Remzi Iscimen

Early Identification of Patients at Risk of Acute Lung Injury: Evaluation of Lung Injury Prediction Score in a Multicenter Cohort Study

RATIONALE Accurate, early identification of patients at risk for developing acute lung injury (ALI) provides the opportunity to test and implement secondary prevention strategies. OBJECTIVES To determine the frequency and outcome of ALI development in patients at risk and validate a lung injury prediction score (LIPS). METHODS In this prospective multicenter observational cohort study, predisposing conditions and risk modifiers predictive of ALI development were identified from routine clinical data available during initial evaluation. The discrimination of the model was assessed with area under receiver operating curve (AUC). The risk of death from ALI was determined after adjustment for severity of illness and predisposing conditions. MEASUREMENTS AND MAIN RESULTS Twenty-two hospitals enrolled 5,584 patients at risk. ALI developed a median of 2 (interquartile range 1-4) days after initial evaluation in 377 (6.8%; 148 ALI-only, 229 adult respiratory distress syndrome) patients. The frequency of ALI varied according to predisposing conditions (from 3% in pancreatitis to 26% after smoke inhalation). LIPS discriminated patients who developed ALI from those who did not with an AUC of 0.80 (95% confidence interval, 0.78-0.82). When adjusted for severity of illness and predisposing conditions, development of ALI increased the risk of in-hospital death (odds ratio, 4.1; 95% confidence interval, 2.9-5.7). CONCLUSIONS ALI occurrence varies according to predisposing conditions and carries an independently poor prognosis. Using routinely available clinical data, LIPS identifies patients at high risk for ALI early in the course of their illness. This model will alert clinicians about the risk of ALI and facilitate testing and implementation of ALI prevention strategies. Clinical trial registered with www.clinicaltrials.gov (NCT00889772).

Transfusion from male-only versus female donors in critically ill recipients of high plasma volume components

Objective:To reduce the incidence of transfusion-related acute lung injury (ALI), the American Association of Blood Banks recently recommended rapid implementation of strategies to minimize transfusion of high plasma volume components, fresh frozen plasma and apheresis platelets, from potentially alloimmunized donors, especially females. The objective of this study was to evaluate the effect of transfusing components from male-only vs. female donors on development of ALI, gas exchange, and outcome in critically ill patients. Design:In this retrospective case-control study, we identified patients who received high plasma volume components from male-only donors and compared them with patients matched by severity of illness, postoperative state, and number of transfusions but who received high plasma volume components from female donors. Setting:Four intensive care units at a tertiary medical center. Patients:Critically ill patients who received >2 units of fresh frozen plasma or apheresis platelets. Interventions:None. Measurements and Main Results:From a database of 3,567 patients who received a total of 46,101 units of fresh frozen plasma and 6,251 units of apheresis platelets, we identified 112 patients who received three or more male-only donor components and 112 matched controls. Baseline characteristics, ALI risk factors, and development of ALI were similar between the two groups. Arterial oxygenation (Pao2/Fio2) worsened after the female (mean difference −52, 95% confidence interval −14 to −91, p = .008) but not after male-only donor product transfusion (mean difference 22, 95% confidence interval −23 to 67, p = .325). Male-only component recipients had more ventilator-free days (median 28 vs. 27, p = .006) and a trend toward lower hospital mortality rates (14% vs. 24%, p = .054). Conclusions:In critically ill recipients of high plasma volume components, gas exchange worsened significantly after transfusion of female but not male donor components. Prospective studies are needed to evaluate the effect of recommendations by the American Association of Blood Banks on outcome of transfused critically ill patients.

Prophylactic endotracheal intubation in critically ill patients undergoing endoscopy for upper GI hemorrhage

BACKGROUND Cardiopulmonary complications are common after endoscopy for upper GI (UGI) hemorrhage in the intensive care unit (ICU). OBJECTIVE To evaluate the practice and outcome of elective prophylactic endotracheal intubation before endoscopy for UGI hemorrhage in the ICU. DESIGN Retrospective, propensity-matched case-control study. SETTING A 24-bed medical ICU in a tertiary center. PATIENTS ICU patients who underwent endoscopy for UGI hemorrhage. MAIN OUTCOME MEASUREMENTS Cardiopulmonary complications, ICU and hospital length of stay, and mortality. In a propensity analysis, patients who were intubated for airway protection before UGI endoscopy were matched by probability of intubation to controls who were not intubated before UGI endoscopy. RESULTS Of 307 patients, 53 underwent elective prophylactic intubation before UGI endoscopy. The probability of intubation depended on the Acute Physiology and Chronic Health Evaluation III (APACHE III) score (OR 1.4; 95% CI, 1.2-1.6), age (OR 0.97; 95% CI, 0.95-0.09), the presence of hemetemesis (OR 1.9; 95% CI, 0.8-5.1), previous lung disease (OR 2.1; 95% CI, 0.8-4.9), and the number of transfusions (OR 1.1; 95% CI, 1.0-1.1 per unit). Nonintubated matched controls were identified for all but 4 patients with active massive hemetemesis, who were excluded from matched analysis. Cumulative incidence of cardiopulmonary complications (53% vs 45%, P = .414), ICU length of stay (median 2.2 vs 1.8 days, P = .138), hospital length of stay (6.9 vs 5.9 days, P = .785), and hospital mortality (14% vs 20%, P = .366) were similar. CONCLUSIONS Cardiopulmonary complications are frequent after endoscopy for acute UGI bleeding in ICU patients and are largely unaffected by the practice of prophylactic intubation.

