Objective: : Hypernatremia is a common complication encountered during the treatment of neurocritically ill patients. However, it is unclear whether clinical outcomes correlate with the severity of hypernatremia in such patients. Therefore, we investigated the impact of hypernatremia on mortality of these patients, depending on the degree of hypernatremia. Methods: : Among neurosurgical patients admitted to the intensive care unit (ICU) in a tertiary hospital from January 2013 to December 2019, patients who were hospitalized in the ICU for more than 5 days and whose serum sodium levels were obtained during ICU admission were included. Hypernatremia was defined as the highest serum sodium level exceeding 150 mEq/L observed. We classified the patients into four subgroups according to the severity of hypernatremia and performed propensity score matching analysis. Results: : Among 1146 patients, 353 patients (30.8%) showed hypernatremia. Based on propensity score matching, 290 pairs were included in the analysis. The hypernatremia group had higher rates of in-hospital mortality and 28-day mortality in both overall and matched population (both p<0.001 and p=0.001, respectively). In multivariable analysis of propensity score-matched population, moderate and severe hypernatremia were significantly associated with in-hospital mortality (adjusted odds ratio [OR], 4.58; 95% confidence interval [CI], 2.15–9.75 and adjusted OR, 6.93; 95% CI, 3.46–13.90, respectively) and 28-day mortality (adjusted OR, 3.51; 95% CI, 1.54–7.98 and adjusted OR, 10.60; 95% CI, 5.10–21.90, respectively) compared with the absence of hypernatremia. However, clinical outcomes, including in-hospital mortality and 28-day mortality, were not significantly different between the group without hypernatremia and the group with mild hypernatremia (p=0.720 and p=0.690, respectively). The mortality rates of patients with moderate and severe hypernatremia were significantly higher in both overall and matched population. Interestingly, the mild hypernatremia group of matched population showed the best survival rate. Conclusion : Moderate and severe hypernatremia were associated with poor clinical outcomes in neurocritically ill patients. However, the prognosis of patients with mild hypernatremia was similar with that of patients without hypernatremia. Therefore, mild hypernatremia may be allowed during treatment of intracranial hypertension using hyperosmolar therapy.

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: The aim of this study was to analyze the temporal change of resuscitation fluid use based on all fluids administered in a surgical intensive care unit (ICU). Methods: The administration of resuscitation fluid to all patients admitted to a surgical ICU of a tertiary referral hospital was investigated from 2008 to 2015. The types and volumes of fluid, and laboratory data taken within 7 days after ICU admission were evaluated. Resuscitation fluids were defined as fluids infused according to stat orders, rather than routine orders. Results: There were a total of 8,885 admissions to the ICU for 7,886 patients. The volumetric proportion of crystalloid to total resuscitation fluids increased significantly over the study period (p < 0.001; 79.6% in 2008; 93.7% in 2015). Although the proportion of 0.9% saline to crystalloids decreased, that of balanced solutions increased (p < 0.001; 29.5% in 2008; 55.6% in 2015). The use of colloids decreased from 20.4% in 2008, to 6.3% in 2015 (p < 0.001). Proportions calculated using the number of individual fluids administered revealed trends similar to those calculated using volumetric data. The amount of infused 0.9% saline was weakly correlated with the lowest blood pH and the highest serum chloride levels (ρ = -0.26 and 0.19, respectively). Conclusion Changes in the trends of fluid resuscitation practice were noted in a single surgical ICU over the 8-year study period. Crystalloid use increased owing to a rise in the utilization of balanced solutions with a downward trend in colloid use.

