Adjuvants for balanced anesthesia in ambulatory surgery

Balanced anesthesia relies on the simultaneous administration of different drugs to attain an anesthetic state. The classic triad of anesthesia is a combination of a hypnotic, an analgesic, and a neuromuscular blocker. It is predominantly the analgesic pillar of this triad that became more and more supported by adjuvant therapy. The aim of this approach is to evolve into an opioid-sparing technique to cope with undesirable side effects of the opioids and is fueled by the opioid epidemic. The optimal strategy for balanced general anesthesia in ambulatory surgery must aim for a transition to a multimodal analgesic regimen dealing with acute postoperative pain and ideally reduce the most common adverse effects patients are faced with at home; sore throat, delayed awakening, memory disturbances, headache, nausea and vomiting, and negative behavioral changes. Over the years, this continuum of "multimodal general anesthesia" adopted many drugs with different modes of action. This review focuses on the most recent evidence on the different adjuvants that entered clinical practice and gives an overview of the different mechanisms of action, the potential as opioid-sparing or hypnotic-sparing drugs, and the applicability specifically in ambulatory surgery.

Adult essential extracorporeal membrane oxygenation (ECMO) skills for use in an e-learning program for ICU physicians, nurses and perfusionists: a consensus by a modified Delphi questionnaire

BACKGROUND

Education in ECMO starts with basic theory and physiology. For this type of training, self-assessment e-learning modules may be beneficial. The aim of this study was to generate consensus on essential ECMO skills involving various professional groups involved in caring for ECMO patients. These skills can be used for educational purposes: development of an e-learning program and fine-tuning of ECMO-simulation programs.

METHODS

Experts worldwide received an e-mail inviting them to participate in the modified Delphi questionnaire. A mixture of ECMO experts was contacted. The expert list was formed based on their scientific track record mainly in adult ECMO (research, publications, and invited presentations). This survey consisted of carefully designed questionnaires, organized into three categories, namely knowledge skills, technical skills, and attitudes. Each statement considered a skill and was rated on a 5-point Likert-scale and qualitative comments were made if needed. Based on the summarized information and feedback, the next round Delphi questionnaire was developed. A statement was considered as a key competency when at least 80% of the experts agreed or strongly agreed (rating 4/5 and 5/5) with the statement. Cronbach's Alpha score tested internal consistency. Intraclass correlation coefficient was used as reliability index for interrater consistency and agreement.

RESULTS

Consensus was achieved in two rounds. Response rate in the first round was 45.3% (48/106) and 60.4% (29/48) completed the second round. Experts had respectively for the first and second round: a mean age of 43.7 years (8.2) and 43.4 (8.8), a median level of experience of 11.0 years [7.0-15.0] and 12.0 years [8.3-14.8]. Consensus was achieved with 29 experts from Australia (2), Belgium (16), France (1), Germany (1), Italy (1), Russia (2), Spain (1), Sweden, (1), The Netherlands (4). The consensus achieved in the first round was 90.9% for the statements about knowledge, 54.5% about technical skills and 75.0% about attitudes. Consensus increased in the second round: 94.6% about knowledge skills, 90.9% about technical skills and 75.0% about attitudes.

CONCLUSION

An expert consensus was accomplished about the content of "adult essential ECMO skills". This consensus was mainly created with participation of physicians, as the response rate for nurses and perfusion decreased in the second round.

Kinetics of lead storage in teeth and bones: an epidemiologic approach

Lead content in teeth of three Belgian populations with different exposures are considered in the framework of a three-compartment model describing lead exchanges in the body. The value of the first-order kinetic constant governing the transfer of lead from blood to teeth is shown to be approximately 1.85 yr-1, which is in good agreement with other studies using stable isotope tracers on a few subjects. Application of these findings to bones, where, contrary to teeth, remobilization processes cannot be neglected, leads to a tentative estimation of the rates of lead output from various kinds of bones, on the basis of epidemiologic data on their lead contents reported in the literature.

Lead accumulation in teeth as a function of age with different exposures

The level of lead exposure in industrial, urban, and rural populations has been evaluated by sampling permanent teeth gathered from three regions of Belgium. When tooth lead concentrations are plotted against tooth age, a linear function appears to fit the empirical results satisfactorily. On the contrary, comparing only the arithmetical means of the three samples would bring a possible bias of the results because their mean ages are different. The slope of the three best regression lines obtained respectively with data from the three regions increases significantly in the sequence rural less than urban less than industrial. A simplified mathematical model shows that this slope is directly related to the mean intake of lead under uniform exposure. It is suggested that this slope could be used as an index of the population's exposure to lead.