Acute and Critical Care

Volume 20 (1); June 2005

Review

Evaluation and Management of Perioperative Hypertension: Keon Hee Ryu; Korean J Crit Care Med. 2005;20(1):1-13.

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Abstract PDF: No abstract available.

Original Articles

Effects of Amrinone and Dobutamine on Regional Myocardial Function and Oxygen Balance in Normal and Stunned Myocardium in Dogs: Jun Suh Park, Jong Eun Park, Sung Tae Jeong, Seongwook Jeong, Sung Su Chung, Kyung Yeon Yoo; Korean J Crit Care Med. 2005;20(1):14-23.

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Abstract PDF: BACKGROUND
We examined the effects of amrinone and dobutamine on regional mechanical function, coronary blood flow (CBF), and myocardial oxygen consumption (MVO2) in normal and stunned myocardium in an open-chest canine model.
METHODS
Dogs were instrumented to measure aortic and left ventricular pressures, pulmonary and left anterior descending (LAD) coronary blood flows, and subendocardial segment length in the region supplied by LAD. Incremental doses of either amrinone (2~10microgram/ml of LAD flow, n=13) or dobutamine (0.05~0.375microgram/ml of LAD flow, n=14) were directly infused into a coronary artery before (normal) and after a 15 min of LAD occlusion and subsequent 30 min-reperfusion (stunned). Percent segment shortening (%SS) and percent post-systolic shortening (%PSS) were evaluated. Myocardial extraction of oxygen (EO2) and lactate (Elac) was calculated. RESULTS: Amrinone or dobutamine in the normal myocardium caused dose-dependent increases in %SS that were comparable (range, 20~40%) but had no effect on %PSS. MVO2 increased in parallel with %SS for both amrinone and dobutamine. With amrinone, CBF increased more than MVO2, resulting in a modest decrease in EO2, whereas with dobutamine, CBF increased in proportion to MVO2, resulting in no change in EO2. After the ischemia and reperfusion, %SS and Elac were reduced, but similar %SS and CBF responses to both agents were observed, except that both agents caused progressive reductions of %PSS. CONCLUSIONS: These results indicate that both amrinone and dobutamine exert positive inotropic effects in normal and stunned canine myocardium. It is also indicated that amrinone causes direct coronary vasodilation, which is not affected by ischemia and reperfusion, while dobutamine has no direct effect on coronary vascular tone in either normal or stunned myocardium.

The Effects of Intrathecal Ketamine and NBQX on Neurologic Injury and Spinal Cord Glutamate Receptor mRNA Expression in Transient Spinal Ischemia in the Rat: Seung Hoon Baek, Jung Min Hong, Kyoo Sub Chung; Korean J Crit Care Med. 2005;20(1):24-31.

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Abstract PDF: BACKGROUND
Spinal cord injury occurring as the result of surgical repair of thoracic and thoracoabdominal aortic disease remains a devastating complication. Excitatory amino acids have been known to cause neurologic injury after neuronal ischemia. The purpose of this study was to elucidate the effects of intrathecal ketamine or NBQX on neurologic outcome and NMDA receptor gene expression in transient spinal ischemia. METHODS: Sprague-Dawley rats were anesthetized with enflurane, divided by 4 groups: Control (C group), Intrathecal ketamine 0.1 mg (K-1 group), Intrathecal ketamine 0.2 mg (K-2 group), and intrathecal NBQX 1 nM (N group). Spinal ischemia was produced by both induced hypotension and thoracic aortic cross clamping. After spinal ischemia, neurologic scores were assessed after 1, 2, 3 hours. After 3 hours rats were euthenized and spinal cords were removed for the assay of NMDAR and mGlu1 mRNA. RESULTS: The neurol ogic scores of K-2 and N groups were significantly lower than C group and K-1 group. There were no significant difference between K-1 group and C group. The NMDAR and mGlu1 gene expression was increase in C and K-1 group compared to sham operation. In K-2 and N groups, the gene expressions were significantly lesser than C group.
CONCLUSIONS
The NMDAR and mGlu1 gene expressions were increased in transient spinal ischemia. Intrathecal ketamine and NBQX were effective in preventing neurologic injury after transient spinal ischemia. The NMDA antagonistic action of ketamine might involve to prevent neurologic injury.

