Category Archives: Original Research

The Impact of Hyperoxia Treatment on Neurological Outcomes and Mortality in Moderate to Severe Traumatic Brain Injured patients

Raymond Khan, Sarah Alromaih, Hind Alshabanat, Nosaiba Alshanqiti, Almaha Aldhuwaihy, Sarah Abdullah Almohanna, Muna Alqasem, Hasan Al-Dorzi

King Saud bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, Saudi Arabia

DOI: 10.2478/jccm-2021-0014

Background: Traumatic brain injury is a leading cause of morbidity and mortality worldwide. The relationship between hyperoxia and outcomes in patients with TBI remains controversial. We assessed the effect of persistent hyperoxia on the neurological outcomes and survival of critically ill patients with moderate-severe TBI.
Method: This was a retrospective cohort study of all adults with moderate-severe TBI admitted to the ICU between 1st January 2016 and 31st December 2019 and who required invasive mechanical ventilation. Arterial blood gas data was recorded within the first 3 hours of intubation and then after 6-12 hours and 24-48 hours. The patients were divided into two categories: Group I had a PaO2 < 120mmHg on at least two ABGs undertaken in the first twelve hours post intubation and Group II had a PaO2 ≥ 120mmHg on at least two ABGs in the same period. Multivariable logistic regression was performed to assess predictors of hospital mortality and good neurologic outcome (Glasgow outcome score ≥ 4).
Results: The study included 309 patients: 54.7% (n=169) in Group I and 45.3% (n=140) in Group II. Hyperoxia was not associated with increased mortality in the ICU (20.1% vs. 17.9%, p=0.62) or hospital (20.7% vs. 17.9%, p=0.53), moreover, the hospital discharge mean (SD) Glasgow Coma Scale (11.0(5.1) vs. 11.2(4.9), p=0.70) and mean (SD) Glasgow Outcome Score (3.1(1.3) vs. 3.1(1.2), p=0.47) were similar. In multivariable logistic regression analysis, persistent hyperoxia was not associated with increased mortality (adjusted odds ratio [aOR] 0.71, 95% CI 0.34-1.35, p=0.29). PaO2 within the first 3 hours was also not associated with mortality: 121-200mmHg: aOR 0.58, 95% CI 0.23-1.49, p=0.26; 201-300mmHg: aOR 0.66, 95% CI 0.27-1.59, p=0.35; 301-400mmHg: aOR 0.85, 95% CI 0.31-2.35, p=0.75 and >400mmHg: aOR 0.51, 95% CI 0.18-1.44, p=0.20; reference: PaO2 60-120mmHg within 3 hours. However, hyperoxia >400mmHg was associated with being less likely to have good neurological (GOS ≥4) outcome on hospital discharge (aOR 0.36, 95% CI 0.13-0.98, p=0.046; reference: PaO2 60-120mmHg within 3 hours.
Conclusion: In intubated patients with moderate-severe TBI, hyperoxia in the first 48 hours was not independently associated with hospital mortality. However, PaO2 >400mmHg may be associated with a worse neurological outcome on hospital discharge.

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Prevalence of Depression, Anxiety and Stress among Patients Discharged from Critical Care Units

Mohammad Saeidi1, Alireza Safaei2, Zohreh Sadat3, Parisa Abbasi4, Masoumeh Sadat Mousavi Sarcheshmeh5, Fariba Dehghani6, Mehran Tahrekhani7, Mohammad Abdi8

1 Department of Anesthesiology and Critical Care, Qom University of Medical Sciences, Qom, Iran
2 School of Science, Engineering and Environment, University of Salford, Manchester, UK
3 Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, Iran
4 Baharlo Hospital, Tehran University of Medical Sciences, Tehran, Iran
5 Bahman Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
6 Researcher of Spiritual Health Research Center, Qom University of Medical Sciences, Qom, Iran
7 Department of Nursing Education, Abhar School of Nursing, Zanjan University of Medical Sciences, Zanjan, Iran
8 Department of Medical Education, Medical School, Tehran University of Medical Sciences, Tehran, Iran

