Author Archives: administrare

Bronchoscopic Intrapulmonary Recombinant Factor VIIa for Diffuse Alveolar Hemorrhage- induced Acute Respiratory Failure in MPO-ANCA Vasculitis: A Case Report

Illaa Smesseim1, Titia Schaepman-Ruys1, Jan Willem Duitman1,2, Yosta Vegting3, Jorinde Raasveld4, Marc Hilhorst3, Alexander Vlaar4, Josien van Es1, Peter Bonta1

1 Department of Respiratory Medicine, Amsterdam University Medical Center, University of Amsterdam and Free University Amsterdam, The Netherlands
2 Department of Experimental Immunology (EXIM), Amsterdam University Medical Center, University of Amsterdam, The Netherlands
3 Department of Internal Medicine, Section of Nephrology, Location Meibergdreef Amsterdam UMC, University of Amsterdam, The Netherlands
4 Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands

DOI: 10.2478/jccm-2022-0004

Introduction: Diffuse alveolar haemorrhage (DAH) is a potentially life-threatening disease, characterized by diffuse accumulation of red blood cells within the alveoli. It can be caused by a variety of disorders. In case DAH results in severe respiratory failure, veno-venous extracorporeal membrane oxygenation (VV-ECMO) can be required. Since VV-ECMO coincides with the need for anticoagulation therapy, this results in a major clinical challenge in DAH patients with hemoptysis.
Case presentation: We report a patient case with severe DAH-induced acute respiratory failure and hemoptysis in need for VV-ECMO complicated by life-threatening membrane oxygenator thrombosis. The DAH-induced hemoptysis was successfully treated with local bronchoscopic recombinant factor VIIa (rFVIIa), allowing systemic anticoagulation to prevent further membrane oxygenator thrombosis. Neither systemic clinical side effects nor differences in the serum coagulation markers occured after applying recombinant factor VIIa (rFVIIa) treatment endobronchially.
Conclusion: This is, to our knowledge, the first case that reports the use of rFVIIa in a patient with DAH due to vasculitis and in need for VV-ECMO complicated by membrane oxygenator thrombosis.

Keywords: , , , ,
Full text: PDF

Early Empirical Anidulafungin Reduces the Prevalence of Invasive Candidiasis in Critically Ill Patients: A Case-control Study

Md Jahidul Hasan1, Sharmind Neelotpol2, Raihan Rabbani3

1 Clinical Pharmacy Service, Department of Pharmacy, Square Hospitals Ltd, Dhaka, Bangladesh
2 Department of Pharmacy, BRAC University, Dhaka, Bangladesh
3 Internal Medicine and ICU, Square Hospitals Ltd., Dhaka, Bangladesh

DOI: 10.2478/jccm-2022-0006

Introduction: Invasive candidiasis (IC) in critically ill patients is a serious infection with high rate of mortality. As an empirical therapy, like antibiotics, the use of antifungals is not common in intensive care units (ICUs) worldwide. The empirical use of echinocandins including anidulafungin is a recent trend.
Aim of the study: The objective of this study was to assess the impact of empirical anidulafungin in the development of invasive candidiasis in critically ill patients in ICU.
Methods: This retrospective case-control study was conducted on 149 patients with sepsis with/without septic shock and bacterial pneumonia. All the patients were divided into two groups. The ‘control group’ termed as ‘NEAT group’ received no empirical anidulafungin therapy and the ‘treated group’ termed as ‘EAT group’ received empirical anidulafungin therapy in early hospitalization hours.
Results: Seventy-two and 77 patients were divided into the control and the treated group, respectively. Patients in EAT group showed less incidences of IC (5.19%) than that of the NEAT group (29.17%) (p = 0.001). Here, the relative risk (RR) was 0.175 (95% CI, 0.064-0.493) and the risk difference (RD) rate was 24% (95% CI, 12.36%-35.58%). The 30-day all-cause mortality rate in NEAT group was higher (19.44%) than that of in EAT group (10.39%) (p = 0.04). Within the first 10-ICU-day, patients in the EAT group left ICU in higher rate (62.34%) than that in the NEAT group (54.17%).
Conclusion: Early empirical anidulafungin within 6 h of ICU admission reduced the risk of invasive candidiasis, 30-day all cause mortality rate and increased ICU leaving rate within 10-day of ICU admission in critically ill patients.

