Author Archives: administrare

Critical Care Management of Decompensated Right Heart Failure in Pulmonary Arterial Hypertension Patients – An Ongoing Approach

Ioan Tilea1,2, Andreea Varga1, Anca-Meda Georgescu1,3, Bianca-Liana Grigorescu1,4

1 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Department of Cardiology II, Emergency Clinical County Hospital, Targu Mures, Romania
3 Infectious Disease Clinic, Clinical County Hospital, Targu Mures, Romania
4 Department of Anaesthesia and Intensive Care, Emergency Clinical County Hospital, Targu Mures, Romania

DOI: 10.2478/jccm-2021-0020

Despite substantial advancements in diagnosis and specific medical therapy in pulmonary arterial hypertension patients’ management, this condition continues to represent a major cause of mortality worldwide. In pulmonary arterial hypertension, the continuous increase of pulmonary vascular resistance and rapid development of right heart failure determine a poor prognosis. Against targeted therapy, patients inexorable deteriorate over time. Pulmonary arterial hypertension patients with acute right heart failure who need intensive care unit admission present a complexity of the disease pathophysiology. Intensive care management challenges are multifaceted. Awareness of algorithms of right-sided heart failure monitoring in intensive care units, targeted pulmonary hypertension therapies, and recognition of precipitating factors, hemodynamic instability and progressive multisystem organ failure requires a multidisciplinary pulmonary hypertension team. This paper summarizes the management strategies of acute right-sided heart failure in pulmonary arterial hypertension adult cases based on recently available data.

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The Use of Hydroxyurea in the Treatment of COVID-19

Melissa Robin Bowman Foster1, Ali Atef Hijazi2, Rebecca Opoku2, Priya Varghese2,
Chun Li2

1 Winston-Salem State University, Winston-Salem, NC, USA
2 Independent

DOI: 10.2478/jccm-2021-0019

Introduction: The rapid worldwide spread of COVID-19 motivated medical professionals to pursue and authenticate appropriate remedies and treatment protocols. This article aims to analyze the potential benefits of one treatment protocol developed by a group of care providers caring for severe COVID-19 patients.
Methods: The clinical findings of COVID-19 patients who were transferred to a specialized care hospital after unsuccessful treatment in previous institutions, were analyzed. The specialized care hospital used a treatment protocol including hydroxyurea, a medication commonly used for sickle cell treatment, to improve respiratory distress in the COVID-19 patients. None of the COVID-19 patients included in the analyzed data were diagnosed with sickle cell, and none had previously taken hydroxyurea for any other conditions.
Results: In all presented cases, patients reverted to their baseline respiratory health after treatment with the hydroxyurea protocol. There was no significant difference in the correlation between COVID-19 and hydroxyurea. However, deaths were extremely low for those taking hydroxyurea.
Conclusions: Fatality numbers were extremely low for those taking hydroxyurea; death could be attributed to other underlying issues.

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Critical Care Workers Have Lower Seroprevalence of SARS-CoV-2 IgG Compared with Non-patient Facing Staff in First Wave of COVID19

Helen E. Baxendale1, David Wells2, Jessica Gronlund1, Angalee Nadesalingham2, Mina Paloniemi2, George Carnell2, Paul Tonks2, Lourdes Ceron-Gutierrez3, Soraya Ebrahimi3, Ashleigh Sayer3, John A.G. Briggs4, Xiaoli Ziong4, James A Nathan2, Guinevere Grice2, Leo C James4, Jakub Luptak4, Sumita Pai1, Jonathan L Heeney2, Sara Lear3, Rainer Doffinger3

1 Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
2 University of Cambridge, UK
3 Cambridge University Hospitals NHS Foundation Trust, UK
4 MRC Laboratory of Molecular Biology, UK

