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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
  • 10,248 View
  • 432 Download
  • 53 Web of Science
  • 58 Crossref
AbstractAbstract PDF
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.

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Surgery
Reducing Unnecessary Testing in the Intensive Care Unit by Choosing Wisely
Ruth M. Kleinpell, J. Christopher Farmer, Stephen M. Pastores
Acute Crit Care. 2018;33(1):1-6.   Published online February 28, 2018
DOI: https://doi.org/10.4266/acc.2018.00052
  • 16,949 View
  • 553 Download
  • 12 Web of Science
  • 13 Crossref
AbstractAbstract PDF
Overuse of laboratory and X-ray testing is common in the intensive care unit (ICU). This review highlights focused strategies for critical care clinicians as outlined by the Critical Care Societies Collaborative (CCSC) as part of the American Board of Internal Medicine Foundation’s Choosing Wisely® campaign. The campaign aims to promote the use of judicious testing and decrease unnecessary treatment measures in the ICU. The CCSC outlines five specific recommendations for reducing unnecessary testing in the ICU. First, reduce the use of daily or regular interval diagnostic testing. Second, do not transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 mg/dl. Third, do not use parenteral nutrition in adequately nourished critically ill patients within the first 7 days of ICU stay. Fourth, do not deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation. Finally, do not continue life support for patients at high risk of death without offering patients and their families the alternative of comfort focused care. A number of strategies can be used to reduce unnecessary testing in the ICU, including educational campaigns, audit and feedback, and implementing prompts in the electronic ordering system to allow only acceptable indications when ordering routine testing. Greater awareness of the lack of outcome benefit and associated costs can prompt clinicians to be more mindful of ordering tests and procedures in order to reduce unnecessary testing in the ICU.

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Pulmonary
Patient-Ventilator Dyssynchrony
Elvira-Markela Antonogiannaki, Dimitris Georgopoulos, Evangelia Akoumianaki
Korean J Crit Care Med. 2017;32(4):307-322.   Published online November 30, 2017
DOI: https://doi.org/10.4266/kjccm.2017.00535
  • 33,401 View
  • 2,050 Download
  • 12 Web of Science
  • 10 Crossref
AbstractAbstract PDF
In mechanically ventilated patients, assisted mechanical ventilation (MV) is employed early, following the acute phase of critical illness, in order to eliminate the detrimental effects of controlled MV, most notably the development of ventilator-induced diaphragmatic dysfunction. Nevertheless, the benefits of assisted MV are often counteracted by the development of patient-ventilator dyssynchrony. Patient-ventilator dyssynchrony occurs when either the initiation and/or termination of mechanical breath is not in time agreement with the initiation and termination of neural inspiration, respectively, or if the magnitude of mechanical assist does not respond to the patient’s respiratory demand. As patient-ventilator dyssynchrony has been associated with several adverse effects and can adversely influence patient outcome, every effort should be made to recognize and correct this occurrence at bedside. To detect patient-ventilator dyssynchronies, the physician should assess patient comfort and carefully inspect the pressure- and flow-time waveforms, available on the ventilator screen of all modern ventilators. Modern ventilators offer several modifiable settings to improve patient-ventilator interaction. New proportional modes of ventilation are also very helpful in improving patient-ventilator interaction.

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Basic science and research
The Role of Oliguria and the Absence of Fluid Administration and Balance Information in Illness Severity Scores
Neil J. Glassford, Rinaldo Bellomo
Korean J Crit Care Med. 2017;32(2):106-123.   Published online May 31, 2017
DOI: https://doi.org/10.4266/kjccm.2017.00192
  • 13,110 View
  • 319 Download
  • 4 Web of Science
  • 4 Crossref
AbstractAbstract PDF
Urinary examination has formed part of patient assessment since the earliest days of medicine. Current definitions of oliguria are essentially arbitrary, but duration and intensity of oliguria have been associated with an increased risk of mortality, and this risk is not completely attributable to the development of concomitant acute kidney injury (AKI) as defined by changes in serum creatinine concentration. The increased risk of death associated with the development of AKI itself may be modified by directly or indirectly by progressive fluid accumulation, due to reduced elimination and increased fluid administration. None of the currently extant major illness severity scoring systems or outcome prediction models use modern definitions of AKI or oliguria, or any values representative of fluid volumes variables. Even if a direct relationship with mortality is not observed, then it is possible that fluid balance or fluid volume variables mediate the relationship between illness severity and mortality in the renal and respiratory physiological domains. Fluid administration and fluid balance may then be an important, easily modifiable therapeutic target for future investigation. These relationships require exploration in large datasets before being prospectively validated in groups of critically ill patients from differing jurisdictions to improve prognostication and mortality prediction.

