Category Archives: issue

Effects of Extracorporeal Membrane Oxygenation Initiation on Oxygenation and Pulmonary Opacities

DOI: 10.2478/jccm-2020-0040

Introduction: There is limited data on the impact of extracorporeal membrane oxygenation (ECMO) on pulmonary physiology and imaging in adult patients. The current study sought to evaluate the serial changes in oxygenation and pulmonary opacities after ECMO initiation.
Methods: Records of patients started on veno-venous, or veno-arterial ECMO were reviewed (n=33; mean (SD): age 50(16) years; Male: Female 20:13). Clinical and laboratory variables before and after ECMO, including daily PaO2 to FiO2 ratio (PFR), were recorded. Daily chest radiographs (CXR) were prospectively appraised in a blinded fashion and scored for the extent and severity of opacities using an objective scoring system.
Results: ECMO was associated with impaired oxygenation as reflected by the drop in median PFR from 101 (interquartile range, IQR: 63-151) at the initiation of ECMO to a post-ECMO trough of 74 (IQR: 56-98) on post-ECMO day 5. However, the difference was not statistically significant. The appraisal of daily CXR revealed progressively worsening opacities, as reflected by a significant increase in the opacity score (Wilk’s Lambda statistic 7.59, p=0.001). During the post-ECMO period, a >10% increase in the opacity score was recorded in 93.9% of patients. There was a negative association between PFR and opacity scores, with an average one-unit decrease in the PFR corresponding to a +0.010 increase in the opacity score (95% confidence interval: 0.002 to 0.019, p-value=0.0162). The median opacity score on each day after ECMO initiation remained significantly higher than the pre-ECMO score. The most significant increase in the opacity score (9, IQR: -8 to 16) was noted on radiographs between pre-ECMO and forty-eight hours post-ECMO. The severity of deteriorating oxygenation or pulmonary opacities was not associated with hospital survival.
Conclusions: The use of ECMO is associated with an increase in bilateral opacities and a deterioration in oxygenation that starts early and peaks around 48 hours after ECMO initiation.

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Post-Traumatic Stress Disorder and Burnout in Healthcare Professionals During the SARS-CoV-2 Pandemic: A Cross-Sectional Study

DOI: 10.2478/jccm-2020-0042

Introduction: Healthcare professionals who are directly involved in the diagnosis, treatment, and general care of patients with SARS-CoV-2 are at risk of developing adverse psychological reactions. A cross-sectional study of healthcare professionals aimed to determine the impact of the SARS-CoV-2 pandemic on the mental health of healthcare professionals in two of the largest referral hospitals in Athens, Greece.
Methods: The study was conducted in the two largest SARS-CoV-2 referral hospitals in Athens, Greece. An assessment and the interrelationship of post-traumatic stress disorder, using the Impact of Event Scale-Revised [IES-R]) and burnout, using the Maslach Burnout Inventory [MBI]) was carried out.
Results: A total of 162 subjects were enrolled in the study. Fifty-six (35%) had an IES-R score > 33, suggesting post-traumatic stress disorder. Forty-nine (30%) had an MBI score > 27. Seventy-five (46%) had a personal accomplishment score of < 33 and 46 (28%) had a depersonalization score >10. Stepwise backward logistic regression revealed that the only independent variable that was retained regarding the presence of post-traumatic stress disorder was the emotional exhaustion score of the MBI (at a cut-off of 24 in this scale, the 95% CI of the odds ratio for the presence of post-traumatic stress disorder was 1.077-1.173).
Conclusions: In this sample of first-line Greek healthcare professionals against SARS-CoV-2, most of them were proven to be quite resilient to this challenge. One-third of them had post-traumatic stress disorder, which depended on their degree of emotional exhaustion. Healthcare professionals, as represented by this study, performed their duties without feeling helpless and developing adverse psychological reactions.

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COVID -19 complicated by Acute Respiratory Distress Syndrome, Myocarditis, and Pulmonary Embolism. A case report

DOI: 10.2478/jccm-2020-0041

A 49-year-old female Qatari woman, with no past medical history, presented at a hospital complaining of a history of cough and shortness of breath. The patient tested positive for severe acute respiratory syndrome (ARDS) and COVID-19. Subsequently, her course of treatment was complicated by severe acute respiratory distress syndrome, pulmonary embolism and severe myocarditis requiring treatment with venous-arterial extracorporeal membrane oxygenation as a bridge to complete recovery.

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Atypical Variant of Guillain Barre Syndrome in a Patient with COVID-19

DOI: 10.2478/jccm-2020-0038

Objective: A rare variant Miller Fisher Syndrome overlap with Guillain Barre Syndrome is described in an adult patient with SARS-COV-2 infection.
Case Presentation: The clinical course of a 45-year-old immunosuppressed man is summarized as a patient who developed ataxia, ophthalmoplegia, and areflexia after upper respiratory infection symptoms began. A nasopharyngeal swab was positive for COVID-19 polymerase chain reaction. He progressed to acute hypoxemic and hypercapnic respiratory failure requiring intubation and rapidly developed tetraparesis. Magnetic resonance imaging of the spine was consistent with Guillain Barre Syndrome. However, the clinical symptoms, along with positive anti-GQ1B antibodies, were consistent with Miller Fisher Syndrome and Guillain Barre Syndrome overlap. The patient required tracheostomy and had limited improvement in his significant neurological symptoms after several months.
Conclusions: The case demonstrates the severe neurological implications, prolonged recovery and implications in the concomitant respiratory failure of COVID-19 patients with neurological symptoms on the spectrum of disorders of Guillain Barre Syndrome.

