Acute and Critical Care

Volume 33 (2); May 2018

Review

Basic science and research
Role of Mitochondrial Oxidative Stress in Sepsis: Harsha Nagar, Shuyu Piao, Cuk-Seong Kim; Acute Crit Care. 2018;33(2):65-72. Published online May 31, 2018; DOI: https://doi.org/10.4266/acc.2018.00157

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Mitochondria are considered the power house of the cell and are an essential part of the cellular infrastructure, serving as the primary site for adenosine triphosphate production via oxidative phosphorylation. These organelles also release reactive oxygen species (ROS), which are normal byproducts of metabolism at physiological levels; however, overproduction of ROS under pathophysiological conditions is considered part of a disease process, as in sepsis. The inflammatory response inherent in sepsis initiates changes in normal mitochondrial functions that may result in organ damage. There is a complex system of interacting antioxidant defenses that normally function to combat oxidative stress and prevent damage to the mitochondria. It is widely accepted that oxidative stress-mediated injury plays an important role in the development of organ failure; however, conclusive evidence of any beneficial effect of systemic antioxidant supplementation in patients with sepsis and organ dysfunction is lacking. Nevertheless, it has been suggested that antioxidant therapy delivered specifically to the mitochondria may be useful.

Citations

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Original Articles

Infection
Current Status and Survival Impact of Infectious Disease Consultation for Multidrug-Resistant Bacteremia in Ventilated Patients: A Single-Center Experience in Korea: Insu Kim, Won-Young Kim, Eun Suk Jeoung, Kwangha Lee; Acute Crit Care. 2018;33(2):73-82. Published online April 26, 2018; DOI: https://doi.org/10.4266/acc.2017.00591

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Abstract PDF

Background
We evaluated the current status and survival impact of infectious disease consultation (IDC) in ventilated patients with multidrug-resistant (MDR) bacteremia.
Methods
One hundred sixty-one consecutive patients from a single tertiary care hospital were enrolled over a 5-year period. Patients with at least one of the following six MDR bacteremias were included: methicillin-resistant Staphylococcus aureus, extended-spectrum β-lactamase-producing gram-negative bacteria (Escherichia coli and Klebsiella pneumonia), carbapenem-resistant gram-negative rods (Acinetobacter baumannii and Pseudomonas aeruginosa), and vancomycin-resistant Enterococcus faecium.
Results
Median patient age was 66 years (range, 18 to 95), and 57.8% of subjects were male. The 28-day mortality after the day of blood culture was 52.2%. An IDC was requested for 96 patients based on a positive blood culture (59.6%). Patients without IDC had significantly higher rate of hemato-oncologic diseases as a comorbidity (36.9% vs. 11.5%, P < 0.001). Patients without an IDC had higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (median, 20; range, 8 to 38 vs. median, 16; range, 5 to 34, P < 0.001) and Sequential Organ Failure Assessment (SOFA) score (median, 9; range, 2 to 17 vs. median, 7; range, 2 to 20; P = 0.020) on the day of blood culture and a higher 28-day mortality rate (72.3% vs. 38.5%, P < 0.001). In patients with SOFA ≥9 (cut-off level based on Youden’s index) on the day of blood culture and gram-negative bacteremia, IDC was also significantly associated with lower 28-day mortality (hazard ratio [HR], 0.298; 95% confidence interval [CI], 0.167 to 0.532 and HR, 0.180; 95% CI, 0.097 to 0.333; all P < 0.001] based on multivariate Cox regression analysis.
Conclusions
An IDC for MDR bacteremia was requested less often for ventilated patients with greater disease severity and higher 28- day mortality after blood was drawn. In patients with SOFA ≥9 on the day of blood culture and gram-negative bacteremia, IDC was associated with improved 28-day survival after blood draw for culture.

