Category Archives: issue

The Relevance of Coding Gene Polymorphysms of Cytokines and Cellular Receptors in Sepsis

Anca Meda Georgescu1, Bianca Liana Grigorescu2, Ioana Raluca Chirteș1, Alexander A. Vitin3, Raluca Ștefania Fodor4

1 Infectious Diseases Clinic, University of Medicine and Pharmacy Tirgu Mures, Romania
2 Discipline of Pathophysiology, University of Medicine and Pharmacy Tirgu Mures, Romania
3 University of Washington, Medical Center, Seattle, USA
4 Anesthesiology and Intensive Care Clinic, University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/jccm-2017-0001

Sepsis is an injurious systemic host response to infection, which can often lead to septic shock and death. Recently, the immune-pathogenesis and genomics of sepsis have become a research topic focusing on the establishment of diagnostic and prognostic biomarkers. As yet, none have been identified as having the necessary specificity to be used independently of other factors in this respect. However the accumulation of current evidence regarding genetic variations, especially the single nucleotide polymorphisms (SNPs) of cytokines and other innate immunity determinants, partially explains the susceptibility and individual differences of patients with regard to the evolution of sepsis. This article outlines the role of genetic variation of some serum proteins which have the potential to be used as biomarker values in evaluating sepsis susceptibility and the progression of the condition.

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Neutrophil Gelatinase-Associated Lipocalin as a Marker for Renal Dysfunction Detection in Critically Ill Patients with Increased Intraabdominal Pressure

Claudiu Puiac1, Janos Szederjesi2, Alexandra Lazăr2, Codruța Bad2, Lucian Pușcașiu1

1 Gynecology and Obstetrics Department, University of Medicine and Pharmacy of Tirgu Mures, Romania
2 Anesthesiology Department, University of Medicine and Pharmacy of Tirgu Mures, Romania

DOI: 10.1515/jccm-2017-0006

Introduction: Elevated intraabdominal pressure (IAP) it is known to have an impact on renal function trough the pressure transmitted from the abdominal cavity to the vasculature responsible for the renal blood flow. Intraabdominal pressure is found to be frequent in intensive care patients and also to be a predictor of mortality. Intra- abdominal high pressure is an entity that can have serious impact on intensive care admitted patients, studies concluding that if this condition progresses to abdominal compartment syndrome mortality is as high as 80%.
Aim: The aim of this study was to observe if a link between increased intraabdominal pressure and modification in renal function exists (NGAL, creatinine clearance).
Material and Method: The study enrolled 30 critically ill patients admitted in the Intensive Care Unit of SCJU Tîrgu Mures between November 2015 and August 2016. The study enrolled adult, hemodynamically stable patients admitted in intensive critical care – defined by a normal blood pressure maintained without any vasopressor or inotropic support, invasive monitoring using PICCO device and abdominal pressure monitoring.
Results: The patients were divided into two groups based on the intraabdominal pressure values: normal intraabdominal pressure group= 52 values and increased intraabdominal group= 35 values. We compared the groups in the light of NGAL values, 24 hours diuresis, GFR and creatinine clearance. The groups are significantly different when compared in the light of NGAL values and GFR values. We obtained a statistically significant correlation between NGAL value and 24 hour diuresis. No other significant correlations were encountered between the studied items.
Conclusions: NGAL values are increased in patients with high intraabdominal pressure which may suggest its utility as a cut off marker for patients with increased intraabdominal pressure. There is a significant decreased GFR in patient with elevated intraabdominal pressure, observation which can help in early detection of renal injury in patients due to high intraabdominal pressure. No correlation was found between creatinine clearance and increased intraabdominal pressure.

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Emergency Surgery in a Critically Ill Patient with Major Drug-Induced Bleeding and Severe Ischaemic Heart Failure

Dana Tomescu1,2, Mihai Popescu1,2

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

DOI: 10.1515/jccm-2017-0003

Introduction: Anticoagulant overdose frequently occurs in elderly populations especially in remote areas where medical services are scarce. When emergency surgery is required, such patients offer major anaesthetic challenges.
Case presentation: We describe the case of an elderly patient admitted to a surgical ward with acute abdominal pain, on dual anti-platelet therapy and acenocoumarol for a recent acute myocardial infarction treated percutaneously with two drug-eluting stents. Laboratory tests showed severe anticoagulant overdose with uncoagulable INR. The decision was made to use of both light transmission aggregometry [LTA] for platelet function testing and thromboelastography to aid in the management of perioperative haemostasis in order to prevent both severe bleeding and stent thrombosis. Surgery revealed haemoperitoneum, volvulus of the ileum and a venous mesenteric infarction. Intraoperative blood loss was minimal and no blood products were administered. Postoperative course was uneventful without either thrombotic or haemorrhagic complications and the patient was discharged from the Postanaesthesia Care Unit on postoperative day two.
Conclusion: The use of aggregometry and thrombography helped in both evaluation and management of haemostasis of a high-risk patient by goal-directed administration of pro-and anti- coagulants.

