Anesthesia Intensive Care Research Articles

Infection markers as predictors of Bacteremia in an Intensive Care Unit: A prospective study.

Objective:Although several biomarkers have been evaluated for the diagnosis and prognosis of sepsis, the gold standard biomarker has not yet been found. We aimed to evaluate the diagnostic value of neutrophil-to-lymphocyte count ratio (NLCR), neopterin, pro-adrenomedullin (pro-ADM) and the other infection markers to predict bacteremia in patients with SIRS, sepsis and severe sepsis/septic shock.Methods:A prospective cohort study was conducted on septic patients in a tertiary referral hospital between December 2014- July 2015. A total of 156 patients diagnosed with SIRS, sepsis and severe sepsis/septic shock in Anesthesia intensive care unit (ICU) were included in the study.Results:A total of 156 patients who had been diagnosed as SIRS(10.9%), sepsis (44.2%) and severe sepsis/septic shock (44.9%) were included. Positive blood cultures were obtained in 64 patients. NLCR, neopterin and pro-ADM levels were insignificant in predicting bacteremia (p>0.05). The mortality rate was significantly higher in bacteremic sepsis (43.9%) compared to non-bacteremic patients (20.8%) (p=0.001). Only procalcitonin levels were significant predictor of mortality (p<0.001).Conclusion:NLCR, CRP, procalcitonin, neopterin and pro-ADM levels were insignificant in diagnosis of bacteremia in critically ill patients. The gold standard method in predicting bacteremia is still blood culture positivity.

The complexities of delivering anesthesia and pediatric intensive care to a critically Ill pediatric refugee

The complexities of delivering anesthesia and pediatric intensive care to a critically Ill pediatric refugee

Sore throat following three adult supraglottic airway devices: A randomised controlled trial.

Sore throat is a common complaint after surgery. It affects patient satisfaction and can affect activity after discharge. The supraglottic airway device (SAD) offers an alternative to traditional tracheal intubation with potential benefit in preventing sore throat. The aim of this study was to compare the incidence of sore throat following three different SADs, the laryngeal mask airway Unique (LMA-U) and the more recent LMA Supreme (LMA-S) and the I-gel. A randomised single-blind controlled three parallel-group trial. University Hospital of Nîmes, Division of Anaesthesia Intensive Care Pain and Emergency, Nîmes, France, from April 2009 to September 2012. A total of 546 patients scheduled to undergo elective surgery of less than 2 h under general anaesthesia were randomly allocated to receive the LMA-U, the LMA-S or the I-gel. Anaesthesia was induced with propofol and sufentanil and maintained with propofol or with sevoflurane in air-oxygen. After airway device insertion, intra-cuff pressure was adjusted to less than 60 mmHg (LMA-U, LMA-S) and pressure-controlled ventilation initiated. The primary study endpoint was to compare incidence of sore throat 24 h postoperatively (H+24) following placement of the LMA-U, LMA-S and the I-gel. Secondary endpoints were clinical performance (airway leak pressure, dynamic airway compliance, complications during maintenance), ease of use (device insertion time, success on first attempt, ease of insertion and removal) and other adverse events (neck or jaw pain, dysphonia, dysphagia, nausea and vomiting). The authors analysed 177, 174 and 173 patients who received LMA-U, the LMA-S and the I-gel, respectively. The primary endpoint was assessed in 436 patients. In total, 104 patients (23.9%) patients reported a H+24 sore throat, with no difference between groups (P = 0.34). H+24 dysphagia with liquids was higher (P = 0.0065) with the LMA-S (12.1%) compared with LMA-U (5.3%) and I-gel (2.9%). Airway leak pressure (cmH2O) was lower (P < 0.0001) with LMA-U [21 (18 to 27)] compared with I-gel [26 (20 to 30)] and LMA-S [25 (21 to 30)]. Device insertion time (sec) was shorter (P < 0.0167) with the I-gel [30 (20 to 40)] compared with the LMA-U [34 (23 to 48)] and LMA-S [32 (22 to 50)]. The incidence of postoperative sore throat was not significantly different between the three SADs studied.

