진행시간표안내 April 25 (Friday), 2014 진행시간표안내 April 26 (Saturday), 2014 - i - - ii -
행사장안내도 - iii - - iv -
The 34 th Annual Conference of the Korean Society of Critical Care Medicine Free Paper 안내 Best Abstract Prize Competition 진행순서 일자시간 No. 좌장 25 일 ( 금 ) 10:30 12:00 Best Abstract Prize Competition 1 9 (Conv ention Hall C) 곽상현 ( 전남의대 ) Oral Presentation 진행순서 일자 시간 No. 좌장 25일 ( 금 ) 08:30 10:10 O1-1 10 (Convention Hall C) 임춘학 ( 고려의대 ) 일자 시간 No. 좌장 08:30 10:10 O2-1 10 (Convention Hall A) 김석찬 ( 가톨릭의대 ) 26 일 ( 토 ) 08:30 10:10 O3-1 1 0 (Conv ention Hall C) 류호걸 ( 서울의대 ) 10:30 12:10 O4-1 10 (Convention Hall C) 조헌 ( 동국의대 ) Poster Session 진행순서 일자 시간 No. 좌장 13:00 13:56 P1-1 7 (Conference Room 1) 김인병 ( 관동의대 ) 13:00 13:56 P2-1 7 (Conference Room 1) 김석재 ( 전남의대 ) 13:00 13:56 P3-1 7 (Conference Room 2) 문석환 ( 가톨릭의대 ) 13:00 13:56 P4-1 7 (Conference Room 2) 이흥범 ( 전북의대 ) 13:00 13:56 P5-1 7 (Conference Room 3) 정성태 ( 전남의대 ) 26 일 ( 토 ) 13:00 13:56 P6-1 7 (Conference Room 3) 안태훈 ( 조선의대 ) 13:00 13:56 P7-1 7 (Conference Room 4) 김시호 ( 차의과학대학 ) 13:00 13:56 P8-1 7 (Conference Room 4) 윤석화 ( 충남의대 ) 13:00 13:56 P9-1 7 (Conference Room 5) 유도성 ( 가톨릭의대 ) 13:00 13:48 P10-1 6 (Conf erence Room 5) 황성희 ( 한림의대 ) 13:00 13:56 P11-1 7 (Conf erence Room 6) 박희평 ( 서울의대 ) 13:00 13:56 P12-1 7 (Conf erence Room 6) 이재길 ( 연세의대 ) - v -
The 34 th Annual Conference of the Korean Society of Critical Care Medicine 정기학술대회 Program April 25 (Friday), 2014 H al l A 10:30 12:00 Ref resher Course Ventilator Associated Pneumonia 이상민 ( 서울의대 ) Deep Vein Thrombosis and Pulmonary Embolism 조영재 ( 서울의대 ) Dyskalemias in Pediatric ICU 조희연 ( 성균관의대 ) 12:10 13:00 Luncheon Symposium [Roche Diagnostics Korea] 좌장 : 홍성진 ( 가톨릭의대 ) Biomakers in sepsis and MODS 이강현 ( 연세원주의대 ) 13:00 13:20 Coffee Break 13:20 14:50 R ef resher Course Difficult intubation in ICU or ward 박상일 ( 충남의대 ) Advanced Neuromonitoring in Critically ill patients 고상배 ( 서울의대 ) Neurogenic pulmonary edema in patient with increased ICP 김종연 ( 연세원주의대 ) 14:50 15:10 Coffee Break 15:10 16:40 R ef resher Course 뇌사장기기증자관리 이재명 ( 아주의대 ) Therapeutic Hy pothermia in Critical Il lnesses 조유환 ( 서울의대 ) ECPR 정재승 ( 고려의대 ) H al l B 08:30 08 : 40 Opening Ceremony 대한중환자의학회회장신증수 08:40 10:00 Pl enary Lecture 좌장 : 신증수 (President of KSCCM) ICU director and leader: what are the tools Chris Farmer (President of SCCM, Mayo Cl inic) that you need to be successful? My past ex perience of intensiv e care and the f uture direction of intensiv e care in J apanese Y oshihito U j ik e (President of JSICM, Okayama University) 10:00 10:30 Coffee Break - vi -
10:30 12:00 Special Lecture 좌장 : 고신옥 ( 연세의대 ) Mul ticentre research in Asian intensiv e care - a new d aw n J ason Phua (National University Hospital, Singapore) Cardiopulmonary Interactions d uring M echanical V entilation J igi D iv atia (Tata Memorial Hospital) 12:10 13:00 Luncheon Sy mposium [E d w ard s Lif esciences Korea] 좌장 : 이상민 ( 성균관의대 ) Application of a new transpulmonary thermod ilution techniq ue Hofer Christoph Karl (Triemli City Hospital Zurich) 13:00 13:20 Coffee Break 13:20 14:50 Sy mposium 1 [AR D S] 좌장 : 정성수 ( 전남의대 ) Fibroproliferativ e stage in patients with ARDS 홍상범 ( 울산의대 ) 급성호흡곤란증후군에서의생체표지자 (Biomarkers in ARDS) 박무석 ( 연세의대 ) Treatment in patients with AR DS 배홍범 ( 전남의대 ) 14:50 15:10 Coffee Break 15:10 16:40 Sy mposium 3 [Sepsis] 좌장 : 임채만 ( 울산의대 ) Learning from E xperience of Surv iv ing Sepsis Campaign Guideline 이영주 ( 이화의대 ) Oxidativ e stresses during sepsis - Antiox idant? 권운용 ( 서울의대 ) 패혈증에의한급성호흡곤란증후군의기계환기전략 리원연 ( 연세원주의대 ) 16:40 17:10 General Assembly H al l C 08:30 10:00 Oral Presentation 10:00 10:30 Coffee Break 10:30 12:00 Best Abstract Prize Competition 좌장 : 곽상현 ( 전남의대 ) 12:10 13:00 Luncheon Sy mposium 중환자의학전담전문의제도의추진과정서지영 ( 성균관의대 ) 13:00 13:20 Coffee Break 13:20 14:50 Sy mposium 2 [AKI in the I CU ] 좌장 : 전종헌 ( 한양의대 ) How to predict acute kidney injury in ICU 문주영 ( 경희의대 ) 급성신손상의약물치료 조민현 ( 경북의대 ) When and How much renal replacement therapy in the ICU 장혜련 ( 성균관의대 ) 14:50 15:10 Coffee Break 15:10 16:40 Sy mposium 4 [Fl uid M anagement in the I CU ] 좌장 : 김동찬 ( 전북의대 ) The Recent Fluid Trials: Crystalloids or Colloids? 박치민 ( 성균관의대 ) Fluid responsiveness 홍석경 ( 울산의대 ) Fluid Balance and Outcome: More Fluid or E arly Vasopressor 나성원 ( 연세의대 ) - vii -
April 26 (Saturd ay ), 20 1 4 H al l A 08:30 10:00 Oral Presentation 10:00 10:30 Coffee Break 10:30 12:00 Sy mposium 5 [ 중환자의최신간호 ] 좌장 : 권은옥 ( 서울대학교병원 ) 중환자실에서의시뮬레이션교육 박민아 ( 서울대학교병원 ) 중환자가족의간호 박숙현 ( 삼성서울병원 ) 중환자안전간호 양경순 ( 서울아산병원 ) 12:10 13:00 Luncheon Sy mposium [H anl im Pharm] 좌장 : 이경민 ( 건국의대 ) The R oles of ul inastatin on the Stress R esponse 곽상현 ( 전남의대 ) to Surgery and Trauma 13:00 14:00 Poster Oral Presentation (Conf erence room) (Poster E x hibition 0 9 : 0 0 1 6: 0 0 ) 14:00 15:30 Sy mposium 6 [R R T ] 좌장 : 권재영 ( 부산의대 ) Key Elements of Rapid Response System 전경만 ( 성균관의대 ) Ov ercoming Barriers to Successf ul R R T I mplementation 곽현정 ( 한양의대 ) Policy, Protocol, E d ucation and T ools of R R T 박상헌 ( 서울의대 ) H al l B 08:30 10:00 Pl enary Lecture 좌장 : 이국현 ( 서울의대 ) Changing icu care to improv e patient outcomes: Dale Needham (Johns Hopkins University) the rol e of early rehabil itation How to E nhance Korean Critical Care M edicine: Full- time Intensiv ist 고윤석 (2015, WFSICCM 조직위원장 ) 10:00 10:30 Coffee Break 10:30 12:00 Special Lecture I 좌장 : 김시오 ( 경북의대 ), Shinichi Nishi (H y ogo Col l ege of M ed icine) Autophagy in sepsis and ARDS Augustine Choi (Weill Cornell Medical College) The New Bird Flu: What Does I t Mean to Intensiv ists? Du Bin (Peking Union Medical College Hospital) 12:10 13:00 Luncheon Sy mposium [H ospira] 좌장 : 김재열 ( 중앙의대 ) PAD guidelines in the ICU: What s next? 류호걸 ( 서울의대 ) 13:00 13:50 Special Lecture I I 좌장 : 서지영 ( 성균관의대 ) Our ev olv ing mod el of how we practice critical care medicine: Chris Farmer (President of SCCM, Mayo Cl inic) what is the destination? 13:00 14:00 Poster Oral Presentation (Conf erence R oom) (Poster E x hibition 0 9 : 0 0 1 6: 0 0 ) - viii -
14:00 15:30 Sy mposium 7 [D el irium in the I CU ] 좌장 : 김재열 ( 중앙의대 ) Diagnosis and Risk Factors of Delirium 정 산 ( 한림의대 ) Delirium and Acute Confusional State: Prev ention and M anagement 고임석 ( 국립중앙의료원 ) Cognitiv e Dy sfunction in ICU Patients 이준홍 ( 일산병원 ) H al l C 08:30 10:00 Oral Presentation 10:00 10:30 Coffee Break 10:30 12:00 Oral Presentation 12:10 13:00 Luncheon Sy mposium [Phil ips] 좌장 : 신증수 ( 연세의대 ) Philips IntelliVue - Clinical Decision Support and Alarm Management Gerhard Goebl (Philips) 13:00 14:00 Poster Oral Presentation (Conf erence R oom) (Poster E x hibition 0 9 : 0 0 1 6: 0 0 ) 14:00 15:30 Sy mposium 8 [E CM O in I CU ] 좌장 : 하영록 ( 분당제생병원 ) Trouble Shooting of ECMO in ICU 임상현 ( 아주의대 ) Quick Priming of E CMO and management (any one in I CU can d o it) 이종탁 ( 양산부산대학교병원 ) Inter- hospital T ransport Under E CMO Support (I CU to I CU) 정경운 ( 전남의대 ) - ix -
The 34 th Annual Conference of the Korean Society of Critical Care Medicine CONTENTS Refresher Course Ventilator Associated Pneumonia 이상민 3 Deep Vein Thrombosis and Pulmonary Embolism 조영재 5 Dyskalemias in Pediatric ICU 조희연 7 Difficult intubation in ICU or ward 박상일 8 Advanced Neuromonitoring in Critically ill patients 고상배 9 Neurogenic pulmonary edema in patient with increased ICP 김종연 10 뇌사장기기증자관리 이재명 11 Therapeutic Hypothermia in Critical Illnesses 조유환 12 ECPR 정재승 14 Plenary Lecture 좌장 : 신증수 ICU director and leader: what are the tools that you need to be successful? Chris Farmer 16 My past experience of intensive care and the future direction of intensive care in Japanese Yoshihito Ujike 17 Special Lecture 좌장 : 고신옥 Multicentre research in Asian intensive care - a new dawn Jason Phua 18 Cardiopulmonary Interactions during Mechanical Ventilation Jigi Divatia 19 Symposium 1 [ARDS] 좌장 : 정성수 Fibroproliferative stage in patients with ARDS 홍상범 21 급성호흡곤란증후군에서의생체표지자 (Biomarkers in ARDS) 박무석 22 Treatment in patients with ARDS 배홍범 25 Symposium 3 [Sepsis] 좌장 : 임채만 Learning from Experience of Surviving Sepsis Campaign Guideline 이영주 27 Oxidative stresses during sepsis - Antioxidant? 권운용 28 패혈증에의한급성호흡곤란증후군의기계환기전략 리원연 30 - x -
Symposium 2 [AKI in the ICU] 좌장 : 전종헌 How to predict acute kidney injury in ICU 문주영 33 급성신손상의약물치료 조민현 34 When and How much renal replacement therapy in the ICU 장혜련 35 Symposium 4 [Fluid Management in the ICU] 좌장 : 김동찬 The Recent Fluid Trials: Crystalloids or Colloids? 박치민 36 Fluid responsiveness 홍석경 39 Fluid Balance and Outcome: More Fluid or Early Vasopressor 나성원 40 Symposium 5 [ 중환자의최신간호 ] 좌장 : 권은옥 중환자실에서의시뮬레이션교육 박민아 47 중환자가족의간호 박숙현 48 중환자안전간호 양경순 50 Symposium 6 [RRT] 좌장 : 권재영 Key Elements of Rapid Response System 전경만 52 Overcoming Barriers to Successful RRT Implementation 곽현정 53 Policy, Protocol, Education and Tools of RRT 박상헌 55 Plenary Lecture 좌장 : 이국현 Changing ICU care to improve patient outcomes: the role of early rehabilitation Dale Needham 57 How to Enhance Korean Critical Care Medicine: Full-time Intensivist 고윤석 58 Specical Lecture I 좌장 : 김시오, Shinichi Nishi Autophagy in Sepsis and ARDS Augustine Choi 59 The New Bird Flu: What Does It Mean to Intensivists? Du Bin 60 Special Lecture II 좌장 : 서지영 Our evolving model of how we practice critical care medicine: what is the destination? Chris Farmer 61 Symposium 7 [Delirium in the ICU] 좌장 : 김재열 Diagnosis and Risk Factors of Delirium 정산 62 Delirium and Acute Confusional State: Prevention and Management 고임석 63 Cognitive Dysfunction in ICU Patients 이준홍 64 Symposium 8 [ECMO in ICU] 좌장 : 하영록 Trouble Shooting of ECMO in ICU 임상현 66 Quick Priming of ECMO and management (anyone in ICU can do it) 이종탁 67 Inter-hospital Transport Under ECMO Support (ICU to ICU) 정경운 68 - xi -
Best Abstract Prize Competition 좌장 : 곽상현 B-1 Predictors of malignant brain edema in middle cerebral artery infarction using computed tomography angiography images 73 Hoon Kim, Seoung Rim Kim, Ik-Seong Park, Young Woo Kim, Kwang Wook Jo Department of Neurosurgery, Bucheon St. Mary s Hospital, The Catholic University of Korea B-2 의사소통이불가능한중환자의통증사정도구 *(Critical Care Non-verbal Pain Scale, CNPS) 적용효과 73 임옥분, 이선주, 정연화, 양경순, 이순행 1, 강소희, 박가영, 박영아, 박은혜, 이영주, 이효진, 장지은, 정미수, 정진아, 임채만 2 1 서울아산병원중환자간호팀장, 2 서울아산병원중환자실장 B-3 Stearoyl lysophosphatidylcholine 은 AMPK 활성증가를통하여 LPS-induced HMGB1 의 release 를억제한다 74 배홍범, 장은아, 전휘, 곽상현, 이현정전남대학교의과대학마취통증의학과교실 B-4 기계환기로부터의이탈 : 횡격막신경전도검사를이용한이탈곤란의예측 74 박윤희, 서지영 1, 정치량 1, 성덕현 2 성균관대학교의과대학삼성창원병원재활의학과, 성균관대학교의과대학삼성서울병원중환자의학과 1, 성균관대학교의과대학삼성서울병원재활의학과 2 B-6 Comparison of Morphine and Remifentanil on the duration of weaning from mechanical ventilation 75 Jae-Myeong Lee 1, Seong Heon Lee 2, Sang Hyun Kwak 2, Hyeon Hui Kang 3, Sang-Hak Lee 3, Jae-Min Lim 4, Mi-Ae Chung 5, Young-Joo Lee, Chae-Man Lim 7 1 Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea, 2 Department of Anesthesiology and Pain Medicine, Chonnam National University, Medical School, Gwangju, Korea, 3 Division of Pulmonology, Critical Care and Sleep Medicine, Department of Internal Medicine, St. Paul's Hospital, The Catholic University of Korea, Seoul, Korea, 4 Department of Pulmonology, Kangreung Asan Medical Center, Kangreung, Korea, 5 Department of Anesthesiology and Pain Medicine, Hanyang University School of Medicine, Seoul, Korea, 6 Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Republic of Korea, 7 University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea B-7 중환자실특성에따른중환자실입실환자의사망위험예측 75 송원준 1, 황승식 2, 박성훈 3, 박상헌 4, 김인병 5, 이상민 6, 서지영 1, 그외 VSKI 연구자성균관대학교의과대학삼성서울병원호흡기내과 1, 인하대학교의과대학예방의학교실 2, 한림대학교성심병원호흡기알레르기내과 3, 분당서울대학교병원마취통증의학과 4, 명지병원응급의학과 5, 서울대학교의과대학내과학교실 6 B-8 Expression of syndecan is mediated by oxidative signaling in lipopolysaccharide induced acute lung injury model 76 Hee Jung Choi, Sang-Min Lee Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine B-9 The clinical value of neutrophil extracellular traps in Acute respiratory distress syndrome 76 Chang-Won Hong 1, Chang Whan Kim 2, Dong-Keun Song 1, Yong Bum Park 2, Lung Research Institute of Hallym University, So Young Park 2 Department of Pharmacology, Institute of Natural Medicine, Infectious Diseases Medical Research Center, Hallym University College of Medicine 1, Pulmonary, Allergy and Critical Care Medicine, Gang Dong Sacred Heart Hospital, Hallym University Medical Center 2 Oral Presentation 1 좌장 : 임춘학 O1-1 Omega-3 Fatty Acids Reduce Pulmonary NF-κB activation in a Murine Ventilator-Induced Lung Injury 81 Young-Jae Cho, Yoon Je Lee, Eun Young Eo, Yeon Joo Lee, Choon-Taek Lee, Jae Ho Lee Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital O1-2 Flecainide acetate attenuates LPS-induced ALI by neutrophils mediated inflammatory process 81 송지아, 곽상현, 배홍범, 김석재, 이현정, 한혜정전남대학교의과대학마취통증의학교실 - xii -
O1-3 The usefulness of lung ultrasound in differential diagnosis for bilateral diffuse infiltration 82 Jin Jeon, Sang-Woo Shim, SoHee Park, Jin Won Huh, Younsuck Koh, Chae-Man Lim, Sang-Bum Hong Department of Intensive Care Unit, Asan Medical Center, Korea O1-4 외상성골반골절환자중쇼크를동반한중환자의임상양상및사망률 82 노효근, 권수경, 금민애, 김태현, 김호승, 마대성, 신성대, 정윤중, 홍석경울산대학교의과대학외과학교실서울아산병원외상중환자외과 O1-5 중환자의수면과미다졸람적정용량에대한선행연구 83 김세중 1, 박지수 1, 이연주 1,2, 박종선 1, 윤호일 1, 이재호 1, 이춘택 1, 조영재 1,2 분당서울대학교병원호흡기내과 1, 분당서울대학교병원중환자진료부 2 O1-6 외과계중환자실환자섬망발생위험요인분석 83 문경은, 정윤중, 오수진, 조희주, 정미수, 송정미, 김세라, 이선주, 이순행, 금민애 1, 마대성 1, 김태현 1, 홍석경 1 서울아산병원중환자간호팀, 울산대학교의과대학서울아산병원외상및중환자 1 O1-7 중환자조기재활치료의안전성 84 고영준 1, 이윤미 2, 정진희 2, 김현주 2, 김선미 2, 고진영 3, 이대상, 유정암, 조양현 4, 양정훈, 전경만, 박치민, 박윤희 5, 성덕현 6, 서지영, 정치량삼성서울병원중증치료센터중환자의학과, 삼성서울병원재활의학과물리치료실 1, 삼성서울병원중증치료간호팀내과계중환자실 2, 삼성서울병원약제부임상지원팀 3, 삼성서울병원중증치료센터흉부외과 4, 삼성창원병원재활의학과 5, 삼성서울병원재활의학과 6 O1-8 Preoperative and intra-operative risk factors for pressure ulcers in critically ill patients 84 Hyunjeong Lee, Minjeong Lee, Shin Ok Koh, Sungwon Na, Cheungsoo Shin, Jeongmin Kim 1 Department of Anesthesiology and Pain Medicine, 2 Anesthesia and Pain Research Institute, Yonsei University College of Medicine O1-9 An Unusual Case of Hepatopulmonary Syndrome 85 김기훈 1, 장항재 2, 허찰스인제대학교해운대백병원외과학교실 1, 인제대학교해운대백병원내과학교실 O1-10 Comparison of three HFNC: subjective comfort and effect on lung volume 85 So Hee Park, Hee Jung Suh, Eun Young Kim, Sang-Bum, Hong, Younsuck, Koh, Chae-Man Lim Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Oral Presentation 2 좌장 : 김석찬 O2-1 Case report: urine color change after propofol use 86 Kwan Hyung Kim 1, Jeongmin Kim 1,2, Shin Ok Koh 1,2, Cheung Soo Shin 1,2, Sungwon Na 1,2 Department of Anesthesiology and Pain Medicine 1, Anesthesia and Pain Research Institute, Yonsei University College of Medicine 2 O2-2 AICAR 는 p38 MAPK 의인산화증가를통해자연사세포의제거를증가시킨다 86 배홍범, 전휘, 곽상현, 이현정전남대학교의과대학마취통증의학과교실 O2-3 Low serum NADPH and GSH were associated with the 28-day mortality in patients with septic shock 87 유경민, 권운용, 김경수, 서길준, 부지환, 이세종, 김재승서울대학교병원응급의학과 O2-4 경희의료원신경외과중환자실과타과중환자실간의감염률변화와그원인에관한 5 개년간의비교분석 87 오인호, 박봉진, 이미숙 1, 천희경 1, 김민기, 최석근, 김태성, 임영진경희대학교의과대학신경외과학교실, 경희대학교의과대학감염내과학교실 1 O2-5 Effect of dexmedetomidine on gastric peristalsis during endoscopic submucosal dissection 88 Namo Kim 1, Young Chul Yoo 1,2, Sungwon Na 1,2, Kyung Tae Min 1,2 1 Department of Anesthesiology and Pain Medicine, 2 Anesthesia and Pain Research Institute, Yonsei University College of Medicine O2-6 Changes in plasma lipid profile of critically ill patients are associated with prognosis 88 Sang Hoon Lee 1, Byung Hoon Park 1, Kyung Soo Chung 1, Won Jai Jung 2, Song Yee Kim 1, Eun Young Kim 1, Ji Ye Jung 1, Young Ae Kang 1, Young Sam Kim 1, Se Kyu Kim 1, Joon Chang 1, Moo Suk Park 1 1 Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Disease, - xiii -
Yonsei University College of Medicine, 2 Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Korea University College of Medicine O2-8 Low Caloric Intake in Orthotopic Liver Transplantation: A New Concept Using Graft Weight 89 경규혁, 이승규 1, 남창우 2, 나양원 2 울산대학교의과대학울산대학교병원권역외상센터, 외과학교실 2, 서울아산병원외과학교실 1 O2-9 간이식수술전후 Cl 농도가수술후급성신손상발생에미치는영향 89 민세희, 이한나, 류호걸서울대학교의과대학마취통증의학교실 O2-10 10kg 미만의영아에서시행한지속적신대체치료의조기경험 90 조화진 2, 양은미 2, 김도완 1, 김선미 3, 김애영 3, 정인석 1 전남대학교병원흉부외과 1, 전남대학교병원소아청소년과 2 전남대학교병원외과계중환자실 3 Oral Presentation 3 좌장 : 류호걸 O3-1 Predictors of prolonged ventilator weaning after lung transplantation: the role of body mass index 90 Min Jeong Lee, Sarah Soh, Hyun Jeong Lee, Hyo-Chae Paik 1, Moo Suk Park 2, Sungwon Na Department of Anesthesiology and Pain Medicine, Severance Hospital, Department of Chest Surgery, Severance Hospital 1 Division of Pulmonary, Severance Hospital 2 O3-2 중환자실환자의섬망과사망률, 재실기간및입원기간의상관관계 91 손정현 1,2, 신증수 3, 라세희 3, 손인정 1,2, 오주영 1,2, 안지선 2, 박진영 1,2 1 연세대학교의과대학정신과학교실, 강남세브란스병원정신건강의학과, 2 연세대학교의과대학의학행동과학연구소, 3 연세대학교의과대학마취통증의학교실 O3-3 Outcomes of Unplanned Extubations in the Intensive Care Units 92 A Lan Lee 1, Chi Ryang Chung 1, Jeong Hoon Yang 1,2, Kyeongman Jeon 1,3, Chi-Min Park 1,4, Gee Young Suh 1,3 1 Department of Critical Care Medicine, 2 Division of Cardiology, Department of Medicine, 3 Division of Pulmonary, Department of Medicine, 4 Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea O3-4 The feasibility of ocular ultrasonography for increased intracranial pressure in adult patients 92 전진수 1, 류호걸 2, 이한나 2 서울대학교의과대학신경외과학교실 1, 서울대학교의과대학마취통증의학과학교실 2 O3-5 Continuous cerebral monitoring with amplitude-integrated electroencephalography during ECMO support 93 Hwa Jin Cho 2, Kyung Woon Jeung 3, Do Wan Kim 1, Sun Mi Kim 4, Ae Young Kim 4, In Seok Jeong 1 1 Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, 2 Department of Pediatrics, Chonnam National University Hospital, 3 Department of Emergency medicine, Chonnam National University Hospital, 4 Surgical Intensive Care Unit, Chonnam National University Hospital O3-6 Conventional direct and video laryngoscope at intubation during cardiopulmonary resuscitation 93 Dong Hyun Lee, Myongja Han, Ji young An, Ji young Jung, Younsuck Koh, Chae-Man Lim, Jin Won Huh, Sang-Bum Hong Department of Pulmonary and Critical Care Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea O3-7 Predictors of Neurologic Outcome after Successful Extracorporeal Cardiopulmonary Resuscitation 94 Jeong-Am Ryu 1, Yang Hyun Cho 2, Kiick Sung 2, Seung Hyuk Choi 3, Jeong Hoon Yang 1,3, Jin-Ho Choi 4, Ji-Hyuk Yang 2 1 Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, 2 Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, 3 Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, 4 Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea O3-8 Developing a Risk Prediction Model in Cardiac Arrest Patients who Undergo ECMO 94 양정훈, 박성범, 조양현 1, 정치량, 박치민, 전경만, 서지영성균관대학교의과대학중환자의학과, 흉부외과 1 O3-9 The adequacy of ventilator as a method to ventilation during cardiopulmonary resuscitation 95 Hong Joon Ahn, Kun Dong Kim, Joon Wan Lee, In Sool You, Seung Ryu Department of Emergency Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine - xiv -
O3-10 Weekend versus weekday hospital death in adult patients receiving ECPR 95 Dae-Sang Lee 1, Yang Hyun Cho 2, Kiick Sung 2, Chi Ryang Chung 1, Chi Min Park 1,3, Kyeongman Jeon 1,4, Gee Young Suh 1,4, Jeong Hoon Yang 1,4 Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine 1 ; Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine 2 ; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine 3 ; Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine 4 Oral Presentation 4 좌장 : 조헌 O4-1 Extracorporeal life support as a bridge to heart transplantation: Importance of organ failure in recipient selection 96 Yang Hyun Cho 1, Dong SeopJeong 1, Kiick Sung 1, Pyo Won Park 1, Wook Sung Kim 1, Young Tak Lee 1, Eun-SeokJeon 2 1 Department of Thoracic and Cardiovascular Surgery, 2 Department of Internal Medicine, Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea O4-2 Impact of extracorporeal membrane oxygenation in adult patients with refractory septic shock 96 Taek Kyu Park 1, Jeong Hoon Yang 1,2, Seung-Hyuk Choi 1, Jin-Ho Choi 1, Hyeon-Cheol Gwon 1, Chi Ryang Chung 2, Chi Min Park 2, Kyeongman Jeon 2, Yang Hyun Cho 3, Kiick Sung 3, Gee Young Suh 2 1 Division of Cardiology, Department of Medicine, 2 Department of Critical Care Medicine, 3 Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea O4-3 Vancomycin pharmacokinetics in patients undergoing extracorporeal membrane oxygenation 97 So Jin Park 1, Jeong Hoon Yang 2,3, Hyo Jung Park 1, Yong Won In 1, Young Mi Lee 1, Yang Hyun Cho 4, Kiick Sung 4, Chi Ryang Chung 2, Chi Min Park 2, Kyeongman Jeon 2,5, Gee Young Suh 2,5 1 Department of Pharmaceutical Services, Samsung Medical Center, Seoul, Korea; 2 Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 3 Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 4 Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 5 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea O4-4 진단되지않은가와사키병에의한심장관련합병증으로발현된심정지 1 례 97 김재승, 김경수, 권운용, 서길준서울대학교의과대학응급의학과교실 O4-5 Clinical outcome after rescue ECPR for out-of-hospital cardi 98 Tae Sun Ha, Jeong Hoon Yang 성균관대학교의과대학중환자의학과교실 O4-6 Over-Estimation of Cardiac Output after Reperfusion with Bioreactance-Nicom During Liver Transplant 98 Ji Uk Yoon, Hyun Su Ri, In Yeob Baek Department of Anesthesiology and Pain Medicine, Pusan National University Yangsan Hospital O4-7 A Meta-Analysis of Renal Function with Pulsatile Perfusion in Cardiac Surgery 99 남명지 3, 김용휘 1, 김연희 1, 손호성 2, 선경 2, 이혜원 1, 임춘학고려대학교의과대학마취통증의학과교실 1, 흉부외과교실 2, 의학전문대학원 3 O4-8 이차성복막염으로응급수술을받은중환자에서사망과관련된인자분석 99 장지영 1, 이승환, 심홍진 1, 김형원, 이재길연세대학교의과대학외과학교실연세대학교원주의과대학외과학교실 1 O4-9 The anti-oxidation capacity change in traumatic hemorrhagic shock patients 100 김형원, 이승환, 장지영 1, 이재길연세대학교의과대학외과학교실, 연세대학교원주의과대학외과학교실 1 O4-10 외상으로인해대량수혈을받은환자에대한임상적고찰 100 김호승, 김태현, 마대성, 금민애, 권수경, 노효근, 정윤중, 신성대, 홍석경울산대학교의과대학외과학교실서울아산병원외상및중환자외과 - xv -
Poster Session 1 좌장 : 김인병 P1-1 Facility Characteristics as an Independent Prognostic Factor of Nursing Home-Acquired Pneumonia 105 Joo-Won Min 1, Che Wan Lim 1, Sang Joon Park 1, Hee-Jin Hwang 2, Jae Ho Chung 3 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Myongji Hospital 1, Geriatric Center and Department of Family Medicine, Kwangdong University College of Medicine 2, Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Kwandong University College of Medicine 3 P1-2 중환자에서의반코마이신초기혈중농도분석 105 김문석 1, 임유진 2, 박가영 2, 전수정 2, 남궁형욱 2, 이은숙 2, 송경호 3, 박상헌 4 분당서울대학교병원중환자진료부 1, 분당서울대학교병원약제부 2, 분당서울대학교병원내과 3, 분당서울대학교병원마취통증의학과 4 P1-3 Risk factors for nephrotoxicity in elderly critically ill patients receiving intravenous colistin 105 Sung Eun Kim, A Jeong Kim, Yun Hee Jo, Hyeon Joo Hahn, Jinwoon Lee 1, Sang-Min Lee 1, Hyangsook Kim Department of Pharmacy, Seoul National University Hospital, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine 1 P1-4 중환자실에입실한중증인플루엔자감염환자에서주사제 peramivir 를사용에대한임상적경험 106 유정완, 허진원, 임채만, 고윤석, 홍상범울산대학교의과대학서울아산병원호흡기내과 P1-5 손위생이행률향상을위한개선활동이집중치료실병원감염률에미치는효과 : 단일병원의경험 106 김민수, 이창섭 1, 고경래, 김영림, 김홍주, 현혜연, 황주희, 김영숙, 김민정, 양은정, 김흥업 1 제주대학교병원외과계집중치료실, 제주대학교의학전문대학원의과학연구소 1 P1-6 Necrotizing Fasciitis of the Chest Wall 107 전재현 1, 박샘이나 2, 복진산 2, 황유화 2, 이현주 2 국립암센터폐암센터 1, 서울대학교의과대학흉부외과학교실 2 P1-7 A case of successful surgical management for necrotizing pneumonia 107 Yun Jung Jung 1, Sungsoo Lee 2, Keu Sung Lee 1 Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine 1, Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine 2 Poster Session 2 좌장 : 김석재 P2-1 면역저하가없는성인에서발생한침습성장관아스페르길루스증 1예 108 길은미, 정치량, 박치민 1, 서지영 2, 전경만 2, 양정훈 3 성균관대학교의과대학삼성서울병원중환자의학과교실, 성균관대학교의과대학삼성서울병원외과학교실 1, 성균관대학교의과대학삼성서울병원호흡기내과학교실 2, 성균관대학교의과대학삼성서울병원순환기내과학교실 3 P2-2 정상면역기능을가진성인에서발생한 Norcardia farcinica 감염증 1예 108 김진영, 윤희정을지대학교의과대학내과학교실 P2-3 발열을동반하지않은객혈로내원한감염성심내막염 1례 108 이세종, 김경수, 권운용, 서길준서울대학교병원응급의학과 P2-4 The High flow nasal cannula can be suitable method in patients with post-extubation 109 김대성, 권오정, 오선희, 나문준, 최유진, 손지웅, 권선중건양대학교병원내과 P2-5 높은기도압이지속된기계환기환자에서연속적으로발생한양측기흉, 종격동기종, 피하기종 109 박진 1, 이승엽 2, 한철 2, 이영주 1 1 이화여자대학교부속목동병원중환자의학과, 2 이화여자대학교부속목동병원응급의학과 P2-6 인플루엔자와 Streptococcus pyogenes 가병발된지역사회폐렴 1 예 110 박태선, 유정완, 강병주, 허진원, 홍상범, 임채만, 고윤석 - xvi -
울산대학교의과대학서울아산병원호흡기내과 P2-7 Toxicity of Intravenous Colistin as a Factor Interfering with Weaning from Mechanical Ventilation 110 Hyo Seok Lim, Yee Hyung Kim 1, Cheon Woong Choi 1, Myung Jae Park, Jee-Hong Yoo 1, Hong Mo Kang Department of Pulmonary and Critical Care Medicine, Kyung Hee University College of Medicine, Seoul, Korea, Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea 1 Poster Session 3 좌장 : 문석환 P3-1 만성신부전환자에서수술후수액과다투여에의한폐부종으로오인된관상동맥혈전 111 황부영, 권재영부산대학교의과대학마취통증의학과교실 P3-2 Improved survival of IPAH after the introduction of targeted therapies 111 Byung Ju Kang, Sang-Do Lee, Yeon-Mok Oh, Jae Seung Lee Department of Pulmonary and Critical Care Medicine P3-3 Successful thrombolysis of bidirectional(bd) Glenn shunt thrombotic obstruction 112 Yong-In Kim, Sun Kyung Min Department of Thoracic and Cardiovascular Surgery, Inje University, Seoul Paik Hospital P3-4 Air embolism associated with central venous catheter placement: 2 case reports 112 양광호, 문기명 Division of Hepato-Biliary-Pancreatic surgery and Transplantation Department of Surgery Pusan National University Yangsan Hospital P3-5 Effect of prior antiplatelet on the functional outcome in ischemic stroke patients treated with rtpa 113 Seunguk Jung, Yerim Kim, Chi-Kyung Kim, Sang-Bae Ko, Seung-Hoon Lee, Byung-Woo Yoon Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea P3-6 Regurgitatation of inflow catheter on veno-venous arterial extracorporeal membrane oxygenation 114 Soonyoung Park, Dong Hyun Lee, Jin Won Huh, Chae-Man Lim, Younsuck Koh, Sang-Bum Hong Department of Critical Care Medicine, Asan Medical Center, University of Ulsan college of Medicine, Seoul, Korea P3-7 The clinical features of concomitant chronic obstructive pulmonary disease and systolic heart failure in patients who admitted at intensive or coronary care unit due to dyspnea 114 최성일한양대학교의과대학구리병원심장내과 Poster Session 4 좌장 : 이흥범 P4-1 인공심박동기삽입후발생한무증상의정맥접근로반대측에발생한기흉및심낭기종 115 조영진, 차명진, 최의근, 오세일서울대학교의과대학내과학교실 P4-2 혈청허혈변형알부민농도와관상동맥경화증병변개수의연관성 115 최병호, 정루비, 유승목, 손창환, 오범진 Dept Emergency Medicine, Asan Medical Center, Ulsan College of Medicine P4-3 An alternative chest compression posture beside the bed using the kneeling stool 116 오재훈, 임태호, 지영준 1 한양대학교의과대학응급의학교실, 울산대학교공과대학의공학교실 1 P4-4 Cardiac Arrest by Pulmonary Thromboembolism: Importance of Percutaneous Cardiopulmonary Support 116 Hyo Jin Kim 1, Yang Hyun Cho 2, Wook Sung Kim 2, Kiick Sung 2, Dong Seop Jeong 2, Young Tak Lee 2, Pyo Won Park 2, Duk-kyung Kim 3 Department of Anesthesiology and Pain Medicine 1, Department of Thoracic and Cardiovascular Surgery 2, Department of Internal Medicine, Division of Cardiology 3, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea - xvii -
P4-6 급성심정지로발현된 Brugada syndrome - 증례발표 - 117 부지환, 김경수, 권운용, 서길준, 유경민, 김재승, 이세종서울대학교병원응급의학과 P4-7 Feasibility of optic nerve sheath diameter as an early neurologic outcome predictor 117 김용환, 황성연, 조광원, 이준호, 강문주, 이동우, 여정훈성균관대학교삼성창원병원응급의학과 Poster Session 5 좌장 : 정성태 P5-1 Effect of sham feeding on postoperative ileus after liver transplantation 118 이한나 1, 오승영 2, 류호걸 1 서울대학교병원서울대학교의과대학마취통증의학과교실 1, 서울대학교병원서울대학교의과대학외과교실 2 P5-2 Massive IVC and right atrial thrombosis complicated by acute pancreatitis: a case report 118 이강의, 박태진국립중앙의료원응급의학과 P5-3 내과계중환자실영양집중지원팀의료진과의회진연계활동전ㆍ후영양공급현황비교분석연구 119 이정문 2, 박승용 1, 최영훈 1, 정미선 4, 유희철 3, 이흥범전북대학교병원호흡기알레르기내과 1, 외상팀 2, 간담췌이식외과 3, 영양팀 4 P5-4 Lymphoma presenting as antiphospholipid syndrome and thrombotic thrombocytopenic purpur 119 Jung-Kyu Lee, Jinwoo Lee, Sang-Min Lee Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea P5-5 Thrombotic Thrombocytopenic Purpura with Right Heart Failure Following Total Knee Replacement 120 Sangwoo Shim 1, Jin Jeon 2, Chae-Man Lim 3, Younsuck Koh 3, Sang-Bum Hong 3 Department of Internal Medicine, School of Medicine, Catholic University of Daegu 1, Intensive Care Unit, Asan Medical Center 2, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, College of Medicine, University of Ulsan 3 P5-7 중환자실환자의영양상태변화와퇴원후장기적예후 120 이혜미, 라세희, 신증수연세대학교의과대학마취통증의학교실및마취통증의학연구소 Poster Session 6 좌장 : 안태훈 P6-1 예정수술후중환자집중치료의필요성을예측할수있는요인에대한후향적분석 120 조진범, 박일영, 성기영, 백종민, 이준현, 이도상가톨릭대학교의과대학외과학교실, 부천성모병원외과 P6-2 A device of continuous monitoring of head of bed elevation in intensive care unit 121 Ki Young Kyeong, Seukkyun Kim, Young Sang Lee, Seungmin Kwak 1,2, Junhyeok Lim 2, Jeongmin Lee 2, Jae Hwa Cho 1,2 College of Information Technology Inha University, Department of Internal medicine School of Medicine Inha University 1, Divisition of Pulmonary and Critical Care Medicine Inha Univesity Hospital 2 P6-3 A Survey for head of bed elevation in a tertiary intensive care unit 121 Jungheuk Lim 1, Jae Hwa Cho 1,2, Jeongmin Lee 1, Seungmin Kwak 1,2, Jeongseon Ryu 1,2, Haeseong Nam 1,2, Honglyeol Lee 1,2 Division of Pulmonary and Critical Care Medicine, Inha University Hospital 1, Department of Internal Medicine, Inha University 2 P6-4 Incidence and risk factors of postoperative delirium in liver transplant patients 122 이한나, 유용재, 류호걸서울대학교병원서울대학교의과대학마취통증의학과교실 P6-5 Characteristics of Rapid Response Team patients in a University Hospital 122 Hwa Young Lee 1, Hye Seon Kang 1, Hea Yon Lee 1, Keum Sook Jeun 2, Mi Ra Han 2, Yong Suk Lee 2, Eun Hyoung Kang 2, Chin Kook Rhee 1, Ji Young Kang 1, Seung Joon Kim 1, Sook Young Lee 1, Young Kyoon Kim 1, Seok Chan Kim 1 - xviii -
1 Division of Pulmonary and Critical Care Medicine, St. Mary s Advanced Life Support Team (SALT), Seoul St. Mary s Hospital, Catholic University of Korea, Seoul, Korea, 2 St. Mary s Advanced Life Support Team (SALT), Department of Nursing, Seoul St. Mary s Hospital, Catholic University of Korea, Seoul, Korea P6-6 폐암수술후종양색전에의해발생한급성말초동맥폐쇄질환의진단및치료 123 황유화, 이현주, 김영태서울대학교의과대학흉부외과교실 P6-7 Incidence and risk factors of delirium in a surgical intensive care unit 123 이한나, 주재우, 류호걸서울대학교병원, 서울대학교의과대학마취통증의학과교실 Poster Session 7 좌장 : 김시호 P7-1 외과계중환자의적절한전해질이상교정을위한전해질투여량과전후혈중농도변화조사 124 방은숙, 이재명 1 아주대학교병원약제팀, 아주대학교의과대학외과학교실 1 P7-2 Unusual cause of left lower abdominal pain presenting to emergency department 124 Kun Dong Kim, Hong Joon Ahn, Won Joon Jeong, Joon Wan Lee Department of Emergency Medicine, Chungnam National University School of Medicine P7-3 중환자실재실기간동안환자들이경험하는통증과불안의연관성 125 오주영 1, 손정현 1, 신증수 2, 라세희 2, 윤형준 1, 김재진 1,3, 박진영 1,3 연세대학교의과대학강남세브란스병원정신건강의학과 1, 연세대학교의과대학강남세브란스병원마취통증의학과 2, 연세대학교의과대학행동과학연구소 3 P7-4 Analysis of blood transfusion requirements in vascular injury with pelvic trauma 125 Hong Kyung Shin, Ho-Seong Han 서울대학교의과대학외과학교실 P7-5 다발성외상환자에서지연발견된쇄골하동맥의가성동맥류의치료 126 김희진, 이정안, 권상휘대구파티마병원외과 P7-6 경부자상으로수술시행후발생한뇌경색 - 증례보고 126 정필영 1, 장지영 1, 변천성 2, 오지웅 3, 심홍진 1 연세대학교원주의과대학외과학교실 1, 흉부외과학교실 2, 신경외과학교실 3 P7-7 복부둔상에의한장골동맥폐색의혈관내치료 127 김희진, 이정안, 권상휘대구파티마병원혈관외과 Poster Session 8 좌장 : 윤석화 P8-1 Anatomic relation of internal jugular vein and internal carotid artery in Korean: A CT evaluation 127 김상훈 1,2, 소금영 1,2, 김동규 2 Departments of Anesthesiology and Pain Medicine, Chosun University, School of Medicine 1, Departments of Anesthesiology and Pain Medicine, Chosun University Hospital 2 P8-2 폐절제술후발생한폐염전에대한증례보고 (3 례 ) 128 박샘이나, 김영태, 박인규, 전재현, 이현주서울대학교의과대학흉부외과교실 P8-3 체외막형산소화장치를적용한중환자에서조기재활치료의안정성 128 고영준, 김선미 1, 정진희 1, 이윤미 1, 김현주 1, 조양현 2, 서지영 3, 정치량삼성서울병원재활의학과물리치료실, 삼성서울병원중증간호팀내과계중환자실 1, 삼성서울병원중증치료센터흉부외과 2, 삼성서울병원중증치료센터중환자의학과 3 - xix -
P8-4 Therapeutic hypothermia after decompressive craniectomy in malignant cerebral infarction- 3 cases 129 장준영 1, 한문구분당서울대학교병원신경과, 신경외과 1 P8-5 우상엽절제술후발생한지속적딸꾹질 129 복진산, 이현주, 김영태서울대학교의과대학흉부외과학교실 P8-6 Early reality-orienting assuring and sleep assurance for delirium in Intensive care unit (ICU) 130 박승용 1, 김현선 2, 최영훈 1, 김소리 1, 박성주 1, 이용철 1, 이흥범전북대학교병원호흡기알레르기내과 1, 간호팀 2 P8-7 Ultrasound-guided PDT without bronchoscopic guidance in critically ill patients 130 박동일, 정재욱, 문재영충남대학교병원내과학교실호흡기내과분과 Poster Session 9 좌장 : 유도성 P9-1 일반병동내중증패혈증또는패혈성쇼크환자의중환자실전동예측에대한수정조기경고점수의유용성 131 홍상범 1, 허진원 1, 최혜란 2, 서현숙, 이진미, 한명자, 신유정, 최선희, 손정숙, 정윤경, 정지영, 이주리서울아산병원의료비상팀, 울산대학교의과대학서울아산병원중환자실 1, 울산대학교의과대학간호대학 2 P9-2 커피다이어트이후발생한급성중증심근염증례 131 김정현, 김희경, 한규현, 김보해, 김학수, 신선영, 김은경, 정혜철, 이지현차의과학대학교분당차병원호흡기 - 중환자의학과교실 P9-3 검체에따른 POCT 검사법 (Alere Triage R NGAL Test) 로측정한 NGAL 농도의차이 132 최병호, 정루비, 유승목, 손창환, 오범진 Dept of Emergency Medicine, Asan Medical Center, Ulsan College of Medicine P9-4 간이식후조기사망률예측을위한 APACHE IV, APACHE II, SAPS 3, MELD 점수간의비교분석 132 이한나, 김혜림, 류호걸서울대학교병원서울대학교의과대학마취통증의학과 P9-5 The Incidence of Atropine Induced Psychosis in Organophosphate Intoxication 133 김태훈, 정우진, 김오현, 차용성, 차경철, 이강현, 황성오, 김현연세대학교원주의과대학응급의학교실 P9-6 응급실체류시간이패혈성쇼크의치료에미치는영향 133 김정현, 김희경, 김새암, 김학수, 김보혜, 조혜정, 신재경, 홍희진, 이지현차의과학대학교호흡기 - 중환자의학과교실 P9-7 혈중호중구젤라티나제관련리포칼린 (NGAL) 의병원내예후인자로서의미 133 유승목, 손창환, 최병호, 정루비, 오범진 Dept Emergency Medicine, Asan Medical Center, Ulsan College of Medicine Poster Session 10 좌장 : 황성희 P10-1 Two Mortality Cases from Delayed Traumatic Intracerebra hemorrhage during the DIC Period 134 오지웅 1, 황금 1, 김종연 1, 조성민 1, 홍순기 1, 허철 1, 변진수 1, 리원연 2 연세대학교원주의과대학신경외과학교실 1, 호흡기내과학교실 2 P10-2 The value of arterial spin labeling cerebral blood flow imaging in the diagnosis of seizures 134 Yerim Kim, Chi Kyung Kim, Seunguk Jung, Seung-Hoon Lee, Byung-Woo Yoon, Sang-Bae Ko Department of Neurology, Seoul National University Hospital P10-3 Continuous electroencephalogram for detecting vasospasm in subarachnoid hemorrhage: A Case Report 135 Jongsoo Kang, Hee-Joon Bae, Gyo Jun Hwang 1, Jae Seung Bang 1, Jeong-Ho Hong 2, Moon-Ku Han Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea 1 Department of Neurology, Dongsan Medical Center, Deagu, Korea 2 - xx -
P10-4 Asymmetric transmedullary veins and clinical outcomes in acute middle cerebral artery infarction 135 김치경, 정승욱, 김예림, 이승훈, 윤병우, 고상배서울대학교병원신경과 P10-5 Bromocriptine for Control of Central Hyperthermia in Acute Stroke Patient Accompanied with Pneumonia 136 남경협 1, 김선희 2, 김재훈 3, 김영대 2 부산대학교의과대학신경외과학교실 1, 부산대학교의과대학흉부외과학교실 2, 부산대학교의과대학외과학교실 3 P10-6 급성일산화탄소중독환자에서심근및뇌손상을예측할수있는초기검사항목 136 정루비, 손창환, 최병호, 유승목, 오범진 Dept of Emergency Medicine, Asan Medical Center, Ulsan College of Medicine Poster Session 11 좌장 : 박희평 P11-1 기관부지법시행직후에생긴객담으로인한일측폐의완전폐쇄 137 김규남, 정미애, 최성락, 이영선, 전종헌한양대학교의과대학마취통증의학과교실 P11-2 Intravascular lymphoma presenting metabolic acidosis and pulmonary infiltrate: Case report 137 Tae Yun Park, Jinwoo Lee, Sang-Min Lee Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital P11-3 Clinical characteristics and prognostic factors of the patients who admitted in intensive care units with nursing and healthcare-associated pneumonia 138 Myoung Kyu Lee, Sang-Ha Kim, Suk Joong Yong, Kye Chul Shin, Hyun Sik Kim, Tae-Sun Yu, Jae Ho Seong, Ye-Ryung Jung, Won-Yeon Lee Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Gangwon, Korea P11-4 A case of ventilatory monitoring in a patient with ARDS using Electronic Impedance Tomography (EIT) 139 Hyun Jung Kim, So Hee Park 1, Younsuck Koh, Sang-Bum Hong, Chae-Man Lim Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Division of Pulmonary and Critical Carre Medicine, Department of Internal Medicine, College of Medicine, University of Kyenghee, Kangdong Hospital 1 P11-5 기관내삽관튜브발관후지연되어발생한치료되지않던기도부종 139 김경우 1, 김지연 2, 김준현 2 인제대학교서울백병원마취통증의학과 1, 인제대학교일산백병원마취통증의학과 2 P11-6 Therapeutic drug monitoring of anti-tuberculosis agents during ECMO in tuberculosis-ards 140 Hae Wone Chang 1, Hyung Sook Kim 2, Eun Sook Lee 2, Sung Jin Nam 3, Dong Jung Kim 4, Sang Hun Park 1, Young-Jae Cho 3 1 Department of Anesthesia and Pain Medicine, Seoul National University Bundang Hospital, 2 Department of Pharmacy, Seoul National University Bundang Hospital, 3 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, 4 Department of Cardiothoracic Surgery, Seoul National University Bundang Hospital P11-7 Emergency cryoextraction of massive mucus plugs obstructing central airway via flexible bronchoscopy 140 Hyo Jae Kang, Bin Hwangbo, Hee Seok Lee Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea Poster Session 12 좌장 : 이재길 P12-1 소세포성폐암환자에서인공호흡기이탈의어려움으로진단된중증근무력증의 1예 141 박주희, 이진우, 김범석 1 서울대학교의과대학내과학교실서울대학교병원호흡기내과, 혈액종양내과 1 P12-2 증례보고 : 결핵성파괴폐환자에서폐동맥확장으로인하여발생한우측중간기관지협착 142 김수정 1,2,3, 박성수 1,3 서울대학교의과대학내과학교실 1, 서울대학교병원호흡기내과 2, 서울대학교병원운영서울특별시보라매병원호흡기내과 3 - xxi -
P12-3 기관지확장증환자에서일시적상기도폐쇄에의해발생한내인성호기말양압증례 142 윤소희, 김강우, 박종국제주대학교병원마취통증의학과 P12-4 Complications of Percutaneous Dilatational Tracheostomy in Intensive Care Unit 143 Sun Mi Choi, Sang-Min Lee, Jinwoo Lee Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea P12-5 폐렴으로발병한쯔쯔가무시병의급성호흡곤란증후군으로정맥-정맥체외막산소화장치적용 1예 143 김정현, 김은선, 이진우서울대학교의과대학내과학교실, 서울대학교병원호흡기내과 P12-6 면역글로불린정주후발생한급성호흡곤란증후군 144 이봉진, 최유현, 박준동, 김승효 1 서울대학교의과대학소아과학교실, 제주대학교의과대학소아과학교실 1 P12-7 외상후급성호흡곤란증후군으로장기간체외막산소화장치를적용한소아 1 예 144 이옥정, 조양현 1, 조중범성균관대학교의과대학삼성서울병원중환자의학과, 흉부외과 1 - xxii -
April 25 (Friday) 4 월 25 일 ( 금 ) Hall A Refresher Course Hall B Plenary Lecture 좌장 : 신증수 (President of KSCCM) Special Lecture 좌장 : 고신옥 ( 연세의대 ) Symposium 1 [ARDS] 좌장 : 정성수 ( 전남의대 ) Symposium 3 [Sepsis] 좌장 : 임채만 ( 울산의대 ) Hall C Symposium 2 [AKI in the ICU] 좌장 : 전종헌 ( 한양의대 ) Symposium4 [Fluid Management in the ICU] 좌장 : 김동찬 ( 전북의대 )
Refresher Course Ventilator Associated Pneumonia 서울대학교의과대학호흡기내과 이상민 April 25 (Fri) 기계환기폐렴 (ventilator associated pneumonia, VAP) 은병원내폐렴의한종류로서기도삽관후 48시간이후에발생한폐렴을지칭한다 (1). 기계환기폐렴은기도삽관환자의약 9~40% 에서발생한다고알려져있는데최근조사에의하면 1000 기계환기일 (ventilator-days) 당 2~16회정도의발생률을보여주고있다 (2). 기계환기적용후 5~9일정도에발생률이최고점에이른다는보고도있으나, 누적발생률은일반적으로기계환기일수에비례한다고알려져있다. 특히급성호흡곤란증후군환자의경우기계환기폐렴발생의위험성이높은데이는기계환기기간이길고, 진정제요구량이높은것에기인한다고추정된다. 기계환기폐렴이발생할경우환자의예후에악영향을미치는데, 실제기계환기폐렴환자의조사망률 (crude mortality) 은약 22~60% 까지보고되고있으며 (3,4), 기계환기폐렴이발생할경우중환자실내사망가능성이 2배정도증가한다고알려져있다. 또한기계환기폐렴은환자의재원기간을늘려경제적손실도초래한다 (5). 기계환기폐렴은다양한원인균에의해서발생할수있는데, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumanii 등과같은그람음성균과 Staphylococcus aureus 등과같은그람양성균들이흔한원인으로알려져있다. 그외에드물지만면역기능이떨어진환자의경우에는바이러스와진균도원인균으로보고되고있다. 이러한원인균은기계환기기간, 총재원기간, 중환자실재원기간, 이전항생제투여력, 원내균주분포상태등에따라달라질수있다 (1). 최근들어다제내성균주가점차증가하고있는데특히 carbapenem 내성균주 (Pseudomonas, Acinetobacter 등 ) 의증가가임상적으로문제가되고있다 (2,6). 기계환기폐렴의발생은구강내세균의흡인이주요발병기전으로알려져있고, 위나부비동등이이러한세균들의집락화저장소역할을한다고추정되고있다. 그외드물지만공기를통한감염이나혈행을통한감염경로도가능하다 (7). 기계환기폐렴의진단은임상적으로매우어렵다. 일반적으로흉부 X선영상에서새로운혹은진행하는폐침윤이있으면 서임상적으로감염을시사하는소견들 ( 발열, 화농성객담, 백혈구증가, 저산소증 ) 이있을경우의심해볼수있다 (1). 진단에도움을받기위해 Clinical Pulmonary Infection Score (CPIS) 와같은점수체계를이용하기도한다 (8). 기계환기폐렴이의심될경우하기도검체를채취해서도말및배양검사를시행하는것이중요한데, 하기도검체를얻는방법에는간편하게기관내흡인을하는방법과기관지내시경을이용해서기관지페포세척술 (bronchoalveolar lavage, BAL) 이나 protected specimen brush (PSB) 를시행하는방법이있다. 이렇게얻어진하기도검체를가지고정량적배양검사를시행하여단순집락균이나오염균인지아니면실제원인균인지감별하는것이중요하다. 기계환기폐렴의치료는대부분의경우원인균이동정되기전이기때문에경험적인항생제치료가근간이된다. 항생제가늦게투여될경우기계환기폐렴환자사망률이증가한다는사실은잘알려져있기때문에얼마나적절한항생제를조기에투여하느냐여부가임상적으로매우중요하다 (9). 초기경험적항생제선택에있어가장근본이되는기준은환자가다제내성균주의위험인자를가지고있는지여부이다 (1). 다제내성균주의위험인자에는과거 3개월내항생제투여력, 최근 5일이상입원력, 항생제내성이높게나타나는병원이나지역거주환자, 요양원거주환자, 투석환자, 면역억제환자등이알려져있다 (1). 이러한다제내성균주의위험인자가없을경우에는감수성균주를대상으로좁은항균력의항생제를투여하게되고, 위험인자가있을경우에는다제내성균주를대상으로한넓은항균력을가진항생제를병합투여하게된다. 항생제투여후에는대개 48~72시간뒤임상적반응및균음전여부를확인하여항생제변경여부를결정한다. 고전적으로항생제는 14일정도투여하지만, 원인균이 Pseudomonas가아니고적절한항생제가투여되어임상적호전이있을경우에는투여기간을단축할수있다는연구결과들이보고되고있다 (10). 기계환기폐렴의예방법은기계환기폐렴발생의발병기전 3
에따라발생위험인자를줄일목적으로고안이되어왔다. 대표적으로삽관기간을줄이고, 재삽관을피하는것이중요하며가급적진정제사용을줄이고, 구강내청결, 성대문밑분비물의지속적흡인, 앉은자세를유지할것등을추천하고있다 (11). 이러한예방법들은기계환기폐렴다발 (VAP bundle) 의형태로통합되어동시에시행하는것이기계환기폐렴발생을줄일수있다고알려져있다 (12). 결론적으로기계환기폐렴은진단이힘들고발생시예후가나쁘기때문에중환자실담당의사들이진단, 치료및예방에주의를기울여야하는질환이다. 최근다제내성균주에의한기계환기폐렴이점점증가하고있어이에대한새로운항생제개발이요구되고있고, 조기진단및적극적인예방이더욱중요할것으로판단된다. References 1. American Thoracic Society?Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005; 171: 388-416 2. Rosenthal VD, Bijie H, Maki DG, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries, for 2004-2009. Am J Infect Control 2012; 40: 396-407 3. Kollef MH, Hamilton CW, Ernst FR. Economic impact of ventilator-associated pneumonia in a large matched cohort. Infect Control Hosp Epidemiol 2012; 33: 250-256 4. Forel JM, Voillet F, Pulina D, et al. Ventilator-associated pneumonia and ICU mortality in severe ARDS patients ventilated according to a lung-protective strategy. Crit Care 2012; 16: R65 5. Barbier F, Andremont A, Wolff M, Bouadma L. Hospitalacquired pneumonia and ventilatorassociated pneumonia: recent advances in epidemiology and management. Curr Opin Pulm Med 2013, 19: 216-228 6. Chung DR, Song JH, Kim SH, et al. High prevalence of multidrug-resistant nonfermenters in hospital-acquired pneumonia in Asia. Am J Respir Crit Care Med 2011; 184: 1409-1417 7. Valles J, Artigas A, Rello J, et al. Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Ann Intern Med 1995; 122: 179-186 8. Pugin J, Auckenthaler R, Mili N, et al. Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic blind bronchoalveolar lavage fluid. Am Rev Respir Dis 1991; 143: 1121-1129 9. Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002; 165: 867-903 10. Chastre J, Wolff M, Fagon JY, et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA 2003; 290: 2588-2598 11. Coppadoro A, Bittner E, Berra L. Novel preventive strategies for ventilator associated pneumonia. Crit Care 2012; 16: 210 12. Morris AC, Hay AW, Swann DG, et al. Reducing ventilator-associated pneumonia in intensive care: Impact of implementing a care bundle. Crit Care Med 2011; 39: 2218-2224 4
Refresher Course Deep Vein Thrombosis and Pulmonary Embolism Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital Young-Jae Cho, MD April 25 (Fri) Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common, potentially lethal condition with acute morbidity, leading cause of morbidity and mortality in hospitalized patients.(1) Numerous randomized controlled trials (RCTs) show that using thromboprophylaxis (Table 1) in hospitalized patients at risk for VTE is safe, effective and cost-effective. Low-molecular-weight heparin (LMWH) along with vitamin K antagonists (VKAs) and the benefits and proven safety of ambulation have allowed for outpatient management of most cases of DVT in the acute phase. Patients with PE can also be treated in the acute phase as outpatients, a decision dependent on prognosis and severity of PE. Thrombolysis is best reserved for severe VTE; inferior vena cava filters, ideally the retrievable variety, should be used when anticoagulation is contraindicated. In general, DVT and PE patients require 3 months of treatment with anticoagulants, with options including LMWH, VKAs, or direct factor Xa or direct factor IIa inhibitors. Recently, the new Korean 2 nd guideline about the prevention of VTE was developed.(2) This guideline emphasized strategies for the prevention of VTE in Korean patients experiencing surgery, pregnancy, trauma, cancer, and acute medical illness. Based on VTE risk factors (age, immobility, history of VTE, co-morbid illness, and type of surgery or trauma), patients can be stratified into very-low-, low-, moderate-, and high-risk groups. (Table 2, 3) To identify patients who carry a high recurrent risk and require long-term treatment of acute VTE, three algorithms have been proposed: the HERDOO2, the Vienna prediction model, and the DASH score. All identify male sex and elevated D-dimer levels as important risk factors for recurrence. However, important differences among the models should be outlined and further studies are needed to clarify these discrepancies.(3) Venous thromboembolism prevention during critical illness is a widely used quality metric. Trial evidence to date suggests that any type of heparin thromboprophylaxis decreases deep vein thrombosis and pulmonary embolism in medical-surgical Table 1. Methods of thromboprophylaxis Table 2. Levels of VTE risk in medical patients 5
Table 3. VTE risk stratification and recommended prophylactic methods for each risk group critically ill patients, and low-molecular-weight heparin compared with bid unfractionated heparin decreases pulmonary embolism and symptomatic pulmonary embolism. Major bleeding and mortality rates do not appear to be significantly influenced by heparin thromboprophylaxis in the ICU setting.(4) With the adoption of dabigatran, rivaroxaban, and apixaban into clinical practice, a new era has arrived in the practice of oral anticoagulants. The new orally active anticoagulants (NOACs) have reasonably substituted traditional VKAs. Unlike VKA, NOACs do not need frequent monitoring. Therefore, more patients are likely to get therapeutic effects of anticoagulation and thus reduce morbidity and mortality associated with VTE. However, the intensivists need to be circumspect and exercise caution in use of these medications, especially critically ill populations (who are frequently in renal insufficiency). For example, it is important to note that the antidote for NOACs is not available and is a major concern if emergency surgical procedure is required in their presence.(5) In summary, the mainstay of DVT and VTE treatment is anticoagulation, while interventions such as thrombolysis and inferior vena cava filters are reserved for limited circumstances. Multiple therapeutic modes and options exist for VTE treatment with small but nonetheless important differential effects to consider. Anticoagulants will probably always increase bleeding risk, necessitating tailored treatment strategies that must incorporate etiology, risk, benefit, cost, and patient preference. Although great progress has been made, further study to understand individual patient risks is needed to make ideal treatment decisions. Many guidelines aim to define and clarify an optimal strategy for VTE prevention for patients with VTE risk; however, the ultimate decision should be individualized and determined by the intensivists. REFERENCES 1. Wells PS, Forgie MA, Rodger MA. Treatment of venous thromboembolism. JAMA: the journal of the American Medical Association. 2014;311(7):717-28. 2. Bang SM, Jang MJ. Prevention of Venous Thromboembolism, 2nd Edition: Korean Society of Thrombosis and Hemostasis Evidence-Based Clinical Practice Guidelines. Journal of Korean medical science. 2014;29(2):164-71. 3. Poli D, Palareti G. Assessing recurrence risk following acute venous thromboembolism: use of algorithms. Current opinion in pulmonary medicine. 2013;19(5):407-12. 4. Alhazzani W, Lim W, Jaeschke RZ, Murad MH, Cade J, Cook DJ. Heparin thromboprophylaxis in medical-surgical critically ill patients: a systematic review and meta-analysis of randomized trials. Critical care medicine. 2013;41(9):2088-98. 5. Sehgal V, Bajwa SJ, Bajaj A. New orally active anticoagulants in critical care and anesthesia practice: the good, the bad and the ugly. Annals of cardiac anaesthesia. 2013;16(3):193-200. 6
