Are bacterial coinfections really rare in COVID-19 intensive care units?

OBJECTIVES: There are limited data about nosocomial coinfections of COVID-19 cases monitored in the intensive care unit. This study aims to investigate coinfections in COVID-19 patients followed in an intensive care unit of a university hospital. METHODS: This study analyzed retrospectively the data of coinfections of 351 COVID-19 patients in the period 28.02.2020-15.01.2021 in a tertiary care intensive care unit in a university hospital. RESULTS: Bacterial coinfections were present in 216 of the 351 cases. One hundred and thirty of these cases were evaluated as nosocomial infections. On the third day the Sequential Organ Failure Assessment Score, usage of invasive mechanical ventilation and presence of septic shock were significantly higher in the coinfected group. The neutrophil/lymphocyte ratio, polymorphonuclear leukocyte count, procalcitonin, ferritin, and blood urea nitrogen values were significantly higher in the coinfection group. White blood cells (WBC) (OR: 1.075, 95% CI 1.032-1.121, p = 0.001) and ICU hospitalization day (OR: 1.114, 95% CI 1.063-1.167, p < 0.001) were found to be independent risk factors for coinfection in the multivariate logistic regression analysis. The rates of hospitalization day on the day of arrival, the 21st day, as well as total mortality (p = 0.004), were significantly higher in the coinfected group. CONCLUSION: Bacterial coinfections of COVID-19 patients in the intensive care unit remain a problem. Identifying the infectious agent, classifying colonizations and infections, and using the proper treatment of antibiotics are of great importance in the case management of COVID-19 patients in the intensive care unit.

A Case Series of Problems That Can Occur During Open Heart Surgery in Patients With COVID-19 Infection.

The utilization of open cardiac surgery on patients infected with coronavirus disease 2019 (COVID-19) has resulted in a very challenging perioperative management method. High rates of morbidity and mortality have been documented in the literature for patients who have undergone open heart surgery while infected with COVID-19; however, data on complications that may occur during and after surgery in patients with COVID-19 infection are limited. In this article, we aimed to present the clinical course and perioperative consequences of three patients with preoperative COVID-19 infection.

A Case of Late-Onset Local Anesthetic Toxicity Observed as Seizure Activity.

Most of the local anesthetic toxicity cases develop within the first five minutes of peripheral block administration. Late local anesthetic toxicity has been rarely reported in the literature. However, it is an important life-threatening problem that can lead to seizures, hemodynamic collapse, and cardiac arrest if it is ignored and not considered. Here we present the case of an 18-year-old male patient who had ultrasonography-guided infraclavicular brachial plexus block administration with a 30 mL local anesthetic. The patient had convulsions 210 minutes after the block administration and was treated with intravenous diazepam. Intraoperative and postoperative courses were uneventful. He had no neurologic signs or symptoms afterward. All laboratory tests and radiologic investigation tests were normal. This report demonstrates that late local anesthetic toxicity is still possible after several hours of the uneventful peripheral neural blockade, although it is rarely reported.

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.

Effect of cigarette smoking on the washout time of sevoflurane anesthesia.

BACKGROUND: Cigarette smoking affects the pharmacodynamic and pharmacokinetic behavior of many drugs and causes deterioration of pulmonary mechanics. We have evaluated the effect of cigarette smoking on washout time after one minimum alveolar concentration-h (1 MAC-h) of sevoflurane anesthesia. METHODS: We investigated the washout time of sevoflurane in 30 non-smoking and 30 healthy cigarette smoking (>/=20 cigarettes/day for>1 year) ASA I-II physical status patients, aged 18-63 years, who were candidates for otorhinolaryngologic elective surgery under 1MAC-h standardized sevoflurane anesthesia. At the end of the surgery, the sevoflurane vaporizer was turned off and the time taken for the sevoflurane concentration to decrease to MAC-awake (0.3) and 0.1 MAC levels were recorded. In addition, the ratio of the fractions of inspired concentration (Fi) and expired concentration of sevoflurane (Fexp) at 1 MAC and Fexp of sevoflurane at 0.1MAC were recorded. The patients were mechanically ventilated during the washout time. RESULTS: We found no difference between the 2 study groups with regard to washout time of sevoflurane. The times of 1MAC down to MAC-awake (106 +/- 48 sec in non-smokers vs 97 +/- 37 sec in smokers, p > 0.05) and down to 0.1MAC (491 +/- 187 sec in non-smokers vs 409 +/- 130 sec in smokers, p > 0.05) were similar. Similarly, there were no significant differences in the ratios of Fi/Fexp at 1MAC (1.18 in non-smokers vs. 1.19 in smokers, p > 0.05) and Fexp of sevoflurane at 0.1MAC (0.26 in non-smokers vs. 0.25 in smokers, p > 0.05). CONCLUSIONS: Washout time of 1MAC-h sevoflurane anesthesia is not appear to be effected by cigarette smoking in patients without significant pulmonary disease.

