Cerebrospinal Fluid Drainage in Thoracic and Thoracoabdominal Endovascular Aortic Repair: A Survey of Current Clinical Practice in European Medical Centers.

OBJECTIVES: The aim of this survey was to evaluate the daily clinical practice in European hospitals regarding the modalities to prevent spinal cord ischemia, with an emphasis on cerebrospinal fluid drainage (CSFD), in patients undergoing thoracic and thoracoabdominal endovascular repair. DESIGN: A 21-item online survey on current practice of spinal cord protection with an emphasis on CSFD. SETTING: Online service using Castor EDC software. PARTICIPANTS: Members of the European Association of Cardiothoracic Anaesthesiology and Intensive Care and European Society of Vascular Surgeons. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred eighty invitations were sent and 104 were used for analysis. A majority of respondents used a written protocol for spinal cord protection during endovascular thoracic and thoracoabdominal repair (81/104 = 78%). The most common protective measures used were CSFD (79/81 = 98%), controlled hypertension (59/81 = 73%), drugs (11/81 = 14%), and hypothermia (6/81 = 7%). The two most common indications for placement of a spinal catheter were the length of the stent (83/104 = 80%) and location of aneurysm (71/104 = 68%). Preventive placement of the spinal drain (96/104) is the most common approach. In the subgroup of high-volume centers, 86% (12/14) of the respondents used a written protocol and all protocols include CSFD. Ninety-two percent (11/12) had included controlled arterial hypertension in the protocol compared with 70% (48/69) of the non-high-volume centers respondents. CONCLUSIONS: The majority of European centers use a written protocol that includes CSFD. This survey showed the similarities and differences in the management of CSFD in patients undergoing endovascular thoracic and thoracoabdominal repair.

Challenges in the Cardiothoracic and Vascular Anesthesia Fellowship Program Since the Coronavirus Disease 2019 (COVID-19) Pandemic: An Electronic Survey on Potential Solutions.

OBJECTIVE: The authors explored the current practice of fellowship training in cardiothoracic and vascular anesthesia and surveyed the acceptability of potential solutions to mitigate the interrupted fellowship training during the severe acute respiratory syndrome coronavirus disease 2019 (COVID-19) pandemic. DESIGN: A prospective electronic questionnaire-based survey. SETTING: The survey was initiated by the Education Committee of the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC). PARTICIPANTS: The study comprised EACTAIC fellows, EACTAIC, and non-EACTAIC subscribers to the EACTAIC newsletter and EACTAIC followers on different social media platforms. INTERVENTIONS: After obtaining the consent of participants, the authors assessed the perioperative management of COVID-19 patients, infrastructural aspects of the workplace, local routines for preoperative testing, the perceived availability of personal protective equipment (PPE), and the impact of COVID-19 on fellowship training. In addition, participants rated suggested solutions by the investigators to cope with the interruption of fellowship training, using a traffic light signal scale. MEASUREMENTS AND MAIN RESULTS: The authors collected 193 responses from 54 countries. Of the respondents, 82.4% reported cancelling or postponing elective cases during the first wave, 89.7% had provided care for COVID-19 patients, 75.1% reported staff in their center being reassigned to work in the intensive care unit (ICU), and 45% perceived a shortage of PPE at their centers. Most respondents reported the termination of local educational activities (79.6%) and fellowship assessments (51.5%) because of the pandemic (although 84% of them reported having time to participate in online teaching), and 83% reported a definitive psychological impact. More than 90% of the respondents chose green and/or yellow traffic lights to rate the importance of the suggested solutions to cope with the interrupted fellowship training during the pandemic. CONCLUSIONS: The COVID-19 pandemic led to the cancellation of elective cases, the deployment of anesthesiologists to ICUs, the involvement of anesthesiologists in perioperative care for COVID-19 patients, and the interruption of educational activities and trainees' assessments. There is some consensus on the suggested solutions for mitigation of the interruption in fellowship training.

European Association of Cardiothoracic Anesthesiology and Intensive Care Pediatric Cardiac Anesthesia Fellowship Curriculum: First Edition.

Pediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers.

European Association of Cardiothoracic and Vascular Anesthesiology and Intensive Care Fellowship Program: The Graduates' Experience.

