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Background and objective: The European anaesthesia workforce is facing increased demand and expansion of the labour market, which may likely exceed supply. This survey assesses the numbers and practice patterns of anaesthesiologists and studies migration and shortage of the anaesthesia workforce in Europe. Methods: A questionnaire was sent to all national European anaesthesia societies. Countries were grouped according to their relationship with the European Union. Results: The number of anaesthesiologists per 100 000 population varies between 2.7 (Turkey) and 20.7 (Estonia). There seems to be no clear evidence for feminization of the anaesthesia workforce. Anaesthesia physician training lasts between 3 yr (Armenia, Belarus, Uzbekistan) and 7 yr (Ireland, UK), and seems to positively correlate with the number of trainees. Throughout Europe, anaesthesiologists typically work in public practice, and are involved in the entire care chain of surgical patients (anaesthesia, intensive care, chronic pain and pre-hospital emergency medicine). The differences between European salaries for anaesthesiologists are up to 50-fold. Most Western European countries are recipients of migrating anaesthesiologists who often originate from the new member states of the European Union. However, it seems that expectations about anaesthesia workforce shortages are not confined to Eastern Europe. Conclusions: Each European country has its own unique workforce constellation and practice pattern. Westward migration of anaesthesiologists from those countries with access to the European Union labour market may be explained by substantial salary differences. There is a European-wide lack of systematic, comparable data about the anaesthesia workforce, which makes it difficult to accurately assess the supply of anaesthesiologists.

Resume Objectif. – Tester la validite du simulateur d'anesthesie pour evaluer la capacite des internes a resoudre deux types de situation critique. Type d'etude. – Etude prospective, monocentrique, randomisee. Population. – Internes d'anesthesie–reanimation (A/R). Methodes. – Tous les internes d'A/R du CHRU de Lille ont ete invites a participer. Ils etaient libres de refuser. Des scores d'evaluation ont ete etablis pour la preparation de la salle d'anesthesie et pour deux exercices de simulation qui ont ete prealablement valides. Tous les internes ont ete evalues pour la preparation de la salle d'anesthesie. Apres randomisation, la moitie de l'effectif a ete testee pour chacun des exercices. Les grilles d'evaluation des scores ont ete remplies par deux anesthesistes–reanimateurs experimentes. Apres la seance de simulation, une evaluation anonyme de la simulation a ete demandee a chaque participant. Resultats. – Parmi 72 internes en formation, 48 ont participe dont 24 en debut de cursus (1re et 2e annees) et 24 en fin de cursus (3e et 4e annees). Les scores medians entre le debut et la fin d'internat etaient similaires pour la preparation de la salle d'anesthesie (17 vs 17 pour un score maximal de 25) alors que les scores tendaient a etre plus eleves pour les internes de fin de cursus lors des exercices de simulation (scenario 1 [34 vs 19 pour un score maximal de 55 ; p = 0,0009], scenario 2 [17 vs 13 pour un score maximal de 45 ; p = 0,58]). Cependant, des erreurs de prises en charge ont ete observees dont certaines n'ont pas ete modifiees par l'anciennete. Les internes ont evalue comme tres realistes les exercices de simulation. Conclusion. – La simulation apparait comme un outil discriminant et valide pour apprecier les performances des internes d'A/R en situation critique.

