Category Archives: Original Research

Therapeutic Evaluation of Computed Tomography Findings for Efficacy of Prone Ventilation in Acute Respiratory Distress Syndrome Patients with Abdominal Surgery

Masayuki Akatsuka1,2, Hiroomi Tatsumi1, Naoya Yama3, Yoshiki Masuda1

1 Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan,
2 Department of Anaesthesiology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan
3 Department of Diagnostic Radiology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan

DOI: 10.2478/jccm-2020-0003

Introduction: In Acute Respiratory Distress Syndrome (ARDS), the heterogeneity of lung lesions results in a mismatch between ventilation and perfusion, leading to the development of hypoxia. The study aimed to examine the association between computed tomographic (CT scan) lung findings in patients with ARDS after abdominal surgery and improved hypoxia and mortality after prone ventilation.
Material and Methods: A single site, retrospective observational study was performed at the Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan, between 1st January 2004 and 31st October 2018. Patients were allocated to one of two groups after CT scanning according to the presence of ground-glass opacity (GGO) or alveolar shadow with predominantly dorsal lung atelectasis (DLA) on lung CT scan images. Also, Patients were divided into a prone ventilation group and a supine ventilation group when the treatment for ARDS was started.
Results: We analyzed data for fifty-one patients with ARDS following abdominal surgery. CT scans confirmed GGO in five patients in the Group A and in nine patients in the Group B, and DLA in 17 patients in the Group A and nine patients in the Group B. Both GGO and DLA were present in two patients in the Group A and nine patients in the Group B. Prone ventilation significantly improved patients’ impaired ratio of arterial partial pressure of oxygen to fraction of inspired oxygen from 12 h after prone positioning compared with that in the supine position. Weaning from mechanical ventilation occurred significantly earlier in the Group A with DLA vs the Group B with DLA (P < 0.001). Twenty-eight-day mortality was significantly lower for the Group A with DLA vs the Group B with DLA (P = 0.035).
Conclusions: These results suggest that prone ventilation could be effective for treating patients with ARDS as showing the DLA.

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The Dynamical Assessment of Inflammatory Biomarkers in Predicting the Outcome of Septic Patients and the Response to Antimicrobial Therapy

Alina Orfanu1,2, Victoria Aramă1,2, Cristina Popescu1,2, Cătălin Tilişcan1,2, Adrian Streinu-Cercel1,2, Ştefan Sorin Aramă1,2

1 National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, Bucharest
2 University of Medicine and Pharmacy “Carol Davila”, Bucharest

DOI: 10.2478/jccm-2020-0004

Aims: To evaluate the kinetics of inflammatory biomarkers in septic patients in order to identify the most reliable predictor of unfavorable outcome.
Methods: A prospective analysis of septic patients was performed. Median levels of neutrophil/lymphocyte count ratio, fibrinogen, C-reactive protein and procalcitonin were dynamically assessed and comparatively analyzed.
Results: Seventy-seven patients were included. Descendent kinetic patterns were registered for all biomarkers, except C-reactive protein. At 24 hours, neutrophil/lymphocyte count ratio significantly decreased in 42.85% of cases, procalcitonin in 37.33%, C-reactive protein in 16.12% and fibrinogen in 1.58% of cases. At 72 hours, procalcitonin decreased to one-half in 70% of cases and neutrophil/lymphocyte count ratio in 67.53% of cases.
Conclusions: Neutrophil/lymphocyte count ratio and procalcitonin significantly decreased in the first 72 hours, while C-reactive protein increased in the first 24 hours. The proportions of patients with major decrease of baseline values were higher for neutrophil/lymphocyte count ratio and procalcitonin.

