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VOLUME 53 / / SPRING 2013 / / EDITOR GABRIEL M. GURMAN

01-03 05-09 20-24

Comments toWinter Editorial

ESA General Assembly and Elections

Euroanaesthesia Courses and Workshops

Comments to Winter Editorial // Eberhard KochsIs the trend still a patient´s friend at the end when it bends? //In the last issue of our ESA Newsletter, the Newsletter’s editor Gaby Gurman published an article entitled “To be or not to be… an intensivist.” (Vol 52, Winter 2013). The general basis for his further considerations is provided in the first sentence: “Some people, rather than face an inevitable reality, would rather try to change a trend that seems to be irreversible.” The question is if some of the following arguments for a separation of intensive care medicine from our core discipline anaesthesiology reflect a train of thoughts, rather than a trend of thoughts.

One of the goals for our Newsletter is not only to inform our members about recent achievements and forthcoming events but also to stimulate discussions on issues pertinent to future developments of our discipline in all areas of anaesthesiology as defined in the By Laws. The article of Gaby Gurman may serve as such an example. In this article Gaby Gurman, being himself an anaesthesiologist, challenges a dominant role of our discipline in intensive care medicine. Amongst others, he states “...in the last few decades there has been a general trend to separate anaesthesiology from intensive care.”, and “Finally, in various countries the majority of the intensive care units are led and manned by non-anaesthesiologists.” These and other examples in this article are not substantiated by facts. In most European countries anaesthesiology is the backbone of intensive care. In addition, some of Gaby Gurman´s statements are not supported by official European-wide regulations and initiatives. For example, for good reasons the UEMS does not support intensive care as a primary specialty but as a “particular qualification” which can be obtained by colleagues of different disciplines. The ESA, in close cooperation with the EBA and UEMS, does not support the idea of establishing

intensive care medicine as a primary specialty. Anaesthesiology is the interdisciplinary discipline par excellence which is essential in the care of critically ill patients. Inflammation and organ dysfunction do not stop at the boundary of a single discipline. In addition, one of the core competencies of anaesthesiologists is to oversee and cover the process of perioperative medicine from pre-, to intra- and postoperative patient care ultimately resulting in intensive care therapy for an increasing number of patients. Vice versa, in critically ill patients intraoperative care is the start or a continuation of intensive care therapy. What is the alternative to an anaesthesiologist with specific expertise in intensive care for provision of such a continuum of care? There is no rationale to artificially truncate any of these responsibilities from anaesthesiology which would carry the risk of endangering patient care and patient safety.

We thank our esteemed colleague Gaby Gurman for his provocative and stimulating article and we appreciate his personal view in this matter. However, we have to make quite clear that this article does not express the official standpoint of the European Society of Anaesthesiology.

Eberhard KochsESA President // Eberhard.Kochs@esahq.org

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Comments to Winter Editorial // Intensive care should be a particular competence on top of a specialityHUGo VAN AKEN / / GERMANy / / hva@un i -muenste r.de

I can agree with some aspects of the article by Gaby Gurman, but not with all of them. In an editorial “Intensive care medicine: a multidisciplinary approach!� published in the EJA in 2011 (EJA 2011, Vol 28 No 5; 313-315)) the authors outlined that the European Society of Anaesthesiology (ESA), the European Board of Anaesthesiology of the UEMS (EBA) and the Multidisciplinary Joint Committee of Intensive Care Medicine (UEMS MJCICM) do not support the proposal that ICM should become a primary specialty. New fences between areas of medicine are counterproductive with regard to the challenges of modern medicine. The aim should instead be that doctors with various relevant backgrounds and common formalised additional training work together to the benefit of each individual patient and the improvement of quality of ICM.

I totally disagree with Dr. Gurman’s statement that in the last few decades there has been a general trend to separate anaesthesiology from intensive care medicine.

In Germany the DIVI (German Interdisciplinary Society of Intensive Care Medicine and Emergency Medicine) is the umbrella organisation for intensive care from different specialty organisations, that also has the possibility of personal membership. However, 75% of members are anaesthesiologists. Only in Spain and Switzerland is intensive care an independent specialty. In the UK the dual pathway is possible – either as additional competence on top of a primary specialty or as primary specialty.

In most European countries, intensive care medicine can be obtained as a “particular competence” with a common training programme for specialists with Board certification in a variety of base disciplines: anaesthesiology, cardiac surgery, cardiology, internal medicine, neurology, neurosurgery, paediatrics, pneumology, and surgery. Therefore intensive care is a paradigma of cooperation of experts in different fields and generates collegiality and scientific progress for the sake of the patients. A particular competence is an area of expertise in addition to a primary specialty, where extra expertise outside the domain of the specific specialty is required to provide high quality patient care by multidisciplinary input from doctors from various medical specialties.

The 9 medical disciplines in the respective sections of the UEMS involved in intensive care unanimously voted against the idea that intensive care medicine should become an independent specialty. The reasons are rational and obvious: a reduced involvement of the primary specialties in intensive care medicine and problems with physicians. Furthermore, problems with physicians who will leave intensive care medicine after a couple of years due to the enormous physical and mental stress resulting in burnout.

In the new EU medical directives that will be published within the coming months intensive care medicine will appear as particular competence on top of a primary specialty. //

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History is important and it is regrettable that the history of anaesthesia and critical care is no longer formally taught or examined as part of standard medical education.

(Goldhill, Waldman and Soni Anaesthesia 2012;67:472)

Comments to winter Editorial // A regulation perspectiveBENoIt VALLEt / / MEMBER of tHE EURoPEAN BoARd of ANAEStHESIoLoGy ANd PRESIdENt of tHE UEMS MULtId ISCIPL INARy JoINt CoMMIttEE of INtENSIVE CARE MEdIC INE / / UNIVERSIty HoSPItAL L ILLE, fRANCE / / beno i t . va l l e t@chru- l i l l e

Dr. Gaby Gurman published an article entitled “To be or not to be… an intensivist” in the last issue of the ESA Newsletter (Vol 52, Winter 2013) which raised concerns for those who do not wish a separation of Intensive Care Medicine (ICM) from our core discipline Anaesthesiology. Dr Gurman anyway put two important questions to us all: 1) “What is an intensivist?”; 2) “How an anaesthesiologist can be an intensivist”?

Today ICM is not included in the Annex V of the European Directive (2005/36/EC) as Member States have not included ICM as an independent medical specialty which can benefit from automatic recognition. It is recognised as a primary speciality in only three European countries. In the future ICM could develop as a separate speciality in other European countries, but even if this is the case the process will take time. Whatever the evolution, we as anaesthesiologists feel that it would be important that ICM could still be obtained as a particular competence, or as a sub-speciality (either from a unique or from multiple primary specialities), with a “common training programme”. Assumingly this would be claimed by various specialists with board certification in a variety of base disciplines other than Anaesthesiology (General Surgery, Cardiac Surgery, Cardiology, Internal Medicine, Neurology, Neurosurgery, Paediatrics, Pneumology, etc.), providing that these specialities’ Sections and Boards would recognise the required ICM competencies and common training program.

In 1994, the UEMS adopted its Charter on Post Graduate Training (PGT) aimed at providing recommendations at the European level for good medical training. Made up of six chapters, this Charter sets the basis for

the European approach in the field of PGT. With five chapters being common to all specialties, the sixth chapter of the Charter, known as “Chapter 6”, corresponds to the specific needs of the respective specialty. The Section and Board of “Anaesthesiology, Pain and Intensive Care Medicine” (EBA) will present its new Chapter 6 at the UEMS Council in Brussels on April 20 this year. We have to emphasise the important fact that the EBA decided to give to ICM, with close cooperation of all instances active in educating anaesthesiologists, particularly the European Society of Anaesthesiology (ESA), the “European Diploma in Anaesthesiology and Intensive Care (EDAIC)”. Our Chapter 6 proposes that the main field of an expert in anaesthesiology is perioperative medicine (including management of critical conditions), while another major domain of competence is ICM. After defining that a minimum training time of 5 years is necessary to reach the competencies required to become a specialist in anaesthesiology, it is noted that 1 year should be specifically directed to ICM training. Also Chapter 6 emphasises that the ICM competencies can be achieved in respect to the Competency-Based Training in Intensive Care Education (CoBaTrICE) programme. The CoBaTrICE programme, developed and supported by a grant from the European Union’s Leonardo Programme, can be used to define the minimal core of competencies required of a specialist in adult ICM and to maintain multidisciplinary input while standardising the output of training. It will give coherent identity to the question “What is an intensivist?” by decreasing the wide variation in structure, process and outcome of training in ICM, and as a consequence make possible for multiple owners to achieve a unique status.

No doubt that time has not yet come for a separation in Europe between ICM and our core discipline. The Multidisciplinary Joint Committee of ICM (MJCICM) representing the nine sections involved in ICM training, together with the European Board of ICM (EBICM), raised in a recent meeting the importance to propose the recognition of qualifications in ICM based on a Common Training Framework (CTF) by which specialists with particular competence in ICM would move from one country to another even though ICM is not an independent specialty in all Member States. Besides the automatic recognition of qualifications (2005/36/EC, Annex V) and the general system (for specialities not listed in Annex V), the European Commission has proposed to enable a recognition of qualifications based on a CTF. This is described as “a common set of knowledge, skills and competencies necessary for the pursuit of a specific profession” and for which a Member State shall give evidence of qualifications acquired on the basis of such framework the same effect in its territory as the evidence of formal qualifications which it itself issues”.

Taking into consideration the expected evolution of the demand and supply of medical doctors with training and accreditation in ICM, the MJCICM and the EBICM propose that the CoBaTrICE programme should be able to be used as a CTF by trainees from a wide variety of primary speciality training programmes. The EBA and other UEMS Sections, as well as the other professional societies and organisations, will now have to give their input and state whether they support the resulting CTF in order to take this matter forward in a constructive way. //

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Plus ça change… // GoRdoN B. dRUMoNd / / PASt NEWSLEttER EdItoR / / UK / / g .b .d rummond@ed.ac .uk

The most recent editor of the newsletter, Professor Gurman, wrote to me and asked me to comment about original sin… he had asked me to write about the reasons for starting the ESA newsletter, because he knows that I have been associated with the ESA for many years, and have played a part in several ways, in its early years. In fact I attended the first scientific meeting of the ESA, way back when the A stood for anaesthesiologists, not anaesthesiology. That was in Brussels in 1994. The ESA is still located in Brussels, in what a rival newsletter once called a “Gingerbread House”. Much else in the organisation and in our professional and scientific lives has now radically changed. If we thought we needed a newsletter then, why should we need one now?

In his recent newsletter editorial, Gabriel Gurman discussed the value of a printed newsletter, in this era of RSS feeds, 4G phone networks, twitter, facebook and so on. He felt that the printed word was still alive and kicking, despite the glitzy rapid-fire alternatives. I agree. Much of the stuff I am able to find in the newsletter is matters that I wouldn’t have recognised of interest or importance, or searched for on the net, without a triggering factor. Most of it is not the sort of ephemeral comment or off-the-cuff trivia that we associate with media froth. However, when the ESA newsletter drops through the letter box or is picked up from a coffee table, the contents are usually interesting and entertaining.

We do of course get bombarded with glossy magazines, usually advertising things,

and most of them are a waste of trees. However we can pick and choose, and the ESA newsletter is one I now always open. This is not only to read how my favourite organisation is doing, and my colleagues are getting on, but also discover things I didn’t know about topics linked to anaesthesia. It’s a bit like a smorgasbord, short articles waiting to be sampled. Other people, other countries, famous people from the past, some controversy, as well as comment on the present and the opportunity to plan for the future, all there to pique one’s interest. Much of it has been written by people who are not even semi-professional journalists, and it may show, but it doesn’t matter. Some pieces may not display the polish and facility of the professional writer, but most reveal the character that comes from the keyboard of a writer who cares about the topic, and is keen to communicate with colleagues. This raw enthusiasm can shine through and engage the reader, who has the same ideas and ideals and shared experience, but may have a very different background. Even if the background is shared, the opportunity for a writer to explain, develop, and expand on a theme that is important to them brings an immediacy and impact that one often doesn’t find in other places.

To get back to original sin: why did the ESA start its newsletter? For exactly same reason that it continues today, and in large part to meet the purposes that I have suggested above. When the newsletter started, there were much less of the “other media”; in fact it was literally the only medium that we had. When I first became a cog in the ESA

wheel (Scientific Subcommittees, Editing the refresher course supplement, Scientific Chairman, Board member). We were using fax as the most direct form of communication. It’s hard to believe that in 1998, I wrote to all the refresher course contributors “I have enclosed a pre-addressed envelope plus a little one for your disk.” Not quite a bad as when I started my research, when dropping a box of punched cards could set the project back by a week, but hard to imagine in these days of smart phones and twitter.

