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VOLUME 56 / / WINTER 2014 / / EDITOR GABRIEL M. GURMAN

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ESA Council Elections2014 -2017

EDAIC - Report from the Examinations Committee 2013

ESA’s statement on the new safety advice from the EMA

Message from the President // Advancing our Specialty DANIELA F IL IPESCU / / ESA PRESIDENT / / dan ie la . f i l i [email protected]

Dear ESA members,

I am deeply honoured to serve as your president for the next two years and I would like to use this opportunity to thank all Council and Board members past and present for giving me their trust and the unique opportunity to add value to ESA through my knowledge, skills and experience. My motto will be: “Continuity, transparency and teamwork”.

Today ESA is an extremely successful medical society. We are strong and dynamic but we cannot afford to rest on our past or present accomplishments. ESA must expand its educational offerings, grow throughout the international community and consistently show the increasing value of an ESA membership. We have a highly successful annual Congress, an increasingly prestigious Journal, a dedicated professional staff in Brussels and a growing membership base, providing us with the financial strength and stability to continue to develop even further.

This year we will implement the new by-laws, approved during the last General Assembly in Barcelona, which will open up the ESA to more and more anaesthesiologists through their National Societies. This will bring new responsibilities for the ESA leadership and the role of President of the ESA is becoming ever more demanding.

Our duties include: to raise the profile of the profession; to ensure the quality of ESA systems and processes; to engage the best people in the development of ESA; to attract young people to ESA leadership; to strengthen the relationship with our traditional partners, the European

Board of Anaesthesiology (EBA) and the World Federation of Societies of Anaesthesiology (WFSA); to develop collaborative and productive relationships with other European and non-European medical societies; to diversify the cooperation with industry; to preserve the scientific and political independence of ESA; to enhance the delivery of services to members and to acknowledge members contributions.

Finally, it is our duty to build our society's “roadmap” and to figure out where we want to be twenty years from now. This month the leadership will have a strategic meeting to discuss our current achievements and to lay out a course of action that will ensure that ESA thrives on a long term basis.

My vision is for ESA to be recognised as a world leader in setting standards and promoting excellence in anaesthesia, peri-operative medicine, intensive care, pain treatment and emergency medicine. My strategic priorities are to harmonise clinical care throughout Europe, to build ownership, to ensure that ESA is a sustainable organisation and to develop and maintain strong relationship not only with other medical societies but also to other stakeholders involved in health care all over the world. Other medical societies have already approached the European Parliament to promote their mission and we should be inspired by them.

I would like to contribute to this vision by continuing to develop and implement the successful ESA and ESA/EBA/WFSA projects on education (European Diploma of Anaesthesiology and Intensive Care and related activities, CEEA courses, trainee exchange programme,

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hospital visiting and training accreditation programme, masterclasses, teach the teacher courses, clinical guidelines and competence-based training curriculum) and research (through the clinical trial network and awards), by promoting new projects such as e-learning platforms, simulation for training and assessment, registries, interventional studies, and by promoting advocacy and professionalism.

I also think that it is time to strengthen the position of anaesthesiologists in the fields of peri-operative medicine and intensive care medicine. In order to do so we need to develop strategic relationships with related societies, including subspecialty societies, and to invest more in developing and increasing visibility of this part of our profession.

I would like to dedicate my two year term to the implementation of the Helsinki Declaration on Patient Safety and to "bridge the gap" between different countries in terms of patient safety culture through educational programmes, research and active involvement of National Societies from all over Europe in this process. I also hope that more anaesthesiologists from Eastern European countries will become more confident and involved in the development of ESA as different requirements of the Patient Safety Declaration require different approaches in different parts of Europe. It is my belief that this will bring us all to higher and safer standards of anaesthesiology.

To achieve these ambitious objectives we have to improve communication at all levels: Board, Council, Committees, Secretariat and Members. As we grow, we need to communicate more effectively with each other as members and allow everyone the opportunity to become more involved. We undoubtedly have the energy and talent amongst our members to make ESA more successful! The new ESA website has recently been launched and besides being more attractive it is also making our members more aware of our activities. We are now visible through Social Media too and is your collective efforts that will continue to drive the exceptional character of our Society.

Finally, it is my goal to improve the transparency of our governance and I encourage you to contact me, the Board or the Council members at any time with any issues that you feel might improve the work of the Society and the care of those we serve. The ability to build a consensus is crucial to the success of any leadership so we are all moving forward together, united in our ambition to advance our specialty and protect our future.

Thank you for your continued support of the Society. I look forward to hearing from you and working together with you in the coming months. //

Daniela FilipescuESA President //

[email protected]

EDITORS

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EDITORSThe making of a good resident // how difficult would it be?GABRIEL M. GURMAN, MD / / ESA NEWSLETTER EDITOR / / [email protected] . i l

Last November, at the request of the organisers of the ESA 2013 Autumn Meeting in Timisoara, I presented a 30-minute lecture on the residency track in anaesthesiology, which I named "the anatomy of teaching and training anaesthesiology". This editorial includes some excerpts of that lecture, inspired by the fruitful scientific atmosphere of that successful meeting.

That winter of January 1961 in Bucharest, Romania, was a very cold one. A lot of snow and traffic jams put a real obstacle in my way to the hospital where I was awaited for my first day as a resident in anaesthesia and intensive care. This was the start of a long journey with an ill-defined beginning towards an unidentifiable end, as J. Parkhouse defined the anaesthesia residency track in 1980. I and my fellow colleagues in residency did not know exactly to what our career was directed, nor did we have textbooks or a well-established framework for achieving a strong theoretical background. All we knew was that we were needed in the operating room (OR) on a daily basis, and that we had to do anything in order to cover the two most important tasks: to keep the patient asleep and wake him or her up as soon as possible after the end of the surgical procedure. Reality is completely different these days. In spite of still existing differences between various parts of our continent, the anaesthesia residency track is a well-defined journey and the end is well known, too. We prepare our residents to become good specialists in their domain. This means that once getting their professional independence, they would be able to successfully apply in their daily practice what they learned during residency years. A young specialist is the one who knows to assess his/her patient's problems and risks, who is able to select the anaesthesia technique that is

most appropriate to the patient's condition, and who could change the course of the anaesthesia act in conformity with changes in the patient's situation on the operating table. Everything in the name of patient safety. His/her job goes on after surgery. The anaesthesia specialist is responsible for the well-being of the patient in the immediate postoperative period. Stabilisation of vital functions, pain management, fluid administration, and sometimes perioperative antibiotic therapy are all part of our routine activity. In some situations, such as trauma management, the anaesthesiologist accom-panies and takes care of his/her patient in the pre-hospital area, continues that involvement in the emergency room, takes care of the patient on his way to the operating theatre (sometimes passing through the imaging department), anaesthetises the patient in the OR, and would be in charge of the same patient in the critical care department. This is what our colleagues from the other side of the Atlantic Ocean call a "perioperativist".

// How to achieve all the above?

The first step would be a proper selection of candidates. But this is not enough. The ideal situation implies that the best candidate would be selected for residency in a department that is prepared not only to distribute daily tasks, but also or mainly to assure a proper residency track and prepare the young physician for the moment when he/she would act independently and have sole responsibility for a patient's safety.

Above all, one has to be sure that the candidate to the residency track was given all the necessary data in order to understand toward what kind of a professional route they are going.

Anaesthesiology is not a profession like any other. We serve not only the patient but also our fellow surgeons. We do not treat only sick patients, but sometimes healthy human beings (see our job as anaesthesiologists in obstetrics). In comparison to many other medical fields, we are dealing with blind methods, and we are supposed to manage them in a proper and successful way. Our patients do not come to the hospital in order to be anaesthetised, but to be operated on, so adverse events of anaesthesia are much less accepted than surgical complications. Finally, in most situations we are part of a therapeutic team, and this fact demands minimising our ego in favour of the team atmosphere.

Does anybody think that all these particulari-ties are well understood by the new resident on the first day of her/his residency?

// The importance of the extra-OR fields of activity

The anaesthesiologist is by no means "the main intubator of the hospital". Our profession is one with multiple facets. We prepare the patient for the surgery and anaesthesia in the outpatient anaesthesia clinic. We take care of them in the intensive care units. We are in charge of the acute pain service and with the pain management outpatient clinic. We provide sedation in the imaging department for gastroenterology procedures and sedate our younger, smaller patients in the paediatric department for painful procedures.

The extra-OR domains of our profession are essential for making sure that in spite of a need for perfect technical, manual skills in our daily activity, we are first of all physicians, with broad theoretical knowledge and clinical experience and correct clinical judgment.

CORNER

Gabriel M.Gurman // ESA Newsletter Editor

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Editor's note: The Editor would like to thank Prof George Litarczek (anaesthesia history flashes) and Dr Sue Hill (samples of EDAIC questions and answers) for their special contribution to the issues of the ESA Newsletter during 2013

Some people advise that, comparable with the professional life of a surgeon, the average anaesthesiologist will not spend more than 50% of her/his activity in the OR. The other half of our routine activity is to be divided between outside-the-OR clinical activities, as well as research and teaching.

