Author Archives: administrare

Residual Curarization and Postoperative Respiratory Complications Following Laparoscopic Sleeve Gastrectomy. The Effect of Reversal Agents: Sugammadex vs. Neostigmine

Tiberiu Ezri1,4, Shmuel Evron1,4, Irina Petrov1, Pinhas Schechter2, Yitzhak Berlovich3, Mordechai Shimonov2

The Departments of Anesthesia1, Surgery2 and Management3, The Edith Wolfson Medical Center, Holon, Israel and Outcomes Research Consortium,4 Holon, Israel

DOI: 10.1515/jccm-2015-0009

Background: Incomplete muscle relaxant reversal or re-curarization may be associated with postoperative respiratory complications. In this retrospective study we compared the incidence of postoperative residual curarization and respiratory complications in association with the type of muscle relaxant reversal agent, sugammadex or neostigmine, in patients undergoing laparoscopic sleeve gastrectomy.
Material and methods: We reviewed the charts of all patients (179) undergoing laparoscopic sleeve gastrectomy from July 2012 to July 2013 at Wolfson Medical Center. Sugammadex 1.5-2 mg/kg (112 patients) or neostigmine 2.5 mg (67 patients) were used as reversal agents. Results were compared by the type of reversal agent employed. Compared parameters included demographic and anaesthetic data, residual curarization, oxyhemoglobin saturation (SpO2) in the recovery room (PACU), episodes of SpO2 lower than 90% in PACU, unexpected intensive care (ICU) admissions, incidence of atelectasis and pneumonia, re-intubation and duration of hospitalization.
Results: Obstructive sleep apnea syndrome (OSAS) was more frequent in the sugammadex group (19% vs. 8%; p = 0.026). Total intravenous anesthesia (TIVA) was more frequently associated with sugammadex (33% vs. 16%; p = 0.007). There were no differences in postoperative residual curarization, SpO2 < 90% episodes, reintubation, ICU admissions, pulmonary complications and duration of hospitalization.
Conclusion: With the inherent limitations of a retrospective study, the use of sugammadex following laparoscopic sleeve gastrectomy showed no advantage over neostigmine in terms of residual curarization and respiratory complications.

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Differential Diagnosis and Management Issues of Idiopathic Angiooedema and their Resolution

Andrea Zanichelli, Marta Mansi,  Maddalena A. Wu, Giulia Azin, Marco Cicardi

Department of Biomedical and Clinical Sciences “L. Sacco” University of Milan and Ospedale L. Sacco Milan, Italy

DOI: 10.1515/jccm-2015-0008

Angiooedema is a local and self-limiting swelling of the subcutaneous and sub mucosal tissues, produced by vasoactive peptides that temporary increase the vascular permeability.
It is recognized that recurrent angiooedema exposes patients to the risk of fatalities and reduced quality of life, being in some circumstances associated with a critical condition.
Angiooedema can occur with or without wheals. The first symptom is urticaria, the second is a distinct nosologic entity. In absence of an identifiable cause, recurrent angiooedema without wheals can be defined as idiopathic and marked“idiopathic histaminergic angiooedema” when it is responsive to anti histamine treatment, and “idiopathic non-histaminergic angiooedema” when it is not. Furthermore, idiopathic non-histaminergic angiooedema can be diagnosed as hereditary or sporadic by family history.
In this review, we summarize the approaches to diagnose and treat different forms of idiopathic angiooedema.

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Statins as Pleiotropic Modifiers of Vascular Oxidative Stress and Inflammation

Costas Psarros1, Evangelos K. Economou1, Michael Koutsilieris1, Charalambos Antoniades2*

1 Department of Experimental Physiology, Medical School, National and Kapodistrian University of Athens, Greece
2 Radcliffe Department of Medicine, Cardiovascular Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom.

