The power of mechanical ventilation may predict mortality in critically ill patients

BACKGROUND

Mechanical power (MP) is the amount of energy transferred from the ventilator to the patient within a unit of time. It has been emphasized in ventilation-induced lung injury (VILI) and mortality. However, its measurement and use in clinical practice are challenging. "Electronic recording systems (ERS)" using mechanical ventilation parameters provided by the ventilator can be helpful to measure and record the MP. The MP (J/minutes) formula is 0.098 x tidal volume x respiratory rate x (Ppeak - ½ ∆P), in which ∆P is the driving pressure and Ppeak is the peak pressure. We aimed to define the association between MP values and ICU mortality, mechanical ventilation days, and intensive care unit length of stay (ICU-LOS). The secondary outcome was to determine the most potent or essential component of power in the equation that has a role in mortality.

METHODS

This retrospective study was performed in two centers (VKV American Hospital and Bakırköy Sadi Konuk Hospital ICUs) that used ERS (Metavision IMDsoft) between 2014 and 2018. We uploaded the power formula (MP (J/minutes)=0.098×VT×RR×(Ppeak - ½ ∆P) to ERS (METAvision, iMDsoft, and Consult Orion Health) and calculated the MP value by using MV parameters automatically sent from the ventilator. (∆P; driving pressure, VT; tidal volume, RR; respiratory rate and Ppeak; peak pressure).

RESULTS

A total of 3042 patients were included in the study. The median value of MP was 11.3 J/min. Mortality in MP<11.3 J/min was 35.4%, and 49.1% in MP>11.3J/min.; P<0.001. Mechanical ventilation days and ICU-LOS were also statistically longer in the MVP>11.3 J/min group.

CONCLUSIONS

The first 24 h MP maybe a predictive value for the ICU patients' prognosis. This implies that MP may be used as a decision-making system to define the clinical approach and as a scoring system to predict patient prognosis.

Comparing Preoperative Anxiety Effects of Brachial Plexus Block and General Anesthesia for Orthopedic Upper-Extremity Surgery: A Randomized, Controlled Trial

Background and objectives: Preoperative anxiety is an enormous feeling of fear that is seen in all patients undergoing surgery. The severity of anxiety may vary depending on the type of surgery and anesthesia to be performed. The aim of this study is to compare the effects of brachial plexus blocks and general anesthesia methods on preoperative anxiety levels in patients who will undergo orthopedic upper-extremity surgery and to determine the factors affecting anxiety. Materials and Methods: After randomization, the Amsterdam Preoperative Anxiety and Knowledge Scale (APAIS) questionnaire was applied to the patients to determine the preoperative anxiety level, and then anesthesia was applied according to the anesthesia type determined. Pain scores (1, 8, 16, and 24 h) and total opioid consumption of the patients were recorded postoperatively. Results: The APAIS score of the patients in the general anesthesia (GA) group was significantly higher (p = 0.021). VAS score medians at 1, 4, and 8 h postoperatively were found to be significantly higher in the GA group (p < 0.001, p < 0.001 and p = 0.044, respectively). Conclusions: USG-guided BPB may cause less anxiety than GA in patients who will undergo elective upper-extremity surgery. However, these patients have moderate anxiety, although it is more associated with advanced age, female gender, and education level.

Perioperative goal-directed fluid management using noninvasive hemodynamic monitoring in gynecologic oncology

Background

Intraoperative fluid management is important for the prevention of perioperative morbidity and mortality. Our study aimed to investigate the perioperative feasibility and benefits of Goal-Directed Fluid Management (GDFM) using noninvasive hemodynamic monitoring in gynecologic oncology patients with acute blood loss and severe fluid loss. We assessed the effects of GDFM on hemodynamics, organ perfusion, complications, and mortality outcomes.

Methods

This randomized prospective study included 104 patients over the age of 18 years, including 56 patients with endometrial cancer and 48 patients with ovarian cancer who had open surgery. The anesthetic approach was standardized for all patients. We compared the perioperative results of the subjects who were randomized into GDFM (n = 51) and Liberal Fluid Management (LFM) (n = 53) groups using a computer program.

Results

The median perioperative crystalloid replacement (2000 vs. 2700; p < 0.001) and total volume of fluid (2260 vs. 3200; p < 0.001) were lower in the GDFM group compared to the LFM group. The hemodynamic findings and the HCO₃ and lactate levels of the GDFM group did not significantly change perioperatively. The heart rate, mean arterial pressure, and HCO₃ levels of the LFM group decreased and serum lactate levels increased perioperatively. The hospitalization rate in ICU (7.8% vs. 28.3%; p = 0.010), rate of patients with comorbidity conditions indicated in ICU (2% vs. 17%; p = 0.024), and rate of complications (17.6% vs. 35.8%; p = 0.047) were lower in the GDFM group compared to the LFM group.

