Pathological findings associated with the updated European Society of Cardiology 2022 guidelines for preoperative cardiac testing: an observational cohort modelling study.

BACKGROUND: In 2022, the European Society of Cardiology updated guidelines for preoperative evaluation. The aims of this study were to quantify: (1) the impact of the updated recommendations on the yield of pathological findings compared with the previous guidelines published in 2014; (2) the impact of preoperative B-type natriuretic peptide (NT-proBNP) use for risk estimation on the yield of pathological findings; and (3) the association between 2022 guideline adherence and outcomes. METHODS: This was a secondary analysis of MET-REPAIR, an international, prospective observational cohort study (NCT03016936). Primary endpoints were reduced ejection fraction (EF<40%), stress-induced ischaemia, and major adverse cardiovascular events (MACE). The explanatory variables were class of recommendations for transthoracic echocardiography (TTE), stress imaging, and guideline adherence. We conducted second-order Monte Carlo simulations and multivariable regression. RESULTS: In total, 15,529 patients (39% female, median age 72 [inter-quartile range: 67-78] yr) were included. The 2022 update changed the recommendation for preoperative TTE in 39.7% patients, and for preoperative stress imaging in 12.9% patients. The update resulted in missing 1 EF <40% every 3 fewer conducted TTE, and in 4 additional stress imaging per 1 additionally detected ischaemia events. For cardiac stress testing, four more investigations were performed for every 1 additionally detected ischaemia episodes. Use of NT-proBNP did not improve the yield of pathological findings. Multivariable regression analysis failed to find an association between adherence to the updated guidelines and MACE. CONCLUSIONS: The 2022 update for preoperative cardiac testing resulted in a relevant increase in tests receiving a stronger recommendation. The updated recommendations for TTE did not improve the yield of pathological cardiac testing.

Factors affecting adherence to recommendations on pre-operative cardiac testing: A cohort study.

BACKGROUND: Cardiac risk evaluation prior to noncardiac surgery is fundamental to tailor peri-operative management to patient's estimated risk. Data on the degree of adherence to guidelines in patients at cardiovascular risk in Europe and factors influencing adherence are underexplored. OBJECTIVES: The aim of this analysis was to describe the degree of adherence to [2014 European Society of Cardiology (ESC)/European Society of Anaesthesiology (ESA) guidelines] recommendations on rest echocardiography [transthoracic echocardiography (TTE)] and to stress imaging prior to noncardiac surgery in a large European sample and to assess factors potentially affecting adherence. DESIGN: Secondary analysis of a multicentre, international, prospective cohort study (MET-REPAIR). SETTING: Twenty-five European centres of all levels of care that enrolled patients between 2017 and 2020. PATIENTS: With elevated cardiovascular risk undergoing in-hospital elective, noncardiac surgery. MAIN OUTCOME MEASURES: (Non)adherence to each pre-operative TTE and stress imaging recommendations classified as guideline-adherent, overuse and underuse. We performed descriptive analysis. To explore the impact of patients' sex, age, geographical region, and hospital teaching status, we conducted multivariate multinominal regression analysis. RESULTS: Out of 15 983 patients, 15 529 were analysed (61% men, mean age 72 ±â€Š8 years). Overuse (conduction in spite of class III) and underuse (nonconduction in spite of class I recommendation) for pre-operative TTE amounted to 16.6% (2542/15 344) and 6.6% (1015/15 344), respectively. Stress imaging overuse and underuse amounted to 1.7% (241/14 202) and 0.4% (52/14 202) respectively. Male sex, some age categories and some geographical regions were significantly associated with TTE overuse. Male sex and some regions were also associated with TTE underuse. Age and regions were associated with overuse of stress imaging. Male sex, age, and some regions were associated with stress imaging underuse. CONCLUSION: Adherence to pre-operative stress imaging recommendation was high. In contrast, adherence to TTE recommendations was moderate. Both patients' and geographical factors affected adherence to joint ESC/ESA guidelines. TRIAL REGISTRATION: NCT03016936.

