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International audience; This document represents the first update of the Cardiothoracic and Vascular Anaesthesia Fellowship Curriculum of the European Association of Cardiothoracic Anaesthesiology and Intensive Care. After obtaining feedback from exit interviews with fellows in training, graduate fellows, and program directors, 2 modified online Delphi procedures with questionnaires were conducted. A consensus was reached when two-thirds of responding committee members gave green or yellow ratings on a traffic light system, and >70% indicated strong agreement or agreement on a 5-point Likert scale. The new regulations include the following: (1) more flexibility in the fellows` rotation, as long as the total number of days, rotations, and cases are completed during the training year; (2) recommendation for strict compliance with national working-time guidelines; (3) no extension of fellowship training to compensate for annual and/or sick leave, unless the required minimum number of cases and rotations are not reached; (4) interruption of fellowship training for >12 months is allowed for personal or medical reasons; (5) introduction of a checklist for quantitative assessment of standard clinical skills; (6) recommendations for a uniform structure of exit interviews; (7) possibility of a 1-month training rotation in a postanesthesia care unit instead of an intensive care unit; and (8) provided all other requirements have been met, the allowance of progression from the basic training year to the advanced fellowship training year without first passing the transesophageal echocardiography examination.

Introduction/Objective. Revascularization in multivessel coronary artery disease (MVD) in patients with ST elevation myocardial infarction (STEMI) is a matter of debate. We sought to compare outcomes between revascularization strategies based on angiographic lesion severity or inducible ischemia. Methods. In prospective study, first ever STEMI patients with MVD, defined as > 70% stenosis in non-culprit vessel, treated with culprit only primary PCI were randomized to: A. Complete revascularization of all nonculprit significant lesions during initial hospitalization; B. Complete revascularization after 30 days, or C. Revascularization based on non-invasive testing for inducible ischemia. The study explored occurrence of major adverse cardio-cerebral events (MACCE) (cardiac death, repeated MI, cerebrovascular event). Results. The study enrolled 120 patients with door to balloon time within appropriate limits (A 51 ? 26 vs. B 47 ? 33 vs. C 44 ? 29 min, p = 0.604) The patients in group A underwent complete revascularization at 6 [4?7] days after primary PCI, while in the group B it was 35 [32?39] days. In group C, 16/43 (37.2%) patients underwent PCI at 82 [66?147] days after infarction (p < 0.001). The patients were followed for 2.7 ? 0.8 years. The events occurred less frequently in patients that underwent planned complete revascularization compared to those who underwent ischemia testing (7.8 vs. 20.9%, p = 0.040). Kaplan?Meier analysis favored complete delayed revascularization (MACCE A 8.8 vs. B 6.9 vs. C 20.9%, log rank p = 0.041). Conclusions. Planned, angiography guided, complete revascularization after initial event may be favorable strategy compared to single stress test for MVD in STEMI.

Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed as a continuous modality reduces analgesics, prolongs the duration of analgesia, and enhances the patient’s mobilization in some cases. WI benefits are documented in open abdominal surgeries (Caesarean section, colorectal surgery, abdominal hysterectomy, herniorrhaphy), laparoscopic cholecystectomy, oncological breast surgeries, laminectomy, hallux valgus surgery, and radical prostatectomy. Surgical site infiltration requires knowledge of anatomy and the pain origin for a procedure, systematic extensive infiltration of local anesthetic in various tissue planes under direct visualization before wound closure or subcutaneously along the incision. Because the incidence of local anesthetic systemic toxicity is 11% after subcutaneous WI, appropriate local anesthetic dosing is crucial. The risk of wound infection is related to the infection incidence after each particular surgery. For WI to fully meet patient and physician expectations, mastery of the technique, patient education, appropriate local anesthetic dosing and management of the surgical wound with “aseptic, non-touch” technique are needed.

The aim of this paper is to determine which therapy gives best results regarding process of healing of diabetic foot ulcers among three proposed: only negative pressure wound therapy, only hyperbaric oxygen therapy, and both when used in conjunction. This bicentric prospective study included 60 patients, and they were, consecutively, assigned to one of three groups. The first group consisted of 20 patients who were treated only by hyperbaric oxygen therapy, second group consisted of 20 patients treated with combined hyperbaric oxygen and negative pressure wound therapy, and third group consisted of 20 patients who were treated only by negative pressure wound therapy. In some cases, previous revascularization of lower limb was performed and patients with poor run-off, without possibility to perform revascularization, were excluded from the study. Patients were predominantly men (56.7%) and mean age was 60.57 years. Majority of patients had ulcers of ischemic origin (45%), in 30% of cases, the reason of foot ulceration was neuropathy, and in 25% of patients, the etiology was combined. During the study, in three patients (5%), minor amputations were observed. Regarding Wagner classification of foot ulcers, most dominant was stage II (χ = 12.618, df = 4, p

PLOS ONE 17(1), e0262110 (2022). doi:10.1371/journal.pone.0262110, Published by PLOS, San Francisco, California, US

International audience; 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.

