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

Combination of intracostal sutures with muscle flap to decrease post thoracotomy pain: a singleblinded randomized clinical trial

Objective: To assess the efficacy of intercostal nerve protection by intercostal muscle [ICM] flap in post-thoracotomy pain improvement compared to intracostal suturing

Methods: In a randomized controlled trial, ninety-four patients undergoing posterolateral thoracotomy surgery were divided into two subgroups. Intracostal sutures in isolation and in combination with ICM flap techniques were used for thoracotomy closure in both groups. Numeric Pain Scale and Visual Pain Scale as pain scores were assessed on the first, second, third, fourth, fifth, sixth and seventh postoperative days and follow-up visits during the 2[nd] week, 1[st], 2[nd], 4[th] and 6[th] months after thoracotomy

Results: Out of 94 patients, 58 were male and 36 were females. While the mean age of patients in intracostal group was 45.3 +/- 17.6 years, it was 47.4 +/- 16.1 years in intracostal plus ICM flap group. The mean operation time for the first group was 191.0 +/- 74.7 minutes, while it was 219.3 +/- 68.8 minutes in the second [p>0.05]. Numeric rating score and visual pain scale did not demonstrate any significant difference in pain severity on postoperative days and follow-up visits between both groups [p>0.05]. Although the trend of pain reduction was significant in each group [p<0.001], the difference was not statistically significant [p>0.001]

Conclusion: Intracostal sutures in combination with muscle flap did not reduce postoperative pain in thoracotomy compared with intracostal sutures alone in thoracotomy closure

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

Effect of conjugated linoleic acid supplementation on quality of life in rectal cancer patients undergoingpreoperative Chemoradiotherapy

Objectives: This study set out with the aim of evaluating the effect of conjugated linoleic acid [CLA] supplementation on quality of life in rectal cancer patients undergoing to preoperative chemoradiotherapy

Methods: In this study, 33 volunteer patients with rectal cancer treated with preoperative chemoradiotherapy were allocated in the CLA [n=16] and the placebo groups [n=17]. The CLA group and placebo groups received 3 gr CLA/d and 4 placebo capsules for 6 weeks respectively. Before and after intervention, quality of life of patients was assessed by EORTC QLQ-C30

Results: At the end of study, the mean scores of physical function, role function, and cognitive function enhanced significantly in the CLA group while reduced remarkably in the placebo group. Symptom scales improved in the CLA group at the end of study. Comparison of changes in fatigue, pain and diarrhea scores were statistically significant between two study groups [P<0.05]. When we compared the global health status scores between two groups, significant changes were observed [P<0.001]

Conclusion: It appears that CLA may be helpful in rectal cancer patients by improving global quality of life. Although, other clinical trials with large sample size are needed to achieve more precise results

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

Relationship between plasma level of Vitamin D and post operative atrial fibrillation in patients undergoing CABG

Objective: Atrial fibrillation is the most common arrhythmia after cardiac surgery. Several studies have shown the impact of vitamin D on heart disease; however, there have been few studies for the incidence of AF and its relationship with vitamin D levels. According to the different results of these studies, we decided to evaluate the relation of plasma levels of vitamin D and postoperative atrial fibrillation in patients undergoing coronary artery bypass surgery [CABG]

Methods: This cross-sectional study was performed on 50 patients after CABG surgery. Simple random sampling was done. Twenty five patients who developed AF within 48 hours after CABG with Cardiopulmonary bypass [CPB] were enrolled in the case group and 25 patients who did not develop AF within 48 hours after CABG with CPB were enrolled in the control group. Plasma levels of vitamin D in both groups of patients were recorded. Collected data were analyzed by the SPSS software version 17

Results: There was no significant difference in terms of demographic characteristics, comorbidities, lipid profile and kidney function between two groups. The mean plasma level of vitamin D was 27.4 +/- 2.22 ng/ ml in the case group and was 28.2 +/- 1.18 ng/ml in the control group it [p= 0.803]

Conclusions: Plasma levels of vitamin D were almost the same in both groups and there was no statistically significant difference between the groups with and without atrial fibrillation following CABG

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

Complications and safety of percutaneous dilatational tracheostomy with Griggs method versus surgical tracheostomy a prospective trial with six months follow-up

Percutaneous Dilatational Tracheostomy has been developed all across the world during past two decades and is being performed with different methods in Intensive Care Units. The purpose of this study was to compare the complications of surgical tracheostomy versus pecutaneous dilatational traheostomy with Griggs method. In this prospective clinical trial, 100 cases of Percutaneous Dilatational Tracheostomy [PDT], was compared to surgical method. All PDTs were performed with Griggs method. The patients had been followed up for five months on a regular basis and potential complications were recorded. In surgical group we had three complications leading to death: Bleeding, Sever Emphysema and Pneumothorax. In five months of follow-up, we had no ventilatory complication in PDT group. Bleeding and infection rate in Tracheostomy place itself, Pneumothorax, Emphysema, duration of procedure, and required time for total closure of tracheostomy place in PDT were significantly less than surgical group. Percutaneous Dilatational Tracheostomy [PDT] with Griggs method has less complication in comparison to Surgical Tracheostomy. As such it should be recommended as a method of choice for tracheostomy in critically ill patients

