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Successful Management of Airway Emergency in a Patient with Esophageal Cancer.

Samina PARK ; Hyun Joo LEE ; Chang Hyun KANG ; Young Tae KIM

Korean Journal of Critical Care Medicine.2015;30(2):135-138. doi:10.4266/kjccm.2015.30.2.135

A 60-year-old man with advanced esophageal cancer was admitted for surgical placement of a feeding jejunostomy tube before commencement of chemoradiotherapy. His esophageal cancer had directly invaded the posterior tracheal wall, inducing a nearly total obstruction of the distal trachea. On the day before the surgery, respiratory failure developed due to tumor progression and tracheal edema. Tracheal intubation and mechanical ventilation were attempted without success. Application of veno-venous extracorporeal membrane oxygenation (ECMO) corrected the patient's respiratory acidosis and relieved his dyspnea. With full ECMO support, he underwent tracheal stent insertion. Two hours later, he was weaned from ECMO support uneventfully. This was a successful case of tracheal stenting for airway obstruction under rescue veno-venous ECMO.
Acidosis, Respiratory ; Airway Management ; Airway Obstruction ; Chemoradiotherapy ; Dyspnea ; Edema ; Emergencies* ; Esophageal Neoplasms* ; Extracorporeal Membrane Oxygenation ; Humans ; Intubation ; Jejunostomy ; Middle Aged ; Respiration, Artificial ; Respiratory Insufficiency ; Stents ; Trachea ; Tracheal Stenosis

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Transfusion Associated Hyperkalemia and Cardiac Arrest in an Infant after Extracorporeal Membrane Oxygenation.

Do Wan KIM ; Kyeong Ryeol CHEON ; Duck CHO ; Kyo Seon LEE ; Hwa Jin CHO ; In Seok JEONG

Korean Journal of Critical Care Medicine.2015;30(2):132-134. doi:10.4266/kjccm.2015.30.2.132

Cardiac arrest associated with hyperkalemia during red blood cell transfusion is a rare but fatal complication. Herein, we report a case of transfusion-associated cardiac arrest following the initiation of extracorporeal membrane oxygenation support in a 9-month old infant. Her serum potassium level was increased to 9.0 mEq/L, soon after the newly primed circuit with pre-stored red blood cell (RBC) was started and followed by sudden cardiac arrest. Eventually, circulation was restored and the potassium level decreased to 5.1 mEq/L after 5 min. Extracorporeal membrane oxygenation (ECMO) priming is a relatively massive transfusion into a pediatric patient. Thus, to prevent cardiac arrest during blood-primed ECMO in neonates and infants, freshly irradiated and washed RBCs should be used when priming the ECMO circuit, to minimize the potassium concentration. Also, physicians should be aware of all possible complications associated with transfusions during ECMO.
Blood Transfusion ; Death, Sudden, Cardiac ; Erythrocyte Transfusion ; Erythrocytes ; Extracorporeal Membrane Oxygenation* ; Heart Arrest* ; Humans ; Hyperkalemia* ; Infant* ; Infant, Newborn ; Potassium

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A Critical Case of Wernicke's Encephalopathy Induced by Hyperemesis Gravidarum.

Byung Ju KANG ; Min Gu KIM ; Jwa Hoon KIM ; Mingee LEE ; Sang Beom JEON ; Ha Il KIM ; Jin Won HUH

Korean Journal of Critical Care Medicine.2015;30(2):128-131. doi:10.4266/kjccm.2015.30.2.128

Wernicke's encephalopathy is a reversible but potentially critical disease caused by thiamine deficiency. Most patients complain of symptoms such as ophthalmoplegia, ataxia and confusion. Heavy alcohol drinking is commonly associated with the disease, but other clinical conditions also can provoke it. In pregnant women, hyperemesis gravidarum can lead to the depletion of body thiamine due to poor oral intake and a high metabolic demand. We report a case of Wernicke's encephalopathy following hyperemesis gravidarum in a 36-year-old female at 20 weeks of pregnancy, who visited our hospital because of shock with vaginal bleeding. This case suggests that although the initial presentation may include atypical symptoms (e.g., shock or bleeding), Wernicke's encephalopathy should be considered, and thiamine replacement should be performed in pregnant women with neurologic symptoms and poor oral intake.
Acute Kidney Injury ; Adult ; Alcohol Drinking ; Ataxia ; Female ; Humans ; Hyperemesis Gravidarum* ; Neurologic Manifestations ; Ophthalmoplegia ; Pregnancy ; Pregnant Women ; Shock ; Thiamine ; Thiamine Deficiency ; Uterine Hemorrhage ; Wernicke Encephalopathy*

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Multiple System Atrophy Manifested by Bilateral Vocal Cord Palsy as an Initial Sign.

