Category Archives: JCCM 2021

Pneumocephalus Following an Accidental Dural Puncture, Treated Using Hyperbaric Oxygen Therapy. A Case Report

Flávio Marino1, André Ferreira Simões1, Ângela Simas1, João Gonçalves Pereira1,2,3

1 Intensive Care Unit Department, Hospital Vila Franca de Xira, Vila Franca de Xira, Lisboa, Portugal
2 Nova Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
3 Grupo de Infeção e Sépsis, Porto, Portugal

DOI: 10.2478/jccm-2021-0017

Introduction: Neuraxial techniques, including epidural anaesthesia, are often used for perioperative pain control and are generally safe. However, both transient, mild and even severe, life-threatening neurologic complications can occur.
Case presentation: A seventy-eight-year-old man was admitted to the hospital for a radical nephrectomy plus transurethral resection due to kidney and bladder cancer. During the epidural exploration, an accidental dural puncture was noted. This was followed by the patient complaining of an intense headache. The epidural catheter was placed in a different location, and surgery was performed uneventfully. The patient presented with confusion, agitation, vertical nystagmus, vision loss, and paraparesis about two hours later. The epidural levobupivacaine and morphine infusion were stopped, followed by motor block resolution. A computerized head-tomography scan showed extra-axial multiple air spots involving the frontal and temporal lobes. Emergent hyperbaric oxygen therapy was commenced. After a single session, there was complete resolution of all symptoms and a marked reduction in the number and volume of the extra-axial air visible on the CT scan.
Conclusions: Although rare, pneumocephalus is a well-recognized complication of a dural puncture. Its rapid recognition in a patient with new-onset neurological symptoms and early treatment with hyperbaric oxygen therapy allows rapid clinical and imaging resolution and an improved prognosis.

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Candida spp. in Lower Respiratory Tract Secretions – A Ten Years Retrospective Study

Cristina Nicoleta Ciurea1,2, Ario Santini3, Anca Delia Mare1, Irina Bianca Kosovski2,4, Felicia Toma1, Camelia Vintila5, Ionela Anca Pintea-Simon1,2, Adrian Man1,5

1 Department of Microbiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Doctoral school, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
4 Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
5 Mureș Clinical County Hospital, Targu Mures, Romania

DOI: 10.2478/jccm-2021-0016

Introduction: Lower respiratory tract secretions (LRTS) like sputum and tracheal aspirates are frequently sent to the microbiology laboratory from patients with various respiratory pathologies. Improper collection techniques can lead to false-positive results, resulting in improper therapy.
Aim of the study: To determine the percentage of contaminated samples sent to the microbiology laboratory, to establish the prevalence of Candida spp. in non-contaminated samples and therefore, the presence of Candida spp. originating in lower respiratory tract infections.
Material and Methods: A 10-year data survey was conducted to assess the differences in Candida prevalence from contaminated versus non-contaminated samples, assessed and categorised by Bartlett grading system, and to emphasise the importance of quality control for potentially contaminated samples. The data were analysed according to gender, age, referring departments, and the species of Candida. For the statistical analysis, Kruskal-Wallis and Fisher tests were used, and the alpha value was set for 0.5.
Results: The prevalence of Candida spp. in all analysed samples was 31.60%. After excluding the contaminated samples, the actual prevalence was 27.66%. Of all sputum samples, 31.6% were contaminated. Patients aged more than 40 years old were more prone to provide contaminated sputum samples. C. albicans is more prevalent in non-contaminated sputum samples. In both sputum and tracheal aspirates, the chances of identifying a single species are higher than the chances of identifying multiple species.
Conclusions: The study emphasises the importance of assessing the quality of sputum samples because of the high number of improperly collected samples sent to the microbiology laboratory.

