Author Archives: administrare

Neuroleptic Malignant Syndrome or Catatonia? A Case Report

DOI: 10.2478/jccm-2020-0025

Introduction: A review of the literature has shown that there are many similarities in the presentation of neuroleptic malignant syndrome (NMS) and catatonia. Attempts to reconcile the differences have been made by suggesting that NMS and catatonia may represent different presentations of the same illness or that they lie within the same spectrum of a poorly understood clinical syndrome. The described case is of a patient who presented with NMS and catatonia which was difficult to diagnose, but which responded to treatment with intravenous diazepam.
Case presentation: The case concerns a 22-year-old male admitted for pulmonary hypertension to an intensive care unit (ICU). Three days following admission, he developed a high fever that did not respond to antibiotics. The patient then developed rigidity, nocturnal agitation, decreased responsiveness, and somnolence. Without the use of bromocriptine (Novartis, Basel, Switzerland) or dantrolene (Par Pharmaceuticals, Chestnut Ridge, USA) discontinuation of neuroleptics combined with intravenous diazepam (Pfizer, NY, USA) led to a very rapid response and marked improvement in the case.
Conclusions: Early recognition and management of NMS and MC in a complex, gravely ill patient, may be accomplished in the ICU despite obfuscation of traditional signs and symptoms of the NMS and MC syndrome. Such interventions can have life-saving effects on patients in danger of fatal autonomic instability.

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Monitoring Anticoagulation with Unfractionated Heparin on Renal Replacement Therapy. Which Is the Best aPTT Sampling Site?

DOI: 10.2478/jccm-2020-0024

Background: Controlled anticoagulation is key to maintaining continuous blood filtration therapies. Objective: The study aimed to compare different blood sampling sites for activated partial thromboplastin time (aPTT) to evaluate anticoagulation with unfractionated heparin (UFH) in continuous renal replacement therapy (CRRT) and identify the most appropriate sampling site for safe patient anticoagulation and increased filter life span.
Method: The study was a prospective observational single-centre investigation targeting intensive care unit (ICU) patients on CRRT using an anticoagulation protocol based on patient characteristics and a weight-based modified nomogram. Eighty-four patients were included in the study. Four sampling sites were assessed: heparin free central venous nondialysis catheter (CVC), an arterial line with heparinised flush (Artery), a circuit access line (Access), and a circuit return line (Postfilter). Blood was sampled from each of four different sites on every patient, four hours after the first heparin bolus. aPTT was determined using a rapid clot detector, point of care device.
Results: A high positive correlation was obtained for aPTT values between CVC and Access sampling sites (r (84) =0.72; p <0 .05) and a low positive correlation between CVC and Arterial sampling site (r (84) =0.46, p < 0.05). When correlated by artery age, the young Artery (1-3 day old) correlates with CVC, Access and Postfilter (r (45) = 0.74, p >0.05). The aPTT values were significantly higher at Postfilter and Arterial sampling site, older than three days, compared to the CVC sampling site (p<0.05).
Conclusion: Considering patient bleeding risks and filter life span, the optimal sampling sites for safe assessment of unfractionated heparin anticoagulation on CRRT during CVVHDF were the central venous catheter using heparin free lavage saline solution, a heparinised flushed arterial catheter not older than three days, and a circuit access line

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Hypoxic Respiratory Failure Further Complicated During Airway Exchange Catheter Placement

DOI: 10.2478/jccm-2020-0023

Introduction: An airway exchange catheter is a hollow-lumen tube able to deliver oxygen and maintain access to a difficult endotracheal airway. This case report demonstrates an undocumented complication associated with an airway exchange catheter and jet ventilation, particularly in a patient with reduced airway diameter due to thick endotracheal secretions. Due to the frequent use of airway exchange catheters in the intensive care unit, this report highlights an adverse event of bilateral pneumothoraces that can be encountered by clinicians.
Case Presentation: This case report describes a 24-year-old female with severe adult respiratory distress syndrome and thick endotracheal secretions whose hospital course was complicated by bilateral pneumothoraces resulting from the use of an airway exchange catheter connected to jet ventilation. During the exchange, the catheter occluded the narrowed endotracheal tube to create a one-way valve that led to excessive lung inflation.
Conclusion: Airway exchange catheters used with jet ventilation in a patient with a narrowed endotracheal tube and reduced lung compliance have the potential risk of causing a pneumothorax. Clinicians should avoid temporary concomitant oxygenation via jet ventilation in patients with these findings and reserve the use of airway exchange catheters for difficult airways.

