Thrombocytopenia in the intensive care unit

Thrombocytopenia is a frequent finding in intensive care unit especially among adults and medical ICU patients.Thrombocytopenia is defined as a platelet count less than 100×109/l in ICU setting. Platelets are made in the bone marrow from megakaryocytes. Although not fully understood, proplatelets transform into platelets in the lung. The body tries to maintain platelet count relatively constant throughout life. Pathophysiology of thrombocytopenia can be defined by hemodilution, elevated levels of platelet consumption, compromise of platelet production, increased platelet sequestration and increased platelet destruction. Unlike in other situations, absolute platelet count alone does not provide sufficient data in characterizing thrombocytopenia in ICU patients. In such cases, the time course of changes in platelet count is also pivotal. The dynamics of platelet count decrease vary considerably between different ICU patient populations including trauma, major surgery and minor surgery/medical conditions. There are strong evidences available that delay in platelet count restoration in ICU patients is an indicator of a bad outcome

Upper lip bite test for prediction ofdifficult airway: A systematic review

Background and Objective: Upper lip bite test [ULBT] is one of the various bedside tests used for prediction of difficult laryngoscopic intubation. However, its usefulness is not still very clear, and there is controversy regarding its accuracy. The aim of this systematic review was to determine the accuracy of the ULBT for predicting difficult airway including difficult laryngoscopy or difficult tracheal intubation

Methods: We searched the databases of PubMed, Scopus, and Google scholar for prospective studies published up until October 2016 assessing the accuracy of ULBT in comparison to Cormack-Lehane grading. The selected keywords were ''upper lip bite test'', ''upper lip catch test'', ''prediction'', ''difficult airway'', ''difficult laryngoscopy'', ''difficult intubation''. Inclusion criteria were studies assessing ULBT for prediction of difficult intubation, considering Cormack-Lehane grade III and IV as difficult airway, written in English, and reporting sensitivity, specificity, NPV, PPV, and accuracy. Exclusion criteria were studies not reporting accuracy or not having enough data for its calculation. Based on the mentioned criteria, 27 studies enrolling 18141 patients were included. This systematic review was performed based on the guidelines on conducting systematic reviews of diagnostic studies

Results: Prevalence of airway difficulties according to the direct laryngoscopic view varied from 2.8% to 27% and according to the ULBT was from 2% to 21%. In 11 of the 27 studies, sensitivity of ULBT in prediction of difficult airway was more than 70%. All of the studies except one showed a high specificity for ULBT [>85%]. Moreover, these studies indicated a high NPV. Accuracy of ULBT was >85% in 24 out of 27 studies

Conclusion: It appears that ULBT is a useful bedside test for evaluation of patient airway before the general anesthesia

effect of bilateral intrapleural infusion of lidocaine with fentanyl versus only lidocaine in relieving pain after coronary artery bypasses surgery

Background and Objective: Pain control during surgery in order to cause analgesia and reduce the somatic and autonomic response may decrease the morbidity. Intrapleural catheter embedding during surgery under direct vision of surgeon is safe and easy and without potential risk of thoracic epidural block. The aim of this study was to investigate the effect of bilateral intrapleural infusion of lidocaine with fentanyl versus only lidocaine in relieving pain after coronary artery bypass surgery

Methods: In this prospective randomized double blind clinical trial,130 adult patients undergoing elective CABG with age range of 20 to 60 years were divided into two groups receiving either lidocaine and fentanyl [group A] or lidocaine [group B]. The analgesia was evaluated every two hours in all intubated and non-intubated patients using Visual analog scale [VAS] and data were analyzed using SPSS software package

Results: Of all patients, 67 [51.5%] were males and 63 [48.5%] were females. The average age of subjects was 53.49 +/- 5.099 years. Mean pain score six hours after the surgery was statistically different between the groups at all times

Conclusion: The pain in patients receiving combination of lidocaine and fentanyl is less than patients receiving only lidocaine

Comparison of pressure vs. volume controlled ventilation on oxygenation parameters of obese patients undergoing laparoscopic cholecystectomy

Backyround and Objective: There is no special guideline for the best ventilation mode during laparoscopic anesthesia in obese patients and there are too many studies with different controversial points

The aim of this study was to compare the effect of pressure controlled ventilation [PCV] vs. volume controlled ventilation [VCV] on respiratory and oxygenation parameters in patients undergoing laparoscopic cholecystectomy

