Author Archives: administrare

Combining O2 High Flow Nasal or Non-Invasive Ventilation with Cooperative Sedation to Avoid Intubation in Early Diffuse Severe Respiratory Distress Syndrome, Especially in Immunocompromised or COVID Patients?

Fabrice Petitjeans1, Dan Longrois2, Marco Ghignone3, Luc Quintin1

1 Department of Anesthesia-Critical Care, Hôpital d’Instruction des Armées Desgenettes, Lyon, France
2 Bichat-Claude Bernard and Louis Mourier Hospitals, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Paris, France
3 Department of Anesthesia-Critical Care, JF Kennedy North Hospital, W Palm Beach, Fl, USA

DOI: 10.2478/jccm-2024-0035

This overview addresses the pathophysiology of the acute respiratory distress syndrome (ARDS; conventional vs. COVID), the use of oxygen high flow (HFN) vs. noninvasive ventilation (NIV; conventional vs. helmet) and a multimodal approach to avoid endotracheal intubation (“intubation”): low normal temperature, cooperative sedation, normalized systemic and microcirculation, anti-inflammation, reduced lung water, upright position, lowered intra-abdominal pressure.
Increased ventilatory muscle activity (“respiratory drive”) is observed in early ARDS, at variance with ventilatory fatigue observed in decompensated chronic obstructive pulmonary disease (COPD). This increased drive leads to impending then overt ventilatory failure. Therefore, muscle relaxation presents little rationale and should be replaced by lowering the excessive respiratory drive, increased work of breathing, continued or increased labored breathing, self-induced lung injury (SILI), i.e. preserving spontaneous breathing. As CMV is a lifesaver in the setting of failure but does not heal the lung, side-effects of intubation, controlled mechanical ventilation (CMV), paralysis and deep sedation are to be avoided. Additionally, critical care resources shortage requires practice changes.
Therefore, NIV should be routine when addressing immune-compromised patients. The SARS-CoV2 pandemics extended this approach to most patients, which are immune-compromised: elderly, obese, diabetic, etc. The early COVID is a pulmonary vascular endothelial inflammatory disease requiring lower positive-end-expiratory pressure than the typical pulmonary alveolar epithelial inflammatory diffuse ARDS. This leads one to reassess a) the technique of NIV b) the sedation regimen facilitating continuous and extended NIV to avoid intubation. Autonomic, circulatory, respiratory, ventilatory physiology is hierarchized under HFN/NIV and cooperative sedation (dexmedetomidine, clonidine). A prospective randomized pilot trial, then a larger trial are required to ascertain our working hypotheses.

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Endocrine Disorders in Critically Ill Patients – The Smooth Criminal?

Bianca-Liana Grigorescu, Raluca Ștefania Fodor

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

DOI: 10.2478/jccm-2024-0034

The hallmark of critical illness is the rapid initiation of numerous physiologic processes in an effort to reestablish homeostasis. Thus, critical illness can be considered the result of an acute physical stress that acts as a trigger for an acute aggressive inflammatory response [1,2].
The inflammatory response occurs early after primary injury, almost concomitant with coagulation cascade activation, micro- and macrovascular alterations, and hypothalamic-pituitary-peripheral axis disorders, proportionate to the severity of illness. In this context, “The Triad of Critically Illness” is a lethal interplay involving three key factors: inflammation, coagulopathy and hormonal imbalance. [More]

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Acute Calculous Cholecystitis Associated with Leptospirosis: Which is the Emergency? A Case Report and Literature Review

Renata Moriczi, Mircea Gabriel Muresan, Radu Neagoe, Daniela Sala, Arpad Torok, Tivadar jr. Bara, Ioan Alexandru Balmos, Razvan Ion, Anca Meda Vasiesiu