It’s all news! It may not be the disasters and doom and gloom that we find in the newspapers, in fact the content of the ESA newsletter is often heartfelt and happy: the experiences of a trainee who has been on a fellowship, or a volunteer in another country, or a colleague able to expand on a historical vignette, or even to explain a point of view that may have been overlooked or generally adversely presented. Although often frank, an attractive feature of most contributions is a lack of rancour. Some newsletters seek “readability” by using material that parodies and pokes fun at others, and there is no lack of targets. In some cases the parody is so close to reality it’s hard to decide if it really is parody: but the ESA newsletter has wisely avoided this sort of content.

By providing a “soap box” for writers, the Newsletter has always been a valuable stimulus for ideas. I remember contributing to an article on fraud and plagiarism, long before the recent flurry of serious examples of misconduct: there must be other colleagues who have important, heartfelt messages they

Editor's note: We are pleased to host Dr. Gordon B. Drummond's historical note. Dr. Drummond was the first editor of our Newsletter.

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would like to explain to us all, perhaps before it’s too late! There must be many aspects of practice, training, or science where we may see things going wrong, or would like to see improvement.

When I looked back over the past issues of the Newsletter, I found an additional feature that I had not expected. They say that one’s career ends with an interest in history: I found that the past newsletters gave a valuable reminder, and record, of the history of the ESA. It reminded of all those lovely cities I had visited for the ESA meetings: all the friends I had made, arguments I had taken part in over aspects of science that are probably now resolved, all those apparently insoluble controversies that are now a thing of the past. Most humbling of all, all those “miracle cures” that have now become either “a useful addition” or even more likely “not advisable”. There’s plenty of interest in these previous issues: particularly if we wish to place the current world in perspective. Indeed the evolution of the ESA itself shows in the pages of the Newsletter. Some of the slow process of natural selection is couched in careful words: but a proper knowledge of our origins is a humbling and valuable attribute. I wish the Newsletter a long and healthy life, and a cornucopia of new contributors! //

Euroanaesthesia 2013 Barcelona // ESA General AssemblyOn behalf of the Board of Directors, I am pleased to invite ESA members to the Annual General Assembly of the European Society of Anaesthesiology which will be held in Room 114 of the CCIB, Barcelona, Spain, on Sunday 2 June 2013, from 12:15 to 14:15. The By-laws are available on the ESA website (www.esahq.org)

All the categories of Personal Members and one representative of each Member Society may attend, but only Active Personal Members may vote. There are no proxy votes.The minutes of the last General Assembly held in Paris, France, are published in volume 50 (summer 2012) of the ESA Newsletter available on the ESA website.

The agenda of the 2013 General Assembly is:

1 Welcome & approval of the minutes of the 2012 General Assembly

2 By-laws amendments presentation

3 Voting on the by-laws

4 President’s report

5 Results Board elections

6 Secretary’s report (including Council activities)

7 Presentation candidates to Nominations Committee

8 Elections Nominations Committee

9 Treasurer’s report

10 Approval of the ESA 2012 Annual Accounts and 2013 budget

11 Relieving the Board of Directors, Officers and Auditors of their liability for

the ESA 2012 accounts

12 Presentation of ESAACS 2012 accounts and 2013 budget

13 Nominations Committee elections results

14 Any other business

15 Date and place of the next meeting

I look forward to meeting you in Barcelona,

Sincerely,

Andreas Hoeft, ESA Secretary

BOARD

ESA Board // Job descriptionsSecretary

The ESA Secretary directs the Executive Office of the Society, which is under the management of the Executive Director. Specific responsibilities include (non-exhaustive):

• Takes the responsibility of the agenda and minutes of the Board, Council and General Assembly; • Attends the meetings of the Board (every two months), Council (one to two times a year), General Assembly (once a

year) & presents the ESA activities and new developments ;• Attends any other meeting as deemed appropriate: ESA meetings or third party meetings (national, international,

subspecialty societies, industry, etc.) & represents the Society and/or presents the ESA activities and new developments;• Acts as Master of Ceremony during the Euroanaesthesia Opening Ceremony;• Communicates to members on important matters;• Attends occasionally internal Staff meetings; • Approves or comment the annual salary review of the ESA Staff done by the Executive Director;• Allocates a few hours a week to reply to emails (Board decisions, follow-up of correspondence, etc.).

The functions and responsibilities of the Secretary may change from time to time.

Treasurer

The ESA Treasurer is responsible for the security of the assets of this Society, as directed bythe ESA Board of Directors.Specific responsibilities include (non-exhaustive):

• Chairs the Finance Committee, who annually evaluates the investments portfolio and with the help of the Executive Director makes recommendations to the ESA Board;

• Presents the budget and annual accounts of the Society to the Board, Council and the General Assembly (usually once a year);

• The book-keeping is performed by the Secretariat under the supervision of the Executive Director, audited by a Chartered Audit company once a year. The books are available at any time at ESA Headquarters. Quarterly, a financial statement will be presented to the Treasurer;

• Attends meetings of the Board (every two months), Finance Committee (twice a year), Council (one to two times a year) and General Assembly (once a year);

• Attends any other meeting as deemed appropriate: ESA meetings or third party meetings (national, international, subspecialty societies, industry, etc.) & represents the Society;

• Allocates a few hours a week to reply to emails (Board decisions, follow-up of correspondence, etc.);• The Treasurer and the members of the Finance Committee are nominated as commissioner to the General Assembly

of ESAACS (ESA Administration and Conference Services). ESAACS being the Professional Congress Organiser owned by ESA. The ESAACS General Assembly is held once a year just before the Euroanaesthesia meeting at the same venue.

The functions and responsibilities of the Treasurer may change from time to time.

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Non-Officer Member of the Board

Specific responsibilities include (non-exhaustive): • Attends the meetings of the Board (every two months), Council (one to two times a year), General Assembly (once a

year); • Attends any other meeting as deemed appropriate: ESA meetings or third party meetings (national, international,

subspecialty societies, industry, etc.) & represents the Society; • Depending on its expertise and desire, a Member of the Board usually undertakes the responsibility of one or several

project and/or committee;• Allocates a few hours a week to reply to emails (Board decisions, follow-up of correspondence and projects, etc.).

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No one grows old by living, only by losing interest in living

(Marie Roy Anesth Analg 1974;53:411)

Elections and/or re-elections to the ESA Board of directors // Elections and re-elections for Secretary, Treasurer and one Non-Officer to the Board of Directors will take place during the Council meeting that will be held on Friday 31 May 2013 in Barcelona. Term of office is for two years starting as of 1 January 2014.

The composition, election criteria and method of nomination to the Board are detailed in Section 7 of the By-laws of the Society, which are published on the ESA website.

Attention is drawn to the fact that:• at any one time, five elected members of the Board of Directors must have been members of

Council at the time of their election. Currently three elected members fulfil the conditions, which mean two of the new elected members need to be or have been Council member. The third position being open to Council members and Active members.

• no more than two elected members shall reside in the same country or have the same nationality.

• each candidate for office, whether or not they are a Council member, shall have been an active member of the ESA for at least three years.

How to apply?

Please send your CV (max. one A4 page) together with a motivation letter to boardelections@esahq.org no later than Tuesday 30 April 2013 (midnight). Your application will then be forwarded to the Nominations Committee for approval. If you do not wish to go through the Nominations Committee, please send two supporting letters from two active members together with your application.

The CVs and motivation letters will be transferred to the Council members for review. Applicants will be asked to present (maximum three minutes) their motivation and goals during the Council meeting that will be held on Friday 31 May 2013 in Barcelona. //

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ELECTIONSElections and/or re-elections to the ESA Nominations Committee Elections and/or re-elections of four members of the Nominations Committee will take place during the General Assembly that will be held on Sunday 2 June 2013 in Barcelona. The term of office is for two years starting 1 January 2014.

RoleThe Nominations Committee shall advise the Board of Directors about suitable candidates for election to the Board of Directors and for membership of other committees. The Nominations Committee shall comprise the President, the President-Elect and four Active members who are not currently members of the Board of Directors.The term of office of elected members of the Nominations Committee shall be two years, renewable once.

EligibilityApplicants should have been active ESA members for at least 5 years and a member of an ESA committee and subcommittee for at least 3 years. Applicants must demonstrate significant experience of ESA committee work and/or management of the ESA when applying.

ApplicationIf you wish to apply, please send your application with CV, a letter of intention (to be published on the ESA website) and two supporting letters (emails accepted) from ESA Active members to the ESA Secretariat, Benoit Plichon nominations@esahq.org no later than 1 May 2013 midnight.

“

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We are saving your life, we are monitoring you, we are intubating you, we are breathing for you, we are defibrillating you, we are curing you, but….

We have no time to explain and hold your hand, we have no time to talk to your family, we have no time to tell you why and how we are doing these things for you

(Griffith HR Critical Care Medicine Handbook 1974, pp 388)

the ESA is seeking to recruit a future Chairperson of the Scientific Committee // The three-year tenureship of the Chairperson of the Scientific Committee (SC) of the ESA becomes vacant on 1 March 2015. The future chairperson will be appointed on 1 September 2013 and will spend 18 months as deputy before becoming the SC Chairperson.

The new Chairperson will take over from Professor Stefan De Hert, and will liaise closely with him in the months up to 1 March 2015.

The post requires close liaison with the Scientific Department of the ESA Secretariat in Brussels throughout the year, to plan not only the Scientific Programme, but the running of the Euroanaesthesia abstract sessions (including the BAPC), the planning and chairing of two SC meetings per year, and representing the SC on the ESA Board, Research Committee (which includes the awarding of ESA Grants), the Guidelines Committee and the Education and Training Platform of the ESA and chairing the Specialty Societies Committee.

Previous experience in running scientific programmes for large anaesthetic meetings would be advantageous to an applicant.

If you wish to apply, please send by e-mail to Mirka.Cikkelova@esahq.org:• your Curriculum Vitae, which should detail how you meet the criteria, • short outline (maximum one page A4) of your goals and perspectives as chair of the SC,• and list of publications.

Applications must be received no later than 15 May 2013. Appointment will be made by the ESA Board following recommendation by the Nominations Committee. Interviews will be held at the ESA Secretariat or during Euroanaesthesia 2013 in Barcelona to select the successful candidate.

If you would like to discuss any aspect of this post, please contact:Prof. Dr Stefan De Hert, MD, PhDChair, ESA Scientific CommitteeDepartment of AnaesthesiologyUniversity Hospital Ghent - University of GhentDe Pintelaan 185, Ghent, B-9000 Belgiumtel.: +32 (0)9 332 32 81 fax: +32 (0)9 332 49 87 email: stefan.dehert@ugent.be

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

ELECTIONS

EURoANAEStHESIA 2013June, 1-4Barcelona, Spain 09

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IMPROVE“

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From July 24 to December 3, 1952 the Hospital for Communicating Diseases in Copenhagen admitted 2,722 patients (with polio), of whom 315 had respiratory muscles paralysis requiring respiratory support

(Pontoppidan H. Anesthesiology 1977;47:96)

A Liaison Committee to improve cooperation between ESA, the European Board of Anaesthesiology (EBA) and the International federation of Nurse Anaesthetists (IfNA) // CHARLES MARC SAMAMA foR tHE ESA, Char les-Marc .Samama@esahq.org / / HANS KNAPE foR tHE EBA / / JAAP HoEKMAN foR tHE IfNA

Achievements of anaesthetic care in developed countries such as those in Europe are usually the result of teamwork between physician anaesthetist (anaesthesiologists) and nurses (nurse anaesthetist or non-physician anaesthetist).

In Europe three international anaesthesia societies aim at improving anaesthesia care on different podia. It is realised that closer cooperation between these anaesthesia bodies could mutually reinforce their efforts to achieve the same goals.

Our society, the European Society of Anaesthesiology (ESA) is the European body which is mainly devoted to promote science, research and education in Anaesthesiology.

The European Board of Anaesthesiology EBA is one of the sections of the European Union of Medical Specialists EUMS (Union Européenne des Médecins Specialists UEMS). It represents the political arm of European Anaesthesiology. It is also responsible for the training of anaesthetists.

The International Federation of Nurse Anaesthetists (IFNA) is an international organisation representing the nurse anaesthetists. IFNA counts 20 member states in Europe, 10 in Africa, 2 in the Americas and 5 in Asia.

