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Neonatal Resuscitation Practices in Romania: A Survey of the Romanian Association of Neonatology (ANR) and the Union of European Neonatal and Perinatal Societies (UENPS)

Manuela Cucerea1, Marta Simon1, Silvia Maria Stoicescu2, Ligia Daniela Blaga3, Radu Galiș4, Maria Stamatin5, Gabriela Olariu6, Maria Livia Ognean7

1 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Carol Davila University of Medicine and Pharmacy: Universitatea de Medicina si Farmacie Carol Davila din Bucuresti
3 Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
4 Oradea County Emergency Hospital: Spitalul Clinic Judetean De Urgenta Oradea
5 Grigore T Popa University of Medicine and Pharmacy Iasi Faculty of Medicine: Universitatea de Medicina si Farmacie Grigore T Popa lasi Facultatea de MedicinaRinggold ID 162290
6 Emergency County Hospital Timisoara: Spitalul Clinic Judetean de Urgenta Timisoara
7 Lucian Blaga University of Sibiu Faculty of Medicine: Universitatea Lucian Blaga din Sibiu Facultatea de Medicina

DOI: 10.2478jccm-2024-0010

Introduction: This study is part of a European survey on delivery room practices endorsed by the Union of European Neonatal and Perinatal Societies (UENPS) and the Romanian Association of Neonatology (ANR). The aim of our study was to evaluate the current neonatal resuscitation practices in Romanian maternity hospitals and to compare the results between level III and level II centers.
Material and Methods: The questionnaire was distributed through ANR by email link to heads of neonatal departments of 53 Romanian maternity hospitals with more than one thousand of births per year between October 2019 and September 2020, having 2018 as the reference year for data collection.
Results: The overall response rate to the questionnaire was 62.26% (33/53), 83.33% (15/18) for level-III centers and 51.43% (18/35) for level-II centers. Of the responding centers, 18 (54,54%) were academic hospitals, 15 (83,33%) were level III and 3 (16,67%) level II hospitals. In 2018, responding centers reported 81.139 births representing 42.66% of all Romanian births (190.170). There were significant differences between level-III and level-II maternity hospitals regarding the number of births in 2018 (3028.73±1258.38 vs 1983.78±769.99; P=0.006), lowest GA of routinely assisted infants in delivery room (25.07±3.03 weeks vs 30.44±3.28, P<0.001), inborn infants with BW<1500 admitted to neonatal intensive care unit (NICU) in 2018 (66.86±39.14 g vs 22.87±31.50 g; P=0.002), and antenatal counseling of parents before the delivery of a very preterm infant or an infant with expected problems (60% vs 22.2%; P=0.027). There were no significant differences of thermal and umbilical cord management, positive pressure delivery, heart rate assessment between responding centers.
Conclusion: The adherence to new guidelines was high among responding centers regarding thermal and umbilical cord management, initial FiO2, but aspects like antenatal counseling, EKG monitoring, laryngeal mask, and heated/humidified gases availability and administration, and simulation-based training require further implementation.

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Retrospective Study of the Use of Heparins in Pregnant Women and in vitro Testing on the HCT 116 Colorectal Carcinoma Cell Line

Felicia Fiat1,2, Diana-Aurora Arnautu3, Brenda Cristina Bernad2,4, Alina Anton5, Iasmina Marcovici5,6, Alexandra-Denisa Semenescu5,6, Elena Silvia Bernad1

1 Department of Obstetrics-Gynecology II, Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
2 Doctoral School, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
3 Department of Cardiology, Victor Babeș University of Medicine and Pharmacy, Timisoara, Romania
4 Center for Neuropsychology and Behavioral Medicine, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
5 Department of Toxicology, Drug Industry, Management and Legislation, Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy Timisoara, Romania
6 Research Center for Pharmaco-Toxicological Evaluations, University of Medicine and Pharmacy Victor Babes Timisoara, Romania

