The Greek e-journal of Perioperative Medicine

6-12

Authors: Tzima M, Katsanoulas K, Bilali P,Panteleou K, Zemou S, Georgopoulou E,Katsika E

Caesarean section delivery isamong the commonest surgical procedures in our hospital. During an ESRA Hellas descriptive survey, conducted between March 1stand August 31st2016, we decided to extend data collection with further enquiries, concerning the type and dosage of local anaesthetics, technical aspects, anaesthetic complications and their management, as well as neonate’s Apgar score. In comparison to the national survey, the percentage of regional over general anaesthesia (69.2%, 30.8% respectively) was by far exceeded in our department (93%, 7% respectively) with single shot spinal anaesthesia being the most popular technique (96%) as compared to the national level (44.3%).Interestingly, the percentage of combined spinal-epidural anaesthesia in our department was extremely lowcompared to Athens and nationwide. The commonest complication after regional anaesthesia was inadequate level of anaesthesia (4%) while no accidental dural puncture was noted. Post-partum hemorrhage occurred in 2%. Neonates’ general condition was very good. In a low human resources environment, due to personnel shortage, as worsened after the recent financial crisis, we strive to maintain a high-standard environment for the parturients of Northern Greece

20-24

Authors: Karakosta P, Aslanidis T, Thoma G, Agaliadou-Dioritou O

Intravesical bacillus Calmette-Guerin (BCG)therapy, recommended for superficial bladder tumors, triggers side effects in fewer than 5% of patients. Yet, when encountered, high level of suspition and early detection is essential for their succesfull management. In the present article, we present a case of severe sepsis and Steven Johnson syndrome in a male patient afterintravesical BCG instillation.

12-30

Authors: Tsiapakidou S, Fyntanidou B, Amaniti E, Kekkeri E, Papakostantinou P, Aggou M, Fortounis K, Grosomanidis V

Codes of ethics are considered as indispensable parameters of every aspect of medical care. When performing cardiopulmonary resuscitation (CPR) ethical issues become even more important since cardiac arrest (CA) is directly related to death. The aim of this study was to record personal opinions and everyday clinical practice approaches of healthcare professionals (HCPs) regarding ethical issues related to CPR. HCPs answered a questionnaire consisting of 30 questions related to ethical issues in CPR on a voluntary basis. The study included 195 HCPs (88♂& 107♀). Out of the 195 HCPs, 95 were physicians, 71 nurses and 29 paramedics. 49 HCPs (25.1%) worked in the prehospital setting (EMS or Healthcare Centers) and 147 (74.9%) in hospitals. 153 HCPs (78.5%) had previously taken certified resuscitation training courses (CPR-AED, ILS, ALS) and 189 HCPs (96.9%) had participated in resuscitation attempts .Half of them, namely 98 out of 195 (50.2%) believe that CPR should be performed in every case of CA. 112 HCPs (57,4%) reported that this is the common practice in their working environment, whereas 136 (69.7%) stated that there are cases that this approach is not applied. In 68.2% of the cases, physicians make the decision not to attempt CPR, whereas in 25.1% it is a team decision. However, more than half of the HCPs (56.4%) believe that physicians should make that decision. Parameters which should be taken into account when making the decision not to attempt CPR are: preexisting end stage diseases, age of the CA victim, previous functional status and presumed interval between collapse and initiation of CPR. Most of the HCPs, 160 out of 195 (82.1%), do not know the term DNAR, whereas half of them, 105 out of 195 (53.8%), are unaware of the Greek legal system’s position to DNAR orders. 109 HCPs (55.9%) believe that relatives should be involved in the decision making process not to attempt CPR and 166 HCPs (85.1%) think that patient’s past wishes should be taken into consideration.101 HCPs have performed CPR in front of family members of the CA victim but only 43 (22%) believe that relatives should be present during CPR. The decision of discontinuation of CPR in most of the cases is made by physicians (76,4%), in just a few (2.56%) by paramedics and in some it is a team decision (21%). According to their beliefs, decision to terminate CPR should be guided by duration of CPR attempt, absence of reversible relative causes, not gaining ROSC and anticipated prognosis. 112 HCPs (57.4%) are aware of the term Medical Futility. However, 174 HCPs (89.2%) perform CPR even though they know that the attempt is futile and 177 (90.7%) reported that CPR is performed in their working environment even in futile cases. According to the questionnaire, reasons for this practice are: moral sense (78HCPs-40%), certainty of performing the correct health action (67HCPs-34.3%) and fear of legal consequences (62HCPs-31.8%). Finally, 94 HCPs (48.2%) reported that the quality and duration of CPR attempt is the same independent of its obvious futility. Our results do not only reflect Greek reality but also underline the importance of multifactorial approach, introduce all challenging ethical dilemmas and reveal the inadequate education in ethical issues of resuscitation.

