Category Archives: Volume 4

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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Endotracheal Tube Biofilm and its Impact on the Pathogenesis of Ventilator-Associated Pneumonia

DOI: 10.2478/jccm-2018-0011

Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection in mechanically ventilated patients and results in high mortality, prolonged intensive care unit- (ICU) and hospital-length of stay and increased costs. In order to reduce its incidence, it is imperative to better understand the involved mechanisms and to identify the source of infection. The role of the endotracheal tube (ET) in VAP pathogenesis became more prominent over the last decades, along with extensive research dedicated to medical device-related infections and biofilms. ET biofilm formation is an early and constant process in intubated patients. New data regarding its temporal dynamics, composition, germ identification and consequences enhance knowledge about VAP occurrence, microbiology, treatment response and recurrence.
This paper presents a structured analysis of the medical literature to date, in order to outline the role of ET biofilm in VAP pathogenesis and to review recommended methods to identify ET biofilm microorganisms and to prevent or decrease VAP incidence.

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Incidental Finding of a Left Atrial Myxoma while Characterising an Autoimmune Disease

DOI: 10.2478/jccm-2018-0009

Although cardiac tumours are uncommon, cardiac myxomas account for more than fifty percent of all cases and are the most frequent primary cardiac tumour. They have a broad clinical spectrum, usually related to cardiac symptoms, peripheral embolic events or systemic manifestations. We present a case report of a 68-year-old man who presented with systemic symptoms and analytical features suggestive of an autoimmune disease. In the ensuing diagnostic procedures, a cardiac myxoma was found, and after surgical resection, both the systemic manifestations and the analytical abnormalities disappeared.

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Resistance to Antimicrobians – A Global Problem with Sectoral Resolution

DOI: 10.2478/jccm-2018-0010

Mankind has been and still is constantly threatened by infectious diseases. Antimicrobials, used to treat infections, are considered one of the greatest discoveries of the 20th century because they saved millions of lives from diseases that had a high mortality rate. Mankind has been and is still constantly threatened by infectious diseases. Antimicrobials, used to treat infections, are considered one of the greatest discoveries of the 20th century because they saved millions of lives from diseases that had a high mortality rate. Current infectious pathology is worryingly extending due mainly to “globalization”, which confirms the current concept of “Infections Without Borders”. In this context, both the consumption of antimicrobial substances and, inherently, the resistance of the main pathogens involved have increased. Unfortunately, antimicrobials have become victims of their success because their abusive use in humans and animals has led to the emergence of resistance among clinically important pathogens. Each dose of antibiotic creates selective evolutionary pressures, resulting in pandemic spread of highly resistant bacterial clones. Resistance to antibiotics is one of the greatest threats to human health. A return to the pre-antibiotic era would not only make possible the development of epidemics caused by multidrug-resistant bacteria, a major threat to the population, but would also jeopardize some of the most valuable therapies in modern medicine, such as transplantation and immunosuppressive chemotherapy programmes –dependent on supportive antimicrobial treatments. [More]

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Perioperative Stress-Induced (Takotsubo) Cardiomyopathy in Liver Transplant Recipients

DOI: 10.2478/jccm-2018-0006

A comprehensive analysis of published cases of Takotsubo cardiomyopathy, occurred in liver transplant recipients in the perioperative period, has been attempted in this review. Predisposing factors, precipitating events, potential physiological mechanisms, acute and post-event management have been discussed.

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Severe Fatal Systemic Embolism Due to Non-Bacterial Thrombotic Endocarditis as the Initial Manifestation of Gastric Adenocarcinoma: Case Report

DOI: 10.2478/jccm-2018-0008

Introduction: Nonbacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, is a rare, underdiagnosed complication of cancer, in the context of a hypercoagulable state. NBTE represents a serious complication due to the high risk of embolisation from the sterile cardiac vegetations. If these are not properly diagnosed and treated, infarctions in multiple arterial territories may occur.
Case presentation: The case of a 47-year-old male is described. The patient was diagnosed with a gastric adenocarcinoma, in which the first clinical manifestation was NBTE. Subsequently, a hypercoagulability syndrome was associated with multi-organ infarctions, including stroke and eventually resulted in a fatal outcome.
Conclusions: NBTE must be considered in patients with multiple arterial infarcts with no cardiovascular risk factors, in the absence of an infectious syndrome and negative blood cultures. Cancer screening must be performed to detect the cause of the prothrombotic state.

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Post-Pneumonectomy ARDS and Ogilvie Syndrome – A Case Report

DOI: 10.2478/jccm-2018-0007

Introduction: The Acute Respiratory Distress Syndrome (ARDS) is a severe hypoxemic acute lung injury that may complicate lung resections. Reported mortality is very high, up to 50%. This report covers an ARDS case occurring post left pneumonectomy, with a favorable outcome, despite association with an acute colonic pseudo-obstruction syndrome (Ogilvie syndrome) that required abdominal surgery for decompression.
Case report: A 60-year old Caucasian male, diagnosed with a stage IIIA left lung tumor underwent a left pneumonectomy. On the second postoperative day, the patient developed ARDS, requiring ventilatory support. Two days later, as the multiple organ dysfunction worsened, a bowel obstruction occurred. With an acute colonic pseudo-obstruction diagnosis, the decision was to perform laparotomy and a temporary cecostomy. A subsequent improvement in the respiratory parameters and vital functions resulted in weaning from ventilator 8 days after the onset of the ARDS and transfer to the surgery ward 14 days after pneumonectomy.

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Serratia marcescens Sepsis in a Child with Deep Venous Thrombosis – A Case Report

DOI: 10.2478/jccm-2018-0004

Introduction: Venous thromboembolism is a rare condition in paediatrics that included both deep venous thrombosis and pulmonary embolism. Serratia marcescens is a gram-negative bacterium that belongs to the Enterobacteriaceae family and tends to affect immunocompromised hosts.
Case report: We report the case of an 11-year-old boy, admitted in the Pediatric Clinic I from Emergency County Hospital Tîrgu Mureș, Romania with intense pain, swelling, cyanosis and claudication of the left foot. His personal history revealed a recent appendectomy. A close family was reported to have had a deep venous thrombosis. The laboratory tests, performed on the day of admission, revealed increased inflammatory biomarkers and D-dimer. Coagulation tests gave a low activated partial thromboplastin time (APTT). Doppler venous ultrasound and CT-exam established a diagnosis of deep venous thrombosis. Anticoagulant therapy was initiated, but on the tenth day of admission, the patient developed signs and symptoms of sepsis, and the blood culture revealed Serratia marcescens. After antibiotic and anticoagulant therapy, the patient progressed favourably. The patient was a carrier of the heterozygous form of Factor V Leiden.
Conclusions: The association between deep venous thrombosis and Serratia marcescens sepsis can compromise a condition in pediatric patients.

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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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