Martina Kosinová

Interactive algorithms for teaching and learning acute medicine in the network of medical faculties MEFANET

Background Medical Faculties Network (MEFANET) has established itself as the authority for setting standards for medical educators in the Czech Republic and Slovakia, 2 independent countries with similar languages that once comprised a federation and that still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies. Objective We present the education portal AKUTNE.CZ as an important part of the MEFANET’s content. Our focus is primarily on simulation-based tools for teaching and learning acute medicine issues. Methods Three fundamental elements of the MEFANET e-publishing system are described: (1) medical disciplines linker, (2) authentication/authorization framework, and (3) multidimensional quality assessment. A new set of tools for technology-enhanced learning have been introduced recently: Sandbox (works in progress), WikiLectures (collaborative content authoring), Moodle-MEFANET (central learning management system), and Serious Games (virtual casuistics and interactive algorithms). The latest development in MEFANET is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The simulations assume the form of interactive algorithms for teaching and learning acute medicine. An anonymous questionnaire of 10 items was used to explore students’ attitudes and interests in using the interactive algorithms as part of their medical or health care studies. Data collection was conducted over 10 days in February 2013. Results In total, 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ education portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. In the feedback survey, 62 participants completed the online questionnaire (13.5%) from the total 460 addressed. Positive attitudes toward the interactive algorithms outnumbered negative trends. Conclusions The peer-reviewed algorithms were used for conducting problem-based learning sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) and in nursing (emergency medicine for midwives, obstetric analgesia, and anesthesia for midwifes). The feedback from the survey suggests that the students found the interactive algorithms as effective learning tools, facilitating enhanced knowledge in the field of acute medicine. The interactive algorithms, as a software platform, are open to academic use worldwide. The existing algorithms, in the form of simulation-based learning objects, can be incorporated into any educational website (subject to the approval of the authors).

Low-Dose or High-Dose Rocuronium Reversed with Neostigmine or Sugammadex for Cesarean Delivery Anesthesia: A Randomized Controlled Noninferiority Trial of Time to Tracheal Intubation and Extubation.

BACKGROUND:Rocuronium for cesarean delivery under general anesthesia is an alternative to succinylcholine for rapid-sequence induction of anesthesia because of the availability of sugammadex for reversal of neuromuscular blockade. However, there are no large well-controlled studies in women undergoing general anesthesia for cesarean delivery. The aim of this noninferiority trial was to determine whether rocuronium and sugammadex confer benefit in time to tracheal intubation (primary outcome) and other neuromuscular blockade outcomes compared with succinylcholine, rocuronium, and neostigmine in women undergoing general anesthesia for cesarean delivery. METHODS:We aimed to enroll all women undergoing general anesthesia for cesarean delivery in the 2 participating university hospitals (Brno, Olomouc, Czech Republic) in this single-blinded, randomized, controlled study. Women were randomly assigned to the ROC group (muscle relaxation induced with rocuronium 1 mg/kg and reversed with sugammadex 2–4 mg/kg) or the SUX group (succinylcholine 1 mg/kg for induction, rocuronium 0.3 mg/kg for maintenance, and neostigmine 0.03 mg/kg for reversal of the neuromuscular blockade). The interval from the end of propofol administration to tracheal intubation was the primary end point with a noninferiority margin of 20 seconds. We recorded intubating conditions (modified Viby-Mogensen score), neonatal outcome (Apgar score <7; umbilical artery pH), anesthesia complications, and subjective patient complaints 24 hours after surgery. RESULTS:We enrolled 240 parturients. The mean time to tracheal intubation was 2.9 seconds longer in the ROC group (95% confidence interval, −5.3 to 11.2 seconds), noninferior compared with the SUX group. Absence of laryngoscopy resistance was greater in the ROC than in the SUX groups (ROC, 87.5%; SUX, 74.2%; P = 0.019), but there were no differences in vocal cord position (P = 0.45) or intubation response (P = 0.31) between groups. No statistically significant differences in incidence of anesthesia complications or in neonatal outcome were found (10-minute Apgar score <7, P = 0.07; umbilical artery pH, P = 0.43). The incidence of postpartum myalgia was greater in the SUX group (ROC 0%; SUX 6.7%; P = 0.007). The incidence of subjective complaints was lower in the ROC group (ROC, 21.4%; SUX, 37.5%; P = 0.007). CONCLUSIONS:We conclude that rocuronium for rapid-sequence induction is noninferior for time to tracheal intubation and is accompanied by more frequent absence of laryngoscopy resistance and lower incidence of myalgia in comparison with succinylcholine for cesarean delivery under general anesthesia.