DOI: 10.1515/jccm-2015-0007

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the industrialized world and in the future is expected to be the number one killer worldwide. The main cause underlying CVD is atherosclerosis. A key event in atherosclerosis initiation and progression is oxidative stress through the production of reactive oxygen species as well as endothelial dysfunction. Several pro- inflammatory and anti-inflammatory cytokines and proteins are involved in this process, complemented by activation of adhesion molecules that promote leukocyte rolling, tethering and infiltration into the sub-endothelial space. Statins represent the agent of choice since numerous clinical trials have verified that their pharmacological action extends beyond lipid lowering. Statins demonstrate direct anti-oxidant effects by scavenging free radicals and stimulating anti-oxidant enzymes while acting as regulators for cytokine, protein and adhesion molecule expression, all of which are involved in the atherosclerotic process. Statin use is considered one of the most efficient currently used interventions in managing CVD with the likely hood of remaining so in the near future.

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Acute Ischaemic Stroke Secondary to a Mobile Thrombus in the Common Carotid artery – Case Report

Zoltán Bajkó1,2, Smaranda Maier1,2, Silvia Rusu2, Anca Moțățăianu1,2

1 University of Medicine and Pharmacy Târgu Mureș, Department of Neurology, Gheorghe Marinescu street 38, 540139 Târgu Mureș, Romania
2 Mureș County Clinical Emergency Hospital Târgu Mureș, Neurology Clinic I, Gheorghe Marinescu street 50, 540136, Târgu Mureș, Romania

DOI: 10.1515/jccm-2015-0010

A mobile thrombus in the carotid arteries is a very rare ultrasonographic finding and is usually diagnosed after a neurological emergency, such as a transient ischemic attack or cerebral infarction. We present the case of a 54-year-old man with vascular risk factors (a heavy smoker, untreated hypertension) who was admitted to the emergency unit with right sided hemiparesis and aphasia. A cerebral CT scan showed a left middle cerebral artery territory infarction. The duplex ultrasound examination revealed mild atherosclerotic changes in the right common and internal carotid arteries, right-sided complete subclavian steal phenomenon and a complicated hypoechoic atherosclerotic plaque in the left common carotid artery with a large mobile thrombus.  Due to the high embolization risk, the patient was hospitalised and prescribed Aspirin together with low molecular weight Heparin. We recorded an improvement in the patient’s neurological status and the control duplex scan revealed disappearance of the thrombus. The presence of floating thrombus in a patient with clinical and imagistic evidence of stroke is a major therapheutic challenge for the neurologist. The treatment strategies are not standardized and must be individualized, however in our case parenteral anticoagulation proved to be successful.

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Intra-arterial Thrombolysis in Second Trimester of Pregnancy. A Case Report

Endre Pongrácz1, Szabolcs Farkas2, Miklós Dajka3, László Csiba2

1 Department of Neurology, Hetényi Géza Hospital,  H-5001 Szolnok, Tószegi street 21, Hungary
2 Department of Neurology, University of Debrecen, H-4012 Debrecen, Móricz Zsigmond street, no.22, Hungary
3 Department of Radiology, Avas Medical Centre LLC, H-5001 Szolnok, Tószegi street 21, Hungary

DOI: 10.1515/jccm-2015-0005

Here we present a successful intra-arterial thrombolysis performed in the second trimester of pregnancy (21 weeks). The intervention resulted in complete recanalization of the occluded right middle cerebral artery and favourable clinical and gestational outcome. Together with cases described in respective medical literature our report affirms that in pregnancy acute ischemic stroke could be treated effectively applying intra-arterial thrombolysis (using rt-PA). This therapy could provide opportunity to help in such desperate situations.

