Ebru Ortac Ersoy

Measurement of Pulmonary Artery to Aorta Ratio in Computed Tomography is Correlated with Pulmonary Artery Pressure in Critically Ill Chronic Obstructive Pulmonary Disease Patients

AIM Chronic obstructive pulmonary disease (COPD) is one of the leading chronic diseases and a common cause of death. Identification of COPD patients at high risk for complications and mortality is of utmost importance. Computed tomography (CT) can be used to measure the ratio of the diameter of the pulmonary artery (PA) to the diameter of the aorta (A), and PA/A ratio was shown to be correlated with PA pressure (PAP). However, the prognostic value of PA size remains unclear in patients with COPD. We hypothesized that PA enlargement, as shown by a PA/A ratio greater than 1, could be associated with a higher risk of mortality in COPD patients admitted to the intensive care unit. METHODS Data of patients admitted to a medical intensive care unit of a university hospital were retrospectively reviewed between January 2008 and December 2012. Patients who were identified to have a diagnosis of acute exacerbation of COPD and who had an echocardiogram and CT scan were included. Pulmonary artery to aorta ratio was calculated and patients were grouped as PA/A ≤1 and PA/A >1. Comparisons were made between the groups and between patients who died and survived. Correlation analysis, survival analysis, and logistic regression analysis were done, where appropriate. RESULTS One hundred six COPD patients were enrolled. There were 40 (37.4%) patients who had a PA/A >1. Echocardiography measured PAP was higher in the group with PA/A >1 than in those with PA/A ≤1 (62.1 ± 23.2 mm Hg vs 45.3 ± 17.9 mm Hg, P = .002). Mortality rate of patients with PA/A >1 was higher (50%) than of those patients with PA/A ≤1 (36.4%), although the difference did not reach a statistical significance (P = .17). Correlation was found between vmeasured PA diameter and PAP (r = 0.51, P = .001) as well as between the Acute Physiology and Chronic Health Evaluation II values and PAP (r = 0.25, P = .025). CONCLUSION The PA/A ratio is an easily measured method that can be performed on thorax CT scans. Although, we failed to demonstrate a statistically significant association between higher PA/A and increased mortality, PA/A can be used as a surrogate marker to predict the pulmonary hypertension.

Investigation of hemophagocytic lymphohistiocytosis in severe sepsis patients

PURPOSE Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition characterized by uncontrolled inflammation and has common clinical and laboratory features with sepsis. The aim of this study was to investigate patients treated with severe sepsis who had bicytopenia for the presence of HLH. MATERIALS AND METHODS Patients with severe sepsis who were non-responsive to treatment and developed at least bicytopenia were included. Peripheral blood samples were collected and stored for later evaluation for natural killer (NK) activity and soluble interleukin-2 receptor levels. Diagnostic criteria of HLH were retrospectively analyzed. RESULTS Seventy-five of 382 patients (20%) were followed as severe sepsis and septic shock. Among them, 40 patients had bicytopenia. Twenty-six of 40 patients were excluded due to the presence of active solid or hematological malignancies. Three patients died before fulfillment of HLH criteria and one patient denied to give consent. All of the remaining 10 patients had at least five of the eight criteria according to criteria of the Histiocyte Society. Only one of 10 patients was diagnosed as HLH and received treatment during intensive care unit stay. None of the 10 patients survived. CONCLUSIONS This study emphasizes to consider the possibility of HLH and the need of rapid assessment of patients with severe sepsis who had bicytopenia and were resistant to treatment in intensive care.

Severe measles pneumonia in adults with respiratory failure: role of ribavirin and high‐dose vitamin A

Although measles is usually considered a benign viral disease of childhood, adults may be affected at any age and may experience severe respiratory or neurologic consequences. We present three adult cases (one of whom was pregnant) admitted to our University Hospital who were diagnosed to have measles and who had uncommon clinical features such as hepatitis and hyponatremia. All patients were markedly hypoxic; one required mechanical ventilation. Two patients received therapy with intravenous ribavirin and all patients received high‐dose vitamin A for 3 days. Therapy with intravenous ribavirin and vitamin A were well tolerated by our patients except one patient who developed acute renal failure and were associated with reversal of respiratory compromise. Life‐threatening measles pneumonitis in adults may be more common than previously appreciated, regardless of the patients immune status, and ribavirin and high‐dose vitamin A might be a treatment option.

Acute eosinophilic pneumonia secondary to heroin inhalation

Smoking heroin (chasing the dragon), is a method of inhaling heroin via heating the drug on a tin-foil above a flame. It also has been associated both with the indirect effects of heroin overdose and with direct pulmonary toxicity. We describe a case of acute eosinophilic pneumonia secondary to heroin inhalation in our medical intensive care unit. She presented with fever, cough, dyspnea and pleuritic chest pain. Chest radiograph showed bilateral infiltrations. Examination of bronchoalveolar lavage fluid revealed significant eosinophilia. She was diagnosed with acute eosinophilic pneumonia. After heroin abstinence and corticosteroid therapy, remission was achieved rapidly and the patient was discharge on the fourth day of her hospital stay.

Long-term outcome of chronic obstructive pulmonary disease patients with acute respiratory failure following intensive care unit discharge in Turkey.

