PURPOSE: Epidemiologic data on emergency department (ED) patients with systemic inflammatory response syndrome (SIRS) are limited. We examined the prevalence, risk factors, etiologies and outcomes for the various forms of the SIRS, as well as their relationships with infection in ED. METHODS: The subjects were 16,718 non-trauma adult patients who visited a 900- bed university hospital ED between November 2006 and October 2007. ED records were reviewed, and all patients meeting the criteria for SIRS were enrolled retrospectively. SIRS patients were further subdivided into four groups (non-infectious SIRS, sepsis, severe sepsis, septic shock). Baseline characteristics, ED dispositions, and prognoses of patients in each group were analyzed. RESULTS: Among 16,718 patients, there were 2,790 SIRS patients (16.7%). The SIRS patient group was composed of 1,546 non-infectious SIRS patients (55.4%), 1,078 sepsis patients (38.6%), 119 severe sepsis patients (4.3%), and 47 septic shock patients (1.7%). ED patients with SIRS were older on average than non-SIRS patients (52 versus 48, p<0.001). The most common sources of SIRS was the gastrointestinal system (28.3%), followed by the respiratory system (22.9%) and the genitourinary system (11.8%). Pneumonia (18.9%) was the single most common cause of infectious SIRS. The admission rate was higher for SIRS patients than for non-SIRS patients (44% versus 21%). The 28-day mortality rate for non-infectious SIRS, sepsis, severe sepsis, and septic shock patients were 4.5%, 1.3%, 25.2%, and 63.8%. Sepsis severity was correlated with increased rates of both hospital admission and mortality (p<0.001). CONCLUSION: 55% of SIRS patients who visited the ED had a non-infectious cause. SIRS patients were older than non-SIRS patients, and hospital and ICU admission rates were also higher. Sepsis severity was correlated with older age, increased hospital admission rate, increased ICU admission rate, and increased mortality rate.
Adult ; Emergencies ; Epidemiologic Studies ; Hospitals ; Humans ; Pneumonia ; Prevalence ; Prognosis ; Respiratory System ; Retrospective Studies ; Risk Factors ; Sepsis ; Shock, Septic ; Systemic Inflammatory Response Syndrome ; Urogenital System

We report on an anesthetic experience with a 74-year-old female with Isaacs' syndrome, who underwent elective surgery for open rotator cuff repair. Isaacs' syndrome is a rare peripheral motor neuron disorder with clinical manifestations such as involuntary muscle twitching, cramps, mild weakness and increased sweating. To avoid prolonged neuromuscular blockade, the patient was observed with neuromuscular monitoring during total intravenous anesthesia with propofol, remifentanil, and atracurium. No adverse events were observed during the anesthetic management, and the patient recovered smoothly from the neuromuscular blockade. We describe the clinical characteristics of Isaacs' syndrome and its specific considerations in anesthesia.
Anesthesia ; Anesthesia, Intravenous ; Atracurium ; Female ; Humans ; Isaacs Syndrome ; Motor Neurons ; Muscle Cramp ; Muscle, Smooth ; Neuromuscular Blockade ; Neuromuscular Monitoring ; Piperidines ; Propofol ; Rotator Cuff ; Sweat ; Sweating

BACKGROUND: Remifentanil is a short-acting drug with a rapid onset that is useful in general anesthesia. Recently, however, it has been suggested that the use of opioids during surgery may cause opioid-induced hyperalgesia (OIH). Researchers have recently reported that esmolol, an ultra-short-acing beta1 receptor antagonist, reduces the postoperative requirement for morphine and provides more effective analgesia than the administration of remifentanil and ketamine. Hence, this study was conducted to determine whether esmolol reduces early postoperative pain in patients who are continuously infused with remifentanil for anesthesia during laparoscopic cholecystectomy. METHODS: Sixty patients scheduled to undergo laparoscopic cholecystectomy were randomly divided into three groups. Anesthesia was maintained with sevoflurane and 4 ng/ml (target-controlled infusion) of remifentanil in all patients. Esmolol (0.5 mg/kg) was injected and followed with a continuous dosage of 10 microg/kg/min in the esmolol group (n = 20). Ketamine (0.3 mg/kg) was injected and followed with a continuous dosage of 3 microg/kg/min in the ketamine group (n = 20), while the control group was injected and infused with an equal amount of normal saline. Postoperative pain score (visual analog scale [VAS]) and analgesic requirements were compared for the first 6 hours of the postoperative period. RESULTS: The pain score (VAS) and fentanyl requirement for 15 minutes after surgery were lower in the esmolol and ketamine groups compared with the control group (P < 0.05). There were no differences between the esmolol and ketamine groups. CONCLUSIONS: Intraoperative esmolol infusion during laparoscopic cholecystectomy reduced opioid requirement and pain score (VAS) during the early postoperative period after remifentanil-based anesthesia.
Analgesia ; Analgesics, Opioid ; Anesthesia* ; Anesthesia, General ; Cholecystectomy, Laparoscopic* ; Fentanyl ; Humans ; Hyperalgesia ; Ketamine* ; Morphine ; Pain, Postoperative* ; Postoperative Period

