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Volume 27 (3); August 2012
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Review
Muscle Relaxants in Critically Ill Patients with Renal Disease
Jin Young Chon
Korean J Crit Care Med. 2012;27(3):145-150.
DOI: https://doi.org/10.4266/kjccm.2012.27.3.145
  • 4,132 View
  • 125 Download
AbstractAbstract PDF
Critical illness often results in renal dysfunction. Renal disease includes acid base imbalance, electrolyte shift and neuromuscular disturbances in critically ill patients, who are influenced by the pharmacodynamics and pharmacokinetics of muscle relaxants, with kidney dependent metabolism and excretion. In terms of renal dysfunction, not only decreased circulating levels of normal cholinesterase, but also cholinesterase depletion after plasmapheresis and dialysis draw the attention of clinicians, when administering a muscle relaxant to critically ill patients who are compromised with renal function. These patients have a lower clearance of renal excreted drugs, changes of the volume of distribution, water retention, and pH changes that alter the protein bond and degree of ionization of the drugs. Immobilization of the limb and respiratory muscles, leading to muscle atrophy and the up-regulation of nicotinic acetylcholine receptors, associated with critical illness, is observed in many patients hospitalized in the intensive care unit with renal dysfunction. Disease related conditions or iatrogenically induced factors, including sedation, lead to immobilization of skeletal muscles. Aside from systemic inflammation, immobilization is a key contributing factor to the development of critical illness myopathy. Physicians who care for critically ill patients with renal dysfunction should pay attention to the adequate choice of muscle relaxants and their antagonists.
Original Articles
Usefulness of Screening Criteria System Used by Medical Alert Team in a General Hospital
Hyejin Joo, So Hee Park, Sang Bum Hong, Chae Man Lim, Younsuck Koh, Young Seok Lee, Jin Won Huh
Korean J Crit Care Med. 2012;27(3):151-156.
DOI: https://doi.org/10.4266/kjccm.2012.27.3.151
  • 2,759 View
  • 59 Download
  • 4 Citations
AbstractAbstract PDF
BACKGROUND
Rapid response team (RRT) is becoming an essential part of patient safety by the early recognition and management of patients on general hospital wards. In this study, we analyzed the usefulness of screening criteria of RRT used at Asan Medical Center.
METHODS
On a retrospective basis, we reviewed the records of 675 cases in 543 patients that were managed by RRT (called medical alert team in the Asan Medical Center), from July 2011 to December 2011. The medical alert team was acted by requests of attending doctors or nurses or the medical alert system (MAS) criteria composed of abnormal vital sign, neurology, laboratory data and increasing oxygen demand. We investigated the patterns of MAS criteria for targeting the patients who were managed by the medical alert team.
RESULTS
Respiratory distress (RR > 25/min) was the most common item for identifying patients whose condition had worsened. The criteria consist with respiratory distress and abnormal blood pressure (mean BP < 60 mmHg or systolic BP < 90 mmHg) found 70.0% of patients with deteriorated conditions. Vital sign (RR > 25/min, mean BP < 60 mmHg or systolic BP < 90 mmHg, pulse rate, PR > 130/min or < 50/min) and oxygen demand found 79.2% of them. Vital signs, arterial blood gas analysis (ABGA) with lactate level (pH, pO2, pCO2, and lactate) and O2 demand found 98.6% of patient conditions had worsened.
CONCLUSIONS
Vital signs, especially RR > 25/min is useful criteria for detecting patients whose conditions have deteriorated. The addition of ABGA data with lactate levels leads to a more powerful screening tool.

