Category Archives: Case Report

Sudden Deterioration of a Young Patient
During Elective Cesarean Section. Amniotic Fluid Embolism… or Else? – A Case Report

DOI: 10.2478/jccm-2024-0001

Sudden respiratory and circulatory collapse during or immediately after delivery, vaginal or surgical, can have many causes that can lead to poor maternal outcomes. A pregnancy-induced amniotic fluid embolism and anaphylaxis are two distinct medical conditions that appear similar clinically but have very different underlying mechanisms and treatment approaches. Amniotic fluid embolism is a rare but life-threatening obstetric emergency that leads to a systemic inflammatory response that can be easily confounded with an anaphylactic reaction. We report the case of a patient with no comorbidities or allergies before the current pregnancy that was proposed for delivery by C-Section under spinal anesthesia. After delivery of the placenta and administering the test dose of antibiotic, the patient developed sudden circulatory collapse, altered neurological status, and critical respiratory distress. At that point, the two presumed diagnoses were amniotic fluid embolism and anaphylaxis. Concurrently with the diagnostic pathway, supportive measures (intubation, mechanical ventilation, hemodynamic support) were taken. The clinical evolution was favorable, and after day three, the patient was discharged from the hospital. Our case highlights the significance of promptly distinguishing between anaphylaxis and amniotic fluid embolism to facilitate the timely management of the critical situation.

Full text: PDF

Effectiveness of Minitracheostomy After Extubation in Patients with Pneumonia at High Risk of Reintubation: A Case Series

DOI: 10.2478/jccm-2023-0029

Introduction: Minitracheostomy involves the percutaneous insertion of a 4-mm-diameter cricothyroidotomy tube for tracheal suctioning to facilitate the clearance of airway secretions. The advantage of using the minitracheostomy is in the clearance of secretions, however data on their usefulness for respiratory failure after extubation is limited.
Aim of the study: We aimed to assess the use of minitracheostomy for patients with challenging extubation caused by significant sputum.
Material and Methods: We conducted a retrospective analysis of consecutive case series. We analyzed the data of 31 patients with pneumonia. After minitracheostomy, the primary endpoints of reintubation within 72 hours and clinical effects, including mortality, length of intensive care unit (ICU), or hospital stay, were assessed. The successful extubation group included patients who did not require reintubation within 72 hours. Conversely, the reintubation group consisted of patients mandating reestablishment of intubation within 72 hours.
Results: Among those who underwent minitracheostomy after extubation, 22 (71%) underwent successful extubation and 9 underwent reintubation (reintubation rate: 29%). The in-hospital mortality rates after 30 days were 18.2% in the successful extubation group and 22.2% in the reintubation group. The ICU and hospital lengths of stay were 11 days (interquartile range: 8–14.3 days) and 23 days (interquartile range: 15.5–41 days), respectively, in the successful extubation group; they were 14 days (interquartile range: 11–18.5 days) and 30 days (interquartile range: 16–45.5 days), respectively, in the reintubation group.
Conclusions: The prophylactic use of minitracheostomy may be an option as a means of reducing reintubation in patients with pneumonia who are at very high risk of reintubation.Keywords: Airway extubation, weaning, ventilator weaning, respiration, tracheostomy, sputum, pneumonia
Keywords: airway extubation, ventilator weaning, tracheostomy, sputum, pneumonia

Full text: PDF

COVID-19: A Possible Cause of Spontaneous Pneumoperitoneum

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.

Full text: PDF

Post-Operative Delirium Masking Acute Angle Closure Glaucoma

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.

