Impact of Secondary Insults in Brain Death After Traumatic Brain Injury.

In addition to primary injury in severe head trauma, secondary systemic insults that aggravate the brain injury may result in fatal neurologic outcome. We aim to evaluate the correlation between brain death and secondary systemic insults in 100 patients with severe traumatic brain injury (TBI) admitted to the intensive care unit. We collected data on hypotension and hypoxemia at the time of admission to intensive care unit and data on hypotension, hypoxemia, hypocarbia, hypercarbia, shock, anemia, hyperglycemia, and hyperthermia within the first 24 hours. In addition, we recorded the category of TBI according to computed tomography findings. Twenty-six patients (26%) who developed brain death were significantly younger than survivors. Early hypotension (odds ratio [OR], 10.24; 95% confidence interval [CI], 3.64-28.78; P = .000) and early shock (OR, 8.31; 95% CI, 2.65-26.01; P = .000) were significantly more frequent among brain-death patients. The most featured factor that independently predicted the development of brain death in patients with severe TBI was the existence of hypotension (B-2.74; 95% CI, 0.016-0.252; P = .000). The most common type of injury among brain death patients was a surgically evacuated mass lesion. Although all critical care principles are applied to prevent secondary systemic brain insults, when brain death occurs, the prevention of hypotension will become significant in preserving organs in better condition for procurement.

Our Experience with Percutaneous and Surgical Tracheotomy in Intubated Critically Ill Patients.

OBJECTIVE: Open surgical tracheotomy (OST) and percutaneous dilatational tracheotomy (PDT) are commonly used for securing airway in intubated critically ill patients. The purpose of this study was to compare the safety of OST and PDT, particularly in intubated critically ill patients. METHODS: The medical records of intubated critically ill patients who underwent tracheotomy between August 2006 and July 2017 were analyzed retrospectively. Minor and major complication rates were compared according to the tracheotomy technique. Preoperative intubation time, postoperative decannulation time, reason for hospitalization, and demographic data, including the Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, were evaluated. RESULTS: A total of 332 cases were enrolled into the study. The minor and major complication rates for both techniques were 27.2%, 8.8%, 9.7% and 3.2%, respectively. Minor and major complication rates were higher in the OST group (p=0.01, p=0.03, respectively). The rate of every single complication was also compared on groups' basis. Accidental decannulation (p=0.02) and pneumothorax (p=0.05) were found to be significantly frequent in the OST group. There was no impact of the preoperative intubation time on the minor (p=0.20) and major complication (p=0.29) rates found. There was no statistically significant difference regarding the postoperative decannulation time (p=0.32). Also, there was no statistically significant difference between two groups in terms of the APACHE II (p=0.69) and SOFA (p=0.37) scores. However, a statistically significant difference between the groups in terms of overall survival was found, in favor of PDT (p<0.001). CONCLUSION: This study revealed that PDT is safer than OST, particularly in intubated critically ill patients.

Immune and inflammatory role of hydroxyethyl starch 130/0.4 and fluid gelatin in patients undergoing coronary surgery.

OBJECTIVES: Compare the effects on inflammatory (TNF-α, IL-6, IL-8 and IL-10) and immunologic (CD3(+), CD4(+), CD8(+), CD11b(+), CD16(+)/56(+) T cells and total lymphocyte concentration) variables of hydroxyethyl starch 130/0.4, 4% modified fluid gelatin, or crystalloid when used as volume replacement fluids for acute normovolemic hemodilution (a blood conservation technique) in coronary artery bypass graft patients. METHODS: Thirty patients undergoing coronary artery bypass graft surgery were randomized to receive Isolyte S® (Group ISO), 6% hydroxyethyl starch 130/0.4 (Group HES) or 4% modified gelatin solution (Group GEL) for acute normovolemic hemodilution. Blood samples were taken immediately after induction of anaesthesia (T0), and 2 h (T1), 12 h (T2), 24 h (T3), and 48 h (T4) after separation from cardiopulmonary bypass. TNF-α, IL-6, IL-8 and IL-10 levels were determined with commercially available ELISA kits. CD3(+) (mature T cells), CD4(+) (T helper cells), CD8(+) (suppressor cytotoxic T cells), CD16(+)/56(+) (natural killer lymphocytes), and CD11b(+) (Mac-1, adhesion receptor) levels were measured using flow-cytometry reagents. The CD4(+):CD8(+) ratio was calculated. RESULTS: Between-group comparisons showed significantly higher levels of TNF-α at T1 (2 h after weaning from cardiopulmonary bypass) in Group HES compared to Group ISO (p=0.003). IL-8 was significantly lower in Group HES than Group GEL at T1 (p=0.0005). IL-10 was significantly higher in Group HES than in Group GEL at T1 (p=0.0001). The CD4(+):CD8(+) ratio in Group ISO was significantly lower than that in Group HES at T2 (p=0.003). CD11b(+) levels in Group HES were also higher than those in Group GEL and group ISO at T2, but not significantly. CD16/56(+) levels in Group HES were higher than those in Group GEL at T2 (p<0.003). No excessive hemorrhage occurred in any patient. Mediastinal drainage during the first 24 h after surgery in Group HES (347±207 mL) was not significantly different from that of Group GEL (272±177 mL) or Group ISO (247±109) (p>0.05). CONCLUSION: Hydroxyethyl starch 130/0.4 reduced pro-inflammatory responses and increased anti-inflammatory responses to a greater degree than gelatin solution and isolyte S®. The use of hydroxyethyl starch, compared to gelatin solution and isolyte S®, resulted in less decrease in the CD4(+):CD8(+) ratio, suggesting less immunosuppression.