Measurement error of pulse pressure variation.

Dynamic preload parameters are used to guide perioperative fluid management. However, reported cut-off values vary and the presence of a gray zone complicates clinical decision making. Measurement error, intrinsic to the calculation of pulse pressure variation (PPV) has not been studied but could contribute to this level of uncertainty. The purpose of this study was to quantify and compare measurement errors associated with PPV calculations. Hemodynamic data of patients undergoing liver transplantation were extracted from the open-access VitalDatabase. Three algorithms were applied to calculate PPV based on 1 min observation periods. For each method, different durations of sampling periods were assessed. Best Linear Unbiased Prediction was determined as the reference PPV-value for each observation period. A Bayesian model was used to determine bias and precision of each method and to simulate the uncertainty of measured PPV-values. All methods were associated with measurement error. The range of differential and proportional bias were [- 0.04%, 1.64%] and [0.92%, 1.17%] respectively. Heteroscedasticity influenced by sampling period was detected in all methods. This resulted in a predicted range of reference PPV-values for a measured PPV of 12% of [10.2%, 13.9%] and [10.3%, 15.1%] for two selected methods. The predicted range in reference PPV-value changes for a measured absolute change of 1% was [- 1.3%, 3.3%] and [- 1.9%, 4%] for these two methods. We showed that all methods that calculate PPV come with varying degrees of uncertainty. Accounting for bias and precision may have important implications for the interpretation of measured PPV-values or PPV-changes.

Implementation of guidelines in clinical practice; barriers and strategies.

PURPOSE OF REVIEW: Published clinical practice guidelines frequently have difficulties for implementation of the recommendations and adherence in daily clinical practice. The present review summarizes the current knowledge on the barriers encountered when implementing clinical practice guideline and the strategies proposed to address these barriers. RECENT FINDINGS: Studies on strategies for implementation of clinical guidelines are scarce. Evidence indicates that a multidisciplinary policy is necessary in order to address the barriers at various levels. Continuous education and motivation of the stakeholders, together with structural adaptations are key elements in the process. SUMMARY: The barriers for implementation of guidelines involve different levels, including the healthcare system, organizational, societal and cultural specificities, and individual attitudes. All of these should be addressed with policy-driven strategies. Such strategies could include optimization of resources allocations, and establishing well coordinated multidisciplinary networks, finally, future studies should also evaluate the effectiveness of the potential strategies.

Risk assessment for major adverse cardiovascular events after noncardiac surgery using self-reported functional capacity: international prospective cohort study.

BACKGROUND: Guidelines endorse self-reported functional capacity for preoperative cardiovascular assessment, although evidence for its predictive value is inconsistent. We hypothesised that self-reported effort tolerance improves prediction of major adverse cardiovascular events (MACEs) after noncardiac surgery. METHODS: This is an international prospective cohort study (June 2017 to April 2020) in patients undergoing elective noncardiac surgery at elevated cardiovascular risk. Exposures were (i) questionnaire-estimated effort tolerance in metabolic equivalents (METs), (ii) number of floors climbed without resting, (iii) self-perceived cardiopulmonary fitness compared with peers, and (iv) level of regularly performed physical activity. The primary endpoint was in-hospital MACE consisting of cardiovascular mortality, non-fatal cardiac arrest, acute myocardial infarction, stroke, and congestive heart failure requiring transfer to a higher unit of care or resulting in a prolongation of stay on ICU/intermediate care (≥24 h). Mixed-effects logistic regression models were calculated. RESULTS: In this study, 274 (1.8%) of 15 406 patients experienced MACE. Loss of follow-up was 2%. All self-reported functional capacity measures were independently associated with MACE but did not improve discrimination (area under the curve of receiver operating characteristic [ROC AUC]) over an internal clinical risk model (ROC AUCbaseline 0.74 [0.71-0.77], ROC AUCbaseline+4METs 0.74 [0.71-0.77], ROC AUCbaseline+floors climbed 0.75 [0.71-0.78], AUCbaseline+fitnessvspeers 0.74 [0.71-0.77], and AUCbaseline+physical activity 0.75 [0.72-0.78]). CONCLUSIONS: Assessment of self-reported functional capacity expressed in METs or using the other measures assessed here did not improve prognostic accuracy compared with clinical risk factors. Caution is needed in the use of self-reported functional capacity to guide clinical decisions resulting from risk assessment in patients undergoing noncardiac surgery. CLINICAL TRIAL REGISTRATION: NCT03016936.

