Assessment of the Diaphragm Thickness Decrease in Critically Ill COVID-19 Patients: Could Computed Tomography Be of Aid Regarding Diaphragm Muscle Mass?

INTRODUCTION: The diaphragm has a significant clinical value on respiratory performance. There is little literature on the use of thorax computed tomography for the purpose of identifying alterations in diaphragm thickness in critically ill patients diagnosed with COVID-19. The present study aims to investigate dynamic changes in muscle thickness and its association with clinical outcomes. METHODS: A single-center retrospective observational study was conducted in a tertiary intensive care unit (ICU). The study comprised adult patients with severe COVID-19 who were admitted to the ICU and underwent two thorax CT scans. We measured diaphragmatic thickness at the level of the celiac truncus. RESULTS: The average reduction in thickness of the dynamic diaphragm was found to be -0.58 mm for the right diaphragm and -0.54 mm for the left diaphragm. The diaphragm thickness exhibited a substantial decrease on both the right and left sides in both CT scans (p=0.02). A negative correlation coefficient was observed for both the right and left diaphragm. The criterion indicating a poor prognosis for the right diaphragm was a value greater than -0.175, whereas it was more significant for the left diaphragm than -0.435. The cut-off values indicated a high risk of prolonged mechanical ventilation and an increased risk of ICU mortality. CONCLUSION:  CT diaphragm evaluation in mechanically ventilated COVID-19 patients has the possibility of becoming a reliable tool for predicting muscle modifications.

The Diagnostic and Prognostic Role of Vascular Endothelial Growth Factor C in Sepsis and Septic Shock.

INTRODUCTION: Variations in the expression of vascular endothelial growth factor (VEGF) could be used as a biomarker in critically ill patients with sepsis and septic shock. Inflammation potently upregulates VEGF-C expression via macrophages with an unpredictable response. This study aimed to assess one of the newer biomarkers (VEGF-C) in patients with sepsis or septic shock and its clinical value as a diagnostic and prognostic tool. MATERIAL AND METHODS: The study involved 142 persons divided into three groups. Group A consisted of fifty-eight patients with sepsis; Group B consisted of forty-nine patients diagnosed as having septic shock according to the Sepsis -3 criteria. A control group of thirty-five healthy volunteers comprised Group C. Severity scores, prognostic score and organ dysfunction score, were recorded at the time of enrolment in the study. The analysis included specificity and sensitivity of plasma VEGF-C for diagnosis of septic shock. Circulating plasma VEGF-C levels were correlated with the APACHE II, MODS and severity scores and mortality. RESULTS: The mean (SD) plasma VEGF-C levels in septic shock patients (1374(789) pg./m), on vasopressors at the time of admission to the ICU, were significantly higher 1374(789)pg./mL, compared the mean (SD) plasma VEGF-C levels in sepsis patients (934(468) pg./mL); (p = 0.0005, Student's t-test.) Plasma VEGF-C levels in groups A and B were shown to be significantly correlated with the APACHE II (r = 0.21, p = 0.02; r = 0.45, p = 0.0009) and MODS score (r = 0.29, p = 0.03; r = 0.4, p = 0.003). There was no association between plasma VEGF-C levels and mortality [p = 0.1]. The cut-off value for septic shock was 1010 pg./ml. CONCLUSIONS: VEGF-C may be used as a prognostic marker in sepsis and septic shock due to its correlation with APACHE II values and as an early marker to determine the likelihood of developing MODS. It could be used as an early biomarker for diagnosing patients with septic shock.

Improving Clinical Performance of an Interprofessional Emergency Medical Team Through a One-day Crisis Resource Management Training.

INTRODUCTION: Errors are frequent in health care and Emergency Departments are one of the riskiest areas due to frequent changes of team composition, complexity and variety of the cases and difficulties encountered in managing multiple patients. As the majority of clinical errors are the results of human factors and not technical in nature or due to the lack of knowledge, a training focused on these factors appears to be necessary. Crisis resource management (CRM), a tool that was developed initially by the aviation industry and then adopted by different medical specialties as anesthesia and emergency medicine, has been associated with decreased error rates. THE AIM OF THE STUDY: To assess whether a single day CRM training, combining didactic and simulation sessions, improves the clinical performance of an interprofessional emergency medical team. MATERIAL AND METHODS: Seventy health professionals with different qualifications, working in an emergency department, were enrolled in the study. Twenty individual interprofessional teams were created. Each team was assessed before and after the training, through two in situ simulated exercises. The exercises were videotaped and were evaluated by two assessors who were blinded as to whether it was the initial or the final exercise. Objective measurement of clinical team performance was performed using a checklist that was designed for each scenario and included essential assessment items for the diagnosis and treatment of a critical patient, with the focus on key actions and decisions. The intervention consisted of a one-day training, combining didactic and simulation sessions, followed by instructor facilitated debriefing. All participants went through this training after the initial assessment exercises. RESULTS: An improvement was seen in most of the measured clinical parameters. CONCLUSION: Our study supports the use of combined CRM training for improving the clinical performance of an interprofessional emergency team. Empirically this may improve the patient outcome.

