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Aim: Sedation is a fundamental component of the pediatric gastrointestinal endoscopy (GIE). The dosing of drugs to be used for sedating the child is an important aspect of the efficacy and safety of procedural sedation. Besides, outpatient procedures are stressful situations for pediatric patients and also their families, and therefore, parental anxiety may affect children indirectly. The first aim of the study was to assess the association between parental anxiety and required sedative dose in children undergoing GIE. The second aim was to assess the factors associated with children’s preoperative anxiety. Material and Method: This study was a prospective, observational, and single-center study performed by the same fellowship-trained pediatric gastroenterology specialist and the same anesthesiology specialist. Parental anxiety was evaluated with the State-Trait-Anxiety-Scale (STAI) and children's anxiety was evaluated with the Modified Yale Preoperative Anxiety Scale (mYPAS). Midazolam, ketamine, propofol, and fentanyl were administered for the children’s sedation. There were 2 comparisons in this study, the anxiety of parents according to mean STAI scores, and anxiety of children according to mYPAS scores. Results: Of 120 children and parents, 87 parents (73%) and 57 children (48%) had high anxiety. Of 120 parents, 111 parents (92%) were mothers of the children. Younger children had higher anxiety levels. Before and the start of the GIE heart rates of children were higher both in the high anxiety group of parents and children. In sedatives, high anxiety parents’ children and high anxiety children were required more ketamine dosages. (p

Objective: In recent years, the neutrophil-to-lymphocyte ratio (NLR) has become a parameter sought in the prediction of aggressive prognosis or mortality in many studies including sepsis, infectious diseases, and malignancies. There are publications studying the correlation between the high values of this parameter, which can be interpreted as an indirect indicator of the host’s immune response, in the COVID-19 infection with mortality. The primary objective of our study is to evaluate the correlation between the height of NLR values in the patients followed up in our intensive care units (ICU) with the final diagnosis of COVID-19 infection (PCR(+)), the continuation of such high values throughout the treatment and mortality, and finally obtain a cut-off value in predicting the prognosis. Method: The case files with final diagnosis of COVID-19 infection followed up and treated in our 3rd Level Intensive Care Unit from 21 March 2020 to 1 July 2020 were screened retrospectively and included in the study. These cases were examined in two groups: exitus (n=113) and survivors (n=70). The demographics of the cases such as age, gender, comorbid diseases as well as their vital signs and clinical and laboratory features were screened from the Hospital Operating System (HOS) and archive files, and recorded. The correlation among the data obtained as well as the correlation between such data and mortality were analyzed. Findings: In the study conducted on 183 cases, the ages, APACHE II scores, admission NLR values, study endpoint NLR values, neutrophil, procalcitonin, D-dimer, PT and INR levels, and MV (Mechanical Ventilation) durations of the exitus cases were found statistically significantly higher than the survivor cases. In the exitus cases, the cut-off point found for the admission NLR was >7.82. During the course of treatment, the patients with high NLR level had poor prognosis. The patients’ NLR values at the study endpoint were analyzed. The conclusion is that >6 as the cut-off point value is significant from the viewpoint of mortality. In addition, it was observed that a NLR level over 6 despite the treatment increased the mortality rate by 15.6 times. Conclusion: We have found out that old age, long MV duration, prolonged high levels of D-dimer, neutrophil, PT, INR and NLR levels increase the mortality rate. Being able to predict the course of prognosis and using early warning systems will increase the survival rate. In this regards, we consider closer monitoring of the patients with high NLR level, particularly in the intensive care units even if they do not have respiratory distress, will decrease mortality significantly. NLR can help identifying the COVID-19 patients with high risk level. High NLR level during the intensive care monitoring process may be regarded as insufficient immune response, and thus correlated with mortality and aggressive prognosis.

Background: Establishing a relationship between COVID-19 severity and olfactory dysfunction may be beneficial in patient follow-up. Thus, in this study, we aimed to evaluate the association between self-reported olfactory dysfunction and the clinical stages of COVID-19. Methods: The patients included in this study were divided into three groups according to the severity of the novel coronavirus disease as mild, severe, and critical (life-threatening) patients. Patients were then contacted by phone and asked questions with the help of structured questionnaires that evaluated their general status, sense of smell, taste and compared the data within the three groups. Results: Among the 144 subjects evaluated in the present study (mild, n = 60; moderate, n = 61, severe, n = 23), 70 of the participants were males, and 74 were females. The findings showed that olfactory loss was the most prominent feature of the COVID-19's mild clinical course and the majority of the patients with loss of smell were female and young patients. Conclusion: The findings obtained from clinically mild cases suggest that more olfactory dysfunction, indicating that the effects of viral load alone, is not decisive for olfactory dysfunction.

