Mortality predictors in earthquake victims admitted to intensive care unit in Kahramanmaras earthquakes.

BACKGROUND: The purpose of this study is to report the data for patients followed-up in our intensive care unit due to the 6th February 2023, earthquake in Kahramanmaras, Türkiye, and to investigate parameters affecting mortality. METHODS: The demographic characteristics of patients followed-up in intensive care due to trauma following the earthquake, the treatments administered, developing complications, lengths of stay in the hospital and intensive care, and laboratory data were scanned retrospectively and recorded. These data were then compared between the surviving and non-surviving patients. RESULTS: Twenty-six patients, 13 (50 %) male, were followed-up in our intensive care, 24 (92 %) due to being buried under earthquake debris, and 2 (8 %) due to falling from heights. Increased Sequential Organ Failure Assessment (SOFA) (p = 0.027), higher initial serum potassium (p = 0.043), higher initial serum phosphorus (p = 0.035), higher initial and peak serum magnesium (p = 0.004 and p = 0.001), lower initial and peak bicarbonate (p = 0.021 and p = 0.012) and higher initial and peak serum base deficit values (p = 0.012 and p = 0.009) were associated with mortality. In the subgroup with crush injuries, higher initial and peak serum potassium (p = 0.001 and p = 0.025), higher initial and peak serum magnesium (p = 0.005 and p = 0.004), lower initial and peak bicarbonate (p = 0.019 and p = 0.021) and higher initial and peak serum base deficit values (p = 0.017 and p = 0.025) were associated with mortality. Multiorgan dysfunction failure developed in nine patients, sepsis in seven, dissemine intravascular coagulation in four, and acute respiratory distress syndrome in two. Fasciotomy was performed on 2 (8 %) patients and amputation on 8 (31 %). Extremity injuries were most frequently observed. 10 (38.5 %) of the 12 (46 %) patients developing acute kidney injury required renal replacement therapy. 7 (27 %) patients died during follow-up. In logistic regression analysis, higher SOFA scores, lower initial bicarbonate and BE levels, higher serum initial potassium and magnesium levels were a risk factor for mortality. Higher SOFA scores, lower initial bicarbonate and base deficit and higher initial phosphorus values affected mortality in patients with crush syndrome. CONCLUSION: Not only increased SOFA, serum potassium, serum phosphorus, and serum magnesium, but also decreased bicarbonate, and base deficit were associated with mortality in earthquake victims with crush syndrome in ICU.

Can antibiotics affect the clinical features of patients with candidemia? The retrospective evaluation of 5 years of data in an intensive care unit.

BACKGROUND: Candidemia is an opportunistic infection of intensive care units (ICUs) and causes morbidity and mortality. Multiple antibiotic exposure was found to be an independent risk factor for mortality and non-albicans candidemia (NAC) in candidemia patients. AIM: The aim of this study was to determine the relationship between antibiotics and clinical features of patients with candidemia, and to determine the independent risk factors for hospital stay >50 days, 30-day mortality in hospital, candidemia types, and septic shock in candidemia patients. METHODS: Patients were evaluated retrospectively for 5 years. A total of 148 candidemia cases were detected and included in the study. Characteristics of cases were defined and recorded. The relationship between qualitative data was determined by the χ2 test. Logistic regression analysis was used to determine the independent risk factors for hospital stay >50 days, 30-day mortality in hospital, candidemia types, and septic shock in candidemia patients. RESULTS: The incidence of candidemia for 5 years was 4.5%. Candida parapsilosis was the most reported species with 65% (n=97). Linezolid and central venous catheters (CVC) were found to be independent risk factors for NAC. Carbapenems and cephalosporins were found in association to lower mortality. No antibiotics or characteristics were found to be independent risk factors for mortality. Some broad spectrum antibiotics and antibiotic combinations were found in relationship with hospital stay >50 days; however, none of them were found to be independent risk factors. Metisilin resistant staphylococcus aureus (MRSA) antibiotics, meropenem+linezolid piperacillin-tazobactam+fluoroquinolones and comorbidity were found in association with septic shock, although only piperacillin-tazobactam+fluoroquinolones and comorbidity were found to be independent risk factors for septic shock. CONCLUSIONS: This study concluded that many antibiotics were safe for candidemia patients. However, clinicians should pay attention when prescribing linezolid or piperacillin-tazobactam and flouroquinolons concomitantly or sequentially for patients with candidemia risk factors.