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Initial Fluid Resuscitation Following Adjusted Body Weight Dosing in Sepsis and Septic Shock

Oana Antal1,2, Elena Ștefănescu1,2, Monica Mleșnițe1,2, Andrei Mihai Bălan1, Natalia Hagău1,2

1 Department of Anaesthesia and Intensive Care, “Iuliu Hațieganu” University of Medicine and Pharmacy,
Cluj-Napoca, Romania
2 Department of Anaesthesia and Intensive Care, Emergency Clinical County Hospital, Cluj-Napoca, Romania

DOI: 10.2478/jccm-2019-0025

Introduction: Fluid administration is considered a fundamental part of early sepsis treatment. Despite abundant research, fundamental questions about the amount of fluids to be given remain unanswered. Recently, the idea of adjusting the fluid load to the ideal body weight emerged, as obesity rates are increasing, and fluid overload was proven to increase mortality.
Aim of the study: The study aimed to determine whether advanced haemodynamic monitoring supports the adjustment of the initial fluid load to the ideal body weight (IBW).
Methods: Seventy-one patients with sepsis and septic shock were enrolled in the study. The initial fluid resuscitation was performed using local protocols. The haemodynamic status was assessed after the initial fluid load by trans-pulmonary thermos-dilution technique and the renal outcome recorded at twenty-four hours.
Results: 68.6% of the patients included in the study had weight disorders ranging from BMI+20% to morbid obesity. Before IBW adjustment, only 49.3% received the 30 ml/kg fluid load recommended by Surviving Sepsis Campaign Guidelines (2016) (SSC). After IBW adjustment, 70.4% received the recommended fluid dose. The difference in fluid load/kg before and after the bodyweight adjustment was statistically significant (p<0.01). After the initial fluid load, the majority of the macro haemodynamic parameters were in the targeted range. There was no statistically significant difference between the urinary output outcome at 24 hours or the 28 days mortality rates between the patients resuscitated by the SSC and those who received less fluid.
Conclusions: Advanced haemodynamic monitoring was in favour of adjusting the initial fluid load to the IBW. There were no statistically significant differences either in the urinary output outcome at twenty-four hours, or in the twenty-eight-day mortality rates between the patients who received the 30 ml/kg IBW and those who received less than 30 ml/kg IBW.

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The Use of High Dose Eltrombopag in the Management of Sepsis-Associated Thrombocytopenia in Critically Ill Patients

Md. Jahidul Hasan1, Raihan Rabbani2, Shihan Mahmud Redwanul Huq2

1 Department of Clinical Pharmacy, Square Hospitals Ltd., Dhaka, Bangladesh
2 Internal Medicine and ICU, Square Hospitals Ltd., Dhaka, Bangladesh

DOI: 10.2478/jccm-2019-0019

Introduction: Sepsis is a life-threatening condition, and sepsis-associated thrombocytopenia (SAT) is a common consequence of the disease where platelet count falls drastically within a very short time. Multiple key factors may cause platelet over-activation, destruction and reduction in platelet production during the sepsis. Eltrombopag is a thrombopoietin receptor agonist and is the second-line drug of choice in the treatment of chronic immune thrombocytopenia (ITP).
Aim of the study: The objective of this study was to observe the therapeutic outcome of high dose eltrombopag in SAT management in critically ill patients.
Material and Methods: This 6-month-long single group, observational study was conducted on seventeen ICU patients with SAT. Eltrombopag 100 mg/day in two divided doses was given to each patient. Platelet counts were monitored. A low platelet blood count returning to 150 K/μL or above, is taken as indicative of a successful reversal of a thrombocytopenia event.
Results: The mean Apache II score of patients (n= 17) was 18.71 (p-value: >0.05). No eltrombopag-induced adverse event was observed among the patients during the study period. Thrombocytopenia events were reversed successfully in 64.71% of patients (11; n= 17) within eight days of eltrombopag therapy.
Conclusions: The therapeutic potentiality of high dose eltrombopag regime in the management of sepsis-associated thrombocytopenia was found clinically significant in over two-thirds of critically ill adult patients enrolled in the study. These data may point to a new strategy in the management of acute type of thrombocytopenia in septic patients.

