnI浓度降低,心肌梗死体积缩小,Bcl-2表达上调,Bax表达下调(P＜0.05),心肌病理学损伤减轻.苍术苷可取消七氟醚延迟预处理减轻大鼠心肌缺血再灌注损伤的效应(P＜0.05).结论 抑制mPTP开放后可导致Bcl-2表达上调,Bax表达下调,参与了七氟醚延迟预处理减轻大鼠心肌缺血再灌注损伤.     

异氟醚预处理和异丙酚预处理对大鼠心肌缺血再灌注损伤的影响

目的 评价异氟醚预处理和异丙酚预处理对大鼠心肌缺血再灌注损伤的影响.方法 雄性Wistar大鼠36只,体重250～300 g,随机分为4组(n=9):缺血再灌注组(I/R组)、异氟醚预处理组(Ⅰ组)、异丙酚预处理组(P组)和异氟醚预处理联合异丙酚预处理组(I+P组).Ⅰ组异氟醚预处理方法:吸入1.6%异氟醚10 min,停止吸入5 min,共重复2次;P组异丙酚预处理方法:静脉输注异丙酚37.5 mg·kg~(-1)·h~(-1) 10 min,停止输注5 min,共重复2次;I+P组同时进行异氟醚预处理和异丙酚预处理.预处理后立即结扎左冠状动脉前降支60 min,随后松开进行再灌注,I/R组只进行缺血再灌注.再灌注120 min时每组取1只大鼠,取心肌组织,透射电镜下观察心肌细胞超微结构;各组其余大鼠处死后,取左心室,采用TUNEL法测定心肌细胞凋亡情况,计算凋亡指数,并测定心肌细胞线粒体活性氧(ROS)水平.结果 各组均可见凋亡小体,I组、P组和I+P组心肌损伤程度轻于I/R组.与I/R组比较,I组、P组和I+P组心肌细胞凋亡指数和ROS水平降低(P＜0.05),而I组、P组和I+P组间上述指标比较差异无统计学意义(P＞0.05).结论 异氟醚预处理或异丙酚预处理及两种方法联合应用时减轻大鼠心肌缺血再灌注损伤的效应相似.     

七氟醚静-吸复合麻醉对原位肝移植手术患者围术期细胞因子的影响

目的观察七氟醚静-吸复合麻醉对原位肝移植手术患者围术期核因子-κB(NF-κB)及肿瘤坏死因子α(TNF-α)和白细胞介素-8(IL-8)的影响。方法 90例行经典非转流式原位肝移植手术的终末期肝病患者,随机均分为异氟醚组(I组)和七氟醚组(S组),两组均采用静-吸复合麻醉,静脉麻醉药为丙泊酚。分别于术前(T1)、无肝期前(T2)、无肝期35min(T3)、新肝期30min(T4)、新肝期2h(T5)及术后12h(T6),静脉采血检测TNF-α及IL-8。新肝再灌注后2h取部分移植肝组织,用于测定肝组织中NF-κB蛋白表达量及其入核后与靶基因的结合活性。结果与T1时比较,T3~T5时两组患者TNF-α、IL-8水平明显升高(P0.05或P0.01)。T3~T5时S组患者TNF-α、IL-8水平均明显低于I组(P0.05或P0.01);S组患者再灌注后肝组织中NF-κB蛋白表达量明显低于I组(P0.05)。结论与异氟醚比较,肝移植手术中应用七氟醚静-吸复合麻醉可以降低NF-κB、TNF-α和IL-8的表达,减轻肝缺血-再灌注损伤,对保护肝组织有利。     

异氟醚预处理对大鼠肝脏缺血再灌注损伤的影响

目的 探讨异氟醚预处理对大鼠肝脏缺血再灌注损伤的影响.方法 成年雄性SD大鼠24只,体重180～220 g,随机分为3组(n=8):假手术组(S组)吸人纯氧30 min,间隔30 min后仅开腹;肝脏缺血再灌注组(IR组)吸入纯氧30 min,间隔30 min后行肝脏缺血60 min,再灌注4 h;异氟醚预处理组(Iso组)吸入1.4%异氟醚30 min,间隔30 min后行肝脏缺血60 min,再灌注4 h.于再灌注4 h时处死大鼠,留取肝脏及腹主动脉血5ml.测定血清谷丙转氨酶(ALT)和谷草转氨酶(AST)浓度,血清及肝组织匀浆上清液中肿瘤坏死因子α(TNF-α)的浓度,肝组织髓过氧化物酶(MPO)、超氧化物歧化酶(SOD)活性及丙二醛(MDA)含量,观察肝组织病理学改变.结果 与S组比较,IR组、Iso组血清ALT、AST和TNF-α水平明显升高,肝组织TNF-α含量升高,肝组织MPO活性升高,MDA含量升高,SOD活性降低(P＜0.05或0.01),肝组织病理损伤明显;与IR组比较,Iso组血清ALT、AST和TNF-α水平降低,肝组织TNF-α含量降低,肝组织MPO活性降低,MDA含量降低,SOD活性升高(P＜0.05或0.01),肝组织病理损伤程度减轻.结论 1.4%异氟醚预处理可明显减轻大鼠肝脏缺血再灌注损伤,其机制可能与抑制TNF-α的释放、减少中性粒细胞在肝组织的浸润有关.     

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.