Koroner arter bypass greftleme cerrahisi sırasında deksmedetomidin kullanımının serebral etkileri

Kardiyopulmoner bypass’ın (KPB) olumsuz serebral etkilerine karşı tam koruma sağlayacak bir farmakolojik ajan konusunda henüz bir fikir birliği sağlanamadığından bu konudaki arayışlar devam etmektedir. Çalışmamızın amacı hemodinamik stabilite sağlamadaki üstünlüğü bilinen ve hayvan çalışmalarında da nöroprotektif özelliği olduğu gösterilen deksmedetomidinin koroner arter bypass greftleme (KABG) cerrahisi sırasında ortaya çıkan serebral iskemik hasara karşı koruyucu etkisi olup olmadığını belirlemektir. Etik Kurulu onayı ve hastaların izinleri alındıktan sonra KABG yapılacak 50-70 yaşları arası 24 hasta çalışmaya alındı. Hastalar randomize olarak deksmedetomidin alan (Grup D, n = 12) ve almayanlar (Grup K, n = 12) şeklinde iki gruba ayrıldı. Standart anestezi indüksiyonu sonrası tüm hastalara juguler bulb kateteri takılıp bazal kan örnekleri alındı. Grup D’ye 10 dk içinde 1 μg/kg bolus ve ardından 0.7 μg/kg/sa dozunda deksmedetomidin infüzyonu verildi. Hastalardan indüksiyon sonrası, KPB’nin 10.dakikasında, kros-klemp kalkışından 1 dk. sonra, KPB çıkışından 1 dk. sonra, ameliyat sonunda ve postoperatif 24. saatte arteriyel ve juguler venöz kan örnekleri alınarak kan gazı analizleri ile S-100B proteini, nöron spesifik enolaz (NSE) ve laktat değerlerinin ölçümleri yapıldı. Elde edilen değerler gruplar arasında Mann-Whitney U testi ile grup içinde Wilcoxon testi ile karşılaştırıldı. Grup D ve Grup K arasında arteriyel ve juguler venöz pH, PO2, PCO2 değerleri ve O2 saturasyonları açısından herhangi bir fark bulunmadı. S-100B, NSE ve arteriyel-juguler venöz laktat farkı değerleri açısından da iki grup bulguları benzerdi. Postoperatif dönemde hiç bir hastada klinik olarak nörolojik bir komplikasyon izlenmedi. Sonuç olarak, KPB sırasında ve sonrasında gerek S-100B ve NSE gerekse laktat farkları açısından literatürle uyumlu değişiklikler izlediğimiz hastalarımızda deksmedetomidin grubunda kontrol grubundan farklı sonuçlar olmaması, deksmedetomidinin nöroprotektif etkisinin bulunmadığını düşündürmektedir. Daha yüksek ilaç dozları kullanılarak yapılacak çalışmalarla farklı sonuçlar elde edilebilir

Organisation, staffing and resources of critical care units in Kenya

Objective: To describe the organisation, staffing patterns and resources available in critical care units in Kenya. The secondary objective was to explore variations between units in the public and private sectors. Materials and methods: An online cross-sectional survey was used to collect data on organisational characteristics (model of care, type of unit, quality- related activities, use of electronic medical records and participation in the national ICU registry), staffing and available resources for monitoring, ventilation and general critical care. Results: The survey included 60 of 75 identified units (80% response rate), with 43% (n = 23) located in government facilities. A total of 598 critical care beds were reported with a median of 6 beds (interquartile range [IQR] 5–11) per unit, with 26% beds (n = 157) being non functional. The proportion of ICU beds to total hospital beds was 3.8% (IQR 1.9–10.4). Most of the units (80%, n = 48) were mixed/general units with an open model of care (60%, n = 36). Consultants-in-charge were mainly anesthesiologists (69%, n = 37). The nurse-to-bed ratio was predominantly 1:2 with half of the nurses formally trained in critical care. Most units (83%, n = 47) had a dedicated ventilator for each bed, however 63% (n = 39) lacked high flow nasal therapy. While basic multiparametric monitoring was ubiquitous, invasive blood pressure measurement capacity was low (3% of beds, IQR 0–81%), and capnography moderate (31% of beds, IQR 0–77%). Blood gas analysers were widely available (93%, n = 56), with 80% reported as functional. Differences between the public and private sector were narrow. Conclusion: This study shows an established critical care network in Kenya, in terms of staffing density, availability of basic monitoring and ventilation resources. The public and private sector are equally represented albeit with modest differences. Potential areas for improvement include training, use of invasive blood pressure and functionality of blood gas analysers

