Acute and Critical Care

Review Article

Basic science and research
Rehabilitation during extracorporeal membrane oxygenation: bridging the gap between life support and functional recovery: Jin Ho Jang, Eunjeong Choi, Eunjeong Son, Seong Hoon Yoon, Hee Yun Seol, Seung Eun Lee, Woo Hyun Cho, Doosoo Jeon, Yun Seong Kim, Hye Ju Yeo; Acute Crit Care. 2026;41(1):12-32. Published online February 27, 2026; DOI: https://doi.org/10.4266/acc.003250

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Abstract PDF: Rehabilitation during extracorporeal membrane oxygenation (ECMO) has become a promising intervention to mitigate the profound physical and functional decline that occurs with prolonged critical illness. With the wider adoption of ECMO, interest has grown in integrating early mobilization into routine care practices to preserve muscle mass, reduce intensive care unit-acquired weakness, and improve long-term patient outcomes. Emerging observational data indicate that structured rehabilitation protocols—including passive and active mobilization—are feasible and safe, including for individuals undergoing femoral cannulation. Nevertheless, multiple obstacles, including patient instability, technical constraints, staffing limitations, and gaps in clinical knowledge, impede broader implementation. Although the theoretical rationale and initial data are compelling, further robust randomized controlled trials are essential to establish the definitive efficacy, best-practice protocols, and cost-effectiveness of rehabilitation interventions in ECMO-supported patients.

Original Articles

Infection
Association between emergency department–to–intensive care unit transfer time and mortality in patients with septic shock: a target trial emulation with septic shock in South Korea: Ji Hyun Cha, Danbee Kang, Ryoung-Eun Ko, Won Young Kim, Dong-gon Hyun, Yeon Joo Lee, Woo Hyun Cho, Sunghoon Park, Juhee Cho, Gee Young Suh; Acute Crit Care. 2025;40(4):548-556. Published online November 24, 2025; DOI: https://doi.org/10.4266/acc.003575

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Abstract PDF Supplementary Material: Background
Emergency department (ED) overcrowding poses a global challenge, particularly for critically ill patients requiring intensive care unit (ICU) admission. Although delays in ICU transfer increase mortality in critically ill populations, the optimal timing for septic shock remains uncertain.
Methods
We conducted a target trial emulation using a prospective cohort of 815 septic shock patients from 19 Korean hospitals. Delayed ICU transfer was defined using restricted cubic splines. The primary outcome was in-hospital mortality. Multivariable logistic regression and inverse probability treatment weighting were used to adjust for confounders of age, sex, comorbidities, severity of illness, and mechanical ventilation use. Subgroup analyses were performed to assess the effect across patient characteristics.
Results
The median time of ED-to-ICU transfer was 6.7 hours (interquartile range, 4.7–11.4), and only 7% of patients were transferred within 3 hours. ICU transfer within 3 hours was associated with significantly lower in-hospital mortality (odds ratio, 0.48; 95% CI, 0.24–0.94) compared to later transfers. Mortality risk increased with elapsing time up to 6 hours and then plateaued. The benefit of early ICU transfer was consistent across subgroups but was particularly pronounced in patients requiring extracorporeal membrane oxygenation or continuous renal replacement therapy (P for interaction=0.02).
Conclusions
Early ICU transfer within 3 hours significantly reduces mortality in patients with septic shock, with the greatest benefit observed in those requiring advanced organ support. These findings highlight the need for system-wide strategies to reduce ED boarding time and prioritize timely ICU admission for septic shock management.

Pulmonary
Characteristics and management of mechanically ventilated patients in South Korea compared with other high-income Asian countries and regions: Kyung Hun Nam, Kyeongman Jeon, Suk-Kyung Hong, Ah Young Leem, Jee Hwan Ahn, Hang Jea Jang, Ki Sup Byun, So Hee Park, Sojung Park, Yoon Mi Shin, Jisoo Park, Sung Wook Kang, Jin Hyoung Kim, Jinkyeong Park, Deokkyu Kim, Bo young Lee, Woo Hyun Cho, Kwangha Lee, Song I Lee, Tai Sun Park, Yun Jung Jung, Sang-Hyun Kwak, Sang-Beom Jeon, Sung Hyun Kim, Won Jai Jung, Sang-Min Lee, Sunghoon Park, Yun Su Sim, Young-Jae Cho, Younsuck Koh; Acute Crit Care. 2025;40(3):413-424. Published online August 21, 2025; DOI: https://doi.org/10.4266/acc.003336

