The Greek e-journal of Perioperative Medicine

3-16

Authors: Muhammad Umar Younis

Surgery, as a field itself, is a high stress and high pressure workplace environment. The difficulty that surgeons face, in maintaining their work-life balance along with the increasing litigation instances, has made this profession a less rewarding one. This review was carried out in order to determine the prevalence of burnout among surgeons, to identify the risk factors for it, and to employ mitigation strategies to reduce the likelihood of burnout. All full-text articles between 2011-2021 reporting data, related to burnout in surgery according to the criteria specified, were included in this study. The bibliographic databases that were searched included PubMed, MEDLINE and Google Scholar, with data extracted on the characteristics of the articles, including the burnout prevalence and its factors. Sixteen articles were finally included after meeting the determined criteria. The selected studies included over 27,000 participants. Results showed that the most commonly identified risk factors, for surgeons’ burnout, were age, marital status, financial standing, the outcome of their interest, the balance between work and personal life, experience in the field, and gender. The high prevalence of burnout among surgeons is extremely concerning and the identified factors responsible should be explored by surgeons, hospital management boards, training centers in order to find ways to prevent it and to ensure a healthy workplace environment and high-quality surgical patient care.

33-43

Authors: Kyparissa M, Fyntanidou B, Foroulis Ch, Tsagkaropoulos S, Palaska E, Kotzampassi K, Aggou M, Grosomanidis V.

Myasthenia Gravis (MG) is an autoimmune disorder affecting the neuromuscular junction function and causing muscle weakness that gets worse during the day and after physical activity. The most common medication prescribed for MG treatment is pyridostigmine. Pyridostigmine is an anticholinesterase agent, which increases and prolongs the effects of acetylcholine by blocking acetylcholinesterase action. In the present study we present a patient taking pyridostigmine for MG, who was scheduled for elective thymectomy and suffered cardiac arrest (CA) after anesthesia induction. A patient 42yrs male old, ASA-PS:2, with a prior medical history of MG, was scheduled for Video Assisted Thoracoscopic (VATS) thymectomy. Patient had drooping eyelids (ptosis) and had been receiving pyridostigmine for one month (60mgx3). After drug administration and before intubation patient experienced a profound bradycardia, which immediately resulted to asystole. Advanced Cardio Pulmonary Resuscitation (CPR) was initiated and after 1min of CPR, ROSC was achieved. A decision was made to cancel the surgery and to transfer patient to the Intensive Care Unit. Patient was extubated 2 hours later in good hemodynamic and neurological status. Patient suffered a second similar episode in the evening of the same day, which was again managed successfully. A temporary transvenous cardiac pacemaker was placed and on the next day patient was transferred to the Coronary Care Unit and was scheduled for permanent pacemaker implantation. Patient did not give his consent for permanent cardiac pacemaker implantation and was self-discharged against medical advice. Pyridostigmine is an aqcetylcholinesterase (AChE) inhibitor and bradycardia is included in the side effects of these agents.

50-60

Authors: Papadopoulou A, Papagiannopoulou P, Isaakidis A, Paschalidou Ch, Mitsopoulos M, Kamilaki M, Vaxevanidou A

Hypothyroidism is relatively common comorbidity in elderly patients, due to structural and hormonal changes in the aging thyroid. Diagnosis of hypothyroidism, in this population, is considered challenging, since many symptoms are nonspecific and may be attributed to other common medical conditions. Anesthetic management of geriatric patients, with newly diagnosed hypothyroidism, presents a different set of challenges and requires specific perioperative care, due to the increased risk of perioperative complications. Herein, we report a successful case of low-dose spinal anesthesia, in 91-year-old geriatric male patient, with newly diagnosed overt primary hypothyroidism who underwent basicervical femoral neck fracture surgical treatment.

3-11

Authors: Walker C, Carneiro FJ, Bersot CAD, Barros DdMV, Aslanidis Th

Aortic aneurysms occur mainly due to atherosclerotic disease, and their conventional surgical repair is reserved for patients with anatomy unfavorable to endovascular repair. In this context, one of the challenges for the anesthesiologist is perioperative anesthetic-analgesic control. Although the epidural approach is considered the gold standard, it can lead to devastating complications, with neurological injury of hemorrhagic origin being the most feared. The erector spinae plane block (ESP Block) has been shown to be effective in providing anesthesia and analgesia to the chest and abdomen, and the use of adjuvants can improve the quality of the block, in addition to prolonging its duration

18-27

Authors: Antonogiannakis A, Stamatakis E, Skandalou V, Valsamidis D.

Liver transplantation is becoming an increasingly common procedure, as the only viable treatment for liver failure. Many women recover from the acute event and lead mostly normal lives. With their fertility restored, many of them may wish to start their own family and will eventually come across the obstetric anaesthetist. Succesful pregnancies are the norm, but the reported rates of pre-eclampsia, IUGR, sepsis, preterm birth and operative delivery are higher than in the general population. We report the successful management of a post liver-transplant parturient requiring an urgent C-section due to preeclampsia with severe features. We review perioperative concerns and the relevant literature.

