Vasilios Koulouras

Post-implantation syndrome after endovascular repair of aortic aneurysms: need for postdischarge surveillance

OBJECTIVES To present the consequences and the need for readmission due to a vigorous inflammatory response in six patients who underwent endovascular repair of aortic aneurysms and developed post-implantation syndrome (PIS), during the postoperative period. METHODS From January 2007 to December 2009, 162 patients underwent endovascular repair of an aortic aneurysm. PIS was recorded in 49 patients. Among these, we present six patients who developed a systemic inflammatory response syndrome (SIRS) after discharge from hospital, which led to readmission within the first 30 postoperative days. RESULTS Five patients were treated for asymptomatic infrarenal abdominal aortic aneurysm and one for a thoracic one. All patients were discharged from hospital in the absence of any complications, fever or leukocytosis, but several days later they developed features of SIRS leading to readmission, even to the intensive care unit in two of them. After the administration of anti-inflammatory drugs all patients showed a complete recovery and finally left hospital several days later. CONCLUSIONS In some patients, the initial inflammatory response following endovascular aortic aneurysm repair is not always spontaneously attenuated and could lead to the development of SIRS even several days after the operation. It seems reasonable that patients developing PIS after endovascular aneurysm repair might be better kept under surveillance for the first postoperative month.

Inhaled NO and sildenafil combination in cardiac surgery patients with out-of-proportion pulmonary hypertension: acute effects on postoperative gas exchange and hemodynamics.

Background— The goal of this study was to examine the effects of coadministration of sildenafil and inhaled nitric oxide (iNO) in patients with out-of-proportion pulmonary hypertension who underwent cardiac valve replacement surgery. Methods and Results— Twenty consecutive cardiac surgery patients with out-of-proportion pulmonary hypertension were randomly assigned postoperatively into 2 groups: group A received 10 ppm of iNO followed by sildenafil (100 mg) orally 30 minutes later, and group B initially received sildenafil (100 mg) orally followed by 10 ppm of iNO 60 minutes later. Hemodynamic and gas exchange data were obtained at baseline, after administration of either iNO or sildenafil alone, and at 90 minutes from baseline. In group A, iNO resulted in a significant reduction in mean pulmonary artery pressure (MPAP) and pulmonary vascular resistance index (PVRI) (by 9.6% and 20.8%, respectively). In group B, sildenafil administration also resulted in a significant decrease in mean arterial pressure, MPAP, pulmonary artery occlusive pressure, PVRI, and systemic vascular resistance index but also in the PaO2/inspired fraction of oxygen ratio (by 18.7%, 22.0%, 15.7%, 31.6%, 21.3%, and 14%, respectively). In both groups, the coadministration of the 2 drugs resulted in a significant further reduction of mean arterial pressure, MPAP, pulmonary artery occlusive pressure, systemic vascular resistance index, and PVRI, whereas cardiac index and mixed venous oxygen saturation remained unchanged. The hypoxemia after sildenafil administration in group B improved after the coadministration of iNO, and thus PaO2/inspired fraction of oxygen returned to values near baseline. Conclusion— In this study, the postoperative coadministration of iNO and oral sildenafil in patients with out-of-proportion pulmonary hypertension undergoing cardiac surgery is safe and results in an additive favorable effect on pulmonary arterial pressure and pulmonary vascular resistance, without systemic hypotension and ventilation/perfusion mismatch.

Treatment of Toxic Epidermal Necrolysis with the Combination of Infliximab and High-Dose Intravenous Immunoglobulin

Background: Therapeutic evidence for toxic epidermal necrolysis (TEN) is indicative for high-dose intravenous immunoglobulin yet inconclusive for corticosteroids. Objective: To describe the combination of corticosteroids, infliximab and a high-dose intravenous immunoglobulin course for TEN. Patients and Methods: In three patients (SCORTEN survival probabilities: 41.7%, 64.2%, 41.7%) disease control was evaluated by (a) employing quantitative image analysis to measure progression of skin detachment and (b) patients’ outcome (complete re-epithelization). Published cases of TEN treatments with infliximab were retrieved from PubMed. Results: Within 48 h skin disease progression was arrested in all patients. Two patients were discharged after 3 weeks without any sequels from skin or conjunctivae. One patient passed away on the ninth day, however with noticeably improved skin (mortality rate: 33% observed vs. 50% expected). A PubMed search retrieved five TEN patients treated successfully with infliximab. Conclusion: The described combination presents a feasible therapeutic alternative for TEN that warrants further evaluation.

