Herbert West, rianimatore (Italian Edition)

---

Simple Measures to Take Cost reduction can easily be achieved in many areas of anaesthesiology. The following measures have turned out to be effective: The cost-effectiveness of routine prophylactic preparation of cardiac resuscita-tion drugs must be called into question. Another method of avoiding drug wastage is the use of monitors, like BIS or Narcotrend, to hasten recovery and minimise drug usage [7].

Is the use of Woodbridge tubes justified for every patient operated on in the prone position? Can we create an escalation protocol for the treatment of nausea, or must every patient get his serotoninantagonist immediately? Which hypnotic, opioid or muscle-relaxant are we to choose? Who does not know the price, will not take efforts to save the money. I am repeatedly sur-prised by the creativity of some representatives in finding a way of being able to make their product cheaper. Without any further measures, this information led to a still persisting reduction of costs for infusion fluids of about month!

However, it has also been report-ed that "price tags" have no effect on drug usage [9]. As soon as productivity in the OR is directly coupled with the income of an anaesthesia department, responsible planning should be taken over by the anaesthesia department, too. In conclusion, it should be the aim of each anaesthesia department to be able to create an income of its own by clinical and scientific activities.

Next to this, an intra-hospital reimbursement strategy must be developed. A re-distri-bution of the budgets has to take place, since expensive modern anaesthesia leads to more effective cheaper patient care on the general wards. This demands a pro-active attitude, careful documentation of all activities, cost-awareness and ongoing investment in the clinical and academic development of the staff.

Quality has its price, but quality is also sparing costs by avoiding complications - this must be communicated to surgeons, the hospital adminis-tration, health insurance providers, the government and, of course, the patients. J Clin Anesth Weinberg MB Drug wastage contributes significantly to the cost of routine anesthesia care. Can J Anaesth J Med Syst Koperna T How long do we need teaching in the operating room?

The true costs of achieving surgical routine. Introduction Since the first human-to-human heart transplant was performed, in , by Christiaan Barnard [1], remarkable progress in this field has been achieved. Heart transplantation nowadays is efficiently performed worldwide with high rates of success: Improvement of surgical and anesthetic techniques, as well as perioperative care, associated with new immunosuppressive strategies, newer antibiotics plan-ning, improved donor and recipient selection, and graft preservation, have improved results considerably.

After transplantation, the average I-year survival rate is Pre-transplant risk factors are related to the degree of hemodynamic instability of the donor, as well as to the poor general-health conditions of the recipient. An added factor affecting sur-vival is the level of human leukocyte antigen HLA -matching between donor and recipient. The literature reports a progressive reduction in the risk of failure after heart transplantation with better RLA matching.

Graft dysfunction pre-vails as a cause of death during the first month after cardiac transplantation. This is because the patient requires more intensive and invasive care with a subsequently higher risk of infection and rejection; an otherwise inefficiently functioning heart compromises others organs, mainly renal and liver function, which limits the doses of immunosuppressive drugs. According to the literature, acute rejection and infection are the predominant causes of death from the first month to one year after heart transplantation The most significant problem limiting survival after one year is still chronic rejection This is followed by graft failure The immediate management of cardiac transplant recipients is chal-lenging and warrants, beside the basic intensive-care, the administration of immunosuppressive therapies, knowledge of the physiology of the transplant-ed heart and acute rejection management.

Most postoperative management success may be attributed to careful selection of recipient and donor, as well as to protection of the graft against prolonged ischemia. This article aims, based 18 J. General Considerations Indications for Cardiac Transplantation Cardiac transplantation is reserved for a selected group of patients with end-stage heart disease and a poor response to medical therapy or other surgical alternatives. A subgroup of patients with NYHA class III symptoms with limited exercise presenting with maximal oxygen con-sumption values equal or less than 14 mllkg per minute, may also be considered as potential candidates, due to the elevated I-year mortality [2].

In our patients there is also a subgroup with terminal heart failure due to chronic Chagas dis-ease 48 patients, There are several contraindications for cardiac trans-plantation: Although the upper age lim-it for recipients is between 55 and 65 years, survival expectancy and quality of life in selected older patients is equivalent to that of younger recipients [3]. This was confirmed when we analyzed the age of recipients in the year Another point of paramount importance is related to the recipients' previ-ous "cutoff" values of pulmonary vascular resistance PVR.

A fixed PVR greater than 6 Wood units or a transpulmonary gradient higher than 15 mmHg, which does not respond to vasodilators such as oxygen, sodium nitroprusside, milrinone or prostaglandin, was formerly considered a contraindication for orthotopic cardiac transplantation in most centers around the world [4, 5]. Fundamentally, high PVR values in patients with heart failure have been con-sidered as a passive consequence of high pressure back from the left atrium toward the pulmonary circulation as a result of mitral insufficiency in cases of ventricular and annulus dilation.

Nevertheless, PVR commonly remains elevat-ed after transplantation with a tendency to decrease gradually, although the moment of its resolution is still unclear. According to these Authors, the hemodynamic profile of the pulmonary system after transplantation is partially dependent on the level of pulmonary pressure before surgery, at least during the first year after the procedure.

Non-insulin dependent diabetes mellitus may be considered a rela-tive contraindication, depending on the presence of significant end-organ The Best Weaning after Cardiac Transplantation 19 damage, such as nephropathy, retinopathy or neuropathy. On the other hand, insulin-dependent patients usually are considered as risk recipients because of their severe organ injury.

In conclusion, ambulatory patients who have NYHA class III to IV and who are refractory to optimized medical treatment seem the most likely to benefit from cardiac transplant. However, hospital-admitted patients with severe heart failure and supported with inotropic drugs or even mechanical or ventricular assist devices VAD , are likely to benefit from trans-plant if their organs are relatively healthy and if they are free from sepsis or any sort of infection [7, 8. Donor Selection The availability of donor organs remains the main restrictive factor to heart transplantation.

In the year , 22, transplants of different organs were performed from 11, donors, but there is still a waiting list of 80, recipients [9. Once a potential cardiac donor has been identified and all legal processes related to organ donation have been considered, a meticulous protocol of exams must be done. First of all, a record of the previous condition of health and the life-habits of the donor should be obtained. As the majority of potential organ-donors are victims of trauma and have been subjected to critical conditions, a general record of these conditions, principally, the degree of hemodynamic sta-bility and the amount of circulatory supportive therapeutics, should be obtained.

Also, laboratory data, including viral serologies, should be requested. Specific exams, such as EKG, thoracic X-ray and especially echocardiography, are of fundamental importance. Donor and recipient ABO compatibility is essential, and histocompatibility-antigen matching should be taken into account.

A random panel of pooled lymphocytes representing the histocompatibility antigens in the community is used to test the recipient for anti-human-Iymphocyte antigen antibodies that may ignite hyperacute rejec-tion soon after the graft has been implanted. In this case, a prospective negative T-cell crossmatch between the recipient and donor sera is obligatory before transplantation [10, A positive crossmatch, even if performed retrospectively, is an absolute contraindication to transplantation.

Prospective HLA matching, although ideal, is not routinely per-formed due to current allocation criteria and restrictions on ischemic time of the allograft. A significant consideration is size matching between donor and recipient. Acceptable size-matching is guided by similar weight between both, but the presence of higher PVRS in recipients requires hearts grafts with more preload recruitment capacity. In this particular condition it is preferable that donors are larger than recipients.

It is important to consider evidence of myocardial dysfunction after brain death, severe enough to preclude the heart for transplantation in a significant number of cases. These Authors concluded that caspases were elevated in dysfunction-al donor hearts compared to hearts with preserved ventricular function. This fact may establish a possible link to inflammatory activation, endorsing the con-cept that brain death ignites inflammatory activation which can lead to apopto-sis with an important effect on heart function.

Finally, once considered as potential donors, due to the loss of central regulatory mechanisms, these patients are subjected to hypothermia, hypotension and several electrolyte dis-turbances that require intensive-care treatment until the moment of the dona-tion. Recipient Anesthesia A successful heart-transplant program requires the active participation of expert anesthesiologists who are familiar with complex cardiothoracic anesthe-sia techniques and cardiopulmonary bypass.

