Category Archives: Original Research

Evaluation of monitoring critical ill children with traumatic brain injury

Merve Misirlioglu1, Dincer Yildizdas2, Faruk Ekinci2, Ozden Ozgur Horoz2, Gulen Gul Mert3

1 Department of Pediatric Intensive Care, Mersin University Faculty of Medicine, Mersin, Türkiye
2 Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine, Adana, Türkiye
3 Department of Pediatric Neurology, Cukurova University Faculty of Medicine, Adana, Türkiye

DOI: 10.2478/jccm-2025-0001

Introduction: In traumatic brain injury (TBI), direct information can be obtained about cerebral blood flow, brain tissue oxygenation and cerebral perfusion pressure values. More importantly, an idea about the changes in these measurements can be obtained with multidimensional monitoring and widely used monitoring methods.
Aim of the study: We aimed to evaluate the monitoring of critically ill children who were followed up in our pediatric intensive care unit (PICU) due to TBI.
Material and Method: Twenty-eight patients with head trauma who were followed up in our tertiary PICU between 2018 and 2020 were included in the study. Cerebral tissue oxygenation, optic nerve sheath diameter (ONSD), Glasgow coma score (GCS) and Glasgow Outcome Score (GOSE) values were obtained from retrospective file records and examined.
Results: Male gender was 71.4% (n=20). When we classified TBI according to GCS, 50% (n=14) had moderate TBI and 50% had severe TBI. On the first day in the poor prognosis group, ONSD and nICP were found to be higher than in the good prognosis group (for ONSD, p=0.01; and for nICP, p=0.004). On the second day of hospitalization, the ONSD and nICP were significantly higher in the poor prognosis group than in the good prognosis group (for ONSD p=0.002; and for nICP p= 0.001). Cerebral tissue oxygenation values measured on the first and second days decreased significantly on the second day in both the good and poor prognosis groups (p=0.03, 0.006). In the good prognosis group, a statistically significant decrease was found in ONSD and nICP measurements taken on the 2nd day compared to the measurements taken at the time of hospitalization (for ONSD p=0.004; for nICP p<0.001).
Conclusion: The aim of multidimensional follow-up in traumatic brain injury is to protect the brain from both primary and secondary damage; for this reason, it should be followed closely with multimonitoring methods that are possibly multidisciplinary.

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The effect of pre-existing sarcopenia on outcomes of critically ill patients treated for COVID-19

Thomas Bradier1, Sébastien Grigioni2, Céline Savoye-Collet3, Gaétan Béduneau1,4, Dorothée Carpentier1, Christophe Girault1,4, Maximillien Grall1, Grégoire Jolly1, Najate Achamrah2, Fabienne Tamion1,5, Zoé Demailly1,5

1 Intensive Care Unit, Charles Nicolle University Hospital, Rouen, France
2 Department of Nutrition, Charles Nicolle University Hospital, Rouen, France
3 Radiology Department, QUANTIF-LITIS EA 4108, Charles Nicolle University Hospital, Rouen, France
4 Normandie Univ, UNIROUEN, UR 3830-GRHVN, CHU Rouen, F-76000 Rouen, France.
5 Normandie Univ, UNIROUEN, INSERM U1096, CHU Rouen, France

DOI: 10.2478/jccm-2024-0045

Background: Sarcopenia, defined by a loss of skeletal muscle mass and function, has been identified as a prevalent condition associated with poor clinical outcome among critically ill patients. This study aims to evaluate the impact of pre-existing sarcopenia on outcomes in critically ill patients with acute respiratory failure (ARF) due to COVID-19.
Material and Methods: A retrospective study was carried out on COVID-19 patients admitted to intensive care. Pre-existing sarcopenia was assessed using early CT scans. Clinical outcomes, including duration of high-flow oxygenation (HFO), mechanical ventilation (MV), length of hospital stay (LOS) and ICU mortality, were evaluated according to sarcopenia status.
Results: Among the studied population, we found a high prevalence (75 patients, 50%) of pre-existing sarcopenia, predominantly in older male patients. Pre-existing sarcopenia significantly impacted HFO duration (6.8 (+/-4.4) vs. 5 (+/-2.9) days; p=0.005) but did not significantly affect MV requirement (21 (28%) vs. 23 (37.3%); p=185), MV duration (7 vs. 10 days; p=0.233), ICU mortality (12 (16%) vs. 10 (13.3 %); p=0.644) or hospital LOS (27 vs. 25 days; p=0.509). No differences in outcomes were observed between sarcopenic and non-sarcopenic obese patients.
Conclusions: Pre-existing sarcopenia in critically ill COVID-19 patients is associated with longer HFO duration but not with other adverse outcomes. Further research is needed to elucidate the mechanisms and broader impact of sarcopenia on septic critically ill patient outcomes.

