Impact of Secondary Insults in Brain Death After Traumatic Brain Injury.

In addition to primary injury in severe head trauma, secondary systemic insults that aggravate the brain injury may result in fatal neurologic outcome. We aim to evaluate the correlation between brain death and secondary systemic insults in 100 patients with severe traumatic brain injury (TBI) admitted to the intensive care unit. We collected data on hypotension and hypoxemia at the time of admission to intensive care unit and data on hypotension, hypoxemia, hypocarbia, hypercarbia, shock, anemia, hyperglycemia, and hyperthermia within the first 24 hours. In addition, we recorded the category of TBI according to computed tomography findings. Twenty-six patients (26%) who developed brain death were significantly younger than survivors. Early hypotension (odds ratio [OR], 10.24; 95% confidence interval [CI], 3.64-28.78; P = .000) and early shock (OR, 8.31; 95% CI, 2.65-26.01; P = .000) were significantly more frequent among brain-death patients. The most featured factor that independently predicted the development of brain death in patients with severe TBI was the existence of hypotension (B-2.74; 95% CI, 0.016-0.252; P = .000). The most common type of injury among brain death patients was a surgically evacuated mass lesion. Although all critical care principles are applied to prevent secondary systemic brain insults, when brain death occurs, the prevention of hypotension will become significant in preserving organs in better condition for procurement.

Our Experience with Percutaneous and Surgical Tracheotomy in Intubated Critically Ill Patients.

OBJECTIVE: Open surgical tracheotomy (OST) and percutaneous dilatational tracheotomy (PDT) are commonly used for securing airway in intubated critically ill patients. The purpose of this study was to compare the safety of OST and PDT, particularly in intubated critically ill patients. METHODS: The medical records of intubated critically ill patients who underwent tracheotomy between August 2006 and July 2017 were analyzed retrospectively. Minor and major complication rates were compared according to the tracheotomy technique. Preoperative intubation time, postoperative decannulation time, reason for hospitalization, and demographic data, including the Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, were evaluated. RESULTS: A total of 332 cases were enrolled into the study. The minor and major complication rates for both techniques were 27.2%, 8.8%, 9.7% and 3.2%, respectively. Minor and major complication rates were higher in the OST group (p=0.01, p=0.03, respectively). The rate of every single complication was also compared on groups' basis. Accidental decannulation (p=0.02) and pneumothorax (p=0.05) were found to be significantly frequent in the OST group. There was no impact of the preoperative intubation time on the minor (p=0.20) and major complication (p=0.29) rates found. There was no statistically significant difference regarding the postoperative decannulation time (p=0.32). Also, there was no statistically significant difference between two groups in terms of the APACHE II (p=0.69) and SOFA (p=0.37) scores. However, a statistically significant difference between the groups in terms of overall survival was found, in favor of PDT (p<0.001). CONCLUSION: This study revealed that PDT is safer than OST, particularly in intubated critically ill patients.

The role of ultrasound guidance in pediatric caudal block.

OBJECTIVES: To compare the time interval of the procedure, possible complications, post-operative pain levels, additional analgesics, and nurse satisfaction in ultrasonography-guided and standard caudal block applications.  METHODS: This retrospective study was conducted in Celal Bayar University Hospital, Manisa, Turkey, between January and December 2014, included 78 pediatric patients. Caudal block was applied to 2 different groups; one with ultrasound guide, and the other using the standard method.  RESULTS: The time interval of the procedure was significantly shorter in the standard application group compared with ultrasound-guided group (p=0.020). Wong-Baker FACES Pain Rating Scale values obtained at the 90th minute was statistically lower in the standard application group compared with ultrasound-guided group (p=0.035). No statistically significant difference was found on the other parameters between the 2 groups. The shorter time interval of the procedure at standard application group should not be considered as a distinctive mark by the pediatric anesthesiologists, because this time difference was as short as seconds.   CONCLUSION: Ultrasound guidance for caudal block applications would neither increase nor decrease the success of the treatment. However, ultrasound guidance should be needed in cases where the detection of sacral anatomy is difficult, especially by palpations.