Citations

Citations to this article as recorded by  
  • Influence of the Rapid Response Team Activation via Screening by Nurses on Unplanned Intensive Care Unit Admissions
    Ye-Ji Huh, Seongmi Moon, Eun Kyeung Song, Minyoung Kim
    Korean Journal of Adult Nursing.2020; 32(5): 539.     CrossRef
  • Early Experience of Medical Alert System in a Rural Training Hospital: a Pilot Study
    Maru Kim
    The Korean Journal of Critical Care Medicine.2017; 32(1): 47.     CrossRef
  • Temporal patterns of change in vital signs and Cardiac Arrest Risk Triage scores over the 48┬áhours preceding fatal in-hospital cardiac arrest
    HyunSoo Oh, KangIm Lee, WhaSook Seo
    Journal of Advanced Nursing.2016; 72(5): 1122.     CrossRef
  • A combination of early warning score and lactate to predict intensive care unit transfer of inpatients with severe sepsis/septic shock
    Jung-Wan Yoo, Ju Ry Lee, Youn Kyung Jung, Sun Hui Choi, Jeong Suk Son, Byung Ju Kang, Tai Sun Park, Jin-Won Huh, Chae-Man Lim, Younsuck Koh, Sang Bum Hong
    The Korean Journal of Internal Medicine.2015; 30(4): 471.     CrossRef
Nutrition Support in the Intensive Care Unit of 6 Korean Tertiary Teaching Hospitals: A National Multicenter Observational Study
Song Mi Lee, Seon Hyeung Kim, Yoon Kim, Eunmee Kim, Hee Joon Baek, Seungmin Lee, Hosun Lee, Chul Ho Chang, Cheung Soo Shin
Korean J Crit Care Med. 2012;27(3):157-164.
DOI: https://doi.org/10.4266/kjccm.2012.27.3.157
  • 3,159 View
  • 63 Download
  • 4 Citations
AbstractAbstract PDF
BACKGROUND
Malnutrition is a frequent nutritional problem among ICU patients, and their nutritional status is known to affect clinical prognosis. We conducted this study to examine nutritional status and actual nutrition delivery in the ICU patients and its relations to clinical outcomes.
METHODS
This study was a multicenter retrospective observational study based on the medical records of 163 patients admitted to ICU of tertiary teaching hospitals in Korea. We included the patients who were treated with mechanical ventilation for 3 or more days and received enteral or parenteral nutrition.
RESULTS
According to albumin and total lymphocyte count levels, 54.6% of the subjects were moderately or severely malnourished. Mean percentage of calorie and protein delivery to estimated needs for 10 days were 55.8 +/- 29.3% and 46.1 +/- 30.1%, respectively. While parenteral nutrition (PN) started at 1.6 +/- 1.4 days after admission, enteral nutrition (EN) did at 3.6 +/- 2.1 days. Days to PN and EN start, the calorie and protein amount via EN or PN were significantly different among 6 hospitals. No clinical outcomes differed by the levels of calorie or protein delivery. In-hospital mortality was significantly higher in the severely malnourished group at admission as compared to the other 2 groups (54.3% vs. 31.2% vs. 27.7%, p < 0.05) CONCLUSIONS: Malnutrition prevalence is high among Korean intensive care unit patients, but current nutritional therapy practice is inconsistent across institutions and far below the international guidelines. Systematic efforts should be made to develop nutritional support guidelines for Korean ICU patients.