The contribution of left heart disease in COPD patients with pulmonary hypertension

BACKGROUND Pulmonary hypertension (PH), regardless of its etiology, is associated with an impaired outcome in patients with chronic obstructive pulmonary disease (COPD). The aim of our study was to determine the incidence, cause, and effect of PH as detected by echocardiography in COPD patients. METHODS Patients with confirmed COPD of any stage were evaluated by echocardiography for the likelihood of PH according to the proposed criteria. Patients with possible/likely to have PH underwent right heart catheterization, upon agreement, to confirm the presence, severity, and cause of PH. RESULTS Of 91 patients, 39 were in stable condition (group A) and 52 with COPD exacerbation (group B). Group B patients presented with PH and left ventricular diastolic dysfunction more often than group A patients. One of two fulfilled the criteria for possible/likely PH. The incidence of likely/possible PH was significantly higher in group B. Nineteen group B patients with likely/possible PH underwent RHC, and PH was confirmed in 15 cases and in 73.3% was associated with left heart disease. The presence of possible/likely PH was associated with a statistically significant increase in mortality compared to those with unlikely PH. CONCLUSIONS The use of echocardiographic criteria for the presence of PH is adequate for the screening of COPD patients. Patients with acute exacerbation of COPD and possible/likely PH demonstrate worse mortality compared to patients unlikely to have PH.

Burnout and job satisfaction of intensive care personnel and the relationship with personality and religious traits: An observational, multicenter, cross-sectional study

OBJECTIVES To investigate if burnout in the Intensive Care Unit (ICU) is influenced by aspects of personality, religiosity and job satisfaction. RESEARCH METHODOLOGY Cross-sectional study, designed to assess burnout in the ICU and to investigate possible determinants. Three different questionnaires were used: the Malach Burnout Inventory, the Eysenck Personality Questionnaire and the Spiritual/Religious Attitudes Questionnaire. Predicting factors for high burnout were identified by multivariate logistic regression analysis. SETTING/PARTICIPANTS This national study was addressed to physicians and nurses working full-time in 18 Greek ICU departments from June to December 2015. RESULTS The participation rate was 67.9% (n=149) and 65% (n=320) for ICU physicians and nurses, respectively). High job satisfaction was recorded in both doctors (80.8%) and nurses (63.4%). Burnout was observed in 32.8% of the study participants, higher in nurses compared to doctors (p<0.001). Multivariate analysis revealed that neuroticism was a positive and extraversion a negative predictor of exhaustion (OR 5.1, 95%CI 2.7-9.7, p<0.001 and OR 0.49, 95%CI 0.28-0.87, p=0.014, respectively). Moreover, three other factors were identified: Job satisfaction (OR 0.26, 95%CI 0.14-0.48, p<0.001), satisfaction with current End-of-Life care (OR 0.41, 95%CI 0.23-0.76, p=0.005) and isolation feelings after decisions to forego life sustaining treatments (OR 3.48, 95%CI 1.25-9.65, p=0.017). CONCLUSIONS Personality traits, job satisfaction and the way End-of-Life care is practiced influence burnout in the ICU.

Regarding "the impact of endograft type on inflammatory response after endovascular treatment of abdominal aortic aneurysm".

highlighting the utility of endovascular aneurysm repair in this frail group and the importance of careful patient selection for open repair in patients with any degree of COPD. Furthermore, Cox proportional hazards analysis not only confirmed oxygen dependence was associated with diminished 5-year survival, but also medically managed COPD, again emphasizing the ongoing challenge of selecting patients with COPD for aneurysm repair.

