Extracorporeal membrane oxygenation (ECMO) is frequently associated with bleeding and coagulopathy complications, which may lead to the need for transfusion of multiple blood products. However, blood transfusions are known to increase morbidity and mortality, as well as hospital cost, in critically ill patients. In current practice, patients on ECMO receive a transfusion, on average, of 1-5 packed red blood cells (RBCs)/day, with platelet transfusion accounting for the largest portion of transfusion volume. Generally, adult patients require more transfusions than neonates or children, and patients receiving venovenous ECMO for respiratory failure tend to need smaller transfusion volumes compared to those receiving venoarterial ECMO for cardiac failure. Observation studies have reported that a higher transfusion volume was associated with increased mortality. To date, the evidence for transfusion in patients undergoing ECMO is limited; most knowledge on transfusion strategies was extrapolated from studies in critically ill patients. However, current data support a restrictive blood transfusion strategy for ECMO patients, and a low transfusion trigger seems to be safe and reasonable.
Adult ; Blood Transfusion* ; Child ; Critical Illness ; Erythrocytes ; Extracorporeal Membrane Oxygenation* ; Heart Failure ; Hemorrhage ; Hospital Costs ; Humans ; Infant, Newborn ; Mortality ; Platelet Transfusion ; Respiratory Insufficiency

PURPOSE: Acute disseminated encephalomyelitis (ADEM) is a demyelinating disease of the central nervous system and mostly develops after viral illness or vaccinations. We investigated the clinical differences and neurologic outcomes according to the distribution of the lesions on brain MRI. METHODS: The study group was composed of 21 patients from January 1995 to August 2003 in Kyunghee University hospital. We grouped the patients according to the MRI findings as follows. Group I (14 cases): Multi- or unifocal lesions only in the cerebral white matter. Group II (7 cases): lesions in the gray matter with or without white matter involvement. RESULTS: 1.Preceding events were as follows: no defined prodrome (38.1%), upper respiratory tract infection (28.6%), nonspecific febrile illness (19.0%), gastointestinal disturbance and vaccination. 2.Presenting symptoms were as follows: seizures (76.2%), headache/vomiting (47.6%), altered consciousness (38.1%), hemiparesis, cerebellar ataxia, visual disturbance and facial nerve palsy. 3.Laboratory findings were as follows: CSF pleocytosis (76.2%), leucocytosis (38.1%) and elevated CSF protein (28.6%). 4.Fifteen patients were recovered completely without neurological sequelae. Three patients in group I and 1 patient in group II had intractable seizures. Two patients in group I and 2 patients in group II had motor disturbance. CONCLUSION: There were no statistically significant differences in preceding events, presenting symptoms, and neurological outcomes according to the distribution of the lesions on brain MRI. However, the ADEM have quite diverse clinical manifestations and neuroimage findings. MRI plays an important role in making diagnosis of the patients who are suspected of ADEM.
Brain ; Central Nervous System ; Cerebellar Ataxia ; Consciousness ; Demyelinating Diseases ; Diagnosis ; Encephalomyelitis ; Encephalomyelitis, Acute Disseminated* ; Facial Nerve ; Humans ; Leukocytosis ; Magnetic Resonance Imaging* ; Paralysis ; Paresis ; Prognosis* ; Respiratory Tract Infections ; Seizures ; Vaccination

BACKGROUND: Acid-base derangement are commonly encountered in critically ill patients. This study is to investigate underlying mechanisms of acid-base imbalance and also to examine whether they can predict mortality in burn patients. METHODS: We retrospectively reviewed 73 severely burned patients who had admitted to burn intensive care unit, from January to July in 2004. All the patients had inhalation injury, identified by bronchoscopic examination. We analyzed the type and nature of the acid-base imbalances from arterial blood gas analysis, electrolytes and other biological tests between survivors and non-survivors for 30 days after admission. RESULTS: Acidosis was the most common disorder during the early and late hospital periods. Large fractions of those showed decreased strong ion difference (SID), increased anion gap corrected by albumin (AGc) and [Cl-]corrected. Mixed disorder and alkalosis emerged after the 7(th) hospital day. As time went by, albumin, PaO2/FiO2 ratio, pH and SID were more decreased in non-survivors (n=28) than in survivors (n=45) while [Cl-] corrected, alveolar-arterial oxygen tension gradients, peripheral WBC counts and CRP were more increased in non-survivors than in survivors. In the area under the receiver operating characteristic curves for mortality prediction, APACHE II score and % of total body surface area (%TBSA) burn were high: 0.866 (95% CI; 0.785~0.946) for APACHE II score, 0.817 (95% CI; 0.717~0.918) for %TBSA burn. CONCLUSIONS: In burned patients with inhalation injury, various types of acid-base imbalances and electrolytes abnormalities emerged after resuscitation and so, more careful attentions pursued for correcting underlying acid-base derangement.
Acid-Base Equilibrium ; Acid-Base Imbalance* ; Acidosis ; Alkalosis ; APACHE ; Attention ; Blood Gas Analysis ; Body Surface Area ; Burns* ; Critical Illness ; Diagnosis* ; Electrolytes ; Humans ; Hydrogen-Ion Concentration ; Inhalation* ; Intensive Care Units ; Mortality* ; Oxygen ; Resuscitation ; Retrospective Studies ; ROC Curve ; Sudden Infant Death ; Survivors