Nosocomial Acinetobacter pneumonia: Treatment and prognostic factors in 356 cases

Acinetobacter baumannii and A. baumannii/calcoaceticus complex are commonly encountered pathogens in nosocomial infections. This study aimed to evaluate the treatment and prognostic risk factors in nosocomial pneumonia caused by these microorganisms.

Impact of a Basic Nutrition Course for Residents at a Faculty Hospital

Background/Aims: To assess whether a basic nutrition course for residents at a faculty hospital improves their knowledge of nutrition and increases the number of consultation requests for nutrition by alerting participants to the high prevalence of undernutrition in hospitals. Methods: The residents from 34 departments of basic, internal and surgical sciences were recruited to take a 1-day course. Questionnaires, designed to assess knowledge of nutrition, were completed at the beginning and at the end of the course. The results of the questionnaires and the number of consultation demands for nutrition before and after the course were compared. Results: The results of 161 participants were evaluated. The mean (±SE) numbers of correct answers given to the first and second questionnaires were 14.9 ± 0.22 and 18.7 ± 0.21, respectively (p < 0.01). When the number of requests for nutrition consultation during 7-month periods (just before and after the course) were compared, the mean number of requests in each month during these periods were found to be 1.81 ± 0.58 and 4.06 ± 1.20, respectively (p < 0.01). Conclusions: A short course of basic nutrition for residents improves their basic knowledge and leads to an increase in the number of consultation requests for nutritional support.

Guillain-Barré Syndrome and Human Immunodeficiency Virus

Guillain-Barré syndrome (GBS) is an acute disease characterised by symmetrical muscle weakness, loss of sensation and reflex. There is usually a viral infection at the beginning of the disease. Here, we report a GBS case which did not respond to any treatment strategy at first and was diagnosed as Human Immunodeficiency Virus positive (HIV+) during the search for the aetiology. A 32-year-old male patient who presented to a medical centre with symptoms of gait disturbance and arm and leg numbness was found to have albuminocytologic dissociation upon cerebrospinal fluid examination. After the diagnosis of GBS, immunoglobulin G (IVIG) therapy (400 mg kg(-1) day(-1) 5 days) was started as a standard therapy. This therapy was repeated due to a lack of improvement of symptoms. During this therapy, the patient was sent to our clinic with symptoms of respiratory failure and tetraplegia. He was conscious, cooperative, haemodynamically stable and his arterial blood gas analyses were: pH: 7.28, PaO2: 74.4 mmHg, PCO2: 63.8 mmHg. He was intubated, mechanically ventilated and underwent plasmapheresis. After the investigation of aetiology, HIV(+), CD4/CD8: 0.17, absolute CD4: 71 cells mL(-1) were detected and antiretroviral therapy was started. The patient died from multiple organ failure due to sepsis on day 35. In conclusion, HIV infection should be kept in mind in GBS patients, especially those not responding to routine treatment. As a result, not only could the patient receive early and adequate treatment, but also HIV infection transmission would be avoided.

Ogilvie’s syndrome following bilateral knee arthroplasty: a case report

Ogilvies syndrome, also known as acute colonic pseudo-obstruction, is an uncommon but severe postoperative complication of total hip and knee arthroplasty. This syndrome should be borne in mind after arthroplasty surgery. We present a case of this serious postoperative complication and aim to identify the risk factors and alert surgeons to the possibility and appropriate management of Ogilvies syndrome.

Fatal Hydrothorax Due to Misplacement of a Nasoenteric Feeding Tube

Blind nasoenteric intubation was attempted in a patient with chronic parkinsonism. The tube was inadvertently misplaced and penetrated the left pleural cavity. The next day, the patient developed cardiopulmonary arrest during dietary supplement infusion. This complication ultimately led to the patients death. We have reviewed the known complications of nasoenteric tube placement and conclude that difficult insertion in patients at risk from tube misplacement should be followed by chest radiography to confirm the correct placement of the tube before nutritional support is started.

Persistent hypoxemia during extracorporeal membrane oxygenation in delayed diagnosed paraquat intoxication

Paraquat is a highly toxic herbicide used in agriculture worldwide that causes progressive pulmonary fibrosis (PF) due to selective accumulation in the lungs. Paraquat intoxication can result in death due to multi-organ failure within a few days or respiratory failure due to PF within a few weeks. Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is currently a widely used therapeutic strategy for acute respiratory distress syndrome (ARDS). Presently described is case of a 46-year-old man who was hospitalized with ARDS and treated with V-V ECMO. Expected oxygenation levels could not be attained despite ECMO support. When excluding causes for hypoxia in this patient on ECMO, detailed medical history revealed exposure to paraquat 3 weeks previously. Severe hypoxemia persisted during V-V ECMO and the patient died on sixth day after admission. The aim of this study was to examine probable causes of persistent hypoxemia during V-V ECMO observed in this case.

Comparison Of The Effects Of Propofol and Dexmedetomidine Sedation On Axillary Block

Uzm. Dr. Canan Yilmaz, Bursa Şevket Yilmaz Egitim ve Arastirma Hastanesi Yildirim Bursa Turkiye, Tel. 0224 295 50 00 Email. dr_cnnylmz@yahoo.com Gelis Tarihi: 25.04.2014 • Kabul Tarihi: 01.03.2015 ABSTRACT AIM: We aimed to compare the effects of propofol and dexmedetomidine on intra-operative sedation, hemodynamic parameters and post-operative analgesia during fore-arm surgery with axillary block.