Different Types of Intraoperative Hypotension and their Association with Post-Anesthesia Care Unit Recovery

Background: The underlying causative mechanism leading to intraoperative hypotension (IOH) may vary depending on the stage of anesthesia and surgery, resulting in different types of IOH. Consequently, the incidence, severity, and postoperative complications associated with IOH types may differ. This study explores the association between IOH types and post-anesthesia care unit (PACU) recovery, with a focus on duration and complications. Methods: From May 2022 to December 2022, we included 4776 consecutive surgical patients aged ≥18 who underwent elective surgery with planned overnight stays at Acibadem Altunizade Hospital and received general anesthesia. Post-induction hypotension (pIOH) was defined as a decrease in blood pressure during the first 20 minutes after anesthesia induction, while maintenance intraoperative hypotension (mIOH) referred to a decrease in blood pressure occurring after the 20th minute following induction, with or without preceding pIOH.Results: Among the included patients, 22.13% experienced IOH, with a higher prevalence observed among females. Patients with mIOH exhibited higher rates of bleeding, transfusions, hypothermia, longer stays in the PACU, and increased oxygen requirements. The duration of anesthesia did not increase the likelihood of IOH. Multivariate logistic regression analysis revealed that ephedrine usage, hypothermia, the need for additional analgesics, nausea, and vomiting were factors associated with longer PACU duration. Older patients (≥65), patients with ASA≥2 status, those undergoing major surgery, experiencing unexpected bleeding, and exhibiting hypothermia at the end of anesthesia had a higher likelihood of requiring vasopressor support. Conclusions: Patients experiencing hypotension, particularly during the maintenance of anesthesia, are more prone to complications in the PACU and require closer monitoring and treatment. Although less common, mIOH has a more significant impact on outcomes compared to other factors affecting PACU recovery. The impact of mIOH on PACU duration should not be overlooked in favor of other factors. Registration: Clinicaltrials.gov identifier: NCT05671783

C-Reactive Protein and Hemogram Parameters for the Non-Sepsis Systemic Inflammatory Response Syndrome and Sepsis: What Do They Mean?

<div><p>Objectives</p><p>Sepsis is one of the most common reasons of increased mortality and morbidity in the intensive care unit. The changes in CRP levels and hemogram parameters and their combinations may help to distinguish sepsis from non-sepsis SIRS. The aim of this study is to investigate the CRP and hemogram parameters as an indicator of sepsis.</p><p>Methods</p><p>A total of 2777 patients admitted to the ICU of two centers between 2006–2013 were evaluated retrospectively. The patients were diagnosed as SIRS (-), non-sepsis SIRS and sepsis. The patients who were under 18 years old, re-admitted, diagnosed with hematological disease, on corticosteroid and immunosuppressive therapy, SIRS (-), culture negative, undocumented laboratory values and outcomes were excluded. 1257 patients were divided into 2 groups as non-sepsis SIRS and sepsis. The patients’ demographic data, CRP levels, hemogram parameters, length of ICU stay and mortality were recorded.</p><p>Results</p><p>1257 patients were categorized as non-sepsis SIRS (816, 64.9%) and sepsis (441, 35.1%). In the multivariate analysis, the likelihood of sepsis was increased 3.2 (2.2–4.6), 1.7 (1.2–2.4), 1.6 (1.2–2.1), 2.3 (1.4–3.8), 1.5 (1.1–2.1) times by the APACHE II≥13, SOFA score≥4, CRP≥4.0, Lym_C<0.45 and PLT_C<150 respectively (p<0.001 p = 0.007 p = 0.004 p<0.001 p = 0.027). The likelihood of sepsis was increased 18.1 (8.4–38.7) times by the combination of CRP≥4.0, lym_C<0.45 and PLT_C<150 (P<0.001).</p><p>Conclusions</p><p>While WBC_C, Neu_C, Neu%, NLCR and Eo_C are far from being the indicators to distinguish sepsis from non-sepsis SIRS, the combinations of CRP, Lym_C and PLT_C can be used to determine the likelihood of sepsis.</p></div

Comparison of survivor and non-survivor patients.

