Saziye Sahin

Three-Year Evaluation of Nosocomial Infection Rates of the ICU

BACKGROUND AND OBJECTIVES Evaluating the incidence of nosocomial and invasive device-related infections enables the comparison of the health care associated infection (HAI) between the intensive care units of different hospitals and different units in the same hospital. MATERIAL AND METHODS A retrospective surveillance study was performed to identify nosocomial infections, device-related infections rates, and causal agents from January 2007 through December 2010 in the Anesthesiology Intensive care unit (ICU). HAI were defined according to the CDC (Centers for Disease Control and Prevention) criteria, and invasive device-related infections were defined according to National Nosocomial Infection Surveillance System (NNIS) criteria. RESULTS During a two-year period, 939 patients were analyzed throughout a total of 7,892 patient- days. The rates of HAI were 53% in 2007, 29.15% in 2008, 28.85% in 2009 while 16.62% in 2010. Most common HAI was blood stream infection. The rate of soft tissue and skin infection was the second most common. Overall, the most common agents were Gram(-) 56.68%, Gram(+) 31.02% and Candida spp 12.3% among patients with nosocomial infections. CONCLUSIONS The incidence of HAI in the ICU of our hospital was high, compared to the Turkish overall rates obtained at the Refik Saydam Center in 2007. When the rates of device-related infections between 2007 and 2008 were compared, they were higher in 2007. The rates of device- related infections were diminished in 2008 to below-national mean rates by infection control measures. Since the rate of urinary catheter-related infections are still high, we should exert continuous efforts for infection control.

Sedação com cetamina‐propofol em circuncisão

BACKGROUND AND OBJECTIVE to compare the therapeutic effects of ketamine alone or ketamine plus propofol on analgesia, sedation, recovery time, side effects in premedicated children with midazolam-ketamine-atropin who are prepared circumcision operation. METHODS 60 American Society of Anaesthesiologists physical status I-II children, aged between 3 and 9 years, undergoing circumcision operations under sedation were recruited according to a randomize and double-blind institutional review board-approved protocol. Patients were randomized into two groups via sealed envelope assignment. Both groups were administered a mixture of midazolam 0.05mg/kg+ketamine 3mg/kg+atropine 0.02mg/kg intramuscularly in the presence of parents in the pre-operative holding area. Patients were induced with propofol-ketamine in Group I or ketamine alone in Group II. RESULTS in the between-group comparisons, age, weight, initial systolic blood pressure, a difference in terms of the initial pulse rate was observed (p>0.050). Initial diastolic blood pressure and subsequent serial measurements of 5, 10, 15, 20thmin, systolic blood pressure, diastolic blood pressure and pulse rate in ketamine group were significantly higher (p<0.050). CONCLUSION propofol-ketamine (Ketofol) provided better sedation quality and hemodynamy than ketamine alone in pediatric circumcision operations. We did not observe significant complications during sedation in these two groups. Therefore, ketofol appears to be an effective and safe sedation method for circumcision operation.

Três anos de avaliação das taxas de infecção nosocomial em UTI

JUSTIfiCATIVA Y OBJETIVOS: La evaluacion de la incidencia de las infecciones nosocomiales asociadas con los dispositivos invasivos, permite comparar las infecciones relacionadas con la asistencia a la sanidad (IRAS) entre las UCIs de diferentes hospitales y las unidades del mismo hospital. MATERIAL Y METODOS: De enero de 2007 a diciembre de 2010, un estudio de vigilancia retrospectivo fue realizado para identificar infecciones nosocomiales, tasas de infecciones relacionadas con los dispositivos y agentes causantes en la unidad de cuidados intensivos (UCI) de anestesiologia. Las IRAS se definieron de acuerdo con los criterios del Centro de Control y Prevencion de Enfermedades (CDC) y las infecciones relacionadas con los dispositivos invasivos definidas de acuerdo con los criterios del Sistema Nacional de Vigilancia de Infecciones Nosocomiales (NNIS). RESULTADOS: Durante dos anos, se evaluaron 939 pacientes dentro de un universo de 7.892 pacientes/dia. Las tasas de IRAS alcanzaron el umbral del 53% en 2007, 29,15% en 2008, 28,85% en 2009 y 16,62% en 2010. La IRAS mas frecuente fue la infeccion de la corriente sanguinea. La tasa de infeccion de tejido suave y de la piel fue la segunda. Entre los pacientes con infecciones nosocomiales, los agentes causantes mas a menudo encontrados fueron Gr (-) 56,68%, Gr (+) 31,02% y la candidiasis 12,3%. CONCLUSIONES: La incidencia de IRAS en la UCI de nuestro hospital fue alta en comparacion con las tasas turcas globales obtenidas en el Refik Saydam Center en 2007. Cuando las tasas de infecciones relacionadas con los dispositivos se compararon entre 2007 y 2008, fueron mayores en el 2007. Las tasas de infecciones relacionadas con los dispositivos en 2008 quedaron por debajo del promedio nacional a causa de las medidas de control de infeccion. Como la tasa de infecciones relacionada con el cateter urinario todavia permanece alta, debemos esforzarnos mas en el sentido de controlar las infecciones.