The interrelations of radiologic findings and mechanical ventilation in community acquired pneumonia patients admitted to the intensive care unit: a multicentre retrospective study.

BACKGROUND: We evaluated patients admitted to the intensive care units with the diagnosis of community acquired pneumonia (CAP) regarding initial radiographic findings. METHODS: A multicenter retrospective study was held. Chest x ray (CXR) and computerized tomography (CT) findings and also their associations with the need of ventilator support were evaluated. RESULTS: A total of 388 patients were enrolled. Consolidation was the main finding on CXR (89%) and CT (80%) examinations. Of all, 45% had multi-lobar involvement. Bilateral involvement was found in 40% and 44% on CXR and CT respectively. Abscesses and cavitations were rarely found. The highest correlation between CT and CXR findings was observed for interstitial involvement. More than 80% of patients needed ventilator support. Noninvasive mechanical ventilation (NIV) requirement was seen to be more common in those with multi-lobar involvement on CXR as 2.4-fold and consolidation on CT as 47-fold compared with those who do not have these findings. Invasive mechanical ventilation (IMV) need increased 8-fold in patients with multi-lobar involvement on CT. CONCLUSION: CXR and CT findings correlate up to a limit in terms of interstitial involvement but not in high percentages in other findings. CAP patients who are admitted to the ICU are severe cases frequently requiring ventilator support. Initial CT and CXR findings may indicate the need for ventilator support, but the assumed ongoing real practice is important and the value of radiologic evaluation beyond clinical findings to predict the mechanical ventilation need is subject for further evaluation with large patient series.

Community-acquired pneumonia in patients with chronic obstructive pulmonary disease requiring admission to the intensive care unit: risk factors for mortality.

PURPOSE: The aims of this study are to identify factors predicting mortality in patients with chronic obstructive pulmonary disease (COPD) and community-acquired pneumonia (CAP) requiring intensive care unit (ICU) admission and to examine whether noninvasive ventilation treatment reduces mortality. MATERIALS AND METHODS: An analysis was performed on data from patients with CAP hospitalized in the ICUs of 19 different hospitals in Turkey between October 2008 and January 2011. Predictors of mortality were assessed by both univariate and multivariate statistical analyses. RESULTS: Two hundred eleven patients with COPD and CAP were included. The overall ICU mortality was 23.9%. Noninvasive ventilation treatment (odds ratio [OR], 0.12; 95% confidence interval [CI], 0.03-0.49; P = .003), hypertension (OR, 0.13; 95% CI, 0.02-0.93; P = .042), bilateral infiltration (OR, 13.92; 95% CI, 2.94-65.84; P = .001), systemic corticosteroid treatment (OR, 0.19; 95% CI, 0.35-0.96; P = .045), length of ICU stay (OR, 0.65; 95% CI, 0.47-0.89; P = .007), and duration of invasive mechanical ventilation (OR, 1.11; 95% CI, 1.01-1.22; P = .032) were independent factors related to mortality. CONCLUSION: Noninvasive ventilation, hypertension, systemic corticosteroid treatment, and shorter ICU stay are associated with reduced mortality, whereas bilateral infiltration and longer duration of invasive mechanical ventilation are associated with increased risk of mortality in patients with COPD and CAP requiring ICU admission.

Mortality indicators in community-acquired pneumonia requiring intensive care in Turkey.

