Acute and Critical Care

Volume 22 (1); June 2007

Original Articles

Clinical Outcomes of Early Vancomycin Administration before Identification of Methicillin-resistant Staphylococcus aureus in Patients with Nosocomial Pneumonia: Yong Woo Seo, Jung Eun Lee, Bo Ram Min, Jae Seok Park, Jeong Eun Kim, Young Yun Jang, Hun Pyo Park, Nam Hee Ryoo, Won Il Choi; Korean J Crit Care Med. 2007;22(1):1-6.

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Abstract PDF: BACKGROUND
The aim of this study is to determine the clinical outcomes of early vancomycin administration before identification of methicillin-resistant Staphylococcus aureus (MRSA) in patients with nosocomial pneumonia on a ventilator. METHODS: We retrospectively reviewed patients with nosocomial pneumonia in a 20-bed medical ICU during a period of 2 years and 2 months. This study included 52 inpatients, who were admitted for more than 72 hr and had a new or progressive lung infiltrate plus at least two of the following three criteria for pneumonia: abnormal body temperature (>38oC or <35oC), abnormal leukocyte count (>10,000/mm3 or <3,000/mm3), and purulent bronchial secretions. All of the MRSA were identified in tracheal aspirates during mechanical ventilation. RESULTS: A total of 23 patients who received vancomycin prior to identification of MRSA exhibited a 28-day mortality rate of 60%, while 29 patients who received vancomycin after identification of MRSA showed a 28-day mortality rate of 40% (p=0.17). There was no statistically significant difference in severity index and routine laboratory findings between the two groups. CONCLUSIONS: Early vancomycin administration before identification of MRSA does not appear to affect the mortality rate for patients with nosocomial pneumonia.

Analysis of the Description of Ventilator Parameters in Recent Papers Relating Artificial Ventilation Using Anesthesia Machine: Jiyeon Sim, Hee Yeon Park, Wonsik Ahn; Korean J Crit Care Med. 2007;22(1):7-14.

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Abstract PDF: BACKGROUND
Procedures in medical papers should be described in sufficient detail to allow other researchers to reproduce the results. The apparatus including anesthesia machine should be given, too. Anesthesia machine has dramatically improved as bioengineering has developed. There are several ventilator settings in modern anesthesia machines. However, it seems that only a few ventilator settings are described even though modern ventilators are used in research. The purpose of this study is to investigate that how many ventilator parameters were described in the papers of the Korean Journal of Anesthesiology from 2001 to 2006. METHODS: All of papers with human general anesthesia were reviewed except case reports, and papers regarding only induction or intubation procedures. Recruited articles were grouped into papers with strongly related to respiratory parameters (STP), and into ones with slightly related to them based on the research topics. The description of following categories was counted in each paper; the type of anesthesia machine, tidal volume, respiratory rate, inspiratory:expiratory ratio, mode of ventilation, pressure set in pressure targeted ventilation, positive end expiratory pressure, inspiratory pause, and inspiratory rising rate. RESULTS: The description rate of each parameters in STP were 36% in the type of anesthesia machine, 66% in tidal volume, 54% in respiratory rate, and 24% in inspiratory:expiratory ratio. The other settings were seldomly mentioned. CONCLUSIONS: Description on the ventilator parameters was sometimes missed. We should describe adequate ventilator settings to reproduce the results because the modern anesthesia machine has additional ventilator options.

Statistical Analysis of Mortality Associated with Anesthesia and Surgery in a Hospital from 2000 to 2004: Jiyeon Sim, Donguk Kim, Jeong Rim Lee, Wonsik Ahn; Korean J Crit Care Med. 2007;22(1):15-24.

