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Associated factors of transfer to intensive care unit among hospitalized patients with COVID-19 disease-related pulmonary thromboembolism
Introduction: The most common thromboembolic condition in coronavirus disease 2019 (COVID-19) is acute pulmonary embolism (APE). Factors associated with transfer to the intensive care unit among cases diagnosed with COVID-19 are separately known for COVID-19 and APE. However, it is important to identify factors associated with transfer to intensive care in patients with COVID-19-related APE. This study aimed to determine these factors in the coexistence of these conditions. Methods: Adult patients diagnosed with APE by pulmonary computed tomography angiography were included in this cross-sectional study. The patients’ demographic and laboratory data, Wells scores, pulmonary embolism severity index (PESI) scores, and imaging findings were recorded. Pairwise comparisons were made between the patients with and without intensive care unit admissions. Results: Of the 123 patients included in the study, 38 (30.8%) were transferred to the intensive care unit. In pairwise comparisons, age, number of comorbidities, lactate dehydrogenase, neutrophil-to-lymphocyte ratio, C-reactive protein (CRP), CRP-to-albumin ratio, d-dimer values, Wells scores, and PESI scores were higher among patients who transferred to intensive care. A higher Wells score (odds ratio (OR) = 1.70, 95% confidence interval (CI) =1.13 – 2.56, p=0.011), PESI score (OR = 1.03, 95% CI = 1.00 – 1.07, p=0.048), and CRP (OR = 1.01, 95% CI = 1.00 – 1.02, p=0.049) were associated with admission to the intensive care unit among patients with COVID-19-related APE. Discussion and Conclusion: High Wells and PESI scores and CRP levels in adult patients hospitalized with a diagnosis of COVID-19-related APE were determined to increase the probability of transfer to the intensive care unit. Therefore, it is recommended to monitor these patients more closely for intensive care needs.
Copyright © 2025 The Author(s) https://creativecommons.org/licenses/by/4.0
An evaluation of end expiratory lung volume and pulmonary mechanics with different PEEP levels in ARDS patients
Objective: The treatment of acute respiratory distress syndrome (ARDS) is highly complex, and its mortality rate remains significant. Positive end-expiratory pressure (PEEP) titration plays a crucial role in mechanical ventilation; however, the optimal approach for PEEP titration has yet to be established. This study evaluated the volume gain at different PEEP levels along the pressure-volume curve, changes in end-expiratory lung volume (EELV) measured via the modified multiple nitrogen wash-out/wash-in technique, and respiratory compliance. Materials and Methods: Following approval from the ethics committee, 14 patients with ARDS receiving invasive mechanical ventilation in intensive care units were included in the study. According to the Berlin Criteria, there were 2 patients with mild ARDS, 7 with moderate ARDS, and 5 with severe ARDS. The repeated nitrogen wash-out/wash-in technique assessed functional residual capacity (FRC) and EELV at decreasing PEEP levels (±5 cm H2O) were determined. Gain and compliance values were calculated based on the dynamic pressure-volume curves generated. Arterial blood gas analysis was conducted to measure oxygenation at each PEEP level. Results: The highest compliance, gain, and EELV values, as well as the lowest driving pressure and strain values, were observed at a PEEP level of 10 cm H2O. Conversely, the highest PaO2 values, representing oxygenation indicators, were recorded at a PEEP level of 15 cm H2O. Notably, the gain remained largely unaffected by changes in compliance, elastance, driving pressure, and static strain; it was not affected by lung distension. Conclusions: In PEEP titration, alveolar distension was not detected by EELV or gain parameters. Sufficient evidence could not be obtained solely in clinical practice.
Research on attitudes of senior anesthesia assistants and intensive care physicians towards compliance with the “pain, agitation/sedation, immobility, and sleep disruption” guidelines and symptom management in the intensive care units in Türkiye
Introduction: It was aimed to investigate the attitudes of senior anesthesia assistants and intensive care physicians in Türkiye towards compliance with the “Pain, Agitation/Sedation, Immobility and Sleep Disruption” (PADIS) Guidelines and symptom management in the intensive care unit (ICU). Methods: The survey, consisting of 40 questions was sent to the participants electronically. The answers to the questions were evaluated according to the recommendations in the PADIS 2018 guidelines. Results: While anesthesiology and reanimation specialists gave less compatible answers (58.9%) with the guideline in “identifying risk factors affecting pain”; responses were more consistent with the guideline (100%, 69.5%, and 85.3%, respectively) in “use of medication in addition to opioids”, “use of medication to prevent delirium”, and “pharmacological interventions to improve sleep” Discussion and Conclusion: This study demonstrates that intensive care physicians, including anesthesiology and reanimation assistants in Türkiye, generally exhibit a compatible attitude with the PADIS 2018 guideline in the management of “pain, agitation/sedation, delirium, immobility and sleep disruption” symptoms in critically ill adults in the ICU. Additionally, as the medicine career progresses, more guideline-compliant responses in the management of some symptoms have demonstrated the importance of clinical experience in critically ill adults management.
