Category Archives: Review

Therapeutic Hypothermia Following Cardiopulmonary Arrest: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

Robert Maclaren1, Sterling Torian2, Tyree Kiser1, Scott Mueller3, Paul Reynolds4

1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
2 Department of Pharmacy, TriStar Centennial Medical Center, Nashville, Tennessee, USA
3 Department of Pharmacy, University of Colorado Hospital, Aurora, Colorado, USA
4 Department of Pharmacy, VA Eastern Colorado Health Care System, Aurora, Colorado, USA

DOI: 10.2478/jccm-2023-0015

Introduction: The risk-benefit profile of therapeutic hypothermia is controversial with several randomized controlled trials providing conflicting results. Aim of Study: The purpose of this systematic review and meta-analysis was to determine if therapeutic hypothermia provides beneficial neurologic outcomes relative to adverse effects.
Material and Methods: MEDLINE and EMBASE databases were searched for randomized controlled trials of post-cardiac arrest patients comparing therapeutic hypothermia (~33 degrees Celsius) to normothermia or the standard of care (36 – 38 degrees Celsius). Data were collected using the Covidence systematic review software. Statistical analysis was performed by Review Manager software. Risk of bias, sensitivity, and heterogeneity were analyzed using the Cochran’s Collaboration tool, trial sequential analysis (TSA) software, and I2 statistic respectively.
Results: A total of 1825 studies were screened and 5 studies (n=3614) were included. No significant differences existed between the hypothermia group and normothermia for favorable neurologic outcome (risk ratio [RR] 1.17, 95% confidence interval [CI] 0.97 to 1.41) or all-cause mortality (RR 0.97, 95% CI 0.89 to 1.05). When compared to normothermia, the hypothermia group had greater risk of adverse effects (RR 1.16, 95% CI 1.04 to 1.28), which was driven by the onset of arrhythmias. Subgroup analyses revealed that therapeutic hypothermia provided greater neurologic benefit in trials with a higher percentage of subjects with shockable rhythms (RR 0.73, 95% CI 0.6 to 0.88). Trial sequential analysis revealed statistical futility for therapeutic hypothermia and favorable neurologic outcome, mortality, and adverse effects.
Conclusions: Therapeutic hypothermia does not provide consistent benefit in neurologic outcome or mortality in the general cardiac arrest population. Patients with shockable rhythms may show favorable neurologic outcome with therapeutic hypothermia and further investigation in this population is warranted. Any potential benefit associated with therapeutic hypothermia must be weighed against the increased risk of adverse effects, particularly the onset of arrhythmias.

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Post Hospital Discharge Functional Recovery of Critical Illness Survivors. Systematic Review

Irini Patsaki1, Georgia Bachou2, Georgios Sidiras3, Serafim Nanas3, Christina Routsi3, Eleftherios Karatzanos3

1 University of West Attica, Athens, Greece
2 National and Kapodistrian University of Athens, Greece
3 Clinical Ergospirometry, Exercise and Rehabilitation Laboratory, 1st Critical Care Department, Evangelismos Hospital, School of Medicine, National & Kapodistrian University of Athens, Greece

DOI: 10.2478/jccm-2023-0011

Background: Millions of people face critical illnesses and need to be hospitalized in an Intensive Care Unit (ICU) annually worldwide. Despite the fact that survival rates of these patients have increased, they develop various cognitive, psychological and functional impairments. This study aims to investigate the significance of the recovery interventions following intensive care unit discharge, the effectiveness of the rehabilitative protocols and their possible deficits.
Methods: MEDLINE (PubMed) and Physiotherapy Evidence Database (PEDro) were searched for studies analyzing the recovery potentials post-ICU among adults, who spent at least 48 hours at the ICU. Methodological quality of the studies was assessed via PEDro Scale.
Results: Nine randomized controlled trials were included. These took place mainly at specialized rehabilitation gyms as well as patients home environments. Studies analyses showed that treatment group showed improvement in functional ability in relation to control group. Nevertheless, differences between two groups were not statistically significant (P<0.05). The majority of studies assessed cardiorespiratory endurance and muscular strength.
Conclusions: The included rehabilitation programs were determined to be effective. Although they didn’t prove any statistically significant difference between groups, quality of life enhancements and stress reduction were reported. Hence, new randomized controlled trials are required in order to provide more accurate data on the potential benefits of rehabilitation strategies among post-ICU patients.

