Objective: Pressure injuries (PIs) are common in patients receiving intensive care and extracorporeal membrane oxygenation (ECMO). This study assessed the incidence and risk factors of PIs in patients receiving ECMO for COVID-19-associated acute respiratory distress syndrome (ARDS). Method: Patients who were admitted to the intensive care unit (ICU) with severe COVID-19-associated ARDS and received veno-venous ECMO between April 2020 and January 2022 were evaluated. All patients were monitored, evaluated and managed according to the Prevention and treatment of pressure ulcers: clinical practice guideline 2019. The risk for PI was evaluated using the Braden scale. Staging of PIs was made according to the National Pressure Injury Advisory Panel guidelines. Results: A total of 78 patients (median age 45 years) received ICU care and ECMO support. Of these, 75 patients were transferred to the ICU while on ECMO support; 24/78 (30.8%) patients already had PIs. New PIs developed in 24 patients (24/54, 44.4%) during prolonged periods of ECMO (median 48.5 days). The new PIs were mainly stage 2 (55%). The median time to new PI development during ECMO was 21 (range 4-60) days. The mortality rate was 32/54 (59.3%). In multivariable analysis, age (odds ratio (OR): 1.103, 95% confidence interval (CI): 1.022, 1.191; p=0.027) and ECMO duration (OR: 1.048, 95% CI: 1.016, 1.081; p=0.003) were independent predictors of PI development. Conclusion: Strict compliance with the clinical practice guidelines for PIs by a dedicated ICU team may considerably reduce the incidence of PIs among patients receiving ECMO for prolonged periods.

Whether an anticoagulation strategy combining bivalirudin and aspirin during extracorporeal membrane oxygenation (ECMO) would prolong oxygenator use is unknown. No clear data exist on oxygenator life span during prolonged ECMO use. We evaluated 70 adult patients who received ECMO due to coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome for at least 7 days and who required no or at least one ECMO oxygenator replacement due to ECMO-circuit thrombosis. Anticoagulation parameters mainly included activated partial thromboplastin time (aPTT), with monitoring of international normalized ratio and platelet count. The main target aPTT was 45-60 seconds. The indication for oxygenator replacement was ECMO-circuit thrombosis. The mean ECMO duration was 41.8 ± 25.3 days. No oxygenator replacement was required in 48 patients (68.6%) during a mean of 34.9 ± 23.5 ECMO days (range 7-104). Twenty-two patients (31.4%) required 35 oxygenator replacements throughout a mean ECMO duration of 56.9 ± 22.8 days (range 19-102). The mean aPTT was similar throughout ECMO in the two groups. A higher percentage of out-of-target aPTT was associated with a shorter duration of oxygenator use. Bivalirudin plus aspirin may prove to be a more appropriate anticoagulation strategy during ECMO, resulting in more effective utilization of ECMO oxygenators.

