BACKGROUND: Many physicians hesitate to discuss do-not-resuscitate (DNR) orders with patients or family members in critical situations. In the intensive care unit (ICU), delayed DNR decisions could cause unintentional cardiopulmonary resuscitation, patient distress, and substantial cost. We investigated whether the timing of DNR designation affects patient outcome in the medical ICU. METHODS: We enrolled retrospective patients with written DNR orders in a medical ICU (13 bed) from June 1, 2014 to May 31, 2015. The patients were divided into two groups: early DNR patients for whom DNR orders were implemented within 48 h of ICU admission, and late DNR patients for whom DNR orders were implemented more than 48 h after ICU admission. RESULTS: Herein, 354 patients were admitted to the medical ICU and among them, 80 (22.6%) patients had requested DNR orders. Of these patients, 37 (46.3%) had designated DNR orders within 48 hours of ICU admission and 43 (53.7%) patients had designated DNR orders more than 48 hours after ICU admission. Compared with early DNR patients, late DNR patients tended to withhold or withdraw life-sustaining management (18.9% vs. 37.2%, p = 0.072). DNR consent forms were signed by family members instead of the patients. Septic shock was the most common cause of medical ICU admission in both the early and late DNR patients (54.1% vs. 37.2%, p = 0.131). There was no difference in in-hospital mortality (83.8% vs. 81.4%, p = 0.779). Late DNR patients had longer ICU stays than early DNR patients (7.4 ± 8.1 vs. 19.7 ± 19.2, p < 0.001). CONCLUSIONS: Clinical outcomes are not influenced by the time of DNR designation in the medical ICU. The late DNR group is associated with a longer length of ICU stay and a tendency of withholding or withdrawing life-sustaining treatment. However, further studies are needed to clarify the guideline for end-of-life care in critically ill patients.
Advance Directives ; Cardiopulmonary Resuscitation ; Consent Forms ; Critical Illness* ; Hospital Mortality ; Humans ; Intensive Care Units ; Resuscitation Orders* ; Retrospective Studies ; Shock, Septic

No abstract available.

The preferred site of spontaneous intracerebral hemorrhage(SICH) is the supratentorial area, especially the basal ganglia. Large hematomas frequently spread into the ventricle, and in the case of intraventricular hematomas, varying degrees of fresh blood are found within the subarachnoid space. Cases in which SICH of the basal ganglia ruptures the insular cortex and causes thick subarachnoid hemorrhage(SAH) in the basal cisterns, are, however, rare. The authors report a rare case of putaminal SICH with intraventricular hemorrhage(IVH) and SAH in the basal cisterns. This 58-year-old female was stuporous on admission. Neurological examination revealed Glasgow coma scale score 7, left hemiparesis, positive Babinski's sign and neck stiffness. Brain CT showed a large intracerebral hematoma in the right basal ganglion and associated intraventricular hematoma and SAH in the basal cistern. Cerebral angiography demonstrated a small saccular aneurysm at the right M1. Right pterional and trans-sylvian approach revealed thick SAH in the sylvian fissure and a small unruptured aneurysm at the early bifurcation of the middle cerebral artery. The putaminal hematoma had ruptured into the sylvian fissure through a natural opening at the insular cortex between M2 branches. This case illustrates that hypertensive SICH should be included in the differential diagnosis of basal cistern SAH associated with SICH.
Aneurysm ; Basal Ganglia ; Brain ; Cerebral Angiography ; Diagnosis, Differential ; Female ; Ganglion Cysts ; Glasgow Coma Scale ; Hematoma ; Humans ; Middle Aged ; Middle Cerebral Artery ; Neck ; Neurologic Examination ; Paresis ; Putaminal Hemorrhage* ; Reflex, Babinski ; Rupture ; Stupor ; Subarachnoid Hemorrhage* ; Subarachnoid Space

