The Greek e-journal of Perioperative Medicine

3-17

Authors: Bersot CDA, Lessa MA, Aslanidis Th

Respiratory failure due to Coronavirus 2019 (COVID-19) disease has triggered a debate about when and how to apply mechanical ventilation in these patients, as it has been proposed that severe “atypical” ARDS of COVID-19 cause an ARDS pandemic. As global database grows, it is evident that about 6% of patients will need admission to the ICU. About 75% of these will require invasive ventilation, and approximately 10% will need ventilation beyond 14 days. Different ventilation strategies are followed yet there is no strong evidence in favor of anyone. The present article attempts to gather the daily evolving evidence on the subject.

36-47

Authors: Aslanidis Th, Masoura N, Parisiadou P,Tetradi M, Tsakiri A, Kamparoudi Th, Zarda J, Savoulidou S, Thomaidou E, Tragiani E, Moschona E, Nanopoulou P.

Patient care in Intensive Care Units is characterized be high demanding tasks, which lead in daily high workload. In the present study, a questionnaire-based evaluation of ICU nurse’s workload was conducted at the adult general 7 – beds ICU of a small urban hospital. NASA Task Load Index (TLX) along with other two tools, used for the first time in healthcare environment: Instantaneous Self-Assessment (ISA) and Crew Status Survey (CSS) were used for that purpose. Information about every nurse’s professional background and basic demographics were also collected. Responses from 70% of total nurse staff were collected. A total of 93 questionnaires (response rate=total shift coverage 40.25%) were included for further analysis while 2 questionnaires were excluded due to >50% of missing answers. The overall average workload for the period in interest is little to moderate, yet interesting variations do exist. Physical workloads seem to be highly related with both mental workload and time pressure; yet the last two are not related. Increased workload is perceived during morning shifts, and though there is variety in individually recordings, no relation was found between measurements and other characteristics, such as work experience (total or ICU), age of nursing staff, family status or time to work arrival. Subjective workload assessment via NASA TLX index, CSS and ISA workload surveillance tool provide a useful method of early detection of group or individual increased workload that allows proper management measures to be applied.

61-66

Authors: Karakosta P, Aslanidis Th, Flioni E.N, Agaliadou-Dioritou U.

Hemophagocytic Lymphohistiocytosis (HLH) is a life-threatening syndrome of excessive immune activation that mostly occurs as primary (hereditary) disease in children. Acquired HLH is associated with infections, cancer of rheumatological conditions. Both are rare in adults. Turicella otitidis is a bacterium, that is associated with ear infections and there is only one case report of bacteraemia. The present report describes a case of acquired HLH with invasive pulmonary Aspergillosis and Turicella otitidis bacteraemia in an adult patient; and also reviews the relative literature. In conclusion though rare, acquired HLH is a devastating condition that clinicians should have in mind when managing patients with multiple infection or underlying immunosuppression.

3-20

Authors: Staikou Ch,Maliamanis D.

Patients admitted to Intensive Care Units (ICU) have the highest mortality rates among hospitalized patients. For those who survive, recovery is often a prolonged rehabilitation period with physical, cognitive and psychological dysfunction. The aim of the present narrative review was to identify in the existing literature articles providing information about the development of chronic pain after ICU stay. We performed a PubMed search for publications up to 22 March 2020. We identified 41 articles eligible to be included in the present review; 29 of them were original research articles. Pre-existing chronic pain, previous poor health- related quality of life (HRQoL), but also the critical illness itself and organ support with multiple interventions, predispose to the development of chronic pain in the post-critical period, making it difficult to return to the pre-disease functional status. Opioid administration during mechanical ventilation is a common practice, frequently without reliable and systematic assessment of pain or individualized titration of dosage. Multimodal analgesia, including dexmedetomidine, ketamine, adjuvant medication and regional analgesia techniques can prevent chronic pain and treat withdrawal symptoms during opioid weaning. Early mobilization and physiotherapy, continuous assessment of pain and its corresponding treatment and follow-up by a team of specialists comprise a successful management plan for early recognition of complications and effective aftercare treatment of these patients. Chronic pain after ICU stay is a common problem, associated with both critical illness and hospitalization itself. During rehabilitation, vigilance, care and an individualized multimodal analgesic regimen are required, in order to improve the quality of surviving patients lives.

