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- Volume 16 (1); June 2001
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Original Articles
- Management of Post-transplant Lung Recipients
- Sook Whan Song
- Korean J Crit Care Med. 2001;16(1):1-4.
- 1,542 View
- 28 Download
- 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.
- 1,734 View
- 41 Download
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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.
- 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.
- 4,331 View
- 354 Download
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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.
- Bone Marrow Transplantation
- Woo Sung Min
- Korean J Crit Care Med. 2001;16(1):17-22.
- 1,421 View
- 14 Download
- Heart Transplantation. A Retrospective Analysis of the Short and Intermediate Term Results
- Suk Jung Choo, Jung Hun Oh, Jae Joong Kim, Meong Gun Song
- Korean J Crit Care Med. 2001;16(1):23-29.
- 1,288 View
- 15 Download
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Abstract
PDF
- BACKGROUND
Heart transplantation is still the best therapy for end-stage heart disease. However, the longterm outcome among different institutions vary. The current series is an assessment of the important factors which determine prognosis.
METHODS
Between November of 1992 and September of 2000, 85 heart transplantations were performed at our institution. The standard technique was used in the first 57 patients (group I) where as in the latter 28 patients (group II), the Bicaval technique was utilized. The mean waiting time was approximately 4.7 months, and the causes in decreasing order were Dilated cardiomyopathy (n=69), Ischemic cardiomyopathy (n=10), Hypertrophic cardiomyopathy and others (n=6). The mean follow up was about 31 months. The immunosuppressive protocol comprised cyclosporin, Azathioprine (AZA), and prednisone. Later changes included induction with IL-2 receptor monoclonal antibody and changing AZA to mycophenolate mofetil.
RESULTS
The mean donor ischemic time was 95.8 28.3 mins and the implantation time was 59.3 7.6 mins. There was a higher incidence of significant TR in group I along with a greater postoperative pacing requirement. There were 35 postoperative complications of which infectious events were most common (26). Of these, only 3 were early infections and the rest occurred late postoperatively. There were a total of 8 mortalities of which only one occurred early postoperatively and among the 7 late deaths, 3 were medically related and 4 were related to social factors. Only 5% of the patients had graft vascular disease. The overall 1YSR was 92% and the 5 YSR was 85%.
CONCLUSIONS
The superior long term results of this current series was attributable to strong early immunosuppression, a homogenous population, and very low incidence of CMV infection.
- Changes of Heart Rate, Blood Pressure, and Plasma Catecholamine Levels in Rabbits during the Apneic Oxygenation
- Seung Eun Oh, Hyun Jeong Kim, Kwang Won Yum
- Korean J Crit Care Med. 2001;16(1):30-35.
- 1,496 View
- 9 Download
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Abstract
PDF
- BACKGROUND
Permissive hypercapnia and apneic oxygenation are used to provide oxygen to patient without active ventilation. It is well known that hypercapnia induces the release of endogenous catecholamines. However, it is unclear that how much or what kind of catecholamines are released. The aim of this study was to observe changes of basic hemodynamic parameters and plasma catecholamine concentration during apneic oxygenation.
METHODS
Twenty-one rabbits weighing 2.0~3.0 kg were anesthetized with 100% oxygen and isoflurane. 0.05 mg/kg of atropine was injected and endotracheal intubation was done. 1 mg/kg/hr of vecuronium was infused during the experiment. The anesthesia and apneic oxygenation was maintained with 100% oxygen and 2 vol% isoflurane under 1 cmH2O PEEP using continuous positive airway pressure device. During the apneic oxygenation, blood pressure, heart rate, and plasma catecholamine concentration were measured every 10 min using High Performance Liquid Chromatography.
RESULTS
Systolic blood pressure was significantly increased but diastolic blood pressure was not changed until post-apneic 40 min. After then, both systolic and diastolic blood pressure were significantly decreased. At post-apneic 10 min, heart rate was dramatically decreased and slowly recovered to the level of control data until post-apneic 60 min. Plasma epinephrine level was increased higher than that of norepinephrine by 3 to 4 times.
CONCLUSIONS
Epinephrine may play more important role than norepinephrine to compensate the cardiovascular depressive effects of hypercapnia during the apneic oxygenation in rabbits.
- The Effect of Low-dose Dopamine on Splanchnic and Renal Blood Flow in Patients with Septic Shock under the Treatment of Norepinephrine
- Jong Joon Ahn, Tae Hyung Kim, Ki Man Lee, Tae Sun Shim, Chae Man Lim, Sang Do Lee, Woo Sung Kim, Dong Soon Kim, Won Dong Kim, Younsuck Koh
- Korean J Crit Care Med. 2001;16(1):36-41.
- 1,643 View
- 14 Download
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Abstract
PDF
- BACKGROUND
Norepinephrine, which is frequently administered as a vasopressor to the patients with septic shock, can decrease splanchnic and renal blood flows and aggravate splanchnic and renal ischemia. The low-dose dopamine (LDD) has been frequently combined with norepinephrine to ameliorate renal and splanchnic hypoperfusion in patients with septic shock. However, the effect of the LDD on the splanchnic and renal blood flow has not been fully elucidated. This investigation was carried out to determine the effect of the LDD on the splanchnic and renal blood flow in the patients with septic shock under the treatment of norepinephrine.
