Acute and Critical Care

Volume 1 (1); September 1986

Urgency of Systemic Establishment of Critical Care Medicine: Chung Hyun Cho; Korean J Crit Care Med. ;1(1):1-3.

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A Clinical Study on the Mechanical Ventilation during Anesthesia for Thoracotomy: Seong Deok Kim, Young Cheon Won, Joe Hyun Kim; Korean J Crit Care Med. 1986;1(1):4-8.

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An Experimental Comparative Study of HFJV and System J in a Lung Model: Won Oak Kim, Jong Rae Kim, Kang Won Park; Korean J Crit Care Med. ;1(1):9-16.

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Abstract PDF: This experimental study was done to understand the functional difference and variables thought to be important in deterring CO2 elimination and arterial oxygenation during HFJV and system J (System J means that an expiratory valve is attached to the expiratory port of the double lumen tube). In an experimental lung model, a plastic tube, simulating the trachea, was intubated with a double-lumen tracheal tube. Ventilation was performed with a solenoid valve controlled high frequency ventilator. Changing the inspiratory time and driving pressure during HFJV and system J can linearly alter the tidal volume and airway pressure. There was a significant difference in airway pressure between the two modes of high frequency ventilation at I: E ratios of 1: 2 and 1: 3. With air entrainment, HFJV provided more peak flow than system J and less FiO2 with an increasing driving pressure. Some functional characteristics of two high frequency ventilatory system using double-lumen tubes in a lung model are shown in this study.

Efficacy of Sublingual Nifedipine (Adalat) in Hypertensive Emergencies: S.K. Choi, M.H. Kim, N.H. Kim, J.K. Lee, W.S. Yoo; Korean J Crit Care Med. 1986;1(1):17-21.

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Abstract PDF: The effects of sublingual were assessed in 20 patients with severe hyperten - sion in emergency room setting. Sublingual nifedipine 10mg signi6ficandy reduced the systolic and diastolic blood pressures from 15 minutes after administration in all patients. The maximal lowering effects were seen at 1 and halfhour after administration (45.3/34.4mmHg, 22% / 27%). Heart rate did not change significantly except mild in crease in 45 and 60 minutes after administration No serious unwanted effects were observed Nifedipi- ne is a simple, effective and safe alternative drug for managing hypertensive emergencies especially in general practice or amall sized emergency rooms.

Clinical Study in Fractures of the Zygoma: Jai Mann Lew, Hee Chang Ahn, Hyun Tae Shin; Korean J Crit Care Med. 1986;1(1):22-26.

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Abstract PDF: Recognition of various type of zygomatic fractures and their postreduction stability is essential for correct diagnosis and proper treatment of zygomatic fractures. We present the classification of the zygomatic fractures of 160 cases. Treated at Han Yang University Hospital for 10 years according to modified Rowe Killey Clasifica-tion; Type 1. Non-displaced fractures 16 cases(10%). Type 2. Zygomatic fractures 60 cases (37. 5%). Type 3. Rotation around vertical axis 8 cases (5%) A. Medial l case (0 6%) B. Lateral 7 cases (4.4%). Type 4. Rotation around 1ongitudinal axis 13 cases (8%) A. Medial O.B. Lateral 13 cases (8%). Type 5. Displacement without rota tion 54 cases (33.8%.) A. Medial 7 cases (4.4%). B. Lateral O.C Posterior, 31 cases (19.4%). D. Inferior 16 cases (10%). Type 6. Rim fractures 6 cases (3.8%). Type 7. Complex fractures 3 cases (1.9%). The Rowe and Killey classification is superior to the widely accepted Knight and North classification and we think it will more help to predict the postreduction stability and thus help to select the method of treatment according to the type of fracture. The zygomati fractures with rotation or displacement around a vertical or longitudinal axis. shouId be recognized before the operation and its approachs should be determined depending upon the types of fracture because postreduction stability differs considerably in the various type of zygomatic fractures.

A Study on the Educational Level of Patients and the Clinical Course of Acute Appendicitis: Jin Chul Jung, Chi Kyu Won; Korean J Crit Care Med. ;1(1):27-37.