BACKGROUND AND OBJECTIVE Inflammation promotes hyperalgesia and increases opioid binding protein (alpha1-acid glycoprotein) inducing increased opioid requirement. To investigate the influence of an acute episode of inflammatory bowel disease in opioid requirement during major abdominal surgery, 17 patients with Crohn's disease, 12 patients with ulcerative colitis and seven patients without any inflammatory process (control group) were prospectively studied. Sufentanil requirements were assessed during surgery. METHODS Sufentanil administration was adjusted when haemodynamic variables changed more than 20% of preoperative values. In a subgroup of 20 patients (Crohn's disease: 7, ulcerative colitis: 7, control group: 6), plasma concentrations of alpha1-acid glycoprotein and unbound sufentanil were measured. Total plasma clearance of sufentanil was also determined. Data presented as median (25-75 per thousand) were analysed by non-parametric and ANOVA tests. RESULTS Despite similar surgery duration, intraoperative sufentanil requirements were significantly larger in both the Crohn's disease group (0.9 (0.6-1.6) microg kg(-1) h(-1)) and the ulcerative colitis group (1.1 (0.6-1.7) microg kg(-1) h(-1)) than in the control group (0.5 (0.4-0.5) microg kg(-1) h(-1)). Total plasma clearance of sufentanil was larger in patients with inflammatory bowel disease than in the control group. The plasma alpha1-acid glycoprotein concentration was increased in the inflammatory bowel disease group. However, the free fraction of sufentanil was similar in all three groups. The largest sufentanil consumption in patients with inflammatory bowel disease was observed during time of pain stimulation in the area of referred hyperalgesia from the affected viscus. In the control group, the sufentanil requirement was constant throughout surgery. CONCLUSION Inflammatory bowel disease increases opioid requirement during major abdominal surgery.

Resume Objectifs. – Analyser les donnees de l'evaluation a distance des cours FEEA a partir des fiches fournies par le CFAR dans le but d'evaluer l'impact de l'action de FMC. Type d'etude. – Etude ouverte. Materiel. – Recueil des fiches d'evaluation a distance remplies 3-6 mois apres la formation par les participants aux sept cours FEEA dispenses en France en novembre et decembre 1999. Methodes. – Le mode et le lieu d'exercice professionnel, la pratique medicale sur le sujet de formation ont ete releves. L'evaluation pedagogique portait sur six criteres cotes de 1–10 : utilisation du document pedagogique, diffusion des informations a des collegues, entretien avec un responsable, decision de modifier les procedures de soins, application de ces decisions, atteinte de l'objectif de formation. Les resultats ont ete compares selon le mode d'exercice, le theme du cours. Resultats. – . Cinq sur sept organisateurs ont donne suite a l'enquete. Quatre-vingt-onze sur 239 questionnaires potentiels ont ete completes. Le mode d'exercice etait diversifie (clinique : 25, CHU : 31, CHG : 27, PSPH : 8). L'activite etait essentiellement anesthesique (83/91). La pratique medicale etait frequente (75/77 reponses). L'evaluation pedagogique globale a revele des notes moyennes proches de 7 pour tous les criteres a l'exception de l'entretien avec un responsable hierarchique (note 3,6 ± 3,2). L’application de modifications de procedures de soins a ete significativement plus elevee en cliniques comparees aux PSPH. Le document pedagogique a ete plus utilise apres le cours n o 1 (respiration–thorax). Conclusion. – Les participants auraient atteint leur objectif de formation et modifie leur pratique medicale. L'absence de dialogue avec un responsable merite reflexion.

Background All general anesthetics used are known to have a negative inotropic side effect. Since xenon does not have a negative inotropic effect, it could be an interesting future general anesthetic. The aim of this clinical multicenter trial was to test the hypothesis of whether recovery after xenon anesthesia is faster compared with an accepted, standardized anesthetic regimen and that it is as effective and safe. Method A total of 224 patients in six centers were included in the protocol. They were randomly assigned to receive either xenon (60 +/- 5%) in oxygen or isoflurane (end-tidal concentration, 0.5%) combined with nitrous oxide (60 +/- 5%). Sufentanil (10 mcirog) was intravenously injected if indicated by defined criteria. Hemodynamic, respiratory, and recovery parameters, the amount of sufentanil, and side effects were assessed. Results The recovery parameters demonstrated a statistically significant faster recovery from xenon anesthesia when compared with isoflurane-nitrous oxide. The additional amount of sufentanil did not differ between both anesthesia regimens. Hemodynamics and respiratory parameters remained stable throughout administration of both anesthesia regimens, with advantages for the xenon group. Side effects occurred to the same extent with xenon in oxygen and isoflurane-nitrous oxide. Conclusion This first randomized controlled multicenter trial on the use of xenon as an inhalational anesthetic confirms, in a large group of patients, that xenon in oxygen provides effective and safe anesthesia, with the advantage of a more rapid recovery when compared with anesthesia using isoflurane-nitrous oxide.

