Category Archives: Volume 3

Extracorporeal Membrane Oxygenation in Nivolumab Associated Pneumonitis

Thomas-Michael Schneider1*, Friederike Klenner2, Franz Brettner1

1 Department of Intensive Care Medicine, Krankenhaus Barmherzige Brueder, Munich, Germany
2 Department of Internal Medicine V, University of Munich, Germany

DOI: 10.1515/jccm-2017-0013

Background: Newly approved immunotherapeutic agents, like CTLA-4 inhibitors and antibodies against PD-1, are a promising therapeutic option in cancer therapy.
Case presentation: A 74-year-old man, with a history of advanced stage melanoma and treatment with ipilimumab, pembrolizumab and nivolumab, was admitted to the hospital due to respiratory failure with hypoxemia and dyspnoea. He rapidly developed severe acute respiratory distress syndrome (ARDS), which required treatment in the intensive care unit which included mechanical ventilation and extracorporeal membrane oxygenation (ECMO). Computed tomographic imaging (CT) showed signs of a pneumonitis, with an ARDS pattern related to the use of PD-1 antibodies. Treating the patient with high-dose immunosuppressive steroids led to an overall improvement. He was transferred to a rehabilitation hospital and subsequently to his home.
Discussion and conclusion: This is a unique case report of a patient suffering a grade 4 adverse event under nivolumab who survived having been treated with ECMO. It highlights the possibility of associated adverse reactions as well as the use of ECMO in palliative care patients. ECMO can be of great success even in patients with malignancies, but careful decision making should be done on a case by case basis.

Keywords: , , , ,
Full text: PDF

Non-Obvious, Post-Traumatic, Life-Threatening Bleeding in Two Elderly Patients

Rafael García Carretero

Internal Medicine Department, Mostoles University Hospital, Spain

DOI: 10.1515/jccm-2017-0012

The main complication of anticoagulant therapy is major bleeding. Clinicians are usually aware of these side effects and are careful when managing the therapeutic range of vitamin K antagonist drugs. But major bleeding, while life-threatening, can be overlooked if there are no visible signs of bleeding. Two cases are described in which inaccurate diagnoses lead to inadequate treatment.

Keywords: , ,
Full text: PDF

Anticoagulant Therapy in Sepsis. The Importance of Timing

Ecaterina Scarlatescu1, Dana Tomescu1,2, Sorin Stefan Arama2

1 Department of Anesthesiology and Intensive Care III, Fundeni Clinical Institute, Bucharest, Romania
2 University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania

DOI: 10.1515/jccm-2017-0011

Sepsis associated coagulopathy is due to the inflammation-induced activation of coagulation pathways concomitant with dysfunction of anticoagulant and fibrinolytic systems, leading to different degrees of haemostasis dysregulation. This response is initially beneficial, contributing to antimicrobial defence, but when control is lost coagulation activation leads to widespread microvascular thrombosis and subsequent organ failure. Large clinical trials of sepsis-related anticoagulant therapies failed to show survival benefits, but posthoc analysis of databases and several smaller studies showed beneficial effects of anticoagulants in subgroups of patients with early sepsis-induced disseminated intravascular coagulation. A reasonable explanation could be the difference in timing of anticoagulant therapy and patient heterogeneity associated with large trials. Proper selection of patients and adequate timing are required for treatment to be successful. The time when coagulation activation changes from advantageous to detrimental represents the right moment for the administration of coagulation-targeted therapy. In this way, the defence function of the haemostatic system is preserved, and the harmful effects of overwhelming coagulation activation are avoided.

Keywords: , ,
Full text: PDF

Neurosyphilis Masquerading as Stroke in an 84-year-old

Cristina Bologa1, Catalina Lionte1, Diana Halit2, Catalina Luca3

1 Internal Medicine Department, 2nd Internal Medicine Clinic,”Sf. Spiridon” Clinical County Emergency Hospital, “Gr. T. Popa”University of Medicine, Iasi, Romania
2 Neurology Department, “Prof. Dr. N. Oblu” Clinical Emergency Hospital, Iasi, Romania
3 Infectious Disease Department, “Sf. Parascheva” Clinical Hospital, “Gr. T. Popa” University of Medicine, Iasi, Romania

DOI: 10.1515/jccm-2017-0009

The case of an 84 years old woman with uncharacteristic neurologic and cognitive symptoms, suspected of ischemic stroke is presented. Following an extensive assessment in the departments of neurology and internal medicine, the unusual aetiology of stroke was identified as meningovascular neurosyphilis. The patient fully recovered after antibiotic therapy. To our knowledge, this the eldest patient with tertiary neurosyphilis reported in the literature.