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Postpartum Acute Basilar Artery Occlusion Secondary to Vertebral Artery Dissection. Case Report and Literature Review

Iulia-Adela Drăghici1, Lucian Marginean2, Rares-Cristian Filep2, Zoltan Bajko3,
Laura Barcutean3, Teodora Aldea1, Rodica Balasa3

1 1st Neurology Clinic, Emergency County Hospital Targu Mures, Romania
2 Department of Interventional Radiology, Emergency County Hospital Targu Mures, Romania
3 Department of Neurology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2021-0015

Female patients in the peripartum and postpartum periods have an increased risk of stroke than nonpregnant women. Cerebrovascular complications of pregnancy represent a significant cause of maternal mortality and morbidity and are potentially disabling. Acute basilar artery occlusion secondary to spontaneous vertebral artery dissection in the postpartum period is an infrequent entity and a major diagnostic and treatment challenge. In the present case, a 37-year-old female patient, eight weeks after caesarean delivery, presented with a history of sudden cervical pain, followed by headache and dizziness. Some hours later, she was found unconscious by her family and was transferred to the emergency department, where a neurological status assessment suggested vertebrobasilar stroke. The imagistic workup revealed right vertebral artery dissection and basilar artery occlusion without constituted ischemic lesions. The patient underwent endovascular intervention with dilation of the narrowed vertebral artery and stent retriever basilar artery thrombectomy, with a favourable clinical outcome. This report first presents the details of this case and the relevant literature data on postpartum arterial dissections and the subsequent ischemic complications and available treatment options.

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The Impact of Hyperoxia Treatment on Neurological Outcomes and Mortality in Moderate to Severe Traumatic Brain Injured patients

Raymond Khan, Sarah Alromaih, Hind Alshabanat, Nosaiba Alshanqiti, Almaha Aldhuwaihy, Sarah Abdullah Almohanna, Muna Alqasem, Hasan Al-Dorzi

King Saud bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, Saudi Arabia

DOI: 10.2478/jccm-2021-0014

Background: Traumatic brain injury is a leading cause of morbidity and mortality worldwide. The relationship between hyperoxia and outcomes in patients with TBI remains controversial. We assessed the effect of persistent hyperoxia on the neurological outcomes and survival of critically ill patients with moderate-severe TBI.
Method: This was a retrospective cohort study of all adults with moderate-severe TBI admitted to the ICU between 1st January 2016 and 31st December 2019 and who required invasive mechanical ventilation. Arterial blood gas data was recorded within the first 3 hours of intubation and then after 6-12 hours and 24-48 hours. The patients were divided into two categories: Group I had a PaO2 < 120mmHg on at least two ABGs undertaken in the first twelve hours post intubation and Group II had a PaO2 ≥ 120mmHg on at least two ABGs in the same period. Multivariable logistic regression was performed to assess predictors of hospital mortality and good neurologic outcome (Glasgow outcome score ≥ 4).
Results: The study included 309 patients: 54.7% (n=169) in Group I and 45.3% (n=140) in Group II. Hyperoxia was not associated with increased mortality in the ICU (20.1% vs. 17.9%, p=0.62) or hospital (20.7% vs. 17.9%, p=0.53), moreover, the hospital discharge mean (SD) Glasgow Coma Scale (11.0(5.1) vs. 11.2(4.9), p=0.70) and mean (SD) Glasgow Outcome Score (3.1(1.3) vs. 3.1(1.2), p=0.47) were similar. In multivariable logistic regression analysis, persistent hyperoxia was not associated with increased mortality (adjusted odds ratio [aOR] 0.71, 95% CI 0.34-1.35, p=0.29). PaO2 within the first 3 hours was also not associated with mortality: 121-200mmHg: aOR 0.58, 95% CI 0.23-1.49, p=0.26; 201-300mmHg: aOR 0.66, 95% CI 0.27-1.59, p=0.35; 301-400mmHg: aOR 0.85, 95% CI 0.31-2.35, p=0.75 and >400mmHg: aOR 0.51, 95% CI 0.18-1.44, p=0.20; reference: PaO2 60-120mmHg within 3 hours. However, hyperoxia >400mmHg was associated with being less likely to have good neurological (GOS ≥4) outcome on hospital discharge (aOR 0.36, 95% CI 0.13-0.98, p=0.046; reference: PaO2 60-120mmHg within 3 hours.
Conclusion: In intubated patients with moderate-severe TBI, hyperoxia in the first 48 hours was not independently associated with hospital mortality. However, PaO2 >400mmHg may be associated with a worse neurological outcome on hospital discharge.

