Acute and Critical Care

Volume 34 (4); November 2019

Review Article

Nutrition
Fluid management in perioperative and critically ill patients: Dongho Kang, Kyung Yeon Yoo; Acute Crit Care. 2019;34(4):235-245. Published online November 29, 2019; DOI: https://doi.org/10.4266/acc.2019.00717

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Fluid therapy to restore and/or maintain tissue perfusion may affect patient outcomes in perioperative, emergency, and intensive care. Kinetic analyses and outcome-oriented studies have provided more insight into fluid management. Crystalloids are slowly distributed to the interstitial space, and the efficiency (proportion of infused fluid retained in the bloodstream) is 50%−75% as long as infusion continues and may increase up to 100% when the arterial pressure has decreased. Elimination of the infused fluid during general anesthesia and surgery is very slow, amounting to only 10%–20% compared with that in conscious patients. When the endothelial glycocalyx layer is degraded in sepsis or trauma-induced systemic inflammation, turnover of colloids and crystalloids is accelerated and the efficiency is reduced, which may lead to tissue edema, inflammation, poor wound healing, and organ dysfunction. Balanced crystalloids are pragmatic initial resuscitation fluids and improve patient outcomes compared to saline (0.9% sodium chloride). Albumin may be beneficial, but other synthetic colloids appear to increase the risk of acute kidney injury and death among patients in the intensive care unit. Fluid kinetics is likely to change based on patient physiological conditions (e.g., general anesthesia, surgery, stress, dehydration, blood pressure, or inflammation) and fluid types. To maximize efficacy and minimize iatrogenic side effects, fluids should be prescribed based on individual patient factors, disease states, and other treatment remedies.

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Pulse pressure variation guided goal-direct fluid therapy decreases postoperative complications in elderly patients undergoing laparoscopic radical resection of colorectal cancer: a randomized controlled trial
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Meropenem pharmacokinetics in critically ill patients with or without burn treated with or without continuous veno‐venous haemofiltration
Daniel J. Selig, Kevin S. Akers, Kevin K. Chung, Kaitlin A. Pruskowski, Jeffrey R. Livezey, Elaine D. Por
British Journal of Clinical Pharmacology.2022; 88(5): 2156. CrossRef
Does perioperative fluid management affect the development of postoperative complications in major gastrointestinal tract surgery? A retrospective cohort study
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A Porcine Sepsis Model With Numerical Scoring for Early Prediction of Severity
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Frontiers in Medicine.2022;[Epub] CrossRef
Risk Factors for and Outcomes Associated With Peri-Intubation Hypoxemia: A Multicenter Prospective Cohort Study
Nathan J. Smischney, Ashish K. Khanna, Ernesto Brauer, Lee E. Morrow, Uchenna R. Ofoma, David A. Kaufman, Ayan Sen, Chakradhar Venkata, Peter Morris, Vikas Bansal
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Inflammatory response, fluid balance and outcome in emergency high‐risk abdominal surgery
Mirjana Cihoric, Henrik Kehlet, Morten L. Lauritsen, Jakob Højlund, Katrine Kanstrup, Nicolai B. Foss
Acta Anaesthesiologica Scandinavica.2021; 65(6): 730. CrossRef
A review on the physiological and pathophysiological role of endothelial glycocalyx
Huan‐qiu Liu, Ji Li, Cheng‐luan Xuan, Hai‐chun Ma
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Science‐in‐brief: The role of the glycocalyx in critically ill patients with reference to the horse
Bettina Dunkel
Equine Veterinary Journal.2020; 52(6): 790. CrossRef

Original Articles

Rapid response system
Effect of a rapid response system on code rates and in-hospital mortality in medical wards: Hong Yeul Lee, Jinwoo Lee, Sang-Min Lee, Sulhee Kim, Eunjin Yang, Hyun Joo Lee, Hannah Lee, Ho Geol Ryu, Seung-Young Oh, Eun Jin Ha, Sang-Bae Ko, Jaeyoung Cho; Acute Crit Care. 2019;34(4):246-254. Published online November 29, 2019; DOI: https://doi.org/10.4266/acc.2019.00668