Çalışkan kalpte koroner bypass operasyonu sırasında hareketli kalp üzerinde koroner arterlere güvenilir bir anastomozun yapılabilmesı için cerrahi işlemi kolaylaştıracak, mevcut miyokardiyal iskemiyi arttırmayacak, organ perfüzyonunu koruyacak intraoperatif uygun medikasyon önemlidir. Genel anestezik, kas gevşetici ve hastanın kullandığı beta blokörler gibi diğer ilaçlar kardiyovasküler sistemi etkilerler. Anestezi sırasında yüksek doz opiod kullanılacaksa hemodinamiyi etkileyecek kadar ciddi bradikardi yaratmayacak, bir nöromüsküler i̇laç kullanılmalıdır. Bu çalışmada, intraopetatif dönemde kas gevşetici olarak vekuronyum veya pankuronyum kullanılan hastaların atan kalpte yapılan bypass (Beating Heart) ameliyatlarında kalp hızını azaltarak koroner arter anastomozunu kolaylaştırmak amacıyla iv metoprolol uygulamasının, hemodinami ve kardiyak enzimler üzerine etkilerinin incelenmesi amaçlanmıştır. Bu çalışmaya 23 hasta dahil edildi. Anjiografik olarak ileri sol ventrikül disonksiyonu, kontrolsüz veya insüline bağımlı diyabeti, ciddi kronik akciğer hastalığı, periferik damar hastalığı bulunan kalp atım hızı 60 atım/dak altında olan, 1. dereceden fazla kalp bloğu olan hastalar çalışmaya dahil edilmedi. Tüm hastalarda kalp hızı (HR), periferik oksijen satürasyonu (sPO2), invaziv sistolik ve diyastolik arter basıncı (sırasıyla SAB, DAB) monitörize edildi. Santral venöz basınç (CVP), termodilüsyon kateteri takılarak pulmoner arter basıncı (PAB) monitörize edildi. Kardiyak output cihazı (Gould Cardiac Output Computer) ile kardiyak output (CO), kardiak indeks (CI), atım volümü (SV), sol ventrikül atım volümü indeksi (LVSWI), sağ ventrikül atım volümü indeksi (RVSWİ), pulmoner vasküler rezistans (PVR), sistemik vasküler rezistans (SVR) intraoperatif ve postoperatif erken dönemde izlendi. Atan kalpte anastomoz öncesi 2 mg lık dozlar şeklinde iv metoprolol kalp atım hızı 60-70, sistolik kan basıncı 80-100 mm Hg, düzeyince olacak şekilde uygulandı. Bu çalışmada iki grup arasında SKB, DKB, CI, SVİ, LVSWİ, RVSWİ, SVR, PVR ler arasında aynı dönemlerde anlamlı fark bulunmadı (p>0.05). Her iki grupta iv metoprolol ile anastomoz başlangıcında HR, sistolik ve diyastolik kan basıncı, CI azaldı. Kullanılan intraoperatif toplam metoprolol dozları Grup I’ de (11.5± 6.3 mg), Grup II ‘ye (21.7±8.7) göre düşük bulundu (p

During ECMO support, optimal anticoagulant drugs, dosing charts, ideal anticoagulation levels, and monitoring parameters have not yet been definitively established, despite the increasing use of ECMO applications worldwide. Heparin remains a widely used anticoagulant, despite its age and known limitations. While interest in direct thrombin inhibitors is growing, dosage and safety information are still limited. Presently, there is a trend toward combining traditional or newer anticoagulant drug usage with modern technological advancements to manage coagulation disorders more effectively and safely. Achieving optimal anticoagulation during ECMO involves leveraging a multidisciplinary approach that integrates pharmacokinetics and personalized dosing algorithms. The management of anticoagulation should be individualized for each patient, taking into account their specific characteristics, clinical condition, and laboratory results. Treatment plans are tailored based on an individual’s genetic predisposition to clotting and their response to anticoagulants, with the aim of minimizing adverse effects and optimizing therapeutic outcomes. Continuous and real-time assessment of the coagulation status enables timely and appropriate anticoagulation therapy. The integration of cutting-edge technologies such as artificial intelligence and machine learning may enhance the overall safety profile of anticoagulation treatment during ECMO. Advancements in anticoagulant therapy in ECMO continue to progress. This approach, utilizing genetic information, real-time monitoring, and advanced technologies, aims to provide an individually optimized treatment strategy for the management of coagulation disorders.

Background:In this study, we present our experience in treating patients receiving extracorporeal membrane oxygenation for novel coronavirus disease-2019 (COVID-19)-associated acute respiratory distress syndrome using a combined anticoagulant and antiaggregant treatment with intravenous infusion of bivalirudin and aspirin.Methods:Between April 1st, 2020 and January 31st, 2022, a total of 52 adult patients (32 males, 20 females; mean age: 44.5±11.5 years; range, 21 to 71 years) who received extracorporeal membrane oxygenation due to COVID-19-associated acute respiratory distress syndrome and whose anticoagulant treatment consisted of bivalirudin plus aspirin were retrospectively analyzed. During the first 10 days of extracorporeal membrane oxygenation, bivalirudin dosing, activated partial thromboplastin time, and activated clotting time, as well as major bleeding events and patient and/or ECMO-circuit thromboses were recorded.Results:The mean bivalirudin dose per day ranged from 0.03 to 0.04 mg/kg/h, with a mean overall dose of 0.036 mg/kg/h. The mean activated partial thromboplastin time was 49.1±6.9 sec throughout 10 days of the application. The percentage of time in the target range for activated partial thromboplastin time was 58.9±20.1% within 10 days of application, compared to 33.1±31.1% for the first 24 h. The mean daily activated clotting time was below the target range within the first three days, but it was consistently within the target range after Day 3. During the first 10 days of the application, no mortality occurred. Major bleeding occurred in 11 patients (21.1%) and circuit thrombosis occurred in three patients (5.8%).Conclusion:In patients receiving extracorporeal membrane oxygenation for COVID-19-associated acute respiratory distress syndrome, an hourly bivalirudin dose of 0.03 to 0.04 mg/kg/h throughout the first 10 days of application was associated with the targeted anticoagulation profile of 45 to 60 sec. The combination was associated with a comparable rate of major bleeding, but a lower rate of circuit-thrombosis compared to the literature reports.

