Acute and Critical Care

Original Article

Infection
Comparative evaluation of tocilizumab and itolizumab for treatment of severe COVID-19 in India: a retrospective cohort study: Abhyuday Kumar, Neeraj Kumar, Arunima Pattanayak, Ajeet Kumar, Saravanan Palavesam, Pradhan Manigowdanahundi Nagaraju, Rekha Das; Received August 1, 2023 Accepted February 4, 2024 Published online April 1, 2024; DOI: https://doi.org/10.4266/acc.2023.00983 [Epub ahead of print]

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Abstract PDF: Background
Itolizumab downregulates the synthesis of proinflammatory cytokines and adhesion molecules by inhibiting CD6 leading to lower levels of interferon-γ, interleukin-6, and tumor necrotic factor-α and reduced T-cell infiltration at inflammatory sites. This study aims to compare the effects of tocilizumab and itolizumab in the management of severe coronavirus disease 2019 (COVID-19).
Methods
The study population was adults (>18 years) with severe COVID-19 pneumonia admitted to the intensive care unit receiving either tocilizumab or itolizumab during their stay. The primary outcome was clinical improvement (CI), defined as a two-point reduction on a seven-point ordinal scale in the status of the patient from initiating the drug or live discharge. The secondary outcomes were time until CI, improvement in PO2/FiO2 ratio, best PO2/FiO2 ratio, need for mechanical ventilation after administration of study drugs, time to discharge, and survival days.
Results
Of the 126 patients included in the study, 92 received tocilizumab and 34 received itolizumab. CI was seen in 46.7% and 61.7% of the patients in the tocilizumab and itolizumab groups, respectively and was not statistically significant (P=0.134). The PO2/FiO2 ratio was significantly better with itolizumab compared to tocilizumab (median [interquartile range]: 315 [200–380] vs. 250 [150–350], P=0.043). The incidence of serious adverse events due to the study drugs was significantly higher with itolizumab compared to tocilizumab (14.7% vs. 3.3%, P=0.032).
Conclusions
The CI with itolizumab is similar to tocilizumab. Better oxygenation can be achieved with itolizumab and it can be a substitute for tocilizumab in managing severe COVID-19.

Review Article

Meta-analysis
The impact of ketamine on outcomes in critically ill patients: a systematic review with meta-analysis and trial sequential analysis of randomized controlled trials: Yerkin Abdildin, Karina Tapinova, Assel Nemerenova, Dmitriy Viderman; Acute Crit Care. 2024;39(1):34-46. Published online February 28, 2024; DOI: https://doi.org/10.4266/acc.2023.00829

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Abstract PDF: Background
This meta-analysis aims to evaluate the effects of ketamine in critically ill intensive care unit (ICU) patients.
Methods
We searched for randomized controlled trials (RCTs) in PubMed, Scopus, and the Cochrane Library; the search was performed initially in January but was repeated in December of 2023. We focused on ICU patients of any age. We included studies that compared ketamine with other traditional agents used in the ICU. We synthesized evidence using RevMan v5.4 and presented the results as forest plots. We also used trial sequential analysis (TSA) software v. 0.9.5.10 Beta and presented results as TSA plots. For synthesizing results, we used a random-effects model and reported differences in outcomes of two groups in terms of mean difference (MD), standardized MD, and risk ratio with 95% confidence interval. We assessed the risk of bias using the Cochrane RoB tool for RCTs. Our outcomes were mortality, pain, opioid and midazolam requirements, delirium rates, and ICU length of stay.
Results
Twelve RCTs involving 805 ICU patients (ketamine group, n=398; control group, n=407) were included in the meta-analysis. The ketamine group was not superior to the control group in terms of mortality (in five studies with 318 patients), pain (two studies with 129 patients), mean and cumulative opioid consumption (six studies with 494 patients), midazolam consumption (six studies with 304 patients), and ICU length of stay (three studies with 270 patients). However, the model favored the ketamine group over the control group in delirium rate (four studies with 358 patients). This result is significant in terms of conventional boundaries (alpha=5%) but is not robust in sequential analysis. The applicability of the findings is limited by the small number of patients pooled for each outcome.
Conclusions
Our meta-analysis did not demonstrate differences between ketamine and control groups regarding any outcome except delirium rate, where the model favored the ketamine group over the control group. However, this result is not robust as sensitivity analysis and trial sequential analysis suggest that more RCTs should be conducted in the future.

