Easy method to determine fluid responsiveness in septic shock patients: end-tidal CO2 - a prospective observational study.

BACKGROUND: In critically ill patients, especially those with septic shock, fluid management can be a challenging aspect of clinical care. One of the primary steps in treating patients with hemodynamic instability is optimizing intravascular volume. The Passive Leg Raising (PLR) maneuver is a reliable test for assessing fluid responsiveness, as demonstrated by numerous studies and meta-analyses. However, its use requires the measurement of cardiac output, which is often complex and may necessitate clinician experience and specialized equipment. End-Tidal Carbon Dioxide (ETCO2) measurement is relatively easy and is generally stable under steady metabolic conditions. It depends on the body's CO2 production, diffusion of CO2 from the lungs into the bloodstream, and cardiac output. If the other two parameters (metabolic conditions and minute ventilation) are constant, ETCO2 can provide information about cardiac output. The aim of the present study is to investigate the sensitivity of ETCO2 measurement in demonstrating fluid responsiveness. METHODS: All patients diagnosed with septic shock and meeting the inclusion criteria were subjected to a passive leg raising test, and cardiac outputs were measured by echocardiography. An increase in cardiac output of 15% or more was considered indicative of the fluid responder group, while patients with an increase below 15% or no increase were classified as the non-responder group. Patients' intensive care unit admission diagnoses, initial laboratory parameters, tidal volume, minute volume before and after the PLR maneuver, mean and systolic blood pressure, heart rate, Pulse Pressure Variation (PPV) values, and ETCO2 values were recorded. RESULTS: Before and after the ETCO2 test, there was no statistically significant difference between the two groups. However, the change in ETCO2 (ΔETCO2) was significantly higher in the responder group. In the non-responder group, ΔETCO2 was 2.57% (0.81), whereas it was 5.71% (2.83) in the responder group (p<0.001). Receiver Operating Characteristic (ROC) analysis was performed for ΔETCO2, baseline Stroke Volume Variation (SVV), ΔSVV, baseline Heart Rate (HR), ΔHR, baseline PPV, and ΔPPV to predict fluid responsiveness. ΔETCO2 predicted fluid responsiveness with a sensitivity of 85% and a specificity of 86% when it was 4% or higher. When ΔETCO2 was 5% or higher, it predicted fluid responsiveness with a specificity of 99.3% and a sensitivity of 75.5%, with an Area Under the Curve (AUC) of 0.89 (95% confidence interval, 0.828-0.961). CONCLUSION: This study demonstrates that in septic patients, ETCO2 during the PLR test can indicate fluid responsiveness with high sensitivity and specificity and can be used as an alternative to cardiac output measurement.

Success of the Cytokine Absorption Therapies in COVID-19 Patients Diagnosed with Cytokine Release Syndrome.

OBJECTIVE: To compare the effects of cytokine absorption therapy with a resin-based cytokine absorption cartridge to tocilizumab treatment in critically ill COVID-19 patients diagnosed with cytokine release syndrome (CRS). STUDY DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: University of Health Sciences, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey from April 2020 to April 2021. METHODOLOGY: Twenty-four intensive care unit (ICU) patients were included in the study. Inclusion criteria were diagnosis of severe COVID-19, diagnosis of CRS and age of older than 18 years. Exclusion criteria were pregnancy, malignancy, prior COVID-19 vaccination, procalcitonin levels higher than 2 ng/ml and life-threatening comorbidities before ICU admission. Twelve patients received tocilizumab and the other 12 patients received cytokine absorption therapy. The groups were compared for clinical outcomes and inflammatory markers (CRP, fibrinogen, ferritin, D-dimer). RESULTS: Inflammatory markers showed smilar changes with both treatments, mostly toward improvement, on the same post-treatment days. The mortality rate was 58% (seven patients) in the cytokine absorption group and 50% (six patients) in the tocilizumab group (p = 0.682). CONCLUSION: It was found that the cytokine absorption therapy reduces inflammatory mediators in intubated and critically ill Covid-19 patients similar to tocilizumab treatment, and both treatments have comparable clinical outcomes. KEY WORDS: SARS-CoV-2, Cytokine release syndrome, Chemokines, Absorption, Tocilizumab.

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.

[Incidence of chronic pain after ingunial hernia repair]. / Inguinal herni onarimi sonrasi kronik agri insidansi.

OBJECTIVES: The percentage of chronic pain in adults having inguinal hernia repair is 5-35%. Although this pain is thought to be related to some reasons, there is not an exact conclusion about this. In this study, the aim was to point out the incidence of chronic pain after inguinal hernia repair and determination of the risk factors. METHODS: Two hundred and four patients having inguinal hernia surgery between January 2011 and December 2012 were included into this study. The patients' pain was measured with VAS within 24 hours and at the third and the sixth month after surgery. The patients whose VAS was >3 three months after surgery were evaluated to have chronic pain. RESULTS: The incidence of pain continuing 3 months after surgery was 18.6% and 11.2% six months after surgery. 78.3% of the patients had already had pain before surgery, and in 28% of them, chronic pain had evolved. The measure of VAS within 24 hours postoperatively was found higher in patients who developed chronic pain (3.13 ± 1.12/1.71 ± 1.27). 5.2% of the patients had re-operation for reparation and chronic pain developed in all. Chronic pain was neuropathic in 48% of the patients, and its severity was moderate. CONCLUSION: The incidence of chronic pain after inguinal hernia repair was found %18, compatible with similar studies. Compared with other risk factors, preoperative pain, postoperative severe acute pain and reoperations were thought to be the most important risk factors for the development of chronic pain.

A prospective randomized double-blind study on the effects of the temperature of irrigation solutions on thermoregulation and postoperative complications in percutaneous nephrolithotomy.

PURPOSE: This study investigated the effects of irrigation solutions, administered at either 21 or 37 °C in percutaneous nephrolithotomy (PCNL), on hypothermia and related postoperative complications such as late emergence and late recovery from anesthesia, shivering, lactic acidosis, and excess bleeding. METHODS: Sixty patients who were scheduled for PCNL were enrolled in this prospective randomized double-blind study. Irrigation solutions at room temperature were administered to patients in group R (30 patients), and warmed irrigation solutions were administered to patients in group W (30 patients). The two groups were compared for core and peripheral body temperature, incidence of hypothermia, duration of emergence from anesthesia, duration of recovery from anesthesia, shivering, lactic acidosis, and hemoglobin levels. RESULTS: Hypothermia was incident in 19 patients (63.3 %) in group W and in 27 patients (90 %) in group R at the end of surgery. The difference between the initial and the final core body temperature was 0.9 ± 0.6 °C group W and 1.4 ± 0.7 °C in group R (p = 0.003). The extubation time was 4.4 ± 2.2 min in group W and 5.9 ± 3 min in group R (p = 0.032). Shivering was detected in seven patients (23.3 %) in group W and in 15 patients (50 %) in group R (p = 0.032). The recovery duration was 49.8 ± 24.6 min in group W and 67.6 ± 33.9 min in group R (p = 0.023). CONCLUSIONS: Administration of irrigation solutions at room temperature in PCNL operations causes the body temperature to decrease significantly, which results in postoperative complications such as late emergence from anesthesia, late recovery from anesthesia, and shivering.