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Recent Advances Of Mucosal Capnometry And The Perspectives Of Gastrointestinal Monitoring In The Critically Ill. A Pilot Study

Péter Palágyi1*, Sándor Barna2, Péter Csábi3, Péter Lorencz1, Ildikó László1, Zsolt Molnár1

1 Department of Anaesthesiology and Intensive Therapy, University of Szeged, Hungary
2 Department of Anaesthesiology and Intensive Therapy, Bács-Kiskun County Hospital, Teaching Hospital of the University of Szeged, Hungary
3 Department of Anaesthesia and Intensive Care, Wexham Park Hospital, United Kingdom

DOI: 10.1515/jccm-2016-0002

Mucosal capnometry involves the monitoring of partial pressure of carbon dioxide (PCO2) in mucous membranes. Different techniques have been developed and applied for this purpose, including sublingual or buccal sensors, or special gastrointestinal tonometric devices. The primary use of these procedures is to detect compensated shock in critically ill patients or patients undergoing major surgery. Compensatory mechanisms, in the early phases of shock, lead to the redistribution of blood flow towards the vital organs, within ostensibly typical macro-haemodynamic parameters. Unfortunately, this may result in microcirculatory disturbances, which can play a pivotal role in the development of organ failure. In such circumstances mucosal capnometry monitoring, at different gastrointestinal sites, can provide a sensitive method for the early diagnosis of shock. The special PCO2 monitoring methods assess the severity of ischaemia and help to define the necessary therapeutic interventions and testing of these monitors have justified their prognostic value. Gastrointestinal mucosal capnometry monitoring also helps in determining the severity of ischaemia and is a useful adjunctive in the diagnosis of occlusive splanchnic arterial diseases. The supplementary functional information increases the diagnostic accuracy of radiological techniques, assists in creating individualized treatment plans, and helps in follow-up the results of interventions. The results of a pilot study focusing on the interrelation of splanchnic perfusion and gastrointestinal function are given and discussed concerning recent advances in mucosal capnometry.

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Predictors Of Mortality In Patients With ST-Segment Elevation Acute Myocardial Infarction And Resuscitated Out-Of-Hospital Cardiac Arrest

Andreea Bărcan, Monica Chițu*, Edvin Benedek, Nora Rat, Szilamer Korodi, Mirabela Morariu, Istvan Kovacs

University of Medicine and Pharmacy of Tirgu Mureș, Romania, Department of Internal Medicine, Clinic of Cardiology

DOI: 10.1515/jccm-2016-0001

Introduction: In patients with out-of-hospital cardiac arrest (OHCA) complicating an ST-segment elevation myocardial infarction (STEMI), the survival depends largely on the restoration of coronary flow in the infarct related artery. The aim of this study was to determine clinical and angiographic predictors of in-hospital mortality in patients with OHCA and STEMI, successfully resuscitated and undergoing primary percutaneous intervention (PCI).
Methods: From January 2013 to July 2015, 78 patients with STEMI presenting OHCA, successfully resuscitated, transferred immediately to the catheterization unit and treated with primary PCI, were analyzed. Clinical, laboratory and angiographic data were compared in 28 non-survivors and 50 survivors.
Results: The clinical baseline characteristics of the study population showed no significant differences between the survivors and non-survivors in respect to age (p=0.06), gender (p=0.8), the presence of hypertension (p=0.4), dyslipidemia (p=0.09) obesity (p=1), smoking status (p=0.2), presence of diabetes (p=0.2), a clinical history of acute myocardial infarction (p=0.7) or stroke (p=0.17). Compared to survivors, the non-survivor group exhibited a significantly higher incidence of cardiogenic shock (50% vs 24%, p=0.02), renal failure (64.3% vs 30.0%, p=0.004) and anaemia (35.7% vs 12.0%, p=0.02). Three-vessel disease was significantly higher in the non-survivor group (42.8% vs. 20.0%, p=0.03), while there was a significantly higher percentage of TIMI 3 flow postPCI in the infarct-related artery in the survivor group (80.% vs. 57.1%, p=0.03). The time from the onset of symptoms to revascularization was significantly higher in patients who died compared to those who survived (387.5 +/- 211.3 minutes vs 300.8 +/- 166.1 minutes, p=0.04), as was the time from the onset of cardiac arrest to revascularization (103.0 +/- 56.34 minutes vs 67.0 +/- 44.4 minutes, p=0.002). Multivariate analysis identified the presence of cardiogenic shock (odds ratio [OR]: 3.17, p=0.02), multivessel disease (OR: 3.0, p=0.03), renal failure (OR: 4.2, p=0.004), anaemia (OR: 4.07, p=0.02), need for mechanical ventilation >48 hours (OR: 8.07, p=0.0002) and a duration of stay in the ICU longer than 5 days (OR: 9.96, p=0.0002) as the most significant independent predictors for mortality in patients with OHCA and STEMI.
Conclusion: In patients surviving an OHCA in the early phase of a myocardial infarction, the presence of cardiogenic shock, renal failure, anaemia or multivessel disease, as well as a longer time from the onset of symptoms or of cardiac arrest to revascularization, are independent predictors of mortality. However, the most powerful predictor of death is the duration of stay in the ICU and the requirement of mechanical ventilation for more than forty-eight hours.

