Author Archives: administrare

The Use of Diuretic in Mechanically Ventilated Children with Viral Bronchiolitis: A Cohort Study

Nisha Agasthya1,2, Kimberlee Chromey1,2, James H. Hertzog1,2, Jigar C. Chauhan1,2

1 Department of Pediatrics, Division of Critical Care Medicine, Nemours A.I. duPont Hospital for Children, Wilmington, DE, USA
2 Department of Pediatrics, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA, USA

DOI: 10.2478/jccm-2021-0008

Introduction: Viral bronchiolitis is a leading cause of admissions to pediatric intensive care unit (PICU). A literature review indicates that there is limited information on fluid overload and the use of diuretics in mechanically ventilated children with viral bronchiolitis. This study was conducted to understand diuretic use concerning fluid overload in this population.
Material and methods: A retrospective cohort study performed at a quaternary children’s hospital. The study population consisted of mechanically ventilated children with bronchiolitis, with a confirmed viral diagnosis on polymerase chain reaction (PCR) testing. Children with co-morbidities were excluded. Data collected included demographics, fluid status, diuretic use, morbidity and outcomes. The data were compared between groups that received or did not receive diuretics.
Result: Of the 224 mechanically ventilated children with confirmed bronchiolitis, 179 (79%) received furosemide on Day 2 of invasive ventilation. Out of these, 72% of the patients received intermittent intravenous furosemide, whereas 28% received continuous infusion. It was used more commonly in patients who had a higher fluid overload. Initial fluid overload was associated with longer duration of mechanical ventilation (median days 6 vs 4, p<0.001) and length of stay (median days 10 vs 6, p<0.001) even with the use of furosemide. Superimposed bacterial pneumonia was seen in 60% of cases and was associated with a higher per cent fluid overload at 24 hours (9.1 vs 6.3, p = 0.003).
Conclusion: Diuretics are frequently used in mechanically ventilated children with bronchiolitis and fluid overload, with intermittent dosing of furosemide being the commonest treatment. There is a potential benefit of improved oxygenation in these children, though further research is needed to quantify this benefit and any potential harm. Due to potential harm with fluid overload, restrictive fluid strategies may have a potential benefit.

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Erratum

This is a correction for the article Bilateral Ocular Exophthalmia – A Case of Atypical Acute Myeloblastic Leukemia in a Child, published by Réka Toth, Alina Grama, Cristina Maki and Mihaela Ioana Chinceșan in The Journal of Critical Care Medicine 2020;6(4):243-248, DOI: 10.2478/jccm-2020-0031.
The authors received a complaint regarding the publication of the results of genetic analyzes without the consent of the Medical Genetics Laboratory from the Emergency Clinical County Hospital of Targu Mures. At the written request of the authors, the following paragraphs from page 246 will be removed from the published manuscript:

“The FLT3 D835 and DNMT3A R882 mutation was performed by polymerase chain reaction-restriction fragment length polymorphism. For FLT3 ITD and NPM1 fragment analysis was also executed with capillary electrophoresis. Geneticists did not detect any mutations of examined fragments. Quantitative analysis showed FTL3-ITD:VAR=0% and NPM1:VAR=0.08%. The heterozygous deletion was shown at the level of the 2p24.3 region (for exons 2, 3 of the MYCN gene), no copy number variants for the other investigated regions was evidenced, and mutation of JAK3 V617F was not detected.”

This will not affect the information presented in the manuscript, nor the conclusions.

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Effects of Extracorporeal Membrane Oxygenation Initiation on Oxygenation and Pulmonary Opacities

Kiran Batra, Manish Mohanka, Srinivas Bollineni, Vaidehi Kaza, Prabhakar Rajiah, Yin Xi, Amy Hackmann, Michael Wait, Fernando Torres, Amit Banga

