N. Brogly

Pulse contour analysis calibrated by Trans-pulmonar thermodilution (Picco Plus ® ) for the perioperative management of a caesarean section in a patient with severe cardiomyopathy

BACKGROUND The delivery of cardiac patients is a challenge for the anaesthesiologist, to whom the welfare of both the mother and the foetus is a main issue. In case of caesarean section, advanced monitoring allows to optimize haemodynamic condition and to improve morbidity and mortality. OBJECTIVE To describe the use of pulse contour analysis calibrated by Trans-pulmonar thermodilution (Picco Plus(®)) for the perioperative management of a caesarean section in a patient with severe cardiomyopathy. CASE REPORT We describe the case of a 28-year-old woman with a congenital heart disease who was submitted to a caesarean section under general anaesthesia for maternal pathology and foetal breech presentation. Intra- and post-operative management was optimized by advanced haemodynamic monitorization obtained by pulse contour wave analysis and thermodilution calibration (Picco Plus(®) monitor). The information about preload, myocardial contractility and postcharge was useful in guiding the fluid therapy and the use of vasoactive drugs. CONCLUSION This case report illustrates the importance of advanced haemodynamic monitoring with an acceptably invasive device in obstetric patients with high cardiac risk. The increasing experience in advanced haemodynamic management will probably permit to decrease morbidity and mortality of obstetric patients in the future.

Visión moderna sobre una técnica antigua: revisión narrativa de técnicas de localización del espacio epidural

Since the first description of the epidural technique during the 1920s, the continuous progress of knowledge of the anatomy and physiology of the epidural space has allowed the development of different techniques to locate this space while increasing both the safety and efficacy of the procedure. The most common techniques used today are based on the two main characteristics of the epidural space: the difference in distensibility between the ligamentum flavum and the epidural space, and the existence of negative pressure within the epidural space. However, over recent years, technological advances have allowed the development of new techniques to locate the epidural space based on other physical properties of tissues. Some are still in the experimental phase, but others, like ultrasound-location have reached a clinical phase and are being used increasingly in daily practice.

Levosimendana como tratamento para insuficiência renal aguda associada a choque cardiogênico após fratura de quadril

Inotropic drugs are part of the treatment of heart failure; however, inotropic treatment has been largely debated due to the increased incidence of adverse effects and increased mortality. Recently levosimendan, an inotropic positive agent, has been proved to be effective in acute heart failure, reducing the mortality and improving cardiac and renal performance. We report the case of a 75-year-old woman with history of heart and renal failure and hip fracture. Levosimendan was used in preoperative preparation as an adjuvant therapy, to improve cardiac and renal function and to allow surgery.

Levosimendan as a treatment for acute renal failure associated with cardiogenic shock after hip fracture.

Inotropic drugs are part of the treatment of heart failure; however, inotropic treatment has been largely debated due to the increased incidence of adverse effects and increased mortality. Recently levosimendan, an inotropic positive agent, has been proved to be effective in acute heart failure, reducing the mortality and improving cardiac and renal performance. We report the case of a 75-year-old woman with history of heart and renal failure and hip fracture. Levosimendan was used in preoperative preparation as an adjuvant therapy, to improve cardiac and renal function and to allow surgery.

Preparation for the European Diploma of Anaesthesiology - part 1 and results in 2010 and 2011: the Madrid Center experience. The show must go on: 15AP1-8

the residents. The global session and tutor evaluation scores were 8 out of 10; 94% of the residents considered the themes treated during the sessions as adequate. 90% of the residents took the exam, 68% of them passed it. In the last 3 years the percentage of passed residents increased progressively to 81%. Conclusion(s): The session assistance and the exam participation were high. A progressive increase of passed exams was observed. Common sessions, assistance control and the final exam were well accepted. A unified way of teaching allowed us to achieve a more homogenous education and it was a great help in tutor mentoring and in warranting a standard formation. These results encourage us to apply and improve this teaching model in the future. Reference: 1. European Board of Anaesthesiology. Training Guidelines in Anaesthesia or the European Board of Anaesthesiology Reanimation and Intensive Care. Eur J Anaesth 2008;25: 528-30.

European diploma of anesthesiology: The Madrid training center experience: 15AP1-1

Background and Goal of Study: Since 2008, a training for the first part of the European Diploma of Anesthesiology (EDA1) was organized in Madrid with the goal of familiarizing anesthesiologists with this kind of MCQs and prepare them. This observational study was realized to measure the impact of the training on the results of the EDA1 for the course 2010-11. Materials and Methods: All the participants of the training were included in the study. Stage of practice in anesthesia and geographic origin of the students were noted. In every thematic session, before a didactical correction of the exam sample, participants were asked to answer the MCQ‘s in the of ficial sheet of the EDA. The results were anonymously analyzed. At the end of the year, we asked for a feed back on the results of the EDA1 in candidates of the training. Results and Discussion: Forty seven anesthesiologists were inscribed to the training of whom 31(66%) residents (R) and 16(34%) graduated anesthesiologists (GA). 40(85,1%) came from university hospitals, 4 (8,5%) from peripheral hospitals, and 3(6,4%) from other region hospitals. Eighteen (38,3%) anesthesiologists participated to 3 or more sessions (10 (32,3%)R; 8 (50%)GA; p=0,19) and were considered approved for the training. The scores of the sessions were respectively 59,5 [17;79]%, 69,2 [54,4; 88]%, 62,4 [47,2; 76]%, 70,4 [69,6; 81,6]%, 70,4 [58,3; 79,1]% in physiology and anatomy, pharmacology, physics, general anesthesia and specialized anesthesia (p< 0,0001), with greater scores in pharmacology, general anesthesia and specialized anesthesia compared to the others. Setting a pass mark at 70%, the ratio of approval would be 14,7%, 46,4%, 11,8%, 33,3% and 53,8% in each topic.Eleven student of the training who presented to the EDA 1 exam in Madrid gave us their result, and 8 passed (72,7%). These results tend to be higher than those of the rest of candidates in Madrid (41,5%) (p=0,07) and might be better than the overall European pass rate (58%). Conclusion(s): Spain does not dispose of a final theorical exam to check anesthesiologists’ knowledge. The organization of a training for the EDA1 seems to be an ef ficient way to prepare candidates to the exam. This ef fort is expected to promote an increasing number of candidates with higher scores and pass rate in Spain in the next years. The final results compared with the European pass mark are probably overstimated due to a low rate of answer from candidates to the post-EDA1 survey.