Jan Paul J Mulier, MD PhD Diensthoofd anaesthesiology sint Jan Brugge-Oostende Ruddershove 10 Brugge 8000 Belgium geaffillieerd onderzoeker KULeuven dep acute medische wetenschappen 0032 50 452490 office 0032 50 45 2193 secret 0032486729203 GSM email: jan.mulier@azsintjan.be jan.mulier@med.kuleuven.be websites: www.linkedin.com/in/janpaulmulier www.publicationslist.com/jan.mulier www.espcop.org www.ispcop.org www.kuleuven.be/cv/u0054538e.htm www.azbrugge.be/pub/Custom/Artsen/az_ArtsenDetail.aspx?id=252&ognr=105954 www.ncbi.nlm.nih.gov/sites/myncbi/collections/public/10QxdbV06zSV4yylzIAED6/
EDUCATION
1981 KUL optievak: Electronics for medical use 1982 KUL optievak: Medical information technology 1977-1984 KUL dokter in genees-, heel- en verloskunde 1985 ILT 3j French 1986 ILT 3j English 1984-1988 Specialisatie: Anesthesie, Intensieve en Spoedgevallen onder Prof VandeWalle, Prof Vandermeersch en Prof Van Aken. 1987 UCSF one year residency at UCSF onder Prof M Miller 1993 Vlerick management school Gent: Management of research and innovation by Koen Debacker. 1994 Kul Geaggregeerde van het hoger onderwijs in de biomedische wetenschappen. thesis title: The ventricular pressure as a function of volume and flow. Promotor: H Van Aken, Katholieke Universiteit Leuven. Co Promotor: A. Noordergraaf, Penn University Pensylvania, Biomedical Research, 1995 KUL Postgraduate course in applied economics 2008 Wettelijk erkend proefleider voor dier experimenteel onderzoek
EXPERIENCE / POSITIONS 2011 Training courses for Surgeons and anesthesiologists in ERAS for Bariatric Surgery. 2010 Training courses for Bridion use in bariatric anesthesia: international CAPE program for Schering Plough 2010 Manuscript reviewer at Britisch Journal of Anesthesia 2010 Bestuurslid BSAR 2009 Associate academic staff member, Anesthesiology and Algology Kuleuven, Belgium 2009 Training courses in bariatric anesthesia for surgeons and anesthetists with Johnson&Johnson, Covidien 2009 President and founder of the ESPCOP (European society for perioperative care of the obese patient) www.espcop.org 2008 Researcher at KULeuven 2007 Researcher on Ventilator modes improvements for anesthesia 2006 Researcher on Anesthesia for obesity and bariatric surgery: bariatric anaesthesiologist and inventor of safety bird 2005 until now : Researcher on Ventilator safety improvements: inventor of safety frog 2000 until now : als adviserend raadsdokter gevraagd meestal bij verdediging van chirurgen 1999 co Founder of IPEC international training course for echocardiography 1996 until now AZ Sint Jan Brugge Chairmen of anesthesia 1994 1995 KUL supervisor anesthesia KUL 1994 KUL adj supervisor brand wonde centrum 1992-1994 Co founder of the European NO research group founded in Sweden for NO application in anesthesia, intensive care and neonatology 1990 1993 Scientific Advisor for Baxter Key consultant for Continuous cardiac output 1988 till 1994 Basic research with animals at CEHA (center for research in surgery and anesthesia) modeling cardiac pump function using animal hearts 1990 1994 KUL supervisor cardio anesthesia 1990 Co-Founder of Desitech, inc Minneapolis: inventor of cough assist devices. 1988 Basic researcher at Medtronic,inc Minneapolis: dog research on cardio pulmonary synchronisation 1987 Research resident at University of California San Francisco Clinical research with Trans esophageal echocardiography
IF ANY PUBLICATION, ABSTRACT or LECTURE is USED even in part for a lecture, presentation or publication IT SHOULD BE MENTONED WITH REFERENCE AND NAME.
Abstract: To date, the dosing of sugammadex is based on real body weight without taking fat content into account. We compared the reversal of profound rocuronium-induced neuromuscular blockade in morbidly obese patients using doses of sugammadex based on four different weight corrections. One hundred morbidly obese patients, scheduled for laparoscopic bariatric surgery under propofol-sufentanil anaesthesia, were randomly assigned four groups: ideal body weight; ideal body weight + 20%; ideal body weight + 40%; and real body weight. Patients received sugammadex 2 mg.kg(-1), when adductor pollicis monitoring showed two responses. The primary endpoint was full decurarisation. Secondary endpoints were the ability to get into bed independently on arrival to the post-anaesthetic care unit and clinical signs of residual paralysis. There was no residual paralysis in any patient. Morbidly obese patients can safely be decurarised from rocuronium-induced neuromuscular blockade T1-T2 with sugammadex dosed at 2 mg.kg(-1) ideal body weight + 40% (p < 0.0001).
Abstract: BACKGROUND: The effects of the patient's body position on the intraabdominal workspace in laparoscopic surgery were analyzed. METHODS: The inflated volume of carbon dioxide was measured after insufflation to a preset pressure of 15 mmHg for 20 patients with a body mass index (BMI) greater than 35 kg/m(2). The patients were anesthetized with full muscle relaxation. The five positions were (1) table horizontal with the legs flat (supine position), (2) table in 20 degrees reverse Trendelenburg with the legs flat, (3) table in 20 degrees reverse Trendelenburg with the legs flexed 45 degrees upward at the hips (beach chair position), (4) table horizontal with the legs flexed 45 degrees upward at the hips, and (5) table in 20 degrees Trendelenburg with the legs flat. The positions were performed in a random order, and the first position was repeated after the last measurement. Repeated measure analysis of variance was used to compare inflated volumes among the five positions. RESULTS: A significant difference in inflated volume was found between the five body positions (P = 0.042). Compared with the mean inflated volume for the supine position (3.22 +/- 0.78 l), the mean inflated volume increased by 900 ml for the Trendelenburg position or when the legs were flexed at the hips, and decreased by 230 ml for the reverse Trendelenburg position. CONCLUSIONS: The Trendelenburg position for lower abdominal surgery and reverse Trendelenburg with flexing of the legs at the hips for upper abdominal surgery effectively improved the workspace in obese patients, even with full muscle relaxation.