Antibiotic therapy in the critically ill - expert opinion of the Intensive Care Medicine Scientific Subcommittee of the European Society of Anaesthesiology.

Antimicrobial treatment is the cornerstone of infection treatment, and the selection of appropriate antibiotic treatment for critically ill patients is challenging. Clinicians working with critically ill patients usually feel a greater obligation towards their patient than towards maintenance of the delicate ecological balance of prevalent microbiological threats and their resistance patterns. Although antibiotic overtreatment is a frequent phenomenon, patient outcomes need not be compromised when antibiotic treatment is driven by informed decision-making.At the 2016 Euro Anaesthesia Conference (London, UK), the European Society of Anaesthesia Intensive Care Scientific Subcommittee convened an expert panel on antibiotic therapy. This article summarises the main conclusions of the panel, namely the principles of antibiotic therapy that all physicians working with critically ill patients must know.

Could soluble urokinase plasminogen receptor (suPAR) be used as a diagnostic biomarker for ventilator‐associated pneumonia?

Soluble urokinase plasminogen activator receptor (suPAR) is a biomarker that is increasingly used for evaluation of systemic inflammation. This study was performed to investigate whether suPAR may possess a diagnostic value in patients with ventilator-associated pneumonia (VAP). This clinical study was performed in the anesthesia intensive care units (ICUs) of our university. In addition to descriptive data, WBC, serum levels of C-reactive protein (CRP) and suPAR prior to and after development of VAP were noted and compared in 31 patients (22 men, 9 women) diagnosed with VAP (Study Group) and 19 patients without VAP (Control Group) in ICU (14 men, 5 women). The suPAR (P = 0.023), CRP (P = 0.037), WBCs (P = 0.024) in patients with VAP were significantly higher than patients without VAP. There was no remarkable difference in terms of WBCs (P = 0.052) and suPAR levels (P = 0.616) between groups on the first day of connection to mechanical ventilator. The suPAR and CRP levels in patients with VAP were significantly higher than prior to development of VAP (P = 0.001 for both). Area under curve value after diagnosis of pneumonia was found 0.248 (P = 0.002). To conclude, our results suggest that suPAR can be a useful diagnostic biomarker in patients with VAP. However, clinical trials on larger series are warranted to explore the clinical significance more accurately.

Neutrophil to Lymphocyte ratio of Synthetic Cannabinoid Intoxication

Synthetic cannabinoids represent an in-creasingly popular trend, and acute intoxi-cation is widely seen in emergency rooms and intensive care units (ICU), as they are inexpensive and easily accessible. Cannab-inoids mediate their effects through bind-ing specific receptors which are members of the G protein coupled receptor super-family. Cannabinoid-2 receptors are pri-marily found in the immune system and mediate immunosuppression by inducing apoptosis, inhibition of proliferation and suppression of cytokine and chemokine production. Many studies have discussed the effects of cannabinoids on the hema-tological and immune systems but con-troversial results have been reported. The aim of this study was to identify laboratory findings of acute synthetic cannabinoid in-toxication. Forty-two patients, admitted to the ‘Anesthesia intensive care unit’ between 2014 and 2015 with synthetic cannabinoid intoxication, were studied retrospectively to assess the relationship between synthet-ic cannabinoid intoxication and complete blood count (white blood cells (WBC), neutrophils, lymphocytes, monocytes, eosinophils, basophils) and neutrophil to lymphocyte ratio. WBC neutrophil count decreased at ICU discharge when com-pared to ICU admission (p&lt;0.001). The ra-tio of neutrophils to lymphocytes was also lower at ICU discharge when compared to ICU admission (p&lt;0.05).

Renal replacement therapy in adult and pediatric intensive care : Recommendations by an expert panel from the French Intensive Care Society (SRLF) with the French Society of Anesthesia Intensive Care (SFAR) French Group for Pediatric Intensive Care Emergencies (GFRUP) the French Dialysis Society (SFD).

