The influence of N-acetyl-L-cystein infusion on cytokine levels and gastric intramucosal pH during severe sepsis

INTRODUCTION: The purpose of the present study was to evaluate the effects of continuously infused N-acetyl-L-cystein (NAC) on serum cytokine levels and gastric intramucosal pH in humans suffering from severe sepsis. METHODS: Fifty-three patients were included in the study. In the NAC group (n = 27), after an initial intravenous bolus of NAC (150 mg/kg over 5 min), a continuous intravenous infusion of 12.5 mg/kg per hour was given for 6 hours. Patients in the control group (n = 26) were administered dextrose (5% solution) at the same dosage. We recorded the following: haemodynamic parameters, nasopharyngeal temperature, arterial blood gas changes, plasma cytokine levels, biochemical parameters, intramucosal pH, length of stay in the intensive care unit, duration of of mechanical ventilation and mortality. All measurements were taken at baseline (15 min before the start of the study) and were repeated immediately after the bolus infusion, and at 24 and 48 hours after initiation of the continuous NAC infusion. RESULTS: No differences were found between groups in levels of the major cytokines, duration of ventilation and intensive care unit stay, gastric intramucosal pH and arterial oxygen tension/inspired fractional oxygen ratio (P > 0.05). CONCLUSION: We found that NAC infusion at the doses given did not affect cytokine levels, outcomes, or gastric intramucosal pH in patients with severe sepsis. Because of the limited number of patients included in the study and the short period of observation, our findings need confirmation in larger clinical trials of NAC infused in a dose-titrated manner. However, our results do not support the use of NAC in patients with severe sepsis

Alfa-tokoferol’ün ağır sepsiste sitokin düzeyleri ve gastrik intramukozal ph üzerine etkisi

Amaç: Ağır sepsis gelişen olgularda alfa-tokoferol’ün sitokin düzeylerine ve gastrik intramukozal pH üzerine etkisi araştırıldı. Hastalar ve Yöntemler: Çalışmada ağır sepisli 40 hasta rastgele iki gruba ayrıldı. Grup I’deki (n=20) olgulara üç gün 600 mg alfa tokoferol intramusküler, grup II’deki (n=20) olgulara aynı volümde serum fizyolojik uygulandı. Her iki grupta hemodinamik parametreler, glutatyon, katalaz düzeyleri, nazofarengeal vücut ısısı, arteryel kan gazı değişiklikleri, plazma sitokin düzeyleri (interlökin 1? ve 6), biyokimyasal parametreler ve intramukozal pH, yoğun bakım ünitesinde ve mekanik ventilatöre bağlı kalış süresi ve mortalite oranı kaydedildi. Bütün ölçümler başlangıç (çalışmaya başlamadan 15 dakika önce) ve alfa-tokoferol verildikten 24, 48, 72 ve 96 saat sonra yapıldı. Bulgular: İki grup arasında ölçülen parametrelerin hiçbirinde anlamlı fark saptanmadı (p>0.05). Sonuç: Ağır sepsisli olgularda üç gün süreyle verilen 600 mg alfa-tokoferol’ün hemodinamik ve biyokimyasal parametreler, gastrik intramukozal pH veya sitokin düzeylerine veya hasta prognozu üzerine herhangi bir etkisini saptamadık.Objectives: We evaluated the effects of alpha-tocopherol on serum cytokine levels and gastric intramucosal pH in patients with severe sepsis. Patients ve Methods: Forty patients with severe sepsis were randomized to two groups. Group I (n=20) received 600 mg alpha-tocopherol intramuscularly, and group II (control group, n=20) received the same dose physiological saline solution for three days. The following data were recorded for both groups: hemodynamic parameters, glutathione, catalase levels, nasopharyngeal body temperature, arterial blood gas changes, plasma cytokine levels (interleukin 1≤ and 6), biochemical parameters and intramucosal pH, length of stay in the intensive care unit, duration of mechanical ventilation support, and mortality. All measurements were made at baseline (15 min before alpha-tocopherol administration) and 24, 48, 72, and 96 hours after alpha-tocopherol administration. Results: None of the parameters evaluated differed significantly between the two groups (p>0.05). Conclusion: We found that intramuscular alpha-tocopherol 600 mg did not affect hemodynamic and biochemical parameters, gastric intramucosal pH, cytokine levels, or prognosis in patients with severe sepsis

