Prognostic Significance of the Strong Ion Gap in Patients in Medical and Surgical Intensive Care Units.

Background This study aimed to analyze acid-base imbalance by assessing the arterial blood gas (ABG) samples of the medical and surgical intensive care unit (ICU) patients by the Stewart approach and demonstrate the advantages of this method in delineating the acid-base status in cases where Henderson-Hasselbalch, anion gap, and base excess cannot optimally depict the imbalance and create recognition in the clinicians in this regard.  Methodology Adult (i.e., age > 18 years) patients admitted to the ICU of our institution during a one-year study period were included in this study. The patients were divided into two groups based on the indication of admission to the ICU as medical or surgical. The ABG, sodium, potassium, calcium, magnesium, phosphate, chloride, albumin, lactate, hemoglobin, hematocrit, leukocyte, blood urea nitrogen, and creatinine values determined during the first 24-hour period were used for calculating the Acute Physiologic Assessment and Chronic Health Evaluation (APACHE II), strong ion difference apparent (SIDa), and SID effective (SIDe) scores, which were subsequently compared between the groups.  Results Overall, 220 (110 medical and 110 surgical) patients were included. The mean patient age was 63.56 ± 18.08 years. The mean APACHE II scores were 21.99 and 19.63 in the medical and surgical groups, respectively. Overall, 110 patients died, while 110 were referred to the regular patient floor. The mean APACHE II score of the patients who died was 28.3, and the latter group had a mean APACHE II score of 13.57. There was a significant difference between the surgical and medical patient groups regarding mean values of APACHE II, SIDa, and SIDe scores. Also, the differences were significant between the patients who died and were discharged. There was a significant difference between the patients who died and were discharged regarding the strong ion gap (SIG); however, the medical and surgical patient groups were not different concerning the SIG values.  Conclusions We conclude that SIDa, SIDe, and SIG can be used in medical and surgical ICU patients to predict prognosis.

Comparison of Risk Scoring Systems to Predict the Outcome in ASA-PS V Patients Undergoing Surgery: A Retrospective Cohort Study.

Operative decision in American Society of Anesthesiology Physical Status (ASA-PS) V patient is difficult as this group of patients expected to have high mortality rate. Another risk scoring system in this ASA-PS V subset of patients can aid to ease this decision. Data of ASA-PS V classified patients between 2011 and 2013 years in a single hospital were analyzed in this study. Predicted mortality of these patients was determined with acute physiology and chronic health evaluations (APACHE) II, simplified acute physiology score (SAPS II), Charlson comorbidity index (CCI), Porthsmouth physiological and operative severity score for enumeration of mortality and morbidity (P-POSSUM), Surgical apgar score (SAS), and Goldman cardiac risk index (GCRI) scores. Observed and predicted mortality rates according to the risk indexes in these patients were compared at survivor and nonsurvivor group of patients. Risk stratification was made with receiver operator characteristic (ROC) curve analysis. Data of 89 patients were included in the analyses. Predicted mortality rates generated by APACHE II and SAPS II scoring systems were significantly different between survivor and nonsurvivor group of patients. Risk stratification with ROC analysis revealed that area under curve was 0.784 and 0.681 for SAPS II and APACHE II scoring systems, respectively. Highest sensitivity (77.3) is reached with SAPS II score. APACHE II and SAPS II are better predictive tools of mortality in ASA-PS V classified subset of patients. Discrimination power of SAPS II score is the best among the compared risk stratification scores. SAPS II can be suggested as an additional risk scoring system for ASA-PS V patients.

Timing of levosimendan in cardiac surgery.

OBJECTIVE: Levosimendan (LS) is a new inodilator agent that improves cardiac contractility by increasing the sensitivity of troponin C to calcium, which usage in cardiac surgery has been growing in the recent years. We aimed to determine the best timing of the administration of LS in high-risk patients who underwent cardiovascular surgery. METHODS: Fifteen patients were evaluated retrospectively who have left ventricular dysfunction, underwent open-heart surgery and were applied LS in different phases of operation. Patients were divided into 3 groups according to timing of LS. Levosimendan infusion (0. 1 microg-1kg-1min) was applied after the induction of anaesthesia (n=5) (Group 1), during the pump removal period (n=5) (Group 2) and in postoperative period (n=5) (Group 3). Demographic data, operative characteristics, mean arterial pressure (MAP), mean pulmonary arterial pressure (MPAP), pulmonary wedge capillary pressure (PWCP), cardiac index (CI), inotropic agent consumption, postoperative urine output, lactate levels of groups were compared between before and after LS treatment. Data were evaluated by Fisher exact, Kruskal-Wallis, Mann-Whitney U and Wilcoxon rank tests. RESULTS: In all patients, urine output was satisfactory 24 hours after LS application. There was a significant increase in CI of all 3 groups (p=0.04). Also, there was a significant decrease in PCWP of all 3 groups before and after LS (p=0.04). There was a significant decrease in MPAP in Group 2 and 3 (p=0.04). Twenty- four hours after LS application, whereas all inotropic agents could be stopped in Group 1 and 2, in Group 3 inotropic infusion (dopamine [10 microg-1kg-1min (5-17.5)], dobutamine [15 microg-1kg-1min (5-20)] and adrenaline [0.4 microg-1kg-1min (0.15-0.65)]) couldn't be stopped (p=0.007). During postoperative period, in Groups 1 and 2 one case from each required intraaortic balloon pump, while in Group 3 four patients were applied intraaortic balloon pump (p=0.08). CONCLUSION: According to our experience, LS is effective in high-risk cases during cardiac surgery, especially during the intra-operative and pump removal periods;however, no successful outcomes were observed during the post-operative period. As a result, case selection and timing should be performed well when using LS.