Yalım Dikmen

Critically ill obstetric patients in the intensive care unit

We aimed to determine the morbidity and mortality among obstetric patients admitted to the intensive care unit. In this study, we analyzed retrospectively all obstetric admissions to a multi-disciplinary intensive care unit over a five-year period. Obstetric patients were identified from 4733 consecutive intensive care unit admissions. Maternal age, gestation of newborns, mode of delivery, presence of coexisting medical problems, duration of stay, admission diagnosis, specific intensive care interventions (mechanical ventilation, continuous veno-venous hemofiltration, central venous catheterization, and arterial cannulation), outcome, maternal mortality, and acute physiology and chronic health evaluation (APACHE) II score were recorded. Obstetric patients (n=125) represented 2.64% of all intensive care unit admissions and 0.89% of all deliveries during the five-year period. The overall mortality of those admitted to the intensive care unit was 10.4%. Maternal age and gestation of newborns were similar in survivors and non-survivors. There were significant differences in length of stay and APACHE II score between survivors and non-survivors P < 0.05. The commonest cause of intensive care unit admission was preeclampsia/eclampsia (73.6%) followed by post-partum hemorrhage (11.2%). Intensive care specialists should be familiar with these complications of pregnancy and should work closely with obstetricians.

Crush syndrome patients after the Marmara earthquake

Background: To assess the treatment and outcome of patients with crush injury sustained in the Marmara earthquake. Methods: Seven hundred eighty three patients were transferred to a university hospital and 25 of them were admitted to the intensive care unit. The medical records of 18 crush injury patients were retrospectively reviewed. Results: The major associated injuries were in the lower extremities, upper extremities, and chest. Seven patients underwent fasciotomy and six patients had amputations. Twelve patients required mechanical ventilation. Adult respiratory distress syndrome developed in four patients. Oliguria occurred in eight patients. Hyperkalaemia was seen in six patients and four of them underwent emergency haemodialysis. One patient died because of hyperkalaemia on arrival to the intensive care unit. Renal failure was treated with haemodialysis or haemoperfusion in 13 patients. Five patients died because of multiple organ failure and two patients because of sepsis. Conclusion: Crush syndrome is a life treatening event. The authors believe that early transportation and immediate intensive care therapy would have improved the survival rate.

Impact of a multidimensional infection control approach on central line-associated bloodstream infections rates in adult intensive care units of 8 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC)

BackgroundCentral line-associated bloodstream infections (CLABs) have long been associated with excess lengths of stay, increased hospital costs and mortality attributable to them. Different studies from developed countries have shown that practice bundles reduce the incidence of CLAB in intensive care units. However, the impact of the bundle strategy has not been systematically analyzed in the adult intensive care unit (ICU) setting in developing countries, such as Turkey. The aim of this study is to analyze the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control approach to reduce the rates of CLAB in 13 ICUs of 13 INICC member hospitals from 8 cities of Turkey.MethodsWe conducted active, prospective surveillance before-after study to determine CLAB rates in a cohort of 4,017 adults hospitalized in ICUs. We applied the definitions of the CDC/NHSN and INICC surveillance methods. The study was divided into baseline and intervention periods. During baseline, active outcome surveillance of CLAB rates was performed. During intervention, the INICC multidimensional approach for CLAB reduction was implemented and included the following measures: 1- bundle of infection control interventions, 2- education, 3- outcome surveillance, 4- process surveillance, 5- feedback of CLAB rates, and 6- performance feedback on infection control practices. CLAB rates obtained in baseline were compared with CLAB rates obtained during intervention.ResultsDuring baseline, 3,129 central line (CL) days were recorded, and during intervention, we recorded 23,463 CL-days. We used random effects Poisson regression to account for clustering of CLAB rates within hospital across time periods. The baseline CLAB rate was 22.7 per 1000 CL days, which was decreased during the intervention period to 12.0 CLABs per 1000 CL days (IRR 0.613; 95% CI 0.43 – 0.87; P 0.007). This amounted to a 39% reduction in the incidence rate of CLAB.ConclusionsThe implementation of multidimensional infection control approach was associated with a significant reduction in the CLAB rates in adult ICUs of Turkey, and thus should be widely implemented.

