Clinical Characteristics, Outcomes, and Risk Factors for Mortality in Pregnant/Puerperal Women with COVID-19 Admitted to ICU in Turkey: A Multicenter, Retrospective Study from a Middle-Income Country.

BACKGROUND: Coronaviruses have been the cause of 3 major outbreaks during the last 2 decades. Information on coronavirus diseases in pregnant women is limited, and even less is known about seriously ill pregnant women. Data are also lacking regarding the real burden of coronavirus disease 2019 (COVID-19) infection in pregnant women from low/middle-income countries. The aim of this study was to determine the characteristics and clinical course of COVID-19 in pregnant/puerperal women admitted to ICUs in Turkey. METHODS: This was a national, multicenter, retrospective study. The study population comprised all SARS-CoV-2-infected pregnant/puerperal women admitted to participating ICUs between 1 March 2020 and 1 January 2022. Data regarding demographics, comorbidities, illness severity, therapies, extrapulmonary organ injuries, non-COVID-19 infections, and maternal and fetal/neonatal outcomes were recorded. LASSO logistic regression and multiple logistic regression analyses were used to identify predictive variables in terms of ICU mortality. RESULTS: A total of 597 patients (341 pregnant women, 255 puerperal women) from 59 ICUs in 44 hospitals were included and of these patients, 87.1% were unvaccinated. The primary reason for ICU admission was acute hypoxemic respiratory failure in 522 (87.4%), acute hypoxemic respiratory failure plus shock in 14 (2.3%), ischemic cerebrovascular accident (CVA) in 5 (0.8%), preeclampsia/eclampsia/HELLP syndrome in 6 (1.0%), and post-caesarean follow-up in 36 (6.0%). Nonsurvivors were sicker than survivors upon ICU admission, with higher APACHE II (p < 0.001) and SOFA scores (p < 0.001). A total of 181 (30.3%) women died and 280 (46.6%) had received invasive mechanical ventilation (IMV). Myocardial injury, the highest SOFA score during ICU stay, LDH levels on admission, the highest levels of AST during ICU stay, average daily dose of corticosteroids, IMV, prophylactic dose anticoagulation (compared with therapeutic dose anticoagulation), PaO2/FiO2 ratio <100, pulmonary embolism, and shock were identified as predictors of mortality. Rates of premature birth (46.4%), cesarean section (53.7%), fetal distress (15.3%), stillbirth (6.5%), and low birth weight (19.4%) were high. Rates of neonatal death (8%) and respiratory distress syndrome (21%) were also high among live-born infants. CONCLUSIONS: Severe/critical COVID-19 infection during the pregnancy/puerperal period was associated with high maternal mortality and fetal/neonatal complication rates in Turkey.

Epidemiology of sepsis in intensive care units in Turkey: a multicenter, point-prevalence study.

BACKGROUND: The prevalence and mortality of sepsis are largely unknown in Turkey, a country with high antibiotic resistance. A national, multicenter, point-prevalence study was conducted to determine the prevalence, causative microorganisms, and outcome of sepsis in intensive care units (ICUs) in Turkey. METHODS: A total of 132 ICUs from 94 hospitals participated. All patients (aged > 18 years) present at the participating ICUs or admitted for any duration within a 24-h period (08:00 on January 27, 2016 to 08:00 on January 28, 2016) were included. The presence of systemic inflammatory response syndrome (SIRS), severe sepsis, and septic shock were assessed and documented based on the consensus criteria of the American College of Chest Physicians and Society of Critical Care Medicine (SEPSIS-I) in infected patients. Patients with septic shock were also assessed using the SEPSIS-III definitions. Data regarding demographics, illness severity, comorbidities, microbiology, therapies, length of stay, and outcomes (dead/alive during 30 days) were recorded. RESULTS: Of the 1499 patients included in the analysis, 237 (15.8%) had infection without SIRS, 163 (10.8%) had infection with SIRS, 260 (17.3%) had severe sepsis without shock, and 203 (13.5%) had septic shock. The mortality rates were higher in patients with severe sepsis (55.7%) and septic shock (70.4%) than those with infection alone (24.8%) and infection + SIRS (31.2%) (p < 0.001). According to SEPSIS-III, 104 (6.9%) patients had septic shock (mortality rate, 75.9%). The respiratory system (71.6%) was the most common site of infection, and Acinetobacter spp. (33.7%) were the most common isolated pathogen. Approximately, 74.9%, 39.1%, and 26.5% of Acinetobacter, Klebsiella, and Pseudomonas spp. isolates, respectively, were carbapenem-resistant, which was not associated with a higher mortality risk. Age, acute physiology and chronic health evaluation II score at ICU admission, sequential organ failure assessment score on study day, solid organ malignancy, presence of severe sepsis or shock, Candida spp. infection, renal replacement treatment, and a nurse-to-patient ratio of 1:4 (compared with a nurse-to-patient ratio of 1:2) were independent predictors of mortality in infected patients. CONCLUSIONS: A high prevalence of sepsis and an unacceptably high mortality rate were observed in Turkish ICUs. Although the prevalence of carbapenem resistance was high in Turkish ICUs, it was not associated with a higher risk for mortality. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT03249246 . Date: August 15, 2017. Retrospectively registered.