Purpose: The aim of this study was to analyze the temporal change of resuscitation fluid use based on all fluids administered in a surgical intensive care unit (ICU). Methods: The administration of resuscitation fluid to all patients admitted to a surgical ICU of a tertiary referral hospital was investigated from 2008 to 2015. The types and volumes of fluid, and laboratory data taken within 7 days after ICU admission were evaluated. Resuscitation fluids were defined as fluids infused according to stat orders, rather than routine orders. Results: There were a total of 8,885 admissions to the ICU for 7,886 patients. The volumetric proportion of crystalloid to total resuscitation fluids increased significantly over the study period (p < 0.001; 79.6% in 2008; 93.7% in 2015). Although the proportion of 0.9% saline to crystalloids decreased, that of balanced solutions increased (p < 0.001; 29.5% in 2008; 55.6% in 2015). The use of colloids decreased from 20.4% in 2008, to 6.3% in 2015 (p < 0.001). Proportions calculated using the number of individual fluids administered revealed trends similar to those calculated using volumetric data. The amount of infused 0.9% saline was weakly correlated with the lowest blood pH and the highest serum chloride levels (ρ = -0.26 and 0.19, respectively). Conclusion Changes in the trends of fluid resuscitation practice were noted in a single surgical ICU over the 8-year study period. Crystalloid use increased owing to a rise in the utilization of balanced solutions with a downward trend in colloid use.

BACKGROUND: Malnutrition is associated with many adverse clinical outcomes. The present study aimed to identify the prevalence of malnutrition in hospitalized patients in Korea, evaluate the association between malnutrition and clinical outcomes, and ascertain the risk factors of malnutrition. METHODS: A multicenter cross-sectional study was performed with 300 patients recruited from among the patients admitted in 25 hospitals on January 6, 2014. Nutritional status was assessed by using the Subjective Global Assessment (SGA). Demographic characteristics and underlying diseases were compared according to nutritional status. Logistic regression analysis was performed to identify the risk factors of malnutrition. Clinical outcomes such as rate of admission in intensive care units, length of hospital stay, and survival rate were evaluated. RESULTS: The prevalence of malnutrition in the hospitalized patients was 22.0%. Old age (≥ 70 years), admission for medical treatment or diagnostic work-up, and underlying pulmonary or oncological disease were associated with malnutrition. Old age and admission for medical treatment or diagnostic work-up were identified to be risk factors of malnutrition in the multivariate analysis. Patients with malnutrition had longer hospital stay (SGA A = 7.63 ± 6.03 days, B = 9.02 ± 9.96 days, and C = 12.18 ± 7.24 days, P = 0.018) and lower 90-day survival rate (SGA A = 97.9%, B = 90.7%, and C = 58.3%, P < 0.001). CONCLUSION: Malnutrition was common in hospitalized patients, and resulted in longer hospitalization and associated lower survival rate. The rate of malnutrition tended to be higher when the patient was older than 70 years old or hospitalized for medical treatment or diagnostic work-up compared to elective surgery.
Cross-Sectional Studies ; Hospitalization ; Humans ; Intensive Care Units ; Korea ; Length of Stay ; Logistic Models ; Malnutrition ; Multivariate Analysis ; Nutrition Assessment ; Nutritional Status ; Prevalence ; Risk Factors ; Survival Rate

Limited data are available on improved outcomes after initiation of neurointensivist co-management in neurosurgical intensive care units (NSICUs) in Korea. We evaluated the impact of a newly appointed neurointensivist on the outcomes of neurosurgical patients admitted to an intensive care unit (ICU). This retrospective observational study involved neurosurgical patients admitted to the NSICU at Samsung Medical Center between March 2013 and May 2016. Neurointensivist co-management was initiated in October 1 2014. We compared the outcomes of neurosurgical patients before and after neurointensivist co-management. The primary outcome was ICU mortality. A total of 571 patients were admitted to the NSICU during the study period, 291 prior to the initiation of neurointensivist co-management and 280 thereafter. Intracranial hemorrhage (29.6%) and traumatic brain injury (TBI) (26.6%) were the most frequent reasons for ICU admission. TBI was the most common cause of death (39.0%). There were no significant differences in mortality rates and length of ICU stay before and after co-management. However, the rates of ICU and 30-day mortality among the TBI patients were significantly lower after compared to before initiation of neurointensivist co-management (8.5% vs. 22.9%; P = 0.014 and 11.0% vs. 27.1%; P = 0.010, respectively). Although overall outcomes were not different after neurointensivist co-management, initiation of a strategy of routine involvement of a neurointensivist significantly reduced the ICU and 30-day mortality rates of TBI patients.
Brain Injuries ; Cause of Death ; Critical Care Outcomes ; Critical Care* ; Humans ; Intensive Care Units* ; Intracranial Hemorrhages ; Korea ; Mortality ; Neurosurgery ; Observational Study ; Retrospective Studies

