Performance of handheld ultrasound devices in diagnosis of pulmonary hypertension and right heart dysfunction in ICU patients.

AIM: The use of handheld ultrasonography devices (HHUD) has increased recently but there are limited data about their performance in the evaluation of right heart dysfunction (RHD) and pulmonary hypertension (PHT). The aim of the study is to compare the performance of a HHUD with a conventional ultrasound device (CUD) in assessing PHT and RHD. METHODS: This single-center prospective study was performed in a seven-bed teaching hospital intensive care unit (ICU). PHT and RHD criteria were compared by HHUD and CUD. Additional PHT criteria and right ventricle (RV) systolic and diastolic dysfunction criteria were also measured. RESULTS: Forty-six patients were included in the study. There was no significant difference between the imaging rates and mean values of the parameters measured by both devices. When the positivity rates for additional PHT parameters and RHD criteria were compared, there were no significant differences between the devices. In Bland-Altman's analysis, there was good agreement and there was no bias between the measurements of the two devices but left ventricular end-systolic eccentricity index (LVSEI), right atrium area (RAA), and pulmonary artery diameter (PAD). Ninety percent of the patients had PHT probability, of whom 43% had a low, 37% had intermediate and 10% had a high probability of PHT. Ninety-two percent of the patients had RHD and there was no significant difference between the devices in the diagnosis of RHD (p = .212). When RV systolic and diastolic dysfunction evaluations of the devices were compared according to the British Society of Echocardiography (BSE) criteria there was no significant difference between the devices' measurements in the evaluation of systolic and diastolic function. CONCLUSION: The imaging and measurement capabilities of the HHUDs for PHT and RHD parameters were similar to CUDs, and considering the inconsistent parameters, the HHUD can be useful in diagnosing these problems.

Accuracy of Pocket-sized Ultrasound Devices to Evaluate Inferior Vena Cava Diameter and Variability in Critically Ill Patients.

Purpose: By using inferior vena cava (IVC) measurements, clinicians can detect fluid status and responsiveness and find out the etiology of hypotension, acute heart failure, and sepsis easier. Pocket-sized ultrasound devices (PSUD) may take this advantage a few steps further by their lower costs, user-friendly interface, and easily applicable structure.In this study, we aimed to determine the diagnostic value of a PSUD compared with a standard ultrasound device (SD) for the measurement of IVC diameter (IVCD) and its respiratory variability. Materials and methods: We measured the inspiratory, expiratory diameters of IVC, and calculated the inferior vena cava collapsibility index (IVCCI). We investigated 42 intensive care unit (ICU) patients. Results: There was no difference in inspiratory (PSUD: 1.34 ± 0.67 cm; SD: 1.35 ± 0.68 cm) and expiratory (PSUD: 1.98 ± 0.53 cm; SD: 2.01 ± 0.49 cm) IVCD among measurements with PSUD and SD (p > 0.05). There was also no difference between IVCCI's measured with PSUD (39 ± 20%) and SD (39 ± 20%) (p > 0.05). The Bland-Altman analysis revealed that the width of 95% limits of agreement were similar for both devices. There was a good inter-device agreement among PSUD and SD for measurements of IVCD, and there was no difference between IVCCI's measured using both ultrasound devices. Conclusion: We support that the idea of a PSUD is as reliable as a SD for IVC measurements. How to cite this article: Inci K, Gürsel G. Accuracy of Pocket-sized Ultrasound Devices to Evaluate Inferior Vena Cava Diameter and Variability in Critically Ill Patients. Indian J Crit Care Med 2024;28(4):369-374.

Impact of neurological problems on mechanical ventilation and intensive care unit outcomes in pulmonary intensive care unit patients: a retrospective analysis of a single-center cohort.

