Acute and Critical Care

Volume 26 (2); June 2011

Review

Present and Future of ECMO in ICU: Hyung Gon Je, Sang Kwon Lee; Korean J Crit Care Med. 2011;26(2):51-56.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.51

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Extracorporeal Membrane Oxygenation (ECMO) is a variation of cardiopulmonary bypass that temporarily supports tissue oxygenation in patients with life threatening respiratory or cardiac failure. As the ECLS technique becomes safer and simpler following technology advances, and as complications and survival have improved, indication of ECLS has widened. In 2009, a multicentre randomized controlled trial of conventional ventilator support versus extracorporeal life support for severe adult respiratory failure in 180 patients was published (the conventional ventilation or ECMO for severe adult respiratory failure (CESAR) trial). Of patients allocated to ECMO support, 63% survived for six months without disability compared to 47% allocated to conventional ventilation care. This represented the first positive randomized clinical trial on adult ECMO application in acute respiratory distress syndrome patients. In this review, we report on the common terminologies used with ECMO, the practical running mode of ECMO, indications of ECMO application in intensive care unit settings and results of recent clinical trials. In addition, management during ECMO support and common complications of ECMO is outlined. Finally, evolving technologies involved with the progress of ECMO are summarized.

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Successful Use of a Peripheral Extracorporeal Membrane Oxygenator in a Patient with Chronic Heart Failure and Pneumonia
Ji Hyun Lee, Yang Hyun Cho, Gee Young Suh, Jeong Hoon Yang
Korean Journal of Critical Care Medicine.2014; 29(1): 52. CrossRef
Fatal Left Ventricular Thrombosis in an Infant Receiving Extracorporeal Membrane Oxygenation Support - A Case Report -
Hwa Jin Cho, Byung Young Kim, Eun Song Song, Sang-Gi Oh, Bong-Suk Oh, In Seok Jeong
Korean Journal of Critical Care Medicine.2013; 28(2): 123. CrossRef

Original Articles

Prognostic Factors for Mortality in Emergency Department Patients with Hypotension: Deuk Hyun Park, Young Rock Ha, Young Sik Kim, Tae Yong Shin, Sung Han Oh, Sung Sil Choi, Suk Young No; Korean J Crit Care Med. 2011;26(2):57-63.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.57

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Abstract PDF

BACKGROUND
This study was performed to analyze the effects of differences between initial and follow up amounts of central venous oxygen saturation (Scvo2), lactate, anion gap (AG), and corrected anion gap (CAG).
METHODS
Patients with systolic blood pressure that was lower than 90 mmHg participated in this study. Along with Arterial Blood Gas Analysis (ABGA), the amounts of electrolytes, albumin, and Scvo2 were initially checked and then re-checked four hours later. The patients were divided into two groups, which were survived and expired, and the differences in initial and final values were compared in both groups. RESULTS: Out of a total of 36 patients, 29 patients survived and 7 patients died. The data showed almost no difference in mean age, mean arterial pressure, heart rate, respiratory rate, and body temperature between two groups. Comparing the initial amount, there was a statistically significant variation in lactate. Comparing the final values, lactate, AG, and CAG varied significantly. However, for both groups, the differences between the initial and final values were not significant. The area under curve (AUC) of follow up lactate and follow up CAG was 0.89 and 0.88. AUC of ED-APACHEII and original ICU APACHEII was 0.74 and 0.96.
CONCLUSIONS
There was no prognostic effect of Scvo2, lactate, AG, and CAG in hypotensive patients. The initial and final values of lactate and CAG were good prognostic factors for the expired group.

