Survey results continue to reveal that postoperative pain is insufficiently managed throughout Europe and the rest of the world. However, the efficient use of existing resources, as well as the introduction of novel technologies, may aid in its improvement. Use of an acute pain service has the potential to improve pain management through specialized patient care and utilization of effective analgesic techniques. Multimodal analgesic techniques, which include adjuvant non-opioids and/or regional analgesic techniques, can provide effective analgesia and reduce the amount of systemic opioids (or obviate the need) for postoperative pain management. Patient-controlled analgesia modalities may also offer improvements to pain management, as in practice they provide pain relief superior to the intermittent administration of bolus doses of opioids. A novel patient-controlled analgesia modality that has been approved by the European Medicines Evaluation Agency (EMEA) for the treatment of acute, moderate-to-severe pain is the needle-free, pre-programmed fentanyl HCl iontophoretic transdermal system. This system was shown in a recent US clinical trial to be comparable in efficacy to a standard regimen of morphine intravenous patient-controlled analgesia. Adverse events associated with the use of the fentanyl iontophoretic transdermal system are generally similar to those experienced by patients using intravenous morphine patient-controlled analgesia. Considerations regarding the selection of patients for treatment with the fentanyl iontophoretic transdermal system are similar to those with other patient-controlled analgesia modalities; sufficient upper limb mobility and alertness are required to operate the system. Utilization of the fentanyl iontophoretic transdermal system, together with the guidance of an effective acute pain service, may lead to improvements in postoperative pain management.

The wide use of anticlotting drugs by patients scheduled for surgery is a challenge for the anaesthesiologist when considering a regional anaesthesia technique. This practice seems safe if there is an appropriate management based on safety intervals established according to the pharmacology of the drug and the regional technique. Some anaesthesiology societies have published recommendations for the safe practice of regional anaesthesia with the simultaneous use of anticoagulants (heparin, low molecular weight heparins, oral anticoagulants (OA), fondaparinux and others) and antiplatelet agents (aspirin, clopidogrel, ticlopidine, argatroban and others). One of the most recent guidelines has been published by the Spanish Society of Anaesthesia and Critical Care. This article reviews these recommendations and compares them with others published in the last years. The recommendations are similar, but some interesting differences can be observed and need to be considered. A European consensus in this setting would probably be necessary.

Chronic heart failure is known to be an important risk factor for adverse perioperative outcome in patients undergoing non-cardiac surgery. A promising new form of electric therapy is currently being used in a phase III trial in patients with severe chronic heart failure (cardiac contractility modulation). Cardiac contractility modulation is a non-pharmacological approach to improve Ca2+ effect on cardiac myofilaments using electric currents. The cardiac contractility modulation system used at present (OPTIMIZER™ III, Impulse Dynamics, Orangeburg, NY, USA) consists of a subcutaneously implanted pulse generator and three electrodes. As far as we know, cardiac contractility modulation therapy is a safe and feasible way of improving the systolic function of the heart in congestive heart failure patients. No pro-arrhythmic effects of this new therapy have been reported. The technique shows promise as an additive treatment for severe chronic heart failure. The perioperative and intraoperative management of patients should follow current cardiac pacemaker/implantable cardioverter defibrillator guidelines.

Summary

We do not know how general anaesthetics cause their desired effects. Contrary to what has been thought until relatively recently, the clinical state of anaesthesia consists of multiple components that are mediated via interaction of the anaesthetic drugs with different targets on the molecular, the cellular, the network and the structural–anatomical levels. The mechanisms by which some of these drugs induce the different components of ‘anaesthesia’ may be rather specific: discrete mutations of single amino acids in specific proteins profoundly affect the ability of certain anaesthetics to achieve specific endpoints. Despite this potential specificity, inhalational anaesthetics are present in the body at very high concentrations during surgical anaesthesia. Due to their lipid solubility, general anaesthetics dissolve in every membrane, penetrate into organelles and interact with numerous cellular structures in multiple ways. A priori, it is therefore not unreasonable to assume that these drugs have the potential to cause insidious changes in the body other than those acute and readily apparent ones that we routinely monitor for. Some changes may wane within a short time after removal of the drug (e.g. the suppression of immune cell function). Others may persist after complete removal of the drug and even become self-propagating (e.g. spread of malignant cells, the β-oligomerization of proteins), still others may be irreversible (e.g. the induction of apoptosis in the central nervous system) but of unclear significance. This article will focus on evidence for anaesthetic toxicity in the central nervous system, which appears to be susceptible to anaesthetic neurotoxicity primarily at the extremes of ages but via different pathways: in the neonate, during the period of most intense synaptogenesis, anaesthetics can induce excessive apoptosis; in the aging brain subtle cognitive dysfunction can persist long after clearance of the drug and processes resembling neurodegenerative disorders may be accelerated. At all ages, anaesthetics affect gene expression regulating protein synthesis in poorly understood ways. While it seems reasonable to assume that the vast majority of our patients completely restore homeostasis after general anaesthesia, exposure to these drugs probably has more profound and longer-lasting effects on the brain than heretofore imagined.