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. (C) 2019 Elsevier Inc. All rights reserved.

Introduction: Neuroaxial anaesthesia is used for pain control during or after surgery, to treat chronic pain states or to decrease labor and delivery pain in the parturient population. In recent years body tattooing on unusual sites such as the lumbar area have increased in popularity, and may be associated with problems during performing neuroaxial anaesthesia technique. Until now, there were no systematic reviews nor randomized control studies that investigated, primarily, the performance of neuroaxial anaesthesia through a tattoo. Case report: We report a case of a 35-year-old lady who was admitted to our hospital for veins surgery. Preanaesthetic back examination revealed an extensive tattoo covering the entire of her lumbar region with no possibility of performing neuroaxial anaesthesia without penetrating pigment containing skin. It was decided to perform surgery under general anaesthesia. Discussion and conclusions: The main safety concern in performing neuraxial anaesthesia through a tattoo is in the presence of the pigment of the tattoo in the intrathecal or the epidural spaces. Although to date, there are no reported complications from inserting an epidural or spinal needle through the tattoo, this could be because in the past, fewer patients had tattoos involving the midline of the lower back. Also, complications may take time to develop and it may be too early to see these complications which may occur later in time. Therefore, because of safety concerns of introducing pigment into the intrathecal or epidural spaces with the use of hollow needles through tattoos during neuraxial anaesthesia, and no specific guidelines to follow, a safe individual approach should be attempted based on risk/benefit assessment for patient and experience of the anaesthesiologist.

Central venous pressure is a very common clinical measurement, but it is frequently misunderstood and misused. As with all hemodynamic measurements, it is important to understand its basic principles. Use of CVP for the estimating of cardiac preload and volume status requires an understanding of its determinants. Actually, CVP and cardiac output are determined by the interaction of two function curves: the cardiac function curve and the return curve. There are no data to support the widespread practice of using central venous pressure (CVP) to guide fluid therapy. But, CVP is readily available in many patients. The fact that an isolated measurement of CVP does not predict the response to a fluid bolus does not reduce its importance as a hemodynamic variable. CVP may be usefull taken in the context of the whole clinical picture and over time.

Introduction: Aortic Valve Implantation (TAVI) is less invasive and becomes an alternative therapy reserved for patients with high operative risk. Hemodynamic stability is the main objective of anesthetic management during TAVI. Local anesthesia or general anesthesia are both valid alternatives and can be applied according to the patient's characteristics and procedural instances. Case Report: We report a 80-year-old woman who was admitted to our hospital for worsening dyspnea caused by severe aortic stenosis. TAVI was performed under local anesthesia and light sedation without complications. Conclusion: Successful TAVI requires a multidisciplinary team of which cardiac anesthesiologists are a crucial part.

Introduction: Acute hepatotoxicity is a rare but potentially fatal complication of amiodarone use. We report a case of liver injury after intravenous amiodarone administration in a patient with atrial fibrillation after heart surgery. Case report: A 62-year-old man with a history of dissection of the ascending aortic aneurysm presented for emergency ascending aorta surgery. Patient underwent a routine aortic ascending surgery. On the 3rd postoperative day, the patient developed rapid atrial fibrillation, which was treated with intravenous amiodarone. Because of hypotension, 12 h later, phenylephrine and norepinephrine were included. The patient's lactate had increased to 3.8 mmol/ L, the international normalized ratio increased to 3.12, alanine aminotransferase rose to 4401 IU/L, aspartate aminotransferase rose to 7355 IU/L, lactate dehydrogenase rose to 30043 IJ/L and creatinine increased from 96 to 190 μg/l. Amiodarone was discontinued. Urine output decreased. On the 5th postoperative day, rhythm converted to the sinus rhythm. Liver parameters significantly improved and returned to normal. On the 13th postoperative day, patient was discharged to a rehabilitation facility. Conclusion: Amiodarone is used to treat life-threatening arrhythmias in the setting of acutely decompensated heart failure. In the presence of hepatic congestion, the intravenous preparation of amiodarone may cause acute liver injury and liver function should be monitored closely in critically ill patients.

