Abstract Introduction: Acute ischemic stroke (AIS) is the fourth leading cause of death in the US. Numerous studies have demonstrated the use of comprehensive stroke units and neurological intensive care units (NICU) in improving outcomes after stroke. We hypothesized that an expanded neurocritical care (NCC) service would decrease resource utilization in patients with LHI. Methods: Retrospective data from consecutive admissions of large hemispheric infarction (LHI) patients requiring mechanical ventilation were acquired from the hospital medical records. Between 2011-2013, there were 187 consecutive patients admitted to the Jefferson Hospital for Neuroscience (Philadelphia, USA) with AIS and acute respiratory failure. Our intention was to determine the number of tracheostomies done over time. The primary outcome measure was the number of tracheostomies over time. Secondary outcomes were, ventilator-free days (Vfd), total hospital charges, intensive care unit length of stay (ICU-LOS), and total hospital length of stay (hospital-LOS), including ICU LOS. Hospital charges were log-transformed to meet assumptions of normality and homoscedasticity of residual variance terms. Generalized Linear Models were used and ORs and 95% CIs calculated. The significance level was set at α = 0.05. Results: Of the 73 patients included in this analysis, 33% required a tracheostomy. There was a decrease in the number of tracheostomies undertaken since 2011. (OR 0.8; 95% CI 0.6-0.9: p=0.02). Lower Vfd were seen in tracheostomized patients (OR 0.11; 95%CI 0.1-0.26: p<0.0001). The log-hospital charges decreased over time but not significantly (OR 0.9; 95%CI 0.78-1.07: p=0.2) and (OR 0.99; 95%CI 0.85-1.16: p=0.8) from 2012 to 2013 respectively. The ICU-LOS at 23 days vs 10 days (p=0.01) and hospital-LOS at 33 days vs 11 days (p=0.008) were higher in tracheostomized patients. Conclusion: The data suggest that in LHI-patients requiring mechanical ventilation, a dedicated NCC service reduces the overall need for tracheostomy, increases Vfd, and decreases ICU and hospital-LOS.
{"title":"Neurological Critical Care Services’ Influence Following Large Hemispheric Infarction and Their Impact on Resource Utilization","authors":"S. Shah, Y. Au, F. Rincon, M. Vibbert","doi":"10.2478/jccm-2018-0001","DOIUrl":"https://doi.org/10.2478/jccm-2018-0001","url":null,"abstract":"Abstract Introduction: Acute ischemic stroke (AIS) is the fourth leading cause of death in the US. Numerous studies have demonstrated the use of comprehensive stroke units and neurological intensive care units (NICU) in improving outcomes after stroke. We hypothesized that an expanded neurocritical care (NCC) service would decrease resource utilization in patients with LHI. Methods: Retrospective data from consecutive admissions of large hemispheric infarction (LHI) patients requiring mechanical ventilation were acquired from the hospital medical records. Between 2011-2013, there were 187 consecutive patients admitted to the Jefferson Hospital for Neuroscience (Philadelphia, USA) with AIS and acute respiratory failure. Our intention was to determine the number of tracheostomies done over time. The primary outcome measure was the number of tracheostomies over time. Secondary outcomes were, ventilator-free days (Vfd), total hospital charges, intensive care unit length of stay (ICU-LOS), and total hospital length of stay (hospital-LOS), including ICU LOS. Hospital charges were log-transformed to meet assumptions of normality and homoscedasticity of residual variance terms. Generalized Linear Models were used and ORs and 95% CIs calculated. The significance level was set at α = 0.05. Results: Of the 73 patients included in this analysis, 33% required a tracheostomy. There was a decrease in the number of tracheostomies undertaken since 2011. (OR 0.8; 95% CI 0.6-0.9: p=0.02). Lower Vfd were seen in tracheostomized patients (OR 0.11; 95%CI 0.1-0.26: p<0.0001). The log-hospital charges decreased over time but not significantly (OR 0.9; 95%CI 0.78-1.07: p=0.2) and (OR 0.99; 95%CI 0.85-1.16: p=0.8) from 2012 to 2013 respectively. The ICU-LOS at 23 days vs 10 days (p=0.01) and hospital-LOS at 33 days vs 11 days (p=0.008) were higher in tracheostomized patients. Conclusion: The data suggest that in LHI-patients requiring mechanical ventilation, a dedicated NCC service reduces the overall need for tracheostomy, increases Vfd, and decreases ICU and hospital-LOS.","PeriodicalId":44227,"journal":{"name":"Journal of Critical Care Medicine","volume":"52 1","pages":"11 - 5"},"PeriodicalIF":1.1,"publicationDate":"2018-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"69216226","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Z. Bajko, S. Maier, Anca Moţăţăianu, R. Bălaşa, Smaranda Vasiu, A. Stoian, Sebastian Andone
