Easy method to determine fluid responsiveness in septic shock patients: end-tidal CO2 - a prospective observational study.

BACKGROUND: In critically ill patients, especially those with septic shock, fluid management can be a challenging aspect of clinical care. One of the primary steps in treating patients with hemodynamic instability is optimizing intravascular volume. The Passive Leg Raising (PLR) maneuver is a reliable test for assessing fluid responsiveness, as demonstrated by numerous studies and meta-analyses. However, its use requires the measurement of cardiac output, which is often complex and may necessitate clinician experience and specialized equipment. End-Tidal Carbon Dioxide (ETCO2) measurement is relatively easy and is generally stable under steady metabolic conditions. It depends on the body's CO2 production, diffusion of CO2 from the lungs into the bloodstream, and cardiac output. If the other two parameters (metabolic conditions and minute ventilation) are constant, ETCO2 can provide information about cardiac output. The aim of the present study is to investigate the sensitivity of ETCO2 measurement in demonstrating fluid responsiveness. METHODS: All patients diagnosed with septic shock and meeting the inclusion criteria were subjected to a passive leg raising test, and cardiac outputs were measured by echocardiography. An increase in cardiac output of 15% or more was considered indicative of the fluid responder group, while patients with an increase below 15% or no increase were classified as the non-responder group. Patients' intensive care unit admission diagnoses, initial laboratory parameters, tidal volume, minute volume before and after the PLR maneuver, mean and systolic blood pressure, heart rate, Pulse Pressure Variation (PPV) values, and ETCO2 values were recorded. RESULTS: Before and after the ETCO2 test, there was no statistically significant difference between the two groups. However, the change in ETCO2 (ΔETCO2) was significantly higher in the responder group. In the non-responder group, ΔETCO2 was 2.57% (0.81), whereas it was 5.71% (2.83) in the responder group (p<0.001). Receiver Operating Characteristic (ROC) analysis was performed for ΔETCO2, baseline Stroke Volume Variation (SVV), ΔSVV, baseline Heart Rate (HR), ΔHR, baseline PPV, and ΔPPV to predict fluid responsiveness. ΔETCO2 predicted fluid responsiveness with a sensitivity of 85% and a specificity of 86% when it was 4% or higher. When ΔETCO2 was 5% or higher, it predicted fluid responsiveness with a specificity of 99.3% and a sensitivity of 75.5%, with an Area Under the Curve (AUC) of 0.89 (95% confidence interval, 0.828-0.961). CONCLUSION: This study demonstrates that in septic patients, ETCO2 during the PLR test can indicate fluid responsiveness with high sensitivity and specificity and can be used as an alternative to cardiac output measurement.

Does Maintaining a Targeted Abdominal Perfusion Pressure Reduce Renal Damage in Patients with Septic Shock?: A Randomized, Controlled, and Open-label Study

Background: Increased intra-abdominal pressure (IAP) in patients admitted to the intensive care unit leads to reduced abdominal perfusion pressure (APP), causing circulatory insufficiency and organ failure. Aims: To investigate the effect of maintaining a targeted APP on renal injury and the effect of increased IAP on the mortality rate in patients with septic shock. Study Design: Randomized, controlled, open-label study. Methods: A total of 72 patients were randomly divided into two groups (MAP65 or APP60). The MAP target for patients in the MAP65 group (n = 36) was 65 mmHg according to the Surviving Sepsis Guidelines. In the APP60 group (n = 36), the target APP was set to > 60 mmHg. The glomerular filtration rate (GFR), inotrope consumption, and IAP were recorded daily. The need for renal replacement therapy, decrease in GFR, and 30- and 90-day mortality rates were compared between the two groups. Results: In both the groups, the IAP was statistically similar (p = 0.458). The decreased in GFR was similar in both groups during the first 2 days. From day 3, there was a more statistically significant rapid decline in GFR in the MAP65 group than in the APP60 group. The GFR p-values on the 3rd, 4th, and 5th days were 0.040, 0.043, and 0.032, respectively. Eight patients (22.2%) in the MAP65 group and three patients (8.3%) in the APP group required renal replacement therapy (p = 0.101). The 30-day mortality rates in the MAP65 and APP60 groups were 61.1%, and 47.7%, respectively (p = 0.237). The 90-day mortality rates in the MAP65 and APP60 groups were 66.7% and 66.7%, respectively (p = 1). Conclusion: Setting an APP target limited the reduction in GFR. The mortality rates were similar in the two groups and there was no difference in the rate of end-stage renal failure between the groups.

The Efficacy of Erector Spinae Plane Block for Patients Undergoing Percutaneous Nephrolithotomy.

