Author Archives: administrare

The Predictive Potential of Elevated Serum Inflammatory Markers in Determining the Need for Intubation in CoVID-19 Patients

Samuel Windham, Kellen Hirsch, Ryan Peterson, David Douin, Lakshmi Chauhan, Lauren Heery, Connor Fling, Nemanja Vukovic, Fernando Holguin, Shanta Zimmer, Kristine Erlandson

University of Colorado Anschutz Medical Campus, Denver, CO, USA

DOI: 10.2478/jccm-2021-0035

Introduction: The predictive potential of demographics, clinical characteristics, and inflammatory markers at admission to determine future intubation needs of hospitalised CoVID-19 patients is unknown. The study aimed to determine the predictive potential of elevated serum inflammatory markers in determining the need for intubation in CoVID-19 Patients.
Methods: In a retrospective cohort study of hospitalised SARS-CoV2 positive patients, single and multivariable regression analyses were used to determine covariate effects on intubation odds, and a minimax concave penalty regularised logistic regression was used to build a predictive model. A second prospective independent cohort tested the model.
Results: Systemic inflammatory markers obtained at admission were higher in patients that required subsequent intubation, and adjusted odds of intubation increased for every standard deviation above the mean for c-reactive protein (CRP) OR:2.8 (95% CI 1.8-4.5, p<0.001) and lactate dehydrogenase OR:2.1 (95% CI 1.3-3.3, p=0.002). A predictive model incorporating C-reactive protein, lactate dehydrogenase, and diabetes status at the time of admission predicted intubation status with an area under the curve (AUC) of 0.78 with corresponding sensitivity of 86%, specificity of 63%. This predictive model achieved an AUC of 0.83, 91% sensitivity, and 41% specificity on the validation cohort.
Conclusion: In patients hospitalised with CoVID-19, elevated serum inflammatory markers measured within the first twenty-four hours of admission are associated with an increased need for intubation. Additionally, a model of C-reactive protein, lactate dehydrogenase, and the presence of diabetes may play a predictive role in determining the future need for intubation.

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Survey of U.S. Critical Care Practitioners on Net Ultrafiltration Prescription and Practice Among Critically Ill Patients Receiving Kidney Replacement Therapy

Huiwen Chen1,2, Raghavan Murugan1

1 Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
2 Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

DOI: 10.2478/jccm-2021-0034

Introduction: The current prescription and practice of net ultrafiltration among critically ill patients receiving kidney replacement therapy in the U.S. are unclear.
Aim of the study: To assess the attitudes of U.S. critical care practitioners on net ultrafiltration (UFNET) prescription and practice among critically ill patients with acute kidney injury treated with kidney replacement therapy.
Methods: A secondary analysis was conducted of a multinational survey of intensivists, nephrologists, advanced practice providers, and ICU and dialysis nurses practising in the U.S.
Results: Of 1,569 respondents, 465 (29.6%) practitioners were from the U.S. Mainly were nurses and advanced practice providers (58%) and intensivists (38.2%). The median duration of practice was 8.7 (IQR, 4.2-19.4) years. Practitioners reported using continuous kidney replacement therapy (as the first modality in 60% (IQR 20%-90%) for UFNET. It was found that there was a significant variation in assessment of prescribed-to-delivered dose of UFNET, use of continuous kidney replacement therapy for UFNET, methods used to achieve UFNET, and assessment of net fluid balance during continuous kidney replacement therapy. There was also variation in interventions performed for managing hemodynamic instability, perceived barriers to UFNET, belief that early and protocol-based fluid removal is beneficial, and willingness to enroll patients in a clinical trial.
Conclusions: There was considerable practice variation in UFNET among critical care practitioners in the U.S., reflecting the need to generate evidence-based practice guidelines for UFNET.