Abstract: Currently, there is no consensus opinion regarding the optimal procedure of choice in super-super-morbid obesity (Body mass index, BMI > 60 kg/m²). Roux-en-Y gastric bypass (RYGB) is associated with failure to achieve or maintain 50% excess weight loss (EWL) or BMI < 35 in approximately 15% of patients. Also, percent EWL is significantly less after 1-year in the super-super-obese group as compared with the less obese group and many patients are still technically considered to be obese (lowest post-surgical BMI > 35) following RYGB surgery in this group. The addition of adjustable gastric band (AGB) to RYGB has been reported as a revisional procedure but this combined bariatric procedure has not been explored as a primary operation.
Abstract: During insufflation of the abdomen to create a pneumoperitoneum for laparoscopy, both intra abdominal pressure and insufflated volume can be measured and are used to calculate the abdominal pressure-volume relationship. First, an accurate, linear relationship was identified using a mathematical model with an elastance, E, or its reciprocal the compliance C and with a pressure at zero volume, PV0. This function was stable and could be used to describe the abdominal characteristics of patients. With these characteristics the effects of drugs, position, ventilation can be evaluated. Leakage or absorption of CO2 did not affect the measurements in a second study. In a third study the minimal amount of data needed to determine the parameters of the mathematical model was identified. Three pressure-volume measurements were sufficient to describe all cases.
Abstract: BACKGROUND: Various techniques of laparoscopic Roux-en-Y gastric bypass have been described. We completely standardized this procedure to minimize its sometimes substantial morbidity and mortality. This study describes our experience with the standardized fully stapled laparoscopic Roux-en-Y gastric bypass (FS-LRYGB) and its influence on the 30-day morbidity and mortality. METHODS: We retrospectively analyzed 2,645 patients who underwent FS-LRYGB from May 2004 to August 2008. Operative time, hospital stay and readmission, re-operation, and 30-day morbidity/mortality rates were then calculated. The 30-day follow-up data were complete for 2,606 patients (98.5%). RESULTS: There were 539 male and 2,067 female patients. Mean age was 39.2 years (range 14-73), mean BMI 41.44 kg/m(2) (range, 23-75.5). The mean hospital stay was 3.35 days (range 2-71). Mean total operative time was 63 min (range 35-150). One patient died of pneumonia within 30 days of surgery (0.04%). One hundred and fifty one (5.8%) patients had postoperative complications as follows: gastrointestinal hemorrhage (n = 89, 3.42%), intestinal obstruction (n = 9, 0.35%), anastomotic leak (n = 5, 0.19%) and others (n = 47, 1.80%). In 66 patients, the bleeding resolved without any surgical re-intervention. One hemorrhage resulted in hypovolemic shock with subsequent renal and hepatic failure. CONCLUSION: The systematic approach and the full standardization of the FS-LRYGB procedure contribute highly to the very low mortality and the low morbidity rates in our institution. Gastrointestinal bleeding appears to be the commonest complication, but is self-limiting in the majority of cases. Our approach also significantly reduces operative time and turns the technically demanding laparoscopic Roux-en-Y gastric bypass procedure into an easy reproducible operation, effective for training.
Abstract: In three clinical centres, we compared a new method for measuring cardiac output with conventional thermodilution. The new method computes beat-to-beat cardiac output from radial artery pressure by simulating a three-element model of aortic input impedance, and includes non-linear aortic mechanical properties and a self-adapting systemic vascular resistance. We compared cardiac output by continuous model simulation (MF) with thermodilution cardiac output (TD) in 54 patients (18 female, 36 male) undergoing coronary artery bypass surgery. We made three or four conventional thermodilution estimates spread equally over the ventilatory cycle. In 490 series of measurements, thermodilution cardiac output ranged from 2.1 to 9.3, mean 5.0 litre min(-1). MF differed +0.32 (1.0) litre min(-1) on average with limits of agreement of -1.68 and +2.32 litre min(-1). Differences decreased when the first series of measurements in a patient was used to calibrate the model. In 436 remaining series, the mean difference became -0.13 (0.47) litre min(-1) with limits of agreement of -1.05 and +0.79 litre min(-1). When consecutive measurements were made, the change was greater than 0.5 litre min(-1), on 204 occasions. The direction of change was the same with both methods in 199. The difference between the methods remained near zero during surgery suggesting that a single calibration per patient was adequate. Aortic model simulation with radial artery pressure as input reliably monitors changes in cardiac output in cardiac surgery patients. Before calibration, the model cannot replace thermodilution, but after calibration the model method can quantitatively replace further thermodilution estimates.
Abstract: BACKGROUND: Anaesthesia comprising remifentanil plus isoflurane, enflurane or propofol was randomly evaluated in 285, 285 and 284 patients, respectively, undergoing short-procedure surgery. METHODS: Anaesthesia was induced with propofol (0.5 mg x kg(-1) and 10 mg x 10 s(-1)), and a remifentanil bolus (1 microg x kg(-1)) and infusion at 0.5 microg x g(-1) x min(-1). Five minutes after intubation, remifentanil infusion was halved and 0.5 MAC of isoflurane or enflurane, or propofol at 100 microg x kg(-1) x min(-1) were started and titrated for maintenance. RESULTS: Patient demography and anaesthesia duration were similar between the groups. Surgery was performed as daycases (52%) or inpatients (48%). The median times (5-7 min) to extubation and postoperative recovery were similar between the groups. Responses to tracheal intubation (15% vs 8%) and skin incision (13% vs 7%) were significantly greater in the total intravenous anaesthesia (TIVA) group (P<0.05). Fewer patients given remifentanil and isoflurane (21%) or enflurane (19%) experienced > or =1 intraoperative stress response compared to the TIVA group (28%) (P<0.05). Median times to qualification for and actual recovery room discharge were 0.5-0.6 h and 1.1-1.2 h, respectively. The most common remifentanil-related symptoms were muscle rigidity (6-7%) at induction, hypotension (3-5%) and bradycardia (1-4%) intraoperatively and, shivering (6-7%), nausea and vomiting postoperatively. Nausea (7%) and vomiting (3%) were significantly lower with TIVA compared with inhaled anaesthetic groups (14-15% and 6-8%, respectively; P<0.05). CONCLUSION: Anaesthesia combining remifentanil with volatile hypnotics or TIVA with propofol was effective and well tolerated. Times of extubation, postanaesthesia recovery and recovery room discharge were rapid, consistent and similar for all three regimens.
Abstract: A recently developed model of the left ventricle, based on experimental data, has been shown to exhibit the main features of the heart's ability to pump. Two special cases during blood ejection, termed pressure deactivation and hyperactivation, were identified. This study proposes an 'ejection effect' correction to the model that addresses deactivation, hyperactivation and adjusts the shape of the computed ventricular ejection curve in late systole. Also, a new approach based on new animal experiments is proposed to identify the ejection effect mechanism(s).
