Development and validation of nomogram to predict severe illness requiring intensive care follow up in hospitalized COVID-19 cases.

BACKGROUND: Early identification of severe COVID-19 patients who will need intensive care unit (ICU) follow-up and providing rapid, aggressive supportive care may reduce mortality and provide optimal use of medical resources. We aimed to develop and validate a nomogram to predict severe COVID-19 cases that would need ICU follow-up based on available and accessible patient values. METHODS: Patients hospitalized with laboratory-confirmed COVID-19 between March 15, 2020, and June 15, 2020, were enrolled in this retrospective study with 35 variables obtained upon admission considered. Univariate and multivariable logistic regression models were constructed to select potential predictive parameters using 1000 bootstrap samples. Afterward, a nomogram was developed with 5 variables selected from multivariable analysis. The nomogram model was evaluated by Area Under the Curve (AUC) and bias-corrected Harrell's C-index with 95% confidence interval, Hosmer-Lemeshow Goodness-of-fit test, and calibration curve analysis. RESULTS: Out of a total of 1022 patients, 686 cases without missing data were used to construct the nomogram. Of the 686, 104 needed ICU follow-up. The final model includes oxygen saturation, CRP, PCT, LDH, troponin as independent factors for the prediction of need for ICU admission. The model has good predictive power with an AUC of 0.93 (0.902-0.950) and a bias-corrected Harrell's C-index of 0.91 (0.899-0.947). Hosmer-Lemeshow test p-value was 0.826 and the model is well-calibrated (p = 0.1703). CONCLUSION: We developed a simple, accessible, easy-to-use nomogram with good distinctive power for severe illness requiring ICU follow-up. Clinicians can easily predict the course of COVID-19 and decide the procedure and facility of further follow-up by using clinical and laboratory values of patients available upon admission.

Lactate/albumin ratio is more effective than lactate or albumin alone in predicting clinical outcomes in intensive care patients with sepsis.

This study aimed to compare the value of lactate, albumin, and lactate/albumin ratio for the prediction of mortality in sepsis patients. Patients admitted to the intensive care unit (ICU) due to sepsis between January 2016 and January 2019 were evaluated retrospectively. Lactate, albumin, and lactate/albumin ratio values were compared between surviving and non-surviving patients and their predictive value for mortality was evaluated. A total of 1136 sepsis patients admitted to the ICU were included in the study. The mortality rate was 42.7% (485/1136 patients). In ROC analysis for mortality prediction, the area under the curve and optimal cut-off values were 0.816 and >2.2 mmol/L for lactate, 0.812 and ≤26 g/L for albumin, and 0.869 and >0.71 for lactate/albumin ratio, respectively. Our analysis of lactate, albumin, and lactate/albumin ratio in the largest patient sample to date showed that lactate/albumin ratio was a stronger parameter than lactate or albumin alone in predicting mortality among sepsis patients in the ICU. Lactate/albumin ratio is an easily obtained parameter with potential value for critically ill patients.

Does hospitalisation of a patient in the intensive care unit cause anxiety and does restriction of visiting cause depression for the relatives of these patients during COVID-19 pandemic?

OBJECTIVES: During the pandemic, anxiety and depression may occur increasingly in the whole society. The aim of this study was to evaluate the possible cause, incidence and levels of anxiety and depression in the relatives of the patients in the intensive care unit (ICU) in accordance with the patients' SARS-CoV-2 polymerase chain reaction (PCR) result. MATERIALS AND METHOD: The study was prospectively conducted on relatives of patients admitted to tertiary intensive care units during COVID-19 pandemic. Sociodemographic characteristics of the patients and their relatives were recorded. "The Turkish version of the Hospital Anxiety and Depression Scale" was applied twice to the relatives of 120 patients to determine the symptoms of anxiety and depression in accordance with the PCR results of the patients (PCR positive n = 60, PCR negative n = 60). RESULTS: The ratios above cut-off values for anxiety and depression among relatives of the patients were 45.8% and 67.5% for the first questionnaire and 46.7% and 62.5% for the second questionnaire, respectively. The anxiety and depression in the relatives of PCR-positive patients was more frequent than the PCR negative (P < .001 for HADS-A and P = .034 for HADS-D). The prevalence of anxiety and depression was significantly higher in female relatives (P = .046 for HADS-A and P = .009 for HADS-A). There was no significant correlation between HADS and age of the patient or education of the participants. The fact that the patients were hospitalised in the ICU during the pandemic was an independent risk factor for anxiety (AUC = 0.746) while restricted visitation in the ICU was an independent risk factor for depression (AUC = 0.703). CONCLUSION: Positive PCR and female gender were associated with both anxiety and depression while hospitalisation in the ICU due to COVID-19 was an independent risk factor for anxiety and restricted visitation in the ICU is an independent risk factor for depression.

