The Greek e-journal of Perioperative Medicine

2-15

Authors: Volakli E, Sdougka M, Mantzafleri PE, Tsonidis Ch , Kontopoulos E, Tsikoulas I

The goal of of the present study is to investigate short-term and long-term functional outcome of a 8-bed, multidisciplinary pediatric intensive care unit (PICU) of a general hospital 300 PICU patients were enrolled prospectively in this observational cohort study. Functional outcome was evaluated through Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC) scales at admission (baseline), at PICU and hospital discharge, at 3 and 6 months, and at 1 and 2 years. Delta DPCPC and DPOPC alterations at discharge were related to major diagnostic categories and 2-year survival.Baseline PCPC and POPC scores were normal in 67% and 58.7% of study population, mild disability were recorded in 17.3% and 14.7%, moderate disability at 8% and 14%, severe disability at 4.3% and 9.3% and coma at 3.3% and 3.3%, respectively. At two years, normal PCPC and POPC scores were found in 66% and 47% of patients, mild disability in 17.3% and 30.5%, moderate disability in 9.5% and 13.6%, severe disability in 2.9% and 4.9% and coma in 4.1% and 4.1%, accordingly. Two years after discharge patients reached their PCPC baseline categories but lacked behind in POPC categories (p=0.001). Best functional outcome at discharge was recorded in respiratory and postoperative patients followed by cardiovascular, neurologic and trauma patients. Statistically significant differences were found in 2-year survival according to DPCPC [χ2 (2)=77.77, p<0.001] and DPOPC categories [χ2 (2)=44.66, p<0.001]. In conclusion, we found that two years following PICU discharge functional outcome parameters approached their preadmission values. Therefore, this chosen time period seemed to be adequate for studying long-term outcome of pediatric intensive care. Long-term PICU survivors had satisfactory PCPC (92.8%) and POPC (91.1%) categories to live an independent life. The impact of critical illness was greater on overall performance than in cognitive function.

31-37

Authors: Charitidou S, Aslanidis Th, Moutsianos G, Balaouras D, Mameletzi S.

The Fontan procedure and its modifications is the definitive therapy for a number of congenital heart diseases. Anesthesia for semi-elective Caeserian section in a pregnant woman with a history of such surgery history can be a real challenge due to probability of high perioperative morbidity and mortality. We present the anesthetic management of a young parturient with a history of a partially repaired complex cyanotic congenital heart disease and perform a literature review.

46-50

Authors: Mouloudi E, Papadopoulos S, Massa E, Giasnetsova T, Theodoridou Th, Anastasiou A, Fouzas I, Tsonidis Ch, Papanikolaou V, Gritsi - Gerogianni N

Neurologic complications after liver transplantation are quite common, with central pontine myelinolysis (CPM) being a rare but fatal complication. In this report, we describe the case of female liver transplant recipient who developed CPM after orthotopic liver transplantation (OLT).A 62-year old woman was admitted to the ICU for postoperative recovery after OLT. The procedure was described as uneventful. The patient had a history of decompensated cirrhosis, tension ascites, class I hepatic encephalopathy and chronic hyponatremia which necessitated repeated hospitalizations in the year prior to transplantation.The patient was unable to be weaned from ventilator support and did not show an improvement in mental status (GCS=5) despite the cessation of sedation. After neurologic consultation, a brain MRI was performed which showed evidence of CPM in the pons. Despite supportive therapy, the patient did not show an improvement of mental status and after a 55-day hospitalization in the ICU she died from septic complications.The etiology of CPM is multifactorial, with liver transplant recipients being at an increased risk. Supportive treatment is the standard of care, and there are not enough evidence supporting other types of treatment.

2-12

Authors: Petsas D, Griffiths R

Fractures of the proximal femur are of the most frequent, especially in elderly patients. The increased frequency of these fractures highlights the need for effective management of those patients and the impact of these fractures regarding the cost to the national health system. The effects of pain in elderly patients is extremely aggravating, frequently leading to mental (confusion, delirium) and physical (cardiovascular) deterioration and complications. The pain management of these patients in the emergency department (ED) with intravenous administered analgesics might complicate the status of these patients. The use of non-steroidal anti-inflammatory drugs (NSAID’s) might increase the risk of gastric ulceration, gastric haemorrhage and coronary syndromes, while the use of IV opioids– especially in elderly-incorporates the risk of respiratory depression, delirium,hypotension and constipation. The pain management of these patients with the use of fascia iliaca block applied in ED, or even in a prehospital setting from doctors of various specialties, paramedics or nurses seems to gain acceptance because of its steep learning curve, the simple technique, the high success rate and the low rate of significant complications

