A rare case of granulomatosis with polyangiitis with involvement of the gastrointestinal system.

We report a rare case of a 37-year-old man with granulomatosis with polyangiitis (GPA) with gastrointestinal system (GIS) involvement who needed 526 units of blood and blood product transfusions and was followed up in the intensive care unit (ICU). GIS involvement due to GPA is a rare condition that increases morbidity and mortality of patients. Patients may require ultramassive blood product transfusions. Thus, patients with GPA can be admitted to ICUs because of massive hemorrhage due to multisystem involvement, and survival is achievable with meticulous care through a multidisciplinary approach.

Listeria Rhombencephalitis and Infratentorial Brain Abcesses in a Young Adult with Stroke Like Presentation.

Rhombencephalitis refers to the inflammation of rhombencephalon, and Listeria monocytogenes is one of the causes of infectious rhombencephalitis. Listeria rhombencephalitis is a rare and severe infection with high mortality and morbidity. As the disease can present with a variety of neurological symptoms and nonspecific laboratory tests, it can easily be misdiagnosed. Sudden onset of neurological signs without fever can resemble stroke. Magnetic resonance imaging can be useful in patients for confirmation of the diagnosis and during the follow-up. Early diagnosis and treatment are especially important for improvement of the outcomes. Here we report a case with stroke-like presentation that was diagnosed as Listeria rhombencephalitis in follow-up and present the serial brain magnetic resonance imaging features.

Incidence of and Risk Factors for Prolonged Intensive Care Unit Stay After Open Heart Surgery Among Elderly Patients.

OBJECTIVE: Open heart surgery (OHS) is frequently performed on elderly patients. We aimed to investigate the risk factors associated with prolonged intensive care unit (ICU) stay in elderly patients undergoing open heart surgery. MATERIALS AND METHODS: Medical records of all patients ≥ 75 years who underwent OHS (coronary artery bypass grafting (CABG) and/or heart valve surgery) between June 1, 2013, and December 31, 2020, were retrospectively analyzed. Those staying in the ICU longer than five days were determined as prolonged ICU stay. Patients were divided into two groups, according to ICU stay <5 days and ≥5 days. RESULTS: Out of the 198 patients included in the study, 130 (65.7%) were male. Seventy patients (35.4%) had prolonged ICU stay. The mean age was higher in patients within the prolonged ICU stay group when compared to the other group (79.9±3.5 years vs.78.1±2.7 years, p<0.001). The patients who used statins and angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARBs) in the preoperative period had a shorter ICU stay compared to those who did not (45% vs 31.4%, p=0.04; 57% vs 42.9%, p=0.03). The history of previous thoracic surgery (2.3% vs 10% p=0.03), emergency surgery (12.5% vs 24.5% p=0.04), and preoperative pacemaker usage (0.8% vs 7%, 1 p=0.01) were higher in the group of patients with prolonged ICU stay compared to the other group. Preoperative ejection fraction (EF)% (47.7±11.3 vs 51.1±8.8, p<0.001) and hemoglobin level (11.8±1.9 mg/dL vs 12.9±1.6, p<0.001) were lower in the group with prolonged ICU stay compared to the other group. Incidence of cardiac arrest (3.9% vs 15.7% p=0.006), presence of arrhythmia (16.4% vs 41.6%,p<0.001), frequency of pacemaker and intra-aortic balloon pump (IABP) usage (0 vs 10% p=0.002; 1.6% vs 8.6% p=0.02), and need for renal replacement therapy (3.1% vs 12.9%,p=0.02) were higher in the group with prolonged ICU stay compared to the other group. According to the logistic regression analysis; higher age (OR: 1.225, 95%CI 1.104-1.360, p<0.001), preoperative pacemaker usage (OR: 0.100, 95%CI 0.01-0.969, p<0.04), preoperative statin non-use (OR: 2.056, 95%CI 1.040-4.066, p<0.03) and preoperative low EF (OR: 0.947, 95%CI 0.915-0.981, p=0.002) were determined as independent risk factors for prolonged ICU stay. CONCLUSION: The incidence of prolonged ICU stay after OHS among patients ≥75 years was 35.4% in our cohort. Higher age, preoperative pacemaker usage, preoperative statin non-use, and low preoperative EF were associated with prolonged ICU stay.

