Familial dysautonomia (FD), a rare genetic disorder, is characterized by autonomic instability, pulmonary infections, oesophageal dysmotility, spinal abnormalities and episodic ‘dysautonomic crisis’ characterized by rash, vomiting, sweating and hypertension. Frequent anaesthetic complications have been reported.

We performed a comprehensive literature search of perioperative management of FD using an OVID-based search strategy. Identified reports were reviewed to identify perioperative complications as well as anaesthetic techniques and perioperative management strategies developed to minimize or prevent these complications.

Eighteen case reports or series of perioperative management of FD were identified in the literature for a total of 179 patients undergoing 290 anaesthetics. Intraoperative cardiovascular lability, including cardiac arrests and postoperative pulmonary complications were commonly reported. Preoperative hydration, minimizing the use of volatile anaesthetic agents, postoperative ventilation, use of regional anaesthesia and minimally invasive surgical techniques reduced the incidence of these complications.

While patients with FD are reported to have a relatively high rate of various perioperative complications, a full understanding of its pathophysiology can be used to develop a perioperative management strategy to anticipate and prevent many of these complications.

There is a high incidence of pain following intravenous injection of propofol, and many studies have been conducted to find a way of reducing this. The administration of lidocaine and, recently, remifentanil has also been used for this purpose, but it is only partially effective. Thus, the purpose of this study was to investigate the analgesic effect of a combination of pretreatment with remifentanil and premixture of lidocaine with propofol and to compare either treatment alone during propofol injection in dorsal hand-veins.

In a prospective, randomized, double-blinded trial, we studied 141 adult patients scheduled for elective surgery. The combination of pretreatment of remifentanil (0.35 μg kg−1 min−1) and a premixture of lidocaine with propofol (mixture of propofol 1% and lidocaine 1% in a 10 : 1 ratio) was compared with either treatment alone in the prevention of pain on propofol injection. Pain was assessed on a four-point scale (0 = none, 1 = mild, 2 = moderate, 3 = severe) during propofol injection. Patients in Group B received remifentanil (0.35 μg kg−1 min−1) 30 s before the injection of propofol.

The reduction of pain on propofol injection was similar in both the remifentanil pretreatment and lidocaine premixture groups (62.2% vs. 62.2%). Combination therapy was associated with a higher incidence of patients without pain (91.3%) than either treatment alone (P < 0.001). On analysing the injection pain scores, we found a significant reduction of the score in the remifentanil and lidocaine Group C compared with the lidocaine Group A (P < 0.001) and the remifentanil Group B (P < 0.001).

The combination of pretreatment of remifentanil and premixture of lidocaine with propofol was more effective in reducing the incidence of pain on injection of propofol than either treatment alone.

Melatonin (N-acetyl-5-methoxytryptamine) is the main indolamine secreted by the pineal gland. Many studies showed that premedication with melatonin is associated with preoperative anxiolysis and sedation without impairment of cognitive and psychomotor skills and without prolonging recovery. We hypothesized that melatonin decreases the amount of propofol required to produce an adequate depth of hypnosis at induction time.

After approval from the research committee of the anaesthesia department, informed written consent was taken from 45 adult patients undergoing different surgical procedures. They were allocated randomly into three groups according to the premedication. At 100 min preoperatively, premedication was given in the form of oral melatonin 3 mg (M3 group), oral melatonin 5 mg (M5 group) or no premedication (P group). After preoxygenation an anaesthesiologist who was blinded to the premedication injected propofol 10 mg over 5 s every 15 s until the bispectral index (BIS) score fell to 45. The total dose of propofol required to achieve a BIS score of 45 was recorded. Response to verbal commands and eyelash reflex was evaluated and correlated to the BIS score and propofol dosage. When a BIS score of 45 was reached, tracheal intubation was accomplished after administration of a narcotic and muscle relaxant.

