Author Archives: administrare

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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Anemia in Intensive Care: A review of Current Concepts

Gautam Rawal1*, Raj Kumar1, Sankalp Yadav2, Amrita Singh3

1 Respiratory Intensive Care, Max Super Specialty Hospital, Saket, New Delhi, India
2 Department of Medicine & TB, Chest Clinic Moti Nagar, North Delhi Municipal Corporation, New Delhi, India
3 Gen-X Diagnostics, Madhu Vihar, New Delhi, India

DOI: 10.1515/jccm-2016-0017

Anemia in patients admitted to an intensive care unit is common and affects almost all critically ill patients. The intensivist is faced with the challenge of treating multifactorial etiologies, mainly bleeding and blood loss due to phlebotomy and decreased erythropoiesis. Red cell transfusion, the most common treatment for anemia, comes with associated risks, which may further reduce the chance of survival of these patients. The best evidence suggests the practice of restrictive RBC transfusion (transfusion at Hb<7 g/dl).
In this article, the etiopathogenesis of the anemia in critically ill is reviewed, and current opinion on the pros and cons of various management strategies are discussed with emphasize on restrictive transfusion policy.

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Have Severity Scores a Place in Predicting Septic Complications in ICU Multiple Trauma Patients?

Daniela Ionescu

Department of Anesthesia and Intensive Care I, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania; Outcome Research Consortium, Cleveland, USA

DOI: 10.1515/jccm-2016-0023

Risk assessment in ICU critically-ill patients is of tremendous importance for optimizing patients’ clinical management, medical and human resource allocation and supporting medical cost distribution and containment.
The problem of predicting complications and mortality in ICU patients, although not new, is of genuine concern and much effort has been made to detect the most reliable parameters and scores. Numerous attempts have been made to use clinical and laboratory findings integrated into different algorithms or to incorporate these parameters into easy to use composite severity scores which would be applicable in various centers. In addition to clinical data, biomarkers or laboratory findings have been used for this purpose [1-3].
The SOFA, SAPS and APACHE scores and their newer versions, have been used worldwide to evaluate patients’ severity, prognosis, and survival [4-7]. However, it has been reported that there are differences in their performance and estimation probability, in different geographical areas [8]. [More]

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Complications of Sepsis in Infant. A Case Report

Lorena Elena Meliț1, Cristina Oana Mărginean2*, Anca Georgescu3, Carmen Duicu2

1 Pediatrics Clinic 1, County Clinical Emergency Hospital
2 University of Medicine and Pharmacy Tîrgu Mureș, Pediatrics Clinic 1
3 University of Medicine and Pharmacy Tîrgu Mureș, Infectious Diseases Clinic 1

DOI: 10.1515/jccm-2016-0012

Sepsis is a systemic inflammatory response (SIRS) characterized by two or more of the following: fever > 38.5 °C or <36 °C, tachycardia, medium respiratory frequency over two SD for age, increased number of leukocytes.
The following is a case of an eight months old, female infant, admitted in to the clinic for fever (39.7 C), with an onset five days before the admission, following trauma to the inferior lip and gum. Other than the trauma to the lip and gum, a clinical exam did not reveal any other pathological results. The laboratory tests showed leukocytosis, positive acute phase reactants (ESR 105 mm/h, PCR 85 mg/dl), with positive blood culture for Staphylococcus aureus MSSA. at 24 hours. Three days from admission, despite the administration of antibiotics (Vancomycin+Meronem), there was no remission of fever, and the infant developed a fluctuant collection above the knee joint. This was drained, and was of a serous macroscopic nature. A decision was made to perform a CT, which confirmed the diagnosis of septic arthritis. At two days after the intervention, the fever reappeared, therefore the antibiotic regime were altered (Oxacillin instead of Vancomycin), resulting in resolution of the fever. Sepsis in infant is a complex pathology, with non-specific symptoms and unpredictable evolution.

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The Pitfalls of Febrile Jaundice. A Case Report

Maria Obreja1*, Andra Teodor1,2, Daniela Leca1,2, Alexandr Ceasovschih3, Egidia Miftode1,2

1 “Sfânta Parascheva” Infectious Diseases Hospital Iași, România
2 “Grigore T. Popa”University of Medicine and Pharmacy, Iași,România
3 Department of Medicine, “Sfântul Spiridon” Emergency Clinical Hospital, Iași, România

DOI: 10.1515/jccm-2016-0013

Jaundice in sepsis is usually caused by cholestasis, and its onset can precede other manifestations of the infection. Inflammation-induced cholestasis is a common complication in patients with an extrahepatic infection or those with inflammatory processes. We describe the case of a 47 years old female who presented with low back pain and paravertebral muscular contracture. She subsequently developed a cholestatic syndrome with clinical manifestations such as jaundice, followed by fever and sepsis with multiple organ dysfunction. Initially labeled as biliary sepsis, the diagnosis was crucially reoriented as the blood cultures were positive for Streptococcus pyogenes and the magnetic resonance imaging (MRI) findings suggested spondylodiscitis as well as a paravertebral abscess.