Comparison of sequential organ failure assessment (SOFA) scoring between nurses and residents.

PURPOSE: We aimed to evaluate differences in the interobserver reliability and accuracy of sequential organ failure assessment (SOFA) scoring between nurses and residents. METHODS: Eight nurses and eight residents independently scored 24 randomly selected patients. Intraclass correlation coefficients (ICCs) for the reliability of total SOFA scoring were calculated. The residents' and nurses' SOFA scores were compared with a gold standard to assess accuracy. RESULTS: The overall ICC of the total SOFA score was 0.87 (nurses 0.89, residents 0.86) for a single measurement. Residents tended to assign higher total SOFA scores than did nurses, without a statistically significant difference (7.01 ± 4.43 vs. 6.72 ± 4.27, P > 0.05). The mean bias between the nurses' and the gold standard total SOFA scores was -0.16 ± 1.86 and the 95% confidence limit of agreement was -3.8 to +3.49. The mean bias between the residents' and the gold standard total SOFA scores was -0.39 ± 1.81, and the 95% confidence limit of agreement was -3.95 to +3.16. The percentage of accurate data for the total SOFA score was 47.4% for nurses and 51% for residents (P > 0.05). Although not statistically significant, the major error rate (≥2 point deviation from the gold standard score) was higher for nurses than for residents (29.16 and 23.43%, P > 0.05). Accuracy of scoring individual organ systems was similar for the two groups; however, the major error rate in the cardiovascular system score was higher for nurses. CONCLUSION: Interobserver reliability was good and mean SOFA scores were not significantly different between nurses and residents. The accuracy of SOFA scoring was moderate for both groups; however, although the difference was not statistically significant, the major error rate was higher for nurses than for residents.

Evaluation of sepsis/systemic inflammatory response syndrome, acute kidney injury, and RIFLE criteria in two tertiary hospital intensive care units in Turkey.

Sepsis is a common cause of acute renal failure in intensive care units (ICU) with mortality rates as high as 60%. In this study, the clinical and laboratory predictors of acute kidney injury (AKI) in critically ill Turkish patients with sepsis/systemic inflammatory response syndrome were identified. We studied 139 (67 females/72 males) patients admitted to our ICUs with sepsis/systemic inflammatory response syndrome without renal failure. The clinical and laboratory parameters and treatments were recorded. Patients were classified as those without AKI (n = 60; 43.20%) and those with AKI (n = 79; 56.80%) based on the RIFLE (Risk, Injury, Failure, Loss, End-stage renal disease) criteria. Those with AKI were further classified as: risk in 27 (19%), injury in 25 (17.9%), failure in 25 (17.9%), and loss in 2 (1.4%). We found that the mortality rate increased with the severity of renal involvement: 56% in risk, 68% in injury, 72% in failure, and 100% in loss categories. Patients with AKI had a more positive fluid balance, higher central venous pressure, more vasopressor use, and lower systolic blood pressure. In multivariate analysis, the sequential organ failure assessment score, blood pressure, serum creatinine, and fluid balance were risk factors for the development of AKI. In this population, the incidence of AKI was higher and contrary to previous knowledge. A positive fluid balance also carries a risk for AKI and mortality in septic ICU patients. The RIFLE criteria were found to be applicable to our ICU population.

