Introduction: Measurement of intravascular volume status is an ongoing challenge for physicians in the surgical intensive care unit (SICU). Most surrogates for volume status, including central venous pressure (CVP) and pulmonary artery wedge pressure, require invasive lines associated with a number of potential complications. Sonographic assessment of the collapsibility of the inferior vena cava (IVC) has been described as a noninvasive method for determining volume status. The purpose of this study was to analyze the dynamic response in IVC collapsibility index (IVC-CI) to changes in CVP in SICU patients receiving fluid boluses for volume resuscitation. Materials and Methods: A prospective pilot study was conducted on a sample of SICU patients who met clinical indications for intravenous (IV) fluid bolus and who had preexisting central venous access. Boluses were standardized to crystalloid administration of either 500 mL over 30 min or 1,000 mL over 60 min, as clinically indicated. Concurrent measurements of venous CI (VCI) and CVP were conducted right before initiation of IV bolus (i.e. time 0) and then at 30 and 60 min (as applicable) after bolus initiation. Patient demographics, ventilatory parameters, and vital sign assessments were recorded, with descriptive outcomes reported due to the limited sample size. Results: Twenty patients received a total of 24 IV fluid boluses. There were five recorded 500 mL boluses given over 30 min and 19 recorded 1,000 mL boluses given over 60 min. Mean (median) CVP measured at 0, 30, and 60 minutes post-bolus were 6.04 ± 3.32 (6.5), 9.00 ± 3.41 (8.0), and 11.1 ± 3.91 (12.0) mmHg, respectively. Mean (median) IVC-CI values at 0, 30, and 60 min were 44.4 ± 25.2 (36.5), 26.5 ± 22.8 (15.6), and 25.2 ± 21.2 (14.8), respectively. Conclusions: Observable changes in both VCI and CVP are apparent during an infusion of a standardized fluid bolus. Dynamic changes in VCI as a measurement of responsiveness to fluid bolus are inversely related to changes seen in CVP. Moreover, an IV bolus tends to produce an early response in VCI, while the CVP response is more gradual. Given the noninvasive nature of the measurement technique, VCI shows promise as a method of dynamically measuring patient response to fluid resuscitation. Further studies with larger sample sizes are warranted.

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Background: In an observational study, complications of intrathecal catheter pumps necessitating surgical exchange were analyzed. Also the use of a high-volume prophylactic epidural blood patch (EBP) during surgery for preventing post-dural puncture headache (PDPH) with a follow-up for 1 year is described. Materials and Methods: In 22 patients with refractory chronic pain of cancer/noncancer origin or severe spasticity, who were receiving intrathecal morphine including adjuvants or baclofen for symptom relief, catheter exchange with or without pump was performed. In patients with documented symptoms of PDPH following initial intrathecal catheter implantation, a prophylactic EBP with a high blood volume was used for PDPH prevention during surgery. Catheters were replaced using 40 mL EBP before entering dural space at a speed of 5mL/min into the epidural space. Patients were asked to quantify pain experience and functional ability. Results: From a sample of 72 patients admitted for catheter exchange with or without pump, 22 patients (33%) (12 male, 10 female) had a history of PDPH following initial implantation. Diagnostic and therapeutic measures occurring with malfunction of intrathecal catheter pump systems were described. Twenty-one patients were successfully treated with prophylactic EBP, while one patient could not be properly evaluated because of intracranial bleeding as the underlying disease. Conclusions: A new approach using a high-volume prophylactic EBP for preventing PDPH following catheter exchange is presented. The efficacy and safety of this technique for 1 year follow-up have been evaluated and was found to be safe and potentially effective.

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Background: Heart transplant surgeries using cardiopulmonary bypass (CPB) typically requires mechanical ventilation in intensive care units (ICU) in post-operation period. Ultra fast-track extubation (UFE) have been described in patients undergoing various cardiac surgeries. Aim: To determine the possibility of ultra-fast-track extubation instead of late extubation in post heart transplant patients. Materials and Methods: Patients randomly assigned into two groups; Ultra fast-track extubation (UFE) group was defined by extubation inside operating room right after surgery. Late extubation group was defined by patients who were not extubated in operating room and transferred to post operation cardiac care unit (CCU) to extubate. Results: The mean cardiopulmonary bypass time was 136.8 ± 25.7 minutes in ultra-fast extubation and 145.3 ± 29.8 minutes in late extubation patients (P > 0.05). Mechanical ventilation duration (days) was 0 days in ultra-fast and 2.31 ± 1.8 days in late extubation. Length of ICU stay was significantly higher in late extubation group (4.2 ± 1.2 days) than the UFE group (1.72 ± 1.5 days) (P = 0.02). In survival analysis there was no significant difference between ultra-fast and late extubation groups (Log-rank test, P = 0.9). Conclusions: Patients undergoing cardiac transplant could be managed with "ultra-fast-track extubation", without increased morbidity and mortality.

