The Greek e-journal of Perioperative Medicine

2-18

Authors: Pagaki E, Pagdatoglou K, Τsioka A, Koukoubani T, Efthimiadi A., Stavrothanasopoulou A, Kouloumoundri V, Siafi M, Papapostolou G, Bouga E, Pagouni E, Katsiakou Ch, Moriki S, Tasios Th, Katsi Ch, Ilioudi S, Tsigas A, Bairachtaris G, ParaforouTh.

After the implementation of Common Assessment Framework (CAF) – a useful quality tool – in the ICU of General Hospital of Trikala from 2012 up to 2015, we integrated the first cycle of self assessment and we present our results and conclusions of the past 3-year-period (2012- 2013 -2014). We analyzed CAF, FS- ICU 24, TISS-28 and Burn out syndrome questionnaires and medical indicators as Standardized mortality rate (SMR), Length of Stay (LOS), Standardized Resource Use (SRU), SMR/SRU, Therapeutic intervention scoring system (TISS-28), TISS-28/days of hospitalization, Nurse/Patient ratio, cost indicators and mortality. Analyzing the CAF questionnaire the score was 2.5-3.5, counting the indicator TISS- 28 we found an average value higher than 50,concerning the burn-out syndrome questionnaire it was found that 58.82% of the respondent employees working in the ICU had mild symptoms of the syndrome. We analyzed the true Level of ICU (TISS-28/days of hospitalization) with the Level of ICU (nurse /patient ratio) and we found that they were not alike. We found an increase of mortality rate and LOS (length of stay) during the period of 2011 –2015 but a gradual reduction of the SMR/SRU indicator (the whole period ≤ 1) and a decline of the average cost/ patient and the average cost/ day of hospitalization. We found that in some criteria of CAF questionnaire, programming and implementation of the action plan exists and in some other criteria there is also inspection. It was found that in all 8 hour shifts of the nurse personnel, the value was high mainly due to lack of personnel. We found that the work load of the nurse personnel in relation to the condition of the critically ill patients was heavier during the night shifts and the true Level of ICU (TISS-28/days of hospitalization) with the Level of ICU (nurse /patient ratio) were not alike, perhaps because the nurse/patient ratio doesn't include the critical state and the severity of the patient's illness. The cost of service declined. The gradual reduction of the SMR/SRU indicator (the hole period ≤ 1) means that our ICU is functional has a low mortality rate compared with the expected and the cost is still in good levels. At the end, we came up with useful conclusions concerning the quality of health service provided by our ICU and how we can further improve our weak points in order to become better.

24-38

Authors: Fyntanidou B, Veroniki F, Kolettas A, Ourailoglou V, Kotzampassi K, Theodosiadis P, Oloktsidou E, Karakoulas K, Grosomanidis V.

The interaction between increased Intra Abdominal Pressure (IAP) and Intrathoracic Pressure under different Positive End Expiratory Pressure (PEEP) levels is intriguing, since these two conditions coexist frequently in several clinical settings. The aim of our study was to investigate the interaction between different PEEP levels and increased IAP during laparoscopic cholecystectomy. In fifty two patients, who underwent scheduled laparoscopic cholecystectomy, cardiovascular parameters were determined by an Oesophageal Doppler Monitor device during two different time periods, before and after pneumoperitoneum, and under five conditions: (i) PEEP 0 cmH2O. (ii) PEEP 5cm H2O (iii) PEEP 10cm H2O (iv) PEEP 15cm H2O and (v) in the absence of PEEP or ventilation. Cardiac output and stroke volume showed a statistically significant decrease compared to the baseline value after the application of different PEEP levels, when there was no pneumoperitoneum (p<0.05). However, both parameters increased, when PEEP and pneumoperitoneum were applied together (p<0.001). Corrected flow time, peak flow velocity in the descending thoracic aorta and mean acceleration showed similar alterations but not at all PEEP levels. Finally, αt the no PEEP or ventilation phase, the negative effects of increased IAP on the cardiocirculatory function were predominant. According to these results, application of PEEP seems to counterbalance the negative hemodynamic effects of increased IAP. Moreover, it could also be concluded that ‘ideal’ PEEP level might be the one that borders the IAP level, since the best cardiac output and stroke volume values were reported at that point.

46-57

Authors: Gortsou D, Andronikou K, Kyrgia A, Mikropoulou M, Pappa S, Kamperis E, Schizas N, Rallis T,Gogakos A, Paliouras D, Barbetakis N.

