Liver Transplantation and Early Culture Growth: Risk and Impact?

OBJECTIVE: Despite advances in immunosuppressive drugs, postoperative care, and surgical techniques, bacterial infections remain the most important cause of morbidity and mortality in liver transplant patients. The aim of this study is to evaluate the influence of culture results taken on the first day of admission to intensive care unit on mortality, graft rejection, mechanical ventilation duration, and length of intensive care unit stay. Our study has clinical importance because it is the first study evaluating the cultures obtained on the first day of intensive care unit stays in liver transplant patients. METHODS: Patients' demographic data, transplant type, rates of deceased and living donors, culture results, amount of blood and blood products used intraoperatively, previous hospital admission, mortality, incidence of graft rejection, mechanical ventilation duration, and length of intensive care unit stay were recorded. RESULTS: Mortality and graft rejection were 14.8% and 9%, respectively. The mortality was significantly higher in all 3 cultures and/or in only blood culture-positive patients. Graft rejection, mechanical ventilation duration, and length of intensive care unit stay were significantly higher in patients whose 3 cultures were all positive. Only body mass index had a significant effect on mortality, graft rejection, and positive culture results. CONCLUSIONS: Liver transplant patients' first postoperative day culture results were correlated with mortality, graft rejection, mechanical ventilation duration, and length of intensive care unit stay.

Anaesthetic Management for Face Transplantations: The Experience of Akdeniz University.

OBJECTIVE: Solid organ transplantation is a rescue therapy, whereas face transplantation, as well as other composite tissue allotransplantations, offers treatment options to enhance the quality of life. Difficult airway, severe haemorrhage and prolonged operative length are among the frequently encountered complications of anaesthetic management in patients with a history of multiple reconstructive surgeries. METHODS: Five face allotransplants that were performed in our institute, arising from four full and one partial face transplantations, were reviewed. The pitfalls encountered before, during and following surgery were then summarised. RESULTS: Two of our patients (patients 3 and 4) underwent permanent tracheostomy preoperatively. Transplantation was initiated after surgical tracheostomy under local anaesthesia and under sedation in cases 2 and 5. Patient 1 was orally intubated without difficulty under general anaesthesia and was operated following tracheal cannulation via surgical tracheostomy. Thirteen units of red blood cells were transfused each for patients 2 and 4. Two other patients (patients 1 and 4) each received 5 units of red blood cells. Patient 5, who underwent mid-face transplantation lasting for 7.5 h, was not transfused. No major life-threatening complications were observed intraoperatively or following surgery. CONCLUSION: Face transplantation is a surgical procedure in which anaesthetic management may be problematic. The anaesthetist may encounter difficulties, such as difficult airway, severe bleeding, a prolonged operative time and postoperative complications. Side effects and complications may be reduced by strict follow-up and haemodynamic monitoring of patients.

Incidental Aluminum Phosphide Poisoning: Case Report and Current Management.

Aluminum phosphide (AlP) is a commonly used cheap rodenticide, insecticide, and fumigant. Most intoxications in the literature are suicidal ingestions, however, AlP may cause incidental inhalational toxicities as well. After ingestion or inhalation, nausea, vomiting, dyspnea and abdominal pain develops within minutes. Hallmark of toxicity is refractory hypotension, cardiac failure and severe metabolic acidosis developing within a matter of hours are the major cause of mortality. In Turkey, AlP tablets are widely accessible and are sold without any restrictions. However, there are few local case reports in the literature. Additionally, incidental AlP intoxications are rarely reported. Herein, we present a 25-year-old male patient incidentally poisoned with AlP. He was found unconscious in a grain storage unit protected by aluminum phosphide tablets. He had hypotension and tachycardia. Arterial blood gas analysis did not reveal metabolic acidosis. He was quickly intubated and admitted to Intensive Care Unit (ICU). Supportive care crystalloid solution, n-acetyl cysteine and norepinephrine infusion was administered. After 36 hours, he was extubated and discharged without any complications. There is no specific antidote or treatment for AlP toxicity. Literature is controversial regarding treatment approach. Inhalational toxicity may occur under extreme conditions, as presented in this case report. Preventive strategies should be considered to reduce incidents. Clinicians should also be aware that AlP is a widely available and highly toxic compound that has no specific antidote and toxicity needs to be urgently treated with best supportive care.

