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A 61-year-old male patient diagnosed with Coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) was managed with tracheostomy and intermittent prone positioning in the intensive care unit. After a sudden deterioration, examination of tracheostomy tube (TT) and X-ray of the chest revealed that he had aspirated the fractured TT. The fractured tube was removed through the tracheostomy stoma using a rigid ventilating bronchoscope and forceps. Prone positioning is a beneficial postural therapy capable of improving patient oxygenation. However, it has some complications, like unplanned extubation and facial tissue injury. Percutaneous tracheostomy is also a valuable and safe procedure and has been increasingly performed in critical care patients, including those who suffer from COVID-19 ARDS. Fractures and aspiration of a tracheostomy tube can occur anytime after tracheostomy. We think prone positioning may contribute to the rupture and aspiration of the tracheostomy tube in this study. [ABSTRACT FROM AUTHOR]

Objective: Rapid response systems (RRSs), which aim to prevent cardiac arrests and unexpected deaths, have been implemented across hospitals worldwide. Most studies on RRS shave evaluated the effects of its implementation on in-hospital mortality. In this study, we evaluated the predictive factors of in-hospital mortality for patients who were subjects of RRS activation in a newly established major hospital in Turkey. Materials and Methods: Data on RRS activations were reviewed from paper charts and electronic medical records between March 2019 and February 2020. The demographic characteristics of patients, time of and reasons for RRS activation, initial cardiac rhythm, heart rate, mean arterial pressure, pulse oximetry-measured blood oxygen saturation (SpO2), time of arrival of the rapid response team, red cell distribution width, platelet distribution width obtained from the first blood gas analysis and haemogram test results as well as glucose, sodium, potassium, pH, lactate, neutrophils and lymphocyte levels were recorded. Univariate and multivariate logistic regression analyses were conducted to determine the independent predictors of in-hospital mortality. Results: A total of 531 patients were included in the analysis. Of these, 189 (35.6%) died during hospital admission. Compared with survivors, non-survivors were older (median age, 64 vs. 52 years) and more likely to be male (65.6% vs. 34.4%); be admitted for cardiovascular, pulmonary and oncologic diseases and trigger RRS at night and weekends than during the day. Activation of RRS by respiratory and haemodynamic triggers as well as during nighttime and weekend hours oncologic reasons for hospital admission, low SpO2 levels, high neutrophil-to-lymphocyte ratio (NLR), potassium levels and lactate levels were predictive of in-hospital mortality. Conclusion: This study found some weaknesses in the current RRS of the hospital. Hospital staffs working overnight and on weekends should be trained and empowered. SpO2, potassium and lactate levels as well as NLR are predictors of in-hospital mortality and can guide triage decision making, which is usually a challenging and stressful task. [ABSTRACT FROM AUTHOR]

Introduction: Hospital-acquired anemia (HAA) is common, especially in the most intensive care patients (ICP). Several literature series suggest that patients who develop HAA have increased mortality and morbidity compared with those who do not. The cause of HAA is likely multifactorial; iatrogenic blood loss,impaired erythropoiesis, bleeding episodes all can lead to HAA in ICP. Little research has focused on HAA, which develops during ICU admission of ARDS patients. The objective of this study was to investigate the incidence HAA, as well as its relationship with mortality, in COVID-19 associated ARDS patients admitted to ICU. Materials and Methods: We retrospectively analyzed all adult COVID-19 ARDS patients admitted to our ICU between January 2020 and December 2021 (n=1,007). Patients with missing data (n=7) or who have a length of ICU stay of less than 24 hours (n=10) were excluded. In addition, patients with chronic anemia at admission (n=445) were also excluded, because main focus of the study was development of HAA. Anemia is defined as a hemoglobin (Hgb) value <12 g/dL in women and <13 g/dL in men by WHO. HAA was defined as a nadir Hgb value during the course of ICU stay meeting WHO criteria. We further grouped Hgb by degree into mild anemia (Hgb >11 and <12 g/dL in women, >11 and<13 g/dL in men), moderate anemia (Hgb >9 and ≤11 g/dL) and severe anemia (Hgb ≤9 g/dL). COVID-19 ARDS is diagnosed when the patient with confirmed COVID-19 infection meets the Berlin 2012 ARDS diagnostic criteria. Baseline patient characteristics, admission Hgb and lactate levels, lengths of ICU stay and in-hospital mortality of patients who developed HAA were compared with those who did not develop HAA. We further stratified the patients based on the severity of HAA. Results: HAA developed in 373 (68.4%) patients. Characteristics and mortality rates of patients with and without HAA are presents in Table 1. Table 2 shows the data of the patients by presence and severity of HAA. Conclusion: Development of HAA is common and associated with higher in-hospital mortality. Patients who developed severe HAA has the highest mortality rates (73.1%). Hospitals must raise awareness of HAA. [ABSTRACT FROM AUTHOR]