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Abstract PDF: Background
This study investigated the characteristics of mechanically ventilated patients in South Korean intensive care units (ICUs). Methods: We conducted a subgroup analysis of a multinational observational study. Data from 271 mechanically ventilated patients in South Korean ICUs were analyzed for demographics, ventilation practices, and mortality, and were compared with those of 327 patients from other high-income Asian countries. Results: South Korean patients were older (mean age: 67 vs. 62 years, P<0.001) and had lower ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (255.5 vs. 306.2, P<0.001). South Korean ICUs exhibited higher patient-to-nurse ratios (2.6 vs. 1.9, P<0.001) and more beds per unit (20.5 vs. 16.0, P=0.017). The use of sufficient positive end-expiratory pressure for patients (PEEP) for acute respiratory distress syndrome (ARDS) was less frequent in South Korea (62.2% vs. 91.2%, P=0.005). Mortality rates were similar between South Korean patients and those in other high-income Asian countries (38.0% vs. 34.2%, P=0.401). Significant mortality predictors in South Korea included age ≥65 years (odds ratio [OR], 4.03; P=0.039) and a Sequential Organ Failure Assessment score ≥8 (OR, 2.36; P=0.031). The presence of respiratory therapists was associated with reduced mortality (OR, 0.52; P=0.034). Conclusions: Despite higher age and patient-to-nurse ratios in South Korean ICUs, outcomes were comparable to those in other high-income Asian countries. The suboptimal use of sufficient PEEP with ARDS indicates potential areas for improvement. Additionally, the beneficial impact of respiratory therapists on mortality rates warrants further investigation.

Thoracic surgery
Safety of Surgical Tracheostomy during Extracorporeal Membrane Oxygenation: Hye Ju Yeo, Seong Hoon Yoon, Seung Eun Lee, Doosoo Jeon, Yun Seong Kim, Woo Hyun Cho, Dohyung Kim; Korean J Crit Care Med. 2017;32(2):197-204. Published online May 31, 2017; DOI: https://doi.org/10.4266/kjccm.2017.00059

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Abstract PDF

Background
The risk of bleeding during extracorporeal membrane oxygenation (ECMO) is a potential deterrent in performing tracheostomy at many centers. To evaluate the safety of surgical tracheostomy (ST) in critically ill patients supported by ECMO, we reviewed the clinical correlation between preoperative coagulation status and bleeding complication-related ST during ECMO.
Methods
From April 1, 2012 to March 31, 2016, ST was performed on 38 patients supported by ECMO. We retrospectively reviewed and analyzed the medical records including complications related to ST.
Results
Heparin was administered to 23 patients (60.5%) for anticoagulation during ECMO, but 15 patients (39.5%) underwent ECMO without anticoagulation. Of the 23 patients administered anticoagulation therapy, heparin infusion was briefly paused in 13 prior to ST. The median platelet count, international normalized ratio, and activated partial thromboplastin time before ST were 126 ×10⁹/L (range, 46 to 434 ×10⁹/L), 1.2 (range, 1 to 2.3) and 62 seconds (27 to 114.2 seconds), respectively. No peri-procedural clotting complications related to ECMO were observed. Two patients (5.3%) suffering from ST-related major bleeding required surgical hemostasis. Minor bleeding after ST occurred in two cases (5.3%). No significant difference was found according to anticoagulation management (P = 0.723). No fatality was attributable to ST.
Conclusions
The complication rates of ST in the patients supported by ECMO were low. Therefore, ST performed by an experienced operator, and with careful optimization of coagulation status, is a relatively safe procedure; the use of ST with ECMO should thus not be dismissed on account of the potential for bleeding caused by the administration of anticoagulants.

