Category Archives: JCCM 2022, Vol. 8, Issue 3

Personalized Physiological Medicine as the Future of Intensive Care Medicine

Leonard Azamfirei

Department of Anesthesiology and Intensive Care, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu-Mures, Romania

DOI: 10.2478/jccm-2022-0020

Personalized medicine has become increasingly popular over the last decade as a response to the variability of patients’ responses to certain medical or technological therapies [1]. The effectiveness of randomized controlled trials has become increasingly controversial. While personalized medicine came to be associated with the field of oncology, critically ill patients have also become a beneficiary of personalized medicine. Patients admitted to the intensive care unit have a series of multiple and intricate dysfunctions as well as complex and rapidly changing pathophysiological mechanisms underlying their disease. That is the background from which the concept of personalized physiological medicine (PPM) emerged. It is directly related to the therapy needs of a patient and their physiological status, determined by a certain genetic profile and characterized by biomarkers, specific to the individual and not exclusive to the disease [2-4]. Monitoring of organs becomes insufficient without continuous monitoring of microcirculation, cell metabolism, and the entire cellular functionality; the translation of these dynamic data into quantifiable parameters requires predominantly in vivo monitoring. [More]

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A Challenging Diagnosis of Sheehan’s Syndrome in Non-obstetric Critical Care and Emergency Settings: A Case Series of Five Patients with Varied Presentations

Suhail Sarwar Siddiqui1, Nibu Dominic2, Sukriti Kumar3, Kauser Usman4, Sai Saran1, Avinash Agrawal1, Mohan Gurjar5, Syed Nabeel Muzaffar1

1 Department of Critical Care Medicine, King George Medical University, Lucknow, Uttar Pradesh, India
2 Department of Endocrinology, Aster Medcity, Kochi, Kerala, India
3 Department of Radiodiagnosis, King George Medical University, Lucknow, Uttar Pradesh, India
4 Endocrinology Division, King George Medical University, Lucknow, Uttar Pradesh, India
5 Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

DOI: 10.2478/jccm-2022-0018

Sheehan’s syndrome is a life-threatening endocrine emergency seen in postpartum females secondary to ischemic pituitary necrosis. It is a frequent cause of hypopituitarism in developing countries that occurs secondary to postpartum haemorrhage (PPH). Patients with Sheehan’s syndrome often present with organ dysfunctions in critical care settings, secondary to stressors precipitating the underlying hormonal deficiencies. The initial clinical picture of Sheehan’s syndrome may mimic some other disease, leading to misdiagnosis and diagnostic delay. Strict vigilance, timely diagnosis, and appropriate management are essential to avoid diagnostic delay and to improve the patient outcome. In this case series, we describe 5 cases of previously undiagnosed Sheehan’s syndrome (including young, middle aged and postmenopausal females) that presented to critical care and emergency settings with organ failures.

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The use of metaraminol as a vasopressor in critically unwell patients: a narrative review and a survey of UK practice

Lina Grauslyte1, Nathalie Bolding2, Mandeep Phull3, Tomas Jovaisa3

1 Barts Health NHS Trust, London, UK
2 Royal Free Hampstead NHS Trust, London, UK
3 Barking Havering and Redbridge Hospitals NHS Trust, London, UK

DOI: 10.2478/jccm-2022-0017

Background: Major international guidelines state that norepinephrine should be used as the first-line vasopressor to achieve adequate blood pressure in patients with hypotension or shock. However, recent observational studies report that in the United Kingdom and Australia, metaraminol is often used as second line medication for cardiovascular support.
Aim of the study: The aim of this study was to carry out a systematic review of metaraminol use for management of shock in critically unwell patients and carry out a survey evaluating whether UK critical care units use metaraminol and under which circumstances.
Methods: A systematic review literature search was conducted. A short telephone survey consisting of 6 questions regarding metaraminol use was conducted across 30 UK critical care units which included a mix of tertiary and district general intensive care units.
Results: Twenty-six of thirty contacted centres responded to our survey. Metaraminol was used in 88% of them in various settings and circumstances (emergency department, theatres, medical emergencies on medical wards), with 67% reporting use of metaraminol infusions in the critical care setting. The systematic literature review revealed several case reports and only two studies conducted in the last 20 years investigating the effect of metaraminol as a stand-alone vasopressor. Both studies focused on different aspects of metaraminol use and the data was incomparable, hence we decided not to perform a meta-analysis.
Conclusions: Metaraminol is widely used as a vasopressor inside and outside of the critical care setting in the UK despite limited evidence supporting its safety and efficacy for treating shock. Further service evaluation, observational studies and prospective randomised controlled trials are warranted to validate the role and safety profile of metaraminol in the treatment of the critically unwell patient.

