Acute and Critical Care

Original Articles

Pulmonary
Clinical outcomes of difficult-to-wean patients with ventilator dependency at intensive care unit discharge: Jung Mo Lee, Sun-Min Lee, Joo Han Song, Young Sam Kim; Acute Crit Care. 2020;35(3):156-163. Published online August 19, 2020; DOI: https://doi.org/10.4266/acc.2020.00199

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Background
Ventilator-dependent patients in the intensive care unit (ICU) who are difficult to wean from invasive mechanical ventilation (IMV) have been increasing in number. However, data on the clinical outcomes of difficult-to-wean patients are lacking. We aimed to evaluate clinical outcomes in patients discharged from the ICU with tracheostomy and ventilator dependency.
Methods
We retrospectively investigated clinical course and survival in patients requiring home mechanical ventilation (HMV) with a tracheostomy and difficulty weaning from IMV during medical ICU admission from September 2013 through August 2016 at Severance Hospital, Yonsei University, Seoul, Korea.
Results
Of 84 difficult-to-wean patients who were started on HMV in the medical ICU, 72 survived, were discharged from the ICU, and were included in this analysis. HMV was initiated after a median of 23 days of IMV, and the successful weaning rate was 46% (n=33). In-hospital mortality rate was significantly lower in the successfully weaned group than the unsuccessfully weaned group (0% vs. 23.1%, respectively; P=0.010). Weaning rates were similar according to primary diagnosis, but high body mass index (BMI), low Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score at ICU admission, and absence of neuromuscular disease were associated with weaning success. After a median follow-up of 4.6 months (range, 1–27 months) for survivors, 3-month (n=64) and 6-month (n=59) survival rates were 82.5% and 72.2%, respectively. Survival rates were higher in the successfully weaned group than the unsuccessfully weaned group at 3 months (96.4% vs. 69.0%; P=0.017) and 6 months (84.0% vs. 62.1%; P=0.136) following ICU discharge.
Conclusions
In summary, 46% of patients who started HMV were successfully weaned from the ventilator in general wards. High BMI, low APACHE II score, and absence of neuromuscular disease were factors associated with weaning success.

Citations

Citations to this article as recorded by

Long-Term Mortality in Critically Ill Tracheostomized Patients Based on Home Mechanical Ventilation at Discharge
Won-Young Kim, Moon Seong Baek
Journal of Personalized Medicine.2021; 11(12): 1257. CrossRef
Year 2020 in review - Post‑acute intensive care
J Djakow
Anesteziologie a intenzivní medicína.2020; 31(6): 305. CrossRef

Pulmonary
Feasibility of Immediate in-Intensive Care Unit Pulmonary Rehabilitation after Lung Transplantation: A Single Center Experience: Joo Han Song, Ji-Eun Park, Sang Chul Lee, Sarang Kim, Dong Hyung Lee, Eun Kyoung Kim, Song Yee Kim, Ji Cheol Shin, Jin Gu Lee, Hyo Chae Paik, Moo Suk Park; Acute Crit Care. 2018;33(3):146-153. Published online August 31, 2018; DOI: https://doi.org/10.4266/acc.2018.00129

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Abstract PDF

Background
Physical function may influence perioperative outcomes of lung transplantation. We investigated the feasibility of a pulmonary rehabilitation program initiated in the immediate postoperative period at an intensive care unit (ICU) for patients who underwent lung transplantation.
Methods
We retrospectively evaluated 22 patients who received pulmonary rehabilitation initiated in the ICU within 2 weeks after lung transplantation at our institution from March 2015 to February 2016. Levels of physical function were graded at the start of pulmonary rehabilitation and then weekly throughout rehabilitation according to criteria from our institutional pulmonary rehabilitation program: grade 1, bedside (G1); grade 2, dangling (G2); grade 3, standing (G3); and grade IV, gait (G4).
Results
The median age of patients was 53 years (range, 25 to 73 years). Fourteen patients (64%) were males. The initial level of physical function was G1 in nine patients, G2 in seven patients, G3 in four patients, and G4 in two patients. Patients started pulmonary rehabilitation at a median of 7.5 days (range, 1 to 29 days) after lung transplantation. We did not observe any rehabilitation-related complications during follow-up. The final level of physical function was G1 in six patients, G3 in two patients, and G4 in 14 patients. Fourteen of the 22 patients were able to walk with or without assistance, and 13 of them maintained G4 until discharge; the eight remaining patients never achieved G4.
Conclusions
Our results suggest the feasibility of early pulmonary rehabilitation initiated in the ICU within a few days after lung transplantation.