Rocuronium versus suxamethonium for rapid sequence induction of general anaesthesia for caesarean section: influence on neonatal outcomes

BACKGROUND In a previous study we compared rocuronium and suxamethonium for rapid-sequence induction of general anaesthesia for caesarean section and found no difference in maternal outcome. There was however, a significant difference in Apgar scores. As this was a secondary outcome, we extended the study to explore this finding on a larger sample. METHODS We included 488 parturients of whom 240 were women from the original study. Women were randomly assigned to receive either rocuronium 1mg/kg (ROC n=245) or suxamethonium 1mg/kg (SUX n=243) after propofol 2mg/kg. Anaesthesia was maintained with up to 50% nitrous oxide and up to one minimum alveolar concentration of sevoflurane until the umbilical cord was clamped. We compared neonatal outcome using Apgar scores and umbilical cord blood gases. RESULTS Data were analysed for 525 newborns (ROC n=263vs. SUX n=262). There was a statistically significant difference in the proportion of Apgar scores <7 at 1min (ROC 17.5% vs. SUX 10.3%, P=0.023) but no difference at 5min (ROC 8% vs. SUX 4.2%, P=0.1) or 10min (ROC 3.0% vs. SUX 1.9%, P=0.58). There was no difference between groups in other measured outcomes. CONCLUSION The use of rocuronium was associated with lower Apgar scores at 1min compared with suxamethonium. The clinical significance of this is unclear and warrants further investigation.

Controversies in Pediatric Perioperative Airways.

Pediatric airway management is a challenge in routine anesthesia practice. Any airway-related complication due to improper procedure can have catastrophic consequences in pediatric patients. The authors reviewed the current relevant literature using the following data bases: Google Scholar, PubMed, Medline (OVID SP), and Dynamed, and the following keywords: Airway/s, Children, Pediatric, Difficult Airways, and Controversies. From a summary of the data, we identified several controversies: difficult airway prediction, difficult airway management, cuffed versus uncuffed endotracheal tubes for securing pediatric airways, rapid sequence induction (RSI), laryngeal mask versus endotracheal tube, and extubation timing. The data show that pediatric anesthesia practice in perioperative airway management is currently lacking the strong evidence-based medicine (EBM) data that is available for adult subpopulations. A number of procedural steps in airway management are derived only from adult populations. However, the objective is the same irrespective of patient age: proper securing of the airway and oxygenation of the patient.

Anaesthesia and orphan disease: rocuronium and sugammadex in the anaesthetic management of a parturient with Becker's myotonia congenita.

Beckers Disease is an autosomal recessive type of myotonia congenita. Worldwide prevalence is about 1/100000. It is linked to mutations in CLCN1, the gene encoding skeletal muscle chloride channel. It reduces flow of chloride ions during repolarization and leads to sustained muscle contractions. Typical clinical symptoms are myotonic stiffness and “warm-up” phenomenon. 27 year old primipara with homozygote recessive mutation in CLCN1 (c.1437_1450del,p.480HfsX24) was indicated to elective caesarean section in 40 gestational week. In personal history she had thoracic stabilisation for scoliosis and hypothyreosis. We decided to provide the general anaesthesia with propofol in TCI mode (Schnider mode, C e =effective concentration 5 mcg/ml) and rocuronium 1 mg/kg IV for rapid sequence induction, monitoring the depth of neuromuscular blockade (NMB) on TOF WATCH SX device. The male newborn (APGAR score 9-10- 10) with no signs of pathology in acid-base balance in arterial umbilical blood was delivered. At the end of surgery (C e =1 mcg/ml, TOF=0, PTC=0) we administered sugammadex 4 mg/kg IV. It takes 2 min and 15 sec to reach TOF ratio 90% and subsequent extubation. After extubation she was breathing adequately, communicative, transferred to the recovery room and after two hours with no signs of residual NMB or respiratory problems back to the gynaecological ward to the monitored postoperative room. She was discharged home on 4 th day. This is the first report of anaesthetic management of a parturient with Beckers myotonia congenita who underwent CS under general anaesthesia. In this case we wanted to aware of using malignant hyperthermia (MH) triggering drugs, though the association with MH has been regarded as highly unlikely, suxamethonium which can cause total body rigidity and subsequent difficult airway management and neostigmine which can cause myotonic response.

