Monitorization of Acute Brain Dysfunction in Critical Illness

Acute brain dysfunction is a clinical condition which is commonly observed in intensive care units and exhibits neurological changes ranging from delirium to coma. Typically observed during sepsis in critical patients, this syndrome is also named as "sepsis-associated encephalopathy" and this situation is of significance since it is related to mortality, increase of morbidity and long-term cognitive impairment. Monitorization of brain functions in critically ill patients should be commenced with detailed neurological examination and effects of sedative drugs, which can alter neurological responses during evaluation, should be taken into consideration. On the other hand, brain imaging methods and electrophysiological examinations are diagnostic procedures which complement neurological examination. While computed tomography enables diagnosis of structural intracerebral lesions, magnetic resonance imaging provides important information on primary pathological mechanisms of sepsis-associated encephalopathy and structural alterations developing in the brain. Evidence of diagnosis and prognosis of acute brain dysfunction can be acquired through use of electroencephalography for. Although it was believed that neurological biomarkers can be useful in determination of diagnosis and prognosis, further studies are needed in this subject

Relationship between arterial oxygen tension and mortality of patients in intensive care unit on mechanical ventilation support

BACKGROUND: Although there are studies demonstrating hyperoxia may be an independent risk factor for increased mortality and morbidity, this issue remains unclear. Our research then aimed to examine the relationship between arterial oxygen tension, arterial carbon dioxide tension, and in-hospital mortality of critically ill patients in intensive care unit (ICU)

A Different Approach to Toxic Epidermal Necrolysis: Cytokine Filter

Toxic epidermal necrolysis (TEN) is a potentially life-threatening dermatologic disorder that erythema and exfoliation of the skin involve more than 30% of the body surface and usually drug related. A 68-year-old male patient who was admitted to the emergency department with the complaint of extensive bullous lesions on his skin was followed up in the intensive care unit (ICU) with the diagnosis of TEN. He had been on multiple anti-inflammatory, antibiotic and analgesic treatment for approximately 20 days due to respiratory tract infection and gout. Methyl-prednisolone 1 g day(-1) was started after the patient's previous treatments were discontinued. The patient was connected to the mechanical ventilator on 11th day due to sepsis and respiratory mucosal involvement. Regression and epithelialisation of skin lesions started after starting cytokine filter treatment on 14th day. The cytokine filter was applied with a renal replacement therapy machine in our patient. Withdrawal of suspected drugs, maintaining an optimal electrolyte balance, sterile care of skin lesions and management in the ICU of specialised centres are essential. Although agents, such as corticosteroids, intravenous immunoglobulins and cyclosporine, are used in the treatment, we think that the use of cytokine filters will contribute to recovery by stopping the cytokine storm in these cases

The effect of two different glycemic management protocols on postoperative cognitive dysfunction in coronary artery bypass surgery