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The Impact of Prenatal Diagnosis in the Evolution of Newborns with Congenital Heart Disease

Daniela Toma, Elena Moldovan, Liliana Gozar

1 Department of Pediatric Cardiology, Emergency Institute for Cardiovascular Diseases and Transplantation, Targu Mures, Romania;
2 Department of Pediatrics, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Pediatric Intensive Care Unit, Emergency Institute for Cardiovascular Diseases and Transplantation, Targu Mures, Romania

DOI: 10.2478/jccm-2023-0007

Congenital heart malformations are cardiac and/or vascular structural abnormalities that appear before birth, the majority of which can be detected prenatally. The latest data from the literature were reviewed, with reference to the degree of prenatal diagnosis regarding congenital heart malformations, as well as its impact on the preoperative evolution and implicitly on mortality. Studies with a significant number of enrolled patients were included in the research. Prenatal congenital heart malformations detection rates were different, depending on the period in which the study took place, the level of the medical center, as well as on the size of enrolled groups. Prenatal diagnosis in critical malformations such as hypoplastic left heart syndrome, transposition of great arteries and totally aberrant pulmonary venous drainage has proven its usefulness, allowing an early surgical intervention, thus ensuring improved neurological development, increasing the survival rate and decreasing the rate of subsequent complications. Sharing the experience and results obtained by each individual therapeutic center will definitely lead to drawing clear conclusions regarding the clinical contribution of congenital heart malformations prenatal detection.

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Intensive Care Based Interventions to Reduce Family Member Stress Disorders: A Systematic Review of the Literature

Sarah Love Rhoads1, Thomas A. Trikalinos2, Mitchell M. Levy3, Timothy Amass1,4

1 Department of Medicine, Division of Pulmonary Sciences and Critical Care, University of Colorado, Denver, CO, USA
2 Departments of Health Services, Policy, and Practice and of Biostatistics, and Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA
3 Department of Medicine, Division of Pulmonary, Critical Care and Sleep, Brown University, Providence, RI, USA
4 Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, CO; CU Anschutz: University of Colorado – Anschutz Medical Campus, USA

DOI: 10.2478/jccm-2022-0014

Background: Increasing awareness of the emotional impact of an Intensive Care Unit (ICU) hospitalization on patients and their families has led to a rise in studies seeking to mitigate Post Intensive Care Syndrome (PICS) for both groups. In efforts to decrease symptoms of anxiety and depression, ICUs have implemented a variety of programs to reduce family distress.
Methods: We conducted a systematic review of experimental studies which aimed to reduce stress related disorders in family members after the experience of having a patient admitted to the ICU. Multiple databases were searched for randomized controlled trials or nonrandomized comparative trials which targeted family members or surrogate decision makers. A total of 17 studies were identified for inclusion in the review representing 3471 participants.
Results: We describe those interventions which we qualitatively assigned as “not passive,” or those which actively engaged the family to express themselves, as more likely to be successful in both the available pediatric and adult literature than interventions which we identified as “passive.” Studies which described active engagement of family members demonstrated comparative improvements in symptoms of depression, anxiety, and PTSD, as well as reduced hospital costs in the case of two studies.
Discussion: This review may serve to aid in the development of future interventions targeted at reducing family stress and PICS following an ICU hospitalization.

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The Pathophysiology and Management of Diabetic Ketoacidosis in COVID-19 Patients: A Literature Review

Mariana Cornelia Tilinca1, Maximilian Cosma Gliga2, Andreea Varga1

1 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Mures County Hospital, Targu Mures, Romania

DOI: 10.2478/jccm-2021-0024

Diabetic individuals are considered a vulnerable population during the COVID-19 Pandemic, and several studies noted worse outcomes, including death, among those who get infected. Diabetic emergencies, such as ketoacidosis (DKA), are common and potentially life-threatening conditions in uncontrolled patients. While the pathophysiological background of the relationship between COVID-19 and DKA is not fully understood, early reports available so far indicate that patients with pre-existing diabetes who get infected with the SARS-CoV 2 virus are at higher risk of DKA. It was also suggested that DKA is a poor prognostic sign for infected patients, these being at higher risk of developing worse forms of COVID-19 disease and having high mortality. Therefore, healthcare personnel dealing with such patients face a considerable challenge, as the correct and safe emergency management of such cases is far from established. This article aimed to conduct a study that reviews the current published data available about patients with DKA and COVID-19.