With the COVID pandemic, veno-venous (VV) extracorporeal membrane oxygenation (ECMO) was implanted in many patients around the world. Data regarding follow-up and recovery of patients who are placed on ECMO support after COVID-related acute respiratory distress syndrome (ARDS) or ARDS for any other reason are limited. In our study, we share the 1 year follow-up results and cardiopulmonary exercise test results of the discharged patients. Between April 2020 and February 2022, a total of 29 patients who were supported with VV ECMO due to coronavirus disease 2019 (COVID-19)-related ARDS, weaned successfully and discharged to home, and who came for regular follow-up after discharge from the hospital and underwent examinations were included in the study. A total of 35 patients weaned successfully. Thirty patients were discharged to home. Mean age of the patients was 37.1 (±10.3) and 16 (55%) patients were male. Mean ECMO support time was 49.1 (±22.3) days. One year of survival after discharge was 100%. None of the patients had mobilization problems at the end of 12 month follow-up. Mean VO2 max was 18.9 at the end of 12 months. Return to work rate was 90%. We think that starting rehabilitation in the early period, and including patients in post-ECMO follow-up programs by ECMO centers will contribute significantly not only to the functional recovery of patients but also to their integration into social life.

BACKGROUND:The emergence of COVID-19 has amplified the importance of efficient patient transfer, leading to the idea of inter-hospital ECMO transport programs. However, there are limited studies on ECMO transfer protocols and experiences during COVID pandemic. This study aimed to evaluate the effectiveness our transport program and provide insights into establishing and maintaining ECMO programs. METHODS:Over the period from April 2020 to December 2021, 76 patients with severe hypoxic COVID-19 ARDS were transferred to our center under a veno-venous ECMO support. The transfers were performed by the experienced transport ECMO-team, covering both intracity and intercity transports from various hospitals in Istanbul and the Marmara Region. RESULTS:Mean age was 44 (34-54) years. Time until ECMO initiation was 6 (3-11.2) days. The average transport distance was 36.6 ± 58.7 km. Average intracity and intercity transport distance were 17.5 ± 15.7 and 121 ± 96.6 km, respectively. ECMO wean rate was 40.7% and survival to discharge (home) was 38.1%. No major adverse events occurred during the transfer process. In one transport, the oxygen tank was instantly replenished on the road due to the decrease in the oxygen level in the tank. CONCLUSION:In conclusion, this study contributed to the knowledge surrounding ECMO transport programs during pandemics, emphasized the importance of expert coordination and careful patient management with demonstrating feasibility of mobile ECMO program .

