Kubilay Demirag

Neuromuscular deterioration in the early stage of sepsis in rats

IntroductionCritical illness polyneuropathy (CIP) is a clinical condition frequently seen in patients being treated in critical care units in the final stage of sepsis. The etiopathology of CIP is still unclear, and the onset time of appearance of the electrophysiological findings has not been elucidated. The very little research that has been carried out on this topic is limited to clinical electrophysiological and histopathological studies. In this study, electrophysiological alterations in the early stage of experimentally induced sepsis were investigated in septic rats.MethodsWe conducted a prospective, randomized, controlled experimental study in an animal basic science laboratory with 30 male Sprague-Dawley rats, weighing 200 to 250 g. All of the rats were randomly assigned to one of two groups. In the sepsis group (n = 20), cecal ligation and puncture (CLP) was performed to induce experimental sepsis. In the sham-operated group (n = 10), laparotomy without CLP was performed. Before and 24 hours after CLP and laparotomy, the right sciatic nerve was stimulated from the sciatic notch and compound muscle action potentials (CMAPs) were recorded from the gastrocnemius muscle. Recordings of latency, amplitude, and duration of the CMAP were evaluated.ResultsCMAP durations before and 24 hours after surgery were 0.45 ± 0.05 ms and 0.48 ± 0.05 ms, respectively, in the sham-operated group and 0.46 ± 0.05 ms and 0.55 ± 0.01 ms, respectively, in the sepsis group. Latency measurements in the sham-operated group were 0.078 ± 0.010 ms and 0.080 ± 0.015 ms, respectively, whereas measurements were found to be prolonged in the sepsis group: 0.094 ± 0.015 ms and 0.149 ± 0.054 ms before and 24 hours after surgery, respectively (p < 0.05). CMAP amplitudes in the sham-operated group before and 24 hours after surgery were 8.41 ± 0.79 mV and 8.28 ± 1.92 mV, respectively, whereas in the sepsis group the amplitude measurements decreased to 7.60 ± 1.75 mV and 4.87 ± 3.44 mV, respectively (p < 0.05).ConclusionThe results of the study indicate that electrophysiological alterations appear in the first 24 hours after experimental sepsis and are characterized by an increase in latency and a decrease in CMAP amplitude. The results also suggest that electrophysiological findings seen in patients with CIP might appear before clinical signs of CIP.

The Effects of N-Acetylcysteine on Oxidative Stress in Organophosphate Poisoning Model

Organophosphate compounds act by irreversible inhibition of cholinesterase. In addition to their muscarinic, nicotinic, and central nervous system effects, some organophosphate insecticides cause oxidative stress by increasing lipid peroxidation in erythrocytes and by increasing levels of the enzymes Superoxide dismutase and catalase. In this study, the effects of an antioxidant,N-acetylcysteine (NAC), in organophosphate poisoning were investigated. After obtaining Animal Ethics Committee approval, 16 male Wistar rats were divided into 2 groups. Following anesthesia, rats were tracheostomized and mechanically ventilated. Invasive hemodynamic monitoring was begun and all rats were injected with 70 mg/kg of dichlorvos (DDVP) intraperitoneally. The rats in group 1 received placebo intravenous 0.9% NaCl and the rats in group 2 received 150 mg/kg intravenous NAC. Blood samples were obtained before injection of DDVP and 60 minutes after injection to determine levels of malondialdehyde, superoxide dismutase, and catalase. Hemodynamic data and biochemistry test results were compared by analysis of variance and Wilcoxon test.P< .05 was regarded as statistically significant. Superoxide dismutase and malondialdehyde levels were significantly increased in group 1 while no difference was observed in group 2. It was concluded that organophosphate compounds might cause oxidative stress by interfering with antioxidant defense mechanisms in erythrocytes and that NAC might prevent increased lipid peroxidation. In addition to classic treatments, drugs with antioxidant effects might therefore be promising in the treatment of organophosphate poisoning.

The effects of standard and branched chain amino acid enriched solutions on thermogenesis and energy expenditure in unconscious intensive care patients

BACKGROUND & AIMS This study aims to compare the effects of standard and branched chain amino acid enriched solutions on thermogenesis and energy expenditure in unconscious and mechanically ventilated intensive care patients. DESIGNS The study was carried out at multidisciplinary intensive care unit. Twenty unconscious and mechanically ventilated patients (18-65 years of age) were included in the study. Patients were hemodynamically stable and all received continuous enteral nutrition. Energy expenditure was calculated using the Harris-Benedict Equation for all of the patients. Patients were randomly assigned to receive a 4h infusion of 0.4 g/kg protein as amino acid solution. Group I (n = 10) received standard amino acid solution and group II (n = 10) received branched chain amino acid enriched solution. Energy expenditure, oxygen consumption and carbon dioxide production were measured by indirect calorimetric method every 30 min during the 4h infusion period and 3h thereafter. Rectal temperature was recorded concomitantly with the metabolic measurements throughout the study. RESULTS There was a statistically significant increase in body temperature during the infusion of amino acid solution between 30 and 210 min in group I and between 30 and 120 min in group II (P <0.05). We observed a significant increase in energy expenditure at 30, 150, 180 and 210 min in group I and at 30-240 min in group II (P <0.05). There were no differences between the two groups in terms of thermogenesis or energy expenditure values during the study (P >0.05). CONCLUSION Thermogenesis and energy expenditure values were increased during the parenteral infusion of both standard amino acid and branched chain amino acid enriched solutions in unconscious intensive care patients without any significance in between.