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The Role of Angiopoietine-2 in the Diagnosis and Prognosis of Sepsis

Janos Szederjesi1, Emoke Almasy1, Alexandra Lazar1, Adina Huțanu2, Anca Georgescu3

1 University of Medicine and Pharmacy Tîrgu Mureş, Romania, Discipline of Intensive Care, 38 Gheorghe Marinescu street, Tirgu Mures, 540139, Romania
2 County Clinical Emergency Hospital Tirgu Mures, Romania, 50 Gheorghe Marinescu street Tirgu Mures, 540139, Romania
3 University of Medicine and Pharmacy Tîrgu Mureş, Romania, Discipline of Infectious Diseases, 38 Gheorghe Marinescu street, Tirgu Mures, 540139, Romania

DOI: 10.1515/jccm-2015-0004

Introduction: Angiopoietin-2 (ANG-2) is a new biomarker whose blood-serum values increase in sepsis and its expression is elevated in line with the severity of the degree of inflammation. The aim of this study was to identify the diagnostic role of ANG-2 in patients with non-surgical sepsis addmitted to an intensive care unit.
Material and methods: This was a prospective randomized study including 74 patients admitted in the Clinic of Intensive Care of the County Clinical Emergency Hospital Tirgu Mureș, divided into two groups: Group S: patients with sepsis (n=40, 54%) and Group C: control, without sepsis (n=34, 46%). ANG-2 levels were determined in both groups.
Results: From the Group S, 14 patients (35%) had positive haemocultures. ANG-2 values varied between 1 and 43 ng/mL, with an average of 6.0 ng/mL in patients without sepsis and 10.38 ng/mL in patients with sepsis (p=0.021). A positive correlation between ANG-2 and SAPS II, SOFA and APACHE II severity scores was demonstrated, as was a positive correlation between serum levels of ANG-2 and procalcitonine. ANG-2 had a 5.71% specificity and 74.36% sensitivity for diagnosis of sepsis.
Conclusions: ANG-2 serum levels were elevated in sepsis, being well correlated with PCT values and prognostic scores. ANG-2 should be considered as a useful biomarker for the diagnosis and the prognosis of this pathology.

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Drug Closure of a Patent Ductus Arteriosus in an Extremely Low Birth Weight Premature Newborn. A Case Report

Elena Moldovan1, Manuela Cucerea1,2

1 University of Medicine and Pharmacy Tîrgu-Mureş, Romania, 38 Gheorghe Marinescu street, Tirgu Mures, 540139, Romania

2 Regional Center of Neonatal Intensive Care Unit UGON, 50 Gheorghe Marinescu street, Tirgu Mures, 540139, Romania

DOI: 10.1515/jccm-2015-0006

Introduction: Patent ductus arteriosus involves maintaining the permeability of the vascular ductus located between the pulmonary artery and the descending aorta, due to the failure of transition from foetal to adult type circulation. This malformation is characteristic to premature newborns with extremely low birth weight. The main pathophysiological factors identified in this pathology are immaturity of the smooth muscles, presence of vasodilator mediators and persistent hypoxaemia. Ductal-dependent cardiac malformations require drug therapy for keeping the permeability of the ductus arteriosus until the time of corrective surgery.
Case presentation: We present the case of an extremely low birth weight premature new-born, derived from twin pregnancy with suspected specific pathology, respectively feto-fetal transfusion syndrome, admitted to the Regional Centre of Neonatal Intensive Care Unit Tîrgu-Mureş.
Premature newborn with gestational age 31-32 weeks, extremely low birth weight, derived from twin pregnancy, with adequate prenatal follow up, was born by caesarean section for severe intrauterine growth restriction secondary to feto-fetal transfusion syndrome suspicion. The newborn developed respiratory distress syndrome by surfactant deficiency, intraventricular-haemorrhage grade I/II, and severe retinopathy. The detection of a systolic murmur in the second week of life, the diastolic theft revealed by trans-fontanellar ultrasound as well as lowered diastolic blood pressure values raised the suspicion of a patent ductus arteriosus and therefore specific treatment with ibuprofen, a cyclooxygenase inhibitor, was initiated. Progressive alteration of the newborn`s condition and the evidence of a coarctation of the aorta imposed the initiation of Prostaglandin E1 therapy and subsequent surgical correction.
Conclusions: Although beneficial, prophylactic or therapeutic closure of persistent ductus arteriosus may worsen the evolution of a newborn with a “silent” cardiac malformation and associated pathology.

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