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Death below 2 g/dL of Hemoglobin Concentrations: As an Independent Predictor of Death
Sun Young Park, Sung Hyun Kang, Sang Hoon Park, Hea Rim Jeon, Mun Gyu Kim, Se Jin Lee
Soonchunhyang Medical Science.2013; 19(1): 45. CrossRef
Analysis of Prognostic Factors Early in Emergency Department (ED) and Late in Intensive Care Unit (ICU) of the Critically Ill Patients Admitted in the ICU via ED
Ru-Bi Jeong, Jung-Hwan An, Hyun-Min Jun, Sung-Min Jeong, Tae-Yong Shin, Young-Sik Kim, Young-Rock Ha
Korean Journal of Critical Care Medicine.2012; 27(4): 237. CrossRef

A Simulation Study for Quality of Chest Compression Provided by Health Personnel: Jun Mo Yeo, Min Hong Choa, Sang Won Chung, In Byung Kim, Ji Hoon Kang, Kyung Wuk Kim, Jai Woog Ko; Korean J Crit Care Med. 2011;26(2):64-68.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.64

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Abstract PDF

BACKGROUND
Effective chest compression may improve the return of spontaneous circulation and neurologic outcome in arrest victims. For fear of rescuer's fatigue, guidelines for cardiopulmonary resuscitation (CPR) recommended that chest compression (CC) should be switched every 2 minutes, but there is little evidence. We investigated whether health personnel could provide consistent quality of CC for 2 minutes.
METHODS
We recruited prospectively health personnel working on one university hospital. On the day assigned randomly, CPR performance data was collected with use of CPR recording technology. Quality of CPR was calculated every 30 seconds interval. To identify the quality decay, we used repeated measure analysis of variance with SPSS 17.0 for analysis.
RESULTS
We analyzed 8,485 CCs performed by 41 subjects. Total number of CC decayed between 90 to 120 seconds (51.6 +/- 3.3 to 50.8 +/- 3.5, p = 0.020) within recommended range. The ratio of correct depth CC decayed between 90 to 120 seconds, falling from 83.4 +/- 24.9% to 68.3 +/- 38.4% (p = 0.002). The ratio of low depth CC increased significantly over time (10.2 +/- 20.7% to 31.3 +/- 38.5%, p < 0.001).
CONCLUSIONS
Health personnel may provide adequate number of CC for 2 minutes. But, the number of correct depth CC may decay between 90 to 120 seconds. Also the number of low depth CC may increase over time.

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Comparisons of the qualities of chest compression according to various positions of rescuer to patient at the in-hospital cardiopulmonary resuscitation model
Geon-Nam Kim, Seong-Woo Choi, Jin-Yeong Jang, So-Yeon Ryu
The Korean Journal of Emergency Medical Services.2014; 18(1): 7. CrossRef
Comparison on the Quality and fatigue of hands-Only CPR According to the Presence or Absence of Verbal counting by Some Middle-aged Women
Geon-Nam Kim, Sung-Soo Choi, Seong-Woo Choi
Journal of the Korea Academia-Industrial cooperation Society.2013; 14(3): 1320. CrossRef

Adequacy of Epinephrine Administration during Advanced Cardiovascular Life Support in terms of Dosing and Intervals between Doses: Seung Joon Lee, Byung Kook Lee, Kyung Woon Jeung, Hyoung Youn Lee, Tag Heo, Yong Il Min, Jong Geun Yun, Jae Hoon Lim; Korean J Crit Care Med. 2011;26(2):69-77.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.69

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Abstract PDF

BACKGROUND
Consensus guidelines clearly define how epinephrine is administered during cardiopulmonary resuscitation (CPR). In South Korea, it is not known whether epinephrine is administered in accordance with the current advanced cardiovascular life support (ACLS) guidelines during actual practice. We sought to investigate adherence to ACLS guidelines during actual CPR in terms of the dose of epinephrine and the interval between doses.
METHODS
A retrospective review of medical records was performed on 394 adult cardiac arrest patients who received CPR at an emergency room. Data including the duration of CPR, the dose of epinephrine, and the interval between doses was collected from CPR records.
RESULTS
Standard-dose epinephrine (1 mg) was used in 166 of 394 patients (42.1%). In 58.8% of patients, the average between-dose interval was within the 3-5 min recommended in the guidelines, whereas it was shorter than 3 min in 31.4% of patients. As a whole, epinephrine was administered in accordance with the current ACLS guidelines in only 96 of 394 patients (24.4%). Logistic regression analysis revealed the duration of CPR to be an independent factor affecting the use of standard-dose epinephrine and the adequate between-dose interval.
CONCLUSIONS
Epinephrine was not administered according to the ACLS guideline in most patients. A national multi-center study is required to determine whether the poor adherence to the ACLS guideline is a widespread problem. In addition, efforts to improve adherence to the ACLS guideline are required.

