Giovanna Panarello is chief of ICU working as intensivist and infectivologist. She is involved in the critical care of severe respiratory insufficiency due to infection disease and end stage lung disease as treatment provider and in the etiology study and in the implementation of Scientific trial.

Pneumocystis jiorvecii pneumonia is often AIDS exordium opportunistic infection. Evolution in respiratory distress syndrome is common and is potentially reversible but is still burdened by a mortality rate as high as 30% to 40% if managed by conventional treatment mainly based on optimal mechanical ventilation. Since 2009 the use of Extracorporeal Membrane Oxygenation has been shown to be very effective as salvage therapy in case of severe respiratory insufficiency not responsive to conventional therapy. HIV seropositivity has been considered a contraindication to extracorporeal life support. We report two cases of Pnumocystis jiorvecii pneumonia as AIDS exordium opportunistic infection. Both evolved to severe ARDS and were successfully treated with VV ECMO support.

Robert Farrar is currently the Chairman of Summit Anesthesia Associates in Summit, NJ. He was the Vice President of Medical Affairs for Somnia Anesthesia. He has 30 years’ experience as an Anesthesiologist as well as 25 years’ experience with development and implementation of quality systems. He served as Director of Cardiothoracic Anesthesiology at Lower Bucks Hospital in Bristol, Pennsylvania and Chairman of Anesthesiology at Easton Hospital in Easton, PA. He previously worked at Atlantic Care Health System and Jersey City Medical Center. He also served a senior staff anesthesiologist at Henry Ford Hospital in Detroit, MI where he was a Member of both the Cardiothoracic and Critical Care Divisions. He received his Medical Degree from the Catholic University and his Law Degree from the University of Detroit/Mercy. He completed a residency in Anesthesiology at UMDNJ and a fellowship in cardiovascular anesthesiology at Loyola/Chicago.

The impaired healthcare professional is one who is unable, to practice medicine according to accepted standards as a result of substance abuse, behavioral problems, mental illness or cognitive decline. Substance abuse is exacting a tremendous toll on the health care community as well as society at large. The prevalence of substance abuse among healthcare workers parallels that of the general population with a variance noted for the types of substances used. Impaired providers generally manifest their illness in one of three ways: overt intoxication, self-declared or the high index of suspicion. While the first 2 categories are readily identified, the high index category poses the greatest challenge for identification, intervention and treatment. The key factor needed to identify the impaired provider in the high index category is to recognize a series of irregular behaviors that are out of sync with the norm. While none of these behaviors by themselves are dispositive of impairment, together they form the basis for the performance of an intervention. A check list and careful documentation are essential. The goals of an intervention are to assure patient safety, provide for the wellbeing of the provider and minimize exposure of the organization. During the intervention, the healthcare worker is confronted with objective evidence of the problem. This may not be received well since impaired providers are intelligent, have much at stake and (almost) invariably are in denial. Ultimately, they are offered a choice to either get into treatment through the state medical society’s  hysician Impairment Program; or, have their case turned over to the medical board. Most choose the treatment option since it provides a mechanism for preserving their career. Treatment consists of inpatient therapy followed by outpatient therapy. Some providers are eventually able to reenter medical practice at some point but need to be followed closely.

Nadia Najafi is the Belgian representative at the European Society for Paediatric Anaesthesiology. She is specialized in paediatric anaesthesiology, paediatrics, and paediatric intensive care medicine. She developed her expertise in improving safety of children undergoing general anaesthesia and procedural deep sedation and analgesia both in and outside of operating rooms.

Gastrointestinal endoscopic procedures in children cause fear, pain and distress. Deep sedation or general anaesthesia is most likely required to overcome these inconvenience, and to provide high quality procedures for endoscopists as well as a maximum safe environment for children. However, providing deep sedation for these procedures may be challenging due to the comorbid conditions of the child, gastrointestinal pathology requiring endoscopy, and potentially sedation- or anaesthesia related adverse respiratory events. In addition, the anatomical considerations of gastrointestinal tract interfering with both the respiratory abilities and the small caliber of the pediatric airway may become an issue while performing endoscopy in children. Anesthesiologists have been traditionally assigned to provide general anaesthesia or deep sedation in children at risk for developing adverse events. Careful pre- rocedural assessment, identification of children potentially at risk for sedation or anaesthesia-related complications, vigilant monitoring during and after the procedure are some of the key elements of a successful sedation strategy. Both cautious selection of anesthetic drug and the dosage administered may also help reducing the adverse events. In addition, safety measurements should always be taken and a careful plan for treating complications should be in place. Moreover, a multidisciplinary approach and communication between anesthesiologists and pediatric gastroenterologists is of utmost important in improving the outcome of children. During the entire sedation process, the predictors of both successful and failed sedation will be discussed.

