Principles of anesthesia for medical students IRCCS Ospedale San Raffaele Milano Università Vita-Salute San Raffaele Principles of anesthesia for medical students Vita-Salute University of Milano May 14° 2009 Speaker: Landoni G

ITACTA ONGOING RCTs TOPICS HOSPITALS PATIENTS GRANTS VOLATILE ANESTHETICS FENOLDOPAM DESMOPRESSIN ESMOLOL LEVOSIMENDAN VALVOLE PERCUTANEE landoni.giovanni@hsr.it www.itacta.org 4 200 AIFA 2006 34 1.000 MINISTRY 2008 3 200 3 200 10 1.000 3 150

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? 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%

INTRA AORTIC BALLOON PUMP 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% 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 duties Research (ENGLISH) Teaching Congresses (developing countries)

Levosimendan and Mortality in Cardiac Surgery

Levosimendan and Mortality in Cardiac Surgery P=0.007 NNT = 12

Impact Factor 2006 Journal 51,3 NEW ENGL J MED 25,8 LANCET 23,2 JAMA 14.8 10,9 9,7 7,3 6,6 5,5 4,2 2,1 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

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 HOSPITALS PATIENTS GRANTS VOLATILE ANESTHETICS FENOLDOPAM DESMOPRESSIN ESMOLOL LEVOSIMENDAN VALVOLE PERCUTANEE landoni.giovanni@hsr.it www.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