DOI: 10.2478/jccm-2021-0018

Introduction: In early 2020, at first surge of the coronavirus disease 2019 (COVID-19) pandemic, many health care workers (HCW) were re-deployed to critical care environments to support intensive care teams looking after patients with severe COVID-19. There was considerable anxiety of increased risk of COVID-19 for these staff. To determine whether critical care HCW were at increased risk of hospital acquired infection, we explored the relationship between workplace, patient facing role and evidence of immune exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within a quaternary hospital providing a regional critical care response. Routine viral surveillance was not available at this time.
Methods: We screened over 500 HCW (25% of the total workforce) for history of clinical symptoms of possible COVID19, assigning a symptom severity score, and quantified SARS-CoV-2 serum antibodies as evidence of immune exposure to the virus.
Results: Whilst 45% of the cohort reported symptoms that they consider may have represented COVID-19, 14% had evidence of immune exposure. Staffs in patient facing critical care roles were least likely to be seropositive (9%) and staff working in non-patient facing roles most likely to be seropositive (22%). Anosmia and fever were the most discriminating symptoms for seropositive status. Older males presented with more severe symptoms. Of the 12 staff screened positive by nasal swab (10 symptomatic), 3 showed no evidence of seroconversion in convalescence.
Conclusions: Patient facing staff working in critical care do not appear to be at increased risk of hospital acquired infection however the risk of nosocomial infection from non-patient facing staff may be more significant than previous recognised. Most symptoms ascribed to possible COVID-19 were found to have no evidence of immune exposure however seroprevalence may underrepresent infection frequency. Older male staff were at the greatest risk of more severe symptoms.

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Pneumocephalus Following an Accidental Dural Puncture, Treated Using Hyperbaric Oxygen Therapy. A Case Report

Flávio Marino1, André Ferreira Simões1, Ângela Simas1, João Gonçalves Pereira1,2,3

1 Intensive Care Unit Department, Hospital Vila Franca de Xira, Vila Franca de Xira, Lisboa, Portugal
2 Nova Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
3 Grupo de Infeção e Sépsis, Porto, Portugal

DOI: 10.2478/jccm-2021-0017

Introduction: Neuraxial techniques, including epidural anaesthesia, are often used for perioperative pain control and are generally safe. However, both transient, mild and even severe, life-threatening neurologic complications can occur.
Case presentation: A seventy-eight-year-old man was admitted to the hospital for a radical nephrectomy plus transurethral resection due to kidney and bladder cancer. During the epidural exploration, an accidental dural puncture was noted. This was followed by the patient complaining of an intense headache. The epidural catheter was placed in a different location, and surgery was performed uneventfully. The patient presented with confusion, agitation, vertical nystagmus, vision loss, and paraparesis about two hours later. The epidural levobupivacaine and morphine infusion were stopped, followed by motor block resolution. A computerized head-tomography scan showed extra-axial multiple air spots involving the frontal and temporal lobes. Emergent hyperbaric oxygen therapy was commenced. After a single session, there was complete resolution of all symptoms and a marked reduction in the number and volume of the extra-axial air visible on the CT scan.
Conclusions: Although rare, pneumocephalus is a well-recognized complication of a dural puncture. Its rapid recognition in a patient with new-onset neurological symptoms and early treatment with hyperbaric oxygen therapy allows rapid clinical and imaging resolution and an improved prognosis.

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Candida spp. in Lower Respiratory Tract Secretions – A Ten Years Retrospective Study

Cristina Nicoleta Ciurea1,2, Ario Santini3, Anca Delia Mare1, Irina Bianca Kosovski2,4, Felicia Toma1, Camelia Vintila5, Ionela Anca Pintea-Simon1,2, Adrian Man1,5

1 Department of Microbiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Doctoral school, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
4 Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
5 Mureș Clinical County Hospital, Targu Mures, Romania