The renal effect of replacement fluids in controlled severe hemorrhagic shock: an experimental study.

BACKGROUND: This experimental study examined the effects of resuscitation with Ringer's lactate (RL), 6% hydroxyethyl starch (130/0.4-HES), and the combination of RL and HES on renal function in hemorrhagic shock (HS). METHODS: Twenty-four male New Zealand white rabbits weighing 2198-3435 g were divided at random into four groups. HS was constituted by maintaining the mean arterial blood pressure at 30 mmHg and blood lactate at >4 mM/L. Subsequently, Group 1 (control) was not resuscitated, while the study rabbits' resuscitation was initiated with RL (Group 2), HES (Group 3), or the combination of RL and HES (Group 4). RESULTS: In all groups, the serum creatinine and blood urea nitrogen (BUN) levels were observed to be within normal limits, while the lactate dehydrogenase and alpha-1 microglobulin levels statistically significantly increased when time points were compared with beginning values (p<0.05). Furthermore, cystatin-C levels were observed to be increased after the HS (p<0.05), but returned to the normal level after resuscitation in all the study groups. Interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha levels were increased in all the rabbits after HS (p<0.05), and there were no significant differences among the study groups after resuscitation (p>0.05). There were no differences in the histological imaging between the groups (p>0.05). CONCLUSION: The 6% HES (130/0.4) did not have any harmful effects on the kidney when it was used alone or in combination with crystalloid for resuscitation of HS in rabbits.

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.

Off-pump coronary artery bypass surgery in patients with chronic renal failure.

OBJECTIVE: Patients with dialysis-dependent renal disease frequently present with coronary artery disease. These patients are considered to be at high risk for coronary artery bypass grafting. Therefore, off-pump coronary artery surgery may become a good option for these patients. Off-pump coronary artery bypass surgery in patients with dialysis-dependent renal failure was retrospectively reviewed in this study. METHODS: From March 2001 through May 2005, we performed off-pump coronary bypass grafting in 10 patients with dialysis-dependent renal failure. Coronary artery bypass grafting was performed on beating heart in all of the patients. The patients were evaluated for perioperative variables and postoperative outcomes. RESULTS: Mean age was 58.7+/-8.9 years with a range between 45 to 76 years. Eight of the patients were male and two were female. No perioperative and postoperative deaths or ischemic cardiac events were observed. Anginal symptoms of the patients were relieved during the postoperative period. Functional status of the patients was improved postoperatively. None of the patients needed revision due to hemorrhage. Mean distal anastomosis number was 1.8+/-0.6. Mean intensive care unit stay was 1.8+/-0.8 days and hospital stay was 5.3+/-0.9 days. CONCLUSION: Off-pump coronary artery bypass grafting can be performed with good clinical results. We believe that off-pump coronary revascularization is a good option in patients with dialysis-dependent renal failure.

Protective effects of levosimendan and iloprost on lung injury induced by limb ischemia-reperfusion: a rabbit model.