Duodenal necrosis during nasogastric tube feeding: A case report

Akut solunum sıkıntısı sendromu tanısıyla yoğun bakım ünitesinde yatan 45 yaşlarndaki erkek hastada, nazogastrik tüp ile beslenme esnasında geli şen duodenal nekroz olgusu literatür eşliğinde sunuldu. Olaysız geçen birkaç günden sonra, abdominal distansiyon gelişti, laparotomi yapılıp, duodenal nekroz olduğu saptandı. Bağırsaklarda tı kanıklık veya mezenterik damar hasarı yoktu. Hastaya sedasyon sağlamak için verilen yüksek dozda fentanil, midazolam ve inotropik ajan olan dopamin infüzyonu, mukozal perfüzyonun hasarlanması ile gelişen nekrozda büyük katkı faktörü olarak suçlanabilir.A case of duodenal necrosis during nasogastric tube feeding in a 45-year-old male patient hospitalized in intensive care unit with a diagnosis of acute respiratory distress syndrome is reported with a review of literature. Abdominal distension developed after several days of uneventful nasogastric tube feeding. At laparotomy patchy necrosis of the duedonum was found without signs of bowel obstruction or impaired mesenteric perfusion. In this case, the large doses of fentanyl, midazolam and dopamine given for sedation, were suspected to be a major contributing factor to the development of the necrosis by impairing mucosal perfusion

Atrakuryum, rokuronyum, mivakuryum, sisatrakuryum, pankuronyum ve vekuronyumda Escherichia coli üremesi

Amaç: Biz çalışmamızda atrakuryum, rokuronyum, mivakuryum, sisatrakuryum, pankuronyum ve vekuronyumun Escherichia coli üremesi üzerine olan etkinliğini araştırdık. Hastalar ve Yöntemler: Patojen bakteri, atrakuryum, rokuronyum, mivakuryum, sisatrakuryum, pankuronyum ve vekuronyum ile 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, ve 24 saat oda sıcaklığında temas ettirildi. Bulgular: Escherichia coli ortalama koloni sayısı rokuronyumda istatiksel anlamlı olarak atrakuryum, mivakuryum, sisatrakuryum, pankuronyum ve vekuronyumdan daha düşük saptandı (sırasıyla p=0.002, 0.000, 0.000, 0.001, ve 0.002). Atrakuryum, mivakuryum, sisatrakuryum, pankuronyum ve vekuronyumda ortalama koloni sayısı açısından anlamlı fark saptanmadı (p<0.05). Sonuç: Rokuronyum, diğer nöromusküler kas gevşetici ajanlardan daha kuvvetli antimikrobiyal etki gösterdi.Objectives: We studied in vivo growth of Escherichia coli in atracurium, rocuronium, mivacurium, cisatracurium, pancuronium, and vecuronium. Patients and Methods: The pathogen was exposed to atracurium, rocuronium, mivacurium, cisatracurium, pancuronium and vecuronium for 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24 h at room temperature, respectively. Results: The mean colony counts of Escherichia coli after exposure to rocuronium was significantly lower than the counts after exposure to atracurium, mivacurium, cisatracurium, pancuronium and vecuronium (p=0.002, 0.000, 0.000, 0.001, and 0.002, respectively). No significant difference was found with respect to the mean colony counts with atracurium, mivacurium, cisatracurium, pancuronium and vecuronium (p&lt;0.05). Conclusion: Rocuronium had more powerful antimicrobial effects than the other neuromuscular agents

Determining the Efficiency of Different Preoperative Difficult Intubation Tests on Patients Undergoing Caesarean Section

