Yoğun Bakım Hastalarında Akut Böbrek Hasarı ve Mortalite İlişkisinin Belirlenmesinde RIFLE, AKIN ve KDIGO Kriterlerinin Yeri

Amaç: Akut böbrek hasarının (ABH) daha kesin biçimde tanımlanması ve takip sürecinin daha iyi yönetilmesi amacıyla çok sayıda sınıflama gündeme gelmiştir. Bunlar arasında en yaygın kabul görenler risk, injury, failure, loss, and end stage (RIFLE), acut kidney injury network (AKIN) ve kidney disease: Improving global outcomes (KDIGO) sınıflamaları olmuştur. Bu çalışmada, yoğun bakımda izlenen ve ABH tanısı alan hastalarda RIFLE, AKIN ve KDIGO kriterlerine göre ABH şiddeti ile mortalite arasındaki ilişkinin saptanması amaçlanmıştır. Gereç ve Yöntem: Dahiliye yoğun bakım ünitesinde izlenen 1.491 hastaya ait veriler retrospektif olarak incelendi ve ABH saptanan hastalar çalışmaya dahil edildi. Tüm hastalar için RIFLE, AKIN ve KDIGO kriterlerine kullanılarak ABH şiddeti belirlendi. Bulgular: Çalışmaya 155 hasta dahil edildi. RIFLE kriterlerine göre risk, hasar, yetmezlik evrelerinde yer alan hasta oranları sırasıyla; %14,8, %40,0, %45,2; AKIN kriterlerine göre evre 1, evre 2 ve evre 3’te yer alan hasta oranları sırasıyla; %45,6, %30,6, %23,8; KDIGO kriterlerine göre evre 1, evre 2 ve evre 3’te yer alan hasta oranları sırasıyla; %18,7, %21,7, %54,1 idi. AKIN ve RIFLE kriterlerine göre belirlenen ABH evreleri arasında mortalite oranları açısından farklılık saptanmazken, KDIGO evre 3’te yer alan hastalarda evre 1 ve evre 2 ABH gruplarına göre mortalite daha yüksek saptandı. Sonuç: Her üç tanı ve evreleme sistemi de ABH etiyolojisini dikkate almamaktadır. Bu nedenle mortalite ve ABH şiddeti arasındaki ilişkiyi doğru yansıtmamaları söz konusu olabilir. Bununla birlikte, kendisinden önce kullanılan evreleme sistemlerindeki eksikliklerden doğan ihtiyaçla ortaya çıkan KDIGO evreleme sistemi bu açıdan daha geçerli görünmektedir

Maximum Inspiratory Pressure: Can it Be A Helpful Parameter for Predicting Successful Weaning in Chronic Obstructive Pulmonary Disease Patients?

Objective: To evaluate the predictive value of maximum inspiratory pressure (MIP) besides rapid and shallow breathing index (RSBI) in the weaning of chronic obstructive pulmonary disease (COPD) patients. Material and Methods: Fifty-six COPD patients with acute exacerbation and type II respiratory failure requiring invasive mechanical ventilation for more than 24 hours were enrolled in this study. Extubation was planned if the patients tolerated pressure support mode for at least two hours and spontaneous breathing during a 30 minutes T-piece trial. Breathing frequency, exhaled tidal volume, rapid and shallow breathing index (RSBI), minute ventilation (Vmin), MIP and vital capacity measurements were recorded prior to extubation. Patients were divided into two groups according to weaning success (WS) and failure. WS was defined as 48 hours of independence from mechanical ventilation after extubation. Results: Although RSBI values between two groups were not significantly different, there were statistically significant differences between the two groups in terms of MIP (30 vs 18 cmH2O; p= 0.008) and Vmin (10.40 vs 8.25; p= 0.032). Patients with a MIP value greater than or equal to 25 cm H2O had greater WS when compared to those with values lower than 25 cm H2O. Conclusion: RSBI alone seems not reliable enough to predict weaning outcome in COPD patients with type II respiratory failure due to acute exacerbation. Supported with MIP, better results may be achieved to predict weaning outcome

Severity scores and factors related with mortality in cases with community- acquired pneumonia patients in intensive care unit

