KSCCM·ACCC 2020

KSCCM·ACCC 2020 The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 July 31(Fri)~August 1(Sat) 2020 Online Conference

Contact Us TEL: 02-2077-1533 E-mail: [email protected] Website: 2020.ACCC.or.kr The Korean Society of Critical Care Medicine

The Korean Society of Critical Care Medicine

CONTENTS

초대의 글 | INVITATION············································································· 4

초록집 다운로드 | ABSTRACT BOOK DOWNLOAD············································ 5

프로그램 | PROGRAM AT A GLANCE····························································· 6

세부 프로그램 | SCIENTIFIC PROGRAM························································ 7

해외 연자 소개 | INTERNATIONAL LECTURERS············································ 14

강의 목차 | SCIENTIFIC PROGRAM CONTENTS············································· 17

구연발표 목차 | ORAL PRESENTATION CONTENTS········································ 23

강의 노트 | LECTURE NOTE····································································· 39

구연발표 | ORAL PRESENTATION····························································· 193

후원사(온라인 참여 전시업체) | SPONSORSHIP (E-BOOTH)··························· 294 초대의 글 | INVITATION

Welcome to KSCCM • ACCC 2020

On behalf of the Korean Society of Critical Care Medicine, I am pleased to welcome you all to the 40th KSCCM Annual Congress • Acute and Critical Care Conference (ACCC) 2020, which will be held in Jul 31 - Aug 1, 2020. 2020 is another meaningful year as it will mark the 40th anniversary of the KSCCM, which was founded in 1980.

KSCCM has played a leading role in establishing a better critical care system in Korea, and hopes that its annual meetings could add momentum to growing efforts by other Asian countries to enhance their critical care capacity. Thus, ACCC 2020 will be a wonderful platform for all participants from different countries to share ideas and experience in critical care medicine as well as to promote their opportunities for growth.

Various programs will be held to enact the interaction between participants and to make the whole event more informative and useful in terms of ongoing critical care practices and research activities. Speeches will be presented by domestic and international speakers.

KSCCM offers awards for outstanding abstracts submitted by international participants. In other words, travel grants will be offered based on the scientific merit of abstract.

We welcome you to this congress in July 2020 and look forward to your participation.

Sanghyun Kwak, MD, PhD President of the Korean Society of Critical Care Medicine

4 KSCCM·ACCC 2020 초록집 다운로드 | ABSTRACT BOOK DOWNLOAD

The 40th KSCCM Annual Congress ·Acute and Critical Care Conference 2020

초록집은 QR 코드로 다운로드 받으실 수 있습니다. You can download the abstract book with QR Code.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 5 프로그램 | PROGRAM AT A GLANCE

July 31(Fri), 2020

Time Room 1 Room 2 Room 3 Room 4 Room 5 Time Room 6 Room 7 Room 8

09:00- Opening Plenary: Happy 40th Anniversary 10:20

10:20- Memorial Lecture 11:00

Sepsis in Updates in Optimizing Transfusion 11:00- Oral Oral ICU Oral Special Mechanical Antibiotics in ECMO Strategies 12:30 Cardio 1 General 1 Neuro 1 Populations Ventilation the ICU

Coagulation COVID-19 Critical Care Updated PAD 12:30- Oral Oral Oral Patient Safety and Pandemic Pharmacy in Critical Care 14:00 Surgery 1 Sepsis 1 Sepsis 2 Thrombosis

Surgical Critical Neuro-Critical 14:30- Oral Oral Oral CRRT Infection Care Care 16:00 Cardio 2 Surgery 2 Basic 1

Satellite Satellite 16:00- Oral Oral Symposium I Symposium Ⅱ 17:00 Neuro 2 Pharma

※ Satellite Symposium은 양일간 2개씩 진행됩니다.

August 1(Sat), 2020

Time Room 1 Room 2 Room 3 Room 4 Room 5 Time Room 6 Room 7 Room 8

Intensive Care Challenging Cases: Pediatric Critical Clinical Oral Oral Management Diagnostic Reasoning Care: Solid Organ Trials and Hepatic 09:00- Oral ICU ICU for COVID-19 and Avoiding Errors Transplanation in International Dysfunction 10:30 EM/CPR General 3 General 4 Patients in Acutely Ill Patients Children Collaboration

Critical Care Nursing Oral War against 10:30- Oral Oral : Daring to Find Joy Critical Care Ethics Trauma Nutrition ICU COVID-19 12:00 Quality 2 Pulmo 1 and Meaning at Work General 2 13:00- General Assembly & Award Ceremony 14:00

How Will Current Research COVID-19 Summary of Recent Extracorporeal 14:30- Oral Oral Oral Battlegrounds and Ethics Change the Major RCTs Life Support 16:00 RRT Quality 1 PED in Sepsis Symposium World?

Recovering Specialized from Critical Rapid General Critical Care Cardiopulmonary Fluid Illness: Response Update Resuscitation 2020 Therapy Patients and Systems 16:00- Oral Oral Intensivists 17:30 Pulmo 2 Nursing

Satellite Satellite ARDS Symposium Ⅲ Symposium Ⅳ

※ Satellite Symposium은 양일간 2개씩 진행됩니다.

6 KSCCM·ACCC 2020 세부 프로그램 | SCIENTIFIC PROGRAM

Day 1 | July 31 (Fri), 2020

Live Streaming Speaker 09:00-10:20 Opening Plenary: Happy 40th Anniversary Welcome Address Sanghyun Kwak (KSCCM President, Korea) 40 Years of KSCCM: Looking Back, Planning Ahead Sung-Jin Hong (The Catholic Univ of Korea, Korea) Major Goals of KSCCM in the Next 10 Years Sanghyun Kwak (KSCCM President, Korea) ICU in Korea: 2019 Survey Sang Bum Hong (Univ of Ulsan, Korea) 10:20-11:00 Memorial Lecture What I Have Learned in Critical Cares Younsuck Koh (Univ of Ulsan, Korea) Room 1 Speaker Sepsis in Special Populations Postoperative Sepsis: What Intensivists Need to Know Chi-Min Park (Sungkyunkwan Univ, Korea) COVID-19 Pandemic COVID-19: Clinical Features and Therapeutic Option Pyeong Gyun Choe (Seoul National Univ, Korea) Coronavirus Disease 2019 during the 2019-2020 Epidemic: Seungsik Hwang (Seoul National Univ, Korea) Preparing Intensive Care Units-the Experience in South Korea Satellite Symposium I Addressing Clinical Challenges with Central Line Care Jin Young Ahn (Yonsei Univ, Korea) Room 2 Speaker Updates in Mechanical Ventilation Recent Updates on Weaning (Liberation) from MV Kyeongman Jeon (Sungkyunkwan Univ, Korea) Recent Evidence of Mechanical Ventilation in ARDS Je Hyeong Kim (Korea Univ, Korea) Electrical Impedance Tomography for Optimizing Mechanical Gee Young Suh (Sungkyunkwan Univ, Korea) Ventilation Critical Care Pharmacy Critical Care Nutrition You-Min Sohn (Samsung Medical Center, Korea) Neurocritical Care Pharmacotherapy Young Joo Song (Seoul National Univ Bundang Hosp, Korea) Adverse Drug Reactions in Critically Ill Patients Eunyoung Choi (Ulsan Univ Hosp, Korea)

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 7 세부 프로그램 | SCIENTIFIC PROGRAM

Surgical Critical Care Polymyxin B Hemoperfusion in Abdominal Septic Shock: Eun Young Kim (The Catholic Univ of Korea, Korea) Option for Refractory Shock in the Era of Surgery Acute Care Surgery: A Different System Stressor Lewis J Kaplan (Univ of Pennsylvania, USA) Protecting the Gut in Critical Illness Jung-Min Bae (Yeungnam Univ, Korea) Satellite Symposium II A Roadmap of Optimal ICU Sedation for ABCDE(F) Bundle; Sang-Min Lee (Seoul National Univ, Korea) Role of Precedex Room 3 Speaker Transfusion Strategies Rationale and Physiology behind Transfusion in the Critically Ill Ho Geol Ryu (Seoul National Univ, Korea) Blood Management for the Critically Ill Jaemyeong Lee (Korea Univ, Korea) Massive Transfusion in Critically Ill Patients Hangjoo Cho (The Catholic Univ of Korea, Korea) Updated PAD in Critical Care Gaps between the PADIS Guideline and Practice Chi Ryang Chung (Sungkyunkwan Univ, Korea) Pediatric Delirium Hyo-Won Kim (Univ of Ulsan, Korea) Role of Ketamine and Antiepileptic Drugs in the Treatment of Miroslaw Czuczwar Acute Postoperative Pain (Medical Univ of Lublin, Poland) CRRT Correcting Acid Base and Electrolyte Imbalance with CRRT Sung Yoon Lim (Seoul National Univ, Korea) Drug Dosing during CRRT You-Min Sohn (Samsung Medical Center, Korea) Weaning from CRRT and Management Thereafter Hye Ryoun Jang (Sungkyunkwan Univ, Korea) Room 4 Speaker Optimizing Antibiotics in the ICU Antibiotic De-escalation Strategies in the ICU Michael Klompas (Harvard Univ, USA) PK-PD Optimized Therapy Jeffrey Lipman (Univ of Queensland, Australia) Biomarker-guided Antibiotic Therapy Jinsoo Min (The Catholic Univ of Korea, Korea) Patient Safety Approaching Patient Safety as Science Asad Latif (Aga Khan Univ, Pakistan) Do Critically Ill Patients All Need Oxygen Therapy? Jozef Kesecioglu (UMC Utrecht, the Netherlands) ICU Design and Infection Prevention Michael Klompas (Harvard Univ, USA)

8 KSCCM·ACCC 2020 세부 프로그램 | SCIENTIFIC PROGRAM

Neuro-Critical Care Who Benefits from TTM in Neurological Intensive Care Unit? Ji Man Hong (Ajou Univ, Korea) Novel Strategies in Enhancing Recovery from Traumatic Brain Injury Lewis J Kaplan (Univ of Pennsylvania, USA) Room 5 Speaker ECMO Microcirculation in VA-ECMO Tony Yeh (National Taiwan Univ Hosp, Taiwan) VV-ECMO without Systemic Heparin Anticoagulation - Is It Possible Miroslaw Czuczwar and Feasible? (Medical Univ of Lublin, Poland) Mechanical Ventilation on VV ECMO: The Current Practice and Sunghoon Park (Hallym Univ, Korea) Adjunctive Treatments Coagulation and Thrombosis VTE Prevention Elliott Haut (Johns Hopkins School of Medicine and Bloomberg School of Public Health, USA) A Scenario-based Approach to Thrombocytopenia in ICU Won-Il Choi (Myongji Hosp, Korea) Infection Therapeutic Drug Monitoring of Beta-lactams Jeffrey Lipman (The Univ of Queensland, Australia) The Antipyretic in Febrile Critically Ill Patients. HOT or COOL Moritoki Egi (Kobe Univ, Japan) Room 6 Chair 11:00-12:30 Oral Cardio 1 Ho Geol Ryu (Seoul National Univ, Korea) 12:30-14:00 Oral Surgery 1 Chi-Min Park (Sungkyunkwan Univ, Korea) 14:30-16:00 Oral Cardio 2 Choon-hak Lim (Korea Univ, Korea) 16:00-17:00 Oral Neuro 2 Do-Sung Yoo (The Catholic Univ of Korea, Korea) Room 7 Chair 11:00-12:30 Oral ICU General 1 Jang Won Sohn (Hanyang Univ, Korea) 12:30-14:00 Oral Sepsis 1 Sang Bum Hong (Univ of Ulsan, Korea) 14:30-16:00 Oral Surgery 2 Suk-kyung Hong (Univ of Ulsan, Korea) 16:00-17:00 Oral Pharma Chi Ryang Chung (Sungkyunkwan Univ, Korea) Room 8 Chair 11:00-12:30 Oral Neuro 1 Sung-Hee Hwang (Hallym Univ, Korea) 12:30-14:00 Oral Sepsis 2 Sang-Min Lee (Seoul National Univ, Korea) 14:30-16:00 Oral Basic 1 Jae Hwa Cho (Yonsei Univ, Korea)

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 9 세부 프로그램 | SCIENTIFIC PROGRAM

Day 2 | August 1 (Sat), 2020

Live Streaming 13:00-14:00 General Assembly & Award Ceremony Room 1 Speaker Intensive Care Management for COVID-19 Patients Korean Guideline on Management of Critically Ill Adults with Kyeongman Jeon (Sungkyunkwan Univ, Korea) COVID-19 Clinical Features and Short-term Outcomes of Critically Ill Patients Jae Seok Park (Keimyung Univ, Korea) with COVID-19: A Report of Single COVID-19 Designated Hospital’s Intensive Care Unit in Daegu Venous Thromboembolism in COVID-19 Patients Jae-Bum Kim (Keimyung Univ, Korea) War against COVID-19 COVID-19 Surveillance System in Communities and Medical Jin Yong Kim (Incheon Medical Center, Korea) Institutions Disaster Planning during a COVID-19 Outbreak Hyun-Soo Chung (Yonsei Univ, Korea) Where We’re at with Vaccines and Treatments for COVID-19 Jae-Hoon Ko (Sungkyunkwan Univ, Korea) How Will COVID-19 Change the World? Ethics and Resource Allocation for Pandemic Infectious Diseases Younsuck Koh (Univ of Ulsan, Korea) A Guide for the ‘New Normal’ after COVID-19 Jihoon Jeong (Kyung Hee Cyber Univ, Korea) Specialized Rapid Response Systems Difficult Airway Response Team (DART) Seungho Jung (Yonsei Univ, Korea) Neurologic Alert Team Sang-Beom Jeon (Univ of Ulsan, Korea) Satellite Symposium III Strategy for Early Appropriate Antibiotic Use for HAP/VAP Patients: Sunghoon Park (Hallym Univ, Korea) Recent Update on Ceftolozane+Tazobactam Room 2 Speaker Challenging Cases: Diagnostic Reasoning and Avoiding Errors in Acutely Ill Patients Factors Associated with Motor Subtypes of Delirium in a Surgical Hee-Jeong Kim (Seoul St. Mary’s Hosp, Korea) Intensive Care Unit Palliative Care in Pediatric ICU Aisoon Park (Severance Hosp, Korea) Diagnostic Reasoning and Avoiding Errors in Acutely Ill Patients: Young Ae Kang (Asan Medical Center, Korea) Challenging Cases in Coronary Care Unit

10 KSCCM·ACCC 2020 세부 프로그램 | SCIENTIFIC PROGRAM

Critical Care Nursing: Daring to Find Joy and Meaning at Work Understanding and Eliminating Workplace Stress Sookhyun Park (Samsung Medical Center, Korea) Support for Nurses through Hospital Policy Change Eun Koung Seo (Pyeongtaek Good Morning Hosp, Korea) Leadership and Success in a Caring Profession Eunju Cho (Seoul National Univ Hosp, Korea) Summary of Recent Major RCTs What`s New in Sepsis? - Recent Major RCTs in 2019-2020 Hannah Lee (Seoul National Univ, Korea) Recent Randomised Clinical Trials of Neurointensive Care Kwang Wook Jo (The Catholic Univ of Korea, Korea) Summary of Recent Major RCTs: Pulmonary/ARDS Woo Hyun Cho (Pusan National Univ, Korea) General Critical Care Update Common Colorectal Disorders Encountered in the ICU Heung-Kwon Oh (Seoul National Univ, Korea) Managing Old and New Onset Atrial Fibrillation in the ICU Myung-Jin Cha (Seoul National Univ, Korea) Assessment of Renal Function in the Critically Ill Patients Sung Yoon Lim (Seoul National Univ, Korea) Satellite Symposium IV Connected Care Solution for COVID-19 and ICU Patient Care Kevin Kim (PHILIPS) Room 3 Speaker Pediatric Critical Care: Solid Organ Transplantation in Children Living Donor Lung Transplantation in Children Motomu Kobayashi (Okayama Univ, Japan) Liver Failure in PICU Seak Hee Oh (Univ of Ulsan, Korea) From Home PN to Intestinal Transplantation Jin Soo Mun (Seoul National Univ, Korea) Critical Care Ethics Impact of Intervention on the Decision of POLST Joohae Kim (National Medical Center, Korea) Death Education: Literature Review Jae Young Moon (Chungnam National Univ, Korea) Moral Injury - Suffering of Physicians Facing the Death of Patients So Young Park (Ewha Womans Univ, Korea) Extracorporeal Life Support Extracorporeal Life Support for Heart Transplantation Yang Hyun Cho (Sungkyunkwan Univ, Korea) LVAD in Heart Failure Young-Nam Youn (Yonsei Univ, Korea) Back-Flow Arteriovenous Shunt Test for Weaning of VA ECMO Min Ho Ju (Pusan National Univ, Korea) Cardiopulmonary Resuscitation 2020 Preview of 2020 Korean Guidelines for Pediatric Life Support Do Kyun Kim (Seoul National Univ, Korea) Effectiveness and Rationale of Sodium Bicarbonate during CPR Ki Young Jeong (Kyung Hee Univ, Korea) Post Cardiac Arrest Care after In-Hospital Cardiac Arrest Focusing Wook-jin Choi (Univ of Ulsan, Korea) on Targeted Temperature Management (TTM)

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 11 세부 프로그램 | SCIENTIFIC PROGRAM

Room 4 Speaker Clinical Trials and International Collaboration High Quality Clinical Research: The Role of ESICM Jozef Kesecioglu (UMC Utrecht, the Netherlands) Data Science in Critical Care: International Database Collaboration Tony Yeh (National Taiwan Univ, Taiwan) Trauma Damage Control Surgery Principles for the Non-Surgeon Elliott Haut (Johns Hopkins School of Medicine and Bloomberg School of Public Health, USA) Current Battlegrounds in Sepsis Emerging Strategies for Sepsis Care Lewis J Kaplan (Univ of Pennsylvania, USA) Blood Purification for Sepsis and Acute Kidney Injury Kent Doi (Univ of Tokyo, Japan) Application of Artificial Intelligence in Critical Care: A Single Kuo-Ching Yuan (Taipei Medical Univ, Taiwan) Institution's Experience (Including Sepsis) Recovering from Critical Illness: Patients and Intensivists Post-Intensive Care Syndrome Lewis J Kaplan (Univ of Pennsylvania, USA) Post ICU Clinic Yeon Joo Lee (Seoul National Univ, Korea) Burnout Syndrome of Korean ICU Professionals Jeongmin Kim (Yonsei Univ, Korea) Room 5 Speaker Hepatic Dysfunction Perioperative Management of the Patient with Hepatic Disease Asad Latif (Aga Khan Univ, Pakistan) Nutrition New Guidelines on Nutritional Intervention in the ICU - ASPEN, Miroslaw Czuczwar ESPEN or Local? (Medical Univ of Lublin, Poland) Nutrition for Patients on ECMO Support Eunjeong Heo (Seoul National Univ Bundang Hosp, Korea) Research and Ethics Symposium Reporting Guidelines Soo Young Kim (Hallym Univ, Korea) Impress Journal Editors through Clarity and Impact in Your Yunhee Whang (Compecs, Inc., Korea) Academic Writing Fluid Therapy Update in Colloids for Critically Ill Patients Sahadol Poonyathawon (Chulalongkorn Univ, Thailand) ARDS The Risk of Spontaneous Breathing in ARDS Takeshi Yoshida (Osaka Univ, Japan)

12 KSCCM·ACCC 2020 세부 프로그램 | SCIENTIFIC PROGRAM

Surrogate Markers for Optimal PEEP in ARDS Dong Hyun Lee (Dong-A Univ, Korea) Neuromuscular Blockers for ARDS: To Use or Not to Use Jae Young Moon (Chungnam National Univ, Korea) Room 6 Chair 09:00-10:30 Oral ICU General 3 Won-Il Choi (Myongji Hospital, Korea) 10:30-12:00 Oral ICU General 2 Seong Heon Lee (Chonnam National Univ, Korea) 14:30-16:00 Oral RRT Young-Jae Cho (Seoul National Univ, Korea) 16:00-17:30 Oral Pulmo 2 Sunghoon Park (Hallym Univ, Korea) Room 7 Chair 09:00-10:30 Oral EM/CPR Young-Rock Ha (Bundang Jesaeng General Hosp, Korea) 10:30-12:00 Oral Quality 2 Jin Won Huh (Univ of Ulsan, Korea) 14:30-16:00 Oral Quality 1 Seung-Young Oh (Seoul National Univ, Korea) 16:00-17:30 Oral Nursing Sungwon Na (Yonsei Univ, Korea)​ Room 8 Chair 09:00-10:30 Oral ICU General 4 Young-Sam Kim (Yonsei Univ, Korea) 10:30-12:00 Oral Pulmo 1 Je Hyeong Kim (Korea Univ, Korea) 14:30-16:00 Oral PED Won Kyoung Jhang (Univ of Ulsan, Korea)

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 13 해외 연자 소개 | INTERNATIONAL LECTURERS

Lewis J Kaplan (Univ of Pennsylvania, USA) July 31(Fri), 2020

Room 2 Surgical Critical Care Acute Care Surgery: A Different System Stressor Room 4 Neuro-Critical Care Novel Strategies in Enhancing Recovery from Traumatic Brain Injury

August 1(Sat), 2020

Room 4 Current Battlegrounds in Emerging Strategies for Sepsis Care Sepsis Room 4 Recovering from Critical Post-Intensive Care Syndrome Illness: Patients and Intensivists

Miroslaw Czuczwar (Medical Univ of Lublin, Poland) July 31(Fri), 2020

Room 3 Updated PAD in Critical Care Role of Ketamine and Antiepileptic Drugs in the Treatment of Acute Postoperative Pain Room 5 ECMO VV-ECMO without Systemic Heparin Anticoagulation - Is It Possible and Feasible?

August 1(Sat), 2020

Room 5 Nutrition New Guidelines on Nutritional Intervention in the ICU - ASPEN, ESPEN or Local?

Michael Klompas (Harvard Univ, USA) July 31(Fri), 2020

Room 4 Optimizing Antibiotics in the Antibiotic De-escalation Strategies in the ICU ICU Room 4 Patient Safety ICU Design and Infection Prevention

Jeffrey Lipman (Univ of Queensland, Australia) July 31(Fri), 2020

Room 4 Optimizing Antibiotics in the ICU PK-PD Optimized Therapy Room 5 Infection Therapeutic Antibiotic Monitoring of Beta-lactams

14 KSCCM·ACCC 2020 해외 연자 소개 | INTERNATIONAL LECTURERS

Asad Latif (Aga Khan Univ, Pakistan)

July 31(Fri), 2020

Room 4 Patient Safety Approaching Patient Safety as Science

August 1(Sat), 2020

Room 5 Hepatic Dysfunction Perioperative Management of the Patient with Hepatic Disease

Jozef Kesecioglu (UMC Utrecht, the Netherlands)

July 31(Fri), 2020

Room 4 Patient Safety Do Critically Ill Patients All Need Oxygen Therapy?

August 1(Sat), 2020

Room 4 Clinical Trials and International High Quality Clinical Research: The Role of ESICM Collaboration

Tony Yeh (National Taiwan Univ, Taiwan)

July 31(Fri), 2020

Room 5 ECMO Microcirculation in VA-ECMO

August 1(Sat), 2020

Room 4 Clinical Trials and International Data Science in Critical Care: International Database Collaboration Collaboration

Elliott Haut (Johns Hopkins School of Medicine, USA)

July 31(Fri), 2020

Room 5 Coagulation and Thrombosis VTE Prevention

August 1(Sat), 2020

Room 4 Trauma Damage Control Surgery Principles for the Non-Surgeon

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 15 해외 연자 소개 | INTERNATIONAL LECTURERS

Moritoki Egi (Kobe Univ, Japan)

July 31(Fri), 2020

Room 5 Infection The Antipyretic in Febrile Critically Ill Patients. HOT or COOL

Motomu Kobayashi (Okayama University, Japan)

August 1(Sat), 2020

Room 3 Pediatric Critical Care: Solid Living Donor Lung Transplantation in Children Organ Transplantation in Children

Kent Doi (Univ of Tokyo, Japan)

August 1(Sat), 2020

Room 4 Current Battlegrounds in Sepsis Blood Purification for Sepsis and Acute Kidney Injury

Sahadol Poonyathawon (Chulalongkorn Univ, Thailand)

August 1(Sat), 2020

Room 5 Fluid Therapy Update in Colloids for Critically Ill Patients

Takeshi Yoshida (Osaka Univ, Japan)

August 1(Sat), 2020

Room 5 ARDS The Risk of Spontaneous Breathing in ARDS

Kuo-Ching Yuan (Taipei Medical Univ, Taiwan)

August 1(Sat), 2020

Room 4 Current Battlegrounds in Sepsis Application of Artificial Intelligence in Critical Care: A Single Institution's Experience (Including Sepsis)

16 KSCCM·ACCC 2020 강의 목차 | SCIENTIFIC PROGRAM CONTENTS

July 31(Fri), 2020 (Day 1)

Memorial Lecture What I Have Learned in Critical Cares Younsuck Koh ······························41

Sepsis in Special Populations Postoperative Sepsis: What Intensivists Need to Know Chi-Min Park································42

COVID-19 Pandemic COVID-19: Clinical Features and Therapeutic Option Pyeong Gyun Choe·······················43

Coronavirus Disease 2019 during the 2019-2020 Epidemic: Preparing Intensive Care Seungsik Hwang···························45 Units-the Experience in South Korea

Updates in Mechanical Ventilation Recent Updates on Weaning (Liberation) from MV Kyeongman Jeon··························46

Recent Evidence of Mechanical Ventilation in ARDS Je Hyeong Kim······························49

Electrical Impedance Tomography for Optimizing Mechanical Ventilation Gee Young Suh·····························52

Critical Care Pharmacy Critical Care Nutrition You-Min Sohn·······························53

Neurocritical Care Pharmacotherapy Young Joo Song····························54

Adverse Drug Reactions in Critically Ill Patients Eunyoung Choi·····························56

Surgical Critical Care Polymyxin B Hemoperfusion in Abdominal Septic Shock: Option for Refractory Shock in Eun Young Kim ····························59 the Era of Surgery

Acute Care Surgery: A Different System Stressor Lewis J Kaplan······························63

Protecting the Gut in Critical Illness Jung-Min Bae·······························64

Transfusion Strategies Rationale and Physiology behind Transfusion in The Critically Ill Ho Geol Ryu ································67

Blood Management for the Critically Ill Jaemyeong Lee·····························68

Massive Transfusion in Critically Ill Patients Hangjoo Cho································70

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 17 강의 목차 | SCIENTIFIC PROGRAM CONTENTS

Updated PAD in Critical Care Gaps between the PADIS Guideline and Practice Chi Ryang Chung ·························72

Pediatric Delirium Hyo-Won Kim·······························73

Role of Ketamine and Antiepileptic Drugs in the Treatment of Acute Postoperative Pain Miroslaw Czuczwar······················74

CRRT Correcting Acid Base and Electrolyte Imbalance with CRRT Sung Yoon Lim······························76

Drug Dosing during CRRT You-Min Sohn·······························77

Weaning from CRRT and Management Thereafter Hye Ryoun Jang····························79

Optimizing Antibiotics in the ICU Antibiotic De-escalation Strategies in the ICU Michael Klompas··························80

PK-PD Optimized Therapy Jeffrey Lipman······························83

Biomarker-guided Antibiotic Therapy Jinsoo Min····································85

Patient Safety Approaching Patient Safety as Science Asad Latif·····································87

Do Critically Ill Patients All Need Oxygen Therapy? Jozef Kesecioglu ··························88

ICU Design and Infection Prevention Michael Klompas··························89

Neuro-Critical Care Who Benefits from TTM in Neurological Intensive Care Unit? Ji Man Hong·································91 Novel Strategies in Enhancing Recovery from Traumatic Brain Injury Lewis J Kaplan······························92

ECMO Microcirculation in VA-ECMO Tony Yeh·······································93

VV-ECMO without Systemic Heparin Anticoagulation - Is It Possible and Feasible? Miroslaw Czuczwar······················94

Mechanical Ventilation on VV ECMO: The Current Practice and Adjunctive Treatments Sunghoon Park·····························96

Coagulation and Thrombosis VTE Prevention Elliott Haut···································99

A Scenario-based Approach to Thrombocytopenia in ICU Won-Il Choi································100

18 KSCCM·ACCC 2020 강의 목차 | SCIENTIFIC PROGRAM CONTENTS

Infection Therapeutic Antibiotic Monitoring of Beta-lactams Jeffrey Lipman····························102

The Antipyretic in Febrile Critically Ill Patients. HOT or COOL Moritoki Egi································103

August 1(Sat), 2020 (Day 2)

Intensive Care Management for COVID-19 Patients Korean Guideline on Management of Critically Ill Adults with COVID-19 Kyeongman Jeon ·······················107

Clinical Features and Short-term Outcomes of Critically Ill Patients with COVID-19: A Jae Seok Park·····························108 Report of Single COVID-19 Designated Hospital’s Intensive Care Unit in Daegu

Venous Thromboembolism in COVID-19 Patients Jae-Bum Kim······························109

War against COVID-19 COVID-19 Surveillance System in Communities and Medical Institutions Jin Yong Kim ······························111

Disaster Planning during a COVID-19 Outbreak Hyun-Soo Chung························112

Where We’re at with Vaccines and Treatments for COVID-19 Jae-Hoon Ko·······························113

How Will COVID-19 Change the World? Ethics and Resource Allocation for Pandemic Infectious Diseases Younsuck Koh·····························114

A Guide for the ‘New Normal’ after COVID-19 Jihoon Jeong······························115

Specialized Rapid Response Systems Difficult Airway Response Team (DART) Seungho Jung·····························117

Neurologic Alert Team Sang-Beom Jeon·························119

Challenging Cases: Diagnostic Reasoning and Avoiding Errors in Acutely Ill Patients Factors Associated with Motor Subtypes of Delirium in a Surgical Intensive Care Unit Hee-Jeong Kim ··························121

Palliative Care in Pediatric ICU Aisoon Park ·······························124

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 19 강의 목차 | SCIENTIFIC PROGRAM CONTENTS

Diagnostic Reasoning and Avoiding Errors in Acutely Ill Patients: Challenging Cases in Young Ae Kang···························126 Coronary Care Unit

Critical Care Nursing: Daring to Find Joy and Meaning at Work Understanding and Eliminating Workplace Stress Sookhyun Park····························128

Support for Nurses through Hospital Policy Change Eun Koung Seo···························130

Leadership and Success in a Caring Profession Eunju Cho···································131

Summary of Recent Major RCTs What`s New in Sepsis? - Recent Major RCTs in 2019-2020 Hannah Lee································133

Recent Randomised Clinical Trials of Neurointensive Care Kwang Wook Jo··························136

Summary of Recent Major RCTs: Pulmonary/ARDS Woo Hyun Cho···························137

General Critical Care Update Common Colorectal Disorders Encountered in the ICU Heung-Kwon Oh·························139

Managing Old and New Onset Atrial Fibrillation in the ICU Myung-Jin Cha···························141

Assessment of Renal Function in the Critically Ill Patients Sung Yoon Lim····························142

Pediatric Critical Care: Solid Organ Transplantation in Children Living Donor Lung Transplantation in Children Motomu Kobayashi····················143

Liver Failure in PICU Seak Hee Oh·······························144

From Home PN to Intestinal Transplantation Jin Soo Mun·······························145

Critical Care Ethics Impact of Intervention on the Decision of POLST Joohae Kim·································146

Death Education: Literature Review Jae Young Moon·························147 Moral Injury - Suffering of Physicians Facing the Death of Patients So Young Park·····························149

Extracorporeal Life Support Extracorporeal Life Support for Heart Transplantation Yang Hyun Cho···························151

LVAD in Heart Failure Young-Nam Youn························152

Back-Flow Arteriovenous Shunt Test for Weaning of VA ECMO Min Ho Ju···································156

20 KSCCM·ACCC 2020 강의 목차 | SCIENTIFIC PROGRAM CONTENTS

Cardiopulmonary Resuscitation 2020 Preview of 2020 Korean Guidelines for Pediatric Life Support Do Kyun Kim ······························157

Effectiveness and Rationale of Sodium Bicarbonate during CPR Ki Young Jeong···························159

Post Cardiac Arrest Care after In-Hospital Cardiac Arrest Focusing on Targeted Wook-jin Choi····························162 Temperature Management (TTM)

Clinical Trials and International Collaboration High Quality Clinical Research: The Role of ESICM Jozef Kesecioglu·························165

Data Science in Critical Care: International Database Collaboration Tony Yeh ····································166

Trauma Damage Control Surgery Principles for the Non-Surgeon Elliott Haut·································167

Current Battlegrounds in Sepsis Emerging Strategies for Sepsis Care Lewis J Kaplan····························168

Blood Purification for Sepsis and Acute Kidney Injury Kent Doi·····································169

Application of Artificial Intelligence in Critical Care: A Single Institution's Experience Kuo-Ching Yuan··························170 (Including Sepsis)

Recovering from Critical Illness: Patients and Intensivists Post-Intensive Care Syndrome Lewis J Kaplan····························172

Post ICU Clinic Yeon Joo Lee······························173

Burnout Syndrome of Korean ICU Professionals Jeongmin Kim·····························175

Hepatic Dysfunction Perioperative Management of the Patient with Hepatic Disease Asad Latif···································177

Nutrition New Guidelines on Nutritional Intervention in the ICU Miroslaw Czuczwar····················179 - ASPEN, ESPEN or Local?

Nutrition for Patients on ECMO Support Eunjeong Heo·····························181

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 21 강의 목차 | SCIENTIFIC PROGRAM CONTENTS

Research and Ethics Symposium Reporting Guidelines Soo Young Kim···························183

Impress Journal Editors through Clarity and Impact in Your Academic Writing Yunhee Whang···························185

Fluid Therapy Update in Colloids for Critically Ill Patients Sahadol Poonyathawon ·············187

ARDS The Risk of Spontaneous Breathing in ARDS Takeshi Yoshida··························189

Surrogate Markers for Optimal PEEP in ARDS Dong Hyun Lee···························190

Neuromuscular Blockers for ARDS: To Use or Not to Use Jae Young Moon·························192

22 KSCCM·ACCC 2020 구연발표 목차 | ORAL PRESENTATION CONTENTS

Oral Presentation

Oral Cardio (1) 01 Change in T/QRS Ratio Can be a Supplementary Diagnostic Tool in Predicting Coronary Artery Disease in Patients with NSTEMI······················································································································· 195 Jae Hoon LEE Emergency Medicine, Dong-A University College of Medicine, Korea

Oral Cardio (1) 02 The association between bleeding complication and mortality in patients underwent extracorporeal cardiopulmonary resuscitation································································································ 196 Min-Goo KANG1, Yunim LEE1, Ryoung-Eun KO1, Yang Hyun CHO1,3, Chi Ryang CHUNG 1, Kyeongman JEON1,4, Gee Young SUH1,4, Jeong Hoon YANG1,2 1Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University, Korea; 2Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University, Korea; 3Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University, Korea; 4Division of Pulmonology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University, Korea

Oral Cardio (1) 03 The role of thrombolysis in myocardial infarction (TIMI) score in predicting mortality among acute coronary syndrome patients in Indonesia: a hospital-based cohort study················································· 196 Hening TIRTA KUSUMAWARDANI1, Etra ARIADNO2, Eko BUDI PRASETYO1 1Anesthesiology and Intensive Therapy Departments, Dr. Mintohardjo Naval Hospital, Jakarta, Indonesia; 2Internal Medicine Departments, Cilandak Marine Hospital, Jakarta,, Indonesia

Oral Cardio (1) 04 Comparison of Effects of Triple Antithrombotic Therapy and Dual Antiplatelet Therapy on Long-Term Outcomes of Acute Myocardial Infarction··················································································· 198 Mei-Tzu WANG1, Guang-Yuan MAR1, Cheng Chung HUNG1, Shu-Hung KUO1, Wang-Ting HUNG1, Pei-Ling TANG1, Cheng-Hung CHIANG1,2,3, Jin-Shiou YANG3, Chun-Peng LIU1,3, Wei-Chun HUANG1,2,3 1Critical Care Medicine, Kaohsiung Veterans General Hospital, Taiwan; 2School of Medicine, National Yang-Ming University, Taiwan; 3Physical Therapy, Fooyin University, Taiwan

Oral Cardio (1) 05 The Effectiveness of Intra-aortic Balloon Pump (IABP) in Patients with or without Cardiogenic Shock Following Acute Myocardial Infarct (AMI)··························································································· 198 Muhamad Fajri ADDA’I1, Jonathan Hasian HAPOSAN2, Andi Khomeini Takdir HARUNI3, Amiliana M. SOESANTO4 1Emergency Medicine, Johar Baru Health Care, Jakarta, Indonesia; 2Pediatric Research Office, University of Gadjah Mada, Yogyakarta, Indonesia; 3Internal Medicine, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia; 4Cardiology, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia

Oral Cardio (1) 06 What we learned from the STEMI patients complicated with RBBB? Extension of Sgarbossa················· 199 Tzong-Luen WANG WITHDRAWAL Emergency Medicine, Chang Bing Show Chwang Memorial Hospital, Taiwan

Oral Cardio (1) 07 Influence of ventilation strategies on gas distribution by EIT after cardiac surgery with cardiopulmonary bypass····································································································································· 199 Yung-Chi HSU1, Chien-Sung TSAI2, Tso-Chou LIN1 1Anesthesiology, Tri-Service General Hospital, Taiwan; 2Cardiovascular Surgery, Tri-Service General Hospital, Taiwan

Oral Cardio (1) 08 Clinical Outcomes of Extracorporeal Membrane Oxygenation for Patients with Cancer: Hematologic versus Oncologic Malignancy····································································································· 200 Chul PARK1, Ui Won KO1, Soo Jin NA1, Jeong Hoon YANG1,2, Kyeongman JEON1,3, Gee Young SUH1,3, Kiick SUNG4, Yang Hyun CHO4 1Critical Care Medicine, Samsung Medical Center, Korea; 2Division of Cardiology, Department of Internal Medicine , Samsung Medical Center, Korea; 3Pulmonary and Critical Care Medicine, Samsung Medical Center, Korea; 4Thoracic and Cardiovascular Surgery, Samsung Medical Center, Korea

Oral Cardio (1) 09 The impact of hypoxic hepatitis on clinical outcomes in patients who underwent extracorporeal cardiopulmonary resuscitation·························································································································· 201 Yun Im LEE1, Min Goo KANG1, Ryung-Eun KO1, Taek Kyu PARK2, Chi Ryang CHUNG1, Yang Hyun CHO3, Kyeongman JEON1,4, Gee Young SUH1,4, Jeong Hoon YANG1,2 1Department of Critical Care Medicine, Samsung Medical Center, Korea; 2Devision of Cardiology, Samsung Medical Center, Korea; 3Department of Thoracic

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 23 구연발표 목차 | ORAL PRESENTATION CONTENTS

and Cardiovascular Surgery, Samsung Medical Center, Korea; 4Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Korea

Oral Cardio (2) 10 Palliative Care at ICU for Postcardiotomy End-Stage Heart Failure Patients with ECMO or VAD Support························································································································································ 202 TSUNG-PO TSAI Division of Cardiovascular Surgery, Chung Shan Medical University Hospital, Taiwan

Oral Cardio (2) 11 The outcome of extracorporeal membrane oxygenation in the major trauma patient with hemorrhagic shock and emergency surgery in a level I trauma center························································ 202 Sung Jeep KIM Department of Trauma Surgery, Ulsan University Hospital, Korea

Oral Cardio (2) 12 The impact of microbial colonization of membrane oxygenators on clinical outcomes···························· 203 Taehwa KIM1, Woo Hyun CHO1, Dohyung KIM2, Doosoo JEON1, Yun Seong KIM1, Hye Ju YEO1, Yun Seong KIM1, Jinook JANG1, Eun Jeong SON1, Jin Ho Jang JANG1 1Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Korea; 2Department of Cardiovascular and Thoracic Surgery, Pusan National University Yangsan Hospital, Korea

Oral Cardio (2) 13 Clinical application of Korean smart all-in-one extracorporeal life support device for bridging to lung transplantation: case study······················································································································· 204 Sun Young CHOI1, Sung Yoon LIM1, Yeon-Joo LEE1, Dong Jung KIM2, Sanghoon JHEON2, Young-Jae CHO1 1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Korea; 2Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Korea

Oral Cardio (2) 14 Hyperlactatemia and Myocardial injury in ST-segment Elevation Myocardial Infarction: A Cardiac magnetic resonance Imaging Study································································································ 204 Hyun kyu CHO1, Ik Hyun PARK2, Young Bin SONG3, Woo Jin JANG4 1Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical center, Sungkyunkwan University School of Medicine, Korea; 2Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Korea; 3Division of Cardiology, Department of Internal Medicine, Samsung Medical center, Sungkyunkwan University School of Medicine, Korea; 4Division of Cardiology, Department of Internal Medicine, Ewha Womans University Medical Center , Korea

Oral Cardio (2) 15 Prediction of survival with serial ECMO lactate level in VA ECMO with cardiogenic shock······················ 205 Dowan KIM, Yuldashev NODIRBEK, Hwajin CHO, Inseok JEONG Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Korea

Oral Pharma 01 Incidence of QTc Prolongation associated with Fluoroquinolones and a Risk Factor································· 206 Eun Jung CHOI1, Jin Seon BEOM1, Hyo Cho AHN1, Seung Yong PARK2, Heung Bum LEE2 1Pharmacy, Jeonbuk National University Hospital, Korea; 2Internal Medicine, , Research Center for Pulmonary Disorders, Jeonbuk National University Medical School and Hospital, Korea

Oral Pharma 02 Optimal Infusion Rate of Dexmedetomidine for Adult Patients in the Intensive Care Unit······················ 206 Jee Yun KIM1, Jin SHIN2 1Pharmacy, Catholic Kwandong University International St. Mary’s Hospital , Korea; 2Physical Therapy, Gyeong-In Rehabilitation Center Hospital, Korea

Oral Pharma 03 Effects of Pharmacist’s Participation in a Trauma Intensive Care Unit (TICU)············································· 207 JiNa CHOI1, Janghwan CHO1, Jungeun HOE1, Dayeong HOE1, Eunjoo JEONG1, YoungWhan KIM2, JiEun KANG1 1Pharmacy, National Medical Center, Korea; 2Trauma Center, National Medical Center, Korea

Oral Pharma 04 Clinical Significance of PDDI in PICU· ············································································································· 207 In Hwa LEE1, Mi Hee YANG1, Hye Jung BAE1, Yun Hee JO1, Yoon Sook CHO1, You sun KIM2, Hong yul AHN2, Yu Hyeon CHOI2, June dong PARK2 1Department of Pharmacy, Seoul National University Hospital, Korea; 2Department of Pediatrics, Seoul National University College of Medicine, Korea

24 KSCCM·ACCC 2020 구연발표 목차 | ORAL PRESENTATION CONTENTS

Oral Pharma 05 Hypotension Incidence with Intravenous Propacetamol vs Acetaminophen in Heart Intensive Care Unit······························································································································································ 208 Min Jung GEUM 1, Shin Young HONG 1, Jae Song KIM1, Eun Sun SON1, Yun Mi YU2 1Department of Pharmacy, Severance Hospital, College of Medicine, Yonsei University, Korea; 2Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Korea Oral Surgery (1) 01 Predicting mortality of Korean geriatric trauma patients : A comparison between GTOS (Geriatric trauma outcome score) and TRISS(Trauma and injury severity score)·························································· 208 Ji Ye PARK1, Yun Hwan LEE2 1Department of Trauma and Acute Care Surgery, Ajou University School of Medicine, Korea; 2Department of Preventive Medicine, Ajou University Graduate School of Public Health, Korea Oral Surgery (1) 02 Risk factor of early biliary sepsis immediate after elective hepatopancreatobiliary surgery····················· 209 Hyun-Il GIL1, Kyoung Won YOON2, Chi-Min PARK2,3 1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Korea; 2Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea; 3Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea Oral Surgery (1) 03 Usefulness of BIA as tool for volume assessment in critically ill patients after major surgery················· 210 Yu Mi KIM, Eun Young KIM WITHDRAWAL Department of General Surgery, Division of Trauma and Surgical Critical Care, Seoul St. Mary’s Hospital, Korea

Oral Surgery (1) 04 A Nationwide Assessment of Pediatric Surgical and Anesthesia Capacity in Mongolia···························· 210 Burmaa SANJAA 1, Laura GOODMAN 2, Erdenetsetseg CHULUUN 3, Sanchin URJIN 3 1Critical Care and Anesthesiology , Mongolian National University of Medical Sciences , Mongolia; 2Surgery , University of California Davis Health, USA;3Surgery , Mongolian National University of Medical Sciences , Mongolia

Oral Surgery (1) 05 Are Preinjury Anticoagulant and Antiplatelet Medications a Pitfall in the Bleeding Tendencies of Elderly Trauma Patients in Intensive Care?······································································································ 211 Se Heon KIM1, Young Hoon SUL1,2, Jin Young LEE1, Jin Bong YE1, Jin Suk LEE1, Hong Rye KIM3, Soo Young YOON4, Joong Suck KIM5 1Trauma Surgery, Chungbuk National University Hospital, Korea; 2Trauma Surgery, College of Medicine, Chungbuk National University, Korea; 3Neurosurgery, Chungbuk National University Hospital, Korea; 4Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Korea;5Trauma Surgery, Cheju Halla General Hospital, Korea

Oral Surgery (1) 06 Selection of appropriate Reference Creatinine Estimate for Acute Kidney Injury diagnosis In Severe Trauma Patients··················································································································································· 212 Ho-Hyun KIM, Kang-Ho LEE, Hyun-Woo SUN, Dong-Yeon RYU Department of Trauma Surgery and Surgical Critical Care, Pusan National University Hospital, Busan, Korea

Oral Surgery (2) 07 The influence of environmental factors and air pollution on brain injury after road accidents··············· 212 Carlos Shu-Kee LIN1, Kuo-Hsing LIAO2, Wen-Ta CHIU3, Ta-Chien CHAN4, Min-Huei HSU5, Chih-Wei PAI6 1Critical and emergency department, Wan Fang Hospital, Taipei Medical University, School of Medicine, Taipei Medical University, Taiwan; 2Department of Neurosurgery, Wan Fang Hospital, Taipei Medical University, Center for Neurotrauma and Neuroregeneration, Taipei Medical University , Taiwan; 3Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taiwan; 4Research Center for Humanities and Social Sciences, Academia Sinica, Nankang, Taiwan; 5Graduate Institute of Data Science, College of Management, Taipei Medical University, Taiwan; 6Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taiwan

Oral Surgery (2) 08 Geographic Analysis for the Impact of Stroke and Trauma Centers Availability: Possible Impact on Stroke and Trauma Patients by Distance to Medical Centers········································································ 213 WITHDRAWAL Dorji HARNOD Department of Emergency and Critical Care Medicine, FU-Ren Catholic University Hospital, FU-Ren Catholic University, Taiwan Oral Surgery (2) 09 Analysis of the Effect of IVIG Use in Patients with Sepsis from Secondary Peritonitis······························ 214 Young Un CHOI, Hong Jin SHIM Surgery, Clinical Assistant Professor, Korea

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 25 구연발표 목차 | ORAL PRESENTATION CONTENTS

Oral Surgery (2) 10 Evaluation of the association between the proportion of isotonic crystalloids in postoperative fluid management after major abdominal surgery and clinical outcomes·················································· 215 Seung-Young OH1,2, Yun-Suhk SUH2, HannahWITHDRAWAL LEE3, Ho Geol RYU3 1Critical Care Center, Seoul National University Hospital, Korea; 2Department of Surgery, Seoul National University College of Medicine, Korea; 3Department of Anesthesiology, Seoul National University College of Medicine, Korea Oral Surgery (2) 11 Acute Kidney Injury in Trauma·························································································································· 215 Tae-Yoon KIM, Jeong-Woo LEE, Jong-Kwan BAEK, HakJae LEE, Suk-Kyung HONG Department of Surgery, Asan Medical Center, Korea Oral Surgery (2) 12 Risk factors for treatment failure of polymyxin B hemoperfusion in patients with septic shock caused by peritonitis··········································································································································· 216 Ara CHO1, Seung-Young OH1,2, Hannah LEE3, Ho Geol RYU3 1Department of Surgery, Seoul National University College of Medicine, Korea; 2Critical Care Center, Seoul National University Hospital, Korea; 3Department of Anesthesiology, Seoul National University College of Medicine, Korea Oral Sepsis (1) 01 Prevalence and outcomes of comorbid conditions in patients with sepsis in Korea: a Nationwide Cohort Study from 2011 to 2016······················································································································ 216 Hannah LEE1, Seung-Young OH2, Ho Geol RYU1, Eun Jin JANG3 1Anesthesia and Pain medicine, Seoul National University Hospital, Korea; 2Surgery, Seoul National University Hospital, Korea; 3Statistics, Andong National University, Korea Oral Sepsis (1) 02 Usefulness of delta neutrophil index in patients with necrotizing fasciitis················································· 218 Ji Young JANG1, Jong Wook LEE2, Hui-Jae BANG3, Ik Yong KIM3 1Department of Surgery, National Health Insurance Service Ilsan Hospital , Korea; 2Department of Laboratory Medicine, Konyang University Hospital, Korea; 3Department of Surgery, Yonsei University Wonju College of Medicine, Korea Oral Sepsis (1) 03 Circulating Mitochondrial N-Formyl Peptides Contribute to Poor Prognosis of Septic Shock Patients··· 218 Woon Yong KWON1,2, Gil Joon SUH1,2, Yoon Sun JUNG2, Seung Min PARK3, Subi OH3, Sung Hee KIM2, A Rum LEE2, Byoung Choul KIM4 1Emergency Medicine, Seoul National University College of Medicine, Korea; 2Emergency Medicine, Seoul National University Hospital, Korea; 3Medical student, Seoul National University College of Medicine, Korea; 4Nano-Bioengineering, Incheon National University, Korea Oral Sepsis (1) 04 A metabolomic approach for early detection of ARDS in patients with pneumonia: discriminant biomarkers of pneumonia-induced ARDS········································································································ 219 Youjin CHANG1, Sang-Bum HONG2, Chae-Man LIM2, Su Jung KIM3, Hyun Ju YOO3, Jin Won HUH2, Younsuck KOH2 1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University College of Medicine, Sanggye Paik Hospital, Korea; 2Department of Pulmonary and Critical Care Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Korea; 3Biomedical Research Center, Department of Convergence Medicine, Asan Institute for Life Sciences, Asan Medical Center, Korea BEST Oral Sepsis (1) 05 Safety and usefulness of the TSF(Target SpO2 Feedback control by FiO2) in High flow nasal cannular system···················································································································································· 220 Woo Jung SEO, Youn suck KOH, Sang-Bum HONG , Jin-Won HUH, Chae-Man LIM Pulmonary and Critical Care Medicine, Asan Medical Center, seoul, Korea Oral Sepsis (1) 06 The prognostic value of red cell distribution width (RDW) in sepsis and related-mortality······················ 221 Atika Budhy SETYANI1, Michael DWINATA2, Muhammad ABDUH3 1Emergency Medicine, Cempaka Putih General Hospital, Jakarta, Indonesia; 2Internal Medicine, Depati Hamzah General Hospital, Pangkal Pinang, Indonesia; 3Cardiology, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia Oral Sepsis (2) 07 Higher Glycemic Variability within first day of ICU admission Is Associated with an Increased 30-day Mortality in ICU patients with Sepsis··············································································································· 221 Ming-Cheng CHAN1, Wen-Cheng CHAO2, Chieh-LiangWITHDRAWAL WU2 1Department of Internal Medicine, Section of Critical Care and Respiratory Therapy, Taichung Veterans General Hospital, Taiwan; 2Department of Critical Care Medicine, Taichung Veterans General Hospital, Taiwan

26 KSCCM·ACCC 2020 구연발표 목차 | ORAL PRESENTATION CONTENTS

Oral Sepsis (2) 08 Sepsis patients without initial fever showed poor prognosis than sepsis patient with fever···················· 223 Hyeongkyu KWAK1, Gil Joon SUH1, Sola KIM2 1Emergency department, Seoul national university hospital, Korea; 2Emergency department, Seoul national university Bundang hospital, Korea

Oral Sepsis (2) 09 HYPOXIC HEPATITIS IN SEPSIS PATIENTS; Incidence and mortality in a multicenter sepsis cohort study························································································································································ 223 Yong Jun CHOI1, Jae Hwa CHO1, Kyeongman JEON2, Dong Kyu OH3, Chae-Man LIM3, Korean Sepsis Aliance group (KSA)4 1Pulmonology and Critical Care Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; 2Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 3Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea; 4Korean Sepsis Alliance (KSA) study group, , Korea

Oral Sepsis (2) 10 Early mortality prediction of LPC16:0 and lactate according to sepsis time course·································· 224 Se Hyun KWAK1, Eun Hye LEE1,2, Mi Hwa SHIN1, Jae Chul PYUN3, Su Hwan LEE1, Ah Young LEEM1, Kyung Soo CHUNG1, Young Sam KIM1, Moo Suk PARK1 1Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University, College of Medicine, Korea; 2Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-Si, Gyeonggi-Do, Korea; 3Department of Materials Science and Engineering, Yonsei University, 50 Yonsei-Ro, Seodaemun-Gu Seoul, Korea

Oral Basic 01 Lipid emulsion reverses levobupivacaine-mediated inhibition of carnitine acylcarnitine translocase ···· 225 Ju-Tae SOHN1, Da Won KANG2, Soo Hee LEE1, Seong-Ho OK1, Yeran HWANG1 1Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Korea; 2Department of Physiology, Gyeongsang National University College of Medicine, Korea

Oral Basic 02 Extracellular mitochondrial dysfunction in cerebrospinal fluid of patients with delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage ················································································· 225 Jin Pyeong JEON1,2, Dong Hyuk YOUN2, Bong Jun KIM2, Youngmi KIM2 1Neurosurgery, Hallym University College of Medicine, Korea; 2Institute of New Frontier Stroke Research, Hallym University College of Medicine, Korea

Oral Basic 03 Diagnosis and classification of Acute Respiratory Distress Syndrome by SpO2/FiO2································· 226 1 Umme Kulsum CHY WITHDRAWAL 1Emergency Department, United Hospital Limited, Bangladesh; 2Department of Anaesthesia, Analgesia, Palliative Care and ICU, Dhaka medical College Hospital, Bangladesh

Oral Basic 04 Protective effect of Umbelliferone against Biofilm Production by Methicillin-resistant Staphylococci at Intensive Care Units·············································································································· 227 Vikas KUMAR1, Firoz ANWAR2 1Pharm. Sci., SHUATS, India; 2Biochemistry, King Abdulaziz University, Saudi Arabia

Oral Basic 05 Early and delayed effects of lipopolysaccharide induced acute lung injury in aged mouse······················ 227 Sei Won KIM, In Kyoung KIM, Sang Haak LEE Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Korea

Oral Basic 06 The effect of sodium butyrate in murine lipopolysaccharide - induced acute lung injury during neutropenia recovery·········································································································································· 228 Kyu Yean KIM, Jong Min LEE, Ji Hye KIM, Tai Joon AN, Chin Kook RHEE, Hyung Kyu YOON Pulmonary, Allergy and Critical Care Medicine, Korea

Oral Basic 07 Urolithin A (UA), gut microbial-derived metabolites of ellagic acid (EA), may constitute a novel preventive strategy for Neurodegenerative Diseases····················································································· 228 Jung Hee KIM1,2, Kkot Byeol KIM2, Seonah LEE2 1Department of Neurosurgery, Seoul Medical Center, Korea; 2Research Institute, Seoul Medical Center, Korea

Oral Neuro (1) 01 The effects of bundle for management of external ventricular drain ························································· 229 Hye Seon KIM, Kyeong Hee BAEK, Jin Wook KIM, Won-Sang CHO, Chul-Kee PARK, Sun Ha PAEK, Eun Jin HA Department of neurosurgery, Seoul National University Hospital, Korea

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 27 구연발표 목차 | ORAL PRESENTATION CONTENTS

Oral Neuro (1) 02 Outcome of targeted temperature management after decompressive hemicraniectomy for large hemispheric infarction········································································································································ 229 Sukyoon LEE1, Han-Gil JEONG1, Seung Bin KIM1, Moon Ku HAN2, Jae Seung BANG3 1Department of Critical Care Medicine, Seoul National University Bundang Hospital, Korea; 2Department of Neurology, Seoul National University Bundang Hospital, Korea; 3Department of Neurosurgery, Seoul National University Bundang Hospital, Korea

Oral Neuro (1) 03 Role of Neurosurgeon in Neuro-Intensive Care: A Brief Report on the Survey Results of Korean Neurosurgeons······················································································································································ 230 KwangWook JO1, Do Sung YOO2 1Neurosurgery, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Korea; 2Neurosurgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Oral Neuro (1) 04 The temperature difference between the brain cortex and axilla in hypothermia treated patient·········· 231 KwangWook JO1, Do Sung YOO2 1Neurosurgery, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea; 2Neurosurgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Oral Neuro (1) 05 The dedicated neurointensivists are associated with the outcome in patients with ischemic stroke based on the linked big data for stroke in Korea···························································································· 231 Tae Jung KIM1,2, Ji Sung LEE3, Byung-Woo YOON1, Sang-Bae KO1,2 1Neurology , Seoul National University Hospital, Korea; 2Critical Care Medicine, Seoul National University Hospital, Korea; 3Clinical Epidemiology and Biostatistics, Asan Medical Center, Korea

Oral Neuro (1) 06 Usefulness of Modified Early Warning Score (MEWS) for predicting massive transfusion in severe trauma patients with traumatic brain injury·······································································································232 Seok Jin RYU, Dong Hun LEE Emergency Department, Chonnam National University Hospital, Korea

Oral Neuro (1) 07 Neurological complications in the intensive care unit··················································································· 233 Jin-Heon JEONG1, Dong Hyun LEE2 1Department of Intensive Care Medicine & Neurology, Dong-A University Hospital, Korea; 2Department of Intensive Care Medicine & Pulmonology, Dong-A University Hospital, Korea Oral Neuro (2) 08 Clinical outcomes and risk factors for spinal cord injury: Early (≤48 hours) versus late (>48 hours) Surgery································································································································································· 233 Moinay KIM, Seungjoo LEE Neurosurgery, Asan Medical Center, Korea Oral Neuro (2) 09 Systematic management of traumatic cervical spinal cord injury patient in intensive care unit: A case report·························································································································································234 Chi Hyung LEE, Soon Ki SUNG, Dong Wuk SON, Sang Weon LEE, Geun Sung SONG Department of Neurosurgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Korea Oral Neuro (2) 10 Neurologic prognostication by Deep learning based Neuroimaging analysis in post cardiac arrest patients····················································································································································· 235 Jung Hwa LEE1, Young Joo LEE2, Seung Min BACK2 1Critical care medicine & Neurology , Ewha Women’s University Mockdong Hospital, Ewha Women’s University College of Medicine, Korea; 2Critical care medicine , Ewha Women’s University Mockdong Hospital, Ewha Women’s University College of Medicine, Korea Oral Neuro (2) 11 Non-invasive and continuous monitoring of cerebral blood flow as a parameter of neurological deterioration in the acute brain injury············································································································· 236 Soo-Hyun PARK1, Tae Jung KIM2, Eun Jin HA3, Won Sang CHO4, Hyun-Seung KANG4, Jung Eun KIM4, Sang-Bae KO2 1Department of Neurology and Critical Care Medicine, Inha University Hospital, Korea; 2Department of Neurology and Critical Care Medicine, Seoul National University Hospital, Korea; 3Department of Neurosurgery and Critical Care Medicine, Seoul National University Hospital, Korea; 4Department of Neurosurgery , Seoul National University Hospital, Korea

28 KSCCM·ACCC 2020 구연발표 목차 | ORAL PRESENTATION CONTENTS

Oral Neuro (2) 12 Machine learning algorithm to predict outcome after targeted temperature management for malignant cerebral infarction···························································································································· 236 Han-Gil JEONG1, Sukyoon LEE1, Seung Bin KIM1, Moon-Ku HAN2 1Critical Care Medicine, Seoul National University Bundang hospital, Korea; 2Neurology, Seoul National University Bundang hospital, Korea

Oral Neuro (2) 13 Prediction of poor prognosis using frontal EEG in patients with ischemic brain injury····························· 237 Jae Hoon LEE Emergency Medicine, Dong-A University College of Medicine, Korea

Oral ICU General (1) 01 Effect of a nutritional support protocol on enteral nutrition and clinical outcomes of critically ill patients············································································································································ 238 Heemoon PARK1, Sung Yoon LIM1, Yeon Joo LEE1, Sebin KIM2, Hyung-Sook KIM3, Soyeon KIM3, Young-Jae CHO1 1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Korea; 2Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Korea; 3Nutritional Support Team, Seoul National University Bundang Hospital, Korea

Oral ICU General (1) 02 Simple Method to Confirm Proper Positioning of Central Venous Catheter Tip·········································· 239 Minwoo KANG, Tae Nyoung CHUNG Emergency medicine, Bundang CHA medical center , Korea Oral ICU General (1) 03 Bleeding complications during the molecular adsorbent recirculating system (MARS)···························· 239 Seon Woo YOO1, Deok Kyu KIM1, Seung Yong PARK2, Heung Bum LEE2 1Anesthesiology and Pain Medicine, Jeonbuk National University Medical School and Hospital, Jeonju, Korea, Korea; 2Internal Medicine, Research Center for Pulmonary Disorders, Jeonbuk National University Medical School and Hospital, Jeonju, Korea, Korea

Oral ICU General (1) 04 Association of sudden cardiac death and electrocardiography in patients with hemodialysis················· 241 Nam Eun KIM1, Hyun Jin LEE1, Jung Tak PARK2, Ea Wha KANG3, Junbeom PARK4, Su Hwan LEE1 1Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Korea; 2Department of Nephrology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Korea; 3Department of Nephrology, NHIC Ilsan Hosipital, Goyang, Korea; 4Division of Cardiology, Department of Internal Medicine, College of Medicine, Ewha Womans University, Korea

Oral ICU General (1) 05 A case report of ascending aortic IABP insertion; alternative to retrograde femoral route······················ 241 Ashish Govinda AMATYA Anaesthesia and Intensive Care , Shahid Gangalal National heart Center, Nepal

Oral ICU General (1) 06 Innovative multidisciplinary care model can improve rate of pain, agitation and delirium in critical patients···· 242 Ya-Meei LUE1, Hsing-Chi CHUNG1, Ming-Shiuan HUANG1, Hsing-Lin LIN1, Sheng-Huei HUANG1, Yu-Ping YIN1, Pei-Lin WU1, Tsuen-Xiao GUO1, Hsia-Yun HSU1, Ya-Hui HUANG1, Kang-Pan CHEN1, Shu-Hung KUO2, Kun-Chang LIN2, Mei-Lin YEH1, Hui- Ping LIN1, Yu-Yi TANG1, Wei-Chun HUANG2, Chun-Peng LIU2 1Nursing, Kaohsiung Veterans General Hospital, Taiwan; 2Critical Care Medicine, Kaohsiung Veterans General Hospital, Taiwan

Oral ICU General (1) 07 Nurses’ perspectives on flexible intensive care unit visitation in a Taiwan tertiary medical center········ 242 Anne CHAO WITHDRAWAL Department of Anesthesia, National Taiwan University Hospital, Taiwan

Oral ICU General (1) 08 The obesity paradox on ICU mortality in critically ill patients ····································································· 243 Beong Ki KIM1, Sua KIM2, Chi Young KIM1, Seung Heon LEE1, Yu Jin KIM1, Je Hyeong KIM1,2 1Division of Pulmonology, Department of Internal Medicine, Korea University Ansan Hospital, Korea; 2Department of Critical Care Medicine, Korea University Ansan Hospital, Korea

Oral ICU General (1) 09 Serotonin syndrome treated with targeted temperature management······················································· 244 Taeyoung WON, Yongil CHO, Jaehoon OH, Hyunggoo KANG Emergency medicine, College of medicine, Hanyang University, Seoul, Korea

Oral ICU General (2) 10 Effects of Prophylactic Dialysis on Coronary Bypass Surgery········································································ 244 Chia-Sheng CHANG1 WITHDRAWAL 1Department of Anesthesiology, China Medical University Hospital, Taiwan; 2Department of Anesthesia, China Medical University, Taiwan

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 29 구연발표 목차 | ORAL PRESENTATION CONTENTS

Oral ICU General (2) 11 Comparison between ringer lactate and combination of ringer lactate with hes 6% (200/0.5) in hemodynamic and regional oxygen saturation (rSO2) in rabbit with hemorrhagic shock························· 245 Faisal MUCHTAR, Syafri KAMSUL ARIF, Husni TANRA, Arif SANTOSO, Amin HISBULLAH, Irfan SJATTAR Anestesiology, Intensive Care and Pain Management, Medical Faculty, Hasanuddin University, Indonesia Oral ICU General (2) 12 Occupational inhalation injury by Hydrogen Sulfide causing multi organ failure· ···································· 245 Karishma SHAMARUKH, Mohammad Omar FARUQ General intensive care Unit, United Hospital Limited, Bangladesh Oral ICU General (2) 13 Hypomagnesemia is associated with increase in mortality and morbidity in ICU : Can we use it as prognostic marker?············································································································································· 245 MD MOTIUL ISLAM Critical Care Medicine, Bangladesh Society of Critical Care Medicine (BSCCM), Bangladesh Oral ICU General (2) 14 Impact of hypomagnesemia in critically ill patients: experience in ICU······················································ 246 MD. Ashraful Haque1, DR Rawshan Arra Khanam2 1Department Critical Care Medicine, Sheikh Fazilatunnessa Muzib Memorial KPJ Specialized Hospital, Bangladesh; 2Consultant, Department of Pulmonology, United Hospital Limited, Bangladesh Oral ICU General (2) 15 Incidence, risk factors and outcome of delirium in surgical intensive care unit········································· 247 Muhammad Faisal KHAN5, Asghar ASHRAF1, Madiha HASHMI2, Amir RAZA3, Bushra SALEEM4 1Anaesthesiology, Aga Khan University, Pakistan; 2Anaesthesiology, Aga Khan University, Pakistan; 3Anaesthesiology, Aga Khan University, Pakistan; 4Anaesthesiology, Aga Khan University, Pakistan; 5Anaesthesiology, Aga Khan University, Pakistan Oral ICU General (2) 16 Acute mesenteric ischaemia secondary to portal and superior mesenteric vein thrombosis···················· 248 Hui-Jae BANG Surgery, Yonsei university Wonju college of medicine, Korea Oral ICU General (2) 17 Sensoryneural hearing loss after carbon monoxide poisoning······································································ 248 Heekyung LEE, Hyunggoo KANG, Youngil CHO, Byunk Sung KO, Jaehoon OH Department of Emergency Medicine, Hanyang Univertisity Hospital, Korea Oral ICU General (3) 18 Effect of fibrinogen concentrate on postoperative blood loss: A systematic review and meta-analysis of randomised trials··················································································································· 249 Ka Ting NG1, Jasmine Li Ling YAP2, Pei En KWOK3 1Department of Anaesthesiology, University of Malaya, Malaysia; 2Department of Internal Medicine, Hospital Sultanah Aminah, Malaysia; 3Department of Anaesthesiology, Dalhousie University, Canada Oral ICU General (3) 19 Novel information reminding system improve Early goal directed mobility in critical patients··············· 249 Hsing-Chi CHUNG1, Hsiu-Fen YANG 1, Ya-Meei LUE1, Hsing-Lin LIN2, Sheng-Huei HUANG1, Ming-Shiuan HUANG1, Yu-Ping YIN 1, Pei-Lin WU1, Tsuen-Xiao GUO1, Hsia-Yun HSU1, Mei-Lin YEH1, Ya-Hui HUANG1, Kang-Pan CHEN1, Shu-Hung KUO 2, Hsin-Li LIANG2, Wei-Chun HUANG2,3,4,5, Chun-Peng LIU2 1Nursing, Kaohsiung Veterans General Hospital, Taiwan; 2Critical care medicine and cardiovascular center, Kaohsiung Veterans General Hospital, Taiwan; 3School of Medicine, National Yang-Ming University, Taiwan; 4Physical Therapy, Fooyin University, Taiwan; 5Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Taiwan

Oral ICU General (3) 20 Diabetic Ketoacidosis in High Altitude managed with Hemodialysis: A Case Report································· 250 Sushil KHANAL, Kamal PANDIT, Subhash Prasad ACHARYA Department of Critical Care Medicine, Grande International Hospital, Nepal

Oral ICU General (3) 21 Kefir peptides attenuates high cholesterol diet-induced atherosclerosis and bone loss by reducing oxidative stress and systemic inflammation in Apolipoprotein E knockout mice······································· 250 Chih-Ching YEN1,2 WITHDRAWAL 1Department of Pulmonary and Critical Care Medicine, China Medical University Hospital, Taichung , Taiwan; 2Department of Life Science, National Chung Hsing University, Taichung, Taiwan

30 KSCCM·ACCC 2020 구연발표 목차 | ORAL PRESENTATION CONTENTS

Oral ICU General (3) 22 Removal of Obstructive Fibrinous Tracheal Pseudomembrane showing near total obstruction with valve-manner movement by flexible bronchoscopy: A Case Report····························································· 251 Jongyeol OH, Jick Hwan HA Division of pulmonology, allergy and critical care medicine, Incheon Saint Mary’s Hospital, the Catholic University of Korea, Korea

Oral ICU General (3) 23 Acute Mitral Regurgitation as an unexpected cause of atypical unilateral pulmonary consolidation···· 252 Jung Hee KIM1,2, Jong Hyun BAEK1,2,3 1Thoracic & Cardiovascular Surgery, Yeungnam University medical center, Korea; 2Thoracic & Cardiovascular Surgery, The Korean Society of Critical Care Medicine, Korea; 3Thoracic & Cardiovascular Surgery, The Korean Society of Acute Care Surgery, Korea

Oral ICU General (3) 24 Incidental detection of a retained left atrial catheter via intraoperative transesophageal echocardiography in a patient undergoing tricuspid valve replacement: A case report···························· 253 Wan JU1, Joungmin KIM2 WITHDRAWAL 1Department of Anesthesiology and Pain Medicine, Chonnam University Hospital, Korea; 2Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Korea

Oral ICU General (3) 25 High flow nasal cannula application during intubation with a laryngomalacia infant patient: Case report··· 253 Ji-Yoon KIM, Mi Ae JEONG Anesthesiology and Pain Medicine, Hanyang University Medical Center, Korea

Oral ICU General (4) 26 A Case of Pulmonary Tumor Thrombotic Microangiopathy Treated with High Dose Steroid and Heparization·························································································································································· 254 Jae Young CHOI1, Dong Hyun LEE1, Jin-Heon JEONG1, Kyung hee LIM2, Jae Hwang CHA3 1Department of Intensive Care Medicine, Dong-A University College of Medicine, Korea; 2Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Korea; 3Division of Gastroenterology,Department of Internal Medicine, Dong-A University College of Medicine, Korea

Oral ICU General (4) 27 Prognosis of oncological patients in intensive care unit················································································ 255 Min-Seok KIM, Bo-Gun KHO, Cheol-Kyu PARK, In-Jae OH, Young-Chul KIM Department of Internal Medicine, Chonnam National University Medical School, Korea

Oral ICU General (4) 28 Clinical characteristics of nursing home/hospital residents who admit to medical intensive care unit····256 Sua KIM1,2, Beong Ki KIM3, Yu Jin KIM3, Je Hyeong KIM1,3 1Critical care medicine, Korea University College of Medicine, Ansan Hospital, Korea; 2Cardiology, Korea University College of Medicine, Ansan hospital, Korea; 3Pulmonology, Korea University College of Medicine, Ansan hospital, Korea

Oral ICU General (4) 29 Left ventricular decompression during veno-arterial extracorporeal membrane oxygenation················· 256 Ho Jin YONG1, Kyung Joon KIM1, Doh Hyung KIM2, Tae Soo KANG3, Dong Min KIM3, Sung Wook CHANG4 1Internal Medicine, Dankook University Hospital, Korea; 2Internal Medicine, Division of Pulmonary Medicine and Allergy, Dankook University Hospital, Korea; 3Internal Medicine, Division of Cardiology, Dankook University Hospital, Korea; 4Thoracic and Cardiovascular Surgery, Dankook University Hospital, Korea

Oral ICU General (4) 30 Development of Sepsis sub-classification for risk prediction and personalized treatment······················· 257 Jung Hwa LEE1,7, Doyeop KIM2, Seung-Won LEE3, Chi oh SONG4, Ka-Kyung KIM5, Jeongwon HEO6, Seung Min PACK1, Young Joo LEE1 1Critical care medicine, Ewha Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea; 2Biomedical Informatics, Ajou University School of Medicine, Korea; 3Data Science, College of Software Convergence, Sejong University, Seoul, Korea; 4Computer Engineering, Linewalks Inc., Korea; 5Clinical Diagnostic, Macrogen Inc, Korea; 6Internal Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Korea; 7Neurology, Ewha Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea

