The Greek e-journal of Perioperative Medicine

3-15

Authors: Varvarousi G, Klimi P, Stamatakis E, Saiti A, Iliopoulou Ch, Papa M, Scandalou V, Valsamidis D.

Obstetric haemorrhage is the leading cause of mortality in parturients. In massive haemorrhage, fibrinogen is the first coagulation factor to decrease and a value < 2 gr/lt is a prognostic indicator of severe haemorrhage. A small decrease in fibrinogen leads to an increased effect on coagulability and continued haemorrhage. Coagulation disorders may be due to either consumption of coagulation factors or dilution. The type, severity and time of onset of the coagulation disorder depend on both the size and the cause of the haemorrhage. Early recognition of the cause of haemorrhage, low fibrinogen and its immediate correction are essential in the perioperative management of haemorrhage. The use of viscoelastic coagulation measurements contributes to rapid, individualized and targeted management of haemorrhage and coagulation disorders. It reduces transfusion of blood products and their complications, the length of hospital stay and in-hospital mortality. In obstetric haemorrhage, the target is haemoglobin > 8 gr/dl. Fibrinogen should be greater than 2g/L and replaced with cryoprecipitate or fibrinogen concentrate. Replacement of fibrinogen by plasma will lead to administration of large amounts of plasma and increase the risk of complications. Platelet count should be > 75 X100/l. Their administration is indicated in pre-existing thrombocytopenia, coagulation disorder from consumption and blood loss > 5000 ml. At the same time, it is important to avoid acidosis, hypocalcaemia and hypothermia.

55-61

Authors: Çağla Yazar, Nedim Çekmen

Thoracic epidural anaesthesia (TEA) is frequently used for anaesthesia and analgesia in today’s practice. Although cholecystectomy is a surgical procedure performed under general anaesthesia (GA), many studies in recent years have shown that neuraxial techniques can be used safely. We aimed to present the anaesthesia management under dexmedetomidine sedation with TEA in high-risk patients who underwent laparoscopic cholecystectomy surgeries. Both patients were of geriatric age and had several comorbidities. In patients, we preferred TEA to avoid the cardiorespiratory effects of GA. Preoperative preparation of patients with a multidisciplinary approach, cooperation, and close follow-up is essential in preventing complications.

3-17

Authors: Guimarães Pereira JE, Palmeira C, Saffier IP, Darcy Alves Bersot C, Aslanidis Th, Ashmawi HA

Objective: A systematic review to investigate the efficacy and safety of medicinal cannabis on clinical outcomes of patients suffering from sickle cell anemia pain. Data sources: The following databases were searched: PubMed, COCHRANE, LILACS and Science Research from inspection up to March 8th, 2022. No restrictions applied. The terms used for search were sickle cell anemia and cannabis and their synonyms. Study selection: We included Non-Randomized Studies (NRS) and Randomized controlled trials (RCTs) evaluating Cannabis Medicinal for Pain originating from Sickle Cell Disease (SCD). Data extraction: Reviewers independently screened potentially eligible articles; extracted data from included studies on populations, interventions and outcomes and assessed their risk of bias. Data synthesis: 1 RCT including 34 participants and 5 NRS, including a total of 37871 participants, proved eligible. We could not find enough publications to further proceed with a meta-analysis. Conclusions: There is no evidence in the literature about treating pain from sickle cell anemia with cannabis. There is an association between cannabis use and hospital emergency department visits.

26-44

Authors: Deligianni M, Fyntanidou B, Foroulis Ch, Kioumis I, Tsagkaropoulos S, Alexiou I, Kotzampassi K, Grosomanidis V

