Chul Park, Nam Su Ku, Dae Won Park, Joo Hyun Park, Tae Sun Ha, Do Wan Kim, So Young Park, Youjin Chang, Kwang Wook Jo, Moon Seong Baek, Yijun Seo, Tae Gun Shin, Gina Yu, Jongmin Lee, Yong Jun Choi, Ji Young Jang, Yun Tae Jung, Inseok Jeong, Hwa Jin Cho, Ala Woo, Sua Kim, Dae-Hwan Bae, Sung Wook Kang, Sun Hyo Park, Gee Young Suh, Sunghoon Park
Acute Crit Care. 2024;39(4):445-472. Published online November 18, 2024
Background Despite recent advances and global improvements in sepsis recognition and supportive care, mortality rates remain high, and adherence to sepsis bundle components in Korea is low. To address this, the Korean Sepsis Alliance, affiliated with the Korean Society of Critical Care Medicine, developed the first sepsis treatment guidelines for Korea based on a comprehensive systematic review and meta-analysis.
Methods A de novo method was used to develop the guidelines. Methodologies included determining key questions, conducting a literature search and selection, assessing the risk of bias, synthesizing evidence, and developing recommendations. The certainty of evidence and the strength of recommendations were determined using the Grading of Recommendations, Assessment, Development, and Evaluations approach. Draft recommendations underwent internal and external review processes and public hearings. The development of these guidelines was supported by a research grant from the Korean Disease Control and Prevention Agency.
Results In these guidelines, we focused on early treatments for adult patients with sepsis and septic shock. Through the guideline development process, 12 key questions and their respective recommendations were formulated. These include lactate measurement, fluid therapies, target blood pressure, antibiotic administration, use of vasopressors and dobutamine, extracorporeal membrane oxygenation, and echocardiography.
Conclusions These guidelines aim to support medical professionals in making appropriate decisions about treating adult sepsis and septic shock. We hope these guidelines will increase awareness of sepsis and reduce its mortality rate.
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It is well known that cardiac dysfunction in sepsis is associated with significantly increased mortality. The pathophysiology of sepsis-induced cardiac dysfunction can be summarized as involving impaired myocardial circulation, direct myocardial depression, and mitochondrial dysfunction. Impaired blood flow to the myocardium is associated with microvascular dysfunction, impaired endothelium, and ventriculo-arterial uncoupling. The mechanisms behind direct myocardial depression consist of downregulation of β-adrenoceptors and several myocardial suppressants (such as cytokine and nitric oxide). Recent research has highlighted that mitochondrial dysfunction, which results in energy depletion, is a major factor in sepsis-induced cardiac dysfunction. Therefore, the authors summarize the pathophysiological process of cardiac dysfunction in sepsis based on the results of recent studies.
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Cardiac arrest associated with hyperkalemia during red blood cell transfusion is a rare but fatal complication. Herein, we report a case of transfusion-associated cardiac arrest following the initiation of extracorporeal membrane oxygenation support in a 9-month old infant. Her serum potassium level was increased to 9.0 mEq/L, soon after the newly primed circuit with pre-stored red blood cell (RBC) was started and followed by sudden cardiac arrest. Eventually, circulation was restored and the potassium level decreased to 5.1 mEq/L after 5 min. Extracorporeal membrane oxygenation (ECMO) priming is a relatively massive transfusion into a pediatric patient. Thus, to prevent cardiac arrest during blood-primed ECMO in neonates and infants, freshly irradiated and washed RBCs should be used when priming the ECMO circuit, to minimize the potassium concentration. Also, physicians should be aware of all possible complications associated with transfusions during ECMO.
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Background Neurological complications are a serious concern during extracorporeal membrane oxygenation (ECMO) support in neonates and infants. However, evaluating brain injury during ECMO has limitations. Herein, we report our experience with bedside electroencephalographic monitoring during ECMO support and compared this to post-ECMO brain imaging studies and immediate neurologic outcomes.
Methods We retrospectively reviewed the data for 18 children who underwent ECMO. From these subjects, we reviewed the medical records of 10 subjects who underwent bedside EEG monitoring during ECMO support. We collected data on patient demographics, clinical details of the ECMO course, electroencephalographic monitoring, brain imaging results, and neurologic outcomes.
Results The median age was 4 months (range: 7 days-22 months), the median weight was 5 (3.6-12) kg, and the median length of ECMO therapy was 86 (27-206) hours. Eight patients (80%) were weaned successfully, and seven (70%) survived to discharge. Those with normal to mildly abnormal electroencephalographic findings had non-specific to mildly abnormal brain computed tomography findings and no neurologic impairment. Those patients with a moderately to severely abnormal electroencephalograph had markedly abnormal brain computed tomography findings and remained neurologically impaired.
Conclusions Normal electroencephalographic findings are closely related to normal or mild neurologic impairment. Our results indicate that electroencephalographic monitoring during ECMO support can be a feasible tool for evaluating brain injury although further prospective studies are needed.
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Thromboembolism in patients receiving extracorporeal membrane oxygenation (ECMO) support is a feared complication. Systemic anticoagulation during ECMO in patients with a massively dilated left ventricle (LV) and decreased LV systolic function is still debated. Hearin, we report a case of a 5-month old infant on ECMO support who had fatal thrombus formation in the massively dilated LV and a consequent thromboembolic event.
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