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Sepsis is one of the main causes of morbidity and mortality in critically ill patients despite the use of modern antibiotics and resuscitation therapies. Outcomes in sepsis have improved overall, probably because of an enhanced focus on early diagnosis and other improvements in supportive care, but mortality rates still remain unacceptably high. The diagnosis and definition of sepsis is a critical problem due to the heterogeneity of this disease process. Although it is apparent that much more needs to be done to advance our understanding, sepsis and related terms remain difficult to define. A 1991 consensus conference developed initial definitions that systemic inflammatory response syndrome (SIRS) to infection would be called sepsis. Definitions of sepsis and septic shock were revised in 2001 to incorporate the threshold values for organ damage. In early 2016, the new definitions of sepsis and septic shock have changed dramatically. Sepsis is now defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. The consensus document describes organ dysfunction as an acute increase in total Sequential Organ Failure Assessment (SOFA) score two points consequently to the infection. A significant change in the new definitions is the elimination of any mention of SIRS. The Sepsis-3 Task Force also introduced a new bedside index, called the qSOFA, to identify outside of critical care units patients with suspected infection who are likely to develop sepsis. Recently updated the consensus definitions improved specificity compared with the previous descriptions.

Turkey is constitutionally secular with a Muslim majority. There is no legal basis for limiting life-support at the end-of-life (EOL) in Turkey. We aimed to investigate the opinions and attitudes of intensive care unit (ICU) physicians regarding EOL decisions, for both their patients and themselves, and to evaluate if the physicians' demographic and professional variables predicted the attitudes of physicians toward EOL decisions. An online survey was distributed to national critical care societies' members. Physicians' opinions were sought concerning legalization of EOL decisions for terminally ill patients or by patient-request regardless of prognosis. Participants physicians' views on who should make EOL decisions and when they should occur were determined. Participants were also asked if they would prefer cardiopulmonary resuscitation (CPR) and/or intubation/mechanical ventilation (MV) personally if they had terminal cancer. A total of 613 physicians responded. Religious beliefs had no effect on the physicians' acceptance of do-not-resuscitate (DNR) / do-not-intubate (DNI) orders for terminally ill patients, but atheism, was found to be an independent predictor of approval of DNR/DNI in cases of patient request (p<0.05). While medical experience (≥6 years in the ICU) was the independent predictor for the physicians' approval of DNI decisions on patient demand, the volume of terminal patients in ICUs (between 10-50% per year) where they worked was an independent predictor of physicians' approval of DNI for terminal patients. When asked to choose personal options in an EOL scenario (including full code, only DNR, only DNI, both DNR and DNI, and undecided), younger physicians (30-39 years) were more likely to prefer the \"only DNR\" option compared with physicians aged 40-49 years (p<0.05) for themselves and age 30-39 was an independent predictor of individual preference for \"only DNR\" at the hypothetical EOL. Physicians from an ICU with <10% terminally ill patients were less likely to prefer \"DNR\" or \"DNR and DNI\" options for themselves at EOL compared with physicians who worked in ICUs with a higher (>50%) terminally ill patient ratio (p<0.05). Most ICU physicians did not want legalization of DNR and DNI orders, based solely on patient request. Even if EOL decision-making were legal in Turkey, this attitude may conflict with patient autonomy. The proportion of terminally ill patients in the ICU appears to affect physicians' attitudes to EOL decisions, both for their patients and by personal preference, an association which has not been previously reported.