<p>Abbreviations: APACHE II, Acute Physiology And Chronic Health Evaluation; CRP, c-reactive protein; Eo_C, eosinophil count; PLT_C, platelet count; SOFA, Sequential Organ Failure Assessment.</p

Study flowchart.

<p>Abbreviations: APACHE II, Acute Physiology And Chronic Health Evaluation; SIRS, systemic inflammatory response syndrome; SOFA, Sequential Organ Failure Assessment.</p

Combinations of CRP and hemogram parameters for likelihood of sepsis.

<p>Abbreviations: CRP, c-reactive protein; Eo_C, eosinophil count; PLT_C, platelet count. ^#, p<0.001.</p

Late Presented Posttraumatic Pulmonary Arteriovenous Fistulea Occlusion With Septal Occluder Device

Posttraumatic pulmonary arteriovenous fistula is a rare complication of penetrating injury. Cases may remain asymptomatic for years prior to diagnosis. We present a case of pulmonary arteriovenous fistula related to a penetrating injury of the thorax 6 years previously that was occluded with a septal occluder device. Consistent use of CT or conventional catheter pulmonary angiography following penetrating injury to the thorax is essential to the early diagnosis of pulmonary arteriovenous fistula during the asymptomatic stage. Modern occlude devices facilitate the transcatheter approach as a viable alternative to surgery for the closure large, high pressure defects

Late presentation of posttraumatic pulmonary arteriovenous fistulea occlusion with septal occluder device

Posttraumatic pulmonary arteriovenous fistula is a rare complication of penetrating injury. Cases may remain asymptomatic for years prior to diagnosis. We present a case of pulmonary arteriovenous fistula related to a penetrating injury of the thorax 6 years previously that was occluded with a septal occluder device. Consistent use of CT or conventional catheter pulmonary angiography following penetrating injury to the thorax is essential to the early diagnosis of pulmonary arteriovenous fistula during the asymptomatic stage. Modern occlude devices facilitate the transcatheter approach as a viable alternative to surgery for the closure large, high pressure defects

Elective Tracheotomy Practices in Turkey.

Elective tracheotomy (ET) procedures in intensive care units (ICU) might be different in accordance with countries and ICUs' features. The aim of the present study was to search the epidemiology of ET procedures in Turkey.A questionnaire which consists of 43 questions was sent by e-mail to 238 ICUs which were officially recognized by The Turkish Ministry of Health. All answers were obtained between August 1, 2015 and August 31, 2015.Two hundred and three ICUs (85.3%) participated in this study. 177 (87.2%) and 169 (83.4%) of ICU's were level III and mixed ICUs respectively. Anesthesiologists were the director of 189 (93.0%) ICUs. Estimated total count of admitted, mechanically ventilated and tracheotomized patients in 2014 were 126282, 80569 (63.8%) and 8989 (7.1%) respectively. Most common indication for ET was prolonged mechanical ventilation (76.9%). The first choice for ET procedure was percutaneous in 162 (79.8%) ICUs. Griggs guide wire dilatational forceps (GWDF) technique was used as the first choice for elective percutaneous tracheotomy (EPT) by 143 (70.4%) ICUs. Most common early EPT complication was bleeding (68.0%) and late EPT complication was stenosis (35.0%). While facilitation of weaning was most important advantage (26.1%), bleeding and tracheal complications were most important disadvantages for EPT (29.1%).Most common indications for ET are prolonged MV and coma in Turkish ICUs. EPT is the preferred procedure for ET and GWDF is the most common technique. Bronchoscopy and USG are rarely used as a guide

Foreign Material in the Gastrointestinal Tract: Cocaine Packets

Smuggling drugs by swallowing or inserting into a body cavity is not only a serious and growing international crime, but can also lead to lethal medical complications. The most common cause of death in ‘body packers', people transporting drugs by ingesting a packet into the gastrointestinal tract, is acute drug toxicity from a ruptured packet. However, more than 30 years after the initial report of body packing, there is still no definitive treatment protocol for the management of this patient group. The treatment strategy is determined according to the particular condition of the patient and the clinical experience of the treatment center. Surgical intervention is also less common now, due to both the use of improved packaging materials among smugglers and a shift towards a more conservative medical approach. Herein, we report a case of toxicity from ingested packets of cocaine that leaked and, despite surgery, resulted in exitus of the patient