Background: Pregnancy-induced anatomical and physiological changes in the airway make airway management difficult in obstetric patients; thus, preoperative evaluation of the airway is important for obstetric patients. Aims: To determine the effectiveness of the modified Mallampati test; the interincisor, sternomental and thyromental distances and the upper limb bite test. The second aim was to assess the effectiveness of the combination of the upper limb bite test with the other tests in obstetric patients. Study Design: Cross-sectional study. Methods: Pregnant women (n=250) scheduled for caesarean section were analysed. The patients' ages, heights and weights were collected. Preoperative airway evaluation was done by using a modified version of the Mallampati test. The interincisor, sternomental and thyromental distances were measured, and the upper limb bite test was performed. The laryngoscopy difficulty was evaluated by using Cormack-Lehane classification. Results: No statistically significant differences were found between groups in age, height or weight (p&gt;0.05). The modified Mallampati test and interincisor, sternomental and thyromental distances revealed a lower number of easy intubations than that determined by the Cormack-Lehane classification and a higher number of difficult intubations than the actual number of cases (p&lt;0.05). The sensitivity and specificity of the modified Mallampati test, the upper limb bite test, the interincisor distance test and the sternomental and thyromental distance tests were found to be 73.08, 57.69, 84.62, 80.77 and 88.46 and 90.62, 99.11, 83.04, 84.37 and 87.05, respectively. When the combinations were examined, the sensitivity and specificity of the combination of the upper limb bite test with the modified Mallampati test were found to be 57.69 and 100, respectively. When the upper limb bite test was combined with the interincisor distance, the sensitivity and specificity were 46.15 and 100, respectively. We found a sensitivity and specificity of 93.75 and 95.30, respectively, for the combination of the upper limb bite test with the thyromental distance test. The sensitivity and specificity of the combination of the upper limb bite test with the modified Mallampati test and interincisor distance test were found to be 46.15 and 100, respectively. For combination of all the tests, the sensitivity and specificity was 42.31 and 100, respectively. Conclusion: When all combinations are evaluated in the decision of difficult intubation, the combination of the upper limb bite test and thyromental distance test is superior to the use of other methods alone to predict difficult intubation in pregnant women

The Effects of Different Insufflation Pressures on Liver Functions Assessed with LiMON on Patients Undergoing Laparoscopic Cholecystectomy

Purpose. Laparoscopic cholecystectomy has been accepted as an alternative to laparotomy, but there is still controversy regarding the effects of pneumoperitoneum on splanchnic and hepatic perfusion. We assessed the effects of different insufflation pressures on liver functions by using indocyanine green elimination tests (ICG-PDR). Methods. We analyzed 43 patients who were scheduled for laparoscopic cholecystectomy. The patients were randomly allocated to two groups. In Group I, the operation was performed using 10 mmHg pressure pneumoperitoneum. In Group II, 14 mmHg pressure pneumoperitoneum was used. The ICG-PDR measurements were made after induction (ICG-PDR 1) and after the end of the operation (ICG-PDR 2). Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin levels were all recorded preoperatively, 1 hour, and postoperative 24 hours after surgery. Results. The ICG-PDR 1 values for Groups I and II were as follows: 26.78 ± 4.2% per min versus 26.01 ± 2.4% per min (P > 0.05). ICG-PDR 2 values were found to be 25.63 ± 2.1% per min in Group I versus 19.06 ± 2.2% per min in Group II (P < 0.05). There was a statistically significant decrease between baseline and postoperative ICG-PDR values in Group II compared to Group I (P < 0.05). Statistically, there was an increase between baseline and postoperative 1st-hour serum AST and ALT level in Group II (P < 0.05) compared to Group I. No statistical differences were detected on postoperative 24st-hour serum AST and ALT levels and all the time bilirubin between groups (P > 0.05). Conclusion. In conclusion, the results show that 14 mmHg pressure pneumoperitoneum decreased the blood flow to the liver and increased postoperative 1st-hour serum AST and ALT levels. We think that 10 mmHg pressure pneumoperitoneum is superior to 14 mmHg pressure pneumoperitoneum in laparoscopic cholecystectomy

Fat embolism associated with anesthesia induction with propofol-lidocaine combination: A case report

