Approach to The Occluded Permanent Hemodialysis Catheter

Objective: Central venous catheterization (CVC) is a type of surgery that hemodialysis (HD) patients frequently undergo. Presently, permanent CVCs (pCVCs) are the alternative to vascular access for patients requiring long-term catheterization. Additionally, identification of the type of catheter has a great importance for the right intervention.Our study aims: The aim was to discuss the identification procedure of an HD catheter, whether it is permanent or temporary, by presenting an HD catheter case done by CVC.Case presentation: A 75-year-old female patient having a routine of 3 days/week HD treatment was admitted to the critical care unit. A nonfunctional HD catheter was present in the left subclavian vein. A new HD catheter was placed in the right subclavian vein and continuous renal replacement therapy with heparin was initiated. Radiography revealed an opacity with a size of around 3 cm detected at the tip of the nonfunctional catheter. The catheter was removed with an incision after an unsuccessful attempt of removal by pulling it out. Further investigation of the catheter revealed that it was occluded.Conclusion:It is crucial to determine whether the catheter is temporary or permanent in order to do the right intervention and not to have unwanted consequences while removing a nonfunctional HD catheter

Isoflurane exposure in infant rats acutely increases aquaporin 4 and does not cause neurocognitive impairment

Isoflurane is commonly used in pediatric population, but its mechanism of action in cognition is unclear. Aquaporin 4 (AQP4) regulates water content in blood, brain, and cerebrospinal fluid. Various studies have provided evidence for the role of AQP4 in synaptic plasticity and neurocognition. In this study, we aimed to determine whether a prolonged exposure to isoflurane in infant rats is associated with cognition and what effect this exposure has on AQP4 expression. Ten-day-old [postnatal day (P) 10] Wistar albino rats were randomly allocated to isoflurane group (n = 32; 1.5% isoflurane in 50% oxygen for 6 hours) or control group (n = 32; only 50% oxygen for 6 hours). Acute (P11) and long-term (P33) effects of 6-hour anesthetic isoflurane exposure on AQP4 expression were analyzed in whole brains of P11 and P33 rats by RT-qPCR and Western blot. Spatial learning and memory were assessed on P28 to P33 days by Morris Water Maze (MWM) test. The analysis revealed that isoflurane increased acutely both mRNA (~4.5 fold) and protein (~90%) levels of AQP4 in P11 rats compared with control group. The increasing levels of AQP4 in P11 were not observed in P33 rats. Also, no statistically significant change between isoflurane and control groups was observed in the latency to find the platform during MWM training and probe trial. Our results indicate that a single exposure to isoflurane anesthesia does not influence cognition in infant rats. In this case, acutely increased AQP4 after isoflurane anesthesia may have a protective role in neurocognition

Evaluation of Readmitted Patients After Intensive Care Unit Discharge (Retrospective Study)

Objective:Nearly %10 of the discharged patients are readmitted to intensive care unit (ICU) at the same hospital stay. Reduction of readmission rates could be used as a hospital performance indicator. Our aim is to analyse the reasons and results of readmissions of patients who were discharged to a general ward from ICU in a two-year period.Method:Readmissions of the patients who had been treated in our ICU between the dates of 01.01.2015-31.12.2016 were analysed retrospectively. Demographic characteristics of patients, readmission rates, initial admission indications and comorbidities, distribution of readmission indications, timing of readmission after discharge, distribution of patients in terms of mechanical ventilation need, discharge time of readmitted patients at initial admission to ICU after weaning, readmission mortality rates, Glasgow Coma Scale (GCS), APACHE-II and SOFA scores of patients at initial admission and readmission were analysed and compared.Results:59 patients (3.55%) are readmitted to ICU after discharge at the same hospital stay. When examining the departments where the readmitted patients came from, it is seen that 19 patients (32.2%) were readmitted to ICU from department of general surgery. 22 of readmissions (37.29%) occurred within first 48 hours after discharge. The most common reasons of readmissions are for postoperative monitoring after revisional surgery (44.07%) and acute respiratory failure (40.68%).Conclusion:The patients who are discharged from ICU are at a high risk of being readmitted to ICU (35). Readmission to ICU is associated with higher mortality risk than the initial admission. The first step of reducing the rates of readmission to ICU process is to anticipate the patients who would be readmitted to ICU priorly and improve service wards healthcare quality

