Category Archives: issue

The Management of Staphylococcal Toxic Shock Syndrome. A Case Report

Victoria Bîrluțiu1,2*, Ofelia Criștiu3, Marius Baicu4, Rareș Mircea Bîrluțiu1,5

1 Lucian Blaga University of Sibiu, Faculty of Medicine, Sibiu, Romania
2 Sibiu County Clinical Emergency Hospital, Infectious Diseases Department, Sibiu, Romania
3 Pediatric Clinical Hospital Sibiu, Infectious Diseases Department, Sibiu, Romania
4 Pediatric Clinical Hospital Sibiu, Intensive Care Department, Sibiu, Romania
5 Foişor Clinical Hospital of Orthopedics, Traumatology and Osteoarticular Tuberculosis, Bucharest, Romania

DOI: 10.1515/jccm-2016-0011

Staphylococcal toxic shock syndrome (TSS) is most frequently produced by TSS toxin-1 (TSST-1) and Staphylococcal enterotoxin B (SEB), and only rarely by enterotoxins A, C, D, E, and H. Various clinical pictures can occur depending on severity, patient age and immune status of the host. Severe forms, complicated by sepsis, are associated with a death rate of 50-60%. The case of a Caucasian female infant, aged seven weeks, hospitalized with a diffuse skin rash, characterized as allergodermia, who initially developed TSS with axillary intertrigo, is reported. TSS was confirmed according to 2011 CDC criteria, and blood cultures positive for Methicillin-sensitive Staphylococcus aureus (MSSA). Severe development occurred initial, including acidosis, consumption coagulopathy, multiple organ failures (MOF), including impaired liver and kidney function. Central nervous system damage was manifest by seizures. Clinical management included medical supervision by a multidisciplinary team of infectious diseases specialist and intensive care specialist, as well as the initiation of a complex treatment plan to correct hydro electrolytic imbalances and acidosis. This treatment included antibiotic and antifungal therapy, diuretic therapy, immunoglobulins, and local treatment similar to a patient with burns to prevent superinfection of skin and mucous membranes lesions. There was a favourable response to the treatment with resolution of the illness.

Keywords: , ,
Full text: PDF

Parkinsonian Syndrome and Toxoplasmic Encephalitis

Anca-Adriana Arbune1*, Manuela Arbune2, Victorita Stefanescu2

1 Carol Davila Medicine and Pharmacy University, Bucharest
2 ”Dunarea de Jos” University Galati

DOI: 10.1515/jccm-2016-0009

Toxoplasmosis encephalitis in patients with human immunodeficiency virus may progress rapidly with a potentially fatal outcome. Less common neurological symptoms associated with this are Parkinsonism, focal dystonia, rubral tremor and hemichorea–hemiballismus syndrome.
A 58 year old woman suddenly lost consciousness and was admitted to the emergency service. Her medical history was unremarkable, except for frequent headaches in the last year, recurrent herpes simplex skin lesions and an episode of urticaria. A computer tomography scan showed supra and infra-tentorial lesions on suggestive of cerebral toxoplasmosis. Both Toxoplasma gondii and HIV tests were positive. In the intensive care unit, antiparasitic and antiretroviral drugs were administered, and she recovered from the coma after six weeks but presented with tetraparesis, diplopia, and depression. The LCD4 count increased from 7 to 128/mm3. The neurological lesions slowly resolved over the next two months, although postural instability, rigidity, bradykinesia and predominantly left side tremor persisted. Mild improvement was achieved after the administration of levodopa.
Associated Parkinsonian syndrome in HIV patients is a rare condition, explained by the location of the brain and basal ganglia lesions, and by the observed effect of Toxoplasma gondii which increases dopamine metabolism in neural cells. Early HIV diagnostic and treatment are necessary to prevent neurological disability.

Keywords: , , ,
Full text: PDF

Influence of Ventilation Parameters on Intraabdominal Pressure

Claudiu Puiac1, Janos Szederjesi1*, Alexandra Lazar1, Emoke Almasy1, Paul Rad1, Lucian Puscasiu2

