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Congenital Heart Disease Requiring Maintenance of Ductus Arteriosus in Critically Ill Newborns Admitted at a Tertiary Neonatal Intensive Care Unit

Manuela Cucerea1*, Marta Simon1, Elena Moldovan2, Marcela Ungureanu3, Raluca Marian1, Laura Suciu1

1 University of Medicine and Pharmacy Tirgu Mureș, Romania
2 Institute of Cardiovascular Disease and Transplant Tirgu Mureș, Romania
3 Department of Neonatal Intensive Care,County Clinical Emergency Hospital Tirgu Mureş, Romania

DOI: 10.1515/jccm-2016-0031

Introduction: Congenital heart diseases (CHD) have been reported to be responsible for 30 to 50% of infant mortality caused by congenital disabilities. In critical cases, survival of newborns with CHD depends on the patency of the ductus arteriosus (PDA), for maintaining the systemic or pulmonary circulation. The aim of the study was to assess the efficacy and side effects of PGE (prostaglandin E) administration in newborns with critical congenital heart disease requiring maintenance of the ductus arteriosus.
Material and method: All clinical and paraclinical data of 66 infants admitted to one referral tertiary level academic center and treated with Alprostadil were analyzed. Patients were divided into three groups: Group 1: PDA dependent pulmonary circulation (n=11) Group 2: PDA dependent systemic circulation (n=31) Group 3: PDA depending mixed circulation (n=24)
Results: The mean age of starting PGE1 treatment was 2.06 days, 1.91 (+/-1.44) days for PDA depending pulmonary flow, 2.39 (+/-1.62) days for PDA depending systemic flow and 1.71 (+/1.12) for PDA depending mixing circulation. PEG1 initiation was commenced 48 hours after admission for 72%, between 48-72 hours for 6%, and after 72 to 120 hours for 21% of newborns detected with PDA dependent circulation. Before PEG1 initiation the mean initial SpO2 was 77.89 (+/- 9.2)% and mean initial oxygen pressure (PaO2) was 26.96(+/-6.45) mmHg. At the point when stable wide open PDA was achieved their mean SpO2increased to 89.73 (+/-8.4)%, and PaO2 rose to 49 (+/-7.2) mmHg. During PGE1 treatment, eleven infants (16.7%) had apnea attacks, five children (7.5%) had convulsions, 33 (50%) had fever, 47 (71.2%) had leukocytosis, 52 (78.8%) had edema, 25.8% had gastrointestinal intolerance, 45.5% had hypokalemia, and 63.6% had irritability.
Conclusions: For those infants with severe cyanosis or shock caused by PDA dependent heart lesions, the initiation and maintenance of PGE1 infusion is imperative. The side effects of this beneficial therapy were transient and treatable.

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Persistent Ductus Arteriosus in Critically Ill Preterm Infants

Maria Livia Ognean1*, Oana Boantă1, Simona Kovacs2, Corina Zgârcea1, Raluca Dumitra1, Ecaterina Olariu1, Doina Andreicuţ2

1 Neonatology I, Clinical County Emergency Hospital Sibiu, Romania
2 Neonatology II-Premature Infants, Clinical County Emergency Hospital Sibiu, Romania