Keywords: , , , ,
Full text: PDF

Severe Coronary Artery Vasospasm after Mitral Valve Replacement in a Diabetic Patient with Previous Stent Implantation: A Case Report

Alexandra Iulia Stoica1,2, Marius Harpa1, Cosmin Marian Banceu1,2, Judith Kovacs1,2, Horatiu Suciu1,2

1 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures
2 Institute for Cardiovascular Diseases and Heart Transplantation, Targu Mures, Romania

DOI: 10.2478/jccm-2022-0005

Postoperative coronary vasospasm is a well-known cause of angina that may lead to myocardial infarction if not treated promptly. We report a case of a 70-year-old female with severe mitral regurgitation submitted to mitral valve replacement, and a history of diabetes mellitus type II, stroke, idiopathic thrombocytopenic purpura on steroid therapy, and previous percutaneous coronary intervention (PCI) for severe obstruction of the circumflex coronary artery, 4 months prior to surgery. Immediately after intensive care unit admission, the patient developed pulseless electrical activity which required extracorporeal membrane oxygenation for hemodynamic support. The coronary angiography showed diffuse occlusive coronary artery vasospasm, ameliorated after intra-coronary administration of nitroglycerin. The following postoperative evolution was marked by cardiogenic shock and multiple organ dysfunction syndrome. Subsequent echocardiographic findings showed an increase in left ventricular function with an EF of 40%, and extracorporeal membrane oxygenation (ECMO) support was weaned after seven days. However, after a few hours, the patient progressively deteriorated, with cardiac arrest and no response to resuscitation maneuvers. Hemodynamic instability following the surgical procedure in a patient with previous PCI associated with an autoimmune disease and diabetes mellitus should raise the suspicion of a coronary artery vasospasm.

Keywords: , , , ,
Full text: PDF

Using Machine Learning Techniques to Predict Hospital Admission at the Emergency Department

Georgios Feretzakis1,3, George Karlis2, Evangelos Loupelis1, Dimitris Kalles3, Rea Chatzikyriakou1, Nikolaos Trakas1, Eugenia Karakou1, Aikaterini Sakagianni1, Lazaros Tzelves1, Stavroula Petropoulou1, Aikaterini Tika1, Ilias Dalainas1, Vasileios Kaldis1

1 Sismanogleio General Hospital, Athens, Greece
2 Sotiria General Hospital of Chest Diseases of Athens, Athens, Greece
3 Hellenic Open University, Patras, Greece

DOI: 10.2478/jccm-2022-0003

Introduction: One of the most important tasks in the Emergency Department (ED) is to promptly identify the patients who will benefit from hospital admission. Machine Learning (ML) techniques show promise as diagnostic aids in healthcare.
Aim of the study: Our objective was to find an algorithm using ML techniques to assist clinical decision-making in the emergency setting.
Material and methods: We assessed the following features seeking to investigate their performance in predicting hospital admission: serum levels of Urea, Creatinine, Lactate Dehydrogenase, Creatine Kinase, C-Reactive Protein, Complete Blood Count with differential, Activated Partial Thromboplastin Time, DDimer, International Normalized Ratio, age, gender, triage disposition to ED unit and ambulance utilization. A total of 3,204 ED visits were analyzed.
Results: The proposed algorithms generated models which demonstrated acceptable performance in predicting hospital admission of ED patients. The range of F-measure and ROC Area values of all eight evaluated algorithms were [0.679-0.708] and [0.734-0.774], respectively. The main advantages of this tool include easy access, availability, yes/no result, and low cost. The clinical implications of our approach might facilitate a shift from traditional clinical decision-making to a more sophisticated model.
Conclusions: Developing robust prognostic models with the utilization of common biomarkers is a project that might shape the future of emergency medicine. Our findings warrant confirmation with implementation in pragmatic ED trials.

