Volume 10, Issue 4, October 2024
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Category Archives: JCCM 2024
Tracheoesophageal Iatrogenic Fistulas in ICU: Still a Pandora’s Box?
DOI: 10.2478/jccm-2024-0044
Tracheoesophageal fistulas (TEF) in the ICU are still considered a relatively rare, but life-threatening complication of prolonged intubation, with an incidence of approximately 0.5% of cases [1]. Classically, their occurrence was considered the result of the direct interaction between two mechanical factors: the endotracheal tube (ETT) or the tracheostomy tube placement on the membranous wall of the trachea, and the esophageal feeding tube that affects esophageal mucosa, leading to ischemic lesions and decubitus injury. The question that arises is why, despite this simple explanation, the incidence of TEF remains low? In reality, the occurrence of TEF in ICU is related to the complex interactions between patients’ comorbidities and the particularities of pathophysiology and management in critically ill patients, leading to local tissue metabolic disorders and favoring fistulas’ occurrence. Malnutrition, diabetes, chronic anemia, reflux esophagitis, prolonged inflammation, sepsis, hemodynamic instability, prolonged hypoxemia, vasoactive drugs or corticosteroids are the mainly factors favoring fistulas’ development. [More]
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The Analgesic Effect of Morphine on Peripheral Opioid Receptors: An Experimental Research
DOI: 10.2478/jccm-2024-0042
Opioids represent one of the key pillars in postoperative pain management, but their use has been associated with a variety of serious side effects. Thus, it is crucial to investigate the timing and course of opioid administration in order to ensure a best efficacy to side-effect profile. The aim of our article was to investigate the analgesic effects of locally administered morphine sulfate (intraplantar) in a carrageenan-induced inflammation model in rats. After carrageenan administration, the rats were divided into 10 equal groups and were injected with either morphine 5 mg/kg or 0.9% saline solution at different time intervals, depending on the assigned group. The analgesic effect was assessed through thermal stimulation. Our results showed that paw withdrawal time was significantly higher in rats treated with morphine compared to those in the control group 9.18 ± 3.38 compared to 5.14 ± 2.21 seconds, p=0.012). However, differences were more pronounced at certain time intervals post-carrageenan administration (at 180 minutes compared to 360 minutes, p=0.003 and at 180 minutes compare to 1440 minutes p<0.001), indicating that efficacy varies depending on the timing of treatment. In conclusion, our findings support the hypothesis that locally administered morphine may alleviate pain under inflammatory conditions and underscores the importance of considering treatment timing when evaluating the analgesic effect.
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The Correlation of Hemostatic Parameters with the Development of Early Sepsis-Associated Encephalopathy. A Retrospective Observational Study
DOI: 10.2478/jccm-2024-0040
Introduction: Sepsis-associated encephalopathy (SAE) is one of the most common complications seen both in early and late stages of sepsis, with a wide spectrum of clinical manifestations ranging from mild neurological dysfunction to delirium and coma. The pathophysiology of SAE is still not completely understood, and the diagnosis can be challenging especially in early stages of sepsis and in patients with subtle symptoms.
Aim of the study: The objective of this study was to assess the coagulation profile in patients with early SAE and to compare the hemostatic parameters between septic patients with and without SAE in the first 24 hours from sepsis diagnosis.
Material and methods: This retrospective observational study included 280 patients with sepsis in the first 24 hours after sepsis diagnosis. A complete blood count was available in all patients; a complex hemostatic assessment including standard coagulation tests, plasmatic levels of coagulation factors, inhibitors, D-dimers, and Rotation thromboelastometry (ROTEM, Instrumentation Laboratory) was performed in a subgroup of patients.
Results: Early SAE was diagnosed in 184 patients (65.7%) and was correlated with a higher platelet count, after adjusting for age and leucocyte count. Compared to patients without neurological dysfunction, patients with early SAE presented a more active coagulation system revealed by faster propagation phase, increased clot firmness and elasticity with a higher platelet contribution to clot strength. The initiation of coagulation and clot lysis were not different between the groups.
Conclusion: In the early stages of sepsis, the development of SAE is correlated with increased systemic clotting activity where platelets seem to have an important role. More research is needed to investigate the role of platelets and the coagulation system in relation to the development of early SAE.
