Category Archives: Original Research

Feasibility and Safety of Peripheral Intravenous Administration of Vasopressor Agents in Resource-limited Settings

Ajay Padmanaban1, Ramesh Venkataraman1, Senthilkumar Rajagopal1, Dedeepiya Devaprasad2, Nagarajan Ramakrishnan1

1 Apollo Hospitals Chennai, Chennai, India
2 Apollo Cancer Hospitals, Chennai, India

DOI: 10.2478/jccm-2020-0030

Background: Vasopressors are conventionally administered through a central venous catheter (CVC) and not through a peripheral venous catheter (PVC) since the latter is believed to be associated with increased risk of extravasation. Placement of a CVC requires suitably trained personnel to be on hand, and in resource-limited settings, this requirement may delay placement. Because of this and in cases where suitably trained personnel are not immediately available, some clinicians may be prompted to utilise a PVC for infusing vasopressors. The objective of this study is to assess the feasibility and safety of vasopressors administered through a PVC.
Materials and methods: Patients who received vasopressors through a PVC for more than one hour were included in a single centre, consecutive patient observational study. Patients with a CVC at the time of initiation of vasopressors were excluded. Data regarding the size, location of PVCs, dose, duration and number of vasopressors infused were recorded. The decision to place CVC was left to the discretion of the treating physician. Extravasation incidents, severity and management of such events were recorded.
Results: One hundred twenty-two patients age 55(4) years [mean (SD)] were included in the study. The commonest PVC was of 18G calibre (57%), and the most common site of placement was the external jugular vein (36.5%). Noradrenaline was the most common vasopressor used at a dose of 10.6 (7) mcg/min [mean (SD)] and the median duration of nine hours (IQR: 6-14). CVC was placed most commonly due to an increasing dose of vasopressors after 4.5(4) hours [mean (SD)]. Grade 2 Extravasation injury occurred in one patient after prolonged infusion of fifty-two hours, through a small calibre (20G) PVC, which was managed conservatively without any sequelae.
Conclusion: Vasopressors infused through a PVC of 18G or larger calibre into the external jugular, or a forearm vein is feasible and safe. Clinicians need to balance the safety of peripheral vasopressor infusion with the additional costs and complications associated with CVC in resource-limited settings.

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A Comparison of Nosocomial Infection Density in Intensive Care Units on Relocating to a New Hospital

Zeynep Ture1, Tugba Ustuner2, Ario Santini3, Serhat Aydogan2, İlhami Celik2

1 Erciyes University Faculty of Medicine Kayseri, Turkey
2 City Hospital of Kayseri, Turkey
3 George Emil Palade University of Medicine, Pharmacy Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2020-0028

Background: The study aimed to investigate the changes in nosocomial infection density after patients were transferred to the intensive care unit (ICU) of a new-build hospital.
Methods: The types and rates of nosocomial infections were obtained for a one-year period retrospectively before leaving the old hospital premises and for a one-year periods after moving into the new hospital. The intensive care unit in the “old” premises was comprised of a 17-bedded hall, and thirty-three nurses shifted to work forty-eight hours a week, with each nurse assigned to provide care for two patients. The intensive care unit in the “new” premises consisted of single rooms, each with twenty-eight beds.
Results: The median nosocomial infection density decreased from 23 to 15 per 1000 in-patient days. The catheter-related urinary tract infection rate decreased from 7.5 to 2.6 per100 catheter days.
Conclusions: Treatment of patients in the new hospital resulted in a decrease in nosocomial infection density.

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Opioid Use Is Associated with ICU Delirium in Mechanically Ventilated Children

Neha Gupta1, Allison Woolley2, Saurabh Talathi1, Ganisher Davlyatov3, Candice Colston3, Leslie Hayes3

1 University of Oklahoma Health Sciences Center, Oklahoma City, USA
2 Children’s of Alabama, Birmingham, USA
3 University of Alabama at Birmingham, Birmingham, USA