Chronic obstructive pulmonary disease (COPD) remains a globally significant cause of mortality, although COPD mortality varies from country to country, and across different regions within each country. The primary objective of this study was to determine the mortality rates of COPD patients who present with acute respiratory failure (ARF) to a tertiary care referral center in different stages of their follow‐up (ICU, in‐hospital and after discharge). The secondary objective was to determine factors associated with mortality in this group of patients.

Glutaric Aciduria Type 2 Presenting With Acute Respiratory Failure In An Adult

Glutaric aciduria (GTA) type II can be seen as late onset form with myopathic phenotype. We present a case of a 19-year old female with progressive muscle weakness was admitted in intensive care unit (ICU) with respiratory failure and acute renal failure. Patient was unconscious. Pupils were anisocoric and light reflex was absent. She had hepatomegaly. The laboratory results showed a glucose level of 70 mg/dl and the liver enzymes were high. The patient also had hyponatremia (117 mEq/L) and lactate level of 3.9 mmol/L. Tandem MS and organic acid analysis were compatible with GTA type II. Carnitine 1gr, riboflavin 100 mg and co-enzymeQ10 100 mg was arranged. After four months from beginning of treatment tandem MS results are improved. Respiratory failure, acute renal failure due to profound proximal myopathy can be due to glutaric aciduria type II that responded rapidly to appropriate therapy.

The Choice of Ventilator and Ventilator Setting

Obesity is highly prevalent throughout the world. There have been multiple studies about obese critically ill patients, and the prevalence of obesity in intensive care unit (ICU) is estimated at 25%. Critically ill morbidly obese patients have higher ICU mortality compared to nonobese patients; morbid obesity is associated with prolonged mechanical ventilation and extended “weaning” period. Therefore, choosing ventilator and managing settings is important in obese patients in ICU. NIV can be applied with volume-limited or pressure-limited devices. Both ICU ventilators and portable noninvasive ventilators can be used. Positioning of obese patient is also important. In this chapter, the choice of ventilator and ventilator settings will be described in obese ICU patients.

Sleep in Intensive Care: Is there or not?

Uyku, organizmanın çevreyle iletişiminin geçici, kısmi ve periyodik olarak kesilmesine neden olan, birçok organ sistemini etkileyen fizyolojik bir durumdur. İyi bir uyku kritik hastalarda büyük öneme sahip birçok fonksiyonu düzeltebilir. Bunlar; anabolik fonksiyonlar (büyüme hormonu salınımı), metabolik fonksiyonlar (ısı regülasyonu ve toksin atılımı) ve immunolojik (immun sistemin sitokinler aracılığı ile regülasyonu) fonksiyonlardır (1). Akut ve kronik uyku deprivasyonunun (uykusuzluk) metabolik dengesizliğe neden olduğu ve mortaliteyi arttırdığı bildirilmiştir. Ayrıca, infeksiyon ile tetiklenen sitokin değişiklikleri uyku yapısında bozukluklara neden olmaktadır (2). Uyku, yoğun bakımlarda yatan kritik hastalarda iyileşme ve sağkalım için önemlidir. Yoğun bakımlarda gürültü, ağrı, mekanik ventilatör modları, ilaçlar, hemşire bakımları, hastalara uygulanan işlem ve girişimler hastaların uykusunu etkilemekte ve uyku bölünmelerine neden olmaktadır (3, 4). Mekanik ventilasyon uygulanan hastalarda ventilatör modlarının da uykuyu etkilediği belirtilmiştir. Gece gündüz farkının ortadan kalkarak hormonal dengenin bozulması ve melatonin salınımının azalması da yoğun bakım hastalarında uyku bozukluklarının nedenlerindendir (5). Uyku deprivasyonu infeksiyonların iyileşmesini zorlaştırır. Hastalarda deliryum ve ajitasyon gibi nörolojik sorunlara neden olur. Uyku deprivasyonu sonucu post travmatik stres bozukluğu, çekilme semptomları, depresyon ve uyku bölünmeleri meydana gelebilir. Hastaların yoğun bakımda kalış süreleri ve buna bağlı olarak mortalite ve morbiditeleri artar. Yoğun bakımlarda uykunun nasıl monitorize edileceği önemlidir. Çünkü hastalar oldukça heterojendir ve uykuyu etkileyebilen birçok ilaç almaktadırlar. Uyku değerlendirmesi için altın standart polisomnografidir. Yoğun bakımlarda aktigrafi ve anketlerle de uyku çalışmaları yapılmıştır. Bu çalışmalarda yoğun bakım uykusunun oldukça fazla bölündüğü, derin uyku ve REM uykusunun azaldığı tespit edilmiştir (6-8). Yoğun bakım hastalarında uykunun monitorize edilmesi ile uykuyu bozan faktörler belirlenerek gerekli önlemler alınabilir. Bu önlemler arasında yoğun bakıma yatan hastalara profilaktik olarak melatonin verilmesi, gürültünün önlenmesi, ventilatör uyumunun sağlanması, uykuyu inhibe eden ilaçların kısıtlanması, hasta konforunun sağlanması yer alabilir. Entübe ve mekanik ventilatöre bağlı hastalarda uykunun değerlendirilmesi ile yeni mekanik ventilasyon stratejileri geliştirilebilir. Bu derlemede amaç yoğun bakımda yatan, mekanik ventilasyon uygulanan hastalarda uykuyu etkileyen faktörlerin açıklanması ve uyku yapısının bozulmasının hastalar üzerindeki etkilerinin değerlendirilmesidir.