Continuous Noninvasive Blood Pressure Measurement With "ClearSight" Compared to Standard Intermittent Blood Pressure Measurement in Patients With Peripheral Arterial Disease. Are Potential Differences Influenced by Phenylephrine or Dobutamine?

OBJECTIVES: To investigate the agreement between continuous noninvasive blood pressure measurement with the ClearSight system (cNIBP-CS) and standard intermittent noninvasive blood pressure measurement (iNIBP) in patients with peripheral arterial disease (PAD). Additionally, the influence of vasoactive medication on potential measurement differences was assessed. DESIGN: A secondary analysis of a randomized controlled trial. SETTING: At a university hospital. PARTICIPANTS: Thirty-four patients with PAD undergoing percutaneous transluminal angioplasty of the lower limbs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Continuous noninvasive blood pressures were measured with the "ClearSight" system and compared to standard iNIBPs. Bland-Altman analysis revealed a mean bias of 13 mmHg (±15) between cNIBP-CS and iNIBP, with 95% limits of agreement (LOA) ranging from -17 to 42 mmHg. When comparing both medication groups, a similar mean bias was found for phenylephrine and dobutamine (12 mmHg [±13] and 13 mmHg [±13], respectively). CONCLUSION: In this study, in patients with PAD, cNIBP-CS showed an underestimation of blood pressure compared to iNIBP in phenylephrine- and dobutamine-treated patients. Compared to previous studies, a larger bias and wider 95% LOA were found.

A consensus statement on the meaning, value and utility of training programme outcomes, with specific reference to anaesthesiology: A consensus statement on training programme outcomes.

It is timely and necessary to consider what Postgraduate Medical Training Programme outcomes are, how they are defined and revised over time, and how they can be used to align health professional performance with the healthcare needs of society. This article which addresses those issues, with specific reference to training in anaesthesiology, was prepared using a modified nominal group (or expert panel) approach.

Fatigue amongst anaesthesiology and intensive care trainees in Europe: A matter of concern.

BACKGROUND: There is a growing awareness of the effects of fatigue on trainee wellbeing and health. Trainees in anaesthesiology and intensive care work long hours, switching work schedules frequently with insufficient rest. This may have unwanted long-term effects on mental and physical health and emotional well being, resulting in burnout and affecting patient safety. OBJECTIVE: The study aimed to evaluate the prevalence, severity, causes and effects of work-related fatigue in trainees in anaesthesiology and intensive care. DESIGN: Online survey of trainees in anaesthesiology and intensive care. SETTINGS: A total of 31 countries within Europe were included in the survey. PARTICIPANTS: European anaesthesiology and intensive care trainees who responded to an invitation to take part by electronic mail or through social media. MAIN OUTCOME MEASURES: Responses from a 29-item online survey to assess the realities within European countries with regards to work-related fatigue. RESULTS: One thousand and two hundred trainees from 31 European countries answered the survey demonstrating that an alarming number of trainees were fatigued by their working patterns and night shifts. Trainees reported effects on personal well being, safe commuting and potential for clinical errors. Respondents described a lack of support from hospitals and management for recovery during and after night shifts. CONCLUSION: Fatigue among trainees in anaesthesiology and intensive care has a significant impact on their well being and potentially, on the incidence of clinical errors. Current measures from authorities and hospital management are not sufficient to prevent serious fatigue, and therefore a fatigue risk management system should be considered. Failure to address this issue might lead to a further decline in trainees' wellbeing, their capacity to work in the speciality in the future, and potentially increase patient care errors.

ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation.