Glycemic variability and mortality in critically ill patients: higher risk in non-diabetic patients
Objective: Glycemic variability (GV) is associated with increased morbidity and mortality in critically ill patients. This study aimed to contribute to the knowledge on the subject and to investigate the situation in our intensive care patient population. Method: Patients who were admitted to the Intensive Care Unit (ICU) between January 2015 and August 2020 were screened using the hospital’s database. The following data were collected: demographic characteristics of the patients, comorbidities, APACHE II scores, SOFA scores, mean amplitude of glycemic excursions (MAGE) based on daily blood glucose measurements from the first day of ICU admission until discharge up to the 28th day of their stay, length of stay (LOS), and 28-day mortality status. Results: In this study, 136 patients were enrolled and divided into high (n=70) and low GV (n=66). No differences were found between the two groups in terms of age, gender, comorbidity, APACHE II, mean SOFA scores, treatments, ICU LOS, and mortality. MAGE was higher in nonsurvivors (78.8 ±32.2) compared to survivors (65.4 ±22.5) (t=-2.78, p= 0.005). Regarding the mortality, the AUC value for GV was 0.611 (p=0.02) for MAGE >61 mg/dl, with a sensitivity of 68.5% and specificity of 50%. Patients were grouped according to GV (MAGE>65) and the presence of diabetes mellitus (DM). Mortality was highest in patients with high GV and without DM (53.3%). Conclusion: In this study, MAGE levels were higher in non-survivors than survivors, and glycemic variability was moderately associated with mortality. Patients with high GV and without DM had a higher mortality rate compared to those with DM.
Content analysis of Youtube videos related to brain death
Introduction: This study aimed to evaluate the quality of information content in YouTube videos related to brain death. Methods: A search was conducted on the YouTube video platform using the keywords “brain death” and “brain death and organ donation” on November 20, 2024. A total of 42 videos were included in the evaluation. Data regarding the number of views, likes, comments, video duration, the number of days since the video was uploaded, and the source of the video were recorded. To classify the quality of the video content, DISCERN (Quality Criteria for Consumer Health), GQS (Global Quality Scale) for evaluating educational content, JAMA (Journal of the American Medical Association) for assessing the accuracy of the video source, and USEFULNESS for determining the utility of the videos were used. Results: Among the analyzed videos, 25 (59.52%) were uploaded by physicians. Sixteen videos (38.10%) were rated as having very low educational quality, 13 (30.95%) provided partially sufficient information about the video source, 16 (38.10%) were of low information quality, and 13 (30.95%) were found to be of low usefulness. The quality scores of videos uploaded by physicians were significantly higher compared to other groups. Discussion and Conclusion: The quality and educational value of YouTube videos related to brain death are low. Therefore, it is crucial that videos accessed through YouTube and other social media platforms are supervised by experts in the field to ensure accurate and useful information.
Retrospective evaluation of the effect of intensive care specialist on productivity in a 2nd level hospital
Introduction: While intensive care practices in 3rd level hospitals are carried out by a full-time intensive care team, 2nd level hospitals, there is mostly open type intensive care. In this study, the evaluation of the positive results observed in health care by employing an intensive care (ICU) specialist in a 2nd level ICU was investigated. Materials and Methods: Patients hospitalized in the 2nd level intensive care unit of Gümüşhane State Hospital were retrospectively examined. Non-covid patients from the period between October 2020-2021 (period without an ICU specialist) and October 2021-2022 (period with an ICU specialist) were compared. Patients were compared in terms of age, gender, post-operative status, comorbidities, APACHE 2 score, malignancy, hospitalization day, transfer to the service, out-of-province referral, and intensive care mortality. Results: 127 of 142 patients in the October 2020-2021 period and 212 of 402 patients in the October 2021-2022 period were included in the study. It was determined that the number of post-operative patients was higher and the length of stay was lower in the period when there was an ICU specialist. The average hospitalization day and ICU mortality of the patients were significantly less in the period when there was an ICU specialist (p<0.001). The number of patient transfers to the service was significantly higher in the period when there was an ICU specialist. The rate of out-of-province referrals was significantly lower in the period when there was an ICU specialist (p<0.001). Conclusion: We came to the conclusion that intensive care specialists can work in 2nd level hospitals and that on-site health services are possible in addition to more active and effective intensive care practices. In our country, it is important for intensive care specialist physicians to actively take part in the processes in both 2nd and 3rd level hospitals and to develop intensive care units there.
Reliability and validity of the Turkish version of the Chelsea critical care physical assessment tool (CPAx-TR)
Objective: Assessing physical function in Intensive Care Unit(ICU) patients is essential for clinical decision-making. The Chelsea Critical Care Physical Assessment Tool(CPAx) is a validated instrument developed to evaluate functional status. This study aimed to cross culturally adapt the CPAx into Turkish and examine its validity and reliability. Materials and Methods: The tool was translated into Turkish using forward–backward translation and administered to 60 ICU patients. For the reliability analysis, internal consistency was evaluated using Cronbach’s alpha coefficient. The construct validity of the CPAx was tested by factor analysis. The criterion validity was performed using the correlation between the CPAx and the Physical Function ICU Test (PFIT). Results: The internal consistency of the tool was found to be high and Cronbach’s alpha value was calculated as 0.960. All item-total score correlations were above 0.30. Exploratory Factor Analysis revealed that all items were grouped into a single factor. In Confirmatory Factor Analysis, the model showed good fit (CMIN/df=1.207;CFI=0.993;NFI=0.959;GFI=0.907; RMSEA=0.059). Furthermore, the correlation analysis with P-FIT revealed a strong positive relationship (r=0.892; p<0.001). Conclusion: It has been determined that the CPAx-TR shows acceptable levels of validity and reliability in evaluating functionality in ICU patients.
Family needs, psychological distress and social support in the intensive care unit: a cross-sectional study
Objectives: The aim of the study was to determine the relationships between sociodemographic factors related to the needs of individuals and family needs, psychological distress and social support. Methods: A Personal Information Form, Critical Care Family Needs Inventory (CCFNI), Kessler Psychological Distress Scale (K10-PDS), and Multidimensional Scale of Perceived Social Support (MSPSS) were used to collect data. Results: The domains in which the participants were determined to have the greatest degree of need were information (38.45±5.23) and support (32.04±7.05). Participants with low education level and who visited their patients more frequently than once a week had significantly higher scores on the information, assurance, proximity, and comfort subscales. The participants had high K10-PDS (25.77±9.99) and MSPSS (68.62±15.54) scores. There was a significant positive relationship between the CCFNI and MSPSS scores of the participants (r=0.400). Conclusions: The family members of intensive care patients were determined to have a high degree of need and high levels of psychological distress. It is extremely important for health professionals to support the family and include them in the care process. Increasing the quality of care for the patient and providing psychological relief to the family will increase the quality of care.
