우리나라의 중환자의학 세부전문의 제도

김동찬 대한중환자의학회 2009 Acute and Critical Care Vol.24 No.3

The Korean Society of Critical Care Medicine (KSCCM) has introduced the Subspecialty System for Critical Care Medicine in Korea under the auspices of the Korean Academy of Medical Sciences (KAMS) in March 2008. Nine medical societies that included the Korean Association of Internal Medicine, the Korean Academy of Tuberculosis and Respiratory Diseases, the Korean Society of Anesthesiology, the Korean Neurological Association, the Korean Neurosurgical Society, the Korean Surgical Society, the Korean Society of Emergency Medicine, the Korean Society for Thoracic and Cardiovascular Surgery and the Korean Pediatric Society participated to the new critical care subspecialty. The Board of Critical Care should be certified again every 5 year after achieving the required qualification by the KSCCM. This paper summarizes the Subspecialty Certification System for Critical Care Medicine in Korea. 1980년 7월 26일 일본 동경에서 개최된 서태평양 중환자의학회(Western Pacific Association of Critical Care Medicine, WPACCM) 창립 총회에 참석을 계기로 대한중환자의학회의 창립과 함께 우리나라에서 중환자의학이 시작되었고 2010년이면 대한중환자의학회는 30세의 청년기를 맞이한다. 그 동안 우리나라 중환자의학의 발전과 국내중환자진료의 문제점들을 개선하고 극복하기 위한 여러 가지 노력들이 있었으나 그중 중환자의학 세부전문의 제도의 시작은 그 핵심이라고 하겠다. 이는 이 제도를 통하여 중환자 진료의 체계적인 수준 향상과 국내 중환자의학의 학문적, 임상적 발전이 이루어지는 기초를 마련한 것이기 때문이다. 이 제도의 성공적인 정착과 발전을 위해서는 이를 뒷받침할 내실 있는 교육 및 수련제도의 정착이 중요하며, 중환자의학에 관련된 모든 사람들의 아낌없는 지원과 노력이 필요하다. 그리고 무엇보다 성인중환자실에 전문의 전담의사가 중환자진료를 담당할 수 있는 국가의 제도적 뒷받침이 시급히 이루어져야 한다.

중환자실 구성이 2009년 인플루엔자 A/H1N1 중증환자의 사망률에 미친 영향

조재화,이훈재,홍상범,서지영,박무석,김석찬,곽상현,이명구,임재민,이현경,고윤석,대한중환자학회h1n1연구회 대한중환자의학회 2012 Acute and Critical Care Vol.27 No.2

Background: During 2009 pandemic period, many Koreans were infected and admitted with Influenza A/H1N1. The primary aim of this study was to evaluate whether the structures of an intensive care unit (ICU) were associated with the outcomes of critically ill patients. Methods: This retrospective observational study examined critically ill adult patients with influenza A/H1N1, who were admitted to 24 hospitals in Korea, from September 2009 to February 2010. We collected data of ICU structure, patients and 90 days mortality. Univariate and multivariate logistic regression analysis, with backward elimination, were performed to determine the most significant risk factors. Results: Of the 239 patients, mortality of 90 days was 43%. Acute physiology and chronic health evaluation (APACHE) II score (p < 0.001), sequential organ failure assessment (SOFA) score (p < 0.0001), nurse to beds ratio (p = 0.039) and presence of intensivist (p = 0.024) were significant risk factors of 90 days mortality. Age (p = 0.123), gender (p = 0.304), hospital size (p = 0.260), and ICU type (p = 0.409) were insignificantly associated with mortality. In a multivariate logistic regression analysis, patients with less than 6 SOFA score had significantly lower mortality, compared with those with more than 10 SOFA score (odds ratio 0.156, p < 0.0001). The presence of intensivist had significantly lower mortality, compared with the absence (odds ratio 0.496, p = 0.026). Conclusions: In critically ill patients with influenza A/H1N1, the severity of the illness and presence of intensivist might be associated with 90 days mortality.

