Category Archives: JCCM 2022

Burnout Syndrome During COVID-19 Second Wave on ICU Caregivers

DOI: 10.2478/jccm-2022-0026

Objective: The main objective of this article is to evaluate the prevalence of burnout syndrome (BOS) among the Intensive Care Unit (ICU) healthcare workers.
Methods: The COVID-impact study is a study conducted in 6 French intensive care units. Five units admitting COVID patient and one that doesn’t admit COVID patients. The survey was conducted between October 20th and November 20th, 2020, during the second wave in France. A total of 208 professionals responded (90% response rate). The Maslach Burnout Inventory scale, the Hospital Anxiety and Depression Scale and the Impact of Event Revisited Scale were used to study the psychological impact of the COVID-19 Every intensive care unit worker.
Results: The cohort includes 208 professionals, 52.4% are caregivers. Almost 20% of the respondents suffered from severe BOS. The professionals who are particularly affected by BOS are women, engaged people, nurses or reinforcement, not coming willingly to the intensive care unit and professionals with psychological disorders since COVID-19, those who are afraid of being infected, and people with anxiety, depression or post-traumatic stress disorder. Independent risk factors isolated were being engaged and being a reinforcement. Being a volunteer to come to work in ICU is protective. 19.7% of the team suffered from severe BOS during the COVID-19 pandemic in our ICU. The independent risk factors for BOS are: being engaged (OR = 3.61 (95% CI, 1.44; 9.09), don’t working in ICU when it’s not COVID-19 pandemic (reinforcement) (OR = 37.71 (95% CI, 3.13; 454.35), being a volunteer (OR = 0.10 (95% CI, 0.02; 0.46).
Conclusion: Our study demonstrates the value of assessing burnout in health care teams. Prevention could be achieved by training personnel to form a health reserve in the event of a pandemic.

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Variability of Steroid Prescription for COVID-19 Associated Pneumonia in Real-Life, Non-Trial Settings

DOI: 10.2478/jccm-2022-0025

The RECOVERY study documented lower 28-day mortality with the use of dexamethasone in hospitalized patients on invasive mechanical ventilation or oxygen with COVID-19 Pneumonia. We aimed to examine the practice patterns of steroids use, and their impact on mortality and length of stay in ICU. We retrospectively examined records of all patients with confirmed Covid 19 pneumonia admitted to the ICU of Dubai hospital from January 1st, 2020 – June 30th, 2020. We assigned patients to four groups (No steroids, low dose, medium dose, and high dose steroids). The primary clinical variable of interest was doses of steroids. Secondary outcomes were 28-day mortality and length of stay in ICU”. We found variability in doses of steroid treatment. The most frequently used dose was the high dose. Patients who survived were on significantly higher doses of steroids and had significantly longer stays in ICU. The prescription of steroids in Covid-19 ARDS is variable. The dose of steroids impacts mortality rate and length of stay in ICU, although patients treated with high dose steroids seem to stay more days in ICU.

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Pharmacokinetics of Teicoplanin in a Patient with Coronavirus Disease 2019 Receiving Veno-venous Extracorporeal Membrane Oxygenation

DOI: 10.2478/jccm-2022-0021

Introduction: Patients with severe coronavirus disease 2019 (COVID-19) receiving ventilation or pulmonary support via veno-venous extracorporeal membrane oxygenation (VV-ECMO) can be infected with drug-resistant bacteria. When introducing VV-ECMO, the changes in serum antibiotic concentration should be considered due to an increased volume of distribution (Vd). However, no pharmacokinetic study has assessed teicoplanin (TEIC) treatment in patients with COVID-19 receiving VV-ECMO.
Case presentation: A 71-year-old man diagnosed with COVID-19 visited a primary hospital. His oxygenation conditions worsened despite treatment with favipiravir and methylprednisolone as well as oxygen therapy. After his transfer to our center, tracheal intubation and steroid pulse therapy were initiated. Seven days after admission, VV-ECMO was performed. TEIC was administered for secondary bacterial infection. The serum TEIC concentration remained within the therapeutic range, indicating that VV-ECMO did not significantly affect TEIC pharmacokinetics. VV-ECMO was discontinued 17 days after admission. However, he developed multi-organ disorder and died 42 days after admission.
Conclusion: As TEIC prevents viral invasion, it may be used with ECMO in patients with COVID-19 requiring ventilation; however, the altered pharmacokinetics of TEIC, such as increased Vd, should be considered. Therefore, TEIC pharmacokinetics in VV-ECMO should be assessed in future studies with an appropriate number of patients.

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Cardiological Monitoring – A Cornerstone for Pediatric Inflammatory Multisystem Syndrome Temporally Associated with COVID-19 Outcome: A Case Report and a Review from the Literature

DOI: 10.2478/jccm-2022-0022

Introduction: Pediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS) is a rare life-threatening condition requiring a complex management and multidisciplinary approach, whose outcome depends on the early diagnosis.
Case report: We report the case of a 2 years and-5-month-old boy admitted in our clinic for fever, abdominal pain and diarrhea. The clinical exam at the time of admission revealed influenced gen-eral status, bilateral palpebral edema and conjunctivitis, mucocutaneous signs of dehydration, and abdominal tenderness at palpation. The laboratory tests performed pointed out lymphopenia, thrombocytopenia, anemia, elevated C-reactive protein – CRP, erythrocyte sedimentation rate and ferritin levels, hyponatremia, hypopotassemia, hypertriglyceridemia, elevated D-dimer, in-creased troponin and NT-proBNP. The real-time polymerase chain reaction (RT-PCR) test for SARS-CoV-2 infection was negative, but the serology was positive. Thus, established the diagnosis of PIMS-TS. We initiated intravenous immunoglobulin, empirical antibiotic, anticoagulation therapy and symptomatic drugs. Nevertheless, the clinical course and laboratory parameters worsened, and the 2nd echocardiography pointed out minimal pericardial effusion, slight dilation of the left cavities, dyskinesia of the inferior and septal basal segments of the left ventricle (LV), and LV systolic dysfunction. Therefore, we associated intravenous methylprednisolone, angiotensin converting enzyme inhibitors, spironolactone and hydrochlorothiazide, with outstanding favorable evolution.
Conclusions: Echocardiographic monitoring might be a lifesaving diagnostic tool in the management of PIMS-TS.

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Treatment of Lethal Caffeine Overdose with Haemodialysis: A Case Report and Review

DOI: 10.2478/jccm-2022-0019

Caffeine, chemically 1,3,7-trimethylxanthine, is the most widely consumed central nervous system stimulant in the world with pleiotropic effects on the cardiovascular, pulmonary, and renal systems. The advent of over the counter (OTC) caffeine formulations has opened the window for potential toxicity, either by inadvertent or intentional overdosing. We present the case of a patient who attempted suicide by caffeine overdose treated with emergent haemodialysis and a review of the literature.

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Personalized Physiological Medicine as the Future of Intensive Care Medicine

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

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

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

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

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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