F. Gilsanz

Quality and safety guidelines of postanaesthesia care: Working Party on Post Anaesthesia Care (approved by the European Board and Section of Anaesthesiology, Union Européenne des Médecins Spécialistes).

Postanaesthesia care units are standard parts of hospital care in most European Union countries. Their main purpose is to identify and immediately treat early complications of surgery or anaesthesia, before they develop into deleterious problems. This review, prepared by the Working Party on Post Anaesthesia Care of the European Board of Anaesthesiology. European Union of Medical Specialists (Union Européenne des Médecins Spécialistes) and approved by the European Board and Section of Anaesthesiology, gives recommendations on relevant aspects of organization, responsibilities, methods, safety and quality control of postanaesthesia care.

An inhalation bolus of sevoflurane versus an intravenous bolus of remifentanil for controlling hemodynamic responses to surgical stress during major surgery: a prospective randomized trial.

We studied 120 patients scheduled for elective major thoracic or abdominal surgery, randomized into 2 groups: a Sevoflurane group (n = 63) and a Remifentanil group (n = 57). Heart rate (HR) and mean arterial pressure (MAP) are indicative of sympathetic response to surgical stress. A positive response was defined as a 15% increase in the HR and MAP above baseline mea-surements. When a positive response occurred, in the Sevoflurane group we administered a bolus dose of 8% sevoflurane (fresh gas flow 6 L/min) and in the Remifentanil group, an IV bolus dose of remifentanil 1 &mgr;g · kg−1 · min−1, which was maintained until MAP and HR returned to baseline measurements (effective bolus). If, after a bolus dose, a decrease in MAP and/or HR of >15% occurred with respect to baseline values, the response was considered to be excessive. The bolus dose was ineffective in 4.8% of the responses in the Sevoflurane group and in 17.8% of the responses in the Remifentanil group (P < 0.05). In the Sevoflurane group, an excessive effect occurred in 12% of responses, and in 26.7% in the Remifentanil group (P < 0.05). An inhalation bolus of sevoflurane seems to be more effective than an IV remifentanil bolus during maintenance, with more effective control of hemodynamic responses to surgical stress.

Pharmacokinetics and Pharmacodynamics of a Single Bolus of Propofol 2% in Healthy Volunteers

This study was undertaken to assess the bioequivalence between a new formulation of propofol 2% and the commercially available product Diprivan. Secondary objectives were to compare the times to onset of and emergence from hypnosis, the hemodynamic effects, and the safety profiles. Twelve healthy male volunteers were included in a randomized crossover study. Subjects were administered a 2‐mg/kg single bolus injection of each formulation separated by a 7‐ to 10‐day washout period. Plasma propofol was determined by reversed‐phase liquid chromatography with fluorescence detection. Eleven subjects completed the study, and both formulations were considered bioequivalent. There were no serious or severe adverse events. The concentration‐time profiles of all the subjects could adequately be described using a three‐compartment model. The mean times to cessation of counting out loud (17 vs. 18 s) and to eye opening (245 vs. 244 s) were not statistically different between treatment groups. Moreover, they seem to show some degree of pharmacodynamic bioequivalence, although a higher number of subjects are necessary to unequivocally demonstrate it.

Altered regulation of calcium channels and exocytosis in single human pheochromocytoma cells

We established primary cultures of human pheochromocytoma chromaffin cells. We then tried to find what mechanism of their secretory apparatus could be altered to produce the massive release of catecholamines into the circulation and the subsequent hypertensive crisis observed in patients suffering this type of tumor. Their whole-cell Ca2+ channel currents could be pharmacologically separated into components similar to those found in normal human adrenal chromaffin cells: 20% L-type, 30% N-type, and 50% P/Q-type Ca2+ channels. However, modulation of the channels by exogenous or endogenous ATP and opioids, via a G-protein membrane-delimited pathway, was deeply altered; some cells having no modulation or very little modulation alternated with others having normal modulation. This may be the cause of the uncontrolled secretory response, measured amperometrically at the single-cell level. Some cells secreted for long time periods and were insensitive to nifedipine (L-type channel blocker) or to ω-conotoxin MVIIC (N/P/Q-type channel blocker), while others were highly sensitive to nifedipine and partially sensitive to ω-conotoxin MVIIC. Alteration of the autocrine/paracrine modulation of Ca2+ channels may lead to indiscriminate Ca2+ entry and exacerbate catecholamine release responses in human pheochromocytoma cells.

The Effects of Sevoflurane or Remifentanil on the Stress Response to Surgical Stimulus

Tissue injury secondary to surgical lesion produces profound changes in endocrine-metabolic function and defence mechanisms in the patient (inflammatory, immunological), leading to an increase in catabolism, immunosuppression and postoperative morbidity. The best anaesthetic and surgical technique should be capable of modulating this response, especially in major surgery, where it can be most harmful and increase patient morbidity. Many of the changes that maintain homeostasis are controlled by the hypothalamicpituitary- adrenal axis. The autonomic-adrenal response is usually immediate, compared to the hypothalamus-pituitary gland, which is slower and longer lasting. Cytokine synthesis and release are the earliest stages in the response to tissue lesion. The most frequently studied cytokines in surgical stress response are IL-6 and TNF-α. Inflammatory mediator concentrations are direct indicators of perioperative stress, while haemodynamic changes are considered the indirect indicators of this response. Multiple anaesthetic techniques have been described to modify the stress response in patients undergoing elective surgery. The aim of this review is to present clinical evidence on perioperative stress modulation with different anesthetics. We also describe a different point of view in immunomodulation with the intraoperative management of haemodynamic responses with inhalational bolus of sevoflurane or with remifentanil intravenous bolus. The effects of sevoflurane used as an inhalational bolus to counteract patients intraoperative haemodynamic responses modulates the immune response the same than opioid remifentanil.

