[Venous thromboembolism prophylaxis methods in trauma and emergency surgery intensive care unit patients: low molecular weight heparin versus elastic stockings + intermittent pneumatic compression]. / Travma ve acil cerrahi yogun bakim hastalarinda venöz tromboemboli profilaksisi: Düsük molekül agirlikli heparin ile elastik çorap + aralikli pnömotik kompresyonun karsilastirilmasi.

BACKGROUND: We aimed to evaluate the efficacy and safety of low molecular weight heparin (LMWH) compared to elastic stockings in combination with intermittent pneumatic compression (ES+IPC) in venous thromboembolism (VTE) prophylaxis in the intensive care unit (ICU) of trauma and emergency surgery. METHODS: From June 2005 to June 2007, 259 patients who were on mechanic ventilation in the ICU were assigned to two groups as either LMWH (152 patients) or ES+IPC (94 patients). Color flow Doppler sonography was performed on the 3rd and 7th days. RESULTS: Deep venous thrombosis was determined in 3 (2%) of the LMWH group and in 1 (1%) in the ES+IPC group. Minor bleeding was seen in 15 patients. The frequency of VTE was 1.5%. Two patients suffered from fatal pulmonary embolism (PE) among a total of 4 patients with PE. CONCLUSION: We believe that the protocol applied for VTE prophylaxis in the Emergency Surgery Department of Istanbul Medical Faculty is effective and safe in this group with such high mortality and morbidity.

The effects of airway pressure and inspiratory time on bacterial translocation.

BACKGROUND: Mechanical ventilation with high peak inspiratory pressure (PIP) induces lung injury and bacterial translocation from the lung into the systemic circulation. We investigated the effects of increased inspiratory time on translocation of intratracheally inoculated bacteria during mechanical ventilation with and without extrinsic positive end-expiratory pressure (PEEP). METHODS: Rats were ventilated in pressure-controlled mode with 14 cm H2O PIP, 0 cm H2O PEEP, I:E ratio 1/2, and Fio2 1.0. Subsequently, 0.5 mL of 10(5) cfu/mL Pseudomonas aeruginosa was inoculated through tracheostomy and rats were randomly assigned to six groups; two low-pressure groups (LP)1/2, 14 cm H2O PIP, 0 cm H2O PEEP, I:E = 1/2, and LP2/1 14 cm H2O PIP, 0 cm H2O PEEP, I:E = 2/1; two high-pressure groups (HP)1/2, 30 cm H2O PIP, 0 cm H2O PEEP, I:E = 1/2, and HP2/1, 30 cm H2O PIP, 0 cm H2O PEEP, I:E = 2/1; two HP PEEP groups (HPP)1/2, 30 cm H2O PIP, 10 cm H2O PEEP, I:E = 1/2, and HPP2/1, 30 cm H2O PIP, 10 cm H2O PEEP, I:E = 2/1. Blood cultures were obtained every 30 min. The rats were killed and their lungs were processed. RESULTS: When compared with baseline values, Pao2 decreased in the LP1/2, LP2/1, HP1/2, and HP2/1 groups at the last time point, but the decline in Pao2 reached statistical significance in only the HP1/2 group. The bacterial translocation rate was greater in group HPP2/1 than group HPP1/2 (P = 0.01). CONCLUSIONS: We found that high PIP, with or without prolonged inspiratory time, increased the rate of bacterial dissemination. PEEP prevented bacterial translocation in the high PIP group. However, the protective effect of PEEP was lost when inspiratory time was prolonged.

Effects of body temperature on ventilator-induced lung injury.