DOI: 10.2478jccm-2024-0009

Introduction: Pregnant women manifest an increased risk of developing coagulation disorders. Unfractionated heparin (HEP) and low-molecular-weight heparin (LMWHep) are considered as selective medication in the case of pregnancy which needs anticoagulant treatment. In addition to anticoagulant properties, HEP and its derivatives manifest other properties including anti-cancer potential. According to Globocan’s latest data, colorectal cancer (CRC) is the second most encountered form of malignancy in the case of women, manifesting some special particularities, as confusion of symptoms from cancer with symptoms encountered normally in pregnant women (such as constipation or rectal bleeding), delayed diagnosis because of limitations imposed both for the fetus and for the mother, and the need for special treatment.
Aim: The aim of the present work is to follow the incidence and safety of consumption of HEP and LMWHep in the case of pregnant women and to analyze their potential on the HCT 116 colorectal carcinoma cells.
Results: Analyzing the consumption of heparins in case of pregnant women hospitalized from 01.01.2022 to 31.12.2022 at the Pius Brînzeu” Emergency Clinical Hospital from Timisoara, Obstetrics and Gynecology Clinic I, it was observed that 44,6% of the patients were administered the following medication and no administration risks were observed. When tested on HCT 116 cells, heparins manifested a significant anti-migratory effect (with wound healing rates of 2,6%, when tested with HEP 100 UI concentration and 14.52% wound healing rates in case of fraxiparine 100 UI). In addition, different signs of apoptosis were observed, suggesting the pro-apoptotic potential of the tested substances.
Conclusions: Heparins remain the preferred medication to be administered to pregnant women with the potential for coagulation disorders, showing a high safety profile. Testing on the cancerous line of colorectal carcinoma highlights important properties that stimulate future studies, to establish the anti-tumor potential and the exact mechanism of action.

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Weaning Outcome is Associated with ELWI and Impaired Diastolic Function

Dimitra Bagka1, George Zakynthynos2, Vasiliki Tsolaki1, Jonh Papanikolaou3, Vasilis Vazgiourakis1, Maria Baka1, Konstantinos Pratsas1, Demosthenes Makris1

1 General University Hospital of Larissa, Larisa, Greece
2 University of Athens, Athens, Greece
3 General Hospital of Trikala, Greece

DOI: 10.2478jccm-2024-0008

Objectives: To evaluate hemodynamic profiles of critical care patients undergoing spontaneous t-piece trial (SBT) and present weaning failure.
Methods: Prospective observational study conducted in ready-to-wean non-cardiac ICU patients. Clinical, echocardiographic and thermodilution-derived variables were recorded before and after a 2-hour SBT. Weaning from mechanical ventilation was defined as preservation of spontaneous breathing for 48 hours following successful SBT.
Results: Fourteen patients succeeded weaning, five manifested T-trial-failure and six late-failure. Weaning outcome was significantly associated with ELWI(Extravascular lung-water index), global-end-diastolic index and impaired diastolic function, as indicated by pre-T Doppler early wave velocities (E/Em); Fifty-six percent of participants presented ELWI≥7mL/kg when fulfilling predetermined criteria for weaning. ELWI, impaired pulmonary permeability and left ventricular diastolic dysfunction were independent determinants of ELWI.
Conclusions: ELWI before SBT and impaired diastolic function (as indicated by pre-T E/Em) might be weaning outcome determinants and their assessment may allow better risk stratification in weaning decision making.

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Pediatric Critical Care Illness Severity Toolkit: Stata Commands for Calculation of Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction Scores

Razvan Azamfirei1,2, Colleen Mennie1, James C. Fackler1,3, Sapna R. Kudchadkar1,3,4

1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
2 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Department of Pediatrics, Charlotte R. Bloomberg Children’s Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
4 Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA

DOI: 10.2478/jccm-2023-0033

Introduction: Illness severity scoring tools, such as PRISM III/IV, PIM-3, and PELOD-2, are widely used in pediatric critical care research. However, their application is hindered by complex calculation processes, privacy concerns with third-party online calculators, and challenges in accurate implementation within statistical packages.
Methods: We have developed a comprehensive, open-source toolkit for implementing the PIM-3, Simplified PIM-3, and PELOD-2 scores. The toolkit includes the pim3 and pelod2 commands and is compatible with Stata versions 12 and above. It features robust data validation, error messaging, a graphical interface, and support for SI and Imperial units. The toolkit’s accuracy was validated through unit testing and synthetic data, comparing results with existing implementations.
Results: In performance tests, the toolkit exhibited a median processing time of 21.82 seconds for PELOD-2, 14.06 seconds for PIM-3, and 9.74 seconds for Simplified PIM-3, when applied to datasets of 10,000,000 records. It consistently achieved 100% accuracy in both synthetic data tests and manual spot checks.
Conclusion: The toolkit decreases processing time and improves accuracy in calculating pediatric critical care severity scores such as PELOD-2, PIM-3, and Simplified PIM-3. Its application in large datasets and validation highlights its utility as a tool for streamlining pediatric critical care research.