An unexpected consequences of severe rhabdomyolysis induced by Plasmodium Vivax: Acute respiratory failure with preserved renal function
We described a case of a previously healthy young man with Plasmodium vivax induced severe rhabdomyolysis with a creatinine kinase (CK) level of 812,000 U/L leading to acute respiratory failure and subsequent weaning failure. Mix infections with Plasmodium falciparum were ruled out by polymerase chain reaction (PCR) and other causes including trauma, heat exhaustion, autoimmune diseases, inflammatory myopathy, drugs, and infections such as leptospirosis and COVID-19 were excluded. He presented with respiratory distress requiring intubation and ventilatory support. There was no heart or lung pathology, fever, metabolic acidosis, anaemia, or drop in consciousness level upon presentation. Extubation was attempted twice during the first week of admission, however, respiratory failure ensued after each attempt requiring reintubation in which one of the episodes was complicated by lung collapse. The respiratory distress upon presentation and failed extubation episodes were attributed to respiratory muscle weakness secondary to severe rhabdomyolysis. He was successfully extubated after almost two weeks of admission. Despite the extremely high CK level, renal function was unexpectedly preserved without the need for renal replacement therapy. To the best of our knowledge, this is the first reported case of severe rhabdomyolysis induced by P. vivax leading to respiratory failure but with preserved renal function. This case highlights that P. vivax infection can cause severe rhabdomyolysis and consequently acute respiratory failure due to muscle weakness. Awareness of such complications will guide clinicians’ decisions for timely initiation and weaning from mechanical ventilation, hence avoidance of associated complications.
Rational use of intensive care beds in Turkey: Point prevalence survey study
Objective: The limitation or withdrawal of futile treatment is widely accepted in the intensive care and medical ethics literature. However, implementing this in clinical practice is often difficult. The aim of the study is to understand the situation of non-indicated admissions and treatments in ICU beds in our country, as well as the doctors’ approaches to this issue. Materials and Methods: The study is planned as a one-day point prevalence survey consisting of 35 questions (Google Survey form) to be conducted on January 18, 2024. The study is based on two main topics: the proportion of patients admitted to intensive care unit (ICU) without indication and the reasons for it, and the proportion of patients who receive futile treatment in the ICU, as well as identifying the views and recommendations of ICU doctors on these issues. Results: A total of 127 doctors working in the ICU participated in the study. Among the participants, 58 reported that 10% of their patients, and 27 reported that 20% of their patients could not be transferred to the wards despite no longer needing ICU care. Due to the lack of available beds in the relevant clinics, 92 physicians stated that patient stays were extended by 1-5 days, and 21 physicians reported an extension of 6-10 days. In cases where transfer to palliative care services was not possible, 50 physicians indicated that 10% of their patients, 26 physicians indicated that 20%, and 21 physicians indicated that 30% of their patients remained in the ICU. Forty physicians reported a waiting time of more than 20 days for palliative care service. All physicians stated that futile treatments were being administered in the intensive care unit. Only 8.7% of the physicians reported that the patient was not in the terminal stage. Conclusion: Useless treatment that prevents rational bed use in intensive care units; It is a preventable situation with solutions in the light of correct analysis of the problems.
The relationship between awake prone positioning and need for invasive mechanical ventilation in COVID-19 related acute respiratory distress syndrome
Introduction: Prone positioning (PP) is beneficial in acute respiratory distress syndrome (ARDS) patients with orotracheal intubated (OTI) patient, however further studies are needed for awake patients with ARDS. We aim to evaluate the relationship between the duration and number of PP and the need for invasive mechanical ventilation (IMV) in awake patients with COVID-19 related ARDS (C-ARDS). Methods: This is an observational, single-centred, and retrospective study of 32 patients underwent invasive mechanical ventilation (IMV) and matched 33 non-IMV patients with C-ARDS receiving HFNC (high flow nasal cannula). Independent variables such as total number and duration of PP, clinical features, and patient characteristics were obtained. Logistic regression models were used to investigate variables associated with IMV need. Subsequently, models were adjusted for ROX index, APACHE II and SOFA scores, and LOS (length of stay). Results: The SOFA score, ROX index at 4 h, and LOS differed between groups. PaO2, SpO2, respiratory rate (RR) and ROX index of all patients improved after the first prone position (t = -6,93, p < ,001; t = -7,30, p < ,001; t = 5,35, p < ,001; t = 6,02, p < ,001; respectively). Diagnostic decision-making features of PP number (AUC = 0,690) and PP duration (AUC = 0,723) in predicting the need for IMV were examined with the ROC curve. We found that total number of prone position (aOR: 0,70; [CI %95: 0,51 - 0,96]; p = 0,026) and duration of prone position (aOR: 0,95; [CI %95: 0,92 - 0,99]; p = 0,22) are associated with decreased risk of undergoing IMV. Conclusion: IMV need is negatively correlated with duration and total number of PP in the awake patients with C-ARDS receiving HFNC, even after adjusting for possible confounding factors. To generalise these results, additional studies that are multi-centred and with a larger sample sizes are needed.
