Category Archives: JCCM 2015, Vol. 1, Issue 2

Fading Sugammadex, or Just Cautiously (re) Considered?!

Sanda-Maria Copotoiu

University of Medicine and Pharmacy of Tirgu Mures, 38 Gheorghe Marinescu street, Tirgu Mures, 540139, Romania

DOI: 10.1515/jccm-2015-0012

Sugammadex, a synthetic cyclodextrin sodium salt, was heralded and initially marketed as the first selective relaxant binding agent (SRBA) designed to reverse rocuronium [1]. This chemically modified cyclodextrin basically swallowed rocuronium removing it from the effector site, which was a “paradigm shift” from the then current methodology [2]. Following the launch of rocuronium and the rapidly spreading practice of intubation on rocuronium in rapid sequence instead of succinylcholine, a need to reverse muscle relaxation in case of intubation failure emerged. Moreover, the well-known undesirables side effects of cholinesterase inhibitors needing blunting by coadministration of muscarinic antagonists enlarged the odds of experiencing unwanted extra drug effects [3]. Further studies supported the use of sugammadex to reverse a life-threatening situation defined as “cannot intubate, cannot ventilate” [4]. It was a genuine revolutionary approach [5].Thus sugammadex appeared as a rescue drug. It was then used as the best, the most rapid and the safest if not the single solution to reverse curarization, although controversies as to the standard ofrapid sequence induction and intubation[6] are going on [7]. The odds were favorable and still are if it were not for certain voices to say “nay” to sugammadex as a routine drug based mainly on cost related issues. [More]

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Is therapeutic hypotermia viable in our region as a new option for sudden cardiac arrest caused by acute myocardial infarction?

Bărcan Andreea, Rat Nora, Orzan Marius

University of Medicine and Pharmacy of Tirgu Mures, Clinic of Cardiology, Tirgu Mures, Gheorghe Marinescu street no. 540139, Romania

DOI: 10.1515/jccm-2015-0011

To the editor of JCCM
Therapeutic hypothermia has become a widely accepted option for management of patients with cardiac arrest occurring in the setting of an Acute Myocardial Infarction [1]. Infarct size is one of the major determinants of future evolution of patients with myocardial infarction and every attempt should be made in order to reduce the amount of infarcted, necrotic myocardium. It has been suggested that induction of hypothermia before performing a percutaneous coronary intervention for urgent revascularisation might play a decisive role in reduction of infarct size [1]. In the same time, applying a mild cooling protocol in patients surviving an out-of-hospital cardiac arrest might significantly improve the rates of neurologically intact survivals on long term [2].
It has been proved that via application of therapeutic hypothermia protocols, a 7% reduction in cerebral metabolism can be achieved per each 1oC of hypothermia, that would further lead to a decrease consumption of glucose and oxygen and prevention of neuronal injury [2]. All these are strongly correlated with the evolution of the neurological status in the post-resuscitation period. [More]

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Residual Curarization and Postoperative Respiratory Complications Following Laparoscopic Sleeve Gastrectomy. The Effect of Reversal Agents: Sugammadex vs. Neostigmine

Tiberiu Ezri1,4, Shmuel Evron1,4, Irina Petrov1, Pinhas Schechter2, Yitzhak Berlovich3, Mordechai Shimonov2

The Departments of Anesthesia1, Surgery2 and Management3, The Edith Wolfson Medical Center, Holon, Israel and Outcomes Research Consortium,4 Holon, Israel

