Epidemiology of surgery associated acute kidney injury (EPIS-AKI): a prospective international observational multi-center clinical study

Purpose: The incidence, patient features, risk factors and outcomes of surgery-associated postoperative acute kidney injury (PO-AKI) across different countries and health care systems is unclear. Methods: We conducted an international prospective, observational, multi-center study in 30 countries in patients undergoing major surgery (> 2-h duration and postoperative intensive care unit (ICU) or high dependency unit admission). The primary endpoint was the occurrence of PO-AKI within 72 h of surgery defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary endpoints included PO-AKI severity and duration, use of renal replacement therapy (RRT), mortality, and ICU and hospital length of stay. Results: We studied 10,568 patients and 1945 (18.4%) developed PO-AKI (1236 (63.5%) KDIGO stage 1500 (25.7%) KDIGO stage 2209 (10.7%) KDIGO stage 3). In 33.8% PO-AKI was persistent, and 170/1945 (8.7%) of patients with PO-AKI received RRT in the ICU. Patients with PO-AKI had greater ICU (6.3% vs. 0.7%) and hospital (8.6% vs. 1.4%) mortality, and longer ICU (median 2 (Q1-Q3, 1-3) days vs. 3 (Q1-Q3, 1-6) days) and hospital length of stay (median 14 (Q1-Q3, 9-24) days vs. 10 (Q1-Q3, 7-17) days). Risk factors for PO-AKI included older age, comorbidities (hypertension, diabetes, chronic kidney disease), type, duration and urgency of surgery as well as intraoperative vasopressors, and aminoglycosides administration. Conclusion: In a comprehensive multinational study, approximately one in five patients develop PO-AKI after major surgery. Increasing severity of PO-AKI is associated with a progressive increase in adverse outcomes. Our findings indicate that PO-AKI represents a significant burden for health care worldwide

Učinak položaja bolesnika na rane komplikacije indukcije spinalne anestezije u artroskopskoj operaciji koljena

Spinal anesthesia is widely used in different patient positions to create efficient and rapid anesthesia induction in surgical interventions. Early and late complications of spinal anesthesia may vary according to the type of needle, drug dose and concentration, patient weight and height, puncture technique, and position of the patient. This study aimed to prospectively compare early complications of spinal anesthesia between patients in sitting and lateral decubitus positions with motor block onset time and sensory block time to T10 level. Spinal anesthesia was performed in 100 ASA I-II patients aged 18-65 years (group S=48; and group L=52) undergoing arthroscopic knee surgery. Hemodynamic data, early complications, sensory and motor block onset times were recorded. Systolic, diastolic and mean arterial pressures were significantly lower in lateral decubitus position as compared to sitting position after spinal anesthesia induction. Arterial blood pressure values decreased significantly in lateral decubitus position as compared with sitting position. Motor block onset time and sensory block onset time were shorter in lateral decubitus position than in sitting position. Accordingly, sitting position could be suggested during induction of spinal anesthesia because it was associated with less pronounced decrease in blood pressures.Spinalna anestezija uobičajena je metoda koja se primjenjuje u različitim položajima bolesnika stvarajući učinkovitu i brzu indukciju anestezije u kirurškim intervencijama. Rane i kasne komplikacije spinalne anestezije mogu se razlikovati ovisno o vrsti igle, koncentraciji i dozi lijeka, težini i visini bolesnika, tehnici uboda i položaju bolesnika. Cilj ovoga istraživanja bio je prospektivno usporediti rane komplikacije spinalne anestezije kod bolesnika koji sjede i u bočnom dekubitusu s vremenom početka blokade motora i osjetnom blokadom do razine T10. U ovom istraživanju spinalna anestezija primijenjena je na 100 bolesnika s ASA I-II u dobi od 18-65 godina (skupina S=48, skupina L=52) koji su bili podvrgnuti artroskopskoj operaciji koljena. Zabilježeni su hemodinamski podaci, rane komplikacije, vrijeme nastanka senzorne i motorne blokade. Sistolički tlak, dijastolički tlak i srednji arterijski tlak bili su značajno niži u položaju bočnog dekubitusa nakon indukcije spinalne anestezije u usporedbi sa sjedećim položajem. Vrijednosti arterijskog krvnog tlaka značajno su se smanjile u položaju bočnog dekubitusa u usporedbi sa sjedećim položajem. Vrijeme nastupa motoričke blokade i vrijeme početka osjetne blokade bilo je kraće u položaju bočnog dekubitusa u usporedbi sa sjedećim položajem. Rezultati pokazuju da se sjedeći položaj može preporučiti tijekom indukcije spinalne anestezije, jer se krvni tlak manje snižava u tom položaju

