Nur Baykara

The effect on intraocular pressure of endotracheal intubation or laryngeal mask use during TIVA withoutthe use of muscle relaxants

Background: Depolarizing and non‐depolarizing muscle relaxants possess many untoward side effects. In most patients endotracheal intubation may be performed with a propofol and alfentanil combination. The purpose of this study was to compare the effect on intraocular pressure (IOP) and haemodynamics of endotracheal (ET) intubation or laryngeal mask (LMA) insertion during total intravenous anaesthesia (TIVA) without the use of muscle relaxants.

Predicting recovery from deep neuromuscular block by rocuronium in the elderly.

STUDY OBJECTIVE To determine the influence of aging on the relationship between posttetanic count (PTC) and train-of-four (TOF) response during intense neuromuscular blockade caused by rocuronium. DESIGN Prospective, observational, clinical comparison study. SETTING Operating room of a university hospital. PATIENTS 42 ASA physical status I and II patients, 20 of whom were elderly (ages 65 to 80 yrs) and 22 younger control patients (ages 18 to 40 yrs), who were scheduled for elective orthopedic surgery and ear, nose, and throat surgery with a planned duration of 2 hours. INTERVENTIONS Neuromuscular blockade was evaluated with accelerometry of the thumb, using posttetanic twitch (PTT) and TOF stimulation of the ulnar nerve, in patients who received rocuronium 1 mg x kg(-1). MEASUREMENTS AND MAIN RESULTS The first responses to posttetanic nerve stimulation were seen at mean times of 38.5 and 35.2 minutes after the injection of rocuronium in the elderly and in the young, respectively (NS). The average interval between the appearance of a posttetanic response and the first response to TOF stimulation (T1) was longer in the elderly than the young (22.3 +/- 8.1 (SD) vs.14.8 +/- 4.2 min, p < 0.05). There was a significant correlation between PTC and the time to first response to TOF nerve stimulation both in the elderly and in the young (r = -0.73, p < 0.0001 and r = -0.87, p < 0.0001, respectively). CONCLUSIONS Posttetanic twitch stimulation is a useful method of monitoring intense neuromuscular blockade caused by rocuronium in both age groups. The interval between the earliest appearance of a posttetanic response and the first response to TOF stimulation (T1) is greater in the elderly than in the young.

Evaluation of Sepsis/Systemic Inflammatory Response Syndrome, Acute Kidney Injury, and RIFLE Criteria in Two Tertiary Hospital Intensive Care Units in Turkey

Sepsis is a common cause of acute renal failure in intensive care units (ICU) with mortality rates as high as 60%. In this study, the clinical and laboratory predictors of acute kidney injury (AKI) in critically ill Turkish patients with sepsis/systemic inflammatory response syndrome were identified. We studied 139 (67 females/72 males) patients admitted to our ICUs with sepsis/systemic inflammatory response syndrome without renal failure. The clinical and laboratory parameters and treatments were recorded. Patients were classified as those without AKI (n = 60; 43.20%) and those with AKI (n = 79; 56.80%) based on the RIFLE (Risk, Injury, Failure, Loss, End-stage renal disease) criteria. Those with AKI were further classified as: risk in 27 (19%), injury in 25 (17.9%), failure in 25 (17.9%), and loss in 2 (1.4%). We found that the mortality rate increased with the severity of renal involvement: 56% in risk, 68% in injury, 72% in failure, and 100% in loss categories. Patients with AKI had a more positive fluid balance, higher central venous pressure, more vasopressor use, and lower systolic blood pressure. In multivariate analysis, the sequential organ failure assessment score, blood pressure, serum creatinine, and fluid balance were risk factors for the development of AKI. In this population, the incidence of AKI was higher and contrary to previous knowledge. A positive fluid balance also carries a risk for AKI and mortality in septic ICU patients. The RIFLE criteria were found to be applicable to our ICU population.