BACKGROUND: Severe community-acquired pneumonia (SCAP) is a fatal disease. This study was conducted to describe an outcome analysis of the intensive care units (ICUs) of Turkey. METHODS: This study evaluated SCAP cases hospitalized in the ICUs of 19 different hospitals between October 2008 and January 2011. The cases of 413 patients admitted to the ICUs were retrospectively analyzed. RESULTS: Overall 413 patients were included in the study and 129 (31.2%) died. It was found that bilateral pulmonary involvement (odds ratio (OR) 2.5, 95% confidence interval (CI) 1.1-5.7) and CAP PIRO score (OR 2, 95% CI 1.3-2.9) were independent risk factors for a higher in-ICU mortality, while arterial hypertension (OR 0.3, 95% CI 0.1-0.9) and the application of non-invasive ventilation (OR 0.2, 95% CI 0.1-0.5) decreased mortality. No culture of any kind was obtained for 90 (22%) patients during the entire course of the hospitalization. Blood, bronchoalveolar lavage, and non-bronchoscopic lavage cultures yielded enteric Gram-negatives (n=12), followed by Staphylococcus aureus (n=10), pneumococci (n=6), and Pseudomonas aeruginosa (n=6). For 22% of the patients, none of the culture methods were applied. CONCLUSIONS: SCAP requiring ICU admission is associated with considerable mortality for ICU patients. Increased awareness appears essential for the microbiological diagnosis of this disease.

Levosimendan up-regulates transforming growth factor-beta and smad signaling in the aorta in the early stage of sepsis.

BACKGROUND: This prospective, controlled experimental study was planned to investigate the effects of levosimendan on transforming growth factor (TGF)-beta3 and Smad1, Smad2 and Smad3 expression in the early stages of sepsis. METHODS: Twenty-four rats were randomized into four groups: (1) sham-operated controls, (2) dobutamine group--subjected to abdominal hypertension and peritonitis-induced sepsis using cecal ligation and puncture (CLP), then treated with 10 microg x kg(-1) min(-1) intravenous (IV) dobutamine infusion, (3) levosimendan group--as in 2, then treated with levosimendan IV bolus 200 microg x kg(-1) followed by 200 microg x kq(-1) min(-1) IV infusion, and (4) a control group as in 2, with no treatment. All rats were killed 8 hours after CLP. Aorta tissue samples were analyzed by immunohistochemical staining. RESULTS: CLP caused mild interleukin (IL)-1 immunostaining in both control and dobutamine groups. Immunoreactivity of tumor necrosis factor (TNF)-alpha was mild in both sham and control groups. TGF-beta3 immunostaining was mildly increased in groups sham, control and dobutamine, whereas it was found moderate in group levosimendan. Smad1, Smad2 and Smad3 were found moderately increased only in group levosimendan. CONCLUSION: Beneficial effects of levosimendan on hemodynamics and global oxygen transport were reported in experimental and clinical trials. Besides its potency on C++ ion sensitivity, it should influence inflammatory cytokine production by diminishing TGF-beta3 and Smad1, Smad2 and Smad3 expression.

The effect of remifentanil on the emergence characteristics of children undergoing FBO for bronchoalveolar lavage with sevoflurane anaesthesia.

BACKGROUND AND OBJECTIVE: The aim of this study was to compare the effects of sevoflurane vs. sevoflurane and remifentanil on cough and agitation during emergence and recovery after fiberoptic bronchoscopy. METHODS: Children between 2 and 6 years of age undergoing fiberoptic bronchoscopy were enrolled. All patients were premedicated with oral midazolam. Patients were randomly assigned to either group S (sevoflurane alone, n = 25) or group SR (sevoflurane with remifetanil, n = 25). Anaesthesia was induced and maintained with sevoflurane in all patients. Group SR received remifentanil at a bolus dose of 1 microg/kg over 2 min followed by a maintenance infusion of 0.15 microg/kg/min. In addition to routine anaesthesia documentation, agitation scores and cough scores were recorded every 5 min during emergence and recovery. RESULTS: Duration of the procedure, anaesthesia and emergence phases was similar in both groups (P > 0.05). Time until recovery was significantly shorter in group SR than in group S (7.0 +/- 5.5 min and 13.0 +/- 3.5 min, respectively; P = 0.001). Cough scores were not significantly different between the two groups during emergence and recovery (Kruskal-Wallis ANOVA test, P > 0.05). However, the mean agitation score at 5 min in group SR was significantly higher than that in group S (Kruskal-Wallis ANOVA test, P < 0.01). One case of hypoxaemia from thoracic rigidity occurred in a patient in group SR. CONCLUSION: The addition of remifentanil significantly shortened recovery time in children undergoing fiberoptic bronchoscopy under sevoflurane anaesthesia. In the recovery period, remifentanil did not decrease cough, and increased agitation.

