Principles of anesthesia for Principles of anesthesia for medical studentsmedical students
Speaker:Speaker: Landoni GLandoni G Vita-Salute University of MilanoVita-Salute University of Milano
May 14° 2009May 14° 2009
IRCCS Ospedale San Raffaele MilanoIRCCS Ospedale San Raffaele MilanoUniversità Vita-Salute San RaffaeleUniversità Vita-Salute San Raffaele
ITACTA ONGOING RCTsTOPICS HOSPITALS PATIENTS GRANTS
VOLATILE ANESTHETICS
FENOLDOPAM
DESMOPRESSIN
ESMOLOL LEVOSIMENDAN VALVOLE PERCUTANEE
4 200 AIFA 2006
34 1.000 MINISTRY 2008
3 200
3 200 10 1.000 3 150
HSR
100 ANESTHESIOLOGISTS30 students/residents (6 per year)
Clinical dutiesResearchTeachingCongresses(developing countries)
Anesthesiology (US)
Anesthesiologists are physicians that administer anesthetics to alleviate pain and suppress consciousness, as well as monitor and support life functions during surgery. They also provide medical care and consultation outside the operating room and participate in the diagnosis and treatment of pain syndromes.
CLINICAL DUTIES (ITALY)
ANESTHESIAINTENSIVE CAREEMERGENCY DEPARTMENTIN-HOSPITAL EMERGENCYOUT-OF-HOSPITAL EMERGENCIESHYPERBARIC MEDICINEPAIN THERAPY
CLINICAL DUTIES (ITALY)
ANESTHESIA
IPNOSISMUSCLE RELAXATIONPAIN(REFLEXES)
CLINICAL DUTIES (ITALY)
ANESTHESIAINTENSIVE CARE
NEUROLOGIC STATUSLUNGSCARDIOVASCULARKIDNEYSDRUGS
CLINICAL DUTIES (ITALY)
ANESTHESIAINTENSIVE CAREEMERGENCY DEPARTMENTIN-HOSPITAL EMERGENCYOUT-OF-HOSPITAL EMERGENCIES
BLSALSATLS
INVASIVE PROCEDURES
Hai mai utilizzato un vero defibrillatore manuale? Si No 97% Hai mai utilizzato un vero defibrillatore semi-automatico? Si No 94% Hai mai effettuato una cardioversione sincronizzata? Si No 95%
Hai effettuato la gestione di base delle vie aeree (apertura delle vie aeree, estensione del capo, posizionamento cannula orofaringea)? Si No 81%
Hai effettuato la gestione avanzata delle vie aeree (intubazione orotracheale, posizionamento maschera laringea)? Si No 88%
Hai effettuato una cricotiroidotomia? Si No 100%
Hai effettuato una ventilazione manuale con pallone autoespansibile (“Ambu”)? Si No 70%
Department of Cardiothoracic and Vascular Anesthesia and Intensive Care
Vita-Salute San Raffaele University, Milan, Italy
INTRA AORTIC BALLOON PUMP
Hai posizionato un’agocannula venosa? Si No 39% Hai effettuato un prelievo venoso? Si No 0% Hai effettuato un prelievo arterioso (emogasanalisi)?
Si No 9%
1. Hai effettuato una rachicentesi? Si No 99% Hai posizionato un sondino naso-gastrico? Si No 73% Hai effettuato una paracentesi? Si No 95% Hai posizionato un drenaggio toracico? Si No 99% Hai effettuato una pericardiocentesi? Si No 100%
Hai effettuato esercitazioni di rianimazione cardiopolmonare? Si No 69% ( 0%)
Hai effettuato esercitazioni sull’esame del paziente adulto in rapido peggioramento?
Si No 87% Hai effettuato esercitazioni di valutazione e assistenza al paziente
critico pediatrico? Si No 81%
Ti senti adeguatamente preparato per una prima valutazione ed assistenza ad un paziente critico?