Current Statement of Intensive Care Units in Turkey: Data obtained from 67 Centers.

OBJECTIVES: We aimed to obtain information about the characteristics of the ICUs in our country via a point prevalence study. MATERIAL AND METHODS: This cross-sectional study was planned by the Respiratory Failure and Intensive Care Assembly of Turkish Thoracic Society. A questionnaire was prepared and invitations were sent from the association's communication channels to reach the whole country. Data were collected through all participating intensivists between the October 26, 2016 at 08:00 and October 27, 2016 at 08:00. RESULTS: Data were collected from the 67 centers. Overall, 76.1% of the ICUs were managed with a closed system. In total, 35.8% (n=24) of ICUs were levels of care (LOC) 2 and 64.2% (n=43) were LOC 3. The median total numbers of ICU beds, LOC 2, and LOC 3 beds were 12 (8-23), 14 (10-25), and 12 (8-20), respectively. The median number of ventilators was 12 (7-21) and that of ventilators with non-invasive ventilation mode was 11 (6-20). The median numbers of patients per physician during day and night were 3.9 (2.3-8) and 13 (9-23), respectively. The median number of patients per nurse was 2.5 (2-3.1); 88.1% of the nurses were certified by national certification corporation. CONCLUSION: In terms of the number of staff, there is a need for specialist physicians, especially during the night and nurses in our country. It was thought that the number of ICU-certified nurses was comparatively sufficient, yet the target was supposed to be 100% for this rate.

Consideration of difficulties and exit strategies in a case of face allotransplantation resulting in failure.

We describe the first rescue procedure in a case of total face allotransplantation. The recipient was a 54-year-old man with severe disfigurement of the entire face following an accidental gunshot injury 5 years previously. The large defect included the maxilla, mandible, and mid-face. Full face procurement was performed from a multiorgan cadaveric donor and was allotransplanted to the recipient. The post-transplant induction immunosuppressive regimen included ATG combined with tacrolimus, mycophenolate mofetil, and prednisone, while maintenance was provided by the last three of these. Although the early postoperative period was uneventful, squamous cell carcinoma developed in the upper and lower extremities in the fifth postoperative month, and post-transplant lymphoproliferative disorder (PTLD) occurred in the sixth month postoperatively. Malignancies were treated, involving both surgical and medical approaches. The patient developed opportunistic pulmonary and cerebellar aspergillosis. In order to reduce the adverse affects and metabolic and immunological load, the transplanted face was removed and replaced with a free flap. Although the early postoperative period was promising, with the transferred flap surviving totally and all vital signs and general status appearing to be improving, the patient was eventually lost due to complicated infectious and metabolic events. Although this case was unsuccessful, we suggest that the immunological and metabolic load should be reduced as soon as stable medical conditions are established in case of diagnosis of a situation involving a high rate of mortality, such as PTLD and untreatable opportunistic infections. This should include withdrawal of all immunosuppressive drugs and removal of all allotransplanted tissues.

A randomized placebo-controlled phase II study of a Pseudomonas vaccine in ventilated ICU patients.

