Category Archives: JCCM 2018

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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Ibuprofen, a Potential Cause of Acute Hemorrhagic Gastritis in Children – A Case Report

Maria Oana Mărginean1,2, Lorena Elena Meliț1,2, Simona Mocanu3, Vlăduț Săsăran2

1 Paediatrics Clinic 1, Târgu Mureș, Romania
2 University of Medicine, Pharmacy, Sciences and Technology of Târgu Mureş, Romania
3 Pathology Department County Clinic Hospital, Târgu Mureș, Romania

DOI: 10.2478/jccm-2018-0022

Introduction: Upper gastrointestinal bleeding is an uncommon but possible life-threatening entity in children, frequently caused by erosive gastritis. Non-steroidal anti-inflammatory drugs are one of the most common class of drugs which can cause gastrointestinal complications, including hemorrhagic gastritis.
Case report: The case of a 6-year-old male, admitted for hematemesis, abdominal pain and loss of appetite. It was ascertained at the time of admission, that ibuprofen had been prescribed as the patient had a fever. This was inappropriately administered as the mother did not respect the intervals between the doses.
Initial laboratory tests revealed neutrophilia, leukopenia, high levels of lactate dehydrogenase and urea. An upper digestive endoscopy revealed an increased friability of the mucosa, digested blood in the gastric corpus and fornix. No active bleeding site was detected. The histopathological examination described a reactive modification of the corporeal gastric mucosa. Intravenous treatment with proton pump inhibitors and fluid replacement were initiated, with favorable results.
Conclusion: Ibuprofen can lead to upper digestive hemorrhage independently of the administered dose. Parents should avoid administering Ibuprofen for fever suppression without consulting their pediatrician.

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Diagnostic pitfalls in identification of Elizabethkingia meningoseptica

Gurmeet Ram Rahim1, Neha Gupta1, Gaurav Aggarwal2

1 Microbiology Department, Shah Satnam Ji Speciality Hospitals, Sirsa, Haryana, India
2 Department of Medicine, Shah Satnam Ji Speciality Hospitals, Sirsa, Haryana, India

DOI: 10.2478/jccm-2018-0021

To the Editor of JCCM,
Regarding the article “Emerging Infection with Elizabethkingia meningoseptica in Neonate. A Case Report” by Arbune et al. (2018) [1], there are specific facts which need clarification regarding the reporting of this organism.
First of all, Arbune reported the isolation of the organism from the cerebrospinal fluid (CSF) and blood culture of one case, and that no source of infection was identified. Elizabethkingia meningoseptica, although linked to meningitis and nosocomial infections, can be an environmental contaminant as well. Repeat cultures of the samples are mandatory for the confirmation of such unusual pathogens.[More]

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The Peer Review Process: Underwriting Manuscript Quality & Validity

Ario Santini1,2

1 University of Medicine and Pharmacy of Tîrgu Mureș, Romania
2 Hon Fellow, University of Edinburgh, United Kingdom

DOI: 10.2478/jccm-2018-0020

Evidence-based practice is the first step in underpinning and shaping how the profession delivers patient care. The Oxford Dictionary defines evidence as: ‘the available body of facts or information indicating whether a belief or proposition is true or valid’. The majority of evidence, though not all, is provided by research studies published in professional journals. Best evidence should be of high quality and is thus founded on the status of publishing journals and the process by which journals, editors and the editorial team separate out the “good” from both the “mediocre” and the “bad”.
This is undertaken by the process of Peer reviewing or refereeing; it is the practice of critically examining an author’s submitted research manuscript by experts in the same field before a paper is accepted for publishing in a journal. When well done, it confers a stamp of approval to the substance, authenticity, and value of articles and therefore is a crucial element, integral to scholarly research and the validation of published evidence. [More]

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Factors Associated with Mortality in Patients with a Solid Malignancy Admitted to the Intensive Care Unit – A Prospective Observational Study

Pascal Kingah, Nasser Alzubaidi, Jihane Zaza Dit Yafawi, Emad Shehada, Khaled Alshabani, Ayman O. Soubani

Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, 3990 John R, 3 Hudson, Detroit MI 48201, USA

