Author Archives: administrare

Prevalence of Depression, Anxiety and Stress among Patients Discharged from Critical Care Units

Mohammad Saeidi1, Alireza Safaei2, Zohreh Sadat3, Parisa Abbasi4, Masoumeh Sadat Mousavi Sarcheshmeh5, Fariba Dehghani6, Mehran Tahrekhani7, Mohammad Abdi8

1 Department of Anesthesiology and Critical Care, Qom University of Medical Sciences, Qom, Iran
2 School of Science, Engineering and Environment, University of Salford, Manchester, UK
3 Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, Iran
4 Baharlo Hospital, Tehran University of Medical Sciences, Tehran, Iran
5 Bahman Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
6 Researcher of Spiritual Health Research Center, Qom University of Medical Sciences, Qom, Iran
7 Department of Nursing Education, Abhar School of Nursing, Zanjan University of Medical Sciences, Zanjan, Iran
8 Department of Medical Education, Medical School, Tehran University of Medical Sciences, Tehran, Iran

DOI: 10.2478/jccm-2021-0012

Introduction: The widespread use of advanced technology and invasive intervention creates many psychological problems for hospitalized patients; it is especially common in critical care units.
Methods: This cross-sectional study was conducted on 310 patients hospitalized in critical care units, using a non-probability sampling method. Data were collected using depression, anxiety, and stress scale (DASS-21) one month after discharge from the hospital. Data analysis was performed using descriptive and inferential statistics.
Results: 181 males and 129 females with a mean age (SD) of 55.11(1.62) years were enrolled in the study. The prevalence of depression, anxiety and stress were 46.5, 53.6 and 57.8% respectively, and the depression, anxiety and stress mean (SD) scores were 16.15(1.40), 18.57(1.46), 19.69(1.48), respectively. A statistically significant association was reported between depression, anxiety and stress with an increase in age, the number of children, occupation, education, length of hospital stay, use of mechanical ventilation, type of the critical care unit, and drug abuse.
Conclusion: The prevalence of depression, anxiety and stress in patients discharged from critical care units was high. Therefore, crucial decisions should be made to reduce depression, anxiety and stress in patients discharged from critical care units by educational strategies, identifying vulnerable patients and their preparation before invasive diagnostic-treatment procedures.

Keywords: , , ,
Full text: PDF

Effect of Early versus Delayed Parenteral Nutrition on the Health Outcomes of Critically Ill Adults: A Systematic Review

Suresh Kumar Sharma, Ritu Rani, Kalpana Thakur

All India Institute of Medical Sciences – Rishikesh, Rishikesh, India

DOI: 10.2478/jccm-2021-0011

Objectives: This systematic review aims to evaluate and summarise the findings of all relevant studies which identified the effect of early vs delayed parenteral nutrition (PN), early PN vs early supplemental PN and early PN vs standard care for critically ill adults.
Methods: The literature search was undertaken using PubMed, Embase, Medline, Clinical Key, and Ovid discovery databases. The reference lists of studies published from 2000 till June 2020 were hand searched.
Result: On screening 2088 articles, a total of five RCTs with 6,277 patients were included in this review. Only one clinical trial compared early PN and late PN; the results reported significantly shorter periods in intensive care unit (ICU) stay (p=0.02) and less ICU related infections (p=0.008) in the late PN group compared to the Early PN group. Two trials compared total parenteral nutrition (TPN) and enteral nutrition (EN) +TPN groups. Both found a significantly longer hospital stay duration (p<0.05 and p<0.01) with a higher mortality rate in the TPN group compared to the EN+TPN group. A statistically significant improvement was observed in patients’ quality of life receiving early PN compared to standard care (p=0.01). In contrast, no significant difference was found in the supplemental PN vs the standard care group.
Conclusion: The supplemental PN patients had shorter ICU stay and lower mortality rates than TPN. However, these findings should be interpreted carefully as included studies have different initiation timing of nutritional support, and the patients’ diagnosis varied.
Systematic review registration: PROSPERO: CRD42020183175

Keywords: ,
Full text: PDF

Contrast Medium-Induced Encephalopathy after Coronary Angiography – Case Report

Sebastian Andone1, Rodica Balasa2, Laura Barcutean1, Zoltan Bajko2, Valentin Ion3, Anca Motataianu2, Adina Stoian4, Smaranda Maier2

1 Doctoral School, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Department of Neurology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Department of Analytical Chemistry and Drug Analysis, Faculty of Pharmacy, 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

DOI: 10.2478/jccm-2021-0010

Introduction: Contrast-induced encephalopathy represents a rare, reversible complication that appears after intravenous or intra-arterial exposure to contrast agents. There is no consensus in the literature regarding the mechanism of action. However, the theoretical mechanism is set around the disruption of the blood-brain barrier and the contrast agents’ chemical properties.
Case report: The case of a 70-year-old patient, known to have hypertension and type 2 diabetes mellitus is reported. The patient had undergone a diagnostic coronary angiography during which he received 100ml of Ioversol (Optiray 350™). Soon after the procedure, the patient began experiencing a throbbing headache, followed by intense behavioural changes and aggressive tendencies. He was transferred to the Neurology Clinic. The neurological examination was without focal neurological signs; however, the patient was very aggressive and uncooperative. The CT scan revealed a mild hyper-density in the frontal lobes. MRI scan revealed no pathological changes. Conservative treatment with diuretics and hydration was administered, and the patient experienced a complete resolution of symptoms in 72 hours.
Conclusion: Contrast-induced encephalopathy is a possible secondary complication to contrast agents and a diagnostic challenge, and it should not be overlooked, especially following procedures that use contrast agents.

