The Greek e-journal of Perioperative Medicine

2-67

Authors: Schizodimos Th, Soulountsi V.

Invasive fungal infections are a growing problem in critically ill patients and are associated with increased morbidity and mortality. Complex medical and surgical problems, disruption of natural barriers, multiple invasive procedures and prolonged antibiotic treatment are some of the factors contributing to the alarming increase of fungal infections in the Intensive Care Unit (ICU) setting. In terms of occurrence rates, the most important fungal infections are invasive candidiasis (IC) and invasive pulmonary aspergillosis (IPA). Invasive candidiasis in ICU patients includes mainly candidemia, primary or catheter-related, and intra-abdominal candidiasis. Candida bloodstream infections occur at highest rates in the ICU population, with this setting accounting for 33–55% of all candidemias. The epidemiology of Candida infections is not constant. Incidence rates, species distribution, and even antifungal susceptibility seem to be changing.The Candida species that are responsible for more than 90% of all IC including candidemias are C. albicans, C. glabrata, C. krusei, C. parapsilosis, and C. tropicalis. Although the most common Candida species responsible for bloodstream infection remains C. albicans, the past two decades has seen a rising proportion of infections caused by non-albicans species. This changing spectrum has been partly explained by the increasing prophylactic use of fluconazole and other antifungal regimens, the presence of a central venous catheter, the mean number of antibiotics per day and neutropenia. The emergence of clinical treatment failures in Candida spp. due to resistant isolates is also described in last decade. This trend reflects the large and expanding use of newer broad-spectrum antifungal agents, such as triazoles and echinocandins. Echinocandin resistance in Candidais a great concern, as the echinocandin drugs are recommended as first line therapy for patients with IC. Invasive pulmonary aspergillosis (IPA) may be one of the most lethal and unrecognized infections in critically ill patients. Lastly, there is a growing appreciation of IPA in patients without classicrisk factors, such as critically ill patients without documented immunodeficiency. The new emerging risk factors include chronic obstructive pulmonary disease, chronic use of systemic and inhaled corticosteroids, cirrhosis, malnutrition, and severe sepsis. Data regarding the incidence of invasive aspergillosis in ICU are scarce, and the incidence varies as the diagnosis of IA remains difficult as well as the discrimination between colonization andprobable IPA in ICU patients with Aspergillus-positive endotracheal aspirate cultures. In more recent studies a recent trend of decreasing mortality in patients with aspergillosis has been described. This decreasing trend may have resulted from numerous factors, including appropriate antifungal therapy, more timely and accurate diagnostic approaches, earlier initiation of therapy and technological advances in ICU care.

101-106

Authors: Costa G, Gomes M, Marques-Cunha M, Moura F.

Amiodarone-induced thyrotoxicosis is a rare but serious complication of amiodarone use, especially in patients with severe cardiac disease. We discuss the anaesthetic considerations and management of patients with severe cardiac disease who require lifesaving thyroidectomy. We present a patient who developed amiodarone-induced thyrotoxicosis, following administration of amiodarone and hepatotoxicity due to thiamazole. Patient’s life depended upon surgery as soon as possible. Total thyroidectomy was performed under general anaesthesia with precautions related to hyperthyroidism and cardiac stability. Complete cardiac rehabilitation was achieved two weeks after surgery. Total thyroidectomy is, in selected cases, the only treatment option and should not be delayed based on the hypothesis that pre-operative medical preparation will optimize the patient’s condition (endocrine and cardiac).

2-18

Authors: Pagaki E, Pagdatoglou K, Τsioka A, Koukoubani T, Efthimiadi A., Stavrothanasopoulou A, Kouloumoundri V, Siafi M, Papapostolou G, Bouga E, Pagouni E, Katsiakou Ch, Moriki S, Tasios Th, Katsi Ch, Ilioudi S, Tsigas A, Bairachtaris G, ParaforouTh.

