Category Archives: Original Research

Initial Fluid Resuscitation Following Adjusted Body Weight Dosing in Sepsis and Septic Shock

DOI: 10.2478/jccm-2019-0025

Introduction: Fluid administration is considered a fundamental part of early sepsis treatment. Despite abundant research, fundamental questions about the amount of fluids to be given remain unanswered. Recently, the idea of adjusting the fluid load to the ideal body weight emerged, as obesity rates are increasing, and fluid overload was proven to increase mortality.
Aim of the study: The study aimed to determine whether advanced haemodynamic monitoring supports the adjustment of the initial fluid load to the ideal body weight (IBW).
Methods: Seventy-one patients with sepsis and septic shock were enrolled in the study. The initial fluid resuscitation was performed using local protocols. The haemodynamic status was assessed after the initial fluid load by trans-pulmonary thermos-dilution technique and the renal outcome recorded at twenty-four hours.
Results: 68.6% of the patients included in the study had weight disorders ranging from BMI+20% to morbid obesity. Before IBW adjustment, only 49.3% received the 30 ml/kg fluid load recommended by Surviving Sepsis Campaign Guidelines (2016) (SSC). After IBW adjustment, 70.4% received the recommended fluid dose. The difference in fluid load/kg before and after the bodyweight adjustment was statistically significant (p<0.01). After the initial fluid load, the majority of the macro haemodynamic parameters were in the targeted range. There was no statistically significant difference between the urinary output outcome at 24 hours or the 28 days mortality rates between the patients resuscitated by the SSC and those who received less fluid.
Conclusions: Advanced haemodynamic monitoring was in favour of adjusting the initial fluid load to the IBW. There were no statistically significant differences either in the urinary output outcome at twenty-four hours, or in the twenty-eight-day mortality rates between the patients who received the 30 ml/kg IBW and those who received less than 30 ml/kg IBW.

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The Use of High Dose Eltrombopag in the Management of Sepsis-Associated Thrombocytopenia in Critically Ill Patients

DOI: 10.2478/jccm-2019-0019

Introduction: Sepsis is a life-threatening condition, and sepsis-associated thrombocytopenia (SAT) is a common consequence of the disease where platelet count falls drastically within a very short time. Multiple key factors may cause platelet over-activation, destruction and reduction in platelet production during the sepsis. Eltrombopag is a thrombopoietin receptor agonist and is the second-line drug of choice in the treatment of chronic immune thrombocytopenia (ITP).
Aim of the study: The objective of this study was to observe the therapeutic outcome of high dose eltrombopag in SAT management in critically ill patients.
Material and Methods: This 6-month-long single group, observational study was conducted on seventeen ICU patients with SAT. Eltrombopag 100 mg/day in two divided doses was given to each patient. Platelet counts were monitored. A low platelet blood count returning to 150 K/μL or above, is taken as indicative of a successful reversal of a thrombocytopenia event.
Results: The mean Apache II score of patients (n= 17) was 18.71 (p-value: >0.05). No eltrombopag-induced adverse event was observed among the patients during the study period. Thrombocytopenia events were reversed successfully in 64.71% of patients (11; n= 17) within eight days of eltrombopag therapy.
Conclusions: The therapeutic potentiality of high dose eltrombopag regime in the management of sepsis-associated thrombocytopenia was found clinically significant in over two-thirds of critically ill adult patients enrolled in the study. These data may point to a new strategy in the management of acute type of thrombocytopenia in septic patients.

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Determination of Cut-off Serum Values for Resistin and S100B Protein in Patients Who Survived a Cardiac Arrest

DOI: 10.2478/jccm-2019-0018

Introduction: In an attempt to identify patients who have successfully survived a resuscitated cardiac arrest (CA), attention is drawn to resistin and S100B protein, two biomarkers that have been studied in relation to CA.
Aim: The study aimed to identify the potential cut-off serum values for resistin and S100B in patients who had CA, compared to healthy volunteers, given that, currently, none of the markers have normal and pathological reference range limits for human assay levels related to this pathology.
Materials and Methods: Forty patients, resuscitated after out-of-hospital CA and forty healthy controls, were included in the study. All patients were followed up for seventy-two hours after CA or until death. Blood samples for biomarkers were collected on admission to the ED (0-time interval) and at 6, 12, 24, 48 and 72 hours following resuscitation. Only one blood sample was collected from the controls. The serum concentrations of biomarkers were measured.
Results: For each time interval, median serum levels of resistin and S100 B were ​​ significantly higher in patients with CA compared to healthy controls. The cut-off value for resistin in patients with CA, at the 12-hours versus controls, was > 8.2 ng/ml. The cut-off value for S100B in patients with CA versus controls recorded at 6 hours, was > 11.6 pg/ml.
Conclusion: Serum levels of resistin and S100B are higher among resuscitated CA patients compared to controls.