Neurological problems (NPs) are frequently connected with different critical illnesses in intensive care unit (ICU) patients, and they may influence ICU outcomes. This study aims to examine the effects of NPs on ICU outcomes, especially in pulmonary ICU patients. This is a retrospective observational study comprising adult pulmonary critical care patients who were hospitalized between 2015 and 2019. The frequency of NPs at admission, their impact on mechanical ventilation (MV), ICU outcomes, the rate of NP development during the ICU stay, and risk factors for them were investigated. A total of 361 patients were included in the study, and 130 of them (36%) had NPs (group 1). The noninvasive ventilation requirement rate in patients with NPs was less than in those without NPs (group 2), and the requirement of MV was significantly more frequent in this group (37% and 19%, p<0.05). The duration of MV (19±27 and 8±6 days, p=0.003) and sepsis rate (31% and 18%, p=0.005) were also higher in group 1. NPs developing after ICU admission increased the MV requirement 3 times as an independent risk factor. Risk factors for ICU-acquired NPs were the existence of sepsis during admission [odds ratio (OR): 2.01, confidence interval (CI) 95%: 1.02-4, p=0.045] and longer MV durations before ICU admission (OR: 1.05, CI 95%: 1.004-41.103, p=0.033). NPs were not independent risk factors for mortality (OR: 0.67, CI 95%: 0.37-1.240, p=0.207). NPs did not increase mortality but more frequently caused MV requirement, more extubation failure, and a longer ICU stay in this study population. Additionally, our data suggest that having sepsis during admission and a longer length of MV prior to admission may increase the neurological complication rate.

Assessment of different computing methods of inspiratory transpulmonary pressure in patients with multiple mechanical problems.

While plateau airway pressure alone is an unreliable estimate of lung overdistension inspiratory transpulmonary pressure (PL) is an important parameter to reflect it in patients with ARDS and there is no concensus about which computation method should be used to calculate it. Recent studies suggest that different formulas may lead to different tidal volume and PEEP settings. The aim of this study is to compare 3 different inspiratory PL measurement method; direct measurement (PLD), elastance derived (PLE) and release derived (PLR) methods in patients with multiple mechanical abnormalities. 34 patients were included in this prospective observational study. Measurements were obtained during volume controlled mechanical ventilation in sedated and paralyzed patients. During the study day airway and eosephageal pressures, flow, tidal volume were measured and elastance, inspiratory PLE, PLD and PLR were calculated. Mean age of the patients was 67 ± 15 years and APACHE II score was 27 ± 7. Most frequent diagnosis of the patients were pneumonia (71%), COPD exacerbation(56%), pleural effusion (55%) and heart failure(50%). Mean plateau pressure of the patients was 22 ± 5 cmH2O and mean respiratory system elastance was 36.7 ± 13 cmH2O/L. EL/ERS% was 0.75 ± 0.35%. Mean expiratory transpulmonary pressure was 0.54 ± 7.7 cmH2O (min: - 21, max: 12). Mean PLE (18 ± 9 H2O) was significantly higher than PLD (13 ± 9 cmH2O) and PLR methods (11 ± 9 cmH2O). There was a good aggreement and there was no bias between the measurements in Bland-Altman analysis. The estimated bias was similar between the PLD and PLE (- 3.12 ± 11 cmH2O) and PLE and PLR (3.9 ± 10.9 cmH2O) measurements. Our results suggest that standardization of calculation method of inspiratory PL is necessary before using it routinely to estimate alveolar overdistension.

Are pocket sized ultrasound devices sufficient in the evaluation of lung ultrasound patterns and aeration scoring in pulmonary ICU patients?

