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Relationship between optic nerve sheath diameter, Glasgow Coma Scale, and the impact of PEEP in critically ill patients: a prospective observational study
Objective: Optic nerve sheath diameter (ONSD) has been increasingly recognized as a non-invasive surrogate marker for intracranial pressure (ICP) in critically ill patients. The Glasgow Coma Scale (GCS) is a widely used tool for assessing neurological status. However, the relationship between GCS and ONSD in intensive care unit (ICU) patients remains underexplored. This study aimed to investigate the association between ONSD and GCS scores in ICU patients, while also evaluating the impact of positive end-expiratory pressure (PEEP) on ONSD measurements. Methods: This prospective observational study included 66 ICU patients. ONSD measurements were obtained using ultrasonography at 24 and 48–72 hours after ICU admission. Patients were categorized into three groups based on GCS scores (3–7, 8–11, 12–15). The effect of PEEP and other clinical parameters on ONSD was analyzed using linear mixed models, with a significance level of p < 0.05. Results: ONSD was significantly higher in patients with lower GCS scores (p < 0.001). Additionally, PEEP application was strongly associated with increased ONSD (p < 0.001), whereas other factors such as mean arterial pressure, heart rate, and sepsis status did not show significant effects. Conclusion: ONSD is significantly associated with GCS scores, supporting its role as a non-invasive marker of neurological deterioration. The influence of PEEP on ONSD suggests a potential impact of mechanical ventilation on ICP dynamics, warranting further investigation.
Copyright © 2026 The Author(s) https://creativecommons.org/licenses/by/4.0
Unraveling paroxysmal sympathetic hyperactivity syndrome; what is behind the storm?
Paroxysmal sympathetic hyperactivity syndrome (PSH) is a rarely diagnosed syndrome associated with acute brain injury which involves traumatic brain injury, stroke, infectious diseases, and encephalopathy, and results in cyclic episodes of sympathetic and motor hyperactivity (hypertension, tachypnea, hyperthermia, diaphoresis, dystonic posturing). Even though there are some theories regarding the pathophysiology of PSH, the main mechanism still remains unclear. However, it is mostly agreed upon that PSH is caused by an unbalanced activation of the autonomic nervous system caused by the loss of inhibition of excitation in the sympathetic nervous system. Although PSH has been well known for many decades there were misunderstandings regarding the nomenclature and the definition of this syndrome. The term “Paroxysmal Sympathetic Hyperactivity and a diagnostic tool consisted of two different components and named PSH-Assessment Measure (PSH-AM),” was developed to help guiding clinical management in 2014. These components are the diagnostic likelihood tool and the clinical features scale. To diagnose this syndrome first other neurological issues should be ruled out. Once diagnosed in order to treat and avoid secondary brain damage and other adverse outcomes of this syndrome an approach of both pharmacological (such as opioids, B-blockers, alfa2 agonists, benzodiazepines, gabapentin and muscle relaxants) and nonpharmacological should be combined. Pharmacological approach focuses on symptom abortion, prevention and refractory treatment.
paroxysmal sympathetic hyperactivity syndrome
Artificial intelligence in preoperative assessment and optimization: a narrative review
Background: Preoperative assessment and optimization are pivotal for complex surgical patients, yet traditional scores and clinician-driven workflows may miss subtle risk interactions and modifiable factors. Artificial intelligence (AI), especially machine learning (ML), can leverage large-scale electronic health record (EHR) data to improve risk stratification and support targeted optimization strategies. Methods: We conducted a narrative review focusing on practical, clinically actionable AI applications in preoperative assessment and optimization, emphasizing recent advances and implementation considerations for high-risk surgical patients. Results: ML-based preoperative risk models can outperform conventional calculators, exemplified by a gradient-boosted decision-tree model trained on >1.4 million surgical cases that achieved an AUROC of 0.95 for 30-day mortality and exceeded NSQIP performance, with prospective real-world deployment. Automated frailty phenotyping from structured preoperative EHR data (demographics, ASA/acuity, ICD-10/CCS diagnoses, and routine labs) has also been externally validated in older adults and shows strong stepwise associations with adverse outcomes. AI additionally supports preoperative optimization by identifying actionable targets such as anemia risk (supporting early iron/EPO pathways), penicillin allergy delabeling opportunities, and improved detection of risky alcohol use via natural language processing of clinical notes. Successful clinical impact depends on workflow integration, interpretability, and attention to privacy, bias, regulation, and prospective evidence. Conclusions: AI-enabled preoperative assessment can enhance identification of high-risk patients and systematically surface modifiable factors for optimization, with early evidence of improved predictive performance and feasible integration into point-of-care workflows. Future work should prioritize robust external validation across diverse populations, implementation studies demonstrating patient-centered benefit, and governance frameworks ensuring safety, fairness, and clinician trust.
