Psychological Responses among Humidifier Disinfectant Disaster Victims and Their Families

To substantiate psychological symptoms following humidifier disinfectant (HD) disasters, counseling records of 26 victims and 92 family members of victims (45 were bereaved) were analyzed retrospectively. Among the victims, 34.6% had Clinical Global Impression-Severity scores of over 4, which meant they were moderately ill. While anxiety/fear and depression with respiratory symptoms were frequently observed in victims and family members, chronic psychological distress such as alcohol/smoking abuse and insomnia was relatively high in bereaved family members. In conclusion, it is important to provide mental health support for victims and their families, focusing on the characteristic symptoms of each group as well as monetary compensation.

Improvement in the survival rates of extracorporeal membrane oxygenation-supported respiratory failure patients: a multicenter retrospective study in Korean patients

Background

Although the utilization of extracorporeal membrane oxygenation (ECMO) is increasing and its technology is evolving, only a few epidemiologic reports have described the uses and outcomes of ECMO. The aim of this study was to investigate the changes in utilization and survival rate in patients supported with ECMO for severe respiratory failure in Korea.

Methods

This was a multicenter study on consecutive patients who underwent ECMO across 16 hospitals in Korea. The records of all patients who required ECMO for acute respiratory failure between 2012 and 2015 were retrospectively reviewed, and the utilization of ECMO was analyzed over time.

Results

During the study period, 5552 patients received ECMO in Korea as a whole, and a total of 2472 patients received ECMO at the participating 16 hospitals. We analyzed 487 (19.7%) patients who received ECMO for respiratory failure. The number of ECMO procedures provided for respiratory failure increased from 104 to 153 during the study period. The in-hospital survival rate increased from 30.8% to 35.9%. The use of prone positioning increased from 6.8% to 49.0% (p < 0.001), and the use of neuromuscular blockers also increased from 28.2% to 58.2% (p < 0.001). Multiple regression analysis showed that old age (OR 1.038 (95% CI 1.022, 1.054)), use of corticosteroid (OR 2.251 (95% CI 1.153, 4.397)), continuous renal replacement therapy (OR 2.196 (95% CI 1.135, 4.247)), driving pressure (OR 1.072 (95% CI 1.031, 1.114)), and prolonged ECMO duration (OR 1.020 (95% CI 1.003, 1.038)) were associated with increased odds of mortality.

Conclusions

Utilization of ECMO and survival rates of patients who received ECMO for respiratory failure increased over time in Korea. The use of pre-ECMO prone positioning and neuromuscular blockers also increased during the same period.

Prognostic value of blood biomarkers in patients with unprovoked acute pulmonary embolism

BACKGROUND:

Better outcomes have been observed in patients with acute unprovoked than provoked pulmonary embolism (PE). Prognostic biomarkers were studied in heterogeneous patient population and were not verified in patients with unprovoked PE.

METHODS:

Patients diagnosed with unprovoked acute PE from 2010 to 2017 at Asan Medical Center, South Korea, were analyzed retrospectively. Adverse composite outcomes were defined as thrombolysis, thrombectomy, extracorporeal membrane oxygenation, or death. Venous blood samples were collected at the first visit before anticoagulant treatment. Biomarkers associated with composite outcomes were analyzed and compared with preexisting risk models.

RESULTS:

This study included 265 patients (48.7% male) with a median age of 66.0 (interquartile range 52.0, 75.0) years. Composite outcomes occurred in 20 (7.5%) patients. Hemoglobin, uric acid, and glucose were significantly and independently associated with adverse composite outcomes. This biomarker model showed the highest prognostic accuracy for adverse composite outcomes, with an area under the curve of 0.806 (95% confidence interval: 0.702–0.911, P < 0.001), which was significantly better than that of PE severity index (PESI) or simplified PESI, and comparable to that of the European Society of Cardiology (ESC) risk classification.

CONCLUSIONS:

The biomarker model including hemoglobin, uric acid, and glucose has good prognostic performance comparable to the ESC risk classification while PESI or simplified PESI score was not useful in unprovoked PE.