Oral ICU General (4) 31 A case of BK virus associated fulminant colitis after allogenic hematopoietic stem cell transplantation in patient with mixed phenotype acute leukemia······························································· 258 Byung-Hyun LEE, Ka-Won KANG, Yong PARK, Byung Soo KIM Internal medicine, Korea University College of Medicine, Korea

Oral ICU General (4) 32 Unusual case report for invasive pulmonary aspergillosis to arise in patient on short-term steroid treatment····························································································································································· 258 Seung Hoon KIM, Gyu Yeon KIM, Hyun Soo JOO, Jin Woo KIM Internal medicine, The Catholic University of Korea Uijeongbu St. Mary’s Hospital, Korea

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 31 구연발표 목차 | ORAL PRESENTATION CONTENTS

Oral ICU General (4) 33 Rhabdomyolysis during free flap surgery in the patient with severe peripheral vascular disease············ 259 Jun-Young JO, In-Cheol CHOI Anesthesia and pain medicine, Asan Medical Center, Korea

Oral RRT 01 Efficacy of a medical emergency team activated by an electronic medical record-based screening system················································································································································· 260 Ryoung-Eun KO1, Soo Jin NA1, Myeong Gyun KO2, Ahra KO2, Kyeongman JEON1,3 1Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 2Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 3Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Oral RRT 02 The effect of daytime rapid response system on return of spontaneous circulation in patient with cardiac arrest in a tertiary university hospital ······························································································· 260 Ji Young JANG1,2, Jungwon LEE2,, Seulgi OH2,, Dae Ja UM3, Hongjin SHIM2,4, Sung Oh HWANG5, Seok Jeong LEE2,6, Won-Yeon LEE2,6 1Department of Surgery, National Health Insurance Service Ilsan Hospital, Korea; 2Rapid response team , Wonju Severance Christian Hospital , Korea; 3Department of Anesthesiology , Yonsei University Wonju College of Medicine, Korea; 4Department of Surgery, Yonsei University Wonju College of Medicine, Korea; 5Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Korea; 6Department of Internal Medicine, Yonse University Wonju College of Medicine, Korea; 7Division of Nursing, Wonju Severance Christian Hospital, Korea

Oral RRT 03 Changing trends of cardiopulmonary resuscitation with mature medical emergency team in general ward patients········································································································································· 261 Hohyung JUNG1, Ryoung-Eun KO1, Myeong Gyun KO2, Ahra KOH2, Kyeongman JEON1,3 1Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 2Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 3Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Oral RRT 04 Limited effect of the group III rapid response team on monitoring and treatment in deteriorating ward patients······················································································································································· 262 Tae Sun HA1, HYESEON YUN3, Seok Jae LEE1, AERIN BAEK2, JIHYE OH3 1Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Gyeonggi-Do, Republic of Korea, Korea; 2Medicine, division of Pulmonary, Soonchunhyang University Bucheon Hospital, Bucheon, Gyeonggi-Do, Republic of Korea, Korea; 3Rapid Response Team Nursing, Soonchunhyang University Bucheon Hospital, Bucheon, Gyeonggi-Do, Republic of Korea, Korea Oral RRT 05 Risk Factors for Early Medical Emergency Team Reactivation in Hospitalized Patients····························· 262 Yeonseok CHOI1, Soo Jin NA2, Ryoung-Eun KO2, Myeong Gyun KO3, Ahra KOH3, Chi Ryang CHUNG2, Gee Young SUH1,2, Kyeongman JEON1,2 1Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 2Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 3Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Oral RRT 06 The Intensity of Rapid Response Team Operation and General Ward Cardiopulmonary Resuscitation Incidence······························································································································································ 262 Dong Hyun LEE, So Hye KIM, Jin-Heon JEONG Intensive Care Medicine, Dong-A University Hospital, Dong-A University, College of Medicine, Busan, Korea Oral RRT 07 Effects of expanding the coverage of a rapid response system on code rates in medical wards·············· 263 Sulhee KIM1, Seongkyeong LEE1, Jina KIM1, Hwajung LEE1, Soyoung PARK1, Sang-Min LEE2, Jinwoo LEE2, Jaeyoung CHO2, Hong Yeul LEE2, Hyun Joo LEE3, Hannah LEE4, Ho Geol RYU4, Seung-Young OH5,6, Eun Jin HA6, Sang-Bae KO7 1Rapid Response Team, Seoul National University Hospital, Korea; 2Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Korea; 3Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Korea; 4Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Korea; 5Department of General Surgery, Seoul National University Hospital, Korea; 6Critical Care Center, Seoul National University Hospital, Korea; 7Department of Neurology, Seoul National University Hospital, Korea Oral RRT 08 The attitude and barriers to implementation of rapid response system······················································ 263 Choon geun LEE, Jaeyoung CHO, Nakwon KWAK, Sun Mi CHOI, Jinwoo LEE, Young Sik PARK, Chang-Hoon LEE, Chul-Gyu YOO, Young Whan KIM, Sang-Min LEE Division of Pulmonary and Critical Care Medicine, Seoul National University College of Medicine, Seoul national university hospital, Korea

32 KSCCM·ACCC 2020 구연발표 목차 | ORAL PRESENTATION CONTENTS

Oral PED 01 Risk factors for mortality in critically ill pediatric patients with bone marrow transplantation·············· 264 Da Hyun KIM1, Won Kyoung JHANG3, Kyung-Nam KHO2, Hyery KIM2, Ho Joon IM2, Seong Jong PARK3 1Pediatrics, Asan Medical Center, Korea; 2Division of Pediatric Hemato-Oncology, Asan Medical Center, Korea; 3Division of Pediatric Critical Care, Asan Medical Center, Korea

Oral PED 02 Outcomes of extracorporeal membrane oxygenation support in pediatric hemato-oncology patients·· 264 Hong Yul AN, Yu Hyeon CHOI, You Sun KIM, June Dong PARK Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Korea

Oral PED 03 Low concentration of Vitamin C and prognosis in critically ill children ····················································· 265 Min Jung KIM, Soo Yeon KIM, Ga Eun KIM, Jae Hwa JUNG , Yoon Hee KIM, Myung Hyun SOHN, Kyung Won KIM Department of Pediatrics, Yonsei University College of Medicine, Korea

Oral PED 04 P50 implies adverse clinical outcomes in Pediatric Acute Respiratory Distress Syndrome by reflecting extrapulmonary organ dysfunction································································································· 265 Jae Hwa JUNG, Yura KIM, Ga Eun KIM, Soo Yeon KIM, Min Jung KIM, Yoon Hee KIM, Kyung Won KIM, Myung Hyun SOHN Department of Pediatrics, Severance Children’s Hospital, Yonsei University College of Medicine, Korea

Oral PED 05 Clinical usefulness of SpO2/FiO2 ratio in children with high-flow nasal cannula······································ 266 Ga Eun KIM, Jae Hwa JUNG, Soo Yeon KIM, Min Jung KIM, Yoon Hee KIM, Kyung won KIM, Myung Hyun SOHN Department of Pediatrics, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, Korea

Oral PED 06 Tracheostomy in Pediatric Intensive Care Unit: Indication and Complications··········································· 267 Jung Eun KWON1, Da Eun ROH1, Hyun Ho CHO2, Yeo Hyang KIM1 1Department of Pediatrics, School of Medicine, Kyungpook National University, Division of Pediatric Cardiology, Kyungpook National University Children’s hospital, Daegu, Korea; 2Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Kyungpook National University, Daegu, Korea

Oral PED 07 The Experience of Education on non-specialist for the reliable identification and management of pediatric sepsis ··················································································································································· 267 Da Eun ROH, Jung Eun KWON, Yeo Hyang KIM Department of Pediatrics, School of Medicine, Kyungpook National University, Division of Pediatric Cardiology, Kyungpook National University Children’s hospital, Daegu, Korea

Oral Quality (1) 01 Lactate level and unplanned intensive care unit readmission in surgical patients: A retrospective cohort study······························································································································· 268 Chami IM1, Tak-Kyu OH2 1Surgery, Seoul National University Bundang Hospital , Korea; 2Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital , Korea

Oral Quality (1) 02 Novel Interactive Patient Centered Care- The Introduce of Shared Decision Making Impact on Early Tracheostomy in Prolonged Intubated Critical Patient········································································· 269 Shu-Hung KUO1, Ming-Sun CHUANG1, Che-Shang YANG1, Chun-Chuang LIN1, Chun-Ping YANG1, Hsi-Chen CHEN1, Mong-Chen WU1, Whei-Ni CHEN1, Se-Chun CHUANG1, Shu-Ya CHUANG1, Hsin-Li LIANG1, Wei-Chun HUANG1,2,3,4 1Critical care medicine and cardiovascular center, Kaohsiung Veterans General Hospital, Taiwan; 2School of Medicine, National Yang-Ming University, Taiwan; 3Physical Therapy, Fooyin University, Taiwan; 4Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Taiwan Oral Quality (1) 03 Prognostic Value of Neutrophil Gelatinase-Associated Lipocalin (NGAL) Ratio Measurement to Predict Acute Kidney Injury in the Intensive Care Unit (ICU) Patients························································· 269 Adika Zhulhi ARJANA1, Ninda DEVITA2, Isni MEILASARI1 1Clinical Pathology and Laboratory Medicine, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada, Indonesia; 2Medical Doctor Programme, Faculty of Medicine, Universitas Islam Indonesia, Indonesia

Oral Quality (1) 04 Study in prevalence of decubitus in intensive care unit of mongolian hospitals········································ 270 Battsetseg BAASANJAV, Naranpurev MENDSAIKHANWITHDRAWAL The First Central Hospital Of Mongolia, Mongolian Society of Intensive Care Medicine, Mongolia

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 33 구연발표 목차 | ORAL PRESENTATION CONTENTS

Oral Quality (1) 05 The impact of ABCDE bundle on the outcome of patients with mechanical ventilator····························· 270 Chin-Ming CHEN1,2 1Intensive Care Medicine, Chi-Mei Medical Center, Taiwan; 2Center for Quality Management, Chi-Mei Medical Center, Taiwan

Oral Quality (1) 06 The impacts of airway management team on the prognosis of critically ill patients································· 271 Sumi CHOI1, Seungho JUNG2, Jeongmin KIM2, Minju KIM1, Sungwon NA2 1Division of Nursing, Severance Hospital, Yonsei University Health System, Seoul, Korea, Korea; 2Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine,, Korea

Oral Quality (1) 07 Decreased psychological distress in ICU caregivers after singing-based music therapy intervention····· 272 Sungwon NA1, Ji Woo SEO1, Ga Eul YOO2, Soo Ji KIM2,3, Jeonmgmin KIM1, Myung Sun YEO2 1Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Korea; 2Department of Music Therapy, Graduate School, Ewha Womans University, , Korea; 3Music Therapy Education, Graduate School of Education, Ewha Womans University, Korea

Oral Quality (2) 08 The application of quality improvement and artificial intelligence to improve the outcome of patients with ventilator in the intensive care units······································································································· 272 Jou-Chun CHEN1, Chin-Ming CHEN2 1Department of Healthcare Administration , Asia University, Taiwan; 2Intensive Care medicine, Chi-Mei Medical Center, Taiwan

Oral Quality (2) 09 Head Nurse·························································································································································· 273 Pei Jun CHEN WITHDRAWAL Intensive care unit, Chi Mei Medical Center, Chiali, Taiwan

Oral Quality (2) 10 Baseline survey on hand hygiene compliance at intensive care units in Iraq············································· 273 Jinki JUNG1, Sukh Que PARK2, Min Chang KANG3, Bo Young LEE4, Eun Hynag CHU5, Layla ALI HAKEEM6, Ali Saad JABER AL ALLAWEE7 1International Project Corp., Soonchunhyang University Hospital, Korea; 2Neurosurgery, Soonchunhyang University Hospital, Korea; 3Surgery, Soonchunhyang University Hospital, Korea; 4Pulmonology and Allergy, Soonchunhyang University Hospital, Korea; 5Intensive Care Unit, Soonchunhyang University Hospital, Korea; 6Intensive Care Unit, Ghazi Hariri Hospital for Specialized Surgery, Korea; 7Intensive Care Unit, Baghdad Teaching Hospital, Korea

Oral Quality (2) 11 Quick Sepsis-related Organ Failure Assessment score and Modified Early Warning Score for detecting clinical deterioration of patients in general ward········································································· 274 Ryoung-Eun KO1, Kyung-Jae CHO2, O-Yeon KWON2, Hyun-Ho PARK2, Yeon Joo LEE3, Joon-Myoung KWON4, Jinsik PARK5, Jung Soo KIM6, Man-Jong LEE6, Ah Jin KIM6, You Hwan JO7, Yeha LEE2, Kyeongman JEON1,8 1Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 2VUNO, Seoul, , Korea; 3Division of Pulmonary and Critical Care Medicine, Seoul National University Bundang Hospital, Gyeonggi-Do, Korea; 4Department of Critical care and Emergency Medicine, Mediplex Sejong Hospital, Incheon, Korea; 5Division of Cardiology, Cardiovascular Center, Mediplex Sejong Hospital, Incheon, Korea; 6Division of Critical Care Medicine, Department of Hospital Medicine, Inha College of Medicine, Incheon, Korea; 7Department of Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggi-Do, Korea; 8Division of Pulmonology and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Oral Quality (2) 12 Comparison of clinical aspects of unplanned admissions to intensive care unit (ICU) in two medical ward: hospitalist ward and non-hospitalist ward············································································ 275 Sang Won YOON, Jaeyoung CHO, Nakwon KWAK, Jinwoo LEE, Young Sik PARK, Chang-Hoon LEE, Chul-Gyu YOO, Young Whan KIM, Sun Mi CHOI, Sang-Min LEE Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Korea

Oral EM/CPR 01 Characteristics and outcomes of in-hospital cardiac arrest in a tertiary referral center with rapid response system········································································································································ 275 Hohyung JUNG1, Ryoung-Eun KO1, Myeong Gyun KO2, Ahra KOH2, Kyeongman JEON1 1Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea; 2Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea

Oral EM/CPR 02 Successfully resuscitated refractory ventricular fibrillation with double sequence defibrillation: a case report························································································································································· 276 Sung-Hyuk CHOI, Young-Hoon YOON, Jung-Youn KIM, Young-Duck CHO, Sung-Jun PARK, Eu-Sun LEE, Ji-Young LEE Department of Emergency Medicine, College of Medicine, Korea University, Seoul, Korea

34 KSCCM·ACCC 2020 구연발표 목차 | ORAL PRESENTATION CONTENTS

Oral EM/CPR 03 Effects of Mild Therapeutic Hypothermia in Post-anoxic Comatose Patients with Hypotension Events····· 276 Jae Hoon LEE Emergency department, Dong-A university college of medicine, Korea Oral EM/CPR 04 Successful adjunctive treatment of compartment syndrome by acute isocyanates inhalation using hyperbaric oxygen therapy································································································································· 278 Dongki KIM, Junho HAN, Sungmin LEE, Tag HEO Emergency medicine, Chonnam National university hospital, Korea Oral EM/CPR 05 Coronary angiography is associated with post-cardiac arrest outcomes in patients with ever shockable rhythm················································································································································ 278 Chih-Wei SUNG1, Chien-Hua HUANG2, Wen-Jone CHEN2,3, Wei-Tien CHANG2, Jia-How CHANG1, Min-Shan TSAI2 1Emergency medicine, National Taiwan University Hospital Hsin-Chu Branch, Taiwan; 2Emergency medicine, National Taiwan University Hospital, Taiwan; 3Internal Medicine, National Taiwan University Hospital, Taiwan Oral EM/CPR 06 Association between the reduction of time to reach target temperature and clinical outcomes in patients treated with targeted temperature management after cardiac arrest·········································· 279 Kun-Chang LIN1, Thung-Hsien HSU2, Yun-Te CHANG2, Wang-Chuan JUANG3, Jie-Ling HUANG4, Cheng-Chang YEN3, Hai-Yu CHEN4, Ya-Meei LUE4, Ru-Huei WANG4, Yong-Huei TANG4, Hsin-Li LIANG1, Wei-Chun HUANG1,6,7,8 1Critical care medicine and cardiovascular center, Kaohsiung Veterans General Hospital, Taiwan; 2Emergency, Kaohsiung Veterans General Hospital, Taiwan; 3Neurology, Kaohsiung Veterans General Hospital, Taiwan; 4Nursing, Kaohsiung Veterans General Hospital, Taiwan; 5Quality management, Kaohsiung Veterans General Hospital, Taiwan; 6School of Medicine, Kaohsiung Veterans General Hospital, Taiwan; 7Physical Therapy, Fooyin University, Taiwan; 8Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Taiwan Oral EM/CPR 07 Clinical Outcomes of Extracorporeal Cardiopulmonary Resuscitation for Cardiac Arrest of Surgical Patients·················································································································································· 280 Jong-Kwan BAEK, Jeong Woo LEE, Tae Yoon KIM, Hak-Jae LEE, Suk-Kyung HONG Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, Korea Oral EM/CPR 08 Prediction of In-hospital cardiopulmonary arrest in cancer patients··························································· 281 Wonho HAN, Sungwoo KANG, Jeehee KIM Intensive care unit, National Cancer Center, Korea Oral Nursing 01 Efficacy of Inhaled Budesonide on Prevention of Acute Mountain Sickness during Emergent Ascent: A Meta-analysis of Randomized Controlled Trials·························································································· 281 GAURAV NEPAL Medicine, Tribhuvan University Institute of Medicine, Nepal

Oral Nursing 02 Implementation of rapid response team of SNU-SMG Boramae Medical Center······································· 282 Daeun JUNG1, Jung-Hee SONG1, Tae-Yeon PARK1,2, Seoyoung YOON1,2, Jung-Nam AHN1,2, Eunyoung HEO2 1Critical Care Medicine, SNU-SMG Boramae medical center, Korea; 2Internal Medicine, SNU-SMG Boramae medical center, Korea

Oral Nursing 03 Development of End-of-life Nursing Care Protocol for Intensive Care Unit: Delphi Survey Method······· 282 Jungeun KIM Intensive care unit, Yonsei cancer center, Korea

Oral Nursing 04 Risk Factors associated with Heel Pressure Injury in Adult Patients in Cardiovascular Intensive Care Unit ····························································································································································· 283 Hyeon Jeong LEE1, Min Young HAN2 1Heart intensive Care Unit (HICU), Severance Hospital , Korea; 2Coronary Care Unit (CCU), Severance Hospital , Korea Oral Pulmo (1) 01 Impact of non-cystic fibrosis bronchiectasis on critically ill patients·························································· 283 Youngmok PARK, Ah Young LEEM, Kyung Soo CHUNG, Moo Suk PARK, Young Sam KIM, Su Hwan LEE Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea, Korea

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 35 구연발표 목차 | ORAL PRESENTATION CONTENTS

Oral Pulmo (1) 02 Clinical Safety and Efficacy of the Machine with Automatic Closed-Suction System· ···························· 284 Yune Young SHIN, Young-Jae CHO Pulmonology, Seoul National University Bundang Hospital, Korea

Oral Pulmo (1) 03 Change in Management and Outcome of Mechanical Ventilation in Korea··············································· 284 Jae Kyeom SIM, Gee Young SUH Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Oral Pulmo (1) 04 Association of pressure support vs. T-piece spontaneous breathing trials with weaning outcomes in medical intensive care unit································································································································ 285 Kyeongman JEON1, Soo Jin NA1, Myeong Gyun KO2, Jimyoung NAM1 1Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea; 2Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea

Oral Pulmo (1) 05 Innovative thoracic phantom for lung pathologies simulation····································································· 285 Chun-Yi TSAI2, Wen-Min TSENG2, Hsiu-Yung PAN3, Wei-Chun HUANG1 1Critical Care Medicine, Kaohsiung Veterans General Hospital, Taiwan; 2Emergency Medicine, Kaohsiung Veterans General Hospital, Taiwan; 3Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan

Oral Pulmo (1) 06 Looking into the center of a chest X-ray: a rare case of mucoepidermoid carcinoma causing nearly impossible airway················································································································································ 286 Chi-Hsin CHEN1, Wei-Tien CHANG2, Chih-Wei SUNG1, Jia-How CHANG1, Edward Pei-Chuan HUANG1,2 1Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Taiwan; 2Department of Emergency Medicine, National Taiwan University Hospital, Taiwan

Oral Pulmo (1) 07 Validity of lung injury prediction score as a predictor of acute respiratory distress syndrome in intensive care unit sanglah hospital WITHDRAWALdenpasar································································································ 287 Cynthia Dewi SINARDJA, Budi HARTONO Department of Anesthesia and Intensive Care, Faculty of Medicine, Udayana University, Indonesia

Oral Pulmo (1) 08 A Randomized Control Trial Comparing Channeled Videolaryngoscope and Macintosh Laryngoscope For Endotracheal Intubation in The Critically ill····································································· 287 Dharanindra MOTURU Department of Critical Care Medicine, Bharati Vidyapeeth University- College Of Medicine, India

Oral Pulmo (2) 09 The Exploration of Recurrent Intubation with Ventilator of Older Patients at ICU in a Southern Taiwan Hospital··································································································································································· 288 Jia-Wei LIN1,2, Shu-Chen HSING3, Kuei-Ling TSENG4 1Departments of Neurology Medicine, Chi Mei Medical Center, Liouying, Taiwan; 2Departments of Healthcare Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan; 3Departments of Respiratory Therapy, Chi Mei Medical Center, Tainan, Taiwan; 4Departments of Respiratory Therapy, Chi Mei Medical Center, Tainan, Taiwan

Oral Pulmo (2) 10 Impact of timing of renal replacement therapy initiation on outcome of acute kidney injury in septic patients in a tertiary care centre in a low-middle country············································································ 289 Muhammad Sohaib AZHAR, Nasir KHOSO, Madiha HASHMI, Zahoor AHMED Anaesthesiology Department, Aga Khan University, Pakistan

Oral Pulmo (2) 11 Factors associated with extubation failure in Intensive Care Unit Patients after Spontaneous Breathing Trial····················································································································································· 290 Niraj Kumar KEYAL1, Roshana AMATYA2, Gentle Sundar SHRESTHA3, Saurabh PRADHAN4, Krishna Kumar AGRAWAL5, Hem Raj PANERU6 WITHDRAWAL 1Critical Care Medicine, B & C Medical College Teaching Hospital & Research Center Pvt Ltd. Birtamode-5, Jhapa. Province no 1, Nepal, Nepal; 2Anaesthesiology, Tribhuvan University Teaching Hospital.Maharajgunj Kathmandu., Nepal; 3Anaesthesiology, Tribhuvan University Teaching Hospital. Maharajgunj Kathmandu, Nepal; 4Anaesthesiology, Tribhuvan University Teaching Hospital.Maharajgunj Kathmandu, Nepal; 5Nephrology, Nepal Medical College, Nepal; 6Anaesthesiology, Tribhuvan University Teaching Hospital.Maharajgunj Kathmandu, Nepal

36 KSCCM·ACCC 2020 구연발표 목차 | ORAL PRESENTATION CONTENTS

Oral Pulmo (2) 12 High-flow nasal cannula therapy can be effective for extubated patients with hypercapnia·················· 291 Hong Rae CHO1, Jong-Joon AHN2, Chuiyoung PAK3, Jin Hyoung KIM3, Byung Ju KANG2 1Department of Surgery, Ulsan University Hospital, Korea; 2Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Korea; 3Department of Internal Medicine, Ulsan University Hospital, Korea

Oral Pulmo (2) 13 Effect of high flow oxygen therapy in spontaneous breathing trial on weaning: An interim analysis of randomized trial······························································································································· 292 Hong Yeul LEE, Jaeyoung CHO, Nakwon KWAK, Jinwoo LEE, Sun Mi CHOI, Young Sik PARK, Chang-Hoon LEE, Chul-Gyu YOO, Young Whan KIM, Sang-Min LEE Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Korea

Oral Pulmo (2) 14 Characteristics and outcome of lung cancer patients admitted to intensive care units··························· 292 Hee-Sung KIM, Yoon Mi SHIN Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University college of Medicine, Korea

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 37

KSCCM·ACCC 2020 The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020

July 31(Fri), 2020 (Day 1)

Live Streaming

th ■ Opening Plenary: Happy 40 Anniversary ■ Memorial Lecture

Room 1

■ Sepsis in Special Populations ■ COVID-19 Pandemic ■ Satellite Symposium I

Room 2

■ Updates in Mechanical Ventilation ■ Critical Care Pharmacy ■ Surgical Critical Care ■ Satellite Symposium II

Room 3

■ Transfusion Strategies ■ Updated PAD in Critical Care ■ CRRT Room 4

■ Optimizing Antibiotics in the ICU ■ Patient Safety ■ Neuro-Critical Care

Room 5

■ ECMO ■ Coagulation and Thrombosis ■ Infection

Room 6

■ Oral Cardio 1 ■ Oral Surgery 1 ■ Oral Cardio 2 ■ Oral Neuro 2

Room 7

■ Oral ICU General 1 ■ Oral Sepsis 1 ■ Oral Surgery 2 ■ Oral Pharma

Room 8

■ Oral Neuro 1 ■ Oral Sepsis 2 ■ Oral Basic 1 Younsuck Koh ■ What I Have Learned in Critical Cares

Memorial Lecture July 31 (Fri) What I Have Learned in Critical Cares

Younsuck Koh

Asan Medical Center, University of Ulsan College of Medicine

In recent clinical studies, some critical care pre- enhancing the outcome of intensive care. Spiritual cepts that had prevailed as standard care have been support to the critically ill should also be delivered challenged in their efficacy. Larger tidal volumes, in intensive care units for their well-being. Critical strict glucose control, RBC transfusion, and appro- caregivers need to be able to empathize with the priate sedation in critically ill patients have physio- patients while maintaining proper emotional dis- logical justification. However, low tidal mechanical tance from them so that appropriate medical de- ventilation, less rigid blood glucose control, con- cisions can be made with due consideration of pa- servative RBC transfusion, and earlier spontaneous tient’s best interest. This is especially true in making breathing trial from mechanical ventilation have decisions related to end-of-life cares. shown better outcomes than the traditional ap- To be a good critical caregiver, you need foremost proaches in critically ill patients. These clinical data be able to focus on your professional responsibili- remind us that less intervention frequently results ties. But you should at the same time be conscious in greater benefit for many critically ill patients. As not to burn yourself out or be abused working in in- shown in sepsis, earlier appropriate management appropriate working environment. Caregivers must can save more critically ills. Close monitoring with think critically and question continuously even serial follow-up of clinical variables is crucial in de- while performing routine clinical practices when it termining appropriate level of intensive care. Fol- involves seriously ill patients. Our attentiveness for low-up of patients who had been discharged from earlier interventions, frequent visits to patients, and intensive care unit to general ward also reduces avoidance of harmful practices play more import- re-admission risk as well as post-intensive care unit ant roles in improving patient outcomes rather than syndrome. being too dependent on expensive technical moni- To perform these tasks well, critical care team toring or laboratory data. The answer to best critical must be armed with effective teamwork. Frequent care may lie in personalized care that is in line with communication with critically ills, their families the resources available to each individual intensive and among team members can serve as a tool in care unit team.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 41 Chi-Min Park ■ Postoperative Sepsis: What Intensivists Need to Know

Sepsis in Special Populations

Postoperative Sepsis: What Intensivists Need to Know

Chi-Min Park

Sungkyunkwan Univ, Korea

The clinical definition of postoperative sepsis in- Early recognition is most important as other sepsis cludes all types of postoperative patients with an or septic shock, however, there are several problem infection leading to sepsis, severe sepsis, and septic in diagnosis of sepsis in postoperative patients. First, shock as defined by the American College of Chest many postoperative patients have fever and leukocy- Physicians/Society of Critical Care Medicine (ACCP/ tosis which are the classical marker of infection. Sec- SCCM) consensus conference committee guidelines. ond, most common shock after surgery is hypovole- Postoperative sepsis does not necessarily include all mic or hemorrhagic shock. So if early postoperative postoperative infections. patients show the clinical feature of shock, surgeon Surgical site infection is most common postopera- usually consider postoperative bleeding. Further- tive infection and complication and Surgical patients more, some patients have both hemorrhagic shock account for one third of all septic patients. 1.2% and septic shock and differentiation or diagnosis of patients developed postoperative sepsis in study to sepsis could be very difficult in this cases. Several evaluate the incidence of postoperative sepsis after marker id studying for diagnosis of surgical infection, elective procedure. After nonelective surgery 4.24% such as procalcitonin and presepsin. of patients developed postoperative sepsis. The mor- Treatment guidelines of postoperative sepsis tality rate due to sepsis as a proportion of total mor- fall under the ‘Surviving Sepsis Campaign’ as do tality for elective procedures was 23.9% after elective other types of sepsis. Early diagnosis, source con- surgery and 29.8% after nonelective surgery, respec- trol, prompt and appropriate antibiotic treatment, tively. maintaining appropriate intravascular fluid balance, Risk factor include age, surgery type, co-morbidity, maintaining adequate blood pressure and tissue poor nutritional status, immunosuppression, steroid, perfusion and oxygen delivery are the cornerstones and hyperglycemia. GI, cardiovascular, or thoracic of our current treatment. Among these treatment, procedures accounted for nearly 50% of cases of antibiotics could be difficult in postoperative sepsis, postoperative sepsis, and the rates of postoperative because it could be hospital acquired infection and sepsis were highest for esophageal, pancreatic, gas- have high risk of MDR. Antibiotics should be chosen tric, small bowel, hepatic, and biliary procedures. carefully according to MDR the risk factor.

42 KSCCM·ACCC 2020 Pyoeng Gyun Choe ■ COVID-19: Clinical Features and Therapeutic Option

COVID-19 Pandemic July 31 (Fri) COVID-19: Clinical Features and Therapeutic Option

Pyoeng Gyun Choe

Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea

In December 2019, a new strain of betacoronavi- Symptoms may include fever, cough, sore throat, rus, severe acute respiratory syndrome coronavirus malaise, and myalgias. Some patients have gastro- 2 (SARS-CoV-2), that cause coronavirus disease intestinal symptoms, including anorexia, nausea, 2019 (COVID-19), emerged in Wuhan, China [1]. and diarrhea [7]. Anosmia and ageusia have also Subsequently, the virus quickly spread world- been reported [8]. The spectrum of illness can range wide, and the World Health Organization declared from asymptomatic infection to severe pneumonia COVID-19 as a global pandemic on March 11, 2020. with acute respiratory distress syndrome (ARDS) As of June 24, 2020, there were more than 9.12 mil- and death. In a report from the Chinese Center lion confirmed cases worldwide, with total deaths for Disease Control and Prevention that included exceeding 473,797 [2]. approximately 44,500 confirmed infections, most SARS-CoV-2 is primarily spread from person to cases were classified as mild (81%; i.e., non-pneu- person through respiratory droplets. A significant monia and mild pneumonia). However, 14% were challenge to containing the spread of SARS-CoV-2 severe (i.e., dyspnea, respiratory frequency ≥30/ is that mildly symptomatic patients with COVID-19 min, blood oxygen saturation ≤93%, partial pres- could transmit the virus from the first day of illness sure of arterial oxygen to fraction of inspired oxy- through daily activities in the community [3]. Re- gen ratio <300, lung infiltrates >50% within 24 to 48 cent reports suggest that patients may be infectious hours), and 5% were critical (i.e., respiratory failure, 1 to 3 days before symptom onset and that up to 40 septic shock, and/or multiple organ dysfunction or to 50% of cases may be attributable to transmission failure) [9]. from asymptomatic or presymptomatic people [4]. Age is a strong risk factor for severe illness, com- Just before or soon after symptom onset, patients plications, and death. Heart disease, hypertension, have high nasopharyngeal viral levels, which then prior stroke, diabetes, and chronic lung disease fall over approximately one week [5]. have all been associated with increased illness se- The median incubation period is approximately verity and adverse outcomes [10, 11]. It is unclear 4 to 5 days, and 97.5% of symptomatic patients will whether certain other conditions (kidney disease, have symptoms within 11.5 days after infection [6]. immunosuppression, cancer, and uncontrolled

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 43 Pyoeng Gyun Choe ■ COVID-19: Clinical Features and Therapeutic Option human immunodeficiency virus [HIV] infection) transmissions of 2019 novel coronavirus (SARS- confer an increased risk of complications. However, CoV-2) in the community from infectors with com- mon cold symptoms. Korean J Intern Med 2020. because these conditions may be associated with [Epub ahead of print] https://doi.org/10.3904/ worse outcomes after infection with other respira- kjim.2020.122 tory pathogens, close monitoring of patients with 4. He X, Lau EHY, Wu P, et al. Temporal dynamics in Covid-19 who have these conditions is warranted. viral shedding and transmissibility of COVID-19. Current clinical management for COVID-19 main- Nat Med 2020. 5. Wölfel R, Corman VM, Guggemos W, et al. Viro- ly includes infection prevention and control mea- logical assessment of hospitalized patients with sures and supportive care, including supplemental COVID-2019. Nature 2020; 581(7809): 465-9. oxygen and mechanical ventilatory support when 6. Lauer SA, Grantz KH, Bi Q, et al. The Incubation indicated. Presently, there are no drugs or other Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estima- therapeutics approved for the treatment of COV- tion and Application. Ann Intern Med 2020; 172(9): DI-19, although remdesivir, an investigational anti- 577-82. viral drug, is available through an FDA emergency 7. Wang D, Hu B, Hu C, et al. Clinical Characteristics use authorization. In a randomized, double-blind of 138 Hospitalized Patients With 2019 Novel Coro- trial in 1,063 adults hospitalized with COVDI-19, a navirus-Infected Pneumonia in Wuhan, China. JAMA 2020; 323(11): 1061-9. 10-day course of intravenous remdesivir was supe- 8. Giacomelli A, Pezzati L, Conti F, et al. Self-reported rior to placebo in shortening the time to recovery, olfactory and taste disorders in SARS-CoV-2 pa- from a median of 15 days among placebo recipients tients: a cross-sectional study. Clin Infect Dis 2020. to 11 days among those receiving remdesivir. A [Epub ahead of print] https://doi.org/10.1093/cid/ trend toward lower mortality among patients who ciaa330 9. Wu Z, McGoogan JM. Characteristics of and Im- received remdesivir (7.1%) than among those who portant Lessons From the Coronavirus Disease received a placebo (11.9%) was also observed, but 2019 (COVID-19) Outbreak in China: Summary of the difference did not reach statistical significance a Report of 72314 Cases From the Chinese Center [12]. Definitive clinical trial data are needed to for Disease Control and Prevention. JAMA 2020; 323(13): 1239-42. identify safe and effective treatments for COVID-19. 10. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with References COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395(10229): 1054-62. 1. Zhu N, Zhang D, Wang W, et al. A Novel Coronavi- 11. Grasselli G, Zangrillo A, Zanella A, et al. Baseline rus from Patients with Pneumonia in China, 2019. Characteristics and Outcomes of 1591 Patients In- N Engl J Med 2020; 382(8): 727-33. fected With SARS-CoV-2 Admitted to ICUs of the 2. WHO. Coronavirus disease (COVID-2019) situa- Lombardy Region, Italy. JAMA 2020; 323(16): 1574- tion report-156. 2020. Available at: https://www. 81. who.int/emergencies/diseases/novel-coronavi- 12. Beigel JH, Tomashek KM, Dodd LE, et al. Remde- rus-2019/situation-reports/. Accessed June 25, sivir for the Treatment of Covid-19 - Preliminary 2020 Report. N Engl J Med 2020. [Epub ahead of print] 3. Kim NJ, Choe PG, Park SJ, et al. A cluster of tertiary https://doi.org/10.1056/NEJMoa2007764.

44 KSCCM·ACCC 2020 Seungsik Hwang ■ Coronavirus Disease 2019 during the 2019–2020 Epidemic: Preparing Intensive Care Units-the Experience in South Korea

COVID-19 Pandemic July 31 (Fri) Coronavirus Disease 2019 during the 2019–2020 Epidemic: Preparing Intensive Care Units-the Experience in South Korea

Seungsik Hwang

Seoul National Univ, Korea

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 45 Kyeongman Jeon ■ Recent Updates on Weaning (Liberation) from MV

Updates in Mechanical Ventilation

Recent Updates on Weaning (Liberation) from MV

Kyeongman Jeon

Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine

Weaning from mechanical ventilation (MV), readiness to wean on the basis of their subjective which has also been referred as the discontinuation impression. Numerous weaning predictors have of MV or liberation from the ventilator, is a complex been studied, but none appear to be superior to process involving daily assessment of readiness objective clinical criteria in predicting a patient’s to wean and spontaneous breathing trial (SBT) to readiness to wean. The rapid shallow breathing in- extubation. The weaning process comprises at least dex (RSBI) is the most extensively studied and pop- 40% of the total duration of MV, and prolonged ular weaning predictor. weaning is associated with higher mortality. A good When conducting an SBT, a number of different understanding of the weaning process will reduce techniques can be used. During a T-piece SBT, a pa- the duration of MV, lead to successful extubation, tient receives supplemental oxygen but no ventila- and eventually reduce the mortality rate and length tory assistance. Alternatively, a patient may receive of stay in the intensive care unit (ICU). pressure support ventilation (PSV), during which a The current standard of care for managing pa- small amount of positive pressure (eg, 5-8 cm H2O) tients with MV involves daily screenings to identify assists inspiration. While in the past, low quality patients who are ready to undergo a SBT to ascer- evidence suggested that no single SBT method (ie, tain those ready to be separated from MV. Manual T-piece, low level of PSV, or CPAP) was superior to daily screening protocols and automated systems the other, newer data support for SBT with low lev- have been recommended to identify a patient’s els of PSV (ie, inspiratory pressure augmentation). readiness for weaning as well as their ability to A meta-analysis of four randomized trials reported undergo a weaning trial. An international consen- that SBT with PSV resulted in a higher rate of suc- sus conference (ICC) composed of clinicians with cessful extubation at 48 hours (85 vs. 77%) when expertise on weaning from MV proposed several compared with T-piece and was associated with clinical criteria that can be used to identify patients an insignificant reduction in ICU mortality (12 vs. who are ready to begin weaning. All of the criteria 9%). Limitations to this analysis include the lack of are objective, since clinicians are poor at predicting blinding and significant heterogeneity among the

46 KSCCM·ACCC 2020 Kyeongman Jeon ■ Recent Updates on Weaning (Liberation) from MV populations studied. Best illustrating the superiori- bedside and not rely solely on these parameters. If ty of PSV-SBT is from the recent randomized trial of it is determined that weaning was successful, the July 31 (Fri) 1153 patients who were assessed as ready for wean- decision must be made about whether to remove ing, that compared 30 minutes of PSV (8 cm H2O; the endotracheal tube. This requires an assessment “less demanding”) with 2 hours of a T-piece trial of whether the patient can protect their airway. If (“more demanding”), published in 2019 . Successful it is determined that weaning was failed, the eti- extubation was more common in those undergoing ology of weaning failure should always be sought. PSV-SBT (82 vs. 74%). In addition, hospital mortal- Common causes include the underlying source of ity was lower in patients assigned to PSV-SBT than the respiratory failure not being fully corrected, vol- T-piece trials (10 vs. 15%). No difference in rates of ume overload, cardiac dysfunction, neuromuscular reintubation or hospital stay was reported. Findings weakness, delirium, anxiety, and metabolic distur- were consistent across subgroups including older bances. Once the likely cause of weaning failure patients (>70 years), those ventilated for longer has been identified, it should be corrected and then than four days, medical and surgical patients, and weaning resumed. However, the optimal weaning those with chronic obstructive pulmonary disease. strategy following initial weaning failure is uncer- However, physicians were not blinded and more tain due to conflicting data. patients were subjected to prophylactic high flow In 2007, the ICC on weaning from MV proposed nasal oxygen or noninvasive ventilation in the PSV- a classification into three different groups (simple, SBT group (24.7 vs. 18.7%) which may have impact- difficult, and prolonged weaning) according to the ed the results. number, duration, and results of SBTs as well as The optimal duration of an SBT is unknown but extubation outcomes to simply classify and deeply typically ranges from 30 minutes to 2 hours. In gen- understand the weaning process. However, ICC eral, an initial SBT of 30 minutes duration is con- classification had some problems when applied in sidered sufficient to determine whether MV can be clinical practice: (a) it does not apply to patients discontinued. For patients who fail their initial SBT, without a weaning trial (unplanned extubation, longer trials of up to 2 hours may be warranted. Re- death, or tracheostomy before weaning trial), (b) cent data suggest that for patients who are mechan- patients with tracheostomy tube before weaning ically ventilated for more prolonged periods (eg, trials are difficult to classify with ICC, and (c) ICC more than 10 days), trials of 30 minutes may still be classification is based only on the results of SBT. sufficient. Therefore, approximately half of mechanically ven- Regardless of the weaning strategy used, the tilated patients could not be classified by the ICC clinician must determine whether weaning was a classification. To overcome these limitations, the success or failure. Objective criteria that may in- WIND (Weaning according to a New Definition) dicate weaning failure include tachypnea, respira- Study Group and the REVA (Réseau Européen de tory distress, hemodynamic change, desaturation, Recherche en Ventilation Artificielle) Network and changes in mental status. However, clinicians proposed a new classification using four different should also use their clinical judgement at the groups (Groups 1, 2, 3, and no weaning [NW]).

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 47 Kyeongman Jeon ■ Recent Updates on Weaning (Liberation) from MV

A recent validation study of WIND classification 3. Liberation From Mechanical Ventilation in Crit- suggests that it could be a better tool for predicting ically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clin- weaning outcomes than ICC classification because ical Practice Guideline: Inspiratory Pressure Aug- WIND classification is applicable to all mechanical- mentation During Spontaneous Breathing Trials, ly ventilated patients and has higher discriminatory Protocols Minimizing Sedation, and Noninvasive power for weaning outcomes. Ventilation Immediately After Extubation. Chest. 2017;151:166-180. 4. Epidemiology of Weaning Outcome According to a References New Definition. The WIND Study. Am J Respir Crit 1. Statement of 6th International Consensus Confer- Care Med. 2017;195:772-783. ence on Intensive Care Medicine. Weaning from 5. Effect of Pressure Support vs T-Piece Ventilation mechanical ventilation. Eur Respir J 2007;29:1033- Strategies During Spontaneous Breathing Trials on 1056 Successful Extubation Among Patients Receiving 2. An Official American Thoracic Society/Ameri- Mechanical Ventilation: A Randomized Clinical can College of Chest Physicians Clinical Practice Trial. JAMA. 2019;321:2175-2182. Guideline: Liberation from Mechanical Ventilation 6. Comparison of T-piece and Pressure Support in Critically Ill Adults. Rehabilitation Protocols, Ventilation as Spontaneous Breathing Trials in Ventilator Liberation Protocols, and Cuff Leak Critically Ill Patients: A Systematic Review and Me- Tests. Am J Respir Crit Care Med. 2017;195:120- ta-Analysis. Crit Care. 2020;24:67. 133.

48 KSCCM·ACCC 2020 Je Hyeong Kim ■ Recent Evidence of Mechanical Ventilation in ARDS

Updates in Mechanical Ventilation July 31 (Fri) Recent Evidence of Mechanical Ventilation in ARDS

Je Hyeong Kim

Department of Critical Care Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea

In the management of acute respiratory distress group. Therefore, in the judgement of the potential syndrome (ARDS), the most important issue is to further reduce VILI, the study about feasibility ventilator-induced lung injury (VILI). Lung protec- and safety of ultra-protective ventilation with extra- tive ventilation (LPV) is the strategies to prevent or corporeal CO2-removal, the SUPERNOVA study [3], minimize the VILI. There are four main strategies was performed. The study concluded that the use of in LPV. Low tidal volume (LTV) is to minimize extracorporeal CO2-removal to facilitate ultra-pro- physical stretch injury by limiting tidal volume tective ventilation was feasible. A randomized clini- and plateau pressure. High positive-end expiratory cal trial is required to assess the overall benefits and pressure (PEEP) strategy is to prevent atelectrauma harms of ultra-protective ventilation. by decreasing repeated collapse and reopening of The ARDS mechanical ventilation guidelines the alveoli in the dependent lungs. And prone po- conditionally recommend applying higher PEEP in sition ventilation and recruitment maneuver are to moderate to severe ARDS patients with moderate increase global homogeneity by decreasing hetero- confidence [1]. High PEEP can improve alveolar geneity. recruitment, reduce lung stress and strain, and pre- The current ARDS mechanical ventilation guide- vent atelectrauma, but can induce end-inspiratory line strongly recommends LTV with moderate alveolar overdistention, increase intrapulmonary confidence [1]. However, even in the LTV, the risk of shunt and dead space, and heighten pulmonary VILI is present. Therefore, the clinical investigators vascular resistance leading to cor pulmonale. tried to decrease tidal volume less than 6 milliliter Therefore, deciding and optimizing PEEP is very per kg. According to the Xtravent study [2] using important clinical issue. The current best way is to ultra-protective ventilation with extracorporeal decide optimal PEEP can be based on transpul-

CO2-removal, in the subgroup analysis for the pa- monary pressure, which is available by subtracting tients with PaO2/FiO2 ratio < 150 mmHg, ventilator pleural pressure from alveolar pressure. At present, free days were significantly longer in ultra-pro- the appropriate way to estimate the pleural pres- tective ventilation group compared with control sure is to measure the esophageal pressure. EPVent

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 49 Je Hyeong Kim ■ Recent Evidence of Mechanical Ventilation in ARDS study [4] evaluated the potential benefits of esoph- study [7], a trial assessing the effects of a DP-limited ageal pressure monitoring in optimization of PEEP strategy using very low tidal volumes versus a con- in ARDS management. The results of the study ventional ventilation strategy on clinical outcomes suggested potential effects of esophageal pressure is feasible.. monitoring based high PEEP strategy. Therefore, The prone position ventilation is strongly recom- the EPVent-2 [5] study was performed. However, the mended in severe ARDS patients in ARDS mechan- results of the study could not support the esopha- ical ventilation guideline [1]. This recommendation geal pressure-guided PEEP titration in ARDS is almost by the results of the PROSEVA study [8]. ARDS lung is frequently called as baby lung. It In the ARDS mechanical ventilation guideline, re- means severe decrease in functional lung size. In cruitment maneuver is conditionally recommend- this condition, VILI is caused by multiple factors, ed with low to moderate confidence [1]. However, such as volume, pressure, tidal atelectasis, flow, and in the result of recent ART trial [9], the routine use respiration rate. However, the LTV and high PEEP of lung recruitment maneuver and PEEP titration strategies target the only volume, pressure, and tidal could not be supported. And in another study atelectasis. If there is one parameter which reflects about recruitment maneuver, the PHARLAP study these all factors, it could be very useful and helpful [10], also concluded that maximal lung recruitment in mechanical ventilation of ARDS patients. Howev- did not reduce the duration of ventilation free days er, it is very difficult to expect it now. But, in recent, or mortality and associated with increased cardio- there was a remarkable progress. That is emergence vascular adverse events. of driving pressure (DP) or delta P which can reflect In summary, the results described above are the the relationship among functional lung size, tidal current evidence of LPV strategies. The results of volume, and PEEP. DP in which tidal volume is in- EPVent-2, ART, and PHARLAP studies are disap- trinsically normalized to functional lung size can be pointing. However, the results of SUPERNOVA routinely calculated as the plateau pressure minus study and emergence of driving pressure are hope- extrinsic PEEP. The clinical meaning of DP has be- ful. In the EPVent-2, ART, and PHARLAP studies, come apparent by the multilevel mediation analysis there were many important limitations. If these for previous 9 studies [6], In result of the combined limitations could be overcome by the future trials cohort after multivariate adjustment, multivariate like the history of studies about prone position relative risk of death in the hospital was significant- ventilation. We can see potential hopeful effects of ly associated with increase in DP. However, this esophageal pressure guided PEEP and recruitment effect of DP is from retrospective analyses through maneuver in ARDS management. a very sophisticated statistical procedure, There- fore, clinical trials are needed to confirm that ven- tilatory strategies targeting reduced DP are more References efficacious. And the first thing that need to be done 1. Fan E, Del Sorbo L, Goligher EC, Hodgson CL, is the study about DP-limited ventilatory strategies Munshi L, Walkey AJ, et al. An Official American are feasible at bedside. According to the ART2pilot Thoracic Society/European Society of Intensive

50 KSCCM·ACCC 2020 Je Hyeong Kim ■ Recent Evidence of Mechanical Ventilation in ARDS

Care Medicine/Society of Critical Care Medicine With Acute Respiratory Distress Syndrome: A Ran- Clinical Practice Guideline: Mechanical Venti- domized Clinical Trial. JAMA 2019;321:846-57.

lation in Adult Patients with Acute Respiratory 6. Amato MB, Meade MO, Slutsky AS, Brochard L, July 31 (Fri) Distress Syndrome. Am J Respir Crit Care Med Costa EL, Schoenfeld DA, et al. Driving pressure 2017;195:1253-63. and survival in the acute respiratory distress syn- 2. Bein T, Weber-Carstens S, Goldmann A, Muller T, drome. N Engl J Med 2015;372:747-55. Staudinger T, Brederlau J, et al. Lower tidal volume 7. Pereira Romano ML, Maia IS, Laranjeira LN, Dami- strategy ( approximately 3 ml/kg) combined with ani LP, Paisani DM, Borges MC, et al. Driving Pres-

extracorporeal CO2 removal versus ‘conventional’ sure-limited Strategy for Patients with Acute Re- protective ventilation (6 ml/kg) in severe ARDS: spiratory Distress Syndrome. A Pilot Randomized the prospective randomized Xtravent-study. Inten- Clinical Trial. Ann Am Thorac Soc 2020;17:596-604. sive Care Med 2013;39:847-56. 8. Guerin C, Reignier J, Richard JC, Beuret P, Gacou- 3. Combes A, Fanelli V, Pham T, Ranieri VM, Europe- in A, Boulain T, et al. Prone positioning in severe an Society of Intensive Care Medicine Trials G, the acute respiratory distress syndrome. N Engl J Med “Strategy of Ultra-Protective lung ventilation with 2013;368:2159-68. Extracorporeal CORfN-OmtsAi. Feasibility and 9. Writing Group for the Alveolar Recruitment for

safety of extracorporeal CO2 removal to enhance Acute Respiratory Distress Syndrome Trial I, Cav- protective ventilation in acute respiratory distress alcanti AB, Suzumura EA, Laranjeira LN, Paisani syndrome: the SUPERNOVA study. Intensive Care DM, Damiani LP, et al. Effect of Lung Recruitment Med 2019;45:592-600. and Titrated Positive End-Expiratory Pressure 4. Talmor D, Sarge T, Malhotra A, O’Donnell CR, Ritz (PEEP) vs Low PEEP on Mortality in Patients With R, Lisbon A, et al. Mechanical ventilation guided Acute Respiratory Distress Syndrome: A Random- by esophageal pressure in acute lung injury. N ized Clinical Trial. JAMA 2017;318:1335-45. Engl J Med 2008;359:2095-104. 10. Hodgson CL, Cooper DJ, Arabi Y, King V, Bersten 5. Beitler JR, Sarge T, Banner-Goodspeed VM, Gong A, Bihari S, et al. Maximal Recruitment Open Lung MN, Cook D, Novack V, et al. Effect of Titrating Ventilation in Acute Respiratory Distress Syn- Positive End-Expiratory Pressure (PEEP) With an drome (PHARLAP). A Phase II, Multicenter Ran- Esophageal Pressure-Guided Strategy vs an Empir- domized Controlled Clinical Trial. Am J Respir Crit ical High PEEP-Fio2 Strategy on Death and Days Care Med 2019;200:1363-72. Free From Mechanical Ventilation Among Patients

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 51 Gee Young Suh ■ Electrical Impedance Tomography for Optimizing Mechanical Ventilation

Updates in Mechanical Ventilation

Electrical Impedance Tomography for Optimizing Mechanical Ventilation

Gee Young Suh

Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Electrical impedance tomography (EIT) uses elec- applications of EIT have been developed during the trical tissue conductivity, which is probed by inject- last few years and the technique has been generat- ing AC currents and measuring boundary voltages ing increasing interest among researchers. Howev- from multiple electrodes attached around the chest er, among clinicians, there is still a lack of knowl- to gather information relevant to the bedside clini- edge regarding the technical principles of EIT and cian. Up to now, EIT has primarily been used as a potential applications in ARDS patients. Now more monitoring tool that allows the bedside clinician to evidence is emerging on the potential of EIT to act evaluate the distribution of pulmonary ventilation as a continuous monitoring of hemodynamics in continuously, in real time, and which has proven ventilated patients. In the future, it may become to be useful in optimizing mechanical ventilation essential monitoring tool in ventilated critically-ill parameters in critically ill patients. Several clinical patients.

52 KSCCM·ACCC 2020 You-Min Sohn ■ Critical Care Nutrition

Critical Care Pharmacy July 31 (Fri) Critical Care Nutrition

You-Min Sohn

Department of pharmaceutical services, Samsung Medical Center

Nutrition support is an integral part of treating malnutrition syndromes in the acute setting [3, 4]. critically ill patients. The nutritional status of inten- The purpose of this lecture is to compare the sive care unit (ICU) patients deteriorate rapidly af- guidelines and approach to best practice of critical ter admission because of severe catabolism caused care pharmacist to manage the nutrition support by stress related and proinflammatory cytokines activity of parenteral nutrition. and hormones, even when patients are well nour- ished. Within 10 days patients may lose 10-25 % References of their body protein content, most pronounced 1. Puthucheary ZA, Rawal J, McPhail M, et al. Acute among patients with multiorgan dysfunction syn- skeletal muscle wasting in critical illness. JAMA drome [1]. Nutrition is necessary for the prevention 2013;310:1591-1600. and malnutrition often coexist as the intricate lay- 2. Raiten DJ, Sakr Ashour FA, Ross AC et al. Inflam- ers of the inflammatory response intertwine with mation and nutritional science for program/ policies and interpretation of research evidence nutrient homeostatis. In the presence of disease or (INSPIRE). J Nutr 2015;145:1039S-1108S. injury, chronic and acute inflammation affect nutri- 3. Meclave SA, Martindale RG, Vanek VW et al. tional status through impaired nutrient absorption, Guidelines for the provision and assessment of nutrient shifts between cellular spaces, increased nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) nutrient metabolism, and catabolism [2]. and American Society for Parenteral and Enteral The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). J Parenteral Enteral Nutr Nutrition (ASPEN) and the European Society for 2016;40:159-211. Clinical Nutrition and Metabolism (ESPEN) formed 4. Singer P, Blaser AR, Berger MM et al. ESPEN guide- an international guideline committee and proposed line on clinical nutrition in the intensive care unit. Clin Nutr2019;38:48-79. an etiology-based approach for diagnosing adult

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 53 Young Joo Song ■ Neurocritical Care Pharmacotherapy

Critical Care Pharmacy

Neurocritical Care Pharmacotherapy

Young Joo Song

Critical Care Pharmacy, Seoul National University Bundang Hospital, Korea

Pharmacotherapy in critically ill patients is chal- changes in neurocritical care population should be lenging. Because there are very few studies target- considered at all stages. Most acute stroke patients ing just critically ill patients, critical care pharma- receive medication and diet through tube feeding, cists should review multiple data and check their and meningitis patients require antibiotics that can clinical applicability to design optimal medication1. be distributed through the blood brain barrier3. Especially in neurocritical care, it is necessary to Using pharmacotherapy to counter adverse effects consider both the patient’s intrinsic factor and criti- of cooling or to treat an intrinsic process under hy- cally ill status, and neurological injury. pothermic conditions requires understanding how In addition, each critically ill patient has a differ- hypothermia will influence the clinical effects of the ent pathophysiology and a rapidly changing physi- drug, including the drug’s pharmacokinetics and ological state, which makes it even more difficult to pharmacodynamics. The pharmacologic aspects treat. Individualized treatment begins with select- of therapeutic hypothermia in relation to physiol- ing appropriate dosing regimen that minimizes side ogy and adverse effects are reviewed4. Augmented effects while maximizing clinical outcomes. renal cleaanace in patients with subarachnoid Understanding pharmacokinetics (PK) and phar- hemorrhage was reported5. This lecture describes macodynamics (PD) is paramount for successful pharmacotherapy in neurocritical care. This pre- individual drug therapy. All drugs entering the sentation focuses on how to optimize pharmaco- body undergo absorption, distribution, metabo- therapy by minimizing therapy failure and adverse lism, and elimination, but each drug exhibits a dif- drug reaction by considering changes in PK and ferent dynamic. This process will ultimately deter- PD in various situations of patients in neurocritical mine how much the drug is capable of acting at the care. target site. Critically ill patients are dynamic and heterogeneous patient population, and in PK, pa- References rameters such as clearance and volume of distribu- 1. Simon WL. Pharmacokinetics, pharmacodynam- tion greater and more variable than less severely ill ics, pharmacogenomics. American college of clini- patients2. Pharmacokinetic and pharmacodynamic cal pharmacy CCSAP 2016 Book 2; 7-25.

54 KSCCM·ACCC 2020 Young Joo Song ■ Neurocritical Care Pharmacotherapy

2. Erstad BL. Designing drug regimens for special 4. Arpino PA, Greer DM. Practical pharmacologic intensive care unit populations. World J Crit Care aspects of therapeutic hypothermia after cardiac

Med. 2015;4:139-151 arrest. Pharmacotherapy. 2008;28:102-111 July 31 (Fri) 3. Roberts DJ, Hall RI. Drug absorption, distribution, 5. May CC, Arora S, Parli SE, Fraser JF, Bastin MT, metabolism and excretion considerations in crit- Cook AM. Augmented renal clearance in patients ically ill adults. Expert Opin Drug Metab Toxicol. with subarachnoid hemorrhage. Neurocrit Care. 2013;9:1067-1084 2015;23:374-379

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 55 Eunyoung Choi ■ Adverse Drug Reactions in Critically Ill Patients

Critical Care Pharmacy

Adverse Drug Reactions in Critically Ill Patients

Eunyoung Choi

Department of Pharmacy, Ulsan University Hospital

Adverse drug reaction (ADR) is an important tubulointerstitial inflammation secondary to an clinical problem in the intensive care unit (ICU). allergic reaction (acute interstitial nephritis), from Indeed, critically ill patients often cumulate mul- precipitation of drug crystals resulting in obstruc- tiple conditional factors rendering them vulner- tion (nephrolithiasis), or from an immune-medi- able to ADR, namely the complexity of disease, ated reaction resulting in injury to the glomerulus pathophysiological status characterized by a board (glomerulonephritis). Several agents that decrease range of changes in organ dysfunction (altering intravascular volume and renal perfusion (diuret- pharmacokinetics), high number of medications ics), constrict the afferent arteriole (NSAIDs, cyclo- administered, administration of complex drug reg- oxygenase-2 inhibitors) or dilate the efferent arte- imens, and increased length of hospital stay [1]. It riole ( ACEIs, ARBs) can induce AKI. Of these, the is therefore essential for critical care pharmacists most frequently associated with AKI are the ACEIs to understand the characteristics of risk factors and and NSAIDs [3]. known mechanism of ADR in the ICU. 2. Hyper/hypoglycemia

1. Acute kidney injury (AKI) It is known that advanced age, alcohol intake, The current evidence indicates an increased risk hepatic dysfunction, history of hypoglycemia, hos- of AKI in critically ill patients with older age, diabe- pitalization within past 30 days, and polypharmacy tes, higher baseline creatinine, heart failure, sepsis/ are risk factors in drug-induced hypoglycemia. And, SIRS, use of nephrotoxicity drugs, higher severity higher doses of suspected drug, drug interactions of disease scores, use of vasopressors/inotropes, (use of drugs that may increase the plasma concen- high risk surgery, emergency surgery [2]. The drugs tration and/or hyperglycemic effect) are associated implicated in causing drugs-induced AKI can re- with drugs inducing hyperglycemia. Hyperglycemia sult from renal hemodynamic alteration leading to and hypoglycemia both results from an imbalance decreased renal perfusion, from direct toxicity to between plasma glucose and insulin concentration. the renal tubule cells (acute tubular necrosis), from Drugs may induce hyper- or hypoglycemia through

56 KSCCM·ACCC 2020 Eunyoung Choi ■ Adverse Drug Reactions in Critically Ill Patients a variety of mechanism, including alteration of in- dine [5]. sulin secretion and sensitivity, changes in glucone- July 31 (Fri) ogenesis, and direct cytotoxic effects on pancreatic 5. Hyponatremia beta cells [3]. Medications may cause hyponatremia either by affecting the homeostasis of sodium and water 3. Bradycardia/tachycardia (diuretics) or by altering the water homeostasis as Drugs being used for treatment of cardiac con- a consequence of the syndrome of inappropriate ditions may promote arrhythmias by re-entrant secretion of antidiuretic hormone (ADH). There are mechanisms or via triggered activity. Common three possible ways medications may impair wa- causes of drug-induced bradycardia include con- ter homeostasis: they can increase AHD secretion comitant use of several atrioventricular nodal centrally, potentiate the effect of endogenous ADH blocking agents, reflex bradycardia and use of at the renal medulla, and reset the osmostat, thus direct cardiac depressants. Tachycardia in the lowering the threshold for ADH secretion [6]. ICU may lead to cardiorespiratory instabilities in 6. Blood pressure changes critical ill patients, it is important to detect earlier. Hypotension in the ICU occurs frequently when It can be developed by catecholamine vasopres- patients are stabilized after a critical condition sors (epinephrine, dopamine, norepinephrine), and then restarted on their antihypertensive home beta-adrenergic agonists (dotutamine, albuterol, medication. Antihypertensive have mechanisms for theophylline). Corrected QT (QTc) prolongation lowering blood pressure by antagonize the body’s can lead to torsade de pointes which is a destruc- endogenous response and releasing of histamine tive arrhythmia that can cause sudden death. There (vancomycin, atracurium), alph1 receptor blocking are medications that are well known to cause QTc effects, direct effect of the solvent (amiodarone), prolongation are antiarrhythimics, macrolides, flu- calcium channel blocking effects, and decreasing oroquinolones, azole antifungals, antipsychotics [4]. the intravascular volume. Hypertension caused by medications can occur as a result of sodium reten- 4. Hyperkalemia tion (corticosteroid), direct or indirect stimulation of the sympathetic nervous system (ketamine), and Medications can cause hyperkalemia by a vari- extracellular volume expansion or viscosity (eryth- ety of mechanisms including reduction in renal ropoietin stimulating agents) [4]. potassium excretion due to hypoaldosteronism, A comprehensive understanding and awareness reduction in passive potassium excretion, increase of the medications mechanisms responsible for in extracellular potassium shifts and increase in po- ADRs may allow for better prediction of harmful tassium supply. Medications that impair renal po- outcomes and ultimately the implementation of tassium excretion are mainly represented by ACEIs, more individualized, rational, and safe therapies for ARBs, NSAIDs, calcineurin inhibitors, heparin ICU patients. and derivatives, aldosterone antagonists, potassi- um-sparing diuretics, trimethoprim, and pentami-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 57 Eunyoung Choi ■ Adverse Drug Reactions in Critically Ill Patients

References management. ASHP, 2018. 4. Kennelly C, Esaian D. Drug-induced cardiovascu- 1. Reis AM, Cassiani SH. Adverse drug events in an lar adverse events in the intensive care unit. Crit intensive care unit of a university hospital. Eur J Care Nurs Q. 2013;36(4):323-334. Clin Pharmacol. 2011;67(6):625-632. 5. Pucci, M. Mechanisms of drug-induced hyperka- 2. Cartin-Ceba R, Kashiouris M, Plataki M, Kor DJ, lemia. Adverse Drug Reaction Bulletin. 2011;271: Gajic O, Casey ET. Risk factors for development of 1043-1046. acute kidney injury in critically ill patients: a sys- 6. Liamis G, Milionis H, Elisaf M. A Review of tematic review and meta-analysis of observational Drug-Induced Hyponatremia. American Journal of studies. Crit Care Res Pract. 2012;2012:691013. Kidney Diseases. 2008;52(1):144-153. 3. Tisdale, James E., and Douglas A. Miller, eds. Drug-induced diseases: prevention, detection, and

58 KSCCM·ACCC 2020 Eun Young Kim ■ Polymyxin B Hemoperfusion in Abdominal Septic Shock: Option for Refractory Shock in the Era of Surgery

Surgical Critical Care July 31 (Fri) Polymyxin B Hemoperfusion in Abdominal Septic Shock: Option for Refractory Shock in the Era of Surgery

Eun Young Kim

Division of Trauma and Surgical Critical Care, Department of Surgery, Seoul St. Mary’s Hospital, Seoul, Korea

Intra-abdominal infection is one of the common randomized controlled trials in the meantime. In causes of sepsis or septic shock and is associated the EUPHAS I trial of 2009, PMX-HP significantly with a high mortality rate of 19.5%. Because of reduced the 28-day mortality and improved SOFA the inherent bacterial colonization in abdomen, score in patients with septic shock associated with gram-negative bacilli (GNB) are probably the major gram-negative infeciton. In the EUPHAS 2 trial of source of infection. Lipopolisaccharide (LPS) is the 2014, there was a significant decrease in SOFA score core lipid portion of the endotoxin in gram-neg- in patients with only abdominal sepsis. ative microorganisms, and has been considered In terms of hemodynamic aspects, the inotropic as one of the important triggers of sepis or septic score and VDI decreased significantly in the PMX shock. It induces a systemic inflammatory response group consistent with previous studies that showed syndrome resulting in the release of cytokines such a significantly increment in arterial pressure and as tumor necrosis factor-α (TNF-α), interleukin-1β decreased need for vasopressor after PMX-HP (IL-1β) and nitrous oxide, and also activates the treatment. Polymyxin B is a lipopeptide antibiotics coagulation and complement system of the host. isolated from Bacillus polymyxa. It disrupts the Moreover, LPS translocation into the blood stream outer membrane of gram-negative bacilli and binds when the intestinal mucosa is impaired in sepsis, to the lipid A portion of LPS selectively. Circulating results in multiorgan failure. LPS from gram-negative bacteria usually activates Polymyxin B is an antibiotic, which binds to LPS the inflammatory reaction, complement or coagu- of GNB and inactivates the endotoxin with in- lation system of the hosts. Nakamura et al. reported creased affinity. Hemofiltration with polymyxin B that circulating monocyte and neutrophils were (PMX-HP) immobilized to a polysterene-derived removed through the PMX cartridge, and PMX- fiber was developed in Japan in the 1990s, to se- HP reduced the levels of TNF-alpha, IL-6,10, plas- lectively adsor and remove the endotoxin of GNB minogen activator inhibitor 1, metalloproteinase in the blood stream. Actually, there have been and anandamide. These mechanisms of PMX-HP studies to identify the effect of PMX-HP in various improved tissue oxygenation and hemodynamic

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 59 Eun Young Kim ■ Polymyxin B Hemoperfusion in Abdominal Septic Shock: Option for Refractory Shock in the Era of Surgery status against infection, and contributed to the and protect pulmonary functions in patients after improvement of hemodynamics in critically ill pa- emergency surgery due to abdominal sepsis who tients with abdominal septic shock. has high risk of pulmonary complications such as Moreover, PMX-HP treatment improved the ARDS. In addition, one of the most common com- cardiac function via elimination of myocardial plications of septic shock is acute kidney injury depressant mediator such as anandamide of 2-ara- (AKI) and it occurs in more than 20 % of patients chidonoylglycerol. Therefore, it reduces the dosage with sepsis that is related to higher mortality rate. of catecholamine drugs and enhances the hemo- Ebihara et al. suggested that PMX-HP restored the dynamic outcome. This mechanism could decrease angiopoietin-1 levels and diminished the levels of the adverse cardiovascular effects of high-dose cat- angiopoietin-2 in septic AKI, thereby preventing echolamines such as arrhythmia, decreased cardiac the apoptosis of renal tubular cells resulting in a output, ischemic change of mesentery caused by protective effect against AKI. The removal of endo- potent vasoconstriction. Maynar et al. reported that toxin or cytokines might protect the renal function 28-day mortality rates were significantly decreased in abdominal septic shock. in patients who reduced their norepinephrine dose PMX-HP wolud be more effective in patients with by more than half within 24 hours after PMX-HP. abdominal sepsis following surgical elimination of The preliminary results of our institution also re- infection foci. In case of other gram-negative infec- vealed a significant improvement in the inotropic tions except for intra-abdominal infections, such as score and VDI of the PMX group and suggested that infection of the lower respiratory tract, the control PMX-HP treatment in reduced the levels of myocar- of infectious source should be accomplished via dial depressant mediator in cardiac function. eradication of the bacterial pathogens using anti- The role of PMX-HP in septic shock would also biotics, and this limitation might be implicated in a affect the pulmonary function by absorbing vari- resistance to antibiotics or drug toxicity. In patients ous inflammatory mediators during septic shock with abdominal sepsis, PMX-HP may be used after including endotoxins and proinflammatory cyto- complete elimination of infection focus via surgical kines. The improvement in hypercytokinemia and control, resulting in clearance of the residual circu- inflammation prevented the damage to pulmonary lating endotoxin more effectively compared with endothelium and reduced the intrapulmonary other sites of infection. shunting, consequently. Based on the possibility of As a result, PMX-HP would be a feasible treatment pulmonary protective function by PMX-HP, Takeda modality in SICU patients with peritonitis to restore et al reported that it improved the pulmonary ox- organ function and improve hemodynamics. It is ygenation in severe cases of acute respiratory dis- expected to facilitate clinical outcomes especially tress syndrome (ARDS). Pulmonary complications in patients with complete elimination of the source are common in septic shock, and rapidly increased of GNB infection via surgical procedures. A further due to fluid resuscitation or compromised respi- prospective study with large samples is needed to ratory function triggered by anesthesia after major establish the precise guidelines for PMX-HP thera- surgery, and therefore PMX-HP might improve py.

60 KSCCM·ACCC 2020 Eun Young Kim ■ Polymyxin B Hemoperfusion in Abdominal Septic Shock: Option for Refractory Shock in the Era of Surgery

References kine plasma levels in patients with abdominal sep- sis. Minerva Anestesiol. 2010;76(6):405-412.