Refresher Course Dyskalemias in pediatric ICU Department of Pediatrics, Samsung Medical Center, Seoul, Korea Heeyeon Cho April 25 (Fri) Potassium (K + ) is the most abundant intracellular cation in the body and a high intracellular K + concentration should be maintained by the homeostatic mechanisms. The mechanisms for the high intracellular K + concentration do so through their effects on the basolateral cell membrane enzyme, Na + -K + - ATPase, which is regulated by insulin, thyroid hormone, catecholamines, and aldosterone. Secretion of these hormones is influenced by other stimuli including dietary intake, plasma volume, and plasma K + concentration. External balance is primarily determined by the rate of extracellular fluid K + uptake and renal excretion, which is regulated by principal cells in the cortical collecting duct. The cortical collecting duct K + secretary rate is affected by tubular flow rate, cytosolic K + concentration, luminal Na + concentration, and luminal nonreabsorbable anions. Although chronic K + balance is primarily regulated by the kidneys, acute K + tolerance is largely determined by extrarenal tissues such as liver, muscle, or intestine, and regulated by several hormone including insulin and epinephrine. Pediatric ICU (PICU) patients are at increased risk for hyperkalemia due to frequent comorbid conditions (sepsis, acidosis, trauma, and renal failure), transfusion, and exposure to multiple medications, and the diagnostic approach including a detailed history, review of medical records, and a variety of laboratory tests are needed. Acid-base balance and dyskalemias are often clinically linked. Among the tests, the transtubular potassium gradient (TTKG), which can be calculated by using urine K +, plasma K + concentrations, urine osmolality and plasma osmolality, can be used to evaluate renal K + handling for hyper and hypokalemia. Potassium chloride has been identified as high-alert medication, which results in death of serious injury related to medication errors, by The Joint Commission on the Accreditation of Healthcare Organization, and dyskalemia can cause life-threatening conditions. Therefore, particular attention should be paid to potassium balance in the PICU, and the appropriate protocols and policies in ICU for the administration of supplemental K + and management of dyskalemia can improve patient safety for this frequently encountered electrolyte imbalance. REFERENCES 1. Doucet A. Function and control of Na-K-ATPase in single nephron segments of the mammalian kidney. Kidney Int. 1988;34(6):749-60. 2. Bia MJ, DeFronzo RA. Extrarenal potassium homeostasis. Am J Physiol. 1981;240(4):F257-68. 3. Lee Hamm L, Hering-Smith KS, Nakhoul NL. Acid-base and potassium homeostasis. Semin Nephrol. 2013;33(3):257-64. 4. 'High-alert' medications and patient safety. Int J Qual Health Care. 2001;13(4):339-40. 5. White JR, Veltri MA, Fackler JC. Preventing adverse events in the pediatric intensive care unit: prospectively targeting factors that lead to intravenous potassium chloride order errors. Pediatr Crit Care Med. 2005;6(1):25-32. 7
Refresher Course Difficult intubation in ICU or ward Chungnam National University School of Medicine Sang Il Park Airway management in the ICU/ward is quite different from the operating room. Airway management during anesthesia is mostly an elective procedure and a difficult airway is usually due to anatomy alterations, which can be predicted and appropriately treated. Also, anesthesiologists are well trained in the use of alternative airway management methods. However, this is not the case in the ward/icu. The absence of a well experienced practitioner as well as other airway management methods can lead to catastrophic consequences.[1,2] It is now known that unsuccessful, repeated attempts with a laryngoscope is not a good option. In order to reduce complications, it is important to provide an institutional strategy for difficult airway, individual carful assessment, through planning and good communication/teamwork.[3] Priority must be given toward adequate ventilation, not to intra-tracheal intubation. This session will first focus on methods that can make intra-tracheal intubation more comfortable during cardiopulmonary resuscitation, since this is the most common cause of airway management in the ICU.[4] Secondly, Alternative methods in case of difficult intubation will also be discussed.[5,6] In order to be properly prepared, it is critical to be aware of clinical parameters that can be used in order to predict a difficult airway and will be discussed in this session as well. At the end of the session we will focus on percutaneous tracheostomy and retrograde intubation, which are two relatively easy techniques that can be used for quick airway management in emergency situations. REFERENCES 1. Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth 2011; 106: 632-42. 2. Berkow L. What's New in Airway Management. ASA Refresher Courses in Anesthesiology 2013; 41: 31-7. 3. Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth 2012; 109: i68-i85. 4. Cook TM, Hommers C. New airways for resuscitation? Resuscitation 2006; 69: 371-87. 5. Levitan RM, Chudnofsky C, Sapre N. Emergency airway management in a morbidly obese, noncooperative, rapidly deteriorating patient. Am J Emerg Med 2006; 24: 894-6. 6. Levitan RM, Heitz JW, Sweeney M, Cooper RM. The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices. Ann Emerg Med 2011; 57: 240-7. 8
Refresher Course Advanced Neuromonitoring in Critically ill patients Division of Critical Care Neurology, Department of Neurology, Seoul National University Hospital, Seoul, Korea Sang-Bae Ko, MD, PhD. April 25 (Fri) Multimodality monitoring (MMM) is a recently developed method that aids in understanding real-time brain physiology. Early detection of physiological disturbances is possible with the help of MMM, which allows identification of underlying causes of deterioration and minimization of secondary brain injury (SBI). MMM is especially helpful in comatose patients with severe brain injury because neurological examinations are not sensitive enough to detect SBI. The variables frequently examined in MMM are hemodynamic parameters such as intracranial pressure, cerebral perfusion pressure, and mean arterial pressure; brainspecific oxygen tension; markers for brain metabolism including glucose, lactate, and pyruvate levels in brain tissue; and cerebral blood flow. Continuous electroencephalography can be performed, if needed. The majority of SBIs stem from brain tissue hypoxia, brain ischemia, and seizures, which lead to a disturbance in brain oxygen levels, cerebral blood flow, and electrical discharges, all of which are easily detected by MMM. Here, we will briefly review how MMM variables are used in individual patients care. 9
Refresher Course Neurogenic pulmonary edema in patient with increased ICP Yonsei University, Wonju Severance Christian Hospital, Neurosurgery Jong Yeon Kim Neurogenic pulmonary edema (NPE) is a clinical syndrome characterized by the acute onset of pulmonary edema following a significant central nervous system (CNS) insult. It has been reported regularly for a long time in numerous and various injuries of the central nervous system in both adults and children, but remains poorly understood because of the complexity of its pathophysiologic mechanisms involving hemodynamic and inflammatory aspects. The sudden development of hypoxemic respiratory failure following a catastrophic CNS event, which cannot be attributed to other causes of ARDS, is the only universally agreed upon characteristic of NPE. Most probably, such edema develops on the basis of a rapid systemic sympathetic discharge, leading to pulmonary vascular congestion with perivascular edema, extravasation and the intra-alveolar accumulation of protein-rich edema fluid and intraalveolar hemorrhage. There exists evidence that intracranial pressure is also of some importance. The level of anesthesia might be crucial for the extent of neurogenic pulmonary edema development. There are several models of neurogenic pulmonary edema; however, those in which neurogenic pulmonary edema is induced by central nervous system injury should be preferred. Early and appropriate treatment of the underlying neurologic cause is the cornerstone of NPE management. Most patients should be intubated, sedated, appropriately ventilated with PEEP and maintained with normal hemodynamic stability. The management of NPE is difficult and there is little in the way of evidence-based guidelines to aid therapy. Treatment is supportive and should follow the principles of reversing the underlying pathophysiology. 10
Refresher Course 뇌사장기기증자관리 아주대학교의과대학외과학교실 이재명 April 25 (Fri) 서론 중환자실에서잠재뇌사상태로장기기증이동의된환자를관리하는것은중환자분야의꽃이라고불리어도과언이아니다. 뇌사환자는중추신경에의존하는생리적항상성의소실로환자의상당수가매우불안정한혈역학적상태를보이며, 저혈압, 저체온, 심부정맥, 전해질장애, 뇨붕증, 대사성산증, 폐부종, 심장정지등다양한합병증이동반되기때문에, 그야말로심한중증환자이다. 이런환자들을관리하여생체징후를안정화시킨후, 되도록많은수의최고상태의장기가기증될수있도록함으로써여러수혜자의생명을살릴수있는일이기때문이다. 본론 장기기증동의가이루어진잠재뇌사환자의뇌사장기기증자관리는크게세가지목적으로이루어진다. 첫째는, 1, 2 차에걸친뇌사조사와무호흡검사, 두경부 CT 나 SPECT 등여러보조검사, 뇌파검사, 이후뇌사판정위원회라는전과정을거침으로써환자가뇌사라는것을확진하는것이다. 특히 1 차뇌사조사를빨리성공적으로시행하여야그이후의단계 ( 수혜자선정등 ) 가진행될수있고, 설사기증이불가능한상황이발생하더라도, 정부의뇌사장기기증자지원금수혜가가능하고기증자관리비에대한보험인정을받을수있다. 둘째는, 뇌사장기기증자로서적합한지에대한철저한검증이다. 기증자가간염, 바이러스등전염성질환또는전이가능한암등을갖고있지않은지에대한파악은필수이고, 기증자의나이, 혈액형, 기왕력뿐만아니라, 각장기에대한기능평가검사를시행하여장기별기증적합성을파악하여야한다. 셋째는, 뇌사장기기증자관리의궁극적인목표인공여장기의질또는기능향상이다. 되도록많은수의장기를최상의상태로기증하기위해서는조직관류및산소공급을항상염두에두어야한다. 특히뇌사장기기증자관리초기의수액치료가관리기간중생체징후에큰영향을미치므로, 초기관리 를적극적으로시행하도록한다. 뇌사장기기증자관리시작부터장기구득순간까지권장되는생리적수치값은, systolic blood pressure 90 mmhg, mean arterial pressure 60 mmhg, pulmonary capillary wedge pressure 12mmHg, left ventricular stroke work index > 15g.m/M 2, cardiac index > 2.5 L/min/M 2, core temperature > 35 o C, hematocrit 25%, O 2 saturation > 95%, ph 7.35-7.45, Lactate < 2.0 mmole 등과같고이는일반중환자관리의지침과크게다르지않다. 항생제치료, 영양공급, 혈당조절, 혈역학관리, 호흡기관리등뇌사장기기증자관리의중요한세부면면이많지만, 지면관계상, 뇌사장기기증자관리의특별한사항두가지만언급하고자한다. 1. Cortisol, vasopressin, 갑상선호르몬등호르몬보충이권장되는데, 이러한호르몬보충이승압제사용을감소시키는등, 뇌사장기기증자혈역학적안정을꾀하여, 궁극적으로구득장기의수증가, 이식장기기능향상을유도하였다는보고가있었기때문이다. 2. 뇌사환자의 80% 정도에서는항이뇨호르몬분비가적어서뇨붕증이발생하며, 이는뇌사장기기증자에서관찰되는다뇨의가장큰원인이다. 고나트륨혈증 (190mEq/L 이상도관찰됨 ), 저칼륨혈증, 저칼슘혈증, 저마그네슘혈증등심한전해질불균형이관찰되므로, 이에따른수액치료를통해전해질수치를안정화시키는데주력하여야한다. vasopressin 소량점적이나 desmopressin 등을투여하여호르몬을보충함으로써, 소변양은 1-4 ml/kg/hr 를유지하여야한다. 결론 뇌사장기기증자관리중환자를심장사에이르게하는실패율을낮추고공여장기의질을높이기위해서는중환자의학의기본지식이필수이다. 특히뇌사환자특유의생리적특성을이해하고적절한수액치료, 전해질교정을포함한공격적이고적극적인초기치료를시행하여야만좋은결과를얻을수있다. 11
Refresher Course Therapeutic Hypothermia in Critical illnesses Department of Emergency Medicine, Seoul National University Bundang Hospital You Hwan Jo, MD, PhD Therapeutic hypothermia (TH) was introduced as a protective management for the brain and it has been used in the operating room to provide anesthesia surgery [1,2]. More recently, clinical studies have suggested that the use of TH improves the outcomes after out-of-hospital cardiac arrest [3,4]. Several human trials have shown the advantage of TH in many critical illnesses including cardiac arrest, but the beneficial effect of the TH was not consistent. In the neonatal hypoxic-ischemic encephalopathy, TH improved survival and decreased disability especially in the severe neonatal encephalopathy [5,6]. In the meta-analysis of Cochrane Database review, both systemic hypothermia and selective head cooling improved survival and neurological outcome in the encephalopathy [7]. Therefore, TH is recommended strongly now in the neonatal encephalopathy and routinely used. TH has been used in patients with severe traumatic brain injury and increased intracranial pressure refractory to medical treatment. In the early studies, TH has lowered intracranial pressure and improved survival in the severe traumatic brain injury [8,9]. However, well-designed randomized control studies did not revealed the advantages of TH in adult and pediatric patients with severe brain injury [10,11]. Given the quality of the data available, no benefit of TH on survival or neurological outcome could be identified. TH is one of the most extensively studied in acute ischemic stroke. Based on the many animal studies, TH was induced in patients with severe ischemic stroke in the middle cerebral artery territory and it has been reported that TH lowered intracranial pressure and mortality [12,13]. However, TH with intravenous thrombolysis did not improved outcome and the frequency of serious adverse effects has been reported higher than normothermia [14,15]. Two ongoing clinical trials are investigating the effect of TH in acute stroke (ICTuS 2/3 and EuroHYP-1). These ongoing phase 2 and 3 clinical trials will validate the TH as a treatment of acute ischemic stroke. Intracranial hypertension is commonly encountered in aneurysmal subarachnoid hemorrhage (SAH) and is associated with poor outcome. TH has been used intraoperatively, but did not show significant benefit in reduction of mortality and neurological outcome [16]. There are a few clinical studies on the effect of systemic TH in SAH. The control of Intracranial pressure was able to be achieved and one study reported the good clinical outcome, but further well-designed studies are warranted [17]. In other critical illnesses such as spinal cord injury, hepatic encephalopathy, epilepsy, cardiogenic shock, and adult respiratory distress syndrome, several case reports and series, and small clinical studies revealed the beneficial effects of TH in terms of survival, neurological outcome and hemodynamic variables. However, large randomized studies are lacking and it is difficult to recommend TH routinely in these patients. In conclusion, TH has been used in many critical illnesses and several large clinical studies are ongoing. Further studies are necessary to identify the potential applications and the most effective TH strategy and candidates, and to understand the benefits and detrimental effects of TH. REFERENCES 1. Sealy WC, Brown IW Jr, Young WG Jr. A report on the use of both extracorporeal circulation and hypothermia for open heart surgery. Ann Surg 1958;147:603-613. 2. Kawamura S, Suzuki A, Hadeishi H, et al. Cerebral blood flow and oxygen metabolism during mild hypothermia in patients with subarachnoid haemorrhage. Acta Neurochir 12
You Hwan Jo: Therapeutic Hypothermia in Critical illnesses 2000;142:1117-1121. 3. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;346:549-556. 4. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002;346:557-563. 5. Jacobs SE, Morley CJ, Inder TE, et al. Whole-body hypothermia for term and near-term newborns with hypoxic-ischemic encephalopathy. Arch Pediatr Adolesc Med 2001;165: 692-700. 6. Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicenter randomized trial. Gluckman PD, Wyatt JS, Azzopardi D et al. Lancet 2005; 365:663-670. 7. Jacobs SE, Berg M, Hunt R, et al. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev 2013. 8. Zhi D, Zhang S, Lin X, et al. Study on therapeutic mechanism and clinical effect of mild hypothermia in patients with severe head injury. Surg Neurol 2003;59:381-385. 9. Jiang JY, Yu MK, Zhu C. Effect of long-term mild hypothermia therapy in patients with severe traumatic brain injury: 1-year follow-up review of 87 cases. J Neurosurg 2000;93: 546-549. 10. Clifton GL, Miller ER, Choi SC, et al. Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med 2001;344:556-563. 11. Hutchison JS, Ward RE, Lacroix J, et al. Hypothermia therapy after traumatic brain injury in children. N Engl J Med 2008;358:2447-2456. 12. Schwab S, Schwarz S, Spranger M, et al. Moderate hypothermia in the treatment of patients with severe middle cerebral artery infarction. Stroke 1998;29:2461-2466. 13. Schwab S, Georgiadis D, Berrouschot J, et al. Feasibility and safety of moderate hypothermia after massive hemispheric infarction. Stroke 2001;32:2033-2035. 14. Hemmen TM, Raman R, Guluma KZ, et al. Intravenous thrombolysis plus hypothermia for acute treatment of ischemic stroke (ICTuS-L). Stroke 2010;41:2265-2270. 15. Bi M, Ma Q, Zhang S, et al. Local mild hypothermia with thrombolysis for acute ischemic stroke within a 6-h window. Clin Neurol Neurosurg 2011;113:768-773. 16. Todd MM, Hindman BJ, Clarke WR, et al. Mild intraoperative hypothermia during surgery for intracranial aneurysm. N Engl J Med 2005;352:135-145. 17. Seule MA, Muroi C, Mink S, et al. Therapeutic hypothermia in patients with aneurysmal subarachnoid hemorrhage, refractory intracranial hypertension, or cerebral vasospasm. Neurosurgery 2009;64:86-92. April 25 (Fri) 13
Refresher Course ECPR Department of Thoracic and Cardiovascular Surgery, Anam Hospital, Korea University Medical Center Jae-Seung Jung, MD, PhD Despite some recent advances, the outcome after cardiac arrest is still poor with survival rates for in-hospital cardiac arrest (IHCA) of 22.3% in 2009. and survival rates after out-of-hospital cardiac arrest (OHCA) seem to improve marginally, but remain at just 9%. High-quality cardiopulmonary resuscitation (CPR), which emphasizes minimal interruption in chest compression and complete chest recoil, was addressed in the 2010 American Heart Association (AHA) Guidelines for Resuscitation. However, standard CPR is inherently inefficient, providing less than 25% of blood flow to the heart and brain. Extracorporeal CPR (ECPR), applied during CPR, was developed as an adjuvant rescue therapy for standard CPR. In the 2010 AHA Guidelines for Resuscitation, ECPR was placed as class IIb recommendation when the no flow time was brief and the cause of cardiac arrest was potentially reversible. In recent years important advances in technology, in particular miniaturisation of devices to facilitate transport, better biocompatibility with heparin-coating, plasma-resistant membranes and improvement of percutaneous cannulas, resulted in a rapidly expanding use of extracorporeal cardiopulmonary resuscitation (E-CPR). Several retrospective case series have been published, presenting survival rates of 26-39% for IHCA. Expectedly, survival for OHCA is inferior with a reported rate of 4-17%. Fagnoul D et al showed an important approach for effective E-CPR and improving results. 1 st Strict inclusion criteria 2 nd Automatic mechanical chest compression device for transport to the hospital 3 rd Intra-arrest hypothermia with a core temperature of 32.3 o C at ECMO initiation 4 th Tried to avoid hyperoxia 5 th Early percutaneous coronary intervention (PCI) to treat cardiac ischemia. Still, beyond these important steps, the optimal practice of many details of E-CPR is not clear and may give a chance for further improvement: There is no doubt that the time to extracorporeal life support (ECLS) should be the shortest possible and CPR must not be interrupted on the way to hospital. Therapeutic hypothermia of 32-34 o C has been resulted in superior neurological outcome19,20; to start it at the earliest possible moment, as was done in the current study, seems intuitively reasonable. However, hypothermia inhibits the coagulation cascade and, as many E-CPR patients develop massive bleeding for various reasons, it may be wise to vary the target temperature in individual patients, weighing potential cerebral protection against the side effects of massive transfusions. Hyperoxaemia after a period of anoxia causes additional damage to neuronal structures and other organs by the formation of toxic oxygen-radicals. Even more dangerous may be hypocapnia with alkalosis, which can lead to fatal cerebral vasoconstriction in an already injured brain. The optimal mean arterial pressure (MAP) during ECLS is not clear. Higher MAP may maintain a better cerebral perfusion, but needs higher ECMO flow and/or higher doses of vasopressors. Higher ECMO flow resulting in a higher MAP elevates the after-load of the heart, increases the risk for pulmonary edema and also increase the risk of intra-cavitary clot formation because of stagnate blood flow. For oxygen transport and delivery, flow of blood is more important than MAP. Measurement of central venous saturation, lactic acid and cerebral saturation by near-infrared spectroscopy may be helpful and should be used in all patients on VA-ECMO. 14
Jae-Seung Jung: ECPR After resuscitation many patients develop massive bleeding due to disseminated intravascular coagulopathy, iatrogenic anticoagulation, anti-platelet therapy and invasive procedures. The role of hydrocortisone to attenuate SIRS is not defined, but may be reasonable. As aspiration pneumonia is common, possibly exaggerated by hypothermia, antibiotic coverage is advisable. Short-acting analgosedation is essential to be able to judge neurological outcome early and reliably. Modern extracorporeal life support has established a place in the treatment of prolonged cardiac arrest with failing conventional CPR. To further improve the outcome after cardiac arrest with the use of E-CPR, a joint venture with exchange of individual experiences, organisation of multi-centre prospective trials and the collection of data and results, possibly in already existing international databases like the registry of the Extracorporeal Life Support Organization (ELSO), is inevitable REFERENCES 1. Girotra S, Nallamothu BK, Spertus JA, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med 2012;367:1912-20. 2. Abrams HC, McNally B, Ong M, Moyer PH, Dyer KS. A composite model of survival from out-of-hospital cardiac arrest using the Cardiac Arrest Registry to Enhance Survival (CARES). Resuscitation 2013;84:1093-8. 3. Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S640-S656. 4. Andreka P, Frenneaux MP. Haemodynamics of cardiac arrest and resuscitation. Curr Opin Crit Care 2006;12:198-203. 5. Cave DM, Gazmuri RJ, Otto CW, et al. Part 7: CPR techniques and devices -2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S720-S728. 6. Fagnoul D, Taccone FS, Behlaj A, et al. Extracorporeal life support associated with hypothermia and normoxia in refractory cardiac arrest. Resuscitation 84(2013) 1519-1524 7. Muller T, Lubnow M. The future of E-CPR: A joint venture. Resuscitation 84 (2013) 1463-1464 April 25 (Fri) 15
Plenary Lecture ICU director and leader: what are the tools that you need to be successful? President of SCCM, Mayo Clinic Chris Farmer Learning Objectives ㆍ To discuss and review the changing demands on critical care ㆍ To discuss and review the impact of these changes on the role of an ICU director and leader ㆍ To discuss future trends and how critical care leaders must adapt and change Abstract The leadership role and function of an ICU director is complementary but is distinctly different than the role of ICU clinician. What are the required elements of this skill set? How does an ICU practitioner develop these skills and how do these individuals assume these additional responsibilities? What is the impact of the changing demands of critical care on the role of an ICU director and leader? In addition to clinical credibility, an ICU director and leader must acquire the following skills: ㆍ Knowledge of clinical and administrative operations ㆍ Ability to effect the science of change management ㆍ Excellent communications ㆍ Leadership ㆍ Extensive knowledge of the science of quality and process improvement In addition, an ICU leader and director must be knowledgeable regarding how to talk to medical administrators, and must understand their needs and perspectives. We will also discuss some of the common pitfalls that ICU leaders must overcome in the workplace. 16
Plenary Lecture My past experience of intensive care and the future direction of intensive care in Japan The Chair of the Executive Board of JSICM, Chief Professor of Department of Emergancy & Critical Care Medicine, Okayama University and Hospital, Okayama, Japan April 25 (Fri) Yoshihito Ujike, MD, Ph.D In Japan, the first ICU was made in 1964 at Juntendo University Hospital and Tohoku University Hospital started the ICU firstly in 1968 as a national university hospital. The Japanese Society of Intensive Care Medicine (JSICM) was established by anesthesiologists and cardiologists in 1974. However, there was no ICU in my Sapporo Medical University hospital when I graduated from it in 1975. After graduation, I became a resident of Department of Anesthesiology of my university. I had the first training for intensive care in Hakodate City Hospital in 1976-1977. It was only one ICU in Hokkaido at that time. I learned the postoperative intensive care there. In 1978, Ministry of Health of Japan started the Critical Care & Emergency (CCE) Center System. In Hokkaido, Asahikawa Red Cross Hospital was appointed as the first CCE center. In the hospital which had no specialist for intensive care and emergency medicine, I worked from 1978 to 1982 and had many experience for critical care. In 1985, Sapporo Medical University Hospital built the emergency and intensive care unit. I became a chief of the intensive care unit as assistant professor and started to take care of very severe patients with seven young doctors who were gathered from different department. We began to use cardiopulmonary bypass for cardiac arrest out of hospital in 1987. In Japan, the resuscitation method had developed very much as percutaneous cardiopulmonary support (PCPS) in 1990 s. Then we tried to do enteral nutrition in stead of perenteral nutrition for MOF patients. At that time, many Japanese doctors criticized our trial as enteral nutrition is unstable for nutrition method. However, we had the data that the prognosis of patients with enteral nutrition is better than those with parenteral nutrition. Now, enteral nutrition has become standard method in ICU. In 2000, I moved to Okayama University Hospital as a first professor of Department of Emergency & Critical Care Medicine. Okayama University Hospital had been famous for the lung transplantation and the congenital heart operation, and the postsurgical ICU had been managed by an excellent anesthesiologist. On the other hand, there were no beds for intensive care of emergency patients. In 2003, the ICU for emergency and critical patients was built, I could begin the critical care in Okayama University too. I became a vice president of JSICM in 2010 and became a president of it in 2012. The start of JSICM in 1974 was early, but, for recent ten years, the development has stopped. I intended to rebuild it. JSICM made text DVD for intensive care specialist (intensivist) and started to publish the English journal (Journal of Intensive Care) in 2013. We invited MCCRC to Japan last year as KSCCM did. In Japan, the board system of specialist will changed from 2017. Nineteen basic specialties will be established, and forty-nine sub-specialties (super-specialties) will be positioned above them. JSICM decided that intensivists become a specialist above anesthesiologist, emergency physician, pediatrics and other specialists. Intensivist should be doctor s doctor. Now, we are making the standardized educational program and curriculum for the intensivists. We want to make good relations with many medical societies in the world about intensive care and want to consider collaborative investigation, the joint education system, etc. 17
Special Lecture Multicentre research in Asian intensive care - a new dawn National University Hospital, Singapore Jason Phua Asia is Earth s largest continent. It is the home of 4.3 billion people, which makes up 60% of the world s population. Correspondingly, Asia accounts for more than half of all critically ill patients internationally. Sadly though, the paucity of multicentre and multinational studies from Asian intensive care units provides a stark contrast to the vibrant critical care literature from the West. Multiple barriers to such research exist in Asia, including the diversity of its population, the gap in wealth across the continent, poor infrastructure for not just research but also intensive care itself in many countries, and simply, the non-existence of a research culture in most intensive care communities. Yet, there is a limit to how much one can extrapolate findings from studies performed in the West to patients in the East. Collaborative research and large-scale studies by Asians and for Asians are needed if we truly want to understand how best to help our critically ill. There is however a bright spot on the horizon. In recent years, various multicentre studies have emerged in Asian intensive care, not just within nations but also between nations. Intensivists from across the continent have banded together to form the Asian Critical Care Clinical Trials (ACCCT) Group. This talk will describe the journey that these intensivists have taken and discuss what lies ahead for Asian intensive care research. 18
Special Lecture Cardiopulmonary Interactions during Mechanical Ventilation Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India JV Divatia, MD, FICCM, FCCM April 25 (Fri) Major determinants of heart-lung interactions are: * Changes in Intrathoracic Pressure (ITP), leading to changes in the preload of the right ventricle (RV) and afterload of the left ventricle (LV) * Changes in Lung volume, affecting the pulmonary vascular resistance (PVR), causing compression of the heart and changes in autonomic tone and humoral effects * Ventricular interdependence. A series effect occurs because the output of the RV is the preload of the LV. A parallel effect occurs because the RV and LV share a common septum, and are enclosed in the pericardium which limits expansion of both ventricles. * In addition, during inspiration, the diaphragm descends and produces changes in intra-abdominal pressure. Effects of changes in intrathoracic pressure Effect on preload During spontaneous ventilation, right atrial pressure (Pra) decreases, enhancing venous return. During intermittent positive pressure ventilation (IPPV), the increased Pra results in reduced venous return and a fall in cardiac output. The extent of this hemodynamic change is influenced by the volume status of the patient as well as the compliance of the lungs and chest wall. Effect on Left ventricular (LV) afterload and intrathoracic transmural pressure The LV afterload depends on the LV end-diastolic volume (LVEDV) and the transmural pressure of the LV. The LV transmural pressure is the difference between the intraventricular pressure and pleural pressure. If the pleural pressure is negative, as during spontaneous breathing, the LV transmural pressure and hence its afterload is increased, increasing the impedance to LV ejection. Similarly, the transmural pressure across the intrathoracic aorta is increased, also increasing LV afterload. During IPPV, the effect of positive intrapleural pressure is to decrease the LV afterload, thus improving ejection of the LV. This is clinically beneficial in heart failure. Conversely, during weaning from mechanical ventilation, the increase in preload coupled with increased afterload on resumption of spontaneous unassisted ventilation may result in pulmonary edema and failure to wean. Effect on hemodynamic measurements Increased intrapleural pressure also increases the measured central venous pressure (CVP) and pulmonary artery occlusion pressure (PAOP). However the filling pressure of the cardiac chambers is actually the transmural pressure, which cannot be determined unless the pleural pressure is measured. It is difficult to quantify the proportion of pleural pressure that is transmitted to the CVP and PAOP. The index of transmission has been described, and is affected by the pulmonary compliance. Cardiovascular effects of increase in lung volume Changes in PVR The pulmonary circulation is made up of alveolar and extra-alveolar vessels. At high lung volumes, PVR is increased as overdistended alveoli compress the alveolar capillaries. At low lung volumes, when lung voume decreases below the functional residual capacity (FRC), the tortuosity of extra-alveolar vessels increases causing kinking and collapse of these vessels. In addition, terminal airway collapse may lead to hypoxic pulmonary vasoconstriction, leading to an increased PVR. As the 19
lung is inflated from residual volume towards FRC, there is a decrease in extra-alveolar vessel resistance, but possible increase in alveloar capillary PVR due to overdistension. The net PVR is least at FRC and increases above and below the FRC. Right ventricular (RV) afterload is determined mainly by the PVR. PVR is often elevated in several pulmonary and vasuclar conditions and further increases in PVR during mechanical ventilation with high PEEP or tidal volume can precipitate acute cor pulmonale. Ventricular interdependence Changes in RV output or RVEDV influence the output from the LV. Parallel effect Diastolic filling of one ventricle affects the diastolic compliance of the other. Spontaneous breathing is associated with increased venous return and RVEDV. The increased RVEDV may cause shift of the septum into the LV reducing LV diastolic compliance, LVEDV and LV output. If pericardial disease or effusion prevents dilatation of the RV, the pressure is transmitted to the left atrium with reduction in pulmonary venous return as well as reduced cardiac output. This clinically results in an exaggerated drop in systolic pressure during inspiration in a spontaneously breathing patient, called pulsus paradoxus. Series effect During IPPV, phasic increases in lung volume and intrathoracic pressure increase the right atrial pressure, resulting in decreased venous return to the RV and decreased intrathoracic blood volume. After about three heart beats, the decreased flow reaches the LV, and if it is preload-responsive, then its output also transiently decreases. Thus, seeing either LV stroke volume or its surrogate arterial pulse pressure variation (SVV and PPV, respectively) during ventilation identifies patients as being volume responsive. This interaction can be used clinically to monitor preload responsiveness using parameters such as the systolic pressure variation (SPV), pulse pressure variation (PPVV) and stroke volume variation (SVV) i\n mechanically ventilated patients. Summary IPPV results in several effects on hemodynamics, some of which are beneficial while others are detrimental. Adverse effects may predominate in the presence of pre-existing acute or chronic pulmonary disease, hypovolemia and RV dysfunction, while benefit may be seen in cardiac failure. These interactions may have implications for other organs. It is important to understand these cardiopulmonary interactions to understand the hemodynamic status of the patient and to optimise ventilatory management in critically ill patients. 20
Symposium 1: ARDS Fibroproliferative stage in patients with ARDS Professor of Medicine, Department of Pulmonary and Critical Care Medicine, Asan Medical Center, Univ. of Ulsan College of Medicine Sang-Bum Hong, MD, PhD April 25 (Fri) Despite advances in clinical care, particularly lung protective strategies of mechanical ventilation, Acute respiratory distress syndrome (ARDS) has a high mortality 40~45%. Most survivors experience impaired health-related quality of life for years after the acute illness. Recently ECMO is spreading rapidly all over the world after severe ARDS trial and pandemic influenza ARDS. We as clinician are learning long run ECMO patients who recover slowly after severe lung injury. One of causes of impaired poor lung function is fibroproliferative response characterised by fibroblast accumulation and deposition of collagen and other extracellular matrix components in the lung. The factors that determine which patients develop fibroproliferative ARDS and the cellular mechanisms responsible for this pathological response are not well understood. Recent advances in the field of fibroproliferative ARDS focus on the primary contributing factors with a focus on cellular and soluble factors, and mechanisms involved in repair and remodelling. Based on the mechanisms underlying the remodeling process, some therapeutic options can be considered. For examples, there are steroid, ACE inhibitors, stem cell and new molecular targeting agents which developed to treat pulmonary fibrosis. syndrome: mechanisms and clinical significance. Burnham EL, Janssen WJ, Riches DW, Moss M, Downey GP. Eur Respir J. 2014 Jan;43(1):276-85. 2. Fibroproliferative changes on high-resolution CT in the acute respiratory distress syndrome predict mortality and ventilator dependency: a prospective observational cohort study. Ichikado K, Muranaka H, Gushima Y, Kotani T, Nader HM, Fujimoto K, Johkoh T, Iwamoto N, Kawamura K, Nagano J, Fukuda K, Hirata N, Yoshinaga T, Ichiyasu H, Tsumura S, Kohrogi H, Kawaguchi A, Yoshioka M, Sakuma T, Suga M. BMJ Open. 2012 Mar 1;2(2):e000545. 3. Lung parenchyma remodeling in acute respiratory distress syndrome. Rocco PR, Dos Santos C, Pelosi P. Minerva Anestesiol. 2009 Dec;75(12):730-40. 4. Advances in mechanisms of repair and remodelling in acute lung injury. Dos Santos CC. Intensive Care Med. 2008 Apr;34(4):619-30. 5. Therapeutic potential and mechanisms of action of Mesenchymal Stromal Cells for Acute Respiratory Distress Syndrome. Curley GF, Scott JA, Laffey JG. Curr Stem Cell Res Ther. 2014 Feb 28. REFERENCES 1. The fibroproliferative response in acute respiratory distress 21
Symposium 1: ARDS 급성호흡곤란증후군에서의생체표지자 (Biomarkers in ARDS) 연세대학교의과대학내과학교실 박무석 급성호흡곤란증후군 ( 이하 ARDS) 은폐렴, 패혈증, 흡인, 외상등여러가지원인에의해폐상피세포와폐미세혈관계의내피세포장벽에손상이생겨폐간질과폐포에비심인성부종이생기고, 이에의해호흡곤란과중증저산소증이발생하는복합적인증후군이다 1,2. 최근개정된 ARDS 베를린정의에의하면 1) 1주이내악화또는새로이발생한호흡기증상, 2) 양측성폐침윤, 3) 비심인성호흡부전, 4) 저산소증으로 ARDS를정의하고있으며, 저산소증의정도에따라경증 (mild; 200 mm Hg < PaCO 2 /FiO 2 300 mm Hg = 과거 ALI), 중등증 (moderate; 100 mm Hg < PaCO 2 /FiO 2 200 mm Hg), 중증 (severe; 100 mm Hg PaCO 2 /FiO 2 ) 으로정의하고있다 3. 염증조절장애 (dysergulated inflammation), 백혈구와혈소판의부적절한활성화와침착, 조절되지않는응고인자들의활성화, 폐상피세포와내피세포장벽의투과성변화등이 ARDS의주요병태생리학적개념이다 2. 이러한 ARDS의주요병태생리에기반을둔적절한생체표지자를찾기위한새로운염증성매개체와기전, 단백질들 ( 상피세포기원, 내피세포기원, 응고인자등 ), 면역반응물질, 유전적다양성에대한수많은생체표지자들이연구되고있으나아직임상적유용성을명확히증명한하나의생체지표는없는실정이며, 이들을어떻게해석하고임상적으로이용할지에대한고민이필요하며, 임상의의신중한판단이요구된다. 생체표지자란객관적으로측정되고, 평가되는정상또는비정상생체반응을대변하며, 진단및예후예측에도움을주거나치료중재에대한약물학적반응을대변하는특징적인생체물질로정의한다 4. 이상적인생체표지자는 SMART로요약되며 1) 높은민감도 (Sensitivity) 과특이도 (Specificity), 2) 정확히측정가능함 (Measurable), 3) 쉽게이용가능함 (Available), 4) 반응적이고, 재현가능함 (Responsive and Reproducible), 5) 적절한시간과알맞은처리공정 (Timely fashion) 이어야한다 5. 널리사용하기위해서는타당성검증 (validation) 와자격인정 (qualification) 을받아야하며, 신뢰도 (reliability) 확인, 경계점 (cutoffs) 설정, 적절한시간과알맞은처리공정이필요하다 6. ARDS 환자의혈액또는기관지폐포척액에서생체표지자를검출하기위한노력이오랜기간동안이루어져왔으며, ARDS의발생위험예측, 진단, 예후예측에유용한생체지표들은대리표지자 (surrogate marker) 로서폐손상및복구 (repair) 의병태생리에대해큰정보를제공하며, 새로운치료약제의개발에큰도움을줄수있을것으로예상된다 7. ARDS 의생체표지자로크게다음 4개군으로나눌수있다 7-11. (1) 염증성매개체 (Inflammatory mediators); 염증전구싸이토카인인 IL-1β, TNF-α, IL-6, IL-8 및항염증싸이토카인인 IL-1Ra, IL-10, IL-13 등, (2) 혈액응고인자활성화와섬유소분해 (coagulation and fibrinolysis) 억제 : protein C, plasminogen activator inhibitor (PAI-1), thrombomodulin, tissue factor 등, (3) 폐포상피표지자 (Biomarkers of epithelial cell injury): 1형폐포세포 (pneumocyte) 손상시 RAGE (receptor for advanced glycation end products), 2형손상시계면활성제 (surfactant proteins), KL-6 (Kerbs von den Lungren-6), 클라라세포 (Clara cell) 손상시 CC-16 (Clara cell-specific protein) 등, (4) 혈관내피세포표지자 (Biomarkers of endothelial cell injury): von Willebrand factor (VWF), selectins, 세포내부착인자 (intercellular adhesion molecules), VEGF(vascular endothelial growth factor), angiopoietin 2 (Ang-2) 등이있다 7-11. 또한이들의생체표지자들을동시에이용하여 ARDS의위험예측및진단과예후에이용한연구들도있다 12-14. 앞선연구에서처럼이미중환자실에서인공호흡기치료를받고있는환자에서 ARDS를진단하고예후를예측하는인자를찾는것이아니라, 응급실이나병동에서조기에 ALI/ ARDS의위험이있는환자를예측하고, 조기치료하여기계호흡이필요한 ARDS로진행하는위험을줄여나가기위한위험인자를판별해나가는연구도진행되었다 15-18. 또한폐손상예측점수 (lung injury prediction score; LIPS) 4점초과의위험군에서 aspirin이 ALI 진행을감소시키는지에대한대규모다기관연구 (LIPS-A) 가진행중이며, 흡입베타 2항진제또 22
박무석 : 급성호흡곤란증후군에서의생체표지자 (Biomarkers in ARDS) 는부신피질호르몬이조기 ALI 환자군에서인공호흡기치료가필요한 ALI로진행을예방하거나치료에도움이되는지에대한연구 (LIPS-B) 가진행중이다 (2013 ATS). 현재유전적정보와유전체분석 (genome-wide information), 유전자발현분석 (gene expression assay), 단백질유전정보 (proteomics), 대사물질정보 (metabolomics) 등의기술이눈부시게발전하고있다. 이러한기술의발전이임상적으로응용되기위해서는표현형이잘구별된환자군과이들의대량검체들과유전정보들을이용한대규모공동연구가필요하다 11,19-23. 결론적으로 ARDS 환자에대한생체표지자들은위험 (risk) 을예측하거나, 진단, 중증도, 경과, 예후및치료반응을예측하는데에도움을준다. 현재알려진 ARDS의생체표지자는감염표지자 (IL-6, IL-8, stnfr-i), 혈액응고표지자 (Protein C, PAI-1), 폐포상피및혈관내피손상표지자 (SPs, RAGE, CC-16, ICAM-1, VWF, Ang-2, selectins) 등이있으나아직까지완벽한하나의생체표지자는개발되지않았다. 유전체분석 (genome-wide information), 유전자발현분석 (gene expression assay), 단백질유전정보 (proteomics), 대사물질정보 (metabolomics) 등새로운기술의발전으로혁신적인생체표지자가개발되어환자개인의유전적위험, 취약성, 진단, 치료반응, 예후등을예측할수있고, 중증으로진행하기전단계인조기 ARDS상태에서위험의예방과치료가선행되도록하기위한대규모공동연구가필요하다. 참고문헌 1. Ware LB, Matthay MA. The acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1334-1349. 2. Matthay MA, Ware LB, Zimmerman GA. The acute respiratory distress syndrome. J Clin Invest 2012;122:2731-2740. 3. The ARDS Definition Task Force. Acute respiratory distress syndrome: the Berlin definition. JAMA. 2012;307(23):2526-2533. 4. The Biomarker Definitions Working Group. Biomarkers and surrogate endpoints: preferred definitions and conceptual framework. Clin Pharmacol Ther 2001;69:89-95. 5. Shehabi Y, Seppelt I. Pro/Con debate: is procalcitonin useful for guiding antibiotic decision making in critically ill patients? Crit Care 2008;12(3):211 6. Clerico A, Plebani M. Biomarkers for sepsis: an unfinished journey. Clin Chem Lab Med 2013;1:1-4 7. Cross LM, Matthay MA. Biomarkers in acute lung injury: Insights into the pathogenesis of acute lung injury. Crit Care Clin 2011;27:355-77. 8. Binnie A, Tsang JL, dos Santos CC. Biomarkers in acute respiratory distress syndrome. Curr Opin Crit Care 2014;20(1): 47-55. 9. Bhargava M, Wendt CH. Biomarkers in acute lung injury. Transl Res 2012;159:205-17. 10. Levitt JE, Gould MK, Ware LB, Matthay MA. The pathogenetic and prognostic value of biologic markers in acute lung injury. J Intensive Care Med 2009;24:151-67. 11. Janz DR, Ware LB. Biomarkers of ALI/ARDS: pathogenesis, discovery, and relevance to clinical trials. Semin Respir Crit Care Me. 2013;34(4):537-48. 12. Fremont RD, Koyama T, Calfee CS, et al. Acute lung injury in patients with traumatic injuries: utility of a panel of biomarkers for diagnosis and pathogenesis. J Trauma 2010; 68(5):1121-1127. 13. Calfee CS, Ware LB, Glidden DV, et al; National Heart, Blood, and Lung Institute Acute Respiratory Distress Syndrome Network. Use of risk reclassificationwithmultiple biomarkers improves mortality prediction in acute lung injury. Crit Care Med 2011;39(4):711-717. 14. Ware LB, Koyama T, Billheimer DD, et al; NHLBI ARDS Clinical Trials Network. Prognostic and pathogenetic value of combining clinical and biochemical indices in patients with acute lung injury. Chest 2010;137(2):288-296. 15. Levitt JE, Bedi H, Calfee CS, Gould MK, Matthay MA. Identification of early acute lung injury at initial evaluation in an acute care setting prior to the onset of respiratory failure. Chest 2009; 135(4):936-43. 16. Gajic O, Dabbagh O, Park PK, et al. U.S. Critical Illness and Injury Trials Group: Lung Injury Prevention Study Investigators (USCIITG-LIPS). Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study. Am J Respir Crit Care Med 2011;183(4):462-70. 17. Trillo-Alvarez C, Cartin-Ceba R, Kor DJ, Kojicic M, Kashyap R, Thakur S, Thakur L, Herasevich V, Malinchoc M, Gajic O. Acute lung injury prediction score: derivation and validation in a population-based sample. Eur Respir J 2011;37(3):604-9. April 25 (Fri) 23
18. Levitt JE, Matthay MA. The utility of clinical predictors of acute lung injury: towards prevention and earlier recognition. Expert Rev Respir Med. 2010 Dec;4(6):785-97. 19. Fang X, Bai C, Wang X. Bioinformatics insights into acute lung injury/acute respiratory distress syndrome. Clin Transl Med 2012;1:9. 20. Lam E, dos Santos CC. Advances in molecular acute lung injury/acute respiratory distress syndrome and ventilator-induced lung injury: the role of genomics, proteomics, bioinformatics and translational biology. Curr Opin Crit Care 2008;14:3-10. 21. Gao L, Barnes KC. Recent advances in genetic predisposition to clinical acute lung injury. Am J Physiol Lung Cell Mol Physiol 2009;296(5):L713-25. 22. Flores C, Pino-Yanes MM, Casula M, Villar J. Genetics of acute lung injury: past, present and future. Minerva Anestesiol 2010;76(10):860-4. 23. Lacy P. Metabolomics of sepsis-induced acute lung injury: a new approach for biomarkers. Am J Physiol Lung Cell Mol Physiol 2011;300(1):L1-L3. 24
Symposium 1: ARDS Treatment in patients with ARDS 전남대학교의과대학마취통증의학과 배홍범 April 25 (Fri) 급성호흡곤란증후군의발생기전에대한연구와그결과에기초한치료에대해광범위하게연구되어왔지만현재는폐보호환기전략과제한적수액요법의보존적치료 (supportive care) 에서만주로치료효과를보이고있다. (1,2) 이런결과를바탕으로 Surviving sepsis campaign에서는패혈증에의해발생되는급성호흡곤란증후군환자에서일회호흡량을 6 ml/kg (PBW) 하고고평부압을 30 cmh 2 O 이하로유지할것을권하고있으며, shock이없는경우 conservative fluid management할것을권하고있다. 그밖에도 adequate nutrition, prevention of ventilator associated pneumonia, prophylaxis for deep venous thrombosis, gastric ulcers, 가능한빠른 weaning of sedation and mechanical ventilation, physiotherapy 와재활치료등을권하고있다. (3) 하지만치료기술의발전에도불구하고급성호흡곤란증후군은사망률이 30-40% 에이를정도로여전히높으며, (4) 현재에도계속해서전임상, 임상실험을통하여약물치료의효과에대한연구가지속되고있다. 급성호흡곤란증후군은직접적원인에의한것과간접적폐손상에의한것으로나뉠수있으며이런원인들에의한폐의염증반응은자연치유되거나악화될수있으며기계호흡, 저혈압, 감염등에의한 2차적손상에의해악화될수있다 (Figure 1). (5) 초기염증반응에의한폐포 -모세혈관방벽 (barrier) 의손상은폐부종 (proteinaceous fluid filled alveolar edema) 을일으키며이런폐부종은 surfactant system에장애를일으킨다. 호중구는폐에침착이일어나고활성화된호중구는 inflammatory mediators와활성산소기등을분비하여폐포상피세포와모세혈관내피세포를더욱손상시킨다. 과도하게활성화되고분비된염증매개물질이전신순환을하고이는결국다발성장기손상을일으키는것으로알려져있다. 약물학적치료는급성호흡곤란증후군의초, 중기 (0-7일) 에과도하게활성화된면역반응을조절하고후기 ( 약 8-28일 ) 에는섬유화과정을억제와해소를목표로하고있다. (5,6) Ketoconazole, ACE inhibitor, antioxidants, beta2-adrenergic receptor agonists, exogenous surfactant, steroids 등다양한약물이시도되었다. 하지만지난 40여년에걸친광범위한치료에도불구하고현재급성호흡곤란증후군에단독으로효과가있는약물은아직밝혀지지않았는데, 이는약물에용량, 주입시기, 방법등의오류에기인할수도있으며다양한원인과기전에의해발생하는급성호흡곤란증후군자체의특성에기인할수도있다. 급성호흡곤란증후군의치료약물효과의접근에있어 onesize-fits-all 방식이영향을미칠수도있다. 따라서앞으로는급성호흡곤란증후군의발생원인에따른접근이나여러가지약물을동시에사용하는 (therapeutic bundle) 방식에대한고민이필요하다고할수있겠다. 참고문헌 1. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000; 342: 1301-1308. 2. Wiedemann HP, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006; 354: 2564-2575. 25
3. Dellinger RP, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.Crit Care Med 2013 Feb; 41(2): 580-637. 4. Phua J, et al. Has mortality from acute respiratory distress syndrome decreased over time?: a systematic review. Am J Respir Crit Care Med 2009; 179: 220-227. 5. Bosma KJ, et al. Emerging therapies for treatment of acute lung injury and acute respiratory distress syndrome. Expert Opin Emerg Drugs. 2007 Sep;12(3):461-77. 6. Bosma KJ, et al. Pharmacotherapy for prevention and treatment of acute respiratory distress syndrome: current and experimental approaches. Drugs. 2010 Jul 9;70(10):1255-82. 26
