Development, Implementation, Evaluation, and Long-Term Outcome of a Program to Increase Student Interest in Anesthesia and Intensive Care Training.

OBJECTIVES: The increasing need for anesthetists has been coupled with a rising number of open training positions. Thus, there is an increased need to attract future anesthetists among students and graduates from medical universities. Using results from a questionnaire, we designed an information and training program to increase interest in anesthesia and intensive care. MATERIALS AND METHODS: With the use of semistructured interviews, medical students were questioned about factors influencing their decision for a speciality. We used the results to design an information and practice program for students and young doctors. This program was held 12 times at different anesthesia departments in different hospitals. Evaluation was obtained through a feedback questionnaire at the end of each sessions and with another questionnaire 2 to 4 years after the program. RESULTS: Feedback showed positive responses concerning utility for practical work, actuality, and relevance for daily practical work. There was a 22.7% response from participants for the follow-up questionnaire. Of these, 87% stated that interest in anesthesia was increased by the program, and 74% underwent practical training in an anesthesia department. Seventeen participants started a speciality training for anesthesia and intensive care medicine. CONCLUSIONS: The design of this practice-oriented program was effective in eliciting, spreading, and increasing interest and attracting students to a medical specialty.

Transvenous, intracardial cardioversion for the treatment of postoperative atrial fibrillation.

Atrial fibrillation (AF) following cardiac surgery is an important factor contributing to postoperative morbidity. Transvenous, intracardial cardioversion (TIC) has been shown to be effective in the treatment of chronic AF, but is an invasive and cost-intensive procedure. However, TIC would definitely be a beneficial approach if recurrence of AF following TIC is low and pharmacological treatment could be avoided. Thus, we hypothesised that TIC would be superior to conventional treatment with amiodarone with respect to the conversion rate and recurrence of AF. We compared TIC and conventional amiodarone therapy in a prospective, randomised and controlled trial in patients who developed AF following cardiac surgery. Twenty-three patients developed AF out of a total of 76 patients who gave written informed consent. Eighteen of these AF patients could be randomised into two equally sized groups to receive either an ALERT pulmonary artery catheter and TIC, or a standard pulmonary artery catheter and treatment with amiodarone. Haemodynamic parameters were registered before intervention to exclude pulmonary hypertension or fluid overload. Rates of cardioversion were compared by a Likelyhood ratio test. Out of the nine ALERT patients, AF in five cases converted to sinus rhythm (SR) with a median of two shocks (6 J). After 24 hours however, only two patients remained in sinus rhythm. On the other hand, six of the nine patients treated with amiodarone were still in SR after 24 hours. Whereas no difference was detectable in the conversion rate, persistence of SR following TIC was low. Thus, TIC without antiarrhythmic treatment is not recommendable for the treatment of postoperative AF.

Descending necrotizing mediastinitis treated with rapid sternotomy followed by vacuum-assisted therapy.

BACKGROUND: Descending necrotizing mediastinitis (DNM) is a life-threatening emergency after oropharyngeal infection. The diagnosis must be established rapidly. DNM is associated with septic shock and respiratory insufficiency. Because mortality rates may be as high as 60%, aggressive surgical treatment is indicated. METHODS: Between December 2001 and December 2005, 5 patients (3 men, 2 women) with DNM, average age of 69 years (range, 24 to 72 years), were treated at our department. Surgical treatment consisted of one or more cervical drainages and drainage of the mediastinum through sternotomy after mediastinitis had been confirmed by computed tomography. The latter investigation also revealed mediastinal abscess and empyema. After radical debridement, a vacuum-assisted closure device was inserted. RESULTS: The outcome was favorable in 4 patients. A 72-year-old woman died of prolonged septic shock and subsequent multiple organ failure. Tracheotomy was performed in all patients to create an airway. The duration of the intensive care unit stay was 51 +/- 24.2 days. CONCLUSIONS: Rapid and extensive cervical and mediastinal debridement is mandatory in patients with DNM. A vacuum-assisted closure device is useful because it promotes tissue approximation and stimulates the ingrowth of granulation tissue.