Comparison of confirmed and probable COVID-19 patients in the intensive care unit during the normalization period.

The decrease in social distance together with the normalization period as of June 1, 2020 in our country caused an increase in the number of COVID 19 patients. Our aim was to compare the demographic features, clinical courses and outcomes of confirmed and probable coronavirus disease 2019 (COVID-19) patients admitted to our intensive care unit (ICU) during the normalization period. Critically ill 128 COVID-19 patients between June 1 - December 2, 2020 were analyzed retrospectively. The mean age was 69.7±15.5y (61.7% male). Sixty-one patients (47.7%) were confirmed. Dyspnea (75.0%) was the most common symptom and hypertension (71.1%) was the most common comorbidity. The mean Acute Physiology and Chronic Health Evaluation System (APACHE II) score; Glasgow Coma Score (GCS); Sequential Organ Failure Assessment (SOFA) scores on ICU admission were 17.4 ± 8.2, 12.3 ± 3.9 and 5.9 ± 3.4, respectively. 101 patients (78.1%) received low flow oxygen, 48 had high flow oxygen therapy (37.5%) and 59 (46.1%) had invasive mechanical ventilation. 53 patients (41.4%) had vasopressor therapy and 30 (23.4%) patients had renal replacement therapy (RRT) due to acute kidney injury (AKI). Confirmed patients were more tachypneic (p=0.005) and more hypoxemic than probable patients (p<0.001). Acute respiratory distress syndrome (ARDS) and AKI were more common in confirmed patients than probable (both p<0.001). Confirmed patients had higher values of hemoglobin, C- reactive protein, fibrinogen, D-dimer than probables (respectively, p=0.028, 0.006, 0.000, 0.019). The overall mortality was higher in confirmed patients (p=0.209, 52.6% vs 47.4%). Complications are more common among confirmed COVID-19 patients admitted to ICU. The mortality rate of confirmed COVID-19 patients admitted to the ICU was found to be higher than probable patients. Mortality of confirmed cases were higher than prediction of APACHE-II scoring system.

Early Postoperative Acute Kidney Injury Among Pediatric Liver Transplant Recipients.

OBJECTIVES: Acute kidney injury after pediatric liver transplant is associated with increased morbidity and mortality. Here, we evaluated children with acute kidney injury early posttransplant using KDIGO criteria to determine incidence, risk factors, and clinical outcomes. MATERIALS AND METHODS: In this retrospective cohort study, medical records of all patients < 16 years old who underwent liver transplant from April 2007 to April 2017 were reviewed. RESULTS: Of 117 study patients, 69 (59%) were male and median age at transplant was 72 months (range, 12-120 mo). Forty children (34.2%) had postoperative acute kidney injury, with most having stage 1 disease (n = 21). Compared with children who had acute kidney injury versus those who did not, preoperative activated partial thromboplastin time (median 35.6 s [interquartile range, 32.4-42.8 s] vs 42.5 s [interquartile range, 35-49 s]; P = .007), intraoperative lactate levels at end of surgery (median 5.3 mmol/L [interquartile range, 3.3-8.6 mmol/L] vs 7.9 mmol/L [interquartile range, 4.3-11.2 mmol/L]; P = .044), and need for open abdomen (3% vs 15%; P= .024) were significantly higher. Logistic regression analysis revealed that preoperative high activated partial thromboplastin time (P= .02), intraoperative lactate levels at end of surgery (P = .02), and need for open abdomen (P = .03) were independent risk factors for acute kidney injury. Children who developed acute kidney injury had significantly longer intensive care unit stay (7.1 ± 8.5 vs 4.4 ± 5.4 days, P= .04) and mortality (12.8% vs 1.8%; P = .01). CONCLUSIONS: Early postoperative acute kidney injury occurred in 34.2% of pediatric liver transplant recipients, with patients having increased mortality risk. High preoperative activated partial throm-boplastin time, high intraoperative end of surgery lactate levels, and need for open abdomen were shown to be associated with acute kidney injury after pediatric liver transplant.

