Acute and Critical Care

Volume 21 (2); December 2006

Original Articles

Comparison of Impedance Cardiography with Thermodilution of Hemodynamic Parameters in Critically Ill Patients: Hyung Goo Kang, Sang Won Chung, Ki Hyun Byun, In Byung Kim; Korean J Crit Care Med. 2006;21(2):77-82.

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Abstract PDF: BACKGROUND
To evaluate the feasibility of noninvasive hemodynamic monitoring (impedance cardiography, ICG) in critically ill patients, we compared this technique with simultaneous invasive monitoring with a pulmonary artery thermodilution catheter.
METHODS
A prospective observational study was done comparing invasive monitoring and noninvasive monitoring in 12 critically ill patients. The cardiac output (CO), the stroke volume (SV) and the systemic vascular resistance (SVR) measured by using a standard thermodilution pulmonary artery catheter technique were compared with the corresponding measurements simultaneously using an ICG.
RESULTS
The value of CO, SV and SVR measured by ICG were closely correlated to those by the thermodilution methods [r: 0.659 (p<0.01), 0.536 (p<0.01), 0.738 (p<0.01)].
CONCLUSIONS
ICG can provide hemodynamic information previously available only by invasive monitoring with a thermodilution catheter.

Diagnosis of Right Ventricular Dysfunction in Acute Pulmonary Embolism with N-terminal Probrain Natriuretic Peptide (NT-proBNP): Young Ju Lee; Korean J Crit Care Med. 2006;21(2):83-88.

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Abstract PDF: BACKGROUND
Patients with pulmonary embolism are at high risk of death because of right ventricular dysfunction (RVD) and mortality rate increases with worsening right ventricular dysfuction. The utility of N-terminal probrain natriuretic peptide (NT-proBNP) testing in the emergency department for diagnosing right ventricular dysfunction with pulmonary embolism and optimal cut-off points for its uses are not well established.
METHODS
Forty-nine consecutive patients with confirmed pulmonary embolism, who visited our emergency medical center from March 2005 to September 2006, were recruited. Patients with congestive heart failure and chronic renal failure were excluded from study enrollment. The diagnosis of right ventricular dysfunction was based on echocardiographic evidence of right ventricular dysfunction.
RESULTS
The mean age was 68+/-11 yr, and 71% of the patients were women. The median NT-proBNP level among 29 patients (59%) who had RVD was 1296 versus 250 pg/ml for those 20 patients (41%) who did not have RVD (p=0.01). The area under the receiver operating characteristic curve was 0.94 (95% CI of 0.89~0.98). At a cutoff of 400 pg/ml, NT-proBNP had a sensitivity of 97%, a specificity of 75%, and an overall accuracy of 88% for RVD (p=0.01). An NT-proBNP level <400 pg/ml was optimal for ruling out RVD, which was a negative predictive value of 94%. Increased NT- proBNP was the strong independent predictor of RVD (odds ratio 13, 95% CI 4.3-39.0, p=0.01).
CONCLUSIONS
NT-proBNP levels are frequently increased in patients with pulmonary embolism who have RVD than who did not have RVD. In acute pulmonary embolism, NT-proBNP elevation is highly predictive of RVD.

Effects of Ventilation Modes and Levels of PEEP on Respiratory Mechanics during Controlled Ventilation under General Anesthesia: Jong Cook Park, Sang Hyun Park, Hyun Jun Kwag, Soo Young Park; Korean J Crit Care Med. 2006;21(2):89-94.

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Abstract PDF: BACKGROUND
Application of PEEP increases lung volume and improves oxygenation. High PEEP levels may cause alveolar overdistension or barotrauma. It was hypothesized that there will be an effect of level of PEEP on respiratory resistance and an effect of ventilatory mode on respiratory compliance. This study aimed to investigate the effects of ventilation modes and levels of PEEP on respiratory mechanics during controlled ventilation under general anesthesia.
METHODS
In 14 mechanically ventilated patients without cardiopulmonary symptoms and signs, we measured the respiratory mechanics using the inspiration interrupter technique during a constant flow. Dynamic and static compliance, airway resistance, visco-elastic tissue and total respiratory system resistance were calculated at 0, 5, 10, 15, and 20 cmH2O of positive end-expiratory pressure (PEEP) in VCV mode, VCV with inspiratory pause mode, and PCV mode, respectively.
RESULTS
The dynamic compliance of the PCV mode was higher than that of the VCV mode. The highest static compliance was at 10 cmH2O PEEP. At 20 cmH2O PEEP, pulmonary compliance was decreased and the tissue resistance was increased.
CONCLUSIONS
These results suggest that the respiratory mechanics including respiratory resistance should be monitored for applying PEEP. Further studies on clinical condition such as acute lung injury and ARDS were needed.

