Deep brain stimulation in ireland for Parkinson's disease and essential tremor.

Deep brain stimulation (DBS) is highly effective neurosurgery for idiopathic Parkinson's disease (IPD), essential tremor (ET) and primary dystonia. DBS involves stereotactic surgical implantation of a battery-operated stimulator into deep brain nuclei. Irish patients are referred abroad for DBS and have to travel repeatedly for pre and post-operative care resulting in stress, anxiety and hardship. Safe pre and post-operative care of these complex, ageing patients is compromised by the absence of a DBS service in Ireland. Moreover, both DBS surgery and the subsequent post-operative care abroad incurs substantial cost to the state. The Dublin Neurological Institute at the Mater Misericordiae University Hospital (DNI) is a non-profit institute for the care of patients with neurological diseases. The DNI developed, in collaboration with the Mater Private Hospital (MPH) and the Walton Centre, Liverpool, a DBS programme in 2008/2009. We performed DBS at the Mater Campus on three carefully selected patients from a cohort of movement disorder patients attending the DNI and continue to provide pre-operative assessment and post operative care for patients following DBS in Ireland and abroad.

Use of recombinant factor VIIa in massive post-partum haemorrhage.

BACKGROUND AND OBJECTIVE: Massive post-partum haemorrhage continues to be one of the world's leading causes of maternal morbidity and mortality. Any new treatment that potentially helps at risk parturients should be thoroughly investigated. Recombinant factor VIIa (rVIIa) is increasingly being used in the treatment of massive haemorrhage. We performed a case-matched analysis of its use since 2003 in the treatment of massive post-partum haemorrhage at our hospital. METHODS: Twenty-eight cases of massive post-partum haemorrhage were identified over a 3-yr period since 2003. In six of these cases, rVIIa was used as part of their management. Six case-matched controls were sought. The six women with the greatest requirement for packed red cell transfusion who also had a deranged prothrombin time were included. The groups were then compared for differences. The worst prothrombin time in each group was noted as was the best prothrombin time within 6 h, this was used as our measure of response to treatment. RESULTS: There was no statistical difference in age, gestation, parity, transfusion requirements, mode of delivery or the severity of the coagulopathy between the two groups. In both groups the prothrombin time improved with management. There was no significant difference in either the magnitude of the improvement in the value of the prothrombin time or the absolute value of the best prothrombin time (P = 0.09). Five out of the six women in the rFVIIa group had normal or low prothrombin times within 6 h yet only one woman who did not receive rFVIIa had a normal prothrombin time within 6 h though this was not significant (P = 0.08). CONCLUSIONS: This case-matched analysis supports the management of massive post-partum haemorrhage with appropriate resuscitation, surgical intervention and use of blood and blood products. This study does not support the routine use of rFVIIa in the management of massive obstetric haemorrhage. rFVIIa may have a role to play in this management but further studies and analyses will be required.

Guidelines for sedation and/or analgesia by non-anaesthesiology doctors.

The still ever increasing demand for sedation and/or analgesia for diagnostic and therapeutic procedures puts high pressure on anaesthesia care providers all over Europe. Since the capacity to provide that service by anaesthetists is limited in most European countries, guidelines for non-anaesthetist doctors who want to sedate patients on a high-quality level and especially in a safe way are mandatory. This paper, produced by a working party of the European Board of Anaesthesiology of the European Union of Medical Specialists (EUMS/UEMS), gives direction to those practitioners who feel responsibilities in this area of medicine. Close cooperation with anaesthesiologists seems mandatory to achieve and sustain a high-quality standard for our patients undergoing medical or surgical procedures under sedation.

Guidelines for anaesthesiologist specialist training in pain medicine.