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

DOI: 10.1515/jccm-2016-0016

Introduction: Intraabdominal pressure monitoring is not routinely performed because the procedure assumes some invasiveness and, like other invasive procedures, it needs to have a clear indication to be performed. The causes of IAH are various. Mechanically ventilated patients have numerous parameters set in order to be optimally ventilated and it is important to identify the ones with the biggest interference in abdominal pressure. Although it was stated that mechanical ventilation is a potential factor of high intraabdominal pressure the set parameters which may lead to this diagnostic are not clearly named.
Objectives: To evaluate the relation between intraabdominal pressure and ventilator parameters in patients with mechanical ventilation and to determine the correlation between intraabdominal pressure and body mass index.
Material and method: This is an observational study which enrolled 16 invasive ventilated patients from which we obtained 61 record sheets. The following parameters were recorded twice daily: ventilator parameters, intraabdominal pressure, SpO2, Partial Oxygen pressure of arterial blood. We calculated the Body Mass Index (BMI) for each patient and the volume tidal/body weight ratio for every recorded data point.
Results: We observed a significant correlation between intraabdominal pressure (IAP) and the value of PEEP (p=0.0006). A significant statistical correlation was noted regarding the tidal volumes used for patient ventilation. The mean tidal volume was 5.18 ml/kg. Another significant correlation was noted between IAP and tidal volume per kilogram (p=0.0022). A positive correlation was found between BMI and IAP (p=0.0049), and another one related to the age of the enrolled patients. (p=0.0045).
Conclusions: The use of positive end-expiratory pressures and high tidal volumes during mechanical ventilation may lead to the elevation of intraabdominal pressure, a possible way of reducing this risk would be using low values of PEEP and also low volumes for the setting of ventilation parameters. There is a close positive correlation between the intraabdominal pressure levels and body mass index.

Keywords: , ,
Full text: PDF

Intubation-Surfactant: Extubation on Continuous Positive Pressure Ventilation. Who Are the Best Candidates?

Maria Livia Ognean1*, Silvia-Maria Stoicescu2, Oana Boantă1, Leonard Năstase2,
Carmen Gliga3, Manuela Cucerea3,4

1 Clinical County Emergency Hospital Sibiu, Neonatology Department
2 University of Medicine and Pharmacy Carol Davila Bucuresti, Institute of Mother and Child Care – Polizu, Neonatology Department
3 Clinical County Emergency Hospital Târgu Mureș, Regional Neonatal Intensive Care Center
4 University of Medicine and Pharmacy Târgu Mureș

DOI: 10.1515/jccm-2016-0010

Introduction: Respiratory distress syndrome (RDS) continues to be the leading cause of illness and death in preterm infants. Studies indicate that INSURE strategy (INtubate-SURfactant administration and Extubate to nasal continuous positive airway pressure [nCPAP]) is better than mechanical ventilation (MV) with rescue surfactant, for the management of respiratory distress syndrome (RDS) in very low birth weight (VLBW) neonates, as it has a synergistic effect on alveolar stability.
Aim of the study: To identify the factors associated with INSURE strategy failure in preterm infants with gestational age (GA) ≤ 32 weeks.
Materials and Methods: This was a retrospective cohort study, based on data collected in the Romanian National Registry for RDS patients by three regional (level III) centers between 01.01.2010 and 31.12.2011. All preterm infants of ≤ 32 weeks GA were included. Prenatal and neonatal information were compared between (Group 1), the preterm infants successfully treated using INtubation-SURfactant-Extubation on nasal CPAP (INSURE) strategy and (Group 2 ), those who needed mechanical ventilation within seventy-two hours after INSURE.
Results: A total of 637 preterm infants with GA ≤ 32 weeks were included in the study. INSURE strategy was performed in fifty-seven cases (8.9%) [ Group 1] and was successful in thirty-one patients (54.4%). No differences were found as regards the studied prenatal and intranatal characteristics between (Group 1) and Group 2 who needed mechanical ventilation. Group 2 preterm infants who needed mechanical ventilation within 72 hours after INSURE had significantly lower mean Apgar scores at 1 and 5 minutes and lower peripheral oxygen saturation (SpO2) during resuscitation at birth (p<0.05). Successful INSURE strategy was associated with greater GA, birth weight (BW), fraction of inspired oxygen (FiO2) during resuscitation, and an increased mean dose of surfactant but these associations were not statistically significant (p>0.5).
Conclusion: In preterm infants ≤ 32 weeks gestation, increased INSURE failure rates are associated with complicated pregnancies, significantly lower Apgar scores at 1 and 5 minutes, and lower peripheral oxygen saturation during resuscitation.