METHODS
Eleven patients with septic shock were included in this study. All of them were under the norepinephrine treatment as the mean arterial pressure (MAP) was less than 70 mm Hg in spite of the adequate fluid resuscitation. With stabilization of MAP, the LDD (2 g/kg/min) was administered for two hours in each patients. Hemodynamics, gastric intramucosal pH (pHi), gastric regional PCO2 (rPCO2), rPCO2 - PaCO2, urine volume, urine sodium excretion and creatinine clearance were compared between with and without the LDD infusion. Diuretics was not used during the study period.
RESULTS
Age of patients (n=11) was 64 12 and the APACHE III score was 84 17. The mortality rate of the subjects was 64%. Dosage of norepinephrine was 0.55 0.63 g/kg/min during the study period. There were no significant differences in hemodynamics (central venous pressure, cardiac output, pulmonary artery occlusion pressure, mixed venous gas), pHi, rPCO2, rPCO2 - PaCO2 depending on the concomitant infusion of the LDD. The volume of urine tended to increase (P=0.074) after concomitant LDD, but the changes in urine sodium excretion and creatinine clearance were not significantly different.
CONCLUSIONS
The combined infusion of the LDD with norepinephrine did not improve splanchnic and renal blood flow in the patients with septic shock.
- Evaluation of the Efficacy of the Flexiblade Laryngoscope in Endotracheal Intubation
- Sun Young Jang, Sang Kyi Lee
- Korean J Crit Care Med. 2001;16(1):42-47.
- 1,623 View
- 13 Download
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Abstract
PDF
- BACKGROUND
A new laryngoscope, Flexiblade has flexible adjustable rigid blade. The Flexiblade is composed of a handle and a blade with an adjunct trigger. Squeezing the trigger changes the blade curvature from nearly a straight Miller blade into a curved Macintosh blade. This study was designed to evaluate the clinical application of the Flexiblade laryngoscope in endotracheal intubation for adult patients.
METHODS
Following the induction of general anesthesia and muscle paralysis, the laryngoscopic views of 50 patients were measured while five different blade positions in the oral cavity were performed. The laryngoscopic view which was described by Cormack and Lehane was classified from grade 1 to grade 4 except one blade position. Adjusting maneuvers such as laryngeal lift and/or a styletted intubation were used to facilitate a tracheal intubation. Complications which were directly related to the Flexiblade laryngoscope were also evaluated.
RESULTS
In use of the Flexiblade laryngoscope just like straight Miller blade, the vocal cord (< or =grade 2) were exposured in 82% of the patients. The 96% of patients showed a good vocal cord exposure (< or =grade 2) with a partial depression of the triggers of the laryngoscope. Overall rate of a successful intubation was 98%. In partial depression of trigger of the Flexiblade laryngoscope compared with neutral position, 22 patients of 26 patients with laryngoscopic view of grade 2 were improved by one grade, and 15 patients of the 17 patients with laryngoscopic view of grade 3 were improved by more than one grade.
CONCLUSIONS
The Flexiblade laryngoscope is useful for endotracheal intubation for adult patients.
- Effect of Endotoxin on Cerebrospinal Fluid Formation in the Rat
- Dong Chan Kim, Yu Jeong Kim, Gi Chul Min
- Korean J Crit Care Med. 2001;16(1):48-54.
- 1,453 View
- 20 Download
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Abstract
PDF
- BACKGROUND
Bacterial lipopolysaccharide (LPS), an endotoxin, can increase nitric oxide (NO) production by expression of an inducible isoforms of nitric oxide synthase (iNOS). Bacterial infections of the central nervous system dilate cerebral vessels and increase cerebral blood flow. We hypothesized that systemic and intraventricular application of bacterial lipopolysaccharide would increase cerebrospinal fluid (CSF) production due to increase in blood flow to choroid plexus caused by NO-induced vasodilation.
METHODS
Ventriculocisternal perfusion was used to measure the production of CSF in pentobarbital-anesthetized rats. The lateral ventricle and cisterna magna were cannulated stereotactically and perfused continuously with artificial CSF with blue dextran 2000 as the indicator. Baseline collections of CSF began after steady state outflow was established; then, endotoxin was administered intravenously or intraventricularly. The baseline rate of CSF production was compared with that measured during 3 hours after endotoxin administration.
RESULTS
The baseline rate of CSF production was 2.6 0.3 (2.2~3.5)microliter/minute in the rat. There were no significant changes in CSF production rate after intravenous or intraventriculr administration of endotoxin.
CONCLUSIONS
We could not observe significant changes in CSF production rate with the ventriculocisternal perfusion method of measuring CSF production after intravenous or intraventriculr administration of endotoxin in the rats.
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