The Greek e-journal of Perioperative Medicine

3-32

Authors: Papageorgiou L, Staikou Ch

Procedural sedation and analgesia (PSA) is often necessary in order to deal with anxiety, pain and stress that may accompany patients at the hospital during invasive, unpleasant and/or painful procedures. The literature has not presented firm conclusions regarding ideal sedative agents in terms of efficacy and safety in PSA or even present firm data regarding superiority of specific drugs over others which are considered the “gold-standard” in sedation (i.e. propofol). Ketofol is a combination of ketamine and propofol and is considered by many health-care professionals to cause less respiratory suppression and haemodynamic instability, ensuring better analgesia and often amnesia, and possibly improved patient satisfaction. We reviewed the existing evidence regarding superiority of ketofol in mitigating cardiorespiratory effects when administered as a main agent for PSA in comparison to other drugs administered for such purposes underlying the safety and efficacy profile of this cocktail medication. We conducted three times an advanced Pubmed research using the following terms: “ketofol” or “ketamine and propofol” and “sedati*” and “analgesia or pain” in “Title/Abstract” of articles using filters, such as “clinical study”, “clinical trial”, “controlled clinical trial”, “meta-analysis”, “multicentre study”, “randomised controlled trial”, “review”, “systematic review”, “comparative study”, “observational study” in English language and in population of “Adult: 19+ years”. We found 46 articles appropriate to be included in this review. We found limited evidence to support superiority of ketofol compared to other agents, specifically to propofol, the “gold-standard” drug in sedation; undoubtedly, propofol frequently leads to respiratory suppression, hypotension and bradycardia. It seems that the addition of ketamine to propofol in sub-dissociative doses is associated with less respiratory and haemodynamic complications during PSA, while achieving adequate analgesia and deeper sedation, possibly more amnesia and consequently high satisfaction in both patients and health-care professionals. Frequent side-effects of ketofol, such as increased psychomimetic complications, nausea and vomiting and perhaps more prolonged recovery do not outweigh its potential benefits during PSA. Therefore, we consider that it represents a good choice for PSA, especially in specific populations. Further research with large, well designed, randomised clinical trials is necessary to extract firm conclusions regarding superiority of ketofol against other agents used for PSA

44-64

Authors: Schizodimos Th, Soulountsi V, Iasonidou Ch.

Acute brain injury (ABI) is a common clinical problem that requires immediate and urgent treatment. In addition to the treatment of primary brain injury, the main focus of management is the prevention of secondary brain injury (SBI), i.e. any physiological event after the initial injury that can lead to further damage to nervous tissue. Several systemic factors have been found to contribute to SBI, which can compromise the balance between brain oxygen supply and consumption, leading to brain tissue hypoxia. They include arterial hypotension, low cardiac output, hypercapnia, hypocapnia, systemic hypoxia, anemia, hyperthermia, and blood glucose abnormalities. In patients with impaired autoregulation, arterial hypotension leads to cerebral ischemia due to cerebral perfusion pressure reduction and possibly through the development of cortical spreading depression. Low cardiac output, mainly due to volume depletion, can lead to decreased cerebral blood flow (CBF) and brain tissue hypoxia, which can also be caused by other systemic factors that affect oxygen delivery, such as hypoxemia and anemia. Carbon dioxide variations may have a significant effect on CBF, with hypocapnia causing vasoconstriction of cerebral arterioles and a decrease in CBF. Finally, hyperthermia occurs in at least 70% of patients after ABI, and hyperglycemia has been identified for years as an important risk factor for poor outcome.

84-88

Authors: Bihorac E, Çekmen N

Alport syndrome (AS) is a rare hereditary disease, in which there is a defect in type IV collagen, an essential constituent of basal membrane in kidney, ear and eye. This can cause progressive renal damage and eventually renal failure, as well as hearing loss and visual impairment. Definitive treatment, when end stage renal disease (ESRD) has ensued, is renal transplantation. Concerning the anesthetic management of renal transplantation, in patients with AS, major anesthetic challenges are related to renal failure, which involves also electrolyte disorders that may cause cardiac function impairement. Hypertension and hemorrhagic diathesis can also be present. In the present article we present the anesthetic management of a 35-year old male patient, with Alport syndrome, who underwent renal transplantation. Concerning AS patients, comprehensive preoperative multidisciplinary approach and intraoperative close hemodynamic monitoring are considered important factors in order to reduce perioperative complications.

3-11

Authors: Sivrioğlu D, Tuç Ö, Ersoy Z, Çekmen N, Torgay A

Glycogen storage disease type Ia (GSD-Ia; Von Gierke disease) is an inherited disease caused by glucose-6-phosphatase deficiency. Perioperative management of patients with GSD has important implications for anaesthesiologists due to different system involvements. In the case reported here, an 8-year-old patient with GSD type-Ia underwent liver transplantation (LT) for hepatic adenoma that had malignant transformation, severe hypoglycemia and metabolic acidosis, occurred in this patient intraoperatively. The metabolic complications were managed successfully by administering balanced volume of glucose and sodium bicarbonate intravenously (iv). Although liver transplantation is an important treatment option in these patients, anesthesia management requires a multidisciplinary approach, comprehensive perioperative assessment and close intraoperative follow-up for successful outcomes.