effect of intramuscular ephedrine in prevention of hypotension due to propofol

To evaluate the effect of intramuscular [IM] ephedrine before injection of propofol, to reduce hypotension. It was a prospective, hospital based study conducted during March 2003 to December 2003, at Nikookary Hospital, Tabriz Medical Science University, Iran. This study was performed on one hundred patients who were candidates for elective ophthalmic surgeries randomized to two groups of 50 patients. In one group [group A] ephedrine 10mg [2cc] and in other group [group B] sterile water 2cc were injected intramuscularly. Twenty minutes before induction of anesthesia or before injection of propofol, during intubation, in 1[st], 4[th], 7[th] and 10th minutes of anesthesia blood pressure and heart rate were measured in both groups. The mean values were compared in two groups. There was only one case with significant mean diastolic blood pressure drop at 1[st] minute after intubation in group A comparing with group B. P=0.001. In other cases, differences of mean blood pressures were not significant. Also heart rates in all mentioned minutes were significantly higher in group A than group B. P<0.05]. IM injection of ephedrine before induction of anaesthesia with propofol does not have any significant effect in decreasing of patient's hypotension during operation, however it increases their heart rates. According to the potential hazards of the later complication, especially in old patients, this procedure is not recommended

Comparison of recovery after anesthesia with remifentanil infusion versus halothane in children undergoing strabismus surgery

To compare recovery after anesthesia with remifentanil infusion versus halothane for strabismus surgery. This study was performed from September 2004 to March 2005 in Tabriz Nikookary Hospital, Tabriz, Iran on children aged 2-12 years scheduled for strabismus surgery randomized into 2 groups of 25 patients each: the H group in which anesthesia was maintained with halothane and the R group in which anesthesia was maintained with remifentanil. There was no meaningful difference in extubation time after discontinuing drugs between the 2 groups [p=0.14]. However, there was a significant difference in the time of purposeful movements, proper oxygenation, consciousness, and discharge from the post anesthetic care unit between the 2 groups, all being shorter in group R. Also in group R, the time to spontaneous breathing return was longer, cases of neuromuscular reversal were fewer and cases of limb movements were more than group H. Maintenance of anesthesia with remifentanil in children aged 2-12 years undergoing strabismus surgery provided desired hemodynamic status and shorter time of discharge criteria

Validity of fasting blood sugar on the day of surgery compared with the preinduction blood glucose level in type II diabetic patients

It is necessary that the diabetic patients who are scheduled for elective surgery, be operated as the first cases, but usually it is not possible due to large number of surgeries. The aim of this study was to compare the fasting blood sugar [FBS] on the morning of operation day with pre-operative blood glucose level. Prospective, hospital based study conducted during September 2004-July 2005. Nikookary Hospital, Tabriz Medical Science University, Iran. One hundred patients scheduled for ophthalmic surgery, were enrolled in this study. The levels of fasting and preoperative blood sugar [by lab and glucometery] were measured and compared with the FBS and with each other, as well. There was a significant difference between FBS and pre-operative Blood Sugar glucometery and the laboratory [P< 0.001 and P=0.001, respectively], and also between the mean preoperative BS by the glucometery and the laboratory procedures [P<0.001]. It is not possible to use FBS on the morning of operation day instead of the pre-operative BS level in diabetic patients

wake tracheal intubation via intubating laryngeal mask vs direct laryngoscopy and cervical spine excursion

To compare intubating laryngeal mask airway [ILMA] with direct laryngoscopy in patients with cervical spine injury. Prospective, hospital based study conducted during March 2004 to May 2005, in Imam Khomeini Hospital, Tabriz Medical Science University, Iran. We compared the excursion of the upper cervical spine during tracheal intubation using direct laryngoscopy with awake intubation via Laryngeal mask airway in 40 patients. Intubating laryngeal mask caused less extension [at C2-3 and C1-2] than intubation by direct laryngoscope. Patients, who were locally anesthetized and sedated tolerate intubation well. However laryngoscopy is still the fastest method to secure an airway. In traumatic patients who require intubation and have limitation with cervical spine movement, we can use intubating laryngeal mask in awake patients locally anesthetized as a safe, tolerable and relatively fast method to secure an airway

relationship between cerebral oxygen saturation changes and post operative neurologic complications in patients undergoing cardiac surgery

To study the relationship between cerebral oxygen saturation changes and postoperative neurologic complications. Seventy two adult patients with ASA class II, III who were scheduled for elective cardiac surgery, were randomized into three groups: Group I: with CPB [on-pump] Group II: without CPB [off-pump] Group III: valve surgery. Neuropsychological outcome was assessed by the Mini-Mental State Examination [MMSE]. Cerebral oxygen saturation was also measured. There was no statistical difference in desaturation of more than 20% among three groups [P=0.113] but it was significant between group I and II [P=0.042]. Changes of rSO2 in different hours of surgery was significant in group I and group II [P=0.0001 in both] but it was not significant in group III [P=0.075]. Although cerebral oximetry is a noninvasive and useful method of monitoring during cardiac surgery, it has low accuracy to determine postoperative neurologic complications