Documento de consenso de la Sociedad Española de Anestesiología y Reanimación (SEDAR) y la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) para la adquisición de competencias y obtención del diploma acreditativo en el uso de la Ecocardiografía básica en Cuidados Intensivos y Urgencias / Diploma on Basic Echocardiography training and competencies for Intensive Care and Emergency medicine: Consensus document of the Spanish Society of Anesthesiology and Critical Care (SEDAR) and the Spanish Society of Emergency Medicine (SEMES)

El uso de la ecocardiografía a pie de cama se ha convertido en una herramienta indispensable en la monitorización hemodinámica y diagnóstico en el paciente crítico. Su conocimiento, manejo e indicaciones requieren por parte de las sociedades científicas una implicación para una formación reglada que capacite al profesional. El grupo de trabajo de Ecografía Clínica en Cuidados Intensivos de la Sociedad Española de Anestesiología y Reanimación (SEDAR) y el grupo de trabajo de Ecografía Clínica de la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) han desarrollado un documento de consenso en el que se definen los objetivos de aprendizaje y los requisitos necesarios para adquirir las competencias recomendadas en relación con el uso de la Ecocardiografía básica en Cuidados Intensivos y Urgencias, y así poder obtener un diploma acreditativo en Ecocardiografía básica en Cuidados Intensivos y Urgencias. En este documento se definen las competencias y el programa de formación para alcanzar el nivel básico en Ecocardiografía en Cuidados Intensivos y Urgencias, como parte del Diploma Completo en Ecografía en Cuidados Intensivos y Urgencias de la SEDAR y SEMES. La Sociedad Española de Anestesiología y Reanimación (SEDAR), junto con la Sociedad Española de Medicina Interna (SEMI) y la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES), ha desarrollado un documento de consenso determinando las competencias y un programa formativo para la adquisición de un diploma en ecografía (pulmonar, vascular y abdominal) en Cuidados Intensivos y Urgencias. Solo cuando se obtenga el Diploma en Ecocardiografía básica y el Diploma en Ecografía pulmonar, vascular, abdominal de la SEDAR, SEMI y SEMES se podrá adquirir el Diploma Completo de Ecografía en Cuidados Intensivos y Urgencias de la SEDAR y SEMES.(AU)

Cardiac ultrasound has become an essential tool for diagnosis and hemodynamic monitoring in critically ill patients. Scientific societies need to work toward developing a training program that will allow clinicians to acquire competence in performing cardiac ultrasound and understanding its indications. The Clinical Ultrasound for Intensive Care task force of the Spanish Society of Anesthesiology and Critical Care (SEDAR) and the Spanish Society of Emergency Medicine (SEMES) have drawn up this position statement defining the learning objectives and training required to acquire the competencies recommended for basic ultrasound management in the intensive care and emergency setting in order to obtain a diploma in Basic Ultrasound in Intensive Care and Emergency Medicine. This document defines the training program and the competencies needed for basic skills in ultrasound in Intensive Care and Emergency Medicine - part of the Diploma in Ultrasound for Intensive Care and Emergency Medicine awarded by SEDAR/SEMES. The Spanish Society of Anesthesia (SEDAR), Spanish Society of Internal Medicine (SEMI) and Spanish Society of Emergency Medicine (SEMES) have drawn up a position statement determining the competencies and training program for a diploma in ultrasound (lung, abdominal and vascular) in Intensive Care and Emergency Medicine. To obtain the SEDAR/SEMES Diploma in Ultrasound in Intensive Care and Emergency Medicine, clinicians must have completed the SEDAR, SEMI and SEMES Diploma in basic ultrasound and the Diploma in lung, abdominal, and vascular ultrasound.(AU)

Diploma on Basic Echocardiography training and competencies for Intensive Care and Emergency medicine: Consensus document of the Spanish Society of Anesthesiology and Critical Care (SEDAR) and the Spanish Society of Emergency Medicine (SEMES).

