Category Archives: Editorial

Let’s Talk About Sepsis

DOI: 10.1515/jccm-2017-0031

The current definition of sepsis is based on comparatively contemporary knowledge. However, the disease process is not fully understood and treatment still profoundly challenging. Definitions and guidelines have changed over the recent years, and clinicians are always interested to know what the new and current thoughts on the subject are.
Many papers have been published in the medical press, reporting on definitions, scores, models, cytokines, therapies, new trends, statistics, campaigns, including a sepsis anniversary day-which is not celebrating but fighting against sepsis. Together they signify the enormous interest in the subject.
The American College of Chest Physicians and the Society of Critical Care Medicine met in 1992 and gave the first definition of sepsis and associated organ failure [1]. Eleven years later, American intensivists met European intensivists to evaluate if there was a need for a new definition of sepsis [2]. [More]

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Highlights for Improvement of Scientific Writing for Publication in High Impact Journals

DOI: 10.1515/jccm-2017-0022

For research scientists around the world, a primary goal is to publish results from their projects in high impact international journals.  Such an achievement can be highly rewarding because it is a formal way to release discoveries to the world and to be recognised for the discoveries, it allows findings to be shared and used by colleagues, and it can bring in personal benefits in awards and promotions.  However, achieving the goal is not a simple task, and it can sometimes be frustrating.  Therefore, this editorial was written to provide some highlights on how to improve chances for high impact publications and recognitions. [More]

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The Eleventh Hour: Neurosyphilis, Still Fashionable but a Controversial Diagnosis

DOI: 10.1515/jccm-2017-0015

Syphilis is a consequence of a symbiotic relationship between Treponema pallidum and humankind.
The spirochete is nowadays well characterized in shape and in length, and its entire genome is sequenced. Despite all these, confirmation of infection is based on serologic tests. The diagnosis of nervous system disease heavily depends on examination of the cerebrospinal fluid [1-4].
Neurologic involvement is generally dichotomized into early/secondary (acute meningitis, cranial nerves involvement) or late/tertiary (all the rest of the manifestations) [1].
In the current issue of Journal of Critical Care Medicine, Bologa et al. present the utility of having meningovascular syphilis in mind as a possible diagnosis, in an apparent average case of an 84-year-old patient diagnosed with stroke [5]. [More]

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Simulation-based Training as Perceived by Young Anesthesiology and Intensive Care Residents

DOI: 10.1515/jccm-2017-0007

Medical  simulation-based teaching  includes a variety of educational techniques used to complement actual patient experiences with true-to-life yet artificial tasks.
This field is rapidly growing and is widely used in critical care graduate medical education programs, having teaching, learning and assessment roles.
Its use is on the increase due to many factors including patient discontent with being “practiced on”, current considerations regarding patient safety, and the significance of early attainment of complex medical proficiencies. Simulation-based assessment (SBA) is advancing to the point where it can revolutionize the way clinical competence is assessed in residency training programs. [More]

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Epidural Anaesthesia: How Easy Is It to Walk on Quicksand?

DOI: 10.1515/jccm-2016-0032

The effectiveness of neuraxial blockade remains a very debatable issue. Many orthopaedic surgical procedures can be performed using either a single spinal shot, an epidural catheter neuraxial blockade, or general anesthesia.
Memtsoudis (2013) reviewed nearly 400.000 patients undergoing primary hip or knee arthroplasties compared neuraxial versus general anesthesia, and reported that the 30-day mortality, the length of stay, the hospital cost and the in-hospital complications were all was significantly lower than with other forms of anesthesia [1]. Similarly Helwan (2015) in a study comparing general with regional anesthesia for total hip arthroplasty reported a reduction in deep surgical site infection rates, the length of hospital stay, postoperative cardiovascular rates, and pulmonary complications [2]. However, a recent systematic review of more than 10.000 patients enrolled in randomized control trials and prospective comparative studies, found no statistically significant differences between spinal or epidural blockade and general anaesthesia with respect to mortality, surgical duration, surgical site of infections, nerve palsies, postoperative nausea and vomiting or thromboembolic diseases, when thrombo-prophylaxis was used. The authors concluded that there is limited evidence to support the view that neuraxial anesthesia is superior to general anesthesia with regards to postoperative outcomes [3]. [More]

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Have Severity Scores a Place in Predicting Septic Complications in ICU Multiple Trauma Patients?