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Critical Care Management of Decompensated Right Heart Failure in Pulmonary Arterial Hypertension Patients – An Ongoing Approach

Ioan Tilea1,2, Andreea Varga1, Anca-Meda Georgescu1,3, Bianca-Liana Grigorescu1,4

1 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Department of Cardiology II, Emergency Clinical County Hospital, Targu Mures, Romania
3 Infectious Disease Clinic, Clinical County Hospital, Targu Mures, Romania
4 Department of Anaesthesia and Intensive Care, Emergency Clinical County Hospital, Targu Mures, Romania

DOI: 10.2478/jccm-2021-0020

Despite substantial advancements in diagnosis and specific medical therapy in pulmonary arterial hypertension patients’ management, this condition continues to represent a major cause of mortality worldwide. In pulmonary arterial hypertension, the continuous increase of pulmonary vascular resistance and rapid development of right heart failure determine a poor prognosis. Against targeted therapy, patients inexorable deteriorate over time. Pulmonary arterial hypertension patients with acute right heart failure who need intensive care unit admission present a complexity of the disease pathophysiology. Intensive care management challenges are multifaceted. Awareness of algorithms of right-sided heart failure monitoring in intensive care units, targeted pulmonary hypertension therapies, and recognition of precipitating factors, hemodynamic instability and progressive multisystem organ failure requires a multidisciplinary pulmonary hypertension team. This paper summarizes the management strategies of acute right-sided heart failure in pulmonary arterial hypertension adult cases based on recently available data.

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Effect of Early versus Delayed Parenteral Nutrition on the Health Outcomes of Critically Ill Adults: A Systematic Review

Suresh Kumar Sharma, Ritu Rani, Kalpana Thakur

All India Institute of Medical Sciences – Rishikesh, Rishikesh, India

DOI: 10.2478/jccm-2021-0011

Objectives: This systematic review aims to evaluate and summarise the findings of all relevant studies which identified the effect of early vs delayed parenteral nutrition (PN), early PN vs early supplemental PN and early PN vs standard care for critically ill adults.
Methods: The literature search was undertaken using PubMed, Embase, Medline, Clinical Key, and Ovid discovery databases. The reference lists of studies published from 2000 till June 2020 were hand searched.
Result: On screening 2088 articles, a total of five RCTs with 6,277 patients were included in this review. Only one clinical trial compared early PN and late PN; the results reported significantly shorter periods in intensive care unit (ICU) stay (p=0.02) and less ICU related infections (p=0.008) in the late PN group compared to the Early PN group. Two trials compared total parenteral nutrition (TPN) and enteral nutrition (EN) +TPN groups. Both found a significantly longer hospital stay duration (p<0.05 and p<0.01) with a higher mortality rate in the TPN group compared to the EN+TPN group. A statistically significant improvement was observed in patients’ quality of life receiving early PN compared to standard care (p=0.01). In contrast, no significant difference was found in the supplemental PN vs the standard care group.
Conclusion: The supplemental PN patients had shorter ICU stay and lower mortality rates than TPN. However, these findings should be interpreted carefully as included studies have different initiation timing of nutritional support, and the patients’ diagnosis varied.
Systematic review registration: PROSPERO: CRD42020183175

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Perioperative Management of Pulmonary Hypertension. A Review

Christopher Wood1, Mindaugas Balciunas1, Jim Lordan2, Adrian Mellor1

1 James Cook University Hospital, Middlesbrough, UK
2 Newcastle Upon Tyne Hospitals NHS Foundation Trust

DOI: 10.2478/jccm-2021-0007

Pulmonary hypertension is a rare and progressive pathology defined by abnormally high pulmonary artery pressure mediated by a diverse range of aetiologies. It affects up to twenty-six individuals per one million patients currently living in the United Kingdom (UK), with a median life expectancy of 2.8 years in idiopathic pulmonary hypertension. The diagnosis of pulmonary hypertension is often delayed due to the presentation of non-specific symptoms, leading to a delay in referral to specialists services. The complexity of treatment necessitates a multidisciplinary approach, underpinned by a diverse disease aetiology from managing the underlying disease process to novel specialist treatments. This has led to the formation of dedicated specialist treatment centres within centralised UK cities. The article aimed to provide a concise overview of pulmonary hypertension’s clinical perioperative management, including key definitions, epidemiology, pathophysiology, and risk stratification.