Effects of Minimal Flow Sevoflurane or Desflurane Anaesthesia on Hemodynamic Parameters, Body Temperature and Anaesthetic Consumption.

OBJECTIVE: We aimed to compare minimal flow sevoflurane and desflurane anaesthesia in terms of hemodynamic parameters, body temperature, anaesthetic gas consumption and cost. METHODS: 120 patients with ASA I-II (>18yo) who underwent elective surgery for longer than 60 min after general anaesthesia were randomized into two groups. The Dräger Perseus® A500 workstation was used. Pre-oxygenation was performed for 3 min with 6 L min-1 to 100% oxygen. Fractional inspirium oxygen concentration (FiO2) was reduced to 40%, fresh gas flow was 4 L min-1 after intubation. Sevoflurane or desflurane was started at 1.5 minimal alveolar concentration (MAC). When the MAC value reached 0.9, fresh gas flow was reduced to 0.5 L min-1, FiO2 was increased to 68%. At the end of the surgery, the vaporizer was switched off, the fresh gas flow was increased (4 L min-1, FiO2 100%). When the train-of-four (TOF) ratio was 100%, extubation was carried out. RESULTS: There were no differences in patient characteristics and initial hemodynamic parameters of the groups. There were statistically significant differences between the times to reach 0.9 MAC, extubation and eye opening; anaesthetic, O2 and air consumption in both groups. CONCLUSION: With minimal flow, the time to reach target MAC, time to extubation and eye opening were significantly faster for desflurane and anaesthetic, oxygen and air consumption in desflurane anaesthesia were less than sevoflurane. Thus, we can say that desflurane has faster anaesthetic induction and recovery time with lower anaesthetic consumption than sevoflurane.

Assessment of the effectiveness of a ventilator associated pneumonia prevention bundle that contains endotracheal tube with subglottic drainage and cuff pressure monitorization

ABSTRACT The effectiveness of prevention bundles on the occurrence and mortality of ventilator associated pneumonia (VAP) was evaluated in many studies. However, the effectiveness of endotracheal tube with subglottic secretion drainage (ETT-SD) and cuff pressure monitorization in VAP bundles have not been adequately assessed. In this study, we aimed to evaluate the effectiveness of VAP bundle containing ETT-SD and cuff pressure monitorization. This was a prospective, controlled study that was carried out between March 2011 and April 2012 including intubated patients. The study was conducted at the Anesthesiology Intensive Care Unit 1 and 2 (10 beds each) in a 898-bed university hospital. Occurrence of VAP and compliance with the parameters of the VAP prevention bundles were assessed daily. Patients intubated with the standard endotracheal tube were recruited as controls, mainly in the first six months of the study as ETT-SD and cuff pressure monometer had not yet been implemented. In the second term, patients intubated with ETT-SD were included as cases. Occurrence of VAP, mortality, and compliance with VAP prevention bundles were monitored. A total of 133 patients, 37 cases and 96 controls were recruited. VAP incidence declined from 40.82 to 22.16 per 1000 ventilator days among controls and cases, respectively (p < 005). On average, VAP occurred 17.33 ± 21.09 days in the case group and 10.43 ± 7.83 days in the control group (p = 0.04). However, mortality of cases and controls at the 14th and 30th days was not different. VAP prevention bundles including the utilization of ETT-SD, monitoring cuff pressure, and oral care with chlorhexidine were efficient in reducing the rate of VAP.