19-23

Authors: Kandemir E, Çekmen N, Torgay A, Haberal M

Glycogen storage disease type 1a is a rare inborn error of metabolism. It causes severe fasting intolerance and lactic acidosis due to the deficiency of glucose-6-phosphatase enzyme. Anesthetic management of these patients is very difficult due to their course with different system involvements. Our case report evaluates the anesthetic management and considerations of a glycogen storage disease type 1a patient with air embolism during liver transplantation. Although orthotopic liver transplantation is an important treatment option in these patients, anesthesia management requires a multidisciplinary approach and care should be taken in terms of perioperative complications.

31-36

Authors: Tuç Ö, Bihorac E, Ersoy Z, Çekmen N

Hereditary angioedema (HAE) is a life-threatening rare autosomal dominant (AD) disorder caused by C1-esterase inhibitor (C1-INH) deficiency or dysfunction. HAE is not related to mast cell and histamine pathway; as a result, it does not respond to antihistamines, glucocorticoids, or epinephrine. Attacks may occur spontaneously or after a trauma. The upper airway swelling and laryngeal edema cause asphyxia, which can be life-threatening. Treatment of HAE includes C1-INH concentrate, recombinant human C1-INH, bradykinin B2-receptor antagonists, recombinant plasma kallikrein inhibitors, fresh frozen plasma (FFP) and androgen steroids. In this case we report anesthetic management of a 62 years old female patient with HAE, undergoing endoscopy and colonoscopy, for which highly selective α2 adrenergic receptor agonist dexmedetomidine intravenous (IV) infusion was used. We administered icatibant (bradykinin B2-receptor antagonist) for prophylaxis, and FFP was prepared in case of use. Anesthetic management and preoperative preparation are critical for the patient with HAE. Difficult airway management should be kept in mind in case of airway edema and early intubation.

3-15

Authors: Varvarousi G, Klimi P, Stamatakis E, Saiti A, Iliopoulou Ch, Papa M, Scandalou V, Valsamidis D.

Obstetric haemorrhage is the leading cause of mortality in parturients. In massive haemorrhage, fibrinogen is the first coagulation factor to decrease and a value < 2 gr/lt is a prognostic indicator of severe haemorrhage. A small decrease in fibrinogen leads to an increased effect on coagulability and continued haemorrhage. Coagulation disorders may be due to either consumption of coagulation factors or dilution. The type, severity and time of onset of the coagulation disorder depend on both the size and the cause of the haemorrhage. Early recognition of the cause of haemorrhage, low fibrinogen and its immediate correction are essential in the perioperative management of haemorrhage. The use of viscoelastic coagulation measurements contributes to rapid, individualized and targeted management of haemorrhage and coagulation disorders. It reduces transfusion of blood products and their complications, the length of hospital stay and in-hospital mortality. In obstetric haemorrhage, the target is haemoglobin > 8 gr/dl. Fibrinogen should be greater than 2g/L and replaced with cryoprecipitate or fibrinogen concentrate. Replacement of fibrinogen by plasma will lead to administration of large amounts of plasma and increase the risk of complications. Platelet count should be > 75 X100/l. Their administration is indicated in pre-existing thrombocytopenia, coagulation disorder from consumption and blood loss > 5000 ml. At the same time, it is important to avoid acidosis, hypocalcaemia and hypothermia.

55-61

Authors: Çağla Yazar, Nedim Çekmen

Thoracic epidural anaesthesia (TEA) is frequently used for anaesthesia and analgesia in today’s practice. Although cholecystectomy is a surgical procedure performed under general anaesthesia (GA), many studies in recent years have shown that neuraxial techniques can be used safely. We aimed to present the anaesthesia management under dexmedetomidine sedation with TEA in high-risk patients who underwent laparoscopic cholecystectomy surgeries. Both patients were of geriatric age and had several comorbidities. In patients, we preferred TEA to avoid the cardiorespiratory effects of GA. Preoperative preparation of patients with a multidisciplinary approach, cooperation, and close follow-up is essential in preventing complications.

3-17

Authors: Guimarães Pereira JE, Palmeira C, Saffier IP, Darcy Alves Bersot C, Aslanidis Th, Ashmawi HA

Objective: A systematic review to investigate the efficacy and safety of medicinal cannabis on clinical outcomes of patients suffering from sickle cell anemia pain. Data sources: The following databases were searched: PubMed, COCHRANE, LILACS and Science Research from inspection up to March 8th, 2022. No restrictions applied. The terms used for search were sickle cell anemia and cannabis and their synonyms. Study selection: We included Non-Randomized Studies (NRS) and Randomized controlled trials (RCTs) evaluating Cannabis Medicinal for Pain originating from Sickle Cell Disease (SCD). Data extraction: Reviewers independently screened potentially eligible articles; extracted data from included studies on populations, interventions and outcomes and assessed their risk of bias. Data synthesis: 1 RCT including 34 participants and 5 NRS, including a total of 37871 participants, proved eligible. We could not find enough publications to further proceed with a meta-analysis. Conclusions: There is no evidence in the literature about treating pain from sickle cell anemia with cannabis. There is an association between cannabis use and hospital emergency department visits.