Factors affecting the attitudes and opinions of ICU physicians regarding end-of-life decisions for their patients and themselves: A survey study from Turkey.

INTRODUCTION: Turkey is constitutionally secular with a Muslim majority. There is no legal basis for limiting life-support at the end-of-life (EOL) in Turkey. We aimed to investigate the opinions and attitudes of intensive care unit (ICU) physicians regarding EOL decisions, for both their patients and themselves, and to evaluate if the physicians' demographic and professional variables predicted the attitudes of physicians toward EOL decisions. METHODS: An online survey was distributed to national critical care societies' members. Physicians' opinions were sought concerning legalization of EOL decisions for terminally ill patients or by patient-request regardless of prognosis. Participants physicians' views on who should make EOL decisions and when they should occur were determined. Participants were also asked if they would prefer cardiopulmonary resuscitation (CPR) and/or intubation/mechanical ventilation (MV) personally if they had terminal cancer. RESULTS: A total of 613 physicians responded. Religious beliefs had no effect on the physicians' acceptance of do-not-resuscitate (DNR) / do-not-intubate (DNI) orders for terminally ill patients, but atheism, was found to be an independent predictor of approval of DNR/DNI in cases of patient request (p<0.05). While medical experience (≥6 years in the ICU) was the independent predictor for the physicians' approval of DNI decisions on patient demand, the volume of terminal patients in ICUs (between 10-50% per year) where they worked was an independent predictor of physicians' approval of DNI for terminal patients. When asked to choose personal options in an EOL scenario (including full code, only DNR, only DNI, both DNR and DNI, and undecided), younger physicians (30-39 years) were more likely to prefer the "only DNR" option compared with physicians aged 40-49 years (p<0.05) for themselves and age 30-39 was an independent predictor of individual preference for "only DNR" at the hypothetical EOL. Physicians from an ICU with <10% terminally ill patients were less likely to prefer "DNR" or "DNR and DNI" options for themselves at EOL compared with physicians who worked in ICUs with a higher (>50%) terminally ill patient ratio (p<0.05). CONCLUSION: Most ICU physicians did not want legalization of DNR and DNI orders, based solely on patient request. Even if EOL decision-making were legal in Turkey, this attitude may conflict with patient autonomy. The proportion of terminally ill patients in the ICU appears to affect physicians' attitudes to EOL decisions, both for their patients and by personal preference, an association which has not been previously reported.

Neutrophil gelatinase-associated lipocalin is a better biomarker than cystatin C for the prediction of imminent acute kidney injury in critically ill patients.

Aims The prevention of acute kidney injury can be lifesaving for the intensive care unit patients. However, conventional methods are not sufficient for the prediction of the risk of future acute kidney injury. In this study, the promising biomarker, neutrophil gelatinase-associated lipocalin, was compared with cystatin C as an indicator for the risk of future acute kidney injury. Methods One hundred and eighty-three adult patients without chronic kidney disease or renal replacement therapy were included in this study. The plasma and urine concentrations of neutrophil gelatinase-associated lipocalin and cystatin C were assessed on the second day after intensive care unit admission and were followed for seven days to monitor the development of acute kidney injury. Acute kidney injury diagnosis was based on the risk, injury, failure, loss, end-stage renal failure criteria. Results Thirty-four per cent of the patients had acute kidney injury; 17 patients who did not fulfil criteria at the beginning, developed acute kidney injury from days 3 to 7 after admission. The mean serum creatinine on admission did not significantly differ between this and control groups (0.72 ± 0.20 and 0.83 ± 0.21; P = 0.060); however, the serum and urinary neutrophil gelatinase-associated lipocalin concentrations on the second day were significantly different (median: 75.69 [54.18-91.18] and 123.68 [90.89-166.31], P = 0.001; and median: 17.60 [8.56-34.04] and 61.37 [24.59-96.63], P = 0.001). Notably, the 48-h serum cystatin C concentration did not differ. Conclusion Neutrophil gelatinase-associated lipocalin concentrations in the urine and serum on the second day of intensive care unit admission could be used to predict the development of acute kidney injury in the following three to seven days in the intensive care unit; however, the cystatin C concentration did not have predictive value.

