Murat Sungur

The Role of Plasma Exchange in HELLP Syndrome

Plasma exchange therapy has been successfully used in selected patients with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome who have organ failure or refractory to treatment. There is no prospective study regarding plasma exchange and its effect in HELLP syndrome. The aim of this study was to investigate the effects of early postpartum use of plasma exchange in patients with HELLP syndrome on outcomes. The mortality rate and the recovery times were compared in patients with HELLP syndrome treated with plasma exchange and historic control group of patients treated conservatively. During a 3-year period (between April 2000 and December 2003), 29 consecutive patients with HELLP syndrome were treated with single or multiple plasma exchange by using fresh-frozen plasma at post-partum period. The control group consist of 26 patients with HELLP syndrome treated between 1993 and 1999. Maternal mortality rate was 23.1% in the control group; there was no death in plasma exchange group; and the mortality rate was significantly higher in the control group (p=0.006). The length of stay at the intensive care unit was shorter in the plasma exchange group (p<0.0001). Rapid improvement of the platelet, aspartate aminotransferase, alanine aminotransferase, and lactic dehydrogenase levels were observed in the plasma exchange group. This study showed that postpartum early plasma exchange therapy improves treatment outcomes in patients with severe HELLP syndrome.

The Effects of Fresh Frozen Plasma on Cholinesterase Levels and Outcomes in Patients with Organophosphate Poisoning

Objective: The aim of this study is to determine the effects of fresh frozen plasma, as a source of cholinesterase, on butyrylcholinesterase (BuChE; plasma or pseudo cholinesterase) levels and outcomes in patients with organophosphate poisoning. Materials and Methods: This prospective study was performed at the Department of Intensive Care of Erciyes University Medical School. Over 2 yrs, patients admitted to the ICU for OP poisoning were entered into the study. OP poisoning was diagnosed on the basis of history and BuChE levels. All patients received atropine. Fresh frozen plasma was given to 12 patients. The study was approved by the Ethical Committee, and verbal informed consent was obtained. Results: Thirty‐three patients were included in the study. BuChE levels measured at admission and the pralidoxime and atropine doses administered were not different between groups (p > 0.05). Although intermediate syndrome developed in 28.6% of patients receiving pralidoxime, there were no intermediate syndrome cases in patients receiving plasma prior to developing intermediate syndrome. The mortality rates were 14.3% in the pralidoxime group and 0% in the plasma + atropine + pralidoxime group. Two patients received plasma after developing the intermediate syndrome, and one patient who received only atropine died. BuChE levels of fresh frozen plasma were 4069.5 ± 565.1 IU/L. Every two bags of plasma provided an increase in BuChE levels of approximately 461.7 ± 142.1 IU/L. Conclusion: Fresh frozen plasma therapy increases BuChE levels in patients with organophosphate poisonings. The administration of plasma may also prevent the development of intermediate syndrome and related mortality. Plasma (fresh frozen or freshly prepared) therapy may be used as an alternative or adjunctive treatment method in patients with organophosphate pesticide poisoning, especially in cases not given pralidoxime. Further randomized controlled and animal studies are required to infer a definitive result.

Acute amitraz poisoning in adults : Clinical features, laboratory findings, and management

Background. Amitraz is a formamidine pesticide widely used in agriculture and veterinary medicine as an insecticide and acaricide. Reports on amitraz poisoning in humans are not as prevalent as those in animals. Of human intoxications in the medical literature, the majority of intoxications are in children. The number of adult intoxications with amitraz is limited. Methods. In this study, we discuss the clinical features, laboratory findings, and management of 23 adults with amitraz poisoning cared for in our center. Data were extracted from the charts retrospectively, and included age, gender, mode of poisoning, initial symptoms, time to appearance of initial symptoms, clinical and laboratory findings, management, and prognosis. Results. Fourteen of 23 patients were female (61%). Ages ranged from 16 and 78 years (mean 38.6 ± 19.8 years). Twenty-one patients ingested amitraz orally while one was exposed through skin contact and one probably through skin contact and/or inhalation. Seven patients ingested amitraz with intent to commit suicide and 11 patients accidentally. Vomiting, altered consciousness, and drowsiness were the predominant initial symptoms. Initially, hypotension was present in seven patients (30%), bradycardia in two (8.7%), myosis in six (26%), and mydriasis (without atropine administration) in three (13%). Time to appearance of the initial symptoms ranged from 5 to 120 minutes. Laboratory findings included an initial blood glucose level higher than 120 mg/dL in 62% of patients (mean 191 ± 70 mg/dL) and elevations in AST levels in four patients (81 ± 28 U/L) and ALT levels in three (60 ± 14 U/L). Ten patients had central nervous system depression, which resolved spontaneously. Five patients required mechanical ventilation for respiratory depression (mean duration of mechanical ventilatory support: 50 ± 16 hours). Six patients were thought to have been poisoned with an organophosphate and three with a carbamate pesticide due to confusing clinical picture; four of these nine patients received pralidoxim. Conclusions. In spite of a rapidly progressing and life-threatening clinical picture, amitraz intoxication in humans carries a low morbidity and mortality when appropriate supportive treatment is given. No antidote has been developed for use in more serious cases. To prevent accidental ingestions, prominent and clear warning labels should be placed on its containers.