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Anticoagulation in COVID – 19: An Update

Nishant R Tiwari1, Khalid I Khatib2, Subhal B Dixit3, Prajay K Rathore4, Sameer Melinkeri5, Abhijeet Ganapule6, Kapil S Borawake7, Ujwala Mhatre8

1 Byramjee Jeejeebhoy Medical College and Sassoon General Hospital, Pune, Maharashtra, India
2 Smt Kashibai Navale Medical College and General Hospital, Pune, India
3 Sanjeevan Hospital, Pune, India
4 Danbury Hospital, Danbury, USA
5 Deenanath Mangeshkar Hospital and Research Centre, Pune, India
6 Niche Hematology Care, Kolhapur, India
7 Prayag Hospital, Pune, India
8 Nanavati Hospital, Mumbai, India

DOI: 10.2478/jccm-2020-0033

The novel coronavirus disease, 2019 (COVID – 19) evolved as an unprecedented pandemic. The severe acute respiratory syndrome-corona virus-2 (SARS-CoV-2) infection has been associated with significantly deranged coagulation parameters and increased incidence of thrombotic events. Deranged coagulation parameters, such as D-dimers and fibrin degradation products, can indicate a poor prognosis, and their measurement will help stratify the patients according to the disease severity, need of intensive care unit admission, and prediction of the clinical course. Gaps in understanding the natural history of the disease cause difficulties in tailoring therapies and optimizing the management of patients. Lack of specific treatment further complicates this situation. While thrombotic events can cause significant morbidity and mortality in patients, a focused approach to the prevention and treatment of venous thromboembolism (VTE) can, to a great extent, decrease the disease burden caused by thrombotic diseases. Pharmacological prophylactic anticoagulants and mechanical therapies such as pneumatic compression devices can help prevent venous thromboembolism and other thrombotic events. Thrombotic events due to COVID-19, their prevention and management, are the focus of this paper, with the prospect of providing insights into this relatively unexplored area.

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Anaesthesia for Liver Transplantation: An Update

Lavinia Nicoleta Brezeanu1, Radu Constantin Brezeanu2, Mircea Diculescu1,3, Gabriela Droc1,3

1 Fundeni Clinical Institute, Bucharest, Romania
2 “Bagdasar-Arseni” Emergency Hospital, Bucharest, Romania
3 “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

DOI: 10.2478/jccm-2020-0011

Liver transplantation (LT) is a challenging surgery performed on patients with complex physiology profiles, complicated by multi-system dysfunction. It represents the treatment of choice for end-stage liver disease. The procedure is performed under general anaesthesia, and a successful procedure requires an excellent understanding of the pathophysiology of liver failure and its implications. Despite advances in knowledge and technical skills and innovations in immunosuppression, the anaesthetic management for LT can be complicated and represent a real challenge. Monitoring devices offer crucial information for the successful management of patients. Hemodynamic instability is typical during surgery, requiring sophisticated invasive monitoring. Arterial pulse contour analysis and thermo-dilution techniques (PiCCO), rotational thromboelastometry (RO-TEM), transcranial doppler (TCD), trans-oesophageal echocardiography (TEE) and bispectral index (BIS) have been proven to be reliable monitoring techniques playing a significant role in decision making. Anaesthetic management is specific according to the three critical phases of surgery: pre-anhepatic, anhepatic and neo-hepatic phase. Surgical techniques such as total or partial clamping of the inferior vena cava (IVC), use of venovenous bypass (VVBP) or portocaval shunts have a significant impact on cardiovascular stability. Post reperfusion syndrome (PRS) is a significant event and can lead to arrhythmias and even cardiac arrest.

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