The Greek e-journal of Perioperative Medicine

1-2

Authors: Papagiannopoulou P, Mouloudi E.

Editorial

21-35

Authors: Panteleou K,Katsanoulas K, Tzima M, Zemou S, Grousouzakou I, Zafeiriadis D, Katsika E.

Postdural puncture headache (PDPH) may occur after inadvertent dura mater puncture inepidural anaesthesiaor after spinal puncture in spinal anesthesia, spinal diagnostic or therapeutic procedures. It is characterized by severe headache that occurs within 5 days following thepuncture, located in the frontal and/or occipital region, not necessarily worsened in the upright position. PDPH is associated with substantially increased postpartum risks of major neurologicand other maternal complications, underscoring the importance of early recognition, follow up andtreatment particularly in obstetrics. Despite the fact that epidural blood patch is recognized as thegold standard in the treatment of PDPH, it is not without risk andpotentially may fail. Nerve blocks andnewer therapieshave been reported that could be efficacious, easy to administer and with less risk. In this review wepresent updated evidence and potential alternative therapies in the treatment of PDPH.

45-61

Authors: Pezikoglou I, Fyntanidou B, Foroulis Ch, Amaniti A, Alexiou Ι, Kyparissa M, Palaska E, Grosomanidis V

Pneumothorax is a collection of air in the pleural space between the lungs and the chest wall and depending on its cause it could be either spontaneous or traumatic. Tension Pneumothorax (TPT) can be a cause of cardiac arrest (CA) or might be a complication after chest compressions. According to the 2015 European Resuscitation Council guidelines on resuscitation, TP is considered one of the reversible causes of CA, which should be recognized and treated during cardiopulmonary resuscitation (CPR). A 61yrs old patient (ASA-PS:3, NYHA:2) was scheduled for a video-assisted mesothoracoscopy. The patient was a former smoker and suffered from hypertension and chronic obstructive pulmonary disease. He underwent an uneventful video-assisted mesothoracoscopy, was extubated in the operating theatre and was transferred to the High Dependency Unit. Approximately 40min later and after a prolonged cough episode, he experienced severe dyspnea, tachypnea, tachycardia, hypertension, SpO2 reduction and he became anxious. A bedside chest x-ray has been already performed before this episode but the image was not yet available to the physicians. Patient deteriorated very fast, he became agitated, experienced a severe blood pressure decrease, which was followed by CA. The initial CA rhythm was Pulseless Electrical Activity (PEA). CPR was initiated immediately with chest compressions, mask ventilation and intravenous administration of 1mg adrenaline. After endotracheal intubation it was impossible to ventilate the (intubated) patient with a bag-valve device. Esophageal Intubation was excluded since endotracheal intubation has been performed by an experienced consulting anesthesiologist and the direct laryngoscopy was easy and classified as Cormack-Lehane grade 1 and therefore tension pneumothorax was highly suspected. Immediately at this time point two chest tubes were inserted bilaterally without any interruption of the chest compressions. Air was expelled only from the right chest. CA rhythm remained PEA and Return of Spontaneous Circulation (ROSC) was achieved after 5min of CPR and without administration of a second adrenaline dose. After ROSC, patient was transferred to the Intensive Care Unit, where he was extubated the next day without any neurological deficits and thereafter he experienced an uneventful recovery. Pneumothorax is one of the possible complications of video-assisted mesothoracoscopy, while TPT is a reversible cause of CA. Recognition of CA, immediate CPR initiation and early diagnosis and treatment of TPT contributed to short CA-ROSC time and to the survival of this patient without any neurological impairment.

1

Authors: Papagiannopoulou P, Mouloudi E.

Editorial

5-12

Authors: Rashid A, Nazir S, Junaid S, Mir I, Zaieem M

COVID-19 has officially been declared as a pandemic. Although the ultimate course and impact of COVID-19 is yet to be seen, the disease has already overwhelmed health care infrastructure. Operation theaters are high-risk areas for transmission of respiratory infections given the involvement of multiple staff, and the need for high transmission-risk aerosol generating activities. The current study aims to establish a guide for establishing optimum protection conditions that should be done before, during and after surgical intervention. A clear plan has to be developed to only provide essential surgical care during the pandemic. All the elective and non-essential procedures need to be deferred. Whenever close contact is mandated with the suspected patients, the staff should wear proper personal protective equipment. There should be proper training in the appropriate use and application of PPE. The most important thing in the chain is hand hygiene and 70% alcohol solutions should be placed strategically. Universal pre-operative testing of patients is discouraged. Minimum possible staff should be used to transfer the patient to and from the operating theater. The path of the patient should be kept clear. Consider designating a specific operating theater for all suspected COVID-19 cases. Though general anaesthesia is not contra-indicated in suspected or confirmed COVID-19 cases, regional anesthesia with IV sedation, if feasible, should be preferred. Bag mask ventilation should be avoided for as long as possible. The most skilled provider should do intubation. The risk of aerosol exposure and the resultant transmission of infection to the operative team during a laparoscopic procedure is a likely issue and have led people to advocate open surgery in suspected COVID-19 patients. Laparoscopic surgery in COVID-19 positive patients should be performed in a negative pressure room and smoke evacuation systems should be used. The patient should be extubated in the operating room itself and should be shifted only once they have recovered fully. Appropriate disinfection of atmosphere and OT walls and floors should be done. Patients should be shifted to an area earmarked for COVID patients. Negative airflow should be used preferably in areas that are reserved for suspected COVID-19 patients. It is essential that every center develops its own protocols bearing in mind the local factors, but the protocols developed should be followed stringently in order to break the transmission of COVID-19 and protect health-care workers and the patients alike.