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Neutrophil-to-Lymphocyte Ratio and Thrombocyte-to-Lymphocyte Ratio as a Predictor of Severe and Moderate/Mild Acute Respiratory Distress Syndrome Patients: Preliminary Results

Mihai Claudiu Pui1, Mihaela Butiulca1,2, Vlad Cehan1, Florin Stoica3,4, Alexandra Lazar1,2

1 Department of Anesthesiology and Intensive Care Medicine, Emergency County Hospital, Targu Mures, Romania
2 Department of Anesthesiology and Intensive Care Medicine, Faculty of General Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Department of Internal Medicine, Emergency County Hospital, Targu Mures, Romania
4 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2024-0005

Introduction: Acute respiratory distress syndrome (ARDS) represents a major cause of mortality in the intensive care unit (ICU). The inflammatory response is escalated by the cytokines and chemokines released by neutrophils, therefore the search for quantifying the impact of this pathophysiological mechanism is imperative. Neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) are indicators of systemic inflammation, widely accessible, inexpensive, and uncomplicated parameters.
Methods: We conducted a prospective study between March 2023 and June 2023 on patients which presented Berlin criteria for the diagnosis of ARDS during the first 24 hours from admission in the ICU. We included 33 patients who were divided into two groups: one group of 11 patients with severe ARDS and the second group of 22 patients with moderate/mild ARDS. The study evaluated demographic characteristics, leukocyte, lymphocyte, neutrophil, and platelet counts, as well as NLR and PLR values from complete blood count, and severity scores ( APACHE II score and SOFA score). We investigated the correlation of NLR and PLR in the two main groups (severe and moderate/mild acute respiratory distress syndrome patients).
Results: For the NLR ratio statistically significant differences between the the two groups are noted: Severe ARDS 24.29(1.13-96) vs 15.67(1.69-49.71), p=0.02 For the PLR ratio, we obtained significant differences within the group presenting severe ARDS 470.3 (30.83-1427) vs. the group presenting mild/moderate ARDS 252.1 (0-1253). The difference between the two groups is statistically significant (0.049, p<0.05). The cut-off value of NLR resulted to be 23.64, with an Area Under the Curve (AUC) of 0.653 (95% CI: 0.43-0.88). The best cut-off value of PLR was performed to be 435.14, with an Area Under the Curve (AUC) of 0.645 (95% CI: 0.41-0.88).
Conclusion: Our study showed that NLR and PLR ratios 24 hours in patients with moderate/severe ARDS diagnosis can be a good predictor for severity of the disease. These biomarkers could be used in clinical practice due to their convenience, inexpensiveness, and simplicity of parameters. However, further investigations with larger populations of ARDS patients are necessary to support and validate these current findings.

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Simplified Diagnosis of Urosepsis by Emergency Ultrasound Combined with Clinical Scores and Biomarkers

Alice Nicoleta Dragoescu1, Petru Octavian Dragoescu1, Andreea Doriana Stanculescu2, Vlad Padureanu1, Dalia Dop1, Mihai Alexandru Radu1, Mirela Marinela Florescu1, Daniela Teodora Maria1, Dan Nicolae Florescu1, George Mitroi1

1 Faculty of Medicine, University of Medicine and Pharmacy of Craiova, Craiova, Romania
2 Faculty of Pharmacy, University of Medicine and Pharmacy of Craiova, Craiova, Romania

