Vaccination status of COVID-19 patients followed up in the ICU in a country with heterologous vaccination policy: A multicenter national study in Turkey.

OBJECTIVE: Vaccination against severe acute respiratory syndrome coronavirus-2 (SARS-2) prevents the development of serious diseases has been shown in many studies. However, the effect of vaccination on outcomes in COVID-19 patients requiring intensive care is not clear. METHODS: This is a retrospective multicenter study conducted in 17 intensive care unit (ICU) in Turkey between January 1, 2021, and December 31, 2021. Patients aged 18 years and older who were diagnosed with COVID-19 and followed in ICU were included in the study. Patients who have never been vaccinated and patients who have been vaccinated with a single dose were considered unvaccinated. Logistic regression models were fit for the two outcomes (28-day mortality and in-hospital mortality). RESULTS: A total of 2968 patients were included final analysis. The most of patients followed in the ICU during the study period were unvaccinated (58.5%). Vaccinated patients were older, had higher Charlson comorbidity index (CCI), and had higher APACHE-2 scores than unvaccinated patients. Risk for 28-day mortality and in-hospital mortality was similar in across the year both vaccinated and unvaccinated patients. However, risk for in-hospital mortality and 28-day mortality was higher in the unvaccinated patients in quarter 4 adjusted for gender and CCI (OR: 1.45, 95% CI: 1.06-1.99 and OR: 1.42, 95% CI: 1.03-1.96, respectively) compared to the vaccinated group. CONCLUSION: Despite effective vaccination, fully vaccinated patients may be admitted to ICU because of disease severity. Unvaccinated patients were younger and had fewer comorbid conditions. Unvaccinated patients have an increased risk of 28-day mortality when adjusted for gender and CCI.

Effectiveness of the oxygen reserve index in detecting and preventing hyperoxia in critically ill patients on mechanical ventilation: a randomized controlled trial.

AIM: To assess the effectiveness of fraction of inspired oxygen (FiO2) titration guided by oxygen reserve index (ORi) in preventing hyperoxia in intensive care unit (ICU) patients receiving mechanical ventilator support. METHODS: Patients aged 18 years and older who were admitted to a tertiary ICU and required mechanical ventilator support were randomly divided into two groups: the control group (n=30) and the oxygen saturation (SpO2) +ORi group (n=30). In the SpO2+ORi group, the goal was to maintain SpO2 between 95% and 98% and ORi at 0.00. In both groups, SpO2, ORi, partial pressure of oxygen (PaO2), partial pressure of carbon dioxide, positive end-expiratory pressure, FiO2, and hemodynamic parameters were recorded every six hours for two consecutive days. RESULTS: A very strong positive linear correlation was found between PaO2 and ORi (r=0.937; P<0.001). In the ORi+SpO2 group, PaO2 values were significantly lower and decreased with FiO2 titration over time. Severe hyperoxia was observed in 24.8% of the control group and in only 3.3% of the ORi+SpO2 group. When PaO2>120 mm Hg, FiO2>0.40 was found in 83.5% of the control group, and in 40% of the ORi+SpO2 group. CONCLUSION: FiO2 titration guided by ORi+SpO2 effectively prevents hyperoxia and reduces the exposure time to hyperoxia in critically ill patients.

Diagnostic value of procalcitonin and C reactive protein for infection and sepsis in elderly patients.