The standard protocol for cardiac anesthesia is used for heart transplantation. Usually, heart transplantation is an emergency and "full-stomach" precautions should be taken into account. Long-term congestive heart failure promotes down-regulation of cardiac beta-l recep-tors and there is a partial uncoupling of these receptors from adenylate cyclase.

At the same time, altered ratios of inhibitory stimulatory signal-transduction proteins decrease receptor sensitivity to beta agonists. These factors, associated with a high circulatory dependency of increased preload and afterload, may lead the recipient heart to a poor tolerance of potent inhaled anesthetics and a sud-den decrease in systemic resistance [15]. Anesthesia induction and maintenance should be carefully tailored, preferably by utilizing a BIS biospectral index sys-tem to guide the dose. Our practice is based on hypnomidate and small doses of fentanyl or sufentanil as induction agents, in association with isofluorane or sevofluorane as well as muscle-relaxation agents with fast elimination for main-tenance.

All patients are monitored with central venous lines, Foley catheters, radial artery catheters, central temperature probes, pulmonary artery catheters and transesophageal echocardiography. The pulmonary artery catheter is retracted during heart removal and graft anastomosis and then advanced again into the pulmonary artery at the end of the surgical procedure. Long-term anti-coagulation of the recipient, such as during thromboembolic prophylaxis, or a deficiency in the coagulation system due to generalized hypoperfusion, conse-quent to congestive heart failure, may cause a significant disturbance in coagu-lation after cardiopulmonary bypass CPB.

Anti-fibrinolytics, such as aprotinin or aminocaproic acid, have been routinely used to reduce the risk of hemor-The Best Weaning after Cardiac Transplantation 21 rhage after CPB. In conclusion, due to impairment of systolic and diastolic func-tion and consequent lower ejection fraction, the recipient should be carefully managed before CPB. Complete hemodynamic monitoring and judicious use of inotropic and vasodilators agents are indicated to obtain a cardiac output nec-essary to maintain organ perfusion from the initiation of anesthesia until CPB.

Hemodynamic support is continued after CPB, when the transplanted heart is allowed to beat. However, the transplanted heart presents physiologic character-istics that require special attention, discussed below. Physiology of the Denervated Heart At the time of cardiac transplant surgery, the donor's heart is completely dener-vated. Orthotopic implantation of the donor's heart is currently performed using the bicaval anastomotic technique, using the following anastomoses: Due to this technique, the autonomic nerve connection is totally disrupted.

The function of the recently transplanted heart is strongly influenced by the previ-ous PVR of the recipient and the presence of total denervation. Ischemia induces diastolic dysfunction, which requires higher atrial filling pressures than normal. Characteristically, the cardiac allograft may present several degrees of impaired contractility and systolic dysfunction [16]. As a consequence of the lack of direct innervation, the transplanted heart may show an exacerbated chronotropic and inotropic response to the systemic infu-sion of adrenergic agents.

This fact, often referred to as an exaggerated sensitiv-ity to catecholamines, seems to result from the associated loss of sympathetic and parasympathetic innervation [17]. The inotropic supersensitivity seems to be a consequence ofloss of pre-synaptic re-uptake and the depletion of endoge-nous pre-synaptic catecholamine stores [18]. The practical consequence of denervation is the necessity of catecholamine infusion after transplantation. Due to the exaggerated chronotropic and energetic response mainly to beta-agonists, the doses of exogenous catecholamine should be carefully adjusted to avoid these side effects, described in the literature.

The same Authors evidenced that transplanted recipients exhibit a larger fall in contractile effectiveness and significant oxygen wasting during dobutamine infusion, when compared to nor-mal volunteers. The fall in myocardial efficiency, as induced by dobutamine, cor-related with increased heart rate and presented as the same effect, i.

This result may be caused by the loss of inhibitory parasympathetic innervation [19]. Stark and colleagues et al. Immediate Postoperative Management The standard care for cardiac-transplanted patients in the immediate postoper-ative period obeys the same pattern employed for patients who have undergone cardiac surgery. Additional protection against infection is added to the general care, and patients may be admitted to a special leu area.

Early complications after cardiac transplantation include acute and hyperacute rejection; low car-diac output, more commonly due to right ventricle failure; arrhythmias; pul-monary and systemic hypertension and renal failure. Early infection may occur, mainly pulmonary infection due to common bacteria, while opportunistic, viral and fungal infections become more frequent after a couple of weeks.

Secondary Verifications

Although rare, hyperacute rejection caused by preformed recipient cytotoxic antibodies against donor heart antigens, is a cause of global graft failure. Most of the time this is life-threatening, requiring urgent plasmapheresis and, in critical situa-tions, are-transplant [8]. In our protocol, as soon as the anastomosis is completed and the heart starts to beat, a complete hemodynamic profile and an echo cardiographic evaluation of cardiac function is obtained. Depending on the heart function, specifically, the right ventricle performance, as well as the PVR and pulmonary artery val-ues, a direct beta-adrenergic agonist is started.

Routinely, a drip of dobutamine 5. In the presence of evident right-ventricle dysfunction, milrinone can be included 0. Sodium nitroprusside often is required additionally in order to offset peripheral and pulmonary vasoconstriction. Right ventricle dysfunction associated with elevated pulmonary vascular resis-tance is a significant problem immediately after epE.

Inflammatory mediators released during ePB may aggravate previous pulmonary hypertension of the recipient. There is no specific treatment of severe pulmonary hypertension due to the lack of a selective pulmonary vasodilator. An increase in pulmonary artery pressure in the first hours after transplantation may reflect low capacity of vasoreactivity in the pul-monary system, which means that pressure becomes flow dependent.

Elevated right atrial pressure, above 15 mmHg, may be evidence of right ventricle dys-function; if confirmed by echo cardiography, this may require more aggressive drug therapy, including vasodilator agents. Right atrial pressures above 20 mmHg are associated with a rapid decline in renal function due to low cardiac output [21]. Due to the lack of a selective pulmonary vasodilator, nitric oxide, an endothelium-derived factor that produces relaxation of the vascular smooth muscle, has been used.

In 10 patients after heart transplantation we observed a beneficial effect of inhaled nitric oxide, by decreasing PVR, transpulmonary The Best Weaning after Cardiac Transplantation 23 gradient and increasing cardiac index, demonstrating that nitric oxide acts mainly on the pulmonary system [ Tacrolimus is a macrolide antibiotic that shares many pharmacological properties with cyclosporine. Several studies have compared the immunosuppressive results of tacrolimus and cyclosporine, related to survival and rejection, but the results of clinical trials are inconclusive [ Acute rejection can be manifested with sig-nals of low cardiac output, arrhythmias, and fever.

Most of the episodes are insidious, and right ventricular endomyocardial biopsy remains the gold stan-dard for the diagnosis of acute rejection. This is done by means of a percuta-neous approach through the right internal jugular vein. The weaning of vasoactive drugs is performed according to hemodynamic and echocardiographic data. In general, after days only a small dosage of dobutamine or epinephrine is maintained, and then a few days later the vasoac-tive drugs are completely withdrawn guided by echo cardiography and clinical signals.

Invasive monitoring is removed as soon as stable hemodynamic condi-tion is reached, on average after transplantation. In our practice, we sub-sequently maintain only a central venous line during the first week after trans-plantation. If the patient is then free from major complications, he or she is dis-charged from the ICU. Respiratory Management Patients submitted to heart transplantation are treated with the same protocol used in patients undergoing major cardiothoracic surgery.

At the same time, alveolar recruitment maneuvers, comprising CPAP 20 to 30 cm H20, 20 s, repeated every two or three hours, are employed until the PaOiFi02 ratio is restored to adequate. Ideal PEEP is calculated utilizing the best compli-ance, set at 2 cm up to the best point. Due to the delicate balance between right ventricle ejection fraction and the pulmonary system, all these maneuvers should be carefully performed.