DOI: 10.2478/jccm-2020-0026

Introduction: Pediatric delirium is a significant problem when encounterd in an intensive care unit (ICU). The pathophysiology of pediatric delirium is complex and the etiology is typically multifactorial. Even though various risk factors associated with pediatric delirium in a pediatric ICU have been identified, there is still a paucity of literature associated with the condition, especially in extremely critically ill children, sedated and mechanically ventilated. Aim of the study: To identify factors associated with delirium in mechanically ventilated children in an ICU.
Material and Methods: This is a single-center study conducted at a tertiary care pediatric ICU. Patients admitted to the pediatric ICU requiring sedation and mechanical ventilation for >48 hours were included. Cornell Assessment of Pediatric Delirium scale was used to screen patients with delirium. Baseline demographic and clinical factors as well as daily and cumulative doses of medications were compared between patients with and without delirium. Firth’s penalized maximum likelihood logistic regression was used on a priori set of variables to examine the association of potential factors with delirium. Two regression models were created to assess the effect of daily medication doses (Model 1) as well as cumulative medication doses (Model 2) of opioids and benzodiazepines.
Results: 95 patient visits met the inclusion criteria. 19 patients (20%) were diagnosed with delirium. Older patients (>12 years) had higher odds of developing delirium. Every 1mg/kg/day increase in daily doses of opioids was associated with an increased risk of delirium (OR=1.977, p=0.017). Likewise, 1 mg/kg increase in the cumulative opioid dose was associated with a higher odds of developing delirium (OR=1.035, p=0.022). Duration of mechanical ventilation was associated with the development of delirium in Model 1 (p=0.007).
Conclusions: Age, daily and cumulative opioid dosage and the duration of mechanical ventilation are associated with the development of delirium in mechanically ventilated children.

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Monitoring Anticoagulation with Unfractionated Heparin on Renal Replacement Therapy. Which Is the Best aPTT Sampling Site?

Florin Ioan Anton1, Paul Adrian Rus2, Natalia Hagau3

1 Regina Maria Hospital, Cluj-Napoca, Romania
2 Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Emergency Clinical County Hospital, Cluj-Napoca, Romania
3 Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Regina Maria Hospital, Cluj-Napoca, Romania

DOI: 10.2478/jccm-2020-0024

Background: Controlled anticoagulation is key to maintaining continuous blood filtration therapies. Objective: The study aimed to compare different blood sampling sites for activated partial thromboplastin time (aPTT) to evaluate anticoagulation with unfractionated heparin (UFH) in continuous renal replacement therapy (CRRT) and identify the most appropriate sampling site for safe patient anticoagulation and increased filter life span.
Method: The study was a prospective observational single-centre investigation targeting intensive care unit (ICU) patients on CRRT using an anticoagulation protocol based on patient characteristics and a weight-based modified nomogram. Eighty-four patients were included in the study. Four sampling sites were assessed: heparin free central venous nondialysis catheter (CVC), an arterial line with heparinised flush (Artery), a circuit access line (Access), and a circuit return line (Postfilter). Blood was sampled from each of four different sites on every patient, four hours after the first heparin bolus. aPTT was determined using a rapid clot detector, point of care device.
Results: A high positive correlation was obtained for aPTT values between CVC and Access sampling sites (r (84) =0.72; p <0 .05) and a low positive correlation between CVC and Arterial sampling site (r (84) =0.46, p < 0.05). When correlated by artery age, the young Artery (1-3 day old) correlates with CVC, Access and Postfilter (r (45) = 0.74, p >0.05). The aPTT values were significantly higher at Postfilter and Arterial sampling site, older than three days, compared to the CVC sampling site (p<0.05).
Conclusion: Considering patient bleeding risks and filter life span, the optimal sampling sites for safe assessment of unfractionated heparin anticoagulation on CRRT during CVVHDF were the central venous catheter using heparin free lavage saline solution, a heparinised flushed arterial catheter not older than three days, and a circuit access line

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Takotsubo Syndrome: Is This a Common Occurrence in Elderly Females after Hip Fracture?