Objective To compare and validate the original EuroSCORE risk stratification models with the renewed EuroSCORE II model in a contemporary cardiac surgical practice. Design A consecutive observational study to validate EuroSCORE II performances, conducted as retrospective analysis of prospectively collected data. Setting A tertiary university institute for cardiovascular diseases. Participants Adult patients undergoing cardiac surgery between January and December 2012. Methods One thousand eight hundred sixty-four consecutive patients were scored preoperatively using additive and logistic EuroSCORE as well as EuroSCORE II. The discriminative power of the EuroSCORE models was tested by calculating the area under the receiver operating characteristic curve (AUC). The calibration of the models was assessed by Hosmer-Lemeshow statistics and with observed-to-expected mortality ratio. Measurements and Main Results The in-hospital overall mortality was 3.65%, with predicted mortalities according to additive EuroSCORE, logistic EuroSCORE, and EuroSCORE II of 5.14%, 6.60%, and 3.51%, respectively. The observed-to-expected (O/E) mortality ratio confirmed good calibration for the entire cohort only for EuroSCORE II (1.05, 95% confidence interval 0.81 – 1.29). Hosmer-Lemeshow test confirmed overall good calibration only for additive EuroSCORE (p = 0.129). The EuroSCORE II confirmed very good discriminatory power for a prolonged intensive care unit (ICU) stay of>2 days and>5 days (AUCs>0.75). Acceptable discriminatory power was confirmed for a prolonged postoperative stay of>7 days and>12 days (AUCs>0.70). Conclusion EuroSCORE II confirmed very good discriminatory capacity, good calibration ability (O/E mortality ratio), and good capability to predict prolonged ICU and postoperative stays in a contemporary patient cohort undergoing cardiac surgery.

Sudden occlusion of an artery caused by a thrombus or emboli is the most frequent cause of acute brain ischemia (ABI). Carotid endarterectomy (CEA) represents the gold standard for preventing strokes of carotid origin. However, neuronal damage caused by ischemia and/or reperfusion may contribute to a poor clinical outcome after CEA. In response to shear stress caused by hypoxic-ischemic conditions in patients undergoing CEA, stimulation of the hypothalamic-pituitaryadrenal axis leads to biological responses known as hypermetabolic stress, characterized by hemodynamic, metabolic, inflammatory and immunological changes. These changes maintain homeostasis and assist recovery, but an unregulated inflammatory response could lead to further tissue damage and death of neurons. Nitric oxide (NO) is an important signaling molecule involved in several physiological and pathological processes, including ABI. However, an excess of NO could have detrimental effects. We hypothesized that the hypoxic-ischemic state induced by carotid clamping leads to overexpression of inducible NO synthase and that uncontrolled production of NO could adversely affect outcome after CEA. © 2018 Elsevier Ltd

Purpose. To present the feasibility, safety, and efficacy of carotid endarterectomy in patients with type II internal carotid artery occlusions, including the long-term outcomes. Methods. From March 2008 to August 2015, 74 consecutive patients (48 men with a mean age of 65.1 ± 8.06 years) underwent carotid endarterectomy because of internal carotid artery (ICA) segmental occlusions. These were verified with preoperative carotid duplex scans (CDS) and CT angiography (CTA). Also, brain CT scanning was performed in all these patients. The indication for treatment was made jointly by a vascular surgeon, neurologist, and an interventional radiologist in a multidisciplinary team (MDT) context. After successful treatment, all the patients were followed-up at 1, 3, 6, and 12 months, then every 6 months thereafter. Results. The most common symptom at presentation was transient ischaemic attack (TIA) in 49 patients (66.2%), followed by stroke in the past six months in the 17 remaining patients (23%). Revascularisation of the ICA with endarterectomy techniques was performed successfully in all the patients with an average clamp time of 11.9 min. All the procedures were performed under general anaesthesia in combination with a superficial cervical block. The early complication rate was 8.1% and included two cardiac events (2.7%) (one rhythm disorder and one acute coronary syndrome), three TIAs (4.1%), and one intracerebral hemorrhage (1.3%). Only one patient with the intracerebral hemorrhage died 5 days after surgery giving a postoperative mortality of 1.3% for this series. During the follow-up period (mean 50.4 ± 31.3 months), the primary patency rates at 1, 3, 5, and 7 years were 98.4%, 94.9%, 92.9%, and 82.9%, respectively. Likewise, the survival rates were 98.7%, 96.8%, 89%, and 77.6%, respectively. Ultrasound Doppler controls during follow-up detected 8 ICA restenoses; however, only 3 of these patients required further endovascular treatment. Conclusions. Carotid endarterectomy of internal carotid artery (ICA) segmental occlusion is a safe and effective procedure associated with acceptable risk and good long-term results. Therefore, the current guidelines which do not recommend carotid endarterectomy in this patient group should be reassessed, with the requirement for ongoing large-scale randomized controlled trials to compare CEA with best medical therapy in this patient cohort.

