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.

Risks of Polymyxin B Nephrotoxicity and Its Precursors in the Intensive Care Unit: A Retrospective Cohort Study.

BACKGROUND AND AIM: Polymyxin group antibiotics constitute a part of our limited arsenal in the treatment of multidrug-resistant gram-negative bacteria. However, their use is limited especially due to nephrotoxicity and other side effects. In this study, we primarily aimed to determine the effect of polymyxin B on the rate of nephrotoxicity in critically ill patients, and secondly to identify the factors that facilitate nephrotoxicity caused by polymyxin B. MATERIALS AND METHODS: The study was designed as a retrospective cohort study and conducted by scanning patients aged 18 years or older who had been admitted to our intensive care unit (ICU) in 2022 and treated with polymyxin B for at least 72 hours. Patients without chronic renal failure and acute kidney injury (AKI) before starting polymyxin B therapy were included and AKI was examined after the use of polymyxin B. The patients were then divided into two groups, those with AKI and those without AKI. We tried to find factors that may facilitate AKI by comparing the two groups. RESULTS: Of the patients, 26 were female and 34 were male. In 21 of the patients (35%), renal damage of varying degrees developed; these patients belonged to the nephrotoxicity (NT) group, while the rest belonged to the non-nephrotoxicity (non-NT) group. We found that advanced age (p=0.008), low baseline GFR (p=0.01), baseline creatinine (p=0.006), BMI (p=0.011), concomitant diseases (p<0.001), and days of use of polymyxin B (p=0.006) were statistically different between the two groups. In multivariate analysis of univariate analysis, we found that duration of polymyxin B use, BMI, and advanced age were independent risk factors for AKI development. CONCLUSION: We found that 21 (35%) of 60 intensive care unit patients who had no previous history of kidney injury developed kidney injury after being treated with polymyxin B. We identified advanced age, high BMI, and duration of polymyxin B use as independent risk factors. Therefore, we recommend close monitoring of renal function and prompt intervention, particularly in patients with risk factors, during polymyxin B use.

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.

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.

Diagnostic value of procalcitonin and C reactive protein for infection and sepsis in elderly patients.

BACKGROUND: Biomarkers are useful for diagnosing infection and sepsis in adults, but data are limited in elderly patients. Furthermore, clinical symptoms of infection in elderly patients are usually atypical or unclear. We aimed to assess the usefulness of PCT, CRP, and WBC in distinguishing elderly patients infected with sepsis from infected without sepsis and those with no-infection. We also aimed to find a cut-off value for diagnosing sepsis and infection without sepsis in elderly critically ill patients. METHODS: In this single-center and prospective observational study, patients older than 65 years were enrolled. Serum levels of PCT, CRP, and WBC were measured within 24 h. Patients were allocated into sepsis (S), infected without sepsis (IWS), and noinfection (NI) groups. Data were analyzed with Mann-Whitney U test and Kruskal-Wallis test. RESULTS: We analyzed 188 patients with a mean age of 77.05 ± 7.4 in the study; 95 (50.5%) of them were women. Sixty-four (34%) of whom were classified as IWS, 29 (15%) as S, and 95 (50.5%) as NI group. There were significant differences in the PCT, CRP levels between the IWS and NI, S and NI (p < 0.001, p < 0.001, p < 0.001, p < 0.01, respectively). The PCT levels were significantly different when the NI group was compared to IWS (p < 0.001) and S (p < 0.001) groups. The CRP levels were also different when the NI group was compared to both IWS (p < 0.001) and S (p < 0.001). The PCT cut-off values were 0.485 µ/L and 1.245 µg/L for the discrimination of patients with IWS and S, respectively. The cut-off values of CRP level were 59.45 mg/L and 57.50 mg/L for infected without sepsis and sepsis, respectively. DISCUSSION: PCT was found to be a more valuable marker than CRP and WBC for the discrimination of elderly patients with infected without sepsis and sepsis.

Current Statement of Intensive Care Units in Turkey: Data obtained from 67 Centers.

OBJECTIVES: We aimed to obtain information about the characteristics of the ICUs in our country via a point prevalence study. MATERIAL AND METHODS: This cross-sectional study was planned by the Respiratory Failure and Intensive Care Assembly of Turkish Thoracic Society. A questionnaire was prepared and invitations were sent from the association's communication channels to reach the whole country. Data were collected through all participating intensivists between the October 26, 2016 at 08:00 and October 27, 2016 at 08:00. RESULTS: Data were collected from the 67 centers. Overall, 76.1% of the ICUs were managed with a closed system. In total, 35.8% (n=24) of ICUs were levels of care (LOC) 2 and 64.2% (n=43) were LOC 3. The median total numbers of ICU beds, LOC 2, and LOC 3 beds were 12 (8-23), 14 (10-25), and 12 (8-20), respectively. The median number of ventilators was 12 (7-21) and that of ventilators with non-invasive ventilation mode was 11 (6-20). The median numbers of patients per physician during day and night were 3.9 (2.3-8) and 13 (9-23), respectively. The median number of patients per nurse was 2.5 (2-3.1); 88.1% of the nurses were certified by national certification corporation. CONCLUSION: In terms of the number of staff, there is a need for specialist physicians, especially during the night and nurses in our country. It was thought that the number of ICU-certified nurses was comparatively sufficient, yet the target was supposed to be 100% for this rate.

