Category Archives: issue

Intensive Care Fundamentals in Romania. A Critical Step in Romanian Intensive Care Education

Cosmin Balan1,2, Serban-Ion Bubenek-Turconi1,2, Mo Al-Haddad3

1 Institutul de Urgenta pentru Boli Cardiovasculare Prof Dr C C Iliescu, Bucharest, Romania
2 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
3 Queen Elizabeth University Hospital, University of Glasgow, Glasgow, UK

DOI: 10.2478/jccm-2024-0029

Any doctor working in the field of Intensive Care Medicine (ICM) remembers their first placement in the Intensive Care Unit (ICU). Most would remember that time as being characterized by trepidation, confusion and worry. In order to mitigate these negative experiences, various institutions run ad hoc induction and orientation programs. The European Society of Intensive Care Medicine (ESICM) has recently developed the Intensive Care Fundamentals (ICF) course to standardize induction and orientation to ICU for this group of doctors throughout Europe and beyond. Now, the ICF has arrived in Romania. [More]

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A Comparative Analysis of the Effects of Haloperidol and Dexmedetomidine on QTc Interval Prolongation during Delirium Treatment in Intensive Care Units

Ali Haspolat1, Fuat Polat2, Ali Şefik Köprülü3

1 Kolan International Hospital, İstanbul, Turkey
2 Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
3 Yeni Yuzyil University, İstanbul, Turkey

DOI: 10.2478/jccm-2024-0027

Background: Haloperidol and dexmedetomidine are used to treat delirium in the intensive care unit (ICU). The effects of these drugs on the corrected QT (QTc) interval have not been compared before. It was aimed to compare the effects of haloperidol and dexmedetomidine treatment on QTc intervals in patients who developed delirium during ICU follow-up.
Method: The study is single-center, randomized, and prospective. Half of the patients diagnosed with delirium in the ICU were treated with haloperidol and the other half with dexmedetomidine. The QTc interval was measured in the treatment groups before and after drug treatment. The study’s primary endpoints were maximal QT and QTc interval changes after drug administration.
Results: 90 patients were included in the study, the mean age was 75.2±12.9 years, and half were women. The mean time to delirium was 142+173.8 hours, and 53.3% of the patients died during their ICU follow-up. The most common reason for hospitalization in the ICU was sepsis (%37.8.). There was no significant change in QT and QTc interval after dexmedetomidine treatment (QT: 360.5±81.7, 352.0±67.0, p= 0.491; QTc: 409.4±63.1, 409.8±49.7, p=0.974). There was a significant increase in both QT and QTc interval after haloperidol treatment (QT: 363.2±51.1, 384.6±59.2, p=0.028; QTc: 409.4±50.9, 427.3±45.9, p=0.020).
Conclusions: Based on the results obtained from the study, it can be concluded that the administration of haloperidol was associated with a significant increase in QT and QTc interval. In contrast, the administration of dexmedetomidine did not cause a significant change in QT and QTc interval.

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Development of a Machine Learning-Based Model for Predicting the Incidence of Peripheral Intravenous Catheter-Associated Phlebitis

Hideto Yasuda1,2,3,4, Claire M. Rickard3, 4, 5, Olivier Mimoz6,7,8, Nicole Marsh3,4,5, Jessica A Schults3,4,5, Bertrand Drugeon6,7, Masahiro Kashiura1, Yuki Kishihara1, Yutaro Shinzato1, Midori Koike1, Takashi Moriya1, Yuki Kotani9, Natsuki Kondo10, Kosuke Sekine11, Nobuaki Shime12, Keita Morikane13, Takayuki Abe14,15

1 Department of Emergency and Critical Care Medicine, Jichi Medical University Saimata Medical Center, Saitama, Japan
2 Department of Clinical Research Education and Training Unit, Keio University Hospital Clinical and Translational Research Center (CTR), Tokyo, Japan
3 School of Nursing, Midwifery and Social Work, UQ Centre for Clinical Research, The University of Queensland, QLD, Australia
4 School of Nursing and Midwifery; Alliance for Vascular Access Teaching and Research, Griffith University, Nathan, QLD, Australia
5 Herston Infectious Diseases Institute; Nursing and Midwifery Research Centre, Royal Brisbane and Women’s Hospital, Metro North Health, Herston, QLD, Australia
6 CHU de Poitiers, Emergency Department and prehospital care, Poitiers, France
7 University of Poitiers, INSERM U1070, Pharmacology of antimicrobial agents and antibiotics resistance (PHAR2), Poitiers, France
8 University of Poitiers, Faculty of Medicine and Pharmacy, Poitiers, France
9 Department of Intensive Care Medicine, Kameda Medical Center, Chiba, Japan
10 Department of Emergency Medicine, Koga Community Hospital, Shizuoka, Japan
11 Department of Medical Engineer, Kameda Medical Center, Chiba, Japan
12 Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
13 Division of Clinical Laboratory and Infection Control, Yamagata University Hospital, Yamagata, Japan
14 Biostatistics, Clinical and Translational Research Center, Keio University School of Medicine, Tokyo, Japan
15 School of Data Science, Kyoto Women’s University, Kyoto, Japan