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Reply to letter “Improving ROSC with high dose of epinephrine. Are we really?”
Kyung Woon Jeung, Hyun Ho Ryu, Kyung Hwan Song, Byung Kook Lee, Hyoung Youn Lee, Tag Heo, Yong Il Min
Resuscitation.2012; 83(3): e73. CrossRef

Lactate Clearance and Outcome in Septic Shock Patients with Low Level of Initial Lactate: Yun Su Sim, Cho Rom Hahm, So Yeon Lim, Gee Young Suh, Kyeongman Jeon; Korean J Crit Care Med. 2011;26(2):78-82.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.78

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Abstract PDF: BACKGROUND
Serum lactate is a potentially useful biomarker to risk-stratify patients with severe sepsis and septic shock. However, there are only a few studies on the association of serum lactate levels and prognosis in septic shock patients with initial low lactate levels.
METHODS
To evaluate whether initial and follow-up lactate levels associated with mortality in septic shock patients with low lactate level, we conducted a retrospective observational study of patients with septic shock, who were hospitalized through the emergency department in February-July 2008. Initial lactate level was stratified as low (<4 mmol/L) or high (> or =4 mmol/L). The primary outcome was 28-day mortality and multiple logistic regression analysis was used to adjust for potential confounders in the association between lactate clearance and mortality.
RESULTS
Of 90 patients hospitalized with septic shock during the study period, 68 (76%) patients had low initial lactate. Mortality at 28 days was 18% in patients with low lactate level. In these patients, initial lactate level was not associated with mortality (p = 0.590). However, increased lactate at follow-up and lactate clearance were associated with mortality (p = 0.006, p = 0.002, respectively). In a multiple logistic regression analysis, increased mortality rate independently associated with age (OR 1.162, 95% CI 1.041-1.298) and lactate clearance (OR 0.654, 95% CI 0.498-0.859).
CONCLUSIONS
In septic shock patients with a low lactate level, lactate clearance independently associated with a decreased mortality rate. Therefore, lactate clearance could be useful for predicting the outcome in these patients.

The Consistency and Clinical Significance between Bronchoscopic Samples and Endotracheal or Tracheostomic Aspirates in Severe Pneumonia Under Mechanical Ventilation: Hye Sung Park, Seo Woo Kim, Yun Su Sim, Ji Hye Kim, Yon Ju Ryu, Jin Hwa Lee, Jung Hyun Chang; Korean J Crit Care Med. 2011;26(2):83-88.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.83

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Abstract PDF

BACKGROUND
Distal airway bacterial colonization occurs more frequently in patients with endotracheal tubes or tracheostomy of intensive care units (ICU) care. In general, bronchoscopic samples are considered more accurate than transtracheal aspirates. In this study, we evaluated the consistency and clinical significance between bronchoscopic samples and transtracheal aspirates (TTA) in severe pneumonia under mechanical ventilation.
METHODS
We investigated the consistency between bronchoscopic samples and transtracheal aspirates among patients with endotracheal tubes or tracheostomy, retrospectively. Fiberoptic bronchoscopy was performed in 212 patients with mechanical ventilation via endotracheal tube or tracheostomy between January 1st, 2004 and December 31th, 2008 in ICU at Ewha Womans University Hospital. We evaluated consistency in terms of true pathogen according to the arbitrary ICU days progress.
RESULTS
Among the 212 enrolled patients, 113 (53%) had consistency between bronchoscopic samples and transtracheal aspirates. When evaluated alteration trends in consistency according to ICU stay, the consistency was maintained for 5 to 9 ICU days with statistical significance (p< 0.05) since adjusting for age, sex, and combined risk factors. Consistency in sampling status between the endotracheal tube and tracheostomy was also evaluated, however, there was no statistical significance (OR 1.9 vs. 1, 95% CI = 0.997-3.582, p = 0.051).
CONCLUSIONS
Shorter hospital stay (within 9 days of ICU stay) had higher probability of consistency between bronchoscopic samples and TTA samples. TTA may be as confident as bronchoscopic samples in patients of pneumonia under mechanical ventilation with shorter ICU stays, especially less than 10 days.