Introduction: Low hemoglobin levels are associated with an increased risk of mortality in intensive care (ICU) patients. The underlying reason is due to the limitation in oxygen delivery to the tissues caused by a reduction in the number of oxygen carrying erythrocytes. This study aimed to examine the relationship between hemoglobin drop (DHgb= admission hemoglobin-nadir hemoglobin), nadir hemoglobin levels (NdrHgb; the lowest hemoglobin value during ICU stay) and mortality in COVID ARDS patients admitted to intensive care. Materials and Methods: This was a prospective non-randomized study of consecutive COVID ARDS patients who had at least two determinations of hemoglobin level (the first on admission) separated by 24 hours and an ICU stay <14 days. Admission hemoglobin (AdmHgb), NdrHgb and DHgb levels were analyzed. Data on blood transfusions were also collected. Results: Although high DHgb and low NdrHgb levels were significantly associated with mortality in univariate analysis of patients, this was not sustained in multivariate analysis. The area under the ROC curve (AUC) of DHgb was 0.577, with a cut-off value of 1.9 g/dL, sensitivity and specificity were 50.7%, and 65.2%, respectively. NdrHgb had a cut-off value of 10.7 g/ dL, with an AUC of 0.423, sensitivity and specificity of 50%. Conclusion: Our results showed that DHgb and low NdrHgb levels are both predictive markers for mortality with moderate sensitivity and specifity. We recommend further studies evaluating a simple scoring model based on DHgb and NdrHgb for predicting mortality. [ABSTRACT FROM AUTHOR]

Introduction: Stroke is the second most common cause of death (85%) worldwide. In addition, stroke patients with good nutritional parameters have a lower risk of death and earlier discharge from the hospital. In our study, we evaluated nutritional and other factors affecting intensive care mortality in stroke patients followed in the general intensive care unit. Materials and Methods: The data of 239 hemorrhagic and ischemic stroke patients followed in general intensive care units following ethics committee approval were evaluated retrospectively. Nutritional, sociodemographic and clinical characteristics of patients with hemorrhagic and ischemic stroke were compared and the effects of these characteristics on mortality were evaluated. Results: Comparisons of patients with hemorrhagic - ischemic stroke and stroke patients who lived and died was given in Table 1. Results of univariate and multivariate cox regression analysis performed to determine risk factors affecting intensive care mortality was given in Table 2. In the univariate model, stoke type, CPR (cardio-pulmonary resuscitation) requirement during intensive care stay, feeding time rate, nasogastric requirement, oral nutritional status, chronic kidney disease and APACHE II were statistically significant. In the multivariate model, the need for CPR, oral nutritional status, and APACHE II were statistically significant during ICU admission (respectively, p=0.032, p<0.001, p<0.001). Mortality risk was 14.8 times higher in patients who could not be fed orally than in patients who were fed orally. It was determined that a one-unit increase in the APACHE II score increased the mortality risk 1.07 times. Conclusion: We can say that mortality will decrease in stroke patients who can be fed orally, have a low APACHE II score, and do not need CPR during intensive care follow-up [ABSTRACT FROM AUTHOR]

Neuromuscular blocking agents can be used for purposes such as eliminating ventilator-patient dyssynchrony, facilitating gas exchange by reducing intra-abdominal pressure and improving chest wall compliance, reducing risk of lung barotrauma, decreasing contribution of muscles to oxygen consumption by preventing shivering and limiting elevations in intracranial pressure caused by airway stimulation in patients supported with mechanical ventilation in intensive care units. Adult Respiratory Distress Syndrome (ARDS), status asthmaticus, increased intracranial pressure and therapeutic hypothermia following ventricular fibrillation--associated cardiac arrest are some of clinical conditions that can be sustained by neuromuscular blockade. Appropriate indication and clinical practice have gained importance considering side effects such as ICU-acquired weakness, masking seizure activity and longer durations of hospital and ICU stays. We mainly aimed to review the current literature regarding neuromuscular blockade in up-to-date clinical conditions such as improving oxygenation in early ARDS and preventing shivering in the therapeutic hypothermia along with summarising the clinical practice in adult ICU in this report. [ABSTRACT FROM AUTHOR]