Keywords: , , ,
Full text: PDF

Toxic Megacolon – A Three Case Presentation

Irina Magdalena Dumitru1, Eugen Dumitru2, Sorin Rugina1,3, Liliana Ana Tuta2

1 Discipline of Infectious Diseases, Faculty of Medicine, Ovidius University of Constanta, Romania
2 Discipline of Internal Medicine, Faculty of Medicine, Ovidius University of Constanta, Romania
3 The Academy of Romanian Scientists

DOI: 10.1515/jccm-2017-0008

Introduction: Toxic megacolon is a life-threatening disease and is one of the most serious complications of Clostridium difficile infection (CDI), usually needing prompt surgical intervention. Early diagnosis and adequate medical treatment are mandatory.
Cases presentation: In the last two years, three Caucasian female patients have been diagnosed with toxic megacolon and treated in the Clinical Infectious Diseases Hospital, Constanta. All patients had been hospitalized for non-related conditions. The first patient was in chemotherapy for non-Hodgkin’s lymphoma, the second patient had undergone surgery for colon cancer, and the third patient had surgery for disc herniation. In all cases the toxin test (A+B) was positive and ribotype 027 was present. Abdominal CT examination, both native and after intravenous contrast, showed significant colon dilation, with marked thickening of the wall. Resolution of the condition did not occur using the standard treatment of metronidazole and oral vancomycin, therefore the therapy was altered in two cases using intracolonic administration of vancomycin and intravenous tigecycline.
Conclusions: In these three cases of CDI, the risk factors for severe evolution were: concurrent malignancy, renal failure, obesity, and immune deficiencies. Ribotype 027, a marker for a virulent strain of CD, was found in all three cases complicated by toxic megacolon. The intracolonic administration of vancomycin, and intravenous tigecycline was successful when prior standard therapy had failed, and surgery was avoided.

Keywords: , ,
Full text: PDF

Simulation-based Training as Perceived by Young Anesthesiology and Intensive Care Residents

Sanda-Maria Copotoiu1, Ruxandra Copotoiu2

1 University of Medicine and Pharmacy of Tirgu Mures, Romania
2 Nouvel Hôpital Civil de Strasbourg, Pole d’anesthésie, Strasbourg, France

DOI: 10.1515/jccm-2017-0007

Medical  simulation-based teaching  includes a variety of educational techniques used to complement actual patient experiences with true-to-life yet artificial tasks.
This field is rapidly growing and is widely used in critical care graduate medical education programs, having teaching, learning and assessment roles.
Its use is on the increase due to many factors including patient discontent with being “practiced on”, current considerations regarding patient safety, and the significance of early attainment of complex medical proficiencies. Simulation-based assessment (SBA) is advancing to the point where it can revolutionize the way clinical competence is assessed in residency training programs. [More]

Keywords: , ,
Full text: PDF

Anaesthesia and Intensive Care Residents’ Perception of Simulation Training in Four Romanian Centres

Horațiu N Vasian1, Simona C Mărgărit1, Ioana Grigoraș2, Leonard Azamfirei3, Dan Corneci4, Daniela Ionescu1,5

1 Iuliu Hațieganu University of Medicine and Pharmacy, 1st Department of Anaesthesia and Intensive Care, Cluj-Napoca, Romania
2 Department of Anaesthesiology and Intensive Care, Gr. T. Popa University of Medicine and Pharmacy, Iași, Romania
3 Department of Intensive Care, University of Medicine and Pharmacy, Târgu-Mureș, Romania
4 Department of Anaesthesiology and Intensive Care, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
5 Outcome Research Consortium, Cleveland, Ohio, USA

DOI: 10.1515/jccm-2017-0005

Introduction: Simulation training offers an opportunity to educate anaesthesia and intensive care (AIC) residents safely. At present, it is not yet a mandatory part of residency curriculum.
The aim of the study was to evaluate the residents’ perception of the inclusion of simulation-based training in the Romanian AIC residency program.
Material and methods: Romanian AICs in anaesthesia and intensive care from four training centres completed a twenty-question survey regarding their views on simulation during their residency training. Residents were divided into junior, in the first three years, or senior groups, in the last two years of residency training. The questionnaire included Likert-scale multiple-choice, open-ended, and “yes” or “no” questions regarding simulator learning, the frequency of simulation sessions, and the value of the simulation sessions in improving practice, skills or teamwork. The open-ended questions, asked which were the respondents’ preferred topics to be included in simulation sessions.
Results: Fifty-six percent of residents completed and returned the questionnaire. Ninety-eight percent of them considered simulation-learning useful once a month or every three months especially in the first two years of training. All residents thought simulation sessions would improve their skills, communication abilities, and teamwork. Senior residents paid more attention to clinical scenarios (p=0.007), haemodynamic monitoring (p=0.017) and mechanical ventilation (p=0.004) as compared to juniors. All residents considered difficult airway management, and cardiac life support to be very important issues to be included in simulation sessions.
Conclusion: The survey demonstrated that simulation-based training should play a greater role and eventually became compulsory in training program in AIC academic centres.