Background We investigated changes to transfusion practices over time in paediatric liver transplant centre and evaluated the effect of transfusion practice to mortality. Methods A pilot retrospective study included two cohorts each with 101 sequential paediatric LT recipients: an Early group (1994-1998) and a Recent group (2009-2013). Demographic characteristics and data on the intraoperative transfusion of red blood cells (RBC), fresh-frozen plasma (FFP), platelets and cryoprecipitate were collected. Postoperative laboratory results were also obtained, together with donor and data regarding 1- and 5-year survival. Appropriate intergroup comparisons, univariate and multivariate analysis were made and P ≤ 0·05 was considered statistically significant. Results There were no significant group differences in demographic data (except patient height). Despite the fact that median total blood loss did not differ between groups (111 ml/kg in both groups), the Early group had greater levels of intraoperative RBC transfusion (75 vs. 59 ml/kg, respectively, P = 0·04) and less use of FFP (53 vs. 62 ml/kg, respectively, P = 0·01). Overall we noted a lower 1- and 5-year survival in the Early group (88·2% vs. 96%, P = 0·04 and 82·4% vs. 89·1%, P = 0·01, respectively). Univariate, but not multivariate regression analyses demonstrated that higher PELD score, RBC and FFP transfusion, and inclusion in the Early group were contributing factors to 1-year higher mortality. Conclusions This retrospective analysis of blood loss and replacement in paediatric LT patients demonstrates that the majority of our patients suffer major haemorrhage and require large-volume RBC and FFP replacements. In our pilot study, large volume of RBC and FFP replacement did not contribute to mortality. Paediatric LT involves a number of multidisciplinary teams. Thus, all care-related factors and combinations thereof that may contribute to outcome and should be evaluated in the future.

Introduction Unilateral right-sided pulmonary edema (UPE) is a rare but potentially life-threatening complication after minimally invasive mitral valve surgery (MICS). Methods We will present a case of severe unilateral pulmonary edema with cardiopulmonary instability after mitral valve repair with right minithoracotomy. Results A 45-year-old man (182 cm, 82 kg) was referred to the authors’ hospital for surgical treatment of mitral regurgitation. His medical history included hypertension and chronic obstructive pulmonary disease. Mitral valve repair was performed with plication of prolapsed part of the posterior leaflet and annuloplasty, under general anesthesia. The right lung was decompressed with differential lung ventilation by a double-lumen tracheal tube. Cross-clamp time was 128 min, and CPB time was long (193 min). Three hours after the surgery, oxygen saturation suddenly dropped to approximately 90 %, and frothy pink sputum was blast out from the tracheal tube. Chest radiograph showed unilateral right-sided massive infiltrate. No evidence of residual mitral insufficiency was detected by trans-thoracic echocardiography. Arterial pressure was maintained with high dose norepinephrine. Cardiac output was maintained with epinephrine and dobutamine, which were gradually attenuated within the first postoperative day. Mechanical ventilation was performed with high PEEP and high FiO2 (12 mmHg, 100 %, respiratory rate 16/min, tidal volume 5 ml/kg) by assist/control mode to maintain oxygenation. Pulse steroid therapy was applied for 3 days. Urine output was maintained at least 50 ml/h through the perioperative period. Patient was extubated 21 h after surgery. On the postoperative day 2, chest radiography showed reduced right-sided infiltration. Patient was discharged home on the 8th postoperative day. Discussion The reasons of unilateral right-sided pulmonary edema are multifactorial, including complete lung collapse and ischemic reperfusion injury, systemic inflammatory reaction and extracorporeal circulation, level of mean pulmonary arterial pressure, chronic obstructive pulmonary disease, and increasing CPB time. Perioperative medical team should be aware of the heightened perioperative risk of UPE during MICS.

Introduction: Anticoagulation and antiplatelet therapy in the presence of the epidural catheter is still controversial. It is well known that dual antiplatelet therapy is indicated for 12 months after the placement of drug-eluting stents (DES). Removal of an epidural catheter during that period is related to an increased risk of stent occlusion in case of discontinuation of platelet function inhibitors or, on the other hand, increased risk of epidural hematoma associated with neurological deficit if suppressed platelet function is still present. Case Report: Here we present a case of a 63-year-old man who was admitted to Institute for Cardiovascular Diseases Dedinje for elective aortic surgery. Before the induction, an epidural catheter was inserted at the Th10-Th11 epidural space. Uneventful surgery was performed under the combined epidural and general anesthesia. On the 2nd postoperative day, the patient sustained a ST depression myocardial infarction treated with percutaneous coronary intervention with DES placement, while epidural catheter was still in place. Dual antiplatelet therapy with 600mg of clopidogrel, 100 mg of acetilsalicylic acid (ASA) and low molecular weight heparin (LMWH) were started during the procedure. The next day, clopidogrel (75 mg) and ASA (100 mg) were continued as well as LMWH. The decision to remove the epidural catheter was made on the 9th postoperative day, after platelet aggregation assays were performed. Six hours after catheter removal the patient again received clopidogrel, ASA and LMWH. There were no signs of epidural hematoma. Conclusion: This case shows that point-of-care testing with platelet aggregation assays may be useful in increasing the margin of safety for epidural catheter removal during dual antiplatelet therapy.