Citations

Citations to this article as recorded by

Post-operative, inpatient rehabilitation after lung transplant evaluation (PIRATE): A feasibility randomized controlled trial
Benjamin J Tarrant, Elizabeth Quinn, Rebecca Robinson, Megan Poulsen, Louise Fuller, Greg Snell, Bruce R Thompson, Brenda M Button, Anne E Holland
Physiotherapy Theory and Practice.2023; 39(7): 1406. CrossRef
Early Gait Function After Lung Transplantation in Patients With and Without Pretransplant Extracorporeal Membrane Oxygenation Support
Junghwa Do, Hyojin Lim, Kyung Cheon Seo, Suyoung Park, HyeRin Joo, Junghoon Lee, Eunjae Ko, Jaehwal Lim, Ho Cheol Kim, Dongkyu Oh, Sang-Bum Hong, Won Kim
Transplantation Proceedings.2023; 55(3): 616. CrossRef

Infection
Implications of Plasma Renin Activity and Plasma Aldosterone Concentration in Critically Ill Patients with Septic Shock: Kyung Soo Chung, Joo Han Song, Won Jai Jung, Young Sam Kim, Se Kyu Kim, Joon Chang, Moo Suk Park; Korean J Crit Care Med. 2017;32(2):142-153. Published online May 31, 2017; DOI: https://doi.org/10.4266/kjccm.2017.00094

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Abstract PDF Supplementary Material

Background
The renin-angiotensin-aldosterone system is closely associated with volume status and vascular tone in septic shock. The present study aimed to assess whether plasma renin activity (PRA) and plasma aldosterone concentration (PAC) measurements compared with conventional severity indicators are associated with mortality in patients with septic shock.
Methods
We evaluated 105 patients who were admitted for septic shock. Plasma levels of the biomarkers PRA and PAC, the PAC/PRA ratio, C-reactive protein (CRP) level, and cortisol level on days 1, 3, and 7 were serially measured. During the intensive care unit stay, relevant clinical information and laboratory results were recorded.
Results
Patients were divided into two groups according to 28-day mortality: survivors (n = 59) and non-survivors (n = 46). The survivor group showed lower PRA, PAC, Acute Physiologic and Chronic Health Evaluation (APACHE) II score, and Sequential Organ Failure Assessment (SOFA) score than did the non-survivor group (all P < 0.05). The SOFA score was positively correlated with PRA (r = 0.373, P < 0.001) and PAC (r = 0.316, P = 0.001). According to receiver operating characteristic analysis, the areas under the curve of PRA and PAC to predict 28-day mortality were 0.69 (95% confidence interval [CI], 0.58 to 0.79; P = 0.001) and 0.67 (95% CI, 0.56 to 0.77; P = 0.003), respectively, similar to the APACHE II scores and SOFA scores. In particular, the group with PRA value ≥3.5 ng ml^-1 h^-1 on day 1 showed significantly greater mortality than did the group with PRA value <3.5 ng ml^-1 h^-1 (log-rank test, P < 0.001). According to multivariate analysis, SOFA score (hazard ratio, 1.11; 95% CI, 1.01 to 1.22), PRA value ≥3.5 ng ml^-1 h^-1 (hazard ratio, 3.25; 95% CI, 1.60 to 6.60), previous history of cancer (hazard ratio, 3.44; 95% CI, 1.72 to 6.90), and coronary arterial occlusive disease (hazard ratio, 2.99; 95% CI, 1.26 to 7.08) were predictors of 28-day mortality.
Conclusions
Elevated PRA is a useful biomarker to stratify the risk of critically ill patients with septic shock and is a prognostic predictor of 28-day mortality.