Do critical care nurses recognize delirium adequately? A cross-sectional multicenter study
Objective: Delirium is a common and often misdiagnosed condition associated with increased mortality and cognitive dysfunction in intensive care units. Critical care nurses have a unique opportunity as healthcare providers to assess for and early identify delirium. This study aimed to investigate the knowledge of critical care nurses about delirium care. Materials and Methods: The study were conducted between April 2022-July 2022 with critical care nurses who had at least one year of experience working in three hospitals. The study data were collected with the “Nurse Characteristic Form” and “Delirium Care Knowledge Questionnaire”. Results: In total, 253 nurses completed the test. The overall mean score was 10.66±2.29 (possible range 0-16). Correct answers for the subject areas were as follows: (a) 71.1% in symptoms, types, and outcomes; (b) 71.4% in high-risk groups; (c) 81.5% in predisposing and precipitating factors; and (d) 42.7% in assessment and detection. The questions with a high percentage of wrong answers were related to delirium subtypes and assessment. Delirium knowledge scores increased significantly with increasing age and with greater work experience (p<0.05). Conclusion: The results of this study reveal the need to improve the ability of critical care nurses to accurately identify and assess delirium by using valid tools.
Organ donation attitudes of relatives of patients in the wards and intensive care units: Will you be a life?
Objective: Inadequate organ donation rate is still an obstacle to organ transplantation. Lack of information and negative attitudes are the most important obstacles. Having a patient in intensive care unit may change the perspective and create sensitivity. We aimed to compare the perspectives on organ donation between relatives of patients in intensive care and inpatient services. Material and Method: It is a cross-sectional descriptive survey study. Group I: relatives of patients hospitalized in the 3rd level intensive care unit, and Group II: relatives of patients at inpatient services. Written informed consents were obtained. Questions were consisted of;1-Demographic data, 2- Level of knowledge about organ donation, 3-Attitudes and behaviors regarding organ donation. Results: There was a significant difference between the groups regarding the purpose of organ donation (p=0.006). The overall rate of support for organ donation by Group I (75.9%) was significantly higher than the Group II (18.7%) (p<0.001). Conclusion: The attitudes of relatives of patients in intensive care, towards organ donation are better than those who do not have patients in intensive care. Education and awareness-raising activities on organ donation should be carried out more intensively and effectively. Specially designed questionnaires, psychological support, empathy, respectful and early communication can also be effective.
Retrospective evaluation of the efficacy of two different dexamethasone doses on hyperinflammation in ARDS patients followed in COVID-19 intensive care unit
Introduction: To retrospectively compare the clinical and laboratory results of two different dexamethasone treatment protocols used in ARDS patients followed with COVID-19 in intensive care unit. Materials and Methods: Patients who started dexamethasone treatment in Pandemic Intensive Care Units were divided into two groups. Group 1: 6 mg/day (n=41), Group 2: 0-5 days 20 mg/day and 6-10 days 10 mg/day (n=39). Clinical results and changes in laboratory values between groups from day 0 to day 10 were compared. Results: Day 0 APACHE II scores were significantly higher in patients who received 20 mg (p: 0.039). When the parameter changes on days 0 and 10 after 10 days of dexamethasone treatment in the intensive care unit were analysed, it was determined that procalcitonin and D-Dimer values showed a statistically significant increase in the 20 mg group (p: 0.038 and p: 0.025, respectively). Finally, the effect of dexamethasone treatment on mortality was analysed and no difference was found between the groups. Discussion and Conclusion: Mortality comparisons have been made in the literature regarding dexamethasone treatment in ARDS patients in COVID-19 intensive care units. We compared mortality and laboratory parameters. In conclusion; dexamethasone treatment improves clinical and laboratory parameters, but in terms of benefit / harm ratio and side effects; we think that 6 mg can be used safely in cases requiring oxygen therapy in viral respiratory tract infections and 20 mg in severe cases where hyperinflammation is at the forefront.
Prognostic value of measurements of cross-sectional muscle area and subcutaneous, mediastinal fat tissue in COVID-19 patients’ thoracic tomography images
Introduction: Sarcopenia is common in patients with COVID-19 who are admitted to the ICU. Cross-sectional muscle area measurement calculated from thoracic tomography imaging is a method to evaluate presence of sarcopenia. We aimed to investigate the prognostic value of the muscle and fat tissue volume measurements which are calculated from the chest CT images taken at ICU admission in COVID-19 pneumonia patients, in terms of duration of MV, ICU stay and the rate of mortality. Methods: After ethical committee approval, adult patients who were admitted to the ICU between August 2020 and February 2021, with positive COVID PCR and respiratory distress were included into the study. Patients with inadequate thorax tomography imaging were excluded. The laboratory parameters, admission APACHEII, SOFA, NUTRIC scores, durations of MV, ICU and hospital stay, rates of mortality at 28 and 90 days were recorded from the hospital data system. Chi-Square Tests, Mann-Whitney U tests, Spearman correlations, multivariate binary logistic regression tests were used for statistical analyses. Results: A total of 139 patients were included into the analysis. The median duration of mechanical ventilation was 7 days, ICU stay was 17 days, and the 90-day mortality rate was 43%. There were no statistically significant correlations between the measurement of the muscle/fat tissue volume and the NUTRIC score, the durations of the MV, ICU or hospital stay. We found significant correlations between NUTRIC score and the duration of MV (p <0.01, r = 0.364), ICU stay (p = 0.011, r =0.216), the prealbumin value on the 14th day (p<0.01, r=0.496).The NUTRIC score (B=0.558, p.026) and SOFA score (B=0.760, p.001) at admission day were independent predictors of mortality. Discussion and Conclusion: The measurements of muscle and fat tissue volume from chest CT images don’t have prognostic value for predicting duration of MV, ICU stay and mortality whereas NUTRIC score is a predictor for mortality in critically ill COVID-19 patients.
