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Septic shock is the most severe form of sepsis, characterized by (a) persistent hypotension despite fluid resuscitation and (b) the presence of tissue hypoperfusion. Delays in the diagnosis and initiation of treatment of septic shock is associated with increasing risk for mortality. Early and effective fluid resuscitation and vasopressor administration play a crucial role in maintaining tissue perfusion in septic shock patients. A low diastolic arterial pressure (DAP) correlates with severity of arteriolar vasodilation, compromises left ventricle oxygen supply and can be used for identifying septic shock patients that would potentially benefit from earlier vasopressor therapy. Controversy currently exists as to the balance of fluids and vasopressors to maintain target mean arterial pressure. The aim of this article is to review the rationale for fluid resuscitation and vasopressor therapy and the importance of both mean and diastolic blood pressure during the initial resuscitation of the septic shock. We relate our personal prescription of balancing fluids and vasopressors in the resuscitation of septic shock.

The Clinical Pulmonary Infection Score (CPIS) based on chest X-ray has been developed to facilitate clinical diagnosis of ventilator-associated pneumonia (VAP); however, this scoring system has a low diagnostic performance. We developed the Lung Ultrasound and Pentraxin-3 Pulmonary Infection Score (LUPPIS) for early diagnosis of VAP and evaluated the performance of this new scoring system. In a prospective study of 78 patients with suspected VAP, we assessed the detection accuracy of LUPPIS for pneumonia in adult patients. We also evaluated the diagnostic performance of pentraxin-3 (PTX-3) findings of infection. On the day of the study, lung ultrasound was performed, PTX-3 levels were determined, and an endotracheal aspirate was obtained for Gram staining and culture. No significant differences were found between groups with respect to age, mechanical ventilation time, APACHE II score, or SOFA score ( > 0.05). Procalcitonin and PTX-3 levels were significantly higher in the VAP (+) group ( < 0.001 and < 0.001, respectively). The threshold for LUPPIS in differentiating VAP (+) patients from VAP (-) patients was > 7. In predicting VAP, LUPPIS > 7 (sensitivity of 84%, specificity of 87.7%) was superior to CPIS > 6 (sensitivity of 40.1%, specificity of 84.5%). LUPPIS appears to provide better results in the prediction of VAP compared to CPIS, and the importance of lung ultrasound and PTX-3 is emphasized, which is a distinctive property of LUPPIS.

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.

Objectives: Vitamin D has potent immunomodulatory effects with the capability of acting as an autocrine and paracrine agent, and inhibits inflammatory signaling. In this study, our aim was to evaluate the relationship between vitamin D levels in systemicinflammatory response syndrome (SIRS), sepsis and, septic shock patients and outcomes. Patients and Methods: A total of 45 patients whose vitamin D levels were measured within the first 48 hours of Intensive Care Unit(ICU) admission and 20 healthy controls were studied prospectively. The patients were grouped as, SIRS (Group-I,n=10), sepsis(Group-II,n=25), septic shock (Group-III,n=10) and healthy subjects (Group-IV,n=20). Serum vitamin D levels were categorized asa deficiency (≤15ng/mL), insufficiency (16-29ng/mL) and sufficiency (≥30ng/mL). Demographic characteristics, Acute Physiologyand Chronic Health Assessment II (APACHE-II) scores, and biochemical parameters were noted. Results: Vitamin D levels were significantly lower in all study groups compared to the control group (p<0.01), but were similar amongthe study groups. The hospital and ICU length of stay (LOS), and biochemical parameters were similar among the study groups. Themortality rates were 40% in Group I, 57 % in Group II, and 80 % in Group III. Conclusion: In our study patients with SIRS, sepsis and septic shock had lower serum 25-OH vitamin D levels compared to thecontrol group. Our results are in line with the literature that supports a relationship between vitamin D deficiency and inflammation.

