Perioperative and Critical Care Medicine Educational Issues

245 Pages·2007·4.15 MB·English

by  J.L. Atlee

Perioperative and Critical Care Medicine
Educational Issues 2005
University of Trieste
School of Anaesthesia and Intensive Care
APICE School of Critical Care Medicine,Trieste,Italy
Editors:A.GULLO,G.BERLOT
Associate Editors:U.LUCANGELO,G.RISTAGNO
A.Gullo • G.Berlot (Eds.)
Perioperative and
Critical Care Medicine
Educational Issues 2005
1 3
ANTONINOGULLO
GIORGIOBERLOT
Department ofPerioperative Medicine
Intensive Care and Emergency
Trieste University School ofMedicine
Trieste,Italy
Library ofCongress Control Number:2005934227
ISBN 10 88-470-0416-0 Springer Milan Berlin Heidelberg New York
ISBN 13 978-88-470-0416-0 Springer Milan Berlin Heidelberg New York
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Preface
Teaching is an ancient activity;it requires a predisposition and ability to trans-
mit one’s own knowledge to others.It is also an innate quality that tends to
strengthen over time,due to the interaction between teacher and pupil that
develops and intensifies during their association,and to the ready availability of
constantly improving teaching methods.Teaching is a predisposition to commu-
nication.It is a constant commitment that becomes a way of life and offers the
capacity for self-renewal. In the clinical context, this desire to transfer and
receive information,together with the ability to summarise and authoritatively
reach decisions take on both professional and ethical significance.
Training provides an opportunity to deepen one’s foundation of knowledge
and to stimulate the development ofa reasoned clinical approach that allows sig-
nificant elements to be emphasised,with a view to improving one’s ability to cor-
rectly recognise and evaluate important clinical indications,both in routine and
in emergency situations.Clinical evaluation marks a key moment in the training
process,and knowing how to take note of all the relevant elements,including
paucisymptomatic ones,forms an integral part of a long process that,though
fully attainable,demands methodological meticulousness and the use of spe-
cialised forms ofteaching.These include teaching in small groups,establishing a
one-to-one relationship between teacher and pupil,taking advantage ofcomput-
er systems (micro-teaching),and a willingness of the teaching team to share
ideas while employing a practical,personalised approach.Finally,also required is
a close empathy between teachers and pupils,who must share the aim ofgaining
excellence (mastery learning); this is best supported through multidisciplinary
collaboration. For example, if a diagnosis cannot be confirmed by standard
investigations,the doctor must call into play all available resources,so that the
clinical approach is newly focused and geared towards improving the patients’
quality oflife.
This type ofsituation underlines the importance ofcontinuous improvement
of those methods associated with the most delicate phase of the long medical
teaching process.Training in medicine is a critical element;it requires a series of
educational instruments and methods able to optimise the various curricula.
VI Preface
This is especially true if we take into account the fact that the theoretical aspect
and the professional training elements are closely linked.
In 2004,the Board of the School ofAnaesthesia and Intensive Care of Trieste
considered that the time had come to offer pupils a collection ofselected lessons
offered by members of the teaching staff of the School,and by internationally
renowned researchers and clinicians.
The first volume stimulated considerable interest and encouraged us to con-
tinue with the initiative.The main goal is to offer pupils a useful guide to explore
the key components ofthe training process for future specialisation.With this in
mind,the aims ofthe course of2005 have been confirmed due to the keen partic-
ipation ofthe teachers ofthe School,its staff,and those who have edited the pre-
sent volume.The lessons and seminars contained within this volume are dedicat-
ed to the pupils and to all those who have an interest in supporting a continuous
educational process in the field ofanaesthesiology and intensive therapy.
Trieste Antonino Gullo
November 18th,2005 Giorgio Berlot
Table of Contents
Professionalism,Ethics and Curricula for the Renewal of the Health System
A.GULLO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Respiratory Mechanics in Health
E.D’ANGELO,A.LUCANGELO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Principles of Respiratory Mechanics and Clinical Correlations
J.MILIC-EMILI,N.G.KOULOURIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Understanding the Mechanism of Ventilator-Induced Lung Injury
C.S.N.B.GARCIA,P.R.M.ROCCO,W.A.ZIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Lung Parenchyma Remodelling in the Acute Respiratory Distress Syndrome
A.B.SOUZA-FERNANDES,P.R.M.ROCCO,W.A.ZIN . . . . . . . . . . . . . . . . . . . . . . . . . 61
Strategies To Modify Lung Remodelling in the Acute Respiratory Distress Syndrome