Original Article

Pulmonary
Comparison of preoxygenation with a high-flow nasal cannula and a simple face mask before intubation in Korean patients with head and neck cancer: Jun-Young Jo, Jungpil Yoon, Heeyoon Jang, Wook-Jong Kim, Seungwoo Ku, Seong-Soo Choi; Acute Crit Care. 2024;39(1):61-69. Published online January 26, 2024; DOI: https://doi.org/10.4266/acc.2022.01543

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Abstract PDF Supplementary Material: Background
Although preoxygenation is an essential procedure for safe endotracheal intubation, in some cases securing sufficient time for tracheal intubation may not be possible. Patients with head and neck cancer might have a difficult airway and need a longer time for endotracheal intubation. We hypothesized that the extended apneic period with preoxygenation via a high-flow nasal cannula (HFNC) is beneficial to patients who undergo head and neck surgery compared with preoxygenation with a simple mask. Methods: The study was conducted as a single-center, single-blinded, prospective, randomized controlled trial. Patients were divided into groups based on one of the two preoxygenation methods: HFNC group or simple facemask (mask group). Preoxygenation was performed for 5 minutes with each method, and endotracheal intubation for all patients was performed using a video laryngoscope. Oxygen partial pressures of the arterial blood were compared at the predefined time points. Results: For the primary outcome, the mean arterial oxygen partial pressure (PaO2 ) immediately after intubation was 454.2 mm Hg (95% confidence interval [CI], 416.9–491.5 mm Hg) in the HFNC group and 370.7 mm Hg (95% CI, 333.7–407.4 mm Hg) in the mask group (P=0.002). The peak PaO2 at 5 minutes after preoxygenation was not statistically different between the groups (P=0.355). Conclusions: Preoxygenation with a HFNC extending to the apneic period before endotracheal intubation may be beneficial in patients with head and neck cancer.

Review Article

Neurosurgery
Target temperature management in traumatic brain injury with a focus on adverse events, recognition, and prevention: Kwang Wook Jo; Acute Crit Care. 2022;37(4):483-490. Published online November 10, 2022; DOI: https://doi.org/10.4266/acc.2022.01291

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Abstract PDF

Traumatic brain injury (TBI) is a critical cause of disability and death worldwide. Many studies have been conducted aimed at achieving favorable neurologic outcomes by reducing secondary brain injury in TBI patients. However, ground-breaking outcomes are still insufficient so far. Because mild-to-moderate hypothermia (32°C–35°C) has been confirmed to help neurological recovery for recovered patients after circulatory arrest, it has been recognized as a major neuroprotective treatment plan for TBI patients. Thereafter, many clinical studies about the effect of therapeutic hypothermia (TH) on severe TBI have been conducted. However, efficacy and safety have not been demonstrated in many large-scale randomized controlled studies. Rather, some studies have demonstrated an increase in mortality rate due to complications such as pneumonia, so it is not highly recommended for severe TBI patients. Recently, some studies have shown results suggesting TH may help reperfusion/ischemic injury prevention after surgery in the case of mass lesions, such as acute subdural hematoma, and it has also been shown to be effective in intracranial pressure control. In conclusion, TH is still at the center of neuroprotective therapeutic studies regarding TBI. If proper measures can be taken to mitigate the many adverse events that may occur during the course of treatment, more positive efficacy can be confirmed. In this review, we look into adverse events that may occur during the process of the induction, maintenance, and rewarming of targeted temperature management and consider ways to prevent and address them.

Citations

Citations to this article as recorded by

Trends and hotspots in research of traumatic brain injury from 2000 to 2022: A bibliometric study
Yan-rui Long, Kai Zhao, Fu-chi Zhang, Yu Li, Jun-wen Wang, Hong-quan Niu, Jin Lei
Neurochemistry International.2024; 172: 105646. CrossRef
Severe traumatic brain injury in adults: a review of critical care management
Siobhan McLernon
British Journal of Neuroscience Nursing.2023; 19(6): 206. CrossRef

Original Articles

Nursing
The effect of time management education on critical care nurses’ prioritization: a randomized clinical trial: Fatemeh Vizeshfar, Mahnaz Rakhshan, Fatemeh Shirazi, Roya Dokoohaki; Acute Crit Care. 2022;37(2):202-208. Published online April 28, 2022; DOI: https://doi.org/10.4266/acc.2021.01123