Mechanical ventilation outside intensive care unit. A growing demand in a vulnerable population. Are there possible solutions

We read with interest this fascinating article, which analyzes the factors associated with mortality in patients on mechanical ventilation (MV) in internal medicine wards [1]. This article reveals major aspects of actual controversy over the growing demand of intensive care unit (ICU) beds and limitations on this availability. This health problem is exponential that affects all health systems with different solutions and patterns around the world. We agree with Hersch et al [1] with these predictors analyzed and implications for mortality. It is true that these factors associated with increased aging and comorbidities are crucial to survival and are not modifiable factors; however, there lacks some aspects, and some recommendations could optimize this model of MV organization in internal medicine wards. First, it could be interesting to know what kind of surveillance or monitoring was receiving these patients. In this sense, some potential solutions could be applications of telemetry as it may appear to allow greater control of patients with lower nursing ratio/number of patients [2]. This approach would allow cost-savings effect. This would allow greater control over the patients at highest risk for mortality. In this sense, developing effective surveillance teams formed by multidisciplinary emergency medical team or intensivists performing periodic assessment of MV outside the ICU may improve results [3]. In addition, there is lack of information about what triage before endotracheal intubation and MV were used. Secondly, it is unknown in this study, the prevalence of patients undergoing other mechanical ventilatory support such as noninvasive MV (NIV). This option has been determined to be effective in complications in elderly patients with greater comorbidities such as cardiac chronic insufficiency or pulmonary obstructive diseases. It would be interesting to know this information and clarification. Third, strategy of weaning from MV especially in prolonged MV (N21 days) could be one crucial aspect that needs to be considered in this model of MV in internal medicine wards [4]. It is unknown in this study if patients at highest risk for prolonged MV or ventilator-dependent patients have been included in a specific strategy of weaning protocol such as early extubation with NIV support or decannulation in selected patients. Fourth is care MV factor. This is an important aspect if there is implementing accessibility of these patients to the combined action of multidisciplinary teams (chest respiratory physiotherapist, pulmonary rehabilitation) that allow for an early weaning [5]. In some parts of Europe and North America, a “respiratory team” (including intensivists and/or respiratory therapists) could be very helpful, applying the best protocol for setting the ventilators and for weaning; this team could also effectively apply NIV instead of MV whenever possible. Finally, this team could promote training for ward staff [6]. Fifth, authors did not analyze a proper determination of what factors are determinants of long-term survival and functional recovery. Currently, there is a lack of specific scale scores or reliability about it, and this study opens a great debate [6,7]. Finally, there is a lack of a direct or indirect cost–human analysis in this study and if this strategy could reduce the final cost having in mind that these patients with prolonged MV outside ICU need complementary procedures and complementary techniques such as physiotherapy techniques, cardiopulmonary rehabilitation, and others. Some solutions for improved locations outside ICU in respiratory internal medicine wards are respiratory stepdown unit (or semi-intensive unit, or high dependency unit, etc) dedicated to the most severe ward respiratory patients, which could be less expensive than an ICU and more effective than a ward [8]. Clearly, this study highlights the continuing and growing demand for solutions of patients requiring MV and the health care model.

Chediak-Higashi syndrome in the intensive care unit.

Chediak–Higashi Syndrome is a rare autosomal recessive disease characterized by recurrent infections, giant cytoplasmic granules and oculocutaneous albinism. We describe the clinical and laboratory findings of a patient with Chediak–Higashi syndrome who was diagnosed and treated in the intensive care unit because of bleeding tendency after surgery.

Threshold of number of rib fractures in elderly blunt trauma: A simple or complex matter of numbers?