Malignant Syndrome in Parkinson Disease Similar to Severe Infection

이동훈,문정미,조용수 대한중환자의학회 2017 Acute and Critical Care Vol.32 No.4

A 70-year-old woman with Parkinson disease was admitted to the emergency department with altered consciousness, fever and convulsive movements without experiencing withdrawal from antiparkinsonian medication. Six hours after the emergency department visit, the patient had a hyperpyrexia (>40°C) and a systolic blood pressure of 40 mmHg. There was no evidence of bacterial infection based on extensive workups. The patient was discharged without aggravation of Parkinson disease symptoms after treatment that included administration of dantrolene sodium, enforcement of continuous renal replacement therapy and cooling blankets. Malignant syndrome should be suspected if high fever occurs in Parkinson disease patients without evidence of a definitive infection.

Recombinant Activated Factor VII as a Second Line Treatment for Postpartum Hemorrhage

박순창,염석란,한상균,조영모,김형빈 대한중환자의학회 2017 Acute and Critical Care Vol.32 No.4

Background: Severe or massive postpartum hemorrhage (PPH) has remained a leading cause of maternal mortality for decades across the world and it results in critical obstetric complications. Recombinant activated factor VII (rFVIIa) has emerged as a gold standard adjunctive hemostatic agent for the treatment of life-threatening PPH refractory to conventional therapies although it remains off-licensed for use in PPH. We studied the effects of rFVIIa on coagulopathy, transfusion volume, prognosis, severity change in Korean PPH patients. Methods: A retrospective review of medical records between December 2008 and March 2011 indicating use of rFVIIa in severe PPH was performed. We compared age, rFVIIa treatment, transfusion volume, and Sequential Organ Failure Assessment (SOFA) score at the time of arrival in the emergency department and after 24 hours for patients whose SOFA score was 8 points or higher. Results: Fifteen women with SOFA score of 8 and above participated in this study and eight received rFVIIa administration whereas seven did not. Patients’ mean age was 31.7 ± 7.5 years. There was no statistically significant difference in initial and post-24 hours SOFA scores between patients administered rFVIIa or not. The change in SOFA score between initial presentation and after 24 hours was significantly reduced after rFVIIa administration (P = 0.016). Conclusions: This analysis aimed to support that the administration of rFVIIa can reduce the severity of life-threatening PPH in patients. A rapid decision regarding the administration of rFVIIa is needed for a more favorable outcome in severe PPH patients for whom there is no effective standard treatment.

One Hundred Seven Days of ECMO as a Bridge to Lung Transplantation: The Longest Duration Among Elderly Patients

김은정,백효채,박무석,김명화,고신옥,이유진,나성원 대한중환자의학회 2014 Acute and Critical Care Vol.29 No.1

Extracorporeal membrane oxygenation (ECMO) is a means for supporting adequate gas exchange in patients with severe respiratory failure and is the only therapeutic option for ventilation-refractory patients awaiting lung transplantation. Moreover, defining the patients likely to benefit from ECMO as a bridge to transplantation has recently become a point of interest. Here, we report a case of prolonged ECMO support to a patient awaiting lung transplantation. A 66-year-old woman was diagnosed with acute interstitial pneumonia and was placed on veno-venous (VV) ECMO due to unsatisfactory gas exchange despite maximal ventilator care. She underwent bilateral lung transplantation after 99 days of ECMO and was successfully weaned from it on the 107th ECMO day. This is the longest period of ECMO support to be reported among elderly patients.

Acute Physiology and Chronic Health Evaluation II Score and Sequential Organ Failure Assessment Score as Predictors for Severe Trauma Patients in the Intensive Care Unit

이민아,최강국,유병철,박재정,박영은,곽지훈,이정남,전양빈,마대성,이길재 대한중환자의학회 2017 Acute and Critical Care Vol.32 No.4

