Author Archives: administrare

When a Stroke is not Just a Stroke: Escherichia coli Meningitis with Ventriculitis and Vasculitis: A Case Report

Barbara Ribeiro1, Peter Bishop1, Sima Jalili2

1 Intensive Care Unit, Colchester General Hospital, East Suffolk and North Essex NHS Foundation Trust, United Kingdom
2 Microbiology Department, Colchester General Hospital, East Suffolk and North Essex NHS Foundation Trust, United Kingdom

DOI: 10.2478/jccm-2020-0002

Introduction: Community-acquired Escherichia coli ventriculitis is considered a rare condition. Central nervous system (CNS) infection due to gram-negative bacilli is usually associated with previous neurosurgical interventions. The recent publication of cases of Escherichia coli meningitis and ventriculitis suggests its prevalence may be underestimated by the literature.
Case presentation: A case of community-acquired Escherichia coli CNS infection on a 58 year old patient presenting with altered consciousness but without neck stiffness, nor significant past medical history is reported. Imaging and lumbar puncture findings suggested a complex case of meningitis with associated ventriculitis and vasculitis. Escherichia coli was later identified in cultures. Subsequent multi-organ support in Intensive Care was required. The patient was treated with a prolonged course of intravenous antimicrobials guided by microbiology, resulting in some neurological recovery. The main challenges encountered in the management of the patient were the lack of clear recommendations on the duration of treatment and the potential development of multi-resistant organisms.
Conclusion: Bacterial central nervous system infections can have an atypical presentation, and an increasing number of cases of community-acquired ventriculitis have been reported. Early consideration should be given to use magnetic resonance imaging to help guide treatment. A long course of antibiotics is often required for these patients; however, the optimal duration for antimicrobial treatment is not well defined.

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Therapeutic Evaluation of Computed Tomography Findings for Efficacy of Prone Ventilation in Acute Respiratory Distress Syndrome Patients with Abdominal Surgery

Masayuki Akatsuka1,2, Hiroomi Tatsumi1, Naoya Yama3, Yoshiki Masuda1

1 Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan,
2 Department of Anaesthesiology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
3 Department of Diagnostic Radiology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan

DOI: 10.2478/jccm-2020-0003

Introduction: In Acute Respiratory Distress Syndrome (ARDS), the heterogeneity of lung lesions results in a mismatch between ventilation and perfusion, leading to the development of hypoxia. The study aimed to examine the association between computed tomographic (CT scan) lung findings in patients with ARDS after abdominal surgery and improved hypoxia and mortality after prone ventilation.
Material and Methods: A single site, retrospective observational study was performed at the Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan, between 1st January 2004 and 31st October 2018. Patients were allocated to one of two groups after CT scanning according to the presence of ground-glass opacity (GGO) or alveolar shadow with predominantly dorsal lung atelectasis (DLA) on lung CT scan images. Also, Patients were divided into a prone ventilation group and a supine ventilation group when the treatment for ARDS was started.
Results: We analyzed data for fifty-one patients with ARDS following abdominal surgery. CT scans confirmed GGO in five patients in the Group A and in nine patients in the Group B, and DLA in 17 patients in the Group A and nine patients in the Group B. Both GGO and DLA were present in two patients in the Group A and nine patients in the Group B. Prone ventilation significantly improved patients’ impaired ratio of arterial partial pressure of oxygen to fraction of inspired oxygen from 12 h after prone positioning compared with that in the supine position. Weaning from mechanical ventilation occurred significantly earlier in the Group A with DLA vs the Group B with DLA (P < 0.001). Twenty-eight-day mortality was significantly lower for the Group A with DLA vs the Group B with DLA (P = 0.035).
Conclusions: These results suggest that prone ventilation could be effective for treating patients with ARDS as showing the DLA.