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Perioperative Lung Protective Ventilatory Management During Major Abdominal Surgery: A Hungarian Nationwide Survey

DOI: 10.2478/jccm-2019-0002

Lung protective mechanical ventilation (LPV) even in patients with healthy lungs is associated with a lower incidence of postoperative pulmonary complications (PPC). The pathophysiology of ventilator-induced lung injury and the risk factors of PPCs have been widely identified, and a perioperative lung protective concept has been elaborated. Despite the well-known advantages, results of recent studies indicated that intraoperative LPV is still not widely implemented in current anaesthesia practice.
No nationwide surveys regarding perioperative pulmonary protective management have been carried out previously in Hungary. This study aimed to evaluate the routine anaesthetic care and adherence to the LPV concept of Hungarian anaesthesiologists during major abdominal surgery.
A questionnaire of 36 questions was prepared, and anaesthesiologists were invited by an e-mail and a newsletter to participate in an online survey between January 1st to March 31st, 2018.
A total of one hundred and eleven anaesthesiologists participated in the survey; 61 (54.9%), applied low tidal volumes, 30 (27%) applied the entire LPV concept, and only 6 (5.4%) regularly applied alveolar recruitment manoeuvres (ARM). Application of low plateau and driving pressures were 40.5%. Authoritatively written protocols were not available resulting in markedly different perioperative pulmonary management. According to respondents, the most critical risk factors of PPCs are chronic obstructive pulmonary diseases (103; 92.8%); in contrast malnutrition, anaemia or prolonged use of nasogastric tube were considered negligible risk factors. Positive end-expiratory pressure (PEEP) and regular ARM are usually ignored. Based on the survey, more attention should be given to the use of LPV.

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Factors Associated with Mortality in Patients with a Solid Malignancy Admitted to the Intensive Care Unit – A Prospective Observational Study

DOI: 10.2478/jccm-2018-0019

Purpose: Several studies show conflicting results regarding the prognosis and predictors of the outcome of critically ill patients with a solid malignancy. This study aims to determine the outcome of critically ill patients, admitted to a hospital, with a solid malignancy and the factors associated with the outcomes.
Methods and Materials: All patients with a solid malignancy admitted to an intensive care unit (ICU) at a tertiary academic medical center were enrolled. Clinical data upon admission and during ICU stay were collected. Hospital, ICU, and six months outcomes were documented.
Results: There were 252 patients with a solid malignancy during the study period. Urogenital malignancies were the most common (26.3%) followed by lung cancer (23.5%). Acute respiratory failure was the most common ICU diagnosis (51.6%) followed by sepsis in 46%. ICU mortality and hospital mortality were 21.8% and 34.3%. Six months mortality was 38.4%. Using multivariate analysis, acute kidney injury, OR 2.82, 95% CI 1.50-5.32 and P=0.001, use of mechanical ventilation, OR 2.67 95% CI 1.37 – 5.19 and P=0.004 and performance status of ≥2 with OR of 3.05, 95% CI of 1.5- 6.2 and P= 0.002 were associated with hospital mortality. There were no differences in outcome between African American patients (53% of all patients) and other races.
Conclusion: This study reports encouraging survival rates in patients with a solid malignancy who are admitted to ICU. Patients with a poor baseline performance status require mechanical ventilation or develop acute renal failure have worse outcomes.

