Simay Serin

Costs and risk factors for ventilator-associated pneumonia in a Turkish University Hospital's Intensive Care Unit: A case-control study

BackgroundVentilator-associated pneumonia (VAP) which is an important part of all nosocomial infections in intensive care unit (ICU) is a serious illness with substantial morbidity and mortality, and increases costs of hospital care. We aimed to evaluate costs and risk factors for VAP in adult ICU.MethodsThis is a-three year retrospective case-control study. The data were collected between 01 January 2000 and 31 December 2002. During the study period, 132 patients were diagnosed as nosocomial pneumonia of 731 adult medical-surgical ICU patients. Of these only 37 VAP patients were assessed, and multiple nosocomially infected patients were excluded from the study. Sixty non-infected ICU patients were chosen as control patients.ResultsMedian length of stay in ICU in patients with VAP and without were 8.0 (IQR: 6.5) and 2.5 (IQR: 2.0) days respectively (P < 0.0001). Respiratory failure (OR, 11.8; 95%, CI, 2.2–62.5; P < 0.004), coma in admission (Glasgow coma scale < 9) (OR, 17.2; 95% CI, 2.7–107.7; P < 0.002), depressed consciousness (OR, 8.8; 95% CI, 2.9–62.5; P < 0.02), enteral feeding (OR, 5.3; 95% CI, 1.0–27.3; P = 0.044) and length of stay (OR, 1.3; 95% CI, 1.0–1.7; P < 0.04) were found as important risk factors. Most commonly isolated microorganism was methicillin resistant Staphylococcus aureus (30.4%). Mortality rates were higher in patients with VAP (70.3%) than the control patients (35.5%) (P < 0.003). Mean cost of patients with and without VAP were 2832.2+/-1329.0 and 868.5+/-428.0 US Dollars respectively (P < 0.0001).ConclusionRespiratory failure, coma, depressed consciousness, enteral feeding and length of stay are independent risk factors for developing VAP. The cost of VAP is approximately five-fold higher than non-infected patients.

Tramadol Versus Low Dose Tramadol-paracetamol for Patient Controlled Analgesia During Spinal Vertebral Surgery

Pain intensity may be high in the postoperative period after spinal vertebral surgery. The aim of the study was to compare the effectiveness and cost of patient controlled analgesia (PCA) with tramadol versus low dose tramadol‐paracetamol on postoperative pain. A total of 60 patients were randomly divided into two groups. One group received 1.5 mg/kg tramadol (Group T) while the other group received 0.75 mg/kg tramadol plus 1 g of paracetamol (Group P) intravenously via a PCA device immediately after surgery and the patients were transferred to a recovery room, Tramadol was continuously infused at a rate of 0.5 mL/h in both groups, at a dose of 10 mg/mL in Group T and 5 mg/mL in Group P. The bolus and infusion programs were adjusted to administer a 1 mL bolus dose of tramadol with a lock time of 10 minutes. In Group P, 1 g of paracetamol was injected intravenously every 6 hours. The four‐point nausea scale, numeric rating scale for pain assessment, Ramsey sedation scale, blood pressure, heart rate, respiration rate, peripheral oxygen saturation values and side effects were recorded at 0, 15 and 30 minutes, and at 1, 2, 4, 6, 12, 18 and 24 hours. The time to reach an Aldrete score of 9 was also recorded. A cost analysis for both groups was performed. In Group P, the numeric rating scale scores were significantly lower than that in Group T at 0 and 15 minutes. The number of side effects, additional analgesic requirement and the total dose of tramadol were lower in Group P than in Group T. However, the total cost of postoperative analgesics was significantly higher in Group P than in Group T (p < 0.001). We conclude that PCA using tramadol‐paracetamol could be used safely for postoperative pain relief after spinal vertebral surgery, although at a higher cost than with tramadol alone.

Hydrogen sulfide toxicity in a thermal spring: a fatal outcome

Introduction. Hydrogen sulfide (H2S) is a toxic gas with the smells of “rotten egg”; its toxic effects are due to the blocking of cellular respiratory enzymes leading to cell anoxia and cell damage. Case presentation. We report two cases with acute H2S intoxication caused by inhalation of H2S evaporated from the water of a thermal spring. Two victims were found in a hotel room were they could take a thermal bath. A 26-year-old male was found unconscious; he was resuscitated, received supportive treatment and survived. A 25-year-old female was found dead. Autopsy showed diffuse edema and pulmonary congestion. Toxicological blood analysis of the female revealed the following concentrations: 0.68 mg/L sulfide and 0.21 mmol/L thiosulfate. The urine thiosulfate concentration was normal. Forensic investigation established that the thermal water was coming from the hotels own illegal well. The hotel was closed. Conclusion. This report highlights the danger of H2S toxicity not only for reservoir and sewer cleaners, but also for individuals bathing in thermal springs.

Effects of high thoracic epidural anesthesia on mixed venous oxygen saturation in coronary artery bypass grafting surgery.