DOI: 10.1515/jccm-2016-0023

Risk assessment in ICU critically-ill patients is of tremendous importance for optimizing patients’ clinical management, medical and human resource allocation and supporting medical cost distribution and containment.
The problem of predicting complications and mortality in ICU patients, although not new, is of genuine concern and much effort has been made to detect the most reliable parameters and scores. Numerous attempts have been made to use clinical and laboratory findings integrated into different algorithms or to incorporate these parameters into easy to use composite severity scores which would be applicable in various centers. In addition to clinical data, biomarkers or laboratory findings have been used for this purpose [1-3].
The SOFA, SAPS and APACHE scores and their newer versions, have been used worldwide to evaluate patients’ severity, prognosis, and survival [4-7]. However, it has been reported that there are differences in their performance and estimation probability, in different geographical areas [8]. [More]

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Knowledge Is Power

DOI: 10.1515/jccm-2016-0014

When Sir Francis Bacon published in his work, Meditationes Sacrae (1597), the saying: “knowledge itself is power”, he most likely wanted to transmit the idea that having and sharing knowledge is the cornerstone of reputation and influence, and therefore power; all achievements emanate from this. Today, scientific knowledge is shared through publications that not only inform, but have the capacity to influence decision making.
The Journal of Critical Care Medicine, a publication of the University of Medicine and Pharmacy Tîrgu Mureș, Romania launched in 2015, was recently included in the Master Journal List of the Emerging Sources Citation Index (ESCI), which is part of the Thomson Reuters Web of Science Core Collection. This new index ensures the indexing of high-quality medical articles that undergo a specific peer-review process prior to publication. The inclusion of the journal in this international database ensures a larger and more consistent international profile, as well as a probable increase in the citation of published articles. [More]

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Out-of-Hospital Cardiac Arrest in Acute Myocardial Infarction and STEMI Networks

DOI: 10.1515/jccm-2016-0007

Out-of-hospital cardiac arrest (OHCA) remains associated with a poor prognosis, with a survival rate of approximately 10% [1]. Only 40% of patients presenting with OHCA are successfully resuscitated, and only 25% of them survive to hospital discharge [1].
In many cases of OHCA associated with acute myocardial infarction, the cardiac arrest is caused by ventricular fibrillation, occurring during the first hours after the onset of symptoms, and before the patient being admitted to hospital [2]. In these critical cases, implementation of specific protocols and dedicated networks are crucial for providing effective advanced cardiac life support.
Several treatment modalities have been proposed to improve outcomes in the post-resuscitation period. One such measure is induced therapeutic hypothermia, consisting of administering cooling infusions to cool the patient down to 32-34⁰C, and maintaining this for 12-24 hours. Evidence shows that when initiated promptly, cooling improves neurological outcomes in survivors of OHCA [3,4]. However, there is no clear evidence that hypothermia would lead to a significant reduction in mortality in these patients. Current guidelines recommend early therapeutic hypothermia as a class Ib indication, in the post-resuscitation phase, after cardiac arrest in patients who are comatose or deeply sedated [2]. [More]

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The Significance of Cardiac Arrhythmias in Septic ICU Patients

DOI: 10.1515/jccm-2015-0028

The review article published in this issue by Schwartz A et al [1] draws attention to the importance of cardiac arrhythmias and especially that of new-onset atrial fibrillation (AF) and the clinical outcome of septic patients. The incidence of this phenomenon varies in different reports, from 5.8% [2] to 31-40% [3-4].
Causes are numerous and different mechanisms have been described in the literature and by the authors of the review. Endotoxin induces tachycardia, increases the cardiac index, and reduces blood pressure and systemic vascular resistance without change in stroke volume [5]. Fluid administration results in a decrease in left ventricular ejection fraction and an increase in ventricular volumes even more than before the administration of fluid therapy [5].
An increased inflammatory response also plays an important role in pathogenesis of cardiac arrhythmias and dysfunction in septic patients. Increased plasma levels of C-reactive protein, IL-6 and TNF-α may contribute to the onset of AF in septic patients [1,6]. [More]

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Oxidative Stress in the Critically Ill Polytrauma Patient

DOI: 10.1515/jccm-2015-0013

The critically ill patient with primary multiple traumas and having secondary complications, presents a complex challenge to the trauma team. The most commonly encountered primary injuries are traumatic brain, spinal cord, pulmonary and abdominal injuries or trauma to the pelvis and the extremities. Moreover, severe inflammations, infections, hyper-metabolism, as well as biochemical and physiological imbalances, lead to a significant increase in morbidity and mortality.
Most recently, the role of free radicals has been a largely debated and reported topic. Once produced in excess, free radicals are responsible for inducing oxidative stress. The redox species known to have a destructive effect on cells include the superoxide anion, the hydroxyl radical, hydrogen peroxide, nitric oxide, peroxynitrite, lipid peroxyl and alkoxy lipid. Under normal conditions, free radicals are produced in the human body in small amounts, their activity being minimized by the body’s physiologically anti-oxidant systems which include superoxide dismutase, catalase, glutathione, glutathione peroxidase, peroxiredoxins, and glutaredoxins.
In the critically ill patient, severe physiological and biochemical imbalances significantly reduce the body’s anti-oxidant capacity, disrupting the redox balance [1]. A series of biomarkers are in use, designed to quantify oxidative stress. These comprise interleukin 1 beta, interleukin 6, interleukin 10, tumor necrosis alpha, components of the complement, plasmatic levels of antioxidant enzymes and the microRNA species [2]. [More]

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