Deceased donor liver transplantation (DDLT) raises ethical and social questions about liver transplantation for patients who are not expected to live. Patients with post-hepatectomy liver failure must have DDLT as soon as possible. Here, we detail a particular dilemma that the transplant team had while deciding whether to harvest liver from a deceased donor in the face of the recipient’s non-reactive, fully dilated pupils while they awaited a liver transplant in the intensive care unit. Despite having fixed dilated pupils during the neurologic evaluation, the patient eventually had effective DDLT, indicating that DDLT should not be done unless there is obvious brain death.

We present the case of a 74-year-old female who had a right hepatectomy performed laparoscopically to donate her liver to her a 40-year-old son who had alcoholic liver cirrhosis. She voluntarily cooperated, and thorough medical and psychological evaluations were carried out. The receiver underwent surgery in 296 minutes, while the donor took 158 minutes. With normal liver function, the donor and recipient were released from the hospital on days 10 and 14, respectively, after a smooth recovery. Three months following the living donor liver transplant, both the receiver and the living liver donor have not experienced any problems and are doing well.

Purpose: Cytomegalovirus (CMV) infection is common in immunocompromised patients. Enterocolitis caused by CMV infection can lead to perforation and bleeding of the gastrointestinal (GI) tract, which requires emergency operation. We investigated the demographics and outcomes of patients who underwent emergency operation for CMV infection of the GI tract. Methods: This retrospective study was conducted between January 2010 and December 2020. Patients who underwent emergency GI operation and were diagnosed with CMV infection through a pathologic examination of the surgical specimen were included. The diagnosis was confirmed using immunohistochemical staining and evaluated by experienced pathologists. Results: A total of 27 patients who underwent operation for CMV infection were included, 18 of whom were male with a median age of 63 years. Twenty-two patients were in an immunocompromised state. Colon (37.0%) and small bowel (37.0%) were the most infected organs. CMV antigenemia testing was performed in 19 patients; 13 of whom showed positive results. The time to diagnose CMV infection from operation and time to start ganciclovir treatment were median of 9 days. The reoperation rate was 22.2% and perforation was the most common cause of reoperation. In-hospital mortality rate was 25.9%. Conclusion CMV infection in the GI tract causes severe effects, such as hemorrhage or perforation, in immunocompromised patients. When these outcomes are observed in immunocompromised patients, suspicion of CMV infection and further evaluation for CMV detection in tissue specimens is required for proper treatment.

Purpose: Acute care surgery (ACS) has been practiced in several tertiary hospitals in South Korea since the late 2000s. The medical emergency team (MET) has improved the management of patients with clinical deterioration during hospitalization. This study aimed to identify the clinical effectiveness of collaboration between ACS and MET in hospitalized patients. Methods: This was an observational before-and-after study. Emergency surgical cases of hospitalized patients were included in this study. Patients hospitalized in the Department of Emergency Medicine or Department of Surgery, directly comanaged by ACS were excluded. The primary outcome was in-hospital mortality rate. The secondary outcome was the alarm-to-operation interval, as recorded by a Modified Early Warning Score (MEWS) of >4. Results: In total, 240 patients were included in the analysis (131 in the pre-ACS group and 109 in the post-ACS group). The in-hospital mortality rates in the pre- and post-ACS groups were 17.6% and 22.9%, respectively (P = 0.300). MEWS of >4 within 72 hours was recorded in 62 cases (31 in each group), and the median alarm-to-operation intervals of each group were 11 hours 16 minutes and 6 hours 41 minutes, respectively (P = 0.040). Conclusion Implementation of the ACS system resulted in faster surgical intervention in hospitalized patients, the need for which was detected early by the MET. The in-hospital mortality rates before and after ACS implementation were not significantly different.

