The Greek e-journal of Perioperative Medicine

3-23

Authors: Pantelidis A, Resvani P, Tsaousi G

Acute sepsis-related kidney damage (S-AKI) is a common complication of the critically ill patient, with high mortality rates. Prevention of S-AKI is a daunting task because by the time patients seek medical help, most have already developed acute kidney damage. Thus early detection is an issue of utmost importance. Recent studies show that microvascular dysfunction, inflammation and metabolic reprogramming are the three fundamental mechanisms that contribute to the development of S-AKI. The rapid diagnosis of S-AKI aims to minimize the deterioration of renal function. Research on this field is intensive with particular emphasis on the discovery of new biomarkers with enhanced sensitivity in renal function assessment. Neutrophil gelatinase-associated lipocalin (NGAL) is overexpressed in renal tubules during ischemia and inflammation. Both plasma and urinary NGAL levels have a strong prognostic value for renal impairment and are associated with an increased probability for renal replacement therapy institution. Cystatin C is increased during the early and milder stages of tubular damage, while kidney damage molecule-1 (ΚΙΜ-1) increases in ischemia and nephrotoxic damage and appears to play a similar role to NGAL in S-AKI detection. Tissue metalloproteinase-2 inhibitor and insulin-like growth factor-7 binding protein increase in tubular cells when their DNA is damaged. The product of the two biomarkers has the highest diagnostic value in S-AKI detection of all the biomarkers studied so far. Prevention of S-AKI is often impossible. Early and specific use of antibiotics together with the treatment of sepsis reduces the risk of developing S-AKI. Adequate fluid intake appears to improve renal function although opinions differ. The use of balanced crystalline solutions and avoidance of synthetic colloids is recommended. Norepinephrine is the drug of choice for the treatment of septic shock, while angiotensin II shows promising results.

47-70

Authors: Grosomanidis V, Fyntanidou B, Gkarmiri S, Theodosiadis P, Kazakos G , Kyparissa M,Pertsikapa M, Kotzampassi K.

Increased Intraabdominal Pressure (IAP) is common in critical care patients and has detrimental effects on organs and systems. Several mechanisms and causes are involved in its pathogenesis. The aim of the present study was to investigate and record IAP effects alone and in combination with sepsis on respiratory mechanics. Sixteen male pigs were included in the study, which were randomized in two groups of 8 pigs (Group A & B). After baseline measurements, IAP increased in both groups by Helium insufflation to 25mmHg and remained elevated throughout the study period. In Group B, sepsis was induced after 60min by intravenous lipopolysaccharide (LPS) administration. Recorded parameters included PIPAW, PIPES, EIPAW, EIPES, PmeanAW, PmeanES, PEEPAW, PEEPES, CRS, CCW, CL, RinspRS, RexpRS RinspCW, RexpCW, Vexp and were measured at baseline and every 20min for 3hrs. Airway pressures in Group A (PIPAW, EIPAW, PmeanAW) increased after IAP elevation but returned to their baseline values after IAP normalization. In Group B airway pressures increased even further after LPS administration and decreased after IAP normalization but they never reached their baseline values. On the contrary esophageal pressures (PIPES, EIPES, PmeanES) showed similar alterations in both groups. PEEP did not change in any of the study groups. Respiratory system compliance decreased in both groups and returned to baseline values only in Group A. Chest wall compliance showed similar alterations in both groups. Lung compliance decreased after IAP increase in both groups and showed a further decrease after LPS administration in Group B, which remained after IAP normalization. Respiratory system inspiratory resistances increased only in Group B, whereas respiratory system expiratory resistances increased in both groups. Chest wall inspiratory resistances did not show any alterations. Our study results showed that the effects of IAP increase are reversible, whereas the effects of coexisting sepsis remain even after IAP normalization

76-81

Authors: Papadopoulou D, Diagoupi A, Trantzas P, Paraskevopoulos T, Bairaktari A

We present the case of a 64-year old super-obese female who underwent Open Reduction Internal Fixation (ORIF) for proximal humeral fracture, and our anaesthetic management. We performed interscalene brachial plexus block prior to induction, and general anaesthesia, following the guidelines for difficult airway. What is interesting about this case, are the technical difficulties that often arise in such obese individuals, concerning both the peripheral nerve block and the airway management. Moreover, due to those difficulties we created a systematic management plan consistent with guidelines so as to minimize the failure risk.