Yes, we are teachers and we teach and train other people from the very first day we possess the necessary knowledge and experience for sharing it with others: students, younger residents, physicians from other specialties, nurses, and other healthcare professionals.

Teaching the teacher is not an amateur field. It demands skills and vocation. But above all we need to train the future trainer, because nobody is born a teacher.

// The end of the residency track is as important as its start

One must be aware of the fact that starting a residency in anaesthesiology does not assure a 100% successful outcome. The obstacles in the way of a resident to become a young specialist are sometimes more difficult to overcome than a difficult tracheal intubation or performance of a spinal anaesthesia for a morbidly obese patient.

Challenges are spread throughout the residency track. The resident is supposed to prove on-line his/her capabilities to fulfil the future tasks of a specialist.

Periodic assessment of the resident is the utmost demand. Final examination is a must and it has to bring the examiners to the conclusion that the resident possesses all the necessary qualities to become an independent professional.

One crucial question refers to the situation in which the physician completed the residency track, but did not pass the final examination.

What would be her/his professional status? Are the medical administration and the medical community ready and able to accept this "no resident, no specialist" individual and use his/her professional capabilities in a framework in which he/she would act under the supervision of a specialist, but possessing a certain degree of professional independence?

// A final word

We create specialists since residency is not a perennial profession.

We offer residents everything they have to know in order to be, one day, on their own.

We, the teachers, have a civic and moral responsibility towards their future patients.

In most cases we will not be able to follow-up on their career and in the best case we would be lucky to hear from time to time about their professional evolution.

But in our eyes, they will remain our residents, our trainees, our pupils. This is why we must fulfil our task as teachers.

We do not create robots, nor professionals who just follow algorithms, protocols, and guidelines. We produce professionals with a human attitude towards the patient, doubled by a healthy clinical judgment and high skills. We ask and teach each of them to know his/her own limits and say, if necessary: "I do not know".

Eventually the former specialist, now the young resident, takes with him a good part of our personality and life experience. Eventually they copy us. This is why our responsibility, as teachers and chiefs, is far beyond the strict track of residency. //

CORNER

05

“”

Tell me and I forget, teach me and I may remember, involve me and I learn

(Benjamin Franklin 1708-1790)

ESA Council Elections 2014 -2017 // The ESA has started the procedure to elect the new council members for the society for the next three year term of office which will run from 1 April 2014 to 31 March 2017.

The call for candidates was published in the e-News and an email was sent to all active and trainee members of the society.

The council member from your country represents your interests within the society. They can act as “your voice” and liaise with the board and discuss any issues that may arise at the Annual Council Meeting.

Remember that with your vote your elected national representative can influence the decision making process of the ESA!

NEW : Trainee Council MembersDue to a change in our by-laws, from 2014 we will also have 2 trainee members on the ESA Council. These will be elected by our trainee members.

The trainee council members will represent and protect the rights of all trainee members. These two representatives will be responsible for contact and regular transfer of information between ESA and its trainee members.

The ESA feels it is very important to have the views and input from our newer and younger members heard in a constructive manner!

The elections will be held early in 2014 and the new Council will meet for the first time at Euroanaesthesia 2014 in Stockholm.

All countries with at least 25 active and trainee members, or at least 10% of the total number of practicing anaesthetists in a given country are entitled to have a member sitting on the council.The list of countries is available on the ESA website (www.esahq.org).

We strongly encourage all eligible ESA active and trainee members to cast their vote in the upcoming elections. //

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VACANCIES

Associate Editor for the EJA //The European Journal of Anaesthesiology is seeking an associate editor.

Associate editors independently handle 20 to 30 articles per year and ensure a smooth and efficient procedure from submission to completion, maintaining good and timely contact with peer reviewers and authors. Basic English proficiency is necessary to communicate with authors, peer reviewers and editorial staff, although our English language editors deal with the final draft of the submissions. An editor’s term is three years, renewable twice.

Candidates must be members of the ESA, active researchers, and familiar with the international guidelines of good quality of data reporting (CONSORT, PRISMA etc).The European Journal of Anaesthesiology is especially looking for experts in intensive care, neuroanaesthesia and pharmacology/pharmacokinetics. Interested colleagues are invited to submit a short CV (max 1 page A4), and a list of your publications of the last three years (since January 2011) to Mrs Bridget Benn, Journal Manager, at [email protected].

Application deadline: 28 February 2014

“”

Whatever other interests the anaesthetist may have, whether it be intensive care, the treatment of chronic pain or respiratory pathophysiology, his foundation must be always the administration of anesthesia

(DD Howat , Anaesthesia 1977;32:979)

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VACANCIESESA Research Committee Chairperson // The ESA is seeking to recruit a new Chairperson of the ESA Research Committee.

The three-year tenureship of the Chairperson of the ESA Research Committee (RC) becomes vacant on 1 January 2015. The future RC Chairperson will be appointed on 1 April 2014 and will spend 9 months as deputy before becoming the RC Chairperson.

RoleThe new Chairperson will take over from Professor Andreas Hoeft, and will liaise closely with him in the months up to 1 January 2015. The RC plays an important role in the activities of the Society. The Committee is composed currently of eight members. The RC Chairperson post requires close liaison with the Research Department of the ESA Secretariat in Brussels throughout the year to:

• review grant applications in the fields of clinical and basic sciences relevant to Anaesthesia, Intensive Care and Pain Medicine, and to make recommendations for the award of grants;

• advise on the organisation and management of the grant evaluation process; • advise the ESA Board on the range of research grant schemes offered by the ESA; • play an active role in the improvement of the activities of the Committee;• play an active role in the ESA Clinical Trial Network.

The appointed members will be required to attend 3 to 4 meetings of the Research Committee. Travel expenses to attend meetings of the Committee are provided according to standard ESA policy.

RequirementsApplications are encouraged from active ESA members across Europe who meet the following criteria:

• established academic reputation; • experience in writing grant applications and obtaining competitive funding; • expertise in clinical and / or laboratory research is required.

Term of officeThe new Chairperson of the Research Committee will spend 9 month as from 1 April 2014 as deputy before becoming the Chairperson on 1 January 2015. The Past-Chairperson will remain a member of the RC for 18 months after the end of his term as Chairperson.

How to apply?If you are interested, and wish to apply, please send by e-mail:

• the application form available at www.esahq.org;• your Curriculum Vitae, which should detail how you meet the criteria; • short outline (maximum one page A4) of your perspectives as RC Chair.

Applications must be received to [email protected] no later than 1 March 2014 (23:59 CET) with the following subject ‘ESA Research Committee Chairperson - vacancy 2014’.

Appointment will be made by the ESA Board following recommendation by the Nominations Committee. It is possible that interviews will be held at the ESA Secretariat to select the successful candidate.If you would like to discuss any aspect of this post, please contact: Prof. A. HoeftChairman ESA Research [email protected]

For more information about the ESA Research Committee please visit the ESA website www.esahq.org.

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“”

The wise man lives as long as he should, not as long as he can. He will always think of life in terms of quality and quantity

(Seneca`4 BC-AD 65)

ESA

Obituary Dr. Geraldine O´Sullivan // EBERHARD KOCHS // ESA PAST PRESIDENT // [email protected]

It is with great sadness that I have to inform you that Dr. Geraldine O´Sullivan passed away on 2 December 2013 after a long and courageous battle with cancer. Dr. O´Sullivan was a tireless member of the European Society of Anaesthesiology, serving in a number of different roles. She was elected Chair of the National Anaesthesiology Societies Committee (NASC) in 2011 and with her unique dedication was very successful to further develop the role and importance of NASC within ESA. An example of her success was via NASC to organise the first ESA “Teach the Teacher” course which adapted the ISIA (International School for Instructors in Anaesthesia) concept, previously organised by WFSA and ESA under the direction of our esteemed colleague Gaby Gurman. She was also an ex-officio member of the Guidelines Committee, the Education and Training Platform and the Board of Directors. She was elected to ESA Council in 2010 and became a member of Faculty of Euroanaesthesia Congresses in 2009. A speaker at a variety of scientific meetings, she was a member of the Task Force on Preoperative Guidelines (2009-2011). She was also the past President of the Obstetric Anaesthetists’ Association (OAA), the largest sub-specialty society in anaesthesia in the UK.

Dr. O´Sullivan was lead clinician for obstetric anaesthesia at St. Thomas´ Hospital, the largest maternity unit in London and a tertiary referral centre for high-risk pregnancies. In addition to her clinical work, she was actively involved in research, publishing extensively in obstetric anaesthesia and was on the Editorial Board of the International Journal of Obstetric Anaesthesia. The development and teaching of anaesthesia in the so-called “less affluent countries” was one of Dr. O´Sullivan’s big interests and a matter very close to her heart. She was always willing to give lectures and teach colleagues in those countries and has co-organised meetings on obstetric anaesthesia in Romania and Serbia. Right up until her death, she was planning similar meetings in Kosovo and Nepal.