Citations

Citations to this article as recorded by

Tracheostomy in Critically Ill COVID-19 Patients on Extracorporeal Membrane Oxygenation: A Single-Center Experience
Phillip Staibano, Shahzaib Khattak, Faizan Amin, Paul T. Engels, Doron D. Sommer
Annals of Otology, Rhinology & Laryngology.2023; 132(12): 1520. CrossRef
Does Tracheostomy Improve Outcomes in Those Receiving Venovenous Extracorporeal Membrane Oxygenation?
Joel C. Boudreaux, Marian Urban, Shaun L. Thompson, Anthony W. Castleberry, Michael J. Moulton, Aleem Siddique
ASAIO Journal.2023; 69(6): e240. CrossRef
Tracheostomy in high-risk patients on ECMO: A bedside hybrid dilational technique utilizing a Rummel tourniquet
Britton B. Donato, Marisa Sewell, Megan Campany, Ga-ram Han, Taylor S. Orton, Marko Laitinen, Jacob Hammond, Xindi Chen, Jasmina Ingersoll, Ayan Sen, Jonathan D'Cunha
Surgery Open Science.2023; 16: 248. CrossRef
Assessing Clinical Feasibility and Safety of Percutaneous Dilatational Tracheostomy During Extracorporeal Membrane Oxygenation Support in the Intensive Care Unit
Tae Hwa Hong, Hyung Won Kim, Hyoung Soo Kim, Sunghoon Park
Journal of Acute Care Surgery.2022; 12(1): 18. CrossRef
Retrospective analysis of open bedside tracheotomies in a German tertiary care university hospital
Maximilian Riekert, Matthias Kreppel, Philipp Schminke, Annelies Weckx, Joachim E. Zöller, Volker C. Schick
Journal of Cranio-Maxillofacial Surgery.2021; 49(2): 140. CrossRef
Otolaryngology during COVID-19: Preventive care and precautionary measures
Chen Zhao, Alonço Viana, Yan Wang, Hong-quan Wei, Ai-hui Yan, Robson Capasso
American Journal of Otolaryngology.2020; 41(4): 102508. CrossRef
Tracheostomy while on Extracorporeal Membrane Oxygenation: A Comparison of Percutaneous and Open Procedures
Ismael A. Salas De Armas, Kha Dinh, Bindu Akkanti, Pushan Jani, Reshma Hussain, Lisa Janowiak, Kayla Kutilek, Manish K. Patel, Mehmet H. Akay, Rahat Hussain, Jayeshkumar Patel, Chandni Patel, Yafen Liang, John Zaki, Biswajit Kar, Igor D. Gregoric
The Journal of ExtraCorporeal Technology.2020; 52(4): 266. CrossRef

Cardiology/Pulmonary
Clinical Characteristics of Respiratory Extracorporeal Life Support in Elderly Patients with Severe Acute Respiratory Distress Syndrome: Woo Hyun Cho, Dong Wan Kim, Hye Ju Yeo, Seong Hoon Yoon, Seung Eun Lee, Doo Soo Jeon, Yun Seong Kim, Bong Soo Son, Do Hyung Kim; Korean J Crit Care Med. 2014;29(4):266-272. Published online November 30, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.4.266

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1 Crossref

Abstract PDF

BACKGROUND
Extracorporeal membrane oxygenation (ECMO) strategy is proposed to reduce the ventilator-induced lung injury in acute respiratory distress syndrome (ARDS). As ECMO use has increased, a number of studies on prognostic factors have been published. Age is estimated to be an important prognostic factor. However, clinical evidences about ECMO use in elderly patients are limited. Therefore, we investigated clinical courses and outcomes of ECMO in elderly patients with ARDS.
METHODS
We reviewed medical records of patients with severe ARDS who required ECMO support. Study patients were classified into an elderly group (> or = 65 years) and a non-elderly group (< 65 years). Baseline characteristics, ECMO related outcomes and associated factors were retrospectively analyzed according to group.
RESULTS
From February 2011 to June 2013, a total of 31 patients with severe ARDS were treated with ECMO. Overall, 14 (45.2%) were weaned from ECMO, 9 (29.0%) survived to the general ward and 7 (22.6%) survived to discharge. Among the 18 elderly group patients, 7 (38.9%) were weaned from ECMO, 4 (22.2%) were survived to the general ward and 2 (11.1%) were survived to discharge. Overall intensive care unit survival was inversely correlated with concomitant acute kidney injury or septic shock.
CONCLUSIONS
In this study, ECMO outcome was poor in severe ARDS patients aged over 65 years. Therefore, the routine use of ECMO in elderly patients with severe ARDS is not warranted except in highly selective cases.

Citations

Citations to this article as recorded by

Venovenous Extracorporeal Membrane Oxygenation for Negative Pressure Pulmonary Hemorrhage in an Elderly Patient
Kenichiro Ishida, Mitsuhiro Noborio, Nobutaka Iwasa, Taku Sogabe, Yohei Ieki, Yuki Saoyama, Kyosuke Takahashi, Yumiko Shimahara, Daikai Sadamitsu
Case Reports in Critical Care.2015; 2015: 1. CrossRef