G.J.LAURENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Application of the Negative Expiratory Pressure Technique in Clinical Research
N.G.KOULOURIS,J.MILIC-EMILI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Non-Invasive Ventilation
A.PERATONER,V.ANTONAGLIA,U.LUCANGELO . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Pulmonary Effects of Acute Normovolaemic Haemodilution
C.B.MARGARIDO,D.A.OTSUKI,J.O.C.AULERJR. . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Microcirculation During Low Flow States
G.RISTAGNO,W.TANG,Y.-T.CHANG,M.H.WEIL . . . . . . . . . . . . . . . . . . . . . . . . . . 119
The Effects of Gasping During Cardiac Arrest and Cardiopulmonary Resuscitation
Y.-T.CHANG,W.TANG,G.RISTAGNO,M.H.WEIL . . . . . . . . . . . . . . . . . . . . . . . . . . 131
VIII Table of Contents
Perioperative Risk Assessment and Decision Making
A.BACHER,M.ZIMPFER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Anaesthesia and Sedation Outside the Operating Room
J.RUPREHT,J.HOFLAND,K.LEENDERTSE-VERLOOP . . . . . . . . . . . . . . . . . . . . . . . . . 153
Anaesthesia for Endovascular Repair of Abdominal and Descending
Thoracic Aortic Aneurysm
B.DRENGER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Postoperative Pain Management:Organisation and Audits
D.CARISTI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Introduction to Trauma Care and Improving Performance
F.DELLACORTE,G.L.VIGNAZIA,C.OLIVIERI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Fluid Resuscitation in Trauma
G.BERLOT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Ongoing Challenges in Sepsis and Organ Dysfunction
A.E.BAUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Microdialysis Monitoring of Organ Chemistry in the Intensive Care Unit
U.UNGERSTEDT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Ethical Dilemmas in Surgical Critical Care
A.E.BAUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
List of Contributors
Antonaglia V. Caristi D.
Department ofPerioperative Department ofPerioperative
Medicine,Intensive Care and Medicine,Intensive Care and
Emergency,School ofAnaesthesia and Emergency,School ofAnaesthesia and
Intensive Care,Cattinara University Intensive Care,Cattinara University
Hospital,Trieste,Italy Hospital,Trieste,Italy
Auler J.O.C.Jr. Chang Y.-T.
Anaesthesia and Intensive Care Unit Weil Institute ofCritical Care
Department,Hospital das Clínicas, Medicine,Rancho Mirage,California,
InCor (Heart Institute) University United States
ofSão Paulo Medical School,
São Paulo,Brazil D’Angelo E.
Institute ofHuman Physiology I,
Bacher A. University ofMilan,Milan,Italy
Department ofAnaesthesiology and
General Intensive Care,Medical Della Corte F.
University ofVienna,Austria Department ofAnaesthesiology and
Intensive Care,University ofEastern
Baue A.E. Piedmont ‘A.Avogadro’,Novara,Italy
Former Chairman Department
ofSurgery,Yale University School Drenger B.
ofMedicine,New Haven, Department ofAnaesthesia,Hadassah
Connecticut,United States University Hospital at Mount Scopus,
Jerusalem,Israel
Berlot G.
Department ofPerioperative Garcia C.S.N.B.
Medicine,Intensive Care and Laboratory ofPulmonary
Emergency,School ofAnaesthesia Investigation,Carlos Chagas Filho
and Intensive Care,Cattinara Institute ofBiophysics,Federal
University Hospital, University ofRio de Janeiro,
Trieste,Italy Rio de Janeiro,Brazil
X List of Contributors
Gullo A. Milic-Emili J.
Department ofPerioperative Medicine, Meakins-Christie Laboratories,
Intensive Care and Emergency,School McGill University,Montreal,
ofAnaesthesia and Intensive Care, Quebec,Canada
Cattinara University Hospital,
Trieste,Italy Olivieri C.
Department ofAnaesthesiology
Hofland K. and Intensive Care,University
Department ofAnaesthesiology, ofEastern Piedmont ‘A.Avogadro’,
Erasmus University,Rotterdam, Novara,Italy
The Netherlands
Otsuki D.A.
Koulouris N.G. Veterinary School,and Department
Respiratory Function Laboratory, ofAnaesthesiology ofUniversity
Department ofRespiratory Medicine, ofSão Paulo Medical School,
University ofAthens Medical School, São Paulo,Brazil
‘Sotiria’Hospital,Athens,Greece
Peratoner A.
Laurent G.J. Department ofPerioperative
Centre for Respiratory Research,Rayne Medicine,Intensive Care and
Institute,Royal Free & University Emergency,School ofAnaesthesia
College Medical School,London, and Intensive Care,Cattinara
United Kingdom University Hospital,
Trieste,Italy
Leendertse-Verloop K.
Department ofAnaesthesiology, Ristagno G.
Erasmus University,Rotterdam, Weil Institute ofCritical Care
The Netherlands Medicine,Rancho Mirage,
California,United States
Lucangelo A.
Department ofPerioperative Medicine, Rocco P.R.M.
Intensive Care and Emergency, Laboratory ofPulmonary
School ofAnaesthesia and Intensive Investigation,Carlos Chagas Filho
Care,Cattinara University Hospital, Institute ofBiophysics,Federal
Trieste,Italy University ofRio de Janeiro,
Rio de Janeiro,Brazil
Margarido C.B.
Department ofAnaesthesiology, Rupreht J.
Hospital das Clínicas, Department ofAnaesthesiology,
University ofSão Paulo Medical Erasmus University,Rotterdam,
School,São Paulo,Brazil The Netherlands