Author Archives: administrare

Fluid Therapy from Friend to Foe

Raluca Fodor

Department of Anesthesiology and Intensive Care, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2023-0019

The general management of shock, or any syndrome characterized by inadequate tissue perfusion involves identifying and addressing the underlying cause while also reversing the disorder produced in any of the 4 components of the cardiovascular system (blood and fluid compartment, vascular system, heart and circulatory system) [1] through combined therapeutic methods that are based on rapid volume resuscitation, usually pursuing target goals. Although the “salvage, optimization, stabilization, de-escalation” mnemonic has been utilized as a broad framework for volume resuscitation since 2016 [2], the approach to fluid therapy in critically ill patients remains inconsistent with current clinical practice, contingent upon the practices adopted by individual healthcare institutions. [More]

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Kidney injury in critically ill patients with COVID-19 – From pathophysiological mechanisms to a personalized therapeutic model

Cosmin Balan1, Tudor Ciuhodaru2, Serban-Ion Bubenek-Turconi1,3

1 Prof. Dr. C. C. Iliescu Emergency Cardiovascular Diseases Institute, Bucharest, Romania
2 Prof. Dr. Nicolae Oblu Emergency Clinical Hospital, Iași, Romania
3 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania

DOI: 10.2478/jccm-2023-0023

Acute kidney injury is a common complication of COVID-19, frequently fuelled by a complex interplay of factors. These include tubular injury and three primary drivers of cardiocirculatory instability: heart-lung interaction abnormalities, myocardial damage, and disturbances in fluid balance. Further complicating this dynamic, renal vulnerability to a “second-hit” injury, like a SARS-CoV-2 infection, is heightened by advanced age, chronic kidney disease, cardiovascular diseases, and diabetes mellitus. Moreover, the influence of chronic treatment protocols, which may constrain the compensatory intrarenal hemodynamic mechanisms, warrants equal consideration. COVID-19-associated acute kidney injury not only escalates mortality rates but also significantly affects long-term kidney function recovery, particularly in severe instances. Thus, the imperative lies in developing and applying therapeutic strategies capable of warding off acute kidney injury and decelerating the transition into chronic kidney disease after an acute event. This narrative review aims to proffer a flexible diagnostic and therapeutic strategy that recognizes the multifaceted nature of COVID-19-associated acute kidney injury in critically ill patients and underlines the crucial role of a tailored, overarching hemodynamic and respiratory framework in managing this complex clinical condition.

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Fluids and early vasopressors in the management of septic shock: Do we have the right answers yet?

Carlos Sanchez E.1, Michael R. Pinsky2, Sharmili Sinha3, Rajesh Chandra Mishra4, Ahsina Jahan Lopa5, Ranajit Chatterjee6

1 Department of Critical Care Medicine, King Salman Hospital, Riyadh, Saudi Arabia
2 Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
3 Department of Critical Care Medicine, Apollo Hospitals, Bhubaneswar, India
4 Department of Critical Care Medicine, Ahmedabad Khyati Multi-speciality Hospitals, Ahmedabad, India. Department of Critical Care Medicine, Ahmedabad Shaibya Comprehensive Care Clinic, Ahmedabad, India
5 ICU and Emergency Department, Shahabuddin Medical College Hospital, Dhaka, Bangladesh
6 Department of Critical Care Medicine, accident and emergency, Swami Dayanand Hospital Delhi, India

DOI: 10.2478/jccm-2023-0022

Septic shock is a common condition associated with hypotension and organ dysfunction. It is associated with high mortality rates of up to 60% despite the best recommended resuscitation strategies in international guidelines. Patients with septic shock generally have a Mean Arterial Pressure below 65 mmHg and hypotension is the most important determinant of mortality among this group of patients. The extent and duration of hypotension are important. The two initial options that we have are 1) administration of intravenous (IV) fluids and 2) vasopressors, The current recommendation of the Surviving Sepsis Campaign guidelines to administer 30 ml/kg fluid cannot be applied to all patients. Complications of fluid over-resuscitation further delay organ recovery, prolong ICU and hospital length of stay, and increase mortality. The only reason for administering intravenous fluids in a patient with circulatory shock is to increase the mean systemic filling pressure in a patient who is volume-responsive, such that cardiac output also increases. The use of vasopressors seems to be a more appropriate strategy, the very early administration of vasopressors, preferably during the first hour after diagnosis of septic shock, may have a multimodal action and potential advantages, leading to lower morbidity and mortality in the management of septic patients. Vasopressor therapy should be initiated as soon as possible in patients with septic shock.