The incidence of pulmonary complications in heart transplant recipients has not been completely studied. In their retrospective review, 47 of recipients They concluded that patients who have pulmonary complications after transplantation have a higher mortality than patients with-out pulmonary complications. The influence of cardiac allograft vasculopathy 24 J. In conclusion, heart transplantation has evolved from an experimental pro-cedure to a well accepted therapy for selected patients with heart failure refrac-tory to medical treatment. The success of the procedure depends on several factors: Barnard CN The operation.

A human cardiac transplant: S Afr Med J J Heart Lung Transplant J Heart Transplant 7: Am J Surg Edmunds HL Jr Heart transplant. Cardiac surgery in the adult. McGraw-Hill chapter 49 9. Overall heart and adult heart transplantation statistics. Accessed February 14 Davis FD Coordination of cardiac transplantation: Chetham PM Anesthesia for heart or single or double lung transplantation in the adult patient. Renlund GD Cardiac transplantation. Topol EJ ed Comprehensive car-diovascular medicine.

Schwaiger M, Hutchins GD, KalffV et al Evidence for regional catecholamine uptake and storage sites in the transplanted human heart by positron emission tomography. J Clin Invest Evidence of sensory reinnervation after cardiac transplantation. N Engl J Med Miller WL Heart transplantation in critical care. Kobashigawa JA Postoperative management following heart transplanta-tion. Schwaiblmair M, von Scheidt W, Uberfuhr P et al Lung function and car-diopulmonary exercise performance after heart transplantation: By way of example, we examine two extremely important topics: For a more spe-cific analysis of the physical applications, the reader is invited to refer to spe-cialist articles echocardiography, aortic and thoracic acoustic imaging, neuro-muscular monitoring, infrared spectroscopy, etc.

The Gas Laws The ideal gas laws [1] show the interrelations between volume V , pressure P , temperature n and quantities of gas, and they are applied to diluted gases at temperatures above boiling point. The boiling point of a gas is the temperature at which, at a standard pressure, the gas condenses to the liquid state.

The boil-ing point can be increased by increasing the pressure, up to a critical tempera-ture above which the gas cannot change to the liquid state regardless of the amount of pressure applied. The closer the temperature is to the boiling point, the greater the error will be in using the gas laws. Boyle's Law If the temperature and the quantity of gas are constant, the volume V of a gas is inversely proportional to the pressure P: Charles's Law If the pressure and quantity of gas are constant, the volume is proportional to the temperature: Accardo Gay-Lussac's Law If the volume and quantity of gas are constant, the pressure is proportional to the temperature: A mole is one gram multiplied by the molecular weight of a substance therefore, its molecular weight expressed in grams.

According to Avogadro's law, 1 mole of any ideal gas always occu-pies I For example, the molecular weight of oxygen is 32, therefore 1 mole of oxygen equals 32 grams of oxygen and occupies The concepts outlined so far are combined in the ideal gas law or ideal gas equation of state , which states that the pressure of a gas is directly propor-tional to the temperature and number of molecules constituting it, and inverse-ly proportional to the volume in which it is contained: If a gas, such as oxygen, is in a cylinder, the pressure gauge gives an accurate estimate of the quantity of gas contained within it.

According to convention, the volumes of blood gas are measure in STPD, or standard temperature 0 C or K and pressure mmHg or 1 atm dry. Basic Physics for Anaesthesia and Intensive are 31 Gas volumes in respiration, by contrast, are measured in BTPS, or body tem-perature 37C , ambient pressure and saturated with water vapour 47 mmHg. Dalton's Law of Partial Pressure The pressure of a gas mixture is the sum of the partial pressures of the individ-ual components of the mixture. In other words, the pressure exerted by each gas is the same as that which it would exert if it occupied the container alone: The ideal gas law can be similarly reformulated: Therefore, when calculating the partial pressure of a gas where water vapour is present, the total barometric pressure needs to be corrected before calculating the partial pressure of each gas.

Graham's Law The diffusion velocity v of a gas is inversely proportional to the square root of its molecular mass: Accardo For the diffusion of a gas through a tissue, such as the alveolar membrane, Fick's law is used, which reformulates some of the concepts considered in the previous two laws.

The velocity of transfer of a gas through a layer of tissue is directly proportional to the area of tissue A , the difference in partial pressure of the gases on either side PI - P2 and the gas diffusion constant, and inverse-ly proportional to the thickness of the tissue 5: The concepts outlined so far are also important for understanding the action of volatile anaesthetics.

The solubility of a volatile anaesthetic is described by the blood-gas partition coefficient, which describes the relation-ship between the concentration of the anaesthetic in the blood and the con-centration in the alveolar air, under conditions of equilibrium between the two phases, and constant temperature and pressure. The greater the solubility of an inhalation anaesthetic, the less is its speed of action, given that it dissolves rapidly in the blood. For this reason, an inhalation anaesthetic is more powerful the less soluble it is. During induc-tion with nitrogen monoxide, upon reaching the alveoli the gas diffuses accord-ing to the concentration gradient more rapidly than nitrogen, and the other gases present become concentrated in a reduced space concentration effect.

Furthermore, if another anaesthetic agent is present, its effective concentration increases second gas effect. During the anaesthesia recovery period, howev-er, the opposite effect occurs: Volatile halogenated anaesthetics are vapours and not gases in that they are present in liquid form at ambient temperature. For anaesthetic purposes, a vaporiser - a device which transforms the anaesthetic from the liquid to the vapour state - is used.

Passing through the vaporiser is a mixture of carrier gases in which a controllable quantity of the anaesthetic is released. The change from a liquid to a gaseous phase requires work, and therefore a Basic Physics for Anaesthesia and Intensive Care 33 consumption of energy. If the energy required is not supplied externally through the administration of heat, the work is performed at the expense of the kinetic energy of the molecules of the liquid, which undergoes gradual cooling. The evaporation heat is the quantity of heat to be administered per unit mass of a liquid, at a certain temperature, in order to transform the liquid into saturated vapour at the same temperature.

This problem is avoided by modern precision vaporisers, which are equipped with metal blades that vary the resis-tance at the entrance of the vaporisation chamber with respect to its internal temperature. The reduction of resistance under conditions of reduced temper-ature enables an increase in flow. Fluid dynamics Fluids include gases and liquids and have two important properties: They can, how-ever, support a normal perpendicular force to their surface; that force per surface unit is, of course, pressure.

Because the Pascal is a very small unit, the com-monly used measurement is the kilopascal kPa. Another unit of measure-ment is the bar, which is a multiple of the Pascal: Accardo The torr named after Evangelista Torricelli, who invented the mercury barometer in is the pressure of a column of mercury of 1 mm mmHg: It is used solely for the measurement of the pressure in the airways, because the viscosity of air is low and the pressure gradient required to overcome the resistance within the conducting airways is in the order of the mmHg.

The manometer is an instrument used for measuring the pressure of fluids, such as arterial blood, and it consists of a tube containing mercury or water. The weight of the column of liquid is used to equilibrate the pressure exerted against it, and the height reached by the column indicates the pressure to be measured.

The pressure of the manometer, therefore, only depends on the density of the fluid used and the vertical height of the col-umn. A fundamental characteristic of fluids is described in Pascal's law of fluid pressures Blaise Pascal [2]: This principle lies at the basis of the Heimlich manoeuvre, by which a sharp increase in pressure applied to the abdomen is transferred to the throat, causing the expulsion of food particles from the trachea.

Another example in which this principle is applied is a water bed, which uniformly distributes the body's weight thus reducing decubitus pain. The easiest fluids to study are ideal fluids, which have a number of charac-teristics in contrast with real fluids. An ideal or perfect fluid is one which is: In reality, gases are easily compressed, whereas liquids are not. Viscosity is responsible for shear forces between one layer and another of the fluid in motion.

When these forces can be assumed to be zero, the fluid is said to be inviscid. A fluid will have, by contrast, turbulent motion when the velocity changes in time and vortices are formed [3]. Basic Physics for Anaesthesia and Intensive Care 35 Under conditions of laminar flow, the elements of a fluid move following non-intersecting streamlines. The velocity in each point is the tangent to the streamline at that point. The fluid moves staying within a flow tube, which is determined by the sum of all of the streamlines passing through the points of a closed curve.