BACKGROUND: Biomarkers are useful for diagnosing infection and sepsis in adults, but data are limited in elderly patients. Furthermore, clinical symptoms of infection in elderly patients are usually atypical or unclear. We aimed to assess the usefulness of PCT, CRP, and WBC in distinguishing elderly patients infected with sepsis from infected without sepsis and those with no-infection. We also aimed to find a cut-off value for diagnosing sepsis and infection without sepsis in elderly critically ill patients. METHODS: In this single-center and prospective observational study, patients older than 65 years were enrolled. Serum levels of PCT, CRP, and WBC were measured within 24 h. Patients were allocated into sepsis (S), infected without sepsis (IWS), and noinfection (NI) groups. Data were analyzed with Mann-Whitney U test and Kruskal-Wallis test. RESULTS: We analyzed 188 patients with a mean age of 77.05 ± 7.4 in the study; 95 (50.5%) of them were women. Sixty-four (34%) of whom were classified as IWS, 29 (15%) as S, and 95 (50.5%) as NI group. There were significant differences in the PCT, CRP levels between the IWS and NI, S and NI (p < 0.001, p < 0.001, p < 0.001, p < 0.01, respectively). The PCT levels were significantly different when the NI group was compared to IWS (p < 0.001) and S (p < 0.001) groups. The CRP levels were also different when the NI group was compared to both IWS (p < 0.001) and S (p < 0.001). The PCT cut-off values were 0.485 µ/L and 1.245 µg/L for the discrimination of patients with IWS and S, respectively. The cut-off values of CRP level were 59.45 mg/L and 57.50 mg/L for infected without sepsis and sepsis, respectively. DISCUSSION: PCT was found to be a more valuable marker than CRP and WBC for the discrimination of elderly patients with infected without sepsis and sepsis.

The interrelation between body mass index and post-dural puncture headache in parturient women.

BACKGROUND AND AIMS: Post-dural puncture headache is seen more frequently in pregnant women due to stress, dehydration, intra-abdominal pressure, and insufficient fluid replacement after delivery. Obesity protects against post-dural puncture headache in pregnant women; increased intra-abdominal fat tissue reduced cerebrospinal fluid leakage by increasing the pressure in the epidural space. Therefore, this study investigated the influence of body mass index on post-dural puncture headache in elective cesarean section patients in whom 27G spinal needles were used. MATERIAL AND METHODS: The study included 464 women who underwent elective cesarean section under spinal anesthesia. Dural puncture performed with a 27G Quincke spinal needle at the L3-4 or L4-5 intervertebral space and given 12.5 mg hyperbaric bupivacaine intrathecally. The patients were questioned regarding headache and low back pain 6, 12, 24, and 48 h after the procedure, and by phone calls on days 3 and 7. RESULTS: Post-dural puncture headache developed in 38 (8.2%) patients. Of the patients who developed post-dural puncture headache, 23 (60.5%) had a body mass index <30 and 15 (39.5%) had a body mass index ≥30. Of the patients who did not develop post-dural puncture headache, 258 (60, 6%) had a body mass index <30 and 168 (39, 4%) had a body mass index ≥30. CONCLUSION: This prospective study found the body mass index values did not affect post-dural puncture headache in the elective cesarean section performed under spinal anesthesia.

Is Procalcitonin a Marker of Neurologic Outcome or Early Infection in Patients Treated with Targeted Temperature Management?

OBJECTIVES: Although high procalcitonin (PCT) levels are associated with poor neurological outcomes and increased mortality rates in patients treated with targeted temperature management (TTM) in the postcardiac arrest (CA) period, there are limited data about the correlation between PCT levels and infection. The aim of our study was to assess the relationship of PCT levels in the first 48 hours with early period infections, late period neurological prognosis, and mortality in patients treated with TTM after CA. MATERIALS AND METHODS: Serum PCT was measured on admission days 1 and 2. The early onset infection diagnosis before the seventh day in the intensive care unit (ICU) was made according to the criteria of infection centers for disease control and prevention. Mortality and neurologic outcomes were assessed 90 days after CA according to cerebral performance category (CPC) score. RESULTS: There was no statistically significant correlation between early period infection diagnosis and PCT levels at the time of admission, 24th, and 48th hours. Patients with poor neurologic outcomes on the 90th day had significantly high PCT levels at 24 (p = 0.044) and 48 hours (p = 0.004). There was no statistically significant correlation between admission PCT levels and neurological prognosis. While the correlation between mortality and PCT levels at 24 (p = 0.049) and 48 (p = 0.004) hours was significantly high, no statistically significant correlation was found between admission PCT levels and mortality. CONCLUSION: In patients treated with TTM after CA, increased PCT levels were significantly correlated with poor neurologic outcomes and mortality. However, the elevated PCT levels were not significantly correlated with early period infections. HOW TO CITE THIS ARTICLE: Zincircioglu C, Yavuz T, Saritas A, Çakmak M, Güldogan IK, Uzun U, et al. Is Procalcitonin a Marker of Neurologic Outcome or Early Infection in Patients Treated with Targeted Temperature Management? Indian J Crit Care Med 2020;24(5):327-331.

