Tag Archives: critical care

Extracorporeal Membrane Oxygenation as Circulatory Support in Adult Patients with Septic Shock: A Systematic Review

Muhammad Faisal Khan1, Mohsin Nazir1, Muhammad Khuzzaim Khan2, Raj Kumar Rajendram3, Faisal Shamim1*

1 Department of Anesthesiology, Aga Khan University Hospital, Karachi, Pakistan
2 Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
3 College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

DOI: 10.2478jccm-2024-0017

Introduction: The utilization of extracorporeal membrane oxygenation (ECMO) in adult patients experiencing septic shock is a subject of ongoing debate within the medical community. This study aims to comprehensively address this issue through a systematic review conducted in accordance with the PRISMA guidelines.
Aim of Study: The primary objective of this study is to assess the outcomes of ECMO utilization in adult patients diagnosed with septic shock, thereby providing insights into the potential benefits and uncertainties associated with this treatment modality.
Materials and Methods: Our research encompassed a thorough search across electronic databases for relevant English-language articles published up until April 2023. The inclusion criteria were based on studies reporting on ECMO usage in adult patients with septic shock. Among the eligible studies meeting these criteria, a total of eleven were included in our analysis, involving a cohort of 512 patients. The mean age of the participants was 53.4 years, with 67.38% being male.
Results: In the pooled analysis, the mean survival rate following ECMO treatment was found to vary significantly across different ECMO modalities. Patients receiving venovenous-ECMO (VV-ECMO) and veno-venous-arterial ECMO (VVA-ECMO) demonstrated higher survival rates (44.5% and 44.4%, respectively) compared to those receiving venoarterial-ECMO (VA-ECMO) at 25% (p<0.05). A chi-square test of independence indicated that the type of ECMO was a significant predictor of survival (χ²(2) = 6.63, p=0.036). Additionally, patients with septic shock stemming from respiratory failure demonstrated survival rates ranging from 39% to 70%. Predictors of mortality were identified as older age and the necessity for cardiopulmonary resuscitation (CPR).
Conclusions: In septic shock patients, ECMO outcomes align with established indications like respiratory and cardiogenic shock. VV-ECMO and VVA-ECMO suggest better prognoses, though the optimal mode remains uncertain. Patient selection should weigh age and CPR need. Further research is vital to determine ECMO’s best approach for this population.

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Weaning Outcome is Associated with ELWI and Impaired Diastolic Function

Dimitra Bagka1, George Zakynthynos2, Vasiliki Tsolaki1, Jonh Papanikolaou3, Vasilis Vazgiourakis1, Maria Baka1, Konstantinos Pratsas1, Demosthenes Makris1

1 General University Hospital of Larissa, Larisa, Greece
2 University of Athens, Athens, Greece
3 General Hospital of Trikala, Greece

DOI: 10.2478jccm-2024-0008

Objectives: To evaluate hemodynamic profiles of critical care patients undergoing spontaneous t-piece trial (SBT) and present weaning failure.
Methods: Prospective observational study conducted in ready-to-wean non-cardiac ICU patients. Clinical, echocardiographic and thermodilution-derived variables were recorded before and after a 2-hour SBT. Weaning from mechanical ventilation was defined as preservation of spontaneous breathing for 48 hours following successful SBT.
Results: Fourteen patients succeeded weaning, five manifested T-trial-failure and six late-failure. Weaning outcome was significantly associated with ELWI(Extravascular lung-water index), global-end-diastolic index and impaired diastolic function, as indicated by pre-T Doppler early wave velocities (E/Em); Fifty-six percent of participants presented ELWI≥7mL/kg when fulfilling predetermined criteria for weaning. ELWI, impaired pulmonary permeability and left ventricular diastolic dysfunction were independent determinants of ELWI.
Conclusions: ELWI before SBT and impaired diastolic function (as indicated by pre-T E/Em) might be weaning outcome determinants and their assessment may allow better risk stratification in weaning decision making.

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Post-Operative Delirium Masking Acute Angle Closure Glaucoma

Zariel Jiaying Sim1, Xing Jieyin2, Thangavelautham Suhitharan2

1 Singhealth, Singapore, Singapore
2 Singapore General Hospital, Singapore, Singapore

DOI: 10.2478/jccm-2023-0016

Introduction: Acute angle closure glaucoma (AACG) is an ophthalmological emergency, and can lead to the devastating consequence of permanent vision loss if not detected and treated promptly. We present a case of an atypical presentation of unilateral AACG on post operative day (POD) 1, after a prolonged operation under general anaesthesia (GA).
Case presentation: A 65-year-old female underwent a 16 hour long operation for breast cancer and developed an altered mental status with a left fixed dilated pupil on POD 1. She was intubated to secure her airway in view of a depressed consciousness level and admitted to the intensive care unit. Initial blood investigations and brain imaging were unremarkable. On subsequent review by the ophthalmologist, a raised intraocular pressure was noted and she was diagnosed with acute angle closure glaucoma. She was promptly started on intravenous acetazolamide and pressure-lowering ophthalmic drops. Her intraocular pressure normalized in the next 24 hours with improvement in her mental status to baseline.
Conclusion: AACG needs to be consistently thought of as one of the top differentials in any post-operative patient with eye discomfort or abnormal ocular signs on examination. A referral to the ophthalmologist should be made promptly once AACG is suspected.