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Determination of Cut-off Serum Values for Resistin and S100B Protein in Patients Who Survived a Cardiac Arrest

Raluca M. Tat1, Adela Golea2, Ştefan C. Vesa3, Daniela Ionescu4

1 Department of Anesthesia and Intensive Care I, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
2 Surgical Department of “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
3 Department of Pharmacology, Toxicology and Clinical Pharmacology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
4 Department of Anesthesia and Intensive Care I, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania; Outcome Research Consortium, Cleveland, United States of America

DOI: 10.2478/jccm-2019-0018

Introduction: In an attempt to identify patients who have successfully survived a resuscitated cardiac arrest (CA), attention is drawn to resistin and S100B protein, two biomarkers that have been studied in relation to CA.
Aim: The study aimed to identify the potential cut-off serum values for resistin and S100B in patients who had CA, compared to healthy volunteers, given that, currently, none of the markers have normal and pathological reference range limits for human assay levels related to this pathology.
Materials and Methods: Forty patients, resuscitated after out-of-hospital CA and forty healthy controls, were included in the study. All patients were followed up for seventy-two hours after CA or until death. Blood samples for biomarkers were collected on admission to the ED (0-time interval) and at 6, 12, 24, 48 and 72 hours following resuscitation. Only one blood sample was collected from the controls. The serum concentrations of biomarkers were measured.
Results: For each time interval, median serum levels of resistin and S100 B were ​​ significantly higher in patients with CA compared to healthy controls. The cut-off value for resistin in patients with CA, at the 12-hours versus controls, was > 8.2 ng/ml. The cut-off value for S100B in patients with CA versus controls recorded at 6 hours, was > 11.6 pg/ml.
Conclusion: Serum levels of resistin and S100B are higher among resuscitated CA patients compared to controls.

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Perioperative Lung Protective Ventilatory Management During Major Abdominal Surgery: A Hungarian Nationwide Survey

Zoltán Ruszkai1, Erika Kiss2, Zsolt Molnár2

1 Department of Anaesthesiology and Intensive Therapy, Péterfy Sándor Hospital, Budapest, Hungary
2 University of Szeged, Department of Anaesthesiology and Intensive Therapy, Szeged, Hungary
Abstract

DOI: 10.2478/jccm-2019-0002

Lung protective mechanical ventilation (LPV) even in patients with healthy lungs is associated with a lower incidence of postoperative pulmonary complications (PPC). The pathophysiology of ventilator-induced lung injury and the risk factors of PPCs have been widely identified, and a perioperative lung protective concept has been elaborated. Despite the well-known advantages, results of recent studies indicated that intraoperative LPV is still not widely implemented in current anaesthesia practice.
No nationwide surveys regarding perioperative pulmonary protective management have been carried out previously in Hungary. This study aimed to evaluate the routine anaesthetic care and adherence to the LPV concept of Hungarian anaesthesiologists during major abdominal surgery.
A questionnaire of 36 questions was prepared, and anaesthesiologists were invited by an e-mail and a newsletter to participate in an online survey between January 1st to March 31st, 2018.
A total of one hundred and eleven anaesthesiologists participated in the survey; 61 (54.9%), applied low tidal volumes, 30 (27%) applied the entire LPV concept, and only 6 (5.4%) regularly applied alveolar recruitment manoeuvres (ARM). Application of low plateau and driving pressures were 40.5%. Authoritatively written protocols were not available resulting in markedly different perioperative pulmonary management. According to respondents, the most critical risk factors of PPCs are chronic obstructive pulmonary diseases (103; 92.8%); in contrast malnutrition, anaemia or prolonged use of nasogastric tube were considered negligible risk factors. Positive end-expiratory pressure (PEEP) and regular ARM are usually ignored. Based on the survey, more attention should be given to the use of LPV.