3-9

Authors: Mitos G, Thoma G, Tsaousi G

Volatile induction of anesthesia with sevoflurane is an old and conventional technique. However, there is no consensus on the appropriate mode and duration of sevoflurane administration when attempting inhalational induction to adults in order to achieve acceptable intubating conditions. This article attempts to gather the evidence presented in the literature that dictate the optimal method of sevoflurane inhalational induction until intubation is achieved.

23-38

Authors: Grosomanidis V, Fyntanidou B, Amaniti A, Chatsiou E, Karagkouni D, Fengoudaki M, Theodosiadis E, Ourailoglou V.

Hypertonic solutions combined or not with colloids have been used successfully to restore intravascular volume and to enhance cardiovascular function. The aim of the present study was to investigate the hemodynamic effects of hypertonic saline solution administration in normovolemic patients. Forty-five patients who underwent elective surgery were included in the study. After anesthesia induction, initiation of mechanical ventilation and fluid replacement of fasting deficit all patients received 4ml/kg NaCl 7,5% intravenously in the maximum possible infusion rate. Esophageal Doppler Monitoring (ODM II) was used in all patients to assess cardiac function throughout the study period. Measurements were obtained before NaCl 7,5% administration (Phase 1), after completion of NaCl 7,5% administration (Phase 2) and every 5 min thereafter for one hour (Phases 3 to 14). Furthermore, at Phases 1, 2 and 14 sodium plasma levels (Na), hemoglobin (Hb) and hematocrit (Hct) were also measured. Altogether recorded parameters included heart rate (HR), blood pressure (BP) (Systolic, Diastolic and Mean), cardiac output (CO), stroke volume (SV), peak velocity (PV), mean acceleration (MA), flow time corrected (FTc), Na, Hb and Hct. At Phase 1 SV and CO were 62,4ml and 4l/min respectively. Both parameters increased and reached 100ml and 7,3l/min at Phase 2. Thereafter, SV and CO had gradually decreased and at the end of the study their values were 78ml και 5,2l/min respectively. PV increased from 57,7cm/sec (Phase 1) to 77,7cm/sec (Phase 2) and finally to 66 cm/sec at the end of the study (Phase 14). At Phase 1, MA and FTc were 5,7cm/sec2 and 0,4sec respectively, then both increased and reached 7,5cm/sec2 and 0,5sec respectively (Phase 2) and finally at Phase 14 their values were 6,1cm/sec2 and 0,5sec respectively. All before mentioned parameter values increased in a statistically significant manner after NaCl 7,5% administration compared to baseline measurements. The increase remained to be statistically significant throughout the study. HR increased from 64b/min before NaCl 7,5% administration to 74b/min after NaCl 7,5% administration but reached baseline values after 10min. BP (SBP, DBP and MBP) decreased from 118/64mmHg to 92/53mmHg and then reached rapidly baseline values. NaCl 7,5% administration resulted in CO and SV increase and contributed to cardiac function enhancement. This beneficial impact remained statistically significant for 60min throughout the study period. Those positive effects can be attributed to the intravascular volume increase, the vascular resistance decrease and possibly to the enhancement of left heart contractility which are all caused by the hypertonic saline solution administration.

49-56

Authors: Varvarousi G, Loukeri A, Lappas T, Haidopoulos D, Valsamidis D.

The novel coronavirus disease 2019 (COVID-19) caused by severe respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a global health emergency since its declaration as a pandemic by the World Health Organization. Advanced maternal age is considered a high-risk pregnancy and therefore may affect the severity of Covid-19. In this case report, we discuss the perioperative management of an in vitro fertilization (IVF) cesarean section in a 48-year-old woman with Covid-19 infection. A 48-year-old parturient with pregnancy of 37 weeks 3 was scheduled for cesarean section, due to advanced maternal age, after she had a positive result for real time polymerase chain reaction (RT-PCR) test for (SARS-CoV-2). In our case of extremely advanced maternal age cesarean section the obstetric outcome was positive. Physiologic and vascular changes in advanced maternal pregnancies may exacerbate Covid-19 symptoms and increase the risk for poor pregnancy outcome. Further studies are needed to investigate the factors that influence the outcome in pregnancy of increased maternal age with Covid-19 infection.