Impact of a custom-made 3D printed ergonomic grip for direct laryngoscopy on novice intubation performance in a simulated easy and difficult airway scenario-A manikin study

Direct laryngoscopy using a Macintosh laryngoscope is the most widely used approach; however, this skill is not easy for novices and trainees. We evaluated the performance of novices using a laryngoscope with a three-dimensional (3D)-printed ergonomic grip on an airway manikin. Forty second-year medical students were enrolled. Endotracheal intubation was attempted using a conventional Macintosh laryngoscope with or without a 3D-printed ergonomic support grip. Primary outcomes were intubation time and overall success rate. Secondary outcomes were number of unsuccessful attempts, first-attempt success rate, airway Cormack-Lehane (CL) grade, and difficulty score. In the easy airway scenario, intubation time, and the overall success rate were similar between two group. CL grade and ease-of-use scores were significantly better for those using the ergonomic support grip (P < 0.05). In the difficult airway scenario, intubation time (49.7±37.5 vs. 35.5±29.2, P = 0.013), the first-attempt success rate (67.5% vs. 90%, P = 0.029), number of attempts (1.4±0.6 vs. 1.1±0.4, P = 0.006), CL grade (2 [2, 2] vs. 2 [1, 1], P = 0.012), and ease-of-use scores (3.5 [2, 4] vs. 4 [3, 5], P = 0.008) were significantly better for those using the ergonomic support grip. Linear mixed model analysis showed that the ergonomic support grip had a favorable effect on CL grade (P<0.001), ease-of-use scores (P<0.001), intubation time (P = 0.015), and number of intubation attempts (P = 0.029). Our custom 3D-printed ergonomic laryngoscope support grip improved several indicators related to the successful endotracheal intubation in the easy and difficult scenario simulated on an airway manikin. This grip may be useful for intubation training and practice.

Central Extracorporeal Membrane Oxygenation and Early Rehabilitation for Persistent Severe Pulmonary Hypertension Following Pulmonary Endarterectomy

Chronic thromboembolic pulmonary hypertension is potentially curable with a pulmonary endarterectomy. However, approximately 20% of patients have persistent pulmonary hypertension after pulmonary endarterectomy, which is a major risk factor for postoperative death. Here, we report a 34-year-old woman who suffered persistent severe pulmonary hypertension following a successful pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Extracorporeal membrane oxygenation (ECMO) and atrial septostomy were successfully performed as rescue treatments, and active rehabilitation during ECMO was prescribed to facilitate recovery.

Effect of vitamin D deficiency in Korean patients with acute respiratory distress syndrome

BACKGROUND/AIMS

Vitamin D modulates innate and adaptive immune responses, and vitamin D deficiency is associated with increased mortality in hospitalized patients with pneumonia. We evaluated the prevalence of vitamin D deficiency in Korean patients with acute respiratory distress syndrome (ARDS) and its effect on the clinical outcomes of ARDS.

METHODS

We retrospectively analyzed the data of 108 patients who had a measured serum level of 25-hydroxy vitamin D3 (25(OH)D3) at the time of diagnosis with ARDS. The clinical outcomes were evaluated based on 25(OH)D3 levels of 20 ng/mL and stratified by quartiles of 25(OH)D3 levels.

RESULTS

The mean age of patients was 59.4 years old; 77 (71.3%) were male. Vitamin D deficiency was found in 103 patients (95.4%). The mean 25(OH)D3 level was 8.3 ± 7.0 ng/mL. Neither in-hospital mortality (40.0% vs. 68.0%) nor 6-month mortality (40.0% vs. 71.8%) significantly differed between groups. There were no significant differences in 25(OH)D3 level between survivors (8.1 ± 7.6 ng/mL) and non-survivors (8.5 ± 6.8 ng/mL, p = 0.765). There were no trends toward a difference in mortality among quartiles of 25(OH)D3 levels. However, 25(OH)D3 levels were inversely related with length of hospital stay and intensive care unit stay among in-hospital survivors.

CONCLUSION

Vitamin D deficiency was prevalent in Korean patients with ARDS. However, levels of vitamin D were not associated with mortality. A large, prospective study is needed to evaluate the effects of vitamin D deficiency on clinical outcomes of ARDS.

The First Living-Donor Lobar Lung Transplantation in Korea: a Case Report

Lung transplantation is the only treatment for end-stage lung disease, but the problem of donor shortage is unresolved issue. Herein, we report the first case of living-donor lobar lung transplantation (LDLLT) in Korea. A 19-year-old woman patient with idiopathic pulmonary artery hypertension received her father's right lower lobe and her mother's left lower lobe after pneumonectomy of both lungs in 2017. The patient has recovered well and is enjoying normal social activity. We think that LDLLT could be an alternative approach to deceased donor lung transplantation to overcome the shortage of lung donors.