The Effects of Single-Dose Rectal Midazolam Application on Postoperative Recovery, Sedation, and Analgesia in Children Given Caudal Anesthesia Plus Bupivacaine

Background. This study aimed to compare the effects of rectal midazolam addition after applying bupivacaine and caudal anesthesia on postoperative analgesia time, the need for additional analgesics, postoperative recovery, and sedation and to find out its adverse effects in children having lower abdominal surgery. Methods. 40 children between 2 and 10 years of ASA I-II were randomized, and they received caudal anesthesia under general anesthesia. Patients underwent the application of caudal block in addition to saline and 1 mL/kg bupivacaine 0.25%. In the postoperative period, Group C (n = 20) was given 5 mL saline, and Group M (n = 20) was given 0.30 mg/kg rectal midazolam diluted with 5 mL saline. Sedation scale and postoperative pain scale (CHIPPS) of the patients were evaluated. The patients were observed for their analgesic need, first analgesic time, and adverse effects for 24 hours. Results. Demographic and hemodynamic data of the two groups did not differ. Postoperative sedation scores in both groups were significantly lower compared with the preoperative period. There was no significant difference between the groups in terms of sedation and sufficient analgesia. Conclusions. We conclude that caudal anesthesia provided sufficient analgesia in peroperative and postoperative periods, and rectal midazolam addition did not create any differences. This trial is registered with ClinicalTrials.gov NCT02127489

Conduta no perioperatório de paciente pediátrico com trombastenia de glanzmann durante adenoidectomia

JUSTIFICATIVA E OBJETIVOS: Trombastenia de Glanzmann (TG) é uma doença autossômica recessivamente hereditária das plaquetas. Não há nenhum tratamento específico. A transfusão de plaquetas é atualmente o tratamento padrão quando o sangramento não responde a medidas locais e/ou a medicamentos antifibrinolíticos, podendo, entretanto, resultar em aloimunização. O fator VII recombinante ativado (rFVIIa) pode ser usado para evitar a transfusão recorrente de plaquetas. RELATO DE CASO: Apresentamos um tratamento precoce com dose baixa de rFVIIa associada à transfusão de plaquetas em um caso pediátrico (cinco anos de idade), com diagnóstico de TG e apresentando sangramento prolongado durante adenoidectomia eletiva. Uma dose total de 1.200 mg (60 µg.kg-1) de rFVIIa obteve sucesso em estancar o sangramento, o que pode ser aceito como uma dose baixa. CONCLUSÕES: Relatos de casos podem encorajar o uso de tratamento precoce com baixas doses de rFVIIa em hemorragias graves que não estacam a despeito da transfusão de plaquetas e na prevenção de sangramento em procedimentos cirúrgicos em pacientes com TG. Estudos adicionais são necessários para definir a dose mínima eficaz. Portanto, as tentativas para determinar a dose eficaz mais baixa desse composto devem ser incentivadas consideando o resultado deste caso em face de restrições financeiras no sistema de saúde

An assessment of ventilator-associated pneumonias and risk factors identified in the Intensive Care Unit

KOSTAKOGLU, UGUR/0000-0002-4589-0962WOS: 000383112000005PubMed: 27648020Objectives: Ventilator-associated pneumonia (VAP) is a significant cause of hospital-related infections, one that must be prevented due to its high morbidity and mortality. the purpose of this study was to evaluate the incidence and risk factors in patients developing VAP in our intensive care units (ICUs). Methods: This retrospective cohort study involved in mechanically ventilated patients hospitalized for more than 48 hours. VAP diagnosed patients were divided into two groups, those developing pneumonia (VAP(+)) and those not (VAP(-)). Results: We researched 1560 patients in adult ICUs, 1152 (73.8%) of whom were mechanically ventilated. the MV use rate was 52%. VAP developed in 15.4% of patients. the VAP rate was calculated as 15.7/1000 ventilator days. Mean length of stay in the ICU for VAP(+) and VAP(-) patients were (26.7 +/- 16.3 and 18.1 +/- 12.7 days (p<0.001)) and mean length of MV use was (23.5 +/- 10.3 and 12.6 +/- 7.4 days (p<0.001)). High APACHE II and Charlson co-morbidity index scores, extended length of hospitalization and MV time, previous history of hospitalization and antibiotherapy, reintubation, enteral nutrition, chronic obstructive pulmonary disease, cerebrovascular disease, diabetes mellitus and organ failure were determined as significant risk factors for VAP. the mortality rate in the VAP(+) was 65.2%, with 23.6% being attributed to VAP. Conclusion: VAPs are prominent nosocomial infections that can cause considerable morbidity and mortality in ICUs. Patient care procedures for the early diagnosis of patients with a high risk of VAP and for the reduction of risk factors must be implemented by providing training concerning risk factors related to VAP for ICU personnel, and preventable risk factors must be reduced to a minimum