Comparison of Bronchoscopy-Guided and Real-Time Ultrasound-Guided Percutaneous Dilatational Tracheostomy: Safety, Complications, and Effectiveness in Critically Ill Patients.

OBJECTIVE: To compare the efficacy, safety, and incidence of complications between fiber-optic bronchoscopy-guided percutaneous dilatational tracheostomy (FOB-PDT) and ultrasound-guided percutaneous dilatational tracheostomy (US-PDT) and to determine whether US-PDT is a viable alternative to FOB-PDT. METHODS: This randomized prospective study was carried out in 80 patients who were randomly divided into US-PDT and FOB-PDT groups. Demographic data and Acute Physiology and Chronic Health Evaluation II (APACHE II), procedure duration, hemorrhage status, complications, procedure difficulty, displacement of entry location after US, and hemodynamic data were evaluated in both groups. Tracheal incision was performed with real-time US and a transverse probe position in the out-of-plane mode. RESULTS: No significant differences were observed between the 2 groups in terms of demographic data, oral intubation time, APACHE II values, difficulty of the procedure, or the number of needle interventions (P > .05). The mean hemorrhage ratio of the FOB-PDT group was significantly higher than that of the US-PDT group (P < .05). The entry location was changed in 6 patients in the US-PDT group following neck examination with US. The mean duration of the procedure for the FOB-PDT group was significantly longer than that for the US-PDT group (P < .05). CONCLUSION: Ultrasound-guided percutaneous dilatational tracheostomy is a safe procedure for critically ill patients and has the advantages of a low complication rate, short duration of procedure, being informative with regard to neck anatomy, and facilitating prevention of vascular puncture. Thus, US-PDT can be used as an alternative to FOB-PDT.

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.

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.

The role of fiberoptic bronchoscopy monitoring during percutaneous dilatational tracheostomy and its routine use into tracheotomy practice.

OBJECTIVE: To evaluate percutaneous dilatational tracheostomy with and without the use of the bronchoscope and compare the safety and complications of the procedure. METHODS: The prospective, randomised-controlled study was conducted at the Professor A. Ilhan Ozdemir State Hospital, Giresun, Turkey, between October 2013 and February 2014, and comprised patients ≥18 years of age who were dependent on mechanical ventilation for an extended duration and were scheduled to undergo percutaneous dilatational tracheostomy with Griggs technique. The patients were randomly divided into two groups; group A received standard c that was opened without using fiberoptic bronchoscopy, while group B received percutaneous dilatational tracheostomy that was opened using fiberoptic bronchoscopy. Complications and number of applied needle approaches were recorded. RESULTS: Of the 60 patients, 35(58.3%) were women. The patients were divided into two groups of 30(50%) each. None of the patients developed pneumothorax, subcutaneous emphysema, or oesophageal perforation. The numbers of needle interventions and total complications were significantly higher in group A than group B (p<0.05). Procedure duration was significantly longer in group B (p<0.05). CONCLUSIONS: Percutaneous dilatational tracheostomy was reliable when applied with fiberoptic bronchoscopy due to the significantly lower complication rates.

Comparison of clinical effects of prilocaine, dexamethasone added to prilocaine and levobupivacaine on brachial plexus block.