DOI: 10.2478/jccm-2021-0012

Introduction: The widespread use of advanced technology and invasive intervention creates many psychological problems for hospitalized patients; it is especially common in critical care units.
Methods: This cross-sectional study was conducted on 310 patients hospitalized in critical care units, using a non-probability sampling method. Data were collected using depression, anxiety, and stress scale (DASS-21) one month after discharge from the hospital. Data analysis was performed using descriptive and inferential statistics.
Results: 181 males and 129 females with a mean age (SD) of 55.11(1.62) years were enrolled in the study. The prevalence of depression, anxiety and stress were 46.5, 53.6 and 57.8% respectively, and the depression, anxiety and stress mean (SD) scores were 16.15(1.40), 18.57(1.46), 19.69(1.48), respectively. A statistically significant association was reported between depression, anxiety and stress with an increase in age, the number of children, occupation, education, length of hospital stay, use of mechanical ventilation, type of the critical care unit, and drug abuse.
Conclusion: The prevalence of depression, anxiety and stress in patients discharged from critical care units was high. Therefore, crucial decisions should be made to reduce depression, anxiety and stress in patients discharged from critical care units by educational strategies, identifying vulnerable patients and their preparation before invasive diagnostic-treatment procedures.

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Renal Recovery in Critically Ill Adult Patients Treated With Veno-Venous or Veno-Arterial Extra Corporeal Membrane Oxygenation: A Retrospective Cohort Analysis

Braghadheeswar Thyagarajan1, Mariana Murea2, Deanna N. Jones2, Amit K. Saha3, Gregory B. Russell4, Ashish K. Khanna1,5

1 Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
2 Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
3 Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
4 Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
5 Outcomes Research Consortium, Cleveland, OH, USA

DOI: 10.2478/jccm-2021-0006

Introduction: Patients on extracorporeal membrane oxygenator (ECMO) therapy are critically ill and often develop acute kidney injury (AKI) during hospitalisation. Little is known about the association of exposure to and the effect of the type of ECMO and extent of renal recovery after AKI development. Aim of the study: In patients who developed AKI, renal recovery was characterised as complete, partial or dialysis-dependent at the time of hospital discharge in both the Veno-Arterial (VA) and Veno-Venous (VV) ECMO treatment groups.
Material and methods: The study consisted of a single-centre retrospective cohort that includes all adult patients (n=125) who received ECMO treatment at a tertiary academic medical centre between 2015 to 2019. Data on demographics, type of ECMO circuit, comorbidities, exposure to nephrotoxic factors and receipt of renal replacement therapy (RRT) were collected as a part of the analysis. Acute Kidney Injury Network (AKIN) criteria were used for the diagnosis and classification of AKI. Group differences were assessed using Fisher’s exact tests for categorical data and independent t-tests for continuous outcomes.
Results: Sixty-four patients received VA ECMO, and 58 received VV ECMO. AKI developed in 58(91%) in the VA ECMO group and 51 (88%) in the VV ECMO group (p=0.77). RRT was prescribed in significantly higher numbers in the VV group 38 (75%) compared to the VA group 27 (47%) (p=0.0035). At the time of discharge, AKI recovery rate in the VA group consisted of 15 (26%) complete recovery and 5 (9%) partial recovery; 1 (2%) remained dialysis-dependent. In the VV group, 22 (43%) had complete recovery (p=0.07), 3(6%) had partial recovery (p=0.72), and 1 (2%) was dialysis-dependent (p>0.99). In-hospital mortality was 64% in the VA group and 49% in the VV group (p=0.13).
Conclusions: Renal outcomes in critically ill patients who develop AKI are not associated with the type of ECMO used. This serves as preliminary data for future studies in the area.