Abstract: PURPOSE: Cisatracurium besylate (Nimbex Injection, Glaxo Wellcome Inc., Research Triangle Park, NC) is an intermediate-acting bis-benzylisoquinolinium neuromuscular blocking drug that is one of the stereoisomers of atracurium. At doses < or = 8 x ED95, it caused no clinically important cardiovascular side effects or histamine release in healthy patients. The purpose of the present study was to investigate the haemodynamic effects of high doses of cisatracurium in patients with coronary artery disease. METHODS: One hundred patients undergoing myocardial revascularization participated in a pilot study (seven patients) and a double-blinded, randomized, controlled trial comparing the haemodynamic effects of cisatracurium with vecuronium at three centres. The patients were anaesthetized using oxygen 100%, with etomidate, fentanyl and a benzodiazepine, and tracheal intubation was facilitated using succinylcholine. After baseline haemodynamic measurements, the study drug was administered over 5-10 sec according to group assignment: Group A (pilot) cisatracurium, 0.20 mg.kg-1 (4 x ED95), (n = 7); Group B-cisatracurium, 0.30 mg.kg-1 (6 x ED95), (n x ED95), (n = 31); Group C-vecuronium, 0.30 mg.kg-1 (6 x ED95), (n = 31); Group D cisatracurium, 0.40 mg.kg-1 (8 x ED95), (n = 21); Group E-vecuronium, 0.30 mg.kg-1 (6 x ED95), (n = 10). The haemodynamic measurements were repeated at 2, 5, and 10 min after cisatracurium or vecuronium. RESULTS: Two patients in Group D had > 20% decreases in MAP, but only one required therapy for hypotension. The haemodynamic changes from pre- to post-injection in the cisatracurium patients were minimal and similar to patients receiving vecuronium. CONCLUSIONS: In patients with coronary artery disease, rapid cisatracurium (4-8 x ED95) boluses and vecuronium (6 x ED95) result in minor, clinically insignificant haemodynamic side effects.
Abstract: Myocardial contractile properties form the cornerstone of the heart's ability to pump blood. Efforts have been made to characterize these properties via classic elasticity theory concepts, which can lead to spurious results, as demonstrated by experiments measuring intramyocardial pressure. Two ways out of these difficulties are identified. One is to start at the cellular level, the other at the chamber level. The latter allows separation of ventricle (source) and arterial (load) effects on measured pressure and flow, distinct from previous definitions of ventricular contractility which tended to lump the two.
Abstract: We designed a randomized study to compare the effect of eltanolone and propofol on cardiac contractility. Patients were anesthetized, tracheally intubated and ventilation controlled. Propofol, 1.25 or 2.5 mg/kg, or eltanolone, 0.5 or 1 mg/kg, or a lipid emulsion only was administered in an intravenous (i.v.) bolus dose. Pressure-volume analysis was used based on radial artery pressure and transesophageal left ventricular cross-sectional area. Both propofol and eltanolone have negative inotropic properties in humans. We conclude that equianesthetic doses of these drugs produce similar changes in myocardial contractility.
Abstract: During extracorporeal circulation (ECC) a continuous monitoring of venous oxygen saturation yields a quantitative impression of the equilibrium of oxygen supply and oxygen consumption in steady state conditions. The aim of the investigation was to study whether the measurements of venous oxygen saturation and haemoglobin of a continuous on-line monitor (CDI-100) agree with those of the ABL-4 bloodgasmonitor or the haemoglobincyanid method in hospital laboratory. The study group consisted of 21 patients, with comparable conditions of anesthesia and ECC set-up. Measurements of saturation and haemoglobin were compared at three moments, resulting in a total of 189 measurements. Analysis was based on the Bland Altman method, using the differences between correspondent measurements, which contain all the information needed to decide whether the methods agree. Bias of saturation measurement (CDI-100 versus ABL-4) is -3.4, 3.0 and -3.5% at times 1,2 and 3. All values are situated within the limits of agreement. Bias of haemoglobin measurement (CDI-100 versus ABL-4) is 0.3, 0.3, and 0.2 gr/dl at times 1, 2 and 3. All values (except one value) are situated within the limits of agreement. Bias of hemoglobin measurement (CDI-100 versus hospital laboratory) is 0.2, 0.0 and 0.1 gr/dl, and all values are situated within the limits of agreement. The results confirm that the CDI-100, in the set-up as described, can be used as a reliable instrument to monitor venous oxygen saturation and haemoglobin during ECC.
Abstract: STUDY OBJECTIVE: To measure the interaction of two antibiotics (clindamycin and colistin) on neuromuscular blockade induced by pipecuronium bromide (a new long-acting, steroidal, nondepolarizing neuromuscular blocking drug). DESIGN: Prospective, randomized, placebo-controlled study. SETTING: Inpatient gynecologic and gastroenterologic service at a university medical center. PATIENTS: Three groups of 20 ASA physical status I and II patients with normal kidney and liver function, taking no medication, and undergoing elective surgery under general anesthesia. INTERVENTIONS: Anesthesia was induced with propofol and alfentanil intravenously (IV) and maintained with a propofol infusion and 60% nitrous oxide in oxygen. Pipecuronium bromide 50 micrograms/kg was administered after reaching a stable baseline of single-twitch response. At 25% recovery of pipecuronium-induced neuromuscular blockade, patients received one of two antibiotics, clindamycin 300 mg or colistin 1 million IU, or a placebo. MEASUREMENTS AND MAIN RESULTS: The recovery index (RI, defined as time from 25% to 75% recovery of neuromuscular blockade) was measured using the single-twitch response of the adductor pollicis muscle with supramaximal stimulation of the ulnar nerve at the wrist. RI after administration of an antibiotic (given at 25% recovery) was measured and compared with RI of the control group using Student's unpaired t-test. Statistical analyses of the results showed a significant prolongation of the recovery time (from 25% to 75% recovery) of 40 minutes for colistin. CONCLUSIONS: When this type of antibiotic is used during anesthesia with pipercuronium as a muscle relaxant, one must be aware of a significant prolongation of an already long-acting neuromuscular blockade and (although not observed in this study) possible problems in antagonism.