The mean (standard devitation (SD)) induction dose of propofol producing a BIS score of 45 was 134 (25) mg in the placebo group vs. 115 (19.5) and 114 (20.9) mg in the M3 and M5 groups, respectively (P < 0.05). The propofol dose required to achieve loss of eyelash reflex and loss of response to verbal commands was more in the placebo group. Anxiety score as assessed by visual analogue scale (VAS) scored more in the placebo group than both melatonin groups. Time spent in the recovery room did not differ between the three groups.

Melatonin premedication, in an oral dose of either 3 or 5 mg, reduced the required dose of propofol to achieve a BIS score of 45, reflecting a sufficient level of hypnosis for tracheal intubation without prolongation of postoperative recovery room stay.

The European anaesthesia workforce is facing increased demand and expansion of the labour market, which may likely exceed supply. This survey assesses the numbers and practice patterns of anaesthesiologists and studies migration and shortage of the anaesthesia workforce in Europe.

A questionnaire was sent to all national European anaesthesia societies. Countries were grouped according to their relationship with the European Union.

The number of anaesthesiologists per 100 000 population varies between 2.7 (Turkey) and 20.7 (Estonia). There seems to be no clear evidence for feminization of the anaesthesia workforce. Anaesthesia physician training lasts between 3 yr (Armenia, Belarus, Uzbekistan) and 7 yr (Ireland, UK), and seems to positively correlate with the number of trainees. Throughout Europe, anaesthesiologists typically work in public practice, and are involved in the entire care chain of surgical patients (anaesthesia, intensive care, chronic pain and pre-hospital emergency medicine). The differences between European salaries for anaesthesiologists are up to 50-fold. Most Western European countries are recipients of migrating anaesthesiologists who often originate from the new member states of the European Union. However, it seems that expectations about anaesthesia workforce shortages are not confined to Eastern Europe.

Each European country has its own unique workforce constellation and practice pattern. Westward migration of anaesthesiologists from those countries with access to the European Union labour market may be explained by substantial salary differences. There is a European-wide lack of systematic, comparable data about the anaesthesia workforce, which makes it difficult to accurately assess the supply of anaesthesiologists.

Propofol is associated with pain on injection. It is common practice to premix lidocaine with propofol prior to injection. Lipuro propofol, a propofol emulsified in medium- and long-chain triglycerides, has been shown to reduce the intensity of injection pain compared to Diprivan®, although a number of studies report no reduction in overall incidence of pain.

We conducted this randomized double-blind trial to determine the extent of further pain reduction by adding lidocaine to Lipuro propofol. A total of 328 ASA I–III patients were randomized to one of four groups to receive Diprivan propofol (Group DP), Lipuro propofol (Group LP), Diprivan with lidocaine (Group DL) and Lipuro propofol with lidocaine (Group LL). The drug mixture was administered at a constant rate of 400 mL h−1 via a 20-G cannula into a dorsal hand vein. Pain was assessed during induction and upon patient recovery, using a 10-point visual analogue scale.

Both the incidence and severity of pain were found to be significantly lower with addition of lidocaine to Lipuro propofol (P < 0.0002) compared to Lipuro alone, Diprivan with or without the addition of lidocaine.

Lidocaine added to Lipuro propofol makes induction of anaesthesia less painful compared to Lipuro propofol alone or Diprivan with lidocaine.

This study was conducted to compare bispectral index, state entropy and response entropy in patients undergoing coronary artery bypass grafting.

In 66 patients, anaesthesia was maintained at two different levels using bispectral index. Doses of sufentanil and midazolam were adjusted to achieve a bispectral index in the range of 45–55 in 33 patients (BIS 50 group) and 35–44 in another 33 patients (BIS 40 group). Simultaneously, state entropy and response entropy were recorded.

