Retrospective analysis of the long-term outcomes of percutaneous endoscopic gastrostomy in critically ill patients and the satisfaction of their caregivers.

OBJECTIVE: Long-term benefits of percutaneous endoscopic gastrostomy and satisfaction of patients' caregivers have not been investigated in the literature in detail. Hence, this study was carried out to investigate the long-term nutritional benefits of percutaneous endoscopic gastrostomy in critically ill patients and their caregivers' acceptance and satisfaction rates. PATIENTS AND METHODS: The population of this retrospective study consisted of critically ill patients who underwent percutaneous endoscopic gastrostomy between 2004 and 2020. Data about the clinical outcomes were obtained via telephone interviews using a structured questionnaire. The long-term benefits of the procedure in terms of weight change and the current thoughts of the caregivers about percutaneous endoscopic gastrostomy were addressed. RESULTS: The study sample consisted of 797 patients with a mean age of 66.4 ± 17.1 years. Patients' Glasgow Coma Scale scores ranged from 4.0 to 15.0, with a median score of 8. Hypoxic encephalopathy (36.9%) and aspiration pneumonitis (24.6%) were the most common indications. There was neither change in body weight nor weight gain in 43.7% and 23.3% of the patients, respectively. Oral nutrition could be recovered in 16.8% of the patients. Of the caregivers, 37.8% stated that percutaneous endoscopic gastrostomy was beneficial. CONCLUSIONS: Percutaneous endoscopic gastrostomy may be a feasible and effective method for long-term enteral nutrition in critically ill patients treated in intensive care units.

Impact of positive end-expiratory pressure with alveolar recruitment maneuver on respiratory and oxygenation parameters of patients during laparoscopic bariatric surgery.

OBJECTIVE: Laparoscopic bariatric surgery is frequently associated with disturbances in respiratory mechanics. An alveolar recruitment maneuver (ARM) with positive end-expiratory pressure (PEEP) is a strategy to overcome such respiratory conditions. This study aimed to evaluate the effect of ARM+PEEP on intraoperative and postoperative respiratory and hemodynamic parameters of patients with laparoscopic bariatric surgery. PATIENTS AND METHODS: Patients who underwent laparoscopic bariatric surgery between 2009 and 2016 were retrospectively evaluated. The study sample was divided into four groups based on PEEP values and the presence of ARM: Group PEEP 5 (5 cm H2O PEEP only), Group PEEP 5/RM (5 cm H2O PEEP plus ARM), Group PEEP 10 (10 cm H2O PEEP only), Group PEEP 10/RM (10 cm H2O PEEP plus ARM). Patients' demographic characteristics, ventilatory, respiratory, and oxygenation parameters were recorded. Oxygenation index (PaO2/FiO2) was the study's primary outcome. RESULTS: There were 156, 158, 299, and 210 patients in Groups PEEP 5, PEEF 5/RM, PEEP 10, and PEEP 10/RM, respectively. Tidal volume, driving tidal volume/compliance, PaO2, PaO2/FiO2, and PaCO2 were significantly lower in Groups PEEP 5 and PEEP 5/RM, whereas SpO2 and FiO2 were significantly higher in Groups PEEP 5 and PEEP 5/RM (p<0.05). Patients in Group PEEP 5 had significantly higher end-tidal carbon dioxide (EtCO2) values than those of other groups (p<0.001). Patients in Group PEEP 5/RM had significantly higher SpO2 values than those in Group PEEP 5 (p<0.001). Rate of postoperative atelectasis was significantly higher in Group PEEP 5/RM compared to the other groups (p=0.011). CONCLUSIONS: A PEEP level of at least 10 cm H2O with ARM improved intraoperative respiratory parameters and caused a significant reduction in postoperative atelectasis.

Various scoring systems for predicting mortality in Intensive Care Unit.