26-44

Authors: Qyli Z

Nosocomial infections continue to increase all over the world and remain a major cause of morbidity and mortality in hospitals. There are three elements required for the transmission of nosocomial infections: a reservoir of microbial agent, a susceptible host with a portal of entry receptive to the agent and a mode of transmission for the microbial agent. Microorganisms that cause nosocomial infections derive primarily from human sources1-3 , but inanimate environmental sources are implicated in transmission4. Human reservoirs include patients, healthcare personnel, household members and visitors5. People in hospitals are usually already in a ‘poor state of health’, impairing their defense against bacteria. Invasive devices impair natural lines of defense against pathogens and provide an easy route for infection. Patients already colonized at the time of admission are instantly put at greater risk when they undergo invasive procedures6. Environmental surfaces are contaminated with microbial agents and healthcare workers serve as a route of transmission of these infections to patients. Pathogens may also be transferred directly from contaminated surfaces to susceptible patients7-9. Studies have shown that techniques of cleaning or disinfection of the environment can reduce transmission of healthcare-associated pathogens10,11. The hospital environment, especially surgical wards plays an important role in the spread of hospital-associated infections. The operating theater is a complex environment that poses a high risk of infection for patients and health care workers who may easily contract diseases because of their long exposures to various risks, including chemical, physical and biological12-15. Nosocomial infection is a frequent and potentially lethal complication in obstetrics for women and babies. Disinfection strategy, guidelines for infection prevention and control should be established in each obstetrics unit to prevent nosocomial infections16,17. This study aimed to make an overview for the microbial contamination of environments at the Surgery and Maternity Departments of the Regional Hospital of Korca, Albania. This hospital has a capacity of 510 beds with an average of 70 daily admissions. Surgery Department consists of the operating rooms, surgery intensive care unit and the rooms of the patients. Maternity Department consists of the obstetric ward, gynecologic ward, neonatology ward and the room of the patients.

62-69

Authors: Papachristou D, Aslanidis Th.

West Nile virus is an RNA virus, member of the Japanese encephalitis serogroup of the genus Flavivirus, family Flaviviridae. First isolated in 1937, the virus has re-emerged after giving several outbreaks after the 1990 both in Europe and North America. Though severe neurological infection is only 1% of the total cases, mortality can reach 14% after CNS involvement. The present case report describes a case of WNV encephalitis with concomitant acute flaccid paralysis.

2-4

Authors: Aidoni Z, Primikiri S, Trifonidou H, Papakonstantinou P, Veroniki F, Geka E

Editorial

13-20

Authors: Bersot C.D.A, Pereira J.E.G, Aslanidis Th.

Coronaviruses are a large family of viruses that cause illnesses ranging from the common cold to more severe diseases. SARS-CoV-2 is a new virus that has not been previously identified in humans. Patients with SARS-CoV-2 commonly develop acute respiratory distress syndrome (ARDS), myocardial injury, ventricular arrhythmias, and shock, all of which increase their risk of cardiac arrest. The main objective of this brief review is to raise the discussion on the possible indication of cardiopulmonary resuscitation in a patient with SARS-CoV-2 in prone position as a way to save time, since the entire process of decubitus change is complex and often slow, due to the number of devices used in these patients, such as catheters, infusion pumps and monitors. In addition to a price of high demand for stressed human resources

32-34

Authors: Savoulidou S, Aslanidis Th

Nasogastric tube is commonly used for administration of nutrition or medication in hospital wards and Intensive Care Units. However, its use is not without complications.In the present paper, a case report of nasogastric tube breakage is presented.

6-12

Authors: Tzima M, Katsanoulas K, Bilali P,Panteleou K, Zemou S, Georgopoulou E,Katsika E

Caesarean section delivery isamong the commonest surgical procedures in our hospital. During an ESRA Hellas descriptive survey, conducted between March 1stand August 31st2016, we decided to extend data collection with further enquiries, concerning the type and dosage of local anaesthetics, technical aspects, anaesthetic complications and their management, as well as neonate’s Apgar score. In comparison to the national survey, the percentage of regional over general anaesthesia (69.2%, 30.8% respectively) was by far exceeded in our department (93%, 7% respectively) with single shot spinal anaesthesia being the most popular technique (96%) as compared to the national level (44.3%).Interestingly, the percentage of combined spinal-epidural anaesthesia in our department was extremely lowcompared to Athens and nationwide. The commonest complication after regional anaesthesia was inadequate level of anaesthesia (4%) while no accidental dural puncture was noted. Post-partum hemorrhage occurred in 2%. Neonates’ general condition was very good. In a low human resources environment, due to personnel shortage, as worsened after the recent financial crisis, we strive to maintain a high-standard environment for the parturients of Northern Greece

