Acute and Critical Care

Corrigendum

Pediatrics
Corrigendum to: Development of a deep learning model for predicting critical events in a pediatric intensive care unit: In Kyung Lee, Bongjin Lee, June Dong Park; Received March 15, 2024 Accepted March 15, 2024 Published online April 1, 2024; DOI: https://doi.org/10.4266/acc.2023.01424.e1 [Epub ahead of print]; Corrects: Acute Crit Care 2024;39(1):186

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Original Articles

Pediatrics
Development of a deep learning model for predicting critical events in a pediatric intensive care unit: In Kyung Lee, Bongjin Lee, June Dong Park; Acute Crit Care. 2024;39(1):186-191. Published online February 20, 2024; DOI: https://doi.org/10.4266/acc.2023.01424; Correction in: https://doi.org/

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Abstract PDF: Background
Identifying critically ill patients at risk of cardiac arrest is important because it offers the opportunity for early intervention and increased survival. The aim of this study was to develop a deep learning model to predict critical events, such as cardiopulmonary resuscitation or mortality. Methods: This retrospective observational study was conducted at a tertiary university hospital. All patients younger than 18 years who were admitted to the pediatric intensive care unit from January 2010 to May 2023 were included. The main outcome was prediction performance of the deep learning model at forecasting critical events. Long short-term memory was used as a deep learning algorithm. The five-fold cross validation method was employed for model learning and testing. Results: Among the vital sign measurements collected during the study period, 11,660 measurements were used to develop the model after preprocessing; 1,060 of these data points were measurements that corresponded to critical events. The prediction performance of the model was the area under the receiver operating characteristic curve (95% confidence interval) of 0.988 (0.9751.000), and the area under the precision-recall curve was 0.862 (0.700–1.000). Conclusions: The performance of the developed model at predicting critical events was excellent. However, follow-up research is needed for external validation.

Pediatrics
Outcomes of extracorporeal membrane oxygenation support in pediatric hemato-oncology patients: Hong Yul An, Hyoung Jin Kang, June Dong Park; Acute Crit Care. 2024;39(1):108-116. Published online January 24, 2024; DOI: https://doi.org/10.4266/acc.2023.01088

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Abstract PDF Supplementary Material: Background
In this study, we reviewed the outcomes of pediatric patients with malignancies who underwent hematopoietic stem cell transplantation (HSCT) and extracorporeal membrane oxygenation (ECMO). Methods: We retrospectively analyzed the records of pediatric hemato-oncology patients treated with chemotherapy or HSCT and who received ECMO in the pediatric intensive care unit (PICU) at Seoul National University Children’s Hospital from January 2012 to December 2020. Results: Over a 9-year period, 21 patients (14 males and 7 females) received ECMO at a single pediatric institute; 10 patients (48%) received veno-arterial (VA) ECMO for septic shock (n=5), acute respiratory distress syndrome (ARDS) (n=3), stress-induced myopathy (n=1), or hepatopulmonary syndrome (n=1); and 11 patients (52%) received veno-venous (VV) ECMO for ARDS due to pneumocystis pneumonia (n=1), air leak (n=3), influenza (n=1), pulmonary hemorrhage (n=1), or unknown etiology (n=5). All patients received chemotherapy; 9 received anthracycline drugs and 14 (67%) underwent HSCT. Thirteen patients (62%) were diagnosed with malignancies and 8 (38%) were diagnosed with non-malignant disease. Among the 21 patients, 6 (29%) survived ECMO in the PICU and 5 (24%) survived to hospital discharge. Among patients treated for septic shock, 3 of 5 patients (60%) who underwent ECMO and 5 of 10 patients (50%) who underwent VA ECMO survived. However, all the patients who underwent VA ECMO or VV ECMO for ARDS died. Conclusions: ECMO is a feasible treatment option for respiratory or heart failure in pediatric patients receiving chemotherapy or undergoing HSCT.