Citations

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Impact of a Pro-Active Infectious Disease Consultation on the Management of a Multidrug-Resistant Organisms Outbreak in a COVID-19 Hospital: A Three-Months Quasi-Experimental Study
Davide Fiore Bavaro, Nicolò De Gennaro, Alessandra Belati, Lucia Diella, Roberta Papagni, Luisa Frallonardo, Michele Camporeale, Giacomo Guido, Carmen Pellegrino, Maricla Marrone, Alessandro Dell’Erba, Loreto Gesualdo, Nicola Brienza, Salvatore Grasso, Gi
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Timeliness of Infectious Diseases Referral and Inappropriate Antibiotic Usage Post-Referral in an Asian Tertiary Hospital
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CPR/Resuscitation
APACHE II Score Immediately after Cardiac Arrest as a Predictor of Good Neurological Outcome in Out-of-Hospital Cardiac Arrest Patients Receiving Targeted Temperature Management: Sang-Il Kim, Youn-Jung Kim, You-Jin Lee, Seung Mok Ryoo, Chang Hwan Sohn, Dong Woo Seo, Yoon-Seon Lee, Jae Ho Lee, Kyoung Soo Lim, Won Young Kim; Acute Crit Care. 2018;33(2):83-88. Published online May 31, 2018; DOI: https://doi.org/10.4266/acc.2017.00514

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Abstract PDF

Background
This study assessed the association between the initial Acute Physiology and Chronic Health Evaluation (APACHE) II score and good neurological outcome in comatose survivors of out-of-hospital cardiac arrest who received targeted temperature management (TTM).
Methods
Data from survivors of cardiac arrest who received TTM between January 2011 and June 2016 were retrospectively analyzed. The initial APACHE II score was determined using the data immediately collected after return of spontaneous circulation rather than within 24 hours after being admitted to the intensive care unit. Good neurological outcome, defined as Cerebral Performance Category 1 or 2 on day 28, was the primary outcome of this study.
Results
Among 143 survivors of cardiac arrest who received TTM, 62 (43.4%) survived, and 34 (23.8%) exhibited good neurological outcome on day 28. The initial APACHE II score was significantly lower in the patients with good neurological outcome than in those with poor neurological outcome (23.71 ± 4.39 vs. 27.62 ± 6.16, P = 0.001). The predictive ability of the initial APACHE II score for good neurological outcome, assessed using the area under the receiver operating characteristic curve, was 0.697 (95% confidence interval [CI], 0.599 to 0.795; P = 0.001). The initial APACHE II score was associated with good neurological outcome after adjusting for confounders (odds ratio, 0.878; 95% CI, 0.792 to 0.974; P = 0.014).
Conclusions
In the present study, the APACHE II score calculated in the immediate post-cardiac arrest period was associated with good neurological outcome. The initial APACHE II score might be useful for early identification of good neurological outcome.

Citations

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Current Cardiovascular Risk Reports.2021;[Epub] CrossRef

Surgery
Feasibility of Percutaneous Dilatational Tracheostomy with a Light Source in the Surgical Intensive Care Unit: Jong-Kwan Baek, Jung-Sun Lee, Minchang Kang, Nak-Jun Choi, Suk-Kyung Hong; Acute Crit Care. 2018;33(2):89-94. Published online April 26, 2018; DOI: https://doi.org/10.4266/acc.2017.00563

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Abstract PDF

Background
Although percutaneous dilatational tracheostomy (PDT) under bronchoscopic guidance is feasible in the intensive care unit (ICU), it requires extensive equipment and specialists. The present study evaluated the feasibility of performing PDT with a light source in the surgical ICU.
Methods
The study involved a retrospective review of the outcomes of patients who underwent PDT with a light source performed by a surgery resident under the supervision of a surgical intensivist in the surgical ICU from October 2015 through September 2016. During the procedure, a light wand was inserted into the endotracheal tube after skin incision. Then, the light wand and the endotracheal tube were pulled out slightly, the passage of light through the airway was confirmed, and the relevant point was punctured.
Results
Fifty patients underwent PDT with a light source. The average procedural duration was 14.0 ± 7.0 minutes. There were no procedure-associated deaths. Intraoperative complications included minor bleeding in three patients (6%) and paratracheal placement of the tracheostomy tube in one patient (2%); these were immediately resolved by the surgical intensivist. Two patients required conversion to surgical tracheostomy because of the difficulty in light wand insertion into the endotracheal tube and a very narrow trachea, respectively.
Conclusions
PDT with a light source can be performed without bronchoscopy and does not require expensive equipment and specialist intervention in the surgical ICU. It can be safely performed by a surgical intensivist with experience in surgical tracheostomy.