Copyright © 2025 The author(s) https://creativecommons.org/licenses/by/4.0
Oxygen administration is foundational in anesthesiology and perioperative medicine, yet growing evidence challenges the routine use of high inspired oxygen concentrations. While preventing hypoxia remains essential during induction, emergence, and perioperative urgencies, both hypoxia and hyperoxia carry significant risks—including inflammation, oxidative stress, vasoconstriction, and impaired organ perfusion. These effects are especially pronounced in high-risk surgical patients. Recent advances in noninvasive hemodynamic and oxygenation monitoring now allow dynamic, individualized titration of oxygen delivery (DO2), moving beyond conventional SpO2 targets. Guidelines from cardiovascular societies increasingly support focused oxygenation goals during perioperative cardiac and cerebro-vascular emergencies. In the context of perioperative complexity and management of high-risk patients, anesthesiologists are uniquely positioned to lead a shift toward goal-directed oxygen therapy. Recognizing oxygen as a dose-dependent drug offers an opportunity to optimize outcomes through a nuanced, physiology-informed approach to intraoperative and perioperative care.
The predictive values of chest computed tomography severity score for air-leak syndrome in critically ill patients with coronavirus disease-2019
Introduction: Predicting Air-Leak (AL) syndrome and knowing its risk factors in critically ill patients with Coronavirus Disease-2019 (COVID-19) can reduce morbidity and mortality. In this study, we aimed to investigate whether the thorax computed tomography severity score (CT-SS) can predict the development of AL. Methods and Materials: COVID-19 patients were divided into two groups based on whether they developed AL syndrome. CT-SS was calculated for all patients. The predictive power of CT-SS for the development of AL syndrome and possible risk factors for AL were investigated. Results: AL syndrome developed in 52 out of 272 patients included in the study (19.1%). The median CT-SS was significantly higher in the AL group. The CT-SS value in the AL group was 19 (2-25), while it was 13 (1-25) in the non-AL group (p-value <0.001). CT-SS was found to have good diagnostic performance in predicting the occurrence of AL (p<0.001). When comparing the ICU mortality rates of the groups, it was 42.3% in the non-AL group and 88.5% in the AL group. Discussion and Conclusion: CT-SS may have predictive potential for the development of AL syndrome associated with COVID-19. However, further studies are needed in this area.
Toxic Methemoglobinemia Caused by Prilocaine: Presentation of Two Cases
Prilocaine is a local anesthetic agent used in many areas, but it may cause the methemoglobinemia, a life-threatening side effect. As a result, hypoxia may develop in the tissues. In this study, two toxic methemoglobinemia cases are presented since they develop depending on the local prilocaine used during the invasive intervention by radiology. Methemoglobinemia is a serious hematological disease and occurs when iron in hemoglobin is oxidized and becomes trivalent (Fe+++). Methemoglobinemia should be brought to mind in the differential diagnosis in the case of determining nonconcurrence or cyanosis between PaO2 and SaO2 values after using a local anesthetic. In such circumstances, it is appropriate to monitor patients in fully equipped intensive care units in terms of problems that may develop. Methylene blue and ascorbic acid were successfully used in treatment. In this paper, two cases are presented since methemoglobinemia developed depending on the use of prilocaine for local anesthesia and they were treated by intravenous methylene blue and/or ascorbic acid.
Copyright © 2023 The Author(s) https://creativecommons.org/licenses/by/4.0
Comparison of Mini-bronchoalveolar Lavage Technique with Endotracheal Aspirate and Bronchoscopic Specimens in Isolating Ventilator-associated Pneumonia Factors in Patients Under Intensive Care
Objective: Our study aimed to compare the mini-bronchoalveolar lavage (mini-BAL) method with the classical methods of endotracheal aspiration (ETA) and BAL in patients followed up in the intensive care unit (ICU) diagnosed with nosocomial pneumonia. Materials and Methods: Our study comprised 30 patients who were followed up with a suspicion of ventilator-associated pneumonia (VAP) between February 2014 and January 2015 at İstanbul University, İstanbul Faculty of Medicine, Department of Anesthesiology and Reanimation, ICU. Results: A total of 40% (12 people) of the patients were women, 60% (18 people) were men, and the mean age was 54.23±21.37 years. The mean duration of mechanical ventilation was 9.7±22.8 days. The mean Simplified Acute Physiology Score III of the patients was 36.06±8.46, the Acute Physiology and Chronic Health Evaluation-II score was 21.36±4.90, and the Clinical Pulmoner Infection score was 5.90±1.91. The consistency of the mini-BAL method, according to bronchoscopy, was 86.7%, and its consistency, compared with tracheal aspiration, was 63.3%. The consistency between the ETA and bronchoscopy method was 60%. Conclusion: Therefore, in the comparison of the methods used in the diagnosis of patients with suspected VAP in the ICU, mini-BAL gave reliable results in the early period.