Abdulaleem Alatassi is the Chairman of the Pediatric Anaesthesia Fellowship Scientific Committee at the Saudi Commission for Health Specialties. He is a consultant in Anesthesia and Intensive Care Unit at King Abdulaziz Medical City. Abdulaleem Alatassi holds the position of Deputy Director-Operative Room Services at King Abdulla Specialized Children Hospital. Between 2012-15 he was the Head of Pediatric Anesthesia Section at King Abdulaziz Medical City in Riyadh, Saudi Arabia

Statement of the Problem: In this presentation i will review few areas in pediatric anesthesia to emphasize on the latest evidence based practice which includes: 1. Rapid sequence induction and cricoid pressure in pediatric anesthesia. 2. The difference in airway anatomy between pediatrics and adult. 3. The type of  ndotracheal tubs we should use in pediatrics. 4. Revising the current threshold for blood transfusion. 5. Highlighting the approach to achieve homeostasis in pediatric patients. 6. Looking into the possibility of regional anesthesia in awake pediatric patients. 7. Looking into the role of ultrasound in pediatric anesthesia caudal blocks.

Ray Murtagh has worked in the field of Anaesthesia for the last 35 years and is currently employed in Australia as an Anaesthesia Allied Health Practitioner. He has specialized in paediatric Anaesthesia and is currently the specialist Anaesthesia assistant for all paediatric anaesthesia at his facility. He completed his dip AOTT at the Royal Prince Alfred Hospital Sydney in 1982 and has since worked in several hospitals throughout the Eastern Seaboard of Australia. Ray has been the President of ASAPO (Australian Society of Anaesthesia Paramedical Officers), now AAAHP (Australian Anaesthesia Allied Health Practitioners) of whom he is  now registrar. Ray has witnessed many first-hand crisis in Anaesthia and considers this topic of vital interest to those who work in the field.

During the past 40 years, there has been continual speculation and discussion on the safety and success of Anaesthesia. Over the last 40 years we have also seen many improvements in Anaesthesia, i.e. 1) Computerised monitoring of patients. 2) Improved modes of TIVA Anaesthesia. 3) Changes in gas flow rates for Anaesthesia. 4)Development and implementation of brainwave monitoring for anaesthetized patients. 5) Development of new and improved Anaesthesia medications. 6) Improved training of Anaesthesiologists and their Assistants. 7)More research into difficult airway management and other clinical crisis. With these advances and so-called improvements, what can we say, without a doubt, makes Anaesthia Successful and Safe? I propose to discuss in detail these advances and hopefully demonstrate the real reason as to What Makes Anaesthesia Successful and Safe. For a patient to die on the operating table is rare — but for patients with serious problems in their medical history, post-traumatic stress after a long operation can under some circumstances lead to death. Complications relating to anaesthesia are rare, and can usually be brought under control very quickly.

Arvid Steinar Haugen has his research expertise in surveys and clinical quality improvement trials of patient safety interventions with focus on surgical safety checklists, since 2008. He has clinical experience as a nurse anaesthetists since 1999 at Haukeland University Hospital, Bergen, Norway. His research include further trials on safety checklists in surgical wards, handover protocols, discharge checklist from medical wards and development of checklists for patients to use. He was awarded with the European Society of  nesthesiologists’ Baxter Prize in 2015 for the publication: Effect of the World Health Organization Checklist on Patient Outcomes: A Stepped Wedge Cluster Randomized Controlled Trial. Ann Surg. He is currently a visiting senior Post-Doc Researcher at the Centre of Implementation Science, Institute of Psychiatry, Psychology & Neuroscience, Health Service & Population Research Department, Kings College London, UK