Perioperative Venoarterial Extracorporeal Membrane Oxygenation Support During Heart Transplant.

OBJECTIVES: Heart transplant is the only definitive treatment of end-stage heart failure. Venoarterial extracorporeal membrane oxygenation may be used as a bridge to heart transplant. This technique may be used after heart transplant for conditions refractory to medical treatment like primary graft failure. Previously, we reported our experience with patients who received extracorporeal support as a bridge to emergency heart transplant. In this study, we present our perioperative experience with heart transplants in which extracorporeal support was used. MATERIALS AND METHODS: We retrospectively screened the data of 31 patients who were seen at our center between January 2014 and June 2016. We screened for patients who were admitted tothe intensive care unit before transplant and who required venoarterial extracorporeal membrane oxygenation for circulatory support and postoperative patients who required extracorporeal support. Patient demographics and characteristics, clinical data, and extracorporeal support data were collected from our electronic database and patient medical records. RESULTS: There were 14 patients who required perioperative extracorporeal support. Preoperative support was performed in 3 patients before transplant, and postoperative support was performed in 11 patients after transplant. The mean age was 37.7 years in patients within the preoperative group and 29.7 years in patients within the postoperative group. One patient with preoperative support and 5 with postoperative support were pediatric patients. The main indication for transplant was dilated cardiomyopathy in both groups (100% and 63.7%). Overall mortality rates were 33% in the preoperative group and 63.7% in the postoperative group. CONCLUSIONS: For patients on heart transplant wait lists who are worsening despite optimal medical therapy, venoarterial extracorporeal membrane oxygenation support is a safe and viable last resort. In addition, extracorporeal support can be used during the posttransplant period as salvage therapy in heart recipients with hemodynamic deterioration. In our experience, preoperative extracorporeal support had lower mortality rates compared with postoperative support.

Assessment of the effectiveness of a ventilator associated pneumonia prevention bundle that contains endotracheal tube with subglottic drainage and cuff pressure monitorization.

The effectiveness of prevention bundles on the occurrence and mortality of ventilator associated pneumonia (VAP) was evaluated in many studies. However, the effectiveness of endotracheal tube with subglottic secretion drainage (ETT-SD) and cuff pressure monitorization in VAP bundles have not been adequately assessed. In this study, we aimed to evaluate the effectiveness of VAP bundle containing ETT-SD and cuff pressure monitorization. This was a prospective, controlled study that was carried out between March 2011 and April 2012 including intubated patients. The study was conducted at the Anesthesiology Intensive Care Unit 1 and 2 (10 beds each) in a 898-bed university hospital. Occurrence of VAP and compliance with the parameters of the VAP prevention bundles were assessed daily. Patients intubated with the standard endotracheal tube were recruited as controls, mainly in the first six months of the study as ETT-SD and cuff pressure monometer had not yet been implemented. In the second term, patients intubated with ETT-SD were included as cases. Occurrence of VAP, mortality, and compliance with VAP prevention bundles were monitored. A total of 133 patients, 37 cases and 96 controls were recruited. VAP incidence declined from 40.82 to 22.16 per 1000 ventilator days among controls and cases, respectively (p<005). On average, VAP occurred 17.33±21.09 days in the case group and 10.43±7.83 days in the control group (p=0.04). However, mortality of cases and controls at the 14th and 30th days was not different. VAP prevention bundles including the utilization of ETT-SD, monitoring cuff pressure, and oral care with chlorhexidine were efficient in reducing the rate of VAP.

Hemolysis, elevated liver enzymes, and low platelet syndrome: Outcomes for patients admitted to intensive care at a tertiary referral hospital.