Symposium 3: Sepsis Learning from Experience of Surviving Sepsis Campaign Guideline 이화여자대학교의과대학목동병원마취통증의학과 April 25 (Fri) 이영주 중증패혈증과패혈성쇼크 (severe sepsis/septic shock, SS/ SS) 는임상에서실제적으로유병률과사망률의심각한문제를야기하는것으로병태생리학의이해와여러치료제의개발로사망률은감소하고있는추세이나 SS/SS 발생률은미국에서지난 80 년간증가하고있다. Angus 등 (1) 과 Martin 등 (2) 의보고에의하면, 미국에서중증패혈증은비심장중환자실에서가장흔한사망의원인이되고, 전체사망원인중 11 번째이며, 감염질환으로인한사망원인중 3 번째이다. 최소한년평균 75 만명의새로운패혈증환자가발생하며, 그중 50% 가패혈성쇼크로발전하며, 또그중약 50% 인 200,000 명이사망한다고한다. 사망률은기관의보고에따라 30-70% 가되며평균 50% 이다. 지난 2004 년부터범세계적으로펼쳐지고있는 Surviving Sepsis Campaign Guideline"(3) 은 11 개의국제적중환자관리학회와감염학회관계자들로구성된위원회에서중증패혈증과패혈성쇼크의표준이되는치료 18 가지 (A-R) 를증거에근거한추천 (evidence-based recommendation) 을하였다. 그당시의목적은 1. 세계적으로패혈증의사망률을줄이고자, 2. 패혈증치료의기준을만들며, 3. 변하기힘든임상의사들을교육하며, 4. 연구기금을조성하여대형의료산업회사의도움에서벗어나고자하는것이었다. 2004 년시작한중증패혈증과패혈성쇼크환자의생존을위한세계적인치료지침캠페인은 2008 년,(4) 2013 년의 3 번의개정을거치면서치료의틀이정착되어가고있다. 2013 년도지침서는 30 개국제학회의 68 명의대가가모여작성하였다.(5) 이번지침서는중증패혈증환자를목표로하는부분과중환자와중증패혈증의가능성이높은환자를위한일반적치료로구성되었다. 쇼크치료의기본틀인산소공급, 장기의관류를위한수액공급과혈압유지를위한 6 시간내의치료원칙은변하지않았다. 항생제는혈액배양검사후투여하여야하며, 패혈성쇼크인지 1 시간내에광범위항생제를투여하여야한다. 초기수액도전 (challenge) 는최소 30 ml/kg 을권한다. 수액은종전에는 crystalloid 와 colloid 의겸용을권하였으나이번지침서에서는 colloid 중 hetastarch 사용을금한다. 수액도전법은 dynamic variable 이나 static variable 에근거하여혈역학향상이있으면계속한다. 중심동맥압 65 mmhg 이상을유지하기위한 First-choice 승압제는 norepinephrine 이며 dopamine 사용을금하였다. Second-choice 승압제로 epinephrine, vasopressine 을권하였다. Steroid 투여는수액과승압제로혈압유지가안될때만권하고, 오직 hydrocortisone 200mg/day 계속정주만을권하였다. 혈당조절은두번연속으로혈당치가 180 mg% 이상일때 insulin 치료를시작하며목표치는 180 mg% 이하이다. 구강이나관급식은 SS/SS 진단 48 시간내가능하면시작하는것을권한다. 참고문헌 1. Angus DC, Linde-Zwirble WT, Lidicker J, et al: Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001;29:1303-1310 2. Martin GS, Mannino DM, Eaton S, et al: The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003;348:1546-1554 3. Dellinger RP, Carlet JM, Masur H, et al: Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32:858-873 4. Dellinger RP, Levy MM, Carlet JM, et al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36:296-327 5. Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Crit Care Med 2013; 41:580-637 27
Symposium 3: Sepsis Oxidative stresses during sepsis - Antioxidant? Department of Emergency Medicine, Seoul National University Hospital Woon Yong Kwon, MD, PhD Regulation and coordination of the inflammatory response by cytokines and other mediators is essential in host defence. Dysregulation of the inflammatory response may occur in sepsis, leading to excessive or inappropriate release of mediators and ultimately host cell and organ damage. The common mechanism by which tissues are damaged by the septic response is most probably related to widespread vascular endothelial injury, and consequently a decreased oxygen and substrate supply to the tissues. The ischemia or ischemia-reperfusion during the early goal-directed therapy in sepsis activates various immune cells and leads to the excessive production of reactive oxygen species (ROS). ROS appear to be involved as messengers in cellular signal transduction and gene activation. During sepsis, ROS are implicated in the activation of the intracellular signaling pathway, such as the nuclear factor κb (NF-κB) pathway and the mitogen-activated protein kinase (MAPK) pathway, which regulates the transcription of various genes involved in pro-inflammatory responses [1,2], and it has been reported that ROS-related oxidative stresses are a major contributing factor to the high mortality rate associated with severe sepsis and septic shock. Oxidative stresses occur when the balance between the production of ROS and their removal by the endogenous antioxidant defence system is not maintained. The glutathione redox (reduction-oxidation) cycle is an endogenous intracellular antioxidant system in which glutathione peroxidase (GPx) eliminates hydrogen peroxide (H 2 O 2 ) through the oxidation of reduced glutathione (GSH) to glutathione disulfide (oxidized glutathione, GSSG) [3]. Then, glutathione reductase reconverts GSSG to GSH by the oxidation of reduced nicotinamide adenine dinucleotide phosphate (NADPH) to NADP [4]. Selenium is an essential trace element used to synthesize selenoproteins including GPx. It has been suggested that the antioxidative properties of selenium are at least in part mediated by the enhancement of GPx activity. The treatment of patients with septic shock with selenium has been widely investigated. Some clinical data have reported that a high dose of selenium improves the clinical outcome of the patients [5,6]. However, other clinical data failed to show any benefits [7,8]. In our experimental data, selenium decreased the NADPH and GSH levels and the GSH/GSSG ratio in a dose-dependent manner. These data indicate that the selenium-induced enhancement in GPx activity converts GSH to GSSG and may induce relative GSH depletion. Our other experimental study also showed that selenium significantly increases GPx activity in paraquat-intoxicated rats. However, it decreased the GSH/ GSSG ratio and failed to improve survival [9]. We suggest that the limited antioxidant effect of selenium may be due to the relative depletion of GSH and that niacin may restore the GSH level and the GSH/GSSG ratio by the increase of the NADPH level. Niacin (vitamin B3) is a widely used lipid-regulating agent. As a precursor of NAD+, it increases NADPH and GSH levels, reduces ROS level, and downregulates intracellular signaling pathways. In recent experimental study, we found that the combination therapy of clinically relevant doses of niacin and selenium attenuated lung injury and improved survival during endotoxemia and that its therapeutic benefits were associated with the activation of the glutathione redox cycle, which involves niacin-induced increases in the NADPH level and the GSH/GSSG ratio and a selenium-induced increase in GPx activity, the reduction of the H 2 O 2 level, and the downregulation of the ROS-dependent NF-κB pathway. However, a recent randomized controlled study failed to demonstrate the benefits of niacin that outweigh the risks associated with the therapy [10]. Our previous experimental data 28
Woon Yong Kwon: Oxidative stresses during sepsis - Antioxidant? also failed to show therapeutic benefits from a single clinically relevant dose of niacin. Furthermore, another randomized controlled trial reported safety problems associated with the combination therapy of niacin/laropiprant and simvastatin [11], and the feasibility and safety of niacin treatment should be tested before its clinical use. REFERENCES 1. Kwon WY, Suh GJ, Kim KS, et al. Niacin attenuates lung inflammation and improves survival during sepsis by downregulating the nuclear factor-κb pathway. Crit Care Med 2011;39:328-334. 2. Kwon WY, Suh GJ, Kim KS, et al. Niacin suppresses the mitogen-activated protein kinase pathway and attenuates brain injury after cardiac arrest in rats. Crit Care Med 2013;41: e223-e232. 3. Harlan JM, Levine JD, Callahan KS, et al. Glutathione redox cycle protects cultured endothelial cells against lysis by extracellularly generated hydrogen peroxide. J Clin Invest 1984;73:706-713. 4. Ganji SH, Qin S, Zhang L, et al. Niacin inhibits vascular oxidative stress, redox-sensitive genes, and monocyte adhesion to human aortic endothelial cells. Atherosclerosis 2009;202: 68-75. 5. Angstwurm MW, Engelmann L, Zimmermann T, et al. Selenium in Intensive Care (SIC): results of a prospective randomized, placebo-controlled, multiple-center study in patients with severe systemic inflammatory response syndrome, sepsis, and septic shock. Crit Care Med 2007;35:118-126. 6. Alhazzani W, Jacobi J, Sindi A, et al. The effect of selenium therapy on mortality in patients with sepsis syndrome: a systematic review and meta-analysis of randomized controlled trials. Crit Care Med 2013;41:1555-1564. 7. Andrews PJ, Avenell A, Noble DW, et al. Scottish Intensive care Glutamine or selenium Evaluative Trial Trials Group. Randomised trial of glutamine, selenium, or both, to supplement parenteral nutrition for critically ill patients. BMJ 2011;342:d1542. 8. Heyland D, Muscedere J, Wischmeyer PE, et al. A randomized trial of glutamine and antioxidants in critically ill patients. N Engl J Med 2013;368:1489-1497. 9. Kim KS, Suh GJ, Kwon WY, et al. Antioxidant effects of selenium on lung injury in paraquat intoxicated rats. Clin Toxicol 2012;50:749-753. 10. Boden WE, Probstfield JL, Anderson T, et al. Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. N Engl J Med 2011;365:2255-2267. 11. HPS2-THRIVE Collaborative Group. HPS2-THRIVE randomized placebo-controlled trial in 25,673 high-risk patients of ER niacin/laropiprant: trial design, pre-specified muscle and liver outcomes, and reasons for stopping study treatment. Eur Heart J 2013;34:1279-2391. April 25 (Fri) 29
Symposium 3: Sepsis 패혈증에의한급성호흡곤란증후군의기계환기전략 연세대학교원주의과대학원주세브란스기독병원호흡기내과 리원연 급성호흡곤란증후군은다양한원인에의하여발생하는중증호흡부전으로특히중증산소화장애를특징으로한다. 패혈증을비롯한다양한원인에의하여발생하므로원인질환에대한치료가중요하지만기타장기부전에대한지지요법과함께신체주요기관의저산소증에대한장애의조절이나합병증의예방이우선적으로해결이되어야한다. 증증호흡부전의치료는저산소증의교정을위하여산소화요법이시행되며다양한산소화요법에도불구하고교정이안되거나환기부전이발생할경우기계환기요법이필요하다. 급성호흡곤란증후군에서기계환기의목적은적절한산소화를유지하며산소독성과기계환기의합병증을최소화하는데있다. 이를위한여러가지효과적인또는실험적인기계환기전략이연구되고시행되고있다. 여기서는 surviving sepsis campaign guideline (1) 을기초로기술하려고한다. 1. 폐보호환기폐보호환기는 ARDS network study (2) 에서시행한 12 ml/kg( 예측체중 ) 와 50 CmH2O 이하의기도압을적용한군과 6 ml/kg와 30 CmH2O이하의기도압을적용한군의비교연구에서저일회환기량을적용한군에서유의있게사망률을낮춘것 (39.8% vs 31%) 이보고된후 6ml/kg의저일회환기량기계환기가급성호흡곤란증후군환자의사망률을낮추기위하여보편적으로적용되었으며 (grade 1A) 그이후에이루어진메타분석에서도 28일사망률과입원사망률을줄일수있음이보고되었다 (3). 또한고평부기도압을 30 CmH2O이하로유지하는것을권장하고있으며 (grade 1B) 저일회환기량기계환기와함께고평부기도압을 30 CmH2O이하로유지하였을때 2년사망률을감소시킴이보고되었다 (4). 그러나고평부기도압이폐의과팽창정도를절대적으로반영하는것이아니므로흉곽의탄성도와환자의자발흡기압을고려하여야할것이다 (5). 2. 관용적고이산화탄소혈증폐포의과팽창을줄이기위하여저일환기량기계환기를시행하면고이산화탄소혈증에의한호흡성산증이나타나게된다. 고이산화탄소혈증은호흡수를증가시키거나사강을줄이기위하여기관내튜브의길이를줄여서감소시킬수있으며 (6) 열습기교환기보다는가온가습기가고이산화탄소혈증을줄일수있다는연구도있다 (7). 그러나대부분의환자에서고이산화탄소혈증에의한호흡성산증은심각한문제를일으키지않으며고이산화탄소혈증자체보다는산증이문제가된다. 산증이심해지면이론적으로뇌부종, 경련, 심혈관질환, 부정맥, 저혈량증, 소화기출혈, 등이있는환자에서해로운영향을미칠수있으므로 ph가 7.15-7.20 이하로감소되는것에주의하여야하며 7.15 이하로감소될경우는중탄산나트륨을투여할수있다. 또한저일회환기량기계환기에의한폐과팽창감소효과이외에호흡성산증자체가기계환기연관폐손상을줄일수있다는연구결과도있다 (8,9). 3. 호기말양압급성호흡곤란증후군에서호기말양압은산소화를호전시켜흡입산소분압의요구량을감소시킬뿐만아니라반복되는폐허탈을방지하여기계환기폐손상을예방할수있는장점이있다 (grade 1B). 개방폐환기전략 (open lung ventilation strategy) 은저일회환기량기계환기와함께적절한호기말양압을적용하여허탈이된폐포를최대로복원하고자하는시도로환자의사망률을낮추는것으로보고되고있다 (10,11). 그러나폐포를최대로복원시키는적절한호기말양압을찾는방법이여러가지제시되고있으나 (10,12) 임상에서적용하기에제한점이있다. 개방폐환기전략의한방법으로높은호기말양압을적용하는연구가시도되었으며산소화에는도움이되었지만사망률의감소에는도움을주지못하였다 (13-15). 그러나환자군 30
리원연 : 패혈증에의한급성호흡곤란증후군의기계환기전략 을세분하여분석한결과 PaO2/FiO2가 200mmHg 이하인중등증과중증급성호흡곤란증후군환자에서는높은호기말양압이사망률을낮추는것으로보고되었다 (15,16) (grade 2C). 4. 폐포복원술폐포복원술은아주높은호기말양압을짧은시간동안적용하여허탈된폐포를복원시키기위한환기전략으로 (17) 산소화와생리학적지표의호전을가져오지만사망률의감소를가져오지는못하는것으로보고되고있다 (18). 그러므로모든환자에서시행될수는없지만급성호흡부전증후군은다양한환자군을포함하고있으므로중증의저산소증환자에서는고려해볼수있을것이다 (grade 2C). 5. 엎드림체위변경엎드림체위변경은누운상태에서심해진아래쪽의허탈된폐의환기량과혈류량의불균형을개선하여산소화를개선한다 (19). 이전의연구에서는생존율의개선에는효과가없는것으로보고되었으나최근의연구에서 Pao2/Fio2가 100 mmhg 이하인경우에생존율의개선을보여 (20) 중증급성호흡부전증후군환자에서시행하는것을권고하고있다 (grade 2B). 6. 비침습적기계환기급성호흡부전증후군환자에서대부분침습적기계환기를시행하므로비침습적양압환기에대한경험이많지않다. 그러나혈역학적으로안정적인환자이며경증의환자라면고려해볼수있을것으로생각되며 (grade 2B) 소규모의연구이기는하나침습적기계환기를줄일수있다는연구도있었다 (21). 패혈증에의한급성호흡곤란증후군은다양한원인의감염에의하여발생하므로원인감염에대한적절한치료가중요하며일반적인급성호흡곤란증후군과마찬가지로중증호흡부전에대한조절이우선되어야할것이며그것은폐보호환기전략을비롯한다양한기계환기전략을통해시도될수있을것이다. 참고문헌 1. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Critical care medicine. 2013;41(2):580-637. 2. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. The New England journal of medicine. 2000;342(18):1301-8. 3. Petrucci N, Iacovelli W. Lung protective ventilation strategy for the acute respiratory distress syndrome. The Cochrane database of systematic reviews. 2007(3):CD003844. 4. Needham DM, Colantuoni E, Mendez-Tellez PA, Dinglas VD, Sevransky JE, Dennison Himmelfarb CR, et al. Lung protective mechanical ventilation and two year survival in patients with acute lung injury: prospective cohort study. Bmj. 2012;344:e2124. 5. Talmor D, Sarge T, O'Donnell CR, Ritz R, Malhotra A, Lisbon A, et al. Esophageal and transpulmonary pressures in acute respiratory failure. Critical care medicine. 2006;34(5): 1389-94. 6. Richecoeur J, Lu Q, Vieira SR, Puybasset L, Kalfon P, Coriat P, et al. Expiratory washout versus optimization of mechanical ventilation during permissive hypercapnia in patients with severe acute respiratory distress syndrome. American journal of respiratory and critical care medicine. 1999;160(1): 77-85. 7. Prin S, Chergui K, Augarde R, Page B, Jardin F, Vieillard- Baron A. Ability and safety of a heated humidifier to control hypercapnic acidosis in severe ARDS. Intensive care medicine. 2002;28(12):1756-60. 8. Broccard AF. Respiratory acidosis and acute respiratory distress syndrome: time to trade in a bull market? Critical care medicine. 2006;34(1):229-31. 9. Kregenow DA, Rubenfeld GD, Hudson LD, Swenson ER. Hypercapnic acidosis and mortality in acute lung injury. Critical care medicine. 2006;34(1):1-7. 10. Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. The New England journal of medicine. 1998;338(6):347-54. 11. Villar J, Kacmarek RM, Perez-Mendez L, Aguirre-Jaime A. A high positive end-expiratory pressure, low tidal volume ventilatory strategy improves outcome in persistent acute res- April 25 (Fri) 31
piratory distress syndrome: a randomized, controlled trial. Critical care medicine. 2006;34(5):1311-8. 12. Huh JW, Jung H, Choi HS, Hong SB, Lim CM, Koh Y. Efficacy of positive end-expiratory pressure titration after the alveolar recruitment manoeuvre in patients with acute respiratory distress syndrome. Critical care. 2009;13(1):R22. 13. Brower RG, Lanken PN, MacIntyre N, Matthay MA, Morris A, Ancukiewicz M, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. The New England journal of medicine. 2004;351(4):327-36. 14. Mercat A, Richard JC, Vielle B, Jaber S, Osman D, Diehl JL, et al. Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA : the journal of the American Medical Association. 2008;299(6):646-55. 15. Santa Cruz R, Rojas JI, Nervi R, Heredia R, Ciapponi A. High versus low positive end-expiratory pressure (PEEP) levels for mechanically ventilated adult patients with acute lung injury and acute respiratory distress syndrome. The Cochrane database of systematic reviews. 2013;6:CD009098. 16. Briel M, Meade M, Mercat A, Brower RG, Talmor D, Walter SD, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA : the journal of the American Medical Association. 2010;303(9):865-73. 17. Richard JC, Maggiore SM, Jonson B, Mancebo J, Lemaire F, Brochard L. Influence of tidal volume on alveolar recruitment. Respective role of PEEP and a recruitment maneuver. American journal of respiratory and critical care medicine. 2001;163(7):1609-13. 18. Hodgson C, Keating JL, Holland AE, Davies AR, Smirneos L, Bradley SJ, et al. Recruitment manoeuvres for adults with acute lung injury receiving mechanical ventilation. The Cochrane database of systematic reviews. 2009(2):CD006667. 19. Gattinoni L, Tognoni G, Pesenti A, Taccone P, Mascheroni D, Labarta V, et al. Effect of prone positioning on the survival of patients with acute respiratory failure. The New England journal of medicine. 2001;345(8):568-73. 20. Gattinoni L, Taccone P, Carlesso E, Marini JJ. Prone position in acute respiratory distress syndrome. Rationale, indications, and limits. American journal of respiratory and critical care medicine. 2013;188(11):1286-93. 21. Zhan Q, Sun B, Liang L, Yan X, Zhang L, Yang J, et al. Early use of noninvasive positive pressure ventilation for acute lung injury: a multicenter randomized controlled trial. Critical care medicine. 2012;40(2):455-60. 32
Symposium 2: AKI in the ICU How to predict acute kidney injury in ICU 경희대학교의과대학 문주영 April 25 (Fri) 급성신손상에서의신대체요법을시작한지국내에서도 60 년이넘었고, 방법의발전이있었음에도불구하고급성신손상에서신대체요법을받는환자의병원내사망률은아직도약 50% 로높은상태이다. 급성신손상의또한가지문제점은장기적으로만성신기능저하의중요한원인이되는것이다. 급성신손상에대한특이치료법이존재하지않는현재의시점에서는조기진단을통해원인을확인하고, 진행을막기위한치료적개입이중요하다. 따라서급성신손상의정의를수치화하고신장기능의저하시점을제시하는노력들이꾸준히있어왔다. 최근 KDIGO (Kidney Disease Improving Global Outcomes) 에서는기존의 RIFLE과 AKIN criteria를통합해급성신손상의정의와 stage 1,2,3에대한가이드라인을제시하였다. 혈청크레아티닌과요량의변화로구성되어있으며, 혈청크레아티닌이 48시간이내에 0.3 mg/dl 이상증가하거나, 최근 7일내의기저치로부터 1.5배이상증가하거나, 요량이 6시간동안 0.5 ml/kg/h로감소하는셋중에한가지를만족하면급성신손상으로정의한다. 임상에서사용하기에실제적이지않은면이있으나, 조기진단을통한공중보건의향상이나임상연구에사용하기는편리한측면이있다. 이렇게진단된급성신손상에대해서는노출된위험성 ( 패혈증, 쇼크, 사고, 화상, 심혈관수술, 심혈과수술을제외한주요수술, 신독성약물, 조영제사용, 식물과동물에의한음독 ) 을점검하고, 환자가가진취약성 ( 체액부족, 노약자, 여성, 만성신부전, 당뇨병, 암, 빈혈, 만성질환 ( 심장, 간, 폐 ) 에대해판단한다. 급성신손상환자를직접보면서판단해야할점은체액이부족하지않은가, 요로계폐색은없는가, 신독성약물의사용은없는가, 신장질환은없는가, 기존의환자상태가신손상의취약성이있지않는가, 신조직검사가필요한가등이되겠다. 급성신손상은신장의손상 (damage) 과기능적변화 (functional change) 라는두가지측면의상태로나누어생각할수있다. 임상적인판단의기준인혈청크레아티닌과요량은기능적변화를대변하는지표이지만, 신독성제재의사용의초기나한쪽요로계폐색과같은기능적변화이전의신손상단계를발견하는지표가없는것이문제였다. 따라서이를극복하기위한바이오마커의개발이수년간지속되어왔었고 urine NGAL, KIM-1, IL-18, L-FABP등이의미있는바이오마커로연구되어왔다. 최근에는급성손상을받으면세포에서 G1 phase arrest가발생되는점을이용해 G1 phase arrest inducer인 TIMP-2와 IGFBP7을요에서측정하면급성신손상을손쉽게진단할수있는키트가개발되어해외에서는사용에들어갔다. 또, 관상동맥증후군의대표적인지표인 Troponin과같은급성신손상지표를개발하고자환자의상태와크레아티닌청소률을곱하여만든 renal angina index도조기진단에유용한결과를보고하였다. 33
Symposium 2: AKI in the ICU 급성신손상의약물치료 경북대학교어린이병원소아청소년과 조민현 급성신손상은성인환자뿐만아니라소아환자에서도예후를결정하는중요한요인으로인식되고있다. 이러한급성신손상의예방및치료를위한약물학적접근법이다양하게이루어지고있는데, 이는크게신관류를최적화하는방법과신장내병태생리적손상기전을조절하는방법으로구분할수있다 [1]. 현재까지보고된후보약물로는 diuretics[2,3], dopamine [4], atrial natriuretic peptides (ANPs) [5], N-acetylcysteine[6], thyroid hormone[7], theophylline [8], simvastatin[9], insulin-like growth factor-1 (IGF-1) [10], sodium bicarbonate[11], antioxidant[12] 등이있다. 이러한약물들중에는이미임상에서사용되는경우도있고, 실험적으로사용된약물도있으나, 대부분급성신손상발생이전단계에서부분적인예방효과만일부보고되었으며실제적인임상적효용성은그리높지않은것이현상황이다. 따라서, 급성신손상의예방이무엇보다도중요하며, 급성신손상을조기에발견할수있는새로운생물학적표지자의발견이필수적이다. 참고문헌 1. Joannidis M. Medical therapy of acute kidney injury. Acta Clin Belg Suppl 2007;2:353-356. 2. Karajara V, Mansour W, Kellum JA. Diuretics in acute kidney injury. Minerva Anestesiol 2009;75:251-257. 3. Townsend DR, Baqshaw SM. New insights on intravenous fluids, diuretics and acute kidney injury. Nephron Clin Pract 2008;109:c206-c216. 4. Ladoni G, Blondi-Zoccai GG, Tumlin JA, et al. Beneficial Impact of Fenoldopam in Critically Ill Patients With or at Risk for Acute Renal Failure: A Meta- Analysis of Randomized Clinical Trials. Am J Kidney Dis 2007; 49:56-68. 5. Lim GW, Lee MI, Kim HS, et al. Hyponatremia and syndrome of inappropriate antidiuretic hormone secretion in Kawasaki disease. Korean Circ J 2008;38:507-513. 6. Brown JR, Block CA, Malenka DJ, et al. Soium bicarbonate plus N-acetylcysteine prophylaxis. J Am Coll Cardiol Intv 2009;2:1116-1124. 7. Thyroid hormones for acute kidney injury. Cochrane Database of Systematic Reviews 2013, Issue 1 8. Yap SC, Lee HT. Adenosine and protection from acute kidney injury. Curr Opin Nephrol Hypertens 2012;21: 24-32. 9. Yasuda H, Yuen PS, HuX, et al. Simvastatin improves sepsis-induced mortality and acute kidney injury via renal vascular effects. Kidney Int 2006;69:1535-1542. 10. Prevot A, Julita M, Tung DK, et al. Beneficial effect of insulin-like growth factor-1 on hypoxemic renal dysfunction in the newborn rabbit. Pediatr Nephrol 2009; 24:973-981. 11. Sodium bicarbonate supplements for treating acute kidney injury. Cochrane Database of Systematic Reviews 2012, Issue 6. 12. Koyner JL, Sher Ali R, Murray PT. Antioxidant. Do they have a place in the prevention or therapy of acute kideny injury? Nephron Exp Nephrol 2008;109:e109-117. 34
Symposium 2: AKI in the ICU When and How much renal replacement therapy in the ICU 성균관대학교의과대학삼성서울병원신장내과 April 25 (Fri) 장혜련 급성신손상 (acute kidney injury, AKI) 은전체입원환자의약 5-20% 에서발생한다고보고되었으며, 중환자실재원환자들중약 35-65% 에서동반되는것으로알려져있다. AKI가발생할경우약 3-5배정도치명율이증가한다고보고되었다. AKI에서 refractory fluid overload, signs of uremia (pericarditis, encephalopathy, neuropathy), hyperkalemia (K>6.5 mmol/l) or rapidly rising potassium level, metabolic acidosis (ph<7.1) 및이와같은상태가발생할위험성이높을경우에는신대체요법 (renal replacement therapy, RRT) 를시작하여야한다. CRRT (Continuous Renal Replacement Therapy) 는 RRT 의한가지방법으로서활력징후가불안정한중환자들에서주로사용되며, 구체적인적응증은다음과같다. : With / at risk for hypotension, at risk of cerebral complications (hepatic failure, stroke or head trauma, high risk for cerebral edema), increased metabolic needs (massive burn, sepsis, multiple organ failure), volume overload (massive volume overload, 기저질환또는합병증으로인해다량의수혈이나수액이필요하며, 다량의수혈이나수액공급이필요하지않더라도 volume overload가환자의상태를악화시킬위험성이있는경우 ) AKI를동반한중환자에서 RRT의시작시기에관한여러연구를분석한 meta-analysis에의하면, RRT를일찍시작한조기치료군에서 28일째치명율이후기치료군에비해더낮았다. 그러나, 분석에포함된여러연구의대상환자들의특징이매우상이하였고대상환자들이특징과연구의설계차이를고려한층화분석에서는조기치료군과후기치료군사이에전체적인치명율이유사하였다. CRRT dose는 effluent flow rate로다음과같이계산할수있다. 적절한 CRRT dose에대한여러가지연구중에서전향적무작위배정으로시행된대규모연구는 ATN trial과 RENAL trial이며, 이연구결과에의하면 effluent flow rate 20-25 ml/kg/hr 정도되도록하는것이가장적절하다. Effluent flow rates를 25 ml/kg/hr 보다더크도록 CRRT dose를증량하는것이환자의생존율을증가시키지못했다. 패혈증을동반한급성신손상환자를대상으로최근연구에서도 hemofiltration 의 dose를증량하는것이생존율을호전시키지못했다. 그러나, 심한대사성산증을보이는급성신손상환자에서 CRRT 의시작초기에 effluent volume-based dose를높이는것은저혈압을호전시키고승압제의요구량을감소시키는데유의한효과를보이는것으로보고되었다. CRRT의시작시기와 dose는환자의기저질환과 AKI의발생원인및특성등을고려하여환자상태에맞게결정되어야할것이며, 전체적인임상적경과와검사결과에따라 CRRT dose를적절하게조정하여야할것이다. 35
Symposium 4: Fluid Management in the ICU The Recent Fluid Trials: Crystalloids or Colloids? 성균관대학교의과대학삼성서울병원중환자의학과 / 외과 박치민 서론수액공급은적절한혈장량을유지시킴으로조직의관류를향상시키는치료로중환자치료에있어필수불가결한, 그리고가장기본적이면서도가장중요한치료중하나이다. 수액치료에있어가장중요한점은조직에필요한적절한관류 (perfusion) 을유지하는것이다. 관류를유지하기위해서는 oxygen delivery를유지시켜야하며그러기위해서는수액공급을통한심박출량의증가가가장기본적으로이루어져야한다. 이를위해서는적절한양의수액의공급이가장중요하다. 또한수액의량뿐만아니라어떤환자에게어떤종류의수액을공급하는냐도중요한요소이다. 이를위해수액치료를함에있어각수액의장점과단점을잘이해하여각각의환자에게맞는적당한수액을선택해야한다. Colloid는 osmotic pressure에의하여 crystalloid에비하여더오랜시간동안 intravascular volume으로유지할수있다는장점으로널리상용되고있으며중환자에서 colloid와 crystalloid에대한연구도많이보고되어왔다. 그러나현재까지도연구에따라다른결과를보이고있어어느수액이더 outcome 개선에도움이된다고확실하게말할수없다. 본론에서는최근보고된 colloid 와 crystalloid에대한비교연구들을살펴보고각각의수액의장점과단점, 그리고어떠한경우에선택하는것이바람직한지에대하여살펴보았다. 본론 Albumin vs. Crystalloids Serum albumin은혈장단백질의가장많은부분을차지하며혈중 osmotic pressure를유지하는데가장중요한역할을하며 hypoalbuminemia는 poor clinical outcome과관련이있다는것은잘알려져있다. 수액제재로써의 albumin은 volume expansion 효과와더불어 serum albumin concentration의증가와 osmotic pressure 증가, hemodilution 효과등의장점으로 여러환자군에서수액제로많이사용되고있다. 그러나 crystalloid에비해 30배이상비싸며이러한장점에반해 clinical outcome 개선효과에는 controversy가있다. 가장대표적인연구인 SAFE study에서는 albumin와 saline 을사용한군사이에서 survival의차이를보이지않았으나 severe sepsis 환자에서는 survival에도움이되는경향을보였으나유의성은없었다. Cochrane meta-analysis에서도유의한차이를보이지않았으며 hypovolemia 환자, hypoalbuminemia가있는환자군에서도유의한차이가없었으며 burn 환자에서만도움이되는결과를보였다. 그러나 sepsis 환자만을대상으로한 meta-analysis에서는 odds ratio 0.82 (95% confidence limits 0.67-1.0, p=0.047) 으로 albumin resuscitation이 mortality를감소시키는결과를보고하였다. 최근 severe sepsis 또는 septic shock 환자를대상으로한 ALBIOS trial의결과가 NEJM에보고되었는데 albumin을사용한군에서 hemodynamics나 fluid balance, serum albumin level에서는유의한 benefit을보였으나전체환자의 survival에는두군간에차이가없었다 (relative risk, 0.94; 95% CI, 0.85 1.05; P=0.29). 그러나 subgroup analysis에서는 randomization 당시 septic shock이있었던환자에서는 survival benefit이있다는결과를보였다 (relative risk, 0.87; 95% CI, 0.77 0.99). ARDS 환자에서 albumin에대한연구도많이시행되었다. 여러실험적연구에서 albumin은 crystalloid에비하여 alveolar-capillary permeability를감소시키고 histological damage와 inflammatory cell infiltration를감소시키며더빠른혈역학적안정성을유지할수있다는장점이보고되었다. 그러나최근보고된 meta-analysis 결과 albumin이 oxygenation 측면에서는도움이되었으나 mortality는유의한차이를보이지않았다 (relative risk, 0.89; 95% CI, 0.62 1.28; P=0.539). HES vs. Crystalloids About HES Colloid에는 Natural colloid로 Albumin, Artificial colloid로 36
박치민 : The Recent Fluid Trials: Crystalloids or Colloids? Gelatin, Dextran, HES 등있다. 여러 colloid 중 HES는 nonionic starch로혈장보충제로가장많이사용되는 colloid 수액이다. HES는 molecular weight와 molar substitution, concentration, C2/C5 ratio 등에따라 Pentastarch, Hexastarch, tetrastarch 등여러종류로나누어진다. Advantage of HES Colloid는종류에따라다른안전성과수액으로써의효과를보이고있어 circulatory system에머무르는시간또한차이가있다. Gelatin과 albumin 같은 low to medium molecular weight colloid에비하여 HES 같은 large molecular weight colloid는조금더오랫동안혈장액으로유지가되는것으로알려져있어더적은양으로 volume 을유지할수있는장점이있을것으로생각된다 (volume-sparing effect). Side effect of HES HES는오랫동안혈장액으로작용한다는성질때문에많이사용되어왔으나부작용에대한우려가제기되었다. 대표적으로신기능장애와혈액응고장애를들수있다. 정확한기전을밝혀져있지않으나 kidney의경우 molecule 자체에의한것으로생각되고있으며 coagulopathy는 factor VIII, von Willebrand Factor (vwf) 의분비감소와 platelet function에영향을주는것으로알려져있다. 특히이러한 side effect는 HES의 molecular weight와 molar substitution, concentration 에따라차이가있는것으로알려져있으며 concentration이낮고 molecular weight와 molar substitution이적을수록덜발생한다. 또한투여된 volume 과도연관성이있어많은양의 HES 가투여되었을경우더잘발생할수있다. Recent study for HES 임상적으로 HES를투여하였을때 crystalloid에비하여 kidney injury나 coagulopathy가더많이발생한다는연구는그동안없으나최근 crystalloid와 colloid 또는 HES를비교한여러편의 large scale 연구들이보고되었으며 2012년도에는중요한 3개의연구가 2013년도에는 1편의중요한연구가발표되었다. 2008년에 NEJM에발표된 VISEP trial에서는 537명의 severe sepsis 환자를대상으로 Ringer s lactate와 pentastarch를비교하였으며 mortality는차이가없었으나 acute renal failure (22.8% vs. 34.9%) 나 renal replacement therapy (18.8% vs. 31.0%), transfusion (68.7% vs. 76.0%) 은 pentastarch 군에서더안좋은결과를보였다. 2012년에 Critical Care에발표된 CRYSTMAS trial에서는 severe sepsis 환자들대상으로 normal saline과 6% hydroxyethylstarch 130/0.4를비교하였으며 mortality나 acute kidney injury, transfusion은두군간에차이가없었으나 hemodynamic stabilization 까지들어간전체 volume은 HES에서더적은것으로보고하여 (1379 ml vs. 1709 ml) HES가 volume sparing effect가있음을나타냈다. 2012년 NEJM에발표된 6S trial은 Ringer s Lactate solution과 6% hydroxyethylstarch 130/0.4를비교한연구로 HES 군에서유의하게 mortality (51% VS. 43%, P=0.03) 와 renal replacement therapy (22% vs 16% P=0.04) 많았음을보고하였다. 마찬가지로 2012년에 NEJM에보고된 CHEST trial은 ICU 환자를대상으로 normal saline과 6% hydroxyethylstarch 130/0.4 를비교하였으며 mortality에서는차이가없었고 hemodynamic stabilization은 HES군에서더좋았으나 HES 군에서유의하게 renal replacement therapy를받은환자가더많았다 (7.0% vs 5.8% p=0.04). 2013 JAMA에보고된 CRISTAL trial은앞의연구들과달리 renal function이나 renal replacement therapy를받은경우는두군간에차이가없었으며 (RR, 0.93; 95% CI, 0.83 1.03; P=0.19) 90일 mortality는오히려 HES 군이더낮은것으로보고하였다 (RR, 0.92; 95% CI, 0.86 0.99; P=0.03). 그러나이연구는여러질병군의중환자를대상으로하였으며 HES 단독이아닌여러종류의 colloid 수액이포함되었고 10 년이라는장기간동안진행된연구, blind 되지않은점등의여러 bias의가능성이높다는논란이제기되고있다. 이외에도아직 publish되지않았으나 2013 ISICEM에서발표된 BaSES study에서도 mortality와 AKI의발생은차이가없었으며 HES군에서 hospital LOS가줄어드는결과를보고하였다. 이상의최근연구결과를바탕으로 FDA에서는 HES의안전성에대한권고안을발표하였는데 sepsis를포함한 critically ill patients, pre-existing renal dysfunction, cardiopulmonary bypass를받는 open heart surgery 환자에서는주의해야함을권고하였다. 결론중환자에서의 resuscitation에있어 colloid와 crystalloid에대한연구는연구방법, 환자군에따라다양한결과를보이고있다. Colloid 수액을선택할때는우선적으로 colloid에대한정확한지식을가지고어떠한경우에도움이되고어떠한경우에주의를해야하는지를고려해야한다. 특히 HES의경우 Critical ill patient, 특히 sepsis 환자나 acute kidney injury의위험성이높은경우, bleeding의 risk가높은경우는주의를해야 April 25 (Fri) 37
하며투여하는경우라도고용량은피해야한다, 그러나이러한주의사항을모든환자로확대해석하는것에는피해야한다. 실제 volume sparing effect는대부분의연구에서공동적으로보고하는바혈장량증량이필요하며동시에 volume overloading의위험성이있는환자에서는 albumin이나 HES가좋 은수액제가될수도있다. 두수액중어느수액이좋은가에대답은결론적으로아직정확한답을내릴수없으며비용적인측면을고려할때 crystalloid를우선적으로사용하는것이현재까지는바람직할것으로생각된다. 38
Symposium 4: Fluid Management in the ICU Fluid responsiveness Division of Trauma and Surgical Critical Care, Department of Surgery, Ulsan University College of Medicine, Asan Medical Center Suk-Kyung Hong, MD, PhD April 25 (Fri) Hemodynamic monitoring is a cornerstone of critical care for the hemodynamically unstable patients. The single absolute monitoring value is Static hemodynamic monitoring. But its utility of absolute value is questionable. Functional hemodynamic monitoring performed to evaluate the effect of treatment. First, the primary goal of volume challenge is preload responsiveness. Challenge a relatively small intravascular volume rapidly and observe the subsequent change of in terms of blood pressure, pulse, and cardiac output. In high risk patient, passive Leg raising maneuver can be replaced. The transient hemodynamic effect of passive leg raising on left ventricular stroke volume. PLR is considered as a reversible fluid challenge which allow for rapid and reversible preload challenge without additional fluid challenge. On second, the change of central venous pressure (CVP) with respiration can be used. The hemodynamic effect of the respiration is dependent on the change of intrathoracic pressure. With spontaneous respiration, venous return increases in association with the decrease in intrathoracic pressure. CVP will decrease with intrathoracic pressure decrease. Last, respiration will induce a cyclic variation in cardiac output and arterial pulse pressure in hypovolemic patients. To identify cardiac output change, the stroke volume variation (SVV), pulse pressure variation (PPV), and systolic pressure variation (SPV) can be used. Hemodynamic monitoring is of utmost importance in the management of critically ill patients. We should try to find out individualized adequate hemodynamic goal. The best monitor is the caregiver who understands the monitoring equipment, alarm and resulting data. Key words: Hemodynamic monitoring, cardiac output, stroke volume, central venous pressure, fluid, stroke volume 39
Symposium 4: Fluid Management in the ICU Fluid Balance and Outcome: More Fluid or Early Vasopressor 연세대학교의과대학 나성원 저혈량 (hypovolemia) 환자에게수액을공급하는것은저혈압, 급성신손상, 다발성장기부전등저혈량과연관된합병증을예방하기위해매우중요한일이다. 하지만, 수액투여를과다하게할경우폐및심장, 소화기기능에지장을주어합병증을유발하고회복기간을늘릴수있음이밝혀지면서 1,2 적절한수액투여의기준을마련하기위한노력이지속되고있다. 이에대안으로마련된것이목표지향 (goal-directed) 수액치료인데, 이는정상혈압과조직관류를유지하는데중점을두며패혈증환자에서치료성적을향상시킨다는것이입증된바있다. 3 하지만수액치료의실제임상적용에는여러가지난관이버티고있는데, 정상혈량 (normovolemia) 에대한정의가확립되어있지않고, 환자에게최선의결과를초래하는 적절한 수액요구량을모니터하기어려운것이중환자에서수액치료를시행하는데있어애로점이라하겠다. 이글에서는저혈량증, 혈량과다증 (hypervolemia), 조직관류등수액치료에필수적인개념들과그에따른연구결과들을살펴보고혈관내용적을모니터하는방법에대해고찰하도록하겠다. 그리고마지막으로흔히 liberal, restrictive로일컬어지는수액치료전략의장단점에대해기술하도록하겠다. 1. 저혈량증및조직관류저하 저혈량증은심박출량의감소로이어져조직관류를감소시키고심할경우다장기부전을초래한다. 4 수액투여는생리학적으로 Starling 공식에근거하여행해지고있는데, 혈관내피세포의당단백층의역할에중점을둔새로운이론이최근제기된바있다. 5 Starling 공식의기본개념은모세혈관과모세혈관후세정맥 (post-capillary venule) 이반투과성을가지며혈관내외의정수압과삼투압의차이를이용하여간질액으로부터수액을흡수한다는것이다. 하지만 Adamson 등이 6 밝힌바에따르면간질액의실제삼투압이일 반적인 Starling 공식에서예상한수치보다매우낮아모세혈관에서는수액이간질액으로이동한반면, 세정맥에서의수액의흡수는일어나지않았다. 대신간질액이순환으로돌아가는기전은전적으로림프에의존하였다. 또한혈관내피세포의 glycocalyx 층이혈장과간질액사이의 interface 역할을하면서수액의이동을중계하는것으로알려지고있다 (Fig. 1). 중환자에서저혈량증을유발하는요인은여러가지가있는데출혈, 금식, 염증및진정으로인한혈관확장등이대표적이다. 조직관류가감소했다는것은나타내는지표로가장널리쓰이는것이젖산농도이다. 조직관류저하는반드시혈압감소로인해서만나타나는것이아니고정상혈압상태에서도혈관수축등으로인해생길수있다. 이에대한근거로 15000 여명의수술전정상신기능을가진환자에서술후급성신손상이발생한 121명의환자를대상으로조사하였을때정상혈압을유지하였던환자에서도승압제사용등으로인해급성신손상이발생하였던것을들수있다. 7 내장혈관수축 (splanchnic vasoconstriction) 은쇼크가발생했을때혈액을뇌, 심장등필수장기로더많이가게하는역할을하며내장혈관의수축정도는다른장기에비해더욱빠르고심하다. 8 따라서장점막의관류저하는저혈량증및쇼크를조기에발견할수있게하는모니터로서기능하며, 이는혈압저하나소변량감소보다도먼저나타난다. 2. 혈량과다증 (hypervolemia) 혈량과다증은수술전혹은평소몸무게의 10% 이상의체중증가가있을때의심할수있고사망률및중환자실체류일수증가를유발할수있다. 9 심한혈량과다증은두가지측면에서좋지않은예후를초래할수있는데, 수액투여가과다했다는것이환자가그만큼더안좋은상태여서수액요구량이많았다는것을반증할수도있고, 수액투여를과량으로한것자 40
나성원 : Fluid Balance and Outcome: More Fluid or Early Vasopressor April 25 (Fri) 체도치료성적에좋지않은영향을미칠수있다. 1 수액투여과다가각장기에미칠수있는영향은다음과같다. 폐부종으로인한가스교환저하및폐렴발생증가 10 위장관부종으로인한운동저하, 장폐색증 (ileus), 11 수술문합부의열개 (dehiscence) 12 복수의증가및복부구획증후군 (abdominal compartment syndrome) 13 창상회복지연 응고인자의희석으로인한응고장애 778명의패혈성쇼크환자를대상으로시행한연구에서, 14 중심정맥압과수액균형 (fluid balance) 의차이에따른 28일사망률을비교한결과중심정맥압이 8 mmhg 이하인군이가장낮은사망률을보였고, 12 mmhg 이상일때유의하게높은사망률을보였다. 또한 fluid balance와중심정맥압사이의상관관계는 12시간까지는유지되었으나그이후에는아무런상관관계를보이지않았다. 급성폐손상환자에서수액치료전략을 conservative vs liberal로나누어적용한결과, conservative 군에서저혈압발생비율이증가하지않으면서산소화가향상되고호흡기사용일수및중환자실체류기간이감소하는양상을보였다. 2 반면, 수술환자를대상으로시행한연구에따르면 32 명의 대장절제술환자를대상으로, 제한적수액치료를적용한군과자유롭게수액을투여한군을비교한결과수술후폐기능및산소화는제한적치료를적용한군에서호전되었으나혈중혈관수축호르몬농도는더높은양상을보였다. 15 또한각각 48명의환자를대상으로담낭절제술 16 및슬관절치환술 17 에서수액요법의영향을살펴본결과, 수액을다량투여한군에서구역 / 구토가감소하고, 운동능력이향상되며, 알도스테론, 안지오텐신등스트레스호르몬농도가감소하는효과를보였다. 3. 혈관내용적에영향을미치는요인전술한바와같이중환자의혈관내용적에영향을미치는요인은출혈, 금식, 염증, 약물등으로다양하다. 수술환자와관련하여특히금식과수술전설사제사용 (bowel preparation) 이저혈량증을유발하는요인으로알려져있는데, 흔히알고있는바와는대조적으로수술전 10시간정도의금식은혈관내용적을크게감소시키지않는것으로밝혀졌다. 18 Bowel preparation은삼투성수액소실을일으키며심한저혈량증을유발할수있으므로가능한한적게사용하는것이권장된다. 그외척추마취, 경막외진통제주입등진정 / 진통제의사 41
용으로인한혈관확장, 수술및염증에따른수액소실, 외상에따른출혈등이저혈량증발생과밀접하게관련되어있다. 4. 혈관내용적의모니터링 중환자에서수액치료의목표는혈관내용적및심박출량을적절히유지하는것이다. 이를모니터하기위해다양한방법이사용되고있는데, 먼저일반적인생리적지표, 즉혈압, 심박수, 소변량등을저혈량증을진단하는기준으로많이사용하고있으나이런지표들은 subclinical hypovolemia 상태를찾아내기어렵다는단점이있다. 중심정맥압및폐모세혈관쐐기압의유용서에대해서는최근신뢰성이떨어진다는연구들이발표된바있다. 24개연구, 803명의환자를대상으로분석한결과, 19 중심정맥압과혈액량의상관계수는 0.16으로매우낮았으며, 시험적수액투여 (fluid challenge) 에따른중심정맥압변화도혈액량을예측하는데는한계가있었다 ( 상관계수 0.18). 소변량은저혈량증을진단하는지표로많이사용되고있으나막상수술후급성신손상을예측할수있는지는의문이다. 20 혼합정맥혈혹은중심정맥혈산소포화도 (mixed venous/ central venous oxygen saturation) 는전신의산소전달및산소소모의균형을측정한다는측면에서이론적장점이있으나혈역학적으로불안정한상태에서어느정도신뢰성을가지고있는지는아직불명확하다. 21 앞선강의에서다룰동적인지표 (dynamic parameter) 로호흡에따른혈압, 심박출량변화를지수화하거나, 경식도도플러를이용해일회심박출량을측정하여사용하기도하는데, 이런방법의단점은자발호흡을하고있는환자에게서는사용하기어렵고, 부정맥및복압상승환자에게서신뢰성이떨어진다는것이다. 5. 수액투여전략 (fluid strategies) 전술한바와같이수액치료의목적은정상혈액량을유지하여심박출량및조직관류가저하되어장기손상이일어나는것을방지하는것이다. 일반적으로수액치료는수액소실량과유지량을계산하여투여하는 fixed volume strategy가사용되어왔는데목표지향치료가치료성적을향상시킨다는결과가계속발표되면서설자리를잃고있는실정이다. 1) Fixed volume strategy 수액소실량을 third space loss, insensible loss, urine output 등으로구분하여보충하고, 척추마취, 염증등으로인한혈관확장을대비하여수액을미리투여하는등의전략이다. 전통적으로실혈량은 3배의 crystalloid로보충해왔는데이에대한근거는미약하다. 이방법을사용할경우혈량과다증을초래할확률이상대적으로높다. 1,22 2) Restrictive fluid strategy 수액투여량을최소화하기위해소실량만을보충해주는것을지칭한다. 전술한바와같이패혈증, 급성폐손상환자에서이전략을사용할경우사망률이감소하는등치료성적호전이있으며, 수술환자에서위장관회복이촉진되고, 중환자실체류기간이감소하는효과도보고된바있으나, 수액의종류및치료성적이일관적이지않고작은규모의연구들이혼재하고있는등의문제점이있다. 15,17,23 3) 목표지향수액치료 목표지향전략은수액투여를미리설정된수치를달성하기까지투여하는방법을지칭한다. 24,25 일회심박출량, 혼합정맥혈산소포화도등수액치료의목표를설정해두고 200-300 ml 정도의시험적수액투여 (fluid challenge) 를반복하는방법인데, 동물실험에서는말초순환의호전을가져온바있다. 26,27 9개의연구를메타분석한연구에의하면이와같은목표지향수액치료가위장관기능의회복을촉진시키고식사시작시점을앞당기며, 병원체류기간을감소시킨다고하였다. 28 또다른메타분석에서는구역 / 구토및장폐색이유의하게감소하였다. 29 결론 수액치료의실패는 overhydration이건 underhydration이건장기기능에심각한영향을미칠수있다. 따라서수액치료의일차목표는적절한혈관내용적을유지하여심박출량이감소되지않게미연에방지하고장기손상을예방하는것이다. 수액치료를적용할때 fixed volume strategy보다는제한적수액치료나목표지향수액치료를적용하는것이바람직하다. 제한적수액요법은패혈성쇼크및급성폐손상환자에서치료성적을향상시킨바있다. 하지만수술환자에서는수액을자유롭게투여한군에서스트레스호르몬반응이감소하고수술후구역구토가호전되는양상도보인바있다. Sensible/Insensible loss를보충하기위해서는정질액이바 42
나성원 : Fluid Balance and Outcome: More Fluid or Early Vasopressor 람직하며교질액은실혈을보충하거나혹은수혈적응증이되기전까지목표지향수액치료를하는데유용하다. 참고문헌 1. Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. British journal of anaesthesia 2002;89:622-32. 2. Wiedemann HP, Wheeler AP, Bernard GR, et al. Comparison of two fluid-management strategies in acute lung injury. The New England journal of medicine 2006;354: 2564-75. 3. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. The New England journal of medicine 2001;345:1368-77. 4. Brandstrup B. Fluid therapy for the surgical patient. Best Pract Res Clin Anaesthesiol 2006;20:265-83. 5. Woodcock TE, Woodcock TM. Revised Starling equation and the glycocalyx model of transvascular fluid exchange: an improved paradigm for prescribing intravenous fluid therapy. British journal of anaesthesia 2012;108:384-94. 6. Adamson RH, Lenz JF, Zhang X, Adamson GN, Weinbaum S, Curry FE. Oncotic pressures opposing filtration across non-fenestrated rat microvessels. The Journal of physiology 2004;557:889-907. 7. Kheterpal S, Tremper KK, Englesbe MJ, et al. Predictors of postoperative acute renal failure after noncardiac surgery in patients with previously normal renal function. Anesthesiology 2007;107:892-902. 8. Chieveley-Williams S, Hamilton-Davies C. The role of the gut in major surgical postoperative morbidity. Int Anesthesiol Clin 1999;37:81-110. 9. Lowell JA, Schifferdecker C, Driscoll DF, Benotti PN, Bistrian BR. Postoperative fluid overload: not a benign problem. Critical care medicine 1990;18:728-33. 10. Arieff AI. Fatal postoperative pulmonary edema: pathogenesis and literature review. Chest 1999;115:1371-7. 11. Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology 2005;103: 25-32. 12. Schnuriger B, Inaba K, Wu T, Eberle BM, Belzberg H, Demetriades D. Crystalloids after primary colon resection and anastomosis at initial trauma laparotomy: excessive volumes are associated with anastomotic leakage. The Journal of trauma 2011;70:603-10. 13. Balogh Z, McKinley BA, Cocanour CS, et al. Supranormal trauma resuscitation causes more cases of abdominal compartment syndrome. Archives of surgery 2003;138:637-42;discussion 42-3. 14. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011;39:259-65. 15. Holte K, Foss NB, Andersen J, et al. Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study. British journal of anaesthesia 2007;99:500-8. 16. Holte K, Klarskov B, Christensen DS, et al. Liberal versus restrictive fluid administration to improve recovery after laparoscopic cholecystectomy: a randomized, double-blind study. Annals of surgery 2004;240:892-9. 17. Holte K, Kristensen BB, Valentiner L, Foss NB, Husted H, Kehlet H. Liberal versus restrictive fluid management in knee arthroplasty: a randomized, double-blind study. Anesthesia and analgesia 2007;105:465-74. 18. Jacob M, Chappell D, Conzen P, Finsterer U, Rehm M. Blood volume is normal after pre-operative overnight fasting. Acta anaesthesiologica Scandinavica 2008;52:522-9. 19. Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008;134:172-8. 20. Alpert RA, Roizen MF, Hamilton WK, et al. Intraoperative urinary output does not predict postoperative renal function in patients undergoing abdominal aortic revascularization. Surgery 1984;95:707-11. 21. Knotzer H, Hasibeder WR. Microcirculatory function monitoring at the bedside--a view from the intensive care. Physiol Meas 2007;28:R65-86. 22. Lobo DN. Fluid overload and surgical outcome: another piece in the jigsaw. Annals of surgery 2009;249:186-8. 23. Bundgaard-Nielsen M, Secher NH, Kehlet H. 'Liberal' vs. 'restrictive' perioperative fluid therapy--a critical assessment of the evidence. Acta anaesthesiologica Scandinavica 2009; April 25 (Fri) 43
53:843-51. 24. Bundgaard-Nielsen M, Holte K, Secher NH, Kehlet H. Monitoring of peri-operative fluid administration by individualized goal-directed therapy. Acta anaesthesiologica Scandinavica 2007;51:331-40. 25. Abbas SM, Hill AG. Systematic review of the literature for the use of oesophageal Doppler monitor for fluid replacement in major abdominal surgery. Anaesthesia 2008;63:44-51. 26. Hiltebrand LB, Kimberger O, Arnberger M, Brandt S, Kurz A, Sigurdsson GH. Crystalloids versus colloids for goal-directed fluid therapy in major surgery. Critical care 2009;13:R40. 27. Kimberger O, Arnberger M, Brandt S, et al. Goal-directed colloid administration improves the microcirculation of healthy and perianastomotic colon. Anesthesiology 2009; 110:496-504. 28. Phan TD, Ismail H, Heriot AG, Ho KM. Improving perioperative outcomes: fluid optimization with the esophageal Doppler monitor, a metaanalysis and review. Journal of the American College of Surgeons 2008;207:935-41. 29. Giglio MT, Marucci M, Testini M, Brienza N. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. British journal of anaesthesia 2009;103:637-46. 44
April 26 (Saturday) 4 월 26 일 ( 토 ) Hall A Symposium 5 [ 중환자의최신간호 ] 좌장 : 권은옥 ( 서울대학교병원 ) Symposium 6 [RRT] 좌장 : 권재영 ( 부산의대 ) Hall B Plenary Lecture 좌장 : 이국현 ( 서울의대 ) Special Lecture I 좌장 : 김시오 ( 경북의대 ), Shinichi Nishi (Hyogo College of Medicine) Special Lecture II 좌장 : 서지영 ( 성균관의대 ) Symposium 7 [Delirium in the ICU] 좌장 : 김재열 ( 중앙의대 ) Hall C Symposium 8 [ECMO in ICU] 좌장 : 하영록 ( 분당제생병원 )
Symposium 5: 중환자의최신간호 중환자실에서의시뮬레이션교육 Critical Care Nurse Educator, Seoul National University Hospital, Surgical intensive care unit1 Min Ah Park 의학및간호학분야에서시뮬레이션훈련의활용은지속적으로증가하고있으며 (Yoo, Park, Ko, & Yoon, 2010), 시뮬레이션훈련은교육, 관련자격획득및건강관리의질을형성하는데큰가능성을가지고있다 (Issenberg et al., 1999). 특히응급상황에서의시뮬레이션훈련은환자나타인을위험에빠트리지않으면서교육의기회를제공하고, 교육생은 실패에대한면죄부 를가지고실제로일어나면안되는경험을통해많은것을배울수있기때문이다 (Long, 2005; Perkins, 2007). 중환자실간호사는고도의지식과기술을갖추고, 첨단의의료장비를이용하는능력을중환자실간호사는갖추어야한다 (Yang, J.H., 2008). 중환자실간호사에게요구되는지식과기술, 의료장비를이용하는능력을기르기위한방법으로현장에서의시뮬레이션교육이활용이되고있다. 최근의연구에따르면중환자실의신규간호사에게응급상황시뮬레이션교육이신규간호사의응급상황에관련수행능력을증가시키는데에효과가있다고하였다 (Chang, Kwon, Kwon, & Kwon, 2010). 시뮬레이션교육을계획하기위하여고려할사항이몇가지가있다. 먼저시뮬레이션교육의목적이다. 교육생에게상황을경험하게하기위함인지, 기술향상이목적인지, 문제해결방향을찾아가기위함인지등, 목적을고려해야한다. 두번째는교육대상자이다. 간호사를대상으로하는경우, 간호사의연차에따른교육또는전체대상등으로나눌수있다. 세번째고려할사항은어떤방법으로교육을진행할것이냐하는시뮬레이션종류이다. 시뮬레이터를이용할것인지, 환자역할시뮬레이션을할것인지, 마네킹을이용한시뮬레이션을할것인지이다. 이런시뮬레이션교육의방법에따라시나리오도변경될수있다. 마지막으로고려할점은교육에사용할자원이다. 자원은장소, 시간, 강사교육에필요한물품등을아울러말한다. 활용할수있는자원을잘고려하여시뮬레이션교육계획을세워야한다. 시뮬레이션교육은교육생이사전학습 ( 강의, 자가학습등 ) 을하고, 시뮬레이션교육전충분히오리엔테이션을진행할 수있도록하고, 시뮬레이션을진행한다. 교육이끝난후디브리핑을충분히가지도록한다. 중환자실에서적용할수있는시뮬레이션교육은기계사용법및활용, 응급상황대처, 오류상황재연을통한문제해결, 수기술향상, 리더쉽발휘등으로다양한주제와방법으로임상교육현장에적용할수있다. References 1. Chang, S., Kwon, E., Kwon, Y. O., & Kwon, H. K. (2010). The effects of simulation training for new graduate critical care nurses on knowledge, self-efficacy, and performance ability of emergency situations at intensive care unit. Journal of Korean Academy Adult Nurse, 22(4), 375-383. 2. Issenberg, S. B., McGaghie, W. C., Hart, I. R., Mayer, J. W., Felner, J. W., Pertrusa, E. R., et al.(1999). Simulation technology for health care professional skills training and assessment. Journal of the American Medical Association, 282(9), 861-866. 3. Issenberg, S. B., McGaghie, W. C., Hart, I. R., Mayer, J. W., Felner, J. W., Pertrusa, E. R., et al.(1999). Simulation technology for health care professional skills training and assessment. Journal of the American Medical Association, 282(9), 861-866. 4. Long, R. E. (2005). Using simulation to teach resuscitation: An important patient safety tool. Critical Care Nursing Clinics of North America, 17(1), 1-8. 5. Yang, J. H. (2008). Experiences of admission for critically ill patients in ICU. Journal of Korean Academy of Adult Nursing, 20(1), 149-162. 6. Yoo, H. B., Park, J. H., Ko, J. K., & Yoon, T. Y. (2010). A systematic review of training that use an integrated patient simulator. Korean Journal of Medical Education, 22(4), 257-268. April 26 (Sat) 47
Symposium 5: 중환자의최신간호 중환자가족의간호 삼성서울병원 박숙현 중환자실은환자의중증도에따라지속적이고집중적인관찰과관리가이루어지는곳으로가족들의접근이일부제한되어왔다. 그러나의료환경이고령화, 만성화되었고가족이환자치료에적극적으로참여하고자하는요구가증가되면서보건의료전달체계의변화가급격하게진행되고있다. 2001년미국내과학회에서는질병중심, 의료진중심보다환자의선호와신념에맞는환자중심의치료를권고하였고이를바탕으로 2007년환자- 가족중심의간호 (PFCC) 에대한구체적인가이드라인이제시되었다. 이가이드라인에서제시한중환자실가족의지지적역할에대해자세히살펴보기로한다. 1) 의사결정중환자실에서의의사결정은의료진, 환자, 가족의치료적파트너쉽에근거해야한다. 실무자는환자의현재상태와예후를충분하게설명하고그에적합한치료방법에대해명확하게설명해야한다. 가족미팅은중환자실입실 24-48시간이내에시행되며의료진들은의사소통, 문제해결, 가족미팅을촉진시킬수있는역량들에대해교육받아야한다. 2) 가족대처의료진은가족의요구, 가족의스트레스, 불안수준을어떻게평가하는지에대해교육받아야한다. 의사, 간호사는가능한지속적으로담당했던환자를간호하며가족들이이해할수있는용어로주기적인상태설명을해야하고정보를제공하는의료진의수는가능한최소화한다. 또한환자의상태에따라허용되는범위내에서가족이참여할수있도록격려하며편안하게간호를제공할수있도록돕는다. 가족구성원은안위를위한적절한방법에대해정보를제공받는다. 이러한가족지지는사회복지사, 성직자, 간호사, 의사, 및부모지지그룹을포함한다학제간팀에의해제공되어야한다. 3) 가족상호작용과관련한의료진스트레스의료진의스트레스를줄이기위해서는다학제간팀의치료목표를일관되게수립하고이를가족들에게제공하여야한다. 이를통하여의료진과가족의갈등그리고의료진간의갈등을줄일수있다. 4) 문화적지지보건의료전문가들은문화적역량을향상시키기위해교육받아야한다. 치료에따른의사결정에적극적으로참여하는환자와가족사이에갈등이생기면가족들의의견보다환자의요구가우선한다. 절차에대한동의가필요한경우, 문화적규범을고려하고환자, 가족의의견을가능한한존중하여야한다. 만약환자가정보보안을요청했다면이요구는존중되어져야할것이다. 환자질병에대한예후는환자가요청한적절한방법과문화적으로적절한방법으로설명되어져야한다. 또한경과내용은의무기록으로작성되어야한다. 5) 정신적, 종교적지지환자의영적요구는의료진에의해사정되어진다. 의사는환자치료에대한다학제간의견해를통합하기위해성직자, 사회복지사, 간호사의기록을면밀히검토할것이다. 성직자와사회복지사는영적이슈를고찰하도록, 중환자전담의는환자상태에따른의미있는견해를제공할수있도록훈련이필요하다. 간호사와의사는영적, 종교적이슈에대한인식을교육받음으로서성직자와사회복지사가기록한환자계획의결과를이용하고적절하게환자를사정할수있게된다. 6) 가족면회성인중환자실환경에서자율면회는환자, 가족을위해유 48
박숙현 : 중환자가족의간호 동적으로이루어지며때로는사례에따라결정되어지기도한다. 면회스케쥴은환자, 가족, 간호사가공동으로결정하며, 이스케쥴은환자에게있어최선의선택이어야한다. PICU와 NICU 면회는부모나보호자에게 24시간개방되기도한다. PICU와 NICU에형제, 자매의방문은사전방문교육과정에참여한후에이루어지며부모의허락이있어야하고, 면역력이떨어져있는영아의형제, 자매방문은의사의허락이있어야한다. 청결하고적절한예방접종을마친애완견의중환자실방문은엄격하게제한할필요는없다. 가이드라인에서는애완동물을이용하여환자의활동을보조하는방법을제시하고있다. 7) 돌봄을위한환경가족공간을포함한개별병상은환자의기밀유지, 사생활을보호, 사회적지지를향상시킨다. 중환자실에방문하는가족의정신건강을위하여가구배치, 자연친화적접근, 자연채광, 긍정적전환 ( 음악, 웃음, 예술 ) 그리고소음조절의효과에관한연구가반복되어진행되고있다. 8) 회진시가족참여중환자실에서부모혹은아동의보호자는회진에참여할수있는기회가주어진다. 또한가능하다면성인환자혹은의사결정권자도회진에참여할기회가주어진다. 회진에참여하는부모와가족은회진시제공되는정보를명확하게하기위해질문할기회가주어져야한다. 9) 심폐소생술시가족참여병원차원에서심폐소생술동안에가족구성원이함께하는것을허락하고의료진의설명을포함하도록구조적과정을둘수있다. 소생팀에게는멤버를지명하고소생을목격하는가족을지지하도록훈련되어진다. 또한교육에는소생팀과중환자의료진이심폐소생술시가족참여의과정과근거에관한정보를포함시킨다. 10) 완화간호 상, 부작용, 기능적결손그리고치료와그질병의결과로인한가족의대처능력을포함해야하며가족교육은사정결과에근거해서해야한다. 가족은임종이임박했을때의증상및증후에대해발달단계, 문화적으로적절한방법으로교육받아야한다. 또한지역사회기관혹은호스피스기관에의뢰하거나정보를받을수있도록조율해야한다. 사별서비스는환자가사망한후에가족이이용가능해야하며추적관찰을포함한다. 완화간호에대한교육은중환자실교육의필수적요소이다. 환자-가족중심간호 (PFCC) 의핵심개념은존엄과존중, 정보공유, 참여, 협력이다. 중환자실에서의료진과환자, 가족의치료적파트너십은환자의치료에긍정적인영향을미칠뿐아니라가족의불안및스트레스감소, 의료진과의의사소통향상등에도효과적이라는연구결과를보이고있다. 앞으로, 이에따른중요성을인식하고환자- 가족중심간호 (PFCC) 가실무에정착되기를기대한다. REFERENCES 1. AACN Protocols for Practice. Creating Healing Environments. 2nd edition, 2007. 2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, National Academies Press, 2001. 3. Judy E, Karen Powers, Kamyar M, et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004 2005. Crit Care Med 2007; 35: 605-622. 4. Kathleen L, Jeff Clark, Susan Eggly. Family-Centered Care in the Pediatric Intensive Care Unit. Pediatr Clin N Am 60 (2013) 761-772. 5. Marion M, Wendy C, Elizabeth B,et al. Adult Critical Care Positive Effects of a Nursing Intervention on Family- Centered Care in Adult Critical Care. Am J Crit Care 2009;18:543-552 April 26 (Sat) 완화간호사정에는질병에대한가족의이해정도, 결과, 증 49
Symposium 5: 중환자의최신간호 중환자안전간호 서울아산병원내과계중환자실 양경순 환자안전은최근중요한이슈중의하나이다. 환자와관련된안전사고는환자의생명과직결되는문제이기때문에의료서비스의질을결정하는데있어가장중요한요소로병원의모든구성원들이관심을가져야한다는점에서그중요성이점차로커지고있다. 국내에서도환자안전에대한인식이점차증가하고있고환자안전위원회도조직되어활동을하고있다. 안전한환경에서치료를받는것은환자의기본적인권리중하나이다. 병원을방문하는모든환자와가족들은병원에서의입원및진료를받는동안안전하고최고의치료를기대하지만의료기술이계속발전하고의료수준이높아지고있음에도환자의안전은더욱더위협을받고있다. 특히중환자실의환자들은중증도가점차증가하고있고그에따라각종침습적인처치와시술등치료적인의료행위와간호가시행되고각종치료를위한장비사용도증가하고있다. 이로인해중환자실에입실한환자와그들을치료하는의료진들도위험에노출되어지고있다. 중환자실에서발생하는환자안전사례는투약오류, 욕창, 수혈오류, 감염, 비계획적탈관, 낙상등이있다. 이러한오류들중많은부분이예방할수있는것이었음이보고되고있어환자안전에대한관심과예방을위한적절한시스템구축이동반되어야한다. 환자안전은 Joint Commission International과국내보건복지부의의료기관인증의핵심개념으로담겨있다. 2014년 Critical Access Hospital National Patient Safety Goals은 1) 정확한환자확인, 2) 효율적인의사소통, 3) 안전한약물사용, 4) 안전한알람관리, 5) 의료관련감염관리, 6) 안전한수술 / 시술을제시하고있다. 보건복지부의의료기관인증평가의최근기준은환자안전에대한모든항목을충족하는것이필수적이다. 환자안전중첫번째는환자확인이다. 2가지이상의정보를통해환자를확인해야하며안전사고예방을위해정확하게의사소통하고낙상예방활동및의료관련감염을예방하기위해손위생을철저히해야한다. 중환자실간호사의환자안전문화에대한인식과안전간호활동수행정도 ( 이지민외, 2013) 에서중환자실간호사들은자신이근무하는부서의환자안전에대한인식은 5점만점에 3.40점이었으며, 직속상관 / 관리자태도에관한인식점수가가장높았고, 병동근무환경에대한인식점수가가장낮았다. 중환자실간호사의안전간호활동은 5점만점에 4.16점으로비교적높게나타났으며, 감염관리영역의활동점수가가장높았고, 화재안전영역의활동점수가가장낮았다. 안전간호활동수행정도에가장영향을미치는변수는안전문화의하부영역인의사소통이었으며, 일반적특성은중환자실근무경력과안전사고교육횟수이었다. 조직내의사소통이중환자실의안전간호활동수행정도에큰영향을미치는것으로밝혀져안전관리업무개발과안전간호활동을증진시키는전략을개발할때의사소통기술을강화시킬수있는내용을고려할필요가있다고하였다. 환자안전및안전간호활동에대한부산지역간호사의인식 ( 남문희외, 2010) 에서간호사들의환자안전에대한전반적인인식은 5점만점에 3.46점이었다. 대상자의특성에따라 2년미만의근무경력과주당 45시간미만근무시간, 3차의료기관의환자안전인식이유의하게높았다. 안전간호활동수준에영향을미치는요인은 40세이상, 대학원이상, 중환자실근무자, 2등급병원, 병원환경, 사고보고빈도점수가높을수록안전간호활동수준이높았다. 간호사의환자안전방안을위해서교육수준을높이고간호등급상향조정및충분한인력, 적정한근무시간, 사고보고시스템의개선등이가장중요하다고하였다. 병원에서의환자안전관리활동은구성원들간의의사소통에가장큰영향을받으므로조직구성원들간의원활한의사소통을위한노력이요구된다. 또한부서내의사소통과직원들의안전의식수준을향상시키기위한안전교육의실시, 적정업무부담및안전관리시스템의구축, 부서내의사소통의활성화를위한경영진의노력이필요하다 ( 정준, 2006). 중환자의안전이잘지켜지기위해서는개방적이고명확한 50
양경순 : 중환자안전간호 의사소통, 조직구성원의지속적인교육과훈련, 자격있는충분한인력배치, 부서간의협력적인관계, 환자안전인식수준의향상등이선행되어야하며바람직한환자안전이지켜질때양질의의료 / 간호서비스의제공, 환자만족도가증가할수 있다. 의료진과소비자들이환자의안전을위해인식을개선하고시스템적으로안전한환경, 안전한치료를받고자함께노력해나가야하겠다. April 26 (Sat) 51
Symposium 6: RRT Key Elements of Rapid Response System 성균관대학교의과대학삼성서울병원호흡기내과 / 중환자의학과 전경만 초기대응시스템 (rapid response system, RRS) 이란일반병실에서악화징후를보이는환자를조기에발견하여치료하는진료시스템으로 위험에처한환자를발견 (identification or notification) 하고, 사정 (evaluation) 하고, 치료 (management) 하여추가악화를방지 하는일반적인진료시스템과동일하다. 즉, 악화징후를보이는환자를발견하는부분 (afferent limb) 과악화를교정하는부분 (efferent limb) 으로구성된다. 하지만위험에처한환자를 조기에 발견 (early identification or notification) 함으로써적절한처치가 조기에 적용 (early and appropriate intervention) 되어야한다는점에서일반적인진료와다르다. RRS을통한진료는악화된환자를조기에안정화시켜악화로인한사망을줄이고자하는시스템으로, RRS의임상적효과에대한초기연구에따르면예측되지않았던심정지 (cardiac arrest) 발생을줄였고, 입원환자들의사망률도줄였다고보고하고있다. 하지만최근에보고된비교임상연구 (MERIT study) 의결과나이전연구결과들을이용한메타분석에서는의미있는사망률감소를보여주지못하고있다. 본강좌에서는 RRS를구성하는기본적인요소, 즉위험에처한환자를발견하고그원인을교정하는것이실제진료에서어떻게수행되어야하는지논의하고자한다. 첫째, 위험에처한환자를어떻게인지할것인가 하는것은 RRS를활성화 (activation) 시키는가장기본적인요소이다. 하지만, 어떤환자들이악화되고있는지또는어떤징후들이악화의초기징후인지명확하지않다. 명확하지않은징후는일부악화위험의 환자들에게 RRS가적용되지않거나반대로일부환자에서는불필요한 RRS을적용하게된다. RRS에서사용되는초기징후들은사망한환자들의사망전임상상의변화를반영하는것들이지만, 이들이모든악화의징후를대변하지못하고있다. 또한, 같은징후라하더라도이를객관화시키기어려우며, 일부징후는정상적인신체반응을악화징후로오인시킬수있어일률적인적용이어렵다. 따라서, 효과적인 RRS를위해서는정확한위험환자의발견을위한노력이필요하다. 둘째, 위험에처한환자가발견되었을때조기에적절한치료가이루어지는것이중요하다. 많은중환자의학관련연구에서초기대응의지연또는부적절한대응은환자들의좋지못한임상결과와관련이있다고보고하고있다. 아무리악화의초기징후를보이는환자들을잘발견한다고하더라도악화전처치가조기에이루어지지않는다면, 또는그처치가적절하지않다면, 환자는더욱악화될것이고이로인한합병증으로이후의처치는환자의임상결과를바꿀수없을것이다. 따라서, 효과적인 RRS를위해서는상황에맞는적절한대응을할수있는진료팀이구성되어야하며, 이팀이조기에진료에참여할수있도록하여야한다. RRS의기본개념은단순하다. 하지만, RRS를구성하는기본요소즉, 위험에처한환자를조기에발견 (early identification or notification) 하여적절한처치가조기에적용 (early and appropriate intervention) 되는것이이루어져야진정한 RRS가될것이다. 52