Dr. O´Sullivan will always be held in high esteem by all who knew her. A dedicated colleague and a delight to meet, she always served the ESA in the best interests of our European community. She will be remembered by many whose lives she touched and it is with enormous sadness that the ESA has to say goodbye to one of its greatest colleagues and foremost leaders. Her untimely death leaves a big gap in the national and international anaesthesia community and our thoughts are with her family and friends at this very sad time. //

Dr. O’Sullivan lecturing at the last Euroanaesthesia 2013 meeting in Barcelona

Thank you letter from Professor Richard Collin

December 2013

Dear ESA Board & Staff

Many thanks for all your cards, letters, telephone calls and messages of sympathy and understanding for the loss of Geraldine. She was a very special person on all counts as a caring human being, doctor, wife and mother and we are all three devastated. Our loss is, however, much more bearable with all your wonderful support and thank you for the wonderful obituary you made for Geraldine.

Richard, Sophie & Olivia

09ESA

ESA Autumn meeting 4 in Timisoara // Romania The ESA Autumn Meeting has now entered its fourth year. It is a satellite event to the summer Euroanaesthesia congress, with an aim to extend educational activities to European countries, which for practical reasons cannot accommodate events of a similar size to Euroanaesthesia. The Autumn Meeting also aims to improve access for attendees from Central and Eastern Europe. This fourth ESA Autumn Meeting was held in Timisoara, Romania on 8 and 9 November 2013 and organised with the cooperation of the Romanian Society of Anaesthesiology and Intensive Care Medicine (RSAICM).

ESA Past President Eberhard Kochs and Dorel Săndesc, President of RSAICM, welcomed the 641 attendees and launched the two-day programme, which included 34 presentations. The topics covered updates in anaesthesia and intensive care, new ESA guidelines, acute and chronic pain management, locoregional anaesthesia and a hot topics session on patient safety and financing anaesthesia and intensive care in low-income countries. In addition, an airway hands-on workshop was held on both days. An exhibition hall hosted industry representatives. ESA members and Autumn Meeting attendees can download lecturers’ presentations by logging into the ESA website and choosing Congresses > Past Autumn Meetings > Autumn Meeting 2013 > Autumn Meeting Presentations.

The atmosphere during the Autumn meeting was excellent, with good interactions between lecturers and the audience and active exchanges between attendees. The overall feedback on the event was also very good. The relevance of the topic areas and the quality of speakers and presentations were positively received by participants. The attendance at the workshops and problem-based learning discussions confirmed the interest for these session formats, and the comments on organisation, venue, facilities and catering were excellent. The extensive social programme was very much appreciated by delegates.

The ESA would like to extend a heartfelt thank you to RSAICM for their extensive support and collaboration in the organisation of this very successful 4th ESA Autumn Meeting. //

EDAICEuropean Diploma in Anaesthesiology and Intensive Care (EDAIC) //Report from the Examinations Committee 2013ZEEV GOLDIK / / CHAIRMAN, EXAMINATIONS COMMITTEE / / go ld ikzeev@c la l i t .o rg . i l

This year we celebrate the 30th Anniversary of the European Diploma in Anaesthesiology and Intensive Care (EDAIC). We can be proud of our impressive achievements. Over time, delegates from many European Countries have joined the Examinations Committee and one could now compare it to a small European parliament!

Examinations Committee: Zeev Goldik (Chair) (IL), Eric Buchser (CH), Sue Hill (UK), Brian Sweeney (UK), Elisabeth Van Gessel (CH), Andrey Varvinskiy (UK), Lars Wiklund (SE).

Examinations Subcommittee Part I: Sue Hill (Chair) (UK), Estibaliz Alsina (ES), Pedro Amorim (PT), Luca Brazzi (IT), Tobias Broecheler (DE), Serban Bubenek (RO), Akos Csomos (HU), Zeev Goldik (IL), Vesna Novak Jankovic (SI), Svetlana Plamadeala (MD), Altan Sahin (TR), Wolfgang Toller (AT), Albert Urwyler (CH), Andrey Varvinskiy (UK), Magdalena Wujtewicz (PL) (in addition, 4 vacant positions were recently advertised on the ESA website).

Examinations Subcommittee Part II: Eric Buchser (Chair) (CH), Bazil Ateleanu (UK), Peter Biro (CH), Joerg Brederlau (DE), Zeev Goldik (IL), Jean-Jacques Lehot (FR), Brian Sweeney (UK), Mario Zerafa (MT) (1 vacant position was recently advertised on the ESA website).

OLA Subcommittee: Sue Hill (Chair) (UK), Zekeriyya Alanoglu (TR), Nicolas Brogly (ES), Wolfram Engelhardt (DE), Zeev Goldik (IL), Marcin Sicinski (UK), Armen Varosyan (AM) (2 vacant positions were recently advertised on the ESA website).

Meeting of the Examinations Subcommittees// in Brussels, October 2013

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EDAIC Part I (written examination)2076 candidates sat the Part I in 2013 compared to 1541 in 2012 (an increase of 35%).Of these 2076, 1161 were successful and 915 failed, with an overall pass rate of 56%.New Part I centres in 2013: Beirut, Berlin, Cairo, Dublin, Ghent, Pamplona, Thessaloniki and Utrecht.

Candidates sitting the EDAIC Part I 1984 - 2013

The candidate who obtained the highest scores at the Part I examination in 2013 is Dr Aslam Sher Khan Akbar (pictured) who will receive the John Zorab Prize. As an Indian working in Bahrain, Dr Akbar is the first non-European to win this prize. Many congratulations to him!

Dr Aslam Sher Khan Akbar// John Zorab Prize winner 2013

Board of Part II Examiners in London // UK Board of Part II Examiners in Istanbul // Turkey

ITA (In-Training Assessment)In 2013, 286 candidates sat the ITA against 332 last year. This decrease is a consequence of the start of the OLA in 2013 and the shift from ITA to OLA will probably continue in the coming years.

OLA (On-Line Assessment)203 candidates sat this new computer based assessment across 36 centres on 19 April 2013.

The next OLA will take place on 11 April 2014 and will be offered in 7 languages: English, French, German, Russian, Spanish, Polish and Turkish. On-line applications for this OLA will close on 20 February 2014.

EDAIC Part II (oral examination)

A total of 502 candidates sat the Part II examinations in 2013. 340 were successful and 162 failed (pass rate: 68%).

New Part II centres: Berlin in 2012; Istanbul and London in 2013; Warsaw in 2014.

In 2014, the Part II centres will be: Porto, Barcelona, Göttingen, Uppsala, Madrid, Zürich, Istanbul, Vienna, Erlangen, Warsaw and London.

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Part I (MCQ) and In-Training Assessment (ITA)Amsterdam - Netherlands Athens - Greece Barcelona - Spain

Beirut - Lebanon Belgrade - Serbia Berlin - GermanyBerne - Switzerland Bucharest - Romania Budapest - Hungary

Cairo - Egypt Chisinau - Moldova Cork - IrelandDublin - Ireland Genoa - Italy Ghent - Belgium

Göttingen - Germany Groningen - Netherlands Innsbruck - AustriaIstanbul - Turkey Jakarta - Indonesia Jerusalem - IsraelLiège - Belgium Lisbon - Portugal London - UKLund - Sweden Ljubljana - Slovenia Madrid - Spain

Milan - Italy Moscow - Russia Msida - MaltaOslo - Norway Pamplona - Spain Paris - France

Porto - Portugal Riga - Latvia Rome - ItalyRotterdam - Netherlands St. Petersburg - Russia Tbilisi - Georgia

Thessaloniki - Greece Trondheim - Norway Turku - FinlandUppsala - Sweden Utrecht - Netherlands Valencia - SpainVienna - Austria Warsaw - Poland Yerevan - Armenia

OLA CentresAnkara - Turkey Basel - Switzerland Braga - Portugal

Bregenz - Austria Bucharest - Romania Budapest - HungaryCluj-Napoca - Romania Coimbra - Portugal Cork - Ireland

Dublin - Ireland Erlangen - Germany Freiburg - GermanyFunchal - Portugal Genoa - Italy Groningen - NetherlandsHeraklion - Greece Iasi - Romania Jakarta - Indonesia

Lausanne - Switzerland Lisbon - Portugal Ljubljana - SloveniaMaastricht - Netherlands Madrid - Spain Msida - MaltaNijmegen - Netherlands Nis - Serbia Oslo - Norway

Porto - Portugal Sanliurfa - Turkey Tenerife - SpainTonsberg - Norway Torquay - United Kingdom Valencia - Spain

Vienna - Austria Vila Nova de Gaia - Portugal Yerevan - Armenia

EDAIC Part I Centres // in 2014 new centres will open including Belgrade, Genoa, Rotterdam and Tbilisi.