Introduction: Postoperative cognitive dysfunction (POCD) is an adverse outcome of surgery that is more common after open heart procedures. The aim of this study is to investigate the role of tightly controlled blood glucose levels during coronary artery surgery on early and late cognitive decline. Methods: 40 patients older than 50 years undergoing elective coronary surgery were randomized into two groups. In the “Tight Control” group (GI), the glycemia was maintained between 80 and 120 mg dL−1 while in the “Liberal” group (GII), it ranged between 80–180 mg dL−1. A neuropsychological test battery was performed three times: baseline before surgery and follow-up first and 12th weeks, postoperatively. POCD was defined as a drop of one standard deviation from baseline on two or more tests. Results: At the postoperative first week, neurocognitive tests showed that 10 patients in the GI and 11 patients in GII had POCD. The incidence of early POCD was similar between groups. However the late assessment revealed that cognitive dysfunction persisted in five patients in the GII whereas none was rated as cognitively impaired in GI (p = 0.047). Conclusion: We suggest that tight perioperative glycemic control in coronary surgery may play a role in preventing persistent cognitive impairment. Resumo: Introdução: A disfunção cognitiva pós-operatória (DCPO) é um resultado adverso cirúrgico que é mais comum após cirurgias cardíacas abertas. O objetivo deste estudo foi investigar o papel dos níveis de glicose no sangue rigorosamente controlados durante a cirurgia coronariana no declínio cognitivo precoce e tardio. Métodos: Quarenta pacientes com idades acima de 50 anos e submetidos à cirurgia coronariana eletiva foram randomizados em dois grupos. No grupo “controle rigoroso” (GI), a glicemia foi mantida entre 80-120 mg.dL−1; enquanto no grupo “liberal” (GII), variou entre 80-180 mg.dL−1. A bateria de testes neuropsicológicos foi realizada três vezes: fase basal, antes da cirurgia e na primeira e décima segunda semana de acompanhamento no pós-operatório. DCPO foi definida como uma queda de um desvio padrão da fase basal em dois ou mais testes. Resultados: Na primeira semana de pós-operatório, os testes neurocognitivos mostraram que 10 pacientes no GI e 11 pacientes no GII apresentaram DCPO. A incidência de DCPO precoce foi semelhante entre os grupos. No entanto, a avaliação tardia revelou que a disfunção cognitiva persistiu em cinco pacientes no GII, enquanto nenhum paciente foi classificado como cognitivamente prejudicado no GI (p = 0,047). Conclusão: Sugerimos que o controle glicêmico rigoroso no perioperatório de cirurgia coronariana pode desempenhar um papel na prevenção da deterioração cognitiva persistente. Keywords: Glucose control, Cognitive dysfunction, Coronary artery bypass surgery, Palavras-chave: Controle glicêmico, Disfunção cognitiva, Cirurgia de revascularização do miocárdi

Neuroimaging Findings in Sepsis-Induced Brain Dysfunction: Association with Clinical and Laboratory Findings

BackgroundIncidence and patterns of brain lesions of sepsis-induced brain dysfunction (SIBD) have been well defined. Our objective was to investigate the associations between neuroimaging features of SIBD patients and well-known neuroinflammation and neurodegeneration factors.MethodsIn this prospective observational study, 93 SIBD patients (45 men, 48 women; 50.612.7years old) were enrolled. Patients underwent a neurological examination and brain magnetic resonance imaging (MRI). Severity-of-disease scoring systems (APACHE II, SOFA, and SAPS II) and neurological outcome scoring system (GOSE) were used. Also, serum levels of a panel of mediators [IL-1, IL-6, IL-8, IL-10, IL-12, IL-17, IFN-, TNF-, complement factor Bb, C4d, C5a, iC3b, amyloid- peptides, total tau, phosphorylated tau (p-tau), S100b, neuron-specific enolase] were measured by ELISA. Voxel-based morphometry (VBM) was employed to available patients for assessment of neuronal loss pattern in SIBD.ResultsMRI of SIBD patients were normal (n=27, 29%) or showed brain lesions (n=51, 54.9%) or brain atrophy (n=15, 16.1%). VBM analysis showed neuronal loss in the insula, cingulate cortex, frontal lobe, precuneus, and thalamus. Patients with abnormal MRI findings had worse APACHE II, SOFA, GOSE scores, increased prevalence of delirium and mortality. Presence of MRI lesions was associated with reduced C5a and iC3b levels and brain atrophy was associated with increased p-tau levels. Regression analysis identified an association between C5a levels and presence of lesion on MRI and p-tau levels and the presence of atrophy on MRI.Conclusions p id=Par4 Neuronal loss predominantly occurs in limbic and visceral pain perception regions of SIBD patients. Complement breakdown products and p-tau stand out as adverse neuroimaging outcome markers for SIBD

