Category Archives: issue

Cardiac Arrhythmias in a Septic ICU Population: A Review

Andrei Schwartz, Evgeni Brotfain*, Leonid Koyfman, Moti Klein

Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel

DOI: 10.1515/jccm-2015-0027

Progressive cardiovascular deterioration plays a central role in the pathogenesis of multiple organ failure (MOF) caused by sepsis. Evidence of various cardiac arrhythmias in septic patients has been reported in many published studies. In the critically ill septic patients, compared to non-septic patients, new onset atrial fibrillation episodes are associated with high mortality rates and poor outcomes, amongst others being new episodes of stroke, heart failure and long vasopressor usage. The potential mechanisms of the development of new cardiac arrhythmias in sepsis are complex and poorly understood. Cardiac arrhythmias in critically ill septic patients are most likely to be an indicator of the severity of pre-existing critical illness.

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Invasive Candida Infections in the ICU: Diagnosis and Therapy

Péter Hankovszky, Domonkos Trásy, Nándor Öveges, Zsolt Molnár*

Department of Anaesthesiology and Intensive Therapy, University of Szeged, Albert Szent-Györgyi Health Center, Szeged, Hungary

DOI: 10.1515/jccm-2015-0025

Invasive fungal infections have become a serious problem in the critically ill. One of the main reasons is the development of an immunocompromised condition. The most frequently found pathogens are Candida species. In order to provide adequate treatment, understanding this potentially life-threatening infection is mandatory. The aim of this summary is to view Candida infections from a different perspective and to give an overview on epidemiology, the range of pathophysiology from colonization to the invasive infections, and its impact on mortality. New therapeutic options will also be discussed and how these relate to current guidelines. Finally, the key issue of the choice of antifungal agents will be evaluated.

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The Significance of Cardiac Arrhythmias in Septic ICU Patients

Daniela Ionescu

Department of Anesthesia and Intensive Care, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania; Outcome Research Consortium, Cleveland, USA

DOI: 10.1515/jccm-2015-0028

The review article published in this issue by Schwartz A et al [1] draws attention to the importance of cardiac arrhythmias and especially that of new-onset atrial fibrillation (AF) and the clinical outcome of septic patients. The incidence of this phenomenon varies in different reports, from 5.8% [2] to 31-40% [3-4].
Causes are numerous and different mechanisms have been described in the literature and by the authors of the review. Endotoxin induces tachycardia, increases the cardiac index, and reduces blood pressure and systemic vascular resistance without change in stroke volume [5]. Fluid administration results in a decrease in left ventricular ejection fraction and an increase in ventricular volumes even more than before the administration of fluid therapy [5].
An increased inflammatory response also plays an important role in pathogenesis of cardiac arrhythmias and dysfunction in septic patients. Increased plasma levels of C-reactive protein, IL-6 and TNF-α may contribute to the onset of AF in septic patients [1,6]. [More]

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Acquired Tracheal Diverticulum as an Unexpected Cause of Endotracheal Tube Cuff Leak

René Agustin Flores-Franco*, Jesús Silva-Alcaraz

Departamento de Neumología y Medicina Interna, Hospital General Regional “Dr. Salvador Zubirán Anchondo”, Chihuahua, México

DOI: 10.1515/jccm-2015-0024

Introduction: Tracheal diverticulum has been associated with problems during endotracheal intubation but there are no reports concerning air leakage around an endotracheal tube (ETT).
Case report: The case of an elderly woman under mechanical ventilatory support because an exacerbation of chronic obstructive pulmonary disease (COPD) is reported. She presented with an inexplicably air leak around the endotracheal tube not attributed to structural defects. The intra-cuff pressure value was as high as 30 mmHg to prevent an air leakage. Bronchoscopy revealed a tracheal diverticulum at the site ofthe tube cuff that allowed air leakage around it. The problem was overcome by re-intubating the patient with a larger diameter tube and positioning its distal end above the diverticular opening.
Discussion: Endotracheal tube air leak is a frequently neglected problem. COPD and other inflammatory conditions are associated with changes in the elastic properties of the airways resulting in tracheomegaly or acquired tracheal diverticulum. Both entities have been linked to problems during intubation or ventilation of patients. However tracheal diverticulum has not been described previously as a cause of air leakage.
Conclusion: Acquired tracheal diverticulum should be recognized as a cause of air leakage in the intubated patient, especially if associated with a normal or elevated intracuff pressure.

