Category Archives: Review

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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Perioperative Management of Lactic Acidosis in End-Stage Liver Disease Patient

Alexander A. Vitin1, Leonard Azamfirei2, Dana Tomescu3, John D. Lang1

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

DOI: 10.1515/jccm-2017-0014

Lactic acidosis (LA) in end-stage liver disease (ESLD) patients has been recognized as one of the most complicated clinical problems and is associated with increased morbidity and mortality. Multiple-organ failure, associated with advanced stages of cirrhosis, exacerbates dysfunction of numerous parts of lactate metabolism cycle, which manifests as increased lactate production and impaired clearance, leading to severe LA-induced acidemia. These problems become especially prominent in ESLD patients, that undergo partial hepatectomy and, particularly, liver transplantation. Perioperative management of LA and associated severe acidemia is an inseparable part of anesthesia, post-operative and critical care for this category of patients, presenting a wide variety of challenges. In this review, lactic acidosis applied pathophysiology, clinical implications for ESLD patients, diagnosis, role of intraoperative factors, such as anesthesia- and surgery-related, vasoactive agents impact, and also current treatment options and modalities have been discussed.

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Anticoagulant Therapy in Sepsis. The Importance of Timing

Ecaterina Scarlatescu1, Dana Tomescu1,2, Sorin Stefan Arama2

1 Department of Anesthesiology and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania
2 University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania

DOI: 10.1515/jccm-2017-0011

Sepsis associated coagulopathy is due to the inflammation-induced activation of coagulation pathways concomitant with dysfunction of anticoagulant and fibrinolytic systems, leading to different degrees of haemostasis dysregulation. This response is initially beneficial, contributing to antimicrobial defence, but when control is lost coagulation activation leads to widespread microvascular thrombosis and subsequent organ failure. Large clinical trials of sepsis-related anticoagulant therapies failed to show survival benefits, but posthoc analysis of databases and several smaller studies showed beneficial effects of anticoagulants in subgroups of patients with early sepsis-induced disseminated intravascular coagulation. A reasonable explanation could be the difference in timing of anticoagulant therapy and patient heterogeneity associated with large trials. Proper selection of patients and adequate timing are required for treatment to be successful. The time when coagulation activation changes from advantageous to detrimental represents the right moment for the administration of coagulation-targeted therapy. In this way, the defence function of the haemostatic system is preserved, and the harmful effects of overwhelming coagulation activation are avoided.

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The Relevance of Coding Gene Polymorphysms of Cytokines and Cellular Receptors in Sepsis

Anca Meda Georgescu1, Bianca Liana Grigorescu2, Ioana Raluca Chirteș1, Alexander A. Vitin3, Raluca Ștefania Fodor4

1 Infectious Diseases Clinic, University of Medicine and Pharmacy Tirgu Mures, Romania
2 Discipline of Pathophysiology, University of Medicine and Pharmacy Tirgu Mures, Romania
3 University of Washington, Medical Center, Seattle, USA
4 Anesthesiology and Intensive Care Clinic, University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/jccm-2017-0001

Sepsis is an injurious systemic host response to infection, which can often lead to septic shock and death. Recently, the immune-pathogenesis and genomics of sepsis have become a research topic focusing on the establishment of diagnostic and prognostic biomarkers. As yet, none have been identified as having the necessary specificity to be used independently of other factors in this respect. However the accumulation of current evidence regarding genetic variations, especially the single nucleotide polymorphisms (SNPs) of cytokines and other innate immunity determinants, partially explains the susceptibility and individual differences of patients with regard to the evolution of sepsis. This article outlines the role of genetic variation of some serum proteins which have the potential to be used as biomarker values in evaluating sepsis susceptibility and the progression of the condition.

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