37-44

Authors: Karakosta P, Aslanidis Th,Voudouris A, Agaliadou-Dioritou U

Though metformin is considered as first choice drug in type II diabetes, clinicians should be alert both for presence of potential contraindications to its use and to possible adverse reactions. Bad therapy compliance along and/or concomitant comorbidities may lead to serious toxicity. We hereby describe a case of extreme lactic acidosis- associated with metformin therapy- in an elder woman, managed with Continuous Renal Replacement Therapy in Intensive Care Unit environment. Short review of the literature about the place of renal replacement therapy in such cases is also discussed.

2-12

Authors: Massa E, Agapakis D, Kotsamidi J,Mouloudi E

Patients discharging the Intensive Care Unit (ICU) still need a high level of care because of the severity of their disease. In fact, they have an increased risk for readmission to the ICU. Moreover, urgent readmissions to the ICU are a widely used tool to assessment the quality of Health Care services. Although a lot of efforts are being made to reduce them, these adverse events still exist. It is noted that readmitted patients to the ICU have a much poorer prognosis, as its mortality rates are six times higher, and also have eleven times higher probability to die in hospital compared with other hospitalized patients. Recent studies and meta-analyses show that the frequency of readmissions and the outcome of these patients have not changed significantly last years. Although the causes of such readmissions as well as the specific characteristics of these patients have been examined there is not yet a clear conclusion. Also, there are only a few studies underlining the need for new health services providing a higher care for patients discharging the ICU. Future research should focus on identifying modifiable risk factors of patients who need readmission to the ICU as well as the role of health services to reduce the incidence and outcomes of this adverse event

22-38

Authors: Dalakakis I, Fyntanidou B, Amaniti A, Kapanidis K, Lolakos K, ProvitsakiCh, Tsakiridou Ch, Grosomanidis V..

Induction of anesthesia can be accomplished with intravenous or inhalational anesthetic agents, which have both desired and side effects. The aim of this study was to record, investigate and compare the hemodynamic profile of five different induction anesthetic agents in patients undergoing major vascular surgery. One hundred and fifty patients, who were scheduled for major vascular surgery, were randomly assigned into five groups according to the anesthetic agent that was used for anesthesia induction. The five agents used for anesthesia induction were: propofol [2mg/kg], thiopental [3mg/kg], etomidate [0.3mg/kg], midazolam [0.2mg/kg] and diazepam [0.3mg/kg]. Before induction of anesthesia patients were administered Ringer lactate to replace volume deficit due to preoperative fasting. Besides standard intraoperative monitoring, an arterial catheter and a pulmonary artery catheter were placed in all patients before anesthesia induction. Study parameters were either measured or calculated via algorithms and included: heart rate [HR], systolic, diastolic and mean systemic arterial blood pressure [SAPs, SAPd, SAPm], central venous pressure [CVP], right ventricle systolic and diastolic pressure [RVPs, RVPd], systolic, diastolic and mean pulmonary arterial pressure [PAPs, PAPd, PAPm], pulmonary artery occlusion pressure [PAOP], stroke volume [SV], cardiac output [CO], systemic and pulmonary vascular resistance [SVR, PVR]. Data were recorded before induction of anesthesia and 10min after intubation and initiation of mechanical ventilation. Data were compared both between groups and within groups for the two different phases of the study. There was no statistically significant difference between the groups in any of the recorded parameters at any phase of the study. On the contrary, comparison of the two study phases within groups revealed statistically significant differences in most of the recorded study parameters without any relation to the used anesthetic induction agent. HR, SAPs, SAPd, SAPm, SV and CO decreased statistically significant after anesthesia induction in all five groups. In contrast to that, CVP, RVPs, RVPd, PAPs, PAPd, PAPm and PAOP increased after anesthesia induction and initiation of mechanical ventilation. Administration of induction anesthetic agents and increase of intrathoracic pressures caused by initiation of mechanical ventilation had negative effects on patients hemodynamics, which however were not detrimental and cardiovascular stability was maintained in all patients during the study. Despite contradictory literature data, our study did not reveal any statistically significant difference between the five different anesthetic agents used for induction with regard to their hemodynamic effects. Replacement of volume deficit before induction of anesthesia, application of small tidal volumes and avoidance of high PEEP levels decreased any of the negative hemodynamic effects of anesthesia medications and mechanical ventilation. Based on the results of this study, it seems that in normovolemic patients, induction of anesthesia can be safe and without any significant hemodynamic effects regardless of the anesthetic agent used.

