Comparison of inferior vena cava collapsibility, distensibility, and delta indices at different positive pressure supports and prediction values of indices for intravascular volume status

Background/aim: To compare the inferior vena cava (IVC) indices, identify their variation rates at positive pressure values and accurate predictive values for the volume status in patients with spontaneous respiration receiving different positive pressure support. Materials and methods: The study included 100 patients who were divided into 4 pressure support groups, according to the different pressure supports received, and 3 volume groups according to their CVP values. Ultrasonography was applied to all of the patients to define their IVC diameters at different pressure supports. Dynamic parameters were derived from the ultrasonographic assessment of the IVC diameter [collapsibility (CI-IVC), distensibility (dIVC), and delta (ΔIVC) indices]. Results: There were significant differences between the 3 indices (CI-IVC, dIVC, and ΔIVC) according to the pressure groups [(10/5), (10/0), (0/5), (t tube 0/0)]. The median value for the dIVC percentages was ≤18% for all of the positive pressure support hypervolemic groups, apart from the hypervolemic t tube group (19%). For the hypervolemic groups, the best estimation according to the cut-off value appeared to be for the dIVC. Values with the highest sensitivity for differentiation of the hypovolemic individuals were calculated with the dIVC. Conclusion: The dIVC had a more accurate predictive role in predicting the volume status when compared with the CI-IVC and ΔIVC, and may be used reliably with positive pressure supports.

First step toward a better trauma management: Initial results of the Northern Izmir Trauma Registry System for children.

BACKGROUND: Trauma is an important health problem in children, and improvement in national trauma care is only possible through the knowledge gathered from trauma registry systems. This information is not available in our country, because there is no current trauma registry system at the hospitals. Our aim is to explain the trauma registry system we have developed and present the first year's data. METHODS: The planned trauma registry system was integrated into the emergency department registry system of 14 hospitals in Izmir province. The data of pediatric multiple trauma patients have been recorded automatically through the registry system. Demographics, vital signs, mechanism, type of trauma, anatomical region, ISS, PTS, GCS, length of hospital stay and need for blood transfusion/endotracheal intubation/surgery/hospitalization were evaluated by patient transfer status and outcome. RESULTS: At the end of one year, a total of 356 pediatric major trauma patients were included in the study. The most common type of trauma was blunt trauma (91.9%) and the mechanism was vehicle-related traffic accidents (28.1%). In the group with the worse outcome than the Glasgow outcome score, age was greater, ISS was higher and PTS was lower. Motorcycle accidents, sports injuries, and penetrating injuries were more frequent in this group. All the scales were significantly different between direct and transferred patients. The referral time to the hospital of the transferred patients were longer than directly admitted patients, but the results were not different. CONCLUSION: Pediatric major trauma is an important cause of mortality and morbidity, and our trauma registry system, which is a successful example abroad, is not enough in the country. We hope that the trauma registry system we planned and started the pilot application will be expanded to include other hospitals throughout the country with the aim of developing a national registry system.

Effect of video-based education on anxiety and satisfaction of patients undergoing spinal anesthesia / Efeito de informações por meio de vídeo sobre a ansiedade e satisfação de pacientes submetidos à anestesia espinhal

Abstract Background: Providing sufficient information during a preanesthetic interview may help improve patient understanding and decrease anxiety related to spinal anesthesia. We investigated the effect of video-based education on anxiety and satisfaction in patients about to undergo spinal anesthesia. Methods: A total of 198 patients scheduled for minor elective surgery under spinal anesthesia were prospectively enrolled. The State-Trait Anxiety Inventory (State-Trait Anxiety Inventory/State and State-Trait Anxiety Inventory/Trait) questionnaires and visual analog scale were used to measure anxiety levels before the standard anesthesia evaluation was initiated. Then, 100 patients in Group 1 received written, verbal, and video-based education, whereas 98 patients in Group 2 received only written and verbal instructions regarding spinal anesthesia. Then all participants completed the State-Trait Anxiety Inventory/State and visual analog scale to evaluate anxiety. Finally, a 5-point Likert scale was used to measure satisfaction during postoperative period. Results: No differences were found in the State-Trait Anxiety Inventory/State, State-Trait Anxiety Inventory/Trait, or visual analog scale scores between the two groups before the information period. The State-Trait Anxiety Inventory/State scores evaluating anxiety during the post-information period were differed in both groups and they found as 36.5 ± 10.0 in Group 1 and 39.6 ± 8.6 in Group 2 (p = 0.033). The 5-point Likert scale scores to measure satisfaction were stated as 4.5 ± 0.6 in Group 1 and 3.5 ± 1.2 in Group 2 (p < 0.001). Conclusions: Providing video-based information during the preanesthetic interview alleviated anxiety and increased satisfaction in patients undergoing spinal anesthesia.