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Background
To determine the effects of implementing a rapid response system (RRS) on code rates and in-hospital mortality in medical wards.
Methods
This retrospective study included adult patients admitted to medical wards at Seoul National University Hospital between July 12, 2016 and March 12, 2018; the sample comprised 4,224 patients admitted 10 months before RRS implementation and 4,168 patients admitted 10 months following RRS implementation. Our RRS only worked during the daytime (7 AM to 7 PM) on weekdays. We compared code rates and in-hospital mortality rates between the preintervention and postintervention groups.
Results
There were 62.3 RRS activations per 1,000 admissions. The most common reasons for RRS activation were tachypnea or hypopnea (44%), hypoxia (31%), and tachycardia or bradycardia (21%). Code rates from medical wards during RRS operating times significantly decreased from 3.55 to 0.96 per 1,000 admissions (adjusted odds ratio [aOR], 0.29; 95% confidence interval [CI], 0.10 to 0.87; P=0.028) after RRS implementation. However, code rates from medical wards during RRS nonoperating times did not differ between the preintervention and postintervention groups (2.60 vs. 3.12 per 1,000 admissions; aOR, 1.23; 95% CI, 0.55 to 2.76; P=0.614). In-hospital mortality significantly decreased from 56.3 to 42.7 per 1,000 admissions after RRS implementation (aOR, 0.79; 95% CI, 0.64 to 0.97; P=0.024).
Conclusions
Implementation of an RRS was associated with significant reductions in code rates during RRS operating times and in-hospital mortality in medical wards.

Citations

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Effects of a Rapid Response Team on Patient Outcomes: A Systematic Review
Qiuxia Zhang, Khuan Lee, Zawiah Mansor, Iskasymar Ismail, Yi Guo, Qiao Xiao, Poh Ying Lim
Heart & Lung.2024; 63: 51. CrossRef
Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023
Kimia Honarmand, Randy S. Wax, Daleen Penoyer, Geoffery Lighthall, Valerie Danesh, Bram Rochwerg, Michael L. Cheatham, Daniel P. Davis, Michael DeVita, James Downar, Dana Edelson, Alison Fox-Robichaud, Shigeki Fujitani, Raeann M. Fuller, Helen Haskell, Ma
Critical Care Medicine.2024; 52(2): 314. CrossRef
Rapid Response Systems
Bradford D. Winters
Critical Care Clinics.2024; 40(3): 583. CrossRef
The role of emergency medical services in the management of in-hospital emergencies: Causes and outcomes of emergency calls – A descriptive retrospective register-based study
Henna Myrskykari, Timo Iirola, Hilla Nordquist
Australasian Emergency Care.2023;[Epub] CrossRef
Improving sepsis recognition and management
Merrilee I Cox, Hillary Voss
Current Problems in Pediatric and Adolescent Health Care.2021; 51(4): 101001. CrossRef
A Somogy Megyei Kaposi Mór Oktató Kórház által bevezetett gyors reagálású rendszer hatása a kórházi mortalitásra
János Fogas, Rita Koroseczné Pavlin, Krisztina Szabó, Eszter Héra, Imre Repa, Mariann Moizs
Orvosi Hetilap.2021; 162(20): 782. CrossRef
Evidence revealed the effects of rapid response system
Jae Hwa Cho
Acute and Critical Care.2019; 34(4): 282. CrossRef

Trauma
The association between the initial lactate level and need for massive transfusion in severe trauma patients with and without traumatic brain injury: Young Hoon Park, Dong Hyun Ryu, Byung Kook Lee, Dong Hun Lee; Acute Crit Care. 2019;34(4):255-262. Published online November 29, 2019; DOI: https://doi.org/10.4266/acc.2019.00640

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Background
Exsanguination is a major cause of death in severe trauma patients. The purpose of this study was to analyze the prognostic impact of the initial lactate level for massive transfusion (MT) in severe trauma. We divided patients according to subgroups of traumatic brain injury (TBI) and non-TBI.
Methods
This single-institution retrospective study was conducted on patients who were admitted to hospital for severe trauma between January 2016 and December 2017. TBI was defined by a head Abbreviated Injury Scale ≥3. Receiver operating characteristic analysis was used to analyze the prognostic impact of the lactate level. Multivariate analyses were performed to evaluate the relationship between the MT and lactate level. The primary outcome was MT.
Results
Of the 553 patients, MT was performed in 62 patients (11.2%). The area under the curve (AUC) for the lactate level for predicting MT was 0.779 (95% confidence interval [CI], 0.742 to 0.813). The AUCs for lactate level in the TBI and non-TBI patients were 0.690 (95% CI, 0.627 to 0.747) and 0.842 (95% CI, 0.796 to 0.881), respectively. In multivariate analyses, the lactate level was independently associated with the MT (odds ratio [OR], 1.179; 95% CI, 1.070 to 1.299). The lactate level was independently associated with MT in non-TBI patients (OR, 1.469; 95% CI, 1.262 to 1.710), but not in TBI patients.
Conclusions
The initial lactate level may be a possible prognostic factor for MT in severe trauma. In TBI patients, however, the initial lactate level was not suitable for predicting MT.