The targeted values of bispectral index were achieved in both groups and the bispectral index values differed significantly during whole anaesthesia. Median response entropy and state entropy fell to 19–26 during anaesthesia in both groups. Response entropy and state entropy values in the two groups differed significantly only after induction of anaesthesia and did not differ during further anaesthesia. There was no explicit intraoperative recall in both groups. Patients in Group BIS 40 received significantly (P < 0.05) more sufentanil than the BIS 50 group (704 ± 181 μg vs. 490 ± 107 μg, respectively) and midazolam (18.5 ± 6.1 mg vs. 15.6 ± 3.8 mg, respectively). After cardiopulmonary bypass, significantly (P < 0.05) more patients in Group BIS40 needed inotropic support with dobutamine (79%) than in the BIS50 group (52%). Time to extubation did not differ between the two groups.

In patients undergoing coronary artery bypass grafting, no relationship was found between bispectral index levels and state entropy and response entropy at two different stages of a sufentanil–midazolam anaesthesia. A bispectral index level of 45–55 reduced anaesthetic medications used and the need for inotropic support.

Target-controlled infusion, via the calculated effect compartment concentrations, may help anaesthesiologists to titrate anaesthetic depth and to shorten recovery from anaesthesia.

In this prospective, randomized clinical study, we compared the performance of six inexperienced anaesthesiologists with <1 yr of training when using target- or manually controlled infusion of propofol, combined with manual dosing of fentanyl. Ninety-two premedicated ASA I–III patients undergoing minor elective urological or gynaecological surgery were assigned to the manual- or target-controlled infusion group. Bispectral index was recorded in a blinded manner. Subjective assessment of anaesthetic depth on a 10 point numerical scale (1 = very deep anaesthesia, 10 = awake) was asked at regular intervals and the correlation with the blinded bispectral index was analysed using the prediction probability, PK. The propofol concentration profile was calculated post hoc.

Propofol administration was similar in both groups with no significant difference for the administered amount and concentrations of propofol. Recovery times were also not different. In both groups, a large percentage of the bispectral index data points recorded during surgery showed bispectral index values below the recommended value of 40, but in the target-controlled infusion group there were significantly less bispectral index values above the recommended upper limit of 60 (2.5% vs. 5.1%).

A target-controlled infusion system does not help inexperienced anaesthesiologists to assess anaesthetic depth or to shorten recovery times, but may reduce episodes of overly light anaesthesia and thus help to prevent awareness.

To study the effect of 0.2 mg mL−1 of ondansetron added to morphine patient-controlled analgesia solution after a 4 mg loading dose on the incidence and severity of postoperative nausea and vomiting.

One hundred and sixty patients scheduled for elective surgery, between 18 and 65 yr old, were studied. Patients who smoked, received antiemetics and hormonal therapy, had a history of motion sickness or gastrointestinal disease, a body mass index >35 or menstruation at the time of the study were excluded. Patients were assigned to the ondansetron and control groups by block randomization. At the end of anaesthesia, all patients received 4 mg of ondansetron intravenously and the same patient-controlled analgesia regimen of morphine. The ondansetron group (n = 80) received 0.2 mg of ondansetron per 1 mg of morphine. The nausea score, vomiting score and the requested ondansetron dose were evaluated at 1, 2, 6, 12 and 24 h. Patient-satisfaction for nausea/vomiting was recorded at the end of the study.

Patient characteristics and cumulative morphine consumption were similar but ondansetron group had higher pain scores (P = 0.006). The ondansetron group had a lower nausea and vomiting scores, and more patients were free from nausea and vomiting than the control group (41 vs. 26, respectively, P = 0.025). The ondansetron group had fewer cumulative ondansetron doses than the control group and better patient satisfaction than the control group (P < 0.05).

Ondansetron 4 mg plus 0.2 mg mL−1 given with PCA morphine can reduce nausea and vomiting thus improving patient satisfaction.

Patients undergoing off-pump coronary artery bypass grafting (CABG) may need emergent institution of cardiopulmonary bypass (CPB) for circulatory collapse during the operation. Our aim was to evaluate outcome in such patients and identify preoperative and intraoperative risk factors.

This is an observational study in a University Hospital setting. In the period June 2001–July 2003, data from 988 consecutive patients undergoing CABG in our institution were prospectively collected. No interventions were made. Prolonged hospital stay (>7 days), hospital mortality, temporal trends and risk factors for conversion from off-pump to on-pump surgery were studied.