Lung ultrasound (LUS) is a practical diagnostic tool for several lung pathologies. Pocket sized USG devices (PSUDs) are more affordable, accessible, practical, and learning to use them is easier than standard ultrasound devices (SUDs). Their capability in image quality have been found as comparable with standard USG machines. Studies have been showing that these devices can be useful as much as SUDs in the evaluation of heart, abdomen, vascular structures, diaphragm and optic nerve. The aim of this study is to compare PSUD with a standard ultrasound devices (SUD) in the evaluation of LUS patterns such as alveolar, interstitial syndromes and lung aeration score (LAS). Study performed in an University Hospital Pulmonary ICU. All patients older than 18 years old were included in this study. The sector probe of SUD (Vivid-Q) and PSUD (Vscan) were used for investigation of A lines, interstitial (B lines), alveolar syndromes (consolidation, hepatisation, air bronchograms) and pleural effusion. 33 patients were included in the study. When PSUD was compared with SUD in terms of total B2 count, and LAS in the right, left and both lung, there was an agreement without proportional bias according to Bland Altman test. There was also good inter class correlation coefficient value as greater than 0.8 and 0.7 between two physicians in terms of counting of total B1, B2, total B lines and calculating of total LAS for SUD and PSUD respectively. PSUDs is a reliable and valid method for evaluation of LUS patterns like SUDs.

The usefulness of subxiphoid view in the evaluation of acceleration time and pulmonary hypertension in ICU patients.

BACKGROUND: Pulmonary hypertension (PHT) is very frequent in ICUs. Estimation of systolic pulmonary artery pressure (PASP) by using tricuspid regurgitation velocity (TRV) is impossible in 25% of patients. However, it may be possible to estimate PHT in these patients by obtaining subxiphoid imaging of short axis (SX-SAX) and measuring pulmonary artery diameter (PAD) and right ventricular outflow tract (RVOT) acceleration time (AT). We first aimed to compare the values of AT and PAD measured at the parasternal short axis view (PSAX) and SX-SAX and then to compare AT measurements obtained in the RVOT and pulmonary artery (PA) in ICU patients. METHODS: This prospective observational study was conducted in a 7-bed ICU of a tertiary academic teaching hospital. Measurements of TRV, PAD, and AT in parasternal and subxiphoid SAX were obtained. AT was measured in RVOT and PA locations. We measured other echocardiographic signs of PHT to assess the probability of PHT in addition to TRV measurements. RESULTS: The study consisted of 61 patients. TRV was measured in 85% of the patients, and SX-SAX was visualized in 78%. The probability of PHT was high (49%) in this study population. There were agreement and no proportional bias between the measurements of PAD and AT at both SX-SAX and PSAX. Measurements of AT in the RVOT and PA were similar, as well. CONCLUSION: These results suggested that measurements of AT in the PSAX and SX-SAX and RVOT and PA were similar in the ICU patients.

Does it make difference to measure diaphragm function with M mode (MM) or B mode (BM)?

Diaphragm dysfunction occurs in mechanically ventilated subjects. Recent literature suggests that diaphragm thickening fraction (DTF) measured by ultrasound can be useful to predict weaning outcome. However, there is no standardized approach in the measurement of diaphragm thickness (DT) and limited data exists comparing different measurement techniques of diaphragm thickness (M mode-MM or B mode-BM). The goal of this study was to compare MM with BM in the measurements of DT and excursion in the ICU subjects. DT measurements were obtained from the right diaphragm during tidal and maximal inspiratory breathing. Three measurements of the DT were taken both in MM and BM and their mean values were calculated. DT was measured during inspiration and expiration and DTF was calculated. Excursion of diaphragm was also measured with MM and BM during tidal and maximal inspiratory breathing. Bias and agreement between the two measurement methods were evaluated with Bland and Altman test. Sixty-two subjects were enrolled in the study. While 25 (40%) subjects were receiving invasive mechanical ventilation, 14 (23%) subjects ventilated noninvasively. There were no significant difference between the measurement results of MM and BM. BM and MM tidal diaphragm measurements during the inspiratory (0.3 ± 0.08 and 0.31 ± 0.08 cm; P = 0.022), expiratory (0.24 ± 0.07 and 0.24 ± 0.07 cm; P = 0.315) phases and tidal DTF were (27 ± 16 and 31 ± 14%, P = 0.089) respectively. Results of our study suggests that except tidal inspiratory diaphragm thickness, all thickness and excursion measurements with MM and BM are very compatible with each other. Further studies are necessarry to confirm our results and to standardize the measurements of diaphragm.