Equation of Continuity [2] In a fluid undergoing laminar flow, the flow rate remains constant; that is, the product of the area of the section through which the flow passes multiplied by the velocity is constant: To demonstrate this equation, consider a tube with abrupt variations in the area of the section in which a perfect fluid is moving. Al and A2 are two areas of normal sections of the tube and VI and V 2 are the velocities of the fluid pass-ing through those sections.

If in a certain time interval M the fluid in Al trav-els a distance Xl' in the same time interval the fluid in A2 will travel a distance xl" Once the velocity of a fluid is given by the distance travelled in a time inter-val: Accardo Under conditions of laminar flow, the quantities of fluid which pass through sections Al and A2 in At have equal volumes because, by definition, no fluid can leave or enter through the walls. The flow rate Q will also be constant: If the tube narrows, the streamlines draw closer together and the velocity of the flu-id increases.

In physiology, the equation of continuity can be applied in an approximate manner to the movement of air through the bronchial tree. The bronchial tree is characterised by an irregular dichotomous ramification, through which the section area increases at each generation of airways, despite the formation of branches continually smaller in diameter and shorter in length.

Another application of the law is in pulmonary vascularisation. Pulmonary blood-flow can be considered constant in time. Therefore, its velocity is greater in the arteries and the arterioles, where the section area is greater, than it is in the pulmonary capillary network. This reduction in velocity has the physiological advantage of lengthening the time for gas exchange through the alveolar-capillary membrane. Bernoulli's Theorem [2,3,4] This theorem takes its name from the mathematician and physicist Daniel Bernoulli and it is the principle of conservation of mechanical ener-gy applied to a fluid in motion.

It states that, for each element of a perfect fluid in movement in a gravitational force field, the sum of the pressure energy, the kinetic energy due to movement and the potential energy due to the force of gravity times a unit of volume is constant: Basic Physics for Anaesthesia and Intensive Care 37 That sum corresponds to the mechanical energy which is conserved in lam-inar movement, given that there are no viscous forces. Let us return now to the perfect fluid flowing in a tube under stationary con-ditions. In other words, the force required to increase the velocity is guar-anteed by the reduction in pressure.

Therefore, if the potential energy is con-sidered constant, an increase in velocity is accompanied by a reduction in pres-sure, and viceversa. The pressure force F1 exerted on A1 promotes the movement of the fluid, whereas the force F2 exerted on A2 opposes movement. If L1 and L2 are, corre-spondingly, the work performed: Accardo The overall change in kinetic energy dK and potential energy M!

In the case of a viscous fluid, a part of the work performed by the forces in action does not contribute to increasing the kinetic energy, in that it is dissipated as heat due to friction. The theorem can explain the situation in which for some reason an airway narrows: There are numerous applications for Bernoulli's theorem, such as the lift an aeroplane wing receives. The lower surface of the wing is flat, whereas the upper surface is convex. This divides the air into two currents which pass one above the wing and one below and then meet up again. The current passing above the wing travels a greater distance, and will therefore be faster.

As a con-sequence the pressure exerted above the wing will be less than the pressure exerted below. This imbalance in pressure creates the lift the plane receives Fig. Representation of the wing of an aeroplane Another important application of this theorem is the Venturi tube Giovanni Venturi, , which is a tube in which a section is narrowed.

Its purpose is to measure the flow rate in a tube and it is therefore inserted hori-zontally into a section of the tube itself. As can be seen in Fig. Venturi tube from http: P, Pressure; v, velocity; A, area According to Bernoulli's theorem, the pressure in Al is greater than the pres-sure in A2 , and this can be measured by inserting a manometer in correspon-dence with the two sections. The Venturi tube operates on the general principle that the pressure in a narrowed region is lower than the pressure in the main tube.

If the velocity of flow in the tube is sufficiently high, then the pressure in the narrow region may be lower than atmospheric pressure; this fact is exploited in the carburetor of an automobile. In the chamber of the carburetor, the fuel is under the effects of atmospheric pressure. The carburetor vaporises the liquid fuel and forces it up a tube, where air passes, which narrows in the middle. This narrow section accelerates the mixture of air and fuel, and the acceleration causes a fall in pressure, which in turn vaporises more fuel [5].

The Venturi principle is also the basis for the functioning of the mask for the administration of high-flow oxygen, known as the Venturi mask or ventimask. The oxygen is supplied to the mask at a low-flow velocity; at the entrance to the mask, however, it is drawn into a narrow hole, and this passage generates high-velocity flow. The flow of gas produced in its turn draws ambient air into the mask. By adjusting the diameter of the hole, the 02 can be appropriately dilut-ed with ambient air, obtaining Fi02 [6] Fig. Basic Physics for Anaesthesia and Intensive are Gas accelerate here a The Bernoulli elfect, with a flow of gas passing through a narrow tuhe.

Note how the pressure falls at the narrow point. The Bernoulli effect, b representation of the Venturi mask 41 It has been demonstrated, however, that the ventimask, rather than function-ing according to the Venturi principle, functions according to the principle of jet mixing. The variation of the flow of oxygen through the hole modifies the pres-sure only at the level of the narrowing, and this slight pressure gradient is insignificant for the air inlet. The flow of oxygen in movement, upon meeting still ambient air, generates a viscous force which transports with it the nearby laminar flows of air to a degree proportional to the flow velocity.

The entrance of air, therefore, practically takes place at constant pressure, as a result of the vis-cosity of the fluid, and each pressure variation is a consequence of the mixing process [5, 7]. Accardo Viscosity A real liquid can be considered incompressible to a fair degree of approxima-tion, but it always presents a certain viscosity, a certain force of internal friction. Consider a fluid in movement under conditions of laminar flow along a hori-zontal cylindrical tube. If the liquid were perfect, the pressure would be the same in all of the sections, whereas in the case of a real liquid the pressure decreases in the direction of movement, and between two sections of liquid there is always a pressure difference, known as pressure or head loss.

This loss is typical of frictional or dissipative forces, the intensity of which is determined by a property known as viscosity. The viscosity of liquids is influenced by the van der Walls cohesive forces between the molecules and is reduced with heat, whereas the viscosity of gases derives from the collision between particles of gas which move rapidly and increase their velocity with heat. One of the effects of viscosity is that the velocity of each particle of fluid depends on the distance from the axis of the tube.

Laminar flow is character-istically made up of a series of concentric layers whose velocity V m increases from the layer nearest the edge towards the centre of the tube Fig. Laminar flow from http: R, Radius of the layer nearest the edge; r, radius of a layer nearer the centre. Arrows indi-cate the vector of the flow velocity along the axis of the tube All laminar movement is regulated by Poiseuille's law: With blood transfusions, for example, increasing the diameter of the needle is preferable to increasing the height of the bag with Basic Physics for Anaesthesia and Intensive Care 43 respect to the needle.

Doubling the diameter of the needle increases the flow rate sixteen times. In contrast, halving the diameter increases the resistance sixteen times [7]. If the fluid velocity is increased, the laminar motion becomes turbulent, with the direction of the velocity at one point changing from instant to instant.

This leads to the creation of vortices, or small areas of flow which close in on them-selves and maintain their own individual motion within the tube. Initially, sig-nificant kinetic energy is associated with the vortices which then due to inter-nal friction is dissipated in heat and the vortices dissolve. With the same pres-sure difference between the two ends of the tube, therefore, the flow rate is less than it would be under conditions of laminar motion, and Poiseuille's law is no longer applicable.

Real liquids can be divided into Newtonian and non-Newtonian liquids according to whether their viscosity remains constant or not [8]. A Newtonian liquid has a Reynold's number around 2, Accardo Those values can also be considered valid for blood under normal condi-tions, even though it is a non-Newtonian liquid. The blood viscosity coefficient increases with haematocrit, whereas it decreases in capillaries with a diameter less than a millimetre Fahraeus-Lidqvist effect. An explanation for this feature is that in the capillaries blood has bubble motion, in which almost all of the plasma is found between one erythrocyte and another, therefore the apparent viscosity tends towards zero.