Objective: Percutaneous nephrolithotomy (PCNL) is accompanied by somatic and visceral pain intraoperatively and postoperatively. However, pain management strategies lack a decisive consensus. Erector spinae plane block (ESPB) is a novel paraspinal fascial block that can be used in PCNL patients, and we aimed to investigate whether ESPB will reduce intraoperative and postoperative opioid consumption and postoperative pain scores in PCNL patients. Methods: The study was randomized, controlled, and open-label. Two groups were formed as the control group (GCont) and block group (Gblock), and patients received total intravenous anaesthesia. GBlock received an ESPB catheter in addition in the prone position. Intraoperative parameters and infusion doses, postoperative rescue analgesic doses, and pain scores were recorded. The primary endpoint was intraoperative analgesic consumption, and the secondary endpoints were postoperative pain scores and analgesic consumption. Results: Sixty-four patients were analyzed. Remifentanil consumption of GCont was found to be significantly higher (GBlock: 0.0865 ± 0.030 vs GCont: 0.1398 ± 0.034, µg kg-1 min-1, P < 0.001). The control group reported higher pain scores between the 30th min and 24th hours and needed more analgesics between the 1st and 6th hours postoperatively. GBlock received local anaesthetics via ESPB catheter before nephrostomy tube removal and fewer patients needed analgesics [5 patients (15.6%) vs. 28 patients (87.5%), P < 0.001]. GCont consumed more tramadol postoperatively (262.5 mg vs. 75 mg, P < 0.001). Conclusion: We found that ESPB reduced intraoperative opioid consumption. It also reduced the need for rescue analgesia and postoperative pain scores during nephrostomy tube removal. We concluded that the ESPB catheter may effectively be used in analgesia management during and after PCNL operations.

Effectiveness of Using a Gelatine-Based Model in Ultrasonography-guided Jugular Central venous Catheter Placement Training: A Randomised Clinical Trial.

OBJECTIVE: To evaluate the effectiveness of using a gelatine-based model, that can be prepared easily and at a low cost, compared to training without a model in ultrasonography (USG) guided internal jugular venous catheter placement training. STUDY DESIGN: An open-label, randomised clinical trial. PLACE AND DURATION OF STUDY: (UHS) Izmir Bozyaka Training and Research Hospital, Izmir, Turkey, from 1st to 30th July 2019. METHODOLOGY: Analysis was conducted with the data of 48 participants (resident physicians-RP). Group 1 (n: 26) received imaging training with USG on a human subject and then performed needle insertion training on the gelatine-based jugular vein model with the USG guidance. Group 2 (n: 22) received the same imaging training with USG but did not perform needle insertion training. Evaluation of the participants included successful long axis vein imaging time, successful in-plane needle imaging, number of changes in needle angles, the total number of punctures, successful vein puncture time, successful catheterization time, and catheterization success with the gelatine-based test manikin. RESULTS: Comparison of the rates of successful in-plane needle imaging (Group 1: 92.3%, Group 2: 59.1%; p = 0.006), catheterization success (Group 1: 92.3%, Group 2: 59.1%; p = 0.006), successful catheterisation time (Group 1: 77.5 sec, Group 2: 152.5 sec; p = 0.026), and total complications (Group 1: 3.8%, Group 2: 31.8%; p = 0.010) demonstrated that the model-trained RPs were significantly more successful. CONCLUSION: The study results suggest that the use of a gelatine-based model in USG-guided central jugular vein catheterisation training can be an effective method to reduce complications. KEY WORDS: Central venous catheter, Medical training, Simulation-based training, Ultrasonography.

Success of the Cytokine Absorption Therapies in COVID-19 Patients Diagnosed with Cytokine Release Syndrome.

OBJECTIVE: To compare the effects of cytokine absorption therapy with a resin-based cytokine absorption cartridge to tocilizumab treatment in critically ill COVID-19 patients diagnosed with cytokine release syndrome (CRS). STUDY DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: University of Health Sciences, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey from April 2020 to April 2021. METHODOLOGY: Twenty-four intensive care unit (ICU) patients were included in the study. Inclusion criteria were diagnosis of severe COVID-19, diagnosis of CRS and age of older than 18 years. Exclusion criteria were pregnancy, malignancy, prior COVID-19 vaccination, procalcitonin levels higher than 2 ng/ml and life-threatening comorbidities before ICU admission. Twelve patients received tocilizumab and the other 12 patients received cytokine absorption therapy. The groups were compared for clinical outcomes and inflammatory markers (CRP, fibrinogen, ferritin, D-dimer). RESULTS: Inflammatory markers showed smilar changes with both treatments, mostly toward improvement, on the same post-treatment days. The mortality rate was 58% (seven patients) in the cytokine absorption group and 50% (six patients) in the tocilizumab group (p = 0.682). CONCLUSION: It was found that the cytokine absorption therapy reduces inflammatory mediators in intubated and critically ill Covid-19 patients similar to tocilizumab treatment, and both treatments have comparable clinical outcomes. KEY WORDS: SARS-CoV-2, Cytokine release syndrome, Chemokines, Absorption, Tocilizumab.