Effects of levosimendan and dobutamine on experimental acute lung injury in rats.

The effects of levosimendan on acute lung injury induced by peritonitis and abdominal hypertension in the early stages of sepsis in rats were investigated. Twenty-four adult male Wistar rats were randomized into: (1) sham, (2) subjected to abdominal hypertension and peritonitis induced lung injury using cecal ligation and puncture, then treated by dobutamine, (3) subjected to abdominal hypertension and peritonitis induced lung injury using cecal ligation and puncture, then treated by levosimendan, and (4) controls subjected to abdominal hypertension and peritonitis induced lung injury using cecal ligation and puncture with no treatment. In the control and levosimendan groups, cecal ligation and puncture resulted in moderate IL-1beta immunolabelling in lung tissue; marked IL-1beta immunolabelling was demonstrated in the dobutamine group. TNF-alpha immunolabelling was negative in both the sham and levosimendan groups, but moderate and weak immunoreactivities were observed in the dobutamine and control groups, respectively. There were almost no TUNEL positive cells in the sham, but they were prominent in the control. TUNEL positive cells were significantly less in the levosimendan treated lungs when compared to control and dobutamine groups. Immunoreactivity of eNOS was stronger in the dobutamine group when compared with the levosimendan group. In addition, iNOS immunoreactivity was strongly detected in the control group; this immunoreactivity was less in the levosimendan group than the dobutamine group. In this experimental sepsis model, treatment with levosimendan had a marked effect on attenuating or decreasing apoptosis and inflammation in the lung.

Chronic pain after Lichtenstein and preperitoneal (posterior) hernia repair.

BACKGROUND: Hernia repair is one of the most common surgical procedures, and some patients suffer from chronic pain after hernia surgery. The aim of the present study was to evaluate chronic postherniorrhaphy pain in men who underwent Lichtenstein mesh repair or preperitoneal (posterior) repair. METHODS: Our study included 94 male inpatients. Two surgeons experienced in both Lichtenstein and preperitoneal hernia repair performed the procedures. We controlled postoperative pain with systemic analgesic therapy. We evaluated the patients over the subsequent 12 months, using a questionnaire to focus on chronic pain and its limitations to their quality of life. RESULTS: The overall incidence of chronic pain at 2 months was 5%. About 6% of patients who underwent Lichtenstein repair (n = 70) and 4% of patients who underwent preperitoneal repair (n = 24) experienced chronic pain. All patients with chronic pain rated their pain as slight or moderate. Their pain was present occasionally and was related to physical stress. None of the patients were unable to work. After 12 months of follow-up, the overall incidence of chronic pain decreased to 3%, with 3 patients in Lichtenstein group reporting chronic pain with slight limitations in sports and social activities. CONCLUSION: The incidence rates of chronic pain after Lichtenstein and preperitoneal repair were 6% and 4%, respectively. Inpatient status might have resulted in low incidences with both approaches.

Pretreatment with pro- and synbiotics reduces peritonitis-induced acute lung injury in rats.