BACKGROUND: In recent years, there has been increasing focus on the use of cardiac biomarkers in patients undergoing noncardiac surgery. AIMS: The aim of this focused guideline was to provide updated guidance regarding the pre-, post- and combined pre-and postoperative use of cardiac troponin and B-type natriuretic peptides in adult patients undergoing noncardiac surgery. METHODS: The guidelines were prepared using Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. This included the definition of critical outcomes, a systematic literature search, appraisal of certainty of evidence, evaluation of biomarker measurement in terms of the balance of desirable and undesirable effects including clinical outcomes, resource use, health inequality, stakeholder acceptance, and implementation. The panel differentiated between three different scopes of applications: cardiac biomarkers as prognostic factors, as tools for risk prediction, and for biomarker-enhanced management strategies. RESULTS: In a modified Delphi process, the task force defined 12 critical outcomes. The systematic literature search resulted in over 25,000 hits, of which 115 full-text articles formed the body of evidence for recommendations. The evidence appraisal indicated heterogeneity in the certainty of evidence across critical outcomes. Further, there was relevant gradient in the certainty of evidence across the three scopes of application. Recommendations were issued and if this was not possible due to limited evidence, clinical practice statements were produced. CONCLUSION: The ESAIC focused guidelines provide guidance on the perioperative use of cardiac troponin and B-type natriuretic peptides in patients undergoing noncardiac surgery, for three different scopes of application.

Blood pressure control with phenylephrine or dobutamine: a randomized controlled trial comparing effects on cerebral and paravertebral tissue oxygen saturation measured with near-infrared spectroscopy.

Preserving haemodynamics is expected to positively affect tissue oxygen saturation. We hypothesized that maintaining mean arterial blood pressure (MAP) (using phenylephrine (PE) or dobutamine (Dobu)) would equally affect regional cerebral and paravertebral tissue saturation (rScO2 and rSpvO2, respectively). Thirty-four patients were randomly assigned to receive either PE or Dobu, in order to keep MAP within 20% of the preoperative value. Their effect on haemodynamics, rScO2 and rSpvO2 at thoracic level T3-T4, T9-T10 and lumbar level L1-L2 was calculated at different doses. Drug-induced haemodynamic effects differed between groups (∆MAP: -2%±21 and - 19%±17, ∆CI: -14.6%±14.6 and 24.1%±49.9, ∆HR: -21%±21 and 0%±16 for PE and Dobu, respectively). Both groups exhibited a significant decrease in rScO2, with a more pronounced decline in the PE group (-14.1%±16.1) compared to the Dobu group (-5.9%±10.6). There were no significant changes at the paravertebral level in either group, but a slight but statistically significant difference was detected between the two groups at T3-T4 and L1-L2. Current guidelines advocate maintaining adequate systemic blood pressures to prevent spinal cord ischaemia in specific procedures. However, it is still unknown which circulatory supportive drug is more beneficial for maintaining spinal cord perfusion. Our data indicates that, when used for maintenance of blood pressure within a 20% range of preoperative values, neither phenylephrine nor dobutamine affect paravertebral tissue saturation.

Retailoring training programmes in anaesthesia and intensive care after the coronavirus disease 2019 outbreak.

PURPOSE OF REVIEW: In this review, we want to collect all the adaptations that anaesthesiology training has faced because of the health crisis and social distancing measures resulting from coronavirus 2019 disease (COVID-19). We reviewed new teaching tools launched during the COVID-19 outbreak worldwide and particularly those implemented by the European Society of Anaesthesiology and Intensive Care (ESAIC) and the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC). RECENT FINDINGS: Globally, COVID-19 has interrupted health services and all aspects of training programmes. These unprecedented changes have led to teaching and trainee support innovation tools, focusing on online learning and simulation programmes. Airway management, critical care and regional anaesthesia, have been enhanced during the pandemic, while there were major obstacles in paediatrics, obstetrics and pain medicine. SUMMARY: The COVID-19 pandemic has altered profoundly the functioning of health systems worldwide. Anaesthesiologists and trainees have fought on the front lines of the battle against COVID-19. As a result, training in anaesthesiology during the last 2 years has focused on managing patients in intensive care. New training programmes have been designed to continue teaching residents of this speciality, focusing on e-learning and advanced simulation. It is necessary to present a review describing the impact that this turbulent period has had on the different subsections of anaesthesiology and to review the innovative measures that have been implemented to address these possible deficits in education and training.