CONTEXT: Various scoring systems have been developed to predict mortality and morbidity in Intensive Care Unit (ICU), but different data has been reported so far. AIMS: This retrospective clinical study aims to evaluate predictability of Acute Physiology and Chronic Health Evaluation II (APACHE II), APACHE IV, Simplified Acute Physiology Score III (SAPS III) scoring systems regarding with mortality. SETTINGS AND DESIGN: Sixteen bed surgical-medical ICU in university hospital. MATERIALS AND METHODS: The study comprised 487 patients older than 18 years treated in ICU for at least 24 h. Age, gender, body weight, initial diagnosis, clinic of referral, intubation, comorbidities, APACHE II, APACHE IV, Glasgow coma scale, SAPS III scores, length of hospitalization before referral to ICU, length of stay in ICU, mechanical ventilation were recorded. RESULTS: Most of the patients (54.6%) were consulted from operating room. The most frequent diagnosis was acute respiratory failure. Total mortality rate was 26%. Mortality rate was higher in patients admitted from wards other than surgery (48%) (P < 0.005). In the presence of comorbidities, mortality rate was higher with comorbidities than without (P < 0.05). Regression analysis indicated a significant positive relationship between length of stay in ICU, length of mechanical ventilation and high mortality risk in patients referred from emergency service (P < 0.05). Accuracy rates of predicting mortality were 81%, 79%, and 81% for APACHE II, APACHE IV, and SAPS III, respectively. CONCLUSIONS: The investigated scoring systems are similar in sensitivity and specificity mortality prediction whereas the accuracy was higher for SAPS III and APACHE II than APACHE III in our patient population.

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 11 adult intensive care units from 10 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC).

PURPOSE: To evaluate the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional approach on the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 11 intensive care units (ICUs), from 10 hospitals, members of the INICC, in 10 cities of Turkey. METHODS: A prospective active before-after surveillance study was conducted to determine the effect of the INICC multidimensional approach in the VAP rate. The study was divided into two phases. In phase 1, active prospective surveillance of VAP was conducted using the definitions of the Centers for Disease Control and Prevention National Health Safety Network, and the INICC methods. In phase 2, we implemented the multidimensional approach for VAP. The INICC multidimensional approach included the following measures: (1) bundle of infection control interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback of VAP rates, and (6) performance feedback of infection control practices. We compared the rates of VAP obtained in each phase. A time series analysis was performed to assess the impact of our approach. RESULTS: In phase 1, we recorded 2,376 mechanical ventilator (MV)-days, and in phase 2, after implementing the multidimensional approach, we recorded 28,181 MV-days. The rate of VAP was 31.14 per 1,000 MV-days during phase 1, and 16.82 per 1,000 MV-days during phase 2, amounting to a 46 % VAP rate reduction (RR, 0.54; 95 % CI, 0.42-0.7; P value, 0.0001.) CONCLUSIONS: The INICC multidimensional approach was associated with a significant reduction in the VAP rate in these adult ICUs of Turkey.

Differential perfusion: a new technique for isolated brain cooling during cardiopulmonary bypass.

BACKGROUND: The purpose of this study was to determine the feasibility of differential perfusion of the aortic arch and descending aorta during cardiopulmonary bypass using a cannula designed for aortic segmentation. METHODS: Pigs weighing 57 kg (n = 8), underwent cardiopulmonary bypass using the dual lumen aortic cannula. An inflatable balloon separated proximal (aortic arch) and distal (descending aorta) ports. During differential perfusion, the aorta was segmented and the arch and descending aorta perfused differentially using parallel heat exchangers. Ability to independently control brain and body temperature, cardiopulmonary bypass flow rate and mean arterial blood pressure was determined. RESULTS: During differential perfusion cerebral hypothermia (27 degrees C) with systemic normothermia (38 degrees C) was established in 23 minutes. Independent control of arch and descending aortic flow and mean arterial blood pressure was possible. Analysis of internal jugular venous O2 saturation data indicated an increase in the ratio of cerebral O2 supply to demand during differential perfusion. CONCLUSIONS: A cannulation system segmenting the aorta allows independent control of cerebral and systemic perfusion. This device could provide significant cerebral protection while maintaining the advantages of warm systemic cardiopulmonary bypass temperatures.

Effect of cerebral embolization on regional autoregulation during cardiopulmonary bypass in dogs.

