The impact of COVID-19 pandemic on the indications of non-COVID-19 obstetric and gynecological admissions to the intensive care unit (ICU) and its overall consequences.

Since COVID-19 outbreak caused a substantial reduction in intensive care unit (ICU) bed capacity, a significant change in triaging ICU admissions has become necessary for obstetric and gynecologic (OG) patients, as well. In the present study, we aimed to analyze the patients admitted to ICU for non-COVID-19 OG pathologies to understand the probable effects of the pandemic on demographics, admission rates and indications, complications, and the overall outcome. Medical records of patients who were admitted to ICU for OG diseases between 2018 and 2022 were reviewed. This four-year time was divided into two equal periods; Group I (March 2018 to March 2020, before the pandemic starts) and Group II (March 2020 to March 2022, during pandemic). Demographics, indications for admissions to ICU, length of stay, acute physiology and chronic health evaluation II (APACHE-II) scores and the factors contributing to their morbidity and mortality were recorded. Chi-square Kolmogorov-Smirno and Shapiro-Wilk tests were used to compare the variables. p < 0.05 was considered statistically significant. 511 patients were in Group I (61.94%) and 314 in Group II (38.06%). Between 2020 and 2022, our ICU admitted 38.56% fewer OG inpatients, compared with the pre-pandemic period (p < 0.05). While number of patients with gynecological pathologies increased (50 vs 57%), obstetric patients' admission to ICU decreased (49 vs 42%). In gynecologic patients, postoperative complications and sepsis showed a significant rise (57 vs 69% and 7 vs 12%, p < 0.05), and most were after oncological operations (81%). There was a significant rise in numbers of pregnancy-induced hypertension and placental pathologies (29 vs 36% and 41 vs 58%, p < 0.05). Outcome of obstetric patients in ICU was good (99% survival rate). Mortality was higher in gynecologic patients (4 vs 9%, p < 0.05), correlated with the increased APACHE-II score (8 vs 10, p < 0.05). Older age and oncologic operations were the primary factors increasing mortality. Length of stay in ICU prolonged in these patients, as well (1 vs 3 days, p < 0.05). Selection of priority patients by gynecologists and intensive care specialists in cooperation, and meticulous implementation of the rule of only accepting patients with strict indications may explain the change in OG admissions during the outbreak. These findings will question the accuracy of wider indications for ICU admissions in pre-pandemic period, and help in planning the policy for future post-pandemic days.

Previous chemotherapy can cause PONV.

BACKGROUND: Although the treatment and mechanisms of postoperative nausea and vomiting (PONV) and chemotherapy-induced nausea and vomiting (CINV) are similar, the interactions between these 2 morbidities require more research. OBJECTIVES: In our prospective observational study, we investigated whether previous chemotherapy has an effect on PONV in breast cancer surgery. MATERIAL AND METHODS: One hundred and forty-eight female patients with the American Society of Anesthesiologists (ASA) physical status I or II, aged 18-65 years and with a scheduled breast cancer surgery were recruited into the study. After they completed preoperative follow-up questionnaires, anesthesia was induced with propofol (2 mg/kg), remifentanil (1.0 µg/kg) and rocuronium (0.6 mg/kg), and maintained with sevoflurane (1.5-2.0%), 45% oxygen/air mixture and infusion of remifentanil (0.1-0.2 µg/kg/min). After extubation, the intensity of PONV was assessed during the first 2 h and at 2-24 h after surgery. The symptoms of PONV were classified as mild (mild nausea, vomiting once, and nausea caused by an external stimulant (eating, drinking or motion)), moderate (vomiting twice, mild nausea without an external stimulant, and antiemetic medication required once) and severe (vomiting more than twice, severe nausea, antiemetic medication required more than once) by a different researcher. Preoperative interview forms, perioperative anesthetic follow-up forms and postoperative assessment forms were recorded and evaluated by different members of this research group. RESULTS: Data of 143 patients were analyzed. In the group of patients who received chemotherapy, the prevalence of nausea and vomiting within the postoperative period of 2-24 h significantly increased (p < 0.05). CONCLUSION: Previous chemotherapy may be a risk factor for the presence of PONV.

Lateral flow assay (LFA) in the diagnosis of COVID-19-associated pulmonary aspergillosis (CAPA): a single-center experience.

