Category Archives: Review

Extracorporeal Life Support and New Therapeutic Strategies for Cardiac Arrest Caused by Acute Myocardial Infarction – a Critical Approach for a Critical Condition

Theodora Benedek1*, Monica Marton Popovici2, Dietmar Glogar3

1 University of Medicine and Pharmacy Tirgu Mures, Romania, Clinic of Cardiology
2 Swedish Medical Center, Department of Internal Medicine and Critical Care, Edmonds, Washington, USA
3 Medical University of Vienna, Austria

DOI: 10.1515/jccm-2016-0025

This review summarizes the most recent developments in providing advanced supportive measures for cardiopulmonary resuscitation, and the results obtained using these new therapies in patients with cardiac arrest caused by acute myocardial infarction (AMI). Also detailed are new approaches such as extracorporeal cardiopulmonary resuscitation (ECPR), intra-arrest percutaneous coronary intervention, or the regional models for systems of care aiming to reduce the critical times from cardiac arrest to initiation of ECPR and coronary revascularization.

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Sepsis-Associated Coagulopathy

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-2016-0024

Systemic inflammatory activation in sepsis often leads to coagulation activation, but the relationship is bilateral, as coagulation also modulates the inflammatory response. This close associate has significant consequences for the pathogenesis of microvascular thrombosis and organ dysfunction in sepsis. While coagulation activation can be beneficial for immune defense, it can also be detrimental once it becomes widespread and uncontrolled. The knowledge of the pathophysiologic mechanisms involved in the interaction between infection and coagulation may lead to the better timing for the administration of targeted antithrombotic therapies in septic patients. This brief review highlights the pathophysiologic pathways leading to the prothrombotic state in sepsis and the mechanisms that play a role in the interaction between infection and coagulation.

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The Diagnosis and Hemodynamic Monitoring of Circulatory Shock: Current and Future Trends

Adham Hendy1,2*, Şerban-Ion Bubenek-Turconi1,2

1 Ph.D Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
2 1st Department of Cardiovascular Anesthesia and Intensive Care, “C.C.Iliescu” Emergency Institute for Cardiovascular Diseases, Bucharest, Romania

DOI: 10.1515/jccm-2016-0018

Circulatory shock is a complex clinical syndrome encompassing a group of conditions that can arise from different etiologies and presented by several different hemodynamic patterns. If not corrected, cell dysfunction, irreversible multiple organ insufficiency, and death may occur.  The four basic types of shock, hypovolemic, cardiogenic, obstructive and distributive, have features similar to that of hemodynamic shock.  It is therefore essential, when monitoring hemodynamic shock, to making accurate clinical assessments which will guide and dictate appropriate management therapy.
The European Society of Intensive Care has recently made recommendations for monitoring hemodynamic shock. The present paper discusses the issues raised in the new statements, including individualization of blood pressure targets, prediction of fluid responsiveness, and the use of echocardiography as the first means during the initial evaluation of circulatory shock.  Also, the place of more invasive hemodynamic monitoring techniques and future trends in hemodynamic and metabolic monitoring in circulatory shock, will be debated.

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Anemia in Intensive Care: A review of Current Concepts

Gautam Rawal1*, Raj Kumar1, Sankalp Yadav2, Amrita Singh3

1 Respiratory Intensive Care, Max Super Specialty Hospital, Saket, New Delhi, India
2 Department of Medicine & TB, Chest Clinic Moti Nagar, North Delhi Municipal Corporation, New Delhi, India
3 Gen-X Diagnostics, Madhu Vihar, New Delhi, India

DOI: 10.1515/jccm-2016-0017

Anemia in patients admitted to an intensive care unit is common and affects almost all critically ill patients. The intensivist is faced with the challenge of treating multifactorial etiologies, mainly bleeding and blood loss due to phlebotomy and decreased erythropoiesis. Red cell transfusion, the most common treatment for anemia, comes with associated risks, which may further reduce the chance of survival of these patients. The best evidence suggests the practice of restrictive RBC transfusion (transfusion at Hb<7 g/dl).
In this article, the etiopathogenesis of the anemia in critically ill is reviewed, and current opinion on the pros and cons of various management strategies are discussed with emphasize on restrictive transfusion policy.