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Comparison of the Pattern in Semi-Quantitative Sputum Cultures Based on Different Endotracheal Suction Techniques
Jiwoong Oh, Kum Whang, Hyenho Jung, Jongtaek Park
Korean Journal of Critical Care Medicine.2012; 27(2): 70. CrossRef

Randomized Controlled Trial

Optimal Timing of Topical Lidocaine Spray on the Hemodynamic Change of Tracheal Intubation: Keun Seok Lee, Hyun Jung Shin, Yang Ju Tak, Sang Tae Kim; Korean J Crit Care Med. 2011;26(2):89-93.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.89

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Abstract PDF: BACKGROUND
Tracheal intubation stimulates the sympathetic nervous system, resulting in hypertension, tachycardia and sometimes critical complications, especially in patients with underlying hypertension, cardiovascular disease or cerebrovascular disease. In this study, we sprayed 4% lidocaine into the trachea before intubation, and observed the hemodynamic changes after tracheal intubation.
METHODS
We randomly allocated 87 patients, whose ASA physical status was I or II, into three groups. The 4% topical lidocaine was sprayed before intubation at the following specific times: just before intubation (group 0), or 1 minute (group 1) and 2 minutes before intubation (group 2). For maintenance of anesthesia, TIVA (total intravenous anesthesia; propofol-remifentanil infusion with orchestra(R)) was used. We observed hemodynamic changes between the groups just after the intubation, as well as 1, 3 and 5 minutes after the intubation. Hemodynamic changes were also monitored in the same group.
RESULTS
When the patients arrived at the operating room, we found no significant difference in heart rate and arterial pressure between the groups. However, heart rate after intubation in group 1 was significantly lower than group 0. The diastolic and mean arterial pressure just after intubation were lower in group 1 and 2 than in group 0.
CONCLUSIONS
Spraying lidocaine 1 or 2 minutes before intubation was more effective than spraying it just before intubation for reducing hypertensive responses after intubation.

Case Reports

Inhospital Spontaneous Acute Subdural Hematoma (SADH) Patient with Antiplatelet Therapy due to Acute Cerebral Ischemia: A Case Report: Hyo Chang Kim, Chun Sik Choi, Jae Young Yang, Hyun Chul Shin, Yu Sam Won, Young Jun Kwon; Korean J Crit Care Med. 2011;26(2):94-97.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.94

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Abstract PDF: A case of "spontaneous" acute subdural hematoma caused by aspirin and plavix therapy has not been described previously. As an isolated cerebrovascular event related to aspirin and plavix therapy, this is the first report described in the literature. It also represents a new differential diagnosis for nontraumatic acute subdural hematomas.

Detection of Pulmonary Artery Catheter Knotting by Transesophageal Echocardiography: A Case Report: Eun Soo Kim, Seung Hoon Baek, Kyu Youn Jung, Jae En Kim; Korean J Crit Care Med. 2011;26(2):98-100.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.98

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Abstract PDF

Placement of a pulmonary artery catheter is associated with various complications, including catheter knotting. Fluoroscopy can be used to visualize and confirm catheter knotting. Transesophageal echocardiography is readily available to detect knot formation in the operating room or intensive care unit. We present a case in which pulmonary artery catheter knotting was detected by transesophageal echocardiography. This method may be useful in the operating room or in the intensive care unit to identify the presence and location of catheter knotting.