Modification of the prolonged mechanical ventilation prognostic model score to predict short-term and 1-year mortalities

BACKGROUND AND OBJECTIVE

We aimed to validate the use of the Prolonged Mechanical Ventilation Prognostic Model (ProVent) score in medically ill patients with co-morbidities and to modify the score to improve the prediction power of 1-year mortality.

METHODS

We conducted a retrospective study of all patients who required at least 14 days of mechanical ventilation (MV) and established two groups (14-20 and ≥21 days of MV) based on the MV duration. We performed external validation of the present ProVent Model in our patients on Day 14 (or Day 21 for the ≥21-day MV group) of MV, and established the extended ProVent model, while considering the albumin and bilirubin levels and co-morbidities (chronic obstructive pulmonary disease and cancer).

RESULTS

A total of 1288 patients (666 and 622 with 14-20 and ≥21 days of MV, respectively) with at least 14 days of MV were enrolled. The 1-year mortality was 79.9% and 78.7% in the ≥21- and 14-20-day groups, respectively. Most of the observed mortality rates in all groups were within the 95% CI of predicted mortality as per the ProVent Model, except for the ProVent scores of 0 and 5. In the ProVent model, the area under the curve for the prediction of 1-year mortality was 0.69 in all patients with ≥14 days of MV, whereas in the extended ProVent model, the area under the curve was 0.89.

CONCLUSION

The extended ProVent model, which considers co-morbidities and laboratory data, increases the prediction power of 1-year mortality in patients who require prolonged MV.

Anti-inflammatory Role of Mesenchymal Stem Cells in an Acute Lung Injury Mouse Model

Background

Mesenchymal stem cells (MSCs) attenuate injury in various lung injury models through paracrine effects. We hypothesized that intratracheal transplantation of allogenic MSCs could attenuate lipopolysaccharide (LPS)-induced acute lung injury (ALI) in mice, mediated by anti-inflammatory responses.

Methods

Six-week-old male mice were randomized to either the control or the ALI group. ALI was induced by intratracheal LPS instillation. Four hours after LPS instillation, MSCs or phosphate-buffered saline was randomly intratracheally administered. Neutrophil count and protein concentration in bronchoalveolar lavage fluid (BALF); lung histology; levels of interleukin (IL)-1β, IL-6, tumor necrosis factor (TNF)-α, and macrophage inflammatory protein-2; and the expression of proliferation cell nuclear antigen (PCNA), caspase-3, and caspase-9 were evaluated at 48 hours after injury.

Results

Treatment with MSCs attenuated lung injury in ALI mice by decreasing protein level and neutrophil recruitment into the BALF and improving the histologic change. MSCs also decreased the protein levels of proinflammatory cytokines including IL-1β, IL-6, and TNF-α, but had little effect on the protein expression of PCNA, caspase-3, and caspase-9.

Conclusions

Intratracheal injection of bone marrow-derived allogenic MSCs attenuates LPS-induced ALI via immunomodulatory effects.

Video laryngoscopy versus direct laryngoscopy for first-attempt tracheal intubation in the general ward

Background

Recent trials showed that video laryngoscopy (VL) did not yield higher first-attempt tracheal intubation success rate than direct laryngoscopy (DL) and was associated with higher rates of complications. Tracheal intubation can be more challenging in the general ward than in the intensive care unit. This study aimed to investigate which laryngoscopy mode is associated with higher first-attempt intubation success in a general ward.

Methods

This is a retrospective study of tracheal intubations conducted at a tertiary academic hospital. This analysis included all intubations performed by the medical emergency team in the general ward during a 48-month period.