After the implementation of Common Assessment Framework (CAF) – a useful quality tool – in the ICU of General Hospital of Trikala from 2012 up to 2015, we integrated the first cycle of self assessment and we present our results and conclusions of the past 3-year-period (2012- 2013 -2014). We analyzed CAF, FS- ICU 24, TISS-28 and Burn out syndrome questionnaires and medical indicators as Standardized mortality rate (SMR), Length of Stay (LOS), Standardized Resource Use (SRU), SMR/SRU, Therapeutic intervention scoring system (TISS-28), TISS-28/days of hospitalization, Nurse/Patient ratio, cost indicators and mortality. Analyzing the CAF questionnaire the score was 2.5-3.5, counting the indicator TISS- 28 we found an average value higher than 50,concerning the burn-out syndrome questionnaire it was found that 58.82% of the respondent employees working in the ICU had mild symptoms of the syndrome. We analyzed the true Level of ICU (TISS-28/days of hospitalization) with the Level of ICU (nurse /patient ratio) and we found that they were not alike. We found an increase of mortality rate and LOS (length of stay) during the period of 2011 –2015 but a gradual reduction of the SMR/SRU indicator (the whole period ≤ 1) and a decline of the average cost/ patient and the average cost/ day of hospitalization. We found that in some criteria of CAF questionnaire, programming and implementation of the action plan exists and in some other criteria there is also inspection. It was found that in all 8 hour shifts of the nurse personnel, the value was high mainly due to lack of personnel. We found that the work load of the nurse personnel in relation to the condition of the critically ill patients was heavier during the night shifts and the true Level of ICU (TISS-28/days of hospitalization) with the Level of ICU (nurse /patient ratio) were not alike, perhaps because the nurse/patient ratio doesn't include the critical state and the severity of the patient's illness. The cost of service declined. The gradual reduction of the SMR/SRU indicator (the hole period ≤ 1) means that our ICU is functional has a low mortality rate compared with the expected and the cost is still in good levels. At the end, we came up with useful conclusions concerning the quality of health service provided by our ICU and how we can further improve our weak points in order to become better.

24-38

Authors: Fyntanidou B, Veroniki F, Kolettas A, Ourailoglou V, Kotzampassi K, Theodosiadis P, Oloktsidou E, Karakoulas K, Grosomanidis V.

The interaction between increased Intra Abdominal Pressure (IAP) and Intrathoracic Pressure under different Positive End Expiratory Pressure (PEEP) levels is intriguing, since these two conditions coexist frequently in several clinical settings. The aim of our study was to investigate the interaction between different PEEP levels and increased IAP during laparoscopic cholecystectomy. In fifty two patients, who underwent scheduled laparoscopic cholecystectomy, cardiovascular parameters were determined by an Oesophageal Doppler Monitor device during two different time periods, before and after pneumoperitoneum, and under five conditions: (i) PEEP 0 cmH2O. (ii) PEEP 5cm H2O (iii) PEEP 10cm H2O (iv) PEEP 15cm H2O and (v) in the absence of PEEP or ventilation. Cardiac output and stroke volume showed a statistically significant decrease compared to the baseline value after the application of different PEEP levels, when there was no pneumoperitoneum (p<0.05). However, both parameters increased, when PEEP and pneumoperitoneum were applied together (p<0.001). Corrected flow time, peak flow velocity in the descending thoracic aorta and mean acceleration showed similar alterations but not at all PEEP levels. Finally, αt the no PEEP or ventilation phase, the negative effects of increased IAP on the cardiocirculatory function were predominant. According to these results, application of PEEP seems to counterbalance the negative hemodynamic effects of increased IAP. Moreover, it could also be concluded that ‘ideal’ PEEP level might be the one that borders the IAP level, since the best cardiac output and stroke volume values were reported at that point.

46-57

Authors: Gortsou D, Andronikou K, Kyrgia A, Mikropoulou M, Pappa S, Kamperis E, Schizas N, Rallis T,Gogakos A, Paliouras D, Barbetakis N.

During recent years the application of non invasive ventilation (NIV) has emerged as a central component of respiratory failure management, acute and chronic. Although the use of NIV in acute respiratory failure was initially meant to be given in critical care units, it is nowadays natural to provide it in other settings as well, provided that there are the necessary resources and expertise. NIV represents a viable alternative to endotracheal ventilation and despite most data refer to patients with chronic obstructive pulmonary disease; its indications are continuously expanding to cover more clinical scenarios. Randomized controlled studies are needed in order to provide sound evidence regarding optimal patient-ventilator interface, NIV duration and ventilation parameters in thoracic surgery patients.