Fluid therapy is a core concept in the management of perioperative patients for maintenance of intravascular volume and organ perfusion. The aim of perioperative fluid therapy is to keep patients at all times in the optimal volume loading, due to both hypovolemia and volume overload may cause organ dysfunction. Intravenous fluid is a drug and because of that, timing and dose is important. 'Liberal' or 'restrictive' strategies and crystalloid or colloid solutions are the unsolved controversies. The term 'restriction' is commonly interpreted to imply hypovolemia, whereas it may simply represent avoidance of the fluid excess seen in the 'liberal' group. The aim of goal-directed fluid therapy is to guide fluid and pharmacological (inotrope) therapy, by using flow-directed hemodynamic parameters, to maintain adequate tissue blood flow, circulating volume, and oxygen delivery. In order to minimize the complications related to fluid administration, preventive strategies and prompt treatments are of utmost importance.

Introduction: Aortic dissection is one of the most fatal vascular emergencies. Almost 40% of the patients do not reach hospital in time while more than quarter die in the first 24 hours after the dissection begins. Case Report: A 37-year old man was admitted to our hospital with severe anterior chest pain which had lasted for over a week. Suspected aortic dissection was rapidly confirmed using imaging modalities - MDCT chest scan and TTE, followed by an urgent surgical management - Bentall procedure. MDCT chest scan also discovered adrenal incidentaloma defined as malignant, pheochromocytoma like mass. Due to the critical state of the patient, there was not enough time for further endocrinologic testing. Discussion and conclusion: When treating patients with pheochromocytoma and acute aortic disection, it is crucial to obtain a stable hemodynamic state before the surgery, since they can trigger a severe hypertensive crisis due to high levels of cathecholamines induced chronic vasoconctriction. The most vulnerable periods are the induction of anesthesia and perioperative hemodynamic oscillations, so treating patients with short acting alpha- 1 adrenergic blocking agents preoperatively has proven to be helpful - Phentolamine. Both dissection of aorta and pheochromocytoma present challenges for anesthesiologists and early recognition of symptoms is essential in establishing the diagnosis and reducing the mortality rate.

Introduction: Postdural puncture headache (PDPH) is a complication of puncture of the dura mater. It is a common side effect of spinal anesthesia, lumbar puncture and occasionally, may accidentally occur in epidural anesthesia. The headache is defined as a bilateral headache that develops within 7 days after lumbar puncture and disappears within 14 days. It has been described in some cases that headaches can last from a few mounts to even years. Factors that increase the risk of PDPH is young age, female sex and pregnancy. Incidence is strongly related to the needle size and type. Case Report: We report a case of a 49-year-old man who was admitted to our Institute for elective veins surgery. We choose spinal anesthesia for this operation and use 25 gauged spinal needle. Patient was hemodynamically stable during the whole surgery without headache and he was discharged home at 1st post operative day. However, after two days, patient came to the hospital complaining of severe headache in frontal and occipital areas, followed by neck stiffness. Our first approach in treatment was conservative therapy. Recumbent positioning, oral and intravenous fluid, 500 mg coffeine iv. bid and morphine 4 qid. The headache persisted for the next 2 days, despite conservative therapy. Our next approach was epidural blood patch like effective treatment for PDPH. First we placed patient in the lateral position and inserted epidural needle at the level L3 - L4. Then we injected 15 ml of autologes blood into epidural space. His headache resolved within one hour of procedure, he denied any further headache one month after discharge. Conclusion: In our case, it was shown that lumbar puncture is an important cause of iatrogenic morbidity in the form of postdural puncture headache. Incidence of headache can be resolved by using thinner needle. When the headache does not respond to conservative therapy, epidural blood patch is a reasonable and effective treatment. Surgical closure is the last option.

All perioperative patients are at increased risk of pulmonary thromboembolism (PTE). The most common findings of PTE in patients undergoing general anesthesia are hypotension, tachycardia, hypoxemia, and decreased end-tidal CO2 air. Computed tomographic scanning is the preferred definitive diagnostic study, but transesophageal echocardiography may be valuable in making a presumptive diagnosis in the operating room. Early diagnosis allows supportive therapy and anticoagulation.

EREBRAL ISCHEMIA/HYPOXIA may occur in a vari-ety of perioperative circumstances. The main pathophy-siologic aspects involved in cerebral ischemia/reperfusion arecaused by adenosine triphosphate (ATP) consumption, theexcitotoxic actions of glutamate, changes in ionic homeostasis,and formation of free radicals (Fig 1). Outcomes from suchevents range from subclinical neurocognitive deficits to cata-strophic neurologic morbidity or death.