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Knotting of Pulmonary Artery Catheter During Tricuspid Valve Surgery - A Case Report -
Kyung Chen Lee, Wol Seon Jung, Yong Beom Kim, Ji Yeon Lee
Korean Journal of Critical Care Medicine.2012; 27(1): 45. CrossRef

A Case of Fatal Mechanical Mitral Valve Leaflet Fracture Embolization: A Case Report: Won Yik Lee, Jong Myeon Hong, Jang Whan Bae; Korean J Crit Care Med. 2011;26(2):101-104.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.101

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Abstract PDF

The fracture embolization of a mechanical valve is a very rare but potentially fatal event that can cause acute severe valve regurgitation and subsequent decompensated heart failure. Generally, the mechanical valve is durable and semi-permanent. If this is not the case, bacterial endocarditis can occur. However, leaflet fracture embolizations related to mechanical failure may occur in the specific mechanical valve brands associated with the subjects own structural fragilities. In this case, we dealt with a case of fatal Edward-Duromedics mechanical mitral valve leaflet fracture embolization that had been implanted 20 years ago. The patient presented with severe acute heart failure and shock. Severe transvalvular mitral regurgitation and only one valve leaflet was observed in echocardiography. Although the emergency mitral valve replacement was performed under the diagnosis with valve leaflet fracture embolization, the patient was not resuscitated from systolic pump failure and died.

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A rare case series of mechanical prosthetic heart valve structural deterioration presented as severe mitral regurgitation
Jignesh Kothari, Sandip Lukhi, Utkarsh Sanghavi, Devvrat Desai, Ishan Gohil
Heart, Vessels and Transplantation.2023; 7(Issue 4): 278. CrossRef
An unusual cause of acute mitral regurgitation in TTK Chitra heart valve prosthesis
Muthukumar Sundaram, Aayush Poddar, Ancy Robinson, Soundaravalli Balakrishnan, Muralidharan Srinivasan, Chandrasekar Padmanabhan
Indian Journal of Thoracic and Cardiovascular Surgery.2021; 37(5): 546. CrossRef

Successful Management of Tracheobronchomalacia Associated with Empyema Using a Covered Metallic Tracheobronchial Stent: A Case Report: Young Sik Park, Hyo Jae Kang, Yung Jeong Jeong, Sun Mi Choi, Eun Young Heo, Hyeon Jong Moon, Chang Hoon Lee, Hee Soon Chung, Deog Kyeom Kim; Korean J Crit Care Med. 2011;26(2):105-109.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.105

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Abstract PDF: Tracheobronchomalacia is developed by excessively weakened walls of the trachea and bronchi, and shows dynamic collapse of the airway on expiration and causes dyspnea. Airway stenting or surgical correction of the airway may be helpful. We report a case with tracheobronchomalacia which was combined with chronic empyema and treated successfully with stent insertion.

Successful Treatment of Accidental Hypothermia with Injury: A Case Report: Kyu Hyouck Kyoung, Young Hwan Kim, Suk Kyung Hong; Korean J Crit Care Med. 2011;26(2):110-113.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.110

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Abstract PDF: Accidental hypothermia is an uncommon health issue that can cause fatal problems. Mortality related to hypothermia has been reported to be up to 50%. Prognosis of hypothermia depends on the grade of hypothermia, interval of re-warming from the accident and the re-warming rate. Hypothermic patients with injury show worse prognosis. A 66 year-old man with history of cerebrovascular accident was rescued in the mountains. His Glasgow coma scale (GCS) was 3, core temperature was 25.2degrees C and he had a right lateral malleolar fracture. The second patient was a 45 year-old man whose GCS was 8 and core temperature 17.2degrees C. Blood pressure was unmeasurable with only palpable pulse and showed Osborn J wave on electrocardiography for both patients. Active re-warming was performed with forced warm air, warm saline infusion and bladder irrigation. Patient core temperature raised by 1.5degrees C/hour and 3.3degrees C/hour, respectively. The two patients were discharged without any other sequelae and disability.