Extracorporeal membrane oxygenation (ECMO) is frequently associated with bleeding and coagulopathy complications, which may lead to the need for transfusion of multiple blood products. However, blood transfusions are known to increase morbidity and mortality, as well as hospital cost, in critically ill patients. In current practice, patients on ECMO receive a transfusion, on average, of 1-5 packed red blood cells (RBCs)/day, with platelet transfusion accounting for the largest portion of transfusion volume. Generally, adult patients require more transfusions than neonates or children, and patients receiving venovenous ECMO for respiratory failure tend to need smaller transfusion volumes compared to those receiving venoarterial ECMO for cardiac failure. Observation studies have reported that a higher transfusion volume was associated with increased mortality. To date, the evidence for transfusion in patients undergoing ECMO is limited; most knowledge on transfusion strategies was extrapolated from studies in critically ill patients. However, current data support a restrictive blood transfusion strategy for ECMO patients, and a low transfusion trigger seems to be safe and reasonable.
Adult ; Blood Transfusion ; Child ; Critical Illness ; Erythrocytes ; Extracorporeal Membrane Oxygenation ; Heart Failure ; Hemorrhage ; Hospital Costs ; Humans ; Infant, Newborn ; Mortality ; Platelet Transfusion ; Respiratory Insufficiency

Noninvasive ventilation (NIV) has been an important strategy to support patients with respiratory failure, while preventing complications assorted with invasive mechanical ventilation. Physicians need to be aware of the various roles of NIV and the challenges encountered in clinical practice.Current Concepts: Traditionally, the application of NIV has been well-known to be associated with reduced mortality in patients with chronic obstructive pulmonary disease (COPD) or acute pulmonary edema and those suffering from acute respiratory failure. However, despite some positive results of NIV treatment in patients with de novo hypoxemic respiratory failure such as acute pneumonia or acute respiratory distress syndrome, NIV failure (or delayed intubation) can have deleterious effects on patients outcomes. Besides, the aggravation of lung injury should also be taken into consideration when applied to patients exhibiting high respiratory drive. Nonetheless, NIV has potential for wide applications in various clinical situations such as facilitation of ventilator weaning, post-operative respiratory failure, or palliative treatment.Discussion and Conclusion: In addition to the strong evidence in patients with acute respiratory failure due to COPD or acute pulmonary edema, the NIV treatment can be potentially used for various clinical conditions. However, compared to European countries, the prevalence of NIV use continues to remain lower in South Korea. Nevertheless, when applied in appropriately selected patients in a timely manner, NIV treatment can be associated with improved patient outcomes.

Purpose: We investigated the effects of cold water immersion (CWI) treatment during half-time break on performance related physiological indices during second half soccer match. Methods: Twenty-two collegiate soccer players participated in the study. Subjects undertook 3 minutes head out seated with whole body immersion at 19 o C to 21 o C. Total four venous blood samples were collected and analyzed for markers of ionic regulations and inflammatory (interleukin [IL]-1b, IL-6, IL-8, IL-10, tumor necrosis factor-α , and vascular endothelial growth factor) and immune functions (immunoglobulin [Ig] G, IgG2, IgG2, IgG3, IgG4, IgA, and IgM). Results: Partial oxygen concentration and %SO 2 level was lowered in CWI. Hemoglobin and hematocrit values were not significantly different between experimental groups. While there was no notable effect was shown in Na ＋ and Ca 2＋ , K ＋ concentration was higher in CWI during second half match. There were no effects in any of inflammatory and/or anti-inflammatory cytokines and Ig. Conclusion These results suggest that CWI during half time break exert positively affects in buffering capacity and promote oxygen delivery to the actively recruited skeletal muscle, possibly results in improve soccer performance during second half match.

