The Greek e-journal of Perioperative Medicine

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.