OBJECTIVES: In 2009, the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC) established a fellowship program to train highly qualified specialists in the field of cardiac anesthesia. For the further development of the program, a survey among graduates was distributed to get information about the individual motivation and career perspectives of fellows. DESIGN: Online survey among graduates of the EACTAIC cardiothoracic and vascular anesthesia (CTVA) fellowship program. SETTING: Twenty-four-item online survey after personal invitation from the EACTAIC office PARTICIPANTS: Forty-nine graduates. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The survey had a response rate of 77%. On average, graduates joined the EACTAIC fellowship program four years after completing their residency program. Participants felt well-prepared by the program regarding their clinical and nonclinical skills. The majority participated in research activities during the fellowship and continued to work in the field of CTVA. Ninety-two percent of the respondents found a job opportunity within a reasonable time after completing the training. CONCLUSIONS: Among the respondents, the survey showed a high satisfactory rate with the received training and good job opportunities after completing the fellowship. Further research should investigate the question of beneficial effects on research activities after completing the fellowship.

Interruption of the European Association of Cardiothoracic Anaesthesiology (EACTA) Fellowship Program During the Coronavirus Disease 2019 Pandemic: Consequences and Solutions.

This article discusses the impact of the COVID-19 pandemic on the EACTA fellowship program. The authors present three points that in their view are important and give cause for concern because they could make it difficult or impossible to achieve the original goals of the fellowship program. Corresponding points are discussed and possible solutions are presented. An implementation in the fellowship curriculum is planned.

European Association of Cardiothoracic Anesthesiology (EACTA) Cardiothoracic and Vascular Anesthesia Fellowship Curriculum: First Edition.

This special article summarizes the design and certification process of the European Association of Cardiothoracic Anesthesiology (EACTA) Cardiothoracic and Vascular Anesthesia (CTVA) Fellowship Program. The CTVA fellowship training includes a two-year curriculum at an EACTA-accredited educational facility. Before fellows are accepted into the program, they must meet a number of requirements, including evidence of a valid license to practice medicine, a specialist degree examination in anesthesiology, and appropriate language skills as required in the host centers. The CVTA Fellowship Program has 2 sequential and complementary levels of training-both with a modular structure that allows for individual planning and also takes into account the differing national healthcare needs and requirements of the 36 countries represented in EACTA. The basic training period focuses on the anesthetic management of patients undergoing cardiac, thoracic, and vascular surgery and related procedures. The advanced training period is intended to deepen and to extend the clinical and nontechnical skills that fellows have acquired during the basic training. The goal of the EACTA fellowship is to produce highly trained and competent perioperative physicians who are able to care for patients undergoing cardiac, thoracic, and vascular anesthesia.

Neostigmine-based reversal of intermediate acting neuromuscular blocking agents to prevent postoperative residual paralysis: A systematic review.

BACKGROUND: Neostigmine is widely used to antagonise residual paralysis. Over the last decades, the benchmark of acceptable neuromuscular recovery has increased progressively to a train-of-four (TOF) ratio of at least 0.9. Raising this benchmark may impact on the efficacy of neostigmine. OBJECTIVE(S): The systematic review evaluates the efficacy of neostigmine to antagonise neuromuscular block to attain a TOF ratio of at least 0.9. DESIGN: We performed a systematic search of the literature from January 1992 to December 2015. DATA SOURCES OR SETTING: PubMed, EMBASE and the Cochrane Controlled Clinical Trials database were searched for randomised controlled human studies. Search was performed without language restrictions, using the following free text terms: 'neostigmine', 'sugammadex', 'edrophonium' or 'pyridostigmine' AND 'neuromuscular block', 'reversal' or 'reverse'. ELIGIBILITY CRITERIA: Studies were accepted for inclusion if they used quantitative neuromuscular monitoring and neostigmine as the reversal agent. Selected trials were checked by two of the authors for data integrity. Trials relevant for inclusion had to report the number of patients included, the type of anaesthetic maintenance, the type of neuromuscular blocking agent used, the reversal agent and dose used, the depth of neuromuscular block when neostigmine was administered and the reversal time (time from injection of neostigmine until a TOF ratio ≥0.9 was attained). RESULTS: 19 trials were eligible for quantitative analysis. In patients with deep residual block [T1 (first twitch height) <10%] 70 µg kg neostigmine was used (five trials, 118 patients), and the mean reversal time was 17.1 min (95% confidence interval (CI) [12.4 to 21.8]). In patients with moderate residual block (T1 10% to <25%) the mean neostigmine dose was 56 µg kg (seven trials, 342 patients), and the mean reversal time was 11.3 min (95% CI [9.2 to 13.4]). In patients with a shallow residual block (T1 ≥ 25%) the mean neostigmine dose was 40 µg kg (13 trials, 535 patients), and the mean reversal time was 8.0 min (95% CI [6.8 to 9.2]). CONCLUSION: Based on the findings of this systematic review, we recommend that the administration of neostigmine be delayed until an advanced degree of prereversal recovery has occurred (i.e. a T1 >25% of baseline), or that a recovery time longer than 15 min be accepted.