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    Neil J. Glassford, Rinaldo Bellomo
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Status Epilepticus and Beyond: A Clinical Review of Status Epilepticus and an Update on Current Management Strategies in Super-refractory Status Epilepticus
Roy Poblete, Gene Sung
Korean J Crit Care Med. 2017;32(2):89-105.   Published online May 31, 2017
DOI: https://doi.org/10.4266/kjccm.2017.00252
  • 23,885 View
  • 1,979 Download
  • 3 Web of Science
  • 6 Crossref
AbstractAbstract PDF
Status epilepticus and refractory status epilepticus represent some of the most complex conditions encountered in the neurological intensive care unit. Challenges in management are common as treatment options become limited and prolonged hospital courses are accompanied by complications and worsening patient outcomes. Antiepileptic drug treatments have become increasingly complex. Rational polytherapy should consider the pharmacodynamics and kinetics of medications. When seizures cannot be controlled with medical therapy, alternative treatments, including early surgical evaluation can be considered; however, evidence is limited. This review provides a brief overview of status epilepticus, and a recent update on the management of refractory status epilepticus based on evidence from the literature, evidence-based guidelines, and experiences at our institution.

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Cardiology
Blood Transfusion Strategies in Patients Undergoing Extracorporeal Membrane Oxygenation
Hyoung Soo Kim, Sunghoon Park
Korean J Crit Care Med. 2017;32(1):22-28.   Published online February 28, 2017
DOI: https://doi.org/10.4266/kjccm.2016.00983
  • 20,073 View
  • 694 Download
  • 14 Web of Science
  • 13 Crossref
AbstractAbstract PDF
Extracorporeal membrane oxygenation (ECMO) is frequently associated with bleeding and coagulopathy complications, which may lead to the need for transfusion of multiple blood products. However, blood transfusions are known to increase morbidity and mortality, as well as hospital cost, in critically ill patients. In current practice, patients on ECMO receive a transfusion, on average, of 1-5 packed red blood cells (RBCs)/day, with platelet transfusion accounting for the largest portion of transfusion volume. Generally, adult patients require more transfusions than neonates or children, and patients receiving venovenous ECMO for respiratory failure tend to need smaller transfusion volumes compared to those receiving venoarterial ECMO for cardiac failure. Observation studies have reported that a higher transfusion volume was associated with increased mortality. To date, the evidence for transfusion in patients undergoing ECMO is limited; most knowledge on transfusion strategies was extrapolated from studies in critically ill patients. However, current data support a restrictive blood transfusion strategy for ECMO patients, and a low transfusion trigger seems to be safe and reasonable.