Retrospective analysis of the efficacy of molnupiravir and favipiravir in COVID-19 patients admitted to intensive care unit
Objective: During the pandemic, molnupiravir and favipiravir treatments have been applied at different stages of the treatment of COVID-19 patients. However, their effectiveness in COVID-19 patients admitted to the ICU is not clear. Methods: Patients who were admitted to the ICU between March 1, 2022, and December 31, 2023 and managed according to the guidelines of the Scientific Committee of the Turkish Ministry of Health were included. Results: Data of 152 patients who met the inclusion criteria for the study were evaluated. Patients were divided into two groups according to the treatment modality applied. When both groups were compared in terms of median hospital stay; It was found to be statistically significant (p=0.025) in Group F and 16 (11) days in Group M. When respiratory support was examined in the entire cohort; the percentage of invasive mechanical ventilation application was found to be significant as 40 (60.5) in Group F and 61 (80.3) in Group M (p=0.008). Similarly, the number of days of invasive mechanical ventilation was found to be significant as 9 (14) in Group F and 12 (8) in Group M (p=0.010). On the other hand, when evaluated in terms of hospital mortality percentage; it was found to be 42 (55.3) in Group F and 39 (51.3) in Group M and no statistically significant difference was found (p=0.626). Conclusion: In our study, no difference was found in terms of mortality rate between molnupiravir and favipiravir, two antiviral drugs used in COVID-19 treatment. However, further studies are needed to clarify this issue.
The prognostic value of the early brain edema score (SEBES) in traumatic and non-traumatic subarachnoid hemorrhage
Background: Subarachnoid hemorrhage (SAH) is a life-threatening cerebrovascular event with high morbidity and mortality. Early brain edema is a key determinant of prognosis and can be quantified using the Subarachnoid Hemorrhage Early Brain Edema Score (SEBES). Although SEBES has demonstrated prognostic value in spontaneous SAH, its utility in traumatic SAH remains underexplored. This study aimed to evaluate the relationship between SEBES and clinical outcomes in both traumatic and non-traumatic SAH patients. Methods: In this retrospective cohort study, 50 SAH patients (30 traumatic, 20 non-traumatic) admitted to the intensive care unit (ICU) between January 2023 and May 2024 were analyzed. SEBES scores were calculated from brain CT scans obtained within 24 hours of SAH onset. Patients were classified by etiology and SEBES grade (≤2 vs. >2). Demographic data, clinical scores, laboratory parameters, and mortality at 1 and 3 months were compared. A subgroup analysis was performed to assess SEBES-associated outcomes within each SAH etiology. Results: SEBES scores were markedly higher in non-traumatic SAH patients. Higher SEBES (>2) was associated with lower admission and discharge neurological scores (GCS, FOUR), longer ICU and ventilator duration, and higher 1- and 3-month mortality (all p < 0.05). Subgroup analysis revealed that the negative prognostic impact of elevated SEBES was evident in both traumatic and non-traumatic SAH groups, particularly regarding mortality and ICU burden. Conclusion: SEBES is a valuable and simple radiological prognostic tool applicable to both traumatic and non-traumatic SAH. A SEBES score >2 may predict worse neurological outcomes, higher mortality, and increased ICU resource utilization. Its early application may aid in risk stratification and critical care planning.
Renal resistive index and biomarkers of cell cycle arrest in the early diagnosis of sepsis-induced acute kidney injury in rats
Objective: This study evaluates the diagnostic performance of renal resistive index (RRI) and urinary cell cycle arrest biomarkers for early detection of sepsis-induced acute kidney injury (AKI) in a rat model using cecal ligation and puncture (CLP). Materials and Methods: Sixty female Wistar Albino rats were allocated into six groups (n=10): five CLP groups based on measurement timing (3, 6, 12, 24, and 48 hours post-procedure) and one sham group. Following CLP, RRI measurements were performed, and blood, urine, and tissue samples were collected before sacrifice. Urinary tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein-7 (IGFBP-7) were quantified via enzyme-linked immunosorbent assay (ELISA). Serum creatinine and lactate levels were measured, and histopathological kidney examination was conducted. Results: RRI increased significantly at six hours (0.44±0.04), peaking at 24 hours (0.73±0.02) post-CLP. The [TIMP-2×IGFBP-7] combination elevated significantly at three hours (P<0.05) versus sham, reaching maximum levels at 48 hours. Strong positive correlations existed between histopathological injury severity and IGFBP-7 (p=0.764), TIMP-2 (p=0.779), [TIMP-2×IGFBP-7] (p=0.785), and RRI (p=0.837) (all P<0.0001). For predicting grade ≥3 tubular injury (>25% damage), cell cycle arrest biomarkers outperformed serum creatinine and lactate. RRI >0.45 demonstrated optimal diagnostic accuracy (sensitivity 89%, specificity 87%). Conclusions: In this CLP-induced polymicrobial sepsis model, both RRI and urinary cell cycle arrest biomarkers predicted early AKI within similar timeframes, with RRI >0.45 showing superior predictive value.
