Category Archives: Volume 5

Perioperative Care for Organ Transplant Recipient: Time for Paradigm Shift

Alexander A. Vitin

Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle WA, USA

DOI: 10.2478/jccm-2019-0016

Transplantation medicine, one of the emerging major medical disciplines, encompasses a wide variety of clinical subspecialties.
The concept of replacing organs which are failing or showing insufficiency, with single or multiple organs, either artificial or from donors, is accepted in literally every clinical field
There is explosive growth in the transplant sector driven by an ever-increasing patient demand fuelled by the already well-proven efficiency of organ transplantation as an ultimate treatment for end-stage organs failure and the ever-expanding infrastructure of the transplantation industry.
The foundation of this industry rests on two pillars: transplantation medicine and transplantation science. The sheer magnitude of the progress within the transplantation industry, as it stands today, maybe best illustrated by impressive statistics and facts, accomplishments and ongoing research trends. [More]

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Precision Medicine and its Role in the Treatment of Sepsis: A Personalised View

Alexandra Lazăr1, Anca Meda Georgescu2, Alexander Vitin3, Leonard Azamfirei1

1 Department of Anesthesiology and Intensive Care, University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Romania
2 Department of Infectious Diseases, University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Romania
3 Department of Anesthesiology & Pain, Medicine University of Washington Medical Center, Seattle WA, USA

DOI: 10.2478/jccm-2019-0017

In recent years, a new form of medicine has become increasingly significant, namely, personalised medicine (PM). PM is a form of care in which treatment is tailored for an individual patient.
PM is about using multiple data sets to create a digital human mapping. A person’s biological traits are determined by the interactions of hundreds of genes and gene networks, as well as external factors such as diet and exercise. Combining and then investigating these multiple databases with powerful statistical tools, allows a new understanding of how genetic intricacy drives health and disease and so leads to a closer personalised medical approach that targets each individual’s unique genetic make-up.
Sepsis is a systemic inflammatory response to infection, ranging from systemic inflammatory response syndrome (SIRS) to septic shock and multiple organ dysfunction syndromes (MODS). Sepsis is the most common cause of death in intensive care patients. Treatments in an ICU may need to be adapted to the continuous and rapid changes of the disease, making it challenging to identify a single target. PM is thus seen as the future of sepsis treatment in the ICU.
The fact that individual patients respond differently to treatment should be regarded as a starting point in the approach to providing treatment. The disease itself comes secondary to this concept.

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The Management of a Thirteen Weeks Pregnant Woman Rendered Brain-Dead Following a Ruptured Aneurysm

Iwona Pikto-Pietkiewicz, Antoni Okniński, Rafał Wójtowicz, Marlena Wójtowicz

Central Clinical Hospital of the MSWiA. Clinical Department of Intensive Care and Anaesthesiology. Warsaw, Poland

DOI: 10.2478/jccm-2019-0015

Introduction: The current lack of clear guidelines on how to manage cases of brain-dead pregnant patients makes this topic controversial and extremely difficult to deal with for both medical and ethical reasons. This report deals with such a situation.
Case presentation: A twenty-seven years old woman, thirteen weeks pregnant, with a ruptured brain aneurysm was admitted to an Intensive Care Unit. She presented with loss of all brain functions, but somatic support was sustained to enable the delivery of her baby.
Conclusion: The case report gives a detailed account of the management of the mother before the successful delivery of her baby. It indicates the need for ongoing contributions to the debate on this delicate subject area to establish guidelines on how to manage brain-dead pregnant patients.

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Locked-In Syndrome Following Cervical Manipulation by a Chiropractor: A Case Report

Guillaume Giordano Orsini1, Giorgios-Emmanouil Metaxas2, Vincent Legros3

1 Emergency Department, University Hospital of Reims, Reims, France
2 Radiology Department, University Hospital of Reims, Reims, France
3 Intensive Care Unit, University Hospital of Reims, Reims, France

