The Total Intra Venous Anesthesia Effect Versus Volatile Anesthesia, on Stress and Pain Levels, in Patients Undergoing Breast Reconstruction in Ambulatory Surgery Center Total Intra Venous Anesthesia Protocol and Stress Response.

AIM: To compare pain and stress response through cortisol and DHEA levels, implementing. Total intra venous anesthesia (TIVA) versus general anesthesia with volatile anesthetics (VOL). DESIGN: This is a prospective randomized correlation study with consecutive measurements. METHODS: In an ambulatory surgical center from October of 2019 to August of 2020, patients who underwent breast reconstruction with autologous fat grafting were randomized into 2 groups. Patients in the TIVA group (n = 23) received intravenous anesthesia and those in the VOL group (n = 23) received volatile anesthesia (desflurane). Demographic, anthropometric and clinical data were recorded. Arterial systolic (SP) and diastolic (DP) blood pressure, heart rate and oxygen saturation were recorded. Pain and stress levels were evaluated through salivary cortisol and DHEA levels at 4 different time points: T0) 1 hour before induction, T1) during the induction, T2) during anesthesia maintenance, and T3) in recovery phase. Statistical analysis was performed with SPSS 25.0 at significant level α = .05. FINDINGS: There were no statistically significant differences between the 2 groups regarding demographic features. Interestingly that there was a statistically significant difference in the vital sign monitoring where patients in the TIVA group reported with higher levels of SP(T2) and DP (T2), whilst DHEA (T1) levels was correlated positively with patient's age and cortisol (T1) levels and negatively with DP (T3). CONCLUSIONS: This study supports the use of TIVA as a safe and effective option for anesthesia in patients undergoing breast reconstruction with autologous fat grafting.

Effects of the Enhanced Recovery Program on the Recovery and Stress Response in Patients With Cancer Undergoing Pancreatoduodenectomy.

Aim the study was the comparison of enhanced recovery after surgery (ERAS) versus conventional care (CON) protocols in patients undergoing pancreatoduodenectomy with regard to pain intensity, emotional response (optimism/sadness/stress), and stress biomarker levels (adrenocorticotropopic hormone, cortisol). We conducted a prospective two-group randomized controlled study with repeated measures in 85 patients with cancer pancreatoduodenectomy. In the ERAS group (N = 44), the ERAS protocol was followed, compared with the CON group (N = 41). We assessed pain with the numeric rating scale and a behavioral scale (Critical Care Pain Observation Tool), emotional responses (numeric rating scale), and serum adrenocorticotropopic hormone and cortisol levels at three time points: T1, admission day; T2, day of surgery; and T3, discharge day (ERAS) or the fifth day of stay (CON). Data were analyzed by linear mixed modeling to account for repeated measurements. We observed decreased postoperative pain in ERAS patients after adjusting for confounders (p = .002) and a trend for less complications. No significant associations with stress/emotional responses were noted. Only age, but not protocol, appeared to have a significant effect on adrenocorticotropopic hormone levels despite a significant interaction with time toward increased adrenocorticotropopic hormone levels in the ERAS group. In conclusion, despite its fast track nature, ERAS is not associated with increased stress in patients undergoing pancreatoduodenectomy and is associated with decreased pain.

Factors Affecting Stress Levels in Hospitalized Patients after Implementation of Fast-Track Protocol in Hepatopancreatobiliary Surgery.

OBJECTIVE: The objective was to explore factors affecting stress levels in hospitalized patients after implementation of fast-track (FT) protocol in hepatopancreatobiliary surgery. METHODS: This was a prospective cross-sectional study, where 90 patients were included. Exploration of environmental postoperative stress levels was conducted by serum adrenocorticotropic hormone and cortisol levels, the Intensive Care Unit Environmental Stressor Scale, and three self-reported Numeric Analog Scale questions, with regard to emotional/stress level, specifically "How sad do you feel right now?" "How stressed do you feel right now?" and "How optimistic do you feel right now, about the future?" at 3 time points: (T1) Before surgery, (T2) the day of surgery, and (T3) the 3rd postoperative day. The trial profile is conformed according to the CONSORT guidelines. Statistical analysis was carried out by SPSS software version 22 (IBM SPSS software, Chicago, Illinois, USA) at a significance level of 0.05. RESULTS: Serum cortisol T2 levels were positively correlated with the day of removal the drainage tube (rho = 0.235, P = 0.027). Furthermore, serum cortisol T3 levels were positively correlated with age and body mass index and negatively with the day of drainage tube removal (rho = 0.231, P = 0.028, rho = 0.235, P = 0.026, and rho = -0.279, P = 0.008, respectively). CONCLUSIONS: The findings of this study highlight that after evaluation of stress levels; nurses could interfere and reduce stress levels, knowing the factors which cause the increased stress levels, after the implementation of FT protocols.