Abstract: To establish whether continuous transcutaneous O2 and CO2 measurement in the recovery room is suitable for non-invasive monitoring of spontaneous respiration in patients newly operated upon, comparative transcutaneous and arterial pO2 and pCO2 investigations were carried out on 35 adults. There was a correlation coefficient of 0.66 between paO2 and tcpO2. The transcutaneous pO2 values measured were 45.3 mm Hg under the arterial values. When the transcutaneous CO2 values were compared with the arterial values, the correlation coefficient was 0.906. The mean transcutaneous pCO2 values measured lay around 0.7 mm Hg above the arterial values. On the basis of this slight deviation in CO2 values, the method appears to be suitable for continuous non-invasive determination of pCO2. The very large deviations in the O2 values indicate that transcutaneous measurement of oxygen partial pressure in this specific examination situation is not sufficiently reliable, which makes questionable the practice of using one piece of equipment for both measurements. In the clinical setting presented, transcutaneous O2 monitoring does not represent an alternative to close clinical observation and pulse oximetry.
Abstract: In 40 patients, the cardiovascular effects of low- and high-dose propofol anesthesia (single bolus of 1.5 mg/kg in group A, 2.5 mg/kg in group C) were examined and compared with those of low- and high-dose thiopental (4 mg/kg in group B, 6.5 mg/kg in group D) (n = 10 patients per group). After induction of anesthesia with etomidate, all patients were ventilated with 70% nitrous oxide in oxygen. Peripheral arterial systolic blood pressure (SAP) and transesophageal echocardiographic short-axis measurements were used to calculate the end-systolic pressure-volume relationship (E) as an index of global myocardial contractility. In all groups SAP decreased significantly below baseline levels for the duration of the measurements (15 min after drug administration), except for the lower dose of thiopental, where SAP returned to baseline values within 10 min. Propofol at a dose of 1.5 mg/kg significantly decreased cardiac output (CO) (from 5.1 +/- 0.25 [mean +/- SEM] to 4.2 +/- 0.23 L/min), stroke volume (SV) (from 64 +/- 3 to 56 +/- 3.6 mL), and the slope of E (from 71 +/- 3.5 to 65 +/- 4.2 mm Hg/mL) until 4 min after drug administration. The higher dose of propofol significantly decreased CO (from 5.1 +/- 0.29 to 4.1 +/- 0.26 L/min), SV (from 64 +/- 3 to 52 +/- 4.6 mL), and the slope of E (from 71 +/- 3.6 to 62 +/- 3.7 mm Hg/mL) until 10 min after drug administration.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: STUDY OBJECTIVE: To compare a total intravenous (IV) anesthetic technique based on propofol and alfentanil with a commonly used anesthetic technique for craniotomy. DESIGN: Open-label, randomized, clinical study. SETTING: Neurosurgical clinic at a university hospital. PATIENTS: Forty patients, aged 18 to 55 years, scheduled for brain tumor surgery. INTERVENTIONS: In 20 patients, anesthesia was induced with fentanyl and thiopental sodium and maintained with fentanyl, dehydrobenzperidol, isoflurane, nitrous oxide (N2O), and a thiopental sodium infusion. Twenty patients were anesthetized with a propofol loading infusion followed by a maintenance infusion at a fixed rate. In addition, alfentanil was administered as a loading bolus, followed by a variable-rate infusion, with additional doses as necessary to maintain hemodynamic stability. MEASUREMENTS AND MAIN RESULTS: A decrease in blood pressure (BP) after induction with thiopental sodium was followed by a significant increase in BP and heart rate (HR) during intubation. BP and HR did not change during the propofol loading infusion. However, the administration of alfentanil was followed by a similar decrease in BP with a return to baseline values during the intubation period. Return of normal orientation (7 +/- 5 minutes vs 27 +/- 23 minutes) and concentration (12 +/- 12 minutes vs 35 +/- 37 minutes) was shorter and more predictable for the propofol-alfentanil-treated patients than for the thiopental sodium patients. Maintenance propofol concentration (nine patients) was between 3 +/- 0.69 micrograms/ml and 3.36 +/- 1.17 micrograms/ml, while the concentration at awakening was 1.09 microgram/ml. Alfentanil concentration at extubation (nine patients) was 79 +/- 34 ng/ml. CONCLUSION: A total IV anesthetic technique with propofol and alfentanil is a valuable alternative to a more commonly used technique based on thiopental sodium, N2O, fentanyl, and isoflurane.
Abstract: Thirty patients who developed arterial hypertension following coronary artery bypass grafting, despite sedation, were treated randomly with sodium nitroprusside (SNP), ketanserin or urapidil. All drugs significantly decreased arterial pressure. Two patients were withdrawn because hypertension failed to respond to ketanserin. Significant tachycardia was noted only in the SNP group. An increase in Q and significant decreases in systemic and pulmonary vascular resistances were seen in all groups. Following administration of SNP, (PaO2-PaO2) and Qs/Qt increased significantly, whereas PaO2 decreased significantly. Three patients were withdrawn from the SNP group because Qs/Qt was greater than 30%. (PAO2-PaO2) and Qs/Qt showed no significant changes following the administration of ketanserin or urapidil. These drugs may have advantages over SNP in the management of hypertension following coronary artery bypass surgery.
Abstract: Anaesthesia for neurosurgical patients should provide haemodynamic stability, reduce cerebral metabolism, preserve cerebral autoregulation, avoid increases of intracranial pressure and guarantee rapid recovery without respiratory depression. A commonly used Balanced Anaesthesia (BA, n = 20) (thiopental and fentanyl bolus induction and maintenance with repetition boluses of fentanyl and droperidol, thiopental infusion, and isoflurane in N2O/O2) was compared to Total Intravenous Anaesthesia (TIVA, n = 20) with propofol and alfentanil infusion. Pancuronium was employed for muscle relaxation in both groups. The TIVA evinced more haemodynamic stability during induction; notably, there was no increase in blood pressure after intubation, as seen in the BA group. Another advantage of TIVA is that it obviates the use of N2O. Quality of recovery after the procedure was determined by standardised psychometric tests. The time span between awakening of patients to orientation and concentration was significantly shorter in the TIVA group compared to the BA group. There was also a smaller deviation of these parameters in the TIVA group indicating a more predictable recovery.
Abstract: 20 patients who developed arterial hypertension following coronary artery bypass grafting were randomly treated with either sodium nitroprusside (SNP) or urapidil. Both drugs led to a significant decrease in blood pressure. A significant tachycardia was noted only in the SNP-group. A decrease in peripheral and pulmonary vascular resistance was seen in both groups. Following application of SNP, alveolarterial oxygen difference and venous admixture increased significantly, whereas PaO2 showed a significant decrease. Three patients had to be taken out of the SNP group because of an increase of venous admixture. Alveoloarterial oxygen difference and venous admixture showed no significant changes following application of urapidil.