40-45

Authors: Pertsas E, Flioni EN, Aslanidis Th.

As climate changes accelerate, heatstroke becomes more and more often; both in its classical (non-exertional) form and in its exertional form. We hereby present a case of exertional heatstroke in a young man that was hospitalized in intensive care unit and discuss the relevant literature.

3-15

Authors: Soulountsi V, Schizodimos Th

Medical nutrition therapy shall be considered for all patients staying in the intensive care unit (ICU), mainly for more than 48 hours. It is well-known that over- and underfeeding are associated with worse outcome, so optimization of nutrition support is one of the most important goals of clinicians. Prescribing the optimal amount and time of administration of nutritional therapy is particularly difficult in critical ill patients due to numerous factors that may lead to significant daily variations in energy expenditure in and between these patients. In ICU calculating resting energy expenditure (REE) closely reflect all energy requirements involved in the basal metabolism because of minimal physical activity. Predictive equations, indirect calorimetry (IC), and ventilator VCO2 are the main methods to estimate REE. Nutritional guidelines discourage the use of predictive equations as these formulas unaccounted many factors that affect caloric needs. IC remains the gold standard to adequately prescribe the nutrition therapy. An international multicenter study (ICALIC), supported by two academic societies has recently led to the evaluation of a new generation calorimeter, Q-NRG. It can be used in both mechanically ventilated and spontaneously breathing patients and overcomes the issue of inaccuracy, high cost, and lack of time of the currently used calorimeters. Lastly, REE calculations based on CO2 measurements from the mechanical ventilator, or the pulmonary arterial catheter have been proposed as a surrogate to IC. Nevertheless, this method has consistently been shown to be inferior to IC but more accurate than predictive equations.

30-35

Authors: Aslanidis Th, Papachatzopoulou E, Matsi K

Despite the vast progress in contemporary medicine, the burden of spinal cord injury has increased over the last decades. Thus, more and more often patients with paraplegia appear for an emergency or elective surgery below the level of the injury. Anesthetic management of those patients can be turn out to be a challenge. In this article we present a case report of monitored anesthesia care in a paraplegic patient for an orthropaedic procedure and perform a short literature review on the subject.

45-49

Authors: Gökdemir BN, Çekmen N

Prader-Willi syndrome (PWS) is a rare genetic disorder characterized by various abnormalities, such as hypotonia, high body mass index (BMI), craniofacial anomalies, and obstructive sleep apnea. Anesthetic management of these patients requires special perioperative planning and care due to multisystem involvement. In this case report we present the anesthetic considerations and perioperative management of a 9-year-old male patient with PWS, who underwent adenoidectomy-tonsillectomy surgery.

3-32

Authors: Papageorgiou L, Staikou Ch

Procedural sedation and analgesia (PSA) is often necessary in order to deal with anxiety, pain and stress that may accompany patients at the hospital during invasive, unpleasant and/or painful procedures. The literature has not presented firm conclusions regarding ideal sedative agents in terms of efficacy and safety in PSA or even present firm data regarding superiority of specific drugs over others which are considered the “gold-standard” in sedation (i.e. propofol). Ketofol is a combination of ketamine and propofol and is considered by many health-care professionals to cause less respiratory suppression and haemodynamic instability, ensuring better analgesia and often amnesia, and possibly improved patient satisfaction. We reviewed the existing evidence regarding superiority of ketofol in mitigating cardiorespiratory effects when administered as a main agent for PSA in comparison to other drugs administered for such purposes underlying the safety and efficacy profile of this cocktail medication. We conducted three times an advanced Pubmed research using the following terms: “ketofol” or “ketamine and propofol” and “sedati*” and “analgesia or pain” in “Title/Abstract” of articles using filters, such as “clinical study”, “clinical trial”, “controlled clinical trial”, “meta-analysis”, “multicentre study”, “randomised controlled trial”, “review”, “systematic review”, “comparative study”, “observational study” in English language and in population of “Adult: 19+ years”. We found 46 articles appropriate to be included in this review. We found limited evidence to support superiority of ketofol compared to other agents, specifically to propofol, the “gold-standard” drug in sedation; undoubtedly, propofol frequently leads to respiratory suppression, hypotension and bradycardia. It seems that the addition of ketamine to propofol in sub-dissociative doses is associated with less respiratory and haemodynamic complications during PSA, while achieving adequate analgesia and deeper sedation, possibly more amnesia and consequently high satisfaction in both patients and health-care professionals. Frequent side-effects of ketofol, such as increased psychomimetic complications, nausea and vomiting and perhaps more prolonged recovery do not outweigh its potential benefits during PSA. Therefore, we consider that it represents a good choice for PSA, especially in specific populations. Further research with large, well designed, randomised clinical trials is necessary to extract firm conclusions regarding superiority of ketofol against other agents used for PSA

44-64

Authors: Schizodimos Th, Soulountsi V, Iasonidou Ch.