PURPOSE: To evaluate the effects of body temperature on ventilator-induced lung injury. MATERIAL AND METHODS: Thirty-four male Sprague-Dawley rats were randomized into 6 groups based on their body temperature (normothermia, 37 +/- 1 degrees C; hypothermia, 31 +/- 1 degrees C; hyperthermia, 41 +/- 1 degrees C). Ventilator-induced lung injury was achieved by ventilating for 1 hour with pressure-controlled ventilation mode set at peak inspiratory pressure (PIP) of 30 cmH2O (high pressure, or HP) and positive end-expiratory pressure (PEEP) of 0 cmH2O. In control subjects, PIP was set at 14 cmH2O (low pressure, or LP) and PEEP set at 0 cmH2O. Systemic chemokine and cytokine (tumor necrosis factor alpha , interleukin 1 beta , interleukin 6, and monocyte chemoattractant protein 1) levels were measured. The lungs were assessed for histological changes. RESULTS: Serum chemokines and cytokines were significantly elevated in the hyperthermia HP group compared with all 3 groups, LP (control), normothermia HP, and hypothermia HP. Oxygenation was better but not statistically significant in hypothermia HP compared with other HP groups. Cumulative mean histology scores were higher in hyperthermia HP and normothermia HP groups compared with control and normothermia HP groups. CONCLUSIONS: Concomitant hyperthermia increased systemic inflammatory response during HP ventilation. Although hypothermia decreased local inflammation in the lung, it did not completely attenuate systemic inflammatory response associated with HP ventilation.

[Iatrogenic hypernatremia during hydatid cyst operation]. / Karaciger Kist Hidatik Operasyonunda Iyatrojenik Hipernatremi.

Hypernatremia due to salt gain is generally iatrogenic. This case report presents a 55 year-old woman who was operated because of hepatic hydatid cyst. At the end of the operation, following extubation the patient was unconscious and serum sodium concentration was found to be 185 mEq/ L. The patient was entubated again and transferred to the intensive care unit. When the patient awaked and became conscious at 36th hour in intensive care unit, she was extubated and transferred to ward with serum sodium concentration of 142 mEq/L. The serum sodium concentration should be monitored carefully in hydatid cyst operation, during which hypertonic saline is used for scelosidal effects as general anesthesia can mask neurologic signs due to hypernatremia.

Recruitment Maneuver Does not Increase the Risk of Ventilator Induced Lung Injury.

BACKGROUND: Mechanical ventilation (MV) may induce lung injury. AIMS: To assess and evaluate the role of different mechanical ventilation strategies on ventilator-induced lung injury (VILI) in comparison to a strategy which includes recruitment manoeuvre (RM). STUDY DESIGN: Randomized animal experiment. METHODS: Thirty male Sprague-Dawley rats were anaesthetised, tracheostomised and divided into 5 groups randomly according to driving pressures; these were mechanically ventilated with following peak alveolar opening (Pao) and positive end-expiratory pressures (PEEP) for 1 hour: Group 15-0: 15 cmH2O Pao and 0 cmH2O PEEP; Group 30-10: 30 cmH2O Pao and 10 cmH2O PEEP; Group 30-5: 30 cmH2O Pao and 5 cmH2O PEEP; Group 30-5&RM: 30 cmH2O Pao and 5 cmH2O PEEP with additional 45 cmH2O CPAP for 30 seconds in every 15 minutes; Group 45-0: 45 cmH2O Pao and 0 cmH2O PEEP Before rats were sacrificed, blood samples were obtained for the evaluation of cytokine and chemokine levels; then, the lungs were subsequently processed for morphologic evaluation. RESULTS: Oxygenation results were similar in all groups; however, the groups were lined as follows according to the increasing severity of morphometric evaluation parameters: Group 15-0: (0±0.009) < Group 30-10: (0±0.14) < Group 30-5&RM: (1±0.12) < Group 30-5: (1±0.16) < Group 45-0: (2±0.16). Besides, inflammatory responses were the lowest in 30-5&RM group compared to all other groups. TNF-α, IL-1ß, IL-6, MCP-1 levels were significantly different between group 30-5&RM and group 15-0 vs. group 45-0 in each group. CONCLUSION: RM with low PEEP reduces the risk of ventilator-induced lung injury with a lower release of systemic inflammatory mediators in response to mechanical ventilation.

Role of magnesium sulfate in postoperative pain management for patients undergoing thoracotomy.