Improving nontechnical skills of an interprofessional emergency medical team through a one day crisis resource management training.

Errors are frequent in healthcare, but Emergency Departments are among the highest risk areas due to frequent changes in team composition, complexity and variety of cases, and difficulties encountered in managing multiple patients simultaneously.Crisis resource management (CRM) training has been associated with decreased error rates in the aviation industry as well as in certain areas of acute medical care, such as anesthesia and emergency medicine. In this study, we assessed whether a single day CRM training, combining didactic and simulation sessions, improves nontechnical skills (NTS) of interprofessional emergency medical teams.Seventy health professionals with different qualifications, working in an emergency department, were enrolled in the study. Twenty individual interprofessional teams were created. Each team was assessed before and after the training, through 2 in situ simulated exercises. The exercises were videotaped and were evaluated by 2 assessors who were blinded as to whether it was the initial or the final exercise. They used a new tool designed specifically for the assessment of emergency physicians' NTS. The intervention consisted of one-day training, combining didactic and simulation sessions, followed by an instructor facilitated debriefing. All participants went through this training after the initial assessment exercises.A significant improvement (P < 0.05) was shown for all the NTS assessed, in all professional categories involved, regardless of the duration of prior work experience in the Emergency Department.This study shows that even a short intervention, such as a single day CRM training, can have a significant impact in improving NTS, and can potentially improve patient safety.

Moving Toward a Universal Digital Era in Mass Casualty Incidents and Disasters: Emergency Personnel's Perspective in Romania.

BACKGROUND: Despite a recognized need for improved communications and logistics in high acuity situations, the integration of telemedicine services into the mainstream health services has been difficult. This study reports on the opinions of Romanian professional responders to mass casualty incidents and disasters regarding the use and requirements of specific electronic medical documentation solutions. MATERIALS AND METHODS: Doctors, nurses, paramedics, and fire department officers participated in a customized online structured questionnaire. To assess factors associated with the current use of information technology and the willingness to adopt an exclusive optimized electronic system, a multivariate analysis was performed. Logistic regression was used for free input key elements regarding the most useful technical and operative improvements and medical documentation solutions for large-scale events. RESULTS: A total of 536 respondents provided answers between the second half of the year 2014 and the first half of the year 2015. Doctors and nurses were the most frequent users of documentation techniques, especially if they were employed at a high-level emergency care center. Professionals' duties were perceived as increasingly impaired by the use of current electronic systems as those duties became more complex. All respondents favored an optimized large-scale event electronic solution, emphasizing the need for enhanced communications, technical equipment, cooperation, and workflow mainly by integrating mobile devices, dedicated software, remote databases, and interlink capabilities. CONCLUSIONS: Professionals support the implementation of an integrated electronic system for large-scale events if outlined requirements are met to maximize user acceptance.

Caspase 3 expression and plasma level of Fas ligand as apoptosis biomarkers in inflammatory endotoxemic lung injury.

OBJECTIVE: The objective of this study is to evaluate if the immunohistochemical expression of a pulmonary apoptosis marker and plasma level of Fas ligand (FasL) correlates with the dose- and time-dependent severity of lung injury, induced by the administration of lipo-polysaccharide (LPS) in an endotoxemic rat model. MATERIALS AND METHODS: Our study included 30 male Wistar rats, randomly divided into three groups: one control group (n=6) and two experimental groups (n=12÷group), in whom we induced endotoxemia by intraperitoneal injection of progressively increasing doses of LPS (5, 10 mg÷kg). We measured FasL plasma levels of the rats at different time points and analyzed the relationships with markers of lung injury. To investigate the level of caspase 3-protein expression, the immunohistochemistry of the lung tissue was assessed. RESULTS: The median percentage of caspase 3-stained cells for the 5 mg÷kg LPS dose was 0.36%, for the 10 mg÷kg LPS dose was 0.4% and for the control group was 0.03% (p<0.0001). The elevated expression levels of caspase 3 were consistent with the altered lung morphologies observed (rs=0.88). LPS administration in rats resulted in a significant dose-dependent increase in the levels of plasma FasL (p<0.0001). These levels correlated with markers of lung injury: degree of hypoxemia (rs=-0.42), histological measured lung injury score (rs=0.72), the density of the caspase 3 staining cells in the immunohistochemistry assessment of apoptosis (rs=0.81) and with the plasma RAGE (receptor for advanced glycated end-products) values (rs=0.70). CONCLUSIONS: Apoptosis is increased in edotoxemia induced lung injury and is likely to contribute to alveolar injury.