21-31

Authors: Apostolidis K, Aslanidis Th, Nikolaidou O, Charitidou S, Syrmou E, Allios D, Tsioupa A, Iliadis K, Karabelidou Ch.

COVID-19 pandemic has created an unprecedented citation for the healthcare system; such that its effects are now started to become obvious. The main aim of this report is to describe the time trends of utilization of prehospital emergency medical system in a region of northern Greece from first confirmed case of the COVID-19 in the country, at 26/02/2020, till the first order for loosing lockdown at 04/05/2020. Use of data retrospectively collected for PEMS usage, in the regional unit of Thessaloniki, Northern Greece 26/02/2020, till the first order for loosing lockdown at 04/05/2020. The area of interest represents a little more than 10% of the total population of Greece. Daily cases of selected categories (suicides, assaults, animal bites, cardiac arrests, and car accidents) were recorded. Comparison with the daily cases in the previous 2 years (2019,2018), for the same period was performed. Comparison of suicides reveals larger daily case for 2020 in regard to both 2019 (p=0.049) and to 2018 (p=0.000438); while this was not the case in assaults (p=0.09 and 0.103 respectively) and animal bites cases (p = 0.38 and 0.101 respectively). Yet, for the later, the net number of animal bites cases was larger during the lockdown. Cardiac arrests were more in comparison with the previous 2 years (2019:p=1.88 x 10-5, 2018:p=7.12 x10-5); and, as expected, the opposite was valid for card accidents : they were more in 2018 that the same period of 2019 (p=1.03×10-6) and 2020 (p= 2.53 x10-12). It seems that lockdown has affected daily cases of suicides, cardiac arrests more than the other categories under research. Net number of animal bites cases were also increased. Assaults cases seem to be unaffected during the lockdown period, although more careful interpretation is needed. Finally, car accidents, due to travel limitations, were fewer in the same period. However, larger studies are needed -especially from highly affected from the pandemic areas- to reach certain conclusions.

1-5

Authors: Papagiannopoulou P, Mouloudi E.

Editorial

13-19

Authors: Kalopita K, Antsaklis P, Saiti A, Valsamidis D

Mitochondrial diseasesrepresent a wide range of disorders caused by impairment of mitochondrial metabolism and energy production. We report a case of an uneventful perioperative management of a pregnant patient with early childhood-onset mitochondrial encephalopathy, attributed to a novel AIFM1 (Apoptosis-Inducing Factor, Mitochondrion-associated 1) mutation. After a multi-disciplinary team consultation, it was decided to be posted for elective caesarean delivery at 36+2weeks of gestation, under titrated combined spinal-epidural anaesthesia and multimodal analgesia. Unique anaesthetic challenges were to ensure normoglycaemia, normothermia and adequate hydration while avoiding perioperative stress and acidosis.

25-38

Authors: Pezikoglou I, Fyntanidou B, Kyparissa M,Alexiou Ι, Pertsikapa M,Lolakos K,Kapanidis K, Grosomanidis V.

Pericardial decompression syndrome (PDS) is a rare but eventually fatal syndrome, which occurs after pericardial drainage. In this report we describe a patient who suffered from cardiovascular collapse and pulmonary edema after pericardial drainage. A male patient aged 42yrs complained of progressive dyspnea over the past 2 months and presented with clinical signs of pericardial tamponade. The patient underwent a surgical subxiphoid pericardial drainage under general anesthesia and mechanical ventilation. After pericardial drainage of 2.2lt, the patient was transferred to the Intensive Care Unit, where he was extubated2 hours later. Immediately after extubation, he showed clinical signs of cardiovascular collapse and pulmonary edema. The patient was reintubated immediately and placed on mechanical ventilation. He was extubated after 12hrs. His postoperative course was uneventful and he was discharged from the hospital after a few days.