Symposium 6: RRT Overcoming Barriers to Successful RRT Implementation Hanyang Rapid Response Team (HaRRT), Hanyang University Hospital Hyun Jung Kwak An rapid response system (RRS), which has also been called a medical emergency team (MET), a rapid response team (RRT), or a critical care outreach (CCO) team, is an innovative system for identifying at-risk patients and saving the lives of them in general wards. The RRS was first described in 1995, but investigators are still attempting to quantify the types and magnitude of the benefits. Although many studies are preliminary in the sense that they are not randomized prospective placebo controlled clinical trials, they nevertheless provide considerable support for the concept of a planned system response to crisis that would reliably rescue patients as they deteriorate. However, the teams frequently are seen as a challenge to the established order, and they may be met with resistance. Barriers to the introduction of an RRS have a number of cultural issues across organizations that are difficult to discern and to overcome. The culture for patients safety, professional silos, the deficits of educational system and financial problem could be main problems in implementation of a RRS. These barriers effect on both implementation of RRS and maintenance of this system. Many ideas and trials were suggested to overcome these barriers but still there were no definite solutions. REFERENCES 1. M.N DeVita et al. Text book of Rapid Response System; concept and Impementation; chapter 15. Barriers to the Implementation of RRS 2. Devita MA, Bellomo R, Hillman K, Kellum J, Rotondi A, Teres D, Auerbach A, Chen WJ, Duncan K, Kenward G, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med 2006;34:2463-78. 3. Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med 2011;365:139-46. 4. Baxter AD, Cardinal P, Hooper J, Patel R. Medical emergency teams at The Ottawa Hospital: the first two years. Can J Anesth 2008;55:223-31. 5. Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. BMJ 2002;324:387-90. 6. Jones L, King L, Wilson C. A literature review: factors that impact on nurses effective use of the Medical Emergency April 26 (Sat) Barrier Failure to view errors as products of the system rather than individual mistakes Lack of data that RRTs are life-saving Professional silos* Professional control Eduational system Financial *A system, process, department, etc. that operates in isolation from others Suggested approach Multidisciplinary event reviews of care antecedents to a crisis Review current data : run-focused trial; Multidisciplinary crisis and event reviews Multidisciplinary event reviews; teach "system" of care Emphasize RRTs to support, not supplant primary team s coverage; return patients to primary team immediately after event Emphasize benefit of better supervision of trainees by crisis team responders; track outcomes, delays in current system Utilize current resources to staff RRT response; identify frequency of avoiding ICU admission; identity mortality benefit to offset cost 53
Team (MET). J Clin Nurs 2009 Dec;18:3379-90 7. Foraida MI, DeVita MA, Braithwaite RS, Stuart SA, Brooks MM, Simmons RL. Improving the utilization of medical crisis teams (Condition C) at an urban tertiary care hospital. J Crit Care 2003;18:87-94. 8. Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, Finger S, Flabouris A; MERIT study investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet 2005;365: 2091-7. 9. Jones D, Bellomo R, Bates S, Warrillow S, Goldsmith D, Hart G, Opdam H, Gutteridge G. Long term effect of a medical emergency team on cardiac arrests in a teaching hospital. Crit Care 2005;9:R808-15. 10. Buist M, Harrison J, Abaloz E, Van Dyke S. Quality improvement report - Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan teaching hospital. BMJ 2007;335:1210-2. 54
Symposium 6: RRT Policy, Protocol, Education and Tools of RRT Seoul National University College of Medicine Sang-Heon Park 1. Policy and protocols Policy (what you must do), guidelines (what you should do), and procedures (who, how and when to do it) define and standardize the expectations and essential processes of the RRT. It is important to obtain broad-based input when developing your own or modifying these materials for your institutions needs and to periodically review updates. This will assure that new best practices have been incorporated and facilitate buy in and adoption by all stakeholders. You will need to obtain approval of your RRT policy and procedure from the appropriate administrative, nursing and medical staff committees. - The policy should set expectations and responsibilities for the 4 arms of the RRT (Fig. 1) - The procedure/ protocols/ algorithms should address the initial assessment of at-risk patients, activation criteria, notification of the primary care physician, initial management and patient disposition - When designing them, it is important that new best prac- Figure 1. Rapid Response System structure. tice therapies are incorporated. - Policy a. RRT alert can be activated by any health care clinician and will be available 24 hours a day. b. RRT members (RRT nurse, respiratory therapist, intensivist, clinical educator etc) c. Bedsides nurses - Procedures a. Assessment and Treatment b. Order/Laboratory c. Reporting d. Charting - Protocols Respiratory failure protocol, coagulation factor replacement protocol, fluid challenge protocol, hypovolemic protocol, vasopressor protocol, dysrhythmia protocol, distributive protocol, initial antibiotics selection, shock protocol 2. Education Education is key for the whole spectrum of health professionals involved in RRT and largely responsible for success or not. - To have the greatest impact on patient outcomes, the front-line providers must have an understanding of the connection between abnormal vital signs and critical events causing progression from stability to instability. Equally important is an understanding of the pathophysiology of critical illness, in terms of sensitivity and specificity of an abnormal vital sign. - Recognizing at-risk patients: CPR and unplanned ICU admission occur not only as a result of sudden cardiac or respiratory decompensation, but are more often the final April 26 (Sat) 55
Table 1. Summary and comparisons of RRT cart designs Type Advantages Disadvantages No backpack or cart Backpack or roller bag Multiple cart Central cart Decentralized Code cart Fast Zero implementation time Light Easy to carry, stock Never too far away Always have backup Allows for some specialization according to location Easier to maintain including stocks of a diverse set of medicines Each team member bring sown materials and is self-sufficient Little transport time No additional purchase Many useful functions present Depend on ward to provide materials and may consume manpower Limit number of supplies that can be carried Harder to keep system updated And properly stocked. Require formal stocking or exchange system Longer transport times Require familiarity with contents Require higher levels of departmental motivation and communication Reqires adding/changing medicine and materials Require information a larger set of user common pathway for many on-going reversible processes that were undetected and uncorrected. - Systemwide education and focused educational programs provided for both the afferent and efferent limbs are essential for success. - Programs for the afferent (bedside nurse) and efferent limb (RRT) should focus on early recognition utilizing easy to recognize and measure physiologic parameters, i.e., 10 SOV, understanding the sensitivity and specificity of each with subsequent development of differentials, and prioritization of the problems to begin the treatment process. 3. Tools - Equipment : availability, autonomy and responsibility, avoid weak links, reassess and maintain flexibility, educate and orient. - Summary and comparisons of RRT cart designs (Table 1) 56
Plenary Lecture Changing ICU Care to Improve Patient Outcomes: The Role of Early Rehabilitation Johns Hopkins University Dale M. Needham, MD, PhD Implementing early rehabilitation in the intensive care unit (ICU) has a clear historical precedent and a strong rationale for its potential benefit to patients. Clinical research evidence evaluating early rehabilitation demonstrates its safety, feasibility and beneficial effects on ICU patients outcomes. However, for many ICUs, embracing early rehabilitation requires important changes in culture. Such changes in ICU care can be facilitated through implementation of structured quality improvement projects whereby barriers to change are explicitly identified and surmounted. After embracing such culture change, there are many exciting new areas of research and clinical practices that have potential to continue improving patient outcomes after critical illness. April 26 (Sat) 57
Plenary Lecture How to Enhance Korean Critical Care Medicine: Full-time Intensivist Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine Younsuck Koh, MD, PhD, FCCM Critical Care Medicine is a branch of Medicine concerned with provision of life support system in patients who are critically ill and who usually needs intensive monitoring and urgent professional cares. This service is provided in the setting of what is known as Intensive Care Unit (ICU). ICU is not a place for critically ill patients to drop by before to die. ICU is the place to reverse patients acute problems with minimum squeal in cost effective and ethical ways. ICU is inherently a high stress and time sensitive environment. Although ICU is always prone to medical errors because of the complexity of patients and interdependence of practitioners of different specialties, the philosophy of patient care dictates the intensivists to perform Right care Right now, The current challenge faced by Korean ICUs is to perform evidence-based standardized intensive care on right time. Korean intensive units have been suffering by poor reimbursement of required medical expenses for appropriate critical cares. As such, there are deficit in qualified intensivists and weak standardized care. There is also wide variation in care levels between even University hospitals and between urban and rural areas on the top of wide differences in medical resources. Here are few things that what we, as intensivists, can do now. First of all qualified full-time intensivists should operate individual ICU. The critical care delivery charged by qualified intensivists has been long appeal of the KSCCM to our government since 2,000. A newspaper reported that our Ministry of Health and Welfare will request full-time intensivists in tertiarly referred hospitals ICUs last February 27. The presence of full-time intensivists will be an important forward step toward better our critical care level. A qualified intensivist is different from a self-intensivist. A qualified intensivist is like a CPU in well functioning computer. A full-time intensivist should involve in every step of critical cares from a triage of critically ill to ICU discharge. The expansion of full-time intensivists presence from University hospital to general hospitals should go with the improvement of ICU care reimbursement step by step. Secondary, full-time intensivists should develop an ICU care team, which has rapid decision making capability. The team needs not to be big. Thirdly, the interaction ways between nurses to doctors in ICUs have to be efficient enough for on-time right care. Fourthly, we should develop patients and their family centered ICUs. We should know a patient s and the patient s family need and expectation to us for better shared clinical decisions. Fifthly, prioritize equipment build up in resource deficient ICUs. High touch care is more crucial than high technology based care for better outcome in ICUs. Sixthly, step-down unit is needed to reduce care burden for chronically critically ill patient in ICU. Finally rapid response team (RRT) should be more implemented in University hospitals to outreach critical care beyond ICUs. Through preemptive critical care by a functioning RRT can improve the patients outcome, who require an ICU admission. In conclusion Full-time intensivists are the key persons to play central roles on critical care enhancement in Korea. And all intensive care providers should more keen on basic but essential management with strong medical evidences together with continuous endeavor for critically ill patients safety. 58
Special Lecture I Autophagy in Sepsis and ARDS Weill Cornell Medical College Augustine Choi Cellular (macro)-autophagy, a regulated pathway for the turnover of cytoplasmic organelles and protein, represents an essential cellular homeostatic mechanism. During autophagy, damaged proteins or organelles are sequestered within double-membrane vesicles, or autophagosomes. Maturing autophagosomes fuse with lysosomes where the contents are degraded. This process regenerates metabolic precursors that are recycled for macromolecular synthesis and energy production. Thus, autophagy provides a mechanism for prolonging survival under cellular stress, including starvation. Accumulating evidence also suggests that autophagy may be linked to programmed cell death. Very little is currently known on the function of autophagy in lung diseases. We have shown that the autophagy protein, microtubule associated protein light chain-3b (LC3B) regulates epithelial cell apoptosis. We have also observed the localization of LC3B to the caveolae (lipid raft) compartment of epithelial cells and its interaction(s) with death inducing signaling complex (DISC), namely Fas. Upon exposure to oxidant stress, the LC3B-Fas complex dissociates, releasing Fas, suggestive of regulatory mechanisms by which autophagy protein LC3B can initiate the extrinsic apoptosis pathway. We will review the mechanism by which autophagy regulates apoptosis. We will also examine the crosstalk between autophagy and inflammation. Recent advances in inflammatory signaling have revealed the existence of a novel signaling complex called the inflammasome which activates caspase-1, leading to the maturation and secretion of downstream pro-inflammatory cytokines such as IL-18 and IL-1β. We recently reported that autophagy deficiency activates inflammasome via mitochondrial dysfunction and reactive oxygen species. We will review the mechanism by which autophagy regulates mitochondrial function and inflammasome activation in various pathophysiologic states including ARDS and sepsis. April 26 (Sat) 59
Special Lecture I The New Bird Flu: What Does It Mean to Intensivists? Medical ICU, Peking Union Medical College Hospital, Beijing, China Du Bin, MD From March 30, 2013 till August 12, 2013, a total of 135 cases infected with a novel avian influenza (H7N9) virus had been reported to World Health Organization, with 44 deaths. This novel H7N9 virus was the product of reassortment of viruses that were of avian origin. The gene sequences indicated that these viruses might be better adapted than other avian influenza viruses to infecting mammals, e.g. the presence of Q226L in the HA protein which was associated with increased binding affinity for α-2,6-linked sialic acid receptor in the human lower respiratory tract. About three quarter of avian influenza A(H7N9) confirmed cases reported history of exposure to animals, mainly chickens, ducks and pigeons. Direct contact with live poultry was an independent risk factor for human infection, and significantly more poultry workers had a high (> 80) antibody titer to influenza A(H7N9). All these findings strongly indicated infected poultry as a major source of infection. Few family clusters were reported, but no person to person transmission was confirmed. Although there were few mild cases, majority of patients had pneumonia, which resulted in hospitalization, ICU admission, mechanical ventilation, or even death. The median age was 61 years, and 68.5% were male. Fever and cough were the most common presenting symptoms. Common laboratory abnormalities included lymphocytopenia, thrombocytopenia, elevated liver enzymes, and mild-to-moderate rhabdomyolysis. Neuroaminidase inhibitors including oseltamivir and peramivir were used in almost all patients, however, only fewer than 10% of cases were treated with antiviral agents within 48 hours after symptom onset. Case-control study suggested that shorter time interval from disease onset to antiviral therapy was associated with a better clinical outcome. Corticosteroids were administered in 60% of cases. More than 70% of cases were complicated with ARDS, followed by circulatory shock and acute kidney injury. Mechanical ventilation remained the most common supportive therapy, and the susceptibility to barotrauma precluded the use of high PEEP, which also encouraged the use of ECMO in almost 20% of patients. However, refractory hypoxemia still remained the leading cause of death, followed by shock. 60
Special Lecture II Our evolving model of how we practice critical care medicine: what is the destination? President of SCCM, Mayo Clinic Chris Farmer Learning Objectives ㆍTo discuss and review the external and internal forces that impact how we care for critically ill and injured patients ㆍ To discuss and review current CCM practice models ㆍ To outline potential solutions for these challenges Abstract Meeting clinical workforce requirements for critically ill and injured patients, now and in the future, is a dilemma. Simply stated and for multiple reasons (not just aging population) there aretoo few critical care trained professionals, too many patients, and insufficient funds to reasonably scale upward. This is a worldwide concern as we debate how to deal with rapidly rising health care costs, increased demand for critical care resources, and static critical care work force numbers. The tension between these forces is further strained by expansive societal expectations. Three primary domains broadly impact critical care and lack clear answers (plans): ㆍ What care (and how much) is needed? ㆍ Who provides this care? ㆍWhich critical care models advance quality, are affordable, and are sustainable? Two distinct hospital environments must be addressed because their critical care workforce needs are appreciably different. These can be broadly labeled as trainee and nontrainee hospitals/institutions. Our critical care roots are historically linked to geography, actual physical boundaries creating a place called an ICU. These boundaries were created in order to concentrate patients, people, tools, drugs. Today, these boundaries are less inclusive because critical illness is more diffuse, both inside and outside the hospital. Our care models, patient and family expectations, and clinical tools must evolve to accommodate these changing realities. April 26 (Sat) 61
Symposium 7: Delirium in the ICU Diagnosis and Risk Factors of Delirium Department of Neurology, Hallym University Medical Center, Kang Nam Sacred Heart Hospital, Seoul, Korea San Jung Delirium is a common neuropsychiatric syndrome characterized by acute onset of fluctuating cognition and inattention linked to triggering factors. Delirium is very commonly encountered in hospital medicine and complicating at least 10% of all medical admissions [1]. Delirium occurs in 70 87% in critical care patients [2]. Patients with delirium have an increased length of stay, increased mortality and increased risk of institutional placement. Hospital mortality rates of patients with delirium are twice of matched controls [3]. A disturbance of consciousness and altered cognition are essential components of delirium. Some patients are drowsy and lethargic, others are agitated and confused. Visual hallucinations, tremulousness, and myoclonus/asterixis are variably present. Delirium is a multi-factorial disorder. The most commonly identified risk factors are underlying brain diseases such as dementia, stroke, or Parkinson disease [4]. Factors that may precipitate delirium are numerous and varied. Some common examples include polypharmacy (particularly psychoactive drugs), infection, dehydration, immobility (including restraint use), malnutrition, and the use of bladder catheters. Recommendations for evaluating and treating delirium are based primarily upon clinical observation and expert opinion [5]. The diagnosis of delirium should be confirmed using the clinical assessing tools. The Confusion Assessment Method (CAM) has become a standard screening device in clinical studies of delirium and the CAM-ICU has been developed and validated for identification of delirium in the intensive care units (ICU) [6, 7]. A careful assessment must be made to exclude all common causes. Careful attention to the key features of acute onset, fluctuating course, altered consciousness, and cognitive decline should readily distinguish delirium from depression, psychotic illness, and dementia. REFERENCES 1. Nayeem K, O Keefe S. Delirium. Clinical Medicine 2003;3: 412-415. 2. Inouye SK. Delirium in Older Persons. The New England Journal of Medicine 2006;354:1157-1165. 3. Potter J, George J. The prevention, diagnosis and management of delirium in older people: concise guidelines. Clinical Medicine 2006;6:303-308. 4. Fick DM, Agostini JV, Inouye SK. Delirium superimposed on dementia: a systematic review. J Am Geriatr Soc 2002; 50:1723. 5. Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994; 97:278. 6. Wei LA, Fearing MA, Sternberg EJ, Inouye SK. The Confusion Assessment Method: a systematic review of current usage. J Am Geriatr Soc 2008;56:823. 7. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001;286:2703. 62
Symposium 7: Delirium in the ICU Delirium and Acute Confusional State: Prevention and Management 국립중앙의료원 고임석 Delirium is an acute-/subacute-onset organ dysfunction occurs in central nervous system and characterized by acute fluctuating global mental dysfunction, should be treated as an acute neurologic emergency. Between 14% and 56% of all hospitalized patients develop delirium, depending on the population studied [1]. Older adults and those in the intensive care unit (ICU) are at especially high risk, with an incidence as high as 82% among mechanically ventilated patients [2]. In intensive-care unit patients, especially in the neurocritical care population, severe neurological complications could be masked by delirium. Through evaluation, accurate diagnosis, and thoughtful non-pharmacological and pharmacological management are necessary to reduce morbidity and improve prognosis. Because the treatment of delirium rests on the identification and treatment of the underlying illness, the astute clinician must tease apart these various possibilities with a careful history and physical examination and judicious use of laboratory tests and imaging studies. The most important intervention for managing delirium is correction of the underlying systemic condition responsible for the delirium [3,4,5]. No convincing evidence shows that pharmacological prevention or treatment is effective. Drug reduction for sedation and analgesia and nonpharmacological approaches are recommended. Whereas administration of antipsychotics may represent an option for symptomatic treatment, further studies are needed to evaluate the effects of pharmacological approaches on long-term outcomes in elderly patients with delirium. REFERENCES 1. Siddiqi N, Stockdale R, Britton AM, Holmes J. Interventions for preventing delirium in hospitalised patients. Cochrane Database Syst Rev 2007;(2):CD005563. 2. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004;291(14):1753 1762. 3. Schwartz TL, Masand PS. The role of atypical antipsychotics in the treatment of delirium. Psychosomatics 2002;43:171-174 4. Delirium; Diagnosis, Prevention and Management. National Institute of Health and Clinical Excellence, NICE guideline 103. July 2010. 5. Inouye SK, Bogardus st, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J MED 1999;340:669-676 April 26 (Sat) 63
Symposium 7: Delirium in the ICU Cognitive Dysfunction in ICU Patients Department of Neurology, National Health Insurance Service Ilsan Hospital Jun Hong Lee, M.D., Ph.D. The utilization of intensive care units (ICUs) has expanded rapidly over the past decades, with a concomitant increase in the proportion of patients surviving an episode of critical illness. This has resulted in a growing number of ICU survivors [1]. Results from previous studies suggest that ICU survivors may suffer from significant long term morbidity [2]. An important long-term complication of critical illness and ICU treatment is cognitive impairment. Cognitive impairment is associated with a reduced quality of life, and it is a major determinant of societal healthcare costs and care giving needs [3-5]. A large proportion of ICU patients consist of elderly people, and especially this population is prone to develop cognitive impairment [6]. However, it appears that younger, relatively healthy patients are also at risk for cognitive impairment following critical illness. Cognitive impairment often becomes apparent after ICU discharge, and intensivists may therefore not be aware of the occurrence of this complication. The pathophysiology of cognitive impairment after ICU admission is believed to be multifactorial [8,11]. The most frequently reported explanation for an abrupt decrease in cognitive functioning after ICU admission is that patients with multi-organ failure may also develop brain damage [8,12]. Severe sepsis can lead to a neuroinflammatory response, resulting in increased levels of cytokines in the brain [12,13]. Elevated cytokine levels are associated with impaired memory in healthy volunteers[14], and neuro-inflammation is associated with the development of Alzheimer s disease [15]. Long-term cognitive impairment in patients may therefore represent a maladaptive version of cytokine-induced disease [13]. Other possible causes are hypoxemia and hypotension, which have been related to cognitive impairment in numerous investigations [7,8]. Sedatives and analgesics are used extensively in the ICU, and some studies suggest that this may also play a causal role in the development of long-term cognitive impairment [8]. Both hyperglycemia and hypoglycemia as well as fluctuations in blood glucose are also associated with poor cognitive outcomes [10,16]. An association between delirium and long-term cognitive impairment has been reported, but the underlying cause remains to be elucidated [9,17]. Impaired cognitive functioning is common and persists after critical illness, and although improvement is seen with time, only a minority of critical care survivors return to their cognitive baseline. The mechanisms of CI remain incompletely understood. Interventional trials to improve cognitive outcomes for ICU survivors through prevention and rehabilitation are only now beginning. Further study to elucidate the causes and pathophysiology of this newly acquired chronic brain injury in different patient populations and strategies to return patients to their baseline cognitive status are important research priorities. For now, CI in survivors of critical illness highlights opportunities to improve care, possibly through risk reduction, in the ICU (e.g., timely resuscitation, sedation stewardship), on the hospital ward (e.g., assessment of sleep efficiency, mobilization), and after discharge in the post hospital recovery period (e.g., ongoing cognitive or physical therapy, screening for psychological morbidity). REFERENCES 1. Ehlenbach WJ, Hough CL, Crane PK, Haneuse SJ, Carson SS, Curtis JR, Larson EB (2010) Association between acute care and critical illness hospitalization and cognitive function in older adults. JAMA 303(8):763-770. 2. Desai SV, Law TJ, Needham DM (2011) Long-term complications of critical care. Crit Care Med 39(2):371-379. 3. Timmers TK, Verhofstad MHJ, Moons KGM,Van Beeck 64
Jun Hong Lee: Cognitive Dysfunction in ICU Patients EF, Leenen LPH (2011) Long-term quality of life after surgical intensive care admission. ArchSurg 146(4):412-418. 4. Davidson TA, Caldwell ES, Curtis JR, Hudson LD, Steinberg KP (1999) Reduced quality of life in survivors of acute respiratory distress syndrome compared with critically ill control patients. JAMA 281(4):354-360. 5. Iwashyna TJ, Ely EW, Smith DM, Langa KM (2010) Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 304(16):1787-1794. 6. Boumendil A, Somme D, Garrouste- Orgeas M, Guidet B (2007) Should elderly patients be admitted to theintensive care unit? Intensive Care Med 33(7):1252-1262. 7. Hopkins RO, Weaver LK, Collingridge D, Parkinson RB, Chan KJ, Orme JF Jr (2005) Two-year cognitive, emotional, and quality-of-life outcomes in acute respiratory distress syndrome. Am J Respir Crit Care Med 171(4):340-347. 8. Jackson JC, Hart RP, Gordon SM, Shintani A, Truman B, May L, Ely EW (2003) Six-month neuropsychological outcome of medical intensive care unit patients. Crit Care Med 31(4):1226-1234. 9. Girard TD, Jackson JC, Pandharipande PP, Pun BT, Thompson JL, Shintani AK, Gordon SM, Canonico AE, Dittus RS, Bernard GR, Ely EW (2010) Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med 38(7):1513-1520. 10. Duning T, van den Heuvel I, Dickmann A, Volkert T, Wempe C, Reinholz J, Lohmann H, Freise H, Ellger B (2010) Hypoglycemia aggravates critical illness-induced neurocognitive dysfunction. Diabetes Care 33(3):639-644. 11. Sukantarat KT, Burgess PW, Williamson RC, Brett SJ (2005) Prolonged cognitive dysfunction in survivors of critical illness. Anaesthesia 60(9):847-853. 12. Hopkins RO, Weaver LK, Chan KJ, Orme JF Jr (2004) Quality of life, emotional, and cognitive function following acute respiratory distress syndrome. J Int Neuropsychol Soc 10(7):1005-1017. 13. Dantzer R, O Connor JC, Freund GG, Johnson RW, Kelley KW (2008) From inflammation to sickness and depression: when the immune system subjugates the brain. Nat Rev Neurosci 9(1):46-56. 14. Reichenberg A, Yirmiya R, Schuld A, Kraus T, Haack M, Morag A, Pollmacher T (2001) Cytokine associated emotional and cognitive disturbances in humans. Arch Gen Psychiatry 58(5):445-452. 15. Anastasio TJ (2011) Data-driven modeling of Alzheimer disease pathogenesis. J Theor Biol 290C:60-72. 16. Hopkins RO, Key CW, Suchyta MR, Weaver LK,Orme JF Jr (2010) Risk factors for depression and anxiety in survivors of acute respiratory distress syndrome. Gen Hosp Psychiatry 32(2):147-155. 17. van den Boogaard M, Schoonhoven L, Evers AW, van der Hoeven JG, van Achterberg T, Pickkers P (2012) Delirium in critically ill patients: impact on long-term health-related quality of life and cognitive functioning. Crit Care Med 40(1):112-118. April 26 (Sat) 65
Symposium 8: ECMO in ICU Trouble Shooting of ECMO in ICU 아주대학교의과대학흉부외과 임상현 국내최초로 1994년에세브란스병원에서 pneumonectomy 후발생한호흡부전환자에서 ECMO를적용하여치료한이후 [1], 최근 6~7년사이에급성페기능부전과심부전환자들, 또한급성심정지환자들에서의 ECMO 사용이매우빠르게증가하고있다 [2]. ECMO는쉽게사용될수있도록고안된변형된심폐기계 (modified heart-lung machine) 로서우심방이나대정맥 (vena cava) 으로부터피를뽑아내어모터와산화기를거쳐서심장으로피를넣어주는데, 산소가충만해진혈액을우심방으로넣어줄때정- 정맥간 (veno-veno) ECMO, 대동맥으로넣어줄때정- 동맥간 (veno-arterial) ECMO로분류된다. 초기 ECMO는폐기능부전환자들에서주로사용되었으나, 이제는소아와성인모두에서가역성급성심부전증, 심장이식이나폐이식을위한가교역할로서, 급성폐기능부전증그리고비외상성급성심정지의환자에서의심폐소생도구로그적응이매우넓어졌다 [3]. ECMO는구동을위하여혈액의입출입을위한굵은 cannula 를경정맥이나대퇴정맥, 혹은대퇴동맥이나쇄골하동맥, 그리고경우에따라서는개흉술을시행한이후에우심방이나대동맥에직접적인삽관을시행해야하는데, 이러한침습적인행위에의한혈관과관련된위중한합병증들이발생할수있다. 또한몸에서나온피가 tube와산화기, 그리고모터를지나게될때혈액에대한화학적, 물리적인손상들이발생하게되며, 혈전생성을예방하기위해사용하는항응고제로인한출혈성합병증, 특히뇌출혈등의크고작은합병증들의발생할수있다. 또한 ECMO를통하여전달되는혈액이정상의혈류와다른비박동성혈류라는것도위중한환자에서조직관류에영향을줄수있다. 외국에서는이미 ECMO 사용에따른문제점들의발생에대한분석이이루어지고, ECMO 사용을결정할때 ECMO를사용함으로써의이익과위험을잘고려하여결정해야한다는보고도있으나 [4], 국내에서는이러한판단이주로각기관의경험에의해주관적으로결정되고있으며, 또한 ECMO가변형된심폐 기임을고려할때, 심폐체외순환에대한충분한이해및공부와함께많은경험을가진전문가나심폐체외순환을시행하고있는전문가들에의해조작되어야함에도불구하고그렇지못한경우들이발생하게됨으로써 ECMO 사용에따른문제발생시적절한조치가제때에이루어지지못하는경우들이발생하고있다. 결론적으로 ECMO는위중한상태의가역적인심장및폐기능부전에서사용할수있는좋은치료도구이지만, ECMO를환자에게적용하기전에는반드시해당환자에서 ECMO를사용함으로써발생할수있는문제점들에대하여사전에예측하는것이필요하며, 문제점발견시에는이에대한빠른인지와함께정확한교정이필수적으로시행되어야한다. REFERENCES 1. Hong KP, Kim HK, Park MS, et al. Extracorporeal membrane oxygenation for postpneumonectomy respiratory failure - a case report. Korean J Thorac Cardiovasc Surg 1994; 27(1): 60-2 2. Chung ES. Current ECMO in Korea. From 15 Centers Data. 2013; abstract from 2nd Korea ECMO Symposium. 3. Allen S, Holena D, McCunn M, et al. A Review of the Fundamental Principles and Evidence Base in the Use of Extracorporeal Membrane Oxygenation (ECMO) in Critically Ill Adult Patients. Journal of Intensive Care Medicine. 2011; 26(1):13-26 4. Cheng R, Hachamovitch R, Kittleson M, et al. Complications of Extracorporeal Membrane Oxygenation for Treatment of Cardiogenic Shock and Cardiac Arrest: A Meta- Analysis of 1866 Adult Patients. Ann Thorac Surg 2014; 97:610-6 66
Symposium 8: ECMO in ICU Quick Priming of ECMO and management (anyone in ICU can do it) 양산부산대학교병원흉부외과체외순환실 이종탁ㆍ이석호 ECMO (Extracorporeal membrane oxygenation) 는회복가능성이있는심각한호흡부전이나순환부전이있는환자에서일반적인치료방법으로호전이불가능한경우심폐기능이회복될때까지수일에서수주일동안생명유지를도와주는체외순환의일종이다. ECMO에서가장중요한것은적절한 cannular의선택과 Quick ECMO priming, 지속적인 ECMO monitoring이다. 이중 Quick ECMO priming은 ECMO의빠른적용으로환자의 motality를낮출수있게된다. 기존에많이사용되고있는 ECMO 장비는 EBS와 PLS (Rotaflow) 가있다. EBS는 Auto priming기능이있어서손쉽고빠르게적용할수있지만 PLS(rotaflow) 는 priming 방법이복잡하고시간도많이지체되는문제가있다. 이에변형된 Quick PLS priming 방법을소개하고자한다. 변형된 PLS priming 원리 1. Centrifugal cone을 air가잘나갈수있도록 cone의 outlet쪽이위쪽으로향하도록위치시킨다. 2. Oxygenator 앞면위쪽의노란색 luer lock을연다. 3. Oxygenator 뒷면윗부분 leur lock에 3-way 를연결후 pressure line (180cm) 연결하고, 18G needle로 priming solution에 puncture 후 Priming을시작한다. 4. Oxygenator outlet tubing line에 partial clamp한후일정한 Pressure를주어 oxygenator에서 air가잘나갈수있도록해준다. 5. RPM을 1500으로올리고멈추고를반복하여 tubing line과 centrifugal cone에 air가 oxygenator로이동하면 oxygenator를 clamp로두드려서 oxygenator에있는 air를제거한다. 6. De-airing이완료되면 circuit에있는모든 3-way의개방성을폐쇄한다. ECMO priming에서중요한것은 circuit에 leakage가없어야하며 3-way와 luer lock port는풀리지않도록단단히조여야한다. 이유는 ECMO 적용중 centrifugal cone 앞쪽 3-way가풀리면 macro air embolism이생길수있으며 centrifugal cone 뒤쪽에 3-way가풀리면과도한 blood loss가발생할수있기때문에아주중요하다. ECMO 운영중에관리되어야할사항들로는적절한 anticoagulation로 ACT 150~200sec로유지하는것과적절한 pressure monitoring을해주어야한다. 적절한 negative pressure (-60mmHg 이하 ) 와 positive pressure (+300mmHg 이하 ) 를유지해주어야과도한 hemolysis 를방지할수있으며 ECMO로인한 complication을줄일수있다. April 26 (Sat) 67
Symposium 8: ECMO in ICU Inter-hospital Transport Under ECMO Support (ICU to ICU) Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea Kyung Woon Jeung Extracorporeal membrane oxygenation (ECMO) constitutes the last option for patients with severe cardiac and/or respiratory failure refractory to conservative treatment. However, up to now, ECMO was limited to a few tertiary care centers. The pre-existing diseases that make patients eligible for ECMO often show a dramatic progression over the course of time. As a consequence, transporting these patients from local hospitals to ECMO centers is risky without ECMO support. Thus, in some severely ill patients, it may be necessary to initiate ECMO at the local hospital and, thereafter, transport the patient back to the ECMO center. Furthermore, many centers which are able to deploy ECMO are limited in their ability to provide prolonged extracorporeal support or cardiac transplantation. Such patients may require interhospital transport while on ECMO for additional support or therapy. Transport on ECMO was already used in the nineties of the previous century [1-4]. Several studies indicate that inter-hospital transport of patients on ECMO can be performed safely and without technical difficulties [5-7]. For safe transport, a particularly equipped ambulance serving as mobile intensive care unit should be available. Not only should it offer enough space for all the medical personnel, the devices, and equipment, but also have a connection for power and oxygen supply, high-quality ventilator and full-range of hemodynamic monitoring. However, in Korea, most ambulances are small and cramped. It is hard to arrange patient, medical staff and machinery in the ambulance. Most of them lack the ventilators, which could meet the requirements of ECMO transport. In many studies on out-of-center ECMO, ECMO team essentially consists of a surgeon, who places the cannulae, and a perfusionist who runs the ECMO, and an intensivist or anesthesioloigist who takes care of the ventilation and drug management during transportation [8,9]. Recently, ultra compact and portable ECMO device, which integrates all components of ECMO into one compact device, has been developed and has been used mainly in European centers [9,10]. Since the sizes of the ECMO devices which are currently used in Korea are large, the control panel of ECMO system needs to be separated from standard transport trolley during transport. REFERENCES 1. Cornish JD, Gertsmann DR, Null DM, et al. Inflight use of extracorporeal membrane oxygenation for severe neonatal respiratory failure. Perfusion 1986;1:281-287. 2. Kee SS, Sedgwick J, Bristow A. Interhospital transfer of a patient undergoing extracorporeal carbon dioxide removal. Br J Anaesth 1991;66:141-144. 3. Faulkner SC, Taylor BJ, Chipman CW, et al. Mobile extracorporeal membrane oxygenation. Ann Thorac Surg 1993;55:1244-1246. 4. Bennet JB, Hill JG, Long WB 3 rd, et al. Interhospital transport of the patient on extracorporeal cardiopulmonary support. Ann Throac Surg 1994;57:107-111. 5. Haneya A, Philipp A, Fontan M, et al. Extracorporeal circulatory systems in the interhospital transfer of critically ill patients: experience of a single institution. Ann Saudi Med 2009;29:110-114. 6. Linden V, Palmer K, Reinhard J, et al. Inter-hospital transportation of patients with severe acute respiratory failure on extracorporeal membrane oxygenation - national and international experience. Intensive Care Med 2001-24-1643-8. 7. Cabrera AG, Prodhan P, Cleves MA, et al. Interhospital transport of children requiring extracorporeal membrane oxygenation support for cardiac dysfunction. Congenit Heart Dis 68
Kyung Woon Jeung: Inter-hospital Transport Under ECMO Support (ICU to ICU) 2011;6:202-8. 8. Lebreton G, Sanchez B, Hennequin JL, et al. The French airbridge for circulatory support in the Carribean. Interactive Cardiovasc Thorac Surg 2012;15:420-425. 9. Philipp A, Arlt M, Amann M, et al. First experience with the ultra compact mobile extracorporeal oxygenation system Cardiohelp in interhospital transport. Interactive Cardiovasc Thorac Surg 2011;12:978-81. 10. Lunz D, Philipp A, Judemann K, et al. First experience with the deltastream R DP3 in venovenous extracorporeal membrane oxygenation and air-supported inter-hospital transport. Interactive Cardiovasc Thorac Surg 2013;17:773-7. April 26 (Sat) 69
April 25 (Friday) 4 월 25 일 ( 금 ) Convention Hall C Best Abstract Prize Competition
Best Abstract Prize Competition Best Abstract Prize Competition-1 Predictors of malignant brain edema in middle cerebral artery infarction using computed tomography angiography images *(Critical Care Non-verbal Pain Scale, CNPS) 적용효과 임옥분, 이선주, 정연화, 양경순, 이순행 1, 강소희, 박가영, 박영아, 박은혜, 이영주, 이효진, 장지은, 정미수, 정진아, 임채만 2 Hoon Kim, Seoung Rim Kim, Ik-Seong Park, Young Woo Kim, Kwang Wook Jo Department of Neurosurgery, Bucheon St. Mary s Hospital, The Catholic University of Korea Background And Purpose: Early detection of the risk factors of fatal brain swelling in patients with middle cerebral artery (MCA) infarction may be useful in selecting patients in need of aggressive therapies such as decompressive hemicraniectomy Methods: A total of 64 patients diagnosed with major MCA infarction with occlusion MCA with or without internal carotid artery within 8 hours of symptom onset between January 2011 and October 2012 were reviewed retrospectively. Early clinical, laboratory, and CT angiography (CTA) parameters were analyzed for malignant brain edema (MBE). Results: Twenty out of 64 patients (31%) had MBE and among them, the clinical outcome was poor (3 months modified ranking scale >2) in 95%. The mean baseline National Institutes of Health Stroke Scale (NIHSS) scores, lower Alberta Stroke Program Early CT score (ASPECTS), lower clot burden score (CBS) and lower collateral score (CS) (18.5, 4.9, 3.8. 1.5, p=0.003, p=0.002, p=0.005, p< 0.001, respectively) on CTA showed statically significant differences in MBE patients. Dichotomization of the NIHSS score to > 18, ASPECTS 7, CBS 6, CS < 2 revealed statistical significance with only NIHSS score > 18, CS< 2 as well as recanalization status. Multivariable analysis, adjusted for age and sex, identified the independent predictors of MBE: NIHSS score > 18 (OR 4.4., 95% CI 1.22 16.04, P=0.023), CS<2 (OR 7.28, 95% CI 1.74 30.38, p=.006) Conclusions: In patients with suspected larger MCA infarction, baseline NIHSS score > 18 or CS <2 on CTA increases the risk of developing malignant brain edema. The data is easy to obtain and can provide useful information to primary physicians at an early stage. 1 서울아산병원중환자간호팀장, 2 서울아산병원중환자실장연구배경 : 중환자를위한최적의통증관리는정확한통증사정을바탕으로이루어지나의사소통이불가능한환자의통증사정이정확하게이루어지지않고부적절한통증조절은심각한신체적손실을초래할수있다. 이에 2012년병원중환자간호사회에서개발하고중재기준을수립한의사소통이불가능한중환자의통증사정도구인 CNPS를실무에적용하여도구적용전, 후의효과를분석함으로써정확한통증사정및통증관리를하고자한다. 대상및방법 : 서울시내 A 종합병원 8개성인중환자실의만 20세이상, 24시간이상재원한의사소통이불가능한중환자를대상으로전자의무기록을열람, 조사하였다. 사전조사는 2013년 3월 1일부터 5 월 31일, 사후조사는 2013년 7월 1일부터 9월 30일까지로하였다. 결과및결론 : 중환자실입실기준 24시간동안도구적용전통증사정을한경우는전체대상자 698명중 325명 (46.6%), 통증사정을하지않거나부적절한경우는 373명 (53.4%) 으로조사되었다. 도구적용후통증사정을한경우는전체대상자 607명중 590명 (97.2%) 으로 CNPS 적용후통증사정이유의하게증가하였다 (p<0.001). 이는 CNPS 통증관리지침의교육및사용을통한긍정적인행위변화의결과로보여진다. 통증중재조사에서도구적용전약물적중재및비약물적중재를시행한환자수가 19.7%(n=137) 를차지한데비해도구적용후에는 26.5%(n=161) 로중재율또한유의하게증가되었다 (p=0.003). 환자안전의주요한변수인비계획적탈관률을비교한결과도구적용전 11.7%(n=82), 적용후 2.3%(n=14) 로유의한감소를보였다 (p<0.001). 정확한통증사정및중재결과로비계획적탈관율이감소되었고이는환자안전을도모하는데매우긍정적인효과라할수있다. Key word: CNPS BEST ABSTRACT PRIZE COMPETITION Key words: brain edema; cerebral infarction; computed tomography; angiography Best Abstract Prize Competition-2 의사소통이불가능한중환자의통증사정도구 73
분비를용량의존적으로억제하였으며 AMPK inhibitor인 compound C와 CamKKbeta inhibitor 인 STO609에의해 LPC(18:0) 의효과는억제되었다. 또한 AMPKa1을 small interfering RNA를이용하여 knock-down하였을경우, LPC(18:0) 는 macrophage 에서 LPS에의한 HMGB1 의분비를효과적을억제하지못하였다. Macrophage 의 G2A receptor 를차단하였을경우 LPC(18:0) 에의한 AMPK 인산화는억제되었으며 LPS에의한 HMGB1의분비를억제하지못하였다. In vivo모델에서 LPC(18:0) 10mg/kg를피하로전투약또는후투약하였을경우 LPS에의한폐내 HMGB1 의분비증가를억제하였다. 결론 : LPC(18:0) 은 LPS에의해유도된급성염증과정에서분비되는 HMGB1의분비를 AMPK의활성화를통하여억제하였다. Key words: lysophosphatidylcholine, HMGB1, AMPK Best Abstract Prize Competition-4 기계환기로부터의이탈 : 횡격막신경전도검사를이용한이탈곤란의예측 박윤희, 서지영 1, 정치량 1, 성덕현 2 Best Abstract Prize Competition-3 Stearoyl lysophosphatidylcholine은 AMPK 활성증가를통하여 LPS-induced HMGB1의 release를억제한다 배홍범, 장은아, 전휘, 곽상현, 이현정전남대학교의과대학마취통증의학과교실연구배경 : Macrophages 에서분비되는 nucleosomal protein인 high-mobility group box 1 (HMGB1) 은염증반응에관여하며이의분비를억제할시패혈증모델에서사망률을개선한다고보고되고있다. oxidized low-density lipoprotein 의주요구성성분인 Stearoyl lysophosphatidylcholine (LPC (18:0)) 은 HMGB1 의분비를억제한다고보고되고있으나그정확한기전을알려져있지않다. 연구방법 : 세포내 AMPK 및여러단백의활성은 western blot을통하여측정하였다. Extracellular HMGB1 의측정은 ELISA기법을이용하여측정하였다. 실험결과 : LPC(18:0) 은용량및시간의존적으로 AMPK 인산화를증가시켰으며이는 AMPK의상위 signal인 LKB1, CamKKbeta와 TAK1 중에서 CamKKbeta의 inhibitor에의해억제되었다. LPC (18:0) 는 macrophage 에서 LPS에의한 HMGB1의 성균관대학교의과대학삼성창원병원재활의학과, 성균관대학교의과대학삼성서울병원중환자의학과 1, 성균관대학교의과대학삼성서울병원재활의학과 2 연구배경 : 중환자실획득근쇠약은말초신경계를침범하여사지의근쇠약을유발하며, 특히횡격막쇠약을초래하여기계환기로부터의이탈을어렵게한다. 본연구의목적은횡격막신경전도검사와이탈곤란의정도가관련성을가지는지살펴보는데있다. 대상및방법 : 과거력상신경학적문제가없고 7일이상기계환기중인중환자실환자 24명 ( 남자 19명, 여자 5명, 평균연령 63.71±13.0세 ) 에대해양측횡격막신경전도검사를시행하여복합근육활동전위의원위잠시 (distal latency, 참고치 : 5.56~6.94 msec) 와진폭 (amplitude, 참고치 : 0.47~1.21 mv) 을측정하였다. 기계환기이탈이종료된후대상환자의경과를후향적으로조사하여 International Consensus Conference on Intensive Care Medicine 의분류 에따라 simple (A군, 7명 ), difficult (B군, 7명 ), prolonged weaning (C군, 10명 ) 으로나누었고, 측정된원위잠시 (~6.94, 6.94~8.0, 8.0~9.0, 9.0~) 와진폭 (0.47~, 0.31~0.47, 0.15~0.31, ~0.15) 을각각 4단계로구분하였다. 일원배치분산분석으로세군간에원위잠시와진폭의유의한차이가있는지검정하였고, 선형대선형결합분석으로기계환기이탈경과와원위잠시의증가또는진폭의감소가유의한경향성을보이는지검정하였다. 74
Best Abstract Prize Competition 결과및결론 : 신경전도검사결과는다음과같다 (A군: 원위잠시 6.92±1.01 msec, 진폭 0.56±0.18 mv, B군 : 7.95±0.93 msec, 0.48±0.09 mv, C군 : 7.65±1.28 msec, 0.29±0.18 mv). 일원배치분산분석결과원위잠시는군간분석에서유의한차이를보이지않았으나, 진폭은유의한차이를보였고 (p=0.007), Post Hoc test 에서 A군과 C군의진폭차이가유의하게나타났다 (p=0.008). 선형대선형결합분석에서기계환기이탈경과와원위잠시의증가는유의한경향성을보이지않았으나, 진폭의감소는유의한경향성을보였다 (p=0.005). 본연구에서기계환기이탈이어려운환자는횡격막신경전도검사상복합근육활동전위의진폭크기가상대적으로작게측정되었고, 이탈곤란이심할수록복합근육활동전위의진폭크기가감소하는경향이관찰되어, 횡격막신경전도검사가중환자의기계환기이탈곤란을예측하는데도움이될것으로생각한다. 참고문헌 : Boles JM, et al: Weaning from mechanical ventilation. Eur Respir J 2007; 29:1033-56. Introduction; A randomized, multicenter, open-label, parallel group study was performed to compare the effects of remifentanil and morphine as analgesic drugs on the duration of weaning time from mechanical ventilation (MV). Methods; A total of 105 patients with MV in 6 medical and surgical intensive care units (ICU) were randomly assigned to either, remifentanil (0.1-0.2 mcg/kg/min, n = 56) or morphine (0.8-35 mg/hr, n = 49) from the weaning start. The weaning time was defined as the total ventilation time minus the sum of controlled mode duration. Results; Compared with the morphine group, the remifentanil-based analgesic group showed a tendency of shorter weaning time (mean 143.9 hrs, 89.7 hrs, respectively: p = 0.069). Secondary outcomes such as total ventilation time, successful weaning rate at the 7th of MV day was similar in both groups. There was also no difference in the mortality rate at the 7th and 28th hospital day. Kplan-Meyer curve for weaning was not different between the two groups. Conclusion; Remifentanil usage during the weaning phase tended to decrease weaning time compared with morphine usage. Key words: remifentanil, morphine, mechanical ventilation, weaning Best Abstract Prize Competition-7 Key words: 중환자실획득근쇠약, 기계환기이탈, 횡격막신경전도검사 Best Abstract Prize Competition-6 Comparison of Morphine and Remifentanil on the duration of weaning from mechanical ventilation Jae-Myeong Lee 1, Seong Heon Lee 2, Sang Hyun Kwak 2, Hyeon Hui Kang 3, Sang-Hak Lee 3, Jae-Min Lim 4, Mi-Ae Chung 5, Young-Joo Lee, Chae-Man Lim 7 1 Department of Surgery, Ajou University School of Medicine, Suwon, Korea, 2 Department of Anesthesiology and Pain Medicine, Chonnam National University, Medical School, Gwangju, Korea, 3 Division of Pulmonology, Critical Care and Sleep Medicine, Department of Internal Medicine, St. Paul's Hospital, The Catholic University of Korea, Seoul, Korea, 4 Department of Pulmonology, Kangreung Asan Medical Center, Kangreung, Korea, 5 Department of Anesthesiology and Pain Medicine, Hanyang University School of Medicine, Seoul, Korea, 6 Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea, 7 University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea 중환자실특성에따른중환자실입실환자의사망위험예측 송원준 1, 황승식 2, 박성훈 3, 박상헌 4, 김인병 5, 이상민 6, 서지영 1, 그외 VSKI 연구자 성균관대학교의과대학삼성서울병원호흡기내과 1, 인하대학교의과대학예방의학교실 2, 한림대학교성심병원호흡기알레르기내과 3, 분당서울대학교병원마취통증의학과 4, 명지병원응급의학과 5, 서울대학교의과대학내과학교실 6 연구배경 : 국내각병원마다중환자치료의질향상을위해중환자실의인력충원및치료체계를개선하려는노력이있어왔다. 하지만국내중환자실개별특성이실제중환자실에입실하는환자의사망위험에미치는영향에대해서는구체적으로밝혀진바가없다. 본연구에서는중환자실특성과중환자실입실환자의사망위험간연관성을알아보고자하였다. 대상및방법 : 2010년 7월 1일부터 2011년 1월 31일까지국내 15개병원 22곳중환자실에서시행한전향적다기관코호트연구인 Validation of Simplified acute physiology score 3(SAPS 3) in Korean ICUs (VSKI) 자료를토대로, 이중중환자실특성을조사한 18개중환자실에입원한환자 5,053명을대상으로하였다. 개별환자의 SAPS 3로보정한사망위험률을중환자실별군집단위로하여각중환자실특성변수 ( 중환자실의기본구성, 관리도구및진료체계의총 44개 ) 로로버스트로지스틱회귀분석을하였고회귀계수를이용해보정위험비 (adjusted risk ratio) 및위험차 (adjusted risk difference) 를산출하였다. 결과및결론 : 각중환자실특성에대해사망위험비는중환자실상주전담교수 / 전문의여부 (0.61 (95% CI 0.45-0.81 P<0.05)), 중환 BEST ABSTRACT PRIZE COMPETITION 75