Resumo Justificativa: Fornecer informação suficiente durante uma consulta pré-anestesia pode aumentar a compreensão do paciente e diminuir a ansiedade relacionada à anestesia espinhal. Investigamos o efeito do fornecimento de informação via vídeo sobre a ansiedade e satisfação em pacientes prestes a serem submetidos à anestesia espinhal. Métodos: Foram inscritos prospectivamente 198 pacientes agendados para cirurgias eletivas de pequeno porte sob anestesia espinhal. Os questionários de avaliação de estado e traço de ansiedade (State-Trait Anxiety Inventory/State e State-Trait Anxiety Inventory/Trait) e uma escala visual analógica foram usados para medir os níveis de ansiedade antes de a avaliação-padrão da anestesia ter sido iniciada. Em seguida, 100 pacientes do Grupo 1 receberam informação por escrito, verbal e via vídeo, enquanto 98 pacientes do Grupo 2 receberam apenas informação por escrito e verbal sobre a anestesia espinhal. Em seguida, todos os participantes responderam os inventários de estado e traço de ansiedade e a escala visual analógica para avaliar a ansiedade. Por fim, a escala de Likert de 5 pontos foi usada para medir a satisfação durante o período pós-operatório. Resultados: Não houve diferença nos escores dos questionários de estado e traço de ansiedade e da escala visual analógica entre os dois grupos antes do período de informação. Os escores de estado e traço de ansiedade que avaliam a ansiedade durante o período pós-informação foram diferentes em ambos os grupos: 36,5 ± 10,0 no Grupo 1 e 39,6 ± 8,6 no Grupo 2 (p = 0,033). Os escores da escala Likert de 5 pontos para medir a satisfação foram: 4,5 ± 0,6 no Grupo 1 e 3,5 ± 1,2 no Grupo 2 (p < 0,001). Conclusão: Fornecer informação via vídeo durante a consulta pré-anestésica aliviou a ansiedade e aumentou a satisfação em pacientes submetidos à anestesia espinhal.

Low levels of vitamin D are associated with nosocomial infections but not with short-term mortality in critically ill patients

Background/aim: A prospective observational study was conducted to determine the relationship between vitamin D deficiency and nosocomial infections among intensive care unit (ICU) patients. Materials and methods: Demographic data, season of admission, vitamin D levels at admission, premorbid lifestyle scores, comorbid conditions, and admission diagnosis were recorded in 306 ICU patients. Infections that developed at least 48 h after admission to the ICU were the primary outcome, and ICU, hospital, and 1-year mortality were the secondary outcomes. Infections were evaluated for 28 days, and for the entire duration of ICU stay independently. Multiple logistic regression analysis was performed to control for confounding factors that were statistically significant in univariate analysis. Results: All infection and mortality rates were significantly higher in low 25 (OH) D groups in univariate analysis. After adjusting for confounding factors, infection rates remained higher in the deficient group. However, ICU and hospital mortality did not show any statistically significant difference between deficient and nondeficient groups. Only the 1-year mortality rate was significantly higher among patients with 25 (OH) D levels less than 20 ng/mL. Conclusion: Low vitamin D levels are significantly associated with ICU-related infections but not with ICU or hospital mortality. However, further studies are needed to identify the role of vitamin D deficiency in predicting ICU outcomes.

Brain Death in Intensive Care Units: Problems, Differences in Methods of Diagnosis, and Donor Care.

OBJECTIVES: Our aim was to investigate the most common problems in diagnosing brain death, the care of the organ donor, and organ donation after death. MATERIALS AND METHODS: A survey was sent randomly to clinicians working in national intensive care units in Turkey. The survey, which consisted of 17 questions for clinicians, had 163 responders. RESULTS: The most common cause of brain death was traumatic brain injury. Although 22% of clinicians found the apnea test necessary for brain death diagnosis, 78% stated that it could be used as an optional confirmatory test. However, 65.6% of the clinicians were not familiar with the modified apnea test. The most frequently used vasoactive agent for hypotension in patients with brain death was noradrenaline (54.6%) and dopamine (41.6%). Regarding time of death, 50.3% of clinicians considered it as the time and date when the patient was diagnosed with brain death and 47.8% as the time and date of cardiac arrest. When asked whether they terminate the treatment of a patient with brain death when organ donation is rejected, only 16.1% discontinued all advanced life support. According to the survey, the most common reason for not accepting organ transplant was for religious reasons. CONCLUSIONS: In intensive care units, differences in definitions and care of patients with brain death continue to be a complication. There has been a lack of progress in criterion standards of brain death diagnosis and donor care, as verified by our survey.