Objective: In coronavirus disease – 19 (COVID-19) patients, cytokine storm develops due to the increase of pro-inflammatory cytokines. Tocilizumab (TCZ), has been used in the treatment of COVID-19 patients and successful results have been obtained. The aim of this study was to determine the efficacy of TCZ and also investigate the prognostic factors affecting the success of treatment and mortality in COVID-19 patients treated with TCZ.Patients and Methods: Between March 2020 and August 2021, a total of 326 confirmed severe COVID-19 pneumonia patients, treated in the intensive care unit, were included in the study.Results: The mean age of the patients was 63.02±11.58 years, and 203 (62.3%) of the patients were male. Patients treated with TCZ therapy had a longer survival time compared with the standard therapy (p=0.012). It was found that type of respiratory support (HR:2.19, CI:1.10-4.36, p=0.025) and hyperlactatemia on the day of TCZ therapy admission (HR:2.93 CI:1.53-5.64, p=0.001) were the significant and independent prognostic factors of survival in severe COVID-19 pneumonia patients treated with TCZ.Conclusion: Tocilizumab therapy improved 30-days survival in critically ill COVID-19 pneumonia patients. Also, among the patients treated with TCZ, types of respiratory support and hyperlactatemia on the day of TCZ admission were the independent prognostic factors.

Objective: Hypophosphatemia is a common complication of kidney transplantation. However, the relationship between hypophosphatemia and renal function in patients undergoing kidney transplantation remains uncertain. This study aimed to evaluate the relationship between serum phosphate levels and graft function in patients undergoing renal transplantation within the first 3 months after transplantation.Methods: We conducted a retrospective cohort study included patients who underwent kidney transplantation between 2016 and 2020. Data on patient demographics and clinical and laboratory findings, such as serum creatinine, phosphate, calcium, hemoglobin and parathormone levels, were collected from the hospital database.Results: Hypophosphatemia was observed in 59 (47.5%), 41 (33.06%) and 32 (25.8%) patients at the 1st week, 1st month and 3rd month after transplantation. The post-transplant median creatinine levels decreased to 1.36 (1.01-1.58) mg/dL, 1.22 (1.04-1.5) mg/dL, and 1.20 (1.0-1.49) mg/dL at week 1, month 1 and month 3. The median phosphate level before transplantation was 5.1 (4.8-5.7) mg/dL. This value decreased to 2.5 (1.8-3.27) mg/dL, 2.82 (2.05-3.55) mg/dL, and 3.01 (2.30-3.73) mg/dL at week 1, month 1 and month 3. There was no significant difference in serum creatinine and estimated glomerular filtration rate between the hypophosphatemic and normophosphatemic groups at week 1 (p=0.839, p=0.931), month 1 (p=0.453, p=0.441) and month 3 (p=0.592, p=0.570). The causes of end-stage renal disease were chronic glomerulonephritis in 20 patients (16.1%), hypertension in 35 (28.2%), diabetes mellitus in 18 (14.5%) (17 type 2 and 1 type 1), and secondary amyloidosis in 5 (4%). Nephrolithiasis, autosomal dominant polycystic kidney disease, vesicoureteral reflux, and no identifiable cause were found in 7 (5.6%), 4 (3.2%), 16 (12.9%) and 19 (15.3%), patients respectively.Conclusion: Hypophosphatemia is common after kidney transplantation. No correlation was identified between hypophosphatemia and functional performance of the transplanted kidney.

Ancillary tests can be used for the diagnosis of brain death in cases wherein uncertainty exists regarding the neurological examination and apnoea test cannot be performed. Transcranial Doppler ultrasonography (TCD) is a useful, valid, non-invasive, portable, and repeatable ancillary test for the confirmation of brain death. Despite its varying sensitivity and specificity rates with regard to the diagnosis of the brain death, its clinical use has steadily increased in the intensive care unit because of its numerous superior properties. The use of TCD as an ancillary test for the diagnosis of brain death and cerebral circulatory arrest is discussed in the current review.