2-17

Authors: Katsanoulas K, Zemou S, Tzima M, Katsika E.

Clinical management of acute severe bleeding in the perioperative setting is one of the major challenges for an anesthetic team. The dynamic nature of bleeding calls for rapid diagnosis and immediate interventions. Trauma induced coagulopathy and/or perioperative coagulopathy management is crucial for successful and life saving interventions, involving blood and blood product transfusions in an individualized and rationalized manner. Traditional coagulopathy monitoring using bleeding times offers very little in prediction and guidance during severe bleeding. They are mostly designed for stable patients under anticoagulant treatments and their very long turnaround time renders them impractical for clinical use in this setting. In contrast, viscoelastic devices are designed to assess whole-blood clotting kinetics and whole-blood clot strength and better reflect the interaction between pro- and anti-coagulants, pro- and anti-fibrinolytic factors, and platelets. The most notable advance in haemostatic management using viscoelastic testing is a fibrin-specific clot assessment. The system uses a combination of assays to characterize the coagulation profile for obtaining more detailed information about haemostasis and suggests the cause of the observed coagulopathy. The article offers a thorough and concise presentation of both traditional and viscoelastic methods and techniques in use during severe haemorrhage, followed by a literature review on the use of viscoelastic haemostatic monitoring in different clinical settings.

38-44

Authors: Kotsovolis G, Hatzopoulos E, Trikoupi A, Vasilakos D,Goutziomitrou E, Bratzou Ch.

In 2014, the European Society of Cardiology and European Society of Anaesthesiology published guidelines on preoperative assessment and management of patients scheduled for non-cardiac surgery. Compliance with these guidelines has not been evaluated in Greece. The main objective was to evaluate the level of compliance with the published recommendations. A retrospective, observational study was designed. The status 1–4 who underwent scheduled non-cardiac surgery between February 2016 and April 2016 in five tertiary hospitals were reviewed. Patients treated in intensive care units were excluded. Primary outcomes were the rates of compliance with the published recommendations for preoperative testing, continuation or not of medication and overall compliance. The secondary outcome measure was the time required to perform unnecessary preoperative investigations. 3197 (63.8%) preoperative electrocardiograms, 522 (83.8%) cardiac ultrasonographic imaging procedures, and 55 (93.2%) non-invasive imaging stress tests should not have been performed. Only 101 (30.3%) and 4 (6%) patients who should or could have been evaluated by cardiac ultrasonography or a non-invasive stress test, respectively, underwent the recommended tests. None of the 1055 patients who should have discontinued angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for hypertension did so; 31 (53.4%) patients with known systolic heart failure were not taking these medications as recommended. Only 27.3% of patients were being managed exactly as recommended. The 2014 guidelines for preoperative management of non-cardiac surgery patients are not being followed appropriately by hospitals in Greece.

55-59

Authors: Aslanidis Th, Grosomanidis V, Karakoulas K, Chatzisotiriou A

The case of a 33y old man is presented, who after a car accident, was transferred to the ED with a right hip dislocation and slightly obtunded but in a stable hemodynamic condition. After an emergent CT scan, a thoracic aortic rupture along with intestine rupture and retroperitoneal hematoma were noted. The patient was administered 1 g tranexamic acid (TXA) and 1 g fibrinogen concentrate (FC) preoperatively and then was transferred to the OR, where primarily, under monitored anesthetic care (MAC) the aortic trauma was restored intraluminally and then, under general anesthesia, he underwent laparotomy and hip dislocation reduction. During operation, no diffuse bleeding was noted, nor was any transfusion of blood or blood product necessary. After a short ICU stay the patient was discharged in good general health state. The aim of this case report is to present a case of traumatic aortic rupture bleeding, effectively managed with prophylactic tranexamic acid (TXA) and fibrinogen concentrate (FC) administration without need of any kind of transfusion.