Spinal Cord Early Ischemic Preconditioning Activates the Stabilized Fraction of β-Catenin After Thoracoabdominal Aortic Occlusion in Pigs

BACKGROUND Paraplegia after thoracoabdominal aortic surgery is a devastating complication attributed to motor neurons loss and dysfunction, due to spinal cord ischemia. β-Catenin is a protein that has been associated with cell survival and healing and many studies have correlated this protein with late ischemic preconditioning (IPC). Herein we investigate the potential contribution of β-catenin in an early IPC animal model, and its relationship with heat shock protein 70 (Hsp70), suggesting a possible role of this protein as a first window of protection. METHODS A total of 42 pigs were used in an experimental thoracoabdominal aortic occlusion model. Twelve animals were used for neurologic evaluation and were randomly assigned to 2 groups (A and B). The remaining 30 animals were used in experiments for biologic measurements and innunohistochemical studies, and were randomly assigned to 5 groups (1-5). Western blotting analysis and immunoprecipitations were performed to study the levels of β-catenin and its binding relationship with Hsp70. The cellular distribution of β-catenin at various time-points was investigated by immunohistochemical studies. RESULTS According to neurologic evaluation, the animals in the IPC+ischemia group had significantly better neurologic scores compared with those in the ischemia group, indicating a protective role for IPC. The biologic measurements demonstrated a significant (P=0.03) increase in β-catenin levels and translocation of the protein in the nucleus at the end of ischemic preconditioning. CONCLUSIONS Our results suggest a significant role of β-catenin in early IPC protection of spinal cord after thoracoabdominal occlusion, as IPC seems to trigger the activation of the β-catenin stabilized fraction and, thus, its survival pathway.

The impact of healthcare professionals’ personality and religious beliefs on the decisions to forego life sustaining treatments: an observational, multicentre, cross-sectional study in Greek intensive care units

Objectives To assess the opinion of intensive care unit (ICU) personnel and the impact of their personality and religious beliefs on decisions to forego life-sustaining treatments (DFLSTs). Setting Cross-sectional, observational, national study in 18 multidisciplinary Greek ICUs, with >6 beds, between June and December 2015. Participants 149 doctors and 320 nurses who voluntarily and anonymously answered the End-of-Life (EoL) attitudes, Personality (EPQ) and Religion (SpREUK) questionnaires. Multivariate analysis was used to detect the impact of personality and religious beliefs on the DFLSTs. Results The participation rate was 65.7%. Significant differences in DFLSTs between doctors and nurses were identified. 71.4% of doctors and 59.8% of nurses stated that the family was not properly informed about DFLST and the main reason was the family’s inability to understand medical details. 51% of doctors expressed fear of litigation and 47% of them declared that this concern influenced the information given to family and nursing staff. 7.5% of the nurses considered DFLSTs dangerous, criminal or illegal. Multivariate logistic regression identified that to be a nurse and to have a high neuroticism score were independent predictors for preferring the term ‘passive euthanasia’ over ‘futile care’ (OR 4.41, 95% CI 2.21 to 8.82, p<0.001, and OR 1.59, 95% CI 1.03 to 2.72, p<0.05, respectively). Furthermore, to be a nurse and to have a high-trust religious profile were related to unwillingness to withdraw mechanical ventilation. Fear of litigation and non-disclosure of the information to the family in case of DFLST were associated with a psychoticism personality trait (OR 2.45, 95% CI 1.25 to 4.80, p<0.05). Conclusion We demonstrate that fear of litigation is a major barrier to properly informing a patient’s relatives and nursing staff. Furthermore, aspects of personality and religious beliefs influence the attitudes of ICU personnel when making decisions to forego life-sustaining treatments.