OLA Centres in 2013

The next Part I examination will take place on Saturday 20 September 2014. Applications for the 2014 Part I examination and ITA will open in March 2014.

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Candidates sitting the EDAIC Part II 1985 - 2013

Applications for the 2014 Part II examinations were opened in December 2013.

Adoption of the EDAIC in the Netherlands

The Dutch Society of Anaesthesiology (NVA - Nederlandse Vereniging voor Anesthesiologie) decided to adopt the EDAIC Part I as the official national primary examination from 2014. The OLA will be used as a second session in April. Congratulations and good luck to all Dutch residents and organisers!

AcknowledgmentsI want to thank the Examinations Committee and Subcommittees chairs and members, especially Sue Hill, Eric Buchser, Andrey Varvinskiy and Brian Sweeney for their long-lasting and invaluable contribution; all examiners and hosts for their time and dedication and the whole ESA Secretariat staff for the excellent job they have done.

I would like to express our gratitude to all colleagues who contributed to the development of the EDAIC during all these 30 first years.

EDAIC 30th Anniversary celebrationA celebration session for our 30th anniversary will take place during the next Euroanaesthesia Congress in Stockholm (31 May-3 June 2014, Stockholmsmässan). //

Dr Hans Jürgen Gerbershagen (left) and Dr Mattijn Buwalda (right) posing with their diplomas and Dr Zeev Goldik in the Netherlands

EDAIC Coordinators Hugues Scipioni (left), Raffaella Donadio (middle) and Murielle Piette (right)

THE EUROPEAN DIPLOMA IN ANAESTHESIOLOGY & INTENSIVE CARE (EDAIC) IS: • Amultilingualtwo-partexamination• OrganisedbytheEuropeanSocietyof

Anaesthesiology(ESA)• EndorsedbytheEuropeanBoardof

Anaesthesiology(EBA)

THE EDAIC COVERS:• Basicappliedscience• Managementofanaesthesia,intensive

care,peri-operativecare,chronicpain,resuscitationandemergencymedicine

Boost your career!

Setting the European Standard for Anaesthesiology and Intensive Care

ThecurriculumandexamaresetbyindependentEuropeananaesthesiologists.

RaiseyourtrainingtoEuropeanlevel.

European Society of Anaesthesiology, 24 Rue des Comédiens, B-1000 Brussels, Belgium T: +32-(0)2-743-3290 | F: +32-(0)2-743-3298 | E: [email protected] | www.esahq.org

Moreinformationonwww.esahq.org

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Boost your career!






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Preparation for the EDAIC // Multiple Choice Questions for Part ISUE HILL // CHAIRMAN PART 1 EDAIC SUBCOMMITTEE // sue.h i l [email protected]

Paper A consists of 60 multiple true/false questions . Each question has five parts, each of which can independently be true (T) or false (F). Of these 60 questions, 20 are physiology, 20 pharmacology, 18 physics and equipment and 2 statistics. The following five questions have been taken from the EDAIC question bank for Paper A (Basic Science).

1. Regarding stretch reflexes: A. the knee-jerk is a monosynaptic reflexB. the latency of the human knee jerk is 200 msC. muscle contraction is a result of gamma-motor neurone

activationD. the efferent component arises in anterior horn cellsE. nerves conducting the afferent component are unmyelinated

2. Drugs which decrease myocardial oxygen demand include:A. nitroglycerinB. dopamineC. sodium nitroprussideD. isoproterenol (isoprenaline)E. amiodarone

3. Concerning the electromagnetic spectrum:A. individual wavelengths are proportional to the reciprocal

of their frequencyB. the frequency of X-rays is lower than of gamma rays C. the wavelength of ultraviolet is longer than that of infra-

red lightD. radio waves have a lower frequency than X-raysE. oxygen is capable of absorbing the energy of high-

frequency ultraviolet light

4. When using indirect measurement of arterial pressure:A. the width of the cuff should be 40% of the mid

circumference of the armB. use of a normal cuff in an obese person would tend to

underestimate the arterial pressureC. the systolic arterial pressure is normally slightly below that

sensed by direct measurementD. oscillometric methods require the sensing of both static

and dynamic pressures changesE. in oscillometry the systolic pressure is determined at the

point where the first pulse is sensed

5. Student's unpaired t-test is a statistical technique that:A. determines the degrees of freedomB. may be applied to a comparison of the means of two

samples when the sample sizes are smallC. avoids the use of the null hypothesisD. is used for comparing samples where the data are

approximately normally distributedE. assumes p < 0.01 for significance

Answers and Explanations //1. Regarding stretch reflexes: answers for parts a to e are: TFFTF

The knee jerk is a classic example of a monosynaptic reflex: just one synapse is involved in the anterior horn between the sensory afferent and the unilateral motor efferent. Stretch of the quadriceps activates its muscle spindles, which send a type Ia afferent sensory nerve signal to the spinal cord through the dorsal horn. This signal passes through the dorsal horn and synapses on the cell bodies of the alpha-motor neurones in the anterior horn that transmit the efferent motor signal that leads to contraction of the muscle. Type Ia sensory fibres are myelinated, rapidly conducting sensory nerves with their cell bodies in the dorsal root ganglia. Alpha motor neurones are also rapidly conducting, myelinated fibres. Both Ia and alpha motor neurones conduct at 80-120 m/s. The latency of the knee jerk is very short, much less than 200 ms - around 20 ms. You could estimate this knowing the distance travelled from knee to spinal cord is around 1 m, so with nerves that conduct at 100 m/s 2 m will be covered in 2/100 s or 20 ms (synaptic transmission is so quick it can be discounted). Gamma-motor neurones are also activated causing contraction of intrafusal fibres within the muscle spindle; but it is the alpha-motor neurones that innervate the extrafusal fibres responsible for muscle contraction.

2. Drugs which decrease myocardial oxygen demand include: answers a-e: TFTFT

Myocardial oxygen demand will be increased by drugs that increase the work of the heart and reduced by drugs that reduce the work of the heart. This question asked about drugs that reduce myocardial oxygen demand. This includes drugs that directly or indirectly reduce contractility - including those that reduce afterload and reduce heart rate. Therefore nitroglycerin and sodium nitroprusside reduce myocardial oxygen demand by reducing afterload and amiodarone by reducing heart rate. Dopamine and isoproterenol both increase the heart rate and so increase work of the heart and oxygen demand.

3. Concerning the electromagnetic spectrum: answers a-e: TTFTT

This basic physics question is not one of the mainstream topics, but nevertheless knowledge of the electromagnetic spectrum is important to our practice. The wavelength range of the electromagnetic spectrum is very wide but of importance to us. Approximate wavelength ranges, with longest first, is: the infra-red range (1 mm to 760 nm), the visible spectrum of colours (760 nm to 380 nm), ultraviolet light (between visible and X-rays, 1 - 380 nm), X-rays (1 Angstrom to 1 nm) and gamma-rays (0.1 Angstrom to 1 Angstrom). There is an inverse relationship between frequency and wavelength: the longer the wavelength the lower the frequency. Frequency (f) is equal to the speed of light (c) divided by the wavelength (λ) (f = c/λ). Thus the order in terms of frequency (highest first) is: gamma rays; X-rays; ultraviolet; visible light; infra-red. Thus X-rays have a lower frequency than gamma rays and ultraviolet has a shorter wavelength than infra-red light. You should know that radio waves have much longer wavelengths, the frequency of broadcasts are in the 50 MHz to 1000 MHz - wavelengths vary between several hundred metres and a few millimetres. For completeness, the wavelength range of microwaves lies between radio waves and infra-red light. The ability of a substance to absorb the energy of electromagnetic waves and hence block their transmission depends on the material itself and the frequency of the wave in question. Oxygen can absorb high-frequency energy and hence can absorb electromagnetic radiation in the X-ray and UV part of the spectrum, but not visible light or waves with lower frequencies - otherwise radios or mobile phones could not function! Infra-red excites water vapour in air and is blocked for this reason.

RESEARCH

4. When using indirect measurement of arterial pressure: answers a-e: TFTTF

Indirect measurement of blood pressure involves manual or mechanical inflation of a blood pressure cuff and detection of pulsations. A properly-fitting blood pressure cuff is essential for accurate readings. The cuff should be 20% wider than the diameter of the part of the limb being used or cover two-third its length. Since circumference is 2πr = πd (r: radius; d: diameter) and the value of π is approximately 3, 40% of the circumference is 4/10 of 3d or 12/10 of d which is the same as 20% (2/10) greater than the diameter of the arm. A cuff that is too small tends to overestimate and a cuff that is too large underestimates the systolic pressures. In mechanical oscillometry, the cuff both inflates and senses the pulsations. The systolic pressure is recognised as the point where the rate of increase in the size of oscillation is maximal and diastolic pressure at the point of maximal rate of decrease in size of oscillation. Therefore oscillometry must measure both the value of the pressure pulse (static) and its rate of change (dynamic). Mean blood pressure values measured by oscillometry are accurate compared with direct, invasive measurement, but systolic is often a little lower and diastolic a little higher than when measured directly.