Acute renal failure (ARF) in critically ill patients is currently very frequent and requires renal replacement therapy (RRT) in many patients. During the last 15 years, several studies have considered important issues regarding the use of RRT in ARF, like the time to initiate the therapy, the dialysis dose, the types of catheter, the choice of technique, and anticoagulation. However, despite an abundant literature, conflicting results do not provide evidence on RRT implementation. We present herein recommendations for the use of RRT in adult and pediatric intensive care developed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system by an expert group of French Intensive Care Society (SRLF), with the participation of the French Society of Anesthesia and Intensive Care (SFAR), the French Group for Pediatric Intensive Care and Emergencies (GFRUP), and the French Dialysis Society (SFD). The recommendations cover 4 fields: criteria for RRT initiation, technical aspects (access routes, membranes, anticoagulation, reverse osmosis water), practical aspects (choice of the method, peritoneal dialysis, dialysis dose, adjustments), and safety (procedures and training, dialysis catheter management, extracorporeal circuit set-up). These recommendations have been designed on a practical point of view to provide guidance for intensivists in their daily practice.

Development of Acute Renal Failure after Magnetic Resonance with Gadopentetate

Gadolinium (Gd) based contrast materials are traditionally considered non nephrotoxic. In the past, acute renal failure (ARF) has been reported after gadolinium administration in some publications. A 65 year old female patient was underwent upper abdominal MR examination. She had no history of diabetes, hypertension and kidney problems. Neither there was any history of NSAIDs nor nephrotoxic agents. During examination process, 50mg gadopentetate was used. Three days later, rapidly progressive anuric acute renal failure developed. In anesthesia intensive care unit, she was underwent dialysis for six sessions. Her renal biopsy was carried out and its results turned out to be acute tubular necrosis and acute intersistial nephritis. Acute renal failure improved after subsequent hemodialysis sessions. General condition and laboratory values improved, all treatment was gradually withdrawn and and the patient was discharged without any complications.

Antimicrobial Resistance Rate is Observed in Anesthesia Intensive Care

Antimicrobial Resistance Rate is Observed in Anesthesia Intensive Care

Novel Parameters of Extended Complete Blood Cell Count under Fluorescence Flow Cytometry in Patients with Sepsis

We first describe a patient who developed urosepsis from an ordinary urinary tract infection. In this case, the new hematological parameters of immature leukocytes, that is, the high-fluorescence lymphocyte cell (HFLC) and immature granulocyte (IG) counts peaked early, whereas the established infection parameters, that is, C-reactive protein (CRP) and total white blood cell count showed less dynamic regarding infection and therapy. To investigate this phenomenon in greater detail, the novel parameters HFLC and IG counts are investigated retrospectively in a cohort of 38 patients who were admitted to the anesthesia intensive care unit. Three groups of patients have been analyzed and compared: patients without signs of infection, patients with limited infections, and patients with sepsis. Data were collected with a Sysmex XE-5000 hematological analyzer. In patients (n = 22) without any signs of infection, both values are very low. In patients with limited local infections (n = 10), moderate elevations of the IG and HFLC counts are seen. In patients with sepsis (n = 6), the IG and HFLC counts are significantly higher. The total IG count seems to be useful for distinguishing a septic patient from a nonseptic (P < 0.004). Hematological parameters have the advantage of being measured easily during routine blood cell analysis.

Anesthesia Maintenance During Mini-Invasive Cardiac Valve Surgery

Based on own experience and published data the authors analyze the features and specific components of anesthesia maintenance during mini-invasive cardiac valve surgery. The following clinically relevant aspects of anesthesia and perioperative intensive care were identified: preoperative patient selection and surgical and anesthesia risk prediction; one-lung ventilation; peripheral connection of circulation and specific features of its performance; control of oxygen delivery in the bed of aortic arch branches; and echocardiographic monitoring. The main risks and probable complications due to these interventions, such as cerebral hypoxia, respiratory failure, pulmonary hypertension, etc., are described. The mechanisms of their development and the modes of prevention and treatment are shown. Key words: anesthesia in cardiac surgery, mini-invasive cardiac surgery, one-lung ventilation, anesthesia during cardiac valve surgery.