Citations

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Association of initial lactate levels and red blood cell transfusion strategy with outcomes after severe trauma: a post hoc analysis of the RESTRIC trial
Yoshinori Kosaki, Takashi Hongo, Mineji Hayakawa, Daisuke Kudo, Shigeki Kushimoto, Takashi Tagami, Hiromichi Naito, Atsunori Nakao, Tetsuya Yumoto
World Journal of Emergency Surgery.2024;[Epub] CrossRef
Predictors of massive transfusion protocols activation in patients with trauma in Korea: a systematic review
Dongmin Seo, Inhae Heo, Juhong Park, Junsik Kwon, Hye-min Sohn, Kyoungwon Jung
Journal of Trauma and Injury.2024; 37(2): 97. CrossRef
Prehospital Lactate Levels Obtained in the Ambulance and Prediction of 2-Day In-Hospital Mortality in Patients With Traumatic Brain Injury
Francisco Martin-Rodriguez, Ancor Sanz-Garcia, Raul Lopez-Izquierdo, Juan F. Delgado Benito, Francisco T. Martínez Fernández, Santiago Otero de la Torre, Carlos Del Pozo Vegas
Neurology.2024;[Epub] CrossRef

Thoracic Surgery
How small is enough for the left heart decompression cannula during extracorporeal membrane oxygenation?: Sua Kim, Jin Seok Kim, Jae Seung Shin, Hong Ju Shin; Acute Crit Care. 2019;34(4):263-268. Published online November 29, 2019; DOI: https://doi.org/10.4266/acc.2019.00577

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Background
Left ventricular (LV) distension is a recognizable problem accompanied by subsequent complications during venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, no gold standard for LV decompression has been established, and no minimal flow requirement has been designated. Thus, we evaluated the efficacy of the 8-Fr Mullins sheath for left heart decompression during VA-ECMO in adult patients.
Methods
Left heart decompression was performed when severe pulmonary edema was detected on chest radiography or when no generation of pulse pressure followed severe LV dysfunction in patients receiving VA-ECMO. We punctured the interatrial septum and inserted an 8-Fr Mullins sheath into the left atrium via the femoral vein. The sheath was connected to the venous catheter used for ECMO. The catheter was maintained during VA-ECMO.
Results
The left heart decompression procedure was performed in seven of 35 patients who received VA-ECMO between February 2017 and June 2018. Three patients had acute myocardial infarction; three, fulminant myocarditis; and one, dilated cardiomyopathy. Four patients showed noticeable improvement of pulmonary edema within 3 days, and three patients with a pulse pressure of <10 mm Hg showed an increase in pulse pressure of >20 mm Hg within 24 hours from the left heart decompression procedure. All seven patients were successfully weaned from VA-ECMO. No complications related to the left heart decompression procedure occurred.
Conclusions
An 8-Fr sheath may be a possible option for left heart decompression in adult patients with LV distension under VA-ECMO who are expecting recovery of LV function.