Cardiac ultrasound has become an essential tool for diagnosis and hemodynamic monitoring in critically ill patients. Scientific societies need to work toward developing a training program that will allow clinicians to acquire competence in performing cardiac ultrasound and understanding its indications. The Clinical Ultrasound for Intensive Care task force of the Spanish Society of Anesthesiology and Critical Care (SEDAR) and the Spanish Society of Emergency Medicine (SEMES) have drawn up this position statement defining the learning objectives and training required to acquire the competencies recommended for basic ultrasound management in the intensive care and emergency setting in order to obtain a diploma in Basic Ultrasound in Intensive Care and Emergency Medicine. This document defines the training program and the competencies needed for basic skills in ultrasound in Intensive Care and Emergency Medicine-part of the Diploma in Ultrasound for Intensive Care and Emergency Medicine awarded by SEDAR/SEMES. The Spanish Society of Anesthesia (SEDAR), Spanish Society of Internal Medicine (SEMI) and Spanish Society of Emergency Medicine (SEMES) have drawn up a position statement determining the competencies and training program for a diploma in ultrasound (lung, abdominal and vascular) in Intensive Care and Emergency Medicine. To obtain the SEDAR/SEMES Diploma in Ultrasound in Intensive Care and Emergency Medicine, clinicians must have completed the SEDAR, SEMI and SEMES Diploma in basic ultrasound and the Diploma in lung, abdominal, and vascular ultrasound.

Diploma on Ultrasound training and competency for Intensive Care and Emergency Medicine: Consensus document of the Spanish Society of Anesthesia (SEDAR), Spanish Society of Internal Medicine (SEMI) and Spanish Society of Emergency Medicine (SEMES). / Documento de consenso de la Sociedad Española de Anestesiología y Reanimación (SEDAR), Sociedad Española de Medicina Interna (SEMI) y Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) para la definición de competencias mínimas de ecografía en Cuidados Intensivos y Urgencias y la obtención del Diploma acreditativo.

The use of ultrasound as a clinical diagnostic tool and guide of bedside procedures has become an indispensable examination in the acute critically ill patient. The training of professionals in minimum skills of knowledge, management and indications of use of ultrasound required to be defined by the Scientific Societies. The Intensive Care Ultrasound Working Group of the Spanish Society of Anesthesiology and Resuscitation (SEDAR), of the Spanish Society of Internal Medicine (SEMI) and the Spanish Society of Emergency Medicine (SEMES) has developed this consensus document in which the recommended training program and the minimum competencies to be achieved with regard to the use of Ultrasound in Intensive Care, Anesthesia and Emergency medicine are defined. This document defines the training program and the skills to acquire in order to achieve the diploma in lung, abdominal and vascular ultrasound. This document can serve as a guide to define the skills to be acquired in the training programs of residents (MIRs) of specialists working in intensive care, anesthesia, and emergency medicine.

Ethosuximide enantiomers in pregnancy and lactation.

A gas-chromatographic method was used to determine plasma concentrations of the ethosuximide enantiomers during three pregnancies in two epileptic women, in samples from the umbilical cord in one, and in breast milk in two patients. The ratio of the two enantiomers of ethosuximide ranged from 1.00 to 1.36 and was apparently unaffected by pregnancy, passage into breast milk, and transfer over the placenta. Hence, determination of total ethosuximide concentrations appear to be sufficient for therapeutic drug monitoring during pregnancy and lactation.

Hearing impairment related to plasma quinine concentration in healthy volunteers.

1. Hearing impairment was investigated in six healthy volunteers who received oral doses of 5, 10 and 15 mg kg-1 quinine single-blind and in random order. 2. The plasma concentration of quinine was followed for 48 h and the time course was fitted by a linear one compartment pharmacokinetic model. 3. Hearing thresholds were measured by pure tone audiometry. There was a delay between impairment in hearing and change in plasma quinine concentration. Thus the method of effect compartment modelling was applied. 4. The effect on hearing (L), measured as a shift in hearing threshold (dB), was used to estimate the rate constant for elimination of drug from the assumed effect compartment (ke0) and two parameters specifying the effect model (gamma and k). The effect model applied was L = 10 (log k + gamma x log Ce) where Ce is the calculated drug concentration in the effect compartment. This model is a logarithmic transform of a power expression equivalent to the Hill equation at the lower end of the effect range. In all experiments where there was a clear effect on hearing, convergence on a set of parameter estimates occurred, but inter- and intraindividual variability was large. The mean value of ke0 was 3.32 +/- 5.93 h-1 s.d., for gamma it was 1.73 +/- 1.14 s.d. and for k it was 0.59 +/- 0.66 s.d.

