Category Archives: Review

Precision Medicine and its Role in the Treatment of Sepsis: A Personalised View

Alexandra Lazăr1, Anca Meda Georgescu2, Alexander Vitin3, Leonard Azamfirei1

1 Department of Anesthesiology and Intensive Care, University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Romania
2 Department of Infectious Diseases, University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Romania
3 Department of Anesthesiology & Pain, Medicine University of Washington Medical Center, Seattle WA, USA

DOI: 10.2478/jccm-2019-0017

In recent years, a new form of medicine has become increasingly significant, namely, personalised medicine (PM). PM is a form of care in which treatment is tailored for an individual patient.
PM is about using multiple data sets to create a digital human mapping. A person’s biological traits are determined by the interactions of hundreds of genes and gene networks, as well as external factors such as diet and exercise. Combining and then investigating these multiple databases with powerful statistical tools, allows a new understanding of how genetic intricacy drives health and disease and so leads to a closer personalised medical approach that targets each individual’s unique genetic make-up.
Sepsis is a systemic inflammatory response to infection, ranging from systemic inflammatory response syndrome (SIRS) to septic shock and multiple organ dysfunction syndromes (MODS). Sepsis is the most common cause of death in intensive care patients. Treatments in an ICU may need to be adapted to the continuous and rapid changes of the disease, making it challenging to identify a single target. PM is thus seen as the future of sepsis treatment in the ICU.
The fact that individual patients respond differently to treatment should be regarded as a starting point in the approach to providing treatment. The disease itself comes secondary to this concept.

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Sepsis in Acute Mediastinitis – A Severe Complication after Oesophageal Perforations. A Review of the Literature

Mircea Mureșan1, Simona Mureșan2, Ioan Balmoș1, Daniela Sala1, Bogdan Suciu3, Arpad Torok1

1 University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Surgery Clinic No.2
2 University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Physiology Department
3 University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Thoracic Surgery Department

DOI: 10.2478/jccm-2019-0008

Background. Despite recent advancements in antibiotic therapy and the progress made in critical care and modern diagnostic methods, acute mediastinitis continues to be a severe condition.
Diagnosis and treatment. Acute mediastinitis can occur in the context of cardio-thoracic surgery, oesophageal perforations and oropharyngeal infections condition. Forty-five percent of oesophageal perforations occurs during simple endoscopy. Spontaneous perforation (Boerhaave syndrome) accounts for 15% of perforations, and twelve percent are due to the ingestion of foreign bodies. Other causes include blind or penetrating trauma, and circa 9% to intraoperative lesions. CT scan is the standard investigation that reveals direct signs of mediastinitis. The oral administration of contrast substances can underscore the level of oesophageal perforation. Conservative treatment is the first-choice treatment and surgical treatment is reserved only for specific situations. The principles of surgical treatment consist of drainage, primary suture, oesophageal exclusion with or without the application of oesophagectomy, endoscopic vacuum wound assisted therapy of the perforation and associated paraoesophageal mediastinal drainage and endoscopic stenting associated with drainage.
Conclusions. The lowest mortality rate is recorded in patients with perforations diagnosed less than twenty-four hours after the onset of symptoms. Surgical treatment remains the gold standard especially in cases of thoracic and abdominal perforations while further investigations are mandatory before endoscopic stenting is carried out.

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Critical Care Aspects of Gallstone Disease

Piero Portincasa1, Emilio Molina-Molina1, Gabriella Garruti2, David Q.-H. Wang3

1 Clinica Medica “A. Murri”, Department of Biomedical Sciences & Human Oncology, University of Bari Medical School, Bari, Italy
2 Section of Endocrinology, Department of Emergency and Organ Transplantations, University of Bari “Aldo Moro” Medical School, Piazza G. Cesare 11, 70124 Bari, Italy
3 Department of Medicine, Division of Gastroenterology and Liver Diseases, Marion Bessin Liver Research Center, “Albert Einstein” College of Medicine, Bronx, NY 10461, USA

DOI: 10.2478/jccm-2019-0003

Approximately twenty percent of adults have gallstones making it one of the most prevalent gastrointestinal diseases in Western countries. About twenty percent of gallstone patients requires medical, endoscopic, or surgical therapies such as cholecystectomy due to the onset of gallstone-related symptoms or gallstone-related complications. Thus, patients with symptomatic, uncomplicated or complicated gallstones, regardless of the type of stones, represent one of the largest patient categories admitted to European hospitals.
This review deals with the important critical care aspects associated with a gallstone-related disease.