Methods: Seventy patients with 30

Results: Patients in VCV group needed higher tidal volume and respiratory rate to maintain target C02 in 35 and 55 minutes after the study. Plateau pressure and mean airway pressure in two groups didn't have significant difference between two groups but peak airway pressure in 35 and 55 minutes after pneumoperitoneum was significantly higher in VCV group than PCV group. There were no significant differences between two groups regarding P02, PC02 and pH, except 35 and 55 minutes after pneumoperitoneum. In mentioned times, patients in PCV group had significantly higher P02 levels compared to VCV group

Conclusion: Despite some beneficial effects regarding plateau, mean airway pressure and oxygenation parameters with PCV, there was no significant clinical difference between PCV and VCV in obese patients undergoing laparoscopic cholecystectomy

Comparison of blood glucose level in diabetics undergoing orthopedic surgeries with general or spinal anesthesia

Background: Diabetes increases the risk of peri-operative morbidity and mortality and research to decrease intraoperative blood glucose variations has been continued without any results. The objective of this study was to evaluate the blood glucose level in diabetics undergoing orthopedic surgeries with general or spinal anesthesia

Methods: In this prospective cross-sectional descriptive analytic study the blood glucose levels were evaluated in 80 diabetic patients undergoing orthopedic surgeries during general and spinal anesthesia before surgery, after incision, after one hour and in recovery

Results: 25 patients were male and 55 were female. The age of patients in spinal group was 64.90+/- 10.73 and in general group 60.78+/-10.86 years old. Body Mass Index in spinal group was 27.85+/-3.69 and in general group 29.43+/-3.57. Blood glucose levels were not significantly different between two groups. The blood glucose levels were significant in samples taken between incision and recovery period in both groups

Conclusions: The blood glucose level during surgery and anesthesia has been increased continuously and this increase in general group had a steeper slope but it was acceptable

Comparison of three methods in improving bag mask ventilation

Increasedlife expectancy in populations has brought along specific new scenarios in the fields of medicine for the elderly; prevalence of physical complications such as edentulism and patients with dentures is growing. Management of anesthesia and ventilation in this group of patients has turned into a great challenge. Some researchers suggest dentures to be left in place during bag-mask ventilation; yet, no unanimous agreement exists in this regard. In a single blind randomized clinical trial, we studied 300 patients with ASA class I, II [American Society of Anesthesiologists], Mallampati class [I, II] and aged over 55 years in three groups. After induction of anesthesia, in group G dentures were removed and in each buccal space an eight-layer 10x10 cm gauze and an oral airway were placed. In group D, the dentures and an oral airway were left in place. In group C [control], after removing dentures just an appropriate oral airway was placed. Then, each three group underwent bag-mask ventilation. Success of bag-mask ventilation [BMV] was considered as increase in end-tidal carbon dioxide to more than 20 mmHg and back to baseline with fresh gas flow of 3 L/min and adjustable pressure limiting valve pressure of 20 cm H[2]O. Success rates were evaluated between groups. Effective BMV was possible in 91 [91%], 64 [64%] and 41 [41%] patients in groups G, D and C respectively. The differences were statistically significant. Successful BMV rate was significantly higher in female patients in group G compared to group C; 43/44 versus 25/46 individuals, P = 0.0001, odds ratio = 0.03, 95% confidence interval [0.00, 0.22]. Leaving dentures in place in edentulous patients after inducing anesthesia improves bag-mask ventilation. However, placing folded compressed gauze in buccal space leads to more significant improvement in BMV compared to leaving dentures in place

Baby cuff as a reason for laryngeal mask airway cuff malfunction during airway management for anesthesia

Placement of laryngeal mask airway [LMA] is a blind procedure without requiring laryngoscopy. The reported success rate for LMA insertion at the first attempt is almost 95%; however, many functioning LMAs may not be in an ideal anatomic place. It seems that disposable LMAs have more stable cuff pressure compared to reusable LMAs; therefore, Anesthesiologists should bear in mind this fact when using reusable LMAs to achieve a proper sealing and safe airway management. In this report, we introduced a case with malfunction of LMA cuff during the airway management

Allopurinol as a preventive contrivance after acute ischemic stroke in patients with a high level of serum uric acid: a randomized, controlled trial

To assess the clinical relevance [functional outcome] of a 3-month allopurinol regimen in patients with high serum uric acid [SUA] levels and acute ischemic stroke without considering the changes in SUA levels. In a randomized, double-blind, controlled study, 70 patients [45 females, 25 males] with acute ischemic stroke who had elevated levels of SUA were included. They were divided in two 35-patient groups to investigate the effect of 3 months of an allopurinol [200 mg/day] regimen versus placebo on their functional outcome, which was evaluated using a modified Rankin scale. The overall mean age was 68.9 +/- 11.33 years [range 27-89]. The final favorable functional status [mRS = 0-2] was 23 [65.7%] and 14 [40.0%] in the treated and placebo groups, respectively, which was strongly associated with allopurinol consumption [OR = 4.646, p = 0.014] and age