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The Dynamical Assessment of Inflammatory Biomarkers in Predicting the Outcome of Septic Patients and the Response to Antimicrobial Therapy

Alina Orfanu1,2, Victoria Aramă1,2, Cristina Popescu1,2, Cătălin Tilişcan1,2, Adrian Streinu-Cercel1,2, Ştefan Sorin Aramă1,2

1 National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, Bucharest
2 University of Medicine and Pharmacy “Carol Davila”, Bucharest

DOI: 10.2478/jccm-2020-0004

Aims: To evaluate the kinetics of inflammatory biomarkers in septic patients in order to identify the most reliable predictor of unfavorable outcome.
Methods: A prospective analysis of septic patients was performed. Median levels of neutrophil/lymphocyte count ratio, fibrinogen, C-reactive protein and procalcitonin were dynamically assessed and comparatively analyzed.
Results: Seventy-seven patients were included. Descendent kinetic patterns were registered for all biomarkers, except C-reactive protein. At 24 hours, neutrophil/lymphocyte count ratio significantly decreased in 42.85% of cases, procalcitonin in 37.33%, C-reactive protein in 16.12% and fibrinogen in 1.58% of cases. At 72 hours, procalcitonin decreased to one-half in 70% of cases and neutrophil/lymphocyte count ratio in 67.53% of cases.
Conclusions: Neutrophil/lymphocyte count ratio and procalcitonin significantly decreased in the first 72 hours, while C-reactive protein increased in the first 24 hours. The proportions of patients with major decrease of baseline values were higher for neutrophil/lymphocyte count ratio and procalcitonin.

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Initial Fluid Resuscitation Following Adjusted Body Weight Dosing in Sepsis and Septic Shock

Oana Antal1,2, Elena Ștefănescu1,2, Monica Mleșnițe1,2, Andrei Mihai Bălan1, Natalia Hagău1,2

1 Department of Anaesthesia and Intensive Care, “Iuliu Hațieganu” University of Medicine and Pharmacy,
Cluj-Napoca, Romania
2 Department of Anaesthesia and Intensive Care, Emergency Clinical County Hospital, Cluj-Napoca, Romania

DOI: 10.2478/jccm-2019-0025

Introduction: Fluid administration is considered a fundamental part of early sepsis treatment. Despite abundant research, fundamental questions about the amount of fluids to be given remain unanswered. Recently, the idea of adjusting the fluid load to the ideal body weight emerged, as obesity rates are increasing, and fluid overload was proven to increase mortality.
Aim of the study: The study aimed to determine whether advanced haemodynamic monitoring supports the adjustment of the initial fluid load to the ideal body weight (IBW).
Methods: Seventy-one patients with sepsis and septic shock were enrolled in the study. The initial fluid resuscitation was performed using local protocols. The haemodynamic status was assessed after the initial fluid load by trans-pulmonary thermos-dilution technique and the renal outcome recorded at twenty-four hours.
Results: 68.6% of the patients included in the study had weight disorders ranging from BMI+20% to morbid obesity. Before IBW adjustment, only 49.3% received the 30 ml/kg fluid load recommended by Surviving Sepsis Campaign Guidelines (2016) (SSC). After IBW adjustment, 70.4% received the recommended fluid dose. The difference in fluid load/kg before and after the bodyweight adjustment was statistically significant (p<0.01). After the initial fluid load, the majority of the macro haemodynamic parameters were in the targeted range. There was no statistically significant difference between the urinary output outcome at 24 hours or the 28 days mortality rates between the patients resuscitated by the SSC and those who received less fluid.
Conclusions: Advanced haemodynamic monitoring was in favour of adjusting the initial fluid load to the IBW. There were no statistically significant differences either in the urinary output outcome at twenty-four hours, or in the twenty-eight-day mortality rates between the patients who received the 30 ml/kg IBW and those who received less than 30 ml/kg IBW.

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Hyperammonemic Encephalopathy and Lipid Dysmetabolism in a Critically Ill Patient after A Short Course of Amiodarone

Maximilien Cappe1, Philippe Hantson1, Mina Komuta2, Marie-Françoise Vincent3, Pierre-François Laterre1, Ismaïl Ould-Nana1

¹ Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, 1200 Brussels, Belgium
² Department of Pathology, Cliniques St-Luc, Université catholique de Louvain, 1200 Brussels, Belgium
³ Department of Clinical Chemistry, Cliniques St-Luc, Université catholique de Louvain, 1200 Brussels, Belgium

DOI: 10.2478/jccm-2019-0026

The case is reported of a 39-year-old severely obese woman who developed acute metabolic disorders after the administration of a short course of intravenous amiodarone. The main biological features were hypertriglyceridemia, hypoglycaemia, hyperlactatemia and hyperammonemia; all were reversible after amiodarone discontinuation. There was an associated rise in liver enzymes. However, the influence of co-factors on these metabolic disorders, such as acquired carnitine deficiency, severe obesity, a long-term course of pancreatitis, and abdominal infections, could not be excluded.