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The Use of Biomarkers Testing in Emergency Department

Sonia Luka1,2, Adela Golea2,3, Raluca Mihaela Tat1, Eugenia Maria Lupan Mureșan2,3, George Teo Voicescu2,3,4, Ștefan Cristian Vesa5, Maria Adriana Albu6, Daniela Ionescu7

1 Faculty of Medicine, Iuliu Hagieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
2 Clinical Emergency County Hospital, Cluj-Napoca, Romania
3 Discipline of Emergency Medicine, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
4 CRIMEDIM Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
5 Discipline of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
6 Department of Emergency Medicine and First Aid, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
7 Discipline of Anaesthesia and Intensive Care I, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania

DOI: 10.2478/jccm-2024-0041

Introduction: In the fast-paced environment of Emergency Departments (EDs), biomarkers are essential for the rapid diagnosis and management of critical conditions.
Aim of the study: This study evaluates the current clinical practice on key biomarkers in Romanian EDs, addressing the needs of emergency medicine physicians, and the challenges associated with biomarker testing.
Material and Methods: An online survey was sent to physicians working in ED to explore their perceptions, needs, and barriers regarding biomarkers, including Point-of-care (POC). Data was collected anonymously through an online platform and subsequently analyzed.
Results: This survey analyzed data from 168 completed responses, with 95.2% of respondents being specialists in emergency medicine. Procalcitonin and presepsin were most preferred for PoCT, while troponin and D-dimer were highly rated regardless of the testing method, reflecting their utility in sepsis and cardiovascular emergencies. Neuron-specific enolase, interleukin-6, and procalcitonin were the biomarkers considered needed.
Conclusions: The most frequently used biomarkers in ED were troponin, D-dimer, BNP/NT-proBNP, and procalcitonin. NSE, IL-6, and procalcitonin were the most recommended for future integration. High costs, limited availability, and false-positive concerns remain significant challenges in biomarker use.

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The Analgesic Effect of Morphine on Peripheral Opioid Receptors: An Experimental Research

Nader-Mugurel Jafal, Smaranda Stoleru, Aurelian Zugravu, Carmen Orban, Mihai Popescu, Ruxandra Cristina Marin, Ion-Gigel Fulga

“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

DOI: 10.2478/jccm-2024-0042

Opioids represent one of the key pillars in postoperative pain management, but their use has been associated with a variety of serious side effects. Thus, it is crucial to investigate the timing and course of opioid administration in order to ensure a best efficacy to side-effect profile. The aim of our article was to investigate the analgesic effects of locally administered morphine sulfate (intraplantar) in a carrageenan-induced inflammation model in rats. After carrageenan administration, the rats were divided into 10 equal groups and were injected with either morphine 5 mg/kg or 0.9% saline solution at different time intervals, depending on the assigned group. The analgesic effect was assessed through thermal stimulation. Our results showed that paw withdrawal time was significantly higher in rats treated with morphine compared to those in the control group 9.18 ± 3.38 compared to 5.14 ± 2.21 seconds, p=0.012). However, differences were more pronounced at certain time intervals post-carrageenan administration (at 180 minutes compared to 360 minutes, p=0.003 and at 180 minutes compare to 1440 minutes p<0.001), indicating that efficacy varies depending on the timing of treatment. In conclusion, our findings support the hypothesis that locally administered morphine may alleviate pain under inflammatory conditions and underscores the importance of considering treatment timing when evaluating the analgesic effect.

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The Correlation of Hemostatic Parameters with the Development of Early Sepsis-Associated Encephalopathy. A Retrospective Observational Study

Florin Scarlatescu1, Ecaterina Scarlatescu2,3, Dana Rodica Tomescu2,3, Daniela Bartos2

1 Clinical Emergency Hospital Bucharest, Romania
2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
3 Fundeni Clinical Institute, Bucharest, Romania

