Perioperative care of diabetic patients.

Diabetes mellitus is the most common metabolic disease and its incidence is increasing. New classifications have been recently proposed based upon a better knowledge of pathogenesis, mechanisms of glucose transport and insulin resistance. The perioperative care of diabetic patients is less dependent on blood-glucose control, which needs to be exceptionally tight, and is usually easily obtained thanks to pharmacological improvements, human insulins and analogues, technical progress with blood-glucose monitoring at the bedside and infusion with constant flow rates. More important is the influence of end-organ pathology, often clinically silent, which must be carefully assessed during the preoperative evaluation. The organ impairments concern especially the heart, but also all those organs that were modified by abnormal glycosylated proteins. The pre-existing pathology has many consequences on anaesthesia management; the anaesthetic technique depends essentially on their existence. A better long-term control of diabetes both for Type 1 and Type 2 by insulins, and the new oral anti-diabetic drugs reduce the incidence of the end-organ pathology and the risk linked to organ failures in the perioperative period.

Continuous professional development for anaesthetists.

Anaesthesia, as well as the whole of medicine, is involved in a revolution not only technical but also economic, because of the need for cost-containment in healthcare delivery. Continuing medical education, primarily devoted to updating knowledge and skills, is moving rapidly towards continuous professional development. A permanent evolution of practitioners is mandatory in order that they are able to adapt their practice to technical, ethical and economic changes, integrated in a team-working and multidisciplinary approach to patient care.

In vitro toxicity of halogenated anaesthetics on guineapig alveolar macrophages, surviving in gas phase.

The potential toxicity of halogenated anaesthetics on cellular immunity has been investigated on guineapig macrophages in gas phase by measuring the adenosine 5' triphosphate (ATP) concentration in the macrophages. A toxicity index (TI) was obtained by comparing the ATP concentration in vapour or gas-exposed macrophages with that of control cells. The TI for 5% halothane in air after 24 h was 31.2 +/- 8.3%. The TI for 5% enflurane in air was 12.7 +/- 6.6% (P less than 0.01). In an oxygen-enriched gas mixture (60%), the halothane TI increased to 65 +/- 6.6%, whereas that for enflurane remained at 15.4 +/- 16.9% (P less than 0.01). In macrophages exposed to 1% halothane, or 2% enflurane, in 50% nitrous oxide in oxygen, for 3 and 6 h, the halothane TI (0.4 +/- 3.3%) and the enflurane TI (2.5 +/- 4.1%) did not differ significant from the control group after 3 h. However, after 6 h exposure the halothane TI (31.3 +/- 9.6%) and the enflurane TI (17 +/- 20%) were different (P = 0.05) from control. It is concluded that the prolonged administration of high concentrations of halothane and enflurane alone decreased macrophages ATP concentration. A high concentration of oxygen in the gas mixture increased significantly the halothane TI.