Category Archives: Original Research

Study of Biochemical Parameters as Predictors for Need of Invasive Ventilation in Severely Ill COVID-19 Patients

Azmat Kamal Ansari1, Anjali Pitamberwale2, Shabana Andleeb Ansari1, Tariq Mahmood3, Kirti Limgaokar4, Geeta Karki1, Lalit Singh1

1 Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
2 Enzene Biosciences, Pune, Maharashtra, India
3 Teerthanker Mahaveer Medical College and Research Centre, Moradabad, Uttar Pradesh, India
4 Fergusson College, Pune, Maharashtra, India

DOI: 10.2478/jccm-2023-0030

Background: Though laboratory tests have been shown to predict mortality in COVID-19, there is still a dearth of information regarding the role of biochemical parameters in predicting the type of ventilatory support that these patients may require.
Methods: The purpose of our retrospective observational study was to investigate the relationship between biochemical parameters and the type of ventilatory support needed for the intensive care of severely ill COVID-19 patients. We comprehensively recorded history, physical examination, vital signs from point-of-care testing (POCT) devices, clinical diagnosis, details of the ventilatory support required in intensive care and the results of the biochemical analysis at the time of admission. Appropriate statistical methods were used and P-values < 0.05 were considered significant. Receiver operating characteristics (ROC) analysis was performed and Area Under the Curve (AUC) of 0.6 to 0.7, 0.7 to 0.8, 0.8 to 0.9, and >0.9, respectively, were regarded as acceptable, fair, good, and exceptional for discrimination.
Results: Statistically significant differences (p<0.05) in Urea (p = 0.0351), Sodium (p = 0.0142), Indirect Bilirubin (p = 0.0251), Albumin (p = 0.0272), Aspartate Transaminase (AST) (p = 0.0060) and Procalcitonin (PCT) (p = 0.0420) were observed between the patients who were maintained on non-invasive ventilations as compared to those who required invasive ventilation. In patients who required invasive ventilation, the levels of Urea, Sodium, Indirect bilirubin, AST and PCT were higher while Albumin was lower. On ROC analysis, higher levels of Albumin was found to be acceptable indicator of maintenance on non-invasive ventilation while higher levels of Sodium and PCT were found to be fair predictor of requirement of invasive ventilation.
Conclusion: Our study emphasizes the role of biochemical parameters in predicting the type of ventilatory support that is needed in order to properly manage severely ill COVID-19 patients.

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Limitation of Non-Beneficial Interventions and their Impact on the Intensive Care Unit Costs

Sotiria Koutsouki1, Dimitrios Kosmidis2, Eva-Otilia Nagy3, Alexandra Tsaroucha4, Georgios Anastasopoulos5, Ioannis Pnevmatikos6, Vasileios Papaioannou7

1 General Hospital of Kavala, Kavala, Greece
2 Nursing Department, International Hellenic University, Didymoteicho, Greece
3 General Hospital of Kavala, Kavala, Greece
4 Postgraduate program on Bioethics, Laboratory of Bioethics, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
5 Medical Informatics Laboratory, Democritus University of Thrace, Alexandroupolis, Greece
6 Faculty of Medicine, University of Cyprus, Lefkosia, Cyprus
7 Faculty of Medicine, Democritus University of Thrace, Alexandroupolis, Greece

DOI: 10.2478/jccm-2023-0028

Introduction: Using a plan to limit non-beneficial life support interventions has significantly reduced harm and loss of dignity for patients at the end of life. The association of these limitations with patients’ clinical characteristics and health care costs in the intensive care unit (ICU) needs further scientific evidence. Aim of the study: To explore decisions to limit non-beneficial life support interventions, their correlation with patients’ clinical data, and their effect on the cost of care in the ICU.
Material and Methods: We included all patients admitted to the general ICU of a hospital in Greece in a two-year (2019-2021) prospective study. Data collection included patient demographic and clinical variables, data related to decisions to limit (withholding, withdrawing) non-beneficial interventions (ΝΒΙs), and economic data. Comparisons were made between patients with and without limitation decisions.
Results: NBIs were limited in 164 of 454 patients (36.12%). Patients with limitation decisions were associated with older age (70y vs. 62y; p<0,001), greater disease severity score (APACHE IV, 71 vs. 50; p<0,001), longer length of stay (7d vs. 4.5d; p<0,001), and worse prognosis of death (APACHE IV PDR, 48.9 vs. 17.35; p<0,001). All cost categories and total cost per patient were also higher than the patient without limitation of NBIs (9247,79€ vs. 8029,46€, p<0,004). The mean daily cost has not differed between the groups (831,24€ vs. 832,59€; p<0,716). However, in the group of patients with limitations, all cost categories, including the average daily cost (767.31€ vs. 649.12€) after the limitation of NBIs, were reduced to a statistically significant degree (p<0.001).
Conclusions: Limiting NBIs in the ICU reduces healthcare costs and may lead to better management of ICU resource use.

