Author Archives: administrare

Anticoagulation in COVID – 19: An Update

Nishant R Tiwari1, Khalid I Khatib2, Subhal B Dixit3, Prajay K Rathore4, Sameer Melinkeri5, Abhijeet Ganapule6, Kapil S Borawake7, Ujwala Mhatre8

1 Byramjee Jeejeebhoy Medical College and Sassoon General Hospital, Pune, Maharashtra, India
2 Smt Kashibai Navale Medical College and General Hospital, Pune, India
3 Sanjeevan Hospital, Pune, India
4 Danbury Hospital, Danbury, USA
5 Deenanath Mangeshkar Hospital and Research Centre, Pune, India
6 Niche Hematology Care, Kolhapur, India
7 Prayag Hospital, Pune, India
8 Nanavati Hospital, Mumbai, India

DOI: 10.2478/jccm-2020-0033

The novel coronavirus disease, 2019 (COVID – 19) evolved as an unprecedented pandemic. The severe acute respiratory syndrome-corona virus-2 (SARS-CoV-2) infection has been associated with significantly deranged coagulation parameters and increased incidence of thrombotic events. Deranged coagulation parameters, such as D-dimers and fibrin degradation products, can indicate a poor prognosis, and their measurement will help stratify the patients according to the disease severity, need of intensive care unit admission, and prediction of the clinical course. Gaps in understanding the natural history of the disease cause difficulties in tailoring therapies and optimizing the management of patients. Lack of specific treatment further complicates this situation. While thrombotic events can cause significant morbidity and mortality in patients, a focused approach to the prevention and treatment of venous thromboembolism (VTE) can, to a great extent, decrease the disease burden caused by thrombotic diseases. Pharmacological prophylactic anticoagulants and mechanical therapies such as pneumatic compression devices can help prevent venous thromboembolism and other thrombotic events. Thrombotic events due to COVID-19, their prevention and management, are the focus of this paper, with the prospect of providing insights into this relatively unexplored area.

Keywords: , , , ,
Full text: PDF

Bilateral Ocular Exophthalmia – A Case of Atypical Acute Myeloblastic Leukemia in a Child

Réka Toth1, Alina Grama2, Cristina Maki3, Mihaela Ioana Chinceșan2

1 County Clinical Emergency Hospital Targu Mures, Romania
2 Department of Pediatrics I, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Ophthalmology Clinic, Mures County Clinical Hospital, Targu Mures, Romania

DOI: 10.2478/jccm-2020-0031

Introduction: In acute myeloblastic leukaemia (AML) explosive proliferation and accumulation of immature myeloid cell clones take place, replacing the bone marrow, with the possibility of the formation of extramedullary tumour masses composed of myeloid cells. The onset of the disease less frequently consists of symptoms of extramedullary manifestation.
Case presentation: A Caucasian male child aged three years and 11 months was hospitalized for bilateral exophthalmos and otorrhea, due to an alteration in his general condition. Ocular ultrasound revealed an inhomogeneous thickening of the upper right muscles superior to the eyeball. A complete blood count showed severe anaemia, leucocytosis with neutropenia and thrombocytopenia. A peripheral blood smear evidenced myeloblasts. The result of the cytology of bone marrow confirmed the diagnosis of AML. Following blood product replacements and cytostatic treatment (AML-BFM 2004 HR protocol), the remission of exophthalmos and the correction of haematological parameters were favourable.
Conclusion: In a child with a sudden onset of exophthalmia and altered general condition, the diagnosis of acute leukaemia should be considered. The importance of performing a peripheral blood smear and bone marrow examination is emphasized so that diagnosis and initiation of treatment are not delayed.

Keywords: , , ,
Full text: PDF

Feasibility and Safety of Peripheral Intravenous Administration of Vasopressor Agents in Resource-limited Settings

Ajay Padmanaban1, Ramesh Venkataraman1, Senthilkumar Rajagopal1, Dedeepiya Devaprasad2, Nagarajan Ramakrishnan1