Carlo Rostagno1, Gianluca Polidori2, Alice Ceccofiglio2, Alessandro Cartei2, Alberto Boccaccini2, Adriano Peris2, Gaia Rubbieri2, Roberto Civinini1, Massimo Innocenti1

1 Universita degli Studi di Firenze, Firenze, Italy
2 Azienda Ospedaliero Universitaria Careggi, Firenze, Italy

DOI: 10.2478/jccm-2020-0022

Background: The prevalence of Takotsubo syndrome in hip fracture is not known.
Methods: Hip fracture patients were evaluated in a multidisciplinary unit. Patients with ECG abnormalities and increased troponin I values at the time of hospital admission were included in the study Follow-up was clinical at 30 days and by telephonic interview at one year.
Results: Between October 1st 2011 to September 30th 2016, 51of 1506 patients had preoperative evidence of myocardial damage. Eight, all females, fulfilled the Mayo criteria for Takotsubo syndrome, six had no coronary lesions. Hip surgery was uneventful, and all eight were alive at thirty days, and seven of these were still alive after one year. Forty-three patients had myocardial infarction: mortality at thirty days and one year were 11% and 44% (p<0.0001, Student’s t-test;log-rank test).
Conclusion: At least 15% of patients with hip fracture and preoperative myocardial damage had Takotsubo syndrome. They were all elderly females. Contrary to myocardial infarction, Takotsubo syndrome has a favourable long term prognosis.

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The Diagnostic and Prognostic Role of Vascular Endothelial Growth Factor C in Sepsis and Septic Shock

Emoke Almasy1, Janos Szederjesi1, Bianca Liana Grigorescu2, Iudita Badea1,
Marius Petrisor3, Cristina Manasturean4, Valentina Negrea4, Agota-Evelyn Timar1,
Oana Coman1, Leonard Azamfirei1, Ario Santini5, Sanda Maria Copotoiu1

1 Anesthesiology and Intensive Care Clinic, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Discipline of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Department of Simulation Applied to Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
4 Infectious Diseases Clinic, University Hospital Targu Mures, Romania
5 The University of Edinburgh, UK

DOI: 10.2478/jccm-2020-0020

Introduction: Variations in the expression of vascular endothelial growth factor (VEGF) could be used as a biomarker in critically ill patients with sepsis and septic shock. Inflammation potently upregulates VEGF-C expression via macrophages with an unpredictable response. This study aimed to assess one of the newer biomarkers (VEGF-C) in patients with sepsis or septic shock and its clinical value as a diagnostic and prognostic tool.
Material and methods: The study involved 142 persons divided into three groups. Group A consisted of fifty-eight patients with sepsis; Group B consisted of forty-nine patients diagnosed as having septic shock according to the Sepsis -3 criteria. A control group of thirty-five healthy volunteers comprised Group C. Severity scores, prognostic score and organ dysfunction score, were recorded at the time of enrolment in the study. The analysis included specificity and sensitivity of plasma VEGF-C for diagnosis of septic shock. Circulating plasma VEGF-C levels were correlated with the APACHE II, MODS and severity scores and mortality.
Results: The mean (SD) plasma VEGF-C levels in septic shock patients (1374(789) pg./m), on vasopressors at the time of admission to the ICU, were significantly higher 1374(789)pg./mL, compared the mean (SD) plasma VEGF-C levels in sepsis patients (934(468) pg./mL); (p = 0.0005, Student’s t-test.) Plasma VEGF-C levels in groups A and B were shown to be significantly correlated with the APACHE II (r = 0.21, p = 0.02; r = 0.45, p = 0.0009) and MODS score (r = 0.29, p = 0.03; r = 0.4, p = 0.003). There was no association between plasma VEGF-C levels and mortality [p = 0.1]. The cut-off value for septic shock was 1010 pg./ml.
Conclusions: VEGF-C may be used as a prognostic marker in sepsis and septic shock due to its correlation with APACHE II values and as an early marker to determine the likelihood of developing MODS. It could be used as an early biomarker for diagnosing patients with septic shock.