36-48

Authors: Vrigga M, Papagiannopoulou P, Ntritsou V, Isaakidis A , Chatziiokimidis Ch, Kostoglou Ch, Zachariadou Ch

The aim of this study was to compare the combinati on of oral tramadol and midazolam to oral mi- dazolam alone, in children undergoing adenotonsillectom y, as an oral premedication, regarding also sedation and postoperative pain relief. Sixty children selected for elective adenotonsillectomy were enrolled in this randomized, controlled prospec tive study. Patients were randomly allocated into two groups. Group M (n=30) received 0.5 mg.kg -1 oral midazolam and group MT (n=30) received 0.2 mg.kg -1 oral midazolam with 1 mg.kg -1 oral tramadol as a premed ication 30min preoperatively. Standard general anesthesia technique was used. A 5 points-sedation score (1 asleep to 5 agitated) on arrival to the operating room, a 3 points-acceptance score of separation from the parents and a 3 points-mask cooperation score at induction of anesthes ia (1 easy to 3 markedly resistant) were used. Aldrete score, extubation time and intraoperatively consumption of remifentanil were also recorded. Pain intensity was assessed using a modification of the Hannallah pain score scale at 30min, 6h and 24h postoperatively. If pain score was higher than 3, additional anal gesics were provided. Cumula- tive analgesic consumption in 24hrs was also noted. A satisfactory le vel of sedation scores were re- corded in both groups. Group MT offered significantly more children in an awake, calm and quiet state, who were easily separated from th eir parents. The parental separation scores did not differ statistically significant between groups. The mask acceptance was statistic ally significant easier in group MT, while chil- dren in midazolam group (group M) were statistically significant re sistant compared to children in group MT. Pain and modified Aldrete scores were comparable between groups. The amount of re- mifentanil consumed intraoperatively was statisti cally significant lower in group MT. Postoperative analgesic consumption was lower in group MT comp ared to group M but with no statistic al signifi- cance. Adding oral tramadol to midazolam as a premedication in children provides good quality of sedation and decreases periope rative analgesic requirement s following adenotonsillectomy.

54-58

Authors: Stamatakis E, Aroni F, Loukeri A, Valsamidis D

Intrathecal drug administration extends beyond the purposes of anaesthesia, to therapeutic applications. Here, we describe the case of a patient with severe Systemic Lupus Erythematosus having affected multiple organs and had a meningococcal infection. She was treated with intrathecal antibiotic therapy resulting in a successful outcome.

2-27

Authors: Koraki E, Giannaki Ch, Andreopoulos K, Trikoupi A

Effective postoperative analgesia in geriatric patients is both challenging and rewarding. Inadequate pain control after surgery is associated with adverse outcomes in the older patient. This review will attempt to describe the difficulty with assessment of pain and variations in pain experience of elderly patients. Physiological changes related to aging need to be also carefully considered,because aging is individualized and progressive.Pharmacokinetic and pharmacodynamic changes in geriatric patients, the higher incidence of co-morbidities and concurrent use of other drugs, must be carefully adjusted to suit each geriatric patient, concerning postoperative pain management. Medication for postoperative pain will be discussed. Unfortunately, many medications have not been studied well in the older population. Non-pharmacological approaches to postoperative pain management will not be discussed, although this would be an interesting topic for further discussion

39-51

Authors: Theodosiadis P, Grosomanidis V, Hatzibaloglou A, Fyntanidou B, Kotso E, Oloktsidou E, Skourtis Ch

Factors affecting cardiac function in dialysis patients include arterial blood pressure, anemia, intra-vascular volume and the arteriovenous fistula (AVF). We investigated the acute and chronic effects of basilic vein transposition (mean upper arm brachial artery basilic vein anastomosis) on both the cardiovascular system and the oxygen status. Sixteen patients with end stage renal failure were enrolled in this study. Patients with heart failure,pericardial effusion or valvular heart disease were not included in the study. Echocardiography (preoperatively and six months after, stages 1 and 2 respectively) and a Swan-Ganz catheter(perio-peratively) were used to assess the hemodynamic status during the phases of AVF construction. Flow measurements were made in the parts of the AVF system before, during and after the construction of the AVF.Moreover, at the same time phases blood sampling from the arterial line and the pulmonary artery catheter was performed, in order to assess oxygen and acid-base status. Cardiac output, cardiac index, stroke volume, stroke volume index, left ventricular stroke work increased statistically significant 20 and 30min after the AVF construction and they returned to baseline at 40min after the procedure. On the contrary, systemic vascular resistance decreased statistically significant 20 and 30min after the operation and they remained decreased for the whole study period. No other differences were recorded regarding the hemodynamic, oxygen and acid-base status. As far as the echocardiographical findings are concerned, ejection fraction showed a tendency to increase but not significantly in contrast to the inter-ventricular septum which increased statistically significant in both systole and diastole (p<0.01). Posterior wall thickness decreased minimally in both systole and diastole. Regarding the AVF system diameters, there were no changes recorded during the study. Basilic vein transposition in selected patients provides a well functioning AV fistula and is not an appreciable cause of circulatory or pulmonary congestion for at least a period of six months.