Resume Objectifs : Les craintes exprimees concernant l’evolution de la demographie des anesthesistes-reanimateurs en France ont conduit le College francais des anesthesistes–reanimateurs (Cfar) et la Societe francaise d’anesthesie et de reanimation (Sfar), en partenariat avec l’Institut national d’etudes demographiques (Ined) a organiser une enquete nationale aupres de l’ensemble des medecins anesthesistes–reanimateurs. Les trois principaux objectifs etaient de denombrer la population des medecins anesthesistes-reanimateurs (MAR) exercant en France, de decrire sa dynamique demographique et d'analyser son activite professionnelle. Methodes : L’enquete reposait sur un questionnaire individuel auto-administre ayant fait l’objet d’une declaration a la Commission nationale informatique et libertes (CNIL). L’enquete s’est deroulee fin 1998, dans les 1484 etablissements, publics (590) et prives (894) ou se pratiquait de l’anesthesie–reanimation, sous le controle de referents d’etablissements et regionaux. Le denombrement des postes d’anesthesie–reanimation a abouti a un total de 9741 postes se repartissant pour 5694 dans le public (58 %), 3569 dans le prive (37 %) et 478 dans les etablissements participant au service public hospitalier (PSPH) (5 %). L’estimation du nombre d’anesthesistes–reanimateurs a partir du nombre de postes a necessite une methodologie de redressement de l’enquete pour tenir compte des non-reponses et des activites multiples. Resultats : L’enquete a permis d’estimer qu’environ 8876 medecins exercaient l’anesthesie–reanimation en France au debut de l’annee 1999, dont 216 dans les DOM-TOM. Ce denombrement rejoint celui effectue par le Conseil de l’Ordre des medecins qui publiait un nombre de 8716 anesthesistes-reanimateurs au 1er janvier 1999 en France metropolitaine et de 234 medecins dans les DOM-TOM, soit un effectif total de 8950. La croissance demographique annuelle a chute, de 9 % par an, avant 1989, pour approcher le zero sur l’annee 1999. La masculinisation de la specialite se poursuit avec une proportion qui n’atteint pas plus de 35,7 % de femmes, de meme que le vieillissement, l’âge moyen etant passe de 42,8 ans en 1989 a 45,9 ans en 1999. La pyramide des âges n’est plus celle d’une population croissante, mais d’une population qui vieillit « par le bas ». La densite medicale, de 14,75 anesthesistes–reanimateurs pour 100 000 habitants en 1999, contre 12,9 en 1989, est legerement superieure a la moyenne europeenne, mais la repartition geographique est tres inegale entre le Nord et le Sud, les grandes villes, sieges de CHU et les plus petites, meme si une tendance a l’attenuation des differences s’est faite jour. L’etude des diplomes et qualifications, des modes d’exercice et l’analyse de l’activite professionnelle apportent une evaluation chiffree importante a confronter avec les evolutions demographiques previsibles. Conclusion : L’evolution demographique previsible doit integrer la diminution des entrees dans la specialite, des cessations d’activite mais aussi les evolutions sociologiques liees a la reduction du temps de travail. Les solutions face a une penurie annoncee passent par une reorganisation des structures, une redefinition des tâches et du fonctionnement, sans pour autant faire l’economie d’une correction de trajectoire demographique indispensable.