Conclusion

The amount of intraoperatively administered crystalloid solution and complication rates were significantly lower in gynecologic oncologic surgery patients who received GDFM. Besides, hemodynamic findings, and lactate levels of the GDFM group did not change significantly during the perioperative period.

Comparison of Respiratory and Hemodynamic Parameters of COVID-19 and Non-COVID-19 ARDS Patients

Background

COVID-19 can cause a clinical spectrum from asymptomatic disease to life-threatening respiratory failure and acute respiratory distress syndrome (ARDS). There is an ongoing discussion whether the clinical presentation and ventilatory parameters are the same as typical ARDS or not. There is no clear understanding of how the hemodynamic parameters have been affected in COVID-19 ARDS patients. We aimed to compare hemodynamic and respiratory parameters of moderate and severe COVID-19 and non-COVID-19 ARDS patients. These patients were monitored with an advanced hemodynamic measurement system by the transpulmonary thermodilution method in prone and supine positions.

Patients and methods

Data of 17 patients diagnosed with COVID-19 and 16 patients diagnosed with other types of diseases with moderate and severe ARDS, mechanically ventilated, placed in a prone position, had advanced hemodynamic measurements with PiCCO, and stayed in the intensive care unit for more than a week were analyzed retrospectively. Patient characteristics and arterial blood gases analysis recorded at admission and respiratory and advanced hemodynamic parameters during the first week were compared in prone and supine positions.

Results

No difference was observed in the respiratory parameters including respiratory system compliance between COVID-19 and non-COVD-19 patients in prone and supine positions. In comparison of advanced hemodynamic parameters in the first week of intensive care, the extravascular lung water and pulmonary vascular permeability indexes measured in supine position of COVID-19 ARDS patients were found to be significantly higher than non-COVID-19 patients. Duration of prone position was significantly longer in patients diagnosed with COVID-19 ARDS.

Conclusions

The results of this study suggested that COVID-19 ARDS is a variant of typical ARDS with a different pathophysiology.

How to cite this article

Asar S, Acicbe Ö, Sabaz MS, Tontu F, Canan E, Cukurova Z, et al. Comparison of Respiratory and Hemodynamic Parameters of COVID-19 and Non-COVID-19 ARDS Patients. Indian J Crit Care Med 2021;25(6):704-708.

The Systematic Effect of Mesenchymal Stem Cell Therapy in Critical COVID-19 Patients: A Prospective Double Controlled Trial

The aim of this clinical trial was to control the cytokine storm by administering mesenchymal stem cells (MSCs) to critically-ill COVID-19 patients, to evaluate the healing effect, and to systematically investigate how the treatment works. Patients with moderate and critical COVID-19 clinical manifestations were separated as Group 1 (moderate cases, n = 10, treated conventionally), Group 2 (critical cases, n = 10, treated conventionally), and Group 3 (critical cases, n = 10, treated conventionally plus MSCs transplantation therapy of three consecutive doses on treatment days 0, 3, and 6, (as 3 × 106 cells/kg, intravenously). The treatment mechanism of action was investigated with evaluation markers of the cytokine storm, via biochemical parameters, levels of proinflammatory and anti-inflammatory cytokines, analyses of tissue regeneration via the levels of growth factors, apoptosis markers, chemokines, matrix metalloproteinases, and granzyme-B, and by the assessment of the immunomodulatory effects via total oxidant/antioxidant status markers and the levels of lymphocyte subsets. In the assessment of the overall mortality rates of all the cases, six patients in Group-2 and three patients in Group-3 died, and there was no loss in Group-1. Proinflammatory cytokines IFNγ, IL-6, IL-17A, IL-2, IL-12, anti-inflammatory cytokines IL-10, IL-13, IL-1ra, and growth factors TGF-β, VEGF, KGF, and NGF levels were found to be significant in Group-3. When Group-2 and Group-3 were compared, serum ferritin, fibrinogen and CRP levels in Group-3 had significantly decreased. CD45 +, CD3 +, CD4 +, CD8 +, CD19 +, HLA-DR +, and CD16 + / CD56 + levels were evaluated. In the statistical comparison of the groups, significance was only determined in respect of neutrophils. The results demonstrated the positive systematic and cellular effects of MSCs application on critically ill COVID-19 patients in a versatile way. This effect plays an important role in curing and reducing mortality in critically ill patients.

