The Greek e-journal of Perioperative Medicine

2-12

Authors: Petsas D, Griffiths R

Fractures of the proximal femur are of the most frequent, especially in elderly patients. The increased frequency of these fractures highlights the need for effective management of those patients and the impact of these fractures regarding the cost to the national health system. The effects of pain in elderly patients is extremely aggravating, frequently leading to mental (confusion, delirium) and physical (cardiovascular) deterioration and complications. The pain management of these patients in the emergency department (ED) with intravenous administered analgesics might complicate the status of these patients. The use of non-steroidal anti-inflammatory drugs (NSAID’s) might increase the risk of gastric ulceration, gastric haemorrhage and coronary syndromes, while the use of IV opioids– especially in elderly-incorporates the risk of respiratory depression, delirium,hypotension and constipation. The pain management of these patients with the use of fascia iliaca block applied in ED, or even in a prehospital setting from doctors of various specialties, paramedics or nurses seems to gain acceptance because of its steep learning curve, the simple technique, the high success rate and the low rate of significant complications

36-48

Authors: Vrigga M, Papagiannopoulou P, Ntritsou V, Isaakidis A , Chatziiokimidis Ch, Kostoglou Ch, Zachariadou Ch

The aim of this study was to compare the combinati on of oral tramadol and midazolam to oral mi- dazolam alone, in children undergoing adenotonsillectom y, as an oral premedication, regarding also sedation and postoperative pain relief. Sixty children selected for elective adenotonsillectomy were enrolled in this randomized, controlled prospec tive study. Patients were randomly allocated into two groups. Group M (n=30) received 0.5 mg.kg -1 oral midazolam and group MT (n=30) received 0.2 mg.kg -1 oral midazolam with 1 mg.kg -1 oral tramadol as a premed ication 30min preoperatively. Standard general anesthesia technique was used. A 5 points-sedation score (1 asleep to 5 agitated) on arrival to the operating room, a 3 points-acceptance score of separation from the parents and a 3 points-mask cooperation score at induction of anesthes ia (1 easy to 3 markedly resistant) were used. Aldrete score, extubation time and intraoperatively consumption of remifentanil were also recorded. Pain intensity was assessed using a modification of the Hannallah pain score scale at 30min, 6h and 24h postoperatively. If pain score was higher than 3, additional anal gesics were provided. Cumula- tive analgesic consumption in 24hrs was also noted. A satisfactory le vel of sedation scores were re- corded in both groups. Group MT offered significantly more children in an awake, calm and quiet state, who were easily separated from th eir parents. The parental separation scores did not differ statistically significant between groups. The mask acceptance was statistic ally significant easier in group MT, while chil- dren in midazolam group (group M) were statistically significant re sistant compared to children in group MT. Pain and modified Aldrete scores were comparable between groups. The amount of re- mifentanil consumed intraoperatively was statisti cally significant lower in group MT. Postoperative analgesic consumption was lower in group MT comp ared to group M but with no statistic al signifi- cance. Adding oral tramadol to midazolam as a premedication in children provides good quality of sedation and decreases periope rative analgesic requirement s following adenotonsillectomy.

54-58

Authors: Stamatakis E, Aroni F, Loukeri A, Valsamidis D

Intrathecal drug administration extends beyond the purposes of anaesthesia, to therapeutic applications. Here, we describe the case of a patient with severe Systemic Lupus Erythematosus having affected multiple organs and had a meningococcal infection. She was treated with intrathecal antibiotic therapy resulting in a successful outcome.

2-27

Authors: Koraki E, Giannaki Ch, Andreopoulos K, Trikoupi A

Effective postoperative analgesia in geriatric patients is both challenging and rewarding. Inadequate pain control after surgery is associated with adverse outcomes in the older patient. This review will attempt to describe the difficulty with assessment of pain and variations in pain experience of elderly patients. Physiological changes related to aging need to be also carefully considered,because aging is individualized and progressive.Pharmacokinetic and pharmacodynamic changes in geriatric patients, the higher incidence of co-morbidities and concurrent use of other drugs, must be carefully adjusted to suit each geriatric patient, concerning postoperative pain management. Medication for postoperative pain will be discussed. Unfortunately, many medications have not been studied well in the older population. Non-pharmacological approaches to postoperative pain management will not be discussed, although this would be an interesting topic for further discussion

39-51

Authors: Theodosiadis P, Grosomanidis V, Hatzibaloglou A, Fyntanidou B, Kotso E, Oloktsidou E, Skourtis Ch

Factors affecting cardiac function in dialysis patients include arterial blood pressure, anemia, intra-vascular volume and the arteriovenous fistula (AVF). We investigated the acute and chronic effects of basilic vein transposition (mean upper arm brachial artery basilic vein anastomosis) on both the cardiovascular system and the oxygen status. Sixteen patients with end stage renal failure were enrolled in this study. Patients with heart failure,pericardial effusion or valvular heart disease were not included in the study. Echocardiography (preoperatively and six months after, stages 1 and 2 respectively) and a Swan-Ganz catheter(perio-peratively) were used to assess the hemodynamic status during the phases of AVF construction. Flow measurements were made in the parts of the AVF system before, during and after the construction of the AVF.Moreover, at the same time phases blood sampling from the arterial line and the pulmonary artery catheter was performed, in order to assess oxygen and acid-base status. Cardiac output, cardiac index, stroke volume, stroke volume index, left ventricular stroke work increased statistically significant 20 and 30min after the AVF construction and they returned to baseline at 40min after the procedure. On the contrary, systemic vascular resistance decreased statistically significant 20 and 30min after the operation and they remained decreased for the whole study period. No other differences were recorded regarding the hemodynamic, oxygen and acid-base status. As far as the echocardiographical findings are concerned, ejection fraction showed a tendency to increase but not significantly in contrast to the inter-ventricular septum which increased statistically significant in both systole and diastole (p<0.01). Posterior wall thickness decreased minimally in both systole and diastole. Regarding the AVF system diameters, there were no changes recorded during the study. Basilic vein transposition in selected patients provides a well functioning AV fistula and is not an appreciable cause of circulatory or pulmonary congestion for at least a period of six months.

64-71

Authors: Theodorou E , Georgopoulou S, Sarakatsianou Ch , Tzovaras G

The aim of this case report is to demonstrate the efficacy and safety of Continuous Spinal Anesthesia (CSA) in an elderly patient with severe Chronic Obstructive Pulmonary Disease(COPD), who was scheduled for elective laparoscopic cholecystectomy . CSA can be used to provide a sufficient block in order to allow laparoscopic chol ecystectomy to be performed even in patients with severely abnormal respiratory function . Safety,efficacy and a decreased need for postoperative analgesia render this approach a valid option for patients with symptomatic gallstone disease,who are poor candidates for general anesthesia due to cardiorespiratory or airway problems as well as for patients with other contraindications for general anesthesia.