자전담의에의한다학제회진여부 (0.61 (95% CI 0.41-1.01)) 및입퇴실기준관리여부 (0.57 (95% CI 0.41-0.79)), 손씻기순응도비율 (80% 기준준수여부 ) (0.67 (95% CI 0.47-0.92)), 계획되지않은발관모니터링여부 (0.62 (95% CI 0.46-0.82)), 지난 1년간중환자실사망률 (30% 기준 ) (1.78 (95% CI 1.35-2.36)) 및지난 1개월간욕창발생률 (2% 기준 ) (1.59 (95% CI 0.71-3.56)) 로확인되었다. 중환자실입실환자의사망위험예측에있어개별환자의중증도와함께중환자실별특성도고려되어야하겠다. Key words: 사망예측모형, 중환자실, VSKI Background: Acute lung injury (ALI) and acute respiratory distress syndrome have still high mortality. However, there are few therapeutic options. We have to devise the method to decrease lung inflammation and fibrosis in ALI. Syndecans are single transmembrane domain proteins that are thought to act as coreceptors, especially for G protein-coupled receptors. Syndecan-4 is also known to regulate early neutrophil migration and inflammation in response to lipopolysaccharide, which is not known well in the field of ALI. In this work, we wished to determine the role of syndecan in ALI and the regulatory mechanism of syndecan. Methods: In vitro experiment, lipopolysaccharide(lps) was exposed to RAW 264.7 cell. In vivo experiment, LPS was instilled into C57BL/6 mice intratracheally and fixed lung tissue and mouse lung lysates were analyzed by light microscope and Western blotting. Bronchoalveolar lavage (BAL) was performed to check cell count and cytokine levels. N-acetylcysteine was treated to in vivo and in vitro ALI models to block oxidative stress. Results: Preliminary studies indicated that LPS induced syndecan-4 in RAW 264.7 cells in dose and time dependent manner. Parallel studies in mice also showed an increase in syndecan-4 in lung tissue by LPS. LPS increased neutrophil count and pro-inflammatory cytokine such as TNF-α and IL-6 in BAL fluid. We next investigated the effect of NAC upon the LPS induced syndecan-4 expression. Pre-treatment with NAC suppressed lung inflammation in H&E stain and cytokine levels in BAL fluid. We observed that LPS induced syndecan-4 expression was attenuated by NAC both in vitro and vivo experiment. Conclusion: We found that LPS induced syndecan expression in the model of ALI. Oxidative signaling might be involved in the induction mechanism of syndecan by LPS. Key words: Syndecan, LPS, N-acetylcysteine, ALI Best Abstract Prize Competition-8 Expression of syndecan is mediated by oxidative signaling in lipopolysaccharide induced acute lung injury model Hee Jung Choi, Sang-Min Lee Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine Best Abstract Prize Competition-9 The clinical value of neutrophil extracellular traps in Acute respiratory distress syndrome Chang-Won Hong 1, Chang Whan Kim 2, Dong-Keun Song 1, Yong Bum Park 2, Lung Research Institute of Hallym University, So Young Park 2 Department of Pharmacology, Institute of Natural Medicine, Infectious Diseases Medical Research Center, Hallym University College of Medicine 1, Pulmonary, Allergy and Critical Care Medicine, Gang Dong Sacred Heart Hospital, Hallym University Medical Center 2 Background: Neutrophil extracellular traps (NETs) are structures composed of DNA and granular proteins, which rapidly trap and kill pathogens. The release of NETs has been identified as a novel immune response in innate immunity. However, the morphology and functions of NETs have not been evaluated in pneumonia ARDS. We evaluated the clinical value of NETs for the prognosis of adult patients with pneumonia ARDS. Method: We investigated the presence of NETs in the blood from12 patients with pneumonia. We isolated neutrophils from community-acquired pneumonia patients on day 1 and day 3. Then we determined the ROS generation, NETs formation, surface expression value of granule markers (CD63, CD66b, CD35; which are specific markers for azurophil granule, specific granule and secretory vesicle, respectively). Results: Out of 12 patients with pneumonia, 4 (33.3%) were male; whose median age was 74.6 years median acute physiology and chronic health evaluation (APACHE) II was 28.7 and median SOFA 11 at admission. In the follow-up, 8(67%) patient survived at 28 days. NETs were identified in from all patients. When neutrophils were stimulated with PMA, PD1 neutrophils showed increased NETs formation whereas reactive Oxygen Species (ROS) generation was rather attenuated. Neutrophils from pneumonia patients have fewer lobes 76
Best Abstract Prize Competition compared to neutrophils from healthy volunteer. In addition, neutrophils from pneumonia patients showed more condensed, oval shaped nucleus. CD62LdimCD16bright subset was significantly increased in neutrophils of pneumonia ARDS patients. Higher NET formation was shown in survival group than non survival group(p=0.04). NET formation showed negative relationship with lactate. Conclusion: NETs in serum may reflect prognosis of pneumonia sepsis. Quantification of NETs in serum may provide a new indicator of inflammation. Key words: Neutrophil extracellular traps, ARDS, pneumonia BEST ABSTRACT PRIZE COMPETITION 77
April 25 (Friday) 4 월 25 일 ( 금 ) April 26 (Saturday) 4 월 26 일 ( 토 ) Convention Hall A ㆍ C Oral Presentation
Oral O1-1 Omega-3 Fatty Acids Reduce Pulmonary NF-κB activation in a Murine Ventilator-Induced Lung Injury Young-Jae Cho, Yoon Je Lee, Eun Young Eo, Yeon Joo Lee, Choon-Taek Lee, Jae Ho Lee Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital Background: The NF-κB activation is a pivotal signal pathway in the inflammatory response of ventilator-induced lung injury (VILI). To enable the assessment of NF-κB activity in the lungs, we developed a murine VILI models using in vivo bioluminescence imaging system (IVIS; PerkinElmer Inc., CA). Regulation of the NF-κB activation is known to be an important therapeutic effect of ω-3 fatty acids (ω-3 FAs), which produce pro-resolving lipid mediators including resolvin D1 (RvD1). Materials and Methods: We transfected a luciferase based NF-κB reporter into the lungs of C57BL/6 mice, which showed specific luciferase expression in the pulmonary tissues. Using these mouse models, we studied the kinetics of NF-kB activation following exposure to lipopolysaccharide (LPS) and mechanical ventilation injury and elucidated whether aspirin-triggered ω-3 FAs reduce the activation of the NF-κB signal pathway provoked by LPS and VILI. Results: The kinetics of NF-κB activation following intratracheal administration of LPS could be measured by IVIS and signal activities were emphasized by applying ventilator injury with high tidal volume (Fig. 1). Quantification of the induced lung signal reached a plateau at 4 hours following injury. Despite conventional pathological changes didn t be showed, pulmonary NF-κB signal activation was detected by IVIS. After pre-treatment of ω-3 FAs for 1 week, the NF-κB activation attenuated compared to control mice. The signal activities were more reduced after intravenous aspirin administration and this results were similar with pre-treatment of intravenous RvD1 (Fig. 2). Conclusions: Aspirin-triggered ω-3 FAs could reduce pulmonary NF-κB activation in a murine model of ventilator-induced lung injury using IVIS. Key words: Ventilator-induced lung injury, NF-κB, ω-3 fatty acids O1-2 Flecainide acetate attenuates LPS-induced ALI by neutrophils mediated inflammatory process 송지아, 곽상현, 배홍범, 김석재, 이현정, 한혜정 전남대학교의과대학마취통증의학교실 Background and Goal of Study: Although flecainide acetate is a sodium channel blocker and an anti-arrhythmic agent, many results suggest that modulating in anti-inflammatory responses and alveolar fluid clearance (AFC) are mediated, in part, by sodium channel activity. So, we hypothesized that the spectrum of activity of flecainide acetate was extend to include novel role of anti-inflammatory effects and decreasing pulmonary edema. The experiment was performed to evaluate the ORAL 81
effects of flecainide acetate on endotoxin-induced acute lung injury (ALI) in a rat model. Materials and Methods: Subcutaneously continuous infusion of saline or flecanide acetate was started 3 hours before and continued until 24 hours after injection of saline or endotoxin. And we measured the effects of flecainide acetate on severity of pulmonary neutrophil accumulation, level of proinflammatory cytokine in bronchoalveolar lavages fluid (BALF), degree of pulmonary edema and mortality rate. Results and Discussion: In present study, the main findings are that animals treated by flecainide acetate were protected from endotoxin-induced ALI, as determined by severity of neutrophils mediated inflammatory process, degree of pulmonary edema and mortality. Conclusion(s): it was extended the activities of neutrophil function and AFC in which flecainide acetate has a role by demonstrating that flecainide acetate is capable of attenuating endotoxin-induced ALI under in vivo conditions. Background: Bedside chest radiography is routinely used to assess the respiratory condition of critically ill patients. Many patients have bilateral diffuse infiltration on chest radiography in the intensive care unit (ICU). Differential diagnosis between acute cardiogenic pulmonary edema and pneumonia or acute respiratory distress syndrome (ARDS) may often be difficult on chest radiography. It is important to differentiate pulmonary edema from bilateral pneumonia. The risk of pulmonary edema is the main limiting factor in fluid therapy in the critically ill patients. We evaluated the ability of lung ultrasound by differential diagnosis. Patients and Methods: This prospective observational study was performed for the patients (over 18 years old) with bilateral diffuse infiltration on chest X-ray in the ICU during 10 months. At first, we checked the presence of: 1) alveolar-interstitial syndrome (AIS) 2) pleural lines abnormalities 3) absence or reduction of "gliding" sign 4) "spared areas" 5) consolidations 6) pleural effusion 7) "lung pulse" using 2-6MHz curved probe. Then we checked heart to detect 3Esㅡ Effusion (cardiac tamponade), Equality (Right ventricular enlargement), Ejection fractionㅡ on parasternal long axis and apical or subcostal four chamber view using 2-4 MHz probe. We divided all the possible conditions into 3 categories (pneumonia, pulmonary edema, mixed). We compared it with clinical diagnosis, post-ultrasound diagnosis, which was categorized with the same method and examined the agreements using kappa statistics. Results: 53 patients were finally enrolled. Cohen s kappa between clinical diagnosis and post-ultrasound diagnosis was 0.705. Conclusion: Lung ultrasound can be helpful in differential diagnosis for bilateral diffuse infiltration on chest radiography in the ICU. Key words: lung ultrasound, bilateral infiltration Key words: Flecanide acetate, acute lung injury, neutrophil O1-3 The usefulness of lung ultrasound in differential diagnosis for bilateral diffuse infiltration Jin Jeon, Sang-Woo Shim, SoHee Park, Jin Won Huh, Younsuck Koh, Chae-Man Lim, Sang-Bum Hong Department of Intensive Care Unit, Asan Medical Center, Korea O1-4 외상성골반골절환자중쇼크를동반한중환자의임상양상및사망률 노효근, 권수경, 금민애, 김태현, 김호승, 마대성, 신성대, 정윤중, 홍석경 울산대학교의과대학외과학교실서울아산병원외상중환자외과 목적 : 외상성골반골절환자중쇼크를동반한중환자의임상양상과컴퓨터단층촬영소견에따른사망률을조사하여치료프로토콜을개선하고자하였다. 대상및방법 : 2011년 1월부터 2013년 12월까지 3년간수상 24시간이내내원한총 120명의골반골절을동반한중증외상환자중내원당시쇼크가있었던 46명의중환자를대상으로당시의수축기혈압, 혈색소수치, 수혈량, 초기컴퓨터단층촬영소견, 지혈을위한혈관색전술시행여부, 사망률등을조사하였다. 결과 : 3년간수상 24시간이내내원한 120명의골반골절이있었던중증외상환자중내원당시쇼크를동반한중환자는총 46명이었다. 46명의환자중초기컴퓨터단층촬영상조영제의혈관밖유출로 82
Oral 급성출혈소견이있었던경우는 22명 (22/46=47.8%) 이었고, 평균 GCS는 10.0점, 수축기혈압 65.6(mmHg), 맥박 101.9( 회 / 분 ) 혈색소는 9.9(g/dl), 유당은 5.6(mmol/L), ISS는 36.9점, 총적혈구수혈양은 17.3(Pack) 이었다. 이 22명중 20명의환자에응급으로혈관조영술을시행, 그중명확한출혈부위가확인되지않은 2명을제외한 18 명의환자에혈관색전술을시행하였다. 22명중 8명의환자가사망 (36.4%) 하였고, 사망자중 7명이혈관색전술을시행받았었다. 조영제의혈관밖유출이없었던 24명 (24/46=52.2%) 의평균 GCS는 11.0점, 수축기혈압 65.6(mmHg), 맥박 98.9( 회 / 분 ) 혈색소는 11.8(g/dl), 유당은 6.1(mmol/L), ISS는 41.7점, 총적혈구수혈양은 13.2(Pack) 이었다. 이중총 4명의환자가혈관조영술을시행받았고, 그중 3명이혈관색전술을시행받았다. 24명중 5명의환자가사망 (20.8%) 하였고, 사망자중 1명만혈관색전술을시행받았었다. 결론 : 골반골절이있는중증외상환자중쇼크를동반한중환자의초기컴퓨터단층촬영상조영제의혈관밖유출이있는경우에유출이없었던환자보다초기혈색소수치가더낮고, 수혈양도더많았으며, 초기소생술후의사망률도더높았다. 따라서조영제의혈관밖유출소견이있는경우빠른수혈및혈관색전술등의적극적인처치가필요할것으로본다. Key words: 골반골절, 컴퓨터단층촬영, 혈관조영술 결과 : 총 6명의환자가본연구에등록되었다. 미다졸람 0.08 mg/kg/h 을투여한환자는수면다원검사에서혼수상태 (coma) 로수면단계를평가할수없었다. 나머지 5명의수면다원검사결과총수면시간은중앙값 ( 사분위수 ) 494.0 (113.5-859.0) 분이었으며, 렘수면은 10.0 (6.0-50.5) 분, 3단계수면은전혀없었다. 수면중각성지수 (wake index) 는 16.1 (7.6-28.6) /h 이었다. 미다졸람용량과총수면시간간에는통계적으로유의한양의상관관계를보였다 (r=0.975, P=0.005). 결론 : 중환자실환자에서정상적인수면의양을위하여는미다졸람 0.02-0.03 mg/kg/h의용량이적당할것으로판단된다. 그러나, 이환자들의수면의질은매우나빠, 앞으로중환자실환자의수면의질향상을위한노력이필요할것으로판단된다. Key words: 중환자, 수면, 미다졸람 O1-6 외과계중환자실환자섬망발생위험요인분석 문경은, 정윤중, 오수진, 조희주, 정미수, 송정미, 김세라, 이선주, 이순행, 금민애 1, 마대성 1, 김태현 1, 홍석경 1 서울아산병원중환자간호팀, 울산대학교의과대학서울아산병원외상및중환자 1 O1-5 중환자의수면과미다졸람적정용량에대한선행연구 김세중 1, 박지수 1, 이연주 1,2, 박종선 1, 윤호일 1, 이재호 1, 이춘택 1, 조영재 1,2 분당서울대학교병원호흡기내과 1, 분당서울대학교병원중환자진료부 2 연구배경 : 중환자실에서치료받고있는많은환자들은수면박탈을경험한다. 중환자실환자들은고통을줄이고불안을감소시키며수면을취하기위하여흔히진정제인미다졸람을투여받는다. 그러나, 아직까지미다졸람지속적정맥주입중인환자의수면에대한평가는없었다. 이에본연구에서는미다졸람으로진정중인중환자실환자에서 24시간수면다원검사를시행하여미다졸람의용량과수면의양및질의관계를살펴보고자하였다. 대상및방법 : 전향적연구로서내과계중환자실에입원해기계환기치료중진정제로미다졸람을투여받고있는 18세이상의환자를대상으로하였다. 미다졸람의용량은매 4시간마다 Richmond Agitation Sedation Scale (RASS) 을측정하여 -2에서 0 사이를유지하도록조절하였다. 수면다원검사는 SOMNOwatch, plus (SOMNOmedics, Randersacker, Germany) 를이용하여 24시간동안측정하였다. 연구배경 : 섬망은중환자의 80% 에서발생하는급성뇌손상의한형태로사고의장애나인지기능장애, 의식변화, 수면각성주기의변화를주특징으로하는급성의학적상황이다. 환자는파괴적이거나폭력적인성향을나타내면서환자의혼란스런사고는의료진과의협조를불가능하게하고치료에어려움을주거나안전에문제가생길수있어섬망을조기발견하고예방하는것은중환자실간호에서중요시되어야한다. 연구목적 : 본연구는외과계중환자실에서의섬망의발생정도및섬망발생관련요인을분석하여섬망에대한이해를높이고이를근거로중환자실섬망발생환자에대한간호중재개발의기초자료를제공하고자시행하였다. 연구방법 : 전향적연구로, 2013년 4월 -8월동안외과계중환자실에입실하는환자로언어적또는비언어적의사소통이가능한환자를대상으로하였으며입실후 7일동안 CAM ICU 도구를이용하였으며섬망발생군과비발생군으로나누어섬망발생요인 ( 일반적특성, 질환관련특성, 치료관련특성 ) 을분석하였다. 연구결과 : 섬망발생군과섬망비발생군과의특성을비교하여분석한결과나이 (p=.000), 시력장애 (p=.014), 결혼력 (p=.001), 입실경로 (p=.012), 타중환자실경유 (p=.000), 입실사유 (p=.000), 입실전의식상태 (p=.048), 인공기도삽관 (p=.000), 억제대 (p=.000), 투석 (p=.000), 격리실 (p=.002), 쇼크 (p=.002), 진정제 (p=.000), APACHE II(p=.000) 에서유의한차이를보였다. 유의한차이를보인항목에대해다변량분석을시행한결과나이가많을수록, 시력장 ORAL 83
애가있을수록, 타중환자실을경유하여입실할수록, 억제대사용율이높을수록, 격리실을사용하지않을수록, 쇼크가동반될수록, 진정제를사용할수록섬망발생율이높았다. 결론 : 중환자실환경적요인을개선하려는노력을통하여노력을통해섬망발생을예방하고변화된환자상태를조기에발견하는것이최선의방법으로제안되며, 진정제주입의경우환자의상태를기준으로약물을적절히투여할수있도록올바른감사와중재를하는것이필요하겠다. Key words: 섬망, 중환자실 O1-7 중환자조기재활치료의안전성 고영준 1, 이윤미 2, 정진희 2, 김현주 2, 김선미 2, 고진영 3, 이대상, 유정암, 조양현 4, 양정훈, 전경만, 박치민, 박윤희 5, 성덕현 6, 서지영, 정치량 삼성서울병원중증치료센터중환자의학과, 삼성서울병원재활의학과물리치료실 1, 삼성서울병원중증치료간호팀내과계중환자실 2, 삼성서울병원약제부임상지원팀 3, 삼성서울병원중증치료센터흉부외과 4, 삼성창원병원재활의학과 5, 삼성서울병원재활의학과 6 연구배경 : 중환자실에서생존퇴원한환자는점점증가하고있으며, 중환자실치료후발생하는신체적기능장애를경험하는환자역시늘어나고있다. 중환자실에서시작하는조기운동 (early mobilization) 은중환자실획득쇠약 (ICU acquired weakness) 으로인한장애동반을감소시킨다. 하지만실제임상적용의안전성에대해서는연구가더욱필요한상황이다. 대상및방법 : 삼성서울병원중환자실에입원한환자를대상으로후향적관찰연구를 2013년 5월부터 12월까지진행하였다. 조기운동치료중발생한안전사건 (safety event) 및부작용을조사하였으며, 치료를중단하게된사유를확인하였다. 결과및결론 : 189명의연구기간내 24시간이상입원한환자는총 1134회의중환자실내재활치료를시행하였다. 107명을대상으로수동적가동범위운동 (passive range of motion, PROM) 은 614 회 (54%), 99명을대상으로조기운동치료를포함한 6가지종류의적극적재활치료를 520회 (46%) 시행하였다. 그중기계환기 (248회, 48%), 인공기도유지 (341회, 66%), 중심정맥도관 (252회, 48%) 및동맥관거치 (410회, 79%), 지속적신대체요법 (36회, 7%) 체외막형산화요법 (69회, 13%) 적용중이었다. 치료중발생한안전사건은인공기도발관이 1회보고되었으며, 중단사유는빈호흡, 빈맥순서였다. 중환자실에서시행한조기운동치료의적용은안전하였으며, 중대한이상반응은보고되지않았다. O1-8 Preoperative and intra-operative risk factors for pressure ulcers in critically ill patients Hyunjeong Lee, Minjeong Lee, Shin Ok Koh, Sungwon Na, Cheungsoo Shin, Jeongmin Kim 1 Department of Anesthesiology and Pain Medicine, 2 Anesthesia and Pain Research Institute, Yonsei University College of Medicine Introduction: Pressure ulcers (PU) are localized injuries to the skin and/or underlying tissue, resulting in increased length of stay, morbidity, and adverse outcomes. However, far too little attention has been paid to peri-operative risk factors for postoperative pressure ulcer in surgical patients. The aim of this study was to overall evaluate and validate preoperative and intra-operative risk factors for postoperative pressure ulcers in critically ill postoperative patients. Methods: A retrospective observational design was used to exam total 126 adult surgical patients underwent surgical procedures and admitted in intensive care unit (ICU) using electronic documentation applications from Jan 2012 through Dec 2013. The primary outcome was hospital-acquired pressure ulcer categorized as stage more than II. Results: We identified two independent preoperative risk factors in our adult surgical patients. The significant risk factors associated in the matched dataset were preoperative albumin and lactate. (OR, 0.17; P=0.010, OR, 2.13; P=0.013, respectively) Conclusion: Postoperative pressure ulcers developed in 4.2% of critically ill patients in our study. Preoperative albumin and lactate levels were associated with postoperative pressure ulcer development on adjusted analysis. 1) O'Brien DD, Shanks AM, Talsma A, Brenner PS, Ramachandran SK: Intraoperative risk factors associated with postoperative pressure ulcers in critically ill patients: a retrospective observational study. Crit Care Med 2014; 42: 40-7. Key words: 조기운동치료, 중환자, 중환자실획득쇠약 84
Oral Hepatopulmonary syndrome takes place in patients with liver cirrhosis in which nonfunctiong liver cannot metabolize the strong vasodilator, Vasoactive Intestinal Peptides that cause pulmonary capillary vasodilatation, leading to hypoxia. In this report, we present a patient with mild hepatitis, in whom the highest value of serum alanine aminotransferase enzyme (ALT) was only 390 units/l, who developed severe hypoxia. Case Report: A 32-year-old man was admitted to another hospital because of dyspnea. A plain chest radiography was unremarkable. The initial serum creatinine was 4.0 mg/dl, but came down to near normal level with hydration. PO 2 was 112 torr with oxygen mask. Hemoglobin was 11.8g. ALT was160 units/l. Ultrasonography of liver revealed a diffuse fatty liver in moderate degree. On the second hospital day, SpO 2 became 80%. The patient was placed on ventilator with orotracheal intubation. Chest CT angiography was taken, the reading of which was pulmonary edema. The hypoxia was so severe that ECMO had to be started. Methylpredinisolone had been administered for a week with antibiotics. Sputum culture did not show any growth. The patient was transferred to this hospital. Procalcitonin was 0.22, probnp 277, WBC 13.7, hematocrit 28.2%, ALT 207 units/l, and BUN/Creatinine 29/1.48. ALT went up to 390 units/l. PO 2 was 58 torr on ECMO. Chest radiography showed bilateral diffuse consolidation. Sputum culture revealed the growth of Klebsiella pneumoniae. Chest CT angiography taken at the other hospital reviewed by us, suggested the evidence of pulmonary peripheral vasodilatation, indicating hepatopulmonary syndrome. The patient expired on 7 days after admission to this hospital. Conclusion: Although hepatitis alone was not severe enough to develop hepatopulmonary syndrome, the pre-existing fatty liver complicated it most likely. Key words: hypoxia, hepatitis O1-9 An Unusual Case of Hepatopulmonary Syndrome 김기훈 1, 장항재 2, 허찰스 인제대학교해운대백병원외과학교실 1, 인제대학교해운대백병원내과학교실 O1-10 Comparison of three HFNC: subjective comfort and effect on lung volume So Hee Park, Hee Jung Suh, Eun Young Kim, Sang-Bum, Hong, Younsuck, Koh, Chae-Man Lim Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Background: High flow Nasal Cannula (HFNC) delivers high flow warmed and humidified air and oxygen via nasal cannula. Electrical impedance tomography (EIT) estimates changes in lung volume by measuring changes of lung impedance. The purpose of our study was to investigate the effect of the other nasal cannula device (OmniOx- HFT500, MEKICS, Seoul, Korea, Optiflow, Fisher & Paykel ORAL 85
Healthcare, Auckland, New Zealand and Vapotherm Inc, Stevensville, Maryland, USA) on global and regional end expiratory lung impedance variation( EELI), nasopharyngeal pressure and subjective comfort. Method: Prospective study with 29healthy volunteers was performed from September 01, 2013 to November 01, 2013. After 2 minutes breathing ambient air, HFNC was applied for 12 minutes. The air flow was increased from 30L/min to 40L/min every 3 minutes. For each device, global and regional end-expiratory lung impedance variations (ΔEELI) were measured by EIT. Pharyngeal pressure, air flow rate, and ΔEELI were recorded as flow increased. Result: The BMI of healthy volunteers was 23.3±4.0 kg/m2 and male were 14. HFNC increased global EELI and after applied HFNC, EELI was homogeneous. There was not different in pharyngeal pressure (p=0.107, and p=0.11) and global ΔEELI (p=0.15, and p=0.22) at 30L/min and 35L/min between 3 nasal device. At 40L/min, there was a significant difference in pharyngeal pressure (OmniOx: 3.7±0.8 vs. Optiflow: 3.5±0.6 vs. Vapotherm: 2.9±0.7, p=0.013) but, global ΔEELI was similar (OmniOx: 1.4±1.4 vs. Optiflow: 1.4±1.0 vs.vapotherm: 2.0±2.4, p=0.467). The volunteers evaluated optiflow as the most comfortable device. Conclusion: New nasal device and conventional nasal device similarly increased the end expiratory lung volume and created positive oropharyngeal airway pressure. remifentanil. The patient s urine became greenish 23hours after continuous propofol infusion. Urinalysis revealed the following: ph, 5.5; urine SG, 1.016; bilirubin content, -; and urobilinogen 1+. Urine culture was negative. As there were no signs of infection and no other known medication that could have discolored the urine, we suspected propofol as the cause. Conclusion: In conclusion, urine discoloration after propofol is benign and rare, prompt recognition of such side effects is important in limiting medical expenditures, inordinate drug exposure, and distress among patients and clinicians Reference: 1) Lee JS, Jang HS, Park BJ: Green discoloration of urine after propofol infusion. Korean J Anesthesiol 2013; 65: 177-9. Key words: propofol, urine Key words: high flow nasal cannula, electrical impedance tomography, nasopharyngeal pressure O2-1 Case report: urine color change after propofol use Kwan Hyung Kim 1, Jeongmin Kim 1,2, Shin Ok Koh 1,2, Cheung Soo Shin 1,2, Sungwon Na 1,2 Department of Anesthesiology and Pain Medicine 1, Anesthesia and Pain Research Institute, Yonsei University College of Medicine 2 Introduction: Propofol is a hypnotic agent that is widely used for the induction and maintenance of general anesthesia and sedation in critically ill patients. Case report: A 55-year-old man with inguinal pain due to chondrosarcoma of femur head elected to undergo wide excision of tumor and partial cystectomy because of metastatic region of bladder. After the surgery, the patient was admitted to the ICU and we instigated mechanical ventilation under deep sedation with propofol and O2-2 AICAR 는 p38 MAPK 의인산화증가를통해자연사세포의제거를증가시킨다. 배홍범, 전휘, 곽상현, 이현정 전남대학교의과대학마취통증의학과교실 연구배경 : 5-aminoimidazole-4-carboxamide-1- -D-ribofuranoside (AICAR) 는세포내에서 ZMP로변환되어 AMP-activated protein kinase (AMPK) 의활성을증가시키고세포의대사및면역조절에관여하며 bacteria에대한식작용을증가시키는것으로알려져있다. 하 86
Oral 지만자연사세포 (apoptotic cell) 의식작용 (efferocytosis) 에미치는효과는알려져있지않다. 대상및방법 : 세포내 AMPK 및단백의활성은 western blot을통하여측정하였다. Efferocytosis는 PKH26 labelled apoptotic thymocyte or apoptotic neutrophil을배양된 thioglycollate-induced mice peritoneal macrophage와 Raw264.7 cell에넣고 90 분또는 120분배양한다음, apoptotic thymocyte에대해서는 FITC-conjugated CD11b (macrophage marker) 와 APC-conjugated CD90.2 (thymocyte marker) 를처치하여 flow cytometry를통하여측정하였으며 apoptotic neutrophil에대해서는 HEMA3 stain 후현미경을통해측정하였다. 결과 : AICAR는시간의존적, 용량의존적으로 AMPK 활성을증가시켰으며 E. coli와 apoptotic thymocyte 그리고 apoptotic neutrophil 에대한 phagocytosis를증가시켰다. AMPK inhibitor인 compound C 는 E.coli 식작용에미치는 AICAR의효과를억제하였지만 efferocytosis에대한 AICAR의효과를억제하지못하였다. Adenosine 수용체를차단하거나 adenosine kinase inhibitor를통해세포내에서 AICAR가 ZMP로변환하는과정을차단하였음에도불구하고 AICAR에의한 efferocytosis 증가를억제하지못하였다. 또한 AMPKa1을 small interfering RNA를이용하여 knock-down하였을경우에도 AICAR는 efferocytosis를증가시켰다. AICAR는 AMPK independent하게 p38 MAPK의인산화를증가시켰으며이는 compound C와 AMPKa1 sirna를통하여증명하였다. AICAR에의한 efferocytosis의증가는 p38 inhibitor와 TAK1 (p38 proximal signal) inhibitor에의해억제되었다. AICAR를 mouse 복강내투입시 apoptotic cell에대한폐에서의제거가증가되었다. 결론 : AICAR는 bacteria 및 apoptotic cell에대한 phagocytosis를 in vitro와 in vivo에서증가시켰다. 본실험결과는급성폐손상이나전신성홍반성루푸스와같은 apoptotic cell이병인에중요한역할을하는질환에서 AICAR의치료제로서가능성을제시하고있다. Methods: This study was a prospective observational study conducted in a 12-bed intensive care unit (ICU) of a tertiary referral hospital. Consecutive patients admitted to the ICU with septic shock were enrolled from September, 2012 to February, 2013. According to the 28-day mortality, the enrolled patients were divided into the two groups: the survivors and the non-survivors. We obtained serum samples from the patients at admission (0 h), 24 h (24 h), and 72 h after admission (72 h). We measured serum NADPH and GSH levels, GPx activity, and malondialdehyde (MDA) level. Results: 34 patients were grouped into the survivors and 16 into the non-survivors. Age, APACHE II score, and SOFA score of the survivors were lower than those of the non-survivors (p = 0.013, < 0.001, and < 0.001, respectively). Multivariate analyses revealed that higher NADPH at 72 h and higher tgsh at 24 h were independently associated with lower mortality (p = 0.008 and p = 0.032, respectively), and higher MDA at 24 h was independently associated with higher mortality (p = 0.003). Conclusion: Low serum NADPH and GSH levels and high serum MDA level were associated with the increased 28-day mortality in patients with septic shock. Key words: Septic Shock, NADPH, Glutathione Key words: AICAR, efferocytosis, p38 MAPK ORAL O2-4 O2-3 Low serum NADPH and GSH were associated with the 28-day mortality in patients with septic shock 유경민, 권운용, 김경수, 서길준, 부지환, 이세종, 김재승 서울대학교병원응급의학과 Background: To investigate whether the changes in serum reduced nicotinamide adenine dinucleotide phosphate (NADPH) and total glutathione (tgsh) levels and glutathione peroxidase (GPx) activity were associated with the 28-day mortality of patients with septic shock. 경희의료원신경외과중환자실과타과중환자실간의감염률변화와그원인에관한 5 개년간의비교분석 오인호, 박봉진, 이미숙 1, 천희경 1, 김민기, 최석근, 김태성, 임영진 경희대학교의과대학신경외과학교실, 경희대학교의과대학감염내과학교실 1 Object: 신경외과환자의치료과정에서중환자실의사용은환자의적극적인치료와관리를위해필수적인요소이다. 이러한환자들은일반적으로의식의저하를보이며많은의료기구가삽입되고인공호흡기를사용해야만하는상태가많아병원내감염에쉽게노출되고 87
있는현실이다. 이로인해항생제의사용이증가하게되어다제내성균에의한감염이증가되고환자및의료인에게도정신적경제적부담이되고있다. 저자들은단일병원신경외과중환자실감염의다년간변화와원인을타중환자실과비교하여개선점에대해알아보고자하였다. Methods: 2008년 1월부터 2012년 12월까지 5년간총 9676명의환자가경희의료원 3개과중환자실에서퇴원하였으며총 57262환자일수에대해월별및연도별로비교분석하였다. 감염경로는 UTI(urinary tract infection), BSI(blood stream infection), VAP(ventilator associated pneumonia) 세종류의도관삽입에대해비교하였으며퇴원환자 100명당감염률과환자일수 1000일당감염률에대해분석하였다. 신경외과중환자실, 내과중환자실과외과중환자실의 3개중환자실에대해동일하게분석하였으며도관사용이제한적인신경과중환자실및준중환자실은제외하였다. Results: 2008년신경외과중환자실의환자일수 1000일당감염률은 12.1 이었으며내과중환자실 9.0, 외과중환자실 7.5로나타났다. 이는 2008년 5월과 11월 19.7과 17.3으로감염의발생이특이적으로높아진것이확인되었고이로인해 MRSA active surveillance와감염률을낮추는노력이시행되었다. 2009년부터강화교육이후에순차적으로감염률이낮아지는것을관찰할수있었다. 2012년환자일수 1000일당감염률은신경외과중환자실 4.5, 내과중환자실 3.9, 외과중환자실 3.5로감소된양상을볼수있었으며 5개년간감소율을대략적으로볼때감시체계의관리와강화교육이감소율과관계가있다고생각되었다. Conclusion: 중환자실내감염은최근많은연구, 교육및관리가시행되지만현재까지도발생률이 10-50% 까지다양하게보고되고있다. 특히신경외과중환자실의환자들은질환의특이도로인해서타중환자실과감염률이다르게나타나기도한다. 이의예방및감소를위해감염관리를지속적인분석과교육이시행되어야할것으로생각된다. have been reported to suppress GI motility and inhibit gastric emptying. We compared the anti-spasmodic effect and therapeutic efficacy of dexmedetomidine and propofol during ESD. Method: 59 patients scheduled for ESD were randomized to receive dexmedetomidine or propofol. Reminfentanil was infused continuously at the rate of 6 μg/kg/h in both groups. In the dexmedetomidine-remifentanil (DR) group, a bolus dose of 0.5mcg/kg dexmedetomidine was injected intravenously for 5 minutes before the start of the procedure, and continuous infusion dose of 0.3-0.7mcg/hr/kg was started. In the propofol-remifentanil group(pr group), a bolus injection of 0.5 mg/kg of propofol was followed by a continuous infusion at a rate of 30 μg/kg/min. The easiness of advancing the scope and procedure, sedation level and motility grading were evaluated. Results: Demographic data were comparable between the groups. During the sedation, there were no differences in MOAA/S sedation scale and vital signs except lower heart rate in DR group. Advancing the scope was easier in PR group (endoscopists answer very easy 17 vs. 7, P=0.01), and GI motility was more suppressed in DR group (endoscopists answer minimal 28 vs. 22, P=0.013). More endoscopists felt the procedure was facilitated in DR group (endoscopists answer easy 29 vs. 26, P=0.042). Conclusions: This study showed that dexemedetomidine could suppress GI motility and be helpful to facilitate ESD comparing to propofol. Key words: dexmedetomidine, gastric peristalsis, endoscopy Key words: Neurosurgery, ICU, infection O2-5 Effect of dexmedetomidine on gastric peristalsis during endoscopic submucosal dissection Namo Kim 1, Young Chul Yoo 1,2, Sungwon Na 1,2, Kyung Tae Min 1,2 1 Department of Anesthesiology and Pain Medicine, 2 Anesthesia and Pain Research Institute, Yonsei University College of Medicine Introduction: Suppressing gastric peristalsis is important in endoscopic submucosal dissection (ESD). Recently, dexmedetomidine O2-6 Changes in plasma lipid profile of critically ill patients are associated with prognosis 88
Oral Sang Hoon Lee 1, Byung Hoon Park 1, Kyung Soo Chung 1, Won Jai Jung 2, Song Yee Kim 1, Eun Young Kim 1, Ji Ye Jung 1, Young Ae Kang 1, Young Sam Kim 1, Se Kyu Kim 1, Joon Chang 1, Moo Suk Park 1 1 Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Disease, Yonsei University College of Medicine, 2 Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Korea University College of Medicine Background: Despite many studies and an improved standard of care, sepsis remains a critical disorder with high mortality rate. Sepsis is accompanied by severe metabolic alterations including lipid profiles. In previous studies, lipoproteins have shown to play a important role in modulating inflammation. Objects: To investigate whether disorders of lipid metabolism are associated with worse disease activity and mortality. Method: We evaluated 117 patients with sepsis (65 survivors and 52 non-survivors) who were admitted to the intensive care unit of a university-affiliated hospital in Korea. Serum levels of cholesterol, triglyceride (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), free fatty acid (FFA), and apolipoprptein (apo) A-1 were measured on day 0, 1, 3, 7. Patients with previously used statin or steroids, lipid diseases, and liver diseases were excluded in this study. Results: Compared with the survivors, patients who died within 28 days, showed significantly higher SOFA score. Non-survivors displayed low serum level of cholesterol, TG, HDL, LDL, and apo A-1 on day 0, 1, 3, 7. In linear mixed model analysis, the variation in TG, LDL, FFA and apo A-1 levels between groups over time was significantly different (p = 0.043, 0.020, 0.005, and 0.015, respectively). There were no significant differences over time in the cholesterol, and HDL between groups. In multivariate analysis, TG level and SOFA scores were associated with mortality (p = 0.018 and 0.008, respectively). Conclusion: Our study showed that nutritional TG level was associated with mortality in ICU patient with sepsis. This may be due to alterations in the metabolism of serum lipids during sepsis modulating the host response to inflammation in critical illness patients. Further large scale studies are needed to demonstrate role of lipid metabolism in sepsis. Key words: lipid, sepsis, prognosis O2-8 Low Caloric Intake in Orthotopic Liver Transplantation: A New Concept Using Graft Weight 경규혁, 이승규 1, 남창우 2, 나양원 2 울산대학교의과대학울산대학교병원권역외상센터, 외과학교실 2, 서울아산병원외과학교실 1 Background: Recipients of orthotopic liver transplantation (OLT) are in a high risk for a critically ill condition. In the area of critical care medicine, it has been widely accepted that low-caloric intake is associated with better outcomes in the acute period. Though variable factors are correlated with early graft function (EGF) after OLT, caloric supplement is not under consideration in the early postoperative period. Patients and Methods: We conducted a retrospective study to investigate the correlation between caloric intake and EGF between January 2010 and December 2013. Patients were divided into 2 groups according to their caloric intake until 72 hours after OLT: low caloric (LC) (<20kcal/kg/day) versus eucaloric ( 20kcal/kg/day) group. EGF was measured by aminotransferase, bilirubin, international normalized ratio (INR) and by the model for end-stage liver disease score at postoperative days (POD) 0, 3 and 7. The variable affected by the amount of calories was compared to identify the superiority between calorie-body weight ratio (CBWR) and calorie-graft weight ratio (CGWR). Results: Of 40 patients were 32 patients in the LC group. INR on POD 3 was significantly low in the LC group (1.08 ± 0.13 versus 1.25 ± 0.23, P = 0.012). CGWR showed better correlation than CBWR on INR on POD 3 (r = 0.27, P = 0.09 versus r = 0.388, P = 0.013). Conclusion: Low caloric intake has a beneficial effect on the restoration of EGF and large studies are needed to establish a new concept of CGWR. Key words: low caloric intake, liver transplantation, early graft function O2-9 간이식수술전후 Cl 농도가수술후급성신손상발생에미치는영향 민세희, 이한나, 류호걸 서울대학교의과대학마취통증의학교실 연구배경 : 급성신장손상은간이식환자에게발생하는흔한합병증중하나로, 그발생률은정의에따라 17-95% 까지다양하기나타난다. ORAL 89
급성신손상발병의위험요인은수술중실혈, 저혈압, 패혈증의발생, calcineurin inhibitor 유도혈관수축등다양하게존재하며, 환자에게선존한간신증후군, 감염또는혈량부족등의전신상태가영향을미칠수있다. Cl은인체내에서산- 염기평형에관계하는중요한이온으로, 혈중 Cl의양은신장에의해조절되어진다. 수술중발생한고염소혈증은대사성산증을유발하며, 이로인해신장내혈관수축이유도되고, 결과적으로사구체여과율감소와소변량감소를초래한다는연구는이미보고되었다. 그럼에도불구하고현재간이식환자에서수술전후혈중 Cl 농도가급성신손상의발생에미치는영향및그상관관계에대한연구는미미한실정이다. 수술전, 후혈중 Cl 농도와간이식수술후급성신손상발생의상관관계를후향적연구를통해검증하고자한다. 대상및방법 : 2010년 7월부터 2012년 12월까지간이식수술을시행받은성인환자를대상으로수술전과수술후 72시간까지 chloride 농도의 time weighted average (TWA) 를기준으로 Cl 101 미만, 101-110, 110 이상의 3군으로나누어 RIFLE criteria 정의에따른급성신손상의연관성을분석하였다. 또한급성신손상여부에따라환자들을분류하여급성신손상의위험인자들을회귀분석을통하여도출하고자하였다. 결과및결론 : 총 363명의간이식환자중급성신손상이발생한환자는 86명 (23.7%) 이었다. TWA Cl 기준으로나눈 3군사이에급성신손상의발생률차이는유의하지않았다 (p=0.85). 급성신손상의위험인자를추출하기위한단변수분석에서추출된요인들 (total bilirubin, prothrombin time, Chronic kidney disease, sex, donor type, HBV 유무, HCC 유무, 신대체요법사용유무등 ) 과 TWA Cl을포함하여변수선택법 (stepwise) 을사용한다변수회귀분석을시행한결과 MELD score (1.037 [1.006, 10.68], p=0.0174), deceased donor (2.746 [1.515, 4.987], p=0.0009) 수술전신대체요법사용 (21.918 [4.459, 107.738], p=0.0001) 등이위험인자로확인되었다. 간이식수술을받는환자에서수술전후의 Cl 농도는수술후급성신손상에영향을미치지않는것으로보인다. Key words: 급성신손상, 간이식 O2-10 10kg 미만의영아에서시행한지속적신대체치료의조기경험 조화진 2, 양은미 2, 김도완 1, 김선미 3, 김애영 3, 정인석 1 전남대학교병원흉부외과 1, 전남대학교병원소아청소년과 2 전남대학교병원외과계중환자실 3 연구배경 : 소아환아에서발생한급성신손상의치료에있어서지속적신대체치료는사용빈도가증가되고있으며신생아에서도활발 하게적용되고있다. 본연구는 10kg미만의영아에서시행한지속적신대체치료의초기경험를보고하고자한다. 대상및방법 : 전남대학교병원에서소아지속적신대체치료를시작한 2012년 10월 25일부터 2013년 12월 31일까지 14개월동안신대체치료를시행한소아환아 21명중에서치료당시체중이 10kg 미만인 11명영아의의무기록을후향적으로분석하였다. 결과 : 치료당시나이와체중의중앙값은 5개월 (2일 ~16개월 ), 4.8kg (2.2~10kg) 였다. 치료의원인은개심술후발생한급성신부전 (7명) 과패혈증 (1명), 선천성신무형성증 (1명), 중증폐동맥고혈압 (1명), 용혈성요독중후군 (1명) 이였다. 신대체치료를지속한시간의중앙값은 59시간 (10~285시간) 이였으며, 7명의환아에서는별도의카테타삽입을시행하지않고체외막형산화장치회로에연결하여치료를시행하였다. 신대체치료를위해별도의카테타삽입을시행한 4 명의환아에서 ( 우측경정맥 : 2명, 대퇴정맥 : 2명 ) 카테타삽입과관련되어발생한합병증은 1명의환아에서일시적인하지허혈증상이있 었다. 7명 (64%) 의환아에서신대체치료의이탈이가능했고 5명 (45%) 에서생존하여퇴원하였다. 결론 : 일개병원의초기경험이지만 10kg 미만의영아에서시행한신대체치료의결과는아직만족스럽지않았다. 하지만신생아와조기영아에서기존의약물치료에반응을보이지않은급성신손상이발생한경우지속적신대체치료의적용은적합한치료방법이라생각한다. Key words: 소아, 지속적신대체치료 O3-1 Predictors of prolonged ventilator weaning after lung transplantation: the role of body mass index Min Jeong Lee, Sarah Soh, Hyun Jeong Lee, Hyo-Chae Paik 1, Moo Suk Park 2, Sungwon Na Department of Anesthesiology and Pain Medicine, Severance Hospital Department of Chest Surgery, Severance Hospital 1, Division of Pulmonary, Severance Hospital 2 Introduction: Weaning from mechanical ventilation is difficult at ICU. Many controversial questions are remained concerning to the predictors of weaning failure. This study investigated the characteristics of lung transplantation patients in terms of prolonged weaning after lung transplantation. Methods: This study retrospectively investigated the medical records of 17 lung transplantation patients from Oct 2012 to Dec 2013. Patients who were able to wean from mechanical ventilation in 8 days after the surgery were assigned to early group and the rest of patients 90
Oral were assigned to delayed group. Patients intraoperative and postoperative characteristics were collected and analyzed as well as conventional weaning predictors including rapid shallow breathing index (RSBI). Results: The results of early group showed that they had significantly shorter period of stay at ICU as well as in the hospital. This group had apparently higher Body mass index and body surface area (p = 0.004, p=0.023). In addition, less reopen cases were occurred for early group than delayed group (1/9 vs. 5/8, p = 0.05). During spontaneous breathing trial, tidal volume and arterial oxygen tension was significantly higher for early group, but RSBI and respiratory rate could not reach to statistical significance. Conclusion: Low body mass index could be associated with delayed weaning in lung transplantation patients. In Addition, instead of RSBI and RR, tidal volume may be a better predictor for ventilator weaning after lung transplantation. Key words: Lung transplantation, mechanical ventilation, weaning, body mass index O3-2 중환자실환자의섬망과사망률, 재실기간및입원기간의상관관계 손정현 1,2, 신증수 3, 라세희 3, 손인정 1,2, 오주영 1,2, 안지선 2, 박진영 1,2 1 연세대학교의과대학정신과학교실, 강남세브란스병원정신건강의학과, 2 연세대학교의과대학의학행동과학연구소, 3 연세대학교의과대학마취통증의학교실 ORAL 연구배경 : 섬망증상은중환자실재원환자에서질병의심각성과다중성, 정신약물의집중적사용, 인구학적특성등으로인해높은빈도로나타나며, 퇴원시사망률및중환자실재실기간, 총입원기간에도영향을미치는것으로보고되어왔다. 현재까지국내에서관련연구가활발하지않았던바, 본연구는이러한고찰을위해중환자실환자에서섬망유무에따라퇴원시사망률, 중환자실재실기간, 총입원기간의차이가있는지알아보고자하였다. 대상및방법 : 2013년 3월부터 2013년 9월까지강남세브란스병원중환자실에입실한환자총820명 ( 평균연령 60.45세, range 10~93세 ) 중재원기간 90일이상이거나의사소통이불가능한환자 ( 혼수그룹포함 ) 를제외한 598명이분석에포함되었다. 중환자실간호사가일 2 회이상 CAM-ICU를적용해환자전수의각성및의식수준을평가 91
하였으며, 이를토대로정신건강의학과의사가일 1회 정상, 섬망상태, 혼수상태 여부를판정하였다. 재실기간내내 혼수상태 로평가된환자는 혼수그룹, 1회이상 섬망상태 로평가된환자는 섬망그룹, 이외에는 비섬망그룹 으로정의하였다. 섬망그룹 과 비섬망그룹 간의사망률, 중환자실재실기간, 총입원기간을종속변인으로서비교하는분석을시행하였으며, 성별, 연령, 수술여부, 질병심각성 (APACHE-II score) 를교란변수로서고려하였다. 결과 : 섬망그룹은재원중사망률 (Pearson correlation=14.918, p< 0.001), 중환자실재실기간 (t=9.818, p<0.001), 입원기간 (t=6.410, p<0.001) 모두비섬망그룹에비하여유의하게증가해있는결과를보였다. 성별, 연령, 수술여부와질병심각성의영향을배제한후에도두그룹간유의미한차이는유지되었다 (p=0.025, p<0.001, p<0.001). 결론 : 본연구에서섬망은교란변수에관계없이중환자실환자의임상적결과에영향을미치는것으로나타났다. 섬망은중증환자의독립적예후인자로알려져있으나현재까지중환자실재원환자대상의연구가활발하지않았던바, 이러한점에서본연구의의의가있다. 섬망의원인이되는약물과그외예측인자, 섬망의아형에따른예후와의상관성, 통증및불안과의상관관계등이추후연구주제의탐색에고려되어야할것이다. Key words: 중환자실섬망, 사망률, 재실기간 O3-3 Outcomes of Unplanned Extubations in the Intensive Care Units A Lan Lee 1, Chi Ryang Chung 1, Jeong Hoon Yang 1,2, Kyeongman Jeon 1,3, Chi-Min Park 1,4, Gee Young Suh 1,3 1 Department of Critical Care Medicine, 2 Division of Cardiology, Department of Medicine, 3 Division of Pulmonary, Department of Medicine, 4 Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Background: Unplanned extubations of patients requiring mechanical ventilation in intensive care units (ICU) are associated with poor outcomes for patients and organizations. This study was performed to identify outcomes associated with unplanned extubation among patients receiving mechanical ventilation. Methods: Between January 2010 and December 2013, patients who noted unplanned extubation among all adult patients admitted in ICU who required mechanical ventilation were included in the study. The person who found the incident first were noted the cause of the incident and its impact on the course of the patient s illness. Results: The rate of unplanned extubation was 0.88% of all patients admitted in ICU. Of them, the incident noted 75.3% in medical ICU and 24.7% in surgical ICU. The male patients were dominant in the incident (74%). The incidences of self-extubation were 96.3% while the rest patients were accidentally extubated. There were noted 2 cases with cardiac arrest combined respiratory arrest after unplanned extubation. However, patients treated just 2L/min oxygen apply after unplanned extubation were noted in almost half of all incident. The critical courses of the patient s illnesss requiring CPR or re-intubation were more shown in self-extubated than accidental extubated patients (47.8% vs 25%, respectively). The majorities of patients experienced unplanned extubation were stable vital status (71.6%), and using sedative and no restrain (69.3%, 60.5%). Conclusions: Of patients experienced unplanned extubations in ICU, self-extubated patients were more frequent and developing severe clinical courses. Key words: Unplanned extubation, Intensive care unit O3-4 The feasibility of ocular ultrasonography for increased intracranial pressure in adult patients 전진수 1, 류호걸 2, 이한나 2 서울대학교의과대학신경외과학교실 1, 서울대학교의과대학마취통증의학과학교실 2 Rapid monitoring of increased intracranial pressure (IICP) with non-invasive tool can be advantageous for patients who require serial assessment or were not suitable for transfer. Previous studies have shown that optic nerve sheath diameterover 5mm using an ocular ultrasonography is useful for the detection of IICP in a Caucasian population-based cohort. However, cut-off point value which optimally stratifies IICP has not been studies in Korean population. In this study, we present our experience with ocular ultrasonography to detect IICP in adult patients suffering from traumatic brain injury, tumor or hemorrhage with conventional radiologic methods such as MRI or CT as the reference. In addition, we also present the cut-off value for defining IICP. Key words: increased intracranial pressure, optic nerve sheath diameter, ultrasonography 92
Oral suppression pattern (5 patients), low voltage pattern (3 patients). Eights (21%) patients had periods of seizure activity. Five (13.5%) patients who shown the burst suppression and low voltage pattern had severe neurologic complications at discharge period. Conclusions: Continuous cerebral monitoring with the aeeg provides the simplified information. The aeeg is feasible for bedside neuromonitoring during ECMO support in both pediatrics and adults. Key words: ECMO, Neuromonitoring, aeeg O3-6 O3-5 Continuous cerebral monitoring with amplitude-integrated electroencephalography during ECMO support Hwa Jin Cho 2, Kyung Woon Jeung 3, Do Wan Kim 1, Sun Mi Kim 4, Ae Young Kim 4, In Seok Jeong 1 1 Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, 2 Department of Pediatrics, Chonnam National University Hospital, 3 Department of Emergency medicine, Chonnam National University Hospital, 4 Surgical Intensive Care Unit, Chonnam National University Hospital Introduction: It is well known that the amplitude-integrated electroencephalography (aeeg) provides the useful information for neonatal encephalopathy. The aim of this study is to determine the efficacy of aeeg for identifying the brain injury during extracorporeal membrane oxygenation (ECMO). Methods: We retrospectively reviewed data of 37 subjects who had bedside aeeg monitoring and who were survived to discharge after ECMO support from Janurary 1, 2012 to December 31, in Chonnam National University Hospital. We collected the data including patient demographics, clinical details of ECMO courses, and data of aeeg monitoring. Results: A median age was 57 years (range, 2 days to 79 years), and a median length of ECMO therapy was 78 hours (range, 6 to 529 hours). Twelve patients (32%) received the extracorporeal cardiopulmonary resuscitation. The following findings of four voltage classifications were found in initial aeeg findings: continuous normal pattern (11 patients), discontinuous pattern (8 patients), burst Conventional direct and video laryngoscope at intubation during cardiopulmonary resuscitation Dong Hyun Lee, Myongja Han, Ji young An, Ji young Jung, Younsuck Koh, Chae-Man Lim, Jin Won Huh, Sang-Bum Hong Department of Pulmonary and Critical Care Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea Background: Although tracheal intubation is mandatory in patients with cardiopulmonary resuscitation (CPR), it is a high-risk procedure even for the skilled operators. Recently developed video laryngoscope visualizes pharyngeal structure and allows easy and safe tracheal intubation. However, the efficacy of video laryngoscope in CPR has not been evaluated. Methods: Patients who were intubated during CPR between January 2011 and December 2013 were reviewed. Initial intubation trial using conventional direct laryngoscope and video laryngoscope were compared. Results: Total 238 patients were intubated during unexpected CPR. Mean age was 62.7 years and 156 patients (65.5%) were male. Direct laryngoscope was used in 112 patients (47.1%) and video laryngoscope in 122 patients (51.3%) as initial method. Patients were successfully intubated with single trial in 59 patients (52.7%) with direct laryngoscope and 87 patients (71.3%) with video laryngoscope (p=0.004). Medical specialists showed significantly higher success rate at first trial compared with residents (72.5% versus 52.6%, p=0.002). Patients failed at initial intubation trial exhibited significantly longer time of intubation (3.8 ± 4.0 min versus 1.3 ± 0.9 min, p<0.001) and higher incidence of procedure-related complication (17.2% versus 4.7%, p=0.002). However, the mortality at 28 days did not show significant difference (66.9% versus 67.0%, ORAL 93