1 Apollo Hospitals Chennai, Chennai, India
2 Apollo Cancer Hospitals, Chennai, India

DOI: 10.2478/jccm-2020-0030

Background: Vasopressors are conventionally administered through a central venous catheter (CVC) and not through a peripheral venous catheter (PVC) since the latter is believed to be associated with increased risk of extravasation. Placement of a CVC requires suitably trained personnel to be on hand, and in resource-limited settings, this requirement may delay placement. Because of this and in cases where suitably trained personnel are not immediately available, some clinicians may be prompted to utilise a PVC for infusing vasopressors. The objective of this study is to assess the feasibility and safety of vasopressors administered through a PVC.
Materials and methods: Patients who received vasopressors through a PVC for more than one hour were included in a single centre, consecutive patient observational study. Patients with a CVC at the time of initiation of vasopressors were excluded. Data regarding the size, location of PVCs, dose, duration and number of vasopressors infused were recorded. The decision to place CVC was left to the discretion of the treating physician. Extravasation incidents, severity and management of such events were recorded.
Results: One hundred twenty-two patients age 55(4) years [mean (SD)] were included in the study. The commonest PVC was of 18G calibre (57%), and the most common site of placement was the external jugular vein (36.5%). Noradrenaline was the most common vasopressor used at a dose of 10.6 (7) mcg/min [mean (SD)] and the median duration of nine hours (IQR: 6-14). CVC was placed most commonly due to an increasing dose of vasopressors after 4.5(4) hours [mean (SD)]. Grade 2 Extravasation injury occurred in one patient after prolonged infusion of fifty-two hours, through a small calibre (20G) PVC, which was managed conservatively without any sequelae.
Conclusion: Vasopressors infused through a PVC of 18G or larger calibre into the external jugular, or a forearm vein is feasible and safe. Clinicians need to balance the safety of peripheral vasopressor infusion with the additional costs and complications associated with CVC in resource-limited settings.

Keywords: , , ,
Full text: PDF

Role of Transesophageal Echocardiography in the Diagnosis of Multi-chamber Intracardiac Thrombosis During Liver Transplantation: A Case Series

Jocelyn Y. Wang, G. Burkhard Mackensen, Alexander Vitin, Kenneth Martay

University of Washington, Seattle, WA, USA

DOI: 10.2478/jccm-2020-0029

Intra-cardiac thrombosis is one of the most devastating complications during liver transplantation. In the majority of cases, ICT, followed by massive pulmonary embolism, is commonly occurring shortly after liver graft reperfusion, but it has been reported to occur at any stage of the surgery. We present a series of 3 cases of intra-cardiac thrombosis during orthotopic liver transplantation surgery, including a case of four-chamber intra-cardiac clot formation during the pre-anhepatic stage. This article represents a single-centre 14 year-long experience. Intra-operative TEE is the gold standard to diagnose intra-cardiac thrombosis, monitoring its size, location and dynamics, as well as myocardial performance and the effects of resuscitation efforts.

Keywords: , ,
Full text: PDF

A Comparison of Nosocomial Infection Density in Intensive Care Units on Relocating to a New Hospital

Zeynep Ture1, Tugba Ustuner2, Ario Santini3, Serhat Aydogan2, İlhami Celik2

1 Erciyes University Faculty of Medicine Kayseri, Turkey
2 City Hospital of Kayseri, Turkey
3 George Emil Palade University of Medicine, Pharmacy Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2020-0028

Background: The study aimed to investigate the changes in nosocomial infection density after patients were transferred to the intensive care unit (ICU) of a new-build hospital.
Methods: The types and rates of nosocomial infections were obtained for a one-year period retrospectively before leaving the old hospital premises and for a one-year periods after moving into the new hospital. The intensive care unit in the “old” premises was comprised of a 17-bedded hall, and thirty-three nurses shifted to work forty-eight hours a week, with each nurse assigned to provide care for two patients. The intensive care unit in the “new” premises consisted of single rooms, each with twenty-eight beds.
Results: The median nosocomial infection density decreased from 23 to 15 per 1000 in-patient days. The catheter-related urinary tract infection rate decreased from 7.5 to 2.6 per100 catheter days.
Conclusions: Treatment of patients in the new hospital resulted in a decrease in nosocomial infection density.

Keywords: , , ,
Full text: PDF

Mechanical Ventilation – A Friend in Need?