Sedation with intravenous ketamine and midazolam for painful procedures in children

Background: Children often require relief of pain and anxiety when undergoing painful procedures. The purpose of this study is to evaluate the effectiveness and safety of painful pediatric procedures performed by pediatric intensivist, using the combination of intravenous ketamine and midazolam for sedation and analgesia.

Prevalence of Malnutrition in Various Political, Economic, and Geographic Settings

BACKGROUND Disease-related malnutrition (DRM) represents a critical public health concern. Therefore, Fight Against Malnutrition (FAM) should be a state priority, but the degree to which this is true appears to differ considerably among European countries. The aim of this study was to put the problem into perspective by comparing the prevalence of malnutrition in countries from opposite parts of the continent. METHODS Six countries-Croatia, Estonia, Greece, Lithuania, Poland, and Turkey-participated in the study. A short questionnaire was used to assess DRM: its prevalence, the current situation in hospitals, regulations for reimbursement, and general healthcare circumstances. Data from ESPENs NutritionDay 2006 were used to broaden the perspective. RESULTS At admission in October 2012, 4068 patients were assessed. The study was performed in 160 hospitals and 225 units with 9143 beds. The highest proportions of patients with 3 or more points on the Nutritional Risk Screening 2002 were observed in Estonia (80.4%) and Turkey (39.4%), whereas the lowest were in Lithuania (14.2%). The provision of nutrition support was best in Turkey (39.4% required intervention, 34.4% received intervention) and Poland (21.9% and 27.8%, respectively). Nutrition support teams (NSTs) are active in some countries, whereas in others they virtually do not exist. CONCLUSION The prevalence of malnutrition was quite high in some countries, and the nutrition approach differed among them. It could be the result of the lack of reimbursement, inactive or nonexistent NSTs, and low nutrition awareness. Those facts confirmed that the continuation of FAM activities is necessary.

Can antiemetics really relieve pain

The analgesic properties of 2 antiemetic agents—metoclopramide and ondansetron—were investigated in studies which showed that metoclopramide may decrease postoperative opioid requirements, but the analgesic effect of ondansetron is controversial. The postoperative effects of metoclopramide and ondansetron on pain in patients undergoing laminectomy were evaluated. Forty six patients were randomized into 3 groups: group M, which consisted of 15 patients who received intravenous (IV) metoclopramide 0.5 mg 30 minutes before surgery; group O, which consisted of 16 patients who received ondansetron IV 0.1 mg 30 minutes before surgery; and group C, which consisted of 15 patients who received the same volume of saline IV 30 minutes before surgery. The efficacy and duration of analgesia were assessed using a visual analogue scale (VAS) at 0, 0.5, 1, 3, 6, and 24 hours after surgery. Hemodynamic parameters, additional analgesic requirements, and adverse effects were recorded for the study groups. Diclofenac 75 mg was administered intramuscularly as a rescue analgesic during the postoperative period. VAS scores were lower in the metoclopramide group than in the ondansetron and control groups (P < .05, each). The patients in the ondansetron and control groups required much more diclofenac than the patients in the metoclopramide group (P < .05). Metoclopramide administered preoperatively provided postoperative analgesia in patients undergoing elective laminectomy

Old method, new drugs: comparison of the efficacy of sevoflurane, isoflurane, and desflurane in achieving controlled hypotension in spinal surgery.

This study compared the efficacy of isoflurane, sevoflurane, and desflurane in achieving hemodynamic stability in spinal procedures using moderate levels of controlled hypotension. After obtaining ethics committee approval and written informed consent, 32 American Surgical Association I-II patients were randomly allocated to receive isoflurane (n=12), sevoflurane (n=10), or desflurane (n=10) in O2-N2O (1:1) for maintenance of anesthesia. The induction of anesthesia, fentanyl dosage, and initial and maintenance volume replacements were standardized. Blood pressure was invasively monitored and maintained within a target systolic blood pressure (SBP) range of 80 to 90 mm Hg during the study. SBP outside this range was recorded. Volatile anesthetic concentration was adjusted according to the same protocol for all 3 agents. SPB control was maintained better with sevoflurane and isoflurane than desflurane; median SBP was outside the target range during 32% (range, 15%-55%) of study time with isoflurane, 26% (12%-42%) with sevoflurane, and 44% (20%-80%) with desflurane. Total blood loss did not differ among the groups. Sevoflurane and isoflurane administered in 2 L/min fresh gas flow were more effective than desflurane in achieving controlled hypotension in spinal surgery.