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Pulse Oximetry During the First 24 Hours as a Screening Tool For Congenital Heart Defects

Mihaela Patriciu1, Andreea Avasiloaiei2, Mihaela Moscalu3, Maria Stamatin2

1 “Grigore T. Popa” University of Medicine and Pharmacy, Iași, România
2 Mother and Child Care Department, “Grigore T. Popa” University of Medicine and Pharmacy, “Cuza Voda” Neonatal Intensive Care Unit, Iași, România
3 Interdisciplinary Sciences Department, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, România

DOI: 10.1515/jccm-2017-0004

Introduction: Although screening for congenital heart defects (CHD) relies mainly on antenatal ultrasonography and clinical examination after birth, life-threatening cardiac malformations are often not diagnosed before the patient is discharged.
Aim: To assess the use of routine pulse oximetry in the delivery room and at 24 hours postpartum, and to study its feasibility as a screening test for CHD.
Material and Methods: In this prospective study, all infants born in “Cuza Voda” Maternity Hospital, Iasi, Romania, were enrolled over a thirteen-month period. Preductal oximetry was assessed during the first hour, and postductal oximetry was evaluated at twenty-four hours postpartum. Data were then analyzed to establish the sensitivity and specificity of pulse oximetry, as a screening test for CHD.
Results: 5406 infants were included in the study, with a mean gestational age of 38.2 weeks and a mean birth weight of 3175 grams. During the first minute, blood oxygen saturation varied between 40% and 90% and at 24 hours of life, it ranged between 90% and 100%. Following oximetry assessment, 14 infants with critical CHD were identified. Blood oxygen saturation values in infants with CHD were lower throughout the entire period of evaluation. Pulse oximetry had good sensitivity and specificity at 1 hour (Se=87.5%, Sp=95.5%) and 24 hours (Se=92.5%, Sp=97.4%) for the diagnosis of CHD. Blood oxygen saturation values at one minute, 1 hour and 24 hours are strong discriminative parameters for the early diagnosis of CHD.
Conclusion: Routine pulse oximetry during the first 24 hours postpartum represents an early indicator of CHD to facilitate timely intervention. Pulse oximetry provides excellent sensitivity and specificity and has tremendous potential as a standard screening test for CHD during the first 24 hours of life.

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Toxic Epidermal Necrolysis – A Case Report

Laura Stătescu1, Magda Constantin2, Horia Silviu Morariu3, Laura Gheucă Solovăstru1

1 Dermatology Department, University of Medicine and Pharmacy “Grigore T. Popa”, Iaşi, Romania
2 Dermatology Department, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
3 Dermatology Department, University of Medicine and Pharmacy Târgu Mureş, România

DOI: 10.1515/jccm-2017-0002

Toxic epidermal necrolysis (TEN) is an acute, life-threatening muco-cutaneous disease, often induced by drugs. It is characterized by muco-cutaneous erythematous and purpuric lesions, flaccid blisters which erupt, causing large areas of denudation. The condition can involve the genitourinary, pulmonary and, gastrointestinal systems. Because of the associated high mortality rate early diagnosis and treatment are mandatory.
This article presents the case of a sixty-six years old male patient, known to have cirrhosis, chronic kidney failure, and diabetes mellitus. His current treatment included haemodialysis. He was hospitalized as an emergency to the Dermatology Department for erythemato-violaceous, purpuric patches and papules, with acral disposition, associated with rapidly spreading erosions of the oral, nasal and genital mucosa and the emergence of flaccid blisters which erupted quickly leaving large areas of denudation. Based on the clinical examination and laboratory investigations the patient was diagnosed with TEN, secondary to carbamazepine intake for encephalopathic phenomena. The continuous alteration in both kidney and liver function and electrolyte imbalance, required him to be transferred to the intensive care unit. Following pulse therapy with systemic corticosteroids, hydro-electrolytic re-equilibration, topical corticosteroid and antibiotics, there was a favourable resolution of TEN.
The case is of interest due to possible life-threatening cutaneous complications, including sepsis and significant fluid loss, in a patient with associated severe systemic pathology, highlighting the importance of early recognition of TEN, and the role of a multidisciplinary team in providing suitable treatment.