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

DOI: 10.2478/jccm-2024-0033

Introduction: Leptospirosis is a bacterium with a worldwide distribution and belongs to the group of zoonoses that can affect both humans and animals. Most cases of leptospirosis present as a mild, anicteric infection. However, a small percentage of cases develop Weil’s disease, characterized by bleeding and elevated levels of bilirubin and liver enzymes. It can also cause inflammation of the gallbladder. Acute acalculous cholecystitis has been described as a manifestation of leptospirosis in a small percentage of cases; however, no association between leptospirosis and acute acalculous cholecystitis has been found in the literature.
Case presentation: In this report, we describe the case of a 66-year-old patient who presented to the emergency department with a clinical picture dominated by fever, an altered general condition, abdominal pain in the right hypochondrium, nausea, and repeated vomiting. Acute calculous cholecystitis was diagnosed based on clinical, laboratory, and imaging findings. During preoperative preparation, the patient exhibited signs of liver and renal failure with severe coagulation disorders. Obstructive jaundice was excluded after performing an abdominal ultrasound and computed tomography scan. The suspicion of leptospirosis was then raised, and appropriate treatment for the infection was initiated. The acute cholecystitis symptoms went into remission, and the patient had a favorable outcome. Surgery was postponed until the infection was treated entirely, and a re-evaluation of the patient’s condition was conducted six-week later.
Conclusions: The icterohemorrhagic form of leptospirosis, Weil’s disease, can mimic acute cholecystitis, including the form with gallstones. Therefore, to ensure an accurate diagnosis, leptospirosis should be suspected if the patient has risk factors. However, the order of treatments is not strictly established and will depend on the clinical picture and the patient’s prognosis.

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Understanding the Correlation between Blood Profile and the Duration of Hospitalization in Pediatric Bronchopneumonia Patients: A Cross-Sectional Original Article

Dessika Listiarini1, Dev Desai2, Yanuar Wahyu Hidayat1, Kevin Alvaro Handoko3

1 Dr. Soeselo General Hospital, Slawi, Central Java, Indonesia
2 Smt. NHL Municipal Medical College, Ahmedabad, Gujarat, India
3 Bhakti Rahayu Tabanan Hospital, Tabanan, Bali, Indonesia

DOI: 10.2478/jccm-2024-0031

Introduction: Pediatric bronchopneumonia is a prevalent life-threatening disease, particularly in developing countries. Affordable and accessible blood biomarkers are needed to predict disease severity which can be based on the Duration of Hospitalization (DOH).
Aim of the Study: To assess the significance and correlation between differential blood profiles, especially the Neutrophil-Lymphocyte Ratio (NLR), and the DOH in bronchopneumonia children.
Material and Methods: A record-based study was conducted at a secondary care hospital in Indonesia. After due ethical permission, following inclusion and exclusion criteria, 284 children with confirmed diagnoses of bronchopneumonia were included in the study. Blood cell counts and ratios were assessed with the DOH as the main criterion of severity. Mann-Whitney test and correlation coefficient were used to draw an analysis.
Results: Study samples were grouped into DOH of ≤ 4 days and > 4 days, focusing on NLR values, neutrophils, lymphocytes, and leukocytes. The NLR median was higher (3.98) in patients hospitalized over 4 days (P<0.0001). Lymphocyte medians were significantly higher in the opposite group (P<0.0001). Thrombocyte medians were similar in both groups (P=0.44481). The overall NLR and DOH were weakly positively correlated, with a moderate positive correlation in total neutrophils and DOH, and a moderate negative correlation in total lymphocytes and DOH. The correlation between the DOH ≤ 4 days group with each biomarker was stronger, except for leukocyte and thrombocyte. Analysis of the longer DOH group did not yield enough correlation across all blood counts.
Conclusions: Admission levels of leukocyte count, neutrophil, lymphocyte, and NLR significantly correlate with the DOH, with NLR predicting severity and positively correlated with the DOH.

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Rate of Sodium Correction and Osmotic Demyelination Syndrome in Severe Hyponatremia: A Meta-Analysis

Xin Ya See1, Yu-Cheng Chang2, Chun-Yu Peng2, Shih-Syuan Wang3, Kuan-Yu Chi4, Cho-Hung Chiang5, Cho-Han Chiang6

1 Unity Hospital, Rochester Regional Health, Rochester, NY, USA
2 Danbury Hospital, Danbury, CT, USA
3 SUNY Downstate Medical Center, Brooklyn, NY, USA
4 Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
5 National Taiwan University Hospital, Taipei, Taiwan
6 Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, USA

DOI: 10.2478/jccm-2024-0030

Introduction: Current guidelines recommend limiting the rate of correction in patients with severe hyponatremia to avoid severe neurologic complications such as osmotic demyelination syndrome (ODS). However, published data have been conflicting. We aimed to evaluate the association between rapid sodium correction and ODS in patients with severe hyponatremia.
Materials and methods: We searched PubMed, Embase, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials from inception to November 2023. The primary outcome was ODS and the secondary outcomes were in-hospital mortality and length of hospital stay.
Results: We identified 7 cohort studies involving 6,032 adult patients with severe hyponatremia. Twenty-nine patients developed ODS, resulting in an incidence rate of 0.48%. Seventeen patients (61%) had a rapid correction of serum sodium in the first or any 24-hour period of admission. Compared with a limited rate of sodium correction, a rapid rate of sodium correction was associated with an increased risk of ODS (RR, 3.91 [95% CI, 1.17 to 13.04]; I2 = 44.47%; p = 0.03). However, a rapid rate of sodium correction reduced the risk of in-hospital mortality by approximately 50% (RR, 0.51 [95% CI, 0.39 to 0.66]; I2 = 0.11%; p < 0.001) and the length of stay by 1.3 days (Mean difference, -1.32 [95% CI, -2.54 to -0.10]; I2 = 71.47%; p = 0.03).
Conclusions: Rapid correction of serum sodium may increase the risk of ODS among patients hospitalized with severe hyponatremia. However, ODS may occur in patients regardless of the rate of serum sodium correction.