Awake fi beroptic intubation of a patient with amyotrophic lateral sclerosis: case report

Amyotrophic Lateral Sclerosis is a rapidly progressive disease from the fi fth to sixth decades of life causing degeneration and death of the upper and lower motor neurons and no effective treatment. The diagnosis isdependent on the clinical presentation and consistent electrodiagnostic studies. Progressive denervation affects the muscles, causing muscular weakness and atrophy, when the ventilation muscles are affected deathdue to respiratory failure occurs within a few years. We present the case of a 54 years old, 180 cm height and 94 kg weight male patient with amyotrophic lateral sclerosis who underwent surgical treatment of thyroidcancer. Fiberoptic intubation was orally performed providing spontaneus breathing. Propofol was applied after passing vocal cords. Anesthesia was maintained with sevofl orane (%2) and a mixture of oxygen and airunder volume controlled ventilation. Rocuronium was used 20 mg at the beginning of the surgery. At the end of surgery, he wasn’t extubated and transferred to anesthesia intensive care unit. He was extubated after tenhours and he was awaked perfectly. The patient was discharged from intensive care unit after 24 hours and from hospital after ten days. We reported that amyotrophic lateral sclerosis patient with limited mouth opening who underwent thyroid surgery, using awake intubation.

NEW TECHNOLOGIES IN SURGERY OF NON-TRAUMATIC INTRACRANIAL HEMORRHAGES

The new possibilities in therapy of cerebral aneurysms, arteriovenous malformations and hypertensive intracranial hematomas recently have come into the neurosurgical sphere due to development of neurovisualization and neurophysiology methods and widely usage of microsurgical principles as well as neuroendoscopy, neuronavigation systems and methods of intraoperative control for operative radicality in surgery of non-traumatic intracranial hemorrhages. Besides this progress was not possible without extensive development of several aspects of anesthesiology and reanimatology focused on anesthetic management and intensive care of neurosurgical patients in particular. Timely diagnostics and optimal choice of treatment methods in patients with non-traumatic intracranial hemorrhages allow to achieve good functional outcomes with trend to mortality minimization.

Acute mountain sickness occurring with corpus callosum, globus pallidus and cerebellar peduncle involvement: MRI findings

Acute mountain sickness (AMS) is a pathological reaction, occurring as a result of failure to adapt to altitude. The main symptoms reported are headache, nausea, vomiting and fatigue. However, high altitude cerebral and pulmonary edema, occurring in AMS, cause potentially fatal consequences. In our 31-year-old case, who is the group leader and activity organizer among nine mountaineers, who climbed Mt. Ağrı for winter climbing, nausea, vomiting, unconsciousness, lack of appetite and severe headache have occurred in connection with high altitude at 4200 m. Brain MRI of the patient revealed wide-spread hyperintense lesions at subcortical white matter, corpus callosum, globus pallidi, and bilateral cerebellar peduncles on T2 and FLAIR series. The patient was referred to anesthesia–intensive care unit of our hospital. Since the appearances are demonstrative, MRI findings are presented.

Impact of a long specialized training in anaesthesia on the quality of care in a developing country: Experience in Laos