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Total Psoas Area and Psoas Density Assessment in COVID-19 Patients Using CT Imaging – Could Muscle Mass Alteration During Intensive Care Hospitalization be Determined?

Oana Elena Branea1, Anca Gabriela Vlad2, Mihai Pui2, Diana Andreea Becica2, Mihai Emanuel Becica2, AnaMaria Romina Budeanu2, Razvan Gabriel Budeanu2, Florin Stoica1, Alexandra Elena Lazar1

1 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Targu Mures County Emergency Clinical Hospital, Romania

DOI: 10.2478/jccm-2023-0026

Background: Since its debut, as reported by the first published studies, COVID-19 has been linked to life-threatening conditions that needed vital assistance and admission to the intensive care unit. Skeletal muscle is a core element in an organism’s health due to its ability to keep energy balance and homeostasis. Many patients with prolonged hospitalization are characterized by a greater probability prone to critical illness myopathy or intensive care unit-acquired weakness.
Objective: The main aim of this study was to assess the skeletal muscle in a COVID-19 cohort of critically ill patients by measuring the psoas area and density.
Material and methods: This is a retrospective study that included critically ill adult patients, COVID-19 positive, mechanically ventilated, with an ICU stay of over 24 hours, and who had 2 CT scans eligible for psoas muscle evaluation. In these patients, correlations between different severity scores and psoas CT scans were sought, along with correlations with the outcome of the patients.
Results: Twenty-two patients met the inclusion criteria. No statistically significant differences were noticed regarding the psoas analysis by two blinded radiologists. Significant correlations were found between LOS in the hospital and in ICU with psoas area and Hounsfield Units for the first CT scan performed. With reference to AUC-ROC and outcome, it is underlined that AUC-ROC is close to 0.5 values, for both the psoas area and HU, indicating that the model had no class separation capacity.
Conclusion: The study suggested that over a short period, the psoas muscle area, and the psoas HU decline, for both the left and the right sight, in adult COVID-19 patients in ICU conditions, yet not statistically significant. Although more than two-thirds of the patients had a negative outcome, it was not possible to demonstrate an association between the SARS-COV2 infection and psoas muscle impairment. These findings highlight the need for further larger investigations.

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A Retrospective Cohort Study of Traumatic Brain Injury in Children: A Single-Institution Experience and Determinants of Neurologic Outcome

Merve Misirlioglu1, Faruk Ekinci2, Dincer Yildizdas2, Ozden Ozgur Horoz2, Hayri Levent Yilmaz3, Faruk Incecik4, Mazhar Ozsoy5, Ahmet Yontem2, Sevcan Bilen3, Sena Silay6

1 Department of Pediatric Intensive Care, Mersin University Faculty of Medicine, Mersin, Turkey
2 Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine, Adana, Turkey
3 Department of Pediatric Emergency, Cukurova University Faculty of Medicine, Adana, Turkey
4 Department of Pediatric Neurology, Cukurova University Faculty of Medicine, Adana, Turkey
5 Department of Neurosurgery, Cukurova University Faculty of Medicine, Adana, Turkey
6 Department of Pediatrics, Cukurova University Faculty of Medicine, Adana, Turkey