BACKGROUND: The aim of this study was to clarify whether levosimendan could prevent lung tissue injury from limb ischemia/reperfusion. METHODS: The common femoral arteries of 50 New Zealand white rabbits, both male and female, each weighing about 3 kg, were clamped and 1 h of ischemia followed by 4 h of reperfusion. In an attempt to decrease reperfusion injury, the rabbits were given levosimendan in Group A. In Group B, iloprost was infused at the same period. A similar value of saline solution was given in the control group, Group C correspondingly. Levosimendan and iloprost were given together the Group E, and Group D was sham group without medication and ischemia. Blood pH, pO2, pCO2, HCO3, Na, K, creatine phosphokinase, lactate dehydrogenase values were determined at the end of the reperfusion period. Malondialdehyde (MDA) was measured in plasma and lung as an indicator of free radicals. Hemodynamics parameters were noted for each group. After the procedure, left lung tissues were taken for histopathologic study. RESULTS: Blood PO2 and HCO3 levels were significantly higher (P < 0.05) and creatine phosphokinase, lactate dehydrogenase, and MDA levels were significantly lower (P < 0.05) in Groups A, B, D, and E compared with Group C. Similarly, the MDA levels in the lung tissue and plasma levels were significantly lower in the treatment groups compared with the control group (P < 0.05). Lung damage was significantly higher in Group C. There was no significant difference between groups in other parameters. CONCLUSIONS: The results suggest that levosimendan and iloprost are useful for attenuating oxidative lung damage occurring after a period of limb ischemia/reperfusion.

Off-pump coronary artery bypass surgery in patients with coronary artery disease and malign neoplasia: results of ten patients and review of the literature.

Cardiopulmonary bypass has been reported to have many effects on the immune system. The aim of this study was to investigate the efficiency and usefulness of off-pump coronary artery bypass (OPCAB) surgery on patients who had coronary artery disease besides malign neoplasia. We applied OPCAB operations to 217 patients between March 2001 and April 2004, ten of whom had malign neoplasia. These patients were diagnosed to have coronary artery disease on their routine examination for their oncologic operation. The malignancies were stomach cancer (2 patients), colon-rectum carcinoma (3 patients), breast carcinoma (2 patients), surrenal carcinoma (1 patient), larynx carcinoma (1 patient), and meningioma (1 patient). The patients were operated on for their neoplasia by the related clinics at a mean of 42 days after the OPCAB surgery. The patients were discharged with surgical success and without any cardiac complications. Coronary artery bypass surgery before a noncardiac major operation may effectively decrease the long-term mortality due to myocardial ischemia. Severe coronary artery disease should be surgically treated in those patients who are scheduled to undergo an operation for malign neoplasia. Extracorporeal circulation impairs the immune system and negatively affects the defense of host against malignancy. Therefore, patients with severe coronary artery disease who are candidates for oncologic operation should be treated with OPCAB.

Surgical treatment of postinfarction left ventricular pseudoaneurysms.

OBJECTIVE: Left ventricular pseudoaneurysm is a rare but serious complication of acute myocardial infarction. It is under debate whether surgical intervention is mandatory in asymptomatic patients. The aim of this report was to present our experience based on surgical treatment and midterm outcomes of patients with postinfarction left ventricular pseudoaneurysm. METHODS: Eight consecutive patients who underwent left ventricular pseudoaneurysm operation between January 1, 1995, and January 1, 2006, were included in the study. There were 5 male and 3 female patients. Mean age was 62.87 +/- 5.03 years. All patients had echocardiography and coronary angiography before the operation. Two anterior and 6 posterior pseudoaneurysms were detected. Left ventricular pseudoaneurysm was repaired with a synthetic patch by the remodeling ventriculoplasty method of Dor in all patients. Coronary revascularization was performed if necessary. Preoperative, operative, and postoperative data were collected from the patient cohorts. RESULTS: The mean duration from myocardial infarction to diagnosis of the ventricular septal rupture was 13.5 +/- 12 days. Additional coronary artery bypass surgery was performed with a median of 1.2 grafts in 5 patients (62.5%). The mean postoperative mechanic ventilator support time was 20.12 +/- 29.22 hours. Overall 30-day mortality was 12.5% with 1 patient death. The mean intensive care unit stay was 3.75 +/- 2.1 days. The late mortality rate was 12.5%. In the follow-up period (mean, 30.66 +/- 16.86 months), of the 6 patients who were alive, 5 were in New York Heart Association class I or II and 1 was in class III because of pre-existing low left ventricular ejection fraction. Transthoracic echocardiography showed good left ventricular configurations without a false aneurysm together with increases in the ejection fractions. CONCLUSION: Prompt diagnosis and early surgical intervention is essential for patients with large or expanding left ventricular pseudoaneurysms due to the high propensity of fatal rupture. Associated coronary artery bypass grafting may reduce early mortality of patients with left ventricular pseudoaneurysm by resuscitating the ischemic myocardium.