Acute brain injury (ABI) is a common clinical problem that requires immediate and urgent treatment. In addition to the treatment of primary brain injury, the main focus of management is the prevention of secondary brain injury (SBI), i.e. any physiological event after the initial injury that can lead to further damage to nervous tissue. Several systemic factors have been found to contribute to SBI, which can compromise the balance between brain oxygen supply and consumption, leading to brain tissue hypoxia. They include arterial hypotension, low cardiac output, hypercapnia, hypocapnia, systemic hypoxia, anemia, hyperthermia, and blood glucose abnormalities. In patients with impaired autoregulation, arterial hypotension leads to cerebral ischemia due to cerebral perfusion pressure reduction and possibly through the development of cortical spreading depression. Low cardiac output, mainly due to volume depletion, can lead to decreased cerebral blood flow (CBF) and brain tissue hypoxia, which can also be caused by other systemic factors that affect oxygen delivery, such as hypoxemia and anemia. Carbon dioxide variations may have a significant effect on CBF, with hypocapnia causing vasoconstriction of cerebral arterioles and a decrease in CBF. Finally, hyperthermia occurs in at least 70% of patients after ABI, and hyperglycemia has been identified for years as an important risk factor for poor outcome.

84-88

Authors: Bihorac E, Çekmen N

Alport syndrome (AS) is a rare hereditary disease, in which there is a defect in type IV collagen, an essential constituent of basal membrane in kidney, ear and eye. This can cause progressive renal damage and eventually renal failure, as well as hearing loss and visual impairment. Definitive treatment, when end stage renal disease (ESRD) has ensued, is renal transplantation. Concerning the anesthetic management of renal transplantation, in patients with AS, major anesthetic challenges are related to renal failure, which involves also electrolyte disorders that may cause cardiac function impairement. Hypertension and hemorrhagic diathesis can also be present. In the present article we present the anesthetic management of a 35-year old male patient, with Alport syndrome, who underwent renal transplantation. Concerning AS patients, comprehensive preoperative multidisciplinary approach and intraoperative close hemodynamic monitoring are considered important factors in order to reduce perioperative complications.

3-11

Authors: Sivrioğlu D, Tuç Ö, Ersoy Z, Çekmen N, Torgay A

Glycogen storage disease type Ia (GSD-Ia; Von Gierke disease) is an inherited disease caused by glucose-6-phosphatase deficiency. Perioperative management of patients with GSD has important implications for anaesthesiologists due to different system involvements. In the case reported here, an 8-year-old patient with GSD type-Ia underwent liver transplantation (LT) for hepatic adenoma that had malignant transformation, severe hypoglycemia and metabolic acidosis, occurred in this patient intraoperatively. The metabolic complications were managed successfully by administering balanced volume of glucose and sodium bicarbonate intravenously (iv). Although liver transplantation is an important treatment option in these patients, anesthesia management requires a multidisciplinary approach, comprehensive perioperative assessment and close intraoperative follow-up for successful outcomes.

19-23

Authors: Kandemir E, Çekmen N, Torgay A, Haberal M

Glycogen storage disease type 1a is a rare inborn error of metabolism. It causes severe fasting intolerance and lactic acidosis due to the deficiency of glucose-6-phosphatase enzyme. Anesthetic management of these patients is very difficult due to their course with different system involvements. Our case report evaluates the anesthetic management and considerations of a glycogen storage disease type 1a patient with air embolism during liver transplantation. Although orthotopic liver transplantation is an important treatment option in these patients, anesthesia management requires a multidisciplinary approach and care should be taken in terms of perioperative complications.

31-36

Authors: Tuç Ö, Bihorac E, Ersoy Z, Çekmen N

Hereditary angioedema (HAE) is a life-threatening rare autosomal dominant (AD) disorder caused by C1-esterase inhibitor (C1-INH) deficiency or dysfunction. HAE is not related to mast cell and histamine pathway; as a result, it does not respond to antihistamines, glucocorticoids, or epinephrine. Attacks may occur spontaneously or after a trauma. The upper airway swelling and laryngeal edema cause asphyxia, which can be life-threatening. Treatment of HAE includes C1-INH concentrate, recombinant human C1-INH, bradykinin B2-receptor antagonists, recombinant plasma kallikrein inhibitors, fresh frozen plasma (FFP) and androgen steroids. In this case we report anesthetic management of a 62 years old female patient with HAE, undergoing endoscopy and colonoscopy, for which highly selective α2 adrenergic receptor agonist dexmedetomidine intravenous (IV) infusion was used. We administered icatibant (bradykinin B2-receptor antagonist) for prophylaxis, and FFP was prepared in case of use. Anesthetic management and preoperative preparation are critical for the patient with HAE. Difficult airway management should be kept in mind in case of airway edema and early intubation.