Pediatrics
Eleven years of experience in operating a pediatric rapid response system at a children’s hospital in South Korea: Yong Hyuk Jeon, Bongjin Lee, You Sun Kim, Won Jin Jang, June Dong Park; Acute Crit Care. 2023;38(4):498-506. Published online November 29, 2023; DOI: https://doi.org/10.4266/acc.2023.01354

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Abstract PDF Supplementary Material: Background
Various rapid response systems have been developed to detect clinical deterioration in patients. Few studies have evaluated single-parameter systems in children compared to scoring systems. Therefore, in this study we evaluated a single-parameter system called the acute response system (ARS).
Methods
This retrospective study was performed at a tertiary children’s hospital. Patients under 18 years old admitted from January 2012 to August 2023 were enrolled. ARS parameters such as systolic blood pressure, heart rate, respiratory rate, oxygen saturation, and whether the ARS was activated were collected. We divided patients into two groups according to activation status and then compared the occurrence of critical events (cardiopulmonary resuscitation or unexpected intensive care unit admission). We evaluated the ability of ARS to predict critical events and calculated compliance. We also analyzed the correlation between each parameter that activates ARS and critical events.
Results
The critical events prediction performance of ARS has a specificity of 98.5%, a sensitivity of 24.0%, a negative predictive value of 99.6%, and a positive predictive value of 8.1%. The compliance rate was 15.6%. Statistically significant increases in the risk of critical events were observed for all abnormal criteria except low heart rate. There was no significant difference in the incidence of critical events.
Conclusions
ARS, a single parameter system, had good specificity and negative predictive value for predicting critical events; however, sensitivity and positive predictive value were not good, and medical staff compliance was poor.

Pediatrics
Clinical implications of discrepancies in predicting pediatric mortality between Pediatric Index of Mortality 3 and Pediatric Logistic Organ Dysfunction-2: Eui Jun Lee, Bongjin Lee, You Sun Kim, Yu Hyeon Choi, Young Ho Kwak, June Dong Park; Acute Crit Care. 2022;37(3):454-461. Published online July 29, 2022; DOI: https://doi.org/10.4266/acc.2021.01480

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Abstract PDF: Background
Pediatric Index of Mortality 3 (PIM 3) and Pediatric Logistic Organ Dysfunction-2 (PELOD-2) are validated tools for predicting mortality in children. Research suggests that these tools may have different predictive performance depending on patient group characteristics. Therefore, we designed this study to identify the factors that make the mortality rates predicted by the tools different.
Methods
This retrospective study included patients (<18 years) who were admitted to a pediatric intensive care unit from July 2017 to May 2019. After defining the predicted mortality of PIM 3 minus the predicted mortality rate of PELOD-2 as “difference in mortality prediction,” the clinical characteristics significantly related to this were analyzed using multivariable regression analysis. Predictive performance was analyzed through the Hosmer-Lemeshow test and area under the receiver operating characteristic curve (AUROC).
Results
In total, 945 patients (median [interquartile range] age, 3.0 [0.0–8.0] years; girls, 44.7%) were analyzed. The Hosmer-Lemeshow test revealed AUROCs of 0.889 (χ2=10.187, P=0.313) and 0.731 (χ2=6.220, P=0.183) of PIM 3 and PELOD-2, respectively. Multivariable linear regression analysis revealed that oxygen saturation, partial pressure of CO2, base excess, platelet counts, and blood urea nitrogen levels were significant factors. Patient condition-related factors such as cardiac bypass surgery, seizures, cardiomyopathy or myocarditis, necrotizing enterocolitis, cardiac arrest, leukemia or lymphoma after the first induction, bone marrow transplantation, and liver failure were significantly related (P<0.001).
Conclusions
Both tools predicted observed mortality well; however, caution is needed in interpretation as they may show different prediction results in relation to specific clinical characteristics.