DOI: 10.2478/jccm-2018-0019

Purpose: Several studies show conflicting results regarding the prognosis and predictors of the outcome of critically ill patients with a solid malignancy. This study aims to determine the outcome of critically ill patients, admitted to a hospital, with a solid malignancy and the factors associated with the outcomes.
Methods and Materials: All patients with a solid malignancy admitted to an intensive care unit (ICU) at a tertiary academic medical center were enrolled. Clinical data upon admission and during ICU stay were collected. Hospital, ICU, and six months outcomes were documented.
Results: There were 252 patients with a solid malignancy during the study period. Urogenital malignancies were the most common (26.3%) followed by lung cancer (23.5%). Acute respiratory failure was the most common ICU diagnosis (51.6%) followed by sepsis in 46%. ICU mortality and hospital mortality were 21.8% and 34.3%. Six months mortality was 38.4%. Using multivariate analysis, acute kidney injury, OR 2.82, 95% CI 1.50-5.32 and P=0.001, use of mechanical ventilation, OR 2.67 95% CI 1.37 – 5.19 and P=0.004 and performance status of ≥2 with OR of 3.05, 95% CI of 1.5- 6.2 and P= 0.002 were associated with hospital mortality. There were no differences in outcome between African American patients (53% of all patients) and other races.
Conclusion: This study reports encouraging survival rates in patients with a solid malignancy who are admitted to ICU. Patients with a poor baseline performance status require mechanical ventilation or develop acute renal failure have worse outcomes.

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Improving Clinical Performance of an Interprofessional Emergency Medical Team through a One-day Crisis Resource Management Training

Teodora Sorana Truța1, Cristian Marius Boeriu1, Marc Lazarovici2, Irina Ban3, Marius Petrișor1, Sanda-Maria Copotoiu1

1 University of Medicine and Pharmacy of Tîrgu Mureș, Street Gheorghe Marinescu 38, 540139 Tîrgu Mureș, Mureș, Romania
2 Institut für Notfallmedizin und Medizinmanagement – INM, Klinikum der Universität, Ludwig-Maximilians-Universität München, Schillestraße 53, 80336 München, Germany
3 Department of Medicine, University of Padova, Via V. Galluci, 13-35121, Padova, Italy

DOI: 10.2478/jccm-2018-0018

Introduction: Errors are frequent in health care and Emergency Departments are one of the riskiest areas due to frequent changes of team composition, complexity and variety of the cases and difficulties encountered in managing multiple patients. As the majority of clinical errors are the results of human factors and not technical in nature or due to the lack of knowledge, a training focused on these factors appears to be necessary. Crisis resource management (CRM), a tool that was developed initially by the aviation industry and then adopted by different medical specialties as anesthesia and emergency medicine, has been associated with decreased error rates.
The aim of the study: To assess whether a single day CRM training, combining didactic and simulation sessions, improves the clinical performance of an interprofessional emergency medical team.
Material and Methods: Seventy health professionals with different qualifications, working in an emergency department, were enrolled in the study. Twenty individual interprofessional teams were created. Each team was assessed before and after the training, through two in situ simulated exercises. The exercises were videotaped and were evaluated by two assessors who were blinded as to whether it was the initial or the final exercise. Objective measurement of clinical team performance was performed using a checklist that was designed for each scenario and included essential assessment items for the diagnosis and treatment of a critical patient, with the focus on key actions and decisions. The intervention consisted of a one-day training, combining didactic and simulation sessions, followed by instructor facilitated debriefing. All participants went through this training after the initial assessment exercises.
Results: An improvement was seen in most of the measured clinical parameters.
Conclusion: Our study supports the use of combined CRM training for improving the clinical performance of an interprofessional emergency team. Empirically this may improve the patient outcome.

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Online Information about Stroke – A Soft Challenge for Critical Care Professionals

Septimiu-Daniel Popescu1, Mihaela Dănilă2, Valentin Nădășan3

1 Department of Radiology and Imaging, Emergency County Hospital Tîrgu Mureș, Romania
2 Cardiovascular and Transplant Emergency Institute Tîrgu Mureş, Romania
3 University of Medicine and Pharmacy, Tîrgu Mureș, Romania

DOI: 10.2478/jccm-2018-0017

According to “The Burden of Stroke in Europe” report, Romania had, in 2015, the highest incidence and highest mortality due to stroke per 100,000 inhabitants [1]. Moreover, the Central and Eastern European Stroke Society Working group reported that, in 2015, in Romania, only about 1% of stroke patients had access to stroke units [2].
Critical care professionals are familiar with the phrase “time is brain” and are well aware that even a couple of minutes delay in delivering thrombolytic intravenous treatment or endovascular thrombectomy can have an enormous impact on patients’ survival rates and the length of disability-free life [3,4]. [More]

 

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