Comparison of the effectiveness of delirium evaluation tools in intensive care patients: pre-deliric versions 1 and 2, E-pre-deliric and ICDSC.

OBJECTIVE: This study's objective was to compare the effectiveness of the delirium prediction model (pre-deliric) and the early prediction model (E-pre-deliric) in delirium prediction in an intensive care unit (ICU) according to the Intensive Care Delirium Screening Checklist (ICDSC). Our aim was to determine these models' usability and cut-off values for ICU patients. PATIENTS AND METHODS: We classified the studied patients based on their highest ICDSC scores (tested twice daily) during ICU hospitalization. ICDSC scores of 4 or higher indicated positive results for delirium, whereas a score of 0 represented a negative result. We recorded the patients' demographic and clinical details and characteristics and calculated their E-pre-deliric and pre-deliric version 1 and version 2 scores. To evaluate the effectiveness of the models, we used receiver operating characteristic (ROC) curve analysis. RESULTS: Two hundred fifty patients (55.6% males, mean age 60.6±18.7 years) participated in this study. Their mean Acute Physiology and Chronic Health Evaluation II (APACHE-II) score was 17.0±9.1. Delirium was more common in men, patients of older ages, those with high APACHE-II scores, those who had undergone urgent admissions, those with histories of trauma, those with high urea or creatinine values and those who had undergone sedation or mechanical ventilation. Compared to patients who did not develop delirium, those who did had longer ICU stays and hospital stays, as well as greater mortality risk. The cutoff values for the patients' pre-deliric version 1, pre-deliric version 2 and E-pre-deliric scores were 38% [area under ROC (AUROC)=1], 22% (AUROC=1) and 28% (AUROC=1), respectively. CONCLUSIONS: This study is the first to compare the pre-deliric and E-pre-deliric prediction models. These models' validity and reliability were acceptable. They were clinically useful, and we identified their cut-off values. These models provide options for early detection of delirium and are easily applicable in the ICU.

Investigation of the effectiveness of prone ventilation in patients followed up for acute respiratory distress syndrome in the intensive care unit.

OBJECTIVE: Prone positioning has been found to improve oxygenation in most patients with acute respiratory distress syndrome (ARDS). The study aimed to investigate the effectiveness of the prone position in patients with ARDS. PATIENTS AND METHODS: The prone position is one of the ventilator techniques included in recent guidelines for acute respiratory distress syndrome. This study was a retrospective evaluation of the records of 100 ARDS patients who were administered prone position mechanical ventilation in our intensive care unit. All patients were placed in the prone position for a total of 12 hours per day at 4-hour intervals (supine-prone) while admitted to the intensive care unit. RESULTS: This study included 100 participants. These patients were divided into two groups as survivors [(n=38, 16 females, 22 males, median age: 60 (24-86)] and non-survivors [(n=62, 19 females, 43 males, median age: 64 (21-93)], according to their intensive care follow-ups. Acute physiology and chronic health evaluation (APACHE) II score, the sequential organ failure assessment score (SOFA), and inflammation markers were statistically significantly higher in the non-survivor group. Between the two groups, there was no statistically significant difference in terms of fundamental characteristics. In the sub-group evaluation of the subjects in patients with ARDS with and without novel coronavirus disease 2019 (COVID-19) groups, the patients in the COVID-19 (+) group were older, had shorter hospital stays, had higher APACHE II and SOFA scores, and higher rates of cardiovascular disease and sepsis. CONCLUSIONS: Applying prone-position mechanical ventilation in the cohorts of our patients with ARDS resulted in a demonstrable significant improvement in the oxygenation levels of our patients.

Magnetic resonance imaging evaluation of shoulder joint in patients with early stage of ankylosing spondylitis: A case-control study.

PURPOSE: The goal of this prospective study was to determine the prevalence of shoulder abnormalities on magnetic resonance imaging (MRI) in patients with ankylosing spondylitis (AS) who have normal shoulder X-ray examinations and no clinical shoulder abnormalities using a case-control study. MATERIALS AND METHODS: Fifty-three patients with AS according to the SpondyloArthritis international Society (ASAS) criteria were enrolled in the study. Fifty-three patients with no AS served as control subjects. Shoulder MRI examinations of patients in the two groups were analyzed and results were compared. RESULTS: In the patient group, 26/53 patients (49.1%) demonstrated one or two of the defined pathological shoulder MRI findings, whereas 5/53 patients (9.4%) had similar findings in the control group. In the patient group, 11/53 patients (20.8%) had enthesal bone marrow edema, 19/53 patients (35.8%) had increased synovial fluid, 8/53 patients (15.1%) had tendinitis, and 2/53 patients (3.8%) had bursitis. There was statistically significant difference between the patient and control groups in terms of prevalence of enthesal bone marrow edema, increase in synovial fluid, and tendinitis. CONCLUSION: Shoulder involvement is often overlooked in AS. Knowledge of the early-stage findings of the shoulder involvement due to AS is important to establish an early diagnosis and select treatment options.