UNLABELLED Hypotension is common after mivacurium injection in healthy patients. This hemodynamic event had not been investigated in hypertensive patients characterized by more intense hemodynamic instability. In this open-label, multicenter, randomized, and controlled study, we sought to determine whether mean arterial blood pressure (MAP) and heart rate variations were larger in hypertensive versus normotensive patients after a bolus dose of mivacurium injected over 10 or 30 s. After the induction of anesthesia with fentanyl and etomidate, normotensive (n = 149) and hypertensive (n = 57) patients received a single dose of mivacurium 0.2 mg/kg injected over 10 or 30 s by random allocation. Heart rate and MAP were recorded electronically. The incidence of hypotension (defined as a 20% MAP decrease from the control value before mivacurium injection) was 21% and 36% (10-s injection) or 11% and 10% (30-s injection) in the Normotensive and Hypertensive groups, respectively. In Hypertensive patients, the maximum decrease in MAP was significantly greater when mivacurium was injected over 10 s compared with 30 s: 20% vs 11%, respectively (P = 0.002). This difference was not observed in Normotensive patients. Hypotension after rapid (e.g., 10 s) mivacurium injection was more frequent and more pronounced in Hypertensive than in Normotensive patients. IMPLICATIONS When mivacurium (0.2 mg/kg) is injected rapidly (e.g., 10 s) the incidence and the intensity of hypotension are greater in hypertensive patients than in healthy patients.

Resume Objectif : Faire le point sur les connaissances actuelles de l’anesthesie au xenon. Sources des donnees : References obtenues dans la banque de donnees Medline®, les revues generales recentes, la bibliotheque du service et les documents personnels. Selection des travaux : L’ensemble des categories d’articles sur le theme a ete retenu. Extraction des donnees : Les articles ont ete analyses pour l’historique, la biophysique, la pharmacologie, la toxicite et les effets environnementaux et les perspectives d’utilisation. Synthese des donnees : Le xenon, dont les effets anesthesiques sont connus depuis plus de 50 ans, est decrit comme un gaz ayant beaucoup des caracteristiques de l’agent anesthesique ideal. Depourvu de toxicite, neutre sur le plan hemodynamique, il possede une cinetique d’action qui autorise des reveils anesthesiques extremement rapides. Le xenon est reste neanmoins peu utilise en pratique quotidienne du fait de sa rarete entrainant un cout tres eleve. L’interet pour l’anesthesie au xenon est recemment reapparu pour deux raisons : a) la prise de conscience de la toxicite pour l’individu et l’environnement des anesthesiques par inhalation ; b) le developpement de nouveaux systemes d’anesthesie en circuit ferme permettant la recuperation du gaz utilise. La diminution importante de la quantite de xenon necessaire pour la realisation de l’anesthesie rend ainsi son utilisation financierement acceptable. Le xenon pourrait donc trouver sa place dans l’arsenal des produits anesthesiques, dans des indications qui restent a preciser. Une etude multicentrique europeenne de phase III en cours permettra de mieux evaluer l’interet clinique de ce gaz.

UNLABELLED We evaluated the effect of perioperative administration of two doses of morphine for postoperative analgesia after remifentanil-based anesthesia. The prospective, randomized study included 245 patients from 33 centers. All patients were scheduled for abdominal or urological surgery lasting more than 1 h. General anesthesia used remifentanil as the perioperative opioid (1 microg/kg as a bolus then, 0.5 microg/kg as a continuous infusion). A morphine bolus of 0. 15 mg/kg (0.15-mg group) or 0.25 mg/kg (0.25-mg group) was administered 30 min before the end of surgery. In the postanesthesia care unit, pain scores for patients were evaluated by using behavioral pain scores of 1-3, verbal pain scores of 0-3, and visual analog scale scores of 0-10). Postoperative analgesia was obtained by a morphine titration (3 mg every 5 min). Demographic and surgery characteristics were similar in both groups. The delay for first demand of morphine was similar in the 0.15-mg and the 0.25-mg groups (26 [9-60] and 30 [10-60] min, respectively). The frequency of morphine titration was similar in both groups (75% and 66%, respectively). The amount of morphine used in the postanesthesia care unit was smaller in the 0.25-mg group (0.16 [0.0-1.25] vs 0.10 [0.0-0.56] mg/kg; P = 0.008). In the 0.25-mg group, the behavioral pain score was lower at 15 min, the verbal pain score was lower at 60 min (P < 0.001), and similar at 30 min. The visual analog scale pain score at 30 min and 60 min was similar in both groups. The incidence of minor side effects was similar in both groups. However, three cases of postoperative respiratory depression occurred in the 0.25-mg group compared with no cases in the 0.15-mg group. In conclusion, perioperative administration of morphine alone does not provide entirely adequate immediate postoperative pain control after remifentanil-based anesthesia in major surgery. IMPLICATIONS The administration of 0.15 or 0.25 mg/kg perioperative morphine during remifentanil-based anesthesia for major surgery does not preclude additional morphine administration in the postanesthesia care unit. The larger dose of 0.25 mg/kg slightly improves postoperative analgesia; however, it may be responsible for postoperative respiratory depression.

