Category Archives: JCCM 2023

Total Psoas Area and Psoas Density Assessment in COVID-19 Patients Using CT Imaging – Could Muscle Mass Alteration During Intensive Care Hospitalization be Determined?

DOI: 10.2478/jccm-2023-0026

Background: Since its debut, as reported by the first published studies, COVID-19 has been linked to life-threatening conditions that needed vital assistance and admission to the intensive care unit. Skeletal muscle is a core element in an organism’s health due to its ability to keep energy balance and homeostasis. Many patients with prolonged hospitalization are characterized by a greater probability prone to critical illness myopathy or intensive care unit-acquired weakness.
Objective: The main aim of this study was to assess the skeletal muscle in a COVID-19 cohort of critically ill patients by measuring the psoas area and density.
Material and methods: This is a retrospective study that included critically ill adult patients, COVID-19 positive, mechanically ventilated, with an ICU stay of over 24 hours, and who had 2 CT scans eligible for psoas muscle evaluation. In these patients, correlations between different severity scores and psoas CT scans were sought, along with correlations with the outcome of the patients.
Results: Twenty-two patients met the inclusion criteria. No statistically significant differences were noticed regarding the psoas analysis by two blinded radiologists. Significant correlations were found between LOS in the hospital and in ICU with psoas area and Hounsfield Units for the first CT scan performed. With reference to AUC-ROC and outcome, it is underlined that AUC-ROC is close to 0.5 values, for both the psoas area and HU, indicating that the model had no class separation capacity.
Conclusion: The study suggested that over a short period, the psoas muscle area, and the psoas HU decline, for both the left and the right sight, in adult COVID-19 patients in ICU conditions, yet not statistically significant. Although more than two-thirds of the patients had a negative outcome, it was not possible to demonstrate an association between the SARS-COV2 infection and psoas muscle impairment. These findings highlight the need for further larger investigations.

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A Retrospective Cohort Study of Traumatic Brain Injury in Children: A Single-Institution Experience and Determinants of Neurologic Outcome

DOI: 10.2478/jccm-2023-0027

Introduction: Traumatic brain injury (TBI) has become a significant cause of death and morbidity in childhood since the elucidation of infectious causes within the last century. Mortality rates in this population decreased over time due to developments in technology and effective treatment modalities.
Aim of the study: This retrospective cohort study aimed to describe the volume, severity and mechanism of all hospital-admitted pediatric TBI patients at a university hospital over a 5-year period. Material and
Methods: This was a single-center, retrospective cohort study including 90 pediatric patients with TBI admitted to a tertiary care PICU. The patients’ demographic data, injury mechanisms, disease and trauma severity scores, initiation of enteral nutrition and outcome measures such as hospital stay, PICU stay, duration of mechanical ventilation, mortality, and Glasgow Outcome Scale (GOS) were also recorded. Late enteral nutrition was defined as initiation of enteral feeding after 48 hours of hospitalization.
Results: Of the 90 patients included in the cohort, 60% had mild TBI, 21.1% had moderate TBI and 18.9% had severe TBI. Their mean age was 69 months (3-210 months). TBI was isolated in 34 (37.8%) patients and observed as a part of multisystemic trauma in 56 (62.2%). The most commonly involved site in multisystemic injury was the thorax (33.3%). The length of hospitalization in the late enteral nutrition group was significantly higher than that in the early nutrition group, while the PICU stay was not significantly different between the two groups. The multiple logistic regression analysis found a significant relationship between GOS-3rd month and PIM3 score, the presence of diffuse axonal injury and the need for CPR in the first 24 h of hospitalization.
Conclusion: Although our study showed that delayed enteral nutrition did not affect neurologic outcome, it may lead to prolonged hospitalization and increased hospital costs. High PIM3 scores and diffuse axonal injury are both associated with worse neurologic outcomes.