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Right Heart Thrombus in an Adult COVID-19 Patient: A Case Report

DOI: 10.2478/jccm-2020-0039

Introduction: Right heart thrombus (RiHTh) can be considered a rare and severe condition associated with thromboembolic phenomena. A case is described of a COVID-19 patient presenting with an isolated thrombus in the right ventricle.
Case presentation: An 80-years-old Caucasian male was admitted in an intensive care unit (ICU) for COVID-19 related acute respiratory distress syndrome. The patient showed signs of hemodynamic instability, elevated cardiac troponin I and altered coagulation. On further assessment, a thrombotic mass near the apex of the right ventricle was detected. Moreover, the apex and the anteroseptal wall of the right ventricle appeared akinetic. Following the administration of a therapeutic dose of unfractionated heparin over a forty-eight hour period, re-evaluation of the right chambers showed that the thrombotic mass had resolved entirely.
Conclusion: COVID-19 patients could constitute a population at risk of RiHTh. Routine use of echocardiography and a multidisciplinary approach can improve the management of this condition.

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Acute Eosinophilic Pneumonia Due to Vaping-Associated Lung Injury

DOI: 10.2478/jccm-2020-0037

A case is described of a 29-year-old female who presented with acute hypoxic respiratory failure due to acute eosinophilic pneumonia, associated with the use of electronic cigarettes to vape tetrahydrocannabinol (THC), together with the contemporary clinical understanding of the syndrome of electronic-cigarette associated lung injury (EVALI). Attention is drawn to acute eosinophilic pneumonia as a potential consequence of vaping-associated lung injury to understand the diagnostic evaluations and therapeutic interventions for acute eosinophilic pneumonia associated with vaping THC.

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Cardiopulmonary Arrest Following a Single 25 mg Dose of Quetiapine: A Case Report

DOI: 10.2478/jccm-2020-0035

Introduction: Quetiapine is commonly used in intensive care units (ICU) to treat delirium. Cardiopulmonary arrest caused by low dose quetiapine is unreported. Only two cases in the literature have reported acute respiratory failure after single doses of 50mg and 100mg respectively. We report a case of cardiopulmonary arrest in a patient after the administration of a single 25mg dose of quetiapine.
Case presentation: A 72-year-old Chinese female with multiple cardiovascular co-morbidities was admitted to the ICU intubated, following complications from an elective endovascular repair of an infrarenal abdominal aortic aneurysm. She was alert and extubated the following day. She subsequently showed signs of delirium and was administered a single 25mg dose of oral quetiapine. Seven hours after ingestion, she developed type 2 respiratory failure and eventually cardiopulmonary arrest. She was successfully resuscitated and other causes for cardiopulmonary arrest were excluded. Twenty-four hours following her cardiopulmonary arrest, her respiratory failure had completely reversed and she was extubated uneventfully.
Conclusion: This case report demonstrates that a single dose of oral quetiapine 25mg is sufficient to cause respiratory failure and cardiopulmonary arrest. Caution is advised when prescribing quetiapine in the elderly, especially in those with impaired drug clearance.

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Hemoadsorption in Critical Care – It Is a Useful or a Harmful Technique?

DOI: 10.2478/jccm-2020-0036

Since ancient times it has been known that elimination of toxins from the body helps to relieve symptoms, heal patients; for that hot baths, sweating techniques, enemas, and phlebotomy were used in the treatment of severe diseases.
Blood purification is still practiced today, but using modern techniques. The theoretical basis for the elimination of toxins by osmosis and dialysis through a semipermeable membrane was laid by Thomas Graham in the 19th century, but the first “artificial kidney”, was built and used successfully by Kolff only in 1943, in patients with acute renal failure.
Since then, blood purification has developed a lot, today it is possible to eliminate endo- and exotoxins in acute and chronic renal failure, liver failure, intoxications with various substances, but also the elimination of mediators formed in excess in sepsis and systemic inflammatory syndrome of other etiologies, and elimination of immune complexes in autoimmune and graft versus host diseases.

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The Prolonged Use of VV ECMO Support in COVID-19: A Case Report

DOI: 10.2478/jccm-2020-0034

COVID-19 has resulted in unprecedented global health and economic challenges. The reported mortality in patients with COVID-19 requiring mechanical ventilation is high. VV ECMO may serve as a lifesaving rescue therapy for a minority of patients with COVID-19; however, its impact on overall survival of these patients is unknown. To date, few reports describe successful discharge from ECMO in COVID-19 after a prolonged ECMO run. The only Australian case of a COVID-19 patient, supported by prolonged VV ECMO in conjunction with prone ventilation, complicated by significant airway bleeding, and successfully decannulated after forty-two days, is described. VV ECMO is a resource-intense form of respiratory support. Providing complex therapies such as VV ECMO during a pandemic has its unique challenges. This case report provides a unique insight into the potential clinical sequelae of COVID-19, supported in an intensive care environment which was not resource-limited at the time, and adds to the evolving experience of prolonged VV ECMO support for ARDS with a goal to lung recovery.

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