Usefulness of Bispectral Index Monitoring for the Detection and Diagnosis of the Brain Death
Objective: Bispectral index (BIS) is a parameter generated from a mathematical analysis of frontal cortex activity. BIS monitoring has been widely used in cerebral pathologies such as traumatic brain injury, brain death, metabolic coma and barbiturate coma and some studies have reported a good correlation between neurological status and BIS values. We evaluated the validity of BIS monitoring for the detection and diagnosis of brain death in our study Materials and Methods: Our study was a methodological prospective study. Twenty-eight patients with severe coma [Glasgow coma scale score (GCS)<8] at intensive care unit (ICU) admission are monitored by BIS. Eight patients were excluded from the study due to varies reasons. Data of twenty patients with brain death were evaluated. Results: The most common diagnoses were intracranial hemorrhage (8 patients-40%) and subarachnoid hemorrhage (8 patients-40%). The most common used ancillary method was computed tomography angiography. BIS and suppression ratio (SR) were determined as 0 and 100 respectively at the moment of brain death diagnosis in 12 of 20 patients, whereas BIS was determined >0 in the remainders. When the receiver operating characteristic curve analysis was performed for the 34041 BIS values of 20 patients, the area under curve was found as 0.582 (0.576-0.588), which was statistically significant (p<0.05). There was a strong negative correlation between BIS and SR and it was statistically significant (R:-0.959, p<0.05). Conclusion: BIS is a non-invasive method and it may be used in the ICU. BIS monitoring may be useful, especially in patients with head trauma and GCS =3. BIS monitoring provides information about the neurological prognosis. We consider that BIS monitoring can prevent the loss of time by providing to detect the moment of the brain death and thus facilitating the organ transplantation process and however it can not take the place of the other ancillary methods.
Turkish Publications in SCI/SCI-E Indexed Journals in the Field of Intensive Care: A Bibliographic Analysis
Objective: Our study aimed to evaluate publications originating from Turkey in the field of “intensive care” in the journals with Science Citation index (SCI) and SCI-Expanded (SCI-E). Materials and Methods: Journals related to "Intensive Care" in the SCI-E database of "Thomson Reuters Web of Science" were scanned. The Institute for Scientific Information Web of Science search engine was used in advanced mode by typing “IS = ISSN number” to identify publications in the journal. By typing “IS = ISSN number and CU = Turkey”, articles related to intensive care originating from Turkey were found. Mann-Whitney U test was used to statistically evaluate the percentages and annual averages of publications in journals originating from Turkey and grouped according to different criteria. The relationship between the impact factors of the journals and the percentage and annual publication average of publications originating from Turkey was analyzed with the Pearson correlation test. A p value of less than 0.05 was considered a significant difference. Results: According to the percentage of publications in the field of intensive care, the three journals with the highest publications originating from Turkey were determined as "Burns", "Journal of Burn Care & Research", "Journal of Critical Care". While Turkey ranked 22nd between 1975 and 2021, it rose to 19th place in the last decade and the last five years. The total number of publications originating from Turkey, the average number of annual publications and the percentage of publications are significantly higher in journals published in English than in journals published in other languages (p<0.05). Conclusion: The article with the highest rate from Turkey in the field of intensive care was published in the journals "Burns", "Journal of Burn Care & Research", "Journal of Critical Care". While our country is not behind other countries in terms of the number of intensive care beds and workforce, as seen during the coronavirus disease period, it is lagging behind in the field of intensive care publication; It should be an academic driving force.
Copyright © 2024 The Author(s) https://creativecommons.org/licenses/by/4.0
Effect of Music Therapy and Sound Isolation on the Comfort of Mechanically Ventilated Patients
Objective: This study was conducted experimentally to examine the effect of music therapy and sound isolation on the comfort of mechanically ventilated patients. Materials and Methods: The study was conducted in the anesthesiology and reanimation intensive care unit of a university hospital between November 2019 and January 2020. Three different interventions were applied to n=24 patients who constituted the research sample. Each patient listened to Western Classical Music and Nihavend magam Turkish Classical Music separately for 60 minutes (min) and received an intervention of sound isolation for 60 min through a special headset. Results: The mean age of the patients participating in the study was 64.88±14.05. Of the patients, 66.7% were male, 79.2% were married, and 45.8% were illiterate. Patients’ systolic and diastolic blood pressures, pulse rate, respiratory rate, Critical-Care Pain Observation Tool score, and scores on agitation and anxiety sub-dimensions of the American Association of Critical Care Nurses Sedation Assessment scale were influenced by Western Classical Music, Nihavend maqam Turkish Classical Music, and sound isolation. No difference was found among the three different implementation interventions. Conclusion: Music therapy and sound isolation interventions administered to mechanically ventilated patients positively affected the hemodynamic parameters of the patients and reduced the severity of pain perceived by the patients and the need for sedation. In this context, the most important finding of the study was that an intervention that eliminates noise in the intensive care environment for mechanically ventilated patients increases the comfort level of the patients. Another important and critical result of this research was that music therapy also acts as an intervention without noise stimuli.
Pain Behaviors and Physiological Parameters During Painful Procedures in Surgical Intensive Care Patients
Objective: This research was conducted to determine the pain behaviors and physiological parameters of patients connected to mechanical ventilators in the postoperative surgical intensive care unit. Materials and Methods: This study was conducted descriptively and observationally with 176 patients. The introductory information form, physiological parameters follow-up form, behavioral pain scale (BPS), and Ramsey sedation scale were used to collect data. Descriptive statistics, Two-Way variance in repeated measures, Friedman analysis, post-hoc Bonferroni analysis, One-Way variance analysis, Kruskal-Wallis analysis, and Spearman correlation analysis were used. Results: The mean arterial pressure (MAP), heart rate and mean BPS scores increased (p<0.001), and oxygen saturation decreased during aspiration, wound care, and position change (p<0.001). Additionally, while a moderate, positive correlation was found between BPS and MAP and heart rate during wound care (r=0.447; p=0.001, r=0.306; p=0.033). A moderate negative correlation was found between oxygen saturation and BPS during aspiration (r=-0.389; p=0.000). Conclusion: It has been revealed that individuals connected to mechanical ventilators experience pain during wound care, position change and aspiration. Physiological parameters and behavioral symptoms resulting from pain should be analyzed together. Pain should be relieved with pharmacological and non-pharmacological nursing interventions in pain management.