p=1.000) Conclusion: Use of video laryngoscope in patients under unexpected CPR showed significantly higher success rate of intubation in single trial. Key words: intubation, cardiopulmonary resuscitation, laryngoscopes O3-7 Predictors of Neurologic Outcome after Successful Extracorporeal Cardiopulmonary Resuscitation Jeong-Am Ryu 1, Yang Hyun Cho 2, Kiick Sung 2, Seung Hyuk Choi 3, Jeong Hoon Yang 1,3, Jin-Ho Choi 4, Ji-Hyuk Yang 2 1 Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, 2 Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, 3 Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, 4 Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Background: Extracorporeal membrane oxygenation (ECMO) has been used for refractory cardiogenic shock and respiratory failure. Extracorporeal cardiopulmonary resuscitation (E-CPR) refers to use of the ECMO in cardiopulmonary arrest. Although E-CPR will increase survival rate, it may also increase the number of patients with poor neurologic status. Thus, we investigated predictors of good neurologic outcome after successful E-CPR. Methods: This study is retrospective cohort study. From May 2004 to June 2013, a total 227 patients underwent E-CPR at Samsung Medical Center. Successful E-CPR was defined when a patient was alive over 24 hours after E-CPR. After excluding 90 out of 205 successful E-CPR patients whose neurologic outcome could not be obtained, 115 patients were included in the study. Neurologic outcome was assessed at the time of discharge using the Glasgow-Pittsburgh Cerebral Performance Categories scale (CPC). CPC 1 and 2 were classified to a good neurological outcome, whereas CPC 3, 4, and 5 were considered as poor neurological outcome. Results: Mean age was 54±18 years. Eighty patients (70%) were male. CPR was performed from non-hospital area in17% (19 cases). Bystander CPR performed in 9 (47%) of 19 cases; cardiac etiology was verified in 76 (66%). Hypothermia was performed in 10 cases (5%).The 68 patients (59%) had good neurologic outcome and the 47 patients (41%) did not. Multivariate analysis revealed the neurologic outcome was affected by the level of hemoglobin (p=0.012) and serum lactic acid (p<0.001) before ECMO insertion and CPR to ECMO interval (p=0.011). Conclusions: The level of hemoglobin, serum lactic acid before ECMO insertion, and CPR to ECMO interval were important for the neurologic outcome after successful E-CPR. Early institution of ECMO and liberal blood transfusion may improve neurologic outcome of patients who survived from E-CPR. Key words: ECPR, neurologic outcome, predictor O3-8 Developing a Risk Prediction Model in Cardiac Arrest Patients who Undergo ECMO 양정훈, 박성범, 조양현 1, 정치량, 박치민, 전경만, 서지영 성균관대학교의과대학중환자의학과, 흉부외과 1 Background: Limited data are available on a risk model for survival to discharge after extracorporeal membrane oxygenation (ECMO)- assisted cardiopulmonary resuscitation (ECPR). We develop a risk prediction model for survival to discharge in cardiac arrest patients who undergo ECMO. Method: Between January 2004 and December 2012, 505 patients supported by ECMO were enrolled in a retrospective, observational 94
Oral registry. Among those, we studied 152 adult patients with in-hospital cardiac arrest. The primary outcome was survival to discharge. A new predictive scoring system, named the ECPR Score, was developed to monitor survival to discharge using the β coefficients of prognostic factors from the logistic model, which were internally validated. Results: In-hospital death occurred in 104 patients (68.4%). In multivariate logistic regression, age 66, shockable arrest rhythm, CPR to ECMO pump-on time 38 minutes, post-ecmo arterial pulse pressure > 24 mmhg, and post-ecmo Sequential Organ Failure Assessment Score 14 were independent predictors for survival to discharge. Survival to discharge was predicted by the ECPR Score with a c-statistic of 0.8595 (95% confidence interval [CI], 0.80-0.92; p < 0.001) which was similar to the c-statistics obtained from internal validation (training vs. test set; c-statistic, 0.86 vs. 0.86005; 95% CI, 0.80-0.92 vs. 0.77-0.94). The sensitivity and specificity for prediction of survival to discharge were 89.6% and 75.0%, respectively, when the ECPR Score was > 10. Conclusion: The new risk prediction model might be helpful for decisions about ECPR management and could provide better information regarding early prognosis. (a=plimit 40cmH2O, b=plimit 50cmH2O, c=plimit 60cmH2O). the tidal volume (Vt) and the peak airway pressure (Ppeak) were measured using a flow analyzer. The ventilation adequacy was determined when the Vt was in the range of 400~600 ml and the Ppeak was 50 cmh2o or lower. The significance level was set at a p-value < 0.05. Results: In model 1, there was the difference in the Vt and the Ppeak among the self-inflating bag resuscitator and ventilators but within an appropriate range. In model 2, When the self-inflating bag resuscitator was used during chest compression, adequate Vt and Ppeak levels were observed at 17%, and the Ppeak adequacy was 20% and the Vt, 65%. In the two types of mechanical ventilators, the adequate Vt and Ppeak levels were 79% and 26%; the Ppeak adequacy, 79%/70%; and the Vt adequacy, 100%/52%, respectively, at 50 cmh2o of Plimit. Conclusion: Comparison of self-inflating bag resuscitator, we do not found any inferior qualities of mechanical ventilator for ventilation during chest compression. A patient who is performed endotracheal intubation can be resuscitated by mechanical ventilator in case of cardiac arrest. Key words: cardiopulmonary resuscitation, extracorporeal membrane oxygenation, predictor Key words: cardiopulmonary resuscitation, ventilator, peak airway pressure, tidal volume, pressure limit O3-9 O3-10 The adequacy of ventilator as a method to ventilation during cardiopulmonary resuscitation Hong Joon Ahn, Kun Dong Kim, Joon Wan Lee, In Sool You, Seung Ryu Department of Emergency Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine Background: In cases of in-hospital cardiac arrest patients, endotracheal intubation has been conducted, or mechanical ventilator has been used. However, when unexpected cardiac arrest occurs to those patients, there are no guidelines have been established yet. In this study, the adequacy of ventilators to cardiopulmonary resuscitation (CPR) in cardiac arrest cases is investigated. Methods: With using one type of self-inflating bag resuscitator and two types of ventilators, two groups were tested in this study: the experiment Model 1 (CPR manikin without chest compression) and the experiment Model 2 (CPR manikin with chest compression). And model 2 was divided into three subgroups by ventilator pressure limit Weekend versus weekday hospital death in adult patients receiving ECPR Dae-Sang Lee 1, Yang Hyun Cho 2, Kiick Sung 2, Chi Ryang Chung 1, Chi Min Park 1,3, Kyeongman Jeon 1,4, Gee Young Suh 1,4, Jeong Hoon Yang 1,4 Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine 1 ; Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine 2 ; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine 3 ; Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine 4 Background: Extracorporeal cardiopulmonary resuscitation (ECPR) requires urgent decision and high quality skills, which may not be uniformly available throughout the week. We investigated the weekendeffect on in-hospital mortality in patients who underwent ECPR. Methods: Between May 2004 and December 2012, we examined 152 adult patients undergoing extracorporeal cardiopulmonary resuscitation in hourly time segments, defining weekend as 23:00 on Friday to ORAL 95
6:59 on Monday, and day/evening as 07:00 to 22:59, night as 23:00 to 6:59. The primary outcome was survival to discharge. Results: A total of 111 ECPR cases of in-hospital cardiac arrest occurred during weekdays (including 93 on day/evening hours and 18 on night hours), and 41 cases occurred during weekends (including 35 on day/evening hours and 6 on night hours). CPR to ECMO pump-on time on weekends was significantly longer than that on weekdays (51.7 ± 29.0 vs 37.8 ± 22.5, p = 0.002) and the incidence of limb ischemia was also significantly higher in ECPR on weekends (19.5% vs 7.2%, p = 0.038). Survival to discharge was not different between weekday and weekend (34.2% vs 24.4%, p=0.247). Furthermore, the rates of survival to discharge were not significantly different between day/evening hours and night hours in patients with cardiac arrests during weekdays (36.6% vs 22.2%, p = 0.241) and during weekends (25.7% vs 16.7%, p = 0.633), respectively. Conclusion: ECPR on weekends was related not only numerically low survival rate but also low resuscitation quality, such as longer CPR to ECMO time and higher limb ischemia, although survival to discharge was not statistically difference between weekdays and weekends. Our findings suggest that rapid response ECMO team with 24 hours per day, 7 days per week onsite staffing would be needed to improve the outcomes in the setting of ECPR. Key words: cardiopulmonary resuscitation, extracorporeal membrane oxygenation, weekend O4-1 Extracorporeal life support as a bridge to heart transplantation: Importance of organ failure in recipient selection Yang Hyun Cho 1, Dong SeopJeong 1, Kiick Sung 1, Pyo Won Park 1, Wook Sung Kim 1, Young Tak Lee 1, Eun-SeokJeon 2 1 Department of Thoracic and Cardiovascular Surgery, 2 Department of Internal Medicine, Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Background: The aim of the study was to investigate the utility of comprehensive scoring systems of organ failure compared with the duration of extracorporeal life support (ECLS). Methods: From November 2004 to August 2013, 25 adult patients ultimately underwent heart transplantation while they were on ECLS. We did not include patients who were younger than 18 years old or patients with extracorporeal ventricular assist devices. Results: There were seven patients (28%) who died within one year after transplantation. The areas of under curve of the sequential organ-failure assessment (SOFA) and the model for end-stage liver disease score modified by the United Network for Organ Sharing (MELD UNOS) scores were 0.794 (95% confidence interval: 0.590 ~0.930) and 0.825 (95% confidence interval: 0.586~0.928), respectively. The estimated 1-year survival rate of patients with MELD UNOS scores > 24 and 24 were 33% and 91%, respectively, and their survival curves were significantly different (Log rank p = 0.001). Conclusion: The duration of ECLS may not be an independent predictor of poor outcomes of heart transplantation. The MELD UNOS score seems to be more prognostic than the duration of ECLS. Key words: heart transplantation, extracorporeal membrane oxygenation, organ failure O4-2 Impact of extracorporeal membrane oxygenation in adult patients with refractory septic shock Taek Kyu Park 1, Jeong Hoon Yang 1,2, Seung-Hyuk Choi 1, Jin-Ho Choi 1, Hyeon-Cheol Gwon 1, Chi Ryang Chung 2, Chi Min Park 2, Kyeongman Jeon 2, Yang Hyun Cho 3, Kiick Sung 3, Gee Young Suh 2 1 Division of Cardiology, Department of Medicine, 2 Department of Critical Care Medicine, 3 Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Background: Although extracorporeal membrane oxygenation (ECMO) has been considered an important alternative in pediatric patients with refractory septic shock, role of ECMO in adult patients remains controversial. We sought to describe the clinical outcomes of adult patients supported by ECMO during refractory septic shock unresponsive to conventional treatment. Methods: We analyzed consecutive adult patients with refractory septic shock, assisted by ECMO system between January 2004 and December 2013 in a retrospective, observational registry. The primary outcome was in-hospital mortality. Results: A total of 32 patients (22 males) were implanted ECMO for refractory septic shock. Of these, 14 patients (43.8%) had received cardiopulmonary resuscitation (CPR) at ECMO implantation. ECMO were weaned off successfully in 13 patients (41%) after 4 (3-6) days, but 8 patients (25%) survived to hospital discharge. The 96
Oral non-survivor group had a high peak lactate (15.1 vs. 8.4 mmol/l, p = 0.03), high SOFA day 3 score (19 vs. 16, p = 0.02), and low peak troponin I (3.4 vs. 24.5 ng/ml, p = 0.04) compared with the survivor group. All patients (31.3%) in whom ECMO was initiated over 30.8 hours after onset of septic shock died. Patients with CPR had a higher rate of all-cause death than those without CPR during follow-up period (p = 0.02). Conclusions: In-hospital mortality of adult patients with refractory septic shock remains high in spite of ECMO support. Our findings suggest that the implantation of ECMO might be considered in highly selected septic patients without prolonged shock period or not received CPR. Key words: septic shock, extracorporeal membrane oxygenation O4-3 Vancomycin pharmacokinetics in patients undergoing extracorporeal membrane oxygenation Results: A total of 20 patients were included (age 50.1 ± 16.2, 17 males). Sixteen patients (80.0%) received first dose of 1.0 g intravenously followed by 1.0 g/12 h. Non steady state vancomycin trough levels after starting administration were subtherapeutic in 19 patients (95.0%). Vancomycin clearance was 1.27 ± 0.51 ml/min/kg, vancomycin /creatinine clearance ratio was 0.90 ± 0.37 and elimination rate constant was 0.12 ± 0.04 h-1. Vancomycin dosing frequency and daily dose were significantly increased after clinical pharmacokinetic service of pharmacist (2.1 ± 0.72 vs. 2.9 ± 0.97, p = 0.002 and 32.5 ± 8.4 vs.42.2 ± 14.6 mg/kg, p = 0.014, respectively). Conclusion: current dosing strategy of vancomycin was not enough to achieve target trough in initial period in most patients receiving ECMO, despite elimination rate for vancomycin was acceptable. These findings suggest that an increased initial vancomycin dosage would be needed for early achievement of the therapeutic target concentration in critically ill patients on ECMO. Key words: vancomycin, extracorporeal membrane oxygenation O4-4 So Jin Park 1, Jeong Hoon Yang 2,3, Hyo Jung Park 1, Yong Won In 1, Young Mi Lee 1, Yang Hyun Cho 4, Kiick Sung 4, Chi Ryang Chung 2, Chi Min Park 2, Kyeongman Jeon 2,5, Gee Young Suh 2,5 1 Department of Pharmaceutical Services, Samsung Medical Center, Seoul, Korea; 2 Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 3 Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 4 Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 5 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Background: Limited data are available on vancomycin pharmacokinetics in adult patients who undergo extracorporeal membrane oxygenation (ECMO). We investigated an appropriateness of current dosing strategy based on body weight and creatinine clearance in adult patients on ECMO. Method: Between March 2013 and November 2013, patients treated with vancomycin on ECMO were enrolled in a retrospective, observational registry. Among those, we excluded patients receiving a continuous renal replacement therapy and studied adult patients undergoing ECMO alone. Early trough levels were obtained within forth dosing and maintenance levels were checked at steady state. Pharmacokinetic data were then estimated using an Exact-fit method. 진단되지않은가와사키병에의한심장관련합병증으로발현된심정지 1 례 김재승, 김경수, 권운용, 서길준 서울대학교의과대학응급의학과교실 서론 : 가와사키병 (Kawasaki s disease) 은 5세이하의소아에게주로발생하는원인이명확히알려져있지않은중간크기의동맥을침범하는급성혈관염이다. 치료받지않은환자의 25% 에서심장관련합병증이발생하며, 전체환자의사망률은 0.1% 정도로보고되고있다. 저자들은급성심정지로내원하여심폐소생술후자발순환의회복을얻은뒤심혈관조영술을통해가와사키병에의한관상동맥합병증으로진단된환자를경험하였기에이를보고하고자한다. 증례 : 환자는기저질환없이건강하던 41세남자환자로내원당일목격된비외상성심정지로신고되어응급실로내원하였다. 목격자심폐소생술은시행되지않았으며, 심정지발생 5분뒤 119 구급대가도착하여자동제세동기에의한제세동이 1회시행되었다. 제세동이후무맥성전기활동으로심폐소생술지속하면서심정지발생 14분뒤응급실에도착하였다. 응급실도착시자발순환의회복이확인되었으나심정지발생 24분째에다시심실세동이발생하여 200J로제세동을시행한뒤자발순환이회복되었다. 2번째자발순환회복후심전도는전에없었던 II, III, avf lead 의최대 4mm의 q파와 T 분절의하강이관찰되었다. 이후환자는통증에반응이없는무의식상태로중환자실로입원하여 24시간저체온요법을시작하면서진단적심 ORAL 97
혈관조영술을시행하였다. 심혈관조영술에서 3개의관상동맥에걸친다발성동맥류와협착및좌관상동맥에서우관상동맥으로의측부혈행이관찰되었다. 이후내원 3일째재가온완료하고의식의회복을확인하였으며당일경피적관상동맥중재술을시행하여스텐트를삽입하였다. 좌측중대뇌동맥의비파열동맥류와흉부대동맥말단부의국소내막편외에다른혈관에서동맥류나협착은관찰되지않았다. 내원 10일째잔여신경학적장애없이 CPC 1으로퇴원하였다. Key words: Kawasaki, CPR, coronary them and In-hospital death occurred in 20 patients (80%). Initial rhythm was asystole in 7 patients (28%), pulseless rhythm in 7 patients (28%) and ventricular tachycardia/fibrillation in 11 patients (44%). The mean time of CPR to ECMO pump-on was 98.4 minutes (range: 30-420). Median duration of ECMO was 70 hours (range 0.5-501). Therapeutic hypothermia was performed in 4 patients (16%) and ECMO was successfully weaned in 7 patients (28%). Five in-hospital survivors were alive during follow-up period with a favourable neurologic outcome (4 patients with CPC score of 1 and 1 patient with CPC score of 2). Conclusion: Survival rate for ECPR in the setting of out-of-hospital cardiac arrest is very poor. Our findings suggest that ECMO implantation should be restricted following OHCA. Key words: cardiopulmonary resuscitation, extracorporeal membrane oxygenation, out-of-hospital O4-6 Over-Estimation of Cardiac Output after Reperfusion with Bioreactance-Nicom During Liver Transplant Ji Uk Yoon, Hyun Su Ri, In Yeob Baek O4-5 Clinical outcome after rescue ECPR for out-of-hospital cardi Tae Sun Ha, Jeong Hoon Yang 성균관대학교의과대학중환자의학과교실 Background: Extracorporeal cardiopulmonary resuscitation (ECPR) has been shown to have survival benefit in patients with in-hospital cardiac arrest. However, limited data are available on role of extracorporeal membrane oxygenation (ECMO) for out-of-hospital cardiac arrest (OHCA). Therefore, we aimed to investigate survival outcome after ECPR in patients with OHCA. Methods: From January 2009 to December 2012, 177 patients received ECPR were enrolled in retrospective, single-center, observational registry. Among those, we studied 25 adult patients with OHCA. The primary outcome was survival to discharge. Results: Among 25 patients, characterized median age 54.3 (±10.8) years and 21 male (84%), ECMO implantation was successful all of Department of Anesthesiology and Pain Medicine, Pusan National University Yangsan Hospital Introduction: Hemodynamic instability is common during liver transplantation. And so continuous cardiac output (CO) monitoring is important. Diverse CO measuring systems exist, and all systems have their own specialties based on technology of CO calculation. In these cases show the quality of CO measurement during reperfusion between CO monitoring systems. Case: In these 2 cases, 3 systems applied to recipient of liver transplantation for CO measurements; pulmonary artery catheter (PAC)/ Vigilance 2 system; FloTrac/Vigileo system; Bioreactance/Nicom system. CO Data of each system is acquired throughout surgery and data of reperfusion period is illustrated as figure 1 and 2. ( Data from download software which is supported by the manufacture ) Result & Conclusion: PAC/Vigilance 2 system and FloTrac/Vigileo system showed decrease in CO during reperfusion period however, Bioreactance/Nicom system showed increase in CO. The point at which reperfusion, CO may increase with central venous pressure and pulmonary artery pressure which is attributed to increase of venous return (preload). Following that point, CO can vary according to the 98
Oral changes of heart rate, mean arterial pressure, systemic vascular resistance and so on. In these cases, since PAC/Vigilance 2 system, as a gold standard, showed a decrease in CO, we consider the data of Bioreactance/Nicom system is overestimated. Bioreactance/Nicom system use their unique system called Bioreactance. Thoracic resistance elements and reactance elements can influence on Bioreactance as a variables. A graft preservation solution contains high electrolyte content and they can alter the thoracic resistance elements during graft reperfusion within seconds. So we conclude that Bioreactance/Nicom system can overestimate the CO after graft reperfusion and the cause of overestimation is graft preservation solution. Key words: cardiac output, hemodynamic monitoring 고려대학교의과대학마취통증의학과교실 1, 흉부외과교실 2, 의학전문대학원 3 The aim of this study was to determine whether pulsatile or non-pulsatile perfusion had a greater effect on renal dysfunction in randomized controlled trials. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were used to identify available articles published before Jan 10, 2014. A meta-analysis was conducted on the effects of pulsatile perfusion on postoperative renal functions such as creatinine clearance (CrCl), serum creatinine (Cr), the neutrophile gelatinase-associated lipocalin (NGAL) in urine, and incidence of acute renal insufficiency (ARI). Nine studies involving 674 patients who received pulsatile perfusion and 698 patients who received non-pulsatile perfusion during cardiopulmonary bypass (CPB) were considered in the meta-analysis. There was no significant difference on NGAL in both patients receiving pulsatile and non-pulsatile flow during CPB. However, patients receiving pulsatile perfusion had a significantly greater CrCl and lower Cr levels compared to those in patients receiving non-pulsatile perfusion at postoperative 24 h (p < 0.00001, both). The incidence of ARI was significantly lower in patients receiving pulsatile flow compared to those in patients receiving non-pulsatile perfusion (p < 0.00001). In conclusion, our meta-analysis suggests that the use of pulsatile flow during CPB results in better postoperative renal function. Key words: cardiopulmonary bypass, meta-analysis, pulsatile perfusion, renal function O4-8 이차성복막염으로응급수술을받은중환자에서사망과관련된인자분석 ORAL 장지영 1, 이승환, 심홍진 1, 김형원, 이재길 연세대학교의과대학외과학교실연세대학교원주의과대학외과학교실 1 O4-7 A Meta-Analysis of Renal Function with Pulsatile Perfusion in Cardiac Surgery 남명지 3, 김용휘 1, 김연희 1, 손호성 2, 선경 2, 이혜원 1, 임춘학 연구배경 : 복강내감염은지속적인중환자실관리및항생제의발전에도불구하고 10-20% 가량의높은사망률을보이며, 중환자실에서발생하는패혈증의원인중두번째를차지하는질환이다. 이러한환자들의사망과관련한인자에대한문헌은제한적이다. 이에이차성복막염으로응급수술을받고중환자실에입실하였던환자에서사망에영향을미치는인자에대하여분석하였다. 대상및방법 : 2007년 1월부터 2011년 12월까지, 세브란스병원에서이차성복막염으로응급수술을받고중환자실에입실한환자 338명을대상으로하였다. 환자의전자의무기록을후향적으로분석하였다. 결과 : 남자는 131명 (38.8 %), 평균나이는 62.8 세였으며, 중환자실 99
입실당시의 APACHE II 점수는 19.5점이었다. 수술전혈액배양검사를시행한 184명중 22명 (12 %) 에서균이동정되었다. 수술후쇼크는 107명 (31.7 %) 에서확인되었으며, 41명 (12.1 %) 의환자는재수술을시행받았다. 재원기간과중환자실입원기간은각각중앙값 20일, 3일이었다. 사망환자는 47명 (13.9 %) 이었다. 생존군과사망군을비교하였을때, APACHE II는각각 18.9점 23.8점으로유의한차이가있었으며 (p = 0.001), 면역억제환자는생존환자중 77명 (26.5 %) 과사망환자중 26명 (55.3 %) 으로유의한차이가있었다 (p < 0.001). 수술전혈액배양검사양성비율도두군간의차이가있었으며 (9.4 % vs 29.2 %, p = 0.005), 수술전혈색소와알부민수치의차이가확인되었다 (p = 0.002, p = 0.005). 사망환자에서수술후핍뇨발생률이 52.3 % 로생존환자의 11.8 % 보다유의하게높았다 (p < 0.001). 재수술율도사망환자에서 25.5 % 로생존환자에서의 10 % 보다의미있게높았다 (p = 0.002). 또한사망환자에서수술후폐렴, 흉수, ARDS 그리고급성신부전등의합병증의빈도가생존환자에서보다유의하게높았다 (p < 0.001, p = 0.001, p <0.001, p <0.001). 다변량분석을시행하였을때, APACHE II 점수 (OR 1.164), 수술전혈액미생물배양검사양성여부 (OR 44.979), 수술전면역억제 (OR 19.430), 그리고수술후핍뇨가 (OR 16.425) 사망과관련하여의미있는인자로확인되었다. 결론 : 수술전혈액배양양성과수술전면역억제여부가사망과관련된수술전인자였으며, 수술후인자중에서는핍뇨의발생이의미있는인자로확인되었다. Key words: secondary peritonitis, mortality, ICU O4-9 The anti-oxidation capacity change in traumatic hemorrhagic shock patients 김형원, 이승환, 장지영 1, 이재길 연세대학교의과대학외과학교실, 연세대학교원주의과대학외과학교실 1 Purpose: To evaluate the relation between the oxygen radical activity, anti-oxidation capacity and clinical severity of hemorrhagic shock in trauma patients. Design: Preliminary prospective observational study. Methods: Eleven patients with traumatic hemorrhagic shock were enrolled. Hemorrhagic shock was classified by the American College of Surgeons into 4 classifications. Patients were divided into two groups (group A: class I, II vs. group B: class III, IV). Using CR3000 (Callegari 1930, Italy), oxygen radical activity and anti-oxidation capacity were measured with peripheral blood. The measurement was performed on the day of arrival to emergency room, the 2nd day, and the 5th day of hospitalization. Patients characteristics such as injury severity score, revised trauma score, biochemical parameters and organ dysfunction scales were evaluated. Results: In-hospital mortality rate, APACHE II score, duration of mechanical ventilation, and length of ICU stay were significantly different between two groups (group A vs. group B). Median oxygen radical activities were significantly lower in group B than group A. However, group B showed higher median anti-oxidation capacities than group A. In group B, oxygen radical activity was increased over time significantly after trauma. Although anti-oxidation capacity was decreased steadily during the same period in group B, it was not statistically significant. Conclusion: Anti-oxidation capacity decreased over time in both groups after trauma, and sustained higher level in patients with severe hemorrhagic shock than those with mild traumatic hemorrhage. Contrary to expectations, oxygen radical activity of trauma patients with severe hemorrhagic shock was lower than those with mild traumatic hemorrhage. Key words: oxygen radical activity, anti-oxidant capacity, hemorrhagic shock O4-10 외상으로인해대량수혈을받은환자에대한임상적고찰 김호승, 김태현, 마대성, 금민애, 권수경, 노효근, 정윤중, 신성대, 홍석경 울산대학교의과대학외과학교실서울아산병원외상및중환자외과 목적 : 본연구는외상으로인해대량수혈을시행한환자의특징및예후와의관련성을찾고자구성되었다. 방법 : 2011년 1월부터 2013년 12월까지외상으로인해본원으로내원하여대량수혈 (24시간이내에적혈구를 10개이상투여 ) 을시행한환자를후향적으로조사하였다. 결과 : 총 52명의환자가포함되었으며, 평균나이는 46.8±19.6세, 남녀비율은 33:19, 평균 Injury Severity Score 는 45.4±22.3였다. 총수혈량은 52.7±47.2개였으며, 적혈구, 신선동결혈장, 혈소판은각각 23.9±18.3, 15.6±16.1, 13.1±16.2개였다. 주손상장기는뇌및목손상 11명 (21.2%), 흉부 5명 (9.6%), 복부 18명 (34.6%), 골반 12명 (23.1%), 사지 6명 (11.5%) 였으며, 각각의총수혈량은 44.8±21.7: 57.6±49.1:72.0±63.1:39.1±40.1:32.0±17.2였다. 총 28명 (53.9%) 이사망하였고, 재원일수, 중환자실재실일수, 인공호흡기치료일수는각각 24.7±27.2, 9.1±11.0, 8.3±10.4일이였다. 사망한환자에서 100
Oral 평균수혈량이많았으며, (P-value:0.003) 신선동결혈장대적혈구의비율을 1:1.5에따라두군으로나누었을때, 신선동결혈장을많이준군에서생존률이높았다.(P-value:0.043 OR:3.238) 하지만, 재원일수, 중환자실재실일수, 인공호흡기치료일수는수혈력과뚜렷한상관관계를보이지는않았다. 결론 : 최근대량수혈에대한많은연구가이루어지고있으며, 외상뿐만이아니라여러임상적상황에서대량수혈이고려되고있다. 본 연구는외상에의해대량수혈이필요한환자들을대상으로임상적특징및수혈력과생존률등을비교분석하였다. 이에대한이해는외상환자뿐만이아니라대량수혈이필요한중환자에서효과적인치료를위해활용될수있을것으로생각된다. Key words: 대량수혈, 외상, 예후 ORAL 101
April 26 (Saturday) 4 월 26 일 ( 토 ) Conference Room 1, 2, 3, 4, 5, 6 Poster Session
Poster P1-1 Facility Characteristics as an Independent Prognostic Factor of Nursing Home-Acquired Pneumonia Joo-Won Min 1, Che Wan Lim 1, Sang Joon Park 1, Hee-Jin Hwang 2, Jae Ho Chung 3 P1-2 중환자에서의반코마이신초기혈중농도분석 김문석 1, 임유진 2, 박가영 2, 전수정 2, 남궁형욱 2, 이은숙 2, 송경호 3, 박상헌 4 분당서울대학교병원중환자진료부 1, 분당서울대학교병원약제부 2, 분당서울대학교병원내과 3, 분당서울대학교병원마취통증의학과 4 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Myongji Hospital 1, Geriatric Center and Department of Family Medicine, Kwangdong University College of Medicine 2, Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Kwandong University College of Medicine 3 Objectives: Recently, nursing home-acquired pneumonia (NHAP) is increasing and the leading cause of death among nursing home residents. The objective of this study was to identify risk factors associated with the risk of NHAP mortality focused on facility characteristics. Setting: A total 297 patients with old-age pneumonia (118 patients with NHAP) Measurements: Data on all patients 70 years of age admitted with newly diagnosed pneumonia were collected. To exclude overt hospital-acquired pneumonia, patients with any current malignancy, end-stage renal disease undergoing renal replacement therapy, or advanced liver cirrhosis were excluded from the study. To compare the quality of care in nursing facilities, the following three groups were defined: patients who acquired pneumonia in (A) the community, (B) Care Homes, and (C) Care Hospitals. In these patients, 90-day mortality was compared. Results: In a survival analysis, 90-day mortality was higher in patients in Care Homes. When all 297 patients were included in the analysis, residence in a Care Home, cerebrovascular disease, and pneumonia accompanied by a UTI, but not age, were risk factors for mortality. Within the 118 NHAP patients, residence in a Care Home, structural lung diseases, and treatment with inappropriate antimicrobial agents for accompanying infections were risk factors. In both analyses, residence in a Care Home and a high PSI score, but not the infection by potentially drug-resistant pathogens (DRPs), were factors associated significantly with 90-day mortality. Conclusion: Unfavorable environmental factors in Care Homes, such as residence in a facility with fewer registered nurses and without a full-time physician, were important prognostic factors for NHAP. These pre-hospitalization factors should be considered in the design of future trials that aim to identify the optimum antimicrobial treatments. Key words: Nursing home, pneumonia, prognosis 연구배경 : 통상용법및용량의반코마이신투여시상당수의환자에서투약초기목표혈중농도달성이실패하는것으로알려져있어부하용량투여의필요성이제기되고있다. 그러나, 중환자에서의반코마이신투약초기혈중농도에대한자료는부족하다. 연구자들은중환자에서반코마이신초기혈중농도를예측- 분석하여부하용량필요성연구의기초자료를만들고자하였다. 대상및방법 : 2010년 1월부터 2013년 5월까지중환자실환자중반코마이신투여시작후용법및용량의변경없이임상약동학자문이의뢰된환자를연구대상으로하였다. 반코마이신혈중농도를바탕으로 Abbot Pharmacokinetic System v.1.10 프로그램을이용하여개별환자의약동학지표를계산하였으며, 혈중농도예측에는 Bayesian 법을이용하였다. 1회투약후다음투약직전의반코마이신혈중농도를 초기혈중농도 로정의하였고, 이값이 10ug/ml 이상인경우 목표혈중농도 에도달하였다고가정하였다. 결과및결론 : 연구대상환자는총 146명이었다. 반코마이신초기혈중농도가목표혈중농도이상인환자는 32명 (22%), 목표혈중농도미만인환자는 114명 (78%) 였다. 체중당투여량에따라 25mg/kg, 25-20mg/kg, 20-15mg/kg, <15mg/kg 투여군으로환자를분류하였을때, 평균초기혈중농도는각각 10.4±3.1ug/ml, 7.5±3.5ug/ml, 7.8±3.2ug/ml, 6.6±2.6ug/ml였으며, 목표혈중농도에도달한환자비율은각각 62.5%, 12.5%, 25.9%, 12.9% 였다. 투약당시의신기능저하여부와관계없이 25mg/kg이상투여군의경우에만평균초기혈중농도가목표혈중농도이상이었다. 본연구를통하여중환자에서통상적인용법및용량으로반코마이신투여를시작할경우조기유효혈중농도달성에실패할가능성이높음 ( 약 80%) 을알수있었다. Key words: 반코마이신, 약동학, 중환자 P1-3 Risk factors for nephrotoxicity in elderly critically ill patients receiving intravenous colistin Sung Eun Kim, A Jeong Kim, Yun Hee Jo, Hyeon Joo Hahn, Jinwoon Lee 1, Sang-Min Lee 1, Hyangsook Kim Department of Pharmacy, Seoul National University Hospital, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of POSTER 105
Medicine 1 Background: Colistin is an antimicrobial agent used to treat multidrug-resistant Gram-negative infections. The high rate of nephrotoxicity has been reported in patients treated with colistin. Elderly critically ill patients are potentially vulnerable to the development of adverse drug reaction. The aim of this study was to evaluate incidence and risk factors associated with development of nephrotoxicity in elderly critically ill patients receiving intravenous (IV) colistin. Methods: A retrospective study was performed over 42 months in 45 elderly ( 65 years of age) patients who had been treated with IV colistin 3 days in medical intensive care unit and had baseline creatinine (Cr) <1.3 mg/dl. Renal function was assessed on Day 7 and at the end of treatment (EOT). Severity of nephrotoxicity was defined by the RIFLE criteria with serum Cr level. Results: Twenty (44%) and twenty-nine (64%) patients developed nephrotoxicity on Day 7 and EOT, respectively. Patients who experienced nephrotoxicity were in the Risk (25%), Injury (25%), or Failure (50%) categories on Day 7 and in the Risk (28%), Injury (34%), or Failure (38%) categories on EOT. The logistic regression model showed that development of nephrotoxicity at EOT associated with baseline urinary output <1.4 ml/kg/hr and concomitant use of vasopressor. Conclusion: In elderly critically ill patients administered IV colistin, nephrotoxicity occurred at a high rate. Elderly patients especially who use vasopressor and have low baseline urinary output should be closely monitored when receiving IV colistin. Key words: Colistin, Nephrotoxicity, Elderly P1-4 중환자실에입실한중증인플루엔자감염환자에서주사제 peramivir 를사용에대한임상적경험 유정완, 허진원, 임채만, 고윤석, 홍상범 울산대학교의과대학서울아산병원호흡기내과 연구배경 : 중증인플루엔자감염환자에서치료제로경구용또는흡입용 neuraminidase 억제제를사용해왔었다. 2009 대유행인플루엔자 A (H1N1) 발생후부터국내에서주사용 neuramidase 억제제인 peramivir 사용이허가되었다. 중증인플루엔자감염의 peramivir의임상결과에대해서는국내에보고된적이없어, 저자들은한대학병원에서의중증인플루엔자감염에서의 peramivir의임상적경험을보고하고자한다. 대상및방법 : 2009년 12월부터 2014년 2월까지중증인플루엔자감염으로중환자실에 24시간이상입원한환자들을대상으로, 의무기 록을후향적으로분석하였다. 결과 : 총 48명의환자가등록이되었고, 평균연령은 62.9세였고, 남성이 54.2% 를차지하였다. 면역억제상태는 39.6% (19/48) 이었다. 42 명 (87.5%) 에서중환자입원당시폐렴이관찰되었다. 인플루엔자 A 형이 85.4% (41/48) 이었다. 평균 APACHE II 점수는 23.1이었다. 임상적합병증으로쇼크는 31명 (64.6%), 급성중증호흡곤란증후군은 26명 (54.2%) 에서발생하였다. 평균항바이러스제사용기간은 13 일이었고, Peramivir는평균 9.6일투여되었다. Peramivir 단독투여는 18명 (37.5%) 에서이루어졌고, 그외에는다른항바이러스제의병합요법이이루어졌다. 40명 (83.3%) 에서침습적기계환기가적용되었고, 39명 (81.3%) 에서승압제를사용하였다. 19명 (39.6%) 환자는혈액투석을받았고, 50% 에서스테로이드가투여되었다. 28일사망률은 41.7% (20/48), 중환자실사망률은 52.1% (25/48) 이었다. 결론 : Peramivir의투여기간은다양하였고, 2/3에서다른항바이러스제와병용을많이하였다. 중증인플루엔자감염으로중환자실에입원하여, 주사제 peramivir를사용함에도중환자사망률은높은경향을보여향후더임상적효과에대해서는추가연구가필요할것으로생각된다. Key words: 중증인플루엔자, 중환자사망률, peramivir P1-5 손위생이행률향상을위한개선활동이집중치료실병원감염률에미치는효과 : 단일병원의경험 김민수, 이창섭 1, 고경래, 김영림, 김홍주, 현혜연, 황주희, 김영숙, 김민정, 양은정, 김흥업 1 제주대학교병원외과계집중치료실, 제주대학교의학전문대학원의과학연구소 1 연구배경 : 병원감염률을낮추기위해서는적은병상수에비해많은감염이일어나는집중치료실의병원감염을낮추려는시도가필수적이다. 그리고병원감염률을낮출수있는가장간단하고효율적인방법이손위생관리라는것은이미잘알려져있다. 이에제주대학교병원외과계집중치료실에서 손위생이행률향상을위해기울인개선활동 ( 이하개선활동 ) 과그성과를보고하려한다. 대상및방법 : 제주대학교병원외과계집중치료실에근무하거나출입하는의료인 ( 의사, 간호사 ) 및의료보조인 ( 방사선사, 물리치료사 ) 을대상으로하여개선활동을하였고, 병원감염률과손위생이행률간의상관관계를조사하였다. 개선활동의내용은 1표준화된감염관리지침교육, 2손위생이행격려및모니터링지속, 3세면대 1대확충및자동수전시설로의교체, 4손소독제추가배치및사용, 5 격리환자관리관련물품사용수칙준수, 6일회용흡인관 (suction tip) 사용이었다. 병원감염률은매월마다미생물실및감염관리실에서감염률을모니터링하였고, KONIS 2010 ICU manual 에서제시한감염률산출법을사용하였다. 손위생이행률은매분기마다감염 106
Poster 관리실 직원이 중환자실에 대기하며 대상자의 손씻기 이행률 및 방 법의 적절성을 모니터링 하였고, 제주대학교병원 감염관리실에서 만 든 손 위생 이행도 관찰 기록지 를 이용하였다. 처치가 까다로운 부위에 대해서도 비교적 간편하게 창상을 치료할 수 있었다. 결과: 손 위생 이행률 모니터링 결과는 개선활동 전인 2011년 6월 73.4%에서 개선활동 후인 2011년 9월 83.8%로 증가하는 경향을 보 였다. 병원감염률은 개선활동 후인 2011년 하반기 1000재원일당 Key words: 괴사성 근막염, 흉벽, 음압 치료 3.96으로 전년 동기의 7.85에서 감소하는 경향을 보였다. 손 위생 이 행률이 증가하며 병원감염률이 감소하는 경향을 보였다. 결론: 손 위생 이행률을 향상시키기 위한 활동은 병원감염률을 감소 P1-7 시킬 수 있는 유용한 방법이다. Key words: hand hygiene, intensive care unit, nosocomial infection A case of successful surgical management for necrotizing pneumonia Yun Jung Jung1, Sungsoo Lee2, Keu Sung Lee1 Department of Pulmonary and Critical Care Medicine, Ajou University 1 School of Medicine, Department of Thoracic and Cardiovascular 2 Surgery, Yonsei University College of Medicine P1-6 Necrotizing pneumonia is characterized by pneumonic consolidation Necrotizing Fasciitis of the Chest Wall 전재현1, 박샘이나2, 복진산2, 황유화2, 이현주2 1 2 국립암센터 폐암센터, 서울대학교 의과대학 흉부외과학교실 서론: 흉벽의 괴사성 근막염은 비교적 드문 질환으로, 근막을 따라 빠 르게 진행하면서 침범된 조직의 허혈과 괴사를 일으켜, 주변 피부, 피 하조직, 근육과 주변 연부조직을 광범위하게 손상시킨다. 국소적으 로는 농흉, 종격동염 등의 합병증을 일으키며, 전신적으로 패혈증, 신 부전, 쇼크 등을 일으키면서 사망할 수도 있는 치명적인 질환이다. 조 기 진단이 중요하고, 광범위한 항생제 투여 및 근막층의 적절한 배농 후, 괴사된 조직을 절제하는 반복적인 변연 절제술을 시행하는 것이 치료 원칙이다. 하지만, 병변이 광범위할 경우 변연부의 괴사된 조직 을 완전히 절제하는 것이 어려우며, 반복적인 괴사조직 절제와 항생 제 용액의 세척은 환자 및 의료진에게 고통스럽고 번거로운 치료가 될 수 있다. 이에 본 교실에서는 수술적 치료와 동반하여, 음압 상처 치료로, 광범위한 흉벽의 괴사성 근막염을 성공적으로 치료하였기에 보고하는 바이다. with multiple necrosis of the lung parenchyma. Medical therapy is usually mainstay of management. In rare cases, surgical treatment can be essential because this infection could be life-threatening. To date, there are no established surgical indications for necrotizing pneumonia. A 51-year-old man visited our emergency department due to necrotizing pneumonia in the right upper lung. The patient had co-morbities such as diabetes mellitus and alcohol abuse, whose necrotizing pneumonia was not controlled by proper medical treatments with antibiotics but deteriorated progressively. The patient underwent surgical management and showed successful treatment outcomes. Early aggressive surgical management should be considered in achieving a curative treatment in patients with necrotizing pneumonia who are refractory to optimal medical treatments. This should also be accompanied by multidisciplinary approaches with clinicians in other specialty areas. Key words: Necrotizing pneumonia, sepsis, surgical management 증례: 60세 남자 환자가 우측 액와부 부위에서 흉벽으로 진행하는 부 종과 통증을 주소로 내원하였다. 흉부 CT에서 우측 어깨부터 골반의 장골능선까지 근막층을 따라 광범위한 공기 음영 및 농양이 관찰되 POSTER 었다. 환자는 응급 배농 절개 및 괴사조직 제거를 시행하였고, 반복적 으로 괴사된 조직을 절제하고 항생제가 섞인 용액으로 세척하였다. 하지만, 복벽 및 장골 능선 주위의 잔여 농양 및 괴사된 조직의 치료 가 충분하지 않다고 판단되어, 추가적인 상처 음압 치료를 적용하였 다. 2-3일에 한번씩 상처 음압 부위를 교체하였으며 한 달간의 치료 후에 환자 상태는 호전되었고 상처 부위의 일차 봉합 후 퇴원하였다. 결론: 음압 상처 치료는 괴사조직을 효과적으로 흡인하여 제거하므 로 창상세척 및 괴사된 조직제거를 대신할 수 있었고 잦은 창상치료 로 인한 시간을 줄일 수 있었다. 또한 근막을 따라 심층으로 진행되어 괴사조직 제거가 어려운 경우에도 흡인을 통해 괴사조직을 흡수할 수 있어 치료효과가 뛰어났으며 광범위한 흉벽 부위와 같이 수술적 107
P2-2 정상면역기능을가진성인에서발생한 Norcardia farcinica 감염증 1 예 김진영, 윤희정 을지대학교의과대학내과학교실 P2-1 면역저하가없는성인에서발생한침습성장관아스페르길루스증 1 예 길은미, 정치량, 박치민 1, 서지영 2, 전경만 2, 양정훈 3 성균관대학교의과대학삼성서울병원중환자의학과교실, 성균관대학교의과대학삼성서울병원외과학교실 1, 성균관대학교의과대학삼성서울병원호흡기내과학교실 2, 성균관대학교의과대학삼성서울병원순환기내과학교실 3 서론 : 침습성장관아스페르길루스증은드물게발생하는질환으로, 주로면역저하환자에서파종성감염에의한 2차발생으로나타나며. 특히일차성장관기원침습성아스페르길루스증은매우드물다. 저자는최근일차성장관아스페르길루스증을경험하여보고하는바이다. 증례 : 53세남자가내원 1일전과량의음주후발생한쇼크로내원하였다. 환자는 5년간매일음주를하였고, 다른병력은없었다. 내원당시활력징후는혈압 82/50mmHg, 맥박수 78회 / 분, 호흡수 28회 / 분, 체온 34도였고, 동맥혈가스검사에서 ph 6.74, HCO3 2.8mmol/l의심한대사성산증과 17.55mmol/l의심한젖산증을보였다. 복부 CT 에서급성췌장염및장관염소견이관찰되어이에의한패혈성쇼크진단하에기계환기와신대체요법등의중환자실치료를시행하였다. 재원 10일째복부 CT에서장관염은호전되었으나혈변발생하였다. 대장내시경에서허혈성대장염이의심되었으나복부증상없고활력징후안정적인상태로대증적치료를유지하였다. 재원 13일째환자는다시쇼크상태로진행하였고, 복부팽만및복강내압상승있어장허혈및복막염의심하에개복술을시행하였다. 수술소견에서근위부소장약 1m를제외한소장과전대장에허혈및괴사성변화있어소장과전대장결장절제술및공장루조형술을시행하였다. 수술후시행한병리검사에서침습성장관아스페르길루스증이관찰되었다. 환자는수술후복강내출혈, 감염증지속된상태에서보호자원하여연고지병원으로전원하였다. 결론 : 면역저하의병력이없는환자에서아스페르길루스증을의심하기가어렵기때문에진단및치료가늦어지고, 이는나쁜예후로귀결될수있다. 그러므로장관점막의방어기전이손상된환자에서는면역저하의병력이없이도침습성아스페르길루스증의발생가능성에유의해야겠다. Key words: aspergillosis, immunocompetant, gastrointestinal Norcardia farcinica는호기성그람양성균으로전세계적으로발견되는기회감염균이다. Norcardia에의한감염증은대부분암환자를비롯해후천성면역결핍증후군환자나스테로이드를투여받는환자등면역저하환자에서발생한다. 저자들은고혈압외에특이병력이없는 64세남자환자에게서발생한 N. farcinica 감염에의한종격동염및폐렴증례를경험하여보고하는바이다. 환자는내원 1주전부터발생한좌측흉곽통증과경한호흡곤란을주소로내원하였다가종격동에서염증성종괴가발견되고, 폐렴소견을보이며, 흉수에서 16s rrna 염기서열법에의해 N. farcinica가동정됨에따라즉시 trimethoprim sulfamethoxazole을포함한항생제치료후호전되었다. 면역저하환자뿐만아니라, 특별한기왕력이없는환자에서도뇌농양, 폐렴, 연조직염등파종성염증질환의소견을보일경우 N. farcinica 에의한감염증일수있음을배제할수없으며, 적극적인원인균동정을통하여적절한항생제치료가필요할것이다. Key words: Norcardia, 면역, 항생제 P2-3 발열을동반하지않은객혈로내원한감염성심내막염 1 례 이세종, 김경수, 권운용, 서길준 서울대학교병원응급의학과 서론 : 감염성심내막염은심장의내막에미생물이증식하는감염성질환으로질병이중하고, 사망의위험도가높아효과적인치료를위해서는신속한진단이중요하다. 임상적인진단을위해다양한기준이제시되었고, 심초음파의발달로감염성심내막염의가장특징적인병변인증식증을진단하는것도용이해졌으나, 임상양상의다양성과비특이성으로인해실제진료현장에서진단이어려운경우가많이있다. 저자들은발열이없는객혈로내원한환자에서 bed side echo를통한선별검사로감염성심내막염을의심하여빠른심초음파검사및항생제투여로효과적으로환자치료한경험을보고하고자한다. 증례 : 환자는내원전날부터발생한객혈과호흡곤란을호소한 72세여자로승모판협착증으로 2012년 3월승모판막성형술을시행받았고좌측중대뇌동맥영역뇌경색과동반된심방세동으로 Warfarin 복용중이다. 환자는내원전날부터종이컵반컵이상의객혈과호흡곤 108
Poster 란이악화되어타원응급실방문후 PT INR 4.12로 vitamin K 및 Tranxamic acid 투여후전원되었다. 응급실내원당시발열은없었으나오한및기침, 객담등호소하였고객혈및호흡곤란있었다. 활력징후는혈압 192/100, 맥박 137, 호흡수 26, 체온 36.6 였으며안면마스크로산소 15L 투여하면서 SpO2 97% 보이고있었다. 신체검진시급성병색과양폐하부에서악설음이청진되었고, 불규칙한심박동을보였으나명확한심잡음은들리지않았다. 혈액검사결과 ABGA 7.43-35-79-23.2 (O2 15L), WBC 14400(Seg. 86.0%), Hb 11.5, Hct 35.4, PLT 148, 000, Na 129, K 5.5, BUN/Cr 35/1.21, CRP 12.4로측정되었고심전도상급성심실반응을동반한심방세동, 흉부전산화단층촬영에서미만성폐포출혈과폐부종의심되는소견관찰되어 Diltiazem, Transamine 투여하였다. 이후응급실에서시행한 bedside echo 선별검사에서늘어난좌심방과승모판막협착, 승모판부위에 echogenic mass 관찰되어혈액배양검사시행하고 Vancomycin, Tazocin 투여하였다. 이후시행한정식심초음파검사상전방승모판엽끝부위 echogenic mass 관찰되었고혈액배양검사상그람양성사슬구균관찰되었으며다른감염의병소는관찰되지않아감염성심내막염으로생각하고 Vancomycin과 ceftriaxone 치료후혈액배양검사음전되어퇴원하였다. Key words: 감염성심내막염, 선별초음파, 승모판협착 P2-4 The High flow nasal cannula can be suitable method in patients with post-extubation 김대성, 권오정, 오선희, 나문준, 최유진, 손지웅, 권선중 건양대학교병원내과 Background: Reintubation is associated with increased mortality. Applying high flow nasal cannula (HFNC) can be immediately an alternative method in place of noninvasive respiratory support in patients with postextbation. However, the benefit of the use of HFNC after extubation was not clear. Materials and Methods: We conducted study retrospectively to examine whether HFNC can reduce the risk of reintubation in patients after extubation in the ICUs. Patients were liberated from mechanical ventilation using daily spontaneous breathing trail. We set HFNC as follows. Flow rate was 30~60L/min and fraction of inspired oxygen (FiO2) could retain peripheral capillary oxygen saturation (SpO2) above 90%. We checked clinical parameters and arterial blood gas analysis after extubation. The primary outcome was the rate of reintubation after extubation. Results: A total of 39 extubated patients who receive treatment with HFNC were included in the analysis from Nov. 2011 to Feb. 2014. The median duration of mechanical ventilation was 9.1 days and median PaO2/FiO2 ratio on time of ventilator weaning day was 311.87 mmhg. Five patients (12.8%) were required reintubation during ICU stay. Two patients (5.1%) and 3 patients (7.7%) were required reintubation within 48 hours and after 48 hours after extubation. The median time from extubation to reintubation was 12.5hours. Conclusion: The use of HFNC as respiratory support after extubation in ICU patient was effective method for preventing reintubation. Key words: high flow nasal cannula, reintubation, noninvasive positive pressure ventilation P2-5 높은기도압이지속된기계환기환자에서연속적으로발생한양측기흉, 종격동기종, 피하기종 박진 1, 이승엽 2, 한철 2, 이영주 1 1 이화여자대학교부속목동병원중환자의학과, 2 이화여자대학교부속목동병원응급의학과 서론 : 기계환기가필요한중환자실입원환자에서기흉, 종격동기종, 피하기종등압력손상 (barotrauma) 은흔하게발생하는합병증이나최근낮은 1회호흡량의사용으로감소하고있다. 압력손상의기전은양압기계환기로세기관지와폐포에압력이걸리며발생하는전단력이폐포를손상시키고, 손상된폐포를통해유입된공기가폐사이질의혈관을따라이동함에따라기흉, 종격동기동, 피하기종등이나타나는것으로알려져있다. 쇄골하중심정맥도관등침습적시술, 천식, 급성호흡곤란증후군, 등의기저질환이외기계환기중높은최대흡기압 (PIP), 호기말양압 (PEEP) 등의위험인자가있다. 본연구는높은기도압이지속된환자에서기흉발생이후반대편에새로운기흉과종격동기종, 피하기종이연속적으로발생한증례보고이다. 증례 : 54세 65kg 남자환자가심정지로내원후심폐소생술로회복하여중환자실에입원후기계환기를시작하였다. 낮은 1회호흡량으로설정하였고동반된폐렴과호흡기와의부조화현상으로최대흡기압이계속증가하여항생제투여및부조화현상을줄이기위하여미다졸람, 펜타닐및근이완제를투여하였다. 그러나적절한산소분압을위한호기말양압에도최대흡기압이 50-60cmH2O로높게지속되고이산화탄소분압이높게측정되었다. 입원 18일째쇄골하중심정맥도관을유치하고나서시행한단순흉부X-선촬영상좌측기흉이발견되어흉관삽입하였고기흉은호전되었으나 6일후반대쪽의기흉이새로발생하였으며 7일이후종격동기종이나타나고피하기종이흉벽, 경부, 상완, pectoralis로진행하였다. 흉관삽입과함께폐포압력을낮추기위하여호기말양압, 1회호흡량을줄인후기흉및종격동기종, 피하기종은호전되었다. 결론 : 본증례는높은기도압이지속되던환자에서중심정맥도관시술후나타난기흉에이어연속적으로발생한압력손상에대한보고 POSTER 109
이다. 이는기계환기중인환자에서압력손상의위험인자를가지는경우침습적시술에의한다발성압력손상이발생할가능성에대해주의가필요함을시사한다. Key words: airway pressure, pneumothorax, pneumomediastinum P2-6 인플루엔자와 Streptococcus pyogenes 가병발된지역사회폐렴 1 예 박태선, 유정완, 강병주, 허진원, 홍상범, 임채만, 고윤석 울산대학교의과대학서울아산병원호흡기내과 서론 : 중증인플루엔자폐렴에서세균성폐렴이동반되는경우가있으며 Streptococcus pneumoniae가흔한균으로알려져있다. 본증례에서는국내에아직까지보고가없는인플루엔자와 Streptococcus pyogenes가병발된지역사회폐렴예를보고자하고한다. 증례 : 파킨슨병에대한약물치료를하면서평소일상생활에문제없이지내오던 67세여자환자가내원 3일전부터시작된호흡곤란을주소로내원하였다. 내원당시생체징후는혈압 100/67 mmhg, 맥박 117회 / 분, 호흡수 24회 / 분, 체온 38.0, 동맥혈검사 ph 7.43, pco2 30.0 mmhg, po2 60.0 mmhg, HCO3 20.0 mmhg이었으며, 흉부방사선검사상우하폐경화및흉수소견이관찰되었다. 내원당일호흡곤란및저산소혈증악화로기관삽관및기계환기치료를시작하였고기관지내시경소견상우하폐엽에서다량의혈성분비물이있었다. 기관지세척검체에서인플루엔자 A 바이러스 PCR 양성 ( 아형 H1N1) 으로항바이러스제를시작하였다. 내원 1일째 100% 산소공급에도산소포화도유지가어렵고혈압저하, 소변량감소, 우측흉수의증가와함께심초음파에서좌심실의전반적인운동저하가보여 venoarterial extracorporeal membrane oxygenation (VA ECMO) 과함께 continuous renal replacement therapy 및흉관삽입을시행하였고혈성삼출액이배액되었다. 내원 4일째혈액배양검사및기관지세척액배양검사에서 Streptococcus pyogenes가배양되었으며페니실린 G 투여를시작하였다. 내원 9일째환자의상태가호전되어 ECMO 이탈및제거에성공하였으나간부전이지속되는상태였다. 내원 10 일째기관절개를하였고기계호흡이탈을시작하였으나섬망이지속되어이탈에어려움을겪었다. 내원 16일째복부전산화단층촬영상급성담낭염으로진단되어경피적담낭배액술을시행하였다. 또한좌측폐의침윤이발생하였고기관내흡입액배양검사에서 carbapenem resistant Acinetobacter baumannii가배양되어인공호흡기관련폐렴으로진단되었다. 이후 colistimethate로치료하였으나다발성장기부전으로내원 38일째사망하였다. 결론 : 중증인플루엔자폐렴에서초기에세균성폐렴이동반되는경우가있으며 Streptococcus pneumoniae 외에 Streptococcus pyogenes 와같은다른균의감염도고려해야한다. Key words: Influenza, Pneumonia, Streptococcus pyogenes P2-7 Toxicity of Intravenous Colistin as a Factor Interfering with Weaning from Mechanical Ventilation Hyo Seok Lim, Yee Hyung Kim 1, Cheon Woong Choi 1, Myung Jae Park, Jee-Hong Yoo 1, Hong Mo Kang Department of Pulmonary and Critical Care Medicine, Kyung Hee University College of Medicine, Seoul, Korea, Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea 1 Introduction: The use of colistin, which is commonly used agents for Acinetobacter isolates resistant to first-line agents, is associated with considerable toxicity, mainly nephrotoxicity and neurotoxicity. We report a case of neurotoxicity of intravenous colistimethate sodium (CMS) manifesting as a potential factor interfering with weaning from mechanical ventilation. Case: A 71-year-old woman visited the hospital with aggravated dyspnea and purulent sputum, who has been managed with low dose macrolide for bronchiectasis. Laboratory was significant for leukocytosis and elevated C-reactive protein. A chest radiograph showed newly appeared infiltration on right lung field. She was intubated and admitted to the intensive care unit(icu) for type 2 respiratory failure and received empirical antibiotics including piperacillin/tazobactam and levofloxacin for pneumonia. On day 10 after her admission, sputum culture grew acinetobacter baumannii resistant to all antimicrobials including colistin. Therapy was instituted with intravenous CMS (2.5mg/kg every 12h) and imipenem(500mg every 6h), which had been administrated for 2 weeks. On day 10 after intubation, we tried weaning from mechanical ventilation because the consolidation was nearly resolved on the chest radiograph with much improved clinical aspects and PaO2/FiO2 ratio became more than 200. However, it was failed to wean off the mechanical ventilator for 4 days consecutively even after all analgesics and sedatives were completely discontinued. So the possibility of CMS-induced neuromuscular toxicity was suspected, and therapy with CMS was withheld. One day later, she became tolerable with T-piece. She was extubated within 48 hours after discontinuation of CMS and was then transferred to the floor. Conclusion: Patients receiving colistin could be exposed to the potential risk of neurological toxicity. As the use of colistin in ICU continues to increase, its neurotoxicity should be considered when weaning from mechanical ventilation is difficult. 110
Poster Key words: Colistin, toxicity, mechanical ventilation P3-1 만성신부전환자에서수술후수액과다투여에의한폐부종으로오인된관상동맥혈전 황부영, 권재영 부산대학교의과대학마취통증의학과교실 수술은환자의신기능과전신상태에영향을미칠수있고, 이런이유로만성신부전환자는수술전후의관리에있어세심한관찰과주의를요한다. 저자들은심근경색의병력이있는만성신부전환자에서수술후수액과다투여에의한폐부종으로오인된관상동맥혈전의진단과치료에대하여보고하고자한다. 증례 : 68세남자환자는회전근개증후군수술을위해내원하였고, 6 년전신부전진단받고주 3회혈액투석, 관상동맥질환으로 5년, 1년전에일반금속스텐트삽입술시행후 clopidogrel과 aspirin 복용하고있었다. 수술일주일전약물투여를중단하고미분획헤파린을투여하다 4시간전에중단하였다. 수술전심장초음파상심박출계수는 35%, 좌하전동맥과우관상동맥영역운동저하가있었고, 혈역학적검사는안정적인상태를보였다. 수술후중환자실입실후안정적인모습을보였고혈액검사와흉부방사선소견은수술전과큰차이를보이지않았다. 다음날오전환자가갑자기호흡곤란, 의식저하, 수축기혈압 60 mmhg 미만의저혈압양상을보여기관내삽관후즉시시행한심장초음파소견에서심박출계수 25%, 우심실의수축력이저하되고흉부방사선상양쪽폐문주위음영이증가하여수액과다투여로인한심부전악화로생각하고이뇨제를투여한후혈액투석시작하였다. 이후관상동맥조영술을시행한결과우관상동맥과좌하전동맥의새로운부위에혈류가줄어든양상보였고, 우관상동맥에혈전이발견되어 (Fig.1) 스텐트를삽입하였다. 결론 : 만성신부전환자에서는수술전심혈관이나말초혈관병여부, 심기능평가도함께이루어져야한다. 또한각과의협진으로전반적인평가와관리가필요하다. 수액과다투여로인한심부전과혈전에의한심근경색을감별하기위하여수술중이나후에최소한의수액투여를하고수술후심전도, 심초음파, 혈액검사가필요하다. 또한수술후가능한빨리헤파린을투여하는것이관상동맥혈전을방지하는데도움이된다. Key words: 만성신부전, 관상동맥혈전, 헤파린투여 P3-2 Improved survival of IPAH after the introduction of targeted therapies Byung Ju Kang, Sang-Do Lee, Yeon-Mok Oh, Jae Seung Lee Department of Pulmonary and Critical Care Medicine Background: Idiopathic pulmonary arterial hypertension (IPAH) is an inextirpable disease with high mortality. To manage this disease in Korea, targeted therapies such as prostanoids, endothelin receptor antagonists, and phosphodiesterase type 5 inhibitors have been used since 2004. The aim of this study was to analyze the survival of Korean patients with IPAH after the introduction of targeted therapies. Methods: We performed a retrospective cohort study of 71 patients diagnosed with IPAH in a tertiary hospital between January 1994 and February 2013. Patients were classified into conventional therapy group (treated with conventional therapies and/or beraprost) and targeted therapy group (treated with targeted therapies other than beraprost) according to the treatment they received for 1 year after diagnosis. Results: The mean age of the patients was 35.5±14.8 years and 50 patients (70.4%) were female. The mean interval from the onset of symptoms to diagnosis was 38.9±51.0 months and the most common presenting symptom was dyspnea. The survival rate at 1, 3, 5, and 10 years was 80.1% 62.0%, 51.5%, and 26.8%, respectively. The survival rate in the targeted therapy group was greater than in the conventional therapy group (p-value = 0.026) or in the beraprost-only group (p-value = 0.035). Conclusion: Survival of Korean patients with IPAH improved after the introduction of targeted therapy. POSTER Key words: survival, IPAH, therapy 111