Predicting recovery from deep neuromuscular block by rocuronium in children and adults

STUDY OBJECTIVE To compare the response to motor nerve stimulation at a rate of 1 Hz after 50 Hz tetanus [posttetanic count (PTC)] and 2 Hz for 2 seconds [train-of-four (TOF)] in children and adults during spontaneous recovery from blockade caused by rocuronium. DESIGN Prospective, clinical, observational, multicenter study. SETTING Operating rooms of two university hospitals. PATIENTS 22 children (ASA physical status I and II) aged 2 to 5 years, scheduled to undergo dental treatment and 20 adults aged 18 to 60 years, scheduled to undergo elective general or orthopedic surgery during general anesthesia with tracheal intubation. MEASUREMENTS Neuromuscular blockade was evaluated with accelerometry of the thumb, using PTC and TOF stimulation of the ulnar nerve, in patients who received rocuronium 1 mg x kg(-1). MAIN RESULTS The first response to posttetanic and TOF nerve stimulation appeared earlier in children than in adults. The time from injection of rocuronium to appearance of the fourth response to TOF ranged from 27 to 62 minutes in children and from 37 to 94 minutes in adults. The average interval between the appearance of a posttetanic response and the first detectable response to TOF stimulation (T1) was also shorter in children, 7 minutes, than in adults, 16 minutes. The relationship between PTC and the time interval between a given PTC and the first detectable TOF response in both children and adults was exponential (R = -0.64 and R = -0.81, respectively). CONCLUSIONS Children recover faster than adults from neuromuscular blockade after administration of 1 mg x kg(-1) rocuronium. The relationship between PTC and time to first response to TOF is exponential both in children and adults during recovery from neuromuscular blockade caused by rocuronium.

Evaluation of intense neuromuscular blockade caused by rocuronium using posttetanic count in male and female patients.

STUDY OBJECTIVE To establish the relationship between train-of-four (TOF) nerve stimulation and the number of posttetanic twitches (posttetanic count [PTC]) during neuromuscular blockade caused by rocuronium in males and females. DESIGN Prospective, observational, clinical comparison. SETTING Operating room of a university hospital. PATIENTS 60 ASA physical status I and II patients (30 women and 30 men), aged 18 to 60 years, who were scheduled for elective orthopedic surgery and ear, nose, throat surgery with a planned duration of 2 hours. INTERVENTIONS; During fentanyl, propofol, and nitrous oxide (N(2)O) anesthesia, neuromuscular blockade was evaluated with accelerometry of the thumb using TOF and posttetanic twitch stimulation (PTTS) of the ulnar nerve in patients who received rocuronium 1 mg.kg(-1). MEASUREMENTS AND MAIN RESULTS The first responses to PTTS were seen at mean times of 34.9 and 37.7 minutes after rocuronium injection in male and female patients, respectively (NS). The average interval between the appearance of a posttetanic response and the first response to TOF stimulation (T1) was not significantly different between male and female patients (15.4 +/- 4.8 min (SD) vs. 15.9 +/- 4.9 min, respectively). There was a significant negative correlation between PTC and the time to first response to TOF nerve stimulation (r = -0.83; p = 0.0001). Gender did not have a statistically significant effect on this relation (F = 0.9; p = 0.34). The intervals from administration of rocuronium to the first appearances of T1 and T2 were not significantly different between the two groups, but the intervals to the first appearances of T3 and T4 were significantly longer in female patients. CONCLUSIONS Even though the times from initial administration of rocuronium 1 mg.kg(-1) to the first appearances of T3 and T4 are significantly longer in female patients, the intervals to the first detectable responses to PTTS and TOF are not significantly different between females and males. Gender has no significant effect on the relation between PTC and the time to T1.

Neutrophil gelatinase-associated lipocalin levels during the first 48 hours of intensive care may indicate upcoming acute kidney injury.

