Long-term care hospitals in Turkey: a review.

A long-term care hospital (LTCH) is a specialized facility for patients with serious health problems who require continuous and intensive care but not comprehensive diagnostic methods. LTCHs provide prolonged complex care and wound care in the period following the acute stage of disease. When intensive care unit (ICU) stay is prolonged in the United States of America, the patients may be transferred to an LTCH. Medicare suggests hospitalization > 25 days in LTCHs. The LTC system in Europe differs from that in other non-European countries and differences are also seen among European countries. In practice, patients who need LTC in Turkey are hospitalized in ICUs. Long term care is a new concept for the Turkish health system and there are no studies on LTCHs in Turkey. A significant proportion of intensive care beds in Turkey are used for long-term hospitalized patients with complex problems. This is a clear waste of resources. The establishment of LTCHs in Turkey would prevent from this waste and provide the opportunity to increase experience of complex treatments.

Perioperative outcome and cost-effectiveness of spinal versus general anesthesia for lumbar spine surgery.

BACKGROUND AND AIM: General anesthesia (GA) is the most commonly used anesthetic technique for spinal surgery. This study aimed to compare spinal anesthesia (SA) and GA in patients undergoing spinal surgery, in terms of perioperative outcome and cost effectiveness. MATERIALS AND METHODS: The study included 80 patients with ASA (American Society of Anesthesiologists) physical status I-II. The patients were randomized to receive SA (n = 40) or GA (n = 40). Heart rate (HR), mean arterial blood pressure (MABP), blood loss, duration of surgery, duration of anesthesia, surgeon satisfaction, and duration in the post-anesthesia care unit (PACU) were recorded. Postoperative analgesic requirement, nausea and vomiting (PONV), perioperative hemodynamic variables, and anesthetic costs were determined. RESULTS: HR and MABP were significantly higher in the GA group than in the SA group at the end of surgery and at PACU admission. Duration of anesthesia, surgeon satisfaction, postoperative analgesic requirement, and anesthetic costs were significantly higher in the GA group. Mean blood loss was lower in the SA group than in the GA group, but the difference was not significant. Duration of surgery, duration in the PACU, perioperative hemodynamic variables, and complications were similar in both groups. CONCLUSIONS: SA could be considered a reliable alternative to GA in patients undergoing lumber spine surgery, as it is clinically as effective as GA, but more cost effective.

Anesthetic management of a child with both Marfan syndrome and Turner syndrome.

Marfan syndrome is an autosomal dominant heritable disorder of the connective tissue that involves primarily the skeletal, ocular, and cardiovascular systems. Turner syndrome is a genetic disorder resulting from partial or complete X chromosome monosomy. We report the anesthetic management of a case of Marfan-Turner syndrome, which is the first such case to appear in the literature to our knowledge. A 3 year old ASA III girl was scheduled to undergo minor plastic surgery. She had a short webbed neck, prognathism, micrognathia, low-set ears, and a high palate. Her anterior and posterior facial heights were long. She had growth retardation, pectus excavatum, and joint laxity. She also had high-degree mitral insufficiency, mitral valve prolapse, and an atrial septal defect. After sevoflurane induction, the airway was secured using a size 2 LMA without any difficulty in the spontaneously breathing patient. Her blood pressure was within normal limits, no arrthymia occurred, and anesthesia was uneventful. Special care should be given to syndromic patients. Prior medical evaluations and any prior anesthetic history can help to focus preoperative evaluations and planning. Preoperatively targeting relevant organ systems, any anatomic or laboratory abnormalities that can be optimized, and perioperative airway management are all key to a successful outcome.

Palliative care after stroke.