DOI: 10.2478/jccm-2024-0028

Introduction: Early and accurate identification of high-risk patients with peripheral intravascular catheter (PIVC)-related phlebitis is vital to prevent medical device-related complications.
Aim of the study: This study aimed to develop and validate a machine learning-based model for predicting the incidence of PIVC-related phlebitis in critically ill patients.
Materials and methods: Four machine learning models were created using data from patients ≥ 18 years with a newly inserted PIVC during intensive care unit admission. Models were developed and validated using a 7:3 split. Random survival forest (RSF) was used to create predictive models for time-to-event outcomes. Logistic regression with least absolute reduction and selection operator (LASSO), random forest (RF), and gradient boosting decision tree were used to develop predictive models that treat outcome as a binary variable. Cox proportional hazards (COX) and logistic regression (LR) were used as comparators for time-to-event and binary outcomes, respectively.
Results: The final cohort had 3429 PIVCs, which were divided into the development cohort (2400 PIVCs) and validation cohort (1029 PIVCs). The c-statistic (95% confidence interval) of the models in the validation cohort for discrimination were as follows: RSF, 0.689 (0.627–0.750); LASSO, 0.664 (0.610–0.717); RF, 0.699 (0.645–0.753); gradient boosting tree, 0.699 (0.647–0.750); COX, 0.516 (0.454–0.578); and LR, 0.633 (0.575–0.691). No significant difference was observed among the c-statistic of the four models for binary outcome. However, RSF had a higher c-statistic than COX. The important predictive factors in RSF included inserted site, catheter material, age, and nicardipine, whereas those in RF included catheter dwell duration, nicardipine, and age.
Conclusions: The RSF model for the survival time analysis of phlebitis occurrence showed relatively high prediction performance compared with the COX model. No significant differences in prediction performance were observed among the models with phlebitis occurrence as the binary outcome.

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Uncommon Malposition of an Ultrasound-Guided Central Venous Catheter in the Renal Vein through the Superficial Femoral Vein: A Case Report

Ting-Chia Remus Young1,2, Kuang-Hua Cheng1,3, Kuan-Pen Yu1,4

1 Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei, Taiwan
2 Department of Medicine, Mackay Medical College, New Taipei, Taiwan
3 Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taiwan
4 Department of Anesthesiology, MacKay Memorial Hospital, Taipei, Taiwan

DOI: 10.2478/jccm-2024-0026

Introduction: Malposition is a relatively rare complication associated with peripherally inserted central catheters (PICCs), particularly in cases of superficial femoral vein (SFV) catheterization. To the best of our knowledge, we are the first to report this rare case of SFV PICC malposition in the contralateral renal vein.
Case presentation: An 82-year-old woman underwent bedside cannulation of the SFV for PICC under ultrasound guidance. Subsequent radiographic examination revealed an unexpected misplacement, with the catheter tip positioned toward the contralateral renal vein. After pulling out the catheter on the basis of the X-ray result, it was observed that the catheter retained its function.
Conclusion: Although rare, tip misplacement should be considered in SFV PICC placement. Prompt correction of the tip position is crucial to prevent catheter malfunction and further catastrophic consequences. For critical patients receiving bedside SFV PICC insertion, postoperational X-ray is crucial for enhancing safety.