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Brain Tissue Oxygen Levels as a Perspective Therapeutic Target in Traumatic Brain Injury. Retrospective Cohort Study

Gal Roman1, Ondrej Hrdy1, Kamil Vrbica1, Jan Hudec1, Andrej Mrlian2, Martin Smrcka2

1 Department of Anaesthesiology and Intensive Care Medicine, Masaryk University and University Hospital Brno, Brno, Czech Republic
2 Department of Neurosurgery, Masaryk University and University Hospital Brno, Brno, Czech Republic

DOI: 10.2478/jccm-2023-0001

Introduction: Management of traumatic brain injury (TBI) requires a multidisciplinary approach and represents a significant challenge for both neurosurgeons and intensivists. The role of brain tissue oxygenation (PbtO2) monitoring and its impact on posttraumatic outcomes remains a controversial topic.
Aim of the study: Our study aimed to evaluate the impact of PbtO2 monitoring on mortality, 30 days and 6 months neurological outcomes in patients with severe TBI compared with those resulting from standard intracranial pressure (ICP) monitoring.
Material and methods: In this retrospective cohort study, we analysed the outcomes of 77 patients with severe TBI who met the inclusion criteria. These patients were divided into two groups, including 37 patients who were managed with ICP and PbtO2 monitoring protocols and 40 patients who were managed using ICP protocols alone.
Results: There were no significant differences in demographic data between the two groups. We found no statistically significant differences in mortality or Glasgow Outcome Scale (GOS) scores one month after TBI. However, our results revealed that GOS scores at 6 months had improved significantly among patients managed with PbtO2; this finding was particularly notable for Glasgow Outcome Scale (GOS) scores of 4–5. Close monitoring and management of reductions in PbtO2, particularly by increasing the fraction of inspired oxygen, was associated with higher partial pressures of oxygen in this group.
Conclusions: Monitoring of PbtO2 may facilitate the appropriate evaluation and treatment of low PbtO2 and represents a promising tool for the management of patients with severe TBI. Additional studies will be needed to confirm these findings.

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

Christian C Toquica Gahona, Ashwin Kodagnur Bharadwaj, Monarch Shah, Umesh Bhagat, Paul Sterman, William Vasquez

Saint Peter’s University Hospital, New Brunswick, NJ, USA

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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Inhaled Nitric Oxide in Patients with Severe COVID-19 Infection at Intensive Care Unit – A Cross-Sectional Study

Laura Herranz, Juliana Gurgel da Silveira, Luis Filipe Lannes Trocado, Anna Luiza Alvaraes, Juliana Fittipaldi

Instituto D’Or de Pesquisa e Ensino, Rio de Janeiro, Brazil

DOI: 10.2478/jccm-2021-0033

In adults with severe hypoxemia, inhaled nitric oxide (iNO) is known to reduce pulmonary shunt and pulmonary hypertension, improving V/Q matching [1]. Studies in refractory hypoxemia among patients with severe acute respiratory distress syndrome (ARDS) suggest that iNO may be allied to other ventilatory strategies as a bridge to clinical improvement [2, 3].
A trial from the 2004 Beijing Coronavirus Outbreak showed that low dose iNO could shorten the time of ventilatory support [4]. Additionally, preclinical studies suggest an inhibitory effect of iNO on viral replication [5]. To date, the role of iNO in COVID19 infection is still unclear. [More]

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Critical Care Workers Have Lower Seroprevalence of SARS-CoV-2 IgG Compared with Non-patient Facing Staff in First Wave of COVID19

Helen E. Baxendale1, David Wells2, Jessica Gronlund1, Angalee Nadesalingham2, Mina Paloniemi2, George Carnell2, Paul Tonks2, Lourdes Ceron-Gutierrez3, Soraya Ebrahimi3, Ashleigh Sayer3, John A.G. Briggs4, Xiaoli Ziong4, James A Nathan2, Guinevere Grice2, Leo C James4, Jakub Luptak4, Sumita Pai1, Jonathan L Heeney2, Sara Lear3, Rainer Doffinger3