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Ease of intubation with McGrath videolaryngoscope and incidence of adverse events during tracheal intubation in COVID-19 patients: A prospective observational study

Faisal Shamim, Muhammad Sohaib, Khalid Samad, Muhammad Faisal Khan, Adil A. Manji, Asad Latif

Aga Khan University Hospital, Karachi, Pakistan

DOI: 10.2478/jccm-2023-0020

Background: Tracheal intubation in critically ill patients remains high-risk despite advances in equipment, technique, and clinical guidelines. Many patients with COVID-19 were in respiratory distress and required intubation that is considered an aerosol-generating procedure (AGP). The transition to videolaryngoscopy as a routine first line option throughout anesthetic and ICU practice has been reported. We evaluated the ease of intubation, success rate, use of accessory maneuvers and adverse outcomes during and 24 hours after intubation with the McGrath videolaryngoscope.
Methods: This was a prospective, observational single center study conducted at non-operating room locations that included all adults (>18 years old) with suspected or confirmed COVID-19 infection and were intubated by McGrath videolaryngoscope. The anesthesiologist performed tracheal intubation were requested to fill online data collection form. A co-investigator was responsible to coordinate daily with assigned consultants for COVID intubation and follow up of patients at 24 hours after intubation.
Results: A total of 105 patients were included in our study. Patients were predominantly male (n=78; 74.3%), their COVID status was either confirmed (n=97, 92.4%) or suspected (n=8, 7.6%). Most were intubated in the COVID ward (n=59, 56.2%) or COVID ICU (n=23, 21.9%). The overall success rate of intubation with McGrath in the first attempt was 82.9%. The glottic view was either full (n=85, 80.95%), partial (n=16, 15.24%) or none (n=4, 3.81%). During intubation, hypoxemia occurred in 18.1% and hypotension in 16.2% patients. Within 24 hours of intubation, pneumothorax occurred in 1.9%, cardiac arrest and return of spontaneous circulation in 6.7% and mortality in 13.3% of patients.
Conclusion: These results illustrate the ease and utility of the McGrath videolaryngoscope for tracheal intubation in COVID-19 patients. Its disposable blade is of significant value in protectin during tracheal intubation.

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COVID-19: A Possible Cause of Spontaneous Pneumoperitoneum

Patrícia Varela Ramos, Ana Maria Oliveira, Ângela Simas, Margarida Rocha Vera Cruz

Intensive Care Unit, Hospital de Vila Franca de Xira, Vila Franca de Xira, Portugal

DOI: 10.2478/jccm-2023-0018

Introduction: Pneumoperitoneum is the presence of air within the peritoneal cavity and is mostly caused by organ rupture. Spontaneous pneumoperitoneum accounts 5% to 15% of the cases and occurs in the absence of organ damage. The pulmonary origin of pneumoperitoneum is unusual, and probably associated with mechanical ventilation and alveolar leak. In patients with coronavirus disease 2019 (COVID-19) there are some reports of air leak, like pneumothorax, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema.
Case presentation: We present the case of a 70-year-old man with COVID-19 pneumonia admitted to the Intensive Care Unit (ICU). Since admission he was on Non-Invasive Ventilation (NIV), without improvement, needing Invasive Mechanical Ventilation (IMV) due to severe respiratory failure. Five days after IMV despite protective lung ventilation, massive spontaneous subcutaneous emphysema, pneumomediastinum and pneumoperitoneum were diagnosed. Besides initial conservative management 12 hours later, the patient developed abdominal compartment syndrome requiring percutaneous needle decompression.
Conclusions: Pneumoperitoneum can be considered a rare complication of COVID-19 pneumonia and its management, resulting not only from the viral pulmonary but also from secondary causes. Conservative management should be usually enough. However, in the presence of abdominal compartment syndrome prompt recognition and treatment are crucial and eventually lifesaving.