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Right Heart Failure as an Atypical Presentation of Chronic Type A Aortic Dissection – Multimodality Imaging for Accurate Diagnosis and Treatment. A case report and mini-review of literature

Ioan Tilea1,2, Robert Adrian Dumbrava1,2, Alexandra Mihaela Ratiu1,3, Marius Mihai Harpa1,4, Cosmin Marian Banceu1,4, Dorina Nastasia Petra1,2, Horatiu Suciu1,4

1 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Department of Internal Medicine II – Cardiology II, Emergency Clinical County Hospital, Targu Mures, Romania
3 Department of Radiology and Medical Imaging, Emergency Clinical County Hospital, Targu Mures, Romania
4 Cardiac Surgery Clinic, The Emergency Institute for Cardiovascular Diseases and Transplantation, Targu Mures, Romania

DOI: 10.2478/jccm-2022-0016

Background: An intrapericardial organized haematoma secondary to chronic type A aortic dissection is an extremely rare cause of right heart failure. Imaging studies are essential in recognising and diagnosis of this distinctive medical condition and guiding the anticipated treatment.
Case presentation: A 70-year-old male patient was admitted for progressive symptoms of right heart failure. His cardiovascular history exposed an aortic valve replacement 22 years before with a Medtronic Hall 23 tilting valve with no regular follow-up. Classical signs of congestion were recognized at physical examination. Transthoracic two-dimensional echocardiography and thoraco-abdominal computed tomography angiography, as essential parts of multimodality imaging algorithm, established the underlying cause of right heart failure. Under total cardiopulmonary bypass and cardiac arrest, surgical removal of the haematoma and proximal repair of the ascending aorta with a patient-matched vascular graft were successfully performed. The patient was discharged in good condition with appropriate pharmacological treatment, guideline-directed; no imagistic signs of acute post-surgery complications were ascertained.
Conclusion: This paper highlights the importance of recognizing and providing a timely clinical and imagistic diagnosis of this very rare, potentially avoidable cause of right heart failure in patients with previous cardiac surgery.

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Characteristics and risk factors for mortality in critically ill patients with COVID-19 receiving invasive mechanical ventilation: the experience of a private network in Sao Paulo, Brazil

Eduardo Atsushi Osawa, Alexandre Toledo Maciel

Imed Group, Research Department, Sao Paulo, Brazil; Adult Intensive Care Unit, São Camilo Hospital, Brazil

DOI: 10.2478/jccm-2022-0015

Introduction: The use of invasive mechanical ventilation (IMV) in COVID-19 represents in an incremental burden to healthcare systems.
Aim of the study: We aimed to characterize patients hospitalized for COVID-19 who received IMV and identify risk factors for mortality in this population.
Material and Methods: A retrospective cohort study including consecutive adult patients admitted to a private network in Brazil who received IMV from March to October, 2020. A bidirectional stepwise logistic regression analysis was used to determine the risk factors for mortality.
Results: We included 215 patients, of which 96 died and 119 were discharged from ICU. The mean age was 62.7 ± 15.4 years and the most important comorbidities were hypertension (62.8%), obesity (50.7%) and diabetes (40%). Non-survivors had lower body mass index (BMI) (28.3 [25.5; 31.6] vs. 31.2 [28.3; 35], p<0.001, and a shorter duration from symptom onset to intubation (8.5 [6.0; 12] days vs. 10 [8.0; 12.5] days, p = 0.005). Multivariable regression analysis showed that the risk factors for mortality were age (OR: 1.07, 95% CI: 1.03 to 1.1, p < 0.001), creatinine level at the intubation date (OR: 3.28, 95% CI: 1.47 to 7.33, p = 0.004), BMI (OR: 0.91, 95% CI: 0.84 to 0.99, p = 0.033), lowest PF ratio within 48 hours post-intubation (OR: 0.988, 95% CI: 0.979 to 0.997, p = 0.011), barotrauma (OR: 5.18, 95% CI: 1.14 to 23.65, p = 0.034) and duration from symptom onset to intubation (OR: 0.76, 95% CI: 0.76 to 0.95, p = 0.006).
Conclusion: In our retrospective cohort we identified the main risk factors for mortality in COVID-19 patients receiving IMV: age, creatinine at the day of intubation, BMI, lowest PF ratio 48-hours post-intubation, barotrauma and duration from symptom onset to intubation.