Unexplained neuropsychiatric symptoms in intensive care: A Fahr Syndrome case.

Fahr Syndrome is a rare disease where calcium and other minerals are stored bilaterally and symmetrically in the basal ganglia, cerebellar dentate nucleus and white matter. Fahr Syndrome is associated with various metabolic disorders, mainly parathyroid disorders. The presented case discusses a 64-year old male patient admitted to the intensive care unit of our hospital diagnosed with aspiration pneumonia and urosepsis. The cranial tomography examination to explain his nonspecific neurological symptoms showed bilateral calcifications in the temporal, parietal, frontal, occipital lobes, basal ganglia, cerebellar hemisphere and medulla oblongata posteriorly. His biochemical test results also indicated parathormone-calcium metabolic abnormalities. Fahr Syndrome must be considered for a definitive diagnosis in patients with nonspecific neuropsychiatric symptoms and accompanying calcium metabolism disorders in order to control serious morbidity and complications because of neurological damage.

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.

Investigation of SARS-CoV-2 using RT-PCR in vaginal swab samples of female patients with a diagnosis of severe COVID-19.

OBJECTIVE: It is important to determine the presence of SARS-CoV-2 in the vaginal fluid samples of reproductive-aged women with severe disease during the acute stage of the disease and to determine the risks of transmission by sexual or vertical transmission. MATERIAL AND METHODS: Adult women with confirmed severe COVID-19 who were admitted to Ankara City Hospital intensive care unit (ICU) between December 1st, 2020, and January 1st, 2021, were enrolled in the study. Vaginal swab samples were collected within 48 h in the ICU using Dacron or rayon swabs and tested for SARS-CoV-2 using reverse transcription real-time polymerase chain reaction (RT PCR). RESULTS: Thirty women of reproductive age were included in the study, five (16.7%) of whom were pregnant. The mean age was 44.9 (±10.5) years. The most common symptoms were headache (100%), muscle soreness (86.7%), cough (76.7%), fever (60%), and nausea and vomiting (20%). Nineteen (63.3%) patients had underlying medical conditions. The time interval from obtaining vaginal swab samples to admission to the ICU was 48 h. The time between vaginal sampling and PCR positivity ranged from 2 to 18 days. SARS-CoV-2 was not detected in any vaginal samples. CONCLUSION: Our study showed that women with severe COVID-19 did not have SARS-CoV-2 in their vaginal fluids. Investigation of the presence of SARS-CoV-2 in vaginal secretions may help in determining the risks of sexual transmission and vertical transmission from mother to baby. Information on this subject is still limited. Larger studies on comprehensive biological samples are needed.

Protective effect of dexmedetomidine in a rat model of α-naphthylthiourea-induced acute lung injury.

BACKGROUND: We assessed the effects of dexmedetomidine in a rat model of α-naphthylthiourea (ANTU)-induced acute lung injury. METHODS: Forty Wistar Albino male rats weighing 200-240 g were divided into 5 groups (n = 8 each), including a control group. Thus, there were one ANTU group and three dexmedetomidine groups (10-, 50-, and 100-µg/kg treatment groups), plus a control group. The control group provided the normal base values. The rats in the ANTU group were given 10 mg/kg of ANTU intraperitoneally and the three treatment groups received 10, 50, or 100 µg/kg of dexmedetomidine intraperitoneally 30 min before ANTU application. The rat body weight (BW), pleural effusion (PE), and lung weight (LW) of each group were measured 4 h after ANTU administration. The histopathologic changes were evaluated using hematoxylin-eosin staining. RESULTS: The mean PE, LW, LW/BW, and PE/BW measurements in the ANTU group were significantly greater than in the control groups and all dexmedetomidine treatment groups (P < 0.05). There were also significant decreases in the mean PE, LW, LW/BW and PE/BW values in the dexmedetomidine 50-µg/kg group compared with those in the ANTU group (P < 0.01). The inflammation, hemorrhage, and edema scores in the ANTU group were significantly greater than those in the control or dexmedetomidine 50-µg/kg group (P < 0.01). CONCLUSION: Dexmedetomidine treatment has demonstrated a potential benefit by preventing ANTU-induced acute lung injury in an experimental rat model. Dexmedetomidine could have a potential protective effect on acute lung injury in intensive care patients.