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COVID -19 complicated by Acute Respiratory Distress Syndrome, Myocarditis, and Pulmonary Embolism. A case report

Rajai F. Bulbul, Jassim Al Suwaidi, Mohammed Al-Hijji, Hassan Al Tamimi, Ibrahim Fawzi

Hamad Medical Corporation, Doha, Qatar

DOI: 10.2478/jccm-2020-0041

A 49-year-old female Qatari woman, with no past medical history, presented at a hospital complaining of a history of cough and shortness of breath. The patient tested positive for severe acute respiratory syndrome (ARDS) and COVID-19. Subsequently, her course of treatment was complicated by severe acute respiratory distress syndrome, pulmonary embolism and severe myocarditis requiring treatment with venous-arterial extracorporeal membrane oxygenation as a bridge to complete recovery.

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Challenges in Management of the Brain-Dead Organ Donor During the COVID-19 Pandemic

Ioana Marina Grințescu

“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

DOI: 10.2478/jccm-2021-0013

Starting in Wuhan, China [1], the infection caused by the novel SARS-CoV-2 virus became a public health issue when, due to the extreme contagiousness of this virus, a pandemic has been declared [2], putting a strain on both the global medical staff as well as the authorities in an effort to better manage an unprecedented situation in the modern era. Looking at the society we are living in, we can easily see that the COVID-19 pandemic has brought impressive social, economic, political, cultural and medical changes as well as personal ones; I believe that the perspectives and priorities of many of us have changed.
Before discussing the transplant activity, mainly the one regarding diagnosis and maintenance of the brain-dead organ donor patient, an activity that has been carried out for many years in Anesthesiology and Intensive Care Clinics, to which many of us are devoted, practicing it with deep respect, we need to review the daily activity. As is well known, the work effort in intensive care units is extremely demanding both mentally and physically. It involves the care of critical patients with severe decompensated pathologies, requiring maximum therapeutic management, special attention, continuous specific monitoring as well as the use of advanced medical and pharmacological techniques. The new measures and regulations, personal protective equipment, structural changes and working protocols implemented to prevent and limit COVID-19 infection, as well as the rigors imposed by the care of these patients have created additional stress for the medical staff. [More]

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Prevalence of Depression, Anxiety and Stress among Patients Discharged from Critical Care Units

Mohammad Saeidi1, Alireza Safaei2, Zohreh Sadat3, Parisa Abbasi4, Masoumeh Sadat Mousavi Sarcheshmeh5, Fariba Dehghani6, Mehran Tahrekhani7, Mohammad Abdi8

1 Department of Anesthesiology and Critical Care, Qom University of Medical Sciences, Qom, Iran
2 School of Science, Engineering and Environment, University of Salford, Manchester, UK
3 Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, Iran
4 Baharlo Hospital, Tehran University of Medical Sciences, Tehran, Iran
5 Bahman Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
6 Researcher of Spiritual Health Research Center, Qom University of Medical Sciences, Qom, Iran
7 Department of Nursing Education, Abhar School of Nursing, Zanjan University of Medical Sciences, Zanjan, Iran
8 Department of Medical Education, Medical School, Tehran University of Medical Sciences, Tehran, Iran

