Category Archives: issue

Guillain–Barré and Acute Transverse Myelitis Overlap Syndrome Following Obstetric Surgery

Adina Stoian1,2, Anca Motataianu2,3, Zoltan Bajko2,3, Adrian Balasa4,5

1 Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Neurology 1 Clinic, Emergency Clinical County Hospital of Targu Mures, Romania
3 Department of Neurology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
4 Neurosurgery Clinic, Emergency Clinical County Hospital of Targu Mures, Romania
5 Department of Neurosurgery, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2020-0008

Introduction: There are rare reports of the occurrence of acute transverse myelitis and Guillain–Barré syndrome after various surgical procedures and general/epidural anaesthesia. The concomitant occurrence of these pathologies is very rare and is called Guillain–Barré and acute transverse myelitis overlap syndrome. In this article, we present the case of a second trimester pregnant patient who developed Guillain–Barré and acute transverse myelitis overlap syndrome.
Case presentation: We report the case of a 16-year-old female patient who underwent a therapeutic termination of pregnancy two weeks prior to the onset of the disease with gradual development of a motor deficit with walking and sensitivity disorders, fecal incontinence. The diagnosis was based on clinical exam, electroneurography and spinal magnetic resonance imaging. Endocrinopathies, infectious diseases, autoimmune and inflammatory diseases, neoplastic diseases and vitamin deficiencies were ruled out. Our patient attended five sessions of therapeutic plasma exchange, followed by steroid treatment, intravenous immunoglobulin with minimum recovery of the motor deficit in the upper limbs, but without significant evolution of the motor deficit in the lower limbs. The patient was discharged on maintenance corticotherapy and immunosuppressive treatment with azathioprine.
Conclusions: We report a very rare association between Guillain–Barré syndrome and acute transverse myelitis triggered by a surgical intervention with general anaesthesia. The overlap of Guillain–Barré syndrome and acute transverse myelitis makes the prognosis for recovery worse, and further studies are needed to establish the first-line therapy in these cases.

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Cerebellar Haemorrhage Leading to Sudden Cardiac Arrest

Ankit Agrawal1, Maria Cardinale2, Douglas Frenia3, Aveek Mukherjee1

1 Division of Internal Medicine, Rutgers Robert Wood Johnson Medical School, Saint Peter’s University Hospital, New Brunswick, NJ, USA
2 Division of Pharmacy, Ernest Mario School of Pharmacy, Rutgers University, Saint Peter’s University Hospital, New Brunswick, NJ, USA
3 Division of Pulmonary and Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, Saint Peter’s University Hospital, New Brunswick, NJ, USA

DOI: 10.2478/jccm-2020-0007

Introduction: Intracranial haemorrhage (ICH) is a known, but a rare cause of out of hospital cardiac arrest (OHCA). It results in the development of non-shockable rhythms such as asystole or pulseless electrical activity (PEA).
Case Report: A 77- years old male had an OHCA without any prodrome. An emergency medical services (EMS) team responded to an emergency call and intubated the patient at the site before transporting him to the Acute Care Hospital, New Brunswick, New Jersey, USA. On admission, a non-contrast computed tomography scan of the head revealed a large cerebellar haemorrhage. Non-traumatic ICH is a rare cause of OHCA. Although subarachnoid haemorrhage causing cardiac arrest has been described in the literature, cerebellar haemorrhage leading to cardiac arrest is rare. The mechanism by which ICH patients develop cardiac arrest is likely explained by a massive catecholamine surge leading to cardiac stunning.
Conclusion: A non-shockable rhythm in the setting of a sudden cardiac arrest should raise alarms for a primary non-cardiac ethology, especially a primary cerebrovascular event. The absence of brainstem reflexes increases the likelihood of an intracranial process.

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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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When a Stroke is not Just a Stroke: Escherichia coli Meningitis with Ventriculitis and Vasculitis: A Case Report

Barbara Ribeiro1, Peter Bishop1, Sima Jalili2

1 Intensive Care Unit, Colchester General Hospital, East Suffolk and North Essex NHS Foundation Trust, United Kingdom
2 Microbiology Department, Colchester General Hospital, East Suffolk and North Essex NHS Foundation Trust, United Kingdom

DOI: 10.2478/jccm-2020-0002

Introduction: Community-acquired Escherichia coli ventriculitis is considered a rare condition. Central nervous system (CNS) infection due to gram-negative bacilli is usually associated with previous neurosurgical interventions. The recent publication of cases of Escherichia coli meningitis and ventriculitis suggests its prevalence may be underestimated by the literature.
Case presentation: A case of community-acquired Escherichia coli CNS infection on a 58 year old patient presenting with altered consciousness but without neck stiffness, nor significant past medical history is reported. Imaging and lumbar puncture findings suggested a complex case of meningitis with associated ventriculitis and vasculitis. Escherichia coli was later identified in cultures. Subsequent multi-organ support in Intensive Care was required. The patient was treated with a prolonged course of intravenous antimicrobials guided by microbiology, resulting in some neurological recovery. The main challenges encountered in the management of the patient were the lack of clear recommendations on the duration of treatment and the potential development of multi-resistant organisms.
Conclusion: Bacterial central nervous system infections can have an atypical presentation, and an increasing number of cases of community-acquired ventriculitis have been reported. Early consideration should be given to use magnetic resonance imaging to help guide treatment. A long course of antibiotics is often required for these patients; however, the optimal duration for antimicrobial treatment is not well defined.

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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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Hyperammonemic Encephalopathy and Lipid Dysmetabolism in a Critically Ill Patient after A Short Course of Amiodarone

Maximilien Cappe1, Philippe Hantson1, Mina Komuta2, Marie-Françoise Vincent3, Pierre-François Laterre1, Ismaïl Ould-Nana1

¹ Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, 1200 Brussels, Belgium
² Department of Pathology, Cliniques St-Luc, Université catholique de Louvain, 1200 Brussels, Belgium
³ Department of Clinical Chemistry, Cliniques St-Luc, Université catholique de Louvain, 1200 Brussels, Belgium

DOI: 10.2478/jccm-2019-0026

The case is reported of a 39-year-old severely obese woman who developed acute metabolic disorders after the administration of a short course of intravenous amiodarone. The main biological features were hypertriglyceridemia, hypoglycaemia, hyperlactatemia and hyperammonemia; all were reversible after amiodarone discontinuation. There was an associated rise in liver enzymes. However, the influence of co-factors on these metabolic disorders, such as acquired carnitine deficiency, severe obesity, a long-term course of pancreatitis, and abdominal infections, could not be excluded.

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Accidental Modopar© Poisoning in a Two-Year-Old Child. A Case Report

Adnane Lahlou, Saïd Benlamkaddem, Mohamed Adnane Berdai, Mustapha Harandou

Obstetric and Pediatric Intensive Care Unit, Hassan II Academic Hospital, Fez, Morocco

 

DOI: 10.2478/jccm-2019-0024

Levodopa is a dopamine precursor and a mainstay treatment in the management of Parkinson’s disease. Its side effects induce dyskinesia, nausea, vomiting, and orthostatic hypotension. Acute levodopa acute poisoning is uncommon, with only a few reported cases in the medical literature. Treatment of poisoning by levodopa is mainly supportive. The case of a child admitted to a hospital for acute levodopa poisoning is presented in this report.

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