Preoperative abnormal P and QTc dispersion intervals in patients with metabolic syndrome.

We evaluated P wave dispersion (Pwd), QT, corrected QT (QTc), QT dispersion, and corrected QT dispersion (QTcd) intervals in patients with metabolic syndrome (MetS). Patients scheduled to undergo elective noncardiac surgery were included in the study. The main diagnoses, anthropometric measurements, waist circumferences, body mass index, electrocardiograms, serum levels of electrolytes, glucose, and lipids were recorded for all patients. QTc, QTcd intervals were determined with the Bazett formula. MetS (group M, n = 36) was diagnosed using the Adult Treatment Panel III. Controls (group C, n = 40) were chosen on the basis of patients with no MetS and matched for age and gender. There were no differences between groups in terms of age, sex, or serum electrolyte levels (P > 0.05). Waist circumferences, body mass index, serum glucose, and triglyceride values in group M were significantly higher than those in group C (P < 0.001). In group M, Pwd, QTc, QT dispersion and QTcd intervals were significantly longer than those in group C (P < 0.001). This finding and our retrospective analysis suggest that these patients may be at greater risk of perioperative arrhythmias.

Thiol/Disulfide Homeostasis as an Early Biomarker to Differentiate Sepsis from Pneumonia in Intensive Care Units.

BACKGROUND: It is possible that patients with pneumonia may also have sepsis and the separation of these two clinical entities may cause some trouble to clinicians. OBJECTIVE: In order to separate a patient with pneumonia and a patient with sepsis, we qualify thiol/disulfide homeostasis as a potential biomarker. METHODS: This study was designed between February 2018 - February 2019 prospectively. All patients in the intensive care unit with pneumonia and sepsis were enrolled in the study. At the time of hospitalization, thiol/disulfide homeostasis was measured. Patients diagnosed with sepsis and pneumonia were compared, in regards to thiol/disulfide homeostasis. RESULTS: During research period, 103 patients with sepsis and 120 patients with pneumonia were enrolled into the study. When we compared native-thiol, total-thiol, and disulfide levels in both sepsis and pneumonia patients, we had similar results (p>0.05). In sepsis group, index-1 (disulfide/native thiol ratio) and index-2 (disulfide/total thiol ratio) were found to be statistically higher than the pneumonia group, and index-3 (native thiol/total thiol ratio) was statistically lower than the pneumonia group (p=0.020, p= 0.021, p=0.021, respectively). CONCLUSION: In this study, we showed that thiol/disulfide homeostasis could be used as new markers in the early period in order to separate patients with sepsis and patients with pneumonia.

Brief report: the effects of the menstrual cycle on the hemodynamic response to laryngoscopy and tracheal intubation.

We designed this study to determine the effect of the menstrual cycle on the hemodynamic response to tracheal intubation (TI). Sixty-two ASA I women who were either in the follicular phase (group F, n = 31) or luteal phase (group L, n = 31) of their menstrual cycle were included in the study. Patients received propofol and rocuronium for intubation. Hemodynamic variables were recorded before administration of the IV anesthetic, as well as after TI. Rate pressure products were calculated. Groups were similar in terms of demographic data. Rate pressure products values at the first minute after TI were significantly increased in group L than were those in group F (P < 0.001). We conclude that the phase of the menstrual cycle is an important factor in the hemodynamic response to TI.

Effect of menstrual cycle on the injection pain due to propofol.

BACKGROUND: This prospective, double-blind and randomized study is designed to determine the effect of menstrual cycle on the injection pain of propofol. METHODS: Seventy-two patients scheduled for elective surgery under general anaesthesia were divided into two groups according to the phase of the menstrual cycle. Patients were at follicular phase (Pd 8-12) in Group F (n = 36) and luteal phase (Pd 20-24) in Group L (n = 36). Injection pain was evaluated with 10-point numeric rating scale after 25% of the total propofol dose was injected over 20 s. RESULTS: There were no significant differences in terms of patient characteristics (P > 0.05). The mean propofol pain score was found 1.81 +/- 2.30 in Group F and 4.83 +/- 3.09 in Group L. Group L was found to have higher propofol injection pain scores than Group F (P < 0.001). CONCLUSION: We conclude that the menstrual phase changes the perception of pain due to propofol injection, which is higher in the lutheal phase. In clinical practice, the phases of the menstrual cycle may have a significant role on injection pain of propofol in woman.