Five-year Clinical follow-up after Revascularization for Chronic Total Coronary Artery Occlusion: Woo Seok Park, Myung Ho Jeong, Eun Suk Shin, Ju Hyup Yum, Seung Hyun Lee, Young Joon Hong, Ock Young Park, Ju Han Kim, Weon Kim, Young Keun Ahn, Jeong Gwan Cho, Jong Chun Park, Jung Chaee Kang; Korean J Crit Care Med. 2005;20(1):32-37.

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Abstract PDF: BACKGROUND
Chronic total occlusion (CTO) has been considered as an unsuitable lesion for percutaneous coronary intervention (PCI) because of technical difficulty and low success rate. Owing to technical advances and increased operator's experience, PCI has been attempted in a large number of patients with CTO in recent years, but there are few long-term follow-up reports for PCI to CTO. METHODS: We analyzed 83 patients (59.7+/-9.2 years, 28 female) with CTO on diagnostic coronary angiogram at the Heart Center and Coronary Care Unit of Chonnam National Hospital from January 1996 to July 1997. The patients were divided into two groups according to revascularization by PCI or CABG (coronary artery bypass graft): the revascularized group (received PCI or CABG, Group I) and non-revascularized group (Group II).
RESULTS
PCI was tried in 46 patients and successful in 33 patients (71.7% of the success rate). Eleven patients (13.3%) were treated with the coronary artery bypass graft (CABG) and 31 (37.3%) patients were medically treated. During 5-year clinical follow-up 11 patients died [13.1%; cardiac death 6 (7.1%), non-cardiac death 5 (6.0%)] and the major adverse cardiac events occurred to 24 (28.6%) patients. Cardiac death occurred to one patient of the Group I and 5 patients of Group II (p=0.06). The mean survival time was significantly different (57.8+/-9.2 months in Group I and 50.9+/-19.5 months in Group II, p=0.038). CONCLUSIONS: Revascularization for CTO prolonged the mean survival time of the patients on long- term clinical follow-up.

Clinical Findings of Critical Illness Polyneuropathy in Patients with Mechanical Ventilator Treatment: Sung Soon Lee, Jae Yong Chin, Chae Man Lim, Younsuck Koh; Korean J Crit Care Med. 2005;20(1):38-43.

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Abstract PDF: BACKGROUND
Critical illness polyneuropathy (CIP) is a primary distal axonal degeneration of motor and sensory fibers leading to severe limb weakness and difficulty in weaning from ventilator in critically ill patients. The object of this study is to evaluate the clinical findings of CIP and the risk factors associated with CIP development in patients with mechanical ventilator treatment. METHODS: We examined 40 patients, between March 2002 to February 2003, who manifested muscular weakness and received mechanical ventilation (MV) more than three days, prospectively. Nerve conduction velocity (NCV) and electromyography (EMG) were performed in all patients in the ICU. We examined the use of drugs (neuromuscular blocking agents, corticosteroid, and aminoglycoside), duration of MV and weaning, and APACHE II score. RESULTS: We observed 40 patients who showed muscular weakness, 9 patients were diagnosed as CIP. NCV study demonstrated decreased action potential amplitude, predominantly in motor nerve, distal part. There was no significant difference in duration of MV and weaning, drug use, APACHE II score between the groups with CIP and without CIP. CONCLUSIONS: CIP is an important neuromuscular complication of the patients in ICU. We should consider the possibility of the development of CIP in patients who showed muscular weakness and difficult weaning in critically ill patients.

The Effect of Epidural Block on Renal Function in Patients Undergoing Subtotal Gastrectomy with General Anesthesia: Moon Seok Chang; Korean J Crit Care Med. 2005;20(1):44-48.

