Category Archives: JCCM 2020

Spontaneous Sublingual Haematoma in a 90-year Old Patient: A Complication of Direct Oral Anticoagulants

Johannes Daniël Cnossen, Jeannette Fenna Schoonderbeek, Maaike Muller

Ikazia Hospital Rotterdam, The Netherlands

DOI: 10.2478/jccm-2020-0010

Sublingual haematoma is a rare complication of anticoagulants and can be life-threatening. As the number of prescribed anticoagulants is increasing, the incidence of complications of these drugs will continue to increase. A report of a sublingual haematoma in an elderly patient with chronic atrial fibrillation treated with edoxban (Lixiana ©, Daiichi Sankyo Europe GmbH, München, Germany) is reported. A 90-year male presented at the emergency department with an obstructed upper airway due to a sublingual haematoma. The patient received tranexamic acid, prothrombin complex, and fresh frozen plasma. After fiberoptic nasal intubation, the patient was monitored in the intensive care unit. After four days, the patient was extubated, and after six days, the swelling resolved completely. Complications of anticoagulants are rare but can be life-threatening. Recognition of an endangered airway and reversing the effects of the anticoagulant are essential. Surgical evacuation of the haematoma could be considered but is not necessary.

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To Be or Not to Be… Sepsis? A Daily Challenge in ICU

Adrian Man1, Bianca Liana Grigorescu2

1 Department of Microbiology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, Romania
2 Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2020-0012

Nowadays, one of the most challenging medical issues is related to high morbidity and mortality in sepsis and septic shock. Despite the medical progress regarding early diagnosis and management, this complex pathology remains a life-threatening condition. During the last decades, many definitions and including criteria were developed both in sepsis and septic shock, principally as many early biomarkers became available. However, many issues still exist regarding this subject.
The clinical definitions of sepsis and systemic inflammatory response syndrome (SIRS) have been refined, but both conditions manifest with similar clinical features [1]. The Third International Consensus Definitions Task Force (Sepsis-3) defined sepsis as “a life-threatening organ dysfunction resulting from a dysregulated host response to infection”. Septic shock is “a subset of sepsis in which circulatory, cellular and metabolic alterations are associated with a higher mortality rate than sepsis alone” [2] morphology, cell biology, biochemistry, immunology, and circulation. These definitions are related to the pathophysiology of sepsis, which are the cornerstones of a better understanding of the underlying mechanisms and disorders that occur [3]. [More]

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Impact of Intravenous Fluids and Enteral Nutrition on the Severity of Gastrointestinal Dysfunction: A Systematic Review and Meta-analysis

Varsha M. Asrani1,2, Annabelle Brown3, Ian Bissett1,4, John A. Windsor1,4

1 Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
2 Department of Nutrition and Dietetics, Auckland City Hospital, Auckland, New Zealand
3 Discipline of Nutrition and Dietetics, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
4 Department of General Surgery, Auckland City Hospital, Auckland, New Zealand

DOI: 10.2478/jccm-2020-0009

Introduction: Gastrointestinal dysfunction (GDF) is one of the primary causes of morbidity and mortality in critically ill patients. Intensive care interventions, such as intravenous fluids and enteral feeding, can exacerbate GDF. There exists a paucity of high-quality literature on the interaction between these two modalities (intravenous fluids and enteral feeding) as a combined therapy on its impact on GDF.
Aim: To review the impact of intravenous fluids and enteral nutrition individually on determinants of gut function and implications in clinical practice.
Methods: Randomized controlled trials on intravenous fluids and enteral feeding on GDF were identified by a comprehensive database search of MEDLINE and EMBASE. Extraction of data was conducted for study characteristics, provision of fluids or feeding in both groups and quality of studies was assessed using the Cochrane criteria. A random-effects model was applied to estimate the impact of these interventions across the spectrum of GDF severity.
Results: Restricted/goal-directed intravenous fluid therapy is likely to reduce ‘mild’ GDF such as vomiting (p = 0.03) compared to a standard/ liberal intravenous fluid regime. Enterally-fed patients experience increased episodes of vomiting (p = <0.01) but are less likely to develop an anastomotic leak (p = 0.03) and peritonitis (p = 0.03) compared to parenterally fed patients. Vomiting (p = <0.01) and anastomotic leak (p = 0.04) were significantly lower in the early enteral feeding group.
Conclusions: There is less emphasis on the combined approach of intravenous fluid resuscitation and enteral feeding in critically ill patients. Conservative fluid resuscitation and aggressive enteral feeding are presumably key factors contributing to severe life-threatening GDF. Future trials should evaluate the impact of cross-interaction between conservative and aggressive modes of these two interventions on the severity of GDF.