BACKGROUND: Invasive pulmonary aspergillosis (IPA) is seen during coronavirus-2019 (COVID-19), has been reported in different incidences, and is defined as COVID-19-associated pulmonary aspergillosis (CAPA). Detection of galactomannan antigen is an important diagnostic step in diagnosing IPA. Enzyme-linked immunoassay (ELISA) is the most frequently used method, and lateral flow assay (LFA) is increasingly used with high sensitivity and specificity for rapid diagnosis. The present study aimed to compare the sensitivity of LFA and ELISA in the diagnosis of CAPA in COVID-19 patients followed in our hospital's ICU for pandemic (ICU-P). METHODS: This study included patients with a diagnosis of COVID-19 cases confirmed by polymerase chain reaction and were followed up in ICU-P between August 2021 and February 2022 with acute respiratory failure. The diagnosis of CAPA was based on the European Confederation of Medical Mycology (ECMM) and the International Society for Human and Animal Mycology 2020 (ECMM/ ISHAM) guideline. Galactomannan levels were determined using LFA and ELISA in serum samples taken simultaneously from the patients. RESULTS: Out of the 174 patients followed in the ICU-P, 56 did not meet any criteria for CAPA and were excluded from the analysis. The rate of patients diagnosed with proven CAPA was 5.7% (10 patients). A statistically significant result was obtained with LFA for the cut-off value of 0.5 ODI in the diagnosis of CAPA (p < 0.001). The same significant statistical relationship was found for the cut-off value of 1.0 ODI for the ELISA (p < 0.01). The sensitivity of LFA was 80% (95% CI: 0.55-1.05, p < 0.05), specificity 94% (95% CI: 0.89-0.98, p < 0.05); PPV 53% (95% CI: 0.28-0.79, p > 0.05) and NPV was 98% (95% CI: 0.95-1.01, p < 0.05). The risk of death was 1.66 (HR: 1.66, 95% CI: 1.02-2.86, p < 0.05) times higher in patients with an LFA result of ≥ 0.5 ODI than those with < 0.5 (p < 0.05). CONCLUSIONS: It is reckoned that LFA can be used in future clinical practice, particularly given its effectiveness in patients with hematological malignancies and accuracy in diagnosing CAPA.

Biventricular Native Valve Endocarditis in a Patient with No Cardiac Disease and Predisposing Factor - Case Report.

Background: Infective endocarditis is a challenging clinical situation that causes numerous complications. Multi-valvular endocarditis, which is seen less frequently than single valvular endocarditis, is often a fatal disease. In this article, we present a case of endocarditis with native mitral and tricuspid valve involvement in a patient without any underlying predisposing factors. Case report:A 62-year-old patient was admitted to hospital with shortness of breath without any underlying predisposing factors. Covid-19 PCR swab was negative. Transthoracic echocardiography revealed bi-sided valve endocarditis with mitral and tricuspid valve involvement. The patient was taken to the intensive care unit. Transthoracic and transesophageal echocardiography revealed valvular involvement, flail mitrale with severe regurgitation on both valvules. The patient and patient's relatives refused the valvular operation because of the higher risk. Despite the antibiotic treatment, the general condition of the patient deteriorated and died. Conclusion:Multi-valvular endocarditis is a serious disorder with high mortality. In diagnosis, imaging procedures should be utilized as early as possible. Staphylococci are the most common pathogens in such cases, in which early diagnosis and treatment, particularly using a surgical approach, are appropriate.

Evaluation of Intraventricular/Intrathecal Antimicrobial Therapy in the Treatment of Nosocomial Meningitis Caused by Multidrug-Resistant Gram-Negative Bacteria after Central Nervous System Surgery.

INTRODUCTION: Postoperative meningitis (POM) is an infection with high mortality and morbidity following central nervous system surgery due to trauma or tumor. Intrathecal/intraventricular (IT/IVT) antibiotic administrations have been considered as the last treatment options for multidrug-resistance (MDR) Gram-negative bacteria that do not respond to intravenous (IV) regimens. IT/IVT can bypass the blood-brain barrier, obtain a more effective antibiotic concentration in CSF, and reduce systemic side effects. We aimed to determine the characteristics of postoperative patients who were diagnosed with MDR POM during follow-up in our intensive care unit (ICU). Material and Methods. In this study, POM patients who were followed up in ICU after the central nervous system intervention between January 2016 and December 2019 and whose MDR Gram-negative bacteria were isolated from CSF were evaluated. As soon as the patients were diagnosed with POM, a catheter was inserted and treatment was started. RESULTS: Microbiological eradication was achieved in 3 ± 0.8 days with 30 mg/day amikacin treatment in POM due to K. pneumoniae and 3.7 ± 1.95 days with colistin sodium 10 mg/day treatment in POM due to A. baumannii via IT/IVT catheter. IT/IVT treatment was utilized for a median of 10 days and continued until the defined cure criteria were achieved. While cure was achieved in 6 of 14 POM cases, 8 of them were exitus. Discussion and Conclusion. To avoid the severe consequences of postoperative meningitis, acting fast and adding IT/IVT methods to parenteral administration routes by considering the distribution of MDR microorganisms within the hospital while planning effective treatment will increase the clinical success.

Cardiopulmonary safety of propofol versus midazolam/meperidine sedation for colonoscopy: a prospective, randomized, double-blinded study.

