th INTERNATIONAL MEDICAL CLASS PAEDIATRIC CRITICAL CARE 2020

within the30th Symposium on Intensive Care Medicine + Nursing

Bremen Exhibition and Conference CentreFebruary 26 - 28, 2020

Image: ROBINAID

Happy Birthdayand all the very best for the next 30 years.

Thank you so much for giving us the opportunity to celebrate also the anniversary of the 5th INTERNATIONAL MEDICAL CLASS PAEDIATRIC CRITICAL CARE

within this unique scientific event as a satellite symposium.

30th Symposium on Intensive Care Medicine + Nursing

Cartoon: Bettina Bexte

We are looking forward to welcome you

We are pleased to invite you for participating in the

5th International Medical Class Paediatric Critical Care within the

30th Symposium on Intensive Care Medicine + Nursing

at the beautiful City of Bremen.

In 2020, the combination of the 30th Symposium and the 5th International Medical Classis a very special anniversary edition and we are grateful that we were able to establishour satellite symposium successfully in recent years as a collaborative project betweenROBINAID foundation and the annual Bremen Symposium. Thanks to all who made thishappen.

Physicians, nurses, medical technicians, and other healthcare workers from our inter-national medical projects in Africa, the Middle East, Asia, Eastern Europe, as well ascolleagues from different partnered organizations are warmly invited to join this uniquescientific event.

But, it would be a great pleasure for us to welcome also German colleagues involved inthe field of paediatric critical care as well as interested students: if you want to lookbeyond narrow horizons and if you would like to meet health professionals from othercountries, please come and join our sessions.

Photo: BTZ Bremen Touristik-Zentrale / Jochen Knobloch

Traditionally, our opening session is dealing with a significant societal topic. This timewe address ethical issues concerning the distributional justice of medical services withinrich and poor countries, ask about moral and political responsibility, and show howmedical projects, leaded by dedicated people, can overcome social inequalities.

In the second session, we take a look beyond the horizon by presenting selectedreports, case studies, and exemplary lectures from our international partnered hospitals.

Following, we are working in two sessions under the headline "clinical practice” on majortopics in the field of paediatric critical care: in one of these both sessions we arefocusing on important considerations in safe drug therapy in critically ill children; in theother session we want to discuss how to manage unexpected and challenging scenariosin daily work which often have a great preference to arise in the middle of the night.

Last but not least, the 5th session comprises contributions about strategies of capacitybuilding, patient safety, quality management, and ethical aspects in improving criticalcare services.

Once again, we warmly invite you to join us.

We hope that we will succeed in offering you an interesting, exciting, and multifacetedprogram; we are looking forward to a lively exchange with all our participants sharingpersonal experiences, interacting in a respectful manner, and building up sustainablerelationships: coming as colleagues and leaving as friends.

Knowing what to expect

Photo: ROBINAID

Program overview

Tuesday, February 25, 2020 Arrival 19:30 h: Welcome dinner at the hotel

Wednesday, February 26, 2020 08:00 h: Join the symposium 13:30 h: Opening of the International Medical Class and Session 1 16:30 h: Session 2 20:00 h: Dinner at the hotel

Thursday, February 27, 2020 08:00 h: Join the symposium 13:30 h: Session 3 16:30 h: Session 4 19:00 h: Join the party at the exhibition centre or dinner at the hotel

Friday, February 28, 2020 08:00 h: Join the symposium 13:00 h: Session 5 and Closing of the International Medical Class 19:00 h: Farewell dinner at the hotel

Saturday, February 29, 2020 Bremen sightseeing Departure

The special topic:

Health, healthcare, and distributive justice in a world marked by great inequalitiesbetween rich and poor countries

Session chairs:

Matthias Angrés (Hamburg, DE)Stefan Buchen (Hamburg, DE)

Welcome address of the Vice President of the Bremen State ParliamentAntje Grotheer (Bremen, DE)

A fundamental and inalienable human right: the right to health and living a life indignityPeter Schwick (Munich, DE)The right to health is a fundamental part of our human rights and of a life in dignity. It was first articulated andestablished in the 1946 Constitution of the World Health Organization (WHO), whose preamble states that “the enjoy-ment of the highest attainable standard of health is one of the fundamental rights of every human being withoutdistinction of race, religion, political belief, economic or social condition.” But, what is the significance of this right in lightof the fact that access to comprehensive health services and financial protection for health, which we take for grantedin our rich world, is an unattainable good for the vast majority of people in poor countries, of migrants and refugees?