Abstract Introduction: Lesions of the carotid and vertebral arteries secondary to direct trauma, called blunt cerebrovascular injuries (BCVI) are relatively rare and are markedly different from spontaneous dissections. Ischaemic stroke is a significant complication, with high morbidity and mortality rates. The basis of a diagnosis relies on appropriate, high sensitivity imaging screening. Case report: We present the case of a 31 years old male patient with polytraumatism secondary to a motor vehicle accident, who was admitted to an orthopaedic clinic for multiple lower extremity fractures. His fractures were treated surgically. He developed in the 3rd day after the admission left sided hemiparesis secondary to ischaemic stroke. The diagnosis of traumatic carotid artery injury (TCAI) was based on duplex ultrasound and angio CT scans. The outcome was favourable despite the severe carotid lesions presenting with occlusion secondary to dissection. Conclusions: In the majority of BCVI cases there is a variable latent period between the time of injury and the development of stroke. The management of cases is challenging because in the majority of cases there are multiple associated injuries. Although antithrombotics are widely used in the treatment, there is no consensus regarding the type of agent, the optimal dose or treatment duration.
{"title":"Stroke Secondary to Traumatic Carotid Artery Injury – A Case Report","authors":"Z. Bajko, S. Maier, Anca Moţăţăianu, R. Bălaşa, Smaranda Vasiu, A. Stoian, Sebastian Andone","doi":"10.2478/jccm-2018-0003","DOIUrl":"https://doi.org/10.2478/jccm-2018-0003","url":null,"abstract":"Abstract Introduction: Lesions of the carotid and vertebral arteries secondary to direct trauma, called blunt cerebrovascular injuries (BCVI) are relatively rare and are markedly different from spontaneous dissections. Ischaemic stroke is a significant complication, with high morbidity and mortality rates. The basis of a diagnosis relies on appropriate, high sensitivity imaging screening. Case report: We present the case of a 31 years old male patient with polytraumatism secondary to a motor vehicle accident, who was admitted to an orthopaedic clinic for multiple lower extremity fractures. His fractures were treated surgically. He developed in the 3rd day after the admission left sided hemiparesis secondary to ischaemic stroke. The diagnosis of traumatic carotid artery injury (TCAI) was based on duplex ultrasound and angio CT scans. The outcome was favourable despite the severe carotid lesions presenting with occlusion secondary to dissection. Conclusions: In the majority of BCVI cases there is a variable latent period between the time of injury and the development of stroke. The management of cases is challenging because in the majority of cases there are multiple associated injuries. Although antithrombotics are widely used in the treatment, there is no consensus regarding the type of agent, the optimal dose or treatment duration.","PeriodicalId":44227,"journal":{"name":"Journal of Critical Care Medicine","volume":"4 1","pages":"23 - 28"},"PeriodicalIF":1.1,"publicationDate":"2018-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"69216239","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background. Guidelines for sedation, ventilator weaning, and delirium screening are helpful to avoid too deep sedation and to identify signs of delirium in the intensive care unit (ICU). Methods. National ICU registry members ( ) were surveyed regarding use of scoring instruments and guidelines for sedation and ventilator weaning, choice of drugs, and daily sedation interruption practices. Results were merged with registry data on ventilator time and length of stay for ICU patients ventilated >24 hours (7.075 ICU stays). Results. Eighty-five percent of the 33 responding ICUs used sedation scales and 39% and 55% had sedation and weaning protocols, respectively. An association was found between using protocols and longer mean ventilator time and mean length of ICU stay. Thirty three percent (11/33) practiced daily sedation interruption. Regular delirium assessment was associated with significantly shorter mean ventilator time and mean length of ICU stay but used by few. Conclusion. More ICUs had guidelines for weaning than for sedation. The ventilator time and length of ICU stay compared well with other studies. Although having guidelines was associated with longer ventilator time and ICU stay, the differences were rather small. Daily sedation interruption was seldom used. Few units used delirium scoring instruments.