OBJECTIVE: The purpose of this study was to investigate the effect of magnesium sulfate on pain management for post-thoracotomy patients. DESIGN: A prospective, randomized, controlled clinical study. SETTING: University hospital. PARTICIPANTS: Twenty-four patients undergoing thoracotomy. INTERVENTIONS: After thoracotomy operations, patients were assigned to 2 groups. The control group received intravenous morphine (0.5 mg/h infusion, 0.3 mg patient-controlled anesthesia dose, 15-minute lockout time) via patient-controlled analgesia, and the magnesium group received magnesium sulfate (30-mg/kg bolus, 10 mg/kg/h infusion for 48 hours) plus the same patient-controlled analgesia protocol. MEASUREMENTS AND MAIN RESULTS: Visual analog scale for pain score, sedation score, mean arterial pressure, heart rate, and valid and invalid analgesic demand were recorded. Serum magnesium levels were determined at postanesthesia care unit admission, at 24 hours, and at 48 hours. Side effects were also recorded. There were no significant differences between groups with respect to demographics, sedation score, and pain score. Cumulative mean morphine consumption was found to be higher in the control group compared with the magnesium group at 4, 8, and 48 hours (5.6 +/- 1 mg v 3.2 +/- 0.6 mg [p < 0.0001], 10.2 +/- 1.8 mg v 7.2 +/- 1.6 mg [p = 0.0003), and 40.2 +/- 4.5 mg v 34.8 +/- 6.3 mg [p = 0.02], respectively). CONCLUSION: Postoperative use of magnesium sulfate reduced opioid consumption for pain after thoracotomy operations.

Risk factors for mortality of nosocomial bacteraemia in intensive care units.

OBJECTIVE: The aim of this study was to follow critically ill patients prospectively in intensive care units (ICUs) to determine risk factors for mortality and outcome associated with nosocomial bacteraemia (NB). SUBJECTS AND METHODS: A case-control study of 176 patients was conducted to identify the risk factors for mortality of NB in ICU patients. The study was performed in emergency, surgical and general surgical ICUs with 23 beds during a 15-month period. A total of 1,450 patients were admitted to the ICUs during the study period. The USA Center for Disease Control and Prevention definitions were used to diagnose nosocomial infections. Nosocomial bacteraemia was defined as the isolation of one or more organisms from blood cultures taken at least 48 h after admission, which were not related to a problem present on admission. An assessment of whether the isolated organisms represented true bacteraemia rather than contamination was made by clinical or laboratory evidence of infection. RESULTS: A total of 214 bacteraemia episodes were found in the 176 patients (64 female, 112 male; 51.3 +/- 21.3 years old), 90 of whom died and 86 survived. The bacteraemia rate was 12.1%. The most common etiological agents of bacteraemia were Klebsiella pneumoniae: 46 (21.5%), methicillin-resistant Staphylococcus aureus: 46 (21.5%), Pseudomonas aeruginosa: 32 (14.9%), and Escherichia coli: 20 (9.3%). Multivariate analysis showed that the requirement of mechanical ventilation for more than 7 days (p < 0.001), total parenteral nutrition (p = 0.034), inotropic drug (p < 0.001), and increased creatinine level (p = 0.034) were independent risk factors for mortality of NB in ICUs. CONCLUSIONS: Nosocomial infections caused by Gram-negative bacteria continue to be one of the major sources of morbidity and mortality.

Time required for equilibration of arterial oxygen pressure after setting optimal positive end-expiratory pressure in acute respiratory distress syndrome.