Intoxications in Intensive Care: Cost and Bed Occupancy According to Glasgow Coma Scale

Objective:Intensive care units (ICU) are the units in which critical patient care and follow-up are conducted. About 3.7-40% of ICU beds are used for intoxications. In ICU, intoxications may be mortal or can be discharged only by observation without any complication. The necessity of hospitalization of all these patients to the ICU is controversial in terms of bed occupancy and cost. In our study, it was aimed to determine the necessity and cost of hospitalization of ICU patients who were admitted to ICU with diagnosis of intoxication.Materials and Methods:This study was conducted by investigating the files of 205 intoxication patients who underwent more than 24 hours of follow-up and treatment at second and third level ICU. While patients were admitted to ICU, they were divided into two groups according to Glasgow Coma score (GCS) 15 (group=15) and below 15 (group <15). The patients’ age, gender, GCS, cause of poisoning, number of days stayed in the ICU and the need for mechanical ventilation (MV) were recorded, and the ICU costs of the groups were calculated. In addition, the cost that would be generated if the patients in group=15 were followed in the service environment rather than in the ICU was calculated.Results:Of the 205 patients examined, 145 had GCS of 15, while the GCS of 60 patients were below 15. The number of patients with GCS=15 and the intoxication case with suicide intent were higher in female gender. While the number of intoxications with cardiovascular system drugs and analgesic drugs was greater in group=15, the number of intoxications with carbon monoxide and drug substances was greater in group <15. The number of days stayed in ICU, MV requirement and ICU costs were higher in group <15. If the patients in group=15 had been followed up in the service environment, the cost would have been lower than the cost in ICU.Conclusion:GCS; it can be used to determine the necessity of hospitalization of intoxication cases into ICU due to its specificity and easy applicability. It is common belief that intoxications leading to life threatening and organ failure should be followed in second and third level ICUs. The fact that ICU beds in our country are not used according to the criteria is a big problem, which may increase the cost of use and also cause an increase in mortality. Adhering to the criteria for admitting patients to high cost units which require specialist and technological equipment such as ICUs will prevent unnecessary bed occupancy and ensure proper use of resources. According to our study, close follow-up of patients, who admitted to ICU with GCS=15, in an equipped service may reduce cost and bed occupancy

Cost analysis and evaluation of nosocomial infections in intensive care units

Background/aim: The purpose of this study was to evaluate nosocomial infections occurring in our hospital intensive care units (ICUs) and the risk factors for these, and to determine the effect of these infections on mortality and cost. Materials and methods: This retrospective study was performed via infection control committee surveillance data, ICU records, and information processing data between 1 January and 31 December 2013 at the Kanuni Education and Research Hospital. Results: A total of 309 nosocomial infections were observed in 205 out of 566 patients. The density of nosocomial infections was 25.4 in 1000 patient days. Hospitalization was prolonged, and APACHE II and Charlson comorbidity scores were high in patients developing nosocomial infections (P < 0.001). Of the patients diagnosed with a nosocomial infection, 170 died. Infections were determined as the cause of death in 62 (36.5%) of the nonsurviving patients with a nosocomial infection. Acinetobacter baumannii was identified in 46 (74.2%) of the patients that died from nosocomial infections. The mean cost in patients developing a nosocomial infection was 15,229.30 Turkish lira (TL), compared to 9648.00 TL in patients without a nosocomial infection (P = 0.002). Conclusion: Regular infection control education sessions need to be held and the number of nurses needs to be increased in order to be able to reduce this high mortality, morbidity, and cost