The comparison of therapeutic effects of atropine and pralidoxime on cardiac signs in rats with experimental organophosphate poisoning

Organophosphate poisoning causes disturbances in cardiac conduction and potentially fatal severe cardiac rhythm abnormalities. This study investigated the cardiac effects of atropine and pralidoxime in the treatment of organophosphate poisoning in rats. Three groups of 10 adult male Wistar rats were anesthetized with an intraperitoneal injection of ketamine 100 mg/kg and xylazine 10mg/kg and connected to a computerized electrocardiographic monitor. Each rat was then injected intraperitoneally with the pesticide dichlorvos 70 mg/kg. Sixty seconds after the injection, 10 rats were injected with saline, 10 with pralidoxime mesylate 20 mg/kg, and 10 with atropine 10 mg/kg. During the computerized electrocardiographic monitoring, each rat’s heart rate and QTc intervals were recorded and analyzed as the injections were administered. The heart rates in all 3 groups did not differ before the dichlorvos was administered, nor at 60 seconds afterward, but in the atropine group, the time elapsed before the first decline in heart rate was significantly longer than that in the control group (P< .05). In addition, the interval before death was significantly longer in the atropine group than in either the control group or the pralidoxime group (P< .05 for both). The QTc was almost identical in each of the groups. Atropine has beneficial effects on the heart rate, prolongs the time before the heart rate declines, and delays death but has no effect on the QTc interval. Further research about the toxic effects of organophosphate compounds on myocardial cells is warranted.

Elderly coronary artery bypass graft patients with left ventricular dysfunction are hemodynamically stable after two different doses of rocuronium

OBJECTIVE To clarify the detailed hemodynamic responses to bolus administration of 2x 95% effective dose (ED95) and 3x ED95 of rocuronium in elderly patients with left ventricular dysfunction undergoing elective coronary artery bypass grafting (CABG). DESIGN Prospective, randomized, clinical study. SETTING University hospital. PARTICIPANTS Twenty patients aged older than 65 who had coronary artery disease with left ventricular ejection fractions equal to or less than 40%. INTERVENTIONS Using invasive cardiac monitoring, the detailed hemodynamic profile was obtained before and at 2, 4, 6, 8, and 10 minutes after the injection of rocuronium. MEASUREMENTS AND MAIN RESULTS Minor changes in all the measured or derived hemodynamic variables within the two groups did not attain statistical significance. Except for a higher baseline and the subsequent mean arterial pressures in one group, there were neither statistically nor clinically significant differences between two different doses of rocuronium in any of the variables at any time. CONCLUSION The results demonstrate that bolus administration of rocuronium (2x to 3x ED95) in combination with high-dose fentanyl provides sufficient cardiovascular stability among elderly CABG patients with left ventricular dysfunction. The cardiovascular profile of the two different bolus doses was similar. Rocuronium, in both doses, appears to be a suitable agent for muscle relaxation, especially for patients who require a high degree of cardiovascular stability.

Ventilator-associated pneumonia in critically ill patients with intensive antibiotic usage.

Objective: Ventilator-associated pneumonia (VAP) is an infection with high mortality and morbidity that prolongs the length of stay in the intensive care unit (ICU) and hospitalisation. VAP is one of the most common infections in critically ill patients. This study aimed to prospectively determine the VAP rate and associated factors in critically ill patients with intensive antibiotic usage during a one-year period. Methods: In total, 125 out of 360 patients admitted to the intensive care unit during the one-year study period (September 2010-2011) were included for follow-up for VAP diagnosis. Demographic data, APACHE II scores, diagnoses on admission, clinical pulmonary infection scores (CPIS), CRP, procalcitonin, risk factors for infection, time to VAP diagnosis, and bacteriological culture results were recorded. All data were assessed in terms of ICU, hospital and 28-day mortality. Results: In total, 56 (45%) out of 125 patients were diagnosed with VAP. In addition, 91% of patients diagnosed with VAP were administered antibiotics before diagnosis. In the VAP patients, the mortality rates were 48, 68 and 71% for 28-day, ICU and hospital mortality, respectively. Conclusion: The coexistence of clinical and microbiological parameters should not be sought when diagnosing VAP in patients who use antibiotics intensively. VAP can be diagnosed when CPIS≤6 in cases with sufficient microbiological evidence. This strategy may decrease mortality by preventing a delay in therapy.