Thromboelastography in the evaluation of coagulation disorders in patients with sepsis.

AIM: Unbalanced hemostasis and disseminated intravenous coagulopathy serve as key participants in organ dysfunction and disability. In this study we evaluated the coagulation profiles of patients diagnosed with systemic inflammatory syndrome (SIRS)-sepsis and multiple organ dysfunction syndrome. We also researched coagulation in sepsis by comparing thromboelastography (TEG) data with those of nonsepsis patients to determine the usefulness of the TEG device. MATERIALS AND METHODS: Data were collected from 55 anesthesiology and surgery intensive care unit (ICU) patients: 21 with SIRS-sepsis (Group S) and 34 patients without SIRS-sepsis (Group C). Blood samples were taken upon admission to the ICU (t1) and on day 3 of the ICU stay (t2). TEG data (R = reaction time, K = coagulation time, a = alpha angle, and MA = maximum amplitude) were recorded. TEG parameters were compared with routine coagulation and hemogram studies. RESULTS: The mean R value in Group C was higher than that of Group S at both t1 and t2. Group S had a significantly lower K value and higher alpha angle at t1 compared to Group C (P < 0.05). CONCLUSION: Hypercoagulability was observed in SIRS-sepsis patients in the ICU, as measured with TEG. We believe that TEG will be a useful tool in the evaluation of coagulation disorders developing in septic critically ill patients.

The effects of lornoxicam on neuroprotection following diffuse traumatic brain injury in rats.

AIM: In this study, the effects of lornoxicam on the prevention of secondary brain injury via the apoptotic pathway were studied in a rat model of head injury. MATERIAL AND METHODS: Thirty adult male Wistar albino rats were anesthetized, and experimental closed head trauma was induced by allowing a 450 g weight to fall two meters onto a metallic disk fixed to the intact skull. After head injury, the rats were randomly divided into two groups: Group I (n=15) rats were administered 2 mL saline intraperitoneally (controls); Group II (n=15) rats were administered 2 mL 1.3 mg kg-1 lornoxicam intraperitoneally. Brain tissue samples were divided into two pieces by interhemispheric incision for biochemical and histological analysis. RESULTS: TUNEL positivity was seen in neuroglia cells of the brain cortex in both groups. While the immunoreactivities of caspase 8, 9 and Fas/ Fas ligand were similar in both groups, the immunoreactivity of caspase 3 was greater in Group I than Group II. MDA was significantly lower in Group II than in Group I (p < 0.05). The decrease in SOD level was higher in Group I than Group II. CONCLUSION: Lornoxicam did not prevent apoptosis in this rat model of brain trauma but causes a decrease.

The effects of lornoxicam on brain edema and blood brain barrier following diffuse traumatic brain injury in rats.

BACKGROUND: In this experiment, the effects of lornoxicam on brain edema and the blood brain barrier (BBB) following diffuse traumatic brain injury (TBI) were studied. METHODS: Twenty adult male Wistar albino rats were anesthetized, and experimental closed head trauma was induced by the Marmarou method. After head injury, the rats were randomly divided into two groups: Group I was the control group, to which 2 ml saline was administered intraperitoneally, and Group II was the lornoxicam group, to which 2 ml 1.3 mg kg-1 lornoxicam was administered intraperitoneally. Twenty-four hours after head trauma, 99 mTc pentetate (DTPA) was injected at a dose of 37 MBq, and posterior planar images of each rat were obtained using an Infinia gamma camera. After imaging of BBB permeability, brain tissues were dissected from the cranium. The brain water content (BWC) of each sample was calculated using the wet-dry method. RESULTS: The lesion/background (L/b) ratio of Group I was 3.76±0.46 and 3.02±0.66 for early (5th min) and late (60th min) imaging, respectively. In Group II, the L/b ratios were 3.52±0.96 and 2.63±0.63 for early and late imaging, respectively (p>0.05). BWC was 79.6±2.5% and 77.5±1.1% for Groups I and II, respectively (p<0.05). CONCLUSION: In this rat model of TBI, lornoxicam reduced brain edema but did not affect BBB permeability.

Sudden death of a pregnant woman in third trimester with no risk factor.

Acute myocardial infarction in pregnancy is rare and life-threatening for both the mother and the fetus. We present the case of a 31-year-old previously healthy woman with no risk factors at 32 weeks of gestation who applied with vomiting, dyspnea and orthopnea. A respiratory arrest developed followed by loss of the fetal viability, cardiac arrest, and failure of resuscitation. We aim to raise awareness about the clinical approach to pregnant patients who are to be considered with a broad spectrum of differential diagnosis.