Category Archives: JCCM 2021

Should We Go “Regional” in Intensive Care?

DOI: 10.2478/jccm-2021-0042

Pain is one of the major concerns in Intensive Care Units (ICU). The majority of the patients admitted in ICU experience a certain degree of pain during their stay. Opioid analgesia constitutes the main analgesic option for ICU patients [1].
Opioids are known to have serious side effects, some of them such as ileus, respiratory depression, which leads to prolonged mechanical ventilation, can interfere with the patient’s outcome can lengthen the stay in ICU and leads to iatrogenic withdrawal syndrome (IWS) [1, 2]. In the last few years, a new concept of pain management in ICU patients was introduced: opioid free analgesia (OFA). This concept implies achieving good quality analgesia without using any type of opioids, in any manner [3]. [More]

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Plasmapheresis in the Treatment of Refractory Myoclonic Status. A Case Report

DOI: 10.2478/jccm-2021-0041

A case of myoclonic status treated with plasmapheresis in a patient of 63 years of age who was admitted to a Spanish intensive care unit is reported. The patient showed clinical and radiological evidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection; molecular tests did not verify this.

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Comparison of the National Early Warning Scores and Rapid Emergency Medicine Scores with the APACHE II Scores as a Prediction of Mortality in Patients with Medical Emergency Team Activation: A Single-centre Retrospective Cohort Study

DOI: 10.2478/jccm-2021-0040

Introduction: The medical emergency team enables the limitation of patients’ progression to critical illness in the general ward. The early warning scoring system (EWS) is one of the criteria for medical emergency team activation; however, it is not a valid criterion to predict the prognosis of patients with MET activation.
Aim: In this study, the National Early Warning Score (NEWS) and Rapid Emergency Medicine Score (REMS) was compared with that of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score in predicting the prognosis of patients who had been treated a medical emergency team.
Material and Methods: In this single-centre retrospective cohort study, patients treated by a medical emergency team between April 2013 and March 2019 and the 28-day prognosis of MET-activated patients were assessed using APACHE II, NEWS, and REMS.
Results: Of the 196 patients enrolled, 152 (77.5%) were men, and 44 (22.5%) were women. Their median age was 68 years (interquartile range: 57-76 years). The most common cause of medical emergency team activation was respiratory failure (43.4%). Univariate analysis showed that APACHE II score, NEWS, and REMS were associated with 28-day prognostic mortality. There was no significant difference in the area under the receiver operating characteristic curve of APACHE II (0.76), NEWS (0.67), and REMS (0.70); however, the sensitivity of NEWS (0.70) was superior to that of REMS (0.47).
Conclusion: NEWS is a more sensitive screening tool like APACHE II than REMS for predicting the prognosis of patients with medical emergency team activation. However, because the accuracy of NEWS was not sufficient compared with that of APACHE II score, it is necessary to develop a screening tool with higher sensitivity and accuracy that can be easily calculated at the bedside in the general ward.

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Survey of U.S. Critical Care Practitioners on Net Ultrafiltration Prescription and Practice Among Critically Ill Patients Receiving Kidney Replacement Therapy

DOI: 10.2478/jccm-2021-0034

Introduction: The current prescription and practice of net ultrafiltration among critically ill patients receiving kidney replacement therapy in the U.S. are unclear.
Aim of the study: To assess the attitudes of U.S. critical care practitioners on net ultrafiltration (UFNET) prescription and practice among critically ill patients with acute kidney injury treated with kidney replacement therapy.
Methods: A secondary analysis was conducted of a multinational survey of intensivists, nephrologists, advanced practice providers, and ICU and dialysis nurses practising in the U.S.
Results: Of 1,569 respondents, 465 (29.6%) practitioners were from the U.S. Mainly were nurses and advanced practice providers (58%) and intensivists (38.2%). The median duration of practice was 8.7 (IQR, 4.2-19.4) years. Practitioners reported using continuous kidney replacement therapy (as the first modality in 60% (IQR 20%-90%) for UFNET. It was found that there was a significant variation in assessment of prescribed-to-delivered dose of UFNET, use of continuous kidney replacement therapy for UFNET, methods used to achieve UFNET, and assessment of net fluid balance during continuous kidney replacement therapy. There was also variation in interventions performed for managing hemodynamic instability, perceived barriers to UFNET, belief that early and protocol-based fluid removal is beneficial, and willingness to enroll patients in a clinical trial.
Conclusions: There was considerable practice variation in UFNET among critical care practitioners in the U.S., reflecting the need to generate evidence-based practice guidelines for UFNET.