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Abstract PDF: Acute appendicitis can be easily treated by early diagnosis and surgery. But in case with perforation resulting from the delay in diagnosis or surgery, although the mortality has been reduced markedly by the effective therapy with antibiotics and intensive pre- and postoperative management, problems including serious complications. and the proIonged hosp- ital stay with increased hospital expense occur very often. The author reviewed 360 cases of appendicitis admitted. to the Department of Surgery, Hanyang University Hospital from July 198I to June 1982 and investigated their hospital course and expenses, the patients educational background and knowledges on health. The result was as follows. 1) The incidence of the perforation of acute appendicitis was 26. 9%, resulting from the delay in diagnosis and surgery. 2) Perforation occured in 68. 1% of cases operated later than 48 hours of the appearance of symptom. 3) The rate of wrong diagnosis (rnistaking other conditions for appendicitis) was 13.8% 4) The frequency of delayed operation was 13.5% in the group of patients visited Hanyang University Hospital at first. Among those who missed the opportunity of early operation, the largest group of patients wasted time only by taking medicine purchased at drug stores 5) Average length of hospital stay of the nonperforated and perforated group were 6. 0 and. 12. 2 days respectively. 6) The overall incidence of postoperative complications of appendectomy was 16.4%; 0.5%; of the nonperforated and 46. 4% of the perforated. 7) The higher was the educational level of the patient, the lower the incidence of perfo- ration was. 8) As for the choice of medical facilities by the patient with appendicitis, the highly edu- cated group showed a tendency to visit hospital first while the majority of those having lower educational background first visited drug store. 9) The result of survey through quetionnaire(for the student of schools of various level) was somewhat different. To the question asking what kind of medical facility they should.

The Effects of Air Bubble on Damping of Arterial Pressure Waves during Monitoring of Mean Arterial Pressure: Seong Deok Kim, Kwang Woo Kim, Hee Chan Kim, Byoung Goo Min; Korean J Crit Care Med. 1986;1(1):38-45.

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Abstract PDF: By virtue of the development of monitoring system and increasing tendency of critically ilI patients, We have performed cannuIation of radia1 artery after Allen's test for the continuous monitoring of arterial pressure. It is very important to measure blood pressure accurately, so it gives us many informations in. the poor risk patients. During monitoring of blood pressure for several years, we have had much troubles because of damping of arterial pressure waves due to air bubbles. In this study, we used P23 Db pressure tranducer and Spacelab Alpha System for monitoring of blood pressure, following cannulation of radial artery. Air bubbles of 0.5 ml, 1. 0 ml, 15 mI and 2. 0 ml were inserted into m0nitoring system, i.e. fluid-filled catheter respectivey. The statistical analysis by paired student T-test showed following results. 1) Systolic blood pressure were decreased significantly from 110

Effect of Nifedipine on Coronary and Portal Flow During Vasopressin Infusion: Bo Yang Suh, Hong Jin Kim, Hee Won Ham, Sung Hoon Kim, Koing Bo Kwun; Korean J Crit Care Med. 1986;1(1):46-52.

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Abstract PDF: Vasopressin(Pitressin), when used to control gastrointestinal bleeding, has been shown to significantly reduce coronary flow. Our purpose was to determine if Nifedipine could be used to counteract Vasopressin's coronary effect. Six mongrel dogs, weighing approximately 25 kg, underwent laparotomy and left thoracotomy under Pentobarbital anesthesia. Electromagnetic flowmeter probes were used to measure blood flow in the circumflex coronary artery(CCF), the superior mesenteric artery(SVAF) and portal vein(PVFP). Portal venous pressure(PP), femoral arterial and Swan-Ganz catheters were inserted. After baseline control psrameters were recorded, Pitressin was administered at a continuous rate of 0. 04 U/kg/min. When all parameters stabilized., Nifedipine was infused at 0,3μg kg/min. Under Pitressin infusion PVP, PP, SMAF, CCF and cardiac output decreased by an average of 43.4, 73.1, 56.8, 54.8 and 59.1% respectively. When Nifedipine was added to Pitressin infusion, CCF and cardiac output increased significantly, averaging 105 and, 83.5% of control, respectively; SMAF also increased moderately to an average of 76% of control value. However, both PVF and PP remained lower than control by average of 59. 7 and 78.1% respectively. These data indicate that with Pitressin and. Nifedipine infusion PVP and PP were reduced significantly while CCF and cardiac output were preserved

