Petr Stourac, Brno- 10 x participant of ESA
Every year, the representatives of individual national societies and members of the European Society of Anaesthesiology (ESA) begin Euroanaesthesia with an assessment of the past period and an intense discussion on the future of this society of international importance.
Furthermore, ESA was presented in figures, 9748 active members is a very good membership base. Yet further discussions were dominated by the theme of raising the numbers of ESA members. Although it may be gratifying at the glance that the Czech Republic has risen to the 17 th place among European countries by number of ESA members, the real number of fewer than 50 members is rather a sad picture. The cornerstone of the discussion was the low-income countries and representatives of the so-called Trainees, doctors in preparation process for attestation. It was interesting to compare the salaries of these young doctors in the individual member states, and the traditional western-eastern European gradient was, in some cases, clearly denied.
This was followed by a summary of the upcoming congress in statistics. There were supposed to be 431 speakers at the congress, 7 congress pre courses, 35 workshops and 135 lecture blocks.
Some new presentation formats (Agora, Late Breaking Session…) have been presented. All these facts brought more than 5,500 participants to the lecture halls, and the congress ranked among the successful ones.
The Educational Commission reported on EDAIC diploma activities. In 2018, completed 2524 candidates Part I, with a success rate of 57.6%. The test took place in 71 centres. Part II took place in 15 centres with a participation of 780 candidates with a success rate of 56.8%.
And if you would asked me, whether Wiener Schnitzel at Figlmuller or Tafelspitz at Plachutta? ... I choose the latter.
The other opportunities to meet will be the October ESA Focus Meeting in Rome, Italy, focusing on mother and child perioperative themes, followed by a meeting in Barcelona in a year.
Josef Klučka, Brno
The first day of the Euroanaesthesia Congress was promissing some truly interesting lectures. To begin with, I was impressed by the symposium organized with the support of Anesthesia and Analgesia, with the title "Bloody mess: transfusion and coagulation". In his first lecture, Professor Payen (France, Grenoble) presented his opinion about bleeding in craniotrauma (TBI) patients. He pointed out the significant risk factors for TBI patient´s negative outcome, namely hypotension, anaemia and coagulopathy. Hypotension represents a risk when the systolic pressure drops below 110 mmHg for 5 minutes or more. Anaemia alone does not lead to a worse outcome if the adequate tissue oxygenation of the brain is maintained. Coagulopathy is present in 10-50% of patients with TBI. Risk factors for coagulopathy are age over 50 and higher shock index. In the management of a patient with TBI, it is important to aim for a normalization of hemodynamics (noradrenaline + crystalloids), normoventilation and an aggressive correction of coagulopathy (platelet transfusion, fibrinogen, frozen plasma, reversal of drug-induced coagulopathy). Professor Pittet (USA, Birmingham) gave a lecture on coagulopathy in surgical bleeding. Traumatic coagulopathy is a complex condition, formed by abnormal and insufficient thrombin formation and protein C activation, along with hypoperfusion, catecholamine release and subsequent fibrinolysis. In patients with trauma-induced coagulopathy, 2 phenotypes can be found - hyperfibrinolysis and hypercoagulopathy. Haemostatic resuscitation is based on the patient's initial management needs including local treatment, permissive hypotension, eventually pre-hospital blood transfusion, administration of antifibrinolytics, consideration of whole blood administration (military conditions). Another effort should be aimed at minimizing the dose of crystalloids. Professor Butwick (USA, Stanford) gave a lecture on obstetric bleeding - update. The first option is to minimize a post delivery/ caesarean section bleeding by the administration of the uterotonics. The first choice is oxytocin, but methylergometrine is the second line treatment in the absence of a satisfactory response. The massive transfusion protocol (6ERD: 4FFP: 1TAD) can be applied in obstetrics, or targeted management can be selected according to viscoelastic methods. Although it is important to maintain fibrinogen levels above 2g / l, the fall below a given value in obstetrics is rather rare. The tranexamic acid has its place in life-threatening bleeding in the delivery room.