1. Yaroustovsky M, Abramyan M, Krotenko N, Popov 9. Dellinger R, Levy M, Rhodes A, Annane D, Ger- July 31 (Fri) D, Plyushch M, Rogalskaya E. A pilot study of se- lach H, Opal S, Sevransky J, Sprung C, Douglas lective lipopolysaccharide adsorption and coupled I, Jaeschke R, et al. Surviving Sepsis Campaign: plasma filtration and adsorption in adult patients international guidelines for management of se- with severe sepsis. Blood Purif. 2015;39(1-3):210- vere sepsis and septic shock, 2012. Crit Care Med. 217. 2013;41(2):580-637. 2. Angus D, WT. L-Z, Lidicker J, Clermont G, Car- 10. Rhodes A, Evans LE, Alhazzani W, Levy MM, An- cillo J, Pinsky M. Epidemiology of severe sepsis tonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung in the United States: analysis of incidence, out- CL, Nunnally ME, et al. Surviving Sepsis Cam- come, and associated costs of care. Crit Care Med. paign: International Guidelines for Management of 2001;29(7):1303-1310. Sepsis and Septic Shock: 2016. Intensive Care Med. 3. Cutuli SL, Artigas A, Fumagalli R, Monti G, Ranieri 2017;43(3):304-377. VM, Ronco C, Antonelli M. Polymyxin-B hemoper- 11. Singer M, Deutschman CS, Seymour CW, Shan- fusion in septic patients: analysis of a multicenter kar-Hari M, Annane D, Bauer M, Bellomo R, registry. Ann Intensive Care. 2016;6:77. Bernard GR, Chiche JD, Coopersmith CM, et al. 4. Cruz D, Antonelli M, Fumagalli R, Foltran F, Brien- The Third International Consensus Definitions za N, Donati A, Malcangi V, Petrini F, Volta G, FM. for Sepsis and Septic Shock (Sepsis-3). JAMA. B-P, et al. Early use of polymyxin B hemoperfusion 2016;315(8):801-810. in abdominal septic shock: the EUPHAS random- 12. Group EC. Polymyxin B hemoperfusion in clinical ized controlled trial. JAMA. 2009;301(23):2445- practice: the picture from an unbound collabora- 2452. tive registry. Blood Purif. 2014;37:22-25. 5. Takeyama N, Noguchi H, Hirakawa A, Kano H, 13. Maynar J, F. M-S, M. H-G, Martí F, Candel F, Belda Morino K, Obata T, Sakamoto T, Tamai F, Ishikura H, Kase Y, et al. Time to initiation of treatment with J, Castaño S, JÁ. S-I. Direct hemoperfusion with polymyxin B cartridge hemoperfusion in septic polymyxin B-immobilized cartridge in severe sep- shock patients. Blood Purif. 2012;33:252-256. sis due to intestinal perforation: hemodynamic 6. Chihara S, Masuda Y, Tatsumi H, Nakano K, Shi- findings and clinical considerations in anticoagu- mada T, Murohashi T, Yamakage M. Early induc- lation therapy. Rev Esp Quimioter. 2013;26(2):151- tion of direct hemoperfusion with a polymyxin-B 158. immobilized column is associated with amelio- 14. Monti G, Terzi V, Calini A, Di Marco F, Cruz D, Pu- ration of hemodynamic derangement and mor- lici M, Brioschi P, Vesconi S, Fumagalli R, Casella G. tality in patients with septic shock. J Artif Organs. Rescue therapy with polymyxin B hemoperfusion 2017;20(1):71-75. in high-dose vasopressor therapy refractory septic 7. Li Bassi G, Marti JD, Xiol EA, Comaru T, De Rosa shock. Minerva Anestesiol. 2015;81(5):516-525. F, Rigol M, Terraneo S, Rinaudo M, Fernandez L, 15. Payen D, Guilhot J, Launey Y, Lukaszewicz A, Kaaki Ferrer M, et al. The effects of direct hemoperfusion M, Veber B, Pottecher J, O. J-B, L. M-L, Jabaudon using a polymyxin B-immobilized column in a pig M, et al. Early use of polymyxin B hemoperfusion model of severe Pseudomonas aeruginosa pneu- in patients with septic shock due to peritonitis: a monia. Ann Intensive Care. 2016;6(1). multicenter randomized control trial. Intensive 8. Zagli G, Bonizzoli M, Spina R, Cianchi G, Pasquini Care Med. 2015;41(6):975-984. A, Anichini V, Matano S, Tarantini F, Di Filippo A, 16. Solomkin J, Mazuski J, Bradley J, Rodvold K, Gold- Maggi E, et al. Effects of hemoperfusion with an stein E, Baron E, O’Neill P, Chow A, Dellinger E, immobilized polymyxin-B fiber column on cyto- Eachempati S, et al. Diagnosis and management of

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 61 Eun Young Kim ■ Polymyxin B Hemoperfusion in Abdominal Septic Shock: Option for Refractory Shock in the Era of Surgery

complicated intra-abdominal infection in adults ble P-selectin, platelet factor 4 and beta-thrombo- and children: guidelines by the Surgical Infection globulin. Inflamm Res. 1999;48(4):171-175. Society and the Infectious Diseases Society of 22. Nakamura T, Kawagoe Y, Matsuda T, Shoji H, Ueda America. Clin Infect Dis. 2010;50(2):133-164. Y, Tamura N, Ebihara I, Koide H. Effect of polymyx- 17. Solomkin J, Ristagno R, Das A, Cone J, Wilson S, in B-immobilized fiber on blood metalloprotein- Rotstein O, Murphy B, Severin K, Bruss J. Source ase-9 and tissue inhibitor of metalloproteinase-1 control review in clinical trials of anti-infective levels in acute respiratory distress syndrome pa- agents in complicated intra-abdominal infections. tients. Blood Purif. 2004;22(3):256-260. Clin Infect Dis. 2013;56(12):1765-1773. 23. Wang Y, Liu Y, Sarker K, Nakashima M, Seriza- 18. Mitaka C, Masuda T, Kido K, Uchida T, Abe S, Mi- wa T, Kishida A, Akashi M, Nakata M, Kitajima I, yasho T, Tomita M, Inada E. Polymyxin B hemo- Maruyama I. Polymyxin B binds to anandamide perfusion prevents acute kidney injury in sepsis and inhibits its cytotoxic effect. FEBS Lett. model. J Surg Res. 2016;201(1):59-68. 2000;470(2):151-155. 19. Kawazoe Y, Sato T, Miyagawa N, Yokokawa Y, 24. Takeda S, Munakata R, Abe S, Mii S, Suzuki M, Kushimoto S, Miyamoto K, Ohta Y, Morimoto T, Kashiwada T, Azuma A, Yamamoto T, Gemma A, Yamamura H. Mortality Effects of Prolonged He- Tanaka K. Hypercytokinemia with 2009 pandemic moperfusion Therapy Using a Polymyxin B-Im- H1N1 (pH1N1) influenza successfully treated with mobilized Fiber Column for Patients with Septic polymyxin B-immobilized fiber column hemoper- Shock: A Sub-Analysis of the DESIRE Trial. Blood fusion. Intensive Care Med. 2010;36(5):906-907. Purif. 2018;46(4):309-314. 25. Brooks-Brunn JA. Predictors of postoperative pul- 20. Vincent J, Moreno R, Takala J, Willatts S, De Men- monary complications following abdominal sur- donça A, Bruining H, Reinhart C, Suter P, Thijs L. gery. Chest. 1997;111(3):564-571. The SOFA (Sepsis-related Organ Failure Assess- 26. Schrier RW, Wang W. Acute renal failure and sep- ment) score to describe organ dysfunction/failure. sis. N Engl J Med. 2004;351:159-169. On behalf of the Working Group on Sepsis-Related 27. Ebihara I, Hirayama K, Nagai M, Shiina E, Koda M, Problems of the European Society of Intensive Care Gunji M, Okubo Y, Sato C, Usui J, Yamagata K, et Medicine. Intensive Care Med. 1996;22(7):707-710. al. Angiopoietin Balance in Septic Shock Patients 21. Nakamura T, Ebihara I, Shoji H, Ushiyama C, Suzu- With Acute Kidney Injury: Effects of Direct Hemo- ki S, Koide H. Treatment with polymyxin B-immo- perfusion With Polymyxin B-Immobilized Fiber. bilized fiber reduces platelet activation in septic Ther Apher Dial. 2016;20(4):368-375. shock patients: decrease in plasma levels of solu-

62 KSCCM·ACCC 2020 Lewis J Kaplan ■ Acute Care Surgery: A Different System Stressor

Surgical Critical Care July 31 (Fri) Acute Care Surgery: A Different System Stressor

Lewis J Kaplan

Perelman School of Medicine, University of Pennsylvania

This session will chronicle the genesis of Acute amined with a focus on system stress. Acute Care Care Surgery from a base of trauma and critical care Surgery as part of a healthsystem approach to man- medicine. Issues in perspective, workflow, staffing, aging urgent and emergent clinical conditions will support services, academic productivity, and inter- be evaluated as a driver of finances, patient flow, as well as intra-department dynamics will be ex- and career selection.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 63 Jung-Min Bae ■ Protecting the Gut in Critical Illness

Surgical Critical Care

Protecting the Gut in Critical Illness

Jung-Min Bae

Department of Surgery, Yeungnam University Medical Center, Daegu, Korea

General physiology of GUT fense by preventing bacteria, digestive enzyme and water-soluble toxic molecules to traverse the mu- The gut is covered by epithelial layer with a sur- cosal surface.[6] In critical illness, the mucus’ role face area of 30m2. These size of surface area is simi- damaged. The mucus layer is damaged that results lar in size to half a badminton court. in epithelial cell dysfunction. The gut ischemia/ The gut is a continuously renewing organ with the reperfusion leads to a loss of hydrophobicity of the majority of cells turning over within 1week.[1] mucus layer and altered intestinal permeability.[6] The various intestinal cells including absorptive In critical illness, the gut is susceptible to injury, enterocyte, mucus-producing goblet cell, hor- and this gut injury is happened commonly. mone-producing enteroendocrine cell and tuft cell These injuries result in impairment of the gut bar- are differentiated from intestinal stem cell reside rier and dysregulation of the intestinal microbiota. near the base of crypt of Lieberkühn. [7,8] Therefore, small-intestinal mucosal integrity The epithelium plays a critical role as first line may be damaged in critically ill patients, leading to protection against pathogen, management of host increased intestinal permeability and intolerance to homeostasis and the central coordinator of muco- enteral nutrition.[9] sal immunity. These gut hyperpermeability and barrier dysfunc- The gut has been hypopthesized to be the ‘motor’ tion may lead to systemic inflammatory response of critical illness.[2,3] This theory is that critical ill- syndrome. This clinical state is called ‘gut-derived ness induces intestinal hyperpermeability, leading sepsis’.[10] to bacterial translocation, and leading to subse- Therefore, the maintanance of gut mucosal integ- quent systemic infection. rity in critical illness is very important. In critically ill patients, the microbiota are severe- ly altered and became unstable.[4] The critical ill- ness leads to multiple changes to the microbiome, Protecting of gut and approach including loss of diversity and overgrowth of patho- of enhancing gut integrity and genic bacteria.[5] permeability Mucus plays an important role in mucosal de- Mucosal exposure of enterally feed nutrient (e.g.,

64 KSCCM·ACCC 2020 Jung-Min Bae ■ Protecting the Gut in Critical Illness glutamine, alanine), stimulates enteric blood flow, References maintain mucosal barrier function by preserving

1. Otani S, Coopersmith CM. Gut integrity in critical July 31 (Fri) tight-junction integrity, and induces production illness. 2019;7:17. and release of mucosal immunoglobulin and criti- 2. Clark JA, Coopersmith CM. Intestinal crosstalk: cal endogenous growth factors [11]. a new paradigm for understanding the gut as the No significant treatment modality exist to en- “motor” of critical illness. Shock 2007;28:384-93. 3. Meng M, Klingensmith NJ, Coopersmith CM. New hancing gut epithelial integrity, permeability or insights into the gut as the driver of critical illness mucus layer in critically ill patients. and organ failure. Curr Opin Crit Care 2017;23:143-8. However, several pre-clinical strategies intro- 4. Wischmeyer PE, McDonald D, Knight R. Role of duced. the microbiome, probiotics, and ‘dysbiosis therapy’ in critical illness. Curr Opin Crit Care 2016;22:347- The GLP-2 may promote sufficient gut hypertro- 53. phy in some short bowel syndrome patients.[12] 5. McDonald D, Ackermann G, Khailova L, Baird C, The enterocyte-specific nutrients such as gluta- Heyland D, Kozar R, et al. Extreme Dysbiosis of the mine and the short chain fatty acid products will Microbiome in Critical Illness. mSphere 2016;1. prevent gut atrophy and maintain gut mucosal in- 6. Qin X, Caputo FJ, Xu DZ, Deitch EA. Hydrophobic- ity of mucosal surface and its relationship to gut tegrity.[12] barrier function. Shock 2008;29:372-6. Glutamine was first reported as a gut fuel.[13] Ac- 7. Li H, Chen Y, Huo F, Wang Y, Zhang D. Association etoacetate may replace glutamine.[12] between acute gastrointestinal injury and bio- Epidermal growth factor is much more efficacious markers of intestinal barrier function in critically ill patients. BMC Gastroenterol 2017;17:45. in preventing gut atrophy than glutamine.[12] 8. Lankelma JM, van Vught LA, Belzer C, Schultz MJ, Membrane permeant inhibitor of MLCK : improve van der Poll T, de Vos WM, et al. Critically ill pa- intestinal permeability[14] tients demonstrate large interpersonal variation in Mucus surrogate : prevent trauma/hemorrhagic intestinal microbiota dysregulation: a pilot study. shock induced gut injury[15] Intensive Care Med 2017;43:59-68. 9. Burgstad CM, Besanko LK, Deane AM, Nguyen Pharmacologic vagus nerve agonist : attenuate NQ, Saadat-Gilani K, Davidson G, et al. Sucrose toxic mesenteric lymph induced lung injury [16] malabsorption and impaired mucosal integrity Immune enhancing diet : glutamine, arginine, in enterally fed critically ill patients: a prospec- fish-oil( ω−3 fatty acid ), γ-linoleic acid and nucleo- tive cohort observational study. Crit Care Med tides [17] 2013;41:1221-8. 10. Deitch EA. Gut-origin sepsis: evolution of a con- Microbiome approach : probiotics, fecal microbial cept. Surgeon 2012;10:350-6. transplantation, selective decomtamination of the 11. Townsend CM, Beauchamp RD, Evers BM, Mattox digestive tract ; however, the evidence is not high KL. Sabiston textbook of surgery : the biological quality.[1] basis of modern surgical practice; 2017. 12. Townsend CM, Sabiston DC. Sabiston Textbook of In conclusion, the gut have important function surgery : the biological basis of modern surgical in immunity. In critical illness, the gut is damaged practice. Philadelphia: W.B. Saunders; 2001. easily. In critical illness, several approach have 13. Windmueller HG, Spaeth AE. Uptake and metab- been adapted for protecting gut function. olism of plasma glutamine by the small intestine. J

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 65 Jung-Min Bae ■ Protecting the Gut in Critical Illness

Biol Chem 1974;249:5070-9. hemorrhagic shock. Ann Surg 2014;260:1112-20. 14. Zahs A, Bird MD, Ramirez L, Turner JR, Choudhry 16. Langness S, Costantini TW, Morishita K, Eliceiri MA, Kovacs EJ. Inhibition of long myosin light- BP, Coimbra R. Modulating the Biologic Activity of chain kinase activation alleviates intestinal damage Mesenteric Lymph after Traumatic Shock Decreas- after binge ethanol exposure and burn injury. Am es Systemic Inflammation and End Organ Injury. J Physiol Gastrointest Liver Physiol 2012;303:G705- PLoS One 2016;11:e0168322. 12. 17. Sertaridou E, Papaioannou V, Kolios G, Pneuma- 15. Fishman JE, Sheth SU, Levy G, Alli V, Lu Q, Xu D, tikos I. Gut failure in critical care: old school versus et al. Intraluminal nonbacterial intestinal com- new school. Ann Gastroenterol 2015;28:309-22. ponents control gut and lung injury after trauma

66 KSCCM·ACCC 2020 Ho Geol Ryu ■ Rationale and Physiology behind Transfusion in the Critically Ill

Transfusion Strategies July 31 (Fri) Rationale and Physiology behind Transfusion in the Critically Ill

Ho Geol Ryu

Department of Anesthesiology, Surgical ICU, Seoul National University Hospital, Seoul, Korea

Transfusion is a key component in reversing these clinical trials help us with our everyday deci- shock when patients can benefit from increased sions, there are still numerous gray areas for which oxygen delivery through increased arterial oxygen high level evidence is lacking. In these circum- content. The benefit (or lack of) of transfusion may stances, sound physiologic basis is key, along with differ depending on the type of shock, type of dis- clinical reasoning, in developing a clinical scheme ease or procedure, and underlying comorbidity. that poses the greatest benefit to our patients. However, the physiologic rationale is often over- In this lecture, the rationale and physiologic basis looked and most clinical studies comparing ‘liberal’ of transfusion will be reviewed and some of the cur- vs. ‘restrictive’ transfusion strategies use hemo- rent literature regarding transfusion in the critically globin levels as triggers for transfusion. Although, ill will also be discussed.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 67 Jaemyeong Lee ■ Blood Management for the Critically Ill

Transfusion Strategies

Blood Management for the Critically Ill

Jaemyeong Lee

Department of Acute Care Surgery, Korea University Anam Hospital

Among the major revisions of the 2016 Transfu- disease, etc., or when the oxygen saturation is less sion Guidelines of the Korea Centers for Disease than 90%, or a situation requiring massive trans- Control and Prevention/Korean Transfusion Soci- fusion, or in case of postpartum bleeding etc., it is ety, the representative contents for the critically ill recommended that appropriate transfusions should are as follows. be performed to suit the patient’s condition. 1. In sepsis, the guidelines for transfusion of In critically ill patients, it is important to proceed erythrocytes target the hemoglobin level of 7 g/dl with a desired transfusion, but it is also important or higher. to prevent unnecessary blood loss. 2. The use of erythropoietin (EPO) as a treatment 1. It is necessary to reduce unnecessary blood for sepsis-related anemia is not recommended. collection, and to activate point of care tests requir- 3. In critically ill ICU patients with hemodynami- ing as little blood collection as possible. In fact, it cally stable medical conditions, strict guidelines for is a reality that every arterial blood test need about erythrocyte transfusion (transfusion at hemoglobin 5cc of blood thrown away before the real sampling. below 7 g/dl and the post-transfusion hemoglobin So, it is necessary to reduce unnecessary blood target between 7 and 9 g/dl) are recommended tests prescriptions such as every hour ABGA test 4. In adult trauma patients at risk of massive repeat. Blood sampling should be performed at a bleeding, the initial transfusion ratio of red blood minimum number of times when there is a clear cell and plasma product is empirically 1:1. objective, such as for diagnostic purposes or to de- 5. Inject tranexamic acid once as soon as possible termine treatment guidelines. after trauma and inject it at a maintenance dose. 2. If the patient continues to bleed, it is necessary The injection dose, maintenance dose, and duration to maintain the patient’s pH, blood ionized calcium are determined in consideration of the patient’s un- concentration, and body temperature appropriately derlying disease and side effects. to induce blood clotting. However, if the patient is a child less than 6 3. In patients undergoing hemodialysis or extra- months old, or the patient has a cardiovascular dis- corporeal membrane oxygen supply treatment, ease, cerebrovascular disease, peripheral vascular appropriate anticoagulants should be used so that

68 KSCCM·ACCC 2020 Jaemyeong Lee ■ Blood Management for the Critically Ill blood can be returned to the patient and not dis- centrations of intravenous iron supplementation carded due to unnecessary coagulation. in intensive care units have not yet shown good July 31 (Fri) 4. Treatments such as central venous catheter results, such as a reduction in patients’ mortality insertion and arterial catheter insertion should be or infection rates. It is thought that further study performed neatly at one time to reduce unneces- will be needed to see if the supplementation of sary blood loss. high-concentration intravenous iron may be effec- 5. Be cautious of blood loss accidents, such as tive in critically ill patients with severe bone mar- blood leaking out of the injection line such as line row suppression and severe inflammatory reactions disconnection. under stress.

Anemia observed in patients in critically ill pa- References tients has one of these three condition, 1) actual 1. 질병관리본부/대한수혈학회 수혈가이드라인 2016년 iron deficiency from blood loss, 2) sequestration of 전면개정판 iron due to inflammatory conditions, and 3) func- 2. Critical Care Medicine 2014(42)9;2048-2057. tional iron deficiency from erythropoietin stimulat- 3. Litton E et al. Intensive Care Med 2016;42:1715–22. ing erythropoiesis. It should be understood as iron 4. P.eters F et al. Transfus Med Hemother 2018;45:42–6. 5. Boshuizen et al. Ann. Intensive Care (2018) 8:56. deficiency syndrome accompanied by one or more 6. Transfusion and Apheresis Science 50 (2014) 16-19. of these three conditions from several causes of 7. Current status of Pharmacologic therapies anemia. in patient blood management. Anesth Analg Several studies on the treatment with high con- 2013;116:15–34.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 69 Hangjoo Cho ■ Massive Transfusion in Critically Ill Patients

Transfusion Strategies

Massive Transfusion in Critically Ill Patients

Hangjoo Cho

Department of Trauma Surgery, Uijeongbu St. Mary’s Hospital, The Catholic University of Korea, Uijeongbu, Korea

Definition of Massive transfusion amount of crystalloid and blood were infused, ear- lier infusion of blood compared with crystalloid re- Hemorrhagte is the most common cause of death sulted in better outcome in animal study. Recently, from trauma. Generally when more than 10 units Riskin and coworkers identified improved outcomes of red blood cells(RBC) are transfused, we call this massive transfusion. And not only in trauma, other with rapid administration of blood products to ap- disease also need massive transfusion. propriate patients even if equivalent amounts of FFP and PRBCs were employed. MTP protocols Physician should clinically assess the extent of hemorrhage using various methods and start trans- For prevent and correct dilutional coagulopathy, fusion as early as possible. fixed guideline for plasma and platelet replacement ABC score and Shock index is well known tools of is needed. The goal of an MTP is to standardize the pediction of transfusion. replacement of platelets and clotting factors in an optimum ratio to RBCs. So, increase in speed and efficacy of transfusion is possible from this protoco- Monitoring lization. - Hemoglobin or hematocrit - Platelet count Use Blood product - Prothrombin time (PT)

Generally, with a higher the ratio of FFP:PRBC, - Partial thromboplastin time (aPTT) probability of survival was increased. - Fibrinogen level - Ratio between RBC and plasma is 1:1 or 2:1 - Calcium level - Single donor plateletor or 6 units of random do- - POC thrmoboelastometry nor platelet is prepared. Effect of Giving Uncross-matched Timing of replacement Blood

Early replacement is very important. Even if same The decision for giving uncross-matched type-O

70 KSCCM·ACCC 2020 Hangjoo Cho ■ Massive Transfusion in Critically Ill Patients

PRBCs is a subjective assessment based on vital - Platelet 100 X 109/L (Ongoing bleeding or Trau- signs, physical examination and experience. Ad- matic brain injury) July 31 (Fri) ministration of uncross-matched blood was indica- - Hb > 7 g/dL tive of the need for massive transfusion and higher - PT or aPTT < 1.5 times normal mortality. Conclusion

Target of transfusion Early and protocolized transfusion is required for - Fibrinogen > 150mg/dl survival of bleeding critically ill patients.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 71 Chi Ryang Chung ■ Gaps between the PADIS Guideline and Practice

Updated PAD in Critical Care

Gaps between the PADIS Guideline and Practice

Chi Ryang Chung

Department of Critical Care Medicine and Medicine, Samsung Medical Center, Seoul, Korea

In 2018 the Society of Critical Care Medicine protocol would be more crucial for enhancing the published the revised ICU PADIS (pain, agitation, clinical outcomes in ICU. ICU clinicians should em- delirium, immobility, and Sleep) guideline after the brace the evidence gaps when applying the PADIS 2013 PAD guideline [1, 2]. guidelines to their critically ill patients. Guidelines have shown that dissemination alone is not sufficient to ensure that recommendations References are incorporated into everyday ICU real clinical 1. Devlin JW, Skrobik Y, Gélinas C, Needham DM, practice. We are expecting the ‘real-world’ prac- Slooter AJC, Pandharipande PP, Watson PL, tice-based guideline recommendations, might re- Weinhouse GL, Nunnally ME, Rochwerg B et al: quire improvements in some areas. Clinical Practice Guidelines for the Prevention In the 2018 guideline evidence gaps enclosed in and Management of Pain, Agitation/Sedation, De- lirium, Immobility, and Sleep Disruption in Adult each section and Dr. John Devlin and Yoanna Skro- Patients in the ICU. Critical care medicine 2018, bik, SCCM PADIS guideline main authors, recently 46(9):e825-e873. published the ‘Pain and Delirium in Critical Illness: 2. Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, An Exploration of Key 2018 SCCM PADIS Guideline Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM et al: Clinical practice guidelines for the man- Evidence Gaps’ review article [3]. Referring to the agement of pain, agitation, and delirium in adult article, I have tried to summarize the gaps into my patients in the intensive care unit. Critical care presentation for the 2020 KSCCM conference. medicine 2013, 41(1):263-306. Although many lines of recommendations can 3. Pisani MA, Devlin JW, Skrobik Y: Pain and Deliri- support better practice, customized adaptation um in Critical Illness: An Exploration of Key 2018 SCCM PADIS Guideline Evidence Gaps. Seminars for each environment, educational efforts to ev- in respiratory and critical care medicine 2019, ery caregiver and consistent effort to follow the 40(5):604-613.

72 KSCCM·ACCC 2020 Hyo-Won Kim ■ Pediatric Delirium

Updated PAD in Critical Care July 31 (Fri) Pediatric Delirium

Hyo-Won Kim

University of Ulsan College of Medicine, Asan Medical Center

Delirium is a syndrome of acute, fluctuating brain sequelae of pediatric delirium. Delirium could dysfunction, with hallmark features of disrupted affect a child’s physical, cognitive, emotional, and arousal, attention, cognition, sleep, and perception social health. A recent systematic review shows that [1]. The reported prevalence of delirium in critically children post critical illness are at risk for cognitive ill children varies from 20% to 30% [2]. impairment [4]. PTSD symptoms are often reported One of the most challenging issues in pediatric in these children and their parents [5]. delirium is how to diagnose pediatric delirium accurately in critically ill children, especially in References children who are younger than 3 years or may have 1. Turkel SB, Tavare CJ: Delirium in children and ad- intellectual disabilities. The acute occurrence of a olescents. J Neuropsychiatry Clin Neurosci 2003; disturbance of cognition, emotions, consciousness, 15:431–435 or a behavioral disturbance in a critically ill child 2. Schieveld JNM, Ista E, Knoester H, et al.: Pediatric could be an early sign for pediatric delirium [3]. delirium: A practical approach, in IACAPAP e-Text- book of Child and Adolescent Mental Health. Ed- Nonpharmacologic interventions such as music ited by Rey JM. Geneva, International Association listening, massage, promoting sleep, maintaining for Child and Adolescent Psychiatry and Allied a regular day-night cycle, avoiding overstimula- Professions, 2015, pp I–5 tion by light and sounds, mobilization, and family 3. Silver G, Traube C, Kearney J et al (2012). Detecting pediatric delirium: development of a rapid obser- engagement, help prevent delirium or reduce the vational assessment tool. Intensive Care Medicine, severity and duration [2]. 38:1025-1031 Studies on the pharmacological treatment of 4. Kachmar AG, Irving SY, Connolly CA, et al: A sys- pediatric delirium are scarce. Antipsychotics are tematic review of risk factors associated with cog- widely used, but potential impact of antipsychotics nitive impairment after pediatric critical illness. Pediatr Crit Care Med 2018; 19:e164–e171 on developing brain is not studied well. 5. Colville G, Pierce C (2012). Patterns of post-trau- In general, critically ill children with delirium matic stress symptoms in families after paediatric have a higher resilience (and better prognosis) than intensive care. Intensive Care Medicine, 38:1523- adults. But there are no studies on the long term 1531.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 73 Miroslaw Czuczwar ■ Role of Ketamine and Antiepileptic Drugs in the Treatment of Acute Postoperative Pain

Updated PAD in Critical Care

Role of Ketamine and Antiepileptic Drugs in the Treatment of Acute Postoperative Pain

Miroslaw Czuczwar

Department of Anesthesiology and Intensive Care Medical University of Lublin, Poland

Postoperative pain management for many years fects. Some antiepileptic drugs, including gabapen- has been largely dominated by pharmacologic in- tin and pregabalin, were investigated as adjuncts terventions and concern for toxicity of these agents, in the treatment of acute postoperative pain in the requiring an increasing strategy for a multimodal perioperative period and they are included in many approach. Treatment strategies in postoperative ERAS pathways, although the optimal dosing regi- analgesia are still evolving and recent studies in- men and duration of administration is unclear. The dicate that there is a potential for both morbidity N-methyl-D-aspartate (NMDA) glutamate receptor and mortality with many agents, in particular opi- antagonists, including ketamine, are also known oid medications. Most opioids traditionally have to interfere with nociceptive processing and devel- been prescribed by nonperioperative physicians. opment of chronic pain, which makes them useful However, during the past decades, perioperative in providing a nonopioid mechanism of analgesia. providers have ordered substantial amounts of opi- Multimodal analgesia with nonopioid analgesics, oids, both intravenous and oral, to achieve optimal including gabapentin, pregabalin, and ketamine, pain control for their patients. Opioids have been is likely to result in less opioid use, although exten- a cornerstone of postoperative analgesia for many sive published data for this hypothesis is lacking. years; however, they are associated with many On the other hand, multimodal analgesia can re- adverse effects that may prevent patient recovery sult in unanticipated consequences resulting from after surgery. Although multimodal, opioid-spar- drug-drug interactions and adverse effects, as was ing analgesia has been promoted for more than 20 recently demonstrated by authors who have called years, only recently with the increasing adoption of into question potential negative effects of unfet- ERAS pathways has it begun to have broad uptake. tered use of non-opioid painkillers. Meta-analyses ERAS pathways typically use a standardized mul- to date have likely underestimated gabapentinoid timodal analgesic regimen with nonopioid agents and ketaine-associated adverse effects, particularly or techniques to minimize the use of perioperative the risk of respiratory depression and neurologic opioid and to decrease opioid related adverse ef- side effects. The efficacy of gabapentinoids and- ket

74 KSCCM·ACCC 2020 Miroslaw Czuczwar ■ Role of Ketamine and Antiepileptic Drugs in the Treatment of Acute Postoperative Pain amine for prevention of chronic postsurgical pain on Nonopioids: Intravenous or Oral Analgesics for also remains unclear. The purpose of the lecture is Perioperative Pain Management, Anesthesiol Clin,

2017; 35: 55-71. July 31 (Fri) to discuss the recent literature on the topic of the 2. Wick EC, Grant MC, Wu CL. Postoperative Multi- perioperative use of antiepileptic drugs and ket- modal Analgesia Pain Management With Nonopi- amine as opioid-sparing agents and their potential oid Analgesics and Techniques: A Review. JAMA usefulness in preventing chronic pain syndromes. Surg, 2017; 152: 691-697. 3. Kumar AH, Habib AS. The role of gabapentinoids in acute and chronic pain after surgery. Curr Opin References Anaesthesiol, 2019; 32: 629-634. 1. Kaye AD, Cornett EM, Helander E et al. An Update

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 75 Sung Yoon Lim ■ Correcting Acid Base and Electrolyte Imbalance with CRRT

CRRT

Correcting Acid Base and Electrolyte Imbalance with CRRT

Sung Yoon Lim

Seoul National Univ, Korea

Severe Acute kidney injury (AKI) frequently asso- or dialysis solutions by administering additional bi- ciated with life threatening electrolyte or acid-base carbonate is commonly used for patients with lactic disorders in critically ill patients. The initiation of acidosis. However, hyperlactemia causes acidosis dialysis can efficiently manage acid-base and elec- by increasing unmeasured anion lactate, not by trolyte imbalances including metabolic acidosis, decreasing serum bicarbonate. Thus, bicarbonate hyper/hypokalemia, and hyper/hyponatremia. administration via CRRT corrects acidosis by add- Continuous renal replacement therapy (CRRT) ing sodium cation in bicarbonate solution at the ex- may be useful in these situations as they allow pense of sodium load that can contribute to hyper- more time for correction and to maintain balance. volemia and further impair ventilation. In addition, Although a standard solution and prescription is bicarbonate may be converted to peripheral carbon acceptable in most clinical circumstances, prescrip- dioxide, which requires adequate pulmonary func- tion of CRRT needs to be individualized depending tion and gas exchange to be expired by the respira- on a specific disorder by adjustment of replacement tory system. Therefore, CRRT dose adjustment by fluid or dialysate composition or using separate increasing blood and dialysate flow and correction electrolyte infusion. Lactic acidosis is particularly of the underlying causative disturbances should be common in the intensive care unit requiring CRRT. first considered in the management of severe lactic In clinical practice, customized replacement and/ acidosis.

76 KSCCM·ACCC 2020 You-Min Sohn ■ Drug Dosing during CRRT

CRRT July 31 (Fri) Drug Dosing during CRRT

You-Min Sohn

Department of pharmaceutical services, Samsung Medical Center

Acute kidney injury (AKI) is a common compli- membranes may allow the overcoming of this issue cation of sepsis, and most patients who undergo throughout the assessment of RRT effects on drug’s life-threatening fluid and/or electrolyte changes concentration in blood and may guide drug dosing due to AKI require renal replacement therapy (RRT). adjustments [4]. The mortality rate of adult patients with AKI is 60% The most important factors able to affect drug PK in many studies, and 10% of all-cause mortality in during RRT are volume of distribution (Vd), protein the United States is the result of sepsis and septic binding, and molecular weight (MW); the knowl- shock [1, 2]. Continuous renal replacement thera- edge of these parameters, along with total body pies (CRRTs) are the primary RRT in the intensive clearance (CLTB) and pharmacodynamics (PDs) care unit (ICU) because critically ill patients with allows determination of the significance of extra- hemodynamic instability tolerate it better than corporeal removal of a given drug [6]. standard intermittent hemodialysis [3]. The purpose of this lecture is to identify the PK/ Most of the ICU patients undergoing RRT for PD properties of drugs of CRRT and review with AKI are treated with antimicrobials, and an ap- dosing recommendations for commonly utilized propriate drug dosing adjustment is essential to antimicrobials in critically ill adult patients receiv- avoid overdosing-related toxicity as well as under- ing CRRT. dosing-related treatment failure and/or potential onset of bacterial resistance [4, 5]. Sepsis-related References AKI often develops in the context of multiple or- 1. Barbar SD, Binquet C, Monchi M et al. Impact on gan dysfunction syndrome (MODS) and leads to mortality of the timing of renal replacement ther- relevant modifications of several pharmacokinetic apy in patients with severe acute kidney injury in (PK) parameters. And the start of RRT adds further septic shock: the IDEAL-ICU study(initiation of complexity related to the additional extracorporeal dialysis early versus delayed in the intensive care unit): study protocol for a randomized controlled clearance of many drugs especially antimicrobials. trial. Trials 2014;15:270. In this regard, the knowledge of the main princi- 2. Bagshaw SM, Uchino S, Bellomo R et al. Septic acute ples regulating transport of solutes across dialysis kidney injury in critically ill patients: clinical char-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 77 You-Min Sohn ■ Drug Dosing during CRRT

acteristics and outcomes. Clin J Am Soc Nephrol ment therapy. Crit Care Med 2009;37:2268-82. 2007;2:431-9. 5. Eyler RF, Mueller BA. Antibiotic dosing in criti- 3. Jang SM, Pai MP, Shaw AR et al. Antibiotic expo- cally ill patients with acute kidney injury. Nat Rev sure profiles in trials comparing intensity of con- Nephrol 2011;7:226-35. tinuous renal replacement therapy. Crit Care Med 6. Pistolesi V, Morabito S, Di Mario F, Regolisti G et al. 2019 Nov;47(11): e863-e871. A guide to understanding antimicrobial drug dos- 4. Choi G, Gomersall CD, Tian Q et al. Principles of ing in critically ill patients on renal replacement antibacterial dosing in continuous renal replace- therapy 2019 Jul 25;63(8):e0053-19.

78 KSCCM·ACCC 2020 Hye Ryoun Jang ■ Weaning from CRRT and Management Thereafter

CRRT July 31 (Fri) Weaning from CRRT and Management Thereafter

Hye Ryoun Jang

Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Continuous renal replacement therapy (CRRT) is checked and corrected before stopping CRRT. Af- regarded as the best modality of renal replacement ter weaning from CRRT, adequate volume control, therapy (RRT) in critically ill patients with renal fail- attenuation of uremic complications, prevention ure. Although many previous studies investigated of hyperkalemia and metabolic acidosis should be the optimal initiation timing or the adequate dos- achieved to reduce the risk of RRT reinitiation. Vol- age of CRRT, the ideal timing of CRRT weaning and ume may be controlled with proper administration management thereafter are not well known. Timely of diuretics and adjustment of diet and drugs may weaning from CRRT and adequate management help prevent progressive uremia, hyperkalemia, thereafter are crucial issues for better renal and and metabolic acidosis. overall patient outcome as well as cost effective- ness. Most previous studies investigating discontin- References uation of CRRT reported urine output as the most 1. 17th Acute Disease Quality Initiative (ADQI) Con- important predictor of successful weaning from sensus Group, Blood Purif 2016; 42:224–237. CRRT. However, a more practical criteria and man- 2. Romero-González et al, Contrib Nephrol. agement for CRRT weaning are required because 2018;194:118–125. CRRT weaning is usually attempted before full 3. Gibney N et al, Clin J Am Soc Nephrol 2008;3:876- 880. recovery of renal function. In this session, import- 4. Moore PK et al, Am J Kidney Dis. 2018; 72:136-148. ant clinical parameters and practical management 5. Wu VC et al, Intensive Care Med 2008; 34: 101–108. when weaning from CRRT will be reviewed. Since 6. Uchino S et al, Crit Care Med 2009;37:2576-2582. volume overload, uremia, electrolyte imbalance, 7. Bouman VC et al, Crit Care Med 2002; 30: 2205– 2211. and acid base disturbance are major indications 8. Jeon J et al, Crit Care 2018;22:255-265. for CRRT, volume status and simple laboratory 9. Fröhlich S et al, J Crit Care. 2012; 27:744.e1-5. parameters including blood urea nitrogen, serum 10. Cano et al. Clin Nutr 2009;28:401–414. creatinine, potassium, and bicarbonate should be

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 79 Michael Klompas ■ Antibiotic De-escalation Strategies in the ICU

Optimizing Antibiotics in the ICU

Antibiotic De-escalation Strategies in the ICU

Michael Klompas

Harvard University, USA

A recent international point-prevalence study a more nuanced approach. The increased risk of documented that 70% of ICU patients were receiv- death associated with delays in appropriate an- ing at least one antibiotic but only 54% had suspect- tibiotics is most evident for patients with sepsis, ed or proven infections.1 Standardized audits sug- particularly septic shock.3,4 Multiple investigations gest that 30% of antibiotics prescribed in the ICU bear out the safety, and indeed potential benefits, for >72 hours are inappropriate. The most common of gathering diagnostic data to confirm infection reasons for inappropriate antibiotics include overly before starting antibiotics for patients without broad spectra of activity relative to patients’ syn- septic shock.5-8 Likewise, the breadth of initial an- dromes, lack of evidence of infection, use of anti- tibiotics should be informed by a combination of bacterials for non-bacterial infections, prolonged patient-specific risk factors for antibiotic resistant duration of therapy, failure to de-escalate antibiot- organisms, the local ecology of antibiotic resistance ics to match available organism identities and sus- in the patient’s unit of care, and the patient’s sever- ceptibilities, inactive antimicrobial choices relative ity of illness (insofar as less ill patients may be able to patients’ pathogens, redundant antimicrobials to tolerate withholding antibiotics until organism (e.g. double anerobic coverage), and inappropriate identities and susceptibilities are available whereas doses or intervals.2 more ill patients may not be able to tolerate any Multiple strategies have been proposed to de- delay in appropriate antibiotics).9 Broad spectrum crease inappropriate antibiotic utilization. The coverage, as with antibiotics in general, is a dou- first opportunity to decrease unnecessary use is to ble-edged sword. Both undertreatment and over- be more circumspect about starting antibiotics in treatment are associated with higher mortality rates the first place. The traditional approach to starting in patients with suspected sepsis and septic shock.10 antibiotic over the past two decades has been to Once antibiotics have been started patients encourage early initiation of broad-spectrum an- should be re-evaluated daily to determine wheth- tibiotics even when the diagnosis is unclear given er there is ongoing necessity for antibiotics and to data associating delays in appropriate therapy with focus treatment according to culture results. Retro- increased mortality. More recent studies suggest spective analyses of patients admitted to intensive

80 KSCCM·ACCC 2020 Michael Klompas ■ Antibiotic De-escalation Strategies in the ICU care with a diagnosis of sepsis suggest that 20-40% further beyond these targets.23 most likely misdiagnosed and were not infected.11,12 In patients that fail to improve after initial resusci- July 31 (Fri) Once an alternative diagnosis becomes apparent tation despite antibiotics active against their identi- antibiotics should be stopped. Suspected respira- fied pathogens or in whom cultures are all negative, tory infections are the most common indication for the reason is rarely due to failure to cover an occult antibiotics in hospitalized patients.13,14 One practi- but active pathogen. More likely reasons include cal strategy to determine necessity of antibiotics for the presence of a pyogenic complication (such as patients with suspected pneumonia is to assess se- empyema or abscess), inadequate source control, a rial oxygenation parameters. In ventilated patients, mechanical complication (such as bowel perfora- observational data suggest it is safe to stop antibi- tion or obstruction), or a non-infectious diagnosis otics after as few as 2 days in patients with minimal (such as pancreatitis, drug reaction, or malignan- and stable ventilator settings.15,16 cy). Refocusing the therapeutic plan to identify and A slew of recent studies have compared short vs address one of these alternative explanations for long course treatments for a range of different con- persistent illness is more likely to bring clarity and ditions include gram-negative bacteremia, pneu- facilitate improvement rather than escalating anti- monia, pyelonephritis, intra-abdominal infections, biotics or continuing a failing regimen indefinitely. skin and soft tissue infections, and others. In the vast majority of cases, short courses were associated References with similar or better outcomes compared to longer 1. Vincent JL, Sakr Y, Singer M, et al. Prevalence and courses. As such, the default duration of treatment Outcomes of Infection Among Patients in Intensive for gram negative bacteremia is now 7 days, partic- Care Units in 2017. JAMA. 2020. 2. Trivedi KK, Bartash R, Letourneau AR, et al. Op- ularly if paired with serial monitoring of c-reactive portunities to Improve Antibiotic Appropriateness 17,18 protein. Hospital-acquired pneumonia should in U.S. ICUs: A Multicenter Evaluation. Crit Care be treated for 7 days and community-acquired Med. 2020;48(7):968-976. pneumonia for 5 days.19,20 Pyelonephritis can be 3. Seymour CW, Gesten F, Prescott HC, et al. Time to Treatment and Mortality during Mandat- adequately treated with 5-7 days of antibiotics.21 In- ed Emergency Care for Sepsis. N Engl J Med. tra-abdominal infections with source control can be 2017;376(23):2235-2244. 22 managed with just 4 days of antibiotics. All these 4. Liu VX, Fielding-Singh V, Greene JD, et al. The Tim- recommendations should, of course, be tempered ing of Early Antibiotics and Hospital Mortality in Sepsis. Am J Respir Crit Care Med. 2017;196(7):856- with clinical judgement and customized according 863. to patients’ clinical trajectories, adequacy of source 5. Fagon JY, Chastre J, Wolff M, et al. Invasive and control, certainty of infection, host vulnerability, noninvasive strategies for management of suspect- causative pathogens, and response to treatment. ed ventilator-associated pneumonia. A random- Serial monitoring of procalcitonin values may be a ized trial. Ann Intern Med. 2000;132(8):621-630. 6. Hranjec T, Rosenberger LH, Swenson B, et al. Ag- useful adjunct to help reinforce clinicians’ comfort gressive versus conservative initiation of antimi- in achieving these shorter courses and indeed help- crobial treatment in critically ill surgical patients ing clinicians to consider shortening courses even with suspected intensive-care-unit-acquired

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 81 Michael Klompas ■ Antibiotic De-escalation Strategies in the ICU

infection: a quasi-experimental, before and after 2017;64(7):870-876. observational cohort study. Lancet Infect Dis. 16. Singh N, Rogers P, Atwood CW, Wagener MM, Yu 2012;12(10):774-780. VL. Short-course empiric antibiotic therapy for 7. Ramsamy Y, Muckart DJ, Bruce JL, Hardcastle TC, patients with pulmonary infiltrates in the intensive Han KS, Mlisana KP. Empirical antimicrobial ther- care unit. A proposed solution for indiscriminate apy for probable v. directed therapy for possible antibiotic prescription. Am J Respir Crit Care Med. ventilator-associated pneumonia in critically in- 2000;162(2 Pt 1):505-511. jured patients. S Afr Med J. 2016;106(2):196-200. 17. Yahav D, Franceschini E, Koppel F, et al. Seven 8. Baker AM, Meredith JW, Chang M, Dunagan D, Versus 14 Days of Antibiotic Therapy for Uncom- Smith A, Haponik E. Bronchoscopically guided plicated Gram-negative Bacteremia: A Noninferi- management of ventilator-associated pneumonia ority Randomized Controlled Trial. Clin Infect Dis. in trauma patients. J Bronchology. 2003;10. 2019;69(7):1091-1098. 9. Kalil AC, Metersky ML, Klompas M, et al. Manage- 18. von Dach E, Albrich WC, Brunel AS, et al. Ef- ment of Adults With Hospital-acquired and Venti- fect of C-Reactive Protein-Guided Antibiotic lator-associated Pneumonia: 2016 Clinical Practice Treatment Duration, 7-Day Treatment, or 14- Guidelines by the Infectious Diseases Society of Day Treatment on 30-Day Clinical Failure Rate America and the American Thoracic Society. Clin in Patients With Uncomplicated Gram-Negative Infect Dis. 2016;63(5):e61-e111. Bacteremia: A Randomized Clinical Trial. JAMA. 10. Rhee C, Kadri SS, Dekker JP, et al. Prevalence of 2020;323(21):2160-2169. Antibiotic-Resistant Pathogens in Culture-Proven 19. Chastre J, Wolff M, Fagon JY, et al. Comparison of Sepsis and Outcomes Associated With Inadequate 8 vs 15 days of antibiotic therapy for ventilator-as- and Broad-Spectrum Empiric Antibiotic Use. sociated pneumonia in adults: a randomized trial. JAMA Netw Open. 2020;3(4):e202899. JAMA. 2003;290(19):2588-2598. 11. Klein Klouwenberg PM, Cremer OL, van Vught 20. Uranga A, Espana PP, Bilbao A, et al. Duration of LA, et al. Likelihood of infection in patients with Antibiotic Treatment in Community-Acquired presumed sepsis at the time of intensive care unit Pneumonia: A Multicenter Randomized Clinical admission: a cohort study. Crit Care. 2015;19:319. Trial. JAMA Intern Med. 2016;176(9):1257-1265. 12. Heffner AC, Horton JM, Marchick MR, Jones AE. 21. Eliakim-Raz N, Yahav D, Paul M, Leibovici L. Du- Etiology of illness in patients with severe sepsis ration of antibiotic treatment for acute pyelone- admitted to the hospital from the emergency de- phritis and septic urinary tract infection-- 7 days partment. Clin Infect Dis. 2010;50(6):814-820. or less versus longer treatment: systematic review 13. Fridkin S, Baggs J, Fagan R, et al. Vital signs: im- and meta-analysis of randomized controlled trials. proving antibiotic use among hospitalized patients. J Antimicrob Chemother. 2013;68(10):2183-2191. MMWR Morb Mortal Wkly Rep. 2014;63(9):194- 22. Sawyer RG, Claridge JA, Nathens AB, et al. 200. Trial of short-course antimicrobial therapy 14. Shorr AF, Zilberberg MD, Micek ST, Kollef MH. Vi- for intraabdominal infection. N Engl J Med. ruses are prevalent in non-ventilated hospital-ac- 2015;372(21):1996-2005. quired pneumonia. Respir Med. 2017;122:76-80. 23. de Jong E, van Oers JA, Beishuizen A, et al. Efficacy 15. Klompas M, Li L, Menchaca JT, Gruber S. Ultra- and safety of procalcitonin guidance in reducing short-course antibiotics for patients With suspect- the duration of antibiotic treatment in critically ill ed ventilator-associated pneumonia but minimal patients: a randomised, controlled, open-label tri- and stable ventilator settings. Clin Infect Dis. al. Lancet Infect Dis. 2016;16(7):819-827.

82 KSCCM·ACCC 2020 Jeffrey Lipman ■ PK-PD Optimized Therapy

Optimizing Antibiotics in the ICU July 31 (Fri) PK-PD Optimized Therapy

Jeffrey Lipman

Mayne Academy of Critical Care, The University of Queensland

Pharmacokinetics is the concentration-time re- - CrCl >130mls/min)(3). It is the younger patients lationship of a drug. It is basically how the body with some inflammatory insult (eg head injury, handles a drug. Pharmacodynamics relates to the or sepsis) and little or no organ dysfunction that concentration-effect of a drug and is basically what classically would present with a warm vasodilated the drug does to or within the body. circulatory response. These patients would have In effect when addressing PK/PD of antibiotics a high cardiac output, increased renal blood flow, the “PK” is serum levels of the drug and the “PD” and hence increased GFR and high CrCl. High CrCl relates to MIC of organisms. mean high drug clearances and underdosing. A multi-centered study across 4 continents revealed Pharmacokinetics 65% of patients admitted to multidisciplinary ICUs with a “normal” serum creatinine manifest ARC. Patients in ICU have different pharmacokinetics In view of the PK differences in ICU patients we to “normal” people.1,2 often will use much higher than “normal” doses ie Drug discovery and subsequent release for mar- off label doses of many of the antibiotics.4 keting involves phase 1, 2 and 3 studies which usu- ally don’t involve ICU patients. Critically ill patients have different haemodynam- Pharmacodynamics ics, often have low serum proteins and increased The PD target of an antihypertensive drug is easy volume of distributions of hydrophilic antibiotics. to achieve (Blood pressure control), that of many These differences necessitate the need to give load- of the antibiotics is still debatable.7 The most com- ing doses of many of the antibiotics. Clearances of monly used PD for antibiotics is the MIC ie PK-PD these agents are independent of loading doses.2 can be regarded as antibiotic concentrations (PK) There is a group of patients within the ICU who related to MIC (PD). are admitted with an inflammatory response but Whilst we can accurately measure serum concen- “normal” renal function and have high Creatinine trations of drugs (and we routinely use therapeutic Clearances (Augmented Renal Clearance – ARC beta-lactam monitoring – ie TDM5) the measure-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 83 Jeffrey Lipman ■ PK-PD Optimized Therapy ment of MIC is less accurate such that within the References same lab, with the same technical support there 1. Roberts JA, Lipman J. Critical Care Med 2009 6 can be a 2-4 fold difference in the measured MIC. Mar;37(3):840-51. 2. Roberts JA et al. Intensive Care Med 2016; 42:1797- MIC Measurements6 1800. 3. Udy A et al. Clin Pharmacokinet 2010;49:1-16. I will specifically go into the problems and in- 4. Udy A et al. Intensive Care Med 2013;39:2070-82. accuracies of measurement of bacterial MICs and 5. McWhinney B et al. J Chromatogr B 2010;878:2039- then the adjustment of pharmacokinetic parame- 43. 6. Mouton J et al. J Antimicrob Chemother 2018;73: ters to overcome rising MICs. 564-8. Finally, noting theses MIC inaccuracies, and 7. Roberts JA et al Lancet Infect Dis 2014;14:498-509. widespread increasing resistance profiles (ie rising MICs) we advise aggressive targets for PK/PD.

84 KSCCM·ACCC 2020 Jinsoo Min ■ Biomarker-guided Antibiotic Therapy

Optimizing Antibiotics in the ICU July 31 (Fri) Biomarker-guided Antibiotic Therapy

Jinsoo Min

The Catholic University of Korea College of Medicine, Republic of Korea

The overuse and the misuse of antibiotics over sensitivity of 68-92% and a specificity of 50-67% as a the past decades has resulted in a widespread of marker of bacterial infection. There is evidence that antimicrobial resistance.1 A proper antibiotic pre- CRP is as useful as PCT in reducing antibiotic use in scribing strategy must be part of an integrative pro- critically ill septic patients.5 cess-of-care, which assures a prompt recognition of Presepsin is an immunologic biomarker which infection, not colonization, a timely initiation and has been demonstrated as new, emerging, early in- duration of an appropriate antimicrobial therapy. dicator for the detection of different infections.6 An Biomarkers are biological characteristics that are advantage of the assessment of presepsin is its ca- objectively measured and used as an indicator of pacity to predict the severity of a bacterial infection. physiological or pathological pathways or a phar- To increase the accuracy, presepsin could be used macologic response to therapeutic interventions.2 in combination with other markers and standard They help physician triage, diagnose, stratify risk, methods of infection diagnosis. The search for new and monitor clinical course as well as response to biomarker useful guiding antibiotic therapy has antibiotics. produced some promising candidates, such as sol- Only a limited number of investigated biomark- uble triggering receptor expressed on myloid cells ers became routinely available in clinical practice. 1 (sTREM-1) and soluble urokinase plasminogen Procalcitonin (PCT) is the most widely studied activator receptor (suPAR). biomarker for antibiotic stewardship3 and showed Every antibiotic stewardship strategy recognizes a sensitivity of 77% and a specificity of 79% for early that antibiotics are cornerstones in the treatment diagnosis of sepsis in critically ill patients.4 It has of infection but acknowledges that its misuse and been tested as an aid to the initiation and/or dis- overuse in ICU patients is associated with increased continuation of antibiotics, both in children and duration of mechanical ventilation, length of stay, adults presenting with distinct sources of infection mortality, recurrence of infection, direct toxicity, and in different scenarios, from primary care to organ failure, emergence of bacterial resistance emergency departments, hospital wards and inten- and costs.7 Biomarkers are useful tools that help sive care unit. Serum C-reactive protein (CRP) has a clinicians in different settings to optimize antibi-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 85 Jinsoo Min ■ Biomarker-guided Antibiotic Therapy otic therapy. It should also be highlighted that the clinical use in acute infection. Ann Intensive Care study of implementation science and a deep under- 2013;3:22. 4. Cho S-Y et al. Biomarkers of sepsis. Infect Chemo- standing of what motivates antibiotic prescribing ther 2014;46:1-12. 8 advance simultaneously. 5. Kiaei BA et al. Procalcitonin and C-reactive pro- tein as markers in response to antibiotic treatment References in ventilator-associated pneumonia in intensive care unit hospitalized patients. Adv Biomed Res 1. Nora D et al. Biomarker-guided antibiotic ther- 2015;4:240. apy – strengths and limitations. Ann Transl Med 6. Memar MY et al. Presepsin: A promising biomark- 2017;5(10):208 er for the detection of bacterial infections. Biomed 2. Biomarkers Definitions Working Group. Biomark- Pharmaco 2019;111:649-656. ers and surrogate endpoints: Preferred definitions 7. Povoa P et al. Biomarker guided antibiotic therapy. and conceptual framework. Clin Pharmacol Ther What’s new? ICU Manag Pract 2016;1:24-28. 2001;69:89-95. 8. Doernberg SB et al. Will biomarker be the answer 3. Dupuy AM et al. Role of biomarkers in the man- for antibiotic stewardship? Lancet Respir Med agement of antibiotic therapy: an expert panel 2020;8:130-132. review: I – currently available biomarkers for

86 KSCCM·ACCC 2020 Asad Latif ■ Approaching Patient Safety as Science

Patient Safety July 31 (Fri) Approaching Patient Safety as Science

Asad Latif

Aga Khan Univ, Pakistan

Patient safety in healthcare is an essential re- ed, and potential defects that can adversely com- quirement for providing high quality care. However, promise patient safety. Every system is designed research shows that in the US health care system, to achieve the results is gets; focusing on systems people receive the recommended evidence-based rather than individuals is the key to moving forward care only about half the time on average. As many with improving. as 440,000 deaths per year have been attributed to As healthcare professionals, we can overcome preventable harm in US hospitals, which would these errors by understanding the principles of safe make it the third leading cause of death each year. design: Standardize where possible, create inde- Research shows that gaps in applying safe practic- pendent checks, and if things do go wrong we need es most often come from a lack of multidisciplinary to learn from those errors. Frontline workers input involvement in checklist/protocol development, from all disciplines should be considered as well. confusion regarding proper use, pragmatic work- We need to understand that teams make wise deci- flow issues, lack of access to required resources, sions with diverse and independent input. Lasting and provider beliefs and attitudes. In response, improvement is far more complex than a checklist. a growing body of literature is linking improved We need to engage frontline staff on a continuous teamwork, communication, and safety culture, with basis as they are the ones most capable of identify- patient outcomes. ing and fixing local issues. Any lack of compliance with best practices should Keywords: Patient safety, quality improvement, be considered a lapse in the quality of care provid- systems thinking

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 87 Jozef Kesecioglu ■ Do Critically Ill Patients All Need Oxygen Therapy?

Patient Safety

Do Critically Ill Patients All Need Oxygen Therapy?

Jozef Kesecioglu

UMC Utrecht, the Netherlands

The oxidative stress induced by hyperoxia on pul- The sigmoidal shape of the oxyhaemoglobin dis- monary, cardiovascular, and neurological systems sociation curve indicates that even small changes have been demonstrated in several in vitro, animal in SpO₂ could be harmful because they lead to large and human studies. Hyperoxic acute lung injury is increases in PaO₂. Many experimental studies have the most known form of oxygen-related toxicity but found increased levels of reactive oxygen-derived many other organs and systems may be impaired. free radicals, an influx of inflammatory cells, in- Sustained hyperoxia exerts detrimental effects at creased pulmonary permeability and endothelial the cellular level, especially in the mitochondria. cell injury with the use of high FiO2. Mitochondria usually plays a key role in detoxifying Animal data strongly implicate hyperoxia as a cells from reactive oxygen species. High amounts clinically important cause of lung injury. Hyperoxia of oxygen are hard to handle by the mitochondria is shown to be related to higher mortality in ICU and may lead to an imbalance between pro- and patients in large retrospective studies, systematic anti-oxidant molecules with significant damages reviews and meta analysis. Different criteria have to cell components. This may lead to activation of been used in clinical studies to define hyperoxia apoptotic pathways, loss of cellular homeostasis leading to heterogeneous results difficult to com- and cell death. pare. The oxidative stress may induce the formation of The results of systematic reviews and meta anal- reactive nitrogen species and the decrease of nitric ysis must be interpreted cautiously due to this het- oxide production with significant alteration in mi- erogenous results. On the other hand, there is quite crocirculation and tissue perfusion. Animal studies consistent data on the harmful effects of hyperoxia have shown that hyperoxia can promote vasocon- in a number of studies performed during the last striction, inflammation, and oxidative stress on pul- decade, especially when PaO2 exceeds 200 mm Hg. monary, cardiovascular, and neurological systems.

88 KSCCM·ACCC 2020 Michael Klompas ■ ICU Design and Infection Prevention

Patient Safety July 31 (Fri) ICU Design and Infection Prevention

Michael Klompas

Harvard University, USA

Intensive care units have long been recognized as proaches to preventing fomite-based transmission reservoirs for the cultivation and spread of infec- include universal use of private rooms, copper-im- tions within hospitals. Infections can spread within pregnated surfaces, and UV light discharge cleaning ICUs via surfaces, air, and water. Thoughtful design systems. and utilization of ICU space may help mitigate this The ongoing Covid-19 pandemic is a salient risk. remind of the possibility of airborne spread of in- Surface contamination of intensive care units fection. Other examples of airborne illnesses com- is common. One can recover a host of multidrug monly cared for in the intensive care unit included resistant organisms from high touch surfaces in disseminated varicella, tuberculosis, and more rare- intensive care units including multidrug resistant ly, measles. Design features that can help prevent bacteria and Clostridium difficile. Sharing a room the spread of airborne infections include universal with a patient infected with typical nosocomial use of private rooms, provision of negative pressure pathogens are up to 5 times more likely to be infect- systems, assuring high rates of air exchanges, HEPA ed with the same organism compare to roommates of uninfected patients.1 This bespeaks the value 5 Enabling ICUs to have the capacity to turn filtration, and incorporation of in-room UV light of private rooms. Similarly, patients admitted to all rooms to negative pressure as well as designing fixtures. rooms previously occupied by patients with MRSA, VRE, resistant gram negative bacteria, or to contaminated to transition zones can help man- Clostrid- units to facilitate one-way flow of traffic from clean ioides difficile are 2-5 times more likely acquire age large numbers of patients during epidemics of these pathogens.1 The role of environmental con- airborne pathogens. tamination in facilitating spread of infection is fur- Hospital water systems are well-recognized sourc- ther borne out by studies comparing infection rates es of outbreaks and infections. Potential pathogens in ICU patients following a move to a new facility. include Legionella, non-tuberculous mycobacteria, Switching to new premises has been variably asso- and multidrug resistant gram negative bacilli such ciated with decreases in nosocomial infection rates, as Pseudomonas aeruginosa, Acinetobacter species, antibiotic utilization, and length-of-stay.2-4 Novel ap- and carbapenem-resistant Enterobacteriaceae. In

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 89 Michael Klompas ■ ICU Design and Infection Prevention some cases, infections appear to be attributable to Intern Med. 2011;171(1):32-38. colonization of sink drains that lead to aerosoliza- 3. Kim HJ, Jeong E, Choe PG, Lee SM, Lee J. Inten- sive Care Unit Relocation and Its Effect on Multi- tion of pathogens when running faucets.6 Some hos- drug-Resistant Respiratory Microorganisms. Acute pitals have experimented with routine disinfection Crit Care. 2018;33(4):238-245. of drains using chemical and/or mechanical clean- 4. McDonald EG, Dendukuri N, Frenette C, Lee TC. ers.7 Other ICUs have experimented with removing Time-Series Analysis of Health Care-Associated In- fections in a New Hospital With All Private Rooms. JAMA Intern Med. 2019. to “waterless” care. The former has been associat- all plumbing fixtures from the ICU and transitioning 5. Nardell EA, Nathavitharana RR. Airborne Spread ed with less colonization of organisms but has not of SARS-CoV-2 and a Potential Role for Air Disin- yet clearly been associated with fewer infections.7 fection. JAMA. 2020. The latter is complicated to implement but limited, 6. Parkes LO, Hota SS. Sink-Related Outbreaks and early data are promising.8 Mitigation Strategies in Healthcare Facilities. Curr Infect Dis Rep. 2018;20(10):42. 7. Buchan BW, Arvan JA, Graham MB, et al. Effective- References ness of a hydrogen peroxide foam against bleach for the disinfection of sink drains. Infect Control 1. Cohen B, Liu J, Cohen AR, Larson E. Association Hosp Epidemiol. 2019;40(6):724-726. Between Healthcare-Associated Infection and Ex- 8. Shaw E, Gavalda L, Camara J, et al. Control of en- posure to Hospital Roommates and Previous Bed demic multidrug-resistant Gram-negative bacteria Occupants with the Same Organism. Infect Control after removal of sinks and implementing a new Hosp Epidemiol. 2018;39(5):541-546. water-safe policy in an intensive care unit. J Hosp 2. Teltsch DY, Hanley J, Loo V, Goldberg P, Gursah- Infect. 2018;98(3):275-281. aney A, Buckeridge DL. Infection acquisition fol- lowing intensive care unit room privatization. Arch

90 KSCCM·ACCC 2020 Ji Man Hong ■ Who Benefits from TTM in Neurological Intensive Care Unit?

Neuro-Critical Care July 31 (Fri) Who Benefits from TTM in Neurological Intensive Care Unit?

Ji Man Hong

Department of Neurology, School of Medicine, Ajou University, Suwon, Korea

Therapeutic hypothermia (TH) or targeted tem- emia-reperfusion injury. It can be clinically bene- perature management (TTM) is an intentional ficial in various clinical fields such as post-cardiac cooling or temperature control technique using a arrest syndrome, stroke, and cerebral edema. In thermostatic equipment for specific therapeutic order to obtain the possible advantages of the purposes. Theoretically, TTM can benefit from aforementioned TTM, high quality of TTM should fever, increased metabolic demand, and isch- be implemented.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 91 Lewis J Kaplan ■ Novel Strategies in Enhancing Recovery from Traumatic Brain Injury

Neuro-Critical Care

Novel Strategies in Enhancing Recovery from Traumatic Brain Injury

Lewis J Kaplan

Perelman School of Medicine, University of Pennsylvania

While primary brain injury will have already by an improved understanding of cerebral dynam- occurred, and the patient will have encountered ics and inflammation, new therapeutics are being many secondary brain injuriants prior to ICU ar- trialed at the bedside, or being refined in the lab. rival, there is an ongoing need to mitigate the im- Some of the most promising will be highlighted in pact of TBI on outcome. To support cognitive and this session as a preview of what the future of neu- functional recovery after blunt TBI in particular, a rocognitive recovery enhancement may hold for variety of interventions have been applied with less the intensivist. improvement that desired. At present, and aided

92 KSCCM·ACCC 2020 Tony Yeh ■ Microcirculation in VA-ECMO

ECMO July 31 (Fri) Microcirculation in VA-ECMO

Tony Yeh

National Taiwan University Hospital, Taiwan

In 2001 early-goal directed therapy, it is important sify the blood flow of each vessel. It is crucial to to maintain an adequate CVP, MVP, and a value of follow the consensus to conduct microcirculation central venous oxygen saturation higher than 70%. research. Perfused small vessel density (PSVD) By doing these efforts, the 28-day mortality was re- is lower in the sepsis patients than in the healthy duced from 49.2% to 33.4%. However, in 2014 and volunteers. In patients with sepsis, PSVD is much 2015, there were 3 papers in NEJM, all reported that lower in the non-survivors than in the survivors. In EGDT did not reduce mortality for patients with patients with VA-ECMO, the microcirculatory dys- shock. There are many explanations and interpre- function is severer in the nonsurvivors compared to tations for the negative results of EGDT. Microcir- the survivors. Moreover, patients with higher total culation can help to avoid some pitfalls. Microscan vessel density were more likely to have a successful is a second generation video microscopy, and it weaning from VA-ECMO. Increase the VA-ECMO can measure the sublingual microcirculation. Cy- flow, may decrease or increase the PSVD. Further tocam is a third generation of video microscopy studies are required to investigate the predictors for with higher resolution. We can use semi-automated the change of PSVD after adjusting VA-ECMO flow. software to calculate the vessel density and clas-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 93 Miroslaw Czuczwar ■ VV-ECMO without Systemic Heparin Anticoagulation - Is It Possible and Feasible?

ECMO

VV-ECMO without Systemic Heparin Anticoagulation - Is It Possible and Feasible?

Miroslaw Czuczwar

Department of Anesthesiology and Intensive Care Medical University of Lublin, Poland

Venovenous extracorporeal membrane oxygen- (LMWH). To date most of the evidence on the use ation (V-V ECMO) has been advocated as an estab- of LMWH as an alternative is supported only by lished method of support in severe respiratory fail- case series and retrospective studies, especially in ure resistant to conventional treatment. According particular groups of patients (e.g. after trauma). We to international guidelines, ECMO initiation and hypothesized that anticoagulation with LMWH is management requires anticoagulation to prevent noninferior to UFH in the number of thrombotic clotting in the extracorporeal circuit. Unfractionat- complications during the therapy while decreasing ed heparin (UFH) is considered the anticoagulant the number of hemorrhagic complications and of choice during ECMO support. In a large multi- transfusion requirements. Therefore, we conducted center survey, 96% of centers confirmed that UFH a retrospective, multicenter, observational study to is the anticoagulant of choice during V-V ECMO. evaluate the safety and feasibility of an anticoagu- However, systemic infusion of UFH requires coag- lation strategy based on subcutaneous LMWH only ulation monitoring several times daily to maintain in comparison to UFH during V-V ECMO. The study therapeutic clotting times. Despite this monitoring, included 67 consecutive adult patients (35 antico- V-V ECMO circuit failure occurs in 16.1% of patients agulated with nadroparin and 32 in the UFH group). and is mainly associated with thrombosis on the ox- Patients in the LMWH group received a single dose ygenator’s membrane. Furthermore, in as many as of 5,700 international units (IU) of nadroparin sub- 30% of patients, substantial bleeding can occur, and cutaneously once daily if body weight was below in up to 17% of ECMO support cases, hemorrhagic 100 kg. If patient body weight was 100–120 kg, 7,600 complications lead directly to death. It is notewor- IU of nadroparin was injected, whereas patients thy, that most severe bleeding complications during weighing >120 kg received 9,500 IU. Patients in the ECMO, regardless of the mode used, are associated UFH group received continuous infusion to target with UFH infusion. One of the possible ways to in- the therapeutic APTT (60–80 s) or activated clotting crease patients’ safety during ECMO support is to time (ACT) (140–160 s), as advised by the ELSO Red replace UFH with low-molecular-weight heparins Book. The primary outcomes of our study includ-

94 KSCCM·ACCC 2020 Miroslaw Czuczwar ■ VV-ECMO without Systemic Heparin Anticoagulation - Is It Possible and Feasible? ed thrombotic and bleeding complications during nadroparin. Based on these results, we conclude ECMO treatment. In terms of thrombotic complica- that LMWH anticoagulation is noninferior to UFH July 31 (Fri) tions, we assessed the number of acute thromboses in the number of thrombotic and hemorrhagic in the circuit and change in resistance to flow in the events, and the need for transfused blood products oxygenator during the first 7 days of support. Resis- is comparable during V-V ECMO support. Those tance to flow in the oxygenator, defined as pressure conclusions need confirmation in well-designed drop across the oxygenator divided by flow in the prospective randomized studies. extracorporeal circuit, was recorded every 6 hours. In terms of bleeding complications, we assessed the References number of bleeds and number of life-threatening 1. Aubron C, Cheng AC, Pilcher D, et al: Factors asso- bleeds, number of transfused blood products, se- ciated with outcomes of patients on extracorporeal rum hemoglobin level at the termination of ECMO, membrane oxygenation support: A 5-year cohort and platelet count during the first 7 days of ECMO study. Crit Care 17: R73, 2013. support. To our knowledge, this was the first study 2. Oliver WC: Anticoagulation and coagulation man- agement for ECMO. Semin Cardiothorac Vasc comparing anticoagulation with subcutaneous Anesth 13: 154–175, 2009. LMWH to systemic infusion of UFH in patients un- 3. Brogan T, Lequier L, Lorusso R, et al: Extracorpore- dergoing V-V ECMO. Our results show that antico- al Life Support: The ELSO Red Book. Red Book 5th agulation with subcutaneous doses of nadroparin ed. Ann Arbor, MI, 2017 4. Piwowarczyk P, Borys M, Kutnik P, et al. Unfrac- was not inferior to systemic UFH infusion in terms tionated Heparin Versus Subcutaneous Nad- of the number of acute thrombotic events and the roparin in Adults Supported With Venovenous number of bleeds during therapy. The number of Extracorporeal Membrane Oxygenation: a Ret- transfused PRBC units per day was similar in both rospective, Multicenter Study. ASAIO J. 2020 doi: groups, but significantly fewer RBC units per thera- 10.1097/MAT.0000000000001166. py were transfused in patients anticoagulated with

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 95 Sunghoon Park ■ Mechanical Ventilation on Venovenous ECMO: The Current Practice and Adjunctive Treatments

ECMO

Mechanical Ventilation on Venovenous ECMO: The Current Practice and Adjunctive Treatments

Sunghoon Park

Internal Medicine, Hallym University Sacred Heart Hospital, Korea

Since the landmark study of patients with acute be widely used in clinical practice, and physicians respiratory distress syndrome (ARDS) by the ARDS should be aware that ECCO2R might be insufficient network [1], targeting a tidal volume (TV) as low as for oxygenation and CO2 removal in patients with 6 ml/kg (predicted body weight [PBW]) has been severe ARDS. the cornerstone for mechanical ventilation strate- Importantly, in 2015, Amato et al published the gies for pateints with ARDS. However, from animal results of pooled analysis of nine randomized studies, a TV less than 4 ml/kg was associated with controlled trial on ARDS and emphasized the im- decreased lung injury [2], and as the extracoropreal portance of driving pressure [7]. They showed that membrane oxygenation (ECMO) use increased, a a higher PEEP was not always protective and the lower tidal volume of < 4 ml/kg, as part of the ul- driving pressures was a significant risk factor for traprotective lung ventilation (i.e., TV of < 4 ml/kg mortality. In a recent study by Serpa Neto et al.