DOI: 10.2478/jccm-2024-0040

Introduction: Sepsis-associated encephalopathy (SAE) is one of the most common complications seen both in early and late stages of sepsis, with a wide spectrum of clinical manifestations ranging from mild neurological dysfunction to delirium and coma. The pathophysiology of SAE is still not completely understood, and the diagnosis can be challenging especially in early stages of sepsis and in patients with subtle symptoms.
Aim of the study: The objective of this study was to assess the coagulation profile in patients with early SAE and to compare the hemostatic parameters between septic patients with and without SAE in the first 24 hours from sepsis diagnosis.
Material and methods: This retrospective observational study included 280 patients with sepsis in the first 24 hours after sepsis diagnosis. A complete blood count was available in all patients; a complex hemostatic assessment including standard coagulation tests, plasmatic levels of coagulation factors, inhibitors, D-dimers, and Rotation thromboelastometry (ROTEM, Instrumentation Laboratory) was performed in a subgroup of patients.
Results: Early SAE was diagnosed in 184 patients (65.7%) and was correlated with a higher platelet count, after adjusting for age and leucocyte count. Compared to patients without neurological dysfunction, patients with early SAE presented a more active coagulation system revealed by faster propagation phase, increased clot firmness and elasticity with a higher platelet contribution to clot strength. The initiation of coagulation and clot lysis were not different between the groups.
Conclusion: In the early stages of sepsis, the development of SAE is correlated with increased systemic clotting activity where platelets seem to have an important role. More research is needed to investigate the role of platelets and the coagulation system in relation to the development of early SAE.

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Understanding the Difficulties in Diagnosing Neonatal Sepsis: Assessing the Role of Sepsis Biomarkers

Nicoleta Lungu1, Ana-Maria-Cristina Jura2, Daniela-Eugenia Popescu1, Florin George Horhat3, Aniko Maria Manea1, Marioara Boia1

1 Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy, Timișoara, Romania
2 University of Medicine and Pharmacy Victor Babes Timisoara, Timisoara, Romania
3 Multidisciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), Microbiology Department, “Victor Babes” University of Medicine and Pharmacy, Timișoara, Romania

DOI: 10.2478/jccm-2024-0039

Background. Neonatal sepsis is a serious condition with high rates of morbidity and mortality, caused by the rapid growth of microorganisms that trigger a systemic reaction. Symptoms can range from mild to severe presentations. The causative microorganism is usually transmitted from mothers, especially from the urogenital tract, or can originate from the community or hospital.
Methods. Our retrospective study assessed 121 newborns, including both preterm and term infants, divided into three groups within the first 28 days of life: early-onset sepsis (35), late-onset sepsis (39), and a control group (47). Blood samples and cultures were obtained upon admission or at the onset of sepsis (at 24 and 72 hours). The study aimed to evaluate the limitations of commonly used biomarkers and new markers such as lactate dehydrogenase and ferritin in more accurately diagnosing neonatal sepsis.
Results. Our study revealed a significant difference between the initial and final measures of lactate dehydrogenase (LDH) and ferritin in the early-onset sepsis (EOS) and late-onset sepsis (LOS) groups.
Conclusion. Ferritin and LDH may serve as potential markers associated with systemic response and sepsis in cases of both early and late-onset sepsis. Monitoring these biomarkers can aid in the timely detection and management of sepsis, potentially improving patient outcomes.

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Outcomes of Patients Transferred to Tertiary Center by Life-Saving System in Saudi Arabia. A Propensity Score Matching Observational Study

Mohammed Soliman1, Hanan Alenzi1, Rehab Alfenaikh1, Ahmed Aletreby2, Malak Alenzi1, Hend Alenzi1, Jennifer Gano1, Rana Alrashed1, Yasmeen Altaymani3, Mohammed Al-Odat1, Waleed Aletreby1

1 King Saud Medical City, Riyadh, Ar Riyad, Saudi Arabia
2 Faculty of Medicine, Alexandria University, Alexandria, Egypt
3 Imam Abdulrahman Alfaisal Hospital, Riyad, Saudi Arabia

DOI: 10.2478/jccm-2024-0038

Background: Inter-hospital transfer is intended to provide access to centralized special care for critically ill patients, when resources in their hospitals are not available. However, an empirical gap exists in available evidence, as outcomes of transferred patients to higher centers are inconsistent.
Method: Single center propensity score matching retrospective observational study. Life-Saving transfers during 2023 were matched to direct admissions to the ICU. Hospital mortality, ICU length of stay, and costs of both groups were compared.
Results: During the study period, 328 Life-Saving transfers were matched to 656 direct admissions. Propensity score matching eliminated all imbalances between groups. Hospital mortality was not different between groups, there were 114 (34.8%) hospital mortalities of Life-Saving transfers, while there were 216 (32.9%) hospital mortalities of direct admissions, with a percent difference of 1.9% (95% CI: -4.5%, 8.4%); p value = 0.6, this result persisted in the sensitivity analysis. There were no differences in mortality risks for all the studied subgroups except pediatric patients. ICU length of stay of direct admissions and Life-Saving transfers were 10 ± 13.1 and 11.6 ± 12.4 days respectively, mean difference was statistically significant (-1.6 [95% CI: -3.2, 0.1]; p = 0.005). Life-Saving transfers entailed significantly higher costs per admission by 28,200 thousand SAR (95% CI: 26,400 – 30,000; p < 0.001).
Conclusion: Our study shows no difference in hospital mortality between Life-Saving transfers and direct admissions to ICU, however, Life-Saving transfers had a longer ICU length of stay, and higher costs per admission.