BACKGROUND: Currently, no vaccine against Pseudomonas is available. IC43 is a new, recombinant, protein (OprF/I)-based vaccine against the opportunistic pathogen, Pseudomonas aeruginosa, a major cause of serious hospital-acquired infections. IC43 has proven immunogenicity and tolerability in healthy volunteers, patients with burns, and patients with chronic lung diseases. In order to assess the immunogenicity and safety of IC43 in patients who are most at risk of acquiring Pseudomonas infections, it was evaluated in mechanically ventilated ICU patients. METHODS: We conducted a randomized, placebo-controlled, partially blinded study in mechanically ventilated ICU patients. The immunogenicity of IC43 at day 14 was determined as the primary endpoint, and safety, efficacy against P. aeruginosa infections, and all-cause mortality were evaluated as secondary endpoints. Vaccinations (100 µg or 200 µg IC43 with adjuvant, or 100 µg IC43 without adjuvant, or placebo) were given twice in a 7-day interval and patients were followed up for 90 days. RESULTS: Higher OprF/I IgG antibody titers were seen at day 14 for all IC43 groups versus placebo (P < 0.0001). Seroconversion (≥4-fold increase in OprF/I IgG titer from days 0 to 14) was highest with 100 µg IC43 without adjuvant (80.6%). There were no significant differences in P. aeruginosa infection rates, with a low rate of invasive infections (pneumonia or bacteremia) in the IC43 groups (11.2-14.0%). Serious adverse events (SAEs) considered possibly related to therapy were reported by 2 patients (1.9%) in the group of 100 µg IC43 with adjuvant. Both SAEs resolved and no deaths were related to study treatment. Local tolerability symptoms were mild and rare (<5% of patients), a low rate of treatment-related treatment-emergent adverse events (3.1-10.6%) was observed in the IC43 groups. CONCLUSION: This phase II study has shown that IC43 vaccination of ventilated ICU patients produced a significant immunogenic effect. P. aeruginosa infection rates did not differ significantly between groups. In the absence of any difference in immune response following administration of 100 µg IC43 without adjuvant compared with 200 µg IC43 with adjuvant, the 100 µg dose without adjuvant was considered for further testing of its possible benefit of improved outcomes. There were no safety or mortality concerns. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00876252 . Registered on 3 April 2009.

Retrospective Analysis of Prognostic Factors of Severe Traumatic Brain Injury in a University Hospital in Turkey.

AIM: To examine the use of prognostic factors such as age, Glasgow Coma Scale (GCS) score, pupil reactivity and computerized tomography (CT) findings for predicting the prognosis of severe traumatic brain injury (TBI) patients in Turkey. MATERIAL AND METHODS: We retrospectively evaluated TBI patients who were accepted to Akdeniz University Intensive Care Unit between 1 January 2007 and 31 December 2009. Patient data were collected from the hospital information system. Marshall CT classification was performed and CT findings were noted. The Glasgow outcome scale (GOS) score of patients was calculated according to their 6-months follow up. RESULTS: A total of 101 patients with severe TBI were studied. The mean age of the patients was 34.7 ± 14.1 years. Of these, male patients (81.2%) were dominant and road accidents (83.2%) were the most common mechanism of TBI development. In addition, poor neurological outcome was detected in 58.4% of the patients and 29 patients (28.7%) died. The mechanism of injury (p = 0.34), gender (p = 0.64) or age (p = 0.34) did not lead to a difference in neurologic outcomes while the GCS score (p = 0.01), pupillary reactivity (p = 0.000), Marshall CT classification (p = 0.01) and the presence of traumatic subarachnoid haemorrhage (p = 0.04) affected the GOS scores. CONCLUSION: In our study, GCS score, CT findings and pupil reactivity were prominent as prognostic factors, but a relationship between age and prognosis was not observed.

Maxillary sinusitis in patients ventilated for a severe head injury and with nostrils free of any foreign body.

BACKGROUND: This study aims to determine the frequency of maxillary sinusitis in the patients with traumatic head injury and nostrils free of any foreign body. In addition, the sensitivity and specificity of ultrasonography (US) for the detection of the presence of fluid in maxillary sinuses were evaluated. PATIENTS AND METHODS: Forty patients with severe traumatic head injury were included in the study. The patients who had displaced maxillary sinus fracture at the medial wall and naso-tracheal and/or naso-gastric tube were excluded. Paranasal computed tomography (CT) was performed along with the routine cranial CT scanning or in case of unknown source of infection and compared with the results of ultrasonographic examination of maxillary sinuses performed by a single radiologist who was unaware of the CT results. In the patients, who had clinical and radiological signs of sinusitis, a trans-nasal puncture was performed using sinoject (SinoJect, ATOS Medical, Sweden), a spring-activated puncture instrument, to take a sample for microbiologic examination and to drain maxillary sinuses. RESULTS: Eighty-five percent of the patients were tracheotomised on the fifth day (on average) of their intensive care unit (ICU) stay. The frequency of sinusitis in the study group was found to be 32.5% (13 patients). The most frequently isolated species were Pseudomonas spp. (37.5%), Escherichia coli (20.8%) and Peptostreptococcus (16.7%). Five of the aspirates were polymicrobial. The sensitivity, specificity, positive predictive value and negative predictive value of B-mode US, compared with CT for the detection of fluid presence in maxillary sinuses in a 100 maxillary sinus examinations, were 92.2%, 81.6%, 83.9% and 90.9%, respectively. CONCLUSION: Maxillary sinusitis should be considered as a source of infection or sepsis in patients with traumatic head injury because of its high frequency. US is likely to be used as the first-line diagnostic tool for the determination of fluid in maxillary sinuses, especially in patients who do not require CT or cannot be transported to a radiology unit for CT.

