Translation and cultural adaptation of the Greek version of the confusion assessment method diagnostic algorithm and the nursing delirium screening scale and their inter-rater reliability: A prospective cohort study.

AIM: The lack of standardized tools limits the diagnosis οf postoperative delirium (POD) in the Greek population. Our aim was the translation and the cultural adaptation of the confusion assessment method (CAM) diagnostic algorithm and the nursing delirium screening scale (nu-DESC) in the Greek surgical population, and the determination of their inter-rater reliability. METHODS: After Ethical approval and registration as a clinical trial (NCT04154176), a prospective cohort study was conducted in the Department of Anesthesiology, University Hospital of Larissa, Greece. Patients at least 60 years old, undergoing elective non-cardiac surgery, under general anesthesia were included. RESULTS: Data from 60 patients, 180 records in total, were analyzed. There was an "almost perfect agreement" between the raters with the use of CAM (Cohen's Kappa estimate: 0.960; 95 % CI: 0.905-1.000) and nu-DESC (Cohen's Kappa estimate: 0.981; 95 % CI: 0.944-1.000). The agreement on each specific question of CAM and nu-DESC ranged from "substantial" to "almost perfect agreement". Based on the CAM, the sensitivity and specificity of nu-DESC were 0.97 (95 % CI: 0.82-1.00) and 0.99 (95 % CI: 0.96-1.00), respectively. The Greek versions of CAM and nu-DESC showed a high inter-rater agreement. CONCLUSION: With the translation, the cultural adaptation, and the determination of their inter-rater agreement, the CAM diagnostic algorithm and the nu-DESC may serve as reliable instruments for the detection of POD in the Greek population. HIPPOKRATIA 2020, 24(1): 8-14.

Postoperative cognitive disorders: an update.

BACKGROUND: Cognitive dysfunction is a common complication after surgery. It is a major cause for increased, sometimes long-term, morbidity and mortality. METHODS: In this narrative review we performed a literature search regarding postoperative cognitive decline regarding risk factors, the type of surgical intervention, potential neuroprotective effects of anesthetic drugs, and associated quality of life and healthcare costs. RESULTS: Several risk factors are implicated in postoperative cognitive impairment. Cardiac surgery and specific orthopedic interventions are associated with a higher incidence of postoperative cognitive disorders. Results regarding the neuroprotective effects of anesthetics agents are still controversial but promising. Postoperative cognitive alterations are a major public healthcare issue as they impair the everyday quality of life, and expand the yearlong expenses. CONCLUSIONS: Postoperative cognitive disorders are devastating, potentially life-threatening complications. High-suspicion, especially in high-risk patients and operations, and adoption of available neuroprotective strategies may prove lifesaving. HIPPOKRATIA 2018, 22(4): 147-154.

Mortality associated with standard prescription transfusions in cardiac surgery.

BACKGROUND: Before applying new blood management strategies, the extent of blood product transfusions and its correlation with perioperative mortality should be identified. METHODS: This study retrospectively analyzed the extent of perioperative transfusions of red blood cells (RBC), fresh frozen plasma (FFP), and platelets (PLT) in 565 consecutive cardiac surgery patients, who received transfusions based on standard prescriptions. Patients were stratified in four groups according to perioperative transfusion units (no transfusion, <5, 5-10, >10 units). Mortality was analyzed in relation to the type and extent of each blood product transfused and their combinations. Subsequently, the ability of transfusion volume to predict mortality was tested. RESULTS: Most patients received blood product transfusions perioperatively.  The observed mortality (11.7 %) correlated significantly with the volume of transfusion. Patients transfused with >5 RBC or FFP units or >10 PLT units had increased mortality compared with those receiving fewer transfusions (23.9 % vs 4.5 %, 27.4 % vs 6 %, 24.5 % vs 8.5 %, p <0.05, respectively). Analysis revealed that cutoffs of >5 units of RBC or >15 units of RBC, FFP, and PLT additively (sensitivity: 74.2 % and 72.7 %, specificity: 68.7 % and 69.5 %, respectively) had an acceptable discrimination ability for perioperative mortality (Area under the ROC curve: 0.756, p <0.001, and 0.735, p <0.001, respectively). CONCLUSIONS: This study confirmed a dose-dependent, transfusion-associated, increased mortality in cardiac surgery patients who received standard prescription transfusions. The results support the need for applying validated, patient-specific blood conservation strategies that correspond to the patient's actual perioperative transfusion needs. HIPPOKRATIA 2018, 22(2): 68-74.

