Gul Gursel

Value of APACHE II, SOFA and CPIS Scores in Predicting Prognosis in Patients with Ventilator-Associated Pneumonia

Background: Ventilator-associated pneumonia (VAP) is the most frequent infection with high mortality rates in intensive care units (ICUs) and the prediction of outcome is important in the decision-making process. Objective: To assess the value of the Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and Clinical Pulmonary Infection Score (CPIS) in the prediction of mortality during VAP episodes in pulmonary patients. Methods: This study was a prospective observational cohort study. Sixty-three patients who were admitted to the ICU and developed VAP were included in the study consecutively. Clinical and laboratory data conforming to the APACHE II and SOFA scores were recorded on admission and APACHE II, SOFA and CPIS scores on the day of the diagnosis of VAP. The outcome measure was the ICU mortality. Logistic regression and receiver operating characteristic (ROC) curve analyses and the area under the curve (AUC) were used to estimate the predictive ability of the scoring systems. Results: Mortality rate was 54%. The mean APACHE II (21 ± 6, 14 ± 5; p = 0.001), SOFA (7 ± 3, 4 ± 2; p = 0.002) and CPIS (8 ± 2, 7 ± 3; p = 0.025) scores determined at the time of VAP diagnosis were significantly higher in nonsurvivors than in survivors. Discrimination was excellent for APACHE II (ROC AUC: 0.81; p = 0.001) and acceptable for SOFA (ROC AUC: 0.71; p = 0.005) scores. Of the three scores only APACHE II >16 was an independent predictor of the mortality (OR: 5; 95% CI: 1.3–18; p = 0.019) in the logistic regression analysis. Conclusion: These results suggest that APACHE II determined at the time of VAP diagnosis may be useful in predicting mortality in the pulmonary ICU patient population who develops VAP.

Determinants of the Length of Mechanical Ventilation in Patients with COPD in the Intensive Care Unit

Background: About 10% of the patients with chronic obstructive pulmonary disease (COPD) are at high risk for prolonged mechanical ventilation (MV >21 days), and mortality ranges from 55 to 78% in these patients. Objective: To determine the potential risk factors for MV over periods of 1, 2 and 3 weeks in patients with COPD. Patients and Method: The characteristics of patients during the stable period of their disease, on admission to the intensive care unit (ICU) and during the ICU stay were recorded prospectively and analyzed retrospectively for this study. t test, XXX2 test and logistic regression analysis were used for statistical analysis. Results: 86 patients with COPD requiring MV were included in the study. 73, 33, and 13% of the patients required MV longer than 1, 2 and 3 weeks, respectively. There were no significant relationships between the duration of MV and bronchiectasis or the presence of community-acquired pneumonia on admission, baseline pulmonary function test results or blood gas parameters on admission. Development of ventilator-associated pneumonia (VAP; odds ratio, OR: 6; 95% confidence interval, CI: 2–23, p = 0.011) and sepsis (OR: 10; 95% CI: 2–54, p = 0.007) were independent predictors for MV >7 days. VAP was still a risk factor for MV >15 days with an OR of 14 (95% CI: 3–66, p = 0.001). On the other hand MV >21 days was primarily determined by increasing age (OR: 1.2; 95% CI: 1–1.3, p = 0.042), severity of the disease on admission measured by APACHE II score (OR: 1.4; 95% CI: 1–1.7, p = 0.002) and albumin levels (OR: 0.10, 95% CI: 0.01–0.54, p = 0.007). Conclusion: Advanced age, severity of disease on admission and development of VAP during ICU stay are the main determinants of MV duration in patients with COPD.Background: About 10% of the patients with chronic obstructive pulmonary disease (COPD) are at high risk for prolonged mechanical ventilation (MV >21 days), and mortality ranges fro

The Use of Plasma and Urine Neutrophil Gelatinase Associated Lipocalin (NGAL) and Cystatin C in Early Diagnosis of Septic Acute Kidney Injury in Critically Ill Patients

Aim: To assess and compare the roles of plasma and urine concentrations of neutrophil gelatinase associated lipocalin (NGAL) and Cystatin C for early diagnosis of septic acute kidney injury (AKI) in adult critically ill patients. Methods: Patients were divided into three groups as sepsis-non AKI, sepsis-AKI and non sepsis-non AKI. Plasma samples for NGAL and Cystatin C were determined on admission and on alternate days and urinary samples were collected for every day until ICU discharge. Results: One hundred fifty one patients were studied; 66 in sepsis-non AKI, 63 in sepsis-AKI, 22 in non-sepsis-non-AKI groups. Although plasma NGAL performed less well (AUC 0.44), urinary NGAL showed significant discrimination for AKI diagnosis (AUC 0.80) with a threshold value of 29.5 ng/ml (88% sensitivity, 73% specificity). Both plasma and urine Cystatin C worked well for the diagnosis of AKI (AUC 0.82 and 0.86, thresholds 1.5 and 0.106 mg/L respectively). Conclusion: Plasma and urinary Cystatin C and urinary NGAL are useful markers in predicting AKI in septic critically ill patients. Plasma NGAL raises in patients with sepsis in the absence of AKI and should be used with caution as a marker of AKI in septic ICU patients.