Sex difference and intra-operative tidal volume: Insights from the LAS VEGAS study

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (VT). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients.OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference.DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries.MAIN OUTCOME MEASURES: Women and men were compared with respect to use of LTVV, defined as VT of 8 ml kg-1 or less predicted bodyweight (PBW). A VT was deemed 'default' if the set VT was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation.RESULTS: This analysis includes 9864 patients, of whom 5425 (55%) were women. A default VT was often set, both in women and men; mode VT was 500 ml. Median [IQR] VT was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg-1 PBW, P < 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P < 0.001]. In the mediation analysis, patients' height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default VT.CONCLUSION: In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher VT than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV.TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, NCT01601223

Early mobilisation in critically ill COVID-19 patients: a subanalysis of the ESICM-initiated UNITE-COVID observational study

Background Early mobilisation (EM) is an intervention that may improve the outcome of critically ill patients. There is limited data on EM in COVID-19 patients and its use during the first pandemic wave. Methods This is a pre-planned subanalysis of the ESICM UNITE-COVID, an international multicenter observational study involving critically ill COVID-19 patients in the ICU between February 15th and May 15th, 2020. We analysed variables associated with the initiation of EM (within 72 h of ICU admission) and explored the impact of EM on mortality, ICU and hospital length of stay, as well as discharge location. Statistical analyses were done using (generalised) linear mixed-effect models and ANOVAs. Results Mobilisation data from 4190 patients from 280 ICUs in 45 countries were analysed. 1114 (26.6%) of these patients received mobilisation within 72 h after ICU admission; 3076 (73.4%) did not. In our analysis of factors associated with EM, mechanical ventilation at admission (OR 0.29; 95% CI 0.25, 0.35; p = 0.001), higher age (OR 0.99; 95% CI 0.98, 1.00; p ≤ 0.001), pre-existing asthma (OR 0.84; 95% CI 0.73, 0.98; p = 0.028), and pre-existing kidney disease (OR 0.84; 95% CI 0.71, 0.99; p = 0.036) were negatively associated with the initiation of EM. EM was associated with a higher chance of being discharged home (OR 1.31; 95% CI 1.08, 1.58; p = 0.007) but was not associated with length of stay in ICU (adj. difference 0.91 days; 95% CI − 0.47, 1.37, p = 0.34) and hospital (adj. difference 1.4 days; 95% CI − 0.62, 2.35, p = 0.24) or mortality (OR 0.88; 95% CI 0.7, 1.09, p = 0.24) when adjusted for covariates. Conclusions Our findings demonstrate that a quarter of COVID-19 patients received EM. There was no association found between EM in COVID-19 patients' ICU and hospital length of stay or mortality. However, EM in COVID-19 patients was associated with increased odds of being discharged home rather than to a care facility. Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021)

Respiratory System Mechanics during Low Versus High Positive End-Expiratory Pressure in Open Abdominal Surgery: A Substudy of PROVHILO Randomized Controlled Trial