Effect of norepinephrine infusion on hepatic blood flow and its interaction with somatostatin: an observational cohort study.

BACKGROUND: Norepinephrine (NE) is a α1-adrenergic mediated vasopressor and a key player in the treatment of perioperative hypotension. Apart from modulating systemic hemodynamics, NE may also affect regional blood flow, such as the hepatic circulation, which contains a wide variety of adrenergic receptors. It may alter regional vascular tonus and hepatic blood flow (HBF) by reducing portal vein flow (PVF) or hepatic arterial flow (HAF). The aim of this study was to assess the effects of NE on HBF. METHODS: Patients scheduled for pancreaticoduodenectomy were included. All patients received standardized anesthetic care using propofol and remifentanil and were hemodynamically stabilized using a goal-directed hemodynamic strategy guided by Pulsioflex™. On surgical indication, somatostatin (SOMATO) was given to reduce pancreatic secretion. HBF measurements were performed using transit-time ultrasound (Medistim™). Baseline hemodynamic and HBF measurements were made after pancreatectomy, at T1. Afterwards, NE infusion was initiated to increase mean arterial pressure (MAP) by 10 - 20% of baseline MAP (T2) and by 20 - 30% of baseline MAP (T3). HBF and hemodynamic measurements were performed simultaneously at these three time-points. RESULTS: A total of 28 patients were analyzed. Administration of NE significantly increased MAP but had no effect on cardiac index. NE infusion reduced total HBF in all patients (p < 0.01) by a reduction HAF (p < 0.01), while the effect on PVF remained unclear. Post-hoc analysis showed that SOMATO-treated patients had a significant lower PVF at baseline (p < 0.05), which did not change during NE infusion. In these patients, reduction of total HBF was primarily related to a reduction of HAF (p < 0.01). In untreated patients, NE infusion reduced total HBF both by a reduction HAF (p < 0.01) and PVF (p < 0.05). CONCLUSION: Administration of NE reduced total HBF, by decreasing HAF, while the effect on PVF remained unclear. SOMATO-treated patients had a lower PVF at baseline, which remained unaffected during NE infusion. In these patients the decrease in total HBF with NE was entirely related to the decrease in HAF. In SOMATO-untreated patients PVF also significantly decreased with NE. TRIAL REGISTRATION: Study protocol EC: 2019/0395. EudraCT n°: 2018-004,139-66 (25 - 03 - 2019). Clin.trail.gov: NCT03965117 (28 - 05 - 2019).

Practice of oxygen use in anesthesiology - a survey of the European Society of Anaesthesiology and Intensive Care.

BACKGROUND: Oxygen is one of the most commonly used drugs by anesthesiologists. The World Health Organization (WHO) gave recommendations regarding perioperative oxygen administration, but the practice of oxygen use in anesthesia, critical emergency, and intensive care medicine remains unclear. METHODS: We conducted an online survey among members of the European Society of Anaesthesiology and Intensive Care (ESAIC). The questionnaire consisted of 46 queries appraising the perioperative period, emergency medicine and in the intensive care, knowledge about current recommendations by the WHO, oxygen toxicity, and devices for supplemental oxygen therapy. RESULTS: Seven hundred ninety-eight ESAIC members (2.1% of all ESAIC members) completed the survey. Most respondents were board-certified and worked in hospitals with > 500 beds. The majority affirmed that they do not use specific protocols for oxygen administration. WHO recommendations are unknown to 42% of respondents, known but not followed by 14%, and known and followed by 24% of them. Respondents prefer inspiratory oxygen fraction (FiO2) ≥80% during induction and emergence from anesthesia, but intraoperatively < 60% for maintenance, and higher FiO2 in patients with diseased than non-diseased lungs. Postoperative oxygen therapy is prescribed more commonly according to peripheral oxygen saturation (SpO2), but shortage of devices still limits monitoring. When monitoring is used, SpO2 ≤ 95% is often targeted. In critical emergency medicine, oxygen is used frequently in patients aged ≥80 years, or presenting with respiratory distress, chronic obstructive pulmonary disease, myocardial infarction, and stroke. In the intensive care unit, oxygen is mostly targeted at 96%, especially in patients with pulmonary diseases. CONCLUSIONS: The current practice of perioperative oxygen therapy among respondents does not follow WHO recommendations or current evidence, and access to postoperative monitoring devices impairs the individualization of oxygen therapy. Further research and additional teaching about use of oxygen are necessary.

