Emre Erbabacan

The effects of intravenous, enteral and combined administration of glutamine on malnutrition in sepsis: a randomized clinical trial.

Our aim was to compare the effects of intravenous, enteral, and enteral plus intravenous supplemented glutamine on plasma transferrin, nitrogen balance, and creatinine/height index in septic patients with malnutrition. Blood and urine samples were collected for transferrin, urea and creatinine measurements. Samples, SOFA score and protein-calorie intake values were repeated on days 7 and 15. Patients (n:120) were randomly divided into 4 groups. Group I received 30 g/day IV glutamine, group II received 30 g/day enteral glutamine, group III received 15 g/day IV and 15 g/day enteral glutamine. Group IV received only enteral feeding as a control group. Transferrin levels decreased in group IV (p<0.01 0-7 days, p<0.01 7-15 days, p<0.01 0-15 days). Nitrogen balance levels were highest in group IV when compared with group I (p<0.05, p<0.001), group II (p<0.001), and group III (p<0.05, p<0.001) on days 7-15. Creatinine/height indexes increased in group I (p<0.001), group II (p<0.001), group III (p<0.001), and group IV (p<0.05) on day 15. In group III the creatinine/height index was higher than in groups I and II (p<0.05). In group IV, creatinine/height index was lower than in group I (p<0.01) and group II (p<0.001). Protein-calorie intake in group IV was higher than others on day 7 (p<0.05). SOFA scores of group IV were higher than the other groups on day 15 (p<0.05). This study demonstrated, that combined route of gln supplementation resulted in the most positive outcome to transferrin, creatine/height index and nitrogen balance (on days 7 and 15) during the catabolic phase of septic patients with malnutrition.

Ultrasound-assisted transversus abdominis plane block vs wound infiltration in pediatric patient with inguinal hernia: randomized controlled trial

STUDY OBJECTIVE To compare the analgesic efficacy of ultrasound-assisted transversus abdominis plane (TAP) block and wound infiltration during the first postoperative 24hours. DESIGN A prospective, observer-blinded, randomized, and controlled study SETTING Operating room of a university hospital. PATIENTS Forty patients received a TAP block (TAP group) and 40 patients received wound infiltration (INF group) at the end of the surgery. INTERVENTIONS Patients were randomized to receive a TAP block or wound infiltration. Postoperative analgesics were administered on request and selected based on pain severity. MEASUREMENTS Pain scores, analgesic drug requirement, and side effects were observed for 24hours. MAIN RESULTS Postoperative pain scores were lower in TAP group compared to INF group (P<.001). Analgesic consumption was significantly higher at the 5th minute and 1st, 6th, and 12th hours in the INF group (P<.001). The frequency of additional analgesic use in home and the total analgesic used during the postoperative 24hours were significantly higher in INF group (P<.001). Side effects were lower in the TAP group. Parents satisfaction scores were higher in TAP group. CONCLUSION Transversus abdominis plane block is effective method with convenient technique, drug dosage, and volume in pediatric patients undergoing inguinal hernia surgery.

Comparison of Transversus Abdominis Plane Block and IV Patient-Controlled Analgesia after Lower Abdominal Surgery.

OBJECTIVE We aimed to compare the first 24-hour postoperative analgesic efficiency of ultrasound (USG)-assisted transversus abdominis plane (TAP) block to IV morphine patient-controlled analgesia (PCA) in patients undergoing lower abdominal surgery. METHODS Fifty ASA I-III patients were included into this randomised, prospective clinical study. At end of surgery, Group 1 received 1 mg kg(-1) 0.5% bupivacaine and 1 mg kg(-1) 1% lidocaine in a 30-mL volume during TAP-block. Group 2 received 1 mg kg(-1) tramadol IV 10 minutes before extubation, and PCA was started with 1 mL morphine IV at a concentration of 1 mg kg(-1) and a 10-min lock time. Visual analogue scale (VAS), heart rate (HR), respiratory rate, peripheral oxygen saturation (SpO2), additional analgesic need and nausea-vomiting at the postoperative 30(th) minute and 1, 2, 3, 6, 12, and 24 hours were evaluated. In both groups, when VAS values were >4, patients were given 1 mg kg(-1) tramadol IV in first evaluation at the 30(th) minute or 15 mg kg(-1) paracetamol at other evaluations. RESULTS No difference was observed between groups in terms of VAS values. No difference was observed in terms of HR in the within-group comparison, but Group 1 HR values were lower compared to Group 2 (p<0.01). No difference was observed in additional analgesic need at any times. Nausea-vomiting score was higher in Group 2 in the between-group comparison at the 30(th) minute (p<0.04), but no difference was observed after the 1(st) hour. CONCLUSION Transversus abdominis plane block is effective as IV morphine-PCA in postoperative pain therapy in lower abdominal surgery, when given in a 30-mL volume. It may be preferable to IV-PCA, as the analgesic effect starts earlier and decreases the systemic effect of the morphine used in PCA.