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Role of Quetiapine in the Prevention of ICU Delirium in Elderly Patients at a High Risk

Walid Y. Kamel1, Heba Y. Kamel2, Ibrahim M. Elsherif1

1 Department of Anesthesia, Intensive Care and Pain Management, Ain Shams University, Abbasiya, Cairo, Egypt
2 Geriatrics and Gerontology department, Faculty of Medicine, Ain Shams University, Abbasiya, Cairo, Egypt

DOI: 10.2478/jccm-2024-0032

Background: The aim of the present study was to denote the effectiveness of Quetiapine as additive to preventive bundle of delirium in elderly patients with multiple risks for delirium.
Patients and methods: The study was performed on 90 elderly patients over 60 years. The patients were divided into Group Q (Quetiapine) and Group C (No Quetiapine). Delirium was assessed using Intensive Care Delirium Screening Checklist (ICDSC) and the Confusion Assessment Method for the ICU (CAM-ICU).
Results: The incidence of delirium was significantly higher in group C. The severity of delirium was higher among group C; however, it was not statistically significant. The dominant type of delirium was hypoactive in group Q whereas hyperactive in group C. The interrater reliability between CAM-ICU-7 and ICDSE showed a kappa 0.98 denoting excellent correlation between the two scores. Somnolence was the most common side effect of Quetiapine (25%) followed by dry mouth (18%).
Conclusions: Prophylactic low dose of Quetiapine in elderly population in the preventive bundle could reduce the incidence of delirium with a low incidence of a major side effect, as well as CAM-ICU-7 is as effective as ICDSC in monitoring and early diagnosis of delirium.

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Outcome and Determining Characteristics of ICU Patients with Acute Kidney Injury in a Low-Income Country, a Multicenter Experience

Abubakar Ballah1, Jika Mohammed2, Gyadale Abdulhamid Njidda2, Halima Bidemi Yahaya3, Nwokorie Mabong Rosemary4, Ibrahim Naziru2, Adamu Yusuf Baffah2, Hassan Ali Maina5, Hajara Galadima2, Abdullahi Maryam Mohammed6, Franklin Andibanbang7, Adam Ibrahim Abdullahi8

1 Abubakar Tafawa Balewa University, Bauchi, Nigeria
2 Federal Medical Centre Gombe, Gombe, Nigeria
3 Airdale NHS Foundation Trust, Steeton, England
4 Nile University of Nigeria, Abuja, Nigeria
5 Modibbo Adama University of Technology, Yola, Nigeria
6 Aminu Kano Teaching Hospital, Kano, Nigeria
7 Saudi Arabia Ministry of Health, Fayfa, Saudi Arabia
8 Bauchi State University Gadau, Bauchi, Nigeria