The role of liver resection in the management of intermediate and advanced stage hepatocellular carcinoma. A systematic review.

BACKGROUND: The ideal management for patients with intermediate and advanced stage hepatocellular carcinoma (HCC) is controversial. The main purpose of this systematic review is to examine the role of liver resection in patients with intermediate stage HCC (multinodular HCCs) and in advanced stage HCC [mainly patients with portal vein tumor thrombosis (PVTT)]. METHODS: A systematic search of the literature was performed in Pud Med and the Cochrane Library from 01.01.2000 to 30.06.2016. RESULTS: Twenty-three articles with 2412 patients with multinodular HCCs were selected. Also, 29 studies with 3659 patients with HCCs with macrovascular invasion were selected. In patients with multinodular HCCs the median post-operative morbidity was 25% and the 90-day mortality was 2.7%. The median survival was 37 months and the 5-year survival 35%. The 5-year survival was much better for patients with a number of HCCs ≤3 vs. HCCs >3 (49% vs. 23%). In patients with macrovascular invasion, who underwent hepatic resection, the median post-operative morbidity was 33% and the in-hospital mortality 2.7%. The median survival was 15 months. The 3 and 5year survival was 33% and 20% respectively. Moreover a significant difference in survival was noted according to PVTT stage: 5- year survival for distal PVTT, PVTT of the main intrahepatic PV branch and PVTT extending to the main PV was 45%, 19% and 14.5% respectively. CONCLUSIONS: Liver resection in patients with multinodular HCCs and HCCs with PVTT offers satisfactory long-term survival and should be considered in selected patients.

Propofol vs Sevoflurane anaesthesia on postoperative cognitive dysfunction in the elderly. A randomized controlled trial.

BACKGROUND: Postoperative cognitive dysfunction is a topic of special importance in the geriatric surgical population which primarily resolves within the short term postoperative period, but it can become a long term disorder with significant impact on patient's quality of life. This study was designed to compare the short and long term postoperative cognitive function after propofol and sevoflurane anaesthesia in the elderly and to evaluate the role of the inflammatory process. METHODS: Patients, aged 60-74, scheduled for a non-cardiac operation of more than two-hour duration were enrolled in this prospective randomized controlled trial and allocated into two groups in order to receive propofol or sevoflurane anaesthesia. Postoperative early cognitive function was assessed by means of the Mini Mental State Examination test (MMSE) 48 hours postoperatively. Late cognitive function was evaluated by means of 10 psychometric tests, 9 months postoperatively. The role of inflammation was estimated by the incidence of SIRS and the levels of the inflammatory markers. RESULTS: Statistical significant decrease was observed in the postoperative MMSE values in the sevoflurane group. Nine months postoperatively, there was a decline in test performance in the same group and an increase in postoperative values of inflammatory markers in both groups, which turned non-significant in their between comparison (except CRP). CONCLUSION: According to the neuropsychological test evaluation of cognition, there is a negative influence of sevoflurane anaesthesia on the early and late postoperative state. As far as the inflammatory markers are concerned, they don't relate to the patient's cognitive status.

Massive bleeding in cardiac surgery. Definitions, predictors and challenges.

BACKGROUND: Severe or massive bleeding in cardiac surgery is an uncommon but important clinical scenario. Its existing definitions are diverse. Its characteristics constantly change during an active hemorrhage and, thus is difficult to define appropriately. METHODS: In this narrative, non-systematic review, we performed a literature search to retrieve data that could contribute to answering clinical questions on the definition and grading of severe hemorrhage and massive transfusion, identifying factors that predict and affect bleeding and transfusion-related mortality and describing the risks of re-exploration and the economic impact of severe bleeding in cardiac surgery.   Results: Massive perioperative bleeding is currently described by indices of its rate and extent and the magnitude of the consequent blood products transfusion. It has a significant impact on mortality, service logistics, and hospital financing. Proper and early identification of a massive bleeding is possible. Among other factors, patient's co-morbidities, bleeding severity and transfusion volume seem to predict the associated mortality. Consequent to severe bleeding, re-exploration, is also a potentially hazardous adverse event that also affects morbidity and mortality. CONCLUSIONS: Severe perioperative hemorrhage in cardiac surgery carries significant morbidity and mortality. Currently, prediction and identification of massive bleeding is a feasible but incomplete clinical task despite the availability of effective treatment regimens. A still missing, compact definition of massive perioperative bleeding in cardiac surgery that incorporates all phases of treatment could augment clinical preparedness, allow for the development of accurate prediction tools and permit the application of well-validated protocols of management. Hippokratia 2016, 20(3): 179-186.