Full text: PDF

Multiple Organ Dysfunction Secondary to Herpes Simplex Virus -1 Reactivation After Treatment With Dexamethasone and Sarilumab for Covid-19 Disease

DOI: 10.2478/jccm-2023-0010

Introduction: The immunological response to the SARS-CoV-2 virus and the treatment of COVID-19 disease present a potential susceptibility to viral reactivation, particularly Herpes simplex virus-1 (HSV-1).
Case Presentation: A 49-year-old female presented to hospital with severe COVID-19 pneumonitis and was given sarilumab and dexamethasone. She was intubated and ventilated in the intensive care unit (ICU) and initially demonstrated biochemical and clinical evidence of improvement. This was followed by a severe acute deterioration in respiratory, renal, and cardiovascular function, accompanied by a vesicular rash on the face. Polymerase chain reaction confirmed HSV-1 reactivation and treatment with acyclovir was commenced. After 49 days in ICU the patient was successfully weaned from all organ support, and she made a satisfactory recovery.
Conclusions: HSV-1 reactivation is common in COVID-19 and likely contributes to poorer clinical outcomes. The mechanism causing susceptibility to viral reactivation is not clearly defined, however, the development of critical illness induced immunosuppression via dysfunction of interferon and interleukin pathways is a likely mechanism. This effect could be perpetuated with immunosuppressant medications, although further research is needed to characterise this phenomenon.

Full text: PDF

Brief Report: Diabetic Keto-Acidosis (DKA) Induced Hypothermia May Be Neuroprotective in Cardiac Arrest

DOI: 10.2478/jccm-2023-0004

Despite the decreased survival associated with diabetes with out-of-hospital cardiac arrest and the overall low survival to hospital discharge, we would like to present two cases of OHCA in diabetics who despite prolonged resuscitation efforts had complete neurological recovery likely due to concomitant hypothermia. There is a steady decreasing rate of ROSC with longer durations of CPR so that outcomes are best when <20 minutes compared to prolonged resuscitation efforts (>30-40 minutes). It has been previously recognized that hypothermia prior to cardiac arrest can be neurologically protective even with up to 9 hours of cardiopulmonary resuscitation. Hypothermia has been associated with DKA and although often indicates sepsis with mortality rates of 30-60%, it may indeed be protective if occurring prior to cardiac arrest. The critical factor for neuroprotection may be a slow drop to a temperature <25⁰C prior to OHCA as is achieved in deep hypothermic circulatory arrest for operative procedures of the aortic arch and great vessels. It may be worthwhile continuing aggressive resuscitation efforts even for prolonged periods before attaining ROSC for OHCA in patients found hypothermic from metabolic illnesses as compared to only from environmental exposures (avalanche victims, cold water submersions, etc.) as has been traditionally reported in the medical literature.

Full text: PDF

The Use of Caffeine Citrate for Respiratory Stimulation in Acquired Central Hypoventilation Syndrome: A Case Series

DOI: 10.2478/jccm-2023-0003

Introduction: Caffeine is commonly used as a respiratory stimulant for the treatment of apnea of prematurity in neonates. However, there are no reports to date of caffeine used to improve respiratory drive in adult patients with acquired central hypoventilation syndrome (ACHS).
Presentation of case series: We report two cases of ACHS who were successfully liberated from mechanical ventilation after caffeine use, without side effects. The first case was a 41-year-old ethnic Chinese male, diagnosed with high-grade astrocytoma in the right hemi-pons, intubated and admitted to the intensive care unit (ICU) in view of central hypercapnia with intermittent apneic episodes. Oral caffeine citrate (1600mg loading followed by 800mg once daily) was initiated. His ventilator support was weaned successfully after 12 days. The second case was a 65-year-old ethnic Indian female, diagnosed with posterior circulation stroke. She underwent posterior fossa decompressive craniectomy and insertion of an extra-ventricular drain. Post-operatively, she was admitted to the ICU and absence of spontaneous breath was observed for 24 hours. Oral caffeine citrate (300mg twice daily) was initiated and she regained spontaneous breath after 2 days of treatment. She was extubated and discharged from the ICU.
Conclusion: Oral caffeine was an effective respiratory stimulant in the above patients with ACHS. Larger randomized controlled studies are needed to determine its efficacy in the treatment of ACHS in adult patients.