DOI: 10.2478/jccm-2021-0012

Introduction: The widespread use of advanced technology and invasive intervention creates many psychological problems for hospitalized patients; it is especially common in critical care units.
Methods: This cross-sectional study was conducted on 310 patients hospitalized in critical care units, using a non-probability sampling method. Data were collected using depression, anxiety, and stress scale (DASS-21) one month after discharge from the hospital. Data analysis was performed using descriptive and inferential statistics.
Results: 181 males and 129 females with a mean age (SD) of 55.11(1.62) years were enrolled in the study. The prevalence of depression, anxiety and stress were 46.5, 53.6 and 57.8% respectively, and the depression, anxiety and stress mean (SD) scores were 16.15(1.40), 18.57(1.46), 19.69(1.48), respectively. A statistically significant association was reported between depression, anxiety and stress with an increase in age, the number of children, occupation, education, length of hospital stay, use of mechanical ventilation, type of the critical care unit, and drug abuse.
Conclusion: The prevalence of depression, anxiety and stress in patients discharged from critical care units was high. Therefore, crucial decisions should be made to reduce depression, anxiety and stress in patients discharged from critical care units by educational strategies, identifying vulnerable patients and their preparation before invasive diagnostic-treatment procedures.

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Effect of Early versus Delayed Parenteral Nutrition on the Health Outcomes of Critically Ill Adults: A Systematic Review

Suresh Kumar Sharma, Ritu Rani, Kalpana Thakur

All India Institute of Medical Sciences – Rishikesh, Rishikesh, India

DOI: 10.2478/jccm-2021-0011

Objectives: This systematic review aims to evaluate and summarise the findings of all relevant studies which identified the effect of early vs delayed parenteral nutrition (PN), early PN vs early supplemental PN and early PN vs standard care for critically ill adults.
Methods: The literature search was undertaken using PubMed, Embase, Medline, Clinical Key, and Ovid discovery databases. The reference lists of studies published from 2000 till June 2020 were hand searched.
Result: On screening 2088 articles, a total of five RCTs with 6,277 patients were included in this review. Only one clinical trial compared early PN and late PN; the results reported significantly shorter periods in intensive care unit (ICU) stay (p=0.02) and less ICU related infections (p=0.008) in the late PN group compared to the Early PN group. Two trials compared total parenteral nutrition (TPN) and enteral nutrition (EN) +TPN groups. Both found a significantly longer hospital stay duration (p<0.05 and p<0.01) with a higher mortality rate in the TPN group compared to the EN+TPN group. A statistically significant improvement was observed in patients’ quality of life receiving early PN compared to standard care (p=0.01). In contrast, no significant difference was found in the supplemental PN vs the standard care group.
Conclusion: The supplemental PN patients had shorter ICU stay and lower mortality rates than TPN. However, these findings should be interpreted carefully as included studies have different initiation timing of nutritional support, and the patients’ diagnosis varied.
Systematic review registration: PROSPERO: CRD42020183175

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Contrast Medium-Induced Encephalopathy after Coronary Angiography – Case Report

Sebastian Andone1, Rodica Balasa2, Laura Barcutean1, Zoltan Bajko2, Valentin Ion3, Anca Motataianu2, Adina Stoian4, Smaranda Maier2

1 Doctoral School, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Department of Neurology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Department of Analytical Chemistry and Drug Analysis, Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
4 Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2021-0010

Introduction: Contrast-induced encephalopathy represents a rare, reversible complication that appears after intravenous or intra-arterial exposure to contrast agents. There is no consensus in the literature regarding the mechanism of action. However, the theoretical mechanism is set around the disruption of the blood-brain barrier and the contrast agents’ chemical properties.
Case report: The case of a 70-year-old patient, known to have hypertension and type 2 diabetes mellitus is reported. The patient had undergone a diagnostic coronary angiography during which he received 100ml of Ioversol (Optiray 350™). Soon after the procedure, the patient began experiencing a throbbing headache, followed by intense behavioural changes and aggressive tendencies. He was transferred to the Neurology Clinic. The neurological examination was without focal neurological signs; however, the patient was very aggressive and uncooperative. The CT scan revealed a mild hyper-density in the frontal lobes. MRI scan revealed no pathological changes. Conservative treatment with diuretics and hydration was administered, and the patient experienced a complete resolution of symptoms in 72 hours.
Conclusion: Contrast-induced encephalopathy is a possible secondary complication to contrast agents and a diagnostic challenge, and it should not be overlooked, especially following procedures that use contrast agents.

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