Category Archives: Editorial

The implementation gap in critical care: From nutrition to ventilation

Razvan Azamfirei

Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA

DOI: 10.2478/jccm-2025-0011

Critical care medicine pushes boundaries. We talk about personalized medicine and wax poetic on sophisticated trial design, all while debating using diaphragmatic ultrasound for ventilator weaning. Our excitement about the latest mechanical circulatory support device or novel vasopressor is matched only by the rush to share the latest “groundbreaking” meta-analysis – inevitably analyzing the same five trials as the last one, just with a different statistical twist. None of this is to say that such discussions do not have merit. But our fascination with tomorrow’s breakthroughs disguises a more fundamental challenge: we consistently fail to deliver basic, routine care at the bedside.[More]

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Tracheoesophageal Iatrogenic Fistulas in ICU: Still a Pandora’s Box?

Radu Stoica

Clinical Hospital Sanador Bucharest, Romania

DOI: 10.2478/jccm-2024-0044

Tracheoesophageal fistulas (TEF) in the ICU are still considered a relatively rare, but life-threatening complication of prolonged intubation, with an incidence of approximately 0.5% of cases [1]. Classically, their occurrence was considered the result of the direct interaction between two mechanical factors: the endotracheal tube (ETT) or the tracheostomy tube placement on the membranous wall of the trachea, and the esophageal feeding tube that affects esophageal mucosa, leading to ischemic lesions and decubitus injury. The question that arises is why, despite this simple explanation, the incidence of TEF remains low? In reality, the occurrence of TEF in ICU is related to the complex interactions between patients’ comorbidities and the particularities of pathophysiology and management in critically ill patients, leading to local tissue metabolic disorders and favoring fistulas’ occurrence. Malnutrition, diabetes, chronic anemia, reflux esophagitis, prolonged inflammation, sepsis, hemodynamic instability, prolonged hypoxemia, vasoactive drugs or corticosteroids are the mainly factors favoring fistulas’ development. [More]

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Endocrine Disorders in Critically Ill Patients – The Smooth Criminal?

Bianca-Liana Grigorescu, Raluca Ștefania Fodor

George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu-Mures, Romania

DOI: 10.2478/jccm-2024-0034

The hallmark of critical illness is the rapid initiation of numerous physiologic processes in an effort to reestablish homeostasis. Thus, critical illness can be considered the result of an acute physical stress that acts as a trigger for an acute aggressive inflammatory response [1,2].
The inflammatory response occurs early after primary injury, almost concomitant with coagulation cascade activation, micro- and macrovascular alterations, and hypothalamic-pituitary-peripheral axis disorders, proportionate to the severity of illness. In this context, “The Triad of Critically Illness” is a lethal interplay involving three key factors: inflammation, coagulopathy and hormonal imbalance. [More]

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The Role of Microcirculation in Haemodynamics: A Journey from Atlas to Sisyphus

Constantin Bodolea

University of Medicine and Pharmacy Iuliu Hatieganu Cluj Napoca, Romania

DOI: 10.2478/jccm-2024-0021

Microcirculation, through its complex network of vessels (arterioles, capillaries and venules), plays a pivotal role in maintaining cellular functions. Located between the macrocirculatory system- the heart and large vessels, and the interstitial environment, microcirculation acts as a gateway for oxygen supply (O2), removal of carbon dioxide (CO2), delivery of nutrients and hormones, and plays a crucial role in the immune response, thermoregulation and coagulation control.
In order to maintain an adequate supply of oxygen and nutrients to cells and tissues at the levels of the macro-, regional- and microcirculatory fields, the physiological mechanisms that regulate blood perfusion are closely interrelated.
This functional interdependence between macrohaemodynamics, microhaemodynamics, interstitial space and subcellular structures (such as the mitochondria, the bioenergetic factory of the organism) was demonstrated by Dr. Henry Weil, who explicitly defined the condition of acute circulatory failure or circulatory shock [1,2]. In his work, he highlights the catastrophic consequences of arterial hypotension associated with tissue hypoperfusion in various states of shock. [More]

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Optimizing Nutrient Uptake in the Critically Ill: Insights into Malabsorption Management