Purpose: In the intensive care unit, a peripherally inserted central catheter (PICC) may be an alternative option to standard central venous catheters, particularly in patients with coagulopathies or at high risk of infection. The purpose of this research was to assess the feasibility of bedside ultrasound (US)-guided PICC placement by critical care fellows on intensive care units.
Methods: All bedside US-PICCs inserted by critical care fellows from July 2013 to September 2015 were retrospectively reviewed focusing on the rate of successful insertion, complications of insertion, or during maintenance.
Results: A total of 177 US-guided PICCs were inserted in 163 patients and included in the analysis. The median age was 62 years (IQR 50-70 years) and 104 cases (58.8%) were male. There were 172 cases (90.4%) of PICCs inserted in the upper arm. Anticoagulant therapy was used in 26 patients (14.7%) and 8 patients (5.2%) had severe coagulopathies. The median procedural time was 30 minutes (IQR 19-45 minutes). Insertion success rate was 93.2%, and there were no major complications during insertions except for malposition (12.1%). Catheters remained in place for a total of 3,878 days (median 16 days: IQR 8-31 days). There was only 1 case (0.6%) of catheter-related bloodstream infection, and 2 cases (1.2%) of symptomatic venous thromboembolism.
Conclusion Bedside US-guided placement of PICCs by critical care fellows is safe and feasible. The success rate of the procedure was “acceptable,” and was not associated with significant risks of infectious and non-infectious complications, even in patients with coagulopathies.

Purpose: In the intensive care unit, a peripherally inserted central catheter (PICC) may be an alternative option to standard central venous catheters, particularly in patients with coagulopathies or at high risk of infection. The purpose of this research was to assess the feasibility of bedside ultrasound (US)-guided PICC placement by critical care fellows on intensive care units.
Methods: All bedside US-PICCs inserted by critical care fellows from July 2013 to September 2015 were retrospectively reviewed focusing on the rate of successful insertion, complications of insertion, or during maintenance.
Results: A total of 177 US-guided PICCs were inserted in 163 patients and included in the analysis. The median age was 62 years (IQR 50-70 years) and 104 cases (58.8%) were male. There were 172 cases (90.4%) of PICCs inserted in the upper arm. Anticoagulant therapy was used in 26 patients (14.7%) and 8 patients (5.2%) had severe coagulopathies. The median procedural time was 30 minutes (IQR 19-45 minutes). Insertion success rate was 93.2%, and there were no major complications during insertions except for malposition (12.1%). Catheters remained in place for a total of 3,878 days (median 16 days: IQR 8-31 days). There was only 1 case (0.6%) of catheter-related bloodstream infection, and 2 cases (1.2%) of symptomatic venous thromboembolism.
Conclusion Bedside US-guided placement of PICCs by critical care fellows is safe and feasible. The success rate of the procedure was “acceptable,” and was not associated with significant risks of infectious and non-infectious complications, even in patients with coagulopathies.

Purpose: Critically ill patients often require multidisciplinary treatment for both acute illnesses and pre-existing medical conditions. Since different medical conditions are managed in the intensive care unit (ICU), consultation is often required. This study aimed to identify the frequency and type of consultation required and analyze changes in consultation patterns after the introduction of intensivist-directed care in the surgical ICU (SICU). Methods: Between June 2006 and December 2013, a retrospective cohort study was conducted to identify the frequency and type of consultation at 3 different ICUs. Consultations for patients who were admitted to the ICUs for more than 48 consecutive hours were included. The pattern of consultations in each ICU was investigated. In addition, the pattern of consultations before and after the implementation of intensivist-directed care in the SICU was compared. Results: During the study, 11,053 consultations were requested for 7,774 critically ill patients in a total of 3 ICUs. Consultations with the Departments of Cardiology, Infectious Diseases, and Pulmonology were requested most frequently in the SICU. However, after the implementation of the intensivist-directed care approach, there was an increase in the frequency of consultation requests to the Department of Neurology, followed by the Departments of Cardiology, and Infectious Diseases. Conclusion Analysis of consultation patterns is an important method of assessing the complexity and severity of illnesses, and of evaluating the needs of available health system resources. Based on our findings, we suggest the development of an appropriate protocol for frequently consulted services.