Abstract: Twenty patients requiring management of postoperative arterial hypertension following coronary artery bypass grafting (CABG) were randomly treated with either ketanserin (n = 10) or sodium nitroprusside (SNP) (n = 10). After surgery all patients were mechanically ventilated in the intensive care unit (F1O2:0.5; PEEP: +5 cm H2O). During the therapy with either drug F1O2 was adjusted to achieve normal blood oxygen tensions (F1O2 always greater than 0.3). Samples of arterial and mixed-venous blood were obtained simultaneously before administration of either drug and at each time point. Data acquisition followed over 12 h. Both drugs led to a significant decrease in arterial blood pressure, although 2 patients had to be withdrawn from the ketanserin group because there was no adequate decrease in systolic arterial pressure. A significant increase in heart rate was noted only in patients receiving SNP. In the SNP-treated patients F1O2 had to be increased because of a marked decrease in paO2, resulting in a significant increase in alveolar-arterial oxygen difference (A-aDO2). In 3 patients SNP had to be stopped because of an increase in intrapulmonary shunt (Qsp/Qt) more than 30%. No significant changes in Qsp/Qt, A-aDO2, or paO2 were seen in the ketanserin-treated patients.
Abstract: This article introduces a compact versatile system that can be used when transporting high-risk patients. The equipment can be coupled to a standard hospital bed. An instrument carrier device mounted on rollers which is independent of the medical equipment manufacturer can take up every kind of storage-battery driven apparatus required for monitoring, infusion therapy and continuous drug supply, as well as an artificial respiration unit with sufficient O2 for more than 20 hours of artificial respiration. The entire setup occupies a minimum of space.
Abstract: The measurement of the abdominal pressure volume relation (APVR) gives information on compliance and its reciprocal, elastance (E). The APVR is linear under clinical situations, allowing for easy calculation of compliance. The relationship is easily quantified with only a few points of measurement; which show the effects of medications and be used to compare patients.
Two parameters, E and the pressure at zero volume (PV0) describe the linear relationship. PV0, the pressure at zero inflated volume, varies between 0 and 10 mmHg. Muscle relaxants and the trendelenburg position decrease the PV0. A high BMI increases the PV0. Positive end-expiratory pressure (PEEP) and high tidal volume change the PV0 if measured during inspiration. E varies widely between patients, from 1 to 5 mmHg/L. Children and small persons have a high elastance due to their size. Woman who have been pregnant two or more times have a lower E due to elongation of fascia, while older persons have a higher E due to decreased elastine levels. Flexion of the legs changes the E while table position affects PV0.
It is difficult to calculate the E and PV0 before surgery. The bladder pressure is different from the abdominal pressure and use of a gastric balloon is too complicated. During the initial abdominal inflation the measurement of E and PV0 can be used to calculate the ideal inflation pressure for each patient. Under muscle relaxation and with the ideal positioning, a working volume at the lowest inflation pressure can be achieved. This facilitates pulmonary ventilation and CO2 removal. Persons with a very low E can be identified. They have a high risk of overdose with muscle relaxants. New techniques are being developed to improve the surgical working space during laparoscopy in these patients.
Abstract: During mechanical ventilation a high end-tidal PCO2 increases cardiac output and improves microcirculation in obese patients.(1) The goal of this study was to accept a higher end-tidal PCO2 and to measure the effect on ventilation and vasopressor use Twenty obese patients with a BMI above 40 who underwent bariatric surgery received pressure controlled ventilation (PCV) at a rate of 14 respirations/min and a positive end-expiratory pressure (PEEP) of 5 cmH2O with approval of the hospital ethical committee. The adapted pressure was set to achieve an end-tidal PCO2 below 40 mmHg in one group and below 60 mmHg in the other group. To evaluate the comparability of the groups, each patient received volume controlled ventilation (VCV) before PCV, at a tidal volume of 500 ml, a rate of 14 respirations/min, and a PEEP of 5 cmH2O while the plateau airway pressure was measured. During PCV the following parameters were measured: the adapted minute volume, the airway pressure, the end-tidal PCO2 and the amount of ephedrine injected to keep the systolic arterial pressure above 140 mmHg during inspection of the staple line. These parameters were compared between the groups using a non paired t test. Oxygen saturation measured by pulse oximetry, switching to spontaneous breathing and awakening time were also compared. There were no significant differences in BMI, age and airway pressure during VCV between the groups. Minute volume ventilation, airway pressures and ephedrine use were significantly higher in the group with low end-tidal PCO2. Ventilation at a high end-tidal PCO2 is possible. Cardiac output was not measured but was probably higher as less ephedrine was needed to elevate the blood pressure. In the group with the high end-tidal PCO2, oxygen saturation was not lower, and spontaneous breathing and awakening occurred more rapidly. We conclude that there is an advantage in slight hypoventilation in obese patients during a pneumoperitoneum with CO2.
1. Hager H. Hypercapnia improves tissue oxygenation in morbidly obese surgical patients.
Anesth Analg. 2006 Sep;103(3):677-81.
Abstract: A dedicated anesthetist and good peri-operative care are important but not enough.
Surgeons should be aware of various parameters of anesthesia that can make a difference during surgery.
1. Proper positioning lowers the risk of difficult intubation to the risk associated with normal intubation. Use of an inflatable pillow to facilitate positioning during intubation is simple and effective.
2. Use muscle relaxation but be aware that the monitoring at the thumb does not correlate well with abdominal relaxation. Know that muscle relaxants have no effect on the abdomen in some patients and that the abdomen of a woman who has not been pregnant is small.
3. Position the patient with maximal flexion of the legs. This facilitates lung ventilation and abdominal inflation. Horizontal positioning of the table further improves abdominal inflation while the reverse trendelenburg position is preferable for lung ventilation.
4. Measure the abdominal pressure volume relation in the reverse trendelenburg position with the legs flexed. Inflate the abdomen to reach a volume of 3 L. Keep this pressure constant.
5. Ventilate with positive end-expiratory pressure (PEEP) using the pressure controlled mode if airway pressure is too high. Use a recruitment maneuver only briefly if saturation is below 90 and immediately maintain with PEEP.
6. Allow the end-tidal PCO2 to rise above 40 mmHg. This prevents volutrauma, facilitates ventilation, improves microcirculation and wound healing and keeps blood pressure elevated.
