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Sedation in the Critically Ill Patients (중환자에서의 진정 진통 치료)

  • Kim, Tae-Hyung
    • Tuberculosis and Respiratory Diseases
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    • v.72 no.2
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    • pp.117-123
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    • 2012
  • Optimal level of sedation and analgesia is important for the comfort and safety of critically ill patients. However, suboptimal sedation is relatively common in the intensive care unit (ICU) and it could cause prolonged mechanical ventilation and ICU stay, also increase delirium and ICU acquired weakness and resultant decreased survival. Therefore, accurate assessment of the level of sedation and analgesia, maintaining adequate level of sedation, and daily evaluation of each patient and following adjustment could be important treatment strategy in critically ill patients. Recently, the strategy for sedation in the ICU is changing toward the direction of lowering sedation level or even "no sedation" with concurrent use of analgesics and the use of ultra short acting analgesics could be helpful in some patients. Clinicians should be aware of the importance of algorithmic approach including daily interruption of sedative and assessment of sedation level and especially in the patients under mechanical ventilation, organizational approaches such as the 'ABCDE' bundle could improve the management of critically ill patients.

Does the Mean Arterial Pressure Influence Mortality Rate in Patients with Acute Hypoxemic Respiratory Failure under Mechanical Ventilation?

  • Gjonbrataj, Juarda;Kim, Hyun Jung;Jung, Hye In;Choi, Won-Il
    • Tuberculosis and Respiratory Diseases
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    • v.78 no.2
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    • pp.85-91
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    • 2015
  • Background: In sepsis patients, target mean arterial pressures (MAPs) greater than 65 mm Hg are recommended. However, there is no such recommendation for patients receiving mechanical ventilation. We aimed to evaluate the influence of MAP over the first 24 hours after intensive care unit (ICU) admission on the mortality rate at 60 days post-admission in patients showing acute hypoxemic respiratory failure under mechanical ventilation. Methods: This prospective, multicenter study included 22 ICUs and compared the mortality and clinical outcomes in patients showing acute hypoxemic respiratory failure with high (75-90 mm Hg) and low (65-74.9 mm Hg) MAPs over the first 24 hours of admission to the ICU. Results: Of the 844 patients with acute hypoxemic respiratory failure, 338 had a sustained MAP of 65-90 mm Hg over the first 24 hours of admission to the ICU. At 60 days, the mortality rates in the low (26.2%) and high (24.5%) MAP groups were not significantly different. The ICU days, hospital days, and 60-day mortality rate did not differ between the groups. Conclusion: In the first 24 hours of ICU admission, MAP range between 65 and 90 mm Hg in patients with acute hypoxemic respiratory failure under mechanical ventilation may not cause significantly differences in 60-day mortality.

Extended Use of Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: A Retrospective Multicenter Study

  • Kim, Won-Young;Park, SeungYong;Kim, Hwa Jung;Baek, Moon Seong;Chung, Chi Ryang;Park, So Hee;Kang, Byung Ju;Oh, Jin Young;Cho, Woo Hyun;Sim, Yun Su;Cho, Young-Jae;Park, Sunghoon;Kim, Jung-Hyun;Hong, Sang-Bum
    • Tuberculosis and Respiratory Diseases
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    • v.82 no.3
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    • pp.251-260
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    • 2019
  • Background: Beyond its current function as a rescue therapy in acute respiratory distress syndrome (ARDS), extracorporeal membrane oxygenation (ECMO) may be applied in ARDS patients with less severe hypoxemia to facilitate lung protective ventilation. The purpose of this study was to evaluate the efficacy of extended ECMO use in ARDS patients. Methods: This study reviewed 223 adult patients who had been admitted to the intensive care units of 11 hospitals in Korea and subsequently treated using ECMO. Among them, the 62 who required ECMO for ARDS were analyzed. The patients were divided into two groups according to pre-ECMO arterial blood gas: an extended group (n=14) and a conventional group (n=48). Results: Baseline characteristics were not different between the groups. The median arterial carbon dioxide tension/fraction of inspired oxygen ($FiO_2$) ratio was higher (97 vs. 61, p<0.001) while the median $FiO_2$ was lower (0.8 vs. 1.0, p<0.001) in the extended compared to the conventional group. The 60-day mortality was 21% in the extended group and 54% in the conventional group (p=0.03). Multivariate analysis indicated that the extended use of ECMO was independently associated with reduced 60-day mortality (odds ratio, 0.10; 95% confidence interval, 0.02-0.64; p=0.02). Lower median peak inspiratory pressure and median dynamic driving pressure were observed in the extended group 24 hours after ECMO support. Conclusion: Extended indications of ECMO implementation coupled with protective ventilator settings may improve the clinical outcome of patients with ARDS.