Keywords: platelets, sepsis-associated encephalopathy, rotation thromboelastometry, clotting, clot strength
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Understanding the Difficulties in Diagnosing Neonatal Sepsis: Assessing the Role of Sepsis Biomarkers
DOI: 10.2478/jccm-2024-0039
Background. Neonatal sepsis is a serious condition with high rates of morbidity and mortality, caused by the rapid growth of microorganisms that trigger a systemic reaction. Symptoms can range from mild to severe presentations. The causative microorganism is usually transmitted from mothers, especially from the urogenital tract, or can originate from the community or hospital.
Methods. Our retrospective study assessed 121 newborns, including both preterm and term infants, divided into three groups within the first 28 days of life: early-onset sepsis (35), late-onset sepsis (39), and a control group (47). Blood samples and cultures were obtained upon admission or at the onset of sepsis (at 24 and 72 hours). The study aimed to evaluate the limitations of commonly used biomarkers and new markers such as lactate dehydrogenase and ferritin in more accurately diagnosing neonatal sepsis.
Results. Our study revealed a significant difference between the initial and final measures of lactate dehydrogenase (LDH) and ferritin in the early-onset sepsis (EOS) and late-onset sepsis (LOS) groups.
Conclusion. Ferritin and LDH may serve as potential markers associated with systemic response and sepsis in cases of both early and late-onset sepsis. Monitoring these biomarkers can aid in the timely detection and management of sepsis, potentially improving patient outcomes.
Keywords: biomarkers, ferritin, neonatal sepsis, lactate dehydrogenase, neonatal intensive care unit
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Outcomes of Patients Transferred to Tertiary Center by Life-Saving System in Saudi Arabia. A Propensity Score Matching Observational Study
DOI: 10.2478/jccm-2024-0038
Background: Inter-hospital transfer is intended to provide access to centralized special care for critically ill patients, when resources in their hospitals are not available. However, an empirical gap exists in available evidence, as outcomes of transferred patients to higher centers are inconsistent.
Method: Single center propensity score matching retrospective observational study. Life-Saving transfers during 2023 were matched to direct admissions to the ICU. Hospital mortality, ICU length of stay, and costs of both groups were compared.
Results: During the study period, 328 Life-Saving transfers were matched to 656 direct admissions. Propensity score matching eliminated all imbalances between groups. Hospital mortality was not different between groups, there were 114 (34.8%) hospital mortalities of Life-Saving transfers, while there were 216 (32.9%) hospital mortalities of direct admissions, with a percent difference of 1.9% (95% CI: -4.5%, 8.4%); p value = 0.6, this result persisted in the sensitivity analysis. There were no differences in mortality risks for all the studied subgroups except pediatric patients. ICU length of stay of direct admissions and Life-Saving transfers were 10 ± 13.1 and 11.6 ± 12.4 days respectively, mean difference was statistically significant (-1.6 [95% CI: -3.2, 0.1]; p = 0.005). Life-Saving transfers entailed significantly higher costs per admission by 28,200 thousand SAR (95% CI: 26,400 – 30,000; p < 0.001).
Conclusion: Our study shows no difference in hospital mortality between Life-Saving transfers and direct admissions to ICU, however, Life-Saving transfers had a longer ICU length of stay, and higher costs per admission.
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Role of Quetiapine in the Prevention of ICU Delirium in Elderly Patients at a High Risk
DOI: 10.2478/jccm-2024-0032
Background: The aim of the present study was to denote the effectiveness of Quetiapine as additive to preventive bundle of delirium in elderly patients with multiple risks for delirium.
Patients and methods: The study was performed on 90 elderly patients over 60 years. The patients were divided into Group Q (Quetiapine) and Group C (No Quetiapine). Delirium was assessed using Intensive Care Delirium Screening Checklist (ICDSC) and the Confusion Assessment Method for the ICU (CAM-ICU).
Results: The incidence of delirium was significantly higher in group C. The severity of delirium was higher among group C; however, it was not statistically significant. The dominant type of delirium was hypoactive in group Q whereas hyperactive in group C. The interrater reliability between CAM-ICU-7 and ICDSE showed a kappa 0.98 denoting excellent correlation between the two scores. Somnolence was the most common side effect of Quetiapine (25%) followed by dry mouth (18%).