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Intensive Care Based Interventions to Reduce Family Member Stress Disorders: A Systematic Review of the Literature

Sarah Love Rhoads1, Thomas A. Trikalinos2, Mitchell M. Levy3, Timothy Amass1,4

1 Department of Medicine, Division of Pulmonary Sciences and Critical Care, University of Colorado, Denver, CO, USA
2 Departments of Health Services, Policy, and Practice and of Biostatistics, and Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA
3 Department of Medicine, Division of Pulmonary, Critical Care and Sleep, Brown University, Providence, RI, USA
4 Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, CO; CU Anschutz: University of Colorado – Anschutz Medical Campus, USA

DOI: 10.2478/jccm-2022-0014

Background: Increasing awareness of the emotional impact of an Intensive Care Unit (ICU) hospitalization on patients and their families has led to a rise in studies seeking to mitigate Post Intensive Care Syndrome (PICS) for both groups. In efforts to decrease symptoms of anxiety and depression, ICUs have implemented a variety of programs to reduce family distress.
Methods: We conducted a systematic review of experimental studies which aimed to reduce stress related disorders in family members after the experience of having a patient admitted to the ICU. Multiple databases were searched for randomized controlled trials or nonrandomized comparative trials which targeted family members or surrogate decision makers. A total of 17 studies were identified for inclusion in the review representing 3471 participants.
Results: We describe those interventions which we qualitatively assigned as “not passive,” or those which actively engaged the family to express themselves, as more likely to be successful in both the available pediatric and adult literature than interventions which we identified as “passive.” Studies which described active engagement of family members demonstrated comparative improvements in symptoms of depression, anxiety, and PTSD, as well as reduced hospital costs in the case of two studies.
Discussion: This review may serve to aid in the development of future interventions targeted at reducing family stress and PICS following an ICU hospitalization.

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Predictive Value of Systemic Immune-inflammation Index in Determining Mortality in COVID-19 Patients

Tahsin Karaaslan1, Esra Karaaslan2

1 Medeniyet University Göztepe Training and Research Hospital, Istanbul, Turkey
2 Istanbul Medipol University, Istanbul, Turkey

DOI: 10.2478/jccm-2022-0013

Aim: The aim of this study was to evaluate whether systemic immune-inflammation index (SII) could predict mortality in patients with novel coronavirus 2019 (COVID-19) disease.
Methods: This two-center, retrospective study included a total of 191 patients with confirmed diagnosis of COVID-19 via nucleic acid test (NAT). The SII was calculated based on the complete blood parameters (neutrophil × platelet/lymphocyte) during hospitalization. The relationship between the SII and other inflammatory markers and mortality was investigated.
Results: The mortality rate was 18.3%. The mean age was 54.32±17.95 years. The most common symptoms were fever (70.7%) and dry cough (61.3%), while 8 patients (4.2%) were asymptomatic. The most common comorbidities were hypertension (37.7%), diabetes (23.0%), chronic renal failure (14.7%), and heart failure (7.9%) which all significantly increased the mortality rate (p<0.001). There was a highly positive correlation between the SII and polymorphonuclear leukocyte (PNL), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) (r=0.754, p<0.001; r=0.812, p<0.001; r=0.841, p<0.001, respectively), while a moderate, positive correlation was found between the SII and C-reactive protein (CRP) (r=0.439, p<0.001). There was a significant correlation between the SII and mortality (U=1,357, p<0.001). The cut-off value of SII was 618.8 (area under the curve=0.751, p<0.001) with 80.0% sensitivity and 61.5% specificity. A cut-off value of >618.8 was associated with a 4.68-fold higher mortality.
Conclusion: Similar to NLR and PLR, the SII is a proinflammatory marker of systemic inflammation and can be effectively used in independent predicting COVID-19 mortality .

