The main concerns of European anaesthesiology postgraduate trainees: A European survey

This is the first study intended to identify the European anaesthesiology trainees' main concerns, to initiate a process of improvement of the training in anaesthesiology by the European Society of Anaesthesiology (ESA). The authors developed an electronic survey which addressed seven different concerns: autonomy transition, technical skills, exchange programs, residency costs, residency workload, employment prospects and educational contents/preparation for the European Diploma in Anaesthesiology and Intensive Care (EDAIC). The survey was disseminated by email to all anaesthesiology trainees registered in ESA and all European National Societies were asked to distribute the survey to their graduating trainees. 665 trainees initiated the survey with a completion rate of 54.6%. The trainees' main concerns were in descending order: educational contents, residency costs, employment prospects, residency workload, exchange programs, technical skills and autonomy transition. This report analyzes the three main concerns in more detail. 68% of respondents were unaware of the existence of the ESA e-learning platform. Other means to improve the preparation for the EDAIC such as a multiple-choice questions book should be developed. The main reason for not becoming an ESA Trainee member was the associated cost and 68% of respondents gave up activities or opportunities during their residency due to economic constraints; 56% of respondents considered emigrating for economic reasons and 28% elected Northern/Central Europe. The results of the present survey may provide additional background information for the development of specific improvements in strategies for training in anaesthesiology. (c) 2018 Elsevier Ltd. All rights reserved

Bronchodilation induced by PGE2 is impaired in Group-III pulmonary hypertension

BACKGROUND AND PURPOSE: In patients with pulmonary hypertension (PH) associated with lung disease and/or hypoxia (Group III), a reduction of pulmonary vascular tone and tissue hypoxia are considered therapeutically beneficial. Prostaglandin (PG) E2 and PGI2 induce potent relaxation of human bronchi from non-PH (control) patients via EP4 and IP receptors, respectively. However, the effects of PGE2 /PGI2 and their mimetics on human bronchi from PH-patients are unknown. Our aim was to compare the relaxant effects of several PGI2 -mimetics approved for treating PH-Group I with several PGE2 -mimetics in bronchial preparations derived from PH-Group III and control patients. EXPERIMENTAL APPROACH: Using an organ bath system, the tone of bronchial muscle was investigated in tissue from either control or PH-Group III patients. Expression of prostanoid receptors were analyzed by Western blot and real-time PCR and endogenous PGE2 , PGI2 and cAMP levels were determined by ELISA. KEY RESULTS: Maximal relaxations induced by different EP4 agonists (PGE2 , L-902688, ONO-AE1-329) were significantly decreased in human bronchi from PH-patients versus controls. In contrast, the maximal relaxations produced by PGI2 -mimetics (iloprost, treprostinil, beraprost) were similar for both groups of patients. Both EP4 and IP receptor protein and mRNA expressions were significantly lower in human bronchi from PH-patients. cAMP levels significantly correlated with PGI2 but not with PGE2 levels. CONCLUSION AND IMPLICATIONS: This study shows that PGI2 -mimetics have preserved maximal bronchodilation in PH-Group III patients. The decreased bronchodilation induced by EP4 agonists suggests that restoration of EP4 expression in airways of PH-patients with respiratory diseases could bring additional therapeutic benefit

Lepirudin as an alternative to "heparin allergy" during cardiopulmonary bypass

A treatment strategy of a difficult and unusual problem is presented. We are reporting a case of a patient who had a documented allergy to heparin and required Cardiac surgery for an ASD closure. The anticoagulation regime used during cardiopulmonary bypass was lepirudin based