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Abstract PDF: BACKGROUND
Epidural block is widly used for anesthesia or analgesia, so many researches has been done in the field of cardiovascular system. And we reported the effects of epidural block on renal function in patients undergoing total abdominal hysterectomy with general anesthesia. In this research I evaluated the effect of epidural anesthesia on renal function in patients undergoing subtotal gastrectomy with general anesthesia. The earlier was in lumbar level and the later was in thoracic level. METHODS: We studied 15 patient who were in ASA 1 or 2. The epidural catheter was inserted via 17 gauge Tuohy needle through the T10-T11 intervertebral space of the patients before general anesthesia. Anesthesia for all the patients were maintained with isoflurane, nitrous oxide and oxygen. We measured urine output and hemodynamic profiles such as mean arterial pressure, pulse, CVP, cardiac output during 2 hours of general anesthesia period. And then we injected 10ml of 0.15% bupivacaine to the epidural space and measured the same parameters as those of general anesthesia period during another 2 hours of epidural anesthesia combined with general anesthesia. We also compared urine output and renal function (creatinine clearance, Na clearance, fractional excretion of Na and free water clearance) between each of the two periods. RESULTS: Mean arterial pressure and pulse were lower after epidural injection than before (p<0.05), but Cardiac output and CVP were not significantly different between two periods. Renal function data were not significantly different between the two periods.
CONCLUSIONS
Renal function was maintained during sympathetic block by thoracic epidural anesthesia combined with general anesthesia.

Energy Deficiency Aggravates Clinical Outcomes of Critically Ill Patients: Hye Kyung Chung, Song Mi Lee, Jae Hoon Lee, Cheung Soo Shin; Korean J Crit Care Med. 2005;20(1):49-53.

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Abstract PDF: BACKGROUND
Adequate nutrition support reduces infectious complications, mortality and length of hospitalizationin intensive care unit. However, there are multi factors like frequent null per os (NPO) due to examination, intolerance to tube feeding, complication of TPN (total parenteral nutrition) and ineffective recognition by medical staff. The purpose of this study is to identify detrimental effects of cumulative energy deficiency in critically ill patients.
METHODS
The patients who were received tube feeding or total parenteral nutrition for more than 5 days were investigated. Daily and cumulative energy deficiency was tabulated until oral intake was achieved or until they discharged or died. Patients were divided into two groups, severe energy deficient group (>10, 000 kcal) or mild energy deficient group (<5, 000 kcal). Then we compared clinical outcomes between two groups. RESULTS: Total 150 patients were studied. 48 (32%) patients were severe energy deficient group and 42 (28%) patients were mild energy deficient group. Mortality and nosocomial infection were significantly higher in severe energy deficient group than in mild group. Hospital day and ICU day were significantly higher in severe energy deficient group than in mild group. CONCLUSIONS: Severe energy deficiency was very common in critically ill patients and it deteriorated the clinical outcomes such as mortality, nosocomial infection, hospital day and ICU day.

Clinical Characteristics in Patients with Vancomycin-Resistant Enterococci Colonization or Infection during 5 years in a Private General Hospital: Jin Kyung Kim, Cheol Hong Kim, Seung Yong Han, Hyeon Woo Byun, Woo Jung Park, Heung Jeong Woo, In Gyu Hyun, Jae Jung Lee, Kyu Man Lee; Korean J Crit Care Med. 2005;20(1):54-62.

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Abstract PDF: BACKGROUND
Vancomycin-resistant enterococci (VRE) is increasing rapidly through the world and is now a major cause of nosocomial infection. The transmission dynamics and factors contributing their dissemination are complex. We conducted a study to investigate clinical characteristics in patients with VRE colonization or infection during recent 5 years. METHODS: 154 cases that had the VRE infection or colonization from January 1, 2000 to April, 2004, were reviewed. We analyzed the risk factors of VRE infection and colonization and also compared various parameters contributing their dissemination between burn and non-burn patients with VRE. RESULTS: Total 212 strains of VRE were isolated from 154 patients. Of 212 strains of VRE, Enterococcus faecium (178 strains, 83.9%) were most common and followed by E. casseliflavus (28 strains, 13.2%), E. faecalis (5 strains, 2.4%) and E. gallinaum (1 strains, 0.5%). The most common place of VRE isolation was in burn intensive care unit (ICU), 95 cases (61.7%); 27 cases (17.5%) in general wards; 17 cases (11.0%) in surgical ICU; 15 cases (9.7%) in medical ICU. Compared with patients with VRE colonization, patients with VRE infection had older age, higher APACHE II scores and high death rate significantly. Then, VRE colonization were more common in burn patients while VRE infection were more common in non-burn patients.
CONCLUSIONS
The findings from this study suggest that VRE infection are not uncommon among hospitalized patients. More strict infection control, close surveillance and judicious use of antibiotics may be warranted to prevent infection and transmission of VRE.