PURPOSE: The aim was to assess outcomes for pregnancies in which hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome develops and the patient requires transfer for critical care. MATERIALS AND METHODS: The cases of women with HELLP syndrome who delivered at our tertiary center or surrounding hospitals and were admitted to the intensive care between January 2007 and July 2012 were retrospectively analyzed. Results were compared for the surviving and non-surviving patients. RESULTS: Among the 77 women with HELLP syndrome, maternal mortality rate was 14% and 24 (30%) of 81 fetuses and newborns died in the perinatal period. The most common maternal complications were disseminated intravascular coagulation (DIC) (n = 22; 29%), acute renal failure (n = 19; 25%), and postpartum hemorrhage (n = 16; 21%). Compared with surviving women, the non-surviving women had higher mean international normalized ratio (INR) (p < 0.0001); higher mean serum levels of aspartate aminotransferase (AST) (p < 0.0001); higher alanine aminotransferase (ALT) (p < 0.0001); higher lactate dehydrogenase (LDH) (p < 0.0001), and higher bilirubin (p = 0.040) levels; and lower platelet count (p = 0.005). CONCLUSION: DIC is a major risk factor for maternal outcome among patients with HELLP syndrome who require intensive care. Low platelet count; high AST, ALT, LDH, INR; and total bilirubin are associated with high mortality risk in this patient group. In addition, low platelet count; low fibrinogen level; prolonged activated thromboplastin time; high INR; and high total bilirubin, LDH, blood urea nitrogen, and creatinine are associated with high risk for complications in this patient group.

Venoarterial Extracorporeal Membrane Oxygenation Support as a Bridge to Heart Transplant: Report of 3 Cases.

Heart transplant is the only definitive treatment of end-stage heart failure. Venoarterial extracorporeal membrane oxygenation may be used as a bridge to heart transplant. Among 31 patients who underwent heart transplant between January 2014 and June 2016, we present our experiences with 3 patients who received venoarterial extracorporeal support as a bridge to heart transplant. The first patient was a 51-year-old male with ischemic dilated cardiomyopathy. Transplant was performed after 6 days of extracorporeal support, and the patient was discharged and alive at follow-up. Patient 2 was a 12-yearold girl with dilated cardiomyopathy who presented with cardiac arrest. Extracorporeal support was initiated during cardiopulmonary resuscitation. She had full neurologic recovery and remained on the wait list. She received a transplant 22 days after resuscitation. She survived and was alive at day 220 posttransplant. The third patient was a 50-year-old male with ischemic dilated cardiomyopathy requiring venoarterial extracorporeal support. Percutaneous balloon atrial septostomy was performed for left ventricle venting. He underwent transplant on day 28 after intensive care unit admission. He died 29 days after release from the hospital. Regarding patients on heart transplant wait lists who are worsening despite optimal medical therapy, venoarterial extracorporeal membrane oxygenation support is a safe and viable last resort.

Late Intensive Care Unit Admission in Liver Transplant Recipients: 10-Year Experience.

OBJECTIVES: We evaluated late intensive care unit admission in liver transplant recipients to identify incidences and causes of acute respiratory failure in the postoperative period and to compare these results with results in patients who did not have acute respiratory failure. MATERIALS AND METHODS: We retrospectively screened the data of 173 consecutive adult liver transplant recipients from January 2005 through March 2015 to identify patients with late admission (> 30 d posttransplant) to an intensive care unit. Patients were divided into 2 groups: patients with and without acute respiratory failure. Acute respiratory failure was defined as severe dyspnea, respiratory distress, decreased oxygen saturation, hypoxemia or hypercapnia on room air, or need for noninvasive or invasive mechanical ventilation. Demographic, laboratory, clinical, and respiratory data were collected. Model for End-Stage Liver Disease, Acute Physiology and Chronic Health Evaluation II, and Sequential Organ Failure Assessment scores; lengths of intensive care unit and hospital stays; and hospital mortality were assessed. RESULTS: Among 173 patients, 37 (21.4%) were admitted to an intensive care unit, including 22 (59.5%) with acute respiratory failure. The leading cause of acute respiratory failure was pneumonia (n = 19, 86.4%). Patients with acute respiratory failure had significantly lower levels of albumin before intensive care unit admission (P = .003). In patients with acute respiratory failure, severe sepsis and septic shock were more frequently observed and tracheotomy was more frequently performed (P = .041). CONCLUSIONS: Acute respiratory failure developed in 59.5% of liver transplant recipients with late intensive care unit admission. The leading cause was pneumonia, with this group of patients having higher requirements for invasive mechanical ventilation and tracheotomy, longer stays in an intensive care unit, and higher mortality.