Comfort and patient-centred care without excessive sedation:the eCASH concept

We propose an integrated and adaptable approach to improve patient care and clinical outcomes through analgesia and light sedation, initiated early during an episode of critical illness and as a priority of care. This strategy, which may be regarded as an evolution of the Pain, Agitation and Delirium guidelines, is conveyed in the mnemonic eCASH—early Comfort using Analgesia, minimal Sedatives and maximal Humane care. eCASH aims to establish optimal patient comfort with minimal sedation as the default presumption for intensive care unit (ICU) patients in the absence of recognised medical requirements for deeper sedation. Effective pain relief is the first priority for implementation of eCASH: we advocate flexible multimodal analgesia designed to minimise use of opioids. Sedation is secondary to pain relief and where possible should be based on agents that can be titrated to a prespecified target level that is subject to regular review and adjustment; routine use of benzodiazepines should be minimised. From the outset, the objective of sedation strategy is to eliminate the use of sedatives at the earliest medically justifiable opportunity. Effective analgesia and minimal sedation contribute to the larger aims of eCASH by facilitating promotion of sleep, early mobilization strategies and improved communication of patients with staff and relatives, all of which may be expected to assist rehabilitation and avoid isolation, confusion and possible long-term psychological complications of an ICU stay. eCASH represents a new paradigm for patient-centred care in the ICU. Some organizational challenges to the implementation of eCASH are identified.SCOPUS: re.jinfo:eu-repo/semantics/publishe

[Is NO becoming a word from the heart?]

Nitric oxide (NO) is involved in,the endothelium-dependent relaxation of vascular smooth muscle. This messenger may also play a role in the regulation of cardiac contractility. Indeed, various targets for NO have been described in cardiac myocytes. Stimulation of the heterodimeric guanylyl cyclase by NO leads to the cGMP-dependent modulation of phosphodiesterases, cGMP-dependent protein kinase, and ionic channels. In addition, NO could regulate intracellular calcium homeostasis and mitochondrial respiration in a cyclic GMP-independent manner. In light of this variety of effects in the cardiac myocytes, it is not surprising that NO is often, but not always, found to modulate cardiac contractility. The endogenous production of NO, by constitutive isoforms of nitric oxide synthase (NOS) seems to participate in various aspects of cardiac homeostasis. For instance, myocardial NO-synthases can control the efficiency of the sympathetic and parasympathetic systems in the heart. The relevance of the different sources of NO in the heart is the object of ongoing research. Yet, NO may be viewed as a paracrine factor (when produced by the endothelium) and/or as an autocrine factor (when produced by the myocyte). The expression of an inducible isoform of NOS (iNOS) in various cardiac cell types, was shown to occur in both experimental and human cardiac pathologies, However, while the effects of iNOS induction have been described in detail in vitro, the pathophysiological consequences of iNOS induction in vivo are not fully understood. Thus, it is still unclear whether iNOS activity in the heart should be considered as beneficial or deleterious

Does the use of a volatile anesthetic regimen attenuate the incidence of cardiac events after vascular surgery?

OBJECTIVE: To compare the effects of a volatile anesthetic to a non-volatile anesthetic regimen on the incidence of postoperative cardiac events, including the postoperative elevation of troponin I values after arterial vascular surgery in high risk patients. DESIGN: Retrospective analysis of data of a phase II study that compared the Na+/H+ exchanger type II inhibitor, zoniporide to placebo on the occurrence of cardiac events. SETTING: Multicenter study conducted in 105 sites throughout the United States, South America, Europe and Asia. PARTICIPANTS: 784 subjects scheduled for urgent or elective major arterial vascular surgery and a history of at least 3 of the following: age > or = 65 years, hypertension, documented stroke or transient ischemic attack, previous myocardial infarction, active angina pectoris diabetes mellitus, congestive heart failure, or symptomatic cardiac arrhythmia. INTERVENTIONS: Type of anesthesia was retrospectively retrieved from the database and patients were subdivided in two groups: inhalational (group A) vs non-inhalational anesthetic regimen (group B). Incidence of postoperative cardiac events was compared between the two groups. MEASUREMENTS AND MAIN RESULTS: The incidence of postoperative cardiac events was not different between the two groups. Maximum postoperative troponin I levels was not different between the two groups in the total population and in the patients undergoing peripheral arterial surgery. In patients undergoing aortic surgery the incidence of elevated troponin levels higher than 1.5 and 4 ng x mL(-1) tended to be lower in group A than in group B in the aortic surgery (28% vs 18% and 30% vs 20% respectively) but this difference did not reach statistical significance. CONCLUSION: The results of this hypothesis-generating study suggest that potential beneficial effects on extent of postoperative myocardial damage in high risk patients undergoing arterial surgery will probably be more apparent in abdominal aortic surgery than in peripheral vascular surgery. Further sufficiently powered studies using a standardized protocol should now be performed to definitively address this questio