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Intensive Care Fundamentals in Romania. A Critical Step in Romanian Intensive Care Education

Cosmin Balan1,2, Serban-Ion Bubenek-Turconi1,2, Mo Al-Haddad3

1 Institutul de Urgenta pentru Boli Cardiovasculare Prof Dr C C Iliescu, Bucharest, Romania
2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
3 Queen Elizabeth University Hospital, University of Glasgow, Glasgow, UK

DOI: 10.2478/jccm-2024-0029

Any doctor working in the field of Intensive Care Medicine (ICM) remembers their first placement in the Intensive Care Unit (ICU). Most would remember that time as being characterized by trepidation, confusion and worry. In order to mitigate these negative experiences, various institutions run ad hoc induction and orientation programs. The European Society of Intensive Care Medicine (ESICM) has recently developed the Intensive Care Fundamentals (ICF) course to standardize induction and orientation to ICU for this group of doctors throughout Europe and beyond. Now, the ICF has arrived in Romania. [More]

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A Comparative Analysis of the Effects of Haloperidol and Dexmedetomidine on QTc Interval Prolongation during Delirium Treatment in Intensive Care Units

Ali Haspolat1, Fuat Polat2, Ali Şefik Köprülü3

1 Kolan International Hospital, İstanbul, Turkey
2 Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
3 Yeni Yuzyil University, İstanbul, Turkey

DOI: 10.2478/jccm-2024-0027

Background: Haloperidol and dexmedetomidine are used to treat delirium in the intensive care unit (ICU). The effects of these drugs on the corrected QT (QTc) interval have not been compared before. It was aimed to compare the effects of haloperidol and dexmedetomidine treatment on QTc intervals in patients who developed delirium during ICU follow-up.
Method: The study is single-center, randomized, and prospective. Half of the patients diagnosed with delirium in the ICU were treated with haloperidol and the other half with dexmedetomidine. The QTc interval was measured in the treatment groups before and after drug treatment. The study’s primary endpoints were maximal QT and QTc interval changes after drug administration.
Results: 90 patients were included in the study, the mean age was 75.2±12.9 years, and half were women. The mean time to delirium was 142+173.8 hours, and 53.3% of the patients died during their ICU follow-up. The most common reason for hospitalization in the ICU was sepsis (%37.8.). There was no significant change in QT and QTc interval after dexmedetomidine treatment (QT: 360.5±81.7, 352.0±67.0, p= 0.491; QTc: 409.4±63.1, 409.8±49.7, p=0.974). There was a significant increase in both QT and QTc interval after haloperidol treatment (QT: 363.2±51.1, 384.6±59.2, p=0.028; QTc: 409.4±50.9, 427.3±45.9, p=0.020).
Conclusions: Based on the results obtained from the study, it can be concluded that the administration of haloperidol was associated with a significant increase in QT and QTc interval. In contrast, the administration of dexmedetomidine did not cause a significant change in QT and QTc interval.

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Development of a Machine Learning-Based Model for Predicting the Incidence of Peripheral Intravenous Catheter-Associated Phlebitis

Hideto Yasuda1,2,3,4, Claire M. Rickard3, 4, 5, Olivier Mimoz6,7,8, Nicole Marsh3,4,5, Jessica A Schults3,4,5, Bertrand Drugeon6,7, Masahiro Kashiura1, Yuki Kishihara1, Yutaro Shinzato1, Midori Koike1, Takashi Moriya1, Yuki Kotani9, Natsuki Kondo10, Kosuke Sekine11, Nobuaki Shime12, Keita Morikane13, Takayuki Abe14,15