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The Use of Diuretic in Mechanically Ventilated Children with Viral Bronchiolitis: A Cohort Study

Nisha Agasthya1,2, Kimberlee Chromey1,2, James H. Hertzog1,2, Jigar C. Chauhan1,2

1 Department of Pediatrics, Division of Critical Care Medicine, Nemours A.I. duPont Hospital for Children, Wilmington, DE, USA
2 Department of Pediatrics, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA, USA

DOI: 10.2478/jccm-2021-0008

Introduction: Viral bronchiolitis is a leading cause of admissions to pediatric intensive care unit (PICU). A literature review indicates that there is limited information on fluid overload and the use of diuretics in mechanically ventilated children with viral bronchiolitis. This study was conducted to understand diuretic use concerning fluid overload in this population.
Material and methods: A retrospective cohort study performed at a quaternary children’s hospital. The study population consisted of mechanically ventilated children with bronchiolitis, with a confirmed viral diagnosis on polymerase chain reaction (PCR) testing. Children with co-morbidities were excluded. Data collected included demographics, fluid status, diuretic use, morbidity and outcomes. The data were compared between groups that received or did not receive diuretics.
Result: Of the 224 mechanically ventilated children with confirmed bronchiolitis, 179 (79%) received furosemide on Day 2 of invasive ventilation. Out of these, 72% of the patients received intermittent intravenous furosemide, whereas 28% received continuous infusion. It was used more commonly in patients who had a higher fluid overload. Initial fluid overload was associated with longer duration of mechanical ventilation (median days 6 vs 4, p<0.001) and length of stay (median days 10 vs 6, p<0.001) even with the use of furosemide. Superimposed bacterial pneumonia was seen in 60% of cases and was associated with a higher per cent fluid overload at 24 hours (9.1 vs 6.3, p = 0.003).
Conclusion: Diuretics are frequently used in mechanically ventilated children with bronchiolitis and fluid overload, with intermittent dosing of furosemide being the commonest treatment. There is a potential benefit of improved oxygenation in these children, though further research is needed to quantify this benefit and any potential harm. Due to potential harm with fluid overload, restrictive fluid strategies may have a potential benefit.

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Effects of Extracorporeal Membrane Oxygenation Initiation on Oxygenation and Pulmonary Opacities

Kiran Batra, Manish Mohanka, Srinivas Bollineni, Vaidehi Kaza, Prabhakar Rajiah, Yin Xi, Amy Hackmann, Michael Wait, Fernando Torres, Amit Banga

University of Texas Southwestern Medical Center at Dallas, TX, USA

DOI: 10.2478/jccm-2020-0040

Introduction: There is limited data on the impact of extracorporeal membrane oxygenation (ECMO) on pulmonary physiology and imaging in adult patients. The current study sought to evaluate the serial changes in oxygenation and pulmonary opacities after ECMO initiation.
Methods: Records of patients started on veno-venous, or veno-arterial ECMO were reviewed (n=33; mean (SD): age 50(16) years; Male: Female 20:13). Clinical and laboratory variables before and after ECMO, including daily PaO2 to FiO2 ratio (PFR), were recorded. Daily chest radiographs (CXR) were prospectively appraised in a blinded fashion and scored for the extent and severity of opacities using an objective scoring system.
Results: ECMO was associated with impaired oxygenation as reflected by the drop in median PFR from 101 (interquartile range, IQR: 63-151) at the initiation of ECMO to a post-ECMO trough of 74 (IQR: 56-98) on post-ECMO day 5. However, the difference was not statistically significant. The appraisal of daily CXR revealed progressively worsening opacities, as reflected by a significant increase in the opacity score (Wilk’s Lambda statistic 7.59, p=0.001). During the post-ECMO period, a >10% increase in the opacity score was recorded in 93.9% of patients. There was a negative association between PFR and opacity scores, with an average one-unit decrease in the PFR corresponding to a +0.010 increase in the opacity score (95% confidence interval: 0.002 to 0.019, p-value=0.0162). The median opacity score on each day after ECMO initiation remained significantly higher than the pre-ECMO score. The most significant increase in the opacity score (9, IQR: -8 to 16) was noted on radiographs between pre-ECMO and forty-eight hours post-ECMO. The severity of deteriorating oxygenation or pulmonary opacities was not associated with hospital survival.
Conclusions: The use of ECMO is associated with an increase in bilateral opacities and a deterioration in oxygenation that starts early and peaks around 48 hours after ECMO initiation.