The impact of the inspiratory-to-expiratory ratio on mechanical power in ARDS patients
Objective: Mechanical power (MP) is a promising parameter that may guide lung-protective ventilation strategies. The MP equation encompasses all variables involved in the pathogenesis of ventilator-induced lung injury (VILI), as well as the inspiratory-to-expiratory (I:E) ratio. Shortening the inspiratory time—by altering the I:E ratio—increases gas flow and may lead to lung injury. The optimal I:E ratio for preventing VILI remains uncertain. The present study aimed to investigate the effects of different I:E ratios on inspiratory gas flow and MP in patients with acute respiratory distress syndrome (ARDS). Materials and Methods: This study was conducted on 19 adult patients diagnosed with moderate ARDS who were admitted to the intensive care unit and received mechanical ventilation. Patients were ventilated at a PEEP level of 10 cmH2O, a tidal volume of 6 mL/kg, and three sequentially applied I:E ratios (1:2, 1:1, and 1.5:1), each maintained for 10 minutes. MP and respiratory parameters across the three I:E groups were compared using repeated-measures ANOVA. Results: Compared with the I:E ratio of 1:2, ventilation with an I:E ratio of 1:1 resulted in slower inspiratory gas flow, lower inspiratory resistance and peak inspiratory pressure, higher dynamic compliance, and lower MP values. Plateau pressure and driving pressure did not differ significantly. When comparing I:E 1:1 with I:E 1.5:1, a persistent slowing of inspiratory gas flow was observed, but no significant difference in MP was detected. Conclusion: In patients with ARDS, transitioning the I:E ratio from the conventional 1:2 to 1:1 or 1.5:1 resulted in progressively slower inspiratory gas flow and lower resistive and total mechanical power, suggesting that reducing inspiratory flow may enhance lung-protective ventilation.
A case of thoracic aortic thrombosis in a patient with COVID-19 pneumonia
Patients infected with the 2019 novel coronavirus (COVID-19) predominantly present with respiratory symptoms. In severe cases, COVID-19 creates a prothrombotic state that significantly increases the risk of thromboembolic events. These complications are primarily in the form of venous thromboembolism, with a cumulative incidence of up to 49% among hospitalized patients. In contrast, arterial thromboembolic events such as ischemic stroke and myocardial infarction have been rarely reported in the literature. In this case report, we present a case of aortic thrombosis complicated by peripheral embolism and/or thrombosis as an example of arterial thromboembolism.
Refractory lactic acidosis and hypoglycemia: a very rare presentation in critically ill leukemic patient possibly associated with adult-onset glycogen storage disease type Ib
Lactic acidosis is a serious and frequently encountered condition in oncological critical care. Although it is commonly associated with generalized or localized tissue hypoperfusion, metabolic and drug-related causes should also be considered. Early recognition and appropriate management are essential for improving outcomes in critically ill patients. We report a case of refractory lactic acidosis associated with unexplained hypoglycemia, hypertriglyceridemia, and hyperuricemia. Common causes of type A lactic acidosis, including hypoperfusion, anemia, hypoxia, and seizures, were excluded. Other potential causes of type B and D lactic acidosis, such as liver disease and medication effects, were also ruled out. The patient had no known history of metabolic disease during childhood; however, the clinical presentation and laboratory findings were highly suggestive of glycogen storage disease type Ib (GSD-Ib). GSD-Ib is a rare autosomal recessive metabolic disorder caused by mutations in the glucose-6-phosphate translocase (G6PT) gene located on chromosome 11q23. The resulting defect impairs both glycogenolysis and gluconeogenesis, leading to metabolic abnormalities including hypoglycemia, hyperlactatemia, hyperuricemia, and hypertriglyceridemia. GSD-Ib Patients commonly develop neutropenia, which predisposes them to recurrent infections and often requires treatment with granulocyte colony-stimulating factor (G-CSF). Long-term G-CSF therapy has been associated with an increased risk of myeloid malignancies, particularly acute myeloid leukemia (AML). Glycogen storage diseases are genetic disorders that are typically diagnosed in childhood, making diagnosis in adulthood extremely rare. In this case, a late genetic mutation was suspected to have resulted in adult-onset GSD-Ib and malignancy. This rare presentation suggests a possible link between GSD-Ib and AML. Therefore, surveillance for glycogen storage disease in patients with AML, and vice versa, may be warranted. This association should be considered in critically ill AML patients presenting with refractory lactic acidosis after exclusion of other etiologies.