Fifty-four patients with emergency operations and six with associated carotid artery surgery were excluded. Of the remaining 928 patients, 450 (48.5%) were planned for off-pump surgery. Thirty-seven (8.2%) of them required conversion to CPB on an emergency basis. These patients had higher mortality (5.4%) than the off-pump group (1.5%) and the CPB group (0.4%), P = 0.02. The incidence of prolonged hospital stay was also higher (conversion group = 27%, off-pump group = 12.3%, CPB group = 17.6%; P = 0.02). We did not identify any perioperative characteristics significantly associated with the risk of requiring conversion. The conversion rate was uniformly distributed over the study period.

Patients who are emergently converted to CPB during attempted off-pump procedures are at higher risk of death and prolonged hospital stay; this population should be included in comparative studies as ‘intention to treat’ in the off-pump group.

In this randomized clinical study, we compared the intubation success rates of the intubating laryngeal mask airway with the GlideScope® in patients with normal airways. The primary hypothesis was that the intubating laryngeal mask airway was equally effective as the GlideScope® in terms of successful intubation times.

Sixty ASA I and II adult patients undergoing elective gynaecological surgery were randomly allocated into either the intubating laryngeal mask airway group or the GlideScope® group. After a standard anaesthetic intravenous induction, orotracheal intubation was performed. Time taken for successful tracheal intubation, ease of device insertion, difficulty of tracheal intubation, manoeuvres needed to aid tracheal intubation, number of intubation attempts, haemodynamic changes every 2.5 min interval for 5 min and complications during tracheal intubation were recorded.

Time to successful intubation was longer (mean 68.4 s ± 23.5 vs. 35.7 s ± 10.7; P < 0.05), mean difficulty score was higher (mean 16.7 ± 16.3 vs. 7.3 ± 13.1; P < 0.05) and more intubation attempts were required in the intubating laryngeal mask airway group.

The GlideScope® improved intubation time and difficulty score for tracheal intubation when compared with the intubating laryngeal mask airway in our patients. Blind intubation through the intubating laryngeal mask airway offers no advantages over the GlideScope® in patients with normal airways. Despite its limitations, the intubating laryngeal mask airway is a valuable adjunct, especially in cases of difficult airway management when it can provide ventilation in between intubation attempts.

The case/problem-based learning discussion method was recently introduced into the theory-based training program for residents run by the Catalan Society of Anaesthesiology. This study was designed to assess and compare its effectiveness with that of the lecture-based approach for teaching pre-anaesthetic assessment, applying an objective tool for knowledge evaluation before and after teaching.

A prospective randomized study of two consecutive year groups of first year anaesthesiology residents was conducted. Twenty-nine residents attended a lecture, and 25, a case/problem-based learning discussion session. Their knowledge of pre-anaesthetic assessment was assessed before and after the teaching session with tests on four different clinical cases measuring six fields: (1) ‘recognizing clinical data with anaesthetic implications’; (2) ‘reasoning clinical data with anaesthetic implications’; (3) ‘ASA class’; (4) ‘Mallampati class’; (5) ‘choice of anaesthetic technique’; (6) ‘reasoning choice of anaesthetic technique’.

Before the teaching session, the lecture group scored significantly higher on field 1 (P = 0.006). Both teaching methods improved scores on fields 1, 2 and 4. The case/problem group also improved on fields 3 and 6. After the teaching session, the field 1 score was still significantly higher in the lecture group (P = 0.005), and the field 3 score was significantly higher in the case/problem group (P = 0.044).

The effectiveness of lecture and case/problem-based learning discussion differed little in terms of improving participants’ immediate knowledge of ‘pre-anaesthetic assessment’.

The main aim of this review is to summarize the literature with respect to the impact of anticoagulation monitoring strategies and therapeutic strategies to manage heparin resistance and optimize anticoagulation with cardiac surgery.