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In this paper, we report a case of drug-induced pancreatitis just after taking a pain pill including a low-dose combination of acetaminophen and codeine. Codeine-induced pancreatitis has been rarely reported, however, well-established. The proposed mechanism for codeine-induced pancreatitis is by increasing Oddi sphincter pressure. However, the clinically important point is that the codeine-induced pancreatitis is seen almost only in the cholecystectomized patients due to lacking of its reservoir capacity. Codeine is commonly used alone or in combination in pain medicine. Therefore, it is fairly important to question whether a patient underwent cholecystectomy when a physician decides to prescribe codeine-included preparations.

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Background: Traditional approach to predicting trauma-related mortality utilizes scores based on anatomical, physiological, or a combination of both types of criteria. However, several factors are reported in literature to predict mortality independent of severity scores. The objectives of the study were to identify predictors of 1 year mortality and determine their magnitude and significance of association in a resource constrained scenario . Materials and Methods: Prospective observational study enrolled 572 patients. Information regarding factors known to affect mortality was recorded. Other factors which may be important in resource constrained settings were also included. This included referral from a peripheral hospital, number of surgeries performed on the patient, and his socioeconomic status (below poverty line (BPL) card). Patients were followed till death or upto a period of 1year. Logistic regression, actuarial survival analysis, and Cox proportionate hazard model were used to identify predictors of 1year mortality. Limited estimate of external validity of the study was obtained using bootstrapping. Results: Age of patient, Injury Severity Score (ISS), abnormal activated partial thromboplastin time (APTT), Glasgow Coma Scale (GCS) score at admission, and systolic blood pressure (BP) at admission were found to significantly predict mortality on logistic regression and Cox proportionate hazard models. Abnormal respiratory rate at admission was found to significantly predict mortality in the logistic regression model, but no such association was seen in Cox proportionate hazard model. Bootstrapping of the logistic regression model and Cox proportionate hazard model provide us with a set of factors common to both the models. These were age, ISS, APTT, and GCS score at admission. Conclusion: Multivariate analysis (logistic and Cox proportionate hazard analysis) and subsequent bootstrapping provide us with a set of factors which may be considered as valid predictors universally. However, since bootstrapping only provides limited estimates of external validity, there is a need to test these factors against the well accepted requirements of external validity namely population, ecological, and temporal validity.

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Background and Aim: To allocate resources at the national level and ensure the safety level of roads with the aim of economic efficiency, cost calculation can help determine the size of the problem and demonstrate the economic benefits resulting from preventing such injuries. This study was carried out to elicit the cost of traffic injuries among Iranian drivers of public vehicles. Materials and Methods: In a cross-sectional study, 410 drivers of public vehicles were randomly selected from all the drivers in city of Tehran, Iran. The research questionnaire was prepared based on the standard for willingness to pay (WTP) method (stated preference (SP), contingent value (CV), and revealed preference (RP) model). Data were collected along with a scenario for vehicle drivers. Inclusion criteria were having at least high school education and being in the age range of 18 to 65 years old. Final analysis of willingness to pay was carried out using Weibull model. Results: Mean WTP was 3,337,130 IRR among drivers of public vehicles. Statistical value of life was estimated 118,222,552,601,648 IRR, for according to 4,694 dead drivers, which was equivalent to 3,940,751,753 $ based on the dollar free market rate of 30,000 IRR (purchase power parity). Injury cost was 108,376,366,437,500 IRR, equivalent to 3,612,545,548 $. In sum, injury and death cases came to 226,606,472,346,449 IRR, equivalent to 7,553,549,078 $. Moreover in 2013, cost of traffic injuries among the drivers of public vehicles constituted 1.25% of gross national income, which was 604,300,000,000$. WTP had a significant relationship with gender, daily payment, more payment for time reduction, more pay to less traffic, and minibus drivers. Conclusion: Cost of traffic injuries among drivers of public vehicles included 1.25% of gross national income, which was noticeable; minibus drivers had less perception of risk reduction than others.

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Background: Trauma leads to considerable morbidity and mortality. The aim of this study is to elucidate the pattern and characteristics of trauma at Benue State University Teaching Hospital (BSUTH), Makurdi, Nigeria. Materials and Methods: Case records of all patients who presented to the Accident and Emergency (A and E) Department with trauma between January and December 2013 were analyzed for demographic data, types of injuries sustained, causes and circumstances of injuries, as well as outcome of treatment were extracted from the case files and entered onto a computerized questionnaire. Data were analyzed using the software Statistical Package for Social Sciences for Windows version 15.0 (SPSS Inc; Chicago, Illinois). Results: A total of 250 traumatized patients were studied consisting of 203 (81.2%) males and 47 (18.8%) females with a modal age group of 21-30 years. Unintentional injuries were the most predominant form of trauma (n = 209, 83.6%) with road traffic accidents being the leading cause (n = 180, 72.0%). Open wounds (n = 95, 28.2%) were the most common form of injury sustained and the extremities (n = 148, 43.5%), the most frequently injured body region. Most patients (n = 133, 53.2%) were treated and discharged home without permanent disabilities, while death occurred in 15.2%. Conclusion: Trauma in Makurdi is a predominantly young adult male occurrence with road traffic accidents being the leading etiological factor. Reducing road traffic accidents will likely reduce mortality and morbidity due to trauma.