Mesenchymal stem cells treatment in COVID-19 patient with multi-organ involvement

The aim of this study is to evaluate the therapeutic effect of mesenchymal stem cells (MSCs) in a severe case of brain and multiple organ involvement in a patient with COVID-19. Here, a 51-year-old male patient with multi-organ involvement due to COVID-19 infection and developing cardiac arrest is presented. MSCs were transplanted to the patient four times systematically and once intrathecally. As a result, the application of MSCs has been found to have a healing effect on organs in this patient with severe COVID-19 infection. In addition, transplantation of MSCs both systematically and intrathecally is considered to be effective in the treatment of the central nervous system (Tab. 2, Fig. 2, Ref. 24). Keywords: mesenchymal stem cell, COVID-19, organ involvement.

DNA damage effects of inhalation anesthetics in human bronchoalveolar cells

BACKGROUND

The main objective was to evaluate and compare the local genotoxicity of sevoflurane and desflurane in bronchoalveolar cells, while the secondary outcome was to detect systemic oxidative DNA damage. To our knowledge, our study is the first one to evaluate the local effects of inhalation anesthetics in human bronchoalveolar cells in patients.

METHODS

American Society of Anesthesiologists group I-II patients scheduled for lumbar discectomy surgery were enrolled in this randomized prospective study. Patients were randomized to sevoflurane or desflurane for anesthesia maintenance. Bronchoalveolar lavage samples and peripheral blood samples were taken at 2-time points: the first point (baseline, T1); and the second point (postexposure, T2). Final number of 48 samples were the sevoflurane (n = 22) and desflurane (n = 26) groups. Comet assay was applied to examine genotoxic properties. Oxidative DNA damage in plasma was measured with 8-hydroxy-2'-deoxyguanosine (8-OHdG).

RESULTS

T2 values were higher than baseline values in both the desflurane group (tail-length: 66 ± 24, %DNA in tail: 72 ± 60, tail moment: 47.52 ± 14.4; P = .001, P = .005, P = .001, respectively) and the sevoflurane group (tail-length: 58 ± 33, %DNA in tail: 88 ± 80, tail moment: 51.04 ± 26.4; P = .001, P = .012, P = .001, respectively). T2 plasma 8-OHdG levels were also higher than baseline levels in the desflurane group (3.91 ± 0.19 ng/ml vs 1.32 ± 0.20 ng/ml, P = .001) and sevoflurane group (3.98 ± 0.18 ng/ml vs 1.31 ± 0.11 ng/ml, P = .001). There were no differences between the 2 groups in comet parameters and 8-OHdG levels.

CONCLUSION

Our results indicate that both inhalation agents cause DNA damage in the bronchoalveolar cells. Also, we detected increases in plasma 8-OHdG concentrations. Local genotoxicity and systemic oxidized DNA damage were similar in both groups.

The Effectiveness of Scoring Systems in the Prediction of Diagnosis-Based Mortality

Scoring systems are used for mortality and morbidity rating in intensive care conditions, prognosis prediction, standardization of scientific data and the monitoring of clinical quality. The aim of this study was to retrospectively analyze the efficacy of APACHE II (Acute Physiology and Chronic Health Evaluation), APACHE IV and SAPS (Simplified Acute Physiology Score) III prognostic scorings in the prediction of mortality and disease severity of patients admitted to the Anesthesia and Reanimation Clinic Intensive Care Unit (ICU) in Bakırköy Dr. Sadi Konuk Training and Research Hospital according to general and specific diagnoses. A total of 1896 patient files were included in the study. With the exception of single system or head trauma patient groups, a statistically significant difference was found in the mortality prediction rates in all other diagnosis groups (P < 0.05). The discrimination calculated with AUROC fields was sufficient in all groups, and calibration was evaluated as good except for the neurological and neurosurgical patient group. In respect of standard mortality prediction, APACHE II and IV were good in cases of sepsis, and SAPS III made almost exact predictions for cardiovascular diseases, APACHE II for neurological diseases, and APACHE IV for gastrointestinal system diseases. From the results of this study, it was seen that different scoring systems vary in predictions according to the diagnoses, therefore, it can be recommended that the diagnosis should be taken into account more when applying scoring systems.

