Category Archives: Volume 4

Diagnostic pitfalls in identification of Elizabethkingia meningoseptica

DOI: 10.2478/jccm-2018-0021

To the Editor of JCCM,
Regarding the article “Emerging Infection with Elizabethkingia meningoseptica in Neonate. A Case Report” by Arbune et al. (2018) [1], there are specific facts which need clarification regarding the reporting of this organism.
First of all, Arbune reported the isolation of the organism from the cerebrospinal fluid (CSF) and blood culture of one case, and that no source of infection was identified. Elizabethkingia meningoseptica, although linked to meningitis and nosocomial infections, can be an environmental contaminant as well. Repeat cultures of the samples are mandatory for the confirmation of such unusual pathogens.[More]

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The Peer Review Process: Underwriting Manuscript Quality & Validity

DOI: 10.2478/jccm-2018-0020

Evidence-based practice is the first step in underpinning and shaping how the profession delivers patient care. The Oxford Dictionary defines evidence as: ‘the available body of facts or information indicating whether a belief or proposition is true or valid’. The majority of evidence, though not all, is provided by research studies published in professional journals. Best evidence should be of high quality and is thus founded on the status of publishing journals and the process by which journals, editors and the editorial team separate out the “good” from both the “mediocre” and the “bad”.
This is undertaken by the process of Peer reviewing or refereeing; it is the practice of critically examining an author’s submitted research manuscript by experts in the same field before a paper is accepted for publishing in a journal. When well done, it confers a stamp of approval to the substance, authenticity, and value of articles and therefore is a crucial element, integral to scholarly research and the validation of published evidence. [More]

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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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Online Information about Stroke – A Soft Challenge for Critical Care Professionals

DOI: 10.2478/jccm-2018-0017

According to “The Burden of Stroke in Europe” report, Romania had, in 2015, the highest incidence and highest mortality due to stroke per 100,000 inhabitants [1]. Moreover, the Central and Eastern European Stroke Society Working group reported that, in 2015, in Romania, only about 1% of stroke patients had access to stroke units [2].
Critical care professionals are familiar with the phrase “time is brain” and are well aware that even a couple of minutes delay in delivering thrombolytic intravenous treatment or endovascular thrombectomy can have an enormous impact on patients’ survival rates and the length of disability-free life [3,4]. [More]

 

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Hospital Resilience: A Recent Concept in Disaster Preparedness

DOI: 10.2478/jccm-2018-0016

Planning for a disaster must anticipate how demands imposed by a disaster equate with the capacity of the available facilities. Resources must be organized before an event occurs so that they are best prepared in every way to treat as many victims as possible. The actual number of victims is less relevant than the extent receiving facility can be adjusted to meet the appropriate requirements of victims. Multiple casualty incidents (MCIs) are defined as a large number of casualties generated over a short period that are appropriately managed with existing or extended resources. Mass casualty events (MCEs), in contrast, are major medical disasters that erode organized community support mechanisms and result in casualty numbers which overwhelm resources [1].
Due to the increased frequency and impact of disasters, including natural disasters, pandemics and terrorism, the concept of disaster resilience is accepted as being of increasing importance.
The notion of resilience can be defined as the capacity to adapt to unexpected challenges and the flexibility to revert to normality. Additionally, the issues learned from the experience should be incorporated into protocols which would allow for better preparedness for future challenges [2,3]. [More]

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Acute Pulmonary Embolism in a Teenage Female – A Case Report

DOI: 10.2478/jccm-2018-0015

Thrombophilia represents a tendency towards excessive blood clotting and the subsequent development of venous thromboembolism (VTE). VTE is a rare condition in children that comprises both deep venous thrombosis (DVT) and pulmonary embolism (PE). This paper reports the case of a 16-year-old girl, admitted to the Pediatrics Clinic No. 1, Tîrgu Mureș, Romania, for dyspnea, chest pain and loss of consciousness. Her personal history showed that she had had two orthopedic surgical interventions in infancy, two pregnancies, one spontaneous miscarriage and a recent caesarian section at 20 weeks of gestation for premature detachment of a normally positioned placenta associated with a deceased fetus. Laboratory tests showed increased levels of D-dimers. Angio-Computed Tomography (Angio-CT) showed multiple filling defects in both pulmonary arteries, establishing the diagnosis of PE. The laboratory tests were undertaken to assist in the diagnoses of a possible thrombophilia underlined a low level of antithrombin III. Antiphospholipid syndrome was ruled out and genetic tests revealed no specific mutation. Anticoagulant therapy was initiated with unfractionated heparin and afterwards subcutaneously low molecular heparin was prescribed for three months. Later it has been changed to oral therapy with acenocoumarol. The patient was discharged in good general status with the recommendation of life-long anticoagulation therapy. Thrombophilia is a significant risk factor for PE, and it must be ruled out in all cases of repeated miscarriage.

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Transplant Critical Care: Is There A Need for Sub-specialized Units? — A Perspective

DOI: 10.2478/jccm-2018-0014

The critical care involved in solid-organ transplantation (SOT) is complex. Pre-, intra- and post-transplant care can significantly impact both – patients’ ability to undergo SOT and their peri-operative morbidity and mortality. Much of the care necessary for medical optimization of end-stage organ failure (ESOF) patients to qualify and then successfully undergo SOT, and the management of peri-operative and/or long-term complications thereafter occurs in an intensive care unit (ICU) setting. The current literature specific to critical care in abdominal SOT patients was reviewed. This paper provides a contemporary perspective on the potential multifactorial advantages of sub-specialized transplant critical care units in providing efficient, comprehensive, and collaborative multidisciplinary care.

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