'Multimodal' approach to management of prostate biopsy pain and effects on sexual function: efficacy of levobupivacaine adjuvant to diclofenac sodium - a prospective randomized trial.

We assessed the analgesic efficacy of levobupivacaine when administered as an adjuvant to diclofenac sodium in prostate biopsy pain management and effects of prostate biopsy on sexual function. Ninety patients underwent transrectal ultrasound (TRUS)-guided biopsy of the prostate and were randomly assigned to three groups: group D received diclofenac sodium suppository; Group L received periprostatic injection of levobupivacaine; group DL received diclofenac suppository and levobupivacaine in addition. Patients were asked to use a visual analogue scale score (VAS) questionnaire about pain after 10 core prostate biopsy. Sixty-two patients reported to be prostate cancer-free underwent further evaluation with the International Index of Erectile Function-5 (IIEF-5) questionnaire at 1 and 3 months after biopsy. Mean pain scores during prostate biopsy were significantly lower in group DL and were superior to the group L and group D (P < 0.001). Mean IIEF-5 score prior to biopsies was significantly higher when compared with the mean IIEF-5 score 1 month after biopsy (P < 0.0001). Mean IIEF-5 scores 1 month after biopsy were significantly lower when compared with the mean IIEF-5 scores 3 months after biopsy (P = 0.002). TRUS-guided prostate biopsies have a statistically significant impact on short-term erectile function, but this difference is not clinically significant; however, medium-term erectile function is not affected both statistically and clinically.

Late-onset pulmonary edema due to propofol.

Pulmonary edema after the administration of propofol has rarely been reported. In this case report, we describe pulmonary edema due to the administration of propofol during a Cesarean section and while in the intensive care unit. The skin tests demonstrated strong positive weal and flare reactions to propofol. The patient was treated successfully with mechanical ventilatory support. This report emphasizes that this fatal complication may be seen with propofol and underlying mechanisms and therapeutic approach are discussed.

Effects of halothane, isoflurane, and sevoflurane on lipid peroxidation following experimental closed head trauma in rats.

BACKGROUND: In a rat closed head trauma model we examined both the time course of lipid peroxidation and the effects of halothane, isoflurane, and sevoflurane on it by analysis of malondialdehyde (MDA) formation. METHODS: Animals were divided randomly into five groups: sham-operated (SO), n=18; control-closed head trauma to left frontal pole, n=18; closed head trauma model+halothane, n=18; closed head trauma model+isoflurane, n=18; and closed head trauma model+sevoflurane, n=18. Halothane, isoflurane, or sevoflurane were applied 15 min after trauma for 30 min. Rats were euthanized 1,3, and 5 h after the inhalation agents. Brain tissue samples were taken 5 mm from the left and right frontal poles. MDA was considered to reflect the degree of lipid peroxidation. RESULTS: MDA concentrations were greater in the control, halothane, sevoflurane, and isoflurane groups than in SO animals (P<0.001). No statistical difference between the hemispheres was found between the halothane, isoflurane, or sevoflurane groups, but MDA levels were lower with isoflurane than in the halothane, sevoflurane, and control groups at 1, 3, and 5 h (P<0.001). MDA levels were higher as compared with the halothane and sevoflurane groups at 1 h but not at 3 or 5 h (P<0.001). CONCLUSION: MDA levels with the isoflurane group were lower than in the other trauma groups, which suggest that isoflurane, given after closed head trauma, might be protective against lipid peroxidation of cerebral injury.

Gabapentin reduces cardiovascular responses to laryngoscopy and tracheal intubation.