Bianca-Liana Grigorescu

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

DOI: 10.2478/jccm-2020-0027

The development of modern medicine has imposed a new approach both in anaesthesiology and in intensive care. This is the reason why, in the last decades, more and more devices and life-support techniques were improved in order to achieve the highest medical outcomes.
Key features of the critically ill patient are severe respiratory, cardiovascular or neurological derangements, often in combination, reflected in abnormal physiological observations. All these changes converge towards the establishment of pulmonary or extrapulmonary respiratory failure requiring mechanical ventilatory support. In the current conception, mechanical ventilation does not represent a curative method for respiratory pathology, however, it represents a bridge therapy ensuring the rest and preservation of respiratory muscles, improves gas exchange and assists in maintaining a normal pH until the recovery of the patient [1].
Despite decades of research, there are limited therapeutic options directed towards the underlying pathological processes and supportive care with mechanical ventilation remaining the cornerstone of patient management. [More]

Keywords:
Full text: PDF

Opioid Use Is Associated with ICU Delirium in Mechanically Ventilated Children

Neha Gupta1, Allison Woolley2, Saurabh Talathi1, Ganisher Davlyatov3, Candice Colston3, Leslie Hayes3

1 University of Oklahoma Health Sciences Center, Oklahoma City, USA
2 Children’s of Alabama, Birmingham, USA
3 University of Alabama at Birmingham, Birmingham, USA

DOI: 10.2478/jccm-2020-0026

Introduction: Pediatric delirium is a significant problem when encounterd in an intensive care unit (ICU). The pathophysiology of pediatric delirium is complex and the etiology is typically multifactorial. Even though various risk factors associated with pediatric delirium in a pediatric ICU have been identified, there is still a paucity of literature associated with the condition, especially in extremely critically ill children, sedated and mechanically ventilated. Aim of the study: To identify factors associated with delirium in mechanically ventilated children in an ICU.
Material and Methods: This is a single-center study conducted at a tertiary care pediatric ICU. Patients admitted to the pediatric ICU requiring sedation and mechanical ventilation for >48 hours were included. Cornell Assessment of Pediatric Delirium scale was used to screen patients with delirium. Baseline demographic and clinical factors as well as daily and cumulative doses of medications were compared between patients with and without delirium. Firth’s penalized maximum likelihood logistic regression was used on a priori set of variables to examine the association of potential factors with delirium. Two regression models were created to assess the effect of daily medication doses (Model 1) as well as cumulative medication doses (Model 2) of opioids and benzodiazepines.
Results: 95 patient visits met the inclusion criteria. 19 patients (20%) were diagnosed with delirium. Older patients (>12 years) had higher odds of developing delirium. Every 1mg/kg/day increase in daily doses of opioids was associated with an increased risk of delirium (OR=1.977, p=0.017). Likewise, 1 mg/kg increase in the cumulative opioid dose was associated with a higher odds of developing delirium (OR=1.035, p=0.022). Duration of mechanical ventilation was associated with the development of delirium in Model 1 (p=0.007).
Conclusions: Age, daily and cumulative opioid dosage and the duration of mechanical ventilation are associated with the development of delirium in mechanically ventilated children.

Keywords: , ,
Full text: PDF

Neuroleptic Malignant Syndrome or Catatonia? A Case Report

Sebastian Rodriguez1, Keith A. Dufendach2, Robert M. Weinreib3

1 University of California San Francisco, San Francisco, USA
2 University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, USA
3 University of Pennsylvania Health System, Perelman School of Medicine, University of Pennsylvania, USA

DOI: 10.2478/jccm-2020-0025

Introduction: A review of the literature has shown that there are many similarities in the presentation of neuroleptic malignant syndrome (NMS) and catatonia. Attempts to reconcile the differences have been made by suggesting that NMS and catatonia may represent different presentations of the same illness or that they lie within the same spectrum of a poorly understood clinical syndrome. The described case is of a patient who presented with NMS and catatonia which was difficult to diagnose, but which responded to treatment with intravenous diazepam.
Case presentation: The case concerns a 22-year-old male admitted for pulmonary hypertension to an intensive care unit (ICU). Three days following admission, he developed a high fever that did not respond to antibiotics. The patient then developed rigidity, nocturnal agitation, decreased responsiveness, and somnolence. Without the use of bromocriptine (Novartis, Basel, Switzerland) or dantrolene (Par Pharmaceuticals, Chestnut Ridge, USA) discontinuation of neuroleptics combined with intravenous diazepam (Pfizer, NY, USA) led to a very rapid response and marked improvement in the case.
Conclusions: Early recognition and management of NMS and MC in a complex, gravely ill patient, may be accomplished in the ICU despite obfuscation of traditional signs and symptoms of the NMS and MC syndrome. Such interventions can have life-saving effects on patients in danger of fatal autonomic instability.

Keywords: , , ,
Full text: PDF