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Athia Haron, Lutong Li, Eryl A. Davies, Peter D.G. Alexander, Brendan A. McGrath, Glen Cooper, Andrew Weightman
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Ethics
Transcultural Adaptation and Validation of Quality of Dying and Death Questionnaire in Medical Intensive Care Units in South Korea: Jun Yeun Cho, Jinwoo Lee, Sang-Min Lee, Ju-Hee Park, Junghyun Kim, Youlim Kim, Sang Hoon Lee, Jong Sun Park, Young-Jae Cho, Ho Il Yoon, Jae Ho Lee, Choon-Taek Lee, Yeon Joo Lee; Acute Crit Care. 2018;33(2):95-101. Published online May 31, 2018; DOI: https://doi.org/10.4266/acc.2017.00612

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Abstract PDF Supplementary Material

Background
Providing palliative care to dying patients in the intensive care unit (ICU) has recently received much attention. Evaluating the quality of dying and death (QODD) is important for appropriate comfort care in the ICU. This study aimed to validate the Korean version of the QODD questionnaire.
Methods
This study included decedents in the ICUs of three tertiary teaching hospitals and one secondary hospital from June 2016 to May 2017. ICU staff members were asked to complete the translated QODD questionnaire and the visual analogue scale (VAS) questionnaire within 48 hours of patient death. The validation process consisted of evaluating construct validity, internal consistency, and interrater reliability.
Results
We obtained 416 completed questionnaires describing 255 decedents. The QODD score was positively correlated with the 100-VAS score (Pearson correlation coefficient, 0.348; P<0.001). An evaluation of the internal consistency presented favorable results (calculated Cronbach’s alpha if a given item exceeded 0.8 in all items). The interrater reliability revealed no concordance between doctors and nurses.
Conclusions
The QODD questionnaire was successfully translated and validated in Korean medical ICUs. We hope further studies that use this valuable instrument will be conducted in Korea.

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Editorial

Basic science and research
Scoring Systems for the Patients of Intensive Care Unit: Seongwook Jeong; Acute Crit Care. 2018;33(2):102-104. Published online May 31, 2018; DOI: https://doi.org/10.4266/acc.2018.00185

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Case Reports

Thoracic Surgery
Chemical Pleurodesis Using Viscum album Extract in Gorham’s Disease Complicated with Chylothorax: Suk Ju Cho, Su Wan Kim; Acute Crit Care. 2018;33(2):105-109. Published online December 30, 2016; DOI: https://doi.org/10.4266/acc.2016.00164

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Abstract PDF

Gorham’s disease, also known as massive osteolysis, is characterized by unregulated proliferation of lymphatic or vascular capillaries within bone, resulting in destruction and replacement with angiomatous tissue. This disease can lead to chylothorax that can be lethal. Viscum album extract from European mistletoe is a complementary anti-cancer drug which is commonly prescribed in many European countries and is considered as a new generation of chemical agent for pleurodesis. A 14-year-old girl presented with dyspnea and chest pain. She was diagnosed as Gorham’s disease who was definitively treated with Viscum album extract for chylothorax that was refractory to standard conservative management.

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Basic science and research
Anterograde Amnesia after Acute Glufosinate Ammonium Intoxication: Hyuk-Hoon Kim, Young-Gi Min; Acute Crit Care. 2018;33(2):110-113. Published online May 31, 2018; DOI: https://doi.org/10.4266/acc.2016.00444

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Abstract PDF

Glufosinate ammonium (GA) intoxication causes several neurologic complications. We report a rare but typical case of GA intoxication associated with anterograde amnesia and bilateral hippocampal involvement. A 53-year-old woman with GA intoxication presented to the emergency department. Initial general and neurologic examinations were unremarkable but, from the day after admission, she exhibited anterograde amnesia. On brain magnetic resonance imaging, the signal intensity in the hippocampus was symmetrically and bilaterally increased. She was discharged with no medical problems, but the anterograde amnesia remained. Eleven days after the onset of amnesia, she returned to the neurology outpatient department with persisting anterograde amnesia but improving symptoms.

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Image in Critical Care

Trauma
Trauma-Induced Retroperitoneal Paraganglioma Rupture Which Was Misunderstood as a Massive Retroperitoneal Hemorrhage: Hongjin Shim, Ji Young Jang, Yeong Ju Kim, Jung Soo Lim, Keum Seok Bae; Acute Crit Care. 2018;33(2):114-116. Published online April 26, 2018; DOI: https://doi.org/10.4266/acc.2017.00234

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