7. Keep blood pressure elevated at the end of the procedure when all staple lines are evaluated to minimize the risk of post operative bleeding. Know how to position a gastric tube properly (the more rigid and thicker the easier to position) and perform a leak test with volume load.
8. Give inhalation anesthetics at a high concentration (2 Mac) to improve muscle relaxation at the end of the operation when full relaxation is not possible before awakening.
9. Start pressure support ventilation at the end of the procedure with an initially high support. Lower the support level when the abdomen is deflated, when muscle relaxation is reversed and when the patient awakens. The pressure support mode accelerates weaning from the ventilator.
10. A short surgical time is important. Early extubation and sitting up improves outcome. If a patient cannot breathe enough, do not delay (re) intubation and ventilation. Use non invasive support ventilation if possible.
Abstract: Many anesthetists are reluctant to anesthetize morbidly obese patients because the risk of difficult intubation is higher than in non-obese patients. Morbid obesity also increases the risk of a patient having retained gastric contents that can be aspirated. Proper positioning is suggested to decrease the difficulty of intubation, but positioning heavy patients with pillows or sandbags is challenging and time consuming and therefore not easy to execute.
We developed an easy to position, inflatable bag, the âsafety birdâ, that elevates and rotates the thoracic spinal column. The patient can lay on it uninflated before induction. During induction the bag is inflated with a manual bulb until laryngoscopy reveals the best tracheal view. CT images of 3 patients who were difficult to intubate (group A) were compared with those of 5 patients who were easy to intubate (group B) with approval of the hospital ethical committee. The angle between the trachea and the hypopharynx was greater than 30° in group A and less than 30° in group B. Simple elevation of the head, known as the sniffing position, reduced the angle sufficiently in group B In group A, the sniffing position was not effective and elevation of the upper thorax with the âsafety birdâ was needed to reduce the angle below 30°. A study with more patients is needed to validate CT imaging as a preoperative screening test for diagnosing difficult intubation.
Conclusion: The measurement of the tracheal-hypopharyngeal angle and its reduction by the sniffing positioning and inflation of the âsafety birdâ can help facilitate intubation. Proper positioning may reduce the risk of intubating morbidly obese patients to the level associated with non-obese patients.
Abstract: An improvement in surgical working space is achieved by positioning the patient so that the lowest abdominal pressure is achieved at a given volume. A low abdominal pressure is also important to facilitate pulmonary ventilation. However, it is not known whether a position with low abdominal pressure also lowers airway pressure and improves lung compliance.
The goal of this study was to measure the difference in airway pressure associated with different positions using an analysis of variance on repeated measurements. In 10 patients scheduled for bariatric surgery the abdomen was inflated to 3 L using the abdominal pressure volume relationship (APVR) as previously described and with approval of the hospital ethical committee. Abdominal pressure, peak airway pressure and lung compliance were measured with the thorax horizontal with the legs flat and flexed, the thorax in the reverse trendelenburg position with the legs flat and flexed, and thorax in the trendelenburg position with the legs flat while the volume was kept constant. All patients were volume ventilated at 14 respirations per minute with a positive end expiratory pressure (PEEP) of 5 cmH2O. The tidal volume was adapted to achieve an end-tidal PCO2 of 40 mmHg and kept constant during the measurements.
Conclusion: The reverse trendelenburg position with the legs flexed provided the greatest lung compliance, which differed significantly from the compliance in other positions. The horizontal position with the legs flexed provided the second highest lung compliance. The trendelenburg position was associated with a significant reduction in lung compliance.
1. J.P.Mulier, B Dillemans, A Vanlander, K Verbeke Volume instead of pressure controlled abdominal insufflation in morbid obese patients. Obes Surg 2007 Suppl IFSO
Abstract: Being alert and fully awake and having muscle force is important for obese patients after laparoscopic bariatric surgery. However, the time to close after laparoscopy is short compared to laparatomy. If pressure support ventilation can be started before the end of the laparoscopy, end tidal PCO2 can rise without having a patient breathing against the ventilator. The purpose of this study was to verify whether pressure support ventilation (PSV) is possible after a leak test and before full decurarisation. A secondary purpose was to compare PSV and pressure controlled ventilation (PCV) in terms of the total dose of muscle relaxants and the time between the end of surgery and extubation.
Thirty patients with a BMI above 40 who underwent gastric bypass surgery were randomly assigned to receive PCV until spontaneous breathing resumed or PSV after the leak test with approval of the hospital ethical committee. Cisatracurium and sufentanil were given as clinically required; desflurane was given above 1 Mac and the concentration was reduced before the end of surgery. All patients were given neostigmine 0,5 mg after abdominal deflation. Patients with a non elastic abdomen needing more than 15 mmHg to achieve a 3 L inflated volume were excluded.
All 15 patients assigned to receive PSV underwent the transition to this ventilator setting quickly and easily. The average T4 stimulation at the moment of the leak test was 1.4 in the PSV group versus 0.6 in the PCV group. There was significantly more cisatracurium (32 mg ± 4) used in the PCV group than the PSV group (23 mg ± 2). There was no difference in the dose of sufentanil. End tidal PCO2 was significantly higher in the PSV group than the PCV group ( 54 mmHg ± 10 vs 44 mmHg ± 6 ) and the assisted breathing did not disturb the surgical field. The mean time between end of surgery and extubation was significantly shorter in the PSV group than the PCV group (3 ± 2 minutes vs. 5 ± 6 minutes). Conclusion. PSV at the end of laparoscopic surgery is possible, accelerates the awakening and facilitates the extubation.
Abstract: Having a sufficient abdominal inflation volume at the lowest possible abdominal pressure is important in obese patients to improve the surgical working space. We calculated the ideal abdominal pressure to achieve a working space of 3 L. It is not clear whether changes in the patientâs position change the volume of the working space. The goal of this study was to measure the change in abdominal elastance (E) or pressure at zero volume (PV0), indicators of abdominal volume, associated with a change in the patientâs position.
The abdominal pressure volume relation was measured as previously described. (1) This measurement was taken in 10 patients with approval of the hospital ethical committee with the thorax horizontal and the legs horizontal or flexed, the thorax in the reverse trendelenburg position and the legs horizontal or flexed, or the thorax in the trendelenburg position. E and PV0 were calculated for each position and an analysis of variance was performed on repeated measurements..
Flexing the legs significantly lowered E from 3.6 to 2.6 mmHg/L without affecting the PV0. Reverse trendelenburg increased PV0 by 0.7 mmHg and trendelenburg insignificantly decreased PV0 by 0.3 mmHg without affecting E.