This review was generated using peer-reviewed manuscripts pertinent to this topic that were identified using a computer-based Medline search.

There are a small number of well-controlled prospective, randomized studies, some of which suggest that bleeding and transfusion can be attenuated by refining heparin monitoring techniques by sustaining better anticoagulation during cardiopulmonary bypass especially when applied to operative cases that involve complex procedures that require long intervals on cardiopulmonary bypass. Recent studies indicate that antithrombin III concentrates can be used to treat heparin resistance and thereby enhance preservation of the hemostatic system during CPB. A few recent retrospective analyses suggest that low ATIII concentration is associated with negative outcomes.

The literature indicates that enhanced anticoagulation via more sophisticated heparin monitoring schemes can reduce bleeding and transfusion and that antithrombin III concentrates can be used to effectively manage heparin resistance during cardiac surgery. Well-controlled, randomized studies are needed to better define the relative importance of AT IIII supplementation with respect to either the management of heparin resistance or with respect to optimization of anticoagulation during CPB and specifically if these interventions are able to decrease the incidence of bleeding and/or thrombotic complications.

Midlatency auditory-evoked potentials, as measures of the anaesthetic state, were evaluated at similar levels of bispectral index in cardiac surgical patients maintained with either propofol or isoflurane anaesthesia.

Twenty-four patients were randomly allocated to anaesthesia with propofol (n = 12) or isoflurane (n = 12). Bispectral index was maintained below 60 during surgery. Auditory-evoked potentials were collected before induction of anaesthesia, 10 min after intubation, 30 min after sternotomy, during cardiopulmonary bypass at the time of cross-clamping of the aorta and during stable mild hypothermia, after de-clamping of the aorta, and after the operation.

At the pre-determined time points, bispectral index values showed comparable depth of hypnosis in both groups. The latency of the Nb component of midlatency auditory-evoked potentials was significantly increased in the isoflurane group after intubation (P < 0.001) and that of both the Nb and the Pa components after sternotomy (P < 0.001) compared with the propofol group. No differences between the groups were detected with respect to haemodynamic variables. No patient reported recall of intraoperative events.

After intubation and surgical stimulation, when bispectral index was at a constant level, there was a difference in the Nb and Pa components of the midlatency auditory-evoked potentials between the two anaesthetic regimens, indicating a distinction in the state of anaesthesia. Our results suggest that the parallel use of these two electrophysiological methods can show differences in the components of anaesthesia between various anaesthesia methods in cardiac surgical patients.

Arterial pulse waveform analysis has been proposed for cardiac output (CO) determination and monitoring without calibration or thermodilution (FloTrac™/Vigileo™; Edwards Lifesciences, Irvine, CA, USA). The accuracy and clinical applicability of this technology has not been fully evaluated. We designed this prospective study to compare the accuracy of the FloTrac™ system (COFT) vs. pulmonary artery catheter standard bolus thermodilution (COPAC) in patients undergoing coronary artery bypass grafting.

We studied 11 patients referred for coronary artery bypass grafting. COFT and COPAC were determined at six time points in the operating room including before and 5 min after volume expansion (500 mL 6% hetastarch). Measurements were performed on arrival in the intensive care unit and every 4 h afterwards. Bland–Altman analysis was used to assess the agreement between COFT and COPAC.

COPAC ranged from 2.0 to 7.6 L min−1 and COFT ranged from 1.9 to 8.2 L min−1. There was a significant relationship between COPAC and COFT (r = 0.662; P < 0.001). Agreement between COPAC and COFT was −0.26 ± 0.87 L min−1. Volume expansion induced a significant increase in both COPAC and COFT (from 3.4 ± 0.8 to 4.4 ± 1.0 L min−1; P < 0.001 and from 3.9 ± 1.2 to 5.0 ± 1.1 L min−1; P < 0.001, respectively) and there was a significant relationship between percent change in COPAC and COFT following volume expansion (r = 0.722; P = 0.01).

We found clinically acceptable agreement between COFT and COPAC in this setting. This new device has potential clinical applications.