Category Archives: issue

Perioperative Management of Lactic Acidosis in End-Stage Liver Disease Patient

Alexander A. Vitin1, Leonard Azamfirei2, Dana Tomescu3, John D. Lang1

1 Department of Anesthesiology & Pain, Medicine University of Washington Medical Center, Seattle WA, USA
2 University of Medicine and Pharmacy of Tîrgu Mureș, Romania
3 “Carol Davila” University of Medicine and Pharmacy, Anesthesiology and Intensive Care Department 3, Fundeni Clinical Institute, Bucharest, Romania

DOI: 10.1515/jccm-2017-0014

Lactic acidosis (LA) in end-stage liver disease (ESLD) patients has been recognized as one of the most complicated clinical problems and is associated with increased morbidity and mortality. Multiple-organ failure, associated with advanced stages of cirrhosis, exacerbates dysfunction of numerous parts of lactate metabolism cycle, which manifests as increased lactate production and impaired clearance, leading to severe LA-induced acidemia. These problems become especially prominent in ESLD patients, that undergo partial hepatectomy and, particularly, liver transplantation. Perioperative management of LA and associated severe acidemia is an inseparable part of anesthesia, post-operative and critical care for this category of patients, presenting a wide variety of challenges. In this review, lactic acidosis applied pathophysiology, clinical implications for ESLD patients, diagnosis, role of intraoperative factors, such as anesthesia- and surgery-related, vasoactive agents impact, and also current treatment options and modalities have been discussed.

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The Use of Endotoxin Adsorption in Extracorporeal Blood Purification Techniques. A Case Report

Adina N. Hadade1, Caius M. Breazu1,2, Iulian V. Ilie3, Calin I. Mitre1

1 University of Medicine and Pharmacy “ Iuliu Hatieganu”, Cluj-Napoca, 1st Department of Anesthesia and Intensive Care, Cluj-Napoca, Romania
3 Regional Institute of Gastroenterology and Hepathology “ Octavian Fodor”, Cluj-Napoca, Romania
3 University of Veterinary Medicine, Cluj-Napoca, Romania

DOI: 10.1515/jccm-2017-0010

Sepsis and septic shock are major healthcare problems, resulting in high morbidity and mortality. The Surviving Sepsis Campaign (SSC), which standardised the approach to sepsis, was recently updated. Strategies to decrease the systemic inflammatory response have been proposed to modulate organ dysfunctions. Endotoxin, derived from the membrane of Gram-negative bacteria, is considered a major factor in the pathogenesis of sepsis. Endotoxin adsorption, if effective, has the potential to reduce the biological cascade of Gram-negative sepsis.  We present a case of a 64-year-old man with severe Gram-negative sepsis, following purulent peritonitis secondary to rectosigmoid adenocarcinoma. To reduce the amplitude of the general effects of endotoxins we used a novel device, the Alteco® LPS Adsorber (Alteco Medical AB, Lund, Sweden), for lipopolysaccharide (LPS) adsorption
The efficacy markers were: the overall haemodynamic profile, translated into decreased vasopressor requirements, the normalisation of the cardiac index, the systemic vascular resistance index combined with the lactate level and the reduction in procalcitonin (PCT) levels. A decrease in the sequential organ failure assessment (SOFA) score at twenty-four hours was demonstrated. The clinical course following treatment was favourable for the days immediately following the treatment.This was attributed to the removal of endotoxin from the systemic circulation. The patient died one week after the endotoxin removal session, developing an ischemic bowel perforation with subsequent multiple organ failures.

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Extracorporeal Membrane Oxygenation in Nivolumab Associated Pneumonitis

Thomas-Michael Schneider1*, Friederike Klenner2, Franz Brettner1

1 Department of Intensive Care Medicine, Krankenhaus Barmherzige Brueder, Munich, Germany
2 Department of Internal Medicine V, University of Munich, Germany