PBW, plateau pressure [Pplat] < 25 cm H2O, positive driving pressure was significantly assocaited with end-expiratory pressure [PEEP] > 10 cm H2O, and increased mortality in patients with ARDS receiving slow respiratory rate) has been frequently used ECMO [4]. These studies may indicate the impor- in pateitns with ARDS [3]. Recently, the use of ul- tance of TV corrected by lung compliance rather traprotective lung ventilation strategy has been well than body weight. However, considering no ran- documented in both retrospective (by Serpa Neto domized controlled studies on driving pressure, it is et al, 2016 [4]) and prospective studies (by Schmidt reasonable that we use driving pressure as a safety et al, 2019; LIFEGUARDS [5]), where an average limit for applied TVs [3]. TV of 3 – 4 ml/kg PBW was used during the ECMO Application of optimal PEEP is important for treatment. Besides, in a recent pilot study (i.e., SU- treatment of ARDS (i.e., open lung strategy). Al- PERNOVA study), extracorporeal carbondioxide though there are some concerns about high PEEP removal (ECCO2R) was also used to treat patients levels (e.g., alveolar overdistention, decreased ve- with moderate ARDS, with some promising results nous return, and right ventricular failure) , it should

[6]. However, more data are needed for ECCO2R to be sufficiently high in pateints on ECMO for whom

96 KSCCM·ACCC 2020 Sunghoon Park ■ Mechanical Ventilation on Venovenous ECMO: The Current Practice and Adjunctive Treatments a very low TV of < 4 ml/kg is applied to decrease some limitations in the study. When considering atelectasis and tidal recruitment, which can lead to the importance of patient-ventilator synchrony to July 31 (Fri) ventilator induced lung injury (VILI) [8-10]. prevent VILI and SILI, there still seems to be a room Since about 5 years ago, experts have payed atten- for NMB agents for the treatment of patients with tion to ‘mechanical power’, an energy transferred ARDS [14,15]. from mechanical ventilator to the patient, in the Lastly, prone positioning is an important way progress of VILI. There are severe formulas to cal- to overcome refractory hypoxemia [16]. In some culate the mechanical power but Gattinoni et al. ECMO centers, prone positiong is also applied in demonstrated that driving pressure, tidal volume patients receiving ECMO. Although there are some and respiratory rate can increase mechanical pow- concerns about complications during proning, a er [11]. In patients with ARDS, due to non-aerated recently review article demonstrated that the oc- and consolidated areas, the lung surface that can currence of cannula dislodgement was very rare receive the mecahnical power is insufficient and so [17]. Especially, it should be noted that in the EO- it can aggravate VILI [12]. Besieds, lung compliance, LIA study where survival benefit of ECMO was not as a severity marker of ARDS, can be used to predict demonstrated, prone positioning was performed in outcomes in ARDS patients on ECMO. From the 60% of the ECMO group (vs. 90% in the convention- Korean registry data on patients with venovenous al group) [18]. Beside, a French group recently pub- ECMO, we found that higher lung compliance, lished data on their experience on prone positiong wheter before or during ECMO, may be an import- in patietns receiving ECMO, and showed a higher ant predictor of patient’s outcome [13], and in the survival in the proning ECMO group compared to recent LIFEGUARDS study, patients with a high TV the ECMO-only group [19]. Therefore, in the future, and low driving pressure were associated with im- further randomized controlled trial is needed to proved survival [5]. clarify the effect of prone positioning in patients re- However, as well as VILI, physicians should be ceiving ECMO. aware of the downside of self respiration in patients with severe lung injury [9,14]. In those patients, due References to aggravating gas exchange and lung edema, their 1. Acute Respiratory Distress Syndrome N, Brower inpsiraory drive (and respiratory rates) frequently RG, Matthay MA, Morris A, Schoenfeld D, Thomp- increases, and subsequently, transpulmonary driv- son BT, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for ing pressures increase and pendelluft phenomenon acute lung injury and the acute respiratory distress can occur. Hence, lung injury can be aggravated syndrome. N Engl J Med 2000;342:1301-8. by self respiration (i.e., self-inflicted lung injury, 2. Frank JA, Gutierrez JA, Jones KD, Allen L, Dobbs L, SILI) [9]. In this context, neuromuscular blocking Matthay MA. Low tidal volume reduces epithelial (NMB) agents in the early peroid of ARDS can be and endothelial injury in acid-injured rat lungs. Am J Respir Crit Care Med 2002;165:242-9. helpful. Although the recent ROSE trial demon- 3. Retamal J, Libuy J, Jimenez M, Delgado M, Besa C, strated no difference between patients who re- Bugedo G, et al. Preliminary study of ventilation ceived NMB agents and those who didn’t, there are with 4 ml/kg tidal volume in acute respiratory

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 97 Sunghoon Park ■ Mechanical Ventilation on Venovenous ECMO: The Current Practice and Adjunctive Treatments

distress syndrome: feasibility and effects on cyclic management during extracorporeal membrane ox- recruitment - derecruitment and hyperinflation. ygenation for acute respiratory distress syndrome: Crit Care 2013;17:R16. a retrospective international multicenter study. 4. Serpa Neto A, Schmidt M, Azevedo LC, Bein T, Crit Care Med 2015;43:654-64. Brochard L, Beutel G, et al. Associations between 11. Gattinoni L, Tonetti T, Cressoni M, Cadringher P, ventilator settings during extracorporeal mem- Herrmann P, Moerer O, et al. Ventilator-related brane oxygenation for refractory hypoxemia and causes of lung injury: the mechanical power. In- outcome in patients with acute respiratory distress tensive Care Med 2016;42:1567-75. syndrome: a pooled individual patient data analy- 12. Silva PL, Ball L, Rocco PRM, Pelosi P. Power to sis : Mechanical ventilation during ECMO. Inten- mechanical power to minimize ventilator-induced sive Care Med 2016;42:1672-84. lung injury? Intensive Care Med Exp 2019;7:38. 5. Schmidt M, Pham T, Arcadipane A, Agerstrand C, 13. Kim HS, Kim JH, Chung CR, Hong SB, Cho WH, Ohshimo S, Pellegrino V, et al. Mechanical Venti- Cho YJ, et al. Lung Compliance and Outcomes in lation Management during ECMO for ARDS: An Patients With Acute Respiratory Distress Syndrome International Multicenter Prospective Cohort. Receiving ECMO. Ann Thorac Surg 2019;108:176- Am J Respir Crit Care Med 2019. http://dx.doi. 82. org/10.1164/rccm.201806-1094OC. 14. Park S, Schmidt M. Early neuromuscular blockade 6. Combes A, Fanelli V, Pham T, Ranieri VM, Europe- in moderate to severe acute respiratory distress an Society of Intensive Care Medicine Trials G, the syndrome: do not throw the baby out with the “Strategy of Ultra-Protective lung ventilation with bathwater! J Thorac Dis 2019;11:E231-e4. Extracorporeal CORfN-OmtsAi. Feasibility and 15. Slutsky AS. Neuromuscular blocking agents in safety of extracorporeal CO2 removal to enhance ARDS. N Engl J Med 2010;363:1176-80. protective ventilation in acute respiratory distress 16. Guerin C, Reignier J, Richard JC, Beuret P, Gacou- syndrome: the SUPERNOVA study. Intensive Care in A, Boulain T, et al. Prone positioning in severe Med 2019;45:592-600. acute respiratory distress syndrome. N Engl J Med 7. Amato MB, Meade MO, Slutsky AS, Brochard L, 2013;368:2159-68. Costa EL, Schoenfeld DA, et al. Driving pressure 17. Culbreth RE, Goodfellow LT. Complications of and survival in the acute respiratory distress syn- Prone Positioning During Extracorporeal Mem- drome. N Engl J Med 2015;372:747-55. brane Oxygenation for Respiratory Failure: A Sys- 8. Nielsen ND, Kjaergaard B, Koefoed-Nielsen J, tematic Review. Respir Care 2016;61:249-54. Steensen CO, Larsson A. Apneic oxygenation com- 18. Combes A, Hajage D, Capellier G, Demoule A, bined with extracorporeal arteriovenous carbon Lavoue S, Guervilly C, et al. Extracorporeal Mem- dioxide removal provides sufficient gas exchange brane Oxygenation for Severe Acute Respiratory in experimental lung injury. ASAIO J 2008;54:401- Distress Syndrome. N Engl J Med 2018;378:1965- 5. 75. 9. Yoshida T, Torsani V, Gomes S, De Santis RR, Beral- 19. Guervilly C, Prud’homme E, Pauly V, Bourenne J, do MA, Costa EL, et al. Spontaneous effort causes Hraiech S, Daviet F, et al. Prone positioning and occult pendelluft during mechanical ventilation. extracorporeal membrane oxygenation for severe Am J Respir Crit Care Med 2013;188:1420-7. acute respiratory distress syndrome: time for a ran- 10. Schmidt M, Stewart C, Bailey M, Nieszkowska A, domized trial? Intensive Care Med 2019;45:1040-2. Kelly J, Murphy L, et al. Mechanical ventilation

98 KSCCM·ACCC 2020 Elliott Haut ■ VTE Prevention

Coagulation and Thrombosis July 31 (Fri) VTE Prevention

Elliott Haut

The Johns Hopkins School of Medicine, USA

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 99 Won-Il Choi ■ A Scenario-based Approach to Thrombocytopenia in ICU

Coagulation and Thrombosis

A Scenario-based Approach to Thrombocytopenia in ICU

Won-Il Choi

Department of Internal Medicine, Myongji Hospital, Korea

Thrombocytopenia is often encountered in the to the intensive care unit due to fever, chills and intensive care unit. If less than 150,000 per microli- reduced blood pressure. As a multiple myeloma, ter of blood, it is defined as thrombocytopenia, and he received chemotherapy (bortezomib and dexa- if it is less than 50,000, it is classified as severe. In methasone) 2 days before visit. After receiving che- the intensive care unit, 35-45% of patients experi- motherapy, the patient fell on his way to home and ence thrombocytopenia, and 5-20% develop severe wounded his right arm. At the time of admission, thrombocytopenia. In general, there are six mech- systemic inflammatory reaction was increased in anisms for platelet reduction. (1) pseudothrombo- the blood (C-reactive protein, 247.0mg/L [normal cytopenia, (2) hemodilution, (3) increased platelet value ≤5.0mg/L]; procalcitonin, 223ng/mL [0-0.5ng/ consumption, (4) reduced platelet production, (5) mL]); He had renal failure (creatinine 4.0 mg/dL). increased platelet sequestration, (6) immune-me- PT INR was 1.7; aPTT was 34 seconds, and the diated platelet destruction, etc. platelet count was reduced to 48 × 109/L. The causes and treatment of thrombocytopenia in the intensive care unit will be discussed through Scenario 3. An 18-year-old woman was admitted the following scenarios. with multiple trauma (subarachnoid hemorrhage, bilateral pneumothorax, pelvic fracture) and hem- Scenario 1. A 67-year-old male patient under- orrhagic shock due to falling on the fourth floor. went percutaneous coronary intervention as an There was severe anemia (Hb, 6.0 g/dL); PT INR is acute coronary syndrome. Several stents were 1.3; aPTT was 48 seconds. At the time of admission, inserted, including the left main coronary artery. the number of platelets was 299 × 109/L, which was Anticoagulation was started with unfractionated in the normal range. CT scans of the abdomen and heparin (UFH), and aspirin and clopidogrel were pelvis revealed peritoneal bleeding and rupture of prescribed. After 6 hours of stent insertion, plate- the pelvic vessels. Despite the transfusion of two let counts decreased from 270 × 109/L to 6 × 109/L. platelet concentrates as part of the mass transfusion There were no obvious bleeding sign or symptoms. protocol, platelet counts rapidly decreased to 51 × Scenario 2. A 64-year-old patient was admitted 109/L after 7 hours of hospitalization.

100 KSCCM·ACCC 2020 Won-Il Choi ■ A Scenario-based Approach to Thrombocytopenia in ICU

Scenario 4. A 75-year-old woman is undergoing cardial infarction. She was taking aspirin and clopi- mechanical ventilation due to stroke, right hemiple- dogrel. The patient was admitted to the intensive July 31 (Fri) gia, recurrent seizures, dysphagia, and pneumonia. care unit after a successful cardiac resuscitation at The patient was receiving multiple medications, the emergency department. The cause of cardiac including antibiotics, sedatives, aspirin, preventive arrest was being diagnosed with in-stent thrombo- doses of UFH, diuretics and anticonvulsants. On sis. It was managed by coronary angioplasty. Aspi- the 7th day of hospitalization, to control seizures, rin and clopidogrel were continued and therapeutic valproic acid was added to levetiracetam and lora- doses of unfractionated heparin (UFH) were start- zepam. On the 10th day of hospitalization, platelet ed. The patient had been developed cardiogenic counts began to drop below 50,000 per microliter. shock and multi-organ failure. The platelet count decreased from 326 × 109/L to 28 × 109/L on day 5 of Scenario 5. A 79-year-old woman was implanted intensive care unit treatment. with a coronary stent three weeks ago due to myo-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 101 Jeffrey Lipman ■ Therapeutic Antibiotic Monitoring of Beta-lactams

Infection

Therapeutic Antibiotic Monitoring of Beta-lactams

Jeffrey Lipman

Mayne Academy of Critical Care, The University of Queensland

To understand Therapeutic Drug Monitoring To me treating difficult patients with a beta-lactam (TDM) of any drug one needs to understand how and not measuring resultant concentrations is like the drug is handled within the body (Pharmacoki- treating diabetes without measuring blood sugars. netics - PK) and how the drug works on the body (Pharmacodynamics - PD). References TDM is used to monitor and prevent toxicity or to 1. Roberts JA et al , Ulldemolins M, Roberts MS, help with efficacy. Routine measurement facilities McWhinney B, Ungerer J, Paterson DL, Lipman J. (Immunoassays) were produced for vancomycin Therapeutic drug monitoring ofβ -lactams in criti- and aminoglycoses as there was a universal need cally ill patients: proof of concept. Int J Antimicrob to prevent toxicity of these agents. The large thera- Agents 2010;36:332-339. 2. Smith NL, Freebairn R, Park M, Roberts J, Wallis S, peutic index of beta-lactams produced little toxicity Lipman J. The need for therapeutic drug monitoring but nowadays it has been shown that under-dosing when using cefepime in CRRT: Seizures associated significant issue and hence TDM of beta-lactams with cefepime. Crit Care Resus 2012;14:312-315. has been used to help in optimizing efficacy of these 3. Wong G, Sime FB, Lipman J, Roberts JA. How do we use therapeutic drug monitoring to improve agents. TDM can also be used to prevent toxicity of outcomes from severe infections in critically ill pa- bet-lactams particularly of imipenem and cefepime. tients? BMC Infect Dis 2014 : 14 : 288. ICUs are treating older, sicker, obese patients. 4. Huttner A, Harbarth S, Hope W, Lipman J, Roberts Standard drug dosing strategies were not designed JA.Therapeutic drug monitoring of the beta-lac- for these patient populations tam antibiotics: What is the evidence and which patients should we be using it for? J Antimicrob ICU patients have different pharmacokinetic Chemother 2015;70:3178-3183. parameters to ward patients (Augmented renal 5. Roberts JA, Paul SK, Akova M, Bassetti M, De clearance, hypo-albuminaemia). We are interven- Waele JJ, Dimopoulos G, Kaukonen K-M, Koulenti ing more (CRRT, ECMO), often with differing drug D, Martin C, Montravers P, Rello J, Rhodes A, Starr clearance phenomena. T, Wallis SC, Lipman J. DALI: Defining Antibiotic Levels in Intensive care unit patients: Are current One size doesn’t fit all, noting obesity becoming a beta-lactam antibiotic doses sufficient for critically “bigger” issue ill patients? Clin Infect Dis 2014;58:1072-1083.

102 KSCCM·ACCC 2020 Moritoki Egi ■ The Antipyretic in Febrile Critically Ill Patients. HOT or COOL

Infection July 31 (Fri) The Antipyretic in Febrile Critically Ill Patients. HOT or COOL

Moritoki Egi

Kobe University Hosp.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 103

KSCCM·ACCC 2020 The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020

August 1(Sat), 2020 (Day 2)

Live Streaming

■ General Assembly & Award Ceremony

Room 1

■ Intensive Care Management for COVID-19 Patients ■ War against COVID-19 ■ How Will COVID-19 Change the World? ■ Specialized Rapid Response Systems ■ Satellite Symposium III

Room 2

■ Challenging Cases: Diagnostic Reasoning and Avoiding Errors in Acutely Ill Patients ■ Critical Care Nursing: Daring to Find Joy and Meaning at Work ■ Summary of Recent Major RCTs ■ General Critical Care Update ■ Satellite Symposium IV

Room 3

■ Pediatric Critical Care: Solid Organ Transplantation in Children ■ Critical Care Ethics ■ Extracorporeal Life Support ■ Cardiopulmonary Resuscitation 2020 Room 4

■ Clinical Trials and International Collaboration

■ Trauma ■ Current Battlegrounds in Sepsis ■ Recovering from Critical Illness: Patients and Intensivists

Room 5

■ Hepatic Dysfunction ■ Nutrition ■ Research and Ethics Symposium ■ Fluid Therapy ■ ARDS

Room 6

■ Oral ICU General 3 ■ Oral ICU General 2 ■ Oral RRT ■ Oral Pulmo 2

Room 7

■ Oral EM/CPR ■ Oral Quality 2 ■ Oral Quality 1 ■ Oral Nursing

Room 8

■ Oral ICU General 4 ■ Oral Pulmo 1 ■ Oral PED Kyeongman Jeon ■ Korean Guideline on Management of Critically Ill Adults with COVID-19

Intensive Care Management for COVID-19 Patients

Korean Guideline on Management of Critically Ill Adults with COVID-19

Kyeongman Jeon

Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea August 1 (Sat)

Since the 2019 novel coronavirus disease guidelines of COIVD-19, as part of the Pan-ac- (COVID-19) outbreak originated from Wuhan, ademic Task Force, from the Korean Society of Hubei Province, China, at the end of 2019, it has Critical Care Medicine and the Korean Academy of become a clinical threat to the general population Tuberculosis and Respiratory Disease, and released worldwide. However, there is little empirical evi- first on Feb 23. Based on feedbacks from clinicians dence to guide management of COVID‐19, espe- taking care of patients with COVID‐19 and addi- cially in critically ill patients. tional information on severe COVID-19 from China, The first COVID-19 case in Korea was identified the guideline was revised on Mar 1. Unfortunate- on Feb 19, but clinical and epidemiological features ly, however, there were no further updates as the of COVID-19 was not well known at the time. After Pan-academic Task Force stopped working. experiencing the 2015 outbreak of Middle East re- The suggestions were based upon scarce direct spiratory syndrome (MERS) in Korea, the Korean evidence, indirect evidence, and clinical observa- government and medical communities were well tions. The most important part was to clarify the aware of the importance of preparing for new in- criteria for early detection of critically ill patients fectious disease. Although the spread of COVID-19 and admission to intensive care units, and to make was limited before Feb 20, the Pan-academic Task recommendations for the efficient use of limited Force of medical academic societies was developed medical resources. Finally, recommendations that to guide management of COVID-19 in Korea. could be applied to actual care based on the latest The Korean guideline on the management of findings and evidence-based medicine, such as critically ill patients with COVID-19 was drafted by management of hypoxemic respiratory failure and members of the working committee for practice acute respiratory distress syndrome, and sepsis.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 107 Jae Seok Park ■ Clinical Features and Short-term Outcomes of Critically Ill Patients with COVID-19: A Report of Single COVID-19 Designated Hospital’s Intensive Care Unit in Daegu

Intensive Care Management for COVID-19 Patients

Clinical Features and Short-term Outcomes of Critically Ill Patients with COVID-19: A Report of Single COVID-19 Designated Hospital’s Intensive Care Unit in Daegu

Jae Seok Park

Division of Pulmonology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea

On February 18, 2020, South Korea confirmed its 31st care unit (ICU) beds expanded to 20 beds in this case in Daegu, a member of Shinchenji religious orga- critical care collaboration period. nization. After then, there was an explosive increase From February 21 to April 20, 730 COVID-19 in the number of Coronavirus Disease-19 (COVID-19) patients hospitalized in Daegu Dongsan hospital. patients in late February which made Daegu, the Among these, 149 (20.4%) patients required oxygen center of the outbreak in Korea.[1] Hospitals in Dae- and 35 (4.8%) patients needed ICU treatment. Four- gu, there could not handle the surging number of teen (40%) of them applied mechanical ventilation Covid-19 patients with existing hospital beds alone. and three patients received ECMO treatment. Elev- Keimyung University Dongsan Medical Center en (31.4%) patients were died in the ICU. emptied its branch hospital, Daegu Dongsan Hos- pital, for Covid-19 designated hospital to treating References COVID-19 patients with cohort isolation on 21 Feb- 1. Korea Centers For Disease Control & Preven- ruary. Daegu Dongsan Hospital is a secondary gen- tion. The updates on COVID-19 in Korea as of 17 eral hospital with 200 hospital beds, located where April. [updated 2020]. Available at: https://www. Keimyung University Dongsan Hospital used to cdc.go.kr/board/board.es?mid= a20501000000 be. By February 29, the daily new patient count in &bid=0015&list_no=366942&act=view. Accessed Daegu had reached 741 and thousands waited for 18 April 2020. 2. SW kim, KS LEE, K Kim, et al. A Brief Telephone hospital beds as cases surged. Three patients died Severity Scoring System and Therapeutic Living at home during waiting for hospitalization on Feb- Centers Solved Acute Hospital-Bed Shortage ruary 27, 28, and March 1.[2] Following the rapid during the COVID-19 Outbreak in Daegu, Korea. J increased in the number of critically ill patients, the Korean Med Sci. 2020 Apr 20;35(15):e152 Korean Society of Critical Care Medicine (KSCCM) 3. JH Kim, SK Hong, YH Kim, et al. Experience of augmenting critical care capacity in Daegu during decided to recruit volunteers and dispatched in- COVID-19 incident in South Korea. Acute and Crit- tensive care team to Daegu Dongsan hospital from ical Care. 2020 May 35(2):110-114 March 10 to April 19. [3] The number of intensive

108 KSCCM·ACCC 2020 Jae-Bum Kim ■ Venous Thromboembolism in COVID-19 Patients

Intensive Care Management for COVID-19 Patients

Venous Thromboembolism in COVID-19 Patients

Jae-Bum Kim

Thoracic and Cardiovascular surgery, Keimyung University Dongsan medical center, Daegu, Korea August 1 (Sat)

A novel coronavirus was identified in late 2019 syndrome (MERS-CoV)[3–6] . COVID-19 is associat- that rapidly reached pandemic proportions. The ed with marked abnormalities in markers of hyper- World Health Organization has designated the dis- coagulability, including elevated levels of D-dimer, ease caused by the virus (severe acute respiratory fibrinogen, and factor VIII, a shortened activated syndrome coronavirus 2 [SARS-CoV-2]) as corona- partial thromboplastin time (aPTT) and an elevated virus disease 2019 (COVID-19)[1,2]. Cardiovascular sepsis induced coagulopathy (SIC) score[7] . Investi- disease and, in particular, venous thromboembo- gational therapies for the management of severely ill lism (VTE) has emerged as an important consider- COVID-19 patients may carry an increased risk for ation in the management of hospitalized patients VTE or have implications for drug interactions with with COVID-19. Interim guidance has been pub- established agents used for the acute and chronic lished by the International Society on Thrombosis management of VTE, such as the direct oral antico- and Haemostasis (ISTH), and frequently asked agulants (DOACs) and Vitamin K antagonists such questions are posted on the websites of the Ameri- as warfarin. Hospitalized COVID-19 patients share can Society of Hematology (ASH) and the American similar strong clinical intrinsic and extrinsic risk College of Cardiology (ACC). The diagnosis of VTE factors for VTE, which include advanced age, obe- using standardized objective testing is problematic sity, immobility/stroke with paralysis, a history of in these patients, given the risk of infecting non- cancer/active cancer, management in an intensive COVID-19 hospitalized patients and hospital per- care unit (ICU)/coronary care unit (CCU) setting, a sonnel, coupled with the usual challenges of per- prior history of VTE or known thrombophilia, that forming diagnostic testing in critically-ill patients. are present in hospitalized medically ill patients[7,8] Early reports suggest a high incidence of VTE in . However, risk stratification for VTE and the opti- hospitalized COVID-19 patients, particularly those mal intensity and duration of anticoagulant throm- with severe illness, that is similar to the high VTE boprophylaxis, including post-hospital discharge rates observed in patients with other viral pneumo- prophylaxis, remains uncertain in hospitalized nias, including severe acute respiratory COVID-19 patients. Syndrome (SARS) and Middle East respiratory

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 109 Jae-Bum Kim ■ Venous Thromboembolism in COVID-19 Patients

References JTH 2020. https://doi.org/10.1111/jth.14830. 5. Obi AT, Tignanelli CJ, Jacobs BN, Arya S, Park PK, 1. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Wakefield TW, et al. Empirical systemic anticoagu- Clinical features of patients infected with 2019 lation is associated with decreased venous throm- novel coronavirus in Wuhan, China. Lancet Lond boembolism in critically ill influenza A H1N1 acute Engl 2020;395:497–506. https://doi.org/10.1016/ respiratory distress syndrome patients. J Vasc Surg S0140-6736(20)30183-5. Venous Lymphat Disord 2019;7:317–24. https:// 2. Novel Coronavirus (2019-nCoV) situation reports doi.org/10.1016/j.jvsv.2018.08.010. n.d. https://www.who.int/emergencies/diseases/ 6. Giannis D, Ziogas IA, Gianni P. Coagulation disor- novel-coronavirus-2019/situation-reports (ac- ders in coronavirus infected patients: COVID19, cessed March 17, 2020). SARS-CoV-1, MERS-CoV and lessons from the past. 3. Klok FA, Kruip MJHA, van der Meer NJM, Ar- J Clin Virol 2020:104362. https://doi.org/10.1016/ bous MS, Gommers DAMPJ, Kant KM, et al. In- j.jcv.2020.104362. cidence of thrombotic complications in critically 7. Driggin E, Madhavan MV, Bikdeli B, Chuich T, ill ICU patients with COVID-19. Thromb Res Laracy J, Bondi-Zoccai G, et al. Cardiovascular 2020:S0049384820301201. https://doi.org/10.1016/ Considerations for Patients, Health Care Workers, j.thromres.2020.04.013. and Health Systems During the Coronavirus Dis- 4. Cui S, Chen S, Li X, Liu S, Wang F. Prevalence of ease 2019 (COVID-19) Pandemic. J Am Coll Cardiol venous thromboembolism in patients with severe 2020:S0735109720346374. https://doi.org/10.1016/ novel coronavirus pneumonia. J Thromb Haemost j.jacc.2020.03.031.

110 KSCCM·ACCC 2020 Jin Yong Kim ■ COVID-19 Surveillance System in Communities and Medical Institutions

War against COVID-19

COVID-19 Surveillance System in Communities and Medical Institutions

Jin Yong Kim

Incheon Medical Center, Korea August 1 (Sat)

The most effective method to counter the pan- toring system that responds to pandemic and how demic of COVID-19 known to date is rapid diagno- to prepare for it in the future. sis and isolation of patients, and tracking of contact differences. However, a larger picture is needed to References respond to the pandemic, and a surveillance system 1. WHO, Operational considerations for COVID-19 that can see the progress of the future is essential. surveillance using GISRS, Interim guidance, 26 Surveillance systems include lab-based virologic, March 2020. syndromic, and notifiable disease surveillance, and 2. WHO, Surveillance strategies for COVID-19 human mortality data, point-prevalence survey, and sero- infection, Interim guidance, 10 May 2020. 3. CIDRAP, COVID-19: The CIDRAP Viewpoint, July 9, surveillance. 2020, Part 5: SARS-CoV-2 infection and COVID-19 In this lecture, we will look at what kind of moni- surveillance: a national framework.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 111 Hyun-Soo Chung ■ Disaster Planning during a COVID-19 Outbreak

War against COVID-19

Disaster Planning during a COVID-19 Outbreak

Hyun-Soo Chung

Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea

COVID-19 has developed into a pandemic world- and emergency department, since theses are the wide, overwhelming the healthcare system. Pan- areas where critical patients are being taken care of. demic, not like other disaster situations, gives the Expansion and preparation of space will consist of healthcare system and hospitals great challenge. critical care beyond the intensive care unit. As for Not only does the hospital have to cope with the staffing, maintaining service capabilities and pro- illness of the patient, the hospitals also need to tecting healthcare workers are utmost important, protect the healthcare staffs from contamination, and education with re-training system needs to be as well as protecting the spread of infection to the established. Supplies could be the main problem in community. The hospital has the challenge of pro- developing the expansion plan. Protective equip- viding optimal care to the four group of patients: the ment for the providers, as well as life-supporting “suspected” but stable, the “suspected” but unsta- supplies could be overwhelmed in a short period of ble, “non-suspected” and stable, “non-suspected” time. Despite of the chaos situation, it is important and unstable. They will have to share the resources that we do not forget to ensure quality clinical care to all 4 group of patients, and therefore, careful to the patients. Standards need to be updated and planning to manage this surge is important. The communicated to the providers. This presentation 4 surges that need to be planned are space, staff, will be dealing with the principles, strategies, and supplies, and standards. The planned response is future implications of the 4S (space, staff, supplies, a continuum and will vary based on the scale and standards) of surge capacity during the pandemic severity of the event. The surge capacity will be situation. talked about focusing on the intensive care unit

112 KSCCM·ACCC 2020 Jae-Hoon Ko ■ Where We're at with Vaccines and Treatments for COVID-19

War against COVID-19

Where We're at with Vaccines and Treatments for COVID-19

Jae-Hoon Ko

Division of Infectious Disease, Department of Medicine, Samsung Medical Center August 1 (Sat)

Since the declaration of coronavirus disease 2019 have also been tried. To date, many clinical studies (COVID-19) pandemic, global spread of COVID-19 have been published for the re-purposing drugs has not been diminished. From January 2020, when and anti-inflammatory agents, though data are the COVID-19 outbreak was limited to the main still not solidly conclusive. In addition, as targeted land China and several neighboring countries, agent for SARS-CoV-2 has not been developed yet, many re-purposing drugs such as hydroxychlo- vaccine is another important means to cope with roquine, lopinavir/ritonavir, and remdesivir have the current COVID-19 pandemic. Many companies been focused and clinically tried, based on in-vitro are concentrated on the vaccine development and data and clinical experiences from SARS-CoV and/ some are under clinical trials. In the present lec- or MERS-CoV outbreaks. To abate inflammatory ture, current evidences for the treatment of SARS- reactions occurred by the SARS-CoV-2 infection, CoV-2 infection and status of vaccine development several anti-inflammatory agents including sys- are reviewed. temic steroid, inhaled steroid, and biologic agents

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 113 Younsuck Koh ■ Ethics and Resource Allocation for Pandemic Infectious Diseases

How Will COVID-19 Change the World?

Ethics and Resource Allocation for Pandemic Infectious Diseases

Younsuck Koh

Asan Medical Center, University of Ulsan College of Medicine

When hospitals are overwhelmed by a sharp in- sions frequently changes from respecting patients’ crease of pandemic infectious disease in its region, autonomy to justice of medical services. Allocation caregivers will be faced with difficult situation of of limited medical resources and triage of patients having to make ethically challenging decisions must be carried out despite the medical service al- in patients’ triage, allocation of limited medical ready being overwhelmed. Healthcare profession- resources, determining level of cares and many als are also asked to fulfill their duty for patients’ others. Moreover, caregivers have to deal with emo- care while worrying about their own exposure to tionally overwhelmed patients and family members infection. Healthcare institutions should ethically to get informed consent and/or to discuss end-of- address conflict of interests that could occur in pa- life cares in a very strenuous short amount of time. tients’ care and local community leaders must not There is no ethical one-size-fits-all approach for forgo their duty to support healthcare services. pandemic infectious disease – more so if the re- Preemptive preparation and protocolization of gion is ill equipped to handle emergency situations relevant ethical and public issues based on public brought on by disasters. Dominant framework of agreement is necessary to attain the goal of best for ethical principles includes autonomy, beneficence, the most based on fair allocation of resources. Con- non-maleficence, and justice. Another ethical sideration should also be made to the moral distress principle suggests clinicians to consider medical healthcare providers face while fighting the pan- indication, patient’s preference, quality of life, and demic infectious diseases. Last but not least, timely relevant context when making a medical decision. drills and revision of prepared protocols through Ethical analysis is needed depending on the en- consultation among healthcare professionals and countered situation based on patients’ best interest. related government authorities are also important. When faced with a disaster, priority in care deci-

114 KSCCM·ACCC 2020 Jihoon Jeong ■ A Guide for the 'New Normal' after COVID-19

How Will COVID-19 Change the World?

A Guide for the 'New Normal' after COVID-19

Jihoon Jeong

Partner, Digital Healthcare Partners, Seoul, Republic of Korea August 1 (Sat)

COVID-19 pandemic is changing the world. 20 percent in all states in the United States before Many believe the change will not only be a short- March 2020, but the rate began to increase from term change, but a “new normal” that will become Washington State in the first week of March to Cal- a fundamental change. Stephen Walt wrote in a ifornia and New York State, and in the last week of contribution to the Foreign Policy that the world March, it was more than 50 percent in the majority would be less open, less prosperous and less free. of states in the United States. The pattern and order There is also a huge change in industry, especially of propagation are exactly the same as the order in aviation industry, the number of seats dropped in which COVID-19 is propagated, which means sharply from more than 100 million seats a week in that COVID-19 has a decisive effect. While most January 2020 to barely over 30 million seats in April indicators point to stagnation, some are soaring [1]. People’s lifestyles are also changing greatly. along with COVID-19. Zoom, which is said to be the Public transportation such as subways and buses is fastest growing service in Silicon Valley history, has not as congested as in the past to live in isolation or seen its index grow 20 times in March 2020 com- social distancing, while the number of people using pared to December 2019, and services such as Goo- personal mobility such as bicycles and kickboards gle’s classroom and doordash, which deliver food, has increased significantly. As the number of hours are also growing more than several times. spent living at home has increased significantly, COVID-19 is also changing health care signifi- various consumption is on the rise because they cantly. The biggest change is that telemedicine is work and do leisure activities at home. According becoming a trend. Many telemedicine platforms to the Box data insight analysis, there is also a big have grown significantly in the Asian market as change in the time people work. Compared to 2019, well as platforms such as Teladoc, which are ser- the peak of the working hours in 2020 is lower, and viced in North America. According to similar web the low point is higher, meaning that people’s work- data, which can measure the popularity of mobile ing hours will be flattened to the full 24 hours [2]. apps, telemedicine apps such as Doctor Anywhere, The percentage of people who answered that the MyDoc, Halodoc, Alodokter, and HotDoc have main place to work was home was also less than grown significantly compared to the previous year

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 115 Jihoon Jeong ■ A Guide for the 'New Normal' after COVID-19 in medical-related apps in Asian countries [3]. In for fostering public health objectives. Telemedicine Korea, telemedicine is temporarily allowed with can improve access to healthcare and the quality of COVID-19, which is gaining huge popularity as Me- patient outcomes, allowing patients in remote areas diHere and others. Driving forces of the rise of tele- with urgent care needs to see physicians rapidly. It medicine are followings. Firstly, Patient acceptance also takes advantage of new services and data eco- is the most important factor. Pandemic make vir- systems in healthcare policy decisions. tual visits on telemedicine platforms have become Then, what will happen to the future of the med- the safe and convenient solution. Patients were icine in “new normal” era? Mobile health using able to gain access to medical advice and treatment smartphones will be more active than now. Smart- without any risk of contracting the virus. Secondly, phones have unparalleled advantages in terms of government has more favorable attitude than be- accessibility and affordability over other digital fore. Pandemic cleared the benefits of digital health medical devices. The importance of technology to platforms in many countries. Some Governments integrate EHR and personal data into analysis and quickly made digital health platforms available management will increase. Through this, it will inte- to the general public. Lastly, Insurers also started grate data held by hospitals and activity indicators accept and reimburse the telemedicine solutions. of individuals to make judgments that suit to each Many insurers quickly added telemedicine services person. The importance of AI technology will also to standard policies and multiple insurers across increase. When telemedicine is performed, it will the region now have set up special partnerships play a role of supporting the medical doctors, and with telemedicine platforms to sponsor free consul- a wide variety of AI will be encountered during the tations. In order for this change to continue and be- diagnosis, treatment, monitor and management. come “new normal”, it will be necessary to satisfy the In order for digital healthcare to take another leap following needs of many stakeholders. For health- forward, the development and distribution of home care service providers, they should serve patients healthcare medical devices that can be used at more effectively. For this goal, telemedicine solution home will also be expanded. Through this, the lev- should integrate offline and online care together to el of care that utilizes telemedicine, AI, and home deliver better patient experiences and lower the cost healthcare devices will greatly increase. of care. Many providers will use telemedicine for add-on services such as drug delivery, appointment References scheduling, electronic records management and 1. Blue Swan Daily and OAG Data on May 19, 2020 ongoing monitoring of conditions. For payers, they accessible at https://bit.ly/3ekSN7I will request improve plans and performance with 2. Box Data Insight, Work Unleashed - Where, When, telemedicine and digital healthcare solutions. They and How We Work is Changing, accessible at need to develop partnerships with digital insurgents https://blog.box.com/work-unleashed-where- when-and-how-we-work-changing to create differentiated healthcare plans, while 3. Top Free Medical Apps (major Asian countries), lowering cost of care and harness patient data and assessed in July 10th 2020, accessible at https:// analytics to improve pricing and claims manage- www.similarweb.com/ ment. For regulators, they need to make evidence

116 KSCCM·ACCC 2020 Seungho Jung ■ Difficult Airway Response Team (DART)

Specialized Rapid Response Systems

Difficult Airway Response Team (DART)

Seungho Jung

Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine August 1 (Sat)

Airway management of the critically ill patients in order to minimize the number of attempts and is very challenging and difficult airway issue can risk of transmission. They also suggest using vid- be a life-threatening problem in those patients. eo-guided laryngoscopy [4]. Endotracheal intuba- Unfortunately, emergent and unexpected airway tion to COVID-19 patients is usually performed in a management outside the operating room is often negative pressure room and protective equipment more difficlut and at risk. This can be caused by not is needed to prevent transmission. They can limit only patient’s factor such as inappropriate position, the movement of medical staff and delay imme- underlying severe hypoxemia, lack of starving time, diate additional support from other staff. Airway inability of preoxygenation process but also by the management is also an aerosol-generating proce- factors of medical staff such as disorganized team dure and often need close contact of procedure and work process, unaccustomed equipment and lack patients. To minimize the number of the total med- of experience in airway management. Such difficul- ical staff involved in this situation may be helpful to ties can lead to serious complications –aspiration, prevent transmission [5]. Hence, it can be helpful severe hypoxemia, hypotension, hypoxic brain for the safety of both patients and medical staff to damage, and even cardiac arrest- while establishing maximize the chances of first pass success in short airway and have a harmful effect on the patient’s time with minimal member but best performancing prognosis [1-3]. Therefore, well organized and team. This can result in increasing the need for es- trained medical team with high quality skills and tablishing the organized team specialized in airway equipments for airway management can provide management. higher level of safety to the critically ill patients. Emergent airway management is very stressful Recently, Coronavirus Disease 2019 (COVID-19) situation for even well trained and experienced has become pandemic and worldwide medical clinician. This can lead to a basic critical medi- issue. In Surviving Sepsis Campaign guideline for cal error not by lack of experience or proper skill. COVID-19, they recommend that endotracheal in- Many of airway management guidelines are for the tubation be performed by the health-care worker preparation for difficult airway and they are diffi- who is most experienced with airway management cult to be applied in real time clinical situation. In

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 117 Seungho Jung ■ Difficult Airway Response Team (DART) addition, most of them are predominantly directed References at anesthesiologists. The Vortex approach, intro- 1. Walz JM, Zayaruzny M, Heard SO. Airway man- duced by Chrimes N., is designed to be used during agement in critical illness. Chest 2007;131:608-20. real time, highly challenging and urgent situation. 2. Cook TM, Woodall N, Harper J, Benger J. Major Noninvasive airway techniques, such as face mask complications of airway management in the UK: ventilation, placement of supraglottic airway (SGA), results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult or endotracheal tube can be attempted to deliver Airway Society. Part 2: intensive care and emer- oxygen to lung. Each lifelines can be attempted by gency departments. Br J Anaesth 2011;106:632-42. up to 3 times and at least one attempt should be by 3. Frerk C, Mitchell VS, McNarry AF, Mendonca C, most experienced clinician. If all three linelines are Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unantici- unsuccessful, CICO(can’t intubate, can’t oxygenate) pated difficult intubation in adults. Br J Anaesth rescue should be initiated by standardized surgical 2015;115:827-48. technique. The Vortex can be used as simple, suit- 4. Alhazzani W, Møller MH, Arabi YM, Loeb M, able approach in real world process during airway Gong MN, Fan E, et al. Surviving Sepsis Campaign: emergencies to support airway managing team guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). function in real time [6]. Intensive Care Med 2020;46:854-87. There can be some barriers to making special- 5. Tran K, Cimon K, Severn M, Pessoa-Silva CL, ized airway management team. One of them is Conly J. Aerosol generating procedures and risk the considerable cost required for developing and of transmission of acute respiratory infections to maintaining the team and the facilities. To clarify healthcare workers: a systematic review. PLoS One 2012;7:e35797. the responsibilities between team members and 6. Chrimes N. The Vortex: a universal ‘high-acuity attending physicians can be an another issue. Burn implementation tool’ for emergency airway man- out problem of the medical staff in airway manag- agement. Br J Anaesth 2016;117 Suppl 1:i20-i7. ing team also can be an important matter. These 7. Mark L, Lester L, Cover R, Herzer K. A Decade of Difficult Airway Response Team: Lessons Learned problems should be kept in mind and necessary to from a Hospital-Wide Difficult Airway Response be prepared before implementing difficult airway Team Program. Crit Care Clin 2018;34:239-51. management program [7-8]. 8. Seys D, Wu AW, Gerven EV, Vleugels A, Euwema M, Panella M, et al. Health Care Professionals as Second Victims after Adverse Events: A System- atic Review. Evaluation & the Health Professions 2012;36:135-62.

118 KSCCM·ACCC 2020 Sang-Beom Jeon ■ Neurologic Alert Team

Specialized Rapid Response Systems

Neurologic Alert Team

Sang-Beom Jeon

Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Republic of Koera August 1 (Sat)

Hospitalized patients are at potential risk of ex- procedures, surgeries, and initiation or cessation periencing serious adverse events unrelated to the of medications. Therefore, early detection and presenting medical condition. To manage in-hos- management of neurological symptoms are of pital medical emergencies, an increasing number paramount importance. Paradoxically, however, of hospitals has adopted specialized rapid response multiple studies reported that care delivery may team; the rapid response teams have shown use- be slower in hospitalized patients with in-hospi- fulness in early detection and management of tal neurological emergencies than in those with deteriorating patient conditions, thereby resulting community-onset neurological symptoms. The oc- in decreased rates of intrahospital transfer to inten- currence of acute neurological symptoms or signs sive care units (ICUs), unexpected cardiac arrest, during hospital admission are associated with high and death. To date, however, rapid response team rate of mortality and ICU transfer, longer length of approaches designated for specifically managing hospital stay, recurrence of neurological symptoms, acute neurological symptoms have not been high- and poor functional status. Especially, substantial lighted. time delays ensue in the evaluation and manage- Occurrence of acute neurological symptoms en- ment of ICU-onset stroke. tails abrupt brain damage and subsequent deteri- We established the Neurological Alert Team (NAT) oration. In ischemic stroke patients with untreated to manage patients who developed acute neuro- large cerebral artery occlusion, approximately 1.9 logical symptoms during hospital stay and to solve million neurons are lost every minute. In patients problems underlying the conventional system for with prolonged seizure activity, permanent neu- consulting neurologists. This hospital-wide NAT ronal injury and pharmacoresistance may occur activity was chosen for the Performance Improve- unless the seizure is treated in a timely manner. ment Project 2017 of the Asan Medical Center and Multiple types of brain disorders can cause sud- was formally implemented on March 21, 2017. This den stupor or coma, which are potentially lethal was motivated by our success in previous project unless reversed by prompt treatment. The risk of to decrease in-hospital delay for stroke thrombol- such events may arise from comorbidities, invasive ysis in the emergency department: the median

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 119 Sang-Beom Jeon ■ Neurologic Alert Team door-to-thrombolysis time decreased from 46.0 to full-time neurointensivist to run a closed-type 20.5 minutes. Accordingly, all routine neurological neurological intensive care unit. J Clin Neurology 2019;15:360-368. consultations for in-hospital neurological emergen- 4. Jeon SB, Ryoo SM, Lee DH, et al. Multidisciplinary cies were replaced by on-call consultations to the approach to decrease in-hospital delay for stroke NAT, a process dubbed as “NAT activation.” thrombolysis. J Stroke. 2017;19:196-204. In this session, we will present our experience of 5. Kim HJ, Jeong S, Jeon SB. Documenting the invis- neurological rapid response team for patients with ible in stroke-like symptoms during extracorpo- real membrane oxygenation. Intensive Care Med. acute neurological symptoms, which developed 2017;43:566-567. during hospitalization with nonneurological illness. 6. Ko MA, Lee JH, Jeon SB. Ischemic penumbra We aim to call for enhanced awareness and hospi- and blood-brain barrier disruption in cere- tal-wide strategies for managing in-hospital neuro- bral air embolism. Am J Respir Crit Care Med. 2020;201:369−370. logical emergencies occurring in initially nonneu- 7. Kim YJ, Jeon SB. Cerebral air embolism treated rological patients. using hyperbaric oxygen therapy. J Neurocrit Care 2019;12:64−65. References 8. Jeon SB. The solution to neurological emergencies: The NAT Book. Seoul, Korea: Daehan Medical 1. Jeon SB, Lee BH, KooYS, et al. Neurological emer- Book. 2019 (ISBN. 979-11-5590-130-4). gencies in patients hospitalized with non-neu- 9. Jeon SB. The past, presence, and future of neurolog- rological illness. J Patient Saf. 2020;doi:10.1097/ ical intensive care unit and the Neurological Alert PTS.0000000000000682. Team of Asan Medical Center. https://www.ksccm. 2. Jo S, Chang JY, Jeong S, et al. Newly developed org/html/?pmode=BBBS0006700030&page=1&s- stroke in patients admitted to non-neurological mode=view&seq=2087&searchValue=&searchTi- intensive care units. J Neurol. 2020;doi: 10.1007/ tle=strCategory&schCategory=17 s00415-020-09955-5. 3. Ko MA, Lee JH, Kim JG, et al. Appointment of a

120 KSCCM·ACCC 2020 Hee-Jeong Kim ■ Factors Associated with Motor Subtypes of Delirium in a Surgical Intensive Care Unit

Challenging Cases: Diagnostic Reasoning and Avoiding Errors in Acutely Ill Patients

Factors Associated with Motor Subtypes of Delirium in a Surgical Intensive Care Unit

Hee-Jeong Kim

Department of Surgical Intensive Care Unit, Seoul St. Mary’s Hospital, Republic of Korea August 1 (Sat)

Delirium is a disorder of attention or conscious- irritation, and refusal to cooperate with treatments. ness, accompanied by underlying cognitive chang- In contrast, hypoactive delirium manifests as a es. The incidence rate is 14%~24% [1] in hospital- reduced level of psychomotor activity, which is ized patients and 27.2%~63.0% [3–5] in critically ill accompanied by being droopy and lethargic, close patients, with the highest rate of incidence occur- to confusion. Mixed delirium is also a disorder of ring in the field of internal medicine [5,6]. Delirium attention or consciousness. However, the psycho- yields several negative patient outcomes in terms motor activity is at a moderate level or fluctuates of the mortality rate, number of days of ventilator rapidly in mixed delirium [1]. application, length of stay in the surgical intensive The frequency of each delirium subtype differs care unit, length of hospital stay, and cognitive across study methods and subjects. However, hy- impairment after discharge [2]. As a preventive poactive and mixed delirium subtypes show high method, intensive care units are performing envi- prevalence at 33.6%~61.8% and 30%~51% [8,9], ronmental interventions, such as periodically as- respectively, in terminal cancer patients and acute sessing delirium, repetitively providing orientation, patients. Moreover, hypoactive delirium is more providing assistive devices, such as glasses and common compared to hyperactive delirium at in- hearing aids, reducing noise, and encouraging early tensive care units [4]. However, most patients who ambulation. Non-pharmacological interventions, consulted psychiatrists when the medical staff rec- such as physical interventions, which minimize ognized delirium as a concern were found to have unnecessary intubation, medication, and restraints, hyperactive delirium (47.4%~50.8%) [10,11], and are also being implemented [7]. most treatments or interventions for patients with Delirium is classified into hyperactive, hypoac- delirium are currently focused on hyperactive de- tive, and mixed subtypes, according to the level lirium. of the individual’s psychomotor activity. Hyper- Delirium has different characteristics, responses active delirium manifests as an excessive level of to treatments, and prognoses according to the sub- psychomotor activity, which causes mood swings, type. Hypoactive delirium is associated with severe

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 121 Hee-Jeong Kim ■ Factors Associated with Motor Subtypes of Delirium in a Surgical Intensive Care Unit cognitive impairment [12], and the history of de- Among 1,112 patients, 172 patients showed de- pression or comorbidities occur often compared to lirium (15.5%). After excluding dementia patients other delirium motor subtypes [11,13], with a high- and patients refusing to participate in the study, er incidence of pressure ulcers [14]. Patients with 126 patients included in the final analysis. Delirium mixed delirium had more intravenous lines com- patients were classified as hyperactive delirium pared to patients with hyperactive or non-motor (32.5%), hypoactive delirium (42.9%), mixed de- delirium [15] and a higher incidence of unplanned lirium (11.9%), and non-motor subtype delirium extubation compared to those with the other de- (12.7%). Hypertension was associated with hyper- lirium motor subtypes [14]. In the terminally ill active delirium (OR =0.04, 95% CI =0.00~0.36) and patients with hypoactive and mixed delirium, the hypoactive delirium (OR=0.09, 95% CI =0.01~0.73). survival time was shorter [5] and the mortality rate Richmond Agitation and Sedation Scale (RASS) higher in patients with acute disease over 60 years score from -3 to -1 and from +1 to +4 was associ- of age [8]. In contrast, patients with hyperactive ated with hypoactive delirium (OR=36.49, 95% CI: delirium were younger than patients with mixed 4.62~288.37) and mixed delirium (OR=33.97, 95% delirium, and antipsychotic medications were used CI: 2.75~418.97). more frequently for delirium care [10]. The study shows that hypoactive delirium is the However, early detection and environmental in- most prevalent subtype in a SICU and delirium mo- terventions using the delirium assessment tools are tor subtypes were associated with different patient currently being conducted in clinical practice with- characteristics. Therefore, it is necessary to assess out consideration to the subtypes, and questions early the subtypes of delirium using structured on the effectiveness of such nursing interventions tools and develop appropriate nursing interven- remain [7] In particular, it was difficult to find nurs- tions suitable for each subtype. ing studies that classified delirium motor subtypes using the delirium motor subtype classification References tool in South Korea as the basic research to develop 1. American Psychiatric Association. Diagnostic and nursing interventions for delirium. Therefore, it is statistical manual of mental disorders. 5th ed. necessary to classify motor subtypes of delirium Kwon JS, Kim JJ, Namkoong K, Park WM, Shin MS, and develop nursing interventions accordingly. Yoo BH, et al., translator. Seoul: Hakjisa; 2015. p. Data were collected in SICU in a tertiary hospital 650-651. 2. Salluh JI, Wang H, Schneider EB, Nagaraja N, Ye- in * city from October 2018 to June 2019. Delirium nokyan G, Damluji A, et al. Outcome of delirium was detected using the Confusion Assessment in critically ill patients: Systematic review and me- Method for the ICU (CAM-ICU) and motor sub- ta-analysis. BMJ. 2015;350:h2538. types were measured with the Delirium Motor Sub- 3. Chun YK, Park JY. Risk factors of delirium among the patients at a surgical intensive care unit. Jour- type Scale (DMSS)-4. Patients’ characteristics were nal of Korean Critical Care Nursing. 2017;10(3):31- obtained by using the electronic medical records. 40. Descriptive statistics and multinomial logistic re- 4. Choi SJ, Cho YA. Prevalence and related risk fac- gression were used to analyze data. tors of delirium in intensive care units as detected

122 KSCCM·ACCC 2020 Hee-Jeong Kim ■ Factors Associated with Motor Subtypes of Delirium in a Surgical Intensive Care Unit

by the CAM-ICU. Journal of Korean Clinical Nurs- with delirium. Journal of Korean Neuropsychiatric ing Research. 2014;20(3):406-416. Association. 2015;54(4):489-494. 5. Shim MY, Song SH, Lee MM, Park MA, Yang EJ, 12. Kumar A, Bakhla AK, Gupta S, Raju BM, Prasad A. Kim MS, et al. The effects of delirium prevention Etiologic and cognitive differences in hyperactive intervention on the delirium incidence among and hypoactive delirium. Primary Care Compan- postoperative patients in a surgical intensive care ion to CNS Disorders. 2015;17(6). unit. Journal of Korean Clinical Nursing Research. 13. Gual N, Inzitari M, Carrizo G, Calle A, Udina C, 2015;21(1):43-52. Yuste A, et al. Delirium subtypes and associated 6. Ahn JS, Oh JY, Park JS, Kim JJ, Park JY. Incidence characteristics in older patients with exacerbation and procedure-related risk factors of delirium in of chronic conditions. American Journal of Geriat- patients admitted to an intensive care unit. Korean ric Psychiatry. 2018;26(12):1204-1212. Journal of Psychosomatic Medicine. 2019;27(1):35- 14. Robinson TN, Raeburn CD, Tran ZV, Brenner August 1 (Sat) 41 LA, Moss M. Motor subtypes of postoperative 7. Rivosecchi RM, Smithburger PL, Svec S, Campbell delirium in older adults. Archives of Surgery. S, Kane-Gill SL. Nonpharmacological interventions 2011;146(3):295-300. to prevent delirium: An evidence-based systematic 15. Morandi A, Di Santo SG, Cherubini A, Mossello E, review. Critical Care Nurse. 2015;35(1):39-50; quiz Meagher D, Mazzone A, et al. Clinical features as- 51. sociated with delirium motor subtypes in older in- 8. Avelino-Silva TJ, Campora F, Curiati JAE, Jacob-Fil- patients: Results of a multicenter study. American ho W. Prognostic effects of delirium motor sub- Journal of Geriatric Psychiatry. 2017;25(10):1064- types in hospitalized older adults: A prospective 1071. cohort study. PloS One. 2018;13(1):e0191092. 16. Van den Boogaard M, Schoonhoven L, van der 9. Kim SY, Kim SW, Kim JM, Shin IS, Bae KY, Shim HJ, Hoeven JG, van Achterberg T, Pickkers P. Incidence et al. Differential associations between delirium and short-term consequences of delirium in crit- and mortality according to delirium subtype and ically ill patients: A prospective observational co- age: A prospective cohort study. Psychosomatic hort study. International Journal of Nursing Stud- Medicine. 2015;77(8):903-910. ies. 2012;49(7):775-783. 10. Paik SH, Min S, Ahn JS, Park KC, Kim MH. Symp- 17. Bui LN, Pham VP, Shirkey BA, Swan JT. Effect of tomatic and clinical profiles across motoric sub- delirium motoric subtypes on administrative doc- types in delirium. Korean Journal of Psychosomat- umentation of delirium in the surgical intensive ic Medicine. 2015;23(2):79-85. care unit. Journal of Clinical Monitoring and Com- 11. An T, Ra Y, Han C, Kim H-S, Lee K-S, Bae H. Clin- puting. 2017;31(3):631-640. ical correlates of subtype and severity in patients

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 123 Aisoon Park ■ Palliative Care in Pediatric ICU

Challenging Cases: Diagnostic Reasoning and Avoiding Errors in Acutely Ill Patients

Palliative Care in Pediatric ICU

Aisoon Park

RN, MSN, PICU, Severance Hospital, Seoul, Korea

The goal of palliative care is minimizing suffering of Korea. In this team, critical care staff members, from physical, psychosocial, emotional, and spiri- who provide a primary palliative approach to the tual distress to ensure the quality of life for patients patients will request secondary palliative care-ex- with a life-threatening illness and their families.[1] pert to give them consultation, advice, and help The America Academy of Pediatrics recommended as needed. Through this interdisciplinary inter- that pediatric palliative care should be offered at vention, we have provided pediatric palliative care the time of diagnosis and continue throughout the such as support of the family unit, communication illness, regardless of the outcome.[2] with the child and family about treatment goals, The needs for palliative care are increasing as the ethics and shared decision making, relief pain and life expectancy of the children with life-limiting other symptoms, continuity of care, grief and be- conditions is increasing with the help of a well-de- reavement support, etc.[5] veloped medical system. Then, in 2003, the UN From these efforts, we found several things that Committee on the Rights of the Child declared that should be improved in our system for giving better palliative care as a child’s basic rights.[3] palliative care services. In this presentation, it will In South Korea, the annual number of children be discussed about the development of a proper with complex chronic conditions reaches about palliative care system for Koreans, guidelines, edu- 130,000.[4] As an effort for giving high-quality care cation program for staff, prevention of the exhaus- for pediatric patients, especially those who suffered tion of staff within an organized support system from a serious illness, Severance Hospital has been and evaluation criteria for measuring the perfor- providing pediatric palliative care in its intensive mance result based on our experiences obtained care unit (ICU) since 2010. Recently, Severance from the palliative care service performed during Hospital actively operates Pediatric Palliative Care the last several years in the Pediatric Intensive Care Team to provide practical intervention through Unit, Severance Hospital. an interdisciplinary approach as a pilot project for the improvement of pediatric palliative care with References the support of the Ministry of Health and Welfare

124 KSCCM·ACCC 2020 Aisoon Park ■ Palliative Care in Pediatric ICU

1. Madden K, Wolfe J, Collura C. Pediatric Palliative 4. Kim MS, Lim NG, Kim HJ, et al. Pediatric Deaths Care in the Intensive Care Unit. Crit Care Nurs Clin Attributed to Complex Chronic Conditions over 10 North Am. 2015 Sep;27(3):341-54. Years in Korea: Evidence for the Need to Provide 2. American Academy of Pediatrics. Committee on Pediatric Palliative Care. J Korean Med Sci. 2018 Bioethics and Committee on Hospital Care. Pallia- Jan 1;33(1):e1. tive care for children. Pediatrics. 2000 Aug;106(2 Pt 5. Truog RD, Campbell ML, Curtis JR, et al. Recom- 1):351-7. mendations for end-of-life care in the intensive 3. Child UCotRot. General comment No. 15 (2013) on care unit: a consensus statement by the American the right of the child to the enjoyment of the high- College [corrected] of Critical Care Medicine. Crit est attainable standard of health (art. 24). Care Med. 2008 Mar;36(3):953-63. August 1 (Sat)

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 125 Young Ae Kang ■ Diagnostic Reasoning and Avoiding Errors in Acutely Ill Patients: Challenging Cases in Coronary Care Unit

Challenging Cases: Diagnostic Reasoning and Avoiding Errors in Acutely Ill Patients

Diagnostic Reasoning and Avoiding Errors in Acutely Ill Patients: Challenging Cases in Coronary Care Unit

Young Ae Kang

Clinical Nurse Specialist, R.N., Cardiovascular Surgery ICU, ASAN Medical Center

World Health Organization (WHO) data from 2016 infarction (STEMI) and non-ST elevation myocardi- reveals that cardiovascular diseases are the number al infarction (NSTEMI)] as well as unstable angina 1 cause of death globally, an estimated 17.9 million (UA). Immediate assessment of ACS includes clini- people die from cardiovascular diseases. Especially, cal presentation, 12-lead electrocardiography (ECG) ischemic heart diseases are the top cause of cardio- recording, and measurement of cardiac-specific vascular diseases death. marker (troponin or CK-MB). Ischemic heart disease (IHD) is a condition in Pain is the most common presenting complaint which there is an inadequate blood supply and ox- and the pain is deep and visceral; the principal pre- ygen to a portion of myocardium; it typically occurs sentations are resting angina, new onset angina and when there is an imbalance between myocardial increasing angina (more frequent, longer duration oxygen supply and demand. The most common or lower in threshold). Typically, the pain involves cause of myocardial ischemia is atherosclerotic the central portion of chest or epigastrium and on disease of epicardial coronary arteries, sufficient occasion, it radiates to the arms. to cause a regional reduction in myocardial blood The ECG is cornerstone in diagnosis of acute and flow and inadequate perfusion. Acute event usually chronic ischemic heart disease. A 12-lead ECG represents rupture of a vulnerable atherosclerotic should be obtained promptly in patients with chest plaque, exposing a thrombogenic subendocardial discomfort consistent with ACS, if the diagnosis of matrix within the vessel. Platelets aggregation en- STEMI is in doubt, serial ECG may elucidate the di- sues limiting blood flow to the myocardium distal agnosis. The ECG manifestations are T wave chang- to the legion and this progress to mechanical ob- es, ST segment changes and pathologic Q waves. struction. Ischemia exerts complex time-dependent effects Acute coronary syndrome (ACS) refers to any on electrical properties of myocardial cells. Se- clinical symptoms that are compatible with acute vere acute ischemia lowers the resting membrane myocardial ischemia and encompass acute myo- potential and shortens the duration of action po- cardial infarction [ST segment elevation myocardial tential. Such changes cause a voltage gradient be-

126 KSCCM·ACCC 2020 Young Ae Kang ■ Diagnostic Reasoning and Avoiding Errors in Acutely Ill Patients: Challenging Cases in Coronary Care Unit tween normal and ischemic zones. These currents accompanied with severe coronary artery diseases. of injury are presented on ECG by deviation of ST People with ischemic heart diseases or who are at segment. Presence of ≥1mm ST segment changes high cardiovascular risk need early detection and in two consecutive ECG leads. In addition, peaked management. With earlier detection and treatment, upright T wave may be first ECG manifestation of less myocardial muscle damage is incurred and MI and development of new pathologic Q wave (> better outcomes are achieved. 40msec) is considered diagnostic for MI. Cardiac-specific troponin I(cTnI) or troponin T References (cTnT) is preferred biomarker for diagnosis MI. Se- 1. Carlson, K. K. (Ed.). (2008). AACN Advanced Crit- rum levels of cTnI and cTnT increase increase 3-12 ical Care Nursing-E-Book Version to be sold via August 1 (Sat) hours after onset of MI, peak at 24-48 hours, and e-commerce site. Elsevier Health Sciences. return to baseline over 5-14 days. Creatinine kinase 2. Godara, H. (2013). The Washington manual of (CK-MB) has > 95% sensitivity for myocardial inju- medical therapeutics. Lippincott Williams & Wilkins. ry, levels increase within 3-12 hours of chest pain, 3. Loscalzo, J. (2013). Harrison’s Cardiovascular Med- peak at 24 hours and return to baseline after 48-72 icine 2/E. McGraw-Hill Education. hours. Increased CK-MB also occurs infrequently as 4. Garcia, T. B., & Garcia, D. J. (2019). Arrhythmia rec- result of release from noncardiac source or dimin- ognition: The art of interpretation. Jones & Bartlett Learning. ished clearance. 5. Hwang, H. J. and Lee, M. H. (2012). Ventricular In addition, symptoms of left ventricle dysfunc- tachycardia in structural heart disease. In Korean tion or congestive heart failure and life-threatening Heart Rhythm society, Arrhythmia (pp 298-303). dysrhythmias like ventricular arrhythmia may be Paju: Koonja press

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 127 Sookhyun Park ■ Understanding and Eliminating Workplace Stress

Critical Care Nursing : Daring to Find Joy and Meaning at Work

Understanding and Eliminating Workplace Stress

Sookhyun Park

Critical Care Nursing, Samsung Medical Center

In modern society, rapid changes inclu-ding nurse and of threat to patient safety and degraded structuralization, specialization, and diversification quality of medical care to the organization. Physi- are causing influence on hospital organization and cal symptoms related to nurse’s job stress include thus compe- tition between hospitals is intensify- cardiac disorder and gastric ulcer, depression, loss ing. Rapid changes in medical environment and of motivation, and anger are also threatening their competition are requiring better me-dical services mental health. for patient satisfaction and accordingly health care A healthy work environment increases nurse’s job provider’s job stress is increasing[1]. satisfaction and reduces job stress and exhaustion Especially Intensive Care Unit must pro-vide and ultimately enables provision of quality nursing comprehensive and skilled nursing ranging from to patients[6]. It also has a significant influ- ence on nursing for patients in criti-cal condition or end not only nurse’s job result but also nurse attraction of life care that requires a high degree of skill and and maintenance[7]. Like for nurses is essential for judg-ment and it is also known that their job stress reducing nurse turnover and retaining excellent is high due to high responsibility for patient recov- nurses. ery[2]. For this reason, the turnover rate of nurses In 2005, American Association of Criti-cal care working in ICU is 13.1% on average: 9.9% for hospi- Nurse announced skilled com- munication in a tal ward and 8.6% for operating room[3]. It is report- healthy work environm- ent, true collaboration, ed that the main cause of high turnover in nurses is effective decision making, appropriate staffing, working environment that causes work conflict and meaningful recognition, and authentic leader- stress[4]. ship[8]. In work context, nurse’s job stress is inevitable. Al- In Korea as well, various approaches are being at- though some level of stress is helpful for nurse’s role tempted for making a heal- thy work environment. performance and contributes to individual growth In addition to improving resilience at the individual and productivity increase[5], the response to exces- nurse level in ICU, systemic support at the orga- sive job stress leads to exhaustion, which results in nizational level is needed. Nursing leaders should negative consequences of turnover to individual make continuous efforts to improve policies and

128 KSCCM·ACCC 2020 Sookhyun Park ■ Understanding and Eliminating Workplace Stress apply them into clinical practice. of nurse turnover.2008. 38(2): p. 248-257. 5. Han, K.-S., et al., Factors influencing job stress of health care providers.2012. 20(3): p. 209-220. References 6. Hall, L., Indicators of nurse staffing and quality 1. Kim, J.K., et al., Job stress, job satisfac-tion and oc- nursing work environments.2005. cupational commitment among Korean emergen- 7. Aiken, L.H., et al., Effects of hospital care en- cy physicians.2010. 21(2): p. 246-258. vironment on patient mor-tality and nurse out- 2. Lee, J.H. and Y.J.J.o.K.C.N.R. Song, Pre- comes.2008. 38(5): p. 223. dictive factors of turnover intention among inten- 8. Care, A.A.o.C.-C.N.J.A.J.o.C., AACN stan-dards for sive care unit nurses. 2018. 24(3): p. 347-355. establishing and sus- taining healthy work envi- 3. Kim, Y.J.S.S.N.U., Nursing turnover cost estimation: ronments: a journey to excellence.2005. 14(3): p. 187-197.

a tertiary hospital case [dissertation].2015: p. 1-102. August 1 (Sat) 4. Lee, Y.-J. and K.-B.J.J.o.K.A.o.N. Kim, Ex-periences

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 129 Eun Koung Seo ■ Support for Nurses through Hospital Policy Change

Critical Care Nursing : Daring to Find Joy and Meaning at Work

Support for Nurses through Hospital Policy Change

Eun Koung Seo

Pyeongtaek Good Morning Hosp, Korea

Small and medium-sized local hospitals are suf- growth of 10 percent every year. fering from a shortage of nurses. Poor education The special measure is to invest heavily in nursing and poor working condition of new nurses cause staff. The background of the investment of nursing turnover, which leads to the overburden of experi- staff was supported by the improvement of the per- enced nurses, leading to a vicious cycle of leaving ception that it is directly related to patient safety. the hospital. Good Morning Hospital has maintained its first According to a survey conducted by the National grade in nursing since 2016 and maintained the Health and Medical Industry Union on 16,296 nurs- number of experienced nurses at 70% of all nurs- es in 2018, the rate of nurses’ turnover was 15.55% es for patient safety through strategies to improve (2,535), 2.3 times higher than the average rate of working condition and reform the working envi- 6.67% for other occupations excluding nursing ronment of the nurses, including wage increase workers. Especially, the new nurses’, in their first (super gap strategy), a takeover system reform (vid- to third years, turnover rate was 66.5% among the eo transition), a night shift change (reduction in nursing profession. In other words, seven out of 10 the number of night shifts), a pattern work system new nurses will be transferred. (maintenance of schedule patterns), a new nurse Some hospitals even call it “pouring water into education program (introduction of on-site edu- the bottomless pit” over the recruitment of nursing cation instructors), a leave system, improving the staff. culture of the organization (management initiative, Good Morning Hospital, one of small and medi- improvement of communication culture) and other um-sized hospitals in the province, has taken spe- strategies. cial measures, and as a result, it has shown steady

130 KSCCM·ACCC 2020 Eunju Cho ■ Leadership and Success in a Caring Profession

Critical Care Nursing : Daring to Find Joy and Meaning at Work

Leadership and Success in a Caring Profession

Eunju Cho

Medical Intensive Care Unit, Seoul National University Hospital August 1 (Sat)

An important part of the ongoing concern in the Therefore, the efforts to improve organizational critical care nursing leadership is the retention of climate/culture are very necessary. good nurses. Retaining good nurses require a new Another important organizational factors in and more comprehensive organizational perspec- maintaining good nurses are “supporting for pro- tives. fessional practice” and “continuing clinical compe- Organizational climate is an important determi- tence of nursing”. Organizations that exhibit these nant of intend to leave among ICU nurses. Because characteristics may experience decreased nurse higher wages do not reduce intend to leave, in- turnover.[6] “Supporting for professional practice” creased pay alone without attention to organiza- and “continuing clinical competence of nursing” tional climate is likely insufficient to reduce nurse can be achieved through a well-designed nursing turnover. Implementing interventions aimed at education system. creating a positive organizational climate may be Current nursing leadership should focus on creat- a more effective strategy.[1] Relationships among ing a positive climate, reducing negative factors in communication, interdisciplinary politics, and the organization simultaneously building and im- nurse stability are very close.[2] Especially, The plementing an educational system to enhance the ICU climate is concerned with not only improving organization’s clinical competency. patient safety,[3] but also preventing occupational injuries of staffs.[4] References The latest major issue in nursing organizations is 1. Stone PW, Mooney-Kane C, Larson EL, et al. Nurse bullying in the workplace. Working Conditions, Organizational Climate, and Disruptive behaviors are toxic not only to the Intent to Leave in ICUs: An Instrumental Variable nursing profession but also to the institution in Approach. Health Serv Res. 2007 June;42:1085-104. which they occur. High staff turnover, sickness 2. Hart SK, Moore MN. The Relationship Among Organizational Climate Variables and Nurse Sta- absence, impaired performance, lower productiv- bility in Critical Care Units. J Prof Nurs. 1989 May- ity, poor team spirit, and increasing litigation are Jun;5(3):124-31. among the outcomes of workplace bullying.[5] 3. Pronovost PJ, Berenholtz SM, Goeschel C, et

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 131 Eunju Cho ■ Leadership and Success in a Caring Profession

al. Improving patient safety in intensive care 5. Field, T. Bullying in medicine. BMJ. 2002; 324, 786. units in Michigan. Journal of Critical Care. 2008 6. Stone PW, Larson EL, Mooney-Kane C, et al. June;23(2):207-21. Organizational Climate and Intensive Care Unit 4. Stone PW, Gershon RR. Nurse work environments Nurses’ Intention to Leave. Crit Care Med. 2006 and occupational safety in intensive care units. Jul;34(7):1907-12. Policy Polit Nurs Pract. 2006 Nov;7(4):240-7.

