Medical simulation is used in a growing number of medical education institutions all over the world. Since 2013, the University of Medicine and Pharmacy of Tîrgu Mureş has introduced a number of simulation methods into the curriculum of certain subjects, the number of which is expanding. This article sums up some of the knowledge available in the literature regarding medical simulation and presents the general framework under which it is used in medical learning in our University.
Background: Anesthesia and Intensive Care is a teaching subject that arguably benefits the most from the use of simulation based methods in education. The availability of technically advanced complex simulators allows instructors to develop training scenarios that can be deeply integrated within the teaching curriculum. Aim: The present study aimed to assess whether the students undergoing Anesthesia and Intensive Caresimulation training are satisfied with the perceived educational outcome. Material and method: We carried out a retrospective transversal study in which we analyzed 256 feedback forms received from medical students between October 2014 and June 2015. The forms contained 5 fixed questions that required rating a certain parameter with grades from 1 to 5. Results: The simulation sessions used in Anesthesia and Intensive Care training were well perceived by students, over 90% of whom considered that these training session are useful from a professional and career development point of view. Conclusion: Based on the students’ perception, simulation training sessions in Anesthesia and Intensive Care can be further developed and integrated with the clinical practical content of this subject.
Background. Validating new sepsis biomarkers can contribute to early diagnosis and initiation of therapy. The aim of this study is to evaluate the sepsis predictive capacity of soluble urokinase plasminogen receptor (suPAR) and its role in evaluating the prognosis of bloodstream infections. Material and method. We conducted a prospective pilot study on 49 systemic inflammatory response syndrome (SIRS) patients admitted to the intensive care unit (ICU), that were divided, on the basis of bacteremia in group A (SIRS with bacteremia, n=14) and group B (SIRS without bacteremia, n=35). Hemoculture and blood samples were drawn on the first day to determine suPAR, C-reactive protein (CRP) and procalcitonin (PCT). We set to identify significant cut-off values in estimating bacteremia and mortality in septic patients. Results. In group A, suPAR values were 14.3 ng/mL (range 10-45.5 ng/mL) and in group B, 9.85 ng/mL (range 3.4-48 ng/mL) p=0.008. Area under the curve (AUC) for suPAR was 0.745 (95% CI: 0.600-0.859), for CRP 0.613 (95% CI: 0.522-0.799) and for PCT 0.718 (95% CI: 0.477-0.769). Cut-off value for suPAR in bacteremia prediction was 9.885 ng/mL, with 100% sensibility and 51.43% specificity. Mortality in group A was 85.7% (12/14) and in group B 74.3% (26/39), p>0.05. Area under the curve (AUC) for suPAR was 0.750 (95% CI: 0.455-0.936), for CRP 0.613 (95% CI: 0.413-0.913) and for PCT 0.618 (95% CI: 0.373-0.888). Cut-off value of suPAR in predicting mortality was 11.5 ng/mL, with 66.67% sensibility and 100% specificity. Conclusions. In our study suPAR had a predictive capacity for bacteremia and seems to be an independent factor for mortality prognosis in septic patients.
Introduction: Cupriavidus pauculus is a rarely isolated non-fermentative, aerobic bacillus, which occasionally causes severe human infections, especially in immunocompromised patients. Strains have been isolated from various clinical and environmental sources.
Case presentation: A 67-year-old man was admitted to the Intensive Care Unit with acute respiratory failure. The patient was diagnosed with bilateral pneumonia, pulmonary sepsis and underwent invasive mechanical ventilation. Examination revealed diminished bilateral vesicular breath sounds, fever, intense yellow tracheal secretions, a respiratory rate of 24/minute, a heart rate of 123/minute, and blood pressure of 75/55 mmHg. Vasoactive treatment was initiated. Investigations revealed elevated lactate and C-reactive protein levels. A chest X-ray showed bilateral infiltration. Parenteral ciprofloxacin and ceftriaxone were administered. Tracheal aspirate culture and blood culture showed bacterial growth of Cupriavidus pauculus. Colistin was added to the treatment. There was a poor clinical response despite repeated blood culture showing negative results. The diagnosis of multiple organ dysfunction syndrome (MODS) caused by C. pauculus was made. The patient died eleven days after admission.
Conclusions: Clinical improvement cannot always be expected in spite of targeted antibiotic therapy. This pathogen should be considered responsible for infections that usually develop in immunocompromised patients.
Introduction: Elevated intraabdominal pressure (IAP) it is known to have an impact on renal function trough the pressure transmitted from the abdominal cavity to the vasculature responsible for the renal blood flow. Intraabdominal pressure is found to be frequent in intensive care patients and also to be a predictor of mortality. Intra-abdominal high pressure is an entity that can have serious impact on intensive care admitted patients, studies concluding that if this condition progresses to abdominal compartment syndrome mortality is as high as 80%.