Neuromuscular blocking agents can be used for purposes such as eliminating ventilator-patient dyssynchrony, facilitating gas exchange by reducing intra-abdominal pressure and improving chest wall compliance, reducing risk of lung barotrauma, decreasing contribution of muscles to oxygen consumption by preventing shivering and limiting elevations in intracranial pressure caused by airway stimulation in patients supported with mechanical ventilation in intensive care units. Adult Respiratory Distress Syndrome (ARDS), status asthmaticus, increased intracranial pressure and therapeutic hypothermia following ventricular fibrillation--associated cardiac arrest are some of clinical conditions that can be sustained by neuromuscular blockade. Appropriate indication and clinical practice have gained importance considering side effects such as ICU-acquired weakness, masking seizure activity and longer durations of hospital and ICU stays. We mainly aimed to review the current literature regarding neuromuscular blockade in up-to-date clinical conditions such as improving oxygenation in early ARDS and preventing shivering in the therapeutic hypothermia along with summarising the clinical practice in adult ICU in this report. [ABSTRACT FROM AUTHOR]

Objective: Noninvasive mechanical ventilation (NIMV) decreases the incidence of endotracheal intubation and complications related to the endotracheal intubation in acute respiratory failure. However, there is some concern that it can increase mortality due to the delay of endotracheal intubation. We aimed to evaluate the efficacy of NIMV in acute pulmonary edema (APE) and postoperative respiratory failure (PORF) patients. Materials and Methods: Records of 100 NIMV assisted patients suffering from APE and PORF were evaluated, retrospectively, for a period from Jan 01, 2011 to Dec 15, 2012. The patients were divided into two groups as APE (group 1; n=59) and PORF (group 2; n=41) patients. The demographic data of the patients having a frequency of endotracheal intubation after NIMV, the time between initiation of NIMV and intubation, ejection fraction (EF), systolic pulmonary arterial pressure, APACHE II scores, intensive care unit/hospital length of stay and mortality rate were recorded. Results: There were no significant differences between the groups in terms of endotracheal intubation incidence and the time between initiation of NIMV and intubation. The intubated patients had a longer length of hospitalization and stay in intensive care unit, higher baseline APACHE II scores, and mortality rates compared to nonintubated patients in both groups. The patients with chronic obstructive pulmonary disease in group 1 and with lower EF in group 2 were more likely to be intubated. Conclusion: In this study, we observed that higher baseline APACHE II scores were associated more with a high mortality rate than the extension of time between NIMV and endotracheal intubation in patients with two different acute respiratory failures, like APE and PORF. [ABSTRACT FROM AUTHOR]

Introduction: Massive PTE is a life-threatening clinical condition with high mortality.In this case report, we aimed to draw attention to a case who underwent VA-ECMO after systemic tPA with the diagnosis of massive PTE. Case: A 19-year-old male patient without comorbidity was admitted to ER with the complaint of dyspnea. PTE was diagnosed since thrombus was seen in main PA in pulmonary CT angiography. Half-dose tPA was administered to the desaturated patient during the follow-up in ER and patient develops cardiac arrest in ER. CPR is performed. Response to CPR is obtained, second arrest develops while being transferred to ICU (5 min CPR). RV dilatation, paradoxical movement in the septal wall and deviation to LV (D septum), severe hypokinesia indicating RV dysfunction were observed in bedside ECHO in ICU. The decision to apply VA-ECMO was made to the patient who developed massive PTE and shock with ECHO and CT findings. Bedside femoro-femoral VA-ECMO was performed. D septum and RV dilatation disappeared in the control ECHO. The patient’s hemodynamics returned to normal limits. However, bleeding from the cannula entry sites developed in a tPA patient before. Despite blood product replacements and pressure dressing, patient’s bleeding continued. Three hours after he was taken to VA-ECMO, patient arrested and died. Discussion: In the treatment of massive PTE, tPA and VA-ECMO can be applied. In a research consisting of cases similar to case presented in literature, it was reported that in the patient group with PTE who underwent systemic tPA and VA-ECMO, more CPR was applied before ECMO, major bleeding was more common, and there was no difference in mortality between the two groups. Massive PTE mortality is quite high. Although the response to tPA is good, adequate results may not always be obtained and more aggressive treatment modality such as VA-ECMO may be required. Hemorrhage, which is the biggest risk of VA-ECMO application after tPA, also poses a serious risk for mortality [ABSTRACT FROM AUTHOR]

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Central venous catheterization is performed frequently in especially intensive care, major surgery and cancer patients and arterial cannulation is one of the most serious complications of this procedure. Assessment of the colour, pulsatility and pressure of blood coming from the needle or injector, USG guidance, assessment of blood gases, fluoroscopy and echocardiography can be used for avoiding and recognizing this complication during the procedure. In this report; we interpreted the doubt of carotid artery cannulation because of very high oxygenation levels of the blood obtained from catheter after jugular venous catheterization in an intensive care patient with sepsis. [ABSTRACT FROM AUTHOR]