An uncommon procedure for a rare ailment: massive bronchoalveolar lavage in a patient with pulmonary alveolar proteinosis.

As a rare procedure, massive bronchoalveolar lavage (MBAL) is a large-volume lavage which necessitates general anesthesia and one-lung ventilation (OLV). During MBAL isotonic saline is instilled into one lung and drained through one lumen of a double-lumen tube. MBAL is the most effective treatment for symptomatic pulmonary alveolar proteinosis (PAP). A 27-year-old male with PAP was scheduled for therapeutic MBALs. After standard preoxygenation, monitoring and anesthesia induction, a double-lumen tube was placed. Tube position was verified by a fiberoptic bronchoscope. The internal jugular vein, radial and pulmonary arteries were cannulated. A temperature probe and foley catheter were inserted. The nonventilated lung was filled with 1000 mL saline and then drained in each session. The left and right lung were lavaged with an interval of 2 weeks. A total of 20 L saline was used in each MBAL without retention. MBALs were terminated after the effluent became clear. Duration of the left and right MBALs were 325 and 275 minutes, respectively. Despite increased shunt fraction, oxygenation was within acceptable limits during OLV. The trachea was extubated in the operating room uneventfully after each MBAL. The patients clinical and laboratory findings were evidently improved. Consequently, if proper conditions are provided, MBAL is safe and beneficial despite its risks and the long duration.

A 5-Year Evaluation of Invasive Device-Associated Infections Rates in Intensive Care Unit of a Training Hospital in Turkey -

Objective: This study aimed to determine invasive instrument-related infections in the general intensive care unit by comparative evaluation of the annual infection control measures. Methods: A surveillance study was made based on the data of 1494 patients treated for 48 hours in the general intensive care unit (GICU) between January 2008 and December 2012. Results: The hospital infection (HI) rates of the GICU for each year of the study period were calculated as 29.15%, 28.85%, 16.62%, 18.05% and 8.30% respectively. For each 1000 patient days, the infection rates for each year were calculated as ventilator-related pneumonia (VRP) 2.31, 4.32, 2.77, 11.49 9.62, central venous catheter-related bloodstream infections (CVCRBI) 1.57, 2.23, 8.58, 0.56, 1.03, and catheter-related urinary system infections (CRUSI) 6.00, 7.09, 4.35, 4.57, 3.17. When the infection agents were isolated and evaluated, the infection rates were determined as 61.92% Gr(-) bacteria infections, 20.89% fungal infections and 17.16% Gr(+) bacteria infections. Conclusions: Although the infection control precautions which were taken improved urinary and central catheter infection rates, no significant fall was obtained in rates of ventilator-related pneumonia. It can be concluded that it is necessary to increase the infection control precautions in this area to reduce infection rates.

Ketamine-propofol sedation in circumcision

BACKGROUND AND OBJECTIVE To compare the therapeutic effects of ketamine alone or ketamine plus propofol on analgesia, sedation, recovery time, side effects in premedicated children with midazolam-ketamine-atropin who are prepared circumcision operation. METHODS 60 American Society of Anaesthesiologists physical status I-II children, aged between 3 and 9 years, undergoing circumcision operations under sedation were recruited according to a randomize and double-blind institutional review board-approved protocol. Patients were randomized into two groups via sealed envelope assignment. Both groups were administered a mixture of midazolam 0.05mg/kg+ketamine 3mg/kg+atropine 0.02mg/kg intramuscularly in the presence of parents in the pre-operative holding area. Patients were induced with propofol-ketamine in Group I or ketamine alone in Group II. RESULTS In the between-group comparisons, age, weight, initial systolic blood pressure, a difference in terms of the initial pulse rate was observed (p>0.050). Initial diastolic blood pressure and subsequent serial measurements of 5, 10, 15, 20thmin, systolic blood pressure, diastolic blood pressure and pulse rate in ketamine group were significantly higher (p<0.050). CONCLUSION Propofol-ketamine (Ketofol) provided better sedation quality and hemodynamy than ketamine alone in pediatric circumcision operations. We did not observe significant complications during sedation in these two groups. Therefore, ketofol appears to be an effective and safe sedation method for circumcision operation.