The next lectures I visited was devoted to regional anesthesia. Specifically, whether to use preferentially catheter techniques, or the possibility of applying adjuvant drugs that extend single-shot blockade. Lectures were designed as pro versus con debate. In the first lecture, Prof. Albrecht (Switzerland, Lausanne) advocated a single shot blockade + application of adjuvant drugs. He pointed out that catheter methods do not lead to deep enough analgesia, and up to 45% of patients show VAS greater than 3. In addition to the lack of effect, catheter methods are associated with more time and personnel demands, the possibility of catheter migration, failure, withdrawal, leakage, or pump failure. Other side effects include a higher risk of systemic toxicity, risk of infection, abscess, or nerve damage that is significantly lower with single shot blockade (0.04% versus 0.7-4%). As for the possible adjuvants, dexmedetomidine, which can be administered perineurally (50-60µg), appears to be the most effective. It can be administrated only in the form of a preservative-free solution and in a separate syringe from local anesthetic. The procedure remains off-label and it extends the single shot block effect up to 8 hours. Another possibility, with comparable effect, is intravenous administration of dexamethasone 4mg. An interesting option is a combination of intravenous administration of 2 potential adjuvans dexamethasone + dexmedetomidine.
Dr. Johnston (United Kingdom, Belfast) highlighted the benefits of catheter techniques, including a shorter hospital stay of up to 15-24 hours. Faster and more effective rehabilitation and up to 9 times higher patient satisfaction rate with established catheter technique, which reduce VAS by 0-2 points during the first 48 hours after surgery and significantly increase patient satisfaction...
Marek Kovář, Brno
When I have found out that ESA 2019 will be in Vienna, I have immediately told myself that I could use the trainee status and travel to the austrian capital. When I was checking the program, an ultrasound workshop for anaesthesiology and intensive medicine cought my eye, and I have decided about my Saturday's program.
I have appreciated some USabcd courses, that were sent to us before the beginning of the ESA ultracound course itself. In this way, I could have prepared my theoretical knowledge in advance. The topics were indeed extensive from TTE (FATE protocol), TEE, FAST protocol in traumatology, to POCUS devoted to airways examination, gastric content determination. These theoretical courses were concluded with a test to summarize the knowledge gained through the test itself and leaving the possibility to sent feedback to the authors.
The ESA course itself, was based just on "hand-on" experience we added the screening of renal blood supply and lung to the above mentioned. The whole afternoon was full of hypo- / hyperechoic findings and Doppler curves and it was completely exhausting. I have to admit that these 4 hours were the most beneficial from ESA 2019 for me.
The second experience was a lecture, or the series of lectures, covering the topic Fluid, blood and oxygen: Friend or foes? Dr. Thomas Scheeren (Groningen, Netherlands), demonstrated the potential threats of administration, as well as restriction of fluid, blood, and oxygenation therapies. Therefore, the physician's goal is to consider the lowest risk (attempting to administer the optimum dose) on the U-curve, and to individualize the therapy to each patient needs. At the end of the lecture, he recalled Paracels' claim that poison from the drug is only distinguished by the administered amount.
Martina Klincová, Brno
This year's Euroanesthesia did not disappoint. A huge number of anaesthesiologists from all around the world arrived with the same intention- to learn something new, to gain a different perspective, to reassess existing practices ... and not to burn out. Especially from the perspective of a young anaesthetist, I find this incredibly motivating. The ESA Trainees Committee did a great job and this year's program for young anaesthetists was very rich and practically orientated. I hope that thanks to the Trainees Travel Fellowships, the number of young doctors from the Czech Republic will increase every year, so they can experience this atmosphere on their own. I think that the only negative point is the inability to be in more places at once because it is very difficult to choose from a number of lectures.