Introduction Pain after cardiac surgery can be caused by the incisions, cutting, heating, intraoperative tissue retraction and dissection, multiple intravascular cannulation, and chest tubes. Achieving optimal pain relief after cardiac surgery can be challenging. Most surgeons, anesthesiologist and nurses believe that cardiac surgery is not very painful, and related to that, pain levels after cardiac surgery are often severe and undertreated. The aim of this study is to evaluate perioperative pain management practices in patients undergoing cardiac surgery in the University hospital. Methods That is a prospective observational study including adult patients undergoing cardiac surgery. Patients were recruited on the first post-operative day (POD1). Assessment of patient reported outcomes (assessed in a questionnaire consisting of 13 questions, addressing severity of pain; its interference with activities; effect on affect; adverse effects; degree of satisfaction, whether the patient wished for more treatment for pain) and clinical variables were performed on the POD1. Results There were 130 patients (105 men), average age of 64.3±8.2 years. 44.8% of patients had worst pain higher than 6. 58.8% of patients were more than 20% of time in severe pain. High level of drowsiness was registered in 43.9% patients. Only 4% of patients have been out of bed on the POD1. 44.8% of patients wished more treatment. 73% of patients received morphine and 31.5% of patients received acetaminophen during the first 24 h after surgery for pain relief. Discussion It was suggested that incorrect assessment of pain, the use of protocols and inappropriate drug use, patients’ inability or unwillingness to communicate, and the hypothesis that patients should wake early from anesthesia and their blood pressure be stable, pain control is very often postponed to the next step. Several issues may be important for effective pain management, including providing the information about pain management options, systematic evaluation and the use of a multimodal approach.

t G p c c THE FIRST CAROTID ENDARTERECTOMY (CEA) was performed at St Mary Hospital, London, England, in 1954.1 This is a surgical procedure performed to reduce the ncidences of embolic and thrombotic stroke. The incidence of erioperative stroke during CEA is approximately 2.3%.2 The ncidence of perioperative myocardial infarction (MI), which is efined by Q-wave criteria on an electrocardiogram, in patients ndergoing CEA is 2%.3 The overall mortality for CEA was eported to be 1.3% to 1.8% in 2 large systematic reviews in hich the highest rate was 15%.4,5 To reduce the incidences of morbidity and mortality, there is a constant search for optimal anesthetic and surgical techniques.

We investigated the impact of preoperative ultrasonography of the forearm circulation on radial artery conduit selection. Preoperative ultrasound of the forearm circulation was performed routinely in 536 patients planned for radial artery harvesting. The safety assessment of the harvest included the following algorithm of tests: the ultrasound, the Allen test, and pulse oximetry. The quality criteria that were used to exclude a radial artery from harvesting were small size of the artery, diffuse atherosclerosis, calcifications, and severe neointimal hyperplasia. The overall rejection rate due to safety reasons was 16.4%. Seventy-one (13.2%) radial arteries did not fulfill the conduit quality criteria and consequently these arteries were not harvested. In 13.4% of radial arteries, localized arterial wall disease was found in the distal third of the artery. The distal part of the artery was discarded and the rest was used as a conduit. Our results indicate that the ultrasound provides an accurate preoperative insight into the radial artery morphology, enabling selection of the arteries with favorable morphological features.

Background/Aim. In order to reduce the risk of cerebrovascular insults (CVI), the latest recommendations suggest that carotid endarterectomy (CEA) is strongly indicated in patients scheduled for coronary surgery when significant carotid artery stenosis is symptomatic and/or bilateral. The best results are obtained in small studies with CEA performed immediately prior to off-pump coronary bypass (OPCAB). We present 16 consecutive patients who underwent synchronous CEA and OPCunder general anesthesia combined with high thoracic epidural anesthesia (TEA) in order to evaluate the safety and potential benefits of such anesthetic management. Methods. A total of 16 consecutive patients scheduled for simultaneous CEA and OPCwith no contraindication for TEA were enrolled in the study. All the patients were anesthetized with TEA combined with general anesthesia. Early extubation was planed in all the patients for early assessment of neurological outcome. Demographics, comorbidity, quality of postoperative recovery, duration of mechanical ventilation, successful early extubation, outcome, length of Intensive Care Unit (ICU) and hospital stay were recorded. Results. Only two patients did not fulfill the criteria for early extubation. The average duration of mechanical ventilation for patients who fulfilled criteria for early extubation was 87.9 ± 85.0 (0-255) min. Five (31.25%) patients were extubated in the operating theater at the end of surgery. There were no deaths, nor neurological complications of TEA. Seven (43.7%) patients had at least one of the postoperative complications considered significant. None of them had CVI. None of the early extubated patients was reintubated or had postoperative respiratory failure. Conclusion. Our study revealed that a combination of general anesthesia with TEA appears to be good choice in synchronous CEA and OPCdue to advantages of early extubation and early neurological assessment. Larger studies are necessary to determine real benefits on both short and long-term outcomes of such anesthetic management in synchronous CEA and OPCAB.