Citations

Citations to this article as recorded by  
  • Nutritional Status of Intensive Care Unit Patients According to the Referral to the Nutrition Support Team and Compliance with the Recommendations
    Yunjin Sohn, Taisun Hyun
    Korean Journal of Community Nutrition.2022; 27(2): 121.     CrossRef
  • Comparison of the nutritional indicators of critically Ill patients on extracorporeal membrane oxygen (ECMO)
    Nah-Mee Shin, Suk Yeon Ha, Yoon Soo Cho
    Journal of Nutrition and Health.2021; 54(5): 489.     CrossRef
  • The impact of multidisciplinary nutritional team involvement on nutritional care and outcomes in a medical intensive care unit
    H J Jo, D B Shin, B K Koo, E S Ko, H J Yeo, W H Cho
    European Journal of Clinical Nutrition.2017; 71(11): 1360.     CrossRef
  • The effect of nutritional supply on clinical outcomes and nutritional status in critically ill patients receiving continuous renal replacement therapy
    Ju Yeun Kim, Ji-Myung Kim, Yuri Kim
    Journal of Nutrition and Health.2015; 48(3): 211.     CrossRef
Relationship of Temperature and Humidity with the Number of Daily Emergency Department Visits for Acute Heart Failure: Results from a Single Institute from 2008-2010
Sang Hyun Ha, Bong Gun Song, Na Kyoung Lee, Chang Shin Choi, Chong Kun Hong, Jun Ho Lee, Seong Youn Hwang
Korean J Crit Care Med. 2012;27(3):165-172.
DOI: https://doi.org/10.4266/kjccm.2012.27.3.165
  • 2,524 View
  • 16 Download
AbstractAbstract PDF
BACKGROUND
The incidence of acute heart failure (AHF) increases in cold weather. Whether or not AHF has seasonal variation in Korea is unclear, and the influence of humidity on AHF incidence is also unclear. The aim of this study was to examine the correlation between the number of daily emergency department (ED) visits for AHF and the temperature and humidity in Korea.
METHODS
On a retrospective basis, we investigated the medical records of patients who visited the ED with dyspnea from Jan. 1, 2008 to Dec. 31, 2010. Inclusion criteria comprised both evidence of clinical symptoms and the presence of signs of pulmonary congestion on chest X-rays. Exclusion criteria included a medical history showing end-stage renal disease with dialysis or showing an acute ST elevation myocardial infarction. The number of daily ED visits for AHF was compared with meteorological data after stratifying temperature or humidity into 3 parts.
RESULTS
After stratification by humidity, the results revealed that the number of daily ED visits was significantly associated with minimum temperatures occurring one to 2 days prior to ED admission, although only in the lowest tertile of humidity (p = 0.012, p = 0.021, respectively). The relationship between humidity and daily ED visits for AHF was the same as that mentioned above (p = 0.016, p = 0.039, respectively).
CONCLUSIONS
The number of patients with AHF in Korea increases in cold weather, as is the case in other countries. Specifically, AHF incidence was related to temperature minimums occurring one to 2 days prior to ED admission, as well as with humidity.
Case Reports
Anesthetic Management of Whole-Lung Lavage Using Propofol-Remifentanil in a Patient with Pulmonary Alveolar Proteinosis
Ji Hyeon Lee, Chan Jong Chung, Ji Na Oh, Byung Ju Ko, So Ron Choi
Korean J Crit Care Med. 2012;27(3):173-178.
DOI: https://doi.org/10.4266/kjccm.2012.27.3.173
  • 2,129 View
  • 35 Download
  • 1 Citations
AbstractAbstract PDF
Pulmonary alveolar proteinosis (PAP) is characterized by the progressive accumulation of phospholipids and proteins within the alveolar sacs without producing an inflammatory response. Whole-lung lavage (WLL) is performed as the standard therapy for this disease because it serves to wash out the proteinaceous material from the alveoli. In this case, we performed sequential WLL using propofol-remifentanil, which is not related to hypoxic pulmonary vasoconstriction during one-lung ventilation. The patient's symptoms and radiologic findings showed improvement without the occurrence of any specific complications. Therefore, we report a case of anesthetic management of WLL performed repeatedly for a patient with recurrent PAP.

Citations

Citations to this article as recorded by  
  • Whole lung lavage using a rapid infusion system to treat a patient with pulmonary alveolar proteinosis
    Seung Won Ra, Soon Eun Park, Hyung Kwan Lee, Il Sang Han, Se Hun Park
    Yeungnam University Journal of Medicine.2020; 37(1): 67.     CrossRef
Esophageal-Retroesophageal Right Subclavian Artery Fistula: A Case Report
Jin Ho Choi, Chun Sung Byun, Seong Min Kim, Jung Joo Hwang
Korean J Crit Care Med. 2012;27(3):179-181.
DOI: https://doi.org/10.4266/kjccm.2012.27.3.179
  • 2,158 View
  • 14 Download
AbstractAbstract PDF
Fistula between retroesophageal subclavian artery and esophagus is rare but a fatal complication. The purpose of this case study is to describe a case of 47-year old male presented with intracranial hemorrhage being required a long stay in the intensive care unit and to demonstrate the importance of surveillance patients requiring prolonged nasogastric tube. Recognition of this aberrant artery is critical for the prevention of these catastrophic events.
Skin Necrosis after High Dose Vasopressor Infusion in Septic Shock: Two Case Reports
Ah Reum Cho, Jeung Il Kim, Eun Jung Kim, Seung Min Son
Korean J Crit Care Med. 2012;27(3):182-186.
DOI: https://doi.org/10.4266/kjccm.2012.27.3.182
  • 2,804 View
  • 1,849 Download
  • 4 Citations
AbstractAbstract PDF
Survival sepsis campaign recommends that vasopressor therapy is required to maintain mean arterial pressure (MAP) > or = 65 mmHg. However, the absolute maximum dose of vasopressor is difficult to determine. Herein, we report 2 cases of severe skin necrosis after high dose vasopressor infusion to maintain the recommended MAP in septic shock. In our first case, norepinephrine 1.0-2.0 microg/kg/min and vasopressin 0.03-0.1 U/min were infused for 5 days; in the second case, dopamine 10-20 microg/kg/min and norepinephrine 0.25-2.5 microg/kg/min were infused for 7 days. Severe ischemic skin lesions, which required amputations, developed in both cases. The clinical appearance of the skin lesions in the 2 cases was different because of the unique distribution of target receptors for different vasopressors. Thus, when high dose vasopressors are required to achieve recommended MAP, extra vigilance is required. Further studies for dose adjustment are needed.