Binding moral principles are needed: approaches to overcome a world divided byhealth and social inequalitiesStefan Buchen (Hamburg, DE)A world divided by health and social inequalities poses ethical challenges for the global community and demands a highneed for political solutions. Responses to these disparities must be rooted in ethical values about health and itsdistribution, justice and social peace; ethical claims have the power to motivate, delineate principles, duties andresponsibilities, and hold global and national actors morally responsible for achieving common goals. A strong will tochange and binding commitments are necessary; but currently the biggest problem seems to be the lack of a commoninternational moral framework for managing such important problems. We have to solve it now.

Building health services and providing free medical treatment to underprivilegedpeople in Sub-Saharan Africa: the new Rwanda Heart CentreSir Magdi Yacoub (London, UK / Aswan, EG) + Julia Backhaus (London, UK)Sub-Saharan Africa has the highest prevalence of heart diseases in children and young adults, including congenitalheart disease (CHD), rheumatic heart disease (RHD), and cardiovascular effects of malaria; these diseases are themajor causes of serious morbidity and mortality at the age group of 0 – 14 years. Cardiac surgery is a key interventionin preventing early mortality among these patients. Currently there are no facilities in Central/Eastern Africa offeringsuch treatment. This has led to the idea of establishing a state of the art Heart Centre in Kigali, the capital of Rwanda,to take up this challenge. The Aswan Heart Centre in Egypt forms the basis of this new project and serves as model.By taking this step, the founder of the Aswan Heart Center, Prof. Sir Magdi Yacoub, opens another chapter in thedevelopment of high-quality medical care in Africa showing that medicine can take an exemplary leading role inovercoming social inequalities.

Session 1: February 26, 2020; 13:30 - 16:00 h; Room London

Looking beyond the horizon:

Selected reports and exemplary lectures from our international partners

Session chairs:

Yasser Sedky (Aswan, EG)Matthias Angrés (Hamburg, DE)

Promoting biomedical research: basic science and applied clinical research as anintegral concept at the Aswan Heart Research CentreYasmine Agiub (Aswan, EG)From the inception of the Aswan Heart Centre in 2009, it was planned and agreed that a strong research programme isan important part of the mission statement of the centre, designed to integrate and strengthen the clinical programmein its commitment to achieve excellence and importantly to train a new generation of physicians and scientists. Teamsfrom different disciplines and scientific backgrounds are interacting closely to understand heart diseases, particularlythose that are prevalent in Egypt, and find innovative treatment options to provide the medical treatments of tomorrow.

A new surgical technique: mid-term outcome of a modified Mustard operation forneglected transposition of the great arteries at the Aswan Heart CentreYasser Sedky (Aswan, EG)Currently, the arterial switch operation (ASO) is the treatment of choice for the majority of patients with transposition ofthe great arteries (TGA). However, in low- and middle-income countries, a significant number of patients present toolate for ASO. The modified Mustard operation (MMO) could play an important role in the management of the manyneglected patients with TGA in the developing world.

Broad clinical experience: incidence and management of rheumatic heart diseasein children and adolescents at the TSSF Cardiac Centre in CameroonCharles Mve Mvondo (Yaoundé, CM)Rheumatic heart disease (RHD) still remains a major cause of morbidity and mortality in less developed countries,despite its eradication in developed societies. The disease results from damage to heart valves caused by one orseveral episodes of rheumatic fever, an autoimmune inflammatory reaction to throat infection caused by group Astreptococci. It most commonly occurs in childhood and in adolescent age and can lead to death or life-long disability.Only effective early intervention can prevent premature mortality from RHD.

The Hanover Medical School teaching concept: pathophysiology and managementof shock in childrenMichael Sasse (Hanover, DE)Shock is a leading cause of morbidity and mortality in the paediatric population and belongs to the most frequentlydiagnosed disorders in the paediatric critical care unit. The precise definition of clinical signs and symptoms thatcomprise shock remains still controversial due to the great diversity of disorders that cause shock in critically ill andinjured children. But, early management and reversal of the shock state is associated with significantly improvedoutcomes. However, early management is critically dependent upon early recognition and diagnosis of shock at thebedside. And this requires a comprehensive knowledge of the pathophysiological aspects as well as an ongoingtraining in the right assessment and proper handling of such critical patients.