A Comparison of 2 Venous Puncture Sites for Peripheral Implanted Ports.

The use of peripheral implanted ports to administer parenteral nutrition in a number of patient cohorts is increasingly seen as a safe alternative to chest ports with equivalence in long-term outcomes. Two insertion sites on the upper arm were compared using the zone insertion method (ZIM), which was developed as an approach to optimize and reduce catheter-related exit site complications. The ZIM divides the medial upper arm into 3 main colors, red, green, and yellow, which are based on musculoskeletal, skin, and vessel characteristics. The optimal exit site is considered to be the green zone, the middle third of the upper arm. Thirty-five patients were allocated to vein puncture at the yellow/green zone (group A) and 35 patients at the yellow zone near the axilla (group B). All devices were implanted in the distal green zone. Successful peripheral port implantation was 91.4% (n = 35) for group A and 100.0% (n = 35) for group B (P = .07). No procedural or postprocedural complications were observed.

Peripherally inserted central catheter ports: A vascular access specialist's systematic approach.

Implanted ports are an important vascular access device for patients with malignancies requiring long-term chemotherapy. Peripherally placed ports are increasing in use as they are a safe, cost-effective alternative to chest-placed ports. Most peripheral ports can be placed bedside by specialist nurses in designated clinical areas rather than costly operating rooms or interventional radiology suites. Peripheral ports are considered less invasive compared with chest port placement because of reduced procedural risk. To enhance the success rate of peripheral port placement and minimize risks, we provide vascular access specialists with a systematic approach along with some technical advice tips and tricks to help avoid mechanical complications such as repeated puncture of the vein, excessive bleeding, thrombosis or skin dehiscence, as well as latent complications such as catheter migration and catheter-related blood stream infection.

Cross-Correlation Among Visual Analog, Observational, and Behavioral Pain Scales of Oncological Patients Undergoing Major Abdominal Surgery.

PURPOSE: To determine the perception of postoperative pain intensity between nurses and oncology patients undergoing major abdominal surgery. DESIGN: A prospective cross-correlation study with 173 oncology patients undergoing major abdominal surgery, such as hepatectomy or pancreatectomy. METHODS: Postoperative pain intensity was evaluated by clinical pain assessment tools such as critical-care pain observation tool (CPOT) and behavioral pain scale (BPS) recorded by the researcher, whereas the visual analog scale was completed by patients. Demographic and clinical data were recorded. FINDINGS: The Cronbach's α for CPOT and BPS was α = 0.738 for each. There was a significant correlation between CPOT and BPS (ρ = 0.796, P < .001), whereas the visual analog scale was correlated with CPOT and BPS (ρ = 0.351, P < .001 and ρ = 0.352, P < .001, respectively), showing that nurses did not underestimate patients' pain levels. CONCLUSIONS: The management of postoperative pain intensity after major abdominal surgery requires clinical comprehension by nurses to achieve the reduction or suppression of pain.

Fast-Track Recovery Program After Major Liver Resection: A Randomized Prospective Study.

The objective of this study was to compare fast-track (FT) recovery protocol with the conventional one in patients treated with major liver resection by evaluating perioperative morbidity, length of hospitalization, and readmission rate. Sixty-two patients suffering from malignant liver tumors were surgically treated from May 2012 to April 2014. After randomization, they were prospectively divided into two groups: Group A patients (n = 32) followed FT recovery protocol and Group B patients (n = 30) were treated with the conventional (CON) protocol. Postoperative morbidity, readmission rate, and median hospital stay in the two groups were studied. Fast-track protocol was associated with a decreased complication (25%, p = .002), whereas the risk of postoperative morbidity was 2.4 times higher in patients treated with the CON protocol (60%, p = .002). Readmission rate was not significantly different between the two groups (6.25%, p = .35). Age (p = .382) and body mass index (p = .818) were not a suspending factor for following the FT protocol. Overall length of stay (postoperative days) in the FT group was (mean ± SD) 5.75 ± .5 and in the CON group was 13.5 ± 6.7 (p < .001). Fast-track recovery protocol seems to be safe and particularly efficient in patients undergoing major liver resections.