Despite a shortage of intensivists, there is an increased need for intensivist staffing in intensive care units (ICUs). Western studies showed that the survival rate of critically ill patients improved and the length of ICU stay decreased in "closed" or "high-intensity" ICU, where intensivists dedicated themselves to the ICU and were primary physicians. This system was also associated with an increased compliance of evidence-based medicine and a decreased medical error. The Leapfrog Group and American College of Critical Care Medicine recommend the implementation of intensivist staffing system in the ICU. Although there are still barriers to implement this system, such as the economic burden to hospitals and conflicts among medical staff, intensivist staffing in the ICU is important in terms of timely diagnosis and treatment and multidisciplinary team approach. The presence of intensivists may also increase the efficacy of ICU systems and save treatment cost. Although the "24 hours/7 days intensivist staffing" system may be ideal, recent data showed that high-intensity ICU system during daytime is not inferior to 24-hour intensivist staffing system in terms of hospital mortality. It is especially important to large-scale academic hospitals, where many severely ill patients are treated. However, few ICUs have intensivists who are committed to caring for ICU patients in Korea. Therefore, we have to try to expand this system throughout the whole country. Additionally, the definition of ICU standard, the role of intensivists, and the policy of financial reward also need to be clarified more clearly.
Compliance ; Critical Care ; Critical Illness ; Evidence-Based Medicine ; Health Care Costs ; Hospital Mortality ; Humans ; Critical Care ; Intensive Care Units ; Korea ; Medical Errors ; Medical Staff ; Reward ; Survival Rate

Sepsis is a life-threatening condition caused by infection and represents a substantial global health burden. Recent epidemiological studies showed that sepsis mortality rates have decreased, but that the incidence has continued to increase. Although a mortality benefit from early-goal directed therapy (EGDT) in patients with severe sepsis or septic shock was reported in 2001, three subsequent multicenter randomized studies showed no benefits of EGDT versus usual care. Nonetheless, the early administration of antibiotics and intravenous fluids is considered crucial for the treatment of sepsis. In 2016, new sepsis definitions (Sepsis-3) were issued, in which organ failure was emphasized and use of the terms “systemic inflammatory response syndrome” and “severe sepsis” was discouraged. However, early detection of sepsis with timely, appropriate interventions increases the likelihood of survival for patients with sepsis. Also, performance improvement programs have been associated with a significant increase in compliance with the sepsis bundles and a reduction in mortality. To improve sepsis management and reduce its burden, in 2017, the World Health Assembly and World Health Organization adopted a resolution that urged governments and healthcare workers to implement appropriate measures to address sepsis. Sepsis should be considered a medical emergency, and increasing the level of awareness of sepsis is essential.
Anti-Bacterial Agents ; Compliance ; Delivery of Health Care ; Emergencies ; Epidemiologic Studies ; Global Health ; Humans ; Incidence ; Mortality ; Sepsis* ; Shock, Septic ; World Health Organization

Purpose: A tracheostomy is often used to wean patients off the ventilator, as it helps maintain extracorporeal membrane oxygenation (ECMO) without sedation. A percutaneous dilatational tracheostomy (PDT) performed in critically ill patients is widely accepted, however, its feasibility and safety in ECMO is unclear. Methods: This retrospective observational study included 78 patients who underwent a PDT and ECMO at the surgical intensive care unit (SICU) in a tertiary hospital between January 1, 2016 and December 31, 2019. We analyzed their medical records, including PDT-related complications and clinical variables. Results: The median values of hemoglobin, platelet count, international normalized ratio, partial thromboplastin time, and activated partial thromboplastin time before the tracheostomy were 9.2 (8.5-10.2) g/dL, 81 (56-103) × 103/dL, 1.22 (1.13-1.30), 15.2 (14.3-16.1) seconds, and 55.1 (47.4-61.1) seconds, respectively. No clotting was observed within the extracorporeal circuit, however, minimal bleeding was observed at the tracheostomy site in 10 (12.8%) patients. Of 4 patients with major bleeding, local hemorrhage was controlled in 3 patients, and intratracheal bleeding continued in 1 patient. The mortality rate was 60.9% and 57.1% in the complication and no-complication group, respectively. The durations of SICU stay, hospital stay, and mechanical ventilation were not statistically different between the groups. Conclusion A PDT performed in critically ill patients was associated with a low rate of bleeding. Complications did not appear to significantly affect the patient outcome. PDT can be performed in patients who usually require a tracheostomy to maintain ECMO.