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Abstract PDF: BACKGROUND
Surgical patients should be provided adequate information on operation. The information on mortality is extremely important among them. The purposes of this study are to investigate the recent mortality associated with anesthesia and surgery, and to get a logistic regression model of mortality based on patient information. METHODS: We collected all of the anesthetic cases except local anesthesia during 5 years (between 2000 and 2004) in a hospital. All deaths within 7 days after anesthesia were retrieved. These data were analyzed in terms of age, gender, department in charge, time point after anesthesia, elective or emergency surgery, type of anesthesia, operation name, and diagnosis. The combined effects of the variables on the mortality were evaluated with logistic regression. The causes of death were also analyzed. RESULTS: There were 155 deaths among 74,458 patients under anesthesia. Age less than 1 year old or greater than 80 years old, male gender, department of thoracic surgery, emergency operation, cardiovascular surgery, and diseases for transplantation had higher mortality than their counterparts. Regression model was followed with assignment of '1' for the above mentioned categories. Other categories were designated by '0'. Log[p (death)/{1-p (death)}] = -9.15+1.03xage+0.66xsex+0.79xdepartment+2.77xemergency+2.52 xdiagnosis+0.89xoperation The leading cause of death was sepsis (21.9%). CONCLUSIONS: The average of mortality within 7 days after anesthesia was 21 per 10,000 anesthetic cases (0.21%). Estimated mortality based on logistic regression ranged from 0.01% to 10.25% depending on patient information.

Nonlinear Analysis of Heart Rate Variability: Possible Predictor for Atrial Fibrillation after Coronary Artery Bypass Graft (CABG) Surgery: Kyung Sil Im, Jong Bun Kim, Jae Myeong Lee, Kuhn Park, Hyun Ju Jung, Jeong Yun Rhee; Korean J Crit Care Med. 2007;22(1):25-29.

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Abstract PDF: BACKGROUND
Heart Rate Variability (HRV) is a valuable marker of autonomic tone and may assist evaluating the prognosis in patients with heart disease. The purpose of this study was to assess whether preoperative heart rate variability analysis predicts atrial fibrillation in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: This study was designed as a prospective observational study. After IRB approval was obtained by our institution, 76 patients scheduled for elective CABG surgery underwent a 10-min electrocardiogram recordings 1~2 hours prior to surgery. Heart rate variability analysis was performed with spectral analysis and point correlation dimension. RESULTS: There was no significant difference in the low and high frequency component (LF/HF) ratio preoperatively between patients with atrial fibrillation and patients with normal sinus rhythm postoperatively (3.0+/-2.45, 4.25+/-3.70, p=0.085). Baseline peak point correlation dimension (pPD2) was significantly higher in patients with atrial fibrillation than in patients with normal sinus rhythm postoperatively (4.2+/-0.8, 3.8+/-0.7, p=0.042). CONCLUSIONS: Patients who developed atrial fibrillation postoperatively had a higher baseline pPD2 value preoperatively. Point correlation dimensions may predict the occurrence of postoperative atrial fibrillation after CABG surgery. However, further studies are needed to confirm whether point correlation dimensions are an effective predictor for postoperative atrial fibrillation.

The Effects of Mild Hypothermia on the Expression of the Apoptosis-related Proteins following Transient Global Ischemia in Gerbil Hippocampus: Young Min Kim, Kyu Nam Park, Seung Pil Choi, Tai Yong Hong, Se Kyung Kim; Korean J Crit Care Med. 2007;22(1):30-41.

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Abstract PDF: BACKGROUND
The neuroprotective mechanisms of hypothermia remain unclear. Recently, attenuation of apoptosis by hypothermia has been suggested as one of the responsible mechanisms. The aim of this study is to investigate the effects of post-ischemic hypothermia on apoptotic neuronal death as well as expression of some apoptosis-related proteins in a gerbil transient global ischemia model.
METHODS
Following 5 minutes of ischemia, normothermia (NT, 37+/-0.5degrees C) or mild hypothermia (HT, 33+/-0.5degrees C) was immediately induced and maintained for 3 hours. The hippocampal CA1 neurons were examined on day 2, 3, 4, and 7 after ischemia for the survived neuronal densities, DNA nick end labeling and immunohistochemical expressions of Bcl-2, Bax, and caspase 3 in each group. Additionally, DNA gel electrophoresis and western blot analysis for each protein in hippocampus were performed. RESULTS: The neuronal death in CA1 area on day 3, 4, and 7 was significantly reduced in HT group compared to NT group. The number of TUNEL positive cells in HT group was also significantly reduced than NT group on day 3, 4, and 7. DNA laddering of hippocampus on day 4 and 7 also reduced in HT group. Expressions of Bax on days 2, 3 and activated caspase 3 on days 3, 4 were reduced in HT group. Western blots also disclosed a decrease in the intensity of the Bax on day 2 and 3 in HT group compared to NT group. CONCLUSIONS: These results suggest that mild post-ischemic hypothermia attenuates the apoptotic neuronal death through the inhibition of the intrinsic pathway of caspase activation following transient global ischemia and these effects may be related to a reduction of pro-apoptotic events.