Session 2: February 26, 2020; 16:30 - 19:00 h; Room London

Clinical Practice I:

Safe and appropriate drug therapy in paediatric critical care

Session chairs:

Matthias Angrés (Hamburg, DE)Frank Jochum (Berlin, DE)

Essentials in understanding of pharmacokinetic and pharmacodynamic effectsFrank Jochum (Berlin, DE)Rational drug therapy requires the application of pharmacologic principles to maximize efficacy while minimizingadverse reactions. In the setting of paediatric critical care rational drug therapy is predicated on an understanding ofthe pathophysiology of the disease being treated and the pharmacology of the drugs applied. Paediatric patients arerecognized as a special population for drug therapy, many physiological changes take place during the various stagesof child development which may have an impact on the pharmacokinetics and dynamics of a compound. Paediatricintensivists need to be aware of theses anatomical and physiological changes that affect pharmacological profiles.

The concept of antimicrobial stewardship to optimize antibiotic use

Taibullah Bandawal (Kabul, AF)An estimated 40 - 80% of paediatric critical care patients receive antibiotics and as much as half of that use may beinappropriate. Antibiotic overuse can have deleterious consequences, including drug toxicities, clostridium difficileinfections, and antibiotic resistance. The need for judicious antibiotic use has been highlighted by several internationalorganizations and antimicrobial stewardship (AMS) is a Joint Commission standard for all hospitals. AMS is an import-ant strategy of quality improvement but successful implementation is often difficult to achieve. Lack of resources andprescriber opposition are reported barriers. A leadership style focusing on empowering frontline staff to take responsi-bility is the best approach to implement changes.

Inotropes in the postoperative care following paediatric cardiac surgery

Ahmed Tharwat (Aswan, EG)An important aspect of perioperative care following paediatric cardiac surgery is maintenance of optimal hemodynamicstatus to prevent or treat low cardiac output syndrome and low perfusion pressure. The ideal inotrope consistentlyimproves systolic and diastolic cardiac function, decrease afterload, improve cardiac output, have a favorable effect onmyocardial oxygen hemodynamics, and improve survival and quality of life, with as little adverse effects andinteractions as possible. Unfortunately, the ideal inotrope does not exist. But the paediatric intensivist does have anumber of pharmacological options at disposal with well-known hemodynamic effects.

Postoperative analgesia and sedation following paediatric cardiac surgeryMatthias Angrés (Hamburg, DE)Sedation and analgesia following paediatric cardiac surgery have a major influence on the postoperative recoveryprocess. An effective strategy has to start in the operating theater and to continue in the postoperative period. Asuccessful concept aims toward avoiding the development of postsurgical stress syndrome, reducing potential hemo-dynamic side effects, speeding recovery, and minimizing PICU length of stay. Understanding the pharmacologicalaspects of various sedative/analgesic drugs as well as continuous dose adjustment according to the patient's conditionand response are necessary. Patient-tailored protocols should be implemented and a close cooperation between theanaesthetist and intensivist is mandatory.

Session 3: February 27, 2020; 13:30 - 16:00 h; Room G3

Clinical Practice II:

Challenging scenarios during everyday activities in paediatric critical care

Session chairs:

Cristian Bulescu (Bucharest, RO)Matthias Angrés (Hamburg, DE)

Management of the difficult airway in infants and children: a systematic approachChristoph Mahn (Hamburg, DE)Tracheal intubation is defined as an artificial airway established in order to provide mechanical ventilation duringsurgical procedures under general anaesthesia, treatment in a critical care unit, as well as in emergency situations.Fortunately, there is a lower incidence of paediatric difficult airways as compared with adults; yet, the consequencesresulting from poor management are more serious. While published data exist on the management of the difficult adultairway, clinical data regarding the difficult paediatric airway, including the incidence and optimal management, are morelimited. Recommendations are often extrapolated from adult data. This lecture proposes a simple step-wise algorithmfor the difficult paediatric airway.

Management of postoperative bleeding following paediatric cardiac surgeryCristian Bulescu (Bucharest, RO)Significant postoperative bleeding following cardiac surgery under the use of cardiopulmonary bypass (CBS) is one ofthe most frequent complications associated with postoperative morbidity and mortality in children. The definition ofsignificant postoperative blood loss is based on the calculation involving the circulating blood volume (CBV). It hasbeen considered as clinically significant when a loss of 10% to 20% of the CBV is observed within the first 6 hourspostoperatively. Postoperative blood loss can always have two origins: surgical and nonsurgical. To manage suchcomplication properly needs a close cooperation between the intensivist and surgeon.