Neutrophil gelatinase-associated lipocalin levels during the first 48 hours of intensive care may indicate upcoming acute kidney injury.

PURPOSE: The recognition of acute kidney injury (AKI) as early as possible is important in the intensive care unit. This study proposes that serum and urine levels of neutrophil gelatinase-associated lipocalin (NGAL) may be used for this purpose. METHODS: One hundred and seven critically ill adult patients with no previous renal failure were included. NGAL levels were measured during the first 48 hours after admission; NGAL levels were followed for 7 days and classified based on Risk, Injury, Failure, Loss, and End-Stage Renal Failure criteria. RESULTS: The AKI incidence was 35.5%, and serum NGAL (sNGAL) and urinary NGAL (uNGAL) levels were higher in the AKI group. The area under the receiver operating characteristic curve was 0.76 (P<.001) for sNGAL and 0.75 (P<.001) for uNGAL. Seventy-one percent of AKI cases were observed within 48 hours, with 11 additional cases in the ensuing 7 days. The mean serum creatinine levels in the 11 patients were not different from non-AKI levels (P=.197), but the NGAL values were different, and the area under the receiver operating characteristic curve for sNGAL uNGAL was 1.00 (P=.014) and 0.93 (P=.02), respectively. CONCLUSIONS: Most AKI cases were diagnosed within the first 48 hours after admission, and NGAL was useful for predicting upcoming AKI.

[Comparison of bupivacaine-fentanyl versus bupivacaine-morphine for patient controlled epidural analgesia]. / Hasta kontrollü epidural analjezide bupivakin-fentanil ile bupivakain-morfinin karsilastirilmasi.

Analgesic efficacy and possible side effects of bupivacaine-fentanyl (BF) and bupivacaine-morphine (BM) combinations for patient controlled epidural analgesia (PCEA) have been compared. Sixty ASA I-II patients who had PCEA following lower abdominal surgery were admitted to the study. Epidural catheter was inserted at the level of L3-4 or L4-5 following induction of general anesthesia. In Group BF epidural drug solution was prepared as bupivacaine 0.1 % and fentanyl 2 microg/ml. In Group BM, solution was prepared as bupivacaine 0.1 % and morphine 0.2 microg/ml. In both groups PCEA was set as; bolus dose: 4 ml, lock - out period: 20 minutes, 4 hour limit: 30 ml. VAS was measured at postoperative 1, 2, 3, 6, 9, 12 and 24th hours. In both groups adequate postoperative analgesia was provided. VAS score was higher in Group BF than Group BM at postoperative 12th hour (p<0.05). One patient in Group BF had unilateral motor block, one patient in Group BM had respiratory depression responding to i.v. naloxon administration. The incidence of pruritus was higher in Group BM than Group BF (p<0.05). Both treatment modalities provided adequate postoperative analgesia, but the risk of respiratory depression with opioid use should be considered.

Treatment of Posterior Reversible Encephalopathy Syndrome that Occurred in a Patient with Systemic Lupus Erythematosus by Plasmapheresis.