DOI: 10.1515/jccm-2016-0026

Introduction: Persistent ductus arteriosus (PDA) is found with increased incidence in preterm infants, significantly affecting neonatal morbidity and mortality rates.
Aim: To evaluate the association between the presence of PDA and the severity of clinical condition at birth in critically ill preterm infants, with gestational ages (GA) ≤ 32 weeks and severe respiratory distress.
Methods: All preterm infants with GA ≤ 32 weeks admitted to the neonatal intensive care unit (NICU) of the Clinical County Emergency Hospital, Sibiu between 1 January 2010 and 31 December 2015 were included in the study. These were categorized as Group 1 [Preterm infants with PDA; n=154] and Group 2 [Preterm infants without PDA; n=186]. Epidemiological and clinical data were collected in the National Registry for Respiratory Distress Syndrome for all children, and data related to prenatal period, clinical characteristics at birth i.e GA, weight, gender, Apgar scores, and clinical features such as resuscitation at birth, surfactant administration, need and duration of respiratory support, neonatal sepsis, complications associated with prematurity, and death, were analyzed.
Results: Group 1 infants had significantly lower GA and birth weights, were more often out born (p=0.049, HR 1.69), and had significantly lower Apgar scores at 1 and 10 minutes (p=0.022, p=0.000). They presented a significantly higher need for surfactant administration (42.9% vs 24.7%, p<0.0001) and respiratory support (96.8% vs 90.3%, HR 3.19, p=0.019 for need of CPAP and 22.1% vs 10.8%, HR 2.35, p=0.004 for mechanical ventilation). Duration of respiratory support was also significantly higher in the Group 1 (7.6%±7.5 vs. 5.1±3.8 days, p<0.0001 for CPAP and 20.1±22.5 vs. 12.0±15.7 days, p<0.0001 for mechanical ventilation).
Conclusion: In very preterm infants, PDA may be associated with a critical clinical condition leading to serious complications. The presence of PDA after the seventh day of life was associated with an increased need for respiratory support, both CPAP and mechanical ventilation, increased severity of the respiratory distress syndrome, requiring a longer duration of respiratory support, and increased the hospitalization length. In very preterm infants, PDA presence was also associated with a higher rate of severe complications and death, indicating the need for a careful and proper management of these critical cases in neonatal intensive care units.

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Extracorporeal Life Support and New Therapeutic Strategies for Cardiac Arrest Caused by Acute Myocardial Infarction – a Critical Approach for a Critical Condition

Theodora Benedek1*, Monica Marton Popovici2, Dietmar Glogar3

1 University of Medicine and Pharmacy Tirgu Mures, Romania, Clinic of Cardiology
2 Swedish Medical Center, Department of Internal Medicine and Critical Care, Edmonds, Washington, USA
3 Medical University of Vienna, Austria

DOI: 10.1515/jccm-2016-0025

This review summarizes the most recent developments in providing advanced supportive measures for cardiopulmonary resuscitation, and the results obtained using these new therapies in patients with cardiac arrest caused by acute myocardial infarction (AMI). Also detailed are new approaches such as extracorporeal cardiopulmonary resuscitation (ECPR), intra-arrest percutaneous coronary intervention, or the regional models for systems of care aiming to reduce the critical times from cardiac arrest to initiation of ECPR and coronary revascularization.

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Sepsis-Associated Coagulopathy

Ecaterina Scarlatescu1, Dana Tomescu1,2*, Sorin Stefan Arama2

1 Department of Anesthesiology and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania
2 University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania

DOI: 10.1515/jccm-2016-0024

Systemic inflammatory activation in sepsis often leads to coagulation activation, but the relationship is bilateral, as coagulation also modulates the inflammatory response. This close associate has significant consequences for the pathogenesis of microvascular thrombosis and organ dysfunction in sepsis. While coagulation activation can be beneficial for immune defense, it can also be detrimental once it becomes widespread and uncontrolled. The knowledge of the pathophysiologic mechanisms involved in the interaction between infection and coagulation may lead to the better timing for the administration of targeted antithrombotic therapies in septic patients. This brief review highlights the pathophysiologic pathways leading to the prothrombotic state in sepsis and the mechanisms that play a role in the interaction between infection and coagulation.

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Epidural Anaesthesia: How Easy Is It to Walk on Quicksand?