Five classes Euroscore modification improves accuracy of prediction of postoperative mortality and possibly the length of mechanical ventilation of cardiac surgery patients.

AIM: The additive EuroSCORE system for predicting operative mortality of cardiac patients tends to underestimate the mortality risk of high risk patients and concomitantly to overestimate that of low risk patients. We propose a modification of stratification groups aiming at improving its precision. We also tested its ability to predict the length of postoperative mechanical ventilation of our patients. METHODS: The high risk group of the EuroSCORE system (>6 points) was divided into three additional groups (group I: 0-2 points, group II: 3-5 points, group III: 6-8 points, group IV: 9-13 points, group V: >14 points) thus producing a 5 classes system. In a group of 301 cardiac surgery patients operated on in a low volume cardiac center, we calculated the expected mortality rate for each EuroSCORE class, the calibration of the modified scoring system, the ROC and the corresponding AUC values and the relative risk of each predisposing factor used by the original EuroSCORE sytem. RESULTS: The proposed modification increased the discrimination ability of EuroSCORE in predicting mortality (Hosmer-Lemeshow P=0.78, ROC size: 0.791) and marginally affected its accuracy in predicting length of postoperative mechanical ventilation (Hosmer-Lemeshow: 0.11, ROC size: 0.711). Combined operations of CABG and valve replacement were shown to exert a statistically significant effect on mortality (odds ratio 3.85, CI: 1.15-12.87, P=0.028). CONCLUSION: The proposed modification of additive EuroSCORE can presumably increase its discrimination ability in predicting mortality of cardiac patients handled in a low volume cardiac center. The need for prolonged mechanical ventilation could be predicted with acceptable accuracy, possibly providing support in resource management.

Impact of metabolic syndrome in surgical patients: should we bother?

Clinicians inevitably encounter patients who meet the diagnostic criteria for the metabolic syndrome (MetS); these criteria include central obesity, hypertension, atherogenic dyslipidaemia, and hyperglycaemia. Regardless of the variations in its definition, MetS may be associated with adverse outcomes in patients undergoing both cardiac and non-cardiac surgery. There is a paucity of data concerning the anaesthetic management of patients with MetS, and only a few observational (mainly retrospective) studies have investigated the association of MetS with perioperative outcomes. In this narrative review, we consider the impact of MetS on the occurrence of perioperative adverse events after cardiac and non-cardiac surgery. Metabolic syndrome has been associated with higher rates of cardiovascular, pulmonary, and renal perioperative events and wound infections compared with patients with a non-MetS profile. Metabolic syndrome has also been related to increased health service costs, prolonged hospital stay, and a greater need for posthospitalization care. Therefore, physicians should be able to recognize the MetS in the perioperative period in order to formulate management strategies that may modify any perianaesthetic and surgical risk. However, further research is needed in this field.

The effect of ondansetron on postoperative delirium and cognitive function in aged orthopedic patients.