Furthermore, in small vessels the erythrocytes, being large cells, tend to accumulate in the faster central part of the flow, such that there are few cells near the vessel walls that contribute to wall friction. In many vessels with normal levels of arterial pressure, turbulence is practi-cally absent, and the blood flow can be well described with Poiseuille's law. Only in the central part of the aorta does the blood flow reaches critical veloc-ity and becomes turbulent. Poiseuille's law can also be applied to gas flow in the airways.

In this case tJ. During free breathing, with the excep-tion of the superior extra-pulmonary airways, the motion can be considered laminar in all regions. With an increase in ventilation, motion becomes turbu-lent in the trachea and the main bronchi, where the velocity is highest, where-as in the distal ramifications, due to the increase in the total section, the veloc-ity decrease and the motion returns to being laminar.

In the regions around the bifurcations there are transition areas, characterised by tracts of laminar motion and tracts of turbulent motion [8]. Fluids apply resistance to the motion of a body immersed in them. The lay-er of fluid around the surface of the body in movement is the boundary layer, whose motion is given by the Reynold's number. At low Re values, viscous forces prevail and the motion in the boundary layer is laminar. At high Re val-ues, the forces of inertia prevail with consequent pressure variations and the entire boundary layer is turbulent.

For intermediate Re values, the motion is laminar in the near-surface layer and turbulent immediately thereafter. Stokes's Law The resistance encountered by a body immersed in a fluid in laminar motion is due to a force F proportional to the velocity v and the radius r of the body: Basic Physics for Anaesthesia and Intensive Care 45 where there is a coefficient dependent on the shape of the body and where S is the maximum section of the body. The flowmeter in anaesthetic devices utilises several of the principles described above. It consists of a vertical tube, whose section increases from bottom to top, and a coil or rotameter on its inside.

The space between the rotameter and the wall of the tube is known as the annular space and is con-sidered equivalent to a circular canal having the same transverse area. With an increase in the flow supplied, the rotameter rises and the annular space increases owing to the widening of the tube. The rotameter reaches a point of equilibrium for a given flow volume when the pressure raising it equals its weight. The reduction in pressure which is created via the annular space is maintained constant for any position of the rotameter such devices are there-fore called constant-pressure flowmeters.

What does change is the type of dependence of the flow on that pressure difference. At low flows the annular space is long and narrow, and therefore the flow is laminar, dependent on the viscosity of the gas and regulated by Poiseuille's law. At high flows, however, the annular space is wide and short, and the flow is tur-bulent, dependent on the density of the gas and regulated by Graham's law the velocity of a gas is inversely proportional to the square root of its density.

Given that the changes of the area of the transverse section of flow are abrupt and not gradual, Bernoulli's theorem does not accurately describe this type of flow. The flow above the rotameter is very turbulent, and the turbulence dissi-pates the kinetic energy in heat. However, the introduction of an empirical con-stant discharge coefficient , which varies with the shape of the hole and the Reynold's number, makes the application of the law possible [9, 10].

Giannazzo E Lezioni di biofisica e tecnologie biomediche, Piccin. Ambrosiana, Milan, ch 16 3. Paravia, Turin, ch 13 4. Rosati S Fisica generale. Ambrosiana, Milan, ch 17 5.

Scacci R Air entrainment mask: Marino PL Terapia intensiva. Masson, Milan, pp 7. Miller RD Trattato di anestesia. Delfino, Rome, p 8. Zanichelli, Bologna, ch 9 9. Delfino, Rome, ch 9 e 32 BERLOT The brief history of critical care medicine has been marked by some hotly debated issues, including the "crystalloid-colloid controversy", the "stay and play vs. Basically, despite the relevance of the debated points and the high scientific ranks of the advocates of the different approaches, no study has been able to demonstrate conclusively that one given therapeutic behaviour is always the best option for all patients.

In other words, an up-to-date reader of the scien-tific journals dealing with these issues can hardly draw a firm conclusion on the strategy to adopt in his daily clinical work. The very same considerations apply to the on-the-scene tracheal intubation TI of trauma patients, the role of which has been recently questioned by a number of studies mainly from the USA and Canada, in which a worse outcome was demonstrated in patients treated with on-the-scene TI. I find this particularly disturbing, because when I was young trainee I was taught and I presently teach to my younger col-leagues that early TI can make the difference between life and death in trauma patients.

On the side of life, needless to say. Despite these advantages, different Authors have demonstrated that patients intubated at the scene of the accident had a worse prognosis than patients who received TI up on their arrival at the Emergency Department ED. In a poorly randomized study performed on a paediatric population, Gausche et al.

In other terms, in this patient population TI apparently proved more harmful than good. In another study [5] comparing major trauma patients treated with BVM or TI performed by emergency medicine technicians EMT without the assistance of sedatives and muscle relaxants a remarkably better outcome was 50 G. Berlot demonstrated in the BVM group. However, it must be remarked that the feasibility of TI without drugs is a strong indicator of a grim prognosis [6], thus making it difficult to conclude positively that TI is harmful in itself. Recently, Di Bartolomeo et ai.

Regardless of the relevant role played by highly trained personnel working in the ground ambu-lances, these results are in sharp contrast with those of a previous study from the same group in which a remarkably better outcome was demonstrated in patients treated by the HEMS [8]. If these studies clearly indicate that on-the-scene TI may be harmful or ineffective in term of outcome improvement, oth-er investigators have demonstrated the exact opposite: As stated above, it is difficult to draw definite conclusions from these con-flicting studies, yet some considerations can be made.

Although different devices have been developed and used to this end, including laryn-geal mask airways LMA and combitubes, TI remains the gold standard against which all these approaches must be challenged. However, its use is not risk-free and requires an appropriate level of manual skill and the safe use of drugs whose actions and side effects must be known and recognized.

According to the aforementioned studies, in trauma patients TI appears safe and cost-effective in terms of outcomes, provided that a it is performed by highly trained professionals, able either to secure the airways in a short time in the vast majority if not all patients; and b the same individuals must be able to adopt alternative measures, i. These operative capabilities apply to physicians specially trained in the man-To Tube or Not To Tube? A Critical Point in Emergency and Trauma 51 agement of the airways. In this setting, anaesthetists appears to be the best candidates for this role, as their syllabus includes from the very early days of training a full knowledge of the drugs and the techniques to keep the airways open and clear from secretions.

Secondly, a safe and rapid TI might not be sufficient for preventing death or disabling neurological consequences: Indeed, in an earlier study, Stocchetti et al. It should be borne in mind that both conditions may be caused by a pneumothorax PNX , whose deleterious effects can be precipitated by the mechanical ventilation used after T1. It follows then that, although appropriate management of the airway remains an absolute priority, this is only the beginning, and the on-the-scene subsequent care of trauma patients must be performed by professionals specif-ically trained in the recognition and treatment of these harmful conditions.

In settings where emergency care is provided by professionals with heterogeneous training and background trained police officers and fire fighters, volunteers, etc. Conversely, when skilled physicians are involved, these complications are fully diagnosed and treated. In our region, similar rates of TI and PNX drainage by means of a small-sized thoracotomy performed in the pre-flight phase have been accomplished by anaesthetists operating in the regional HEMS. Finally, the TI-BVM controversy should not be considered a component of the wider "scoop and run" vs. Although there is no doubt that in the presence of active bleeding the definitive care must be sup-plied in the surgical theatre, it is not conceivable, even in the most extreme conditions, that an asphyxiating patient could be rushed to the hospital with-out securing the airways and looking for other immediate life-threatening injuries.

This also applies to situations in which multiple patients must be triaged and cared for simultaneously. In a recent paper dealing with the treat-ment of the victims of a terrorist attack in Israel, the only immediate proce-dures were the TI and the needle decompression of PNX, which were per-formed either on-the-scene or en route to the ED [14]. Again, these manoeuvers require specific training which cannot be acquired only theoretically or with minimal practice. Actually, a suboptimal level of both basic and advanced training could account for the negative results present in some studies dealing with the high rate of complications of TI performed by medics [15] and the worse outcome of patients in whom a considerable pre-ED time was spent in attempting to establish an intravenous line [16].