Effect of regional cerebral oximetry to estimate neurologic prognostic outcomes in patients administered targeted temperature management.

PURPOSE: The aim of our study is to research the role and efficacy of cerebral oximetry in predicting neurologic prognosis when applied during TTM to patients experiencing coma after CA. METHODS: This study was performed on surviving adult comatose patients after CA treated with TTM. The average scores of rSO2 was measured at 6h intervals for the first 2days and once a day for the following 3days with a NIRS device during TTM. The CPC scale was used to define the neurologic outcomes of patients. We compared the correlations of rSO2 values between good (CPC 1-2) and poor (CPC 3-5) neurologic outcomes in CA patients. RESULTS: There was no statistically significant difference identified between the prognosis groups in terms of rSO2, CPR durations, hemoglobin values and admission body temperature (p>0.05). When the variation in rSO2 values over time is investigated, though there was no significant difference between the good and poor prognosis groups, it appeared to fall in the first 6h in both prognosis groups. The median NT-proBNP and lactate values were observed to be higher in the poor prognosis group. CONCLUSION: There is no significant correlation between rSO2 values and neurologic outcomes. Multimodal monitoring methods may be useful and further studies with a larger patient population are necessary in this area.

[Effect of video-based education on anxiety and satisfaction of patients undergoing spinal anesthesia]. / Efeito de informações por meio de vídeo sobre a ansiedade e satisfação de pacientes submetidos à anestesia espinhal.

BACKGROUND: Providing sufficient information during a preanesthetic interview may help improve patient understanding and decrease anxiety related to spinal anesthesia. We investigated the effect of video-based education on anxiety and satisfaction in patients about to undergo spinal anesthesia. METHODS: A total of 198 patients scheduled for minor elective surgery under spinal anesthesia were prospectively enrolled. The State-Trait Anxiety Inventory (State-Trait Anxiety Inventory/State and State-Trait Anxiety Inventory/Trait) questionnaires and visual analog scale were used to measure anxiety levels before the standard anesthesia evaluation was initiated. Then, 100 patients in Group 1 received written, verbal, and video-based education, whereas 98 patients in Group 2 received only written and verbal instructions regarding spinal anesthesia. Then all participants completed the State-Trait Anxiety Inventory/State and visual analog scale to evaluate anxiety. Finally, a 5-point Likert scale was used to measure satisfaction during postoperative period. RESULTS: No differences were found in the State-Trait Anxiety Inventory/State, State-Trait Anxiety Inventory/Trait, or visual analog scale scores between the two groups before the information period. The State-Trait Anxiety Inventory/State scores evaluating anxiety during the post-information period were differed in both groups and they found as 36.5±10.0 in Group 1 and 39.6±8.6 in Group 2 (p=0.033). The 5-point Likert scale scores to measure satisfaction were stated as 4.5±0.6 in Group 1 and 3.5±1.2 in Group 2 (p<0.001). CONCLUSIONS: Providing video-based information during the preanesthetic interview alleviated anxiety and increased satisfaction in patients undergoing spinal anesthesia.

Risk factors for colistin-associated nephrotoxicity and mortality in critically ill patients

Background/aim: Colistin is gaining popularity against multidrug-resistant bacteria. The primary concern with colistin is its nephrotoxicity (NT). The aim of this study was to evaluate the incidence and risk factors for NT and to evaluate the risk factors for mortality in the toxicity group. Materials and methods: NT was defined according to the RIFLE criteria. Data of patients who did or did not develop NT were compared. Positive and negative predictive values, risk ratio, and correlation coefficients were calculated. Results: NT was seen in 39 patients (70%). Hypoalbuminemia, old age, and the use of vasopressors (VPs) were associated with NT. The use of VPs had the highest positive predictive value, while age had the highest negative predictive value and risk ratio. The only variable that was associated with mortality in the toxicity group was VP use. Conclusion: Aging, hypoalbuminemia, and the use of VPs were shown to be risk factors for NT, while the last of these was the only significant risk factor for mortality in the toxicity group.