Supplementary material

Keywords: , , ,
Full text: PDF

The Relevance of Coding Gene Polymorphysms of Cytokines and Cellular Receptors in Sepsis

Anca Meda Georgescu1, Bianca Liana Grigorescu2, Ioana Raluca Chirteș1, Alexander A. Vitin3, Raluca Ștefania Fodor4

1 Infectious Diseases Clinic, University of Medicine and Pharmacy Tirgu Mures, Romania
2 Discipline of Pathophysiology, University of Medicine and Pharmacy Tirgu Mures, Romania
3 University of Washington, Medical Center, Seattle, USA
4 Anesthesiology and Intensive Care Clinic, University of Medicine and Pharmacy Tirgu Mures, Romania

DOI: 10.1515/jccm-2017-0001

Sepsis is an injurious systemic host response to infection, which can often lead to septic shock and death. Recently, the immune-pathogenesis and genomics of sepsis have become a research topic focusing on the establishment of diagnostic and prognostic biomarkers. As yet, none have been identified as having the necessary specificity to be used independently of other factors in this respect. However the accumulation of current evidence regarding genetic variations, especially the single nucleotide polymorphisms (SNPs) of cytokines and other innate immunity determinants, partially explains the susceptibility and individual differences of patients with regard to the evolution of sepsis. This article outlines the role of genetic variation of some serum proteins which have the potential to be used as biomarker values in evaluating sepsis susceptibility and the progression of the condition.

Keywords: , , , ,
Full text: PDF

Neutrophil Gelatinase-Associated Lipocalin as a Marker for Renal Dysfunction Detection in Critically Ill Patients with Increased Intraabdominal Pressure

Claudiu Puiac1, Janos Szederjesi2, Alexandra Lazăr2, Codruța Bad2, Lucian Pușcașiu1

1 Gynecology and Obstetrics Department, University of Medicine and Pharmacy of Tirgu Mures, Romania
2 Anesthesiology Department, University of Medicine and Pharmacy of Tirgu Mures, Romania

DOI: 10.1515/jccm-2017-0006

Introduction: Elevated intraabdominal pressure (IAP) it is known to have an impact on renal function trough the pressure transmitted from the abdominal cavity to the vasculature responsible for the renal blood flow. Intraabdominal pressure is found to be frequent in intensive care patients and also to be a predictor of mortality. Intra- abdominal high pressure is an entity that can have serious impact on intensive care admitted patients, studies concluding that if this condition progresses to abdominal compartment syndrome mortality is as high as 80%.
Aim: The aim of this study was to observe if a link between increased intraabdominal pressure and modification in renal function exists (NGAL, creatinine clearance).
Material and Method: The study enrolled 30 critically ill patients admitted in the Intensive Care Unit of SCJU Tîrgu Mures between November 2015 and August 2016. The study enrolled adult, hemodynamically stable patients admitted in intensive critical care – defined by a normal blood pressure maintained without any vasopressor or inotropic support, invasive monitoring using PICCO device and abdominal pressure monitoring.
Results: The patients were divided into two groups based on the intraabdominal pressure values: normal intraabdominal pressure group= 52 values and increased intraabdominal group= 35 values. We compared the groups in the light of NGAL values, 24 hours diuresis, GFR and creatinine clearance. The groups are significantly different when compared in the light of NGAL values and GFR values. We obtained a statistically significant correlation between NGAL value and 24 hour diuresis. No other significant correlations were encountered between the studied items.
Conclusions: NGAL values are increased in patients with high intraabdominal pressure which may suggest its utility as a cut off marker for patients with increased intraabdominal pressure. There is a significant decreased GFR in patient with elevated intraabdominal pressure, observation which can help in early detection of renal injury in patients due to high intraabdominal pressure. No correlation was found between creatinine clearance and increased intraabdominal pressure.

Keywords: , , , , , ,
Full text: PDF

Emergency Surgery in a Critically Ill Patient with Major Drug-Induced Bleeding and Severe Ischaemic Heart Failure

Dana Tomescu1,2, Mihai Popescu1,2

1 “Carol Davila” University of Medicine and Pharmacy, Department of Anaesthesia and Critical Care, Bucharest, Romania
2 Fundeni Clinical Institute, Department of Anaesthesia and Critical Care III, Bucharest, Romania

DOI: 10.1515/jccm-2017-0003

Introduction: Anticoagulant overdose frequently occurs in elderly populations especially in remote areas where medical services are scarce. When emergency surgery is required, such patients offer major anaesthetic challenges.
Case presentation: We describe the case of an elderly patient admitted to a surgical ward with acute abdominal pain, on dual anti-platelet therapy and acenocoumarol for a recent acute myocardial infarction treated percutaneously with two drug-eluting stents. Laboratory tests showed severe anticoagulant overdose with uncoagulable INR. The decision was made to use of both light transmission aggregometry [LTA] for platelet function testing and thromboelastography to aid in the management of perioperative haemostasis in order to prevent both severe bleeding and stent thrombosis. Surgery revealed haemoperitoneum, volvulus of the ileum and a venous mesenteric infarction. Intraoperative blood loss was minimal and no blood products were administered. Postoperative course was uneventful without either thrombotic or haemorrhagic complications and the patient was discharged from the Postanaesthesia Care Unit on postoperative day two.
Conclusion: The use of aggregometry and thrombography helped in both evaluation and management of haemostasis of a high-risk patient by goal-directed administration of pro-and anti- coagulants.

Keywords: , , , ,
Full text: PDF