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Ischemic Stroke in Patients with Cancer: A Retrospective Cross-Sectional Study

Anca Motataianu1, Smaranda Maier1, Sebastian Andone2, Laura Barcutean1, Georgiana Serban2, Zoltan Bajko1, Adrian Balasa1

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

DOI: 10.2478/jccm-2021-0002

Introduction: An increasing trend of cancer associated stroke has been noticed in the past decade.
Objectives: To evaluate the risk factors and the incidence of neoplasia in stroke patients.
Material and Method: A retrospective, observational study was undertaken on 249 patients with stroke and active cancer (SAC) and 1563 patients with stroke without cancer (SWC). The general cardiovascular risk factors, the site of cancer, and the general clinical data were registered and evaluated. According to the “Oxfordshire Community Stroke Project” (OCSP) classification, all patients were classified into the clinical subtypes of stroke. The aetiology of stroke was considered as large-artery atherosclerosis, small vessel disease, cardio-embolic, cryptogenic or other determined cause.
Results: The severity of neurological deficits at admission were significantly higher in the SAC group (p<0.01). The haemoglobin level was significantly lower, and platelet level and erythrocyte sedimentation rate were significantly higher in the SAC group. Glycaemia, cholesterol and triglycerides levels were significantly higher in the SWC group. The personal history of hypertension was more frequent in the SWC group. In the SAC group, 28.9% had a cryptogenic aetiology, compared to 9.1% in SWC group. Cardio-embolic strokes were more frequent in the SAC group (24%) than the SWC group (19.6%). In the SAC group, 15,6% were diagnosed with cancer during the stroke hospitalization, and 78% of the SAC patients were without metastasis.
Conclusions: The most frequent aetiologies of stroke in cancer patients were cryptogenic stroke, followed by large-artery atherosclerosis. SAC patients had more severe neurological deficits and worse clinical outcomes than SWC patients. Stroke in cancer patients appears to be more frequently cryptogenic, probably due to cancer associated thrombosis. The association between stroke and cancer is important, especially in stroke of cryptogenic mechanism, even in the presence of traditional cardiovascular risk factors.

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The Correspondence between Fluid Balance and Body Weight Change Measurements in Critically Ill Adult Patients

Ana Carolina Peçanha Antonio1, Vivian Rodrigues Fernandes2, Karina de Oliveira Azzolin3

1 Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
2 Fellow nurse, Instituto de Cardiologia, Porto Alegre, Brazil
3 Universidade Federal do Rio Grande do Sul Instituto de Ciencias Basicas da Saude, Porto Alegre, Brazil