University of Texas Southwestern Medical Center at Dallas, TX, USA

DOI: 10.2478/jccm-2020-0040

Introduction: There is limited data on the impact of extracorporeal membrane oxygenation (ECMO) on pulmonary physiology and imaging in adult patients. The current study sought to evaluate the serial changes in oxygenation and pulmonary opacities after ECMO initiation.
Methods: Records of patients started on veno-venous, or veno-arterial ECMO were reviewed (n=33; mean (SD): age 50(16) years; Male: Female 20:13). Clinical and laboratory variables before and after ECMO, including daily PaO2 to FiO2 ratio (PFR), were recorded. Daily chest radiographs (CXR) were prospectively appraised in a blinded fashion and scored for the extent and severity of opacities using an objective scoring system.
Results: ECMO was associated with impaired oxygenation as reflected by the drop in median PFR from 101 (interquartile range, IQR: 63-151) at the initiation of ECMO to a post-ECMO trough of 74 (IQR: 56-98) on post-ECMO day 5. However, the difference was not statistically significant. The appraisal of daily CXR revealed progressively worsening opacities, as reflected by a significant increase in the opacity score (Wilk’s Lambda statistic 7.59, p=0.001). During the post-ECMO period, a >10% increase in the opacity score was recorded in 93.9% of patients. There was a negative association between PFR and opacity scores, with an average one-unit decrease in the PFR corresponding to a +0.010 increase in the opacity score (95% confidence interval: 0.002 to 0.019, p-value=0.0162). The median opacity score on each day after ECMO initiation remained significantly higher than the pre-ECMO score. The most significant increase in the opacity score (9, IQR: -8 to 16) was noted on radiographs between pre-ECMO and forty-eight hours post-ECMO. The severity of deteriorating oxygenation or pulmonary opacities was not associated with hospital survival.
Conclusions: The use of ECMO is associated with an increase in bilateral opacities and a deterioration in oxygenation that starts early and peaks around 48 hours after ECMO initiation.

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Reflections on a Year of SARS-CoV-2

Elisabeth Abeles, Razvan Azamfirei

Johns Hopkins University School of Medicine, Baltimore, MD, USA

DOI: 10.2478/jccm-2021-0005

As we are writing this editorial 12 months following the publication of “The 2019 Novel Coronavirus: A Crown Jewel of Pandemics?”, there are 96 million cases with over 2 million total deaths, a public health tragedy of staggering proportions [1]. The early stages of the pandemic were characterized by scientific uncertainty, with many authors postulating hypotheses about the transmission of SARS-CoV-2, the appropriate medical treatment, and the most effective public health measures. In retrospect, many of the early takes on coronavirus ended up being incorrect. Since January 2020, science has advanced at a breathtaking pace and the disease caused by SARS-CoV-2 has taken on dimensions few of us anticipated. In this piece, we aim to reflect on the last year, discussing aspects of the pandemic that the scientific community correctly anticipated, and highlighting where we went wrong. [More]

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Cerebellar Stroke in a COVID-19 Infected Patient. A Case Report

Khang Ning Loo1, You Jiang Tan2, Kaavya Narasimhalu2, Krishan Kumar Sharma3, Dorinda Chee Yee Chew4, Hei Man Wong5, Yvonne Fu Zi Chan5, Ken Cheah Hooi Lee6

1 Department of Internal Medicine, Singapore General Hospital, Singapore, Singapore
2 Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore, Singapore
3 Department of Neurosurgery, National Neuroscience Institute, Singapore General Hospital, Singapore, Singapore
4 Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore
5 Department of Infectious Disease, Singapore General Hospital, Singapore, Singapore
6 Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore

DOI: 10.2478/jccm-2021-0004

Background: Recent studies have reported that COVID-19 infected patients with stroke, who were often in the older age group, had a higher incidence of vascular risk factors, and more severe infection related respiratory symptoms. These observations provided little evidence to suggest that COVID-19 infection is a potential causative factor for stroke. This report describes a young patient with a cerebellar stroke secondary to COVID-19 infection.
Case presentation: A 45-year old male presented at a hospital, reporting a two-day history of headache, vertigo, persistent vomiting, and unsteady gait. Physical examination revealed gaze-evoked nystagmus on extraocular movement testing, left-sided dysmetria and dysdiadochokinesia. He was diagnosed with a left cerebellar stroke. An external ventricular drain was inserted, and sub-occipital craniectomy was performed to manage the effects of elevated intracranial pressure due to the extent of oedema secondary to the infarct. He also underwent screening for the COVID-19 infection, which was positive on SARS-COV-2 polymerase chain reaction testing of his endotracheal aspirate. Blood and cerebrospinal fluid samples were negative. After the surgery, the patient developed atrial fibrillation and had prolonged vomiting symptoms, but these resolved eventually with symptomatic treatment. He was started on aspirin and statin therapy, but anticoagulation was withheld due to bleeding concerns. The external ventricular drain was removed nine days after the surgery. He continued with active rehabilitation.
Conclusions: Young patients with COVID-19 infection may be more susceptible to stroke, even in the absence of risk factors. Standard treatment with aspirin and statins remains essential in the management of COVID-19 related stroke. Anticoagulation for secondary prevention in those with atrial fibrillation should not be routine and has to be carefully evaluated for its benefits compared to the potential harms of increased bleeding associated with COVID-19 infection.

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Resolution of Laryngeal Oedema in a Patient with Acquired C1-Inhibitor Deficiency. A Case Report

Noémi-Anna Bara1, Valentin Nadasan2

1 Hereditary Angioedema Expertise Centre, Sangeorgiu de Mures, Romania
2 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2021-0003

Introduction: Laryngeal oedema caused by acquired angioedema due to C1-inhibitor deficiency (C1-INH-AAE) is a life-threatening condition. The swelling is bradykinin mediated and will not respond to the usual treatment with antihistamines, corticosteroids, or epinephrine. Instead, kallikrein-bradykinin-targeted therapies should be used promptly to prevent asphyxiation.
Case presentation: A 43 years old female presented at the Hereditary Angioedema Centre reporting a one-year history of peripheral, facial, and neck oedema. Treatment with antihistamines and corticosteroids had been ineffective. Laboratory results showed complement level deficiencies and monoclonal gammopathy characterised as immunoglobulin M. An abdominal ultrasound revealed splenomegaly. A bone marrow biopsy was normal. Based on these data, the diagnosis of C1-INH-AAE associated with monoclonal gammopathy of uncertain significance (MGUS) was made. As C1-INH-AAE can present with life-threatening, standard treatment-resistant laryngeal oedema, an emergency care treatment plan was proposed, and the patient was advised to present to the emergency department (ED) with this medical letter. Based on these recommendations, three laryngeal attacks were successfully treated in the ED with recombinant human C1-inhibitor (two attacks) and fresh frozen plasma (one attack). After these episodes, the patient was prescribed prophylactic treatment with antifibrinolytics. No further angioedema attacks were reported by the patient at the 18 months follow-up visit.
Conclusions: Because angioedema of the upper airways is a life-threatening condition, recognising the specific type of swelling by the emergency physician is critical in providing immediate and effective treatment to reduce the associated risk of asphyxiation. C1-INH-AAE being a rare disorder, patients should have available an emergency care treatment plan with recommendations of acute treatment possibilities.

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Ischemic Stroke in Patients with Cancer: A Retrospective Cross-Sectional Study

Anca Motataianu1, Smaranda Maier1, Sebastian Andone2, Laura Barcutean1, Georgiana Serban2, Zoltan Bajko1, Adrian Balasa1