Citations

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Venting during venoarterial extracorporeal membrane oxygenation
Enzo Lüsebrink, Leonhard Binzenhöfer, Antonia Kellnar, Christoph Müller, Clemens Scherer, Benedikt Schrage, Dominik Joskowiak, Tobias Petzold, Daniel Braun, Stefan Brunner, Sven Peterss, Jörg Hausleiter, Sebastian Zimmer, Frank Born, Dirk Westermann, Holg
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Beong Ki Kim, Jeong In Hong, Jinwook Hwang, Hong Ju Shin
Medicine.2022; 101(37): e30568. CrossRef
Outcomes of left ventricular unloading with a transseptal cannula during extracorporeal membrane oxygenation in adults
Ah‐Ram Kim, Hanbit Park, Sang‐Eun Lee, Jung‐Min Ahn, Duk‐Woo Park, Seung‐Whan Lee, Jae‐Joong Kim, Seung‐Jung Park, Jung Ae Hong, Pil‐Je Kang, Sung‐Ho Jung, Min‐Seok Kim
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Surgical minimal invasive left atrial decompression during venoarterial extracorporeal membrane oxygenation for pediatric acute fulminant myocarditis
Li Fen Ye, Qiang Shu, Chenmei Zhang, Yong Fan, Liyang Ying, Lijun Yang, Ru Lin
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Increasing venoarterial extracorporeal membrane oxygenation flow puts higher demands on left ventricular work in a porcine model of chronic heart failure
Pavel Hála, Mikuláš Mlček, Petr Ošťádal, Michaela Popková, David Janák, Tomáš Bouček, Stanislav Lacko, Jaroslav Kudlička, Petr Neužil, Otomar Kittnar
Journal of Translational Medicine.2020;[Epub] CrossRef
Advanced Pulmonary and Cardiac Support of COVID-19 Patients
Keshava Rajagopal, Steven P. Keller, Bindu Akkanti, Christian Bime, Pranav Loyalka, Faisal H. Cheema, Joseph B. Zwischenberger, Aly El Banayosy, Federico Pappalardo, Mark S. Slaughter, Marvin J. Slepian
Circulation: Heart Failure.2020;[Epub] CrossRef
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Keshava Rajagopal, Steven P. Keller, Bindu Akkanti, Christian Bime, Pranav Loyalka, Faisal H. Cheema, Joseph B. Zwischenberger, Aly El Banayosy, Federico Pappalardo, Mark S. Slaughter, Marvin J. Slepian
ASAIO Journal.2020; 66(6): 588. CrossRef

Trauma
Risk factor, monitoring, and treatment for snakebite induced coagulopathy: a multicenter retrospective study: Yong Jun Jeon, Jong Wan Kim, SungGil Park, Dong Woo Shin; Acute Crit Care. 2019;34(4):269-275. Published online November 18, 2019; DOI: https://doi.org/10.4266/acc.2019.00591; Correction in: Acute Crit Care 2020;35(1):56

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Background
Snakebite can cause various complications, including coagulopathy. The clinical features of snakebite-associated coagulopathy differ from those of disseminated intravascular coagulation (DIC) caused by other diseases and its treatment is controversial.
Methods
We retrospectively reviewed the medical records of patients hospitalized for snakebite between January 2006 and September 2018.
Results
A total of 226 patients were hospitalized due to snakebite. Their median hospital stay was 4.0 days (interquartile range, 2.0 to 7.0 days). Five patients arrived at hospital with shock and one patient died. Twenty-one patients had overt DIC according to the International Society of Thrombosis and Hemostasis scoring system. Two patients developed major bleeding complications. Initial lower cholesterol level at presentation was associated with the development of overt DIC. International normalization ratio (INR) exceeding the laboratory’s measurement limit was recorded as late as 4 to 5 days after the bite. Higher antivenom doses (≥18,000 units) and transfusion of fresh frozen plasma (FFP) or cryoprecipitate did not affect prolonged INR duration or hospital stay in the overt DIC patients without bleeding.
Conclusions
Initial lower cholesterol level may be a risk factor for overt DIC following snakebite. Although patients lack apparent symptoms, the risk of coagulopathy should be assessed for at least 4 to 5 days following snakebite. Higher antivenom doses and transfusion of FFP or cryoprecipitate may be unbeneficial for coagulopathic patients without bleeding.

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Coagulopathy following Crotaliπae snakebites in northeast Florida
Satish Maharaj, Karan Seegobin, Simone Chang
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Anjuman Chander, Tanvir Samra, Sekar Loganathan, Varun Mahajan
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Venom induced consumption coagulopathy and performance of 20-min whole blood clotting test for its detection in viperid envenomation
Bayye Rajkumar, Kolar Vishwanath Vinod, Rakhee Kar, Premkumar Ramasubramani
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The effect of myocardial injury on the clinical course of snake envenomation in South Korea
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Trauma
Lund and Browder chart—modified versus original: a comparative study: Arun Murari, Kaushal Neelam Singh; Acute Crit Care. 2019;34(4):276-281. Published online November 29, 2019; DOI: https://doi.org/10.4266/acc.2019.00647

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Abstract PDF

Background
The Lund and Browder (LB) chart is currently the most accurate and widely used chart to calculate total body surface area affected by a burn injury. However, it is not easy to use charts to calculate burn percentages because of the difficulty in performing mathematical calculations with the percentages attributed to various body regions that are only partially burned. It is also cumbersome to have to perform mental calculations, especially in emergency situations.
Methods
We compared results from the LB chart with a modified Lund and Browder (MLB) chart using 10 assessors on five different burn wounds each drawn on both charts.
Results
Variability of results was significantly reduced using the MLB chart compared to the LB chart.
Conclusions
Assessments performed using the MLB chart are less variable than those using the LB chart. Using this chart will help burn care providers rapidly, accurately, and reliably estimate burn extent.

