The Greek e-journal of Perioperative Medicine

14-29

Authors: Papaioannou V

A majority of current pharmacokinetic and pharmacodynamic data are generated from studies in healthy volunteers and stable patients with single organ dysfunction. However, critically ill patients differ from other patients because of the complex and unstable nature of their illness. Critical illness results in multiple changes that alter drug disposition in the body. As organs fail, so the pharmacokinetic processes of absorption, distribution, and elimination are affected. These alterations change the way drugs are handled by the body, often in unpredictable ways. Furthermore, multiple organ failure may also induce changes in the sensitivity of the target organs to a specific drug. Another problem that arises during treatment of a critically ill concerns polypharmacy, which may sometimes include concomitant administration of more than 20 drugs in a single patient. Evidence suggests that deep understanding of basic pharmacokinetic principles associated with therapeutic drug monitoring might decrease toxicity and could be cost-effective. The aim of this review article is threefold: 1. to describe basic pharmacokinetic principles, 2. discuss their changes during critical illness and 3. emphasize possible alternatives concerning an individualized therapeutic plan design. Its application in every day clinical practice might aid in early intervention, in cases of possible drug-to-drug or drug-to-patient adverse reactions and finally, could decrease morbidity and/or mortality of patients during their stay in the Intensive Care Unit.

41-53

Authors: Papagiannopoulou P, Kostoglou Ch

The management of patients, who had previously undergone percutaneous coronary interventions (PCI) with or without coronary artery stenting and who are presenting for noncardiac surgery has become a major topic of interest and concern for anesthesiologists worldwide. This review will update recent reports, as well as recommendations for the perioperative care of these patients. The two most commonly used stent types, bare-metal stents (BMSs) and drug-eluting stents (DESs), mandate different lengths of dual antiplatelet drug therapy to avoid stent thrombosis. The risks posed at the time of noncardiac surgery by such patients include acute coronary syndromes, as a result of stent thrombosis, after cessation of anti-platelet therapy and excessive bleeding from continued antiplatelet therapy, particularly when patients undergo surgery early after stent implantation. Pre- and intraoperatively, the risk factors for thrombosis have to be balanced against the risk factors for surgical bleeding. As long as prospective trials are not available, the recommendations and guidelines of task forces and experts are based on retrospective studies and case reports. So based on the available literature, all experts recommend avoiding premature discontinuation of antiplatelet drug therapy if possible except for a few surgical procedures. Drugeluting stents carry more risks than bare-metal stents. It is generally agreed that aspirin must be continued throughout the perioperative period, except in circumstances when the risk of bleeding significantly outweighs the benefit of continued anticoagulation, such as procedures performed in a closed space. Postoperative recommendations are also presented, as the occurrence of perioperative stent thrombosis appears to be greatest during this period. Immediate percutaneous coronary intervention is the definitive treatment for perioperative stent thrombosis, and access to an interventional cardiologist should be available. Algorithms for perioperative management of patients with baremetal and drug-eluting stents are proposed.

67-73

Authors: Amaniti A, Chatziioakimidis Ch, Iordanidou S, Papalexi E, Ntonas G, Pourzitaki Ch, Konstantinidis D, Gorgias N

The aim of our study was to compare video laryngoscopy and direct laryngoscopy views, and the resultant intubation conditions as well, provided by video or conventional laryngoscope respectively, in patients receiving general anaesthesia for elective surgery. One hundred patients, with no expected difficult airway, were randomly allocated to undergo tracheal intubation with the Macintosh video laryngoscope or a conventional Macintosh laryngoscope. All of them underwent an initial direct laryngoscopy, which was scored according to the Cormack and Lehane grading system, under general anesthesia and muscle relaxation. Then intubation was performed by another anaesthesiologist, using the Macintosh video laryngoscope or the conventional Macintosh laryngoscope, who gave a second laryngoscopy score as well. The difference in scores between video and direct laryngoscopy views, in patients undergoing intubation with the video laryngoscope was our primary outcome comparison. Comparison of times to intubate and lower oxygen saturation values between the two groups was also performed. Data were analyzed using McNemar, Pearson, Kendal, chi-square and t-test. Significantly lower scores were recorded for Video laryngoscopy views in 38% of patients, evaluated with both laryngoscopy techniques (p<0,001). However, mean time to intubate with the video laryngoscope was significantly prolonged (p<0,001), as it took an additional 10 sec for intubation..