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    Frantzeska G. Frantzeskaki, Stavros Dimopoulos, Dimitrios Konstantonis, Pelagia Katsibri, Kostantinos Kostopanagiotou, Maria Theodorakopoulou, Chrysi Diakaki, Dimitrios Dougenis, Dimitrios Boumpas, Andreas Karabinis, Apostolos Armaganidis, Iraklis Tsangar
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Surgery
Management of Critical Burn Injuries: Recent Developments
David J. Dries, John J. Marini
Korean J Crit Care Med. 2017;32(1):9-21.   Published online February 17, 2017
DOI: https://doi.org/10.4266/kjccm.2016.00969
  • 25,699 View
  • 1,548 Download
  • 8 Web of Science
  • 4 Crossref
AbstractAbstract PDF
Background
Burn injury and its subsequent multisystem effects are commonly encountered by acute care practitioners. Resuscitation is the major component of initial burn care and must be managed to restore and preserve vital organ function. Later complications of burn injury are dominated by infection. Burn centers are often called to manage problems related to thermal injury, including lightning and electrical injuries.
Methods
A selected review is provided of key management concepts as well as of recent reports published by the American Burn Association.
Results
The burn-injured patient is easily and frequently over resuscitated, with ensuing complications that include delayed wound healing and respiratory compromise. A feedback protocol designed to limit the occurrence of excessive resuscitation has been proposed, but no new “gold standard” for resuscitation has replaced the venerated Parkland formula. While new medical therapies have been proposed for patients sustaining inhalation injury, a paradigm-shifting standard of medical therapy has not emerged. Renal failure as a specific contributor to adverse outcome in burns has been reinforced by recent data. Of special problems addressed in burn centers, electrical injuries pose multisystem physiologic challenges and do not fit typical scoring systems.
Conclusion
Recent reports emphasize the dangers of over resuscitation in the setting of burn injury. No new medical therapy for inhalation injury has been generally adopted, but new standards for description of burn-related infections have been presented. The value of the burn center in care of the problems of electrical exposure, both manmade and natural, is demonstrated in recent reports.

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Pulmonary
Lung Ultrasound (in the Critically Ill) Superior to CT: the Example of Lung Sliding
Daniel A. Lichtenstein
Korean J Crit Care Med. 2017;32(1):1-8.   Published online February 14, 2017
DOI: https://doi.org/10.4266/kjccm.2016.00955
  • 18,241 View
  • 858 Download
  • 11 Web of Science
  • 13 Crossref
AbstractAbstract PDF
This review article shows the potential of lung ultrasound in the critically ill (LUCI) to study lung sliding and describes the optimal equipment for its assessment. Then, it analyses the integration of lung sliding within lung ultrasound then whole body critical ultrasound. It describes the place of lung sliding in the BLUE-protocol (bedside lung ultrasound in emergency) (lung and venous ultrasound for diagnosing acute respiratory failure), the FALLS-protocol (fluid administration limited by lung sonography) (the role of lung sliding in circulatory failure), and the SESAME-protocol (sequential assessment of sonography assessing mechanism or origin of severe shock of indistinct cause) (whole body ultrasound in cardiac arrest). In the LUCIFLR project (LUCI favoring limitation of radiations), the consideration of lung sliding allows drastic reduction in irradiation and costs. In conclusion, lung sliding is proposed as a gold standard for indicating the presence of the lung at the chest wall and its correct expansion.

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Cardiology/Surgery/Basic science and research
The Complexities of Intravenous Fluid Research: Questions of Scale, Volume, and Accumulation
Neil J Glassford, Rinaldo Bellomo
Korean J Crit Care Med. 2016;31(4):276-299.   Published online November 30, 2016
DOI: https://doi.org/10.4266/kjccm.2016.00934
  • 19,027 View
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  • 14 Crossref
AbstractAbstract PDF
Despite near ubiquity, information regarding fluids consumption at a health care systems level, and patient exposure at an individual level, is surprisingly limited in the medical literature. The epidemiology of the foundational medical intervention of intravenous fluid administration is incredibly complex, with millions of patients being exposed internationally every year. Fluid is being given for different reasons, to different targets, following different triggers, by different specialties in different countries, and any observations that can be made are thought to have limited external validity to other jurisdictions and patient groups. The independent effects of fluid administration and fluid accumulation are very hard to separate from other markers of illness severity and aspects of the process of care. Fluid accumulation can result in organ injury, even when the fluid is being given to purportedly ameliorate or prevent such injury, and if it were independently associated with mortality then would be an easily accessible and modifiable risk factor for subsequent morbidity or death. Despite their ubiquity, it is clear that we have limited understanding of the effects of the intravenous fluids we use daily in the most vulnerable of patient groups. The research agenda in this field is large and urgent.

