Serial determinations of neutrophil CD64 expression for the diagnosis and monitoring of sepsis in critically ill patients.

BACKGROUND: Early identification of sepsis is important to be able to initiate timely therapy and optimize survival. Neutrophil CD64 (nCD64) expression has been proposed as a potential marker of sepsis. METHODS: In this prospective observational study, adult patients admitted to our 34-bed medico-surgical department of intensive care over a 3.5-month period were included. Neutrophil CD64 expression was measured by flow cytometry at admission and daily until discharge or death. Blood C-reactive protein (CRP) level was measured routinely. Diagnosis of sepsis was recorded and appropriateness of empirical antibiotic treatment was established post hoc. RESULTS: Of the 548 patients included, 468 had flow cytometry measurements within 24 hours after admission, of whom 103 had sepsis. Septic patients had higher admission nCD64 expression than did nonseptic patients (P < .001). A cutoff admission nCD64 expression of 230 median fluorescence intensity (MFI) identified sepsis with a sensitivity of 89% (81%-94%) and specificity of 87% (83%-90%). When combining CRP and nCD64 expression, an abnormal result for both was associated with a 92% probability of sepsis, whereas sepsis was ruled out with a probability of 99% if both were normal. Septic patients receiving inappropriate empirical antibiotics had persistently elevated nCD64 expression, whereas expression decreased over time in patients receiving appropriate antibiotics. In nonseptic patients, an increase in nCD64 expression ≥40 MFI predicted intensive care unit (ICU)-acquired infection (n = 29) with a sensitivity of 88% and specificity of 65%. CONCLUSIONS: Measurement of nCD64 expression at ICU admission, especially when combined with CRP concentrations, is useful in diagnosing sepsis. Serial determinations of nCD64 could be used for monitoring purposes.

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.

Automatic detection of patient-ventilator asynchrony by spectral analysis of airway flow.

INTRODUCTION: Adequate ventilatory support of critically ill patients depends on prompt recognition of ventilator asynchrony, as asynchrony is associated with worse outcomes.We compared an automatic method of patient-ventilator asynchrony monitoring, based on airway flow frequency analysis, to the asynchrony index (AI) determined visually from airway tracings. METHODS: This was a prospective, sequential observational study of 110 mechanically ventilated adults. All eligible ventilated patients were enrolled. No clinical interventions were performed. Airway flow and pressure signals were sampled digitally for two hours. The frequency spectrum of the airway flow signal, processed to include only its expiratory phase, was calculated with the Cooley-Tukey Fast Fourier Transform method at 2.5 minute intervals. The amplitude ratio of the first harmonic peak (H1) to that of zero frequency (DC), or H1/DC, was taken as a measure of spectral organization. AI values were obtained at 30-minute intervals and compared to corresponding measures of H1/DC. RESULTS: The frequency spectrum of synchronized patients was characterized by sharply defined peaks spaced at multiples of mean respiratory rate. The spectrum of asynchronous patients was less organized, showing lower and wider H1 peaks and disappearance of higher frequency harmonics. H1/DC was inversely related to AI (n = 110; r2 = 0.57; P < 0.0001). Asynchrony, defined by AI > 10%, was associated H1/DC < 43% with 83% sensitivity and specificity. CONCLUSIONS: Spectral analysis of airway flow provides an automatic, non-invasive assessment of ventilator asynchrony at fixed short intervals. This method can be adapted to ventilator systems as a clinical monitor of asynchrony.

Evaluation of Cardiopulmonary Resuscitation Conditions in Turkey: Current Status of Code Blue.