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The 2019 Novel Coronavirus: A Crown Jewel of Pandemics?

Razvan Azamfirei

Johns Hopkins School of Medicine, Baltimore, MD, USA

DOI: 10.2478/jccm-2020-0013

Starting from the December 2019 identification of the 2019 novel coronavirus (2019-nCoV), an overwhelming sense of panic has enveloped public discourse. This is likely to be amplified by WHO recently declaring the novel coronavirus outbreak a public health emergency of international concern. It is the third significant occurrence of a zoonotic coronavirus crossing the species barrier to infect humans, and it likely will not be the last. Hope is not lost; and a measured approach, one that is cognizant of the seriousness of this public health crisis without giving into hysteria, is imperative. [More]

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Prognostic Value of Serum Lactate Levels in Critically Ill Patients in an Intensive Care Unit

Hedgar Berty Gutiérrez, Yenisey Arteaga Concepción, Jorge Soneira Pérez, Yanín Díaz Lara, Félix Mario Rivero López, Pedro Rosales Contreras

Miguel Enríquez hospital, La Habana, Cuba

DOI: 10.2478/jccm-2020-0005

Introduction: The patient in critical condition, regardless of the cause of admission, continues to be a challenge for health systems due to the high mortality that it reports. There is a need to identify some marker of early obtaining, easy to interpret and with high relevance in the prognosis of these patients.
Objective: To determine the prognostic value of serum lactate in an Intensive Care Unit (ICU).
Method: One hundred and forty-five patients admitted to an ICU were enrolled in the study. The Acute Physiology and Chronic Health Evaluation II (APACHE) prognosis score, Sequential Organ Failure Assessment, hemodynamic support need, mechanical ventilation, cause of admission, stay in ICU, analytical and physiological variables were determined. The probability of survival of patients who had elevated and normal serum lactate levels was calculated. The risk of dying was determined using the Cox regression model.
Results: Twenty-eight patients died (19%) in the ICU. The serum lactate value was higher in the group of patients with trauma, infections, APACHE II and high creatinine levels; as well as with decreased mean arterial blood pressure, need for hemodynamic support and mechanical ventilation. The survival capacity was higher in patients who had normal serum lactate. Serum lactate was the sole independent predictor of mortality (AHR 1.28 [1.07-1.53], p = 0.008).
Conclusions: Patient assessment through the determination of serum lactate levels provides useful information in the initial evaluation of the critical patient.

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Guillain–Barré and Acute Transverse Myelitis Overlap Syndrome Following Obstetric Surgery

Adina Stoian1,2, Anca Motataianu2,3, Zoltan Bajko2,3, Adrian Balasa4,5

1 Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Neurology 1 Clinic, Emergency Clinical County Hospital of Targu Mures, Romania
3 Department of Neurology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
4 Neurosurgery Clinic, Emergency Clinical County Hospital of Targu Mures, Romania
5 Department of Neurosurgery, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2020-0008

Introduction: There are rare reports of the occurrence of acute transverse myelitis and Guillain–Barré syndrome after various surgical procedures and general/epidural anaesthesia. The concomitant occurrence of these pathologies is very rare and is called Guillain–Barré and acute transverse myelitis overlap syndrome. In this article, we present the case of a second trimester pregnant patient who developed Guillain–Barré and acute transverse myelitis overlap syndrome.
Case presentation: We report the case of a 16-year-old female patient who underwent a therapeutic termination of pregnancy two weeks prior to the onset of the disease with gradual development of a motor deficit with walking and sensitivity disorders, fecal incontinence. The diagnosis was based on clinical exam, electroneurography and spinal magnetic resonance imaging. Endocrinopathies, infectious diseases, autoimmune and inflammatory diseases, neoplastic diseases and vitamin deficiencies were ruled out. Our patient attended five sessions of therapeutic plasma exchange, followed by steroid treatment, intravenous immunoglobulin with minimum recovery of the motor deficit in the upper limbs, but without significant evolution of the motor deficit in the lower limbs. The patient was discharged on maintenance corticotherapy and immunosuppressive treatment with azathioprine.
Conclusions: We report a very rare association between Guillain–Barré syndrome and acute transverse myelitis triggered by a surgical intervention with general anaesthesia. The overlap of Guillain–Barré syndrome and acute transverse myelitis makes the prognosis for recovery worse, and further studies are needed to establish the first-line therapy in these cases.