Yağ embolisi sendromu travmatik, cerrahi ve travma dışı olayları takiben tanımlanmıştır. Uzun kemik kırıkları bu sendromun en olası nedenidir. Yağ embolisine bağlı klinik tablo sıklıkla belirgin olmayabilir. Belirtiler değişiklik gösterdiğinden ve rutin laboratuvar ve radyografik tanı yöntemi olmadığından tanı konması zordur. Propofol, anestezi indüksiyonu ve idamesinde yaygın olarak kullanılmaktadır. Propofole lidokain eklenmesiyle, yağ damlacıkları birleşerek ayrı tabaka meydana getirebilmektedir. Propofol-lidokain karışımının yağ embolisi oluşturma riski, kombinasyonun hazırlanması ve verilmesi arasındaki süreye ve lidokain dozuna bağlıdır. Bu yazıda, trafik kazası sonrası alt ekstremite kırığı nedeniyle uygulanan genel anestezi indüksiyonunda yağ embolisi gelişen bir olgu sunuldu. Yağ embolisinin propofol-lidokain karışımına bağlı olduğu düşünüldü. Yağ embolisi tanısı, klinik değişiklikler, radyolojik ve laboratuvar bulgularının yanı sıra gelişen arteryel hipoksemiye neden olabilecek başka bozuklukların olmaması ile kondu.Fat embolism syndrome has been described following traumatic, surgical, and atraumatic conditions. Long-bone fractures are probably the most common cause of this syndrome. Fat embolic events are often clinically insignificant and difficult to recognize since clinical manifestations vary and there is no routine laboratory or radiographic means of diagnosis. Propofol is widely used for the induction and maintenance of anesthesia. Addition of lidocaine to propofol may result in a coalescence of oil droplets, forming a separate layer. The risk of propofol and lidocaine combination to cause fat embolism depends on the dose of lidocaine and the duration between its preparation and administration. We presented a patient who developed fat embolism following anesthesia induction during surgery for a lower extremity fracture due to a traffic accident. The occurrence of fat embolism was attributed to propofol-lidocaine use. The diagnosis of fat embolism was based on clinical manifestations, radiographic and laboratory findings, and elimination of other causes associated with arterial hypoxemia

Comparıng pulse pressure varıatıon and pleth varıabılıty ındex in the semı-recumbent and trendelenburg posıtıon ın crıtıcally ıll septıc patıents

Introduction. Dynamic tests for predicting fluid responsiveness have generated increased interest in recent years. One of these tests, pulse pressure variation (PPV), is a parameter calculated from respiratory variations of pulse pressure. Another test, pleth variability index (PVI), is based on respiratory variations of the perfusion index and can be measured non-invasively by pulse oximeter. Previous studies have shown that both tests are valuable in determining fluid responsiveness. Methods. In this observational prospective study, our aim was to compare the PVI and PPV in order to identify a convenient tool for determining fluid responsiveness. Our study was performed in a surgical and reanimation intensive care unit. We enrolled one hundred mechanically ventilated adult patients diagnosed with sepsis. Exclusion criteria included brain death, spontaneous breathing, cardiac arrhythmia, and impaired peripheral circulation. We measured the PPV by arterial monitorization and the PVI by using Masimo Radical 7 in the 45° semi-recumbent position (SP) and then 15° Trendelenbug position (TP). We performed correlation and ROC analysis using a >13% fluid responsiveness cut-off value for the PPV and >14% for the PVI. Results. Between the SP and the TP, we did not observe significant decreases in PPV (from 14.17 ± 10.57 to 12.66 ± 9.64; p > 0.05), while we did observe significant decreases in PVI (from 21.91 ± 13.99 to 20.46 ± 14.12; p < 0.05). The PPV fluid responsiveness cut-off value in the SP and TP was 20% (78.95% sensitivity, 77.05% specificity) and 18% (76.67% sensitivity, 72.46% specificity), respectively. The PVI fluid responsiveness cut-off value in the SP and TP was 20% (80.49% sensitivity, 81.03% specificity) and 16% (81.25% sensitivity, 62.69% specificity), respectively. The area under the ROC of the PPV and PVI was 0.843 and 0.858 in the SP, respectively, and 0.760 and 0.747 in the TP, respectively. The PPV and PVI were correlated in the SP (r = 0.578; p = 0.001) and the TP (r = 0.517; p = 0.001). Conclusions. Our results showed that the PPV and PVI were correlated independent of position change in sepsis patients. Both tests appear to be equivalently reliable. However, the ability of the PPV and PVI to predict fluid responsiveness decreased in the TP in our study