Results

For the 958 included patients, the initial laryngoscopy mode was video laryngoscopy in 493 (52%) and direct laryngoscopy in 465 patients (48%). The overall first-attempt success rate was 69% (664 patients). The first-attempt success rate was higher with VL (79%; 391/493) than with DL (59%; 273/465, p < 0.001). The first-attempt intubation success rate was higher among experienced operators (83%; 266/319) than among inexperienced operators (62%; 398/639, p < 0.001). In multivariate logistic regression analyses, VL, pre-intubation heart rate, pre-intubation SpO₂ > 80%, a non-predicted difficult airway, experienced operator, and Cormack–Lehane grade were associated with first-attempt intubation success in the general ward. Over all intubation-related complications were not different between two groups (27% for VL vs. 25% for DL). However, incidence of a post-intubation SpO₂ < 80% was higher with VL than with DL (4% vs. 1%, p = 0.005), and in-hospital mortality was also higher (53.8% vs. 43%, p = 0.001).

Conclusion

In a general ward setting, the first-attempt intubation success rate was higher with video laryngoscopy than with direct laryngoscopy. However, video laryngoscopy did not reduce intubation-related complications. Furthers trials on best way to perform intubation in the emergency settings are required.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0428-0) contains supplementary material, which is available to authorized users.

Safety and Effectiveness of Peramivir in Korean Adult Influenza Patients: Prospective Observational Study Based on Post-Marketing Surveillance Data

BACKGROUND

The safety and clinical effectiveness data of peramivir in the real clinical field are limited. A prospective observational study was conducted based on the post-marketing surveillance data to evaluate the post-marketing safety and effectiveness of peramivir in Korean adults with seasonal influenza.

METHODS

Among adults aged 20 years or older who were diagnosed with influenza A or B, patients who started peramivir within 48 hours from the initial symptoms of influenza were enrolled. All adverse events (AEs) that occurred within 7 days after administration of peramivir were checked. For the evaluation of effectiveness, changes in the severity of influenza symptoms and daily living performance were examined before and 7 days after the administration of peramivir. The date on which influenza related symptoms disappeared was checked.

RESULTS

A total of 3,024 patients were enrolled for safety evaluation and 2,939 patients were for effectiveness evaluation. In the safety evaluation, 42 AEs were observed in 35 (1.16%) patients. The most common AE was fever. AEs were mostly rated as mild in severity. Serious AEs were observed in 10 patients and two of them died. However, both deaths were considered to be less relevant to peramivir. In the effectiveness evaluation, the severity of influenza symptoms decreased by 10.68 ± 4.01 points and daily living performance was improved 5.59 ± 2.16 points. Influenza related symptoms disappeared on average 3.02 ± 2.39 days after peramivir administration.

CONCLUSION

Peramivir showed a tolerable safety profile and acceptable effectiveness in Korean adult patients with seasonal influenza.

Comparison of Accuracy of NUTRIC and Modified NUTRIC Scores in Predicting 28-Day Mortality in Patients with Sepsis: A Single Center Retrospective Study

The NUTRIC (Nutrition Risk in the Critically Ill) and modified NUTRIC scores are nutrition risk assessment tools specifically for intensive care unit (ICU) patients. A modified NUTRIC score is composed of all variables except for IL-6 level in the NUTRIC score. Their use in qualifying critically ill patients at nutritional risk has been extensively evaluated, although not in studies of patients with sepsis, when interleukin 6 levels, which are not included in the modified NUTRIC score, may be elevated. The present study was a retrospective comparison of the accuracy of the NUTRIC and modified NUTRIC scores in predicting 28-day mortality of 482 adult patients with sepsis who were admitted to the medical ICU of a tertiary referral hospital in South Korea between January 2011 and June 2017 and who had ICU stays longer than 24 h. The NUTRIC and modified NUTRIC scores were calculated using data from the patients’ electronic medical records relating to the first 24 h of admission to the ICU. The area under the curve of the NUTRIC Score for predicting 28-day mortality was 0.762 (95% confidence interval (CI): 0.718–0.806) and of the modified NUTRIC Score 0.757 (95% CI: 0.713–0.801). There was no significant difference between the two scores (p = 0.45). The modified NUTRIC score was a good nutritional risk assessment tool for critically ill septic patients.