132 KSCCM·ACCC 2020 Hannah Lee ■ What`s New in Sepsis? - Recent Major RCTs in 2019-2020

Summary of Recent Major RCTs

What`s New in Sepsis? - Recent Major RCTs in 2019-2020

Hannah Lee

Anesthesia and pain medicine, Seoul National University Hospital August 1 (Sat)

Sepsis is a potentially life-threatening condition free of vasopressor administration over 7 days com- which is estimated to affect over 30 million people pared with hydrocortisone infusion alone [8]. Now, worldwide each year [1]. With the exception of anti- we`re looking forward to the results of the ongoing microbials and vasopressors, pharmaceutical inter- VICTAS trial which tests the efficacy of combination ventions have failed to improve patient outcomes therapy with vitamin C (1.5g), thiamine (100mg), in clinical trials [2, 3]. As a result, contemporary and hydrocortisone (50mg) given every 6 h for up to treatment remains limited to early appropriate an- 16 doses in patients with respiratory or circulatory tibiotics, fluid resuscitation, hemodynamic support, dysfunction (or both) resulting from sepsis [9]. and control of infection [4]. Recently, vitamin C has Fluid resuscitation and hemodynamic support garnered interest following previous studies that using vasopressors are unchanging key factors found vitamin C attenuates systemic inflammation in managing septic shock. The Surviving Sepsis and vascular injury and corrects sepsis-induced Campaign proposes to guide hemodynamic resus- coagulopathy [5, 6]. In addition, the combination citation by repeated measurement of blood lactate of high dose IV vitamin C and hydrocortisone to- levels every 2 to 4 hours until normalization [10]. gether with thiamine was associated with shorter The ANDROMEDA-SHOCK randomized clinical duration of vasopressor administration and lower trial [11] was conducted to determine if a periph- hospital mortality in a single-center retrospective eral perfusion-targeted resuscitation using cap- before-and-after study of 94 patients with severe illary refill time during early septic shock is more sepsis or septic shock [7].The VITAMINS random- effective than a lactate level-targeted resuscitation ized clinical trial [8] was conducted to determine for reducing 28-day mortality. In this study of 424 the effect of vitamin C (1.5g q6hr), hydrocortisone patients with early septic shock, 28-day mortality (50mg q6hr), and thiamine (200mg q12hr) infusion was not significantly different between the periph- on time alive and free of vasopressor support in eral perfusion-targeted resuscitation group (34.9%) patients with septic shock. And this preliminary and the lactate level-targeted resuscitation group study showed that this combination therapy did not (43.4%). In the context of fluid resuscitation, the re- significantly improve the duration of time alive and cent SMART (Isotonic Solutions and Major Adverse

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 133 Hannah Lee ■ What`s New in Sepsis? - Recent Major RCTs in 2019-2020

Renal Events Trial) trial showed that balanced crys- vasoplegic shock patients [17, 18]. Moreover, nor- talloids decreased the incidence of the composite epinephrine has immunomodulating effects, while outcome of death, new renal replacement therapy, vasopressin may have a greater effect on reducing or persistent renal dysfunction compared to saline inflammatory cytokine compared with norepineph- among critically ill adults [12]. A secondary analysis rine [19, 20]. The VANCS Ⅱ trial [21] was conducted of the SMART trial found that patients in the bal- to test the hypothesis that vasopressin was superior anced crystalloid group experienced a lower 30-day to norepinephrine to improve outcomes in cancer in-hospital mortality, a lower incidence of major patients with septic shock. They found that 28-day adverse kidney events within 30 days, and a greater mortality was not significant different between number of vasopressor-free days and renal replace- the vasopressin group and the norepinephrine ment therapy-free days compared with the patients group and there were no significant difference in in the saline group [13]. 90-day mortality, number of days alive and free of Generally, intravenous fluid is given first, fol- advanced organ support, or SOFA score in cancer lowed by infusion of vasopressors when the target patient with septic shock [21]. Further studies are blood pressure is not achieved after reaching the needed with low doses of multiple vasopressors in optimal intravascular volume [4]. Recent retrospec- septic shock patients, addressing multiple defects in tive studies suggests the benefits of administering the pathophysiology of shock, and simultaneously norepinephrine at the beginning of resuscitation avoiding adverse effects of high doses of the drugs. [14, 15]. Permpikul et al. performed the CENSER In a near future, the choice of vasopressors for sep- trial [16] to examine the hypothesis that early low- tic shock treatment may be guided by predictive dose norepinephrine (0.05mcg/kg/min) in septic biomarkers, such as copeptin or vasopressinase. shock increases shock control by 6 hours compared with standard care. In this trial, shock control rate References by 6 hours was significantly higher in the early 1. Fleischmann C, Scherag A, Adhikari NK, et al. norepinephrine. Moreover, the early norepineph- Assessment of Global Incidence and Mortality of rine group was associated with lower incidence of Hospital-treated Sepsis. Current Estimates and cardiogenic pulmonary edema and now-onset ar- Limitations. Am J Respir Crit Care Med 2016; 193: rhythmia [16]. A multi-center phase 3 randomized 259-72. 2. Artenstein AW, Higgins TL, Opal SM. Sepsis and sci- clinical trial named CLOVERS (Crystalloid Liberal entific revolutions. Crit Care Med 2013; 41: 2770-2. or Vasopressors Early Resuscitation in Sepsis) is on- 3. Marshall JC. Why have clinical trials in sepsis going. failed? Trends Mol Med 2014; 20: 195-203. Lastly, norepinephrine is the first-line vasopressor 4. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for in septic shock [4]. Vasopressin emerged as a po- Management of Sepsis and Septic Shock: 2016. In- tential alterative to norepinephrine as a vasopressor tensive Care Med 2017; 43: 304-77. agent due to its beneficial effects of reducing atrial 5. Fisher BJ, Seropian IM, Kraskauskas D, et al. Ascor- fibrillation, acute kidney injury, renal replacement bic acid attenuates lipopolysaccharide-induced therapy, and duration of vasopressor therapy in acute lung injury. Crit Care Med 2011; 39: 1454-60. 6. Fowler AA, 3rd, Syed AA, Knowlson S, et al. Phase I

134 KSCCM·ACCC 2020 Hannah Lee ■ What`s New in Sepsis? - Recent Major RCTs in 2019-2020

safety trial of intravenous ascorbic acid in patients Levy B. Comparative effects of early versus delayed with severe sepsis. J Transl Med 2014; 12: 32. use of norepinephrine in resuscitated endotoxic 7. Marik PE, Khangoora V, Rivera R, Hooper MH, shock. Crit Care Med 2007; 35: 1736-40. Catravas J. Hydrocortisone, Vitamin C, and Thia- 15. Bai X, Yu W, Ji W, et al. Early versus delayed ad- mine for the Treatment of Severe Sepsis and Septic ministration of norepinephrine in patients with Shock: A Retrospective Before-After Study. Chest septic shock. Crit Care 2014; 18: 532. 2017; 151: 1229-38. 16. Permpikul C, Tongyoo S, Viarasilpa T, Trainarong- 8. Fujii T, Luethi N, Young PJ, et al. Effect of Vitamin sakul T, Chakorn T, Udompanturak S. Early Use C, Hydrocortisone, and Thiamine vs Hydrocorti- of Norepinephrine in Septic Shock Resuscitation sone Alone on Time Alive and Free of Vasopressor (CENSER). A Randomized Trial. Am J Respir Crit Support Among Patients With Septic Shock: The Care Med 2019; 199: 1097-105. VITAMINS Randomized Clinical Trial. Jama 2020; 17. Serpa Neto A, Nassar AP, Cardoso SO, et al. Va- August 1 (Sat) 323: 423-31. sopressin and terlipressin in adult vasodilatory 9. Lindsell CJ, McGlothlin A, Nwosu S, et al. Update shock: a systematic review and meta-analysis of to the Vitamin C, Thiamine and Steroids in Sepsis nine randomized controlled trials. Crit Care 2012; (VICTAS) protocol: statistical analysis plan for a 16: R154. prospective, multicenter, double-blind, adaptive 18. McIntyre WF, Um KJ, Alhazzani W, et al. Asso- sample size, randomized, placebo-controlled, clin- ciation of Vasopressin Plus Catecholamine Va- ical trial. Trials 2019; 20: 670. sopressors vs Catecholamines Alone With Atrial 10. Levy MM, Evans LE, Rhodes A. The Surviving Sep- Fibrillation in Patients With Distributive Shock: A sis Campaign Bundle: 2018 Update. Crit Care Med Systematic Review and Meta-analysis. Jama 2018; 2018; 46: 997-1000. 319: 1889-900. 11. Hernández G, Ospina-Tascón GA, Damiani LP, et 19. Stolk RF, van der Poll T, Angus DC, van der Hoeven al. Effect of a Resuscitation Strategy Targeting Pe- JG, Pickkers P, Kox M. Potentially Inadvertent Im- ripheral Perfusion Status vs Serum Lactate Levels munomodulation: Norepinephrine Use in Sepsis. on 28-Day Mortality Among Patients With Septic Am J Respir Crit Care Med 2016; 194: 550-8. Shock: The ANDROMEDA-SHOCK Randomized 20. Russell JA, Fjell C, Hsu JL, et al. Vasopressin com- Clinical Trial. Jama 2019; 321: 654-64. pared with norepinephrine augments the decline 12. Semler MW, Self WH, Wanderer JP, et al. Balanced of plasma cytokine levels in septic shock. Am J Re- Crystalloids versus Saline in Critically Ill Adults. N spir Crit Care Med 2013; 188: 356-64. Engl J Med 2018; 378: 829-39. 21. Hajjar LA, Zambolim C, Belletti A, et al. Vasopres- 13. Brown RM, Wang L, Coston TD, et al. Balanced sin Versus Norepinephrine for the Management Crystalloids versus Saline in Sepsis. A Secondary of Septic Shock in Cancer Patients: The VANCS II Analysis of the SMART Clinical Trial. Am J Respir Randomized Clinical Trial. Crit Care Med 2019; 47: Crit Care Med 2019; 200: 1487-95. 1743-50. 14. Sennoun N, Montemont C, Gibot S, Lacolley P,

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 135 Kwang Wook Jo ■ Recent Randomised Clinical Trials of Neurointensive Care

Summary of Recent Major RCTs

Recent Randomised Clinical Trials of Neurointensive Care

Kwang Wook Jo

Department of Neurosurgery,1 Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Korean medical policies are currently heading tensive care units (NCUs and NICUs, respectively) toward emphasizing patient safety and medical require highly trained experts, efficient interdisci- expertise; to align with this trend, hospital systems plinary care, and adequate facilities and equipment are changing rapidly. In particular, the importance and other needs. And an evidence-based manual of intensive care units (ICUs) is being highlighted, related to NCUs’ clinical practice guidelines is es- with particular emphasis on appropriate treatment sential for education and care quality control in for patients with brain and spinal cord injuries. This institutions1). We have provided a brief overview emphasis is because most brain injuries (intracere- of the recent published randermized clinical trials bral hemorrhage, traumatic brain injury [TBI], cere- and put forward recommendations in the field of bral infarction, etc.) can cause irreversible damage neurocritical care. if not properly and timely cared for. Moreover, in the course of neurological treatment, References physicians must address neurology-related medical 1. Sheth KN, Drogan O, Manno E, Geocadin RG, Ziai issues such as fluid management, infection (pneu- W: Neurocritical care education during neurology monia, urinary tract infection, sepsis. etc.), blood residency: AAN survey of US program directors. pressure control, renal injury, and nutritional sup- Neurology 78 : 1793-1796, 2012. port. For this reason, neurosurgical and neuroin-

136 KSCCM·ACCC 2020 Woo Hyun Cho ■ Summary of Recent Major RCTs: Pulmonary/ARDS

Summary of Recent Major RCTs

Summary of Recent Major RCTs: Pulmonary/ARDS

Woo Hyun Cho

Pusan National University Yangsan Hospital August 1 (Sat)

Acute respiratory distress syndrome (ARDS) is still lecture will review these recent RCTs regard ARDS a life-threatening disease among critical illnesses in detail. [1]. Mechanical ventilation is critical for resolving life-threatening hypoxia and hypercapnia. Despite References its lifesaving effects, mechanical ventilation may in- 1. Bellani G, Laffey JG, Pham T, et al. Epidemiolo- duce and exacerbate lung injury, known as ventila- gy, Patterns of Care, and Mortality for Patients tor induced lung injury (VILI) [2]. Up to now, there With Acute Respiratory Distress Syndrome in are lots of clinical evidences to reduce VILI and Intensive Care Units in 50 Countries. JAMA. improve survival of ARDS, such as low tidal volume 2016;315(8):788‐800. doi:10.1001/jama.2016.0291 2. Hegeman M.A., Hennus M.P., Cobelens P.M., et al. [3], prone position ventilation [4] and extracorpo- Dexamethasone attenuates VEGF expression and real membrane oxygenation [5-6]. These evidences inflammation but not barrier dysfunction in a Mu- is still effective but the mortality of ARDS is still rine model of ventilator–induced lung injury. PloS high and ARDS is one of big issues in critical care. One 2013; 8: e57374 3. Acute Respiratory Distress Syndrome Network, In this presentation, recent RCTs regarding ARDS Brower RG, Matthay MA, Morris A, et al. Ventila- is going to be approached to help understanding of tion with lower tidal volumes as compared with this devastating lung disease. I searched Pubmed traditional tidal volumes for acute lung injury and using keyword “ARDS” and setting the limit of date the acute respiratory distress syndrome. N Engl J of publication and age to “since 2019” and “above Med. 2000;342(18):1301. 4. Guérin C, Reignier J, Richard JC, et al. Prone po- 19 years”, respectively. Of 18 first screened papers, sitioning in severe acute respiratory distress syn- 7 were finally reviewed and will be introduced in drome. N Engl J Med 2013; 368:2159 this presentation. Mostly, moderate to severe ARDS 5. Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy is a subject of these researches and various inter- and economic assessment of conventional venti- ventions such as neuromuscular blocking agent, latory support versus extracorporeal membrane oxygenation for severe adult respiratory failure Vitamin C, mesenchymal stem cell, NIV, Pes guided (CESAR): a multicentre randomised controlled tri- PEEP titration, recruitment and liberal oxygenation al. Lancet 2009; 374:1351. above 90 mmHg of PaO2 was assessed [7-13]. This 6. Combes A, Hajage D, Capellier G, et al. Extracor-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 137 Woo Hyun Cho ■ Summary of Recent Major RCTs: Pulmonary/ARDS

poreal Membrane Oxygenation for Severe Acute 2019 Mar 5;321(9):846-857. Respiratory Distress Syndrome. N Engl J Med 2018; 10. Hodgson CL, Cooper DJ, Arabi Y et al. Maximal 378:1965. Recruitment Open Lung Ventilation in Acute 7. National Heart, Lung, and Blood Institute PETAL Respiratory Distress Syndrome (PHARLAP). A Clinical Trials Network, Moss M, Huang DT, Brow- Phase II, Multicenter Randomized Controlled er RG et al. Early Neuromuscular Blockade in the Clinical Trial. Am J Respir Crit Care Med. 2019 Dec Acute Respiratory Distress Syndrome. N Engl J 1;200(11):1363-1372. Med. 2019 May 23;380(21):1997-2008. 11. Barrot L, Asfar P, Mauny F, Winiszewski H et al. 8. Fowler AA 3rd, Truwit JD, Hite RD et al. Effect of Liberal or Conservative Oxygen Therapy for Acute Vitamin C Infusion on Organ Failure and Biomark- Respiratory Distress Syndrome. N Engl J Med. 2020 ers of Inflammation and Vascular Injury in Patients Mar 12;382(11):999-1008. With Sepsis and Severe Acute Respiratory Failure: 12. Matthay MA, Calfee CS, Zhuo H et al. Treatment The CITRIS-ALI Randomized Clinical Trial. JAMA. with allogeneic mesenchymal stromal cells for 2019 Oct 1;322(13):1261-1270. moderate to severe acute respiratory distress syn- 9. Beitler JR, Sarge T, Banner-Goodspeed VM et al. drome (START study): a randomised phase 2a Effect of Titrating Positive End-Expiratory Pressure safety trial. Lancet Respir Med. 2019 Feb;7(2):154- (PEEP) With an Esophageal Pressure-Guided Strat- 162. egy vs an Empirical High PEEP-Fio2 Strategy on 13. He H, Sun B, Liang L et al . A multicenter RCT of Death and Days Free From Mechanical Ventilation noninvasive ventilation in pneumonia-induced Among Patients With Acute Respiratory Distress early mild acute respiratory distress syndrome. Syndrome: A Randomized Clinical Trial. JAMA. Crit Care. 2019 Sep 4;23(1):300.

138 KSCCM·ACCC 2020 Jungwook Suh, Heung-Kwon Oh ■ Common Colorectal Disorders Encountered in the ICU

General Critical Care Update

Common Colorectal Disorders Encountered in the ICU

Jungwook Suh, Heung-Kwon Oh

Division of Colorectal Surgery, Department of Surgery, Seoul National University Bundang Hospital August 1 (Sat)

The purpose of this lecture is to review common Acute mesenteric ischemia is typically defined as colorectal disorders encountered in the ICU. a group of diseases characterized by an interrup- The diagnosis of hemorrhoids is almost always a tion of the blood supply to varying portions of the clinical one and should start with a medical history, small intestine, leading to ischemia and secondary with great care taken to identify symptoms sugges- inflammatory changes. When physical findings tive of hemorrhoidal disease and risk factors such suggestive of an acute intraabdominal catastrophe as constipation, followed by a focused physical are present, bowel infarction already occurred, and examination. The cardinal signs of internal hemor- the chance of survival in this patient population rhoids are painless bleeding with bowel movements with significant associated comorbidity is reduced. with intermittent protrusion. Intrarectal catheters Ischemic colitis is the most common form of gas- (ie, large bore, soft, silicone catheters with a reten- trointestinal (GI) ischemia, accounting for 50 to 60% tion balloon intended to hold the catheter within of all cases and occurring with an incidence of 4.5 the rectum and create a seal) may be used for the to 44 cases per 100,000 person years. Whether the temporary management of diarrhea and fecal in- inciting event was from occlusive or nonocclusive continence, to protect perineal skin and wounds, disease, ischemic colitis presents with acute-onset and to prevent cross infection. abdominal cramping and abdominal pain. The Bowel perforation results from insult or injury to development of pain is very often associated with the mucosa of the bowel wall resulting from a vio- the urge to defecate and may be followed by the lation of the closed system. Evaluation of a patient development of hematochezia within 24 hours. CT with suspected bowel perforation must focus on is the most helpful in the initial assessment of the a thorough history and physical exam. Computer patient with abdominal pain. In patients who de- tomography (CT) scan is the modality of choice for velop worsening peritonitis, perforated viscous, un- not only diagnosing free air but also for localization controlled bleeding, or failure to improve, surgical of the site of perforation. Most cases will progress intervention is usually required. to require direct investigation via laparoscopic or open (laparotomy) exploration.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 139 Jungwook Suh, Heung-Kwon Oh ■ Common Colorectal Disorders Encountered in the ICU

References Rectal Surg. 2012 Dec;25(4):228–235. 5. The American Society of Colon and Rectal Sur- 1. Ileus in Adults. Tim O.Vilz, Burkhard Stoffels, geons Clinical Practice Guidelines for the Manage- Christian Strassburg, Hans H Schild, and Jörg C ment of Hemorrhoids. Davis Bradley R, Lee-Kong Kalff. Dtsch Arztebl Int. 2017 Jul;114(29-30): 508– Steven A, Migaly John, Feingold Daniel L, Steele 518. Scott R, Diseases of the Colon & Rectum. 2018 2. Acute mesenteric ischemia: guidelines of the March;61(3):284-292 World Society of Emergency Surgery. Miklosh Bala. 6. A Retrospective Review of Outcomes Using a Fe- World Journal of Emergency Surgery. 2017 July;38 cal Management System in Acute Care Patients. 3. Bowel Perforation. Jones MW, Kashyap S, Zabbo Ian Whiteley, Gael Sinclair, Anne Marie Lyons, CP. StatPearls. 2020. Jan Roger Riccardi. Ostomy Wound Manage. 2014 4. Management of Ischemic Colitis. Christopher Dec;60(12):37-43. Washington, Joseph C. Carmichael. Clin Colon

140 KSCCM·ACCC 2020 Myung-Jin Cha ■ Managing Old and New Onset Atrial Fibrillation in the ICU

General Critical Care Update

Managing Old and New Onset Atrial Fibrillation in the ICU

Myung-Jin Cha

Seoul National Univ, Korea August 1 (Sat)

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 141 Sung Yoon Lim ■ Assessment of Renal Function in the Critically Ill Patients

General Critical Care Update

Assessment of Renal Function in the Critically Ill Patients

Sung Yoon Lim

Seoul National Univ, Korea

Accurate assessment of kidney function in crit- challenging in patients with AKI due to fluctuations ically ill patients is important in diagnosing acute in kidney function, creatinine metabolism and flu- kidney injury (AKI). It also plays an important role id balance. There are two newer methodologies in for appropriate dosing of drugs and adjustment of development that allow for direct quantitative GFR therapeutic strategies. Currently, serum creatinine measurement. First technique measures GFR by is used daily as a marker for kidney function and to injecting fluorescent markers with repeated three estimate GFR through regression equations includ- blood samples. Second technology is a transdermal ing the Cockcroft Gault, the Modification of Diet GFR measurement system, which measures fluo- in Renal Disease and the Chronic Kidney Disease rescent compounds through the skin and provides Epidemiology Collaboration equations. However, a new approach for real-time monitoring of glo- creatinine concentration is affected by factors other merular filtration rate. Newer methodologies that than kidney function such as variation in creati- directly measure GFR are in clinical trials and may nine production from muscle mass, and extrarenal offer the enhanced ability to diagnose kidney dys- creatinine excretion. Estimating GFR is even more function rapidly and improve clinical outcomes.

142 KSCCM·ACCC 2020 Motomu Kobayashi ■ Living Donor Lung Transplantation in Children

Pediatric Critical Care: Solid Organ Transplantation in Children

Living Donor Lung Transplantation in Children

Motomu Kobayashi

Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan August 1 (Sat)

Lung transplantation has been as an accepted cross match. treatment for children with end-stage pulmonary parenchymal and vascular disease. But there are Table 1. Comparison of BDLTx and LDLTx few lung transplantations in children because of LDLLTx LDLLTx BDLTx (Adult) (Pediatric) relative paucity of pediatric brain-dead donors. In Surgery Urgent Elective Elective Japan, the current shortage of pediatric brain-dead Ischemic Long Short Short donors is very severe and there are few opportuni- time ties for cadaveric brain-dead donor lung transplan- Graft size adequate small adequate tation (BDLTx). Therefore living-donor lobar lung CPB Not need (Adult) Need Need Need (Pediatric, transplantation (LDLLTx) from relatives has been PH) developed as an alternative therapeutic option for HLA crass △ ○ ○ children with end-stage lung disease. In a standard match Healthy None Two One or two LDLLT, the right and left lower lobes from two donor donors donors healthy donors are implanted into a recipient. In our hospital, donors should be spouse or relatives In Okayama University Hospital, we have ever within third degree with compatible blood type. been experienced 39 pediatric lung transplanta- Donor age should be 20 to 60. tions (under 15 years old) including 30 LDLLTs. The Table 1. shows the comparison between BDLTx most common indication disease is bronchiolitis and LDLLTx. Pediatric LDLLTx has some advan- obliterans, the second is pulmonary hypertension, tages compared to BDLTx or adult LDLLTx. It is an and the third is interstitial pneumonia. Five-year elective surgery. Reperfusion injury is mild because survivals of pediatric lung transplants at Okayama of short ischemic time. Graft size is adequate to University and the world average are 89% and 51%, recipient’s chest cavity. Donors are close relatives respectively. In this lecture, I will talk about the (usually parents) and it may be favorable for HLA perioperative management of pediatric LDLLT.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 143 Seak Hee Oh ■ Liver Failure in PICU

Pediatric Critical Care: Solid Organ Transplantation in Children

Liver Failure in PICU

Seak Hee Oh

Pediatrics, Seoul Asan Medical Center and University of Ulsan

Pediatric acute liver failure (PALF) represents a associated with clinical outcome of PALF. Herein, heterogeneous group with variable etiologies. It appropriate decision making is critical in the man- evokes a dynamic clinical condition manifested by agement of PALF. However, the evidence-based an abrupt onset of a liver-related bleeding tenden- medicine is not available in this rare disease. And cy and severe hepatocellular injury. The clinical precise prediction of natural course of PALF is diffi- course is also so dynamic that rapid and massive cult in the era of liver transplantation. deterioration of a whole liver results in hepatic Herein, PICU doctors have struggled catch-as- encephalopathy and multiple organ dysfunction. catch-can approach in the face of uncertainty. Urgent liver transplantation is the only primary However, as PICU doctors have overcome many treatment. obstacles and established great successes in pediat- Due to donor shortage, urgent liver transplan- ric care, we will break through this and we will save tation can be delayed. In addition, due to sponta- more children with PALF. In this lecture, we will neous resolution from PALF, over-transplantation discuss how we can be discerning clinicians in the should be avoided. The etiology is also directly management of PALF.

144 KSCCM·ACCC 2020 Jin Soo Moon ■ From Home PN to the Intestinal Transplantation

Pediatric Critical Care: Solid Organ Transplantation in Children

From Home PN to the Intestinal Transplantation

Jin Soo Moon

Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, Korea August 1 (Sat)

Intestinal failure (IF) is an increasing disease en- el or non-functioning bowel. To achieve the enteral tity in the field of pediatric nutritional support. Ag- autonomy, we usually try to use the tolerable enter- gressive surgical interventions and supportive cares al nutrition and prevent the intestinal failure asso- targeted for patients with volvulus, necrotizing ciated liver disease (IFALD). Use of omega-3 based enterocolitis and Hirschsprung disease make this emulsion and ursodeoxycolic acids seems to be possible. Recently improved postoperative support- better for the prevention or treatment of pediatric ive care including parenteral nutrition (PN), use of IFALD according to a few reports. For the patients hydrolysate formula, and various enteral feeding with PN dependency, home PN could be applied. protocols make also better outcomes than yester- Process of home PN is a kind of meticulous tech- days. However, about one thirds of the patients with nique. This needs lots of knowledge, understand, extensive bowel loss still could not avoid IF status cooperation both from parents and patients. eventually, so there are many unmet needs for this We are still in shortage of resources for the care of group of patients. IF in children worldwide. Doctors, hospitals man- In this lecture, I will briefly summarize the re- agers, governmental officers, pharmaceutical com- cent advance of pediatric parenteral and enteral panies and families with patients should cooperate nutrition for the children with IF and short bowel together to overcome this big huddle in health of syndrome. Enteral autonomy is the key factor of the children. treatment to overcome the handicaps of short bow-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 145 Joohae Kim ■ Impact of Intervention on the Decision of POLST

Critical Care Ethics

Impact of Intervention on the Decision of POLST

Joohae Kim

National Medical Center, Korea

The Life-sustaining Medical Decision Law for dy- and to be aware of well-dying and life-sustaining ing patients was introduced in 2018 in Korea to stop care. Though several studies have shown the effects meaningless life-sustaining care and to respect pa- of improving communication skills or awareness of tients’ right to self-determination. Two years have death through education, the level of education for passed since its introduction, and although the medical staff still does not appear to be sufficient number of cases relying on decisions to withhold in the field, and the need to educate medical staff or withdraw life-sustaining treatment is steadily about death and life-sustaining care has steadily increasing, the patients’ rights have not been suffi- emerged. Also, the decision about life-sustaining ciently considered. Caregivers may not want to dis- care is not straightforward. Because it contains cuss life-sustaining care with the patients, and they medical and ethical issues, doctors should take this often do not know the patient’s desires. Even in sit- into consideration. uations where a prior decision had been created by So we planned to provide interventions for the the patient, it was sometimes ignored by the family. self-reflection as part of education. In this study, Therefore, the role of medical staff in explaining a questionnaire was administered to investigate the patients’ conditions and in discussing end-of- whether a difference could be made in the decision life care with patients and their caregivers may be to withdraw life-sustaining treatment between two important. For this role as a moderator, physicians groups, which are with or without answering ques- need to be involved in constant communication tions about the quality of dying.

146 KSCCM·ACCC 2020 Jae Young Moon ■ Death Education: Literature Review

Critical Care Ethics

Death Education: Literature Review

Jae Young Moon

Chungnam National Univ. College of Medicine, Repub. of Korea August 1 (Sat)

Palliative care is increasingly accepted as an the opportunity to discuss the deaths of patients in essential component of comprehensive care for the ICU as provided by “Death Rounds” proved to critically ill patients [1]. However, previous studies be a valuable experience to residents. The informal have shown that medical students and residents and conversational approach allowed residents receive limited education about palliative and end- to ask freely basic questions about dealing with of-life care [2]. One survey reported that residents patient death that were not typically addressed on rated case-based, patient-centered, experiential morning rounds. Residents were also encouraged learning favorably on ethics education than formal to delve into ethical and emotional issues [1], [4]. lectures [3]. The critical care physicians working in Although it did not reach statistical significance, Korean ICUs have faced the issues of withholding their study show a trend toward decreased avoid- and withdrawing of life-sustaining treatment since ance of end-of-life discussions with patients and the law of ‘Korean Patient Self-Determination Act’ families, and improved comfort with communica- was enforced at Feb. 2018. We need to identify the tion at the end-of-life [4]. physicians’ attitudes on the palliative and the EOL A national survey for US academic medical cen- care in the ICU and to find the effective education- ters revealed that fewer 18% of medical students al method. and residents received formal end-of-life care edu- Catherine and colleagues introduced an interest- cation, 39% of students reported being unprepared ing work “Death Rounds” a monthly discussion of to address patients’ fears, and nearly half felt un- the issues and emotional surrounding the care of prepared to manage their feelings about patients’ dying patients as an academic article over a decade death or help bereaved families [5]. Now we know ago. They paid attention to the fact that residents that improving physician education requires im- complained about the feeling unprepared to care plementation of structured, system wide plans for for dying patients and that the commonly used lec- education of students, residents, and faculty [5]. ture based format was not effective for coping with There are lots of barriers to better integration of emotional and personal aspects of caring for dying palliative care and critical care [1]. One example, patients. Through their report, they suggested that attending physician preferences in withdrawal of

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 147 Jae Young Moon ■ Death Education: Literature Review life support decisions strongly affect residents’ atti- References tude and competency for end-of-life care [3]. 1. R.A. Aslakson, J.E. Nelson, et al. The Changing Multiple societies representing critical care pro- Role of Palliative Care in the ICU. Crit Care Med fessionals have published practice recommen- 2014;42:2418–2428 dations and/or guidelines related to important 2. C.L. Hough, J.R. Curtis, et al. Death Rounds: end- aspects of ICU palliative care [1]. ICU clinicians of-life discussions among medical residents in the intensive care unit. J of Crit Care 2005;20:20–25. should strengthen their knowledge and skills for 3. L. Stevens, J. McMullin, et al. Education, ethics, providing palliative care as a routine part of their and end-of-life decisions in the intensive care unit. critical care practice [1]. Existing educational tools Crit Care Med 2002;30:290–296 and/or an effective way of “Death Rounds” en- 4. L. Smith, C.L. Hough. Using Death Rounds to Im- prove End-of-Life Education for Internal Medicine able ICU providers to improve their palliative care Residents. J of Palliative Med. 2011;14(1):55-58. knowledge and skills. 5. A.M. Sullivan, S.D. Block, et al. The Status of Med- ical Education in End-of-life Care; A National Re- port. J GEN INTERN MED 2003;18:685-695.

148 KSCCM·ACCC 2020 So Young Park ■ Moral Injury - Suffering of Physicians Facing the Death of Patients

Critical Care Ethics

Moral Injury - Suffering of Physicians Facing the Death of Patients

So Young Park

Ewah University Seoul Hospital, Pulmonary and Critical Care Medicine August 1 (Sat)

Despite remarkable advances in medicine, the care they provide. physician should face the patient’s death. While After the death of a patient, a doctor may need to they may never forget their first experience of a prepare a report for a significant event investigation patient dying, they soon become accustomed to or the coroner, or attend an inquest as a witness. death as a part of their working lives. Achieving a For thousands of years, Confucian thought has balance between retaining compassion and staying deeply influenced the culture, philosophy, societal detached enough to be able to do their job is one values, and ethical considerations in Korea. These of the attributes that a doctor must develop and countries have family-based and harmony-orient- maintain. Doctors may be affected by the death ed ethical systems, and consequently, social norms of a patient they knew well, or because of the cir- such as a Confucian way of life, filial piety, and cumstances surrounding the death. They may have familial relationships are stressed more than indi- associated feelings of self doubt, helplessness, guilt, vidual rights. So there can be many barrier commu- or failure, or they may be worried that they will be nication among physician, family and patients in criticised for their involvement in the patient’s care. front of patients’ death. In a study of oncologists in Canada, researchers Disputes in medical settings often resulted from found that grief was considered shameful and un- not only medical judgments but also hidden causes, professional. Doctors in the study said they wres- such as economic problems; a common experience tled with feelings of grief, but hid those feelings of clinicians treating critically ill patients. Some- from others because showing emotion was consid- times, economic factor could be affect patient’s ered a sign of weakness. The researchers reported death. So Economic problems can be another fac- that the impact of the unacknowledged grief was tor of physician’s distress in the face of a patient's inattentiveness, impatience, irritability, emotional death. exhaustion, and burnout. They concluded that the During the past 40 years, we have become all too professional taboo around grief had negative con- familiar with the dehumanisation of modern medi- sequences for doctors, as well as for the quality of cine: new technologies have altered the relationship

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 149 So Young Park ■ Moral Injury - Suffering of Physicians Facing the Death of Patients between doctor and patient; specialised physicians References know more and more about less and less; doctors 1. Wible P. Heart wrenching photo of doctor crying treat diseases rather goes viral: here’s why. 2015. www.idealmedical- than people. However, the doctor's suffering is care.org/blog/heart-wrenching-photo-of-doctor- unavoidable in front of patient’s death. There are crying-goes-viral-heres-why/.\ no quick fixes for the suffering of physicians, just 2. Granek L. When doctors grieve.2012. www.ny- times.com/2012/05/27/opinion/sunday/when- as there are no quick fixes for the suff ering of -pa doctors-grieve.html. tients. In some instances, physicians themselves 3. Rose D. Patient loss: surgeons describe how they need professional care. Alternatively, or in addition cope 2015. bulletin.facs.org/2015/02/patient-loss- to obtaining therapy for themselves, doctors must surgeons-describe-how-they-cope/. 4. Srivastava R. Some patients die: as a doctor I seek—and institutions must provide—avenues for have to live with this inevitable fact. 2015. www. dialogue that allow renewal, self-care, mutual sup- theguardian.com/commentisfree/2015/mar/20/ port, and reflection. In turn, self-care must be seen patients-die-doctor-grief. not as an option but as an obligation. The obligation 5. Meier D, Back A, Morrison R.The inner life of phy- to care for the patient entails the obligation to care sicians and care of the seriously ill. JAMA 2001; 286: 3001–14. for the self, for when the health of the physician is 6. Waldman SV, Diez JC, Arazi HC, et al. Burnout, compromised, is not the quality of patients’ care perceived stress, and depression among cardiology also compromised? We are just beginning to realise residents in Argentina. Acad Psychiatry 2009; 33: that humanising medicine depends in no small part 296–301. on recovering the humanity of physicians. 7. Yasunaga H. The catastrophic collapse of morale among hospital physicians in Japan. Risk Manage Healthcare Policy 2008; 1: 1–6.

150 KSCCM·ACCC 2020 Yang Hyun Cho ■ Extracorporeal Life Support for Heart Transplantation

Extracorporeal Life Support

Extracorporeal Life Support for Heart Transplantation

Yang Hyun Cho

Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center August 1 (Sat)

Venoarterial (VA) extracorporeal life support tion system vary widely by region and country. (ECLS) is a type of non-durable, temporary me- The outcomes of HTx performed directly after chanical circulatory support (MCS) for patients ECLS have been poor. Therefore, ECLS is generally in cardiogenic shock. ECLS can be initiated either replaced by LVAD as a BTT or a bridge to candidacy for newly diagnosed acute cardiac failure or for (BTC). Patients who undergo LVAD implantation as decompensated end-stage heart failure in patients a BTT or BTC may face more surgical risk and high- awaiting heart transplantation (HTx). Although a er costs than those who proceed directly to HTx. durable left ventricular assist device (LVAD) is a Because the highest priority status for HTx includes choice of MCS for bridge to transplantation (BTT), the use of non-durable MCS such as ECLS in some it has many contraindications, such as intolerance countries (e.g., the United States and South Korea), of a vitamin K antagonist, poor right ventricular the short waiting time may justify HTx directly after function, restrictive cardiomyopathy, a severe intra- non-durable MCS. Some critical care physicians cardiac problem, and patient’s refusal to use long- believe that the mortality related to ECLS is attrib- term MCS. Furthermore, the health care system, utable to more than only extracorporeal circulation. availability of devices, patient’s insurance policy, I will review current evidences and my experience sociocultural background, and organ transplanta- of this.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 151 Young-Nam Youn ■ LVAD in Heart Failure

Extracorporeal Life Support

LVAD in Heart Failure

Young-Nam Youn

Division of Cardiovascular Surgery, Severence Caredivascular Hospital, Yonsei University College of Medicine, Seoul, Korea

The mortality rate for the most advanced forms of data on nearly 20,000 patients that have received a heart failure with medical therapy alone remains durable LVAD since 2006. Registrants are primar- unacceptably high at 30% to 80% at 1 year. In the ily male (14,450 of 19 013 [76.0%]), white (12,738 past decade, left ventricular assist devices (VAD) [67.0%]), and aged 60 to 80 years (8,555 [45.0%]), have assumed an increasingly prominent role in with nearly half of these patients (9,126 [48.0%]) the management of these patients. The rapid in- implanted for DT. Patient selection for mechanical crease in the number of patients with advanced HF circulatory support requires integration of multiple has led to substantial progress in VAD technologies data elements to identify those with an illness se- to provide durable long-term support, including verity that predicts treatment benefit while simulta- revolution in pump design, miniaturization, and neously excluding patients with comorbidities that enhanced durability, which have been associated make meaningful survival unlikely. A 2015 non- with significant improvements in outcomes. randomized prospective cohort study (ROADMAP) Ventricular assist devices are intended to sup- compared the outcomes of non–inotrope-depen- plement or totally replace the cardiac output re- dent patients with HF treated with either medical quired to support systemic circulation. This goal therapy or LVAD therapy. The study demonstrated is achieved by removing blood (preload) from the that LVAD-treated patients had superior event-free left ventricle and ejecting it into the proximal aorta. survival and improvement in submaximal exercise These devices are capable of generating up to 8 to performance but more frequent adverse events 10 L of flow based on pump speed, preload, and than the medically managed cohort. Advanced blood pressure. age, other organ dysfunction (kidney, liver, etc), and right heart dysfunction have known to be sig- Indication for Mechanical Circulatory nificant risk factors for LVAD implantation. While Support LVADs improve quality of life and reduce mortality, the therapy requires significant commitment by The Interagency Registry for Mechanically Assist- patients and their caregivers. Careful screening of ed Circulatory Support (INTERMACS) has collected medical compliance, adequate resources, a com-

152 KSCCM·ACCC 2020 Young-Nam Youn ■ LVAD in Heart Failure mitted caregiver, and exclusion of ongoing sub LVAD by 2010. stance use or active psychiatric disease are require- ments

Current use of LVAD (2nd generation LVAD: continuous flow design)

- HeartMate II - The greatest advance in the field of LVAD therapy was the change from pulsatile to continuous flow - HeartWare HVAD- design. This change was in response to clinician Another significant advance in the field was the August 1 (Sat) calls for greater durability and a smaller device introduction of the HeartWare HVAD (Medtronic with easier placement. The first continuous flow Corp), which was the first LVAD to be entirely con- LVAD approved for use was the HeartMate II (Ab- tained within the pericardial space, eliminating the bott Laboratories). While only one-fifth the size of need fora pump pocket. The HVAD uses a centrif- Heart Mate vented electric LVAD, it still required ugal rather than axial flow design as well as partial placement in a preperitoneal pocket. The first pro- magnetic levitation to suspend the rotor, eliminat- spective evaluation of HeartMate II was a single- ing the presence of bearings in the bloodstream. arm prospective observational study of 133 patients The HVAD BTT trial used a noninferiority design comparing outcomes of the patients requiring in 140 patients with BTT that were compared with Bridge-to-transplant (BTT) VAD with previously 499 patients contemporaneously enrolled in IN- established survival criteria. Of the 133 enrollees, TERMACS. Survival to 180 days, transplant, or 100 (75.2%) successfully achieved the primary end device explantation for recovery was achieved in point of being alive on device support, receiving 91% of the patients receiving HVAD and was non- transplantation, or having their device removed inferior to the control cohort. The HVAD was also for recovery at 180 days. Based on the results of the studied in the Evaluate the HeartWare Ventricular extended trial, the HeartMate II received approval Assist System for Destination Therapy of Advanced as a BTT device. The HeartMate II was also studied Heart Failure trial in a DT population (n = 446) in a randomized clinical trial37 that compared the and was found to be noninferior to HeartMate II device with the HeartMate vented electric LVAD at 24 months (55.4% vs 59.1%) for the end point of in a population receiving DT. Patients treated with death, disabling stroke, or removing the device for HeartMate II had a 4-fold higher likelihood of be- malfunction or failure. In this trial, the patients re- ing alive without disabling stroke or the need to ceiving HeartMate II were statistically more likely repair or replace the device at 2 years. The degree to require device exchange, and patients receiving of improvement in outcomes with the continuous HVAD were more likely to experience a stroke. The flow design led to the total discontinuation of pro- trial achieved the primary end point of noninferior- duction of the pulsatile HeartMate vented electric ity with nearly identical results.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 153 Young-Nam Youn ■ LVAD in Heart Failure

wider blood flow gaps mitigate some of the adverse events seen with LVADs.

- HeartMate 3 - The newest LVAD to have completed clinical tri- al is the HeartMate 3 (Abbott Laboratories). This Complications and Adverse Events centrifugal flow pump is also contained within the The INTERMACS has become the accepted stan- pericardium, uses full magnetic levitation, and was dard for reporting the incidence of adverse events designed to mitigate the risks of pump thrombosis in patients supported with LVADs. Nearly 80% of all seen with the HeartMate II and HeartMate HVAD. patients will experience an important adverse event The results of the US MOMENTUM 3 trial, which within the first year following LVAD implantation. randomized 294 patients intended for either BTT The incidence of stroke in patients with LVAD is or DT indication, were published in 2017. There 15% to 29% per year and appears to be dependent were no VAD thromboses reported in patients with on the device. The pathogenesis of stroke is com- HeartMate 3 through 6 months vs 10% in those plex and related to the characteristics of blood flow receiving HeartMate II. However, the incidence of in the pump, activation of the coagulation cascade stroke and bleeding were similar between the 2 de- via contact of blood components with the metal vices. The rates of survival free from disabling stroke housing of the device, ingestion of the thrombus or the need to repair or replace the device was sta- from the native ventricle, and the requisite use of tistically superior with HeartMate 3. The long-term anticoagulation therapy to prevent device throm- cohort from the MOMENTUM 3 trial demonstrated bosis. Risk factors for ischemic stroke with the superiority of the HeartMate 3 LVAD compared commercially available centrifugal flow devices with the HeartMate II when examining the com- include low doses of antiplatelet or anticoagulation bined end point of survival free from disabling medication and systolic blood pressure level great- stroke or the need to reoperate to repair or replace er than 90 mm Hg, whereas risk factors for hemor- the device. The improved outcome was driven rhagic stroke include low doses of aspirin, elevated by fewer device replacements mainly for pump international normalized ratio, and systolic blood thrombosis (1.6% vs 17%; P < .001). The stroke risk pressure level greater than 90 mm Hg. was also reduced with HeartMate 3 compared with Gastrointestinal bleeding occurs in nearly one- HeartMate II (10.1% vs 19.2%; P = .02). Taken to- third of patients treated with a continuous flow gether, these data strongly support the concept that LVAD. Prior work has demonstrated that all pa- a magnetically levitated centrifugal flow device with

154 KSCCM·ACCC 2020 Young-Nam Youn ■ LVAD in Heart Failure tients develop acquired von Willebrand disease ical trials, including the use of variable amount of related to high shear forces in the device. The pulsatile flow and placement, as well as new sur- breakdown of the high-molecular-weight von Wil- gical approaches, such as thoracotomy and use of lebrand protein causes a primary coagulopathy biventricular support. In addition, there are new that increases the incidence of mucosal bleeding. surgical approaches to implantation, including by In addition to the coagulopathy, there is a high- thoracotomy as well as remote charging of batter- er-than-predicted incidence of mucosal arterio- ies and telemetric assessment of device function. venous malformations. While the pathogenesis There has been very substantial progress in the field of arteriovenous malformations has not been of VADs for both temporary and durable support clearly elucidated, there is growing evidence that of the circulation. The future will focus on further August 1 (Sat) elevated levels of angiopoietin 2 may play a role. investigation into modifications in device design to Left ventricular assist device thrombosis is another improve outcomes and patient satisfaction for this challenging device complication that frequently re- continually enlarging population of patients. quires replacement for effective management and has been the subject of significant investigation. References The incidence of LVAD thrombosis appears to be 1. Kirklin JK, Pagani FD, Kormos RL, et al. Eighth an- somewhat specific to the device. An increase in de- nual INTERMACS report: special focus on framing vice thrombosis with the HeartMate II was reported the impact of adverse events. J Heart Lung Trans- in 2014 but appears to have been mitigated in a plant. 2017;36(10):1080-1086. later study that focused on meticulous surgical im- 2. Miller LW, Guglin M. Patient selection for ventric- ular assist devices: a moving target. J Am Coll Car- plantation technique and postimplantation medi- diol. 2013;61(12):1209-1221. cal therapy. 3. Aaronson KD, Slaughter MS, Miller LW, et al; Device-related infections are common causes of HeartWare Ventricular Assist Device (HVAD) LVAD morbidity, with most infections linked to the Bridge to Transplant ADVANCE Trial Investigators. Use of an intrapericardial, continuous-flow, cen- percutaneous driveline. Failure to stabilize the exit trifugal pump in patients awaiting heart transplan- site may result in poor tissue incorporation and tation. Circulation. 2012;125(25):3191-3200. ascending infection. While treatment with target- 4. Rogers JG, Pagani FD, Tatooles AJ, et al. Intraperi- ed short-term antibiotic therapy may be effective, cardial left ventricular assist device for advanced it is common to require either long-term antibi- heart failure. N Engl J Med. 2017;376(5): 451-460. 5. Mehra MR, Naka Y, Uriel N, et al; MOMENTUM 3 otic therapy or surgical debridement for control. Investigators. A fully magnetically levitated circu- Deep-tissue infections related to the pump or the latory pump for advanced heart failure. N Engl J surgical implantation are often more difficult to Med. 2017;376(5):440-450. treat and may lack definitive therapy. 6. Rogers JG. Managing VAD complications: our growth industry. J Am Coll Cardiol. 2016;67(23): 2769-2771. Conclusion 7. Han JJ, Acker MA, Atluri P. Left Ventricular Assist Many new devices and designs are entering clin- Devices. Circulation. 2018;138(24):2841-51.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 155 Min Ho Ju ■ Back-Flow Arteriovenous Shunt Test for Weaning of VA ECMO

Extracorporeal Life Support

Back-Flow Arteriovenous Shunt Test for Weaning of VA ECMO

Min Ho Ju

Pusan National Univ, Korea

Venoarterial (VA) extracorporeal membrane ox- od from VA ECMO applied for pediatric patients, ygenation (ECMO) has contributed to improving creates shunt flow from the arterial system to the the survival of patients with cardiovascular system venous system by reducing the pump flow to create failure for decades. The use of VA ECMO is annu- a negative flow. This method could be easily im- ally increasing, as its effectiveness and availability plemented by turning the pump dial without any are proven. However, despite increasing clinical invasive procedures and withdrawn any time. In practices for VA ECMO, its weaning strategies have this way, we can simulate a condition without me- not been well established. chanical support in the cardiovascular system and The Extracorporeal Life Support Organization check whether the patient could be weaned from provides guidelines for weaning from VA ECMO, VA ECMO. but the protocols suggested are ambiguous and the In a previous report, the PCRTO was reported to description of the method is not specific. Previous be simple and feasible without thromboembolic studies introduced some techniques or available events. However, related studies remain lacking. parameters for weaning from VA ECMO. However, The subjects of previous studies were mainly pe- no widely accepted specific consensus exists due to diatric patients, and reports on adult patients are various clinical limitations. Recently, a few papers insufficient. Therefore, we would like to share our have reported a backflow arteriovenous shunt test hospital experience with BAVST in adult patient (BAVST) for weaning from VA ECMO called pump and discuss existing ECMO weaning strategies, dif- controlled retrograde trial off (PCRTO). ferences and pros and cons. The BAVST, mainly introduced as weaning meth-

156 KSCCM·ACCC 2020 Do Kyun Kim ■ Preview of 2020 Korean Guidelines for Pediatric Life Support

Cardiopulmonary Resuscitation 2020

Preview of 2020 Korean Guidelines for Pediatric Life Support

Do Kyun Kim

Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea August 1 (Sat)

Pediatric out-of-hospital cardiac arrest is rare in and the whole process will mainly take adaptation children in comparison to that in adults. Also it has review method. It seems that there will be little been well known as being associated with high mor- change to current practice when we analyze the re- tality and severe neurological sequelae. However, cent researches so far. However, it is meaningful in outcomes from pediatric in-hospital cardiac arrest that they are based on new evidence from pediatric (IHCA) have markedly improved over the past de- populations, instead of extrapolation from adult cade (survival to hospital discharge, 24% to 39%). data. Unfortunately, high-level clinical research on pe- There are already some good examples for review- diatric resuscitation is far from sufficient compared ing about the relatively well-founded items. For to that of adults. Although many of the guidelines for airway management, under Class 2a recommenda- pediatric resuscitation have been based on extrapo- tion, BMV is reasonable compared with advanced lation of adult research or on extrapolation, studies airway interventions (endotracheal intubation or have been conducted late but recently lacking. SGA) in the management of children during cardi- In 2015, some parts of guidelines were changed ac arrest in the out-of-hospital setting. In addition, after reflecting the results of several studies, such as several large studies on TTM in pediatric patients ventilation during CPR with an advanced airway (1 have recently been published. The results of review breath every 6 seconds), careful fluid resuscitation, by our experts are also thought to be similar as antiarrhythmic drugs for refractory VF or pulseless follows: TTM of 32°C to 34°C followed by 36°C to VT, extracorporeal CPR for IHCA and targeted tem- 37.5°C, or to use targeted temperature management perature management (TTM) proposals with more of 36°C to 37.5°C, for pediatric patients who remain robust evidence. comatose after resuscitation from out-of-hospital A systematic review and renewal of guidelines cardiac arrest or in-hospital cardiac arrest. for Korean pediatric basic life support (PBLS) and pediatric advanced life support (PALS) in 2020 is References currently underway. The number of PICO ques- 1. Duff JP, Topjian AA, Berg MD, et al. 2019 American tions of PBLS and PALS in Korea has been set at 29 Heart Association focused update on pediatric

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 157 Do Kyun Kim ■ Preview of 2020 Korean Guidelines for Pediatric Life Support

advanced life support: An update to the American Paediatric Advanced Life Support Task Force, Feb- Heart Association guidelines for cardiopulmonary ruary 08, 2019. https://costr.ilcor.org/document/ resuscitation and emergency cardiovascular care. advanced-airway-interventions-in-pediatric-car- Pediatrics 2020; 145((1):e20191361. diac-arrest. updated January 24, 2020 2. Duff JP, Topjian AA, Berg MD, et al. 2019 Ameri- 4. Aickin RP, de Caen AR, Atkins DL, et al; on behalf can Heart Association focused update on pediatric of the International Liaison Committee on Resus- basic life support: An update to the American citation Pediatric Life Support Task Force. Pediat- Heart Association guidelines for cardiopulmonary ric targeted temperature management post cardiac resuscitation and emergency cardiovascular care. arrest: Consensus on Science With Treatment Rec- Pediatrics 2020;145(1):e20191358. ommendations. International Liaison Committee 3. Nuthall G, Van de Voorde P, Atkins DL, et al. Ad- on Resuscitation (ILCOR) Pediatric Life Support vanced Airway Interventions in Pediatric Cardiac Task Force, February 25, 2019. https://costr.ilcor. Arrest- Paediatric Consensus on Science with org/document/pediatric-targeted-tempera- Treatment Recommendations: International ture-management-post-cardiac-arrest. updated Liaison Committee on Resuscitation (ILCOR) January 10, 2020.

158 KSCCM·ACCC 2020 Ki Young Jeong ■ Effectiveness and Rationale of Sodium Bicarbonate during CPR

Cardiopulmonary Resuscitation 2020

Effectiveness and Rationale of Sodium Bicarbonate during CPR

Ki Young Jeong

Department of Emergency Medicine, Kyung Hee University Hospital August 1 (Sat)

Sodium bicarbonate (SB) was frequently used in contractility are minor (less than 25%), even at for severe metabolic acidosis during cardiac arrest an extremely low pH (6.5 to 6.8), and in vivo the until the early 1990’s [1,2]. However, at the present decreased effect of catecholamine showed offset time, SB administration in cardiac arrest is contro- response by increased catecholamine production versial and frequency of its use varies greatly be- during acidemic states. Therefore, debate regarding tween clinicians, because of concerns regarding its the use of SB in CPR has been ongoing for decades. potential benefit vs. harm [3,4]. Clinically, cardiac arrest causes severe disruption Metabolic acidosis has been considered a poten- of homeostasis. Tissue hypoxia from hypoperfusion tial cause of adverse outcome in cardiac arrest. It or hypoventilation leads to anaerobic metabolism has been thought to change contractility of isolated with reduced adenosine triphosphate generation cardiac myocytes in an acidemic environment, and increased lactic acid accumulation, thereby leading to decrease cardiac output [5-7]. And, sev- resulting in metabolic acidosis with decreased eral studies reported that the severe acidosis re- plasma pH [11,12]. Moreover, respiratory failure sulting from global hypoperfusion in cardiac arrest reduces CO2 elimination, resulting in respiratory diminished the response of cardiac myocytes and acidosis with CO2 accumulation. Consequentially, vascular cells to catecholamines, which theoretical- impaired oxygen tissue delivery with combined ly could contribute to decreased cardiac output and severe acidosis induces cell damage, as evidenced hypotension [8-10]. Taking these into consideration, by cardiac dysfunction from decreased myocardial the assumption behind using SB in cardiac arrest contractility and hypotension that can progress to was based on pathophysiologic considerations, multi-organ failure. Because of concerns regarding normalization of extracellular and intracellular pH the deleterious effects of acidosis, clinicians have which were considered an important endpoint of used SB as buffer to offset the high acid production, resuscitation. However, because these theoretical in an attempt to regain the normal homeostasis of harms of acidosis are primarily based on animal body in cardiac arrest. However, contrary to their and in vitro studies, the clinical application of these expectations, recent clinical data suggest that SB results is inconclusive. In addition, the reductions administration can have detrimental effects during

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 159 Ki Young Jeong ■ Effectiveness and Rationale of Sodium Bicarbonate during CPR cardiac arrest, including reduced cardiac output and QRS narrowing in cases of cardiac arrest from with increased intracellular acidosis, reduced oxy- hyperkalemia or TCA (class IIb recommendation, gen tissue release with increased affinity of hemo- LOE-C) [16]. In cases where clinicians choose to ad- globin for oxygen (shift of the oxygen dissociation minister SB, it should be given as IV bolus or by IV curve to the left), hypernatremia and hyperosmo- infusion, with standard dose being 1 mg/kg of body larity [13]. As increased concentration of blood and weight as initial dose, followed by 0.5 mg/kg every tissue CO2 leads to dysfunctions of major organs, 10 min for the duration of the arrest. A 50-mL bolus in particular, including the heart, it may be detri- of SB will raise serum pH approximately 0.1 of a pH mental to cardiac resuscitation. In the human trials unit [16]. The guidelines emphasize that acidosis studying the use of SB in cardiac arrest, they show are dynamic processes resulting from the absence no benefit and even possible harm. Although, sev- of blood flow in cardiac arrest [5], therefore high eral human studies have reported the benefits of quality CPR and early defibrillation in attempt to SB administration in cardiac arrest, they are mostly restore spontaneous circulation are the best meth- dated before 1990, at a time when SB administra- ods to restore acid-base balance, with additional tion was routine during CPR, even though without benefit gained by ventilation. evaluation the acid-base status in the majority of The ACLS guidelines mentioned significant po- cases. Moreover, in cardiac arrest of prolonged tential adverse effects related to SB administration duration, the usefulness of SB administration has during cardiac arrest, including inactivation of si- remained unclear with the concerns about possible multaneously administered catecholamines, reduc- its detrimental effects: some studies have suggested tion of systemic vascular resistance, hypernatremia, a beneficial role for SB in the treatment of meta- hyperosmolality and extracellular alkalosis despite bolic acidosis, while other studies showed that SB intracellular PCO2 excess [16]. Drug administration administration may be counter-productive because still has a role in attempts to improve organ perfu- it increases tissue and central venous CO2 tension. sion during CPR, facilitate electrical defibrillation, Although SB has been part of standard therapy for reduce myocardial irritability, terminate malignant treatment of acidosis, data published over the last ventricular arrhythmias, minimize metabolic de- two decades do not support its use in cardiac arrest. rangements and protect the brain from the effects In response to concerns raised by these studies, of ischemia [17]. SB administration is only advised routine use of SB in cardiac arrest has been dis- at the discretion of the clinician directing the re- couraged, and the AHA has deemphasized its use suscitation, based on to patients’ clinical status or in the ACLS algorithms. The 2010 and 2015 ACLS results of blood gas analysis [18]. guidelines for adults state that “Routine use of sodi- um bicarbonate is not recommended for patients in References cardiac arrest” (class III recommendation, based on 1. Standards for cardiopulmonary resuscitation LOE-B) [14,15]. And, the guidelines recommend bo- (CPR) and emergency cardiac care (ECC). 3. lus SB administration as needed for hemodynamic Advanced life support. JAMA 1974;227(7 Sup- stability (adequate mean arterial blood pressure) pl):852–860.

160 KSCCM·ACCC 2020 Ki Young Jeong ■ Effectiveness and Rationale of Sodium Bicarbonate during CPR

2. Batenhorst RL, Clifton GD, Booth DC et al. Eval- ceptors in escape from sympathetic vasoconstric- uation of 516 cardiopulmonary resuscitation at- tion. Am J Physiol 1991;261(3 Pt 2):H868–873. tempts. Am J Hosp Pharm 1985;42(11):2478–2483. 11. Mizock BA, Falk JL. Lactic acidosis in critical ill- 3. Bar-Joseph G, Abramson NS, Kelsey SF, et al. Im- ness. Crit Care Med 1992;20(1):80–93. proved resuscitation outcome in emergency med- 12. Stacpoole PW. Lactic acidosis. Endocrinol Metab ical systems with increased usage of sodium bi- Clin North Am 1993;22(2):221–245. carbonate during cardiopulmonary resuscitation. 13. Adgey AA. Adrenaline dosage and buffers in cardi- Acta Anaesthesiol Scand 2005;49(1):6–15. ac arrest. Heart 1998;80(4):412–414. 4. Velissaris D, Karamouzos V, Koniari C, et al. Use 14. Neumar RW, Otto CW, Link MS, et al. Part 8: of Sodium Bicarbonate in Cardiac Arrest: Current adult advanced cardiovascular life support: 2010 Guidelines and Literature Review J Clin Med Res American Heart Association Guidelines for Car- 2016; 8(4): 277–283. diopulmonary Resuscitation and Emergency Car- August 1 (Sat) 5. Orchard CH, Kentish JC. Effects of changes of pH diovascular Care. Circulation 2010;122(18 Suppl on the contractile function of cardiac muscle. Am J 3):S729–767. Physiol 1990;258(6 Pt 1):C967–981. 15. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: 6. Tang WC, Weil MH, Gazmuri RJ, et al. Reversible Adult Advanced Cardiovascular Life Support: 2015 impairment of myocardial contractility due to American Heart Association Guidelines Update for hypercarbic acidosis in the isolated perfused rat Cardiopulmonary Resuscitation and Emergency heart. Crit Care Med 1991;19(2):218–224. Cardiovascular Care. Circulation 2015;132(18 Sup- 7. Beierholm EA, Grantham RN, O’Keefe D, et al. pl 2):S444–464. Effects of acid-base changes, hypoxia, and cate- 16. Vanden Hoek TL, Morrison LJ, Shuster M, et al. cholamines on ventricular performance. American Part 12: cardiac arrest in special situations: 2010 Journal of Physiology 1975; 228(5):1555–1561. American Heart Association Guidelines for Car- 8. Leitch SP, Patterson DJ. Interactive effects of K+, diopulmonary Resuscitation and Emergency Car- acidosis, and catecholamines on isolated rabbit diovascular Care. Circulation. 2010;122(18 Suppl heart: implications for exercise. J Appl Physiol 3):S829–861. 1994;77(3):1164–1171. 17. Vincent R. Drugs in modern resuscitation. Br J An- 9. Tajimi K, Kosugi I, Hamamoto F, et al. Plasma cat- aesth. 1997;79(2):188–197. echolamine levels and hemodynamic responses of 18. Steedman DJ, Robertson CE. Acid base changes severely acidotic dogs to dopamine infusion. Crit in arterial and central venous blood during car- Care Med 1983;11(10):817–819. diopulmonary resuscitation. Arch Emerg Med. 10. Chen LQ, Shepherd AP. Role of H+ and alpha 2-re- 1992;9(2):169–176.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 161 Wook-jin Choi ■ Post Cardiac Arrest Care after In-Hospital Cardiac Arrest Focusing on Targeted Temperature Management (TTM)

Cardiopulmonary Resuscitation 2020

Post Cardiac Arrest Care after In-Hospital Cardiac Arrest Focusing on Targeted Temperature Management (TTM)

Wook-jin Choi

Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Seoul, Korea

According to data from the Health Insurance Re- 2. Minimize cerebral damage view and Assessment Service in Korea, about 2.46 It is recommended to minimize the cerebral dam- patients per 1,000 inpatients were diagnosed in age by controlling the target body temperature after hospital [4]. The prognosis of cardiac arrest patients resuscitation with the target temperature manage- has improved in recent years with the development ment (TTM) based on new evidence (Class I, LOE of CPR and post-cardiac arrest treatment. In partic- C-EO for IHCA). ular, with the introduction of targeted temperature 3. Treatment of hemodynamic dysfunction management and interventions, which are an im- It is recommended to recognize and correct hypo- portant part of the treatment process, the long-term tension immediately after resuscitation after cardi- prognosis of patients who successfully resuscitate ac arrest. after cardiac arrest is also improving. In the revised American Heart Association Pro- 4. Control of fever after targeted temperature man- fessional Heart Resuscitation Guidelines (2015 CPR agement Guidelines Part 8), the following major problems It is recommended to prevent fever after targeted and goals were presented during the post-cardiac temperature management is accomplished, and fe- treatment process [2]. ver is very harmful to the patient.

5. Prognostication HIGHLIGHTS Prognostication is now recommended no sooner

1. Diagnosis and correction of cause of cardiac arrest than 72 hours after the completion of TTM; for those who do not have TTM, prognostication is not recom- Emergency cardiovascular angiography is rec- mended any sooner than 72 hours after ROSC. ommended for patients with electrocardiographic or hemodynamically unstable patients who have 6. Organ donation elevated ST segments or no suspected ST segment All patients who progress to brain death or circulatory elevation. arrest after initial cardiac arrest must consider whether organ donation is possible (Class I, LOE B-NR).

162 KSCCM·ACCC 2020 Wook-jin Choi ■ Post Cardiac Arrest Care after In-Hospital Cardiac Arrest Focusing on Targeted Temperature Management (TTM)

function of the airway device must be checked to prevent cardiac arrest caused by the respiratory sys- tem. It is recommended to insert a nasogastric tube for stomach decompression. Try to maintain normal

carbonic acid (normocapnia, PaCO2 35-45 mmHg or

ETCO2 30-40 mmHg) with mechanical ventilation (Class IIb, LOE B-NR). In addition, oxygen saturation should be maintained at 94% or higher by supplying

adequate oxygen, but excessive oxygen supply (PaO2 ≥ 300 mmHg) can be harmful, so it is recommended August 1 (Sat) to administer oxygen with appropriate FiO2 when oxygen saturation is 100% (Class IIa, LOE C-LD).

Considerations for hemodynamics It is necessary to prevent hypotension (systolic Figure 1. Post-Cardiac Arrest Care Algorithm (2015 American blood pressure <90 mmHg or mean arterial pres- Heart Association Guidelines Update)[2] sure <65 mmHg) during resuscitation and immedi- ately correct the hypotensive state through admin- istration of appropriate fluids and vasoconstrictor Diagnosis and correction of cause of cardiac arrest drugs (Class IIb, LOE C-LD). There is insufficient To find out the cause of cardiac arrest, related evidence to administer antiarrhythmic drugs in- tests, including electrocardiogram (Class I), medical cluding beta-blockers to all patients after sponta- history and physical examination are performed. neous circulation recovery. The most common causes of acute cardiac arrest are acute myocardial infarction, cardiomyopathy Core body temperature control and target body tem- and arrhythmia. perature maintenance treatment Emergency coronary angiography should be per- Among patients who have recovered spontaneous formed for all patients with suspected cardiac arrest circulation after cardiac arrest, all patients who are due to cardiovascular disease and showing an ST consciously comatose should have the core body segment elevation on the electrocardiogram (Class temperature managed at 32-36°C for at least 24 I, LOE B). Emergency cardiovascular angiography is hours (Class I, LOE C-EO for IHCA) (Class I, LOE also considered regardless of whether the patient's BR). It is also recommended to control fever for 24 consciousness is clear, even in the case of adult pa- hours even after the end of target body temperature tients with cardiac arrest outside the hospital (Class treatment (Class IIb, LOE C-LD). IIa, LOE B-NR), where the elevation of the uncon- scious ST segment with electrical or hemodynamic Other neurocritical care instability is not remarkable (Class IIa, LOE C-LD). After recovery of spontaneous circulation, it is recommended to conduct an EEG to diagnose the Respiratory care considerations occurrence of convulsions, and to interpret the re- After resuscitation is successful, the location and sults, and to monitor the continuous EEG frequently

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 163 Wook-jin Choi ■ Post Cardiac Arrest Care after In-Hospital Cardiac Arrest Focusing on Targeted Temperature Management (TTM)

or continuously (Class I, LOE C-LD). If seizure persist ■ Somatic sensory potential test 24 to 72 hours after without stopping, treatment is performed in the same cardiac arrest or after re-warming way as treatment for status epilepticus (Class IIb, LOE ■ loss of N20 wave at (somato sensory evoked potential, SSEP) C-LD). The usefulness of the prophylactic adminis- ■ Significant reduction in density ratio of gray matter and tration of anti-convulsant drugs is still not clear. white matter on the Brain CT taken within 2 hours after cardiac arrest General intensive care ■ Extensive reduction in head MRI taken 2-6 days after cardiac arrest It may be considered to administer appropriate ■ EEG activity that does not respond to external stimuli sedatives and analgesics agents to control unneces- until 72 hours after cardiac arrest sary shivering in patients undergoing mechanical ventilation and targeted temperature management Summary in an intensive care unit (Class IIb, LOE C). The goal is to optimize oxygenation and ventilation It is recommended to administer fluids and va- sopressors and implement treatment guidelines to and correct electrolyte abnormalities during the first monitor central venous pressure, as well as goal-di- 6 hours of resuscitation after the cardiac arrest. Un- rected therapy introduced in the treatment of less otherwise contraindicated, the patient's cerebral sepsis. Prevent hypoglycemia caused by excessive injury is minimized by targeted temperature man- blood sugar control. Regular steroid administration agement to patients who have recovered sponta- and blood filtration therapy have not been estab- neous circulation after resuscitation and controlling lished (Class IIb, LOE B-R). core body temperature within hours after resusci- tation. After the cardiac arrest, due to the effect of Prognostication the administered drug, it is necessary to judge with For patients with cardiac arrest who have not sufficient time (at least 72 hours) to make it difficult received target temperature management, a prog- to accurately determine the prognosis. nosis should be made after at least 72 hours from ROSC (Class I, LOE B-NR). The appropriate time to make a prognosis may be delayed if there is con- References fusion in the progress of the clinical examination 1. Korean Center for Disease Control and Prevention. due to the residual effect of the sedative or muscle The Report of Cardiac Arrest Cohort. 2009. relaxant (Class IIa, LOE C-LD). Patients who have 2. Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, et al. Part 8: Post-Cardiac undergone target body temperature maintenance Arrest Care: 2015 American Heart Association treatment are also recommended not to make Guidelines Update for Cardiopulmonary Resusci- early judgments by delaying the determination of tation and Emergency Cardiovascular Care. Circu- prognosis up to 72 hours after recovering to normal lation 2015;132:S465-82. 3. Korean Association of Cardiopulmonary Resus- body temperature due to interference factors due to citation. 2015 Korean Guidelines for Cardiopul- drug effects (Class IIb, LOE C-EO). monary Resuscitation. Korea Centers for Disease Clinical findings suggesting poor prognosis3) Control and Prevention; 2015. 4. Choi Y, Kwon IH, Jeong J, Chung J, Roh Y: Inci- ■ The pupillary gloss loss persists until 72 hours after the cardiac arrest dence of adult in-hospital cardiac arrest using ■ Sustained status of myoclonus persisting for 72 hours national representative patient sample in Korea. after cardiac arrest Healthcare informatics research 2016; 22: 277-84.

164 KSCCM·ACCC 2020 Jozef Kesecioglu ■ High Quality Clinical Research: The Role of ESICM

Clinical Trials and International Collaboration

High Quality Clinical Research: The Role of ESICM

Jozef Kesecioglu

UMC Utrecht, the Netherlands August 1 (Sat)

The clinical research in ESICM is coordinated by • The Chairperson of the Education & Training the Research Committee. The Research Committee Committee represents the research interests, activities and rela- • The Deputy of the NEXT tionships of the ESICM. • One nominated representative of the NEXT The aim of the Research Committee is to foster • One representative of the N&AHP Committee high-quality multidisciplinary research in ICM by Duties of the Chairperson is facilitating, integrating, initiating and supporting • To facilitate high quality multidisciplinary re- research conducted by members or research groups search in all aspects of intensive care medicine of the ESICM or external collaborating individuals • To evaluate projects submitted to the Research and groups. The Research Committee provides Committee for endorsement or support, accord- mechanisms for these research groups to interact ing to the set procedure. with the ESICM, and the Research Committee is the • The Research Committee is responsible for eval- responsible body for managing this interaction. uating the scientific excellence of the submitted The members of the ESICM Research Committee projects. The Committee may require all mem- will include bers to participate in this process, or may de- • Chairperson of the Research Committee volve the responsibility to a smaller sub-group. • One representative from each Section (nomi- • The Chairperson of the ESICM Research Com- nated/elected by the voting members of the Sec- mittee is specifically responsible for all the re- tions) search activities and research relationships of • The Chairperson of the Congress Committee the ESICM.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 165 Tony Yeh ■ Data Science in Critical Care: International Database Collaboration

Clinical Trials and International Collaboration

Data Science in Critical Care: International Database Collaboration

Tony Yeh

National Taiwan Univ Hosp, Taiwan

Data Science includes three parts, database, sta- a disease severity and can be used to predict mo- tistics, and AI. For machine learning in medicine, it rality. One study used the data from MIMIC III to is used to predict outcomes, to group the patients build an algorithm of AI-assisted treatment strategy into different patterns, and to assist a diagnosis of for patients with sepsis, and then it use data from image or disease. Database is the foundation for the eICU database to test the algorithm. It shapes a Data science. ANZICS CORE is a very successful future that AI-assisted treatment strategy may help international ICU database. Until now, there are 15 us to treat a patient with sepsis. The integration of countries join in this international collaboration. data is very important for the development of data The main purpose of ANZICS CORE codes is to cal- science. Interaction, collaboration, and linkage of culate the APACHE II, III, and IV scores. It is used different database are important too. Smart ICU is to do a risk adjustment when comparing the data an ongoing change of our clinical practices in criti- among different hospitals. They also develop a dis- cal care today and tomorrow. ease severity score, named as ANZROD. It represent

166 KSCCM·ACCC 2020 Elliott Haut ■ Damage Control Surgery Principles for the Non-Surgeon

Trauma

Damage Control Surgery Principles for the Non-Surgeon

Elliott Haut

The Johns Hopkins School of Medicine, USA August 1 (Sat)

The overarching idea behind damage control Give suggestions for all phases of care targeted at surgery is to ensure a living patient above all else. the non-surgeon Damage control consists of abandoning the defin- Indications for damage control often can be divid- itive operation and replacing it with abbreviated ed into physiologic vs anatomic reasons. Physiolog- surgery, substituting a staged approach with plans ic reasons, in particular after traumatic injury, often for a repeat operation. Damage control is no longer stem from “the lethal triad”- acidosis, hypothermia, a procedure of last resort applied in desperation and coagulopathy. Sometimes, damage control sur- to patients who are near physiologic exhaustion, it gery is performed for anatomic reasons after injury should be considered early optimal care for a small such as inaccessible major venous injury, or man- subset of patients. The technique originally devel- agement of extra-abdominal life-threatening injury. oped for severe trauma, which has now been spread In general surgery, it may be performed for patients to numerous other surgical specialties for critically needing a planned takeback for reassessment of in- ill or injured patients. It can be used in nearly any tra-abdominal contents or for inability to reapprox- body cavity- abdomen, chest, soft tissue, extremity, imate abdominal fascia due to visceral edema. orthopedics. Damage Control consists of four phases, each This lecture has 4 main goals: with its own particular concepts for care ■ Explain the basic premise and theory behind Trauma Bay/ Emergency Department Resuscita- “damage control” surgery tion area ■ Identify anatomic and/or physiologic reasons to ■ Operating Room for abbreviated surgery leave the abdomen open ■ Intensive Care Unit ■ Discuss the stages of “damage control” ■ Operating Room for definitive surgery

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 167 Lewis J Kaplan ■ Emerging Strategies for Sepsis Care

Current Battlegrounds in Sepsis

Emerging Strategies for Sepsis Care

Lewis J Kaplan

Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, USA

Sepsis and septic shock occur with great fre- diagnosis, native immune support, non-antibiotic quency. Critical illness, organ failure, immune based antimicrobial agents, and intervention evalu- suppression and resistant pathogens occur despite ation are warranted. This session will explore each high intensity care, even when source control can of these domains to forecast how sepsis and septic be achieved. Therefore, new approaches to rapid shock care is expanding into new care approaches.

168 KSCCM·ACCC 2020 Kent Doi ■ Blood Purification for Sepsis and Acute Kidney Injury

Current Battlegrounds in Sepsis

Blood Purification for Sepsis and Acute Kidney Injury

Kent Doi

Univ of Tokyo, Japan August 1 (Sat)

Sepsis is defined as a life-threatening organ dys- RRT such as timing, dose, and hemofilter are inves- function due to a dysregulated host response to tigated. Although RRT is basically aimed to replace infection. Sepsis-3 clinical criteria evaluates organ reduced kidney function, other blood purifications dysfunction with an increase of 2 points or more in will be used not only for renal replacement but the Sequential Organ Failure Assessment (SOFA) for eliminate humoral inflammatory mediators in score. Acute kidney injury (AKI) is one of the most septic patients. Endotoxin removal by polymyxin frequent organ dysfunctions in septic patients. It B-coated filter has been used for gram negative has been reported that complication of AKI with bacteria-induced septic shock for the last two de- sepsis significantly worsens the outcomes. Blood cades, however recent randomized controlled trials purification including renal replacement therapy did not support its protective effect against septic (RRT) is widely used for AKI in septic patients. Se- shock. Some hemofilters used in RRT such as AN69- vere AKI which requires RRT (dialysis-requiring ST are shown to remove humoral mediators such AKI; AKI-D) reportedly showed poor outcomes as IL-6 and high mobility group box 1 (HMGB1) by (mortality rate > 50%), although uremic conditions adsorption. RRT with these hemofilters is expected in AKI-D could be sufficiently treated by RRT. Cur- to improve the outcome of sepsis patients compli- rently, several different issues regarding optimal cated with AKI.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 169 Kuo-Ching Yuan ■ Application of Artificial Intelligence in Critical Care: A Single Institution's Experience (including sepsis)

Current Battlegrounds in Sepsis

Application of Artificial Intelligence in Critical Care: A Single Institution's Experience (including sepsis)

Kuo-Ching Yuan

Taipei Medical Univ Hosp, Taiwan

Artificial intelligence (AI) in health care is now Expert was indistinguishable on both the develop- considered merely within touching distance. AI ment and validation cohorts. In 2018, an AI clini- application in ICU care is also under fast develop- cian system was reported to tackle the problems ment and widely applicated in Prediction model1,2, regarding the administration of intravenous fluids Image reading3 and Treatment strategy4. AI using and vasopressors in sepsis patients and provided convolutional neural network and deep learning is better performance than the human clinicians. now profoundly adopted in the image-based med- Taipei Medical University Hospital (TMUH) have ical subspecialties such as radiology, cardiology, devoted on the AI application in critical care and pathology, and ophthalmology5. The data-enriched especially focusing on concise Electric Medical intensive care medicine is an excellent environ- Record system and disease prediction model. The ment for new AI-centric approach with innovative development of AI critical care in TMUH can be di- tools. The increasing availability of complex and vided into 3 stages. In first stage is the infrastructure heterogeneous data derived from ICU patients of EMR. Since various and tremendous data are using Electronic Medical Record (EMR) in daily generated from ICU patient every day. We designed practice makes the renovation approaches for data a comprehensive system, the TED_ICU, to incor- analysis necessary and inevitable. porate all kinds of data, including number, texture, Various subsets of AI have been introduced into and image in a very concise presentation. The TED_ critical care. Barbini etc. compared different models ICU not only dramatically improve working efficacy in predicting ICU morbidity after cardiac surgery but also established a well-structured database and found that Bayesian and logistic regression from everyday practice. On second stage in AI med- performed well in discrimination and calibration ication is topic selection and labelling system setup. for a particular risk. Nemati et al. reported a study We chose sepsis as our study topic and selected 106 of an Artificial Intelligence Sepsis Expert algorithm features relevant to sepsis for data collection. A la- using 65 features on an hourly basis and found that beling system is also embedded in TED_ICU for in- the performance of the Artificial Intelligence Sepsis tensivist to label a patient either sepsis or not-sep-

170 KSCCM·ACCC 2020 Kuo-Ching Yuan ■ Application of Artificial Intelligence in Critical Care: A Single Institution's Experience (including sepsis) sis. After patient labeling and feature collection in 73.63%, specificity = 43.71%). This result has been every day practice using TED_ICU, bigdata collec- published (International Journal of Medical Infor- tion is rapidly achieved and further progress in AI matics 141 (2020) 104176). The clinical implication algorithm is feasible. With the cooperation with of the algorithm is now under thorough evaluation. data science expert, we have developed the proto- In the foreseeable future, AI will inevitably be type of sepsis prediction algorithm (SPA) and both more crucial in ICU care. Combining the advantage showed excellent performance. The established SPA of medicine, computer technology, and data sci- achieved the following: accuracy = 82% ± 1%; sensi- ence in Taiwan, AI in medicine is a goal worthy of tivity = 65% ± 5%; specificity = 88% ± 2%; precision our efforts. = 67% ± 3%; and F1 = 0.66 ± 0.02. The area under re- August 1 (Sat) ceiver operating characteristic curve (AUROC) was References approximately 0.89. The same 1,588 instances were 1. JMIR Med Inform 2016 | vol. 4 | iss. 3 | e28 | p.1 used to analyze the diagnoses using the SOFA score 2. Crit Care Med 2017; XX:00-00 as the sepsis criteria; the diagnostic performance 3. Radiology 2019;291:196-202 of the SOFA score was inferior to the SPA (AUROC 4. Nature Medicine volume 24, pages1716-1720 = 0.596). The threshold of the SOFA score should be (2018) 5. Nature Medicine volume 25, pages44-56 (2019) adjusted to 4 if it is adopted as a criterion for sepsis diagnosis, based on the Youden index (sensitivity =

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 171 Lewis J Kaplan ■ Post-Intensive Care Syndrome

Recovering from Critical Illness: Patients and Intensivists

Post-Intensive Care Syndrome

Lewis J Kaplan

Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, USA

Critically ill or injured patients who survive their triggers, and their unique impact on patients and ICU and hospital stay are at risk of developing family members will be explored in the context of the Post-Intensive Care Syndrome. Such patients mitigation strategies both in the hospital and after share broad overlap with those who develop chron- discharge. Performance improvement leveraging ic critical illness. Key syndromic features, their post-ICU clinic activities will be highlighted as well.