Representatives from the aforementioned bodies met in Brussels in November 2012 to consider the challenges of Anaesthesiology in Europe and to build a Liaison Committee

The Rationale:Taking into account the need for solidarity to provide access to health care for all civilians in Europe, the grip of governments and insurance companies on health care is increasing and will further increase demanding efficient and quality care. Quality of care will have to be maintained by reshuffling of tasks and responsibilities of doctors to nurses and other professions after appropriate training or by substitution of tasks and responsibilities which means the transferral of parts of the anaesthesia domain for instance to an advanced nurse practitioner.

Anaesthesiology is no longer limited to activities in operation rooms only. Anaesthesiology has a key position in healthcare in bearing primary responsibilities in perioperative care, emergency medicine, intensive care medicine, pain medicine, resuscitation and operating room (OR) management. There is general agreement that anaesthesia and all its achievements results from a team effort of medical and non-medical (nurse anaesthetists) anaesthesia personnel.

For anaesthesia it is vital to focus on areas in which we are expert: quality and safety in health care. This will be a rewarding effort because the public, politicians, policy makers and other parties will be very sensitive to that.

As has been observed in the past, the numbers of some surgical procedures have decreased (cerebral aneurysm surgery versus coiling

procedures, invasive aorta repair versus non invasive procedures under local anaesthesia, coronary surgery versus stenting procedures, open heart valve surgery versus minimally invasive surgery under local anaesthesia and sedation).. On the contrary, the demand for monitored anaesthesia care/procedural sedation and/or analgesia for less invasive procedures (coronary stenting, radiotherapy, brachytherapy, etc) is a growing market where anaesthesiologists and nurse anaesthetists should play a major role.

The working time directives for doctors will create opportunities for non-medical anaesthesia personnel. And the position of anaesthesiology can further be reinforced through improvingcost-effectiveness by being proactive in reshuffling responsibilities to non-medical anaesthesia personnel.

It is therefore imperative to recognise and speak out that anaesthesiology is a medical specialty, and that achievements in the health care domain of anaesthesiology are the result of a team effort of medical and non-medical anaesthesia personnel. In order to achieve this, it is important for Europe to limit the subclasses of non-medical anaesthesia personnel, to work towards uniformity in training standards and to work together to set up high quality training programs and European exams for anaesthesiologists and for nurse anaesthetists. The responsibility for the medical training programmes lies with the EBA, the responsibility for the European exams with ESA(endorsed by EBA), and the responsibility for training standards and exams for nurse anaesthetists is with IFNA.

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IMPROVEYet closer cooperation on integration of training programs is a responsibility for all three organisations.

The following issues are therefore essential for the close cooperation between anaesthesiologists and nurse anaesthetists in Europe.• Anaesthesiology is a medical specialty • Anaesthesiology is leading in perioperative

care, emergency medicine, pain medicine, intensive care, OR management, quality and safety in Europe.

• Clinical tasks and responsibilities are assigned to those who are adequately trained for the respective task: doctors must do what they are competent in and good at; likewise nurses must carry out tasks they are competent in and good at

• Mutual respect between nurses and doctors is vital to ensure a true team spirit for quality and safety for a reasonable price.

During the ESA/EBA/IFNA meeting in November 2012 the following plans were agreed upon.• This ESA/EBA/IFNA liaison committee will

meet twice annually. • There is a need for information exchange

on training. • ESA will consider participation of an IFNA

representative as an observer/advisor in any guideline procedure where input from IFNA/ nurse anaesthetists would be welcome.

• A presentation will be given on the future of anaesthesia in Europe and the role of nurse anaesthetists during

the Euroanaesthesia2013 meeting in Barcelona. One by will be given by ESA/EBA, two by IFNA. Further details of the presentations will be negotiated.

• EBA will invite an IFNA representative as an observer/advisor in the Training Guidelines Committee; likewise IFNA will consider the an EBA representive to observe in any training guideline development.

• ESA will invite an IFNA representative for the Task-Force on Safety, chaired by Sven Staender.

Long life to the ESA-EBA-IFNA liaison committee! //

Survey on the ESA NewsletterThanks to all respondents to the survey published in the 2013 Winter issue. Results will be presented in the Summer issue. Dr. Beatriz Nistal Nuño from Lugo, Spain has been granted free registration to Euroanaesthesia 2013!

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ESA launches “patient safety starter kit” //A collection of resources to help implementing the Helsinki declaration. SVEN StAENdER (CHAIRMAN) / / oN BEHALf of tHE EBA/ESA PAt IENt SAfEty tASK foRCE

(ANdREW fAIRLEy-SMItH, GUttoRM BRAttEBoE, dAVId WHItAKER) / / s .s taender@sp i ta lmaennedor f .ch

Euroanaesthesia 2013 in Barcelona will mark the third anniversary of the signing of the EBA/ESA Helsinki Declaration for Patient Safety. The aims of the Declaration were simple, ambitious and powerful, representing a shared European opinion about what was worth doing and, at the same time, practical to improve patient safety in anaesthesiology. It recommends practical steps that all anaesthesiologists and national anaesthesiology societies who are not already using them should adapt for their own practice.

After the initial signing of the Helsinki Declaration by almost all ESA member state societies, the declaration has been signed by industry representatives and patient organisations and over the last three years, its reach has become global. Today the Helsinki Declaration has been signed or has been adopted by a variety of countries and societies worldwide including Latin American countries, the South and Middle American countries, Canada, Australia, New Zealand, the United Arabic Emirates and the countries of the Confederation of the ASEAN Societies of Anesthesiologists, representing Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand and Vietnam. In addition, the Declaration has been signed by hundreds of anaesthetists around the world.

The ESA and European Board of Anaesthesiology (EBA) set up a Patient Safety Task Force in order to help achieve the aims of that Declaration. This Task Force consists of four anaesthesists: two representing the EBA (David Whitaker and Guttorm Brattebø) and two representing ESA (Andrew Fairley-Smith and Sven Staender). The aims of that Task Force were to create knowledge as well as resources for patient safety. Therefore, a wide variety of activities have been

completed by the Task Force over the last three years. Among them are: the template for a departmental saftey report, a drug syringe labelling study (with the University of Geneva and Berlin, published by EJA 2012 Sep;29(9):446-51), a book on patient safety in anaesthesia distributed to every participant of the Euroanaesthesia congress 2011 (Best Practice and Research Clinical Anaesthesiology – Hugo Van Aken, Editor: Elsevier Science publisher, June2011), a survey on the use of capnography in Europe (presented at the Euroanaesthesia congress 2012), a survey on the adherence to core contents of the Helsinki Declaration (to be presented at the Euroanaesthesia congress 2013) and a starter kit with various resources on patient safety.

The kit will be distributed on a memory stick at this year’s Euroanaesthesia 2013 congress in Barcelona, Spain (1-4 June), and will be available on the ESA booth. To cater for the multiple aims of the Helsinki Declaration, the safety starter kit contains the following:• Selected Articles of the publication

“Safety in Anaesthesia” (Best Practice and Research Clinical Anaesthesiology)

• The book on patient safety by Charles Vincent

• A proposed template for an anaesthesia departmental safety report;

• The text of the original Helsinki Declaration

• Hazard warnings published in countries that alert anaesthesiologists to important adverse events (examples provided from from the UK, Germany and Switzerland)

• Powerpoint presentations plus audio podcasts of essential aspects of patient safety; topics covered include human limitations in the operating room, and introduction to critical incident reporting

• Powerpoint presentations for basic lectures on patient safety and risk

management including topics such as medication error, good communication and team work, simulation, engaging with patients and carers, and understanding clinical risk

• Checklists for emergency management in the operating room, for situations such as those involving newborns, anaphylaxis, hypertension, hypotension and other scenarios

• The WHO Safe Surgery Checklist• A list of links to important internet

resourcesThe starter kit is a collection of necessary resources to help fulfilling the aims of the Helsinki Declaration and to make it readily and easily available and useful for anaesthesiologists across Europe, and indeed Worldwide.

Of course, many of the practices and tools referred to in the starter kit may be commonplace in many hospitals in Europe. But ESA hopes that this starter kit will support hospitals—particularly those in less developed countries—that still have a long way to go before the standards of the Helsinki Declaration are fully established.

Following the Euroanaesthesia congress, the ESA will publish the kit in a dedicated section of its website (www.esahq.org), and will also begin working on implementation of the Helsinki Declaration on a national level. This must be done in a joint venture with the European Board of Anaesthesiology (EBA), with the National Anaesthesiologists Societies Committee (NASC) of ESA and the individual national societies themselves. We will be working on a national or even departmental accreditation process that shall demonstrate the adherence to the principle of the Helsinki Declaration. //

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Low flow Anaesthesia and High flow friendship //ANdRIJAN KARtALoV / / PRESIdENt of tHE MACEdoNIAN SoCIEty of ANAEStHESIA ANd INtENSIVE CARE tHERAPy / / SKoPJE, REPUBLIC of MACEdoNIA / / andr i j an_kar ta lov@yahoo.com

The Macedonian Society of Anaesthesia (MSA) held its annual meeting on 21 December, 2012. The meeting has been honored by the participation of the Dean of the Faculty of Medicine of Skopje, Professor Nikola Janukulovsky, who brought us the latest updates in the management of peritonitis.

Our distinguished guest, Professor Goran Kondov, shared with us very interesting case presentations and pathophysiological aspects of thoracic surgery and one lung ventilation (OLV).

MSA has many plans and hopes for the future. But, as with many countries of the former "Eastern Block" we also face difficult financial times. Trying to combine good patient care with logical and economical use of the resources we "rediscovered" the well-known technique of the low flow anaesthesia (LFA). It was also a great and pleasant surprise to discover that an old friend and colleague of ours, Dr. Paul Zilberman from Israel, has a very interesting presentation on this subject. But from theory to practice there is a long way.

Thus, we combined our annual meeting with a series of conferences and operating room practical demonstrations, with Dr.Zilberman as our guest. A few days before the MSA meeting Dr.Zilberman arrived in Macedonia and started rounds of theoretical and practical demonstration of the LFA technique. Speaking in simple and clear terms, Dr.Zilberman showed us how safe, economic and professionally rewarding this technique is, on the condition that a good theoretical basis exists. In the Clinical Hospital of Skopje (different departments), in the Clinical hospitals of Stip and Bitola, The "Remedica" private hospital, and the former Military Hospital, Dr.Zilberman analysed step by step the flows we were used to in our routine work (from 2 to 4 litres/minute) down to 0.4 litres/minute and, at times, even 0.3 litres/minute. It was something we have never seen up to now and I think many colleagues in the world had not either. We witnessed perfectly stable anaesthesias and a calm anaesthetist, explaining everything and answering the questions received from the audience. We saw that these flows can be used perfectly safely, and gained the confidence to progressively apply LFA.

The last day of Dr.Zilberman's visit was the day of the MSA meeting. Colleagues from other parts of the country, that hadn't had the chance to listen to the presentations delivered or see the practical demonstrations, were able to join plenary presentation, that had been "updated" with some photos taken the days before, showing the flows recorded by the monitors.

We are confident that in time we will be able to implement LFA on a routine basis, as it comes as a logical step after we saw it done. And lastly, since Dr.Zilberman reminded us how much mathematics, physiology, time and patience are behind the LFA we agree with him when he says that the "LFA is the mathematical art of volatile anaesthesia" //

Paul Zilberman and the Macedonian colleagues

Presentation of Low flow anaesthesia in department of anaesthesiology, Clinical center, Skopje

SIMULATION

treating a patient with severe haemorrhagic shock after caesarean section and a 5 year old traumatised child in the emergency department:

Real or training? Real training!

Learning principles for simulation fitting also to “easy” skills and procedures like application of

iv.-lines in a forearm.

Simulation in the fields of Anaesthesia // GEoRG BREUER / / ERLANGEN, GERMANy / / georg .b reuer@kfa . imed.un i -e r l angen.de

Learning in medicine is often a hard and bumpy road. During medical school a lot of theory and a lack of practical learning. After the exam the other way around: The “cold water”- shock with the problem of transmitting theory into clinical context and practice. Theory often does not fit into the reality of clinical daily work and – another didactic problem – theory is “volatile” and left behind if not used in the daily work. On the other hand, if a good teaching and learning culture is established there are special clinical constellations which are not fitting with the learning process of the novice: rare or difficult or time limited incidents, so only the experienced specialist should treat the patients. In consequence even there is a willing of an excellent bedside education – if a syndrome is too rare you won´t find enough patients. These circumstances are often in the field of anaesthesia, intensive and emergency medicine: rare life threatening incidents, which must be treated immediately by the expert. So: how to teach them? There is a more and more establishing method solving these problems: simulation!

I hear and I forget. I see and I remember. I do and I understand.