BACKGROUND AND OBJECTIVE: We have compared the effects of gabapentin on arterial pressure and heart rate at induction of anaesthesia and tracheal intubation in a randomized double-blind study. METHODS: Ninety normotensive patients (ASA I) undergoing elective surgery were divided into three groups of 30 patients each. Patients received oral placebo (Group I), 400 mg of gabapentin (Group II) or 800 mg of gabapentin (Group III) 1 h prior to surgery in the operating theatre. After induction of anaesthesia heart rate and mean arterial pressure were recorded at baseline 1, 3, 5, 10 and 15 min after intubation. RESULTS: Patients receiving placebo and 400 mg gabapentin showed a significant increase in blood pressure and heart rate associated with tracheal intubation compared to baseline levels and Group III. There was significant decrease in heart rate and arterial pressure in Group III after intubation 1, 3, 5 and 10 min (P < 0.001, P < 0.001, P < 0.05 and P < 0.05, respectively) compared to Groups I and II. CONCLUSION: Given 1 h before operation gabapentin 800 mg blunted the arterial pressure and heart rate increase in first 10 min due to endotracheal intubation. Oral administration of gabapentin 800 mg before induction of anaesthesia is a simple and practical method for attenuating pressor response to laryngoscopy and tracheal intubation after standard elective induction.

A comparison of the effect on gastric emptying of propofol or dexmedetomidine in critically ill patients: preliminary study.

BACKGROUND: Propofol and dexmedetomidine are widely used for sedation in the intensive care unit yet there are limited data on its effects on gastric motility. In our preliminary study, we examined whether or not any effect of propofol and dexmedetomidine on gastric emptying is preserved in critically ill patients. METHODS: Twenty-four critically ill, enterally fed adult patients each received enteral feeding via a nasogastric tube at 50 mL h-1 throughout the 5-h study period. Either propofol 2 mg kg-1 h-1 (n = 12, Group P) or dexmedetomidine 0.2 microg kg-1 h- (n = 12, Group D) was given intravenously over 5 h. Gastric motility was measured indirectly by analysis of the absorption over time of 1.5 g of paracetamol administered into the stomach at the start of the study period. At the beginning and end of the study, residual gastric volume and pH of residual gastric fluid were measured. RESULTS: Gastric residual volume measured at the end of propofol infusion (19.33 +/- 11.33) was found to be higher when compared with the volume measured before infusion (11.33 +/- 4.84) and after dexmedetomidine infusion (9.17 +/- 4.54). But, there was no difference between groups in gastric emptying time (AUC120 894.53 +/- 499.39 vs. 1113.46 +/- 598.09 propofol and dexmedetomidine groups, respectively). CONCLUSION: In our study, gastric residual volume measured at the end of propofol infusion was found to be higher when compared with the volume measured before infusion and after dexmedetomidine infusion. There was no difference between groups in gastric emptying time.

Gabapentin: an alternative to the cyclooxygenase-2 inhibitors for perioperative pain management.

The cyclooxygenase-2 inhibitor, rofecoxib, was a popular analgesic adjuvant for improving perioperative pain management. We designed this placebo-controlled study to test the hypothesis that gabapentin could produce similar reductions in postoperative pain and opioid analgesic usage, thereby improving the recovery process. One hundred patients undergoing abdominal hysterectomy procedures were randomly assigned to one of four treatment groups: 1) control group received placebo capsules and pills before and for 2 days after surgery, 2) rofecoxib group received 50 mg/d PO and placebo capsules before and after surgery and, 3) gabapentin group received 1.2 g/d PO and placebo pills before and after surgery, and 4) combination group received rofecoxib 50 mg/d and gabapentin 1.2 g/d PO before and after surgery. The anesthetic technique was standardized and the postoperative assessments included verbal rating scales for pain and sedation, IV morphine usage, quality of recovery assessment, recovery of bowel function, resumption of normal activities, and patient satisfaction with their pain management. Postoperative pain scores were significantly reduced in all three analgesic treatment groups (versus control group). Compared with the control group, patient-controlled analgesia morphine usage was also significantly reduced in the 3 analgesic treatment groups at 1, 8, 24, and 30 h after surgery. Total PCA morphine usage was decreased by 43%, 24%, and 50% in groups 2, 3, and 4, respectively, compared with group 1. Oral analgesic consumption was also smaller in groups 2 and 4 when compared with the control group. The opioid-sparing effects of rofecoxib and gabapentin lead to a faster recovery of bowel function. Discharge eligibility scores in groups 2 and 4 were improved at 24 h when compared with group 1, and patient satisfaction with postoperative pain management was significantly higher at 24 h in all 3 analgesic treatment groups. At the 72 h follow-up, all of the patients in group 4 were completely satisfied with their pain management compared with only 32%, 64%, and 72% in groups 1, 2, and 3, respectively. Gabapentin (1.2 g/d PO) appears to be an acceptable alternative to rofecoxib (50 mg/d PO) for short-term use as an adjuvant to opioid analgesics in patients undergoing lower abdominal surgery.

The addition of sufentanil, tramadol or clonidine to lignocaine for intravenous regional anaesthesia.

