Author Archives: administrare

The Use of Extracorporeal Life Support in a Patient Suffering from Venlafaxine Intoxication. A Case Report

Christoph Marquetand1, Harald F. Langer1, Jan Philipp Klein2, Tobias Graf1

1 Department of Cardiology, Angiology and Intensive Care, Medicine Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany
2 Lübeck University, Department of Psychiatry and Psychotherapy, Lübeck, Germany

DOI: 10.2478/jccm-2020-0014

Very few reports exist on serious cardiac complications associated with intake of serotonin-noradrenaline reuptake inhibitors. This paper describes and discusses the case of a patient who ingested a dose of 17.5 g venlafaxine. She developed a full serotonergic syndrome leading to multi-organ failure, including refractory cardiovascular shock, which was managed by early implantation of an extracorporeal life support (ECLS) system as a bridging strategy. This intervention was successful and resulted in full recovery of the patient.

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Associate Professor Silviu-Cosmin Moldovan (1975 – 2020)

Leonard Azamfirei

“George Emil Palade” University of Medicine, Pharmacy, Science and Technology of Târgu Mureș

“George Emil Palade” University of Medicine, Pharmacy, Science and Technology of Târgu Mureş has been deeply affected by the untimely death of Associate Professor Silviu-Cosmin Moldovan, Vice-Dean of the Faculty of Medicine in English.
Associate Professor Silviu-Cosmin Moldovan (PhD) was born on August 9 1975, in Târgu-Mureș, and graduated from the Faculty of Medicine, University of Medicine and Pharmacy of Târgu-Mureș, in 1999.
After graduation, in 2000, he started to work as an intern, and in 2004 he began his residency in pathological anatomy at the Emergency County Hospital of Târgu-Mureș and continued his professional activity as medical specialist and then as senior physician in pathological anatomy at the Emergency County Hospital of Târgu-Mureș. [More]

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Anaesthesia for Liver Transplantation: An Update

Lavinia Nicoleta Brezeanu1, Radu Constantin Brezeanu2, Mircea Diculescu1,3, Gabriela Droc1,3

1 Fundeni Clinical Institute, Bucharest, Romania
2 “Bagdasar-Arseni” Emergency Hospital, Bucharest, Romania
3 “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

DOI: 10.2478/jccm-2020-0011

Liver transplantation (LT) is a challenging surgery performed on patients with complex physiology profiles, complicated by multi-system dysfunction. It represents the treatment of choice for end-stage liver disease. The procedure is performed under general anaesthesia, and a successful procedure requires an excellent understanding of the pathophysiology of liver failure and its implications. Despite advances in knowledge and technical skills and innovations in immunosuppression, the anaesthetic management for LT can be complicated and represent a real challenge. Monitoring devices offer crucial information for the successful management of patients. Hemodynamic instability is typical during surgery, requiring sophisticated invasive monitoring. Arterial pulse contour analysis and thermo-dilution techniques (PiCCO), rotational thromboelastometry (RO-TEM), transcranial doppler (TCD), trans-oesophageal echocardiography (TEE) and bispectral index (BIS) have been proven to be reliable monitoring techniques playing a significant role in decision making. Anaesthetic management is specific according to the three critical phases of surgery: pre-anhepatic, anhepatic and neo-hepatic phase. Surgical techniques such as total or partial clamping of the inferior vena cava (IVC), use of venovenous bypass (VVBP) or portocaval shunts have a significant impact on cardiovascular stability. Post reperfusion syndrome (PRS) is a significant event and can lead to arrhythmias and even cardiac arrest.

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Spontaneous Sublingual Haematoma in a 90-year Old Patient: A Complication of Direct Oral Anticoagulants

Johannes Daniël Cnossen, Jeannette Fenna Schoonderbeek, Maaike Muller

Ikazia Hospital Rotterdam, The Netherlands

DOI: 10.2478/jccm-2020-0010

Sublingual haematoma is a rare complication of anticoagulants and can be life-threatening. As the number of prescribed anticoagulants is increasing, the incidence of complications of these drugs will continue to increase. A report of a sublingual haematoma in an elderly patient with chronic atrial fibrillation treated with edoxban (Lixiana ©, Daiichi Sankyo Europe GmbH, München, Germany) is reported. A 90-year male presented at the emergency department with an obstructed upper airway due to a sublingual haematoma. The patient received tranexamic acid, prothrombin complex, and fresh frozen plasma. After fiberoptic nasal intubation, the patient was monitored in the intensive care unit. After four days, the patient was extubated, and after six days, the swelling resolved completely. Complications of anticoagulants are rare but can be life-threatening. Recognition of an endangered airway and reversing the effects of the anticoagulant are essential. Surgical evacuation of the haematoma could be considered but is not necessary.