Background: Sphingomonas paucimobilis, an aerobic, non-fermentative, Gram-negative opportunistic bacillus, can colonize everywhere in hospital settings where water is used. We reported a hospital S paucimobilis outbreak that persisted for nearly 2 years despite all necessary preventive measures.Methods: Over a period from February 13, 2020 to December 3, 2021, 67 patients were identified to have S paucimobilis as documented by positive cultures from clinical samples, along with 19 positive environmental samples.Results: Bacterial regrowth for molecular analysis could be obtained in 49 isolates (39 clinical, 4 extracorporeal membrane oxygenation (ECMO) water heater devices, 1 unused mouthwash solution, 5 water samples from thoracic drainage aspirators). Two distinct clonally indistinguishable genotypes were detected in APPCR and PFGE analyses, with 100% consistency. The main cluster was obtained consistently throughout the outbreak from 30 samples (61.2%: 24 clinical, 4 ECMO, 1 unused mouthwash solution, 1 water sample from the thoracic drainage aspirator). The other cluster involved 15 clinical samples and 4 water samples from the thoracic drainage aspirators.Conclusions: Given that waterborne pathogens can spread to a wide range of equipment used in healthcare environments, the pathogens can persist on the surfaces of environmental devices even after recommended disinfection measures have been applied. Therefore, individual tracking of all devices used in critical care settings, such as thoracic drainage aspirators and ECMO water heater devices, with records of pre- and post-disinfection procedures is of paramount importance for complete elimination of the source of infection. & COPY; 2022 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Acute lung injury is the second common complication of cardiopulmonary bypass (CPB) after the heart, which varies from mild pulmonary dysfunction to fatal acute lung injury. CPB is the preferred method to repair several intracardiac and major vascular pathologies with adequate body perfusion and oxygenation. Owing to its nature, the heart and both lungs should be bypassed partially during CPB and totally under aortic cross-clamping to provide bloodless and motionless surgical field. During open-heart surgery under CPB, various factors such as extracorporeal circulation, hypothermia, surgical procedure, anesthesia, medications, and blood product transfusions can cause a diffuse lung damage. But, two risk factors, that is, ischemia and foreign surfaces, are the main determinants of the development of perioperative respiratory failure. During CPB, the lungs only receive blood from the diminished bronchial arterial flow, leading to pulmonary ischemia. Particularly, nonpulsatile CPB flow causes several changes in the lungs, leading to impaired lung parameters, such as decreased tissue energy source, changes in newly developed structures, and increased severity of inflammation. Several preventive approaches have employed to decrease lung injury, to improve gas exchange, and to prevent exacerbation of inflammation, such as shortened surgery, using leukocyte depletion filters, ultrafiltration, miniaturized circuits, and using biocompatible surfaces.

Background: Despite low virulence of Stenotrophomonas maltophilia, it represents one of the leading drug -resistant bacteria. We report a large outbreak of S. maltophilia infection associated with an unexpected source, which turned out to be a commercial needleless blood gas injector. Methods: Over a period from January 1 to December10, 2021, 113 patients were identified to have S. malto-philia infection as documented by positive cultures from the clinical samples, extracorporeal membrane oxy-genation (ECMO) water heater devices and commercial needleless blood gas injectors. Results: Sixty-seven isolates (59 clinical, 4 ECMO, 4 blood gas injectors) were sent for molecular analysis. Both arbitrarily primed polymerase chain reaction and pulsed -field gel electrophoresis analyses showed 12 distinct genotypes. Of 67 isolates, 58 were clonally related (86.6%), with 52 indistinguishable strains from 4 blood gas needleless injectors, 46 patients' samples (78%), and 2 ECMO samples (50%). Two ECMO samples and 1 clinical sample were clonally identical. Conclusions: In the event that eradication of infections would not be possible despite taking all environmen-tal disinfection measures including the ECMO devices, unexpected sources, such as a commercial needleless blood gas injector, should not be omitted from the list for surveillance. In addition, obtaining surveillance cul-tures of ECMO water reservoirs should be placed in the routine clinical practice. & COPY; 2022 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Introduction: We aimed to describe the impact of COVID-19 among the patients who had cardiac surgery, with particular emphasis on pulmonary complications and 30-day mortality. Patients and Methods: From March 2020 to June 2021, a total of 2267 patients underwent cardiovascular surgery at Koşuyolu High Specialization Training and Research Hospital.. Patients who tested SARSCoV-2-positive by PCR perioperatively (seven days before or 30 days after surgery), despite testing negative at admission, were included. The primary endpoint of the study was 30-day mortality following surgery. The secondary endpoint was the development of pulmonary complications including acute respiratory distress syndrome (ARDS) or respiratory failure, which were defined according to the Berlin definition, and the need for mechanical ventilation for >48 h after the operation or the need for re-intubation after extubation. Results: Eleven patients out of 2267 (0.48%) had a positive PCR test for COVID-19. In the postoperative period, seven patients were diagnosed with COVID-19 in the clinical wards, of whom three patients were readmitted to the ICU. Nine patients had radiological pulmonary involvement. Five patients (45.5%) developed ARDS within four to seven days after a positive PCR test. Eight patients (72.7%) developed respiratory failure and required re-intubation, of whom two could not be extubated. Five patients (45.5%) died within 30 days, and seven (63.6) died during their hospital stay. Conclusion: COVID-19 has a severe negative impact on the postoperative course of cardiac surgery patients in terms of cardiovascular outcomes, pulmonary complications, and mortality. Given the dramatic impact of COVID-19 infection on postoperative outcomes, it appears that deferring cardiovascular surgeries may be more suitable if COVID-19 positivity is detected.