This study was designed to evaluate the effect of sufentanil, tramadol or clonidine added to lignocaine for intravenous regional anaesthesia. We investigated the onset and duration of sensory and motor block, the quality of the anaesthesia, intraoperative and postoperative haemodynamics, intraoperative and postoperative pain and sedation. Sixty patients undergoing ambulatory hand surgery received intravenous regional anaesthesia using 35 ml of 0.5% lignocaine and either 5 ml saline (Group L, n = 15); sufentanil 25 micrograms (Group LS, n = 15); tramadol 100 mg (Group LT, n = 15) or clonidine 1 microgram.kg-1 (Group LC, n = 15). Before and after the tourniquet application, haemodynamic data, tourniquet pain, sedation scores and analgesic use were recorded. After tourniquet deflation, haemodynamic data, pain and sedation, time to first analgesic requirement and analgesic use were noted. There were no differences among groups in intraoperative haemodynamic data, the time to recovery of sensory block, the onset and the recovery of motor block, sedation scores or postoperative pain. Compared to the other groups, in Group L the onset of sensory block was longer, the time to initial tourniquet pain was shorter and the intraoperative tourniquet pain scores and use of the opioid were higher (P < 0.05). The quality of anaesthesia in Groups LS, LT and LC was better than in Group L (P < 0.05). In conclusion, the addition of sulfentanil, tramadol or clonidine to lignocaine shortened the onset of the sensory block, delayed the onset time of the tourniquet pain and reduced the intraoperative consumption of opioid, but did not affect postoperative pain.

Effect of aminophylline on bispectral index.

BACKGROUND: The aim of the present study was to investigate the effects of aminophylline on BIS as well as clinical recovery in patients anesthetized with sevoflurane. METHODS: Sixty patients with status of ASA I-II scheduled for elective surgery were enrolled in this study. Anesthesia was induced by 2 mg kg(-1) of propofol and 0.5 mg kg(-1) of atracurium, maintained with 1:1 ratio of oxygen and nitrous oxide and 2-2.5% sevoflurane, keeping BIS values at 50 +/- 5. During the last 30 min of the operation no muscle relaxant was given and anesthesia was continued without decreasing anesthetic concentration. After sevoflurane discontinuation, saline was given to Group P, and 5 mg kg(-1) of aminophylline was given to Group A. Bispectral index values, heart rate, blood pressure and oxygen saturation were determined in all the patients before and every min after injection of the test drug for 15 min. The following variables were measured in both groups: eye opening, extubation time, response to command, Aldrete scores, and performing three simple arithmetic calculations. RESULTS: Between groups there was no statistically significant difference in mean arterial blood pressure, SpO2 and anesthesia time. Heart rate was found to be statistically higher (P < 0.001) at 2 to 6 min in Group A when compared with group P. Eye opening, verbal response, extubation and arithmetic calculation times were significantly shorter (P < 0.001) in Group A. Bispectral index scores were significantly higher in Group A at 1 to 12 min after aminophylline injection when compared with placebo (P < 0.001). CONCLUSION: Recovery from sevoflurane anesthesia and BIS scores are improved in early period when aminophylline is given at emerging from anesthesia.

Comparison of oral dolasetron and ondansetron in the prophylaxis of postoperative nausea and vomiting in children.

BACKGROUND AND OBJECTIVE: In a randomized, placebo-controlled, double-blind trial, we compared the efficacy of oral dolasetron and ondansetron in preventing postoperative nausea and vomiting in children after various surgical operations. METHODS: Children were assigned randomly to one of three groups (each contained 50 children) to receive dolasetron 1.8 mg kg(-1) or ondansetron 0.15 mg kg(-1) orally, or a placebo. All children received methylene blue capsules (10 mg) orally as an indicator before the induction of anaesthesia. Postoperatively, contamination of the mouth and the endotracheal tube by methylene blue was recorded, and postoperative nausea and vomiting was recorded for 0-1, 1-24 and 0-24 h. Metoclopramide (0.1 mg kg(-1)) intravenously was used as the rescue antiemetic. RESULTS: In the 0-1 h period after operation, there were no differences between the groups. In the 1-24 h period, dolasetron was significantly better than placebo (nausea 8 versus 24%; vomiting 4 versus 20%; total nausea and vomiting scores 16 versus 48%). Over the 0-24 h period, both dolasetron and ondansetron were significantly better than placebo (nausea 16 versus 26 versus 40%), vomiting (8 versus 16 versus 30%), and total nausea and vomiting scores (32 versus 48 versus 78%). There were no significant differences between dolasetron and ondansetron. There was no important methylene blue contamination, and little use of rescue metoclopramide. There were no important adverse events. CONCLUSIONS: Prophylactic oral dolasetron and ondansetron were effective in reducing postoperative nausea and vomiting in children.