Yuri SEO ; Soomin JEUNG ; Heeyoung YOON ; Min Chul KIM ; Nah Kyum LEE ; Byeong Zu GHANG ; Sun Ju CHUNG ; Younsuck KOH

Korean Journal of Critical Care Medicine.2015;30(2):123-127. doi:10.4266/kjccm.2015.30.2.123

A 71-year-old male initially presented with vocal cord palsy and underwent tracheostomy. After thorough examination, urogenital dysfunction, orthostatic hypotension, and Parkinsonism were found, which led to the diagnosis of multiple system atrophy (MSA). After the tracheostomy, bi-level positive airway pressure ventilation was required during the night due to nocturnal hypoxemia. Night-time hypoxemia is related to central sleep apnea, which is one of the manifestations of MSA. This is the first case of MSA manifested by bilateral vocal cord palsy as an initial sign in Korea. This case supports the notion that MSA should be taken into consideration when vocal cord paralysis is observed.
Aged ; Airway Obstruction ; Anoxia ; Diagnosis ; Humans ; Hypotension, Orthostatic ; Korea ; Male ; Multiple System Atrophy* ; Parkinsonian Disorders ; Sleep Apnea, Central ; Tracheostomy ; Ventilation ; Vocal Cord Paralysis*

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Subclavian Artery Laceration Caused by Pigtail Catheter Removal in a Patient with Pneumothorax.

Hyo Jin KIM ; Yang Hyun CHO ; Gee Young SUH ; Jeong Hoon YANG ; Kyeongman JEON

Korean Journal of Critical Care Medicine.2015;30(2):119-122. doi:10.4266/kjccm.2015.30.2.119

We report a case of subclavian artery laceration caused by the removal of a pigtail pleural drainage catheter in a patient with a pneumothorax. The patient was successfully resuscitated through diagnostic angiography with subsequent balloon occlusion and primary repair of the injured subclavian artery. Although pigtail drainage of a pneumothorax is known to be safe and effective, proper insertion and removal techniques should be emphasized to reduce the risk of complications.
Angiography ; Balloon Occlusion ; Catheters* ; Drainage ; Hemothorax ; Humans ; Lacerations* ; Pneumothorax* ; Subclavian Artery* ; Thoracostomy

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Resuscitative Endovascular Balloon Occlusion of the Aorta in a Trauma Patient with Hypovolemic Shock.

Hong Kyung SHIN ; Ho Seong HAN ; Taeseung LEE ; Do Joong PARK ; Kyuwhan JUNG ; Kyuseok KIM

Korean Journal of Critical Care Medicine.2015;30(2):115-118. doi:10.4266/kjccm.2015.30.2.115

Hemorrhagic shock is one of the most common causes of death in patients with multiple trauma and therefore rapid control of bleeding is the main strategy to save these patients. Resuscitative balloon occlusion of the aorta (REBOA) has been applied in several trauma cases and because of the effectiveness of this procedure it has been adopted in the trauma field. Herein, we report the first successful case of REBOA in Korea performed on a 46-year-old man with hemorrhagic shock after a fall from a height of 14-stories. The patient visited our hospital emergency room with hypovolemic shock, we performed Resuscitative Endovascular Balloon Occlusion of the Aorta under bed side blind technique. His vital sign was stabilized after procedure, then we could performed endovascular bleeding control. The patient was discharged on his 33rd in-hospital day without invasive procedure and major scar.
Aorta* ; Balloon Occlusion* ; Cause of Death ; Cicatrix ; Emergency Service, Hospital ; Hemorrhage ; Humans ; Korea ; Middle Aged ; Multiple Trauma ; Shock* ; Shock, Hemorrhagic ; Vital Signs

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Early Extracorporeal Membrane Oxygenation for Massive Aspiration during Anesthesia Induction.