OBJECTIVE: To evaluate the time course of Pao2 change following the setting of optimal positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome (ARDS). DESIGN: Prospective clinical study. SETTING: Multidisciplinary intensive care unit of a university hospital. PATIENTS: Twenty-five consecutive patients with ARDS. INTERVENTIONS: ARDS was diagnosed during pressure-regulated volume control ventilation with tidal volume of 7 mL/kg actual body weight, respiratory rate of 12 breaths/min, inspiratory/expiratory ratio of 1:2, Fio2 of 1, and PEEP of 5 cm H2O. A critical care attending physician obtained pressure volume curves and determined the lower inflection point. Following a rest period of 30 mins with initial ventilation variables, PEEP was set at 2 cm H2O above the lower inflection point, and serial blood samples were collected during 1-hr ventilation with optimal PEEP. Arterial blood gas analyses were performed at 1, 3, 5, 7, 9, 11, 15, 20, 30, 45, and 60 mins. MEASUREMENTS AND MAIN RESULTS: Twenty-five patients were found eligible for the study. Three patients were excluded due to deterioration of oxygen saturation and hemodynamic instability following the initiation of optimal PEEP. Eight cases (36%) were considered to be of pulmonary origin and 14 cases (64%) of extrapulmonary origin. Optimal PEEP levels were 14 +/- 3 cm H2O and 14 +/- 4 cm H2O in pulmonary and extrapulmonary ARDS, respectively. Pao2 demonstrated a 130 +/- 101% increase at the end of 1-hr period in total study population. This improvement did not differ significantly between pulmonary and extrapulmonary forms of ARDS (135 +/- 118% vs. 127 +/- 95%, p = .8). Mean 90% oxygenation time was found to be 20 +/- 19 mins. In the subset of patients with ARDS of pulmonary origin, 90% oxygenation time was 25 +/- 26 mins, whereas it was 17 +/- 15 mins in patients with ARDS of extrapulmonary origin (p = .8). CONCLUSIONS: Our data showed that 20 mins would be adequate for obtaining a blood gas sample in ARDS patients with pulmonary and extrapulmonary origin after application of optimal PEEP 2 cm H2O above the lower inflection point.

[Is jejunal feeding efficient in critically ill patients?]. / Kritik hastada jejunal beslenme etkin midir?

BACKGROUND: The aim of this study is to compare the results of jejunal and gastric nutrition in the ICU. METHODS: Caloric intake and nutritional complications were recorded for ten days period in patients receiving gastric (n = 21) and jejunal (n = 22) feeding. RESULTS: Caloric requirements were reached on the 3rd day of nutrition in 86% of jejunal and 28% of gastric feeding patients (p 0.001). In jejunal group, delivered calorie/goal calorie ratio was found 15-20% higher than the gastric group. Serum albumin, triglyceride, cholesterol levels and nitrogen balance did not show significant differences between groups. Vomiting (p 0.01) and colouring of tracheal aspirates (p 0.05) were more frequent in gastric group, however positive tracheal culture frequency did not differ between the groups. CONCLUSION: It is concluded that higher caloric intakes could be tolerated earlier in patients receiving jejunal feeding.

Effects of sustained inflation and postinflation positive end-expiratory pressure in acute respiratory distress syndrome: focusing on pulmonary and extrapulmonary forms.

OBJECTIVE: To investigate whether the response to sustained inflation and postinflation positive end-expiratory pressure varies between acute respiratory distress syndrome with pulmonary (ARDS(exp)) and extrapulmonary origin (ARDS(exp)). DESIGN: Prospective clinical study. SETTING: Multidisciplinary intensive care unit in a university hospital. PATIENTS: A total of 11 patients with ARDS and 13 patients with ARDS. INTERVENTIONS: A 7 ml/kg tidal volume, 12-15 breaths/min respiratory rate, and an inspiratory/expiratory ratio of 1:2 was used during baseline ventilation. Positive end-expiratory pressure levels were set according to the decision of the primary physician. Sustained inflation was performed by 45 cm H2O continuous positive airway pressure for 30 secs. Postinflation positive end-expiratory pressure was titrated decrementally, starting from a level of 20 cm H2O to keep the peripheral oxygen saturation between 92% and 95%. Fio2 was decreased, and baseline tidal volume, respiratory rate, inspiratory/expiratory ratio were maintained unchanged throughout the study period. MEASUREMENTS AND MAIN RESULTS: Blood gas, airway pressure, and hemodynamic measurements were performed at the following time points: at baseline and at 15 mins, 1 hr, 4 hrs, and 6 hrs after sustained inflation. After sustained inflation, the Pao2/Fio2 ratio improved in all of the patients both in ARDS(p) and ARDS(exp). However, the Pao2/Fio2 ratio increased to >200 in four ARDS(p) patients (36%) and in seven ARDS(p) patients (54%). In two of those ARDS patients, the Pao2/Fio2 ratio was found to be <200, whereas none of the ARDS(p) patients revealed Pao2/Fio2 ratios of <200 at the 6-hr measurement. Postinflation positive end-expiratory pressure levels were set at 16.7 +/- 2.3 cm H O in ARDS(p) and 15.6 +/- 2.5 cm H2O in ARDS. The change in Pao /Fio ratios was found statistically significant in patients with ARDS(p) (p =.0001) and with ARDS(p) (p =.008). Respiratory system compliance increased in ARDS patients (p =.02), whereas the change in ARDS was not statistically significant. CONCLUSIONS: Sustained inflation followed by high levels of postinflation positive end-expiratory pressure provided an increase in respiratory system compliance in ARDS; however, arterial oxygenation improved in both ARDS forms.