DOI: 10.2478/jccm-2023-0027

Introduction: Traumatic brain injury (TBI) has become a significant cause of death and morbidity in childhood since the elucidation of infectious causes within the last century. Mortality rates in this population decreased over time due to developments in technology and effective treatment modalities.
Aim of the study: This retrospective cohort study aimed to describe the volume, severity and mechanism of all hospital-admitted pediatric TBI patients at a university hospital over a 5-year period. Material and
Methods: This was a single-center, retrospective cohort study including 90 pediatric patients with TBI admitted to a tertiary care PICU. The patients’ demographic data, injury mechanisms, disease and trauma severity scores, initiation of enteral nutrition and outcome measures such as hospital stay, PICU stay, duration of mechanical ventilation, mortality, and Glasgow Outcome Scale (GOS) were also recorded. Late enteral nutrition was defined as initiation of enteral feeding after 48 hours of hospitalization.
Results: Of the 90 patients included in the cohort, 60% had mild TBI, 21.1% had moderate TBI and 18.9% had severe TBI. Their mean age was 69 months (3-210 months). TBI was isolated in 34 (37.8%) patients and observed as a part of multisystemic trauma in 56 (62.2%). The most commonly involved site in multisystemic injury was the thorax (33.3%). The length of hospitalization in the late enteral nutrition group was significantly higher than that in the early nutrition group, while the PICU stay was not significantly different between the two groups. The multiple logistic regression analysis found a significant relationship between GOS-3rd month and PIM3 score, the presence of diffuse axonal injury and the need for CPR in the first 24 h of hospitalization.
Conclusion: Although our study showed that delayed enteral nutrition did not affect neurologic outcome, it may lead to prolonged hospitalization and increased hospital costs. High PIM3 scores and diffuse axonal injury are both associated with worse neurologic outcomes.

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The Prognostic Utility of Cytokines in Hospitalized COVID-19 Patients

Ákos Vince Andrejkovits1, Adina Huțanu2,3, Ervin József Susányi4, Valentina Negrea1,5, Anca Meda Văsieșiu4,5

1 Doctoral School of Medicine and Pharmacy, I.O.S.U.D., George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Department of Laboratory Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Center for Advanced Medical and Pharmaceutical Research, Targu Mures, Romania
4 First Infectious Disease Clinic of Targu Mureș, Mureș County Clinical Hospital, Romania
5 Department of Infectious Disease, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2023-0025

Introduction: The severity of COVID-19 depends on several factors, but the overproduction of pro-inflammatory cytokines remains in center of the interest. The aim of this study was to investigate the predictive utility of interleukin (IL)-6, IL-8, IL-10, IL-12, tumor necrosis factor alpha (TNF-α), and interferon gamma (IFN-γ) in patients with COVID-19.
Material and Methods: We prospectively enrolled 181 adult patients with COVID-19 admitted to the 1st Infectious Disease County Hospital Târgu Mureș from December 2020 to September 2021. Serum cytokine levels were measured and correlated with disease severity, need for oxygen therapy, intensive care unit (ICU) transfer, and outcome.Results: We found significantly higher serum levels of IL-6, IL-8, and IL-10 in patients with severe COVID-19 and in those with a fatal outcome. The logistic regression analysis showed a significant predictive value for IL-8 regarding disease severity, and for IL6 and IL-10 regarding ICU transfer and fatal outcome.
Conclusions: Serum levels of IL-6, IL-8, and IL-10 were significantly increased in patients with COVID-19, but their predictive value regarding disease severity and the need for oxygen therapy was poor. We found IL-6 and IL-10 to have a good predictive performance regarding ICU transfer and fatal outcome.

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The Gender Gap in Aortic Dissection:
A Prospective Analysis of Risk and Outcomes

Cosmin Banceu 1,2,3, Marius Harpa1,3, Klara Brinzaniuc1, Ioan Tilea1, Andreea Varga1, Mirela Liana Gliga1, Septimiu Voidazan1,3, Nicolae Neagu1, Dan Alexandru Szabo1, Diana Banceu4, Daiana Cristutiu3, Ionut Alexandru Balmos1, Alexandra Puscas1,3, Marvin Oprean4, Horatiu Suciu1,3

1 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 I.O.S.U.D George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Emergency Institute for Cardiovascular Diseases and Transplantation Targu Mures, Romania
4 Dimitrie Cantemir University of Targu Mures, Romania

DOI: 10.2478/jccm-2023-0024

Aortic dissection (AD) is a severe cardiovascular condition that could have negative consequences. Our study employed a prospective design and examined preoperative, perioperative, and postoperative data to evaluate the effects of gender on various medical conditions. We looked at how gender affected the results of aortic dissection (AD). In contrast to female patients who had more systemic hypertension (p=0.031), male patients had higher rates of hemopericardium (p=0.003), pulmonary hypertension (p=0.039), and hemopericardium (p=0.003). Dobutamine administration during surgery significantly raised the mortality risk (p=0.015). There were noticeably more women patients (p=0.01) in the 71 to 80 age group. Significant differences in age (p=0.004), eGFR at admission (p=0.009), and eGFR at discharge (p=0.006) were seen, however, there was no association between gender and mortality. In conclusion, our findings highlight that gender may no longer be such an important aspect of aortic dissection disease as we previously thought, and this information could have an important contribution for surgeons as well as for anesthesiologists involved in the management of acute aortic dissection.

