Hellenic Cardiological Society

Editor, We read with great interest the debate fostered through the recently published Editorial by De Robertis et al.1 on the monopolisation of emergency medicine in Europe. Undoubtedly, the introduction of emergency medicine has improved access to high-quality emergency care worldwide. In Greece, as in other countries, emergency medical care is delivered by several specialties, namely anaesthesiology, intensive care medicine, internal medicine, cardiology, surgery, pneumology and paediatrics. Of note, it was only very recently that emergency medicine was officially enacted as a subspecialty in Greece. Nevertheless, no one can assure that critically ill patients receive, or will continue to receive, optimal emergency care by emergency physicians, both in Greece and world-wide. We agree with Søreide et al.2 that the care of critically ill and injured patients will continue to be in the hands of anaesthesiologists either immediately or sometime after admission to the emergency department (ED). However, as Buscher3 correctly stated, anaesthetists may lack experience in diagnosing complex medical conditions and a multidisciplinary approach is therefore mandatory. Alternatively, these patients could be managed by a dedicated specialist equipped to fulfil this role, not only in resuscitation skills but also in diagnostic work-up and communication abilities.3 In our case, this is very important because the physiological derangements resulting from critical illness have significant implications on the peri-operative management of critically ill patients. Based on the aforementioned, we have recently evaluated the introduction of an acute care anaesthesiology team (unpublished data). The acute care anaesthesiology team was created in 2014 to optimise the peri-operative management of extremely critically ill patients who must undergo emergency surgery, and uses a personalised physiology-guided treatment strategy which is divided into three periods. During the pre-operative period, the team provides initial aggressive resuscitation in the ED or on the ward and aims at optimising the physiology of patients or achieving at least the minimum required level of fitness for undergoing emergency surgery, which is similar to the concept of critical emergency medicine. During the intra-operative period, the acute care anaesthesiology team provides high-quality anaesthetic care. The post-operative period begins in the operating room immediately after the end of the surgical procedure and continues into the post-anaesthetic care unit for a maximum of 4 h. In addition, the acute care anaesthesiology team immediately responds to any unpredictable crisis or life-threatening emergencies in the ED upon request. In our institution, the acute care anaesthesiology team has enhanced the quality of care in the ED. In turn, the enactment and implementation of the subspecialisation of emergency medicine is anticipated to enhance the quality of peri-operative management of critically ill patients. We believe that there is only one pathway towards to the goal of patient-centred management: high-quality training and collaboration. Our practice will never be independent; rather it will continue to depend on close cooperation with the other acute care specialties. Therefore, we would like to paraphrase the title of the letter by Hautz et al.4 from ‘professionalisation rather than monopolisation is the future of emergency medicine in Europe’ to ‘collaboration is the future of emergency medicine in Europe’. Acknowledgements relating to this article Assistance with the letter: none. Financial support and sponsorship: none. Conflicts of interest: none.

To investigate the effects of the combination of centhaquin and 6% hydroxyethyl starch 130/0.4 (HES 130/0.4) in a swine model of hemorrhagic shock. Twenty Landrace-Large White pigs were instrumented and subjected to hemorrhagic shock. The animals were randomly allocated in two experimental groups, the control (group CO, n = 10) and the centhaquin groups (0.015mg/kg, n = 10, group CH). Acute hemorrhage was induced by stepwise blood withdrawal (18mL/min) from the internal jugular vein until MAP decreased to 40-45mmHg, whereas anesthesia remained constant. All animals received HES 130/0.4 solution in the resuscitation phase until their mean arterial pressure (MAP) reached 90% of the baseline. The animals were observed for 60min, during which no further resuscitation was attempted. The total amount of blood and the bleeding time did not differ significantly between group CO and group CH (120 ± 13 vs. 120 ± 14mL, p = 0.6; 20 ± 2 vs. 20 ± 1min, p = 0.62, respectively). During the hemorrhagic phase, only a difference in heart rate (97.6 ± 4.4 vs. 128.4 ± 3.6beats/min, p = 0.038) was observed between the two groups. The time required to reach the target MAP was significantly shorter in the centhaquin group compared to controls (13.7 ± 0.4 vs. 19.6 ± 0.84min, p = 0.012). During the resuscitation phase, a statistical significant difference was observed in MAP (75.2 ± 1.6 vs. 89.8 ± 2.1mmHg, p = 0.02) between group CO and group CH. During the observation phase, a statistical significant difference was observed in SVR (1109 ± 32.65 vs. 774.6 ± 21.82dyns/cm5, p = 0.039) and cardiac output (5.82 ± 0.31 vs. 6.9 ± 0.78L/min, p = 0.027) between the two groups. Two animals of group CO and seven animals of group CH survived for 24h (p = 0.008). We observed a marked increase in microvascular capillary permeability in group CO compared to group CH, with the wet/dry weight ratio being significantly higher in group CO compared to group CH (4.8 ± 1.6 vs. 3.08 ± 0.6, p < 0.001). The combination of centhaquin 0.015mg/kg and HES 130/0.4 resulted in shorter time to target MAP, lower wet-to-dry ratio, and better survival rates after resuscitation from hemorrhagic shock.

concentration 118.12 mEq/1).All patients were elderly (mean age 77 yrs), had urine sodium concentration above 40 mEq/1, had normal thyroid and adrenal function, normal plasma creatinine and potassium concentration.The corrected QT interval was prolonged in all patients (mean 520 ms).Neurological symptoms attributable to hyponatremia were observed in all 7 pts.In 3 out of these 7 patients torsade des pointes (TdP) was clinically documented (this arrhythmia was not observed in any of the remaining 132 patients without hyponatremia).The arrhythmia was resolved with the usual care; no patient died.Amiodarone was discontinued in these 3 patients and in one other the dose was reduced.Normalization of sodium concentration was documented in all these 4 pts.after a mean of 2.5 weeks.Conclusion: SIADH is a rare, but serious complication of long term therapy with Amiodarone.This could increase the propensity to TdP induced by this drug.Hyponatremia induced by Amiodarone is reversible by drug discontinuation or dose reduction.