Case Report

Stress-induced Cardiomyopathy Associated with Swine Influenza Infection Which Exacerbated Underlying Emphysema: A Case Report: Sung Gook Song, June Hong Kim, Kook Jin Chun, Jun Kim, Yong Hyun Park, Jeong Su Kim, Ju Hyun Park, Dong Cheul Han, Woo Hyun Cho, Doo Soo Jeon, Yun Seong Kim; Korean J Crit Care Med. 2010;25(4):245-248.; DOI: https://doi.org/10.4266/kjccm.2010.25.4.245

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Abstract PDF: Stress-induced cardiomyopathy (SICM) is an acute cardiac condition that causes left ventricular apical ballooning which mimicks acute coronary syndrome. The risk of in-hospital mortality with SICM is generally low (1% to 3%) and supportive care is usually sufficient for resolution. Swine-origin influenza A (H1N1, S-OIV) is a recently spreading pandemic and a serious public health problem. Although most S-OIV infections have a mild, self-limited course, clinical cases resulting in fatalities and associated with variable co-morbidities remain as a serious concern in some individuals. Among such serious complications, there have been few reports of SICM caused by S-OIV infection. We herein report, for the first time in the literature, a case with fatal hemodynamic instability secondary to SICM caused by S-OIV infection with viral pneumonia.

Original Article

Physiologic Effect and Safety of Pumpless Extracorporeal Interventional Lung Assist in Korean Patients with Acute Respiratory Failure: Woo Hyun Cho, Kwangha Lee, Jin Won Huh, Chae Man Lim, Younsuck Koh, Sang Bum Hong; Korean J Crit Care Med. 2010;25(4):235-240.; DOI: https://doi.org/10.4266/kjccm.2010.25.4.235

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Abstract PDF

BACKGROUND
Pumpless interventional lung assist (iLA) uses an extracorporeal gas exchange system without any complex blood pumping technology, and has been shown to reduce CO2 tension and permit protective lung ventilation. The feasibility and safety of iLA were demonstrated in previous studies, but there has been no experience with iLA in Korea. The purpose of this study was to evaluate the feasibility of the iLA device in terms of physiologic efficacy and safety in Korean patients with acute respiratory failure.
METHODS
iLA was implemented in patients with acute respiratory failure who satisfied the predefined criteria of our study. Initiation of iLA followed an algorithm for implementation, ventilator care, and monitoring. Following insertion of arterial and venous cannulas under ultrasound guidance, the physiologic and respiratory variables and incidence of adverse events were monitored.
RESULTS
iLA was implemented in 5 patients and the duration of iLA ranged from 7 hours to 171 hours. At 24 hours after implementation, the mean changes in pH, PaCO2, and PaO2/FiO2 ranged from 7.204 to 7.393, from 68.4 mm Hg to 33 mm Hg, and from 128.7 mm Hg to 165 mm Hg, respectively. During iLA therapy, one adverse event was observed, which presented with hematochezia without hemodynamic change.
CONCLUSIONS
iLA treatment produced effective removal of carbon dioxide and allowed for protective ventilation in severe respiratory failure. An iLA system can easily be installed by percutaneous cannulation, without procedural complications, and without significant adverse events necessitating discontinuation of iLA after implementation.

Citations

Citations to this article as recorded by

A Case of Pumpless Extracorporeal Interventional Lung Assist for Severe Respiratory Failure - A Case Report -
Young-Jae Cho, Ji Yeon Seo, Yu Jung Kim, Jae-Ho Lee, Choon-Taek Lee
Korean Journal of Critical Care Medicine.2012; 27(2): 120. CrossRef
A Case of iLA Application in a Patient with Refractory Asthma Who Is Nonresponsive to Conventional Mechanical Ventilation - A Case Report -
Young Seok Lee, Hyejin Joo, Jae Young Moon, Jin Won Huh, Yeon-Mok Oh, Chae-Man Lim, Younsuck Koh, Sang-Bum Hong
Korean Journal of Critical Care Medicine.2012; 27(2): 108. CrossRef

Case Report

A Case of Respiratory Failure Caused by Gastropleural Fistula: A Case Report: Woo Hyun Cho, Dong Yup Ryu, Sung Yik Lee, Bo Hyun Kim, Yun Seong Kim; Korean J Crit Care Med. 2005;20(2):183-186.

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Abstract PDF: Gastropleural fistula is a very rare disorder, caused by various conditions, such as trauma and postoperative complication, subphrenic abscess, malignancy, hiatal hernia. The major causes of the gastropleural fistula have changed from trauma and subphrenic abscess to postoperative complication of malignant disorders. We report a case of empyema that developed respiratory failure caused by gastropleural fistula in a middle age woman with review of related articles.

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