OBJECTIVES Our goal was to evaluate the prevalence of and risk factors for pneumothorax in patients with invasive mechanical ventilation in the intensive care unit (ICU) diagnosed with coronavirus disease 2019 pneumonia. METHODS The prevalence of pneumothorax was retrospectively reviewed in 107 patients diagnosed with coronavirus disease 2019 pneumonia and treated in an ICU in Turkey between 11 March 2020 and 30 April 2020. RESULTS The patients were aged 19–92 years; 37 (34.6%) were women. Pneumothorax developed in 8 (7.5%) of the intubated patients. Four (50%) of the patients with pneumothorax and 68 (68.7%) of those without it died. In the univariable logistic regression analysis of the presence of comorbid diseases (P = 0.91), positive end-expiratory pressure (P = 0.18), compliance (P = 0.93), peak pressure (P = 0.41) and the Horowitz index (P = 0.13) did not show statistically significant effects in increasing the risk of pneumothorax. CONCLUSIONS There was no significant increase or decrease in the risk of pneumothorax in patients treated with invasive mechanical ventilation after the diagnosis of coronavirus disease 2019-related pneumonia/acute respiratory distress syndrome. However, consideration of the risk of pneumothorax in these individuals may have the potential to improve the prognoses in such settings.

BACKGROUNDTransesophageal echocardiography (TEE), being a displeasing intervention, usually entails sedation. We aimed to compare the effects of hypnosis and midazolam for sedation in TEE.DESIGN AND SETTINGSA prospective single-blinded study conducted on patients scheduled for TEE between April 2011 and July 2011 at a university in Istanbul, Turkey.METHODSA total of 41 patients underwent sedation using midazolam and 45 patients underwent hypnosis. Patients were given the State-Trait Anxiety Inventory (STAI) test for anxiety and continuous performance test (CPT) for alertness before and after the procedure. The difficulty of probing and the overall procedure rated by the cardiologist and satisfaction scores of the patients were also documented.RESULTSAnxiety was found to be less and attention more in the hypnosis group, as revealed by STAI and CPT test scores (P<.05 and P<.001, respectively).CONCLUSIONHypnosis proved to be associated with positive therapeutic outcomes for TEE with regard to alleviation of anxiety and maintenance of vigilance, thus providing more satisfaction compared to sedation with midazolam.

The results show that US guidance is more effective in maintenance of successful ICB than neurostimulation guidance alone and a reduction of LA doses even to 70% of conventionally used doses seems possible with US guidance. This article is published in English.

OBJECTIVES The incidence of pneumomediastinum (PNMD), its causes of development and its effect on prognosis in the coronavirus disease 2019 (COVID-19) are not clear. METHODS Between March 2020 and December 2020, 427 patients with real-time reverse transcriptase-polymerase chain reaction-confirmed COVID-19 admitted to the intensive care unit were analysed retrospectively. Using receiver operating characteristic analysis, the area under the curve (AUC) for initial invasive mechanical ventilation (MV) variables such as initial peak inspiratory pressure (PIP), PaO2/FiO2 (P/F ratio), tidal volume, compliance and positive end-expiratory pressure was evaluated regarding PNMD development. RESULTS The incidence of PNMD was 5.6% (n = 24). PNMD development rate was 2.7% in non-invasive MV and 6.2% in MV [odds ratio (OR) 2.352, 95% confidence interval (CI) 0.541–10.232; P = 0.400]. In the multivariate analysis, the independent risk factors affecting the development of PNMD were PIP (OR 1.238, 95% CI 1.091–1.378; P &lt; 0.001) and P/F ratio (OR 0.982, 95% CI 0.971–0.994; P = 0.004). P/F ratio (AUC 0.815, 95% CI 0.771–0.854), PIP (AUC 0.780, 95% CI 0.734–0.822), compliance (AUC 0.735, 95% CI 0.677–0.774) and positive end-expiratory pressure (AUC 0.718, 95% CI 0.668–0.764) were the best predictors for PNMD development. Regarding the multivariate analysis, independent risk factors affecting mortality were detected as age (OR 1.015, 95% CI 0.999–1.031; P = 0.04), comorbidity (OR 1.940, 95% CI 1.100–3.419; P = 0.02), mode of breathing (OR 48.345, 95% CI 14.666–159.360; P &lt; 0.001), PNMD (OR 5.234, 95% CI 1.379–19.857; P = 0.01), positive end-expiratory pressure (OR 1.305, 95% CI 1.062–1.603; P = 0.01) and tidal volume (OR 0.995, 95% CI 0.992–0.998; P = 0.004). CONCLUSIONS PNMD development was associated with the initial P/F ratio and PIP. Therefore, it was considered to be related to both the patient and barotrauma. PNMD is a poor prognostic factor for COVID-19.