Hydrocortisone may act through the angiotensin II receptor-2 level in patients with catecholamine-resistant septic shock.

BACKGROUND: This study aimed to compare the serum angiotensin II and its receptor levels (AT1, AT2) in septic patients with catecholamine-responsive or resistant. The effect of hydrocortisone treatment on angiotensin II levels in the catecholamine-resistant septic patients was evaluated. METHODS: This prospective observational study enrolled 40 patients diagnosed with septic shock based on sepsis-3 criteria. Patients were divided into two groups according to the noradrenalin infusion rate required to keep the mean arterial pressure above 65 mmHg: control group and hydrocortisone group (control group: below 0.5 µg/kg/min, hydrocortisone group: above 0.5 µg/kg/min). Serum angiotensin II, AT1, AT2 levels were measured at the time of diagnosis (A), one hour after hydrocortisone treatment (B), and three days later (C). RESULTS: In the catecholamine-resistant group, angiotensin II and AT1 levels were higher than the catecholamine-responder group in all periods. The sensitivity and specificity of AT-1 was observed to be high in all periods. AT2 levels decreased after hydrocortisone treatment in the catecholamine-resistant group and cut-off value was found 11%. CONCLUSIONS: It was concluded that angiotensin II and AT1 can be used as a biomarker of refractory septic shock and hydrocortisone may provide their blood pressure correcting effect by reducing AT2 level in these patients. AT2 can be a therapeutic target in the catecholamine-resistant septic shock patients.

The initial response of a local hospital in the earthquake zone during the February 6, 2023 Kahramanmaras earthquakes: Injuries and challenges.

OBJECTIVE: This study aimed to describe the type and number of traumatic injuries seen after devastating earthquakes and to evaluate the difficulties experienced in the treatment process in a primary affected center. METHODS: Out of the 2176 patients who were treated in the emergency department, 372 (199 male and 173 female) patients with complete data were included in this single-center retrospective study. In addition to the demographic characteristics of the patients, orthopedic injuries, other organ system injuries, type of injury, treatments, mechanisms of injury, and time of presentation to the emergency department were recorded. RESULTS: The most common age group for injury was 20-30 years old, consisting of 73 patients (19.62%), and the second most common age group was between 40 and 50, with 72 patients (19.35%). Injury after being trapped under rubble was seen in 152 (40.86%) patients, while non-debris causes were more common in 220 patients (59.14%). The most common site of injury was in the lower extremities, with 111 patients (29.84%), while multiple injuries were seen in 109 patients (29.3%). Lower extremity fractures were mostly seen in long bones such as the femur (12.28%) and tibia (11.4%). Upper extremity fractures, especially those due to falls, were most frequently in the distal radius (8.77%). After triage, 117 patients (31.45%) were hospitalized, whereas the majority of patients (58.33%) were discharged from the emergency department. CONCLUSION: This study has shown us that injuries following major earthquakes are of a wide spectrum and occur in large numbers and in a very short time. Even in a well-equipped hospital that is not affected by an earthquake, there are many barriers to appropriate management. The first 24 hours after an earthquake are critical. This period should be kept in mind while organizing and taking necessary precautions, and early responses to earthquakes should be meticulously planned.

Angiotensin II and angiotensin II receptor 2 levels can predict shock and mortality in septic patients.