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To Be or Not to Be… Sepsis? A Daily Challenge in ICU

Adrian Man1, Bianca Liana Grigorescu2

1 Department of Microbiology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, Romania
2 Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2020-0012

Nowadays, one of the most challenging medical issues is related to high morbidity and mortality in sepsis and septic shock. Despite the medical progress regarding early diagnosis and management, this complex pathology remains a life-threatening condition. During the last decades, many definitions and including criteria were developed both in sepsis and septic shock, principally as many early biomarkers became available. However, many issues still exist regarding this subject.
The clinical definitions of sepsis and systemic inflammatory response syndrome (SIRS) have been refined, but both conditions manifest with similar clinical features [1]. The Third International Consensus Definitions Task Force (Sepsis-3) defined sepsis as “a life-threatening organ dysfunction resulting from a dysregulated host response to infection”. Septic shock is “a subset of sepsis in which circulatory, cellular and metabolic alterations are associated with a higher mortality rate than sepsis alone” [2] morphology, cell biology, biochemistry, immunology, and circulation. These definitions are related to the pathophysiology of sepsis, which are the cornerstones of a better understanding of the underlying mechanisms and disorders that occur [3]. [More]

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Impact of Intravenous Fluids and Enteral Nutrition on the Severity of Gastrointestinal Dysfunction: A Systematic Review and Meta-analysis

Varsha M. Asrani1,2, Annabelle Brown3, Ian Bissett1,4, John A. Windsor1,4

1 Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
2 Department of Nutrition and Dietetics, Auckland City Hospital, Auckland, New Zealand
3 Discipline of Nutrition and Dietetics, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
4 Department of General Surgery, Auckland City Hospital, Auckland, New Zealand

DOI: 10.2478/jccm-2020-0009

Introduction: Gastrointestinal dysfunction (GDF) is one of the primary causes of morbidity and mortality in critically ill patients. Intensive care interventions, such as intravenous fluids and enteral feeding, can exacerbate GDF. There exists a paucity of high-quality literature on the interaction between these two modalities (intravenous fluids and enteral feeding) as a combined therapy on its impact on GDF.
Aim: To review the impact of intravenous fluids and enteral nutrition individually on determinants of gut function and implications in clinical practice.
Methods: Randomized controlled trials on intravenous fluids and enteral feeding on GDF were identified by a comprehensive database search of MEDLINE and EMBASE. Extraction of data was conducted for study characteristics, provision of fluids or feeding in both groups and quality of studies was assessed using the Cochrane criteria. A random-effects model was applied to estimate the impact of these interventions across the spectrum of GDF severity.
Results: Restricted/goal-directed intravenous fluid therapy is likely to reduce ‘mild’ GDF such as vomiting (p = 0.03) compared to a standard/ liberal intravenous fluid regime. Enterally-fed patients experience increased episodes of vomiting (p = <0.01) but are less likely to develop an anastomotic leak (p = 0.03) and peritonitis (p = 0.03) compared to parenterally fed patients. Vomiting (p = <0.01) and anastomotic leak (p = 0.04) were significantly lower in the early enteral feeding group.
Conclusions: There is less emphasis on the combined approach of intravenous fluid resuscitation and enteral feeding in critically ill patients. Conservative fluid resuscitation and aggressive enteral feeding are presumably key factors contributing to severe life-threatening GDF. Future trials should evaluate the impact of cross-interaction between conservative and aggressive modes of these two interventions on the severity of GDF.

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The 2019 Novel Coronavirus: A Crown Jewel of Pandemics?

Razvan Azamfirei

Johns Hopkins School of Medicine, Baltimore, MD, USA

DOI: 10.2478/jccm-2020-0013

Starting from the December 2019 identification of the 2019 novel coronavirus (2019-nCoV), an overwhelming sense of panic has enveloped public discourse. This is likely to be amplified by WHO recently declaring the novel coronavirus outbreak a public health emergency of international concern. It is the third significant occurrence of a zoonotic coronavirus crossing the species barrier to infect humans, and it likely will not be the last. Hope is not lost; and a measured approach, one that is cognizant of the seriousness of this public health crisis without giving into hysteria, is imperative. [More]

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Prognostic Value of Serum Lactate Levels in Critically Ill Patients in an Intensive Care Unit

Hedgar Berty Gutiérrez, Yenisey Arteaga Concepción, Jorge Soneira Pérez, Yanín Díaz Lara, Félix Mario Rivero López, Pedro Rosales Contreras

Miguel Enríquez hospital, La Habana, Cuba

DOI: 10.2478/jccm-2020-0005

Introduction: The patient in critical condition, regardless of the cause of admission, continues to be a challenge for health systems due to the high mortality that it reports. There is a need to identify some marker of early obtaining, easy to interpret and with high relevance in the prognosis of these patients.
Objective: To determine the prognostic value of serum lactate in an Intensive Care Unit (ICU).
Method: One hundred and forty-five patients admitted to an ICU were enrolled in the study. The Acute Physiology and Chronic Health Evaluation II (APACHE) prognosis score, Sequential Organ Failure Assessment, hemodynamic support need, mechanical ventilation, cause of admission, stay in ICU, analytical and physiological variables were determined. The probability of survival of patients who had elevated and normal serum lactate levels was calculated. The risk of dying was determined using the Cox regression model.
Results: Twenty-eight patients died (19%) in the ICU. The serum lactate value was higher in the group of patients with trauma, infections, APACHE II and high creatinine levels; as well as with decreased mean arterial blood pressure, need for hemodynamic support and mechanical ventilation. The survival capacity was higher in patients who had normal serum lactate. Serum lactate was the sole independent predictor of mortality (AHR 1.28 [1.07-1.53], p = 0.008).
Conclusions: Patient assessment through the determination of serum lactate levels provides useful information in the initial evaluation of the critical patient.

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