Use and safety of aprotinin in routine clinical practice: A European postauthorisation safety study conducted in patients undergoing cardiac surgery.

BACKGROUND: Aprotinin has been used to reduce blood loss and blood product transfusions in patients at high risk of major blood loss during cardiac surgery. Approval by the European Medicines Agency (EMA) for its current indication is limited to patients at high risk of major blood loss undergoing isolated coronary artery bypass graft surgery (iCABG). OBJECTIVE: To report current real-world data on the use and certain endpoints related to the safety of aprotinin in adult patients. DESIGN: The Nordic aprotinin patient registry (NAPaR) received data from 83 European centres in a noninterventional, postauthorisation safety study (PASS) performed at the request of the EMA. SETTING: Cardiac surgical centres committed to enrolling patients in the NAPaR. PATIENTS: Patients receiving aprotinin agreeing to participate. INTERVENTION: The decision to administer aprotinin was made by the treating physicians. MAIN OUTCOME MEASURES: Aprotinin safety endpoints were in-hospital death, thrombo-embolic events (TEEs), specifically stroke, renal impairment, re-exploration for bleeding/tamponade. RESULTS: From 2016 to 2020, 5309 patients (male 71.5%; >75 years 18.9%) were treated with aprotinin; 1363 (25.7%) underwent iCABG and 3946 (74.3%) another procedure, including a surgical treatment for aortic dissection ( n  = 660, 16.7%); 54.5% of patients received the full-dose regimen. In-hospital mortality in iCABG patients was 1.3% (95% CI, 0.66 to 1.84%) vs. 8.3% (7.21 to 8.91%) in non-iCABG patients; incidence of TEEs and postoperative rise in creatinine level greater than 44 µmol l -1 2.3% (1.48 to 3.07%) and 2.7% (1.79 to 3.49%) vs. 7.2% (6.20 to 7.79%) and 15.5% (13.84 to 16.06%); patients undergoing re-exploration for bleeding 1.4% (0.71 to 1.93%) vs. 3.0% (2.39 to 3.44%). Twelve cases of hypersensitivity/anaphylactic reaction (0.2%) were reported as Adverse Drug Reactions. CONCLUSION: The data in the NApaR indicated that in this patient population, at high risk of death or blood loss undergoing cardiac surgery, including complex cardiac surgeries other than iCABG, the incidence of adverse events is in line with data from current literature, where aprotinin was not used. TRIAL REGISTRATION: EU PAS register number: EUPAS11384.

The science behind banning desflurane: A narrative review.

Potent inhaled anaesthetics are halogenated hydrocarbons with a large global warming effect. The use of fluorinated hydrocarbons (most are not anaesthetics) are being restricted but volatile anaesthetics have been exempted from legislation, until now: the EU has formulated a proposal to ban or at least severely restrict the use of desflurane starting January 2026. This narrative review addresses the implications of a politics-driven decision - without prior consultation with major stakeholders, such as the European Society of Anaesthesiology and Intensive Care (ESAIC) - on daily anaesthesia practice and reviews the potential scientific arguments that would support stopping the routine use of desflurane in anaesthetic practice. Of note, banning or severely restricting the use of one anaesthetic agent should not distract the user from sensible interventions like reducing fresh gas flows and developing technology to capture and recycle or destroy the wasted potent inhaled anaesthetics that we will continue to use. We call to join efforts to minimise our professional environmental footprint.