BACKGROUND: To study whether enteral pretreatment with a synbiotic composition of lactic acid bacteria and bioactive fibers can reduce peritonitis-induced lung neutrophil infiltration and tissue injury in rats. MATERIALS AND METHODS: Rats were divided into five groups, and subjected to induction of peritonitis-induced lung injury using a cecal ligation and puncture model (CLP). All animals were pretreated for 3 weeks prior the CLP by daily gavage with either (1) a synbiotic composition (10(10) CFU of Pediococcus pentosaceus 5-33:3, 10(10) CFU of Leuconostoc mesenteroides 77:1, 10(10) CFU of L. paracasei subspecies paracasei, 10(10) CFU of L. plantarum 2362 plus fermentable fibers), (2) fermentable fibers alone, (3) nonfermentable fibers, (4) a probiotic composition (10(10) CFU of P. pentosaceus 5-33:3, 10(10) CFU of L. mesenteroides 77:1, 10(10) CFU of L. paracasei subsp. paracasei, 10(10) CFU of L. plantarum 2,362), or (5) a heat-killed probiotic composition. All animals were killed 24 hours after CLP and lung tissue samples were studied for degree of neutrophil infiltration and levels of tumor necrosis factor (TNF)-alpha, Interleukin (IL)-1beta. In addition the lung wet-to-dry tissue weight ratio, the myeloperoxidase activity, and malondialdehyde content were also assessed. RESULTS: No mortality was encountered in any of the groups. Histologic signs of lung injury (number of neutrophils and TNF-alpha, IL-1beta staining) were observed in all groups except the synbiotic and probiotic treated groups. Myeloperoxidase activity and malondialdehyde content were significantly lower in the two lactobacillus- pretreated groups, with no difference between them. Heavy infiltration of lung tissue with neutrophils was observed only in fiber-treated (302.20 +/- 7.92) and placebo-treated (266.90 +/- 8.92) animals. This was totally abolished in the synbiotic-treated group (34.40 +/- 2.49). Lung edema (wet-to-dry lung weight ratio) was significantly reduced in the synbiotic-treated group (4.92 +/- 0.13 vs. 5.07 +/- 0.08 and 5.39 +/- 0.10, respectively). CONCLUSION: Three weeks of preoperative enteral administration of a synbiotic composition reduced peritonitis-induced acute lung injury in rats in a CLP model.

The effect of cardiopulmonary bypass on the expression of inducible nitric oxide synthase, endothelial nitric oxide synthase, and vascular endothelial growth factor in the internal mammary artery.

OBJECTIVE: Endothelial function of a vessel may be impaired by local or systemic inflammation initiated by cardiopulmonary bypass (CPB) during coronary artery bypass graft (CABG) surgery. The present study was designed to investigate the early effects of CPB on nitric oxide production and vascular endothelial growth factor (VEGF) expression in internal mammary artery (IMA). DESIGN: Prospective study. SETTING: University hospital. PARTICIPANTS: Twenty patients who were scheduled for elective CABG with CPB. INTERVENTIONS: IMA sections were studied immunohistochemically from these patients. The samples were taken from the distal end of the IMA before the institution of CPB and just before the construction of the IMA-left anterior descending artery anastomosis. MEASUREMENT AND MAIN RESULTS: After CPB, VEGF and endothelial nitric oxide synthase immunoreactivity increased significantly when compared with baseline values in the endothelium (p = 0.0156, p = 0.0313) and adventitia (p = 0.0313, p = 0.0001), respectively. No significant change was observed in inducible nitric oxide synthase immunoreactivity. CONCLUSIONS: The increase in eNOS expression may have been induced by the inflammation caused by CPB.

Hearing loss does not occur in young patients undergoing spinal anesthesia.

BACKGROUND AND OBJECTIVES: Although uncommon, hearing loss after spinal anesthesia has been described. Vestibulocochlear dysfunction after spinal anesthesia in which 22-gauge and 25-gauge Quincke needles were used was investigated to determine if needle size affected hearing. METHODS: Patients with American Society of Anesthesiologists physical status I and II, aged 20 to 40 years, who were undergoing lower extremity surgery under spinal anesthesia were randomized into 2 groups. After intravenous hydration, 3 mL of 0.5% bupivacaine was administered for spinal anesthesia, which was performed with a 22-gauge Quincke needle in group I (n=30) patients and a 25-gauge Quincke needle in group II (n=30) patients. Before surgery and 2 days after surgery, pure-tone audiometry and tympanometry were performed. Preoperative and postoperative hearing data were obtained in the right and left ears for every frequency. Headache, nausea, and vomiting and cranial nerve III, IV, V, VI, VII, and VIII function were assessed on postoperative day 2. RESULTS: Demographic data were not different between the groups. No hypoacousis was noted at any frequency during the entire testing period in either group. Two patients from group I experienced postdural puncture headache on postoperative day 3, and neither had hearing loss. No patient had cranial nerve dysfunction. CONCLUSIONS: We were unable to induce hearing loss in young patients undergoing spinal anesthesia by injecting the anesthetic with a 22-gauge or a 25-gauge Quincke needle.

