The Greek e-journal of Perioperative Medicine

1-2

Authors: Mouloudi E, Papagiannopoulou P

editorial

17-35

Authors: Theodoraki K, Kouki P.

Current evidence suggests that the combination of fluid administration and vasoconstrictive medications should be the main strategy for prevention and management of hypotension accompanying neuraxial anesthesia procedures during cesarean section. Research is still underway in relation to the most appropriate timing for fluid administration, the most appropriate fluid volume as well as the type of fluid that should be administered. However, pre-loading of crystalloids seems to be inefficient as a sole strategy, while co-loading of colloids is more effective than co-loading of crystalloids for prevention of hypotension in the parturient. On the other hand, pre-loading and co-loading of colloids seem to be of equal effectiveness. It should also be emphasized that lower doses of spinal local anesthetics and early administration of phenylephrine are of value in the prevention and treatment of spinally induced hypotension. Gelatins and dextrans should be carefully administered due to serious untoward effects associated with their use while starches should be avoided when there is preexisting renal dysfunction, coagulation abnormalities or sepsis.

50-66

Authors: Giannopoulos A, Aslanidis Th, Tsikrikonis G, Varela Ek, Pavlidis E, Giatsiatsios S, Stoltidis P, Arampatzi E, Alexandridis K, Tsiaousidis K, Prodomou V, Tanidis P, Viarou M, Vornitis I, Tatatzidis Ch, Stamatis E, Tsioupa A

This is the first study in Greece that aims prehospital care by Emergency Medical Services staff and the factors that affecting it. In a prospective 5 month survey study , 13 EMTs recorded data (45 variables) about 1450 cases;1010 of which were included for further analysis. Six (6%) of the cases were characterized as super-emergencies, 46% non-emergent and 35% as emergent. Fourty five (45%) of the cases were recorded in the 15.00-23.00 shift. Geographical distribution of the calls is very different from the pre-located ambulance bases and varies with the type (non-urgent/ urgent) of the call. In 152 the characterization of the call was changed after arrival on the spot. The majority (64%) of the cases are located in their home, the main reason for calling an ambulance is dyspnoea and only in 14.91% of the calls , the reason is related to known medical history. Main response time within the city for “super-emergency” calls was 6 min and 10sec, while the main total time engagement was 47 min. In 365 cases delivery was performed by chair (in total 24,7 distributed to 13 EMTs). In the vast majority (>90%) delivery was achieved by one ambulance crew. Yet, in 110 cases violence or aggressive behavior towards the crew is recorded. Peripheral vein line was place in 1/3 of the emergency calls. Most of the drugs given were anti-hypertensive. Unfortunately, there is only one case of by-stander CPR in cardiac arrest. The present study provides valuable information about the management of pre- hospital calls by EMTs. However, larger studies are needed in order to truly evaluate the present results, and to facilitate future advancement of the given care.

6

Authors: Mouloudi E, Papagiannopoulou P

Editorial

9-10

Authors: Veroniki F

Lecture 1, 15th SAING Congress

16-17

Authors: Zoumbouli A

Lecture 3 15th SAIMNG Congress

21-23

Authors: Fakiris K

Round Table 15th SAIMNG Congr.

28-29

Authors: Pappas P

Round Table 15th SAIMNG Congr.

33-34

Authors: Kotsovolis G

Round Table 15th SAIMNG Cong.

38-39

Authors: Koraki E

Round Table 15th SAIMNG Congr.

47-48

Authors: Douma P

Round Table 15th SAIMNG Congr.

57-58

Authors: Stoumboulis K

Round Table 15th SAIMNG Congr.

63-69

Authors: Matsota P

Lecture 15th SAIMNG Congr.

72-73

Authors: Papathanakos G

Round Table Emergency 15h SAIMNG

84-86

Authors: Nyktari V

Trauma Round Table 15th SAIMNG Cong.

1

Authors: Mouloudi E, Papagiannopoulou P

[letter from the editors]

8-14

Authors: Dubey A

Anesthesiologist always works around the oral and peri oral soft and hard tissue. Oral/nasal intubation might injure hard tissue or “knock out” the tooth. The present study was conducted among anesthetic specialist to assess the measures that they would take to manage an avulsed tooth that might occur during intubation & laryngoscopy. The present study involved 40 anesthetists working in private hospitals. They were asked to answer a questionnaire designed to evaluate the line of action that an anesthetist would follow in case of an iatrogenic tooth avulsion. Anesthesiologists were aware that trauma to oro-facial region might occur during intra oral manipulation. However few knew the correct protocol to be followed in handling the avulsed tooth. There is a need to make anesthetist aware that immediate reimplantation and stabilization of a permanent avulsed tooth should be done.

26-41

Authors: Lolakos K, Foroulis C, Alexiou I, Kyparissa M, Kolettas A, Fyntanidoy B, Veroniki F, Grosomanidis V

Abstract Anesthetic management of patients undergoing thoracic surgical procedures for lung cancer poses unique challenges to the anesthesiologist, including patients’ comorbidities, lateral decubitus position, the need for lung isolation, and the associated pathophysiology during and after these procedures. Anesthetic management is even more challenging in patients with previous pneumonectomy. In this case report we present two patients (patients Α and B), who had a previous history of left pneumonectomy and were scheduled for surgical resection of a tumor in the remaining right lung. Apneic oxygenation was used in both patients intraoperatively, initially by oxygen insufflation via a thin catheter advanced to the level of the carina. For a significant period of time, oxygenation was preserved in both patients. Patients Α and Bshowed time to oxygen desaturation of 30min and 25min respectively. Hypoxemia was recognized immediately by SpO2 decline below 90% and was confirmed via blood gas samples. Apneic oxygenation via a Mapleson-C circuit was applied successfully for hypoxemia management in both patients. Oxygen levels improved immediately and remained stable until the end of apneic oxygenation. Total duration of apneic oxygenation was 90min and 50min in patients A and B, respectively. Increaseof arterialcarbon dioxidetension (PaCO2) and subsequent respiratory acidosis were predictable results of apneic oxygenation thatwere corrected quickly by mechanical ventilation (MV). After the end of surgery, both patients were admitted intubated to the ICU, where weaning from MV was successful after 2hrs. Patients A and B were discharged from the ICU on first postoperativeday after an uncomplicated postoperative course.