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Abstract PDF

necessiBackground: Nurses are at the forefront of patient care, and time management skills can increase their ability to make decisions faster. This study aimed to assess the effect of a time management workshop on prioritization and time management skills among nurses of emergency and intensive care units.
Methods
This randomized clinical trial was performed with 215 nurses. The educational intervention about time management was held in the form of a workshop for the intervention group. The time management questionnaire was completed by both groups before, immediately after, and 3 months after the intervention.
Results
Most participants were female (n=191, 88%), with a mean age of 31.82 years (range, 22–63 years). Additionally, the participants’ work experience ranged from 1 to 30 years (mean±standard deviation, 8.00±7.15 years). After the intervention, the mean score of time management increased significantly in the intervention group, but no significant difference was observed in this regard in the control group. The results also revealed a significant difference between the intervention and control groups regarding the mean score of time management 3 months after the intervention (P<0.001).
Conclusions
Time management training helped nurses adjust the time required to perform and prioritize various tasks.

Citations

Citations to this article as recorded by

Nursing core competencies for postresuscitation care in Iran: a qualitative study
Mahnaz Zali, Azad Rahmani, Kelly Powers, Hadi Hassankhani, Hossein Namdar-Areshtanab, Neda Gilani
BMJ Open.2024; 14(1): e074614. CrossRef
Critical care nurses’ experiences of caring challenges during post-resuscitation period: a qualitative content analysis
Mahnaz Zali, Azad Rahmani, Hadi Hassankhani, Hossein Namdar-Areshtanab, Neda Gilani, Arman Azadi, Mansour Ghafourifard
BMC Nursing.2024;[Epub] CrossRef
Impact of time management program on stress and coping strategies adopted by nursing students with regard to academic performance
Juby Mary Chacko, Achamma Varghese, Nirmala Rajesh
IP Journal of Paediatrics and Nursing Science.2023; 6(1): 48. CrossRef
Perceived clinical competence and predictive role of time management in nursing students
Maryam Behdarvand, Mehrnaz Ahmadi, Nasrin Khajeali
Nurse Education in Practice.2023; 72: 103789. CrossRef
Examining the impact of time management and resilience training on work-family conflict among Iranian female nurses: a randomized controlled trial
Sedigheh Peykar, Hakimeh Vahedparast, Tayebeh Gharibi, Razieh Bagherzadeh
BMC Nursing.2023;[Epub] CrossRef

Pulmonary
The feasibility and safety of percutaneous dilatational tracheostomy without endotracheal guidance in the intensive care unit: Ji Eun Kim, Dong Hyun Lee; Acute Crit Care. 2022;37(1):101-107. Published online February 17, 2022; DOI: https://doi.org/10.4266/acc.2021.00906

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Abstract PDF: Background
Percutaneous dilatational tracheostomy (PDT) is a common procedure in intensive care units (ICUs). Although it is thought to be safe and easily performed at the bedside, PDT usually requires endotracheal guidance, such as bronchoscopy. Here, we assessed the clinical outcomes and safety of PDT conducted without endotracheal guidance.
Methods
In the ICU and coronary ICU at a tertiary hospital, PDT was routinely performed without endotracheal guidance by a single medical intensivist using the Griggs technique PDT kit (Portex Percutaneous Tracheostomy Kit). We retrospectively reviewed the electronic medical records of patients who underwent PDT without endotracheal guidance.
Results
From January 1 to December 31, 2018, 78 patients underwent PDT without endotracheal guidance in the ICU and coronary ICU. The mean age of these subjects was 71.9±11.5 years, and 29 (37.2%) were female. The mean Acute Physiology And Chronic Health Evaluation (APACHE) II score at 24 hours after admission was 25.9±5.8. Fifty patients (64.1%) were on mechanical ventilation during PDT. Failure of the initial PDT attempt occurred in 4 patients (5.1%). In two of them, PDT was aborted and converted to surgical tracheostomy; in the other two patients, PDT was reattempted after endotracheal reintubation, with success. Minor bleeding at the tracheostomy site requiring gauze changes was observed in five patients (6.4%). There were no airway problems requiring therapeutic interventions or procedure-related sequelae.
Conclusions
PDT without endotracheal guidance can be considered safe and feasible.