Background To investigate possible effects of high thoracic epidural anesthesia (HTEA) on mixed venous oxygen saturation (SvO2) in coronary artery bypass grafting surgery (CABGS). Material/Methods Sixty-four patients scheduled for CABGS were randomly assigned to either test (HTEA) or control group. Standard balanced general anesthesia was applied in both groups. Mean arterial blood pressure (MAP), heart rate (HR), oxygen saturation (SpO2), central venous pressure (CVP), cardiac output (CO), cardiac index (CI), systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), mean pulmonary arterial pressure (PAP), pulmonary capillary wedge pressure (PCWP), pulmonary compliance (C), bispectral index (BIS), body temperature, SvO2, hematocrit values were recorded before induction. Postoperative hemodynamic changes, inotropic agent, need for vasodilatation, transfusion and additional analgesics, recovery score, extubation time, visual analogue scale (VAS) values, duration of stay in intensive care unit (ICU) and hospital were recorded. Results Study groups were similar in SpO2, CVP, PCWP, PAP, C, body temperature, BIS values, development of intraoperative bradycardia. In HTEA group, intraoperative MAP, SVR, PVR, need for transfusion were lower, whereas CO, CI, SvO2, hematocrit values were higher (p<0.05). Postoperative MAP, HR, hypertension development, need for vasodilatator, transfusion, analgesics, extubation time, recovery data, duration of stay in ICU, hospital were lower in HTEA group (p<0.05). VAS score decreased in 30 minutes and 12 hours following extubation in HTEA and control group, respectively. Conclusions HTEA may improve balance between oxygen presentation and usage by suppressing neuroendocrin stress response; provide efficient postoperative analgesia, more stabile hemodynamic, respiratory conditions, lower duration of stay in ICU, hospital.

Comparison of halothane/thiopental and propofol anesthesia for strabismus surgery.

Day case surgery has become a widely accepted practice for many ophthalmological procedures including strabismus surgery. Prompt recovery from anesthesia and minimal postoperative morbidity are especially requested to the anesthesiologists to deal with the high day case surgery burden. The purpose of this study was to compare two anesthesia techniques, halothane/thiopental anesthesia and propofol anesthesia, for patients undergoing monocular strabismus surgery. We studied the level of postoperative consciousness, nausea and vomiting, ocular pain, starting oral intake and activity in 43 patients, ranging from 7 to 41 years of age. A scoring system was used to assess these parameters in the first postoperative 48 h. Although there was not a significant difference in the level of ocular pain, the propofol group had less morbidity in terms of having a better level of consciousness and appetite, less nausea and vomiting and enhanced activity than the halothane/thiopental group. We conclude that propofol anesthesia has significant advantages over halothane/thiopental anesthesia on an outpatient basis for strabismus surgery.

Combinations of fentanyl and levobupivacaine for post-thoracotomy pain

The aim of the present study is to evaluate the analgesic activity, patient satisfaction, and side effect profile of different concentrations of levobupivacaine plus fentanyl administered through thoracic epidural patient-controlled analgesia in patients undergoing thoracotomy. The study included 60 patients who were randomly divided into three groups. At the end of the surgery, group I (n = 20) received 0.125% levobupivacaine plus 3 mg fentanyl, group II received 0.1% levobupivacaine plus 3 mg fentanyl, and group III received 0.05% levobupivacaine plus 3 mg fentanyl via an epidural catheter placed at the level of T(10-11) or T(11-12). For all groups, the patient-controlled analgesia device was programmed to deliver a loading dose of 14 mL at an infusion rate of 4 mL/h, and a bolus dose of 2 mL/h, with a locked out interval of 15 minutes and 60 mL of a 4-hour limit. The following parameters were evaluated at 5, 10, 15, 20, 30, and 40 minutes and at 1, 2, 4, 8, 16, and 24 hours after admission to the intensive care unit, at which nausea and vomiting scales, Visual Analog Scale I-II, Ramsay sedation scale, Bromage scale, pupil diameter, arterial blood pressure, heart rate, respiratory rate, and SpO(2) were measured and recorded. Any side effect was also documented. As the result of the evaluation, visual Analog Scale I-II scores, patient satisfaction scores, mean arterial blood pressure, and heart rate significantly differed in group I as compared with groups II and III. No side effects were encountered except mild nausea, which was seen in group III and did not require treatment. Motor blockage, pupil size, respiratory rate, and SpO(2) were not monitored in any of the patients in all groups. In conclusion, our study suggested that the use of 0.125% levobupivacaine, together with 3 mg/mL fentanyl, constitutes a good combination, and can be used safely without causing hemodynamic change and motor block.

Nosocomial infections in a Turkish university hospital: a 2-year survey.

REFERENCES 1. Srinivasan A, Song X, Ross T, et al. A prospective study to determine whether cover gowns in addition to gloves decrease nosocomial transmission of vancomycinresistant enterococci in an intensive care unit. Infect Control Hosp Epidemiol 2002;23:424-428. 2. Slaughter S, Hayden MK, Nathan C, et al. A comparison of the effect of universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care unit. Ann Intern Med 1996;125:448-456. 3. Puzniak LA, Leet T, Mayfield J, et al. To gown or not to gown: the effect on acquisition of vancomycin-resistant enterococci. Clin Infect Dis 2002;35:18-25. 4. Hospital Infection Control Practices Advisory Committee (HICPAC). Recommendations for preventing the spread of vancomycin resistance. MMWR 1995;44(RR12):1-13. 5. U.S. Department of Labor, Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens: final rule. Federal Register 1991;56:6400464182. 6. Belkin NL. Gowns: selection on a procedure-driven basis. Infect Control Hosp Epidemiol 1994;15:713-716.