OBJECTIVE: Globally, previously determined teams activated by 'code blue' calls target rapid and organised responses to medical emergency situations. This study aimed to evaluate the cardiopulmonary resuscitation (CPR) conditions in Turkey. METHODS: A web-based survey was sent to anaesthesiologists in Turkey via email. The survey included 36 questions about demographic features and 'code blue' practices and procedures. RESULTS: A total of 180 participants were included. The mean working duration was 16.1±7.5 years. Of the anaesthesiologists who participated, 35% worked in university, 26.1% in education and research, 1.7% in city hospitals, 18.9% in state hospitals and 18.3% in private hospitals; 68.3% had CPR certification. There were code blue systems in 97.6% of the organisations. For code blue calls, 71.9% were activated by calling '2222'. There were 41.5% organisations with code blue teams of 3-4 people, whereas 26.7% had 2-member teams. Among call responders, 68.5% were anaesthesia technicians/paramedics, 60.7% were anaesthesiologists and 42.7% were anaesthesia assistants. In organisations, 66.3% regularly conducted code blue training. In total, 63.3% of the participants stated that the time to reach the location was nearly 2-4 minutes. During CPR, the use of capnography was 18.3%. Of the participants, 73.8% chose endotracheal intubation as priority airway device during CPR. CONCLUSION: Today, code blue practice is an important quality criterion for hospitals. This study shows the current status of 'code blue' according to the results of respondent data completing the survey. To prevent in-hospital cardiac arrest, a chain of preventive measures should be established, including personnel training, monitoring of patients, recognition of patient deterioration, the presence of a call for help system and effective intervention.

Carbon monoxide poisoning.

Carbon monoxide (CO) is the leading cause of poisoning deaths in many countries, including Japan. Annually, CO poisoning claims about 2000-5000 lives in Japan, which is over half of the total number of poisoning deaths. This paper discusses the physicochemical properties of CO and the toxicological evaluation of CO poisoning.

The association between the OPRM1 A118G polymorphism and addiction in a Turkish population.

Susceptibility to addiction has a complex genetic basis that includes genes associated with the action and metabolism of drugs of abuse. One important gene in that respect is OPRM1, which codes for the µ-opioid receptor and has an important role in mediating the rewarding effects of addiction substances. The aim of our study was to assess the prevalence of the OPRM1 A118G polymorphism (rs1799971) in Turkish population and to investigate its association with opioid and other substance addiction. In addition, we examined the association of rs1799971 in addicted patients who were also diagnosed with psychiatric disorders. The study included 103 patients addicted to opioids, cocaine, ecstasy, alcohol, lysergic acid diethylamide (LSD), cannabis, and sedative/hypnotic substances and 83 healthy volunteers with similar demographic features as controls. rs1799971 polymorphisms were identified with the polymerase chain reaction restriction fragment length polymorphism method (PCR-RFLP). The genotype frequencies were significantly higher in the addicted patients than controls (32.0 % vs 16.9 %, respectively; p=0.027). The prevalence of the G allele was 16.1 % in the addicted group and 8.4 % in the control group (p=0.031). Our study confirmed the association between the rs1799971(G) allele frequency and opioid and other substance addiction, but not with psychiatric disorders.

Considerations in the aeromedical evacuation of a critically ill blast victim: lessons learned.

Rationale for the decision to transport and assessment of available resources are integral components of the decision for aeromedical evacuation of critically ill patients. We present the case of a 20-year-old man who sustained significant trauma after his vehicle struck a land mine. This case reviews and emphasizes the factors to consider in arriving at the decision to transport as well as the accurate assessment of available equipment and personnel resources.

The effect of race on long term mortality in mechanically ventilated patients.

OBJECTIVE: Determine the impact of race on one-year mortality following mechanical ventilation. BACKGROUND: There is a lack of prospective studies on the effect of race on survival following mechanical ventilation. METHODS: Observational study of adult patients on ventilatory support for <24 h prior to enrollment. Socioeconomic factors, laboratory and clinical data were recorded. Primary outcome was one-year mortality. RESULTS: We enrolled 178 patients; 100 African American (AA), 78 other races (OTH). One-year mortality for AA was 49% and 33% for OTH (p = 0.035). After correcting for covariates, race was not significantly associated with mortality (p = 0.42). AA patients had higher mean arterial blood pressure, serum creatinine, heart rate, and peak (p < 0.01) and mean (p = 0.05) airway pressures. CONCLUSIONS: AA patients who underwent mechanical ventilation had greater one-year mortality, although race per se was not a significant factor. It remains to be determined if strict blood pressure control and lower airway pressures may improve survival in this racial group.

The effects of desflurane on human platelet aggregation in vitro.