To the Editors: Trauma in the elderly is a particular and high-risk condition. Although the number of rib fractures increase and worsen the shortand long-term prognosis, in clinical practice there are other factors that affect outcome. We have read with interest the large database study by Shulzhenko et al that highlights the threshold of number of rib fractures with great interest. The authors describe that in older patients with trauma, sustaining 5 rib fractures is a significant predictor of worse outcomes independent of patient characteristics, comorbidities, and trauma burden. We would like to point out that other factors are relevant as well. First, the authors did not take therapeutic interventions into account, and the lack of details of the treatments is a shortcoming, because these can be important in patient outcome. Second, one main practical aspect is that they evaluated only the number of rib fractures, but not the coexisting injuries. The role of coexisting injuries in elderly patients needs to be taken into account along with underlying comorbidities. Blunt thoracic trauma often is associated with other injuries (eg, about 20%–30% with head trauma), which can have an important effect on patient outcome. Third, in acute respiratory failure due to rib fractures, ventilation strategies may have an important role and invasive mechanical ventilation or noninvasive mechanical ventilation should be considered. For instance, in a study comparing invasive mechanical ventilation and noninvasive mechanical ventilation in patients with a flail chest, mortality was significantly greater in intubated patients compared with patients who received noninvasive ventilation. We suggest that future studies and clinical trials need to take into account other factors along with number of ribs fractures in elderly trauma patients. The number of rib fractures does not tell the whole story.

Unplanned Extubation and Mortality in Surgical Critically Patients: An Accidental Association or Cause?

Unplanned extubation (UE) is commonly associated with poor outcomes in mechanically ventilated, critically ill patients. Preventive strategies are still difficult in the intensive care unit (ICU) [1]. Understanding the causes and consequences of UE are complex and still being debated. Lee et al. [2] describe the clinical conditions of UE in surgical patients. Their major findings were that UE was associated with higher ICU and hospital mortality, reintubation rates, and acute physiology, age, and chronic health evaluation (APACHE) II scores. It was also associated with prolonged mechanical ventilation (MV) and ICU days. UE was associated with less sedation as assessed by the Richmond Agitation-Sedation Scale, a low PaO2/FiO2 ratio, and prolonged use of MV. We have read their study, which opens with a good debate regarding information on how to design a proper protocol to prevent UE and for early prediction of high-risk patients. Although these results are congruent with those in previous studies, some aspects need clarification for adequate practical extrapolation. First, for a practical point of view, it should be clarified whether the relation of UE and mortality in critical surgical patients is an association or a cause. Briefly, it is necessary to take into account some key details of the surgical procedure: (1) during emergency surgery, some confounding factors (e.g., APACHE II score and neurologic diseases), which were more prevalent in UE patients, could influence the results [2]. There is no information on whether the UE subgroup patients were sicker than patients undergoing elective surgery. Commonly, as in this study, the latter group undergoes a shorter duration of MV and progress more favorably after extubation. Additionally, emergency surgery is associated with a higher mortality rate than elective cases, regardless of the UE rate. (2) Another issue is the finding that UE was more frequent in patients with unplanned admissions than in elective cases [2]. Knowing more about these factors could help us understand the differences. Second, how sedation is applied and its influence on reintubation rates in the UE situation needs more clarification because it is a controversial issue [3]. For instance, De Groot et al. [4] found a significant association between UE and midazolam use. Curiously, Tung et al. [5] did not report patients suffering agitation and delirium or restraint use, which can interfere with the safety of MV. These clinical conditions may influence the UE rate and outcome. Third, a key element is the relation between MV practice and UE. We know that during weaning from MV some factors—e.g., the weaning protocol, ventilation mode, gas exchange, inspiratory oxygenation fraction (FiO2)—influence UE [6]. These factors influence the patient–ventilator interaction, possibly shortening the duration of MV required and decreasing UE [7]. It would have been helpful to see some commentary on this subject by the authors. Fourth, for preventive protocols, it would be interesting to know if the authors analyzed the timing for application of UE. Was there an association with the staff’s workload or the nurse-to-patient ratio? Was the quality of care different during daytime and after hours? A. M. Esquinas (&) Intensive Care Unit and Noninvasive Ventilation Unit, Hospital Morales Meseguer, Avenida Marques de Los Velez, s/n, 3088 Murcia, Spain e-mail: antmesquinas@gmail.com