PURPOSE The recognition of acute kidney injury (AKI) as early as possible is important in the intensive care unit. This study proposes that serum and urine levels of neutrophil gelatinase-associated lipocalin (NGAL) may be used for this purpose. METHODS One hundred and seven critically ill adult patients with no previous renal failure were included. NGAL levels were measured during the first 48 hours after admission; NGAL levels were followed for 7 days and classified based on Risk, Injury, Failure, Loss, and End-Stage Renal Failure criteria. RESULTS The AKI incidence was 35.5%, and serum NGAL (sNGAL) and urinary NGAL (uNGAL) levels were higher in the AKI group. The area under the receiver operating characteristic curve was 0.76 (P<.001) for sNGAL and 0.75 (P<.001) for uNGAL. Seventy-one percent of AKI cases were observed within 48 hours, with 11 additional cases in the ensuing 7 days. The mean serum creatinine levels in the 11 patients were not different from non-AKI levels (P=.197), but the NGAL values were different, and the area under the receiver operating characteristic curve for sNGAL uNGAL was 1.00 (P=.014) and 0.93 (P=.02), respectively. CONCLUSIONS Most AKI cases were diagnosed within the first 48 hours after admission, and NGAL was useful for predicting upcoming AKI.

The effect of midazolam-thiopental coinduction on recovery in minor surgery

AbstractPurpose. The effects of midazolam–thiopental coinduction on recovery were investigated and compared with thiopental induction. Methods. Fifty patients, ASA 1 or 2, undergoing minor orthopedic surgery, were randomly divided into coinduction and thiopental groups. During preoxygenation, the patients received midazolam 0.1 mg·kg−1 (coinduction group) or saline (thiopental group) 1 min before induction of anesthesia with thiopental. Isoflurane and nitrous oxide were used to maintain anesthesia. Isoflurane concentration was adjusted to keep blood pressure within ±20% of the preoperative value. The time to awaken (open eyes, give name and birth-date) and the time to discharge readiness were recorded. Psychomotor tests, including simple light reaction time (SLRT), sedation analogue scale (SAS), and digit span test, were performed pre- and postoperatively. Results. The induction dose of thiopental was significantly lower in the coinduction group. End-tidal isoflurane concentration during surgery was also lower in the coinduction group. There were no significant differences in awakening times and discharge readiness between the two groups. Although SAS values were lower in the coinduction group than in the thiopental group 8 and 24 h after anesthesia, other test results were similar in both groups. The frequency of nausea and vomiting in the recovery period was lower in the coinduction group. Conclusion. We conclude that midazolam–thiopental coinduction is a suitable technique when used in conjunction with isoflurane in day-case surgery.

Epidemiology of sepsis in intensive care units in Turkey: a multicenter, point-prevalence study

BackgroundThe prevalence and mortality of sepsis are largely unknown in Turkey, a country with high antibiotic resistance. A national, multicenter, point-prevalence study was conducted to determine the prevalence, causative microorganisms, and outcome of sepsis in intensive care units (ICUs) in Turkey.MethodsA total of 132 ICUs from 94 hospitals participated. All patients (aged > 18 years) present at the participating ICUs or admitted for any duration within a 24-h period (08:00 on January 27, 2016 to 08:00 on January 28, 2016) were included. The presence of systemic inflammatory response syndrome (SIRS), severe sepsis, and septic shock were assessed and documented based on the consensus criteria of the American College of Chest Physicians and Society of Critical Care Medicine (SEPSIS-I) in infected patients. Patients with septic shock were also assessed using the SEPSIS-III definitions. Data regarding demographics, illness severity, comorbidities, microbiology, therapies, length of stay, and outcomes (dead/alive during 30 days) were recorded.ResultsOf the 1499 patients included in the analysis, 237 (15.8%) had infection without SIRS, 163 (10.8%) had infection with SIRS, 260 (17.3%) had severe sepsis without shock, and 203 (13.5%) had septic shock. The mortality rates were higher in patients with severe sepsis (55.7%) and septic shock (70.4%) than those with infection alone (24.8%) and infection + SIRS (31.2%) (p < 0.001). According to SEPSIS-III, 104 (6.9%) patients had septic shock (mortality rate, 75.9%). The respiratory system (71.6%) was the most common site of infection, and Acinetobacter spp. (33.7%) were the most common isolated pathogen. Approximately, 74.9%, 39.1%, and 26.5% of Acinetobacter, Klebsiella, and Pseudomonas spp. isolates, respectively, were carbapenem-resistant, which was not associated with a higher mortality risk. Age, acute physiology and chronic health evaluation II score at ICU admission, sequential organ failure assessment score on study day, solid organ malignancy, presence of severe sepsis or shock, Candida spp. infection, renal replacement treatment, and a nurse-to-patient ratio of 1:4 (compared with a nurse-to-patient ratio of 1:2) were independent predictors of mortality in infected patients.ConclusionsA high prevalence of sepsis and an unacceptably high mortality rate were observed in Turkish ICUs. Although the prevalence of carbapenem resistance was high in Turkish ICUs, it was not associated with a higher risk for mortality.Trial registrationClinicalTrials.gov ID NCT03249246. Date: August 15, 2017. Retrospectively registered.