BACKGROUND: Embolization during cardiopulmonary bypass probably alters cerebral autoregulation. Therefore, using laser Doppler flowmetry we investigated the cerebral blood flow velocity changes in response to changes in arterial pressure, before and after embolization in a canine bypass model. METHODS: After Institutional Animal Care and Use Committee approval, 8 anesthetized dogs had a laser Doppler flow probe positioned over the temporoparietal dura. During 37 degrees C cardiopulmonary bypass, the cerebral blood flow velocity response to changing mean arterial pressure (40 to 85 mm Hg in random order) was assessed before and after systemic embolization of 100 mg of 97-microm latex microspheres. RESULTS: Before embolization, cerebral blood flow velocity increased 39% as mean arterial pressure increased from 40 to 85 mm Hg. Following embolization, a 94% increase in cerebral blood flow velocity was demonstrated over the same mean arterial pressure range. The slopes of the curves relating cerebral blood flow velocity to mean arterial pressure were 0.21+/-0.74 and 1.31+/-0.87, before and after embolization (p = 0.016) respectively. CONCLUSIONS: Regional cerebral blood flow autoregulation may be impaired by microembolization known to occur during cardiopulmonary bypass, increasing the dependence of cerebral blood flow on mean arterial pressure.

Bypass flow, mean arterial pressure, and cerebral perfusion during cardiopulmonary bypass in dogs.

OBJECTIVE: To determine if normal cardiopulmonary bypass (CPB) pump flows maintain cerebral perfusion in the context of reduced mean arterial pressure at 33 degrees C. DESIGN: A prospective investigation. SETTING: Animal CPB research laboratory. PARTICIPANTS: Seven dogs that underwent CPB. INTERVENTIONS: Seven dogs underwent CPB at 33 degrees C using alpha-stat management and a halothane, fentanyl-midazolam anesthetic. Cerebral blood flow was measured using the sagittal sinus outflow technique. After control measurements at 70 mm Hg, cerebral physiologic values were determined under four conditions in random order: (1) mean arterial pressure of 60 mm Hg achieved by a reduction in pump flow, (2) mean arterial pressure of 60 mmHg determined by partial opening of a femoral arterial-to-venous reservoir shunt, (3) mean arterial pressure of 45 mm Hg by reduced pump flow, and (4) mean arterial pressure of 45 mm Hg by shunt. A 9F femoral arterial-to-venous reservoir shunt was controlled by a screw clamp. MEASUREMENTS AND MAIN RESULTS: Except for the controlled variables of mean arterial pressure and bypass flow, physiologic determinants of cerebral blood flow (temperature, PaCO2 and hematocrit) did not differ under any of the CPB conditions. Pump flow per se was not a determinant of cerebral perfusion. Cerebral blood flow and cerebral oxygen delivery did not differ with changes in pump flow if mean arterial pressure did not differ. Cerebral blood flow depended on mean arterial pressure under all pump flow conditions, however. CONCLUSIONS: Over the range of flows typical in adult CPB at 33 degrees C, pump flow does not have an effect on cerebral perfusion independent of its effect on mean arterial pressure. A targeted pump flow per se is not sufficient to maintain cerebral perfusion if mean arterial blood pressure is reduced.

Relationship between cardiopulmonary bypass flow rate and cerebral embolization in dogs.

BACKGROUND: Cerebral embolization is a primary cause of cardiac surgical neurologic morbidity. During cardiopulmonary bypass (CPB), there are well-defined periods of embolic risk. In theory, cerebral embolization might be reduced by an increase in pump flow during these periods. The purpose of this study was to determine the CPB flow-embolization relation in a canine model. METHODS: Twenty mongrel dogs underwent CPB at 35 degrees C with alpha-stat management and a fentanyl-midazolam anesthetic. In each animal, CPB flow was adjusted to achieve a mean arterial pressure of 65-75 mmHg. During CPB, an embolic load of 1.2 x 10(5) 67 microm fluorescent microspheres was injected into the arterial inflow line. Before and after embolization, cerebral blood flow was determined using 15-microm microspheres. Tissue was taken from 12 brain regions and microspheres were recovered. The relation between pump flow and embolization/g of brain was determined. RESULTS: The mean arterial pressure at embolization was 67 +/-4 mmHg, and the range of pump flow was 0.9-3.5 l x min(-1)x m(-2). Cerebral blood flow was independent of pump flow. At lower pump flow, the percentage of that flow delivered to the brain increased. There was a strong inverse relation between pump flow and cerebral embolization (r = -0.708, P < 0.000 by Spearman rank order correlation). CONCLUSIONS: Cerebral embolization is determined by the CPB flow. At an unchanged mean arterial pressure, as pump flow is reduced, a progressively greater proportion of that flow is delivered to the brain.

Cerebral response to hemodilution during hypothermic cardiopulmonary bypass in adults.