DOI: 10.2478/jccm-2024-0006

Background: Urosepsis is a life-threatening medical condition due to a systemic infection that originates in the urinary tract. Early diagnosis and treatment of urosepsis are critical to reducing mortality rates and preventing complications. Our study was aimed at identifying a fast and reliable method for early urosepsis diagnosis and severity assessment by combining prognostic scores such as SOFA and NEWS with ultrasound examination and serum markers PCT and NLR.
Methods: We performed a single-center prospective observational study in the Craiova Clinical Emergency Hospital. It initially analysed 204 patients admitted for sepsis of various origins in our hospital between June and October 2023. Those with urological conditions that were suspected to have urosepsis have been selected for the study so that finally 76 patients were included as follows: the severe cases with persistent hypotension requiring vasopressor were enrolled in the septic shock group (15 patients – 19.7%), while the rest were included in the sepsis group (61 patients – 80.3%). Mortality rate in our study was 10.5% (8/76 deaths due to sepsis).
Results: Both prognostic scores SOFA and NEWS were significantly elevated in the septic shock group, as were the sepsis markers PCT and NLR. We identified a strong significant positive correlation between the NEWS and SOFA scores (r = 0.793) as well as PCT and NLR (r=0.417). Ultrasound emergency evaluation proved to be similar to CT scan in the diagnosis of urosepsis (RR = 0.944, p=0.264). ROC analysis showed similar diagnostic performance for both scores (AUC = 0.874 for SOFA and 0.791 for NEWS), PCT and NLR (AUC = 0.743 and 0.717).
Conclusion: Our results indicate that an accurate and fast diagnosis of urosepsis and its severity may be accomplished by combining the use of simpler tools like emergency ultrasound, the NEWS score and NLR which provide a similar diagnosis performance as other more complex evaluations.

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Posterior Reversible Encephalopathy Syndrome, not so Uncommon in Pediatric Patients with Renal Involvement: A Case Series

Ana-Maria Roxana Koller1, Alexandra Man1, Carmen Muntean2

1 Department of Pediatrics, County Emergency Clinical Hospital Targu Mures, Romania
2 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2024-0004

Introduction: Posterior reversible encephalopathy syndrome (PRES) primarily shows neurological symptoms and is more frequent in males, often occurring in oncological patients. It can also be associated with renal conditions like post-streptococcal glomerulonephritis, a common cause of pediatric hypertension. Management involves blood pressure and seizure treatment. In some cases, it may lead to irreversible and severe complications. Early treatment is essential for prevention.
Presentation of case series: In the past six months, we have documented the cases of two patients, aged 15 and 10, both of whom presented with PRES and renal disease. These patients were admitted because of general malaise, headaches, nausea, vomiting, visual disturbances, and elevated blood pressure. Subsequently, both patients experienced epileptic episodes. Only the first patient required transfer to the Pediatric Intensive Care Unit (PICU). Cerebral magnetic resonance imaging (MRI) scans revealed distinct PRES lesions in both cases. Following comprehensive investigations, both cases were diagnosed with PRES in the context of acute post-streptococcal glomerulonephritis.
Conclusions: The patients showed improvement following the administration of antihypertensive and anticonvulsant medications, along with treatment for the underlying renal condition.

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Lower Free T3 Levels Linked to Poorer Outcomes in Chronic Obstructive Pulmonary Disease Patients with Acute Hypercapnic Respiratory Failure

Türkay Akbaş1, Harun Güneş2

1 Düzce University, School of Medicine, Düzce, Türkiye
2 Balıkesir University, School of Medicine, Balıkesir, Türkiye

DOI: 10.2478/jccm-2024-0002

Aim of the Study: Non-thyroidal illness syndrome (NTIS) is often observed in critically ill patients. This study aimed to examine thyroid hormone changes in patients with chronic obstructive pulmonary disease (COPD) experiencing acute hypercapnic respiratory failure (AHRF) and to evaluate the impact of these alterations on clinical outcomes.
Materials and Methods: This retrospective investigation involved 80 COPD patients (age 71.5±9.5 years; 57.5% male) admitted to the intensive care unit (ICU) due to AHRF. NTIS was identified when free triiodothyronine (fT3) levels were below the lower limit, and thyroid-stimulating hormone (TSH) and free thyroxine (fT4) levels were within the normal range or below the lower limits.
Results: NTIS was detected in 63.7% of the patients. Decreased fT3 levels were found in 36.3% of the patients, reduced T4 levels in 33.8%, and diminished TSH levels in 15%. Patients with low fT3 levels exhibited elevated C-reactive protein levels, white blood cell counts, and APACHE II scores, necessitated vasopressor infusion more frequently during their ICU stay, and had increased mortality. The in-hospital mortality rate was 28.8%. Logistic regression analysis revealed that fT3 level (odds ratio [OR]., 0.271; 95% confidence interval [CI]., 0.085-0.865; p=0.027), APACHE II score (OR, 1.155; 95% CI, 1.041-1.282; p=0.007), and vasopressor use (OR, 5.426; 95% CI, 1.439-20.468; p=0.013) were crucial predictors of in-hospital mortality.
Conclusions: A high prevalence of NTIS is observed in COPD patients with AHRF, with low fT3 levels frequently observed. The presence of lower levels of fT3 is associated with a greater severity of the disease and a significant prognostic indicator.