The effects of total intravenous anesthesia and inhalational anesthesia on intra-abdominal pressure in the supine prone positions

Amaç: Sırtüstü ve yüzüstü pozisyonları verilerek ameliyat edilen olgularda, total intravenöz anestezi ve inhalasyonda sevofluran anestezisinin intraabdominal basınç, kardiyovasküler ve solunum sistemlerine etkileri karşılaştırıldı. Çalışma Planı: Çalışmaya, lomber diskektomi ameliyatı geçirecek ASA I-II 30 olgu (17 erkek, 13 kadın; ort. yaş 50; dağılım 35-70) total intravenöz anestezi (grup I, n=15) ve sevofluran anestezisi (grup II, n=15) uygulanmak üzere rastgele iki gruba ayrıldı. Grup I’de, intravenöz olarak uygulanan alfentanil ve propofol ile sağlanan indüksiyondan sonra entübasyon atrakuryum ile gerçekleştirildi. Anestezinin idamesinde ise alfentanil ve 10 dakikalık sürelerle azalan dozlarda propofol infüzyon şeklinde kullanıldı. Grup II’de, intravenöz propofol ile sağlanan indüksiyondan sonra atrakuryum ile entübasyon gerçekleştirildi. Anestezi sürekliliği sevofluran ile sağlandı. Olguların sırtüstü pozisyonda anestezi indüksiyonundan önce ve hemen sonra; yüzüstü pozisyonuna çevrildikten hemen sonra, ameliyat boyunca her 30 dakikada bir ve sırtüstü pozisyonda ekstübasyondan hemen sonra intraabdominal basınç, arter basıncı, kalp atım hızı, periferik oksijen satürasyonu, endtidal CO2 basıncı ölçülerek kaydedildi. Bulgular: İki grup arasında bütün ölçüm zamanlarında, intraabdominal basınç, hemodinamik ve solunum parametre değerleri arasında anlamlı farklılık bulunmadı. Sonuç: Her iki pozisyonda uygulanan total intravenöz anestezi ve sevofluran anestezisinin, intraabdominal basınç ile hemodinamik ve solunum parametrelerinde değişiklik oluşturmadığı belirlendi.Objectives: We compared the effects of total intravenous anesthesia and inhalational anesthesia with sevoflurane on intra-abdominal pressure and cardiovascular and respiratory systems in patients undergoing surgery in the supine and prone positions. Study Design: Thirty ASA I-II patients (17 males, 13 females; mean age 50 years; range 35 to 70 years) undergoing elective lumbar discectomy were randomly assigned to total intravenous anesthesia (group I, n=15) and inhalational anesthesia with sevoflurane (group II, n=15). In group I, after anesthesia induction with intravenous alfentanil and propofol, entubation was performed with atracurium. Anesthesia was maintained with alfentanil and decreasing doses of propofol. In group II, induction was obtained with intravenous propofol, entubation with atracurium, and maintenance with sevoflurane. Intra-abdominal pressure, arterial pressures, heart rate, peripheral oxygen saturation, and endtidal CO2 were monitored and recorded in the supine position before and after anesthesia induction, immediately after turning to the prone position, every 30 minutes throughout the operation, and immediately after extubation in the supine position. Results: At all times of monitoring, no significant differences were found between the two groups with respect to intraabdominal pressure, hemodynamic and respiratory parameters. Conclusion: Total intravenous anesthesia and sevoflurane anesthesia do not appear to affect intra-abdominal pressure, hemodynamic and respiratory parameters in both positions