Current trends in anesthetic depth and antinociception monitoring: an international survey.

Current trends in anesthetic depth (i.e., hypnosis) and antinociception monitoring are unclear. We thus aimed to determine contemporary perspectives on monitoring these components of anesthesia during general anesthesia. Participants received and responded anonymously to an internet-based international survey supported by the European Society of Anaesthesiology and Intensive Care. Comparisons, when applicable, were carried out using Chi2 analysis or Fischer's exact test. A total of 564 respondents, predominantly from Europe (80.1%), participated. There was a strong participation from Belgium (11.5%). A majority (70.9%) of anesthetists considered hypnotic monitoring important on most occasions to always. In contrast, a majority (62.6%) never or only occasionally considered antinociception monitoring important. This difference in the perceived importance of anesthetic depth versus antinociception monitoring was significant (p < 0.0001). A majority of respondents (70.1%) believed that guiding hypnosis and antinociception using these monitors would improve patient care on most occasions to always. Nonetheless, a substantial number of participants were unsure if hypnotic (23%) or antinociception (32%) monitoring were recommended and there was a lack of knowledge (58%) of any published algorithms to titrate hypnotic and/or antinociceptive drugs based on the information provided by the monitors. In conclusion, current trends in European academic centers prioritize anesthesia depth over antinociception monitoring. Despite an agreement among respondents that applying strategies that optimize anesthetic depth and antinociception could improve outcome, there remains a lack of knowledge of appropriate algorithms. Future studies and recommendations should focus on clarifying goal-directed anesthetic strategies and determine their impact on perioperative patient outcome.

Incongruous effect of phenylephrine on changes in cerebral blood volume measured by near-infrared spectroscopy (NIRS) indicating extracranial contamination.

We assessed extracranial contamination of the near-infrared spectroscopy (NIRS) signal during administration of phenylephrine. The study was performed with NIRO 200NX which employs both the Modified Beer-Lambert (MBL) method to measure total hemoglobin (tHb, expressed in µM), and Spatially Resolved Spectroscopy (SRS) to measure total hemoglobin content (nTHI, expressed in arbitrary units (a.u.)). SRS tends to not be affected by extracranial blood flow. As vasoconstriction with phenylephrine mainly occurs in the extracranial area, we hypothesized that if NIRS measurements are indeed prone to extracranial contamination, tHb will be more affected by the administration of phenylephrine than nTHI. After ethical committee approval, 20 consenting cardiac surgery patients were included. Phenylephrine was administered whenever clinically indicated and its effect on nTHI and tHb was evaluated. To adjust for the difference in raw scale units, Z-scores were calculated. Data were analyzed with Wilcoxon Signed Ranks Test and the Hodges-Lehmann method. A total of 191 data sets were obtained in 20 patients (10 male, 65 ± 15 years, 77 ± 16 kg, 166 ± 11 cm). The median difference before and after administration of phenylephrine was - 0.006 a.u. [95%CI - 0.010 to - 0.002] (p < 0.001) and - 0.415 µM [95%CI - 0.665 to - 0.205] (p < 0.001) for nTHI and tHb, respectively. The median difference between the Z-scores of nTHI and tHb was - 0.02 [95%CI - 0.04 to - 0.003] (p = 0.03), with a higher variability in the Z-scores of tHb. Phenylephrine induced significant larger changes in MBL values compared to SRS values, indicating that the MBL method might be more prone to extracranial contamination. Trial and clinical registry: Trial registration number: B670201939459, ethical committee number: 2019/0265, date of approval: March 19, 2019.

New algorithm to quantify cardiopulmonary interaction in patients with atrial fibrillation: a proof-of-concept study.