BACKGROUND: In the 2014 PROtective Ventilation using HIgh versus LOw positive end-expiratory pressure (PROVHILO) trial, intraoperative low tidal volume ventilation with high positive end-expiratory pressure (PEEP = 12 cm H2O) and lung recruitment maneuvers did not decrease postoperative pulmonary complications when compared to low PEEP (0-2 cm H2O) approach without recruitment breaths. However, effects of intraoperative PEEP on lung compliance remain poorly understood. We hypothesized that higher PEEP leads to a dominance of intratidal overdistension, whereas lower PEEP results in intratidal recruitment/derecruitment (R/D). To test our hypothesis, we used the volume-dependent elastance index %E2, a respiratory parameter that allows for noninvasive and radiation-free assessment of dominant overdistension and intratidal R/D. We compared the incidence of intratidal R/D, linear expansion, and overdistension by means of %E2 in a subset of the PROVHILO cohort. METHODS: In 36 patients from 2 participating centers of the PROVHILO trial, we calculated respiratory system elastance (E), resistance (R), and %E2, a surrogate parameter for intratidal overdistension (%E2 > 30%) and R/D (%E2 < 0%). To test the main hypothesis, we compared the incidence of intratidal overdistension (primary end point) and R/D in higher and lower PEEP groups, as measured by %E2. RESULTS: E was increased in the lower compared to higher PEEP group (18.6 [16.22] vs 13.4 [11.0.17.0] cm H2O\ub7L-1; P <.01). %E2 was reduced in the lower PEEP group compared to higher PEEP (-15.4 [-28.0.6.5] vs 6.2 [-0.8.14.0] %; P <.05). Intratidal R/D was increased in the lower PEEP group (61% vs 22%; P =.037). The incidence of intratidal overdistension did not differ significantly between groups (6%). CONCLUSIONS: During mechanical ventilation with protective tidal volumes in patients undergoing open abdominal surgery, lung recruitment followed by PEEP of 12 cm H2O decreased the incidence of intratidal R/D and did not worsen overdistension, when compared to PEEP 642 cm H2O

Kinetics of plasma biomarkers of inflammation and lung injury in surgical patients with or without postoperative pulmonary complications

BACKGROUND Postoperative pulmonary complications (PPCs) are common after major abdominal surgery. The kinetics of plasma biomarkers could improve identification of patients developing PPCs, but the kinetics may depend on intraoperative ventilator settings. OBJECTIVE To test whether the kinetics of plasma biomarkers are capable of identifying patients who will develop PPCs, and whether the kinetics depend on the intraoperative level of positive end-expiratory pressure (PEEP). DESIGN A preplanned substudy of a randomised controlled trial. SETTING Operation room of five centres. PATIENTS Two hundred and forty-two adult patients scheduled for abdominal surgery at risk of developing PPCs. INTERVENTIONS High (12cmH 2 O) versus low ( 642cmH 2 O) levels of PEEP. MAIN OUTCOME MEASURES Individual PPCs were combined as a composite endpoint. Plasma samples were collected before surgery, directly after surgery and on the fifth postoperative day. The levels of the following were measured: tumour necrosis factor (TNF)-\u3b1, interleukin (IL)-6 and IL-8, the soluble form of the Receptor for Advanced Glycation End-products (sRAGE), Surfactant Protein (SP)-D, Clara Cell protein (CC)-16 and Krebs von den Lungen 6 (KL6). RESULTS Blood sampling was complete in 242 patients: 120 patients in the high PEEP group and 122 patients in the low PEEP group. Increases in plasma levels of TNF- IL-6, IL-8 and CC-16, and a decrease in plasma levels of SP-D were greater in patients who developed PPCs; however, the area under the receiver operating characteristic curve was low for all biomarkers. CC-16 was the only biomarker whose level increased more in patients who had received high levels of PEEP. CONCLUSION In patients undergoing abdominal surgery and at risk of developing PPCs, plasma levels of biomarkers for inflammation or lung injury showed distinct kinetics with development of PPCs, but none of the biomarkers showed sufficient prognostic value. The use of high levels of PEEP was associated with increased levels of CC-16, suggesting lung overdistension. TRIAL REGISTRATION The PROVHILO trial, including this substudy, was registered at clinicaltrials.gov (NCT01441791)

Association between pre-operative biological phenotypes and postoperative pulmonary complications: An unbiased cluster analysis