Citations

Citations to this article as recorded by

Association of Active Renin Content With Mortality in Critically Ill Patients: A Post hoc Analysis of the Vitamin C, Thiamine, and Steroids in Sepsis (VICTAS) Trial*
Laurence W. Busse, Christopher L. Schaich, Mark C. Chappell, Michael T. McCurdy, Erin M. Staples, Caitlin C. Ten Lohuis, Jeremiah S. Hinson, Jonathan E. Sevransky, Richard E. Rothman, David W. Wright, Greg S. Martin, Ashish K. Khanna
Critical Care Medicine.2024; 52(3): 441. CrossRef
Renin as a Prognostic Marker in Intensive Care and Perioperative Settings: A Scoping Review
Yuki Kotani, Alessandro Belletti, Giacomo Maiucci, Martina Lodovici, Stefano Fresilli, Giovanni Landoni, Rinaldo Bellomo, Alexander Zarbock
Anesthesia & Analgesia.2024; 138(5): 929. CrossRef
Renin as a Prognostic and Predictive Biomarker in Sepsis: More Questions Than Answers?*
Emily J. See, James A. Russell, Rinaldo Bellomo, Patrick R. Lawler
Critical Care Medicine.2024; 52(3): 509. CrossRef
Dysfunction of the renin-angiotensin-aldosterone system in human septic shock
Christopher L. Schaich, Daniel E. Leisman, Marcia B. Goldberg, Micheal R. Filbin, Ashish K. Khanna, Mark C. Chappell
Peptides.2024; 176: 171201. CrossRef
Blood urea nitrogen - independent marker of mortality in sepsis
Martin Harazim, Kaiquan Tan, Marek Nalos, Martin Matejovic
Biomedical Papers.2023; 167(1): 24. CrossRef
Critically ill children with septic shock: time to rediscover renin?
Isabella Guzzo, Fabio Paglialonga
Pediatric Nephrology.2023; 38(9): 2907. CrossRef
The role of proadrenomedullin, interleukin 6 and CD64 in the diagnosis and prognosis of septic shock
Yasemin Bozkurt Turan
BMC Anesthesiology.2023;[Epub] CrossRef
Renin Kinetics Are Superior to Lactate Kinetics for Predicting In-Hospital Mortality in Hypotensive Critically Ill Patients*
Maniraj Jeyaraju, Michael T. McCurdy, Andrea R. Levine, Prasad Devarajan, Michael A. Mazzeffi, Kristin E. Mullins, Michaella Reif, David N. Yim, Christopher Parrino, Allison S. Lankford, Jonathan H. Chow
Critical Care Medicine.2022; 50(1): 50. CrossRef
Mechanisms of Post-critical Illness Cardiovascular Disease
Andrew Owen, Jaimin M. Patel, Dhruv Parekh, Mansoor N. Bangash
Frontiers in Cardiovascular Medicine.2022;[Epub] CrossRef
Renin as a Marker of Tissue Perfusion, Septic Shock and Mortality in Septic Patients: A Prospective Observational Study
Patrycja Leśnik, Lidia Łysenko, Małgorzata Krzystek-Korpacka, Ewa Woźnica-Niesobska, Magdalena Mierzchała-Pasierb, Jarosław Janc
International Journal of Molecular Sciences.2022; 23(16): 9133. CrossRef
Angiotensin II and Vasopressin for Vasodilatory Shock: A Critical Appraisal of Catecholamine-Sparing Strategies
Mojdeh S. Heavner, Michael T. McCurdy, Michael A. Mazzeffi, Samuel M. Galvagno, Kenichi A. Tanaka, Jonathan H. Chow
Journal of Intensive Care Medicine.2021; 36(6): 635. CrossRef
Treatment of Renin-Angiotensin-Aldosterone System Dysfunction With Angiotensin II in High-Renin Septic Shock
Jonathan H. Chow, Marianne Wallis, Allison S. Lankford, Zackary Chancer, Rolf N. Barth, Joseph R. Scalea, John C. LaMattina, Michael A. Mazzeffi, Michael T. McCurdy
Seminars in Cardiothoracic and Vascular Anesthesia.2021; 25(1): 67. CrossRef
Good clinical practice for the use of vasopressor and inotropic drugs in critically ill patients: state-of-the-art and expert consensus
Andrea CARSETTI, Elena BIGNAMI, Andrea CORTEGIANI, Katia DONADELLO, Abele DONATI, Giuseppe FOTI, Giacomo GRASSELLI, Stefano ROMAGNOLI, Massimo ANTONELLI, Elvio DE BLASIO, Francesco FORFORI, Fabio GUARRACINO, Sabino SCOLLETTA, Luigi TRITAPEPE, Luigia SCUDE
Minerva Anestesiologica.2021;[Epub] CrossRef
Use of Angiotensin II in Severe Vasoplegia After Left Pneumonectomy Requiring Cardiopulmonary Bypass: A Renin Response Analysis
Brian Trethowan, Christopher J. Michaud, Sarah Fifer
Critical Care Medicine.2020; 48(10): e912. CrossRef
Renin as a Marker of Tissue-Perfusion and Prognosis in Critically Ill Patients*
Patrick J. Gleeson, Ilaria Alice Crippa, Wasineenart Mongkolpun, Federica Zama Cavicchi, Tess Van Meerhaeghe, Serge Brimioulle, Fabio Silvio Taccone, Jean-Louis Vincent, Jacques Creteur
Critical Care Medicine.2019; 47(2): 152. CrossRef

