Best practice & research. Clinical anaesthesiology
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The distribution of anaesthesia-related staff in Europe is characterized by a wide disparity between countries--and also within countries, between the rural regions and between large and small cities. The density of anaesthesiologists varies in different European areas--for example, 4.4 per 100,000 inhabitants in Ireland compared to 15.6 in Italy; conversely, trainee anaesthesiologists are more numerous in those countries in which the number of qualified specialists is low. ⋯ Important modifications could come from an increase in the workload, a decrease in the working time, and perhaps from the development of migratory flows when Eastern European countries join the European Union. The evolution of anaesthesiology in the future will depend on many unknown events: progress in pharmacology and techniques, the development of day-case anaesthesia, the behaviour of new consumers and, above all, future health policies.
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Best Pract Res Clin Anaesthesiol · Sep 2002
Appraisal and reassessment of the specialist in anaesthesia.
Appraisal and reassessment of the physician is an integral part of ensuring that 'quality of care' provided by the health care system is the best possible within the constraint of resources. Assessment tools used for initial certification at completion of medical school as a general physician and for initial certification as an anaesthesiologist are discussed. The expansion of core or general physician competencies to include behavioural, communication and evidence-based resource management skills in addition to knowledge and clinical skills is reviewed. ⋯ Examples of each level are given. Re-certification of anaesthesiologists currently occurs in two distinct ways: by examination and through continuing medical education. Details of each approach are included.
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Best Pract Res Clin Anaesthesiol · Jun 2002
ReviewSingle-injection applications for foot and ankle surgery.
Foot or ankle surgery is often performed in an ambulatory care setting. The post-operative pain that follows can be moderate to severe in intensity and difficult to control with oral analgesics. Regional anaesthetic techniques have been advocated for such procedures. ⋯ Patients can be safely discharged even when long-acting local anaesthetics are used. In major surgery a continuous technique can be proposed. When the prone position is impossible the lateral approach is an efficient alternative.
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Best Pract Res Clin Anaesthesiol · Jun 2002
ReviewThe Holy Grail: long-acting local anaesthetics and liposomes.
The ability to provide an extended duration of analgesia of days following a single injection without the need for catheters, pumps and infusion systems would be a great benefit in acute and chronic pain. Exciting progress is being made in our ability to combine local anaesthetics with liposomes and polymer microspheres. These interesting formulations in animal models have allowed up to 4 days of analgesia. Their use clinically will be a great advance which could possibly occur in the near future.
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The considerable development of ambulatory surgery has led to an increase in the number of lower extremity procedures performed in an outpatient setting. More recently, the availability of disposable pumps has allowed us to extend the indications of continuous nerve blocks for ambulatory post-operative pain management. Indications for lumbar plexus continuous blocks include anterior cruciate ligament (ACL) reconstruction and patella repairs as well as frozen knee, whereas continuous sciatic blocks are indicated for major foot and ankle surgery. ⋯ This latter technique seems to be the preferred mode because it offers the advantage of tailoring the amount of local anaesthetics, mostly 0.2% ropivacaine, to the individual need and also maximizes the duration of infusion for a given volume of local anaesthetic. Although the preliminary reports indicate that lower extremity continuous blocks provide effective post-operative ambulatory analgesia and are safe, especially as a part of a multimodal approach, appropriate training in these techniques represents one of the most important limiting factors of the placement of perineural catheters. Additional research is required to determine the optimal conditions in which these techniques are indicated.