BACKGROUND: Postoperative delirium and cognitive dysfunction are common in hospitalized patients. The aim of this study was to investigate whether postoperative ondansetron administration has a favorable effect on postoperative delirium and 30th day cognitive function and pain in patients undergoing surgery with general anaesthesia due to femoral or hip fracture. METHODS: A hundred and six patients aged >40 years old scheduled for a femoral or hip fracture rehabilitation surgery, were randomized on a double-blind protocol to receive postoperatively 4 ml of either ondansetron 8 mg (Group A) or placebo (Group B) daily i.v. for five days. Each patient was evaluated preoperatively and on the 2nd, 3rd, 4th and 5th day postoperatively with Confusion Assessment Method test, and preoperatively and on the 30th day postoperatively using a sensitive battery of neuropsychological, functional and pain tests. RESULTS: Patients of both groups did not differ preoperatively significantly in their basic characteristics and predisposing factors associated with postoperative delirium and cognitive dysfunction. The results showed that postoperative administration of ondansetron was followed by a lower incidence and duration of postoperative delirium and improved postoperative neurocognitive function on the 30th postoperative day, regardless of age or history of stroke. This was accompanied by a significant better postoperative functionality and less pain. CONCLUSION: The postoperative ondansetron administration seems to protect and might improve the cognitive function in patients undergoing surgery under general anesthesia. Ondansetron also seems to release analgesic effects.

Epidural anaesthesia and analgesia for liver resection.

Although epidural analgesia is routinely used in many institutions for patients undergoing hepatic resection, there are unresolved issues regarding its safety and efficacy in this setting. We performed a review of papers published in the area of anaesthesia and analgesia for liver resection surgery and selected four areas of current controversy for the focus of this review: the safety of epidural catheters with respect to postoperative coagulopathy, a common feature of this type of surgery; analgesic efficacy; associated peri-operative fluid administration; and the role of epidural analgesia in enhanced recovery protocols. In all four areas, issues are raised that question whether epidural anaesthesia is always the best choice for these patients. Unfortunately, the evidence available is insufficient to provide definitive answers, and it is clear that there are a number of areas of controversy that would benefit from high-quality clinical trials.

The effects of physostigmine on recovery from general anesthesia in elderly patients.

BACKGROUND: Transient cognitive dysfunction after general anesthesia is a frequent finding among elderly patients. The aim of this study was to evaluate whether the use of physostigmine may enhance recovery from general anesthesia in elderly patients. METHODS: Eighty American Society of Anesthesiologists (ASA) physical status I-III patients aged >65 years old who were scheduled for a laparoscopic cholecystectomy received either 2 mg physostigmine in 250 mL N/S 0.9% (Physo group) or 250 mL N/S 0.9% placebo (Control group) after induction of anesthesia via slow IV infusion over 45 minutes. This experiment was performed as a prospective, randomized, double-blinded study. Patients were assessed for sedation, orientation, ability to sit, and ability to pass the "picking up matches" test at 15 minutes, 8 hours, and 24 hours postoperatively. Patients were also evaluated for pain using the visual analogue scale (VAS) score both at rest and with movement. RESULTS: The time to extubation was significantly shorter in the Physo group than in the control group (8.0±2.7 vs. 9.8±3.6 min, P=0.012). The time required to pass the "picking up matches" test was also shorter for the Physo group at all of the time points postoperatively (15 minutes postoperatively: 18.0±7.1 vs. 24.6±11.6 sec, P=0.003, 8 hours postoperatively: 11.8±3.9 vs. 16.0±6.0 sec, P<0.001, 24 hours postoperatively: 8.8±3.4 vs. 11.2±4.7 sec, P=0.008). Evaluations of patient orientation and sedation were similar between the experimental and control groups. The VAS score and analgesic requirement were decreased in the Physo group compared to the control group during the first postoperative day. The ability to sit after extubation was also increased in the Physo group at both 15 minutes (P=0.001) and 8 hours postoperatively (P<0.001). CONCLUSION: The intraoperative infusion of physostigmine enhances alertness, coordination, manual dexterity and mobilization after general anesthesia in elderly patients, but physostigmine administration does not affect orientation or sedation.

Cardiac valve surgery and myocardial damage: the role of cardiac troponin I.