Editorial

Pediatric
Intensivists in the pediatric intensive care unit: conductors for better operational efficiency: June Dong Park; Acute Crit Care. 2020;35(2):115-116. Published online May 31, 2020; DOI: https://doi.org/10.4266/acc.2020.00276

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Case Reports

Cardiology
Percutaneous bicaval dual lumen cannula for extracorporeal life support: Woojung Kim, Hye Won Kwon, Jooncheol Min, Sungkyu Cho, Jae Gun Kwak, June Dong Park, Woong-Han Kim; Acute Crit Care. 2020;35(3):207-212. Published online September 23, 2019; DOI: https://doi.org/10.4266/acc.2019.00584

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Abstract PDF

Veno-venous extracorporeal membrane oxygenation (ECMO) is a useful mechanical device for pediatric patients with severe respiratory failure. Conventional veno-venous ECMO using double cannulation, however, is not feasible due to size limitations in pediatric patients who have small femoral vessels. Recently, percutaneous bicaval dual-lumen cannula can be inserted using single cannulation via the right internal jugular vein. Herein, we report the case of a pediatric patient with severe respiratory failure who was weaned off the ECMO successfully after treatment with bicaval dual-lumen cannulation for 5 days despite the small body size and immunocompromised condition due to chemotherapy for hemophagocytic lymphohistiocytosis.

Citations

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Lipid Emulsion Treatment for Drug Toxicity Caused by Nonlocal Anesthetic Drugs in Pediatric Patients
Soo Hee Lee, Sunmin Kim, Ju-Tae Sohn
Pediatric Emergency Care.2023; 39(1): 53. CrossRef
Mechanisms underlying lipid emulsion resuscitation for drug toxicity: a narrative review
Soo Hee Lee, Ju-Tae Sohn
Korean Journal of Anesthesiology.2023; 76(3): 171. CrossRef

Neurology/Pulmonary
Extensive and Progressive Cerebral Infarction after Mycoplasma pneumoniae Infection: Yu Hyeon Choi, Hyung Joo Jeong, Bongjin Lee, Hong Yul An, Eui Jun Lee, June Dong Park; Korean J Crit Care Med. 2017;32(2):211-217. Published online December 29, 2016; DOI: https://doi.org/10.4266/kjccm.2016.00283

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3 Web of Science
3 Crossref

Abstract PDF

Acute cerebral infarctions are rare in children; however they can occur as a complication of a Mycoplasma pneumoniae (MP) infection due to direct invasion, vasculitis, or a hypercoagulable state. We report on the case of a 5-year-old boy who had an extensive stroke in multiple cerebrovascular territories 10 days after the diagnosis of MP infection. Based on the suspicion that the cerebral infarction was associated with a macrolide-resistant MP infection, the patient was treated with levofloxacin, methyl-prednisolone, intravenous immunoglobulin, and enoxaparin. Despite this medical management, cerebral vascular narrowing progressed and a decompressive craniectomy became necessary for the patient’s survival. According to laboratory tests, brain magnetic resonance imaging, and clinical manifestations, the cerebral infarction in this case appeared to be due to the combined effects of hypercoagulability and cytokine-induced vascular inflammation.

Citations

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Stroke associated with Mycoplasma hominis infection: a case report
Anthoula C. Tsolaki, Galaktion Konstantinidis, Stavroula Koukou, Fotini Michali, Despina Georgiadou, Thomas Tegos, Nikolaos D. Michalis
Journal of Medical Case Reports.2021;[Epub] CrossRef
Thrombosis associated with mycoplasma pneumoniae infection (Review)
Jingwei Liu, Yumei Li
Experimental and Therapeutic Medicine.2021;[Epub] CrossRef
Multiple anatomic sites of infarction in a pediatric patient with M. pneumoniae infection, a case report
Devon W. Hahn, Claire E. Atkinson, Matthew Le
BMC Pediatrics.2021;[Epub] CrossRef

Neurosurgery
Severe Rhabdomyolysis in Phacomatosis Pigmentovascularis Type IIb associated with Sturge-Weber Syndrome: Bongjin Lee, Hyung Joo Jeong, Yu Hyeon Choi, Chong Won Choi, June Dong Park; Korean J Crit Care Med. 2015;30(4):329-335. Published online November 30, 2015; DOI: https://doi.org/10.4266/kjccm.2015.30.4.329

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1 Crossref

Abstract PDF

Phacomatosis pigmentovascularis (PPV) is a rare syndrome characterized by concurrent nevus flammeus (capillary malformation) and pigmentary nevus. According to current research, the major pathophysiologic mechanism in PPV is venous dysplasia with resultant compensatory collateral channels and venous hypertension. Arterial involvement is rare. We herein report our experience on renovascular hypertension, intermittent claudication, and severe rhabdomyolysis due to diffuse stenosis of multiple arteries in a patient with PPV type IIb associated with SWS.