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Comparison of Critical Illness Score in Patients Admitted to Intermediate Care Units of a Tertiary Care Hospital: A Comparative Cross-Sectional Study from Karachi, Pakistan

Amber Sabeen Ahmed, Madiha Iqbal, Sher Muhammad Sethi, Sania Sabir, Aysha Almas

Aga Khan University Hospital, Karachi, Pakistan

DOI: 10.2478/jccm-2024-0003

Introduction: Intermediate care units (IMCUs) serve as step-up units for emergency department patients and as step-down units for critically ill patients transferred from intensive care units. This study compares four critical illness scores for assessment of acutely ill patients and their accuracy in predicting mortality in patients admitted to IMCU.
Methods: A comparative cross-sectional study on patients aged ≥18 admitted to IMCU of Aga Khan University Hospital from 2017 to 2019. All patients admitted to IMCU from the emergency room were included in the study. Patient’s record were reviewed for demographic data, physiological and laboratory parameters. Critical illness scores were calculated from these variables for each patient.
Results: A total of 1192 patients were admitted to the IMCU, of which 923 (77.4%) medical records were finally analyzed. The mean (SD) age of participants was 62 years (± 16.5) and 469 (50.8%) were women. The overall hospital mortality rate of patients managed in IMCU was 6.4% (59/923 patients). The median scores of APACHE II, SOFA, SAPS II and MEWS were 16 (IQR 11–21), 4 (IQR 2–6), 36 (IQR 30–53) and 3 (IQR 2-4) points respectively. AUC for SAPS II was 0.763 (95% CI: 0.71-0.81), SOFA score was 0.735 (95% CI: 0.68-0.79) and MEWS score was 0.714 (95% CI: 0.66-0.77). The lowest ROC curve was 0.584 (95% CI: 0.52-0.64) for APACHE II.
Conclusion: In conclusion, our study found that SAPS II, followed by SOFA and MEWS scores, provided better discrimination in stratifying critical illness in patients admitted to IMCU of a tertiary care hospital in Pakistan.

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Sudden Deterioration of a Young Patient During Elective Cesarean Section. Amniotic Fluid Embolism… or Else? – A Case Report

Ioana Roxana Codru1,2, Marian Valeriu Codru3, Bogdan Ioan Vintilă1,2, Ioana Gherman3, Dragoș Popescu1,3

1 Faculty of Medicine, Lucian Blaga University of Sibiu, Romania
2 Anesthesia and Intensive Care Clinic, Sibiu Emergency County Hospital, Romania
3 Obstetrics and Gynecology Clinic, Sibiu Emergency County Hospital, Romania

DOI: 10.2478/jccm-2024-0001

Sudden respiratory and circulatory collapse during or immediately after delivery, vaginal or surgical, can have many causes that can lead to poor maternal outcomes. A pregnancy-induced amniotic fluid embolism and anaphylaxis are two distinct medical conditions that appear similar clinically but have very different underlying mechanisms and treatment approaches. Amniotic fluid embolism is a rare but life-threatening obstetric emergency that leads to a systemic inflammatory response that can be easily confounded with an anaphylactic reaction. We report the case of a patient with no comorbidities or allergies before the current pregnancy that was proposed for delivery by C-Section under spinal anesthesia. After delivery of the placenta and administering the test dose of antibiotic, the patient developed sudden circulatory collapse, altered neurological status, and critical respiratory distress. At that point, the two presumed diagnoses were amniotic fluid embolism and anaphylaxis. Concurrently with the diagnostic pathway, supportive measures (intubation, mechanical ventilation, hemodynamic support) were taken. The clinical evolution was favorable, and after day three, the patient was discharged from the hospital. Our case highlights the significance of promptly distinguishing between anaphylaxis and amniotic fluid embolism to facilitate the timely management of the critical situation.

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