Citations

Citations to this article as recorded by  
  • Lower Extremity Salvage with Thoracodorsal Artery Perforator Free Flap in Condition of Symmetrical Peripheral Gangrene
    Soo Yeon Lim, Gyeong Hoe Kim, Il Hoon Sung, Dong Woo Jang, Jung Soo Yoon, Youn Hwan Kim, Sang Wha Kim
    BioMed Research International.2018; 2018: 1.     CrossRef
  • A tip from the nose: rhinocerebral mucormycosis in a patient with alcoholic liver cirrhosis and cocaine abuse, an uncommon association
    David Avelar Rodriguez, Gabriel Ochoa Virgen, Roberto Carlos Miranda Ackerman
    BMJ Case Reports.2017; : bcr-2017-220730.     CrossRef
  • Upper Extremity Complications and Concerns in Patients With Cardiac Disease
    Hannah A. Dineen, Ryan D. Gentry, Reid W. Draeger
    The Journal of Hand Surgery.2016; 41(3): 470.     CrossRef
  • Understanding Vasoactive Medications
    John M. Allen
    Journal of Infusion Nursing.2014; 37(2): 82.     CrossRef
A Case of Anaphylactoid Reaction to Gadolinium Contrast Media and Propranolol Complicated with Acute Respiratory Distress Syndrome (ARDS): A Case Report
Jung Hyun Kim, Kyung Ho Kim, Hye Cheol Jeong, Eun Kyung Kim, Ji Hyun Lee
Korean J Crit Care Med. 2012;27(3):187-190.
DOI: https://doi.org/10.4266/kjccm.2012.27.3.187
  • 2,271 View
  • 41 Download
  • 1 Citations
AbstractAbstract PDF
Anaphylaxis/anaphylactoid reaction is a medical emergency. In rare cases, acute respiratory distress syndrome (ARDS) can complicate this disorder. This is a case report of an anaphylactoid reaction complicated with ARDS that was successfully treated using extracorporeal membrane oxygenation (ECMO). A 52-year-old female patient developed sudden dyspnea immediately after she received gadolinium contrast injection and 80 mg of oral propranolol. She progressed rapidly to a state of shock and her chest radiograph showed pulmonary edema. The shock and pulmonary edema did not respond to epinephrine or steroid injection. On the next day, the permeability edema worsened and laboratory test revealed extreme hemoconcentration. The oxygenation goal was not achieved with mechanical ventilation alone, thus ECMO was applied as well. The patient showed clinical improvements on the 3rd day and was weaned from ECMO on the 4th day. She was completely recovered from shock and respiratory distress by day 5. The patient was discharged from hospital without further complications.