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Should Critical Care Professionals Take Hoaxes/Rumours Seriously?

Valentin Nădășan*

University of Medicine and Pharmacy Tîrgu Mureș, Department of Hygiene

DOI: 10.1515/jccm-2016-0030

To the Editor of JCCM,
Thanks to the ever larger penetration of the Internet and especially with the advent of Web 2.0 and social media, hoaxes, rumours and urban legends have become an almost everyday occurrence. While social psychology research contends that rumors can negatively impact on the public by generating distress, intense fear, anxiety, possibly resulting in herd behaviour and violence [1], there is evidence that disease-related rumours may alter health-related behaviors and interfere with medical decision-making [2]. Medical misinformation is most frequently associated with collective emergency situations (e.g., Ebola infected patients refused to be hospitalized because of rumours that international health care workers intentionally brought the virus with them [3]; people from around Kenema, Sierra Leone attacked the hospital after hearing rumours of conspiracy [4]; during the 2011 Fukushima nuclear disaster in Japan, rumours that ingestion of iodized salt could prevent radiation damage lead to a shortage of the product in supermarkets and triggered panic and public unrest [1]) and miracle products or cures that can be commercially exploited [5]. However, there are a number of hoaxes/rumours that probably critical care specialists should neither take lightly as innocuous amusements, nor brush aside with a condescending smile.[More]

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A Fatal Case of Community Acquired Cupriavidus Pauculus Pneumonia

Emoke Almasy1, Janos Szederjesi1*, Paul Rad1, Anca Georgescu2

1 Discipline of Intensive Care, University of Medicine and Pharmacy Tîrgu Mureş, Romania
2 Discipline of Infectious Diseases, University of Medicine and Pharmacy Tîrgu Mureş, Romania

DOI: 10.1515/jccm-2016-0027

Introduction: Cupriavidus pauculus is a rarely isolated non-fermentative, aerobic bacillus, which occasionally causes severe human infections, especially in immunocompromised patients. Strains have been isolated from various clinical and environmental sources.
Case presentation: A 67-year-old man was admitted to the Intensive Care Unit with acute respiratory failure. The patient was diagnosed with bilateral pneumonia, pulmonary sepsis and underwent invasive mechanical ventilation. Examination revealed diminished bilateral vesicular breath sounds, fever, intense yellow tracheal secretions, a respiratory rate of 24/minute, a heart rate of 123/minute, and blood pressure of 75/55 mmHg. Vasoactive treatment was initiated. Investigations revealed elevated lactate and C-reactive protein levels. A chest X-ray showed bilateral infiltration. Parenteral ciprofloxacin and ceftriaxone were administered. Tracheal aspirate culture and blood culture showed bacterial growth of Cupriavidus pauculus. Colistin was added to the treatment. There was a poor clinical response despite repeated blood culture showing negative results. The diagnosis of multiple organ dysfunction syndrome (MODS) caused by C. pauculus was made. The patient died eleven days after admission.
Conclusions: Clinical improvement cannot always be expected in spite of targeted antibiotic therapy. This pathogen should be considered responsible for infections that usually develop in immunocompromised patients.

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Pneumoretroperitoneum after Attempted Epidural Anesthesia

Arkadi Isakov1*, Arnold Shtein2, Sholmo Kyzer1

1 Department of Surgery “B,” Wolfson Medical Center, Holon, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
2 Department of Anesthesiology, Wolfson Medical Center, Holon, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

DOI: 10.1515/jccm-2016-0029

Air may extend to the retroperitoneal space from retroperitoneal perforation of a hollow viscus, infection of the anterior pararenal space with gas-forming organisms and from pneumothorax or pneumomediastinum [1]. Rare pathologies, such as open reduction and internal fixation of femoral fractures and anaerobic abscess of the hip joint have also been described in relation to this complication [1,2]. A rare case of pneumoretroperitoneum caused by insufflation of air during an attempt to achieve epidural anesthesia is described.