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Takotsubo Syndrome: Is This a Common Occurrence in Elderly Females after Hip Fracture?

DOI: 10.2478/jccm-2020-0022

Background: The prevalence of Takotsubo syndrome in hip fracture is not known.
Methods: Hip fracture patients were evaluated in a multidisciplinary unit. Patients with ECG abnormalities and increased troponin I values at the time of hospital admission were included in the study Follow-up was clinical at 30 days and by telephonic interview at one year.
Results: Between October 1st 2011 to September 30th 2016, 51of 1506 patients had preoperative evidence of myocardial damage. Eight, all females, fulfilled the Mayo criteria for Takotsubo syndrome, six had no coronary lesions. Hip surgery was uneventful, and all eight were alive at thirty days, and seven of these were still alive after one year. Forty-three patients had myocardial infarction: mortality at thirty days and one year were 11% and 44% (p<0.0001, Student’s t-test;log-rank test).
Conclusion: At least 15% of patients with hip fracture and preoperative myocardial damage had Takotsubo syndrome. They were all elderly females. Contrary to myocardial infarction, Takotsubo syndrome has a favourable long term prognosis.

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Therapeutic Plasma Exchange: An Indispensable Therapy for Severe Neurological Conditions

DOI: 10.2478/jccm-2020-0021

Therapeutic plasma exchange (TPE) is the most frequent therapeutic apheresis procedure used to remove the plasma, together with its high-molecular-weight agents such as immune complexes, antibodies, complement components, cytokines, different toxins and cryoglobulins, as well as to return of the majority of cellular components to the patients [1]. In the hands of an experienced specialist, TPE has been found by the American Academy of Neurology to be a very important and safe tool that can improve neurological disability in patients with numerous disorders [2]. [More]

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Non-Cardiogenic Pulmonary Oedema Following the Use of Gadolinium-Based Contrast Medium: A Case Report

DOI: 10.2478/jccm-2020-0019

Non-cardiogenic pulmonary oedema can be life threatening and requires prompt treatment. While gadolinium-based contrast is generally considered safe with a low risk of severe side effects, non-cardiogenic pulmonary oedema has become increasingly recognised as a rare, but possibly life-threatening complication. We present a case of a usually well, young 23-year-old female who developed non-cardiogenic pulmonary oedema with a moderate oxygenation impairment and no mucosal or cutaneous features of anaphylaxis following the administration of gadolinium-based contrast. She did not respond to treatment of anaphylaxis but made a rapid recovery following the commencement of positive pressure ventilation. Our case highlights the importance of recognising the rare complication of non-cardiogenic pulmonary oedema following gadolinium-based contrast administration in order to promptly implement the appropriate treatment.

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The Use of Pistacia Lentiscus Chia Resin versus Omeprazole in Protecting Male Rats Peptic Mucosa against Cold Restraint Stress