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Editorial

Evidence revealed the effects of rapid response system: Jae Hwa Cho; Acute Crit Care. 2019;34(4):282-283. Published online November 29, 2019; DOI: https://doi.org/10.4266/acc.2019.00710

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Case Reports

Infection
A successful application of adult polymyxin B-immobilized fiber column hemoperfusion to a neonate with septic shock: Young A Kim, Hyungtae Kim, Yu-Mi Kim, Su Eun Park; Acute Crit Care. 2019;34(4):284-288. Published online November 6, 2018; DOI: https://doi.org/10.4266/acc.2017.00528; Correction in: Acute Crit Care 2023;38(4):515

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Direct hemoperfusion therapy with a polymyxin B-immobilized fiber column (PMX-HP) has been introduced as a therapeutic option for gram negative bacterial septic shock in adults. However, its use in neonates and children has not yet been established. We successfully performed hemoperfusion therapy using an adult polymyxin B-immobilized fiber column in a neonate with carbapenem resistant Acinetobacter baumannii septic shock. The application was technically feasible because the neonate was on extracorporeal membrane oxygenation (ECMO). Although it did not rescue the patient, there was significant short-lasting improvement in pulmonary oxygenation and hemodynamics, leading to wean the patient from ECMO. PMX-HP could be used as an adjunctive treatment for selected neonatal and pediatric patients with gram negative bacterial septic shock.

Citations

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Polymyxin B Hemoperfusion in Pediatric Septic Shock: Single-Center Observational Case Series
Patcharin Saetang, Rujipat Samransamruajkit, Kanokwan Singjam, Tawatchai Deekajorndech
Pediatric Critical Care Medicine.2022; 23(8): e386. CrossRef
Controlling an Outbreak of Multidrug-resistant Acinetobacter baumannii in a Pediatric Intensive Care Unit: a Retrospective Analysis
Joung-Hee Byun, Su Eun Park, Minhae Seo, Jeungmi Jang, Mi Sun Hwang, Ju Yeoun Song, Chulhun L. Chang, Young A Kim
Journal of Korean Medical Science.2021;[Epub] CrossRef
Effects of continuous renal replacement therapy with the AN69ST membrane for septic shock and sepsis-induced AKI in an infant: a case report with literature review of cytokine/mediator removal therapy in children
Naoto Nishizaki, Riko Ueno, Yuki Nagayama, Hanako Abe, Akina Matsuda, Akira Mizutani, Kaoru Obinata, Tadaharu Okazaki, Toshiaki Shimizu
Renal Replacement Therapy.2020;[Epub] CrossRef
Suggestions and tips regarding polymyxin B-immobilized fiber column direct hemoperfusion of neonates with sepsis
Naoto Nishizaki
Acute and Critical Care.2020; 35(3): 226. CrossRef
Case Report: Successful Use of Extracorporeal Therapies After ECMO Resuscitation in a Pediatric Kidney Transplant Recipient
Andrey Rybalko, Anna Pytal, Mikhail Kaabak, Nadejda Rappoport, Anuar Bidzhiev, Vasilii Lastovka
Frontiers in Pediatrics.2020;[Epub] CrossRef

Cardiology
Two women presenting aborted sudden cardiac arrest as the first event of mitral valve disease: Sua Kim, Jae Min Shim, Seong-Mi Park; Acute Crit Care. 2019;34(4):289-293. Published online November 13, 2018; DOI: https://doi.org/10.4266/acc.2017.00570

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Abstract PDF

Mitral valve prolapse (MVP) is a relatively common valvular heart disease and is known to have a benign course. However, a certain subtype of MVP has a pathologic prognosis and can be accompanied by malignant cardiac arrhythmia causing sudden cardiac arrest, which can be characterized by bileaflet mitral valvular thickening and prolapse and frequent premature ventricular ectopic activity upon electrocardiography. Herein, we present two patients with bileaflet mitral prolapse who survived aborted sudden cardiac arrest. These cases show a precise MVP diagnosis that may prevent a devastating life event with the unique MVP subtype.

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Mitral annular disjunction identified peripartum: A case highlighting key features of a recently classified syndrome
Monique Doran, Gemma Reemst, Kenny Ng, Courtney Shaw, Paul Stoodley
Sonography.2023; 10(1): 30. CrossRef

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