64-71

Authors: Theodorou E , Georgopoulou S, Sarakatsianou Ch , Tzovaras G

The aim of this case report is to demonstrate the efficacy and safety of Continuous Spinal Anesthesia (CSA) in an elderly patient with severe Chronic Obstructive Pulmonary Disease(COPD), who was scheduled for elective laparoscopic cholecystectomy . CSA can be used to provide a sufficient block in order to allow laparoscopic chol ecystectomy to be performed even in patients with severely abnormal respiratory function . Safety,efficacy and a decreased need for postoperative analgesia render this approach a valid option for patients with symptomatic gallstone disease,who are poor candidates for general anesthesia due to cardiorespiratory or airway problems as well as for patients with other contraindications for general anesthesia.

2-21

Authors: Korfiotis D, Arvaniti A, Pneumatikos I

Delirium, a serious and common manifestation of brain dysfunction in critically ill patients gained great attention over the last decade. Important risk factors such as use of benzodiazepines, coma, preexisting cognitive impairment, alcoholism and high severity of illness at ICU admission were i-dentified. Screening tools like the CAM-ICU and the ICDSC were extensively validated in many different ICU patient populations and are recommended for routine monitoring in everyday practice. Sedation with novel sedatives such as dexmedetomidine, implementation of non pharma-ceutical, preventive interventions and early mobilization of patients may reduce the incidence of this syndrome. The role of haloperidol and atypical antipsychotics in the prevention and treatment of ICU delirium is still under investigation.

31-43

Authors: Volakli Ε, Mantzafleri PE, Sdougka M

The purpose of this study was to investigate the performance of the Pediatric Risk of Mortality (PRISM III–24) in a Greek pediatric intensive care unit (PICU). We prospectively followed 300 PICU patients in an observational cohort study. PRISM III-24 performance was assessed in the whole population and in 4 preselected groups (infants, patients with length of PICU stay > 4 days, patients with co-morbidities, ventilated patients) with standard discrimination and calibration methods. Efficiency (on admission) was defined as admission of patients with mortality risk >1%, while effectiveness was determined as standardized mortality ratio (SMR). The area under the receiver operating curve (AUC) showed good discrimination of PRISM III-24 score (AUC 0.892, 95%CI 0.821-0.963) and PRISM III-24 predictive model (AUC 0.900, 95%CI 0.836-0.964). Hosmer-Lemeshow goodness-of-fit test showed good calibration of PRISM III-24 score (χ2 (8) =1.716, p = =0.989) and PRISM III-24 predictive model (χ2 (8) = 8.294, p = 0.405). Good performance was also found in the 4 preselected groups (AUC always>0.835, p values of the goodness-of-fit test always > 0.434). Efficiency was 76.7%, predicted PICU mortality was 11.1%, observed PICU mortality at discharge was 9.7%, and the SMR was 0.997 (95% CI 0.67-1.43). PRISM III-24 performed well in our population showing high discrimination and calibration capabilities. Mortality was higher than in relevant studies, probably due to case mix, patient characteristics and the distinct PICU policy of our country. However, efficiency and effectiveness we-re met by an international standard.

60-73

Authors: Iordanidou D, Ntavlis M , Kachri manidou P, Tholioti T , Vranas D , Damianidis E.

The goal of this observesional study was to evaluate the improvement of the visual view of the larynx in neonates, infants and children with difficult airway using the Airtraq® Optical Laryngoscope, compared with visual views of the first conventional laryngoscopy with Macintosh blade. We studied clinical and/or laryngoscopic manifestations of difficult airway and advanced airway management of nine consecutive pediatric patients (2 neonates, 5 infants and 2 children) admitted from 1/1/2011 to 31/08/2012 for elective/emergency surgery or diagnostic procedure under general anesthesia. All nine pediatric patients had successful airway management and intubation, using the Airtraq® Optical Laryngoscope after intubation failure following conventional laryngoscopy. The percentage of glottis opening (POGO), the laryngoscopy difficulty level according to Cormack-Lehane Grade and the Visual Analogue Scale (VAS) of easiness in recognizing the laryngeal structures improved using of Airtraq® Optical Laryngoscope at 2nd attempt. Airtraq® Optical Laryngoscope could be a first-line device for intubation of neonates, infants and children with difficult airway.