{"title":"Relation of Reported Sedation and Ventilator Weaning Practices to Ventilator Time in Norwegian Intensive Care Units","authors":"M. Bekkevold, R. Kvåle, G. Brattebø","doi":"10.1155/2015/173985","DOIUrl":"https://doi.org/10.1155/2015/173985","url":null,"abstract":"Background. Guidelines for sedation, ventilator weaning, and delirium screening are helpful to avoid too deep sedation and to identify signs of delirium in the intensive care unit (ICU). Methods. National ICU registry members ( ) were surveyed regarding use of scoring instruments and guidelines for sedation and ventilator weaning, choice of drugs, and daily sedation interruption practices. Results were merged with registry data on ventilator time and length of stay for ICU patients ventilated >24 hours (7.075 ICU stays). Results. Eighty-five percent of the 33 responding ICUs used sedation scales and 39% and 55% had sedation and weaning protocols, respectively. An association was found between using protocols and longer mean ventilator time and mean length of ICU stay. Thirty three percent (11/33) practiced daily sedation interruption. Regular delirium assessment was associated with significantly shorter mean ventilator time and mean length of ICU stay but used by few. Conclusion. More ICUs had guidelines for weaning than for sedation. The ventilator time and length of ICU stay compared well with other studies. Although having guidelines was associated with longer ventilator time and ICU stay, the differences were rather small. Daily sedation interruption was seldom used. Few units used delirium scoring instruments.","PeriodicalId":44227,"journal":{"name":"Journal of Critical Care Medicine","volume":"2015 1","pages":"1-8"},"PeriodicalIF":1.1,"publicationDate":"2015-05-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1155/2015/173985","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"64822547","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract Background: Trauma in its early stages leads to an acute inflammatory condition affecting all cellular lines. Neutrophil granulocytes make up the largest population of human white blood cells and are fundamental to the innate immune system. The objective of our pilot study was to evaluate neutrophil death and viability alterations in critically ill trauma patients in correlation with their clinical outcome. Material and method: Critical ill trauma patients were enrolled in the study. In order to assess alterations in cellular death, blood samples were drawn using EDTA containing tubes and analyzed in the first twenty four hours after admission, then after forty eight and seventy two hours. Annexin V was used as a marker for apoptotic cells and propidium iodide for necrotic cells. Results: The first two cases exhibited an increase in cellular viability by the second day as shown by a small increase in neutrophil apoptosis and a decrease in neutrophil necrosis. These patients progressed to a positive clinical outcome. The second two cases showed slight modifications in either physiological or pathological cellular death, and increasing levels of cellular necrosis. These patients progressed to a negative clinical outcome. Conclusions: These cases suggest that neutrophil cell viability and death were associated with the patient’s clinical outcome.
{"title":"Neutrophil Viability as a Clinical Outcome Marker in Mechanically Ventilated Critically Ill Trauma Patients: A Case Series","authors":"Orsolya Benedek, M. Veres, M. Dobreanu","doi":"10.1515/jccm-2015-0019","DOIUrl":"https://doi.org/10.1515/jccm-2015-0019","url":null,"abstract":"Abstract Background: Trauma in its early stages leads to an acute inflammatory condition affecting all cellular lines. Neutrophil granulocytes make up the largest population of human white blood cells and are fundamental to the innate immune system. The objective of our pilot study was to evaluate neutrophil death and viability alterations in critically ill trauma patients in correlation with their clinical outcome. Material and method: Critical ill trauma patients were enrolled in the study. In order to assess alterations in cellular death, blood samples were drawn using EDTA containing tubes and analyzed in the first twenty four hours after admission, then after forty eight and seventy two hours. Annexin V was used as a marker for apoptotic cells and propidium iodide for necrotic cells. Results: The first two cases exhibited an increase in cellular viability by the second day as shown by a small increase in neutrophil apoptosis and a decrease in neutrophil necrosis. These patients progressed to a positive clinical outcome. The second two cases showed slight modifications in either physiological or pathological cellular death, and increasing levels of cellular necrosis. These patients progressed to a negative clinical outcome. Conclusions: These cases suggest that neutrophil cell viability and death were associated with the patient’s clinical outcome.","PeriodicalId":44227,"journal":{"name":"Journal of Critical Care Medicine","volume":"1 1","pages":"113 - 117"},"PeriodicalIF":1.1,"publicationDate":"2015-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"66928901","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract Traumatic Brain Injury (TBI) is one of the leading causes of death among critically ill patients from the Intensive Care Units (ICU). After primary traumatic injuries, secondary complications occur, which are responsible for the progressive degradation of the clinical status in this type of patients. These include severe inflammation, biochemical and physiological imbalances and disruption of the cellular functionality. The redox cellular potential is determined by the oxidant/antioxidant ratio. Redox potential is disturbed in case of TBI leading to oxidative stress (OS). A series of agression factors that accumulate after primary traumatic injuries lead to secondary lesions represented by brain ischemia and hypoxia, inflammatory and metabolic factors, coagulopathy, microvascular damage, neurotransmitter accumulation, blood-brain barrier disruption, excitotoxic damage, blood-spinal cord barrier damage, and mitochondrial dysfunctions. A cascade of pathophysiological events lead to accelerated production of free radicals (FR) that further sustain the OS. To minimize the OS and restore normal oxidant/antioxidant ratio, a series of antioxidant substances is recommended to be administrated (vitamin C, vitamin E, resveratrol, N-acetylcysteine). In this paper we present the biochemical and pathophysiological mechanism of action of FR in patients with TBI and the antioxidant therapy available.