Statement of the Problem: WHO Surgical Safety Checklist has become mandatory to use in most countries (WHO, 2009). Initial studies reported large reductions in both mortality and morbidity (Haynes et al 2009), though a large scale Canadian study raised concern about quality of the implementation and actual use of the checklist (Urbach et al 2014, Leap 2014). In recent studies, a stepped wedge RCT in Norway reported significant reduction of morbidity (43%) and length of stay (19 hours) (Haugen et al 2015), and further mortality was reduced in U.S. South Carolina Hospitals by 22% (Haynes et al 2017). In an invited commentary in JAMA Surgery Berry et al (2016) stated that the checklist will not work if you do not use it. The purpose of this study is to describe the experience on how to obtain a high compliance and sustainable use of the checklist.

 

Methodology & Theoretical Orientation: A review of research results and experiences on implementation of the WHO SSC in a stepped wedge cluster RCT and qualitative studies in Norwegian hospitals is combined with compliance rates from January 2014 to April 2017.

 

Findings: The results from our stepped wedge cluster RCT boosted attention to perform the SSC in our hospitals. Health trust and management focus on compliance combined with multi-disciplinary tailoring of the SSC, contributed over time to sustainable and increased actual use of the SSC.

 

Conclusion & Significance: Effectiveness and sustainable use of the SSC is depending on multidisciplinary surgical teams to play an active part in tailoring the checklist, and of managers being accountable for the compliance rates.

Gabor Kiss studied at the Free University of Brussels VUB (Belgium) and he completed his residency training in anesthesiolgy at the ULB Erasme Hospital in Brussels. He also trained in the UK and did his ICU fellowship in Australia. He worked in Brussels as a consultant in Anesthesia. Since 2003 he is a consultant in Anesthesia for Adult Cardiothoracics and Vascular Surgery and its postoperative Intensive Care Unit working in the French Public Health System. He is currently based at the French Reunion Island and attached to the department of  ardiothoracics and Vascular Surgery and its ICU at the University Hospital of Saint Denis.

Given the increasing numbers of complex and high risk patients requiring thoracic surgery, awake thoracic surgery (ATS) could be an option in frail patients especially those with high risks for ventilator dependency to reduce morbidity and mortality. Several papers conclude that ATS was superior to surgery under general anaesthesia in terms of reduced operating room time, better perioperative outcomes, reduced incidence of postoperative respiratory infections and acute respiratory distress syndrome, lower mortality rate, generally less complications, less need for nursing care, lower costs and shorter hospital stays. ATS may allow a fast-track protocol avoiding the intensive care unit. In spite of its benefits, ATS is ethically still widely debated and therefore there remains an urgent need to provide more evidence base medical facts to the current discussion. ATS is technically extremely challenging for the anesthesiologist and requires careful patient selection, thorough anesthetic preparation, high vigilance during the perioperative period, knowledge about potential perioperative difficulties and management of its complications.

Ghassem Attarzadeh worked as an Assistant Professor, Physiology Department, Hormozgan University of Medical Sciences, 1996, Iran. He pursued PhD in Neuroscience, Department of Neuroscience, University of Edinburgh (2002-06). He completed MSc in Human Physiology from Tarbiat Modarres University-Tehran- Iran (1992-95). B.Sc. of Biology: Ferdowsi University-Mashad-Iran, 1984-89. Hormozgan University of Medical Sciences, Department of Physiology, lecturer, 1995-2002.

Millions of people suffer from pain worldwide, and annually, great economic costs are imposed on societies for pain relief. Analgesics such as alpha-2 adrenergic receptor agonists, which have low risk of complications, can be effective in assuaging pain and reducing costs. According to former studies, potassium channels play an important role in the analgesic mechanism of these receptors. This study aimed to determine the role of BK potassium channels in analgesia induced by alpha-2 adrenergic receptors. This study was performed on 56 male Wistar rats weighing 250-300 g that were divided into seven groups of eight rats. We administered  0.7 mg/kg intraperitoneal (IP) injection of clonidine, 1 mg/kg IP injection of yohimbine, and 5 mg/kg intracerebroventricular (ICV) injection of yohimbine. Iberiotoxin at a dose of 100 nm was also injected ICV. Normal saline and DMSO were applied as solvents. Pain severity was evaluated using formalin test at a concentration of 2%. The chronic pain induced by formalin injection was relieved by IP injection of 0.7 μ /kg clonidine. Moreover, 5 μg/kg and 1 μg/kg ICV administration of yohimbine with mean chronic pain scores of 2.29±0.13 and 2.09±0.07, respectively, could significantly inhibit analgesic effect of clonidine with mean chronic pain score of 1.55±0.14 (p<0.001). ICV injection of iberiotoxin with mean chronic pain score of 2.33±0.16 at a dose of 100 nm significantly diminished analgesic effects of clonidine. Alpha-2 adrenergic receptor agonists could induce analgesia in the animals, and the antagonist of this receptor inhibited the analgesic effect of agonists of these receptors. BK channel inhibition prevented nalgesic effect of adrenergic receptor agonists, as well.