Constantin Bodolea*

University of Medicine and Pharmacy “Iuliu Hatieganu“ Cluj Napoca, Romania

DOI: 10.1515/jccm-2016-0032

The effectiveness of neuraxial blockade remains a very debatable issue. Many orthopaedic surgical procedures can be performed using either a single spinal shot, an epidural catheter neuraxial blockade, or general anesthesia.
Memtsoudis (2013) reviewed nearly 400.000 patients undergoing primary hip or knee arthroplasties compared neuraxial versus general anesthesia, and reported that the 30-day mortality, the length of stay, the hospital cost and the in-hospital complications were all was significantly lower than with other forms of anesthesia [1]. Similarly Helwan (2015) in a study comparing general with regional anesthesia for total hip arthroplasty reported a reduction in deep surgical site infection rates, the length of hospital stay, postoperative cardiovascular rates, and pulmonary complications [2]. However, a recent systematic review of more than 10.000 patients enrolled in randomized control trials and prospective comparative studies, found no statistically significant differences between spinal or epidural blockade and general anaesthesia with respect to mortality, surgical duration, surgical site of infections, nerve palsies, postoperative nausea and vomiting or thromboembolic diseases, when thrombo-prophylaxis was used. The authors concluded that there is limited evidence to support the view that neuraxial anesthesia is superior to general anesthesia with regards to postoperative outcomes [3]. [More]

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Nosocomial Staphylococcal Toxic Shock. Case Report

Manuela Arbune1,2*, Loredana Tercu2

1 “Dunarea de Jos” University Galati, Romania
2 Hospital of Infectious Diseases “Sf. Cuvioasa Parascheva” Galaţi, Romania

DOI: 10.1515/jccm-2016-0020

Staphylococcal toxic shock syndrome (STSS) is a rare, potentially lethal infection, with a clinical picture of multiple organ dysfunction and shock. The etiology is Staphylococcus aureus exotoxin, while enterotoxins act as superantigens. Most cases are identified in women using a vaginal tampon.  A 51-year-old female, with a past medical history of biliary dyskinesia, presented in the emergency room complaining of sudden onset of abdominal pain, vomiting, headache, myalgia, and chills. The initial diagnosis was biliary colic and was treated parenterally with Amoxi-clavulanate and fluid replacement. Initially, progress was unsatisfactory. Four days after admission she developed a systemic inflammatory syndrome, diffuse rash, jaundice, oliguria, confusion, persistent hypotension and biological evidence of thrombocytopenia, nitrogen retention, and cholestasis. She was admitted to the intensive care unit. A gluteal phlegmon induced after intramuscular injections was identified and surgically treated. Blood bacteriological cultures were negative, though MRSA was isolated in phlegmon pus. A diagnosis of STSS was based on CDC criteria.
The risks of similar infections could be prevented by limiting intramuscular treatments and monitoring invasive procedures.

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Malignant Middle Cerebral Artery Infarction Secondary to Traumatic Bilateral Internal Carotid Artery Dissection. A Case Report

Zoltán Bajkó1, Rodica Bălaşa1, Anca Moţăţăianu1*, Laura Bărcuţean1, Adina Stoian2, Nicoleta Stirbu3, Smaranda Maier1

1 University of Medicine and Pharmacy Târgu Mureş, Department of Neurology
2 University of Medicine and Pharmacy Târgu Mureş, Department of Pathophysiology
3 Mediab Medical Center Târgu Mureş

DOI: 10.1515/jccm-2016-0021

Traumatic bilateral dissection of the carotid arteries is a rare condition with potentially life-threatening complications. The case of a 57-year-old male patient with acute onset left sided hemiparesis, twelve hours after a blunt head injury, caused by a horse kick, is reported. A cerebral CT scan revealed right middle cerebral artery (MCA) territory infarction. Based on Duplex ultrasound and Angio CT scan findings, a diagnosis of bilateral ICA dissection was established. Despite antithrombotic treatment, the patient presented with a progressive worsening of his neurological status. The control CT scan evidenced malignant right MCA territory infarction that required decompressive craniotomy. The patient was discharged with significant neurological deficits. Together with this case, the aetiologies, clinical manifestations, diagnostic and therapeutical options and outcome of carotid artery dissection are discussed.