172 KSCCM·ACCC 2020 Yeon Joo Lee ■ Post ICU Clinic

Recovering from Critical Illness: Patients and Intensivists

Post ICU Clinic

Yeon Joo Lee

Division of pulmonary and critical care, Seoul National University Bundang Hospital, Republic of Korea August 1 (Sat)

In the past decade, mortality from severe dis- and to diagnose and treat those acquired during eases such as sepsis and acute respiratory distress hospitalization in intensive care. In its conception, syndrome has improved significantly, but at the the main objective of the outpatient clinic was to same time, the number of “ICU survivors” who improve the cost-effectiveness of care. need rehabilitation has more than tripled. Conse- Post-ICU outpatient clinics vary widely in their quently, there is an increasing number of patients need for professionals, patient and/or family eligi- reporting physical and psychological problems af- bility for participation, time and duration of patient ter discharge from the ICU. Studies assessing health and family follow-up, choice of tools for evaluating related quality of life (HRQoL) after intensive care outcomes, and definitions of which patients will show that the HRQoL improves over time but that be referred to reference services. Depending on people do not return to the same level as before the model adopted and available resources, outpa- ICU admission and that the HRQoL is lower than tient clinics can provide aid ranging from clinical the general population for at least the first year. The to information services to ICU survivors and their reported prevalence of anxiety, depression, and families. Depending on the services available, the post-traumatic stress disorder is also high and may following may be offered: functional evaluation, endure for many years. These continuing problems physical therapy evaluation, medical evaluation, have large social and financial implications for pharmaceutical evaluation, medical consultation, patients, their families and carers, and the society. psychosocial support, and rehabilitation therapy, Therefore, the complexity and magnitude of these among others. The greater the range of profession- ICU-related sequelae, recently defined as post In- als, the higher the cost of the operation. tensive Care Syndrome (PICS), requires multidisci- Currently, there is scant evidence as to which plinary care. is the best follow-up model for ICU survivors. To Follow-up outpatient clinics (or clinics) for ICU date, the model of outpatient follow-up after ICU survivors were proposed as a way to follow up discharge does not seem to provide significant ben- survivors after hospital discharge to treat the nu- efits to patients and families and is not cost-effec- merous morbidities prior to admission to the unit tive. However, this limitation should not reduce the

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 173 Yeon Joo Lee ■ Post ICU Clinic importance of the long-term follow-up of patients, ers’ conference. Crit Care Med 2012; 40:502–509. family members, and caregivers. Patients feel con- 2. Medical and Economic Implications of Cognitive and Psychiatric Disability of Survivorship. Semin fident with the participation of intensivists in their Respir Crit Care Med 2012;33:348–356. future therapeutic decisions since the complexity 3. One-Year Outcomes in Survivors of the Acute of their sequelae requires multidisciplinary and Respiratory Distress Syndrome. N Engl J Med specialized follow-up. Relatives feel confident in 2003;348:683-93. clarifying their doubts and exposing their fears to 4. Long-Term Cognitive Impairment after Critical Ill- ness. N Engl J Med 2013;369:1306-16 the team that treated them with respect and digni- 5. Post-intensive care outpatient clinic: is it feasible ty during what was possibly the worst situation in and effective? A literature review Rev Bras Ter In- their lives. tensiva. 2018;30(1):98-111 6. Recommendations for intensive care follow-up clinics;report from a survey and conference References of Dutch intensive cares. Minerva Anestesiol 1. Improving long-term outcomes after discharge 2015;81:135-44 from intensive care unit: Report from a stakehold-

174 KSCCM·ACCC 2020 Jeongmin Kim ■ Burnout Syndrome of Korean ICU Professionals

Recovering from Critical Illness: Patients and Intensivists

Burnout Syndrome of Korean ICU Professionals

Jeongmin Kim

Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea August 1 (Sat)

Burnout has been described as a prolonged re- (23%), 34 associate professors (12%), 101 assistant sponse to chronic emotional and interpersonal professors (40%), and 59 fellowship (23%). When stress on the job [1] that is often the result of a peri- Burnout syndrome was defined using Maslach od of expending excessive effort at work while hav- Burnout Inventory, the prevalence of burnout syn- ing too little recovery time [2]. Burnout was first de- drome in Korea reached 73% and was higher in scribed in 1974 by Freudenberger, thereby inspiring assistant professors/fellowship than professors/ the investigation of the characteristics and preva- associate professors. lence of this phenomenon [3]. Maslach and Jackson defined burnout as having three different aspects: Figure 1. Prevalence of Burnout as Assessed by the Maslach Burnout Inventory emotional exhaustion, depersonalization, and lack of personal and professional completion [4]. The prevalence of burnout syndrome in Western countries is between 33 to 47% among intensive care unit(ICU) physicians and nurses [5,6]. On the other hand, according to a recent cross-sectional survey of 159 ICUs in 16 Asian countries and regions, the prevalence of exhaustion syndrome in Asian ICUs doctors and nurses is around 50-52% [7]. Figure 2. Prevalence of Burnout by Position of Intensivist In 2019, the Burnout syndrome online survey was conducted for 253 intensivists working in the ICU under the supervision of the Korean Society of Crit- ical Care Medicine. The average age of the respon- dents was 39 years old, and the proportion of males was 65%. 156 (62%) worked in the medical ICU and 89 (35%) worked in the surgical ICU. Respondents were classified by academic rank: 59 professors

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 175 Jeongmin Kim ■ Burnout Syndrome of Korean ICU Professionals

In this survey, since 2017, as the law limits the for individuals to cope with stressful environments. residents' maximum working hours per week to 80 The improved awareness, especially among policy hours, 63% of respondents said that the amount of makers, funders, and hospital administrators, and work increased, and 36% said it was the same as be- better communication within teams and systems fore. with structured individualized interventions will be In the multivariate analysis, the independent risk first steps. factors associated with burnout syndrome were an increase in workload after enforcement of regula- References tion of 80-hour resident workweek, conflicts with 1. Maslach C, Schaufeli WB, Leiter MP. Job burnout. colleagues during the last month, the number of Annu Rev Psychol 2001;52:397-422. days to receive house calls last month, and working 2. Schaufeli W, van Dierendonck D. Burnout: preval- at MICU compared to other units. entie, risicogroepen en risicofactoren. 2000. In conclusion, more than two thirds of critical 3. Freudenberger HJ. Staff Burn-Out. Journal of So- cial Issues 1974;30:159-65. care professionals in Korea have burnout syn- 4. Maslach C, Jackson SE. The measurement of expe- drome, but it continues to be under-recognized. rienced burnout. 1981;2:99-113. Furthermore, the impact of these risk factors on 5. Embriaco N, Azoulay E, Barrau K, Kentish N, Po- burnout remains poorly understood. Burn-out syn- chard F, Loundou A, et al. High level of burnout in intensivists: prevalence and associated factors. Am drome occurs in individuals, but resolution strate- J Respir Crit Care Med 2007;175:686-92. gies must consider system or team changes as well 6. Poncet MC, Toullic P, Papazian L, Kentish-Barnes as adequate resource procurement. We can suggest N, Timsit JF, Pochard F, et al. Burnout syndrome shift patterns, improved employee levels, better in critical care nursing staff. Am J Respir Crit Care communication, counseling and collaboration, in- Med 2007;175:698-704. 7. See KC, Zhao MY, Nakataki E, Chittawatanarat K, dividual work awareness, good leadership, and per- Fang WF, Faruq MO, et al. Professional burnout sonalized interventions to address risk factors. Cog- among physicians and nurses in Asian intensive nitive behavioral therapy and relaxation techniques care units: a multinational survey. Intensive Care also need to be considered as effective strategies Med 2018;44:2079-90.

176 KSCCM·ACCC 2020 Asad Latif ■ Perioperative Management of the Patient with Hepatic Disease

Hepatic Dysfunction

Perioperative Management of the Patient with Hepatic Disease

Asad Latif

Aga Khan Univ, Pakistan August 1 (Sat)

Understanding management issues in hepatic atic patients. Potential risk factors for liver disease dysfunction is the key to providing optimal care for need to be examined in-depth. A complete medica- patients with hepatic disease. This talk highlights tion review including other-the-counter (OTC) and the essential protocol that can be taken to poten- herbal agents should be performed. Routine preop- tially minimize complications and optimize out- erative testing of liver function is not recommended comes. because of the low prevalence of liver abnormalities Studies reveal patients with hepatic dysfunction in clinically asymptomatic patients. in need of surgery are at a much higher risk for For patient who have symptoms or physical signs surgical and anesthesia-related complications. indicative of liver dysfunction/disease (e.g., hepato- The complications depend upon the type of liver splenomegaly, spider angiomata, jaundice, gyneco- disease, severity, surgical procedure and the type mastia, palmar erythema, scleral icterus, asterixis, of anesthesia. The two most popular methods for encephalopathy) should prompt further examina- categorizing liver dysfunction in terms of periop- tion with liver function tests, coagulation studies, erative risk to the patient are the Child-Pugh (CP) complete blood cell (CBC) counts and metabolic classification system and the Model for End-stage panels. The evidence suggests that asymptomatic Liver Disease (MELD) score. Both have proved ef- patients with significantly abnormal liver function fective in predicting mortality, particularly prior to should have their elective surgery postponed and emergency surgery. MELD, however, was found to their liver disease investigated for possible reasons be a better predictor of 30- and 90- day mortality and optimization; their perioperative risk needs to than ASA class and age-predicted mortality. be reassessed after their liver dysfunction is charac- Other than evaluation of perioperative risk, the terized. evaluation of any hepatic dysfunction patient un- Specific abnormalities that are identified need to dergoing surgery should include a rigorous physical be corrected preoperatively, as well as often active examination and history taking. This is a particular- managed intraoperatively. These include coagulop- ly essential first-line tool for screening asymptom- athy, which can be because of synthetic dysfunction

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 177 Asad Latif ■ Perioperative Management of the Patient with Hepatic Disease causing decreased coagulation factors or throm- These complications carry a high risk of periopera- bocytopenia due to sequestration. Ascites can lead tive morbidity and mortality, and often need multi- to issues with wound healing and infections, and disciplinary planning and management for optimal even respiratory compromise in advanced cases. outcomes. Ideally it should be managed medically but might Intraoperative management of patients with he- need procedural drainage with it concomitant risks. patic dysfunction works on two principles: continu- Renal dysfunction can frequently accompany he- ing with the management of preoperative issues patic dysfunction, and while it is most commonly through the intraoperative period, minimizing in- due to modifiable causes like volume status, phy- traoperative hepatic insults such as hemodynamic sicians need to be wary of severe forms like hepa- lability and pharmacological toxicity, and account- torenal syndrome with its high morbidity. Hepatic ing for changes in hepatic metabolism. Similar care encephalopathy is the most common neurologic needs to be extended to the postoperative period, manifestation, and can range from mild to severe with patients often requiring close monitoring to needing amelioration with medications. Pulmonary maintain adequate intravascular volume, perfu- issues due to hepatic dysfunction can be severe, sion, oxygenation, and ventilation. with hypoxemia due to intrapulmonary shunts in hepatopulmonary syndrome, and even right heart Keywords: hepatic dysfunction, liver disease, he- compromise from porto-pulmonary hypertension. patic complications, perioperative management

178 KSCCM·ACCC 2020 Miroslaw Czuczwar ■ New Guidelines on Nutritional Intervention in the ICU - ASPEN, ESPEN or Local?

Nutrition

New Guidelines on Nutritional Intervention in the ICU - ASPEN, ESPEN or Local?

Miroslaw Czuczwar

Department of Anesthesiology and Intensive Care Medical University of Lublin, Poland August 1 (Sat)

Although mortality in the ICU has fallen over of metabolic alterations and related conditions in decades, the number of patients with long-term critically ill patients has for many years been guided functional disabilities has increased, leading to by recommendations based essentially on expert impaired quality of life and significant healthcare opinion. Although outcomes have not been ade- costs. As an essential part of the multimodal inter- quately studied in randomized trials, the primary ventions available to improve outcome of critical goal of nutrition support is to alter the course and illness, optimal nutrition therapy should be pro- outcome of the critical illness. Clinicians should be vided during critical illness, especially during the thoughtful of the metabolic changes that occur fol- ICU stay. Multiple guidelines for nutrition in the lowing onset of critical illness and tailor the nutri- critically ill exist, many produced and endorsed by tion delivery to the patients’ actual needs. Targeted societies in nutrition and/or critical care. However, nutrition delivery in the ICU setting emphasizes because of the weakness of the supporting evidence taking into account long-standing basic metabo- and the sometimes-limited clinical plausibility lism data, showing nutritional needs can change between nutritional interventions and the report- significantly over the course of critical illness. Prop- ed outcomes, experts disagree regarding optimal er timing of nutrition therapy and optimal dosing nutritional approaches and conflicting recommen- has been suggested as critical illness and recovery dations have sometimes been published, limiting metabolism changes throughout a patient’s course global acceptance and application. Metabolic alter- and energy expenditure and nitrogen losses appear ations in the critically ill have been studied for more to vary over time. Clinicians must be thoughtful than a century, but the heterogeneity of the critical- about optimal provision of nutrition and metabolic ly ill patient population, the varying duration and therapies throughout all phases of illness and en- severity of the acute phase of illness, and the many sure our patients are getting the right nutrition, in confounding factors have hindered progress in the the right patient, at the right time. field. These factors may explain why management

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 179 Miroslaw Czuczwar ■ New Guidelines on Nutritional Intervention in the ICU - ASPEN, ESPEN or Local?

References 2. Reintam BA, Starkopf J, Alhazzani W, Berger MM, Casaer MP, Deane AM et al. Early enteral nutrition 1. Taylor BE, McClave SA, Martindale RG, Warren in critically ill patients: ESICM clinical practice MM, Johnson DR, Braunschweig C et al. Guide- guidelines. Intensive Care Med, 2017; 43: 380–398. lines for the provision and assessment of nutrition 3. Singer P, Blaser AR, Berger MM, Alhazzani W, support therapy in the adult critically ill patient: Calder PC, Casaer MP et al.ESPEN guideline on Society of Critical Care Medicine (SCCM) and clinical nutrition in the intensive care unit. Clin American Society for Parenteral and Enteral Nutri- Nutr. 2019; 38: 48–79. tion (A.S.P.E.N.). Crit Care Med, 2016; 44: 390–438.

180 KSCCM·ACCC 2020 Eunjeong Heo ■ Nutrition for Patients on ECMO Support

Nutrition

Nutrition for Patients on ECMO Support

Eunjeong Heo

Department of Pharmacy, Seoul National University Bundang Hospital, Seoul, Korea August 1 (Sat)

Veno-arterial extracorporeal membrane oxy- guidelines suggest that hemodynamically unstable genation (VA-ECMO) provides support of cardio- patients not be given enteral nutrition (EN) until pulmonary function in patients with cardiogenic achieving hemodynamic stability [9, 10]. shock and severe heart failure because of acute There have been some observational studies re- myocardial infarction, myocarditis, pulmonary garding nutritional support of patients receiving embolism, or cardiac arrest care [1-3]. Recently, VV-ECMO or VA-ECMO. In these studies, EN was experience and improved VA-ECMO equipment most frequently tried within 24 hours of starting has led to improved outcomes [2]. Nevertheless, ECMO[12]. In one prospective multicenter observa- patients receiving VA-ECMO still face extremely tional study of 107 patients, 5 patients (4.5%) were instability of hemodynamics and multiorgan fail- reported to have bowel ischemia[13]. ure and they have high in-hospital mortality [4, 5]. There is no recommendation that energy and Their conditions are more likely to be exacerbated protein should be supplied for patients receiving by malnutrition because of high metabolism and ECMO. Predictive or weight-based equations are high protein consumption; adequate nutritional used as the method of choice for determining ener- support is often not achieved because of hemody- gy targets in patients receiving ECMO,[7, 11, 14-18]. namic instability requiring high dose of vasoac- And a minimum 1.2 g/kg/d is targeted for protein tive and inotropic agents, liver dysfunction, acute in clinical practice. kidney injury, digestive system failure, and altered mentation caused by sedation, brain injury, sepsis References and seizures [2, 4-7]. Malnutrition in the intensive 1. Hirsch Mehta, M., FACC; Dr. Howard J. Eisen, MD, care unit (ICU) is associated with increased patient FACC; Dr. Joseph C. Cleveland, Jr., MD, FACC Indi- morbidity and mortality, timely nutritional support cations and Complications for VA-ECMO for Car- is essential for these patients [8]. diac Failure. American college of cardiology, 2015. Currently, there are detailed guidelines regard- 2. Makdisi, G. and I.-w. Wang, Extra Corporeal Mem- brane Oxygenation (ECMO) review of a lifesaving ing nutritional support only for neonatal ECMO technology. Journal of thoracic disease, 2015. 7(7): patients [5]. For critically ill adults, nutritional p. E166.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 181 Eunjeong Heo ■ Nutrition for Patients on ECMO Support

3. Marasco, S.F., et al., Review of ECMO (extra corpo- 159-211. real membrane oxygenation) support in critically 11. MacGowan, L., et al., Adequacy of nutrition sup- ill adult patients. Heart, Lung and Circulation, port during extracorporeal membrane oxygen- 2008. 17: p. S41-S47. ation. Clinical Nutrition, 2019. 38(1): p. 324-331. 4. Sorbo, L.D., M. Cypel, and E. Fan, Extracorporeal 12. Nutrition Support in Adult Patients Receiving Ex- life support for adults with severe acute respiratory tracorporeal Membrane Oxygenation failure. The Lancet Respiratory Medicine, 2014. 13. Ridley EJ, Davies AR, Robins EJ, et al. Nutrition 2(2): p. 154-164. therapy in adult patients receiving extracor- 5. Tom Jaksic, M.A.H., Biren P. Modi, A.S.P.E.N. Clin- poreal membrane oxygenation: a prospective, ical Guidelines: Nutrition Support of Neonates multicentre,observationalstudy.CritCareRe- Supported with Extracorporeal Membrane Oxy- susc.2015;17(3):183-189 genation. JPEN, 2010. 34: p. 247-253. 14. Scott LK, Boudreaux K, Thaljeh F, Grier LR, Conrad 6. Farias, M.M., C. Olivos, and R. Diaz, Nutritional SA. Early enteralfeedingsinadultsreceivingvenove- implications for the patient undergoing extracor- nousextracorporealmembrane oxygenation. JPEN poreal membrane oxygenation. Nutr Hosp, 2015. J Parenter Enteral Nutr. 2004;28(5):295-300. 31(6): p. 2346-51. 15. Lukas G, Davies AR, Hilton AK, et al. Nutritional 7. Ridley, E.J., et al., Nutrition therapy in adult pa- support in adult patients receiving extracorpo- tients receiving extracorporeal membrane oxygen- real membrane oxygenation. Crit Care Resusc. ation: a prospective, multicentre, observational 2010;12(4):230-234. study. Critical Care and Resuscitation, 2015. 17(3): 16. Ferrie S, Herkes R, Forrest P., Nutrition support p. 183. during extracorporeal membrane oxygenation 8. Giner, M., et al., In 1995 a correlation between mal- (ECMO) in adults: a retrospective audit of 86 pa- nutrition and poor outcome in critically ill patients tients. Intensive Care Med. 2013;39(11):1989-1994. still exists. Nutrition, 1996. 12(1): p. 23-9. 17. Umezawa Makikado LD, Flordelis Lasierra JL, Pe- 9. Singer, P., et al., ESPEN guideline on clinical nutri- rez-Vela JL, et al. Early enteral nutrition in adults tion in the intensive care unit. Clinical nutrition, receiving venoarterial extracorporeal membrane 2019. 38(1): p. 48-79. oxygenation: an observational case series. JPEN J 10. McClave, S.A., et al., Guidelines for the provision Parenter Enteral Nutr. 2013;37(2):281-284. and assessment of nutrition support therapy in 18. Lu MC, Yang MD, Li PC, et al. Effects of nutrition- the adult critically ill patient: Society of Critical al intervention on the survival of patients with Care Medicine (SCCM) and American Society for cardiopulmonary failure undergoing extracor- Parenteral and Enteral Nutrition (ASPEN). Journal poreal membrane oxygenation therapy. In Vivo. of Parenteral and Enteral Nutrition, 2016. 40(2): p. 2018;32(4): 829-834.

182 KSCCM·ACCC 2020 Soo Young Kim ■ Reporting Guidelines

Research and Ethics Symposium

Reporting Guidelines

Soo Young Kim

Department of Family Medicine, Kangdong Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Korea August 1 (Sat)

Reporting guidelines can be defined as “A check- reviews. list, flow diagram, or structured text to guide au- Which report guidelines to use depends on the thors in reporting a specific type of research, devel- research design. The most commonly used research oped using explicit methodology”.[1] designs and corresponding reporting guidelines are The reporting guideline is a simple, structured shown in the table. tool that health care researchers can use when Reporting guidelines can be helpful for academic drafting their research. The purpose of the reporting journals and researchers. Journals can encourage guidelines is to include in the manuscript a list of authors to follow the reporting guidelines because the minimum information necessary to prepare the doing so ensures that the research is documented manuscript, to 1) help the reader understand the in detail, making it easier for editors, reviewers, and content of the manuscript, 2) reproduce the study, readers to read and understand the manuscript. It 3) provide accurate information when research is may be helpful for the manuscript author to sug- used for decision-making, and 4) provide appro- gest what reporting guidelines were followed in the priate information when included in systematic research methodology.

Table. Reporting guidelines for main study types [2] Study design Reporting guidelines Website Randomized trials CONSORT www.consort-statement.org Systematic reviews and PRISMA (http://prisma-statement.org/ meta-analyses Studies of diagnostic accuracy STARD http://www.equator-network.org/reporting-guidelines/stard/ Observational studies STROBE (http://strobe-statement.org/ http://www.equator-network.org/reporting-guidelines/right- Clinical practice guidelines RIGHT statement/ http://www.equator-network.org/reporting-guidelines/spirit-2013- Study protocols SPIRIT statement-defining-standard-protocol-items-for-clinical-trials/ Case reports CARE http://www.equator-network.org/reporting-guidelines/care/

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 183 Soo Young Kim ■ Reporting Guidelines

References tors. Recommendations for the Conduct, Report- ing, Editing, and Publication of Scholarly Work in 1. Equator network. What is a reporting guideline? Medical Journals. 2019 [Internet]. International [Internet]. Equator network [cited 2020 Jun 3]. Committee of Medical Journal Editors [cited 2020 Available from: https://www.equator-network.org/ Jun 3]. Available from: http://www.icmje.org/icm- about-us/what-is-a-reporting-guideline/. je-recommendations.pdf 2. International Committee of Medical Journal Edi-

184 KSCCM·ACCC 2020 Yunhee Whang ■ Impress Journal Editors through Clarity and Impact in Your Academic Writing

Research and Ethics Symposium

Impress Journal Editors through Clarity and Impact in Your Academic Writing

Yunhee Whang

Compecs Inc., Seoul, Korea August 1 (Sat)

Researchers strive to publish papers, but it is different, but the author’s final selection should often challenging to write papers with clarity and be based on what the author considers important, impact. This can be especially tough for non-native what the author desires the readers to focus on, or English speaking authors because of the language what is treated as old or new information. barrier. As a general rule, non-native speaking au- The author’s careful use of information struc- thors focus on writing grammatical sentences, but ture—positioning the words or phrases appropri- they are aware that merely attending to grammar is ately—increases readability and enables readers to insufficient to ensure that the editors (and readers) better understand the author’s intended meaning understand what the authors want to emphasize [2]. The three basic principles of the information and convey. Thus, the goal of this presentation is structure in English are as follows: to introduce various strategies that the authors can 1. Place important information in the main clause use to improve clarity and achieve impact when instead of the subordinate clause. writing a research paper with a particular focus on 2. Place new or important information at the end information structure (or information packaging), of a sentence. emphasis position, and cohesion in English. 3. Place complex and long information at the end Information structure is about the ways informa- of a sentence. tion is arranged in a given context [1]. The same It is also important to acquire various linguistic message can be conveyed in various ways: for ex- techniques that can control emphasis [3,4]: for ex- ample, (1) The dog chased the cat, (2) The cat was ample, using the position of words or phrases in a chased by the dog, (3) What was chased by the dog sentence, presenting information in an unexpect- was the cat, (4) It was the cat that the dog chased, ed way, isolating the words, or varying sentence (5) As for the dog, it chased the cat, or (6) As for the length. cat, the dog chased it. Since none of these sentenc- Knowing how to achieve cohesion by making ef- es have a grammatical error, and they all describe fective transitions between sentences is also helpful the same event, the sentences may not seem very in improving clarity and impact [5]. Among the var-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 185 Yunhee Whang ■ Impress Journal Editors through Clarity and Impact in Your Academic Writing ious linguistic tools that can be employed, the use References of pronouns and some transitional expressions are 1. Arnold J, Kaiser E, Kahn J, et al. Information examined. Structure: Linguistic, Cognitive, and Processing For non-native English speaking authors, it is Approaches. Wiley Interdiscip Rev Cogn Sci. challenging to achieve clarity and impact in writ- 2013;4(4):403–413. doi:10.1002/wcs.1234. ing. However, I believe that it is possible to develop 2. Gopen G, Swan J. The Science of Scientific Writing. American Scientist 1990;78:550-558. the skill of writing more clearly and powerfully by 3. Schimel J. Writing Science. New York, NY: Oxford understanding how to organize information in a University Press; 2012. sentence or a series of sentences for the optimal in- 4. Williams J, Bizup J. Style: Ten Lessons in Clarity & tended effect, how to arrange words and phrases to Grace. New York, NY: HarperCollins College Pub- lishers; 1994. achieve emphasis, and how to make effective tran- 5. Zeiger M. Essentials of Writing Biomedical Re- sitions between sentences. search Papers. New York, NY: McGraw-Hill; 2000.

186 KSCCM·ACCC 2020 Sahadol Poonyathawon ■ Update in Colloids for Critically Ill Patients

Fluid Therapy

Update in Colloids for Critically Ill Patients

Sahadol Poonyathawon

Chulalongkorn Univ, Thailand August 1 (Sat)

Fluid administration represents one of the core replacement therapy/mortality in mixed group of interventions in management of critically ill pa- critically ill patients while recent study show long- tients. The choice of fluid therapy has been one of term disability-free survival was significantly higher on-going controversial issues in critical care medi- in the colloid than crystalloid in major abdominal cine. Acute aggressive crystalloid loading and acute surgical patients. Albumin plays many roles in criti- hypervolemia result in fluid overload which may cally ill patients including oncotic and non-oncotic be associated with systemic organ dysfunction and properties and has been demonstrated to be ef- increased morbidity/mortality. Role of endothelial fective in patients with septic shock, cirrhosis, and glycocalyx layer in microvascular permeability and renal impairment. Recent data shows 20% albumin inflammatory process has attracted much atten- decrease resuscitation fluid requirements, mini- tion. Protection or restoration of the endothelial mized positive fluid balance without evidence of in- glycocalyx layer may be an important therapeutic creased renal impairment compared with 4-5% al- goal of fluid therapy. bumin. However, albumin-based resuscitation may Colloids are solutions contain macromolecules be cost-effective in some countries while may be such as albumin, hydroxyethyl starch (HES), gelatin proved otherwise in others. Optimizing fluid bolus and dextran have been shown to be more effective therapy with dynamic hemodynamic parameters than crystalloids for intravascular volume effect has been recommended by international guide- and improving systemic hemodynamics. Recent lines. Assisted fluid management strategy with tools metanalysis shows colloids are more efficient than that can suggest fluid bolus therapy & continuously crystalloids at stabilizing resuscitation endpoints. re-assess the patient’s needs for further fluid may Addition of colloids to crystalloids can decrease to- result in less fluid given but better hemodynamic tal amount of fluid required and potentially reduce profile. However, in resource-limited setting where the risk of fluid overload. However, all colloids are intensive care were not available, study shows not the same especially in specific group of pa- fluid bolus either crystalloids or colloids increase tients. Meta-analyses show association between hy- mortality by worsening in respiratory, neurological droxyethyl starch and increased incidence of renal function, hemodilution, and hyperchloremic aci-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 187 Sahadol Poonyathawon ■ Update in Colloids for Critically Ill Patients dosis despite transient improvement in cardiovas- states require different fluid therapy. No single fluid cular function compared with maintenance fluid is always ideal for all disease conditions. Regardless alone in critically ill children. There is increasing of the choice of colloids to be used, colloid therapy evidence that fluid-induced hyperchloremic aci- should be considered as rescue therapy and limited dosis may have a detrimental effect on renal func- to acute profound hypovolemia. Any fluids should tion suggesting the use of balanced crystalloid and be considered as medications and should have tar- colloids solutions in high risk patients who poten- get of treatment, appropriate monitoring and every tially need large amount of fluids. In critically ill effort should be made to avoid unnecessary admin- patients, disease processes are dynamic and fluid istration. response may change over time. Specific disease

188 KSCCM·ACCC 2020 Takeshi Yoshida ■ The Risk of Spontaneous Breathing in ARDS

ARDS

The Risk of Spontaneous Breathing in ARDS

Takeshi Yoshida

Osaka Univ Hosp, Japan August 1 (Sat)

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 189 Dong Hyun Lee ■ Surrogate Markers for Optimal PEEP in ARDS

ARDS

Surrogate Markers for Optimal PEEP in ARDS

Dong Hyun Lee

Dong-A Univ, Korea

Positive end-expiratory pressure (PEEP) is one compliance and then, the lung compliance should of the important ventilator settings variables for be calculated at each level of PEEP. the patients with mechanical ventilation. Although Regarding the fact that the more alveoli opened, it is easily set on the ventilator, the titration as an the better oxygenation is achieved, PEEP can titrat- optimal level in acute respiratory failure (ARDS) is ed with PaO2 or delivery of oxygen. Both PaO2 and challenging. delivery of oxygen also involves calculating or as- PEEP is usually applied to prevent the alveolar sessing the value at each level of PEEP. PEEP should collapse at the end of expiration. Improved oxygen- be set as the level with best PaO2 or highest oxygen ation with optimal PEEP titration is associated with delivery. lower mortality in patients with ARDS. However, PEEP usually represents applied PEEP (at the air- PEEP can result in adverse events and should be set way). Alveoli opening is more related to an end-ex- cautiously with thorough understanding. piratory transpulmonary pressure and some physi- Most physicians use PEEP table suggested by cians use transpulmonary pressure via esophageal ARDS Net, which is based on the oxygen require- pressure measurement. Esophageal pressure is an ment of patient. The PEEP table is somewhat useful estimate of pleural pressure and can be measured because it is intuitive and easy to set. However, sev- with an esophageal balloon catheter. Transpulmo- eral methods to optimize the PEEP level to achieve nary pressure is calculated as follows; airway pres- best outcome for the individualized patient have sure - pleural pressure (esophageal pressure). The been suggested. transpulmonary pressure can then be adjusted by The lung compliance is associated with aerat- titrating PEEP. ed alveoli and PEEP can be set as the pressure at Electric impedance tomography (EIT) is a novel maximal lung compliance. Lung compliance is technology providing changes of intra-thoracic determined from the PV curve (slope equals com- electric impedance which is generated from the pliance) with the equation; Lung compliance = Tid- movement of respiration. This change of electric al volume / (Plateau airway pressure – PEEP). Or impedance is called ‘tidal variation’ and can be PEEP can be set by stepwise titration regarding the used for PEEP titration. Tidal variation is correlated

190 KSCCM·ACCC 2020 Dong Hyun Lee ■ Surrogate Markers for Optimal PEEP in ARDS with change of lung volume change. EIT measure- to assess the individualized patients with ARDS. ment during decremental PEEP titration provides the optimal PEEP with minimal portion of overdis- References tended and collapsed alveoli. Several prospective 1. Am J Respir Crit Care Med. 2017;1;195(9):1253- studies reported PEEP titration using EIT to be safe 1263. An Official American Thoracic Society/Euro- and effective and suggested as a promising tool for pean Society of Intensive Care Medicine/Society of bedside tailored PEEP titration. Critical Care Medicine Clinical Practice Guideline: Regardless of which method is chosen, inflation Mechanical Ventilation in Adult Patients With Acute Respiratory Distress Syndrome beyond the upper inflection point can result in al- 2. BMJ Open Respir Res. 2019;24;6(1):e000420. veolar overdistension and pulmonary barotrauma,

Guidelines on the Management of Acute Respira- August 1 (Sat) as well as impaired cardiac filling and oxygen deliv- tory Distress Syndrome. ery. Physicians should be aware of the clinical im- 3. Criti Care. 2018;22; 263. Electrical impedance to- mography in acute respiratory distress syndrome. plication of PEEP titration and choose the best tool

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 191 Jae Young Moon ■ Neuromuscular Blockers for ARDS: To Use or Not to Use

ARDS

Neuromuscular Blockers for ARDS: To Use or Not to Use

Jae Young Moon

Chungnam National Univ. College of Medicine, Repub. of Korea

Neuromuscular blocking agent (NMBA) has been We need to review and evaluate new studies proposed for early severe acute respiratory distress including Geurvilly’s report and ROSE trial on syndrome (ARDS) because of its survival benefits. NBMAs in critically ill patient with ARDS. However, new studies have provided evidence con- tradicting these results [1]. Much evidence supports References the concepts that both over-distension of the lung 1. A.T.W. HO, S. Patolia et al. Neuromuscular block- and repetitive opening and closing of alveoli [2]. ade in acute respiratory distress syndrome: a sys- Early NMBA, within 48 hours of lung injury, have tematic review and meta-analysis of randomized been historically used in critically ill patients with controlled trials, Journal of Intensive Care 2020; ARDS to aid in increasing alveolar recruitment, im- 8(12):1-11. proving patient-ventilator synchrony, and promot- 2. J.B. Hall, Point: Should Paralytic Agents Be Routinely Used in Severe ARDS?; Yes, CHEST ing oxygenation [3]. 2013;144(5):1440-1442. Despite of the academic strength, the ACURASYS 3. B. Mefford, J.C Donaldson, et al. To Block or Not: Study (2010) lead several key questions and debates, Updates in Neuromuscular Blockade in Acute Re- which the critical care academy need further re- spiratory Distress Syndrome, Annals of Pharmaco- search on. First, the ACURASYS study used a very therapy 2020;(Feb):1–8. 4. L. Papazian, J. Forel, et al. Neuromuscular Blockers conservative approach to PEEP [4], [5]. Second, at in Early Acute Respiratory Distress Syndrome, N least 50% of patients in each study arm received Engl J Med 2010;363:1107-16. as-needed doses of cisatracurium, potentially cloud- 5. C.N. Seller, Counterpoint: Should Paralytic Agents ing the results [5]. Third, it is possible that their re- Be Routinely Used in Severe ARDS?; No, CHEST sults are not reproducible with other NMBAs. 2013;144(5):1442-1445. Since Papazian and colleagues reported that early 6. M Moss, D.T. Huang, et al. Early Neuromuscular Blockade in the Acute Respiratory Distress Syn- administration of a NMBA (cisatracurium besylate) drome, N Engl J Med 2019;380:1997-2008. improved the adjusted 90-day survival and increased 7. C. Guervilly, M. Bisbal, et al. Effects of neuromus- the time off the ventilator without increasing muscle cular blockers on transpulmonary pressures in weakness in 2010, new studies have provided evi- moderate to severe acute respiratory distress syn- dence contradicting these results [6], [7]. drome, Intensive Care Med 2017;43:408-418.

192 KSCCM·ACCC 2020 KSCCM·ACCC 2020 The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020

Oral Presentation

No. Oral Presentation Presentation No. Date Room 1 Oral Cardio 1 01-09 July 31(Fri), 2020 Room 6 2 Oral Cardio 2 10-15 July 31(Fri), 2020 Room 6 3 Oral Pharma 01-05 July 31(Fri), 2020 Room 7 4 Oral Surgery 1 01-06 July 31(Fri), 2020 Room 6 5 Oral Surgery 2 07-12 July 31(Fri), 2020 Room 7 6 Oral Sepsis 1 01-06 July 31(Fri), 2020 Room 7 7 Oral Sepsis 2 07-10 July 31(Fri), 2020 Room 8 8 Oral Basic 1 01-07 July 31(Fri), 2020 Room 8 9 Oral Neuro 1 01-07 July 31(Fri), 2020 Room 8 10 Oral Neuro 2 08-13 July 31(Fri), 2020 Room 6 11 Oral ICU General 1 01-09 July 31(Fri), 2020 Room 7 12 Oral ICU General 2 10-17 August 1(Sat), 2020 Room 6 13 Oral ICU General 3 18-25 August 1(Sat), 2020 Room 6 14 Oral ICU General 4 26-33 August 1(Sat), 2020 Room 8 15 Oral RRT 01-08 August 1(Sat), 2020 Room 6 16 Oral PED 01-07 August 1(Sat), 2020 Room 8 17 Oral Quality 1 01-07 August 1(Sat), 2020 Room 7 18 Oral Quality 2 08-12 August 1(Sat), 2020 Room 7 19 Oral EM/CPR 01-08 August 1(Sat), 2020 Room 7 20 Oral Nursing 01-04 August 1(Sat), 2020 Room 7 21 Oral Pulmo 1 01-08 August 1(Sat), 2020 Room 8 22 Oral Pulmo 2 09-14 August 1(Sat), 2020 Room 6 July 31(Fri), 2020

Room 6 Room 7 Room 8

▶ Oral Cardio 1 ▶ Oral ICU General 1 ▶ Oral Neuro 1

▶ Oral Surgery 1 ▶ Oral Sepsis 1 ▶ Oral Sepsis 2

▶ Oral Cardio 2 ▶ Oral Surgery 2 ▶ Oral Basic 1

▶ Oral Neuro 2 ▶ Oral Pharma

August 1(Sat), 2020

Room 6 Room 7 Room 8

▶ Oral ICU General 3 ▶ Oral EM/CPR ▶ Oral ICU General 4

▶ Oral ICU General 2 ▶ Oral Quality 2 ▶ Oral Pulmo 1

▶ Oral RRT ▶ Oral Quality 1 ▶ Oral PED

▶ Oral Pulmo 2 ▶ Oral Nursing Oral Presentation

Oral Cardio (1) 01 Change in T/QRS Ratio Can be a Supplementary Diagnostic Tool in Predicting Coronary Artery Disease in Patients with NSTEMI Jae Hoon LEE Emergency Medicine, Dong-A University College of Medicine, Korea

Introduction: Changes in the electrocardiographic find- ings, namely the ratio T sum to QRS sum (T/QRS ratio), be- tween the initial electrocardiogram (ECG) and remote ECG have rarely been investigated in patients with non-ST ele- vation myocardial infarction (NSTEMI). Thus, we aimed to determine whether changes in various parameters on ECG, including T/QRS ratio, can assist in distinguishing between coronary artery disease (CAD) and low to moderate risk of NSTEMI with no CAD. Methods: This retrospective study enrolled 2572 patients who presented with ischemic symptoms, were diagnosed with NSTEMI, and who underwent coronary angiography. Figure 2. Overall, 388 patients had prior ECG and echocardiography Table 1. Multivariable analysis of variables predicting coronary artery disease

data available; 110 were included after excluding several Oral Presentation diseases except CAD. Two population subsets of a coronary stenosis group (n=78) and normal coronary group (n=32) were analyzed. Results: We found that acute dynamic change in the most deviated T/QRS ratio in each region of leads of initial ECG from those of remote/recent ECG was an extremely strong predictor of acute CAD (odds ratio, 110; p<0.001) compared to that of initial serum troponin I levels, new-onset regional wall motion abnormalities, and new-onset T inversion or ST depression. T/QRS ratio change >1.5 or <0.5 times in in- jured regional leads was a significant predictor to CAD.

Conclusions: Change in the most deviated T/QRS ratio in the regional leads on initial ECG from the T/QRS ratio in the same lead on remote ECG can assist in predicting CAD risk between patients with CAD and NSTEMI and patients with be low to moderate risk of NSTEMI. Keyword: Acute Coronary Syndrome, Electrocardiography, Non-ST Elevated Myocardial Infarction

Figure 1.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 195 Oral Presentation

Oral Cardio (1) 02 The association between bleeding complication and mortality in patients underwent extracorporeal cardiopulmonary resuscitation Min-Goo KANG1, Yunim LEE1, Ryoung-Eun KO1, Yang Hyun CHO1,3, Chi Ryang CHUNG 1, Kyeongman JEON1,4, Gee Young SUH1,4, Jeong Hoon YANG1,2 1Department of Critical Care Medicine, Samsung Medical Center, Sungkyunk- 2 wan University, Korea; Division of Cardiology, Department of Medicine, Figure 1. Bleeding and mortality according to each bleeding criteria1. Samsung Medical Center, Sungkyunkwan University, Korea; 3Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunk- 4 Results: Among 133 ECPR patients, 69 patients (51.8%) wan University, Korea; Division of Pulmonology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University, Korea had bleeding complications within 24 hours after ECPR. Patients suffered from bleeding complications had longer Introduction: Bleeding complications during extracorpo- arrest time and higher activated partial thromboplastin real membrane oxygenation (ECMO) are frequent but its time and prothrombin time. The most prevalent site of association with prognosis has not fully elucidated. There- bleeding was cannula site (n=58) followed by the thorax (n fore, we investigated the association between bleeding = 12), gastrointestinal bleeding (n=8), ear-nose and throat complication and mortality in patients underwent extra- (n = 6), and hematuria (n=4). Bleeding complication was corporeal cardiopulmonary resuscitation (ECPR). associated with increased in-hospital mortality (53.6% Methods: Between January 2010 and December 2018, versus 35.9%, odd ratio 3.45, 95% confidential interval 133 patients received ECPR were included in this analysis. 1.03-4.13, p=0.04). In addition, negative impact of bleeding We classified the enrolled patients into bleeding group and complication on mortality were also similar in accordance non-bleeding group according to the bleeding academic re- with the various definitions of the Extracorporeal life search consortium (BARC) type 3a or higher within 24 hours support organization (ELSO) and the the Thrombolysis in after ECPR. Primary outcome was in-hospital mortality. Myocardial Infarction (TIMI) major or minor. Table 1. Baseline charateristics Conclusions: Major bleeding as an early complication was associated with a higher in-hospital mortality in ECPR pa- tients. Keyword: Extracorporeal cardiopulmonary resuscitation, Arrest, Bleeding complication

Oral Cardio (1) 03 The role of thrombolysis in myocardial infarction (TIMI) score in predicting mortality among acute coronary syndrome patients in Indonesia: a hospital-based cohort study Hening TIRTA KUSUMAWARDANI1, Etra ARIADNO2, Eko BUDI PRASETYO1 1Anesthesiology and Intensive Therapy Departments, Dr. Mintohardjo Naval Hospital, Jakarta, Indonesia; 2Internal Medicine Departments, Cilandak Marine Hospital, Jakarta,, Indonesia

Introduction: Risk Stratification in acute coronary syn- drome (ACS) both ST elevation myocardial infarction (STEMI) and Unstable Angina Pectoris (UAP)/ Non ST ele-

196 KSCCM·ACCC 2020 Oral Presentation vation myocardial infarction (NSTEMI) patients is an inte- Table 2. Prognostic factor distribution of TIMI STEMI Score gral part in the management of patients. Risk stratification is important to prevent overtreatment in high risk patients, as well as under treatment in low risk patients. Although TIMI STEMI and TIMI UAP/ NSTEMI are scores that have been validated and used widely, but to date no study of its applicability has been done in Indonesia. Differences in characteristics of acute coronary syndrome patients in Indonesia compared to developed countries can have influence on the prognosis of the patient hence a study is needed regarding performance of TIMI scoring system. The aim of this study was to obtain the calibration and discrim- ination performance of TIMI risk score to predict 30 day and 14 day mortality in STEMI and UAP/ NSTEMI patients in Indonesia Methods: A retrospective cohort study with consecutive sampling was done in ACS patients hospitalized in the Intensive Care Cardiac Unit (ICCU) Indonesia’s tertiary hospital between the periods January 2012 until December 2019. Calibration performance of TIMI risk score was eval- uated by calibration plot and Hosmer-Lemeshow test while discrimination performance was analyze with Area Under Oral Presentation Curve (AUC). Table 3. Effect of other prognostic variables on TIMI score performance Table 1. Patient’s characteristic of STEMI and UAP NSTEMI

Results: A total of 714 STEMI patients and 787 UAP/ NSTEMI patients were included in this study. TIMI STEMI risk score have a good calibration and discrimination per- formance with calibration plot of 0.98; Hosmer-Lemeshow

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 197 Oral Presentation test 0.93 and AUC 0,801 (CI 95% 0,759-0,844). A good cal- cardial infarction and does not increase the risk of major ibration and discrimination performance of TIMI UAP/ bleeding, with compare to DAPT. NSTEMI risk score was observed with calibration plot of Keyword: Antithrombotic Therapy, Dual Antiplatelet Ther- 0,88, Hosmer-Lemeshow test 0,86 and AUC 0,727 (CI 95% apy, Acute Myocardial Infarction 0,668-0,786). Conclusions: TIMI risk score has a good calibration and discrimination performance in predicting mortality of ACS Oral Cardio (1) 05 patients in Indonesia. The Effectiveness of Intra-aortic Balloon Pump Keyword: TIMI score, Acute Coronary syndrome, Mortality (IABP) in Patients with or without Cardiogenic Shock Following Acute Myocardial Infarct (AMI) 1 2 Oral Cardio (1) 04 Muhamad Fajri ADDA’I , Jonathan Hasian HAPOSAN , Andi Khomeini Takdir HARUNI3, Amiliana M. SOESANTO4 Comparison of Effects of Triple Antithrombotic 1Emergency Medicine, Johar Baru Health Care, Jakarta, Indonesia; 2Pediatric Research Office, University of Gadjah Mada, Yogyakarta, Indonesia; 3Internal Therapy and Dual Antiplatelet Therapy on Long- Medicine, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia; Term Outcomes of Acute Myocardial Infarction 4Cardiology, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia Mei-Tzu WANG1, Guang-Yuan MAR1, Cheng Chung HUNG1, Shu-Hung 1 1 1 1,2,3 Introduction: Result from previous studies evaluating KUO , Wang-Ting HUNG , Pei-Ling TANG , Cheng-Hung CHIANG , Jin-Shiou YANG3, Chun-Peng LIU1,3, Wei-Chun HUANG1,2,3 benefit use of IABP in AMI patients were inconclusive. This 1Critical Care Medicine, Kaohsiung Veterans General Hospital, Taiwan study aimed to investigate the effect of IABP in patients 2School of Medicine, National Yang-Ming University, Taiwan with or without cardiogenic shock following AMI. 3Physical Therapy, Fooyin University, Taiwan Methods: Databases were systematically searched for Introduction: Warfarin is an alternate choose for patients randomized controlled trials (RCT) comparing the use of who are not eligible for non-vitamin K oral anticoagulants IABP with no IABP in patients with or without cardiogenic after acute myocardial infarction (AMI). This study aimed shock following AMI. The databases were searched with to compare the long-term outcome of triple antithrombotic predefined protocol regardless publication time and lan- therapy (TAT) with that of dual antiplatelet therapy (DAPT) guage restriction based on PRISMA guideline. Analysis was after AMI. performed in RevMan 5.3 to provide pooled measures for Methods: This was a nationwide, propensity score- Odd Ratio (OR) and 95% Confidence Interval (95%CI). matched, case-control study of 186,112 first AMI patients, Results: Fourteen RCT were enrolled including 1057 cases of whom 2,825 received TAT comprised aspirin, clopido- and 1053 controls. IABP intervention showed no statisti- grel, and warfarin. cally significant compared to control group in decreasing Results: Propensity score matching in a ratio of 1:4 was ad- 30-day (OR 0.97, 95%CI[0.97-1.26], p=0.80, I2=0%) and opted, and finally, 2,767 AMI patients and 11,068 matched 6-month mortality (OR 0.93 [0.71-1.21], p=0.57, I2=0%). controls that were administered TAT and DAPT (aspirin and Otherwise, IABP was statistically significant in reducing clopidogrel), respectively, were included in our analysis. 12-month mortality among AMI patients without cardio- The 12-year overall survival rate did not differ between both genic shock (OR 0.60 [0.37-0.96], p=0.03, I2=0%). IABP in- strategies (p=.1826). TAT was beneficial in old age (hazard tervention was statistically significant in lowering risk of re- ratio [HR] = 0.93), female sex (HR = 0.87), atrial fibrillation current ischemic by 46% compared to controlled group (OR (AF) ( HR= 0.86), hypertension (HR = 0.92), cerebrovascular 0.54 [0.35-0.82], p=0.03, I2=0%). Reinfraction (OR 1.03 [0.70- accident (HR = 0.82), and in the absence of percutaneous 1.52], p=0.88, I2=3%), reocclusion of infarct-related artery coronary intervention ( HR = 0.77). TAT reduced the rate (OR 0.63 [0.25-1.54], p=0.31, I2=59%), and new-onset of HF of recurrent myocardial infarction (p=.0064) but did not (OR 0.86 [0.61-1.20], p=0.40, I2=3%) were not statistically affect the rate of stroke p( =.8297), gastrointestinal bleeding different between two group. In comparison with control, (p=.2925), or intracranial hemorrhage (ICH) (p=.1751). IABP could increased side effects such as bleeding (OR 1.69 Conclusions: TAT reduces the incidence of recurrent myo- [1.10-2.58], p=0.02, I2=0%) and vascular compromise (OR

198 KSCCM·ACCC 2020 Oral Presentation

1.69 [1.10-2.58], p=0.88, I2=0%) but not for stroke (OR 1.49 25%. (2 and 8). In consideration of another 21 patients with [0.61-3.66], p=0.26). RBBB but not fulfilled the above criteria and 80 non-STEMI Conclusions: Use of IABP may reduced 12-month mor- with chest pain and RBBB, the overall sensitivity, specific- tality in AMI patients without cardiogenic shock. It also ity, PPV and NPV for criteria (1) are 80%, 100%, 100% and decreased risk of recurrent ischemia. However, it was lim- 70%, respectively. ited evidence of benefit use of IABP in cardiogenic shock Conclusions: Our proposed criteria have been proven to patients following AMI. Bleeding and vascular compromise be of high specificity and PPV in diagnosing STEMI among must also be considered when using IABP. patients with new-onset or pre-existing RBBB. Keyword: Intra-Aortic Balloon Pump, Acute Myocardial Keyword: Myocardial Infarction, Right Bundle Branch Infarct, Cardiogenic Shock Block, Wang’s Criteria

Oral Cardio (1) 06 Oral Cardio (1) 07 What we learned from the STEMI patients Influence of ventilation strategies on gas complicated with RBBB? Extension of Sgarbossa distribution by EIT after cardiac surgery with Tzong-Luen WANG cardiopulmonary bypass 1 2 1 Emergency Medicine, Chang Bing Show Chwang Memorial Hospital, Taiwan Yung-Chi HSU , Chien-Sung TSAI , Tso-Chou LIN 1Anesthesiology, Tri-Service General Hospital, Taiwan; 2Cardiovascular Surgery, Introduction: Right bundle branch block (RBBB) has been Tri-Service General Hospital, Taiwan mentioned as a possible ECG manifestation of ST elevation Introduction: Atelectasis is one of the main reasons caus- myocardial infarction (STEMI) and associated with worse ing complications after cardiac surgery. Cardiopulmonary Oral Presentation outcome. Whether the rationale of Sgabossa criteria can be bypass (CPB) during surgery may lead to atelectasis and applied to patients with presumed new-onset RBBB needs lung injury [1]. Mechanical ventilation during CPB with low to be elucidated. tidal volume and positive end-expiratory pressure (PEEP) Methods: The target study population is the patients di- may improve lung function but influence operation field agnosed as STEMI presenting with presumed new-onset at the same time, which is undesired. The aim of the study RBBB from Jan 2010 to Oct 2018 in three hospitals in a was to examine if various ventilation strategies after CPB health-care system in Taiwan. Demography, laboratory may improve ventilation distribution. tests, ECG,WITHDRAWAL coronary angiograms were included for analy- Methods: The study was designed to randomize patients sis. We extended the rationale of Sgarbossa and modified scheduled for cardiac surgery with CPB to 4 ventilation Sgarbossa criteriain those presenting with RBBB. The de- groups: (1) intermittent mandatory ventilation (IMV), tidal veloped ECG criteria in patients with RBBB include at least volume 7ml/kg, inspiration to expiration time ratio (I:E) 1:2; one of the following: (1) the presence of concordant ST (2) IMV+PEEP:6cmH2O; (3) IMV+I:E 1:1; (4) IMV+PEEP: changes in any two contiguous leads, (2) ST deviation more 6cmH2O +I:E 1:1. Blood gasses, hemodynamics and other than 0.5mV in the leads of discordant ST changes, or (3) outcome parameters were collected. Ventilation distri- the ratio of ST deviation over the amplitude of T waves ex- bution was analyzed with electrical impedance tomogra- ceeding 25%. The sensitivity, specificity, negative predictive phy(EIT) before CPB (after induction of anesthesia) and value and positive predictive value are calculated. after surgery (the end of the surgery) [2]. Results: Of 982 STEMI patients in the study period, there Results: Up to now, 50 patients were included and ana- are 112 fulfilling the above criteria, including 64 with exist- lyzed (n=13 in groups 1 & 4, n= 12 in groups 2 & 3). Demo- ing RBBB and 48 with new-onset or presumed new-onset graphics were comparable in different groups. Investigated RBBB. There are 86 patients with concordant ST changes (58 outcome parameters showed no significant differences as for old RBBB and 28 for new-onset), 16 with discordant ST well. Global inhomogeneity analyzed by EIT was improved deviations more than 0.5mV (4 and 12) and 10 with the ra- in groups 2 ,3 & 4 with statistically (Fig. 1). Center of venti- tio of ST deviation over the amplitude of T waves exceeding

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 199 Oral Presentation lation(CoV) after surgery was highly correlated to patient’s support for respiratory or cardiac failure despite maximal body-mass index. conventional therapy.

Conclusions: Ventilation strategies with IMV added one of PEEP or reverse IE ratio could be able to improve ventila- tion after surgery with CPB analyzed with EIT. Keyword: Electrical Impedance Tomography, Cardiac sur- ger, Perioperative lung injury

Oral Cardio (1) 08 Clinical Outcomes of Extracorporeal Membrane Oxygenation for Patients with Cancer: Hematologic versus Oncologic Malignancy Chul PARK1, Ui Won KO1, Soo Jin NA1, Jeong Hoon YANG1,2, Kyeongman JEON1,3, Gee Young SUH1,3, Kiick SUNG4, Yang Hyun CHO4 1Critical Care Medicine, Samsung Medical Center, Korea; 2Division of Cardiolo- gy, Department of Internal Medicine , Samsung Medical Center, Korea; 3Pulmo- nary and Critical Care Medicine, Samsung Medical Center, Korea; 4Thoracic and Cardiovascular Surgery, Samsung Medical Center, Korea Figure 1. Central image.

Introduction: Life expectancy has improved in malignancy Results: Of 98 eligible patients, 30 (30.6%) were diagnosed patients; however, the application of extracorporeal mem- with hematologic malignancy and 68 (69.4%) were diag- brane oxygenation (ECMO) support remains challenging nosed with oncologic malignancy. Compared to oncologic and controversial in these patients. Here, we selectively malignancy patients, hematologic malignancy patients used ECMO for hematologic or oncologic malignancy and were younger, more neutropenic, more hypotensive, and evaluated our experiences. had a lower charlson comorbidity index, higher sequential Methods: We conducted retrospective observational study organ failure assessment score, and lower platelet count. for compare to clinical outcomes of ECMO between hema- Forty-six (46.9%) patients were successfully weaned from tologic and oncologic malignancy patients between Janu- ECMO, and 30 (30.6%) survived till hospital discharge. Hos- ary 2012 and December 2016 in a single center registry. We pital survival rate was significantly lower in the hematolog- included critically ill adult patients with active malignancy ic malignancy than in the oncologic malignancy group (13.3 within the previous one-year period and received ECMO vs 38.2%, p=0.026). Survival status 6 months after hospital

200 KSCCM·ACCC 2020 Oral Presentation discharge was also significantly lower in hematologic ma- respectively). On multivariable logistic regression, HH, age, lignancy patients (3.3 vs 26.5%, p=0.017). In multivariate cardiac arrest due to ischemic heart disease, shockable analysis, hematologic malignancy, age, acidosis, thrombo- rhythm, out-of-hospital cardiac arrest, low flow time, acute cytopenia, high vasoactive inotrope score, and respiratory kidney injury requiring continuous renal replacement ther- failure were risk factors for in-hospital death. apy were significant predictors for in-hospital mortality. Conclusions: Hematologic malignancy patients who re- quired ECMO had significantly lower hospital survival rate than oncologic malignancy patients. Six-month survival after discharge was extremely low in the hematologic ma- lignancy group. Keyword: Hematology, Oncology, Extracorporeal mem- brane oxygenation

Oral Cardio (1) 09 The impact of hypoxic hepatitis on clinical outcomes in patients who underwent Figure 1. Flow chart. extracorporeal cardiopulmonary resuscitation Yun Im LEE1, Min Goo KANG1, Ryung-Eun KO1, Taek Kyu PARK2, Chi Ryang CHUNG1, Yang Hyun CHO3, Kyeongman JEON1,4, Gee Young SUH1,4, Jeong Hoon YANG1,2 Oral Presentation 1Department of Critical Care Medicine, Samsung Medical Center, Korea; 2Devi- sion of Cardiology, Samsung Medical Center, Korea; 3Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Korea; 4Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Korea

Introduction: Limited data are available on the association be- tween hepatic injury and clinical outcomes in patients under- Figure 2. Relationship. went extracorporeal cardiopulmonary resuscitation (ECPR). Table 1. Multivariate analysis of factors associated with in-hospital mortality after Methods: Patients received ECPR due to either in- or ECPR (n=360) out-of-hospital cardiac arrest from May 2004 to December 2018 were eligible. Hypoxic hepatitis (HH) was defined as an increased aspartate aminotransferase or alanine amino- transferase to more than 20 times the upper normal range. Primary outcome was in-hospital mortality. Secondary outcome was poor neurological outcome defined as a Ce- rebral Performance Categories score 3 to 5 at discharge. Results: Among 365 ECPR patients, 90 patients (24.7%) were identified as HH. The in-hospital mortality and poor neurologic outcomes in HH group were higher than those of non-HH group (72.2% vs 54.9%, p=0.004 and 77.8% vs 63.6%, p=0.013, respectively). In-hospital mortality in pa- tients with albumin < 3 g/dl (n = 272), total bilirubin ≥ 2 mg/dl (n = 159), international normalized ratio ≥ 1.5 (n = 252) as various indicators of hepatic dysfunction were sig- nificant higher than those of the other group (all p<0.001,

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 201 Oral Presentation

Conclusions: Hypoxic hepatic injury is not a rare com- a short period of palliative/spiritual care for patients with plication and is associated with poor clinical outcomes in postcardiotomy end-stage heart failure and their family ECPR patients. members through an interdisciplinary team approach. Keyword: Extracorporeal cardiopulmonary resuscitation, Keyword: ECMO, Palliative Care, Postcardiotomy Syn- Hypoxic hepatitis, Acute liver injury drome

Oral Cardio (2) 10 Oral Cardio (2) 11 Palliative Care at ICU for Postcardiotomy End- The outcome of extracorporeal membrane Stage Heart Failure Patients with ECMO or VAD oxygenation in the major trauma patient with Support hemorrhagic shock and emergency surgery in a TSUNG-PO TSAI level I trauma center Division of Cardiovascular Surgery, Chung Shan Medical University Hospital, Sung Jeep KIM Taiwan Department of Trauma Surgery, Ulsan University Hospital, Korea

Introduction: We designed a palliative program at ICU Introduction: Major trauma with severe chest injuries or to support patients with postcardiotomy end-stage heart with massive hemorrhagic shock can cause a severe ARDS failure and their family members facing the dying and the or acute cardio-pulmonary failure. ECMO can be used as bereavement period spiritually. salvage therapy for these major trauma patients but using Methods: There were 59 out of 1,445 cardiac surgical pa- ECMO in adult trauma patients remains a controversial. tients developed postcardiotomy end-stage heart failure re- Aim of this study is to evaluate the outcome of ECMO as quiring ECMO support. Among them, 5 patients (2 CABG, 1 slavage therapy for major trauma patient with hemorrhagic VSD repair + TVR, 1 Apico-aortic conduit and 1 MVR+TAP) shock and emergency surgery. required ECMO and one patient (CABG) later required Methods: This retrospective study enrolled 9 adult trauma VAD circulatory support for more than 5 days. Their pre- patients receiving ECMO due to acute cardio-pulmonary operative GCS (Glasgow Coma Scale) scores were 15 failure or severe trauma related ARDS in a level I trauma (E4M6V5), however after the surgery, GCS scores changed center between January 2017 and December 2019. Vari- to E3M5Vt, E2M4Vt, E4M6V5, E2M4Vt and E4M6Vt, re- ables collected for analysis were demographics, charac- spectively. The ECMO could not be weaned in each case. teristics of trauma, injury severity score (ISS), amount of Therefore, a palliative care team (including palliative care transfusion, serum biomarkers, damage-control interven- clinician, nurse, family members and patient) was engaged tions, indications of ECMO, and associated complications. in every case to do palliative interventions; team discussion The outcomes were hospital mortality. and explanation of the treatments target, inform the patient Results: The medians of age and ISS were 53 (18-66) years and surrogates the possible complications of using ECMO, and 29 (20-41). All patients had polytrauma and 8 patients consult interdisciplinary experts and pursuit extramural had severe chest trauma (AIS ≥4) and 1 patient had no appeal. chest trauma. The Median initial systolic blood pressure Results: The duration of ECMO application in these 5 pa- and total transfusion within initial 24 hour were 75 (40- tients was from 8 to 50 days with a mean of 19 days. ECMO 80) mmHg and 59 (37-179) units. 8 patient received ECMO could not be weaned or removed in 5 patients until they during first emergency surgery on admission day and the fell unconsciousness again and became hemodynamically median time of receiving ECMO from admission was 2.5 unstable. One patient who gained consciousness but failed hours (2-48hr). Prior to ECMO median PaO2 was 36.5(25- to wean off ECMO decided the inheritance and then loss 43) mmHg, median PaCO2 was 75 (34-101) mmHg and P/ of consciousness later. We gained 95% of satisfaction from F ratio was 40(25-70). Veno-arterial (V-A) and veno-venous patients’ family and surrogates after Questionares. (V-V) ECMO type were used for 5 patients and 4 patients, Conclusions: ECMO is a valuable alternative to provide respectively. There were 6 patients died and 5 patients died

202 KSCCM·ACCC 2020 Oral Presentation on admission day and 1 patient died within 48 hour. (BSI) with same microorganisms. Most of the microorgan- Conclusions: Although using ECMO to provide advanced isms were multidrug resistant. Oxygenator colonization life support in adult major trauma patients remains a con- was significantly correlated with catheter colonization troversial issue, ECMO can be a salvage therapy for select- (r=0.622, p<0.001). However, BSI did not significantly cor- ed major trauma patients who are in severe hemorrhagic relate with oxygenator colonization (r=0.172, p=0.070). shock or Keyword: Trauma, ECMO, Hemorrhage

Oral Cardio (2) 12 The impact of microbial colonization of membrane oxygenators on clinical outcomes Taehwa KIM1, Woo Hyun CHO1, Dohyung KIM2, Doosoo JEON1, Yun Seong KIM1, Hye Ju YEO1, Yun Seong KIM1, Jinook JANG1, Eun Jeong 1 1 SON , Jin Ho Jang JANG Figure 1. 1Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Korea; 2De- partment of Cardiovascular and Thoracic Surgery, Pusan National University Yangsan Hospital, Korea

Introduction: The significance of microbial colonization of oxygenators during extracorporeal membrane oxygenation

(ECMO) is unclear. Oral Presentation Methods: We prospectively collected and cultured ECMO oxygenators at the end of ECMO support, and retrospec- tively reviewed oxygenator colonization, clinical outcomes, and associated factors in ECMO patients (122 oxygenators, 1,196 ECMO days). Results: 11.6% of the oxygenators had microbial coloniza- tion. Patients were divided into oxygenator colonization Figure 2. (n=13) and non-colonization groups (n=99). The weaning success rate from ECMO and survival discharge rate were Table 1. Clinical outcomes based on oxygenator colonization significantly lower in the oxygenator colonization group than that in the non-colonization group (weaning 30.8% vs 90.9%, p<0.001, survival 23.1% vs 76.8%, p<0.001). In mul- tivariate analysis, age (per 10 years) (OR 1.95, 95% CI 1.28- 2.95, p=0.002), oxygenator colonization (OR 15.49, 95% CI 3.31-72.46, p<0.001), and renal replacement therapy (OR 4.61, 95% CI 1.69-12.58, p=0.003) were significantly associ- ated with mortality. Kaplan–Meier analyses revealed that oxygenator colonization predicted mortality (χ2=28.97, p<0.001). The most common pathogen colonizing oxygen- ators was Klebsiella pneumonia, followed by Acinetobacter baumannii and Staphylococcus epidermidis. Nine patients (69.2%) had catheter colonization with same microorgan- isms, and 5 patients (38.5%) had bloodstream infection

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 203 Oral Presentation

Conclusions: Nonetheless, oxygenator colonization is as- 2-3 days postoperatively and weaned thereafter. sociated with poor outcomes in ECMO patients. Conclusions: This is the first case of newly developed, Keyword: Extracorporeal membrane oxygenation, Oxy- Korean smart all-in-one ECMO system. The Korean smart genator, Blood stream infection all-in-one ECMO device was expected effective and safe in comparison to foreign devices. This could contribute to develop and commercialize our domestic ECMO, further- Oral Cardio (2) 13 more to reduce medical expenses and treat critically ill pa- Clinical application of Korean smart all-in-one tients. extracorporeal life support device for bridging to lung transplantation: case study Sun Young CHOI1, Sung Yoon LIM1, Yeon-Joo LEE1, Dong Jung KIM2, Sanghoon JHEON2, Young-Jae CHO1 1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Korea; 2Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Korea

Case: Introduction: The extra-corporeal membrane oxy- genation(ECMO) bridge-to-lung transplantation(TPL) is essential nowadays, however there was no domestic ECMO device. Currently available foreign machines are expensive, lesser mobile with complicated lines and difficult to han- dle. Herein we describe a patient with respiratory failure Figure 1. Ecmo. due to interstitial lung disease (ILD) aggravation who take Keyword: Extra-Corporeal membrane oxygenation, Lung Korean smart all-in-one ECMO before lung TPL. transplantation Case Presentation: A 59-year-old woman developed dys- pnea and general weakness 2 month ago and visited clinic to find subpleural reticular opacities and traction bron- Oral Cardio (2) 14 chiectasis in both lungs at chest computed tomography, probable ILD. Anti-nuclear and Anti-Sjogrens-syndrome Hyperlactatemia and Myocardial injury in ST- (SS-A/RO) antibodies were positive. She took steroid and segment Elevation Myocardial Infarction : A conservative care for a month but fever developed. She Cardiac magnetic resonance Imaging Study admitted another hospital and was treated with intrave- Hyun kyu CHO1, Ik Hyun PARK2, Young Bin SONG3, Woo Jin JANG4 nous antibiotics and steroids for suspected ILD aggravation 1Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical center, Sungkyunkwan University School of Medicine, Korea; due to pneumonia. She was intubated due to respiratory 2 Division of Cardiology, Department of Internal Medicine, Samsung Chang- failure and transferred to our hospital on December, 2019. won Hospital, Sungkyunkwan University School of Medicine, Korea; 3Division Multiple lung infiltrates and diffuse subcutaneous em- of Cardiology, Department of Internal Medicine, Samsung Medical center, Sungkyunkwan University School of Medicine, Korea; 4Division of Cardiology, physema with progressive hypoxemia resulted in ECMO Department of Internal Medicine, Ewha Womans University Medical Center , insertion. Elective Veno-venous ECMO, Korean smart all- Korea in-one ECMO (Figure A), with the first human clinical trial Introduction: Little is known about the causality and was applied for six hours and then changed to commercial pathological mechanism underlying the association be- ECMO. The sono-guided femoral cannulation was done for tween hyperlactatemia and myocardial injury in patients 37 minutes without any procedural events. There were no with ST-segment elevation myocardial infarction (STEMI). device-related clinical events and device-related mechani- We evaluated the association between elevated level of cal events. After 22 days on ECMO she underwent bilateral blood lactate and myocardial injury in STEMI patients cadaveric lung TPL. She needed veno-venous ECMO for undergoing primary percutaneous coronary intervention

204 KSCCM·ACCC 2020 Oral Presentation

(PCI) using cardiovascular magnetic resonance imaging brane oxygenation for patients with cardiogenic shock (CMR). is well-established, and lactate is well known as the bio- Methods: CMR was performed a median of 3.3 days after chemical biomarker of end organ perfusion. We evaluate the index procedure in patients undergoing primary PCI the efficacy of serial lactate level for prediction of survival for STEMI and lactate level was measured on admission in patients with cardiogenic shock during ECMO sup- from arterial blood. Study patients were divided into two port. groups according to the lactate level (≥3.5mmol/L or not) Methods: We respectively reviewed the medical records and we compared myocardial infarct size as assessed by of patients who underwent VA-ECMO for cardiogenic CMR according to the initial level of blood lactate. The in- shock between January 2015 and December 2019. A total verse probability of treatment weighting (IPTW) was also of 237 patients underwent ECMO. Of these, 108 adult pa- performed. tients underwent the venoarterial ECMO for cardiogenic Results: Of 145 study patients, the lactate level was less shock. These patients were divided into survivor and than 3.5 mmol/L in 116 patients (Low lactate group) and nonsurvivor groups, based on survival to hospital dis- the lactate level was 3.5 mmol/L or over in 29 patients (High charge. The clinical information, including serum lactate lactate group). In CMR finding analysis, myocardial infarct level in pre-ECMO condition, ECMO 3rd day and ECMO size tended to be lower in the Low lactate group than in 5th day, were compared between 2 groups. the High lactate group (20.4 ± 10.5% versus 24.2 ± 8.6%; Results: Mean age was 68.1 ± 13.3 years and 41 (37.9%) p=0.074). After performing IPTW adjustment, myocardial patients were female. The overall survival rate to hospital infarct size was significantly lower in the Low lactate group discharge was 50% (n=54). The optimal cut-off values compared with the High lactate group (20.9 ± 10.7% versus for survival prediction were 8.2 (pre-ECMO lactate was, 24.3 ± 8.1%; p=0.007). AUC 0.684, p=0.0003), 3.2 (ECMO 3rd day, AUC 0.708, p=0.0003) and 1.9 (ECMO 7th day, AUC 0.68, p=0.0213). Oral Presentation Conclusions: Higher level of initial blood lactate was In multivariate analysis of serial lacate level (Pre ECMO, associated with advanced myocardial injury as well as ECMO 3rd day and ECMO 7th day), independent predic- increased mortality in STEMI patients even after primary tors of mortality were the lacate level at ECMO 7th day PCI. (OR, 1.84; 95% CI, 1.13-2.99; p=0.0146).