Amaç: Bira potomanyası, nadir görülen bir hiponatremi nedeni olup, ilk olarak 1972’de ağır bira içicilerde tanımlanmıştır. Biranın hipotonisitesi ve alkolün proteoliz üzerindeki süpresif etkisi sonucu oluşan dilüsyonel hiponatremi asemptomatik olabileceği gibi; bulantı, kusma, nöbet gibi semptomlara neden olabilir; koma ve ölümle sonuçlanabilir. Semptom ciddiyeti genellikle hiponatremi derecesiyle ilişkilidir. Bu bildiride amacımız ilk hastane başvurusunda 99 mmol/L sodyum değerine rağmen koopere, oriente olan olgumuzu sunmaktır. Olgu: Depresyon ve FMF dışında ek hastalığı bulunmayan 42 yaşındaki erkek hasta öksürük ve halsizlik şikayetiyle başvurduğu dış merkezde COVID-19 şüphesiyle tetkik edilmiş. PCR negatif gelen hastanın toraks tomografisindeki pnömonik infiltrasyonu nedeniyle COVID-19 öntanısıyla hastanemiz pandemi servisine sevk edilmesine karar verilmiş. Kan gazı tetkikinde sodyum değerinin 99 mmol/L olması üzerine hipertonik salin tedavisi eşliğinde hastanemize transfer edilen hastanın pandemi servisinde alınan kan gazında sodyum değeri tekrar 99 mmol/L gelince hiponatremi tedavisine devam edilmiş. Bu sırada koopere, oriente olan hastada yakın monitorizasyonla beraber kan biyokimya takibi yapılırken ani kardiyak arrest gelişmiş. Hasta, pandemi servisinde yapılan 15 dakikalık KPR sonrasında entübe şekilde yoğun bakımımıza alındı. Kan sodyum düzeyinin 24 saatte 10 mmol/L’den fazla yükseltilmemesi hedeflenerek hiponatremi tedavisine devam edildi. Yapılan tüm diğer kardiyopulmoner destek tedavilerine rağmen yoğun bakıma kabulünün 15. saatinde hasta kaybedildi. Sonuç: “Beer potomonia”, bira gibi hipotonik alkolleri fazla miktarda tüketen kişilerde protein malnütrisyonunun da eklenmesiyle görülebilen kronik bir hiponatremi sendromudur. Ciddi hiponatremisi olan hastalar, özellikle kronik hiponatreminin hızlı düzeltilmesiyle görülebilen “santral pontin myelinolizis” gibi ciddi sonuçlar nedeniyle oldukça korkulan bir hasta grubudur. Bunun yanında hiponatremi nadir de olsa ST segment değişikliklerine ve AV blok gibi kardiyak iletim defektlerine de neden olabilir. Olgumuzun GKS’nin 15, şikayetinin öksürük ve halsizlik olup pandemi döneminde klinisyenlerin COVID-19 öntanısına yoğunlaşmaları, sodyum düşüklüğünün hem dış merkez, hem hastanemiz pandemi servisine ilk kabulünde kan gazı örneklemesiyle gösterilebilmiş olması hastanın yoğun bakıma transferini geciktirmiştir. Anamnezinde özellikle hipotonik alkollerin fazla tüketimi olan hastalarda “bira potomanyası” akla getirilmelidir. [ABSTRACT FROM AUTHOR]