This quote – supposed to be from the Chinese philosopher and reformer Confucius – concentrates the main advantages of learning in a simulated environment in contrast to traditional ex-cathedra teaching. David Gaba - one of the first pioneers of simulation in anaesthesiology - defined simulation as „a technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion”. Simulation skips

the gap between theoretical based learning and bedside “situational” clinical teaching and provides a learning experience also out of mistakes. A try and error learning curve is prohibited with real patients but desirable in simulation. If there are techniques of teaching in a virtual, simulative way there is even an ethical imperative to learn skills in a first step with simulation. So what is simulation in a concrete meaning? There are many ways how simulation could be put into practice: simulation starts with closing the eyes and thinking or discussing of a special clinical case report (“mental simulation”). It ends with high fidelity, complex clinical scenarios, aiming to let the learners forget they are in a virtual scenario (picture 1 and 2). In between there are endless possibilities of teaching with simulation. The characteristics of all simulated scenarios are: a context dependent, problem orientated learning objective, which is standardised and reproductive without bothering any patients. In many fields simulation could be used for this special learning event, many skills and most of the procedures in anaesthesia and emergency medicine could be trained by simulation. This includes the special knowledge-dimension and skills-training: e.g. cardiopulmonary resuscitation: all steps for the different parts of the algorithms are trainable and could be put together to several clinical scenarios. The learning objectives range from the correct cardiac pressure, the use of a specific defibrillator to effective team leading and communication skills. Even for the complex field of intensive care simulation could be a beneficial training-tool: e.g. sepsis treatment algorithm could be learned in virtual scenarios. According to the learning objectives the simulation-type is chosen: for many purposes a simple CPR (cardio-pulmonary resuscitation) manikin

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is satisfactory; high-fidelity simulators are useful, if the operation theatre-setting and monitoring is important for the learning-process.

With a so called “standardised patient”- programme simulation gets a further application: special trained actors, who don’t have to be necessarily medical professionals, behave in standardised scenarios as regular patients. Even special examinations from abdominal are trained in this way in several countries in Europe. This opens the scope of application also to pain medicine and special aspects of intensive care, for example the training of communicational skills, examination-routines and breaking bad news.Out of an educational science perspective, simulation is an effective learning technique which provides a sustainable learning effect. Simulation is an important part of modern context dependent learning concepts. Therefore the most important factor is providing feedback in a positive and confident learning atmosphere. This is as well important for teaching the application of an iv.-line with a single rubber-forearm (picture 3) as for the complex treatment of malignant hyperthermia in an operation theatre setting. However, simulation of course is not the only and singular solution to provide good clinical teaching. The common final path of learning is always the real patient. But simulation prepares this final learning step and provides therefore more effectiveness and safety with real patients. It is essentially important to integrate simulation in a superior curriculum and to define specific learning objectives for the simulation.

Simulation is effective and worthwile of financial investment and recruitment of manpower. But simulation does not

necessarily have to be expensive: The learning effect is not dependent on the technical finesse of the simulator. There is no borderline for fantasy in creating virtual scenarios also without the high-end computerised anaesthesia and emergency simulators.

There is one important additional aspect of simulation worth mentioning: over the last 20 years simulation in anaesthesia was one of the important incentives to bring up concepts of safety into the field of medicine. Anaesthesia was one of the spearheads and still has an import role in the discussion about avoiding failures and providing patient safety in medicine. Especially concepts from aviation have been transferred by simulation into medicine. In so called “high reliability organisations” simulation is an important column in teaching safety concepts. Many trainings in “crisis resource management” (CRM) have been already given Europe-wide supported by the simulation community. Simulation gives the chance to focus on so called “non-technical-skills” like communication, situation awareness, team work, leadership etc. To train these objectives simulation is an essential tool, because it could provide also complex, time limited and threatening scenarios in which learners begin to act like in the normal daily work.

If you could choose between two airplanes, one with simulation trained and one with learning by doing experienced pilots - which are you going to choose? Maybe someday our patients are also asking this question: “Are you simulation trained or did you only swim in the cold water?” //

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fLASHES fRoM tHE HIStoRy of ANAEStHESIoLoGy // fRoM tHE VERy BEGINNING UNtIL todAy

HISTORY

This is a serie 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 // glitarczek@yahoo.com

the Middle Ages // flash 3Medical ‘Middle Ages’ do not fit exactly the historical. In history, the Middle ages are defined as the time period between the fall of Rome under Odoacre in 476 and the fall of Constantinople under Mohamed in 1453. Medical Middle Ages lasted some time longer, we could say, as a perpetuation of ancient medicine, up to the moment in which some scientific observations and eventually research, appeared, that means up to Harvey (circulation), Vesalius (anatomy) and Leeuwenhoek (Micro-anatomy). This is not to say that during this period there was no progress at all, but not much of the medical knowledge and practice inherited from ancient times was changed. Galen and Aristotle were still the masters. The theory of humors was predominant while the teaching of medicine became the attribute of the church, at least in western Europe, as it was the attribute of priests of Asklepios in ancient Greek times. The practice of medicine was performed by monks-doctors, educated later in universities which were church initiated and controlled institutions. Religion and faith played an important role in treatment of disease. In spite of a quite abundant of writing in medicine, the texts and the teaching of medicine was in fact a mixture of mystical and religious considerations and interdictions, practical applications, astrology and subjective interpretations of facts resulting from observation, all leading to pseudo scientific conclusions and foggy explication and so to confusion and illogical explanations of the observed signs of illness. This lead to incapacity of prescribing and performing a logical therapy resulting in extremely poor results. Under these circumstances faith and the will of God was one of the main resources of therapy. Concerning pain, another impediment in combating it was that it was considered an “expiatory virtue” or divine punishment, and praying was the best antidote— which in fact was not completely wrong from the scientific point of view, considering its certain “placebo”

effect. An important event occurred at the beginning of the 13th century (1215) with the “Ecclesia abhoret a sangue (church abhors blood)” Lateran council, which forbade priests and monks to perform bloody maneuvers to the human body. So these were transferred to somebody else and so it came that barbers, the handlers of cutting instruments, razors and scissors, took the job. And thus medicine was dissociated in two branches: doctors who theorised and barbers who practiced, and it took more than 600 years to see the two disciplines reunite. But progress in medicine was performed not by doctors but by these barbers. Surgery as well as anaesthesiology descends from barbers. For a quite long time, the barbers did not act by themselves but only under the supervision of a doctor who had his training in faculty. The studies began with 3 years of preparatory courses in which rhetoric, logic and philosophy was taught, this was followed by 5 years in the faculty of medicine proper where classical texts from Hippocrates, Aristotle, Galen, Avicenna and byzantine authors were read. Since the 13th century barbers were organised in corporations and some of them specialised in medical practice. These were called in France “cyrurgiens”. Later they formed a separate corporation outside academic structures (1268), in France by Jean Puchard. They were in fact the carriers of progress in medicine. This two path evolution of medicine had its consequences on therapy. While barber-surgeons could perform the direct measures on their patients they were not allowed to prescribe medication which was under the control of “doctors”. That means they were not allowed to prescribe pain killing drugs. Later in the 16th century Francois I created, again outside the church academic structures, the Royal College which was a factual medical faculty in which teaching of botanic, anatomy, therapy and surgery was included. Medical teaching was performed in 2 separate institutions, the faculty and the royal college. This later institution was promoted by the Louis XIII and Louis XIV.

Considering the fact, as we will see later, that it was dentists, direct descendants of the barber branch, who realised general anaesthesia, we may consider ourselves, anaesthesiologists as direct descendants from those early barbers.

A reunification of medical teaching was accomplished later, in France in 1803 only after the faculty of medicine of the university was no more under the control of the church. A more or less similar course of events took place in England, Holland, Germany and other western European countries.

But what were those drug mixtures characteristic of medieval times? First let us stress again the fact that pain killers were not favored by the church so there was no liberal prescription of them. Certainly Dioscoride's and Galen's works were known and taught and plants and preparations were used like in antiquity but specific recipes of the time were the “Soporific Sponges” and the “Theriaque” The soporific sponges mentioned in the codex of Monte Cassino abbey and the “Antidorium of Bamberg” contained as primary component poppy extract (opium), mandragore (mandrake), jusquiam, cicuta virosa (cowbrane) and other less important herbs mentioned in a recipe by Theodoric of Cavia. The recipe was very similar to the dental cement of the early Mesopotamian civilizations. The sponges were produced by immersing the sponge in a broth made up from the specified plants, drying them and cut them into small parcels. These were introduced in the nostrils where humidity dissolved the content, which was then absorbed by the nasal mucosa or thrown on to embers and the resulting smoke inhaled. The use of “soporific sponges” continued down to the 18th century and even later. Documents about its use were noted as late as 1927. The effect was graded by the duration of the application or inhalation. Specific side effects

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17HISTORY

were described and later the components of the mixture identified. Another mixture largely used as antidote to poison was the “Theriaque” invented under roman times cited by Dioscorides and referred by Galen. It was a mixture of about 70 plants which were identified as having anti-poison effects and mixed with serpent meat and venom. The recipe was transmitted to us by Nicolas Heral. This Theriaque was used routinely and mixed with wine, by Ambroise Pare— a barber-doctor in the 16th century—as preparation to surgery. The same performed postoperative analgesia by applying to the wound hot bricks soaked with wine and vinegar. Alcoholic beverages were largely used for sedation.

The “Laudanum” of Sydenham and the “Specific Anodin” proposed by Paracelsus were other recipes of analgesic and anaesthetics mixtures. While “Docens” used and administered these prescriptions, the “surgeon-barbers” executed whichever action had to be taken on the patient frequently using to ease their intervention different mixtures similar to those prescribed by doctors. Some even used regional anaesthesia by compressing nerve trunks. Surgeons performed a lot of procedures starting with treatment of wounded soldiers or other trauma cases and continuing with a lot of practices like cauterisation (red iron) considered to be a kind of pain treatment through counter stimulation—similar to acupuncture or moxa, bleeding, enemas, sucking globes, or scarification. Many of these techniques used sedative potions or enemas.

What follows are some outstanding figures who deserve to be mentioned in this over one millennium lasting period. We will start with Avicenna (Abu Ali Ibn Sina 980-1037) who was born and lived in actual Uzbekistan. He was an outstanding highly educated philosopher and scientist. His medical opinions were based on classical

Greek-roman (Hippocrates, Aristotle) tradition. He practiced medicine and had original contributions to medical treatments and Islamic philosophy.

Paracelsus (1493-1561) was born in Switzerland and lived in Austria. His medicine had the same philosophy inspired by the aforementioned classical new-Platonic Pythagorean school. He introduced new ideas about sickness which would result in an imbalance between micro cosmos (man) and macro cosmos (nature) thus taking the same line as the Chinese philosophy. For anaesthesia he is important, along with Valerius Cordus, as he as a dentist produced sulfuric ether which later in the 19th century, which became the first anaesthetic to be used to perform general anaesthesia. He also supposed that diseases were produced by toxins and defined these substances by writing “What is not poison ? Everything is poison, only dosage makes a substance not to be a poison.”

Ambroise Pare (1510-1599) was a french barber-physician like Vesalius in the service of 4 kings. He is considered the father of modern surgery and thus also as a precursor of anaesthesiology. He described new surgical procedures like the ligature of arteries, suture of wounds and described the antiseptic properties of Turpentine.

Andrea Vesalius Andrea van Wesel (1514-1564), Dutch physician and anatomist. With him a new wind began to blow in medicine. He was the first anatomist to make a comprehensive description with text and figures of the human body and to set the basis for modern medicine . In his treaty “De Humanis Corporis Fabrica” he gave us the first treaty of scientific anatomy.

Valerius Cordus (1515-1544) was a German physician and botanist living mostly in Wittenberg. He is the author of a pharmacopoeia “Dispensatorium” . He

identified and described new medically important plants and varieties. He also described a new method to synthesise ether which he called “sweet oil of vitriol”.

William Harvey (1578-1657) English physician doctor in Padua and Cambridge, member of the College of Physicians, Worked in St. Bartholomew's Hospital and practiced only as a physician and not as a barber-surgeon. His most important contribution to medical science was the description of the anatomy and physiology of the circulatory system. His book “Circulation of the blood was published in Frankfurt, Germany in 1628. Anthony van Leeuwenhoek (1632-1723) was a Dutch inventor and maker of the first microscope and was the first to describe the microscopic world. He is considered the father of microbiology.