Si No 82%
Clinical dutiesResearch (ENGLISH)TeachingCongresses(developing countries)
Levosimendan and Mortality in Cardiac Surgery
Review: LEVOSIMENDAN CCH (12/1/2009)Comparison: 01 perioperative levosimendan Outcome: 02 Mortality
Study Levosimendan Control Peto OR Peto ORor sub-category n/N n/N 95% CI 95% CI
Al-Shawaf 1/14 1/16 1.15 [0.07, 19.41] Alvarez 2005 1/15 0/15 7.39 [0.15, 372.38] Alvarez 2006 1/25 1/25 1.00 [0.06, 16.45] Barisin 0/21 0/10 Not estimable De Hert 2007 0/15 3/15 0.12 [0.01, 1.22] De Hert 2008 1/40 4/20 0.11 [0.02, 0.72] Husedzinovic 0/12 0/12 Not estimable Jarvela 1/12 0/12 7.39 [0.15, 372.38] Levin 6/69 17/68 0.31 [0.13, 0.77] Tritapepe 0/12 0/12 Not estimable
Total (95% CI) 235 205 0.35 [0.18, 0.71]Total events: 11 (Levosimendan), 26 (Control)Test for heterogeneity: Chi² = 8.27, df = 6 (P = 0.22), I² = 27.4%Test for overall effect: Z = 2.95 (P = 0.003)
0.001 0.01 0.1 1 10 100 1000
Favours levosimendan Favours control
11/235=4.7% v 26/205=12.7% P=0.007 NNT = 12
Levosimendan and Mortality in Cardiac Surgery
Journal
NEW ENGL J MED LANCET JAMA ANNALS OF INTERNAL MEDICINE CIRCULATION J AM COLL CARDIOL EUR HEART J CRITICAL CARE MEDICINE CLINICAL CHEMISTRY ANESTHESIOLOGY ANAESTHESIA ANALGESIA
Impact Factor 2006
51,325,823,214.8
10,99,77,36,65,54,22,1
Cardioprotection & anaesthesia
Volatile AnestheticsVolatile Anesthetics
blockers “recommended”
Statins “suggested” in selected pts
2 agonists “may be considered” in selected pts
Ca++ antagonists “may be considered” in selected pts
Insulin “reasonable” in hyperglycaemic pts
Volatile Anesthetics “can be beneficial”
Looking for evidence?
Every 1.000 patients receiving extended release METOPROLOL
PREVENTION OF 15 MYOCARDIAL INFARCTON PREVENTION OF 3 CABG PREVENTION OF 7 ATRIAL FIBRILLATION
Every 1.000 patients receiving extended release METOPROLOL
EXCESS OF 8 DEATHS EXCESS OF 5 STROKE EXCESS 53 HYPOTENSION EXCESS 42 BRADICARDIA
NON-RCT
Name of the Hospital% mortality at 30 days
CLINICA SAN ROCCO - BRESCIA 0,26%
OSPEDALE SAN RAFFAELE MILANO 0,36%
PRESIDIO OSPEDALIERO "C. POMA" MANTOVA 0,48%
OSPEDALE CIVILE LEGNANO - MI 0,67%
OSPEDALE SANTA CROCE E CARLE CUNEO 1,15%
OSPEDALE S. CHIARA TRENTO 1,16%
NUOVO POLO CARDIOLOGICO - TRIESTE 1,22%
HESPARIA HOSPITAL S.R.L. MODENA 1,32%
Clinical dutiesResearch (ENGLISH)TeachingCongressesDEVELOPING COUNTRIES
www.projectforpeople.org
AWARENESS
Are you still with me?
All of you?
WHERE DID IT ALL START?
ITACTA ONGOING RCTsTOPICS HOSPITALS PATIENTS GRANTS
VOLATILE ANESTHETICS
FENOLDOPAM
DESMOPRESSIN
ESMOLOL LEVOSIMENDAN VALVOLE PERCUTANEE
4 200 AIFA 2006
34 1.000 MINISTRY 2008
3 200
3 200 10 1.000 3 150
For these and further slides on these topics please feel free to visit the
metcardio.org website:
http://www.metcardio.org/slides.html