DOI: 10.2478/jccm-2024-0037

Background: Acute kidney injury (AKI) is a disease that affects millions of people globally making it a major public health concern. It is defined as an abrupt decrease in kidney function that occurs within ours affecting both the structure and functionality of the kidneys.
The outcome of AKI and the determinants in Nigeria are largely unknown. This study aimed to describe the determining factors of the outcome of AKI patients admitted into the ICU of three tertiary health institutions in Northeast Nigeria.
Methods: The study is a prospective multicentered observational study of the patients admitted into the ICU in three tertiary health institutions from January 2022 to December 2023. KDIGO criteria was used to define AKI. The outcome of the study was to determine survivors among the patients admitted into the ICU with AKI or developed AKI while in ICU and also the determinants of mortality. A chi-square test was done to determine the association between the dependent variable (patient outcome) and the independent variables. To determine the predictors of patient outcomes, a regression analysis was done. The sociodemographic data of the patients admitted during these periods were studied in addition to Acute Physiology and Chronic Health Evaluation (APACHE) II, Kidney Disease: Improving Global Outcomes (KDIGO), Average length of stay in the ICU, Admitting/referring ward (Obstetrics, Gynae, Medical, Surgical or Emergency unit), Ability to afford care (out of pocket payment, social welfare or through Health insurance Scheme, Co-morbidity (presence or absence of comorbidity), Interventions done while in ICU (use of vasopressors and inotropes, mechanical ventilation (MV) support and renal replacement therapy (RRT) and outcome (discharge to the wards or mortality).
Results: Of 1494 patient records screened, 464 met the inclusion criteria. The overall incidence of AKI was 57%. About 53% were females, the mean age was 42.2 years, and 81% of the patients had a normal BMI (18.5 – 24.9). About 40% of the patients had APACHE II scores ≥ 29%. More than three-quarters (79.5%) of the patients paid for their health care expenditure out-of-pocket. Most patients (72%) were from the Medical and Gynae/Ward. Mortality was highest (54.2%) among patients who were brought into the ICU from the Medical ward. Most patients admitted were KDIGO I (44.3%) followed by KDIGO II (35.1%). Among the patients, 61.2% present with one or more comorbidity. Mortality was higher (50%) among those with comorbidity compared to 13.6% among those without comorbidity. Mortality was lowest among patients who stayed in the ICU between 8-14 days compared to those who stayed > 2 weeks. Most of the patients (72%) were from the Medical and Gynae/Ward. Mortality was highest (54.2%) among patients who were brought into the ICU from the Medical ward followed by those brought in from the Obstetric and Gynecological ward (20.4%). An association was found between the intervention received in the ICU and the outcome, which was found to be statistically significant (p < 0.001). A regression analysis was done to determine the predictors of patients’ outcomes admitted in the ICU. The results showed that APACHE II score greater than 10 (p-value < 0.001), presence of comorbidities (p = 0.031) and intervention which included a combination of Vasopressors, mechanical ventilation and RRT (p < 0.01) are the predictors of patients’ outcome. The regression model is valid (X2 = 469.894, df = 24, p < 0.001) and it fits the sample as shown by the Hosmer and Lemeshow test (X2 = 7.749, p = 0.45, df = 8,). It also shows that the predictors account for 92% of patients’ outcomes (Nagelkerke R2 = 0.92).
Conclusions: Our study revealed that the presence of comorbidity, high APACHE II score, and the need for interventional supports including both mechanical ventilatory and ionotropic, were found to be strong mortality predictors in patients with AKI.

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The Role of Feedback Training on Early Postoperative Recovery and Anxiety Scores in an Ambulatory Surgical Unit: A Secular Trend Study

Alexander Dukhan1, Teymur Yusupov1, Naama Kabra1, Tiberiu Ezri1,2, Mona Boaz3

1 Ambulatory Surgery Unit, Anesthesiology, Kaplan Medical Center, Rehovot, Israel
2 Tel Aviv University, Israel| Kaplan Medical Center
3 Ariel University, School of Health Sciences, Ariel, Israel

DOI: 10.2478/jccm-2024-0036

Background: We used a ten-item postoperative quality of recovery score (QoR-10) to assess the perioperative quality of care in an in-hospital ambulatory surgical unit.
Methods: In Phase 1 of this secular trend study (n=300 patients, 3-months duration), we collected QoR-10 scores and potential confounders, including type of anesthesia and surgery; co-morbidities; and anesthesia components of the Amsterdam scale-measured anxiety scores. Phase 2 was the one-month performance feedback learning phase in which modifiable variables identified in Phase 1 were translated to actionable steps, reinforcing the already existing routine of our department’s clinical practices, including pain, shivering and anxiety. The anesthesiology team was instructed and reminded of these steps using performance feedback methods. In Phase 3 (n=300 patients, 3-month duration) we evaluated the efficacy of this performance feedback instruction. QoR-10 scores were compared between Phase 1 and Phase 3.
Results: Phase 1 identified three modifiable variables as targets for improvement: postoperative shivering; percentage of patients with numerical rating pain scale (NRS)<4; and preoperative anxiety from anesthesia scores. Compared to Phase 1, significantly fewer Phase 3 patients had severe shivering (2.3% vs. 7.3%, p = 0.023), and a greater percentage had NRS < 4 points (79% vs. 49.7%, p <0.001). The percentage of patients with a high anxiety score did not differ between phases. A direct association between anxiety score and QoR-10 score was not detected. The QoR-10 score (median (IQR)) was significantly higher in Phase 3 than Phase 1: 50 (49-50) vs. 49(49-50), p<0.001. In a multivariable logistic regression analysis, odds for a QoR-10 score of 49-50 were 1.92 higher in Phase 3 than Phase 1.
Conclusion: Considering the study limitations, team feedback education contributed to improvement of the QoR-10 score, reduced the proportion of patients with severe shivering and increased the percentage of patients with low pain scores.

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