Objective: Since the angiotensin-converting enzyme (ACE) is the functional receptor for SARS-CoV-2, predominantly expressed by the alveoli, SARS-CoV-2 primarily involves the lungs. Aside from the lungs, ACE is expressed in other organs, including the thyroid gland. This study aimed to evaluate the incidence of thyroid dysfunction (TD) in patients admitted to the intensive care unit (ICU) with critical COVID-19, with inflammatory markers and disease severity, compared to patients with normal thyroid function.Materials and Methods: This retrospective study included 52 patients admitted to the ICU with PCR-confirmed critical COVID-19 between April 2020 and September 2021. Thyroid function tests were obtained within the first three days after ICU admission. TD was defined as the detection of any abnormal level in thyroid-stimulating hormone (TSH), free thyroxine hormone (FT4), and free triiodothyronine hormone (FT3). None of the patients had a prior history of thyroid disease or received medications related to thyroid diseases.Results: TD was detected in 34 patients (65.4%). The majority of patients (67%) required extracorporeal membrane oxygenation (ECMO), with a higher frequency in patients with TD (74%). Patients with and without TD were similar concerning age, gender, and the need for ECMO. Patients with TD had significantly decreased levels of TSH, FT3, and FT4 (p=0.002, <0.001, =0.005, respectively); a significantly greater acute physiology and chronic health evaluation II (APACHE-II) score (p=0.048); a significantly higher white blood cell count (p=0.031) and elevated levels of procalcitonin (p=0.003), C-reactive protein (p=0.049) and cardiac troponin T (p=0.025). Other parameters, such as ICU stay, sequential organ failure assessment [SOFA] score, and mortality, did not differ significantly (p=0.449, p=0.315, p=0.142, respectively).Conclusion: Our findings suggest that patients admitted to the ICU with critical COVID-19 are at an increased risk for the development of TD, which should also be taken into account in relation to inflammatory markers, cardiac troponin T levels, and APACHE-II scores.

Objective:This study aimed to evaluate bloodstream infections caused by Stenotrophomonas maltophilia in immunocompetent patients with respect to clinical features and risk factors for mortality.Methods:We reviewed bloodstream infections detected between January 1, 2012, and July 1, 2021, to identify nosocomial S. maltophilia bacteremia in Koşuyolu Research and Training Hospital.Results:We identified a total of 97 patients with S. maltophilia bloodstream infections. Of these, 17 patients were excluded because of community-acquired infections (n=9), contamination with S. maltophilia (n=3), and insufficient data (n=5), with 80 (57.5% males) patients remaining for analysis. The source of infection was the respiratory tract in 28 (35%) patients. A central venous catheter was used in 60 (75%) patients, which required replacement in 23 patients within five days after detecting S. maltophilia bacteremia. On antimicrobial susceptibility testing, 71 strains were found to be susceptible and 9 (11.3%) resistant to trimethoprim-sulfamethoxazole. Thirty-day mortality was 33.8%. Non-survivors differed significantly from survivors with respect to higher rates of central venous catheters ( p=0.020), mechanical ventilation (p=0.006), urinary catheters (p=0.021), septic shock (p=0.001), hypoalbuminemia (p=0.026) and thrombocytopenia (p =0.039). S. maltophilia bacteremia was independently associated with mortality in patients with hypoalbuminemia, and replacement of central venous catheters had a protective role in reducing mortality.Conclusion:As with other bacterial infections, S. maltophilia bacteremia is associated with a considerably high mortality rate in patients with cardiac conditions. The replacement of the catheter seems to play a beneficial role in 30-day survival.