The aim of our study is to evaluate the impact of early vs. late initiation of continuous renal replacement therapy (CRRT), defined by clinical information system (CIS) software using an early warning algorithm based on acute kidney injury network (AKIN) stages, on survival outcome of critically ill intensive care unit (ICU) patients with acute kidney injury (AKI). Of 1144 patients (mean [SD] age: 61.3 [17.9] years, 57.7% were males) hospitalized in ICU over a 2‐year‐period from January 2016 to December 2017, a total of 272 patients who had developed AKI requiring CRRT were included in this retrospective cross‐sectional study. Data on patient demographics (age, gender), reason for ICU hospitalization, AKIN stage, Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, indications for CRRT, and time of CRRT initiation with respect to AKIN early warning algorithm were retrieved from hospital records and the CIS software database. Survivorship status was assessed based on total, in‐hospital and 90‐day post‐discharge mortality rates and analyzed with respect to CRRT onset before vs. after AKIN alarm. CRRT was initiated before the AKIN alarm in 41(15.0%) patients, and after the AKIN alarm in 231(85.0%) patients involving treatment within 0–24 h of alarm in 146 (63.2%) patients and within 24–120 h of alarm in 85 (36.8%) patients. Mortality occurred in 175 (64.3%) patients involving 25 (61.0%) out of 41 patients who received CRRT before AKIN alarm and 150 (64.9%) out of 231 patients who received CRRT after AKIN alarm. Mortality rate was significantly higher in those who received CRRT 24–120 h vs. 0–24 h after the AKIN alarm (82.4% vs. 54.8%, P < 0.001). Pre‐ and post‐CRRT SOFA scores were significantly lower in patients who received CRRT 0–24 h vs. 24–120 h after the AKIN alarm (P = 0.009 and P = 0.004, respectively), while pre‐CRRT APACHE II scores were significantly lower in patients who received CRRT before vs. after the AKIN alarm (P = 0.008). In conclusion, our findings indicate the potential role of using AKIN stage‐based early warning system in guiding time to start CRRT and improved survival in critically ill patients with AKI, provided that the CRRT was initiated within the early (first 24 h) of the alarming AKIN Stage II–III events. Future well‐designed clinical trials addressing early vs. late initiation of CRRT in critical care patients with AKI are needed to find and answer to the ongoing controversy and help clinicians in refining their indications for starting CRRT.

Ankilozan spondilit (AS), sinsi başlangıçlı, kronik, progresif, otoimmün kollajen doku hastalığıdır. AS'de hava yolu temini ve entübasyon sırasında zorluklarla karşılaşılabilir. Zor entübasyon; üç kez laringoskopik girişimde bulunmak, direkt laringoskopi yapılamaması, yardımcı bir alet kullanmak zorunda kalınması ve dışarıdan bası yapılmasına karşın glottisin bir kısmı veya tamamının görülememesi olarak tanımlanmaktadır. Adneksiyal kitle nedeniyle daha önce başka bir merkezde anestezi verilemeyeceği söylenen 48 yaşındaki AS'li kadın hasta, hastanemiz kadın doğum kliniği'ne başvurdu. Ovaryen kist nedeniyle operasyonu planlanan hasta sakroiliyak, diz eklemleri ve omurgadaki ileri derecedeki tutulum nedeniyle, supin pozisyonunda yatamıyordu, boynunu hareket ettiremeyen hastanın başı ekstansiyon yapamıyordu. Ağız açıklığı 2 cm, tiromental mesafe 2 cm, Mallampati skoru 3 idi. Bu hali ile olgunun hava yolu "beklenen zor entübasyon" olarak değerlendirildi. Anestezi planı olarak öngördüğümüz, uyanık veya sedasyon altında fiberoptik yardımıyla nazotrakeal entübasyon ya da laringeal maske yöntemlerinin avantaj ve dezavantajları hastaya anlatıldı. Remifentanil infüzyonu ve lokal mukozal anestezi ile uyanık fiberoptik nazotrakeal entübasyon yapıldı. Biz, "beklenen zor entübasyon" olarak değerlendirdiğimiz AS'li hastada anestezi yaklaşımımızı literatür bilgileriyle tartışarak sunmayı amaçladık.

Objective: Therapeutic plasma exchange (TPE) is currently indicated as an alternative treatment regimen in a number of guidelines for various medical conditions. In this article we retrospectively reviewed cases who underwent TPE in Bakırköy Dr. Sadi Konuk Training and Research Hospital intensive care unit between 2007 and 2016 and compared the findings to the current reports in the literature. Methods: A total of 80 cases were treated with TPE between 2007 and 2016 in our intensive care unit. Information on demographic variables, therapeutic indications, catheterized veins, complications during the procedure, number of sessions, replacement products used and survival data was collected. In addition, preand post-procedure serum triglyceride, cholesterol and amylase levels were also collected in acute pancreatitis cases associated with hypertriglyceridemia. Results: A total of 501 TPE sessions were performed on 80 cases comprising 35 neurology, 18 hematology, 12 hypertriglycemic acute pancreatitis and 7 acute hepatic insufficiency patients, along with 8 cases with less common indications including sepsis, hyperthyroidism resistant to medical therapy and toxic epidermal necrolysis. The age of the subjects ranged between 12 and 82 years (mean; 45.08 ± 14.67 years). Sixteen (23.19%) cases died before the completion of the planned sessions. Pre-and post-procedure serum triglyceride, cholesterol and amylase levels were significantly different in acute pancreatitis cases (p < 0.05). Conclusion: Timely implementation of TPE in applicable indications may be helpful in preventing morbidity and mortality in a wide spectrum of disorders.

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