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The Placement of Post-pyloric Feeding Tubes Using DRX-Revolution Mobile X-Ray System in an ICU. A Case Series

Leonid Koyfman1, Andrei Schwartz1, Yair Benjamin1, Alexander Smolikov2, Moti Klein1, Evgeni Brotfain1*

1 Department of Anesthesiology and Critical Care, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
2 Department of Radiology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel

DOI: 10.1515/jccm-2016-0022

Enteral nutrition is crucial for ensuring that critically ill patients have a proper intake of food, water, and medicine. Methods to ensure this requirement should be initiated as early as possible. The use of PPF has several advantages compared to the use of a nasogastric feeding tube. In the present paper, the cases of three critically ill patients with a nonfunctional gastrointestinal system on admission to ICU, are detailed. Enteral feeding through a nasogastric tube by prokinetic agent therapy had been unsuccessful. The bedside placement of a post-pyloric feeding tube by the DRX-Revolution X-ray system is described.

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Can APACHE II, SOFA, ISS, and RTS Severity Scores be Used to Predict Septic Complications in Multiple Trauma Patients?

Sebastian Trancă1, Cristina Petrișor1, Natalia Hagău1, Constantin Ciuce2

1 Department of Anaesthesia and Intensive Care II, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania
2 Surgical Department I, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania

DOI: 10.1515/jccm-2016-0019

Background: Physiological composite scores are used to predict mortality in multiple trauma patients. Sepsis is the leading cause of late mortality in trauma victims brought about by immune suppression due to homeostasis dysregulation.
Objective: To determine whether APACHE II, SOFA, ISS and RTS scores can predict the occurrence of sepsis in multiple trauma patients.
Methods: APACHE II, SOFA, ISS, and RTS scores were calculated during the first twenty-four hours after the injury for sixty-four adult poly-traumatic patients. The occurrence of infectious complications was investigated over a fourteen-day period. The infection-free rates for the multiple trauma patients were considered as end-points in the Kaplan-Meier plot analysis.
Results: For SOFA, a cutoff score of 4 points was identified as a predictor of the occurrence of sepsis, with 89% of the patients with SOFA<4 being infection-free, while 37% of those with SOFA>4 were infection-free (p<0.01). None of the patients with APACHE II≤5 points developed infections. Eighty-four percent of patients with APACHE II scores of 5-10 did not develop sepsis, while 49% with APACHE II≥11 were infection-free (p<0.01).  A cutoff of 7 points was found to be most discriminative for RTS. Eighty-eight percent of the patients with RTS≥7 and 43% of those with RTS<7 were infection-free (p<0.01). Eighty-eight percent of patients with ISS<22 did not develop sepsis and 56% with ISS≥22 did not develop sepsis (p<0.01).
Conclusion: APACHE II, SOFA, ISS, and RTS functional severity scores can predict mortality as well as the occurrence of sepsis in multiple trauma patients.

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The Diagnosis and Hemodynamic Monitoring of Circulatory Shock: Current and Future Trends

Adham Hendy1,2*, Şerban-Ion Bubenek-Turconi1,2

1 Ph.D Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
2 1st Department of Cardiovascular Anesthesia and Intensive Care, “C.C.Iliescu” Emergency Institute for Cardiovascular Diseases, Bucharest, Romania

DOI: 10.1515/jccm-2016-0018

Circulatory shock is a complex clinical syndrome encompassing a group of conditions that can arise from different etiologies and presented by several different hemodynamic patterns. If not corrected, cell dysfunction, irreversible multiple organ insufficiency, and death may occur.  The four basic types of shock, hypovolemic, cardiogenic, obstructive and distributive, have features similar to that of hemodynamic shock.  It is therefore essential, when monitoring hemodynamic shock, to making accurate clinical assessments which will guide and dictate appropriate management therapy.
The European Society of Intensive Care has recently made recommendations for monitoring hemodynamic shock. The present paper discusses the issues raised in the new statements, including individualization of blood pressure targets, prediction of fluid responsiveness, and the use of echocardiography as the first means during the initial evaluation of circulatory shock.  Also, the place of more invasive hemodynamic monitoring techniques and future trends in hemodynamic and metabolic monitoring in circulatory shock, will be debated.

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