Pretreatment with paricalcitol attenuates level and expression of matrix metalloproteinases in a rat model of renal ischemia-reperfusion injury
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BACKGROUND: Ischemia-reperfusion injury (IRI) is a leading cause of acute kidney injury (AKI). The inflammatory response that drives IRI involves upregulation of matrix metalloproteinases (MMPs), which results in proteolytic degradation of renal microvascular matrix. Evidence suggests a potential protective role of active vitamin D on ischemic injury by downregulating MMPs. In the present study, we aimed to determine the expression and level of MMP-2 and MMP-9 in renal IRI model and the potential beneficial effect of paricalcitol on both level and expression of MMPs and tubular injury caused by IRI. MATERIALS AND METHODS: 20 Wistar albino rats were divided into three groups: sham-operated, ischemia-reperfusion, and paricalcitol-pretreated. IRI model was induced by bilateral clamping of renal arteries for 45 minutes followed by 24 hours of reperfusion. The analysis of serum creatinine and levels of MMPs were performed after 24 hours of IRI. The effects of paricalcitol on the quantity and expression of MMP-2 and MMP-9 in renal tubular epithelial cells were investigated by enzyme-linked immunosorbent assay and immunohistochemistry, respectively. The pathological examinations were performed to score tubular damage by light microscopy. RESULTS: Creatinine levels decreased in the paricalcitol group, although this was not proven to be significant. Rats in the paricalcitol group showed significant decrease in both level and expression of MMPs and in tubular injury scores as compared to the IRI group. CONCLUSION: Paricalcitol may attenuate renal tubular injury caused by IRI by decreasing both level and expression of MMPs. Further studies are required to investigate the interplay between activated vitamin D and MMPs in AKI.
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A Case of Cerebral Malaria Managed by Erythrocyte Exchange.

Plasmodium falciparum may cause serious and sometimes even fatal cerebral malaria. Cerebral malaria is a disease characterized by alterations in consciousness and epileptic attacks; therefore, it requires a rapid evaluation and quick intervention. It may progress to a fatal outcome despite administering targeted therapeutic interventions. There are studies indicating that erythrocyte exchange (erythrocytapheresis) can be a treatment modality for managing severe malaria patients. In this case report, the successful management of a cerebral malaria patient by the combination of antimalarial drug therapy and erythrocyte exchange is presented.

Factors Affecting Anxiety and Depression Symptoms in Relatives of Intensive Care Unit Patients.

AIM: To determine the incidences of anxiety and depression in relatives of patients admitted to an intensive care unit (ICU) and to investigate the relationships between psychological symptoms and demographic features of the patients and their relatives. METHODOLOGY: Relatives of 78 ICU patients were enrolled in the study. Sociodemographic features of patients and their relatives were recorded. The Turkish version of the Hospital Anxiety and Depression Scale was used to assess anxiety and depression. RESULTS: Twenty-eight (35.9%) cases with anxiety and 56 (71.8%) cases with depression were identified. The mean anxiety and depression scores were 9.49 ± 4.183 and 9.40 ± 4.286, respectively. Anxiety (P = .028) and concomitant anxiety with depression (P = .035) were more frequent among family members of young patients. The relationship to the patient, especially being a spouse, was significantly associated with symptoms (anxiety, P = .009; depression, P = .019; and both, P = .005). CONCLUSION: Spouses and family members of relatively young patients had higher rates of anxiety and depression. In contrast to the literature, depression was more common than anxiety among the relatives of ICU patients. Further research is needed on the impact of cultural and regional differences on anxiety and depression rates in family members of ICU patients.

Successful Treatment of Propafenone Intoxication With Intravenous Lipid Emulsion.

Severe cardiac effects, including cardiac arrest, are a rare complication of high-dose propafenone intake. Among patients who experience cardiac arrest, the survival rate is low. This report presents the case of a young female patient who developed cardiac arrest linked to propafenone intake. While spontaneous circulation was restored with cardiopulmonary resuscitation, vital signs did not recover despite supportive treatment. However, after the administration of intravenous lipid emulsion (ILE), vital signs and cardiac functions resolved and the patient survived. This case is the second to describe the successful use of ILE for propafenone intoxication. However, as all of the findings of this patient were clearly linked to propafenone, we believe the benefits of ILE were more clearly defined in this case than in the other.

Postoperative patients in the intensive care unit: Identifying those who do not really need it.

