Category Archives: JCCM 2016, Vol. 2, Issue 3

Nosocomial Staphylococcal Toxic Shock. Case Report

Manuela Arbune1,2*, Loredana Tercu2

1 “Dunarea de Jos” University Galati, Romania
2 Hospital of Infectious Diseases “Sf. Cuvioasa Parascheva” Galaţi, Romania

DOI: 10.1515/jccm-2016-0020

Staphylococcal toxic shock syndrome (STSS) is a rare, potentially lethal infection, with a clinical picture of multiple organ dysfunction and shock. The etiology is Staphylococcus aureus exotoxin, while enterotoxins act as superantigens. Most cases are identified in women using a vaginal tampon.  A 51-year-old female, with a past medical history of biliary dyskinesia, presented in the emergency room complaining of sudden onset of abdominal pain, vomiting, headache, myalgia, and chills. The initial diagnosis was biliary colic and was treated parenterally with Amoxi-clavulanate and fluid replacement. Initially, progress was unsatisfactory. Four days after admission she developed a systemic inflammatory syndrome, diffuse rash, jaundice, oliguria, confusion, persistent hypotension and biological evidence of thrombocytopenia, nitrogen retention, and cholestasis. She was admitted to the intensive care unit. A gluteal phlegmon induced after intramuscular injections was identified and surgically treated. Blood bacteriological cultures were negative, though MRSA was isolated in phlegmon pus. A diagnosis of STSS was based on CDC criteria.
The risks of similar infections could be prevented by limiting intramuscular treatments and monitoring invasive procedures.

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Malignant Middle Cerebral Artery Infarction Secondary to Traumatic Bilateral Internal Carotid Artery Dissection. A Case Report

Zoltán Bajkó1, Rodica Bălaşa1, Anca Moţăţăianu1*, Laura Bărcuţean1, Adina Stoian2, Nicoleta Stirbu3, Smaranda Maier1

1 University of Medicine and Pharmacy Târgu Mureş, Department of Neurology
2 University of Medicine and Pharmacy Târgu Mureş, Department of Pathophysiology
3 Mediab Medical Center Târgu Mureş

DOI: 10.1515/jccm-2016-0021

Traumatic bilateral dissection of the carotid arteries is a rare condition with potentially life-threatening complications. The case of a 57-year-old male patient with acute onset left sided hemiparesis, twelve hours after a blunt head injury, caused by a horse kick, is reported. A cerebral CT scan revealed right middle cerebral artery (MCA) territory infarction. Based on Duplex ultrasound and Angio CT scan findings, a diagnosis of bilateral ICA dissection was established. Despite antithrombotic treatment, the patient presented with a progressive worsening of his neurological status. The control CT scan evidenced malignant right MCA territory infarction that required decompressive craniotomy. The patient was discharged with significant neurological deficits. Together with this case, the aetiologies, clinical manifestations, diagnostic and therapeutical options and outcome of carotid artery dissection are discussed.

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The Placement of Post-pyloric Feeding Tubes Using DRX-Revolution Mobile X-Ray System in an ICU. A Case Series

Leonid Koyfman1, Andrei Schwartz1, Yair Benjamin1, Alexander Smolikov2, Moti Klein1, Evgeni Brotfain1*

1 Department of Anesthesiology and Critical Care, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
2 Department of Radiology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel

DOI: 10.1515/jccm-2016-0022

Enteral nutrition is crucial for ensuring that critically ill patients have a proper intake of food, water, and medicine. Methods to ensure this requirement should be initiated as early as possible. The use of PPF has several advantages compared to the use of a nasogastric feeding tube. In the present paper, the cases of three critically ill patients with a nonfunctional gastrointestinal system on admission to ICU, are detailed. Enteral feeding through a nasogastric tube by prokinetic agent therapy had been unsuccessful. The bedside placement of a post-pyloric feeding tube by the DRX-Revolution X-ray system is described.

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Can APACHE II, SOFA, ISS, and RTS Severity Scores be Used to Predict Septic Complications in Multiple Trauma Patients?

Sebastian Trancă1, Cristina Petrișor1, Natalia Hagău1, Constantin Ciuce2

1 Department of Anaesthesia and Intensive Care II, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania
2 Surgical Department I, “Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania

DOI: 10.1515/jccm-2016-0019

Background: Physiological composite scores are used to predict mortality in multiple trauma patients. Sepsis is the leading cause of late mortality in trauma victims brought about by immune suppression due to homeostasis dysregulation.
Objective: To determine whether APACHE II, SOFA, ISS and RTS scores can predict the occurrence of sepsis in multiple trauma patients.
Methods: APACHE II, SOFA, ISS, and RTS scores were calculated during the first twenty-four hours after the injury for sixty-four adult poly-traumatic patients. The occurrence of infectious complications was investigated over a fourteen-day period. The infection-free rates for the multiple trauma patients were considered as end-points in the Kaplan-Meier plot analysis.
Results: For SOFA, a cutoff score of 4 points was identified as a predictor of the occurrence of sepsis, with 89% of the patients with SOFA<4 being infection-free, while 37% of those with SOFA>4 were infection-free (p<0.01). None of the patients with APACHE II≤5 points developed infections. Eighty-four percent of patients with APACHE II scores of 5-10 did not develop sepsis, while 49% with APACHE II≥11 were infection-free (p<0.01).  A cutoff of 7 points was found to be most discriminative for RTS. Eighty-eight percent of the patients with RTS≥7 and 43% of those with RTS<7 were infection-free (p<0.01). Eighty-eight percent of patients with ISS<22 did not develop sepsis and 56% with ISS≥22 did not develop sepsis (p<0.01).
Conclusion: APACHE II, SOFA, ISS, and RTS functional severity scores can predict mortality as well as the occurrence of sepsis in multiple trauma patients.

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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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Have Severity Scores a Place in Predicting Septic Complications in ICU Multiple Trauma Patients?

Daniela Ionescu

Department of Anesthesia and Intensive Care I, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania; Outcome Research Consortium, Cleveland, USA

DOI: 10.1515/jccm-2016-0023

Risk assessment in ICU critically-ill patients is of tremendous importance for optimizing patients’ clinical management, medical and human resource allocation and supporting medical cost distribution and containment.
The problem of predicting complications and mortality in ICU patients, although not new, is of genuine concern and much effort has been made to detect the most reliable parameters and scores. Numerous attempts have been made to use clinical and laboratory findings integrated into different algorithms or to incorporate these parameters into easy to use composite severity scores which would be applicable in various centers. In addition to clinical data, biomarkers or laboratory findings have been used for this purpose [1-3].
The SOFA, SAPS and APACHE scores and their newer versions, have been used worldwide to evaluate patients’ severity, prognosis, and survival [4-7]. However, it has been reported that there are differences in their performance and estimation probability, in different geographical areas [8]. [More]

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