[The effects of immunonutrition on the development of nosocomial infections and on clinical outcome in critically ill patients]. / Yogun bakim hastalarinda uygulanan immünonütrisyonun nozokomiyal enfeksiyon gelisimine ve klinik sonuca etkisi.

BACKGROUND: We investigated the effects of early immunonutrition on the development of nosocomial infections and clinical outcome in intensive care patients. METHODS: Thirty mechanically ventilated patients were randomly assigned to two enteral nutrition regimens in the intensive care unit. Fifteen patients (8 males, 7 females; mean age 54 years; range 21 to 72 years) received immunonutrition solution containing arginine, nucleotides, and polyunsaturated fatty acids, while controls (10 males, 5 females; mean age 55 years; range 24 to 78 years) received isocaloric solution. The patients were evaluated daily using the APACHE II and SOFA (Simplified Organ Failure Assessment) scoring systems. Infections were sought in tracheal, blood, urine, and catheter cultures. Changes in nitrogen balance, leukocyte count, and APACHE II and SOFA scores were compared. RESULTS: Significant changes in nitrogen balance, APACHE II and SOFA scores, and leukocyte count were found in the study group (p<0.001, p<0.0001, p<0.0001, p<0.05, respectively), whereas no significant differences were detected in the control group. Cultures were positive in nine patients in the immunonutrition group, and in 12 patients in the control group. Septic shock and mortality rates were 26% and 20% in the study patients, and 40% and 33% in the controls, respectively (p>0.05). CONCLUSION: Patients receiving immunonutrition exhibit better nutritional status and improved scores showing clinical severity and organ failure.

The effects of IgM-enriched immunoglobulin preparations in patients with severe sepsis [ISRCTN28863830].

INTRODUCTION: In this prospective, randomized controlled study, we aimed to evaluate the effect of IgM-enriched immunoglobulin treatment on progression of organ failure and septic shock in patients with severe sepsis. MATERIALS AND METHODS: Forty-two patients with severe sepsis were enrolled in the study. Patients in the study group (n = 21) received an intravenous immunoglobulin preparation (Pentaglobin in addition to standard therapy. Pentaglobin therapy was commenced on the day of diagnosis of severe sepsis: 5 ml/kg per day Pentaglobin (38 g/l IgG, 6 g/l IgM, and 6 g/l IgA) was infused over 6 hours and repeated for 3 consecutive days. Patients in the control group (n = 18) received standard sepsis therapy, but no immunoglobulin administration. Blood samples for procalcitonin (PCT) measurements were taken daily for 8 days. Severity of critical illness and development of organ failure were assessed by obtaining daily acute physiological and chronic health evaluation (APACHE) II and sequential organ failure assessment (SOFA) scores. RESULTS AND DISCUSSION: Procalcitonin levels showed a statistically significant decrease in the Pentaglobin group (P < 0.001); however, an improvement in SOFA scores could not be demonstrated. Procalcitonin levels and SOFA scores did not change significantly in the control group. Septic shock incidence (38% versus 57%) and 28-day mortality rate (23.8% versus 33.3%) were found to be similar between the Pentaglobin and control groups. The evaluation of serial APACHE II scores did not demonstrate a difference between Pentaglobin and control groups either. CONCLUSION: Present data could not demonstrate any beneficial effects of polyclonal immunoglobulin preparation Pentaglobin on organ morbidity, septic shock incidence and mortality rate in patients with severe sepsis.

Gastric intramucosal pH is stable during titration of positive end-expiratory pressure to improve oxygenation in acute respiratory distress syndrome.