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Occupational Stress and Quality of Life among Health Professionals during the COVID-19 Pandemic

Efstratios Vamvakas1, Ioanna Kontogeorgou1, Aggeliki Ntaountaki1, Georgia Karkouli1, Eleni Pisimisi1, Eirini Karampekiou1, Efstathios Politis1, Iordana Moskofi1, Dimitrios Konitopoulos1, Eleni Dokoutsidou2, Maria Grigoropoulou3, Maria Theodorakopoulou1, Apostolos Armaganidis1,4

1 Attikon General University Hospital, Athens, Greece
2 University of West Attika, Athens, Greece
3 Second Health Centre, Peristeri, Greece
4 Department of Medicine, National and Kapodistrian University of Athens, Greece

DOI: 10.2478/jccm-2022-0012

Introduction: Healthcare professionals, due to the nature of their work, have always experienced occupational stress, depression and low quality of life, which have been aggravated during the COVID-19 pandemic.
Aim: A large-scale cross-sectional descriptive correlational study aimed to investigate the impact of the COVID-19 pandemic on Greek healthcare professionals’ psychological status and quality of life.
Material and Methods: The study was conducted at “Attikon” General University Hospital and the 2nd Health Region in Athens, Greece. An assessment of anxiety and depression was carried out using the Zung’s Self-Rating Anxiety and Depression Scale (SAS/SDS). To assess the participants’ Quality of Life (QoL) the Short Form Survey-36 (SF-36) was used.
Results: 147 healthcare professionals were enrolled in the study. 70.7% experienced normal stress levels, 23.8% mild, 4.8% moderate and 0.7% severe. Mild depression was experienced by 34.7%, moderate by 10.2% and severe by 1.4%, with a 53.7% showing no depressive symptoms. Women experienced higher levels of anxiety and depression (p=0.001 & 0.001 respectively), and were 5.4 times more at risk to develop anxiety [Odds Ratio (OR) 5.357, 95% Confidence Interval (CI), 1.95-14.72: p=0.001] and 3.4 depression (OR, 3.365, 95% CI, 1.59- 7.12: p=0.002). Nurses and other professionals experienced higher stress and depression levels (p=0.004 & 0.040 respectively) than doctors. Participants reporting more exhaustion exhibited higher anxiety and depression levels (p=0.001). Compared to the pre-COVID-19 era, women (p=0.001), other health professionals (p=0.001) and those experiencing more physical burnout during COVID-19 (p=0.005) reported worse physical health. Anxiety and depression were negatively correlated with most sub scales of SF-36 except social functioning and bodily pain (p=0.001).
Conclusions: Healthcare professionals’ QoL has been affected by the COVID-19 pandemic and they experience higher levels of anxiety and depression. There is a need to develop strategies to address the negative psychological impact of this pandemic on healthcare professionals.

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Effective Outcome of HBOT as an Adjuvant Therapy in Patients Diagnosed with COVID-19 in a Tertiary Care Hospital – A Preliminary Study

Thiruppathy Palaniappan, Asif Shaikh, Navamani Kirthika

Medway Hospital, Chennai, India

DOI: 10.2478/jccm-2022-0008

Introduction: Hyperbaricoxygen therapy (HBOT) is breathing100% oxygen in pressurised chamber. This therapy ensures quick oxygen delivery to the bloodstream. In patients with severe COVID-19 pneumonia, progressive hypoxemia occurs. Oxygen therapy hasa significant role in its management.
Aim of the study: The objective was to study the efficacy of hyperbaric oxygen therapy (HBOT) as adjuvant therapy for reducing the requirement of additional oxygen supplementationin patients with moderate to severe ARDS diagnosed with COVID-19.
Methods: A single-centre prospective pilot cohort study was conducted ata tertiary care hospital from December 2020 to February 2021 over two months. Fifty patients with COVID-19 needingoxygen, satisfying the selection criteria, were included. Hyperbaricoxygen therapy wasgiven to all patients. The patient received30-45 minutes of hyperbaric oxygen with 15 minutes of pressurizing and depressurizing at 2.0 atmosphere absolute (ATA) with or without airbrakesas per the critical care team. Oxygen requirement, PaO2, andcondition at discharge were considered as primary outcome variables.
Results: Among the 50 participants studied, the mean age was 53.64±13.26 years. Out of 50 participants, 49(98.00%) had PaO2≤80 mmHg, and one (2.00%) had >80 PaO2. All the participants 50(100%) had PaO2 as 90 mmHg after three sittings.
Conclusion: This studyshows promising results in using HBOT to overcome respiratory failure in COVID-19. HBOT reduced the need for oxygen by improving the oxygen saturation levels.

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