26-44

Authors: Deligianni M, Fyntanidou B, Foroulis Ch, Kioumis I, Tsagkaropoulos S, Alexiou I, Kotzampassi K, Grosomanidis V

Introduction: Anesthesia for thoracic surgery presents specific challenges since anesthesiologists have to manage patients with several comorbidities, apply One Lung Ventilation (OLV) to facilitate surgery and at the same time they should try to maintain adequate safe oxygen levels. Hypoxemia is a common consequence of OLV. The aim of the present retrospective study was to investigate the impact of intraoperative hypoxia on the early outcome of patients. Material and Methods: In this study120 patients were included, who underwent thoracic surgical procedures with OLV and were assigned into two groups of 60 patients in each group. Group A consisted of patients who experienced severe hypoxia (PiO2/FiO2<100) during OLV, whereas Group B consisted of those who did not suffer from hypoxia. ABG samples were collected intraoperatively at four different phases: Ph1: spontaneous breathing without any oxygen supply before intubation, Ph2: after initiation of mechanical ventilation, Ph3: during OLV and Ph4: immediately before being transferred from the operating theatre. Venous blood samples were collected at three phases: Ph1: after initiation of mechanical ventilation, Ph2: at the time of hypoxia occurrence and Ph3: immediately before being transferred from the operating theatre. During ICU stay, ABG samples were taken at four phases: Ph1: immediately after ICU admission, Ph2: before extubation, Ph3: after extubation and Ph4: before ICU discharge. Results: Intraoperatively, patients in Group B had better oxygenation compared to Group A at all phases. Moreover, during OLV patients in Group A experienced severe hypoxemia. Intraoperative PO2/FiO2 ratio in Group A was 369,8±69,9 / 279,4 ±91,5 / 68,3±11,8 / 324,7± 82,9 and at the corresponding phases the relevant values in Group B were 420,8±68,2 / 373,8±87,5/ 242,9±79,6 / 406,7±64,4. Partial pressure of oxygen in the central venous blood (PcvO2) and Central venous oxygen saturation (ScvO2) differed in a statistically significant manner between the study groups. However, ScvO2 remained at acceptable levels even at the time of hypoxemia in Group A. ScvO2 values in Group A were 78,7±9,1 / 66,8±79,7 / 73,3±5,82 and at the corresponding phases the relevant values in Group B were 87,1±7,2 / 79,8±7,8 / 81,8±7,5. Duration of mechanical ventilation in ICU was longer in Group A compared to Group B (5,34±5,1hrs vs 3,6±2,5hrs), whereas ICU and total hospital stay did not differ between study groups. Conclusion: Hypoxemia during OLV in Group A did not have a negative impact on early outcome of patients.

51-56

Authors: Myrou A, Aslanidis Th, Savopoulos Ch, Didangelos T

Raoultella planticola is a Gram-negative, oxidase-negative, aerobic that belongs to Enterobacteriaceae family and has a lot of similarities with Klebsiella spp. Though initially rare mentioned as an opportunistic infection, more and more reports are published. In the present article we present a case of an R. planticolla upper respiratory infection and we review the relevant literature

2-12

Authors: Aledzhanov N.Yu

The goal of this study is to examine and describe the methods and techniques, as well as the knowledge of the anatomy and treatment of venous pathology, and their influence on the birth of phlebology in ancient Greece and Byzantium.The study was conducted reviewing sources in Russian and foreign literary in Greek and in English language, which, in turn, allowed a detailed study of discoveries and treatment in the field of venous system anatomy. Conservative methods are also described, as well as the first vein surgeries, precursors of modern surgical interventions that were unique for that time and are still relevant today. Brief biographies and discoveries of scientists of those eras are also mentioned.

23-30

Authors: Aslanidis Th, Myrou A, Papachristou D, Flioni EN, Thoma G

COVID-19 has brought up the interest about hyperferritinemic syndromes. Though often seen in COVID-19, especially within the frame of COVID-CSS, hyperferritinemia needs a systematic diagnostic approach, as co-infections or other causes may also increase ferritin. In this article, we present a case report of extreme hyperferrinemia in an male criticall ill patient with COVID-19 and we perform a short synthesis of the available literature.

42-49

Authors: Aslanidis Th, Drampa F, Mytkani K, Syrmou E

Therapy armamentarium for multpile sclerosis include a variety of drugs. Natalizumab, a humanized antibody, is widely used in relapsing-remissing multiple sclerosis. Anticonvulsants, like topiramate, are also widely used for symptomatic relief. We hereby describe a case of Status epilepticus and topiramate induced metabolic acidosis in a female patient with multiple sclerosis under natalizumab therapy.