Management of neurological complications following paediatric cardiac surgeryMahmoud Aslan (Aswan, EG)Although advances in surgical techniques and perioperative management have led to major improvements in outcomesfor children undergoing cardiac surgery, neurological injuries including seizures, ischemic lesions, choreoathetosis, andencephalopathy are still one of the most tragic sequels. Neurological disorders vary depending on the level and extentof injury as well as the etiology. Despite several studies, the ideal neuroprotective treatment is not well understoodbecause of the multifactorial mechanism of brain injury that occurs mostly during extra corporeal circulation. But adetailed understanding of their pathogenesis, prevention, recognition and management, as well as rapid intervention isrequired to prevent or minimize life-long consequential losses.

Stabilisation and transport of the critically ill child: special skills are neededUlrich Trappe (Hamburg, DE)Optimal outcomes for children with life-threatening illness or injury depend on early access to care, rapid recognition ofthe severity of illness with early initiation of appropriate and effective therapy, and optimized transport to units wheredefinitive care can be provided. Medical transport is a key element in the chain of survival for critically ill children;evidence shows that children transported by specialized teams have fewer transport-related adverse events, morestable condition upon arrival, and lower in-hospital mortality. Safe transport of critically ill children remains a globallyimportant issue, particularly in regions where specialized paediatric emergency and transport teams are not existent.

Session 4: February 27, 2020; 16:30 - 19:00 h; Room G3

An ongoing obligation:

Capacity building, patient safety, performance improvement, and ethical aspectsin paediatric critical care

Session chairs:

Matthias Angrés (Hamburg, DE)Mahmoud Abdel Hay (Aswan, EG)

Building sustainable capacity for cardiovascular and critical care services at theAswan Heart Centre: a shining example not only for specialized hospitals in AfricaMahmoud Abdelhay (Aswan, EG)Since opening in 2009, medical training plays a central role at the Aswan Heart Centre to meet the need for well-trainedstaff not just for the center itself, but also to improve medical education throughout the entire country. With planning thenew Aswan Heart Center in Cairo, which envisages a tripling of the treatment capacities, the centre is facing a bigchallenge, where the consistent further development of the training concepts has to prove successfully. The resultingmodel can be groundbreaking not only for Egypt, but also for other countries where there is a high need for capacitybuilding in cardiovascular and critical care services.

Lessons we can learn from aviation: the concept of Crew Resource ManagementMario Bakalov (Frankfurt, DE)Patient safety is mostly based on human performance; communication and coordination among all team members arecrucial success factors. The concept of Crew Resource Management (CRM) was developed to provide a mechanismfor improving communication and team situational awareness within aviation in the late 1970s and early 1980s. Thebasic building blocks of CRM include emphasizing teamwork and strategy, developing and understanding situationalawareness, and improving interpersonal communication. Like aviation, the critical care sector involves considerablecoordination among many people and has a high risk of grave consequences by errors due to lack of communication.

Practicing critical care in resource-limited settings: a permanent balancing actbetween rational professionalism and moral distressMatthias Angrés (Hamburg, DE)Medical ethics is a system of moral principles that apply values and judgments to the practice of medicine. Thesevalues include the respect for autonomy, non-maleficence, beneficence, and justice. Ethically charged situations arecommon in paediatric critical care; however, the principle of distributive justice is of utmost importance when criticalcare resources are scarce. The aspect of how to use the available resources to the greatest potential benefit in order toprovide the necessary treatment to as many patients as possible, plays the decisive role. But, exactly is the biggestdilemma as it is a constant struggle to accept and endure existing limitations.

Closing of the 5th International Medical Class

Summary: Matthias Angrés (Hamburg, DE)

Farewell address: Werner Kuckelt (Bremen, DE)

Distribution of the certificates

Session 5: February 28, 2020; 13:00 - 15:30 h; Room G3

Session chairs and speakers

Dr. med. Matthias AngrésROBINAID FoundationHamburg / Germany

Mahmoud AbdelhayAswan Heart CentreAswan / Egypt

Yasmine Agiub MDAswan Heart CentreAswan / Egypt

Mahmoud Aslan MDAswan Heart CentreAswan / Egypt

Julia BackhausFlux architectsLondon / United Kingdom

Mario BakalovA 380 PilotFrankfurt / Germany

Taibullah Bandawal MDFrench Medical Institute for Mothers and Children Kabul / Afghanistan

Stefan BuchenNorth German Broadcasting Corporation Hamburg / Germany

Cristian Bulescu MDMarie Curie Children's HospitalBucharest / Romania

Antje GrotheerBremen State ParliamentBremen / Germany

PD Dr. med. Frank JochumProtestant Hospital Spandau Berlin / Germany

Prof. Dr. med. Werner KuckeltSymp Intensive Care Medicine + NursingBremen / Germany