Comparative Evaluation of Pain, Stress, Neuropeptide Y, ACTH, and Cortisol Levels Between a Conventional Postoperative Care Protocol and a Fast-Track Recovery Program in Patients Undergoing Major Abdominal Surgery.

BACKGROUND: Fast-track (FT) postoperative protocol in oncological patients after major abdominal surgery reduces complications and length of postoperative stay compared to the conventional (CON) protocol. However, stress and pain responses have not been compared between the two protocols. OBJECTIVES: To compare stress, pain, and related neuropeptidic responses (adrenocorticotropic hormone [ACTH], cortisol, and neuropeptide Y [NPY]) between FT and CON protocols. METHOD: A clinical trial with repeated measurements was conducted (May 2012 to May 2014) with a sample of 63 hepatectomized or pancreatectomized patients randomized into two groups: FT ( n = 29) or CON ( n = 34). Demographic and clinical data were collected, and pain (Visual Analog Scale [VAS] and Behavioral Pain Scale [BPS]) and stress responses (3 self-report questions) assessed. NPY, ACTH, and cortisol plasma levels were measured at T1 = day of admission, T2 = day of surgery, and T3 = prior to discharge. RESULTS: ACTHT1 and ACTHT2 levels were positively correlated with self-reported stress levels (ρ = .43 and ρ = .45, respectively, p < .05) in the FT group. NPY levels in the FT group were higher than those in the CON group at all time points ( p ≤ .004); this difference remained significant after adjusting for T1 levels through analysis of covariance for age, gender, and body mass index ( F = .003, F = .149, F = .015, respectively, p > .05). CONCLUSIONS: Neuropeptidic levels were higher in the FT group. Future research should evaluate this association further, as these biomarkers might serve as objective indicators of postoperative pain and stress.

Persistent left superior vena cava leads to catheter malposition during PICC Port placement.

INTRODUCTION: We present a case of peripherally inserted central catheter (PICC) port placement where the catheter had been malpositioned to the persistent left superior vena cava. METHODS: Despite the obvious elevation of the P-wave signaling proximity of the catheter tip to the sinus node, the catheter was not in the desired location within the superior vena cava or the right atrium, because of the presence of a persistent left superior vena cava. Computed tomography was used in order to locate the catheter. RESULTS: The catheter was located in the persistent left superior vena cava. CONCLUSIONS: Malpositioning of the catheter in the persistent left superior vena cava occurs in 0.3%-0.5% of patients. The catheter was subsequently removed.

First Peripherally Inserted Central Catheter Under Ultrasound Guidance in a Greek Intensive Care Unit: A New Role for Greek Perianesthesia Nurses.

We present a case of a 67-year-old Caucasian female who was admitted to the pulmonary clinic of a general hospital in Athens with fever and respiratory symptoms. A lung biopsy was ordered because a clinical diagnosis of interstitial lung disease was suspected. The patient was then hospitalized in the intensive care unit. Because of the fact that peripheral catheterization was impossible and the prospect of further long-term hospitalization, the patient was referred to a vascular access nursing team composed of perianesthesia nurses to advance a peripherally inserted central catheter and support the line during treatment. The peripherally inserted central catheter line was advanced with no complications, and the position of the catheter was checked using the electrocardiography method.

The impact of laparoscopic Nissen fundoplication on the long-term quality of life in patients with gastroesophageal reflux disease.

Laparoscopic Nissen fundoplication is now the most common surgical procedure for treatment of gastroesophageal reflux disease (GERD), offering promising long-term outcomes. Outcomes for 46 patients with GERD who underwent Nissen fundoplication during the last 5 years (November 2007-June 2012) were prospectively studied using a structured questionnaire that evaluated clinical symptom scores for heartburn, dysphagia, and satisfaction with clinical outcomes. Postoperative care of the patients including analgesia, median hospital stay, overall cost, and complications was also studied. Clinical follow-up data for 2 years after surgery were available for all 46 patients. Forty-two patients (91.3%) were satisfied with their quality of life and only eight patients (17.4%) continued to receive antacids after surgery. Dysphagia to solid and liquid occasionally appeared in 26.1% (N = 12) and 17.4% (N = 8) of patients, respectively. Laparoscopic Nissen fundoplication was an effective long-term treatment for GERD. The operation resulted in a significant reduction of symptoms and minimized the use of antacid drugs with a high degree of patient satisfaction. Although some patients may have returned to antacid treatment at late follow-up or continued to complain of mild discomfort, they were overall pleased with the outcome.

Posttraumatic transdiaphragmatic intercostal hernia: report of a case and review of the literature.