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Plasma Neutrophil Gelatinase Associated Lipocalin (NGAL) – Early Biomarker for Acute Kidney Injury in Critically Ill Patients

Raluca Fodor1, Bianca Grigorescu2*, Mihaly Veres2, Monica Orlandea2, Judita Badea2, Katalin Hlavathy2, Adrian Cioc2

1 Department of Anaesthesiology and Intensive Care, University of Medicine and Pharmacy, Tirgu Mures, Romania
2 Department of Anaesthesiology and Intensive Care, Emergency County Hospital, Tirgu Mures, Romania

DOI: 10.1515/jccm-2015-0023

Introduction: NGAL (Neutrophil Gelatinase Associated Lipocalin) is a biomarker recently introduced into clinical practice for the early diagnosis of acute kidney injury (AKI). The aim of this study was to correlate the plasmatic NGAL value determined at admission with clinical progression and severity of AKI in critically ill patients.
Material and method: Thirty two consecutive critically ill adult patients at risk of developing AKI (trauma, sepsis), admitted in Intensive Care Unit of the Clinical County Emergency Hospital Mures, between January to March 2015 were enrolled in the study. For each patient included in the study plasma NGAL levels were determined on admission, and these were correlated with the degree of AKI development (according to AKIN criteria) at 48 hours and 5 days post admission. The discriminatory power of NGAL, creatinine, creatinine clearance and corrected creatinine (depending on water balance) were determined using the ROC (receiver-operating characteristic) and likelihood ratios.
Results: ROC curve analysis showed a better discriminatory capacity in terms of early diagnosis of AKI for NGAL (AUC=0.81 for NGAL, AUC=0.59 for creatinine, AUC=0.62 for corrected creatinine, AUC=0.29 for creatinine clearance). The value of likelihood ratio was also significantly higher for NGAL (3.01±2.73 for NGAL, 1.27±1.14 for creatinine, 1.78±1.81 for corrected creatinine, and 0.48±0.33 for creatinine clearance).
Conclusions: NGAL biomarker has a better discrimination capacity for early prediction of acute kidney injury compared to previously used markers.

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An Evaluation of Serum Procalcitonin and C-Reactive Protein Levels as Diagnostic and Prognostic Biomarkers of Severe Sepsis

Janos Szederjesi1*, Emoke Almasy1, Alexandra Lazar1, Adina Huțanu2, Iudita Badea1, Anca Georgescu3

1 Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy Tirgu Mures, Romania
2 County Clinical Emergency Hospital Tirgu Mures, Romania
3 Department of Infectious Diseases, University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/jccm-2015-0022

Background: Recommendations have been made, following the multicenter Surviving Sepsis Campaign study, to standardize the definition of severe sepsis with reference to several parameters such as haemodynamic stability, acid-base balance, bilirubin, creatinine, International Normalized Ratio (INR), urine output and pulmonary functional value of the ratio between arterial oxigen partial pressure and inspiratory oxigen concentration. Procalcitonin (PCT) is considered to be a gold standard biomarker for the inflammatory response, and recent studies have shown that it may help to discover whether a seriously ill person is developing sepsis. C-reactive protein (CRP) is also used as a marker of inflammation in the body, as its blood levels increase if there is any inflammation in the body.
The aim of this study was to evaluate serum procalcitonin and C-reactive protein levels as diagnostic and prognostic biomarkers of severe sepsis.
Material and method: Sixty patients, diagnosed as being “septic”, were admitted to the intensive care unit (ICU). Based on laboratory results and clinical findings a diagnosis of “severe sepsis“ was made, and correlated with PCT and CRP values. The APACHE II, SAPS II and SOFA severity scores were calculated, analyzed and correlated with PCT and CRP.
Results: Fifty two patients (86.67%) presented with criteria for severe sepsis. Multivariate correlation analysis indicated a significant positive association between procalcitonin and all severity scores (APACHEII p<0.0001, SOFA p<0.0001, SAPS II p<0.0001). CRP proved to be significantly correlated only with the SAPS II score (p=0.0145). Mortality rate was high, with 48 patients (80%) dying. There was no significant correlation between the levels of the PCT and CRP biomarkers and severe sepsis (p=0.2059 for PCT, p=0.6059 for CRP).
Conclusions: The procalcitonin levels are highly correlated with the severity scores (APACHE II, SAPS II, SOFA) regularly used in ICUs and therefore can be used for determining the severity of the septic process. Quantitive procalcitonin and C-reactive protein analysis was not shown to be useful in diagnosing severe sepsis. However, PCT and CRP can be used to predict the fatal progression of the septic patient.

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Anti-platelet Therapy Resistance – Concept, Mechanisms and Platelet Function Tests in Intensive Care Facilities

Alina Mărginean1,2, Claudia Bănescu1*, Alina Scridon1, Minodora Dobreanu1

1 University of Medicine and Pharmacy of Tîrgu Mures, Romania
2 Emergency Military Hospital “Dr. Constantin Papilian”, Cluj-Napoca, Romania

DOI: 10.1515/jccm-2015-0021

It is well known that critically ill patients require special attention and additional consideration during their treatment and management. The multiple systems and organ dysfunctions, typical of the critical patient, often results in different patterns of enteral absorption in these patients. Anti-platelet drugs are the cornerstone in treating patients with coronary and cerebrovascular disease. Dual anti-platelet therapy with aspirin and clopidogrel is the treatment of choice in patients undergoing elective percutaneous coronary interventions and is still widely used in patients with acute coronary syndromes. However, despite the use of dual anti-platelet therapy, some patients continue to experience cardiovascular ischemic events. Recurrence of ischemic events is partly attributed to the fact that some patients have poor inhibition of platelet reactivity despite treatment. These patients are considered low- or non-responders to therapy. The underlying mechanisms leading to resistance are not yet fully elucidated and are probably multifactorial, cellular, genetic and clinical factors being implicated. Several methods have been developed to asses platelet function and can be used to identify patients with persistent platelet reactivity, which have an increased risk of thrombosis. In this paper, the concept of anti-platelet therapy resistance, the underlying mechanisms and the methods used to identify patients with low responsiveness to anti-platelet therapy will be highlighted with a focus on aspirin and clopidogrel therapy and addressing especially critically ill patients.