Citations

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Oral healthcare management of a child with phakomatosis pigmentovascularis associated with bilateral Sturge‐Weber syndrome
Mariana Leonel Martins, Aline Dos Santos Letieri, Michele Machado Lenzi, Michelle Agostini, Gloria Fernanda Castro
Special Care in Dentistry.2019; 39(3): 324. CrossRef

Infection
Kawasaki Disease with Acute Respiratory Distress Syndrome after Intravenous Immunoglobulin Infusion: Yu Hyeon Choi, Bong Jin Lee, June Dong Park, Seung Hyo Kim; Korean J Crit Care Med. 2014;29(4):336-340. Published online November 30, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.4.336

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1 Crossref

Abstract PDF

Kawasaki disease (KD) is an acute systemic vasculitis of unknown etiology. We report a case of KD with acute respiratory distress syndrome (ARDS) after intravenous immunoglobulin (IVIG) infusion. Lung manifestations associated with KD have previously been reported in the literature. Although IVIG infusion is an effective therapy for acute KD, there are some reported complications related to IVIG infusion: hypotension, aseptic meningitis, acute renal failure, hemolytic anemia, etc. The case of KD reported here was treated with IVIG and aspirin. A few days after recovery from KD, the patient developed fever and maculopapular rash. A diagnosis of relapse KD was made and retreated with IVIG infusion. However, the patient developed ARDS four days after the second IVIG infusion. The patient recovered from ARDS after nine days of ICU care, which included high frequency oscillation ventilation with inhaled nitric oxide, steroid treatment and other supportive care.

Citations

Citations to this article as recorded by

French national diagnostic and care protocol for Kawasaki disease
C. Galeotti, F. Bajolle, A. Belot, S. Biscardi, E. Bosdure, E. Bourrat, R. Cimaz, R. Darbon, P. Dusser, O. Fain, V. Hentgen, V. Lambert, A. Lefevre-Utile, C. Marsaud, U. Meinzer, L. Morin, M. Piram, O. Richer, J.-L. Stephan, D. Urbina, I. Kone-Paut
La Revue de Médecine Interne.2023; 44(7): 354. CrossRef

Original Article

Cardiology/Pediatric
Effectiveness of Bradycardia as a Single Parameter in the Pediatric Acute Response System: Yu Hyeon Choi, Hyeon Seung Lee, Bong Jin Lee, Dong In Suh, June Dong Park; Korean J Crit Care Med. 2014;29(4):297-303. Published online November 30, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.4.297

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Abstract PDF

BACKGROUND
Various tools for the acute response system (ARS) predict and prevent acute deterioration in pediatric patients. However, detailed criteria have not been clarified. Thus we evaluated the effectiveness of bradycardia as a single parameter in pediatric ARS.
METHODS
This retrospective study included patients who had visited a tertiary care children's hospital from January 2012 to June 2013, in whom ARS was activated because of bradycardia. Patient's medical records were reviewed for clinical characteristics, cardiologic evaluations, and reversible causes that affect heart rate.
RESULTS
Of 271 cases, 261 (96%) had ARS activation by bradycardia alone with favorable outcomes. Evaluations and interventions were performed in 165 (64.5%) and 13 cases (6.6%) respectively. All patients in whom ARS was activated owing to bradycardia and another criteria underwent evaluation, unlike those with bradycardia alone (100.0% vs. 63.2%, p = 0.016). Electrocardiograms were evaluated in 233 (86%) cases: arrhythmias were due to borderline QT prolongation and atrioventricular block (1st and 2nd-degree) in 25 cases (9.2%). Bradycardia-related causes were reversible in 202 patients (74.5%). Specific causes were different in departments at admission. Patients admitted to the hemato-oncology department required ARS activation during the night (69.3%, p = 0.03), those to the endocrinology department required ARS activation because of medication (72.4%, p < 0.001), and those to the gastroenterology department had low body mass indexes (32%, p = 0.01).
CONCLUSIONS
Using bradycardia alone in pediatric ARS is not useful, because of its low specificity and poor predictive ability for deterioration. However, bradycardia can be applied to ARS concurrently with other parameters.