Pharmacokinetics of metrifonate and its rearrangement product dichlorvos in whole blood.

Six male healthy volunteers were given single oral doses of 7.5 mg/kg of metrifonate and concentrations of metrifonate and dichlorvos were determined in whole blood using a standardized sampling procedure. Blood was collected in test tubes containing equal volumes of 0.74 M phosphoric acid for the determinations of metrifonate and dichlorvos with gas chromatography and mass spectrometry at different time points for up to 24 hr. Cholinesterases were also determined in blood haemolyzed with water. Metrifonate was quickly absorbed with a Cmax of 50.5 +/- 18.9 mumol/l which was obtained between 0.17 to 1 hr after drug intake. Mean whole blood t1/2, Clo and AUC were 2.07 +/- 0.24 hr, 0.34 +/- 0.06 l/hr/kg and 89.2 +/- 16 mumol.hr/l respectively. The concentrations of dichlorvos closely followed those of metrifonate with a constant ratio of 0.01 to 0.02. The concentrations of metrifonate were detectable for up to 8 hr but those of dichlorvos had fallen below the level of determination by this time. Both plasma and red blood cell cholinesterases were readily inhibited and were still low after 24 hr. None of the volunteers complained of side effects.

Nonstereoselective disposition of ethosuximide in humans.

The total concentration of ethosuximide varied between 80 and 770 mumol/L in plasma samples obtained from 33 patients on long-term treatment with the racemic drug. The ratios between the two enantiomers measured by chiral gas chromatography in the same samples were close to unity (mean +/- SD = 1.06 +/- 0.14; range = 0.76-1.39). This suggests that the disposition of ethosuximide in humans is not stereoselective and that the measurement of total concentrations of ethosuximide is sufficient for therapeutic monitoring.

Determination of metrifonate and dichlorvos in whole blood using gas chromatography and gas chromatography-mass spectrometry.

Analytical methods for determining metrifonate and dichlorvos in whole blood and a sampling procedure suitable for pharmacokinetic studies in man are described. Metrifonate concentrations were determined after chloroform extraction using gas chromatography-nitrogen-phosphorus detection. The within-assay coefficients of variation were 4 and 9% at 19.4 and 0.8 mumol/l (limits of determination), respectively. Dichlorvos was determined using gas chromatography-mass spectrometry of toluene extracts. The within-assay coefficients of variation were 2 and 5% at 225 and 50 nmol/l (limits of determination), respectively. Since both substances are chemically unstable, the blood was collected by dripping it directly from the vein into 0.74 M phosphoric acid.

Diuretic effect and diuretic efficiency after intravenous dosage of frusemide.

1. Frusemide was given intravenously at a dose of 5 mg kg-1 to five healthy volunteers and the diuresis was assessed by frequent spontaneous voiding over 5 h. Urinary volume and contents of sodium, chloride, potassium and frusemide were measured. 2. Diuretic response was evaluated using the sigmoid Emax model and non linear regression of diuresis vs frusemide excretion rate. The time courses of diuresis (pharmacological effect) and diuretic efficiency were constructed from the fitted parameters of the sigmoid Emax model. 3. The frusemide excretion rate associated with maximum efficiency was found, as predicted theoretically, to be less than the excretion rate associated with 50% of maximum effect in four of the five subjects in whom the slope factor was less than 2. 4. The effect over time is dependent both on the instantaneous drug effect but also on its pharmacokinetic properties and mode of administration. An intravenous bolus is the least efficient mode of administration while a controlled input producing a frusemide excretion at maximum efficiency should yield up to a 2.3 times higher diuretic response.

Metrifonate in healthy volunteers: interrelationship between pharmacokinetic properties, cholinesterase inhibition and side-effects.