Prazosin in Refractory Heart Failure a Clinical Hemodynamic Study: Hyeon Kwon, Ock Kyu Park; Korean J Crit Care Med. 1986;1(1):53-63.

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Abstract PDF: To evaluate the hemodynamic effect of prazosin in patients of chronic refratory heart failure, echocardiographic measurement of left ventricular performances was performed in 14 patients acute hemodynamic effects were evaluated around 90 minutes after the administration of prazosin(6mg) orally (Group A, 7 patients) and the chronic hemodynamic effects were evaluated after 7 days with prazosin treatment 24mg daily in four divided doses(Group B, 11 patients). End-systolic dimension of left ventricle was decreased significantly but the end-diastolic dimension was not 90 minutes after treatment. Both endsystolic and end-distolic dimensions were decreased with significance after a week of treatment. The stroke volume was increased in both groups, heart rate decreased in group B only, but neither ventricular ejection time nor cardiac output was significantly changed with praozsin treatment, Ejection fraction, fractional shortening mean rate of cirumferentia1 fiber shortening and stroke work were increased effectively after prazosin the rapy in both groups. Total peripheral resistance was measurably decreased #on#ly in group B. All but one of the study group were clinically improved usually from NYHA functional classes Ⅳ or Ⅲ to Ⅲ or Ⅱ. In so far as it concern with 5 patient, with whom we could followed linically over a 2 to 8 months' period, no discernible, tolerance to the drug was observed,

A Clinical Observation of Postoperative Adhesive Iieus: Young Jin Kim, Hak Yoon Kim; Korean J Crit Care Med. 1986;1(1):64-70.

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Abstract PDF: A clinical observation was made on 212 cases of postoperative adhesive ileus, admitted to Chonnam National University Hospital during 5 years from Jan. 1985. The results were as follows: 1) The most prevalent age group was 6th decade in cases of 64(30, 19%) and male to female ratio was 2. 5: I, 2) The most common cause of postoperative adhesive ileus was appendectomy in 78 cases (36. 79%) and followed by gastric surgery in 40 case(18,87%), small bowel surgery 32 cases (15.09%), large bowel surgery 20 cases(9. 43%), and gynecological surgery 16 cases(3.30% ) 3)The cardinal symptoms and signs were abdominal pain(79,92%),vomiting(69.81%), abdominal distension(64.02%), increased bowel sound(84.91%), abdominal tenderness(69.81%) and rebound tenderness(19, 81%). 4) The most prevalent interval from the previous operation to postoperative adhesive ileus was within 1 year. 5) As for the operative procedure of 100 cases(47. 17%), 52 cases were treated by enterolysis or band lysis, 38 cases by intestinal resection, 7 cases by intestinal bypass and 1 case by colostomy. 9) The site of obstruction was 88% in small bowel(37% in ileum) and 12% in large bowel. 7) The incidence of postoperative complication was 24 cases(24%) and most common complication was wound infection in 41.67%. 8) Overall mortality rate was 0.94% and postoperative mortality was 2%, The causes of death were sepsis with bleeding due to disseminated intravascular coagulation and renal failure.

Clinical Study of Patients with Neonatal Respiratory Distress Syndrome: Shin Ok Koh, Hung Kun Oh, Dong Kwan Han; Korean J Crit Care Med. 1986;1(1):71-81.