Systemic Corticosteroid Treatment in Severe Community-Acquired Pneumonia Requiring Mechanical Ventilation: Impact on Outcomes and Complications (기계환기가 요구된 중증 지역사회획득 폐렴에서 전신 스테로이드의 투여가 예후와 합병증의 발생에 미치는 영향)

  • Lee, Seung-Jun;Lee, Seung-Hun;Kim, You-Eun;Cho, Yu-Ji;Jeong, Yi-Yeong;Kim, Ho-Cheol;Lee, Jong-Deog;Kim, Jang-Rak;Hwang, Young-Sil
    • Tuberculosis and Respiratory Diseases
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    • v.72 no.2
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    • pp.149-155
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    • 2012
  • Background: This study is to evaluate the effect of systemic corticosteroid on the clinical outcomes and the occurrence of complications in mechanical ventilated patients with severe community-acquired pneumonia (CAP). Methods: We retrospectively assessed the clinical outcomes and complications in patients with severe CAP admitted to ICU between March 1, 2003 and July 28, 2009. Outcomes were measured by hospital mortality after ICU admission, duration of mechanical ventilation (MV), ICU, and hospital stay. Complications such as ventilator associated pneumonia (VAP), catheter related-blood stream infection (CR-BSI), and upper gastrointestinal (UGI) bleeding during ICU stay were assessed. Results: Of the 93 patients, 36 patients received corticosteroids over 7 days while 57 patients did not receive corticosteroids. Age, underlying disease, APACHE II, PSI score, and use of vasopressor were not different between two groups. In-hospital mortality was 30.5% in the steroid group and 36.8% in the non-steroid group (p>0.05). The major complications such as VAP, CR-BSI and UGI bleeding was significantly higher in the steroid group than in the non-steroid group (19.4% vs. 7%, p<0.05). The use of steroids and the duration of ICU stay were significantly associated with the development of major complications during ones ICU stay (p<0.05). Conclusion: Systemic corticosteroid in patients with severe CAP requiring mechanical ventilation may have no beneficial effect on clinical outcomes like duration of ICU stay and in-hospital mortality but may contribute to the development of ICU acquired complications.

The Prognostic Value of the Charlson's Comorbidity Index in Patients with Prolonged Acute Mechanical Ventilation: A Single Center Experience

  • Song, Seung Eon;Lee, Sang Hee;Jo, Eun-Jung;Eom, Jung Seop;Mok, Jeong Ha;Kim, Mi-Hyun;Kim, Ki Uk;Lee, Min Ki;Lee, Kwangha
    • Tuberculosis and Respiratory Diseases
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    • v.79 no.4
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    • pp.289-294
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    • 2016
  • Background: The aim of our study was to evaluate the prognostic value of Charlson's weighted index of comorbidities (WIC) in patients with prolonged acute mechanical ventilation (PAMV, ventilator care ${\geq}96$ hours). Methods: We retrospectively enrolled 299 Korean PAMV patients who were admitted in a medical intensive care unit (ICU) of a university-affiliated tertiary care hospital between 2008 and 2013. Survivors were defined as patients who survived for 60 days after ICU admission. Results: The patients' mean age was $65.1{\pm}14.1$ years and 70.6% were male. The mean ICU and hospital length of stay was $21.9{\pm}19.7$ and $39.4{\pm}39.1$ days, respectively. In addition, the 60-day mortality rate after ICU admission was 35.5%. The mean WIC was $2.3{\pm}1.8$, with significant differences between nonsurvivors and survivors ($2.7{\pm}2.1$ vs. $2.1{\pm}1.7$, p<0.05). The area under the curve of receiver-operating-characteristics curve for WIC was 0.593 (95% confidence interval [CI], 0.523-0.661; p<0.05). Based on Kaplan-Meier curves of 60-day survival, WIC ${\geq}5$ had statistically lower survival than WIC <5 (logrank test, p<0.05). In a multivariate Cox proportional hazard model, WIC ${\geq}5$ was associated with poor prognosis (hazard ratio, 1.901; 95% CI, 1.140-3.171; p<0.05). The mortality rate of patients with WIC ${\geq}5$ was 54.2%. Conclusion: Our study showed a WIC score ${\geq}5$ might be helpful in predicting 60-day mortality in PAMV patients.