Case Report

Pulmonary/Thoracic Surgery
Successful Management of Airway Emergency in a Patient with Esophageal Cancer: Samina Park, Hyun Joo Lee, Chang Hyun Kang, Young Tae Kim; Korean J Crit Care Med. 2015;30(2):135-138. Published online May 31, 2015; DOI: https://doi.org/10.4266/kjccm.2015.30.2.135

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Abstract PDF

A 60-year-old man with advanced esophageal cancer was admitted for surgical placement of a feeding jejunostomy tube before commencement of chemoradiotherapy. His esophageal cancer had directly invaded the posterior tracheal wall, inducing a nearly total obstruction of the distal trachea. On the day before the surgery, respiratory failure developed due to tumor progression and tracheal edema. Tracheal intubation and mechanical ventilation were attempted without success. Application of veno-venous extracorporeal membrane oxygenation (ECMO) corrected the patient’s respiratory acidosis and relieved his dyspnea. With full ECMO support, he underwent tracheal stent insertion. Two hours later, he was weaned from ECMO support uneventfully. This was a successful case of tracheal stenting for airway obstruction under rescue veno-venous ECMO.

Citations

Citations to this article as recorded by

An esophageal tumor producing life-threatening tracheal compression in a young adult was resuscitated with a self-inflating resuscitation bag
Rajnish Kumar, Nishant Sahay, Neeraj Kumar, Soumya Singh
Perioperative Care and Operating Room Management.2024; 34: 100365. CrossRef
Thoracic oesophageal cancer as a cause of stridor: a literature review
Robert Munashe Maweni, Venughanan Manikavasagar, Nicholas Sunderland, Sajid Chaudhry
BMJ Case Reports.2018; : bcr-2018-224872. CrossRef

Original Articles

Pulmonary
Percutaneous Dilatational Tracheostomy in Critically Ill Patients Taking Antiplatelet Agents: Sung Jin Nam, Ji Young Park, Hongyeul Lee, Taehoon Lee, Yeon Joo Lee, Jong Sun Park, Ho Il Yoon, Jae Ho Lee, Choon Taek Lee, Young Jae Cho; Korean J Crit Care Med. 2014;29(3):183-188. Published online August 31, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.3.183

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Abstract PDF

BACKGROUND
Percutaneous dilatational tracheostomy (PDT) has been considered as an alternative to surgical tracheostomy in intensive care units (ICU), and is widely used for critically ill patients who need prolonged mechanical ventilation. Few studies have reported on PDT performed in critically ill patients taking antiplatelet agents. Our goals are to assess not only the feasibility and safety of PDT, but also bleeding complications in the patients receiving such therapy.
METHODS
In a single institution, PDTs were performed by pulmonologists at the medical ICU bedside using the single tapered dilator technique and assisted by flexible bronchoscopy to confirm a secure puncture site. From March 2011 to February 2013, the patients' demographic and clinical data, procedural parameters, outcomes and complications were analyzed and compared complications between patients taking antiplatelet agents and those not.
RESULTS
PDTs were performed for 138 patients; the median age was 72 years, mean body mass index was 20.3 +/- 4.8 kg/m2, and mean acute physiology and chronic health evaluation II score was 24.4 +/- 9.4. Overall, the procedural success rate was 100% and the total procedural time was 25 +/- 8.5 min. There were no periprocedural life-threatening complications, and no statistical difference in the incidence of bleeding complications between patients who had taken antiplatelet agents and those had not (p = 0.657).
CONCLUSIONS
PDT performed in critically ill patients taking antiplatelet agents was a feasible procedure and was implemented without additional bleeding complications.

Citations

Citations to this article as recorded by

Open tracheostomy in patients with dual platelet aggregation inhibitors
Lorena Zapata-Contreras, Carlos Eduardo Hoyos-Cuervo, María Cristina Florián-Pérez
Colombian Journal of Anesthesiology.2019; 47(3): 189. CrossRef
Safety of Percutaneous Dilatational Tracheotomy in Patients on Dual Antiplatelet Therapy and Anticoagulation
Enzo Lüsebrink, Konstantin Stark, Mattis Bertlich, Danny Kupka, Christopher Stremmel, Clemens Scherer, Thomas J. Stocker, Mathias Orban, Tobias Petzold, Nikolaus Kneidinger, Hans-Joachim Stemmler, Steffen Massberg, Martin Orban
Critical Care Explorations.2019; 1(10): e0050. CrossRef
Safety and Feasibility of Percutaneous Dilatational Tracheostomy in the Neurocritical Care Unit
Dong Hyun Lee, Jin-Heon Jeong
Journal of Neurocritical Care.2018; 11(1): 32. CrossRef
Comparison of outcomes between vertical and transverse skin incisions in percutaneous tracheostomy for critically ill patients: a retrospective cohort study
Sung Yoon Lim, Won Gun Kwack, Youlim Kim, Yeon Joo Lee, Jong Sun Park, Ho Il Yoon, Jae Ho Lee, Choon-Taek Lee, Young-Jae Cho
Critical Care.2018;[Epub] CrossRef