Percutaneous Dilational Tracheotomy in Solid-Organ Transplant Recipients.

OBJECTIVES: Solid-organ transplant recipients may require percutaneous dilational tracheotomy because of prolonged mechanical ventilation or airway issues, but data regarding its safety and effectiveness in solid-organ transplant recipients are scarce. Here, we evaluated the safety, effectiveness, and benefits in terms of lung mechanics, complications, and patient comfort of percutaneous dilational tracheotomy in solid-organ transplant recipients. MATERIALS AND METHODS: Medical records from 31 solid-organ transplant recipients (median age of 41.0 years [interquartile range, 18.0-53.0 y]) who underwent percutaneous dilational tracheotomy at our hospital between January 2010 and March 2015 were analyzed, including primary diagnosis, comorbidities, duration of orotracheal intubation and mechanical ventilation, length of intensive care unit and hospital stays, the time interval between transplant to percutaneous dilational tracheotomy, Acute Physiology and Chronic Health Evaluation II score, tracheotomy-related complications, and pulmonary compliance and ratio of partial pressure of arterial oxygen to fraction of inspired oxygen. RESULTS: The median Acute Physiology and Chronic Health Evaluation II score on admission was 24.0 (interquartile range, 18.0-29.0). The median interval from transplant to percutaneous dilational tracheotomy was 105.5 days (interquartile range, 13.0-2165.0 d). The only major complication noted was left-sided pneumothorax in 1 patient. There were no significant differences in ratio of partial pressure of arterial oxygen to fraction of inspired oxygen before and after procedure (170.0 [interquartile range, 102.2-302.0] vs 210.0 [interquartile range, 178.5-345.5]; P = .052). However, pulmonary compliance results preprocedure and postprocedure were significantly different (0.020 L/cm H2O [interquartile range, 0.015-0.030 L/cm H2O] vs 0.030 L/cm H2O [interquartile range, 0.020-0.041 L/cm H2O); P = .001]). Need for sedation significantly decreased after tracheotomy (from 17 patients [54.8%] to 8 patients [25.8%]; P = .004]). CONCLUSIONS: Percutaneous dilational tracheotomy with bronchoscopic guidance is an efficacious and safe technique for maintaining airways in solidorgan transplant recipients who require prolonged mechanical ventilation, resulting in possible improvements in ventilatory mechanics and patient comfort.

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.

Extracorporeal membrane oxygenation after living-related liver transplant.

Various types of extracorporeal membrane oxygenation methods have been used in liver transplant operations. The main indications are portopulmonary or hepatopulmonary syndromes and other cardiorespiratory failure syndromes that are refractory to conventional therapy. There is little literature available about extracorporeal membrane oxygenation, especially after liver transplant. We describe our experience with 2 patients who had living-related liver transplant. A 69-year-old woman had refractory aspergillosis pneumonia and underwent pumpless extracorporeal lung assist therapy 4 weeks after liver transplant. An 8-month-old boy with biliary atresia underwent urgent liver transplant; he received venoarterial extracorporeal membrane oxygenation therapy on postoperative day 1. Despite our unsuccessful experience with 2 patients, extracorporeal membrane oxygenation and pumpless extracorporeal lung assist therapy for liver transplant patients may improve prognosis in selected cases.

Blood glucose regulation during living-donor liver transplant surgery.