{"title":"Oxidative Stress and Antioxidant Therapy in Critically Ill Polytrauma Patients with Severe Head Injury","authors":"L. Luca, A. Rogobete, O. Bedreag","doi":"10.1515/jccm-2015-0014","DOIUrl":"https://doi.org/10.1515/jccm-2015-0014","url":null,"abstract":"Abstract Traumatic Brain Injury (TBI) is one of the leading causes of death among critically ill patients from the Intensive Care Units (ICU). After primary traumatic injuries, secondary complications occur, which are responsible for the progressive degradation of the clinical status in this type of patients. These include severe inflammation, biochemical and physiological imbalances and disruption of the cellular functionality. The redox cellular potential is determined by the oxidant/antioxidant ratio. Redox potential is disturbed in case of TBI leading to oxidative stress (OS). A series of agression factors that accumulate after primary traumatic injuries lead to secondary lesions represented by brain ischemia and hypoxia, inflammatory and metabolic factors, coagulopathy, microvascular damage, neurotransmitter accumulation, blood-brain barrier disruption, excitotoxic damage, blood-spinal cord barrier damage, and mitochondrial dysfunctions. A cascade of pathophysiological events lead to accelerated production of free radicals (FR) that further sustain the OS. To minimize the OS and restore normal oxidant/antioxidant ratio, a series of antioxidant substances is recommended to be administrated (vitamin C, vitamin E, resveratrol, N-acetylcysteine). In this paper we present the biochemical and pathophysiological mechanism of action of FR in patients with TBI and the antioxidant therapy available.","PeriodicalId":44227,"journal":{"name":"Journal of Critical Care Medicine","volume":"1 1","pages":"83 - 91"},"PeriodicalIF":1.1,"publicationDate":"2015-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1515/jccm-2015-0014","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"66929260","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
P. Jermin, J. Perry, S. Kalra, Elizabeth Flockton, Henry K. Rourke
Abstract Background: Surgical stabilisation of acute rib fractures has recently undergone rapid change in the UK with respect to what type of injury is surgically stabilised and who undertakes the operation. This paper presents a review of the literature on surgical fixation and presents our early clinical experience using a recently introduced stabilising system. Methods: Data was prospectively collected from the first 10 patients undergoing surgical stabilisation of acute rib fractures using the Synthes Matrix RIB plating system. The data included demographics, Injury Severity Score, length of stay in Intensive Care, length of time on a ventilator, analgesic requirements, pneumonia rates and mortality. Patients were followed up until they were discharged from hospital. Results: Patients had an average Injury Severity Score of 26 (16-57), the average number of ribs fractured was 8.2 (4-14), nine patients had flail chest and one had multiple fractures, mean time from injury to fixation was 2.8 days. In the reported cohort, there were no deaths, two pneumonias (one had pneumonia on presentation). The average length of stay on a ventilator was three days and the average length of stay in Intensive Care was ten days. Conclusion: The early results of this procedure are encouraging. We feel that the modern implants will provide superior results to the highly variable implants that have previously been used. Our results support the literature, showing that with this system, there is a decrease in mortality and morbidity and a decrease in the length of time on a ventilator and stay in Intensive Care.