Clinical efficacy of a protocol-based hemoadsorption therapy in patients with septic shock
Introduction: Hemoadsorption (HA) removes circulating inflammatory mediators and is used as an adjunct in septic shock. We assessed whether a protocol-based HA330 strategy improved early organ dysfunctions and outcomes. Materials and Methods: We performed an observational study of adults with septic shock admitted to a 59-bed mixed ICU (January 2023–June 2024). We compared outcomes of patients who were treated with HA, to those who received standard of care alone. Results: During the study period, 52 of 127 septic shock patients received hemoadsorption therapy (HA group), while 75 received standard care (control group). On ICU admission age, sex, comorbidity, APACHE II, and SOFA scores were similar. By day 3, SOFA score decreased with HA (8 [5–11] to 7 [5–9]; p<0.05) but was unchanged in controls. Vasoactive inotropic score declined in both groups, more prominently with HA. Mechanical ventilation requirement and ICU length of stay were comparable. AKI decreased from 71.2% to 46.2% in the HA but increased from 44.0% to 50.7% in the control group. Hospital stay was longer with HA (29,5 [18-47,75] vs 19 [12-30], p=0.009), whereas 28-day mortality was lower (30.8% vs 49.8%, p<0.05). Conclusions: Protocol-based early HA at high vasopressor requirements was associated with improved organ dysfunctions and reduced 28-day mortality in septic shock patients.
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Posterior Reversible Encephalopathy Syndrome: Two Case Reports
Posterior reversible encephalopathy (PRES) syndrome is a clinical-radiological condition characterized by headache, changes in consciousness, epilepsy and visual disturbances, and usually occurs in the posterior parietal and occipital regions with vasogenic edema due to different etiologic factors. Risk factors include preeclampsia/eclampsia as well as hypertension, human immunodeficiency virus infection, organ transplantation, immunosuppressive and cytotoxic therapy, and analgesics. Treatment is usually aimed at correcting the cause of PRES. The aim of this case report was to present the characteristics of PRES, which was secondary to eclampsia in two cases, to discuss the differential diagnosis and to review the literature.
Copyright © 2019 The Author(s) https://creativecommons.org/licenses/by/4.0
Early Stage Muscarinic Findings and Syndromic Classification in Wild Mushroom Poisoning
Mushroom poisoning is a frequently encountered health problem around the globe. Depending on its type and toxin, it results in a wide spectrum of issues that range from asymptomatic findings to fatal organ failure. Since the toxin of the mushroom leading to poisoning is often unidentified, syndromic classification may benefit clinical management according to the findings of target organ system toxicity. A 64-year-old female patient with comorbidities such as diabetes mellitus, coronary artery disease, hypertension and hyperlipidemia was admitted to the intensive care unit. Approximately four hours after consuming wild mushrooms the patient’s diarrhea, muscle cramps, cold sweating, blurry vision, coughing and shortness of breath complaints have been begun. Her respiratory system examination revealed tachypnea, generalized bilateral rhonchus, bronchorrhea and wheezing. Patient was normotensive and had bradycardia (heart rate 35 beats/minute). She had anxiety and the Glasgow Coma score was 15. Her pupillary bilateral isochoric, miotic and light reflexes were diminished. In her arterial blood gas pH level 7.26, partial carbon dioxide pressure: 34 mmHg, potassium: 5.3 mmol/L, sodium: 130 mmol/L, lactate: 5.3 mmol/L, bicarbonate: 16 mEq/L and base excess: -10,3 mmol/L was found. Target organ system toxicity findings and timing of occurrence indicated early-onset cholinergic syndrome. Treatments that consisted of intravenous atropine, fluid, electrolytes and sodium bicarbonate alleviated the toxicity in a short period of time. Late mycologic examination results that followed the treatment revealed that the patient was poisoned by Inocybe lacera, a mushroom type that contains muscarine. With this case presentation, we summarized the syndromic classification that we use in the clinical management in the light of current information in the literature.
Copyright © 2018 The Author(s) https://creativecommons.org/licenses/by/4.0
Acute Renal Failure Due to Metformin Intoxication: Case Report
Metformin is an oral antidiabetic agent from the group of biguanide compounds. Metformin-related lactic acidosis is one of the adverse effects with high mortality in the cases of metforming poisoning. We aimed to present a case of attempted suicide that developed acute renal failure due to excessive dose of metformin intake, which was treated with methylprednisolone. This is the first case treated with pulse methylprednisolone in the literature without hemodialysis.
Icterohemorrhagic Leptospirosis: A Case Report
Leptospirosis is a zoonotic infection caused by spirochetes and is usually seen in rural areas. The clinical status may range from self-limiting mild leptospirosis to icterohemorrhagic leptospirosis characterized by jaundice, renal failure and hemorrhage progressing to acute respiratory distress syndrome and multiple organ dysfunction syndrome. In this study, we aimed to present a fatal leptospirosis case followed in the intensive care unit.
Hemodiafiltration Practice in a Patient with Severe Amitriptyline Intoxication
Tricyclic antidepressants are widely used drugs for treatment of depression despite serious mortality and morbidity in higher doses. They can cause severe cardiac arrhythmias, hypotension and central nervous system depression. Some patients may remain unresponsive in spite of conventional therapies such as gastric lavage and activated charcoal administration, benzodiazepines, volume replacement, lidocaine and sodium bicarbonate infusion. In this paper we report a 20-year-old female patient who had severe amitriptyline intoxication with a Glasgow Coma Scale score 4 and severe cardiac arrhythmias and was treated with hemodiafiltration. Conventional therapy was inadequate and hemodiafiltration was applied to the patient for 36 hours. At the end of the 36-hours the patient was conscious and became stabilized in terms of hemodynamics. In case of serious intoxication that does not respond to conventional therapy, approaches like hemodialysis, plasmapheresis, hemoperfusion and hemodiafiltration can be a rescue therapy and they should be considered.