Introduction: Anesthesia for thoracic surgery presents specific challenges since anesthesiologists have to manage patients with several comorbidities, apply One Lung Ventilation (OLV) to facilitate surgery and at the same time they should try to maintain adequate safe oxygen levels. Hypoxemia is a common consequence of OLV. The aim of the present retrospective study was to investigate the impact of intraoperative hypoxia on the early outcome of patients. Material and Methods: In this study120 patients were included, who underwent thoracic surgical procedures with OLV and were assigned into two groups of 60 patients in each group. Group A consisted of patients who experienced severe hypoxia (PiO2/FiO2<100) during OLV, whereas Group B consisted of those who did not suffer from hypoxia. ABG samples were collected intraoperatively at four different phases: Ph1: spontaneous breathing without any oxygen supply before intubation, Ph2: after initiation of mechanical ventilation, Ph3: during OLV and Ph4: immediately before being transferred from the operating theatre. Venous blood samples were collected at three phases: Ph1: after initiation of mechanical ventilation, Ph2: at the time of hypoxia occurrence and Ph3: immediately before being transferred from the operating theatre. During ICU stay, ABG samples were taken at four phases: Ph1: immediately after ICU admission, Ph2: before extubation, Ph3: after extubation and Ph4: before ICU discharge. Results: Intraoperatively, patients in Group B had better oxygenation compared to Group A at all phases. Moreover, during OLV patients in Group A experienced severe hypoxemia. Intraoperative PO2/FiO2 ratio in Group A was 369,8±69,9 / 279,4 ±91,5 / 68,3±11,8 / 324,7± 82,9 and at the corresponding phases the relevant values in Group B were 420,8±68,2 / 373,8±87,5/ 242,9±79,6 / 406,7±64,4. Partial pressure of oxygen in the central venous blood (PcvO2) and Central venous oxygen saturation (ScvO2) differed in a statistically significant manner between the study groups. However, ScvO2 remained at acceptable levels even at the time of hypoxemia in Group A. ScvO2 values in Group A were 78,7±9,1 / 66,8±79,7 / 73,3±5,82 and at the corresponding phases the relevant values in Group B were 87,1±7,2 / 79,8±7,8 / 81,8±7,5. Duration of mechanical ventilation in ICU was longer in Group A compared to Group B (5,34±5,1hrs vs 3,6±2,5hrs), whereas ICU and total hospital stay did not differ between study groups. Conclusion: Hypoxemia during OLV in Group A did not have a negative impact on early outcome of patients.

51-56

Authors: Myrou A, Aslanidis Th, Savopoulos Ch, Didangelos T

Raoultella planticola is a Gram-negative, oxidase-negative, aerobic that belongs to Enterobacteriaceae family and has a lot of similarities with Klebsiella spp. Though initially rare mentioned as an opportunistic infection, more and more reports are published. In the present article we present a case of an R. planticolla upper respiratory infection and we review the relevant literature

2-12

Authors: Aledzhanov N.Yu

The goal of this study is to examine and describe the methods and techniques, as well as the knowledge of the anatomy and treatment of venous pathology, and their influence on the birth of phlebology in ancient Greece and Byzantium.The study was conducted reviewing sources in Russian and foreign literary in Greek and in English language, which, in turn, allowed a detailed study of discoveries and treatment in the field of venous system anatomy. Conservative methods are also described, as well as the first vein surgeries, precursors of modern surgical interventions that were unique for that time and are still relevant today. Brief biographies and discoveries of scientists of those eras are also mentioned.

23-30

Authors: Aslanidis Th, Myrou A, Papachristou D, Flioni EN, Thoma G

COVID-19 has brought up the interest about hyperferritinemic syndromes. Though often seen in COVID-19, especially within the frame of COVID-CSS, hyperferritinemia needs a systematic diagnostic approach, as co-infections or other causes may also increase ferritin. In this article, we present a case report of extreme hyperferrinemia in an male criticall ill patient with COVID-19 and we perform a short synthesis of the available literature.

42-49

Authors: Aslanidis Th, Drampa F, Mytkani K, Syrmou E

Therapy armamentarium for multpile sclerosis include a variety of drugs. Natalizumab, a humanized antibody, is widely used in relapsing-remissing multiple sclerosis. Anticonvulsants, like topiramate, are also widely used for symptomatic relief. We hereby describe a case of Status epilepticus and topiramate induced metabolic acidosis in a female patient with multiple sclerosis under natalizumab therapy.