Introduction. The number of geriatric patients is increasing in hemodialysis population over the years and mortality is higher in this group of patients. This study evaluated the factors affecting geriatric hemodialysis patient survival. Materials and Methods. This retrospective cohort study enrolled patients discharged from our nephrology clinic from 2009 to 2014. Data collected included demographics, Eastern Cooperative Oncology Group-Performance Status, vascular access type, and metabolic parameters. Comorbidity was quantified using the modified Liu comorbidity index. The outcome measure was mortality. Results. The study enrolled 99 elderly dialysis patients (42.4% women (n = 42); mean age 75 ± 7 years). The mean follow-up duration was 19.7 ± 11 months. The mortality rate over the four years was 47.5% (n = 46). The modified Liu comorbidity index score, patient age, and Eastern Cooperative Oncology Group-Performance Status were significantly related to mortality in univariate and multivariate analyses. Conclusion. The present study revealed that comorbidities and low performance status at the onset of dialysis had shortened the survival time in the geriatric hemodialysis patient group.

The SARS-CoV-2 has changed since it began to spread. The major mutations identified by the WHO and prevalent in many patients globally are ancestral, beta, delta, and omicron. Clinical characteristics and mortality have reportedly changed over the duration of each mutation. We assessed clinical characteristics and outcomes of ICU patients with a positive SARS-CoV-2 test result during the waves of COVID-19. Turkiye has experienced 4 COVID-19 waves as seen in Fig. 1. The waves were determined by projection according to the number of cases announced by the Ministry of Health on a daily basis (wave 1: November 2020–January 2021; wave 2: February–May 2021; wave 3: July–November 2021; wave 4: December 2021–March 2022). All patients admitted to COVID ICU were included. Patient characteristics, type of oxygen supply and mechanical ventilation, length of stay and mortality rates were evaluated. A total of 509 patients during the four waves of COVID-19 were included. The patients admitted during individual waves were as follows; wave 1: 61 (12%), wave 2: 148 (29%), wave 3: 187 (37%), wave 4: 113 (22%). Characteristics of patients admitted were presented in Table 1. Overall median age was 70 (IQR:21), Median age was lowest during 2nd wave and highest during 4th wave (62 vs 76). Vaccination rate was quite low for overall population. Patients who did not received any dose of any kind of vaccine was 384 (75%). Overall ICU mortality was 81%. Mortality was lowest during 1st wave and highest during 4th wave (66% vs 86%) Outcomes of patients were presented in Table 2. Median length of stay was similar between waves. In patients admitted to ICU with COVID-19 a varied pattern of traits and outcomes was seen between the waves. To ascertain whether the omicron is potentially less pathogenic than earlier versions more investigation is required.

BK polyomavirus infection is a challenging complication of renal transplantation. The management is not standardized and is based on reports from transplantation centers' experiences, usually with small sample sizes. Therefore, we aimed to present our countrywide experience with BK virus nephropathy (BKVN) in renal transplant recipients. Our study was carried out with the participation of 30 transplantation centers from all regions of Turkey. Only cases with allograft biopsy-proven BKVN were included in the study. 13,857 patients from 30 transplantation centers were screened, and 207 BK nephropathy cases were included. The mean age was 46.4 ±  13.1 years, and 146 (70.5%) patients were male. The mean time to diagnosis of BK nephropathy was 15.8 ± 22.2 months after transplantation. At diagnosis, the mean creatinine level was 1.8 ±  0.7 mg/dL, and the mean estimated glomerular filtration rate was 45.8 ± 19.6 mL/min/1.73m . In addition to dose reduction or discontinuation of immunosuppressive drugs, 18 patients were treated with cidofovir, 11 patients with leflunomide, 17 patients with quinolones, 15 patients with intravenous immunoglobulin (IVIG), 5 patients with cidofovir plus IVIG, and 12 patients with leflunomide plus IVIG. None of the patients receiving leflunomide or leflunomide plus IVIG had allograft loss. During follow-up, allograft loss occurred in 32 (15%) out of 207 patients with BK nephropathy. BKVN is still a frequent cause of allograft loss in kidney transplantation and is not fully elucidated. The results of our study suggest that leflunomide treatment is associated with more favorable allograft outcomes.