{"title":"The Use of Novel Adopters for Acute Rib Fixation in Critical Chest Trauma, Undertaken by Orthopaedic Surgeons: an Observational Cohort Study","authors":"P. Jermin, J. Perry, S. Kalra, Elizabeth Flockton, Henry K. Rourke","doi":"10.1515/jccm-2015-0016","DOIUrl":"https://doi.org/10.1515/jccm-2015-0016","url":null,"abstract":"Abstract Background: Surgical stabilisation of acute rib fractures has recently undergone rapid change in the UK with respect to what type of injury is surgically stabilised and who undertakes the operation. This paper presents a review of the literature on surgical fixation and presents our early clinical experience using a recently introduced stabilising system. Methods: Data was prospectively collected from the first 10 patients undergoing surgical stabilisation of acute rib fractures using the Synthes Matrix RIB plating system. The data included demographics, Injury Severity Score, length of stay in Intensive Care, length of time on a ventilator, analgesic requirements, pneumonia rates and mortality. Patients were followed up until they were discharged from hospital. Results: Patients had an average Injury Severity Score of 26 (16-57), the average number of ribs fractured was 8.2 (4-14), nine patients had flail chest and one had multiple fractures, mean time from injury to fixation was 2.8 days. In the reported cohort, there were no deaths, two pneumonias (one had pneumonia on presentation). The average length of stay on a ventilator was three days and the average length of stay in Intensive Care was ten days. Conclusion: The early results of this procedure are encouraging. We feel that the modern implants will provide superior results to the highly variable implants that have previously been used. Our results support the literature, showing that with this system, there is a decrease in mortality and morbidity and a decrease in the length of time on a ventilator and stay in Intensive Care.","PeriodicalId":44227,"journal":{"name":"Journal of Critical Care Medicine","volume":"1 1","pages":"101 - 96"},"PeriodicalIF":1.1,"publicationDate":"2015-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"66929294","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The critically ill patient with primary multiple traumas and having secondary complications, presents a complex challenge to the trauma team. The most commonly encountered primary injuries are traumatic brain, spinal cord, pulmonary and abdominal injuries or trauma to the pelvis and the extremities. Moreover, severe inflammations, infections, hyper-metabolism, as well as biochemical and physiological imbalances, lead to a significant increase in morbidity and mortality. Most recently, the role of free radicals has been a largely debated and reported topic. Once produced in excess, free radicals are responsible for inducing oxidative stress. The redox species known to have a destructive effect on cells include the superoxide anion, the hydroxyl radical, hydrogen peroxide, nitric oxide, peroxynitrite, lipid peroxyl and alkoxy lipid. Under normal conditions, free radicals are produced in the human body in small amounts, their activity being minimized by the body’s physiologically anti-oxidant systems which include superoxide dismutase, catalase, glutathione, glutathione peroxidase, peroxiredoxins, and glutaredoxins. In the critically ill patient, severe physiological and biochemical imbalances significantly reduce the body’s anti-oxidant capacity, disrupting the redox balance [1]. A series of biomarkers are in use, designed to quantify oxidative stress. These comprise interleukin 1 beta, interleukin 6, interleukin 10, tumor necrosis alpha, components of the complement, plasmatic levels of antioxidant enzymes and the microRNA species [2]. Oxidative stress in the polytrauma patient is produced shortly after the initial trauma. Subsequently, it transfers from the macroscopic level to the cellular level and thereafter to the molecular level. At this level, the oxidative stress is enhanced and self-sustained, generating a second wave of injury which is then responsible for a systemic inflammatory response syndrome (SIRS) and for the excessive biosynthesis of free radicals. In the critically ill patient with multiple traumas, these events are manifest by the patient becoming vulnerable to microbial grafting. The multiplication of pathogenic germs, immunosuppression and increased levels of pro-inflammatory molecules frequently leads to sepsis and despite intensive treatment, progresses to multiple organ dysfunction syndrome (MODS) and death. The implications of the oxidative stress in the critically ill polytrauma patient has been the subject of a number of recent reports. Hohl reported a statistically significant correlation between plasma levels of specific biomarkers for oxidative injury with a number of clinical variables, in their study on oxidative stress in patients with traumatic brain injury [3]. Nathens [4], in a similar study, reported a series of statistically significant correlations regarding oxidative stress in patients with pulmonary trauma. Moreover, the reduction of a systemic inflammatory response in these patients, following the adminis