DOI: 10.1515/jccm-2017-0013

Background: Newly approved immunotherapeutic agents, like CTLA-4 inhibitors and antibodies against PD-1, are a promising therapeutic option in cancer therapy.
Case presentation: A 74-year-old man, with a history of advanced stage melanoma and treatment with ipilimumab, pembrolizumab and nivolumab, was admitted to the hospital due to respiratory failure with hypoxemia and dyspnoea. He rapidly developed severe acute respiratory distress syndrome (ARDS), which required treatment in the intensive care unit which included mechanical ventilation and extracorporeal membrane oxygenation (ECMO). Computed tomographic imaging (CT) showed signs of a pneumonitis, with an ARDS pattern related to the use of PD-1 antibodies. Treating the patient with high-dose immunosuppressive steroids led to an overall improvement. He was transferred to a rehabilitation hospital and subsequently to his home.
Discussion and conclusion: This is a unique case report of a patient suffering a grade 4 adverse event under nivolumab who survived having been treated with ECMO. It highlights the possibility of associated adverse reactions as well as the use of ECMO in palliative care patients. ECMO can be of great success even in patients with malignancies, but careful decision making should be done on a case by case basis.

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Non-Obvious, Post-Traumatic, Life-Threatening Bleeding in Two Elderly Patients

Rafael García Carretero

Internal Medicine Department, Mostoles University Hospital, Spain

DOI: 10.1515/jccm-2017-0012

The main complication of anticoagulant therapy is major bleeding. Clinicians are usually aware of these side effects and are careful when managing the therapeutic range of vitamin K antagonist drugs. But major bleeding, while life-threatening, can be overlooked if there are no visible signs of bleeding. Two cases are described in which inaccurate diagnoses lead to inadequate treatment.

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Anticoagulant Therapy in Sepsis. The Importance of Timing

Ecaterina Scarlatescu1, Dana Tomescu1,2, Sorin Stefan Arama2

1 Department of Anesthesiology and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania
2 University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania

DOI: 10.1515/jccm-2017-0011

Sepsis associated coagulopathy is due to the inflammation-induced activation of coagulation pathways concomitant with dysfunction of anticoagulant and fibrinolytic systems, leading to different degrees of haemostasis dysregulation. This response is initially beneficial, contributing to antimicrobial defence, but when control is lost coagulation activation leads to widespread microvascular thrombosis and subsequent organ failure. Large clinical trials of sepsis-related anticoagulant therapies failed to show survival benefits, but posthoc analysis of databases and several smaller studies showed beneficial effects of anticoagulants in subgroups of patients with early sepsis-induced disseminated intravascular coagulation. A reasonable explanation could be the difference in timing of anticoagulant therapy and patient heterogeneity associated with large trials. Proper selection of patients and adequate timing are required for treatment to be successful. The time when coagulation activation changes from advantageous to detrimental represents the right moment for the administration of coagulation-targeted therapy. In this way, the defence function of the haemostatic system is preserved, and the harmful effects of overwhelming coagulation activation are avoided.

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Neurosyphilis Masquerading as Stroke in an 84-year-old

Cristina Bologa1, Catalina Lionte1, Diana Halit2, Catalina Luca3

1 Internal Medicine Department, 2nd Internal Medicine Clinic,”Sf. Spiridon” Clinical County Emergency Hospital, “Gr. T. Popa”University of Medicine, Iasi, Romania
2 Neurology Department, “Prof. Dr. N. Oblu” Clinical Emergency Hospital, Iasi, Romania
3 Infectious Disease Department, “Sf. Parascheva” Clinical Hospital, “Gr. T. Popa” University of Medicine, Iasi, Romania

DOI: 10.1515/jccm-2017-0009

The case of an 84 years old woman with uncharacteristic neurologic and cognitive symptoms, suspected of ischemic stroke is presented. Following an extensive assessment in the departments of neurology and internal medicine, the unusual aetiology of stroke was identified as meningovascular neurosyphilis. The patient fully recovered after antibiotic therapy. To our knowledge, this the eldest patient with tertiary neurosyphilis reported in the literature.

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Toxic Megacolon – A Three Case Presentation

Irina Magdalena Dumitru1, Eugen Dumitru2, Sorin Rugina1,3, Liliana Ana Tuta2

1 Discipline of Infectious Diseases, Faculty of Medicine, Ovidius University of Constanta, Romania
2 Discipline of Internal Medicine, Faculty of Medicine, Ovidius University of Constanta, Romania
3 The Academy of Romanian Scientists