Keywords: , , ,
Full text: PDF

Much Ado About the New Definitions of Sepsis

Sanda-Maria Copotoiu1*, Ruxandra Copotoiu2

1 University of Medicine and Pharmacy of Tirgu Mures, Romania, Clinic of Anesthesia and Intensive Care Emergency County Hospital of Tîrgu Mures, Gheorghe Marinescu street no 38, Tirgu Mures, Romania
2 Les Hôpitaux Universitaires de Strasbourg, Pôle d’anesthésie – réanimations chirurgicales – SAMU – SMUR, Service d’anesthésiologie, Hôpital Civil

DOI: 10.1515/jccm-2016-0015

Following the publication of the new definition of sepsis (Sepsis-3), a plethora of articles have been published in medical journals. Recognizing the epidemiological importance of the previous definitions, first issued in 1992 (Sepsis-1), and subsequently revised in 2001 (Sepsis-2), the most recent opinion emphasizes the failure “to provide adequate groups of patients with homogenous aetiologies, presentations and outcomes”, and blamed one of the causes “for the failure of several randomized controlled trials (RCTs), that tested the efficacy of adjuvant sepsis therapies”. This review summarizes the recent advances in sepsis definition.

Keywords: ,
Full text: PDF

Knowledge Is Power

Leonard Azamfirei, Editor-in-Chief

University of Medicine and Pharmacy of Tirgu Mures, Romania

DOI: 10.1515/jccm-2016-0014

When Sir Francis Bacon published in his work, Meditationes Sacrae (1597), the saying: “knowledge itself is power”, he most likely wanted to transmit the idea that having and sharing knowledge is the cornerstone of reputation and influence, and therefore power; all achievements emanate from this. Today, scientific knowledge is shared through publications that not only inform, but have the capacity to influence decision making.
The Journal of Critical Care Medicine, a publication of the University of Medicine and Pharmacy Tîrgu Mureș, Romania launched in 2015, was recently included in the Master Journal List of the Emerging Sources Citation Index (ESCI), which is part of the Thomson Reuters Web of Science Core Collection. This new index ensures the indexing of high-quality medical articles that undergo a specific peer-review process prior to publication. The inclusion of the journal in this international database ensures a larger and more consistent international profile, as well as a probable increase in the citation of published articles. [More]

Keywords:
Full text: PDF

Role of Plasma Neutrophil Gelatinase Associated Lipocalin as a New Biomarker

Ota Hlinomaz

International Clinical Research Center, St. Anne’s University Hospital Brno, Brno, Czech Republic

DOI: 10.1515/jccm-2016-0004

I read with interest the study of Raluca Fodor et al., on the significance of Plasma Neutrophil Gelatinase-Associated Lipocalin (NGAL), as an early biomarker for acute kidney injury in critically ill patients, published recently in issue no.4/2015 of JCCM journal [1]. In this well-written and interesting study, the authors successfully demonstrated that in critically ill patients, increased levels of NGAL predict, with a good sensitivity and specificity, the development of acute kidney injury within forty-eight hours of admission to an ICU. However, as no information is presented on the aetiology of the acute kidney injury, we believe that the article raises interesting and still un-elucidated hypotheses on the pathophysiological substrate of the systemic release of NGAL in patients with critical conditions. [More]

Keywords:
Full text: PDF

Staphylococcal Toxic Shock Syndrome Caused By An Intravaginal Product. A Case Report

Monica Marton*

Swedish Medical Center, Department of Anesthesiology and Critical Care, Seattle, USA

DOI: 10.1515/jccm-2016-0003

Staphylococcal toxic shock syndrome (STSS) represents a potentially lethal disease, and survival depends primarily on the early initiation of appropriate treatment. As the clinical picture at presentation is usually common, frequently this could lead to misdiagnosis and delays in the initiation of the proper therapy. The case of a 43-years old female who developed a staphylococcal septic shock syndrome caused by a forgotten intravaginal tampon is reported.

Keywords: , ,
Full text: PDF

Total Intravenous Versus Inhalation Anesthesia in Patients Undergoing Laparoscopic Cholecystectomies. Effects on Two Proinflammatory Cytokines Serum Levels: Il-32 and TNF-Alfa.