During recent years the application of non invasive ventilation (NIV) has emerged as a central component of respiratory failure management, acute and chronic. Although the use of NIV in acute respiratory failure was initially meant to be given in critical care units, it is nowadays natural to provide it in other settings as well, provided that there are the necessary resources and expertise. NIV represents a viable alternative to endotracheal ventilation and despite most data refer to patients with chronic obstructive pulmonary disease; its indications are continuously expanding to cover more clinical scenarios. Randomized controlled studies are needed in order to provide sound evidence regarding optimal patient-ventilator interface, NIV duration and ventilation parameters in thoracic surgery patients.

3-14

Authors: Τsioka A, Pagaki E, Efthimiadi A., Pagdatoglou K, Koukoubani T, Stavrothanasopoulou A, Kouloumoundri V, Siafi M, Papapostolou G, Moriki Sp, Pagouni E, Papaspyrou M, Letsiou K, Ilioudi S, Paraforou Th

At 2012 the ICU of General Hospital of Trikala has registered as CAF user in the CAF database. With this quality management instrument, public sector organizations improve their performance by recognizing weaknesses and by promoting strong points. The purpose of using CAF protocols is to improve the quality of provided Health services. For the implementation of CAF we used specialized questionnaires such as: CAF questionnaire, family satisfaction (FS- ICU 24), questionnaire concerning nursing care (TISS – 28) and about fatique of personnel (Burn-out questionnaire). Also, indicators such as observations of mortality in relationship with the cost (SMR/SRU), Bacteraemias, V.A.P (Ventillation associated pneumonia), and the effectiveness of nurse project (Level of ICU) have been used. The design of CAF protocol implementation was adjusted, as structure, according to the data of our ICU. General Indicators concerning Public sector administration have been used but also specialized indicators concerning ICU output, mortality rate, infections and cost. Undergoing this project by using the CAF quality instrument the target is to identify fields were effective functioning was observed (strong points) and fields that need improvement (weak points). The purpose is, throughout self assesment evaluation but also with Bench-marking with other ICUs, to improve the provided health services from the ICU of General Hospital of Trikala.

25-35

Authors: Toulabi T, Kordestani-Moghadam P, Pournia Y

This research was designed to determine the appropriateness and applicability of the Patient Bill of Rights from the viewpoint of nurses in Lorestan University of Medical Sciences to identify barriers and provide operational solutions in 2012. This is a descriptive-analytical study. Out of 440 questionnaires delivered to the nurses, 294 were completed. The data collection tool was a questionnaire related to the five domains of the Patient Bill of Rights including right to receive appropriate services, right to receive appropriate and adequate information, right to choose and decide on health services freely, respecting patient privacy and observing the principle of confidentiality, and finally right to get access to effective complaint handling system. The mean scores for appropriateness (350.16±7.23) and applicability (282.57±54.22) of the Patient Bill of Rights were high. Shortage of work force, nurses and patients’ unawareness of the major barriers of application, provision of necessities for internalization, establishment of the committee of the Patient Bill of Rights, and paying attention to nurses’ rights were the solutions proposed. Enhancing stakeholder’ s awareness and providing necessities by managers can help in the operationalization of the Bill.

45-59

Authors: Changaei F, Simbar M, Irajpour A, Akbari S

Access to appropriate and high quality health care is one of the most important ways to reduce maternal and infant mortality. This study evaluates the quality of care during childbirth, the effective factors, and promoting strategies in Lorestan province, Iran. This research is a mixed explanatory study (i.e., quantitative and qualitative). The quantitative part is descriptive-analytic. The quality of 200 care processes during childbirth was assessed in the health centers of the province. The data were gathered through the checklists prepared according to the guidelines of the Iranian Ministry of Health. Statistical analysis was performed using SPSS software. In the qualitative part, the strategies for solving the problem were assessed through interviews with service providers, maternity administrators, and senior decision-making university officials. According to our results, the levels of care quality during childbirth were intermediate in all four phases. The lowest levels of quality in the first, second and third stages were associated with Leopold’s maneuver, hand washing and pulse control, respectively. Based on the interviews, the main reasons for the reduction of care quality include lack of staff’s motivation, overcrowding and shortage of nursing workforce, low attention of officials to the Department of Midwifery, and the high burden of writing in the maternity. To improve the quality of services, the authorities in Lorestan University of Medical Sciences propose strategies such as making some incentives for care promotion. Considering the quality of care during childbirth as intermediate in all four stages in the province and investigation of the reasons indicating the lack of sufficient incentive in midwives, it is recommended that strategies such as financial incentives, greater use of private sector to reduce public sector workload, quality increase and further use of in-service training to improve the quality of services be adopted