H1N1 Influenza/A Associated ARDS Recovered without Mechanical Ventilatory Support: A Case Report: Byung Ook Lee, Jae Hee Lee, Sung Woon Park, Bo Min Kim, Jae Chol Choi, Jong Wook Shin, In Won Park, Byoung Whui Choi, Jae Yeol Kim; Korean J Crit Care Med. 2011;26(2):114-116.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.114

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Abstract PDF: An eighteen year-old female visited the ER in our hospital with fever of 38.5degrees C for 2 days. She also had cough, myalgia, and dyspnea. Chest PA and lung HRCT showed mild pulmonary edema at both hilar areas. However, she had severe hypoxia (PaO2; 58 mmHg in room air). RT-PCR for H1N1 influenza/A of pharyngeal swab was positive. Tamiflu (150 mg/d) with broad-spectrum antibiotics was prescribed. Two days later, her dyspnea aggravated and chest PA showed diffuse bilateral infiltration. PaO2 dropped to 70 mmHg (O2 10 L/min by face mask with reservoir bag). She was transferred to the MICU and the Tamiflu dose was doubled (300 mg/day). Mechanical ventilator was set aside to prepare respiratory failure. Fortunately, her symptoms and oxygenation improved and she was discharged with full recovery. Although, most cases of ARDS require mechanical ventilatory support, early and adequate dose of Tamiflu may avoid it in the case of ARDS developed by H1N1 influenza/A.

Amiodarone-induced Pulmonary Toxicity within a Short Period of the Initiation of Amiodarone Therapy: A Case Report: Woo Jin Jang, Hae Ri Chon, Jin Sung Jung, Seung Hyun Yoo, Kyu Han Koh, Young Min Koh, Jung Hyuk Kim; Korean J Crit Care Med. 2011;26(2):117-121.; DOI: https://doi.org/10.4266/kjccm.2011.26.2.117

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Abstract PDF

Amiodarone is one of the most commonly prescribed antiarrhythmic drug for almost all atrial or ventricular arrythmias. Amiodarone-induced pulmonary toxicity (APT) was first described in 1980 and has potentially serious side effects that are believed to develop in 5% of patients. In general, APT occurs only when high amiodarone doses are used for a long time. However, during short-term therapy of amiodarone, APT is rarely reported. In this report, we describe a case of amiodarone-induced pulmonary toxicity after a short course of amiodarone therapy for atrial fibrillation.

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A Case of Acute Hepatitis Associated with Intravenous Infusion Amiodarone in Patient with Atrial Fibrillation
Ji Hye Lee, Myug-Shin Kang, Tae-Hoon Kim, Dong Hee Shin, Rak Kyeong Choi, Su Jin Jung
Soonchunhyang Medical Science.2015; 21(2): 208. CrossRef
Amiodarone Induced Multiorgan Toxicity in a Patient of Hypertrophic Cardiomyopathy With Atrial Fibrillation
Dae Jung Kim, Sang Chil Lee, Gi Soo Park, Gyung Jung Kim, Won Tae Hwang, Chang Soo Lee, Moo Hyun Lee, Dae Hee Hahn, Hyeon Cheol Koh
Journal of the Korean Geriatrics Society.2013; 17(4): 223. CrossRef
Very Early Onset of Amiodarone-Induced Pulmonary Toxicity
Wonho Lee, Dong Rueol Ryu, Seon-Sook Han, Sook-Won Ryu, Byung Ryul Cho, Hyucki Kwon, Bo Ra Kim
Korean Circulation Journal.2013; 43(10): 699. CrossRef
Amiodarone-Induced Pulmonary Toxicity: Percutaneous Needle Aspiration Biopsy and Ultrastructural Findings
In Sook Kang, Jin Hwa Lee, Sun Hee Sung, Seong Hoon Park
The Ewha Medical Journal.2013; 36(2): 144. CrossRef

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