Much Ado About the New Definitions of Sepsis.

Following the publication of the new definition of sepsis (Sepsis-3), a plethora of articles have been published in medical journals. Recognizing the epidemiological importance of the previous definitions, first issued in 1992 (Sepsis-1), and subsequently revised in 2001 (Sepsis-2), the most recent opinion emphasizes the failure "to provide adequate groups of patients with homogenous aetiologies, presentations and outcomes", and blamed one of the causes "for the failure of several randomized controlled trials (RCTs), that tested the efficacy of adjuvant sepsis therapies". This review summarizes the recent advances in sepsis definition.

Ischemic preconditioning and inflammatory response syndrome after reperfusion injury: an experimental model in diabetic rats.

Quantification of local ischemia and inflammatory response syndrome correlated with histological changes associated with ischemia-reperfusion injury (IRI) after revascularization techniques. We included 12 adult male Wistar rats, aged eight weeks that were randomly divided into two groups. The first group acted as the control and at the second group, we induced diabetes by intraperitoneal streptozotocin administration (60 mg/kg). After eight weeks, the rats were subject to ischemic preconditioning for 10 minutes at three regular intervals. Twenty-four hours post-preconditioning, both groups were subject to ischemia for 20 minutes, followed by 30 minutes of reperfusion. Oxygen extraction was higher in Group 1, the arterio-venous CO2 gradient was higher in the control group, but not significant. The lactate production was higher in Group 1. The second group had a higher Na+ and also a significant difference in K+ values. Receptor for Advanced Glycation End (RAGE) values were higher in the second group but with no significant difference (RAGE1=0.32 ng/mL versus RAGE2=0.40 ng/mL). The muscle samples from the control group displayed significant rhabdomyolysis, damage to the nucleus, while the preconditioned group showed almost normal morphological characteristics. The lungs and kidneys were most damaged in the control group, with damage expressed as thickened alveolar septa, neutrophil infiltrates, eosinophilic precipitates in the proximal convolute tubule. Ischemic preconditioning significantly attenuates the ischemic reperfusion injury.

Time- and dose-dependent severity of lung injury in a rat model of sepsis.

Different animal models of experimental lung injury have been used to investigate mechanisms of lung injury. Lipopolysaccharide (LPS) administration is the most often used approach to model the consequences of bacterial sepsis. We created an endotoxemia rat model, simulating sepsis-related lung injury, in order to quantify the time and dose dependent severity lesions induced by the administration of lipopolysaccharide. Our study included 42 male Wistar rats, randomly divided into four groups: one control group (n=6) and three experimental groups (n=12/group) in whom we induced sepsis by intraperitoneal injection of progressively increasing doses of LPS (3, 5, 10 mg/kg). At six hours, the animals included in the groups with higher doses of LPS developed thrombocytopenia, elevated lactate levels, and liver and renal injury in a dose and time dependent manner. The severity of hypoxemia at six hours correlated with the increasing doses of LPS, with a slight improvement at 24 hours. Lung injury scores became more severe with increased dose and time of exposure to LPS without reaching the level of hyaline membranes formation. We also demonstrated translocation of a protein from the airspaces into plasma (RAGE - receptor for advanced glycation end products). Induction of sepsis using LPS is a known experimental model, but LPS treatment in rats does not cause the severe endothelial and epithelial injury that occurs in humans with acute respiratory distress syndrome (ARDS). In our study, the clinical, laboratory and histopathological findings confirmed sepsis and the damage of the alveolar-capillary membrane in a dose-dependent manner.

Evaluation of O-POSSUM vs ASA and APACHE II scores in patients undergoing oesophageal surgery.