First Case of COVID-19 Positive Candida auris Fungemia in Turkey

Candida auris is a species of fungus that has gained importance in recent years owing to its ability to cause hospital infections and epidemics, resistant to antifungal agents and disinfection processes and frequently misidentified by commercial systems. Hospital outbreaks caused by C.auris have been reported from some countries. It has been determined that C.auris has lower virulence than Candida albicans; however, it is associated with high mortality rates in immunocompromised individuals. An increase in the incidence of invasive fungal infections which can lead to serious complications and death, has been identified in severe coronavirus-2019 (COVID-19) patients or immunocompromised individuals with underlying disease. Studies demonstrated an increase in the frequency of C.auris isolation in COVID-19 patients with candidemia. In this report, the first case of COVID-19 positive C.auris fungemia detected in Turkey was presented. A 71-year-old male patient with a history of myocardial infarction, diabetes mellitus, donation of a single kidney and lobectomy surgery due to lung cancer was hospitalized in the pandemic thoracic surgery service due to the findings consistent with viral pneumonia on thoracic computed tomography. Favipiravir 2 x 600 mg and intravenous dexamethasone 1 x 6 mg therapy was administered. The patient tested positive for SARS-CoV-2 polymerase chain reaction, and severe involvement of the left lung was detected in the following days. Antibiotics were administered, followed by insertion of a right jugular vein catheter and initation of tocilizumab. The patient was transferred to the intensive care unit due to increased respiratory distress. Yeast growth was detected in the patient's hemoculture. The yeast strain could not be identified using API ID 32C (bioMerieux, France) (Sacchromyces kluyveri, Candida sake, unacceptable profile), but was identified as C.auris using the VITEK MALDI TOF MS (bioMerieux, France) (99.9%) system and confirmed by sequencing. The minimum inhibitor concentration values were detected as 3 mu g/ml for amphotericin B; > 256 mu g/ml for fluconazole; 0.19 mu g/ml for voriconazole; 0.19 mu g/ml for itraconazole; 0.016 mu g/ml for posaconazole; 1 mu g/ml for caspofungin and 0.094 mu g/ml for anidulafungin by using the antibiotic gradient method. The patient's initial treatment comprised meropenem 3 x 1 g, vancomycin 2 x 1 g, caspofungin 1 x 70 mg, and continued as caspofungine 1 x 50 mg after the loading dose, and vancomycin 1 x 1 g/48 hours from the third day of treatment. The patient died on the ninth day after developing candidemia. The present case is the first case of fungemia caused by C.auris in a COVID-19 positive patient in Turkey, and it emphasizes the need of caution for fungemia due to C.auris in intensive care units in our country which has a high COVID-19 incidence

Effects of early and late continuous renal replacement therapy on intensive care unit mortality in patients with COVID-19 with acute respiratory distress syndrome and acute kidney injury: a comparative study

Abstract Introduction Acute kidney injury (AKI) is linked to disease severity and prognosis in patients with coronavirus disease 2019 (COVID-19), and mortality increases even with milder stages. This study primarily investigated the effects of continuous renal replacement therapy (CRRT) timing on intensive care unit (ICU) mortality in patients with COVID-19 with acute respiratory distress syndrome (ARDS) and AKI. Secondary goals were secondary goals for the ICU, days without life support treatment, and change in post-CRRT day biomarker levels, the length of ICU and overall hospital stay. Methods In this retrospective study, patients with COVID-19 with ARDS and AKI were divided into CRRT initiated at AKI stages 1 and 2, early-CRRT (E-CRRT) and AKI stage 3, late-CRRT (L-CRRT) and followed until discharge or death. Results E-CRRT had 20 patients and L-CRRT had 18 patients. No association between CRRT timing and ICU mortality was detected (p = 0.724). Moreover, the timing was not associated with ICU, total hospital stay, or days without life support treatment. However, it was associated with D-dimer levels for both groups and ferritin and C-reactive protein (CRP) levels for E-CRRT. There were no associations for other markers, such as procalcitonin, troponin T, pro-brain natriuretic peptide (pro-BNP), interleukin-6, fibrinogen, or antithrombin III levels. Conclusions CRRT timing was not associated with ICU mortality, total hospital stay, or days without life support treatment in this cohort. For E-CRRT, ferritin and CRP levels, and for both groups, D-dimer levels, were associated with CRRT timing. Randomized controlled trials are needed to examine the effects of CRRT timing in patients with COVID-19 with ARDS and AKI