{"title":"Oxidative Stress in the Critically Ill Polytrauma Patient","authors":"D. Sandesc","doi":"10.1515/jccm-2015-0013","DOIUrl":"https://doi.org/10.1515/jccm-2015-0013","url":null,"abstract":"The critically ill patient with primary multiple traumas and having secondary complications, presents a complex challenge to the trauma team. The most commonly encountered primary injuries are traumatic brain, spinal cord, pulmonary and abdominal injuries or trauma to the pelvis and the extremities. Moreover, severe inflammations, infections, hyper-metabolism, as well as biochemical and physiological imbalances, lead to a significant increase in morbidity and mortality. Most recently, the role of free radicals has been a largely debated and reported topic. Once produced in excess, free radicals are responsible for inducing oxidative stress. The redox species known to have a destructive effect on cells include the superoxide anion, the hydroxyl radical, hydrogen peroxide, nitric oxide, peroxynitrite, lipid peroxyl and alkoxy lipid. Under normal conditions, free radicals are produced in the human body in small amounts, their activity being minimized by the body’s physiologically anti-oxidant systems which include superoxide dismutase, catalase, glutathione, glutathione peroxidase, peroxiredoxins, and glutaredoxins. In the critically ill patient, severe physiological and biochemical imbalances significantly reduce the body’s anti-oxidant capacity, disrupting the redox balance [1]. A series of biomarkers are in use, designed to quantify oxidative stress. These comprise interleukin 1 beta, interleukin 6, interleukin 10, tumor necrosis alpha, components of the complement, plasmatic levels of antioxidant enzymes and the microRNA species [2]. Oxidative stress in the polytrauma patient is produced shortly after the initial trauma. Subsequently, it transfers from the macroscopic level to the cellular level and thereafter to the molecular level. At this level, the oxidative stress is enhanced and self-sustained, generating a second wave of injury which is then responsible for a systemic inflammatory response syndrome (SIRS) and for the excessive biosynthesis of free radicals. In the critically ill patient with multiple traumas, these events are manifest by the patient becoming vulnerable to microbial grafting. The multiplication of pathogenic germs, immunosuppression and increased levels of pro-inflammatory molecules frequently leads to sepsis and despite intensive treatment, progresses to multiple organ dysfunction syndrome (MODS) and death. The implications of the oxidative stress in the critically ill polytrauma patient has been the subject of a number of recent reports. Hohl reported a statistically significant correlation between plasma levels of specific biomarkers for oxidative injury with a number of clinical variables, in their study on oxidative stress in patients with traumatic brain injury [3]. Nathens [4], in a similar study, reported a series of statistically significant correlations regarding oxidative stress in patients with pulmonary trauma. Moreover, the reduction of a systemic inflammatory response in these patients, following the adminis","PeriodicalId":44227,"journal":{"name":"Journal of Critical Care Medicine","volume":"1 1","pages":"81 - 82"},"PeriodicalIF":1.1,"publicationDate":"2015-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1515/jccm-2015-0013","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"66929246","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
L. Suciu, M. Cucerea, M. Simon, A. Avasiloaiei, O. Petrescu, Suciu Bogdan Andrei
Abstract Introduction: Over the past 25 years, caregiver’s knowledge of pain in newborn infants has advanced from the beliefs that newborn infants do not feel pain, to the knowledge that preterm infants experience more pain compare to older children and adults. However, caregivers know that pain exists in this population and research has supported that pain continues to be untreated up to 65% of the time. Aim of the study: The purpose of this study was to investigate the attitude and knowledge of health care professionals from the area of Neonatology in Romania regarding procedural pain management in newborn infants. Material and methods: The sample consisted of 85 physicians and nurses (110 invited) working in five Neonatal Care Centres. Data were collected using a self-completion, 17 items questionnaire designed for this study. Results: With a response rate of 77.27% which was similar in nurses and physicians, respondents in our study were aware about the pain experience during procedural interventions, recognized the items of pain scales assessment, and are not comfortable with the parental presence during painful procedures. Twenty-five percent of nurses versus 9% of physicians reported rushed care as an important barrier of adequate non-pharmacological pain management (95% IC, 0.319-0.003) Conclusions: The use of pain protocols for an effective management of pain during neonatal period is required.