Relationship of percutaneous tracheostomy timing with APACHE II and SOFA scores on the first day of ICU for critically ill patients

Objective: Our study aimed to assess the relation between APACHE II and SOFA scores of critically ill patients on their first day of admission and the timing of percutaneous dilatational tracheotomy (PDT).Methods: Following approval of the Ethics Board of Health Sciences University Istanbul Bağcılar Educational Research Hospital (25.08.2016-2016/495), data of all 91 patients who had been treated with PDT in the ICU between June 1, 2014 and June 1, 2016 have been retrospectively evaluated. We recorded the following information: demographical data (such as age, sex, body mass index) that could be obtained from patient records, APACHE II and SOFA scores on their first day in ICU, and PDT timing.Results: There was no statistically significant difference observed between the timing of the PDT and APACHE II and SOFA scores (p>0.05).Conclusion: Our results showed that most of the patients with PDT had an APACHE II score of 15-24. We noticed that the number of patients with an APACHE II score of 24 and higher was notably lower than the number of patients with scores between 15-24. The fact that the life expectancy for the patient group with a high APACHE II score is low may call the tracheostomy decision into question. On the other hand, no relation was found between differences in APACHE II and SOFA scores and the starting time of PDT

The efficacy of two different positions in axillary blockade

Tıpta Uzmanlık TeziAksiller yaklaşımla brakial pleksus bloğu, el, ön kol ve kolun 1/3 distal bölümünde yapılacak cerrahi girişimler için lokal anestezik kullanılarak uygulanan popüler bir rejyonal anestezi yöntemidir. Aksiller bloğun başarısını arttırmak için yapılan çalışmalar; kola pozisyon vermek, lokal anestezik sonrası aksiller bölgenin kompresyonu, iğnenin daha proksimale yönlendirilmesi, volüm arttırılması gibi yöntemleri kapsamaktadır. Çalışmamızda, aksiller girişimle uygulanan lokal anesteziğin brakial pleksus etki alanının tamamına yayılımını sağlamak amacıyla iki farklı hasta pozisyonunun blok başarısındaki rolünü karşılaştırmayı amaçladık. Çalışma Etik Kurul onayı alınan, kronik böbrek yetmezlikli, kolda arterio-venöz fistül operasyonu uygulanacak, ASA II-III grubu 50 hasta üzerinde gerçekleştirildi. Hastalar gelişi-güzel seçilerek rutin monitörizasyon sonrasında, standart supin veya 20° lateral Trendelenburg pozisyonda iki gruba ayrıldı. Periferik sinir stimülatörü (Stimuplex HNS 11, B Braun Ltd, Melsungen, Almanya) ile sinir identifikasyonu yapıldıktan sonra, aksiller kılıf içine her iki gruba da levobupivakain (Chirocaine ®, Abbott, Türkiye) %0,25 solüsyonundan 30- 40 ml yapıldı. Duyusal blok ölçümü, lokal anestezik enjeksiyonu sonrası ve 30. dk'da hastaların ısı testine verdiği cevapla değerlendirildi. Motor blokajı sinirlerin innerve ettiği kasların fonksiyonuna göre, tam (hareket yokluğu), parsiyel (minor hareket olasılığında), veya motor bloksuz olarak tanımlandı. Her iki grupta anestezi ve cerrahi başlangıç-bitiş süresi ile duyusal ve motor blok başlangıç-bitiş süresi kaydedildi. İki grup arasında cinsiyet, yaş, kilo, anestezi ve cerrahi süreleri yönünden fark yoktu. N. musculocutaneus, n. radialis, n. medianus, n. ulnaris için motor ve duyusal blok sonrası ve 30. dk, VAS değerleri ile duyusal ve motor blok tutulum süreleri arasında da fark bulunamadı. N. axillaris, n. thoracodorsalis ve n. subscapularis sinir tutulumunun başlangıç sürelerinde gruplar arasında fark yok iken blok sonrası 30. dk'da yapılan duyusal ve motor blok değerlendirilmesinde, kola 20° lateral Trendelenburg pozisyonu verilen grupta tutulumun yüksek oranda anlamlı olarak uzadığı tespit edildi. Aksiller pleksus bloğu, aksiller kılıfın multi-kompartman ve septalı yapısı nedeniyle ancak %70 oranında başarılı olabilmektedir. Yaptığımız literatür taramamızda, aksiller pleksus bloğunun başarısını arttırmak için daha yüksek lokal anestezik volümü kullanmak yerine lokal anesteziğin brakial pleksusun proksimaline yayılımının sağlanmasının uygun olacağını saptadık. Çalışmamızda aksiller pleksus bloğu uygulanacak hastalarda, blok sırasında hastanın koluna 20 ° lateral Trendelenburg pozisyonu vererek blok süresinin anlamlı oranda uzadığını belirledik Aksiller yaklaşımla, turnikesiz, brakial pleksus bloğu yapılırken, hastanın koluna 20 ° lateral Trendelenburg pozisyonu verilmesinin, blok başarı yüzdesini ve kalitesini arttıracağı kanısındayız.AbstractAxillary approach to block the