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Factors Associated with Mortality in Patients with a Solid Malignancy Admitted to the Intensive Care Unit – A Prospective Observational Study

Pascal Kingah, Nasser Alzubaidi, Jihane Zaza Dit Yafawi, Emad Shehada, Khaled Alshabani, Ayman O. Soubani

Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, 3990 John R, 3 Hudson, Detroit MI 48201, USA

DOI: 10.2478/jccm-2018-0019

Purpose: Several studies show conflicting results regarding the prognosis and predictors of the outcome of critically ill patients with a solid malignancy. This study aims to determine the outcome of critically ill patients, admitted to a hospital, with a solid malignancy and the factors associated with the outcomes.
Methods and Materials: All patients with a solid malignancy admitted to an intensive care unit (ICU) at a tertiary academic medical center were enrolled. Clinical data upon admission and during ICU stay were collected. Hospital, ICU, and six months outcomes were documented.
Results: There were 252 patients with a solid malignancy during the study period. Urogenital malignancies were the most common (26.3%) followed by lung cancer (23.5%). Acute respiratory failure was the most common ICU diagnosis (51.6%) followed by sepsis in 46%. ICU mortality and hospital mortality were 21.8% and 34.3%. Six months mortality was 38.4%. Using multivariate analysis, acute kidney injury, OR 2.82, 95% CI 1.50-5.32 and P=0.001, use of mechanical ventilation, OR 2.67 95% CI 1.37 – 5.19 and P=0.004 and performance status of ≥2 with OR of 3.05, 95% CI of 1.5- 6.2 and P= 0.002 were associated with hospital mortality. There were no differences in outcome between African American patients (53% of all patients) and other races.
Conclusion: This study reports encouraging survival rates in patients with a solid malignancy who are admitted to ICU. Patients with a poor baseline performance status require mechanical ventilation or develop acute renal failure have worse outcomes.

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Improving Clinical Performance of an Interprofessional Emergency Medical Team through a One-day Crisis Resource Management Training

Teodora Sorana Truța1, Cristian Marius Boeriu1, Marc Lazarovici2, Irina Ban3, Marius Petrișor1, Sanda-Maria Copotoiu1

1 University of Medicine and Pharmacy of Tîrgu Mureș, Street Gheorghe Marinescu 38, 540139 Tîrgu Mureș, Mureș, Romania
2 Institut für Notfallmedizin und Medizinmanagement – INM, Klinikum der Universität, Ludwig-Maximilians-Universität München, Schillestraße 53, 80336 München, Germany
3 Department of Medicine, University of Padova, Via V. Galluci, 13-35121, Padova, Italy

DOI: 10.2478/jccm-2018-0018

Introduction: Errors are frequent in health care and Emergency Departments are one of the riskiest areas due to frequent changes of team composition, complexity and variety of the cases and difficulties encountered in managing multiple patients. As the majority of clinical errors are the results of human factors and not technical in nature or due to the lack of knowledge, a training focused on these factors appears to be necessary. Crisis resource management (CRM), a tool that was developed initially by the aviation industry and then adopted by different medical specialties as anesthesia and emergency medicine, has been associated with decreased error rates.
The aim of the study: To assess whether a single day CRM training, combining didactic and simulation sessions, improves the clinical performance of an interprofessional emergency medical team.
Material and Methods: Seventy health professionals with different qualifications, working in an emergency department, were enrolled in the study. Twenty individual interprofessional teams were created. Each team was assessed before and after the training, through two in situ simulated exercises. The exercises were videotaped and were evaluated by two assessors who were blinded as to whether it was the initial or the final exercise. Objective measurement of clinical team performance was performed using a checklist that was designed for each scenario and included essential assessment items for the diagnosis and treatment of a critical patient, with the focus on key actions and decisions. The intervention consisted of a one-day training, combining didactic and simulation sessions, followed by instructor facilitated debriefing. All participants went through this training after the initial assessment exercises.
Results: An improvement was seen in most of the measured clinical parameters.
Conclusion: Our study supports the use of combined CRM training for improving the clinical performance of an interprofessional emergency team. Empirically this may improve the patient outcome.