Nursing Care for Patient Who Underwent Face Transplant During Intensive Care: A Case Report
There is restricted information on nursing care and follow-up for patients undergoing face transplantation. After face transplantation, the nursing interventions to follow-up and allayment the patient and the discussion of the responsibilities of the nurse in drug management will contribute significantly to the healing process of the patient. This case involves nursing care in the intensive care period after surgery of the patient with face transplantation. To 26-year-old male patient, a full face transplant including the ears and the scalp was performed. In the post-operative intensive care period; the patient was closely monitored for hemodynamic balance, pain management, with the aim of preserving for infection control and tissue viability. The patient was followed-up for 8 days in the intensive care unit and did not develop any life-threatening problems. The importance of nursing in the care of patients undergoing face transplants is undeniable. Especially in the intensive care process; feeling the presence of the nurse for pain and agitation control, drug management sudden changing hemodynamic status, maintaining patient and environmental safety for infection control is the responsibility of the nurse and are important initiatives that contribute to the patient’s recovery. However, the literature on proper nursing care for such an important responsibility is very restricted. This case report is thought to be enlightening for nurses in the care of patients undergoing face transplantation.
Which Thrombolytic Dose Should be Given to Which Patients with Massive Pulmonary Thromboembolism? Two Cases Report
Massive pulmonary thromboembolism (PTE) is a condition characterized by sudden onset of dyspnea, hypotension, right ventricular failure findings, presyncope or syncope and cardiac arrest which must be diagnosed and treated immediately. Massive PTE is an emergent and serious clinical condition with high morbidity and mortality rates. Besides close observation and monitorization during the treatment, due to severe hypoxemia often the need for mechanical ventilation, it is appropriate to follow-up in the intensive care units. According to the massive PTE algorithm in hemodynamically unstable patients, for diagnostic purposes the bedside echocardiography shows right ventricular dysfunction and if not contraindicated thrombolytic therapy must begin immediately. It is an appropriate approach to select the given thrombolytic therapy dose according to the characteristics of the patient and the disease. Two cases of massive PTE admitted to the emergency department due to dyspnea, angina and syncope were treated successfully with different doses of thrombolytic therapy and the cases were evaluated in the light of the literature information.
Acute Respiratory Distress Syndrome Associated Hemophagocytic Syndrome
Hemophagocytic histiocytosis is a syndrome of similar inflammatory response that can occur with different underlying pathologies that can be seen at any age. It is a rare disease characterized by fever, splenomegaly, jaundice, hemophagocytosis of bone marrow and other tissues (phagocytosis of erythrocytes, leukocytes platelets and their precursors by macrophages). There are two forms as primary and secondary, primary form (familial hemophagocytic syndrome) is autosomal recessive inheritance. It is seen in newborn children approximately 1/50.000 ratios. The secondary form is especially associated with Epstein-Barr virus infection, but it can be seen together with viral, bacterial, fungal and parasitic infections, collagen tissue diseases and malignant diseases. In this article, a 44-year-old female patient with no chronic disease history and has respiratory complaints was admitted to the chest diseases service with pre-diagnosis of pneumonia and the patient was admitted to the intensive care unit after the development of acute respiratory distress syndrome (ARDS). In this case, the development of hemophagocytic syndrome due to ARDS which is rarely seen syndrome is presented while ARDS therapy continues.
Spontanous Urinary Bladder Rupture and Urosepsis in Patient with Paraplegia
Spontaneous bladder rupture is a rarely seen clinical condition and usually occurs because of weakening of the bladder wall after urinary retention, urinary tract infections, increased intra-bladder pressure, and alcohol intoxication. Less frequently, perforation may encounter due to foley catheter erosion, inflammation (eosinophilic cystitis, interstitial cystitis), giant bladder stones, intra-arterial chemotherapy or atherosclerotic embolism. Cases due to neurogenic bladder are also involved in the literature. In this paper, we aimed to share our experience by presenting a paraplegic patient, who applied with clinical symptoms of sepsis, was followed-up at the intensive care unit, and was diagnosed with spontaneous urinary bladder perforation at laparotomy.