The Section and Board of Anaesthesiology of the European Union of Medical Specialists aims (EUMS/UEMS) at harmonization of training of anaesthesiologists and at improvement of patient care throughout Europe. Pain medicine is considered to be an area of expertise in anaesthesiology although exclusivity is not claimed. The Section and Board has approved both a core syllabus for pain medicine to be part of the specialist training in anaesthesiology and an additional qualification in pain medicine following the completion of a 5 yr basic specialty training in anaesthesiology. These proposals were prepared by the Working Party on Pain Medicine of the Section and Board. It considers a multidisciplinary approach to pain to contribute to quality in care and has taken the initiative to set up a Multidisciplinary Joint Committee on Pain Medicine within the EUMS/UEMS, for which these guidelines define the area of expertise of anaesthesiology.

Charter on continuing medical education/continuing professional development approved by the UEMS Specialist Section and European Board of Anaesthesiology.

The mission of the Section and Board of Anaesthesiology of the European Union of Medical Specialists (EUMS/UEMS) is to harmonize training and medical practice in all European countries to continuously improve the quality of care. The need for continuous medical education in the field of anaesthesiology has long been recognized. However, specialty-based competencies are not the only requirements for successful medical practice. The need to acquire medical, managerial, ethical, social and personal communication skills on top of specialty-based competencies has developed into the principle of continuous professional development, which embraces both objectives. The Section and Board of Anaesthesiology of the EUMS/UEMS has approved a proposal of its Standing Committee on Continuous Medical Education/Continuous Professional Development to adopt the following charter on the subject.

An assessment of the value of intraperitoneal meperidine for analgesia postlaparoscopic tubal ligation.

UNLABELLED: Patients undergoing laparoscopic procedures may experience postoperative pain. The intraperitoneal (IP) administration of drugs is controversial but has proven effective in some studies for the relief of postoperative pain. However, some investigators have not been able to confirm the analgesic efficacy of IP local anesthetics. The administration of IP opioids for the relief of postoperative pain has received little attention. At the end of laparoscopic tubal ligation, 100 patients received 80 mL of 0.125% bupivacaine with 1:200,000 epinephrine IP and 50 mg of meperidine either IP or IM. Postoperative pain scores were measured at rest and with movement. Pain scores were significantly lower in the group receiving the IP meperidine both at rest (P: < 0.01) and with movement (P: < 0.05). We conclude that the combination of intraperitoneal bupivacaine and intraperitoneal meperidine was better than the combination of IP bupivacaine and IM meperidine for postoperative analgesia in patients undergoing laparoscopic tubal ligation. IMPLICATIONS: The combination of bupivacaine and meperidine delivered to the intraperitoneal cavity proved superior to equivalent doses of intraperitoneal bupivacaine and IM meperidine for postoperative pain relief in patients undergoing laparoscopic tubal ligation. Intraperitoneal delivery of analgesia proved effective in this study and merits further study and more widespread use.

Elective tracheal intubation in cervical spine injuries.

Patients presenting for surgical stabilisation of an unstable cervical spine are at risk of sustaining a further iatrogenic spinal cord injury during intubation of the trachea. Controversy exists regarding the optimal anaesthetic technique for securing the airway. We reviewed the techniques employed for intubating the trachea in our hospital over a five year period. Tracheal intubation was achieved using two different techniques: awake fibre-optic intubation with local anaesthesia, and general anaesthesia via the intravenous or inhalational route with neuromuscular blockade. Forty five patients were included. 16 patients demonstrated a pre-operative neurological deficit. Awake fibre-optic intubation was used in 27 cases, general anaesthesia was employed via the intravenous route in 17 cases and the inhalational route in 1 case. Weighted traction was employed in all cases to immobilize the cervical spine during intubation. There was no new neurological sequelae with any of these techniques. Our study suggests that there is no optimal anaesthetic technique for intubating the trachea in patients with cervical spine injuries and it is noteworthy that in line traction was used in every case.

Anaesthesiological manpower in Europe.

Information about physician anaesthesiologist manpower in the countries of the European Union was collected from questionnaires sent to the delegates representing their respective countries on the European Board of Anaesthesiology. In the countries of the European Union and Switzerland and Norway 40,259 specialist anaesthesiologists are recorded. The number of anaesthesiologists in relation to population varies between as little as 4.4 and 4.6 (Ireland and UK) and as many as 15.6 (Italy), with a mean of 10.8/100,000 inhabitants. There are 11,610 physicians recorded in training in anaesthesiology. The ratio of trainees to specialists in the European Union countries was 28.8/100, varying from as low as 6.5 in France, to as high as 96.7 and 98/100 in Ireland and the UK respectively. These figures indicate a wide difference in the numbers of specialists and trainees between the European countries studied. However, the overall mean figure is close to that reported in the USA (9.2/100,000).