Effect of a probiotic preparation [VSL no.3] in critically ill patients: a randomized, double-blind, placebo-controlled trial [Pilot Study]

Objective: Reactive oxygen species [ROS] are a major contributing factor in diseases pathophysiology in critically ill patients. Oxidative stress usually occurs in critical illnesses, specifically during sepsis, and organ dysfunction. The anti-oxidative properties of probiotics may serve as a defense in intestine and overcome various oxidative stresses. The aim of this trial was to determine the effect of probiotics on inflammation, antioxidant capacity and lipid peroxidation in critically ill patients

Methodology: Forty patients admitted to the intensive care unit were enrolled in this double-blind, randomized controlled trial. They were randomized to receive placebo or probiotic for 7 days. Serum levels of Total Antioxidant Capacity [TAC], Malodialdehyde [MDA], C-Reactive Protein [CRP] and Acute Physiology and Chronic Health Evaluation [APACHE II] score were measured before initiation of the study and on the 7[th] day

Results: There was a significant difference in CRP levels and APACHE II score between two groups at the end of the study [P= 0.003 and 0.001, respectively]. There was not a significant difference in levels of TAC and MDA between two groups

Conclusions: Administration of probiotics to critically ill patients caused reduction in inflammation and improvement of clinical outcome. However, there were not significant changes in markers of oxidative stress

Comparison of postoperative complication between Laryngeal Mask Airway and endotracheal tube during low-flow anesthesia with controlled ventilation

Objective: To compare the postoperative complications between Laryngeal Mask Airway [LMA] and endotracheal tube [ETT] during low-flow anesthesia with controlled ventilation

Methodology: Eighty adult Patients with ASA class I or II were randomly allocated into two forty-patient groups [ETT or LMA]. Cuff pressure was monitored during anesthesia. After high uptake period, fresh gas flow [FGF] was decreased to 1 lit/min and isoflurane set to 1%. Monitoring during anesthesia included non-invasive blood pressure, ECG, ETCO2 and pulse oximetry. System leakage [>100 ml/min], rebreathing and any attempt to increase FGF to overcome the leak were monitored during anesthesia. Later, patients were extubated and transferred to Post Anesthesia Care Unit [PACU]. In PACU, the incidence of sore throat, cough, difficulty in swallowing and shivering was monitored for all patients

Results: Leakage was observed in two and three cases in ETT and LMA groups respectively [P>0.05]. Postoperative cough, sore throat and difficulty in swallowing were significantly less in LMA than ETT group. No significant difference was observed regarding ETCo2 values between 2 groups

Conclusion: If careful measures regarding insertion techniques, correct LMA position and routine monitoring of LMA cuff pressure are taken, LMA can be used as a safe alternative with lower incidence of post operation complication compared with ETT during low-flow controlled anesthesia with modern anesthetic machines

Comparison of prophylactic effects of polyurethane cylindrical or tapered cuff and polyvinyl chloride cuff endotracheal tubes on ventilator-associated pneumonia

Because microaspiration of contaminated supraglottic secretions past the endotracheal tube cuff is considered to be central in the pathogenesis of pneumonia, improved design of tracheal tubes with new cuff material and shape have reduced the size and number of folds, which together with the addition of suction ports above the cuff to drain pooled subglottic secretions leads to reduced aspiration of oropharyngeal secretions. So we conducted a study to compare the prophylactic effects of polyurethane-cylindrical or tapered cuff and polyvinyl chloride cuff endotracheal tubes [ETT] on ventilator-associated pneumonia. This randomized clinical trial was carried out in a 12 bed surgical intensive care unit. 96 patients expected to require mechanical ventilation more than 96 hours were randomly allocated to one of three following groups: Polyvinyl chloride cuff [PCV] ETT, Polyurethane [PU] cylindrical Sealguard ETT and PU Taperguard ETT. Cuff pressure monitored every three hours 3 days in all patients. Mean cuff pressure didn't have significant difference between three groups during 72 hours. Pneumonia was seen in 11 patients [34%] in group PVC, 8 [25%] in Sealguard and 7 [21%] in Taperguard group. Changes in mean cuff pressure between Sealguard and PVC tubes and also between Taperguard and PVC tubes did not show any significant difference. There was no significant difference in overinflation between three groups. The use of ETT with PU material results in reducing ventilator-associated pneumonia compared to ETT with PVC cuff. In PU tubes Taperguard has less incidence of ventilator-associated pneumonia compared to Sealguard tubes