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Accidental Modopar© Poisoning in a Two-Year-Old Child. A Case Report

Adnane Lahlou, Saïd Benlamkaddem, Mohamed Adnane Berdai, Mustapha Harandou

Obstetric and Pediatric Intensive Care Unit, Hassan II Academic Hospital, Fez, Morocco

 

DOI: 10.2478/jccm-2019-0024

Levodopa is a dopamine precursor and a mainstay treatment in the management of Parkinson’s disease. Its side effects induce dyskinesia, nausea, vomiting, and orthostatic hypotension. Acute levodopa acute poisoning is uncommon, with only a few reported cases in the medical literature. Treatment of poisoning by levodopa is mainly supportive. The case of a child admitted to a hospital for acute levodopa poisoning is presented in this report.

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SIRS Triggered by Acute Right Ventricular Function, Mimicked Septic Shock

Yingke He1, John Ong2, Thuan Tong Tan3, Brian K. P. Goh4, Sharon G. K. Ong5

1 Division of Anaesthesiology, Singapore General Hospital, Singapore
2 Department of Engineering, Materials Engineering and Material-Tissue Interactions Group, University of Cambridge, United Kingdom
3 Department of Infectious Diseases, Singapore General Hospital, Singapore
4 Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
5 Department of Surgical Intensive Care, Singapore General Hospital, Singapore

DOI: 10.2478/jccm-2019-0022

Background: The systemic inflammatory response syndrome (SIRS) is a complex immune response which can be precipitated by non-infectious aetiologies such as trauma, burns or pancreatitis. Addressing the underlying cause is crucial because it can be associated with increased mortality. Although the current literature associates chronic heart failure with SIRS, acute right ventricular dysfunction has not previously been reported to trigger SIRS. This case report describes the presentation of acute right ventricular dysfunction that triggered SIRS and mimicked septic shock.
Case presentation: A 70-year-old male presented to the Intensive Care Unit (ICU) with elevated inflammatory markers and refractory hypotension after a robotic-assisted laparoscopic radical choledochectomy with pancreaticoduodenectomy. Septic shock was misdiagnosed, and he was later found to have a pulmonary embolus. Thrombectomy and antimicrobials had no significant effect on lowering the elevated inflammatory markers or improving the persistent hypotension. Through Point of Care Ultrasound (POCUS), right ventricular dysfunction was diagnosed. Treatment with intravenous milrinone improved blood pressure, normalised inflammatory markers and led to a prompt discharge from the ICU.
Conclusion: Acute right ventricular dysfunction can trigger SIRS, which may mimic septic shock and delay appropriate treatment.

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Transient Diabetes Insipidus Following Organophosphorus Poisoning

Niraj Kumar Keyal, Amid Bhujel

Department of Critical Care Medicine, B & C Medical College and Teaching Hospital and Research Center, Birtamode, Nepal

DOI: 10.2478/jccm-2019-0023

Introduction: Organophosphorus poisoning is the most common poison used for suicidal attempt in Nepal. Diabetes insipidus is unusual and rare in this poisoning. This is the second case report of Diabetes insipidus developing in organophosphorus poisoning. Management of diabetes insipidus includes desmopressin and adequate fluid management.
Case presentation: A 34-year-old female patient accompanied by her father presented at the Emergency department with an alleged history of ingestion of unknown amount of chlorpyrifos, cypermethrin and quinalphos. On admission, she had a Glasgow Coma Scale (GCS) of 7/15. Her blood pressure was 110/60 mm Hg, pulse 54/min, respiratory rate 45/min and saturation 35% on room air, pinpoint pupil reactive to light and bilateral crepitations. She was immediately resuscitated with two litres of normal saline and intubated with a 7 mm endotracheal tube. Atropinisation was done, and pralidoxime was started. She developed a urine output of 250-350 ml per hour with rising sodium and serum osmolality. The urine examination showed low sodium and urine specific gravity. A diagnosis of diabetes insipidus was made. There was no immediate improvement in her GCS. She was managed with 5% dextrose and subcutaneous desmopressin and was transferred out of the intensive care unit on the sixth day and was discharged from hospital on the fifteenth day.
Conclusion: Diabetes insipidus is a rare transient complication in organophosphorus poisoning that requires careful observation and early management with desmopressin and adequate fluid balance to improve patient outcome.