Validity and reliability of pocket-sized ultrasound devices in measurement of optic nerve sheath diameter in ICU patients.

The measurement of the optic nerve sheath diameter (ONSD) by ultrasonography (USG) is particularly important for intracranial pressure (ICP) monitoring when invasive measurements are not possible or are contraindicated. Standard USG (SUDs) devices can be bulky and may break down the workflow. The validity and reliability of pocket-sized USG devices (PSUDs) compared to SUDs for ONSD measurement has not been investigated, yet. We compared the reliability and validity of PSUDs with SUDs for ONSD measurement. 35 patients were included in the study. ONSD measurements with PSUDs and SUDs were performed by two clinicians as three different measurements in both sagittal and transverse axis of the eye. There was agreement between mean transverse ONSD (mtONSD), mean sagittal ONSD (msONSD), and mean ONSD(mONSD) values measured with each device according to Bland-Altman test (p = 0.166, p = 0.135, p = 0.066, respectively) with no proportional bias (p = 0.544, p = 0.868, p = 0.929, respectively). Intraclass correlation coefficients (ICC) were found to be greater than 0.7 for mtONSD, msONSD, and mONSD values measured by SUD (ICC = 0.790, ICC = 0.817, and ICC = 0.844, respectively). Similarly, for mtONSD, msONSD, and mONSD values measured by PSUD, ICC were found greater than 0.7 (ICC = 0.763, ICC = 0.814, and ICC = 0.843, respectively). There was no statistically significant difference between mtONSD and msONSD (p = 0.441 for SUD and p = 0.893 for PSUD). There was a good correlation between mtONSD and msONSD (r = 0.767 for SUD and r = 0.816 for PSUD). The total variance between three different measurements in the transverse and sagittal axis was ± 0.6 mm. PSUDs can be used with similar validity and reliability as SUDs for ONSD measurement.

Evaluation of nephrotoxicity and prognosis in patients treated with colistin due to hospital-acquired pneumonia.

INTRODUCTION: Colistimethate sodium (CMS) is frequently used in the treatment of nosocomial multidrug-resistant gram-negative infections. Nephrotoxicity is the most important side effect. The aim of this study is to evaluate the effect of colistin on nephrotoxicity and to assess prognosis in patients treated with CMS due to hospital-acquired pneumonia (HAP). MATERIALS AND METHODS: Patients treated with CMS for HAP due to multidrug-resistant Pseudomonas aeruginosa or Acinetobacter baumannii were included in this cohort study. RESULT: We evaluated 281 patients treated with two different brands of CMS whose administration dose is different: imported (n= 58, low dose/kg) and domestic (n= 223, high dose/kg). Nephrotoxicity developed in 175 patients (62.3%). The median age (73 vs. 66 years, p= 0.004) and mortality rates were higher (66.9% vs. 52.8%, p= 0.022) in patients having nephrotoxicity. The patients receiving high dose/kg had higher nephrotoxicity rate (67.7% vs. 41.4%, p< 0.001). The clinical, bacteriological response and mortality rates of the whole group were 52.0%, 61.0%, 61.6%, respectively. The clinical and bacteriological response rates were similar in the different dose groups. Multivariate analysis showed that nephrotoxicity was associated with domestic brand depending on use of high dose (OR= 3.97), advanced age (ß= 0.29, p= 0.008), male gender (OR= 2.60), hypertension (OR= 2.50), red blood cells transfusion (OR= 2.54), absence of acute kidney injury (OR= 10.19), risk stage of RIFLE (OR= 11.9). CONCLUSIONS: Nephrotoxicity is associated with the use of high dose colistin, age, gender, hypertension, red blood cells replacement and RIFLE stage. The mortality rate is higher in patients developing nephrotoxicity.

A promising marker in early diagnosis of septic acute kidney injury of critically ill patients: urine insulin like growth factor binding protein-7.

