Acute and Critical Care

Original Articles

Thoracic Surgery
Connective tissue disease is associated with the risk of posterior reversible encephalopathy syndrome following lung transplantation in Korea: Tae Jung Kim, Hyun Joo Lee, Samina Park, Sang-Bae Ko, Soo-Hyun Park, Seung Hwan Yoon, Kwon Joong Na, In Kyu Park, Chang Hyun Kang, Young Tae Kim, Sun Mi Choi, Jimyung Park, Joong-Yub Kim, Hong Yeul Lee; Received September 5, 2024 Accepted November 14, 2024 Published online January 7, 2025; DOI: https://doi.org/10.4266/acc.003384 [Epub ahead of print]

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Abstract PDF Supplementary Material: Background
Posterior reversible encephalopathy syndrome (PRES) is a rare complication of lung transplantation with poorly understood risk factors and clinical characteristics. This study aimed to examine the occurrence, risk factors, and clinical data of patients who developed PRES following lung transplantation.
Methods
A retrospective analysis was conducted on 147 patients who underwent lung transplantation between February 2013 and December 2023. The patients were diagnosed with PRES based on the clinical symptoms and radiological findings. We compared the baseline characteristics and clinical information, including primary lung diseases and immunosuppressive therapy related to lung transplantation operations, between the PRES and non-PRES groups.
Results
PRES manifested in 7.5% (n=11) of the patients who underwent lung transplantation, with a median onset of 15 days after operation. Seizures were identified as the predominant clinical manifestation (81.8%, n=9) in the group diagnosed with PRES. All patients diagnosed with PRES recovered fully. Patients with PRES were significantly associated with connective tissue disease-associated interstitial lung disease (45.5% vs. 18.4%, P=0.019, odds ratio=9.808; 95% CI, 1.064–90.386, P=0.044). Nonetheless, no significant variance was observed in the type of immunotherapy, such as the use of calcineurin inhibitors, blood pressure, or acute renal failure subsequent to lung transplantation.
Conclusions
PRES typically manifests shortly after lung transplantation, with seizures being the predominant initial symptom. The presence of preexisting connective tissue disease as the primary lung disease represents a significant risk factor for PRES following lung transplantation.

Neurology
Isolated reversible mydriasis was associated with the use of nebulized ipratropium bromide: a case series using quantitative pupilometer in Korea: Soo-Hyun Park, Tae Jung Kim, Sang-Bae Ko; Acute Crit Care. 2024;39(4):593-599. Published online November 20, 2024; DOI: https://doi.org/10.4266/acc.2024.00983

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Abstract PDF Supplementary Material: Background
Abnormal pupillary reactivity is a neurological emergency requiring prompt evaluation to identify its underlying causes. Although isolated unilateral mydriasis without accompanying neurological abnormalities is rare, it has occasionally been associated with nebulizer use. We aimed to quantitatively assess pupillary changes using a pupillometer in cases of isolated mydriasis, which has not been described in previous studies.
Methods
We retrospectively analyzed patients who developed unilateral mydriasis after using an ipratropium bromide nebulizer using a prospectively collected database in the intensive care unit (ICU) between April 2019 and August 2020. An automated pupillometer (NPi-100 or NPi-200) was used for quantitative pupillary assessment. The Neurological Pupil index (NPi) value at the time of unilateral mydriasis was assessed, and the latency before and after the application of the ipratropium bromide nebulizer was measured.
Results
Five patients with isolated mydriasis were identified (mean age, 68 years; male, 60.0%), none of whom had neurological abnormalities other than pupillary light reflex abnormalities. A quantitative pupillometer examination revealed that the affected pupil was larger (5.67 mm vs. 3.20 mm) and had lower NPi values (0.60 vs. 3.40) than the unaffected side. These abnormalities resolved spontaneously without treatment (pupil size, 3.40 mm; NPi, 3.90). The affected pupil had a prolonged latency of 0.38 seconds (vs. 0.28 seconds), which improved to 0.30 seconds with the resolution of the anisocoria.
Conclusions
In the ICU setting, it is important to keep in mind the ipratropium bromide nebulizer as the benign cause of unilateral mydriasis. Further, an automated pupilometer may be a useful tool for evaluating unilateral mydriasis.