Various scoring systems for predicting mortality in Intensive Care Unit

CONTEXT Various scoring systems have been developed to predict mortality and morbidity in Intensive Care Unit (ICU), but different data has been reported so far. AIMS This retrospective clinical study aims to evaluate predictability of Acute Physiology and Chronic Health Evaluation II (APACHE II), APACHE IV, Simplified Acute Physiology Score III (SAPS III) scoring systems regarding with mortality. SETTINGS AND DESIGN Sixteen bed surgical-medical ICU in university hospital. MATERIALS AND METHODS The study comprised 487 patients older than 18 years treated in ICU for at least 24 h. Age, gender, body weight, initial diagnosis, clinic of referral, intubation, comorbidities, APACHE II, APACHE IV, Glasgow coma scale, SAPS III scores, length of hospitalization before referral to ICU, length of stay in ICU, mechanical ventilation were recorded. RESULTS Most of the patients (54.6%) were consulted from operating room. The most frequent diagnosis was acute respiratory failure. Total mortality rate was 26%. Mortality rate was higher in patients admitted from wards other than surgery (48%) (P < 0.005). In the presence of comorbidities, mortality rate was higher with comorbidities than without (P < 0.05). Regression analysis indicated a significant positive relationship between length of stay in ICU, length of mechanical ventilation and high mortality risk in patients referred from emergency service (P < 0.05). Accuracy rates of predicting mortality were 81%, 79%, and 81% for APACHE II, APACHE IV, and SAPS III, respectively. CONCLUSIONS The investigated scoring systems are similar in sensitivity and specificity mortality prediction whereas the accuracy was higher for SAPS III and APACHE II than APACHE III in our patient population.

Comparative evaluation of two different volumes of lidocaine in intravenous regional anesthesia

Background This study was conducted to compare low concentration-high volume intravenous regional anesthesia (IVRA) method with local anesthetic method in upper extremity surgery in terms of efficiency and adverse effects. Material/Methods Thirty-nine patients were divided into 2 groups; the first group received a 2% concentration of 12–15 mL lidocaine (Group 1) and the second group received a 0.5% concentration of 30–50 mL lidocaine (Group 2). Intraoperative hemodynamic data of patients (systolic blood pressure, diastolic blood pressure, mean blood pressure, heart rate, and peripheral oxygen saturation- SpO2) was recorded before and after anesthesia at 1, 5, 10, 15, 20, and 40 minutes. Results The intergroup and intragroup comparisons did not reveal any significant differences in hemodynamic data. The onset time of sensorial block was shorter and the regression time of sensorial block was longer in Group 1 than Group 2. Group 1 had shorter onset time of motor block and longer regression time of motor block than Group 2. There were no significant differences between the study groups in terms of the time of tourniquet and postoperative analgesia time. Conclusions IVRA technique applied with 2% concentration and volume of 12–15 mL lidocaine may be suggested as a safe option.

Comparison of Spinal, Low-Dose Spinal and Epidural Anesthesia with Ropivacaine plus Fentanyl for Transurethral Surgical Procedures

The aim of This study was to compare spinal, low‐dose spinal, and epidural anesthesia using ropivacaine and fentanyl combinations for transurethral surgical procedures. Sixty patients with American Society of Anesthesiologists scores of I–III were allocated into three groups. After pre‐ loading with 5 mL/kg normal saline, patients in the spinal anesthesia group (Group S) received 15 mg of hyperbaric ropivacaine plus 25 μg of fentanyl intrathecally; patients in the epidural anesthesia group (Group E) received 112.5 mg of ropivacaine plus 25 μg of fentanyl epidurally via an epidural catheter; and patients in the low‐dose spinal anesthesia group (Group L) received 10 mg of hyperbaric ropivacaine plus 25 μg of fentanyl intrathecally. Blood pressure, heart rate, peripheral oxygen saturation, time to onset of thoracic (T)‐10 dermatome, two‐segment sensorial block regression time, full recovery of sensorial block, maximum motor blockade levels, motor blockade regression time, additional analgesic administration, patient comfort, and complications were recorded. The time to the onset of T10 dermatome level was shortest in Group S and longest in Group E (p < 0.001). The sensorial blockade time and motor blockade regression time were shorted in Group L (p < 0.001). The two‐segment sensorial block regression time in Group E exceeded that in the other groups. Additional analgesic administration was not needed in any group. No complications or adverse effects were observed in any patient. We conclude that all three anesthetic techniques may be used safely and are appropriate for transurethral surgical procedures. However, low‐dose spinal anesthesia with ropivacaine plus fentanyl may be preferable in transurethral surgery because we reach an adequate sensorial level with less motor blockade.