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Inhaled Nitric Oxide in Patients with Severe COVID-19 Infection at Intensive Care Unit – A Cross-Sectional Study

DOI: 10.2478/jccm-2021-0033

In adults with severe hypoxemia, inhaled nitric oxide (iNO) is known to reduce pulmonary shunt and pulmonary hypertension, improving V/Q matching [1]. Studies in refractory hypoxemia among patients with severe acute respiratory distress syndrome (ARDS) suggest that iNO may be allied to other ventilatory strategies as a bridge to clinical improvement [2, 3].
A trial from the 2004 Beijing Coronavirus Outbreak showed that low dose iNO could shorten the time of ventilatory support [4]. Additionally, preclinical studies suggest an inhibitory effect of iNO on viral replication [5]. To date, the role of iNO in COVID19 infection is still unclear. [More]

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Severe Acute Motor Axonal Neuropathy Associated with Influenza-A (H1N1) Infection and Prolonged Respiratory Failure – A Case Report

DOI: 10.2478/jccm-2021-0030

Acute Motor Axonal Neuropathy (AMAN) is an immune-mediated disorder of the peripheral nervous system, part of the spectrum of the Guillain-Barre syndrome (GBS). An infectious event most often triggers it reported a few weeks before the onset. The reported case is of a 56 years-old woman who developed acute motor axonal neuropathy three weeks after respiratory infection with influenza A virus subtype H1N1. Despite early treatment with plasmapheresis and intravenous immunoglobulins, the patient remained tetraplegic, mechanically ventilated for five months, with repetitive unsuccessful weaning trails. The probable cause was considered to be phrenic nerve palsy in the context of acute motor axonal neuropathy. This case highlights that acute motor axonal neuropathy is a severe and life-threatening form of Guillain-Barre syndrome associated with significant mortality and morbidity. Neurological and physical recovery strongly depend on the inter-professional effort in an intensive care unit and neurology professionals.

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Shock Due to an Obstructed Endotracheal Tube

DOI: 10.2478/jccm-2021-0027

Endotracheal tube obstruction by a mucus plug causing a ball-valve effect is a rare but significant complication. The inability to pass a suction catheter through the endotracheal tube with high peak and plateau pressure differences are classical features of an endotracheal tube obstruction. A case is described of endotracheal tube obstruction from a mucus plug that compounded severe respiratory acidosis and hypotension in a patient who simultaneously had abdominal compartment syndrome. The mucus plug was not identified until a bronchoscopic assessment of the airway was performed. Due to the absence of classical signs, the delayed identification of the obstructing mucus plug exacerbated diagnostic confusion. It resulted in various treatments being trialed whilst the patient continued to deteriorate from the evasive offending culprit. We suggest that earlier and more routine use of bronchoscopy should be employed in an intensive care unit, especially as a definitive way to rule out endotracheal obstruction.

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Hypothalamic-pituitary axis disorder – “the puppet master” of multiple organ dysfunction in brain-dead patients

DOI: 10.2478/jccm-2021-0029

One of the most revolutionary discoveries of modern medicine was organ transplantation, as it brought hope and healing in cases that seemed incurable. Best outcomes in organ transplantation are related to a rigorous tissue typing and an appropriate immunosuppressant therapy that allowed a longer survival rate for recipients [1]. The management of the potential brain-dead donor is a complex one that involves several well-defined stages: early identification of potential donors, brain death determination, maintaining vital functions, and graft transplantation.
Brain death determination is synonymous with irreversible anatomical and functional injury to the entire brain and brainstem. This process involves a major alteration of the hemodynamic and hormonal homeostasis. Hypothalamic irreversible injury is followed by a profound normothermia dysregulation. The aggressive inflammatory response after brain death occurrence is responsible for capillary leakage and refractory hypotension [2]. Clinical diagnostic tests that assess brain death include brain stem areflexia, apnea, and cerebral unresponsiveness, linked with a known, irreversible cause of coma [3].[More]

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