Safety and Feasibility of Percutaneous Tracheostomy Performed by Medical Intensivists: Hongseok Yoo, So Yeon Lim, Chi Min Park, Gee Young Suh, Kyeongman Jeon; Korean J Crit Care Med. 2011;26(4):261-266.; DOI: https://doi.org/10.4266/kjccm.2011.26.4.261

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6 Crossref

Abstract PDF

BACKGROUND
Tracheostomy is one of the most commonly performed surgical procedures in the intensive care unit (ICU). After its introduction, percutaneous dilatational tracheostomy (PDT) has been recognized in western countries as a reliable alternative to surgical tracheostomy. However, data on the safety and feasibility of PDT performed by medical intensivists are limited in Korea.
METHODS
To evaluate the safety and feasibility of PDT performed by medical intensivists and to compare with those of surgical tracheostomy (ST), we retrospectively analyzed the clinical characteristics of all prospectively registered patients who underwent either PDT or ST in medical ICU from December 2010 to July 2011.
RESULTS
A total of 81 patients underwent tracheostomy over the study period: PDT in 56 (69%) and ST in 25 (31%). One patient in whom major bleeding developed during PDT underwent ST as a substitute for PDT. There were no differences in the demographics, laboratory findings, and parameters of mechanical ventilation between the two groups. Procedure time was significantly shorter in the PDT group (20 [IQR 18-30] min) than that in the ST group (38 [27.5-57.5] min) (p < 0.001). The major complication observed in 24 hours after PDT was bleeding in 6 (11%) patients of the PDT group and 4 (16%) patients of the ST group (p = 0.489). However, surgical interventions for major bleeding were required in 2 patients who underwent.
CONCLUSIONS
PDT performed by medical intensivists was safe and feasible. However, immediate surgical assistance should be available when required.

Citations

Citations to this article as recorded by

Safety and Feasibility of Percutaneous Dilatational Tracheostomy Performed by a Neurointensivist Compared with Conventional Surgical Tracheostomy in Neurosurgery Intensive Care Unit
John Kwon, Yong Oh Kim, Jeong-Am Ryu
Journal of Neurointensive Care.2019; 2(2): 64. CrossRef
Safety and Feasibility of Percutaneous Dilatational Tracheostomy in the Neurocritical Care Unit
Dong Hyun Lee, Jin-Heon Jeong
Journal of Neurocritical Care.2018; 11(1): 32. CrossRef
Is Percutaneous Dilatational Tracheostomy Safe to Perform in the Intensive Care Unit?
Jae Hwa Cho
Korean Journal of Critical Care Medicine.2014; 29(2): 57. CrossRef
Percutaneous Dilatational Tracheostomy in Critically Ill Patients Taking Antiplatelet Agents
Sung-Jin Nam, Ji Young Park, Hongyeul Lee, Taehoon Lee, Yeon Joo Lee, Jong Sun Park, Ho Il Yoon, Jae Ho Lee, Choon-Taek Lee, Young-Jae Cho
Korean Journal of Critical Care Medicine.2014; 29(3): 183. CrossRef
Safety and Feasibility of Percutaneous Dilatational Tracheostomy Performed by Intensive Care Trainee
Daesang Lee, Chi Ryang Chung, Sung Bum Park, Jeong-Am Ryu, Joongbum Cho, Jeong Hoon Yang, Chi-Min Park, Gee Young Suh, Kyeongman Jeon
Korean Journal of Critical Care Medicine.2014; 29(2): 64. CrossRef
A Case of Laryngeal Mask Airway-Assisted Percutaneous Dilatational Tracheostomy
Ji Young Park, Taehoon Lee, Hongyeul Lee, Jae Ho Lee, Choon-Taek Lee, Young-Jae Cho
Korean Journal of Critical Care Medicine.2013; 28(3): 184. CrossRef

Review

The Diagnosis and Pharmacologic Management of Arrhythmia: Heon Kil Lim; Korean J Crit Care Med. 2002;17(2):61-65.

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Abstract PDF: Arrhythmias are categorized as due to abnormal impulse formation, abnormal impulse propagation or combined abnormalities of impulse formation and propagation. The primary tools used in the diagnosis of cardiac arrhythmias are the history, physical examination,12-lead electrocardiogram,24-hour continuous electrocardiographic recording, exercise test,intermittent electrocardiographic recording and clinical electrophysiologic study. Optimal management of cardiac arrhythmias requires knowledge of their mechanism,etiology, natural history and effect on the hemodynamic state.And the antiarrhythmic treatment must be monitored closely for its initial and continued effectiveness and for adverse effects.