PURPOSE: Biochemical markers can help predict neurological outcome in post-resuscitation patients. This prospective study evaluated the prognostic value of serum S100B protein and neuron-specific enolase (NSE) time courses in predicting unfavorable neurological outcomes. METHODS: We serially measured serum S100B protein and NSE levels 12 times during the 96 h after the return of spontaneous circulation (ROSC) in 40 patients. Neurological outcome was assessed at 6 months after cardiac arrest. Patients were divided into good (CPC 1 to 2) and poor (CPC 3 to 5) neurological outcome groups and assessed for cerebral performance category scores. We compared the two groups at each serum value and calculated cut-off values. RESULTS: Serum S100B protein levels over the study period, except at 4 hours, and NSE levels from 14 hours after ROSC were significantly higher in the poor neurological outcome group (n=32) than the good neurological outcome group (n=8). The most predictive serum S100B protein and NSE times were at 14 hours (cut off value=0.16 microgram/L, sensitivity 81.8%, specificity 100%, AUC=0.938) and 54 hours (cut off value=19.21 microgram/L, sensitivity 86.4%, specificity 100%, AUC=0.932). CONCLUSION: Serum S100B protein and NSE levels are early and useful markers for assessing neurological outcome after successful resuscitation from cardiac arrest.
Biomarkers ; Emergencies ; Heart Arrest ; Humans ; Nerve Growth Factors ; Phosphopyruvate Hydratase ; Prognosis ; Prospective Studies ; Resuscitation ; S100 Proteins ; Sensitivity and Specificity ; Sepsis ; Shock, Septic ; Triage

PURPOSE: The goal of this study was to determine the suitability of ultrasonography for detecting endotracheal tube placement in the emergency department. METHODS: Emergency physicians examined patients immediately following intubation or after intubated patients were transferred. A linear ultrasound transducer was placed transversely on the cricothyroid membrane and suprasternal notch in order to check for the "comet head and tail sign"and "double ring sign", and a sagittal view of the neck was also obtained in order to look for the "bold parallel lines sign". Subsequently, simple thoracic sonography and color doppler sonography were used to check for the "lung sliding sign". The examiner evaluated whether the tube was placed in trachea, the esophagus, or the right main bronchus. The accuracy of ultrasonography was calculated, and the required time for ultrasonography was checked. RESULTS: One hundred ten patients were enrolled in the study. The endotracheal tube was placed in the trachea in 107 patients, in the esophagus in 2 patients, and in the right main bronchus in 1 patient. The sensitivity and specificity of ultrasonography were 100%. The bold parallel lines sign and lung sliding sign proved to be good indicators of endotracheal tube placement. The average required time for ultrasonography was 28.6+/-5.8 seconds. It was difficult to determine tube placement by thoracic ultrasonography in patients with pneumothorax, hemothorax, pleural effusion, or empyema. CONCLUSION: Ultrasonography is well suited for confirming endotracheal tube placement in the emergency department.
Bronchi ; Emergencies* ; Emergency Service, Hospital* ; Empyema ; Esophagus ; Head ; Hemothorax ; Humans ; Intubation ; Lung ; Membranes ; Neck ; Pleural Effusion ; Pneumothorax ; Sensitivity and Specificity ; Trachea ; Transducers ; Ultrasonography*

Air injected into the epidural space may spread along the nerves of the paravertebral space. Depending on the location of the air, neurologic complications such as multiradicular syndrome, lumbar root compression, and even paraplegia may occur. However, cases of motor weakness caused by air bubbles after caudal epidural injection are rare. A 44-year-old female patient received a caudal epidural injection after an air-acceptance test. Four hours later, she complained of motor weakness in the right lower extremity and numbness of the S1 dermatome. Magnetic resonance imaging showed no anomalies other than an air bubble measuring 13 mm in length and 0.337 ml in volume positioned near the right S1 root. Her symptoms completely regressed within 48 hours.
Epidural Space ; Female ; Humans ; Hypesthesia ; Injections, Epidural ; Lower Extremity ; Magnetic Resonance Imaging ; Paraplegia

The infectious complications after renal transplantation remain as an important causes of both mortality and graft loss. The lung is the most common target for post-transplant infection. We analyzed the causative agents, treatments and outcomes of post-transplant pulmonary infections. From 1990 to 1998, 192 renal allografts were performed at Hallym University Hospital. Seven cases (3.6%) of 5 males and 2 females developed serious pulmonary infections and required hospitalization. The mean age was 42.6 years. The onsets of pulmonary infections were from a month to 6 months in 3 cases, from 6 months to a year in one case and after a year in 3 cases. Triple therapy regimen was used in 4 cases as an immunosuppression therapy. Acute rejections developed in 6 cases. Causative organisms were Cytomegalovirus in 2 cases, Mycobacteria in 2 cases, Aspergillus in a case, Nocardia in a case and unknown in a case. Despite appropriate antibiotics, four patients did not respond to the treatment and died. The early recognition of infection and appropriate therapy is important to reduce fatal consequence.
Allografts ; Anti-Bacterial Agents ; Aspergillus ; Cytomegalovirus ; Female ; Hospitalization ; Humans ; Immunosuppression ; Kidney Transplantation* ; Kidney* ; Lung ; Male ; Mortality ; Nocardia ; Transplants