Keywords: , , ,
Full text: PDF

Reverse Takotsubo cardiomyopathy after orthotopic liver transplantation. A case report

Lucian Mihalcea1, Isac Sebastian2, Mihail Simion-Cotorogea1, Artsiom Klimko3, Gabriela Droc1

1 Department of Anesthesiology and Intensive Care I, Fundeni Clinical Institute, Bucharest, Romania
2 Carol Davila University of Medicine and Pharmacy Faculty of Pharmacy, Bucharest, Romania
3 Laboratory of Molecular Neuro-Oncology, Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland

DOI: 10.2478/jccm-2022-0002

Introdution: Takotsubo cardiomyopathy is a rare reversible type of heart failure, often precipitated by emotional stress; other risk factors include intracranial bleeding, ischemic stroke, sepsis, major surgery, pheochromocytoma. The clinical, electrical and blood sample analysis features resemble those of a myocardial infarction- however, they occur in the absence of angiographic coronary filling defects.
Case presentation: A 61-year-old male patient, 71 kg, 175 cm, underwent liver transplantation for Child-Pugh B cirrhosis secondary to mixed viral hepatitis (B and D). His medical records revealed mild mitral, aortic, and tricuspid insufficiencies and heart failure with preserved ejection fraction. An initially uneventful perioperative stage was succeeded by cardiogenic shock (cardiac index – 1.2 l/min/sqm), which the patient developed 24 hours after the intervention. Elevated cardiac markers and ECG abnormalities showing ST-T changes in the V2-V5 leads were additionally noted. Transesophageal echocardiography (TEE) revealed an acute onset reduction in the left ventricular systolic function secondary to basal hypokinesia. No coronary obstruction was detected by percutaneous angiography. The above findings lead to the diagnosis of reverseTakotsubo cardiomyopathy. Further, the patient developed acute kidney injury and liver graft failure, succumbing within 48 hours after the surgical procedure.
Conclusions: We report a rare case of reverse Takotsubo cardiomyopathy in a male patient after orthotopic liver transplant.

Keywords: , ,
Full text: PDF

Target Controlled Infusion: An Anaesthetic Technique Brought in ICU

Janos Szederjesi

Department of Anesthesiology and Intensive Care, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu-Mures, Romania

DOI: 10.2478/jccm-2022-0001

Target Controlled Infusion (TCI) represents a technique of intravenous anaesthetic drug administration where we aim a predictable concentration of the drug in a specific body compartment.
The technique uses a computer-controlled infusion pump which delivers the anaesthetic drugs based on patient’s parameters (height, weight, age, gender and others) in order to achieve a predicted plasmatic level (TCIp) or a specific site (brain) (TCIe) [1].
The main advantage of the system consists in theoretical calculations and application of precise doses. TCI is designed upon the three-compartmental pharmacokinetic model, maintaining the same level of sedation, and avoiding drugs accumulation. This delivery method could also reduce the intra-operative awareness, emphasising on patient safety. However, the practice showed that those theoretical facts may not be easily applied into clinical practice [2].[More]

Keywords: ,
Full text: PDF

Clinical Characteristics and Outcomes of COVID-19 Acute Respiratory Distress Syndrome Patients Requiring Invasive Mechanical Ventilation in a Lower Middle-Income Country

Taymmia Ejaz, Fazal Rehman, Arslan Ahmed, Safia Akhlaq, Sheema Saadia, Adil Aziz, Erfan Hussain