A comparison of the outcome of CPR according to AHA 2005 ACLS and AHA 2010 ACLS guidelines in cardiac arrest: multicenter study

The aim of this study was to evaluate whether there is a difference in the return of spontaneous circulation (ROSC) and survival with sequel-free recovery rates between the patients who underwent cardiopulmonary resuscitation (CPR) according to 2005 and 2010 guidelines. This study was conducted in the Bakırköy Dr. Sadi Konuk and Kartal Lütfi Kırdar Training and Research Hospital between dates of October 2010 and 28 February 2011 after approval of Ethics Committee. In the first months of the study, CPR was performed according to AHA 2005 ACLS guidelines (Group-1), while CPR was performed according to AHA 2010 ACLS guidelines after November 2010 (Group-2). Patients were assessed for neurological deficit with Cerebral Performance Categories Scale. Mean age was found as 69.01±13.05 (minimum: 21, maximum: 92) in 86 patients included. Of the 33 patients underwent CPR in the Group 1, ROSC was achieved in 51.5%; and 6.1% of these patients were discharged. Of the 53 patients underwent CPR in the Group 2, ROSC was achieved in 37.7%; and 9.4% of these patients were discharged. Although the number of living patients in Group 2 was higher than Group 1, the difference was not found statistically significant (5 versus 2), (P>0.05). But, neurological outcomes were found better with 2010 compared to 2005 guidelines (3/7 versus 0/2 good cerebral performance). It was found that the 2005 CPR guidelines practices in ED were more successful than the 2010 CPR guidelines practices in ROSC, but less successful in the rate of discharge from hospital and neurological sequel-free discharge rate.

The effect of "multiphase sedation" in the course of computed tomography and magnetic resonance imaging on children, parents and anesthesiologists

BACKGROUND AND OBJECTIVES

We aimed to investigate the effect on children undergoing Computed Tomography (CT) or Magnetic Resonance Imaging (MRI), their parents and attending anesthesiologist of "multiphase sedation" which we define as "the intended sedation level achieved with one or more agents through the same or different routes with more than one administration".

MATERIAL AND METHODS

One hundred children and their parents were randomly allocated to one of two study groups. In phase 1; in Group I the patients were given midazolam (0.5mg.kg(-1)) in 5 mL fruit juice, and the ones in control group (Group II) were given only fruit juice. After intravenous (iv) cannulation; in phase II, boluses of propofol were given to achieve the adequate sedation for imaging. Anxiety scores of children and their parents were recorded using Oucher scale and STAI, respectively, and parental satisfaction was evaluated by visual analogue scale (VAS). The number of attempts for iv cannulation, length of time for preparation, and amount of hypnotics were recorded.

RESULTS

Anxiety state of children was similar between groups before premedication, but later it was lower in Group I. Before procedure, STAI score of parents was similar and later it was lower in Group I. Parental satisfaction in Group I was higher. The number of attempts for iv cannulation and required propofol dose was less in Group I.

CONCLUSION

"Multiphase sedation" procedure provides children to feel less pain and anxiety, and decreases parental anxiety while increasing their satisfaction. It supplies a comfortable and safe sedation, as it provides a short and problem-free preparation process for the attending anesthetist as well.

[Monitorization of the effects of spinal anaesthesia on cerebral oxygen saturation in elder patients using near-infrared spectroscopy]

OBJECTIVE

Central blockage provided by spinal anaesthesia enables realization of many surgical procedures, whereas hemodynamic and respiratory changes influence systemic oxygen delivery leading to the potential development of series of problems such as cerebral ischemia, myocardial infarction and acute renal failure. This study was intended to detect potentially adverse effects of hemodynamic and respiratory changes on systemic oxygen delivery using cerebral oxymetric methods in patients who underwent spinal anaesthesia.

METHODS

Twenty-five ASA I-II Group patients aged 65-80 years scheduled for unilateral inguinal hernia repair under spinal anaesthesia were included in the study. Following standard monitorization baseline cerebral oxygen levels were measured using cerebral oximetric methods. Standardized Mini Mental Test (SMMT) was applied before and after the operation so as to determine the level of cognitive functioning of the cases. Using a standard technique and equal amounts of a local anaesthetic drug (15mg bupivacaine 5%) intratechal blockade was performed. Mean blood pressure (MBP), maximum heart rate (MHR), peripheral oxygen saturation (SpO2) and cerebral oxygen levels (rSO2) were preoperatively monitored for 60min. Pre- and postoperative haemoglobin levels were measured. The variations in data obtained and their correlations with the cerebral oxygen levels were investigated.

RESULTS

Significant changes in pre- and postoperative measurements of haemoglobin levels and SMMT scores and intraoperative SpO2 levels were not observed. However, significant variations were observed in intraoperative MBP, MHR and rSO2 levels. Besides, a correlation between variations in rSO2, MBP and MHR was determined.