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The Management of Staphylococcal Toxic Shock Syndrome. A Case Report

Victoria Bîrluțiu1,2*, Ofelia Criștiu3, Marius Baicu4, Rareș Mircea Bîrluțiu1,5

1 Lucian Blaga University of Sibiu, Faculty of Medicine, Sibiu, Romania
2 Sibiu County Clinical Emergency Hospital, Infectious Diseases Department, Sibiu, Romania
3 Pediatric Clinical Hospital Sibiu, Infectious Diseases Department, Sibiu, Romania
4 Pediatric Clinical Hospital Sibiu, Intensive Care Department, Sibiu, Romania
5 Foişor Clinical Hospital of Orthopedics, Traumatology and Osteoarticular Tuberculosis, Bucharest, Romania

DOI: 10.1515/jccm-2016-0011

Staphylococcal toxic shock syndrome (TSS) is most frequently produced by TSS toxin-1 (TSST-1) and Staphylococcal enterotoxin B (SEB), and only rarely by enterotoxins A, C, D, E, and H. Various clinical pictures can occur depending on severity, patient age and immune status of the host. Severe forms, complicated by sepsis, are associated with a death rate of 50-60%. The case of a Caucasian female infant, aged seven weeks, hospitalized with a diffuse skin rash, characterized as allergodermia, who initially developed TSS with axillary intertrigo, is reported. TSS was confirmed according to 2011 CDC criteria, and blood cultures positive for Methicillin-sensitive Staphylococcus aureus (MSSA). Severe development occurred initial, including acidosis, consumption coagulopathy, multiple organ failures (MOF), including impaired liver and kidney function. Central nervous system damage was manifest by seizures. Clinical management included medical supervision by a multidisciplinary team of infectious diseases specialist and intensive care specialist, as well as the initiation of a complex treatment plan to correct hydro electrolytic imbalances and acidosis. This treatment included antibiotic and antifungal therapy, diuretic therapy, immunoglobulins, and local treatment similar to a patient with burns to prevent superinfection of skin and mucous membranes lesions. There was a favourable response to the treatment with resolution of the illness.

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Parkinsonian Syndrome and Toxoplasmic Encephalitis

Anca-Adriana Arbune1*, Manuela Arbune2, Victorita Stefanescu2

1 Carol Davila Medicine and Pharmacy University, Bucharest
2 ”Dunarea de Jos” University Galati

DOI: 10.1515/jccm-2016-0009

Toxoplasmosis encephalitis in patients with human immunodeficiency virus may progress rapidly with a potentially fatal outcome. Less common neurological symptoms associated with this are Parkinsonism, focal dystonia, rubral tremor and hemichorea–hemiballismus syndrome.
A 58 year old woman suddenly lost consciousness and was admitted to the emergency service. Her medical history was unremarkable, except for frequent headaches in the last year, recurrent herpes simplex skin lesions and an episode of urticaria. A computer tomography scan showed supra and infra-tentorial lesions on suggestive of cerebral toxoplasmosis. Both Toxoplasma gondii and HIV tests were positive. In the intensive care unit, antiparasitic and antiretroviral drugs were administered, and she recovered from the coma after six weeks but presented with tetraparesis, diplopia, and depression. The LCD4 count increased from 7 to 128/mm3. The neurological lesions slowly resolved over the next two months, although postural instability, rigidity, bradykinesia and predominantly left side tremor persisted. Mild improvement was achieved after the administration of levodopa.
Associated Parkinsonian syndrome in HIV patients is a rare condition, explained by the location of the brain and basal ganglia lesions, and by the observed effect of Toxoplasma gondii which increases dopamine metabolism in neural cells. Early HIV diagnostic and treatment are necessary to prevent neurological disability.

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Influence of Ventilation Parameters on Intraabdominal Pressure

Claudiu Puiac1, Janos Szederjesi1*, Alexandra Lazar1, Emoke Almasy1, Paul Rad1, Lucian Puscasiu2

1 Anesthesiology Department, University of Medicine and Pharmacy of Tirgu Mures, Romania
2 Gynecology and Obstetrics Department, University of Medicine and Pharmacy of Tirgu Mures, Romania

DOI: 10.1515/jccm-2016-0016

Introduction: Intraabdominal pressure monitoring is not routinely performed because the procedure assumes some invasiveness and, like other invasive procedures, it needs to have a clear indication to be performed. The causes of IAH are various. Mechanically ventilated patients have numerous parameters set in order to be optimally ventilated and it is important to identify the ones with the biggest interference in abdominal pressure. Although it was stated that mechanical ventilation is a potential factor of high intraabdominal pressure the set parameters which may lead to this diagnostic are not clearly named.
Objectives: To evaluate the relation between intraabdominal pressure and ventilator parameters in patients with mechanical ventilation and to determine the correlation between intraabdominal pressure and body mass index.
Material and method: This is an observational study which enrolled 16 invasive ventilated patients from which we obtained 61 record sheets. The following parameters were recorded twice daily: ventilator parameters, intraabdominal pressure, SpO2, Partial Oxygen pressure of arterial blood. We calculated the Body Mass Index (BMI) for each patient and the volume tidal/body weight ratio for every recorded data point.
Results: We observed a significant correlation between intraabdominal pressure (IAP) and the value of PEEP (p=0.0006). A significant statistical correlation was noted regarding the tidal volumes used for patient ventilation. The mean tidal volume was 5.18 ml/kg. Another significant correlation was noted between IAP and tidal volume per kilogram (p=0.0022). A positive correlation was found between BMI and IAP (p=0.0049), and another one related to the age of the enrolled patients. (p=0.0045).
Conclusions: The use of positive end-expiratory pressures and high tidal volumes during mechanical ventilation may lead to the elevation of intraabdominal pressure, a possible way of reducing this risk would be using low values of PEEP and also low volumes for the setting of ventilation parameters. There is a close positive correlation between the intraabdominal pressure levels and body mass index.

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