& T changes. Cardiac enzyme was within normal limits. Chest CT scan showed thrombosis at the BD Glenn shunt anastomosis site as well as part of proximal right pulmonary artery. Thrombolysis therapy with Urokinase was administered via right cephalic vein immediately and then, switched to intravenous heparin with a target aptt between 60~70 sec. After thrombolysis, ABGA showed improved oxygen saturation above 90% on room air condition and symptoms disappeared. Follow-up chest CT scan showed resolved BD Glenn shunt thrombosis, however, some residual right pulmonary thrombosis with patent circulation pattern. On heparinization, OAC (Warfarin) was started and the dose was adjusted with a target INR between 2~2.5. He was discharged hospital with OAC in a good condition. Chest CT scans 3 months after thrombolytic treatment demonstrated well-patent BD Glenn shunt and right pulmonary artery. Key words: pulmonary thrombosis, bidirectional Glenn operation, single ventricle P3-3 Successful thrombolysis of bidirectional(bd) Glenn shunt thrombotic obstruction Yong-In Kim, Sun Kyung Min Department of Thoracic and Cardiovascular Surgery, Inje University, Seoul Paik Hospital Case Report: For the patients with most uni-ventricular congenital heart disease bidirectional (BD) Glenn operation is a palliative surgical procedure to improve the blood flow to the pulmonary circulation. Thrombosis or thromboembolism in the pulmonary circulation is a potentially fatal complication after this procedure. Prevention of it has not been yet completely elucidated, although some guidelines for prevention of thromboembolism after BD Glenn operation have been released. Very few cases of pulmonary thrombosis after BD Glenn shunt have been reported in the literatures. A 28-year-old man who underwent BD Glenn shunt operation for a single ventricle pathophysiology 4 years ago was admitted the hospital via emergency department because of chest pain and dyspnea. Aspirin prescribed after operation was not taken by him for 6 months and he continued to smoke cigarettes. There was no sign of deep vein thrombosis at both lower extremities. ABGA showed diminished oxygen saturation, 75% on 3 liter per nasal cannula of O2 supply. EKG showed no sign of ST P3-4 Air embolism associated with central venous catheter placement: 2 case reports 양광호, 문기명 Division of Hepato-Biliary-Pancreatic surgery and Transplantation Department of Surgery Pusan National University Yangsan Hospital 112
Poster Introduction: Venous air embolism is a significant complication associated with central venous catheter placement in critically ill patient. In our institute, two patients got a suffer due to air embolism associated with central venous catheter. We reported these cases, and then proposed the tip of prevention and treatment for this serious complication. Case 1: A 63 year old man was admitted for liver transplantation(lt). He diagnosed hepatitis B related liver cirrhosis and hepatocellular carcinoma(hcc). The patient underwent living donor LT and got injury to Rt. Subclavian vein during catheter insertion in operative room. The metal stent insertion and closed thoracostomy had done. On 7th postoperative day, the patient had decreased mentality and showed abdnormal neurologic signs immediately after central catheter disconnection by accident. Computed tomography(ct) and Magnetic resonance image(mri) showed acute cerebral infarction due to air emboli. On 17th postoperative day, Stent insertion was done for flow compromise of Rt. Common carotid artery. One month later, the patient s neurologic status was improved, and then discharged with some sequela. Case 2: A 64 old man was admitted for LT. He diagnosed hepatitis C related liver cirrhosis and HCC. The patient underwent cadaveric donor LT. On 12th postoperative day, the patient had a seizure and decreased mentality suddenly after central catheter removal. The CT showed air embolism at bilateral cerebral hemisphere. Although the patient underwent neurologic treatment, gradually got worse. On 20th postoperative day, the patient confirmed brain death and expired 3weeks later. Conclusion: Air embolism associated with central venous catheter is fatal and can cause serious neurological sequela. So the prevention of this complication is exceedingly important. When inserting and manipulating central venous catheter, several principles such as patient s position and compressive dressing should be obeyed. affects functional outcome in patients with ischemic stroke(is) after intravenous thrombolysis. Some previous reports showed a slight but significant increase in symptomatic ICH, but no different functional outcomes in patients with prior AP therapy. But, other reports concluded the prior AP therapy was associated with a good functional outcome. The aim of this study was to estimate the effect of prior AP therapy on functional outcome in patients with acute IS. This retrospective analysis reviewed 140 consecutive patients with acute IS who were admitted between November 2002 and April 2013. We used an end-point analytic technique to evaluate the association between prior use of AP drugs and functional outcomes: dichotomized analysis for functional dependency (a discharge modified Rankin Scale (mrs) score 3). For the multivariate analyses, we used the logistic regression models. Of the 140 patients who received intravenous thrombolysis, 48 (34.3%) were on single AP therapy and 9 (6.4%) were on dual AP therapy at the time of stroke onset. Twenty-nine of the 48 patients (60.4%) in single AP group and 30 of the 82 patients (36.6%) in no AP group were functionally independent at discharge (mrs score of 0-2) (p=0.03). In the multivariable logistic regression analysis, prior single AP therapy was associated with a favorable outcome at discharge (adjusted OR, 0.39; 95% CI, 0.17 to 0.90). The incidence of sich was not significant, but slightly higher in single and dual AP group (2.4% versus 10.4%, 11.1%; P=0.13). From our study, we documented that the prior single AP therapy was associated with favorable outcome in patients with acute ischemic stroke after intravenous thrombolysis. Key words: antiplatelet therapy, functional outcome, thrombolysis Key words: Air embolism, central cathter, liver transplantation P3-5 Effect of prior antiplatelet on the functional outcome in ischemic stroke patients treated with rtpa POSTER Seunguk Jung, Yerim Kim, Chi-Kyung Kim, Sang-Bae Ko, Seung-Hoon Lee, Byung-Woo Yoon Department of Neurology, Seoul National University Hospital, Seoul, Korea There is some uncertainty whether prior use of antiplatelet(ap) drugs 113
P3-6 Regurgitatation of inflow catheter on veno-venous arterial extracorporeal membrane oxygenation Soonyoung Park, Dong Hyun Lee, Jin Won Huh, Chae-Man Lim, Younsuck Koh, Sang-Bum Hong Department of Critical Care Medicine, Asan Medical Center, University of Ulsan college of Medicine, Seoul, Korea Introduction: Although extracorporeal membrane oxygenation (ECMO) gives advanced life support, there is still lack of experiences in critically ill patient. There are many kinds of unexpected challenges in management during ECMO. We report a case of unusual experience with regurgitation of arterial inflow catheter. Case presentation: A 58 year-old male patient with interstitial lung disease developed refractory cardiogenic shock, which was associated with stress induced cardiomyopathy (Echocardiography; ejection fraction = 11%). Veno-arterial ECMO (V-A ECMO) was applied and followed by conservative treatment. On day 3 after ECMO application, respiratory drive increased and PaO2 was 55mmHg (ECMO FiO2: 1.0, Ventilator FiO2: 0.9) measured on right radial artery. Left ventricular function was improved (Echocardiography; ejection fraction = 40%). Two circulation syndrome was suspected. Mode of ECMO was changed veno-venous arterial ECMO (V-VA ECMO). Although hypoxia was improved there was discrepancy between the amount of outflow current and inflow current. The measurement of the inflow volume was 4.5 L/min on the main inflow catheter (venous outflow catheter: 25 Fr) and 5.3 L/min on venous inflow catheter (25 Fr). There was backward flow of 1.2 L/min on the arterial inflow catheter (15 Fr). Mode of ECMO was changed to veno-venous ECMO (V-V ECMO) to stop arteriovenous shunt flow. Conclusion: There are many kinds of trouble shootings in management during ECMO. Although the regurgitation flow from arterial inflow to venous inflow catheter can affect the cardiovascular function adversely, it can be easily diagnosis by measuring the amount of inflow volume. When V-VA ECMO inserted especially, it should be observed arterial and venous flow carefully. Key words: venovenoarterial extracorporeal membrane, two circulaltion syndrome, regurgitantion flow P3-7 The clinical features of concomitant chronic obstructive pulmonary disease and systolic heart failure in patients who admitted at intensive or coronary care unit due to dyspnea 최성일 한양대학교의과대학구리병원심장내과 Background: Dyspnea is the symptom to cause the life-threatening critical problem and one of the most common admission causes at intensive (ICU) or coronary care unit (CCU). It is known that about 75% causes of dyspnea are associated with heart disease and pulmonary disease. Although the etiology of dyspea is usually limited to one factor or single organ, a considerable portion of dyspnea is related to multi-factorial causes or multi-organ. At recent, some studies have been shown that about 25-50% in patient with dyspnea had concomitant heart disease and respiratory disease simultaneously. However, research on the clinical features of COPD and systolic heart failure (HF) is still scant. Therefore, the aim of this study was designed to investigate the clinical features of concomitant COPD and systolic HF and so to help to establish the treatment strategy for COPD and systolic HF. Methods: This study was composed of 145 patients who admitted at ICU or CCU due to dyspnea. All patients underwent pulmonary function test and echocardiography. The diagnosis of COPD and classification was applied to GOLD COPD guideline (FEV1 is at least 70% of FVC; FEV1/FVC < 0.70 on spirometry). The systolic HF was defined as left ventricular ejection fraction < 50% on echocardiography and classification of HF was applied to New York Heart Association (NYHA) classification. According to the presence of COPD and systolic HF, patients were divided into 2 groups (Group1; COPD+systolic HF vs. Group2; others) and clinical features was compared between 2 groups. Results: 41 patients (28.3%) had concomitant COPD and systolic HF, 42 patients (29.0%) only systolic HF, 37 COPD (25.5%) and 25 patients (17.2%) had preserved left ventricular systolic function. The concomitant COPD and systolic HF group (Group1) had significantly higher prevalence of old age, women, smoker than Group2. Also the Group 1 had smaller cardiothoracic ratio on chest X-ray and higher titer in hs-crp and in BNP. The longer stay in ICU and more frequent use of antibiotics was observed in Group 1. However, the frequency of ventilator care and prevalence of coronary heart disease was not significant between both groups. The concomitant COPD and systolic HF was associated with age > 70 years, women, smoking history and smaller CT ratio. In multiple logistic regression analysis, age and smoker were associated with the concomitant COPD and systolic HF. Conclusion: About 30% patients who admitted at ICU or CCU due 114
Poster to dyspnea had concomitant COPD and systolic heart failure. It implies that one of the desirable approaches to dyspnea is sometimes to comprehend heart disease and respiratory disease simultaneously rather than to separate both diseases. Key words: dyspnea, chronic obstructive pulmonary disease, Heart failure P4-1 인공심박동기 삽입 후 발생한 무증상의 정맥 접근로 반대측에 발생한 기흉 및 심낭 기종 조영진, 차명진, 최의근, 오세일 P4-2 서울대학교 의과대학 내과학교실 혈청 허혈 변형 알부민 농도와 관상동맥 경화증 병변 개수의 연관성 서론: 인공 심박동기 삽입 시 발생 가능한 합병증 중 기흉은 대부분 쇄골하 정맥 접근 시 발생하며, 따라서 혈관 접근과 동측에 발생한다. 능동 고정 조율 유도에 의한 심장 천공은 혈심낭을 유발하며, 드물게 혈흉을 동반한다. 동기능 부전으로 능동 고정 조율유도를 이용한 인 공 심박동기 삽입술 후 무증상이었던 환자에서 흉부 방사선 검사 결 과 발견된 혈관 접근 반대측 기흉 및 심낭기종의 증례를 보고한다. 증례: 43세 남성이 간헐적 어지러움과 호흡곤란을 주소로 내원하였 다. 24시간 심전도 결과, 증상과 연관성을 보이는 동성 서맥이 관찰되 었고, 인공 심박동기 삽입술을 시행하였다. 좌측 쇄골하정맥을 통해 2 개의 능동 고정 조율유도를 우심방귀 및 우심실 첨부에 각각 고정하 였다. 시술은 별다른 사건 없이 완료되었고, 시술 직후 병실 관찰 중 에도 환자는 흉통이나 호흡곤란을 호소하지 않았다. 시술 하루 뒤 시 행한 흉부 방사선 촬영 결과 우측 기흉 및 심낭 기종이 발견되었다 (그림). 흉부 CT에서도 동일한 소견이 확인되었고, 추가로 우심방에 고정한 조율유도 스크류 끝이 우심방 밖에 분출된 모양이 의심되었 다. 폐에 수포가 의심되는 소견은 없었고, 흉수 및 혈심낭의 증거도 없었다. 인공심박동기 분석 시 조율 유도들의 조율 역치, 민감도, 저 항은 시술 직후와 차이를 보이지 않았다. 환자는 기흉이 발견된 날 재 시술을 받았다. 우심방의 능동 고정 조율 유도를 제거, 1시간 뒤 심초 음파로 혈심낭이 진행하지 않음을 확인한 후, 다시 수동 고정 조율 유 도를 우심방귀에 삽입하였다. 이 후 흉관 삽입 없이 산소 요법 만으로 기흉이 호전되어 퇴원하였다. 의 제거가 치료에 필수적이며, 주의 깊게 수동 고정 조율 유도로 변경 하는 것을 고려할 수 있다. Key words: 인공심박동기, 능동고정 조율유도, 기흉, 심낭 기종 Dept Emergency Medicine, Asan Medical Center, Ulsan College of Medicine 목적: 급성 흉통을 호소하는 환자에서 혈중 허혈 변형 알부민(IMA) 은 급성관상동맥증후군의 감별진단에 도움이 된다고 알려져 있다. 초기 심근효소들의 값은 관상동맥 폐쇄의 정도를 반영하는 검사항목 에 대한 연구로 IMA를 이용해 분석해보고자 하였다. 방법: 일개 대학병원 응급실로 내원한 마지막 흉통 발생으로부터 6시 간이 경과하지 않은 성인환자를 대상으로 하였다. 내원 즉시 12유도 심전도를 시행하여 ST 분절상승 심근경색을 배제하였다. 일반적인 혈액검사와 혈중 심근효소(myoglobin, cardiac troponin I, creatinine kinase-mb) 와 BNP, C-reactive protein)을 측정하였다. IMA 측정 은 Albuim Cobalt Binding assay(bar-or et al., 2000)를 이용하여 측 정하였고, ACB assay 를 위한 검체는 SST tube 에 채취하여 채혈 1시 간 이내에 4 C 냉장보관하고 1900 x g 로 15 분간 원심분리 후 분석 할 때까지 -80 C 에서 보관하였다. 관상동맥 경화증 병변의 정도는 관상동맥조영술이 24시간 이내에 시행된 검사결과를 통해 확인하였 다. 자료의 분석은 관상동맥 경화증의 병변의 숫자에 따른 검사 항목 을 비교분석하였고 p 값이 0.05 미만인 경우를 유의한 차이가 있다고 하였다. 결과: 분석대상 환자는 364명(남: 여=280:84, 57.4±13.7세)으로, 마 지막 흉통 지속시간은 3시간이내 258명 3-6시간이 106명이었다. 관 상동맥 경화증의 개수는 0개 180명, 1개 92명, 2개 54명, 3개 38명이 었다. 관상동맥 경화증의 유무에 따라 차이를 보인 최초 혈액 검사항 목들은 myoglbin, ctni, CK-MB, BNP 였고, 관상동맥 경화증의 개 수에 따라 증가하는 양상을 보인 검사항목은 CK-MB (0개 1.49± 1.28, 1개 11.75±26.7, 2개, 13.0±26.2, 3개 14.1±27.3 ng/ml, P<0.001)였다. IMA 농도는 관상동맥 경화증의 개수에 따른 증가양 상을 보였지만 통계학적 차이를 보이지 못했다(0개 0.39±0.18, 1개 115 POSTER 결론: 능동 고정 조율 유도를 이용한 인공 심박동기 삽입 후 무증상 환자에서도 심방 천공의 가능성이 있다. 또한, 혈흉이나 혈심낭 없이 도 혈관 접근로의 반대측 기흉이 발생할 수 있다. 능동 고정 조율유도 최병호, 정루비, 유승목, 손창환, 오범진
0.47±0.11, 2개, 0.49±0.19, 3개 0.52±0.29 ng/ml, P=0.133). 결론 : 혈청 CK-MB의농도가급성관상동맥증후군환자에서관상동맥경화증의개수에따라증가하였다. Key word: acute coronary syndrome, coronary atherosclerosis, ischemia modified albumin P4-3 An alternative chest compression posture beside the bed using the kneeling stool 오재훈, 임태호, 지영준 1 한양대학교의과대학응급의학교실, 울산대학교공과대학의공학교실 1 Backgrounds: We hypothesized that the quality of CC (chest compression) with a kneeling posture using the kneeling stool on which the performer kneels beside the patient on a bed is equal to or superior to that with a standing posture in bed height adjustment. Methods: This study is prospective randomised cross-over trial with 40 providers working at one emergency department. 38 participants were enrolled and randomised to two group with drawing a lots. The first group was knelt on the kneeling stool beside the manikin on a bed whereas the second group was stood on a step stool at knee level. All participants did continuous CCs for 5 minutes without an audio-visual feedback. After 2 weeks, each group changed the posture. Each participant replied the score for the recording the overall of fatigue and pain using visual analogue scale (VAS) in every minute during 5 minutes of CCs. Parameters of CC quality (CC depth, rate, accuracy, and incomplete chest recoil) and VAS score overall and every minute between two groups were compared. Results: Data of 33 participants at both postures were analysed with exclusion of 5 participants. In comparison overall and per minute between two postures, all parameters are not different significantly (all p > 0.05) except overall median of CC rate (p = 0.01). There is no difference significantly between two postures in term of fatigue and pain (all p > 0.05). Conclusion: Using this kneeling stool might be an alternative method for the patient to be received high quality CCs and for the performer to feel the fatigue and pain lightly in hospital cardiopulmonary resuscitation. P4-4 Cardiac Arrest by Pulmonary Thromboembolism: Importance of Percutaneous Cardiopulmonary Support Hyo Jin Kim 1, Yang Hyun Cho 2, Wook Sung Kim 2, Kiick Sung 2, Dong Seop Jeong 2, Young Tak Lee 2, Pyo Won Park 2, Duk-kyung Kim 3 Department of Anesthesiology and Pain Medicine 1, Department of Thoracic and Cardiovascular Surgery 2, Department of Internal Medicine, Division of Cardiology 3, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Background: Cardiac arrest caused by acute pulmonary embolism is associated with high patient mortality. We hypothesized that the use of PCPS is an important predictor of prognosis and surgical outcome for these patients. Method: We reviewed patients who had cardiac arrest by acute pulmonary embolism. Between January 2001 and September 2013 we identified 20 patients at our institution with a confirmative diagnosis of acute pulmonary thromboembolism and cardiac arrest. Percutaneous cardiopulmonary support (PCPS) and surgical embolectomy is the standard course of care for patients in shock or cardiac arrest due to pulmonary thromboembolism at our institution. Patients were divided into two groups (PCPS group, No PCPS group). Result: PCPS was used in 60%. Surgical embolectomy was performed for 85%. Overall in-hospital and surgical mortalities were 35% and 29%, respectively. Based on multivariate analysis, both cardiopulmonary resuscitation > 15 minutes and absence of PCPS were significant risk factors affecting survival (p = 0.001 and 0.049, respectively). Conclusion: When the duration of cardiac arrest is short, surgical embolectomy is a viable option after cardiac arrest due to pulmonary thromboembolism. PCPS may be a useful tool for both patient stabilization and providing a bridge when deciding upon further management options. Key words: pulmonary embolism, extracorporeal membrane oxygenation, cardiopulmonary resuscitation Key words: cardiopulmonary resuscitation, kneeling, posture, chest compression 116
Poster 있었다. 이후환자는심정지로발현된 Brugada 증후군으로삽입형제세동기시술을받고퇴원하였다. 결론 : 기저질환이없고비교적젊은남성에서발생한심정지의경우그원인질환으로 Brugada 증후군을고려하여야한다. Key words: Sudden Cardiac Death, Brugada Syndrome P4-6 급성심정지로발현된 Brugada syndrome - 증례발표 - 부지환, 김경수, 권운용, 서길준, 유경민, 김재승, 이세종 서울대학교병원응급의학과 서론 : 돌연심장사란주로심인성원인에의해증상발현한시간이내에발생하는예기치않은사망을의미하며전세계적으로매년 4, 000, 000 명가량이돌연심장사로사망하는것으로알려져있다. 이런급성사망은주로허혈성심질환과심근병증이기저질환으로있는환자에서발생하는것으로알려져있으며, 10% 정도의환자에서는 long QT 증후군이나 Brugada 증후군을포함하는원발성전기적심질환 (primary electrical disorder) 이원인이다. 저자들은급성심정지로내원하여성공적인심폐소생술후약물유발검사를통해 Brugada 증후군으로진단된환자를경험하였기에이를보고하고자한다. 증례 : 환자는기저질환없이건강하던 22세남자로내원당일 21시 56분목격된심정지로 119 구급대에신고되어응급실로내원하였다. 현장에서일반인심폐소생술이시행되었고, 119 구급대도착후바로자동제세동기제세동이 1회시행되었다. 이후 8분간의심폐소생술에도자발순환이회복되지않아응급실로이송되었다. 응급실도착시간은 20시 13분이었고, 이후심폐소생술중심실세동지속되어총 5번의제세동후 20시 39분자발순환이회복되었다. 자발순환회복후시행한 12-유도심전도검사에서 V2 lead 의 J-point 가 2 mm 이상상승되었고, V3 lead 에서안장모양 (a saddleback appearance) 이관찰되어 Brugada 증후군의제 2형심전도와유사한양상을보였다 (Fig. 1A). 환자는통증에반응이없는무의식상태로응급중환자실로입원하여 24시간동안저체온치료를시행하였고, 입원 5일째부터의식이회복되어입원 7일째기관내튜브를제거하였다. 이후환자는무결석담낭염이발생하여경피적담낭배액술과항생제치료를받았고, 감염이호전되기를기다려입원 25일째 Brugada 증후군에대한약물유발검사를시행하였다. Flecainide 400mg 을경구로투여한후심전도변화를관찰하였고, 약물투여 2시간후 V1~V3 lead 에서 2 mm 이상의 J-point 상승을동반하는 ST 분절의상승과 T 분절의역위소견이관찰되어 (Fig. 1B-D) Brugada 증후군을확진할수 P4-7 Feasibility of optic nerve sheath diameter as an early neurologic outcome predictor 김용환, 황성연, 조광원, 이준호, 강문주, 이동우, 여정훈 성균관대학교삼성창원병원응급의학과 Background: Optic nerve sheath diameter (ONSD) has been used to indirectly assess the intracranial pressure in several clinical setting regardless of measuring method. ONSD enlargement has been associated with increased mortality after severe traumatic brain injury.this study evaluated whether ONSD, an additional parameter in initial brain computed tomography (CT) scans, can be an early predictor of neurological outcome in post-cardiac arrest patients. Methods: 112 cardiac arrest patients who underwent brain CT between November 2012 and October 2013 were identified from a prospective cardiac arrest registry. After exclusion of patients as exclusion criteria, 91 patients were included for this study. ONSD was bilaterally measured at a distance of 3 mm behind the eyeball on initial brain CT scan. ONSD was measured from one side of the optic nerve sheath to the other as a section through the center of the optic nerve at fixed window level. The demographic and clinical data including grey matter to white matter ratio (GWR) besides ONSD were obtained. The performance of ONSD was analyzed using multiple logistic regression analysis, receiver operating characteristic (ROC) curve analysis and cross tabulations. Results: Average ONSD was 5.57 ± 0.30 mm in the good outcome group vs. 6.29 ± 0.46 mm in the poor outcome group (p < 0.001). POSTER 117
In multivariable analysis, average ONSD and GWR were significant predictors for poor neurologic outcome (Odds ratio 1.8 and 1.55, p <0.001). ROC curve analysis revealed average ONSD had excellent discriminative power as average GWR (area under the curve have 100% specificities, the sensitivity of ONSD was 55.9%, which was lower than that of GWR (83.8%). However, the combination of both parameters improved the sensitivity to 92.6%. Conclusion: ONSD correlates closely with the neurologic outcome of hypoxic ischemic encephalopathy. It may be used as an objective ly predictor of poor outcome after cardiac arrest. Key words: heart arrest; prognosis; tomography, x-ray computed tomography 이한나 1, 오승영 2, 류호걸 1 서울대학교병원서울대학교의과대학마취통증의학과교실 1, 서울대학교병원서울대학교의과대학외과교실 2 Background: Postoperative ileus (POI) is a common complication after major abdominal surgery under general anesthesia. Gum chewing stimulates the cephalic-vagal pathway through sight, smell, or chewing without swallowing. We evaluated the usefulness of gum chewing in patients undergoing liver transplantation in reducing the duration of POI, time to first flatus, calorie intake. Methods: A randomized controlled clinical trial was performed. Patients in the sham feeding group chewed 2 pieces of xylitol flavored gum for 15 minutes, 3 times a day after extubation. The primary outcome was time to first flatus. Secondary outcome was time to sips of water, SBD, and cumulative energy intake, length of ICU stay and hospital stay. Results: A total of 30 patients were randomized into 2 groups: the sham feeding group (n=14) or the control group (n=16). Patients in the control group had higher preoperative MELD score (p=0.05) and received more packed RBC during operation (p=0.03). There was no difference between groups with respect to the primary outcome of time to first flatus and with respect to all other secondary outcomes. Conclusion: Our preliminary results show that sham feeding with gum chewing increases caloric intake after liver transplantation and shows a tendency towards shorter postoperative ileus and facilitation of diet. A complete clinical trial is required to confirm the results. Key words: sham feeding, liver transplantation, ileus P5-2 Massive IVC and right atrial thrombosis complicated by acute pancreatitis: a case report 이강의, 박태진 국립중앙의료원응급의학과 P5-1 Effect of sham feeding on postoperative ileus after liver transplantation Introduction: Thrombosis is a rare complication of acute pancreatitis, which mainly involves the splenic and portal vein. We experienced a huge thrombosis through IVC to right atrium complicated by acute pancreatitis. Case Report: A 58-year-old male presented to the emergency department with mental change due to hypoglycemia and right-upper-quadrant abdominal pain. His mentality was recovered after infusion of dextrose solution. He was a heavy alcoholic, with daily alcohol consumption of about 150 ml. In laboratory test, amylase (> 2400 U/L) 118
Poster and lipase (> 400 U/L) were elevated, consistent with acute pancreatitis. In imaging study, massive thrombosis with acute pancreatitis was seen (fig 1.). Gabexate and enoxaparin was administered for pancreatitis and thrombosis. Surgical removal of thrombosis was considered, but wasn't possible due to poor general condition. Despite conservative management, the patient expired. Key words: Pancreatitis, Thrombosis, Inferior vena cava 환자를대상으로의료진과의회진연계활동이이루어진군과활동이전의환자를각각의혈액화학검사결과및입원후 10일간영양지원형태와영양공급량을후향적으로비교분석하였다. 결과 : 2011년 1월 1일부터 3월 19일까지 NST활동이전군 30명과, 2012년 1월 1일부터 3월 4일까지 NST활동이후군 30명, 총 60명의환자를대상으로하였다. 두그룹간의남녀비, 평균연령, 기저체질량지수및입실당시환자의영양상태에는유의한차이는보이지않았다. 중환자실입실사유로는두군모두호흡부전이 60% 이상으로가장많은비율을차지하였다. 활동이전의환자군중경장영양 (enteral feeding, EN) 만공급받는환자는 2명 (6.7%), 경정맥영양 (parenteral nutrition, PN) 만공급받은환자는 4명 (13.3%) 이었고, EN과 PN을동시에공급받은환자는 22명 (73.3%) 이었으며, 전혀영양공급을받지않는환자는 2명 (6.7%) 이었다. 지원팀활동이후 EN만공급받는환자는 15명 (50.0%), PN만공급받은환자는 4명 (13.3%), EN과 PN 을동시에공급받은환자는 11명 (36.7%) 으로활동이전에비해영양공급경로에유의한차이를보였다 (P=0.001). 장관영양시작일은지원활동후빨라진경향을보였으나 (2.7±2.3일 vs. 2.3±1.1일, p=0.392) 통계적으로유의한차이는없었다. 결론 : NST이후장관영양시행비율, 장관영양공급시작일그리고장관영양공급량등의지표는개선되었으나, 열량및단백질총공급량은목표량에비해부족하였고, 중환자실입실시와퇴실시영양상태차이는없었다. 따라서향후영양상태개선을위해좀더적극적이고효율적인영양공급방안을모색하는것과동시에표준화되고체계화된영양지원관리방법이필요할것으로생각된다. Key words: 영양집중지원팀, 회진연계활동, 영양공급 P5-4 P5-3 내과계중환자실영양집중지원팀의료진과의회진연계활동전ㆍ후영양공급현황비교분석연구 이정문 2, 박승용 1, 최영훈 1, 정미선 4, 유희철 3, 이흥범 전북대학교병원호흡기알레르기내과 1, 외상팀 2, 간담췌이식외과 3, 영양팀 4 연구배경 : 중환자에서영양불량은감염을비롯한합병증발생을증가시키고, 기계호흡사용일수및재원일수를늘리며의료비증가를초래하는것으로알려져있다. 본연구는영양집중지원팀이중환자실에입원한환자를대상으로의료진과의회진시환자정보등을교류하면서단기간내적절한영양지원을시행함으로써, 중환자실에입원한환자들에게미치는영향에대해확인해보고자하였다. 대상및방법 : 2011년 1월부터부터 2012년 3월까지전북대학교병원내과계중환자실에입원한 20세이상의성인으로, 5일이상입원한 Lymphoma presenting as antiphospholipid syndrome and thrombotic thrombocytopenic purpur Jung-Kyu Lee, Jinwoo Lee, Sang-Min Lee Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea Background: Lymphoma has often been a diagnostic challenge due to clinically non-specific and protean manifestations. Especially, it may mimic and be combined with various other hematologic diseases. Case report: We present the case of a 46-year-old female with catastrophic antiphospholipid sydrome followed by thrombotic thrombocytopenic purpura. The patient was progressed to multiple organ failure, and finally diagnosed as lymphoma through bone marrow examination. In this case, successful treatments were performed with steroid pulse therapy and plasma exchange for antiphospholipid sy- POSTER 119
drome and thrombotic thrombocytopenic purpura, and rituximab for lymphoma. Key words: Lymphoma, antiphospholipid sydrome, thrombotic thrombocytopenic purpura P5-7 중환자실환자의영양상태변화와퇴원후장기적예후 이혜미, 라세희, 신증수 연세대학교의과대학마취통증의학교실및마취통증의학연구소 P5-5 Thrombotic Thrombocytopenic Purpura with Right Heart Failure Following Total Knee Replacement Sangwoo Shim 1, Jin Jeon 2, Chae-Man Lim 3, Younsuck Koh 3, Sang-Bum Hong 3 Department of Internal Medicine, School of Medicine, Catholic University of Daegu 1, Intensive Care Unit, Asan Medical Center 2, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, College of Medicine, University of Ulsan 3 Thrombotic thrombocytopenic purpura(ttp) is a life-threatening clinical syndrome characterized by microangiopathic hemolytic anemia, thrombocytopenia, renal insufficiency, neurologic abnormalities and fever. The cardiac involvement in TTP is not rare and could be fatal. A 80-year-old female visited to emergency department of ASAN medical center, Seoul, Korea with stuporous mentality. She had received left total knee replacement(tkr) one day before. She showed hypotension, hypoxia, anuria. We had intubation and administered the large volume crystalloid, high dose vasopressors and inotropics. Laboratory data revealed thrombocytopenia, anemia and elevated serum creatinin. Prothrombin time and activated partial prothrombin time were normal range. Electrocardiography showed normal sinus rhythm, but echocardiography showed severe right ventricular dilatation with decreased contractility, borderline pulmonary hypertension and normal left ventricular function. However there was no evidence of pulmonary embolism on dynamic chest CT angiography. Schistocytes were in PB smear. We could diagnosed post-operative TTP. She received four times of plasma exchange. All manifestation of TTP had completely resolved and following echocardiography showed normal RV function. She was discharged alive. This is the first reported case of TTP with right dominant heart failure after TKR. After operation including orthopedic surgery, fatal TTP with heart failure could be developing. So early diagnosis and treatment are key factor to save the life from TTP. Key words: thrombotic thrombocytopenic purpura, heart failure, total knee replacement 연구배경 : 중환자의경우입원당시이미영양불량인경우가크고입원이지속되는동안쉽게악화된다. 중환자의학의 Nutrition guideline 에서는적극적인영양지원을권하고있으나환자의상태나의료진의영양에대한관심부족등으로인하여적절한영양지원이이루어지고있지못하는실정이다. 여러연구에서영양상태가병원혹은중환자실내의사망률에비치는영향에대하여보고하였으나퇴원후장기적인예후와관련성에대해서는연구된바가없다. 그래서본저자들은영양상태의변화가퇴원후사망률에영향을미치는지에대해알아보고자하였다. 대상및방법 : 2006년 ~ 2011년 11월동안본원내- 외과중환자실에입실한환자중 20세미만, DNR 혹은질병의호전없이타병원으로전원된환자, 관상동맥환자를제외한퇴원환자를대상으로선정하여 2012년 11월 30일까지생존여부를알아보았다. 환자의영양상태는 serum albumin 및 total lymphocyte count (TLC) 를평가하여영양상태가비교적양호한환자 (serum albumin 3.5g/dl이상 TLC 1, 400 이상, Well-group), 영양상태가불량한환자 (serum albumin이 2.8g/dl미만, TLC 1, 000미만, Severe-group), 그리고그이외의환자 (Moderate-group) 로세 group으로분류하였다. 중환자실입실후 24 시간이내와퇴원당시영양상태를평가하여변화여부를호전, 변화없음, 악화 (Improved, Nonchange, Worsen-group) 으로나누어 1년, 5년생존율을비교하였다. 결과및결론 : Improved-group의 1년과 5년생존율은 82.3%, 67.1%, nonchange-group은 80.3%, 64%, Worsen-group은 79.6%, 63.1% 로 각군간의통계학적인차이는보이지않았다. 퇴원당시영양상태를비교하였을때 Well-group의 1년과 5년생존율은 80.1%, 75.9% 이며, Moderate-group은 80.1%, 63.3% (HR=1.65, P-value<0.01), Severe-group은 53.3%, 27%(HR=4.73, P-value<0.01) 로각군간의유의한차이를보였다. 중환자실에입실당시의영양상태보다퇴원시호전된영양상태가퇴원후생존율을향상시키지는못하였다. 하지만퇴원당시의절대적인영양상태에따라퇴원후생존에영향을미친다는것을알수있었다. Key words: Nutrition, Post-ICU mortality P6-1 예정수술후중환자집중치료의필요성을예측할수있는요인에대한후향적분석 120
Poster 조진범, 박일영, 성기영, 백종민, 이준현, 이도상가톨릭대학교의과대학외과학교실, 부천성모병원외과 Background: 제한된중환자실자원을꼭필요한환자에게사용하는것은중요하다. 본연구는예정수술 (elective surgery) 후에중환자집중치료의필요성을예측할수있는요인이있는지알아보기위하여후향적으로진행하였다. Methods: 본원외과 (General Surgery) 에서 2013년 1월 1일부터 5월 31일까지예정수술을시행받고중환자실에입실한환자를대상으로의무기록을분석하였다. 중환자실에서적극적인치료를시행받은환자군과감시 (monitoring) 만시행하였던환자군으로나누어두그룹간에인구통계학적특성, 수술전위험도평가, 수술종류및수술중발생한사건 (intra operative events) 의차이가있는지비교하였다. Results: 연구기간동안본원에서는총 135명의환자가예정수술후중환자실로입실하였고이중 16명의환자들이적극적인중환자치료를시행받았다. 1명의환자가호흡부전으로기계환기치료를시행하였고 2명의환자에서출혈성쇼크에대한치료가이루어졌다. 4 명의환자들에서부정맥이관찰되어부정맥약제가투여되었고 5명의환자들은수술후출혈이의심되어수혈및집중감시시행하였다. 나머지 4명의환자들의경우기도삽관을유지한채중환자실로입실한환자들로 1-2일정도의기계환기를시행하였다. 치료군환자들이수술전위험도점수가더높은경향을보였고수술중에더많은사건을겪는경향이있었으나통계적인유의점은없었다. 치료군환자에있어서 Mortality probability model을이용하여측정한예측사망률은 2.48% 였고실제사망률은 0% 였다 Conclusions: 본연구에서는예정수술후중환자실에서적극적인치료를시행받았던환자들과감시만시행받았던환자들사이에서의미있는차이점을밝힐수는없었다. 그러나이같은결과가예정수술후시행하는집중치료의불필요성을반영하는결과는아니라고판단된다. 예정수술을시행받았던 135명의환자들중 16명의환자에서는수술후집중치료가시행이되었고이로인하여수술후사망률을줄일수있었다고판단된다. 추후이어지는연구를통하여더많은환자를대상으로하여모집단의크기를키우면통계적으로유의한차이가발견될것으로생각된다. College of Information Technology Inha University, Department of Internal medicine School of Medicine Inha University 1, Divisition of Pulmonary and Critical Care Medicine Inha Univesity Hospital 2 Introduction: During ventilator care, the bundle care would be recommended for prevention of ventilator associated pneumonia. Head of bed elevation (HOBE) more than 30, oral care with chlorhexidine and hand washing are included in the bundle care. We develop the new device of continuous monitoring of head of bed elevation to improve the performance of HOBE in bundle care. Method: The attitude and heading reference system (AHRS) was used to measure head of bed elevation. The system had 3-axis gyroscope, 3-axis accelerometer and 3-axis magnetometer sensors (EBIMU-9DOF, E2Box, Seoul). With digital display, this kit was placed just under the board of bed. Inha University Embedded system control team conducted this project. We validated our method using a protractor. Attitude and heading reference system. A is the main body of system, B is digital display part and C is connecting cable. Result: To validate our method, several pairs of measurement were collected on unused beds at angles ranging from 0 to 90. The correlation between measurements using AHRS and protractor is within minimal variation along the line of equality. Conclusion: Our new method would be used to measure head of bed elevation easily. Key words: Head of Bed elevation, Ventilator associated pneumonia, Prevention, Semirecumbent position Key words: 수술후중환자치료, 예정수술, 중환자실 P6-2 A device of continuous monitoring of head of bed elevation in intensive care unit P6-3 A Survey for head of bed elevation in a tertiary intensive care unit POSTER Ki Young Kyeong, Seukkyun Kim, Young Sang Lee, Seungmin Kwak 1,2, Junhyeok Lim 2, Jeongmin Lee 2, Jae Hwa Cho 1,2 Jungheuk Lim 1, Jae Hwa Cho 1,2, Jeongmin Lee 1, Seungmin Kwak 1,2, Jeongseon Ryu 1,2, Haeseong Nam 1,2, Honglyeol Lee 1,2 121
Division of Pulmonary and Critical Care Medicine, Inha University Hospital 1, Department of Internal Medicine, Inha University 2 Introduction: During ventilator care, the bundle care would be recommended for prevention of ventilator associated pneumonia (VAP). Head of bed elevation (HOBE) more than 30 degree, oral care with chlorhexidine and hand washing are included in the bundle care. In several studies, compliance of HOBE were variable from 15% to 76% of study time. We assessed the health care worker s perception and performance of HOBE. Methods: Critical care workers answers four questions: What were made of ventilator bundle care? What degree of head of bed elevation for prevention of ventilator-associated pneumonia? During care how frequently do you determine the head of bed elevation? Clinicians were requested to elevate head of bed up to 30 degree. Results: The participants for survey were 38 doctors and 46 nurses who worked in ICU. In October, 2013, the survey was performed in the ICU and HOB was checked with actual ICU bed and monitor of HOBE. The doctors were residents who consisted of medical, surgical, and service departments. The nurses worked in medical, surgical ICU and operating rooms. Thirty three percent of doctors and 49% of nurses correctly answered HOBE is associated with VAP prevention. ICU nurses checked HOBE more frequently rather than doctors. The performance of HOBE 30 degree was more accurate in nurses than in doctors (p=0.014) Conclusion: Education for sepsis and ventilator bundle care would be needed in participants of ICU. Key words: Survery, bundle care, head of bed elevation P6-4 Incidence and risk factors of postoperative delirium in liver transplant patients 이한나, 유용재, 류호걸 서울대학교병원서울대학교의과대학마취통증의학과교실 Introduction: Delirium after liver transplantation remains a contributory factor in postoperative mortality and an obstacle to early discharge of patients. But there has been limited studies focusing on risk factors for incident delirium after liver transplantation in intensive care unit(icu). Our study was aim to investigate the incidence and risk factors of delirium in patients undergoing liver transplantation. Methods: We retrospectively evaluated electronic medical records for patients admitted to the intensive care unit after elective or emergence liver transplantation from November 2012 to June 2013. Delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU). Pre- and post-transplantation and intraoperative factors potentially associated with delirium were evaluated. Results: Of the 99 patients included in the study, 24(24.24%) developed delirium in the intensive care unit after liver transplantation. In a multivariable logistic regression, independent risk factors for delirium were preoperative Child-Pugh score (CPS)(B vs A OR 1.42 [95% Cl 0.11 to 17.90])(C vs A OR 22.90 [95% Cl 2.67 to 196.38]), postoperative mechanical ventilation time(or 1.07 [95% CI 1.02 to 1.13]). Conclusion: Preoperative CPS and postoperative mechanical ventilation time are predictors for the development of postoperative-delirium in liver transplant patients and are associated with increased ICU lengths of stay. Key words: Delirium, liver transplantation, intensive care unit, Confusion Assessment Methods for the ICU. P6-5 Characteristics of Rapid Response Team patients in a University Hospital Hwa Young Lee 1, Hye Seon Kang 1, Hea Yon Lee 1, Keum Sook Jeun 2, Mi Ra Han 2, Yong Suk Lee 2, Eun Hyoung Kang 2, Chin Kook Rhee 1, Ji Young Kang 1, Seung Joon Kim 1, Sook Young Lee 1, Young Kyoon Kim 1, Seok Chan Kim 1 1 Division of Pulmonary and Critical Care Medicine, St. Mary s Advanced Life Support Team (SALT), Seoul St. Mary s Hospital, Catholic University of Korea, Seoul, Korea, 2 St. Mary s Advanced Life Support Team (SALT), Department of Nursing, Seoul St. Mary s Hospital, Catholic University of Korea, Seoul, Korea Background: The rapid response team (RRT) recognize and manage early at-risk patients on general hospital wards. In this study, we analyzed the characteristics of these patients screened by RRT used at Seoul St. Mary s Hospital. Methods: We retrospectively reviewed 46 activated cases among 20, 306 at-risk patients screened by the RRT; called St. Mary s Advanced Life Support Team (SALT) in Seoul St. Mary s Hospital, from June 2013 to January 2014. SALT was activated by requests of attending doctors or nurses or the electronic medical alert system criteria composed of abnormal vital sign, altered mental status and abnormal laboratory findings. We investigated the baseline characteristics and outcomes of all patients who were managed by SALT. Results: Among 46 activated cases, 28 were females (60.9%) and 18 were males (39.1%). 39 cases (84.8%) were activated by direct calls 122
Poster from attending doctors or nurses, and 7 cases (15.2%) by screening the electronic medical alert system criteria. The majority were orthopedic surgery patients (n=24, 52.2%), followed by urology patients (n=6, 13%). Hypoxia (PaO2 < 90%) was the most common criteria (23.3%) for identifying worsening patients. Respiratory distress (RR > 25/min) found 12.3% of deteriorating cases and low systolic BP (SBP < 85 mmhg) found 9.6% of them. The mean Modified Early Warning Score (MEWS) was 4.96 ± 2.66. 24 cases (52.2%) were stabilized in the general ward after appropriate intervention and 22 cases (47.8%) were sent to the ICU after intervention. Despite SALT intervention, 6 patients (13%) died. The mean hospital day was 27.24 days, from activation to discharge. Conclusions: SALT could save more at-risk patients and is an active and automatic system in reducing hospital code and mortality rates. A longer observational period is needed. 급성혈전에의한동맥혈관폐쇄증이확인되었다. 증상발생 6시간뒤, 재관류를위하여전신마취하응급혈전제거술을시행하였고, 수술소견에서슬와동맥에육안상암종세포색전과원위부혈관에혈전이발생된것을확인하였다. 또한동맥혈관폐쇄증으로인해우측하지동맥의허혈성손상및재관류에의한이차적손상에의한구획증후군을예방하기위해근막절개술을추가로시행하고수술을종료하였다. 수술후항응고치료및수액치료를시행하고수술후 22일특이문제없이퇴원하였다. 결론 : 암종세포색전은주로체순환에의해증상이시작되고, 색전의크기와색전의의한혈관의위치에따라급성관류차단에의한장기에허혈손상을유발하고, 심각한또는치명적인합병증을야기한다. 따라서빠른진단및치료가시행되어야한다. Key words: lung cancer, Tumor embolism, rabdomyolysis Key words: rapid response team; RRS; At-Risk Patient; Mortality P6-6 폐암수술후종양색전에의해발생한급성말초동맥폐쇄질환의진단및치료 황유화, 이현주, 김영태 서울대학교의과대학흉부외과교실서론 : 비외상성급성말초동맥폐쇄질환은혈전증 (85%) 및색전증 (15%) 에의해유발된다. 색전증에의한말초동맥폐쇄질환은상지또는하지의허혈성증상이급격히나타나는경우가대부분이며, 그원인의대부분은심방세동을동반한심장질환을가진환자에서유발된색전이고, 매우드물게악성종양의환자에서종양색전이발생하는것으로보고되어있다. 증례 : 70세여자가폐좌측하엽의육종모양폐암에대해수술적치료를위해입원하였다. 수술전흉부 CT 검사에서좌하엽의폐종양은 5.1cm의크기로좌상엽의일부를침범하고있었고좌측주기관지원위부까지인접하여, 좌측폐전절제술을계획하였다. 수술소견상폐종양은좌측폐정맥으로돌출되어있었으며, 특이문제없이개흉하좌측폐전절제술을시행하였다. 중환자실입실직후환자는우측발목아래의감각소실과통증을호소하였다. 신체검진을통해우측하지에서운동능력은보존되어있었으나, 발목아래로이상감각, 창백, 압통, 우측발등동맥맥박소실및모세혈관충전지간지연을확인하였다. 즉시휴대용도플러검사를통한하지동맥혈류를확인을통해, 혈류소실이관찰되어즉각적으로병상초음파검사를시행하였다. 우측얕은넙다리동맥에서부터슬와동맥에걸쳐혈전에의한폐쇄가관찰되고슬와동맥이하로는혈류가관찰되지않음을확인하였다. 정확한부위및급성또는만성증상여부를감별하기위해하지조영제혈관조영 CT 검사를시행하였다. CT 검사에서동일부위의 P6-7 Incidence and risk factors of delirium in a surgical intensive care unit 이한나, 주재우, 류호걸 서울대학교병원, 서울대학교의과대학마취통증의학과교실 Introduction: Delirium in critically ill patients is associated with increased mortality prolonged ICU and hospital LOS, long-term cognitive impairment. The aim of current study is to evaluate the incidence and risk factors of delirium in critically ill patients in surgical intensive care unit (SICU). Methods: We performed a retrospective study of development of delirium from November 1, 2012, to September 30, 2013. A total of 325 patients admitted to SICU for more than 24 h were enrolled. Patients were evaluated for development of delirium using the Confusion Assessment Method for ICU Patients (CAM-ICU). We evaluated risk factors for the development of delirium in with univariate and multivariate analysis. Results: Of the 325 patients, delirium was developed in 89(27.4%) patients. Multivariate analysis demonstrated that age (OR 1.05, 95% POSTER 123
CI 1.02-1.07), intraoperative red blood cell (RBC) transfusion (OR 0.89, 95% CI 0.81-0.98), APACHE II score (OR 1.10, 95% CI 1.05-1.15), history of stroke (OR 3.05, 95% CI 1.37-6.79), intraoperative administration of midazolam (3.97, 95% CI 1.68-9.40) were independent risk factors of delirium. Conclusions: Old age, intraoperative RBC transfusion, higher APACHE II score, history of stroke, and intraoperative administration of midazolam were predictors for the development of delirium. Postoperative delirium in ICU is associated with increased ICU length of stay and ICU and hospital mortality. 타났음을알수있었고영양수액및일반수액으로투여된일평균전해질양은 1일요구량에미치지못하므로추가적인보충이필요함을알수있었다. 또한전해질부족에대한보충이이루어졌지만정상범위내로교정되지못한경우도적지않아서추가투여및이에대한원인파악에대한노력도요구된다. 본연구를참고하여좀더많은환자의사례를검토함으로써중환자실에서적용할수있는전해질투여프로토콜및가이드라인을세워서적절한전해질이상의교정이수행되도록해야할것이다. Key words: 중환자, 전해질부족, 전해질용량 Key words: delirium, Confusion Assessment Method for ICU Patients, ICU P7-1 외과계중환자의적절한전해질이상교정을위한전해질투여량과전후혈중농도변화조사 방은숙, 이재명 1 아주대학교병원약제팀, 아주대학교의과대학외과학교실 1 연구배경및목적 : 중환자에게서흔하게나타나는전해질이상을교정하기위해투여되고있는전해질의용량과전후혈중농도변화를조사하여적절한보충용량가이드를세우기위함이다. 연구대상및방법 : 2013.10월부터 2014.2월까지아주대학교병원외과계중환자실에입실했던환자중금식이유지된기간의환자 17명을대상으로 IV로투여된 K, Mg, P의 1일투여량과투여전후의혈중농도 ( 새벽채혈 ) 변화를조사하였다. 경장영양공급환자, 신대체요법환자, 흉부수술환자, 전후혈중농도결과가없는경우는제외하였다. 연구결과 : 대상환자는남자 10명, 여자 7명으로환자나이는평균 66.6세 ( 연령분포 49-87세, 중앙값 66세 ) 였고대상환자의평균중환자실재실기간은 11.9일 ( 기간분포 3~36일, 중앙값 8일 ) 이었다. 환자당조사일수는 K 6.6일, Mg 7.2일, P 6.5일이었으며저칼륨혈증은 21.8%, 저마그네슘혈증은 3.8%, 저인산혈증은 43.6% 의빈도를보였다. 영양수액및일반수액을포함한주사제를통해일평균 K+ 는 49.7mEq, Mg2+ 는 10.9mEq, PO43-는 18.7mmol이투여되었다. 전해질부족을교정하기위해경험적으로 IV KCl이보충된경우는 53건 (46.9%) 으로평균보충량은 41.9mEq, IV MgSO4의경우는 9 건 (11.4%) 으로평균보충량은 16.24mEq, IV KH2PO4의경우는 48 건 (43.6%) 으로평균보충량은 26mmol이었다. 혈중농도가참고치보다낮은데도보충하지않은경우는 K 2건 (8.3%), Mg 1건 (33.3%), P 25건 (52%) 있었다. 또한혈중농도가낮아서보충했지만참고치범위내로들어오지못한경우는 K 6건 (27.3%), P 16건 (69.6%) 있었고 Mg의경우보충후에모두정상범위내로교정되었다. 연구결론 : 본연구에서는중환자에게서전해질부족빈도가높게나 P7-2 Unusual cause of left lower abdominal pain presenting to emergency department Kun Dong Kim, Hong Joon Ahn, Won Joon Jeong, Joon Wan Lee Department of Emergency Medicine, Chungnam National University School of Medicine Introduction: We present a case of a patient with hypovolemic shock from non-traumatic rupture of the renal artery aneurysm who initially presented as lower abdominal pain. Case: A-51-year old previously healthy female was transfered to our emergency department complaining of severe left lower abdominal pain with a suspicion of a retroperitoneal abscess. On examination, she was found to be hypotensive and tachycardic, with a rigid left lower abdomen. While she was resuscitated immediate review of the adbdominal CT scan taken at the referring hospital raised suspicion of a massive retroperitoneal hemorrhage from ruptured left renal artery aneurysm. Emergency angiography confirmed the diagnosis and embolization of the left renal artery was successful. She is made an uneventful recovery. Conclusion: Aneurysms of the renal artery are uncommon, when it became symptomatic as in our patient, the attributable mortality is high as 70-80%. Diagnosis of this potentially lethal injury requires a high index of suspicion and early and prompt surgical repair remains standard therapeutic modality. With the advent of endovascular treatment, such condition might be resolved by percutaneous vascular intervention. Key words: renal artery aneurysm, retroperitoneal hemorrhage, intervention 124
Poster 제와항불안제의용량을조사하였다. 선형혼합모델을사용하여통증과불안의연관성및통증, 불안이약물에미치는영향에대해서분석하였다. 결과 : 통증및불안이평가된총 123명의환자 ( 나이 : 59.01±17.72세, 여성 : 47명 (38.21%), 평균재실기간 : 5.88±7.96일 ) 내에서통증 (VAS) 과불안 (FAS, SAI, HAM-A) 은깊은연관성을보였다 (Each p<0.0001). 통증의심각도가변화함에따라하루중사용되는항불안제의용량은통계적으로유의미하게변화하였다 (p = 0.0172). 결론 : 본연구를통해중환자실환자들의통증과불안사이에는유의미한상관관계가있다는것을확인할수있었다. 따라서, 재실기간동안통증과불안을통합적으로평가하고치료하는것이중요하다고판단되며, 이를통해더나은환자의예후를기대할수있을것이다. Key words: 중환자실, 통증, 불안 P7-4 Analysis of blood transfusion requirements in vascular injury with pelvic trauma Hong Kyung Shin, Ho-Seong Han 서울대학교의과대학외과학교실 P7-3 중환자실재실기간동안환자들이경험하는통증과불안의연관성 오주영 1, 손정현 1, 신증수 2, 라세희 2, 윤형준 1, 김재진 1,3, 박진영 1,3 연세대학교의과대학강남세브란스병원정신건강의학과 1, 연세대학교의과대학강남세브란스병원마취통증의학과 2, 연세대학교의과대학행동과학연구소 3 연구배경 : 중환자실에입실하는환자들은다양한신체적, 감정적고통을경험하는것으로알려져있다. 재실기간동안경험하는이러한디스트레스는질병으로부터의회복뿐만아니라퇴실이후의삶의질과도밀접히관계되어있다. 중환자실환자들은흔히높은수준의통증과불안을경험하게되는데, 이러한두가지디스트레스가서로어떠한관련성을갖는지에대해서충분한연구가이루어지지않았다. 대상및방법 : 강남세브란스병원중환자실에 2개월간입실한모든환자를대상으로 CAM-ICU (Confusion Assessment Method for ICU) 를시행하였다. 섬망및혼수상태가아닌환자를대상으로매일통증및불안에대한평가가이루어졌다. 통증은 Visual Analogue Pain Scale (VAS pain) 을사용하여평가하였고, 불안은 Faces Anxiety Scale (FAS), State Anxiety Inventory (SAI) 및 Hamilton Anxiety Scale (HAS) 을통해평가하였다. 재실기간동안투여된아편계진통 Background: Appropriate transfusion is important treatment strategy in pelvic injury patient with hypovolemic state, especillay, in vascular injury caused by pelvic trauma. Aim of this study to suggest the treatment strategy in hypovolemic patients with pelvic vascular injury. Materials and Methods: From May 2003 to August 2013, For 201 pelvic injury patients who visited to the emergency room, medical records were reviewed retrospectively. Results: A total of 201 patients analysis performed, mean age was 49.9. Among 201 patients, 33 was pelvic injury patients with vascular damage(16.4%), there was no statistical significant differences between vascular injury patients and none on initial hemoglobin level and hematocrit. Initial mean systolic pressure of vascular injury patients(n=33) was 111.3mmHg and that of non-vascular injury patients(n=161) was 132.2mmHg, there was statistical significant differences(p<0.01). Mean transfusion ratio and mean prbc transfusion in each group was 11.8%, 81.8% and 0.37(±1.43), 5.18(±5.54), there were significant differences, respectively (P<.001, P<.001). There were significant differences in median amount of prbc transfusion and cardiac arrest ratio among Internal Iliac Artery(IIA) brach injury group(n=24), other artery injury group(n=5) and Iliac Vein(IV) injury group(n=4), respectively.( 3 vs. 10 vs. 12.5, P=0.010), (11.5% vs. 0% vs. 75%, P=0.009). There were significant differences between arterial branch injury group (n=29) and IV injury group(n=4) in median prbc transfusion and POSTER 125
