Author Archives: administrare

Pneumoretroperitoneum after Attempted Epidural Anesthesia

Arkadi Isakov1*, Arnold Shtein2, Sholmo Kyzer1

1 Department of Surgery “B,” Wolfson Medical Center, Holon, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
2 Department of Anesthesiology, Wolfson Medical Center, Holon, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

DOI: 10.1515/jccm-2016-0029

Air may extend to the retroperitoneal space from retroperitoneal perforation of a hollow viscus, infection of the anterior pararenal space with gas-forming organisms and from pneumothorax or pneumomediastinum [1]. Rare pathologies, such as open reduction and internal fixation of femoral fractures and anaerobic abscess of the hip joint have also been described in relation to this complication [1,2]. A rare case of pneumoretroperitoneum caused by insufflation of air during an attempt to achieve epidural anesthesia is described.

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Staphylococcal Scalded Skin Syndrome in Child. A Case Report and a Review from Literature

Alina Grama1, Oana Cristina Mărginean1*, Lorena Elena Meliț1, Anca Meda Georgescu2

1 Pediatrics I Department, University of Medicine and Pharmacy Târgu-Mureș, Romania
2 Infectious Diseases Department, University of Medicine and Pharmacy Târgu-Mureș, Romania

DOI: 10.1515/jccm-2016-0028

Staphylococcal scalded skin syndrome (SSSS) is the medical term used to define a skin condition induced by the exfoliative toxins produced by Staphylococcus aureus. The disorder is also known as Ritter disease, bullous impetigo, neonatal pemphigus, or staphylococcal scarlet fever. The disease especially affects infants and small children, but has also been described in adults. Prompt therapy with proper antibiotics and supportive treatment has led to a decrease in the mortality rate.
The current case report describes the clinical progress of a patient with generalized erythema and fever, followed by the appearance of bullous lesions with tendency to rupture under the smallest pressure, and with extended areas of denudation.
The patient aged four years and six months was admitted to our clinic to establish the aetiology and treatment of a generalized bullous exanthema, followed by a skin denudation associated with fever and impaired general status.
Based on clinical and paraclinical examinations a diagnosis of Staphylococcal scalded skin syndrome was established which responded favourably to antibiotic treatment, hydro-electrolytic re-equilibration, and adequate local hygiene.
Staphylococcal infection can represent a problem of significant pathological importance sometimes requiring a multidisciplinary approach involving paediatricians, dermatologists, infectious diseases specialists, and plastic surgeons.

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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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