DOI: 10.2478/jccm-2020-0048

Introduction: Positive fluid status has been associated with a worse prognosis in intensive care unit (ICU) patients. Given the potential for errors in the calculation of fluid balance totals and the problem of accounting for indiscernible fluid losses, measurement of body weight change is an alternative non-invasive method commonly used for estimating body fluid status. The objective of the study is to compare the measurements of fluid balance and body weight changes over time and to assess their association with ICU mortality. Methods: This prospective observational study was conducted in the 34-bed multidisciplinary ICU of a tertiary teaching hospital in southern Brazil. Adult patients were eligible if their expected length of stay was more than 48 hours, and if they were not receiving an oral diet. Clinical demographic data, daily and cumulative fluid balance with and without indiscernible water loss, and daily and total body weight changes were recorded. Agreement between daily fluid balance and body weight change, and between cumulative fluid balance and total body weight change were calculated. Results: Cumulative fluid balance and total body weight change differed significantly among survivors and non survivors respectively, +2.53L versus +5.6L (p= 0.012) and -3.05kg vs -1.1kg (p= 0.008). The average daily difference between measured fluid balance and body weight was +0.864 L/kg with a wide interval: -3.156 to +4.885 L/kg, which remained so even after adjustment for indiscernible losses (mean bias: +0.288; limits of agreement between -3.876 and +4.452 L/kg). Areas under ROC curve for cumulative fluid balance, cumulative fluid balance with indiscernible losses and total body weight change were, respectively, 0.65, 0.56 and 0.65 (p= 0.14). Conclusion: The results indicated the absence of correspondence between fluid balance and body weight change, with a more significant discrepancy between cumulative fluid balance and total body weight change. Both fluid balance and body weight changes were significantly different among survivors and non-survivors, but neither measurement discriminated ICU mortality.

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Prognostic Value of Bone Formation and Resorption Proteins in Heterotopic Ossification in Critically-Ill Patients. A Single-Centre Study

Alice Georgia Vassiliou1, Edison Jahaj1, Zafeiria Mastora1, Ioannis Karnezis2, Ioanna Dimopoulou1, Stylianos E. Orfanos1, Anastasia Kotanidou1

1 First Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
2 Department of Orthopedics, Evangelismos Hospital, Athens, Greece

DOI: 10.2478/jccm-2020-0046

Introduction: A potential complication in critically ill patients is the formation of bone in soft tissues, termed heterotopic ossification. The exact pathogenetic mechanisms are still undetermined. Bone morphogenetic proteins induce bone formation, while signalling through the receptor activator of nuclear factor kappa-Β (RANK) and its ligand (RANKL), regulates osteoclast formation, activation, and survival in normal bone modelling and remodelling. Osteoprotegerin protects bone from excessive bone loss by blocking RANKL from binding to RANK.
Aim: The study aimed to investigate these molecules as potential prognostic biomarkers of heterotopic ossification development in critically ill patients.
Materials and Methods: In this prospective observational study, BMP-2, RANKL, and osteoprotegerin were measured by ELISA in twenty-eight critically-ill, initially non-septic patients, on admission to an ICU, seven days post-admission, and thirty days after ICU discharge.
Results: In the critically-ill cohort, nine of the twenty-eight patients developed heterotopic ossification up to the 30-day follow-up time-point. The patients who developed heterotopic ossification exhibited significantly reduced BMP-2 and RANKL levels on ICU admission, compared to patients who did not; Osteoprotegerin readings were similar in both groups.
Conclusions: Critically-ill patients who will subsequently develop heterotopic ossification, have significantly lower BMP-2 and RANKL levels at the time of ICU admission, suggesting that these proteins may be useful as prognostic markers for this debilitating condition.

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Mortality Rate and Predictors among Patients with COVID-19 Related Acute Respiratory Failure Requiring Mechanical Ventilation: A Retrospective Single Centre Study

Christophe de Terwangne1, Antonio Sorgente2, Redente Tortora3, Diana Cheung3, Frederic Duprez3, Sammy Place1, Jerome R. Lechien4, Lucio Capulzini2, Michael De Cubber2, Sven Saussez4, Fabio Silvio Taccone5, Shahram Mashayekhi3

1 Department of Internal Medicine, Centre Hospitalier EpiCURA Hornu, Hornu, Belgium
2 Department of Cardiology, Centre Hospitalier EpiCURA, Hornu, Belgium
3 Department of Intensive Care, Centre Hospitalier EpiCURA, Hornu, Belgium
4 Department of Human Anatomy and Experimental Oncology, University of Mons, Mons, Belgium
5 Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium