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Post-Operative Delirium Masking Acute Angle Closure Glaucoma

Zariel Jiaying Sim1, Xing Jieyin2, Thangavelautham Suhitharan2

1 Singhealth, Singapore, Singapore
2 Singapore General Hospital, Singapore, Singapore

DOI: 10.2478/jccm-2023-0016

Introduction: Acute angle closure glaucoma (AACG) is an ophthalmological emergency, and can lead to the devastating consequence of permanent vision loss if not detected and treated promptly. We present a case of an atypical presentation of unilateral AACG on post operative day (POD) 1, after a prolonged operation under general anaesthesia (GA).
Case presentation: A 65-year-old female underwent a 16 hour long operation for breast cancer and developed an altered mental status with a left fixed dilated pupil on POD 1. She was intubated to secure her airway in view of a depressed consciousness level and admitted to the intensive care unit. Initial blood investigations and brain imaging were unremarkable. On subsequent review by the ophthalmologist, a raised intraocular pressure was noted and she was diagnosed with acute angle closure glaucoma. She was promptly started on intravenous acetazolamide and pressure-lowering ophthalmic drops. Her intraocular pressure normalized in the next 24 hours with improvement in her mental status to baseline.
Conclusion: AACG needs to be consistently thought of as one of the top differentials in any post-operative patient with eye discomfort or abnormal ocular signs on examination. A referral to the ophthalmologist should be made promptly once AACG is suspected.

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Awake Prone Decubitus Positioning in COVID-19 Patients: A Systematic Review and MetaAnalysis

Agustin García1, Rita Galeiras1, Sonia Pertega-Díaz2

1 A Coruna University Hospital, A Coruña, Spain
2 University of A Coruna, A Coruña, Spain

DOI: 10.2478/jccm-2023-0014

To date, recommendations for the implementation of awake prone positioning in patients with hypoxia secondary to SARSCoV2 infection have been extrapolated from prior studies on respiratory distress. Thus, we carried out a systematic review and metaanalysis to evaluate the benefits of pronation on the oxygenation, need for endotracheal intubation (ETI), and mortality of this group of patients. We carried out a systematic search in the PubMed and Embase databases between June 2020 and November 2021. A randomeffects metaanalysis was performed to evaluate the impact of pronation on the ETI and mortality rates. A total of 213 articles were identified, 15 of which were finally included in this review. A significant decrease in the mortality rate was observed in the group of pronated patients (relative risk [RR] = 0.69; 95% confidence interval [CI]: 0.480.99; p = 0.044), but no significant effect was observed on the need for ETI (RR = 0.79; 95% CI: 0.631.00; p = 0.051). However, a subgroup analysis of randomized clinical trials (RCTs) did reveal a significant decrease in the need for this intervention (RR = 0.83; 95% CI: 0.710.97). Prone positioning was found to significantly reduce mortality, also diminishing the need for ETI, although this effect was statistically significant only in the subgroup analysis of RCTs. Patients’ response to awake prone positioning could be greater when this procedure is implemented early and in combination with noninvasive mechanical ventilation (NIMV) or highflow nasal cannula (HFNC) therapy.

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Artificial Intelligence: The Next Blockbuster Drug in Critical Care?