DOI: 10.1515/jccm-2017-0008

Introduction: Toxic megacolon is a life-threatening disease and is one of the most serious complications of Clostridium difficile infection (CDI), usually needing prompt surgical intervention. Early diagnosis and adequate medical treatment are mandatory.
Cases presentation: In the last two years, three Caucasian female patients have been diagnosed with toxic megacolon and treated in the Clinical Infectious Diseases Hospital, Constanta. All patients had been hospitalized for non-related conditions. The first patient was in chemotherapy for non-Hodgkin’s lymphoma, the second patient had undergone surgery for colon cancer, and the third patient had surgery for disc herniation. In all cases the toxin test (A+B) was positive and ribotype 027 was present. Abdominal CT examination, both native and after intravenous contrast, showed significant colon dilation, with marked thickening of the wall. Resolution of the condition did not occur using the standard treatment of metronidazole and oral vancomycin, therefore the therapy was altered in two cases using intracolonic administration of vancomycin and intravenous tigecycline.
Conclusions: In these three cases of CDI, the risk factors for severe evolution were: concurrent malignancy, renal failure, obesity, and immune deficiencies. Ribotype 027, a marker for a virulent strain of CD, was found in all three cases complicated by toxic megacolon. The intracolonic administration of vancomycin, and intravenous tigecycline was successful when prior standard therapy had failed, and surgery was avoided.

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Simulation-based Training as Perceived by Young Anesthesiology and Intensive Care Residents

Sanda-Maria Copotoiu1, Ruxandra Copotoiu2

1 University of Medicine and Pharmacy of Tirgu Mures, Romania
2 Nouvel Hôpital Civil de Strasbourg, Pole d’anesthésie, Strasbourg, France

DOI: 10.1515/jccm-2017-0007

Medical  simulation-based teaching  includes a variety of educational techniques used to complement actual patient experiences with true-to-life yet artificial tasks.
This field is rapidly growing and is widely used in critical care graduate medical education programs, having teaching, learning and assessment roles.
Its use is on the increase due to many factors including patient discontent with being “practiced on”, current considerations regarding patient safety, and the significance of early attainment of complex medical proficiencies. Simulation-based assessment (SBA) is advancing to the point where it can revolutionize the way clinical competence is assessed in residency training programs. [More]

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Anaesthesia and Intensive Care Residents’ Perception of Simulation Training in Four Romanian Centres

Horațiu N Vasian1, Simona C Mărgărit1, Ioana Grigoraș2, Leonard Azamfirei3, Dan Corneci4, Daniela Ionescu1,5

1 Iuliu Hațieganu University of Medicine and Pharmacy, 1st Department of Anaesthesia and Intensive Care, Cluj-Napoca, Romania
2 Department of Anaesthesiology and Intensive Care, Gr. T. Popa University of Medicine and Pharmacy, Iași, Romania
3 Department of Intensive Care, University of Medicine and Pharmacy, Târgu-Mureș, Romania
4 Department of Anaesthesiology and Intensive Care, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
5 Outcome Research Consortium, Cleveland, Ohio, USA

DOI: 10.1515/jccm-2017-0005

Introduction: Simulation training offers an opportunity to educate anaesthesia and intensive care (AIC) residents safely. At present, it is not yet a mandatory part of residency curriculum.
The aim of the study was to evaluate the residents’ perception of the inclusion of simulation-based training in the Romanian AIC residency program.
Material and methods: Romanian AICs in anaesthesia and intensive care from four training centres completed a twenty-question survey regarding their views on simulation during their residency training. Residents were divided into junior, in the first three years, or senior groups, in the last two years of residency training. The questionnaire included Likert-scale multiple-choice, open-ended, and “yes” or “no” questions regarding simulator learning, the frequency of simulation sessions, and the value of the simulation sessions in improving practice, skills or teamwork. The open-ended questions, asked which were the respondents’ preferred topics to be included in simulation sessions.
Results: Fifty-six percent of residents completed and returned the questionnaire. Ninety-eight percent of them considered simulation-learning useful once a month or every three months especially in the first two years of training. All residents thought simulation sessions would improve their skills, communication abilities, and teamwork. Senior residents paid more attention to clinical scenarios (p=0.007), haemodynamic monitoring (p=0.017) and mechanical ventilation (p=0.004) as compared to juniors. All residents considered difficult airway management, and cardiac life support to be very important issues to be included in simulation sessions.
Conclusion: The survey demonstrated that simulation-based training should play a greater role and eventually became compulsory in training program in AIC academic centres.

Supplementary material

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