Greenland records of aerosol source and atmospheric lifetime changes from the Eemian to the Holocene

The Northern Hemisphere experienced dramatic changes during the last glacial, featuring vast ice sheets and abrupt climate events, while high northern latitudes during the last interglacial (Eemian) were warmer than today. Here we use high-resolution aerosol records from the Greenland NEEM ice core to reconstruct the environmental alterations in aerosol source regions accompanying these changes. Separating source and transport effects, we find strongly reduced terrestrial biogenic emissions during glacial times reflecting net loss of vegetated area in North America. Rapid climate changes during the glacial have little effect on terrestrial biogenic aerosol emissions. A strong increase in terrestrial dust emissions during the coldest intervals indicates higher aridity and dust storm activity in East Asian deserts. Glacial sea salt aerosol emissions in the North Atlantic region increase only moderately (50%), likely due to sea ice expansion. Lower aerosol concentrations in Eemian ice compared to the Holocene are mainly due to shortened atmospheric residence time, while emissions changed little.

Past climate changes in Greenland ice were accompanied by large aerosol concentration changes. Here, the authors show that by correcting for transport effects, reliable source changes for biogenic aerosol from North America, sea salt aerosol from the North Atlantic, and dust from East Asian deserts can be derived.

Age is major factor for predicting survival in patients with acute respiratory failure on extracorporeal membrane oxygenation: a Korean multicenter study

Background

The proportion of elderly patients in the intensive care unit population is increasing. Although the Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score is widely used for survival prediction of extracorporeal membrane oxygenation (ECMO) patients, it is questionable whether the RESP score is applicable to older patients. The aim of this study was to investigate the applicability of the RESP score in Korean cohort.

Methods

Data were retrospectively analyzed from 209 acute respiratory failure (ARF) patients treated with ECMO from 2014 to 2015 at 11 hospitals. A comparison of outcome prediction models was conducted and multivariate logistic regression analysis was performed to identify independent risk factors for hospital mortality.

Results

In all patients, the median age was 58 (IQR, 45-65) years. Overall survival at hospital discharge was 45.9%, and veno-venous ECMO was used in 82.3% of patients. Patients older than 65 years treated with ECMO support were 51 with 31.4% of hospital survival. The PRedicting dEath for SEvere ARDS on VV-ECMO (PRESERVE) and RESP scores significantly predicted mortality in patients, with areas under the curve (AUCs) of 0.63 [95% confidence interval (CI), 0.54-0.72] and 0.66 (95% CI, 0.58-0.73), respectively. In multivariate logistic regression analysis, age is independent risk factor for hospital mortality [odds ratio 1.044 (95% CI, 1.020-1.068), P<0.001] with AUC of 0.67 (95% CI, 0.59-0.74). The RESP score was modified using reclassified age and the modified RESP score obtained AUC of 0.71 (95% CI, 0.63-0.78).

Conclusions

The RESP score is significant model for predicting outcomes in a Korean ECMO population. Elderly patients had higher mortality, and age alone showed similar discrimination ability for prediction of mortality compared to the RESP score.

Global and Regional Ventilation during High Flow Nasal Cannula in Patients with Hypoxia

Background

High flow nasal cannula (HFNC) is known to increase global ventilation volume in healthy subjects. We sought to investigate the effect of HFNC on global and regional ventilation patterns in patients with hypoxia.

Methods

Patients were randomized to receive one of two oxygen therapies in sequence: nasal cannula (NC) followed by HFNC or HFNC followed by NC. Global and regional ventilation was assessed using electric impedance tomography.

Results

Twenty-four patients participated. Global tidal variation (TV) in the lung was higher during HFNC (NC, 2,241 ± 1,381 arbitrary units (AU); HFNC, 2,543 ± 1,534 AU; P < 0.001). Regional TVs for four iso-gravitational quadrants of the lung were also all higher during HFNC than NC. The coefficient of variation for the four quadrants of the lung was 0.90 ± 0.61 during NC and 0.77 ± 0.48 during HFNC (P = 0.035). Within the four gravitational layers of the lung, regional TVs were higher in the two middle layers during HFNC when compared to NC. Regional TV values in the most ventral and dorsal layers of the lung were not higher during HFNC compared with NC. The coefficient of variation for the four gravitational layers of the lung were 1.00 ± 0.57 during NC and 0.97 ± 0.42 during HFNC (P = 0.574).

Conclusions

In patients with hypoxia, ventilation of iso-gravitational regions of the lung during HFNC was higher and more homogenized compared with NC. However, ventilation of gravitational layers increased only in the middle layers. (Clinical trials registration number: NCT02943863).

