IRCCS Ospedale San Raffaele Milano
Università Vita-Salute San Raffaele
Principles of anesthesia for
medical students
Speaker:
Landoni G
Vita-Salute University of Milano
May 14° 2009
ITACTA ONGOING RCTs
TOPICS
HOSPITALS
PATIENTS
GRANTS
 VOLATILE
ANESTHETICS
 4
200
AIFA 2006
 FENOLDOPAM
 34
1.000
MINISTRY 2008
 DESMOPRESSIN
 3
200
3
10
3
200
1.000
150



ESMOLOL
LEVOSIMENDAN
VALVOLE PERCUTANEE
[email protected]
www.itacta.org



HSR
100 ANESTHESIOLOGISTS
30 students/residents (6 per year)
Clinical duties
Research
Teaching
Congresses
(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)
ANESTHESIA
INTENSIVE CARE
EMERGENCY DEPARTMENT
IN-HOSPITAL EMERGENCY
OUT-OF-HOSPITAL EMERGENCIES
HYPERBARIC MEDICINE
PAIN THERAPY
CLINICAL DUTIES (ITALY)
ANESTHESIA
IPNOSIS
MUSCLE RELAXATION
PAIN
(REFLEXES)
CLINICAL DUTIES (ITALY)
ANESTHESIA
INTENSIVE CARE
NEUROLOGIC STATUS
LUNGS
CARDIOVASCULAR
KIDNEYS
DRUGS
CLINICAL DUTIES (ITALY)
ANESTHESIA
INTENSIVE CARE
EMERGENCY DEPARTMENT
IN-HOSPITAL EMERGENCY
OUT-OF-HOSPITAL EMERGENCIES
BLS
ALS
ATLS
INVASIVE PROCEDURES



Hai mai utilizzato un vero defibrillatore manuale?
Hai mai utilizzato un vero defibrillatore semi-automatico?
Hai mai effettuato una cardioversione sincronizzata?

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%



Si
Si
Si
No 97%
No 94%
No 95%
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
Hai
Hai
Hai
Hai
effettuato una rachicentesi?
Si
posizionato un sondino naso-gastrico? Si
effettuato una paracentesi?
Si
posizionato un drenaggio toracico?
Si
effettuato una pericardiocentesi?
Si
No 99%
No 73%
No 95%
No 99%
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 duties
Research (ENGLISH)
Teaching
Congresses
(developing countries)
Levosimendan and Mortality in Cardiac Surgery
Review:
Comparison:
Outcome:
Study
or sub-category
Al-Shawaf
Alvarez 2005
Alvarez 2006
Barisin
De Hert 2007
De Hert 2008
Husedzinovic
Jarvela
Levin
Tritapepe
LEVOSIMENDAN CCH (12/1/2009)
01 perioperative levosimendan
02 Mortality
Levosimendan
n/N
1/14
1/15
1/25
0/21
0/15
1/40
0/12
1/12
6/69
0/12
235
Total (95% CI)
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)
Control
n/N
Peto OR
95% CI
Peto OR
95% CI
1/16
0/15
1/25
0/10
3/15
4/20
0/12
0/12
17/68
0/12
1.15 [0.07, 19.41]
7.39 [0.15, 372.38]
1.00 [0.06, 16.45]
Not estimable
0.12 [0.01, 1.22]
0.11 [0.02, 0.72]
Not estimable
7.39 [0.15, 372.38]
0.31 [0.13, 0.77]
Not estimable
205
0.35 [0.18, 0.71]
0.001 0.01
0.1
Favours levosimendan
1
10
100
Favours control
1000
Levosimendan and Mortality in Cardiac Surgery
11/235=4.7% v 26/205=12.7%
P=0.007
NNT = 12
Journal
Impact Factor 2006
 NEW ENGL J MED
 LANCET
 JAMA
51,3
25,8
23,2
14.8
 ANNALS OF INTERNAL
MEDICINE
 CIRCULATION
10,9
 J AM COLL CARDIOL
9,7
 EUR HEART J
7,3
 CRITICAL CARE MEDICINE
6,6
 CLINICAL CHEMISTRY
5,5
 ANESTHESIOLOGY
4,2
 ANAESTHESIA
2,1
ANALGESIA
Cardioprotection & anaesthesia
Volatile Anesthetics
 b blockers
“recommended”
 Statins
“suggested” in selected pts
 a2 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 duties
Research (ENGLISH)
Teaching
Congresses
DEVELOPING COUNTRIES
www.projectforpeople.org
AWARENESS
Are you still with me?
All of you?
WHERE DID IT ALL START?
ITACTA ONGOING RCTs
TOPICS
 VOLATILE
ANESTHETICS
 FENOLDOPAM
 DESMOPRESSIN



ESMOLOL
LEVOSIMENDAN
VALVOLE PERCUTANEE
[email protected]
www.projectforpeople.org
HOSPITALS
PATIENTS
GRANTS
 4
200
AIFA 2006
 34
1.000
MINISTRY 2008
 3
200
3
10
3
200
1.000
150



For these and further slides on these
topics please feel free to visit the
metcardio.org website:
http://www.metcardio.org/slides.html