James C. Eisenach, M.D., Editor

Tenth International Symposium on Anesthesia and Intensive Care. Zichron Ya'acov, Israel, September 3–5, 1997.

The Tenth International Symposium on Anesthesia and Intensive Care was held at the Radisson Moriah Gardens Hotel in Zichron Ya'acov (about 40 miles north of Tel Aviv, Israel). The organizing committee for the symposium included G. M. Gurman, M.D., President (Soroka Medical Center, Beer Sheav, Israel), N. Weksler, M.D., Chair (Soroka Medical Center), and A. Fisher, M.D., Scientific Secretary (Soroka Medical Center). The symposium was hosted by the Division of Anesthesiology, Soroka Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel.

The opening lecture of the symposium, delivered by D. Linton, M.D. (Hadassah Hebrew University Medical Center, Jerusalem, Israel) reviewed the use of the percutaneous tracheostomy in the intensive care unit. This method has been shown to have morbidity comparable to that achieved with traditional surgical tracheostomy and at the same time to enjoy a number of advantages, including (1) a saving in operating room resources, (2) no need for transport of critically ill patients, and (3) easy availability. The first set of lectures and workshops focused on regional anesthesia for orthopedic procedures. A. D. Rosenberg, M.D. (Hospital for Joint Diseases, New York, NY) reviewed clinical problems in anesthesia for major orthopedic surgery. The presence of rheumatoid arthritis can complicate the anesthetic management of other orthopedic procedures, such as joint replacement and spinal surgery. Particularly significant for the anesthesiologist are the problems associated with airway management in these patients, including a hypoplastic mandible, reduced mouth opening caused by temporomandibular joint (TMJ) arthritis, cricoarytenoid arthritis, cervical spine instability, and anatomic alterations of the larynx. R. L. Bernstein, M.D. (Hospital for Joint Diseases) reviewed the subject of regional anesthesia for upper and lower extremity surgery. At his institution, all regional anesthesia is performed with the use of a nerve stimulator and an insulated needle. With this technique the needle is placed in close proximity to the nerve, without seeking a paresthesia. Avoidance of paresthesia reduces the incidence of nerve damage associated with nerve block. The key to success is obtaining a maximal twitch, at the lowest milliamperage possible, in the nerve distribution to be blocked. M. H. Marshall, M.D. (Hospital for Joint Disease) discussed the medical considerations involved in the selection and treatment of patients undergoing regional anesthesia. Proper, preoperative patient assessment allows widespread application of regional techniques. After the presentations, the lecturers held a three-station, hands-on workshop on regional anesthetic technique for the residents attending the symposium.

The second set of lectures and workshop addressed selected topics in anesthesia. J. Katz, M.D. (University of Texas Houston Health Science Center, Houston, TX) discussed the anesthetic management of carotid endarterectomy. Despite the increasing numbers of patients undergoing this type of surgery, a number of controversies continue to exist as to intraoperative management, including (1) the use of intraoperative electroencephalography (EEG), (2) the need for an intracarotid shunt, and (3) the use of local versus general anesthesia. H. S. Minkowitz, M.D. (University of Texas Houston Health Science Center) reviewed a number of relatively recent technical developments in airway management. Of particular interest was a discussion of fiberoptic intubating laryngoscopes, which are not in common use in Israel. D. B. Abramson, M.B.Ch.B., F.F.A.(SA)(University of Texas Houston Health Science Center) presented data on the “fast track” postoperative treatment of cardiopulmonary bypass patients. Use of propofol in place of midazolam or opioids for anesthesia and postoperative sedation after cardiopulmonary bypass has been shown to shorten the time to arousal and extubation. Fourteen studies, encompassing 3,067 patients were reviewed. Sixty-two percent of patients were extubated early with a reintubation rate of only 1.17%. All published reports have concluded that early extubation is safe, feasible, and desirable.

The third set of lectures and workshops focused on the use of computers in anesthesia. The session was moderated by K. J. Ruskin, M.D. (Yale University School of Medicine, New Haven, CT), who presented an overview of the Internet as a clinical tool for anesthesiologists. In addition to the many current uses of the Internet, increased use of teleconferencing is expected to share scientific conferences and educational activities around the world. R. P. M. Hagenouw, M.D. (University Hospital Rotterdam, Rotterdam, The Netherlands) reviewed the anesthesia resources currently available on the Internet. E. Herzog, M.D. (Soroka Medical Center) provided the Israeli attendees with advice on getting connected to the Internet. D. L. Reich, M.D. (Mount Sinai Medical Center, New York, NY) discussed the use of computerized record keeping in anesthesia. Although the equipment and software required is expensive, there is little doubt that there are major advantages to be gained for quality assurance purposes. In a comparative review of computerized and handwritten anesthesia records, pulse oximeters were found to fail in 2.0% of cases in which a handwritten record was kept and in 8.2% of cases in which a computerized record was kept. On the other hand, there is still debate as to whether computerized records are advantageous from a medicolegal standpoint.