The effect of plasmapheresis on plasma cholinesterase levels in a patient with organophosphate poisoning

Objective: To describe the role of plasmapheresis in management of organophosphate poisonings. Design: Case report. Setting: A medical intensive care unit of a medical faculty. Patient: A patient with organophosphate poisoning whose cholinesterase levels continuously decline and then increase up to a normal level after plasmapheresis is performed for his sepsis. Interventions: Plasmapheresis with fresh frozen plasma. Measurements and main results: Baseline plasma cholinesterase (ChE) level was 4001 IU/L (normal values: 4000-10000 IU/L). Aspiration pneumonia was developed on day 3, and sepsis occurred on day 5. During this period, ChE levels gradually decreased. On day 5, plasmapheresis was performed for sepsis. Interestingly, plasma ChE levels increased from 2101 IU/L to 6144 IU/L after plasmapheresis. Atropine and pralidoxime were stopped, and a high level of ChE continued during hospitalization. The patient was successfully weaned from mechanical ventilation 3 days after plasmapheresis. Conclusion: Plasma exchange therapy may be considered for patients with organophosphate poisoning unresponsive to atropine and pralidoxime.

Changing pattern of antibiotic susceptibility in intensive care units: ten years experience of a university hospital.

The study was performed to assess microorganisms and antibiotic susceptibility patterns during ten years in intensive care units of a University Hospital. Infection Control Committee has active, prospective surveillance in ICUs for thirteen years. Ten years data of ICUs was evaluated retrospectively from surveillance forms. Microorganisms and their antibiotic resistance were recorded according to the years. During ten years, gram negative microorganisms were the most frequent isolated microorganisms from clinical specimens. Acinetobacter baumannii (21.8%), Pseudomonas aerigunosa (16%), Escherichia coli (10.4%) and Klebsiella pneumoniae (8%) were the most common gram negative microorganisms. However, Staphylococcus aureus was the most prevalent gram positive microorganism, the incidence decreased from 18.6% to 4.8% during ten years. Also antibiotic susceptibility of microorganisms changed during ten years. Carbapenem resistance increased from 44% to 92% in A. baumannii and ciprofloxacin resistance increased in E. coli from 28% to 60% and in K. pneumoniae from 21% to 55% during ten years. However, methicilin resistance decreased in S. aureus from 96% to 54%. In conclusion, antibiotic resistance is growing problem in ICUs. Rationale antibiotic policies and infection control measures will prevent the development of resistance.

A retrospective review of intensive care management of organophosphate insecticide poisoning: Single center experience.

BACKGROUND Organophosphate (OP) compounds are used as insecticides. Given the widespread availability and use of these chemicals, OP poisoning is quite common following either accidental or intentional exposures. Immediate intensive care management can save lives in these patients. We aimed to investigate intensive care management provided to OP poisoning patients in a tertiary care hospital in Turkey. SUBJECTS AND METHODS This was a retrospective chart review of 62 patients, admitted to the Intensive Care Unit (ICU) with OP poisoning between 2000 and 2012. RESULTS Of the 62 patients studied, 40 (65%) were male, 45 (73%) were suicide attempts, 59 (95%) ingested the OP compounds, and three patients (5%) (two patients with suicide and 1 with accidental exposure) died in the ICU. There were statistically significant differences between survivors and nonsurvivors for Glasgow Coma Scale (GCS) on admission (P = 0.034), Acute Physiology and Chronic Health Evaluation II (APACHE II) score (P = 0.003), Sequential Organ Failure Assessment (SOFA) score (P = 0.024), time to initiation of treatment (P = 0.034) and serum lactate dehydrogenase (LDH) levels (P = 0.007). CONCLUSIONS Organophosphate poisoning is a life-threatening condition that requires immediate diagnosis and management. GCS, APACHE II score, SOFA score, and time to admission to the emergency department and LDH levels can provide prognostic information and predict outcomes.