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Abdominal Sepsis: An Update

Mircea Gabriel Mureșan1,2, Ioan Alexandru Balmoș1,2, Iudita Badea1,3, Ario Santini1,4

1 University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureş, Romania
2 Surgery Clinic No. 2, Târgu Mureş, Romania
3 Anesthesiology and Intensive Care Clinic No.1, Târgu Mureş, Romania
4 Hon Fellow, University of Edinburgh, United Kingdom

DOI: 10.2478/jccm-2018-0023

Despite the significant development and advancement in antibiotic therapy, life-threatening complication of infective diseases cause hundreds of thousands of deaths world. This paper updates some of the issues regarding the etiology and treatment of abdominal sepsis and summaries the latest guidelines as recommended by the Intra-abdominal Infection (IAI) Consensus (2017). Prognostic scores are currently used to assess the course of peritonitis. Irrespective of the initial cause, there are several measures universally accepted as contributing to an improved survival rate, with the early recognition of IAI being the critical matter in this respect. Immediate correction of fluid balance should be undertaken with the use of vasoactive agents being prescribed, if necessary, to augment and assist fluid resuscitation. The WISS study showed that mortality was significantly affected by sepsis irrespective of any medical and surgical measures. A significant issue is the prevalence of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in the clinical setting, and the reported prevalence of ESBLs intra-abdominal infections has steadily increased in Asia. Europe, Latin America, Middle East, North America, and South Pacific. Abdominal cavity pathology is second only to sepsis occurring in a pulmonary site. Following IAI (2017) guidelines, antibiotic therapy should be initiated as soon as possible after a diagnosis has been verified.

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Abdominal Compartment Syndrome as a Multidisciplinary Challenge. A Literature Review

Gabriel Alexandru Popescu1,2, Tivadar Bara jr.1,2, Paul Rad1,3

1 University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureş, Romania
2 Surgery Clinic No. 2, Târgu Mureş, Romania
3 Anesthesiology and Intensive Care Clinic No. 1, Târgu Mureş, Romania

DOI: 10.2478/jccm-2018-0024

Abdominal Compartment Syndrome (ACS), despite recent advances in medical and surgical care, is a significant cause of mortality. The purpose of this review is to present the main diagnostic and therapeutic aspects from the anesthetical and surgical points of view. Intra-abdominal hypertension may be diagnosed by measuring intra-abdominal pressure and indirectly by imaging and radiological means. Early detection of ACS is a key element in the ACS therapy. Without treatment, more than 90% of cases lead to death and according with the last reports, despite all treatment measures, the mortality rate is reported as being between 25 and 75%. There are conflicting reports as to the importance of a conservative therapy approach, although such an approach is the central to treatment guidelines of the World Society of Abdominal Compartment Syndrome, Decompressive laparotomy, although a backup solution in ACS therapy, reduces mortality by 16-37%. The open abdomen management has several variants, but negative pressure wound therapy represents the gold standard of surgical treatment.

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Transplant Critical Care: Is There A Need for Sub-specialized Units? — A Perspective

Sujit Vijay Sakpal1,2,3, Suresh Kumar Agarwal4, Hector Saucedo-Crespo1,2, Christopher Auvenshine1,2, Robert N. Santella1,3, Steven Donahue2, Jeffery Steers1

1 Avera McKennan Hospital & University Health Center: Avera Medical Group Transplant & Liver Surgery. Sioux Falls, South Dakota, USA
2 Department of Surgery, University of South Dakota. Sioux Falls, South Dakota, USA
3 Department of Internal Medicine, University of South Dakota. Sioux Falls, South Dakota, USA
4 Division of Acute Care, Trauma, Surgical Critical Care. Department of Surgery. Duke University. Durham, North Carolina, USA

DOI: 10.2478/jccm-2018-0014

The critical care involved in solid-organ transplantation (SOT) is complex. Pre-, intra- and post-transplant care can significantly impact both – patients’ ability to undergo SOT and their peri-operative morbidity and mortality. Much of the care necessary for medical optimization of end-stage organ failure (ESOF) patients to qualify and then successfully undergo SOT, and the management of peri-operative and/or long-term complications thereafter occurs in an intensive care unit (ICU) setting. The current literature specific to critical care in abdominal SOT patients was reviewed. This paper provides a contemporary perspective on the potential multifactorial advantages of sub-specialized transplant critical care units in providing efficient, comprehensive, and collaborative multidisciplinary care.