Other important figures who deserve at least to be cited are chronologically: 1662 Boyle described gas laws ; 1665 Wren and Boyle fist intravenous injection of iodine tincture in animals with a syringe manufactured from a bladder attached to a sharpened quill;

1707 Sir J. Floyer sensing of arterial pulse in Europe. In China it was practiced as a diagnostic measure since long;

1733 Vascular cauterisation for measurement of blood pressure;1742 Celsius builds the first temperature measuring apparatus and established the first temperature scale. I conclude here because in the second half of this piece, in the next newsletter, there will appear further personalities that completely changed the evolution of medicine and initiated the field of anaesthesiology. //

References for the flash 31. Viars,P. Rossignon, MD. Si l’anesthesie m’etait contee. Paris, Dept.d’Anesthesie et Reanimation, Hop. Pitie Salpetriere, 1997.2. Boulton,Th,B. Chapt. 3. Pain and Analgesia for Operaive Interventions from the begginning to 1846aesth in

The History of Anaesthesia, The fourth International sympoium on the History of anaesthesia, Hamburg, 1997. Editors: Schulte am Esch J, Goerig M. Luebeck. Draeger Druck, 1997.

3. Fueloep-Miller,R. Triumph over Pain. The Bobbs-Merrill Company, New York, 1962

MACINTOSH18

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Professor Sir Robert Macintosh // PIERRE foEx / / UK / / p ie r re . foex@ndcn.ox .ac .uk

In February 1937, Robert Reynolds Macintosh took up the newly established Nuffield Chair of Anaesthetics, the first in the United Kingdom, Europe, and the Commonwealth.

The previous year Lord Nuffield, a very successful industrialist and philanthropist, had been approached by the University of Oxford to obtain his financial support for the creation of three Chairs in Medicine, Surgery, and Obstetrics and Gynaecology. Lord Nuffield insisted on the addition of a Chair in Anaesthetics suggesting that Robert Macintosh should be appointed.

Born in Timaru, New Zealand on 17 October 1897, Robert Macintosh sailed for Great Britain in 1915 to join the Royal Scots Fusiliers, soon transferring to the Royal Flying Corps. Trained as a fighter pilot, he was shot down behind enemy lines and taken prisoner. He tried to escape on several occasions.

After the First World War he started his medical training at Guy’s Hospital, London, intending to become a surgeon. He qualified in 1924 and began to give anaesthetics for several dental surgeons. After obtaining the Fellowship of the Royal College of Surgeons (Edinburgh) he decided to become an anaesthetist and developed a very successful practice, the Mayfair Gas Company.

After his election to the Chair, he spent most of 1937 visiting other departments including Professor Ralph Waters’ department in Madison, Wisconsin, to gain insights into how to develop a department. An American plastic surgeon asked him to join him in Spain where he saw the problems of anaesthetising the wounded in a war zone. This impressed on him the need to develop a simple, robust, portable vaporiser for the delivery of known concentrations of ether under field conditions.

In order to develop such a draw-over vaporiser he appointed a physicist, Dr HG Epstein, as his senior scientist. This led to the EMO (Epstein Macintosh Oxford) vaporiser. EMOs were used extensively by the armed forces during the Second World War and remained in use for many years. This project highlighted the need for accurate measurements in anaesthesia leading to the publication of “Physics for the Anaesthetist” a very influential textbook.

Professor Macintosh’s priorities were to improve the safety of anaesthesia by developing reliable equipment, including the Macintosh laryngoscope (still in use!) and by improving the training of anaesthetists. Few places could deliver instruction that was both scientifically based, and yet related to

MACINTOSH19

practical needs. During World War II Oxford courses were attended by many armed forces anaesthetists, and after the war by many colleagues from the UK and from abroad.

In 1941 Professor Macintosh became responsible for the anaesthetic services of the Royal Air Force. The department became involved in physiological research on the provision of breathable atmospheres in submarines, the investigation of problems associated with high altitude flying, and the evaluation of self-righting life-jackets. The latter involved the submersion of one of his assistants, fully anaesthetised, in a swimming pool with artificial waves.

Professor Macintosh supported research activities in the department by providing laboratory, workshop, library, as well as technical, and secretarial support. An artist helped with illustrations for scientific papers including eight monographs on local and regional anaesthesia.

During his tenure of the chair positive pressure ventilation started to be used in the Respiration Unit at the Churchill Hospital (established in 1953). Patients with poliomyelitis, Guillain-Barré, tetanus or myasthenia gravis were managed in the Unit. There, research in applied respiratory and

cardiovascular physiology developed rapidly under Dr A. Crampton-Smith (Consultant Anaesthetist, later Nuffield Professor of Anaesthetics) and Dr J Spalding (Consultant Neurologist).

Professor Macintosh led a personal campaign for anaesthesia combining simplicity and a high standard of safety in order to reduce the risk of anaesthetic accidents. An important contribution to safety of anaesthesia was the training of anaesthetic nurses. They did not administer anaesthetics but helped the anaesthetists, greatly facilitating their work. Over the years he visited all Continents and played host to countless visitors. Many became Heads of Departments in the UK and abroad. Later they sent their most promising trainees to Oxford. In this way he exerted considerable influence on the development of anaesthesia abroad as well as in the UK.

Professor Macintosh was knighted in 1955. He received many honorary doctorates and honorary fellowships. He continued to travel after he retired from the Chair in 1965, and regularly attended departmental meetings and functions. Thus his influence continued for another 20 years. He was eager to learn about research in progress. I was privileged to have known him and enjoyed his support for nearly 20 years. Professor Macintosh was

a Fellow and great supporter of Pembroke College. He died on 28th August 1989.

Lord Nuffield knew that the first holder of the chair would make his major contribution by increasing the safety and reducing the undesirable side effects of anaesthesia, also laying the foundations of research making it possible for his successors to develop scientific research. This is exactly what happened.

Professor Macintosh's major contributions were to make anaesthesia safer through safer, scientifically based, equipment, and scientifically based training. He insisted on the need to understand physics and the importance of measurements. His monographs greatly contributed to the safety of regional anaesthesia. He also laid the foundations of intravenous anaesthesia. He supported research in applied respiratory physiology, pharmacology, and cardiovascular medicine, thus making anaesthetics a truly academic specialty.

Major source of information: Jennifer Beinart. A History of the Nuffield Department of Anaesthetics Oxford 1937-1987. Oxford Medical Publications. Oxford University Press. Oxford 1987. //

“”

Today the new generation of physicians enters the respective field to satisfy a career interest and to be of some use to society.

(R.dworkin, Wall Street Journal, August 19, 2009)

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EURoANAEStHESIA 2013

Courses & Workshops //Last Chance to Register

The majority of workshops, symposia and refresher courses are included in the registration fee for delegates of the congress. For the pre-congress courses and workshops with limited access, the additional registration fee is applicable. Places are limited, so pre-registration is strongly recommended (and mandatory in the case of the Basic Sciences Anaesthetic Course).

More information on : www.euroanaesthesia.org > Congresses > Euronaesthesia 2013 > Scientific Programme

European Patient Safety Course (EPSC) // Dates:Part 1 - Friday 31 May 2013, 14:00-18:00 Part 2 - Saturday 1 June 2013, 8:00-12:00

Registration Fee: €250Register now via www.euroanaesthesia.org

Organised by: Marcus Rall (EPSC Course Director), the ESA Patient Safety Task Force - Sven Staender (Chair), Andrew Smith and ESA Scientific Subcommittee 17: Patient Safety - Ravi Mahajan (Chair), Filippo Bressan, Johannes Wacker, Frank Wappler and former SSC 17 members Tanja Manser, Doris Østergaard, François Clergue, Maurice Lamy, Sven Eric Gisvold, Lazlo Vimlati and Peter Dieckmann.

Outline: The Helsinki Declaration on Patient Safety in Anaesthesiology(1) was a landmark publication and consensus in Europe. The EPSC covers all topics of the Declaration and gives examples of the state-of-the-art in patient safety. In connection with Euroanaesthesia 2013, an extracurricular course will be offered by the ESA and its Subcommittee on Patient Safety in collaboration with the international Faculty. Learn about how errors evolve in medicine, what the root-causes are and how patient safety can be improved on a systematic level! The one-day post graduate European Patient Safety Course provides you with a very intensive insight into the general topics of patient safety as endorsed by the ESA and EBA (UEMS) in the Helsinki Declaration on Patient Safety in Anaesthesiology(1). International experts will give you an overview of why things go wrong, what works in practice to reduce errors and enhances the safety culture to make patient care safer. The course is intended for all physicians and nurses in anaesthesiology and intensive care medicine as an overview and perhaps as a primer to start working systematically on patient safety and to start achieving the goals of the Helsinki Declaration on Patient Safety in Anaesthesiology (1). The course also gives you the unique opportunity to exchange and network with colleagues from all over Europe.

1. Mellin-Olsen, Jannicke; Staender, Sven; Whitaker, David; Smith, Andrew F. European Journal of Anaesthesiology. 27(7): 592-597, July2010.

“”

It would be possible to describe everything scientifically, but it would make no sense; it would be without meaning, as if you described a Beethoven symphony as a variation of wave pressure

(Albert Einstein, 1928)

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Pre-congress course on “Current Concepts in Airway Management” //Dates:Part 1 - Friday 31 May 2013, 14:00-18:00 Part 2 - Saturday 1 June 2013, 8:00-12:00

Registration Fee: €250Register now via www.euroanaesthesia.org

Organised by: the ESA Scientific Subcommittee on Airway Management (SSC 19), in collaboration with the European Airway Management Society (EAMS).

Outline: Airway management is a core competence in anaesthesia, intensive care and emergency medicine. Routine airway management in anaesthetic practice has a high success rate. However, when things do go wrong the consequences are potentially catastrophic. Despite recent developments in the field of airway management, e.g. implementation of airway guidelines and introduction of numerous new devices, airway problems still account for a significant percentage of all anaesthesia-related deaths. This course is designed to provide participants with a clear overview of the available equipment, a structured approach to manage the difficult airway, and state-of-the-art information and hands-on experience on a wide range of established and novel airway techniques. There will be explicit attention for paediatric airway management. The course is intended for all grades of anaesthesiologists who wish to acquire, refresh or update their skills.

The course will offer the participants:• small-group, custom-made training in advanced airway management,• a structured approach to manage a difficult airway or an airway emergency in an adult or paediatric patient,• a clear overview of the available techniques with their specific indications and drawbacks,• a hands-on training in routine techniques and a variety of promising new devices,• an opportunity to share ideas and experiences with internationally renowned experts in airway management,• simulated airway scenarios to practice skills and strategies for the management of airway emergencies.

Pre-congress course on “Ultrasound Use in Anaesthesia and Critical Care” //Dates:Part 1 - Friday 31 May 2013, 14:00-18:00 Part 2 - Saturday 1 June 2013, 8:00-12:00

Registration Fee: €250Register now via www.euroanaesthesia.org

Organised by: the ESA Scientific Subcommittee on Clinical and Experimental Circulation (SSC 4) and the ESA Scientific Subcommittee on Intensive Care Medicine (SSC 12).

Outline: The use of Ultrasound in ICU and Anaesthesia is rapidly expanding. Numerous papers have demonstrated its incremental value as a non-invasive monitoring tool and as a unique diagnostic window to the cardiovascular system, the lungs and the abdomen. Its application to the critically ill and surgical patient extends beyond the traditional use of echo in radiology or cardiology. Whole-body ultrasound provides information that is complementary to a physical exam in guiding immediate patient management. It has the great advantage of being non-invasive, safe for the environment, and directly available at the bedside. However, using ultrasound in decision-making processes in the critically ill patient requires qualification. A basic understanding of physics, probe handling, machine settings etc. and knowledge of the limitations of this technique are a prerequisite. The basic use of ultrasound in this setting should focus on the unique pathophysiology and needs of the critically ill (anaesthesia, critical care and emergency medicine). A specific number of vital complications, haemodynamic derangements and typical differential diagnoses can be addressed based on image and pattern recognition. The objective of this pre-congress course is to demonstrate how ultrasound can assist in optimising patient management within the setting of anaesthesia and critical care.

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Pre-congress course on “Crisis in ICU: using simulation training as a tool” //Dates:Part 1 - Friday 31 May 2013, 14:00-18:00 Part 2 - Saturday 1 June 2013, 8:00-12:00

Registration Fee: €250Register now via www.euroanaesthesia.org

Organised by: the ESA Scientific Subcommittee on Intensive Care Medicine (SSC 12).

Outline:Treating critically ill patients is a challenge for physicians in all fields. When effective medical treatment is implemented as early as possible it often has a crucial impact on the level of success (e.g. early antibiotic therapy, early goal-directed haemodynamic therapy). Haemodynamic instability can be a symptom of different disease patterns such as low cardiac output, sepsis or volume depletion. Immediate recognition and treatment should be implemented.To develop the required skill-base for optimal diagnosis and therapy, the ESA offers a specialised crisis resource management course during its annual congress: "Crisis in ICU – using simulation as a tool". After an introduction to the technical ICU environment (ventilator, monitoring), course participants will be able to implement their knowledge in simulated clinical situations. Participants are thus able to obtain immediate feedback on the success or failure of their respective treatments and therefore improve their clinical competencies. This training provides a condensed practical guide to the anaesthetists' non-technical skills and includes suggestions on teamwork, task management, situational awareness and decision making.