Background: Although the first choice of treatment for abdominal aortic aneurysm (AAA) is endovascular aneurysm repair, especially in elderly patients, some patients require open surgical repair. The purpose of this study was to compare the mortality outcomes of open AAA repair between octogenarians and younger counterparts and to identify the risk factors associated with mortality. Methods: All consecutive patients who underwent elective open AAA repair due to degenerative etiology at a single tertiary medical center between 1996 and June 2020 were included in this retrospective review. Medical records and imaging studies were reviewed to collect the following information: demographics, comorbid medical conditions, clinical presentations, radiologic findings, surgical details, and morbidity and mortality rates. For analysis, patients were divided into two groups: older and younger than 80 years of age. Multivariate analysis was performed to identify factors associated with mortality after elective open AAA repair. Results: Among a total of 650 patients who underwent elective open AAA repair due to degenerative AAA during the study period, 58 (8.9%) were octogenarians and 595 (91.1%) were non-octogenarians. Patients in the octogenarian group were predominantly female and more likely to have lower body weight and body mass index (BMI), hypertension, chronic kidney disease, and lower preoperative serum hemoglobin and albumin compared with patients in the non-octogenarian group. Maximal aneurysm diameter was larger in octogenarians. During the median follow-up duration of 34.4 months for 650 patients, the median length of total hospital and intensive care unit stay was longer in octogenarians. The 30-day (1.7% vs. 0.7%, P= 0.374) and 1-year (6.9% vs. 2.9%, P = 0.108) mortality rates were not statistically significantly different between the two groups. Multivariate analysis showed that low BMI was associated with increased 30-day (odds ratio [OR], 16.339; 95% confidence interval [CI], 1.192–224.052; P= 0.037) and 1-year (OR, 8.236; CI, 2.301–29.477; P= 0.001) mortality in all patients. Conclusion Because the mortality rate of octogenarians after elective open AAA repair was not significantly different compared with their younger counterparts, being elderly is not a contraindication for open AAA repair. Low BMI might be associated with increased postoperative mortality.

Purpose: Intensive IV insulin infusion therapy has been applied widely to critically ill patients. However, IV insulin protocols are complex, and require repeated calculations. The purpose of this study was to evaluate the safety and efficiency of a computerized insulin infusion (CII) protocol to replace manual insulin infusion protocols, for glucose control in critically ill patients. Methods: This was an observational study (September 2016 to January 2017) of 43 patients in ICU whose blood glucose level was between 140-180 mg/mL and could not be controlled by the conventional manual insulin protocol. The CII protocol was integrated in to the electronic medical record order system, and automatically calculated the insulin infusion dose and blood sugar test (BST) interval. BSTs were taken 48 hours pre- and post-initiation of the CII protocol. The proportion of BSTs in the normal (70-180 mg/mL), hypoglycemic (70 mg/mL), and severe hyperglycemic (> 250 mg/mL) range were recorded. Results: The mean number of BSTs performed before using the CII protocol was 10.3/person and 0.4/hour, and after implementing the protocol, increased to 21.7/person and 0.7/hour. The mean glucose level (281.4 mg/mL) decreased after using the CII protocol (195.5 mg/mL; p < 0.001). The percentage of BSTs within normal range increased from 22.5% to 44.9% after implementing the protocol (p < 0.001). Severe hyperglycemia (> 250 mg/mL) decreased from 47.3% to 17.9% after protocol implementation (p = 0.020). Conclusion The CII protocol safely and successfully maintained a normal glucose range, and decreased severe hyperglycemia in intensive care patients.

Purpose: Thromboelastography (TEG) was investigated for the diagnosis of coagulopathy compared with traditional coagulation tests, in association with disease severity in patients with severe sepsis or septic shock. Methods: Retrospective data was collected from a single center between January 25th to March 24th, 2016. There were 18 patients with severe sepsis or septic shock admitted to intensive care units included in this study. Laboratory tests including TEG were performed at admission. Disease severity was measured using the Simplified Acute Physiology Score III, Sequential Organ Failure Assessment score, and the level of lactate. Results: There were 18 patients (61% males; median age, 60.5 years) who were diagnosed with severe sepsis, or septic shock requiring a norepinephrine infusion (n = 10, 55.6%). Of these, 4 patients had traditional coagulation tests, and TEG profiles which confirmed hypercoagulability. Eight patients had follow-up tests 48 hours post-admission with a Sequential Organ Failure Assessment score of 6.5 (3-9.5) at admission, decreasing to 4 (2-11) after 48 hours (although not significantly lower), however, the lactate level decreased statistically significantly from 2.965 at admission, to 1.405 mmol/L after 48 hours (p < 0.05). The TEG profiles tended to normalize after 48 hours compared with admission, but there was no statistically significant difference. Conclusion Coagulopathy with severe sepsis or septic shock patients can be life-threatening, therefore it is important to diagnose coagulopathy early and precisely. TEG can be a feasible tool to confirm coagulopathy with traditional coagulation tests.