The effect of intraarticular combinations of tramadol and ropivacaine with ketamine on postoperative pain after arthroscopic meniscectomy.

INTRODUCTION: The purpose of this prospective randomized study was to evaluate the effects of intraarticular combinations of tramadol and ropivacaine with ketamine in postoperative pain control of patients undergoing arthroscopic meniscectomy. MATERIALS AND METHODS: We randomly divided 80 patients into four groups to receive intraarticular 50 mg tramadol (Group T), 50 mg tramadol with 0.5 mg kg(-1) ketamine (Group TK), 75 mg ropivacaine (Group R), 75 mg ropivacaine with 0.5 mg kg(-1) ketamine (Group RK) in 20 ml normal saline at the end of surgery. Postoperative analgesia was provided with patient-controlled analgesia with morphine. Postoperative pain scores, total morphine consumption amount and side effects were recorded at intervals of 0, 1, 2, 4, 8, 12 and 24 h after the operation. RESULTS: Pain scores were higher in Group T when compared with Group R and Group RK at second and fourth hours, also compared with Group RK at zeroth, first, second, fourth and eighth hours. Total morphine consumption amount was found to be higher in Group T when compared to Group TK at eighth and twelfth hours and Group RK at eighth hours (P < 0.05). Total morphine consumption was lowest in Group TK (P < 0.05). There were no significant differences among the study groups regarding side effects. CONCLUSIONS: Administration of intraarticular tramadol-ketamine combination was found to be more effective in decreasing postoperative daily analgesic consumption.

Clinical and laboratory features of COVID-19: Predictors of severe prognosis.

BACKGROUND: Coronavirus disease 2019 (COVID-19) emerged first in December 2019 in Wuhan, China and quickly spread throughout the world. Clinical and laboratory data are of importance to increase the success in the management of COVID-19 patients. METHODS: Data were obtained retrospectively from medical records of 191 hospitalized patients diagnosed with COVID-19 from a tertiary single-center hospital between March and April 2020. Prognostic effects of variables on admission among patients who received intensive care unit (ICU) support and those who didn't require ICU care were compared. RESULTS: Patients required ICU care (n = 46) were older (median, 71 vs. 43 years), with more underlying comorbidities (76.1% vs. 33.1%). ICU patients had lower lymphocytes, percentage of large unstained cell (%LUC), hemoglobin, total protein, and albumin, but higher leucocytes, neutrophils, neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), platelet-lymphocytes ratio (PLR), urea, creatinine, aspartate amino transferase (AST), lactate dehydrogenase (LDH), and D-dimer when compared with non-critically ill patients (p < 0.001). A logistic regression model was created to include ferritin, %LUC, NLR, and D-dimer. %LUC decrease and D-dimer increase had the highest odds ratios (0.093 vs 5.597, respectively) to predict severe prognosis. D-dimer, CRP, and NLR had the highest AUC in the ROC analysis (0.896, 0.874, 0.861, respectively). CONCLUSIONS: The comprehensive analysis of clinical and admission laboratory parameters to identify patients with severe prognosis is important not only for the follow-up of the patients but also to identify the pathophysiology of the disease. %LUC decrease and D-dimer, NLR, and CRP increases seem to be the most powerful laboratory predictors of severe prognosis.

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.

[Non-invasive mechanical ventilation and epidural anesthesia for an emergency open cholecystectomy]. / Ventilação mecânica não invasiva e anestesia peridural em colecistectomia aberta de emergência.

Non-invasive ventilation is an accepted treatment modality in both acute exacerbations of respiratory diseases and chronic obstructive lung disease. It is commonly utilized in the intensive care units, or for postoperative respiratory support in post-anesthesia care units. This report describes intraoperative support in non-invasive ventilation to neuroaxial anesthesia for an emergency upper abdominal surgery.

Non-invasive mechanical ventilation and epidural anesthesia for an emergency open cholecystectomy.

Non-invasive ventilation is an accepted treatment modality in both acute exacerbations of respiratory diseases and chronic obstructive lung disease. It is commonly utilized in the intensive care units, or for postoperative respiratory support in post-anesthesia care units. This report describes intraoperative support in non-invasive ventilation to neuroaxial anesthesia for an emergency upper abdominal surgery.

[The effect of sugammadex on postoperative cognitive function and recovery]. / O efeito de sugamadex sobre a função cognitiva e recuperação no pós-operatório.