UNLABELLED: We examined the cerebral response to changing hematocrit during hypothermic cardiopulmonary bypass (CPB) in 18 adults. Cerebral blood flow (CBF), cerebral metabolic rate for oxygen (CMRO2), and cerebral oxygen delivery (CDO2) were determined using the nitrous oxide saturation technique. Measurements were obtained before CPB at 36 degrees C, and twice during 27 degrees C CPB: first with a hemoglobin (Hgb) of 6.2 +/- 1.2 g/dL and then with a Hgb of 8.5 +/- 1.2 g/dL. During hypothermia, appropriate reductions in CMRO2 were demonstrated, but hemodilution-associated increases in CBF offset the reduction in CBF seen with hypothermia. At 27 degrees C CPB, as the Hgb concentration was increased from 6.2 to 8.5 g/ dL, CBF decreased. CDO2 and CMRO2 were no different whether the Hgb was 6.2 or 8.5 g/dL. In eight patients in whom the Hgb was less than 6 g/dL, CDO2 remained more than twice CMRO2. IMPLICATIONS: This study suggests that cerebral oxygen balance during cardiopulmonary bypass is well maintained at more pronounced levels of hemodilution than are typically practiced, because changes in cerebral blood flow compensate for changes in hemoglobin concentration.

Comparison of halothane/thiopental and propofol anesthesia for strabismus surgery.

Day case surgery has become a widely accepted practice for many ophthalmological procedures including strabismus surgery. Prompt recovery from anesthesia and minimal postoperative morbidity are especially requested to the anesthesiologists to deal with the high day case surgery burden. The purpose of this study was to compare two anesthesia techniques, halothane/thiopental anesthesia and propofol anesthesia, for patients undergoing monocular strabismus surgery. We studied the level of postoperative consciousness, nausea and vomiting, ocular pain, starting oral intake and activity in 43 patients, ranging from 7 to 41 years of age. A scoring system was used to assess these parameters in the first postoperative 48 h. Although there was not a significant difference in the level of ocular pain, the propofol group had less morbidity in terms of having a better level of consciousness and appetite, less nausea and vomiting and enhanced activity than the halothane/thiopental group. We conclude that propofol anesthesia has significant advantages over halothane/thiopental anesthesia on an outpatient basis for strabismus surgery.

Somatostatin: possible cause of bacterial translocation in obstructive jaundiced rats.

The purpose of this study was to examine the effect of endogenous somatostatin hormone on bacterial translocation in obstructive jaundiced rats. Five groups of rats were studied: group I (n = 10), non-operated group (control); group II (n = 10), sham-operated group which underwent laparotomy and dissection of portal elements, while the common bile duct was not ligated and somatostatin was not injected; group III (n = 10), same as group II, plus injection of somatostatin; group IV (n = 10), common bile duct was ligated with laparotomy but somatostatin was not injected; group V (n = 10), same as group IV, plus somatostatin injection. The blood was analyzed for somatostatin, alkaline phosphatase, and bilirubin levels on the third and tenth days in all animals. At study termination (tenth day), peritoneal swab and blood cultures were taken, and liver, spleen, lung, and mesenteric lymph nodes were harvested for microbiological studies. Bacterial translocation levels were higher in groups III, IV, and V when compared with levels in groups I and II. Similar translocation levels were obtained when blood somatostatin levels were comparable. However, the highest translocation rate was found in groups IV and V in which the blood somatostatin level was also higher when compared with that in other groups. This finding shows that blood somatostatin level is increased in obstructive jaundice. This may explain the bacterial translocation and related sepsis found in obstructive jaundice.

Do menopausal hot flashes have any significant effects on arterial blood gas measurements?

OBJECTIVES: To evaluate the effects of menopausal hot flashes on arterial blood gas measurements. METHODS: Twelve postmenopausal women with frequent hot flashes were enrolled in this study. Blood samples from femoral artery were collected before and during menopausal hot flashes in each subject, and all blood samples were analyzed for pH, pCO2, pO2, HCO3 standard, total CO2, and base excess. Arterial blood gas parameters before and during menopausal hot flashes were compared statistically. RESULTS: pH measurements decreased significantly during hot flashes (P < 0.05); although the difference was found to be statistically significant, the amount of decrease and the range in which the change took place led us to conclude that this change was clinically insignificant. Other parameters did not show any statistically significant differences between the preflash and flash measurements. CONCLUSIONS: Our results indicate that menopausal hot flashes do not have any clinically significant effects on arterial blood gas measurements.