Recruitment maneuvers during prone positioning in patients with acute respiratory distress syndrome.

OBJECTIVE: To evaluate the interaction of recruitment maneuvers and prone positioning on gas exchange and venous admixture in patients with early extrapulmonary acute respiratory distress syndrome ventilated with high levels of positive end-expiratory pressure. We hypothesized that a sustained inflation performed after 6 hrs of prone positioning would induce sustained improvement in oxygenation (Pao2/Fio2) and venous admixture. DESIGN: Prospective, interventional study. SETTING: Tertiary care, postoperative intensive care unit. PATIENTS: Fifteen patients with early extrapulmonary acute respiratory distress syndrome. INTERVENTIONS: After 6 hrs of prone positioning, a sustained inflation was performed with 50 cm H2O maintained for 30 secs. Data were recorded in supine position, after 6 hrs of prone positioning, at 3, 30, and 180 mins following the sustained inflation. MEASUREMENTS AND MAIN RESULTS: A response to prone positioning was observed in nine of 15 patients leading to an improvement of Pao2/Fio2 (147 +/- 37 torr vs. 225 +/- 77 torr, p = .005) and venous admixture (35.4 +/- 8.3% vs. 28.9 +/- 9.8%, p = .001). Six patients did not respond to prone positioning. Following the sustained inflation, the responders to prone positioning showed a further increase of Pao2/Fio2 and decrease of venous admixture at 3 mins (Pao2/Fio2, 225 +/- 77 torr vs. 368 +/- 90 torr, p = .018; venous admixture, 28.9 +/- 9.8% vs. 18.9 +/- 6.7%, p = .05). In all six nonresponders to prone positioning, an improvement of Pao2/Fio2 and venous admixture occurred at 3 mins following the sustained inflation (128 +/- 18 torr vs. 277 +/- 59 torr, p = .03; venous admixture, 34.2 +/- 6.0% vs. 23.8 +/- 6.3%, p = .05). The beneficial effects of the sustained inflation remained significantly elevated over 3 hrs in responders and nonresponders to prone positioning. CONCLUSION: In patients with early extrapulmonary acute respiratory distress syndrome, a sustained inflation performed after 6 hrs of prone positioning induced further and sustained improvement of oxygenation and venous admixture in both responders and nonresponders to prone positioning.

Recruitment maneuvers after a positive end-expiratory pressure trial do not induce sustained effects in early adult respiratory distress syndrome.

BACKGROUND: Recruitment maneuvers performed in early adult respiratory distress syndrome remain a matter of dispute in patients ventilated with low tidal volumes and high levels of positive end-expiratory pressure (PEEP). In this prospective, randomized controlled study the authors evaluated the impact of recruitment maneuvers after a PEEP trial on oxygenation and venous admixture (Qs/Qt) in patients with early extrapulmonary adult respiratory distress syndrome. METHODS: After a PEEP trial 30 consecutive patients ventilated with low tidal volumes and high levels of PEEP were randomly assigned to either undergo a recruitment maneuver or not. Data were recorded at baseline, 3 min after the recruitment maneuver, and 30 min after baseline. Recruitment maneuvers were performed with a sustained inflation of 50 cm H2O maintained for 30 s. RESULTS: Compared with baseline the ratio of the arterial oxygen partial pressure to the fraction of inspired oxygen (Pao2/Fio2) and Qs/Qt improved significantly at 3 min after the recruitment maneuver (Pao2/Fio2, 139 +/- 46 mm Hg versus 246 +/- 111 mm Hg, P < 0.001; Qs/Qt, 30.8 +/- 5.8% versus 21.5 +/- 9.7%, P < 0.005), but baseline values were reached again within 30 min. No significant differences in Pao2/Fio2 and Qs/Qt were detected between the recruitment maneuver group and the control group at baseline and after 30 min (recruitment maneuver group [n = 15]: Pao2/Fio2, 139 +/- 46 mm Hg versus 138 +/- 39 mm Hg; Qs/Qt, 30.8 +/- 5.8% versus 29.2 +/- 7.4%; control group: [n = 15]: Pao2/Fio2, 145 +/- 33 mm Hg versus 155 +/- 52 mm Hg; Qs/Qt, 30.2 +/- 8.5% versus 28.1 +/- 5.4%). CONCLUSION: In patients with early extrapulmonary adult respiratory distress syndrome who underwent a PEEP trial, recruitment maneuvers failed to induce a sustained improvement of oxygenation and venous admixture.