Simulation has become essential in all situations where reality was too risky, too expensive, difficult to manage or inaccessible. In anaesthesia, the low rate of accidents and incidents, as well as the necessity to assure patient's safety, limit education and training in crisis management. The progress in data processing allowed the development of realistic anaesthesia simulators, associating the usual environment of an operating room, and made possible the simulation of a wide range of events. Most clinical incidents, mishaps, or manipulation errors can be simulated. A video recording allows the focus of attention on human factors. We assessed simulators in three European University hospitals. In Brussels as in Leiden, simulation was mainly used for training in crisis management. In Basel, the complete operating room staff participated in sessions, including also surgical simulation and improvement of communication within the team was one of the main goals. Simulation is valuable for residents' training, as well as continuing medical education, in crisis management and a better understanding of human factors. It remains without risk for the patient, with video possibilities improving the repetition of selected cases. However, its use for evaluation seems to be premature, due to the absence of studies demonstrating the validity and reproducibility of the results gained with simulation. Beyond technical limits which are amended continuously, the development of simulation is hindered by the very high cost of equipment and instructors.

In orthotopic liver transplantations (OLT), fresh frozen plasma (FFP) is classically used to normalize coagulation factor concentrations. In this study, 28 OLT were performed without the use of FFP. According to their preoperative factor V (FV) levels, two groups of patients were defined: Group 1 (13 patients, FV10% and60%) and Group 2 (15 patients, FV60%). Spontaneous evolution of coagulation factors, concentration, and bleeding were observed during OLT and up to 48 h after surgery. Total intraoperative bleeding was similar in both groups (3460 +/- 2700 mL and 3470 +/- 2110 mL in Groups 1 and 2, respectively). Levels of clotting factors were not different between groups after the anhepatic stage. The lowest values were noted after reperfusion. Thirty-six hours after surgery, all levels of clotting factors in both groups were more than 50%, with FV level increasing the most rapidly. Hematocrit from the subhepatic drainage liquid was 1.8% and less than 1% at 24 and 48 h, respectively, after surgery. No reintervention for bleeding was necessary. These results suggest that, in OLT, correct hemostasis can be assumed without FFP use when hyperfibrinolysis, platelet count, fibrinogen rate, and hemodynamic status are controlled.

Information about physician anaesthesiologist manpower in the countries of the European Union was collected from questionnaires sent to the delegates representing their respective countries on the European Board of Anaesthesiology. In the countries of the European Union and Switzerland and Norway 40,259 specialist anaesthesiologists are recorded. The number of anaesthesiologists in relation to population varies between as little as 4.4 and 4.6 (Ireland and UK) and as many as 15.6 (Italy), with a mean of 10.8/100,000 inhabitants. There are 11,610 physicians recorded in training in anaesthesiology. The ratio of trainees to specialists in the European Union countries was 28.8/100, varying from as low as 6.5 in France, to as high as 96.7 and 98/100 in Ireland and the UK respectively. These figures indicate a wide difference in the numbers of specialists and trainees between the European countries studied. However, the overall mean figure is close to that reported in the USA (9.2/100,000).

Objective To investigate whether changes in gastric intramucosal pH (pHim) occur during major abdominal surgery, and if so, to determine the relationship between classic global indices of tissue perfusion such as mean arterial blood pressure (MAP), heart rate (HR), central venous pressure (CVP), urine flow (UF) and arterial pH (pHa).