Learning objectives hemodynamic management:• Theoretical knowledge of algorithm-guided hemodynamic treatment• Practice of hemodynamic algorithms in clinical scenarios using a full scale simulator• Impact of team aspects, awareness of risks, decision making process, and task management

Pre-congress course on “Spinal Sonography”Dates:Friday 31 May 2013, 9:00-18:00

Registration Fee: €150Register now via www.euroanaesthesia.org

Organised by: Atul Gaur and Aamer Ahmed, The Society for Ultrasound in Anaesthesia (SUA)

Outline: Ultrasound is increasingly being used in the perioperative period as an effective tool to enhance patient care. Over the recent years, ultrasound has proven to be helpful in delineating the anatomy to anaesthetists, and has proven to be an invaluable tool in improving the standards of patient care. The Society for Ultrasound in Anaesthesia (SUA) is organising a pre-congress course on Spinal Sonography.The pre-congress course on spinal sono-anatomy is aimed at anaesthetists and pain physicians who want to access the advantages offered by the ultrasound to make a positive difference to their patients. We have enlightening master classes, demonstrations and panel discussions planned. The speakers are planning to demonstrate on live models (volunteers) the techniques that will eventually help you identify the sono-anatomy, and improve the success rate of your blocks, be they for acute or chronic pain management.

Target Audience: this event is designed for the anaesthesia, intensive care and chronic pain management trainees and independent practitioners.

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thoracic Workshop // Dates: This workshop will be repeated 3 times:Saturday 1 June from 13.00 - 16.00Sunday 2 June from 9.00 to 12.00Sunday 2 June from 14.00 - 17.00

Registration Fee: €60Register now via www.euroanaesthesia.org

Organised by: the ESA Scientific Subcommittee on Respiration (SSC 5), in collaboration with Edmond Cohen, USA.

Outline: The Thoracic Workshop will consist of "hands-on demonstration" of various stations equipped with fiberoptic bronchoscope, video cameras, mannequins, lung models, double lumen tubes, endobronchial blockers, and tube exchangers. A spine model will be used for the practice of thoracic epidural and paravertebral blocks.

Lectures include:• Isolation of the lung: doublelumen tubes• Isolation of the lung: endobronchial blockers• Thoracic epidural

Hands-on demonstrations Include:• Left sided DLT• Right sided DLT• Univent Tube/uniblocker• Cohen endobronchial blocker• Ardnt endobronchialbBlocker• Tube exchangers• Gliderscope• Thoracic epidural• Adult simulator• Pediatric thoracic

Pre-congress course on “CME Update on the use of ultrasound in perioperative care” //Dates:Saturday 1 June 2013, 8:00-12:00

Registration Fee: €75Register now via www.euroanaesthesia.org

Organised by: Thomas Hemmerling and Dario Galante, The Society for Ultrasound in Anaesthesia (SUA)

Outline: Ultrasound is increasingly being used in the perioperative period as an effective tool to enhance patient care. Over the recent years, ultrasound has proven to be helpful in delineating the anatomy to Anaesthetists, and has proven to be an invaluable tool in improving the standards of patient care. The Society for Ultrasound in Anaesthesia(SUA) is organising a CME Update on the use of ultrasound in perioperative care. This update will cover important topics related to the use of ultrasound in perioperative care. The faculty of international repute will deliver lectures related to the use of ultrasound for vascular access, accident and emergency, and pain management. The programme has been designed to be comprehensive, and it also includes a scintillating pro-con debate on the practice of ‘intraneural’ injections. The faculty are very friendly and you are encouraged to ask questions and even share your own views or expertise with them. We look forward to welcoming you warmly for these SUA events. Make it a point to attend-after all, you do not want to hear from someone else as to how good it was and regret missing it!

Target Audience: this event is designed for the anaesthesia, intensive care and chronic pain management trainees and independent practitioners.

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Basic Sciences Anaesthetic Course //Dates:Saturday 1 June 2013 from 13:00 to 16:30Sunday 2 June 2013 from 8:30 to 16:30Monday 3 June 2013 from 8:30 to 16:30Tuesday 4 June 2013 from 8:30 to 12:00

Registration Fee:• 250 Euro for ESA Trainee Members and ESA Active Members Reduced Fee Countries• 430 Euro for ESA Active Members and ESA Affiliate Members

Organised by: the ESA Board of Directors and the ESA Examinations Committee

Outline: This course is intended as one of the tools suitable for the preparation of the EDAIC Examination and in particular for the basic sciences, which is typically the part of the examination where candidates perform less well. Participants are invited to sit the formative On-Line Assessment (OLA) at the end of the course. The 4-day course also includes access to selected Scientific Sessions and the Inaugural Ceremonies of Euroanaesthesia 2013.The Basic Sciences Anaesthetic Course runs at the same place and time as Euroanaesthesia 2013, however attendance is restricted to either the Basic Sciences Anaesthetic course or Euroanaesthesia 2013. Attendees cannot register for both events.Participants must attend the entire course in order to sit the formative On-Line Assessment on 4 June 2013 to obtain the Certificate of Attendance.

the most important and challenging clinical questions are more likely to be solved if several centres join forces! //The ESA Clinical Trial Network (CTN) has been established to facilitate, integrate and support clinical anaesthesiology research on an international level.

New multicentre studies have been recently selected by the ESA Research Committee and they will be starting soon. Would your hospital like to join one of these studies as an actively contributing research centre?

Learn more on on www.esahq.org/research or research@esahq.org

Meet the Chief Investigators at Euroanaesthesia 2013 in Barcelona!

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department of Anaesthesia-Critical Care // Nis, SerbiaRAdMILo JANKoVIC / / SERBIA / / j ankov ic . radmi lo@gma i l .com

The Faculty of Medicine, University of Nis, Serbia, is a state-owned educational and scientific institution that celebrated its 50th anniversary two years ago.

Since the opening of the Simulation Skills Development Centre in 2005, with the significant help of the Tempus project, a more expansive development of the Department of Emergency Medicine and Department of Anaesthesiology and Intensive Care has begun. By consistently adhering to European educational standards, through successful innovations and by motivating perspective young professors and expert assistants, we strive to provide the highest quality emergency medicine, anaesthesiology and intensive medical education within the following programmes:

• integrated academic studies and study programs of basic professional studies

• study programs of specialist professional studies (residency)

• doctoral studies• continued medical educations.

There are currently 25 residents in the Anaesthesiology and Intensive Care Residency Programme. More than 60 specialist candidates completed their specialist studies so far. We also educate residents from other specialities such as emergency medicine, internal medicine and paediatrics. The residency program is an organised program of rotations and educational experiences within the Clinical Centre in Nis, that acts as an educational base of the faculty. We also have a very good co-operation with the medical faculties in Belgrade and Novi Sad as well as with the Military Medical Academy.Our teachers and associates have visited foreign institution for training, achieving at the same time scientific cooperation in the form of joint projects, exchange of lecturers and education ideas.

The research mission of the Department of Anaesthesiology and Intensive care is to

advance knowledge in health and disease and improve clinical care by conducting state of the art pre-clinical and clinical research. Our teachers and associates currently participate in two research projects (“Preventive, therapeutical and ethical approach to the preclinical and clinical research of genes and modulators of redox cell signalisation in immune, inflammatory and proliferatory cell response” and “Electromagnetic radiation monitoring of mobile telecommunication systems in the life surroundings, the analysis of molecular mechanisms and biomarkers of damage after the chronic exposure with the development of the risk estimation models and methods of protection”) approved and financed by the Serbian Ministry of Science and Technological Development. Our young and enthusiastic team also participates in several international research projects: EPIC, EUSOS and ICON. Many results of our studies are already published in internationally recognised journals.

Since 2009 to the present, our team led by Prof. Radmilo Jankovic, in collaboration with Serbian Association of Anaesthesiologists and Intensivists and the Section for Anaesthesiology, Intensive Care and Pain Therapy of the Serbian Medical Society, has organised four spring scientific symposia dedicated to current topics in anaesthesia, intensive care, emergency medicine and pain therapy. We can proudly say that our symposia have aroused great interest from colleagues in many countries in the region, and that Nis has become the gathering place for more than 350 anaesthesiologists every third week of April. Our next fifth and anniversary symposium will be held from 19th to 21st April. Now, we are supported by almost all the major professional associations in the world (ESA, WFSA, ESRA, EAMS, ESICM, EACTA, ESCTAIC and SepsEast Forum). For the second time we will organise, as the pre-congress activity, a Basic Assessment and Support in Intensive Care Course. //

david Wilkinson // president of the WfSA talking at the opening ceremony of fourth Annual Spring Scientific Symposium in Anesthesiology and Intensive Care, April 2012.

Continued medical education: Hands od workshops - Ultrasound in critical care management

Continued medical education: Hands od workshops - Difficult airway management

Medical students practicing at Emergency medicine teaching skills cabinet

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26EDUCATION

CEEA Continuous Education Programme in Anaesthesiology: the successful extension of an European Project //CARMEN GoMAR / / CEEA CHAIR / / SPAIN / / cgomar@c l in ic .ub .es

The CEEA (Committee for European Education in Anaesthesiology) is a committee of ESA acting jointly with WFSA (World Federation of Societies of Anaesthesiologists) whose aim is to organise a programme of Continuous Medical Education in Anaesthesiology. The project started in 1984 in Leiden under the leadership of Prof J. Spierdijk and became the Foundation for European Education in Anaesthesiology (FEEA) with a temporary grant from the European Community (EC), the support of the European Academy of Anaesthesiology and during several years an annual grant from General Electric. FEEA rapidly expanded in the countries of the EC but also in Eastern Europe. A spirit of solidarity between Western and Eastern European centres was strongly established following the FEEA aims: to harmonise CME in Europe and to improve the quality of anaesthetic care. At the end of the 90s, FEEA centres had been established in Israel and South and Middle America, in agreement with CLASA (Confederation of Latin American Societies of Anaesthesiology). The extension outside the European continent continued in several countries of Asia and North Africa. The European contribution of both speakers and centres to the development of this programme worldwide has been and remains extensive. After the amalgamation of all European bodies in Anaesthesiology within ESA, FEEA since 2009 has become CEEA, integrated in the ESA. The CEEA management and administration is within ESA, and decisions are taken in the Assembly of CEEA Regional Centres Directors, which elects a Chairperson and CEEA Committee members in a proportion of European and non-European centres that are all ESA members. Nowadays CEEA represents around 100 Regional Centres covering the same CME schedule – a cycle of six courses addressing all fields of anaesthesia, intensive care, emergency medicine and acute pain management. The topics of the courses are: 1. Respiratory and thorax; 2. Cardiovascular; 3. Intensive care, emergency medicine, blood and blood transfusion; 4. Mother and child. 5. Neurology, locoregional anaesthesia and pain therapy; and 6. Anaesthesia according to the patient, types of surgery and modes of organisation. General topics such as inhalational anaesthesia, adverse reactions, pharmacological interactions, professional risks and infections prophylaxis are inserted in different courses. The participants can follow the courses in different CEEA centres; a certificate is delivered after each course and the certificate of the completed cycle is delivered by the CEEA Chairman. The CEEA courses can be find on the euroviane website (http://www.euroviane.net) gathering all the information about the courses but also many multilingual presentations from the speakers.

The primary unit of CEEA organisation is the Regional Centre that must accomplish the following requirements: an area of influence with about 500 anaesthesiologists, sharing a common language/s, to be directed by an academic anaesthesiologist active in clinical practice, to have the support of the national society and the local university and the explicit commitment to apply the CEEA programme that includes limiting participants to 50, mandatory self assessment of participants and course quality, and to report activities to CEEA Committee.

The CME programme of CEEA is unique in that it is designed as a cycle of courses updating knowledge and decision making in all the fields of anaesthesiology. The programme is periodically updated; it started as a 4 course cycle and, at present contains 6 courses. Increases in the number of courses as well as expanding the content reflects the adaptation of the programme to the changing needs of CME of anaesthesiologists. Basic sciences, formerly included, were substituted by more pain medicine, intensive care, anaesthesia subspecialisation areas, regional anaesthesia etc., according to the increasing extension of the clinical practice

27EDUCATION

of anaesthesiology. The course design gives priority to the transmission of knowledge and its clinical application by expert speakers in the topic. Basic sciences are included as a part of their clinical application. Implementation of more efficient teaching methodology such as hands-on workshops and case based decision making, is promoted by CEEA.