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Abstract PDF: Forty neonates with respiratory distress syndrome were transferred from nursery after birth to the 1CU at Severance Hospital, Yonsei Medical Complex between March 198l to July 1983 and ventilatory support was given with the pressure-cycled ventilator, Baby- log I, Bourns BP 200, in ICU. We have analysed the 40 cases according to sex, incidence, symptoms and signs, birth weight and gestation weeks and time to the ventilator support, 1CU days and mortality. The results were as follows 1) The proportion of the patients was 0.7% neonates and the overall mortality was 52 5% 2) Obstetric and delivery backgrown4 were as follows. Ceasarean section, 19 cases; pre-eclampsia, 5 cases; placenta-previa, 5 cases, spontaneous premature rupture of membrane; 4 cases, 3) The percentage and mortality of male patients was 57.5% and 57,1%, higher than famale patients. 4) All the patients showed symptoms and signs within 12 houre after birth. 5) Mortality of those cases born with less than 32 wks gestation was 15%, but above 32 wks the mortality was 35%. 6) The number of babies born with a birth weight below 2000 grams was 27 and the mortality for them was 70%. 7) The number of cases who had ventilator support begun at 10 hra, 1l-20 and 21- 30 hours after symptoms and signs developed, were 30, 5 and 5. The mortality was 53, 20 and 60% respectively for these 3 groups. 8) The number of ventilator days less than 4 days duration was 27 cases with a 70% mortality but those above 5 days was 13 cases with 16% mortality. In 1981, the number of patients with ventilator days less than 2 days was 11 cases and 2 cases used the ventilator for 7-8 days. But in 1983 the number of patients with less than 4 ventilator days was 6 cases., and 7 cases used ventilator for more than 5 days. 9) The number of patients with ICU days 1ess 5 daye was 23 cases and a morta!ity of 78% and those of 6-10 day stay was 6 cases with a mortality of 50%,. The number of patients with ICU days above 15 days was 18 and a11 survived. In 1981, 10 cases stay in the ICU for less than 5 days. Only 2 cases stayed in the ICU for 6-10 days. In 1983, 6 cases stayed in the ICU for less than 5 days, but 4 cases stayed stayed in the ICU for more than 15 days, 10) Complications were neonatal hyperbilirubinemia, pneumothorax, pneumomediastinum, sepsis, disseminated intravascuIar coagulopathy, bronchopulmonary dysplasia, and cerebraI hemorrhage. From the above results the mortality rate decreased year by year and this is attributed to the early application of ventilator support and adequate intensive care.

A Clinical Study of the Facial Bone Fractures: Jai-Mann Lew; Korean J Crit Care Med. 1986;1(1):82-91.

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Abstract PDF: The cases reported in this paper include all cases with fractures of the facial bones, admitted to the hospital during last 4 years(1972 to 1976). A total of 71 paients with facial bone fractures were admitted, The 46 caes (64.8% of total) had the mandible fractures, zygoma fractures; 16 cases, nasal bone fractures; 5 cases and maxilla; 16 cases. The incidence was 54 cases(76.1%) in male and l7 cases(23,9%) in female. The most cases of the facial bone fractures occurred in the age group of 21 to,30 years old and the most common cause was traffic accidents(59.2%) The injuried site in the mandible fractures were following. 1) The bilateral fractures were 13 cases, 1/4 cases in the left side and l8 cases in the right side. 2) The most common site was the symphsis(32,4%), the condyloid process(9.9%), 3) The multiple fractures cases were 23,9% , The 46 cases were combined other injuies, The treatment were inter-osseus wire fixation, intermaxillary fixation with arch bars and rubber bands in the almost cases, The almost patients were compctely healed within 8 weeks without complication,

Comparison of Cardiac Output Determination by Direct Fick and Thermodilution Methods in Man: B.C. Chang, E.K. Kim, C.J. Lee, B.K. Cho, S.N. Hong, P.W. Hong; Korean J Crit Care Med. ;1(1):92-98.