Does coexistence with bronchiectasis influence intensive care unit outcome in patients with chronic obstructive pulmonary disease

BACKGROUND Bronchiectasis is associated with chronic obstructive pulmonary disease (COPD) in 30% to 50% of patients. This study evaluated whether association with bronchiectasis has any influence on morbidity and mortality in patients with COPD during their intensive care unit (ICU) stay. METHODS The study was conducted at a respiratory ICU of a university hospital, and 93 mechanically ventilated patients with COPD were studied. Twenty-nine (31%) of 93 patients with COPD also had bronchiectasis. Patients with bronchiectasis had more frequent hospitalizations, more severe airflow limitation, and higher pulmonary artery pressure than patients without bronchiectasis. Duration of ICU (27+/-32 days [median: 14]; 16+/-16 days [median: 9]; P=.01) and hospital stays (44+/-44 days [median: 24.5]; 28+/-26 days (median: 20); P=.046) in patients with bronchiectasis were significantly longer than in patients without bronchiectasis, respectively. Bronchiectasis was an independent predictor for ICU stay longer than 10 days (odds ratio: 5, 95% confidence interval: 1.02-21, P=.043). The development rate of ventilator-associated pneumonia, especially with Pseudomonas aeruginosa, was significantly higher in patients with bronchiectasis (P=.034). Despite these prolonged durations, bronchiectasis did not increase mortality in this study population (P=.865). RESULTS These results suggest that the coexistence of bronchiectasis in patients with COPD may increase the duration of ICU stay and hospitalization but does not influence the mortality.

Hospital based survey of lung cancer in Turkey, a developing country, where smoking is highly prevalent.

While the trend of cigarette consumption in some developed countries is on the decline, it has been noted that in many developing countries, smoking is on the increase. Compared to developed countries, there are more male smokers than female smokers in these countries. The aim of this study was to investigate the prevalence and characteristics of the smoking habit in patients having lung cancer (LC) and to find out if there is any relationship with the smoking habit and the pathological diagnosis in our patient population. This hospital-based study was carried out between 1990 and 1996 in two major medical centres. LC was diagnosed in 1046 patients, 966 of whom were males (93%), and the remaining 80 (7%) of whom were females. Upon diagnosing the male patients, it was noted that 83% were current smokers (CS), 12% were ex-smokers (ES defined as abstinence from smoking at least for 1 year), and the remaining 5% were non-smokers (NS). In the female population the findings were as follows, 16% were CS; 8% were ES, and 76% were NS. The period of abstinence in the ES was 10 years or less in 77% of the patients. Among the male patients, squamous cell carcinoma was the most common tumor type seen in the CS group (46%) while adenocarcinoma (45%) was the most commonly seen tumor in the NS group. On the other hand, in the females, CS, the most commonly noted tumor types were small cell (54%), and adenocarcinoma (39%) was most frequently found in NS group. These results indicate that ES patients having LC in this study was quite low. On the other hand, in contrast to the findings of many other studies, from developed countries, the majority of male LC patients were in the CS group, however the majority of female LC patients were in the NS group. This smoking habit data obtained from our LC patients suggests that, similar to underdeveloped or developing countries, smoking cessation rates are very low in men during the past decade, and interestingly smoking rates may increase in women in the near future in our country.

Comparison of the value of initial and serial endotracheal aspirate surveillance cultures in predicting the causative pathogen of ventilator-associated pneumonia.

Abstract Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit (ICU) and its outcome is affected by the adequacy and timing of initial antibiotic therapy. Recent studies have suggested that surveillance cultures of the lower airways may provide microbiological guidance for initial antibiotic prescription and increase the use of appropriate antibiotic therapy. This study aimed to compare the predictive value of initial and serial surveillance cultures of endotracheal aspirates in predicting the causative pathogen of VAP in patients receiving antibiotic therapy. This was an observational prospective cohort study. Ninety-two patients ventilated for at least 4 days were recruited into the study. Initial (IS-ETA) and serial (SS-ETA) endotracheal aspirate surveillance cultures were obtained on the day of intubation and every second day, respectively. The sensitivity, specificity, and positive and negative predictive values for the causative pathogens of VAP were calculated for each surveillance culture. Ninety-two initial and 252 serial surveillance cultures were obtained during the study period. The sensitivity of IS-ETA culture was 12% and of SS-ETA culture was 44%. The sensitivity of SS-ETA in late-onset VAP was 51%. The value of SS-ETA surveillance cultures was better than IS-ETA surveillance in predicting the causative pathogen of VAP, particularly in late-onset pneumonia.