BACKGROUND: Biological phenotypes have been identified within several heterogeneous pulmonary diseases, with potential therapeutic consequences. OBJECTIVE: To assess whether distinct biological phenotypes exist within surgical patients, and whether development of postoperative pulmonary complications (PPCs) and subsequent dependence of intra-operative positive end-expiratory pressure (PEEP) differ between such phenotypes. SETTING: Operating rooms of six hospitals in Europe and USA. DESIGN: Secondary analysis of the 'PROtective Ventilation with HIgh or LOw PEEP' trial. PATIENTS: Adult patients scheduled for abdominal surgery who are at risk of PPCs. INTERVENTIONS: Measurement of pre-operative concentrations of seven plasma biomarkers associated with inflammation and lung injury. MAIN OUTCOME MEASURES: We applied unbiased cluster analysis to identify biological phenotypes. We then compared the proportion of patients developing PPCs within each phenotype, and associations between intra-operative PEEP levels and development of PPCs among phenotypes. RESULTS: In total, 242 patients were included. Unbiased cluster analysis clustered the patients within two biological phenotypes. Patients with phenotype 1 had lower plasma concentrations of TNF-\u3b1 (3.8 [2.4 to 5.9] vs. 10.2 [8.0 to 12.1]\u200apg\u200aml; P\u200a<\u200a0.001), IL-6 (2.3 [1.5 to 4.0] vs. 4.0 [2.9 to 6.5]\u200apg\u200aml; P\u200a<\u200a0.001) and IL-8 (4.7 [3.1 to 8.1] vs. 8.1 [6.0 to 13.9]\u200apg\u200aml; P\u200a<\u200a0.001). Phenotype 2 patients had the highest incidence of PPC (69.8 vs. 34.2% in type 1; P\u200a<\u200a0.001). There was no interaction between phenotype and PEEP level for the development of PPCs (43.2% in high PEEP vs. 25.6% in low PEEP in phenotype 1, and 73.6% in high PEEP and 65.7% in low PEEP in phenotype 2; P for interaction\u200a=\u200a0.503). CONCLUSION: Patients at risk of PPCs and undergoing open abdominal surgery can be clustered based on pre-operative plasma biomarker concentrations. The two identified phenotypes have different incidences of PPCs. Biologic phenotyping could be useful in future randomised controlled trials of intra-operative ventilation. TRIAL REGISTRATION: The PROtective Ventilation with HIgh or LOw PEEP trial, including the substudy from which data were used for the present analysis, was registered at ClinicalTrials.gov (NCT01441791)

Co-infection and ICU-acquired infection in COIVD-19 ICU patients: a secondary analysis of the UNITE-COVID data set

Background: The COVID-19 pandemic presented major challenges for critical care facilities worldwide. Infections which develop alongside or subsequent to viral pneumonitis are a challenge under sporadic and pandemic conditions; however, data have suggested that patterns of these differ between COVID-19 and other viral pneumonitides. This secondary analysis aimed to explore patterns of co-infection and intensive care unit-acquired infections (ICU-AI) and the relationship to use of corticosteroids in a large, international cohort of critically ill COVID-19 patients.Methods: This is a multicenter, international, observational study, including adult patients with PCR-confirmed COVID-19 diagnosis admitted to ICUs at the peak of wave one of COVID-19 (February 15th to May 15th, 2020). Data collected included investigator-assessed co-infection at ICU admission, infection acquired in ICU, infection with multi-drug resistant organisms (MDRO) and antibiotic use. Frequencies were compared by Pearson's Chi-squared and continuous variables by Mann-Whitney U test. Propensity score matching for variables associated with ICU-acquired infection was undertaken using R library MatchIT using the "full" matching method.Results: Data were available from 4994 patients. Bacterial co-infection at admission was detected in 716 patients (14%), whilst 85% of patients received antibiotics at that stage. ICU-AI developed in 2715 (54%). The most common ICU-AI was bacterial pneumonia (44% of infections), whilst 9% of patients developed fungal pneumonia; 25% of infections involved MDRO. Patients developing infections in ICU had greater antimicrobial exposure than those without such infections. Incident density (ICU-AI per 1000 ICU days) was in considerable excess of reports from pre-pandemic surveillance. Corticosteroid use was heterogenous between ICUs. In univariate analysis, 58% of patients receiving corticosteroids and 43% of those not receiving steroids developed ICU-AI. Adjusting for potential confounders in the propensity-matched cohort, 71% of patients receiving corticosteroids developed ICU-AI vs 52% of those not receiving corticosteroids. Duration of corticosteroid therapy was also associated with development of ICU-AI and infection with an MDRO.Conclusions: In patients with severe COVID-19 in the first wave, co-infection at admission to ICU was relatively rare but antibiotic use was in substantial excess to that indication. ICU-AI were common and were significantly associated with use of corticosteroids