Stewart’s Approach for Acid-base Disorders: Does the Strong Ion Difference and Effects Have an Impact on Intensive Care Unit Mortality?
Objective: The diagnosis and treatment of electrolyte and acid-base imbalances in intensive care unit (ICU) patients have critical importance. The value of Stewart’s approach in revealing acid-base disorders is known. There are parameters defined according to this approach. This study investigates the impact of the chloride effect (ClEffect), sodium effect (NaEffect), sodium-chloride effect (Na-ClEffect), strong ion difference (SIDnl) and Cl/Na ratio values calculated according to Stewart’s approach on ICU mortality. Materials and Methods: Two thousand patients whose Na, Cl, K, standard base excess (SBE), pH values were recorded and SIDnl, ClEffect, NaEffect, Na-ClEffect, Acute Physiology Assessment and Chronic Health Evaluation-II (APACHE-II) and Sequential Organ Failure Assessment (SOFA) scores calculated are included in this study. ClEffect, NaEffect, Na-ClEffect, SIDnl, Cl/Na ratio values were evaluated with a multivariable logistic regression model in terms of ICU mortality. Results: Abnormal ranges of SIDnl (SIDnl <30 or SIDnl ≥43) were significantly increased in non-survivors than survivors (p=0.026). ClEffect, NaEffect, Na-ClEffect, Cl/Na ratio and their percentages of abnormal ranges were similar between survivor and non-survivor patients.In the multivariate logistic regression model, the likelihood of mortality was 3.5-fold (2.9-4.3), 1.7-fold (1.4-2.1) and 1.2-fold (1.0-1.5) increased by APACHE-II ≥26, SOFA >7, and SIDnl <30 or SIDnl ≥43 (p<0.001, p<0.001, p=0.041, respectively). Conclusion: SIDnl is associated with ICU mortality, but pH, SBE, ClEffect, NaEffect, Na-ClEffect and Cl/Na ratio is not. SIDnl is one of the independent variables of Stewart’s approach and is a valuable parameter in blood gas evaluations.
Analysis of Heart Rate Variability in Patients Undergoing Mechanical Ventilation
Objective: In this study, the purpose was to determine the changes in the activity of the autonomic nervous system by analyzing the parameters of heart rate variability (HRV) among patients who underwent invasive mechanical ventilation. Materials and Methods: A total of 83 patients who had been followed up in the intensive care unit for at least 24 h, without a diagnosis of any known heart disease or arrhythmia, and aged over 18 years were included in the study. Mechanically ventilated patients were included in group M (n=41) and others in group K (n=42). The electrocardiography (ECGs) of the patients was recorded for 24 h through a Holter device, which records ambulatory ECG with 3 channels. Results: There was no significant difference between the groups regarding the HRV parameters, atrial arrhythmia numbers, heart rates, RR interval times, as well as intervals of QT and QTc. It was found that the number of ventricular arrhythmias was significantly higher in the mechanically ventilated group compared to the non-mechanically ventilated group (p=0.0083). Conclusion: In conclusion, based on the results of this study, we believe that invasive mechanical ventilation did not lead to changes in the HRV parameters of the patients who were hemodynamically stable without any cardiac disease.
Evaluation of Patients with Hematological Malignancies Admitted to the General Intensive Care Unit - Should There be Dedicated Hematological ICUs?
Objective: With new treatment modalities, the overall survival of patients with hematological malignancies (HM) has increased over the years. However, intensive care unit (ICU) mortality is still high. This study aimed to evaluate the clinical characteristics, treatment methods, and results of HM patients admitted to the ICU at a center in Turkey. Materials and Methods: Patients with HM admitted to the ICU between January 2013 and 2020 were retrospectively evaluated. A total of 172 adult patients with HM were included in the study. Results: The median (interquartile range) age of patients was 60 (47-67) years, admission Acute Physiology Assessment and Chronic Health Evaluation-II score was 30 (26-32), Sequential Organ Failure Assessment score was 10 (7-12). Results of the 172 patients, 60 (34.9%) had newly diagnosed malignancies, 16 (9.3%) were in remission, and 96 (55.8%) had relapsed/refractory disease. The ICU admission was mostly required for acute respiratory failure (62.5%) and/or shock (42.3%). Forty-seven (27.3%) patients had stem cell transplantation, and 59 (34.3%) were neutropenic. Of them, 143 (83.2%) patients were admitted to intensive care after intubation and 159 (92.4%) patients needed vasopressors during intensive care stay. Thirteen (7.5%) patients were diagnosed with fiberoptic bronchoscopy-bronchoalveolar lavage sampling only, and treatment was changed in 85% according to the results. We observed that the patients were admitted to the ICU at the 28th hour (11-55) after determining the need for ICU follow-up. Intensive care mortality was 94.3% (163). Conclusion: Early detection of critical illness and rapid admission to the ICU are important for the patients with HM. Collaborative studies determining early admission criteria to ICUs should be performed by the intensivists and hematologists to improve survival. This may be achieved by allocating special ICUs for these patients within the hematology clinics.