BACKGROUND: Different levels of pharmacological sedation ranging from minimal to general anesthesia are often used to increase patient tolerance for a successful colonoscopy. However, sedation increases the risk of respiratory depression and cardiovascular complications during colonoscopy. OBJECTIVES: We aimed to compare the propofol and midazolam/meperidine sedation methods for colonoscopy procedures with respect to cardiopulmonary safety, procedure-related times, and patient satisfaction. PATIENTS AND METHODS: This was a prospective, randomized, double-blinded study, in which 124 consecutive patients undergoing elective outpatient diagnostic colonoscopies were divided into propofol and midazolam/meperidine sedation groups (n: 62, m/f ratio: 26/36, mean age: 46 ± 15 for the propofol group; n: 62, m/f ratio: 28/34, mean age: 49 ± 15 for the midazolam/meperidine group) by computer-generated randomization. The frequency of cardiopulmonary events (hypotension, bradycardia, hypoxemia), procedure-related times (duration of colonoscopy, time to cecal intubation, time to ileal intubation, awakening time, and time to hospital discharge) and patients' evaluation results (pain assessment, quality of sedation, and recollection of procedure) were compared between the groups. RESULTS: There were no statistically significant differences between the two groups with respect to demographic and clinical characteristics of the patients, the frequency of hypotension, hypoxemia or bradycardia, cecal and ileal intubation times, and the duration of colonoscopy. The logistic regression analysis indicated that the development of cardiopulmonary events was not associated with the sedative agent used or the characteristics of the patients. The time required for the patient to be fully awake and the time to hospital discharge was significantly longer in the propofol group (11 ± 8 and 37 ± 11 minutes, respectively) than the midazolam/meperidine group (8 ± 6 and 29 ± 12 minutes, respectively) (P = 0.009 and P < 0.001, respectively). The patient satisfaction rates were not significantly different between the groups; however, patients in the propofol group experienced more pain than patients in the midazolam/meperidine group (VAS score: 0.31 ± 0.76 vs. 0 ± 0; P = 0.002). CONCLUSIONS: Midazolam/meperidine and propofol sedation for colonoscopy have similar cardiopulmonary safety profiles and patient satisfaction levels. Midazolam/meperidine can be preferred to propofol sedation due to a shorter hospital length of stay and better analgesic activity.

The efficacy of intravenous patient-controlled remifentanil versus morphine anesthesia after coronary artery surgery.

OBJECTIVE: To compare the effect of remifentanil and morphine after coronary artery surgery in a patient-controlled analgesia (PCA) protocol. DESIGN: A prospective, randomized, double-blind clinical study. SETTING: Single institution, university hospital. PARTICIPANT: Sixty cardiac surgical patients undergoing primary coronary artery bypass graft (CABG) surgery. INTERVENTIONS: After the operation, patients were allocated to 1 of 2 groups. In the first group (group R, n = 30), the following intravenous PCA protocol was programmed: remifentanil infusion, 0.05 microg/kg/min; bolus, 0.25 microg/kg; and lockout time, 5 minutes. In the second group (group M, n = 30), the intravenous PCA protocol was as follows: morphine infusion, 0.3 mg/h; bolus, 1 mg; and lockout time, 5 minutes. In addition to intravenous opioids, paracetamol was administered during the study. In both groups, tramadol was added to the regimen after PCA had been terminated at 24 hours after surgery. In addition to tramadol and paracetamol, 10 mg of morphine sulfate was administered if the numeric rating scale (NRS) score for pain was 3 or more after the first postoperative day. Pain was assessed with an NRS in each patient at rest, while coughing, and during movement for 72 hours. Sedation levels were measured with the Ramsay sedation scale. Overall effectiveness of pain relief was evaluated with a 4-stage scale ("very good," "good," "moderate," or "bad"). MEASUREMENTS AND RESULTS: During coughing, the NRS values were statistically significantly lower in group R than they were in group M at 12 and 24 hours after surgery (median 1 vs 3 at 12 hours and 2 v 3.5 at 24 hours) (p < 0.05). On movement, NRS values were statistically significantly lower in group R than they were in group M at 12 hours after surgery (median 1 v 2.5) (p < 0.05). After the first 24 hours, the requirement for additional analgesia was similar in both groups. The overall effectiveness of pain relief was rated "very good" or "good"' in 87% of patients in group R and in 72% of patients in group M (p > .05). CONCLUSION: There was no difference in patient satisfaction between the 2 groups. On the basis of the reduction of pain scores (with cough and movement) at 1 or 2 postoperative time points, PCA-remifentanil infusion is a better analgesic technique; overall, both PCA techniques provided for effective pain scores (<3). In patients in whom PCA morphine is contraindicated after CABG surgery, PCA remifentanil is a safe alternative.