DOI: 10.1515/jccm-2015-0009

Background: Incomplete muscle relaxant reversal or re-curarization may be associated with postoperative respiratory complications. In this retrospective study we compared the incidence of postoperative residual curarization and respiratory complications in association with the type of muscle relaxant reversal agent, sugammadex or neostigmine, in patients undergoing laparoscopic sleeve gastrectomy.
Material and methods: We reviewed the charts of all patients (179) undergoing laparoscopic sleeve gastrectomy from July 2012 to July 2013 at Wolfson Medical Center. Sugammadex 1.5-2 mg/kg (112 patients) or neostigmine 2.5 mg (67 patients) were used as reversal agents. Results were compared by the type of reversal agent employed. Compared parameters included demographic and anaesthetic data, residual curarization, oxyhemoglobin saturation (SpO2) in the recovery room (PACU), episodes of SpO2 lower than 90% in PACU, unexpected intensive care (ICU) admissions, incidence of atelectasis and pneumonia, re-intubation and duration of hospitalization.
Results: Obstructive sleep apnea syndrome (OSAS) was more frequent in the sugammadex group (19% vs. 8%; p = 0.026). Total intravenous anesthesia (TIVA) was more frequently associated with sugammadex (33% vs. 16%; p = 0.007). There were no differences in postoperative residual curarization, SpO2 < 90% episodes, reintubation, ICU admissions, pulmonary complications and duration of hospitalization.
Conclusion: With the inherent limitations of a retrospective study, the use of sugammadex following laparoscopic sleeve gastrectomy showed no advantage over neostigmine in terms of residual curarization and respiratory complications.

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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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Statins as Pleiotropic Modifiers of Vascular Oxidative Stress and Inflammation

Costas Psarros1, Evangelos K. Economou1, Michael Koutsilieris1, Charalambos Antoniades2*

1 Department of Experimental Physiology, Medical School, National and Kapodistrian University of Athens, Greece
2 Radcliffe Department of Medicine, Cardiovascular Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom.

DOI: 10.1515/jccm-2015-0007

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the industrialized world and in the future is expected to be the number one killer worldwide. The main cause underlying CVD is atherosclerosis. A key event in atherosclerosis initiation and progression is oxidative stress through the production of reactive oxygen species as well as endothelial dysfunction. Several pro- inflammatory and anti-inflammatory cytokines and proteins are involved in this process, complemented by activation of adhesion molecules that promote leukocyte rolling, tethering and infiltration into the sub-endothelial space. Statins represent the agent of choice since numerous clinical trials have verified that their pharmacological action extends beyond lipid lowering. Statins demonstrate direct anti-oxidant effects by scavenging free radicals and stimulating anti-oxidant enzymes while acting as regulators for cytokine, protein and adhesion molecule expression, all of which are involved in the atherosclerotic process. Statin use is considered one of the most efficient currently used interventions in managing CVD with the likely hood of remaining so in the near future.

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Acute Ischaemic Stroke Secondary to a Mobile Thrombus in the Common Carotid artery – Case Report

Zoltán Bajkó1,2, Smaranda Maier1,2, Silvia Rusu2, Anca Moțățăianu1,2

1 University of Medicine and Pharmacy Târgu Mureș, Department of Neurology, Gheorghe Marinescu street 38, 540139 Târgu Mureș, Romania
2 Mureș County Clinical Emergency Hospital Târgu Mureș, Neurology Clinic I, Gheorghe Marinescu street 50, 540136, Târgu Mureș, Romania

DOI: 10.1515/jccm-2015-0010

A mobile thrombus in the carotid arteries is a very rare ultrasonographic finding and is usually diagnosed after a neurological emergency, such as a transient ischemic attack or cerebral infarction. We present the case of a 54-year-old man with vascular risk factors (a heavy smoker, untreated hypertension) who was admitted to the emergency unit with right sided hemiparesis and aphasia. A cerebral CT scan showed a left middle cerebral artery territory infarction. The duplex ultrasound examination revealed mild atherosclerotic changes in the right common and internal carotid arteries, right-sided complete subclavian steal phenomenon and a complicated hypoechoic atherosclerotic plaque in the left common carotid artery with a large mobile thrombus.  Due to the high embolization risk, the patient was hospitalised and prescribed Aspirin together with low molecular weight Heparin. We recorded an improvement in the patient’s neurological status and the control duplex scan revealed disappearance of the thrombus. The presence of floating thrombus in a patient with clinical and imagistic evidence of stroke is a major therapheutic challenge for the neurologist. The treatment strategies are not standardized and must be individualized, however in our case parenteral anticoagulation proved to be successful.

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