BACKGROUND AND AIMS: Risk and prognostic scores quantify the patient's risk of death or complication according to the severity of his illness. The aim of this study was to evaluate the predictive accuracy of O-POSSUM vs ASA and APACHE II models on patients undergoing oesophageal surgery. MATERIAL AND METHOD: In this observational retrospective study 55 patients were enrolled who had undergone surgical interventions of excision and reconstruction of the oesophagus for neoplastic oesophageal stenosis, in the Surgical Clinics (I and II) of the Clinical County Emergency Hospital Mures, between January 2011 and January 2014. By using patients file records after extracting the data we calculated the predictive mortality, according to the prognostic scores O-POSSUM, ASA and APACHE II and we analyzed its correlations with the postoperative evolution. We evaluated the discriminatory power of the three scores using the ROC (receiver-operating characteristic) curves. According to the cut-off value corresponding to each score, we compared the Kaplan Meier survival curves during the hospitalization period. RESULTS: ROC curves analysis revealed that O-POSSUM had a better discriminatory power for mortality compared to the other two scores: AUC = 0.73 for O-POSSUM, AUC = 0.57 for APACHE II and AUC = 0.64 for ASA (p < 0.001). The cut-off value was statistically significant only in case of O-POSSUM, as it derives from the statistical analysis of the survival curves (p = 0.035). CONCLUSION: O-POSSUM predicts mortality more accurately compared to ASA or APACHE II in patients undergoing oesophageal surgery.

Blood sampling as a cause of anemia in a general ICU - a pilot study.

OBJECTIVE: The objective of our pilot study was to evaluate the influence of daily phlebotomy on patients' haemoglobin levels from our general intensive care unit. METHODS: We prospectively enrolled 35 patients who did not present with acute haemorrhage or developed it during the study period. For each patient we recorded: the diagnosis, age, sex, haemoglobin, hematocrit, SOFA and APACHE II score, blood volume drawn in standardized vials, number of blood tests ordered per day, fluid balance per day, number of ICU days. The collected data were analyzed using the linear regression model, paired t-test, receiver operating characteristic curves, and descriptive analysis. Statistical analysis was performed with SPSS v.17 trial version (IBM, NY, USA). RESULTS: The mean volume of blood drawn per day was 18.1 (SD ± 14.4) ml and the number of blood tests was 3.8 (SD ± 1.75) per day. On univariate linear regression analysis both the blood volume drawn daily (p = 0.04) and the number of blood tests per day (p = 0.009) correlated with a drop in mean haemoglobin concentration. The difference in the mean value of haemoglobin at admission and discharge correlated with overall mortality (p = 0.03). The sensitivity of admission haemoglobin equal to 10.6 g/dL in predicting mortality was 82.4% with a specificity of 50%, (p = 0.019, AUC = 0.732). CONCLUSIONS: We evidenced the predictive power of blood sampling and number of blood tests done on haemoglobin concentration. Besides the main objective of the study we noticed that the difference in the mean value of haemoglobin at admission and discharge correlated with overall mortality. Considering that blood sampling contributes to anemia among ICU patients, we should limit the daily tests undertaken, to the tests absolutely necessary for guiding our therapy.

Effectiveness versus efficiency in a medical skills laboratory.

Medical educators are facing the new challenge of using medical simulation for teaching purposes. The use of simulators seems attractive for trainers and for trainees, but prices of simulators may be prohibitive. In an era of limited resources it is mandatory when using such an expensive tool as simulation, to prove its benefits. Despite the fact that simulation provides opportunity for training, additional advantages are far from being established. The supposed benefits of using medical simulators in teaching and examination needs to be proven regarding two aspects: effectiveness and efficiency.

Predicting scores correlations in patients with septic shock - a cohort study.

BACKGROUND: ICU prognostic scores were developed to measure the severity of the disease and the patients' prognosis. The objective of this study was to assess the validity of the Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and Simplified Acute Physiology Score II (SAPS II) scores in patients with septic shock. METHODS: The APACHE II, SOFA and SAPS II scores were determined prospectively, in the first 24 hours after admission, for all 56 patients with septic shock who were included in this study. Data were statistically evaluated; the discriminating power regarding survivors vs deceased patients was calculated based on the receiver operating characteristic curves (ROC). RESULTS: The overall mortality of the 56 patients with septic shock was 60.71% (34 deaths). The average APACHE II score was 25.36 ± 7.477. The average SOFA score was 7.679 ± 3.197. The average SAPS II score was 44.45 ± 16.97. For the APACHE II and SOFA scores the differences when deceased and survivors were compared were not statistically significant (APACHE II: 26.76 ± 6.742 vs 23.18 ± 8.175 respectively for SOFA: 8.029 ± 3.099 vs 7.136 ± 3.342). For the SAPS II score the values are: 49.12 ± 16.61 in deceased vs 37.23 ± 15.20 in survivors, the difference being statistically significant (p = 0.0092). The areas under ROC for the three scores are 0.622 for APACHE II, 0.575 for SAPS II and 0.705 for SOFA. CONCLUSIONS: In our study the SAPS II score was superior to the other scores for predicting survival in patients with septic shock.