DOI: 10.2478/jccm-2021-0016

Introduction: Lower respiratory tract secretions (LRTS) like sputum and tracheal aspirates are frequently sent to the microbiology laboratory from patients with various respiratory pathologies. Improper collection techniques can lead to false-positive results, resulting in improper therapy.
Aim of the study: To determine the percentage of contaminated samples sent to the microbiology laboratory, to establish the prevalence of Candida spp. in non-contaminated samples and therefore, the presence of Candida spp. originating in lower respiratory tract infections.
Material and Methods: A 10-year data survey was conducted to assess the differences in Candida prevalence from contaminated versus non-contaminated samples, assessed and categorised by Bartlett grading system, and to emphasise the importance of quality control for potentially contaminated samples. The data were analysed according to gender, age, referring departments, and the species of Candida. For the statistical analysis, Kruskal-Wallis and Fisher tests were used, and the alpha value was set for 0.5.
Results: The prevalence of Candida spp. in all analysed samples was 31.60%. After excluding the contaminated samples, the actual prevalence was 27.66%. Of all sputum samples, 31.6% were contaminated. Patients aged more than 40 years old were more prone to provide contaminated sputum samples. C. albicans is more prevalent in non-contaminated sputum samples. In both sputum and tracheal aspirates, the chances of identifying a single species are higher than the chances of identifying multiple species.
Conclusions: The study emphasises the importance of assessing the quality of sputum samples because of the high number of improperly collected samples sent to the microbiology laboratory.

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Postpartum Acute Basilar Artery Occlusion Secondary to Vertebral Artery Dissection. Case Report and Literature Review

Iulia-Adela Drăghici1, Lucian Marginean2, Rares-Cristian Filep2, Zoltan Bajko3,
Laura Barcutean3, Teodora Aldea1, Rodica Balasa3

1 1st Neurology Clinic, Emergency County Hospital Targu Mures, Romania
2 Department of Interventional Radiology, Emergency County Hospital Targu Mures, Romania
3 Department of Neurology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2021-0015

Female patients in the peripartum and postpartum periods have an increased risk of stroke than nonpregnant women. Cerebrovascular complications of pregnancy represent a significant cause of maternal mortality and morbidity and are potentially disabling. Acute basilar artery occlusion secondary to spontaneous vertebral artery dissection in the postpartum period is an infrequent entity and a major diagnostic and treatment challenge. In the present case, a 37-year-old female patient, eight weeks after caesarean delivery, presented with a history of sudden cervical pain, followed by headache and dizziness. Some hours later, she was found unconscious by her family and was transferred to the emergency department, where a neurological status assessment suggested vertebrobasilar stroke. The imagistic workup revealed right vertebral artery dissection and basilar artery occlusion without constituted ischemic lesions. The patient underwent endovascular intervention with dilation of the narrowed vertebral artery and stent retriever basilar artery thrombectomy, with a favourable clinical outcome. This report first presents the details of this case and the relevant literature data on postpartum arterial dissections and the subsequent ischemic complications and available treatment options.

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The Impact of Hyperoxia Treatment on Neurological Outcomes and Mortality in Moderate to Severe Traumatic Brain Injured patients

Raymond Khan, Sarah Alromaih, Hind Alshabanat, Nosaiba Alshanqiti, Almaha Aldhuwaihy, Sarah Abdullah Almohanna, Muna Alqasem, Hasan Al-Dorzi