DOI: 10.2478/jccm-2019-0014

Introduction: Vertebrobasilar occlusion poses difficult diagnostic issues and even when properly diagnosed has a poor prognosis. Newer studies highlight a better outcome when thrombectomy was carried out between six and twenty-four hours after an initial diagnosis of stroke. This paper reports a case where a patient suffered a vertebrobasilar stroke secondary to a traumatic bilateral vertebral arteries dissection was treated with late thrombectomy.
Case presentation: A 34-year-old woman was manipulated on the cervical spinal column by a chiropractor. Following three weeks of cervical pain, she presented with severe aphasia and quadriplegia (NIHSS = 28). An MRI scan indicated ischemia of the vertebrobasilar system. Thirty-one hours after the onset of these symptoms, a thrombectomy was performed. After one month, the patient could move her head and the proximal part of her limbs but remained confined to bed (NIHSS = 13).
Conclusion: The current case illustrates the benefit of late mechanical thrombectomy for a posterior cerebral circulation infarct. Although there was a delay in treatment, partial recovery ensued.

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Cervical Spine Spondylitis with an Epidural Abscess in a Patient with Brucellosis: A Case Report

Mohammad Reza Hasanjani Roushan1, Soheil Ebrahimpour1, Zeinab Mohseni Afshar2, Arefeh Babazadeh1

1 Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, I.R. Iran
2 Department of Infectious Diseases, Kermanshah University of Medical Sciences, Kermanshah, Iran

DOI: 10.2478/jccm-2019-0013

Introduction: Human brucellosis, the most prevalent zoonotic disease worldwide, is a systemic infection which can involve several organs. Among musculoskeletal complaints, spondylitis is the most frequent complication of brucellosis and primarily affects the lumbar and thoracic vertebrae. The involvement of the cervical spine is infrequent.
Case report: This case report concerns an unusual case of cervical spine spondylitis with an epidural abscess due to Brucella in a 43-year-old man. The diagnosis was based on the patient being domiciled in an endemic region, his symptoms and his occupation. Clinical outcomes improved following antimicrobial therapy of rifampin, doxycycline, and gentamycin, and were confirmed radiologically.
Conclusion: Early diagnosis and treatment are crucial for these patients. The timely commencement of medical treatment can help prevent surgery.

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Pyruvate Dehydrogenase Complex Deficiency: An Unusual Cause of Recurrent Lactic Acidosis in a Paediatric Critical Care Unit

Neha Gupta, Chrystal Rutledge

Department of Pediatrics, Division of Pediatric Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA

DOI: 10.2478/jccm-2019-0012

Pyruvate dehydrogenase complex deficiency (PDCD) is a rare neurodegenerative disorder associated with abnormal mitochondrial metabolism. Structural brain abnormalities are common in PDCD. A case of a patient with PDCD with an unusual presentation is described. A 20-month-old boy with hypotonia and developmental delay, presented with hypoxia and respiratory distress due to bronchiolitis. During hospitalisation, he was prescribed PediaSure® feeds. Two days after starting these feeds, he developed respiratory arrest requiring intubation. His blood gas before arrest revealed lactate of 8.9 mmol/L despite normal haemodynamics. After stabilisation and a period of compulsory fasting, subsequent feeding with PediaSure® resulted in the recurrence of lactic acidosis. A metabolic workup revealed an elevated serum pyruvate level. Brain MRI was normal. Skeletal muscle biopsy confirmed PDCD. The most common cause of PDCD is a mutation in the X-linked PDHA1 gene. The severity of PDCD can range from neonatal death to more delayed onset of symptoms as in our index case. Normal brain MRI is reported in only 2% of patients with PDCD. There is no effective treatment for PDCD. In patients with proximal muscle weakness and feeding intolerance with glucose-containing feeds, the presence of lactic acidosis should raise the suspicion of PDCD irrespective of the patient’s age and normal MRI.

