Critical Thinking for Critical Care

<abstract xmlns="http://www.w3.org/1999/xhtml">Cardiogenic shock (CS) is a critical condition which often complicates the evolution of an acute myocardial infarction (AMI). At the same time, co-existence of chronic multi-vessel disease can lead to the development of cardiogenic shock in cases with pronounced haemodynamic instability. Different clinical studies have tried to identify the most appropriate treatment for critical cases of CS complicating AMI. This review aims to present the current status of recommended therapeutic strategies for severe cases of CS presenting as a complication of AMI, and try to shed light on the most appropriate therapeutic strategy as outlined in the current literature. The paper will discuss the different current strategies available for use in the treatment of this condition, includig interventional revascularisation, (complete or culprit), the role of new devices for providing mechanical circulatory support, and the potential role of new drug therapies and of hypothermia.</abstract>

Current Concepts and New Trends in the Treatment of Cardiogenic Shock Complicating Acute Myocardial Infarction

<abstract xmlns="http://www.w3.org/1999/xhtml"><bold>Introduction</bold>: Most children with fever without source will have a self limited viral infection though a small percent will develop a serious bacterial infection (SBI) like urinary tract infection, pneumonia, bacteraemia, meningitis or sepsis. The challenge facing practitioners is to distinguish between these two groups and currently biomarkers, like C-reactive protein (CRP) and Procalcitonin (PCT), are available for this purpose. The aim of the current study was to identify SBI in infants with fever without an identifiable cause using the recently introduced “Lab-score” combining C-reactive protein, procalcitonin and urine dipstick results.<bold>Methods</bold>: This survey is part of an observational study aimed at identifying children with fever without source at risk of SBI. Patients were recruited from the Emergency Department of Tirgu Mures Emergency Clinical County Hospital, Romania, during 2013. SBI diagnosis was based on urine, blood and cerebrospinal fluid cultures and chest radiographs. For infants, aged 7 days to 12 months, CRP and PCT were determined and the “Lab-score” was calculated. Positive and negative likelihood ratios and post test probabilities were calculated for each parameter and score.<bold>Results</bold>: Of the ninety infants included in the study, SBI was diagnosed in nineteen (21.11%). Ten had a urinary tract infection, seven had pneumonia, one had a urinary tract infection and bacteraemia, and one had sepsis. Positive and negative likelihood ratios for CRP (.40.0 mg/L) and PCT (.0.5 ng/mL) were 10.27/0.45 and 7.07/0.24 and post-test probabilities 73%/65%. For a “Lab-score1” (.3), positive and negative likelihood ratios were 10.43/0.28, and the posttest probability was 73%.<bold>Conclusions</bold>: In our survey the “Lab-score” proved a strong predictor for the identification of febrile infants at risk of SBI, but showed no significant difference compared with CRP and PCT which both proved equally good predictors for SBI.</abstract>

University of Medicine and Pharmacy of Tirgu Mures, Gheorghe Marinescu street no.38, Tirgu Mures, 540139, Romania

T☎rgu Mures County Clinical Emergency Hospital, Emergency Department, Gheorghe Marinescu street no.50, Tirgu Mures, 540136, Romania

The Value of the “Lab-Score” Method in Identifying Febrile Infants at Risk for Serious Bacterial Infections

<abstract xmlns="http://www.w3.org/1999/xhtml"><bold>Introduction</bold>: 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.<bold>Material and methods</bold>: 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.<bold>Results</bold>: 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.<bold>Conclusions</bold>: 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.</abstract>

University of Medicine and Pharmacy T┎rgu Mure°, Romania, Discipline of Intensive Care, 38 Gheorghe Marinescu street, Tirgu Mures, 540139, Romania

County Clinical Emergency Hospital T┎rgu Mures, Romania, 50 Gheorghe Marinescu street Tirgu Mures, 540139, Romania

University of Medicine and Pharmacy T┎rgu Mure°, Romania, Discipline of Infectious Diseases, 38 Gheorghe Marinescu street, Tirgu Mures, 540139, Romania

The Role of Angiopoietine-2 in the Diagnosis and Prognosis of Sepsis

<abstract xmlns="http://www.w3.org/1999/xhtml">Here we present a successful intra-arterial thrombolysis performed in the second trimester of pregnancy (21 weeks). The intervention resulted in complete recanalization of the occluded right middle cerebral artery and favourable clinical and gestational outcome. Together with cases described in respective medical literature our report affirms that in pregnancy acute ischemic stroke could be treated effectively applying intra-arterial thrombolysis (using rt-PA). This therapy could provide opportunity to help in such desperate situations.</abstract>

Department of Neurology, Hetényi Géza Hospital, H-5001 Szolnok, Tószegi street 21, Hungary

Department of Neurology, University of Debrecen, H-4012 Debrecen, Móricz Zsigmond street, no.22, Hungary

Department of Radiology, Avas Medical Centre LLC, H-5001 Szolnok, Tószegi street 21, Hungary

Intra-Arterial Thrombolysis in Second Trimester of Pregnancy. A Case Report

<abstract xmlns="http://www.w3.org/1999/xhtml"><bold>Introduction:</bold> Patent ductus arteriosus involves maintaining the permeability of the vascular ductus located between the pulmonary artery and the descending aorta, due to the failure of transition from foetal to adult type circulation. This malformation is characteristic to premature newborns with extremely low birth weight. The main pathophysiological factors identified in this pathology are immaturity of the smooth muscles, presence of vasodilator mediators and persistent hypoxaemia. Ductal-dependent cardiac malformations require drug therapy for keeping the permeability of the ductus arteriosus until the time of corrective surgery.<bold>Case presentation:</bold> We present the case of an extremely low birth weight premature newborn, derived from twin pregnancy with suspected specific pathology, respectively feto-fetal transfusion syndrome, admitted to the Regional Centre of Neonatal Intensive Care Unit Tîrgu-Mureş.Premature newborn with gestational age 31-32 weeks, extremely low birth weight, derived from twin pregnancy, with adequate prenatal follow up, was born by caesarean section for severe intrauterine growth restriction secondary to feto-fetal transfusion syndrome suspicion. The newborn developed respiratory distress syndrome by surfactant deficiency, intraventricular-haemorrhage grade I/II, and severe retinopathy. The detection of a systolic murmur in the second week of life, the diastolic theft revealed by trans-fontanellar ultrasound as well as lowered diastolic blood pressure values raised the suspicion of a patent ductus arteriosus and therefore specific treatment with ibuprofen, a cyclooxygenase inhibitor, was initiated. Progressive alteration of the newborn's condition and the evidence of a coarctation of the aorta imposed the initiation of Prostaglandin E1 therapy and subsequent surgical correction.<bold>Conclusions:</bold> Although beneficial, prophylactic or therapeutic closure of persistent ductus arteriosus</abstract>

University of Medicine and Pharmacy Tîrgu-Mureş, Romania, 38 Gheorghe Marinescu street, Tirgu Mures, 540139, Romania

Regional Center of Neonatal Intensive Care Unit UGON, 50 Gheorghe Marinescu street, Tirgu Mures, 540139, Romania

Drug Closure of a Patent Ductus Arteriosus in An Extremely Low Birth Weight Premature Newborn. A Case Report

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