Conclusions: Prophylactic low dose of Quetiapine in elderly population in the preventive bundle could reduce the incidence of delirium with a low incidence of a major side effect, as well as CAM-ICU-7 is as effective as ICDSC in monitoring and early diagnosis of delirium.
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Outcome and Determining Characteristics of ICU Patients with Acute Kidney Injury in a Low-Income Country, a Multicenter Experience
DOI: 10.2478/jccm-2024-0037
Background: Acute kidney injury (AKI) is a disease that affects millions of people globally making it a major public health concern. It is defined as an abrupt decrease in kidney function that occurs within ours affecting both the structure and functionality of the kidneys.
The outcome of AKI and the determinants in Nigeria are largely unknown. This study aimed to describe the determining factors of the outcome of AKI patients admitted into the ICU of three tertiary health institutions in Northeast Nigeria.
Methods: The study is a prospective multicentered observational study of the patients admitted into the ICU in three tertiary health institutions from January 2022 to December 2023. KDIGO criteria was used to define AKI. The outcome of the study was to determine survivors among the patients admitted into the ICU with AKI or developed AKI while in ICU and also the determinants of mortality. A chi-square test was done to determine the association between the dependent variable (patient outcome) and the independent variables. To determine the predictors of patient outcomes, a regression analysis was done. The sociodemographic data of the patients admitted during these periods were studied in addition to Acute Physiology and Chronic Health Evaluation (APACHE) II, Kidney Disease: Improving Global Outcomes (KDIGO), Average length of stay in the ICU, Admitting/referring ward (Obstetrics, Gynae, Medical, Surgical or Emergency unit), Ability to afford care (out of pocket payment, social welfare or through Health insurance Scheme, Co-morbidity (presence or absence of comorbidity), Interventions done while in ICU (use of vasopressors and inotropes, mechanical ventilation (MV) support and renal replacement therapy (RRT) and outcome (discharge to the wards or mortality).
Results: Of 1494 patient records screened, 464 met the inclusion criteria. The overall incidence of AKI was 57%. About 53% were females, the mean age was 42.2 years, and 81% of the patients had a normal BMI (18.5 – 24.9). About 40% of the patients had APACHE II scores ≥ 29%. More than three-quarters (79.5%) of the patients paid for their health care expenditure out-of-pocket. Most patients (72%) were from the Medical and Gynae/Ward. Mortality was highest (54.2%) among patients who were brought into the ICU from the Medical ward. Most patients admitted were KDIGO I (44.3%) followed by KDIGO II (35.1%). Among the patients, 61.2% present with one or more comorbidity. Mortality was higher (50%) among those with comorbidity compared to 13.6% among those without comorbidity. Mortality was lowest among patients who stayed in the ICU between 8-14 days compared to those who stayed > 2 weeks. Most of the patients (72%) were from the Medical and Gynae/Ward. Mortality was highest (54.2%) among patients who were brought into the ICU from the Medical ward followed by those brought in from the Obstetric and Gynecological ward (20.4%). An association was found between the intervention received in the ICU and the outcome, which was found to be statistically significant (p < 0.001). A regression analysis was done to determine the predictors of patients’ outcomes admitted in the ICU. The results showed that APACHE II score greater than 10 (p-value < 0.001), presence of comorbidities (p = 0.031) and intervention which included a combination of Vasopressors, mechanical ventilation and RRT (p < 0.01) are the predictors of patients’ outcome. The regression model is valid (X2 = 469.894, df = 24, p < 0.001) and it fits the sample as shown by the Hosmer and Lemeshow test (X2 = 7.749, p = 0.45, df = 8,). It also shows that the predictors account for 92% of patients’ outcomes (Nagelkerke R2 = 0.92).
Conclusions: Our study revealed that the presence of comorbidity, high APACHE II score, and the need for interventional supports including both mechanical ventilatory and ionotropic, were found to be strong mortality predictors in patients with AKI.