Intercostal hernias are rare, and usually occur following injuries of the thoracic wall. The scope of this report is to present a case of a 53-year-old obese patient that developed a transdiaphragmatic intercostal hernia. The patient presented with a palpable, sizeable, reducible mass in the right lateral thoracic wall, with evident bowel sounds in the area, 6 months after a motor-vehicle accident. On computed tomography (CT), the hernia sac contained part of the liver and part of the ascending colon. A surgical repair of the defect was performed, using a prosthetic patch. The patient's postoperative course was uneventful and she remains recurrence free at 12 months after surgery. Intercostal hernias should be suspected following high-impact injuries of the thoracic wall, and CT scans will facilitate the diagnosis of intercostal hernia. We consider the surgical repair of the defect, with placement of a prosthetic mesh, as the treatment of choice to ensure a favorable outcome.

Fast-track recovery after major liver and pancreatic resection from the nursing point of view.

Postoperative fast-track recovery protocols combine various methods to support immediate care of patients who undergo major surgery. These protocols include control of postoperative pain and early beginning of oral diet and mobilization. The combination of these approaches may reduce the rate of postoperative complications and facilitate hospital discharge. The aim of this study was to evaluate progress and parameters of fast-track recovery after major liver and pancreatic resection. A descriptive bibliographical review from 2001 to 2012 via electronic databases such as MEDLINE, PubMed, and Google Scholar was undertaken. Articles that focused on a fast-track protocol were studied. Reports focusing on the implementation of a fast-track protocol in the postoperative recovery of patients after major hepatectomy or pancreatectomy were selected. Fast-track protocols may be applicable to patients recovering after major liver or pancreatic resection. Future research should be focused on particular parameters of the fast-track protocol separately.

Liver function tests in viremic and nonviremic chronic hepatitis B virus-infected pregnant women: importance of alanine aminotransferase/sodium ratio.

The major risk factor of perinatal transmission of Hepatitis B virus (HBV) infection is the level of maternal HBV-deoxyribonucleic acid (DNA) during the third trimester of pregnancy. The primary aim of this study was to evaluate the hematological and biochemical status in Hepatitis B e-antigen (HBeAg)-negative chronic HBV-infected pregnant women and to correlate the findings with the presence or absence of viremia. Ninety-five consecutive chronic HBV-infected pregnant women were evaluated between the 28th and 32nd week of gestation. Viral load was determined by using the COBAS TaqMan HBV test. Sixty-nine women were evaluated and 14 of them exhibited HBV-DNA levels higher than 2000 IU·ml. In this study, viremic women exhibited significantly higher alanine aminotransferase (ALT), creatinine, and uric acid values as well as significantly lower white blood cell count compared with nonviremic women. There was also a significant statistical difference concerning ALT/sodium ratio between viremic and nonviremic women (0.20 ± 0.22 vs. 0.10 ± 0.09, respectively, p= .024). The optimal cutoff points discriminating those women with a high probability to have detectable serum HBV-DNA were 0.092 for ALT/sodium ratio (sensitivity = 73.0%, specificity = 61.5%, area under the receiver operating characteristic curve [AUC] = 71.05%) and 12.8 IU/L for ALT (sensitivity = 73.0%, specificity = 63.0%, AUC = 72.2%). Chronic HBV-infected pregnant women with ALT/sodium ratio ≥ 0.11 had the higher probability of having serum HBV-DNA levels higher than 2000 IU/ml (sensitivity = 76.92%, specificity = 58%, AUC = 62.38%). Presence of HBV-DNA in maternal blood during the third trimester of pregnancy is significantly associated with maternal serum ALT levels in HBeAg-negative chronic HBV-infected pregnant women. Women with an ALT/sodium ratio greater than 0.092 have the higher probability of HBV-DNA presence in maternal blood whereas an ALT/sodium ratio greater than 0.11 could discriminate those women with HBV-DNA levels higher than 2000 IU/ml.

Central vascular catheters versus peripherally inserted central catheters in nurse anesthesia. A perspective within the Greek health system.