The Evaluation of the Effects of Erythrocyte Transfusion on Central Venous Oximetry in Major Surgery Patients
Objective: Blood transfussion is generally performed to improve oxygen delivery (DO2). Transfusion decision is mostly based on hemoglobin levels, regardless of actual DO2 requirement. As central venous oxygen saturation (ScvO2) may reflect the imbalance between DO2 and consumption (VO2), the aim of this study was to investigate the effect of red blood cell transfusion on ScvO2 levels in major surgery patients. Materials and Methods: The cases in which the clinician decided to perform blood transfusion among the major surgical cases between American Society of Anesthesiologists I and IV, which received central venous catheter insertion and admitted to intensive care unit after surgery, were included in the study. Arterial hemoglobin levels, oxygen saturations, lactate and base excess levels were measured before red blood cell transfusion (pre-T) and 1 hour after transfusion (post-T). Analysis of these variables was performed with using the Wilcoxon test or the Mann-Whitney U test, and p<0.05 was considered significant. Results: Data’s which belong to totally 128 red blood cell transfusion performed with 101 patients was included in the study. ScvO2 values significantly increased from 72.25±6.8% to 75.25±7.06% after transfusion (p<0.0001). While significant improvements were observed in arterial base excess values there was no change in lactate values. Conclusion: According to the results, it was observed that red blood cell transfusion performed in major surgery patients provided significant improvements in tissue oxygenation.
The Success of ECMO in Flail Chest and ARDS Following Thoracic Gunshot Wound
Extracorporeal membrane oxygenation (ECMO) may be the last option in patients with severe acute respiratory distress syndrome (ARDS) in whom conventional methods have failed. The best results are obtained in patients with severe ARDS after trauma. Injured lungs can recover completely with ECMO therapy. A 44-year-old male patient was brought to the emergency department after sustaining severe thoracic gunshot injury. The patient was rushed into emergency surgery; however, pneumonectomy could not be performed due to morphological variation and widespread contusion in the lungs. The patient had flail chest with extensive damage of the ribs. Titanium plates could not be placed, as there was a major loss in the bone tissue. After cutting the fractured rib ends, the open chest wall was repaired with dual mesh and covered with serratus and latissimus dorsi muscles. However, the flail chest could not be corrected. During the follow-up in the intensive care unit, the patient developed ARDS and conventional therapies were unsuccessful. Thus, ECMO was used to allow lung healing. ECMO treatment was continued for seven days and was completed without any complications. The patient was transferred to the regular ward after 29 days. ECMO can be used as a life-saving treatment that allows lung healing in case conventional treatment methods have failed.
Intoxications in Intensive Care: Cost and Bed Occupancy According to Glasgow Coma Scale
Objective: Intensive care units (ICU) are the units in which critical patient care and follow-up are conducted. About 3.7-40% of ICU beds are used for intoxications. In ICU, intoxications may be mortal or can be discharged only by observation without any complication. The necessity of hospitalization of all these patients to the ICU is controversial in terms of bed occupancy and cost. In our study, it was aimed to determine the necessity and cost of hospitalization of ICU patients who were admitted to ICU with diagnosis of intoxication. Materials and Methods: This study was conducted by investigating the files of 205 intoxication patients who underwent more than 24 hours of follow-up and treatment at second and third level ICU. While patients were admitted to ICU, they were divided into two groups according to Glasgow Coma score (GCS) 15 (group=15) and below 15 (group <15). The patients’ age, gender, GCS, cause of poisoning, number of days stayed in the ICU and the need for mechanical ventilation (MV) were recorded, and the ICU costs of the groups were calculated. In addition, the cost that would be generated if the patients in group=15 were followed in the service environment rather than in the ICU was calculated. Results: Of the 205 patients examined, 145 had GCS of 15, while the GCS of 60 patients were below 15. The number of patients with GCS=15 and the intoxication case with suicide intent were higher in female gender. While the number of intoxications with cardiovascular system drugs and analgesic drugs was greater in group=15, the number of intoxications with carbon monoxide and drug substances was greater in group <15. The number of days stayed in ICU, MV requirement and ICU costs were higher in group <15. If the patients in group=15 had been followed up in the service environment, the cost would have been lower than the cost in ICU. Conclusion: GCS; it can be used to determine the necessity of hospitalization of intoxication cases into ICU due to its specificity and easy applicability. It is common belief that intoxications leading to life threatening and organ failure should be followed in second and third level ICUs. The fact that ICU beds in our country are not used according to the criteria is a big problem, which may increase the cost of use and also cause an increase in mortality. Adhering to the criteria for admitting patients to high cost units which require specialist and technological equipment such as ICUs will prevent unnecessary bed occupancy and ensure proper use of resources. According to our study, close follow-up of patients, who admitted to ICU with GCS=15, in an equipped service may reduce cost and bed occupancy.