AIM: An ideal biomarker for early diagnosis of septic acute kidney injury (AKI) should reflect renal stress or damage at initiation point, at cellular level. The aim of this study was to assess the role of a urinary cell cycle arrest marker, insulin-like growth factor-binding protein 7 (IGFBP7) in early diagnosis of septic AKI in adult critical care patients. METHODS: This was a single-center prospective cohort study. Patients without AKI, admitted to a medical intensive care unit (ICU) between January 2010 and March 2013, were included. According to 'sepsis' and 'AKI' development during their ICU stay, they were grouped as 'sepsis-non AKI', 'sepsis-AKI' and 'non-sepsis-non AKI (control)'. Among these groups, urine IGFBP7 was studied and compared with Human ELISA Kit/96 Test/USCNK(®) first on admission and then on daily collected serial urine samples. RESULTS: A total of 118 patients formed the cohort; 52 in sepsis-non AKI, 43 in sepsis-AKI, 23 in control group. Admission urine IGFBP7 predicted septic AKI development with 72% sensitivity and 70% specificity for a threshold level of 2.5 ng/mL with an area under the receiver operating characteristics curve (AUC) of 0.79 (95% CI: 0.70-0.88). No impact of sepsis was observed on urine IGFBP7 levels in the absence of AKI. In the septic AKI group urine IGFBP7 levels continuously increased up to the day of AKI development and high levels were suspended for 10 days further. CONCLUSION: Admission urine IGFBP7 levels and following its course in ICUs can be used as a promising new biomarker for the early diagnosis of septic AKI development without being affected by sepsis itself.

Can admission serum cystatin C level be an early marker subclinical acute kidney injury in critical care patients?

BACKGROUND: In critical care patients, the diagnosis of subclinical acute kidney injury (AKI) might be difficult with measurements of serum creatinine and estimated glomerular filtration rate (eGFR). Their 'sensitive kidneys' can easily be affected from sepsis, underlying diseases, medications and volume status and if they can be detected earlier, some preventive measures might be taken. In this study we aimed to determine whether admission serum cystatin C (sCys-C) and other clinical parameters can identify subclinical AKI in medical intensive care unit (ICU) patients with normal creatinine-based eGFR at admission. METHODS: A prospective cohort study, performed in an adult ICU of a university hospital between January 2008 and March 2013. The blood samples were obtained within the first 24-48 hours of admission and sCys-C levels were analyzed with particle-enhanced immunonephelometric assay. AKI development was assessed according to RIFLE criteria. The cutoff value of sCys-C for the prediction of AKI was determined with receiver operating characteristic (ROC) curve analysis. RESULTS: A total of 72 patients were included in the study and 19 (26%) of them developed AKI. Among the patients with AKI admission sCys-C levels were significantly higher when compared with non-AKI patients (1.06 ± 0.29 vs. 0.89 ± 0.28 respectively, p = 0.026). With ROC curve analysis, the threshold level for sCys-C was 0.94 mg/L with 63% sensitivity and 66% specificity [AUC: 0.67, p = 0.026]. With logistic regression analysis 'high sCys-C levels at admission' (OR = 4.73; 95%CI 1.03-21.5, p = 0.044) was found as one of the independent variables for the prediction of AKI development, in addition to 'being intubated before ICU admission' (OR = 10.2; 95%CI 1.72-60.4, p = 0.01) and 'hypotension during ICU follow-up' (OR = 12.3; 95%CI 2.5-60.1, p = 0.002). CONCLUSION: In this cohort of patients, a high sCys-C level at admission was found to be a predictor of subclinical AKI arising during their ICU stay. If supported with further studies, it might be used to provide more accurate and earlier knowledge about renal dysfunction and to take appropriate preventive measures.

[Evaluation of risk factors for invasive pulmonary aspergillosis and detection of diagnostic values of galactomannan and PCR methods in bronchoalveolar lavage samples from non-neutropenic intensive care unit patients]. / Nötropenik olmayan yogun bakim hastalarinda invazif pulmoner aspergilloz için risk faktörlerinin degerlendirilmesi ve bronkoalveoler lavaj örneklerinde galaktomannan ve PCR testlerinin tanisal degerinin belirlenmesi.