Cristian Cobilinschi1,2, Liliana Mirea1,2

1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
2 Anesthesiology and Intensive Care Clinic, Clinical Emergency Hospital of Bucharest, Romania

DOI: 10.2478/jccm-2024-0012

It has already been stated that nutritional support represents a crucial component in the care of critically ill patients [1]. Prolonged negative energy balance during intensive care stay was confirmed as an independent risk factor for mortality. High metabolic demand encountered for critically ill patients may cause significant energy deficits responsible for increased risk of infection, prolonged mechanical ventilation and ICU stay [2-4].
Aditionally, providing nutritional support in ICU patients is often deemd challenging, as enteral feeding intolerance devolps secondary to gastrointestinal dysfunction [5]. Exccesive antimicrobial usage along with associated risk of nosocomial diarrhea may further exacerbate feeding intolerance. [More]

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The Human Microbiome in Intensive Care – A Journey Forward?

Leonard Azamfirei

Department of Anesthesia and Intensive Care, George Emil Palade University of Medicine, Pharmacy, Science and Technology, Târgu Mureș, Romania

DOI: 10.2478/jccm-2023-0032

The human microbiome, defined as a personal, genomic signature of our latent or manifest infectious profile (bacterial, viral, fungal), located predominantly in the digestive tract, opens the door to personalized medicine studies on a scale larger than the human genome in terms of data that can be analyzed and interpreted. Compared to the human genome, which has approximately 23,000 genes, the European Metagenomics of the Human Intestinal Tract and the Human Microbiome Project have reported 3.3 million non-redundant microbial genes [1]. [More]

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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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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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Rebranding Nutritional Care for Critically Ill Patients

Liliana Elena Mirea, Cristian Cobilinschi, Ioana Marina Grințescu

Anaesthesia and Intensive Care Clinic, Clinical Emergency Hospital of Bucharest
“Carol Davila” University of General Medicine, Bucharest

DOI: 10.2478/jccm-2023-0008

Since the organic and molecular roles and function of nutrients in supporting homeostasis for hospitalized patients have been already stated, remarkable advances have been achieved in the field of clinical nutrition [1]. Replacing the old terminology of “nutritional support” with the new concept of “nutritional therapy” both European Society for Clinical Nutrition and Metabolism (ESPEN) and American Society for Enteral and Parenteral Nutrition (ASPEN) emphasized that adequate nutrients administration reduces oxidative stress, metabolic response and sustains the immune response [1, 2]. The persistently increased prevalence of hospital malnutrition, inappropriate nutritional support during hospitalisation contributes undeniably to an increased mortality, especially in intensive care units [3].
In order to promote the importance of nutritional care and increase awareness among authorities and clinicians, “The International Declaration on the Human Right to Nutritional Care” was adopted during ESPEN Congress 2022 in Vienna. This Declaration highlights that nutritional therapy is a human right in the same manner as the right to food and health [4]. Moreover, all the undersigned societies, including Romanian Society of Enteral and Parenteral Nutrition (ROSPEN), raise awareness of the high prevalence of disease-related malnutrition along with the lack of access to appropriate nutritional support during and after hospitalisation. [More]

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In between Opioid Crisis and the Need to Treat Pain, Where Do We Stand?

Daniela Ionescu1, Simona Margarit2

1 Department of Anesthesia and Intensive Care I, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
2 Department of Anesthesia and Intensive Care, O Fodor Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania

DOI: 10.2478/jccm-2022-0029

Acute and chronic pain are very disturbing conditions for the patient, with numerous implications on the short- and long-term outcome of patients [1]. While acute pain is experienced mostly after surgery, and in some other medical conditions as well, chronic pain may be the symptom or the result of numerous medical conditions among which cancer, muscle-skeletal or neurodegenerative diseases and surgery or persistent inflammation are, probably, the main causes [2].
This is why guidelines, drugs and medical interventions have been proposed to treat acute and chronic pain [3, 4]. While acute pain, both mild or severe is well manageable with treatment, chronic pain may be very disturbing and debilitating for the patients, especially in patients with cancer, neurodegenerative or muscle-skeletal disorders and is generally much more difficult to treat [5]. [More]

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