Medical malpractice has been raised as an important problem in daily practice, while the media and public remain unforgiving to those perceived to have harmed the patients’ life. This article highlights important legal issues related to medical malpractice and summarizes the sources and the nature of potential errors in anaesthesiology practice.

One of the greatest but also most unfortunate ironies in life is how modern medicine owes some of its existence to the deadly cancer of war. For those whose image of armed conflict is one of disease, death and destruction, this will no doubt be a surprise. However, these very conditions have allowed military surgeons and physicians unparalleled opportunities to experiment and develop using large and dependent populations of potential patients. The catalyzing effect of war has seen the ambulance, the hospital, plastic surgery, preventative medicine and penicillin as just a few products whose history is linked to war. This paper examines whether anaesthesia, and in particular British anaesthesia, can be added to this list when focussing on the First World War (1914–1918). The anaesthesia that was being practiced at the outbreak of the First World War had not drastically altered from that of the mid-nineteenth century. Old anaesthetics given via basic facemasks could be performed by many doctors; specialists were rare. This situation, however, altered during the First World War. This is because the vast number of wounded in the war demanded the introduction of casualty clearing stations to help triage and treat the wounded quickly and efficiently. The workload of these ‘mini hospitals’ created specialist anaesthetist posts within the military. Once in place, the anaesthetists were able to help develop the relatively new concepts of blood transfusion and resuscitation. These were recognized to be vital against shock, something that had previously not been well researched or understood. While at the casualty clearing stations, Geoffrey Marshall readdressed this by studying the effects of different anaesthetic agents in varying amounts of shock. This work led to the popularity of nitrous oxide, ether and oxygen, which in turn stimulated interest in anaesthesia machines. Finally, the treating of facial wounds in casualties at the Queen’s Hospital for facial and jaw injuries at Sidcup, highlighted the possibility of endotracheal intubation, a technique that had a drastic effect on the administration of anaesthetics. Although there were no new wonder anaesthetics, something which would not occur until the neuromuscular blocking drugs of the 1940s, many of these concepts moved into civilian anaesthesia and enabled British anaesthesia to be at the forefront of anaesthesia development for much of the twentieth century.

There is an increasing body of evidence that volatile anaesthetics protect myocardium against ischaemic insult by a mechanism termed ‘anaesthetic preconditioning’. Anaesthetic preconditioning and ischaemic preconditioning share several common mechanisms of action. Since ischaemic preconditioning has been demonstrated in organs other than the heart, anaesthetic preconditioning might also apply in these organs and have significant clinical applications in surgical procedures carrying a high risk of ischaemia–reperfusion injury. After a brief review on myocardial preconditioning, experimental and clinical data on preconditioning in non-cardiac tissues will be presented. Potential benefits of anaesthetic preconditioning during non-cardiac surgery will be addressed.

Anaesthesia is a medical specialty that is particularly concerned with the safety of the patient who is undergoing a surgical procedure. This is a prerequisite in order to provide quality of care, which is based on good clinical practice, on a sound organization, on an agreement on best practice and on adequate communication with other healthcare workers involved. Providing a safe environment for those working in healthcare is at least as important as other factors serving that objective. A working party on Safety and Quality in Anaesthesiological Practice in the Section and Board of Anaesthesiology of the European Union of Medical Specialists (EUMS/UEMS) has prepared guidelines that were amended and approved recently.

Anaesthesiologists, for their knowledge, skills and expertise, have been playing a key role in the development of emergency medicine. In many countries, anaesthesiologists are today fully involved in teaching and practicing emergency medicine, and have leading roles in emergency departments. Proper education and effective interdisciplinary medical cooperation is essential for quality assurance in emergency medicine. This paper, produced by a working party of the European Board of Anaesthesiology of the European Union of Medical Specialists (EUMS/UEMS), gives directions for a core curriculum in emergency medicine integrated in the specialty of anaesthesiology.

The still ever increasing demand for sedation and/or analgesia for diagnostic and therapeutic procedures puts high pressure on anaesthesia care providers all over Europe. Since the capacity to provide that service by anaesthetists is limited in most European countries, guidelines for non-anaesthetist doctors who want to sedate patients on a high-quality level and especially in a safe way are mandatory. This paper, produced by a working party of the European Board of Anaesthesiology of the European Union of Medical Specialists (EUMS/UEMS), gives direction to those practitioners who feel responsibilities in this area of medicine. Close cooperation with anaesthesiologists seems mandatory to achieve and sustain a high-quality standard for our patients undergoing medical or surgical procedures under sedation.

The Section and Board of Anaesthesiology of the European Union of Medical Specialists aims (EUMS/UEMS) at harmonization of training of anaesthesiologists and at improvement of patient care throughout Europe. Pain medicine is considered to be an area of expertise in anaesthesiology although exclusivity is not claimed. The Section and Board has approved both a core syllabus for pain medicine to be part of the specialist training in anaesthesiology and an additional qualification in pain medicine following the completion of a 5 yr basic specialty training in anaesthesiology. These proposals were prepared by the Working Party on Pain Medicine of the Section and Board. It considers a multidisciplinary approach to pain to contribute to quality in care and has taken the initiative to set up a Multidisciplinary Joint Committee on Pain Medicine within the EUMS/UEMS, for which these guidelines define the area of expertise of anaesthesiology.