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The Prognostic Utility of Cytokines in Hospitalized COVID-19 Patients

DOI: 10.2478/jccm-2023-0025

Introduction: The severity of COVID-19 depends on several factors, but the overproduction of pro-inflammatory cytokines remains in center of the interest. The aim of this study was to investigate the predictive utility of interleukin (IL)-6, IL-8, IL-10, IL-12, tumor necrosis factor alpha (TNF-α), and interferon gamma (IFN-γ) in patients with COVID-19.
Material and Methods: We prospectively enrolled 181 adult patients with COVID-19 admitted to the 1st Infectious Disease County Hospital Târgu Mureș from December 2020 to September 2021. Serum cytokine levels were measured and correlated with disease severity, need for oxygen therapy, intensive care unit (ICU) transfer, and outcome.Results: We found significantly higher serum levels of IL-6, IL-8, and IL-10 in patients with severe COVID-19 and in those with a fatal outcome. The logistic regression analysis showed a significant predictive value for IL-8 regarding disease severity, and for IL6 and IL-10 regarding ICU transfer and fatal outcome.
Conclusions: Serum levels of IL-6, IL-8, and IL-10 were significantly increased in patients with COVID-19, but their predictive value regarding disease severity and the need for oxygen therapy was poor. We found IL-6 and IL-10 to have a good predictive performance regarding ICU transfer and fatal outcome.

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The Gender Gap in Aortic Dissection:
A Prospective Analysis of Risk and Outcomes

DOI: 10.2478/jccm-2023-0024

Aortic dissection (AD) is a severe cardiovascular condition that could have negative consequences. Our study employed a prospective design and examined preoperative, perioperative, and postoperative data to evaluate the effects of gender on various medical conditions. We looked at how gender affected the results of aortic dissection (AD). In contrast to female patients who had more systemic hypertension (p=0.031), male patients had higher rates of hemopericardium (p=0.003), pulmonary hypertension (p=0.039), and hemopericardium (p=0.003). Dobutamine administration during surgery significantly raised the mortality risk (p=0.015). There were noticeably more women patients (p=0.01) in the 71 to 80 age group. Significant differences in age (p=0.004), eGFR at admission (p=0.009), and eGFR at discharge (p=0.006) were seen, however, there was no association between gender and mortality. In conclusion, our findings highlight that gender may no longer be such an important aspect of aortic dissection disease as we previously thought, and this information could have an important contribution for surgeons as well as for anesthesiologists involved in the management of acute aortic dissection.

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Risk Factors for Weaning Failure in COVID-19 Patients

DOI: 10.2478/jccm-2023-0021

Background: Data on risk factors associated with mechanical ventilation (MV) weaning failure among SARS-CoV2 ARDS patients is limited. We aimed to determine clinical characteristics associated with weaning outcome in SARS-CoV2 ARDS patients under MV.
Objectives: To determine potential risk factors for weaning outcome in patients with SARS-CoV2 ARDS.
Methods: A retrospective observational study was conducted in the ICUs of four Greek hospitals via review of the electronic medical record for the period 2020-2021. All consecutive adult patients were screened and were included if they fulfilled the following criteria: a) age equal or above 18 years, b) need for MV for more than 48 hours and c) diagnosis of ARDS due to SARS-CoV2 pneumonia or primary or secondary ARDS of other aetiologies. Patient demographic and clinical characteristics were recorded for the first 28 days following ICU admission. The primary outcome was weaning success defined as spontaneous ventilation for more than 48 hours.
Results: A hundred and fifty eight patients were included; 96 SARS-CoV2 ARDS patients. SOFA score, Chronic Obstructive Pulmonary Disease (COPD) and shock were independently associated with the weaning outcome OR(95% CI), 0.86 (0.73-0.99), 0.27 (0.08-0.89) and 0.30 (0.14-0.61), respectively]. When we analysed data from SARS-CoV2 ARDS patients separately, COPD [0.18 (0.03-0.96)] and shock [0.33(0.12 – 0.86)] were independently associated with the weaning outcome.
Conclusions: The presence of COPD and shock are potential risk factors for adverse weaning outcome in SARS-CoV2 ARDS patients.

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Fluid Therapy from Friend to Foe

DOI: 10.2478/jccm-2023-0019

The general management of shock, or any syndrome characterized by inadequate tissue perfusion involves identifying and addressing the underlying cause while also reversing the disorder produced in any of the 4 components of the cardiovascular system (blood and fluid compartment, vascular system, heart and circulatory system) [1] through combined therapeutic methods that are based on rapid volume resuscitation, usually pursuing target goals. Although the “salvage, optimization, stabilization, de-escalation” mnemonic has been utilized as a broad framework for volume resuscitation since 2016 [2], the approach to fluid therapy in critically ill patients remains inconsistent with current clinical practice, contingent upon the practices adopted by individual healthcare institutions. [More]

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Kidney injury in critically ill patients with COVID-19 – From pathophysiological mechanisms to a personalized therapeutic model