Case Reports

Hemolytic Uremic Syndrome Occurred after Esophagectomy: A Case Report: Su Hyeon Park, Sung Tae Jeong, Seok Jai Kim, Hong Beom Bae, Sung Su Chung, Sang Hyun Kwak; Korean J Crit Care Med. 2007;22(1):42-47.

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Abstract PDF: Hemolytic uremic syndrome is an unusual and uncommon disease in adults but more common in children, which is defined by the triad of acute renal failure, thrombocytopenia, and microangiopathic hemolytic anemia. We report a 64-year-old man who developed hemolytic uremic syndrome after esophagectomy and esophagogastrostomy due to esophageal cancer. We treated him using continuous renal replacement therapy and plasmapheresis with large volume fresh frozen plasma transfusion for 9 days. We could not find the cause of hemolytic uremic syndrome, and so finally concluded that it is idiopathic. Bleeding continuously without a particular reason after an operation, it needs an early diagnosis and treatment with considering a possibility of the hemolytic uremic syndrome.

Clinical Experience of the Lower Extremity Nerve Block for a Neurocritically Ill Patient Who is Not Able to Communicate:A Case Report: Jun Rho Yoon, Tae Kwan Kim, Je Chun Yu, Yee Suk Kim, In Soo Han, Yong Ju Oh; Korean J Crit Care Med. 2007;22(1):48-51.

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Abstract PDF: A 73-year-old man was scheduled for the surgical reduction of fractured femur which occurred ar 3 months ago by the accident. The mental status of the patient was stuporous (Glasgow coma scale: 5) due to the complication of the head trauma. We performed nerve blocks (femoral, sciatic, lateral femoral cutaneous, and illiohypogastric nerve blocks) for the surgical reduction of left femur with 55 ml of 0.25% ropivacaine. The electroencephalography was monitored continuously during the 4 hour operation as well as monitoring the hemodynamic and respiratory parameters. The operation was performed successfully and the patient recovered uneventfully.

Acute Pulmonary Edema after Cardioversion for Torsade de Pointes:A Case Report: Na Rae Ha, Duk Joo Lee, Tae Hyung Kim, Ho Joo Yoon, Dong Ho Shin, Jang Won Sohn, Sung Soo Park; Korean J Crit Care Med. 2007;22(1):52-56.

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Abstract PDF: Cardioversion used for the treatment of various cardiac arrhythmias is a safe and effective procedure with infrequent complication. The restoration of sinus rhythm is followed by a improvement in hemodynamics, but acute pulmonary edema has been reported as a rare complication following successful electrical reversion of various tachyarrhythmia to normal sinus rhythm. This report describes a 42-year-old woman with a history of schizophrenia who experienced pulmonary edema after cardioversion for torsade de pointes. She had taken chlorpromazine and haloperidol for schizophrenia. The antipsychotic drugs were suspected to induce QT interval prolongation and resultant torsade de pointes. Two hours after cardioversion, pulmonary edema developed on chest X-ray and chest computed tomography. She responded to conservative treatment including oxygen therapy and the pulmonary edema improved on the second hospital day. The mechanism of pulmonary edema after cardioversion is still uncertain and remains controversial.

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