2-23

Authors: Nastou M, Geleve G, Trikoupi A

Pain is a disastrous manifestation of cancer that influences the patients’ quality of life, their fami-lies, and health care providers. It is a multidimensional symptom that includes the physical, psycho-social, emotional and spiritual character of the human organism. Despite the development of new analgesic drugs and updated guidelines, the pain management remains insufficient, and some pa-tients with mild to severe pain do not received adequate pain treatment. This insufficient manage-ment can be attributed to barriers related to health professionals, to the patients, and the health care system. Common professional barriers include the bad pain evaluation, the lack of knowledge and skills, and the doctors’ reluctance to prescribe opioids. The barriers related to the patient include cognitive factors, emotional factors, and the compliance with analgesic regimens. Barriers related to the health system, like the limited access to opioids, and limited availability of pain and palliative care experts, consist additional challenges, especially in poor countries. Given the multidimensional nature of cancer pain, and the multilevelbarriers involved, the effective pain management demands multimodal interventions from interscientific groups. Educational interventions to the patients and health professionals it is possible to improve the successof pain management.

41-57

Authors: Veroniki F, Ourailoglou V, Fyntanidou B, Tsotsolis N, Kotso E, Kyparissa M, Grosomanidis V

The occurrence of intraoperative oxygenation impairment is common even in healthy individuals and will vary depending on the patient and the type of surgery. The purpose of this study was to evaluate the incidence of oxygenation impairment in patients with normal lung function and to study the safety and efficacy of three different recruitment strategies. Out of a total number of 430 patients, 150 patients developed intraoperative oxygenation impairment, which was defined as the drop of PaO2/FiO2 ratio below 300. These 150 patients were randomly assigned into four study groups according to the recruitment strategy applied. Group A (N: 38): Application of three hyperinflations of the lungs at airway pressure 40cmH2O for 10 sec, followed by an increase in PEEP from 5 to 10cmH2O. Group B (N: 38): Increase in PEEP from 5 to 10cmH2O. Group C (N: 37): Application of three hyperinflations of the lungs at airway pressure 40cmH2O for 10 sec, without any PEEP alteration and Group D (N: 37): No maneuver. Measurements were taken at the phase of oxygenation deterioration and at 5, 15, 30, 45 and 60min after applying the maneuvers and also before extubation. From a total of 430 patients 150 developed oxygenation impairment (38.4%). The median onset time of the deterioration was 30min after intubation and mechanical ventilation. In group A the PaO2/FiO2 ratio increased significantly immediately after the maneuvers and remained elevated until extubation. In group B the PaO2/FiO2 ratio presented a gradual increase to significant levels before extubation. In group C, the instant post-maneuver increase of oxygenation was not sustained until extubation. Finally in group D a gradual decrease of the PaO2/FiO2 ratio was recorded until the end of surgery. According to the results of our study, one third of patients developed intraoperative oxygenation impairment approximately half an hour after intubation. The application of three hyperinflations of the lungs at an airway pressure of 40cmH2O for 10 sec, followed by an increase in PEEP from 5 to 10cmH2O proved to be the most effective treatment of impaired oxygenation.

71-81

Authors: Siopi V, Valasiou I, Papageorgiou E , Veliki N, Tzinevi M, Rallis Th, Gogakos A.S, Paliouras D, Asteriou Ch , Anisoglou S, Barbetakis N .

The objective of postoperative pain management after thoracotomy is the prevention of postoperative complications, the reduction of the length of hospital stay, the increase of the patient’s satisfaction and finally the resumption of the daily living’s normal activities. Thoracic surgery affects postoperative respiratory function, along with a high risk of developing postoperative pulmonary complications. Pain is a subjective experience. Postoperative pain management in thoracic surgery patients should be individually applied, based on a well-organized health care system that emphasizes consistent nursing education regarding proper pain management techniques, with an effective communication between the patient and members of the existing multidisciplinary team, especially the nursing staff.

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.