BACKGROUND: The aim of this study was to evaluate the place of angiotensin II and its receptors in the prognosis of septic patients. METHODS: Patients with sepsis and septic shock were included in the study group. The control group consisted of patients who were followed up in the ICU and had no sepsis/septic shock. Plasma angiotensin II, angiotensin receptor-1 and 2 (AT-1, AT-2) levels were evaluated first and third days. RESULTS: Angiotensin II levels were significantly lower in the septic shock and non-survivor. AT-1 levels were lower in all septic patients on the first day compared to the control. While AT-1 levels on the third day decreased in the septic shock group, it increased in the sepsis group. AT-2 levels were significantly higher in sepsis, and lower in septic shock compared to controls on the first day. Angiotensin II (95%, 82%) and AT-2 levels (100%, 87%) were observed to have high sensitivity and specificity in demonstrating the presence of shock in septic patients. Angiotensin II and AT-1/AT-2 ratios were observed to have high sensitivity and low specificity in the development of mortality. CONCLUSIONS: In septic patients, angiotensin II, AT-2 and AT-1/AT-2 levels can predict the probability of shock development and mortality.

Potential Risk Factors for In-Hospital Mortality in Patients with Moderate-to-Severe Blunt Multiple Trauma Who Survive Initial Resuscitation.

INTRODUCTION: The aim was to identify risk factors that influence in-hospital mortality for patients with moderate-to-severe blunt multiple trauma (BMT) who survive initial resuscitation. METHODS: The prospective study involved 195 adult patients with BMT who were admitted to a referral hospital's emergency department (ED) between May 1, 2015, and May 31, 2016. RESULTS: Forty-three (22%) of the 195 patients died in hospital. Multivariate analysis identified low blood pH (odds ratio [OR] 6.580, 95% confidence interval [CI] 1.12-38.51), high serum lactate level (OR 1.041, 95% CI 1.01-1.07), high ISS (OR 1.109, 95% CI 1.06-1.16), high APACHE II score (OR 1.189, 95% CI 1.07-1.33), traumatic brain injury (TBI) (OR 4.358, 95% CI 0.76-24.86), severe hemorrhage (OR 5.314, 95% CI 1.07-26.49), and coagulopathy (OR 5.916, 95% CI 1.17-29.90) as useful predictors of acute in-hospital mortality. High ISS (OR 1.047, 95% CI 1.02-1.08), TBI (OR 8.922, 95% CI 2.57-31.00), sepsis (OR 4.956, 95% CI 1.99-12.36), acute respiratory distress syndrome (ARDS) (OR 8.036, 95% CI 1.85-34.84), respiratory failure (OR 9.630, 95% CI 2.64-35.14), renal failure (OR 74.803, 95% CI 11.34-493.43), and multiple organ failure [MOF] (OR 10.415, 95% CI 4.48-24.24) were risk factors for late in-hospital mortality. High Glasgow Coma Scale (GCS) was a good predictor for survival at 2, 7, and 28 or more days of hospitalization (OR 0.708 and 95% CI 0.56-0.09; OR 0.835 and 95% CI 0.73-0.95; OR 0.798 and 95% CI 0.71-0.90, resp.). CONCLUSION: Several factors signal poor short-term outcome for patients who present to the ED with moderate-to-severe BMT: low blood pH, high serum lactate level, presence of TBI, severe hemorrhage, coagulopathy, organ failure (respiratory, renal, and MOF), and ARDS. For this patient group, ISS and APACHE II scores might be helpful for stratifying by mortality risk, and GCS might be a good predictor for survival.

The 2-stage liver transplant: 3 clinical scenarios.

The main goal of 2-stage liver transplant is to provide time to obtain a new liver source. We describe our experience of 3 patients with 3 different clinical conditions. A 57-year-old man was retransplanted successfully with this technique due to hepatic artery thrombosis. However, a 38-year-old woman with fulminant toxic hepatitis and a 5-year-old-boy with abdominal trauma had poor outcome. This technique could serve as a rescue therapy for liver transplant patients who have toxic liver syndrome or abdominal trauma. These patients required intensive support during long anhepatic states. The transplant team should decide early whether to use this technique before irreversible conditions develop.