Stroke is the leading cause of disability and one of the most common reasons of death around the world. Information is not sufficient on the palliative care (PC) needs of stroke patients and factors affecting their prognosis. In this study, we have investigated the demographics and comorbidities of stroke patients followed-up in a PC center (PCC), and the factors efficient on their prognosis. Medical records of 132 patients followed-up in PCC with stroke diagnosis between years 2016 and 2017 were reviewed retrospectively. Patients diagnosed with stroke were grouped as ischemic stroke, intracerebral hematoma (ICH) and subarachnoid hemorrhage (SAH). Age, gender, PCC hospitalization period (LOS), Glasgow Coma Scale, comorbidities such as percutaneous endoscopic gastrostomy, tracheostomy, pressure ulcer (PU), and discharge status (home, intensive care unit, exitus) have been compared for the patients included in the study. While average age was 72.41 ± 16.03 and hospitalization period was 35.47 ± 36.13 days, 92 patients (69.7%) were diagnosed with ischemic stroke, 20 patients (15.2%) with ICH, and 20 patients (15.2%) were diagnosed with SAH. The rate of exitus in patients diagnosed with ischemic stroke was significantly higher than patients diagnosed with ICH and SAH (p = 0.02), and hypertension rate was higher in patients with ischemic stroke than patients diagnosed with SAH (p = 0.007). The age of patients with exitus were found to be significantly higher (p = 0.001). Length of stay (LOS) in PC was determined to be significantly higher in patients with tracheostomy and patients diagnosed with ICH compared to patients with SAH. Furthermore, PU rate was significantly higher in patients diagnosed with ICH than patients with SAH (p = 0.007). Patients who experienced stroke and their families need comprehensive palliative care for psychosocial support, determination of patient-focused care objectives, and symptom management. There is a need for studies on larger populations to eliminate prognostic uncertainties and provide successful symptom management in patients following stroke.

An Examination of Factors Affecting the Length of Stay in a Palliative Care Center.

BACKGROUND: With the increase in elderly population, life-threatening chronic diseases are increasing, simultaneously increasing the need for palliative care centers (PCCs). OBJECTIVES: To evaluate the factors affecting the length of stay (LOS) and discharge of patients from a PCC. METHODS: A retrospective scan was made of the records of patients followed up in the PCC between January 2013 and March 2016. A record was made of patient age, gender, diagnosis, conditions/comorbidities, Glasgow Coma Scale, Karnofsky Performance Scale, LOS, prognosis (exitus or surviving), percutaneous endoscopic gastrostomy (PEG), tracheostomy, mechanical ventilator, nutrition (total parenteral nutrition [TPN] or enteral nutrition), and the results of cultures taken during stay in PCCs (blood, tracheal aspirate, urine, rectal swab, wound). Evaluation with regression analysis was made of the data related to factors thought to have a possible effect on the LOS in PCCs. RESULTS: Four hundred thirty-five patients were included in the study, comprising 58.6% men and 41.4% women with a mean age of 70.6 ± 17.2 years. The LOS was 27.2 ± 30.9 days. A total of 234 patients were discharged and 201 (46.2%) were lost to mortality in PCCs. The bacteria most isolated in cultures were Escherichia coli (28.5%) and methicillin resistant Staphylococcus aureus (MRSA) (17%). According to the results of the regression analysis, cancer, hypoxic brain, and advanced age had a negative effect on LOS and PEG, TPN, hypertension, and E. coli, Proteus, Pseudomonas, and Acinetobacter infections increased LOS. CONCLUSION: The results of this study revealed some basic factors that affect LOS in PCCs. However, there may be much variation in the data obtained with the various reasons for which this patient group is admitted to a PCC.

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.

Traumatic brain injury and palliative care: a retrospective analysis of 49 patients receiving palliative care during 2013-2016 in Turkey.