Vancomycin-resistant Enterococcus and Methicillin-resistant Staphylococcus aureus Colonization in Liver Transplant Recipients : A Matched Control Study: Ji Yeon Jeong, Sunghwan Kim, Sung Sim Bae, Chul Woo Jung, Kook Hyun Lee; Korean J Crit Care Med. 2006;21(2):95-100.

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Abstract PDF: BACKGROUND
Despite improvements in surgical technique and immunosuppression, infection following liver transplantation (LT) remains a significant problem. Vancomycin-resistant Enterococcuscus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) have become important nosocomial pathogens. This study was undertaken in attempt to evaluate clinical impact of VRE and MRSA in LT recipients.
METHODS
LT recipients with VRE or MRSA colonization from 2001 to 2004 were identified and matched (age, gender, United Network for Organ Sharing status, liver disease, and transplant date) to control groups without MRSA or VRE colonization. Demographics, clinical factors, length of stay, duration of the use of the mechanical ventilator, complications and survival rates were compared with matched controls.
RESULTS
Eleven patients were colonized by VRE (4.7%) and thirty patients by MRSA (13%). The common sites of VRE culture included the tip of the urinary catheter and urine. The VRE colonized group experienced more biliary complications, relaparotomies, longer length of stay at ICU and ward, and longer use of the mechanical ventilator. One year survival rate was lower in the VRE group. MRSA was commonly cultured from sputum, tip of the central venous catheter or intraarterial catheter, and blood. The MRSA group experienced more relaparotomies, pneumonia, longer stay at ICU and ward, and longer use of mechanical ventilator compared to the control. One year survival rate was lower in the MRSA group. Rejection was not associated with VRE or MRSA infection.
CONCLUSIONS
VRE or MRSA colonization is associated with higher incidence of posttransplant complications and lower survival rate than LT recipients without VRE or MRSA colonization. The patients with VRE or MRSA colonization also utilized more hospital resources.

Clinical Value of GRACE Score in the Prediction of Mortality in Patients with Acute Coronary Syndrome: Eun Suk Shin, Myung Ho Jeong, Young Hun Lee, Sun Il Ji, So Young Jeong, Ok Hee Lee, Jeong Ja Kang, So Young Yun, Jeong Eun Yoo, Hyung Wook Park, Ju Han Kim, Weon Kim, Young Keun Ahn, Jeong Gwan Cho, Jong Chun Park, Jung Chaee Kang; Korean J Crit Care Med. 2006;21(2):101-108.

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Abstract PDF: BACKGROUND
This study was aimed to evaluate the validity of the Global Registry of Acute Coronary Event (GRACE) in patients with acute coronary syndrome (ACS).
METHODS
One thousand thirty hundred seventy eight patients (63.6+/-12.0 years, 921 male), who were admitted at coronary care unit (CCU) of Chonnam National University Hospital between January 2004 and December 2005, were analyzed. The patients were divided into two groups: the survived group (n=1,298, 871 male, 63.1+/-9.7 years) and the moribund group (n=80, 50 male, 67.4+/-8.5 years). Clinical characteristics, risk factors for atherosclerosis, echocardiographic findings, GRACE score and NT-proBNP were compared between groups.
RESULTS
The overall mortality was 5.8 %, 80 out of 1,378 patients. Mortality was higher in patients with Killip IV (46.7%, 50 out of 107 patients) than Killip II or III and elderly patients more than 80 years (42.7%, 38 out of 89 patients). High Killip class and old age were associated with high mortality (p<0.0001 respectively). Total score of GRACE was elevated in the moribund group (142+/-40.3 vs. 240+/-40.0) and high GRACE score was significant predictor of mortality (p<0.0001, r=0.827). Predictive factors for mortality by multiple logistic regression analysis were GRACE score (OR 1.15, 1.11~1.20 95%CI, p<0.0001) and old age (OR 0.88, 1.14~1.33 95%CI, p<0.001).
CONCLUSIONS
GRACE score is useful predictor for the mortality of ACS at CCU.

Collagen Synthesis in an in Vivo Rat Model of Ventilator-induced Lung Injury: Won Il Choi; Korean J Crit Care Med. 2006;21(2):109-115.