Dr. med. Christoph MahnHamburg Children Hospital WilhelmstiftHamburg / Germany

Charles Mve Mvondo MD TSSF Cardiac Centre Yaoundé / Cameroon

Dr. med. Michael SasseHanover Medical SchoolHanover / Germany

Dr. med. Peter SchwickMédecins du Monde GermanyMunich / Germany

Yasser Sedky MD, PhDAswan Heart Centre Aswan / Egypt

Ahmed TharwatAswan Heart CentreAswan / Egypt

Dr. med. Ulrich TrappeHamburg BG Emergency HospitalHamburg / Germany

Prof. Sir Magdi Yacoub MD, PhDImperial College London + Aswan Heart Centre London / United Kingdom + Aswan / Egypt

1990

2015

Global Burden of Disease Study 2015: THE LANCET, Volume 390, ISSUE 10091, P231-266, July 15, 2017

Article 25 of the UN Universal Declaration of Human Rights states that “everyone hasthe right to a standard of living adequate for the health and well-being of himself and ofhis family, including food, clothing, housing and medical care and necessary socialservices”.

But the reality looks quite different: a third of the world’s population lacks of access toadequate quality health care; low and middle-income countries bear 93% of the world´sdisease burden yet account for only 18% of world’s income and 11% of global healthspending.

The Healthcare Access and Quality Index (HAQI) is based on mortality from causesamenable to personal health care in 195 countries; comparing the values from 1990 withthose from 2015 shows alarmingly that particularly in Sub-Saharan Africa the situationhas not significantly improved within the last 25 years.

A world divided by health inequalities

Global efforts to reduce child mortality have focused on reducing death from communi-cable diseases with little to no attention on critical care; in the poor regions of our worldthe burden of paediatric mortality remains still high and a largely undocumented burdenof critical illness exists.

Access to critical care is a crucial and life-saving component of healthcare and involvesa coordinated system of triage, emergency management, and specialized critical careunits. Such proceedings are not affordable for most of the less developed countries;above all, this applies especially in paediatric critical care.

Lack of awareness, competing health priorities, high costs, and a critical shortage ofspecialists are the most important reasons why critical illnesses in children are still notaddressed adequately in low resourced settings. But paediatric critical care is animportant component of reducing morbidity and mortality globally..

The dramatic disproportion between medical access and healthcare services within richand poor countries comprise one of the gravest problems of medical ethics but alsogreat challenges of social as well as political responsibility; we are obligated to findequitable solutions very quickly.

Capacity building of critical care services in less developed countries is predicated onthe belief that all human beings belong to a single community, based on a commonmorality of three basic principles: all people are of equal worth, the dignity of individuals,and the existence of human rights binding to all.

Photo: ROBINAID

Capacity building is a mandatory obligation

About the Bremen Symposium on Intensive Care + Nursing

The Bremen Symposium on Intensive Care Medicine + Nursing is jointly organized bythe Scientific Association for the Promotion of Clinically Applied Research in IntensiveCare Medicine / WIVIM, the Hospital & Critical Care Consulting / HCCM GmbH, and theMESSE BREMEN, M3B GmbH and belongs to one of the largest medical congresses inGermany dealing with anaesthesia, intensive care as well as emergency care.

More than 4,700 participants are coming to Bremen each year. During the symposium,approximately 180 scientific sessions and workshops are being performed and up to 200exhibitors present their products in anaesthesia and critical care.

About ROBINAID foundation

ROBINAID foundation establishes and supports paediatric critical care in less developedcountries according to international quality standards; as a highly specialized medicalexpert organization we focus on the treatment of life-threatening disorders particularlycongenital and acquired heart diseases.

We are always working in conjunction with local partnered hospitals; according to theirneeds we provide teams of medical experts, equipment, and consumables. But, in orderto encourage them in their own abilities to become self-sufficient as soon as possible,medical education is the most important column in our strategy.

MESSE BREMENM3B GmbHProjektleitung: Kordula GrimmFindorffstraße 10128215 Bremen Germanyinfo@intensivmed.de

ROBINAID foundationc/o Gem.AuditDr. med. Matthias Angrés Weidestr. 13422083 Hamburg / Germany info@robinaid.org

HCCM Consulting GmbHProf. Dr. med. Werner KuckeltSögestr. 4828195 Bremen / Germanykontakt@hccm-consulting.de

Photo: MESSE BREMEN / Jan Rathke

Further information

IMAGE: ROBINAID / BODO GSEDL

Image: ROBINAID / Bodo Gsedl