Novel coronavirus-2019 (COVID-19) pandemic has affected all over the world, leading to viral pneumonia-complicating severe acute respiratory distress syndrome and death. Although there is no proven definitive treatment yet, physicians use some assistive methods based on the previous epidemic viral acute respiratory distress syndrome experiences. Extracorporeal membrane oxygenation is one of them. In this report, we present one of the longest survived extracorporeal membrane oxygenation case (71 days) with COVID-19 infection and the pathology of the infected lung, with our veno-venous extracorporeal membrane oxygenation strategy.

Purpose: The aim of this study was compare with the acute phase response of BIPAP and AVAPS which are two of the noninvasive mechanical ventilation modalities used in patients with hypercapnic respiratory failure after open heart surgery in the early period. Materials and Methods: 13 women (38.2%) and 21 men (61.8%) with a mean age of 61.14±11.22 years who had acute hypercapnic respiratory failure were included in the study. The patients were randomized and divided into BIPAP and AVAPS groups.The arterial blood gas data and vital signs of the patients before NIMV (noninvasive mechanical ventilation) were recorded. The NIMV mode initial data set to be EPAP 5 cmH2O, IPAP 15 cmH2O and the pressure values were changed so that the target volume was 6-8 mL/kg (Vt). Starting FiO2 value was started with 40% and saturation levels were aimed to be more than 92%. After NIMV for one hour, the arterials bloods gas data and vital signs were recorded again. Results: There was a significiant difference in the arterials blood gas data pH, PCO2, sO2, cHCO3 and respiratory rate and SpO2 in the AVAPS mode groups (p 0,05). Conclusions: Both BIPAP and AVAPS modes are equally effective for treatment of acute hypercapnic respiratory failure after open heart surgery in the early postoperative period.

Perioperative reperfusion injury, acute right heart failure, and massive pulmonary hemorrhage are the most important factors determining mortality following pulmonary endarterectomy operation (PEA). Our approach for the treatment of intraoperative pulmonary hemorrhage following pulmonary endarterectomy is discussed. We retrospectively studied a PEA case with massive pulmonary hemorrhage that occurred in 2017. We used endobronchial blocker to ensure that the bleeding is stopped and used extracorporeal membrane oxygenation (ECMO) for respiratory and hemodynamic requirements. ECMO is a good alternative for most of the pre- and postoperative major complications of PEA. Combined use of endobronchial blocker and ECMO could be a useful treatment method for massive pulmonary hemorrhage following pulmonary endarterectomy.

arasında kliniğimizde PTE ameliyatı yapılan 235 hastada uyguladığımız anestezi yönetimini ve klinik sonuçlarımızı sunmayı amaçladık

Objective: Acute kidney injury after cardiac surgery is associated with mortality and morbidity.Therefore, strategies to prevent acute kidney injury are very important.The aim of this placebo-controlled randomized double-blind study was to compare the prophylactic efficacy of N-Acetylcysteine and dopamine administration in patients with pre-existing moderate renal insufficiency who were undergoing cardiopulmonary bypass.Methods: This study included 135 patients with pre-existing moderate renal insufficiency who were scheduled for coronary artery bypass grafting surgery.Serum creatinine and GFR were recorded preoperatively and on the first and second postoperative days.Results: On the first and second postoperative days, the drugs used showed statistically significant differences among the creatinine groups (P<0.001).According to Tukey's HSD, on the first and second PO, the creatinine of Group N, D and P were significantly different (P<0.001).On the first and second PO, the used drugs showed statistically significant differences among the effects of eGFR (P<0.001).According to Tukey's HSD on the first postoperative day, the average eGFR score of Group N compared to D and P were significantly difference (P<0.001).On the second postoperative day, the eGFR of Group N and D showed no difference (P=0.37),but P showed a difference (P<0.001).Conclusion: We found that the prophylactic use of intravenous N-Acetylcysteine had a protective effect on renal function, whereas the application of renal dose dopamine did not have a protective effect in patients with pre-existing moderate renal failure.