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Abstract PDF: BACKGROUND
Experimentally, maintaining high pressure or high volume ventilation in animal models produces an acute lung injury, however, there was little information on remodeling. We investigated the collagen synthesis in a rat model of ventilator-induced lung injury.
METHODS
Rats were ventilated with room air at 85 breaths/minute for 2 hours either tidal volume 7 ml/kg or 20 ml/kg (V(T)7 or V(T)20, respectively). After 2 hours of ventilation, rats were placed in the chamber for 24 hours. Lung collagen was evaluated by immunohistochemistry (n=5) and collagen was quantitated by collagen assay (n=5). Static compliance (Csta) of the whole lung as obtained from the pressure volume curves.
RESULTS
Type I collagen was an increase in expression in the interstitium with large V(T) (20 ml/ kg) ventilation after 2 hours of mechanical ventilation (MV), and further increased expression after 24 hours of recovery period. Static lung compliance was significantly (p<0.05) decreased in the V(T)20 compared with V(T)7 (0.221+/-0.05 vs 0.305+/-0.06 ml/cm H2O) after 2 hours of MV. There was a further decrease in lung compliance after 24 hours of recovery period (0.144+/-0.07 vs 0.221+/-0.05, p<0.05) in the V(T)20.
CONCLUSIONS
Large tidal volume ventilation causes an increase in type 1 collagen expression with reduction of lung compliance.

The Study of Rescuer's Fatigue by Changes of Compression-Vetilation Ratio using Manikin Model of the One-Rescuer CPR: Hee Bum Yang, Young Mo Yang, Jong Wan Kim, Won Young Sung, Ho Lee, Jang Young Lee, Sung Youp Hong; Korean J Crit Care Med. 2006;21(2):116-125.

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Abstract PDF: BACKGROUND
The point of this study is focused on the rescuer's fatigue may increase as the ratio of chest compression-ventilation increases.
METHODS
10 students of emergency medical service and resucue had participated in this study. Cardiopulmonary resuscitation (CPR) was carried out with Laerdal's ResusciAnne with 4 types of compression-ventilation ratio (C-V ratio), and the data was recorded. The rescuer's fatigue was subjectively estimated with the visual analogue scale (VAS), objective fatigue was measured by median frequency which was acquired from the electromyography (EMG) signal, heart rate and the serum lactate level was measured. Statistical analysis was accomplished within each C-V ratios.
RESULTS
As C-V ratio increased from 15 : 2 to 30 : 2, the quality of chest compression was improved. Subjective fatigue was increased significantly when C-V ratio increased to 30 : 2 from 15 : 2 and to 60 : 2 from 45 : 2. Gradual downward transition of the median frequency on EMG was shown as a result of increments of C-V ratio. Significant serum lactate accumulation had shown on ratio of 60 : 2 compare to other ratios.
CONCLUSIONS
Fatigue of the rescuers will be aggravated by increase of C-V ratio. Rapid rescuer change is preferable when C-V ratio is increased.

Case Reports

A Case of Spontaneous Intracranial Hypotension with Headache and Tinnitus Treated with Epidural Blood Patch : A Case Report: Bong Jae Lee; Korean J Crit Care Med. 2006;21(2):126-130.

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Abstract PDF: Spontaneous intracranial hypotension (SIH) is a syndrome of low cerebrospinal fluid pressure characterized by postural headaches in patients without any history of dural puncture, back trauma, operative procedure, or medical illness. The clinical spectrum of SIH is quite variable and includes headache, neck stiffness, nausea, horizontal diplopia, dizziness, tinnitus, visual blurring, radicular arm pain. When the headache persists or more incapacitating, more aggressive treatment may be necessary. Autologous epidural blood patch is used in the management of SIH and highly effective. I experienced a case of 39 year old female with postural headache and tinnitus who was diagnosed as having SIH and successfully treated with epidural blood patch.

Malfunction due to Kinking and Bending of a Double Lumen Central Venous Catheter : A Case Report: Kyung Bong Yoon, Won Oak Kim, Jae Ho Cha, Ki Young Lee; Korean J Crit Care Med. 2006;21(2):131-134.

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Abstract PDF: Central venous catheters provide an important means of vascular access and are increasingly used. Catheter occlusion refers to the inability to infuse or withdraw fluids from a catheter and could be caused by either thrombotic or nonthrombotic origin. We report an unusual malfunction of double lumen central venous catheter due to kinking and bending of the catheter at the opening site of proximal lumen.

Nasogastric Tube Insertion using Savary-Gilliard Wire Guide(R) in a Comatose Patient : A Case Report: Hae Jin Lee, Jin Young Chon, Jin Hwan Choi, He Jin Choi, Se Ho Moon; Korean J Crit Care Med. 2006;21(2):135-139.

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Abstract PDF: The insertion of nasogastric tubes in comatose, obtunded or anesthetized patients is often difficult, frustrating and time-consuming. A large variety of methods inserting nasogastric tubes in those uncooperative patients have been reported. As a new effective method, we used Savary-Gilliard Wire Guide(R), which is designed for introducing Savary-Gilliard Dilator(R) into a strictured esophagus, for inserting a nasogastric tube in a comatose patient who was intubated with a ballooned tracheostomy tube. The insertion was successful in the first attempt and no complication occurred.

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