cardiac arrest ratio, respectively.(3 vs. 12.5, P=0.014), (10.3% vs. 75.0%, P=0.014). Conclusion: There were significant differences in transfusion ratio, amount of prbc, cardiac arrest ratio and amount of prbc transfusion among groups divided as injured vascular anatomy. Especially, unlike our knowledge, In IV injury group, the patients underwent more transfusion and cardiopulmonary resuscitation than in arterial branch injury group. Key words: transfusion, pelvic trauma, vascular injury P7-5 다발성외상환자에서지연발견된쇄골하동맥의가성동맥류의치료 김희진, 이정안, 권상휘 대구파티마병원외과 서론 : 쇄골하동맥은주위의뼈와, 근육으로보호되어있기때문에손상을잘받지않는다. 손상의발생빈도는 0.9-3% 로보고되고있으며, 총상이나, 관통상에서는발생빈도가다소높지만, 둔상에서는아주드물게발생한다. 증례 : 71세남자환자로 1개월전 3m 높이에서낙상하여, 대구파티마병원응급실로내원하였다. 내원시, 두부, 척추, 견갑골, 쇄골, 흉부의기흉과혈흉및상완동맥에다발성손상을받았으며, 상완동맥손상및혈전은응급수술을시행하였다, 술후, 특별한문제는없었으며, 환자는수상후 20일후퇴원을하였다. 퇴원 2 주후, 우측쇄골상부에맥박이있는종괴가발견되었으며, 상완동맥과요골동맥의맥박이다소약해져있었으며, 이완된팔의저린증상도더심해졌다. 초음파검사와컴퓨터혈관단층촬영상, 쇄골하동맥의가성동맥류가발견되었다. 우측대퇴동맥을통한동맥조영촬영상, 우측척추동맥이후의쇄골하동맥에서조영제의누출이관찰되었다. 9mm x 5cm Viabahn stent graft (W. L. Gore and Assoc, Flagstaff, Ariz ) 를손상부위에위치시켰으며, 시술후혈관조영사진에서조영제의누출은더이상관찰되지않았다. 1 개월뒤경과관찰에서가성동맥류는보이지않았으며, 상완동맥의맥박은잘만져졌으며, 우측팔의저린증상은호전된양상보였다. 결론 : 쇄골하동맥의손상에의한가성동맥류를수술적방법으로치료하는것은어렵다. 우선, 접근하는방법이나, 근위부동맥을겸자로차단하기가쉽지않다. 다발성손상을받은고령의환자에서, 쇄골하동맥의가성동맥류를혈관내 stent를삽입함으로써특별한문제없이성공적으로치유할수있었다. P7-6 경부자상으로수술시행후발생한뇌경색 - 증례보고 정필영 1, 장지영 1, 변천성 2, 오지웅 3, 심홍진 1 연세대학교원주의과대학외과학교실 1, 흉부외과학교실 2, 신경외과학교실 3 서론 : 경부외상은사망률이 60% 까지보고되는비교적중한질환으로자상의경우대부분수술적치료가필요하다. 다발성외상환자의경우지연성뇌출혈이나뇌부종등의합병증이발생하는경우가있으나수술시행후, 급성뇌경색이발생하는경우는많지않다. 이에저자는경부자상을포함한다발성외상으로내원하여수술후, 급성뇌경색이발생한환자를보고하는바이다. 증례 : 23세여환이강도사건으로인해좌측경부자상, 좌측손목자상, 좌측대퇴부자상, 복부자상으로내원하였다. 내원시신체징후는안정적이였으며좌측경부에서출혈소견이관찰되었다. 혈액수치검사상백혈구수치가증가한소견외특이소견없었다. 응급수술을시행하였으며수술소견상좌측내경정맥손상, 좌측되돌이후두신경손상보여결찰술및일차봉합술시행하였다. 좌측손목과대퇴부도근육손상소견이보여일차봉합술시행하였으며복부자상또한근육손상소견보여일차봉합술시행하였다. 수술후, 중환자실에서인공호흡기치료를시행하였으며수술후 4일에인공호흡기를제거하였다. 수술후 5일에좌측편마비소견보여뇌영상검사를시행하였고급성뇌경색소견관찰되었다. 저분자량헤파린을사용하였으며수술후 19일에증상호전되어퇴원하였다. 결론 : 경부손상및다발성외상발생후, 뇌경색이발생하는경우는매우드물지만항상가능성을염두하여야하며증상발현시적절한치료가필요하다. 또한경우에따라경부손상환자들에게있어예방적인항응고제사용이고려될수있겠다. Key words: 경부자상, 뇌경색, 수술 Key words: 쇄골하동맥, 가성동맥류, 혈관내 stent 삽입술, 126
Poster P8-1 Anatomic relation of internal jugular vein and internal carotid artery in Korean: A CT evaluation 김상훈 1,2, 소금영 1,2, 김동규 2 Departments of Anesthesiology and Pain Medicine, Chosun University, School of Medicine 1, Departments of Anesthesiology and Pain Medicine, Chosun University Hospital 2 P7-7 복부둔상에의한장골동맥폐색의혈관내치료 김희진, 이정안, 권상휘대구파티마병원혈관외과서론 : 총장골동맥은골반골과후복막에위치해있기때문에, 복부둔상에의해손상을받기는매우힘들다. 복부둔상에의한경우는주로골반골의골절을동반하거나, 안전벨트에의해손상을받으며, 이로인해, 이환된다리의허혈증상이발생하게된다. 본원에서, 복부둔상에의해총장골동맥의손상과이로인한폐색이동반된증례가있어, 보고하는바이다. 증례 : 59세남자환자로, 내원 1 시간전, 손수레의핸들과트럭사이에복부가압박당하는손상을받고응급실로내원하였다. 환자는좌측하지의파행 (50m) 과감각이상을호소하였다. 내원당시, 혈압은 140/90, 맥박수 84회로정상이었으며, 신체검사상에서, 복부의압통은없었다. 좌측발이우측발에비해청색증이있었으며, 좌측대퇴동맥및슬와동맥의맥박이소실된소견보였다. 전산화단층혈관조영촬영상, 후복막에전반적인음영증가소견이보였으며, 좌측장골동맥에폐색이관찰되었다. 환자는응급혈관조영술을시행하였으며, 총장골동맥과외장골동맥에혈전용해 (Urokinase 30만 Unit) 치료후, 조영사진상, 총장골동맥의기시부위에동맥벽이불규칙적이며, 동맥류소견이보였다, 조영제의유출현상은보이지않았다. 11mm X 10cm Viabahn stent graft (W. L. Gore and Assoc, Flagstaff, Ariz ) 를삽입하였으며, 이후특별한문제없이시술 5일만에퇴원하였다. 결론 : 복부둔상에의한장골동맥의손상과폐색을수술로치료하기는어렵다. 근위부의혈류를차단하기가쉽지않으며, 전신마취나출혈등의문제가생길수있다. 복부둔상으로, 총장골동맥의손상및혈전이발생한환자에서, 혈관내 stent를삽입함으로써, 특별한문제없이성공적으로치유할수있었다 Background: It is important to have a clear understanding of the anatomy of the IJV and its relationship to the internal carotid arteries (ICA) to avoid inadvertent arterial puncture. The aim of this study was to objectively evaluate anatomic relation of IJV and ICA using a computed tomography (CT) in Koreans. Methods: 162 healthy adult people were retrospectively evaluated using CT imaging taken as a physical checkup from November 2012 to September 2013. The data of both side of IJV and ICA at the level of the cricoid cartilage were recorded and analyzed. Both ICA were taken as reference points for measuring the location of the IJV, recorded as lateral, anterior, medial or posterior. The lateral and anteroposterior (AP) diameters of IJV and ICA were measured. Thereafter, overlap degree (%) was calculated. In addition, we calculated the location changes of IJV by simulating 30 rotation. Results: In a majority of subjects, 96.3% of the IJV were found in the lateral position, 3.7% anteriorly, 0% medially and 0% posteriorly. The mean lateral diameter of right IJV size (15.74 ± 4.09 mm) was significantly greater than that of left IJV (12.61 ± 3.00 mm) (P = 0.007). The mean AP diameter of right IJV (12.79 ± 3.95 mm) was significantly greater than that of left IJV (11.11 ± 3.00 mm) (P = 0.022). Overlap degrees was not significantly different and mean overall percentage of overlap was 42%. However, after simulating rotation, anterior position of IJV was significantly increased [from 4.9 to 18.5% vs. from 2.5 to 21.0%, respectively right (P = 0.007) and left (P = 0.000)]. Conclusions: In Koreans, we should pay attention the chance of puncture of ICA, which will be increased because anterior location of IJV and overlap degrees are increased if spine is rotated with 30. Furthermore, we prefer to choose right over left IJV cannulation for the first attempt because right IJV is larger than left IJV. Key words: anatomical variation, carotid artery, computed tomography, internal jugular vein POSTER Key words: 장골동맥, 복부둔상, 혈관내시술. 127
제34차 대한중환자의학회 정기학술대회 P8-2 폐 절제술 후 발생한 폐 염전에 대한 증례 보고 (3례) 박샘이나, 김영태, 박인규, 전재현, 이현주 서울대학교 의과대학 흉부외과교실 서론: 폐엽 절제술 후 발생하는 폐 염전은 우상엽 절제술 후 우중엽에 서 가장 많이 발생하며 좌측의 경우 좌상엽 절제술 후 좌하엽 염전의 발생이 더 자주 발생 하는 것으로 알려져 있다. 폐암에 대해 폐엽 절 제술 및 종격동 림프절 절제술을 시행 받고 총 세 명의 환자에서 폐 염전이 발생하여 각 증례에 따른 경과와 시행된 치료에 대해 보고하 고자 한다. 증례: 첫 번째 환자는 38세 여자로 2012년 3월 28일 흉강경하 우상엽 절제술 시행 받고 수술 후 4일째 퇴원하였으며 수술 후 10일 경부터 발열 지속되어 응급실로 재내원 하였다. 우중엽 기관지의 완전 허탈 소견 보여 응급 우중엽 절제술을 시행 받고 8일 만에 퇴원하여 현재 양호한 상태이다. 두 번째 환자는 53세 여자로 2012년 6월 5일 흉강 경하 좌상엽절제술 시행 받고 수술 후 2일째 좌하엽의 염전 및 경색 이 의심되어 응급 정복술을 시행하였으나 좌하엽 기관지의 기관지 흉막루 발생하여 농흉과 폐 실질 파괴 지속되었고 흉관 배액을 유지 하였고, 9개월 후 완전 전폐절제술을 시행하였다. 오염된 흉강은 약 3 주간 개방시켜 10회에 걸쳐 세척 후 클라젯 술식 시행하였고 현재 농 흉의 증거 없이 경과 관찰 중이다. 세 번째 환자는 78세 남자로 2012 년 2월 16일 흉강경하 좌상엽 절제술 시행 받고 수술 후 저산소증과 기관지 내시경에서 좌하엽 기관지가 좁아진 소견이 지속되어 수술 후 5일째 응급 기관지 고정술과 폐간막 고정술을 시행하였다. 추가적 인 폐 절제 없이 좌상엽의 기능이 회복 되었으며 폐렴에 대한 치료 후 퇴원하였다. 폐엽 절제술을 시행 받고 남은 폐엽의 기관지와 혈관의 꼬임 현상은 단순히 기관지 협착에 의한 무기폐 뿐만이 아니라 폐동 맥 혹은 폐정맥의 협착을 유발하여 폐 실질의 경색을 유발할 수 있고 기관지의 꼬임이 계속되면 폐기관 흉막루가 발생 할 수 있다. 본 센터 의 사례들을 보면 혈관의 꼬임이 동반되지 않은 경우에는 빠른 정복 술의 시행만으로도 염전된 폐 기능의 회복이 가능하였으나 혈관의 꼬임이 동반되어 정맥성 혹은 동맥성 경색이 동반되면 폐 실질의 회 복은 어려울 것으로 생각된다.폐 엽 절제술 후 저 산소증이 지속되고 흉부 엑스선 영상에서 무기폐가 지속되면 염전의 가능성에 대해 의 심하고 기관지 내시경과 흉부 단층 촬영 영상을 획득하여 빠른 중재 를 통해 잔존폐의 생존을 도모 할수 있을 것으로 생각된다. Key words: 폐염전, 폐엽 절제술, 농흉, 폐경색 P8-3 체외막형산소화장치를 적용한 중환자에서 조기재활치료의 안정성 고영준, 김선미1, 정진희1, 이윤미1, 김현주1, 조양현2, 서지영3, 정치량 삼성서울병원 재활의학과 물리치료실, 삼성서울병원 중증간호팀 1 2 내과계중환자실, 삼성서울병원 중증치료센터 흉부외과, 삼성서울병원 3 중증치료센터 중환자의학과 연구배경: 최근 중환자를 대상으로 한 조기재활치료가 환자의 근력 과 기능향상뿐 아니라 삶의 질의 향상, 중환자실 재원일수의 단축 등 에 긍정적 효과가 있다고 보고되고 있다. 최근 심장 또는 폐기능 부전 환자의 생명 유지를 위하여 중환자실에서 체외막형산소화장치 적용 이 증가되고 있지만 환자의 자세 및 움직임이 제한되어 근 약화 및 전 신 쇠약으로 생존 퇴원 후 삶의 질 저하 및 중대한 신체장애가 남게 된다. 따라서 이러한 환자들의 조기재활치료의 안정성과 유용성에 대한 연구가 필요한 상황이다. 연구대상: 2013년 5월 1일 부터 12월 31일까지 삼성서울병원 중환자 실에서 심장 또는 폐기능 부전으로 체외막형산소화장치를 적용한 환 자 중 조기재활치료를 시행한 9명을 대상으로 후향적 관찰연구를 시 행하였다. 결과: 연구 기간 동안 중환자실에서 체외막형산소화장치를 적용한 9 명의 환자가 조기재활치료를 받았으며, 그 중 5명의 폐이식, 1명의 심 장이식 대기자가 있었다. 총 68회 평균 7.6 ± 5.9회 치료 중 기능적 전기자극치료 및 수동적 가동범위 운동 36회(53%), 근력강화운동 2 회(3%), 기능적 앉기 17회(25%), 일어서기 11회(16%), 보행 2회(3%) 를 시행하였다. 기능적 앉기, 서기, 보행훈련 중 7번(23%)의 치료에 128
Poster 서는 기계환기장치가 동시에 적용되었다. 서기 훈련 중 2회의 빈호흡 (분당호흡수 40초과), 1회의 심박수 증가(130초과)로 치료를 중단하 였으나 휴식 후 바로 회복하였으며, 그 외 특이한 사건은 없었다. 결론: 숙련된 다학제적 치료가 적용 되었을 때 체외막형산소화장치 를 적용한 중환자에서 기능적 앉기, 서기, 보행훈련을 포함한 조기재 활치료가 안전하게 시행될 수 있다. 또한 이러한 환자를 대상으로 포 괄적인 조기재활치료의 효과에 대한 후속 연구가 필요할 것이다. Key words: 체외막형산소화장치, 조기재활치료, 중환자 P8-4 Therapeutic hypothermia after decompressive craniectomy in malignant cerebral infarction3 cases 1 장준영, 한문구 분당서울대학교병원 신경과, 신경외과1 Malignant cerebral infarction consists of 3 to 10% of supratentorial cerebral infarctions and 80% of the patients die without proper treatment. Early decompressive surgery prior to herniation is known to reduce 1- and 6-month mortality to 4.8 and 19.1%, respectively. Moderate hypothermia is also a useful therapeutic option for space-occupying cerebral edema, significantly lowering elevated intracranial pressure and protecting from further neuronal damage. Decompressive hemicraniectomy followed by subsequent therapeutic hypothermia can reduce mortality in patients with malignant cerebral infarction without significantly increasing risk. We report three cases of malignant cerebral infarction treated with hemicraniectomy followed by hypothermia. Case 1 received elective decompressive surgery and hypothermia. Case 2 developed subsequent cerebral infarction with uncal herniation, thus emergent decompressive surgery and hypothermia was performed. Despite surgery and hyperosmolar therapy, case 3 received hypothermia for refractory increased intracranial pressure. All patients survived with a score of 4 or 5 on the modified Rankin scale. Therefore, we find that application of hypothermia after P8-5 POSTER hemicraniectomy is safe and feasible. Several modifications of management strategy could possibly increase the benefit from hypothermia. 우상엽 절제술 후 발생한 지속적 딸꾹질 Key words: brain edema,craniectomy, hypothermia 복진산, 이현주, 김영태 서울대학교 의과대학 흉부외과학교실 서론: 딸꾹질(Hiccup)은 불규칙한 횡격막과 늑간근육의 경련 및 뒤 따른 후두부의 폐쇄에 의해 발생한다. 딸꾹질은 대부분 저절로 호전 되며 이런 경우 대부분 위장의 팽창 및 자극이 그 원인이 된다. 지속 129
적 (persistent) 딸꾹질은 48시간이상지속되는경우를지칭하며 2개월이상지속되는경우난치성 (intractable) 딸꾹질로분류된다. 증례 : 66세남자환자로기침, 가래로내원하였다. 흉부방사선검사에서우상엽결절과폐허탈이발견되었고, 기관지내시경검사소견상기관지내병변으로편평상피세포암으로진단되었다. 폐암에대해흉강경하우상엽절제술및종격동림프절곽청술을시행하였고, 수술중흉막유착이일부있었지만우측횡격막신경과미주신경의손상은없었다. 수술후환자는기관내관을발관된상태로외과계중환자실로전동되었다. 동맥혈검사상 CO2이수술직후 50mmHg에서수술후 1시간 53mmHg, 2시간 58mmHg로증가하는소견이었고, 흡기시심호흡이되지않았다. 환자는과거력상 4년전뇌졸중의후유증으로말이어눌하고, 의사소통이어려운상태였다. 신경학적으로중추신경의이상소견보이지않고자의로조절되지않는규칙적인짧고빠른호흡소견으로특징적인소리는없지만수술후발생한딸꾹질로판단하고가장많은원인인위장팽창을완화시키기위해레빈튜브로배액을시행하고 Metoclopramide를투여하였으나증상은호전되지않았다. 2시간경과후에도증상호전되지않아 Baclofen 5mg을투여하였고일시적으로증상이완화되었으나재발하여 chlorpromazine 25mg을투여하였다. 딸꾹질은약을복용하면수초내에증상이호전되지만 1시간이내다시재발하는양상을반복하였으며 chlorpromazine 50mg을하루 2회투여하고동시에 gabapentin 100mg을하루 3회투여하면서수술 2일후부터조절되었다. 이후약제투여하지않았고수술 6일후합병증없이퇴원하였다. 결론 : 딸꾹질의원인으로는많은것들이알려져있으나가장흔한원인으로는위장의팽창및자극이알려져있다. 딸꾹질의치료방법으로는위장의팽창을감압하는방법들과 chlorpromazine, gabapentin 등의약제들이알려져있다. 이번증례에서도폐암수술후뚜렷한원인없이발생한지속적딸꾹질에대해 chlorpromazine과 gabapentin 투여후증상호전되어이를보고하는바이다. Key words: 폐절제술, 지속적딸꾹질 P8-6 Early reality-orienting assuring and sleep assurance for delirium in Intensive care unit (ICU) 박승용 1, 김현선 2, 최영훈 1, 김소리 1, 박성주 1, 이용철 1, 이흥범 전북대학교병원호흡기알레르기내과 1, 간호팀 2 Background: Delirium is a global disturbance in cognitive function that is characterized by impaired attention associated with changes in the level of consciousness, disorganized thinking, and a fluctuating course. It occurs in up to 60~80% of the ICU patients and has been associated with poor hospital outcomes, including increased morbidity, mortality prolonged length of stay and functional decline. To assess the efficacy of reality-orienting assuring and sleep assurance for delirium prevention, quality improvement project was performed in the ICU patients. Methods: From March 2013 to September 2013, as a part of quality improvement project for decreasing rate of delirium occurrence, reality-orienting assuring and sleep assurance were performed in 12-beds surgical ICU. Patient s medical records were retrospectively reviewed and the patients were stratified into pre- or post- QI groups according to whether the QI projects were applied or not. The primary end point was the incidence of delirium during ICU stays longer than 48 hours. Delirium was assessed using CAM-ICU and related the findings to the level of sedation, as assessed with RASS daily. Results: A total of 130 patients, 88 pre-qi and 42 post-qi patients, were assessed, respectively. The mean age of subjects was 56.6±18.6 (Pre-QI group: 56.9±19.2, Post-QI group: 55.9±17.5), and 54 patients (41.5%) were female. The mean length of ICU stay was 5.1±4.3 days (Pre-QI group: 5.1±4.5, Post-QI group: 5.1±3.9). Even though the length of ICU stay was similar, the rate of delirium incidence was decreased from 34.1% to 19.0% (P = 0.078) with marginal significance. Conclusions: The early reality-orienting assuring and sleep assurance can be relatively effective preventive option for delirium in critically ill patients. Key words: Delirium, reality-orienting assuring, sleep assurance P8-7 Ultrasound-guided PDT without bronchoscopic guidance in critically ill patients 박동일, 정재욱, 문재영 충남대학교병원내과학교실호흡기내과분과 Introduction: To date, percutaneous dilatational tracheostomy (PDT) is a widely used in many intensive care units (ICUs). In general, bronchoscopic guidance during PT performed to avoid injury to surrounding structures, injury to the posterior tracheal wall and in confirming endotracheal placement. However, the use of bronchoscopy requires the availability of specialized equipment, staff and is time-consuming procedure. We thought that ultrasound-guided PDT without bronchoscopic guidance is safe and more rapid method. Methods: We retrospectively analyzed 60 patients who admitted to ICU and performed PDT, half of them was included in broncho- 130
Poster scopic-guided PDT group and another in ultrasound-guided PDT group. Before we performed ultrasound, the endotracheal tube was withdrawn about 15cm~17cm. The ultrasound was used to confirm the level of the tracheal rings, vascular structure and the absence of endotracheal tube in the passage of needle go by. After vertical incision was made, trachea was punctured by needle. We didn t use real-time ultrasound to confirm the needle path up to the anterior wall of trachea. Results: Thirty patients underwent PDT, half of them was in bronchoscopic-guided PDT group and another in ultrasound-guided PDT group. There was no significant difference in baseline characteristics including age, sex, BMI, APACHE II score, SOFA score. The time to finish procedure was 5.1 and 5.2 minutes respectively(no significant difference). There was no complication related to procedure such as significant bleeding, posterior wall injury, pneumothorax and incorrect placement of tracheostomy tube in both PDT groups. Conclusions: Ultrasound-guided percutaneous dilatational tracheostomy is safe and simple method in patients admitted to ICU. 료비상팀에의뢰된시점총다섯시점에서 MEWS를산출하였다. 결과 : 의료비상팀중재이후중환자실의전동여부에따라일반병동군과중환자실군으로분류하였고일반병동군은 62명, 중환자실군은 38명이었다. 의료비상팀에의뢰된시점에서측정한 MEWS는중환자실전동예측에유용하며 (odds ratio 2.02, 95% confidence interval 1.43-2.85), ROC curve를분석한결과의료비상팀에의뢰된시점의곡선하면적은 0.86이었으며, cut-off value 6점을기준으로했을때민감도 82.5%, 특이도 80.5% 로나타났다 (Figure 1). 결론 : MEWS는일반병동내중증패혈증또는패혈성쇼크환자의중환자실전동예측도구로유용하며 cut-off value 6점을기준으로하였을때중환자실전동을가장잘예측할수있음을보여주었다. Key words: 수정조기경고점수, 패혈성쇼크, 중증패혈증 Key words: Percutaneous, tracheostomy, ultrasound P9-1 일반병동내중증패혈증또는패혈성쇼크환자의중환자실전동예측에대한수정조기경고점수의유용성 홍상범 1, 허진원 1, 최혜란 2, 서현숙, 이진미, 한명자, 신유정, 최선희, 손정숙, 정윤경, 정지영, 이주리 서울아산병원의료비상팀, 울산대학교의과대학서울아산병원중환자실 1, 울산대학교의과대학간호대학 2 연구배경 : 패혈증환자의 70% 이상은중증패혈증또는패혈성쇼크로진행되어중환자실치료를필요로한다. 그중 50% 이상은중환자실병상의제한으로일반병동에서치료를받게되고중환자실로의전동지연은사망률을증가시킨다. 수정조기경고점수 (Modified Early Warning Score, MEWS) 는일반병동환자의악화상태를조기에발견할수있는객관적인기준으로중환자실전동률을예측하는데유용하게사용된다. 따라서본연구는일반병동내중증패혈증또는패혈성쇼크환자의시점에따른 MEWS를분석하여중환자실전동예측에대한 MEWS의적절성을알아보고자한다. 연구대상및방법 : 후향적조사연구로 2013년 1월에서 8월까지의료비상팀에의뢰된 18세이상의일반병동내중증패혈증또는패혈성쇼크환자중의료비상팀에의뢰되기전수축기압이 90 mmhg 미만으로감소한환자로하였다. 시점에따른 MEWS를분석하기위해수축기압이 90 mmhg 미만으로처음감소한시점을 zero point로하여 zero point를기준으로 8시간전, 16시간전, 24시간전시점과의 P9-2 커피다이어트이후발생한급성중증심근염증례 김정현, 김희경, 한규현, 김보해, 김학수, 신선영, 김은경, 정혜철, 이지현 차의과학대학교분당차병원호흡기 - 중환자의학과교실 서론 : 급성심근염은다양한원인에의하여발생한다. 최근극심한커피다이어트이후체외막산소교환장치 (ECMO) 까지사용한중증심근염증례를경험하였기에보고한다. 증례 : 41세여환이호흡곤란및구토를주소로내원하였다. 환자는 7 일전부터커피다이어트용물질을복용및관장하였다. 응급실내원 30분만에호흡곤란악화되고발생하여기계환기시작하였으나 FiO2 1.0에서산소유지되지않고승압제사용에도혈압유지되지 POSTER 131
않았다. 흉부사진상폐부종소견보였으며심초음파상전반적인좌심실운동장애와심구축율 15% 를보였다. Veno-arterial (VA) ECMO를적용한이후활력징후및혈중젖산농도가점차정상화되었다. 바이러스와자가항체검사는모두음성을보였으며경도의간, 신손상보였으나 7일이내에회복되었다. 9일후 ECMO 및기계환기이탈하여한달후퇴원하였다. 3달후심초음파상운동장애보이지않았으며심구축율 65% 로회복되었다. 결론 : 급성중증심근염의원인으로본증례와같은독성물질에대한주의가요구된다. Key words: Extracorporeal Membrane Oxygenation, Myocarditis, Toxins 른 EDTA 튜브와 Plain 튜브는원심분리후상층액을냉동보관한뒤동시에측정하였다. 비교분석은수치값과임상적인 3단계 NGAL 농도군 (<100, 150-300, >350 ng/ml) 로나누어단순비교하였다. 결과 : 11명 ( 남 : 여 =9:2, 57.4±12.0세 ) 으로 CKD 환자는 2명였고, 기저심부전이나 AKI 가진단된경우는없었다. 전혈과혈장 NGAL 농도의차이는평균 86.4±122.2 ng/ml ( 범위 -30-357) 였고, 임상적단계로비교하였을때는 2명환자에서차이를보였다. 각각전혈과혈장농도는 51세기저질환 NSCLC with brain metastasis 로구토후병원전심정지로내원하여소생된환자로 NGAL 515 vs. 348 ng/ml 였고, 57세폐렴남자는 208 vs. 149 ng/ml 를보였다. 혈장과혈청 NGAL 농도의차이는평균 152.9±235.3 ng/ml ( 범위 -372-507) 였고, 혈청의농도가임상적단계가 11명중 5명에서혈장에비해낮았다. 2명의환자에서는혈장과혈청을반복적인측정했고임상적분류단계는동일하였다 (#1 1st 572, 2nd 452, #2 1st 384, 2nd 348 ng/ml). 결론 : 매우소수의환자에서전혈과혈장의 NGAL POCT 검사법 (Alere Triage NGAL Test) 측정값은임상적분류범위를고려할때정상과비정상을구분하는데차이가없었다. 그러나, 본단순비교는충분한검체숫자나신뢰성, 재현성, 정확성및환경적변화에대한연구가아님을고려해야하겠다. Key word: NGAL, whole blood, plasma, serum, difference P9-4 간이식후조기사망률예측을위한 APACHE IV, APACHE II, SAPS 3, MELD 점수간의비교분석 이한나, 김혜림, 류호걸 P9-3 검체에따른 POCT 검사법 (Alere Triage R NGAL Test) 로측정한 NGAL 농도의차이 최병호, 정루비, 유승목, 손창환, 오범진 Dept of Emergency Medicine, Asan Medical Center, Ulsan College of Medicine 목적 : 혈중호중구젤라티나제관련리포칼린 (NGAL) 을환자침상곁에서 15분이내에결과를확인할수있는 POCT 검사법 (Alere Triage R NGAL Test, Alere Inc., Waltham, MA, USA) 가최근에국내임상에서도입되고시행되고있다. 검체는헤파린처리된전혈혹은혈장 (plasma) 을이용하는데국내환자에서두검체에대한결과값의차이가있을지단순비교해보았다. 방법 : 성인환자 11명에서한번에 EDTA 튜브 2개및 plain 튜브 1개로검체를채취하였다. 하나의 EDTA 튜브는즉시진단검사의학과로전달되어전혈상태로 Triage R Meters 장비에서측정하였고, 다 서울대학교병원서울대학교의과대학마취통증의학과연구배경 : 간이식후사망률을예측하기위하여 Model for End- Stage Liver Disease (MELD), Child-Pugh 점수, Charlson 동반질환지수등의특이적점수체계들이사용되어왔다. 수용자작업특성곡선아래면적 (the area under the receiver s operating curve [AUC]) 를이용하여구한상기점수들의수행능력은보통이었다. APACHE IV, SAPS 3는비교적최근에개발되었고간이식이후항목을평가항목으로포함하고있다. 본연구에서는간이식환자에서 APACHE IV, APACHE II, SAPS 3, MELD 점수들의수행능력을비교하고자한다. 방법 : 2011년 1월부터 2012년 3월까지생체혹은사체간이식을받은 18세이상의 200명의환자를대상으로하였다. APACHE II, APACHE IV, SAPS 3, 수술후 MELD 점수들은수술후 1일째기록되었다. 수술전 MELD 점수는수술전에계산되었다. 결과 : 전체적인병원내사망률은 4% 였다. Hosmer- Lemeshow 검정을통하여 4개의예측모형이적합함을검증하였다. 곡선아래면적 (AUC) 은 APACHE IV에서 0.807, 수술전 MELD에서 0.853, 수 132
Poster 술후 MELD에서 0.807, SAPS 3는 0.882, APACHE II는 0.841 값을구하였다. 병원내사망과관련된위험인자를분석하기위해단변량및다변량분석을시행한결과, 환자의중증도, 수술후집중치료실체류중승압제사용과적혈구수혈이유의한영향을미치는것으로나타났다. 1년내사망률을평가하였을때, AUC는 APACHE IV 는 0.798, 수술전 MELD는 0.740, 수술후 MELD는 0.745, SAPS 3는 0.757, APACHE II는 0.709 이었다. 결론 : 조기사망률예측에대한 APACHE IV 점수체계의수행능력은우수하였고다른모형들과비슷한정도였다. 이점수체계들은이식대기환자들의선별및수술후관리의평가에사용될수있다고기대된다. Key words: postoperative, liver transplantation, APACHE IV, APACHE II, MELD score P9-5 The Incidence of Atropine Induced Psychosis in Organophosphate Intoxication 김태훈, 정우진, 김오현, 차용성, 차경철, 이강현, 황성오, 김현 연세대학교원주의과대학응급의학교실 배경 : Atropine was administered routinely by intensive care physicians for life-threatening muscarinic symptoms. But its dosage is a matter of debate and its complication is not known definitely. 대상및방법 : This retrospective study was conducted at the emergency department. Patients include that organophosphate intoxicated person and more than 18ys older from March 2008 to December 2013. We collected demographic data, laboratory data and clinical data. The data were analyzed using chi-square, t-test, and ANOVA with SPSS 20.0 K. Data were considered statistically significant when P value was less than 0.05. 결과 : In this study, one hundred fifteen patients were enrolled that was administered atropine therapy in organophosphate intoxication. We had reported thirty-seven patients with atropine induced psychosis and seventy-eight patients had not reported. A psychosis group were showed results significantly that the psychosis occurred in 5.9 ± 2.6 days and atropine infusion dose was 4.04mg ± 0.63mg per hour (0.061mg±0.011mg/h/kg). An APACHE Ⅱ score and an initial Glasgow Coma Scale were not correlation with psychosis, but patients prognosis which was more than 25 points in APACHE Ⅱ were very poor. 결론 : An organophosphate intoxication patients with high doses of atropine showed high incidence the atropine induced psychosis inevitably. Key words: Atropine, Psychosis, Organophosphate intoxication P9-6 응급실체류시간이패혈성쇼크의치료에미치는영향 김정현, 김희경, 김새암, 김학수, 김보혜, 조혜정, 신재경, 홍희진, 이지현 차의과학대학교호흡기 - 중환자의학과교실 연구배경 : 패혈성숔은초기 6시간의처치가중요한응급질환으로대부분의환자는중환자실로전실전까지응급실에서치료를받는다. 이에응급실체류시간이패혈성숔의치료에어떤영향을미치는지알아보고자하였다. 대상및방법 : 2013년 3월 1일부터 9월 30일까지응급실로내원한패혈성숔환자를후향적으로분석하였다. 치료에제한이있거나병동을경유하여중환자실로전실한환자들은제외하였다. 한시간이내항생제사용, 혈중젖산측정및추적, 적절한수액주입, 적절한소변량유지등을묶음처치로정의하였다. 결과및결론 : 총 31명의환자를응급실체류 6시간이내와이상으로구분하였을때각각 15명, 16명이모집되었다. 각군간나이, SAPS II 점수, 기저질환, 초기항생제치료는차이가없었다. 응급실체류시간은각각 258분, 712분이었으며사망률은각각 33%, 53% 로확인되었으나통계적인유의성은없었다. 그러나묶음처치수행률은 13%, 0% 였으며한시간이내항생제투여를제외한나머지처치수행률도각각 93%, 56% 로유의한차이를보였다. Key words: Septic shock, Resuscitation, Time Factors P9-7 혈중호중구젤라티나제관련리포칼린 (NGAL) 의병원내예후인자로서의미 유승목, 손창환, 최병호, 정루비, 오범진 Dept Emergency Medicine, Asan Medical Center, Ulsan College of Medicine 목적 : 혈중호중구젤라티나제관련리포칼린 (NGAL) 은심장수술후사망률과심부전환자의퇴원시사망률을예측할수있다는연구보고가있으나, 만성신질환을가지고있는환자에서는 NGAL 의예후인자로서의역할에대해많은연구가부족하다. 만성신질환 (CKD) 를가진환자에서병원내사망률과혈중 NGAL 농도에대해알아보고자하였다. 방법 : 일개대학병원에입원한환자들중혈중 NGAL 농도가측정된성인환자들을후향적으로분석하였다. AKI 발생시좌심실수축기능저하, BNP, creatinine 농도와기존 CKD 여부및병원입원기간중사망여부를조사하였다. AKI 진단은 Acute Kidney Injury Network과 RIFLE criteria and Kidney Disease Improving Global POSTER 133
Outcomes 기준중하나에부합될때로정의하였다. 혈중 NGAL 농도측정이이루어진시간에가장가까운검사수치와 24시간이내시행한심초음파검사결과와심장내과전문의판단을기준으로심부전을판정하였다. 비교분석은 AKI 군과 Non-AKI 군으로나누고 x2-test, Student t-test를이용하여 p <0.05 일때통계학적으로유의하게다르다고판정하였다. 결과 : 100명 ( 남 : 여 =65:35, 65.0±13.7세 ) 으로 CKD 환자는 44명이었고심부전환자는 37명이었다. 전체환자에서 AKI 군에서 Non- AKI 군보다혈중 NGAL 농도가높았지만 (AKI 780.5±451.8 vs. Non-AKI 476.1±496.2 ng/ml, P=0.011), 원내사망빈도는차이가없었다 [47/81(58.0%) vs. 7/19(36.8%), P=0.126]. CKD를가지고있는환자들에서는 Non-AKI 군의 NGAL 농도가 AKI 보다더높았고 (859.1±460.5 vs. 1149.2±252.8, P=0.043), 원내사망빈도는차이가없었다 (50.0 vs. 66.7%). 심부전환자들에서는 AKI NGAL 농도가 Non-AKI와차이가없었다 (815.8±442.3 vs. 661.8± 530.6, P=0.454), 원내사망빈도도통계적차이가없었다 (51.6 vs. 33.3%). 결론 : 기존에 CKD를가진환자에서는혈중 NGAL 농도가 AKI 여부를통계적으로차이가나지않았다. 그러나, 검사수치의분포를고려할때보다많은연구대상의단일질환군에서추가적인연구의필요성이있을것으로판단된다. Key words: Disseminated intravascular coagulation, DT-ICH, DT- SAH Key word: NGAL, CKD, outcome, prognosis P10-1 Two Mortality Cases from Delayed Traumatic Intracerebra hemorrhage during the DIC Period 오지웅 1, 황금 1, 김종연 1, 조성민 1, 홍순기 1, 허철 1, 변진수 1, 리원연 2 연세대학교원주의과대학신경외과학교실 1, 호흡기내과학교실 2 서론 : Coagluation disorder like disseminated intravascular coagulation (DIC) in a head injury patient was reported in many literature. But preceding DIC and delayed traumatic intracerebral hemorrhage (DT - ICH) was rare, and especially rare pure delayed traumatic subarachnoid hemorrhage (DT - SAH). And it was dangerous disease which can bring about sudden neurologic deterioration or death to an occurrence patient. In this case report, we describe the 2 cases of DIC who was expired from DT-ICH and DT SAH. 증례 : Initial CT brain of both 2 cases was normal. And the laboratory findings of both 2 cases revealed DIC which caused by bleeding from pelvic bone fracture and abdominal surgery. Sudden mental change was occurred from DT ICH, SAH and finally both cases were expired P10-2 The value of arterial spin labeling cerebral blood flow imaging in the diagnosis of seizures Yerim Kim, Chi Kyung Kim, Seunguk Jung, Seung-Hoon Lee, Byung-Woo Yoon, Sang-Bae Ko Department of Neurology, Seoul National University Hospital Introduction: Epileptic seizure leads to a decrease in brain tissue oxygen tension even with an increase in cerebral blood flow (CBF). Arterial Spin Labeling (ASL) perfusion is a non-invasive magnetic resonance imaging technique without need of contrast agent, which is especially useful in patients in the intensive care unit (ICU) because they may have deteriorated renal function. Therefore, we hypothesized that hyperperfusion pattern on ASL map may be useful in identifying ictal hyperperfusion zone in the ICU. 134
Poster Methods: From January 2012 to June 2013, 7 patients with documented seizure (3 had convulsive seizures, and 4 had non-convulsive status epilepticus) on electroencephalogram (EEG) underwent ASL perfusion MRI within 15 minutes after the cessation of seizures. The absolute CSF value was measured and correlated with epileptiform discharge on EEG Results: All with convulsive seizure had higher CBF in the corresponding cortex (55.4 ± 11.3 ml/100g/min) compared to the contralateral mirror area (35.6 ± 8.6) ( P<0.01) on ASL map. In patients with non-convulsive seizure, CBF was elevated in the bilateral thalami (52.1 ± 13.1 ml/100g/min) and superior colliculus (48.3± 9.2 ml/100g/min). Conclusions: Our preliminary case series showed that ASL perfusion might be a useful tool in identifying seizure related hyperperfusion pattern in patients in the ICU. The meaning of different perfusion pattern in convulsive and non-convulsive seizure requires further study. Key words: Arterial Spin Labeling, Cerebral blood flow, seizure P10-3 transcranial doppler for detecting vasospasm were carried out from post-bleed day (the very first day of SAH is day 0) 5 to 9 according to predetermined ceeg protocol. On bleed day 6, neurointensivist detected progressive decrement of alpha/delta ratio on the left hemisphere compared to the right and checked her neurologic status. The patient became acutely right hemiparetic (Medical Research Council, MRC grade 3/5) with global aphasia. Stat conventional cerebral angiography without any kind of CT angiography or CT perfusion was done and showed severe vasospasm on anterior cerebral artery and middle cerebral artery on the left side. Successful chemical angioplasty with intra-arterial infusion of 4mg nimodipine was carried out. She recovered without any significant neurologic deficit and discharged at home. Conclusion: Continuous EEG can be helpful to detect for vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. Real-time and protocol based continuous EEG can reduce the detection time of vasospasm in aneurysmal SAH and also improve clinical outcome. Key words: continuous electroencephalogram, vasospasm, delayed cerebral ischemia, subarachnoid hemorrhage Continuous electroencephalogram for detecting vasospasm in subarachnoid hemorrhage: A Case Report Jongsoo Kang, Hee-Joon Bae, Gyo Jun Hwang 1, Jae Seung Bang 1, Jeong-Ho Hong 2, Moon-Ku Han Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea 1 Department of Neurology, Dongsan Medical Center, Deagu, Korea 2 Background: While symptomatic vasospasm and the associated delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage (SAH) is not uncommon and results in morbidity and mortality, timely recognition of ischemic insult leads to suitable interventions such as stat chemical or balloon angioplasty that prevent to progress to infarction over time. We present a symptomatic vasospasm with early detection using protocol based real-time continuous encephalogram (ceeg) and treated by successful chemical angioplasty without any significant neurologic deficit. Case Report: A 50-year-old woman without any past medical history presented with a severe bifrontal headache, which was found to be due to SAH with ruptured aneurysm on anterior communicating artery (Fisher grade 3). The patient underwent clipping of her aneurysm and craniectomy of left frontal bone. Continuous EEG and daily P10-4 Asymmetric transmedullary veins and clinical outcomes in acute middle cerebral artery infarction 김치경, 정승욱, 김예림, 이승훈, 윤병우, 고상배 서울대학교병원신경과 Introduction: Engorged transmedullary veins (TVs) on Susceptibility weighted imaging are well recognized in patients with acute ischemic stroke, and may represent a state of reduced cerebral perfusion with elevated oxygen extraction fraction. We hypothesized that asymmetric TVs (ATV) in the ischemic hemisphere is associated with poor clinical outcome in patients with acute middle cerebral artery (MCA) infarction. Methods: A consecutive 133 patients with acute MCA infarction within 6 hours from onset were included for the analysis. The numbers of TVs were counted in each hemisphere, and ATV was defined as the difference in number of TVs more than 5. The lesion growth was defined as greater than 10% increase in infarct volume on follow up DWI. Early neurological deterioration (END) was defined as a fall in 4 on NIHSS within 48 hours after admission. The degree of collateral flow was dichotomized as good or poor based on the POSTER 135
ASITN/SIR Collateral Grading System. Results: ATV was identified in 57.1% (76/133) of patients. Patients with ATV had a larger initial infarct volume (33.4mL [IQR, 22.6-47.6] vs. 22.3mL [IQR, 12.2-35.6], p = 0.02) and more severe NIHSS (8 [IQR, 4-15] vs. 3 [IQR, 2-7]; p <0.01). ATV was more frequently found in patients with poor collateral flows (83.3% vs. 31.3%, P <0.01). Patients with ATV experience more END compared with those without (32.9% vs. 14.0%, P = 0.01). After adjusting for age, sex, systolic blood pressure, initial glucose level, and recanalization state, ATV was associated with poor collaterals (OR, 7.7, 95 % CI [1.7-21.6], P <0.01), infarct growth (OR, 5.2, 95% CI [1.5-18.2], p <0.01) and END (OR, 3.9, 95% CI [1.1-13.8], p=0.04). Conclusions: ATV may be a surrogate marker of poor collaterals, predicting infarct growth and neurologic deterioration. Key words: Stroke, MRI, Outcome P10-5 Bromocriptine for Control of Central Hyperthermia in Acute Stroke Patient Accompanied with Pneumonia 남경협 1, 김선희 2, 김재훈 3, 김영대 2 부산대학교의과대학신경외과학교실 1, 부산대학교의과대학흉부외과학교실 2, 부산대학교의과대학외과학교실 3 서론 : Fever is a common complication of acute stroke and central hyperthermia is one of cause. However, the differentiating diagnosis and management of central hyperthermia remain limited. 증례 : A-20-year-old man presented with decreased consciousness. Brain CT and MRI revealed acute infarction at the both cerebellar hemispheres. Although intraarterial thrombolysis, infarction was aggravated and multifocal new lesions involving brain stem were developed. During intensive care, the patient had fever and pneumonia was identified. The fever was responsive to antipyretics. After cessation of deep sedation on two weeks hospital day, high fever was developed with severe diaphoresis and muscle contraction. High fever showed poor response to antipyretics and several antibiotics. On the basis of character of high fever, central hyperthermia was considered as cause. Beta-blocker and baclofen was started, but he showed sustained hyperthermia. Therefore bromocriptine was added, fever was controlled successfully. We speculate that the possibility of central hyperthermia in stroke patients should be considered even though other origin of fever was accompanied. Bromocripine could be an effective treatment for central hyperthermia. Key words: Fever, Stroke, Bromocriptine P10-6 급성일산화탄소중독환자에서심근및뇌손상을예측할수있는초기검사항목 정루비, 손창환, 최병호, 유승목, 오범진 Dept of Emergency Medicine, Asan Medical Center, Ulsan College of Medicine 목적 : 일산화탄소가스에급성으로노출된경우동맥혈일산화탄소혈색소비율과임상소견을함께고려하여고압산소치료를시행하게되는데, 응급실까지내원하는시간간격과고농도산소투여를포함한병원전요소에따라일산화탄소검사값은급격히낮아진다. 병원전요인들에영향을적게받는일산화탄소가스노출정도를알려주는지표와심근및뇌손상을예측할수있는지표가필요하다. 방법 : 급성일산화탄소가스노출성인환자에서 COHb, CK, CK- MB, ctni, BNP, D-dimer와 ischemia-modified albumin을측정하였다. 입원중 CK, CK-MB, ctni 추적검사와심초음파등을통해심근손상을진단하였고, Brain MR diffusion 검사와신경학적평가를통해뇌손상을진단하였다. 심근손상은 ctni 0.7 ng/ml 초과, 뇌손상은영상학적이상소견및신경학적이상으로정의하였다. 통계학적비교는 x2-test, Student t-test, Pearson correlation를이용하여 p < 0.05 일때유의하다고판정하였고, ROC curve 로정확도를비교하였다. 결과 : 84명 ( 남 : 여 =47:37, 39.6±16.4) 으로최초내원응급실 HbCO 29.7±12.8%(65명 ), 심근손상 9.5%(8/71명 ), 뇌손상 16.7%(14/80 명 ) 이었다. 본원응급실 HbCO 18.65±14.6%(81 명 ) 이었다. Ischemiamodified albumin 농도가최초내원응급실 HbCO 와약하지만의미있는상관관계를보였다 (Pearson correlation coefficient 0.234, p= 0.042). 내원시예측인자로 ctni 0.7 ng/ml 초과군에서미만군에비해내원시 (62.5% vs. 11.3%, p=0.003) 및입원중뇌손상빈도가높았다 (52.4% vs. 5.1%, p<0.001). 내원시 ctni 0.7 ng/ml 이하환자에서심근손상에대한진단적정확도는 ROC 곡선밑면적이내원시 lactate 0.947, ctni 0.853, CK-MB 0.852 였다. 뇌손상에대한진단적정확도는 BNP 0.932 였다. 결론 : 급성일산화탄소가스노출의정도를병원전요인에영향을적게받는검사로는 ischemia-modified albumin가, 입원중심근손상에대한예측은내원시 lactate, 그리고뇌손상의예측은 BNP 검사가보조적인도움이될수있을것이다. Key word: carbon monoxide poisoning, heart, brain, prognosis 136
Poster P11-1 기관부지법시행직후에생긴객담으로인한일측폐의완전폐쇄 김규남, 정미애, 최성락, 이영선, 전종헌 한양대학교의과대학마취통증의학과교실 서론 : 고용적저압력의기관삽관튜브의사용에도불구하고장기간의기관내삽관이기관협착의가장흔한원인이다. 기관삽관된환자에서 6-22% 빈도로기관협착이발생하며, 1-2% 에서는심각한합병증을유발한다. 기관부지법은좁아진기도내강의확장을위하여시행되며본증례에서기관부지법시행직후객담으로인해발생한완전한일측기도폐쇄로응급기관절개술을경험하였기에이를보고하고자한다. 증례 : 신장 175 cm, 체중 80 kg의 25세남자환자가두부외상으로인한경막외혈종으로개두술및혈종제거술후에 5일간커프가있는내경 7.5 mm size의기관삽관튜브로기관내삽관된상태로중환자실치료후에일반병실로전실하였다. 수술 25일후호흡곤란을호소하여시행한전산화단층촬영검사결과갑상선근처에서주기관이 3 cm길이로직경이 5.10 mm로좁아진소견을관찰할수있었다. 기관협착의치료를위하여기관부지법을시행하기로결정하였다. Propofol과 remifentanil을사용하여완전정맥마취를시행하였으며, 수술종료후 sugammadex 160 mg을근이완길항을위하여사용하였다. 기관발관 10분후심각한호흡곤란증상을호소하며, 청진상왼쪽폐의호흡음이들리지않았다. 산소마스크로 100% 산소 8 L/min를공급함에도맥박산소포화도가 85% 로감소하여 5.5 mm size의기관삽관튜브를사용하여전신마취하에응급기관절개술을시행하였다. 이후굴곡성기관지경을사용하여기관지를관찰한결과, 기관용골을지나왼쪽주기관지전체가객담으로완전폐쇄되어환기가되지않았다.(Fig.1) 왼쪽주기관지를지나왼쪽위, 아래엽기관지의입구까지객담으로완전폐쇄되어있었다. 굴곡성기관지경에부착된흡입기를사용하여객담을제거후왼쪽폐에서호흡음이확인되었다. 환자는중환자실로이송되었고이후특이소견은관찰되지않았다. P11-2 Intravascular lymphoma presenting metabolic acidosis and pulmonary infiltrate: Case report Tae Yun Park, Jinwoo Lee, Sang-Min Lee Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital Introduction: The lung involvement in intravascular lymphoma is very rare and there were no cases admitted to intensive care unit (ICU) due to rapid progression of acidosis. Case presentation: We report a 62 years old female who presented with fever, cough and myalgia, chest discomfort of two months duration. Due to diffuse ground glass opacities of lung, she was treated with oral antibiotics as a pneumonia. But she developed lactic acidosis and intubated for respiratory fatigue. We made early diagnosis of pulmonary intravascular lymphoma by video-assisted thoracoscopic lung biopsy. After chemotherapy, lactic acidosis and respiratory symptom was improved. Conclusion: The clinical presentation of intravascular lymphoma is highly variable and the diagnosis is often delayed. In patients with rapid progressive acidosis, we should consider the possibility of hematologic malignancy as a differential diagnosis. Key words: lactic acidosis, intravascular lymphoma Key words: airway obstruction, tracheal stenosis POSTER 137
제34차 대한중환자의학회 정기학술대회 mannii were more often isolated and associated with mortality in NHCAP in ICU patients, therefore these MDR pathogens as well as PSI score should be considered as prognostic factors in NHCAP. Key words: Intensive care units; Multi-drug resistant; Mortality; Pneumonia P11-3 Clinical characteristics and prognostic factors of the patients who admitted in intensive care units with nursing and healthcare-associated pneumonia Myoung Kyu Lee, Sang-Ha Kim, Suk Joong Yong, Kye Chul Shin, Hyun Sik Kim, Tae-Sun Yu, Jae Ho Seong, Ye-Ryung Jung, Won-Yeon Lee Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Gangwon, Korea Introduction: The limited studies have been identified about nursing and healthcare-associated pneumonia (NHCAP) requiring intensive care units (ICU) admission. So we evaluated the clinical and microbiological characteristics of NHCAP patients who admitted to ICU. Materials and Methods: NHCAP was categorized as four groups. Reviewed database included age, gender, comorbid diseases, laboratory data and microbiological results. The severity of pneumonia was assessed by using the pneumonia severity index (PSI) and CURB-65. The 30-day mortality and duration of ICU stay were evaluated as endpoints. Results: Total 428 patients (men, 67.1%) were reviewed. The mean age was 71.2 ± 11.9 year-old. Thirty-day mortality was 25.5%, and duration of ICU stay was 13.8 ± 13.3 days. Mortality (P = 0.349) had no significant difference among four groups although duration of ICU stay (P = 0.008) was significantly longer in group C and D. When we performed multivariate logistic analysis using significant variables, PSI score (OR 1.015 95% CI 1.004-1.026, P = 0.009), serum HCO3- level (OR 0.954 95% CI 0.918-0.993, P = 0.020), duration of ICU stay (OR 0.971 95% CI 0.950-0.993, P = 0.010), multidrug-resistant (MDR) pathogens including ESBL-producing K. pneumoniae (OR 2.688 95% CI 1.237-5.840, P = 0.013) and MDR A. baumannii (OR 3.081 95% CI 1.504-6.311, P = 0.002) were significantly associated with 30-day mortality. Conclusion: ESBL-producing K. pneumoniae and MDR A. bau- 138
Poster P11-4 A case of ventilatory monitoring in a patient with ARDS using Electronic Impedance Tomography (EIT) Hyun Jung Kim, So Hee Park 1, Younsuck Koh, Sang-Bum Hong, Chae-Man Lim Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Division of Pulmonary and Critical Carre Medicine, Department of Internal Medicine, College of Medicine, University of Kyenghee, Kangdong Hospital 1 Introduction; Acute respiratory distress syndrome (ARDS) is a common complicated condition with critically ill patients and mechanical ventilation is a cornerstone of the treatment. However, since positive ventilation itself can damage the lung, it is necessary to set optimal pressure and volume for lung ventilation and monitor carefully. Electrical impedance tomography (EIT) can be a useful tool in this way. Case; A 73-year-old woman with dyspnea for five days who has been taking prednisolone 30mg for CNS vasculitis visited to emergency department. She also suffered from fever with chills, crackle was detected on left lower lung field. Blood pressure was 88/65 mmhg and saturation was 83 %. Chest PA showed bilateral diffuse infiltration and EKG was normal sinus rhythm (Fig 1). Empirical antibiotics was administered intravenously and bronchoscopy with bronchoalveolar lavage was done for identifying causative pathogen. Despite of mechanical ventilation with FiO2 1.0, hypoxemia persisted then her position was changed to prone. After that, FiO2 was decreased to 0.45 by eight hours. We asertained that improvement of oxygenation was resulted from that ventilation of lung was changed from heterogeneous to homogeneous by changing prone position using EIT.(Fig.2) EIT of the lung noninvasively measures relative impedance changes in lung tissue during breathing and creates images of the local ventilation distribution at the bedside. Therefore, EIT can be used to assess the effect of recruitment maneuver or prone position and guide ventilator setting based reliable data. Key words: Electrical Impedance Tomography, Acute Respiratory Distress Syndrome, Prone Position P11-5 기관내삽관튜브발관후지연되어발생한치료되지않던기도부종 김경우 1, 김지연 2, 김준현 2 인제대학교서울백병원마취통증의학과 1, 인제대학교일산백병원마취통증의학과 2 Tracheal intubation always has a risk of laryngotracheal injury and the possibility of laryngeal edema due to laryngotracheal injury. Postextubation laryngeal edema (PLE), which could take place immediately after an extubation, makes airway management difficult. The percentage of PLE occurrence is about 2-22%. PLE mainly occurs within 30 minutes after extubation regardless of the severity of symptoms. Forty-seven percent of PLE cases occur within five minutes. We report a case of delayed intractable PLE after extubation in 78-year-old female patient who underwent uneventful operation. The patient had underwent tracheostomy 30 years ago. The PLE occurred 14 hours after post op and intubation was performed. 36 hours after the intubation, extubation was performed. But PLE occurred again 48 hours after the extubation even though many treatment methods were used in the ICU. Re-intubation was performed. On the fifth day after the reintubation, extubation was performed. However, two days later, respiratory distress and decreased SaO2 occurred again. And accompanying pneumonia was found. Because steroid administration was difficult to maintain further due to the pneumonia and inflammation at the operated region, tracheostomy was decided. Fourteen days after the tracheostomy, the pneumonia was resolved, and the patient was discharged from the intensive care unit. POSTER Key words: Airway Management, Airway Obstruction, Laryngeal Edema, Steroids, Tracheal Extubation 139
was changed to intravenous since the patient showed persistent diarrhea. On 32th day of ECMO, serum level of rifampicin was still low, we increased the dose, and continued therapeutic drug monitoring until weaning of ECMO. After then, her trans-tracheal specimens have no bacillus consistently. Patient was weaned from ECMO on 85th day of hospitalization, and we return the standard dose. Patient was recovered from ARDS (Fig 1 B), and was discharged after 6 month hospitalization. Conclusion: Therapeutic drug monitoring could help physician to decide the appropriate dosage of antibiotics during ECMO. P11-6 Key words: Tuberculosis, therapeutic drug monitoring, extracorporeal membrane oxygenation Therapeutic drug monitoring of anti-tuberculosis agents during ECMO in tuberculosis-ards Hae Wone Chang 1, Hyung Sook Kim 2, Eun Sook Lee 2, Sung Jin Nam 3, Dong Jung Kim 4, Sang Hun Park 1, Young-Jae Cho 3 1 Department of Anesthesia and Pain Medicine, Seoul National University Bundang Hospital, 2 Department of Pharmacy, Seoul National University Bundang Hospital, 3 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, 4 Department of Cardiothoracic Surgery, Seoul National University Bundang Hospital Introduction: We report our first experience of treating a patient with acute respiratory distress syndrome (ARDS) induced by military tuberculosis, using therapeutic drug monitoring and extracorporeal membrane oxygenation (ECMO). Case: A 44-year old woman was referred for persistent fever, and dyspnea. She had been suspected to have Behest s disease, prescribed steroid for 2 months. Chest x-ray showed multiple nodules in both lungs suggesting military tuberculosis (Fig 1 A). Mechanical ventilation was initiated to treat acute respiratory failure. Standard doses of anti-tuberculosis agents, including isoniazid, rifampicin, ethambutol, and pyrazinamide were administered, and subsequent bronchoscopy biopsy confirmed tuberculosis. During the course of mechanical ventilation, pneumothorax was eventually developed in both lungs serially. Chest tubes were inserted, and venovenous ECMO was placed to prevent further ventilator-induced lung injuries. On 18th day of ECMO, therapeutic drug monitoring showed sub-therapeutic level of rifampicin (Table 1). We started to increase rifampicin dose by the therapeutic drug monitoring. We received the first report of her trans-tracheal specimens showing no presence of Mycobacterium tuberculosis on smear and culture, on 34th day after starting anti-tuberculosis medications. On 26th day of ECMO, route of rifampicin P11-7 Emergency cryoextraction of massive mucus plugs obstructing central airway via flexible bronchoscopy Hyo Jae Kang, Bin Hwangbo, Hee Seok Lee 140
Poster Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea Introduction: This is the first case of successful emergency cryoextraction of massive mucus plugs using flexible bronchoscopy in the critically ill patient who needed advanced cardiac life support(acls)activation. Case report: A 64 year-old man visited emergency room (ER) due to sudden dyspnea. He was diagnosed with adenocarcinoma of lung of clinical stage IV, two years ago. Despite of palliative chemotherapy and radiation therapy, malignant obstruction of distal trachea and right main bronchus progressed. Initial chest radiography in the ER revealed total collapse of right lung and the chest computed tomography showed massive mucus plugs from distal trachea to right main bronchus. He was intubated and transferred to intensive care unit. Cryoextraction via flexible bronchoscopy was done for removal of massive mucus plugs. However, after first removal of massive mucus plug in trachea successfully, another mucus plugs in right main bronchus spilled over into left main bronchus. And then, oxygen saturation, heart rate, and systolic blood pressure was decreased critically, so ACLS was activated. Cryoextraction was continuously done, for removal of massive mucus plugs obstructing both main bronchi during and after ACLS, and then the patient was fully recovered. The patient was weaned off mechanical ventilator without any neurological sequelae. Conclusion: Cryoextraction is very effective method for rapid removal of massive mucus plugs in patients with central airway obstruction, and can be safely applied even in the critically ill patients. Key words: cryoextraction, airway obstruction, mucus plugs P12-1 소세포성폐암환자에서인공호흡기이탈의어려움으로진단된중증근무력증의 1 예 박주희, 이진우, 김범석 1 서울대학교의과대학내과학교실서울대학교병원호흡기내과, 혈액종양내과 1 서론 : 인공호흡기로부터이탈과정은인공호흡기로부터점차적으로환자자신으로호흡을위한일을이전시키는과정으로인공호흡기이탈실패는신경계, 흉곽, 호흡근육, 기도및폐포등으로구성된환자의호흡기계의여러가지요인이복합적으로작용하여발생할수있다. 증례 : 77세남자환자가호흡곤란으로시행한검사에서오른쪽폐문부종괴소견보여조직검사시행하였고소세포성폐암진단되어항암치료진행하였다. 4차항암치료이후호흡곤란으로응급실내원하였고호흡부전진행되어기도삽관및기계적환기요법시행하였다. 기저폐기종과동반된간질성폐질환있던환자로폐렴과동반된급성악화고려하여스테로이드투약하였고이후로지속적인기계환기이탈의어려운소견보였다. 이에시행한검사및임상소견에서폐렴은호전되고산소요구량감소하였으나호흡근위약및상지근위부근력약화보였다. 심부건반사는사지에서보존되어있었고감각장애및그외의신경학적장애없이양측상지근위부근력약화와호흡근위약소견보여시행한검사에서아세틸콜린수용체항체증가된소견보였으며안륜근과소지외전근, 척측수근굴근에서시행한반복신경자극검사에서양성소견을보였고근육효소는정상이었다. 이에중증근무력증위기로인한호흡부전으로판단하여면역글로블린정맥주사및항콜린에스터레이즈투약후기계환기이탈에성공하였으며이후상지근위부근력회복되었다. 결론 : 인공호흡기이탈의어려움이있을경우에가역적인원인인기저질환과동반된신경근이상또한고려가필요하겠다. POSTER Key words: 소세포성폐암, 중증근무력증, 인공호흡기이탈 141
P12-2 증례보고 : 결핵성파괴폐환자에서폐동맥확장으로인하여발생한우측중간기관지협착 김수정 1,2,3, 박성수 1,3 서울대학교의과대학내과학교실 1, 서울대학교병원호흡기내과 2, 서울대학교병원운영서울특별시보라매병원호흡기내과 3 서론 : 폐동맥고혈압과폐성심이동반된만성폐쇄성폐질환환자에서폐동맥에의한기관지협착의발생은매우드물게보고되고있다. 본증례에서는폐동맥고혈압이동반된결핵성파괴폐환자에서폐동맥확장으로인한우측중간기관지 (bronchus intermedius) 협착이발생한 1예를보고하고자한다. 증례 : 20년전결핵으로치료후완치된 53세여자환자가호흡곤란이악화되어내원하였다. 발열, 기침, 화농성객담동반되었으며흉부사진상양쪽폐하엽의음영증가소견보여폐렴에대하여치료시작하였으나호흡부전진행하여기관삽관후기계호흡을시작하였다. 기계호흡시일호흡용적이 100mL 이상유지되지않았으며우측폐하엽호흡음은청진되지않았고흉부방사선사진에서우하엽음영감소소견이보였다. 흉부단층촬영에서우측폐동맥이확장되어우측중간기관지를누르고있는소견이확인되었고, 심초음파에서폐동맥고혈압 (systolic pulmonary artery pressure=78mmhg) 및폐성심소견이관찰되어우측중간기관지협착으로인한 shunt가호흡부전에기여할것으로판단하였다. 이에기관지내시경하이중관기관지튜브 (double-lumen endobronchial tube) 를삽관후, 기관내튜브를우측중간기관지에위치시켜환기량증가를도모하였다. 이중관기관지튜브삽관후일시적인일호흡용적증가를보였으나다시호흡부전진행하여환자사망하였다. 결론 : 폐동맥확장으로인하여발생한우측중간기관지협착으로이중관기관지튜브를삽관하였으나호흡부전진행하여환자가사망한증례이다. Key words: 폐동맥고혈압, 기관지협착, 이중관기관지튜브 P12-3 기관지확장증환자에서일시적상기도폐쇄에의해발생한내인성호기말양압증례 윤소희, 김강우, 박종국 제주대학교병원마취통증의학과 서론 : 본증례는체위변경으로인하여하기도부에축적되어있던분비물이상부로이동하여일시적으로상기도폐쇄를유발하고, 이로인하여내인성호기말양압이발생하였던경우이다. 상기도폐쇄가있을당시와제거된후의호흡역학의변화를호기말양압적용과관련하여관찰하였다. 증례 : 71세여자 (162cm, 65kg ) 환자가허리통증을주소로디스크제거술을받기위하여내원하였다. 과거력상고혈압과만성폐쇄성폐질환병력이있었으며 NYHA Fc II~III 정도의호흡곤란이있었다. 수술시 7.0mm내경의강화튜브로기관내삽관하고마취기 (GE Datex-Ohmeda Aisys Carestation, USA) 로 500ml x 12회 /min, 흡호기대비 1:2에서최대흡기압 20mmHg, 흡입산소분율 0.5로, 용적조절환기를유지하였다. 수술진행을위하여환자를 Wilson frame 위에복와위로자세변경한후일회호흡량 500ml, 호흡수 10회 /min에서최대흡기압 21mmHg로관찰되었다. 약 15분이경과하였을때최대흡기압이 29mmHg 까지증가하였고추가로근이완제투여후에도흡기압변화는없었다. 호흡기계분비물에의한현상으로생각하여일시적으로 PEEP 0 -> PEEP 10 -> E-tube suction -> PEEP 0 -> PEEP 10을적용하며유량계로호흡기계물리적변수를측정하고분비물제거전과후, 호기말양압설정여부에따른변화를비교하였다. 압력상승이있을때시행한 ABGA 상 7.46-38.7mmHg-57.6mm Hg-90.6% 소견보였고, 이후추적검사결과 7.49-33.7mmHg-255mm Hg-97.7% 로확인하였다. 수술중두드러진혈역학적변화는관찰되지않았다. 결론 : 그림 (Fig 1.) 과같이분비물제거전, 후의호흡의기계적변화값을호흡주기그래프로비교해보면내인성호기말양압이발생함을알수있다. Key words: airway obstruction, auto-peep, respiratory mechanics 142