BACKGROUND AND OBJECTIVE: Sugammadex is the first selective relaxant binding agent. When compared with neostigmine, following sugammadex administration patients wake earlier and have shorter recovery times. In this study, we hypothesized that fast and clear awakening in patients undergoing general anesthesia has positive effects on cognitive functions in the early period after operation. METHODS: Approved by the local ethical committee, 128 patients were enrolled in this randomized, prospective, controlled, double-blind study. Patients were allocated to either Sugammadex group (Group S) or the Neostigmine group (Group N). The primary outcome of the study was early postoperative cognitive recovery as measured by the Montreal Cognitive Assessment (MoCA) and Mini Mental State Examination (MMSE). After baseline assessment 12-24h before the operation. After the operation, when the Modified Aldrete Recovery Score was ≥9 the MMSE and 1h later the MoCA tests were repeated. RESULTS: Although there was a reduction in MoCA and MMSE scores in both Group S and Group N between preoperative and postoperative scores, there was no statistically significant difference in the slopes (p>0.05). The time to reach TOF 0.9 was 2.19min in Group S and 6.47min in Group N (p<0.0001). Recovery time was 8.26min in Group S and 16.93min in Group N (p<0.0001). CONCLUSION: We showed that the surgical procedure and/or accompanying anesthetic procedure may cause a temporary or permanent regression in cognitive function in the early postoperative period. However, better cognitive performance could not be proved in the Sugammadex compared to the Neostigmine.

The effect of sugammadex on postoperative cognitive function and recovery.

BACKGROUND AND OBJECTIVE: Sugammadex is the first selective relaxant binding agent. When compared with neostigmine, following sugammadex administration patients wake earlier and have shorter recovery times. In this study, we hypothesized that fast and clear awakening in patients undergoing general anesthesia has positive effects on cognitive functions in the early period after operation. METHODS: Approved by the local ethical committee, 128 patients were enrolled in this randomized, prospective, controlled, double-blind study. Patients were allocated to either Sugammadex group (Group S) or the Neostigmine group (Group N). The primary outcome of the study was early postoperative cognitive recovery as measured by the Montreal Cognitive Assessment (MoCA) and Mini Mental State Examination (MMSE). After baseline assessment 12-24h before the operation. After the operation, when the Modified Aldrete Recovery Score was ≥9 the MMSE and 1h later the MoCA tests were repeated. RESULTS: Although there was a reduction in MoCA and MMSE scores in both Group S and Group N between preoperative and postoperative scores, there was no statistically significant difference in the slopes (p>0.05). The time to reach TOF 0.9 was 2.19min in Group S and 6.47min in Group N (p<0.0001). Recovery time was 8.26min in Group S and 16.93min in Group N (p<0.0001). CONCLUSION: We showed that the surgical procedure and/or accompanying anesthetic procedure may cause a temporary or permanent regression in cognitive function in the early postoperative period. However, better cognitive performance could not be proved in the Sugammadex compared to the Neostigmine.

Impact of the practising anesthesiologist team member on the laryngeal mask cuff pressures and adverse event rate.

OBJECTIVE: We have planned to evaluate the laryngeal mask cuff pressures (LMcp) inflated by anesthesia workers of several seniority, without using manometer. METHODS: 180 patients scheduled to have short duration surgery with laryngeal mask were included in the study. Five anesthesia specialists (Group S), 10 residents (Group R) and 6 technicians (Group T) inflated the LMc; thereafter LMcp were measured with pressure manometer. Participants have repeated this practice in at least five different cases. LMcp higher than 60 cm H2O at the initial placement or intraoperative period were adjusted to normal range. Sore throat was questioned postoperatively. Groups were compared in terms of mean LMcp and occupational experience. RESULTS: At the settlement of LM, LMcp pressures within the normal range were determined in 26 (14.4%) cases. Mean LMcp after LM placement in Group S, R and T were 101.2 ± 14.0, 104.3 ± 20.5 cm H2O and 105.2 ± 18.4 cm H2O respectively (p > 0.05). Mean LMcp values in all measurement time periods within the groups were above the normal limit (60 cm H2O). When groups were compared in terms of LMcp, no difference has been found among pressure values. Occupational experience was 14.2 ± 3.9; 3.3 ± 1.1 and 6.6 ± 3.8 years for specialists, residents and technicians respectively and measured pressure values were not different in regard of occupational experience. Seven (3.9%) patients had sore throat at the 24th hour interview. CONCLUSION: Considering lower possibility of normal adjustment of LMcp and ineffectiveness of occupational experience to obtain normal pressure values, it is suitable that all anesthesia practitioners should adjust LMcp with manometer.