3-16

Authors: Passakiotou M.

Europe is currently experiencing an unprecedented influx of refugees, asylum seekers and other migrants. More than 1.5 million people arrived in the European Union (EU) and European Economic Area (EEA) in 2015, fleeing countries affected by war, conflict or economic crisis. Member States are increasingly faced with the need to address the public health consequences of this massive arrival of migrants from various parts of the world, which puts national health systems under pressure. The migrant and refugee crisis in Europe has reached a critical point. The great majority of migrants and refugees are in a good physical condition; however, many are challenged with medical and mental problems, social isolation and economic devastation. There are different migrant groups with different rights to access of care. Many European countries are experiencing an increased wave of migrants and refugees and should consider therefore assessing their overall preparedness and response capacity for the management of the disease burden in this population which should be made on the actual migration flows, global disease patterns and consequent needs. Public health interventions in refugee camp settings will not only benefit migrants and refugees at individual level but also assist their integration in to the new home countries. In particular, it is important to consider the economic benefit of early interventions. Intersectoral and international collaboration is important to meet the heterogeneous needs of these populations which could foster integration. Providing newly arrived migrants and refugees a more systematic health-reception, based on a holistic approach by a multidisciplinary team, will not only benefit migrants and refugees but also will protect the public health of host countries. European Member States are facing a challenge to provide accessible and effective health care services for immigrants. It remains unclear how best to achieve this and what characterizes good practice in increasingly multicultural societies across Europe. Although local political debate, level of immigration and the nature of local health care systems influenced the selection and rating of factors within each country, there was a broad European consensus on most factors. Yet, discordance remained both within countries, e.g. on the need for prioritizing cultural differences, and between countries, e.g. on the need for more consistent governance of health care services for immigrants. Experts across Europe asserted the right to culturally sensitive health care for all immigrants. There is a broad consensus among experts about the major principles of good practice that need to be implemented across Europe. However, there also is some disagreement both within and between countries on specific issues that require further research and debate.

36-49

Authors: Margaritis A, Patsouras D, Tsigaridas N, Rammos A, Bolosi M, Ygropoulou O, Tzimas P, Papadopoulos G.

The aim of this study was to determine how low and moderate levels of PEEP affect right ventricular structure and function. The study involved 14 patients under mechanical ventilation (pressure controlled). To perform the study, we used transesophageal echocardiography (M-mode, two-dimensional,tissue Doppler) and 10 parameters were recorded. Measurements were performed initially with PEEP 0 cmΗ2Ο, then 10 minutes after applying PEEP 5cmΗ2Ο and 10 minutes after applying PEEP 10cmΗ2Ο. After applying PEEP 5 cmH2O, there was no statistically significant change observed in any parameter. In contrast, after the application of PEEP 10cmH2O, significant changes in most parameters were recorded: St changed from 10,86±3,8 cm/sec (mean±SD) at ΡΕΕΡ 0 cmH2O to 8,7±2,9 at PEEP 10 cmH2O, TAPSE changed from 2,876±0,643cm to 2,385±0,556cm, IVA from 2,2692±0,93m/sec2 to 2,8536±1,628m/sec2, ΕΤ from 259,27±17,47 msec to 229,34±31,22msec,EDA from 21,372±5,01cm2 to 18,87±4,15cm2, left ventricular eccentricity index at end-diastole from 0,9±0,07 to 0,99±0,08. After applying PEEP 10cmH2O, a trend towards an increase in MPI index of right ventricle and a decline in ESA of the right ventricle were recorded. With respect to other parameters no statistically significant differences were recorded. After applying ΡΕΕΡ=5cmH2O there is no significant change noted in the overall structure and function of right heart. After applying ΡΕΕΡ=10cmH2O changes were recorded in the structure and function of right ventricle caused mainly by the reduction of preload and less by the augmentation of afterload.

67-70

Authors: Karakosta P, Aslanidis T

Central venous catheters (CVC) are an extremely usefull tool in clinical medicine. Yet, its placement and use is not without complication. In the present paper, a case report of Central venous catheter malposition is presented.