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Staphylococcal Scalded Skin Syndrome in Child. A Case Report and a Review from Literature

Alina Grama1, Oana Cristina Mărginean1*, Lorena Elena Meliț1, Anca Meda Georgescu2

1 Pediatrics I Department, University of Medicine and Pharmacy Târgu-Mureș, Romania
2 Infectious Diseases Department, University of Medicine and Pharmacy Târgu-Mureș, Romania

DOI: 10.1515/jccm-2016-0028

Staphylococcal scalded skin syndrome (SSSS) is the medical term used to define a skin condition induced by the exfoliative toxins produced by Staphylococcus aureus. The disorder is also known as Ritter disease, bullous impetigo, neonatal pemphigus, or staphylococcal scarlet fever. The disease especially affects infants and small children, but has also been described in adults. Prompt therapy with proper antibiotics and supportive treatment has led to a decrease in the mortality rate.
The current case report describes the clinical progress of a patient with generalized erythema and fever, followed by the appearance of bullous lesions with tendency to rupture under the smallest pressure, and with extended areas of denudation.
The patient aged four years and six months was admitted to our clinic to establish the aetiology and treatment of a generalized bullous exanthema, followed by a skin denudation associated with fever and impaired general status.
Based on clinical and paraclinical examinations a diagnosis of Staphylococcal scalded skin syndrome was established which responded favourably to antibiotic treatment, hydro-electrolytic re-equilibration, and adequate local hygiene.
Staphylococcal infection can represent a problem of significant pathological importance sometimes requiring a multidisciplinary approach involving paediatricians, dermatologists, infectious diseases specialists, and plastic surgeons.

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Congenital Heart Disease Requiring Maintenance of Ductus Arteriosus in Critically Ill Newborns Admitted at a Tertiary Neonatal Intensive Care Unit

Manuela Cucerea1*, Marta Simon1, Elena Moldovan2, Marcela Ungureanu3, Raluca Marian1, Laura Suciu1

1 University of Medicine and Pharmacy Tirgu Mureș, Romania
2 Institute of Cardiovascular Disease and Transplant Tirgu Mureș, Romania
3 Department of Neonatal Intensive Care,County Clinical Emergency Hospital Tirgu Mureş, Romania

DOI: 10.1515/jccm-2016-0031

Introduction: Congenital heart diseases (CHD) have been reported to be responsible for 30 to 50% of infant mortality caused by congenital disabilities. In critical cases, survival of newborns with CHD depends on the patency of the ductus arteriosus (PDA), for maintaining the systemic or pulmonary circulation. The aim of the study was to assess the efficacy and side effects of PGE (prostaglandin E) administration in newborns with critical congenital heart disease requiring maintenance of the ductus arteriosus.
Material and method: All clinical and paraclinical data of 66 infants admitted to one referral tertiary level academic center and treated with Alprostadil were analyzed. Patients were divided into three groups: Group 1: PDA dependent pulmonary circulation (n=11) Group 2: PDA dependent systemic circulation (n=31) Group 3: PDA depending mixed circulation (n=24)
Results: The mean age of starting PGE1 treatment was 2.06 days, 1.91 (+/-1.44) days for PDA depending pulmonary flow, 2.39 (+/-1.62) days for PDA depending systemic flow and 1.71 (+/1.12) for PDA depending mixing circulation. PEG1 initiation was commenced 48 hours after admission for 72%, between 48-72 hours for 6%, and after 72 to 120 hours for 21% of newborns detected with PDA dependent circulation. Before PEG1 initiation the mean initial SpO2 was 77.89 (+/- 9.2)% and mean initial oxygen pressure (PaO2) was 26.96(+/-6.45) mmHg. At the point when stable wide open PDA was achieved their mean SpO2increased to 89.73 (+/-8.4)%, and PaO2 rose to 49 (+/-7.2) mmHg. During PGE1 treatment, eleven infants (16.7%) had apnea attacks, five children (7.5%) had convulsions, 33 (50%) had fever, 47 (71.2%) had leukocytosis, 52 (78.8%) had edema, 25.8% had gastrointestinal intolerance, 45.5% had hypokalemia, and 63.6% had irritability.
Conclusions: For those infants with severe cyanosis or shock caused by PDA dependent heart lesions, the initiation and maintenance of PGE1 infusion is imperative. The side effects of this beneficial therapy were transient and treatable.

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