Full text: PDF

Ramping Position to Aid Non-invasive Ventilation (NIV) in Obese Patients in the ICU

DOI: 10.2478/jccm-2023-0002

Introduction: The ramping position is recommended to facilitate pre-oxygenation and mask ventilation of obese patients in anaesthetics via improving the airway alignment.
Presentation of case series: Two cases of obese patients admitted to the intensive care unit (ICU) with type 2 respiratory failure. Both cases showed obstructive breathing patterns on non-invasive ventilation (NIV) and failed resolution of hypercapnia. Ramping position alleviated the obstructive breathing pattern and hypercapnia was subsequently resolved.
Conclusion: There are no available studies on the rule of the ramping position in aiding NIV in obese patients in the ICU. Accordingly, this case series is significantly important in highlighting the possible benefits of the ramping position for obese patients in settings other than anaesthesia.

Full text: PDF

Successful Extracorporeal Blood Purification Therapy Using Double Haemoadsorption Device in Severe Endotoxin Septic Shock: A Case Report

DOI: 10.2478/jccm-2022-0028

Introduction: In patients admitted to the Intensive Care Unit (ICU), sepsis can lead to acute kidney injury (AKI), which may require the initiation of continuous renal replacement therapy (CRRT) in 15-20% of cases. There is no consensus about the best extracorporeal treatment to choose in septic patients with AKI.
Case presentation: We describe the case of a 70-year-old woman admitted to the ICU with a severe endotoxin septic shock due to Neisseria meningitidis serogroup C. Despite prompt medical intervention, including fluid resuscitation, high dose vasopressor, inotrope support, and broad-spectrum antimicrobial treatment, in a few hours patient’s haemodynamic worsened and she developed multi-organ failure, including severe AKI, requiring CRRT. So, continuous veno-venous haemodiafiltration was started, using an oXiris® haemodiafilter set, in series with an adsorber device (CytoSorb®). After 48 hours of this combined extracorporeal treatment, haemodynamic parameters improved, allowing a significant reduction of the vasoactive therapy, with a concomitant decrease in endotoxin and inflammatory markers serum levels. In the following days patient’s conditions still improved and renal function recovered.
Conclusions: Timely extracorporeal blood purification therapy, using a double haemoadsorption device, may be effective in the management of severe septic shock.

Full text: PDF

Pharmacokinetics of Teicoplanin in a Patient with Coronavirus Disease 2019 Receiving Veno-venous Extracorporeal Membrane Oxygenation

DOI: 10.2478/jccm-2022-0021

Introduction: Patients with severe coronavirus disease 2019 (COVID-19) receiving ventilation or pulmonary support via veno-venous extracorporeal membrane oxygenation (VV-ECMO) can be infected with drug-resistant bacteria. When introducing VV-ECMO, the changes in serum antibiotic concentration should be considered due to an increased volume of distribution (Vd). However, no pharmacokinetic study has assessed teicoplanin (TEIC) treatment in patients with COVID-19 receiving VV-ECMO.
Case presentation: A 71-year-old man diagnosed with COVID-19 visited a primary hospital. His oxygenation conditions worsened despite treatment with favipiravir and methylprednisolone as well as oxygen therapy. After his transfer to our center, tracheal intubation and steroid pulse therapy were initiated. Seven days after admission, VV-ECMO was performed. TEIC was administered for secondary bacterial infection. The serum TEIC concentration remained within the therapeutic range, indicating that VV-ECMO did not significantly affect TEIC pharmacokinetics. VV-ECMO was discontinued 17 days after admission. However, he developed multi-organ disorder and died 42 days after admission.
Conclusion: As TEIC prevents viral invasion, it may be used with ECMO in patients with COVID-19 requiring ventilation; however, the altered pharmacokinetics of TEIC, such as increased Vd, should be considered. Therefore, TEIC pharmacokinetics in VV-ECMO should be assessed in future studies with an appropriate number of patients.

Full text: PDF