1. George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2. Emergency County Hospital Targu Mures, Romania

DOI: 10.2478/jccm-2021-0002

Introduction: An increasing trend of cancer associated stroke has been noticed in the past decade.
Objectives: To evaluate the risk factors and the incidence of neoplasia in stroke patients.
Material and Method: A retrospective, observational study was undertaken on 249 patients with stroke and active cancer (SAC) and 1563 patients with stroke without cancer (SWC). The general cardiovascular risk factors, the site of cancer, and the general clinical data were registered and evaluated. According to the “Oxfordshire Community Stroke Project” (OCSP) classification, all patients were classified into the clinical subtypes of stroke. The aetiology of stroke was considered as large-artery atherosclerosis, small vessel disease, cardio-embolic, cryptogenic or other determined cause.
Results: The severity of neurological deficits at admission were significantly higher in the SAC group (p<0.01). The haemoglobin level was significantly lower, and platelet level and erythrocyte sedimentation rate were significantly higher in the SAC group. Glycaemia, cholesterol and triglycerides levels were significantly higher in the SWC group. The personal history of hypertension was more frequent in the SWC group. In the SAC group, 28.9% had a cryptogenic aetiology, compared to 9.1% in SWC group. Cardio-embolic strokes were more frequent in the SAC group (24%) than the SWC group (19.6%). In the SAC group, 15,6% were diagnosed with cancer during the stroke hospitalization, and 78% of the SAC patients were without metastasis.
Conclusions: The most frequent aetiologies of stroke in cancer patients were cryptogenic stroke, followed by large-artery atherosclerosis. SAC patients had more severe neurological deficits and worse clinical outcomes than SWC patients. Stroke in cancer patients appears to be more frequently cryptogenic, probably due to cancer associated thrombosis. The association between stroke and cancer is important, especially in stroke of cryptogenic mechanism, even in the presence of traditional cardiovascular risk factors.

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An Incident of a Massive Pulmonary
Embolism following Acute Aortic Dissection. A Case Report

Sofia Fernandes1, Mariana Rodrigues1, Catarina Barreiros1, Hugo Côrte-Real2, Ricardo Ferreira2, Ângelo Nobre2

1. Department of Anesthesiology, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal
2. Department of Cardiothoracic Surgery, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal

DOI: 10.2478/jccm-2021-0001

Acute aortic dissection and acute pulmonary embolism are two life-threatening emergencies. The presented case is of an 81-year-old man who has been diagnosed with an acute Stanford type A aortic dissection and referred to a tertiary hospital for surgical treatment. After a successful aortic repair and an overall favourable postoperative recovery, he was diagnosed with cervical and upper extremity deep vein thrombosis and was anticoagulated accordingly. He later presented with massive bilateral pulmonary embolism.

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The Correspondence between Fluid Balance and Body Weight Change Measurements in Critically Ill Adult Patients

Ana Carolina Peçanha Antonio1, Vivian Rodrigues Fernandes2, Karina de Oliveira Azzolin3

1 Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
2 Fellow nurse, Instituto de Cardiologia, Porto Alegre, Brazil
3 Universidade Federal do Rio Grande do Sul Instituto de Ciencias Basicas da Saude, Porto Alegre, Brazil

DOI: 10.2478/jccm-2020-0048

Introduction: Positive fluid status has been associated with a worse prognosis in intensive care unit (ICU) patients. Given the potential for errors in the calculation of fluid balance totals and the problem of accounting for indiscernible fluid losses, measurement of body weight change is an alternative non-invasive method commonly used for estimating body fluid status. The objective of the study is to compare the measurements of fluid balance and body weight changes over time and to assess their association with ICU mortality. Methods: This prospective observational study was conducted in the 34-bed multidisciplinary ICU of a tertiary teaching hospital in southern Brazil. Adult patients were eligible if their expected length of stay was more than 48 hours, and if they were not receiving an oral diet. Clinical demographic data, daily and cumulative fluid balance with and without indiscernible water loss, and daily and total body weight changes were recorded. Agreement between daily fluid balance and body weight change, and between cumulative fluid balance and total body weight change were calculated. Results: Cumulative fluid balance and total body weight change differed significantly among survivors and non survivors respectively, +2.53L versus +5.6L (p= 0.012) and -3.05kg vs -1.1kg (p= 0.008). The average daily difference between measured fluid balance and body weight was +0.864 L/kg with a wide interval: -3.156 to +4.885 L/kg, which remained so even after adjustment for indiscernible losses (mean bias: +0.288; limits of agreement between -3.876 and +4.452 L/kg). Areas under ROC curve for cumulative fluid balance, cumulative fluid balance with indiscernible losses and total body weight change were, respectively, 0.65, 0.56 and 0.65 (p= 0.14). Conclusion: The results indicated the absence of correspondence between fluid balance and body weight change, with a more significant discrepancy between cumulative fluid balance and total body weight change. Both fluid balance and body weight changes were significantly different among survivors and non-survivors, but neither measurement discriminated ICU mortality.

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