In view of the possible antiplatelet effects of general anesthetics, we investigated the in vitro effects of desflurane, a new inhalation agent, on platelet aggregation. For 15 patients who underwent elective operations, blood was sampled with desflurane induction before and after anesthesia but prior to surgery so that platelet aggregation in the drawn blood could be tested before desflurane anesthesia and again after exposure to the anesthetic. Platelet aggregation was measured with a whole-blood aggregometer. Adenosine diphosphate (ADP), collagen, and ristocetin were used as aggregating agents. Our results showed that aggregation in response to ADP, collagen, or ristocetin was not inhibited in patients who received desflurane anesthesia. This study with an in vitro model showed that desflurane had no influence on platelets in clinically relevant doses.

Effects of halothane, enflurane, and isoflurane on plasma and erythrocyte antioxidant enzymes and trace elements.

Alterations of the normal redox balance in mammals might be attributed to increases of plasma free-radical concentrations and/or a disruption of the protective mechanisms. These conditions lead to damage to cellular structure by the mechanism of lipoperoxidation, particularly in the liver, kidney, and central nervous system. In this study, the effect of general anesthesia on the oxidative metabolism of human plasma and erythrocytes was investigated. Forty-five patients undergoing anesthesia by using halothane, enflurane, or isoflurane were included in this study. Blood samples were taken preoperatively, the first hour, the first day, and the third day after the operation. Superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) enzyme activities and trace elements such as cofactor copper (Cu), zinc (Zn) and selenium (Se) levels were measured in plasma and red blood cells. Our results showed that halothane and enflurane administration increased the plasma GSH-Px activity and reduced zinc levels. In addition, they lowered SOD and GSH-Px activities and trace element levels on erythrocytes. Isoflurane had no effect on plasma antioxidant enzymes, but, similar to the others, isoflurane decreased the plasma zinc levels, erythrocyte SOD and GSH-Px activities and trace element levels.

Axillary brachial plexus blockade: an evaluation of three techniques.

Surgical procedures to the distal humerus, elbow, and proximal forearm are ideally suited to regional anesthetic techniques. Selection of the preferred approach is determined by the innervation of the surgical site, the risks of regional anesthesia-related complications, and the preference and experience of the anesthesiologist. The axillary approach to the brachial plexus is the most commonly used because of its ease of performance, patient acceptance, safety, and reliability, particularly for hand and forearm surgery. Nerve location technique does not affect success rate with the supraclavicular and interscalene approaches but it does with axillary approaches. The purpose of this study was to evaluate three techniques of plexus identification in axillary blockade. Sixty-nine American Society of Anesthesiologists grade I to II patients who had undergone orthopedic or traumatological surgical procedures on the upper extremity during a period of 1 year were chosen. After premedication, patients were divided randomly into three groups according to the technique of plexus identification. Group A (n = 23) consisted of those treated with the Winnie technique; group B (n = 23) consisted of those treated with the transarterial technique; group C (n = 23) consisted of those treated with the combination technique. Axillary blockade performed using the combined technique had higher a success rate than blockade performed with the transarterial and Winnie techniques. Our results suggest that all three techniques are reliable for axillary blockade. But the onset, complete blockade time, and quality of analgesia were better with the combined technique than with the transarterial and Winnie techniques.

Decreased respiratory rate variability during mechanical ventilation is associated with increased mortality.

OBJECTIVE: Patients on ventilatory support often experience significant changes in respiratory rate. Our aim was to determine the possible association between respiratory rate variability (RRV) and outcomes in these patients. DESIGN: A longitudinal, prospective, observational study of patients mechanically ventilated for at least 12 h performed in a medical-surgical intensive care unit. Patients were enrolled within 24 h of the initiation of ventilatory support. We measured airway signals continuously for the duration of ventilatory support and calculated expiratory flow frequency spectra at 2.5-min intervals. We assessed RRV using the amplitude ratio of the flow spectrum's first harmonic to the zero frequency component. Measures of the amplitude ratio were averaged over the total monitored time. Patients with time-averaged amplitude ratios <40 % were classified as high RRV and those ≥40 % as low RRV. All-cause mortality rates were assessed at 28 and 180 days from enrollment with a Cox proportional hazards model adjusted for disease acuity by the simplified acute physiology score II. RESULTS: We enrolled 178 patients, of whom 47 had high RRV and 131 low RRV. Both groups had similar disease acuity upon enrollment. The 28- and 180-day mortality rates were greater for low RRV patients with hazard ratios of 4.81 (95 % CI 1.85-12.65, p = 0.001) and 2.26 (95 % CI 1.21-4.20, p = 0.01), respectively. Independent predictors of 28-day mortality were low RRV, i.v. vasopressin, and SAPS II. CONCLUSIONS: Decreased RRV during ventilatory support is associated with increased mortality. The mechanisms responsible for this finding remain to be determined.