Posterior reversible encephalopathy syndrome is characterized by visual and mental disturbances, nausea and vomiting and generalized or focal convulsions and often represents itself with parietal and occipital oedema formation. We want to report the treatment of posterior reversible encephalopathy syndrome with plasmapheresis, which developed in a 35-year-old woman with systemic lupus erythematosus diagnosed by renal biopsy 3 years ago. She has been followed up in the intensive care unit three times. However, she had been transferred to the nephrology department of our university hospital because of her uncontrolled blood pressure. Oral antihypertensive therapy, corticosteroid 500 mg 1 × 1 and cyclophosphamide were started for the activation of lupus. After the detection of low complement levels, systemic lupus erythematosus activation was suspected. She developed mental deterioration after her first plasmapheresis treatment and was then consulted by the neurology and intensive care unit doctors. Diffusion cranial magnetic resonance imaging was found compatible with posterior reversible encephalopathy syndrome. The patient was transferred to our intensive care unit. The patient gained consciousness after her second plasmapheresis. After 5 days of follow-up in our intensive care unit and after significant regression was observed in the magnetic resonance imaging analysis, the patient was transferred to the nephrology service conscious, cooperated and orientated. At the nephrology service, after a total of 13 times of plasmapheresis, complement levels were increased and she was discharged with corticosteroid therapy. Posterior reversible encephalopathy syndrome can be observed in patients with systemic lupus erythematosus and intensive care unit treatment may be required. To control the hypertension, plasmapheresis should be kept in mind in addition to the multiple antihypertensive therapy in these patients.

Predicting recovery from deep neuromuscular block by rocuronium in the elderly.

STUDY OBJECTIVE: To determine the influence of aging on the relationship between posttetanic count (PTC) and train-of-four (TOF) response during intense neuromuscular blockade caused by rocuronium. DESIGN: Prospective, observational, clinical comparison study. SETTING: Operating room of a university hospital. PATIENTS: 42 ASA physical status I and II patients, 20 of whom were elderly (ages 65 to 80 yrs) and 22 younger control patients (ages 18 to 40 yrs), who were scheduled for elective orthopedic surgery and ear, nose, and throat surgery with a planned duration of 2 hours. INTERVENTIONS: Neuromuscular blockade was evaluated with accelerometry of the thumb, using posttetanic twitch (PTT) and TOF stimulation of the ulnar nerve, in patients who received rocuronium 1 mg x kg(-1). MEASUREMENTS AND MAIN RESULTS: The first responses to posttetanic nerve stimulation were seen at mean times of 38.5 and 35.2 minutes after the injection of rocuronium in the elderly and in the young, respectively (NS). The average interval between the appearance of a posttetanic response and the first response to TOF stimulation (T1) was longer in the elderly than the young (22.3 +/- 8.1 (SD) vs.14.8 +/- 4.2 min, p < 0.05). There was a significant correlation between PTC and the time to first response to TOF nerve stimulation both in the elderly and in the young (r = -0.73, p < 0.0001 and r = -0.87, p < 0.0001, respectively). CONCLUSIONS: Posttetanic twitch stimulation is a useful method of monitoring intense neuromuscular blockade caused by rocuronium in both age groups. The interval between the earliest appearance of a posttetanic response and the first response to TOF stimulation (T1) is greater in the elderly than in the young.

Evaluation of intense neuromuscular blockade caused by rocuronium using posttetanic count in male and female patients.

STUDY OBJECTIVE: To establish the relationship between train-of-four (TOF) nerve stimulation and the number of posttetanic twitches (posttetanic count [PTC]) during neuromuscular blockade caused by rocuronium in males and females. DESIGN: Prospective, observational, clinical comparison. SETTING: Operating room of a university hospital. PATIENTS: 60 ASA physical status I and II patients (30 women and 30 men), aged 18 to 60 years, who were scheduled for elective orthopedic surgery and ear, nose, throat surgery with a planned duration of 2 hours. INTERVENTIONS; During fentanyl, propofol, and nitrous oxide (N(2)O) anesthesia, neuromuscular blockade was evaluated with accelerometry of the thumb using TOF and posttetanic twitch stimulation (PTTS) of the ulnar nerve in patients who received rocuronium 1 mg.kg(-1). MEASUREMENTS AND MAIN RESULTS: The first responses to PTTS were seen at mean times of 34.9 and 37.7 minutes after rocuronium injection in male and female patients, respectively (NS). The average interval between the appearance of a posttetanic response and the first response to TOF stimulation (T1) was not significantly different between male and female patients (15.4 +/- 4.8 min (SD) vs. 15.9 +/- 4.9 min, respectively). There was a significant negative correlation between PTC and the time to first response to TOF nerve stimulation (r = -0.83; p = 0.0001). Gender did not have a statistically significant effect on this relation (F = 0.9; p = 0.34). The intervals from administration of rocuronium to the first appearances of T1 and T2 were not significantly different between the two groups, but the intervals to the first appearances of T3 and T4 were significantly longer in female patients. CONCLUSIONS: Even though the times from initial administration of rocuronium 1 mg.kg(-1) to the first appearances of T3 and T4 are significantly longer in female patients, the intervals to the first detectable responses to PTTS and TOF are not significantly different between females and males. Gender has no significant effect on the relation between PTC and the time to T1.