BackgroundObesity is a complex and multifactorial disease whose incidence has increased, making it a serious public health issue. Laparoscopic sleeve gastrectomy (LSG) is one of the most common surgical procedures that is chosen for bariatric surgery. Decreasing postoperative pain in these patients which will increase patients’ compliance and quality of life will lead to better surgical results. This study aims to compare the effectiveness of trocar site infiltration versus bilateral subcostal transversus abdominis plane block (TAP) in controlling postoperative pain in patients.MethodsForty-five consecutive patients who have undergone LSG in xxx General Surgery Department have been enrolled in the study. Patients were divided into two groups according to the surgeon’s choice. The first group underwent TAP block, while the second group underwent trocar site infiltration. Patients’ pain was recorded via visual analogue scale (VAS) in postoperative periods.ResultsTwenty-nine female (69%) and 13 (31%) male patients were included in the study. Median age was 41 (18–58) and median BMI was 48 (41.1–68). When the VAS values were compared, in the TAPB group, 6th hour resting and coughing pain was statistically significantly less. Other VAS values measured while resting, coughing, and post-mobilization did not show significant differences. There were no significant differences between the groups’ tramadol use.ConclusionsAfter LSG, TAP block and trocar site infiltration yield similar pain control. Due to the faster application and fewer side effects, we concluded that trocar site infiltration should be the intervention of choice in controlling postoperative pain in LSG.

Introduction: Healthcare-associated infection is an important cause of mortality and morbidity worldwide. Well-regulated infection control and hand hygiene are the most effective methods for preventing healthcare-associated infections. This study evaluated and compared conventional hand hygiene observation and an electronic hand-hygiene recording and reminder system for preventing healthcare-associated infections. Methodology: This pre- and post-intervention study, employed an electronic hand-hygiene recording and reminder system for preventing healthcare-associated infections at a tertiary referral center. Healthcare-associated infection surveillance was recorded in an anesthesia and reanimation intensive care unit from April 2016 to August 2016. Hand-hygiene compliance was observed by conventional observation and an electronic recording and reminder system in two consecutive 2-month periods. healthcare-associated infections were calculated as incidence rate ratios. Results: The rate of healthcare-associated infections in the electronic hand- hygiene recording and reminder system period was significantly decreased compared with that in the conventional hand-hygiene observation period (incidence rate ratio = 0.58; 95% confident interval = 0.33-0.98). Additionally, the rate of central line-associated bloodstream infections and the rate of ventilator-associated pneumonia were lower during the electronic hand hygiene recording and reminder system period (incidence rate ratio= 0.41; 95% confident interval = 0.11-1.30 and incidence rate ratio = 0.67; 95% confident interval = 0.30-1.45, respectively). Conclusions: After implementing the electronic hand hygiene recording and reminder system, we observed a significant decrease in healthcare-associated infections and invasive device-associated infections. These results were encouraging and suggested that electronic hand hygiene reminder and recording systems may reduce some types of healthcare-associated infections in healthcare settings.

Primary graft dysfunction (PGD) is a severe form of acute lung injury that is a major cause of early morbidity and mortality encountered after lung transplantation. PGD is diagnosed by pulmonary oedema with diffuse alveolar damage that manifests clinically as progressive hypoxemia with radiographic pulmonary infiltrates. Inflammatory and immunological response caused by ischaemia and reperfusion is important with regard to pathophysiology. PGD affects short- and long-term outcomes, the donor organ is the leading factor affecting these adverse ramifications. To minimize the risk of PGD, reduction of lung ischaemia time, reperfusion optimisation, prostaglandin level regulation, haemodynamic control, hormone replacement therapy, ventilator management are carried out; for research regarding donor lung preparation strategies, certain procedures are recommended. In this review, recent updates in epidemiology, pathophysiology, molecular and genetic biomarkers and technical developments affecting PGD are described.