Hyperoxemia in critically mechanical ventilation patients: A factor yet to be fit for intensivists☆

Optimization of inspired oxygen fraction during mechanical ventilation (MV) is a crucial aspect in maintaining the normal oxygen levels in critically ill patients. It has been shown that there is a “U”shaped behavior of mortality in both hypoxemic and hyperoxemia [1]. Hyperoxemia is easy to diagnose, but its clinical implications are still a matter of debate. The correlation of hyperoxemia with complications of MV (infections, lung and non–lung cell toxicity) is an open question. Also, the behavior of intensivists regarding hyperoxemia is variable. Suzuki et al [2] confirmed that excess O2 delivery and liberal O2 therapywere common inmechanically critically ill ventilated patients. We have read this original contribution with interest because it helps to understand repercussions of hyperoxemia, which is currently unknown.We agreewith Suzuki et al [2] that thefirst step is to define a stratification of hyperoxemia, but there are some aspects to consider. First, hypoxemia may not be a stable condition and fluctuate duringMV, and pulse oximetry does not have the necessary resolution to identify these fluctuations. Second, the study design of Suzuki et al evaluated hyperoxemia during the initial stages of MV, but hyperoxemia can also be seen at the later phases like weaning, where it may influence the respiratory drive and affect the achievement of extubation conditions [3]. Third, this study fails to show a clear associationwith hyperoxemia with lung function because it had been illustrated in intensive care unit survivors and the impact of it on mortality remains unclear [4]. It is very difficult to draw a conclusion from the current study, weather there is a causative association with the complications and mortality, or these are a coincidence. We think that a potential solution to the problem can be the use of closed loop control of inspired oxygen fraction, as proposed by others

Perioperative Temperature Monitoring and Patient Warming: A Survey Study

OBJECTIVE Hypothermia is defined as the decrease of core body temperature under 36°C. Hypothermia is observed at a rate of 50-90% in the perioperative period. In our study, we aimed to measure the perception of hypothermia in our country, to evaluate the measures taken by physicians to intercept hypothermia, to determine the frequency and the methods used to monitor body temperature and the techniques used in warming the patients. Another aim was to develop a guideline for preventing perioperative hypothermia. METHODS The questionnaire consisted of 26 multiple-choice questions. The time needed to answer the questions was 8-10 minutes. RESULTS Of the 1380 individuals, 312 (22.6%) answered the questions in the questionnaire. Of these, 148 (47.4%) declared they were working in university hospitals, 80 (25.6%) in training and research hospitals, 51 (16.4%) in government hospitals and 33 (10.6%) in various private hospitals. Of the 312 individuals, 134 (42.9%) were specialists, 107 (34.3%) were resident physicians, 71 (22.8%) were academics. In addition, 212 (67.9%) reported working in operating rooms, 49 (15.7%) in intensive care units and 42 (13.5%) both in operating rooms and intensive care units. In the answers, there was variation among the hospital types in applications of body temperature monitoring and warming the patient. Another finding was that the individuals had different approaches to the concepts on perioperative hypothermia and its consequences. CONCLUSION The perceptions of physicians and the allied health personnel in government and private hospitals should be enhanced by informing them about the passive and active heating systems to prevent hypothermia. Although the situation in university and training and research hospitals seems to be better, defects are still observed in practice. Preparation of a national guideline for prevention of perioperative hypothermia is needed.

Sedation and Analgesia for Noninvasive Ventilation in Intensive Care

Patient acceptance and tolerance are essential for the success of noninvasive ventilation. In some patients, carefully applied sedation titrated to predetermined levels may increase the chance of patient acceptance. Although its use is controversial, it has been shown in a number of studies that sedation has little or no respiratory effects and decreases the need for endotracheal intubation in acute respiratory failure patients.