DOI: 10.2478/jccm-2023-0023

Acute kidney injury is a common complication of COVID-19, frequently fuelled by a complex interplay of factors. These include tubular injury and three primary drivers of cardiocirculatory instability: heart-lung interaction abnormalities, myocardial damage, and disturbances in fluid balance. Further complicating this dynamic, renal vulnerability to a “second-hit” injury, like a SARS-CoV-2 infection, is heightened by advanced age, chronic kidney disease, cardiovascular diseases, and diabetes mellitus. Moreover, the influence of chronic treatment protocols, which may constrain the compensatory intrarenal hemodynamic mechanisms, warrants equal consideration. COVID-19-associated acute kidney injury not only escalates mortality rates but also significantly affects long-term kidney function recovery, particularly in severe instances. Thus, the imperative lies in developing and applying therapeutic strategies capable of warding off acute kidney injury and decelerating the transition into chronic kidney disease after an acute event. This narrative review aims to proffer a flexible diagnostic and therapeutic strategy that recognizes the multifaceted nature of COVID-19-associated acute kidney injury in critically ill patients and underlines the crucial role of a tailored, overarching hemodynamic and respiratory framework in managing this complex clinical condition.

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Fluids and early vasopressors in the management of septic shock: Do we have the right answers yet?

DOI: 10.2478/jccm-2023-0022

Septic shock is a common condition associated with hypotension and organ dysfunction. It is associated with high mortality rates of up to 60% despite the best recommended resuscitation strategies in international guidelines. Patients with septic shock generally have a Mean Arterial Pressure below 65 mmHg and hypotension is the most important determinant of mortality among this group of patients. The extent and duration of hypotension are important. The two initial options that we have are 1) administration of intravenous (IV) fluids and 2) vasopressors, The current recommendation of the Surviving Sepsis Campaign guidelines to administer 30 ml/kg fluid cannot be applied to all patients. Complications of fluid over-resuscitation further delay organ recovery, prolong ICU and hospital length of stay, and increase mortality. The only reason for administering intravenous fluids in a patient with circulatory shock is to increase the mean systemic filling pressure in a patient who is volume-responsive, such that cardiac output also increases. The use of vasopressors seems to be a more appropriate strategy, the very early administration of vasopressors, preferably during the first hour after diagnosis of septic shock, may have a multimodal action and potential advantages, leading to lower morbidity and mortality in the management of septic patients. Vasopressor therapy should be initiated as soon as possible in patients with septic shock.

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Ease of intubation with McGrath videolaryngoscope and incidence of adverse events during tracheal intubation in COVID-19 patients: A prospective observational study

DOI: 10.2478/jccm-2023-0020

Background: Tracheal intubation in critically ill patients remains high-risk despite advances in equipment, technique, and clinical guidelines. Many patients with COVID-19 were in respiratory distress and required intubation that is considered an aerosol-generating procedure (AGP). The transition to videolaryngoscopy as a routine first line option throughout anesthetic and ICU practice has been reported. We evaluated the ease of intubation, success rate, use of accessory maneuvers and adverse outcomes during and 24 hours after intubation with the McGrath videolaryngoscope.
Methods: This was a prospective, observational single center study conducted at non-operating room locations that included all adults (>18 years old) with suspected or confirmed COVID-19 infection and were intubated by McGrath videolaryngoscope. The anesthesiologist performed tracheal intubation were requested to fill online data collection form. A co-investigator was responsible to coordinate daily with assigned consultants for COVID intubation and follow up of patients at 24 hours after intubation.
Results: A total of 105 patients were included in our study. Patients were predominantly male (n=78; 74.3%), their COVID status was either confirmed (n=97, 92.4%) or suspected (n=8, 7.6%). Most were intubated in the COVID ward (n=59, 56.2%) or COVID ICU (n=23, 21.9%). The overall success rate of intubation with McGrath in the first attempt was 82.9%. The glottic view was either full (n=85, 80.95%), partial (n=16, 15.24%) or none (n=4, 3.81%). During intubation, hypoxemia occurred in 18.1% and hypotension in 16.2% patients. Within 24 hours of intubation, pneumothorax occurred in 1.9%, cardiac arrest and return of spontaneous circulation in 6.7% and mortality in 13.3% of patients.
Conclusion: These results illustrate the ease and utility of the McGrath videolaryngoscope for tracheal intubation in COVID-19 patients. Its disposable blade is of significant value in protectin during tracheal intubation.

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