Cost analysis of ventilator-associated pneumonia in Turkish medical-surgical intensive care units.

A study was carried out to assess treatment success and the overall costs of patients with ventilator-associated pneumonia (VAP). In a prospective case control study, data were collected from 25 intensive care unit (ICU) beds. A total of 162 ICU patients who required mechanical ventilation were assessed. Of these, 81 patients were diagnosed with VAP and the other 81 were controls (without VAP). Risk of mortality was analyzed and total cost of care was recorded. Age, sex and underlying disease were similar between the groups. The mean length of stay (LOS) in the ICUs in the VAP cases (15.7±9.1 days) exceeded that of the controls (4.9±4.9 days) (p 0.0001), and the additional LOS attributable to VAP was estimated at 10.8 days. In the VAP group, 25 patients had early-onset VAP, and the other 56 patients had late-onset VAP. Mortality rates were higher in VAP patients (32%) than controls (19.7%) p 0.05). Total costs were USD 8602.7±5045.5 in the VAP group and USD 2621.9±2053.3 in controls. The additional cost for VAP was found to be USD 5980 per patient. These data suggest that morbidity, mortality, ICU length of stay and costs increase with VAP. The additional costs for VAP are especially based on the use of novel and expensive antibiotics, other drugs, and medical material.

Repeat percutaneous tracheostomy in the neurocritically ill patient.

INTRODUCTION: Percutaneous tracheostomy is a widely used and accepted method for long-term mechanical ventilation and airway protection. Neurocritically ill patients sometimes require repeat tracheostomy, which is traditionally considered a relative contraindication for percutaneous procedure. The aim of this study was to determine the safety of repeat percutaneous tracheostomy in neurocritically ill patients with a history of previous tracheostomy. METHODS: In the 16-bed academic neurointensive care unit, we prospectively enrolled patients who needed new tracheostomy placement for airway protection or prolonged mechanical ventilation and had previously undergone percutaneous tracheostomy placement. We collected data on indications, procedure, periprocedural complications, and outcome of repeated tracheostomy. RESULTS: Between January 2001 and October 2005, we enrolled 12 consecutive patients (mean age 35.4 +/- 7.0 years) who underwent repeat percutaneous tracheostomy. Head injury was the most common underlying diagnosis (seven patients, 58%). Tracheostomy tube placement was easy and successful in all patients, and none of the patients needed conversion to surgical tracheostomy. In three patients, ultrasound-guided needle aspiration was used before the procedure to confirm the position of the trachea. No patients died or experienced serious complication related to the procedure. Two patients (17%) had a minor periprocedural bleeding, which was controlled with local compression. Long-term outcome was poor, with only two patients alive and off the ventilator at hospital discharge, both with serious disability. CONCLUSION: Repeat percutaneous tracheostomy can be performed safely in neurocritically ill patients who have undergone previous tracheostomy.

A botulism outbreak from roasted canned mushrooms.