Risk factors for treatment failure in patients with ventilator-associated pneumonia receiving appropriate antibiotic therapy.

PURPOSE The aim of this study was to investigate modifiable risk factors and predictors for treatment failure (TF) in patients with ventilator-associated pneumonia (VAP) receiving appropriate antibiotic therapy. MATERIALS AND METHODS An observational cohort study performed in an intensive care unit (ICU) of a University hospital. Eighty-nine patients with VAP were enrolled in the study consecutively. Treatment failure was defined as lack of clinical and microbiological response to therapy within 2 weeks. Potential risk factors for TF, related with patients, microorganisms, and ICU therapies, were evaluated. RESULTS Mean age was 72 +/- 13 years. Fifty-three of the patients had TF. Patients with TF were older, had more comorbidities, higher admission and Acute Physiology and Chronic Health Evaluation Score (APACHE II)-VAP scores, lower daily carbohydrate intake, and lymphocyte number below 1000/mm(3) than the treatment success group. Transfusions, bacteremia, infection with multidrug-resistant microorganisms, initial bacterial load (CFU/mL), and steroid therapy were similar across the groups. Comorbidity (odds ratio [OR], 4.4; 95% CI, 1.2-16.8; P = .030), VAP-APACHE II scores above 16 (OR, 6.4; 95% CI, 2.1-18.6; P = .001), daily carbohydrate intake below 190 g/d (OR, 3; 95% CI,1.1-8.6; P = .038), lymphocyte number below 1000/mm3 (OR, 4.1; 95% CI, 1.3-12.9; P = .014) were independent predictors for TF. CONCLUSIONS Patients with comorbidities, who are severely ill and lymphocytopenic at the time of VAP diagnosis, are at high risk for TF.

Tumor necrosis factor-alpha (TNF-α) in pleural fluids

Summary Our study was undertaken to investigate the role of tumor necrosis factor-alpha (TNF-α) at the site of disease activity in tuberculous pleuritis (TP). Concentrations of TNF-α were measured directly by radioimmunoassay (RIA) in the pleural fluid (PF) and plasma (P) of patients with TP ( n = 14), malignant effusions ( n = 18) and transudates ( n = 7). Among these three groups mean plasma levels of TNF-α were not statistically significant ( P > 0.05), but in the TP group mean levels of TNF-α in PF were significantly higher than in the cancer and transudate groups ( P P > 0.05). These results may indicate a local synthesis of TNF-α by cells within the pleural cavity in this disease.

Effects of Inactivated Influenza Virus Vaccination on Bronchial Reactivity Symptom Scores and Peak Expiratory Flow Variability in Patients with Asthma

Even though annual influenza vaccinations are recommended by many authorities, some doctors may be reluctant to vaccinate asthmatic patients because of the risk of inducing bronchial reactivity and exacerbating the asthma. In this study we investigated the effect of inactivated trivalent influenza vaccine on airway reactivity symptom scores and peak expiratory flow (PEF) variability in 24 patients with mild stable asthma. Baseline spirometry and methacholine challenge tests were performed on all patients. Patients were then asked to record their peak expiratory flow every morning and evening, complete daily symptom score charts (morning tightness, daytime asthma, cough, and night asthma), and note bronchodilator usage for 1 week. After baseline measurements, the patients were allocated to inactivated vaccine and placebo in a random and single-blind manner. The lung function measurements and methacholine challenge tests were repeated 1 week after vaccination and placebo administration at the same time of day. PD20 (mg/mL) methacholine doses were 3.06+/-3.0 mg/mL before vaccination, 2.96+/-3.2 mg/mL after vaccination, and 2.76+/-2.91 mg/mL after placebo administration. There were no significant changes in PD20 methacholine after influenza vaccination (p>0.05). There were also no significant changes in symptom scores, bronchodilator usage, and PEFR after vaccination (p>0.05). None of the patients experienced significant local or systemic side effects after vaccination. Immunization with inactivated influenza vaccine does not induce clinical exacerbations of asthma or airway hyperreactivity in patients with mild asthma.

Incidence and risk factors for the development of acute renal failure in patients with ventilator-associated pneumonia

Aim:  Infections are one of the most important risk factors for the development of acute renal failure (ARF) and ventilator‐associated pneumonia (VAP) has been reported as one of the most frequent infection in intensive care units (ICU). Sepsis, shock, multiorgan dysfunction syndrome (MODS), use of nephrotoxic antibiotics and mechanical ventilation are potential risk factors for development of ARF during VAP. The objective of the study was to evaluate the incidence of ARF in patients with VAP and the role of VAP‐related potential risk factors in the development of ARF.