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

Zoltán Ruszkai1, Erika Kiss2, Zsolt Molnár2

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

DOI: 10.2478/jccm-2019-0002

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

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Critical Care Aspects of Gallstone Disease

Piero Portincasa1, Emilio Molina-Molina1, Gabriella Garruti2, David Q.-H. Wang3

1 Clinica Medica “A. Murri”, Department of Biomedical Sciences & Human Oncology, University of Bari Medical School, Bari, Italy
2 Section of Endocrinology, Department of Emergency and Organ Transplantations, University of Bari “Aldo Moro” Medical School, Piazza G. Cesare 11, 70124 Bari, Italy
3 Department of Medicine, Division of Gastroenterology and Liver Diseases, Marion Bessin Liver Research Center, “Albert Einstein” College of Medicine, Bronx, NY 10461, USA

DOI: 10.2478/jccm-2019-0003

Approximately twenty percent of adults have gallstones making it one of the most prevalent gastrointestinal diseases in Western countries. About twenty percent of gallstone patients requires medical, endoscopic, or surgical therapies such as cholecystectomy due to the onset of gallstone-related symptoms or gallstone-related complications. Thus, patients with symptomatic, uncomplicated or complicated gallstones, regardless of the type of stones, represent one of the largest patient categories admitted to European hospitals.
This review deals with the important critical care aspects associated with a gallstone-related disease.

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Management of Pneumomediastinum Associated with H1N1 Pneumonia: A Case Report

Bhavna P Singh1, Gurucharan S Shetty2, Padmakumar Arayamparambil Vijayan1, Ullas Gopalakrishna1, Garud Chandan1, Ario Santini3, Vivek Padegal4

1 Fortis Hospitals, Department of Critical Care Medicine, Bangalore, India
2 Fortis Hospitals, Department of Radiology, Bangalore, India
3 University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureş, Romania; Hon Fellow, University of Edinburgh, United Kingdom
4 Fortis Hospitals, Department of Pulmonology, Bangalore, India

DOI: 10.2478/jccm-2019-0001

H1N1 is seen in tropical countries like India, occurring irrespective of the season. Complications of the disease are frequently encountered and there is little in the way or guidelines as to the how these should be managed. The treatment of one such complication, a recurrent pneumiomediastinum is the subject of the current paper. The management followed guidance for the treatment of a similar condition known as primary spontaneous pneumomediastinum, an uncommon condition resulting from alveolar rupture-otherwise known as the Macklin phenomenon.

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Abdominal Sepsis: An Update

Mircea Gabriel Mureșan1,2, Ioan Alexandru Balmoș1,2, Iudita Badea1,3, Ario Santini1,4

1 University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureş, Romania
2 Surgery Clinic No. 2, Târgu Mureş, Romania
3 Anesthesiology and Intensive Care Clinic No.1, Târgu Mureş, Romania
4 Hon Fellow, University of Edinburgh, United Kingdom

DOI: 10.2478/jccm-2018-0023

Despite the significant development and advancement in antibiotic therapy, life-threatening complication of infective diseases cause hundreds of thousands of deaths world. This paper updates some of the issues regarding the etiology and treatment of abdominal sepsis and summaries the latest guidelines as recommended by the Intra-abdominal Infection (IAI) Consensus (2017). Prognostic scores are currently used to assess the course of peritonitis. Irrespective of the initial cause, there are several measures universally accepted as contributing to an improved survival rate, with the early recognition of IAI being the critical matter in this respect. Immediate correction of fluid balance should be undertaken with the use of vasoactive agents being prescribed, if necessary, to augment and assist fluid resuscitation. The WISS study showed that mortality was significantly affected by sepsis irrespective of any medical and surgical measures. A significant issue is the prevalence of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in the clinical setting, and the reported prevalence of ESBLs intra-abdominal infections has steadily increased in Asia. Europe, Latin America, Middle East, North America, and South Pacific. Abdominal cavity pathology is second only to sepsis occurring in a pulmonary site. Following IAI (2017) guidelines, antibiotic therapy should be initiated as soon as possible after a diagnosis has been verified.