Thirty-day Mortality Outcomes of Trauma Patients in the Intensive Care Unit: A Three-year Retrospective Study
Objective: In this study, we aimed to investigate the characteristics of trauma patients hospitalized in intensive care units of a hospital, the first 30-day mortality rates and the causes affecting mortality in this period. Materials and Methods: In this study, the data of 150 trauma patients hospitalized in Nevşehir State Hospital between January 2013-2016 were examined retrospectively. Patients were divided into two groups, the survivors and the patients who died within the first 30 days (non-survivors). Initial findings of admission to the hospital, characteristics of trauma, interventions in intensive care units’s, and the latest conditions on the 30th day (still in bed, exitus or discharge cases) were recorded. Mortality rates and factors affecting mortality were studied. Results: In the first 30 days of hospitalization to intensive care units due to trauma, 115 (%76.7) of the 150 patients survived and 35 (23,3%) died. The mean Glasgow Koma Skala (GCS) scores were lower and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were higher in the non-survivors group than survivors (p<0.0001). Cardiopulmonary resuscitation (CPR) was successfully performed in 9 patients (6%) in the emergency department or in the first 30 days of intensive care hospitalization. The number of patients receiving CPR was higher in the non-survivors group than the survivors (p<0,0001). The most common cause of trauma was traffic accidents (n=52, 34.7%). Head was the most frequent trauma location (n=30.20%) and 27 (% 90) of them were due to the traffic accidents. Twelve (70.6%) of 17 (11.3%) multi-trauma patients died within the first 30-days and multi-trauma was an independent risk factor for mortality (p<0.0001). Low GCS score, high APACHE II score, multi-trauma and advanced age were identified as independent risk factors. Conclusion: During the first 30 days after admission to intensive care units of trauma patients, mortality rates are affected by factors such as age, multi-trauma, CPR and head trauma. Invasive procedures may increase mortality rates. GCS and APACHE II scores can be used as predictors of 30-day mortality of patients.
Ultrasonography in the Diagnosis of Pneumothorax Not Detected by Chest Radiography: Case Report
In patients with acute respiratory distress syndrome (ARDS), many factors, especially barotrauma may cause pneumothorax. Early detection of pneumothorax is critical in ARDS patients. When pneumothorax is suspected, chest radiography is usually preferred as the first line imaging modality. Recently, ultrasonography has been used by intensive care physicians in many fields, even in imaging of pneumothorax. We present a 75-year-old female patient with ARDS complicated by pneumothorax, in whom chest radiography was not diagnostic but ultrasound was used for diagnosis and follow-up.
Antibiotic Susceptibilities of Pseudomonas aeruginosa, Klebsiella pneumoniae and Acinetobacter baumannii Strains Isolated from Patients in the Pediatric Intensive Care Unit
Objective: In this study, it was aimed to determine the antibiotic susceptibility of Pseudomonas aeruginosa, Klebsiella pneumoniae and Acinetobacter baumanii bacteria isolated from blood and endotracheal aspirate samples, and to start the appropriate empirical antibiotic treatment. Materials and Methods: The antibiogram results of the patients’ whose blood and endotracheal aspirate samples sent from Erciyes University Faculty of Medicine Pediatric Intensive Care Unit to our hospital between January 1, 2013-August 30, 2017, and Pseudomonas aeruginosa, Klebsiella pneumoniae and Acinetobacter baumannii bacteria reproduction detecting were evaluated retrospectively. Results: One hundred thirty-five samples sent from a total of 111 patients [65 male (63.6%), 56 female (36.4%)] with a median age of 17 months (7-112) were analyzed retrospectively. Of these samples reproduction of Pseudomonas aeruginosa were detected in 68 [blood: 31, endotrakealaspirat (ETA): 37], Acinetobacter baumannii in 42 (blood: 22, ETA: 20), Klebsiella pneumoniae in 25 samples (blood: 18, ETA: 7). Amikacin resistance rate was the lovest antibiotic (23.7%), while cefepime, ceftazidime, meropenem, ciprofloxacin and gentamicin resistance rates were 49.6%, 53.7%, 62.2%, 46.7% and 60%, respectively. Amikacin resistance was determined as 5.9%, 64.3% and 4% for Pseudomonas aeruginosa, Acinetobacter baumannii and Klebsiella pneumoniae, respectively. Conclusion: Our study also suggests that, clinicians should be more careful when deciding to use this drug because of the severe carbapenem resistance for Acinetobacter, Pseudomonas and Klebsiella in Intensive Care Units. It also reveals that amikacin is a good option in empirical treatment.
The Effect of Education in Reducing Noise on Health Personnels’ Knowledge Level and Behavioral Change
Objective: Noise must be reduced and taken under control because negatively affects the health of health personnel and preterm newborns in particular. The American Academy of Pediatrics reported that noise levels must be kept below 45 dB. However, many studies demonstrated that the desired level could not be reached. This research was conducted with the aim of evaluating the level of noise in a neonatal intensive care unit (NICU), and the effect of given education on controlling the noise. Materials and Methods: This research was conducted with doctors (4), nurses (18), and personnel (4) who worked in the 3rd level NICU of a university hospital. This research had a pre-test, post-test quasi-experimental design in a single group. Ethics board and institutional approval were granted from the hospital. A noise information form that was prepared by researchers, educational program on noise control, noise observation form, and noise measuring equipment were used in the study. Noise was measured for 24 hours over 7 days in repeated measurements in the unit before education, after education, and 6 weeks after the education program. Results: The noise levels were significantly lower 6 weeks after the education program compared with before the program (p<0.01). The percentage of correct answers given to questions in the information form was significantly higher 6 weeks after the education program compared with before the program among health personnel (p<0.01). The kappa compliance level was found significant among observers in the evaluation of doctors, nurses, and personnel in accordance with the noise observation form (p<0.01). Conclusion: It could be suggested that the education method was effective in terms of reducing noise, reducing noise levels in the environment, improving the information level of health personnel, and positively affecting the behaviors of personnel. It can also be concluded that the noise observation form is reliable.