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Risk Factors for Weaning Failure in COVID-19 Patients

Effrosyni Gerovasileiou1, Apostolis-Alkiviadis Menis2, George Gavriilidis3, Eleni Magira4, Prodromos Temperikidis5, Sofia Papoti2, Nikitas Karavidas1, Michael Spanos1, Epaminondas Zakynthinos6, Demosthenes Makris1

1 University Hospital of Larissa, Larissa, Greece
2 G. Papanikolaou Hospital, Thessaloniki, Greece
3 Sotiria Regional Chest Disease Hospital of Athens, Athens, Greece
4 Evangelismos Athens General Hospital, Athens, Greece
5 Evangelismos Athens General Hospital, Cardiology, Athens, Greece
6 General University Hospital of Larissa, Larissa, Greece

DOI: 10.2478/jccm-2023-0021

Background: Data on risk factors associated with mechanical ventilation (MV) weaning failure among SARS-CoV2 ARDS patients is limited. We aimed to determine clinical characteristics associated with weaning outcome in SARS-CoV2 ARDS patients under MV.
Objectives: To determine potential risk factors for weaning outcome in patients with SARS-CoV2 ARDS.
Methods: A retrospective observational study was conducted in the ICUs of four Greek hospitals via review of the electronic medical record for the period 2020-2021. All consecutive adult patients were screened and were included if they fulfilled the following criteria: a) age equal or above 18 years, b) need for MV for more than 48 hours and c) diagnosis of ARDS due to SARS-CoV2 pneumonia or primary or secondary ARDS of other aetiologies. Patient demographic and clinical characteristics were recorded for the first 28 days following ICU admission. The primary outcome was weaning success defined as spontaneous ventilation for more than 48 hours.
Results: A hundred and fifty eight patients were included; 96 SARS-CoV2 ARDS patients. SOFA score, Chronic Obstructive Pulmonary Disease (COPD) and shock were independently associated with the weaning outcome OR(95% CI), 0.86 (0.73-0.99), 0.27 (0.08-0.89) and 0.30 (0.14-0.61), respectively]. When we analysed data from SARS-CoV2 ARDS patients separately, COPD [0.18 (0.03-0.96)] and shock [0.33(0.12 – 0.86)] were independently associated with the weaning outcome.
Conclusions: The presence of COPD and shock are potential risk factors for adverse weaning outcome in SARS-CoV2 ARDS patients.

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Ease of intubation with McGrath videolaryngoscope and incidence of adverse events during tracheal intubation in COVID-19 patients: A prospective observational study

Faisal Shamim, Muhammad Sohaib, Khalid Samad, Muhammad Faisal Khan, Adil A. Manji, Asad Latif

Aga Khan University Hospital, Karachi, Pakistan

DOI: 10.2478/jccm-2023-0020

Background: Tracheal intubation in critically ill patients remains high-risk despite advances in equipment, technique, and clinical guidelines. Many patients with COVID-19 were in respiratory distress and required intubation that is considered an aerosol-generating procedure (AGP). The transition to videolaryngoscopy as a routine first line option throughout anesthetic and ICU practice has been reported. We evaluated the ease of intubation, success rate, use of accessory maneuvers and adverse outcomes during and 24 hours after intubation with the McGrath videolaryngoscope.
Methods: This was a prospective, observational single center study conducted at non-operating room locations that included all adults (>18 years old) with suspected or confirmed COVID-19 infection and were intubated by McGrath videolaryngoscope. The anesthesiologist performed tracheal intubation were requested to fill online data collection form. A co-investigator was responsible to coordinate daily with assigned consultants for COVID intubation and follow up of patients at 24 hours after intubation.
Results: A total of 105 patients were included in our study. Patients were predominantly male (n=78; 74.3%), their COVID status was either confirmed (n=97, 92.4%) or suspected (n=8, 7.6%). Most were intubated in the COVID ward (n=59, 56.2%) or COVID ICU (n=23, 21.9%). The overall success rate of intubation with McGrath in the first attempt was 82.9%. The glottic view was either full (n=85, 80.95%), partial (n=16, 15.24%) or none (n=4, 3.81%). During intubation, hypoxemia occurred in 18.1% and hypotension in 16.2% patients. Within 24 hours of intubation, pneumothorax occurred in 1.9%, cardiac arrest and return of spontaneous circulation in 6.7% and mortality in 13.3% of patients.
Conclusion: These results illustrate the ease and utility of the McGrath videolaryngoscope for tracheal intubation in COVID-19 patients. Its disposable blade is of significant value in protectin during tracheal intubation.