5. Student's t-test is a statistical technique that: answers a-e:FTFTF

The unpaired t-test attributed to “Student” (a pseudonym for William Gosset) is a parametric statistical test used to compare the mean values of two samples. It can be used for small or large samples. The two samples must be approximately normally distributed and have similar variances (within a factor of 3); there is no need for the sample sizes to be the same. All statistical test need a null hypothesis and the t-test is no exception; the null hypothesis is that there is no difference between the means. In order to perform the test the number of degrees of freedom must be calculated, the test does not calculate degrees of freedom (DoF). DoF depends on the sizes of the samples and is (n-1) + (m-1) where the two samples have sizes n and m respectively. The “p” value is set by the person designing the study, not assumed by the test, and is usually set at 0.05 or 0.01; only if p = 0.01 is specified does p < 0.01 indicate a significant result; if p is set at 0.05 then p < 0.05 is a significant result. //






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A4-EDAIC-AD.indd 1 10/10/2013 12:28:12

Part I EDAIC //Sample Questions SUE HILL // CHAIRMAN PART 1 EDAIC SUBCOMMITTEE // sue.h i l [email protected]

1. GastrinA. is a peptide hormoneB. receptors are found on gastric parietal cellsC. is produced in response to vagal stimulationD. is secreted into the stomachE. is a pancreatic enzyme

2. Central sedation is produced byA. hyoscine (scopolamine)B. clonidineC. droperidolD. glycopyrrolateE. magnesium

3. Inhalational anaesthetic agents with a blood-gas partition coefficient less than 1.0 include:A. sevofluraneB. nitrous oxideC. desfluraneD. isofluraneE. xenon

4. The normal reaction of carbon dioxide with soda lime includesA. formation of sodium bicarbonateB. formation of calcium carbonateC. release of heatD. formation of waterE. liberation of carbon monoxide

5. Concerning central venous pressure (CVP) monitoringA. The presence of atrial fibrillation produces prominent

'a' wavesB. Third degree heart block produces giant 'v' wavesC. Tricuspid regurgitation produces cannon 'a' wavesD. Pulmonary hypertension produces giant 'a' wavesE. Diastole begins immediately after occurrence of the 'c'

wave

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Results of 2014 ESA Research Grant ApplicationsANDREAS HOEFT / / CHAIRPERSON OF THE RESEARCH COMMITTEE / / andreas .hoe f [email protected] i -bonn.de

Fifty applicationsOn 27 November 2013, the Research Committee met in Brussels to discuss the 50 Research Grant applications received: 6 applications in the Research Support Grants winners (15€k) category, 21 in the Projects Grants winners (60€k) category, 17 in the Young Investigator Start-Up Grant (30€k) category and 6 Meta-Analysis Grant (20€k) category

A two-round evaluationApplications were reviewed in a first round by Research Committee members. Each application was ranked independently and according to a predefined threshold value, selected to a short list for final evaluation. From the 50 applications, 23 were shortlisted for the 2014 Research Grants. These applications received also external reviews and were discussed in detail by the Research Committee members during the meeting in November. The following criteria were considered for evaluation: 1) Scientific merit 2) Methodology 3) Relevance4) Budget appropriateness 5) Research group and other consideration.

The following applications were successful:a. Project Grant winners (60,000€)

• Rinat Abramovitch (IL) 'Modifications of the liver regenerative process as a consequence of bleeding and transfusion of red blood cells with different storage time: fresh vs. "aged"'

• Marc Suter (CH) 'Neuropathic pain: how microglia detect peripheral nerve injury?'

b. Research Support Grant winners (15,000€)• Coen Ottenheijm (NL) 'Diaphragm muscle fiber weakness in

mechanically ventilated ICU patients' • Felix Van Lier (NL) 'Perioperative transfusion study in high-

risk cardiovascular patients’

c. Young Investigator Start-Up Grant (30,000€) • Tobias Piegeler (CH) 'Local anaesthetics and inflammatory

cancer signalling'

d. Meta-Analysis Grant (20,000€)• Tanja Manser (CH) 'A meta-analysis of team processes

and patient safety: the moderating role of team and task characteristics'

Due to the high quality of most applications, Research Committee members felt that the selection process was rather difficult. In the end, we are confident that we have chosen four really interesting projects of exceptionally high quality, which are all of significance for our specialty; although many more projects would have deserved to be funded.

We would like to thank all applicants for their interest and the work they have invested into this scientific competition. We also hope that those who were not fortunate this time will be motivated to contribute in the future. It became also obvious from our review work that many of the applications will also have great chances to be funded from alternative resources. In this regard we wish all applicants great success and ongoing enthusiasm for research.

The ESA Research Grants will be formally awarded to winners on Saturday, 31 May 2014 during the Awards Ceremony at the Euroanaesthesia Congress in Stockholm, Sweden. //

HISTORY OF ANAESTHESIA - FLASH 5 // FROM THE VERY BEGINNING UNTIL TODAY

HISTORY

This is a series of flashes to cover the evolution of medicine from its beginnings until anaesthesia appeared and later developed to what it is today.

GEORGE LITARCZEK // ROMANIA // [email protected]

After MortonMorton's demonstration (the first time that there had been a public demonstration of inhaled ether as a surgical anaesthetic, September 1846) can be considered a “big bang” of our specialty. First it expanded extremely rapidly all over the world. In a few weeks it reached Europe and was immediately adopted in many countries starting with Britain where Bigelow from Boston, who witnessed Morton's demonstration, brought the news to England. He did this both by contacting eminment physicians in England by letter and later by moving to England himself. A few days after his letters arrived, dental extraction was performed under ether analgesia, and then an amputation of a leg. In January 1847 Simpson in Edinburgh tried first ether then switched to chloroform for obstetric analgesia. In France ether was received with different opinions. After the first ether anaesthesia, performed by Jobert de Lambelle on 22 December 1846, some surgeons like Malgaigne, adopted the method while some like Roux and Velpeau were reticent. Later Velpeau became an enthusiastic promoter. These well known names were followed by Schuh and Musil in Austria, Heifelder and Dieffenbach in Germany and Pirogoff in Russia. Even Russ in Modavia and Vartidi and Rissdoerfer in Valachia were performing ether anaesthesia in March 1847.

The method also reached South Africa, the Cape, in April the same year where G. Atherstone performed an anaesthesia on 20 April. Considering the traveling conditions at that time, the spread of the method of surgical anaesthesia from Boston throughout the world can be considered prodigious and the acceptance quite unanimous.

Concomitantly with its introduction, general anaesthesia-analgesia generated 2 main problems: the search for better anaesthetics and the construction of better devices for their administration. Chloroform was introduced by Simpson in Edinburgh less than 1 year after Morton's demonstration and ethyl-chloride a few months later.

The first ether anaesthesias were performed by Long and Morton and the Europeans with special designed devices like Morton's, Charrier's and Snow's ones or directly on handkerchiefs soaked with ether or chloroform like Long, Simpson, Velpeau and many others.

All were either dentists or surgeons but not later than 1847 the first professional anaesthetist appeared in the person of John Snow who must be credited also for being the first to realise the correlation between the concentration of anaesthetics and the depth of nervous depression, and created

the first anaesthesia scale with steps and the time to arousal. He was also concerned with the use of nitrous oxide, choloform, ethyl-chloride and proposed the use of oxygen as a complement to general anaesthesia.

Quite rapidly after the introduction of ether and chloroform anaesthesia death cases were recorded and a vivid dispute began, anaesthesia itself was put under discussion by some surgeons while others debated the problem of ether against chloroform.

So physiologists took over and tried to explain what was happening. Claude Bernard and his assistant Paul Bert had outstanding contributions to the problem in stressing the role of hypoxia, vagal reflex cardiac arrest, cardio-toxicity and dependence of deepness of narcosis to its partial pressure in the inhaled gas.

Along with the expanding clinical experience the method of general anaesthesia-analgesia was gradually improved by development along multiple lines. These include development of new anaesthetics, volatile, gaseous or soluble, development of delivering devices and apparatus, invention of the syringe and hypodermic needle, new vaporisers for volatile anaesthetics, and compressed gas cylinders for O2 and N2O, gas mixing and measuring devices.

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HISTORY

New breathing systems were successfully designed and used. A special preoccupation was devoted early to the airway and special manoeuvres like the Esmarch grip, or devices like the different oro-pharyngeal and naso-pharyngeal airways and later on oro or naso-trachaeal tubes and the laryngeal mask were invented and introduced in practice.

With the airway somehow cleared it became obvious the need to combat respiratory depression caused by anaesthesia and thus assisted and controlled respiration, manual at the beginning and mechanical later, joined the armamentarium of the anaesthetist who himself was in the process of growing and becoming a prominent figure in medicine.