Metrifonate concentrations in plasma, its inhibition of blood cholinesterase, and side-effects were studied in 16 healthy volunteers who received a single oral dose of 2.5, 5, 7.5 or 15 mg/kg in a randomized double-blind study (4 subjects for each dose). Metrifonate was determined by a gas chromatographic method. Peak plasma levels were reached within 2 hours; the half-life in plasma, oral clearance, and normalized Cmax and AUCs did not differ significantly between the four groups. Plasma cholinesterase (BuchE) was inhibited to low levels in all subjects, while erythrocyte cholinesterase (AchE) was affected in a dose-dependent fashion. The occurrence of side-effects correlated strongly with peak plasma levels but not with maximum AchE inhibition or with increase in salivation. This study shows that the absorption of metrifonate was not significantly different for doses between 2.5 and 15 mg/kg. The plasma levels of this drug correlated with the occurrence of side-effects.

S-mephenytoin hydroxylation phenotypes in a Swedish population determined after coadministration with debrisoquin.

Mephenytoin (100 mg) and debrisoquin (10 mg) were administered orally, both separately and together, to 41 healthy subjects. The ratios between the S and R enantiomers of mephenytoin and between debrisoquin and 4-OH-debrisoquin in urine were determined by use of GC. These ratios were used as measures of drug hydroxylation. There was no change in the phenotypic trait values of the two drugs when they were coadministered. Mephenytoin and debrisoquin then were coadministered to 253 healthy Swedish subjects, before bedtime, and urine samples were collected at periods of 0 to 8, 8 to 24, and 24 to 32 hours after drug administration. In the first sample, seven of the 253 subjects (2.8%, 95% confidence interval 0.8% to 4.8%) had an S/R ratio of greater than 0.8; this indicated that they were poor hydroxylators of S-mephenytoin. In the two consecutive samples, the S/R ratios of mephenytoin did not change in these seven persons, whereas it decreased to less than 0.2 in the third sample in the extensive hydroxylators. As was reported before, there was no relationship between the mephenytoin S/R ratio and the debrisoquin metabolic ratio (rs = 0.01). Coadministration of debrisoquin and mephenytoin before bedtime and urine collection during two consecutive nights allow for an accurate determination of both phenotypes in the population.

Importance of genetic factors in the regulation of diazepam metabolism: relationship to S-mephenytoin, but not debrisoquin, hydroxylation phenotype.

Single oral 10 mg doses of diazepam and demethyldiazepam were given on different occasions to 16 healthy subjects. The subjects included four poor hydroxylators of debrisoquin and three poor hydroxylators of mephenytoin. There was a correlation between the total plasma clearance of diazepam and demethyldiazepam (rs = 0.83; p less than 0.01). There was no relationship between benzodiazepine disposition and debrisoquin hydroxylation. Poor hydroxylators of mephenytoin had less than half the plasma clearance of both diazepam (p = 0.0008) and demethyldiazepam (p = 0.0001) compared with extensive hydroxylators of mephenytoin. The plasma half-lives were longer in poor hydroxylators than they were in extensive hydroxylators of mephenytoin for both diazepam (88.3 +/- SD 17.2 and 40.8 +/- 14.0 hours; p = 0.0002) and demethyldiazepam (127.8 +/- 23.0 and 59.0 +/- 16.8 hours; p = 0.0001). There was no significant difference in volume of distribution of the benzodiazepines between the phenotypes. This study shows that the metabolism of both diazepam (mainly demethylation) and demethyldiazepam (mainly hydroxylation) is related to the mephenytoin, but not to the debrisoquin, hydroxylation phenotype.

Reversible hearing impairment related to quinine blood concentrations in guinea pigs.

The hearing ability was measured in anaesthetised guinea pigs by recording cochlear evoked potentials induced by standardised sound stimulation. The animals were given quinine intravenously and blood samples were withdrawn for assay of quinine. The shift in hearing threshold was closely related to the quinine blood concentration. The effect-concentration relationships were analysed according to the equation L = 10 (log k+a.log (s-b] which can be viewed as a special case of the Hill equation assuming that the stimulation (s) is of very low intensity compared to the stimulus at which half of the maximum response would be obtained and introducing an absolute limit for a stimulus at which no response is obtained.

Amphetamine secretion in breast milk.

The excretion of amphetamine in human breast milk was studied in a nursing mother with narcolepsy, who was treated with 20 mg daily of a racemic preparation of amphetamine. The concentration of amphetamine was 3 and 7 times higher in breast milk than in maternal plasma on the 10th and 42nd days after delivery. Small amounts of amphetamine were found in urine samples from the infant.