Adina Hadade1*, Daniela Ionescu1, Teodora Mocan2, Alexandru Necula3, Victor Cristea4

1 Department of Anesthesia and Intensive Care, “IuliuHatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
2 Department of Physiology, “IuliuHatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
3 Department of Surgery, Regional Institute for Gastroenterology and Hepatology “Prof dr Octavian Fodor”, Cluj-Napoca, Romania
4 Department of Clinical Immunology, “IuliuHatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

DOI: 10.1515/jccm-2016-0008

Introduction: It has been reported that as compared with total intravenous anesthesia (TIVA), inhalation anesthesia is increasing the postoperative level of proinflammatory interleukins.
The aim of the study is to investigate if there is an in-vivo relationship between proinflammatory cytokines, Interleukin-32 (IL-32) and Tumour necrosis factor – α (TNF- α), in patients undergoing laparoscopic cholecystectomies with two different anesthetic techniques, TIVA or inhalation anesthesia.
Material and Methods: Twenty two consecutive patients undergoing laparoscopic cholecystectomies were prospectively randomized into two groups: Group 1: TIVA with target-controlled infusion (TIVA-TCI) (n=11) and Group 2: isoflurane anesthesia (ISO) (n=11). IL-32 and TNF-α were determined before the induction of anesthesia (T1), before incision (T2) and at 2h (T3) and 24h (T4) postoperatively. Our primary outcome was to compare plasma levels of IL-32 and TNF- α concentrations (expressed as area-under-the-curve) over 24 hours between study groups. Our secondary outcome was to establish whether there is a correlation between plasma levels of IL-32 and of TNF-α at each time point between the two groups.
Results: Area-under-the-curve (AUC) of IL-32 plasma concentration was 7.53 in Group 1 (TIVA) versus 3.80 in Group 2 (ISO), p= 1. For TNF-α, AUC of plasma concentration was 733.9 in Group 1 (TIVA) and 668.7 in Group 2 (ISO), p= 0.066. There were no significant differences in plasma concentrations of both IL-32 and TNF- α between the groups.
Conclusions: IL-32 expression in response to minor surgery is very low. There were no significant difference between plasma levels ofTNF- α and IL-32 after TIVA versus inhalation anesthesia during the first 24 hours postoperatively. Further studies are needed on larger groups to investigate whether there can be a correlation between these interleukins after 2 different anesthetic techniques and the impact of this correlation on postoperative outcome.

Keywords: , , ,
Full text: PDF

Factors Favouring the Development of Clostridium Difficile Infection in Critically Ill Patients

Bianca-Liana Grigorescu1, Raluca Ştefania Fodor1*, Adrian Dan Cioc2, Mihaly Veres2, Monica Orlandea2, Bogdan Lăzescu2, Emoke Almasy2

1 University of Medicine and Pharmacy of Tîrgu Mureş, 38 Gheorghe Marinescu street Tîrgu Mureş, 540139, Romania
2 County Clinical Emergency Hospital Tîrgu Mureş, Romania, 50 Gheorghe Marinescu street Tîrgu Mureş, 540139, Romania

DOI: 10.1515/jccm-2016-0006

Clostridium difficile, an anaerobic, spore-forming, toxin-forming, gram-positive bacillus present in the bacterial flora of the colon is the principal cause of nosocomial diarrhoea in adults.
Aim: Assessment of favouring factors of Clostridium difficile infections as well as the interactions between them, in critically ill hospitalized patients undergoing complex medical and surgical treatments.
Material and Methods: A retrospective case-control study involving eighty patients admitted in the Intensive Care Unit (ICU) of the County Clinical Emergency Hospital Tîrgu-Mureş was conducted between January and October 2014. Patients aged eighteen years and over, who had undergone complex medical and surgical treatment, were divided into two subgroups. Group 1 included patients who developed diarrhoea but were not diagnosed as having a Clostridium difficile infection (CDI). Group 2 included patients who developed diarrhoea due to CDI as indicated by a positive culture and the expression of exotoxin. The assessed parameters were age, length of stay (LOS), antibiotic spectrum, association with proton pump inhibitors (PPI) or H2-receptor antagonists, immunological status, the presence or lack of gastrointestinal tract surgery.
Results: The mean age was 64.6 years with an average LOS of 10 days. Fifty-six percent of patients came to the ICU from internal medicine wards and forty-three percent from surgical wards. 20.5% of them were immunosuppressed. Co-association of ceftriaxone and pantoprazole significantly increased the risk of CDI compared to co-administration of any other antibiotic or pantoprazole (p=0.01). The odds ratio for Pantoprazole together with any antibiotic versus antibiotic therapy alone was significantly higher (p=0.018) with a sevenfold increase in the risk of positive exotoxin increase.
Conclusions: Antibiotic use is associated with “no risk to develop CDI” in the first five days of administration. PPIs associated therapy increased the risk of CDI in first seventy-two hours regardless of the antibiotic type, and contributes to an active expression of CD exotoxin.

Keywords: , , ,
Full text: PDF