Non-neutropenic intensive care unit (ICU) patients are at particular risk for invasive pulmonary aspergillosis. In these cases, radiological and microbiological methods (direct microscopy, culture), which can be used for diagnosis, have quite low sensitivity and specificity. The aims of this study were to evaluate the risk factors for invasive pulmonary aspergillosis (IPA) in non-neutropenic ICU patients and to determine the diagnostic values of galactomannan (GM) antigen and Aspergillus nucleic acid detection methods. A total of 44 patients (13 female, 31 male; age range: 36-96 years) who had been followed at pulmonary ICU with invasive mechanical ventilation and undergone bronchoscopy between January to December 2013, were included in the study. Consecutive bronchoalveolar lavage (BAL) and serum samples were obtained from all of the patients. BAL samples were tested for the presence of Aspergillus DNA by polymerase chain reaction (PCR) and both serum and BAL samples were tested for GM antigen by EIA method (Platelia Aspergillus, BioRad, France). EORTC/MSG criteria were used for the case definition of IPA. Patients were classified as high-probable IPA, possible IPA and non-IPA. ROC (receiver operating characteristics) analysis was used to determine the diagnostic values of BAL Aspergillus PCR and BAL GM in the diagnosis of IPA. Five patients were defined as high-probable IPA and six were defined as possible IPA; thus the incidence rate of IPA was estimated as 11.4% (5/44) among non-neutropenic intensive care unit patients. In high-probable IPA patients, BAL GM levels were significantly higher than non-IPA patients (p< 0.05). The prolonged duration in ICU, presence of septic shock and the use of high cumulative doses (> 460 mg) of steroid were found to be risk factors for IPA development. The cut-off value for GM in BAL samples was determined as 0.7, with a sensitivity rate of 100% (95% confidence interval: 47.9-100) and a specificity rate of 87.9% (95% confidence interval: 71.7-96.5), so optimal GM level in BAL was considered as ≥ 0.7 for the diagnosis of IPA. The specificity rates of serum GM and BAL Aspergillus PCR methods were high (97.1% and 93.9%, respectively), however their sensitivity rates were found quite low (33.3% and 40%, respectively), in the diagnosis of IPA. In conclusion, development of IPA should be assessed in non-neutropenic patients when the stay in ICU extends and high dose cumulative steroids are used. GM antigen detection in BAL can be used effectively for diagnosis of IPA in these patients compared to other diagnostic methods.

The effect of different definitions of hepatic injury on incidence and mortality rates in the ICU patient population with secondary hepatic injury.

OBJECTIVE: The aim was to investigate how different hepatic injury (HI) definitions used in the same study population change incidence and mortality rates and which would best diagnose secondary HI. DESIGN: Single-centre retrospective observational cohort study. SETTING: Tertiary hospital ICU, ANKARA, Turkey. PATIENTS: Four hundred seventy-eight adult patients were included in the study. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Three definitions of HI were compared. Taking the SOFA hepatic criteria (SOFA: Total bilirubin (TBL) > 1.2 mg/dl) as the gold standard, sensitivity, specificity, positive and negative predictive values, and accuracy of the modified 2017 definition by the American College of Gastroenterology (ACG) and the 2019 European Association for the Study of the Liver (EASL) were calculated. RESULTS: Incidence rates ranged from 10% to 45% according to the definition (p < 0.005), while mortality rates ranged from 38% to 57%. When the SOFA1.2 (TBL > 1.2 definition was taken as the gold standard, the diagnostic value of the ACG definition was high, and HI was found to be an independent risk factor that increased mortality four times. CONCLUSIONS: According to this study's results, the incidence and mortality rates of secondary HI vary greatly depending on the definition used. A definition that includes minimal increases in ALT, AST, and TBL predicts mortality with reasonable incidence rates.