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    Elham Estiri, Hossein Mirinejad
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Cardiology/Infection
How Do I Integrate Hemodynamic Variables When Managing Septic Shock?
Olfa Hamzaoui, Jean-Louis Teboul
Korean J Crit Care Med. 2016;31(4):265-275.   Published online November 30, 2016
DOI: https://doi.org/10.4266/kjccm.2016.00927
  • 17,941 View
  • 1,151 Download
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AbstractAbstract PDF
Hemodynamic management of sepsis-induced circulatory failure is complex since this pathological state includes multiple cardiovascular derangements that can vary from patient to patient according to the degree of hypovolemia, of vascular tone depression, of myocardial depression and of microvascular dysfunction. The treatment of the sepsis-induced circulatory failure is thus not univocal and should be adapted on an individual basis. As physical examination is insufficient to obtain a comprehensive picture of the hemodynamic status, numerous hemodynamic variables more or less invasively collected, have been proposed to well assess the severity of each component of the circulatory failure and to monitor the response to therapy. In this article, we first describe the hemodynamic variables, which are the most relevant to be used, emphasizing on their physiological meaning, their validation and their limitations in patients with septic shock. We then proposed a general approach for managing patients with septic shock by describing the logical steps that need to be followed in order to select and deliver the most appropriate therapies. This therapeutic approach is essentially based on knowledge of physiology, of pathophysiology of sepsis, and of published data from clinical studies that addressed the issue of hemodynamic management of septic shock.

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  • Enhancement in Performance of Septic Shock Prediction Using National Early Warning Score, Initial Triage Information, and Machine Learning Analysis
    Hyoungju Yun, Jeong Ho Park, Dong Hyun Choi, Sang Do Shin, Myoung-jin Jang, Hyoun-Joong Kong, Suk Wha Kim
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Policy
The ABCDEF Implementation Bundle
Annachiara Marra, Kwame Frimpong, E. Wesley Ely
Korean J Crit Care Med. 2016;31(3):181-193.   Published online August 30, 2016
DOI: https://doi.org/10.4266/kjccm.2016.00682
  • 33,184 View
  • 1,408 Download
  • 4 Crossref
AbstractAbstract PDF
Long-term morbidity, long-term cognitive impairment and hospitalization-associated disability are common occurrence in the survivors of critical illness, with significant consequences for patients and for the caregivers. The ABCDEF bundle represents an evidence-based guide for clinicians to approach the organizational changes needed for optimizing ICU patient recovery and outcomes. The ABCDEF bundle includes: Assess, Prevent, and Manage Pain, Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT), Choice of analgesia and sedation, Delirium: Assess, Prevent, and Manage, Early mobility and Exercise, and Family engagement. The purpose of this review is to describe the core features of the ABCDEF bundle.

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Pulmonary
Lung Ultrasound in Critically Ill Patients
Jinwoo Lee
Korean J Crit Care Med. 2016;31(1):4-9.   Published online February 29, 2016
DOI: https://doi.org/10.4266/kjccm.2016.31.1.4
  • 10,823 View
  • 409 Download
  • 3 Crossref
AbstractAbstract PDF
Lung ultrasound (LUS) is an emerging tool for intensivists to diagnose and monitor thoracic diseases of critically ill patients. It is easily applied at the bedside in real time and is free of radiation hazards. In the intensive care units (ICUs) lung ultrasound can be used to diagnose pneumothorax and interstitial syndrome. It can also be used to monitor changes in the lung. However, the major limitations of LUS is that it is highly operator dependent and cannot be applied in patients with thoracic dressings, subcutaenous emphysema or pleural calcifications. This article reviews the basic principles of lung ultrasound and discusses how it can be used in ICUs.