OBJECTIVES: The goal of this study was to compare the effects of 2 different regimens on blood glucose levels of living-donor liver transplant. MATERIALS AND METHODS: The study participants were randomly allocated to the dextrose in water plus insulin infusion group (group 1, n = 60) or the dextrose in water infusion group (group 2, n = 60) using a sealed envelope technique. Blood glucose levels were measured 3 times during each phase. When the blood glucose level of a patient exceeded the target level, extra insulin was administered via a different intravenous route. The following patient and procedural characteristics were recorded: age, sex, height, weight, body mass index, end-stage liver disease, Model for End-Stage Liver Disease score, total anesthesia time, total surgical time, and number of patients who received an extra bolus of insulin. The following laboratory data were measured pre- and postoperatively: hemoglobin, hematocrit, platelet count, prothrombin time, international normalized ratio, potassium, creatinine, total bilirubin, and albumin. RESULTS: No hypoglycemia was noted. The recipients exhibited statistically significant differences in blood glucose levels during the dissection and neohepatic phases. Blood glucose levels at every time point were significantly different compared with the first dissection time point in group 1. Excluding the first and second anhepatic time points, blood glucose levels were significantly different as compared with the first dissection time point in group 2 (P < .05). CONCLUSIONS: We concluded that dextrose with water infusion alone may be more effective and result in safer blood glucose levels as compared with dextrose with water plus insulin infusion for living-donor liver transplant recipients. Exogenous continuous insulin administration may induce hyperglycemic attacks, especially during the neohepatic phase of living-donor liver transplant surgery. Further prospective studies that include homogeneous patient subgroups and diabetic recipients are needed to support the use of dextrose plus water infusion without insulin.

Performance of size 1 I-gel compared with size 1 ProSeal laryngeal mask in anesthetized infants and neonates.

PURPOSE: The size 1 I-gel, recommended for small infants and neonates weighing 2-5 kg, has recently been released. There are no prospective studies available that assess the insertion conditions, sealing pressures, or ventilation quality of it. This study was designed to compare the performance of recently released size 1 I-gel with size 1 ProSeal LMA. METHODS: Fifty infants and neonates, ASA I-II were included in this prospective, randomized, and controlled study. Patients were divided into two groups for placing I-gel or ProSeal LMA. The primary outcome was airway leak pressure, and secondary outcomes included insertion time, insertion success and conditions, initial airway quality, fiberoptic view of the larynx, and complications. RESULTS: There were no significant differences in terms of airway leak pressure between the I-gel (27.44 ± 5.67) and ProSeal LMA (23.52 ± 8.15) (P = 0.054). The insertion time for the I-gel was shorter (12.6 ± 2.19 s) than for the ProSeal LMA (24.2 ± 6.059 s) (P = 0.0001). Insertion success and conditions were similar in groups. We encountered few complications. CONCLUSION: Our study demonstrates that the size 1 I-gel provided an effective and satisfactory airway as the size 1 ProSeal LMA. It may be a good alternative supraglottic airway device for use in small infants and neonates. This trial is registered with: ClinicalTrials.gov NCT01704118.

Predictors of postoperative atrial fibrillation after on-pump coronary artery bypass grafting: is duration of mechanical ventilation time a risk factor?