Background The prevalence and mortality of sepsis are largely unknown in Turkey, a country with high antibiotic resistance. A national, multicenter, point-prevalence study was conducted to determine the prevalence, causative microorganisms, and outcome of sepsis in intensive care units (ICUs) in Turkey. Methods A total of 132 ICUs from 94 hospitals participated. All patients (aged > 18 years) present at the participating ICUs or admitted for any duration within a 24-h period (08:00 on January 27, 2016 to 08:00 on January 28, 2016) were included. The presence of systemic inflammatory response syndrome (SIRS), severe sepsis, and septic shock were assessed and documented based on the consensus criteria of the American College of Chest Physicians and Society of Critical Care Medicine (SEPSIS-I) in infected patients. Patients with septic shock were also assessed using the SEPSIS-III definitions. Data regarding demographics, illness severity, comorbidities, microbiology, therapies, length of stay, and outcomes (dead/alive during 30 days) were recorded. Results Of the 1499 patients included in the analysis, 237 (15.8%) had infection without SIRS, 163 (10.8%) had infection with SIRS, 260 (17.3%) had severe sepsis without shock, and 203 (13.5%) had septic shock. The mortality rates were higher in patients with severe sepsis (55.7%) and septic shock (70.4%) than those with infection alone (24.8%) and infection + SIRS (31.2%) ( p < 0.001). According to SEPSIS-III, 104 (6.9%) patients had septic shock (mortality rate, 75.9%). The respiratory system (71.6%) was the most common site of infection, and Acinetobacter spp. (33.7%) were the most common isolated pathogen. Approximately, 74.9%, 39.1%, and 26.5% of Acinetobacter, Klebsiella , and Pseudomonas spp. isolates, respectively, were carbapenem-resistant, which was not associated with a higher mortality risk. Age, acute physiology and chronic health evaluation II score at ICU admission, sequential organ failure assessment score on study day, solid organ malignancy, presence of severe sepsis or shock, Candida spp . infection, renal replacement treatment, and a nurse-to-patient ratio of 1:4 (compared with a nurse-to-patient ratio of 1:2) were independent predictors of mortality in infected patients. Conclusions A high prevalence of sepsis and an unacceptably high mortality rate were observed in Turkish ICUs. Although the prevalence of carbapenem resistance was high in Turkish ICUs, it was not associated with a higher risk for mortality. Trial registration ClinicalTrials.gov ID NCT03249246 . Date: August 15, 2017. Retrospectively registered.

Objective: Mushroom poisonings can lead to life-threatening organ dysfunctions and neurotoxicity-related encephalopathy. This study aimed to detect increased intracranial pressure by measuring optic nerve sheath diameter (ONSD) ultrasonographically and to determine its association with clinical and laboratory parameters. Methods: In this prospective case-control study, we evaluated the patients aged above 18 years who presented to the emergency department with mushroom poisoning. Vital signs, clinical and laboratory parameters and ONSD of both eyes measured with transocular ultrasound were noted at initial admission and the 24th hour. Results: We measured ONSD in 26 cases with mushroom poisoning and 26 healthy volunteers. Baseline ONSD measurements of the poisoning group were significantly higher than those of the control group (5.94±0.73 vs. 4.11±0.64, p<0.0001). ONSD values significantly regressed at 24th hour compared with the baseline measurements in the poisoning group (5.94±0.73 vs. 5.06±0.56, p<0.001).The ONSD values were significantly higher in patients who had a clinical picture of encephalopathy compared with patients who didn’t have (6.05±0.72 vs. 4.36±1.03, p<0.001). No significant deterioration was observed in ammonium levels, hepatic and renal functions of the patients. Conclusion: We detected increased ONSDs in patients with mushroom poisoning compared with those in the control healthy volunteers. Our findings suggest that ONSD, measured by ultrasonography, may be safely and effectively used to diagnose transient encephalopathy associated with neurotoxicity.