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Sugammadex: An Update

Tiberiu Ezri1,2*, Mona Boaz3, Alexander Sherman1, Marwan Armaly4, Yitzhak Berlovitz5

1 Departments of Anesthesia, Wolfson Medical Center, affiliated to Tel Aviv University, Tel Aviv, Israel
2 Outcomes Research Consortium, Cleveland, OH, USA,
3 Faculty of Nutrition Sciences, Ariel University, Ariel, Israel
4 Department of Anesthesiology, the Baruch Padeh Medical Center, Poriya, affiliated to the Faculty of Medicine in the Galilee – Bar Ilan University, Israel
5 Department of Management, Wolfson Medical Center, affiliated to Tel Aviv University, Tel Aviv, Israel

DOI: 10.1515/jccm-2016-0005

The purpose of this update is to provide recent knowledge and debates regarding the use of sugammadex in the fields of anesthesia and critical care. The review is not intended to provide a comprehensive description of sugammadex and its clinical use.

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Out-of-Hospital Cardiac Arrest in Acute Myocardial Infarction and STEMI Networks

Theodora Benedek1*, Mariann Gyöngyösi2

1 University of Medicine and Pharmacy of Tirgu Mures, Romania
2 Medical University of Vienna, Austria

DOI: 10.1515/jccm-2016-0007

Out-of-hospital cardiac arrest (OHCA) remains associated with a poor prognosis, with a survival rate of approximately 10% [1]. Only 40% of patients presenting with OHCA are successfully resuscitated, and only 25% of them survive to hospital discharge [1].
In many cases of OHCA associated with acute myocardial infarction, the cardiac arrest is caused by ventricular fibrillation, occurring during the first hours after the onset of symptoms, and before the patient being admitted to hospital [2]. In these critical cases, implementation of specific protocols and dedicated networks are crucial for providing effective advanced cardiac life support.
Several treatment modalities have been proposed to improve outcomes in the post-resuscitation period. One such measure is induced therapeutic hypothermia, consisting of administering cooling infusions to cool the patient down to 32-34⁰C, and maintaining this for 12-24 hours. Evidence shows that when initiated promptly, cooling improves neurological outcomes in survivors of OHCA [3,4]. However, there is no clear evidence that hypothermia would lead to a significant reduction in mortality in these patients. Current guidelines recommend early therapeutic hypothermia as a class Ib indication, in the post-resuscitation phase, after cardiac arrest in patients who are comatose or deeply sedated [2]. [More]

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Sudden Cardiac Death and Post Cardiac Arrest Syndrome. An Overview