Objective: This study aimed to investigate the impact of tocilizumab, an IL6R inhibitor, on clinical features and laboratory tests of subjects admitted with severe COVID-19 and respiratory failure. Material and Methods: A total of 30 patients with positive polymerase chain reaction for COVID-19 and respiratory failure were analyzed in a retrospective manner. All patients received 8mg/kg body weight tocilizumab i.v. once in addition to the standard COVID-19 treatment protocol, including Oseltamivir phosphate 75mg twice daily, hydroxychloroquine 200 mg twice daily, and azitromycine 250 mg once daily following a 500 mg loading dose. Demographic characteristics, and clinical features including oxygen saturation, the concentration of oxygen inhalation, body temperature, mean arterial pressure and heart rate, and SpO2, end-tidal CO2, and blood tests including complete blood count, procalcitonin, C-reactive protein (CRP), Troponin-I, D-dimer, and liver and kidney function tests were recorded before and after treatment with tocilizumab. Results: A significant increase occurred in SaO2 on first and third days following treatment with tocilizumab (84.3 % and 90.3%, respectively, p

Objective: This study aimed to investigate the factors that affect the preference of the anesthesia method in patients who were indicated for general or regional anesthesia. Material and Methods: A descriptive questionnaire was used to evaluate the opinions of 123 patients who were planned to undergo elective surgery in the orthopedics and traumatology outpatient clinic between January 2018 and June 2019. Results: 73 women (%59) and 50 men (%41) participated in the study. The mean age was 58.62±11 years. General anesthesia was preferred in 58% of the patients. The most common reason for rejection was that the patients who preferred general anesthesia did not want to receive visual and auditory stimuli during the surgical procedure. There was a significant positive correlation between education level and regional anesthesia preference rate. There was a significant positive correlation between the regional anesthesia preference rate of patients receiving hand and foot surgery indications. Conclusion: The preference of the majority of patients was found to be general anesthesia method. Additionally, the type of surgery and education level of the patients was found to be effective in preference of the anesthesia method.

Aim: Inflammation may have deleterious effects on tissue healing. Pressure ulcers impair the quality of life of the patients admitted to intensive care unit (ICU) besides increasing the health costs. Neutrophil to lymphocyte ratio (NLR) and mean platelet volume (MPV) are simple and readily available markers proinflammatory state. This study aimed to investigate whether measurement of admission NLR and MPV could be useful in identification of the patients who are at elevated risk for the development of the pressure ulcers.Methods: This retrospective cohort study evaluated 104 patients admitted to the intensive care unit of a tertiary center. Patients were divided into two groups according to the presence of pressure ulcers as follows: Patients without pressure ulcers throughout hospitalization and patients who developed pressure ulcers while hospitalized. The two groups were compared with respect to the demographic features and complete blood count parameters at admission.Results: The NLR [8.8 (6.6) vs. 5.3 (2.6), P, Amaç: İnflamasyonun doku iyileşmesi üzerinde olumsuz etkileri olabilir. Basınç ülserleri, yoğun bakım ünitesine (YBÜ) kabul edilen hastaların yaşam kalitesini bozmanın yanı sıra sağlık maliyetlerini de arttırır. Nötrofil/lenfosit oranı (NLR) ve ortalama trombosit hacmi (MPV) basit ve kolayca temin edilebilen proinflamatuar belirteçlerdir. Bu çalışma, NLR ve MPV giriş ölçümünün, basınç ülserlerinin gelişimi için yüksek risk altında olan hastaların tanımlanmasında faydalı olup olmadığını araştırmayı amaçlamıştır.Yöntemler: Bu retrospektif kohort çalışması ile üçüncü basamak bir merkezin yoğun bakım ünitesine başvuran 104 hastanın değerlendirilmesi yapıldı. Basınç ülseri varlığına göre hastalar şu şekilde iki gruba ayrıldı: Hastanede yatış boyunca basınç ülseri olmayan hastalar ve hastanede yatış döneminde basınç ülseri gelişen hastalar. İki grup demografik özellikler ve geliş tam kan sayımı parametreleri açısından karşılaştırıldı.Bulgular: NLR [8,8 (6,6) / 5,3 (2,6), P

BACKGROUND: Oxygen therapy provided via high-flow nasal cannula (HFNC) improves gas exchange lung compliance and results in increased lung expiratory volumes. Previous data indicate that hyperbaric and humid states improve the olfactory thresholds compared to hypobaric and dry conditions. This prospective, observational study aimed to determine the impact of oxygen delivery through HFNC on olfactory function in subjects admitted to the ICU for acute respiratory failure (ARF). METHODS: 30 subjects who were admitted to the ICU for ARF underwent an olfactory sniff test before and after oxygen therapy with HFNC. Baseline olfactory function of subjects with ARF was also compared against 30 healthy controls. Odor threshold (OT), odor discrimination (OD), odor identification (OI) and global olfactory score (TDI) were recorded for all subjects. RESULTS: The OT, OD, OI, and TDI scores were significantly higher in the control group compared to the baseline scores of the subjects with ARF (P CONCLUSIONS: Our results indicate that subjects with ARF had relative olfactory dysfunction compared to healthy controls. These results also suggest that implementation of HFNC to relieve hypoxemia in subjects presenting with ARF can lead to a significant improvement in olfactory function.