The ideal position, the trunk horizontal and the legs flexed, increased the abdominal volume by 1000 ml at 15 mmHg in comparison with the horizontal position without leg flexion; reverse trendelenburg without leg flexion, the worst position, decreased the volume by 200 ml.
Conclusion: When reverse trendelenburg is needed to give the surgeon access to the upper abdomen it should be minimal and the legs should be flexed as much as possible to maximize the surgical working space.
1. J P Mulier B Dillemans T Declercq The linearity of the abdominal pressure volume relation. Acta Clinica Belgica, 2007:62 (suppl 1)
Abstract: Effect of a New Intubation Device on the Sterno Mental Distance in Obese Patients
Jan Paul J. Mulier, M.D., Ph.D.
Anaesthesiology, AZ St-Jan AV, Brugge, Belgium
Background and Goal of Study
The sterno mental distance is used as one of the measurements that determine the difficulty in intubation. Elevation of the upper body by blankets or an angulated pillow that is put under the shoulders helps to facilitate the intubation in obese patients. These systems need to be positioned before the intubation and need to be removed after intubation, what is difficult in obese patients. The new proposed device is an inflatable bag that can be positioned flat under the patient. Only at the moment of intubation it is inflated and no removal is needed during the operation.
Materials and Methods
20 patients, ASA class I or II, between 21 and 75 years old and scheduled for a bariatric surgery with a body mass index (bmi) above 25 were included in this study with approval from the hospital ethical committee.
Before anaesthesia induction the new intubation device is positioned uninflated between the thoracic spinal column and the operating table. The head is positioned in the sniffing position with maximum extension. The sterno mental distance is measured in cm as described by Savva D. The intubation device is inflated to its volume of 2,5 liter and the sterno mental distance is measured again. Following parameters are noted for each patient: age, body weight, length, sex, bmi.
Anaesthesia was induced with Propofol 200 mg, Sufentanil 20 ug, Nimbex 20 mg and Sevoflurane 1,5 Mac in a 50 % O2/N2O. After 1 minute the patient is intubated and following intubation conditions are measured: the laryngoscopy grading by Cormack and Lehane, the use of cricoid pressure and the use of a boogie. A paired t test is used to answer the hypotheses that inflating the positioning device increases significantly the sterno mental distance. Linear regression analysis is used to describe the parameters that correlate significantly with the sternomandibular length and length increase.
Results and Discussions
Inflating the intubation device increases significantly the sterno mandibular length from 12,1 cm to 16,3 cm with a p = 0,003. The bmi correlates significantly with the initial sterno mental distance. A small initial sterno mandibular distance correlates significantly with the length increase of the sterno mandibular distance when the intubation device is inflated.
Conclusion
The inflatable intubation device significantly increases the sterno manidibular distance.
References:
Savva D Prediction of difficult tracheal intubation Br. J Aaesth., 1994; 73:149-153
Cormack, Lehane Anaesthesia 1984; 39:1105-1111.
Anesthesiology 2006; 105: A873
Abstract: Are Ventilators with an American or an European Breathing Bag Safe To Prevent Accidental Volutrauma?
Steven M. Cnudde, M.D., Jan Paul Mulier, M.D., Ph.D., Thomas Deckmyn, M.D.
Anaesthesiology, AZ St-Jan AV, Brugge, Belgium
Background and Goal of Study
The adjustable pressure limiting (APL) valve protects against high airway pressures. At induction the fresh gas flow is set high and the APL valve is turned to maximum for facilitating face mask ventilation. This manual mode becomes dangerous after connecting the ventilator to the endotracheal tube without changing the ventilation mode. All ventilators have an alarm when airway pressure exceeds a value, however without opening a valve. Airway pressure rises very fast and causes volutrauma if no immediate reaction occurs.
Materials and Methods
Goal of this study was to evaluate 3 ventilators (Aestiva 5 from Datex-Ohmeda, Julian from Draeger and Neptune from Medec) in the manual ventilation mode without manual compression.
The airway pressure is measured and the time at which an alarm went off. A breathing bag of 2 liter is connected for the manual ventilation. An European type (Ch Medical, Ltd) latex free balloon or an USA type (Vital signs, inc) latex free balloon is connected to the manual system. Fresh gas flow is set at 15 liter per minute and the airway pressure alarm to its maximum level. The artificially lung consists of a Pulmo-Sim apparatus from Blease set at a compliance of 23 ml/cm H20.
At time zero the ventilator is switched to a manual ventilation mode without compression of the breathing bag. The airway pressure is monitored, and the time at which the alarms go off are noted by a high frequency pulse given on the pressure transducer. The recording is stopped after 60 seconds.
A ventilator is considered dangerous if the airway pressure stayed above 20 cmH20 for more than 10 seconds and very dangerous if no alarm did go off in that time.
Results and Discussion
The pressure tracing of the aestiva5 is given in figure 1 with the moment of the alarms.The first alarm (apnoe) started 14 seconds with the european bag and 17 seconds with the USA bag after the pressure reached 20 cmH2O. A second sustained pressure alarm followed after another 9 seconds. The Julian of Draeger had no alarm and the Neptune had an apnoe alarm from the beginning. All ventilators were considered as dangerous and the Julian as very dangerous as no alarm did go off. Correct alarm setting and vigilance remains the cornerstone of safety. Technical improvement is possible to prevent these situation and would be ideal to protect every ventilator with a manual ventilation mode.[figure1]
Anesthesiology 2006; 105: A932
Figure 1
Abstract: The Characteristics of an Intelligent New Ventilator Safety Valve
Jan Paul J. Mulier, M.D., Ph.D., Steven Cnudde, M.D., Thomas Deckmyn, M.D.
Anaesthesiology, AZ St-Jan AV, Brugge, Belgium
Background and Goal of Study
Goal of the study was to measure the characteristics of a new ventilator safety valve (VSV) when connected in a ventilator breathing circuit during the manual mode.
Materials and Methods
The ventilator safety valve is inserted in the breathing circuit. A breathing bag of 2 liter is connected for the manual ventilation. An European type (Ch Medical, Ltd) latex free balloon or an USA type(Vital signs, inc) latex free balloon is connected to the manual system. Fresh gas flow is set at 15 liter per minute. The airway alarm and the APL valve are set at their maximum level. The artificially lung consists of a Pulmo-Sim apparatus from Blease set at a compliance of 23 ml/cmH20.