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Improving Clinical Performance of an Interprofessional Emergency Medical Team through a One-day Crisis Resource Management Training

DOI: 10.2478/jccm-2018-0018

Introduction: Errors are frequent in health care and Emergency Departments are one of the riskiest areas due to frequent changes of team composition, complexity and variety of the cases and difficulties encountered in managing multiple patients. As the majority of clinical errors are the results of human factors and not technical in nature or due to the lack of knowledge, a training focused on these factors appears to be necessary. Crisis resource management (CRM), a tool that was developed initially by the aviation industry and then adopted by different medical specialties as anesthesia and emergency medicine, has been associated with decreased error rates.
The aim of the study: To assess whether a single day CRM training, combining didactic and simulation sessions, improves the clinical performance of an interprofessional emergency medical team.
Material and Methods: Seventy health professionals with different qualifications, working in an emergency department, were enrolled in the study. Twenty individual interprofessional teams were created. Each team was assessed before and after the training, through two in situ simulated exercises. The exercises were videotaped and were evaluated by two assessors who were blinded as to whether it was the initial or the final exercise. Objective measurement of clinical team performance was performed using a checklist that was designed for each scenario and included essential assessment items for the diagnosis and treatment of a critical patient, with the focus on key actions and decisions. The intervention consisted of a one-day training, combining didactic and simulation sessions, followed by instructor facilitated debriefing. All participants went through this training after the initial assessment exercises.
Results: An improvement was seen in most of the measured clinical parameters.
Conclusion: Our study supports the use of combined CRM training for improving the clinical performance of an interprofessional emergency team. Empirically this may improve the patient outcome.

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Effects of Fibrinogen Levels and Platelet Counts on Viscoelastic Testing in Cirrhotic Patients

DOI: 10.2478/jccm-2018-0012

Introduction. Cirrhotic patients have been considered for decades to have a pro-haemorrhagic pattern and were treated as such based on the results from standard coagulation tests. The aim of our study was to determine the effects of platelet count and fibrinogen levels on rotational thromboelastometry (ROTEM) parameters.
Methods. We prospectively included 176 patients with End-Stage Liver Disease (ESLD) admitted to our Intensive Care Unit prior to liver transplantation. Collected data consisted of severity scores, liver, renal and standard coagulation tests, fibrinogen levels, platelet counts and ROTEM parameters. Four ROTEM assays were performed (ExTEM, InTEM, ApTEM and FibTEM) and the following parameters included: CT – clotting time, CFT – clot formation time, MCF – maximum clot firmness, ML – maximum lysis, alpha angle, TPI – thrombin potential index, MaxV – maximum velocity of clot formation (MaxV), MaxVt – time to MaxV, MCE- maximum clot elasticity and AUC – area under the curve.
Results. Statistical analysis demonstrated a linear correlation between platelet counts and ExTEM TPI (R2 linear =0.494), ExTEM MaxV (R2 linear =0.253), ExTEM MCE (R2 linear = 0.351) and ExTEM MCF (R2 cubic = 0.498). Fibrinogen levels correlated linearly with ExTEM MCF (R2 linear = 0.426), ExTEM TPI (R2 linear = 0.544), ExTEM MaxV (R2 linear = 0.332), ExTEM MCE (R2 linear = 0.395) and non-linearly with ExTEM CFT (R2 cubic = 0.475).
Conclusion. Fibrinogen levels and platelet counts had an important effect on both standard and derived ROTEM parameters. Further analysis is required in order to determine clinically oriented cut-off values below which severe coagulopathy would develop.

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Brain Death in Children: Incidence, Donation Rates, and the Occurrence of Central Diabetes Insipidus

DOI: 10.2478/jccm-2018-0005

Introduction: Brain death is currently defined as the loss of full brain function including the brainstem. The diagnosis and its subsequent management in the pediatric population are still controversial. The aim of this study was to define the demographic characteristics, clinical features and outcomes of patients with brain death and determine the incidence of brain death, donation rates and occurrence of central diabetes insipidus accompanying brain death in children.
Methods: This retrospective study was conducted at a twelve-bed tertiary-care combined medical and surgical pediatric intensive care unit of the Ondokuz Mayıs University Medical School, Samsun, Turkey. In 37 of 341 deaths (10.8%), a diagnosis of brain death was identified. The primary insult causing brain death was post-cardiorespiratory arrest in 8 (21.6%), head trauma in 8 (21.6%), and drowning in 4 (18.9%). In all patients, transcranial Doppler ultrasound was utilised as an ancillary test and test was repeated until it was consistent with brain death.
Results: In 33 (89%) patients, central diabetes insipidus was determined at or near the time brain death was confirmed. The four patients not diagnosed with CDI had acute renal failure, and renal replacement treatment was carried out. The consent rate for organ donation was 18.9%, and 16.7% of potential donors proceeded to actual donation
Conclusion: In the current study the consent rate for organ donation is relatively low compared to the rest of the world. The prevalence of central diabetes insipidus in this pedaitric brain death population is higher than reports in the literature, and acute renal failure accounted for the lack of central diabetes insipidus in four patients with brain death. Further studies are needed to explain normouria in brain-dead patients.