Razvan Azamfirei

Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

DOI: 10.2478/jccm-2023-0017

The realm of critical care medicine is always waiting for the game-changing innovation – that elusive breakthrough poised to dramatically transform practice and yield remarkable results. Various contenders have come and gone: surfactant therapy, synthetic colloids, drotrecogin alfa [1-3]. While some have been consigned to the annals of history, a select few, such as low-tidal-volume ventilation, have endured [4]. Others re-emerge time and again, hoping that they’ll have an evidence-based role somewhere. The level of excitement is not always correlated with the staying power of the innovation, and sometimes the hype can overshadow the reality. [More]

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End-of-life Care in the Intesive Care Unit and Nursing Roles in Communicating with Families

Anastasios Tzenalis1, Helen Papaemmanuel2, George Kipourgos2, George Elesnitsalis2

1 University Of Patras, Patra, Greece
2 General Hospital of Thessaloniki Papageorgiou, Greece

DOI: 10.2478/jccm-2023-0013

Introduction: Professionals in Intensive Care Units face death, shifting their role from therapists to caregivers in end-of-life management. The nursing attitude and response to death has been shown to affect the quality of palliative care and end-of-life services that are interrelated services. Aim of the study: The aim of this research was to evaluate the professional attitude of nurses towards the care of the families of critically ill patients in the ICU, leading to the emergence of specific attitudes, relating them to their demographic and professional characteristics, with the aim of drawing conclusions for the improvement of quality in end-of-life care.
Material and Methods: The sample of the study was 81 nurses from a large tertiary hospital. Participants completed the “Nurse Activities for Communicating with Families” (NACF) questionnaire. The questions are about ways in which nurses can help the patient’s family during the patient’s stay in the ICU.
Results: The results revealed that the nurses took actions related to the information and psychological support of the patient’s family. On the contrary, they did not focus on the spiritual / religious needs of the patient and the needs of the family based on their cultural background.
Conclusions: The professional treatment of staff is characterized by compassion and empathy, but it is necessary to train them on important issues related to diversity, including the religious, spiritual values ​​and beliefs of patients and their relatives.

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Therapeutic Hypothermia Following Cardiopulmonary Arrest: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

Robert Maclaren1, Sterling Torian2, Tyree Kiser1, Scott Mueller3, Paul Reynolds4

1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
2 Department of Pharmacy, TriStar Centennial Medical Center, Nashville, Tennessee, USA
3 Department of Pharmacy, University of Colorado Hospital, Aurora, Colorado, USA
4 Department of Pharmacy, VA Eastern Colorado Health Care System, Aurora, Colorado, USA

DOI: 10.2478/jccm-2023-0015

Introduction: The risk-benefit profile of therapeutic hypothermia is controversial with several randomized controlled trials providing conflicting results. Aim of Study: The purpose of this systematic review and meta-analysis was to determine if therapeutic hypothermia provides beneficial neurologic outcomes relative to adverse effects.
Material and Methods: MEDLINE and EMBASE databases were searched for randomized controlled trials of post-cardiac arrest patients comparing therapeutic hypothermia (~33 degrees Celsius) to normothermia or the standard of care (36 – 38 degrees Celsius). Data were collected using the Covidence systematic review software. Statistical analysis was performed by Review Manager software. Risk of bias, sensitivity, and heterogeneity were analyzed using the Cochran’s Collaboration tool, trial sequential analysis (TSA) software, and I2 statistic respectively.
Results: A total of 1825 studies were screened and 5 studies (n=3614) were included. No significant differences existed between the hypothermia group and normothermia for favorable neurologic outcome (risk ratio [RR] 1.17, 95% confidence interval [CI] 0.97 to 1.41) or all-cause mortality (RR 0.97, 95% CI 0.89 to 1.05). When compared to normothermia, the hypothermia group had greater risk of adverse effects (RR 1.16, 95% CI 1.04 to 1.28), which was driven by the onset of arrhythmias. Subgroup analyses revealed that therapeutic hypothermia provided greater neurologic benefit in trials with a higher percentage of subjects with shockable rhythms (RR 0.73, 95% CI 0.6 to 0.88). Trial sequential analysis revealed statistical futility for therapeutic hypothermia and favorable neurologic outcome, mortality, and adverse effects.
Conclusions: Therapeutic hypothermia does not provide consistent benefit in neurologic outcome or mortality in the general cardiac arrest population. Patients with shockable rhythms may show favorable neurologic outcome with therapeutic hypothermia and further investigation in this population is warranted. Any potential benefit associated with therapeutic hypothermia must be weighed against the increased risk of adverse effects, particularly the onset of arrhythmias.

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