83-90

Authors: Aslanidis Th, Katsika E, Lazaridis T h, Paroutsidou G, Koupanis Ch, Gekas I, Sidiropoulos A, Anagnostara E, Tsakona H

The essential help of medical emergency teams (M.E.T.) is to decrease the frequency of sudden deaths and the pointless transport of patients in the intensive care units. Aim of present study is to record the number and the type of urgent intrahospital callings, the departments of hospital that were covered by M.E.T, the staff (medical and/or nursing) that participated in them, the medications that were used, and the number of involved individuals per incident, as well as the type of monitoring and the fluids that were used. In the particular study were recorded the urgent calls from the 07/06/2006 up to the 07/01/2007 (7 months). The teams, that were created, covered daily 12 departments. The main providers in M.E.T were anaesthetists. They were recorded 191 calls in total. Monitoring included, SpO2, arterial pressure, number of breathings and estimation of neurologic condition with the Glasgow scale or AVPU scale, as well as the examination of the pupils. Only one individual was needed in 99 (52%) incidents. The medium time of his employment with the patient was 57{10-300}min. In 89(45%) cases was called 2nd individual (trainee), while in 22(12%) calls a 3rd trainee was called. Nurse of anesthetic department involved only in 17(9%) incidents, while special anesthetist attended in 28(15%) cases. The average amount of fluids were given per patient were 860{0-7500} ml. The rapid sequence induction was used in the majority of cases (63%) with etomidate or thiopentone and the succinylocholine. CONCLUSION: The existence of criteria as well as the response to emergency calls from organized teams, helped in the more objective recognition of befalling crisis as well as in the better and more systematic recording of such incidents, even after completion this study.

100-106

Authors: Zouka M, Zaralidou A, Maidatsi P, Andreopoulos K, Kokkonis G, Giala Μ

The aim of this study was to examine and compare the efficacy and safety of combining strong opioids (transdermal fentanyl) with weak opioids (codeine or tramadol) for the management of severe cancer pain. Forty six patients (25 male / 21 female) aged 42-80 years were studied. According to an eleven-grade numeric rating scale (NRS; 0 = no pain, 10 = severe pain), they all had severe steady pain intensity greater than 5 (NRS >5) despite treatment with weak opioids and adjuvant drugs, as proposed by the 2nd step of the World Health Organization (WHO) analgesic ladder, at the maximum tolerated doses. Enrollment to the 3rd step of the ladder and initiation of transdermal fentanyl (fentanyl-TTS) was decided and informed consent was obtained by all subjects. They were randomly divided into 3 groups: group F (n=15), which constituted the control group, received fentanyl-TTS alone, group C (n=17) received combined codeineacetaminophen (Lonalgal®) tablets in addition to fentanyl-TTS and group T (n=14) had tramadol capsules administered along with fentanyl-TTS. The above additional drugs were given at equipotent doses every 12 hours. All patients were informed so as to increase fentanyl-TTS dosage by 25μg/h/72h in cases of high steady pain intensity (NRS >4). Oral transmucosal fentanyl citrate was prescribed for possible acute pain episodes. A month later, the following parameters were recorded: pain intensity, final dosage of fentanyl-TTS, daily dosage of transmucosal fentanyl citrate, drug-related side effects and patients’ judgment of treatment. Statistically significant results were recorded for pain intensity at the end of the study (p<0.05) compared to pain intensity immediately before enrollment but without significant differences among the studied groups (p>0.05), as well as for mean final dosage of fentanyl-TTS in groups C (p<0.01) and T (p<0.05) compared to the relative dosage in group F. Favorable but not statistically significant (p>0.05) results were recorded for the rest of the endpoints apart from the adverse effects of the drugs used; nausea, vomiting and to a lesser extent constipation and somnolence were seen. In conclusion, the combination of either tramadol or codeine-acetaminophen with fentanyl-TTS were proven to be useful alternatives for long-term treatment of severe cancer pain for patients placed at the 3rd step of the WHO analgesic ladder, probably sparing the need for opioid switching or route rotation. Nevertheless, drug-related side effects were not limited. Moreover, due to lack of sufficient studied data we would not recommend any similar combinations for the management of severe cancer pain.

114-121

Authors: Katsanoulas C, Mouloudi H, Kopatzidis H, Assimaki M, Angelidou S, Gritsi- Gerogianni N

Placenta percreta is a rare complication of pregnancy with pathologic invasion of the full thickness of the uterine wall, causing life-threatening haemorrhage. We present two cases of pregnant women with placenta percreta invading the bladder, along with a short review of the literature. The two women sustained early and late major haemorrhagic complications requiring massive transfusion (up to 142 PRBC and 353 blood product units) and urgent reoperation. They were both treated in the ICU and discharged in good state. Massive haemorrhage due to Placenta percreta may be a fatal complication especially when the placenta invades the bladder. The anaesthetist and the intensivist may be challenged by the severity and extend of perioperative complications demanding rapid decision-making. A multidisciplinary approach for perioperative surgical and anaesthetic management is necessary for maternal outcome optimization. Post-operative care in the ICU is a prerequisite with high index of suspicion to follow transfusion requirements.