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Neurological Critical Care Services’ Influence Following Large Hemispheric Infarction and Their Impact on Resource Utilization

DOI: 10.2478/jccm-2018-0001

Introduction: Acute ischemic stroke (AIS) is the fourth leading cause of death in the US. Numerous studies have demonstrated the use of comprehensive stroke units and neurological intensive care units (NICU) in improving outcomes after stroke. We hypothesized that an expanded neurocritical care (NCC) service would decrease resource utilization in patients with LHI.
Methods: Retrospective data from consecutive admissions of large hemispheric infarction (LHI) patients requiring mechanical ventilation were acquired from the hospital medical records. Between 2011-2013, there were 187 consecutive patients admitted to the Jefferson Hospital for Neuroscience (Philadelphia, USA) with AIS and acute respiratory failure. Our intention was to determine the number of tracheostomies done over time. The primary outcome measure was the number of tracheostomies over time. Secondary outcomes were, ventilator-free days (Vfd), total hospital charges, intensive care unit length of stay (ICU-LOS), and total hospital length of stay (hospital-LOS), including ICU LOS. Hospital charges were log-transformed to meet assumptions of normality and homoscedasticity of residual variance terms. Generalized Linear Models were used and ORs and 95% CIs calculated. The significance level was set at α = 0.05.
Results: Of the 73 patients included in this analysis, 33% required a tracheostomy. There was a decrease in the number of tracheostomies undertaken since 2011. (OR 0.8; 95% CI 0.6-0.9: p=0.02). Lower Vfd were seen in tracheostomized patients (OR 0.11; 95%CI 0.1-0.26: p<0.0001). The log-hospital charges decreased over time but not significantly (OR 0.9; 95%CI 0.78-1.07: p=0.2) and (OR 0.99; 95%CI 0.85-1.16: p=0.8) from 2012 to 2013 respectively.
The ICU-LOS at 23 days vs 10 days (p=0.01) and hospital-LOS at 33 days vs 11 days (p=0.008) were higher in tracheostomized patients.
Conclusion: The data suggest that in LHI-patients requiring mechanical ventilation, a dedicated NCC service reduces the overall need for tracheostomy, increases Vfd, and decreases ICU and hospital-LOS.

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Clinical Features and Outcomes of Fusobacterium Species Infections in a Ten-Year Follow-up

DOI: 10.1515/jccm-2017-0029

Objective. Although uncommon, Fusobacterium infections have a wide clinical spectrum, ranging from local pharyngeal infections to septic shock. Our aim was to characterize and analyze the clinical features and outcomes in patients with Fusobacterium infections, and determine which variables were able to predict a poor outcome.
Methods. We conducted a retrospective, hospital-based study using the computerized records of a second-level Spanish general hospital, serving a population of 155,000 inhabitants. The cohort was enrolled among patients cared for at the hospital between 2007 and 2016. Demographic, clinical data, microbiological characterization and outcomes at discharge, were analyzed.
Results. We collected data for all 26 patients over a 10-year period (annual incidence of 1.78 per 100,000), with an incidence of bacteremia of 0.53 cases per 100,000 population per year. F. nucleatum and F. necrophorum were the most frequent isolations (53.8% and 38.5%, respectively). F. necrophorum was found to be associated with a younger population. Although we found no deaths attributable to Fusobacterium, 15 patients (57%) were found to have severe infections due to this pathogen, and 7 patients (26.9%) were admitted to the Intensive Care Unit (ICU). The only identifiable risk factor for a severe infection (sepsis, septic shock or ICU admission) was the presence of bacteremia.
Conclusions. Fusobacterium infections are uncommon. F. necrophorum tends to cause infection in younger individuals, while F. nucleatum has a preference for older patients. The clinical spectrum is wide, ranging from local, non-severe infections, such as sinusitis or pharyngitis, to abscess formation and life-threatening infections.

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