{"title":"Health Care Professional’s Attitude Towards the Effective Management of Pain in the Critically Ill Neonate","authors":"L. Suciu, M. Cucerea, M. Simon, A. Avasiloaiei, O. Petrescu, Suciu Bogdan Andrei","doi":"10.1515/jccm-2015-0018","DOIUrl":"https://doi.org/10.1515/jccm-2015-0018","url":null,"abstract":"Abstract Introduction: Over the past 25 years, caregiver’s knowledge of pain in newborn infants has advanced from the beliefs that newborn infants do not feel pain, to the knowledge that preterm infants experience more pain compare to older children and adults. However, caregivers know that pain exists in this population and research has supported that pain continues to be untreated up to 65% of the time. Aim of the study: The purpose of this study was to investigate the attitude and knowledge of health care professionals from the area of Neonatology in Romania regarding procedural pain management in newborn infants. Material and methods: The sample consisted of 85 physicians and nurses (110 invited) working in five Neonatal Care Centres. Data were collected using a self-completion, 17 items questionnaire designed for this study. Results: With a response rate of 77.27% which was similar in nurses and physicians, respondents in our study were aware about the pain experience during procedural interventions, recognized the items of pain scales assessment, and are not comfortable with the parental presence during painful procedures. Twenty-five percent of nurses versus 9% of physicians reported rushed care as an important barrier of adequate non-pharmacological pain management (95% IC, 0.319-0.003) Conclusions: The use of pain protocols for an effective management of pain during neonatal period is required.","PeriodicalId":44227,"journal":{"name":"Journal of Critical Care Medicine","volume":"1 1","pages":"107 - 112"},"PeriodicalIF":1.1,"publicationDate":"2015-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"66928854","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
I am writing in reference to the article published by Theodora Benedek and Dan Dobreanu in the first issue of JCCM, entitled "Current Concepts and New Trends in the Treatment of Cardiogenic Shock Complicating Acute Myocardial Infarction". Cardiogenic shock (CS) represents a critical and life-threatening condition. Survival of patients with CS depends largely, not only on the appropriateness of the therapeutic measures, but also on the correct identification of the underlying disease [1]. Treatment of this underlying condition represents a key element for the correction of the patho-phyisiological pathways responsible for the development of a CS. In many cases, CS occurs in association with an acute myocardial infarction, usually large infarcts, located on the anterior ventricular wall [2]. Prompt revascularisation is crucial in these cases, as the re-establishment of coronary flow would immediately improve the haemodynamic status of these critically ill patients. However, in routine clinical practice, the diagnosis of an acute coronary syndrome remains challenging, especially when the physician is faced with a patient who arrives in the emergency room (ER) intubated, after surviving a cardiac arrest of unknown aetiology. In these cases, it is of extreme importance to differentiate between other possible causes of CS, such as pulmonary embolism or acute aortic dissection. Cardiac imaging plays a critical role in diagnosing patients with critical cardiac conditions. The "triple rule-out" exam has been proposed for Cardiac Computed Tomography (CCT) in the ER. This examination allows to rule-out the three major causes of cardiogenic shock: acute coronary syndromes, pulmonary embolism and acute aortic dissection [3]. While CCT examination has been shown to be efficient for the vast majority of patients presenting in the ER with a chest pain, CCT imaging a patient with cardiac arrest or CS is not a trivial task. The above mentioned article published recently in the JCCM discussed the treatment options available nowadays for CS cases, emphasizing the critical role of new devices for providing mechanical circulatory support [4]. However, the addition of a circulatory device makes cardiac imaging even more technically challenging. For example, even the simple use of the classical balloon counter-pulsation pump may not only make the handling of the patient more difficult, but could also further impact on the quality of the obtained image. In conclusion, the role of cardiac imaging in the ER is well established, and several randomised controlled trials reported the advantages of imaging examinations for the evaluation of patients with acute chest pain [5]. However, challenges of CCT in the assessment of patients presenting with CS or after surviving a cardiac arrest requires further investigations. A combined approach, incorporating CCT imaging and analysis together with determination of serum levels of highsensitive troponins could potentially provide a va
{"title":"Challenges of Critical Cardiac Imaging in Cardiogenic Shock","authors":"M. Linguraru","doi":"10.1515/jccm-2015-0020","DOIUrl":"https://doi.org/10.1515/jccm-2015-0020","url":null,"abstract":"I am writing in reference to the article published by Theodora Benedek and Dan Dobreanu in the first issue of JCCM, entitled \"Current Concepts and New Trends in the Treatment of Cardiogenic Shock Complicating Acute Myocardial Infarction\". Cardiogenic shock (CS) represents a critical and life-threatening condition. Survival of patients with CS depends largely, not only on the appropriateness of the therapeutic measures, but also on the correct identification of the underlying disease [1]. Treatment of this underlying condition represents a key element for the correction of the patho-phyisiological pathways responsible for the development of a CS. In many cases, CS occurs in association with an acute myocardial infarction, usually large infarcts, located on the anterior ventricular wall [2]. Prompt revascularisation is crucial in these cases, as the re-establishment of coronary flow would immediately improve the haemodynamic status of these critically ill patients. However, in routine clinical practice, the diagnosis of an acute coronary syndrome remains challenging, especially when the physician is faced with a patient who arrives