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Abstract PDF: Measurement of cardiac output by thermodiiution method is easy to perform and can be repeated at very short intervals and offers a number of theoretical and practical advantages. The purpose of this paper is to reevaluate the accuracy and reproducibility of the thermodilution cardiac output by comparing the results with those obtained by the direct Fick technique. From January through April, 198I (4 months), 26 simultaneous cardiac output measurements were made using thermodilution and dlreck Fick methods in 12 patients in the intensive care unit of Severance Hospital following open heart surgery. The average age of the patients was 34.8

Clinical Survey of Patients of the Intensive Care Unit in Wonju Christian Hospital: Hyon Woo Lee, Won Oak Kim, Dae Ja Um, Ryung Choi; Korean J Crit Care Med. 1986;1(1):99-104.

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Abstract PDF: The intensive care unit (ICU) of our hospital is a 12 bed multidisc1plinary ICU which is under the auspices of the Department of Anesthesiology. The ICU is essentially a respiratory ICU in which all hospital patients requiring ventilatory support are cared for. The patient population encompasses all causes of respiratory failure, medical and surgica1. Another sou- rce of referral (surgical and medical) is a large group of critically ill patients with multi- organ failure, especially due to trauma. Our experience of intensive care therapy began in the recovery room starting in 1959. Since that time the size and facilities of the ICU have been enlarged. We analyzed 4,514 ICU patients admitted between Mar. 1980 and Feb, 1984, to obtain better guidance and management in the ICU. The results of analysis are as follows: 1) Total number of patients was 4, 514; 874 patients in 1980, 832 patients in 1981, 895 patients in l982, 862 patients in 1983 and 1, 051 patients in 1984. The ratio of male to fem- ale patients was nearly 2: l. 2) Total admission time in the ICU was 17, 473 days, The average patient stay was 3. 9 days. The number of patients staying in the ICU more than 9 days increased from 54 cases(6%) in 1980 to 101 cases(10%) in 1984. 3) The forty year age group outrumbered the order age group and was 20.5%. The mortality rate of the pre-teen age group was the highest(19.7%) and the overall mortality was 14. 2% (640 cases) during these 5 years. 4) The number of patients admitted to the ICU from the Department of Neurosurgery was 1,218 (27%)being the highest among all departments. Out of 232 patients who died, the Department of Neurosurgery had the highest mortality rate, 19.1%. From the above -esults, it can be seen that the number. of patients admitted to the ICU, the mortality rate and the patients staying more than 9 days in the ICU has increased annu- ally It is claimed that more facilities allowing for monitoring and support, special qualified staffs and a co-ordinated organization will reduce the mortality rate, particularly in the pre-teen age group.

Application of Continuous Hemofiltration (CHF) to Critically Ill Surgical Patients: Kwang Bo Kwun, Hee Won Ham, Min Chul Shim, Bo Yang Suh, Sung Hoon Kim; Korean J Crit Care Med. 1986;1(1):105-111.

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Abstract PDF: Continuous hemofiltration (CHF) is an extracorporeal process in which fluid electrolytes and other lower molecular weight substances are removed from the patient by ultrafiltration over an extended period. There are several kind of small handy commercially available hemofilters. This device requires only a small amount of blood flow rate (20-70 ml/min) for effective hemofiltration so we applied CHF for various patients who needed dialysis but whose clinical condition precluded either hemodialysis or peritoneal dialysis. 8 patients were treated. 6 were extremely unstable hemodynamically (mean BP around 60mmHg) and 4 were not indicated for peritoneal dialysis because of abdominal pathologies. Angioaccess was by percutaneous needle puncture artery and venous catheterization or Scribner shunt. Average duration of CHF was 55 hours ranging 24-96 hours. Hemofiltration rate were about 3-12 ml/min. Chemical composition of filtrate was same as plasma except very low protein and protein-bound substances. Removal of urea was 5-17 Gms/24hrs. Fluid loss from CHF was replaced by volume to volume. For 4 patients with massive fluid overload volume replacement was restricted to none to I/2 of this filtrates, ln these 4 patients, average about 2,000ml/24hrs of negative fluid balances were achieved without significant hemodynamic alteration. CHF is a simple, safe and effective treatment for acute renal failure and volume overloaded patients who are not indicated for either hemodialysis or peritoneal dialysis due to their conditions.

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