Each course lasts 2.5 to 3 days, and speakers and participants remain in place together all day. The exchange of opinion and experiences among speakers and attendees and among participants themselves is a relevant characteristic of CEEA programme not usually provided by other types of CME modalities. CEEA programmes fulfil the characteristic of an efficient CME activity; adapted to specific needs of the group, locally accepted language, limited number of participants, exchange of clinical experience, self assessment, quality assessment, external accreditation, and limited fees. CEEA courses get accreditation from the corresponding organisations in the specific countries.

The CEEA programme is the more complete, extended, long-lasting CME programme in one speciality that maintains the European mark as a guarantee of quality. About 3000 anaesthesiologists follow CEEA Courses every year.

The extension and success of CME programme is the strength of CEEA but can also identifies issues in organisation that must be worked out within the framework of ESA. A quality assessment programme must be projected and applied to the courses, speakers and teaching material throughout all CEEA centres. CEEA committee members should visit centres as much as possible, especially the newest ones. Grants for speakers giving lectures in regional centres with less academic resources are provided by CEEA and they could help following a developed protocol of quality assessment of the course.

The quality of teaching material is crucial but also the multilingualism of which the ESA certificate is another successful example. After discussing thoroughly this topic it was concluded that the most balanced policy is to maintain multilingual material under the responsibility of the CEEA centre directors but also to create a core material in English covering the CEEA cycle course topics provided by the most expert recognised teachers. That core material would be responsibility of CEEA within the ESA, integrated and connected with the European Diploma in Anaesthesiology and Intensive Care (EDAIC) and other educational activities.

All these projects are mandatory to keep and assure the quality of CEEA CME programme under the umbrella of ESA in cooperation with WFSA, but altogether they are a huge project that requires external sponsoring. However, the diversity of interests of the medical industry in the different countries and continents make it necessary to work hard to find such sponsorship.CEEA has a long and successful track record of creating academic solidarity and efficiency despite limited resources. But now the project must be reinforced and improved within the present framework of ESA. //

Carmen Gomar MD, PhD, EDA, CEEA Chair 2011-2012Professor Anaesthesiology, Department of Anaesthesiology, University of Barcelona, Spain

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Preparation for the EdA //Multiple Choice Questions for Part IPaper A consists of 60 multiple True/False questions (MTF). Each question has five parts, each of which can independently be T or F. Of these 60 questions, 20 are physiology, 20 pharmacology, 18 physics and equipment and 2 statistics. The following five multiple True/False (MTF) questions have been taken from the EDA question bank for Paper A (Basic Science).

1. Cardiac output is decreased bya. a fall in core temperature to 30 oC b. increasing arterial PCO2 c. a change from sinus to nodal rhythm d. a decrease in afterload e. panhypopituitarism

2. The following increase peristalsis of the small intestinea. vagal blockade b. food intake distending the intestine c. stimulation of the splanchnic nerves d. adrenaline e. hypokalaemia

3. Lidocainea. is an ester b. is of use in the treatment of supraventricular tachyarrhythmias c. does not cross the normal blood-brain barrier d. increases myocardial contractility in the normal hearte. commonly cause methaemoglobinaemia

4. Pancuronium bromidea. action is potentiated by volatile anaestheticsb. has pre-junctional effectsc. readily crosses the placental barrier d. is biotransformed in the liver e. is more than 90% bound to plasma protein

5. The standard deviation (S.D.) of normally distributed dataa. is the square root of the variance b. is the square of the standard error of the mean c. 68% of observations lie between 1 S.D. below and 1 S.D above

the mean d. 20% of observations lie outside 2 S.D. either side of the mean e. is proportional to the mean value

In the next issue of the newsletter the correct answers and explanations will be given.

Dr Sue Hill, Chairman Part I EDA subcommittee

Raise Your Training to the European Level!

Register for the Part I written examination or the In-Training Assessment before the 30th of April 2013 on the Education section of the ESA website.

Preparation for EdAIC // AnswersThese are the answers to the questions posed in the previous NewlsetterT= True, F= False

1. In a patient with a hiatus hernia, anaesthetic complications at induction can be reduced bya. the use of ketamineb. preoperative therapy with H2 receptor antagonistsc. the use of cricoid pressured. the use of a laryngeal maske. atropine premedication

Answers: a) F b) T c) T d) F e) F

Explanation: The main risk with hiatus hernia is aspiration causing reduced respiratory function: ketamine will not affect the risk of aspiration; H2 blockers will reduce the acidity of stomach contents and reduce the effects of acid aspiration; cricoid pressure reduces aspiration risk; use of a laryngeal mask will not prevent aspiration; atropine premedication blocks cholinergic effects but does not affect passive aspiration.

2. Factors known to influence total respiratory compliance during anaesthesia includea. changing depth of anaesthesiab. administration of depolarising muscle relaxantsc. duration of anaesthesiad. body positione. pneumoperitoneum

Answers: a )T b) T c) F d) T e)T

Explanation: Total respiratory compliance is a combination of chest wall compliance and pulmonary compliance. Changing depth of anaesthesia alters muscle tone and so alters chest wall compliance; all muscle relaxants increase chest wall compliance; duration of anaesthesia has no specific effect on respiratory compliance; position will affect chest wall compliance in particular the prone position; pneumoperitoneum can splint the diaphragm and so reduce pulmonary compliance.

3. Possible complications of right-sided supraclavicular brachial plexus block includea. Horner's syndromeb. phrenic nerve paralysisc. recurrent laryngeal nerve paralysisd. damage to the thoracic ducte. subclavian artery puncture

Answers: a) T b) T c) T d) F e) T

Explanation: This is an anatomy question: know the anatomy of the brachial plexus, in particular its relations. Temporary Horner’s syndrome is cause by proximal spread and blockade of sympathetic afferents; ipsilateral phrenic nerve paralysis is common; ipsilateral recurrent laryngeal nerve palsy can occur but much less frequently than Horner’s or phrenic nerve palsy; the thoracic duct is on the left, so a right sided block will not damage it; the subclavian artery is at risk of puncture in this block, but with modern ultrasound-guidance this is much less likely than in the past.

4. In a patient with low intracranial compliance, cerebrospinal fluid pressure is directly increased bya. hypercarbiab. hypoxiac. isofluraned. ketaminee. propofol

Answers: a) T b) T c) T d) T e) F

Explanation: This is a neuroanaesthesia question. Low intracranial compliance suggests a patient on the threshold of raised intracranial pressure so any factors increasing cerebral blood volume will increase CSF pressure: hypercarbia, hypoxia, volatile agents all increase blood volume by vasodilatation whereas propofol does not. The effect of ketamine is to increase cerebral metabolic rate (CMR) with a concomitant increase in cerebral blood flow and hence a rise in ICP. There is some debate over this action of ketamine and more recent opinion is that there is no rise in ICP as long as there are adjuvant drugs to reduce CMR such as opioids or propofol. Miller’s textbook states that ketamine is associated with raised ICP and this is the expected answer.

5. In a patient suffering from a thyroid crisis, suitable treatment includesa. beta adrenergic blockadeb. digoxinc. corticosteroidsd. nasogastric potassium iodidee. intravenous methimazole

Answers: a) T b) F c) T d) T e) F

Explanation: This is an emergency medicine/intensive care question. Recommended acute treatment for thyroid crisis is beta blockade, glucocorticosteroids and intravenous propylthiouracil plus oral/nasogastric iodine compounds. Arrhythmias may occur, but digoxin is not the antiarrhythmic of choice. Methimazole should be used orally once the crisis has been treated, not intravenously as initial therapy.

ESA Masterclass on Clinical trials and Clinical Epidemiology,october 31 – November 2 2013 29

ESA trainee Exchange Programme // Birmingham Children’s Hospital, UKMIHALy GERGELy / / BUdAPESt, HUNGARy

In the summer of 2011 a young anaesthetist from Germany arrived to the hospital, where I was working in Budapest. Sylvia was one of the applicants awarded to take part in the ESA Trainee Exchange Programme in that year. During her three months visit I enjoyed working with her, a talented and diligent young specialist fully committed to paediatric anaesthesia. It was very inspiring to exchange ideas on clinical problems, research projects with a trainee coming from a different training system and health care service. Consequently, my decision to apply for the next year's award was much influenced by my excellent personal experiences.

I am Mihaly Gergely and I had the opportunity to spend three months in Birmingham Children’s Hospital (BCH) through the ESA Trainee Exchange Program in 2012. I am particularly interested in paediatric anaesthesia and intensive therapy, therefore BCH was my first choice during the application process. Being a well known paediatric hospital, BCH has a long history of caring for sick children. It was opened in 1861 and during its 150 years history it has become the main paediatric centre in the West Midlands region of the UK and well beyond, and is one of the UK’s leading teaching hospitals. BCH provides a full range of paediatric care with a total patient episodes of around 250000 per year, including nearly 40000 admissions. It is a centre of excellence for children with cancer, national institute of liver, small bowel and kidney transplant, a major trauma and burn centre and has a busy craniofacial and neonatal surgical department as well. In BCH operates one of the UK’s biggest paediatric intensive care unit (PICU) with 27 beds. In nine operating theatres, 26 consultant anaesthetists and over 15 registrars are working, providing approximately 17000 anaesthesias per year. Furthermore, BCH runs a prestigious paediatric cardiac program with over 600 cardiac surgical cases per year. The most complex congenital cardiac defects including hypoplastic left heart

syndrome, corrected transposition of great arteries, and pulmonary atresia with multiple aortopulmonary collaterals are treated here with excellent results. As my home institute is also a paediatric cardiac centre, it was particularly important for me to gain more experience in this highly specialised field.

In March 2012 before my trainee programme started, I visited Birmingham for a preliminary, 7 days, during which I completed the General Medical Council registration as well. Obtaining licence to practise in the UK allowed me to work as a honorary specialist registrar in BCH, with „”hands-on”, under supervision. My tutor, Dr. Ed Carver was always keen to help. On my first day he showed me around the hospital, introduced me to colleagues and helped to sort out all the necessary paperwork. Like every registrar, I had a weekly rota. Each day I was assigned for a particular theatre supervised by a consultant. According to the initial discussion with my tutor, I attended cardiac theatres or cath lab four days a week. The fifth day I was always enrolled to visit various other specialities, like craniofacial, ENT, hepatobiliar, spinal, orthopedics or general surgery.

The day usually started with the cardiac round on the paediatric ICU (PICU) at 8:00 in the morning. During this 30 minutes round cardiac surgeons, cardiologists and intensivists had a short bedside discussion of each cardiac patients admitted to PICU. By joining this round I could easily follow the postoperative treatment and progression of the children. After the round, the cardiac theatre team discussed the listed cases for the day in a short briefing. One of my most important experiences was to see the well-organised, multidisciplinary approach to a given procedure of a particular patient. I was also invited to participate in the cardiac conferences held two times per week. On these conferences all the children waiting for surgery and scheduled for the next week

It was a great pleasure to have Dr. Mihaly Gergely spend three months with us under the auspices of the ESA Trainee Exchange Programme. He came from a background of working in cardiac anaesthesia and was very interested to observe and take part in the provision of anaesthesia for complex congenital cardiac surgery at Birmingham Children’s Hospital.

Dr Gergely’s position in the hospital was that of an Honorary Specialist Registrar in Anaesthesia. As he was able to register with the General Medical Council of the United Kingdom, it was possible to give him hands-on patient contact under direct supervision of fully accredited paediatric anaesthesia consultants whilst working here.

We put together a programme that involved clinical work primarily in the cardiac theatres and angio lab, as well as some time observing management of postop cardiac cases on PICU.

Classic & modern, Birmingham city centre

150 years of caring for sick children in BCH

Birmingham Children’s Hospital, past and present

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were discussed thoroughly. Furthermore, the cardiac team evaluated the results and problems of the recently operated patients or children underwent cardiac catheterisation.In 9 theatres, consultant anaesthetists were also working in a rotational scheme. Although most of them had a particular subspeciality (cardiac, liver, pain…), but they met almost every field of paediatric anaesthesia during their on calls. All of my colleagues were very helpful and I found a friendly, welcoming environment in each theatre. I have learnt a lot from them in theory as well as in practice. Previously I had very little experience in ultrasound guided procedures. Therefore, I found particularly useful the ultrasound skills I was taught in periferal, central venous or arterial canulation and in performing nerve blocks. I think, it is an essential skill in anaesthesia and intensive therapy as well. Concerning special intraoperative scenarios I had a lot of exciting discussions with surgeons, cardiologists and perfusionists as well.