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Evaluation of the Efficiency of the Newly Developed Needle in Emergency Room: A Single-Center Observational Study

Yuki Kishihara, Hideto Yasuda, Masahiro Kashiura, Takatoshi Oishi, Yutaro Shinzato, Takashi Moriya

Jichi Ika University Saitama Medical Center, Saitama-shi, Saitama Japan

DOI: 10.2478/jccm-2024-0025

Aim of the study: Peripheral intravascular catheter (PIVC) insertion is frequently performed in the emergency room (ER) and many failures of initial PIVC insertion occur. To reduce the failures, new needles were developed. This study aimed to investigate whether the use of the newly developed needle reduced the failure of initial PIVC insertion in the ER compared with the use of the existing needle.
Material and methods: This single-centre, prospective observational study was conducted in Japan between April 1, 2022, and February 2, 2023. We included consecutive patients who visited our hospital by ambulance as a secondary emergency on a weekday during the day shift (from 8:00 AM to 5:00 PM). The practitioners for PIVC insertion and assessors were independent. The primary and secondary outcomes were the failure of initial PIVC insertion and number of procedures, respectively. We defined the difficulty of titrating, leakage, and hematoma within 30 s after insertion as failures. To evaluate the association between the outcomes and the use of newly developed needles, we performed multivariate logistic regression and multiple regression analyses by adjusting for covariates.
Results: In total, 522 patients without missing data were analysed, and 81 (15.5%) patients showed failure of initial PIVC insertion. The median number of procedures (interquartile range) was 1 (1–1). Multivariate logistic regression analysis revealed no significant association between the use of newly developed PIVCs and the failure of initial PIVC insertion (odds ratio, 0.79; 95% confidence interval, [0.48–1.31]; p = 0.36). Moreover, multiple regression analysis revealed no significant association between the use of newly developed PIVCs and the number of procedures (regression coefficient, -0.0042; 95% confidence interval, [-0.065–0.056]; p = 0.89).
Conclusions: Our study did not show a difference between the two types of needles with respect to the failure of initial PIVC insertion and the number of procedures.

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Managing Multifactorial Deep Vein Thrombosis in an Adolescent: A Complex Case Report

Măriuca Mănescu 1, Alina Grama2, Andreea Ligia Dincă2, Mihaela Chinceșan2

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

DOI: 10.2478/jccm-2024-0024

Introduction: Although rarely diagnosed in the pediatric population, deep vein thrombosis (DVT) is experiencing a growing incidence, while continuously acquiring different nuances due to the widening range of risk factors and lifestyle changes in children and adolescents.
Case presentation: A 17-year-old female within four weeks after child delivery was admitted to our clinic due to a six-month history of pain in the left hypochondriac region. After a thorough evaluation, the presence of a benign splenic cyst was revealed, which was later surgically removed. Following the intervention, the patient developed secondary thrombocytosis and bloodstream infection which, together with pre-existing risk factors (obesity, compressive effect of a large cyst, the postpartum period, the presence of a central venous catheter, recent surgery, and post-operative mobilization difficulties) led to the occurrence of extensive DVT, despite anticoagulant prophylaxis and therapy with low-molecular-weight heparin.
Conclusions: DVT raises many challenges for the pediatrician, requiring a personalized approach. Although rare, pediatric patients with multiple concomitant high-risk factors should benefit from interdisciplinary care as DVT may not respond to standard therapy in such cases and rapidly become critical. Continual efforts to better understand and treat this condition will contribute to improved outcomes for pediatric patients affected by DVT.

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Challenges of the Regional Anesthetic Techniques in Intensive Care Units – A Narrative Review

Alexandra Elena Lazar1, Mihaela Butiulca1, Lenard Farczadi1,2

1 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Center for Advanced Medical and Pharmaceutical Research, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2024-0023

Effective pain management is vital for critically ill patients, particularly post-surgery or trauma, as it can mitigate the stress response and positively influence morbidity and mortality rates. The suboptimal treatment of pain in Intensive Care Unit (ICU) patients is often due to a lack of education, apprehensions about side effects, and improper use of medications. Hence, the engagement of pain management and anesthesiology experts is often necessary.
While opioids have been traditionally used in pain management, their side effects make them less appealing. Local anesthetics, typically used for anesthesia and analgesia in surgical procedures, have carved out a unique and crucial role in managing pain and other conditions in critically ill patients. This work aims to offer a comprehensive overview of the role, advantages, challenges, and evolving practices related to the use of local anesthetics in ICUs. The ability to administer local anesthetics continuously makes them a suitable choice for controlling pain in the upper and lower extremities, with fewer side effects.
Epidural analgesia is likely the most used regional analgesic technique in the ICU setting. It is primarily indicated for major abdominal and thoracic surgeries, trauma, and oncology patients. However, it has contraindications and complications, so its use must be carefully weighed. Numerous challenges exist regarding critically ill patients, including renal and hepatic failure, sepsis, uremia, and the use of anticoagulation therapy, which affect the use of regional anesthesia for pain management. Appropriate timing and indication are crucial to maximizing the benefits of these methods.
The advent of new technologies, such as ultrasonography, has improved the safety and effectiveness of neuraxial and peripheral nerve blocks, making them feasible options even for heavily sedated patients in ICUs.