3-14

Authors: Τsioka A, Pagaki E, Efthimiadi A., Pagdatoglou K, Koukoubani T, Stavrothanasopoulou A, Kouloumoundri V, Siafi M, Papapostolou G, Moriki Sp, Pagouni E, Papaspyrou M, Letsiou K, Ilioudi S, Paraforou Th

At 2012 the ICU of General Hospital of Trikala has registered as CAF user in the CAF database. With this quality management instrument, public sector organizations improve their performance by recognizing weaknesses and by promoting strong points. The purpose of using CAF protocols is to improve the quality of provided Health services. For the implementation of CAF we used specialized questionnaires such as: CAF questionnaire, family satisfaction (FS- ICU 24), questionnaire concerning nursing care (TISS – 28) and about fatique of personnel (Burn-out questionnaire). Also, indicators such as observations of mortality in relationship with the cost (SMR/SRU), Bacteraemias, V.A.P (Ventillation associated pneumonia), and the effectiveness of nurse project (Level of ICU) have been used. The design of CAF protocol implementation was adjusted, as structure, according to the data of our ICU. General Indicators concerning Public sector administration have been used but also specialized indicators concerning ICU output, mortality rate, infections and cost. Undergoing this project by using the CAF quality instrument the target is to identify fields were effective functioning was observed (strong points) and fields that need improvement (weak points). The purpose is, throughout self assesment evaluation but also with Bench-marking with other ICUs, to improve the provided health services from the ICU of General Hospital of Trikala.

25-35

Authors: Toulabi T, Kordestani-Moghadam P, Pournia Y

This research was designed to determine the appropriateness and applicability of the Patient Bill of Rights from the viewpoint of nurses in Lorestan University of Medical Sciences to identify barriers and provide operational solutions in 2012. This is a descriptive-analytical study. Out of 440 questionnaires delivered to the nurses, 294 were completed. The data collection tool was a questionnaire related to the five domains of the Patient Bill of Rights including right to receive appropriate services, right to receive appropriate and adequate information, right to choose and decide on health services freely, respecting patient privacy and observing the principle of confidentiality, and finally right to get access to effective complaint handling system. The mean scores for appropriateness (350.16±7.23) and applicability (282.57±54.22) of the Patient Bill of Rights were high. Shortage of work force, nurses and patients’ unawareness of the major barriers of application, provision of necessities for internalization, establishment of the committee of the Patient Bill of Rights, and paying attention to nurses’ rights were the solutions proposed. Enhancing stakeholder’ s awareness and providing necessities by managers can help in the operationalization of the Bill.

45-59

Authors: Changaei F, Simbar M, Irajpour A, Akbari S

Access to appropriate and high quality health care is one of the most important ways to reduce maternal and infant mortality. This study evaluates the quality of care during childbirth, the effective factors, and promoting strategies in Lorestan province, Iran. This research is a mixed explanatory study (i.e., quantitative and qualitative). The quantitative part is descriptive-analytic. The quality of 200 care processes during childbirth was assessed in the health centers of the province. The data were gathered through the checklists prepared according to the guidelines of the Iranian Ministry of Health. Statistical analysis was performed using SPSS software. In the qualitative part, the strategies for solving the problem were assessed through interviews with service providers, maternity administrators, and senior decision-making university officials. According to our results, the levels of care quality during childbirth were intermediate in all four phases. The lowest levels of quality in the first, second and third stages were associated with Leopold’s maneuver, hand washing and pulse control, respectively. Based on the interviews, the main reasons for the reduction of care quality include lack of staff’s motivation, overcrowding and shortage of nursing workforce, low attention of officials to the Department of Midwifery, and the high burden of writing in the maternity. To improve the quality of services, the authorities in Lorestan University of Medical Sciences propose strategies such as making some incentives for care promotion. Considering the quality of care during childbirth as intermediate in all four stages in the province and investigation of the reasons indicating the lack of sufficient incentive in midwives, it is recommended that strategies such as financial incentives, greater use of private sector to reduce public sector workload, quality increase and further use of in-service training to improve the quality of services be adopted