Sensitivity of palm print, modified mallampati score and 3-3-2 rule in prediction of difficult intubation

This study evaluated the performance of modified Mallampati score, 3-3-2 rule and palm print in prediction of difficult intubation. In a prospective descriptive study, data from 500 patients scheduled for elective surgery under general anesthesia were collected. An anesthesiologist evaluated the airway using mentioned tests and another anesthesiologist evaluated difficult intubation. Laryngoscopic views were determined by Cormack and Lehane score. Grades 3 and 4 were defined as difficult intubation. Sensitivity, specificity, positive predictive value, negative predictive value and Youden index were determined for all tests. Difficult intubation was reported in 8.9% of the patients. There was a significant correlation between body mass index and difficult intubation [P: 0.004]; however, other demographic characteristics didn't have a significant correlation with difficult intubation. Among three tests, palm print was of highest specificity [96.46%] and modified Mallampati of highest sensitivity [98.40%]. In a combination of the tests, the highest specificity, sensitivity and Youden index were observed when using all three tests together. Palm print has a high specificity for prediction of difficult intubation, but the best way for prediction of difficult intubation is using all three tests together

Multi organ failure following intravenous gasoline for suicide: a case report

Hydrocarbons are ubiquitous in daily life and include plant and animal fats, alcohols, solvents, natural gas, petroleum derivates. Majority of intoxication reports of hydrocarbons are due to inhalation or ingestion, but there is few reports about intravenous injection of gasoline. We report a 58 year-old man who injected gasoline intravenously for suicide. He developed soft tissue necrosis of forearm and bilateral pulmonary infiltration. He underwent fasciotomy and extensive debridement of necrotic tissues, at the operation room. He was intubated and mechanically ventilated because of acute lung injury. He developed acute kidney injury after 2 days. These symptoms seem to be due to extravasation of gasoline from vessels which lead to inflammation, cell damage and organ failure. The patient developed multi organ failure which unfortunately did not respond to our treatment and he died at day 21. Management of gasoline intoxication depends on the rout of exposure. Like other types of toxications, intravenous toxication has pulmonary involvement, however in this case we had multiple organ involvement. It seems that in such cases we should consider early end organ targeted therapy to stop the future organ failure

Modified cricothyroidotomy in skill laboratory

Unsuccessful tracheal intubation is considered the most common cause of anesthesia death or brain damage. This study delineates our experience recommending modifications in the cricothyroidotomy technique. Thirty emergency medicine residents of participated in a study performed on the human simulator moulage in Skill Laboratory of Tabriz University of Medical Science. The cricothyroid membrane was punctured using a 16-gauge cannula. Later, J guide wire was advanced into trachea and standard 16-gauge intravenous cannula with a removable needle stylet withdrawn after the puncture being dilated by a dilator. Consequently, a cuffed tracheal tube [ID= 6] was introduced from the foramen. From 30 residents, 18 residents performed cricothyroidotomy within 1 minute, 7 residents in 2 minutes and 5 residents failed to fulfill the procedure. Several studies using cadavers and human simulators have demonstrated the pre-hospital feasibility of this technique. However, descriptions of clinical pre-hospital experience with percutaneous cricothyroidotomy are limited. This study shows that skill lab may help residents to acquire techniques required in management of difficult airway.

Effects of pantoprazole on systemic and gastric pro- and anti-inflammatory cytokines in critically three patients

Stress-related mucosal damage [SRMD] is a significant cause of morbidity and mortality in critically ill patients due to the gastrointestinal blood loss. Prophylaxis of SRMD with proton pump inhibitors or histamine-2 blockers has gained widespread use in intensive care units. Both demonstrated to be effective in reducing clinically significant bleedings, while PPIs has shown to exert some anti inflammatory effects including the inhibition of producing pro-inflammatory cytokines. As cytokines have role in developing SRMD, the aim of this study was to evaluate the effect of PPIs on the inhibition of cytokine release following the critical illness. A total of 27 critically ill patients with risk factors of developing stress ulcer and intragastric pH < 3.0 enrolled to this Randomized clinical trial study. Patients were randomly assigned in three treatment groups; group one received 40 mg of intravenous pantoprazole every 12 h for 48 h [four doses], group two received 80 mg of intravenous pantoprazole every 24 h continuous infusion for 48 h and the third group received 150 mg of ranitidine intravenously as 24 h continuous infusion for 48 h. Plasma and gastric juice samples were obtained at 0th, 12th, 24th and 48th h for the measurement of EGF, IL-1beta, IL-6, IL-10 and TNF-alpha. Pantoprazole infusion have decreased the plasma IL-1beta concentrations [p = 0.041]. No other significant differences in concentrations of EGF, IL-6, IL-10 and TNF-alpha were detected. There were reverse correlations between the intragastric pH with gastric juice IL-1beta and TNF-alpha concentrations and a direct correlation between the intragastric pH and gastric juice EGF in pantoprazole groups. Our data suggest that pantoprazole may have some anti-inflammatory effects on patients. However, the exact impact of this effect on patients should be assessed by further studies