BACKGROUND: Traditional formulas to calculate pulse pressure variation (PPV) cannot be used in patients with atrial fibrillation (AF). We have developed a new algorithm that accounts for arrhythmia-induced pulse pressure changes, allowing us to isolate and quantify ventilation-induced pulse pressure variation (VPPV). The robustness of the algorithm was tested in patients subjected to altered loading conditions. We investigated whether changes in VPPV imposed by passive leg raising (PLR) were proportional to the pre-PLR values. METHODS: Consenting patients with active AF scheduled for an ablation of the pulmonary vein under general anaesthesia and mechanical ventilation were included. Loading conditions were altered by PLR. ECG and invasive pressure data were acquired during 60 s periods before and after PLR. A generalised additive model was constructed for each patient on each observation period. The impact of AF was modelled on the two preceding RR intervals of each beat (RR0 and RR-1). The impact of ventilation and the long-term pulse pressure trends were modelled as separate splines. Ventilation-induced pulse pressure variation was defined as the percentage of the maximal change in pulse pressure during the ventilation cycle. RESULTS: Nine patients were studied. The predictive abilities of the models had a median r2 of 0.92 (inter-quartile range: 89.2-94.2). Pre-PLR VPPV ranged from 0.1% to 27.9%. After PLR, VPPV decreased to 0-11.3% (P<0.014). The relation between the Pre-PLR values and the magnitude of the changes imposed by the PLR was statistically significant (P<0.001). CONCLUSIONS: Our algorithm enables quantification of VPPV in patients with AF with the ability to detect changing loading conditions.

Treating patients across European Union borders: An international survey in light of the coronavirus disease-19 pandemic.

BACKGROUND: In light of the coronavirus disease-2019 (COVID-19) pandemic, how resources are managed and the critically ill are allocated must be reviewed. Although ethical recommendations have been published, strategies for dealing with overcapacity of critical care resources have so far not been addressed. OBJECTIVES: Assess expert opinion for allocation preferences regarding the growing imbalance between supply and demand for medical resources. DESIGN: A 10-item questionnaire was developed and sent to the most prominent members of the European Society of Anaesthesiology and Intensive Care (ESAIC). SETTING: Survey via a web-based platform. PATIENTS: Respondents were members of the National Anaesthesiologists Societies Committee and Council Members of the ESAIC; 74 of 80 (92.5%), responded to the survey. MEASUREMENTS AND MAIN RESULTS: Responses were analysed thematically. The majority of respondents (83.8%), indicated that resources for COVID-19 were available at the time of the survey. Of the representatives of the ESAIC governing bodies, 58.9% favoured an allocation of excess critical care capacity: 69% wished to make them available to supraregional patients, whereas 30.9% preferred to keep the resources available for the local population. Regarding the type of distribution of resources, 35.3% preferred to make critical care available, 32.4% favoured the allocation of medical equipment and 32.4% wished to support both options. The majority (59.5%) supported the implementation of a central European institution to manage such resource allocation. CONCLUSION: Experts in critical care support the allocation of resources from centres with overcapacity. The results indicate the need for centrally administered allocation mechanisms that are not based on ethically disputable triage systems. It seems, therefore, that there is wide acceptance and solidarity among the European anaesthesiological community that local medical and human pressure should be relieved during a pandemic by implementing national and international re-allocation strategies among healthcare providers and healthcare systems.

Human factors affecting intraoperative patient safety.

PURPOSE OF REVIEW: This review addresses the importance of some of the human factors for intraoperative patient safety with particular focus on the active failures. These are the mishaps or sentinel events related to decisons taken and actions performed by the individual at the delivery end of a system. Such sentinel events may greatly affect intraoperative patient safety. RECENT FINDINGS: Intimidating, aggressive and disruptive communication is a cause of adverse staff interaction, which may then represent an important patient safety threat. Also, anaesthesiologist's physical and mental state and limitations may interfere with patient safety. SUMMARY: The concept of physician well being is multidimensional and includes factors related to each physician as an individual as well as to the working environment. Creating optimal safe conditions for patients, therefore, requires actions at both the personal level and the working conditions. Also, initiatives to ban rude and dismissive communication should be implemented in order to further improve intraoperative patient safety.