84-91

Authors: Ch asou E, Antipa E, Arvaniti M, Bekridelis A, Vasiliagou S, Antoniadou E.

Posterior Reversible Encephalopathy Syndrome (PRES) is a newly recognised clinical entity, accompanied by characteristic depicted findings. Disturbance of consciousness levels, spasms, vomiting and cortical blindness are the clinical manifestations of the syndrome, while the main causes are hypertensive encephalopathy, renal failure, immunosuppressive and cytotoxic drugs. PRES may be displayed with reversible damage (white matter edema), while if infarcts happen, damage is considered irreversible or neuronal. Early MRI and Diffusion-Weighted MRI (DW-MRI) provide instant information, directly related to a prognosis, as DW-MRI can separate the vasogenic edema from the cytotoxic one, which is accompanied by early infarcts.

2-6

Authors: Katsanoulas C

In the field of paediatric critical care, there is considerable uncertainty and variation in the area of analgesia and sedation in critically ill children. Consensus guidelines on sedation and analgesia in critically ill children are available since 2006, although clinical practice reveals variations both in pharmacological agents and regimens used. A patient at comfort, free of pain and able to communicate when required, constitutes the current, widely accepted clinical endpoint of analgosedation. Newer agents like remifentanil, which is now widely used in paediatric practice, allowing for the application of newer algorithms of proven efficacy. The introduction of newer analgosedation algorithms definitely presupposes the extended use of pain and comfort assessment, using several, more or less validated tools. The difficulty with children is that with the progress of age and developmental stage, different scales are proposed with varied degrees of difficulty in application. Directing treatment to specific and individualized goals through analgosedation algorithms will assure that the patient’s needs are met.

37-46

Authors: Nictari V, Diamantaki H, Stefanakis G, Bareka M, Papaioannou A

Mechanical ventilation can have adverse effects on pulmonary function. The present review focuses on what has recently emerged as one of the most serious potential complications of mechanical ventilation, ventilation-induced lung injury (VILI). For the purposes of this review, the forms of lung injury will be discussed according to the following headings: barotrauma, volutrauma, atelectrauma, and biotrauma.

66-82

Authors: Aslanidis Th, Charitidou S, Matiaki E, Bogiatzopoulos M, Dolzenko E, Georgopoulou E, Milonas A, Anagnostara E

The essential contribution of medical emergency teams (M.E.T) is to decrease the frequency of sudden deaths and the pointless transportation of patients in the intensive care units. The aim of the present study is to record the number and the type of emergency in-hospital calls, the clinical follow up and outcome, the departments and the staff of hospital that were covered by M.E.T (medical and/or nursing) that participated in them, the medications that were used, and the number of involved individuals per incident, as well as the type of monitoring and the fluids that were used. This study covered a 5 months period of emergency calls. The emergency teams created, covered 24 hours a day 16 hospital departments. The main providers in M.E.T were anaesthetists. The results were juxtaposed with the results of a previous period that a M.E.T. was activated in the same hospital. (351calls in total, presented in a an already published study) In the current study we recorded 160 calls in total. Monitoring included, SpO2, arterial pressure, number of breaths per minute and an estimation of neurologic condition according to the Glasgow scale or AVPU scale, as well as the examination of the pupils. In the present study, more invasive methods of monitoring were used. Only one individual was needed in 87 (54%) incidents. The medium time of his involvement with every patient and the medium number of persons of the team involved per call was the same as the previous study. Nevertheless, the higher incidence of favorable immediate outcome after inhospital cardiac arrest (38.2% vs 18.2%) which was recorded, along with the drop in the number of patients who needed to be transported to an intensive care unit, implies a better coordination between the different departments and the M.E.T. It also points at an improvement in the management of such incidents; thus a step up in the spread and implementation of appropriate clinical practice regarding intrahospital emergencies. Conclusions: The implementation of criteria as well as the institution and around the clock existence of organized teams for inhospital emergency medical response, facilitated the objective recognition of befalling crisis as well as the better and more systematic recording and management of such incidents.