Relationship between Change of RBC Shape and Multi-organ Failure in Sepsis: Ho Cheol Kim, Yoo Ji Cho, Hwi Jong Kim, Jong Deok Lee, Young Sil Hwang, Me Ae Kim; Korean J Crit Care Med. 2005;20(1):63-67.

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Abstract PDF: BACKGROUND
Microcirculatory derangement in sepsis plays a crucial role in the impairment of tissue oxygenation that can lead to multi-organ failure and death. The change of RBC rheology in sepsis has been known to be important factors in microcirculatory derangement. Several studies have demonstrated that RBCs have decreased deformability in sepsis. We investigated the relationship between multi-organ failure and spherical index of RBC estimated by flow cytometer in critically ill patients with or without sepsis compared with the relationship in healthy volunteers.
METHODS
Fourteen non-septic critically ill patients, 18 septic patients and 10 healthy volunteers were evaluated. We obtained peripheral venous blood from each patient and analyzed the change of RBC shape using flow cytometer (Becton Dickinson FACSCalibur) within 90 minute. The change of RBC shape was accessed with spherical index (M2/M1). A decrease in M2/M1 was correlated with the sphericity of the RBC and considered to have a lower capacity to alter their shape when placed in microcirculation. Multi-organ failure was accessed with sequential organ failure assessment (SOFA) score. RESULTS: The M2/M1 ratio of healthy volunteers, non-septic patients and septic patients were 2.25+/-0.08, 2.16+/-0.39 and 2.05+/-0.53, respectively. But, there was no significant difference between each group (p>0.05). And, there was no significant correlation between M2/M1 ratio of septic and non- septic patients and SOFA score (p>0.05, r2= -0.13). CONCLUSIONS: In our study, the spherical index of RBC was not associated with multi-organ failure in sepsis. But, further studies may be needed to evaluate the role of RBC rheology in sepsis.

Analysis of Cases Requested to the Ethics Committee of an University Hospital for the Discontinuation of Therapy: Jeong Min Kang, Younsuck Koh; Korean J Crit Care Med. 2005;20(1):68-75.

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Abstract PDF: BACKGROUND
A hospital ethics committee (HEC) handles ethics problems in a hospital and mediates conflicts between patients and caregivers. The role of HEC on treatment withdrawal has increased after Boramae-hospital's case on 1997 in Korea. This study is an analysis of cases referred to the HEC of Asan Medical Center for the discontinuation of patient therapy. METHODS: The conference records of the HEC from January 1998 to December 2003 and the relevant patient charts were reviewed retrospectively. RESULTS: Twenty-seven cases related to treatment withdrawal were referred to the HEC during the study period. Based on the number of admitted ICU patients during the study period, the case request rate was 0.05%. The bimodal distribution of the cases in terms of age was neonate, 13 (48%); infant, 6 (22%); adult, 8 (30%). The major causes of treatment withdrawal were futile management, financial difficulty and patient suffering. The HEC recommended the continuation of treatment in 7 cases (25.9%); treatment withdrawal in 11 (40.7%); treatment withholding in 8 (29.6%); transfer to another hospital in one case (3.8%). Of the seven recommendations for treatment continuation, only three were accepted by their families. These three patients were eventually discharged alive. Treatment was withdrawn within one week in all eleven cases recommended for that by the HEC. Treatment was withheld in seven of those eight such recommended cases. CONCLUSIONS: The case referral rate was low in the studied hospital. In all cases, the patients' families requested the case to the HEC. Although the committee's recommendations to withhold or withdraw the treatment were followed by the families, the recommendation to continue therapy was often refused.