Although Snow in Britain and von der Poorten in Germany and some others in different countries dedicated themselves to this unknown specialty, some time had to pass until the specialist and the specialty were recognised in practical and later on in academic activity. This happened first in Britain and the USA where also the first professional associations were created.

Last but not least, along with general anaesthesia Koller introduced in 1884 regional anaesthesia, with cocaine discovered and purified by Niemansome time before.

Most of the time from 1846 to the end of World War II in 1945, anaesthesia followed different ways of development. In Britain and the USA general anaesthesia was continuously improved by introduction of tracheal intubation by I. Magill (1921), the closed circuit by Waters (1923) and the use of muscle relaxants by Griffith (1943) while on the continent general anesthesia was performed on already classical methods using gauze, open drop on face mask or Ombredanne'a apparatus.

Concomitantly some methods of regional anaesthesia were introduced, such as Schleich's local infiltration, Bier's spinal anaesthesia or Kuhlenkampf's plexal anaesthesia. These methods were used in a large proportion of cases except thoracic surgery.

In Europe, Sweden was the only exception by following the British model. Only after the allied troops brought to the old continent the new techniques of general anaesthesia and European physicians visited Britain and the USA, the two types of methods began to mix in both geographical areas. After World War II anaesthsiology slowly became a recognised specilality in all European countries and its development grew up prodigiously.In the early 50s of the last century an anaesthesiologist, H.Ruben, was called by

Lassen, an infectious disease specialist, to help giving respiratory assistance to poliomyelitis patients. This was the moment the first intensive care units were born in Europe. With Frey in Mainz and Bonica in Seattle modern emergency medicine came to life. By coincidence the same pioneers were also the promoters of pain clinics.

One can easily compare the current performance and status of the medical profession with the situation only 75 years ago in order to understand the tremendous progress anaesthesiology has made since then.

The following flashes will depict the development of some of the principal lines mentioned above and the evolution of anaesthesia up to modern times. //

George Litarczek// Professor

EUROANAESTHESIA 2014May, 31-June, 3Stockholm, Sweden 19

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Guinness World Record “Largest CPR training session” in Münster PETER BRINKROLF / / PROJECT LEADER / / RESIDENT DEPARTMENT OF ANAESTHESIOLOGY, INTENSIVE CARE PAIN MEDIC INE, UNIVERSITY HOSPITALHUGO VAN AKEN / / CHAIRMAN DEPARTMENT OF ANAESTHESIOLOGY, INTENSIVE CARE AND PAIN MEDIC INE, UNIVERSITY HOSPITAL / / hva@an i t .un i -muenste r.de

On 17 September, a new Guinness World Record for the ‘Largest CPR training session’ was achieved in Münster, Germany. Organised by the clinic for anaesthesiology, intensive care and pain medicine of the University Hospital Münster, 12,840 pupils successfully took part in the event.

Early in the morning, the city’s palace square looked like a yellow sea. The whole place was crowded with children in yellow tops eager for the life-saving training to start. Thirty-one schools participated, each pupil was wearing a t-shirt claiming “Cardiac arrest? Check, call & press”. The waiting time was bridged by a band-contest under the motto “the life-saving beat”, with local bands performing songs at a frequency of 100 beats per minute.

After the event was officially opened by the guest of honour, Germany’s Minister of Health Daniel Bahr, the 30-minute long training session started. Via large-scale screens anaesthesiologist Dr. Peter Brinkrolf explained the correct action in case of cardiac-arrest. During the session, manikins were used to instruct each student in the correct technique for chest compressions. Thus the event included not only a large number of participants, but also more than 500 medical professionals who were volunteering as instructors at the event.

The training ended with five-minute long simultaneous chest compressions conducted by all participants. A loud cheer filled the air at the point when the clock counted down to zero and the new world record was announced by the London Guinness World Record-official who was supervising the attempt.

“I am more than proud that we managed to break the record,”, Professor Hugo Van Aken, head of the organizing clinic, stated. “In one go, an enormous number of young people learned how to save a life. I am sure this event will have a long-lasting effect,” he continued. With its nearly 13,000 participants, the training session in Münster broke the previous record by far. The last world record was established in 2011 in Singapore. Back then, 7,909 people learned CPR life saving skills.

The training tool used for the large-scale project was Laerdal’s Mini Anne - each student was issued with an individual kit that included a personal manikin for practising chest compressions. Financed by several sponsors, the participants were invited to take home their kit. Thereby, it will also be used by the school children's family and friends, expanding the potential effect of the training.

The record-breaking training session in the city of Münster was the largest activity within the nationwide campaign “Week of Resuscitation – Saving a Life!”. During September 16-22, over 700 events took place all over Germany to rise awareness and knowledge about sudden cardiac arrest. Often, it will be the actions of a lay bystander in those critical moments that may be able to make a difference to the survival of a victim of sudden cardiac arrest.

Further information about the German CPR-campaign and the record, including impressive pictures and aerial film shots, can be found on-line at www.einlebenretten.de. //

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ESA’s statement on the new safety advice from the European Medicines Agency (EMA; PRAC statement from 13 June 2013, and CMDh-Statement from 28 June 2013) // ANDREAS SANDNER-KIESL ING / / MEMBER OF THE ESA BOARD / / andreas [email protected] KOCHS / / ESA PAST PRESIDENT / / eberhard [email protected] W. HOLLMANN / / CHAIRPERSON SCIENTIF IC SUBCOMMITTEE PHARMACOLOGY / / m.w.ho l [email protected] .n lJAN VAN ZUNDERT / / CHAIRPERSON SCIENTIF IC SUBCOMMITTEE ACUTE AND CHRONIC PAIN MANAGEMENT / / j an .vanzunder t@zo l .be

Brussels, 9 December 2013

Diclofenac is one of the most widely used non-steroidal anti-inflammatory drugs (NSAIDs) in Europe. In some countries, these two safety alerts caused major confusion among physicians, and in some institutions a ban on the use of diclofenac was implemented. The comprehensive volume of data, and one current meta-analysis, led to clear statements regarding the cardiovascular risks on diclofenac (and naproxen). Consequently, the EMA issued a safety alert. In contrast, the data on the severe side effects of other NSAIDs are too weak or too few to allow for individual warnings. For all COX-inhibitors, EMA’s class warning still applies unaltered. All current advices and statements are based on observations following the use of NSAIDs at high doses and for a long time.

Background:• The EMA issued a class warning for NSAIDs owing to a slightly

increased number of thromboembolic events (EMA 2005, EMA 2006, EMA 2012) in patients with underlying cardiac or circulatory diseases, or in those with pre-existing risk factors for major vascular events (heart, brain, vessels). These events occurred in 8 out of 1000 NSAID users. This class warning is already part of the current versions of the product information for different NSAIDs.

• Depending on the ratio of COX 1 to COX 2 inhibition, each single NSAID has either more cardio-/cerebrovascular or more gastrointestinal severe side effects.

• Naproxen use at the highest daily dose (and only at this dose) confers a slightly reduced risk of cardiovascular thromboembolic events, but an increased risk of gastrointestinal side effects.

Diclofenac:• Regarding diclofenac, the benefit clearly outweighs the risks.

No public or governmental authority requested a ban on diclofenac.

• Diclofenac has a COX 1: COX 2 ratio (1:50) similar to COX 2- inhibitors like Celecoxib; therefore, it confers a risk for major cardiovascular events that is similar to COX 2- inhibitors (plus 3 events, which means in total 11 events in 1000 NSAID users; Coxib and traditional NSAID Trialists’ Collaboration, Lancet, 2013).

• This observation led the EMA to publish the current safety advice on the use of diclofenac for the following already well-known side effects or contraindications:

• Established congestive heart failure (NYHA class II-IV), ischemic heart disease, peripheral arterial disease or cerebrovascular disease.

• Only one national cohort study has examined the short-term use of diclofenac. Compared to the long-term use, this study reports an initially even increased risk for major vascular events with the short-term use of diclofenac (Olson AM, Circulation, 2012).

For our daily practice:• Before prescribing diclofenac (or any other NSAIDs), the

current contraindications have to be taken into consideration.

• In patients with risk factors for developing major vascular events (like smoking, arterial hypertension, hypercholesterolaemia, diabetes mellitus), prescription of diclofenac (or other NSAIDs) should be started only after careful consideration.

• Diclofenac (like all COX-inhibitors) should be started at the lowest possible dose for the shortest possible time.

• The management of all patients receiving diclofenac on a regular basis should be reviewed carefully at the next appointment.

• This warning applies to systemically applied diclofenac, not to topical applications like ointments.