BACKGROUND: Optimal positive end-expiratory pressure (PEEP) is an important component of adequate mechanical ventilation in acute lung injury and acute respiratory distress syndrome (ARDS). In the present study we tested the effect on gastric intramucosal pH of incremental increases in PEEP level (i.e. PEEP titration) to improve oxygenation in ARDS. Seventeen consecutive patients with ARDS, as defined by consensus criteria, were included in this clinical, prospective study. All patients were haemodynamically stable, and were not receiving vasopressors. From an initial level of 5 cmH2O, PEEP was titrated at 2 cmH2O increments until the partial arterial oxygen tension was 300 mmHg or greater, peak airway pressure was 45 cmH2O or greater, or mean arterial blood pressure decreased by 20% or more of the baseline value. Optimal PEEP was defined as the level of PEEP that achieved the best oxygenation. The maximum PEEP was the highest PEEP level reached during titration in each patient. RESULTS: Gastric mucosal pH was measured using gastric tonometry at all levels of PEEP. The thermodilution technique was used for measurement of cardiac index. Gastric mucosal pH was similar at baseline and at optimal PEEP levels, but it was slightly reduced at maximum PEEP. Cardiac index and oxygen delivery remained stable at all PEEP levels. CONCLUSION: Incremental titration of PEEP based on improvement in oxygenation does not decrease gastric intramucosal perfusion when cardiac output is preserved in patients with ARDS.

Recruitment maneuver: does it promote bacterial translocation?

OBJECTIVE: High peak airway opening pressures (Pao) are used routinely during recruitment maneuvers to open collapsed lung units. High peak Pao, however, can cause lung injury as evidenced by translocation of intratracheally inoculated bacteria. In this study we explored whether recruitment maneuvers that used high Pao could cause translocation of the intratracheally inoculated from the alveoli into the systemic circulation. DESIGN: Prospective, randomized, animal study. SETTING: Experimental animal care laboratory. SUBJECTS: Eighteen male Sprague Dawley rats. INTERVENTIONS Rats were anesthetized, tracheostomized, and ventilated with 14 cm H2O peak Pao and 0 cm H2O positive end-expiratory pressure (PEEP) in pressure-controlled ventilation (frequency, 30 bpm; inspiratory/expiratory ratio, 1:2; Fio, 1). Intratracheal inoculation of 500 microL of saline containing 1 x 10 colony forming units/mL was performed before randomization into three groups (n = 6 in each): a low-pressure group (14 cm H2O peak Pao, 0 cm H2O PEEP), a high-pressure group (45 cm H2O peak Pao, 0 cm H2O PEEP), and a recruitment maneuver group (14 cm H2O peak Pao, 0 cm H2O PEEP, and a recruitment maneuver sustained inflation of 45 cm H2O continuous positive airway pressure for 30 secs every 15 mins). Blood samples for blood gas analysis were obtained before intratracheal instillation of bacteria and at the end of the experimental protocol (2 hrs). Blood cultures were obtained before and after bacterial instillation at 30-min intervals during the experiment. Blood samples were cultured directly in sheep blood, MacConkey, and Iso-Sensitest agars and were observed on the second day. Bacteremia was defined as the presence of one or more colonies of in 1 mL of blood. MEASUREMENTS AND MAIN RESULTS: The blood cultures were positive for in only six rats in the high-pressure group and remained negative throughout the study period in the low-pressure and recruitment maneuver groups. Oxygenation deteriorated in all groups after intratracheal instillation of bacteria. In the high-pressure group, oxygenation decreased from 417 +/- 67 mm Hg to 79 +/- 20 mm Hg ( p=.004), whereas in the low-pressure and recruitment maneuver groups PaO2 decreased from 410 +/- 98 mm Hg and 383 +/- 78 mm Hg to 287 +/- 105 mm Hg ( p=.031) and 249 +/- 59 mm Hg (p =.11), respectively. CONCLUSION: Intermittent recruitment maneuvers applied as a sustained inflation superimposed on low-pressure ventilation with 0 cm H2O PEEP did not cause translocation of intratracheally inoculated.