Background: Reports of the direct effects of volatile anesthetics on cardiac myofibrils, studied in various mammalian species but not in humans, have conflicted. To determine whether volatile anesthetics directly affect cardiac contractile proteins in humans, we examined the effects of various equianesthetic doses of halothane (0.46, 0.83, and 1.23 mM, equivalent to 0.75, 1.50, and 2.25%, respectively) and isoflurane (0.63, 1.22, and 1.93 mM, equivalent to 1.15, 2.30, and 3.50%, respectively) on the Ca 2+ sensitivity and maximal force in human skinned cardiac fibers. Methods: Left ventricular muscle strips were obtained from seven patients undergoing cardiac surgery. Sarcolemma was disrupted with EGTA (ethylene glycol bis (β-aminoethyl ether)-N,N,N',N'-tetraacetic acid), and sarcoplasmic reticulum was destroyed with EGTA plus BRlJ 58 detergent. Ca 2+ sensitivity was studied by observing the isometric tension developed by skinned fiber bundles challenged with solutions of increasing Ca 2+ concentrations expressed in pCa (where pCa=-log10[Ca 2+ ]). Maximal force was measured with a pCa 4.8 solution. Results: Both anesthetics shifted the pCa-tension curves toward higher Ca 2+ concentrations and decreased pCa for half-maximal activation in a dose-dependent and reversible fashion (from 5.71 for control to 5.56 and 5.55 for 1 MAC halothane and isoflurane, respectively) without changing the slope of this relationship (Hill coefficient). No differences between agents were observed at equianesthetic concentrations. The two agents also decreased the maximal activated tension in a dose-dependent fashion (-27 and -28% vs. control for 2 MAC halothane and isoflurane, respectively). Conclusions: The current study indicates that halothane and isoflurane decrease Ca 2+ sensitivity and maximal force in human skinned cardiac fibers at 20 o C. If these effects extend to higher temperatures, they may contribute to the negative inotropic effect of these agents

Resume Le dichlorotetrafluoroethane (DCTFE) est un freon qui procure une cryoanesthesie de courte duree. Le but de cette etude prospective est d'evaluer l'analgesie cutanee obtenue par pulverisation de DCTFE avant la mise en place d'un catheter intraveineux chez l'enfant en vue d'une induction anesthesique. Quatre-vingts enfants âges de 5 a 15 ans, hospitalises pour diverses interventions chirurgicales programmees, ont ete inclus dans l'etude. Deux groupes ont ete compares : le groupe des enfants qui beneficiaient d'une cryoanesthesie (âge moyen = 128 ± 32 mois, n = 40), et le groupe temoin des enfants qui ne beneficiaient pas d'une cryoanesthesie, avec realisation d'une ponction veineuse dans les conditions habituelles (âge moyen = 123 ± 30 mois, n = 40). Le DCTFE etait pulverise a 10 centimetres de la zone choisie pendant 10 secondes. La douleur due a la ponction veineuse a ete quantifiee grâce a une echelle visuelle analogique. L'analyse des resultats obtenus met en evidence un effet analgesique significatif du DCTFE (11,5 contre 48 dans le groupe temoin, valeurs medianes). Aucune modification des conditions de ponction veineuse ni aucun effet indesirable majeur n'a ete observe. En conclusion, l'utilisation de DCTFE permet de pratiquer, dans de bonnes conditions d'analgesie, une ponction veineuse chez des enfants âges de 5 a 15 ans.