3-17

Authors: Bersot CDA, Lessa MA, Aslanidis Th

Respiratory failure due to Coronavirus 2019 (COVID-19) disease has triggered a debate about when and how to apply mechanical ventilation in these patients, as it has been proposed that severe “atypical” ARDS of COVID-19 cause an ARDS pandemic. As global database grows, it is evident that about 6% of patients will need admission to the ICU. About 75% of these will require invasive ventilation, and approximately 10% will need ventilation beyond 14 days. Different ventilation strategies are followed yet there is no strong evidence in favor of anyone. The present article attempts to gather the daily evolving evidence on the subject.

36-47

Authors: Aslanidis Th, Masoura N, Parisiadou P,Tetradi M, Tsakiri A, Kamparoudi Th, Zarda J, Savoulidou S, Thomaidou E, Tragiani E, Moschona E, Nanopoulou P.

Patient care in Intensive Care Units is characterized be high demanding tasks, which lead in daily high workload. In the present study, a questionnaire-based evaluation of ICU nurse’s workload was conducted at the adult general 7 – beds ICU of a small urban hospital. NASA Task Load Index (TLX) along with other two tools, used for the first time in healthcare environment: Instantaneous Self-Assessment (ISA) and Crew Status Survey (CSS) were used for that purpose. Information about every nurse’s professional background and basic demographics were also collected. Responses from 70% of total nurse staff were collected. A total of 93 questionnaires (response rate=total shift coverage 40.25%) were included for further analysis while 2 questionnaires were excluded due to >50% of missing answers. The overall average workload for the period in interest is little to moderate, yet interesting variations do exist. Physical workloads seem to be highly related with both mental workload and time pressure; yet the last two are not related. Increased workload is perceived during morning shifts, and though there is variety in individually recordings, no relation was found between measurements and other characteristics, such as work experience (total or ICU), age of nursing staff, family status or time to work arrival. Subjective workload assessment via NASA TLX index, CSS and ISA workload surveillance tool provide a useful method of early detection of group or individual increased workload that allows proper management measures to be applied.

61-66

Authors: Karakosta P, Aslanidis Th, Flioni E.N, Agaliadou-Dioritou U.

Hemophagocytic Lymphohistiocytosis (HLH) is a life-threatening syndrome of excessive immune activation that mostly occurs as primary (hereditary) disease in children. Acquired HLH is associated with infections, cancer of rheumatological conditions. Both are rare in adults. Turicella otitidis is a bacterium, that is associated with ear infections and there is only one case report of bacteraemia. The present report describes a case of acquired HLH with invasive pulmonary Aspergillosis and Turicella otitidis bacteraemia in an adult patient; and also reviews the relative literature. In conclusion though rare, acquired HLH is a devastating condition that clinicians should have in mind when managing patients with multiple infection or underlying immunosuppression.

3-20

Authors: Staikou Ch,Maliamanis D.

Patients admitted to Intensive Care Units (ICU) have the highest mortality rates among hospitalized patients. For those who survive, recovery is often a prolonged rehabilitation period with physical, cognitive and psychological dysfunction. The aim of the present narrative review was to identify in the existing literature articles providing information about the development of chronic pain after ICU stay. We performed a PubMed search for publications up to 22 March 2020. We identified 41 articles eligible to be included in the present review; 29 of them were original research articles. Pre-existing chronic pain, previous poor health- related quality of life (HRQoL), but also the critical illness itself and organ support with multiple interventions, predispose to the development of chronic pain in the post-critical period, making it difficult to return to the pre-disease functional status. Opioid administration during mechanical ventilation is a common practice, frequently without reliable and systematic assessment of pain or individualized titration of dosage. Multimodal analgesia, including dexmedetomidine, ketamine, adjuvant medication and regional analgesia techniques can prevent chronic pain and treat withdrawal symptoms during opioid weaning. Early mobilization and physiotherapy, continuous assessment of pain and its corresponding treatment and follow-up by a team of specialists comprise a successful management plan for early recognition of complications and effective aftercare treatment of these patients. Chronic pain after ICU stay is a common problem, associated with both critical illness and hospitalization itself. During rehabilitation, vigilance, care and an individualized multimodal analgesic regimen are required, in order to improve the quality of surviving patients lives.