CONCLUSION

Evaluation of the data obtained in the study demonstrated that post-spinal decline in blood pressure and also heart rate decreases systemic oxygen delivery and adversely effects cerebral oxygen levels. However, this downward change did not result in deterioration of cognitive functioning.

Monitorization of the effects of spinal anaesthesia on cerebral oxygen saturation in elder patients using near-infrared spectroscopy

OBJECTIVE

Central blockage provided by spinal anaesthesia enables realization of many surgical procedures, whereas hemodynamic and respiratory changes influence systemic oxygen delivery leading to the potential development of series of problems such as cerebral ischemia, myocardial infarction and acute renal failure. This study was intended to detect potentially adverse effects of hemodynamic and respiratory changes on systemic oxygen delivery using cerebral oxymetric methods in patients who underwent spinal anaesthesia.

METHODS

Twenty-five ASA I-II Group patients aged 65-80 years scheduled for unilateral inguinal hernia repair under spinal anaesthesia were included in the study. Following standard monitorization baseline cerebral oxygen levels were measured using cerebral oximetric methods. Standardized Mini Mental Test (SMMT) was applied before and after the operation so as to determine the level of cognitive functioning of the cases. Using a standard technique and equal amounts of a local anaesthetic drug (15mg bupivacaine 5%) intratechal blockade was performed. Mean blood pressure (MBP), maximum heart rate (MHR), peripheral oxygen saturation (SpO2) and cerebral oxygen levels (rSO2) were preoperatively monitored for 60min. Pre- and postoperative haemoglobin levels were measured. The variations in data obtained and their correlations with the cerebral oxygen levels were investigated.

RESULTS

Significant changes in pre- and postoperative measurements of haemoglobin levels and SMMT scores and intraoperative SpO2 levels were not observed. However, significant variations were observed in intraoperative MBP, MHR and rSO2 levels. Besides, a correlation between variations in rSO2, MBP and MHR was determined.

CONCLUSION

Evaluation of the data obtained in the study demonstrated that post-spinal decline in blood pressure and also heart rate decreases systemic oxygen delivery and adversely effects cerebral oxygen levels. However, this downward change did not result in deterioration of cognitive functioning.

An alternative treatment in hypertriglyceridemia-induced acute pancreatitis in pregnancy: Plasmapheresis

Hormonal influences during pregnancy can compromise otherwise controlled lipid levels in women with familial hypertriglyceridemia and predispose to pancreatitis leading to increased morbidity in both mother and fetus. Both cholesterol and triglyceride levels in serum increase progressively during pregnancy. The mainstay of treatment includes dietary restriction of fatty meal and lipid-lowering medications. Experiences with plasmapheresis are limited. We report two cases of hypertriglyceridemia-induced acute pancreatitis during pregnancy, which were successfully treated by plasmapheresis.

Comparison of dexmedetomidine and three different doses of midazolam in preoperative sedation

Background:

This study was conducted to compare the efficacy and effects of dexmedetomidine and midazolam in preoperative sedation.

Materials and Methods:

A total of 125 patients in American Society of Anaesthesiologists (ASA) I-II were divided into three groups: Group I (n = 40) for controls, Group II (n = 40) for Dexmedetomidine (1 μg/kg), and group III was the midazolam group (n = 45). Group III was further divided into three subgroups according to the doses of midazolam: Group IIIA (n = 15) received 0.02 mg/kg, group IIIB (n = 15) received 0.04 mg/kg, and group IIIC (n = 15) received 0.06 mg/kg of midazolam. Drugs were infused over a 10-minute period with appropriate monitoring. Ramsay and visual analog scores, for sedation and anxiety, respectively, and mean arterial pressure, heart rate, and SpO₂ measurement, including respiratory rates were recorded, every 5 minutes for 30 minutes following infusion.

Results:

There was marked sedation and a decrease in anxiety in groups II and IIIC (P < 0.01). Mean arterial pressure (MAP) and heart rate (HR) decreased significantly in group II (P < 0.01 and P < 0.05, respectively), but there was no associated hypotension (MAP <60 mm Hg) or bradycardia (HR <50 bpm) (P < 0.05). Respiratory rates and SpO₂ values decreased in groups II, IIIA, IIIB, and IIIC. The differences in respiratory rates were not significant (P > 0.05); however, decrease in SpO₂ was significant in group IIIC (P < 0.01).

Conclusions:

Dexmedetomidine was as effective as higher doses of midazolam in sedation. The hemodynamic and respiratory effects were minimal. Although dexmedetomidine caused significant decrease in the blood pressure and heart rate, it probably just normalized increased levels caused by preoperative stress.