ObjectivesAssess the impact on the quality of practices in a developing country (Lao Democratic People's Republic) of a long specialized course in anaesthesia (Certificate of Specialized Studies in Anesthesia-Intensive care and Emergency Medicine [Cesarmu]) versus accelerated trainings. Population and methodStudy concerned all surgical hospitals and all anaesthesiologists of Lao PDR. At hospital level, the quality of care was assessed and compared between hospitals with and without Cesarmu anaesthetists by using the quality of anaesthesia record and the spinal anaesthesia frequency in lower gyneco-obstetrical surgery. On an individual level, we assessed and compared anaesthetists who were Cesarmu trained and those who were not by using theoretical and practical scores. The latter were acquired by observing complete perisurgical care (pre-, per- and postoperative practical scores). ResultsWe visited 29 of the 34 surgical hospitals in Lao PDR and met 90 of the 111 anesthesiologists. At hospital level, quality criteria were higher in the group of hospitals with Cesarmu anaesthesiologists without that difference being significant. On the other hand, all individual scores measured were significantly higher in the Cesarmu group. DiscussionThe improvement of practices resulting from training was obvious at the individual level but its impact at hospital level was not significant. There were most likely not enough trained anaesthetists to significantly influence practices in their departments. ConclusionAccording to the criteria used, the impact of Cesarmu on the quality of anaesthesia in Lao PDR seems positive. However, training needs to be continued and practices homogenized.

Standardization of infusion solutions to reduce the risk of incompatibility

Although critically ill patients usually have various central intravenous (i.v.) lines, numerous drugs have to be infused simultaneously through the same lines. This can result in potentially harmful in-line incompatibility that can cause decreased drug effectiveness or increased microparticle load. To minimize the risk of these medication errors at an anesthesia intensive care unit (ICU), the preparation and administration of continuously infused drugs were standardized and the practicability in daily clinical routine was evaluated. The concentration and diluent of continuously administered i.v. drugs were standardized. The drugs were grouped according to pH, medical indication, and chemical structure. The ICU staff decided to use multilumen central venous catheters, and each group of drugs was assigned to one lumen. Only drugs that belonged to the same group were infused simultaneously through the same lumen; therefore, intragroup incompatibilities had to be excluded before establishing the new drug administration plan at the ICU. The visual compatibility of 115 clinically reasonable intragroup drug mixtures was investigated. All drug combinations were compatible for six hours except mixtures containing thiopental, which was reassigned to a single-line use. In the following year, the practicability of this drug administration plan was evaluated. No deviations were found in the compliance of the staff prescribing and preparing only standardized concentrations and diluents. Further research to investigate the chemical compatibility of the drugs in these multiple mixtures will follow. A project intended to avoid incompatibility among i.v. drugs infused in the intensive care setting included steps to standardize solutions and determine which could be given together.

Presence of patients’ families during cardiopulmonary resuscitation: physicians’ and nurses’ opinions

This paper is a report of a study to determine the opinions of physicians and nurses who work in a university hospital intensive care unit and emergency department about the presence of patients' families during cardiopulmonary resuscitation in these units. Healthcare professionals have conflicting opinions about the presence of patients' families during cardiopulmonary resuscitation. Families who are allowed to be present have less fear and worry, feel they have supported their family member and are able to cope more easily. The data for this descriptive questionnaire study were collected between November 2006 and January 2007. The respondents were 62 physicians and 82 nurses who worked in an emergency department or in cardiology or anaesthesia intensive care units in Turkey. The data were collected using a questionnaire and the responses summarized using frequencies and percentages. The chi-squared test was performed to test for differences in the opinion by profession, educational level, or number of years of working experience in the profession. The response rate was 79%. Of the respondents, 82.6% did not think it was appropriate for patients' families to be present during cardiopulmonary resuscitation. The most common concerns mentioned were that the family would interfere with the team's activities (56.3%) and that resuscitation is a very traumatic procedure (43.6%). Policies need to be developed regarding this topic because the absence of policy can cause misunderstanding and differences in practice. Further research is needed to determine what public education is needed to facilitate implementation of such policies.