King Saud bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, Saudi Arabia

DOI: 10.2478/jccm-2021-0014

Background: Traumatic brain injury is a leading cause of morbidity and mortality worldwide. The relationship between hyperoxia and outcomes in patients with TBI remains controversial. We assessed the effect of persistent hyperoxia on the neurological outcomes and survival of critically ill patients with moderate-severe TBI.
Method: This was a retrospective cohort study of all adults with moderate-severe TBI admitted to the ICU between 1st January 2016 and 31st December 2019 and who required invasive mechanical ventilation. Arterial blood gas data was recorded within the first 3 hours of intubation and then after 6-12 hours and 24-48 hours. The patients were divided into two categories: Group I had a PaO2 < 120mmHg on at least two ABGs undertaken in the first twelve hours post intubation and Group II had a PaO2 ≥ 120mmHg on at least two ABGs in the same period. Multivariable logistic regression was performed to assess predictors of hospital mortality and good neurologic outcome (Glasgow outcome score ≥ 4).
Results: The study included 309 patients: 54.7% (n=169) in Group I and 45.3% (n=140) in Group II. Hyperoxia was not associated with increased mortality in the ICU (20.1% vs. 17.9%, p=0.62) or hospital (20.7% vs. 17.9%, p=0.53), moreover, the hospital discharge mean (SD) Glasgow Coma Scale (11.0(5.1) vs. 11.2(4.9), p=0.70) and mean (SD) Glasgow Outcome Score (3.1(1.3) vs. 3.1(1.2), p=0.47) were similar. In multivariable logistic regression analysis, persistent hyperoxia was not associated with increased mortality (adjusted odds ratio [aOR] 0.71, 95% CI 0.34-1.35, p=0.29). PaO2 within the first 3 hours was also not associated with mortality: 121-200mmHg: aOR 0.58, 95% CI 0.23-1.49, p=0.26; 201-300mmHg: aOR 0.66, 95% CI 0.27-1.59, p=0.35; 301-400mmHg: aOR 0.85, 95% CI 0.31-2.35, p=0.75 and >400mmHg: aOR 0.51, 95% CI 0.18-1.44, p=0.20; reference: PaO2 60-120mmHg within 3 hours. However, hyperoxia >400mmHg was associated with being less likely to have good neurological (GOS ≥4) outcome on hospital discharge (aOR 0.36, 95% CI 0.13-0.98, p=0.046; reference: PaO2 60-120mmHg within 3 hours.
Conclusion: In intubated patients with moderate-severe TBI, hyperoxia in the first 48 hours was not independently associated with hospital mortality. However, PaO2 >400mmHg may be associated with a worse neurological outcome on hospital discharge.

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COVID -19 complicated by Acute Respiratory Distress Syndrome, Myocarditis, and Pulmonary Embolism. A case report

Rajai F. Bulbul, Jassim Al Suwaidi, Mohammed Al-Hijji, Hassan Al Tamimi, Ibrahim Fawzi

Hamad Medical Corporation, Doha, Qatar

DOI: 10.2478/jccm-2020-0041

A 49-year-old female Qatari woman, with no past medical history, presented at a hospital complaining of a history of cough and shortness of breath. The patient tested positive for severe acute respiratory syndrome (ARDS) and COVID-19. Subsequently, her course of treatment was complicated by severe acute respiratory distress syndrome, pulmonary embolism and severe myocarditis requiring treatment with venous-arterial extracorporeal membrane oxygenation as a bridge to complete recovery.

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Challenges in Management of the Brain-Dead Organ Donor During the COVID-19 Pandemic

Ioana Marina Grințescu

“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

DOI: 10.2478/jccm-2021-0013

Starting in Wuhan, China [1], the infection caused by the novel SARS-CoV-2 virus became a public health issue when, due to the extreme contagiousness of this virus, a pandemic has been declared [2], putting a strain on both the global medical staff as well as the authorities in an effort to better manage an unprecedented situation in the modern era. Looking at the society we are living in, we can easily see that the COVID-19 pandemic has brought impressive social, economic, political, cultural and medical changes as well as personal ones; I believe that the perspectives and priorities of many of us have changed.
Before discussing the transplant activity, mainly the one regarding diagnosis and maintenance of the brain-dead organ donor patient, an activity that has been carried out for many years in Anesthesiology and Intensive Care Clinics, to which many of us are devoted, practicing it with deep respect, we need to review the daily activity. As is well known, the work effort in intensive care units is extremely demanding both mentally and physically. It involves the care of critical patients with severe decompensated pathologies, requiring maximum therapeutic management, special attention, continuous specific monitoring as well as the use of advanced medical and pharmacological techniques. The new measures and regulations, personal protective equipment, structural changes and working protocols implemented to prevent and limit COVID-19 infection, as well as the rigors imposed by the care of these patients have created additional stress for the medical staff. [More]

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