The Aga Khan University Hospital, Karachi, Pakistan

DOI: 10.2478/jccm-2021-0044

Background: Covid-19 related acute respiratory distress syndrome (ARDS) requires intensive care, which is highly expensive in lower-income countries. Outcomes of COVID-19 patients requiring invasive mechanical ventilation in Pakistan have not been widely reported. Identifying factors forecasting outcomes will help decide optimal care levels and prioritise resources.
Methods: A single-centre, retrospective study on COVID-19 patients requiring invasive mechanical ventilation was conducted from 1st March to 31st May 2020. Demographic variables, physical signs, laboratory values, ventilator parameters, complications, length of stay, and mortality were recorded. Data were analysed in SPSS ver.23.
Results: Among 71 study patients, 87.3% (62) were males, and 12.7% (9) were females with a mean (SD) age of 55.5(13.4) years. Diabetes mellitus and hypertension were the most common comorbidities in 54.9% (39) patients. Median(IQR) SOFA score on ICU admission and at 48 hours was 7(5-9) and 6(4-10), and median (IQR) APACHE-II score was 15 (11-24) and 13(9-23), respectively. Overall, in-hospital mortality was 57.7%; 25% (1/4), 55.6% (20/36) and 64.5% (20/31) in mild, moderate, and severe ARDS, respectively. On univariate analysis; PEEP at admission, APACHE II and SOFA score at admission and 48 hours; Acute kidney injury; D-Dimer>1.5 mg/L and higher LDH levels at 48 hours were significantly associated with mortality. Only APACHE II scores at admission and D-Dimer levels> 1.5 mg/L were independent predictors of mortality on multivariable regression (p-value 0.012 & 0.037 respectively). Admission APACHE II scores, Area under the ROC curve for mortality was 0.80 (95%CI 0.69-0.90); sensitivity was 77.5% and specificity 70% (cut-off ≥13.5).
Conclusion: There was a high mortality rate in severe ARDS. The APACHE II score can be utilised in mortality prediction in COVID-19 ARDS patients. However, larger-scale studies in Pakistan are required to assess predictors of mortality.

Keywords: , , ,
Full text: PDF

COVID-19 Infection or Buttock Injections? The Dangers of Aesthetics and Socializing During a Pandemic

Derrick Anthony Cleland1, Clarence H. H. Tsai2, Joslyn Vo1, Dafne Moretta1

1 Loma Linda University Medical Center Loma Linda, CA, USA
2 Loma Linda University School of Medicine, Loma Linda, CA, USA

DOI: 10.2478/jccm-2021-0043

Introduction: Silicone (polydimethylsiloxane) injections are used for cosmetic augmentation. Their use is associated with life-threatening complications such as acute pneumonitis, alveolar hemorrhage, and acute respiratory distress among others [1,2]. We report a case of a Hispanic woman who developed severe respiratory distress syndrome after gluteal silicone injections.
Case Presentation: A 44-year-old Hispanic female presented to the Emergency Department complaining of progressive dyspnea on exertion for two weeks. Chest imaging revealed patchy bibasilar airspace opacities of peripheral distribution. Labs were significant for leukocytosis, elevated PT, D-dimer, lactate dehydrogenase, and fibrinogen, concerning for COVID-19, however SARS-CoV-2 testing was negative multiple times. The patient later became encephalopathic, hypoxemic, and eventually required intubation. Further history uncovered that the patient had received illicit gluteal silicone injections a few days prior to her onset of symptoms. The patient was diagnosed with silicone embolism syndrome (SES) and initiated on high dose intravenous methylprednisolone [1].
Case Discussion: Patients from lower socioeconomic backgrounds utilize illicit services to receive silicone injections at minimal costs. This leads to dangerous outcomes. The serology and imaging findings observed in our case have similarities to the typical presentation of COVID-19 pneumonia making the initial diagnosis difficult. This case serves as a cautionary tale of the importance of thorough history taking in patients with concern for COVID-19.

Keywords: , , , ,
Full text: PDF