Antimicrobial dosing recommendations during continuous renal replacement therapy: different databases, different doses.

Meticulous antimicrobial management is essential among critically ill patients with acute kidney injury, particularly if renal replacement therapy is needed. Many factors affect drug removal in patients undergoing continuous renal replacement therapy CRRT. In this study, we aimed to compare current databases that are frequently used to adjust CRRT dosages of antimicrobial drugs with the gold standard. The dosage recommendations from various databases for antimicrobial drugs eliminated by CRRT were investigated. The book 'Renal Pharmacotherapy: Dosage Adjustment of Medications Eliminated by the Kidneys' was chosen as the gold standard. There were variations in the databases. Micromedex, UpToDate, and Sanford had similar rates to the gold standard of 45%, 35%, and 30%, respectively. The Micromedex database shows the most similar results to the gold standard source. In addition, a consensus was reached as a result of the expert panel meetings established to discuss the different antimicrobial dose recommendations of the databases.

Relationship Between Postoperative Acute Kidney Injury and Early Extubation After Pediatric Liver Transplant.

OBJECTIVES: Postoperative acute kidney injury after pediatric liver transplant is a serious complication with considerable short-term and long-term consequences. We hypothesized that incidence of postoperative acute kidney injury after pediatric liver transplant is lower among patients extubated early after surgery in the operating room. MATERIALS AND METHODS: In this retrospective cohort study, we reviewed the medical records of all patients aged <18 years who underwent liver transplant from January 2012 to December 2020. Early extubation was defined as extubation in the operating room. Children were divided into 2 groups: those who were extubated in the operating room and those who were extubated in the intensive care unit. RESULTS: A total of 132 pediatric liver transplant recipients were analyzed. The mean age of transplant was 58.2 ± 60.1 months, and 54.5% were male recipients. Early immediate tracheal extubation in the operating room was performed in 86 patients (65.2%). Postoperative acute kidney injury was seen in 24 children (18.2%) of which 15 (11.4%) had stage 1 acute kidney injury, 8 (6.1%) had stage 2, and 1 (0.8%) had stage 3. There was no statistically significant difference between the 2 groups regarding development of acute kidney injury (18.6% vs 17.4%; P > .05). Compared with patients who were not extubated in the operating room, the need for an open-abdomen procedure (76.9% vs 23.1%; P = .001) was significantly higher in patients who were extubated in the operating room. Durations for length of stay in the intensive care unit and hospital were significantly shorter in patients who were extubated in the operating room (P < .001). CONCLUSIONS: Our results showed that early extubation was performed in nearly two-thirds of our cohort. There was no association between early extubation and development of acute kidney injury among pediatric liver transplant recipients.

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.

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.

Posttransplant Pneumonia Among Solid Organ Transplant Recipients Followed in Intensive Care Unit.

OBJECTIVES: Pneumonia is a significant cause of morbidity and mortality in solid-organ transplant recipients. We studied the demographic characteristics, respiratory management, and outcomes of solid-organ transplant recipients with pneumonia in an intensive care unit. MATERIALS AND METHODS: There have been 2857 kidney, 687 liver, and 142 heart transplants performed between October 16, 1985, and February 28, 2021, at our center. We retrospectively analyzed records for 51 of 193 recipients with pneumonia during the posttransplant period between January 1, 2016, and December 31, 2018. RESULTS: Fifty-one of 193 recipients were followed in the intensive care unit. Mean age was 45.4 ± 16.6 years among 42 male (82.4%) and 9 female (17.6%) recipients. Twenty-six patients (51%) underwent kidney transplant, 14 (27.5%) liver transplant, 7 (13.7%) heart transplant, and 4 (7.8%) combined kidney and liver transplant. Most pneumonia episodes occurred 6 months after transplant (70.6%) with acute hypoxemic respiratory failure. Mean Acute Physiology and Chronic Health Evaluation System II score was 18.9 ± 7.7, and the Sequential Organ Failure Assessment score was 8.5 ± 3.9 at intensive care unit admission. Whereas 66.7% of pneumonia cases were nosocomial acquired, 33.3% were community acquired. The intensive care unit and 28-day mortality rates were 39.2% and 64.7%, respectively. CONCLUSIONS: Solid-organ transplant recipients with pneumonia have been associated with poor prognosis. Our cohort followed in the intensive care unit comprised mostly patients with nosocomial pneumonia with acute hypoxemic respiratory failure, hospitalized 6 months after transplant with high Acute Physiology and Chronic Health Evaluation System II scores predictive of mortality. In this high-risk patient group, careful follow-up, early discovery of warning signs, and rapid treatment initiation could improve the outcomes in the intensive care unit.

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.

Melkersson-Rosenthal Syndrome: A Rare Cause of Recurrent Facial Nerve Palsy and Acute Respiratory Distress Syndrome.

Melkersson-Rosenthal Syndrome (MRS) is a rare disease characterized by persistent or recurrent orofacial oedema, relapsing peripheral facial paralysis, and furrowed tongue. Pathologically, granulomatosis is responsible for oedema of face, labia, oral cavity, and facial nerve. We present a patient with MRS admitted to our hospital with acute respiratory distress syndrome (ARDS). 45-year-old woman was admitted to an emergency department with dyspnea and swelling on her hands and face. She was intubated because of ARDS and accepted to intensive care unit (ICU). After weaning from ventilatory support, peripheral facial paralysis was diagnosed and steroid treatment was added to her therapy. On dermatologic examination, oedema on her face, pustular lesions on her skin, and fissure on her tongue were detected. The patient informed us about her recurrent and spontaneous facial paralysis in previous years. According to her history and clinical findings, MRS was diagnosed.