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Clinical Profile and Course of Patients with Acute Respiratory Distress Syndrome due to Covid-19 in a Middle-Income Region in Mexico

José Antonio Villalobos-Silva, Gladis Lucia Acros-López, Gracia Lizbeth Velázquez-Estrada, Camilo José Muñoz-Chavez, German Antonio Aguirre-Gómez, Obed Isaí Aguilera-Olvera, Alfredo Sánchez-González

Hospital Regional de Alta Especialidad de Ciudad Victoria, Ciudad Victoria, Tamaulipas, Mexico

DOI: 10.2478/jccm-2024-0022

Introduction: COVID-19 leads to severe clinical complications that culminate in respiratory failure and acute respiratory distress syndrome (ARDS). Despite reports of some comorbidities that contribute to the development of COVID-19-mediated ARDS, there is great variation in mortality rates among critical COVID-19 patients in the world. To date, no studies have described the incidence and comorbidities associated with ARDS due to COVID-19 in the northeastern region of Mexico.
Aim of the study: To describe patients diagnosed with ARDS due to COVID-19 in the northeastern region of Mexico, as well as its variations in comparison with other regions of the country.
Material and Methods: We conducted a prospective and observational study in a tertiary care center in Northeastern Mexico. All patients diagnosed with SARS-CoV-2 infection and requiring management in the intensive care unit were included. We developed a database that was updated daily with the patients´ demographic information, pre-existing diseases, disease severity, and clinical variables.
Results: The incidence of ARDS secondary to COVID-19 in HRAEV was high in comparison with other reports. Diabetes mellitus was the risk factor most associated with COVID-19-mediated ARDS.
Conclusion: Based on our findings and those previously reported in the literature, there are differences that we discuss between northeastern and central Mexico, and analyze other areas evaluated around the world.

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Cefiderocol and Intraventricular Colistin for Ventriculitis due to an Extensively Drug-Resistant Pseudomonas Aeruginosa

João Melo e Silva1, Diogo Oliveira2, João A. Louro3, Elisabete Monteiro4

1 Hospital de Vila Franca de Xira, Lisboa, Portugal
2 Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
3 Hospital Professor Doutor Fernando Fonseca EPE, Lisboa, Portugal
4 Centro Hospitalar Universitário de São João , Porto, Portugal

DOI: 10.2478/jccm-2024-0020

Rheumatoid arthritis, an inflammatory rheumatic disease predominantly affecting small limb joints, frequently compromises the cervical spine, resulting in spinal instability and the potential surgical necessity. This may result in severe complications, such as ventriculitis, often associated with a high mortality rate and multidrug-resistant organisms. A major challenge lies in achieving therapeutic antimicrobial concentrations in the central nervous system.
The authors present a case of a 65-year-old female, with cervical myelopathy due to severe rheumatoid arthritis. Following surgery, the patient developed ventriculitis caused by an extensively drug-resistant Pseudomonas Aeruginosa. Early diagnosis and prompt treatment played a crucial role in facilitating neurological and cognitive recovery.

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The Role of Microcirculation in Haemodynamics: A Journey from Atlas to Sisyphus

Constantin Bodolea

University of Medicine and Pharmacy Iuliu Hatieganu Cluj Napoca, Romania

DOI: 10.2478/jccm-2024-0021

Microcirculation, through its complex network of vessels (arterioles, capillaries and venules), plays a pivotal role in maintaining cellular functions. Located between the macrocirculatory system- the heart and large vessels, and the interstitial environment, microcirculation acts as a gateway for oxygen supply (O2), removal of carbon dioxide (CO2), delivery of nutrients and hormones, and plays a crucial role in the immune response, thermoregulation and coagulation control.
In order to maintain an adequate supply of oxygen and nutrients to cells and tissues at the levels of the macro-, regional- and microcirculatory fields, the physiological mechanisms that regulate blood perfusion are closely interrelated.
This functional interdependence between macrohaemodynamics, microhaemodynamics, interstitial space and subcellular structures (such as the mitochondria, the bioenergetic factory of the organism) was demonstrated by Dr. Henry Weil, who explicitly defined the condition of acute circulatory failure or circulatory shock [1,2]. In his work, he highlights the catastrophic consequences of arterial hypotension associated with tissue hypoperfusion in various states of shock. [More]

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