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The concept of early recovery after surgery (ERAS) consists of bundle interventions during the pre-, intra- and postoperative periods and team work. The ERAS, which is a multimodal strategy, enables one to limit the neurohumoral response to the surgery, maintain homeostasis, reduce the risk of complications, shorten the hospital stay, accelerate the return to everyday functioning, improve the patient’s satisfaction, achieve a satisfactory quality of life and finally reduce the treatment costs and eliminate any redundant and ineffective practices. Almost every patient can be classified for the ERAS strategy except for patients undergoing urgent and emergency surgery. The necessity to give up ERAS can result from poor organisation and management. Moreover, the procedure itself can be the cause of the lack of adherence to the planned standard. It is necessary to use protocols and checklists. While fulfilling this doctrine, the anaesthesiologist becomes a perioperative specialist.

A b s t r a c tBackground: Remote preconditioning has been shown to be a potent protective phenomenon in many animals. Several studies aimed to demonstrate it was feasible in humans by trying to show its protective effect during cardiac surgery. Of these, some small studies and one larger trial were positive while two other bigger studies showed no effectiveness of remote preconditioning as assessed by levels of postoperatively released cardiac markers. Recently, two large clinical trials also failed to prove the benefit of remote preconditioning in cardiac surgery. No study showed that remote preconditioning actually increases resistance of human myocardium to standardised ischaemic and reperfusion stimulus in experimental settings. In animal studies, remote preconditioning was shown to improve mitochondrial function and structure, but such data on human myocardium are scarce. Aim:The aim of the study is to determine whether remote preconditioning protects human myocardium against ischaemia-reperfusion injury in both in vivo and in vitro conditions. Methods:The trial is designed as a single-centre, double-blinded, sham-controlled trial of 120 patients. We randomise (1:1) patients referred for coronary artery bypass grafting for stable coronary artery disease to remote preconditioning or "sham" intervention. The remote preconditioning is obtained by three cycles of 5 min inflation and 5 min deflation of a blood pressure cuff on the right arm. Postoperative course including myocardial enzymes profile will be analysed. Moreover, in the in-vitro arm the clinically preconditioned myocardium will be assessed for function, mitochondria structure, and mitochondria-dependent apoptosis. The informed consent of all patients is obtained before enrolment into the study by the investigator. The study conforms to the spirit and the letter of the declaration of Helsinki. Results and conclusions:In case the effect of remote preconditioning is not measurable in ex-vivo assessment, any future attempt at implementing this phenomenon in clinical practice may be futile and should not be continued until the effect can be confirmed in a controlled experimental setting. The study might therefore indicate future directions in trials of clinical implementation of remote preconditioning. INTRODUCTIONNo experimental study showed that human myocardium can be remotely preconditioned against standardised ischaemic/hypoxic insult. We aim to remove this major knowledge gap by applying remote preconditioning to the patient and studying ex-vivo the myocardium obtained thereafter. We assume that we will be able to show that remote preconditioning by brief periods of ischaemia of the arm protects segments of human right atrial appendage myocardium subjected to simulated hypoxia and reoxygenation in-vitro.This proof of principle is crucial. In case the effect of remote preconditioning is not measurable in ex-vivo assessment, any future attempt at implementing this phenomenon in clinical practice may be futile and should not be continued until the e...

Background: The physiological reaction to a decrease of cardiac output (CO) is an increase of oxygen extraction. Patients with compromised circulation often are not capable of this reaction. The oxygen concentration in such cases will not change with respect to the CO; therefore the mixed venous blood saturation (SvO 2 ) will not be a reliable indicator of the blood flow. Aim of the study: The aim of the study was to determine the reliability of the correlation between hemodynamic parameters and indices of tissue oxygenation in patients undergoing cardiac surgery procedures. Material and methods: We performed a retrospective analysis in 19 patients who required Swan-Ganz catheter (SGC) insertion. Measurements were taken at three time points. Values of cardiac index (CI), mixed venous oxygen saturation (SvO 2 ), oxygen uptake (VO 2 ), oxygen extraction ratio (O 2 ER), and base excess (BE) were analyzed and compared with oxygen partial pressure (PaO 2 ), carbon dioxide partial pressure (PaCO 2 ) and arterial blood saturation (SaO 2 ). Results: Our study revealed an increase of CI, VO 2 and O 2 ER and a decrease of SvO 2 after the operation in comparison with the preoperative period. There was a positive correlation between the trends of SvO 2 and CI before and after the surgery. Conclusions: Correct values of SaO 2 , PaO 2 and PaCO 2 do not mean that the level of subcellular processes associated with the extraction of oxygen proceed in a physiological way. Only SvO 2 and CI results obtained with the SGC make it possible to assess the delivery of oxygen and its consumption at the tissue level.

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