On the second day of the symposium, two invited guest lectures were given. I. Azar, M.D. (Albert Einstein College of Medicine, Beth Israel Medical Center, New York, NY) discussed a number of preoperative dilemmas for the anesthesiologist. Inflammation of the upper airways, elevated liver enzymes, and hypokalemia are common preoperative problems, which if not identified and treated correctly may lead to significant anesthetic morbidity. P. Lebowitz, M.D. (New York Medical College, Metropolitan Hospital Center, New York, NY) described, for non-Americans, how financial concerns are affecting the practice of anesthesia in the United States. Managed care has brought to the front ethical issues that remained unresolved in more prosperous times. Although many of the issues discussed have not yet reached Europe or Israel, as with all things American, they cannot be long in coming.

The fourth set of lectures and workshops was dedicated to the use of sevoflurane in pediatric anesthesia. J. Lerman, M.D., F.R.C.P.C., F.A.N.Z.C.A. (The Hospital for Sick Children, The University of Toronto, Toronto, Canada) gave a short introduction to the subject and reported on the Toronto experience with sevoflurane. The low solubility of sevoflurane allows rapid induction of anesthesia, comparable to that with halothane, with a lower incidence of arrhythmias and noxious airway responses. Although the high cost of sevoflurane has been an issue, strategies are available that allow cost-cutting, including (1) use of reduced flows while monitoring exhaled CO2, (2) reducing inspired sevoflurane concentrations after induction, (3) use of adjunct regional anesthesia to reduce sevoflurane requirements, and (4) switching from sevoflurane to less expensive halothane or isoflurane after induction. After this introduction, D. Geva, M.D. (Kaplan Medical Center, Rehovot, Israel) and Y. Katz, M.D. (Schneider Children's Hospital, Petah Tikva, Israel) presented the initial Israeli experience with sevoflurane.

The fifth set of lectures and workshops dealt with the relationship between anesthesiology and critical care medicine. G. M. Gurman, M.D., presented a short history of critical care medicine as an offshoot of anesthesiology until the almost total separation of the two fields in the United States during the 1980s. This divorce has led some of the leaders of the profession to advocate redefining anesthesiologists as perioperative physicians. One solution, being implemented in the Division of Anesthesiology, Soroka Medical Center, has been to require that newly trained specialists in anesthesiology being considered for tenure complete a fellowship in critical care medicine as well. R. P. M. Hagenouw, M.D., V. Paver-Erzen, M.D. (University Medical Center, Ljubljana, Slovenia). N. Mutz, M.D. (Innsbruck, Austria), and P. Sorkine, M.D. (Tel Aviv Medical Center, Tel Aviv, Israel) then each presented their national perspective on the issue. In all of these countries, the interrelationship between anesthesiology and critical care medicine remains strong, with anesthesiologists still retaining a leadership position in critical care.

The sixth set of lectures and workshop dealt with the role of hemopurification in the intensive care unit. D. Linton, M.D., opened the session with an overview of hemopurification techniques in the intensive care unit and a look at expected future technologic advances in the field. S. Rodl, M.D. (Department of Pediatrics, University of Graz, Graz, Austria) reported on his experience with continuous renal replacement therapy (CRRT) in infants and neonates. Over a period of 10 yr, 90 children, with a mean age of 3.3 yr, were treated with CRRT. Fifty-one of these children survived. Continuous hemodiafiltration, driven in either the arteriovenous or venovenous mode, proved to be an effective method of renal support for critically ill neonates and succeeded in controlling fluid balance and metabolic derangement. L. Gotlioib, M.D. (Department of Nephrology, Central Emek Hospital, Afula, Israel) presented the results of a study in which patients with septic multiorgan failure were treated with sequential hemofiltration and bicarbonate hemodialysis in addition to currently used support measures. The surviving patients treated with hemofiltration showed significantly improved oxygenation, APACHE II scores, mean arterial blood pressure, and blood chemistries. There was, however, no difference in the mortality rate between the treated and untreated group. It was concluded that there is room for a prospective, controlled study. N. Weksler, M.D., presented the results of a study in which 32 patients who had suffered 50–70% burns and were both septic and non-oliguric were randomized to either receive, or not receive, high volume continuous venovenous hemofiltration. Patients in the study group had an improved fluid balance and an improved survival rate (70%) as compared to the control group (40%).