Background: The Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system and the Sequential Organ Failure Assessment (SOFA) scoring system are widely used for critically ill patients. We evaluated whether APACHE II score and SOFA score predict the outcome for trauma patients in the intensive care unit (ICU). Methods: We retrospectively analyzed trauma patients admitted to the ICU in a single trauma center between January 2014 and December 2015. The APACHE II score was figured out based on the data acquired from the first 24 hours of admission; the SOFA score was evaluated based on the first 3 days in the ICU. A total of 241 patients were available for analysis. Injury Severity score, APACHE II score, and SOFA score were evaluated. Results: The overall survival rate was 83.4%. The non-survival group had a significantly high APACHE II score (24.1 ± 8.1 vs. 12.3 ± 7.2, P < 0.001) and SOFA score (7.7 ± 1.7 vs. 4.3 ± 1.9, P < 0.001) at admission. SOFA score had the highest areas under the curve (0.904). During the first 3 days, SOFA score remained high in the non-survival group. In the non-survival group, cardiovascular system, neurological system, renal system, and coagulation system scores were significantly higher. Conclusions: In ICU trauma patients, both SOFA and APACHE II scores were good predictors of outcome, with the SOFA score being the most effective. In trauma ICU patients, the trauma scoring system should be complemented, recognizing that multi-organ failure is an important factor for mortality.

Methidathion Poisoning

김기훈,김세훈,Charles Her 대한중환자의학회 2017 Acute and Critical Care Vol.32 No.4

Although methidathion is an organophosphate insecticide, it is different from the other organophosphates in terms of toxicity. Because of its relatively high fat solubility, the apparent volume of methidathion distribution throughout the body is very high, indicating that hemoperfusion is not effective in removing this organophosphate from the body. Redistribution of methidathion from fat to blood can also occur when plasma levels diminish. Additionally, acetylcholinesterase aging, which is the loss of an alkyl side chain that prevents reactivation by oximes, is very rapid so that the effective reactivation by oximes is thwarted. Thus, methidathion’s effect on acetylcholinesterase inhibition is long lasting, particularly with a high dose. In addition to its parasympatholytic effect and ability to induce muscle paralysis, methidathion poisoning is associated with a profound and long-lasting circulatory collapse due to sympathetic ganglion blockade. This report presents the case of a 55-year-old man who accidentally ingested a high dose of methidathion. He later developed enteroinvasive aspergillosis infection-induced multiple bowel perforations on two separate occasions while on mechanical ventilator support, resulting in a fatal outcome. The renin-angiotensin axis activated by sympathetic ganglion blockade may have reduced the patient’s splanchnic blood flow, contributing to translocation of endotoxin. Also, the effect of excessive acetylcholine on non-neuronal acetylcholine receptors may have contributed to the development of fatal enteroinvasive aspergillosis in this patient.

Extracorporeal Membrane Oxygenation Support in Adult Patients with Hematologic Malignancies and Severe Acute Respiratory Failure

Tai Sun Park,You Na Oh,Sang-Bum Hong,Chae-Man Lim,Younsuck Koh,Je-Hwan Lee,Jung-Hee Lee,Kyoo-Hyung Lee,Jin Won Huh 대한중환자의학회 2016 Acute and Critical Care Vol.31 No.3

Background: Administering extracorporeal membrane oxygenation (ECMO) to critically ill patients with acute respiratory distress syndrome has substantially increased over the last decade, however administering ECMO to patients with hematologic malignancies may carry a particularly high risk. Here, we report the clinical outcomes of patients with hematologic malignancies and severe acute respiratory failure who were treated with ECMO. Methods: We performed a retrospective review of the medical records of patients with hematologic malignancies and severe acute respiratory failure who were treated with ECMO at the medical intensive care unit of a tertiary referral hospital between March 2010 and April 2015. Results: A total of 15 patients (9 men; median age 45 years) with hematologic malignancies and severe acute respiratory failure received ECMO therapy during the study period. The median values of the Acute Physiology and Chronic Health Evaluation II score, Murray Lung Injury Score, and Respiratory Extracorporeal Membrane Oxygenation Survival Prediction Score were 29, 3.3, and -2, respectively. Seven patients received venovenous ECMO, whereas 8 patients received venoarterial ECMO. The median ECMO duration was 2 days. Successful weaning of ECMO was achieved in 3 patients. Hemorrhage complications developed in 4 patients (1 pulmonary hemorrhage, 1 intracranial hemorrhage, and 2 cases of gastrointestinal bleeding). The longest period of patient survival was 59 days after ECMO initiation. No significant differences in survival were noted between venovenous and venoarterial ECMO groups (10.0 vs. 10.5 days; p = 0.56). Conclusions: Patients with hematologic malignancies and severe acute respiratory failure demonstrate poor outcomes after ECMO treatment. Careful and appropriate selection of candidates for ECMO in these patients is necessary.