Risk Factors for Prolonged Intensive Care Unit Stay in Patients with Hypercapnic Respiratory Failure.

INTRODUCTION: Hypercapnic respiratory failure (HRF) is one of the most frequent reasons for intensive care unit (ICU) admissions. In this study, we aimed to investigate the risk factors for prolonged ICU stay in HRF patients for longer than 7, 10, and 15 days. METHODS: Impact of demographics, vitals at the admission, comorbid disease severity, respiratory parameters, admission diagnosis, noninvasive mechanical ventilation (NIV) application time and settings, arterial blood gas, and blood biochemistry results were analyzed in patients with HRF to investigate risk factors for longer ICU stay. RESULTS: A total of 210 patients who were admitted to ICU with HRF (PaCO₂ values of 45 mmHg and higher) were included in this retrospective cohort study. The mean age of the patients was 69 ± 12 years, and the mean ICU duration was 9 ± 7 days. Forty-five percent of the patients stayed in the ICU for more than one week and 10% of them stayed for more than 15 days. Risk factors for a prolonged stay in ICU for more than 7 days were high SOFA score, acute renal failure (ARF) at admission, low PaO₂/FiO₂ on the 2^nd day of admission, and high TSH level. Low FEV1 and FEV1/FVC ratio, ARF at admission, and low PaO₂/FiO₂ ratio on the 2nd day of admission were found to be risk factors for prolonged stay in ICU for longer than 10 days. Significant risk factors prolonging the ICU duration for more than 15 days were high SOFA score, low FEV1, low FEV1/FVC ratio (p = 0.008), and hypothyroidism (p = 0.037). FEV1% predicted less than 25.5% and FEV1/FVC% less than 46.5% were significantly associated with ICU stay longer than 10 days. CONCLUSION: Earlier diagnosis and treatment of patients with hypothyroidism and severe airflow obstruction could shorten the length of ICU stay of hypercapnic patients.

Value of Rox Index to Predict Intubation and Intensive Care Unit Outcome in Patients with Respiratory Failure.

BACKGROUND: Recent literature suggests that the respiratory rate oxygenation (ROX) index may be a useful parameter in predicting intubation indication in hypoxemic patients. OBJECTIVE: In this study, we evaluated the accuracy of the ROX index in predicting intubation, length of stay in the ICU, and mortality in ICU patients with hypoxemic respiratory failure with and without hypercapnia. METHODS: Single-centre retrospective cohort study of 290 patients, with a preliminary diagnosis of respiratory failure, who were treated with low flow oxygen systems. Demographics, medical history, clinical, laboratory, treatment, and prognostic data were obtained from the electronic records of the hospital. The ROX index was calculated at the time of ICU admission. RESULTS: Thirty-seven percent of non-hypercapnic and 69% of hypercapnic patients were intubated (p:0.005). In hypercapnic patients, ROX: 6.9 had highest sensitivity (81%) and specificity (65%) values for intubation (p:0.005). In non-hypercapnic patients, ROX: 6.2 had the highest sensitivity (81%) and specificity (40%) values. While 11% of hypercapnic patients and 30% of non-hypercapnic patients were died (p:0.05), 22% of hypercapnic patients and 33% of non-hypercapnic patients stayed in the ICU longer than 14 days (p:0.044). The highest sensitivity and specificity values were found for mortality in hypercapnic patients; for ROX value of 5.94 (sensitivity:86%, specificity:61%) and for ICU stay longer than 14 days; for ROX value of 7.4 (sensitivity:71%, specificity:68%). CONCLUSION: Results of our study suggest that ROX index calculated during ICU admission can be helpful in predicting intubation indication and length of ICU stay in patients with respiratory failure and hypercapnia may influence the cutoff values.