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Inhaled Nitric Oxide in Patients with Severe COVID-19 Infection at Intensive Care Unit – A Cross-Sectional Study

Laura Herranz, Juliana Gurgel da Silveira, Luis Filipe Lannes Trocado, Anna Luiza Alvaraes, Juliana Fittipaldi

Instituto D’Or de Pesquisa e Ensino, Rio de Janeiro, Brazil

DOI: 10.2478/jccm-2021-0033

In adults with severe hypoxemia, inhaled nitric oxide (iNO) is known to reduce pulmonary shunt and pulmonary hypertension, improving V/Q matching [1]. Studies in refractory hypoxemia among patients with severe acute respiratory distress syndrome (ARDS) suggest that iNO may be allied to other ventilatory strategies as a bridge to clinical improvement [2, 3].
A trial from the 2004 Beijing Coronavirus Outbreak showed that low dose iNO could shorten the time of ventilatory support [4]. Additionally, preclinical studies suggest an inhibitory effect of iNO on viral replication [5]. To date, the role of iNO in COVID19 infection is still unclear. [More]

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Hypercoagulopathy in Overweight and Obese COVID-19 Patients: A Single-Center Case Series

Azza Sarfraz1,2, Zouina Sarfraz1,3, Aman Siddiqui1,4, Ali Totonchian4, Syed Hashim Abbas Ali Bokhari5, Hafiza Hussain3, Muzna Sarfraz1, Gaurav Patel1, Muhammad Hassaan Amjad6, Sameer Saleem Tebha1, Ivan Cherrez-Ojeda7,8, Patrick Dreyer1, Harshad Amin1, Jack Michel1

1 Larkin Health System, South Miami, FL, USA
2 Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
3 Research and Publications, Fatima Jinnah Medical University, Lahore, Pakistan
4 Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
5 School of Medicine, The Aga Khan University, Karachi, Pakistan
6 Neurosurgery, Sir Ganga Ram Hospital, Lahore, Pakistan
7 Allergy and Pulmonology, Universidad de Especialidades Espíritu Santo, Ecuador
8 Respiralab Research Center, Guayaquil, Ecuador

DOI: 10.2478/jccm-2021-0032

A case series is presented of five overweight or obese patients with confirmed coronavirus disease 2019 (COVID-19) in South Miami, Florida, United States. A multitude of coagulation parameters was suggestive of a hypercoagulable state among the hospitalized COVID-19 patients. This article reports various manifestations of hypercoagulable states in overweight and obese patients, such as overt bleeding consistent with disseminated intravascular coagulation, venous thromboembolism, gastrointestinal bleeding as well as retroperitoneal hematoma. All of the required admission to the intensive care unit and subsequently patients died. The characteristics of COVID-19-associated coagulopathy are atypical and warrant a further understanding of the pathophysiology to improve clinical outcomes, specifically in overweight or obese patients.

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Severe Acute Motor Axonal Neuropathy Associated with Influenza-A (H1N1) Infection and Prolonged Respiratory Failure – A Case Report

Oana Mosora1, Laura Barcutean1,2, Rodica Balasa1,2, Raluca Fodor3, Smaranda Maier1,2, Zoltan Bajko1,2, Adina Stoian1,4, Anca Motataianu1,2

1 Neurology 1 Clinic, Emergency County Hospital Targu-Mures, Romania
2 Neurology Department, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Anaesthesiology Department, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
4 Pathophysiology Department, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2021-0030

Acute Motor Axonal Neuropathy (AMAN) is an immune-mediated disorder of the peripheral nervous system, part of the spectrum of the Guillain-Barre syndrome (GBS). An infectious event most often triggers it reported a few weeks before the onset. The reported case is of a 56 years-old woman who developed acute motor axonal neuropathy three weeks after respiratory infection with influenza A virus subtype H1N1. Despite early treatment with plasmapheresis and intravenous immunoglobulins, the patient remained tetraplegic, mechanically ventilated for five months, with repetitive unsuccessful weaning trails. The probable cause was considered to be phrenic nerve palsy in the context of acute motor axonal neuropathy. This case highlights that acute motor axonal neuropathy is a severe and life-threatening form of Guillain-Barre syndrome associated with significant mortality and morbidity. Neurological and physical recovery strongly depend on the inter-professional effort in an intensive care unit and neurology professionals.