Citations

Citations to this article as recorded by

Effect of Diurnal Variation of Heart Rate and Respiratory Rate on Activation of Rapid Response System and Clinical Outcome in Hospitalized Children
Lia Kim, Kyoung Sung Yun, June Dong Park, Bongjin Lee
Children.2023; 10(1): 167. CrossRef
Eleven years of experience in operating a pediatric rapid response system at a children’s hospital in South Korea
Yong Hyuk Jeon, Bongjin Lee, You Sun Kim, Won Jin Jang, June Dong Park
Acute and Critical Care.2023; 38(4): 498. CrossRef
Pediatric triage modifications based on vital signs: a nationwide study
Bongjin Lee, June Dong Park, Young Ho Kwak, Do Kyun Kim
Clinical and Experimental Emergency Medicine.2022; 9(3): 224. CrossRef

Case Reports

Disseminated Neonatal Herpes Simplex Virus Infection: Bongjin Lee, Jinsol Hwang, Yu Hyeon Choi, Young Joo Han, Young Hun Choi, June Dong Park; Korean J Crit Care Med. 2013;28(4):331-335.; DOI: https://doi.org/10.4266/kjccm.2013.28.4.331

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Abstract PDF

Disseminated neonatal herpes simplex virus (HSV) infection is one of the most severe neonatal infections, and can have devastating consequences without early proper treatment. However, the administration of acyclovir can often be delayed because the symptoms and signs of HSV infection are non-specific and because HSV polymerase chain reaction (PCR) results may be negative early in the course of HSV infection. We report a case of disseminated neonatal HSV infection that was diagnosed by type 1 HSV PCR on day 8 of admission. Despite delayed administration of acyclovir, the patient was cured and subsequently discharged after 30 days of admission. Fortunately, this patient was treated successfully, but delayed administration of acyclovir has the potential to lead to significant problems. Considering the seriousness of neonatal HSV infection, empirical acyclovir therapy should be considered if HSV infection is suspected.

Citations

Citations to this article as recorded by

A Case of Herpes Simplex Virus Type 2 Encephalitis of a Newborn Delivered by a Mother without Prenatal Screening
Eun Seob Lee, Joon Young Kim, Kon Hee Lee, Jung Won Lee, Yong Ju Lee, Yeon Joung Oh, Ji Seok Bang, Tae-Jung Sung
Korean Journal of Perinatology.2014; 25(3): 195. CrossRef

A Case of Exertional Heat Stroke with Acute Hepatic Failure Treated with Plasma Exchange: A Case Report: Young Joo Han, Jae Wook Choi, Woo Jin Chung, Dong In Suh, June Dong Park; Korean J Crit Care Med. 2012;27(2):130-133.; DOI: https://doi.org/10.4266/kjccm.2012.27.2.130

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1 Crossref

Abstract PDF

Heat stroke is a hyperthermia-induced systemic inflammatory response which may cause multiorgan dysfunction syndrome. We report a case of exertional heat stroke with acute hepatic failure in an 11-year-old boy. He initially presented hyperthermia and unconsciousness, which occurred after heavy exercise. His neurological state improved after terminating the hyperthermia by intensive cooling therapy. However, 24 hours after the initial recovery, his neurological state deteriorated again as acute hepatic injury progressed rapidly. We applied 4 times of total plasma exchange as an immunotherapy for systemic inflammatory response syndrome and acute hepatic failure expecting it to remove endogenous inflammatory factors and hepatotoxic cytokines. Following the plasma exchange, his mental state became normal and serial laboratory findings indicated improvement. He made a complete recovery without sequelae. We experienced successful treatment regarding exertional heat stroke with acute hepatic failure using plasma exchange.