Traumatic brain injury (TBI), which is seen more in young adults, affects both patients and their families. The need for palliative care in TBI and the limits of the care requirement are not clear. The aim of this study was to investigate the length of stay in the palliative care center (PCC), Turkey, the status of patients at discharge, and the need for palliative care in patients with TBI. The medical records of 49 patients with TBI receiving palliative care in PCC during 2013-2016 were retrospectively collected, including age and gender of patients, the length of stay in PCC, the cause of TBI, diagnosis, Glasgow Coma Scale score, Glasgow Outcome Scale score, Karnofsky Performance Status score, mobilization status, nutrition route (oral, percutaneous endoscopic gastrostomy), pressure ulcers, and discharge status. These patients were aged 45.4 ± 20.2 years. The median length of stay in the PCC was 34.0 days. These included TBI patients had a Glasgow Coma Scale score ≤ 8, were not mobilized, received tracheostomy and percutaneous endoscopic gastrostomy nutrition, and had pressure ulcers. No difference was found between those who were discharged to their home or other places (rehabilitation centre, intensive care unit and death) in respect of mobilization, percutaneous endoscopic gastrostomy, tracheostomy and pressure ulcers. TBI patients who were followed up in PCC were determined to be relatively young patients (45.4 ± 20.2 years) with mobilization and nutrition problems and pressure ulcer formation. As TBI patients have complex health conditions that require palliative care from the time of admittance to intensive care unit, provision of palliative care services should be integrated with clinical applications.

Effects of Low-Flow Sevoflurane Anesthesia on Pulmonary Functions in Patients Undergoing Laparoscopic Abdominal Surgery.

Objective. The aim of this prospective, randomized study was to investigate the effects of low-flow sevoflurane anesthesia on the pulmonary functions in patients undergoing laparoscopic cholecystectomy. Methods. Sixty American Society of Anesthesiologists (ASA) physical status classes I and II patients scheduled for elective laparoscopic cholecystectomy were included in the study. Patients were randomly allocated to two study groups: high-flow sevoflurane anesthesia group (Group H, n = 30) and low-flow sevoflurane anesthesia group (Group L, n = 30). The fresh gas flow rate was of 4 L/min in high-flow sevoflurane anesthesia group and 1 L/min in low-flow sevoflurane anesthesia group. Heart rate (HR), mean arterial blood pressure (MABP), peripheral oxygen saturation (SpO2), and end-tidal carbon dioxide concentration (ETCO2) were recorded. Pulmonary function tests were performed before and 2, 8, and 24 hours after surgery. Results. There was no significant difference between the two groups in terms of HR, MABP, SpO2, and ETCO2. Pulmonary function test results were similar in both groups at all measurement times. Conclusions. The effects of low-flow sevoflurane anesthesia on pulmonary functions are comparable to high-flow sevoflurane anesthesia in patients undergoing laparoscopic cholecystectomy.

Survey of postoperative residual curarization, acute respiratory events and approach of anesthesiologists.

BACKGROUND AND OBJECTIVES: residual paralysis following the use of neuromuscular blocking drugs (NMBDs) without neuromuscular monitoring remains a clinical problem, even when NMBDs are used. This study surveys postoperative residual curarization and critical respiratory events in the recovery room, as well as the clinical approach to PORC of anesthesiologists in our institution. METHODS: This observational study included 415 patients who received general anesthesia with intermediate-acting NMBDs. Anesthesia was maintained by non-participating anesthesiologists who were blinded to the study. Neuromuscular monitoring was performed upon arrival in the recovery room. A CRE was defined as requiring airway support, peripheral oxygen saturation <90% and 90-93% despite receiving 3 L/min nasal O2, respiratory rate > 20 breaths/min, accessory muscle usage, difficulty with swallowing or speaking, and requiring reintubation. The clinical approach of our anesthesiologists toward reversal agents was examined using an 8-question mini-survey shortly after the study. RESULTS: The incidence of PORC was 43% (n = 179) for TOFR < 0.9, and 15% (n = 61) for TOFR < 0.7. The incidence of TOFR < 0.9 was significantly higher in women, in those with ASA physical status 3, and with anesthesia of short duration (p < 0.05). In addition, 66% (n = 272) of the 415 patients arriving at the recovery room had received neostigmine. A TOFR < 0.9 was found in 46% (n = 126) of the patients receiving neostigmine. CONCLUSIONS: When routine objective neuromuscular monitoring is not available, PORC remains a clinical problem despite the use of NMBDs. The timing and optimal antagonism of the neuromuscular blockade, and routine objective neuromuscular monitoring is recommended to enhance patient safety.