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Fatal Hypocalcaemia Due to Hungry Bone Syndrome with Secondary Refractory HyperParathyroidism after Parathyroidectomy: A Case Report

Corina Pop Radu1,2, Valentin Daniealopol3, Ario Santini2,4, Ruxandra Darie3, Daniela Tatiana Sala2, 3

1 Endocrinology Department, Mures County Emergency Hospital, Targu Mures, Romania
2 University of Medicine, Pharmacy, Science and Technology of Targu Mures, Romania
3 2nd Surgery Department, Mures County Emergency Hospital, Targu Mures, Romania
4 Hon Fellow, University of Edinburgh, United Kingdom

DOI: 10.2478/jccm-2019-0021

Introduction: Hungry bone syndrome (HBS) refers to the rapid, profound, and prolonged hypocalcaemia associated with hypophosphatemia and hypomagnesaemia, and is exacerbated by suppressed parathyroid hormone (PTH) levels, which follows parathyroidectomy in patients with severe primary hyperparathyroidism (PHPT) and preoperative high bone turnover. [1]
Case report: This report concerns a dialysed patient who underwent surgical treatment for secondary refractory hyperparathyroidism. Haemodialysis was carried out pre-operatively, and subsequently, a total parathyroidectomy with auto-transplantation of parathyroid tissue in the sternocleidomastoid muscle (SCM) was performed. Rapid and progressive hypocalcaemia symptoms developed during the second day postoperatively. Acute cardiac symptoms with tachyarrhythmia, haemodynamic instability and finally asystole occurred, which required cardiopulmonary resuscitation (CPR). The ionic calcium level was 2.2 mg/dL being consistent with a diagnosis of HBS. A second cardiac arrest unresponsive to CPR followed an initial period of normal sinus rhythm. Death ensued shortly after. Before death, the ionic calcium was 3.1 mg/dL.
Conclusion: HBS, after parathyroidectomy in patients with secondary hyperparathyroidism (SHPT), may be severe, prolonged and sometimes fatal. Generally, HBS symptomatology is that of a mild hypocalcaemia. It can, however, include heart rhythm disturbances with haemodynamic alterations requiring intensive care measurements and even cardiopulmonary resuscitation. A close clinical and laboratory post-parathyroidectomy monitoring of dialysed patients is of the utmost importance.

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The Use of High Dose Eltrombopag in the Management of Sepsis-Associated Thrombocytopenia in Critically Ill Patients

Md. Jahidul Hasan1, Raihan Rabbani2, Shihan Mahmud Redwanul Huq2

1 Department of Clinical Pharmacy, Square Hospitals Ltd., Dhaka, Bangladesh
2 Internal Medicine and ICU, Square Hospitals Ltd., Dhaka, Bangladesh

DOI: 10.2478/jccm-2019-0019

Introduction: Sepsis is a life-threatening condition, and sepsis-associated thrombocytopenia (SAT) is a common consequence of the disease where platelet count falls drastically within a very short time. Multiple key factors may cause platelet over-activation, destruction and reduction in platelet production during the sepsis. Eltrombopag is a thrombopoietin receptor agonist and is the second-line drug of choice in the treatment of chronic immune thrombocytopenia (ITP).
Aim of the study: The objective of this study was to observe the therapeutic outcome of high dose eltrombopag in SAT management in critically ill patients.
Material and Methods: This 6-month-long single group, observational study was conducted on seventeen ICU patients with SAT. Eltrombopag 100 mg/day in two divided doses was given to each patient. Platelet counts were monitored. A low platelet blood count returning to 150 K/μL or above, is taken as indicative of a successful reversal of a thrombocytopenia event.
Results: The mean Apache II score of patients (n= 17) was 18.71 (p-value: >0.05). No eltrombopag-induced adverse event was observed among the patients during the study period. Thrombocytopenia events were reversed successfully in 64.71% of patients (11; n= 17) within eight days of eltrombopag therapy.
Conclusions: The therapeutic potentiality of high dose eltrombopag regime in the management of sepsis-associated thrombocytopenia was found clinically significant in over two-thirds of critically ill adult patients enrolled in the study. These data may point to a new strategy in the management of acute type of thrombocytopenia in septic patients.

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