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Shock Due to an Obstructed Endotracheal Tube

Stefanie Foong Ling Chua, Chi Ho Chan, Suhitharan Thangavelautham

Singapore General Hospital, Singapore, Singapore

DOI: 10.2478/jccm-2021-0027

Endotracheal tube obstruction by a mucus plug causing a ball-valve effect is a rare but significant complication. The inability to pass a suction catheter through the endotracheal tube with high peak and plateau pressure differences are classical features of an endotracheal tube obstruction. A case is described of endotracheal tube obstruction from a mucus plug that compounded severe respiratory acidosis and hypotension in a patient who simultaneously had abdominal compartment syndrome. The mucus plug was not identified until a bronchoscopic assessment of the airway was performed. Due to the absence of classical signs, the delayed identification of the obstructing mucus plug exacerbated diagnostic confusion. It resulted in various treatments being trialed whilst the patient continued to deteriorate from the evasive offending culprit. We suggest that earlier and more routine use of bronchoscopy should be employed in an intensive care unit, especially as a definitive way to rule out endotracheal obstruction.

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Hypothalamic-pituitary axis disorder – “the puppet master” of multiple organ dysfunction in brain-dead patients

Bianca-Liana Grigorescu

George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu-Mures, Romania

DOI: 10.2478/jccm-2021-0029

One of the most revolutionary discoveries of modern medicine was organ transplantation, as it brought hope and healing in cases that seemed incurable. Best outcomes in organ transplantation are related to a rigorous tissue typing and an appropriate immunosuppressant therapy that allowed a longer survival rate for recipients [1]. The management of the potential brain-dead donor is a complex one that involves several well-defined stages: early identification of potential donors, brain death determination, maintaining vital functions, and graft transplantation.
Brain death determination is synonymous with irreversible anatomical and functional injury to the entire brain and brainstem. This process involves a major alteration of the hemodynamic and hormonal homeostasis. Hypothalamic irreversible injury is followed by a profound normothermia dysregulation. The aggressive inflammatory response after brain death occurrence is responsible for capillary leakage and refractory hypotension [2]. Clinical diagnostic tests that assess brain death include brain stem areflexia, apnea, and cerebral unresponsiveness, linked with a known, irreversible cause of coma [3].[More]

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The Importance of Iron Administration in Correcting Anaemia after Major Surgery

Mirela Tiglis1,2, Cristian Cobilinschi1,2, Liliana Elena Mirea1,2, Alexandru Emil Băetu1,2, Ileana Peride1, Tiberiu Paul Neagu1, Andrei Niculae1, Ionel Alexandru Checherită1, Ioana Marina Grintescu1,2

1 “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
2 Emergency Clinical Hospital of Bucharest, Romania

DOI: 10.2478/jccm-2021-0028

Introduction: Postoperative anaemia can affect more than 90% of patients undergoing major surgeries. Patients develop an absolute iron deficiency in the face of significant blood loss or preoperative anaemia and major surgery. Studies have shown the negative impact of these factors on transfusion requirements, infections, increased hospitalisation and long-term morbidities.
Aim of the study: The research was performed to determine the correlation between intravenous iron administration in the postoperative period and improved haemoglobin correction trend.
Material and methods: A prospective study was conducted to screen and treat iron deficiency in patients undergoing major surgery associated with significant bleeding. For iron deficiency anaemia screening, in the postoperative period, the following bioumoral parameters were assessed: haemoglobin, serum iron, transferrin saturation (TSAT), and ferritin, direct serum total iron-binding capacity (dTIBC), mean corpuscular volume (MCV) and mean corpuscular haemoglobin (MCH). In addition, serum glucose, fibrinogen, urea, creatinine and lactate values were also collected.
Results: Twenty-one patients undergoing major surgeries (52,38% were emergency and 47,61% elective interventions) were included in the study. Iron deficiency, as defined by ferritin 100-300 μg/L along with transferrin saturation (TSAT) < 20 %, mean corpuscular volume (MVC) < 92 fL, mean corpuscular haemoglobin (MCH) < 33 g/dL, serum iron < 10 μmol/L and direct serum total iron-binding capacity (dTIBC) > 36 μmol/L, was identified in all cases. To correct the deficit and optimise the haematological status, all patients received intravenous ferric carboxymaltose (500-1000 mg, single dose). Using Quadratic statistical analysis, the trend of haemoglobin correction was found to be a favourable one.
Conclusion: The administration of intravenous ferric carboxymaltose in the postoperative period showed the beneficial effect of this type of intervention on the haemoglobin correction trend in these groups of patients.

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