Prognosis of Acute Respiratory Distress Syndrome in Patients With Hematological Malignancies

INTRODUCTION

The intensive care unit (ICU) admission of patients with hematologic malignancies is gradually increasing. Life-threatening events are common, and acute respiratory distress syndrome (ARDS) is one of the most critical conditions. The aim of this study was to investigate the clinical characteristics and outcomes of ARDS in patients with hematological malignancies admitted to the ICU.

METHODS

A retrospective study was performed on all patients with ARDS with hematological malignancies in a single tertiary teaching hospital between 2008 and 2015. Data on the treatment of and the outcomes of ARDS were collected to determine the clinical characteristics associated with ICU mortality.

RESULTS

During the 8-year study period, among a total of 821 patients with ARDS admitted to the ICU, all 185 patients with hematological malignancies were included in the analysis. Most of the patients (88.1%) had moderate-to-severe ARDS, and the median PaO₂/FiO₂ ratio was 122 (interquartile range: 88-157). The overall ICU mortality rate was 57.3% (50.0% for mild, 52.0% for moderate, and 67.7% for severe ARDS). After the univariate and the multivariate logistic regressions, the factors independently associated with a higher ICU mortality were severe ARDS (odds ratio [OR]: 2.47; 95% confidence interval [CI]: 1.17-5.25), identification of carbapenem-resistant gram-negative bacteria (OR: 6.61; 95% CI: 1.31-33.41), the amount of blood product transfusion (OR: 1.25; 95% CI: 1.13-1.38), and the progressive or refractory disease (OR: 3.01; 95% CI: 1.31-6.91). Mortality was independently lower in patients who received the initial low tidal volume ventilation (OR: 0.37, 95% CI: 0.14-0.96).

CONCLUSION

The outcome of ARDS in patients with hematological malignancies is associated with the severity of the underlying diseases, the presence of multidrug-resistance pathogens, and the amount of transfusion; however, strict application of low tidal volume ventilation may improve the outcome of these patients at the time of diagnosis.

The effect of an improvement of experience and training in extracorporeal membrane oxygenation management on clinical outcomes

BACKGROUND/AIMS

The use of extracorporeal membrane oxygenation (ECMO) is spreading rapidly, with successful procedures reported in the ECMO for Severe Adult Respiratory failure (CESAR) trial and treatment of the H1N1 pandemic. However, ECMO is associated with a high mortality rate. This study aimed to show that increased experience and improved teamwork through education may reduce the mortality rate associated with ECMO.

METHODS

A retrospective study was performed. Data were collected from January 1, 2009, to December 31, 2011. The data were divided into two periods: 2009/2010 (period 1) and 2011 (period 2). The protocol and training program were applied during period 2.

RESULTS

Seventy-six patients were included. The most common disease requiring ECMO support was pneumonia (43.4%). ECMO was applied within 7 days in 76.3% of patients. The primary outcomes, such as Intensive Care Unit (ICU) and hospital mortality rates, were higher during period 1 (91.3%) than period 2 (66.7%, p = 0.013). A multivariate analysis revealed that ECMO weaning failure was the only factor associated with ICU and hospital mortality (ICU mortality: hazard ratio [HR], 11.349; 95% confidence interval [CI], 1.281 to 100.505; p = 0.029; hospital mortality: HR, 17.976; 95% CI, 2.263 to 142.777; p = 0.006).

CONCLUSIONS

The mortality rate associated with the ECMO procedure decreased following the ECMO training program. However, applying the training program to ECMO management is not an independent factor for the mortality rate. Further studies should be performed to help reduce the mortality rate associated with ECMO.

Types of household humidifier disinfectant and associated risk of lung injury (HDLI) in South Korea