Conclusions: We conclude that serial measurement of serum lactate was a useful biomarker for prediction of survival in VA ECMO patients with cardiogenic shock. Serum lactate level of 2.0 or more may be an indicator of unfavorable outcomes with the use of ECMO in adult cardiogenic shock at ECMO 7rd day. Keyword: ECMO, Biomarker, Cardiogenic shock Keyword: Lactate, ST-Segment elevation myocardial in- farction, Cardiovascular magnetic resonance

Oral Cardio (2) 15 Prediction of survival with serial ECMO lactate level in VA ECMO with cardiogenic shock Dowan KIM, Yuldashev NODIRBEK, Hwajin CHO, Inseok JEONG Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Korea Figure 1. Introduction: The effectiveness of extracorporeal mem-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 205 Oral Presentation

CI: 36.28~68.62, p<0.000) was the greatest that of moxiflox- acin (95% CI: -37.41~10.69, p<0.274), ciprofloxacin (95% CI: -45.36~-1.14, p<0.039) and gemifloxacin (95% CI: -82.28~- 18.76, p<0.002). QTc baseline of ICU admission (OR, 7.32; 95% CI, 1.35~39.59), treatment with loop diuretics (7.66 [1.12~52.47]), sepsis (8.81 [1.18~65.96]) and the number of QT-prolonging drugs based on the QT drugs list of Credi- bleMeds, especially known risk of TdP (4.83 [1.18~19.79]) were independent risk factors of QTc prolongation. Conclusions: The use of levofloxacin and moxifloxacin is Figure 2. associated with QTc prolongation, and it should be admin- istered with caution, especially in a patient with multiple Oral Pharma 01 risk factors. Keyword: QTc prolongation, Risk factor, Fluoroquinolone Incidence of QTc Prolongation associated with Fluoroquinolones and a Risk Factor Eun Jung CHOI1, Jin Seon BEOM1, Hyo Cho AHN1, Seung Yong PARK2, Oral Pharma 02 Heung Bum LEE2 1 2 Optimal Infusion Rate of Dexmedetomidine for Pharmacy, Jeonbuk National University Hospital, Korea; Internal Medicine, , Research Center for Pulmonary Disorders, Jeonbuk National University Medi- Adult Patients in the Intensive Care Unit cal School and Hospital, Korea Jee Yun KIM1, Jin SHIN2 1 Introduction: Fluoroquinolones (FQs) are widely used in Pharmacy, Catholic Kwandong University International St. Mary’s Hospital , Korea; 2Physical Therapy, Gyeong-In Rehabilitation Center Hospital, Korea the treatment of severe infections. Despite the advantages of high oral bioavailability and broad–spectrum activity Introduction: Dexmedetomidine (DMT) is a selective α-2 against gram negative bacteria, administration of FQs to adrenergic receptor agonist indicated for sedation in me- critically ill patients are restricted due to corrected QT chanically ventilated patients. To avoid adverse reactions interval (QTc) prolongation. The aim of this study was to such as hypotension, bradycardia, and/or atrial fibrillation identify incidence of QTc prolongation in FQs and evaluate along with the use of this drug, individualization and ti- risk factors to cause of QTc prolongation. tration of infusion rate of DMT is recommended . In this Methods: Outcomes of 139 cases which had administered study, we aimed to find the optimal infusion rate of DMT FQs in the Intensive Care Unit (ICU) from January 2018 to for adult critically ill patients admitted at intensive care unit December 2018 were reviewed retrospectively. Dummy (ICU) and possible association of infusion rate of DMT with variable regression was performed to analyze the QTc dif- hospital length of stay and survival rate in these patients. ference before and after QTc prolongation. Multivariate Methods: By reviewing electronic medical records of pa- logistic regression was performed to determine the risk fac- tients admitted at secondary hospital situated at Incheon tors independently associated with QTc prolongation. from January 1, 2019 to December 31 2019, those 35 pa- Results: A total of 126 patients (36.5% females, mean age tients who met following inclusion criteria were included: 72.64±12.23 years) who administered levofloxacin (n=43), 1) Patients who are 18 years or older and administered at moxifloxacin (n=35), gemifloxacin (n=15) and ciproflox- medical or surgical intensive care unit (ICU); and 2) Those acin (n=46) were included in this study. Thirteen patients who receive DMT during their mechanical ventilation of them received two kinds of FQs. Twelve-lead electro- treatment for 2 times and/or above. Statistical analyses cardiogram was measured regularly in the two times per were performed by IBM SPSS Statistics for Windows, ver- day and at QTc prolongation period during continuous bedside monitoring. The interval between before and after sion 23 (IBM Corp., Armonk, N.Y., USA). the occurrence of QTc prolongation in levofloxacin (95% Results: APACHE Ⅱ score and serum aspartate amino- transferase concentration at ICU admission, DMT infusion

206 KSCCM·ACCC 2020 Oral Presentation rate and its total dosage were associated with total hospital 24 to September 30, 2019. To evaluate adequacy of antibi- length of stay in linear regression analysis (Figure 1). Total otics and nutrition support, we retrospectively investigated hospital length of stay, age, glomerular filtration rate, DMT medical records before March and after September 2019. infusion rate, and body mass index were associated with We reviewed bacterial susceptibility testing results and hospital mortality (Figure 2). dosing for indications and renal function, and considered Conclusions: To help reduce adverse reactions of DMT adequate if they are all met. Also, we reviewed parenteral such as bradycardia, hyper-or hypotension, it is recom- nutrition(PN) and enteral nutrition(EN) are suitable for mended to infuse the drug at the rate of 1 ㎍/kg/hour daily requirements of calories and protein. (loading) or 0.2 - 0.7 ㎍/kg/hour (maintenance). In this Results: Sixty-two daily rounds were conducted on 48 study, infusion rate of DMT was associated with total hos- patients after pharmacist participation. There were 89 pital length of stay and mortality of adult critically ill pa- drug interventions and 72 cases of drug information. Sev- tients. Although its patient populated is limited in number enty(78.7%) interventions were accepted. Details are as and ethnical diversity, the study strongly suggests the pos- follows: therapeutic drug monitoring 21(23.6%), nutrition sible link between the DMT infusion rate and the prognosis support 15(16.9%), renal dosing 13(14.6%) and the oth- ers 40(44.9%). Among the drug information, 18(25.0%) of patients at ICU. were the name of available drug for the right ingredients, Keyword: Dexmedetomidine, Infusion rate, ICU Mortality 11(15.3%) were the dosage regimen and 8(11.1%) were the adverse events. The number of TICU patients was 9 in March and 35 in September. The adequate cases of an- tibiotic prescription were 77 of total 96(80.2%) in March

and 268 of total 291 in September. The adequate cases of Oral Presentation Figure1. Predictors of Hospital Length of Stay. nutrition support were 73 of total 137(53.3%) from July to September 2018 and 392 of total 498(78.7%) from July to September 2019. Conclusions: The adequacy of antibiotic prescription and nutrition support was improved after pharmacists’ partic- Figure 2. Predictors of Death. ipation in TICU multidisciplinary team. This study had the limitation to assess exceptional clinical conditions with retrospective medical record review. Oral Pharma 03 Keyword: TICU, Antibiotics, Nutrition Effects of Pharmacist’s Participation in a Trauma Intensive Care Unit (TICU) Oral Pharma 04 JiNa CHOI1, Janghwan CHO1, Jungeun HOE1, Dayeong HOE1, Eunjoo JEONG1, YoungWhan KIM2, JiEun KANG1 Clinical Significance of PDDI in PICU 1 2 Pharmacy, National Medical Center, Korea; Trauma Center, National Medical In Hwa LEE1, Mi Hee YANG1, Hye Jung BAE1, Yun Hee JO1, Yoon Sook Center, Korea CHO1, You sun KIM2, Hong yul AHN2, Yu Hyeon CHOI2, June dong 2 Introduction: National Medical Center(NMC) arranged a PARK 1 2 pharmacist to the TICU since June 2019. Critical care phar- Department of Pharmacy, Seoul National University Hospital, Korea; Depart- ment of Pediatrics, Seoul National University College of Medicine, Korea macist participates in TICU care 5 days a week. This study was conducted to analyze drug intervention and informa- Introduction: The aim of this study was to identify the tion provided by the pharmacist, and to evaluate adequacy current status of multi-drugs administration and potential of antibiotic prescription and nutrition support before and drug-drug interactions (PDDI) in patients admitted to pe- after the pharmacist’s participation. diatric intensive care unit (PICU), to investigate the clinical Methods: We reviewed TICU daily rounds report from June relevance of predicted DDI, and to analyze the clinical fac-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 207 Oral Presentation tors related with DDI. myocardial injury in intensive care units. However, there Methods: A prospective observational study was conduct- is limited data comparing the hypotension incidences ed in PICU in Seoul university hospital between August 19 caused by intravenous propacetamol and acetamino- to October 7, 2019. The pharmacist reviewed and collected phen. This study aims to investigate the incidences and data about drugs administrated and PDDI daily for eligible risk factors of propacetamol‒ and acetaminophen‒asso- patients under 18 years old and stayed at PICU for at least ciated hypotension. 72 hours. Clinical relevance for exposed DDI was con- Methods: From January 1st 2019 to June 30th 2019, we firmed by pediatric intensivists. retrospectively reviewed the electronic medical records Results: A total of 119 distinct drugs and 74 PDDIs were of Heart intensive care unit (HICU) patients who received observed in 35 eligible patients during the study period. intravenous propacetamol or acetaminophen. Hypoten- About 80% of patients were exposed to ≥ 5 drugs with a me- sion was defined as systolic blood pressure (SBP) <90 dian of 8 (5.3-10.4) and ≥ 1 PDDI with a median of 2 (0.17- mmHg, a SBP decrease >30 mmHg from the baseline, or 3.2) during PICU hospitalization. PDDI exposures regardless a >15% decrease in mean arterial pressure (MAP) within of severity were significantly associated with the average 2 hours after the first administration. Moreover, we iden- number of administrated drugs (OR 4.31; 95% CI 1.39-13.37, tified the risk factors of hypotension in the hypotension p=0.012). The most frequently identified drug combinations incidence group by comparing with the control group. of PDDI were identical in only two combinations between Results: We reviewed 98 patients on intravenous propa- pediatric cardiac surgery and other departments. Regardless cetmaol and 106 on intravenous acetaminophen. There of department, the most commonly registered combination was no significant difference in the hypotension incidence of midazolam and remifentanil (10.6 %) was not expected in both groups. However, the incidence of hypotension to clinical relevance with adverse drug reaction, but was in- within 1 hour of administration was significantly higher in tentionally used for favorable effect. Clinically relevant DDI the propacetamol group (21.4%) than the acetaminophen were found in 16.7 % (2/12) of cardiac patient group and group (9.4%) (p=0.017). The risk factor analysis indicat- 26.1 % (6/23) of other patients groups. ed that low albumin level (<3 g/dL) (OR: 2.847, 95% CI: Conclusions: Substantial numbers of patients in PICU are 1.339‒6.054, p=0.007) and high initial SBP (≥140 mmHg) exposed to polypharmacy and PDDI. This study reveals (OR: 3.142, 95% CI: 1.304‒7.574, p=0.011) were highly cor- that clinically relevant DDIs are not uncommon in patients. related with hypotension incidence intravenous. Further research should identify the risk factors of the actu- Conclusions: The critically ill patients may have a poten- al harm to each specific PDDI in order to effectively moni- tial risk of hypotension when administered propacetamol tor many drugs used in PICU. or acetaminophen. Therefore, in critically ill patients, we Keyword: polypharmacy, PDDI, PICU, Prospective obser- highly recommend caution when utilizing these medica- vational study tions and essential blood pressure (BP) monitoring. The patients with low albumin level or high initial SBP may increase the risk of hypotension. Therefore, we suggest Oral Pharma 05 close BP monitoring in high risk group patients. Heart Intensive care units, Propacetamol, Ac- Hypotension Incidence with Intravenous Keyword: Propacetamol vs Acetaminophen in Heart etaminophen, Hypotension Intensive Care Unit Min Jung GEUM 1, Shin Young HONG 1, Jae Song KIM1, Eun Sun SON1, Oral Surgery (1) 01 Yun Mi YU2 1Department of Pharmacy, Severance Hospital, College of Medicine, Yonsei Predicting mortality of Korean geriatric trauma University, Korea; 2Department of Pharmacy and Yonsei Institute of Pharma- patients : A comparison between GTOS(Geriatric ceutical Sciences, College of Pharmacy, Yonsei University, Korea trauma outcome score) and TRISS(Trauma and Introduction: Hypotension is a well‒known adverse ef- injury severity score) fect of intravenous propacetamol and acetaminophen. Ji Ye PARK1, Yun Hwan LEE2 Specially, it increases mortality, acute renal failure, and 1Department of Trauma and Acute Care Surgery, Ajou University School of

208 KSCCM·ACCC 2020 Oral Presentation

Medicine, Korea; 2Department of Preventive Medicine, Ajou University Gradu- ate School of Public Health, Korea

Introduction: With development of resuscitation, the number of survived geriatric trauma patients is increasing in Korea. Though large amount of resources being used for them, many patients fail to recover to desirable state in terms of quality of life. In this context, geriatric trauma outcome score(GTOS) was developed by palliative med- icine experts to predict in-hospital mortality and having been validated since 2015. This study is to validate GTOS as a prognostic indicator for Korean geriatric trauma patients by comparing it with trauma and injury severity score(TRISS) which has already been proved and used as a survival predictor. Methods: Among all patients 65 and over, who were ad- mitted at single trauma center from 2014 to 2018, death Figure 2. ROC curve. on arrivals and hopeless discharges were excluded. Data on age, mechanism, revised trauma score(RTS) on Results: 2586 patients were included with median age of arrival, packed RBC transfusion within 24 hours, inju- 76 years, median ISS 9. In-hospital mortality was 6.2%. AUC ry severity score(ISS), discharge status were collected. of GTOS was 0.832(95% CI 0.817 to 0.846, p<0.0001), which GTOS(age+2.5xISS+22.5[if RBC transfused within 24 was higher than AUC of TRISS with 0.800(95% CI 0.784 to Oral Presentation hours])and TRISS were assessed and receiver operating 0.815, p<0.0001). Hosmer-Lemeshow goodness-of-fit test characteristics(ROC) curves with AUC(Area under the was used and the difference was statistically valid(p<0.05). curve), Youden index, sensitivity, specificity were calcu- Youden index of GTOS was 0.5314 with sensitivity of 89.62 lated respectively. and specificity of 63.52. Youden index of TRISS was 0.4884 with sensitivity of 90.98 and specificity of 57.86. Conclusions: In this study with Korean geriatric trauma patients, the accuracy of GTOS was higher than TRISS in predicting in-hospital mortality. Also GTOS can be used without information of initial RTS in cases of transferred patients. We suggest GTOS as a new useful tool to decide treatment for severe elderly trauma patients. Keyword: Geriatric trauma, Retrospective study, Prognosis

Oral Surgery (1) 02 Risk factor of early biliary sepsis immediate after elective hepatopancreatobiliary surgery Hyun-Il GIL1, Kyoung Won YOON2, Chi-Min PARK2,3 1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Korea; 2Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea; 3Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Figure 1. Flowchart. Medicine, Korea

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 209 Oral Presentation

Introduction: Patients who have undergone HPB (hepa- Seoul St. Mary’s Hospital, Korea to-pancreato-biliary) surgery often have some postop- Introduction: In critically ill patients after major surgery, erative complications. Infectious complication is more the volume status is one of the risk factors for morbid- commonly occurred in HPB surgery than in other types ity and mortality. However, there is no standard tool to of surgery. Biliary sepsis or septic shock is difficult to dis- monitor the volume status and appropriateness of fluid tinguish from other kinds of complications, such as post- therapy. Bioelectrical impedance analysis (BIA) is portable operative fever or hypovolemic shock. The risk factors for technique for assessing body composition. In this study, postoperative biliary sepsis are not well known yet. we assessed the volume status of postoperative patient Methods: This retrospective study included patients who in surgical intensive care units (SICU) using BIA and also underwent HPB operation from January 2018 to Decem- compared the accuracy of BIA as a parameters compared ber 2018 in a single tertiary referral hospital. Among the with conventional method. HPB surgery, pancreaticoduodenectomy and bile duct Methods: This is a prospective observational study and en- resection were included, and cholecystectomy and liver rolled in major surgery patients who were admitted to SICU resection for hepatocellular carcinoma were excluded. The patients with postoperative sepsis before discharge from March to June 2019. The body composition and fluid were classified into the “sepsis” group, and those with status of patients were measured using BIA every morning no postoperative sepsis were classified into the “control” for 5 days from the day of ICU admission. At the same time, group. Other types of shocks, such as hypovolemic shock IVC diameter using ultrasound and ScvO2 were measured or cariogenic shock were included in the “control” group. among conventional methods for measuring fluid status. Preoperative serum total bilirubin level was checked to And this was compared with BIA results. find out significant biliary obstruction before surgery and Results: A total of 179 patients were analyzed. Extracellular the patients with less than 3mg/dL of total bilirubin level water (ECW) and ECW ratio values, which are important were excluded. indicators of body water balance, were increased on post Results: During the study period, 275 patients were re- operative day (POD) 1, but steadily decreased from POD ceived HPB surgery. Of the total patients, 109 had preop- 2. And this was similar in phase angle. Compared with the erative total bilirubin levels of 3 mg/dL or more. Among conventional method (i.e. IVC diameter, ScvO2), ECW, this 109 patients, 14 patients were “sepsis” group and ECW ratio and phase angle values were significantly cor- the other 95 patients were “control” group. The patients related from POD 2, especially from POD 3. in the “sepsis” group were older (73 vs. 66, p=0.012) and Conclusions: BIA is portable, non-invasive, inexpensive had less preoperative biliary drainage procedure (78.6% and easy to manipulation. It is also as accurate as the con- [11/14] vs. 96.8% [92/95], p=0.027) than “control” group.. ventional methods. Therefore, BIA would be a useful as There was no significant difference in other perioperative a tool for assessing volume status in patients after major factors. surgery, it could provide guideline for proper fluid manage- Conclusions: To avoid biliary sepsis after pancreaticodu- ment of postoperative patient. odenectomy or bile duct resection surgery, preoperative Keyword: BIA, Volume assessment biliary drainage may be considered more aggressively. Keyword: Hepatopancreatobiliary surgery, Sepsis , Risk factor Oral Surgery (1) 04 A Nationwide Assessment of Pediatric Surgical Oral Surgery (1) 03 and Anesthesia Capacity in Mongolia Burmaa SANJAA 1, Laura GOODMAN 2, Erdenetsetseg CHULUUN 3, Usefulness of BIA as tool for volume assessment Sanchin URJIN 3 in criticallyWITHDRAWAL ill patients after major surgery 1Critical Care and Anesthesiology , Mongolian National University of Medical Sciences , Mongolia; 2Surgery , University of California Davis Health, USA;3Sur- Yu Mi KIM, Eun Young KIM gery , Mongolian National University of Medical Sciences , Mongolia Department of General Surgery, Division of Trauma and Surgical Critical Care,

210 KSCCM·ACCC 2020 Oral Presentation

Introduction: Mongolia is a country characterized by its plored to aid in developing a comprehensive nationwide vast distances and extreme climate. Pediatric surgical ca- pediatric surgical and post-operative care program. pacity outside the capital Ulaanbaatar however, is unde- Keyword: Surgery , Pediatric , Anesthesia fined. An under-developed medical transport infrastructure makes patient transfer from outlying regions dangerous. Providing pediatric surgical care locally is crucial to improve Oral Surgery (1) 05 the lives of children in the countryside. This is the first struc- Are Preinjury Anticoagulant and Antiplatelet tured assessment of nationwide pediatric surgical capacity. Medications a Pitfall in the Bleeding Tendencies Methods: Operation rates were calculated using data from of Elderly Trauma Patients in Intensive Care? the Mongolian Center for Health Development and popu- Se Heon KIM1, Young Hoon SUL1,2, Jin Young LEE1, Jin Bong YE1, Jin Suk lation data from the Mongolian Statistical Information Ser- LEE1, Hong Rye KIM3, Soo Young YOON4, Joong Suck KIM5 vice. The pediatric personnel, infrastructure, procedures, 1 2 Trauma Surgery, Chungbuk National University Hospital, Korea; Trauma Sur- equipment, and supplies (PediPIPES) survey tool was used gery, College of Medicine, Chungbuk National University, Korea; 3Neurosurgery, 4 to collect data at all survey sites. Descriptive data analyses Chungbuk National University Hospital, Korea; Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Korea;5Trauma Surgery, Cheju were completed using Excel. Studies of association were Halla General Hospital, Korea completed using Stata. All reported percentages are of the Introduction: The elderly are more likely to be on anti- hospitals outside of the capital (n=21). coagulant or antiplatelet medications, which increase Results: All provincial hospital have general surgeons; bleeding. We aimed to determine the effect of preinjury seven (33.3%) of them have pediatric surgeon(s). One fa- anticoagulant or antiplatelet medications on required cility has no anesthesiologist. All facilities perform basic blood transfusions and the trauma outcomes of elderly procedures and provide anesthesia. Four (19%) can treat Oral Presentation common congenital anomalies. All facilities have basic op- patients. erating room equipment. Nine hospitals do not have pulse Methods: We retrospectively reviewed the medical re- oximetry available. Twelve hospitals do not have pediatric cords all elderly trauma patients admitted to Chungbuk surgical instruments always available. Pediatric supplies National University Hospital from January 2016 to June are lacking. 2019. We compared the required number of blood trans- fusion units, complications, and mortality rate between Table 1. Equipment: selected items available at hospitals. those on anticoagulant or antiplatelet medications and Maximum score 22 those that were not, using the chi-squared test, indepen- dent t-test, liner regression analysis, and logistic regres- sion analysis. Results: Out of 466 patients, 142 were on anticoagulant or antiplatelet medications while 324 were not. There was a significant statistical difference in the unit amount of red blood cells transfused within 4 hours of arriving at the hospital between the medicated and non-medicated groups (0.89 vs 1.43 units, respectively, p=0.02); howev- er, multivariate analysis showed no statistical difference (p=0.28). The medication group showed a higher rate of complications compared to the non-medicated group Conclusions: Provincial hospitals in Mongolia can perform (47.9% vs. 29.6%, respectively, p=0.001); bleeding (17.6% basic procedures. However, essential pediatric supplies are vs 2.8%, respectively, p=0.001), and pneumonia (24.4% lacking. Consequently, certain life-saving procedures are vs 14.2%, respectively, p=0.01). There was no statistical not available to children outside of the capital. Procedure, difference in the mortality rate (16.9% vs. 22.2%, respec- equipment, and supply availability should be further ex- tively, p=0.21).

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 211 Oral Presentation

Conclusions: Preinjury anticoagulant or antiplatelet tion, T-MDRD resulted in prognostic ability of mortality medications in elderly trauma patients increased bleed- that was incremental with AKI stage (p<0.001). ing and complications such as pneumonia but did not Conclusions: In this study, T-MDRD may be available as affect transfusion requirement, or mortality rate. the reference creatinine estimates resulting in an optimal Keyword: Anticoagulants, Antiplatelets, Elderly patients post-traumatic AKI diagnosis and prognosis. Keyword: Trauma, Acute kidney injury, Reference creati- nine Oral Surgery (1) 06 Table 1. Characteristics of Study Participant Selection of appropriate Reference Creatinine Estimate for Acute Kidney Injury diagnosis In Severe Trauma Patients Ho-Hyun KIM, Kang-Ho LEE, Hyun-Woo SUN, Dong-Yeon RYU Department of Trauma Surgery and Surgical Critical Care, Pusan National University Hospital, Busan, Korea

Introduction: In patients of severe trauma, the diagnosis of acute kidney injury (AKI) is important because it is known as a factor of poor prognosis and can affect pa- tient care strategies. Although there are some differences according to recent guidelines, diagnosis and staging of AKI are almost based on the difference in serum creati- nine to reference creatinine. However, accurate reference creatinine is often unknown in patient with traumatic injury. This makes it difficult to diagnose AKI in trauma patients. The purpose of this study is to help clarify the diagnosis of AKI in trauma patients by presenting appro- Table 2. Mortality by acute kidney injury stage priate reference creatinine estimate. Methods: This retrospective cohort study reviewed adult severe trauma patients (injury severity score higher than 15, older than 16) requiring ICU admission between 2015 and 2019 (n=3,275) at single regional trauma center in Korea. AKI diagnosis was made based on the current guidelines published by the KDIGO group. AKI deter- mined using the following 4 reference creatinine esti- mates: Modified Diet of Renal Diseases (MDRD), Trauma MDRD (T-MDRD), initial creatinine, and the first-day creatinine nadir. We assessed inclusivity, prognostic ability, incrementality with different reference creatinine estimates. Oral Surgery (2) 07 Results: There was variable AKI incidence from 9% when using initial creatinine to 41% when using T-MDRD. All The influence of environmental factors and air reference creatinine estimates significantly predicted pollution on brain injury after road accidents mortality similar but the receiver-operating characteristic Carlos Shu-Kee LIN1, Kuo-Hsing LIAO2, Wen-Ta CHIU3, Ta-Chien 4 5 6 curve of T-MDRD was the highest and statistically signifi- CHAN , Min-Huei HSU , Chih-Wei PAI 1 cant [area under the curve (AUC), 0.80, p<0.001]. In addi- Critical and emergency department, Wan Fang Hospital, Taipei Medical Uni- versity, School of Medicine, Taipei Medical University, Taiwan; 2Department

212 KSCCM·ACCC 2020 Oral Presentation of Neurosurgery, Wan Fang Hospital, Taipei Medical University, Center for Oral Surgery (2) 08 Neurotrauma and Neuroregeneration, Taipei Medical University , Taiwan; 3Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taiwan; 4Research Center for Humanities and Social Geographic Analysis for the Impact of Stroke Sciences, Academia Sinica, Nankang, Taiwan; 5Graduate Institute of Data and Trauma Centers Availability: Possible Impact Science, College of Management, Taipei Medical University, Taiwan; 6Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei on Stroke and Trauma Patients by Distance to Medical University, Taiwan Medical Centers Dorji HARNOD Introduction: Motorcyclists, bicyclists, and pedestrians are Department of Emergency and Critical Care Medicine, FU-Ren Catholic Uni- vulnerable to road traffic injury (RTI). With increasing versity Hospital, FU-Ren Catholic University, Taiwan RTI casualties in Taiwan, we conducted a multicenter study to analyze the effects of environmental factors on Introduction: Stroke and major trauma are important traumatic brain injury (TBI) among vulnerable road us- public health problems in Taiwan. Our research exam- ers (VRU). ines the geographic variations of medical centers and Methods: Demographics and environmental information the impact on mortality of the stroke and major trauma of the crash scene were collected via police records. This patients. Geographic Information Systems (GIS) tools en- information included the address of crash scene, vehicle able analysis to make the data-driven recommendations and road types, road safety facilities, scene light and time for the government, providing the best and most timely of the crash and was linked to data of 7 trauma centers in healthcare to those stroke and major trauma patients. northern and southern Taiwan. We collected the weather Methods: By using the National Insurance Data from and air pollution data of the crash scenes through GIS. 2005 to 2009, all the stroke and major trauma patients Brain concussion and intracranial hematoma (IH) were who sent to hospitals were included in our research. All considered as outcome parameters. the medical centers are the stroke centers and trauma Oral Presentation Results: Of the 698 TBI patients, 318 sustained IH. The centers under the accreditation from the Department of mean age was 43 years and 51 % of the patients were Health. AllWITHDRAWAL the stroke and major trauma patients were male. The multivariate analyses showed age 25-44, 45- recognized by using the International Classification of 64 and ≥65 (Odds ratio: 2.23,2.73, 3.89; 95% confidence Diseases, 9th Revision (ICD-9-CM). ICDMAP-90 was interval: 1.33-3.73,1.63-4.57, 2.10-7.22), traffic control used for calculating the Injury Severity Score (ISS). There sign without pedestrian sign and lacking control sign (1.88 were 19 medical centers during these years. The Geo- ,2.60; 1.00-3.56 , 1.40-4.86) , refuge island (2.17; 1.20-3.94) graphic Information System analyses including the <60, and lacking pavement striping (2.21; 1.49-3.27) were sig- and >60-minute ground transportation travel bands from nificant risk factors for IH. Hospital distance (3653-6976m the patients’ residence ZIP codes to the different medical and >6976m) and altitude (per5m) also caused more risk centers. Our research is interested in those patients who (2.14, 3.01; 1.24-3.71, 1.63-5.56 and 1.02; 1.01-1.04).Air were more than a 60-minute travel time to the medical Quality Index (moderate, Unhealthy) was also signifi- centers.All GIS analyses were conducted using the Arc- cantly related to IH (1.63, 2.84; 1.06-2.50, 1.29-6.24). GIS software version 10.1. Conclusions: Age was significantly related to IH. Some Results: In our data, four counties with more population road safety facilities may adversely cause more risk. How- (more than 0.5 million) have no medical centers, and one ever, lacking control sign and pavement striping were county with less population (less than 0.5 million) has no significant risk factors. The higher altitude and longer medical center. Compare with the counties with medical hospital distance resulted in a higher risk. Surprisingly, centers, the mortality rates in the stroke patients in the air pollution was a significant risk factor for more severe counties without medical centers are higher (2.6% v.s TBI. Further in-depth evaluation of environmental fac- 4.6%, OR=1.4, p=0.04). Compare with the counties with tors, particularly the air pollution factors, should yield medical centers, the mortality rates in the major trau- valuable information to reduce severe TBI among VRU. ma patients in the counties without medical centers are Keyword: Traumatic brain injury , Vulnerable road users, higher (10.2% v.s 16.8%, OR=1.8, p=0.004). Air pollution Conclusions: Strategies are needed to reduce the disparities

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 213 Oral Presentation in the patients care cross Taiwan for improving the outcomes. to June 2018 and who received surgical treatment and were Keyword: Major Trauma, Stroke, GIS system treated in the intensive care unit. We analyzed initial con- dition (SOFA score, APACHE II score, type of operation, comorbidity, preoperative septic shock, lab findings-Base excess, Lactate, Delta neutrophil index) and results (trans- fusion, death, complications, ventilator application period, CRRT ratio). 415 of the 647 patients were included in the study, of which 38 were IVIG administration group and 377 were non-administration. Age, Gender, SOFA score and APACHE II score, and antibiotic start time was used as matching variables. 1: 2 (38:72) propensity scoring match- ing was done.. Results: Baseline characteristics showed high Delta neu- trophil index(DNI), blood culture positive rate, cancer perforation rate, and CRRT use rate in the IVIG-use group. Survival curve analysis showed that there is a tendency to reduce mortality.

Table 1.

Figure 1. GIS taiwan.

Oral Surgery (2) 09 Analysis of the Effect of IVIG Use in Patients with Sepsis from Secondary Peritonitis Young Un CHOI, Hong Jin SHIM Surgery, Clinical Assistant Professor, Korea

Introduction: In patients with secondary peritonitis, source control and antibiotic administration are essential for re- ducing mortality. Recently, excessive immune response has been paid attention as death cause of septic patients. Antibodies can reduce the inflammatory response. Passive antibody injection can be considered in septic condition and there are various studies on manufactured intravenous immunoglobulin(IVIG) which present possibilities of its usefulness. We wanted to analyze whether administration of IVIG has a positive effect on the prognosis of patients with sepsis due to secondary peritonitis after surgery. Methods: We retrospectively reviewed 646 patients who were diagnosed as secondary peritonitis from March 2013

214 KSCCM·ACCC 2020 Oral Presentation

trose fluids in postoperative fluid therapy and compare incidence of significant postoperative acute kidney injury (AKI) according to the difference in fluid management after major abdominal surgery Methods: Patients who underwent elective major abdom- inal surgery from 2010 to 2016 in Seoul National University Hospital were included. The patients who received surgery requiring specific fluid management, such as organ trans- plantation and emergency surgery, were excluded. We collected data on all infused fluids, including amino acid, lipid formulas and continuous injected drugs, and their amounts. ROC curve analyses were performed to find cut- off point of proportion of isotonic crystalloids for detecting significant AKI higher than KDIGO stage II. To adjust the patient’s underlying disease or immediate postoperative Figure 1. condition, data on Charlson Comorbidity Index score and APACHE II score was also collected. Considering the effects of hyperchloremic acidosis on AKI, mean chloride concen- tration of infused total fluid was calculated. Fluid manage- ment related risk factors for significant AKI were evaluated using univariable and multivariable analyses. Results: Among 1084 enrolled patients, 30 patients (2.8%) Oral Presentation developed postoperative significant AKI. Proportion of isotonic crystalloids was significantly higher in the pa- Figure 2. tients who developed significant AKI after surgery (57.2 Conclusions: There is a statistically significant and clear % vs. 44.3%, p=0.026), and cut-off for detecting significant relationship between additional IVIG use and DNI reduc- postoperative AKI was 52.5% through ROC curve analysis. tion in patients with sepsis who have undergone secondary Univariable and multivariable analyses revealed that the peritonitis. APACHE II score (OR 1.12, 95% CI 1.06~1.18, p<0.001), Keyword: Intravenous immunoglobulin (IVIG), Sepsis, preoperative albumin level (OR 0.37, 95% CI 0.19~0.72, Delta neutrophil index (DNI) p=0.003), and higher proportion of isotonic crystalloids more than 52.5% (OR 2.50, 95% CI 1.11~5.63, p=0.0 Conclusions: The higher proportion of isotonic crystalloids Oral Surgery (2) 10 in the postoperative fluid management is associated with the higher incidence of significant AKI. Evaluation of the association between Keyword: Postoperative fluid therapy, Acute kidney injury, the proportion of isotonic crystalloids in Isotonic crystalloid postoperative fluid management after major abdominal surgery and clinical outcomes Seung-YoungWITHDRAWAL OH1,2, Yun-Suhk SUH2, Hannah LEE3, Ho Geol RYU3 Oral Surgery (2) 11 1Critical Care Center, Seoul National University Hospital, Korea; 2Department of Surgery, Seoul National University College of Medicine, Korea; 3Department Acute Kidney Injury in Trauma of Anesthesiology, Seoul National University College of Medicine, Korea Tae-Yoon KIM, Jeong-Woo LEE, Jong-Kwan BAEK, HakJae LEE, Suk- Introduction: The aim of this study is to find the proper Kyung HONG composition of isotonic crystalloids and hypotonic dex- Department of Surgery, Asan Medical Center, Korea

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 215 Oral Presentation

Introduction: Acute kidney injury (AKI) is an uncommon Introduction: Although the therapeutic effect of poly- but serious complication and increase morbidity and mor- myxin B hemoperfusion (PMX-HP) has been questioned tality after trauma. The objective of this study was to evalu- by negative results of recent prospective studies, PMX-HP ate the clinical characteristics, risk factors and outcomes of still remains a notable treatment option in septic shock. AKI after trauma. The aim of this study is to identify risk factors for treatment Methods: We performed a retrospective observational failure of PMX-HP in patients with septic shock caused by study from January 2014 to December 2017 with 533 trau- peritonitis ma patients who visited emergency department in Asan Methods: Among adult patients (≥18) who admitted to medical center. Among them, 403 patients were enrolled. the SICU after source control surgery due to septic shock Patients were divided into AKI group and no AKI group. caused by peritonitis in Seoul National University Hospital Regression analysis was performed to identify factors asso- from July 2014 to May 2019, the patients who underwent ciated with AKI development. PMX-HP (Toraymyxin®, Toray Medical Co) were included. Results: The overall incidence of AKI was 4.2% (17/403). Treatment failure was defined as mortality without dis- There was no difference in patients` age, sex and total dos- charge from SICU. To evaluate risk factors for treatment age of radio-contrase media during CT-scan between both failure of PMX-HP, demographic, preoperative, operative, groups. Whereas there was significantly difference in Injury and postoperative factors were compared between the two Severity Score (ISS) (17.90 ± 11.77 vs. 27.35 ± 17.75, p=0.04), groups, survivor group and in-ICU mortality group presence of shock (15.8% vs. 50%, p=0.02), lactic acid (2.54 Results: Among 17 included patients, 10 patients (58.8%) ± 1.82 vs. 4.59 ± 3.49, p=0.04) and severe rhabdomyolysis survived to discharge from SICU. There were no significant (CK>5,000IU/L) (12.6% vs. 40%, p=0.01). In multivariate difference in age, preoperative SOFA score, time to PMX- analysis, independent risk factors associated with AKI after HP apply, total duration of PMX-HP, norepinephrine con- trauma were total dosage of radio-contrase media during centration at the point of PMX-HP start, and perioperative CT-scan [odds ratio (OR)=1.005, p<0.01] and serum lactate lactate levels between the two groups. Patients in the in- level (OR=1.382, p<0.01). Patients in AKI group were clas- ICU mortality group had significantly higher proportion sified according to RIFLE criteria as Risk in 4 cases (24%), of coronary artery disease (57.1% vs. 0%, p=0.015), lower Injury in 5 (29%), Failure in 8 (47%), Loss in 0 (0%) and preoperative albumin level (2.5 vs. 3.1, p=0.05), and higher End-stage in 0 (0%). Renal replacement therapy (RRT) was preoperative C-reactive protein level (15.2 vs. 11.4, p=0.025) required for 9 patients (53%) in AKI group. Total hospital than the survivor group. Postoperative WBC less than 4000 days (17.20 ± 26.55 vs. 48.29 ± 48.60, p=0.02), and ICU days was a protective factor for in-ICU mortality. These variables (8.12 ± 12.80 vs. 27.80 ± 33.19, p=0.04) were longer in AKI were also found to be significantly different between the group. Hospital mortality rate was higher in AKI group two groups in (3/17, 17.6%) than no AKI group (5/386, 1.3%) (p=0.03). Conclusions: We suggests that coronary artery disease, Conclusions: Trauma patients with AKI have a long recov- lower albumin level, higher C-reactive protein level, and ery period and a high mortality rate. postoperative leukocytosis as potential risk factors for treat- Keyword: AKI, Trauma, Acute kidney injury ment failure of PMX-HP in the patients with typical indica- tions. Further prospective study is needed. Keyword: Polymyxin B hemoperfusion, Treatment failure, Oral Surgery (2) 12 Risk factor Risk factors for treatment failure of polymyxin B hemoperfusion in patients with septic shock Oral Sepsis (1) 01 caused by peritonitis Ara CHO1, Seung-Young OH1,2, Hannah LEE3, Ho Geol RYU3 Prevalence and outcomes of comorbid conditions 1Department of Surgery, Seoul National University College of Medicine, Korea; in patients with sepsis in Korea: a Nationwide 2Critical Care Center, Seoul National University Hospital, Korea; 3Department Cohort Study from 2011 to 2016 of Anesthesiology, Seoul National University College of Medicine, Korea Hannah LEE1, Seung-Young OH2, Ho Geol RYU1, Eun Jin JANG3

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1Anesthesia and Pain medicine, Seoul National University Hospital, Korea; patients, 46.7% had hypertension; 23.6%, DM; 7.4%, LC; 2Surgery, Seoul National University Hospital, Korea; 3Statistics, Andong Na- tional University, Korea 13.7%, CKD; and 30.7%, malignancy. In-hospital mortal- ity rate in patients with hypertension, DM, LC, CKD, and Introduction: Chronic comorbid conditions are common in malignancy were 25.5%, 25.2%, 34.5%, 28.0%, and 33.3%, sepsis patients and may affect the outcomes of sepsis. And respectively. The overall mortality rate decreased over time the presence of comorbid conditions is associated with the in patients with comorbidities, except in those with CKD incidence of sepsis. This study aimed to assess the preva- (p<0.001), while the incidence of sepsis in patients with lence and outcomes of common comorbidities in patients those comorbidities gradually increased over time. After diagnosed with sepsis. adjusting for baseline characteristics, male sex, older age, Methods: We conducted a nationwide retrospective cohort use of mechanical ventilation or continuous renal replace- study using a population-based healthcare reimbursement ment therapy, LC, CKD, malignancy, and patients support- claims database. Using data from the National Health In- ed by the Medical Aid program were significantly associat- surance Service of Korea, adult patients (age ≥18 years) ed with in-hospital mortality. who were hospitalized in tertiary or general hospitals with Conclusions: Hypertension is the most prevalent comor- a diagnosis of sepsis between 2011 and 2016 were analyzed. bidity in sepsis patients with increasing survival rate. Liver After screening of all International Classification of Dis- cirrhosis, chronic kidney disease, and malignancy with or eases,10th revision (ICD-10) codes for comorbidities and without metastasis have higher mortality rates than hyper- secondary diagnoses, we identified hypertension, diabetes tension and diabetes and are significant risk fa mellitus (DM), liver cirrhosis (LC), chronic kidney disease Keyword: Sepsis, Comorbidity, Mortality (CKD), and malignancy as prevalent comorbidities. Oral Presentation

Figure 1.

Results: Overall, 373,539 patients were hospitalized with a diagnosis of sepsis in Korea from 2011 to 2016. Among the Figure 2.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 217 Oral Presentation

Oral Sepsis (1) 02 Conclusions: DNI may be useful biomarker to predict the bacteremia in patients with NF. Usefulness of delta neutrophil index in patients Keyword: Delta neutrophil index, Necrotizing fasciitis, with necrotizing fasciitis Bacteremia Ji Young JANG1, Jong Wook LEE2, Hui-Jae BANG3, Ik Yong KIM3 1Department of Surgery, National Health Insurance Service Ilsan Hospital , Ko- rea; 2Department of Laboratory Medicine, Konyang University Hospital, Korea; Oral Sepsis (1) 03 3Department of Surgery, Yonsei University Wonju College of Medicine, Korea

Introduction: Necrotizing fasciitis (NF) is a potentially Circulating Mitochondrial N-Formyl Peptides Contribute to Poor Prognosis of Septic Shock fetal subcutaneous tissue and fascia infection. In these Patients patients, White blood cell (WBC), C-reactive protein Woon Yong KWON1,2, Gil Joon SUH1,2, Yoon Sun JUNG2, Seung Min (CRP), serum lactate, and procalcitonin are commonly PARK3, Subi OH3, Sung Hee KIM2, A Rum LEE2, Byoung Choul KIM4 used as clinical biomarker for evaluation of infection 1Emergency Medicine, Seoul National University College of Medicine, Korea; and sepsis. Delta neutrophil index (DNI) can be easily 2Emergency Medicine, Seoul National University Hospital, Korea; 3Medical 4 and simply calculated using an automated cell analyz- student, Seoul National University College of Medicine, Korea; Nano-Bioengi- neering, Incheon National University, Korea er, which represents the ratio of immature granulocytes and is expressed in percent. Recently, some studies in- Introduction: To investigate whether circulating mi- troduced that this biomarker was able to predict patient tochondrial N-formyl peptides (mtFP) released from outcomes for some infectious conditions. Therefore, we injured tissues during septic shock contribute to a devel- evaluated the usefulness of DNI in patients with NF. opment of secondary nosocomial infection resulting in Methods: Between March 2011 and April 2019, 86 pa- delayed mortality in septic shock patients by suppressing tients with NF were enrolled and their medical charts formyl peptide receptor 1 (FPR1)-mediated neutrophils were retrospectively analyzed. Patient characteristics, (PMN) chemotaxis to secondary infective sites. initial and postoperative laboratory findings (WBC, neu- Methods: We collected clinical data from septic shock trophil %, CRP, DNI, and lactate), and clinical outcomes patients admitted to our intensive care unit (ICU) longer were evaluated. We evaluated the risk factor for mortality than 72 hours. Blood samples were obtained at 0, 24, and and bacteremia. 72 hours after the ICU admission. Impacts of circulat- Results: The mean age was 62.8 years, and 18 (20.9%) ing nicotinamide adenine dinucleotide dehydrogenase patients had shock in ER. The most common region was subunit 6 (ND6, the most potent human mtFP) on sec- perineum followed by low extremity, and abdomen/ ondary infection and 90-day mortality were investigated. groin. Bacteremia was identified in 25 patients (30.1%), Then, the role of circulating ND6 in PMN chemotaxis to 23 patients (26.7%) died. Non-survivors had significantly secondary infective sites during septic shock was deter- more frequent low extremity lesion and bacteremia, and mined by ex vivo studies using isolated human PMN. significantly higher initial and postoperative DNI and Results: The mortality rate of secondary infection-posi- lactate than survivors. Bacteremia group had significantly tive patients was higher than secondary infection-nega- more frequent shock in ER and more low extremity, and tive patients (p<0.001). In particular, the mortality rate of significantly higher initial DNI, initial lactate and postop- secondary infection-positive patients rapidly increased erative DNI than non-bacteremia group. Logistic regres- from 14 days. An increase in plasma ND6 level at 0 hour sion analysis showed that Low extremity lesion (OR 4.212, was independently associated with increases in sec- p=0.018), initial DNI (OR 1.068, p=0.001), and LRINEC ondary infection (odds ratio = 30.317, 95% confidence score (OR 1.267, p=0.046) were independent risk factors interval: 2.904 – 316.407, p=0.004) and in 90-day mor- for bacteremia. The receiver-operating characteristics tality (odds ratio = 1.572, 95% confidence interval: 1.002 curve demonstrated that AUC of initial DNI was 0.726 – 2.465, p=0.049). In ex vivo studies, ND6 pretreatment (cut-off 15.15%, sensitivity 56%, specificity 79%, p=0.023). suppressed PMN chemotaxis to a canonical bacterial

218 KSCCM·ACCC 2020 Oral Presentation

FP (fMLF) in a dose-dependent manner. ND6 and fMLF Oral Sepsis (1) 04 treatments decreased FPR1 expression on PMN mem- brane, and PMN chemotaxis to ND6 and fMLF were A metabolomic approach for early detection of completely blocked by cyclosporine H (a selective FPR1 ARDS in patients with pneumonia: discriminant biomarkers of pneumonia-induced ARDS antagonist). 1 2 2 3 Conclusions: Circulating mtFP contributed to a develop- Youjin CHANG , Sang-Bum HONG , Chae-Man LIM , Su Jung KIM , Hyun Ju YOO3, Jin Won HUH2, Younsuck KOH2 ment of secondary infection resulting in delayed mortal- 1Division of Pulmonary and Critical Care Medicine, Department of Internal ity in septic shock patients who survived from the early Medicine, Inje University College of Medicine, Sanggye Paik Hospital, Korea; hyper-inflammatory phase by suppressing FPR1-mediat- 2Department of Pulmonary and Critical Care Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Korea; 3Biomedical Research Center, ed PMN chemotaxis to secondary infective sites. Department of Convergence Medicine, Asan Institute for Life Sciences, Asan Medical Center, Korea

Introduction: Acute respiratory distress syndrome (ARDS) continues to have a mortality above 40% despite intensive therapeutic measures. However, there are no good bio- markers to predict the progression to ARDS. The aim of this study is to identify a discriminant diagnostic metab- olite to predict the progression to ARDS in pneumonia patients using a targeted metabolomics approach. Methods: This study retrospectively analyzed samples from a sepsis registry that was prospectively collected

from Mar 2011 to Feb 2018, along with healthy controls. Oral Presentation The cohort was divided into four groups: patients with pneumonia, patients with pneumonia-induced ARDS, Figure 1. patients with non-pneumonia sepsis-induced ARDS, and healthy controls. Metabolite concentrations of five ana- lyte classes (energy metabolism, free fatty acids, amino acids, phospholipids, sphingolipids) were measured us- ing targeted metabolomics. Results: A total of 112 patients were enrolled, and 185 total metabolites were identified by liquid chromatogra- phy-tandem mass spectrometry (MS/MS) or gas chroma- tography-MS. Compared to the healthy group, the three patient groups showed substantial differences in 104 compounds in all metabolite classes evaluated. Accord- ing to partial least squares-discrimination analysis, the metabolites were clearly able to distinguish the patients from healthy controls, but pneumonia and pneumo- nia-induced ARDS were not clearly separated. Howev- Figure 2. er, tryptophan and α-ketoglutarate were identified as Keyword: Septic shock, Mt-ND6 protein, Secondary infec- significant metabolites discriminating pneumonia and tion pneumonia-induced ARDS using volcano plot and signif- icant analysis of microarray (tryptophan p=0.000114, α -ketoglutarate p=0.002614). Conclusions: This study shows that the serum global

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 219 Oral Presentation metabolomics profiles are similar between patients with of TSF mode and 4 hours of manual adjustment mode pneumonia and those with pneumonia-induced ARDS, (right) in one patient. The ratio of the group with the though validation is required. Although a clear separa- percutaneous oxygen saturation within 94 to 96 percent tion was not observed between pneumonia and pneumo- (yellow), including the target SpO₂ 95 percent, was seen nia-induced ARDS, tryptophan and α-ketoglutarate may as having a higher in TSF mode (automatic oxygen con- be candidate markers to distinguish pneumonia-induced centration control). In Table 3, we identified significant ARDS. differences in statistically in the group with SpO₂ 94-96% Keyword: Respiratory distress syndrome, adult, Bio- Table 1. Patients characteristics marker, Metabolomics

Oral Sepsis (1) 05 BEST Safety and usefulness of the TSF(Target SpO2 Feedback control by FiO2) in High flow nasal cannular system Table 2. Comparision of targeted SpO2 fraction TSF mode and Manual mode Woo Jung SEO , Youn suck KOH, Sang-Bum HONG , Jin-Won HUH, Chae-Man LIM Pulmonary and Critical Care Medicine, Asan Medical Center, seoul, Korea

Introduction: Oxygen therapy is widely used and life- saving treatment in patients with lung disease. Hypoxia should be avoided during oxygen therapy, but hyperoxia should also be avoided as it can result in alveolar damage and acute exacerbations in COPD patients. Currently, oxygen devices are controlled manual adjustment and need to be automated to avoid hyperoxia and to reduce Table 3. Comparison of TSF mode and manual mode intervention delays and labor associated with manual titration. we studied the stability and usefulness of the newly developed closed-loop system to automated oxy- gen concentration, TSF(Targeted SpO₂ Feedback control by FiO₂) Methods: From May to October 2019, patients were re- cruited from intensive care units at two hospitals (Asan medical center, Ilsan Paik hospital). This study designed a prospective open-label crossover study. The TSF mode and manual mode were arranged twice each for 2 hours by computerized randomization. We used the HFT 500machine (MEK-ICS), and the medical staff con- trolled the flow rate andFiO₂ during manual adjustment mode. The TSF state sets the oxygen flow rate at first, and increase and decrease the FiO₂ concentration by 1% de- Conclusions: This study is the first using an oxygen de- pending on the SpO₂. vice to achieve targeted oxygen saturation by controlling Results: A total of 22 patients were recruited, and Table the percentage of oxygen automatically in adults. It has 1 compared their clinical characteristics and number of been implemented safely, and there is less intervention interventions. In Table 2, the left graph compares 4 hours by the medical staffs.

220 KSCCM·ACCC 2020 Oral Presentation

Keyword: High flow nasal cannular , Oxygen auto-Regu- Keyword: RED CELL DISTRIBUTION WIDTH, Sepsis, lation Mortality

Oral Sepsis (1) 06 Oral Sepsis (2) 07 The prognostic value of red cell distribution Higher Glycemic Variability within first day of width (RDW) in sepsis and related-mortality ICU admission Is Associated with an Increased Atika Budhy SETYANI1, Michael DWINATA2, Muhammad ABDUH3 30-day Mortality in ICU patients with Sepsis 1 2 2 1Emergency Medicine, Cempaka Putih General Hospital, Jakarta, Indonesia; Ming-Cheng CHAN , Wen-Cheng CHAO , Chieh-Liang WU 2 Internal Medicine, Depati Hamzah General Hospital, Pangkal Pinang, Indo- 1Department of Internal Medicine, Section of Critical Care and Respiratory 3 nesia; Cardiology, National Cardiovascular Center Harapan Kita, Jakarta, Therapy, Taichung Veterans General Hospital, Taiwan; 2Department of Critical Indonesia Care Medicine, Taichung Veterans General Hospital, Taiwan

Introduction: RDW, a measurement retrieved from rou- Introduction: A high glycemic variability (GV) is frequent tine hematology tests, had been known as a predictor in in critically ill patients; however, the prevalence and several medical conditions. However, the predictive value mortality association of early GV in patients with sepsis of RDW in sepsis remains inconclusive. Thus, to produce remains unclear. robust evidence, we conducted a meta-analysis to inves- Methods: This retrospective cohort study was conducted tigate the association between RDW and sepsis and relat- in a medical intensive care unit (ICU) located in central ed mortality. Taiwan. Patients with sepsis between January 2014 and Methods: Major medical databases were systematically December 2015 were included for analysis. All these pa-

searched for observational studies that assessed the as- tients received protocol-based managements, including Oral Presentation sociation of RDW and sepsis published until December blood sugar monitoring every two hours for the first 24- 2019. The databases were searched with predefined pro- hour of ICU admission. Mean Amplitude of Glycemic Ex- tocols based on PRISMA guidelines. Pooled measures for cursions (MAGE) and coefficient of variation (CoV) were Risk Ratio (RR) and weighted mean difference (WMD) used to assessWITHDRAWAL GV. Results: A total of 452 patients (mean age 71.4±14.7 were obtained using RevMan 5.3. years old; 76.7% men) were enrolled for analysis. They Results: Seventeen studies enrolled 3,183 cases and 5,086 were divided into high-GV (43.4%, 196/452) and low- controls. The higher RDW was independently associated GV (56.6%, 256/512) by using MAGE 65 mg/dL as the with sepsis-related mortality compared to lower RDW (RR cut-off point. Patients with high GV tend to have higher 1.19; 95% CI [1.13–1.26], p<0.00001), comprising in-hos- HbA1c (6.7±1.8 vs. 5.9±0.9, p<0.01) and were more likely pital (RR 1.22 [1.15–1.3], p<0.00001), 1-month (RR 1.34 to have diabetes mellitus (DM) (50.0% vs. 23.4%, p<0.01) [1.08–1.67], p=0.008), and 4-year mortality (RR 1.15 [1.13– as compared with those in low GV group. Kaplan-Mei- 1.17], p<0.00001). The WMD of RDW level between sur- er analysis showed that a high GV was associated with vivor and mortality group was 1.62% (95% CI [1.07–1.95], increased 30-day mortality (log-rank test, p=0.018). The p<0.00001), including mortality in ICU (1.11% [0.26-1.96], association remained strong in non-DM patients (log- p=0.01), in-hospital (2.06% [1.46-2.65], p<0.00001), and rank test, p=0.035), but not in diabetes (log-rank test, within 1-month (1.51% [1.07-1.95], p<0.00001). Among p=0.254). Multivariate Cox proportional hazard regres- in-hospital patients, compared to non-sepsis, sepsis sion model identified that high APACHE II score (adjusted group had higher mean of RDW (WMD 1.91% [0.56–3.25], hazard ratio (aHR) 1.045, 95% confidence interval (CI) p=0.006). 1.013–1.078), high serum lactate level at 0-hr (aHR 1.009, Conclusions: Sepsis cases and related mortality are sig- 95%CI 1.003–1.014), having chronic airway disease (aHR nificantly associated with higher RDW values. Thus, along 0.478, 95%CI 0.302–0.756), high mean day-1 glucose (aHR with other clinical parameters, this promising finding of 1.008, 95%CI 1.000–1.016), and high MAGE (aHR 1.607, RDW could be useful as a simple and affordable progno 95%CI 1.008–2.563) were independently associated with

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 221 Oral Presentation increased 30-day mortality. Table 1. Characteristics of the 452 patients with sepsis categorized by glycemia Conclusions: We found that approximately 40% of septic variability patients had a high early GV, defined by MAGE higher than 65 mg/dL. Higher GV within 24 hours of ICU admis- sion was independently associated with increased 30-day mortality. Keyword: Glycemic variability, Glycemic control, Sepsis

Figure 1.

Figure 2.

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Oral Sepsis (2) 08 Sepsis patients without initial fever showed poor prognosis than sepsis patient with fever Hyeongkyu KWAK1, Gil Joon SUH1, Sola KIM2 1Emergency department, Seoul national university hospital, Korea; 2Emergency department, Seoul national university Bundang hospital, Korea

Introduction: Sepsis is one of the major causes of mor- Results: 765 patients were finally included in this study. tality and morbidity. The Third International Consensus 209 (27.3%) patients had initial fever on emergency depart- Definitions for Sepsis and Septic Shock(Sepsis-3) rec- ment visit. 321 (42.0%) patients were admitted to ICU and ommends using clinical criteria for sepsis if the patient 139 (18.2%) patients died. AORs (95% CIs) of sepsis with- is suspected infection, However, patients without fever out fever were 1.61 (1.03-2.53) for ICU admission and 1.51 often miss sepsis. We hypothesized that sepsis patients (0.96-2.38) for mortality. without fever had a poor prognosis. Conclusions: Sepsis patients without initial fever showed Methods: This is a retrospective observational study us- poor prognosis than sepsis patient with fever. ing a single-center prospective cohort registry of sepsis Keyword: Sepsis, Fever, Prognosis from January 2017 to December 2017. Fever was defined as 38℃ or more. The primary outcome was Intensive Care Unit (ICU) admission and secondary outcome was Oral Sepsis (2) 09 28 days mortality. Multivariable logistic regression was HYPOXIC HEPATITIS IN SEPSIS PATIENTS; used and adjusted odds ratios (AORs) with 95% confi- Incidence and mortality in a multicenter sepsis Oral Presentation dence intervals (95% CIs) were calculated.. cohort study Yong Jun CHOI1, Jae Hwa CHO1, Kyeongman JEON2, Dong Kyu OH3, Chae-Man LIM3, Korean Sepsis Aliance group (KSA)4 1Pulmonology and Critical Care Medicine, Gangnam Severance Hospital, Yon- sei University College of Medicine, Seoul, Korea; 2Critical Care Medicine, Sam- sung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 3Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea; 4Korean Sepsis Alliance (KSA) study group, , Korea

Introduction: Hypoxic hepatitis (HH) is characterized by centrilobular necrosis of liver. The prevalence of HH is reported as 2.4-11% in intensive care unit, and the most common cause of HH is cardiac failure (39–70%), followed by septic shock (6-33%). HH is mainly diagnosed based on the following three criteria: clinical settings of cardiac, circulatory or respiratory failure, rapid increase in serum aspartate aminotransferase (AST) level, and exclusion of other causes of liver injury. Methods: Among sepsis patients at 19 participating hospi- tals from January 1 through January 31, 2018, we diagnosed the patient with initial AST level above 5 times of the upper limit of normal as hypoxic hepatitis after exclusion of other liver disease, and investigated the incidence of HH in sep- sis, and compared 28 days in-hospital mortality of sepsis with HH and that of sepsis without HH.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 223 Oral Presentation

Results: Among 977 sepsis patients, HH occurred in 61 Oral Sepsis (2) 10 patients (6.3%) at the time of admission. Most common cause of HH in sepsis was pulmonary infection (41.9%), Early mortality prediction of LPC16:0 and lactate followed by abdominal infection (37.1%) and urinary according to sepsis time course 1 1,2 1 3 infection (3.2%). All cause 28 days in-hospital mortality Se Hyun KWAK , Eun Hye LEE , Mi Hwa SHIN , Jae Chul PYUN , Su 1 1 1 1 of sepsis patients with HH is higher than that of sepsis Hwan LEE , Ah Young LEEM , Kyung Soo CHUNG , Young Sam KIM , Moo Suk PARK1 patients without HH (42.6 % and 23.6%, respectively, 1Division of Pulmonology, Department of Internal Medicine, Severance Hos- p=0.02). Kaplan-Meier curve of overall survival rate in pital, Yonsei University, College of Medicine, Korea; 2Division of Pulmonology, hospital for 28 days was described in figure 1. The pres- Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-Si, Gyeo- ence of HH was an important factor associated with 28- 3 nggi-Do, Korea; Department of Materials Science and Engineering, Yonsei day hospital mortality in sepsis patients (Hazard ratio: University, 50 Yonsei-Ro, Seodaemun-Gu Seoul, Korea 2.387; 95% confidence interval: 1.587-3.591, p<0.0001). Introduction: Sepsis remains a critical problem with high Significant factor related with 28 days in-hospital mortal- mortality worldwide, but there is still a lack of reliable bio- ity of HH patients was initial lactate level in multivariable markers. We aimed to investigate the changes of lysophos- COX regression (Hazard ratio: 1.218; 95% confidence in- phatidylcholine (LPC)16:0 and lactate for predicting 28-day terval: 1.012-1.465, p=0.037). mortality of sepsis patients. Methods: Sepsis or septic shock patients admitted to in- tensive care unit were enrolled from March 2017 to June 2018. Patients’ blood was collected on the day of ICU ad- mission (D0) and on day 1 (D1), day 3 (D3), and day 7 (D7). Serum LPC16:0 was analyzed using matrix assisted laser desorption/ionization time-of-flight mass spectrometry based on a parylene-matrix chip. Serum lactate levels were measured repeatedly over a period of seven days. LPC 16:0 augmentation (ΔLPC) was calculated as ([LPC 16:0 delayed – LPC 16:0 initial]/LPC 16:0 initial) x100. Lactate clearance (ΔLactate) was calculated as ([Lactate initial – Lactate de- layed])/Lactate initial) x100. Results: Of the 113 patients who met the sepsis diagnostic criteria, 40 patients died (28-day mortality; 35.4%). The area under the curve (AUC) predicting 28-day mortality using ΔLPC and ΔLactate was compared. Lactate had high- Figure 1. er prognostic value than LPC16:0 at initial day of sepsis, whereas ΔLPC better predict 28-day mortality over the time Conclusions: HH is not uncommon and more fatal in progress (ΔLPC D1 AUC,0.714 vs. ΔLactate D1 AUC,0.595, sepsis patients. As delayed in diagnosis and prolonged p=0.165; ΔLPC D3 AUC,0.810 vs. ΔLactate D3 AUC,0.634, HH can worsen outcomes, early assessment and treat- p=0.020). AUC of ΔLPC D7 was 0.830, which was signifi- ment of HH would be important. There is also a need for cantly higher than ΔLactate D7 (AUC 0.665), APACHE II a global study about characteristic, risk factors, and ap- score (AUC 0.694) and SOFA score (AUC 0.678). Mechan- propriate treatment of HH. ical ventilation (HR, 5.268; p=0.043), lactateD0 (HR, 1.391; Keyword: Hypoxic hepatitis, Sepsis p=0.045), ΔLPC D7 less than the cut-off value (ΔLPC D7 ≤223.9; HR=14.91; p<0.001) were significantly associated with an increase in the 28-day mortality rate in a multivari- able analysis.

224 KSCCM·ACCC 2020 Oral Presentation

Conclusions: Our results suggest that in the early days of of mepivacaine-induced inhibition of CACT. Intralipid, sepsis, lactate itself better predict sepsis mortality, whereas NAC and mitotemp attenuated ROS production, mito- LPC16:0 augmentation could better predict sepsis mortality chondrial membrane depolarization, calcium increase over the time progress. and decreased cell viability induced by bupivacaine. Keyword: LPC16:0, Lactate, Sepsis Conclusions: Lipid emulsion reversed toxic concentra- tion of levobupivacaine-mediated inhibition of CACT in a lipid solubility-dependent manner. This effect seems to Oral Basic 01 be associated with lipid emulsion-mediated inhibition of Lipid emulsion reverses levobupivacaine-mediated ROS production, mitochondria membrane depolariza- inhibition of carnitine acylcarnitine translocase tion and calcium increase. Keyword: Lipid emulsion, Local anesthetics, Carnitine Ju-Tae SOHN1, Da Won KANG2, Soo Hee LEE1, Seong-Ho OK1, Yeran 1 acylcarnitine translocase HWANG 1Department of Anesthesiology and Pain Medicine, Gyeongsang National Uni- versity College of Medicine, Gyeongsang National University Hospital, Korea; 2Department of Physiology, Gyeongsang National University College of Medi- Oral Basic 02 cine, Korea Extracellular mitochondrial dysfunction in Introduction: Mitochondria reactive oxygen species cerebrospinal fluid of patients with delayed (ROS) production induces mitochondria membrane de- cerebral ischemia after aneurysmal subarachnoid polarization and intracellular calcium increase. The un- hemorrhage derlying mechanism of lipid emulsion treatment of local Jin Pyeong JEON1,2, Dong Hyuk YOUN2, Bong Jun KIM2, Youngmi KIM2 anesthetic systemic toxicity, includes lipid shuttle and 1Neurosurgery, Hallym University College of Medicine, Korea; 2Institute of New Oral Presentation fatty acid supply. The palmitoyltransferase I (CPT I), car- Frontier Stroke Research, Hallym University College of Medicine, Korea nitine acylcarnitine translocase (CACT), and CPT II are Introduction: Mitochondrial dysfunction is related to involved in long-chain fatty acids transport from the cy- brain ischemic injury and neural cell death. However, lit- toplasm to the cardiac mitochondrial matrix to produce tle is known about the association between mitochondri- APT. The goal of this study was to examine the effect of al dysfunction of cerebrospinal fluid (CSF) and delayed Intralipid on CPT I, CACT and CPT II activity and mito- cerebral ischemia (DCI) following subarachnoid hemor- chondria ROS production induced by toxic dose of local rhage (SAH). The objective of this study was to investigate anesthetics in H9c2 rat cardiomyoblast. whether extracellular CSF mitochondria might serve as a Methods: The effect of Intralipid (0.05, 0.1 and 0.2%) on potential biomarker for DCI. the CPT I, CPT II and CACT activity induced by toxic dose Methods: CSF samples were serially collected at 1, 3, and of local anesthetic (7 X 10-4 M levobupivacaine, 10-3 M 5 days following SAH in 33 patients (DCI, n=12; and non- ropivacaine and 10-2 M mepivacaine) was examined. The DCI, n=21) who underwent coil embolization. To monitor effect of Intralipid (0.1%), ROS scavenger NAC and mito- mitochondrial membrane potentials, JC-1 dye was used. chondrial ROS scavenger mitotemp on the ROS produc- The ratio (red/green) of JC-1 was considered as an indi- tion, mitochondrial membrane potential, intracellular cator of intact mitochondrial membrane potential. Flow calcium level induced by toxic dose of bupivacaine (10-3 cytometry was done to analyze extracellular mitochondria M) was examined. particles and their possible cellular origins. Results: Toxic concentration of local anesthetics in- Results: DCI patients had lower JC-1 red/green ratios than hibited CACT, but it did not affect CPT I and II activity. non-DCI patients at 1 day [3.35 (3.20-3.75) vs. 3.70 (3.40- All the concentration of Intralipid reversed levobupiv- 3.95) in non-DCI] and 3 days [4.65 (4.45-5.00) vs. 5.10 (4.65- acaine-mediated inhibition of CACT. However, middle 5.30) in non-DCI] after SAH. At 5 days after SAH, JC-1 red/ and high concentration of Intralipid reversed ropiva- green ratio was significantly lower in DCI than that in non- caine-mediated inhibition of CACT. Furthermore, high- DCI [3.05 (2.90-3.35) vs. 4.20 (4.10-4.50); p< 0.01)] patients. est concentration of Intralipid only reversed toxic dose

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 225 Oral Presentation

DCI patients had a higher percentage of vWF-positive mi- Keyword: Subarachnoid hemorrhage , Mitochondrial tochondria [40.10% (38.25%-44.90%) vs. 30.20% (25.70%- membrane potential , Delayed cerebral ischemia 36.68%)] and a lower percentage of GLAST-positive mi- tochondria particles [26.85% (17.10%-30.00%) vs. 31.60% (26.70%-35.00%)] than non-DCI patients. However, there Oral Basic 03 was no significant difference in CD45-positive (p=0.369) Diagnosis and classification of Acute Respiratory or CD41/61-positive mitochondrial particles (p=0.155) be- Distress Syndrome by SpO2/FiO2 tween the two groups of patients. Umme Kulsum CHY1 Conclusions: Mitochondrial membrane potential could 1Emergency Department, United Hospital Limited, Bangladesh; 2Department of be a marker of DCI. JC-1 ratios seemed to be able to predict Anaesthesia, Analgesia, Palliative Care and ICU, Dhaka medical College Hospi- future DCI onset. Further studies are needed to determine tal, Bangladesh detailed mechanisms of extracellular mitochondria-medi- Introduction: Acute respiratory distress syndrome ated cell-to-cell signals in DCI. (ARDS) is one of the leading causes of Intensive care unit (ICU) admission and mortality. This study examined the clinical utility of the SpO2/FiO2(SF) as a substitution of PaO2/FiO2(PF) in diagnosis and classification of ARDS. Methods: All consecutive patients with ARDS fulfilling the inclusion & exclusion criteria (n=50) were included in the study. At the time of diagnosis, that is at zero hour, at 24 hour, at 48 hour, PaO2 from ABG, SpO2 from pulse ox- imetry, and FiO2 from ventilator setting measured & then SpO2/FiO2 and PaO2/FiO2 were calculated. All patients of ARDS were divided into three groups severe, moderate and mild ARDSWITHDRAWAL based on PaO2/FiO2. Results: In this study a total of 50 ARDS patients were en- rolled according to Barlin criteria after fulfilling inclusion & exclusion criteria. The age of the patients in this study ranged from 19 to 72 years with mean age of 42.42±16.03 years. Males were predominant in the series, (62%) and 38% were female. Medically ill patients were 33 and Figure 1. surgical patients were 17. Commonest comorbidity was Diabetes mellitus (28%). In this study, cut off value of SF value found against PF 100 at zero hour & 24 hours were 123 (according to best fit linear relationship). No SF value was found at PF 200 at zero hour but at 24 hour & 48 hour it is 235. Conclusions: Cut off value of SpO2/FiO2 for PF 100 is 123 at zero hour and 24 hour in ARDS patients. Cut off value of SpO2/FiO2 for PF 200 is 235. So SpO2/FiO2 ratio can be effectively used for diagnosis and classification of ARDS. Keyword: ARDS- Acute Respiratory Distress Syndrome, S/F- SpO2/FiO2, P/F- PaO2/FiO2 Figure 2.