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The Role of Feedback Training on Early Postoperative Recovery and Anxiety Scores in an Ambulatory Surgical Unit: A Secular Trend Study
DOI: 10.2478/jccm-2024-0036
Background: We used a ten-item postoperative quality of recovery score (QoR-10) to assess the perioperative quality of care in an in-hospital ambulatory surgical unit.
Methods: In Phase 1 of this secular trend study (n=300 patients, 3-months duration), we collected QoR-10 scores and potential confounders, including type of anesthesia and surgery; co-morbidities; and anesthesia components of the Amsterdam scale-measured anxiety scores. Phase 2 was the one-month performance feedback learning phase in which modifiable variables identified in Phase 1 were translated to actionable steps, reinforcing the already existing routine of our department’s clinical practices, including pain, shivering and anxiety. The anesthesiology team was instructed and reminded of these steps using performance feedback methods. In Phase 3 (n=300 patients, 3-month duration) we evaluated the efficacy of this performance feedback instruction. QoR-10 scores were compared between Phase 1 and Phase 3.
Results: Phase 1 identified three modifiable variables as targets for improvement: postoperative shivering; percentage of patients with numerical rating pain scale (NRS)<4; and preoperative anxiety from anesthesia scores. Compared to Phase 1, significantly fewer Phase 3 patients had severe shivering (2.3% vs. 7.3%, p = 0.023), and a greater percentage had NRS < 4 points (79% vs. 49.7%, p <0.001). The percentage of patients with a high anxiety score did not differ between phases. A direct association between anxiety score and QoR-10 score was not detected. The QoR-10 score (median (IQR)) was significantly higher in Phase 3 than Phase 1: 50 (49-50) vs. 49(49-50), p<0.001. In a multivariable logistic regression analysis, odds for a QoR-10 score of 49-50 were 1.92 higher in Phase 3 than Phase 1.
Conclusion: Considering the study limitations, team feedback education contributed to improvement of the QoR-10 score, reduced the proportion of patients with severe shivering and increased the percentage of patients with low pain scores.
Keywords: PACU, performance assessment, secular trend, feedback training, anesthesia, recovery score
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Combining O2 High Flow Nasal or Non-Invasive Ventilation with Cooperative Sedation to Avoid Intubation in Early Diffuse Severe Respiratory Distress Syndrome, Especially in Immunocompromised or COVID Patients?
DOI: 10.2478/jccm-2024-0035
This overview addresses the pathophysiology of the acute respiratory distress syndrome (ARDS; conventional vs. COVID), the use of oxygen high flow (HFN) vs. noninvasive ventilation (NIV; conventional vs. helmet) and a multimodal approach to avoid endotracheal intubation (“intubation”): low normal temperature, cooperative sedation, normalized systemic and microcirculation, anti-inflammation, reduced lung water, upright position, lowered intra-abdominal pressure.
Increased ventilatory muscle activity (“respiratory drive”) is observed in early ARDS, at variance with ventilatory fatigue observed in decompensated chronic obstructive pulmonary disease (COPD). This increased drive leads to impending then overt ventilatory failure. Therefore, muscle relaxation presents little rationale and should be replaced by lowering the excessive respiratory drive, increased work of breathing, continued or increased labored breathing, self-induced lung injury (SILI), i.e. preserving spontaneous breathing. As CMV is a lifesaver in the setting of failure but does not heal the lung, side-effects of intubation, controlled mechanical ventilation (CMV), paralysis and deep sedation are to be avoided. Additionally, critical care resources shortage requires practice changes.
Therefore, NIV should be routine when addressing immune-compromised patients. The SARS-CoV2 pandemics extended this approach to most patients, which are immune-compromised: elderly, obese, diabetic, etc. The early COVID is a pulmonary vascular endothelial inflammatory disease requiring lower positive-end-expiratory pressure than the typical pulmonary alveolar epithelial inflammatory diffuse ARDS. This leads one to reassess a) the technique of NIV b) the sedation regimen facilitating continuous and extended NIV to avoid intubation. Autonomic, circulatory, respiratory, ventilatory physiology is hierarchized under HFN/NIV and cooperative sedation (dexmedetomidine, clonidine). A prospective randomized pilot trial, then a larger trial are required to ascertain our working hypotheses.
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