Use of rocuronium and active reversal of neuromuscular blockadewith sugammadex does not shorten operating time duringcaesarean section in compare to suxamethonium, rocuronium andneostigmine: prospective randomised interventional multicentrictrial

Use of a combination of rocuronium and sugammadex for Caesarean Section (CS) in General Anaesthesia (GA) can be an alternative to suxamethonium for neuromuscular blocking agent during induction of GA for CS. Active selective reversal of neuromuscular blockade induced with rocuronium for CS is described in some case report series, is potentially beneficial and safe for both mother and newborn. Aim of the study is to compare this new method with traditional one.

Re: Influence on neonatal outcomes of rocuronium for rapid sequence induction of general anaesthesia for caesarean section

Radi bychom se vyjadřili k otazce uvedene v dopise. Souhlasime s tvrzenim, že nase navrhovane vysvětleni nižsich skore dle Apgarove v 1. minutě neni přesvědcive a že vzhledem k absenci udajů o transplacentarnim přenosu rocuronia 1 mg / kg existuji alternativni možnosti. Věřime vsak, že nase studie nam připomina, že celkova anestezie může ovlivnit jak matku, tak I novorozence. Nasim ukolem je optimalizovat výsledky obou.

Labor analgesia in Czech Republic and Slovakia: a 2015 national survey

BACKGROUND The purpose of this international survey was to describe the current practices and techniques of labor analgesia in the Czech Republic (CZE) and Slovakia (SVK). METHODS All Czech and Slovak departments that provide obstetric anesthesia were invited to participate in a one-month (November 2015) prospective study that monitored in detail all peripartum anesthetic procedures delivered by anesthesiologists. Participating centers recorded all data on-line in the CLADE-IS database (Masaryk University, CZE). RESULTS The response rate was 71% (70 of 95 departments in CZE, 35 of 54 centers in SVK). Participating centers represented 87.7% of all births in CZE and 66.4% of all births in SVK during the study period. Analgesia for labor, administered by anesthesiologists, was recorded in 12.5% of deliveries (CZE 12.1%, SVK 13.4%). Epidural analgesia was used in most of the cases (CZE 97.2%, SVK 99.1%) whereas spinal (CZE 1.4%, SVK 0.9%) or combined spinal-epidural (CZE 0.5%, SVK 0.0%) and intravenous remifentanil analgesia (CZE 2.4%, SVK 0.0%) were used infrequently. One fifth of the labors with analgesia administered by anesthesiologists (CZE 20.2%, SVK 20.5%) terminated in cesarean section. CONCLUSIONS Although labor analgesia was available in all Czech and Slovak obstetric centers, only a small proportion of parturients received an effective method of labor pain relief (regional or intravenous analgesia).

Ischemic stroke in paediatrics - narrative review of the literature and two cases

Stroke is a rare condition in childhood with an estimated incidence of between 1.3-13/100.000 patients. Clinical manifestation and risk factors for paediatric stroke are different from those of adults. The uncommon incidence, age-associated difference and plethora of clinical symptoms make the diagnosis of such strokes extremely difficult and often delayed. The history and clinical examination should point to diseases or predisposing factors. Neuroimaging (DWI MR) is the golden standard for diagnosis of paediatric stroke and other investigations can be considered according to the clinical condition. Despite advances in paediatric stroke research and clinical care, questions remain unanswered regarding acute treatment, secondary prevention and rehabilitation. The treatment recommendations are mainly extrapolated from studies on adult populations. In the review authors summarized the clinical characteristics and diagnostic steps for stroke in children/adolescents based on the most recent international guidelines and practical directions for recognising and managing the child/adolescent with stroke in paediatric emergency. In the two case reports, we describe the clinical course in both stroke patients.