1 Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
2 University of Cambridge, UK
3 Cambridge University Hospitals NHS Foundation Trust, UK
4 MRC Laboratory of Molecular Biology, UK

DOI: 10.2478/jccm-2021-0018

Introduction: In early 2020, at first surge of the coronavirus disease 2019 (COVID-19) pandemic, many health care workers (HCW) were re-deployed to critical care environments to support intensive care teams looking after patients with severe COVID-19. There was considerable anxiety of increased risk of COVID-19 for these staff. To determine whether critical care HCW were at increased risk of hospital acquired infection, we explored the relationship between workplace, patient facing role and evidence of immune exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within a quaternary hospital providing a regional critical care response. Routine viral surveillance was not available at this time.
Methods: We screened over 500 HCW (25% of the total workforce) for history of clinical symptoms of possible COVID19, assigning a symptom severity score, and quantified SARS-CoV-2 serum antibodies as evidence of immune exposure to the virus.
Results: Whilst 45% of the cohort reported symptoms that they consider may have represented COVID-19, 14% had evidence of immune exposure. Staffs in patient facing critical care roles were least likely to be seropositive (9%) and staff working in non-patient facing roles most likely to be seropositive (22%). Anosmia and fever were the most discriminating symptoms for seropositive status. Older males presented with more severe symptoms. Of the 12 staff screened positive by nasal swab (10 symptomatic), 3 showed no evidence of seroconversion in convalescence.
Conclusions: Patient facing staff working in critical care do not appear to be at increased risk of hospital acquired infection however the risk of nosocomial infection from non-patient facing staff may be more significant than previous recognised. Most symptoms ascribed to possible COVID-19 were found to have no evidence of immune exposure however seroprevalence may underrepresent infection frequency. Older male staff were at the greatest risk of more severe symptoms.

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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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Factors Associated with Mortality in Patients with a Solid Malignancy Admitted to the Intensive Care Unit – A Prospective Observational Study

Pascal Kingah, Nasser Alzubaidi, Jihane Zaza Dit Yafawi, Emad Shehada, Khaled Alshabani, Ayman O. Soubani

Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, 3990 John R, 3 Hudson, Detroit MI 48201, USA

DOI: 10.2478/jccm-2018-0019

Purpose: Several studies show conflicting results regarding the prognosis and predictors of the outcome of critically ill patients with a solid malignancy. This study aims to determine the outcome of critically ill patients, admitted to a hospital, with a solid malignancy and the factors associated with the outcomes.
Methods and Materials: All patients with a solid malignancy admitted to an intensive care unit (ICU) at a tertiary academic medical center were enrolled. Clinical data upon admission and during ICU stay were collected. Hospital, ICU, and six months outcomes were documented.
Results: There were 252 patients with a solid malignancy during the study period. Urogenital malignancies were the most common (26.3%) followed by lung cancer (23.5%). Acute respiratory failure was the most common ICU diagnosis (51.6%) followed by sepsis in 46%. ICU mortality and hospital mortality were 21.8% and 34.3%. Six months mortality was 38.4%. Using multivariate analysis, acute kidney injury, OR 2.82, 95% CI 1.50-5.32 and P=0.001, use of mechanical ventilation, OR 2.67 95% CI 1.37 – 5.19 and P=0.004 and performance status of ≥2 with OR of 3.05, 95% CI of 1.5- 6.2 and P= 0.002 were associated with hospital mortality. There were no differences in outcome between African American patients (53% of all patients) and other races.
Conclusion: This study reports encouraging survival rates in patients with a solid malignancy who are admitted to ICU. Patients with a poor baseline performance status require mechanical ventilation or develop acute renal failure have worse outcomes.

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The Use of Continuous Ketamine for Analgesia and Sedation in Critically Ill Patients with Opioid Abuse: A Case Series

Cierra N. Treu1,2, Christine M. Groth1, Jignesh H. Patel1

1 University of Rochester Medical Center, Rochester, NY, USA
2 SBH Health System, Bronx, New York, USA

DOI: 10.1515/jccm-2017-0026

Managing pain and agitation in patients with opioid abuse is becoming more common in intensive care units. Tolerance to commonly used agents is often observed, leading to inadequate pain control and increased agitation. Ketamine’s unique mechanism of action and opioid-sparing effects make it an ideal agent for patients with suboptimal response to opioid therapy.
This report describes our experience using continuous ketamine infusions for analgesia and sedation in four mechanically ventilated patients with histories of opioid abuse that had suboptimal response to standard therapy. Ketamine was successful in improving analgesia and sedation in three patients while reducing the need for other analgesics and sedatives with minimal adverse effects.
Continuous ketamine infusions may be useful to facilitate mechanical ventilation in patients with histories of opioid abuse with minimal toxicity. More information is needed on the optimal dose and titration parameters.

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