Category Archives: issue

The Importance of Haemogram Parameters in the Diagnosis and Prognosis of Septic Patients

Alina Elena Orfanu1,2, Cristina Popescu1,2, Anca Leuștean1, Anca Ruxandra Negru1,2, Cătălin Tilişcan1,2, Victoria Aramă1,2, Ștefan Sorin Aramă1,2

1 National Institute for Infectious Diseases “Prof. Dr Matei Balș”, Dr Calistrat Grozovici Street, no 1, 021105, Bucharest, Romania
2 University of Medicine and Pharmacy “Carol Davila”, Dionisie Lupu Street, no 37, 020021, Bucharest, Romania

DOI: 10.1515/jccm-2017-0019

Sepsis represents a severe pathology that requires both rapid and precise positive and differential diagnosis to identify patients who need immediate antimicrobial therapy. Monitoring septic patients’ outcome leads to prolonged hospitalisation and antibacterial therapy, often accompanied by substantial side effects, complications and a high mortality risk.
Septic patients present with complex pathophysiological and immunological disorders and with a predominance of pro-inflammatory or anti-inflammatory mediators which are heterogeneous with respect to the infectious focus, the aetiology of sepsis or patients’ immune status or comorbidities. Previous studies performed have analysed inflammatory biomarkers, but a test or combinations of tests that can quickly and precisely establish a diagnosis or prognosis of septic patients has yet to be discovered. Recent research has focused on re-analysing older accessible parameters found in the complete blood count to determine the sensitivity, specificity, positive and negative predictive values for the diagnosis and prognosis of sepsis.
The neutrophil/lymphocyte count ratio (NLCR), mean platelet volume (MPV) and red blood cells distribution width (RDW) are haemogram indicators which have been evaluated and which are of proven use in septic patients’ management.

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Reoccurrence of Bleeding of a Chronic Subdural Haematoma Following a Fall

Rafael García Carretero

Internal Medicine Department, Mostoles University Hospital, Rio Jucar, 28935, Mostoles (Madrid), Spain

DOI: 10.1515/jccm-2017-0020

The case of a 60-year-old patient who presented with an acute-on-chronic subdural haematoma is reported. Chronic haematoma usually remains asymptomatic, and this is considered to be an unusual course of events. Trivial or minor injury may cause the cortical bridge veins and fragile vessels in the former haematoma to rupture with concomitant reoccurrence of bleeding. Old age, repeated traumatic brain injuries, brain atrophy, antiplatelet agents and oral anticoagulants such as warfarin are considered to be the underlying conditions to cause the reoccurrence of bleeding. However, our patient did not have any of those conditions.

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The First Manifestation of a Left Atrial Myxoma as a Consequence of Multiple Left Coronary Artery Embolisms

Martin Novak1,2, Petr Fila3, Ota Hlinomaz1,2, Vita Zampachova4

1 Department of Cardiology, St. Anne´s University Hospital Brno, Pekarska 53, 65691 Brno, Czech Republic
2 International Clinical Research Center, Pekarska 53, 65691 Brno, Czech Republic
3 Centre of Cardiovascular and Transplantation Surgery, Pekarska 53, 65691 Brno, Czech Republic
4 Department of Pathology, St. Anne´s University Hospital Brno, Pekarska 53, 65691 Brno, Czech Republic

DOI: 10.1515/jccm-2017-0018

A case of multiple embolisms in the left coronary artery as a rare first manifestation of left atrial myxoma is reported. A patient with embolic myocardial infarction and congestive heart failure was treated by percutaneous aspirations and balloon dilatations. Transesophageal echocardiography disclosed a villous myxoma with high embolic potential. Surgical resection of the tumour, suturing of a patent foramen ovale suture and an annuloplasty of the dilated tricuspid annulus was performed the third day after the admission.
Recovery of the documented left ventricular systolic function can be explained by resorption of myxomatous material. The patient was discharged ten days after the surgery.

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Raoultella ornithinolytica Diagnosed in a Neurointensive Patient. A Rare Case with Recovery without Antibiotics

Marlene Ersgaard Jellinge

Department of Anesthesiology and Intensive Care Medicine, Odense University Hospital, Denmark

DOI: 10.1515/jccm-2017-0017

Infection with Raoultella ornithinolytica is rare and normally the infection is present in patients with underlying malignancies or chronic diseases. It is normally treated with antibiotics. In this case report, a neuro-intensive patient without malignancies or other severe chronic diseases was colonized with Pseudomonas aeruginosa but infected with Raoultella ornithinolyca. The patient recovered without treatment with antibiotics.

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The Eleventh Hour: Neurosyphilis, Still Fashionable but a Controversial Diagnosis

Rodica Bălaşa

University of Medicine and Pharmacy of Tirgu Mures, Romania

DOI: 10.1515/jccm-2017-0015

Syphilis is a consequence of a symbiotic relationship between Treponema pallidum and humankind.
The spirochete is nowadays well characterized in shape and in length, and its entire genome is sequenced. Despite all these, confirmation of infection is based on serologic tests. The diagnosis of nervous system disease heavily depends on examination of the cerebrospinal fluid [1-4].
Neurologic involvement is generally dichotomized into early/secondary (acute meningitis, cranial nerves involvement) or late/tertiary (all the rest of the manifestations) [1].
In the current issue of Journal of Critical Care Medicine, Bologa et al. present the utility of having meningovascular syphilis in mind as a possible diagnosis, in an apparent average case of an 84-year-old patient diagnosed with stroke [5]. [More]

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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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