DOI: 10.2478/jccm-2020-0018

Introduction: Peptic mucosal damage induced by acute stress is a serious cause of morbidity and mortality in critically ill patients. The study aimed to investigate the protective, antioxidant and anti-inflammatory effects of pre-treatment with Chios mastic gum (CMG), a traditionally consumed herbal resin naturally deriving from the trunk of Pistacia Lentiscus var. Chia compared to Omeprazole, a standard medication used in the prevention and treatment of gastritis, against the effects of cold restraint stress (CRS) in rat gastric and colonic mucosa.
Methods: Twenty-one male Wistar rats were randomly assigned to three groups: Control (C), Omeprazole (O), and CMG (M), according to the pre-treatment regime, and were subjected to CRS at 4oC for 3 hours. The gastric and colonic mucosal lesions were histologically assessed. ELISA measured blood concentrations of TNF-α, IL-1β, peroxidase, superoxide dismutase (SOD) and total antioxidant capacity (TEAC).
Results: In both groups, O and M, gastric mucosal hyperemia, haemorrhagic infiltration and mucosal oedema, as well as colonic mucosal hyperaemia and haemorrhagic infiltration were significantly reduced compared to the controls (p<0.05). No significant differences were observed between Groups O and M. TNF-α levels were significantly lower in group M compared to Group O (p=0.013). IL-1β levels were significantly depressed in groups M and O compared to control (p≤ 0.001). The activity of both peroxidase and SOD enzymes decreased in group M compared to group O (p= 0.043 and p=0.047 respectively) and the control (p=0.018 and p< 0.001 respectively). Conclusions: The natural Chios mastic gum is a promising nutritional supplement with protective properties to the peptic mucosa against CRS, exerting anti-inflammatory and antioxidant effects.

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Catastrophic Caustic Ingestion: A Case Report

DOI: 10.2478/jccm-2020-0017

Introduction: The majority of oral ingestion of caustic material by adults is intentional, and the aftermath varies widely with potentially fatal results. Injuries range from superficial burns of facial and oropharyngeal structures to extensive necrosis of the gastrointestinal tract. Management focuses on the identification of the ingested substance and prompt treatment and supportive care of the multiple complications stemming from the ingestion. Complications following caustic ingestion include both immediate and long term.
Case presentation: A fifty-seven-year-old man presented following intentional ingestion of drain cleaner. The patient was intubated and underwent emergent esophagogastroduodenoscopy [EGD], which revealed extensive damage to his oesophagus and stomach. He survived his initial injury but had a prolonged hospital course and ultimately died after developing tracheoesophageal and bronchooesophageal fistulas which were too extensive for surgical repair.
Conclusion: The sequelae of caustic ingestion can be minor or severe, both immediate and delayed. Despite appropriate prompt management and supportive care, patients may die as a result of the initial injury or subsequent complications.

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An Intentional Aconite Overdose: A Case Report

DOI: 10.2478/jccm-2020-0016

Background: Aconite is one of the most toxic known herbs, widely used for centuries as an essential Chinese medicine, but also for deliberate poisoning throughout history. Clinically indicated in herbal medicine for a range of ailments from headaches to muscle spasm, unfortunately, the narrow therapeutic window may lead to a range of toxic presentations. The mechanism of action of the pharmacologically active compounds in Aconite relate to the activation of voltage-gated sodium channels within a range of tissue including myocardial, neuronal and smooth muscle leading to persistent cellular activity.
Case presentation: We report on a rare case of a fifty-year-old male with intentional aconite overdose presenting with refractory cardiovascular instability from persistent life-threatening arrhythmias, respiratory failure, and seizure activity.
Conclusion: An overview of Aconite, its history, pharmacological effects, treatment of overdose and outcomes is presented.

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Drug Thrombus Resulting in Superior Vena Cava Syndrome: A Case Report

DOI: 10.2478/jccm-2020-0015

Introduction: Superior vena cava syndrome is one of the more serious complications of central venous catheter insertion. Drug interactions of administered drugs used in association with these catheters can lead to formation of precipitations and consequently thrombus formation. These interactions can be either anion-cation or acid-base based and more commonly present in clinical practice than expected.
Case presentation: The case of a 31-year old female who was admitted to an intensive care unit with an intracranial haemorrhage, is presented. Occlusion of the superior vena cava was caused by a drug-induced thrombus, formed by the precipitation and clotting of total parenteral nutrition and intravenous drugs. Given the nature of the thrombus and a recent intracranial haemorrhage, the patient was treated with a central thrombectomy supported by a heparin-free extracorporeal membrane oxygenation.
Conclusion: Knowledge of drug interactions is crucial in order to heighten awareness for the dangers of concomitant drug administration, especially in combination with total parenteral nutrition in critically ill patients.

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