Acute adrenal insufficiency is an uncommon complication of lung cancer and adrenal metastasis resection. Diagnosis is difficult to establish but an early recognition and treatment may be life-saving. A 55-year-old man underwent right upper lobectomy and adrenalectomy for lung carcinoma with right adrenal metastasis. Anaesthesia was obtained with propofol, alfentanil, atracurium and isoflurane. Blood pressure remained stable throughout surgical procedure and blood loss was about 3,000 ml. Several hours after the end of the procedure which was uneventful the circulator status worsened. The blood pressure was initially controlled with 500 ml of gelatin. External blood loss was about 200 ml. Clinical examination, chest X-ray and ECG were normal. Postoperative laboratory data showed a serum sodium at 134 mmol-1.l-1 and a serum potassium 5.1 mmol.l-1; haemoglobin concentration was 93 g.l-1. Arterial blood gas analysis, with a 5.1.min-1 nasal O2 flow showed a PaO2 at 108 mmHg, a PaCO2 at 30 mmHg and a pH at 7.44. Twelve hours later, a transient cardiac arrest occurred which responded to fluid load, dopamine and dobutamine. Six hours later, the patient went in ventricular fibrillation responding to an external electric countershock. No change in clinical status was noticed, except hyperthermia at 39.5% degrees C. Serum potassium concentration before cardiac arrest was 4.7 mmol-l-1. Main considered diagnoses were septic shock and acute adrenal insufficiency. Antibiotics (imipenem, amikacin and vancomycin) and hormonal treatment (hydrocortisone 200 mg.day-1), after blood samples had been obtained for bacteriological and hormonal examinations. The patient's condition improved dramatically within 48 hours. Shock was under control, dopamine and dobutamine were rapidly discontinued.(ABSTRACT TRUNCATED AT 250 WORDS)

Patient controlled analgesia (PCA) is a drug delivery system aimed to control acute pain using negative feedback technology in a closed loop system in which the patient plays an active role. It overcomes the inadequacies of traditional analgesic protocols due to marked differences in pharmacokinetic and dynamy of analgesis between patients. Moreover, doctors and nurses frequently underprescribe opioids in patients with severe pain for fear of dangerous side-effects. A safe and effective delivery of these drugs on patient demand can be achieved using various delivery systems, modes and dosing parameters. Most devices provide both demand dosing, where a constant predetermined dose is self administered, and constant rate infusion plus demand dosing, where the minimum administration rate is determined by the doctor, but can be supplemented by patient demand. Morphine sulphate remains the drug most commonly used in PCA therapy, but meperidine hydrochloride, alfentanil, nalbuphine and buprenorphine are also sometimes administered. The doctor determines the incremental dose per demand, the lockout interval, and the maximum dose per time unit, possibly also the loading dose and the minimum dose rate when a continuous flow is used. PCA provides improved analgesia, which is immediate and independent of nurse availability. This technique decreases opioid requirements, and the required total amounts are lowered. PCA gives patients both behavioural and decisional control. They can titrate the analgesic dose in such a way as to balance pain relief with the degree of side-effects, the patient is willing to tolerate. Patients often choose less than the available total dose of analgesic. The risks consists in the usual opioid side-effects, mainly respiratory depression. These may be due to mechanical problems, machine failure, or user incidents (misprogramming, or miscalculation of doses). Standards help to ensure consistent care and avoid errors that can occur even with handwritten orders. The principles of demand analgesia are now being investigated using other agents, such as local anaesthetics, and other routes of administration, mainly epidural injection. In most patients, even in children, PCA can replace intramuscular injections, which are the standard route for opioid administration. Today PCA and spinal opioids are the two main methods of analgesia for postoperative pain management.

The aim of this study was to test simulator validity to evaluate the ability of anaesthesia residents to solve two simulated scenarios.Monocentre, prospective, randomized study.Anaesthesia residents.All anaesthesia residents were invited to participate into the study but were free to decline to take part. The authors developed grading forms to evaluate preoperative preparation of anaesthesia room and two simulated scenarios which had been previously validated. All residents were evaluated on the preoperative preparation of anaesthesia room. A randomization was performed to select half of the residents to be tested on one of the simulated scenario. Two experienced anaesthesiologists scored the residents' performance. At the end of the simulated session, residents rated the realism of the scenarios.Among 72 training residents in our institution, 48 participated with 24 beginning and 24 advanced residents. Median scores were similar between beginning (first and second year) and advanced residenced (third and fourth year) for the preoperative preparation of anaesthesia room (17 vs 17 for a maximal score of 25) while scores tended to be higher in advanced residents for simulated scenarios (scenario 1 [34 vs 19 for a maximal score of 55; p = 0.0009], scenario 2 [17 vs 13 for a maximal score of 45; p = 0.58]). However, numerous management errors were observed and some of them did not improve with training. Anaesthesia residents rated the simulator scenarios as realistic.This study suggests that mannequin-based simulator appears as a reliable and valid tool to test the performance of anaesthesia residents during critical situations.