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Much Ado About the New Definitions of Sepsis

Sanda-Maria Copotoiu1*, Ruxandra Copotoiu2

1 University of Medicine and Pharmacy of Tirgu Mures, Romania, Clinic of Anesthesia and Intensive Care Emergency County Hospital of Tîrgu Mures, Gheorghe Marinescu street no 38, Tirgu Mures, Romania
2 Les Hôpitaux Universitaires de Strasbourg, Pôle d’anesthésie – réanimations chirurgicales – SAMU – SMUR, Service d’anesthésiologie, Hôpital Civil

DOI: 10.1515/jccm-2016-0015

Following the publication of the new definition of sepsis (Sepsis-3), a plethora of articles have been published in medical journals. Recognizing the epidemiological importance of the previous definitions, first issued in 1992 (Sepsis-1), and subsequently revised in 2001 (Sepsis-2), the most recent opinion emphasizes the failure “to provide adequate groups of patients with homogenous aetiologies, presentations and outcomes”, and blamed one of the causes “for the failure of several randomized controlled trials (RCTs), that tested the efficacy of adjuvant sepsis therapies”. This review summarizes the recent advances in sepsis definition.

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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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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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Oxidative Stress and Antioxidant Therapy in Critically Ill Polytrauma Patients with Severe Head Injury

Loredana Luca1, Alexandru Florin Rogobete1,2,3, Ovidiu Horea Bedreag1,2

1 Clinic of Anaesthesia and Intensive Care, Emergency County Hospital ”Pius Brînzeu”, Timișoara, Romania
2 Faculty of Medicine, ”Victor Babeș” University of Medicine and Pharmacy, Timișoara, Romania
3 Faculty of Chemistry, Biology, Geography, West University of Timișoara, Timișoara, Romania

DOI: 10.1515/jccm-2015-0014

Traumatic Brain Injury (TBI) is one of the leading causes of death among critically ill patients from the Intensive Care Units (ICU). After primary traumatic injuries, secondary complications occur, which are responsible for the progressive degradation of the clinical status in this type of patients. These include severe inflammation, biochemical and physiological imbalances and disruption of the cellular functionality. The redox cellular potential is determined by the oxidant/antioxidant ratio. Redox potential is disturbed in case of TBI leading to oxidative stress (OS). A series of agression factors that accumulate after primary traumatic injuries lead to secondary lesions represented by brain ischemia and hypoxia, inflammatory and metabolic factors, coagulopathy, microvascular damage, neurotransmitter accumulation, blood-brain barrier disruption, excitotoxic damage, blood-spinal cord barrier damage, and mitochondrial dysfunctions. A cascade of pathophysiological events lead to accelerated production of free radicals (FR) that further sustain the OS. To minimize the OS and restore normal oxidant/antioxidant ratio, a series of antioxidant substances is recommended to be administrated (vitamin C, vitamin E, resveratrol, N-acetylcysteine). In this paper we present the biochemical and pathophysiological mechanism of action of FR in patients with TBI and the antioxidant therapy available.

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Differential Diagnosis and Management Issues of Idiopathic Angiooedema and their Resolution

Andrea Zanichelli, Marta Mansi,  Maddalena A. Wu, Giulia Azin, Marco Cicardi

Department of Biomedical and Clinical Sciences “L. Sacco” University of Milan and Ospedale L. Sacco Milan, Italy

DOI: 10.1515/jccm-2015-0008

Angiooedema is a local and self-limiting swelling of the subcutaneous and sub mucosal tissues, produced by vasoactive peptides that temporary increase the vascular permeability.
It is recognized that recurrent angiooedema exposes patients to the risk of fatalities and reduced quality of life, being in some circumstances associated with a critical condition.
Angiooedema can occur with or without wheals. The first symptom is urticaria, the second is a distinct nosologic entity. In absence of an identifiable cause, recurrent angiooedema without wheals can be defined as idiopathic and marked“idiopathic histaminergic angiooedema” when it is responsive to anti histamine treatment, and “idiopathic non-histaminergic angiooedema” when it is not. Furthermore, idiopathic non-histaminergic angiooedema can be diagnosed as hereditary or sporadic by family history.
In this review, we summarize the approaches to diagnose and treat different forms of idiopathic angiooedema.

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