Food-borne botulism is a rare disease that results from ingestion of the toxins produced by Clostridium botulinum. The most common cause of the disease is the consumption of home-canned foods prepared under inappropriate conditions, especially in rural environments. In this report, a food-borne botulism outbreak potentially caused by roasted home-canned mushrooms is evaluated and the major reasons for delayed diagnosis are emphasized. The clinical features, symptoms and prognosis of the five botulism patients involved in this outbreak are presented. The clinical progressions, treatments, durations of mechanical ventilation, intensive care unit stays and hospital stays of the three patients admitted to Akdeniz University Hospital are reported.

Device-associated nosocomial infection rates in Turkish medical-surgical intensive care units.

OBJECTIVE: To describe the incidence of device-associated nosocomial infections in medical-surgical intensive care units (MS ICUs) in a university hospital in Turkey and compare it with National Nosocomial Infections Surveillance (NNIS) system rates. DESIGN: Prospective surveillance study during a period of 27 months. Device utilization ratios and device-associated infection rates were calculated using US Centers for Disease Control and Prevention and NNIS definitions. SETTING: Two separate MS ICUs at Akdeniz University Hospital, Antalya, Turkey. PATIENTS: All patients were included who presented with no signs and symptoms of infection within the first 48 hours after admission. RESULTS: Data on 1,985 patients with a total of 16,892 patient-days were analyzed. The mean overall infection rate per 100 patients was 29.1 infections, and the mean infection rate per 1,000 patient-days was 34.2 infections. The rate of ventilator-associated pneumonia was 20.76 infections per 1,000 ventilator-days, the rate of catheter-associated urinary tract infection was 13.63 infections per 1,000 urinary catheter-days, and the rate of catheter-associated bloodstream infection was 9.69 infections per 1,000 central line-days. The most frequently isolated pathogens were Pseudomonas species among patients with ventilator-associated pneumonias (35.8% of cases), Candida species among patients with catheter-associated urinary tract infections (37.1% of cases), and coagulase-negative staphylococci among patients with catheter-associated bloodstream infections (20.0% of cases). CONCLUSION: We found both higher device-associated infection rates and higher device utilization ratios in our MS ICUs than those reported by the NNIS system. To reduce the rate of infection, implementation of infection control practices and comprehensive education are required, and an appropriate nationwide nosocomial infection and control system is needed in Turkey.

The routine use of pediatric airway exchange catheter after extubation of adult patients who have undergone maxillofacial or major neck surgery: a clinical observational study.

INTRODUCTION: We conducted the present study to determine the usefulness of routinely inserting a pediatric airway exchange catheter (PAEC) before tracheal extubation of adult patients who had undergone maxillofacial or major neck surgery and have risk factors for difficult reintubation. METHODS: A prospective, observational and clinical study was performed in the 25-bed general intensive care unit of a university hospital. Thirty-six adult patients who underwent maxillofacial or major neck surgery and had risk factors for difficult reintubation were extubated after insertion of the PAEC. RESULTS: Four of 36 (11.1%) patients required emergency reintubation after 2, 4, 6 and 18 hours after tracheal extubation, respectively. Reintubation of these patients, which was thought to be nearly impossible by direct laryngoscopy, was easily achieved over the PAEC. CONCLUSION: The PAEC can be a life-saving device during reintubation of patients with risk factors for difficult reintubation such as laryngeo-pharyngeal oedema due to surgical manipulation or airway obstruction resulting from haematoma and anatomic changes. We therefore suggest the routine use of the PAEC in patients undergoing major maxillofacial or major neck surgery.

Utility of transcranial doppler ultrasonography for confirmatory diagnosis of brain death: two sides of the coin.