To analyse the results of delayed evaluation of European teaching sessions using a questionnaire provided by the French College of Anaesthesiologists.Open evaluation.Questionnaires were completed 3-6 months after European courses provided in November-December 1999.The types of professional exercise and the medical practice as well as the theme of the courses were pointed out. The evaluation included six items noted from 1 to 10: usefulness of the abstract book, discussion with colleagues, discussion with a manager, decision to modify medical practice, application of that decision, own objectives fulfilled. The global mean score for each item was calculated. Results were compared according to the professional mode of exercise and the theme of the course.5/7 centres provided information. 91/239 questionnaires were returned to the organizers. The participants were working in different structures (private clinic: 25, university hospital: 31, general hospital: 27, PSPH: 8). The main exercise was anaesthesiology (75/77 answers). Means scores affected to the different items were around 7 for all but one of them. The mean score concerning discussion with a manager was significantly decreased to 3.5 +/- 3.2. Decision to modify their own practise was higher in private clinics compared to PSPH. The abstract book was more consulted after the first course (respiration and thorax).3-6 months following the FEEA courses the participants thought to have fulfil their objectives and declared to have modify their medical practise. The lack of discussion with a manager should be analysed.

Fears related to the future of anaesthesia manpower in France have led the French College of Anaesthesiologists (Cfar) and the French Society of Anaesthesia and Intensive Care (Sfar), in scientific partnership with the National Institute for Demographic Studies (Ined), to set-up a national survey among French anaesthetists (MAR) practicing in France, to describe their demographic evolution and to analyse their professional activities.The survey was based on a personal questionnaire, filled by each individual, approved by the National Commission on Informatics and Freedoms (CNIL). The survey was conducted in November 1998, in the 1484 hospitals, public (590) and private (894) where anaesthetics are performed, under the control of local and regional referents.The anaesthesiologists positions count gave a total of 9741 positions shared between 5694 in public practice (58%), 3569 in private practice (37%) and 478 in private hospitals taking part to the national health service-PSPH (5%). The evaluation of the number of anaesthesiologists from the number of positions has made necessary a methodology of rectification of the survey to take in account the lack of response and the multiple sites of activity. The survey allows an evaluation of around 8876 physicians practising anaesthesia and intensive care in France at the beginning of 1999, among them 216 overseas. This census is in concordance with the count made by the Medical Council--Ordre des médecins--which published a number of 8716 anaesthesiologists in France, and 234 overseas, at the 1st January 1999, corresponding to a total of 8950. The annual demographic growth has felt from 9% per year, before 1989, to reach the level zero, in 1999. The masculinisation of the speciality is growing with a proportion of 35.7% of females, as well as ageing, the overage of age increasing from 42.8 in 1989 to 45.9 years in 1999. The pyramid of ages does not correspond to a growing population but to ageing people due to a decrease of the youngest classes. The medical density of 14.75 anaesthesiologists for 100,000 inhabitants in 1999, compared to 12.9 in 1989, is slightly above the European average, but the geographic distribution is very unequal between north and south, the large cities, centre of a university hospital, and the smaller one even if a reduction of differences is observed. The study and the analysis of professional activities bring important data to take in account side of demographic evolution.The demographic evolution must integrate non-only the reduction of the entries in the speciality, of the retirements, but also the sociological evolutions linked to the working time reduction. The solutions face to the promised shortcut of manpower consist of a reorganisation of the structures, a new definition of tasks and managements, without the possibility to avoid and adjustment of the anaesthesiologists population.