General paediatric surgery in Ireland: a crisis in evolution

In their recently published editorial, Coakley and Grace [1] identify the provision of paediatric surgical services in Ireland as a crisis in evolution. This is based on the case report of a child who could not be anaesthetised because of lack of paediatric anaesthesia, the demise of older general surgeons who received paediatric training or indeed operated on a wide range of conditions in their clinical practices, the lack of uptake of training opportunities in paediatric surgery by general surgery trainees and the increasing development of subspecialisation. The option provided is that we should perhaps move to a system of having three paediatric surgical hospitals similar to the Scottish model. The issues outlined in this paper are very real and deserve the strongest debate among surgeons and health care providers in this country. The recent debate about cancer outcomes and the development of cancer centres are driven by the same needs—expert provision of care by multidisciplinary teams in well-resourced environments with appropriate quality assurance parameters and outcome expectation. The paper by Coakley and Grace also touches on the often-overlooked needs of equity of access across the country. It seems clear that there are three issues that must be addressed—ease of access to care for common emergencies (such as appendicitis) in young patients, provision of surgical care in large hospitals for very young children (cases such as pyloric stenosis, undescended testis, hernias in young children) and tertiary level care for pure paediatric and complex surgery (for example, exomphalos, cardiac surgery). It would appear that the national policy for the latter is to have a national Paediatric Hospital delivering tertiary level care. The provision of care for common paediatric surgical problems such as level 2 issues would seem to me to involve having surgeons trained in paediatrics working in the major teaching /regional hospitals with attached maternity units. Currently, some of these hospitals have appropriately trained general surgeons providing such care. The delivery of care to paediatric patients with common conditions such as tonsillitis, common fractures, appendicitis, etc. involves subspecialist paediatric surgical expertise, especially support from anaesthesiology, intensive care and paediatrics. These services have to be delivered by trained surgeons working in an appropriate environment. The recent publication of the Children’s Surgical Forum Report by the Royal College of England [2] documents current practice and identifies the way forward for Britain and Northern Ireland. It clearly demonstrates the need for effective clinical networks. These would incorporate the national supra-regional centre dealing with rare and more complex cases, regional centres and smaller district general hospitals. It suggests that even smaller-sized district general hospitals will be able to provide support for surgical activity even in the absence of resident paediatricians by having robust cover arrangements in place. The role of general surgeons in the management of common neonatal problems is open to debate. The development of specialist paediatric surgery and transfer to specialist centres has resulted in reduction of the numbers of surgeons dealing with this problem outside non-specialist centres. Clearly this type of surgery is best done by experienced surgeons in an environment where specialised multidisciplinary support from anaesthesia and neonatal intensive care is readily available. M. J. Kerin (&) Department of Surgery, Clinical Science Institute, University College Hospital, Galway, Ireland e-mail: michael.kerin@nuigalway.ie

Approach To Swan Ganz Thermodilution Catheter Complications: 6 Years Experience With 2310 Cases

Aim: A pulmonary artery catheter is the most frequent material used during and after cardiac surgery to monitor the patient in the early period because it gives so much information to surgery and anesthesia teams and intensive care staff. To be knotted or fixation with atrium sutures are rare complications seen in 0.1-3%. Material and Method: During 6 years period between 2001 January and 2006 December, totally 2310 pulmonary artery catheterization(PAC) were performed in cardiovascular operation patients. In 3 (%0.1) patients with preoperative pulmonary hypertension and valve disease operation, resistance to removing of PAC was seen. Radiographic images showed that catheters were resisted to displacement because they were knotted near the thermosistor part in two cases. In the third case catheter was fixed at right atrial level. Results: In the first two cases,catheters were pulled with appropriate manuplations and knot became smaller. Compression prevented the morbid hemorrhage and hematoma complications at catheter placement regions.The third case was reoperated because it was thought to be fixed with atrial sutures and open surgery technique showed that the catheter's distal end was fixed between right atrial auricule purse sutures. The first two cases discharged on postop 7th and the third on postop 8th day,with cure. Conclusion: Percutaneous catheterization of vena jugularis interna and vena subclavia needs time and for adequate skill development practice is necessary.Placement and use of PAC carry potential risks that requires immediate management.Developing the information about their complications' treatment can prevent additional morbidity and mortality.

Analysis of Anaesthetic Intensive Care Unit Admissions: The Anaesthesiologists' Perspective

Analysis of Anaesthetic Intensive Care Unit Admissions: The Anaesthesiologists' Perspective