1 Department of Emergency and Critical Care Medicine, Jichi Medical University Saimata Medical Center, Saitama, Japan
2 Department of Clinical Research Education and Training Unit, Keio University Hospital Clinical and Translational Research Center (CTR), Tokyo, Japan
3 School of Nursing, Midwifery and Social Work, UQ Centre for Clinical Research, The University of Queensland, QLD, Australia
4 School of Nursing and Midwifery; Alliance for Vascular Access Teaching and Research, Griffith University, Nathan, QLD, Australia
5 Herston Infectious Diseases Institute; Nursing and Midwifery Research Centre, Royal Brisbane and Women’s Hospital, Metro North Health, Herston, QLD, Australia
6 CHU de Poitiers, Emergency Department and prehospital care, Poitiers, France
7 University of Poitiers, INSERM U1070, Pharmacology of antimicrobial agents and antibiotics resistance (PHAR2), Poitiers, France
8 University of Poitiers, Faculty of Medicine and Pharmacy, Poitiers, France
9 Department of Intensive Care Medicine, Kameda Medical Center, Chiba, Japan
10 Department of Emergency Medicine, Koga Community Hospital, Shizuoka, Japan
11 Department of Medical Engineer, Kameda Medical Center, Chiba, Japan
12 Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
13 Division of Clinical Laboratory and Infection Control, Yamagata University Hospital, Yamagata, Japan
14 Biostatistics, Clinical and Translational Research Center, Keio University School of Medicine, Tokyo, Japan
15 School of Data Science, Kyoto Women’s University, Kyoto, Japan

DOI: 10.2478/jccm-2024-0028

Introduction: Early and accurate identification of high-risk patients with peripheral intravascular catheter (PIVC)-related phlebitis is vital to prevent medical device-related complications.
Aim of the study: This study aimed to develop and validate a machine learning-based model for predicting the incidence of PIVC-related phlebitis in critically ill patients.
Materials and methods: Four machine learning models were created using data from patients ≥ 18 years with a newly inserted PIVC during intensive care unit admission. Models were developed and validated using a 7:3 split. Random survival forest (RSF) was used to create predictive models for time-to-event outcomes. Logistic regression with least absolute reduction and selection operator (LASSO), random forest (RF), and gradient boosting decision tree were used to develop predictive models that treat outcome as a binary variable. Cox proportional hazards (COX) and logistic regression (LR) were used as comparators for time-to-event and binary outcomes, respectively.
Results: The final cohort had 3429 PIVCs, which were divided into the development cohort (2400 PIVCs) and validation cohort (1029 PIVCs). The c-statistic (95% confidence interval) of the models in the validation cohort for discrimination were as follows: RSF, 0.689 (0.627–0.750); LASSO, 0.664 (0.610–0.717); RF, 0.699 (0.645–0.753); gradient boosting tree, 0.699 (0.647–0.750); COX, 0.516 (0.454–0.578); and LR, 0.633 (0.575–0.691). No significant difference was observed among the c-statistic of the four models for binary outcome. However, RSF had a higher c-statistic than COX. The important predictive factors in RSF included inserted site, catheter material, age, and nicardipine, whereas those in RF included catheter dwell duration, nicardipine, and age.
Conclusions: The RSF model for the survival time analysis of phlebitis occurrence showed relatively high prediction performance compared with the COX model. No significant differences in prediction performance were observed among the models with phlebitis occurrence as the binary outcome.

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Uncommon Malposition of an Ultrasound-Guided Central Venous Catheter in the Renal Vein through the Superficial Femoral Vein: A Case Report

Ting-Chia Remus Young1,2, Kuang-Hua Cheng1,3, Kuan-Pen Yu1,4

1 Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei, Taiwan
2 Department of Medicine, Mackay Medical College, New Taipei, Taiwan
3 Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taiwan
4 Department of Anesthesiology, MacKay Memorial Hospital, Taipei, Taiwan

DOI: 10.2478/jccm-2024-0026

Introduction: Malposition is a relatively rare complication associated with peripherally inserted central catheters (PICCs), particularly in cases of superficial femoral vein (SFV) catheterization. To the best of our knowledge, we are the first to report this rare case of SFV PICC malposition in the contralateral renal vein.
Case presentation: An 82-year-old woman underwent bedside cannulation of the SFV for PICC under ultrasound guidance. Subsequent radiographic examination revealed an unexpected misplacement, with the catheter tip positioned toward the contralateral renal vein. After pulling out the catheter on the basis of the X-ray result, it was observed that the catheter retained its function.
Conclusion: Although rare, tip misplacement should be considered in SFV PICC placement. Prompt correction of the tip position is crucial to prevent catheter malfunction and further catastrophic consequences. For critical patients receiving bedside SFV PICC insertion, postoperational X-ray is crucial for enhancing safety.

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