Namo KIM ; Kwan Hyung KIM ; Jeong Min KIM ; Su Youn CHOI ; Sungwon NA

Korean Journal of Critical Care Medicine.2015;30(2):109-114. doi:10.4266/kjccm.2015.30.2.109

Although the incidence is not high in the general surgical population, pulmonary aspiration of gastric contents can result in serious long-term morbidity and mortality. We report a case of early use of extracorporeal membrane oxygenation (ECMO) to correct severe hypoxemia refractory to conventional mechanical ventilation in a patient with massive aspiration of gastric contents immediately followed by acute lung injury during general anesthesia induction. A 64-year-old woman diagnosed with stomach cancer was scheduled for elective diagnostic laparoscopy. Although there was no sign of gastrointestinal tract obstruction and midnight Nil per Os (NPO) was performed before the operation, pulmonary aspiration occurred during the induction of anesthesia. Despite the endotracheal intubation with mechanical ventilation, severe hypoxemia with hypercapnea persisted. Medical team agreed with applying veno-venous (VV) ECMO, and her blood gas analysis results became stable. ECMO was weaned successfully 9 days after the first aspiration event had occurred. Based on this case, early application of extracorporeal life support can have survival benefits.
Acute Lung Injury ; Anesthesia* ; Anesthesia, General ; Anoxia ; Blood Gas Analysis ; Extracorporeal Membrane Oxygenation* ; Female ; Gastrointestinal Tract ; Humans ; Incidence ; Intubation, Intratracheal ; Laparoscopy ; Middle Aged ; Mortality ; Pneumonia, Aspiration ; Respiration, Artificial ; Stomach Neoplasms

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Lung Transplantation in a Patient with Pre-transplant Colonization of Extensively Drug-resistant Acinetobacter baumannii.

Hwa Young LEE ; Hea Yon LEE ; Sae Bom SHIN ; Kab Soo SHIN ; Bong Woo LEE ; Hwan Wook KIM ; Seok LEE ; Seok Chan KIM

Korean Journal of Critical Care Medicine.2015;30(2):103-108. doi:10.4266/kjccm.2015.30.2.103

Colonization of the pre-transplant lung by multidrug-resistant bacteria affects short- and long-term outcomes of lung transplantation. However, there are no case reports on the colonization of a pre-transplant lung by drug-resistant Acinetobacter baumannii. We report a case of extensively drug resistant (XDR) A. baumannii colonization in the tracheobronchial tree that caused severe infectious complications after bilateral lung transplantation. A 23-year-old man diagnosed with bronchiolitis obliterans syndrome (BOS) 4 years earlier with a history of allogenic bone marrow transplantation for acute lymphoblastic leukemia was admitted to the hospital with dyspnea. Due to progressive hypercapnic respiratory failure, long-term mechanical ventilation was started after a tracheostomy was performed, and the patient underwent a bilateral lung transplantation to treat end-stage BOS. After the transplantation, the colonization of XDR A. baumannii caused severe bacterial pneumonia in the early postoperative period. Combined treatment with colistin and meropenem led to recovery from the pneumonia but caused drug-induced renal failure. Because many centers are willing to transplant candidates who are on mechanical ventilation or extracorporeal life support, the incidence of XDR A. baumannii colonization of pretransplant lungs is expected to increase. Further studies are needed to examine pre-transplant management strategies in patients colonized with XDR A. baumannii.
Acinetobacter baumannii* ; Bacteria ; Bone Marrow Transplantation ; Bronchiolitis Obliterans ; Colistin ; Colon* ; Drug Resistance ; Dyspnea ; Humans ; Incidence ; Lung ; Lung Transplantation* ; Pneumonia ; Pneumonia, Bacterial ; Postoperative Period ; Precursor Cell Lymphoblastic Leukemia-Lymphoma ; Renal Insufficiency ; Respiration, Artificial ; Respiratory Insufficiency ; Tracheostomy ; Young Adult

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Polymyxin B Immobilized Fiber Hemoperfusion in Refractory Intra-abdominal Septic Shock.