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Effects of Fibrinogen Levels and Platelet Counts on Viscoelastic Testing in Cirrhotic Patients

Dana Tomescu1,2, Mihai Popescu1,2, Alexander Vitin3

1 “Carol Davila” University of Medicine and Pharmacy, Department of Anaesthesia and Critical Care Medicine, Bucharest, Romania
2 Fundeni Clinical Institute, Anaesthesia and Critical Care Department III, Bucharest, Romania
3 Department of Anesthesiology & Pain, Medicine University of Washington Medical Center, Seattle WA, USA

DOI: 10.2478/jccm-2018-0012

Introduction. Cirrhotic patients have been considered for decades to have a pro-haemorrhagic pattern and were treated as such based on the results from standard coagulation tests. The aim of our study was to determine the effects of platelet count and fibrinogen levels on rotational thromboelastometry (ROTEM) parameters.
Methods. We prospectively included 176 patients with End-Stage Liver Disease (ESLD) admitted to our Intensive Care Unit prior to liver transplantation. Collected data consisted of severity scores, liver, renal and standard coagulation tests, fibrinogen levels, platelet counts and ROTEM parameters. Four ROTEM assays were performed (ExTEM, InTEM, ApTEM and FibTEM) and the following parameters included: CT – clotting time, CFT – clot formation time, MCF – maximum clot firmness, ML – maximum lysis, alpha angle, TPI – thrombin potential index, MaxV – maximum velocity of clot formation (MaxV), MaxVt – time to MaxV, MCE- maximum clot elasticity and AUC – area under the curve.
Results. Statistical analysis demonstrated a linear correlation between platelet counts and ExTEM TPI (R2 linear =0.494), ExTEM MaxV (R2 linear =0.253), ExTEM MCE (R2 linear = 0.351) and ExTEM MCF (R2 cubic = 0.498). Fibrinogen levels correlated linearly with ExTEM MCF (R2 linear = 0.426), ExTEM TPI (R2 linear = 0.544), ExTEM MaxV (R2 linear = 0.332), ExTEM MCE (R2 linear = 0.395) and non-linearly with ExTEM CFT (R2 cubic = 0.475).
Conclusion. Fibrinogen levels and platelet counts had an important effect on both standard and derived ROTEM parameters. Further analysis is required in order to determine clinically oriented cut-off values below which severe coagulopathy would develop.

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Brain Death in Children: Incidence, Donation Rates, and the Occurrence of Central Diabetes Insipidus

Nazik Yener, Muhammed Şükrü Paksu, Özlem Köksoy

Ondokuz Mayıs University School of Medicine, Division of Pediatric Critical Care, Samsun , Turkey

DOI: 10.2478/jccm-2018-0005

Introduction: Brain death is currently defined as the loss of full brain function including the brainstem. The diagnosis and its subsequent management in the pediatric population are still controversial. The aim of this study was to define the demographic characteristics, clinical features and outcomes of patients with brain death and determine the incidence of brain death, donation rates and occurrence of central diabetes insipidus accompanying brain death in children.
Methods: This retrospective study was conducted at a twelve-bed tertiary-care combined medical and surgical pediatric intensive care unit of the Ondokuz Mayıs University Medical School, Samsun, Turkey. In 37 of 341 deaths (10.8%), a diagnosis of brain death was identified. The primary insult causing brain death was post-cardiorespiratory arrest in 8 (21.6%), head trauma in 8 (21.6%), and drowning in 4 (18.9%). In all patients, transcranial Doppler ultrasound was utilised as an ancillary test and test was repeated until it was consistent with brain death.
Results: In 33 (89%) patients, central diabetes insipidus was determined at or near the time brain death was confirmed. The four patients not diagnosed with CDI had acute renal failure, and renal replacement treatment was carried out. The consent rate for organ donation was 18.9%, and 16.7% of potential donors proceeded to actual donation
Conclusion: In the current study the consent rate for organ donation is relatively low compared to the rest of the world. The prevalence of central diabetes insipidus in this pedaitric brain death population is higher than reports in the literature, and acute renal failure accounted for the lack of central diabetes insipidus in four patients with brain death. Further studies are needed to explain normouria in brain-dead patients.

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