In summary, the ESA emphasises the predominant benefit of diclofenac or COX-inhibitors, especially as part of a multimodal pain therapy regimen. A general ban on diclofenac has never been requested. However, a new meta-analysis has confirmed the already well-known contraindications and the safety advice as they are already present in the current versions of the product information of NSAIDs, especially of diclofenac: Each single prescription has to be considered carefully for each individual and his personal risks, and should be started at the lowest possible dose and for the shortest possible time. An automatic prescription of COX-inhibitors for pain problems is discouraged. Current prescriptions should be re-evaluated at the next appointment. //

The ESA Trainee Exchange Programme // My experience in the AMC (Academic Medical Center) AmsterdamJAN HANOT FROM UZ LEUVEN / / Jan .hanot@hotma i l . com

When I was searching for ways to improve my training in anaesthesiology I learned of the ESA trainee exchange programme through the website of the European Society of Anaesthesiology. Most of my training was situated in the University Hospitals of Leuven and I felt that a change of scenery would help me to re-gain focus and would force me to think beyond the habits I had grown into. I had just completed the first part of the EDAIC exam and I had a feeling the standards were high in the ESA, so I was thrilled when I heard I had been accepted for the programme!

From the list of available host centres I had chosen the AMC Amsterdam. Luckily they were happy to receive me. There were several reasons why I had chosen this hospital. First of all I didn’t want language to be a barrier. A three month period is a short time and I didn’t want to lose any time with learning a new language. And since Dutch was also my own native language it would be easy for me to be registered as a physician in the Netherlands and be able to provide patient care.

Secondly I was curious about the way anaesthesiologists work and are organised in the Netherlands. Although the countries of Belgium and the Netherlands are closely related and share a common history, the health care system is very different. Particularly the logistics and organisation of

the operating theatre is different from what I knew in Leuven.

Thirdly I chose the city of Amsterdam because of its high global profile. It is a city known all around the world and I imagined living there for 3 months would not disappoint me.

That I had made a good choice became clear during my first visit to the AMC Amsterdam in February. During this week my host, Prof. Benedikt Preckel, showed me around in the operating theatre and I got acquainted to some of the staff. We decided my time in the AMC would be a good opportunity to focus on ultrasound guided regional anaesthesia. This was a field in which I was not yet well trained and my three month visit to the AMC would be perfect to develop these skills.

My three month visit to the AMC took place in the summer of 2013, from July until the end of September. During these months I was able to follow the procedures and locoregional techniques performed at the orthopaedic and trauma theatres. Gradually I could progress from observing locoregional techniques to actually performing them myself. I found the members of the locoregional group at the AMC to be very dedicated and very enthusiastic about their profession and they involved me in their activities with a lot of warmth and enthusiasm. With their help it didn’t

take me long to learn the basic locoregional techniques. I had the opportunity to spend time practising with ultrasound on phantoms to improve my learning curve and I was able to attend some workshops organised by the locoregional group.

I was also able to witness the hospital’s trauma care program which took place in their designated trauma room and in which the team of anaesthesia had a prominent role. The AMC is one of the larger dedicated trauma centres in the Netherlands. I was not familiar with this kind of trauma care and was very happy to have been able to witness several cases during these months. I also attended some trauma meetings where severe cases were discussed with all involved: doctors, nurses, ambulance workers and even the call centre personnel. In September the department of anaesthesia had even organised a trauma symposium about damage control resuscitation with two excellent speakers from the UK and the USA, which I of course also could attend. As I expected, the organisation of the operation theatre was different from what I knew in Belgium. I noticed how they had far more staff available to run their ORs. In addition, the anaesthesiologists had anaesthesia co-workers at their disposal. This allowed them to be more flexible and it gave them more time to implement safety checkpoints and quality assessment tools.

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Myself in the AMC work outfit. Jessica and Gan, 2 devoted members of the locoregional group.

Heineken and canals, that’s Amsterdam The AMC by night

The hallway of the AMC with the windows of the OR visible on the second floor.

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Amsterdam is wonderful in the summer

Attendees of the ESA 2013 Masterclass in Clinical Epidemiology // Utrecht, the Netherlands

Unfortunately those three months ended rather quickly. I had a very pleasant and instructive time in the AMC. Moreover, the city of Amsterdam is a very enjoyable city in the summer.

I would like to thank the ESA for giving me this wonderful opportunity. Through this experience I did not only learn about anaesthesia and locoregional techniques. But I also learned how differences in culture and habit can affect our hospital policies and can change the way we deliver care to our patients. This foreign adventure has taught me how different the organisation of an operation theatre can be from what we are used to and how health care economics can influence our day-to-day work.

I would especially like to thank Benedikt Preckel for the organisation of my visit, Jessica Wegener for her guidance and her genuine concern about my well-being, Markus Stevens, Holger Baumann, Gan Van Samkar for their enthusiastic efforts to improve the locoregional practice in the AMC, Jan Eshuis for all the pleasant days we worked together in the surgical day centre and all those others I have worked with. I was received with open arms in the AMC Amsterdam and I had a truly wonderful time. //

Thumbs up for the “Masterclass in Clinical Epidemiology: design and analysis of clinical studies” // MARK COBURN / / [email protected]

31 October – 2 November 2013, Utrecht, Netherlands

As in the previous years the European Society of Anaesthesiology carried out this year´s “Masterclass in clinical epidemiology: design and analysis of clinical studies” at the UMC Utrecht. The class was excellently organised by the ESA Staff, the Department of Epidemiology and Department of Research Anaesthesiology, Intensive Care and Emergency Medicine both at UMC Utrecht. This trio lets you already imagine a well-balanced organisation and composition of clinical and theoretical aspects which were discussed in the course. The theoretical parts were loosened up by challenging practical parts. The teams worked on all aspects of designing clinical trials on a specific topic: postoperative cognitive dysfunction. The topic could not have been chosen better. Postoperative cognitive dysfunction brings up several challenges in designing clinical trials, e.g. the methodological problems in testing cognitive dysfunction, just to mention one example. The discussion was enriched by Lars Rasmussen from Copenhagen University Hospital, Norway, a key expert in the field of postoperative cognitive dysfunction research.

However, not just the bright side of research was part of the Masterclass agenda. There was an excellent talk from Cor Kalkman “Research quality and fraud” which was the basis for intense discussions in the group. In my opinion, this was a great way to bring this topic of utmost importance not just for our society to the next generation of researches to underline the credibility of our own. It was impressive to feel the spirit of the future research generation on this topic and I would wish we would have more such fantastic sessions, not just in this select course.

Furthermore, I was impressed by the selection of attendees, an international mixture, some even coming from Japan, Australia and Iraq. The exchange and discussions between the international attendees and the experts on all aspects of clinical studies was one of the pillars for the great success of this Masterclass. As one could imagine the discussions were continued in the vivid restaurants and bars of Utrecht. //

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Letter to editor //A year after Teach the Teacher courseSTEPHEN SCIBERRAS / / ssc iber ras@gmai l .com

I remember distinctly when Professor Gaby Gurman arrived to Malta, being invited to give a lecture for one of our periodical symposiums. During this lecture, he had mentioned the Teach the Teachers course (former ISIA course), a project that he held close to his heart.

I was lucky enough to be chosen for the third iteration of the course, together with another Maltese colleague. This time, the course was to be held in Crete, Greece, during three weeks spread over a period of a year. It was well attended, with six countries sending their representatives, and we were lucky enough to have excellent tutors, all of them graduates from ISIA-1 and ISIA-2. A special thanks goes to all six of them.

Each week was intensive in itself. Presentation skills, setting up a PowerPoint, how to lead discussions, avoiding common pitfalls, and organisational aspects were introduced step by step. The participants were shown methods of improving the delivery of educational material to others, both by lectures and discussions, and also by frequent assignments.

Finally, we became ISIA graduates and were sent back to our workplaces to start making an impact in our local settings.

So, what has happened a year after? Two workshops later, one course, and too many lectures to remember, we can say that the “Teach the Teacher" (TtT) project has given us the necessary impetus to start to prove ourselves.

With the experience gained, and with the back-up of our mentors, we have managed to embark on an annual workshop in ultrasound guided regional anaesthesia course, with cadaver hands-on sessions. This has already been held twice, and it seems that we are on track for a third course next year, which we hope to expand beyond our local colleagues. It has been an honour to obtain accreditation both from the ESA and the WFSA for this course twice.

We also sought to share our experience to our colleagues. Two sessions on improving presentation skills were held, loosely based on the structure of the TtT workshops. Feedback from this course was good, and to prove our success, one of our participants went on to win the Anne-Dorothy Cuschieri Fund Competition, an event held where trainees compete by presenting their work.

The skills taught at the TtT included more than just teaching others. Numerous guest lecturers provide insight on organisational aspects, to improve patient care and safety. These skills have enabled us to introduce new practices at work, like improving documentation throughout the Intensive Care Unit, standardising post-operative pain recommendations after knee arthroplasties, the introduction of an early warning score pathway throughout hospital, and numerous committees that we both currently are members of.