Clinical Practice Guideline of Acute Respiratory Distress Syndrome

  • Cho, Young-Jae;Moon, Jae Young;Shin, Ein-Soon;Kim, Je Hyeong;Jung, Hoon;Park, So Young;Kim, Ho Cheol;Sim, Yun Su;Rhee, Chin Kook;Lim, Jaemin;Lee, Seok Jeong;Lee, Won-Yeon;Lee, Hyun Jeong;Kwak, Sang Hyun;Kang, Eun Kyeong;Chung, Kyung Soo;Choi, Won-Il
    • Tuberculosis and Respiratory Diseases
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    • v.79 no.4
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    • pp.214-233
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    • 2016
  • There is no well-stated practical guideline for mechanically ventilated patients with or without acute respiratory distress syndrome (ARDS). We generate strong (1) and weak (2) grade of recommendations based on high (A), moderate (B) and low (C) grade in the quality of evidence. In patients with ARDS, we recommend low tidal volume ventilation (1A) and prone position if it is not contraindicated (1B) to reduce their mortality. However, we did not support high-frequency oscillatory ventilation (1B) and inhaled nitric oxide (1A) as a standard treatment. We also suggest high positive end-expiratory pressure (2B), extracorporeal membrane oxygenation as a rescue therapy (2C), and neuromuscular blockage for 48 hours after starting mechanical ventilation (2B). The application of recruitment maneuver may reduce mortality (2B), however, the use of systemic steroids cannot reduce mortality (2B). In mechanically ventilated patients, we recommend light sedation (1B) and low tidal volume even without ARDS (1B) and suggest lung protective ventilation strategy during the operation to lower the incidence of lung complications including ARDS (2B). Early tracheostomy in mechanically ventilated patients can be performed only in limited patients (2A). In conclusion, of 12 recommendations, nine were in the management of ARDS, and three for mechanically ventilated patients.

Unplanned Extubation in Patients with Mechanical Ventilation: Experience in the Medical Intensive Care Unit of a Single Tertiary Hospital

  • Lee, Tae Won;Hong, Jeong Woo;Yoo, Jung-Wan;Ju, Sunmi;Lee, Seung Hun;Lee, Seung Jun;Cho, Yu Ji;Jeong, Yi Yeong;Lee, Jong Deog;Kim, Ho Cheol
    • Tuberculosis and Respiratory Diseases
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    • v.78 no.4
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    • pp.336-340
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    • 2015
  • Background: Potentially harmful unplanned extubation (UE) may occur in patients on mechanical ventilation (MV) in an intensive care unit (ICU) setting. This study aimed to evaluate the clinical characteristics of UE and its impact on clinical outcomes in patients with MV in a medical ICU (MICU). Methods: We retrospectively evaluated MICU data prospectively collected between December 2011 and May 2014. Results: A total of 468 patients were admitted to the MICU, of whom 450 were on MV. Of the patients on MV, 30 (6.7%) experienced UE; 13 (43.3%) required reintubation after UE, whereas 17 (56.7%) did not require reintubation. Patients who required reintubation had a significantly longer MV duration and ICU stay than did those not requiring reintubation ($19.4{\pm}15.1days$ vs. $5.9{\pm}5.9days$ days and $18.1{\pm}14.2days$ vs. $7.1{\pm}6.5days$, respectively; p<0.05). In addition, mortality rate was significantly higher among patients requiring reintubation than among those not requiring reintubation (54.5% vs. 5.9%; p=0.007). These two groups of patients exhibited no significant differences, within 2 hours after UE, in the fraction of inspired oxygen, blood pressure, heart rate, respiratory rate, and pH. Conclusion: Although reintubation may not always be required in patients with UE, it is associated with a poor outcome after UE.

