Is diaphragm ultrasound better than rapid shallow breathing index for predicting weaning in critically ill elderly patients?

Introduction: Prolonged weaning is associated with worse clinical outcomes in elderly patients. Beside traditional rapid shallow breathing index (RSBI), diaphragm ultrasound is a promising technique to evaluate the weaning process. We aimed to perform diaphragm ultrasonography for predicting the weaning process and its relation with frailty in the critically ill elderly population. Materials and Methods: We enrolled thirthy-two patients over 65 years of age who were mechanically ventilated for at least 48 hours. Thickness of diaphragm and excursion were evaluated within 48 h of intubation and during spontaneous breathing trial (SBT). Clinical parameters, frailty, diaphragm ultrasound results were compared according to the weaning status. Results: Mean age (standard deviation) was 79.3 ± 7.9 years, and 18 (56.3%) patients were classified as weaning failure. Diaphragmatic excursion during SBT was the only statistically significant parameter associated with weaning failure [2.37 cm (0.67) vs 1.43 cm (0.15), p= 0.0359]. There was no statistically significant difference regarding RSBI between the groups [70.5 (46) vs 127.5 (80), p= 0.09]. Baseline thickness of diaphragm and excursion at SBT were moderately correlated with frailty. Conclusion: Ultrasound can be used to show diaphragm dysfunction in the elderly frail population, and a multifactorial approach to the extubation process may include ultrasound instead of using traditional RSBI alone.

Association of nutritional status, frailty, and rectus femoris muscle thickness measured by ultrasound and weaning in critically ill elderly patients.

Introduction: Sarcopenia and frailty are critical factors linked with poor clinical outcomes among elderly individuals. This study aims to investigate the association between nutritional assessment tests and frailty with muscle thickness measured by ultrasound and their relationship with weaning among critically ill elderly patients. Materials and Methods: Patients who were over 65 years old and required invasive ventilation were assessed for nutritional status and clinical frailty scale upon admission to the intensive care unit. Additionally, the thickness of their rectus femoris and vastus intermedius muscles were measured by ultrasound within 48 hours of intubation. Correlation analysis was conducted to examine the relationship between screening tests, frailty, and ultrasound results. The association between these parameters and weaning success was also evaluated. Result: Between May and August 2022, 32 consecutive patients were enrolled in the study. The mean age was 79.3 ± 7.9, and 18 (56.3%) of them were female. Median APACHE-II- and first-day SOFA scores were 22.5 (16.2-29.7) and 7 (5-10.75), respectively. There was a moderate negative correlation between the thickness of the rectus femoris and frailty (r= -0.41, p= 0.036), and there was a moderate positive correlation between the rectus femoris and geriatric nutritional risk index (r= 0.45, p= 0.017). Of them, 18 (56.3%) patients were classified as weaning failure in which the mean frailty score was higher (7.6 ± 0.9 vs 6.5 ± 1.7, p= 0.035), sepsis (18 vs 7, p<0.001) and use of vasopressor (17 vs 6, p= 0.004) more common, and in-hospital mortality were higher (18 vs 5, p<0.001). Conclusions: Bedside ultrasound could be beneficial for detecting nutritional high-risk patients. Frailty was associated with muscle thickness, and it was also associated with weaning failure.

A Statistical Model for Early Recognition of Patients Requiring Transfer to Palliative Care (ERPAC).

OBJECTIVE: To develop a scoring system to identify patients at an early stage who will need palliative care during intensive care follow-up. STUDY DESIGN: Analytical study. PLACE AND DURATION OF STUDY: Ankara City Hospital, Neurology and Orthopaedics Hospital, General Intensive Care Unit, Ankara, Turkiye, from June 2019 to March 2020. METHODOLOGY: Intensive care patients were enrolled and divided into palliative care transfer (p1) and nontransfer groups (p2). The predicted logit value / probality score was calculated and a scoring system was developed, using the formula value, [logit= -3.275 + 0.194 (days of hospitalisation) - 0.345 (SOFAmax) +1.659 (ward admission) + 2.08 (cancer)]. RESULTS: One hundred and thirty five patients were analysed. Sixty-eight (50.4%) were males. The mean age was 67.2 ± 17.2 years. Length of hospital stay (p<0.001), highest sequential organ failure score (SOFAmax, p<0.001), previous hospitalisation (p=0.015), and cancer history (p=0.009) affect the need for palliative care significantly.  Predicted probability = epredicted togit / 1+epredicted logit If predicted probabilty >0.5, patient was candidate for palliative care transfer. CONCLUSION:  Every intensive care unit can calculate its own logit value and represent ERPAC score. ERPAC scores can predict which patients will be transferred to palliative care. Predictedlogit value will help to recognise which patients will need palliative care at an early stage. KEY WORDS: Palliative care, Scoring, Intensive care.

