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Unlabelled: This article reviews the development of STANDARDS, Recommendations and Guidelines for practice in anaesthesiology in France and other countries. The French society for anaesthesia and intensive care (Sfar) has published, since 1989, 11 basic, Standards: 1) Recommendations for the monitoring of patients during anaesthesia (June 1989, amended on January 1994) [APSF Newsletter, Summer 1990, page 22]; 2) Recommendations for postanaesthesia monitoring and care (September 1990); 3) Recommendations for preanaesthesia care (September 1991); 4) Recommendations for anaesthetic apparatus and checking before use (January 1994); 5) Recommendations for the equipment of anaesthesia working places (January 1995); 6) Recommendations for the tasks of the nurse anaesthetist (January 1995); 7) Recommendations for hygiene standards in anaesthesia practice (December 1997); 8) Recommendations for outpatient anaesthesia (September 1990); 9) Recommendations for the practice of obstetrical analgesia (September 1992); 10) Recommendations for interhospital physician-accompanied transfers (December 1992); 11) Recommendations for intrahospital physician-accompanied transfers (February 1994). Additionally the Sfar produced or coproduced 9 Experts' conferences, 15 Consensus conferences and 5 Guidelines for clinical practice.

Sedation allows patients to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function and the ability to respond purposefully to verbal command. For ophthalmic surgery patient's anxiety and discomfort can be relieved during placement of a peribulbar block and during surgery by intravenous sedation. Intravenous sedation should only be administered by an anesthetist. Three different classes of drugs are used for intravenous sedation: analgesics (fentanyl and alfentanil), benzodiazepines (midazolam) and profofol, an intravenous anesthetic. Sedation may result in ventilatory, cardiovascular and neurologic complications. Excessive sedation can induce hypoventilation from central ventilatory depression or airway obstruction. Uncontrolled and unexpected movements of the head could result in major surgical complications. For the prevention of the complications related to sedation the same monitoring as for general anesthesia is essential.

We recently developed a simple and fast assay technique, providing the possibility of monitoring of midazolam (M) during sedation. We compared HPLC vs FPIA for the measurement of the sum M plus alpha 1-hydroxymidazolam (OM), its main and pharmacologically active metabolite, in the serum of sedated ICU patients; this activity referred to as M-like. We identified certain patients in whom M-like activity appeared abnormally high in comparison with HPLC assays. Their common denominators were: long-term sedation with M, and seriously impaired renal function. Further, the conjugates of OM (OMG) accumulated in patients with acute renal failure could contribute to the sedation. We compared the metabolic and analytic behavior of M, OM, and OMG in 2 groups of sedated patients either presenting with normal renal functions (group 1) or with a picture of acute renal failure (group 2). Blood samples were assayed by HPLC and by FPIA and analysis was performed before and after hydrolysis of OMG. Before hydrolysis there was a dramatic accumulation of OMG in the patients of group 2, HPLC vs FPIA results were not different within group 1, while in group 2 the FPIA response exceeded that of HPLC. After hydrolysis, measurement by HPLC was greatly increased in group 2, in each group (vs HPLC) and from one group to another, the FPIA signal (the M-like activity) showed a significant increase. It would be important to take OMG into account as a coprotagonist in sedation whenever circumstances predispose to its accumulation.

Postoperative micturition difficulties, considered as minor complications, have a high incidence. Acute urinary retention can follow all types of anaesthetics or operations. Surgical trauma to the pelvic nerves or to the bladder, postoperative oedema around the bladder neck, and pain-induced reflex spasm of the external and internal urethral sphincters may play a role in the development of urinary retention. Acute urinary retention is the most common complication of surgery for benign anorectal disease. The incidence of urinary retention is more likely to occur in old male patients. Preoperative urinary symptoms are not a prerequisite for developing postoperative urinary retention, although they are considered to be a risk factor. The type of anaesthetic, postoperative pain and its management may have little effect on the occurrence of postoperative urinary dysfunction. Studies on the urodynamic effects of various anaesthetic agents are rare. The parasympatholytic drugs increase bladder capacity, decrease the rate of bladder contractions and cause downward trends in urethral resistance. The barbiturates and halothane produce similar effects on urethral resistance. The anaesthetic agents decrease the intrabladder pressure and inhibit the micturition reflex. Halothane decreases bladder contractions and increases its capacity measured by the cystometrogram. Urinary retention is a side effect of opioids, particularly after intrathecal or epidural administration. Epidural morphine relaxes the detrusor muscle with a corresponding increase in the maximal bladder capacity. Spinal opioids influence the function of the lower urinary tract, by direct spinal action on the sacral nociceptive neurons and autonomic fibres, as well as by an effect on supraspinal centres. Naloxone increases detrusor pressure, decreases bladder capacity, and causes a need to void. Urinary retention is less common after a short-acting (lidocaine 5%) than after a long-acting agent (bupivacaine 0.5%). After spinal anaesthesia, detrusor strength and the ability to void restarts with the return of sacral sensation to pinprick. A single episode of bladder overdistention can result in significant morbidity. Overfilling of the bladder can stretch and damage the detrusor muscle, leading to atony of the bladder wall, so that recovery of micturition may not occur when the bladder is emptied. On the other hand, the excessive use of an indwelling catheter can lead to urinary tract infection, urethral stricture and prolonged hospital stay. Short-term prophylactic catheterisation is recommended in patients with obstructive symptoms. Patients at risk for urinary retention should be stimulated to void and provided a quiet environment in which to do so. They should be encouraged to seat, stand or ambulate as early as possible. The alpha 1 adrenergic receptor blocking agents have been used for treatment of organic or functional urinary retention. It is essential to make sure the bladder empties regularly in the postoperative period, especially in day-case surgery or in patients receiving opioid analgesia or after epidural anaesthesia.

In currently available experimental or clinical studies, there is no report of any adverse effect related to the lipid emulsion of propofol, for procedures not exceeding on average four hours of duration. General anaesthesia produced by propofol alone is associated with only moderate alterations of blood lipid concentrations. Therefore there is no restriction to the use of propofol. In the absence of precise data, it is recommended not to use propofol infusion in congenital hyperlipaemias (e.g., hyperchylomicronaemia). The lipid emulsion of propofol may alter the rheological properties of circulating blood, platelet aggregation, chemotactic activity of neutrophils and lymphocytes functions. These alterations are always limited. Furthermore, most studies which have recorded these effects are not directly applicable to clinical practice and additional studies are necessary. There are no data demonstrating that propofol would increase surgical bleeding or the incidence of postoperative infections. Since there is a low probability of these adverse effects, they should not limit the use of propofol.