The effect of single dose etomidate during emergency intubation on hemodynamics and adrenal cortex.

BACKGROUND The study aimed to evaluate and compare the effects of a single dose of etomidate and the use of a steroid injection prior to etomidate during rapid sequence intubation on hemodynamics and cortisol levels. METHODS Sixty patients were divided into three groups (n=20). Before intubation, and at 4 and 24 hours, blood samples were taken for cortisol measurements and hemodynamic parameters (systolic-diastolic-mean arterial pressure, heart rate), and SOFA scores were recorded. Intubation was achieved with 0.3 mg/kg etomidate IV in Group I, 0.3 mg/kg etomidate following 2 mg/kg methylprednisolone IV in Group II, and 0.15 mg/kg IV midazolam in Group III. RESULTS Mean arterial pressure values were lower in Group I at the 24th hour when compared to Groups II and III. In Group I, heart rate values were higher compared to the other Groups. Cortisol levels were lower in Group I at the 4th and at the 24th hour in Groups II and III. CONCLUSION Administration of methylprednisolone 2-4 minutes prior to etomidate use in emergency situations can prevent adrenal insufficiency in patients undergoing rapid sequence intubation. Moreover, midazolam can be used in low induction doses as an alternative to etomidate.

Effects of different modes of ventilation and head position on the size of the vena jugularis interna.

PURPOSE Right internal jugular vein (RIJV) catheterisation is a common procedure in patients undergoing surgery. We aimed to compare diameters and the cross-sectional area (CSA) of the RIJV when the head is in a neutral or 30-degree rotated position during mechanical ventilation in various modes and spontaneous ventilation. METHODS Thirty patients undergoing surgery were included in the study. In each patient, still ultrasound images of the vena jugularis interna were taken with the head in a neutral position and with the neck rotated 30 degrees to the left, first under spontaneous ventilation (group S), then after the induction of anaesthesia under volume-controlled ventilation (group V) and under pressure-controlled ventilation (group P). The six still images were evaluated in terms of transverse and anteroposterior diameters and CSA. RESULTS Diameters in the neutral and lateral positions in group S were significantly smaller than in group P and group V (neutral transverse p = 0.01, anteroposterior p = 0.041, rotated transverse p = 0.01, anteroposterior p = 0.03). The CSAs of the RIJV in the neutral and lateral positions were significantly larger in group P and group V than Group S (lateral CSA p = 0.001, neutral CSA p = 0.002). CSA increased significantly only in group P when the head was rotated 30 degrees laterally (p = 0.002). CONCLUSION We conclude that both pressure-controlled and volume-controlled mechanical ventilation have similar effects on the CSA and diameters of the RIJV. Positioning of the head with a 30-degree rotation laterally has different effects on CSA depending on the ventilation mode used. A neutral position should be preferred with spontaneous ventilation whereas 30 degree rotation should be preferred in patients under pressure-controlled and volume-controlled ventilation.

Perioperative Temperature Monitoring and Patient Warming: A Survey Study

OBJECTIVE Hypothermia is defined as the decrease of core body temperature under 36°C. Hypothermia is observed at a rate of 50-90% in the perioperative period. In our study, we aimed to measure the perception of hypothermia in our country, to evaluate the measures taken by physicians to intercept hypothermia, to determine the frequency and the methods used to monitor body temperature and the techniques used in warming the patients. Another aim was to develop a guideline for preventing perioperative hypothermia. METHODS The questionnaire consisted of 26 multiple-choice questions. The time needed to answer the questions was 8-10 minutes. RESULTS Of the 1380 individuals, 312 (22.6%) answered the questions in the questionnaire. Of these, 148 (47.4%) declared they were working in university hospitals, 80 (25.6%) in training and research hospitals, 51 (16.4%) in government hospitals and 33 (10.6%) in various private hospitals. Of the 312 individuals, 134 (42.9%) were specialists, 107 (34.3%) were resident physicians, 71 (22.8%) were academics. In addition, 212 (67.9%) reported working in operating rooms, 49 (15.7%) in intensive care units and 42 (13.5%) both in operating rooms and intensive care units. In the answers, there was variation among the hospital types in applications of body temperature monitoring and warming the patient. Another finding was that the individuals had different approaches to the concepts on perioperative hypothermia and its consequences. CONCLUSION The perceptions of physicians and the allied health personnel in government and private hospitals should be enhanced by informing them about the passive and active heating systems to prevent hypothermia. Although the situation in university and training and research hospitals seems to be better, defects are still observed in practice. Preparation of a national guideline for prevention of perioperative hypothermia is needed.