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Increased Susceptibility to Postoperative PCA Morphine-Induced Respiratory Depression in a Patient with an Undiagnosed Traumatic Porencephalic Cyst – A Case Report

Cristina Petrișor1,2, Sebastian Trancă1,2, Andreea Cordoș2,3, Vasile Bințințan2,3

1 Anesthesia and Intensive Care II Department, “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania
2 Clinical Emergency County Hospital Cluj-Napoca, Romania
3 Surgery Department I, “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania

DOI: 10.2478/jccm-2019-0011

Introduction: Patient-controlled analgesia with morphine is routinely used for postoperative pain management. Due to the safety profiles of the technique, which are patient/disease related or technique/equipment related, severe respiratory depression requiring opioid antagonists or airway management are uncommon.
Case presentation: The case of a patient with right colon carcinoma who was operated on for hemicolectomy under general anaesthesia and who presented with apnoea, after postoperatively receiving an initial bolus of 1mg of morphine. A large post-traumatic porencephalic cyst of the left brain hemisphere, previously undiagnosed, was found on the computed tomography scan. We excluded human errors, technique and equipment factors, and the patient did not have any other predisposing conditions like sleep apnoea, obesity, recent head injury or concurrent use of other sedatives. Previously the patient had been entirely asymptomatic, and her increased susceptibility to respiratory depression was the only clinical manifestation of porencephaly.
Conclusion: Adult acquired porencephaly is seldom reported in the literature, clinical manifestations depending on the location and size of the cyst. In the present reported case, increased susceptibility to low-dose opioids might be associated with the structural and functional reorganisation of the brain after head trauma with the occurrence of the porencephalic cyst of the brain.

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Refractory Lactic Acidosis and an Approach to Its Management – A Case Report

Yingke He1, John Ong2, Sharon Ong3

1 Division of Anaesthesiology, Singapore General Hospital, Singapore
2 Department of Engineering, Materials Engineering and Material-Tissue Interactions Group, University of Cambridge, United Kingdom
3 Department of Surgical Intensive Care, Singapore General Hospital, Singapore

DOI: 10.2478/jccm-2019-0010

Background: Lactic acidosis (LA) is a complication of diseases commonly seen in intensive care patients which carries an increased risk of mortality. It is classified by its pathophysiology; Type A results from tissue hypo-perfusion and hypoxia, and Type B results from abnormal metabolic activity in the absence of hypoxia. Reports of the co-occurrence of both types have been rarely reported in the literature relating to intensive care patients. This case report describes the challenging management of a patient diagnosed with both Type A and Type B LA.
Case presentation: A 55-year-old female with newly diagnosed diffuse large B-cell lymphoma (DLBCL) developed hospital-acquired pneumonia, respiratory failure, shock and intra-abdominal septicaemia from a bowel perforation. Blood gases revealed a mixed picture lactic acidosis. Correction of septic shock, respiratory failure and surgical repair caused initial improvement to the lactic acidosis, but this gradually worsened in the intensive care unit. Only upon starting chemotherapy and renal replacement therapy was full resolution of the lactic acidosis achieved. The patient was discharged but succumbed to her DLBCL several months later.
Conclusion: Type A and Type B LA can co-occur, making management difficult. A systematic approach can help diagnose any underlying pathology and aid in early management.

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Pulseless Electrical Activity Arrest as the First Symptom of Testicular Cancer with Subsequent Phlegmasia Cerulea Dolens

Shane Belvedere

Department of Vascular Surgery, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria, Australia

DOI: 10.2478/jccm-2019-0009

Introduction: Phlegmasia cerulea dolens (PCD) is a severe, rare complication of deep vein thrombosis, which is characterised by compartment syndrome, arterial compromise, venous gangrene, and shock. Prothrombotic states are the primary risk factor for PCD, which, in most cases, is associated with pulmonary embolism and carries a high mortality.
Case report: A 46-year-old male presented following a pulseless electrical activity (PEA) arrest due to saddle pulmonary embolism (PE). He subsequently developed PCD and venous gangrene secondary to inferior vena cava obstruction, in the setting of a new diagnosis of testicular germ cell tumour.
Discussion: PEA arrest, as the initial presenting problem in malignancy, is rare. It is extreme for the first indication of cancer to be a PEA arrest from massive PE. While hypoxic brain injury from the cardiac arrest precluded intervention in this case, a surgical approach entailing en bloc resection of aortocaval metastasis, with subsequent IVC reconstruction, followed by lower limb venous thrombectomy would have been favoured as it was considered that an endovascular approach would not have been successful.
Conclusion: A case of a patient with phlegmasia cerulea dolens secondary to testicular cancer, who presented following PEA arrest is described.

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