A Pilot Survey of Difficult Intubation and Cannot Intubate, Cannot Ventilate Situations in Korea

김정수,임현경,송정윤,임현근,송경철,조재화 대한중환자의학회 2016 Acute and Critical Care Vol.31 No.3

Background: There have been no studies of airway management strategies for difficult intubation and cannot intubate, cannot ventilate (CICV) situations in Korea. This study was intended to survey devices or methods that Korean anesthesiologists and intensivists prefer in difficult intubation and CICV situations. Methods: A face-to-face questionnaire that consisted of a doctor’s preference, experience and comfort level for alternative airway management devices was presented to anesthesiologists and intensivists at study meetings and conferences from October 2014 to December 2014. Results: We received 218 completed questionnaires. In regards to difficult intubation, the order of preferred alternative airway devices was a videolaryngoscope (51.8%), an optical stylet (22.9%), an intubating laryngeal mask airway (11.5%), and a fiber-optic bronchoscope (10.6%). One hundred forty-two (65.1%) respondents had encountered CICV situations, and most of the cases were identified during elective surgery. In CICV situations, the order of preferred methods of infraglottic airway management was cricothyroidotomy (CT) by intravenous (IV) catheter (57.3%), tracheostomy by a surgeon (18.8%), wire-guided CT (18.8%), CT using a bougie (2.8%), and open surgery CT using a scalpel (2.3%). Ninety-eight (45%) of the 218 respondents were familiar with the American Society of Anesthesiologists’ difficult airway algorithm or Difficult Airway Society algorithm, and only 43 (19.7%) had participated in airway workshops within the past five years. Conclusion: The videolaryngoscope was the most preferred device for difficult airways. In CICV situations, the method of CT via an IV catheter was the most frequently used, followed by wire-guided CT method and tracheostomy by the attending surgeon.

Predisposing Hemodynamic Factors Associated with a Failed Apnea Test during Brain Death Determination

김은영,Ji Hyun Kim 대한중환자의학회 2016 Acute and Critical Care Vol.31 No.3

Background: The apnea test is an essential component in the clinical determination of brain death, however it may incur a significant risk of complications such as hypotension, hypoxia and even cardiac arrest. We analyzed the risk factors associated with a failed apnea test during brain death assessment in order to predict and avoid these adverse events. Methods: Medical records on apnea tests performed for brain-dead donors at our institution between January 2009 and January 2016 were retrospectively reviewed. Age, gender, etiology of brain death, use of catecholamines and results of arterial blood gas analysis (ABGA), systolic/diastolic blood pressure (SBP/DBP), mean arterial pressure and central venous pressure prior to apnea test initiation were collected as variables. A-a gradient and PaO2/FiO2 were calculated for more precise assessment of the respiratory system. In total, 267 cases were divided into two groups based on those who completed the apnea test and those who failed the test. Results: 13 cases failed the apnea test. Among them, seven cases failed due to severe hypotension (SBP < 60 mmHg) and the others failed due to refractory hypoxia. In terms of hemodynamic state, SBP was significantly higher in the completed test group than the failed group (126.5 ± 23.9 vs. 103 ± 15.2, respectively; p = 0.001). In ABGA, the completed test group showed significantly higher PaO2/ FiO2 (313.6 ± 229.8 vs. 141.5 ± 131.0, respectively; p = 0.008) and a lower A-a gradient (278.2 ± 209.5 vs. 506.2 ± 173.1, respectively; p = 0.000). In multivariable analysis, low SBP (p = 0.003) and high A-a gradient (p = 0.044) were independent risk factors associated with a failed apnea test. Conclusions: Although the unexpected adverse events during the apnea test for brain death determination do not occur frequently, they can be fatal. If a brain-dead patient has low SBP and a high A-a gradient, clinicians should pay more attention and prepare for potential complications prior to the apnea test.