3-23

Authors: Pantelidis A, Resvani P, Tsaousi G

Acute sepsis-related kidney damage (S-AKI) is a common complication of the critically ill patient, with high mortality rates. Prevention of S-AKI is a daunting task because by the time patients seek medical help, most have already developed acute kidney damage. Thus early detection is an issue of utmost importance. Recent studies show that microvascular dysfunction, inflammation and metabolic reprogramming are the three fundamental mechanisms that contribute to the development of S-AKI. The rapid diagnosis of S-AKI aims to minimize the deterioration of renal function. Research on this field is intensive with particular emphasis on the discovery of new biomarkers with enhanced sensitivity in renal function assessment. Neutrophil gelatinase-associated lipocalin (NGAL) is overexpressed in renal tubules during ischemia and inflammation. Both plasma and urinary NGAL levels have a strong prognostic value for renal impairment and are associated with an increased probability for renal replacement therapy institution. Cystatin C is increased during the early and milder stages of tubular damage, while kidney damage molecule-1 (ΚΙΜ-1) increases in ischemia and nephrotoxic damage and appears to play a similar role to NGAL in S-AKI detection. Tissue metalloproteinase-2 inhibitor and insulin-like growth factor-7 binding protein increase in tubular cells when their DNA is damaged. The product of the two biomarkers has the highest diagnostic value in S-AKI detection of all the biomarkers studied so far. Prevention of S-AKI is often impossible. Early and specific use of antibiotics together with the treatment of sepsis reduces the risk of developing S-AKI. Adequate fluid intake appears to improve renal function although opinions differ. The use of balanced crystalline solutions and avoidance of synthetic colloids is recommended. Norepinephrine is the drug of choice for the treatment of septic shock, while angiotensin II shows promising results.

47-70

Authors: Grosomanidis V, Fyntanidou B, Gkarmiri S, Theodosiadis P, Kazakos G , Kyparissa M,Pertsikapa M, Kotzampassi K.

Increased Intraabdominal Pressure (IAP) is common in critical care patients and has detrimental effects on organs and systems. Several mechanisms and causes are involved in its pathogenesis. The aim of the present study was to investigate and record IAP effects alone and in combination with sepsis on respiratory mechanics. Sixteen male pigs were included in the study, which were randomized in two groups of 8 pigs (Group A & B). After baseline measurements, IAP increased in both groups by Helium insufflation to 25mmHg and remained elevated throughout the study period. In Group B, sepsis was induced after 60min by intravenous lipopolysaccharide (LPS) administration. Recorded parameters included PIPAW, PIPES, EIPAW, EIPES, PmeanAW, PmeanES, PEEPAW, PEEPES, CRS, CCW, CL, RinspRS, RexpRS RinspCW, RexpCW, Vexp and were measured at baseline and every 20min for 3hrs. Airway pressures in Group A (PIPAW, EIPAW, PmeanAW) increased after IAP elevation but returned to their baseline values after IAP normalization. In Group B airway pressures increased even further after LPS administration and decreased after IAP normalization but they never reached their baseline values. On the contrary esophageal pressures (PIPES, EIPES, PmeanES) showed similar alterations in both groups. PEEP did not change in any of the study groups. Respiratory system compliance decreased in both groups and returned to baseline values only in Group A. Chest wall compliance showed similar alterations in both groups. Lung compliance decreased after IAP increase in both groups and showed a further decrease after LPS administration in Group B, which remained after IAP normalization. Respiratory system inspiratory resistances increased only in Group B, whereas respiratory system expiratory resistances increased in both groups. Chest wall inspiratory resistances did not show any alterations. Our study results showed that the effects of IAP increase are reversible, whereas the effects of coexisting sepsis remain even after IAP normalization

76-81

Authors: Papadopoulou D, Diagoupi A, Trantzas P, Paraskevopoulos T, Bairaktari A

We present the case of a 64-year old super-obese female who underwent Open Reduction Internal Fixation (ORIF) for proximal humeral fracture, and our anaesthetic management. We performed interscalene brachial plexus block prior to induction, and general anaesthesia, following the guidelines for difficult airway. What is interesting about this case, are the technical difficulties that often arise in such obese individuals, concerning both the peripheral nerve block and the airway management. Moreover, due to those difficulties we created a systematic management plan consistent with guidelines so as to minimize the failure risk.