nema

Introduction. Thoracic epidural analgesia, combined with general anesthesia, is an established anesthetic choice for abdominal aortic surgery. However, there are controversies about the level of anesthesia as well as the dose and concentration of the local anesthetic used. The aim of the study was to compare the effects of two different concentrations of epidural bupivacaine on sevoflurane requirements and hemodynamic parameters during aortic surgery under combined epidural/general anesthesia. Methods and Material. Sixty patients scheduled for abdominal aortic surgery were randomly divided into two groups according to the concentration of local anesthetic used for epidural anesthesia: - Group 1- low concentration - where 0.125% bupivacaine was used, and - Group 2 - high concentration - where 0.5% bupivacaine was used at the beginning and then the concentration was reduced to 0.25%. Anesthesia was maintained with sevoflurane, the dose was adjusted to achieve the target entropy of 40-60. The measurements included the inspired sevoflurane concentrations, blood pressure, and heart rate at the beginning and every 5 min during the surgery. Results. Both groups had similar heart rate and blood pressure, but the inspired sevoflurane concentration was significantly higher and more variable in patients where bupivacaine 0.125% was used. Vasopressors were used more often and in higher doses in the 0.5% bupivacaine group, and in the same group the blood loss and fluid requirements were reduced. Conclusion. When 0.5% bupivacaine is used in combined thoracic epidural/ general anesthesia for aortic surgery, the sevoflurane concentrations are lower and less variable. In addition, the blood loss and fluid requirements are reduced.

Copeptin is a sensitive and more stable surrogate marker for arginine vasopressin. In this study, we evaluated copeptin levels in carotid endarterectomy (CEA) patients, perioperatively, to determine whether copeptin levels can be related to carotid artery cross clamping (CC) time and to postoperative neurological outcomes. Copeptin, interleukin 6, C-reactive protein, cortisol, and brain natriuretic peptide were measured preoperatively (T1) and 3 hours postoperatively (T3) as well as intraoperatively (T2). We recruited 77 patients. Values of copeptin rose gradually over the observed times: T1 = 7.9 (6.4-9.6), T2 = 12.6 (9.3-16.8), and T3 = 72.3 (49.1-111.2) pmol/L. There was a significant difference for repeated measurement ( P = .000, P = .000, and P = .000). Duration of carotid artery CC during CEA does not affect postoperative copeptin level (CC ≤ 13 minutes: 106.8 ± 93.6 pmol/L, CC > 13 minutes: 96.7 ± 89.1 pmol/L; P = .634). Preoperative copeptin level was significantly higher in patients with ulcerated plaque morphology. Activation of the stress axis in patients undergoing CEA results in copeptin elevation. Duration of CC during CEA does not affect postoperative copeptin levels.

Introduction. Hybrid procedures represent staged or simultaneous endovascular and open surgical techniques in the treatment of complex pathologies of the thoracic and abdominal aorta. We are presenting a patient with previous abdominal aortic surgery in whom hybrid vascular procedure for descending aorta and left subclavian artery aneurysm was performed. Case Outline. A 63-year-old female patient was admitted for computed tomography angiography. Descending aorta aneurysm (7.6 cm) as well as aneurysm of the left subclavian artery (LSA) was noted. Eight years ago she underwent abdominal aortic aneurysm resection and aortoiliac bypass. Standard TEVAR (thoracic endovascular aortic repair) procedure couldn’t be done due to small dimensions of previous “Y” graft (12.6 mm), so first we did LSA transposition and after three days hybrid procedure. After “Y” graft exposure, anastomosis between the corps of “Y” graft and tubular graft 10 mm was created and through this conduit thoracic stent-graft was placed followed by complete “Y” graft replacement. After 6 months angiography showed regular postoperative findings. Conclusion. Combined surgical and endovascular procedures in thoracic aorta pathology treatment could be useful solutions with favorable outcome. [Projekat Ministarstva nauke Republike Srbije, br. 41002]

Carotid endarterectomy (CEA) is a surgical procedure performed to reduce the incidence of embolic and thrombotic stroke. Although only a preventive procedure, CEA carries the risk of perioperative complications. There is constant searching for an optimal anesthetic technique. There are pros and cons for both anesthetic techniques used: regional (RA) and general anesthesia (GA). A large number of studies have compared RA and GA techniques in CEA surgery patients. The primary outcome was the proportion of patients with stroke, myocardial infarction, or death. However, neither the GALA trial nor the pooled analysis was adequately powered to reliably detect an effect of type of anesthesia on mortality. It may therefore be appropriate to consider other additional parameters (stress response, incidence of postoperative delirium and cognitive impairment, functional recovery, total surgery time, intensive care unit requirement, hospital stay, hospital costs and patients satisfaction) when comparing the outcomes of the two techniques. Although, the debate continues as to whether regional anesthesia or general anesthesia is safer, the choice of anesthetic technique is a complex decision and surgical teams should be able to offer both RA and GA. The individual approach is the ideal choice and should be determined at the discretion of the surgeon, anesthetist and patient depending on the clinical situation and own preferences.