Two years ago, we embarked on a journey to Crete, not knowing who we would meet, and what would come out of our commitment. Now, a year after, we know, and we have to thank ESA, WFSA and our local postgraduate training centre for their funding, our mentors for sharing their knowledge with us, our newly-found friends who were with us, and of course, to all our teachers, who have shown us that with dedication and patience, it is possible to make a difference. //

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CTN Studies // Get Involved! The most important and challenging clinical questions are more likely to be answered if several centres join forces!

The POPULAR study was selected last year by the ESA Research Committee:

POPULAR: POstAnaesthesia PULmonary complications After use of muscle Relaxants in Europe: a Prospective Observational International Multi–centre Cohort Study

Chief Investigator: Prof. Manfred Blobner (Germany)

Recruitment: It is planned to recruit approximately 40,000 patients via an estimated 400 centres in Europe. Recruitment is planned to start as of July 2014.

Become an ESA CTN Centre!Would your hospital like to this study as an actively contributing research centre?

EligibilityThe ESA CTN is open to all clinicians meeting study protocol criteria. Centres may participate in several studies.

ProcessThe ‘Call for Centres form’, available on the ESA website (www.esahq.org/ctnform), must be filled in on-line. The completion of this form will facilitate the coordination and is mandatory for participation in ESA CTN. ESA Secretariat will then contact Centres providing them with additional information.

More information on www.esahq.org/research or contact us at [email protected].

Prepare for the EDAIC with the Basic Sciences Anaesthetic CourseThe Basic Sciences Anaesthetic Course is intended as one of the tools suitable for the preparation of the European Diploma in Anaesthesiology and Intensive Care by improving the candidate's understanding and knowledge of all areas of basic science. This 4-day course will be held in parallel with Euroanaesthesia 2014 so that participants can attend a number of selected scientific sessions and the inaugural ceremonies.

Participation is limited to 150 students.

Pre-registration deadline: 14 May 2014

More about the Basic Sciences Anaesthetic Course: www.esahq.org/BSAC

More about the EDAIC: www.esahq.org/EDAIC

ESA Clinical Trial Network // Call for Study proposals is now open!The European Society of Anaesthesiology Clinical Trial Network (CTN) provides an infrastructure for institutions, clinicians and scientists to work collaboratively across international borders to improve the care of patients in the fields of anaesthesiology, intensive care, peri-operative medicine, emergency medicine and pain medicine.

International networks all over the world have demonstrated the advantages of collaboration to address and answer clinically relevant research questions.

BenefitsA CTN grant of up to € 30,000 is provided for Study costs. The grant is intended mainly to cover travel costs for steering committee meetings, use of a statistician, and possibly study coordination assistance at the institution of the principal investigator (PI). In general, no case money for participating centres is foreseen. In addition to the financial support, the ESA offers to the PI and steering committee members a valuable co-ordination support package: administrative, technical and logistic help for all phases of the study : preparation of documents, centre set-up and coordination, case report forms and cleaning of the data. EligibilityEvery physician can apply for support by the ESA CTN. Non ESA members who are health care professionals are entitled to present proposals in the field of clinical anaesthesiology research on an international level.

ProcessThe PI is asked to submit a study proposal to the ESA Research Secretariat by 15 September 2014 using the ‘CTN Study Proposal form’, available on the ESA website (www.esahq.org/research). Late applications will not be accepted. //

2014Basic Sciences STOCKHOLM, SWEDEN MAY 31 - JUNE 3

Anaesthetic Course

26

Early Bird Registration deadline approaching! // Register for Euroanaesthesia 2014 before 26 February and benefit from the Early Bird registration fee, after this date registration fees will be higher.

More about Registration: www.esahq.org/euroanaesthesia2014/Registration

Photo Contest 2014 // Win a free registration for Euroanaesthesia 2014!

Once again, the ESA is hosting a photo contest, so grab your cameras and start photo shooting!

What can you win?

• The top 3 contestants will win a free registration for Euroanaesthesia 2014

• The 20 best photos will be exhibited at Euroanaesthesia 2014• The 12 best photos will be published individually on the cover of

the EJA

What type of photos are we looking for?Anaesthesia is everywhere in a hospital, and we would like you to capture it. We are looking for photos that show:

• PEOPLE giving anaesthesia• the PLACES they work• SCIENCE in anaesthesia

Entries will be judged on whether they reflect the chosen theme well, their visual impact and composition, originality, aesthetic quality and technical expertise. Decisions of the judges are final and binding on all matters.

How to participate?

Participation in the photo contest is free of charge and only current ESA members can participate (with the exception of photo contest judges and their families).

More on how to participate: www.esahq.org/PhotoContest2014

Submission deadline: 31 March 2014

Scientific Programme // plan your sessions! The Scientific Programme will comprise of: 5 pre-congress courses, 23 refresher courses, 68 symposia, 4 workshops, 3 interactive sessions, 11 lectures, 2 meet the expert sessions, 12 pro-con debates, 2 postgraduate courses as well as several guest sessions and specialist society meetings. Please note that some courses require pre-registration and have a limited participation.

More about the Scientific Programme: www.esahq.org/Euroanaesthesia2014/ScientificProgramme Access the Euroanaesthesia On-line Programme: www.sessionplan.com/esa2014

3rd place winner //Chen-Hwan Cherng, Taiwan

2nd place winner //Helmar Bornemann-Cimenti, Austria

1st place winner //Alexander Milde, Germany

Photo contest 2013 top 3 contestants:

2014The European Anaesthesiology CongressEuroanaesthesia

STOCKHOLM, SWEDEN

MAY 31 - JUNE 3

Future Anaesthesiology Meetings // 2014

2014February, 27-March, 34th Annual UBC Whistler Anesthesiology Summit Contact: [email protected] I B.C, Canada

March, 1-48th Annual Iowa International Anesthesia Symposium www.anesth.uiowa.edu I San Jose del Cabo, Mexico

March, 18-2134th International Symposium on Intensive Care and Emergency Medicine Contact: [email protected] I Brussels, Belgium

March, 21-232nd Global conference on Perioperative and Pain Medicine in the Cancer Patientwww.canceranaesthesia2014.org I Melbourne, Australia

March, 28-29Study in Multidisciplinary Pain Research Meeting - SIMPAR Contact: [email protected] I www.simpar.eu I Rome, Italy

May, 8-10German Anaesthesia Congress – DACwww.dac2014.de I Leipzig, Germany

May, 31-June, 3Euroanaesthesia 2014Contact: [email protected] I www.esahq.org/euroanaesthesia2014 I Stockholm, Sweden

May, 31-June, 3Basic Sciences Anaesthetic Coursewww.esahq.org/BSAC I Stockholm, Sweden

September, 3-633rd Annual ESRA Congress http://esra.kenes.com I Seville, Spain

September, 16-1823rd International Meeting of Anaesthesia Critical Care and Pain www2.kenes.com/icisa/Pages/Home.aspx I Tel Aviv, Israel

September, 17-20SFAR www.sfar.org/evenements/135/congres-national-sfar-2014 I www.simpar.eu I Paris, France

October, 1-44th Biannual International Multidisciplinary Pain Congress Eindhoven, the Netherlands

October, 10-15ASA 2014 www.asahq.org I New Orleans, U.S.A.

October, 23-2525th ESCTAIC Meeting Contact: esctaic2014@esctaic .org I Timisoara, Romania (In cooperation with SRATI)

November, 13-16 13th Annual Pain Medicine Meetingwww.asrameetings.com/13th-annual-pain-medicine-meeting I San Francisco, U.S.A.

November, 24-284th World Congress of Regional Anesthesia and Pain Therapy www.wcrapt2014.com I Cape Town, South Africa

27Printed on FSC certified paper

Copyright 2014The European Society of Anaesthesiology a.i.s.b.l. (ESA) No part of this Newsletter may be reproduced without prior permission. The views expressed in this Newsletter are not necessarily those of the ESA. Where identified, the opinions are those of the author. Otherwise the views expressed are those of the Editor(s). The ESA cannot be responsible for the statements or views of the contributors.

Do you want to publish your event on the ESA calendar list?Then please e-mail us ([email protected]): • the name of the event (maximum 100 characters) • start and end date of the event • location (country, city, venue) • a very short description of the event (3 lines max.), to be published on the website• a related website address and/or email address

Please note that incomplete requests will be ignored. The ESA reserves the right not to publish any event sent for publication

2014MAY 31 - JUNE 3STOCKHOLM, SWEDEN

The European Anaesthesiology CongressEuroanaesthesia

SymposiaRefresher CoursesWorkshopsIndustrial Symposia & ExhibitionAbstract Presentations

CME Accreditation EACCME - UEMS

RegistrationP +32 (0)2 743 32 90F +32 (0)2 743 32 98E [email protected]

Upcoming Deadlines 26 February 2014 - Early Bird Registration deadline31 March 2014 - Photo Contest Submission deadline14 May 2014 - Pre-Registration deadline

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