Predicting recovery from deep neuromuscular block by rocuronium in children and adults.

STUDY OBJECTIVE: To compare the response to motor nerve stimulation at a rate of 1 Hz after 50 Hz tetanus [posttetanic count (PTC)] and 2 Hz for 2 seconds [train-of-four (TOF)] in children and adults during spontaneous recovery from blockade caused by rocuronium. DESIGN: Prospective, clinical, observational, multicenter study. SETTING: Operating rooms of two university hospitals. PATIENTS: 22 children (ASA physical status I and II) aged 2 to 5 years, scheduled to undergo dental treatment and 20 adults aged 18 to 60 years, scheduled to undergo elective general or orthopedic surgery during general anesthesia with tracheal intubation. MEASUREMENTS: Neuromuscular blockade was evaluated with accelerometry of the thumb, using PTC and TOF stimulation of the ulnar nerve, in patients who received rocuronium 1 mg x kg(-1). MAIN RESULTS: The first response to posttetanic and TOF nerve stimulation appeared earlier in children than in adults. The time from injection of rocuronium to appearance of the fourth response to TOF ranged from 27 to 62 minutes in children and from 37 to 94 minutes in adults. The average interval between the appearance of a posttetanic response and the first detectable response to TOF stimulation (T1) was also shorter in children, 7 minutes, than in adults, 16 minutes. The relationship between PTC and the time interval between a given PTC and the first detectable TOF response in both children and adults was exponential (R = -0.64 and R = -0.81, respectively). CONCLUSIONS: Children recover faster than adults from neuromuscular blockade after administration of 1 mg x kg(-1) rocuronium. The relationship between PTC and time to first response to TOF is exponential both in children and adults during recovery from neuromuscular blockade caused by rocuronium.

Epidemiology and risk factors of intensive care unit-acquired infections: a prospective multicentre cohort study in a middle-income country.

INTRODUCTION: This study aimed to determine the incidence and risk factors of infections among patients admitted to intensive care units (ICUs) in tertiary care hospitals in Turkey. METHODS: Adult patients who were admitted to the ICUs of five tertiary care hospitals for over 48 hours between June and December 2007 were monitored daily. Potential risk factors such as age, gender, comorbidities, diagnosis at admission, severity of disease (Acute Physiology and Chronic Health Evaluation II scores), exposure to antibiotics, history of invasive procedures and significant medical interventions were evaluated. A multivariate analysis of these risk factors was carried out using Cox regression. RESULTS: A total of 313 patients with a median ICU stay of 12 days were selected for the study. 236 infectious episodes (33.8/1,000 ICU-days) were diagnosed among 134 patients (42.8/100 patients) in this group. Multivariate analysis revealed that exposure to a cephalosporin antibiotic (hazard ratio [95% confidence interval] 1.55 [1.10-2.19]) was an independent risk factor, whereas having a tracheostomy cannula (0.53 [0.36-0.81]) or nasogastric tube (0.48 [0.33-0.70]) was protective. Patients admitted to the ICUs from surgical wards were significantly more exposed to cephalosporins. CONCLUSION: ICU-associated infections, which are quite high in Turkey, are largely due to inadequate infrastructure and facilities and understaffing. Abuse of antibiotics, particularly in patients who have undergone surgery, and prolonged ICU stays are significant risk factors for such infections.