in the emergency room (ER) intubated, after surviving a cardiac arrest of unknown aetiology. In these cases, it is of extreme importance to differentiate between other possible causes of CS, such as pulmonary embolism or acute aortic dissection. Cardiac imaging plays a critical role in diagnosing patients with critical cardiac conditions. The \"triple rule-out\" exam has been proposed for Cardiac Computed Tomography (CCT) in the ER. This examination allows to rule-out the three major causes of cardiogenic shock: acute coronary syndromes, pulmonary embolism and acute aortic dissection [3]. While CCT examination has been shown to be efficient for the vast majority of patients presenting in the ER with a chest pain, CCT imaging a patient with cardiac arrest or CS is not a trivial task. The above mentioned article published recently in the JCCM discussed the treatment options available nowadays for CS cases, emphasizing the critical role of new devices for providing mechanical circulatory support [4]. However, the addition of a circulatory device makes cardiac imaging even more technically challenging. For example, even the simple use of the classical balloon counter-pulsation pump may not only make the handling of the patient more difficult, but could also further impact on the quality of the obtained image. In conclusion, the role of cardiac imaging in the ER is well established, and several randomised controlled trials reported the advantages of imaging examinations for the evaluation of patients with acute chest pain [5]. However, challenges of CCT in the assessment of patients presenting with CS or after surviving a cardiac arrest requires further investigations. A combined approach, incorporating CCT imaging and analysis together with determination of serum levels of highsensitive troponins could potentially provide a va","PeriodicalId":44227,"journal":{"name":"Journal of Critical Care Medicine","volume":"1 1","pages":"118 - 119"},"PeriodicalIF":1.1,"publicationDate":"2015-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1515/jccm-2015-0020","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"66928953","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract Severe forms of chronic kidney disease can lead to a critical, end-stage condition, requiring renal replacement therapy, which may involve a form of dialysis or renal transplantation. Identification and characterization of novel markers and/or targets of therapy that could be applied in these critically ill patients remains the focus of the current research in the field of critical care medicine and has been the objective of our studies for some years past. To this end, we used models of renal vascular disease, Ang II, L-NAME or mice overexpressing renin, treated with AT1 antagonists at different stages of progression, to create cohorts of animals during progression, reversal or escape from therapy. Transcriptomic analysis and comparisons were performed and genes were selected according to the following criteria: a) not previously described in the kidney, b) highly upregulated during progression and returning to the normal levels during reversal, and c) producing proteins that are either circulating or membrane receptors. The involvement of the selected genes in the mechanisms of renal disease was confirmed in additional models of renal disease, initiated in other compartments of the kidney such as glomeruli (administration of nephrotoxic serum) or the tubular interstitium (unilateral ureteral obstruction). The potential of the therapy was tested using mice lacking the expression of these genes and by in vivo administration of antisense oligonucleotides which blocked the transcription of the targeted genes. This strategy allowed the identification of periostin, an extracellular matrix protein normally involved in bone and tooth development, in addition to the discoidin domain receptor1 (DDR1) as potential targets of therapy against renal inflammation and fibrosis.
{"title":"New Targets for End-Stage Chronic Kidney Disease Therapy","authors":"Niki Prakoura, Panos Kavvadas, C. Chatziantoniou","doi":"10.1515/jccm-2015-0015","DOIUrl":"https://doi.org/10.1515/jccm-2015-0015","url":null,"abstract":"Abstract Severe forms of chronic kidney disease can lead to a critical, end-stage condition, requiring renal replacement therapy, which may involve a form of dialysis or renal transplantation. Identification and characterization of novel markers and/or targets of therapy that could be applied in these critically ill patients remains the focus of the current research in the field of critical care medicine and has been the objective of our studies for some years past. To this end, we used models of renal vascular disease, Ang II, L-NAME or mice overexpressing renin, treated with AT1 antagonists at different stages of progression, to create cohorts of animals during progression, reversal or escape from therapy. Transcriptomic analysis and comparisons were performed and genes were selected according to the following criteria: a) not previously described in the kidney, b) highly upregulated during progression and returning to the normal levels during reversal, and c) producing proteins that are either circulating or membrane receptors. The involvement of the selected genes in the mechanisms of renal disease was confirmed in additional models of renal disease, initiated in other compartments of the kidney such as glomeruli (administration of nephrotoxic serum) or the tubular interstitium (unilateral ureteral obstruction). The potential of the therapy was tested using mice lacking the expression of these genes and by in vivo administration of antisense oligonucleotides which blocked the transcription of the targeted genes. This strategy allowed the identification of periostin, an extracellular matrix protein normally involved in bone and tooth development, in addition to the discoidin domain receptor1 (DDR1) as potential targets of therapy against renal inflammation and fibrosis.","PeriodicalId":44227,"journal":{"name":"Journal of Critical Care Medicine","volume":"1 1","pages":"92 - 95"},"PeriodicalIF":1.1,"publicationDate":"2015-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"66929274","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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