Importance of the National Early Warning Score (NEWS) at the time of discharge from the intensive care unit

Backround/aim: To identify, at an early stage of intensive care, patients who will require readmission to the intensive care unit (ICU) based on their National Early Warning Score (NEWS-d) at discharge. Materials and methods: Overall, 536 patients aged >18 years who stayed at a tertiary ICU for >24 h were included. Patients who readmitted and not readmitted to the intensive care within 48 h after discharge were compared. Results: Mean patient age was 64.26 ± 18.50 years and 252 (44.7%) patients were male. Mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 21.86 ± 8.74; mean NEWS-d was 4.48 ± 2.53. Forty-nine (9.1%) were readmitted to ICU. The reasons for initial admission, age, and NEWS-d vvalues were significantly different between the 2 groups. The NEWS-d values of the readmitted group were significantly higher (9.16 ± 1.05) than nonreadmitted group (4.01 ± 2.13). Based on receiver operation curve analysis, sensitivity and specificity were 98% and 95%, respectively, considering a NEWS-d cut-off value of 7.5 as the limit value for estimating readmission. Conclusion: A NEWS-d value of >7.5 demonstrated high sensitivity and specificity in identifying the risk of readmission for patients being discharged from ICU.

Linezolid and dexamethasone experience in a serious case of listeria rhombencephalitis.

Listeria rhombencephalitis is a rare cause of brain stem encephalitis. We report a case with a history of immunosupressive therapy due to Takayasu's arteritis that was treated with corticosteroids and linezolid for Listeria rhombencephalitis. A 63-year-old woman was admitted to the hospital with fever, headache, nausea, and vomiting. The patient's body temperature was 38°C, and she had a stiff neck. Listeria monocytogenes was isolated from the cerebrospinal fluid (CSF), and penicillin G and gentamicin treatment was initiated. Linezolid and dexamethasone were added. Due to hematuria and thrombocytopenia, the linezolid was discontinued. In immunocompromised patients with CNS infections, Listeria rhombencephalitis should be suspected. Linezolid can be used in combination with dexamethasone.

Stobadine protects rat kidney against ischaemia/reperfusion injury.

1. Ischaemia-reperfusion (I/R) injury, one of the main causes of acute renal failure, still needs satisfactory treatment for routine clinical application. Stobadine, a novel synthetic pyridoindole anti-oxidant, has the ability to reduce tissue injury induced by mechanisms involving reactive oxygen species during I/R. The aim of the present study was to determine the effects of stobadine on renal I/R injury. 2. Forty male Wistar rats were randomly divided into four groups as follows: sham, I/R, stobadine treated and I/R + stobadine treated. Stobadine (2 mg/kg, i.v.) was given intravenously to two groups of rats. The stobadine-treated group was treated with stobadine following sham operation before the abdominal wall was closed, whereas the I/R + stobadine group received stobadine at the beginning of reperfusion. Renal I/R was achieved by occluding the renal arteries bilaterally for 40 min, followed by 6 h reperfusion. Immediately thereafter, blood was drawn and tissue samples were harvested to assess: (i) serum levels of blood urea nitrogen and creatinine; (ii) serum and/or tissue levels of malondialdehyde (MDA), glutathione (GSH), glucose 6-phosphate dehydrogenase (G-6PD), 6-phosphogluconate dehydrogenase (6-PGD), glutathione reductase (GR) and glutathione peroxidase (GPx); (iii) renal morphology; and (iv) immunohistochemical staining for P-selectin. 3. Stobadine was able to significantly attenuate the renal dysfunction as a result of renal I/R injury. Ischaemia-reperfusion resulted in a significant increase in serum and kidney MDA levels and a decrease in serum and kidney GSH. Stobadine treatment at the beginning of reperfusion attenuated both the increased MDA levels and decreased GSH secondary to I/R injury. In addition, the decreased G-6PD activity observed after I/R was significantly attenuated by stobadine treatment. Stobadine did not alter 6-PGD activity after I/R. Neither GR nor GPx activity was significantly changed in the I/R alone or the I/R + stobadine groups compared with the sham group. In addition, stobadine decreased the morphological deterioration and high P-selectin immunoreactivity secondary to renal I/R injury. 4. A pyridoindole anti-oxidant, stobadine exerts a renal protective effect in renal I/R injury, which is probably due to its radical-scavenging and anti-oxidant activities.