Electrolyte and Gas Analysis from Dorsal Vein of Hand during General Inhalational Anesthesia: Keon Kang, Se Hun Park, Chul Ho Shin, Soon Eun Park, Young Min Kim, Dae Woo Kim, Young Woo Cho; Korean J Crit Care Med. 2005;20(1):76-81.

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Abstract PDF: BACKGROUND
To assess the acid-base status and to measure PO2 and PCO2, arterial blood gases (ABG) has been checked usually. We compared the venous blood gases (VBG) from dorsal vein of hand to ABG from radial artery, and tried to determine whether venous blood gas analysis (VBGA) could be the alternative of ABGA. METHODS: Thirty patients who needed continuous arterial pressure monitoring were chosen. At the completion of stability of HR and BP after induction of general inhalational anesthesia, the ABG from radial artery and VBG from dorsal vein of hand were compared. RESULTS: Laboratory findings were as follows (mean+/-SD): arterial pH, 7.44+/-0.04; venous pH, 7.43+/-0.04; arterial HCO3-, 25.56+/-2.39 mmol/L; venous HCO3-, 25.51+/-2.09 mmol/L. The mean values of arterial and venous PO2 were significantly different (247.8+/-48.9 mmHg versus 187.8+/-41.6 mmHg), but the arterial and venous PO2 values were significantly correlated (r=0.706). The PCO2 (r= 0.883), pH (r=0.912), and HCO3- (r=0.901) values, and base excesses of arterial and venous blood (r=0.926) were highly correlated. Also, arterial and venous serum electrolyte (sodium, potassium, and calcium) were highly correlated. CONCLUSIONS: Venous blood gas analysis from dorsal vein of hand can be effectively used as the alternative method to evaluate the acid-base status, PO2, and PCO2, instead of ABGA during general inhalational anesthesia.

Case Reports

Acute Pulmonary Edema following Failed Intubation: A Case Report: Youn Jung Park, Dong Hee Woo, Rim Soo Won, Young Ryong Choi, Mi Hwa Chung; Korean J Crit Care Med. 2005;20(1):82-86.

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Abstract PDF: Pulmonary edema that follows upper airway obstruction may occur in a variety of clinical situations. Post anesthetic laryngospasm has been implicated as the most frequent cause of this syndrome. Risk factors for development of post laryngospasm pulmonary edema include difficult intubation; nasal, oral, or pharyngeal surgical site; and obesity with obstructive apnea. We report a case that developed acute bilateral pulmonary edema after laryngospasm induced by failed intubation.

Re-expansion Pulmonary Edema after Chest Tubing: A Case Report: Seong Wook Jeong, Chang Mo Kim, Cheol Hun Choi, Dong Jin Shin, Hong Beom Bae, Sung Su Chung, Kyung Yeon Yoo, Chang Young Jeong; Korean J Crit Care Med. 2005;20(1):87-91.

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Abstract PDF: Re-expansion pulmonary edema (RPE) is a rare complication associated with the treatment of collapsed lung caused by pneumothorax, atelectasis, pleural effusion in which a large amount of air or effusion fluid is evacuated. In general RPE is resulted from more than 3 days of lung collapse and application of high negative intrapleural pressure. However, it is reported that RPE could be developed despite the collapse period is short and negative pressure suction is not performed. It also has been known that the rate of reexpansion is more important than amount of evacuated air, or collapse period in the development of RPE. Seventeen-year-old female was undergone suture hemostasis for liver laceration, in which RPE was occurred after closed thoracostomy for pleural effusion on postoperative-27 day. We present a case report with review of related articles.

One-lung Ventilation using Wire-guided Endobronchial Blocker and Single Lumen Endotracheal Tube: A Case Report: Hee Zoo Kim, Seung Hwan Oh, Chung Guk Park, Eun Hye Koo, Hye Ran Oh, Mi Kyoung Lee, Sang Ho Lim; Korean J Crit Care Med. 2005;20(1):92-96.

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Abstract PDF: We had done one-lung ventilation using 9 Fr wire-guided endobronchial blocker and outer diameter 41-mm flexible fiberoptic bronchoscope in ruptured esophageal patient who expected difficult tracheal intubation and in esophageal cancer patient who was in need of mechanical ventilation during and after the operation.

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