Totally 48 cases with diagnosed as community-acquired pneumonia who were treated in intensive care units of two different university hospital included to the study. The mean age of cases was 67.8, 29 were males and 19 females. Glasgow Coma Score (GCS), Acute Physiology Assesment and Chronic Health Evaluation II (APACHE II), Pneumonia Severity Index (PSI) and Sequential Organ Failure Assessment Score (SOFA) of 46 cases were determined. The most common comorbid disease was cerebrovascular disease. We determined that microbiological tests were made in 30 cases and pathogen agent was established in 7 cases of them. The mean lenght of stay in hospital and intensive care unit were 16.1 days and 8.8 days respectively. The mean GCS was 11.4, the mean PSI was 130.7 and 38 cases were in high risk classes. The mean APACHE II and SOFA scores were 20.7 and 4.4 respectively. We determined that hypotension and intubation increased the mortality risk. The mean blood urea nitrogen, % PNL and respiratory rate were higher in cases who were died. The mortality rate in group 3b and group 4 were respectively 41.2% and 44.0%. Totally 20 (41.7%) cases died

Noninvasive assisted pressure-controlled ventilation: As effective as pressure support ventilation in chronic obstructive pulmonary disease?

Background: Noninvasive ventilation ( NIV) is being increasingly used in hypercapnic chronic obstructive pulmonary disease ( COPD) patients but the most appropriate ventilation mode is still not known. Objectives: The aim of this study was to investigate if assisted pressure-controlled ventilation ( APCV) can be a better alternative to pressure-support ventilation ( PSV) for NIV in COPD patients with acute hypercapnic respiratory failure ( AHRF). Methods: In this prospective randomized study, we evaluated the early effects of noninvasive APCV and PSV in 34 consecutive COPD patients with AHRF. Patients were randomized into 1 of the 2 modes, and respiratory and hemodynamic values were compared before and after 1 h of NIV. Results: Baseline values did not differ between the 2 groups. There were significant improvements in partial arterial carbon dioxide pressure and pH levels in the APCV group when compared with baseline ( p < 0.05). Cardiac output and cardiac index decreased in both groups ( p < 0.05) but more significantly in the PSV group p < 0.0001). The decreases in stroke volume index and increases in arterial oxygen content after NIV were also considerable in both groups ( p < 0.05). Central venous pressure and systemic vascular resistance index values increased notably only after PSV ( p < 0.05). Conclusions: From these data, we deduce that APCV can be a better alternative to PSV for NIV in COPD patients with AHRF owing to its more beneficial physiological effects. Copyright (C) 2007 S. Karger AG, Basel

Comparison of the Effects of the Remote and Direct Ischemic Preconditioning in the Liver Ischemia-Reperfusion Injury

Objective: Ischemia reperfusion (IR) injury can cause severe organ failures. Remote and direct ischemic preconditioning can be used to prevent ischemia-reperfusion injury. Present study compares the effects of remote and direct ischemic preconditioning in the rat model of hepatic ischemia-reperfusion injury. Material and Methods: Four groups, each including seven rats were included. In the sham group only laparotomy was performed. In the ischemia reperfusion group 25 minutes of total hepatic ischemia was induced followed by 120 minutes of reperfusion. The leg was subjected to three cycles of ischemic preconditioning (IP) before hepatic ischemia reperfusion in the remote IP + IR group. One cycle of hepatic ischemic preconditioning was performed before hepatic ischemia reperfusion in the direct IP+IR group. The length of the experiment was the same in all groups. At the end of the experiment blood and Liver samples were collected. Results: Levels of serum aspartate transaminase (AST) and alanine transaminase (ALT) were significantly lower in the sham group compared to other groups (p<0.001). Levels of serum AST and ALT in the remote IP + IR group were significantly lower than in the direct IP + IR (p<0.001, p<0.001, respectively) and IR groups (p<0.001, p=0.002, respectively). Hepatic tissue malondialdehid level and the histological score of liver injury were significantly lower than in the direct IP + IR group (p<0.001, p=0.002, respectively). Conclusion: Present study showed that when serum AST-ALT levels and hepatic histological score are considered, remote ischemic preconditioning protects the liver from ischemia reperfusion injury better than direct ischemic preconditioning. The effects and mechanisms of these two preconditioning methods must be compared in clinical and experimental studies