PURPOSE: We evaluated severity-scoring systems as predictors of intensive care unit (ICU) need and created a new model for identifying postoperative patients who do not really need ICU. MATERIALS AND METHODS: The American Society of Anesthesiologists (ASA), the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), and Simplified Acute Physiology Score III scores of 100 postoperative patients were calculated, and cutoff values for necessary ICU admission were obtained. Criteria for a "necessary admission" were death, length of stay more than 48 hours, need for vasoactive agents, or mechanical ventilation for more than 24 hours. Patients whose scores were greater than the cutoff values for the 2 most discriminative variables were defined as high-risk patients; and the rest, as low-risk patients (LRPs). Relative risk, positive predictive value, and negative predictive value were calculated. RESULTS: The POSSUM-total (P-total) and ASA were the 2 most discriminative scores. High-risk patients (patients with ASA scores≥3 and P-total≥35) needed ICU 4.83-fold more than LRPs. The new model had the highest relative risk and negative predictive value (0.85) among all variables and the second highest positive predictive value (0.73) after P-total. CONCLUSIONS: The new model can predict LRPs more accurately than each scoring system alone. The care of LRPs in intermediate care units can prevent overuse of ICUs. But the lack of outcome comparison for predicted LRPs in ICUs vs intermediate care units is the most important limitation of our study.

Does topical anesthesia using aerosolized lidocaine inhibit the superior laryngeal nerve reflex?

OBJECTIVE: This study was designed to evaluate the effectiveness of topical lidocaine in attenuating the laryngeal reflex and blunting hemodynamic response by inhibition of the superior laryngeal nerve in laryngeal microsurgery, which would be helpful in preventing potential complications. STUDY DESIGN: A prospective, randomized, double-blind study. SETTING: Tertiary medical center. SUBJECTS AND METHODS: Fifty-four patients requiring glottic and supraglottic laryngeal microsurgery were randomly assigned to 1 of 2 groups, with equal numbers. Before surgery, 10% lidocaine was topically applied to the laryngeal surface of the epiglottis and vocal folds under direct vision in the study group and saline aerosol was applied in the control group. Heart rates, arterial blood pressure, and SPO2 were recorded at baseline, after induction, immediately before and after intubation, during the surgery, and upon extubation. Laryngospasm, agitation, and coughing were recorded during the recovery period. RESULTS: Heart rates, arterial pressure, and SPO2 did not differ significantly from baseline to postintubation period among the groups. SPO2 values measured similar in the remaining study. Heart rates and blood pressures were slightly decreased in the study group after lidocaine administration, but only blood pressure at pre- and post-extubation was significantly decreased in the study group (P < .05). Also laryngospasm and coughing were not statistically different between the 2 groups. There was an obvious gap between the 2 groups for agitation. Study group agitation was noted significantly lower (P < .05). CONCLUSION: These findings indicate that preoperative topical lidocaine application may be helpful in attenuating airway-circulatory reflexes in laryngeal microscopic surgery.

[Evaluation of vancomycin-resistant Enterococcus cases at a tertiary level hospital in Izmir, Turkey]. / Izmir'de Üçüncü Basamak Bir Hastanede Görülen Vankomisine Dirençli Enterokok Olgularinin Degerlendirilmesi.

Vancomycin-resistant enterocococci (VRE) are common pathogens that may lead to infection in intensive care units. VRE strains that colonize the hospital environment can stay alive for a long time on fomites and can easily be spread by the hands of hospital staff and by the instruments. The aim of this study was to evaluate the epidemic and sporadic VRE cases, following an epidemic at anesthesiology intensive care unit (ICU). The records of the patients hospitalized at anesthesiology ICU between October 2010-June 2011 were evaluated retrospectively. The hospitalized patients with VRE positive culture reports were included in this study. Rectal swab samples of the patients and environmental surveillance cultures were inoculated on sheep blood agar and enterococcosel agar media and incubated for 24-48 hours. The isolated strains were identified by conventional methods and automatized Vitek 2.0 system (BioMérieux, France). The molecular detection of VRE was performed by real-time polymerase chain reaction (Cepheid GeneXpert System, USA). A total of 19 VRE colonised or infected cases (11 male, 8 female; age range: 18-96 years, mean age: 60 years) that were detected sporadically or during the epidemic, were included in this study. Ten (52.6%) cases were evaluated as colonization (seven rectal, two urinary and one both urinary and rectal colonisation). Nine patients were considered as infected (five bacteremia, three catheter infections and one urinary tract infection). Five of the nine patients directly progressed to infection. Four of the nine patients progressed to infection after rectal colonization. Eight of the infected cases were treated with daptomycin and one case with linezolid. Five of the infected and treated cases died and the rate of mortality was determined as 55.6%. PCR was applied to the samples of eight cases and vanA was detected in seven of these. VRE were not grown in two of the PCR positive samples and one PCR positive sample did not yield VRE growth in culture. VRE were detected from the samples obtained from patients' monitors, infusion sets, bedside, bedstands and walls and the origin of VRE was thought to be environmental contamination. It was concluded that adherence to infection control guidelines and continuous education of the health-care personel were prerequisites for effective control of VRE colonization and infection in the health-care setting.