Basic life support skills of doctors in a hospital resuscitation team.

The aim of the present study was to evaluate the basic life support skills of doctors in a hospital resuscitation team and to identify potential factors affecting those skills. Twelve anesthesiology residents were induced in this study. Each doctor was asked to perform mouth-to-mouth ventilation for 10 minutes and then chest compression for another 10 minutes on a Laerdal Skillmeter Resusci-Anne manikin during the day (10 am) and at night (10 pm). The rates of correct ventilation, correct chest compression, ventilation errors (i.e., excessive inflation, stomach insufflation, insufficient ventilation), and compression errors (i.e., insufficient chest compression/decompression, excessive chest compression, incorrect hand placement) were determined for each 2-min interval up to 10 min. In addition, effects of sex, seniority, CPR duration, and time of day (day vs night) on those skills were assessed. The mean rates of correct ventilation were 53.3+/-23.9% (day) and 60.4+/-16% (night); the mean rates of correct chest compression, 76.9+/-15% (day) and 76.5+/-14.7% (night). During the first 2-minutes period of testing at night, men doctors more frequently achieved correct ventilation than did women doctors (p<0.05). Overall, the practical CPR skills of the study participants were not influenced by sex, seniority, CPR duration, or time of day; however, the participants' skills were poor. This suggests that all medical staff, especially members of in-hospital resuscitation teams, should undergo regular, periodic CPR training.

Assessment of in-hospital cardiopulmonary resuscitation using Utstein template in a university hospital.

The aim of this study was to evaluate the effectiveness of in-hospital cardiopulmonary resuscitation (CPR) strategies and identify key predictors of post-CPR survival in a university hospital setting. Using a form recommended by the European Resuscitation Council, data regarding in-hospital CPR attempts from January 2001 to December 2002 were recorded and analyzed. The main outcomes of interest were immediate survival after CPR and survival to hospital discharge. Of 307 patients who suffered cardiac arrest in the study period, 103 (33.5%) were resuscitated. Of these 103 patients, 28 (27.2%) survived immediately and 12 (11.7%) survived to hospital discharge. The key predictors of immediate survival were CPR duration and initial cardiac rhythm as monitored by ventricular fibrillation/pulseless ventricular tachycardia (VF/VT). The key predictors of survival to hospital discharge were CPR duration, immediate defibrillation, Glasgow Coma Scale score, and Early Prediction Score. Together, our results suggest that in-hospital CPR strategies require improvement. They also underscore the importance of data collection and analysis in evaluating the effectiveness of inhospital CPR strategies.

Anaesthetic management in McKusick-Kaufman syndrome.

The cardinal features of McKusick-Kaufman syndrome (MKS) are polydactyly and hydrometrocolpos. Sometimes, this abdominopelvic mass may restrict pulmonary function and decrease the oxygenation of the newborn. We present a case of MKS and review the clinical features and appropriate anaesthetic management. A 45-day-old girl, weighing 4450 g, born at term, presented to our Paediatric Surgery Department with abdominal distention, diarrhoea and vomiting, which started on the 15th day of life. On physical examination, peripheral cyanosis, tachycardia and tachypnoea were found. A prominent mass was palpated in the lower abdomen. There was vaginal atresia and a sixth digit was found on her left foot. There was a large cystic mass extending from the pelvis to the level of L1 displacing the diaphragm, and bilateral hydroureteronephrosis were seen on plain abdominal X-ray, ultrasonography and computerized tomography. In the preanaesthetic assessment, the patient was evaluated for multiple congenital anomalies. Our management of anaesthesia, for a neonate with severe hydrometrocolpos compressing the diaphragm, consisted of gastric decompression and preoxygenation before tracheal intubation, routine and airway pressure monitoring, periodic analyses of blood gases and maintenance of anaesthesia with a low concentration of volatile agent, together with an opioid.