Survey of postoperative residual curarization, acute respiratory events and approach of anesthesiologists / Pesquisa de curarização residual no pós-operatório, eventos respiratórios agudos e abordagem de anestesiologistas

BACKGROUND AND OBJECTIVES: residual paralysis following the use of neuromuscular blocking drugs (NMBDs) without neuromuscular monitoring remains a clinical problem, even when NMBDs are used. This study surveys postoperative residual curarization and critical respiratory events in the recovery room, as well as the clinical approach to PORC of anesthesiologists in our institution. METHODS: This observational study included 415 patients who received general anesthesia with intermediate-acting NMBDs. Anesthesia was maintained by non-participating anesthesiologists who were blinded to the study. Neuromuscular monitoring was performed upon arrival in the recovery room. A CRE was defined as requiring airway support, peripheral oxygen saturation <90% and 90-93% despite receiving 3 L/min nasal O2, respiratory rate >20 breaths/min, accessory muscle usage, difficulty with swallowing or speaking, and requiring reintubation. The clinical approach of our anesthesiologists toward reversal agents was examined using an 8-question mini-survey shortly after the study. RESULTS: The incidence of PORC was 43% (n = 179) for TOFR <0.9, and 15% (n = 61) for TOFR <0.7. The incidence of TOFR <0.9 was significantly higher in women, in those with ASA physical status 3, and with anesthesia of short duration (p < 0.05). In addition, 66% (n = 272) of the 415 patients arriving at the recovery room had received neostigmine. A TOFR <0.9 was found in 46% (n = 126) of the patients receiving neostigmine. CONCLUSIONS: When routine objective neuromuscular monitoring is not available, PORC remains a clinical problem despite the use of NMBDs. The timing and optimal antagonism of the neuromuscular blockade, and routine objective neuromuscular monitoring is recommended to enhance patient safety.

JUSTIFICATIVA E OBJETIVOS: A paralisia residual após o uso de bloqueadores neuromusculares (BNMs) sem monitoração neuromuscular continua sendo um problema clínico, mesmo quando BNMs são usados. Este estudo pesquisou a curarização residual pós-operatória e os eventos respiratórios críticos em sala de recuperação, bem como a abordagem clínica da CRPO feita pelos anestesiologistas em nossa instituição. MÉTODOS: Este estudo observacional incluiu 415 pacientes que receberam anestesia geral com BNMs de ação intermediária. A manutenção da anestesia foi feita por anestesiologistas não participantes, "cegos" para o estudo. A monitoração neuromuscular foi realizada no momento da chegada à sala de recuperação. Um ERC foi definido como necessidade de suporte ventilatório; saturação periférica de oxigênio <90% e 90-93%, a despeito de receber 3 L/min de O2 via cânula nasal; frequência respiratória >20 bpm; uso de musculatura acessória; dificuldade de engolir ou falar e necessidade de reintubação. A abordagem clínica de nossos anestesiologistas, em relação aos agentes de reversão, foi avaliada usando um miniquestionário de oito perguntas logo após o estudo. RESULTADOS: A incidência de CRPO foi de 43% (n = 179) para a SQE <0 e 15% (n = 61) para a SQE <0,7. A incidência de SQE <0,9 foi significativamente maior em mulheres, pacientes com estado físico ASA III e com anestesia de curta duração (p < 0,05). Além disso, 66% (n = 272) dos 415 pacientes que chegam à sala de recuperação haviam recebido neostigmina. Uma SQE <0,9 foi encontrada em 46% (n = 126) dos pacientes que receberam neostigmina. CONCLUSÃO: Quando a monitoração neuromuscular objetiva de rotina não está disponível, a CRPO continua sendo um problema clínico, a despeito do uso de BNMs. O momento e o antagonismo ideais do bloqueio neuromuscular e a monitoração neuromuscular objetiva de rotina são recomendados para aumentar a segurança do paciente.