From the specific information I choose the recommended procedure from the symposium organized by the European Group for Malignant Hyperthermia (EMHG) on the preparation of an anaesthetic machine for Trigger-Free Anaesthesia in a patient at risk of malignant hyperthermia. We have three options. 1.To use a device that has never come to contact with inhalation anaesthetics’; 2. To"wash" the device with 100% oxygen for the necessary amount of time given by the manufacturer (usually 60-90 min); 3.To use special activated carbon filters that will capture the particles of inhalation anaesthetics. In all cases, it is important to use a new circuit, filters, carbon dioxide absorber and NOT TO put the machine in STAND-BY mode before anaesthesia. The concentration of the inhalation anaesthetic released from the inner parts of the machine may increase!
Lucie Štětková, Brno
I would like to thank for the opportunity to attend the largest European anaesthesia congress. I have visited many excellent lectures and discussions. I was impressed the most with the workshop organized by the ESA Trainees Committee. Especially an interactive lecture from Karin Becke, targeted at solving the most common complications in paediatric anaesthesia. It was based on an algorithm of bronchospasm and laryngospasm in children. Each step of the diagnosis and treatment was discussed and explained. The subsequent discussion also mentioned the possibility of using topic lidocaine prior to the extubation in patients with increased respiratory irritation and subsequent extubation during deep sedation.
The lectures on "Best practice of paediatric blood management" were also informative. Dr.Goodie from Boston summarizes the experience and news in bleeding management of non-cardiac paediatric patients. According to the data of the patients undergoing craniosynostosis and spinal scoliosis operation, it is beneficial to administer the tranexamic acid in as a bolus followed by continuous administration. Dr. Machott arranged the possibilities of examination by viscoelastic methods, their advantages and limitations. In the "Trauma - State of the art" series of lectures, the risk of dilutional coagulopathy was emphasized regarding the administration of a disproportionate amount of crystalloid solutions and it has also included the recommendation on timing the blood transfusion and considering a control and early treatment of any coagulation disorder.
During all three days, there were opportunities to experience practical skills at corporate exhibitors' stands, such as the use of various types of video laryngoscopes on neonatal, paediatric and adult models, new types of low resistance syringes for epidural anaesthesia, or even virtual reality to calm the patient.
Eva Klabusayová, Brno
ESA 2019 Congress was begun with an interactive lecture of Professor Pablo Pelosi, who asked us whether anaesthesiology is a sort of lifestyle. He wondered how our profession changes us. According to the vote from the audience, most of us agreed that since working as anaesthesiologists, they had a totally different perception of life and death. In addition to the life changes in the perception and experiencing difficult life situations, our profession is very demanding and many anaesthesiologists sooner or later burnout. But I am sure that after Professor Pelosi´s positive motivational speech, this will avoid us for at least some time. At the end of the lecture, he invited five of his colleagues from all over the world to the stage. Each of them was telling their special stories about how anaesthesiology changed their lives. A common thought of all stories was summarized by one of them, Prof. Idit Matot from Tel Aviv:
"If you save a life, you are a hero. If you save more lives, you’re anaesthesiologist."
On the first day of the congress, there was also a very interesting lecture series on the topic of controversy in paediatric anaesthesia. The first two lectures were focused on adolescents and obese children. Paediatric obesity is more difficult to quantify than it is in adult patients. In the obese children, we should be cautious about drug dosage and it is recommended to use a specific tables. In obese children, there are more frequent complications due to the patient's underlying condition (metabolic syndrome, hypertension, obstructive sleep apnea syndrome, etc.), but also anaesthetic complications, especially the higher risk of difficulty securing the airways. We should not forget the ramping position in the introduction to the general anaesthesia, a sufficient preoxygenation as well as apnea oxygenation. Bronchospasm is also more common, so the early use of muscle relaxation should be considered. The last lecture was devoted to preoperative fasting in paediatric patients. In most paediatric units, the practice is that a solid diet and milk can be consumed for up to of 6 hours before surgery. However, numerous studies have not shown a link between fasting time and gastric content aspiration at the beginning of general anaesthesia, so there is no clear consensus on a well-defined fasting time interval. In case of doubt about the patient's gastric emptiness, it is recommended to perform an ultrasound examination to assess the stomach filling. Regarding milk, it has been found that gastric emptying time does not depend so much on the amount of milk but on the calorie content. For clear liquids, it is recommended fasting for at least one hour before the induction to general anaesthesia.