26-44

Authors: Qyli Z

Nosocomial infections continue to increase all over the world and remain a major cause of morbidity and mortality in hospitals. There are three elements required for the transmission of nosocomial infections: a reservoir of microbial agent, a susceptible host with a portal of entry receptive to the agent and a mode of transmission for the microbial agent. Microorganisms that cause nosocomial infections derive primarily from human sources1-3 , but inanimate environmental sources are implicated in transmission4. Human reservoirs include patients, healthcare personnel, household members and visitors5. People in hospitals are usually already in a ‘poor state of health’, impairing their defense against bacteria. Invasive devices impair natural lines of defense against pathogens and provide an easy route for infection. Patients already colonized at the time of admission are instantly put at greater risk when they undergo invasive procedures6. Environmental surfaces are contaminated with microbial agents and healthcare workers serve as a route of transmission of these infections to patients. Pathogens may also be transferred directly from contaminated surfaces to susceptible patients7-9. Studies have shown that techniques of cleaning or disinfection of the environment can reduce transmission of healthcare-associated pathogens10,11. The hospital environment, especially surgical wards plays an important role in the spread of hospital-associated infections. The operating theater is a complex environment that poses a high risk of infection for patients and health care workers who may easily contract diseases because of their long exposures to various risks, including chemical, physical and biological12-15. Nosocomial infection is a frequent and potentially lethal complication in obstetrics for women and babies. Disinfection strategy, guidelines for infection prevention and control should be established in each obstetrics unit to prevent nosocomial infections16,17. This study aimed to make an overview for the microbial contamination of environments at the Surgery and Maternity Departments of the Regional Hospital of Korca, Albania. This hospital has a capacity of 510 beds with an average of 70 daily admissions. Surgery Department consists of the operating rooms, surgery intensive care unit and the rooms of the patients. Maternity Department consists of the obstetric ward, gynecologic ward, neonatology ward and the room of the patients.

62-69

Authors: Papachristou D, Aslanidis Th.

West Nile virus is an RNA virus, member of the Japanese encephalitis serogroup of the genus Flavivirus, family Flaviviridae. First isolated in 1937, the virus has re-emerged after giving several outbreaks after the 1990 both in Europe and North America. Though severe neurological infection is only 1% of the total cases, mortality can reach 14% after CNS involvement. The present case report describes a case of WNV encephalitis with concomitant acute flaccid paralysis.

2-4

Authors: Aidoni Z, Primikiri S, Trifonidou H, Papakonstantinou P, Veroniki F, Geka E

Editorial

13-20

Authors: Bersot C.D.A, Pereira J.E.G, Aslanidis Th.

Coronaviruses are a large family of viruses that cause illnesses ranging from the common cold to more severe diseases. SARS-CoV-2 is a new virus that has not been previously identified in humans. Patients with SARS-CoV-2 commonly develop acute respiratory distress syndrome (ARDS), myocardial injury, ventricular arrhythmias, and shock, all of which increase their risk of cardiac arrest. The main objective of this brief review is to raise the discussion on the possible indication of cardiopulmonary resuscitation in a patient with SARS-CoV-2 in prone position as a way to save time, since the entire process of decubitus change is complex and often slow, due to the number of devices used in these patients, such as catheters, infusion pumps and monitors. In addition to a price of high demand for stressed human resources

32-34

Authors: Savoulidou S, Aslanidis Th

Nasogastric tube is commonly used for administration of nutrition or medication in hospital wards and Intensive Care Units. However, its use is not without complications.In the present paper, a case report of nasogastric tube breakage is presented.