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Tracheobronchial avulsion resulting from blunt trauma is a very rare and serious condition, mostly due to high-speed traffic crashes. In this article, we briefly report the case of an 18-year-old man who was injured in a car accident and because of massive persistent air leakage (despite appropriate chest tube drainage), deemed to have a deep tracheobronchial injury. Due to a rapid drop in the patient's O ₂ saturation, he underwent an anterolateral thoracotomy. Endotracheal intubation was performed under direct visualization. The right mainstem bronchus was disrupted from the carina with a 1.5-cm stump remaining on the carina, and the remainder was crushed to the origin of the right superior lobe bronchus. Hence, a right superior lobectomy was performed and the postoperative course was uneventful.

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Objective: To compare outcomes of critically ill patients transferred from another island compared to those patients with direct admission from Emergency Department to intensive care unit (ICU). Patients and Methods: Retrospective study of prospectively collected data during 8 years. The population studied was all critical adult patients transferred from another island to our hospital and those directly admitted from the Emergency Department. Variables were age, sex, clinical diagnosis (coronary, medical, surgical, or trauma), acute physiology and chronic health evaluation (APACHE) II score at admission, ICU days of stay, days of mechanical ventilation and ICU mortality. Results: During the period of study, 3,115 patients coming from Emergency Department (Group 1) were admitted to our ICU and 138 were transferred from another island (Group 2). No significant statistically differences were found between both groups neither age, sex, APACHE II, ICU days, days of mechanical ventilation, and mortality rate (17.5% versus 20.3%, P = 0.43). The multivariate analysis showed that age, APACHE II score, ICU days of stay, type of patient, and days of mechanical ventilation were independent variables associated with mortality. Conclusions: No differences were found in the global prognosis of the admitted patients transferred from another island compared to those who were admitted directly from the Emergency Department. There is no impact on mortality in transferring a patient in our study population.

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Background: Cardiac dysfunction after brain death has been described in a variety of brain injury paradigms but is not well understood after severe pediatric traumatic brain injury (TBI). Cardiac dysfunction may have implications for organ donation in this patient population. Materials and Methods: We conducted a retrospective cohort study of pediatric patients with severe TBI, both with and without a diagnosis of brain death, who underwent echocardiography during the first 2 weeks after TBI, between the period of 2003-2011. We examined cardiac dysfunction in patients with and without a diagnosis of brain death. Results: In all, 32 (2.3%) of 1,413 severe pediatric TBI patients underwent echocardiogram evaluation. Most patients had head abbreviated injury score 5 (range 2-6) and subdural hematoma (34.4%). Ten patients with TBI had brain death compared with 22 severe TBI patients who did not have brain death. Four (40%) of 10 pediatric TBI patients with brain death had a low ejection fraction (EF) compared with 1 (4.5%) of 22 pediatric TBI patients without brain death who had low EF (OR = 14, P = 0.024). Conclusions: The incidence of cardiac dysfunction is higher among pediatric severe TBI patients with a diagnosis of brain death, as compared to patients without brain death. This finding may have implications for cardiac organ donation from this population and deserves further study.

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Encephalopathy associated with metronidazole administration is an uncommon but potentially reversible disease and depends on the cumulative metronidazole dose, and most patients with this condition recover rapidly after discontinuation of therapy. We present a case as well as a review of the literature regarding this rare but serious adverse event.

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Nontraumatic spontaneous splenic rupture (NSSR) has been encountered much more rarely compared with the traumatic splenic rupture. Although NSSR generally emerges in dialysis patients on account of such causes as the use of heparin during hemodialysis, uremic coagulopathy, infections, and secondary amyloidosis. Herein, we aimed to present a case of spontaneous splenic rupture which had developed soon after the inclusion of the case suffering from end-stage renal disease in routine hemodialysis program in the absence of any trauma or other prespecified risk factors for splenic rupture. A 55-year-old male patient was admitted to our hospital to have the ureteral double J stent removed. The operation was completed without any complication. Complaining an abdominal pain more prominent in the left upper abdominal quadrant in the first postoperative day, the patient underwent a through physical examination which disclosed abdominal distension, widespread tenderness, and rebound and defense positivity. The abdominal tomography depicted 122 Χ 114 Χ 95 mm lesion compatible with a hematoma. On the basis of these findings, an emergency exploratory operation was decided to be performed. Following clearance of the retroperitoneal hematoma, splenectomy was implemented. Experiencing progressive deterioration in his clinical status despite antibiotherapy, the patient unfortunately died of sepsis with multiorgan failure on the 25 ^th postoperative day. In conclusion, NSSR is such an entity that may be missed out, can pursue variable clinical courses, and requires emergency therapy upon definitive diagnosis. The possibility of spontaneous bleedings should be kept in mind in any case with the history of hyperuricemia even in the absence of overt trauma, no matter if they are included in routine hemodialysis or not.

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We report the case of a woman, with severe respiratory impairment as a debut of acute myeloid leukemia who suspecting a pulmonary leukostasis, leukoapheresis was applied.

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