Amaç: Sarkopeni; iskelet kas kütlesinin, kuvvetinin ve performansının özellikle yaşlılarda ilerleyici, yaygın ve istenmeyen kaybı olarak tanımlanmıştır. Yoğun bakımda gelişen akut sarkopeni ya da eşlik eden hastalıklarla birlikte yavaş gelişen kronik sarkopeni entübe hastalarda weaning güçlüğüne, hastane ve yoğun bakım yatış gününün uzamasına ve mortalitede artışa neden olur. COVID-19 pnömonisi sırasında weaning zorluğu yaşadığımız ve eks olan olgumuzda saptadığımız sarkopeniyi tartışmayı amaçladık. Olgu: Alkol bağımlılığı nedeni ile dış merkezde tedavi olurken yüksek ateşi olan 52 yaşındaki erkek olgu (78 kg,174 cm) hastanemiz acil servisine getirildi. Toraks tomografisi COVID-19 uyumlu olduğundan servise yatırıldı. Oksijen ihtiyacı artınca 10. günde genel yoğun bakıma alındı. Bilinç açık, vital bulguları stabildi. Ateşi yoktu. Periferik oksijen satürasyonunun %81- 85 olması üzerine yüksek akımla nazal oksijen tedavisi (%100 oksijen/60 L/dk akım) başlandı. Alkol bağımlılığı açısından gastroenteroloji ve psikiyatri önerileri alındı. Yoğun bakım yatışının 24. saatinde entübe edilerek mekanik ventilatöre bağlandı. Sedasyon başlandı. Yatışının 20. gününde hasta ekstübe edildi. Beş gün ekstübe izlendi. Ancak sonra tekrar entübe edildi. Karaciğer fonksiyonlarında devam eden yükseklik nedeni ile abdominal tomografi (AT) çekildi. AT’de L3 vertebra hizasından iskelet kas kütle ölçümleri (psoas, paraspinal kaslar ve abdominal duvar kasları) yapıldı (Şekil 1). Bulunan değerin olgunun boyunun karesine olan oranının (iskelet kas kütle indeksi: 31,4 cm2/m2, erkeklerde eşik değer: 52,4 cm2/m2) düşük olması sarkopeni lehine değerlendirildi. Yatışının 31. gününde eks oldu. Sonuç: Acil servise gelişte AT olmadığı için var olan sarkopenin akut veya kronik olup olmadığı bilinmemektedir. Olgunun hastaneye gelişte kronik alkol kullanımına bağlı sarkopenik olacağı düşünülmüştür. COVID-19 enfeksiyonunun akut evresinin yaklaşık 2 hafta sürdüğü, oral alımın iştahsızlık veya anosmi nedeni ile azaldığı ve aynı zamanda hızlı bir katabolik süreç geliştiği, vücut ağırlığının yaklaşık %5-10’unun kaybına yol açtığı görülmüştür. Yoğun bakıma yatışının 25. gününde çekilen AT’de iskelet kas kütle indeksinin düşük bulunması sarkopeniyi gösterir. Ancak akut veya kronik ayrımını yaptırmaz. COVID-19 seyrinde sarkopeni gelişebileceği, eşlik eden hastalıkların varlığında sarkopeninin artabileceği, weaning güçlüğü ve mortalite artışına yol açabileceği akılda bulundurulmalıdır. [ABSTRACT FROM AUTHOR]

Amaç: Bu çalışmanın amacı, üçüncü basamak pandemi merkezi olan Ankara Şehir Hastanesi Yoğun Bakımları’nda COVID-19 gebe hastaların dönemsel özelliklerini paylaşmak. Gereç ve Yöntem: 21 Mart 2020-30 Kasım 2021 tarihleri arasında YBÜ’ye kabul edilen gebe hastaların verileri etik kurul onamı sonrası retrospektif olarak incelendi. Hastaların demografik ve klinik özellikleri üç döneme ayrılarak (Ağustos-Aralık 2020, Ocak-Haziran 2021, Temmuz-Kasım 2021) karşılaştırıldı. Bulgular: Toplam 109 gebe COVID-19 hastanın ortalama yaşı 30,5, APACHE II 9,68, gebelik haftası 28,5 idi. Hastaların %98’i tekil gebelik, %72,5’i 3. trimesterde, %92,6’sında PCR pozitif, %20,1’i delta varyantı, 5’i aşılı idi. %94,5’i dispne ile başvurdu, %45’inin IMV gereksinimi oldu, MV süresi 8,5 gün, YBÜ yatış süresi 11,6 gün idi. Yedi hastaya ECMO uygulandı, %21’inde gebelik devam etti, %49,5’ine 250 mg steroid, %34’üne anakinra, %57,8’ine antiviral verildi. Mortalite oranı %25,6’idi. Hastaların 18’i (%16,5), AğustosAralık 2020; 23’ü (%21) Ocak-Haziran 2021, 68’i (%62,4) Temmuz-Kasım 2021’de YBÜ’ye kabul edildi. Sonuç: Gebelerde de en sık başvuru semptomu COVID-19’un tipik semptomu olan dispne idi. YBÜ’ne kabul gebelik süresi ilerledikçe daha fazla idi. Uygulanan tedaviler ve pnömotoraks gibi gelişen komplikasyonlar arasında fark bulunmadı. Ancak delta varyantı son periyotta tespit edildi ve bu dönemde istatistiksel farklılık bulunmasa da YBÜ’ye kabul edilen gebelerin sayısında artış saptandı. Sonuç olarak, bu çalışmada, tüm toplumda olduğu gibi delta varyantının gebeleri de daha fazla enfekte ederek YBÜ’ye başvuru sıklığını artırdığı saptandı. [ABSTRACT FROM AUTHOR]