ObjectivesAcute kidney injury (AKI) affects up to one-quarter of hospitalised patients and 60% of patients in the intensive care unit (ICU). We aim to understand the baseline characteristics of patients who will develop distinct AKI trajectories, determine the impact of persistent AKI and renal non-recovery on clinical outcomes, resource use, and assess the relative importance of AKI severity, duration and recovery on survival.MethodsIn this retrospective, longitudinal cohort study, 156 699 patients admitted to a quaternary care hospital between January 2012 and August 2019 were staged and classified (no AKI, rapidly reversed AKI, persistent AKI with and without renal recovery). Clinical outcomes, resource use and short-term and long-term survival adjusting for AKI severity were compared among AKI trajectories in all cohort and subcohorts with and without ICU admission.ResultsFifty-eight per cent (31 500/54 212) had AKI that rapidly reversed within 48 hours; among patients with persistent AKI, two-thirds (14 122/22 712) did not have renal recovery by discharge. One-year mortality was significantly higher among patients with persistent AKI (35%, 7856/22 712) than patients with rapidly reversed AKI (15%, 4714/31 500) and no AKI (7%, 22 117/301 466). Persistent AKI without renal recovery was associated with approximately fivefold increased hazard rates compared with no AKI in all cohort and ICU and non-ICU subcohorts, independent of AKI severity.DiscussionAmong hospitalised, ICU and non-ICU patients, persistent AKI and the absence of renal recovery are associated with reduced long-term survival, independent of AKI severity.ConclusionsIt is essential to identify patients at risk of developing persistent AKI and no renal recovery to guide treatment-related decisions.

Background Ventilator bundles have been reported to reduce the risk of ventilator-associated pneumonia. However, data concerning the role of the education of the intensive care unit (ICU) staff regarding the items in the bundle and the importance to adhere to its items on the development of ventilator-associated events (VAEs) are limited. This study aimed to compare the frequency of VAEs in subjects admitted to the ICU before and after the education of the ICU staff. Methods A total of 105 subjects were enrolled in this retrospective study. The ICU staff, including the physicians, respiratory therapists, and nurses, received a 2-day educational lecture regarding items in the bundle as well as the need to adhere to its items. The study population was divided into two according to the admission date: subjects who were admitted before the education of the ICU staff regarding the ventilator bundle (preeducation) and subjects who were admitted after the education of the ICU staff regarding the ventilator bundle (posteducation). The difference in VAE rate in subjects admitted before and after bundle training was the primary outcome measure of this study. Results The bundle compliance rates presented by days were significantly higher in the posteducation group compared with the preeducation group. Moreover, the frequency of VAEs was significantly lower in posteducation subjects compared with preeducation subjects (4.7% vs 19.0%, P = .042). Ventilator-associated event rate was also lower in posteducation subjects compared with preeducation subjects (2.5/1000 vs 9.8/1000 ventilator days). There were no significant differences among the groups with respect to ICU mortality. Conclusion The educational intervention performed in this study not only increased the adherence to the ventilator care bundle but also led to a significant reduction in the rate of the VAEs in patients receiving mechanical ventilator support in the ICU.

Background and Objectives: COVID-19 might cause thrombosis in the arterial and venous system either directly or via indirect means such as cytokine storm or hypoxia. Enoxaparin might contribute to clinical recovery in COVID-19 patients, both by reducing the risk of thrombosis with anticoagulant effect and avoiding the cytokine storm with its anti-inflammatory effect. In this study, the clinical results of prophylactic enoxaparin usage in COVID-19 patients in our hospital were investigated. Methods: We retrospectively analyzed the patients who had hospitalized in our hospital with the diagnosis of COVID-19 between March 12 and April 17, 2020. Patients were divided into two groups according to their clinical status. Patients who were discharged to their home were in Group-I and were transferred to intensive care unit (ICU) were in Group-II. Patients’ demographics and laboratory examinations were compared between the groups. Then the effect of LMWH treatment in the rate of ICU transfer was evaluated. Results: There were 1216 hospitalized patients with COVID-19 in the study period. Increased age, levels of D-Dimer and fibrinogen and decreased hemoglobin, platelet, lymphocyte values were found to be statistically significantly risk factor for the need of ICU. Transfer rates of ICU were two times more in the patients who did not used enoxaparin and readmission after the discharge was higher in the patients who did not received enoxaparin in the hospital. Conclusion: Enoxaparin treatment in COVID-19 might be effective not only anticoagulant effect but also anti-inflammatory effect that decreased the risk cytokine storm. In the patients with COVID-19 disease, starting enoxaparin treatment in the earlier stage will decrease the risk of microthrombosis in vital organs and might improve the clinical outcomes. doi: https://doi.org/10.12669/pjms.37.3.3687 How to cite this:Ugur M, Adiyeke E, Recep E, Bakan N, Yiyit N. Aggressive thromboprophylaxis improves clinical process and decreases the need of Intensive Care Unit in Covid-19. Pak J Med Sci. 2021;37(3):668-674. doi: https://doi.org/10.12669/pjms.37.3.3687 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.