Berlot In conclusion, there is no firm evidence that TI is associated with detrimen-tal effects, provided it is performed by trained physicians with a full knowledge of the TI-related drugs, the related complications and the available alternatives. In other terms, the TI vs. BVM controversy appears more a philosophical dis-cussion than a real scientific debate. Curr Opin Crit Care 5: Eckstein M, Chan L, Schneir A et al Effect of prehospital advanced life sup-port on outcomes of major trauma patients.

Lockey D, Davies G, Coats T An observational study of the survival of trau-ma patients who have pre-hospital tracheal intubation without anesthesia or mus-cle relaxants. Br Med J Di Bartolomeo S, Sanson G, Nardi G et al Effects of 2 patterns of prehopsital care on the outcome of patients with severe head injury.

Eur J Emerg Med 1: Winchell RJ, Hoyt DB Endoctracheal intubation on the scene improves sur-vival in patients with severe head injury. Aust N Z J Surg Peleg K, Ahronson-Daniel L, Stein M et al Gunshot and explosion injuries -characteristics, outcomes and implications for care of terror-related injuries in Israel. Am J Emerg Med WElL Myocardial dysfunction, accounts for death during the first 72 h after resusci-tation from cardiac arrest. When the heart stops beating, ischemic injury of myocytes follows cessation of coronary blood flow.

The severity of injury is contingent on the duration of the "no-flow" interval. When ventricular fibrilla-tion VF was electrically induced in 20 male pigs and animals were random-ized to 4 or 7 min of untreated cardiac arrest, the severity of post-resuscitation myocardial dysfunction was proportional to the duration of untreated VF [1].

This conclusion is also supported by human data reported by Schultz et al. Even precordial compression fails to fully supply coronary blood flow in amounts that fulfill myocardial oxygen needs during VF [3]. With the aid of esophageal echo cardiographic measurements, our research team has demon-strated ischemic contracture of the heart with increased thickness of the inter-ventricular septum and the left ventricular free wall during prolonged CPR.

Lunch session rooms located in the main building may overflow! We recommend you arrive on time to ensure access to the sessions you wish to attend. Poster area Poster display boards are located in the lower floor of the main building. To locate your poster board please refer to the programme page Material for poster hanging will be provided in the poster area glue, thumbtacks, staples, sellow-tape are NOT permitted.

Posters can be displayed from 8. The use of simple slides is suggested, without too many animations. We suggest that the PowerPoint presentation size does not exceed 50 MB, videos excluded. We suggest you keep the presentation light, including images in. When non standard fonts are used not included in Windows XP SP2 and Office , it is warmly recommended to bring the fonts at the Congress, to contact the slide centre with the necessary advance and to inform the technicians in charge at least 6 hours before the presentation. The videos saved in the presentation must have the following file extensions: The following codec packs are recommended: It will not be possible to visualise videos created with codec packs made for professional devices.

We recommend not to include more than one video per slide. We suggest the presentation includes only videos smaller than 50 MB each. If the video size exceeds this limit, we also suggest to bring a copy of the videos on VHS, Beta, DVD or other medium, and to inform the technicians at the slide centre with the necessary advance at least 6 hours before the presentation.

To make the presentation download easier at the slide centre, the following media are suggested: Access is restricted to faculty members. On August 29, 30, 31 and September 1, complimentary coffee is served from On August 29, 30 and 31 afternoon, coffee stations are available from 4. Messages Useful information and updates will be displayed on monitors located in the ground floor near the Secretariat Desk , in the upper and lower floors and in the faculty lounge.

Mobile phones Mobile phones must be switched off during all sessions. Smoking policy Smoking is not allowed within the Congress venue. Insurance Participants are advised to arrange health and accident insurance before travelling to the Congress. There are several taxi ranks in the city, including at the back of the Duomo of Florence, in Piazza della Repubblica and at Santa Maria Novella train station.

You can ask your hotel concierge to call a taxi for you or use the following phone number: It is possible to ask for a taxi at the Congress Secretariat, Local Information desk. Florence also has several bus lines — buses are bright orange. Bus stops are marked with orange signs displaying the route of the bus line.

You can get around the historic centre of Florence on bus lines A and B. These are small orange electric buses which can go through the narrow streets of Florence. Bus tickets have to be bought before you get on the bus and stamped with the stamping machine on the bus. Tickets can be bought from newstands and bars displaying the ATAF sign the sign of the bus company in Florence. After the bus ticket is stamped on the bus, it is usually valid for one hour, depending on the type of the bus ticket. Bus tickets can be also purchased at the Local Information desk at Congress secretariat desk.

Currency exchange is provided by banks and exchange agencies. Banks are open Monday to Friday from 8. They are also open in the afternoon, usually from Credit cards Major credit cards are accepted in most hotels, stores and restaurants. Electrical current The electrical current in Italy is volts 50 Hz.

Pre-registered participants should bring with them copy of the invoice for the registration fee paid. New registrations For on-site registrations, participants have to refer to the Congress Secretariat Desk — Courses — Workshops section, fill in the registration form and settle the registration fee. The name badge will be given at the same Desk upon payment. CONGRESS Pre-registered participants Pre-registered participants who have already settled the registration fee and sponsored pre-registered participants can get their name badge and the coupon to collect their congress kit at the Congress Secretariat Desk — Pre-registrations section.

Pre-registered participants should bring with them copy of the invoice indicating their registration number, or the confirmation letter of their sponsoring company. The name badge and the coupon to collect the congress kit will be given at same Desk upon payment. Only members of Societies who have fully paid their affiliation fees may enter as a Delegate to the General Assembly, stand for election for Council or vote.

Relazione Annuale del Presidente Prof. Relazione del Segretario Tesoriere Dr. Varie ed eventuali 4. Gemelli General Hospital Deborah J. Rossi General Hospital Flavio M. Rossi General Hospital Kees H. Gullo Italy The needs for children in natural or manmade disaster A. Argent South Africa Focus on priority: Alexander UK , F. Paruk South Africa Highlights on critical care nursing G.

Williams Australia Critical care in countries with limited resources S. Petrini Italy Restricted-access course, limited to 50 participants. The course will only be held if a minimum of 40 attendants is reached. Antonelli Italy , S. Baroncini Italy , E. Cohen USA , G. Frova Italy , A. Guarino Italy , J. Heuer Germany , S. Jaber France , G. Merli Italy , G. Sangiorgi Italy , M. Pennisi Italy , F. Petrini Italy , M.

Some of My Favorite Literary Works Ordered by Authors

Sorbello Italy , R. Trisolini Italy Speakers will disclose any significant financial relationship with the manufacturer of the commercial products which will be discussed in the presentations. The diagnostic and Overwiew of the topics and therapeutic procedures needed for the advanced management preparation of the scenarios of critically ill patients will be presented The suggested solutions for solving the previous cases will be What everybody can do to discussed asking faculty in role play make patient care safer The expert team will present proposals for clinical algorithms Airway management in ICU.

Are we ready for guidelines? The technique for BAL and brush device protection. Bronchial WS 3 B blockers. WS 4 A Difficult airways for difficult patients: Use of tube exchange catheters. Pittiruti Italy , M. Restricted-access course, limited to 28 participants. The Course will only be held if a minimum of 20 attendants is reached. Pittiruti Italy Evidence in the literature: Cost-effectiveness and safety of US-guided venous puncture Scoppettuolo Italy Discussion Biasucci Italy — M. Pittiruti Italy US visualisation of the internal jugular vein, of the subclavian and axillary veins, of the subclavian-jugular venous confluence and of the innominate trunk on healthy models small group training with separate teachers Vein puncture training on a simulator Teachers: La Greca Italy — G.

Scoppettuolo Italy Example on a simulator of US-guided positioning of a non-tunnelled short-term CVC direct Seldinger technique small group training with separate teachers 5. Simulated Clinical Scenarios Course Directors: Arcadipane Italy , G. Burgio Italy , G. Chiaramonte Italy Restricted-access course, limited to 20 participants physicians, nurses, junior intensivists The workshop will only be held if the established number of 20 attendants is reached Registration fee: Management of multiple organ donors in the intensive care setting Management of patients with fulminant hepatitis admitted to the intensive care unit and candidate for liver transplantation Monothematic restricted-access theoretic-practical course, limited to 28 participants.