OBJECTIVE: To determine whether the addition of 8 mg dexamethasone to axillary brachial plexus block would prolong the duration of sensory and motor block in patients undergoing hand and forearm surgery. METHODS: The prospective, randomised, double-blinded study was conducted at the Eskisehir Osmangazi University Medical School, Turkey, from October 2008 to December 2009. It comprised 45 American Society of Anaesthesiologists grade I and II patients under elective surgery of the hand and forearm. The patients were randomly divided into 3 groups: 5 mg/kg of 2% prilocaine was applied to Group 1; 5 mg/kg of 2% prilocaine +8mg of dexamethasone (2 ml) was applied to Group 2; and 1.5 mg/kg 0.5% levobupivacaine was applied to Group 3. Sensory and motor block onset time as well as the duration of motor and sensory block of those were monitored and recorded. SPSS 15 was used for statistical analysis. RESULTS: Of the 45 patients, 27 (60%) were men and 18 (40%) were women. There was no significant difference among the groups in terms of demographic data. Based on the duration of motor and sensory block, similar periods of time in Group 1 and Group 2 were noted, whereas this period was statistically different and significantly longer in Group 3 (p < or = 0.001). There were no complications encountered. CONCLUSION: The addition of dexamethasone to prilocaine prolonged the duration of sensory and motor block. It could be used as an effective adjuvant agent. Levobupivacain could be a more appropriate local anaesthetic in postoperative analgesia and prolonged surgical procedures.

Care training and family caregiver anxiety: prospective cohort study.

OBJECTIVES: The study aimed to improve family caregivers' skills and evaluate the effect on their anxiety levels. METHOD: In our study, family caregivers of patients unable to perform daily activities were provided with care training. Their anxiety levels were examined before and after the training. RESULTS: Care training increased the family caregivers' sense of self-efficacy but caused no significant difference in their anxiety levels. Factors such as gender, education level and employment status influenced anxiety levels. Higher education and income were associated with lower trait anxiety while employment status was linked to higher anxiety levels. CONCLUSION: Care training increased the family caregivers' sense of self-efficacy while causing no difference in their anxiety levels. In order to reduce anxiety, other negative factors affecting the caregiver should be discovered and corrected.

Safe Hugs in Palliative Care.

Mnemonics are word formulations that aid physicians in recalling instances hidden among typical applications and may be neglected due to workload. Mnemonic abbreviations that benefit not only physicians but the entire care team are widely used throughout the world. Given that palliative care is the work of a multidisciplinary team, these mnemonics become even more significant. The aim of this study is to introduce the acronym "SAFE HUGS IN PC" (Sleep patterns, Analgesia, Feeding, Environment, Hospital Discharge-Home Care, Ulcer, Gastrointestinal, Social Support-Spiritual, Infection, Need of Religion, Physiotherapy-Psychotherapy, Goals of Care), which we believe will meet the requirements in the palliative care. The following databases were searched: CINAHL, Cochrane, Embase, MEDLINE, and Pubmed for studies exploring experiences of palliative care. With this mnemonic, which we use in our own clinic, patients' and patients' relatives' satisfaction and end-of-life quality have increased. We believe this simple mnemonic will encourage teamwork and help improve the quality of life on palliative care.

Convalescent plasma for COVID-19 in the intensive care unit.

INTRODUCTION: We aimed to investigate the clinical features and mortality of critically ill patients treated with convalescent plasma for COVID-19 in the intensive care unit (ICU). MATERIAL AND METHODS: We retrospectively collected clinical and laboratory data of COVID-19 patients treated in the ICU. The patients were divided into two groups: those who received convalescent plasma and those who did not. We evaluated changes in the laboratory parameters and PaO2/FiO2 of the patients in the convalescent plasma group on days 0, 7, and 14. RESULTS: A total of 188 patients were included, 89 of whom received convalescent plasma. There were no significant differences in length of hospitalization [median: 17 vs. 16 days, P = 0.13] or 28-day mortality between the two groups (59% vs. 65%, P = 0.38). The ICU stay of patients who received convalescent plasma was longer (P = 0.001). The dynamics of the laboratory parameters of 44 patients in the convalescent plasma group, who were still in intensive care on the 14th day, were analysed. There was no differences in CRP or PaO2/FiO2 on day 0, 7 or 14 (P = 0.12; P = 0.10, respectively). CONCLUSIONS: Convalescent plasma treatment was not associated with shorter hospitalisation or lower mortality in patients diagnosed with COVID-19. However, the ICU stay was longer in patients who received convalescent plasma.