Ulnar Nerve Block Induced by the New Local Anesthetic IQB-9302 in Healthy Volunteers: A Comparison with Bupivacaine

We evaluated the duration of sensory anesthesia after blockade of the ulnar nerve of IQB-9302, a new local amide anesthetic, compared with bupivacaine. A double-blinded, randomized, cross-over study in 12 healthy volunteers aged 18 to 35 yr was performed. Three milliliters of 0.25% IQB-9302 was administered in one wrist and bupivacaine in the other. A week later, the blocks were repeated with a concentration of 0.5%. These concentrations were chosen because they seemed to be equipotent in previous studies. The duration of sensory anesthesia was the main variable measured; secondary outcomes were motor block, time to onset, and time to recovery from block. The duration of sen- sory block was similar for IQB-9302 and bupivacaine at a concentration of 0.25%; median and range: 409 min (0–800 min) for IQB-9302 and 258 min (0–665 min) for bupivacaine (95% confidence interval for the difference from −47 to 545, P = 0.82, Wilcoxon’s test). The results with 0.5% were: 525 min (440–735 min) and 690 min (365–1098 min), respectively (P = 0.026). There were no significant differences in the other variables measured. No important adverse reactions were seen. We conclude that IQB-9302 is an effective new local anesthetic for blockade of ulnar nerve at the concentrations tested.

Preparation for the European Diploma of Anaesthesiology - part 1 and results in 2010 and 2011: the Madrid Center experience. The show must go on: 15AP1-8

the residents. The global session and tutor evaluation scores were 8 out of 10; 94% of the residents considered the themes treated during the sessions as adequate. 90% of the residents took the exam, 68% of them passed it. In the last 3 years the percentage of passed residents increased progressively to 81%. Conclusion(s): The session assistance and the exam participation were high. A progressive increase of passed exams was observed. Common sessions, assistance control and the final exam were well accepted. A unified way of teaching allowed us to achieve a more homogenous education and it was a great help in tutor mentoring and in warranting a standard formation. These results encourage us to apply and improve this teaching model in the future. Reference: 1. European Board of Anaesthesiology. Training Guidelines in Anaesthesia or the European Board of Anaesthesiology Reanimation and Intensive Care. Eur J Anaesth 2008;25: 528-30.

European diploma of anesthesiology: The Madrid training center experience: 15AP1-1

Background and Goal of Study: Since 2008, a training for the first part of the European Diploma of Anesthesiology (EDA1) was organized in Madrid with the goal of familiarizing anesthesiologists with this kind of MCQs and prepare them. This observational study was realized to measure the impact of the training on the results of the EDA1 for the course 2010-11. Materials and Methods: All the participants of the training were included in the study. Stage of practice in anesthesia and geographic origin of the students were noted. In every thematic session, before a didactical correction of the exam sample, participants were asked to answer the MCQ‘s in the of ficial sheet of the EDA. The results were anonymously analyzed. At the end of the year, we asked for a feed back on the results of the EDA1 in candidates of the training. Results and Discussion: Forty seven anesthesiologists were inscribed to the training of whom 31(66%) residents (R) and 16(34%) graduated anesthesiologists (GA). 40(85,1%) came from university hospitals, 4 (8,5%) from peripheral hospitals, and 3(6,4%) from other region hospitals. Eighteen (38,3%) anesthesiologists participated to 3 or more sessions (10 (32,3%)R; 8 (50%)GA; p=0,19) and were considered approved for the training. The scores of the sessions were respectively 59,5 [17;79]%, 69,2 [54,4; 88]%, 62,4 [47,2; 76]%, 70,4 [69,6; 81,6]%, 70,4 [58,3; 79,1]% in physiology and anatomy, pharmacology, physics, general anesthesia and specialized anesthesia (p< 0,0001), with greater scores in pharmacology, general anesthesia and specialized anesthesia compared to the others. Setting a pass mark at 70%, the ratio of approval would be 14,7%, 46,4%, 11,8%, 33,3% and 53,8% in each topic.Eleven student of the training who presented to the EDA 1 exam in Madrid gave us their result, and 8 passed (72,7%). These results tend to be higher than those of the rest of candidates in Madrid (41,5%) (p=0,07) and might be better than the overall European pass rate (58%). Conclusion(s): Spain does not dispose of a final theorical exam to check anesthesiologists’ knowledge. The organization of a training for the EDA1 seems to be an ef ficient way to prepare candidates to the exam. This ef fort is expected to promote an increasing number of candidates with higher scores and pass rate in Spain in the next years. The final results compared with the European pass mark are probably overstimated due to a low rate of answer from candidates to the post-EDA1 survey.