Chest CT Parameters to Predict the Major Adverse Events in Acute Submassive Pulmonary Embolism (신종인플루엔자 폐렴환자에서 임상적 악화와 연관된 초기 전산화 단층촬영 소견)

  • Ryoo, Seung-Mok;Kim, Won-Young;Lee, Choong-Wook;Sohn, Chang-Hwan;Seo, Dong-Woo;Lee, Yoon-Seon;Lee, Jae-Ho;Oh, Bum-Jin;Kim, Won;Lim, Kyoung-Soo
    • Tuberculosis and Respiratory Diseases
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    • v.69 no.2
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    • pp.103-107
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    • 2010
  • Background: The aim of the present study was to evaluate whether findings on initial chest computed tomography (CT) of influenza pneumonia can help predict clinical outcome. Methods: We reviewed all adult patients admitted to the Emergency Department (ED) with a confirmed diagnosis of novel influenza A H1N1 virus (2009 H1N1) pneumonia, who underwent chest CT upon admission between Aug 26, 2009 and Jan 31, 2010. Radiologic findings were characterized by type and pattern of opacities and zonal distribution. Clinical outcome measures were intensive care unit (ICU) admission, mechanical ventilation, and inhospital death. Results: Of 59 patients diagnosed with 2009 H1N1 pneumonia, 41 (69.5%) underwent chest CT on admission into ED. Nine (22%) of these patients developed adverse clinical outcomes requiring the following treatments: 9 (22.0%) ICU admissions, 5 (12.2%) mechanical ventilation, and 3 (7.3%) inhospital deaths. Counting the number of patients with more than 4 involved lobes, the sensitivity, specificity, positive predictive value, and negative predictive value for detection of adverse clinical outcome were 67%, 84%, 55% and 80%, respectively. Conclusion: Extensive involvement of both lungs (over 4 lobes) is related to ICU admission, mechanical ventilation, and inhospital death. Initial chest CT may help predict an adverse clinical outcome of patients with 2009 H1N1 influenza pneumonia.

Clinical Analysis of Ventilator-Associated Pneumonia in Chest Trauma (흉부외상에 의한 인공호흡기치료 환자에서 발생한 폐렴의 임상분석)

  • Yun, Ju-Sik;Oh, Bong-Suk;Ryu, Sang-Woo;Jang, Won-Chae
    • Journal of Chest Surgery
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    • v.41 no.6
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    • pp.736-741
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    • 2008
  • Background: Pneumonia continues to be the most common major infection in trauma patients. Despite the advances in prevention, diagnosis, and treatment for pneumonia, it remains a major cause of morbidity and mortality. The aim of this retrospective study is to identify the risk factors and clinical features of ventilator-associated pneumonia among chest trauma patients. Material and Method: The study population consisted of 78 mechanically ventilated patients admitted to the ICU of Chonnam National University Hospital between January, 2001, and December, 2006. The patients were divided into two groups: those with pneumonia (Group I) and without pneumonia (Group II). Clinical predictors of the occurrence and mortality for ventilator associated pneumonia were analyzed. Result: There were 57 men and 21 women, with a mean age of $48.3{\pm}19.9$ years. Almost half of the patients, 48.7% (38 of 78), had pneumonia. The mortality rate was 21.0% (8 of 38) in Group I and 2.5% (1 of 40) in Group II. The predictors of ventilator-associated pneumonia were the duration of mechanical ventilation (17.4 days vs 6.5 days, p<0.001), the mean stay in the ICU (21.7 days vs 9.7 days, p<0.001), the use of inotropics due to hemodynamic instability (63.1% vs 25.0%, p=0.001), and the serum level of CRP ($11.3{\pm}7.8$ vs $6.4{\pm}7.3$, p=0.006). Conclusion: Posttraumatic ventilator-associated pneumonia was significantly related with the duration of mechanical ventilation, the mean stay in ICU, and the use of inotropics due to hemodynamic instability. The serum level of CRP at admission was higher in the pneumonia group. Morbidity and mortality can be reduced by early identification of predictive factors for developing pneumonia in chest trauma patients.