DOI: 10.2478/jccm-2020-0043

Aim: The objective of the study was to assess mortality rates in COVID-19 patients suffering from acute respiratory distress syndrome (ARDS) who also requiring mechanical ventilation. The predictors of mortality in this cohort were analysed, and the clinical characteristics recorded.
Material and method: A single centre retrospective study was conducted on all COVID-19 patients admitted to the intensive care unit of the Epicura Hospital Center, Province of Hainaut, Belgium, between March 1st and April 30th 2020.
Results: Forty-nine patients were included in the study of which thirty-four were male, and fifteen were female. The mean (SD) age was 68.8 (10.6) and 69.5 (12.6) for males and females, respectively. The median time to death after the onset of symptoms was eighteen days. The median time to death, after hospital admission was nine days. By the end of the thirty days follow-up, twenty-seven patients (55%) had died, and twenty–two (45%) had survived. Non-survivors, as compared to those who survived, were similar in gender, prescribed medications, COVID-19 symptoms, with similar laboratory test results. They were significantly older (p = 0.007), with a higher co-morbidity burden (p = 0.026) and underwent significantly less tracheostomy (p < 0.001). In multivariable logistic regression analysis, no parameter significantly predicted mortality.
Conclusions: This study reported a mortality rate of 55% in critically ill COVID-19 patients with ARDS who also required mechanical ventilation. The results corroborate previous findings that older and more comorbid patients represent the population at most risk of a poor outcome in this setting.

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The Susceptibility of MDR-K. Pneumoniae to Polymyxin B Plus its Nebulised Form Versus Polymyxin B Alone in Critically Ill South Asian Patients

Md. Jahidul Hasan1, Raihan Rabbani2, Ahmad Mursel Anam3, Ario Santini4, Shihan Mahmud Redwanul Huq2

1 Clinical Pharmacy Services, Square Hospitals Ltd., Dhaka, Bangladesh
2 ICU and Internal Medicine, Square Hospitals Ltd., Dhaka, Bangladesh
3 High Dependency Unit (HDU), Square Hospitals Ltd., Dhaka, Bangladesh
4 University of Medicine, Pharmacy, Science and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2020-0044

Introduction: Critically ill patients in intensive care units are at high risk of dying not only from the severity of their illness but also from secondary causes such as hospital-acquired infections. USA national medical record-data show that approximately 10% of patients on mechanical ventilation in an intensive care unit developed ventilator-associated pneumonia. Polymyxin B has been used intravenously in the treatment of multi-drug resistant gram-negative infections, either as a monotherapy or with other potentially effective antibiotics, and the recent international guidelines have emphasised the use of nebulised polymyxin B together with intravenous polymyxin B to gain the optimum clinical outcome in ventilator-associated pneumonia cases caused by multi-drug resistant gram-negative infections.
Methods: One hundred and seventy-eight patients with ventilator-associated pneumonia due to multi-drug resistant K. pneumoniae were identified during the study period. Following the inclusion and exclusion criteria, 121 patients were enrolled in the study and randomly allocated to two study groups. Group 1 patients were treated with intravenous Polymyxin B plus nebulised polymyxin B (n=64) and Group 2 patients with intravenous Polymyxin B alone (n=57). The study aimed to compare the use of Polymyxin B plus its nebulised form to polymyxin B alone, in the treatment of MDR-K. pneumoniae associated ventilator-associated pneumonia in critically ill patients.
Results: In Group 1, a complete clearance of K. pneumoniae was found in fifty-nine patients (92.1%; n=64) compared to forty patients (70.1%, n=57) in the Group 2 (P<0.003). The average time till extubation was significantly higher in Group 2 compared to Group 1 (P<0.05). The total length-of-stay in the ICU was significantly higher in Group 2 compared to Group 1. (P<0.05). These results support the view that the Polymyxin B dual-route regime may be considered as an appropriate antibiotic therapy, in critically ill South Asian patients with ventilator-associated pneumonia.

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