HLA-DR as a marker for increased risk for systemic inflammation and septic complications after cardiac surgery.

OBJECTIVE: This study investigated the predictive value of a decrease in monocyte HLA-DR expression as an early marker for postoperative SIRS and septic complications. We hypothesized that decreased HLA-DR levels in the first 24 h after cardiac surgery is not related to postoperative SIRS/sepsis. We also compared HLA-DR levels of patients with postoperative complications to those with an uncomplicated course. DESIGN AND SETTING: Prospective observational study in a tertiary care postoperative intensive care unit. PATIENTS: Eighty five consecutive patients undergoing cardiac surgery. MEASUREMENTS AND RESULTS: Expression of HLA-DR on monocytes was analyzed by flow cytometry using a new quantitative and well standardized technique. Arterial blood samples were collected before induction of anesthesia, immediately after admission to the ICU, and on the first postoperative day. Postoperative HLA-DR expression was significantly decreased in all patients. There were no significant differences in HLA-DR expression during the first 24 h after surgery in patients with uncomplicated course and those developing SIRS or septic complications. CONCLUSIONS: In patients undergoing cardiac surgery the monitoring of pre- and immediate postoperative HLA-DR levels during the first 24 h does not help to predict increased risk for postoperative SIRS/sepsis or infectious complications.

Automatic tube compensation in patients after cardiac surgery: effects on oxygen consumption and breathing pattern.

OBJECTIVE: To evaluate patients without prior pulmonary disease after cardiac surgery and to determine whether resistive unloading by automatic tube compensation, pressure support ventilation, and continuous positive airway pressure has different effects on oxygen consumption, breathing pattern, gas exchange, and hemodynamics. DESIGN: Prospective, randomized, controlled study. SETTING: Tertiary care, postoperative intensive care unit. PATIENTS: Twenty-one patients scheduled for open heart coronary artery bypass graft surgery. INTERVENTIONS: Each patient was ventilated with all three modes in random order. MEASUREMENTS AND MAIN RESULTS: Patients were ventilated in three modes, each applied for 30 mins according to computer-generated randomization: pressure support ventilation with 5 cm H2O, continuous positive airway pressure, and automatic tube compensation. Oxygen consumption was calculated by means of indirect calorimetry. The hypnotic state of the patients was monitored by Bispectral Index. For hemodynamic measurements, a fiberoptic pulmonary artery catheter was inserted. The main finding of our study was that oxygen consumption and breathing pattern (tidal volume and respiratory rate) did not differ significantly during automatic tube compensation and pressure support ventilation compared with continuous positive airway pressure (oxygen consumption, 170 +/- 29 vs. 170 +/- 26 vs. 174 +/- 29 mL.min.m, respectively; tidal volume, 466 +/- 132 vs. 484 +/- 125 vs. 470 +/- 119 mL, respectively; respiratory rate, 16 +/- 4 vs. 15 +/- 4 vs. 16 +/- 4 breaths/min, respectively). Automatic tube compensation and pressure support ventilation had no clinical effects on gas exchange and hemodynamic variables compared with continuous positive airway pressure. None of the variables differed significantly during the three ventilatory settings. CONCLUSION: In postoperative tracheally intubated patients with normal ventilatory demand, automatic tube compensation and pressure support ventilation with 5 cm H2O lead to identical oxygen consumption, breathing patterns, gas exchange, and hemodynamics. We, therefore, suggest that this group of patients does not need any additional positive pressure support from the ventilator to overcome the additional work of breathing imposed by the endotracheal tube during the weaning phase from mechanical ventilation.