Multidisciplinary Weaning: Who Weans, Who Extubates, and How?

M IS C E L L Admittedly, retrograde autologous priming can reduce postoperative transfusion rates in conventional extracorporeal circulation (CECC), too. We did not perform retrograde priming in our CECC group. It would certainly be interesting, comparing MiECC and CECC with retrograde priming, to evaluate the differences in terms of blood products. As we have focused on inflammatory processes, we did not add such a third cohort. Overall, we are comparing two different systems—MiECC and CECC—as minimally invasive versus conventional strategies, and could show that MiECC is superior in several aspects. However, the underlying mechanisms are still vague. It is correct that a randomized controlled trial comparing minimally invasive surgery and standard surgical approach combined with minimally invasive extracorporeal circulation would be interesting. The minimally invasive approach is the standard approach for heart valve surgery at our institution. Nowadays, in a highly competitive environment, with new therapy options for the treatment of aortic stenosis on one side and successful surgical competitors on the other side, we just cannot regularly perform heart valve surgery via a non–minimally invasive surgical approach for research purposes only. Therefore, such a randomized trial would not be justifiable.

Severity of community acquired pneumonia in asthma patients. How and what are linked

We have read with great interest the study by Terraneo et al. [1] on the little explored subject of community-acquired pneumonia (CAP) in asthmatic patients. Although this is described as a prospective study, interventions and evaluations done to the patients differ. First, why were bronchoalveolar lavage and tracheobronchial aspirates samples taken, and why were spirometric measurements and pleural puncture done only in some patients? What were the indications for pleural puncture and bronchoscopy? Second, it is important to know which of these patients were ventilated with invasive mechanical ventilation (IMV) and whether non-invasive mechanical ventilation (NIV) was applied to any of those patients. Third, what is the reason for achievingmicrobiological diagnosis only in 42% of patients? These differences in interventions and varying information collected from patients gives the impression of a retrospective study rather than a prospective one. Furthermore, the numbers of patients in the control group and asthma group are vastly different. Additionally, previous studies report that when patients were evaluated according to the severity of asthma, severe asthma patients had different rates of Streptococcus Pneumonia compared to patients with mild to moderate asthma [2]. Patients included in the studywere not grouped according to asthma severity. In light of To et al.’s study [2], it is important to evaluate the difference in terms of asthma severity and lead the anti-biotherapy accordingly. There is no specific evidence for higher pneumonia incidences in asthma patients. Patients with mild asthma are not different from the normal healthy population in contrast to severe asthmatic patients, who have frequent exacerbations. Patients also should have been evaluated according to the number of exacerbations per year. Fourth, the authors described a high rate of previous antibiotic

“Deventilation Syndrome” in CPAP Users with Obstructive Sleep Apnea: Clinical Impact and Solutions

Obstructive sleep apnea is characterized by intermittent upper airway obstruction during sleep. The most effective treatment is continuous positive airway pressure (CPAP) to keep the airway open. In some cases, severe morning dyspnea is seen just after interruption from CPAP therapy, commonly called deventilation syndrome. This chapter reviews the underlying mechanisms that are still not clarified and how to avoid the syndrome.

Noninvasive Mechanical Ventilation in Difficult Weaning in Critical Care: Key Topics and Practical Approach

Noninvasive mechanical ventilation (NIMV) is theoretically able to counteract several physiological mechanisms associated with weaning difficulties. Early extubation and continuing the weaning process with NIMV eliminates the patient’s need for sedation, and this provides hemodynamic stability. Respiratory physiotherapy can be performed more effectively because the patient can be mobilized easily in the bed and can contribute actively.