Increased levels of tissue corticosteroids are associated with important protective responses of critically ill patients. Critical illness and its treatment interfere with the normal corticosteroid response to illness and induce tissue corticosteroid insufficiency. Therefore, corticosteroid is commonly used in critically ill patients. In intensive care units, the main reasons for using steroids are critical illness-related corticosteroid insufficiency (CIRCI), septic shock, acute respiratory distress syndrome (ARDS), airway edema, etc. CIRCI may be suspected due to symptoms or signs such as unconsciousness, hemodynamic instability, fever, or electrolyte imbalance. An adrenocorticotropic hormone stimulation test or measurement of a random plasma cortisol level is necessary to diagnose CIRCI. Corticosteroid administration can be helpful when CIRCI is confirmed. Similar to CIRCI, corticosteroid can be used in septic shock. However, corticosteroid administration is not recommended for patients with sepsis without shock. The use of corticosteroid in patients with ARDS is still controversial. Although steroids are commonly used for critically ill patients, there are controversies related to the use of steroids in the intensive care unit. In this article, we review the physiology of the corticosteroid response to critical illness and practical issues relating to the diagnosis and treatment of corticosteroid insufficiency in critically ill patients.
Adrenal Cortex Hormones ; Adrenal Insufficiency ; Adrenocorticotropic Hormone ; Critical Illness ; Diagnosis ; Edema ; Fever ; Hemodynamics ; Humans ; Hydrocortisone ; Intensive Care Units ; Physiology ; Plasma ; Respiratory Distress Syndrome, Adult ; Sepsis ; Shock ; Shock, Septic ; Steroids ; Unconsciousness

PURPOSE: This study aimed to establish a large-scale database of patients with gastric cancer to facilitate the development of a national-cancer management system and a comprehensive cancer control policy. MATERIALS AND METHODS: An observational prospective cohort study on gastric cancer was initiated in 2010. A total of 14 cancer centers throughout the country and 152 researchers were involved in this study. Patient enrollment began in January 2011, and data regarding clinicopathological characteristics, life style-related factors, quality of life, as well as diet diaries were collected. RESULTS: In total, 4,963 patients were enrolled until December 2014, and approximately 5% of all Korean patients with gastric cancer annually were included. The mean age was 58.2±11.5 years, and 68.2% were men. The number of patients in each stage was as follows: 3,394 patients (68.4%) were in stage IA/B; 514 patients (10.4%), in stage IIA/B; 469 patients (9.5%), in stage IIIA/B/C; and 127 patients (2.6%), in stage IV. Surgical treatment was performed in 3,958 patients (79.8%), endoscopic resection was performed in 700 patients (14.1%), and 167 patients (3.4%) received palliative chemotherapy. The response rate for the questionnaire on the quality of life was 95%; however, diet diaries were only collected for 27% of patients. CONCLUSIONS: To provide comprehensive information on gastric cancer for patients, physicians, and government officials, a large-scale database of Korean patients with gastric cancer was established. Based on the findings of this cohort study, an effective cancer management system and national cancer control policy could be developed.
Cohort Studies* ; Diet ; Drug Therapy ; Humans ; Korea ; Male ; Occupational Groups ; Prospective Studies* ; Quality of Life ; Stomach Neoplasms*

Traumatic carotid-cavernous fistula (TCCF) is a pathologic communication between the internal carotid artery and cavernous sinus, and is associated with craniomaxillofacial trauma. TCCF are very rare, occurring in 0.17~0.27% of craniomaxillofacial trauma cases. We describe a 76-year-old woman treated for multiple fractures including the skull base, left temporal bone, right tibia and fibula, left clavicle, and fifth and seventh rib fractures. She developed symptoms of TCCF two weeks after the initial trauma. We successfully treated her by endovascular occlusion of the internal carotid artery.
Aged ; Carotid Artery, Internal ; Carotid-Cavernous Sinus Fistula* ; Cavernous Sinus ; Clavicle ; Endovascular Procedures ; Female ; Fibula ; Fistula ; Fractures, Multiple ; Humans ; Intracranial Hemorrhages* ; Radiology, Interventional ; Rib Fractures ; Skull Base ; Temporal Bone ; Tibia