At time zero the ventilator is switched to a manual ventilation mode without compression of the breathing bag. The airway pressure is monitored, and the time at which the alarms go off are noted by a high frequency pulse given on the pressure transducer. The recording is stopped after 60 seconds.
Results and Discussions
Graph 1 shows the airway pressure in the Julian ventilator from Datex Ohmeda. The device releases air and prevents a pressure of more than 20 cmH2O to take place longer than 6 sec. Although the patient gets an escape ventilation at a low frequency the ventilator will not measure this and gives an apnoe alarm after 30 seconds.
Conclusion
The device efficiently protects the airway against volutrauma when the ventilator setting was not correct due to human error.[figure1]
Anesthesiology 2006; 105: A941
Figure 1
Abstract: Nieuwe inzichten in Longbeschadiging en bescherming met safety frog
Jan P Mulier, MD PhD
Longbeschadiging door beademing ook wel VILI genoemd (ventilator induced lungtrauma) werd vroeger vooral als barotrauma geïnterpreteerd. Dit treedt op wanneer door te hoge drukken de longblaasjes, slechte term beter longalveool, gaan scheuren met pneumothorax tot gevolg. Beademing aan hoge drukken werd als gevaarlijk beschouwd, alarmen, druk begrenzing werd ingebouwd tijdens beademing.
Maar al snel bleek dat de menselijke factor hierin gevaarlijk was. Het blootstellen van de longen aan hoge druk is mogelijk wanneer de ventilatie niet juist is ingesteld. Ventilatoren en alle beademingsapparatuur worden nu wettelijk begrensd tot 90 cmH20, wat nog steeds zeer hoog is en barotrauma kan geven.
Wanneer niet correcte verbindingen gemaakt worden om zuurstof therapie te geven bij geïntubeerde maar spontaan ademende patiënten wordt het zelfs zeer gevaarlijk. Barotrauma accidenten zijn de laatste jaren nog steeds in deze groep terug te vinden in tegenstelling met de beademingsapparatuur.
Recent is de aandacht voor longtrauma aan lagere drukken gewekt. Zonder hoge drukken kan een long ook beschadigd worden indien de alveool tot een te groot volume uitgerokken wordt. Een eerste onderzoek gebeurde op intensieve waar groot tidal volume beademing vergeleken werd met klein tidal volume beademing dat een veel betere outcome realiseerde. Verder onderzoek toonde dat hoge luchtweg drukken geen kwaad kunnen indien tidal volume klein en de thorax met tape verstijfd is.
Hoe is het mogelijk dat groot tidal volume schadelijker is dan een klein tidal volume zelfs bij grote drukken? Hiervoor moeten we de longfysiologie opnieuw onder de loep nemen en de onze verkeerde voorstelling van longalveolen herzien.
De longen bestaan niet uit een verzameling van kleine ballonnetjes samengeklit tot een long maar vormen een honingraat structuur waarbij de alveolen een gemeenschappelijke wand hebben met dikwijls verbonden zijn met de omliggende alveolen. Dus geen ballon met eigen wand spanning, geen binnen alveolaire druk en buiten pleura druk. Aan de andere zijde van de alveool zit opnieuw een alveool met dezelfde druk en dus geen wandspanning en geen gevaar voor scheur. De wanden zitten al vol openingen naar de omliggende alveolen.
Dit verklaart waarom er geen probleem is bij hoge druk. Zelfs scheuren in de wand. Waarom bestaat er dan een probleem bij groot volume? Hiervoor is opnieuw meer inzicht in de fysiologie nodig die recent door Prof West aangetoond werd die zijn onderzoek eerst richtte op high altitude longoedeem en daarna op longbloeding bij zware sportinspanningen.
Bij zware sportactiviteit stijgt het hartdebiet tot zeer grote waarden met als gevolg hoge capillaire drukken in de pulmonaire circulatie. De capillairen in de longen hebben juist een zeer dunne wand en dunne basale membraan om zuurstof diffusie toe te laten maar gaan breken door de hoge druk met longbloeding tot gevolg. Het basale membraan verdikt en na enkele jaren is geen top prestatie meer mogelijk. Renpaarden gaan hierdoor maar 5 jaar mee.
Recent heeft John West ook aangetoond dat uitzetting van de longalveolen de tractie op het basale membraan rond de capillairen ook verhoogd met weerom scheur mogelijkheid. Dus hoge hartdebiet en/of uitgezet longalveool geeft longbloeding zonder pneumothorax.
Zulk een grote longvolumes zijn mogelijk bij beademing aan groot tidal volumes in longen die niet volledig open staan of wanneer door verkeerde instelling de longen tot een te groot volume opgeblazen worden, zelfs als de druk in de longen laag.
Hierdoor is de beveiliging met overdruk klep niet mogelijk want zelfs een druk van 30 cmH20 kan de long uitrekken. Experimenten op ratten in het labo hebben dit nu ook bewezen dat 30 sec druk van 30 en 40 cmH20 de longcapillairen doet barsten.
In plaats van een overdruk ventiel op druk alleen hebben we een veiligheidsklep nodig die aan lage druk opengaat wanneer de druk abnormaal lang boven de 20 cmH20 blijft.
Zulk een intelligente klep is nu gebouwd met de naam safety frog en beveiligd beademingsapparaten tegen ongewenste longexpansie.
Bij overschakelen van manueel naar mechanische beademing bestaat het risico dat met half gesloten APL klep, en hoge verse gasflow men vergeet de ventilatorcorrect te starten en de APL te openen. Zwaar volutrauma is mogelijk omdat de huidige ventilatoren hiervoor onvoldoende alarmen hebben en zeker geen intelligente veiligheids klep.
De safey frog kan hier helpen en wordt nu in de Medec toestellen al ingebouwd.
Abstract: Critical Care News first met with Dr Jan Paul J. Mulier, MD, PhD during a congress in Austria. Dr Mulier is Founder of the ESPCOP (European Society for peri-operative care of the obese patient) and works at Sint Jan Hospital in Brugge, Belgium.
It was also interesting to travel to the United States and to meet with two anesthesiologists specialized in Bariatrics to hear what they had to say. Dr Jeremy Collins, Chief Assistant Professor of Anesthesia at Stanford University Hospital and Dr Robert H. Pinsker, Medical Director of Anesthesiology at El Camino Hospital, both in Silicon Valley Ìs Palo Alto in California, related their experiences in this field.
Abstract: send an email to info@espcop.org or to Jan.mulier@azbrugge.be or to nathalie.anquez@azbrugge.be and request application form for ESPCOP
form is available now: fill and sent by email of mail