Surgical closure of patent ductus arteriosus (PDA) is still required in selected adult patients. We analyzed the morphology of the anomaly and coexisting pathological findings in adult patients who were recently referred to our institute for surgical PDA repair.Six adult PDA patients who were not considered candidates for percutaneous closure underwent surgical PDA correction. In three patients with isolated PDA, computed tomographic scan revealed short, wide, and distorted ductus. In the remainder three patients, concomitant heart or aortic disease was found. Transpulmonary approach under total cardiopulmonary bypass or hypothermic circulatory arrest was performed.In all patients, a Dacron patch was used to close the duct. The balloon occlusion technique with normothermic cardiopulmonary bypass was performed in four patients. In one of these patients, the balloon occlusion was not feasible because of unfavorable ductal anatomy, and PDA was closed in short hypothermic circulatory arrest. In two patients with aortic aneurysm, PDA closure and aortic reconstruction were performed in deep hypothermic circulatory arrest. No significant complications occurred during postoperative course. After the mean follow-up period of 48 months, neither ductal reopening nor aneurysmal degeneration of remnant ductal tissue was found.Surgical PDA closure in adults remains the treatment of choice in wide, deformed PDAs unsuitable for percutaneous closure and PDAs associated with surgical aortic or heart disease.

Background Central (ScVO2) and mixed venous oxygen saturation (SvO2) and blood lactate are useful measurement tools for evaluating the degree of hypoperfusion in patients with different disease processes. The aim was to study incidence of both low as well as high ScvO2 and assessed their relationship to markers of tissue hypoxia, course and outcome in patients undergoing elective cardiac surgery.

Background/Aim. In spite of the evidence suggesting a significant morbidity associated with blood transfusions, the use of blood and blood products remain high in cardiac surgery. To successfully minimize the need for blood transfusion, a systematic approach is needed. The aim of this study was to investigate the influence of different anesthetic techniques, general vs combine epidural and general anesthesia, as well as different surgery strategies, on-pump vs off-pump, on postoperative bleeding complications and the need for blood transfusions during perioperative period. Methods. Eighty-two consecutive patients scheduled for coronary artery bypass surgery were randomized according to surgical and anesthetic techniques into 4 different groups: group 1 (patients operated on off-pump, under general anesthesia); group 2 (patients operated on off-pump, with combined general and high thoracic epidural anesthesia); group 3 (patients operated on using standard revascularization technique, with the use of extracorporeal circulation, under general anesthesia), and group 4 (patients operated on using standard revascularization technique, with the use of extracorporeal circulation, with combined general and high thoracic epidural anesthesia). Indications for transfusion were based on clinical judgment, but a restrictive policy was encouraged. Bleeding was considered significant if it required transfusion of blood or blood products, or reopening of the chest. The quantity of transfused blood or blood products was specifically noted. Results. None of the patients was transfused blood or blood products during the surgery, and as many as 70/81 (86.4%) patients were not transfused at all during hospital stay. No difference in postoperative bleeding or blood transfusion was noted in relation to the type of surgery and anesthetic technique applied. If red blood cells were transfused, postoperative bleeding was the most influential parameter for making clinical decision. Conclusion. No influence of off-pump surgery or epidural anesthesia on blood transfusion requirements during a perioperative period was confirmed by this study. It seems, however, that encouraging lower hemoglobin triggers in clinical decision-making could result in less transfusions during surgery or hospital stay.

Carotid endarterectomy (CEA) is a surgical procedure performed to reduce the incidence of embolic and thrombotic stroke. Although only a preventive procedure, CEA carries the risk of perioperative complications. There is constant searching for an optimal anesthetic technique. There are pros and cons for both anesthetic techniques used: regional (RA) and general anesthesia (GA). A large number of studies have compared RA and GA techniques in CEA surgery patients. The primary outcome was the proportion of patients with stroke, myocardial infarction, or death. However, neither the GALA trial nor the pooled analysis was adequately powered to reliably detect an effect of type of anesthesia on mortality. It may therefore be appropriate to consider other additional parameters (stress response, incidence of postoperative delirium and cognitive impairment, functional recovery, total surgery time, intensive care unit requirement, hospital stay, hospital costs and patients satisfaction) when comparing the outcomes of the two techniques.Although, the debate continues as to whether regional anesthesia or general anesthesia is safer, the choice of anesthetic technique is a complex decision and surgical teams should be able to offer both RA and GA. The individual approach is the ideal choice and should be determined at the discretion of the surgeon, anesthetist and patient depending on the clinical situation and own preferences.