Management of neuromuscular blockade in ambulatory patients.

PURPOSE OF REVIEW: The use of neuromuscular blocking agents in ambulatory surgery has been described as a double-edged sword. Muscle relaxants may improve the outcome following endotracheal intubation and could be helpful for the surgeon to some extent. However, these agents might increase the risk of postoperative complications because of residual paralysis. This review should summarize recent developments in neuromuscular blockade, neuromuscular monitoring, and reversal with a special reference to day case surgery. RECENT FINDINGS: The use of neuromuscular blocking agents begs a risk of postoperative muscle weakness and has been associated with adverse respiratory events. From the surgical side, there could be an increased request for a more intense neuromuscular block during laparoscopic surgery. Therefore, the use of quantitative neuromuscular monitoring and selective reversal binding agents may gain more importance in the future. For the reversal of a shallow neuromuscular block, cholinesterase inhibitors are still appropriate. SUMMARY: The management of neuromuscular blocks in day case surgery requests a comprehensive approach that should include an adequate dosing of the muscle relaxant, quantitative objective monitoring, and a sufficient and appropriate reversal.

The effect of different lung-protective strategies in patients during cardiopulmonary bypass: a meta-analysis and semiquantitative review of randomized trials.

OBJECTIVES: A variety of lung-protective techniques, including continuous positive airway pressure and vital capacity maneuvers, have been suggested as beneficial when applied during cardiopulmonary bypass (CPB). To better define the efficacy of these techniques, a systematic review of different ventilation strategies during and after CPB was performed. DESIGN: A systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. SETTING: Hospitals. PARTICIPANTS: Eight hundred fourteen participants of 16 randomized controlled trials. INTERVENTIONS: Continuous positive airway pressure (CPAP), low-volume ventilation, or vital capacity maneuvers (VCMs) during CPB. MEASUREMENTS AND MAIN RESULTS: The methodologic validity of the included trials was scored according to the Oxford scale. Included trials had to report on at least 1 of the following parameters: oxygenation, oxygenation index, alveolar-arterial oxygen difference, or shunt fraction. The average quality of the included trials was as low as 2 on a scale from 1 to 5. The use of CPAP or VCM during CPB led to a significant increase in oxygenation parameters immediately after weaning from CPB, but this effect was not sustainable and did not improve patient outcome. CONCLUSIONS: This meta-analysis showed that the positive effects of the designated techniques are probably short-lived with a questionable impact on the long-term clinical outcome of the treated patients. Based on the available data, it might be impossible to advise an optimal or best-evidence strategy of lung preservation during CPB.

An unanticipated prolonged baseline ACT during cardiac surgery due to factor XII deficiency.

Factor XII (FXII) deficiency is a congenital disorder inherited as an autosomal recessive condition. In his heterozygous form, it is relatively common in the general population. However, a total absence of FXII as seen in homozygous patients, is rare, with an incidence of approximately 1/1,000,000 individuals. Surprisingly, FXII deficiency is rather associated with thromboembolic complications. Patients do not experience a higher risk of surgical bleeding despite a markedly prolonged activated partial thromboplastin time. Given its low incidence in the general population, the finding of an unknown FXII deficiency is rare during cardiac surgery. This unique case describes a patient with an unanticipated prolonged baseline activated clotting time (ACT) during cardiac surgery in which his bleeding history and rotational thromboelastometry tracings lead us to the diagnosis of a FXII deficiency. The finding of a hypocoagulable INTEM tracing and a concurrent normal EXTEM tracing in a sample of a patient with prolonged ACT and adverse anamnestic bleeding history should prompt clinicians to consider a FXII deficiency. It may help clinicians in further perioperative management where there is not enough time to wait for the results of individual coagulation factor testing.

Hypnotic agents for induction of general anesthesia in cesarean section patients: A systematic review and meta-analysis of randomized controlled trials.

