Author Archives: administrare

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.

Full text: PDF

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.

Full text: PDF

The Use of Extracorporeal Life Support in a Patient Suffering from Venlafaxine Intoxication. A Case Report

DOI: 10.2478/jccm-2020-0014

Very few reports exist on serious cardiac complications associated with intake of serotonin-noradrenaline reuptake inhibitors. This paper describes and discusses the case of a patient who ingested a dose of 17.5 g venlafaxine. She developed a full serotonergic syndrome leading to multi-organ failure, including refractory cardiovascular shock, which was managed by early implantation of an extracorporeal life support (ECLS) system as a bridging strategy. This intervention was successful and resulted in full recovery of the patient.

Full text: PDF

Associate Professor Silviu-Cosmin Moldovan (1975 – 2020)

“George Emil Palade” University of Medicine, Pharmacy, Science and Technology of Târgu Mureş has been deeply affected by the untimely death of Associate Professor Silviu-Cosmin Moldovan, Vice-Dean of the Faculty of Medicine in English.
Associate Professor Silviu-Cosmin Moldovan (PhD) was born on August 9 1975, in Târgu-Mureș, and graduated from the Faculty of Medicine, University of Medicine and Pharmacy of Târgu-Mureș, in 1999.
After graduation, in 2000, he started to work as an intern, and in 2004 he began his residency in pathological anatomy at the Emergency County Hospital of Târgu-Mureș and continued his professional activity as medical specialist and then as senior physician in pathological anatomy at the Emergency County Hospital of Târgu-Mureș. [More]

Full text: PDF

Anaesthesia for Liver Transplantation: An Update

DOI: 10.2478/jccm-2020-0011

Liver transplantation (LT) is a challenging surgery performed on patients with complex physiology profiles, complicated by multi-system dysfunction. It represents the treatment of choice for end-stage liver disease. The procedure is performed under general anaesthesia, and a successful procedure requires an excellent understanding of the pathophysiology of liver failure and its implications. Despite advances in knowledge and technical skills and innovations in immunosuppression, the anaesthetic management for LT can be complicated and represent a real challenge. Monitoring devices offer crucial information for the successful management of patients. Hemodynamic instability is typical during surgery, requiring sophisticated invasive monitoring. Arterial pulse contour analysis and thermo-dilution techniques (PiCCO), rotational thromboelastometry (RO-TEM), transcranial doppler (TCD), trans-oesophageal echocardiography (TEE) and bispectral index (BIS) have been proven to be reliable monitoring techniques playing a significant role in decision making. Anaesthetic management is specific according to the three critical phases of surgery: pre-anhepatic, anhepatic and neo-hepatic phase. Surgical techniques such as total or partial clamping of the inferior vena cava (IVC), use of venovenous bypass (VVBP) or portocaval shunts have a significant impact on cardiovascular stability. Post reperfusion syndrome (PRS) is a significant event and can lead to arrhythmias and even cardiac arrest.

Full text: PDF

Spontaneous Sublingual Haematoma in a 90-year Old Patient: A Complication of Direct Oral Anticoagulants

DOI: 10.2478/jccm-2020-0010

Sublingual haematoma is a rare complication of anticoagulants and can be life-threatening. As the number of prescribed anticoagulants is increasing, the incidence of complications of these drugs will continue to increase. A report of a sublingual haematoma in an elderly patient with chronic atrial fibrillation treated with edoxban (Lixiana ©, Daiichi Sankyo Europe GmbH, München, Germany) is reported. A 90-year male presented at the emergency department with an obstructed upper airway due to a sublingual haematoma. The patient received tranexamic acid, prothrombin complex, and fresh frozen plasma. After fiberoptic nasal intubation, the patient was monitored in the intensive care unit. After four days, the patient was extubated, and after six days, the swelling resolved completely. Complications of anticoagulants are rare but can be life-threatening. Recognition of an endangered airway and reversing the effects of the anticoagulant are essential. Surgical evacuation of the haematoma could be considered but is not necessary.

Full text: PDF

To Be or Not to Be… Sepsis? A Daily Challenge in ICU

DOI: 10.2478/jccm-2020-0012

Nowadays, one of the most challenging medical issues is related to high morbidity and mortality in sepsis and septic shock. Despite the medical progress regarding early diagnosis and management, this complex pathology remains a life-threatening condition. During the last decades, many definitions and including criteria were developed both in sepsis and septic shock, principally as many early biomarkers became available. However, many issues still exist regarding this subject.
The clinical definitions of sepsis and systemic inflammatory response syndrome (SIRS) have been refined, but both conditions manifest with similar clinical features [1]. The Third International Consensus Definitions Task Force (Sepsis-3) defined sepsis as “a life-threatening organ dysfunction resulting from a dysregulated host response to infection”. Septic shock is “a subset of sepsis in which circulatory, cellular and metabolic alterations are associated with a higher mortality rate than sepsis alone” [2] morphology, cell biology, biochemistry, immunology, and circulation. These definitions are related to the pathophysiology of sepsis, which are the cornerstones of a better understanding of the underlying mechanisms and disorders that occur [3]. [More]

Full text: PDF

Impact of Intravenous Fluids and Enteral Nutrition on the Severity of Gastrointestinal Dysfunction: A Systematic Review and Meta-analysis

DOI: 10.2478/jccm-2020-0009

Introduction: Gastrointestinal dysfunction (GDF) is one of the primary causes of morbidity and mortality in critically ill patients. Intensive care interventions, such as intravenous fluids and enteral feeding, can exacerbate GDF. There exists a paucity of high-quality literature on the interaction between these two modalities (intravenous fluids and enteral feeding) as a combined therapy on its impact on GDF.
Aim: To review the impact of intravenous fluids and enteral nutrition individually on determinants of gut function and implications in clinical practice.
Methods: Randomized controlled trials on intravenous fluids and enteral feeding on GDF were identified by a comprehensive database search of MEDLINE and EMBASE. Extraction of data was conducted for study characteristics, provision of fluids or feeding in both groups and quality of studies was assessed using the Cochrane criteria. A random-effects model was applied to estimate the impact of these interventions across the spectrum of GDF severity.
Results: Restricted/goal-directed intravenous fluid therapy is likely to reduce ‘mild’ GDF such as vomiting (p = 0.03) compared to a standard/ liberal intravenous fluid regime. Enterally-fed patients experience increased episodes of vomiting (p = <0.01) but are less likely to develop an anastomotic leak (p = 0.03) and peritonitis (p = 0.03) compared to parenterally fed patients. Vomiting (p = <0.01) and anastomotic leak (p = 0.04) were significantly lower in the early enteral feeding group.
Conclusions: There is less emphasis on the combined approach of intravenous fluid resuscitation and enteral feeding in critically ill patients. Conservative fluid resuscitation and aggressive enteral feeding are presumably key factors contributing to severe life-threatening GDF. Future trials should evaluate the impact of cross-interaction between conservative and aggressive modes of these two interventions on the severity of GDF.

Full text: PDF