Original Articles

Perioperative Care for Kidney Transplantation: Jong Hoon Lee, Myoung Soo Kim, Kyung Ock Jeon, Yu Seun Kim; Korean J Crit Care Med. 2001;16(1):11-16.

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Abstract PDF: The evaluation of a patient referred for kidney transplantation is divided into 3 phases. First, a through evaluation is carried out, both to identify risk factors for undergoing transplantation. Second, a surgical evaluation is carried out to look for signs of vascular disease and urological abnormalities, and finally an immunologic evaluation is initiated to assess the patient's blood and HLA types. In patients with chest pain, chronic heart failure, or abnormal EEG, non-invasive cardiac test, when necessary followed by coronary angiography, is indicated. Patients with significant narrowing of the major coronary vessels should undergo percutaneous angioplasty or bypass grafting before transplantation. In diabetic patients over the age of 45, coronary artery disease is a common occurrence even in the absence of symptoms or clinical signs. Non-invasive cardiac evaluation during exercise should be performed routinely. The decision to perform a renal transplantation in a patient who has previously been treated for a malignancy is not an easy one. A waiting period of 2 years seems justified for most neoplasm. A waiting time of more than 2 years is required in malignant melanoma, breast carcinoma, or colorectal carcinomas. The advantages of immediate function after kidney transplantation include a higher long-term success rate, the ability to use potentially nephrotoxic immunosuppressive agents at an earlier time, shortened hospitalization and cost of the procedure as well as the avoidance of post-operative dialysis. Deliberate hydration of the patients during surgery is carried out in order to reduce the risk of acute tubular necrosis. This can be done with either crystalloid or colloid solution. The amount of intravenous solution depends on the patient's hydration status at the start of the procedure and CVP reading during the operation. Close monitoring of urine output is maintained in the early post-operative period. Intravenous hydration is maintained to keep up with the post-operative diuresis. Hypertension is very common in the post-operative period and must be controlled to reduce the risk of post-operative bleeding. If the patient is oliguric in the immediate post-operative period, an attempt at deliberate hydration is employed, however, if the oliguria persists, such hydration must be abandoned in order to avoid pulmonary edema. Dialysis will be required if the kidney does not function adequately. The price a transplant recipient pays for effective immunosuppression is an increased risk of developing infectious complications. Empirical administration of antibiotics, anti-viral agents, or anti-fungal agents in clinically declining patients is justified.

Perioperative Intensive Care for Liver Transplantation: Shin Hwang, Dong Lak Choi, Cheol Soo Ahn, Dong Eun Park, Sun Hyung Joo, Jang Yong Jeon, Kyeong Mo Kim, Yang Won Nah, Kwang Min Park, Young Joo Lee, Sung Gyu Lee; Korean J Crit Care Med. 2001;16(1):5-10.

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Abstract PDF: Many liver recipients have required intensive care, which is individualized and customized to each recipient. Prerequisites qualifying this care are wide comprehension of characteristics of end-stage liver disease and mechanisms of surgical procedures and immunologic knowledge. We present our principles of intensive care and experience from more than 300 cases of liver transplantation. There are roughly two types of liver transplantation, cadaveric and living-donor. These two types are different in their postoperative courses as following; severity of preservation injury, graft-size matching and morphologic liver regeneration and risk of vascular and biliary complications. Intensive care for liver recipients should be directed toward preventive and protective care along reasonable prediction of its clinical course. We described our experience about following subjects: management of hepatorenal syndrome, fulminant hepatic failure, acute renal failure, pneumonia, disturbance of consciousness, prophylaxis of viral hepatitis B, tumor recurrence, use of antibiotics, induction of liver function recovery, maintenance of vital signs, electrolyte balance, diet and infection control, nutritional support. The most important factor is the state of transplanted liver graft in determination of posttransplant course. If the graft functions well, many problems will be solved spontaneously. If not, intensive care will be required. Most of operative complications are related to the surgery itself, so that comprehension to surgical procedures to each recipient should be preceded for early detection and proper management. To achieve a favorable posttransplant course, all factors including maintenance of vital signs, elimination of obstacles to hepatic recovery, appropriate immunosuppression and solution of surgical complications should be met altogether. Of course, every member of liver transplantation team should pay durable attention and dedication to each liver recipient.

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