Hae Wone CHANG ; Young Jae CHO ; Sang Hyun PARK ; Moonsuk KIM

Korean Journal of Critical Care Medicine.2015;30(2):95-102. doi:10.4266/kjccm.2015.30.2.95

The effects of direct hemoperfusion with polymyxin B immobilized fiber (PMX) treatment for septic shock have been recently reported. However, little evidence of a true benefit on clinical outcomes, including mortality, is available. Herein, we report three cases of intra-abdominal infection associated with refractory septic shock Case 1 was Escherichia coli peritonitis after a colectomy. PMX treatment improved the hemodynamic parameters and lactic acid levels of the patient. In case 2, secondary peritonitis was associated with septic or cardiogenic shock. Septic cardiomyopathy was assumed to be the cause of shock. 24 hours after the use of PMX, cardiac contractility assessed by echocardiography returned to baseline. In case 3, a patient with Burkitt's lymphoma and neutropenia was found to be gastroenteritis and Klebsiella pneumoniae bacteremia. Intravenous meropenem was administered for 3 days. Hemodynamic parameters improve after the twice use of PMXOverall, the change of serial sequential organ failure assessment score (SOFA) was more significant in surgical cases as compared to the medical case at 72 hours after PMX administration. All patients were discharged from the hospital. In addition to early resuscitation efforts and infection source control, PMX treatment may be beneficial to patients with refractory intra-abdominal infection associated with septic shock.
Bacteremia ; Burkitt Lymphoma ; Cardiomyopathies ; Colectomy ; Echocardiography ; Escherichia coli ; Gastroenteritis ; Hemodynamics ; Hemoperfusion* ; Humans ; Intraabdominal Infections ; Klebsiella pneumoniae ; Lactic Acid ; Mortality ; Neutropenia ; Peritonitis ; Polymyxin B* ; Resuscitation ; Shock ; Shock, Cardiogenic ; Shock, Septic*

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The Adequacy of a Conventional Mechanical Ventilator as a Ventilation Method during Cardiopulmonary Resuscitation: A Manikin Study.

Hong Joon AHN ; Kun Dong KIM ; Won Joon JEONG ; Jun Wan LEE ; In Sool YOO ; Seung RYU

Korean Journal of Critical Care Medicine.2015;30(2):89-94. doi:10.4266/kjccm.2015.30.2.89

BACKGROUND: We conducted this study to verify whether a mechanical ventilator is adequate for cardiopulmonary resuscitation (CPR). METHODS: A self-inflating bag resuscitator and a mechanical ventilator were used to test two experimental models: Model 1 (CPR manikin without chest compression) and Model 2 (CPR manikin with chest compression). Model 2 was divided into three subgroups according to ventilator pressure limits (P(limit)). The self-inflating bag resuscitator was set with a ventilation rate of 10 breaths/min with the volume-marked bag-valve procedure. The mode of the mechanical ventilator was set as follows: volume-controlled mandatory ventilation of tidal volume (Vt) 600 mL, an inspiration time of 1.2 seconds, a constant flow pattern, a ventilation rate of 10 breaths/minute, a positive end expiratory pressure of 3 cmH2O and a maximum trigger limit. Peak airway pressure (P(peak)) and Vt were measured by a flow analyzer. Ventilation adequacy was determined at a Vt range of 400-600 mL with a P(peak) of < or = 50 cmH2O. RESULTS: In Model 1, Vt and P(peak) were in the appropriate range in the ventilation equipments. In Model 2, for the self-inflating bag resuscitator, the adequate Vt and P(peak) levels were 17%, and the P(peak) adequacy was 20% and the Vt was 65%. For the mechanical ventilator, the adequate Vt and P(peak) levels were 85%; the P(peak) adequacy was 85%; and the Vt adequacy was 100% at 60 cmH2O of P(limit). CONCLUSIONS: In a manikin model, a mechanical ventilator was superior to self-inflating bag resuscitator for maintaining adequate ventilation during chest compression.
Cardiopulmonary Resuscitation* ; Manikins* ; Models, Theoretical ; Positive-Pressure Respiration ; Thorax ; Tidal Volume ; Ventilation* ; Ventilators, Mechanical*

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