Pleural effusion due to intraoperative rupture of an infected renal cyst

Pleural effusion can occur after complicated renal cyst operations. Rupture of the cyst into the retroperitoneal space and diffusion of cyst content through diaphragmatic pores is an unusual cause of pleural effusion. Reports about pleural effusion after renal cyst operation are rare in the literature while the diaphragm is intact. Here we report a case of renal cyst operation complicated with intraoperative cyst rupture and ipsilateral pleural effusion postoperatively. The culture of the cyst and the pleural fluid showed the same organism: Klebsiella pneumonia. A 57-year-old male patient was admitted to the emergency department. His complaints were right flank pain, high fever and poor health. Urosepsis was diagnosed after routine tests and the patient was referred to the urology department. In his history there was right nephrolithotomy due to kidney stones and stenting during angiography due to coronary heart disease. After tests for diagnosis of multiple kidney stones, pyonephrosis and a renal cyst approximately 13 cm in size were identified in the non-functional right kidney. Before nephrectomy and cyst excision, a nephrostomy catheter was inserted into the right kidney with intravenous antibiotic therapy for the treatment of pyonephrosis. After preoxygenation with 100% oxygen, anesthesia was induced with thiopental 400 mg and rocuronium 50 mg and maintained with sevoflurane 1.5% in N2O : O2 (50% : 50%). Endotracheal intubation was performed with an 8.0 mm inner diameter (ID) endotracheal tube. The nephrectomy operation was started under laparoscopy, but later was converted to open surgery because of very adherent tissues. The kidney tissue and the cyst were totally removed, but in the 50th minute of the operation the cyst ruptured due to adhesions. After the rupture, the content of the cyst diffused to the retroperitoneal area, and the surgeon aspirated and irrigated the area many times. The operation continued for 40 minutes after the rupture of the cyst. The duration of anaesthesia was 100 minutes. Hemodynamic parameters were stable throughout the operation. The patient was extubated at the end of the surgery but nearly 15 minutes after extubation the patient had difficulty in breathing and he was agitated. Blood gas analysis, which was taken 18 minutes after extubation, showed hypoxaemia; pH: 7.49; pO2: 54 mmHg; pCO2: 30 mmHg; HCO3: 23, SpO2: 88 (with an O2 mask). The patient was taken to the intensive care unit because of respiratory distress. The patient was conscious in the ICU. But on auscultation the right lung sounds were decreased and a serious respiratory distress was present. Chest X-ray revealed a pleural effusion (Fig. 1). The patients respiratory distress decreased after thoracentesis and chest tube insertion. Cultures of the pleural effusion and of cyst fluid taken during the operation were the same: Klebsiella pneumoniae. Imipenem 500 mg qid, linezolid 600 mg bid and metronidazole 500 mg tid were administered. Fig. 1 Pleural effusion was detected on the chest AP X-ray which was taken during respiratory distress. The diaphragm was intact during surgery and there was no defect on CT. We thought that there was retroperitoneal fluid transition through the diaphragmatic pores during the operation. The patients general condition improved with antibiotic therapy and drainage of the pleural fluid. The pathology report indicated chronic pyelonephritis. The patient was referred to the urology department 4 days after surgery, showing improvement in blood gas values, (pH: 7.35, pO2: 88 mmHg, pCO2: 36 mmHg, HCO3: 24, SpO2: 96), respiratory parameters and chest radiography. The chest tube was removed twelve days later and the patient was discharged as healthy. Pleural effusion may occur for a wide variety of reasons. Commonly, it can be a reactive response to infections, malignancies and heart failure. Pseudochylothorax and urinothorax are uncommon causes of pleural effusion. Also chylothorax is a rare cause of pleural effusion and occurs as a leakage of thoracic duct lymph [1]. Pseudochylothorax is a clinical condition characterized by asymptomatic and usually unilateral pleural effusion. In one case report, bilateral pleural effusion was reported after a percutaneous nephrolithotomy operation [2]. Urinothorax is the other rare cause of pleural effusion; it is detection of the urine in the pleura. Urinothorax occurs when there is diffusion of urine through the pleura due to extravasation of a urinoma and urinary tract obstruction [3]. In our patient, none of the above was the cause of his pleural effusion. The cause was cyst fluid transition through the diaphragmatic pores after rupture of the cyst. Complications due to infection or renal hydatid cyst rupture have been reported before [4] and there are many cases of intraperitoneal and retroperitoneal renal cyst rupture. But there are only a few reports of cyst rupture causing pleural effusion. A post-traumatic renal cyst rupture can drain to the peritoneal cavity, retroperitoneum, pelvicalyceal system, and perinephric and subcapsular areas [5]. In our case, the fluid diffused through the diaphragmatic pores during the operation. In conclusion the anesthesia team should always be careful about pulmonary complications during perioperative periods of renal cyst surgery.