brachial plexus is a popular regional anaesthesia technique in which local anesthetic solutions are used in the surgeries of hand, forearm, and the 1/3 distal area of the arm. Studies have shown that such conditions like the position of the arm, the compression of the axillary region, a more proximal direction of the needle, and increasing the volume are all effective in the success of the axillary block. In our study, we compared the efficacy of two different patient positions used for the diffusion of the local anesthetic agent to the whole bracial plexus to achieve the axillary blockade. After obtaining approval from local Ethics Committee and written informed consent, 50 patients with chronic renal failure (ASA physical status II-III) scheduled for arteriovenous fistula surgery on the arm were included in this study. Patients were allocated randomly and divided into two different groups: Standard supine group and a lateral position group (20° Trendelenburg). After routine monitorisation, standard supine position or lateral position, 20° Trendelenburg were applied to patients. A peripheral nerve stimulator (Stimuplex HNS 11, B Braun Ltd, Melsungen, Germany) was used to locate the brachial plexus, In both groups, Levobupivacaine (Chirocaine, Abbott, Turkey) 2,5% 30-40 ml was injected slowly into the axillary sheat. The extent of the sensory block was assessed by the patient?s response to temperature discrimination at two time points: immediately after performing the block and 30 min after injection of the local anaesthetic. Motor blockade was defined as complete (absence of mobility), incomplete (minor movements possible) or no motor block in muscles supplied by the respective nerves. We recorded duration of surgery and anesthesia, motor and sensory block onset and ofset times in both groups. There were no differences between the two groups with regard to gender, age, weight, anesthesia and surgical duration time, sensory and motor block time, VAS values and after 30 min. sensory and motor block for n. ulnaris, n. medianus, n. radials, n. musculocutaneous. Sensory and motor blockade evaluation showed that there was a significantly higher proportion of axillary nerve in the lateral position group (20° Trendelenburg), thirty minutes after the injection. Thoracodorsal nerve and subscapular motor blockade were difference in the lateral position group (20° Trendelenburg), thirty minutes after the injection. Because the axillary sheat has a multicompartmental and septa structure, the success in the axillary plexus block is around 70%. In our literature review, we conclusion that when the the local anaesthetic is diffused into the proximal brachial plexus, with the use of higher volume, the application is much more effective. In our study we suggest that the use of 20° lateral Trendelenburg position in the patient undergoing an axillary block increase the success rate and the quality of the application. We think that the use of 20° lateral Trendelenburg position can effect the performance and quality of the block of the brachial plexus unturnstile with axillary approach

Cerebral Salt Wasting Syndrome

A serum sodium (Na) value below 135 mEq/L is evaluated as hyponatremia. Hyponatremia is the most common electrolyte abnormality observed in hospitalized patients in particular. Hypovolemic hypoosmolar hyponatremia is the most frequent clinical table. One of the reasons of this is cerebral salt-wasting syndrome (CSWS). CSWS is a rare condition progressing with low plasma osmolality, urine osmolality above 100-150 mOsm/kg and urine- Na concentration above 20 mEq/L. In the blood and urine sample analysis performed upon sudden loss of consciousness on the 15th day of the intensive care unit follow-up of 79-year-old female patients due to falling from stairs, blood biochemistry Na value was 120 mEq/L, plasma osmolality was 250 mOsm/kg, urine Na value was 180 mEq/L, urine osmolality was 1200 mOsm/kg, urine diuresis was >3 mL/kg/hour. The central venous pressure was 2 mmHg. The patient, considered to be diagnosed with CSWS, was treated with 9% NaCl and 3% hypertonic saline solution. Her clinical course was improved on the 18th day. She died on the 81st day secondary to septicemia in the subsequent follow-up. In this article, it was aimed to report a patient with CSWS which progresses with low percentage in intensive care unit patients with head trauma, is frequently confused with inappropriate antidiuretic hormone syndrome and progresses mortally when not diagnosed distinctively well