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Abdominal Compartment Syndrome as a Multidisciplinary Challenge. A Literature Review

Gabriel Alexandru Popescu1,2, Tivadar Bara jr.1,2, Paul Rad1,3

1 University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureş, Romania
2 Surgery Clinic No. 2, Târgu Mureş, Romania
3 Anesthesiology and Intensive Care Clinic No. 1, Târgu Mureş, Romania

DOI: 10.2478/jccm-2018-0024

Abdominal Compartment Syndrome (ACS), despite recent advances in medical and surgical care, is a significant cause of mortality. The purpose of this review is to present the main diagnostic and therapeutic aspects from the anesthetical and surgical points of view. Intra-abdominal hypertension may be diagnosed by measuring intra-abdominal pressure and indirectly by imaging and radiological means. Early detection of ACS is a key element in the ACS therapy. Without treatment, more than 90% of cases lead to death and according with the last reports, despite all treatment measures, the mortality rate is reported as being between 25 and 75%. There are conflicting reports as to the importance of a conservative therapy approach, although such an approach is the central to treatment guidelines of the World Society of Abdominal Compartment Syndrome, Decompressive laparotomy, although a backup solution in ACS therapy, reduces mortality by 16-37%. The open abdomen management has several variants, but negative pressure wound therapy represents the gold standard of surgical treatment.

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Ibuprofen, a Potential Cause of Acute Hemorrhagic Gastritis in Children – A Case Report

Maria Oana Mărginean1,2, Lorena Elena Meliț1,2, Simona Mocanu3, Vlăduț Săsăran2

1 Paediatrics Clinic 1, Târgu Mureș, Romania
2 University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureş, Romania
3 Pathology Department County Clinic Hospital, Târgu Mureș, Romania

DOI: 10.2478/jccm-2018-0022

Introduction: Upper gastrointestinal bleeding is an uncommon but possible life-threatening entity in children, frequently caused by erosive gastritis. Non-steroidal anti-inflammatory drugs are one of the most common class of drugs which can cause gastrointestinal complications, including hemorrhagic gastritis.
Case report: The case of a 6-year-old male, admitted for hematemesis, abdominal pain and loss of appetite. It was ascertained at the time of admission, that ibuprofen had been prescribed as the patient had a fever. This was inappropriately administered as the mother did not respect the intervals between the doses.
Initial laboratory tests revealed neutrophilia, leukopenia, high levels of lactate dehydrogenase and urea. An upper digestive endoscopy revealed an increased friability of the mucosa, digested blood in the gastric corpus and fornix. No active bleeding site was detected. The histopathological examination described a reactive modification of the corporeal gastric mucosa. Intravenous treatment with proton pump inhibitors and fluid replacement were initiated, with favorable results.
Conclusion: Ibuprofen can lead to upper digestive hemorrhage independently of the administered dose. Parents should avoid administering Ibuprofen for fever suppression without consulting their pediatrician.

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Diagnostic pitfalls in identification of Elizabethkingia meningoseptica

Gurmeet Ram Rahim1, Neha Gupta1, Gaurav Aggarwal2

1 Microbiology Department, Shah Satnam Ji Speciality Hospitals, Sirsa, Haryana, India
2 Department of Medicine, Shah Satnam Ji Speciality Hospitals, Sirsa, Haryana, India

DOI: 10.2478/jccm-2018-0021

To the Editor of JCCM,
Regarding the article “Emerging Infection with Elizabethkingia meningoseptica in Neonate. A Case Report” by Arbune et al. (2018) [1], there are specific facts which need clarification regarding the reporting of this organism.
First of all, Arbune reported the isolation of the organism from the cerebrospinal fluid (CSF) and blood culture of one case, and that no source of infection was identified. Elizabethkingia meningoseptica, although linked to meningitis and nosocomial infections, can be an environmental contaminant as well. Repeat cultures of the samples are mandatory for the confirmation of such unusual pathogens.[More]

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The Peer Review Process: Underwriting Manuscript Quality & Validity

Ario Santini1,2

1 University of Medicine and Pharmacy of Tîrgu Mureș, Romania
2 Hon Fellow, University of Edinburgh, United Kingdom

DOI: 10.2478/jccm-2018-0020

Evidence-based practice is the first step in underpinning and shaping how the profession delivers patient care. The Oxford Dictionary defines evidence as: ‘the available body of facts or information indicating whether a belief or proposition is true or valid’. The majority of evidence, though not all, is provided by research studies published in professional journals. Best evidence should be of high quality and is thus founded on the status of publishing journals and the process by which journals, editors and the editorial team separate out the “good” from both the “mediocre” and the “bad”.
This is undertaken by the process of Peer reviewing or refereeing; it is the practice of critically examining an author’s submitted research manuscript by experts in the same field before a paper is accepted for publishing in a journal. When well done, it confers a stamp of approval to the substance, authenticity, and value of articles and therefore is a crucial element, integral to scholarly research and the validation of published evidence. [More]

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

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

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

DOI: 10.2478/jccm-2018-0019

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

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