Comparison of the value of initial and serial endotracheal aspirate surveillance cultures in predicting the causative pathogen of ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit (ICU) and its outcome is affected by the adequacy and timing of initial antibiotic therapy. Recent studies have suggested that surveillance cultures of the lower airways may provide microbiological guidance for initial antibiotic prescription and increase the use of appropriate antibiotic therapy. This study aimed to compare the predictive value of initial and serial surveillance cultures of endotracheal aspirates in predicting the causative pathogen of VAP in patients receiving antibiotic therapy. This was an observational prospective cohort study. Ninety-two patients ventilated for at least 4 days were recruited into the study. Initial (IS-ETA) and serial (SS-ETA) endotracheal aspirate surveillance cultures were obtained on the day of intubation and every second day, respectively. The sensitivity, specificity, and positive and negative predictive values for the causative pathogens of VAP were calculated for each surveillance culture. Ninety-two initial and 252 serial surveillance cultures were obtained during the study period. The sensitivity of IS-ETA culture was 12% and of SS-ETA culture was 44%. The sensitivity of SS-ETA in late-onset VAP was 51%. The value of SS-ETA surveillance cultures was better than IS-ETA surveillance in predicting the causative pathogen of VAP, particularly in late-onset pneumonia.

[The role of physiologic dead space measurement in predicting extubation success]. / Fizyolojik ölü bosluk ölçümünün ekstübasyon basarisini tahmin etmedeki rolü.

Dead space ventilation (Vd/Vt) is a valuable parameter which indicates the ventilated but not perfused lung areas. The normal range is between 30-50% in mechanically ventilated patients. Increased levels could be observed in many pulmonary diseases such as pulmonary embolism, acute respiratory distress syndrome and chronic obstructive pulmonary disease. Vd/Vt is also used for the prediction of extubation success and a value of < 55-60% indicates successful extubation according to several studies. The aim of this study is to evaluate the value of baseline capnographic measurements on extubation success. A total of 35 patients were included in this prospective study; and 25 (71%) of them who were extubated successfully were named as group 1 and the remaining 10 (29%) patients with extubation failure were named as group 2. When the two groups were compared, Vd/Vt value, measured at the first 24 hours of hospitalization, was found to be higher in group 2 (0.66 vs. 0.54, p< 0.05). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of baseline Vd/Vt ≥ 0.60 for predicting extubation failure according to ROC curve were 70%, 72%, 58%, 81% and 71%, respectively. In conclusion, results of this study suggest that, higher Vd/Vt values measured on the first day of hospitalization may be an early predictor of extubation failure.

Mortality prediction in community-acquired pneumonia requiring mechanical ventilation; values of pneumonia and intensive care unit severity scores.

Severe community-acquired pneumonia (CAP) is an important cause of intensive care unit (ICU) admissions. Many different pneumonia scoring systems have been developed in order to assess the severity of pneumonia and to decide the ICU follow-up and treatment. But still debate is going on about their performances and also they have not been tested yet if they can predict ICU mortality in severe CAP patients requiring mechanical ventilation. The aim of this study is to evaluate the performances of pneumonia and ICU scores in predicting mortality in CAP patients requiring mechanical ventilation. A retrospective observational cohort study. The files of mechanically ventilated CAP patients were reviewed and demographic, clinic and laboratory characteristics were recorded. Scoring systems of pneumonia [revised American Thoracic Society (ATS) criteria, CURB-65, pneumonia severity index (PSI)] and ICU [Acute Physiology Assessment and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment] were compared for mortality prediction. Thirty eight female and 63 male, a total of 101 severe CAP patients, with the mean age of 68 +/- 16 years, were included in the study. ICU mortality rate was assessed as 55%. Ninety percent of all patients met the revised ATS criteria and 92% of them met the PSI scoring system for ICU admissions. Although the CURB-65, PSI, revised ATS criteria were not found valuable to predict mortality, the increased APACHE II score was found to be related with increased mortality rate (for APACHE II > 20 odds ratio: 3, 95% CI: 1.2-7, p= 0.024). These results suggest that instead of the pneumonia scoring systems the APACHE II score can best predict the ICU mortality. So, more attention should be paid for severe CAP patients with APACHE II score > 20.