AIM: The study investigated the release of cardiac Troponin I (cTnI) levels in heart valve surgery and in coronary artery bypass grafting (CABG). The aims of the research were 1) to evaluate the ability of cTnI to detect the myocardial damage; and 2) to demonstrate possible causative factors of the cTnI release after valve surgery. METHODS: A prospective, single-center study. Ninety consecutive patients were operated on for different types of cardiac surgery; 45 patients underwent cardiac valve surgery - The VALVE group. 45 patients underwent CABG surgery - the CABG group. CTnI levels were measured preoperatively, on the day of operation and the 7 days postoperatively. The diagnosis of damaged myocardium classically performed through the measurement of cTnI, twelve-lead electrocardiograms (ECG) and echocardiographics according to the protocol of the study. RESULTS: Although more elevated cTnI release was noticed in valve group early after operation, no occurrence of cardiac events was found in that group. Statistically significant occurrence of cardiac events was found in CABG group (P=0.015). No relationship was shown between the peak of cTnI and the presence of cardiac events in valve group. A statistically significant correlation was observed between cardiac events and peak cTnI in CABG group (P=0.05). Possible correlations were investigated between the peak of cTnI and perioperative parameters in both two groups. CONCLUSION: The absence of cardiac events and the association of valve surgery with higher early release of cTnI compared to CABG suggest that the type of surgery strongly affects the induction of myocardial damage.

Importance of perioperative monitoring of cerebral tissue saturation in elderly patients: an interesting case.

The authors describe the case of an elderly diabetic patient with a hip fracture who developed neurocognitive dysfunction and dysarthria preoperatively. Upon arrival in the operating room, the monitoring of cerebral oxygenation by near-infrared spectroscopy (NIRS) showed cerebral desaturation (44% on the left hemisphere and 46% on the right). Cerebral oximetry values were stabilized during the surgery after administration of crystalloid fluids and vasoconstrictive drugs and were ameliorated significantly after administration of two units of blood. The patient's cerebral saturation was 60% on the left and 58% on the right hemisphere after the end of surgery and he was in normal neurological status. Observations underlined the importance of preoperative evaluation of cerebral tissue oxygenation by non-invasive cerebral NIRS in elderly diabetic patients who develop hypovolemia and anemia due to major fracture.

Cardiac troponin I versus creatine kinase-MB in the detection of postoperative cardiac events after coronary artery bypass grafting surgery.

AIM: Several studies suggest that postoperarive concentrations of cardiac troponin-I (cTnI) may increase in patients undergoing aorto-coronary bypass grafting (CABG). The degree and pattern of release appears to be associated with perioperative myocardial damage. METHODS: This was a prospective observational study with serial sampling conducted at the Departments of Cardiothoracic Surgery and Anesthesiology, University Hospital of Ioannina, Ioannina, Greece. The levels of cTnI and creatine kinase-MB (CK-MB) preoperatively, upon admission to the intensive care unit and at 12, 24, 36 and 48 hours after surgery, as well as daily from postoperative days 3-7 were determined in 41 consecutive patients (33 males and 8 females, aged 64.8+/-6.1 years) who underwent CABG with cardiopulmonary bypass. The Authors compared the patterns and variation of cTnI and creatine kinase (CK)-MB after CABG in patients with or without postoperative cardiac events (PCEs). RESULTS: Eleven patients experienced a PCE (postoperative ventricular and supraventricular arrhythmia, need for intra-aortic balloon pump (IABP) for >12 hours, or postoperative myocardial infarction, [MI]). In patients without PCE the elevation of cTnI peaked at 24 hours after surgery, while in patients with PCE maximal values of cTnI occurred after 36 hours. CTnI levels correlated with CK-MB after the procedure. Receiver-operating characteristic (ROC) curve analysis indicated that cTnI is superior to CK-MB with regard to PCE diagnosis following CABG (area under the ROC curve, 0.73, 95% CI (0.53-0.93) versus 0.54, 95% CI, (0.25-0.83). CONCLUSION: CTnI seems to be more valuable compared to CK-MB in the detection of PCEs in patients undergoing coronary surgery.

Knotting of an epidural catheter: a rare complication.

Knotting of an epidural catheter leading to entrapment is a rare complication of epidural catheterization. A lumbar epidural catheter inserted in a 28-year-old woman for caesarean section anesthesia and postoperative analgesia proved difficult to remove. After multiple attempts and placing the patient in the same position as when the catheter was initially inserted, the entrapped catheter was dislodged intact, revealing a double knot near its distal tip. Leaving catheters of less than 4 cm in length in the epidural space may help to avoid this complication. It is important the patient be informed of the techniques involved in the extraction of the resistant catheter because patient's cooperation is important for the nonsurgical removal of an entrapped epidural catheter.