The prevention of pain from injection of rocuronium by magnesium sulphate, lignocaine, sodium bicarbonate and alfentanil.

We compared the efficacy of magnesium sulphate, lignocaine, sodium bicarbonate or alfentanil in minimizing pain due to injection of rocuronium in 250 patients. After tourniquet application on the forearm, the patients were given saline, magnesium sulphate, lignocaine, sodium bicarbonate 8.4% or alfentanil, diluted into a 3 ml solution. The occlusion was released after 20 seconds, and rocuronium was injected over 10 to 15 seconds. The patients were observed and asked immediately if they had pain in the arm and the response was assessed. Reactions such as discomfort and pain, withdrawal of the hand and screaming after the administering of the rocuronium were recorded as side-effects and patients were reassessed at 24 hours postoperatively. We concluded that magnesium sulphate, lignocaine, sodium bicarbonate or alfentanil decreased the level of rocuronium injection pain. Of these drugs, magnesium sulphate, lignocaine and sodium bicarbonate were the most effective while alfentanil was the least effective.

The influence of methylene blue infusion on cytokine levels during severe sepsis.

The aim of our study was to assess the effect of methylene blue infusion on plasma levels of cytokines in severe sepsis. In a prospective, randomized, double-blind, placebo-controlled study, patients received either methylene blue 0.5 mg.kg-1.h-1 (MB group, n = 15) or similar volume of isotonic saline (control group, n = 15) i.v. for 6 hours. Plasma concentrations of tumour necrosis factor-alpha, interleukin-1, interleukin-2 receptor, interleukin-6, interleukin-8 were measured by sensitive immunoassays at basal (15 min before start of the study), immediately after, and at 24 and 48 hours after methylene blue infusion. We evaluated haemodynamic parameters (mean arterial pressure, heart rate), blood gases, methaemoglobin levels, and biochemical parameters at the same time. Methylene blue administration had no significant effect on plasma cytokine levels, blood gases and biochemical parameters. When compared to placebo infusion in controls, methylene blue administration resulted in significantly higher mean arterial pressure (85 +/- 14 mmHg vs 74.1 +/- 10.3 mmHg; P < 0.01), and methaemoglobin levels (1.06 +/- 0.22% vs 0.9 +/- 0.05%; P < 0.05). Furthermore, comparison with baseline levels revealed significantly increased both mean arterial pressure (85 +/- 14 mmHg and 74.1 +/- 10.2 mmHg; P < 0.05) and methaemoglobin levels (1.06 +/- 0.22% and 0.88 +/- 0.06%; P < 0.05) in MB group. There was no difference in mortality rates between the groups. We found that methylene blue infusion did not change cytokine levels or outcome in severe sepsis. The administration of methylene blue, however, resulted in a transient increase in arterial pressure. Because of the limited size of the present study, and the short period of observation, our findings need to be confirmed by larger clinical trials of methylene blue infused in a dose-titrated manner.

Genotoxicity of waste anaesthetic gases.

BACKGROUND AND AIM: The possibility of a potential mutagenic or carcinogenic action of chronic exposure to low concentrations of inhalational anaesthetics has been previously studied, with conflicting results. The purpose of this study was to assess whether occupational exposure to waste anaesthetic gases increases genotoxic risk. We examined peripheral lymphocytes from anaesthetists for both sister chromatid exchange (SCE) and for cells with high-frequency SCEs (HFCs). METHOD: A group of 16 non-smoking anaesthetists with occupational exposure to anaesthetic gases and a sex- and age-matched group matched 16 non-smoking matched physicians without occupational exposure to anaesthetic gases were studied. The participants were also selected on the basis of similar responses to a questionnaire assessing risk of genotoxicity relating to other aspects of life. RESULT: SCEs, and HFC percentages obtained from the exposed anaesthetists (6.6+/-2.4 and 12.2+/-15.9) were greater but not statistically significantly so than in the reference group (5.2+/-1.6 and 5.9+/-10.0). CONCLUSION: This study does not support the existence of an association between occupational exposure to waste anaesthetic gases and an increase in SCEs in lymphocytes. The nature of our anaesthesia practice suggests exposure was likely to be low. It should be noted that some anaesthetic gases produce lesions that can be efficiently repaired in mitogen-stimulated lymphocytes in vitro but not in circulating lymphocytes.