Cardiovascular reactions to acrylic bone cement in patients with total hip replacement are a common complication. Hypotension and arrhythmias are the most frequently observed symptoms. Elderly patients with fractures of the femoral neck constitute a special risk group. In some patients these reactions will be fatal. The mechanisms suggested to explain these reactions are embolism of air, polymer or fat, reaction to the heat, and toxic or vasodilating effects of the acrylic monomer. It may be that potentially lethal complications only occur if two or more of the predisposing factors (hypovolemia, myocardial insufficiency, arrhythmia, embolism, histamine release) are present simultaneously. We have experienced a case of complication following bone cement insertion under spinal anesthesia. This female patient was 91 years old with old myocardial infarction on EKG.
Aged ; Anesthesia, Spinal ; Arrhythmias, Cardiac ; Arthroplasty, Replacement, Hip* ; Causality ; Electrocardiography ; Embolism ; Female ; Femur Neck ; Heart Arrest* ; Histamine ; Hot Temperature ; Humans ; Hypotension ; Methylmethacrylate* ; Myocardial Infarction ; Polymers ; Polymethyl Methacrylate

Kawasaki disease (KD) is an acute, self-limiting, small-vessel vasculitis with an unknown cause that affects children between the ages of 6 months and 5 years. Its important acute complication is coronary artery aneurysm. Myocardial infarction caused by thrombus formation inside the aneurysm or by organic obstructive lesion following the regression of aneurysm is the principal cause of death in KD. However, coronary artery aneurysms and stenosis requiring surgery are rare in KD. We report an our experience about anesthetic management of child undergone off-pump coronary artery bypass grafting surgery because of coronary artery aneurysm associated with KD.
Anesthesia ; Aneurysm ; Cause of Death ; Child ; Constriction, Pathologic ; Coronary Artery Bypass, Off-Pump ; Coronary Disease ; Coronary Vessels ; Humans ; Infarction ; Mucocutaneous Lymph Node Syndrome ; Myocardial Infarction ; Thrombosis ; Transplants ; Vasculitis

OBJECTIVE: Our objective was (1) to determine if serum creatine kinase (CK) activity is reduced in rheumatoid arthritis (RA) compared with that of noninflammatory rheumatic diseases, (2) to examine the recently described association of low CK activity and disease variables in our RA population, and (3) to examine the influence of steroid on serum CK activity in patients with RA. METHODS: Cross sectional and longitudinal retrospective analyses of clinical and biochemical data of consecutive patients with RA and noninflammatory arthropathies. In all subjects we evaulated age, sex, weight, and, only for patients with RA, history of use of corticosteroids and Ritchie index. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), hemoglobin, and platelet count were simultaneously determined as variables of disease activity. CK activity was determined by automated biochemical analyzer (Hitachi 747, Japan). RESULTS: Serum CK activity was significantly reduced in RA (mean+SD: 45.7 +24.2 IU/L) compared to controls (81.3+33.9 IU/L) (p < 0.001). Ritchie index, CRP, and platelet count correlated inversely with CK values (correlation coefficient: 0.31, p < 0.01; 0. 45, p < 0.001; 0.42, p < 0.001, respectively). Patients taking steroids had lower CK activity than those without steroid, but not statistically significant.
Adrenal Cortex Hormones ; Arthritis, Rheumatoid* ; Blood Sedimentation ; C-Reactive Protein ; Creatine Kinase* ; Creatine* ; Humans ; Platelet Count ; Retrospective Studies ; Rheumatic Diseases ; Steroids

Hemorrhagic cystitis is potentially life-threatening sequellae of chemotherapy using oxazaphosphorine alkylating agents (cyclophosphamide and ifosfamide). Mesna contains a sulfhydryl group that is believed to bind acrolein within the urinary collecting system and reduce the hemorrhagic cystitis without affecting the chemotherapeutic potential. To date, about thirty cases of hypersensitivity or allergic reactions of the delayed and urticarial type associated with mesna have been reported. We reported two patients with systemic lupus erythematosus who developed facial rash and flushing associated with mesna which imitate malar rash.
Acrolein ; Alkylating Agents ; Cyclophosphamide ; Cystitis ; Drug Therapy ; Exanthema* ; Flushing ; Humans ; Hypersensitivity* ; Lupus Erythematosus, Systemic ; Mesna*

