Review Articles

Acute respiratory distress syndrome (ARDS) is an acute inflammatory lung injury, associated with increased pulmonary vascular permeability, increased lung weight, and loss of aerated lung tissue. There remains limited information about the epidemiology, recognition, management, and outcomes of patients with the ARDS, but in-hospital mortality is still high for those with moderate and severe ARDS (40.3% and 46.1%, respectively). Mechanical ventilation does not cure ARDS but simply buys time by maintaining a gas exchange sufficient for survival. The guiding principle of mechanical ventilation of ARDS is the new setting is less harmful to the lung structure than the previous one, thus avoiding the ventilator induced lung injury (VILI). Among outcome studies testing different tidal volumes, only the study comparing the two extreme values tested (6 mL/kg versus 12 mL/kg) showed a significant benefit of lower tidal volume. ‘The best positive end expiratory pressure (PEEP)’ does not exist. Recruitment maneuvers (RMs) are helpful in increasing aerated lung volume, which decreases strain and tidal recruitment/derecruitment. There is no definitive evidence regarding the clinical effectiveness of RMs to improve clinical outcomes of ARDS patients, although RMs may decrease the mortality of patients with ARDS without increasing the risk for major adverse events. There is no evidence for a difference between pressure control versus volume control ventilation in terms of physiological outcome or mortality. The effect of respiratory rate on the occurrence of VILI or outcome in ARDS has not been independently studied. Increasing inspiratory time has been suggested to improve oxygenation. Prone position (PP) is a standard practice in clinical treatment of ARDS patients to improve systemic oxygenation to any patient with moderate or severe ARDS as it may confer a statistically significant mortality advantage. There is evidence that neuromusculal blockade by cisatracurium besylate has an outcome benefit in ARDS patients since they improve lung mechanics and lung inflammation. Optimal dosing and monitoring strategies will need to be further studied.

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Cardiac surgery is a specialty with a relatively short history. The difficulties and particularities of Cardiac Surgery made apparent right from the beginning that there was a need forspecialized anesthesiological support. In 1940, Cardiac Surgeons pioneers recognized the role and contribution of cardiac anesthesiologists. In 1945, Blalock thanking his anesthesiologist co-workers Lamont and Harmel in public and mentioned that thanks to their anesthesiological support there “was no death during the first 55 operations”. Russell Brock, in 1949, highlighted the importance of collaboration between cardiac surgeons and cardiac anesthesiologists and mentioned “In this type of surgeries co-operation is necessary. The anesthesiologist plays a vital role and deserves special honor and recognition.” Since the first application of the electrocardiogram to operating theatres in 1950, the introduction of transesophageal echocardiography perioperatively in 1971, until the last decade with the application of coagulation monitoring, the newer data in the management of severe bleeding and the anesthesiological support in brand new minimal invasive techniques, cardiac anesthesiologists have vitally supported the evolution of cardiac surgery. The following text is a historical review describing the contribution of cardiac anesthesia in a continuing effort to improving clinical outcome and enhancing the safety of cardiac surgery.

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Invasive fungal infections are a growing problem in critically ill patients and are associated with increased morbidity and mortality. Complex medical and surgical problems, disruption of natural barriers, multiple invasive procedures and prolonged antibiotic treatment are some of the factors contributing to the alarming increase of fungal infections in the Intensive Care Unit (ICU) setting. In terms of occurrence rates, the most important fungal infections are invasive candidiasis (IC) and invasive pulmonary aspergillosis (IPA). Invasive candidiasis in ICU patients includes mainly candidemia, primary or catheter-related, and intra-abdominal candidiasis. Candida bloodstream infections occur at highest rates in the ICU population, with this setting accounting for 33–55% of all candidemias. The epidemiology of Candida infections is not constant.

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Το γαλακτικό οξύ παράγεται στο κυτταρόπλασμα από γλυκόλυση και μεταβολίζεται κυρίως από το ήπαρ (60%) (γλυκογονογένεση και νεογλυκογένεση) και από τα νεφρά (30%), τόσο στο φλοιό (τόπος μεταβολισμού)μέσω της νεογλυκογένεσης όσο και στο μυελό (τόπος παραγωγής). Η σχέση μεταξύ πυρουβικού και γαλακτικού οξέος είναι αμφίδρομη και το παραγόμενο γαλακτικό οξύ μπορεί να μετατραπεί είτε έμμεσα από το πυρουβικό σε οξαλικό οξύ και αλανίνη είτε άμεσα σε γλυκογόνο και γλυκόζη από τα περιπυλαία ηπατικά κύτταρα με τον κύκλο του Cori. Κατά συνέπεια, η αυξημένη γλυκόλυση οδηγεί σε αυξημένη παραγωγή γαλακτικού οξέος.

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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.

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Postoperative pain management has become pre-requisite for early recovery after laparoscopic chole-cystectomy and the ideal management of it is definitely multimodal due to the complexity of its na-ture. Many analgesic approaches have already been tested to relieve pain after laparoscopic cholecys-tectomy and anticonvulsants drugs, like pregabalin and gabapentin might be useful and effec-tive.Pregabalin is an antiepileptic drug that is often used to treat neuropathic pain. The use of pre-gabalin as part of multimodal analgesia is still under evaluation and may have a role in the postopera-tive management, as an adjunct. Several studies have evaluated the efficacy and adverse effects of pregabalin in reducing postoperative pain and opioid consumption.In this review, we discuss the role of pregabalin in acute postoperative management after laparoscopic cholecystectomy. Based on avail-able clinical trials it is difficult to draw solid conclusions. More studies and especially well designed clinical trials are required in order to clarify the optimal dose and the duration of therapy before adopt-ing pregabalin in routine clinical practice.

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Pain is a disastrous manifestation of cancer that influences the patients’ quality of life, their families, and health care providers. It is a multidimensional symptom that includes the physical, psychosocial, 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 patients with mild to severe pain do not received adequate pain treatment. This insufficient management 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.

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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.

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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.

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