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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Letter to the Editor

Neurology
Implication of Neurological Pupil Index for Monitoring of Brain Edema: Tae Jung Kim, Sang-Bae Ko; Acute Crit Care. 2018;33(1):57-60. Published online February 28, 2018; DOI: https://doi.org/10.4266/acc.2017.00213

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Citations

Citations to this article as recorded by

Approaches to Consciousness Assessment in Neurocritically Ill Patients
Dong-Wan Kang, Tae Jung Kim
Journal of the Korean Neurological Association.2024; 42(2): 107. CrossRef
Isolated reversible mydriasis was associated with the use of nebulized ipratropium bromide: a case series using quantitative pupilometer in Korea
Soo-Hyun Park, Tae Jung Kim, Sang-Bae Ko
Acute and Critical Care.2024; 39(4): 593. CrossRef
Quantitative assessments of pupillary light reflexes in neurocritically ill patients
Tae Jung Kim
Journal of Neurocritical Care.2022; 15(2): 79. CrossRef
Automated Quantitative Pupillometry in the Critically Ill
Petra Opic, Stephan Rüegg, Stephan Marsch, Stephan Sebastian Gut, Raoul Sutter
Neurology.2021;[Epub] CrossRef
Neurological Pupil Index as an Indicator of Neurological Worsening in Large Hemispheric Strokes
Tae Jung Kim, Soo-Hyun Park, Hae-Bong Jeong, Eun Jin Ha, Won Sang Cho, Hyun-Seung Kang, Jung Eun Kim, Sang-Bae Ko
Neurocritical Care.2020; 33(2): 575. CrossRef
Eyeing up the injured brain: automated pupillometry and optic nerve sheath diameter
Federico Romagnosi, Filippo Bongiovanni, Mauro Oddo
Current Opinion in Critical Care.2020; 26(2): 115. CrossRef
Objective Pupillometry as an Adjunct to Prediction and Assessment for Oculomotor Nerve Injury and Recovery: Potential for Practical Applications
Salah G. Aoun, Babu G. Welch, Michaela Cortes, Sonja E. Stutzman, Matthew C. MacAllister, Tarek Y. El Ahmadieh, Mohamed Osman, Stephen A. Figueroa, Jonathan A. White, Hunt H. Batjer, Daiwai M. Olson
World Neurosurgery.2019; 121: e475. CrossRef

Case Report

Liver
Brain Oxygen Monitoring via Jugular Venous Oxygen Saturation in a Patient with Fulminant Hepatic Failure: Yerim Kim, Chi Kyung Kim, Seunguk Jung, Sang-Bae Ko; Korean J Crit Care Med. 2016;31(3):251-255. Published online August 30, 2016; DOI: https://doi.org/10.4266/kjccm.2016.00143

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Abstract PDF

Fulminant hepatic failure (FHF) is often accompanied by a myriad of neurologic complications, which are associated with high morbidity and mortality. Although appropriate neuromonitoring is recommended for early diagnosis and to minimize secondary brain injury, individuals with FHF usually have a high chance of coagulopathy, which limits the ability to use invasive neuromonitoring. Jugular bulb venous oxygen saturation (JvO₂) monitoring is well known as a surrogate direct measures of global brain oxygen use. We report the case of a patient with increased intracranial pressure due to FHF, in which JvO₂ was used for appropriate brain oxygen monitoring.

Citations

Citations to this article as recorded by

Bleeding complications associated with the molecular adsorbent recirculating system: a retrospective study
Seon Woo Yoo, Min-Jong Ki, Dal Kim, Seul Ki Kim, SeungYong Park, Hyo Jin Han, Heung Bum Lee
Acute and Critical Care.2021; 36(4): 322. CrossRef
Neurological Monitoring in Acute Liver Failure
Alexandra S. Reynolds, Benjamin Brush, Thomas D. Schiano, Kaitlin J. Reilly, Neha S. Dangayach
Hepatology.2019; 70(5): 1830. CrossRef

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