Leriche syndrome

Leriche syndrome is a disease that is characterized by a thrombotic occlusion in the aorta, frequently in the renal artery distal. The classical symptoms of this syndrome include pain in the lower extremities emerging during activity (claudication), impalpability of the femoral pulses and impotency in male patients. The definitive diagnosis of claudication, due to insufficient circulation as well as neurogenic-caused claudication, is hard. Medical history, physical examination and monitoring methods are important for definitive diagnosis. Impalpability of bilateral femoral pulses in physical examination may be a sign of leriche syndrome. With colored doppler ultrasonography, it can be demonstrated in cases having Leriche syndrome that there is no circulation in both iliac arteries. In these patients, thrombotic occlusion of the aorta shall be confirmed by computed tomography angiography. This case that we present is a case of Leriche syndrome in which the patient came to the hospital with the complaint of claudication and was diagnosed with lumbar disc herniation. Since vascular pathologies were not considered in definitive diagnosis, the treatment was delayed and it resulted in mortality; for this reason it is important. In the case of patients coming to hospital with complaints of leg pain, the vascular pathologies shall be thought of in the definitive diagnosis and the clinicians, and in that way leading to the diagnosis, shall depend on detailed patient history and comprehensive physical examination

Leriche syndrome

Leriche syndrome is a disease that is characterized by a thrombotic occlusion in the aorta, frequently in the renal artery distal. The classical symptoms of this syndrome include pain in the lower extremities emerging during activity (claudication), impalpability of the femoral pulses and impotency in male patients. The definitive diagnosis of claudication, due to insufficient circulation as well as neurogenic-caused claudication, is hard. Medical history, physical examination and monitoring methods are important for definitive diagnosis. Impalpability of bilateral femoral pulses in physical examination may be a sign of leriche syndrome. With colored doppler ultrasonography, it can be demonstrated in cases having Leriche syndrome that there is no circulation in both iliac arteries. In these patients, thrombotic occlusion of the aorta shall be confirmed by computed tomography angiography. This case that we present is a case of Leriche syndrome in which the patient came to the hospital with the complaint of claudication and was diagnosed with lumbar disc herniation. Since vascular pathologies were not considered in definitive diagnosis, the treatment was delayed and it resulted in mortality; for this reason it is important. In the case of patients coming to hospital with complaints of leg pain, the vascular pathologies shall be thought of in the definitive diagnosis and the clinicians, and in that way leading to the diagnosis, shall depend on detailed patient history and comprehensive physical examination

Neurogenic Pulmonary Edema (A Case Report)

Neurogenic pulmonary edema is a life threatening complication of severe central nervous system injury. The most common cause of neurogenic pulmonary edema is subarachnoid hemorrhage followed by head trauma and epilepsy. The rare causes are cervical spine trauma, multiplesclerosis, cerebellar hemorrhage and intracranial tumors. Neurogenic pulmonary edema is characterized by an increase in extravascular lung water in patients who have sustained a sudden change in neurologic condition. The exact pathophysiology is unclear but it probably involves an adrenergic response to the central nervous system injury which leads to increased catecholamine, pulmonary hydrostatic pressure and increased lung capillary permeability. The presenting symptoms are nonspecific and often include dyspnea, tachypnea, tachycardia, hypoxemia, pinkfroty secretion, bilateral pulmonary infiltrates and crackles. These symptoms start within minutes or hours and resolves 48-72 hours that typically for neurogenic pulmonary edema. Basic principles of treatment, surgical decompression, reduce intracranial pressure, controlled ventilation with suplemental oxygen, positive end expiratory pressure and diuresis. We report a case with neurogenic pulmonary edema that occured after head trauma. (Journal of the Turkish Society Intensive Care 2012; 10: 59-62