The seventh set of lectures and workshop addressed the subject of oxygen transport in the critically ill. Y, Bar-Lavie, M.D. (Department of General Intensive Care, Rambam Medical Center, Haifa, Israel) reviewed new treatment modalities in ARDS. These include (1) new modes of ventilation (pressure controlled, inverse ratio, airway pressure release, and high frequency jet ventilation), (2) partial liquid ventilation, (3) prone positioning, (4) new drugs (nitric oxide, prostacycline, and almitrine bimesylate), and (5) a renewed interest in extracorporeal life support. However, most of these new methods have not been studied in a prospective randomized manner. Thus, the chosen techniques often are a matter of personal expertise, preference, or equipment availability. Therapeutic optimization strategies for those with severe ARDS are needed to allow management procedures to be added as the patients' situation demands. W. Hasibeder, M.D. (University of Innsbruck) reviewed the mechanisms of oxygen transport in those with severe sepsis and ARDS. Animal experimental evidence has shown that cellular energy stores are maintained in patients with sepsis. Extramitochondrial enzymatic processes, however, depend on a higher oxygen tension than mitochondrial respiration. Therefore, it is conceivable that significant cellular dysfunction may occur without depletion of energy-rich phosphates. Thus, manipulation of oxygen delivery to supranormal values may have therapeutic benefit.

The third day of the symposium began with a session devoted to free papers, P. Mavoungou, M.D. (Clinique Mutualiste, Nantes, France) reported on the use of the bispectral index of the EEG to manage hypertension during laparoscopy. Because of pneumoperitoneum, increases in blood pressure may occur that are unrelated to depth of anesthesia. Use of the bispectral index of the EEG was useful in differentiating inadequate hypnosis from stimulus-induced activation of the sympathoadrenal system. J. Rubin, M.D. (Durban, South Africa) discussed the influence of perioperative analgesia on the prevention of intractable postamputation pain. Preventive use of the alpha2agonist, clonidine, or the NMDA antagonist, ketamine, may increase the efficacy of postoperative analgesia. T. A. Bensousan, M.D. (General Hospital, Compiegne, France) reported the results of a randomized trial of two rapid tests for the diagnosis of venous thromboembolism through detection of circulating D-dimer, a degradation product of circulating fibrin. The tests were compared to a conventional ELISA assay. The rapid methods were as efficient as the ELISA assay, but the results reconfirmed the lack of specificity of the D-dimer test for detection of thromboembolism. This lack of specificity calls into question the value of this method as a screening test. C. E. Lesmes (Central Emek Hospital, Afula, Israel) proposed a new method of clinical scoring to assess perioperative risk. The score, which resembles the Glasgow Coma Scale score, takes into account the patient's age, preexisting medical condition, and the type of surgery. Scoring systems allow practitioners to define patients using a common language. E. Weinberg, M.D. (Rebecca Sieff Government Hospital, Safed, Israel) presented data showing the decreased requirement for hypnotic anesthetics when bupivacaine spinal block was added to general anesthesia. Although the requirement for all three studied anesthetics (midazolam, propofol, and thiopental) was reduced, presumably because of reduced afferent stimulus, differences in the rate of decrease of each anesthetic suggest the presence of other, agent-specific factors. (This presentation was dedicated to the memory of V. Melnik, M.D., an anesthesiologist from the Rebecca Sieff Government Hospital, Safed, who died in the line of duty in a helicopter crash while serving as a reserve physician in the Israel Defense Forces). T. A. Bensousan, M.D., reported a simple score to define the autonomy in daily activity of patients before their admission to a hospital emergency room. A high degree of autonomy in daily activity, as reflected in this score, correlated with hospital survival, whereas a lower level of autonomy predicted death in the hospital. L. Gaitini, M.D. (Bnai-Zion Medical Center, Haifa, Israel) reported the results of a continuous quality improvement program to reduce a high incidence of intraoperative hypertension. Factors identified as being associated with hypertensive episodes were incorrect preoperative assessment, type of operation, and insufficient depth of anesthesia. After the implementation of corrective measures, a significant reduction in the incidence of hypertension was observed. The methodology of a continuous quality improvement program can be applied to a range of anesthetic problems.

The final session of the symposium was devoted to clinical case discussions open to the entire forum.

The Eleventh International Symposium on Anesthesia and Intensive Care will be held in Israel from November 3–6, 1998. For information, registration, and abstract forms, contact Nathan Weksler, M.D., Division of Anesthesiology, Soroka Medical Center, P.O. Box 151, Beer Sheva, Israel; or the Symposium Secretariat, P.O. Box 29041, Tel Aviv, Israel, 61290.

Daniel Talmor, M.D.

Division of Anesthesiology; Soroka Medical Center; Ben Gurion University of the Negev; Beer Sheva, Israel

Alan A. Artru, M.D.

Department of Anesthesiology; University of Washington School of Medicine; Seattle, Washington