Endre Zima

Semmelweis University, Heart and Vascular Center, Budapest, Hungary

DOI: 10.1515/jccm-2015-0031

A satisfactory neurologic outcome is the key factor for survival in patients with sudden cardiac death (SCD), however this is highly dependent on the haemodynamic status. Short term cardiopulmonary resuscitation and regained consciousness on the return of spontaneous circulation (ROSC) is indicative of a better prognosis. The evaluation and treatment of SCD triggering factors and of underlying acute and chronic diseases will facilitate prevention and lower the risk of cardiac arrest. Long term CPR and a prolonged unconscious status after ROSC, in the Intensive Care Units or Coronary Care Units, indicates the need for specific treatment and supportive therapy including efforts to prevent hyperthermia. The prognosis of these patients is unpredictable within the first seventy two hours, due to unknown responses to therapeutic management and the lack of specific prognostic factors. Patients in these circumstances require the highest level of intensive care and aetiology driven treatment without any delay, independently of their coma state. Current guidelines sugest the use of multiple procedures in arriving at a diagnosis and prognosis of these critical cases.

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Ventricular Septal Rupture – A Critical Condition as a Complication of Acute Myocardial Infarction

Martin Novak*, Ota Hlinomaz, Ladislav Groch, Michal Rezek, Jiri Semenka, Jiri Sikora, Jan Sitar

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

DOI: 10.1515/jccm-2015-0030

Ventricular septal rupture is a potentially fatal complication of acute myocardial infarction. The key to management of this critical condition is an aggressive approach to haemodynamic stabilization and surgical closure of the rupture. Where there is a small rupture and the patient is in a haemodynamically stable condition, surgery can be delayed with the prospect of achieving better perioperative results. However, in unstable critically ill patients either immediate surgery or extracorporeal membranous oxygenation support and delayed surgery is indicated. In some patients, trans-catheter closure may be considered as an alternative to surgery.

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Dual Role of Angiopoietine II in the Complex Management of Critically Ill Patients with Sepsis

Monica Marton-Popovici

Swedish Medical Center, Department of Internal Medicine and Critical Care, Edmonds, Washington, USA

DOI: 10.1515/jccm-2015-0029

I read with great interest the article entitled “The role of Angiopoietine-2 in the diagnosis and prognosis of sepsis”, published by Szederjesi et al in the issue no.1/2015 of JCCM journal [1]. As the authors pointed out, the  prognosis of patients with sepsis is highly dependent on the early establishment of a proper diagnosis and on the early initiation of the adequate therapy. Therefore, identification of new biomarkers characterising this critically ill condition can be considered extremely important for a better understanding of this condition, leading to a more rapid and accurate diagnostic. The study identified angiopoietine-2 (ANG-2) as such a new biomarker characterising septic shock, demonstrating a good correlation between ANG-2 levels, duration of stay in the intensive care unit and the most widely used ICU mortality prediction scores. At the same time, the study showed a good sensitivity and specificity of this biomarker for diagnosis of sepsis and the authors should be congratulated for their results. [More]

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Delayed Recovery from General Anaesthesia: A Post-operative Diagnostic Dilemma and Implications of ICU Management of Serotonin Toxicity. Case report

Asha Naik1, Cristobal Rincon-Aznar2

1 West Suffolk NHS Foundation Trust, United Kingdom
2 Mediclinic Dubai Mall, Dubai, United Arab Emirates

DOI: 10.1515/jccm-2015-0026

We report a case of delayed recovery from general anesthesia following a routine parathyroidectomy. Our objectives are to describe the process of establishing a differential diagnosis and subsequent management of a patient presenting with atypical neurological signs from an unknown etiology and to increase awareness about the potential for serotonin syndrome and neurotoxicity due to known interactions between methylene blue and selective serotonin-noradrenaline re-uptake inhibitors. ICU management of Serotonin Toxicity is briefly described.

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