Basic science and research
Changes in Insulin-like Growth Factor-1 Level in Patients with Sepsis and Septic Shock: Sang Hoon Lee, Byung Hoon Park, Joo Han Song, Song Yee Kim, Kyung Soo Chung, Eun Young Kim, Ji Ye Jung, Young Sam Kim, Se Kyu Kim, Joon Chang, Moo Suk Park; Korean J Crit Care Med. 2016;31(4):324-333. Published online November 30, 2016; DOI: https://doi.org/10.4266/kjccm.2016.00024

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Abstract PDF: Background
Despite many ongoing, prospective studies on the topic, sepsis still remains one of the main causes of death in hospital. The hormone insulin-like growth factor 1 (IGF-1) has a similar molecular structure to that of insulin. IGF-1 exerts anabolic effects and plays important roles in both normal physiology and pathologic processes. Previous studies have observed low serum IGF-1 level in patients with critical illnesses. Here, we evaluated changes in IGF-1 level based on survival of septic patients.
Methods
We evaluated 140 patients with sepsis and septic shock (21 with sepsis and 119 with septic shock) admitted to the intensive care unit of a university-affiliated hospital in Korea. Serum IGF-1 level was measured on days 0, 1, 3, and 7. Patients with liver disease were excluded from this study. All data were analyzed using SPSS version 20 (SPSS Inc., Chicago, IL, USA).
Results
Patients with septic shock had significantly lower serum IGF-1 level on days 1 and 3 than patients without septic shock (p = 0.002 and p = 0.007, respectively). Generally, there was a negative relationship between IGF-1 and serum cortisol levels; however, this relationship was only significant on day 3 (p = 0.029). Furthermore, renin showed significantly negative correlation with IGF-1 on day 3 (p = 0.038). IGF-1 level did not show significant difference between survivors and non-survivors.
Conclusions
Our results showed that IGF-1 was associated with septic shock, and that the IGF-1 axis is severely disrupted in septic patients. Additionally, serum cortisol and renin levels were associated with IGF-1 level.

Case Report

Genetic
Lethal Hyperammonemia due to Ornithine Transcarbamylase Deficiency in a Patient with Severe Septic Shock: Ji An Hwang, Joo Han Song, Young Seok Lee, Kyung Soo Chung, Song Yee Kim, Eun Young Kim, Ji Ye Jung, Young Ae Kang, Young Sam Kim, Joon Chang, Moo Suk Park; Korean J Crit Care Med. 2016;31(2):140-145. Published online May 31, 2016; DOI: https://doi.org/10.4266/kjccm.2016.31.2.140

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Abstract PDF: Severe hyperammonemia can occur as a result of inherited or acquired liver enzyme defects in the urea cycle, among which ornithine transcarbamylase deficiency (OTCD) is the most common form. We report a very rare case of a 45-year-old Korean male who was admitted to the intensive care unit (ICU) due to severe septic shock with acute respiratory failure caused by Pneumocystis jiroveci pneumonia. During his ICU stay with ventilator care, the patient suffered from marked hyperammonemia (>1,700 μg/dL) with abrupt mental change leading to life-threatening cerebral edema. Despite every effort including continuous renal replacement therapy and use of a molecular adsorbent recirculating system (extracorporeal liver support–albumin dialysis) to lower his serum ammonia level, the patient was not recovered. The lethal hyperammonemia in the patient was later proven to be a manifestation of acquired liver enzyme defect known as OTCD, which is triggered by serious catabolic conditions, such as severe septic shock with acute respiratory failure.

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