Low levels of vitamin D are associated with nosocomial infections but not with short-term mortality in critically ill patients

Background/aim: A prospective observational study was conducted to determine the relationship between vitamin D deficiency and nosocomial infections among intensive care unit (ICU) patients. Materials and methods: Demographic data, season of admission, vitamin D levels at admission, premorbid lifestyle scores, comorbid conditions, and admission diagnosis were recorded in 306 ICU patients. Infections that developed at least 48 h after admission to the ICU were the primary outcome, and ICU, hospital, and 1-year mortality were the secondary outcomes. Infections were evaluated for 28 days, and for the entire duration of ICU stay independently. Multiple logistic regression analysis was performed to control for confounding factors that were statistically significant in univariate analysis. Results: All infection and mortality rates were significantly higher in low 25 (OH) D groups in univariate analysis. After adjusting for confounding factors, infection rates remained higher in the deficient group. However, ICU and hospital mortality did not show any statistically significant difference between deficient and nondeficient groups. Only the 1-year mortality rate was significantly higher among patients with 25 (OH) D levels less than 20 ng/mL. Conclusion: Low vitamin D levels are significantly associated with ICU-related infections but not with ICU or hospital mortality. However, further studies are needed to identify the role of vitamin D deficiency in predicting ICU outcomes.

Risk factors for colistin-associated nephrotoxicity and mortality in critically ill patients

Background/aim: Colistin is gaining popularity against multidrug-resistant bacteria. The primary concern with colistin is its nephrotoxicity (NT). The aim of this study was to evaluate the incidence and risk factors for NT and to evaluate the risk factors for mortality in the toxicity group. Materials and methods: NT was defined according to the RIFLE criteria. Data of patients who did or did not develop NT were compared. Positive and negative predictive values, risk ratio, and correlation coefficients were calculated. Results: NT was seen in 39 patients (70%). Hypoalbuminemia, old age, and the use of vasopressors (VPs) were associated with NT. The use of VPs had the highest positive predictive value, while age had the highest negative predictive value and risk ratio. The only variable that was associated with mortality in the toxicity group was VP use. Conclusion: Aging, hypoalbuminemia, and the use of VPs were shown to be risk factors for NT, while the last of these was the only significant risk factor for mortality in the toxicity group.

[Incidence of chronic pain after ingunial hernia repair]. / Inguinal herni onarimi sonrasi kronik agri insidansi.

OBJECTIVES: The percentage of chronic pain in adults having inguinal hernia repair is 5-35%. Although this pain is thought to be related to some reasons, there is not an exact conclusion about this. In this study, the aim was to point out the incidence of chronic pain after inguinal hernia repair and determination of the risk factors. METHODS: Two hundred and four patients having inguinal hernia surgery between January 2011 and December 2012 were included into this study. The patients' pain was measured with VAS within 24 hours and at the third and the sixth month after surgery. The patients whose VAS was >3 three months after surgery were evaluated to have chronic pain. RESULTS: The incidence of pain continuing 3 months after surgery was 18.6% and 11.2% six months after surgery. 78.3% of the patients had already had pain before surgery, and in 28% of them, chronic pain had evolved. The measure of VAS within 24 hours postoperatively was found higher in patients who developed chronic pain (3.13 ± 1.12/1.71 ± 1.27). 5.2% of the patients had re-operation for reparation and chronic pain developed in all. Chronic pain was neuropathic in 48% of the patients, and its severity was moderate. CONCLUSION: The incidence of chronic pain after inguinal hernia repair was found %18, compatible with similar studies. Compared with other risk factors, preoperative pain, postoperative severe acute pain and reoperations were thought to be the most important risk factors for the development of chronic pain.

A prospective randomized double-blind study on the effects of the temperature of irrigation solutions on thermoregulation and postoperative complications in percutaneous nephrolithotomy.

PURPOSE: This study investigated the effects of irrigation solutions, administered at either 21 or 37 °C in percutaneous nephrolithotomy (PCNL), on hypothermia and related postoperative complications such as late emergence and late recovery from anesthesia, shivering, lactic acidosis, and excess bleeding. METHODS: Sixty patients who were scheduled for PCNL were enrolled in this prospective randomized double-blind study. Irrigation solutions at room temperature were administered to patients in group R (30 patients), and warmed irrigation solutions were administered to patients in group W (30 patients). The two groups were compared for core and peripheral body temperature, incidence of hypothermia, duration of emergence from anesthesia, duration of recovery from anesthesia, shivering, lactic acidosis, and hemoglobin levels. RESULTS: Hypothermia was incident in 19 patients (63.3 %) in group W and in 27 patients (90 %) in group R at the end of surgery. The difference between the initial and the final core body temperature was 0.9 ± 0.6 °C group W and 1.4 ± 0.7 °C in group R (p = 0.003). The extubation time was 4.4 ± 2.2 min in group W and 5.9 ± 3 min in group R (p = 0.032). Shivering was detected in seven patients (23.3 %) in group W and in 15 patients (50 %) in group R (p = 0.032). The recovery duration was 49.8 ± 24.6 min in group W and 67.6 ± 33.9 min in group R (p = 0.023). CONCLUSIONS: Administration of irrigation solutions at room temperature in PCNL operations causes the body temperature to decrease significantly, which results in postoperative complications such as late emergence from anesthesia, late recovery from anesthesia, and shivering.