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Neurosurgery
Therapeutic Hypothermia in Traumatic Brain injury; Review of History, Pathophysiology and Current Studies
Do-Keun Kim, Dong-Keun Hyun
Korean J Crit Care Med. 2015;30(3):143-150.   Published online August 31, 2015
DOI: https://doi.org/10.4266/kjccm.2015.30.3.143
  • 8,657 View
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AbstractAbstract PDF
The fact that therapeutic hypothermia (TH) has lowered intracranial pressure and protected brain in severe traumatic brain injury (TBI) is well known throughout past sources and experimental data. In this paper, the result of TH in TBI needs to be confirmed. The result of North American Brain Injury Study; Hypothermia (NAVIS-H) 1 and 2, Eurotherm3235, Japan trauma society study was reviewed throughout randomized controlled study which performed recently. The prognosis was not confirmed throughout TH in NAVIS-H1; however, there was statistical significance among the group of 45 years or less and below 35 degree in celcius which checked when he or she visited initially. Hence, NAVIS-H2 study was preceded. In patient who had surgically removed hematoma, the effects of TH were proved compared to diffuse brain damage in NAVIS-H2 study. This was found in the result of Japan neurotrauma data bank. Eurotherm study has been doing, which leads to collect many data later on. The TBI of TH makes them better prognosis in patients who had surgically removed hematoma and lowered initial body temperature. Later on, it is considered further study is necessary.
Psychology/Neurology
Intensive Care Unit Delirium
Yongsuk Kim, Sung Jin Hong
Korean J Crit Care Med. 2015;30(2):63-72.   Published online May 31, 2015
DOI: https://doi.org/10.4266/kjccm.2015.30.2.63
  • 8,638 View
  • 288 Download
AbstractAbstract PDF
Delirium is described as a manifestation of acute brain injury and recognized as one of the most common complications in intensive care unit (ICU) patients. Although the causes of delirium vary widely among patients, delirium increases the risk of longer ICU and hospital length of stay, death, cost of care, and post-ICU cognitive impairment. Prevention and early detection are therefore crucial. However, the clinical approach toward delirium is not sufficiently aggressive, despite the condition’s high incidence and prevalence in the ICU setting. While the underlying pathophysiology of delirium is not fully understood, many risk factors have been suggested. As a way to improve delirium-related clinical outcome, high-risk patients can be identified. A valid and reliable bedside screening tool is also needed to detect the symptoms of delirium early. Delirium is commonly treated with medications, and haloperidol and atypical antipsychotics are commonly used as standard treatment options for ICU patients although their efficacy and safety have not been established. The approaches for the treatment of delirium should focus on identifying the underlying causes and reducing modifiable risk factors to promote early mobilization.
Policy
How to Enhance Critical Care in Korea: Challenges and Vision
Younsuck Koh
Korean J Crit Care Med. 2014;29(4):246-249.   Published online November 30, 2014
DOI: https://doi.org/10.4266/kjccm.2014.29.4.246
  • 4,153 View
  • 68 Download
  • 2 Crossref
AbstractAbstract PDF
The goal of critical care is to reverse patients' acute problems in effective and ethical ways with minimum costs. Unlike in other medical fields, the quality of Korean critical care has lagged behind that of advanced countries. Moreover, the level of critical care quality differs significantly between university hospitals. The suboptimal critical care level has multifactorial causes. The major challenge to Korean intensivists is, therefore, how to overcome barriers in the current critical care delivery system to improve outcomes for critically ill patients and reduce medical errors in error-prone Intensive Care Unit (ICUs). A long-term task force including all stakeholders should address the multifactorial barriers to better outcomes. The Korean Society of Critical Care Medicine should perform the central role to dismantle the barriers step by step with a long-term vision for a desirable critical care delivery system in our society. A capable critical care team with full-time intensivists is the most urgent requirement for proper, timely care in ICUs. Intensivists should focus on basic but essential management so scarcity of resources can be minimized. Publicity about ICU to the general public is also urgently required to draw the attention of medical policy makers to the current suboptimal level of our critical care system.

Citations

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  • Mortality among adult patients with sepsis and septic shock in Korea: a systematic review and meta-analysis
    Myeong Namgung, Chiwon Ahn, Yeonkyung Park, Il-Youp Kwak, Jungguk Lee, Moonho Won
    Clinical and Experimental Emergency Medicine.2023; 10(2): 157.     CrossRef
  • Major Obstacles to Implement a Full-Time Intensivist in Korean Adult ICUs: a Questionnaire Survey
    Jun Wan Lee, Jae Young Moon, Seok Wha Youn, Yong Sup Shin, Sang Il Park, Dong Chan Kim, Younsuk Koh
    Korean Journal of Critical Care Medicine.2016; 31(2): 111.     CrossRef

ACC : Acute and Critical Care