PURPOSE: We present a study comparing the insertion of central vascular catheter (CVC) and peripherally inserted central catheter (PICC) by an anesthesia nurse at 2 Greek University Hospitals. METHODS: Eighty patients, aged 20-80 years, were enrolled in the study. Patients were divided into 2 groups. In group A (41 patients), a CVC was inserted in the internal jugular vein. In group B (39 patients), a pressure-injectable PICC was inserted in the basilica vein. RESULTS: Correlations between the methods applied, the patients' characteristics, the procedures' characteristics and the overall satisfaction scores for each procedure were examined. The final results show that the patients of group B (PICC method) were more satisfied with the procedure than the patients of group A (CVC method), at the statistical significance level of a=0.01. Also, according to the results of the analysis, the PICC method offers significantly more comfort and relative satisfaction than the CVC method, at the statistical significance level of a=0.01. The satisfaction scores of "physicians" were statistically more significant, at a=0.01, for the patients of group A (classic CVCs) mainly because of the insufficient flow rate of the PICCs when compared with the CVCs and especially if one considers the fact that the physicians did not have any experience with the PICC method at all. CONCLUSIONS: PICCs under ultrasound guidance constitute the solution of choice for patients and they definitely surpass the CVCs focusing mainly on the improvement of the quality of life and the satisfaction of patients.

A randomized double-blind trial of anesthesia provided for colonoscopy by university-degreed anesthesia nurses in Greece: safety and efficacy.

There are numerous studies in the literature of anesthesia administered during colonoscopy including various methods, drugs, and monitoring systems; however, none of them has studied whether a university-degreed nurse anesthesia provider (known as a certified registered nurse anesthetist in the United States) is skillful enough to provide safe anesthesia in patients undergoing endoscopic procedures. The aim of our study was to determine whether anesthesia provided by a university-degreed nurse anesthesia provider during an endoscopic procedure is comparable in terms of safety and efficacy with routine sedation practice. This randomized, double-blind study included 100 adult patients who underwent colonoscopy conducted in the Evgenidion University Hospital during a single year. Subjects were divided into 2 groups: the first group received the usual scheme of intravenous sedation with midazolam and fentanyl administered by a member of the endoscopic team that was blind to Bispectral Index (BIS) values recordings (Group 0). The second group received intravenous bolus injection of propofol bolus by a university-degreed anesthesia registered nurse based on the BIS values (Group 1). The average of the mean BIS values of Group 0 was 85.07 (SD = 8.01) and for Group 1 was 76.1 (SD = 10.88; p = .04). The parameters of "patient memory during procedure" and the satisfaction scores (as self-assessed by the patients as well as 2 gastroenterologists) were also significantly different between the patients of the 2 groups (p = .000). Comparison between the 2 groups showed that the sedation offered by a university-degreed nurse anesthesia provider was absolutely safe and effective, offering particular comfort to the patient during the intervention and contributing significantly to its successful results.

Open or laparoscopic surgery for colorectal cancer: a retrospective comparative study.

Laparoscopic surgery for colorectal cancer has been used with success since 1991. During the last decade, many studies have compared laparoscopic surgery with open colectomy. The aim of this retrospective study was to present the advantages and disadvantages of laparoscopic and open colectomy for cancer, focusing on the postoperative care of patients. Eighty-eight consecutive patients suffering from cancer of the colon and rectum, surgically treated, were studied. They were divided into 2 groups: Group A patients (n = 48) underwent laparoscopic colectomy, and Group B patients (n = 40) were treated with an open procedure. For postoperative care of the patients, analgesia, median hospital stay, overall cost, and complications between the 2 groups were studied and statistically compared. Laparoscopic colectomy was associated with a shorter average hospital stay, fewer complications, earlier start of a normal diet, and better control of postoperative pain. Nonetheless, the cost of surgical instruments used in laparoscopic operation is higher. Laparoscopic surgery, despite its higher cost, seems to add significant advantages in the postoperative recovery of patients suffering from colorectal cancer.

Greece reports prototype intervention with first peripherally inserted central catheter: case report and literature review.

Placement of peripherally inserted central catheters (PICCs), definitely offers a clear advantage over any other method regarding central venous catheterization. Its ultrasonographic orientation enhances significantly its accuracy, safety and efficacy, making this method extremely comfortable for the patient who can continue his or her therapy even in an outpatient basis. We present the first reported case of a PICCS insertion in Greece, which has been performed by a university-degree nurse. The aim of this review of literature was to present the evolution in nursing practice in Greece. A PICC was inserted in a 77-year-old male patient suffering from a recent chemical pneumonia with a history of Alzheimer's disease. A description of all the technical details of this insertion is reported, focusing on the pros and cons of the method and a thorough review of the history and advances in central venous catheterization throughout the years is also presented. PICCs provide long-term intravenous access and facilitate the delivery of extended antibiotic therapy, chemotherapy and total parenteral nutrition. We strongly believe that PICCs are the safest and most effective method of peripherally inserted central venous catheterization. Larger series are necessary to prove the above hypothesis, and they are under construction by our team.