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End-of-life Care in the Intesive Care Unit and Nursing Roles in Communicating with Families

Anastasios Tzenalis1, Helen Papaemmanuel2, George Kipourgos2, George Elesnitsalis2

1 University Of Patras, Patra, Greece
2 General Hospital of Thessaloniki Papageorgiou, Greece

DOI: 10.2478/jccm-2023-0013

Introduction: Professionals in Intensive Care Units face death, shifting their role from therapists to caregivers in end-of-life management. The nursing attitude and response to death has been shown to affect the quality of palliative care and end-of-life services that are interrelated services. Aim of the study: The aim of this research was to evaluate the professional attitude of nurses towards the care of the families of critically ill patients in the ICU, leading to the emergence of specific attitudes, relating them to their demographic and professional characteristics, with the aim of drawing conclusions for the improvement of quality in end-of-life care.
Material and Methods: The sample of the study was 81 nurses from a large tertiary hospital. Participants completed the “Nurse Activities for Communicating with Families” (NACF) questionnaire. The questions are about ways in which nurses can help the patient’s family during the patient’s stay in the ICU.
Results: The results revealed that the nurses took actions related to the information and psychological support of the patient’s family. On the contrary, they did not focus on the spiritual / religious needs of the patient and the needs of the family based on their cultural background.
Conclusions: The professional treatment of staff is characterized by compassion and empathy, but it is necessary to train them on important issues related to diversity, including the religious, spiritual values ​​and beliefs of patients and their relatives.

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Aerosolized Plus Intravenous Polymyxin B Versus Colistin in the Treatment of Pandrug-Resistant Klebsiella Pneumonia-mediated Ventilator-Associated Pneumonia: A Retrospective Cohort Study in Bangladesh

Md Jahidul Hasan1, Chandra Datta Sumi2, Shihan Mahmud Redwanul Huq3, Ahmad Mursel Anam4, Raihan Rabbani3

1 University of New South Wales, Sydney, NSW, Australia
2 The University of Queensland, Brisbane, Australia
3 Internal Medicine and ICU, Square Hospitals Ltd., Dhaka, Bangladesh.
4 High Dependency Unit, Square Hospitals Ltd., Dhaka, Bangladesh

DOI: 10.2478/jccm-2023-0012

Background: Pandrug-resistant Klebsiella pneumoniae ventilator associated pneumonia (VAP) is associated with high rate of mortality in intensive care unit (ICU) and has been recognized as a difficult-to-treat infection worldwide. Polymyxin B or colistin-based combination therapies are frequently used worldwide though microbial eradication rate is not promising.
Aim: The aim of this study is to compare the clinical outcome of intravenous with aerosolized polymyxin B versus colistin in the treatment of pandrug-resistant K. pneumoniae VAP.
Methods: This retrospective cohort study was conducted on 222 mechanically ventilated patients admitted from May 11, 2019 to October 19, 2020. K. pneumoniae isolates were resistant to all available antibiotics, including polymyxins in culture sensitivity tests. As treatment, polymyxin B and colistin was administered in intravenous and aerosolized form concurrently twice daily in 106 patients and 116 patients in PMB and CLN group, respectively for 14 days. Survival rate, safety, and clinical outcomes were compared among the groups. The Cox proportional-hazard model was performed to calculate hazard ratio (HR) with 95% confidence intervals (CI).
Results: Patients in PMB group showed more microbial eradication than the patients CLN group [68.1% (n=116)/83% (n=106), respectively; P <0.05). The median day of intubation and ICU stay in PMB group was shorter than that in CLN group [10 (IQR: 9-12.25) vs. 14 (IQR: 11-19), P <0.05; 12 (IQR: 10-14) vs. 15 (IQR: 9-18.5), P=0.072, respectively] with reduced 60-day all-cause mortality rate [15% (n=106) vs. 21.55% (n=116)]. Polymyxin B improved survival compared to colistin (multivariate HR: 0.662; 95% CI=0.359- 1.222, P=0.195).
Conclusions: Concurrent administration of intravenous and aerosolized polymyxin B in patients with pandrug-resistant K. pneumoniae-associated VAP revealed better microbial eradication, reduced the length of intubation and ICU stay, and improved survival rate compared to colistin.

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