Neutrophil gelatinase-associated lipocalin is a better biomarker than cystatin C for the prediction of imminent acute kidney injury in critically ill patients

Aims The prevention of acute kidney injury can be lifesaving for the intensive care unit patients. However, conventional methods are not sufficient for the prediction of the risk of future acute kidney injury. In this study, the promising biomarker, neutrophil gelatinase-associated lipocalin, was compared with cystatin C as an indicator for the risk of future acute kidney injury. Methods One hundred and eighty-three adult patients without chronic kidney disease or renal replacement therapy were included in this study. The plasma and urine concentrations of neutrophil gelatinase-associated lipocalin and cystatin C were assessed on the second day after intensive care unit admission and were followed for seven days to monitor the development of acute kidney injury. Acute kidney injury diagnosis was based on the risk, injury, failure, loss, end-stage renal failure criteria. Results Thirty-four per cent of the patients had acute kidney injury; 17 patients who did not fulfil criteria at the beginning, developed acute kidney injury from days 3 to 7 after admission. The mean serum creatinine on admission did not significantly differ between this and control groups (0.72 ± 0.20 and 0.83 ± 0.21; P = 0.060); however, the serum and urinary neutrophil gelatinase-associated lipocalin concentrations on the second day were significantly different (median: 75.69 [54.18–91.18] and 123.68 [90.89–166.31], P = 0.001; and median: 17.60 [8.56–34.04] and 61.37 [24.59–96.63], P = 0.001). Notably, the 48-h serum cystatin C concentration did not differ. Conclusion Neutrophil gelatinase-associated lipocalin concentrations in the urine and serum on the second day of intensive care unit admission could be used to predict the development of acute kidney injury in the following three to seven days in the intensive care unit; however, the cystatin C concentration did not have predictive value.

Treatment of Posterior Reversible Encephalopathy Syndrome that Occurred in a Patient with Systemic Lupus Erythematosus by Plasmapheresis

Posterior reversible encephalopathy syndrome is characterized by visual and mental disturbances, nausea and vomiting and generalized or focal convulsions and often represents itself with parietal and occipital oedema formation. We want to report the treatment of posterior reversible encephalopathy syndrome with plasmapheresis, which developed in a 35-year-old woman with systemic lupus erythematosus diagnosed by renal biopsy 3 years ago. She has been followed up in the intensive care unit three times. However, she had been transferred to the nephrology department of our university hospital because of her uncontrolled blood pressure. Oral antihypertensive therapy, corticosteroid 500 mg 1 × 1 and cyclophosphamide were started for the activation of lupus. After the detection of low complement levels, systemic lupus erythematosus activation was suspected. She developed mental deterioration after her first plasmapheresis treatment and was then consulted by the neurology and intensive care unit doctors. Diffusion cranial magnetic resonance imaging was found compatible with posterior reversible encephalopathy syndrome. The patient was transferred to our intensive care unit. The patient gained consciousness after her second plasmapheresis. After 5 days of follow-up in our intensive care unit and after significant regression was observed in the magnetic resonance imaging analysis, the patient was transferred to the nephrology service conscious, cooperated and orientated. At the nephrology service, after a total of 13 times of plasmapheresis, complement levels were increased and she was discharged with corticosteroid therapy. Posterior reversible encephalopathy syndrome can be observed in patients with systemic lupus erythematosus and intensive care unit treatment may be required. To control the hypertension, plasmapheresis should be kept in mind in addition to the multiple antihypertensive therapy in these patients.