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The Use of Pistacia Lentiscus Chia Resin versus Omeprazole in Protecting Male Rats Peptic Mucosa against Cold Restraint Stress

Despoina Kakagia1, Apostolos Papalois2, Maria Lambropoulou3, Fotini Papachristou1, Gregory Trypsiannis4, Constantinos Anagnostopoulos5, Mike Pitiakoudis1, Alexandra Tsaroucha1

1 Democritus University of Thrace Faculty of Medicine Alexandroupolis, Greece
2 Elpen Research Centre, Elpen Pharmaceuticals, Greece
3 Department of Histology- Embryology, Democritus University of Thrace, Faculty of Medicine, Alexandroupolis, Greece
4 Department of Medical Statistics, Democritus University of Thrace, Faculty of Medicine, Alexandropoulis, Greece
5 Department of Biochemistry, Democritus University of Thrace, Faculty of Medicine, Alexandroupolis, Greece

DOI: 10.2478/jccm-2020-0018

Introduction: Peptic mucosal damage induced by acute stress is a serious cause of morbidity and mortality in critically ill patients. The study aimed to investigate the protective, antioxidant and anti-inflammatory effects of pre-treatment with Chios mastic gum (CMG), a traditionally consumed herbal resin naturally deriving from the trunk of Pistacia Lentiscus var. Chia compared to Omeprazole, a standard medication used in the prevention and treatment of gastritis, against the effects of cold restraint stress (CRS) in rat gastric and colonic mucosa.
Methods: Twenty-one male Wistar rats were randomly assigned to three groups: Control (C), Omeprazole (O), and CMG (M), according to the pre-treatment regime, and were subjected to CRS at 4oC for 3 hours. The gastric and colonic mucosal lesions were histologically assessed. ELISA measured blood concentrations of TNF-α, IL-1β, peroxidase, superoxide dismutase (SOD) and total antioxidant capacity (TEAC).
Results: In both groups, O and M, gastric mucosal hyperemia, haemorrhagic infiltration and mucosal oedema, as well as colonic mucosal hyperaemia and haemorrhagic infiltration were significantly reduced compared to the controls (p<0.05). No significant differences were observed between Groups O and M. TNF-α levels were significantly lower in group M compared to Group O (p=0.013). IL-1β levels were significantly depressed in groups M and O compared to control (p≤ 0.001). The activity of both peroxidase and SOD enzymes decreased in group M compared to group O (p= 0.043 and p=0.047 respectively) and the control (p=0.018 and p< 0.001 respectively). Conclusions: The natural Chios mastic gum is a promising nutritional supplement with protective properties to the peptic mucosa against CRS, exerting anti-inflammatory and antioxidant effects.

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Prognostic Value of Serum Lactate Levels in Critically Ill Patients in an Intensive Care Unit

Hedgar Berty Gutiérrez, Yenisey Arteaga Concepción, Jorge Soneira Pérez, Yanín Díaz Lara, Félix Mario Rivero López, Pedro Rosales Contreras

Miguel Enríquez hospital, La Habana, Cuba

DOI: 10.2478/jccm-2020-0005

Introduction: The patient in critical condition, regardless of the cause of admission, continues to be a challenge for health systems due to the high mortality that it reports. There is a need to identify some marker of early obtaining, easy to interpret and with high relevance in the prognosis of these patients.
Objective: To determine the prognostic value of serum lactate in an Intensive Care Unit (ICU).
Method: One hundred and forty-five patients admitted to an ICU were enrolled in the study. The Acute Physiology and Chronic Health Evaluation II (APACHE) prognosis score, Sequential Organ Failure Assessment, hemodynamic support need, mechanical ventilation, cause of admission, stay in ICU, analytical and physiological variables were determined. The probability of survival of patients who had elevated and normal serum lactate levels was calculated. The risk of dying was determined using the Cox regression model.
Results: Twenty-eight patients died (19%) in the ICU. The serum lactate value was higher in the group of patients with trauma, infections, APACHE II and high creatinine levels; as well as with decreased mean arterial blood pressure, need for hemodynamic support and mechanical ventilation. The survival capacity was higher in patients who had normal serum lactate. Serum lactate was the sole independent predictor of mortality (AHR 1.28 [1.07-1.53], p = 0.008).
Conclusions: Patient assessment through the determination of serum lactate levels provides useful information in the initial evaluation of the critical patient.

