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

landoni.giovanni@hsr.itwww.itacta.org

4 200 AIFA 2006

34 1.000 MINISTRY 2008

3 200

3 200 10 1.000 3 150

http://www.estense.com/?module=photos&photo_id=7033

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

landoni.giovanni@hsr.itwww.projectforpeople.org

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