Olga Smékalová, Plzeň
The monitoring of basic vital functions for anaesthesiologists is a daily routine. I was interested in a lecture by prof. Bernd Saugel from Hamburg covering the topic of Perioperative Blood Pressure Management: what is optimum blood pressure? Clinical studies suggest that with MAP values <55 mmHg for 5 minutes, he 30-day mortality increases in patients undergoing non-cardiac surgery. Intraoperative hypotension is also an important factor in the development of post-operative complications such as AKI, myocardial infarction, stroke and delirium. In addition, hypotension may not only occur in the operating room - after induction into general anaesthesia or intraoperatively, but also post-operatively in the ward.
The question is what blood pressure can be considered hypotension in individual patients and whether we will go with a preinduction value of blood pressure with a cut off of 65 mmHg.
In the perioperative medicine, this is considered a "hot topic" and the current research subject of prof. Saugel is an individualized approach to the blood pressure management. In his work, he determined the baseline blood pressure by preoperative assessment, with 1/3 of the patients having the lowest night value below 65 mmHg and could be tolerating even lower values perioperatively, but 2/3 of the patients had higher and they would be profiting from higher perioperative blood pressure. His article also appeared on Monday´s Andreas Hoeft's selection of the most important works in anaesthesiology of the past year.
Martina Kosinová, Brno
This year, I decided to attend lectures devoted to regional anaesthesia, which is part of our anaesthesia practice, which has been so far marginal for me. Therefore, I have only visited some of obstetric and paediatric anaesthesia lectures, which I have observed predominantly during previous years. It is worth mentioning that this year's obstetric section was held in the spirit of regional anaesthesia, and therefore; obstetric lectures largely fulfilled my resolution for expanding my knowledge of regional anaesthesia. Obviously, regional anaesthesia in obstetrics is no longer just a subarachnoid, epidural, epidural anaesthesia with dural puncture (dural puncture epidural) popular in recent years by some anaesthesiologists. Several lectures have mentioned, for example, SPGB, the sphenopalatine ganglion block, that is used in the treatment of postpuncture headache. According to some studies, it has comparable effect to that of a blood clot. Another method used in post puncture headache PDPH may be to block the occipital nerves. The blockages, gaining their position in within obstetric anaesthesia, we can include paravertebral blocks, Quadratus lumborum block, TAP block (can be performed from the surgical field by obstetrician or percutaneously by anaesthesiologist), I-TAP block (Ilioinguinal-transversus abdominis block), ESP - errector spinae plane block.
Not by chance entitled Dominique Chassard from Belgium in his lecture "Hot Topics in Obstetric Analgesia and Anaesthesia - Last 12 months top publications" the year 2018 as a "Year of the Neural Blockade"!
Another novelty in obstetric anaesthesia, which is moving the world, is the use of ultrasound, not only for the mentioned peripheral nerve blockages, but also within the difficult airway management to detect space for emergency cricothyrotomy or to clarify the amount of gastric residue and thus the need for RSI. From the regional anesthesia lectures the possibility of administering Dexamethasone i.v. to prolong the duration of peripheral nerve blockade was a interesting information for me. The efficacy of perineural administration of dexamethasone was an obvious choice, but we are glad to have an elegant alternative to this off-label option now.
We can only thank the organizers for another excellent year and invite other Czech and Slovak anaesthesiologists to the next year congress, which will be held in beautifully sunny Barcelona 30th May - 1st June 2020. What more? In two years, the ESA 2021 will be in Munich, which we also have truly close – so maybe we could aim for another record in number of participants.
Petr Štourač, Jozef Klučka, Marek Kovář, Martina Klincová, Lucie Štětková, Eva Klabusayová, Olga Smékalová, Martina Kosinová