PURPOSE: This study aimed to establish the role of risk factors in the etiology of postoperative atrial fibrillation (AF) after coronary artery bypass grafting (CABG). METHODS: Between September 2001 and March 2008, 1040 patients underwent isolated CABG at our clinic. Nine hundred and eleven of these patients did not have any AF(Non-AF Group) and the other one hundred and twenty-nine had AF (AF Group). A retrospective study was performed for patient, disease and treatment related factors and multivariate analysis was used to identify independent clinical predictors of postoperative AF. RESULTS: Postoperative AF was identified in 129 (12.4%) of the patients, and those were significantly older and had significantly higher additive EuroSCORE score as compared with patients without AF. During the postoperative course, patients with postoperative AF also had significantly higher and prolonged (≥6 hours) mechanical ventilation time, longer and prolonged intensive care unit stay and longer hospital stay. Logistic regression analysis revealed that postoperative AF development ratio was 1.690 times higher when the ventilation time was over 6 hours (OR 1.690, 95% CI 1.092-2.615, p = 0.018); 1.240 times higher in the presence of elevated additive EuroSCORE score (OR 1.240, 95% CI1.109-1.385, p = 0.0001); 1.052 times higher in the presence of advanced age (OR 1.052,95% CI 1.031-1.0741, p = 0.0001). CONCLUSION: Analysis of our data reveals that, patient's age, additive EuroSCORE score, and prolonged ventilation are predictors of postoperative AF. Identification of risk factors might lead to better prevention of this problem and its potential consequences. However, to support our investigation and obtain more reliable evidence, prospective randomized controlled trials are needed.

Dexmedetomidine ameliorates TNBS-induced colitis by inducing immunomodulator effect.

BACKGROUND: Since sedatives are often administered to immune-compromised and critically ill patients, our understanding of immunomodulation by sedation will be critical. Dexmedetomidine, a selective α2-adrenergic receptor agonist, is often used for sedation and analgesia especially in intensive care units. There are conflicting and little data concerning both the effect and the mechanism of dexmedetomidine on immune response. In our study, we aimed to investigate the effect of dexmedetomidine on immune system at two different doses (5 µg.kg(-1) and 30 µg.kg(-1)) during inflammatory bowel disease by using an experimental model, which resembles both systemic and local inflammation. METHODS: The effect of dexmedetomidine on the course of inflammatory bowel disease was investigated by measuring macroscopic and microscopic parameters. We investigated pro-inflammatory Th1, Th2, and Th17 cytokine levels in serum samples to analyze systemic immune response. Following this, local immune response was investigated by measuring cytokine levels in the presence of dexmedetomidine in spleen cell culture. RESULTS: Dexmedetomidine administration led to amelioration of all disease associated pathological manifestations. According to our in vitro and in vivo results, dexmedetomidine shows anti-inflammatory effect by increasing IL-4 and IL-10 levels responsible from anti-inflammatory response via Th2 pathway. Moreover, we showed for the first time in the study that dexmedetomidine administration reduces IL-23, which is responsible from initiation of inflammatory response via Th17 pathway. CONCLUSIONS: Dexmedetomidine can have beneficial effect on preoperative or postoperative inflammatory bowel disease patients in intensive care units by down-regulating inflammatory immune response not only in systemic circulation but also in tissue-specific manner.

A heart transplant recipient lost due to Pneumocystis jiroveci pneumonia under trimethoprim-sulfamethoxazole prophylaxis: case report.

Infections in solid-organ transplant recipients are the most important causes of morbidity and mortality. A primary goal in organ transplant is the prevention or effective treatment of infection, which is the most common life-threatening complication of long-term immunosuppressive therapy. A 21-year-old woman who underwent heart transplant 3 years previous owing to dilated cardiomyopathy was referred to our hospital with symptoms of high fever and cough. The patient's history revealed that she had received a trimethoprim-sulfamethoxazole double-strength tablet each day for prophylactic purposes. On chest radiograph, pneumonia was detected, and in broncho-alveolar lavage sample, Pneumocystis jiroveci cysts were found. After diagnosing P. jiroveci pneumonia, trimethoprim-sulfamethoxazole was initiated at 20 mg/kg/d including intravenous trimethoprim in divided dosages every 6 hours. On the sixth day of therapy, she died in intensive care unit. In solid-organ transplant recipients, although antipneumocystis prophylaxis is recommended within the first 6 to 12 months after transplant, lifelong prophylaxis is also used in several settings. In addition, the physician should keep in mind that P. jiroveci pneumonia may develop in solid organ recipients, despite trimethoprim-sulfamethoxazole prophylaxis.