From 2002 through 2015, hundreds of people died of fatal lung injuries associated with the use of humidifier disinfectants (HDs) in Korea. Several chemical disinfectants used for household humidifiers were later clinically confirmed to cause HD-associated lung injury (HDLI). The aim of this study is to evaluate the registered lung disease cases and to compare the distribution of HDLI patients, including deaths, by HD use characteristics including types of HD and HD brands categorized by age group. A total of 530 registered were clinically examined through two rounds of investigations conducted from July 2013 until April 2015. Information on HD use was obtained from a structured questionnaire and home investigations. Approximately one-half of the patients (n=221) were clinically confirmed to be associated with the use of HDs. Pregnant women (n=35, 16%) and pre-school children≤6years old (n=128, 58%) accounted for most of the HD-associated lung injury patients (n=163, 74%). Sixty-seven percent of HDLI patients developed HDLI after less than one year of HD use. HD products containing polyhexamethylene guanidine phosphate (PHMG) were the most frequently used among confirmed HDLI patients (n=123, 55.7%), followed by oligo (2-(2-ethoxy) ethoxyethyl guanidinium (PGH) (n=24, 10.9%) and a mixture of chloromethylisothiazolinone (CMIT) and methylisothiazolinone (MIT) (n=3, 1.4%). Other HDs did not appear to be linked to HDLI. The majority of the HDLI patients (n=85, 38.5%) was found to use only Oxy Saksak® products containing PHMG. The development of HDLI was clinically found to be associated with the use of several HD products containing PHMG and PGH, and to lesser extent, CMIT/MIT.

Predictors of high flow nasal cannula failure in immunocompromised patients with acute respiratory failure due to non-HIV pneumocystis pneumonia

Background

To evaluate the predictors of high flow nasal cannula (HFNC) failure in pneumocystis pneumonia (PCP) patients with acute respiratory failure (ARF).

Methods

Fifty-two non-HIV-related PCP subjects were divided into a HFNC success group (44%) and a HFNC failure group (who required mechanical ventilation (MV) despite HFNC application) (56%). The clinical characteristics and physiologic effects were retrospectively reviewed and compared between the groups.

Results

At baseline, the heart rate, alveolar-arterial PO₂ difference [P(A-a)O₂], Sequential Organ Failure Assessment (SOFA) score, and proportion of subjects who used vasopressors were significantly higher in the HFNC failure group than in the HFNC success group. The 60-day mortality was 52% in the HFNC failure group and 13% in the HFNC success group (P=0.004). The results of the multivariate analysis indicated that the baseline SOFA score was independently associated with HFNC failure (adjusted odds ratio, 1.74 per each score unit increase; 95% CI, 1.05-2.89; P=0.03). Repeated measures analysis of variance revealed that within 6 h of HFNC initiation, the mean PaO₂/FiO₂ ratio decreased and the mean P(A-a)O₂ increased rapidly in the HFNC failure group.

Conclusions

Patients with ARF due to PCP subjected to HFNC therapy should be carefully monitored, and particular attention should be paid to those who had organ dysfunction and did not show early oxygenation improvement.

A risk scoring model based on vital signs and laboratory data predicting transfer to the intensive care unit of patients admitted to gastroenterology wards

PURPOSE

To compare the ability of a score based on vital signs and laboratory data with that of the modified early warning score (MEWS) to predict ICU transfer of patients with gastrointestinal disorders.

MATERIALS AND METHODS

Consecutive events triggering medical emergency team activation in adult patients admitted to the gastroenterology wards of the Asan Medical Center were reviewed. Binary logistic regression was used to identify factors predicting transfer to the ICU. Gastrointestinal early warning score (EWS-GI) was calculated as the sum of simplified regression weights (SRW).

RESULTS

Of the 1219 included patients, 468 (38%) were transferred to the ICU. Multivariate analysis identified heart rate≥105bpm (SRW 1), respiratory rate≥26bpm (SRW 2), ACDU (Alert, Confused, Drowsy, Unresponsive) score≥1 (SRW 2), SpO₂/FiO₂ ratio<240 (SRW 2), creatinine ≥2.0mg/dL (SRW 2), total bilirubin ≥9.0mg/dL (SRW 2), prothrombin time/international normalized ratio (INR) ≥1.5 (SRW 2), and lactate ≥3.0mmol/L (SRW 2) for inclusion in EWS-GI. The area under the receiver operating characteristic curve of the EWS-GI was larger than that of MEWS (0.76 vs. 0.64; P<0.001).

CONCLUSIONS

EWS-GI may predict ICU transfer among patients admitted to gastroenterology wards. The EWS-GI should be prospectively validated.

Glucose-insulin-potassium correlates with hemodynamic improvement in patients with septic myocardial dysfunction

BACKGROUND

Glucose-insulin-potassium (GIK) demonstrates a cardioprotective effect by providing metabolic support and anti-inflammatory action, and may be useful in septic myocardial depression. The aim of this study was to examine the relationship between GIK and hemodynamic outcomes in septic shock patients with myocardial depression.