Citations

Citations to this article as recorded by

Therapeutic plasma exchange in the treatment of exertional heat stroke and multiorgan failure
Vimal Master Sankar Raj, Amanda Alladin, Brent Pfeiffer, Chryso Katsoufis, Marissa Defreitas, Alicia Edwards-Richards, Jayanthi Chandar, Wacharee Seeherunvong, Gwenn McLaughlin, Gaston Zilleruelo, Carolyn L. Abitbol
Pediatric Nephrology.2013; 28(6): 971. CrossRef

Multiple Bilateral Perfusion Defects in the Infant with Acute Viral Bronchiolitis: A Case Report: Woo Jin Chung, Jae Wook Choi, Young Ju Han, June Dong Park; Korean J Crit Care Med. 2011;26(4):272-275.; DOI: https://doi.org/10.4266/kjccm.2011.26.4.272

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Abstract PDF: Acute viral bronchiolitis (AVB) is an obstructive lung disease which frequently develops in infants and the most common functional involvement is a V/Q ratio change caused by small airway obstruction. We report a case showing the redistribution of pulmonary blood flow by multiple perfusion scan defects in an infant with AVB. A 15 month-old male infant visited ER due to respiratory difficulty. He manifested decreased lung sound in the left lung field, hyperinflation of the left lung on chest x-ray, and metabolic acidosis in blood gas analysis. A perfusion scan showed multiple perfusion defects of both lungs without the evidence of pulmonary embolism on a following cardiac CT and echocardiography. Human Rhinovirus PCR in a nasopharyngeal aspirate was positive. With supportive care, the symptom was resolved in 4 days. AVB can show multiple perfusion defects by the redistribution of pulmonary blood flow of which the direction is opposite to the usual distribution of pulmonary blood flow in children.

Original Article

Atelectasis and the Risk Factors in the Patients Admitted to Pediatric Intensive Care Unit: Woo Jin Chung, Jae Wook Choi, Young Ju Han, Ju Kyung Lee, Dong In Suh, Young Yull Koh, June Dong Park; Korean J Crit Care Med. 2011;26(4):238-244.; DOI: https://doi.org/10.4266/kjccm.2011.26.4.238

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Abstract PDF: BACKGROUND
Atelectasis is a state of a collapsed and non-aerated region of the lung parenchyma, which is otherwise normal. This condition is usually associated with pulmonary disorders. The purpose of this study is to analyze the incidence and risk factors of atelectasis in patients admitted to the pediatric intensive care unit (PICU).
METHODS
We retrospectively analyzed the clinical characteristics and chest radiography of 280 PICU patients under 18 years old. We analyzed the incidence and pattern of atelectasis and compared the incidence according to the phase and mode of mechanical ventilation. We compared the incidence of ventilator care need and respiratory disease in 93 atelectasis patients.
RESULTS
Atelectasis incidence was 33.2%. The age (4.9 +/- 4.4 years) was younger and the admission-duration (17.8 +/- 25.1 days) was significantly longer in atelectasis patients (p < 0.01). Ventilator care need and respiratory disease in atelectasis patients (86.0%, 66.7% respectively) was significantly higher than in non-atelectasis patients (62.6%, 43.3% respectively) (p < 0.01). Atelectasis incidence in ventilator-required patients and respiratory-diagnosed patients (40.6%, 43.4% respectively) was significantly higher than that in non ventilator-required patients and non respiratory-diagnosed patients (15.7%, 22.6% respectively) (p < 0.01). Atelectasis was more common in the right upper lobe (55.6%) and during or after ventilator care (62.6%) (p < 0.05). Atelectasis incidence in ventilator care did not differ between the assist-control and intermittent mandatory ventilation modes.
CONCLUSIONS
In the PICU, atelectasis incidence was higher in patients with ventilator care and respiratory disease. Atelectasis was more common in the right upper lobe and in the phase after ventilator initiation. Atelectasis incidence in ventilator care did not differ between ventilation modes.

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