Aic22-FM.qxd 9/11/02 1:40 PM Page i 22 Recent Advances in Anaesthesia and Intensive Care This page intentionally left blank 22 Recent Advances in Anaesthesia and Intensive Care Edited by A.P. Adams MB BS, MRCS, LRCP, PhD, DA, FRCA, FANZCA Emeritus Professor of Anaesthetics University of London Honorary Consultant Anaesthetist Guy’s, King’s and St Thomas’ Hospitals London, UK Emeritus Consultant to the Army J.N. Cashman BSc, MB BS, BA, MD, FRCA Consultant Anaesthetist, St George’s Hospital, London Honorary Senior Lecturer in Anaesthesia University of London, UK R.M. Grounds MB BS, MRCS, LRCP, MD, DA, FRCA Consultant in Anaesthesia and Intensive Care Medicine St George’s Hospital, London Honorary Reader in Intensive Care Medicine University of London, UK LONDON(cid:1)SAN FRANCISCO www.greenwich-medical.co.uk © 2003 Greenwich Medical Media Limited 137 Euston Road London NW1 2AA 870 Market Street, Ste 720 San Francisco CA 94102 ISBN 1 84110 1176 First Published 2003 While the advice and information in this book is believed to be true and accurate, neither the authors nor the publisher can accept any legal responsibility or liability for any loss or damage arising from actions or decisions based in this book. The ultimate responsibility for the treatment of patients and the interpretation lies with the medical practitioner. The opinions expressed are those of the authors and the inclusion in this book of information relating to a particular product, method or technique does not amount to an endorsement of its value or quality, or of the claims made by its manufacturer. Every effort has been made to check drug dosages; however, it is still possible that errors have occurred. Furthermore, dosage schedules are constantly being revised and new side-effects recognised. For these reasons, the medical practitioner is strongly urged to consult the drug companies' printed instructions before administering any of the drugs mentioned in this book. Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the UK Copyright Designs and Patents Act 1988, this publication may not be reproduced, stored, or transmitted, in any form or by any means, without the prior permission in writing of the publishers, or in the case of reprographic reproduction only in accordance with the terms of the licences issued by the appropriate Reproduction Rights Organisations outside the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publishers at the London address printed above. The rights of A.P. Adams, J.N. Cashman & R.M. Grounds to be identified as editors of this work have been asserted by them in accordance with the Copyright Designs and Patents Act 1988. The publisher makes no representation, express or implied, with regard to the accuracy of the information contained in this book and cannot accept any legal responsibility or liability for any errors or omissions that may be made. A catalogue record for this book is available from the British Library Typeset by Mizpah Publishing Services, Chennai, India Printed in the UK by the Alden Group Ltd, Oxford Distributed by Plymbridge Distributors Ltd and in the USA by Jamco Distribution Contents Preface vii A.P. Adams, J.N. Cashman, R.M. Grounds Contributors xi 1. The COX enzyme system 1 D. Bishop-Bailey, T.D. Warner 2. Drug chirality: stereoselectivity in the action and 31 disposition of anaesthetic agents A.J. Hutt 3. New local anaesthetics 65 G.A. McLeod 4. Asthma 95 L. Cormican, J. Rees 5. Reducing mortality and complications in patients 117 undergoing surgery at high risk for postoperative complications and death R.M. Grounds 6. Prone ventilation of the lungs 135 L. Gattinoni, D. Chiumello, P. Pelosi 7. Antibiotics and nosocomial infection in the ICU 159 J. Chastre, J.-L. Trouillet 8. Neuropathic pain 177 A.B. Petrenko, T. Yamakura, H. Baba, K. Shimoji Aic22-FM.qxd 9/11/02 1:40 PM Page vi vi Contents 9. Managing medical mishaps: learning lessons from industry 209 D. Parker, R. Lawton 10. Legal issues in anaesthesia and intensive care 223 E. Hallinan, N.J.H. Davies 11. Education and training in anaesthesia 237 G. Stanley, J.N. Cashman 12. Resuscitation 259 E. Rowland, H. Binns Index 301 Aic22-FM.qxd 9/11/02 1:40 PM Page vii Preface “An intellectual is a man who takes more words than necessary to tell more than he knows.” Dwight D. Eisenhower (1890–1969) In 1932 J & A Churchill Ltd published the first edition of Recent Advances in Anaesthesia and Analgesia (Including Oxygen Therapy). Nearly 70 years later we commented in the Preface to the Millennium (21st) edition of Recent Advances in Anaesthesia and Analgesia that the pace of advances in anaes- thesia showed no sign of abating. Although 2 years further on this statement remains true, change has now affected the title as well. Harcourt Publishers Ltd has transferred the title from Churchill Livingstone to Greenwich Medical Media Ltd. Coincident with the transfer it was decided to include more Intensive Care Medicine topics and consequently the title has been changed to Recent Advances in Anaesthesia and Intensive Care. In association with this change, we are pleased that Dr Michael Grounds has joined the editorial team. The range of topics covered in this issue represent all aspects of anaesthesia from basic science to clinical practice, from training the anaesthetists of the future to relevant medical conditions, from optimization of patients to resuscitation of patients. As always, the editors are grateful to the many distinguished colleagues who have contributed to Recent Advances in Anaes- thesia and Intensive Care – 22.The first three chapters present developments in pharmacology. It is now appreciated that there are two related, but unique isoforms, of the