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Endotracheal Tube Biofilm and its Impact on the Pathogenesis of Ventilator-Associated Pneumonia

Olguța Diaconu1, Ianis Siriopol1, Laura Iulia Poloșanu2, Ioana Grigoraș1,3

1 Anesthesia and Intensive Care Department, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
2 Microbiology Department, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
3 Anesthesia and Intensive Care Department, Regional Institute of Oncology, Iași, Romania

DOI: 10.2478/jccm-2018-0011

Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection in mechanically ventilated patients and results in high mortality, prolonged intensive care unit- (ICU) and hospital-length of stay and increased costs. In order to reduce its incidence, it is imperative to better understand the involved mechanisms and to identify the source of infection. The role of the endotracheal tube (ET) in VAP pathogenesis became more prominent over the last decades, along with extensive research dedicated to medical device-related infections and biofilms. ET biofilm formation is an early and constant process in intubated patients. New data regarding its temporal dynamics, composition, germ identification and consequences enhance knowledge about VAP occurrence, microbiology, treatment response and recurrence.
This paper presents a structured analysis of the medical literature to date, in order to outline the role of ET biofilm in VAP pathogenesis and to review recommended methods to identify ET biofilm microorganisms and to prevent or decrease VAP incidence.

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Perioperative Stress-Induced (Takotsubo) Cardiomyopathy in Liver Transplant Recipients

Alexander A. Vitin1, Leonard Azamfirei2, Dana Tomescu3

1 Department of Anesthesiology & Pain Medicine, Department of Surgery, Transplant Surgery Division, University of Washington Medical Center, Seattle WA, USA
2 Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy Tîrgu Mureș, Romania
3 Anesthesiology and Intensive Care Department, “Carol Davila “University of Medicine and Pharmacy, Fundeni Clinical Institute, Bucharest, Romania

DOI: 10.2478/jccm-2018-0006

A comprehensive analysis of published cases of Takotsubo cardiomyopathy, occurred in liver transplant recipients in the perioperative period, has been attempted in this review. Predisposing factors, precipitating events, potential physiological mechanisms, acute and post-event management have been discussed.

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Use of Transcranial Doppler in Intensive Care Unit

Sandor Viski1, Laszlo Olah2

1 Department of Family and Occupational Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
2 Department of Neurology, University of Debrecen, Móricz Zs. krt. 22, H-4032 Debrecen, Hungary

DOI: 10.1515/jccm-2017-0021

Use of transcranial Doppler has undergone much development since its introduction in 1982, making the technique suitable for general use in intensive care units. The main application in intensive care units is to assess intracranial pressure, confirm the lack of cerebral circulation in brain death, detect vasospasm in subarachnoid haemorrhage, and monitor the blood flow parameters during thrombolysis and carotid endarterectomy, as well as measuring stenosis of the main intracranial arteries in sickle cell disease in children.
This review summarises the use of transcranial Doppler in intensive care units.

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The Importance of Haemogram Parameters in the Diagnosis and Prognosis of Septic Patients

Alina Elena Orfanu1,2, Cristina Popescu1,2, Anca Leuștean1, Anca Ruxandra Negru1,2, Cătălin Tilişcan1,2, Victoria Aramă1,2, Ștefan Sorin Aramă1,2

1 National Institute for Infectious Diseases “Prof. Dr Matei Balș”, Dr Calistrat Grozovici Street, no 1, 021105, Bucharest, Romania
2 University of Medicine and Pharmacy “Carol Davila”, Dionisie Lupu Street, no 37, 020021, Bucharest, Romania

DOI: 10.1515/jccm-2017-0019

Sepsis represents a severe pathology that requires both rapid and precise positive and differential diagnosis to identify patients who need immediate antimicrobial therapy. Monitoring septic patients’ outcome leads to prolonged hospitalisation and antibacterial therapy, often accompanied by substantial side effects, complications and a high mortality risk.
Septic patients present with complex pathophysiological and immunological disorders and with a predominance of pro-inflammatory or anti-inflammatory mediators which are heterogeneous with respect to the infectious focus, the aetiology of sepsis or patients’ immune status or comorbidities. Previous studies performed have analysed inflammatory biomarkers, but a test or combinations of tests that can quickly and precisely establish a diagnosis or prognosis of septic patients has yet to be discovered. Recent research has focused on re-analysing older accessible parameters found in the complete blood count to determine the sensitivity, specificity, positive and negative predictive values for the diagnosis and prognosis of sepsis.
The neutrophil/lymphocyte count ratio (NLCR), mean platelet volume (MPV) and red blood cells distribution width (RDW) are haemogram indicators which have been evaluated and which are of proven use in septic patients’ management.

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