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.

Comparison of the effects of Truview PCD™ video laryngoscopy and Macintosh blade direct laryngoscopy in geriatric patients.

STUDY OBJECTIVE: To compare the effects of Truview PCD™ video laryngoscopy (TVL) and Macintosh blade direct laryngoscopy (MDL) on hemodynamic responses observed during laryngoscopy and orotracheal intubation conditions in geriatric patients. DESIGN: Randomized prospective study. SETTING: Operating room. PATIENTS: One hundred patients in the risk group American Society of Anesthesiologists I to III aged 65 years and older underwent elective surgery under general anesthesia. INTERVENTIONS: This prospective study was performed between January 2014 and February 2015 after institutional ethics committee approval. Patients were randomly allocated to 2 groups, namely, TVL and MDL. MEASUREMENTS: Hemodynamic parameters, modified Cormack-Lehane grade, intubation period, and preoperative examination (age, sex, American Society of Anesthesiologists, modified Mallampati test score, and thyromental and sternomental distances) of patients were evaluated. MAIN RESULTS: There were no statistically significant differences in hemodynamic responses (heart rates and mean arterial pressure) between the 2 groups (P>.05). The median intubation period in the TVL group was significantly higher than observed in the MDL group (t=4.594; P<.05). The laryngoscopy views in TVL group were better than the views in MDL group. The Cormack-Lehane grade in the TVL group was lower when compared to the MDL group. CONCLUSION: The TVL system does not provide significant hemodynamic response sparing or shorten orotracheal intubation times when compared to MDL in geriatric patients.

Spectrum and Prevalence of Thyroid Disorders in Patients Admitted to the Anaesthesiology Outpatient Clinic for Surgery.

OBJECTIVE: An anaesthetic approach and surgery are important treatment strategies in patients with thyroid dysfunction due to potential complications. We investigated the prevalence of thyroid disorders, the significance of thyroid function tests (TFTs) with respect to anaesthesia in the preoperative period and the need for routine examinations. METHODS: A total of 10,600 patients who were admitted to the anaesthesiology outpatient clinic for surgery were retrospectively screened and enrolled between 2011 and 2013. Evident hypothyroidism was defined as free tetra-iodothyronine (fT4) <0.7 ng dL(-1) and thyroid-stimulating hormone (TSH) >4 mIU mL(-1), and subclinical hypothyroidism was defined as TSH >4 mIU mL(-1) with normal free hormone levels. Evident hyperthyroidism was defined as fT4 >1.7 ng dL(-1) and TSH <0.1 mIU mL(-1), and subclinical hyperthyroidism was defined as TSH <0.1 mIU mL(-1) with normal free hormone levels. Statistical analysis was conducted using the Statistical Package for the Social Sciences (SPSS) version 17.0. Independent samples t-test and one-way analysis of variance were used to compare the difference between groups. RESULTS: Of the participants, 8.5% were found to have hypothyroidism, 2.5% had hyperthyroidism, 3.5% received treatment and 2.5% had their treatment postponed. The likelihood of hypothyroidism was greater among females, and no difference was found between genders with respect to hyperthyroidism. CONCLUSION: We believe that TFTs are important because of regional factors. However, given the high cost of TFTs and because thyroid dysfunction risk increases with age, we concluded that routine TFTs in young patients with normal physical examination findings are not mandatory.

The Decrease of the Duration of Stay in the ICU with Rib Fixation in a Case of Multiple Rib Fracture.

Severe breathing problems arise in multiple rib fractures. As a result, many advantages of the surgical stabilization of the chest wall have been reported. Especially, shortening mechanical ventilation, along with a decrease in the duration of intensive care unit stay, is important for the prevention of possible infection complications. In this study, the dramatic improvement of the breathing pattern, as well as the reduction in ventilator duration after rib fixation time, of a 36-year-old patient with severe respiratory distress who had multiple rib fractures due to a road traffic accident was discussed. Due to this fact, it is concluded that patients could be discharged from the hospital earlier and uncomplicated as a result of fixation of the rib with the right indications.