cyclo-oxygenase (COX) enzyme, which play important but different physiological and pathophysiological roles. An understanding of the differences between COX-1 and COX-2 is necessary for the logical development of new anti-inflammatory drugs. In their chapter on The COX Enzyme System, Dr Bishop-Bailey and Prof. Warner clearly elucidate these Aic22-FM.qxd 9/11/02 1:40 PM Page viii viii Preface differences and their significance. Over recent years, drug stereochemistry has become a topic of considerable interest, with much discussion on the relative merits of using single isomer versus racemic mixtures of chiral drugs. Advances in chiral technology permit the commercial synthesis of single- isomer compounds. Dr Hutt considers the relevance of drug chirality to anaesthesia. With all of this interest in drug stereochemistry it is probably no surprise that chirality has been important in the development of new local anaesthetic agents. In his chapter on New Local Anaesthetics, Dr McLeod describes in detail recent advances in molecular biology with respect to nerve conduction as well as concepts of the method of action of local anaesthetics; he discusses both levobupivacaine and ropivacaine in detail. The prevalence of asthma in society has increased dramatically over the past 30 years and at the same time the death rate has also been increasing alarmingly. Drs Cormican and Rees suggest that the reasons for the increase in the prevalence of atopy are still poorly understood, although a number of explanations have been proposed. They describe current understanding with regard to the epidemiology, genetics and immunopathology of asthma as well as discussing the implication of asthma for anaesthetists. In his chapter on reducing mortality and complications in high-risk surgical patients, Dr Grounds emphasizes that over the last quarter of a century the incidence of death following surgery, that is directly attributable to anaesthesia, has fallen. He suggests that deaths and complications after operation can never- theless be reduced further in high-risk patients by the implementation of early aggressive goal-directed therapy aimed at temporarily improving the cardiovascular performance of these patients. In the next chapter on an intensive care medicine topic, Prof. Gattinoni with Drs Chiumello and Pelosi argue the merits of prone position lung ventilation in patients with acute lung injury or the adult respiratory distress syndrome. They review the pathophysiology related to the prone position, the mechanisms for improving gas exchange and the existing clinical data on the use of prone position ventilation in patients with this spectrum of lung damage. Antibiotic resistance is a source of increasing concern, particularly among patients in the intensive care unit. In their chapter on Antibiotics and Nosocomial Infection in the Intensive Care Unit, Prof. Chastre and Dr Trouillet point out that the excess hospital costs due to antimicrobial resistance may reach tens of billions of dollars a year in the United States of America. They discuss the root cause of the problem and the core issues and suggest that apparently adequate control strategies are unlikely to succeed without clear strategic objectives. Neuropathic Pain, as Drs Petrenko, Yamakura, Baba and Prof. Shimoji point out, is a formidable syndrome that complicates a variety of disease Aic22-FM.qxd 9/11/02 1:40 PM Page ix Preface ix states. They describe the current understanding of the pathophysiology of neuropathic pain, in particular ectopic hyperexcitability and abnormal sodium channels, as well as central sensitization and NMDA receptor activation. Dr Petrenko and colleagues then consider in detail the clinical presentations and treatment of neuropathic pain states. In Managing Medical Mishaps: Learning lessons from industry, Drs Parker and Lawton outline the factors that influence the likelihood of medical failure and how other safety-critical high-risk industries have tackled the problem of error. They stress the importance of moving from a person-centred approach towards a systems approach encompassing the basic premise that human beings are fallible and that errors will always be made. Nevertheless as Ms Hallinan and Dr Davies point out, anaesthesia today is remarkably safe, probably as a result of the high standards of training and of equipment. In their chapter on Legal Issues in Anaesthesia and Intensive Care, the principles behind legal actions for clinical negligence are reviewed together with a discussion of the issues of consent and criminal liability. Anaesthetists are involved in education and training both at an undergraduate and at a post- graduate level. As educational concepts continue to evolve, Drs Stanley and Cashman have reviewed the objectives and strategy for training anaesthetists for the future, and the objective of ensuring life-long learning within the profession. Finally, we make no apology for returning to the fast evolving subject of resuscitation. Not many years ago, the Royal College of Physicians of London stated that all persons involved in direct patient contact should be familiar with the latest resuscitation techniques. Drs Binns and Rowland have compiled a comprehensive review of the latest in resuscitation technology, including the most recent evidence on the beneficial effect of hypothermia in improving outcome after cardiac arrest. Recent Advances in Anaesthesia and Intensive Careis committed to keeping anaesthetists abreast of the very latest developments in our specialty. The editors trust that the reader will find the chapters in this issue as stimulating and interesting as they themselves have done. London A.P.A September 2002 J.N.C R.M.G