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Cerebellar Haemorrhage Leading to Sudden Cardiac Arrest

Ankit Agrawal1, Maria Cardinale2, Douglas Frenia3, Aveek Mukherjee1

1 Division of Internal Medicine, Rutgers Robert Wood Johnson Medical School, Saint Peter’s University Hospital, New Brunswick, NJ, USA
2 Division of Pharmacy, Ernest Mario School of Pharmacy, Rutgers University, Saint Peter’s University Hospital, New Brunswick, NJ, USA
3 Division of Pulmonary and Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, Saint Peter’s University Hospital, New Brunswick, NJ, USA

DOI: 10.2478/jccm-2020-0007

Introduction: Intracranial haemorrhage (ICH) is a known, but a rare cause of out of hospital cardiac arrest (OHCA). It results in the development of non-shockable rhythms such as asystole or pulseless electrical activity (PEA).
Case Report: A 77- years old male had an OHCA without any prodrome. An emergency medical services (EMS) team responded to an emergency call and intubated the patient at the site before transporting him to the Acute Care Hospital, New Brunswick, New Jersey, USA. On admission, a non-contrast computed tomography scan of the head revealed a large cerebellar haemorrhage. Non-traumatic ICH is a rare cause of OHCA. Although subarachnoid haemorrhage causing cardiac arrest has been described in the literature, cerebellar haemorrhage leading to cardiac arrest is rare. The mechanism by which ICH patients develop cardiac arrest is likely explained by a massive catecholamine surge leading to cardiac stunning.
Conclusion: A non-shockable rhythm in the setting of a sudden cardiac arrest should raise alarms for a primary non-cardiac ethology, especially a primary cerebrovascular event. The absence of brainstem reflexes increases the likelihood of an intracranial process.

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Prevalence and Prognostic Impact of Hypernatremia in Sepsis and Septic Shock Patients in The Intensive Care Unit: A Single Centre Experience

Mohamed Shirazy1,2, Islam Omar3,4, Duaa Abduljabbar5, Kamel Bousselmi2, Maryam Alkhaja5, Anis Chaari2, Vipin Kauts2, Karim Hakim2

1 Emergency Department, University Hospitals of Morecambe Bay NHS Foundation Trust, United Kingdom
2 Critical Care Department, King Hamad University Hospital, Kingdom of Bahrain
3 Surgical Department, University Hospitals of Morecambe Bay NHS Foundation Trust, United Kingdom
4 Surgical Department, King Hamad University Hospital, Kingdom of Bahrain
5 Internal Medicine department, King Hamad University Hospital, Kingdom of Bahrain

DOI: 10.2478/jccm-2020-0001

Introduction: Hypernatremia is a commonly associated electrolyte disturbance in sepsis and septic shock patients in the ICU. The objective of this study was to identify the prognostic value of hypernatremia in sepsis and septic shock.
Material and Methods: A prospective study conducted on sepsis and septic shock patients diagnosed prior to admission in the ICU in King Hamad University Hospital, Bahrain from January 1st 2017 to February 28th 2019. Data including age, sex, comorbidities, source of sepsis, sodium levels on days one, three, and seven. Data was correlated with the outcome (survival/death and the length of ICU stay).
Results: Patients included were 168, 110 survived, and 58 died. Hypernatraemia at day seven was associated with significantly higher mortality (P= 0.03). Hypernatraemia at Day1was associated with a significantly prolonged stay in the ICU (p= 0.039).Multivariate analysis to identify the independent predictors of mortality revealed that immunosuppression and hypernatraemia at Day7 proved to be independent predictors of mortality (P= 0.026 and 0.039 respectively).
Conclusion: Hypernatremia can be an independent predictor of poor outcome in septic and septic shock patients in the ICU.

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