Purpose. The main purpose of this study was to investigate the dynamics of pentraxin 3 (PTX3) compared with procalcitonin (PCT) and C-reactive protein (CRP) in patients with suspicion of ventilator-associated pneumonia (VAP). Materials and Methods. We designed a nested case-control study. This study was performed in the Surgical Intensive Care Unit of a tertiary care academic university and teaching hospital. Ninety-one adults who were mechanically ventilated for >48 hours were enrolled in the study. VAP diagnosis was established among 28 patients following the 2005 ATS/IDSA guidelines. Results. The median PTX3 plasma level was 2.66 ng/mL in VAP adults compared to 0.25 ng/mL in non-VAP adults (p<0.05). Procalcitonin and CRP levels did not significantly differ. Pentraxin 3, with a 2.56 ng/mL breakpoint, had 85% sensitivity, 86% specificity, 75% positive predictive value, and 92.9% negative predictive value for VAP diagnosis (AUC = 0.78). Conclusions. With the suspicion of VAP, a pentraxin 3 plasma breakpoint of 2.56 ng/mL could contribute to the decision of whether to start antibiotics.

We evaluated right (RV) and left (LV) ventricle functions by tissue Doppler imaging (TDI) in patients with subclinical hypothyroidism (SH). Twenty-seven patients (24 women, 3 men; mean age 35.4±11.4 years) with newly diagnosed SH and 22 age- and sex-matched healthy subjects (20 women, 2 men; mean age 34.8±8.6 years) were evaluated by standard echocardiography and TDI. The diagnosis of SH was based on increased serum thyrotropin (TSH) level in the presence of normal free T3 and free T4 levels. The following TDI-derived parameters were measured: isovolumic myocardial acceleration (IVA), peak myocardial velocity during isovolumic contraction (IVV), peak systolic velocity during ejection period (S), and diastolic indices including peak early (E') and late (A') diastolic velocities, E'/A' and E/E' ratios, and myocardial performance index. Compared to healthy controls, patients with SH had higher LV mitral A velocity (p=0.022), lower E/A ratio (p=0.021), lower E' velocity (p=0.019), and higher E/E' ratio (p=0.017), suggesting significant LV diastolic dysfunction. The patient group also had lower IVV (p=0.004) and IVA (p<0.001), and higher isovolumic contraction time (p=0.012), suggesting LV subclinical systolic dysfunction. For RV parameters, decreased E/A ratio (p=0.014) and E' velocity (p=0.028) and increased isovolumic relaxation time (p=0.003) in SH patients were consistent with RV diastolic dysfunction, whereas parameters of RV systolic function were similar in the two groups. Myocardial performance indices of both ventricles were also significantly higher in the patient group (p<0.05). Our data suggest that SH is associated with biventricular systolic and diastolic dysfunction.

Objective: The objective of this study was to improve the patient comfort and safety during procedures done under anaesthesia and sedation. The analgesia nociception index (ANI) noninvasively provides information on the nociception-antinociception balance, and it can be used to assess analgesia objectively. We aimed to compare the effects of analgesia management with conventional methods and with ANI monitoring on total opioid consumption, sedation and analgesia levels in patients who underwent colonoscopy using sedo-analgesia. Methods: Adult patients (n=102), scheduled for procedural sedation, were prospectively analysed. After the induction with propofol and ketamine, infusions of propofol (2 mg kg−1 h−1) and remifentanil (0.05 mcg kg−1 min−1) were started. In Group A, remifentanil infusions were titrated to maintain the ANI value between 50 and 70, whereas in Group C, analgesic requirements were met according to the attending anaesthetist’s intention. The heart rate, blood pressure, respiratory rate, SpO2 , BIS, Numeric Rating Scale (NRS) and Ramsay Sedation Scale were monitored. Complications, analgesics consumption, duration of the procedure, demographic information, NRS and the Modified Aldrete Score were evaluated. Results: A total remifentanil amount used in Group A was 66.51±47.87 mcg and 90.15±58.17 mcg in Group C (p=0.011); there was no difference in total amounts of ketamine and propofol given. There was a negative correlation between ANI and NRS scores of Group A patients at Minute 0 at the level of 0.402, which was significant statistically (p=0.003). Conclusion: Opioid consumption was diminished when ANI monitoring was used, and thus the patient safety was improved. Further studies with longer procedure times and with a greater number of patients are required to demonstrate whether there is a difference in side effects and recovery times.