Inhaled NO and Sildenafil Combination in Cardiac Surgery Patients With Out-of-Proportion Pulmonary HypertensionClinical Perspective: Acute Effects on Postoperative Gas Exchange and Hemodynamics

Background— The goal of this study was to examine the effects of coadministration of sildenafil and inhaled nitric oxide (iNO) in patients with out-of-proportion pulmonary hypertension who underwent cardiac valve replacement surgery. Methods and Results— Twenty consecutive cardiac surgery patients with out-of-proportion pulmonary hypertension were randomly assigned postoperatively into 2 groups: group A received 10 ppm of iNO followed by sildenafil (100 mg) orally 30 minutes later, and group B initially received sildenafil (100 mg) orally followed by 10 ppm of iNO 60 minutes later. Hemodynamic and gas exchange data were obtained at baseline, after administration of either iNO or sildenafil alone, and at 90 minutes from baseline. In group A, iNO resulted in a significant reduction in mean pulmonary artery pressure (MPAP) and pulmonary vascular resistance index (PVRI) (by 9.6% and 20.8%, respectively). In group B, sildenafil administration also resulted in a significant decrease in mean arterial pressure, MPAP, pulmonary artery occlusive pressure, PVRI, and systemic vascular resistance index but also in the PaO2/inspired fraction of oxygen ratio (by 18.7%, 22.0%, 15.7%, 31.6%, 21.3%, and 14%, respectively). In both groups, the coadministration of the 2 drugs resulted in a significant further reduction of mean arterial pressure, MPAP, pulmonary artery occlusive pressure, systemic vascular resistance index, and PVRI, whereas cardiac index and mixed venous oxygen saturation remained unchanged. The hypoxemia after sildenafil administration in group B improved after the coadministration of iNO, and thus PaO2/inspired fraction of oxygen returned to values near baseline. Conclusion— In this study, the postoperative coadministration of iNO and oral sildenafil in patients with out-of-proportion pulmonary hypertension undergoing cardiac surgery is safe and results in an additive favorable effect on pulmonary arterial pressure and pulmonary vascular resistance, without systemic hypotension and ventilation/perfusion mismatch.

Inhaled NO and Sildenafil Combination in Cardiac Surgery Patients With Out-of-Proportion Pulmonary Hypertension

Background— The goal of this study was to examine the effects of coadministration of sildenafil and inhaled nitric oxide (iNO) in patients with out-of-proportion pulmonary hypertension who underwent cardiac valve replacement surgery. Methods and Results— Twenty consecutive cardiac surgery patients with out-of-proportion pulmonary hypertension were randomly assigned postoperatively into 2 groups: group A received 10 ppm of iNO followed by sildenafil (100 mg) orally 30 minutes later, and group B initially received sildenafil (100 mg) orally followed by 10 ppm of iNO 60 minutes later. Hemodynamic and gas exchange data were obtained at baseline, after administration of either iNO or sildenafil alone, and at 90 minutes from baseline. In group A, iNO resulted in a significant reduction in mean pulmonary artery pressure (MPAP) and pulmonary vascular resistance index (PVRI) (by 9.6% and 20.8%, respectively). In group B, sildenafil administration also resulted in a significant decrease in mean arterial pressure, MPAP, pulmonary artery occlusive pressure, PVRI, and systemic vascular resistance index but also in the PaO2/inspired fraction of oxygen ratio (by 18.7%, 22.0%, 15.7%, 31.6%, 21.3%, and 14%, respectively). In both groups, the coadministration of the 2 drugs resulted in a significant further reduction of mean arterial pressure, MPAP, pulmonary artery occlusive pressure, systemic vascular resistance index, and PVRI, whereas cardiac index and mixed venous oxygen saturation remained unchanged. The hypoxemia after sildenafil administration in group B improved after the coadministration of iNO, and thus PaO2/inspired fraction of oxygen returned to values near baseline. Conclusion— In this study, the postoperative coadministration of iNO and oral sildenafil in patients with out-of-proportion pulmonary hypertension undergoing cardiac surgery is safe and results in an additive favorable effect on pulmonary arterial pressure and pulmonary vascular resistance, without systemic hypotension and ventilation/perfusion mismatch.