Aim: The aim of this study was to observe if a link between increased intraabdominal pressure and modification in renal function exists (NGAL, creatinine clearance).
Material and Method: The study enrolled 30 critically ill patients admitted in the Intensive Care Unit of SCJU Tîrgu Mures between November 2015 and August 2016. The study enrolled adult, hemodynamically stable patients admitted in intensive critical care - defined by a normal blood pressure maintained without any vasopressor or inotropic support, invasive monitoring using PICCO device and abdominal pressure monitoring.
Results: The patients were divided into two groups based on the intraabdominal pressure values: normal intraabdominal pressure group= 52 values and increased intraabdominal group= 35 values. We compared the groups in the light of NGAL values, 24 hours diuresis, GFR and creatinine clearance. The groups are significantly different when compared in the light of NGAL values and GFR values. We obtained a statistically significant correlation between NGAL value and 24 hour diuresis. No other significant correlations were encountered between the studied items.
Conclusions: NGAL values are increased in patients with high intraabdominal pressure which may suggest its utility as a cut off marker for patients with increased intraabdominal pressure. There is a significant decreased GFR in patient with elevated intraabdominal pressure, observation which can help in early detection of renal injury in patients due to high intraabdominal pressure. No correlation was found between creatinine clearance and increased intraabdominal pressure.
Background: Recommendations have been made, following the multicenter Surviving Sepsis Campaign study, to standardize the definition of severe sepsis with reference to several parameters such as haemodynamic stability, acid-base balance, bilirubin, creatinine, International Normalized Ratio (INR), urine output and pulmonary functional value of the ratio between arterial oxigen partial pressure and inspiratory oxigen concentration. Procalcitonin (PCT) is considered to be a gold standard biomarker for the inflammatory response, and recent studies have shown that it may help to discover whether a seriously ill person is developing sepsis. C-reactive protein (CRP) is also used as a marker of inflammation in the body, as its blood levels increase if there is any inflammation in the body. The aim of this study was to evaluate serum procalcitonin and C-reactive protein levels as diagnostic and prognostic biomarkers of severe sepsis.
Material and method: Sixty patients, diagnosed as being “septic”, were admitted to the intensive care unit (ICU). Based on laboratory results and clinical findings a diagnosis of “severe sepsis“ was made, and correlated with PCT and CRP values. The APACHE II, SAPS II and SOFA severity scores were calculated, analyzed and correlated with PCT and CRP.
Results: Fifty two patients (86.67%) presented with criteria for severe sepsis. Multivariate correlation analysis indicated a significant positive association between procalcitonin and all severity scores (APACHEII p<0.0001, SOFA p<0.0001, SAPS II p<0.0001). CRP proved to be significantly correlated only with the SAPS II score (p=0.0145). Mortality rate was high, with 48 patients (80%) dying. There was no significant correlation between the levels of the PCT and CRP biomarkers and severe sepsis (p=0.2059 for PCT, p=0.6059 for CRP).
Conclusions: The procalcitonin levels are highly correlated with the severity scores (APACHE II, SAPS II, SOFA) regularly used in ICUs and therefore can be used for determining the severity of the septic process. Quantitive procalcitonin and C-reactive protein analysis was not shown to be useful in diagnosing severe sepsis. However, PCT and CRP can be used to predict the fatal progression of the septic patient.
Objective: To demonstrate the relationship between intra-abdominal hypertension (IAH) and cardiac output (CO) in mechanically ventilated (MV), critically ill patients.
Material and methods: This was a single-center, prospective study performed between January and April 2016, on 30 mechanically ventilated patients (mean age 67.3 ± 11.9 years), admitted in the Intensive Care Unit (ICU) of the Emergency County Hospital of Tîrgu Mureș, Romania, who underwent measurements of intra-abdominal pressure (IAP). Patients were divided into two groups: group 1 – IAP <12 mmHg (n = 21) and group 2 – IAP >12 mmHg (n = 9). In 23 patients who survived at least 3 days post inclusion, the variation of CO and IAP between baseline and day 3 was calculated, in order to assess the variation of IAP in relation to the hemodynamic status.
Results: IAP was 8.52 ± 1.59 mmHg in group 1 and 19.88 ± 8.05 mmHg in group 2 (p <0.0001). CO was significantly higher in group 1 than in the group with IAH: 6.96 ± 2.07 mmHg (95% CI 6.01–7.9) vs. 4.57 ± 1.23 mmHg (95% CI 3.62–5.52) (p = 0.003). Linear regression demonstrated an inverse correlation between CO and IAP (r = 0.48, p = 0.007). Serial measurements of CO and IAP proved that whenever accomplished, the decrease of IAP was associated with a significant increase in CO (p = 0.02).