Surgical treatment of prosthetic valve thrombosis: ten years' experience.

BACKGROUND AND AIM OF THE STUDY: Prosthetic valve thrombosis (PVT) is a rare, but serious, complication of heart valve replacement with a mechanical substitute. Herein is presented the authors' surgical experience of 18 patients with PVT. METHODS: A total of 1,584 heart valve operations was performed in 1,365 patients at the authors' institution between June 1995 and September 2005. Surgical reports of prosthetic valve reoperations over the same period were screened. Preoperative, operative and postoperative data were collected from the patient cohorts. RESULTS: Since July 1997, 18 patients (12 females, six males; mean age 35.9 +/- 11.3 years; range: 22-60 years) presented with PVT. The subtherapeutic anticoagulation level was the major etiologic factor involved in the pathogenesis of PVT. Thrombosis occurred in the mitral position in 14 patients (78%), and in the aortic position in four (22%). All mechanical valves implanted were bileaflet (1,097 St. Jude Medical, 324 CarboMedics, and 163 Sorin). The mean duration from valve replacement to PVT was 48.3 +/- 15.4 months. The majority of patients presented with poor functional status (56% in NYHA class IV) and poor anticoagulation (INR < or = 2 in 72% of cases). Valve re-replacement was performed for all patients. The 30-day mortality was 16.7%. CONCLUSION: PVT is a potentially fatal complication of heart valve replacement. These acceptable results suggest that early surgical intervention might be a safe and effective treatment of choice in patients with PVT. Patients with mechanical valve prostheses should be informed adequately about the need for, and the importance of, an effective anticoagulation regimen.

Modified semicircular constricting annuloplasty (Sagban's annuloplasty) in severe functional tricuspid regurgitation: alternative surgical technique and its mid-term results.

OBJECTIVE: De Vega annuloplasty is one of the most effective methods used in surgical correction of functional tricuspid regurgitation (FTR). Physiologic annular motions are protected by De Vega annuloplasty. However, recurrent tricuspid regurgitation secondary to Bowstring (Guitar string) phenomenon may be seen after De Vega annuloplasty as a result of gliding (jiggle) effect. The aim of this new annuloplasty was to prevent Bowstring phenomenon seen in De Vega annuloplasty. METHODS: Twenty-five patients with severe FTR secondary to the left-sided valvular heart disease were included in this study. Modified semicircular constricting annuloplasty (Sagban's annuloplasty): The procedure is performed utilizing 0 and 2-0 polypropylene sutures. At first, 0 and 2-0 polypropylene sutures are fixed and knotted at anteroseptal and posteroseptal comissural regions (named as anchoring points). 2-0 Polypropylene sutures which come from anchoring points in clockwise and counterclockwise direction are used to encircle the free wall annulus as well as 0 polypropylene sutures in spiral fashion (spiral annulary suture technique). When both sutures get to the anteroposterior comissural region (tying point), they are passed through plastic snares. After the annuloplasty is completed, with the heart beating and the pulmonary artery clamped, competency of the valve is tested by injecting saline into the right ventricular chamber before the adjusting suture is tied. In this annuloplasty, 0 polypropylene sutures are used for reduction and constriction, 2-0 polypropylene sutures are used for the fixation of 0 polypropylene sutures in annular level. RESULTS: FTR improved totally in 16 patients (66.7%), 4 patients (16.7%) had first degree, 3 patients (12.5%) had second degree, and only 1 patient (4.2%) had third degree residual tricuspid regurgitation in an average follow-up period of 17.8 months. One patient died from low cardiac output in early postoperative period. CONCLUSION: There is no risk of recurrent regurgitation secondary to Bowstring phenomenon in this alternative annuloplasty technique and this annuloplasty is cost-effective and performed easily.