METHODS

Between October 2012 and March 2014, 45 patients in the intensive care unit who fulfilled the criteria for severe sepsis/septic shock and were treated with GIK were recruited. Patients were divided into two groups according to echocardiographic findings: hypodynamic (27%) and non-hypodynamic (36%).

RESULTS

Baseline vasopressor requirements did not differ between both groups. In 12 patients with hypodynamic septic shock with myocardial depression, mean arterial pressure (MAP) increased with the median [interquartile range (IQR)] area under the curve of 16 (8 to 29) mmHg, and the heart rate (HR) decreased with the median (IQR) area under the curve of -9 (-20 to 2)/min during the first 72 h. The total insulin dose correlated with improvement in MAP (r=0.61, P=0.061) and the cardiovascular Sequential Organ Failure Assessment score (r=-0.64, P=0.045) at 72 h, although this phenomenon was not observed in patients with non-hypodynamic septic shock. Serum glucose and potassium levels were within the target ranges in both groups during the 72-h study period.

CONCLUSIONS

Short-term improvement in hemodynamics correlated with GIK administration in septic shock patients with myocardial depression. The use of GIK was well tolerated in all patients. Further studies are required to demonstrate the role of GIK in septic myocardial dysfunction.

Medical emergency team may reduce obstetric intensive care unit admissions

AIM

Some recent studies have reported that early intervention by a medical emergency team (MET) for clinical deterioration before intensive care unit (ICU) admission was associated with a survival benefit in critically ill cancer patients. We hypothesized that early MET intervention for an obstetric crisis in the general wards would be related to favorable outcomes in critically ill obstetric patients.

METHODS

Data of obstetric patients who were managed by a MET were collected retrospectively from 1 March 2008 to 30 April 2015. A total of 69 obstetric patients were enrolled. Among them, 48 (69.6%) were treated successfully in the general wards and 21 (30.4%) were transferred to the ICU.

RESULTS

Major causes of MET activation were pulmonary edema (n = 23, 33.3%), hypovolemic shock (n = 19, 27.5%), and septic shock (n = 8, 11.6%). Compared with the patients treated in the general ward, the patients transferred to the ICU had significantly higher severity of illness score. Sequential Organ Failure Assessment score was the most useful for prediction of ICU admission of obstetric patients (AUC, 0.810, P < 0.001), and the ideal cut-off was 4 (sensitivity, 81%; specificity, 60%). During the study period, in-hospital mortality of the obstetric patients was 2.9% (2/69).

CONCLUSION

After MET activation many obstetric patients could be successfully treated in the general wards without mortality. Therefore, MET may reduce ICU admissions in critically ill obstetric patients.

Lung function in patients with lung injury due to household chemical inhalation: Post hoc analysis of a prospective nationwide cohort

BACKGROUND AND OBJECTIVE

Inhalation exposure to household chemicals can result in serious health problems, although the long-term outcomes are unclear. We evaluated the changes in lung function after home humidifier disinfectant (HD) exposure.

METHODS

This post hoc analysis of a prospective nationwide cohort involved patients with inhalation lung injury due to HD. Patients underwent spirometric measurements at onset and annually thereafter.

RESULTS

Forty subjects met the eligibility criteria. Overall, mean forced vital capacity (FVC) increased significantly during the first 3 years from 2.10 ± 0.74 to 3.06 ± 1.08 L. Mean forced expiratory volume in 1 s (FEV ₁ ) also rose from 1.84 ± 0.63 to 2.62 ± 0.88 L. Both variables then stabilized. However, in 19 (48%) patients, the FVCs did not normalize. Compared to subjects with an FVC at onset of <2.5 L, subjects with onset FVC ≥2.5 L exhibited significantly more improvement in percent predicted FVC over time (group × time interaction: P < 0.001). Patients with lower exposure also exhibited increasing percent predicted FVC over time, whereas more exposed patients showed a plateau starting at year 1. On multivariate analysis, onset FVC < 2.5 L associated significantly with <80% predicted FVC at year 4 (adjusted OR: 20.33; 95% CI: 1.10-376.53; P = 0.04).

CONCLUSION

Half of the patients with inhalation injury exhibited stabilization of lung function within several years of onset. However, lung function was impaired in the remaining patients. This impairment associated with lung function at onset and exposure intensity.