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.

Oxidative and antioxidative effects of desflurane and sevoflurane on rat tissue in vivo.

General anaesthetics are often used in patients who are under oxidative stress due to a critical illness or surgical trauma. Some anaesthetics may worsen oxidative stress and some may act as antioxidants. The aim of this study was to evaluate liver, brain, kidney, and lung tissue oxidative stress in rats exposed to desflurane and sevoflurane and in unexposed rats. The animals were divided in three groups: control (received only air); sevoflurane (8 %), and desflurane (4 %). After four hours of exposure, we evaluated the levels of malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), Cu, and Zn. Exposure to either of the anaesthetics significantly increased lung MDA levels compared to control (Mann-Whitney U test; P<0.05), probably because it is the tissue directly exposed to anaesthetic gases. Oxidative stress and antioxidant activity in other tissues varied between the desflurane and sevoflurane groups. Our results suggest that anaesthesiologist should not only be aware of the oxidative or antioxidative potential of anaesthetics they use, but should also base their choices on organs which are the most affected by their oxidative action.

Effects of sevoflurane and/or nitrous oxide on bacterial growth in in vitro culture conditions.

The aim of this study was to determine the role of sevoflurane and/or nitrous oxide on bacterial growth under conditions in vitro similar to those of clinical practice. We assessed these effects on Pseudomonas aeruginosa, Acinetobacter lwoffii, and Staphylococcus aureus growth. Bacterial inoculums were prepared from reference strains in nutritive broth. Airtight chambers were filled with bacterial suspensions. Each strain was studied with and without exposure to sevoflurane and/or nitrous oxide at baseline, after 1 and 3 h. Serial dilutions and agar plates were made and the colonies were counted. P. aeruginosa were grown after exposure to the nitrous oxide alone (2.8 x 10(3) colony-forming units/ml; CFU ml(-1)) after 3 h according to the control (P < 0.05). A. lwoffii were grown after exposure to the nitrous oxide and sevoflurane with nitrous oxide (8.7 x 10(3) and 8.0 x 10(3) CFU ml(-1)) (P < 0.05), respectively. There were no changes in S. aureus growth in controls and anesthesia groups. We conclude that the effects of anesthetic agents on bacterial growth may change owing to the type of anesthetic and microorganism.

Effect of volatile anesthetics on oxidative stress due to occupational exposure.

Possible health hazards from long-term exposure to inhalation anesthetics cannot yet be definitively excluded. One of the adverse effects of general anesthetics is the exogen sources of reactive oxygen radicals that are responsible for several diseases. We designed the present study to determine the effect of volatile anesthetics on oxidative stress due to occupational exposure. We enrolled 30 anesthesia and surgery personnel who had been exposed to inhalation anesthetics for 3 years and 30 healthy volunteer personnel who had not been exposed to inhalation anesthetics at any period of their life as the control group. Blood samples were taken from both groups for determination of superoxide dismutase, glutathione peroxidase, and their cofactors, which are selenium, copper, and zinc levels. Our results revealed that plasma and erythrocyte antioxidant activity and trace element levels were significantly lower in operating room personnel compared to that in the control groups. We concluded that the antioxidant defense system was affected by free radical injury in anesthesia and surgery personnel who had been exposed to inhalation anesthetics chronically. Therefore, minimizing occupational exposure to volatile anesthetics is important for protecting operation room personnel from hazards. Operating room personnel should also take antioxidant supplements.