Clinico-pathological particularities of the shock-related pancreatitis.

Acute pancreatitis can develop in patients with shock due to the underlying diseases, surgical interventions or because of severe hypoperfusion. The aim of our work was to study the histological alterations of the pancreas in patients dying after cardiogenic, hypovolemic or septic shock, to demonstrate the presence and severity of pancreatic injury. We performed a retrospective study which included patients who died and who were autopsied after different types of shock, hospitalized between 2007-2009 in general and cardiac intensive care units. We excluded the patients with known pancreatic diseases. From 223 patients included in our study 39 presented necrotising hemorrhagic alteration of the pancreatic tissue. There were no differences in histological and immunohistochemical findings between the different etiopathogenetic types of shock. None of the patients had characteristic clinical signs for acute pancreatitis. The digestive symptoms, they presented, could be related to the underlying disease or to postoperative state. The common findings in these patients were prolonged and severe hypotension, associated renal dysfunction, leucocytosis, hyperglycemia and hypocalcemia. Pancreatitis can occur in patients with shock, due to prolonged hypoperfusion of the pancreas. It is difficult to diagnose it because clinical signs are altered due to severity of underlying disease or analgo-sedation commonly used in intensive care. We therefore recommend in patients with shock to consider the possible development of ischemic pancreatitis for prompt and efficient treatment.

Looking for the best management of myasthenia gravis at the Tg.Mures Clinic of Anesthesia and Intensive Care.

Thymectomy is one of the current management strategies for myasthenia gravis. This is observational study focused on the evolution of the surgical and anesthesiological strategies applied to the patients submitted to thymectomy initially by maximal sternotomy (in the years 1994-1998), followed by unconditioned reorientation towards thymectomy by VATS. A number of 103 patients are included, 51 thymectomy by left VATS. All the thoracoscopic thymectomy were performed in general anesthesia, the lungs were separated by left selective intubation, and the left lung was deflated during the surgical procedure. The surgical complications appeared mainly in the VATS group: one pericardial and one myocardial lesion leading to sternotomy (minimal blood loss, uneventful recovery), contralateral pleural lesion with pneumothorax. The classical approach accounted for one hemothorax. The postoperative mortality was zero in the VATS group vs. 6 out of 52 pts in the sternotomy group. The postoperative evolution confronted the anesthesiologist with the classical crises of myasthenia. Death occurred within the first three weeks following surgery. The demise in 3 cases was due to cardiac complications (preexisting cardiomyopathy complicated by ventricular arrhythmia) and respiratory failure plus sepsis (for the remaining cases that we lost). The treatment options in the ICU are discussed: plasmapheresis, immunosuppression, ventilatory support. VATS is appropriate for almost all thymectomy, but the outcome is heavily based on a team approach: neurologist, surgeon and anesthetist.

Complete blindness after optic neuropathy induced by short-term linezolid treatment in a patient suffering from muscle dystrophy.

We present a case of severe optic neuropathy following linezolid treatment, which led to complete irreversible blindness, in a patient with progressive muscular dystrophy, treated with linezolid for 16 days for methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Interruption of antibiotic therapy did not lead to remission of ocular symptoms. Administration of linezolid may lead to severe neuropathy even in the case of short-term treatment.

[Investigating the possibility of aerosol therapy individualization using the stochastic lung model]. / Investigarea posibilitatii de a individualiza terapia cu aerosoli cu ajutorul modelului pulmonar stochastic.

The aim of our study is to examine the possibility of individualizing aerosol therapy, by determining the ideal diameter of the inhaled particles and the optimal breathing pattern, using a computerized simulation program. In order to find the optimal breathing pattern, we used different variations of the tidal volume and breathing period. We tried to determine the ideal particle diameter by carrying out a series of simulations for particles with diameters ranging from 1 to 10 microns. Our results show that increasing the particle diameter will lead to higher deposition values in the upper respiratory regions and bronchi, and smaller values in the acinary regions of the lung. Repeated simulations have led to two different ideal particle diameters, according to the localization of the desired effect. This way, for the bronchial regions the ideal particle diameter is 10 microns, and for the acinary regions 2 microns.