The progress of mitral regurgitation after isolated coronary artery bypass in cases of ischemic mitral regurgitation.

BACKGROUND: Mitral valve intervention combined with coronary artery bypass surgery is inevitable in the case of severe mitral regurgitation in patients with coronary artery disease because the prognosis is poor without mitral correction. The best treatment protocol for patients with a moderate degree of mitral regurgitation is under debate. To clarify the optimal management for these patients, we evaluated the progress of mitral regurgitation after isolated coronary artery bypass surgery in cases of ischemic mitral regurgitation. METHODS; The study was conducted between March 2001 and April 2003. Forty-seven patients (70% men, with a mean age of 61 years, a mean ejection fraction of 43.7%, and a mean New York Heart Association class of 2.53) with preoperative diagnoses of moderate degree ischemic mitral regurgitation (Grade 3 mitral regurgitation on a scale of 0 to 4) and coronary artery disease, without leaflet pathology, underwent isolated coronary artery bypass surgery. Patients were followed-up at a mean of 22 months and an echocardiographic evaluation was done to determine the progress of the mitral disease. RESULTS: The 30-day operative mortality rate was 2.1%. In the postoperative period, the mean ejection fraction was 46.9% and the mean functional capacity of the patients was 1.31. Mitral regurgitation regressed to a mild degree in 56.9% of the patients. The 2-year survival rate was 93.7%. CONCLUSIONS: Patients with moderate ischemic mitral regurgitation and coronary artery disease who underwent coronary artery bypass surgery alone had acceptable results. We are of the opinion that isolated coronary artery bypass surgery might be a good treatment choice for moderate degree ischemic mitral regurgitation.

Intracoronary shunt reduces postoperative troponin leaks: a prospective randomized study.

OBJECTIVE: The purpose of this study was to evaluate whether intracoronary shunt usage reduced the myocardial damage on the basis of the cardiac markers when compared with the shuntless anastomosis in off-pump coronary artery bypass grafting (OPCABG) surgery of isolated left anterior descending artery lesions. METHODS: Forty patients who had stable angina with isolated left anterior descending (LAD) coronary artery lesion undergoing OPCABG surgery were randomized into two groups. Shunt group consisted of 20 patients who had OPCABG using intracoronary shunt, whereas the shuntless group consisted of 20 patients who underwent OPCABG without using intracoronary shunt. Cardiac troponin I, CK, and CK-MB before and 24h after the surgery were assessed in the groups. RESULTS: There were no deaths in the study. The two groups were similar with respect to sex and age. Duration of LIMA-LAD anastomosis was significantly higher in the shunt group (p=0.01). There was no significant difference between the groups concerning the preoperative and postoperative CK and CK-MB levels. The preoperative troponin I levels of the groups were not different (p=0.238; NS), whereas postoperative levels of this marker was significantly higher in the shuntless group (p=0.003). CONCLUSION: Intracoronary shunt reduced the postoperative troponin I levels significantly, so it may be indicated in the patients who are thought to be susceptible to transient ischemia.

Aortic reoperations: experience with 23 patients using axillary artery cannulation.

The increase in the number of cardiac operations has brought about an increase in aortic pathology that requires reoperation. The aim of the present study was to evaluate axillary artery cannulation in aortic reoperations. We operated on 23 patients diagnosed with acute type A aortic dissection (13 patients), chronic type A aortic dissection (7 patients), aortic pseudoaneursym (2 patients), and arcus aorta aneurysm (1 patient). The right axillary artery was cannulated directly or through a side graft which was anastomosed to the artery. Antegrade cerebral perfusion with moderate degree hypothermia was used for cerebral protection. Four patients were lost after the operation (17.4%) and no cerebral complications were encountered. Axillary artery cannulation provides safe reentry to the chest and provides good cerebral protection in aortic reoperations.