3-9

Authors: Mitos G, Thoma G, Tsaousi G

Volatile induction of anesthesia with sevoflurane is an old and conventional technique. However, there is no consensus on the appropriate mode and duration of sevoflurane administration when attempting inhalational induction to adults in order to achieve acceptable intubating conditions. This article attempts to gather the evidence presented in the literature that dictate the optimal method of sevoflurane inhalational induction until intubation is achieved.

23-38

Authors: Grosomanidis V, Fyntanidou B, Amaniti A, Chatsiou E, Karagkouni D, Fengoudaki M, Theodosiadis E, Ourailoglou V.

Hypertonic solutions combined or not with colloids have been used successfully to restore intravascular volume and to enhance cardiovascular function. The aim of the present study was to investigate the hemodynamic effects of hypertonic saline solution administration in normovolemic patients. Forty-five patients who underwent elective surgery were included in the study. After anesthesia induction, initiation of mechanical ventilation and fluid replacement of fasting deficit all patients received 4ml/kg NaCl 7,5% intravenously in the maximum possible infusion rate. Esophageal Doppler Monitoring (ODM II) was used in all patients to assess cardiac function throughout the study period. Measurements were obtained before NaCl 7,5% administration (Phase 1), after completion of NaCl 7,5% administration (Phase 2) and every 5 min thereafter for one hour (Phases 3 to 14). Furthermore, at Phases 1, 2 and 14 sodium plasma levels (Na), hemoglobin (Hb) and hematocrit (Hct) were also measured. Altogether recorded parameters included heart rate (HR), blood pressure (BP) (Systolic, Diastolic and Mean), cardiac output (CO), stroke volume (SV), peak velocity (PV), mean acceleration (MA), flow time corrected (FTc), Na, Hb and Hct. At Phase 1 SV and CO were 62,4ml and 4l/min respectively. Both parameters increased and reached 100ml and 7,3l/min at Phase 2. Thereafter, SV and CO had gradually decreased and at the end of the study their values were 78ml και 5,2l/min respectively. PV increased from 57,7cm/sec (Phase 1) to 77,7cm/sec (Phase 2) and finally to 66 cm/sec at the end of the study (Phase 14). At Phase 1, MA and FTc were 5,7cm/sec2 and 0,4sec respectively, then both increased and reached 7,5cm/sec2 and 0,5sec respectively (Phase 2) and finally at Phase 14 their values were 6,1cm/sec2 and 0,5sec respectively. All before mentioned parameter values increased in a statistically significant manner after NaCl 7,5% administration compared to baseline measurements. The increase remained to be statistically significant throughout the study. HR increased from 64b/min before NaCl 7,5% administration to 74b/min after NaCl 7,5% administration but reached baseline values after 10min. BP (SBP, DBP and MBP) decreased from 118/64mmHg to 92/53mmHg and then reached rapidly baseline values. NaCl 7,5% administration resulted in CO and SV increase and contributed to cardiac function enhancement. This beneficial impact remained statistically significant for 60min throughout the study period. Those positive effects can be attributed to the intravascular volume increase, the vascular resistance decrease and possibly to the enhancement of left heart contractility which are all caused by the hypertonic saline solution administration.

49-56

Authors: Varvarousi G, Loukeri A, Lappas T, Haidopoulos D, Valsamidis D.

The novel coronavirus disease 2019 (COVID-19) caused by severe respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a global health emergency since its declaration as a pandemic by the World Health Organization. Advanced maternal age is considered a high-risk pregnancy and therefore may affect the severity of Covid-19. In this case report, we discuss the perioperative management of an in vitro fertilization (IVF) cesarean section in a 48-year-old woman with Covid-19 infection. A 48-year-old parturient with pregnancy of 37 weeks 3 was scheduled for cesarean section, due to advanced maternal age, after she had a positive result for real time polymerase chain reaction (RT-PCR) test for (SARS-CoV-2). In our case of extremely advanced maternal age cesarean section the obstetric outcome was positive. Physiologic and vascular changes in advanced maternal pregnancies may exacerbate Covid-19 symptoms and increase the risk for poor pregnancy outcome. Further studies are needed to investigate the factors that influence the outcome in pregnancy of increased maternal age with Covid-19 infection.