1

Authors: Mouloudi E, Papagiannopoulou P

letter from the editors

5-36

Authors: Schizodimos Th , Soulountsi V

Bloodstream infections (BSIs) are a frequent and life threatening condition in hospital settings. The case fatality rate associated with BSI reaches 35-50% when associated with admission to intensive care unit (ICU). The extensive use of intravascular catheters, however, is recognized as the most important factor contributing to the occurrence of BSI. Catheter-related BSIs (CR-BSIs) are the most common types of BSI in ICU. Bacteraemias that occur in the ICU are classified as Community Onset BSI and Hospital Acquired (HA) BSI. They are also distinguished in primary and secondary. Community-onset BSIs are those that occur in outpatients or are first identified 48 h after admission to hospital/ICU, and they may be sub classified further as health care associated (HCA), when they occur in patients with significant prior health care exposure, or community associated, in other cases. Hospital Acquired (HA) and / or ICU-acquired BSIs are defined as those occurring more than 48 hours after the patient’s admission into the hospital or ICU or within 48 hours of leaving the hospital or the ICU. Community acquired BSIs usually due to susceptible bacteria should be clearly differentiated from HCA and HA BSIs frequently due to resistant hospital strains. A bedridden status, presence of indwelling devices, recent hospitalization or contact with health care facilities and recent antibiotic therapy may represent the most important risk factors for the development of emerging multi drug resistant (MDR) GN infections. The basic components of the treatment of a bacteraemia in the ICU are determining the type of bacteraemia in order to target potential pathogens, the initiation of empirical antimicrobial therapy based on the guidelines, and the source control if it is a secondary bacteremia. These goals become difficult to achieve in case of BSI due to multi-drug resistant pathogens with high MICs to antimicrobials. The main mechanisms which have put in danger the marvelous antibiotic weapon are the production of ESBL (several different subtypes), the production of carbapenemases and metallo-betalactamases, with consequent spread of multi or pan-resistant organism and the emerging growing resistance in colistin. The targeted treatment should be applied immediately after receiving the susceptibility test from the cultures. Targeted treatment essentially consists in redefining antibiotic treatment, in de-escalation in order to decrease the antibiotic selection pressure, and in determining the duration of treatment. Source control is recognized as an important part of the therapy of BSIs and has been recently shown to be independently related with outcome. Depending on the source of the infection (pneumonia, CRBSIs, urinary tract infections, intra-abdominal infections), the therapeutic strategy should be based on international guidelines in combination with local microbiology and local antibiotic resistance data.

61-70

Authors: Mouloudi E, Katsanoulas K, Aslanidis T, Lampiri Cl, Papageorgiou Ch, Tholioti Th, Vrochides D

Adequate adrenocortical function is essential to survive critical illness. The goal of this study was to determine whether eosinophilia could serve as a useful and early marker of adrenal insufficiency in critically ill patients with severe septic shock. During a 1-year period, we prospectively studied 294 ICU patients.16 patients (5.4% of ICU admissions) with eosinophilia more than 3% of the white blood cell count and septic shock unresponsive to adequate fluid and vasopressor therapy, were included. A high dose (250 mcg i.v) corticotropin stimulation test was performed. Eosinophilia (>3%) was diagnosed in 16 patients with vasopressor-unresponsive septic shock. Eosinophilia was present 1.9±0.9d (range 8-96h) before the onset of septic shock. 11/16 patients failed to respond to corticotropin stimulation test above the critical level of 9 mcg/dL rise and 2/16 had baseline cortisol concentration <10 mcg/dL. Baseline cortisol level, maximal cortisol increase post-corticotropin administration and Eosinophils count (%) were higher in survivors (p≤0.05). A hydrocortisone infusion (300mg/d) treatment resulted in haemodynamic improvement in 12 of 16 patients (75%). The 28-day mortality (following the onset of septic shock) was 43.7%. Relative eosinophilia may be considered as a useful and early bioassay for adrenocortical function assessment in critically ill patients with septic shock and assumed adrenocortical depression.

76-82

Authors: Voulioti E, Ampatzidou F, Koutsogiannidis Ch P, Karaiskos T, Dimaki A, Asteri Th

Thymoma is one of the most common tumors of the anterior mediastinum in adults, arising from thymic epithelial cells. Complete surgical resection is the treatment of choice in myasthenic patients with thymoma. A 41 year-old male, with myasthenia gravis and thymoma was scheduled for thymectomy. Ten months ago, he developed pneumonia. He had a history of pneumonia (10 months ago) complicated by severe adult respiratory distress syndrome (ARDS), managed successfully with a short-term support with extracorporeal membrane lung assist device NovaLung. Long-term impairments in lung volume and diffusion capacity have been reported in adult respiratory distress syndrome survivors. Total intravenous anesthesia technique and especially muscle relaxants infusion require special attention in this group of patients. Our management strategies in this case included careful assessment of respiratory function, avoidance of premedication, use of short-acting anesthetic agents (propofol, remifentanil), use of suggamadex for reversal of rocuronium-induced neuromuscular block, and intraoperative monitoring with a train-of-four monitor and monitoring in an intensive care unit for 24 hours after surgery.