Citations

Citations to this article as recorded by  
  • Acute Respiratory Distress Syndrome Due to Gadolinium Administration
    Nidhi Gupta, John Davidson, Alex Li
    Journal of the Intensive Care Society.2013; 14(2): 159.     CrossRef
A Fatal Case of Vocal Cord Dysfunction: A Case Report
Eun Ha Cho, Gi Won Cho, Soo Hoon Kwon, Sang Hyuk Im, Hye Ok Kim, Sook Hee Song, Woo Chan Choung, Suhyun Kim
Korean J Crit Care Med. 2012;27(3):191-196.
DOI: https://doi.org/10.4266/kjccm.2012.27.3.191
  • 15,570 View
  • 80 Download
AbstractAbstract PDF
Vocal cord dysfunction is characterized by the paradoxical adduction of the vocal cord during inspiration, causing relapsing wheezing or stridor, chest tightness, shortness of breath, and coughing. If the patient exhibiting symptoms of asthma is not responsive to treatment, there is a need to test whether vocal cord dysfunction is complicated by asthma. Herein, we report a case of vocal cord dysfunction with acute respiratory failure in old age with underlying disease. The patient presented with resting dyspnea, an audible wheeze, and was first diagnosed with acute exacerbation of bronchial asthma. However, her symptoms were not controlled with medical treatment and laryngoscopy showed paradoxical adduction of the vocal cords. Sudden cardiopulmonary arrest occurred after meal on the day of laryngoscopic examination. Although successful cardiopulmonary resuscitation, the patient developed ventilator-associated pneumonia, and multiple organ failure, eventually leading to death. Because the case was fatal, a report is being issued.
Muscular Rigidity and Pulmonary Edema Following Administration of Low Dose Fentanyl: A Case Report
Sung Kyu Rim, Jong Il Kim, Yu Bin Son, Ji Heui Lee
Korean J Crit Care Med. 2012;27(3):197-201.
DOI: https://doi.org/10.4266/kjccm.2012.27.3.197
  • 3,099 View
  • 37 Download
  • 1 Citations
AbstractAbstract PDF
Fentanyl-induced muscular rigidity has been reported exclusively in patients when large fentanyl dosages were employed in the operating room or in the pediatric intensive care unit. Rigidity and pulmonary edema after analgesic doses of fentanyl had not been reported previously. A 25-year-old man underwent removal of a foreign body and application of an Ilizarov frame of tibia under general anesthesia. The patient received 100 microg of fentanyl during emergence of anesthesia and the procedure of dressing. On arrival to the anesthetic recovery room, the patient presented with muscular rigidity and about 1 hour later, developed pulmonary edema. The notable predisposing factors were rapid injection of fentanyl and history of treatment with antidepressants and haloperidol, modifiers of serotonin and dopamine levels. From this case, we suggest the need for careful observation for the development of muscle rigidity complicating airway management in patients taking antidepressants and antipsychotics, especially after administration of an analgesic dose of fentanyl.

Citations

Citations to this article as recorded by  
  • Recurrent Desaturation Events due to Opioid-Induced Chest Wall Rigidity after Low Dose Fentanyl Administration
    Sung Yeon Ham, Bo Ra Lee, Taehoon Ha, Jeongmin Kim, Sungwon Na
    Korean Journal of Critical Care Medicine.2016; 31(2): 118.     CrossRef
Five Successful Experiences in the Treatment of Charcoal Aspiration with Bronchoscopic Toilet: A Case Report
Young Il Kim, Jae Seok Park, Jae Sung Choi, Sung Shik Jou, Hyo Wook Gil, Sae Yong Hong
Korean J Crit Care Med. 2012;27(3):202-206.
DOI: https://doi.org/10.4266/kjccm.2012.27.3.202
  • 2,553 View
  • 28 Download
AbstractAbstract PDF
Although activated charcoal is an effective treatment for most toxic ingestions, aspiration of activated charcoal can be fatal. Here, we report that in 5 charcoal aspiration cases, bronchoscopy with suction and lavage was an effective way to remove charcoal from the lungs. Patients showed high APACHE II scores (range: 10-29), and either low PO2 levels, or low CO2 retention. After bronchoscopic removal of the aspirated charcoal, symptoms of hypoxia, CO2 retention, localized wheezing, and pneumonic infiltration as determined by chest radiography, improved in most patients. We report 5 cases of successful treatment of charcoal aspiration with bronchoscopic toilet.

ACC : Acute and Critical Care