Basilic vein, brachial veins, cephalic vein M. Cost-effectiveness of brachial accesses; advantages of US-guided positioning G. Pittiruti Italy US visualisation of the basilic vein, of the brachial artery and veins, of the cephalic vein on healthy models small group training with separate teachers Vein puncture training on a simulator Teachers: Migliorini Italy — G. Pelagatti Italy , G. Sequential workstations 35 min each with rotation, trainer to trainee ratio 1: Total duration 5 hours. Restricted-access course, limited to 35 participants. The course will only be held if the established number of 35 attendants is reached.

Storti Italy Lung Ultrasound D. Neri Italy , G. Pelagatti Italy US-guided nervous block R. Breitkreutz Germany Deep venous thrombosis, optic nerve and beyond T. Baciarello Parma , G. Danelli Parma , L. Baciarello Parma , A. Bettelli Ancona , E. Solca Melegnano, MI Savoia Napoli Corso a numero chiuso — massimo 20 partecipanti Per iscrizioni scrivere a Gennaro Savoia — e-mail: Borga Orbassano, TO , E. Cerchiari Bologna , E. De Blasio Benevento , G. Savoia Napoli , F. De Blasio Benevento lezione teorica Cerchiari Bologna lezione teorico-pratica Savoia Napoli lezione teorica Semeraro Bologna lezione pratica Borga Orbassano, TO lezione teorica 1.

De Blasio Benevento arbitro: Colella Roma , M. Donato Milanese, MI 3. Cattaneo Bergamo , F. Salandin Treviso , C. A life through critical care M.

Difficult airways in ICU: Braschi Italia , J. Jaber France Airway fibrescope competencies in critically ill patients R. Trisolini Italy Discussion Lecture: Airway management in ICU: Sorbello Italy Sunday 30th August Complications in trauma surgery M. Plani Australia Italy , Penetrating chest trauma D.

Can steroid treatment be made more efficient in ARDS? Demetriades USA , G. Hedenstierna Sweden , J. Marshall Canada , F. Plani Australia , G. Sganga Italy , M. Fever in ICU patients M. De La Cal G. Dobb Australia Spain , Initiative to reduce infection L. Pea Italy Public awareness and perception of sepsis F. Rubulotta Italy Discussion Lecture: Immune system in severe infections E. Citerio Italy Brasil , Multimodal monitoring of cerebral function G.

Maury France Discussion Lecture: Organ donors procurement M. Monitoring perioperative coagulation P. Lumb USA , R. Vincent Consumption coagulopathy in the critically ill Belgium M. Levi The Netherlands Discussion Lecture: Alternatives to blood product transfusion in the critically ill J. What is the role of PA catheter?

Parrillo USA , M. Ultrasound in cardiac intensive care J. Poelaert Belgium Tuesday 1st September Evidence-Based Medicine in critical care S. Le Gall France Discussion Lecture: Standards and guidelines in critical care D. Braschi Italy , L.

www.farmersmarketmusic.com: Literature

Conti Italy The open lung concept: Hedenstierna Sweden Discussion Lecture: Monitoring of the respiratory system U. Sugrue Australia Discussion Lecture: Methodology of a global initiative for improving care P. Dellinger USA , P. Vincent Developing the guidelines: Artigas Spain , P. Dellinger USA , J. Palizas Argentina , K. Reinhart Germany , F. Rubulotta Italy , G. Tulli Italy , J. Vincent Belgium , X. Xi China Tuesday 1st September 1. Sedation and pain assessment P. Lumb USA , F. Metabolic and immunological consequences of pain F.

Rationale of rapid response team M. The role of the medical Emergency Team J. Takala Switzerland Discussion Lecture: Simulation-based education improves the quality of care in critical care M. Gensini Italy Sudden cardiac death G. Gensini Italy Heart failure: Transitioning from invasive to non-invasive intensive critical care monitoring M. Plani Australia Discussion Lecture: Healthcare disparities in critical care S. Bhagwanjee South Africa 1. From arterial pressure to cardiac output G. Marx Germany , M.

De Gaudio Effects of acute, severe hypertension on target organ damage Italy A. De Gaudio Italy Strategies for acute blood pressure management in the critical care setting: Levy USA The perioperative setting — unique considerations in the surgical setting: Ranieri Italy Sweden , Evaluating recent clinical trials L. Slutsky Canada Discussion Lecture: Computerised selection of ventilatory pattern during mechanical ventilation G. Berlot Italy , Pre-hospital trauma care Moderators: Farina South Africa D. Plani Australia Trauma scoring system G.

La-coscienza--gli-stati-di-cose-e-gli-eventi

Dobb Australia Discussion Lecture: Trauma Centre — rationale, organisation, standards, audit and costs D. Demetriades USA Room 3 3. Cook Canada Monday 31st August 4. Glossary of terms and definition M. Antonelli Italy , H. Cook Canada Carriage, colonisation and infection L. Silvestri Italy Classification of micro-organism according to their pathogenicity M. Carriage classification of pneumonia rather than time improves survival H. Role of sedative agents in optimisation of sedation N. Lumb USA , J.

Volpe UK Muscle relaxants: Volpe UK Sedation and analgesia in mechanical ventilation F. Nishimura Japan Analgesia, sedation and awareness in intensive care M. Capuzzo Italy Discussion Room 5 3. Multimodal approach - an introduction A. Luzzani Italy , G. Sganga Italy New model of scoring M. Sugrue Australia Enteral nutrition in acute pancreatitis R. Beale UK Discussion Lecture: Imaging in acute pancreatitis R. Pozzi Mucelli Italy Room 6 3.

Energetic myocardial metabolism and oxidative stress P. Scolletta Italy Cardiovascular anti-inflammatory modulation by statin therapy P. A dangerous triad during shock: Vincent Belgium Room 7 3. Improving quality of care Tuesday 1st September A. Garland USA , A. Gullo Italy , G. Offenstadt France , A. Protocolisation improves the care of the septic patient S. Nishimura Grading severity of respiratory dysfunction Japan , A. Putensen Recruitment, oxygenation and overinflation Germany J.

Rouby France Dead space and clinical significance G. Is the acute respiratory distress syndrome a systemic disease? Trauma in children D. Fisher Australia Trauma in pregnancy D. Ultrasound in trauma F. Plani Australia Monday 31st August Palomar Spain Canada , Systemic antibiotics T. Adembri Italy Systemic antifungals G. Antibiotic pharmacokinetics and pharmacodynamics in critical care S. Singer UK Discussion Lecture: Off-label drugs in critical care G. Quintard France Discussion Lecture: Acid-base regulation in intensive and critical care medicine A. De Gasperi Italy Acute coronary syndrome J.

Knobel Brazil Brazil , Dangerous arrhythmias P. Knobel Brazil Discussion Lecture: Perioperative cardioprotection in high-risk surgical patients P. Optimisation of limited resources: Gallesio Argentina France , Informed consent for critical care research J. Takala Saturday 29th August J. Boles France Switzerland The burn out syndrome: Ethical problems of futile research J. Antonelli Italy Critical Care J. Ranieri Italy , D. Koh Korea Discussion Lecture: CT scan of the lung and the new horizon L.

Imaging in abdominal trauma D. Pozzi Mucelli Italy U. Berlot Italy Discussion Lecture: The critical care management of burns: Blood stream infections M. The problem of resistance H. Zin Brazil Saturday 29th August 1. Ethics and Do Not Resuscitate order M. Extracorporeal liver support and replacement H. Gruttadauria Italy France Decision-making and strategy in perioperative liver transplant S. Faenza Italy Discussion Sunday 30th August 1. Assessment of myocardial ischaemia T.

Fiore Italy , J. Metzler Austria Pharmacological manipulation of microcirculation during shock states D. De Backer Belgium Management of cardiogenic shock J. Auler Brazil Discussion Lecture: Vasopressin Monday 31st August J. Education and training F. Research in critical care J. Simulation for clinical education and training M.