Efficacy of low dose interscalene brachial plexus block on post anesthesia recovery parameters after shoulder surgery

Excellent postoperative pain control plays central role in the outcome of open shoulder surgery which provides early rehabilitation and accelerates functional recuperation. Fifty patients who were candidate for elective shoulder surgery were enrolled in this study. Patients were randomized to two 25-patient groups. One group received morphin sulfate and in the other group small volume Interscalene Brachial Plexus Block [ISBPB] was performed. Pain severity, patient satisfaction scores and post anesthesia recovery parameters were assessed. Patients satisfaction score was significantly improved in ISBPB [P<0.001]. Agitation in ISBPB group was significantly reduced compared to the other group [P: 0.009]. Pain severity score was significantly reduced with ISBPB [P=0.001]. ISBPB did not have any side effects on post anesthesia recovery parameters. Small volume ISBPB may be considered as a suitable technique for reducing intermediate postoperative pain without any effect on post anesthesia care unit parameters and stay in patients undergoing open shoulder surgery

Digital intubation training in residency program as an alternative method in airway management

Digital intubation is a method for airway management in patients with distorted anatomy and cervical or skull fractures wherein movement is undesirable. This study was designed to determine whether digital intubation training is effective for airway control by emergency medicine or anesthesiology residents. A prospective descriptive study of clinical education was carried out in the Nikoukari Hospital. In this study 15 anesthesiology and 15 emergency medicine residents received digital intubation training. Then they were asked to intubate patients with grade I or II Mallampati class, with no more than two attempts. Digital intubation was attempted after induction of anesthesia. Tube placement was confirmed by direct laryngoscopy. The total time for all attempts was recorded. In 18 of 30 trainees, intubation was successful in first attempt [60%]. The success rate was 80% for all attempts. The average time required for digital intubation [either success or failure] was 22 seconds. A 100% success rate was observed in trainees with long fingers. Any trauma induced bleeding in oral cavity was not reported. Although the gold standard for endotracheal intubation is direct laryngoscopy, digital intubation training might be considered as an easy and life-saving adjunction for airway management

comparative study of efficacy of intensive insulin therapy versus conventional method on mortality and morbidity of critically ill patients

Hyperglycemia is associated with increased mortality and morbidity. Current evidence has controversies about Intensive Insulin Therapy [NT] and its effect on reducing mortality in critically ill patients. In this trial we evaluated the effect of intensive insulin therapy with a simple protocol versus traditional method on morbidity and mortality of critically ill patients who were admitted to surgical intensive care unit. Sixty adult patients admitted to surgical intensive care unit between Feb 2009 to Feb 2010 in Shohada Hospital, were enrolled in this study. Patients were randomly allocated to intensive insulin therapy group [with a target blood sugar of 80-120 mg/dl] and conventional group [received insulin if blood glucose was more than 200 mg/dl]. Study was continued through the ICU stay of all patients. Acute Kidney Injury, Renal Replacement Therapy, Bactremia and transfusion were less in intensive insulin therapy without significant difference compared to control group. Mortality also was not significant between two groups. Because of the consequences of hyperglycemia, NT might be considered in critically ill patients, but intermediate levels may be more safe and effective and remains the best practice in Intensive Care Units. Defining ICU capability is critical for implementing tight glycemic control and future multi center studies are needed to consider the effect of NT on mortality as an essential outcome

Tracheal cartilage fracture with the percutaneous dilatational tracheostomy, Ciaglia method

Surgical tracheostomy was first introduced by an ENT surgeon [Chevalier Jackson] in 1900. In 1955, Seldinger, a Swedish radiologist, introduced a way of insertion of a tube with the aid of a guidewire into the hollow spaces of body, such as blood vessels. In 1985 Pasquale Ciaglia performed percutaneous dilatational tracheostomy [PDA] with the Seldinger method. Tracheostomy nowadays is usually performed as PDT in the ICUs[1]. Most of the PDT methods are performed with the Seldinger method. The basic difference between the various PDT methods, however, is in both the way of dilation and the way of dilator entrance [antegrade vs retrograde]. In the Ciaglia method, several dilator tubes are used for tracheal dilation[2]