Keywords:
Full text: PDF

The Removal of a Fractured Guidewire During Mechanical Thrombectomy. A Case Report

Rares Cristian Filep1, Andrei Florin Bloj2, Lucian Marginean3

1 PhD School of Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Emergency Clinical County Hospital Targu Mures, Romania
3 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2021-0009

Recent randomized controlled trials have transformed the treatment of acute ischemic stroke. Mechanical or aspiration thrombectomy is the main treatment option for occlusions of large intracranial vessels. Despite its high technical success rate, endovascular thrombectomy can sometimes be complicated by anatomical peculiarities or device failures. The most frequent complications are related to vessel dissection or vessel perforation by devices while navigating intricate anatomy. Rarer still are technical device failures, like spontaneous stent-retriever detachment, which occurred with older generation retrievers. This case reports a rare device failure, which, to the best of our knowledge, has not been reported in the literature so far, namely a microwire fracture in the middle cerebral artery. This was successfully removed with an Eric stent-retriever. The potential causes and possible management strategies are discussed.

Keywords: , ,
Full text: PDF

Renal Recovery in Critically Ill Adult Patients Treated With Veno-Venous or Veno-Arterial Extra Corporeal Membrane Oxygenation: A Retrospective Cohort Analysis

Braghadheeswar Thyagarajan1, Mariana Murea2, Deanna N. Jones2, Amit K. Saha3, Gregory B. Russell4, Ashish K. Khanna1,5

1 Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
2 Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
3 Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
4 Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
5 Outcomes Research Consortium, Cleveland, OH, USA

DOI: 10.2478/jccm-2021-0006

Introduction: Patients on extracorporeal membrane oxygenator (ECMO) therapy are critically ill and often develop acute kidney injury (AKI) during hospitalisation. Little is known about the association of exposure to and the effect of the type of ECMO and extent of renal recovery after AKI development. Aim of the study: In patients who developed AKI, renal recovery was characterised as complete, partial or dialysis-dependent at the time of hospital discharge in both the Veno-Arterial (VA) and Veno-Venous (VV) ECMO treatment groups.
Material and methods: The study consisted of a single-centre retrospective cohort that includes all adult patients (n=125) who received ECMO treatment at a tertiary academic medical centre between 2015 to 2019. Data on demographics, type of ECMO circuit, comorbidities, exposure to nephrotoxic factors and receipt of renal replacement therapy (RRT) were collected as a part of the analysis. Acute Kidney Injury Network (AKIN) criteria were used for the diagnosis and classification of AKI. Group differences were assessed using Fisher’s exact tests for categorical data and independent t-tests for continuous outcomes.
Results: Sixty-four patients received VA ECMO, and 58 received VV ECMO. AKI developed in 58(91%) in the VA ECMO group and 51 (88%) in the VV ECMO group (p=0.77). RRT was prescribed in significantly higher numbers in the VV group 38 (75%) compared to the VA group 27 (47%) (p=0.0035). At the time of discharge, AKI recovery rate in the VA group consisted of 15 (26%) complete recovery and 5 (9%) partial recovery; 1 (2%) remained dialysis-dependent. In the VV group, 22 (43%) had complete recovery (p=0.07), 3(6%) had partial recovery (p=0.72), and 1 (2%) was dialysis-dependent (p>0.99). In-hospital mortality was 64% in the VA group and 49% in the VV group (p=0.13).
Conclusions: Renal outcomes in critically ill patients who develop AKI are not associated with the type of ECMO used. This serves as preliminary data for future studies in the area.

Keywords: , , , ,
Full text: PDF

Perioperative Management of Pulmonary Hypertension. A Review

Christopher Wood1, Mindaugas Balciunas1, Jim Lordan2, Adrian Mellor1

1 James Cook University Hospital, Middlesbrough, UK
2 Newcastle Upon Tyne Hospitals NHS Foundation Trust

DOI: 10.2478/jccm-2021-0007

Pulmonary hypertension is a rare and progressive pathology defined by abnormally high pulmonary artery pressure mediated by a diverse range of aetiologies. It affects up to twenty-six individuals per one million patients currently living in the United Kingdom (UK), with a median life expectancy of 2.8 years in idiopathic pulmonary hypertension. The diagnosis of pulmonary hypertension is often delayed due to the presentation of non-specific symptoms, leading to a delay in referral to specialists services. The complexity of treatment necessitates a multidisciplinary approach, underpinned by a diverse disease aetiology from managing the underlying disease process to novel specialist treatments. This has led to the formation of dedicated specialist treatment centres within centralised UK cities. The article aimed to provide a concise overview of pulmonary hypertension’s clinical perioperative management, including key definitions, epidemiology, pathophysiology, and risk stratification.

Keywords: , , ,
Full text: PDF

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.

Keywords: , ,
Full text: PDF

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.

Keywords:
Full text: PDF

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.

Keywords: , , , ,
Full text: PDF

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]

Keywords: , ,
Full text: PDF