Although my job was mostly assigned to the theatres, I also had the opportunity to spend some time on the PICU. Observing the busy work of this giant department, it was inspiring to see how guidelines and protocols are applied and integrated into bedside clinical practice. I gained a great deal of experience on new monitoring modalities (Cerebral Function Analysis Monitor, NIRS) and treatment methods (ECMO, CVVH in infants, therapeutic hypothermia).

There were weekly journal clubs discussing the up-to-date literature of various subspecialities. During my stay I had the chance to attend two special courses as well. I participated a vascular access course, organised by my department, which provided comprehensive information and practical sessions about ultrasound guided vascular procedures. The other course, I took part, was the ECMO specialists training, organised by the PICU and Cardiac Services. This three day ECMO specialist course was a very well-

structured training, detailing all the aspects of ECMO-treatment, from indications to the weaning process, including practical sessions and live scenarios as well. My tutor had good relationship with the anaesthetists working in the pediatric cardiac centre of Freeman Hospital, Newcastle. Thanks to his help, I was warmly welcomed for a one-week visit in this famous paediatric heart and lung transplant centre. Children with heart failure, ventricular assist devices and candidates for transplantation are managed by a highly experienced team. I feel very grateful to get the chance to see all this.

In conclusion I think, that the Trainee Exchange Program of ESA provides an excellent opportunity to broaden skills, gain experiences in anaesthesia and critical care, and link up anaesthetists across Europe. It was very inspiring to see the well-organised continuing medical education on each level of BCH’s service, that I would also like to promote after returning home. It helps to maintain competence and keep you up-to-date in a very effective way. I must thank Dr Ed Carver, my tutor, for his continuous guidance and support throughout the whole traineeship. A special thank goes to the entire staff of the Department of Anaesthesia in BCH, many thanks to Monica, Sue, Alistair, Fraser, Jimmy, Raju, Ritchie, Tony and to all the employees. Anaesthtetic consultants and registrars were all always ready to answer my questions and treated me as a competent member of the team. I feel also very grateful to all of the Cardiac Team for their support and for the friendly and unforgettable environment they work in.I would like to say thanks also to all of my colleagues in Budapest, who took over the duties during this period. I hope my experiences will promote their work as well.Finally, my sincere appreciation goes to the ESA Trainee Exchange Program Comittee, for making this 3 months visit possible. I would also like to highlight and thank for Anny Lam’s always available technical assistance and support. //

In addition, Dr. Gergely attended a number of other regular meetings – e.g. morbidity and mortality, echo rounds, cardiac surgery planning meetings etc.

This is the third ESA Trainee Exchange Programme we have hosted and they have proven to be very successful and a great opportunity for exchange of ideas between different centres. We very much enjoyed the visit of Dr. Gergely – he was very enthusiastic and keen to learn as much as possible, as well as being a calm and friendly presence. On behalf of all the anaesthetic department at Birmingham Children’s Hospital, he has our very best wishes for his continuing career in cardiac anaesthesia.

Dr. Ed CarverConsultant anaesthetist and College Tutor at Birmingham Children’s Hospital, UK

the hybrid cardiac theatre

BCH, a regional centre for sick kids

the church of St Martin in the Bull Ring, a meeting point of the city

Preparing for scoliosis surgery, ultra-sound guided central line insertion

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WFSA

Introducing the WfSA Education Committee //WAyNE MoRRIS / / CHAIRMAN WfSA EdUCAtIoN CoMMIttEE / / w.mor r i ss@xt ra .co .nz

Greetings from New Zealand and also from the Education Committee of the World Federation of Societies of Anaesthesiologists! I am very pleased to be able to contribute to the ESA Newsletter.

I work as an anaesthetist in Christchurch, on the east coast of the South Island of New Zealand. I took over from Jannicke Mellin-Olsen as Chair of the Education Committee at the World Congress of Anaesthesiologists in Buenos Aires, Argentina, in March 2012, and I will hold the position until the 2016 World Congress in Hong Kong.

The WFSA is truly an international organisation with 120 member societies representing over 140 countries (some societies represent regional groupings). Its mission is to “unite anaesthesiologists around the world for the enhancement of patient care”.

What does this mean? The WFSA is a networking and solidarity organisation – it represents anaesthesiologists worldwide and focuses on improving patient care, mainly through its work in poorer countries where help is most needed. The contributions from richer member societies

help support our colleagues (and their patients) in poorer countries. The WFSA itself has limited resources, but an excellent record of collaboration and getting value for money. Recent data suggest that, for every dollar spent by the WFSA on projects, an extra seven dollars is given by other donors or volunteers.

Education is a vital part of our vision to improve anaesthesia worldwide. The membership of the Education Committee reflects the global nature of the WFSA - the other members are Mohamed Ben Ammar (Tunisia), Dave Otieno (Kenya), Yoo-Kuen Chan (Malaysia), Getulio de Oliveira Filho (Brazil), Juan Carlos Duarte (Venezuela), Quentin Fisher (USA), Mikhail Kirov (Russia), and Miodrag Milenovic (Serbia),

The Education Committee is responsible for a number of fellowship training programmes around the world. The philosophy of these training centres is to train people from nearby countries so that they can become anaesthetic leaders and teachers when they return home. In this way, we hope to achieve an “educational cascade”, where the trainees will teach many others.

Other Education Committee projects include support for short courses (for example, Primary Trauma Care and Essential Pain Management) and provision of funding or teachers for regional and national meetings. A recent example was support for an anaesthetic refresher course for doctors and nurses in Maputo, Mozambique. This has led to a bigger project, where the Brazilian Society is working with the Mozambican Society to write a series of Portuguese language anaesthesia tutorials.

The ESA and WFSA worked together to establish anaesthetic teacher training courses in Europe. The International School for Instructors in Anaesthesiology (ISIA) has now been run three times in Europe, with plans for the fourth Teach the Teacher course organised by ESA in 2013. Teacher training has now spread beyond Europe, with the first Latin American Teach the Teachers course in 2012. This course was supported by the Colombian Society, Baxter and the WFSA, and comprised both web-based and face-to-face modules.

Of course, the ESA plays a major role in many other international anaesthesiology

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educational activities. Examples include the CEEA continuing education programme, the Trainee Exchange Programme, and the European Diploma in Anaesthesiology and Intensive Care (EDAIC). The CEEA programme is now run in many countries around the world, and there is a lot of international interest in the EDAIC.

I was privileged to attend Euroanaesthesia 2012 in Paris. I enjoyed the scientific programme but it was also wonderful to meet the people who are involved with the ESA’s projects, including Geraldine O’Sullivan (NASC), Carmen Gomar (CEEA Committee), and Konstantin Lebedinsky (CEEA Committee), and Robert Sneyd (ESA Education and Training Platform).

It was clear from our meetings that there are many opportunities for working together, and that the ESA and WFSA educational activities complement each other very well. The world is a big place and there are many opportunities to make a difference!

We are currently working on a pilot ESA-WFSA fellowship training programme in St Petersburg, Russia for trainees from the

former Soviet republics. In some ways, this programme will be similar to the existing ESA Trainee Exchange Programme, but there will be a number of differences. Trainees will be from eastern European countries with limited resources and training opportunities. Teaching will be in Russian and we hope that it will be possible to offer a range of subspecialty options as the programme develops.

I’ve only been Chair of the Education Committee for 10 months but it’s a busy and rewarding role. Our ties with the ESA are very important and I am looking forward to visiting Barcelona in June for Euroanaesthesia 2013! //

“

”

The physician in ICU must learn to discover the individual who lies obscured beneath a maze of tubes and numbers; he must find the thinking, feeling human being hidden behind the anxieties of those entrusted with the life of patients

(Nancy Caroline, Crit Care Med

1977;5:256)

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Editor's note: Our readers are encouraged to send quotations from literature and famous people sayings, regarding life, medicine, anaesthesiology and related fields (pain, critical care, etc.) - gurman@bgu.ac.il

future Anaesthesiology Meetings // 2013-2014

2013April, 19-215th Annual Scientific Symposium in Anesthesiology and Intensive Carewww.facebook.com/symposium2013 I Nis, Serbia

April, 25-2610th Annual Critical Care SymposiumContact: ct.veerappan@gmail.com I www.critcaresymposium.co.uk I Manchester, UK

April, 27 – May, 2Anesthesiology Review Course 2013 www.anesthesiareviewcourse.com/ I San Antonio, TX, USA

April, 28 – May, 55th Association of South-East Asian Pain Societies Conference (ASEAPS 2013)Contact: Aseaps2013@kenes.com I www.aseaps2013.org I Singapore

May, 2-3European Pediatric Resuscitation & Emergency Medicine Meeting [PREM]www.prem2013.be I Ghent, Belgium

May, 17-19Tiantan International Neurosurgical Anesthesia Symposium (TINAS) Contact: tinasbeijing@gmail.com I www.t-nas.com I Beijing, China

May, 22-256th World Congress on Abdominal Compartment Syndrome (WCACS)www.wsacs.org I Cartagena, Colombia

May, 22-25 5th European-American Anesthesia Conference www.hdail.hr/2013 I Rovinj, Croatia

June, 1-4Euroanaesthesia 2013 Contact: secretariat@euroanaesthesia.org I www.euroanaesthesia.org I Barcelona, SpainJune, 6-9FSA 2013 Annual meetingContact: executiveoffice@fsahq.org I www.fsahq.org I Palm Beach, FL, USA

June, 8-1123rd European Neurological Society Meeting www.ensinfo.org I Barcelona, Spain

June, 12-1519th Annual International Meeting of the Society in Europe for Simulation Applied to Medicine Contact: info@sesamparis2013.com I www.sesamparis2013.com I Paris, France

June, 14-163rd International Conference on Interventional Pain Medicine & Neuromodulation - A Satellite INS Event Contact: ciaranwazir@gmail.com I www.painandneuromodulationwarsaw.blogspot.com I Warsaw, Poland

June, 17-209th International Symposium on Pediatric Pain www.ispp2013.org I Stockholm, Sweden

June, 22-27Anesthesiology Review Course 2013www.anesthesiareviewcourse.com I Chicago, Illinois, USA

June, 24-26Anaesthesia 2013Contact: flo.doel@markallengroup.com I www.mahealthcareevents.co.uk/af2013 I London, UK

August, 5-8Hawaii Anesthesiology Update 2013 www.hawaiianesthesia.com I Koloa, Kauai, Hawaii USA

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future Anaesthesiology Meetings // 2013-2014

Copyright 2013the 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.

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

Printed on FSC certified paper

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August, 26-2932nd Congress The Scandinavian Society of Anaesthesiology and Intensive Care medicine www.congress.utu.fi/ssai2013/ I Turku, Finland

August, 28 – September, 111th WFSICCM Congresswww.criticalcare2013.com I Durban, South Africa

August, 29-31First Georgian Symposium in Anesthesiology and related fieldsContact: gsaccm@yahoo.co.uk I www.gsaccm.comBatumi I Georgia

September, 5-7European Congress on Paediatric AnaesthesiaContact: espa2013@symporg.ch I www.euroespa.org I Geneva, Switzerland

September, 7-92nd annual Acute Pain Symposium Contact: pgulur@partners.org I www.massgeneral.org I Boston, MA, USA

September, 9-15Panarab Anaesthesia CongressContact: info@panarabanesthesia2013.org I www.panarabanesthesia2013.org/ I Beirut, Lebanon

September, 18-20Annual Congress of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) www.aagbi.org I Dublin, Ireland

october, 1Anaesthesia for Major Surgery - What’s New? Contact: henry.coleman@rmh.nhs.uk I www.royalmarsden.nhs.uk/anaesthesia I London, UK

october 31 – November 2ESA Masterclass on Clinical Trials and Clinical EpidemiologyContact: masterclass@esahq.org I www.esahq.org/masterclasses I Utrecht, The NetherlandsNovember, 6-9New Zealand Anaesthesia Annual Scientific Meeting www.nzadunedin2013.com I Dunedin, New Zealand

November 8 – 9ESA Autumn Meeting 4Contact: secretariat@euroanaesthesia.org I www.euroanaesthesia.org I Timisoara, Romania

November, 19-21ESA Masterclass on Scientific WritingContact: masterclass@esahq.org I www.esahq.org/masterclasses I Brussels, Belgiumdecember, 13-1767th PostGraduate Assembly in Anesthesiology (PGA) Contact: HQ@nyssa-pga.org I www.nyssa-pga.org I New York, USA

2014May, 31 – June, 3Euroanaesthesia 2014Contact : secretariat@euroanaesthesia.org I www.euroanaesthesia.org I Stockholm, Sweden

June 1- 4

Barcelona, Spain

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