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Prevalence and Prognostic Impact of Hypernatremia in Sepsis and Septic Shock Patients in The Intensive Care Unit: A Single Centre Experience

Mohamed Shirazy1,2, Islam Omar3,4, Duaa Abduljabbar5, Kamel Bousselmi2, Maryam Alkhaja5, Anis Chaari2, Vipin Kauts2, Karim Hakim2

1 Emergency Department, University Hospitals of Morecambe Bay NHS Foundation Trust, United Kingdom
2 Critical Care Department, King Hamad University Hospital, Kingdom of Bahrain
3 Surgical Department, University Hospitals of Morecambe Bay NHS Foundation Trust, United Kingdom
4 Surgical Department, King Hamad University Hospital, Kingdom of Bahrain
5 Internal Medicine department, King Hamad University Hospital, Kingdom of Bahrain

DOI: 10.2478/jccm-2020-0001

Introduction: Hypernatremia is a commonly associated electrolyte disturbance in sepsis and septic shock patients in the ICU. The objective of this study was to identify the prognostic value of hypernatremia in sepsis and septic shock.
Material and Methods: A prospective study conducted on sepsis and septic shock patients diagnosed prior to admission in the ICU in King Hamad University Hospital, Bahrain from January 1st 2017 to February 28th 2019. Data including age, sex, comorbidities, source of sepsis, sodium levels on days one, three, and seven. Data was correlated with the outcome (survival/death and the length of ICU stay).
Results: Patients included were 168, 110 survived, and 58 died. Hypernatraemia at day seven was associated with significantly higher mortality (P= 0.03). Hypernatraemia at Day1was associated with a significantly prolonged stay in the ICU (p= 0.039).Multivariate analysis to identify the independent predictors of mortality revealed that immunosuppression and hypernatraemia at Day7 proved to be independent predictors of mortality (P= 0.026 and 0.039 respectively).
Conclusion: Hypernatremia can be an independent predictor of poor outcome in septic and septic shock patients in the ICU.

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Predictors of In-Hospital Mortality after Recovered Out-of-Hospital Cardiac Arrest in Patients with Proven Significant Coronary Artery Disease: A Retrospective study

Maria Trepa1, Samuel Bastos2, Marta Fontes-Oliveira1, Ricardo Costa1, André Dias-Frias1, André Luz1, Vasco Dias1, Mário Santos1, Severo Torres1

1 Centro Hospitalar Universitario do Porto EPE, Porto, Portugal
2 Universidade do Porto Instituto de Ciencias Biomedicas Abel Salazar

DOI: 10.2478/jccm-2020-0006

Introduction: Recovered Out-of-Hospital Cardiac Arrest (rOHCA) population is heterogenous. Few studies focused on outcomes in the rOHCA subgroup with proven significant coronary artery disease (SigCAD). We aimed to characterize this subgroup and study the determinants of in-hospital mortality.
Methods: Retrospective study of consecutive rOHCA patients submitted to coronary angiography. Only patients with SigCAD were included. Results: 60 patients were studied, 85% were male, mean age was 62.6 ± 12.1 years. In-hospital mortality rate was 43.3%. Patients with diabetes and history of stroke were less likely to survive. Significant univariate predictors of in-hospital mortality were further analysed separately, according to whether they were present at hospital admission or developed during hospital evolution. At hospital admission, initial non-shockable rhythm, low-flow time>12min, pH<7.25mmol/L and lactates >4.75mmol/L were the most relevant predictors and therefore included in a score tested by Kaplan-Meyer. Patients who had 0/4 criteria had 100% chance of survival till hospital discharge, 1/4 had 77%, 2/4 had 50%, 3/4 had 25%. Patients with all 4 criteria had 0% survival. During in-hospital evolution, a pH<7.35 at 24h, lactates>2mmol/L at 24h, anoxic brain injury and persistent hemodynamic instability proved significant. Patients who had 0/4 of these in-hospital criteria had 100% chance of survival till hospital discharge, 1/4 had 94%, 2/4 had 47%, 3/4 had 25%. Patients with all 4 criteria had 0% survival. Contrarily, CAD severity and ventricular dysfunction didn’t significantly correlate to the outcome.
Conclusion: Classic prehospital variables retain their value in predicting mortality in the specific group of OHCA with SigCAD. In-hospital evolution variables proved to add value in mortality prediction. Combining these simple variables in risk scores might help refining prognostic prediction in these patients’ subset.

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