The development of less invasive surgical techniques, economic factors, and patient preferences provided addition impetus to the popularity of ambulatory surgery. Improved equipment, training, evaluation of patients, discovery of better anesthetic agents are the main reasons why ambulatory anesthesia remains so safe in modern times. (1) Obstructive sleep apnea (OSA) is the most commonly encountered form of sleep-disordered breathing (2)(3) (4) as repetitive cessation in airflow during sleep with intermittent hypoxemia, daytime sleepiness, neurocognitive dysfunction, cardiovascular and pulmonary disorders (5). Most patients remain undiagnosed at the time of presentation for surgery. They recommended preoperative assessment for OSA, a checklist of 12 items as a routine, a scoring system based upon the severity of OSA. They published practice guidelines for management of surgical patients with OSA for ambulatory surgery (4). These patients should not be discharged from the recovery area to an unmonitored setting until they are no longer at risk for postoperative respiratory depression, and recommended that upper abdominal procedures and airway procedures are not suitable for ambulatory setting (4) Otherwise The Society for Ambulatory Anesthesia (SAA) Consensus for patient with OSA evaluating the perioperative complications in ambulatory surgery.The preoperative factors that may influence the outcome (e.g., severity of OSA, coexisting medical conditions, and invasiveness of the surgical procedure) were assessed. This review has resulted in several recommendations that are contradictory to the ASA OSA guidelines. In contrast to the ASA guidelines the STOP–Bang screening questionnaire is preferred.(2)  and not support the ASA recommendations that upper abdominal procedures are not appropriate for ambulatory surgery. Currently in Mexico the prevalence of overweight and obesity was 71.3%(6) (7) It has been associated with difficult airway management and others disorders as OAS (3)(5). According ASA and SAA consensus because that and the increased perioperative complications the suitability of ambulatory surgery in patients with OSA remains controversial (2).

 

Statement of the Problem: The objective of this study was to determine if an anesthesiologist pre-operative visit could measurably reduce the common fears of patients scheduled to receive general anesthesia for outpatient surgery.

 

Setting: The preoperative surgical areas at William Beaumont Hospital at Troy, Michigan.

 

Methodology & Theoretical Orientation: The study was a prospective cohort survey that sampled patients scheduled to receive general anesthesia for outpatient elective surgery. Prior to their preoperative visit, patients were provided a five question survey on demographics.  Two identical surveys that asked patients to rate their level of anxiety on nineteen of the most common fears listed in the literature1-4 using a 5-item Likert scale (strongly disagree, disagree, neutral, agree, strongly agree) were distributed before and after the pre-operative visit.  An additional eleven question survey was administered after the pre-operative visit to assess patient perceptions of the anesthesiologist visit. 

 

Results: Fifty patients properly completed the pre and post visit surveys.  A Paired T-Test was utilized to compare the average change in the Anxiety Score before and after speaking with the anesthesiologist.  The overall results are displayed.  The Anxiety Score significantly decreased, on average, by 4.28 points after the patient speaks with the anesthesiologist (P-Value = 0.0002).

 

Conclusion & Significance: A reduction in pre-operative patient anxiety can lead to a reduction in negative patient outcomes, including pain, nausea, vomiting, and length of recovery.5-7  This study demonstrates that an anesthesiologist pre-operative visit can measurably reduce patient anxiety and fears in the pre-operative setting, which may impact post-operative outcomes.  Further statistical analysis is being completed to determine if the pre-operative visit is more effective at addressing specific patient fears above others.