Volume deficiency and poorly defined cupid's bow of the upper lip are frequently encountered problems in secondary cleft lip deformities. In this report, we present the method of a periumbilical dermal graft for correcting secondary cleft lip deformity. A 17-year-old male patient presented with a poorly defined notching cupid's bow and volume deficiency of the upper lip. He had undergone cleft lip surgery when he was 2 years old. We planned to perform a periumbilical dermal graft. There were sufficient amount of periumbilical subdermis and fat tissue thickness to obtain abundant volume. The periumbilical contour was similar to the natural contour of the lip. Less scarring was expected. There was no need to change the posture during operation, making it easy to harvest. Postoperative evaluations showed vermilion symmetry. Ideal cupid's bow shape and position were achieved without color mismatch. As a result, we obtained an ideal volume of the upper lip. Therefore a periumbilical dermal graft is a good option for correcting volume deficiency of the lip with good aesthetic outcomes.
Adolescent ; Cicatrix ; Cleft Lip* ; Congenital Abnormalities* ; Dermis ; Humans ; Lip ; Male ; Methods ; Posture ; Transplants* ; Umbilicus

BACKGROUND: Current guidelines of advanced trauma life support recommend open thoracotomy when pericardiocentesis reveals bloody pericardial effusion in patients with blunt chest trauma. However, open thoracotomy may not be always required for treating patients alive until arriving emergency department, because rapid accumulation of the blood into pericardial space results in immediate death at scene. We report our experiences of treating traumatic pericardial effusion, and discuss the therapeutic modality in patients with traumatic pericardial effusion. METHODS: The study consisted of 37 patients(20 males and 17 females with the mean age 42) sustaining traumatic pericardial effusion. The patients were divided according to treatment modality into 3 groups(group I : patients receiving conservative management, group II : patients treated with pericardiocentesis, group III : patients required emergency thoracotomy). We compared clinical presentations, hemodynamic profiles and echocardiographic findings among three groups. RESULTS: Cardiac tamponade was present in 14 of 37 patients. Pericardiocentesis was performed in 13 patients, and open thoracotomy in 4 patients. Pericardiocentesis was curative in 9 patients. Thoracotomy was performed in only 3(24%) of 13 patients required pericardiocentesis. 3(75%) of 4 patients having moderate or severe pericardial effusion from penetrating injury were required open thoracotomy. CONCLUSION: In selected patients who have traumatic pericardial effusion by blunt chest injury, pericardiocentesis may be curative, and thoracotomy may not be inquired as long as bleeding via indwelling pericardial catheter is not sustained after pericardiocentesis.
Advanced Trauma Life Support Care ; Cardiac Tamponade ; Catheters ; Echocardiography ; Emergencies ; Emergency Service, Hospital ; Female ; Hemodynamics ; Hemorrhage ; Humans ; Male ; Pericardial Effusion* ; Pericardiocentesis ; Thoracic Injuries ; Thoracotomy ; Thorax

Maxillary sinus mucocele can occur due to many medical factors such as chronic infection, allergic sinonasal disease, trauma, and previous surgery. However, it occurs mainly after Caldwell-Luc operation, usually more than 10 years after surgery. There are a few cases of maxillary sinus mucocele with ocular symptoms. Also, a case causing ocular symptoms because of invasion to the orbital floor is rare. Therefore, we report a case of a 55-year-old male patient who underwent Caldwell-Luc operation about 30 years ago. Then, symptoms such as exophthalmos, diplopia, and visual disturbance developed suddenly 3 months prior to admission. Computed tomography showed a cyst invading the orbital floor which resulted in eyeball deviation. The orbital floor defect measured approximately 2.5×3.3 cm. Maxillary sinus mucocele was removed through an endoscopic approach. After this, we reconstructed the orbital floor through a subciliary incision. Observation was carried out after three years, and ocular symptoms such as diplopia and exophthalmos did not recur.
Diplopia ; Exophthalmos ; Humans ; Male ; Maxillary Sinus* ; Middle Aged ; Mucocele* ; Orbit*