Evaluation of Trauma Patients Followed Up and Treated in Intensive Care Unit: The Sample of İstanbul Province Training and Research Hospital
Objective: Trauma is an important cause of functional limitation, disability, and mortality. This study investigated the clinical characteristics of trauma patients and the factors affecting mortality in intensive care unit (ICU). Materials and Methods: The data of patients who were followed up due to trauma in the ICU of University of Health Sciences Turkey, İstanbul Kanuni Sultan Süleyman Training and Research Hospital between January 2019-2020 were evaluated retrospectively. Demographic data, comorbidities, trauma etiologies, Glasgow coma score (GCS), Acute Physiology Assessment and Chronic Health Evaluation-II (APACHE-II) score, revised trauma score (RTS), lactate levels, and mortality were investigated. Results: Two hundred fifty (25.2%) patients were followed up in the ICU with a trauma diagnosis. 60.4% of the patients were male, and the median age was 58.5 (1-97). 71.6% of the patients had no systemic disease. While blunt trauma was observed in 94% of the patients, the most common type of trauma was falling, with 64.4%. ICU and mechanical ventilation (MV) stay median lengths were 4 (1-86) and 1 (0-53) days. The median ICU admission GCS was 11 (3-15), APACHE-II score was 22 (5-56), RTS of 7 (2-10) and lactate value was 1.66 (0.7-19.8) mmoL. While 85.6% of the patients were discharged, 14.4% died. Age, duration of stay in ICU and MV, lactate levels, and APACHE-II scores were significantly higher in patients with mortality. GCS and RTS scores were significantly lower (p<0.05). In multiple logistic regression analyses, RTS and lactate values were independent risk factors for mortality. Conclusion: We think that high lactate levels and low RTS help predict mortality in trauma patients in the ICU.
An Evaluation of the PRE-DELIRIC (PREdiction of DELIRium in ICu Patients) Delirium Prediction Model in Intensive Care Units in Türkiye
Objective: This methodological study was conducted in order to carry out the adaptation and validation of the “PRE-DELIRIC score” prediction of delirium model in Türkiye among patients hospitalized in the intensive care unit (ICU). Materials and Methods: The research involved 172 patients treated in the intensive care units of a training and research hospital between October 2019 and April 2020. The study data were collected using (1) a data collection form to determine the participants’ descriptive characteristics, (2) the PRE-DELIRIC score, and (3) the Confusion Assessment Method for the ICU (CAM-ICU). Receiver operating characteristic (ROC) analysis and diagnostic screening tests were applied for the purpose of determining cut-off points for the groups. The scores’ sensitivity and specificity were calculated. Significance was evaluated at the p<0.05 level. Results: A statistically significant association was determined between the cut-off point obtained for the PRE-DELIRIC score (≥7.58%) and the study groups (p=0.003). Patients with PRE-DELIRIC scores of 7.58 or higher exhibited a 7.404-fold greater risk of being CAM-ICU-positive [odds ratio: 7.404; 95% confidence interval (CI): 1.638-33.469]. The area under the ROC curve was 64.9% (95% CI: 0.538-0.760), and the standard error was 5.6% (p=0.044). Conclusion: The PRE-DELIRIC score yielded reliable results in this study. It appears significant for patients with a likelihood of developing delirium within the ICU, and its use is recommended as a functional score that is easily applied and calculated.
Is There a Relationship Between Mortality Rates and Nutritional Factors in Critical Ill Patients with COVID-19?
Objective: Our aim in this study was to examine whether critically ill patients with coronavirus disease-2019 (COVID-19) achieved the targeted calories (ATC) while being treated in the intensive care unit (ICU) and their relationship with the modified nitric score (mNUTRIC) and mortality. Materials and Methods: The patients were categorized into two cohorts based on the attainment of the intended caloric intake during their stay in the ICU: the ATC group and the not achieved target calorie (NATC) group. A comparative analysis was conducted on the mNUTRIC scores, as well as the ICU and hospital mortality rates, between these two groups. Results: The number of patients in the ATC group was 59 (63.4%) and the number of patients in the group that could NATC was 34 (36.6%). mNUTRIC scores on admission were 3 (2-4) in the ATC group and 5 (4-6) in the NATC group. In multivariate regression analysis, a mNUTRIC score of 5 and higher (p<0.01), hemodynamic instability (p=0.02) and male gender (p=0.04) were found to be significant as independent risk factors for NATC. ICU and hospital mortality was higher in the NATC group than in the ACT group (p<0.01, p<0.03 respectively). Conclusion: Inability to reach the targeted calories and high mNUTRIC score might relate to mortality in critically ill COVID-19 patients treated in the ICU.
Usefulness of APACHE-II, SOFA, ISARIC/WHO 4C Mortality Score and CO-RADS for Mortality Prediction of Critically Ill Coronavirus Disease-2019 Patients
Objective: It was aimed to report the Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score, Sequential Organ Failure Assessment (SOFA) score, Glasgow coma scale (GCS), 4C mortality score and the coronavirus disease-2019 (COVID-19) Reporting and Data System (CO-RADS) in predicting the outcome of critically ill COVID-19 patients. Materials and Methods: Patients with laboratory-confirmed COVID-19 infection or clinical and radiological confirmed COVID-19 infection who were admitted to adult intensive care unit (ICU) were included. Clinical characteristics, outcomes, APACHE-II score, SOFA score, International Severe Acute Respiratory and Emerging Infections Consortium/World Health Organization 4C mortality score and CO-RADS classification were reported at admission. Results: Two hundred seventy six patients were included in this study. The mean age was higher in non-survivor patients. The most common cause of hospitalization was respiratory failure (67%). The common co-morbidities were hypertension (51.8%), cardiac disease (43.4%) and diabetes (33.6%). Organ failure was present in 61.5% of the patients. The mean APACHE-II, SOFA, GCS and 4C mortality scores were higher in non-survivor patients. 4C mortality and SOFA scores showed higher predictive accuracy for mortality with an area under the curve 0.736 and 0.706, respectively. 4C mortality had sensitivity of 78.9% and specificity of 58.1% whereas of SOFA had a sensitivity of 78.9% and a specificity of 53.3%. Conclusion: 4C mortality and SOFA scores could be a predictors of mortality in COVID-19 patients in the ICU.