Conclusions: CO is significantly correlated with IAP in mechanically ventilated patients, and IAH reduction is associated with increase of CO in these critically ill cases.
Introduction: Angiopoietin-2 (ANG-2) is a new biomarker whose blood-serum values increase in sepsis and its expression is elevated in line with the severity of the degree of inflammation. The aim of this study was to identify the diagnostic role of ANG-2 in patients with non-surgical sepsis addmitted to an intensive care unit.
Material and methods: This was a prospective randomized study including 74 patients admitted in the Clinic of Intensive Care of the County Clinical Emergency Hospital Tirgu Mure., divided into two groups: Group S: patients with sepsis (n=40, 54%) and Group C: control, without sepsis (n=34, 46%). ANG-2 levels were determined in both groups.
Results: From the Group S, 14 patients (35%) had positive haemocultures. ANG-2 values varied between 1 and 43 ng/mL, with an average of 6.0 ng/mL in patients without sepsis and 10.38 ng/mL in patients with sepsis (p=0.021). A positive correlation between ANG-2 and SAPS II, SOFA and APACHE II severity scores was demonstrated, as was a positive correlation between serum levels of ANG-2 and procalcitonine. ANG-2 had a 5.71% specificity and 74.36% sensitivity for diagnosis of sepsis.
Conclusions: ANG-2 serum levels were elevated in sepsis, being well correlated with PCT values and prognostic scores. ANG-2 should be considered as a useful biomarker for the diagnosis and the prognosis of this pathology.
Introduction: Intraabdominal pressure monitoring is not routinely performed because the procedure assumes some invasiveness and, like other invasive procedures, it needs to have a clear indication to be performed. The causes of IAH are various. Mechanically ventilated patients have numerous parameters set in order to be optimally ventilated and it is important to identify the ones with the biggest interference in abdominal pressure. Although it was stated that mechanical ventilation is a potential factor of high intraabdominal pressure the set parameters which may lead to this diagnostic are not clearly named.
Objectives: To evaluate the relation between intraabdominal pressure and ventilator parameters in patients with mechanical ventilation and to determine the correlation between intraabdominal pressure and body mass index. Material and method: This is an observational study which enrolled 16 invasive ventilated patients from which we obtained 61 record sheets. The following parameters were recorded twice daily: ventilator parameters, intraabdominal pressure, SpO2, Partial Oxygen pressure of arterial blood. We calculated the Body Mass Index (BMI) for each patient and the volume tidal/body weight ratio for every recorded data point.
Results: We observed a significant correlation between intraabdominal pressure (IAP) and the value of PEEP (p=0.0006). A significant statistical correlation was noted regarding the tidal volumes used for patient ventilation. The mean tidal volume was 5.18 ml/kg. Another significant correlation was noted between IAP and tidal volume per kilogram (p=0.0022). A positive correlation was found between BMI and IAP (p=0.0049), and another one related to the age of the enrolled patients. (p=0.0045).
Conclusions: The use of positive end-expiratory pressures and high tidal volumes during mechanical ventilation may lead to the elevation of intraabdominal pressure, a possible way of reducing this risk would be using low values of PEEP and also low volumes for the setting of ventilation parameters. There is a close positive correlation between the intraabdominal pressure levels and body mass index.
Introduction: There are several approaches for brachial plexus anesthesia: supraclavicular, infraclavicular, interscalenic and axillary. Out of these, the axillary approach is considered to be the safest because of the low risk of lesioning the adjacent structures, low risk of phrenic nerve blockade or of producing an iatrogenic pneumothorax. The block can be performed by one single injection at the site, by two injections or by several injection, among each nerve of the plexus. Ultrasound was introduced in regional anesthesia since 1978, being used initially as an auxiliary method to peripheral neurostimulator.
Objectives: The evaluation of ultrasound efficiency as an auxiliary method for brachial plexus block performance, in terms of success rate, vascular punctures. The influence of obesity on performing time, total duration of the block, and success rate of brachial plexus block.
Material and method: Prospective, randomized study which enrolled adult patients, scheduled for surgical emergency or elective surgical intervention on upper limb with brachial plexus block by axillary approach, using either the peripheral nerve stimulation or the ultrasound guidance.
Results: We enrolled 160 patients, grouped in two sets- the ultrasound group= 82 patients (US) the neurostimulation group = 78 patients (NS). Vascular punctures were statistically significant different p= 0, 04. The success rate was not influenced by the obesity.
Conclusions: Ultrasound guidance makes axillary brachial plexus block safer, we can recommend ultrasound guidance as routine for axillary brachial plexus block. The obese patient can beneficiate by both methods of brachial plexus blockage.