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Challenges of Critical Cardiac Imaging in Cardiogenic Shock

Marius George Linguraru

Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Health System, Washington DC, USA

DOI: 10.1515/jccm-2015-0020

To the editor of JCCM
I am writing in reference to the article published by Theodora Benedek and Dan Dobreanu in the first issue of JCCM, entitled “Current Concepts and New Trends in the Treatment of Cardiogenic Shock Complicating
Acute Myocardial Infarction”.
Cardiogenic shock (CS) represents a critical and life-threatening condition. Survival of patients with CS depends largely, not only on the appropriateness of the therapeutic measures, but also on the correct identification of the underlying disease [1].
Treatment of this underlying condition represents a key element for the correction of the patho-phyisiological pathways responsible for the development of a CS.
In many cases, CS occurs in association with an acute myocardial infarction, usually large infarcts, located on the anterior ventricular wall [2]. Prompt revascularisation is crucial in these cases, as the re-establishment of coronary flow would immediately improve the haemodynamic status of these critically ill patients. However, in routine clinical practice, the diagnosis of an acute coronary syndrome remains challenging, especially when the physician is faced with a patient who arrives in the emergency room (ER) intubated, after surviving a cardiac arrest of unknown aetiology. [More]

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Neutrophil Viability as a Clinical Outcome Marker in Mechanically Ventilated Critically Ill Trauma Patients: A Case Series

Orsolya Benedek1, Mihaly Veres2, Minodora Dobreanu1

1 University of Medicine and Pharmacy of Tirgu Mures, Romania
2 County Clinical Emergency Hospital Tirgu Mures, Romania

DOI: 10.1515/jccm-2015-0019

Background: Trauma in its early stages leads to an acute inflammatory condition affecting all cellular lines. Neutrophil granulocytes make up the largest population of human white blood cells and are fundamental to the innate immune system. The objective of our pilot study was to evaluate neutrophil death and viability alterations in critically ill trauma patients in correlation with their clinical outcome.
Material and method: Critical ill trauma patients were enrolled in the study. In order to assess alterations in cellular death, blood samples were drawn using EDTA containing tubes and analyzed in the first twenty four hours after admission, then after forty eight and seventy two hours. Annexin V was used as a marker for apoptotic cells and propidium iodide for necrotic cells.
Results: The first two cases exhibited an increase in cellular viability by the second day as shown by a small increase in neutrophil apoptosis and a decrease in neutrophil necrosis. These patients progressed to a positive clinical outcome. The second two cases showed slight modifications in either physiological or pathological cellular death, and increasing levels of cellular necrosis. These patients progressed to a negative clinical outcome.
Conclusions: These cases suggest that neutrophil cell viability and death were associated with the patient’s clinical outcome.

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Health Care Professional’s Attitude Towards the Effective Management of Pain in the Critically Ill Neonate

Laura Mihaela Suciu1, Manuela Cucerea1, Marta Simon1, Andreea Avasiloaiei2, Olimpia Petrescu3, Suciu Bogdan Andrei4

1 Department of Pediatrics, University of Medicine and Pharmacy Tîrgu Mures, Romania
2 Department of Pediatrics, University of Medicine and Pharmacy Iasi, Romania
3 Department of Neonatology, County Hospital Brasov, Romania
4 Anatomy and Embryology Department, University of Medicine and Pharmacy Tîrgu Mures, Romania

DOI: 10.1515/jccm-2015-0018

Introduction: Over the past 25 years, caregiver’s knowledge of pain in newborn infants has advanced from the beliefs that newborn infants do not feel pain, to the knowledge that preterm infants experience more pain compare to older children and adults. However, caregivers know that pain exists in this population and research has supported that pain continues to be untreated up to 65% of the time.
Aim of the study: The purpose of this study was to investigate the attitude and knowledge of health care professionals from the area of Neonatology in Romania regarding procedural pain management in newborn infants.
Material and methods: The sample consisted of 85 physicians and nurses (110 invited) working in five Neonatal Care Centres. Data were collected using a self-completion, 17 items questionnaire designed for this study.
Results: With a response rate of 77.27% which was similar in nurses and physicians, respondents in our study were aware about the pain experience during procedural interventions, recognized the items of pain scales assessment, and are not comfortable with the parental presence during painful procedures. Twenty-five percent of nurses versus 9% of physicians reported rushed care as an important barrier of adequate non-pharmacological pain management (95% IC, 0.319-0.003)
Conclusions: The use of pain protocols for an effective management of pain during neonatal period is required.

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