Comparison of Different Gastric Residual Volumes in Intensive Care Patients Receiving Enteral Nutrition Support
Objective: This study aimed to determine and compare the effects of two different gastric residual volume (GRV) thresholds, 200 mL and 400 mL, on target calories and gastrointestinal intolerance in intensive care patients receiving enteral nutrition. Materials and Methods: Prospective data of 56 patients over 18 years of age who were expected to stay in the intensive care unit for more than three days were included in the study. Patients were randomized into two groups as GRV threshold 200 mL (group 1) and GRV 400 mL (group 2). Enteral Measurement of GRV was done every six hours. The feeding was initiated at a rate of 20 mL/h and was increased by 10 mL/h to reach the goal rate. Results: There was no significant difference between two groups regarding gender, age, APACHE II score, body mass index, length of stay in intensive care unit, admission reason, and co-morbidities. There was also no significant difference in the incidence of GRV, vomiting, diarrhea and intolerance. Time to target calories was 24 hours in group 1 and 26 hours in group 2, and no significant difference was found between the two groups. Conclusion: In this study, there was no significant difference between 200 mL and 400 mL GRV regarding time to target calories and incidence of gastrointestinal complications in critical intensive care unit patients.
Successful Treatment of Mushroom Poisoning with Silybin: A Case Report
Although up to 100 of them known to be toxic, there are more than 5,000 mushroom species in the world. Of these, the most poisonous species belong to Amanita and Gallerina species. Alpha-and beta-amanita toxins which are associated with serious liver, kidney and central nervous system damage is produced by Amanita phalloides which is responsible for 90% of fatal mushroom poisoning in Turkey. Two cases that we aimed to present are two male patients aged 55 and 42 who collected and consumed mushrooms in the forest. The patients were admitted to the county state hospital with complaints of nausea, vomiting, diarrhea and fatigue after 18 and 24 hours. Patients with increased liver function tests were referred to our hospital for further examination and treatment, and they were discharged after successful treatment in our intensive care unit.
Tracheal ruptures are one of the life-threatening situations in critical care unit and can be formed after trauma, intubation, tracheotomy, bronchoscopy or spontaneously. Significant risk factors for tracheal rupture include urgent intubation, use of stilet, high cuff pressure, recurrent intubation attempts, double lumen endotracheal tubes, very thick endotracheal tubes, female gender, short height, older age, tracheomalacia, tracheal stenosis, congenital tracheal abnormalities and chronic steroid therapy. Among these risk factors, corticosteroids can cause rupture by inhibiting collagen synthesis and reducing connective tissue stability. In this case report, a case with spontaneous recurrent tracheal rupture was defined and the underlying mechanisms and therapeutic approach to this complication that could be seen in patients using chronic steroids were discussed.
Relationship Between Neutrophil Gelatinase-associated Lipocalin and Mortality in Acute Kidney Injury
Objective: Almost half of intensive care patients are affected by acute kidney injury (AKI). The purpose of this study is to determine parameters that can be used for predicting of early (within 28 days) and late (within 90 days) mortality in patients who are followed-up with AKI in intensive care units. Materials and Methods: In this study, a dataset that contains 50 patients with AKI in intensive care units was used. This dataset contains blood urea nitrogen, creatinine, plasma and urinary neutrophil gelatinase-associated lipocalin (NGAL), lactate dehydrogenase, alkaline phosphatase and gamma-glutamyl transpeptidase values of patients who were admitted to intensive care for various reasons and who developed AKI on the days 1, 3 and 7. In addition to these values, laboratory results such as serum electrolytes on day 1, blood gas; vital signs such as mean arterial pressure, central venous pressure; and demographic data were also recorded. Data mining techniques were applied to determine correlation between all of these data and mortality. Results: The threshold level of urinary NGAL on day 7 was determined to be 69 ng/mL, and strong correlation was found between this threshold level and early mortality. Similarly, the threshold level of plasma NGAL on day 7 was determined to be 150 ng/mL, and this was highly correlated with early mortality. Besides, strong correlation was also found between the difference in the urinary NGAL levels on day 1 and 7, and early mortality. Conclusion: In this study, plasma and urinary NGAL levels were found to be closely related to early mortality in patients who were followed-up with AKI in intensive care units. On the other hand, any parameter associated with late mortality was not found.