20-24

Authors: Karakosta P, Aslanidis T, Thoma G, Agaliadou-Dioritou O

Intravesical bacillus Calmette-Guerin (BCG)therapy, recommended for superficial bladder tumors, triggers side effects in fewer than 5% of patients. Yet, when encountered, high level of suspition and early detection is essential for their succesfull management. In the present article, we present a case of severe sepsis and Steven Johnson syndrome in a male patient afterintravesical BCG instillation.

12-30

Authors: Tsiapakidou S, Fyntanidou B, Amaniti E, Kekkeri E, Papakostantinou P, Aggou M, Fortounis K, Grosomanidis V

Codes of ethics are considered as indispensable parameters of every aspect of medical care. When performing cardiopulmonary resuscitation (CPR) ethical issues become even more important since cardiac arrest (CA) is directly related to death. The aim of this study was to record personal opinions and everyday clinical practice approaches of healthcare professionals (HCPs) regarding ethical issues related to CPR. HCPs answered a questionnaire consisting of 30 questions related to ethical issues in CPR on a voluntary basis. The study included 195 HCPs (88♂& 107♀). Out of the 195 HCPs, 95 were physicians, 71 nurses and 29 paramedics. 49 HCPs (25.1%) worked in the prehospital setting (EMS or Healthcare Centers) and 147 (74.9%) in hospitals. 153 HCPs (78.5%) had previously taken certified resuscitation training courses (CPR-AED, ILS, ALS) and 189 HCPs (96.9%) had participated in resuscitation attempts .Half of them, namely 98 out of 195 (50.2%) believe that CPR should be performed in every case of CA. 112 HCPs (57,4%) reported that this is the common practice in their working environment, whereas 136 (69.7%) stated that there are cases that this approach is not applied. In 68.2% of the cases, physicians make the decision not to attempt CPR, whereas in 25.1% it is a team decision. However, more than half of the HCPs (56.4%) believe that physicians should make that decision. Parameters which should be taken into account when making the decision not to attempt CPR are: preexisting end stage diseases, age of the CA victim, previous functional status and presumed interval between collapse and initiation of CPR. Most of the HCPs, 160 out of 195 (82.1%), do not know the term DNAR, whereas half of them, 105 out of 195 (53.8%), are unaware of the Greek legal system’s position to DNAR orders. 109 HCPs (55.9%) believe that relatives should be involved in the decision making process not to attempt CPR and 166 HCPs (85.1%) think that patient’s past wishes should be taken into consideration.101 HCPs have performed CPR in front of family members of the CA victim but only 43 (22%) believe that relatives should be present during CPR. The decision of discontinuation of CPR in most of the cases is made by physicians (76,4%), in just a few (2.56%) by paramedics and in some it is a team decision (21%). According to their beliefs, decision to terminate CPR should be guided by duration of CPR attempt, absence of reversible relative causes, not gaining ROSC and anticipated prognosis. 112 HCPs (57.4%) are aware of the term Medical Futility. However, 174 HCPs (89.2%) perform CPR even though they know that the attempt is futile and 177 (90.7%) reported that CPR is performed in their working environment even in futile cases. According to the questionnaire, reasons for this practice are: moral sense (78HCPs-40%), certainty of performing the correct health action (67HCPs-34.3%) and fear of legal consequences (62HCPs-31.8%). Finally, 94 HCPs (48.2%) reported that the quality and duration of CPR attempt is the same independent of its obvious futility. Our results do not only reflect Greek reality but also underline the importance of multifactorial approach, introduce all challenging ethical dilemmas and reveal the inadequate education in ethical issues of resuscitation.

37-44

Authors: Karakosta P, Aslanidis Th,Voudouris A, Agaliadou-Dioritou U

Though metformin is considered as first choice drug in type II diabetes, clinicians should be alert both for presence of potential contraindications to its use and to possible adverse reactions. Bad therapy compliance along and/or concomitant comorbidities may lead to serious toxicity. We hereby describe a case of extreme lactic acidosis- associated with metformin therapy- in an elder woman, managed with Continuous Renal Replacement Therapy in Intensive Care Unit environment. Short review of the literature about the place of renal replacement therapy in such cases is also discussed.