Outcomes of percutaneous endoscopic gastrostomy in hospitalized patients at a tertiary care center in Turkey

Background/objectives:The aim of this study was to perform a retrospective analysis characterizing patients receiving tube feeding following percutaneous endoscopic gastrostomy (PEG) tube placement between 2004 and 2012 at Erciyes University Hospital in Turkey.Subjects/Methods:Patients above the age of 18 years who required long-term enteral tube feeding were studied. All PEGs were performed using the pull-through technique by one experienced endoscopist. Demographic, clinical outcomes and PEG-related complication data were collected.Results:Of the 128 subjects studied, 91 were men (71%) and 37 were women (29%). The mean age of this patient population was 54±19 years. The most common reason for PEG tube insertion was the inability to consume oral diet due to complications of cerebrovascular disease (27%), while cerebral hypoxia, occuring after nonneurological medical disorders, was the second most common indication (23%). A total of 70 patients (55%) had chronic comorbidities, with hypertension being the most common (20%). The most common procedure-related complication was insertion-site bleeding, which occurred in 4% of patients. Long-term complications during 1 year were insertion-site cellulitis, gastric contents leakage and peristomal ulceration, which occurred in 14%, 5% and 0.5% of patients, respectively. There were no PEG insertion-related mortalities; 1-year mortality was unrelated to the indication for PEG tube insertion.Conclusions:PEG tube insertion was a safe method to provide enteral access for nutrition support in this hospitalized patient population.

Effects of endosulfan intoxication on pituitary functions.

Abstract Context. We investigated the effects of endosulfan intoxication on pituitary functions in three patients. Methods. This is an observational case series including three patients with endosulfan intoxication. Patients were evaluated 3 months after the acute event. Results. Based on the baseline hormonal values and dynamic endocrine tests, one patient had hypothalamo-pituitary–adrenal axis impairment and was diagnosed as ACTH deficiency (peak cortisol level was found 13.12 μg/dl after low dose ACTH stimulation test), and another one had GH–IGF-I axis impairment and was diagnosed as GH deficiency (peak GH level was found 1.06 μg/L after glucagon stimulation test). Conclusions. Endosulfan intoxication might cause pituitary hormone deficiencies after the acute phase. Therefore, patients with endosulfan toxicity should be followed for possible pituitary gland dysfunction.

Increased DNA damage and increased apoptosis and necrosis in patients with severe sepsis and septic shock

Purpose: Reactive oxygen species (ROS) has a key role in the pathogenesis of sepsis. We wanted to evaluate ROS‐associated lymphocyte necrosis and apoptosis. Materials and methods: A total of 51 patients were included in the study, 29 in the patient group and 22 in the control group. Blood samples were taken from patients in the patient group during severe sepsis or septic shock, then again once they had recovered. Oxidative DNA damage was evaluated by 8‐hydroxy‐2′‐deoxyguanosine (8‐OHdG) levels. Peripheral blood lymphocytes from patients were evaluated with a microscope immediately. The rate of apoptosis and necrosis of lymphocytes were evaluated according to the number of cells in the peripheral. Results: The level of 8‐OHdG increased with severe sepsis or septic shock. There were significant differences between the pre‐ and post‐treatment values for apoptotic cell frequency (4.21 ± 3.15 vs. 3.82 ± 3.07, P < 0.05) and necrotic cell frequency (4.75 ± 3.61 vs. 4.09 ± 3.37, P < 0.05). Apoptosis and necrosis was increased during severe sepsis and septic shock, and apoptosis increase also continued after recovery, but necrosis decreased following disease recovery. Conclusıons: In patients with severe sepsis or septic shock, apoptosis and necrosis were increased along with increased 8‐OHdG level. Highlights:Examined associations of DNA damage with apoptosis and necrosis in severe sepsis and septic shockOxidative and chromosomal DNA damage, apoptotic and necrotic cell frequencies were increased in patients.Chromosomal DNA damage, except micronucleus, was decreased post‐treatment.Apoptosis and necrosis were increased along with increased oxidative and chromosomal DNA damage.Increased DNA damage and increased apoptosis/necrosis in severe sepsis/septic shock

Hospitalized pandemic influenza A (H1N1) patients in a university hospital

The purpose of this study was to describe the demographic and clinical features of hospitalized patients with the pandemic H1N1 influenza A virus infection in a tertiary care hospital in Central Anatolia, Turkey. The patients, all over 16 years of age and hospitalized for influenza-like symptoms between 1 November 2009 and 31 December 2009, were retrospectively identified from the records of the Infectious Diseases Department. Eighty patients whose diagnoses were confirmed by real-time PCR were included in this study. The median age of the patients was 27 years; 41 of them were male. Thirty-seven of the patients had a radiologically proven pneumonia. Eighteen of 37 (48.6%) patients with pneumonia had an underlying co-morbid medical condition, and 14 required intensive care unit admission. Patients with pneumonia had higher levels of C-reactive protein. All patients but one received oseltamivir treatment. Six patients with pneumonia received only antiviral therapy, while 31 of the patients with pneumonia received concomitant antibiotic therapy. Three patients who required mechanical ventilatory support died due to respiratory insufficinency. Although our study implicates the later periods of the pandemic, there were no significant differences for patients’ characteristics between our study and previous reports from the countries where the pandemic first occurred.