BACKGROUND: Although the clinical examination and documentation of the clinical signs of brain death are very uniform, there are significant differences in the guidelines for using technical confirmatory tests to corroborate the clinical signs. The current study examined the utility of transcranial Doppler ultrasonography (TCD) for confirmation of brain death. METHODS: After 19 patients were excluded from the study because of lack of bone window or because an apnea test could not be performed because of desaturation, 100 patients (61 patients with clinical brain death, and 39 control patients with Glasgow Coma Score<5) were included in the study. The following TCD findings were accepted as confirmatory of brain death when they were found bilaterally or in at least three different arteries for at least 3 minutes within the same examination: (1) brief systolic forward flow or systolic spikes and diastolic reverse flow, (2) brief systolic forward flow or systolic spikes and no diastolic flow, or (3) no demonstrable flow in a patient in whom flow had been clearly documented in a previous TCD examination. RESULTS: The sensitivity and specificity of the first TCD examination for confirmation of brain death were 70.5% and 97.4%, respectively. Eighteen patients with clinical brain death required repeat TCD examinations because of detection of forward systolo-diastolic flow or a diastolic to-and-fro flow pattern, which were not confirmatory for the diagnosis of brain death. Brain death was confirmed ultrasonographically in 12 of 18 patients in a second examination after 12.6 +/- 8.3 hours of clinical brain death, in 2 patients in a third TCD examination, and in 1 patient in a fourth examination. Three clinically brain-dead patients had died before the diagnosis was confirmed by repeat TCD examinations. The sensitivity of TCD reached 100% in our study population after the fourth examination. CONCLUSION: The sensitivity of TCD is increased with repeat examinations and should be repeated in cases in which systolo-diastolic forward flow is demonstrated after the first TCD. TCD may prolong or shorten the time to declaration of brain death. The necessity of demonstrating cerebral circulatory arrest in patients with clinical brain death is debatable.

Systemic organophosphate poisoning following the percutaneous injection of insecticide. Case report.

Organophosphates are the most common group of chemicals in the southern part of Turkey. Although organophosphate poisoning (OPP) may occur due to skin exposure or inhalation, severe poisoning is usually the result of ingestion to attempt suicide. Despite the fact that there have been a lot of experimental studies using intravenous or percutaneous injection of organophosphates, reports of human poisoning due to percutaneous injection are rare. The systemic signs of OPP have not been described in these reported patients. We report 2 cases having systemic signs of OPP due to percutaneous injection. In our first case, we noticed a 17-day muscle weakness and a 12-day muscarinic syndrome, which required prolonged atropinization. In the second patient, atropine infusion had to be continued for 2 days. Both cases also had severe swelling of the affected limb and wound infection. In conclusion, in cases of percutaneous injection of organophosphates systemic toxicity may develop in addition to local findings such as necrosis and abscesses. Close observation for evidence of systemic involvement is required, and the patient should be carefully monitored for secondary abscess formation and any delayed impairment of neurologic function.

The use of the laryngeal mask airway as an alternative to the endotracheal tube during percutaneous dilatational tracheostomy.

OBJECTIVE: To evaluate the safety and efficiency of the use of the laryngeal mask airway (LMA) during percutaneous dilatational tracheostomy under bronchoscopic guidance comparing with the ventilation via endotracheal tube (ET). DESIGN AND SETTING: Prospective, randomized clinical trial in the eight-bed general intensive care unit of a university hospital. PATIENTS: 60 consecutive adult critically ill patients who required elective tracheostomy for a period of 12 months. INTERVENTIONS: Patients were randomly assigned to ventilated via LMA ( n=30 patients), and to ventilated via ET ( n=30). MEASUREMENTS AND RESULTS: Blood samples for arterial blood gas analyses were taken before the procedure (first value) and just before the insertion of tracheostomy tube (second value). There was no significant difference in pH, PaO2, or PaCO2 between groups before the procedure. The operating time was significantly shorter in LMA group (4.5+/-0.8 min versus 5.9+/-1.4 min). Although the second PaCO2 values were higher than the first in both groups, the rise in was significantly higher in ET group (6.8+/-3.5 mmHg vs. 4.5+/-2.4 mmHg). Hypercarbia was noted in 10 patients (38.5%) in the LMA group and 17 (56.7%) in the ET group. The decrease in pH related to hypercarbia was noted in both groups, but it was more significant in the ET group ( p<0.05). CONCLUSION: LMA is an effective and successful ventilatory device during percutaneous dilatational tracheostomy. It improves visualization of the trachea and larynx during fiberoptic-assisted percutaneous dilatational tracheostomy and prevents the difficulties associated with the use of ET such as cuff puncture, tube transection by the needle, and accidental extubation. The use of a bronchoscope and the puncture of the ET cuff cause major increases in PaCO2.