STUDY OBJECTIVE: An ideal induction drug for cesarean section (CS) must have quick action, with minimum side effects such as awareness, hemodynamic compromise, and neonatal depression. Thiopentone is frequently used; however, no reliable evidence is available to support its use as a dedicated hypnotic agent in this setting. DESIGN: A systematic review and meta-analysis, using PRISMA methodology, of randomized controlled trials (RCTs), comparing women undergoing CS using thiopentone with those undergoing CS with propofol, ketamine, or benzodiazepines as hypnotic agents. DATA SOURCES: Comprehensive search without language restrictions of MEDLINE, EMBASE, and the Cochrane Controlled Trials Registers until May 2015, with an update in January 2017. Included trials must have reported at least one of the following variables: neonatal arterial or venous umbilical blood gas, maternal systolic blood pressure pre- and post-intubation, or Apgar score. MAIN RESULTS: A total of 911 patients from 18 RCTs were eligible for quantitative analysis. The increase in maternal systolic blood pressure was smaller in patients administered propofol, compared with those administered thiopentone (weighted mean difference [WMD]: -11.52 [-17.60, -5.45]; p = 0.0002). Induction with propofol also resulted in a significantly lower umbilical arterial pO2 (WMD: -0.12 [-0.20, -0.04]; p = 0.004) than induction with thiopentone. A comparison between propofol and thiopentone revealed no significant differences in other umbilical blood gas parameters or in Apgar scores. In contrast, when comparing ketamine with thiopentone, the number of neonates with a lower Apgar score (<7) at 1 and 5 min was significantly higher in the ketamine group than in the thiopentone group (p = 0.004). CONCLUSION: The evidence, based on sparse and relatively old trials, indicates that propofol and thiopentone are equally suited for CS. After 1 and 5 min, ketamine yields lower Apgar scores than thiopentone. Additional well-designed trials are needed to reach firmer conclusions.

Rocuronium is not associated with more vocal cord injuries than succinylcholine after rapid-sequence induction: a randomized, prospective, controlled trial.

Postoperative hoarseness (PH), sore throat (ST), and vocal cord injuries (VCI) are common complications after general anesthesia. Excellent endotracheal intubating conditions are associated with less laryngeal morbidity than good or poor intubating conditions. Thus, we tested the hypothesis that a rapid-sequence induction (RSI) with succinylcholine would lead to less PH and VCI than with rocuronium. In this prospective trial, 160 patients were randomized in 2 groups to receive thiopental 5.0 mg/kg, fentanyl 3.0 microg/kg, succinylcholine 1.0 mg/kg, or rocuronium 0.6 mg/kg during RSI. PH and ST were assessed at 24, 48, and 72 h after surgery, VCI were examined by stroboscopy in those patients who had PH >3 days. Excellent and clinically acceptable intubating conditions were significantly increased in the succinylcholine group compared with the rocuronium group: 57% versus 21% and 89% versus 59%, respectively (P < 0.001). The incidence and severity of PH, and VCI between the succinylcholine and the rocuronium groups did not differ significantly: PH: 50% versus 51% (P = 0.99) and VCI: 3% versus 1% (P = 0.98), respectively. Similar findings were found for ST, 39% versus 28% (P = 0.22), and postoperative myalgia, 39% versus 29% (P = 0.25), respectively. Intubating conditions were significantly better in the succinylcholine group compared with the rocuronium group. The incidence and severity of ST and myalgia were not increased in the patients receiving succinylcholine. However, the rate of PH and VCI was similar to the rocuronium group.

Airway injuries after one-lung ventilation: a comparison between double-lumen tube and endobronchial blocker: a randomized, prospective, controlled trial.

BACKGROUND: Vocal cord injuries, postoperative hoarseness, and sore throat are common complications after general anesthesia. One-lung ventilation can be achieved via two techniques: double-lumen endotracheal tube or endobronchial blocker such as the Arndt blocker. The current study was designed to assess the impact of these techniques for one-lung ventilation on the incidence and severity of postoperative hoarseness, vocal cord lesions, and sore throat. METHODS: In this prospective trial, 60 patients were randomly assigned to two groups. One-lung ventilation was achieved with either an endobronchial blocker (blocker group) or a double-lumen-tube (double-lumen group). Postoperative hoarseness and sore throat were assessed at 24, 48, and 72 h after surgery. Bronchial injuries and vocal cord lesions were examined by bronchoscopy immediately after surgery. RESULTS: In 56 included patients, postoperative hoarseness occurred significantly more frequently in the double-lumen group compared with the blocker group: 44% versus 17%, respectively (P = 0.046). Similar findings were observed for vocal cord lesions: 44% versus 17%, respectively (P = 0.046). The incidence of bronchial injuries was comparable between groups (P = 0.540). Cumulative number of days with hoarseness and sore throat were significantly increased in the double-lumen group compared with the blocker group (P < 0.01). No major complications such as bronchial ruptures were observed. CONCLUSIONS: Clinicians should be aware of an increased incidence of minor airway injuries that may impair patient satisfaction when using a double-lumen tube instead of an endobronchial blocker for one-lung ventilation.