Plani Australia Simulation-based training for complex and unusual clinical situations C. Gullo Italy , C. Ori Italy , F. With an unrestricted L. Bertolini Italy Sunday 30th August Room 3 1. How can we Prevent It? Results from an Austrian study T. Staudinger Austria Monday 31st August Access limited to participants. Saturday 29th August Spontaneous breathing test A. Artigas Spain , M. Gorini Italy Ventilatory asynchrony: Rossi Italy Discussion Room 2 3.

Advances of tissue chemistry monitoring: Stocchetti Italy Sunday 30th August P. Reinstrup Sweden Indications, timing and clinical evidence C. Reinstrup Sweden , N. Stocchetti Italy Room 3 3. The current management of septic shock J. Parrillo USA , J. Sprung Israel Highlights on cardiovascular dysfunction in sepsis and septic shock J. Parrillo USA State of the art on early goal directed therapy in sepsis eight years after the study E. Microcirculation in sepsis C. Classification and outcome of acute kidney injury D. Payen France , E. Piccinni Italy Renal repair and recovery S.

La-coscienza--gli-stati-di-cose-e-gli-eventi

Bagshaw Canada Discussion Lecture: Payen France Room 6 3. Ventilation matters in the extubated cardiac surgery patient: Metzler Austria Supraventricular tachyarrhythmias: Haemodynamic monitoring of high-risk surgical patients A. Rhodes UK Room 7 3. Council of Bioethics A. Pesenti Italy , K. Shukri Saudi A matter of facts or values? Is something changing around the world? Albahrani Oman , J. Curtis USA , B. Du China , M. Fisher Australia , N.

Latronico Italy , F. Gattinoni Italy Saturday 29th August 9. Esteban Spain , M. Gattinoni Italy Mechanical ventilation: Slutsky Canada Non-invasive ventilation M. Antonelli Italy Discussion Lecture: Pre-hospital trauma care in remote locations K. Ban USA , F. Du China Disaster medicine preparedness E. Epidemics and strategies of infectious diseases C. Sepsis definition, classification and epidemiology E. Rivers USA , H. Russell Canada Sepsis and organ dysfunction: What is the evidence? Romand Switzerland The component of fluid challenges J. Vincent Belgium Discussion Lecture: Sepsis and neuroendocrine system Tuesday 1st September D.

In which patients end of life care should be considered G. Gristina Italy , M. End-of-life care around the world C. Celis Rodriguez Colombia , J. Curtis USA , M. Levy USA , A. Montanez Mendoza Peru , K. Shukri Saudi Arabia , C. Sprung Israel , R. Definition, techniques, outcome S. Besso Venezuela Canada , Vascular access and management of anticoagulation J. Slowinski Germany Discussion Lecture: Ventricular fibrillation and refibrillation J.

Nolan UK , R. Raimondi Italy Discussion Lecture: How is the volume given transformed in flow? Payen France Tuesday 1st September The concept of critical ultrasound: Neri Italy France , Ultrasound-enhanced airway management G. Storti Italy Saturday 29th August Ultrasound-enhanced respiratory failure assessment and respiratory monitoring D.

Breitkreutz Germany Ultrasound-enhanced haemodynamic monitoring G. Via Italy Discussion High frequency ventilation G. Lucangelo Italy Optimisation of artificial ventilation in prone position P. Jimenez USA , U. Lucangelo Italy , P. Chemical weapons and accident Y. Donchin Israel , F. Gomersall Natural disasters Hong Kong B. Du China Poisoning and antidotes F. Baud France Discussion Lecture: Guidelines and perspectives on disaster S. Pharmacogenomics of sepsis K. Russell Canada Germany , Clinical implication of mannose binding protein in sepsis J. Koh Korea Belgium Sepsis predisposition J. Marshall Canada Discussion Lecture: Sepsis — decades of challenges: Vincent Belgium Tuesday 1st September 1.

When families oppose withdrawing and withholding treatment M. Fisher Australia Australia , How communication can facilitate the end-of-life decisions N. Azoulay France Discussion Lecture: Breaking bad news M. Central nervous system assessment J. Della Corte Italy Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury J. Sahuquillo Spain Discussion Lecture: Cerebral protection strategies N. Cardiac arrest and Utstein Style R. Gazmuri USA , J. Nolan UK Key points for improving the out-hospital cardiac arrest R.

Fries Germany Discussion 1. Deep venous thrombosis in the critically ill L. Neri Italy , D. Barozzi Italy Ultrasound-guided vascular access and nerve blockage B. Nicholls UK Prehospital emergency ultrasound T. Storti Italy Discussion 1. Prone positioning in ARDS patients: Gattinoni Italy , A. Koh Korea Oxygen delivery in the critically ill patient J.

Russell Canada Weaning from artificial ventilation A. Esteban Spain New system of weaning J. Mancebo Spain Discussion Lecture: Targeting trans-pulmonary pressure to prevent ventilatory induced lung injury D. Koh Korea Is Africa different? Gopalan South Africa Discussion 4. WHO vision for acute care S. Bhagwanjee South Africa Discussion 5. Improving the diagnosis of sepsis M. Levy USA , E. Li Volti Italy Biomarkers for diagnosis and risk assessment K. Reinhart Germany Lactate level and lactate clearance E.

Levy USA Room 4 — 5. De Gaudio Welcome and introduction Italy A. De Gaudio Italy , J. Chastre France The use of procalcitonin for the diagnosis of early sepsis and infection Sunday 30th August E. Polati Italy With an unrestricted Procalcitonin as a prognostic marker educational grant T. Stolz Switzerland Room 5 3. Causes and outcome of non traumatic coma J. Procaccio Italy Discussion Lecture: Harvey USA Room 6 3. Microcirculation during cardiac arrest M.

Donnino USA , G. Wik Norway Discussion Lecture: Airway management and ventilation during CPR J. Saturday 29th August Lecture: Appropriateness of treatment in ICU G. Berlot Italy , G. Maciel Brazil Sepsis and multiple organ failure: Hurtado Uruguay Immunoglobulin in sepsis G. Berlot Italy Organisational issues in hospital sepsis management. What can I do? Girardis Italy Discussion The open abdomen in sepsis G.

Sugrue The importance of relaparatomy Australia M. Sugrue Australia Gastric tonometry revisited J. Catheter-related blood infections B. Substrate metabolism in critical illness: Van den Berghe G. Biolo Italy Belgium , Energetic target and caloric supply J. Wernerman Saturday 29th August P. Singer Israel Sweden Metabolic changes from onset to recovery of critical illness M. Endocrine alterations in the critically ill G. Van den Berghe Belgium How to design a prehospital CPR study K.

Preliminary report or evidence-based manoeuvre W. Kern USA Post-cardiac arrest management: Induced hypothermia and beyond K. Polderman The Netherlands Discussion The future of outcome prediction in ICU M. Piacevoli Italy Discussion Tuesday 1st September Pulmonary embolism despite prophylaxis G. Razek Egypt Human error in critical care Y. Donchin Israel Discussion Room 3 Identifying the barriers to quality improvement J.

Artigas Spain Canada , Does protocol help?

Ferrer Spain Discussion Lecture: Using bundles to improve care: Levy USA Room 4 Prognosis of hypoxic-ischaemic encephalopathy J. Fischer France Belgium , Neurophysiological monitoring in severely brain injured patients G. Nutrition in critical care — the importance of guidelines G. Iapichino Italy , J. Van den Berghe Enteral nutrition Belgium D. Ceraso Argentina Parenteral nutrition in critical Illness G. Iapichino Italy Discussion Lecture: Blood glucose control G.

ECLS for refractory cardiac arrest and cardiogenic shock A. Braschi Italy , S. Sunde Norway Future advances in resuscitation science M. Massetti France Discussion Lecture:

• An Examination of Platos Doctrines Vol 2 (RLE: Plato): Volume 2 Plato on Knowledge and Reality (Routledge Library Editions: Plato)
• Walking in the Supernatural: Another Cup of Spiritual Java
• Apocalypse Overture by Oils up? Whats the worst that can happen?
• The Bar and Beverage Book 5E
• School Days (When We Were A Couple Of Kids)
• A Time of Bliss