Intra-articular morphine for pain relief after knee arthroscopy.

We performed a randomised double-blind controlled study in patients undergoing elective knee arthroscopy to assess the effect of intra-articular morphine on postoperative pain relief. Patients in the study group (n = 10) received 5 mg of morphine in a 25 ml dilution intra-articularly while those in the control group (n = 10) received 25 ml of saline. Postoperative pain was assessed at intervals by a visual analogue scale and the requirement for supplementary analgesia was recorded. Those in the study group had significantly lower pain scores and required less systemic analgesics than those in the control group. Plasma profiles for morphine and its metabolites were assayed and showed that they were too low to produce effective analgesia. Evidence suggests that analgesia was mediated by local action within the joint.

Evidence for analgesia mediated by peripheral opioid receptors in inflamed synovial tissue.

Intra-articular morphine (5 mg in 25 ml) was administered to patients for post-operative analgesia following arthroscopic knee surgery. At various time intervals, 30 min to 4 h post morphine, venous blood samples were taken in order to determine plasma levels of morphine and its primary metabolites, morphine-3-glucuronide and morphine-6-glucuronide. Measurable amounts of morphine and morphine-3-glucuronide were found in the plasma of 7/10 patients whereas morphine-6-glucuronide was detected in only 2/10 patients. The plasma levels of morphine were lower than that regarded sufficient for post-operative analgesia in all but two patients, indicating a possibility of peripheral analgesia. In addition, synovial biopsy samples were assayed for the presence of opioid binding sites. Tissue samples from 11 different patients were analysed and 6/11 exhibited specific binding of [3H]naloxone, indicating the presence of opioid binding sites/receptors. The receptor type (i.e. mu-, delta- or k-) is at present unknown. Taken together, these data provide evidence that locally administered opiates can act on specific opioid receptors in the synovium to mediate analgesia.

The value of self-administered peri-operative physiotherapy.

Sixty patients undergoing cholecystectomy were studied and allocated at random to a control group and a treated group to whom physiotherapy instruction was given. Respiratory function tests were recorded pre-operatively and on the 2nd and 5th post-operative days. These showed no statistical difference in values pre-operatively, a statistically significant difference in value in both groups for all tests on the 2nd postoperative day, with maintenance of such reduced value for forced vital capacity (F.V.C) and peak flow (P.F.) in the control group on the 5th post-operative day.

Cardiovascular and biochemical evidence of stress during major surgery associated with different techniques of anaesthesia.

The relative merits of a potent narcotic and a spinal analgesic to affect the stress response to a standard operation have been assessed. Forty-five fit patients scheduled for abdominal hysterectomy were allocated at random to three groups, referred to as standard (i.v. anaesthesia alone), spinal (spinal plus i.v. anaesthesia) and fentanyl (fentanyl plus i.v. anaesthesia) groups. In the doses used, fentanyl produced the most effective attenuation of the cardiovascular, hormonal and metabolic responses to stress, but had the disadvantage of prolonged respiratory depression. Spinal anaesthesia gave only a modified blockade of the response to stress and did not obtund the response to intubation.

Liver enzyme studies with continuous intravenous anaesthesia.

A battery of liver function tests was carried out before operation and on the 3rd--5th and 13th--15th postoperative days in patients anaesthetised with continuous infusion of thiopentone, Althesin or etomidate for an intermediate operation. Some derangement of enzyme activity was found in one quarter to one third of the patients, and was most marked after Althesin. The findings are compared with published data on ketamine, which had an effect on enzyme activities similar to that of Althesin. On pooling data from different studies it became very apparent that large doses of intravenous anaesthetics cause a greater derangement of liver function than that which occurs using a balanced technique for the same operation.