226 KSCCM·ACCC 2020 Oral Presentation

Oral Basic 04 Oral Basic 05 Protective effect of Umbelliferone against Early and delayed effects of lipopolysaccharide Biofilm Production by Methicillin-resistant induced acute lung injury in aged mouse Staphylococci at Intensive Care Units Sei Won KIM, In Kyoung KIM, Sang Haak LEE 1 2 Vikas KUMAR , Firoz ANWAR Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of 1Pharm. Sci., SHUATS, India; 2Biochemistry, King Abdulaziz University, Saudi Medicine, The Catholic University of Korea, Korea Arabia Introduction: Aging of the population is a serious ques- Introduction: Background: Staphylococci family bacteria tion in Korea. Along with an aging population, the per- usually cause hospital disease due to their ability to shape cent of the elderly patients in intensive care unit (ICU) is the biofilm on embedded devices such as catheters for increasing at a rapid rate. Acute lung injury (ALI) is one dialysis, central venous catheters, urinary catheters, heart of the most common reasons for ICU admission in elder- valves or orthopedic implants, etc. Bacteria of the family ly patients and the survival from ALI is significantly lower of Staphylococci, particularly S. Epidermidis as well as than non-elderly patients. The aging lung shows differ- S. Aureus are both essential pathogens produced by in- ent features in physiologic, cellular and immunologic dwelling medicinal devices biofilm-related infection. The aspects. However, little is known regarding the effects of current study examines the effectiveness of clindamycin aging on the clinical course of ALI. This study is aimed to and vancomycin alone and as a quorum sensing inhibi- evaluate the impact of aging at early and delayed phase tor in combination with Umbelliferone in thwarting the in a murine model of ALI. formation of biofilms via S.aureus and epidermidis. Methods: Seven-to-eight weeks (young) and 18 months Methods: For the determination of biofilm formation and (elderly), C57BL/6J female mice were used. ALI was in- Oral Presentation its strength against the S. Epidermidis and S. Aureus. The duced by intratracheal lipopolysaccharide (LPS, 0.5 mg/ minimum inhibitoryconcentrations (MICs) of clindamy- kg) application. The mice were sacrificed 24 or 72 h after cin and vancomycin against theMethicillin-Resistant S. LPS exposure. epidermidis (MRSE) and Methicillin-Resistant S.aureus Results: In delayed phase, elderly mouse group with (MRSA) strain. The quorum sensing inhibitor effect was LPS exposure showed significantly more weight loss and assessed via clindamycin and vancomycin andalone and increased wet/dry ratio compared to other three groups in combination with Umbelliferone to prevent the bio- including young mouse group with LPS exposure (p<0.05 film formation. The polymerase chain reaction was used and p<0.01, respectively). Interestingly, this differences for the estimation the presence of icaA and icaD. were not seen at acute phase of ALI. From the cell differ- Results: 74.3% were strong biofilm producers, 16.9% entiation of bronchoalveolar lavage, elderly mouse group were moderate and 8.7% were non biofilmproducers. The with LPS exposure showed significantly higher number MIC50 and MIC90 of clindamycin were 0.7μg/ml and of total cell and neutrophil compared with other groups, 0.9 μg/mlagainst the sessile cells; vancomycin were 3μg/ especially compared with young mouse group with LPS ml and 5.2μg/mlagainst the planktonic and sessile cells exposure (p<0.001, respectively). This difference was also and Umbelliferone were 12μg/ml and 36μg/ml against only seen at delayed phase of ALI. the sessile cells. Umbelliferone (25 μg/ml) exhibited the Conclusions: These results suggest that aging factor may inhibition of biofilm formation along combination with aggravate the lung damage and inflammatory signaling clindamycin and vancomycin. in delayed phase of ALI. Conclusions: As a consequence, we may infer that Keyword: Acute lung injurry, Aging, Mouse model Umbelliferone plays a promising role in preventing the development of biofilms against different species with antibiotic resistance. Keyword: Biofilm, Methicillin-Resistant Staphylococci , Umbelliferone

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 227 Oral Presentation

Oral Basic 06 The effect of sodium butyrate in murine lipopolysaccharide - induced acute lung injury during neutropenia recovery Kyu Yean KIM, Jong Min LEE, Ji Hye KIM, Tai Joon AN, Chin Kook RHEE, Hyung Kyu YOON Pulmonary, Allergy and Critical Care Medicine, Korea

Introduction: Patients in neutropenia recovery is vulnera- ble to pneumonia. Therefore, these patients have increased risk of acute lung injury (ALI), leading to poor prognosis. Recently, intestinal microbiota and its metabolites, such as short-chain fatty acids (SCFA), have emerged as positive Figure1. Effect of NaB on histopathology. players that can modulate host inflammation and promote immune tolerance against bacterial and non-bacterial in- fections. Butyrate, a microbiota associated SCFA, has been shown to be a histone deacetylase inhibitor that suppresses activation of nuclear factor kappa B (NF-κB). The aim of this study is to investigate the effect of butyrate on LPS - in- duced acute lung injury (ALI) during neutropenia recovery in mice model. Methods: Cyclophosphamide was given to mice to induce neutropenia. Seven days later, they were administered LPS by intratracheal instillation. Sodium butyrate (NaB) was Figure 2. Effect of NaB on NF-κB signaling. given by intraperitoneal injection once daily starting on day 2 and continuing until day 4. To study the effect of butyrate Oral Basic 07 on acute lung injury, mice were sacrificed on day 5 after development of neutropenia. Urolithin A (UA), gut microbial-derived Results: NaB attenuated the lung edema and histopatho- metabolites of ellagic acid (EA), may constitute a logical changes associated with LPS - induced lung injury. novel preventive strategy for Neurodegenerative The accumulation of neutrophils and the concentrations of Diseases TNF-α, IL-6, IL-1β, CXCL1, and MPO in bronchoalveolar Jung Hee KIM1,2, Kkot Byeol KIM2, Seonah LEE2 lavage fluids were inhibited effectively by NaB. On the oth- 1Department of Neurosurgery, Seoul Medical Center, Korea; 2Research Insti- er hand, NaB promoted the production of anti-inflamma- tute, Seoul Medical Center, Korea tory cytokine IL-10. NaB attenuated LPS - induced phos- Introduction: Oxidative stress causes cell damage and phorylation of IκBα and nuclear translocation of NF-κB death, which contribute to the pathogenesis of neuro- p65. degenerative diseases. Urolithin A (UA), a gut microbi- Conclusions: NaB significantly attenuated LPS - induced al-derived metabolite of ellagitannins and ellagic acid, ALI during recovery from neutropenia by blocking NF-κB has high bioavailability and various health benefits such signaling pathway. These results suggest potential of butyr- as antioxidant and anti inflamatory effects. However, it ate in the treatment of acute lung injury during neutrope- is unknown whether it has protective effects against oxi- nia recovery. dative stree-induced cell death. We investigated whether Keyword: Acute Lung Injury, Neutropenia recovery, Sodi- UA ameliorates H2O2-induced neuronal cell death. um Butyrate Methods: We induced oxidative damage with 300 μM

228 KSCCM·ACCC 2020 Oral Presentation

H2O2 after UA pretreatment at concentrations of 1.25, 2.5, unit. A multidisciplinary team collaborated to develop the and 5 μM in SK-N-MC cells. Cytotoxicity and cell viability EVD care bundle. October 2018 and August 2019, a total of were determined using the CCK-8 assay. The formation 57 patients underwent EVD placement and the drains were of reactive oxygen species (ROS) was measured using a managed using the bundle protocol. The characteristics of 2,7-dichlorofluorescein diacetate assay. Hoechst 33342 patients, infection rate, prophylactic antibiotic usage, and staining was used to characterize morphological changes antibiotics related side effects were reviewed. In order to estimate the “conventional” infection rate, a retrospective in apoptotic cells. The expressions of apoptosis proteins review of 81 patients who had EVD insertion between No- were measured using Western blotting. vember 2016 and September 2018 were performed. In both Results: UA significantly increased cell viability and de- groups, patients who had previously known infection, EVD creased intracellular ROS production in a dose-depen- placed at other hospital or EVD removed within the first dent manner in SK-N-MC cells. It also decreased the Bax/ three days were excluded. Bcl-2 ratio and the expressions of cytochrome c, cleaved Results: In the pilot study, there were 31 female, 26 male caspase-9, cleaved caspase-3, and cleaved PARP. In addi- with the mean age of 53.8 years old. After the implementa- tion, it suppressed the phosphorylation of the p38 mito- tion of the bundle, the infection rate decreased from 3.1% gen-activated protein kinase (MAPK) pathway. to 1.75% (p-value 0.2). The infection rate per 1000 catheter Conclusions: UA attenuates oxidative stress-induced day was statistically low with the bundle care (1.39 per 1000 apoptosis via inhibiting the mitochondrial-related apop- catheter day vs. 1.74 per 1000 catheter day, p-value <0.05). tosis pathway and modulating the p38 MAPK pathway, The overall duration of external drainage was shorter with suggesting that it may be an effective neuroprotective the bundle care (p-value <0.05). agent. Conclusions: Implementation of an EVD bundle sig- Keyword: Neurodegenerative diseases, Reactive oxygen nificantly reduced the number of EVD days and rate of species, Apoptosis EVD-related Oral Presentation Keyword: External ventricular drainage, Cerebrospinal flu- id, Infection Oral Neuro (1) 01 The effects of bundle for management of Oral Neuro (1) 02 external ventricular drain Outcome of targeted temperature management Hye Seon KIM, Kyeong Hee BAEK, Jin Wook KIM, Won-Sang CHO, after decompressive hemicraniectomy for large Chul-Kee PARK, Sun Ha PAEK, Eun Jin HA hemispheric infarction Department of neurosurgery, Seoul National University Hospital, Korea Sukyoon LEE1, Han-Gil JEONG1, Seung Bin KIM1, Moon Ku HAN2, Jae Introduction: Placement of an extraventricular drain (EVD) Seung BANG3 is a common neurosurgical surgery performed when 1Department of Critical Care Medicine, Seoul National University Bundang Hospital, Korea; 2Department of Neurology, Seoul National University Bun- measurement of intracranial pressure (ICP) or drainage 3 dang Hospital, Korea; Department of Neurosurgery, Seoul National University of cerebrospinal fluid is indicated. However, there is no Bundang Hospital, Korea guideline on how to manage the EVDs after the insertion and EVD-related infection continues to be one of the most Introduction: Decompressive hemicraniectomy (DC) for serious complications. The mechanism of EVD-related in- large hemispheric infarction (LHI) is recommended in fection is similar to the central line-associated bloodstream current guidelines. Several studies suggest that targeted infection (CLABSI). The CLABSI prevention bundle has temperature management (TTM) may be beneficial to been shown to reduce the CLABSI rate effectively. Based patients with LHI through several mechanisms. However, on this, we developed a bundle for management of EVD a recently released randomized trial has not demonstrat- and performed a pilot study to compare the effect of the ed the benefits of TTM in patients with LHI who had re- bundle to the “conventional” method. ceived DC. We conducted a retrospective analysis of LHI Methods: This was a retrospective study (the pilot study) patients who received DC and TTM concomitantly and to implemented in a tertiary hospital neurointensive care find out the utility of TTM.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 229 Oral Presentation

Methods: We collected and reviewed medical records in the NCU or NICU in teaching hospitals for neurosurgical the SNUBH TTM registry from February 2011 to Decem- residency training. ber 2018. Eligible criteria included adults 18 years of age Methods: A survey was conducted in 86 neurosurgical and older, unilateral LHI and TTM after or concomitant residency training hospitals that operate the ICU in South with DC. Patients who received DC for rescue therapy Korea, excluding intensive stroke units and ICUs in region- during TTM were excluded. The primary outcome was al trauma centers. The survey duration was conducted over in-hospital mortality. The secondary outcomes were mRS a 10-month period from March 1 to November 31, 2019. at 3, 6 and 12 months, length of intensive care unit (ICU), The survey was carried out on neurosurgeons in charge of length of mechanical ventilation (MV), rate of tracheos- the NCU in each teaching hospital via email, phone call, tomy. and face-to-face interview. After a primary analysis, ques- Results: A total of 15 patients were identified. The medi- tions were asked to survey respondents to clarify unclear an of hypothermia maintenance duration was 109 hours answers or items. The survey questionnaire was mainly and the median of total TTM duration was 176 hours. divided into four criteria including the general information Inhospital mortality case was one (6.7%) and this trend of teaching hospitals, barriers in deploying. lasted up to 6 months. At 12 months, one more patient Results: Of all 86 neurosurgical residency training hos- died, causing two deaths (13.3%). The median length of pitals, 31 hospitals (36.0%) participated in the survey. Of ICU stay was 16 days and median the length of MV was these, 14 hospitals were tertiary level and 17 hospitals were 15 days. Seven patients underwent tracheostomy (46.7%). non-tertiary. In regards to the distribution of hospitals Conclusions: This study showed low inhospital mortal- across the country, 41.9% of the respondent hospitals were ity in LHI patients who received DC and TTM. One-year located in Seoul, 35.5% were in Gyeonggi-do, mostly locat- mortality rate was lower than the meta-analysis results ed in the metropolitan area, and the rest were located in of the previous published studies but was not statistically the order of Busan, Honam region and Gangwon-do. There significant. The low mortality rate may be related to the were 27 private university hospitals and 4 national univer- longer TTM maintenance and and the high use of neu- sity hospitals. In the 2010 survey, a total of 50 hospitals (41 romuscular blockers. In conclusion, the implementation university hospitals and 9 tertiary hospitals) participated. of TTM with DC is still feasible for LHI and a optimized TTM protocol should be developed. Keyword: Cerebral Infarction, Targeted Temperature Management, Decompressive Craniectomy

Oral Neuro (1) 03 Role of Neurosurgeon in Neuro-Intensive Care: A Brief Report on the Survey Results of Korean Neurosurgeons KwangWook JO1, Do Sung YOO2 1Neurosurgery, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Korea; 2Neurosurgery, Eunpyeong St. Mary’s Hospital, Col- lege of Medicine, The Catholic University of Korea, Seoul, Korea

Introduction: The purpose of this study was to explore the infrastructure and operating system and to identify neu- rosurgeons’ opinions on the system of neurointensivists appointed to the NCU or neurointensive care unit (NICU) Figure 1.: 의학정보실수정. and the requirements and effects of the system through a survey by investigating the current status of operation of Conclusions: We need to understand the importance, spe-

230 KSCCM·ACCC 2020 Oral Presentation cialties and limitations of the role of neurosurgeon in NCU higher than axillary temperature. But in normotheria or compared with intensivist in medical ICU. KNS and KNIC hyperthermia patients, brain temperature is about 0.7-0.8°C take a lot of continuous efforts for the successful imple- higher than axillary temperature. mentation and the evolution of neurointensive Table 1. Correlations Keyword: Neurosurgical care unit, Neurointensivist, Criti- cal Care, Korean Neurosurgical Society

Oral Neuro (1) 04 The temperature difference between the brain cortex and axilla in hypothermia treated patient KwangWook JO1, Do Sung YOO2 1Neurosurgery, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea; 2Neurosurgery, Eunpyeong St. Mary’s Hospi- tal, College of Medicine, The Catholic University of Korea, Seoul, Korea

Introduction: According to recent reports, therapeutic hypothermia shows a significant benefit in various neuro- surgical diseases. And measure the brain temperature is in- vasive and required specific devices. In clinical practice, we measure the other body temperature and regard the brain

temperature is about 1°C higher. But almost these results Oral Presentation obtained in normothermia patients. Authors measure the brain cortex temperature with thermal diffusion flowmeter and analyze the temperature difference according to the axillary temperature. Methods: 135 patients who underwent craniectomy or craniotomy and insert the thermal diffusion flowmeter (2 kind of devices: ABER 2000 and Hemedex), were included Figure 1. in this analysis. The temperature of the brain cortex and Keyword: Temperature difference, Brain temperature, Hy- axilla was measured simultaneously in every 2 hours. Body pothermia temperature was divided 3 groups, according to the axillary temperature; hypothermia group (less than 36.5 °C), nor- mothermia group (between 36.5-37.5°C), and hyperther- Oral Neuro (1) 05 mia group (more than 37.5°C). Results: The temperature difference between the cere- The dedicated neurointensivists are associated bral cortex and the axilla was 0.93±0.50°C in all data pairs, with the outcome in patients with ischemic stroke 1.28±0.56°C in hypothermia, 0.87±0.43°C in normothermia based on the linked big data for stroke in Korea and 0.71±0.41°C in hyperthermia. These temperature differ- Tae Jung KIM1,2, Ji Sung LEE3, Byung-Woo YOON1, Sang-Bae KO1,2 ence was statistical significance between the hypothermia 1Neurology , Seoul National University Hospital, Korea; 2Critical Care Medicine, Seoul National University Hospital, Korea; 3Clinical Epidemiology and Biosta- and normothermia groups (p=0.000), but it was non-signif- tistics, Asan Medical Center, Korea icant in normothermia and hyperthermia group (p=0.201). And the measured values by 2 different thermal-diffusion Introduction: Neurocritical care by dedicated neuroin- flowmeter showed no differencep ( =0.340). tensivists may improve outcomes of critically ill patients Conclusions: From this study, in patients with hypother- with severe brain injury. In this study, we aimed to validate mic therapy appears that brain temperature is about 1.3°C whether neurointensive care could improve the outcome

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 231 Oral Presentation in patients with critically ill acute ischemic stroke using the Conclusions: Treatment by dedicated neurointensivists linked big dataset on stroke in Korea. was associated with lower in-hospital and 3-month mor- Methods: We included 1,405 acute ischemic stroke patients tality using the linked big datasets for stroke in Korea. This with mechanical ventilator support in the intensive care finding stresses the importance of neurointensivists in unit (ICU) after an index stroke. Patients were retrieved treating patients with severe ischemic stroke. from linking the Clinical Research Center for Stroke Reg- Keyword: Ischemic stroke, Neurointensivist, Outcome istry and the Health Insurance Review and Assessment Service data from the period between January 2007 and December 2014. The outcomes were mortality at discharge Oral Neuro (1) 06 and at 3 months after the index stroke. The main outcomes Usefulness of Modified Early Warning Score were compared between the centers with and without ded- (MEWS) for predicting massive transfusion in icated neurointensivists. severe trauma patients with traumatic brain injury Results: Among the included patients, 303 (21.6%) were Seok Jin RYU, Dong Hun LEE admitted to the centers with dedicated neurointensivists. Emergency Department, Chonnam National University Hospital, Korea The patients treated by dedicated neurointensivists had significantly lower in-hospital mortality (18.3% vs. 26.8%, Introduction: Exsanguination is fatal and a major cause p=0.002) as well as lower mortality at 3-month (37.6% vs. of death in severe trauma patients. However studies for 49.1%, p<0.001) than those who were treated without neu- predicting massive transfusion (MT) in severe trauma pa- rointensivists. After adjusting for confounders, a treatment tients with traumatic brain injury (TBI) are insufficient. without neurointensivists was independently associated This study aimed to analyze the predictive performance with higher in-hospital mortality (Odds ratio [OR] 1.592, of Modified Early Warning Score (MEWS) for predicting 95% confidence intervals [CI] 1.128-2.247, p=0.008) and (MT) in severe trauma patients with TBI. 3-month mortality (OR 1.497, 95% CI, 1.136-1.973, p=0.004). Methods: This retrospective study included patients admitted for severe trauma between January 2018 and Table 1. Multivariate logistic regression analysis for mortality December 2018. Patients with head Abbreviated Injury Scale scores greater than 3 were defined as TBI patients. Receiver operating characteristic analysis was performed to examine the prognostic performance of shock index, injury severity score (ISS), revised trauma score (RTS), and MEWS. Multivariate logistic regression analyses were performed to evaluate the relationship between MT and MEWS. The primary outcome was MT. Results: Of the 406 patients included in the study, MT was performed in 43 (10.6%) patients. In multivariate analyses, age, ISS, Glasgow Coma Scale ≤12, and body temperature were independently associated with MT in severe trauma patients with TBI. The area under the curves (AUCs) of shock index, ISS, RTS, and MEWS for predicting MT were 0.585 (95% confidence interval [CI], 0.535–0.633), 0.731 (95% CI, 0.685–0.773), 0.751 (95% CI, 0.706–0.792), 0.770 (95% CI, 0.726–0.810), respectively. Conclusions: MEWS had good prognostic performance for predicting MT in severe trauma patients with TBI. Keyword: Massive transfusion, Severe trauma, Traumatic brain injury

232 KSCCM·ACCC 2020 Oral Presentation

Oral Neuro (1) 07 thy (33, 26.4%), stroke (17, 13.6%), seizure (14, 11.2%) and hypoxic brain injury (14, 11.2%) were the most common Neurological complications in the intensive care causes of neurological complications. The length of ICU unit stay and the number of days on mechanical ventilation 1 2 Jin-Heon JEONG , Dong Hyun LEE were significantly longer in patients with neurological 1Department of Intensive Care Medicine & Neurology, Dong-A University Hos- complications. pital, Korea; 2Department of Intensive Care Medicine & Pulmonology, Dong-A University Hospital, Korea Conclusions: Our finding suggest that neurological com- plications were common in critically-ill patients and were Introduction: Neurologic complications in the intensive associated with worsening of clinical outcome. care unit (ICU) are the result of critical illness, inten- Keyword: Neurologic complication, Intensive care unit, sive care therapies, or underlying neurologic disease. Outcome These complications are often underestimated because critically-ill patients are often intubated or sedated. We performed a descriptive analysis of neurological consul- Oral Neuro (2) 08 tations in the ICU to determine the frequency of various Clinical outcomes and risk factors for spinal cord neurological complications and to evaluate the impact of injury: Early (≤48 hours) versus late (>48 hours) these complications. Surgery Methods: This is a retrospective study of all neurolog- Moinay KIM, Seungjoo LEE ical consultations for patients admitted to ICU over a Neurosurgery, Asan Medical Center, Korea 12-month period (1st September 2015 to 31st August 2016). A neurointensivist have started working since Introduction: Surgical management of spinal cord in- September 2015 and all neurological consultations in the jury (SCI) is challenging. The definition of early surgery Oral Presentation ICU have been staffed by a neurointensivist. We retro- has been matter of concern, although mostly limited to spectively analyzed the clinical data and compared the 24-hours post-injury. For some institutions, this could outcomes of patients with or without neurological com- be difficult to implement in practice. Accordingly, we plications. re-evaluated the timing of early surgery as “surgery within 48 hours” and investigated the surgical outcomes of SCI Table 1. depending on whether surgery was performed early (≤48 hours) or late (>48 hours). Methods: A retrospective cohort study in individuals aged 15–85 years, who underwent surgery for SCI between 2005 and 2016 were involved in this study. The rate of Associa- tion Impairment Scale (AIS) grade improvements was mea- sured at 6 months after injury. Of the 86 enrolled patients, 31 (mean 40.9 ± 12.64 hours) and 55 (mean 168.25 ± 93.01 hours) patients were assigned to the early and late surgery groups, respectively. Results: AIS grade improvement was significantly greater in the early than in the late group (p=0.039). In the early group, there was no significant difference in neurological improvements among the AIS B, C, and D groups, but the Results: We included 629 patients admitted to the ICU AIS A group showed a significant improvement (p=0.015). and neurological problems occurred in 125 patients. Al- This finding was not observed in the late group (p=0.060). tered consciousness, seizure and focal deficits were the AIS grade improvement was also significantly greater in the most common reasons for consultations. Encephalopa- incomplete SCI group than in the complete SCI group, for

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 233 Oral Presentation all measurements (early: p=0.007, late: p=0.009). Other fac- tors that significantly impacted clinical outcomes were AIS grade on admission and the level of the injury. Conclusions: Initial AIS grade, injury level, and timing of surgery were the most significant independent factors determining the outcome of SCI patients. Unlike AIS grade and injury level, which cannot be altered, the decision for timing of surgery is mainly at the discretion of the treating physician. Keyword: Spinal cord injury, Trauma, Surgery

Oral Neuro (2) 09 Systematic management of traumatic cervical spinal cord injury patient in intensive care unit: A case report Chi Hyung LEE, Soon Ki SUNG, Dong Wuk SON, Sang Weon LEE, Geun Sung SONG Department of Neurosurgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Korea

Case: IntroductionTraumatic spinal cord injury (SCI) is one of the most signifcant causes of trauma-related mor- bidity and mortality. When SCI patients are treated with appropriate urgency, intensive care unit (ICU) manage- ment, and surgery, acceptable outcomes is can obtained. We recently reviewed a case of a patient who died in the ICU after traumatic cervical spinal cord injury. Case presentation: A 68 years-old man visited our insti- tution complaint of paraplegia after bicycle trauma. Ar- rest occurred in the patient during the transfer and car- diopulmonary resuscitation was performed and he was recoveryed upon arrival. C3 vertebral body(VB) fracture and dislocation was diagnosed on CT image. And spinal cord contusion at C3 - C4 level on MRI image. Because we could not achieve manual reduction, posterior approach was performed for surgical open reduction. After surgery, the intubation was maintained to prevent sudden respi- ration holding and both upper motor strength improved until 5 days of POD. Cooperation was possible, but agita- tion was severe due to delirium. Since the patient’s mus- cle strength had to be checked continuously, both arms suppression and chest restraint used but not effective. So we were treated to moderate sedation, but the shaking of

234 KSCCM·ACCC 2020 Oral Presentation the head was severely intermittent and dose of sedative Conclusion: Traumatic cervical spinal cord injury is a was increased little by little. Posterior displacement of C3 complex and potentially devastating disease process. To VB was observed on a sudden quadriplegia at 10 days af- reduce mortality, systematic management is needed min- ter POD. It was probably caused by trauma to the surgical imize sources of secondary injury in intensive care unit site due to agitation, and emergency revision surgery was Keyword: Spinal cord injury, Moderate sedation, Delirium performed. After that, the patient developed pneumonia without muscle recovery and died of hypovolemic shock due to sudden Gastrointestinal bleeding. Oral Neuro (2) 10 Neurologic prognostication by Deep learning based Neuroimaging analysis in post cardiac arrest patients Jung Hwa LEE1, Young Joo LEE2, Seung Min BACK2 1Critical care medicine & Neurology , Ewha Women’s University Mockdong Hospital, Ewha Women’s University College of Medicine, Korea; 2Critical care medicine , Ewha Women’s University Mockdong Hospital, Ewha Women’s Uni- versity College of Medicine, Korea

Introduction: Post-cardiac arrest syndrome (PCAS) is one of critical illness which show highest mortality and most serious brain injury. Severity of the brain injury is a key de- terminant of whether maximal resources and withdrawal of life sustaining therapy. Early and accurate prognostica- Oral Presentation tion is crucial for decision of therapeutic plan and setting a goal of treatment. This study aims to establish prognostica- tion values of deep learning-based brain image analysis in PCAS patients. Methods: This retrospective study was performed in ter- tiary university hospital in Korea from March 2012 to Feb- Figure 1. 1st post op xray. ruary 2018. We recruited 222 post cardiac arrest syndrome patients treated with therapeutic hypothermia. Multimodal brain images of CT, diffusion weighted images (DWI) im- ages taken within 72 hours after CA and clinical data were collected. Features for prediction model captured by mod- ern deep learning (DL) technique. Cerebral performance category (CPC) scores were used as the main neurologic outcome of survivors after cardiac arrest. Results: The mean age of the patients was 54.34 ±15.63 years old, with the male and female ratio 70.3% vs 29.7%. DL-based brain image analysis accuracy between 109 subjects of test set, 88 subjects had the correct prognosis score (80.73% accuracy). Negative predictive value (NPV) was 59.46% and positive predictive value (PPV) was 91.67. However, false positive rate was still 0.05%. Conclusions: These findings suggest that deep learning analysis of multimodal brain images could predict neuro- Figure 2. Quadriplegia CT. logic outcomes earlier and more accurately in PCAS pa-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 235 Oral Presentation tients treated with hypothermia. Introduction: Monitoring of cerebral blood flow (CBF) is Keyword: Cardiac arrest, Neuro-Prognostication , Deep crucial in caring patients in the neurological intensive care learning unit (NICU). Change of CBF, either hypoperfusion or hy- perperfusion, is associated with neurological deterioration. We aimed to assess that the fluctuation of Cerebral Flow Index (CFI) using non-invasive continuous CBF monitor could correlate with neurologic deterioration. Methods: We prospectively collected data from patients with acute brain injury (Subarachnoid hemorrhage [SAH], Moyamoya disease [MMD], and ischemic stroke) who are at a high risk of CBF disturbance between May 2017 and June 2019. Non-invasive CBF measurement was performed on bifrontal cortex using c-FLOW (Ornim medical Ltd., Ke- far Saba, Israel). Continuous CBF was assessed using CFI. The delta value of CFI and the percent change of CFI were compared between patients with and without neurological deterioration. Results: A total of 45 patients (mean age, 51.6 years; male, Figure 1. Confusion matrix. 48.9 %) were included for the analysis (SAH [n=13], MMD [n=17], and ischemic stroke [n=15]). Mean duration of monitoring was about 52 hours. Among this study, 9 pa- tients (20.0 %) were neurologic worsening on c-FLOW monitoring during NICU. The delta value of CFI (10.0 ± 6.8 vs. 4.2 ± 2.9, p=0.032) and the percent change of CFI (28.5% vs. 9.0%, p<0.001) was significantly higher in groups with neurological deterioration. 2 patients with neurologic dete- rioration, no significant CFI change was observed. Conclusions: Non-invasive and continuous CBF monitor- ing using c-FLOW might be helpful in patients with acute brain injury. Keyword: Cerebral blood flow, Cerebral flow index, Neuro- Figure 2. ROC. logical deterioration

Oral Neuro (2) 11 Oral Neuro (2) 12 Non-invasive and continuous monitoring Machine learning algorithm to predict outcome of cerebral blood flow as a parameter of after targeted temperature management for neurological deterioration in the acute brain malignant cerebral infarction injury Han-Gil JEONG1, Sukyoon LEE1, Seung Bin KIM1, Moon-Ku HAN2 1 2 3 4 Soo-Hyun PARK , Tae Jung KIM , Eun Jin HA , Won Sang CHO , Hyun- 1Critical Care Medicine, Seoul National University Bundang hospital, Korea; Seung KANG4, Jung Eun KIM4, Sang-Bae KO2 2Neurology, Seoul National University Bundang hospital, Korea 1Department of Neurology and Critical Care Medicine, Inha University Hos- pital, Korea; 2Department of Neurology and Critical Care Medicine, Seoul Introduction: Malignant cerebral infarction is the most National University Hospital, Korea; 3Department of Neurosurgery and Critical severe form of ischemic stroke. Targeted temperature man- Care Medicine, Seoul National University Hospital, Korea; 4Department of Neurosurgery , Seoul National University Hospital, Korea agement (TTM) is an effective treatment against cerebral edema. We aimed to develop predictive algorithm of clini-

236 KSCCM·ACCC 2020 Oral Presentation cal outcome in these patients treated by TTM. brain injury after cardiac arrest. Methods: We included 74 patients with malignant cerebral Methods: In this multicenter prospective observational infarction who received TTM. Demographic, risk factors, study, 52 patients with anoxic brain injury after cardiac ar- initial neurologic severity, treatment information, and rest were included. Malignant EEG patterns were detected 3-month modified Rankin Scale (mRS) were obtained from via frontal EEG monitoring using the Sedline© brain func- our stroke registry and medical records. Infarct volume was tion monitor. We analyzed variables of neurological infor- measured in the last preoperative diffusion weighted im- mation and EEG patterns that predict poor outcomes, such age or computed tomography scan. The favorable clinical as cerebral performance categories 3–5, at 6 months from outcome was defined as 3-month modified Rankin Scale of the cardiac arrest. A cerebral performance category score 0 – 4. The dataset was split into train (70%) and test (30%) of 1 or 2 was considered as good prognosis. Logistic regres- set. Decision tree, random forest and gradient boosting sion and receiver operating characteristic curve analyses machine were used to develop classifying algorithms. were performed to determine the association between the Results: The median NIHSS score was 18.5 (interquartile EEG amplitude following the frequency and poor progno- range [IQR], 15.2 – 21.0) and the median infarct volume sis and between the malignant EEG patterns including high was 206 ml [141 - 258]. The target temperature was 33.0 voltage beta and poor outcome, respectively. or 33.5 in 55 (74.3%) and maintained for a median of 99.8 hours [65 - 137]. A total of 22 patients (29.7%) achieved the favorable clinical outcome. The decision tree algorithm with age (cut-off: 79), infarct volume (cut-off: 242), and sex showed receiver operating - area under the curve (ROAUC) of 0.705. The random forest model showed ROAUC of 0.741 and mean decrease Gini was highest in order of age, infarct Oral Presentation volume, time from last image to TTM initiation and TTM duration. The gradient boosting machine showed ROAUC of 0.679 and the relative influence was highest in order of infarct volume, TTM duration, time from last image to TTM initiation and age. Conclusions: The random forest model was best for pre- dicting favorable clinical outcome of malignant cerebral infarction. Age, infarct volume, the rapidity of TTM appli- cation and its duration were the important components of the predicting algorithm. Keyword: Machine learning, Targeted temperature man- agement, Ischemic stroke

Oral Neuro (2) 13 Prediction of poor prognosis using frontal EEG in patients with ischemic brain injury Jae Hoon LEE Emergency Medicine, Dong-A University College of Medicine, Korea

Introduction: To investigate whether background EEG pat- terns, frequency, and amplitude in quantitative EEG mon- itoring can predict poor outcome in patients with anoxic Figure 1.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 237 Oral Presentation

Results: Most patients exhibiting malignant waves or high voltage beta waves in frontal EEG had poor prognosis. The area under the curve was 0.841 at day 1, 0.883 at day 2, 0.92 at day 3, and 0.994 at day 4. All patients with highly malig- nant waves died. Fast or slow waves in background EEG were differentiated with unfavorable outcome when high amplitudes was observed in beta area at 21–30 Hz.in the color density spectral array (CDSA). Conclusions: Frontal EEG monitoring is useful to detect non-convulsive status epilepticus. Background EEG pat- terns and CDSA characteristics using the Sedline© brain function monitor can predict poor prognosis in patients with cardiac arrest. Keyword: Electroencephalography, Out-Of-Hospital Car- diac Arrest, Hypothermia, Induced

Oral ICU General (1) 01 Effect of a nutritional support protocol on enteral nutrition and clinical outcomes of critically ill patients Heemoon PARK1, Sung Yoon LIM1, Yeon Joo LEE1, Sebin KIM2, Hyung- Sook KIM3, Soyeon KIM3, Young-Jae CHO1 1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Korea; 2Interdepart- ment of Critical Care Medicine, Seoul National University Bundang Hospital, Korea; 3Nutritional Support Team, Seoul National University Bundang Hospital, Korea

Introduction: According to recent studies, early enteral nutrition (EN) supply within 24 to 48 hours after intensive Figure 2. care unit (ICU) admission had benefit in clinical outcomes. In this study, it is expected that EN will be started faster and Table 1. Correlation between poor prognosis and amplitude in fast and slow waves except maligmant EEG patterns supply more nutrition by applying a nutritional support protocol. Methods: This is retrospective cohort study in which a nutritional support protocol for ICU called as NICE-NST protocol was used. In this protocol, nutrition target is 100% of the required daily calories and 1.3g/kg of protein. EN was supplied by continuous feeding for 16 hours from 9AM to 1AM the next day. The gastric residual volume (GRV) is measured at 9AM, 5PM, and 11PM. If GRV is over 250ml, EN is hold. After 2 hours holding EN, GRV is rechecked and the same protocol is repeated until 1AM.

238 KSCCM·ACCC 2020 Oral Presentation

Emergency medicine, Bundang CHA medical center , Korea

Introduction: Central venous catheter(CVC) insertion performs important role in the management of critical ill patient and is usually performed in the ER and ICU. The entrance of the CVC tips into the right atrium may cause fatal complications such as perforation. One of the most accurate way to measure the position of the CVC tip is transesophageal echocardiology (TOE), but it is not useful in the ER or ICU. A widely used method to check the loca- tion of the CVC tip is tip-to-carina distance method with chest x-ray (CXR) or computer tomography (CT). Methods: Patients who had inserted CVC and taken CXR Figure 1. Protocol for RV. with Chest CT at Bundang CHA Medical Center from Janu- ary 02 2016 to July 02 2018. The time interval between CXR Results: This study screened 170 patients who entered ICU and CT within 24 hours. A total of 478 patients were en- from December 26, 2017 to March 25, 2018 (control group; rolled. Each horizontal line perpendicular to the carina and nutrition supply without protocol) and from December CVC tip was drawn in the CXR image and CT scout image. 26, 2018 to March 25, 2019 (test group; nutrition supply The vertical distance of the two horizontal lines was mea- with protocol). After excluding, 80 patients (40 in control, sured and defined as tip to carina distance. In CT image, if 40 in test) were used to analyze. Total nutrition supply was the catheter tip is located below the crista terminalis, it is not different, but the nutrition supply by EN showed high defined that the CVC tip has been RA insertion.Statistical Oral Presentation tendency in test group. There was no difference in compli- analysis is using SPCC ROC curve. cations such as the number of holding EN due to excessive Results: 253 were male (53%), the mean age was 68.90 GRV or vomit, hyperglycemia, and hypoglycemia. Further years. The mean value of TC distance is 18.48mm in CXR analysis was done between the groups whose nutritional and is 18.53mm in CT scout. when CVC tip is located with- support team (NST) consultation was done within 3 days in the SVC, the cut-off value with maximum sensitivity (NST within 3 days) or after 3 days (NST after 3 days). The while maintaining 100% specificity is -6.69mm (sensitivity calorie (3.5±1.0 vs 5.3±0.7, p=0.008) and protein supply 89.78%). when CVC tip is inserted within the right atrium, (0.15±0.04 vs 0.25±0.04, p=0.005) by EN were significantly the cut-off value with the maximum specificity while main- higher in NST within 3 days group. The duration time from taining 100% sensitivity is 15.61mm (specificity 58.8%). admission in ICU to starting EN was significantly shorter in Conclusions: If the CVC tip passes the carina level and is NST within 3 days group (115.2±15.6 vs 77.9±14.3, p=0.01). located at TC distance <15.61mm, CVC tip is located in SVC Conclusions: By using the NICE-NST protocol, EN can be and does not become RA insertion. improved. Especially, when NST consultation was done Keyword : Central venous catheter, Chest X-Ray, Tip to ca- within 3 days, starting of EN and nutritional supply by EN rina distance were significantly improved. Keyword: Nutritional support protocol, Enteral nutrition, Critically ill patients Oral ICU General (1) 03 Bleeding complications during the molecular Oral ICU General (1) 02 adsorbent recirculating system (MARS) Seon Woo YOO1, Deok Kyu KIM1, Seung Yong PARK2, Heung Bum LEE2 Simple Method to Confirm Proper Positioning of 1Anesthesiology and Pain Medicine, Jeonbuk National University Medical Central Venous Catheter Tip School and Hospital, Jeonju, Korea, Korea; 2Internal Medicine, Research Center for Pulmonary Disorders, Jeonbuk National University Medical School and Minwoo KANG, Tae Nyoung CHUNG Hospital, Jeonju, Korea, Korea

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 239 Oral Presentation

Introduction: MARS is an artificial liver support system which support excretory liver function in patients with liver failure and is useful as bridge therapy in patients waiting for liver transplantation. However, application of MARS may complicate higher bleeding tendency in some patients and aggravation of existing bleeding. This study was designed to find out how MARS affects coagulopathy and whether there is a specific factor associated with it. Methods: In total 33 MARS sessions were retrospectively analyzed in 14 patients. Complete blood count, coagulation profiles, and blood chemistry values were compared at be- fore and after MARS application. Patients were divided into two groups according to whether there was visual bleeding or strongly suspicion of existing bleeding. Heparin or na- Table 3. Comparison of pretreatment parameter between upper and lower 8 famostat for preventing coagulation did not administer to sessions based on Hb change rate by MARS either group. Results: Seven patients had bleeding complications, one of whom died from massive subdural hematoma. Compared to pre-MARS, alanine aminotransferase, bilirubin, creati- nine, hemoglobin (Hb), platelet and fibrinogen, and factors V, Vll, and X were significantly decreased but prothrombin time, activated partial thromboplastin time (aPTT), fi- brin degradation product and D-dimer were significantly increased after MARS. In non-bleeders, the degree of re- duction of Hb and platelets was significantly greater than in bleeders. However, there was no significant difference Conclusions: MARS appears to exacerbate coagulation-re- in pre-MARS data between these two groups except for lated factors and encourage bleeding complications. How- Hb. In addition, there were significant differences in vaso- ever, the difference is very large for each patient, and vari- pressor application, pre-treatment aPTT, Hb, and factor V ous factors such as Hb, vasopressor application, aPTT, and compared to pretreatment parameters between upper and factor V appear to be suggested. lower 8 sessions based on Hb change rate in MARS apllia- Keyword: Molecular adsorbent recirculating system , cation. Bleeding complication, Liver failure Table 1. Change in laboratory values before and after MARS

Table 2. Comparison of pretreatment parameters in patinets with and without Figure 1. bleeding complications

240 KSCCM·ACCC 2020 Oral Presentation

Table 1. groups in QTc interval, dispersion, and QTpe-end interval of each lead. Serial ECG changes before and after hemo- dialysis were identified using linear mixed model analysis and showed statistically significant changes in the SCD group (QT dispersion, QTpe-end interval of II, III, aVF, V1-6 lead, P <0.001). Conclusions: In terms of ECG, patients with longer QTpe- end interval before hemodialysis, and large ECG changes before and after hemodialysis might have a relatively high- er risk of SCD. Oral ICU General (1) 04 keyword : Sudden cardiac death, ECG, Hemodialysis Association of sudden cardiac death and electrocardiography in patients with hemodialysis Oral ICU General (1) 05 Nam Eun KIM1, Hyun Jin LEE1, Jung Tak PARK2, Ea Wha KANG3, 4 1 Junbeom PARK , Su Hwan LEE A case report of ascending aortic IABP insertion; 1Division of Pulmonology, Department of Internal Medicine, Severance Hos- alternative to retrograde femoral route pital, Yonsei University College of Medicine, Korea; 2Department of Nephrol- ogy, Department of Internal Medicine, Severance Hospital, Yonsei University Ashish Govinda AMATYA College of Medicine, Korea; 3Department of Nephrology, NHIC Ilsan Hosipital, Anaesthesia and Intensive Care , Shahid Gangalal National heart Center, Nepal Goyang, Korea; 4Division of Cardiology, Department of Internal Medicine, Col- lege of Medicine, Ewha Womans University, Korea Case: Introduction: There is an alternative route for in- Introduction: The rate of sudden cardiac death (SCD) sertion of IABP in cardiac surgical patients undergoing Oral Presentation in hemodialysis patients is significantly higher than that sternotomy if the conventional retrograde trans femoral observed in the general population, and arrhythmogenic route is not possible. Few indications are aorto-iliac oc- death is the highest risk for SCD in hemodialysis patients. clusive disease and peripheral arterial disease. The aim of this study is whether different changes of elec- Case report: Sixty years old male diagnosed as recent trocardiography (ECG) before and after hemodialysis were anterior wall MI with severe left ventricular dysfunction. associated with SCD. Echocardiography showed global hypokinesia, ejection Methods: In the retrospective review of three tertiary refer- fraction 20-25% and coronary angiography completely ral hospitals from November 1986 to November 2016, 678 occluded left anterior descending artery(LAD). Patient patients who underwent hemodialysis enrolled and their underwent CABG . Preoperative IABP insertion was at- ECGs before and after hemodialysis were analyzed tempted via right femoral artery. Inotrope and vasopres- Results: Of the 678 patients, 291 (42.9%) patients died, 39 of sor were used at induction of anesthesia and venous graft whom developed SCD. Between 387 survivors without SCD to LAD. At the end of cardiopulmonary bypass, we were and 39 SCD patients, there were no significant differences unable to wean the patient so a saphenous vein graft was in sex, body mass index, presence of hypertension, ejection used as an access conduit for IABP through the ascend- fraction before hemodialysis, electrolyte, glomerular filtra- ing aorta. IABP placed using Seldinger’s technique and tion rate and duration of hemodialysis. However, Presence left subclavian artery pinched to facilitate direction as of DM and atrial fibrillation were significant higher in the recommended by Santini. Patient was followed up after a SCD group in univariate analysis (53.6% vs 78.9%, P = 0.003, year with CT Angiography of the coronary arteries which 1.9 % vs, 11.1%, P = 0.028). In terms of ECG, the QTc inter- showed patent graft to LAD and conduit graft used for val, dispersion, and QT peak-to-end interval (QTpe-end) IABP insertion was thrombosed. of each lead were analyzed. Before hemodialysis, SCD pa- Learning point: Transthoracic IABP is a useful alterna- tients had longer QTpe-end interval at all lead (II, III, aVF, tive when transfemoral insertion fails. Being a second V1-6 lead, p<0.001) than non-SCD patients. After hemodi- choice and a more invasive treatment, transthoracic IABP alysis, there were no significant difference between both is associated with increased mortality.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 241 Oral Presentation

References : information system via ICU mobility scale, critical vir- 1. Meldrum-Hanna WG, Deal CW, Ross DE. Complications tual reality rehabilitation system. Total 387,977 patients of ascending aortic intraaortic balloon pump cannula- admitted from 2017 to 2018 in 6 adult ICUs were divided tion. Ann Thorac Surg 1985 ;40(3):241-4. into 3 groups: pre-interventional group (Jan to July 2017), 2. Santini F, Mazzucco A. Transthoracic intraaortic coun- Interventional group (August to September, 2017) and terpulsation: a simple method for balloon catheter posi- post-interventional group (Oct 2017 to Dec 2018). tioning. Ann Thorac Surg 1997 ;64(3):859-60. Results: The rate of pain improved from 44.2% in pre-in- Keyword: IABP, Cardiac surgery terventional group, to 33.4% in interventional group and to 15.7% in post-interventional group (p<0.05). The rate of agitation improved from 8.5% in pre-interventional group, to 7.4% in interventional group and to 4.9% in post-interventional group (p<0.05). The rate of delirium improved from 29.2% in pre-interventional group, to 25.5% in interventional group and to 14.7% in post-in- terventional group (p<0.05). The average hospital stay reduced from 7.9 days, to 7 and 6 days in post-interven- tional group (p<0.05). The duration of ventilator weaning Figure 1. IABP pinpoint. reduced from 5.47 days, to 4.87 days in post-intervention- al group (p<0.05). The incidence of ventilator associated pneumonia improved from 1.3‰, to 1.1‰ and 0.8‰ Oral ICU General (1) 06 (p<0.05) Innovative multidisciplinary care model can Conclusions: This study showed that innovative multi- improve rate of pain, agitation and delirium in disciplinary care model can improve rate of pain, agita- critical patients tion and delirium in intensive care units. Furthermore, Ya-Meei LUE1, Hsing-Chi CHUNG1, Ming-Shiuan HUANG1, Hsing-Lin average hospital stay, duration of ventilator weaning day LIN1, Sheng-Huei HUANG1, Yu-Ping YIN1, Pei-Lin WU1, Tsuen-Xiao and incidence of ve GUO1, Hsia-Yun HSU1, Ya-Hui HUANG1, Kang-Pan CHEN1, Shu-Hung Keyword: Pain, agitation and delirium, Early rehabilita- 2 2 1 1 1 KUO , Kun-Chang LIN , Mei-Lin YEH , Hui-Ping LIN , Yu-Yi TANG , Wei- tion information system Chun HUANG2, Chun-Peng LIU2 1Nursing, Kaohsiung Veterans General Hospital, Taiwan; 2Critical Care Medi- cine, Kaohsiung Veterans General Hospital, Taiwan Oral ICU General (1) 07 Introduction: Pain, agitation, and delirium (PAD) are Nurses’ perspectives on flexible intensive care common in critically ill patients. However, adequate con- unit visitation in a Taiwan tertiary medical center trol of PAD is still challenging in daily practice. This study Anne CHAO aimed to investigate the impact of innovative multidisci- Department of Anesthesia, National Taiwan University Hospital, Taiwan plinary care model in improving the rate of PAD in adult intensive care units (ICU). Introduction: Growing evidence shows that open ICU vis- Methods: A multidisciplinary team was organized, in- itation helpsWITHDRAWAL engage family in patient care and improve pa- cluding intensivists, cardiologists, , and nursing staffs. tient outcome. Many ICUs still adopt restrictive visitation, The key interventions in this project include innovative including our center. The aim of the study is to survey nurse PAD reminding, navigation information system, digital perspectives on flexible ICU visitation before changing our communication platform among patients, family and current visiting policy. medical team, intelligent situational lighting system, Methods: We sent a questionnaire to all adult ICU nurses art healing design, family engaged early rehabilitation and interviewed all our ICU head nurses.

242 KSCCM·ACCC 2020 Oral Presentation

Results: Ten (60%) ICU head nurses hold positive attitude hospitalized patients, so it is often known to increase towards flexible visitation. They think their staff (90%) mortality. However the obesity paradox, also known as would reject the change because of concerns for workflow the hypothesis that obesity may have positive effect on disruption, legal issues and lack of training to deal with patient mortality in certain medical group, has changed flexible visitation. The response rate of nurse questionnaire the paradigm. Therefore, we investigate the effect of obe- is 98% (297 responders). Their perspectives are summa- sity on mortality in the intensive care unit (ICU). rized in Tables 1 and 2. Methods: This study retrospectively analyzed medical records of adult patients who were admitted to the ICU of Table 1. Nurses’ perspective on current visitation one university affiliated hospital. Results: A total of 127 patients were enrolled, the mean age was 64.8±13.8 years and 63.0% (n=80) were men. The most common cause of ICU admission was respiratory disease (25.2%, n=32). The mean body mass index (BMI) was 23.2±4.3kg/m2. In-hospital mortality was 21.3% Table 2. ICU nurse perspective on flexible visitation (n=27), and was negatively associated with BMI of pa- tients (hazard ratio 0.88, 95% confidence interval 0.78- 0.99, p=0.03). When cut off value was applied using Youd- en index, the mortality rate of patients with BMI ≤ 23.5 kg/m2 was significantly higher than patients with BMI > 23.5 kg/m2 (26.9% vs 12.1%, p=0.04), and Kaplan-Meier curve significantly different overall survival between them (Log rank test p=0.01, Figure). Oral Presentation

Conclusions: Most nurses reject flexible visiting policy in their ICU despite they think family can help them in patient care. Engagement of family care in current visitation is the first step. Training and development of visitation guidelines are required before launching a successful visiting policy. Keyword: ICU visitation, Family engagement, Visitation guidelines

Oral ICU General (1) 08 Figure 1. Kaplan. The obesity paradox on ICU mortality in critically ill patients Conclusions: In our study, higher BMI resulted in lower mortality in critically ill patients. However, because the Beong Ki KIM1, Sua KIM2, Chi Young KIM1, Seung Heon LEE1, Yu Jin 1 1,2 small number of enrolled patients and retrospective design, KIM , Je Hyeong KIM 1 additional prospective studies are needed for clear conclu- Division of Pulmonology, Department of Internal Medicine, Korea University Ansan Hospital, Korea; 2Department of Critical Care Medicine, Korea University sions. Ansan Hospital, Korea Keyword: Obesity, Body mass index, ICU mortality Introduction: Obesity causes various complications in

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 243 Oral Presentation

Oral ICU General (1) 09 Keyword: Serotonin syndrome, targeted temperature management, hyperthermia, SNIR Serotonin syndrome treated with targeted temperature management Taeyoung WON, Yongil CHO, Jaehoon OH, Hyunggoo KANG Oral ICU General (2) 10 Emergency medicine, College of medicine, Hanyang University, Seoul, Korea Effects of Prophylactic Dialysis on Coronary Case: Introduction: We report a case of a patient with Bypass Surgery hyperthermia caused by serotonin syndrome who dis- Chia-Sheng CHANG1 charged with good neurological status after treated with 1Department of Anesthesiology, China Medical University Hospital, Taiwan; 2 targeted temperature management (TTM). Department of Anesthesia, China Medical University, Taiwan Case presentation: A 55-year-old female patient visited Introduction: The presence of renal dysfunction results an emergency department with stuporous mentality. She in several physiologic abnormalities that could contrib- had hypertension, diabetes mellitus, hyperlipidemia, ute to adverse outcome and increase the necessity of and major depressive disorder. She ingested approxi- intensive care especially for postoperative patients. The mately 100 tablets of her medication, which included an effect of prophylactic dialysis on postoperative morbidity unknown amount of serotonin norepinephrine reuptake and mortality rates after cardiac surgery is unknown; we Inhibitor (SNIR), for the purpose of suicide. After several aimed to investigate the effects. generalized tonic-clonic seizures, cardiac arrest of pulse- Methods: Our study was a randomized-controlled clini- less electrical activity rhythm occurred and resuscitated cal trial involving patients with non-dialysis-dependent after 4 minutes of cardiopulmonary resuscitation. Acute renal insufficiency, defined as stage-3 or -4 chronic intracranial lesions were not observed on the computed kidney disease and requiring CABG surgery. Patients in tomography of the brain. She was transferred to a region- the intervention group were treated by dialysis before al emergency center with blood pressure, 126/58 mmHg; CABG surgery. CABG surgery was similar in both groups. pulse, 95/min; respiratory rate, 12/min; body tempera- PostoperativeWITHDRAWAL outcomes, including stroke, ventricular ar- ture, 40.2ºC. She was unconscious with a Glasgow Coma rhythmia, requirement for a second surgery for bleeding Scale score of 3 and bilateral fixed and dilated pupils. or deep infection of the sternum, and duration of venti- Electrocardiogram showed normal sinus rhythm of QTc lation were examined for associations with mortality and interval of 467 milliseconds. The patient was admitted morbidity. to an intensive care unit and treated with TTM. The tar- Results: Eighty-eight patients were included in this study. get body temperature of 34 °C was reached 7 hours after Three months after surgery, 37 patients (42%) had at least initiation of TTM and maintained for 24 hours. She was some form of morbidity, whereas the remaining did not. rewarmed by 0.25 °C per hour, and the normothermia at For 23 patients in the nondialysis group, the average time 36 °C was maintained for 48 hours. Her consciousness to morbidity onset was 79.3 ± 3.9 days, whereas the aver- was restored and extubated on day 3. No specific find- age time to morbidity onset for 14 patients in the dialysis ings were found on brain magnetic resonance imaging group was 77.7 ± 4.8 days. The difference in the time to and she was discharged on the 8th day of hospitalization morbidity onset between the groups was not statistically without any neurological deficits. significant ( p=0.413). Of the 88 patients, 9 (18.9%) died: Conclusions: The serotonin syndrome is a potentially 8 (89%) from the non-dialysis group and 1 (11%) from life-threatening syndrome. Early recognition and treat- the dialysis group. Based on Cox regression analyses, the ment of serotonin syndrome is an important factor to hazard ratio for death in the non-dialysis group was 10.85 have a good prognosis. Especially hyperthermia caused compared to the control group. by serotonin syndrome can lead to neurological sequelae Conclusions: Prophylactic dialysis prior to CABG surgery so early application of TTM may be helpful for treatment. in patients with renal insufficiency may decrease mortal-

244 KSCCM·ACCC 2020 Oral Presentation ity after surgery without affecting morbidity. Oral ICU General (2) 12 Keyword: Prophylactic Dialysis, CABG, Outcome in ICU Occupational inhalation injury by Hydrogen Sulfide causing multi organ failure Oral ICU General (2) 11 Karishma SHAMARUKH, Mohammad Omar FARUQ General intensive care Unit, United Hospital Limited, Bangladesh Comparison between ringer lactate and combination of ringer lactate with hes 6% (200/0.5) in Case: Hydrogen sulfide is a notorious agent known to hemodynamic and regional oxygen saturation cause serious injuries in the occupational field. We are (rSO2) in rabbit with hemorrhagic shock going to discuss a case of a 20 years old male working in a Faisal MUCHTAR, Syafri KAMSUL ARIF, Husni TANRA, Arif SANTOSO, ETP( Effluent Treatment Plant) in Savar, Bangladesh who Amin HISBULLAH, Irfan SJATTAR accidentally entered the fume room and was exposed to Anestesiology, Intensive Care and Pain Management, Medical Faculty, Hasa- nuddin University, Indonesia the toxic gas. He lost his consciousness and was brought to our care from a local hospital in intubated condition. Introduction: Hemorrhagic shock induce inadequate ox- He was found in state of unconsciousness grade III on ygen perfusion at the cellular level. Fluid therapy includ- admission to our ICU.His brain CT scan revealed dif- ing crystalloid is required to maintain tissue perfusion for fuse edema. Chest X-ray revealed findings suggestive of oxygen delivery, however, excessive crystalloid therapy diffuse pneumonitis. Cardiology evaluation suggested leads to edema and microcirculation disruption. Accord- Toxic cardiomyopathy as his Troponin I was very high ingly, new strategy of fluid therapy is required, and this on admission ( 2037ng/L). . Supportive care was given in study is designed to evaluate the outcome of fluid ther- the form of mechanical ventilation, antibiotics, anticon- apy by comparing crystalloid alone vs combination of Oral Presentation vulsant and anti-ischemic medications . Patient regained crystalloid and colloid. consciousness on day 10 after admission and gradually Methods: Experimental study with single-blind random- improved clinically. By the end of the month of stay in ized trial designed to evaluate the hemodynamic and hospital he was significantly improved. regional oxygen saturation (rSO2) in rabbits with hemor- Keyword: Effluent treatment plant, Hydrogen sulphide , rhagic shock. Thirty rabbits were divided into two groups. toxic cardiomyopathy , Chemical pneumonitis, Toxic en- Group-1 resuscitated with RL and group-2 with RL and HES 6% (200/0.5) 2:1 ratio. Hemodynamic comparison cephalopathy consisted of systolic and diastolic blood pressure, heart rate and cerebral and intestinal rSO2. Data presented in ± Oral ICU General (2) 13 SD and analyzed with Mann-Whitney U test. Results: Significant findings were mean systolic, diastolic Hypomagnesemia is associated with increase in blood pressure (p=0.03, p=0.01), and heart rate (p=0.02). mortality and morbidity in ICU : Can we use it as Cerebral rSO2 was significantly higher in group-2 prognostic marker? (p=0.045). Intestinal rSO2 was higher in group-2, howev- MD MOTIUL ISLAM er not statistically significant (p=0.09). Critical Care Medicine, Bangladesh Society of Critical Care Medicine (BSCCM), Conclusions: Combination of RL and HES 6% (200/0.5) Bangladesh as fluid therapy significantly increases the hemodynamic Introduction: Hypomagnesemia is one of the common parameter including systolic and diastolic blood pres- electrolyte disorders in ICUs. It is often an incidental sure, heart rate and cerebral rSO2 compared to RL alone. finding and many times ignored. This study was designed Keyword: Fluid therapy, Regional oxygenation satura- to assess the significance of the “impact of hypomagnese- tion, Hemorrhagic shock mia” on the mortality and morbidity of the ICU patients. Hence the efficacy of hypomagnesemia as prognostic marker was also tested.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 245 Oral Presentation

Methods: Prospective cohort study done at the ICU, of a lyte abnormality but in critically ill-patients it can lead to tertiary care hospital at Dhaka, aiming at finding out of some important clinical consequences. the differences in mortality & morbidity between hypo & Objective: To studyserum magnesium level and to cor- normal magnesium level group, who were composed of relate impact of hypomagnesaemia in critically ill pa- essentially clinically identical patient population except tients considering parameterslike length of stay in ICU, for the serum Mg level. need and duration of ventilatory support, events of cardi- Results: Total 95 medically ill adult patients were includ- ac arrhythmia &mortality in patients admitted in the ICU. ed in the study and 38% of the study subjects were hy- Methods: Method: In one year period, a prospective ob- pomagnesemic and this group of patients needed more servational study was carried out in patients gotadmitted frequent (52.54% vs. 75%, p<0.02), prolonged (3.88±4.10 in the ICU. One hundred patients were included in the vs 2.25±3.18, p<0.04, days) mechanical ventilator support study. Patient’s demographic profile, medical history and had prolonged length of stay in ICU (9.13 vs 6.27, ,detailed clinical examination and laboratory measure- p<0.01) and hospital (14.94 vs 10.47, p<0.007, days) com- ments- S. Electrolytes, Mg+, RFT,LFT, ABG analysis, pared to patients who had normal serum magnesium lev- urine RME, X-ray chest,ECGwere enrolled at admission. el. Incidence of severe sepsis and septic shock were also Patients receiving the diuretics, magnesium supplemen- likely to be more in patients with hypomagnesemia as it tation, those who had undergone GI surgery, post-opera- had significant association with abnormal total leukocyte tive patients, were excluded from the study. Patients were count (69.4% vs 47.5%, p<0.05) and more frequent use of divided into normomagnesemic & hypomagnesemic inotropic support (61.1% vs 38.9%, p<0.05). The mortality groups and compared for various parameters.Parameters rate in hypomagnesemic patients were also high (33.3% assessed were-need for mechanical ventilation,duration vs 11.86% p<0.01). of ventilator support,duration of ICU stay, events of car- Conclusions: Patients with hypomagnesemia needed diac arrhythmia &mortality. more frequent and prolonged mechanical ventilator Results: Result: Out of 100 critically ill-patients, 42 pa- support, stayed longer in hospital and in ICU and used tients (42.0%) were hypomagnesemic. Most of the hypo- inotropes more frequently compared to the normomag- magnesemic patients were elderly (≥60 yrs.) compared nesemic group. The mortality in hypomagnesemic group to normomagnesemic group)(67 % vs 40%). Associated was also high. So hypomagnesemia significantly affected electrolyte abnormalities in hypomagnesemic patients the prognosis of patients. We conclude that serum Mag- were hypokalemia (66.50%) and hypocalcemia (52.50%). nesium level may be used as a prognostic marker for The duration of stay of the patients in ICU, need & dura- severity of critically ill adult medical patients. However tion of ventilator support showed significant variation further researches are needed to support our conclusion. between two groups. In hospital, arrhythmia (18.75%) Keyword: Hypomagnesemia, ICU, Prognostic marker and convulsion (5.50%) developed in hypomagnesemic groups. Mortality of hypomagnesemic group was 38.33% while that of normomagnesemic group was 15.60%. Oral ICU General (2) 14 Conclusions: Conclusion: Measurement of magnesium level should be done essentially in all patients admitted Impact of hypomagnesemia in critically ill patients: experience in ICU in the ICU and should not be overlooke Keyword: Hypomagnesemia, Critical illness, Impact MD. Ashraful Haque1, DR Rawshan Arra Khanam2 1Department Critical Care Medicine, Sheikh Fazilatunnessa Muzib Memorial KPJ Specialized Hospital, Bangladesh; 2Consultant, Department of Pulmonol- ogy, United Hospital Limited, Bangladesh

Introduction: Introduction:Hypomagnesemia is the most frequently overlooked and underdiagnosed electro-

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Oral ICU General (2) 15 Table 1. Characteristics of the patients according to incidence of delirium

Incidence, risk factors and outcome of delirium in surgical intensive care unit Muhammad Faisal KHAN5, Asghar ASHRAF1, Madiha HASHMI2, Amir RAZA3, Bushra SALEEM4 1Anaesthesiology, Aga Khan University, Pakistan; 2Anaesthesiology, Aga Khan University, Pakistan; 3Anaesthesiology, Aga Khan University, Pakistan; 4Anaes- thesiology, Aga Khan University, Pakistan; 5Anaesthesiology, Aga Khan Univer- sity, Pakistan

Introduction: The incidence of delirium in the ICU rang- es from 45% to 87% [1]. To date, limited data is available related to the prevalence of delirium in surgical patients. The aim of this study was to evaluate the incidence and modifiable risk factors of delirium in surgical intensive care unit of tertiary care hospital in a developing country. Methods: We conducted prospective observational study in patients with age more than 18 years and who were ad- mitted to the surgical intensive care unit (SICU) for more than 24 hours in Aga Khan University Hospital from Janu- Oral Presentation ary 2016 to December 2016. The SICU has 9 beds and run be trained Intensivist with 24/7 coverage. Nurse to bed Table 2. In Univariate analysis-factors associated with delirium ratio is 1:1. Admissions are received from the emergency department, operating room and from surgical wards. Pa- tients who had preexisting cognitive dysfunction, signed Do Not Resuscitate order, stay in SICU for less than 24 hours were excluded. Delirium was assessed by Results: The average age of the patient was 43.29±17.38 and BMI was 26.25±3.57 kg/m2. There were 62(78.2%) male and 19(21.8%) female (Table 1). Delirium was observed in 19 of 87 patients with an incidence rate of 21.8%. In univariate analysis, COPD, fever, pain >4, agitation, sedation, hypernatremia, length of ICU stay ≥7 days and mortality were significantly high in those patients who developed delirium (Table 2). Midazolam and Propofol were 4 times more likely to develop de- lirium as well as in analgesic medication Multivariable analysis showed that COPD, pain >4 and hypernatremia were strong predictors of delirium (Table 3). Midazolam [aOR=7.37; 95%CI: 2.04-26.61] and Propofol exposure [aOR=7.02; 95%CI: 1.92-25.76] were also the strongest in- dependent predictors

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 247 Oral Presentation

Table 3. Multivariable logistic regression - factors associated with delirium Oral ICU General (2) 17 Sensoryneural hearing loss after carbon monoxide poisoning Heekyung LEE, Hyunggoo KANG, Youngil CHO, Byunk Sung KO, Jaehoon OH Department of Emergency Medicine, Hanyang Univertisity Hospital, Korea

Case: Carbon monoxide poisoning is a commonly at- tempted suicide method in Korea, resulting in high mortality and complications. Although delayed neuro- psychiatric syndrome has been studied as a serious com- plication, it is rarely toxic to the auditory nerve, which can lead to sensorineural hearing loss. A 33-year-old man Conclusions: Delirium is significant risk factor of poor out- tried to commit suicide by burning an ignition charcoal come in surgical intensive care unit. This study observed an in a car and was sent to emergency department. There independent association between in-adequate pain con- was no underlying disease and the gas exposure was es- trol, sedative medication, COPD, hypernatremia and fever timated to be over 6 hours. The initial mental status was in developing delirium. confused, and the initial carbon monoxide hemoglobin Keyword: Delirium, Surgical ICU, Outcome was checked at 20%. On arterial blood gas test, pH 7.389, pCO2 25.9 mmHg, pO2 102 mmHg, HCO3 15.8 mmol/ L, Base excess -7.0 mmol/L, lactate 6.0 mmol/L were re- Oral ICU General (2) 16 ported, and on chemistry test, BUN/Cr 29.7/3.1 mg/dl, Acute mesenteric ischaemia secondary to portal Creatinine kinase 698 U/L, Troponin I 5.794 ng/ml. Chest and superior mesenteric vein thrombosis radiographs indicated aspiration pneumonia in both lower lung fields, and echocardiograph findings is EF = Hui-Jae BANG 45% in the global hypokinesia of the left ventricle. The Surgery, Yonsei university Wonju college of medicine, Korea patient returned to consciousness after being admitted to Case: Contrast-enhanced computed tomography (CT) ICU, complaining of both hearing impairment, tinnitus greatly improves the diagnosis of superior mesenteric vein and paresthesia of the left ear and shoulder. Hyperbaric (SMV) thrombosis, which presents as the unspecific symp- oxygen treatment was performed 5 times with 2.5 atm for tom of abdominal pain. Prothrombotic states or thrombo- 120 mins. There were no eardrum abnormalities in the philia and local intra-abdominal infections are major causes otolaryngology examination and on pure tone audiom- of SMV thrombosis. A 48-year-old woman was diagnosed etry(PTA) moderate hearing loss with Rt 48 dB/Lt 42 dB with superior mesenteric vein and portal vein thrombosis. was reported. High-dose oral steroids were administered The patient underwent emergency laparotomy and received for 5 days. Rhabdomyolysis, renal failure, and carbon a small bowel resection. Heparization was performed post- monoxide-induced cardiomyopathy improved and were operatively and hematoma developed as a complication. discharged 8 days after admission. Twice intra-tympan- Short bowel syndrome has impaired nutrition. Three weeks ic steroids were administered from the otolaryngology after the operation, the patient’s symptoms worsened and outpatients 1 and 14 days after discharge. The patient infarction was found in the retroperitoneal area. Right colon improved to the right 19 dB / left 14 dB decreases on PTA resection and ostomy were performed. The patient’s symp- on 11 weeks after discharge. Carbon monoxide poisoning toms then gradually resolved. can damage the central and peripheral nervous system Keyword: Superior mesenteric vein, Infarction, Hepariza- and including the auditory nerve. Barotrauma due to hy- tion perbaric oxygen therapy shpuld be differentiated.

248 KSCCM·ACCC 2020 Oral Presentation

Keyword: Carbon monoxide poisoning, Sensory neural tion on the use of fibrinogen concentrate in adult surgical hearing loss, Hyperbaric oxygen therapy patients. However, its use is tolerable without any notable adverse events. It warrants future adequately powered randomised trial to answer this knowledge gap. Oral ICU General (3) 18 Keyword: Blood loss, Fibrinogen, Fibrinogen concentrate Effect of fibrinogen concentrate on postoperative blood loss: A systematic review and meta- Oral ICU General (3) 19 analysis of randomised trials Ka Ting NG1, Jasmine Li Ling YAP2, Pei En KWOK3 Novel information reminding system improve 1Department of Anaesthesiology, University of Malaya, Malaysia; 2Department Early goal directed mobility in critical patients 3 of Internal Medicine, Hospital Sultanah Aminah, Malaysia; Department of Hsing-Chi CHUNG1, Hsiu-Fen YANG 1, Ya-Meei LUE1, Hsing-Lin LIN2, Anaesthesiology, Dalhousie University, Canada Sheng-Huei HUANG1, Ming-Shiuan HUANG1, Yu-Ping YIN 1, Pei-Lin 1 1 1 1 1 Introduction: Perioperative bleeding remains a major WU , Tsuen-Xiao GUO , Hsia-Yun HSU , Mei-Lin YEH , Ya-Hui HUANG , Kang-Pan CHEN1, Shu-Hung KUO 2, Hsin-Li LIANG2, Wei-Chun concern in surgical patients. It is associated with low HUANG2,3,4,5, Chun-Peng LIU2 level of fibrinogen. However, the safety and efficacy of 1Nursing, Kaohsiung Veterans General Hospital, Taiwan; 2Critical care medicine fibrinogen supplementation to minimise postoperative and cardiovascular center, Kaohsiung Veterans General Hospital, Taiwan; bleeding remains unclear. The primary aim of this review 3School of Medicine, National Yang-Ming University, Taiwan; 4Physical Thera- py, Fooyin University, Taiwan; 5Graduate Institute of Clinical Medicine, Kaohsi- is to investigate the effect of fibrinogen concentrate in ung Medical University, Taiwan postoperative blood loss in adult surgical patients. Methods: This systematic review was conducted in the Introduction: Early mobilization in intensive care unit adherence of the Cochrane Handbook of Systematic (ICU) is a candidate intervention to reduce the incidence Oral Presentation Reviews of Interventions. Prior to the search, the study and severity of ICU acquired weakness and improve protocol was submitted and published on PROSPERO, outcomes. Implementing early goal directed mobility CRD42019149164. Databases of MEDLINE, EMBASE (EGDM) was shown to improve duration of mechanical and CENTRAL (Cochrane Central Register of Controlled ventilation, ICU stay, long-term functional indepen- Trials) were systematically searched from their start date dence, and possibly mortality. However, it remained until May 2019. Eligibility criteria included randomised challenging issue in daily practice. clinical trials comparing intravenous fibrinogen concen- Methods: The aim of this study is to investigate the im- trate and placebo in adult surgical patients, regardless of pact of early goal directed mobility using novel informa- type of surgery. Observational studies, case reports, case tion system on patients’ outcome in intensive care unit. series and non-systematic reviews were excluded. All consecutive patients form 2017-2018 in adult ICU Results: Thirteen trials (n=900) were included in this re- were enrolled. The key interventions include novel early view. In comparison to placebo, fibrinogen concentrate rehabilitation information system and virtual reality re- significantly reduced the first 12-hour postoperative habilitation system for critical patients. The patients were blood loss, with a mean difference of -134.62ml (95% divided into three periods: pre-EDGM system period CI -181.85 to -87.38, ρ<0.00001). It also significantly from Jan to July 2017, EDGM system setting period from increased clot firmness in thromboelastometry with August to September 2017 and post-EDGM system peri- a mean difference of 2.48mm (95%CI 1.14 to 3.82, ρ od from October 2017 to December 2018. =0.0003) in the fibrinogen group. No significant differ- Results: The early rehabilitation rate improved from ences were demonstrated in the adverse events associ- 17.1% in pre-EDGM system period, to 20‰ in EDGM ated with fibrinogen concentrate use, namely incidence system setting period and to 95.1% in post-EDGM sys- of thromboembolism, myocardial infarction and acute tem period (p<0.05). Average ICU stay decrease from kidney injury. 7.9 days to 6 days after intervention (p<0.05). Average Conclusions: In conclusion, low level of evidence and ventilator days improved from 5.5 days to 4.9 days in substantial degree of heterogeneity limit recommenda- post-EDGM system period (p<0.05). The incidence of

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 249 Oral Presentation ventilator-associated pneumonia decreased from 1.3‰ Diabetic Ketoacidosis potentially precipitated by Acute to 0.83‰(p<0.05). Mountain Sickness, and use of Acetazolamide and man- Conclusions: The study showed that implementation of aged with hemodialysis in addition to conventional early goal directed mobility using novel information sys- treatment. High altitude trekking can present significant tem could increase early rehabilitation rate, and reduce hazards to diabetic patients, so additional care should be average ICU stay and ventilator days. Furthermore, the encouraged. incidence of ventilator-associated pneumonia also im- Keyword: Diabetic Ketoacidosis, High Altitude, Hemodi- proved. alysis Keyword: Early goal directed mobility, intensive care unit

Oral ICU General (3) 21 Oral ICU General (3) 20 Kefir peptides attenuates high cholesterol diet- Diabetic Ketoacidosis in High Altitude managed induced atherosclerosis and bone loss by reducing with Hemodialysis: A Case Report oxidative stress and systemic inflammation in Sushil KHANAL, Kamal PANDIT, Subhash Prasad ACHARYA Apolipoprotein E knockout mice 1,2 Department of Critical Care Medicine, Grande International Hospital, Nepal Chih-Ching YEN 1Department of Pulmonary and Critical Care Medicine, China Medical Univer- Case: Introduction: Diabetic ketoacidosis (DKA) is life sity Hospital, Taichung , Taiwan; 2Department of Life Science, National Chung threatening complication of diabetes mellitus. The risk Hsing University, Taichung, Taiwan of developing ketoacidosis in patients with type 1 dia- Introduction: Cardiovascular disease and osteoporosis betes mellitus at high altitude increases when a number represent the important causes of morbidity and mor- of factors get combined. Anorexia associated with acute tality worldwide. The two diseases were traditionally mountain sickness, dehydration and additional exercise considered independently related with aging, but recent associated with climbing exacerbates the generation of studies revealed there is a significant positive correlation ketones and the development of ketoacidosis. Here we between them. Dyslipidemia, hypertension, type 2 dia- report a case of severe DKA occurring at high altitude. betes, smoking, alcohol consumption, physical activity, Case presentation: A 33 year old gentleman with known menopause and aging are important risk factors for both history of uncontrolled type 1 Diabetes Mellitus while of them. MostWITHDRAWAL guidelines recommend adequate calcium trekking to Everest Base Camp at an altitude of 3440 intake for prevention and treatment of osteoporosis but meters became unwell and developed altered sensori- calcium supplements may accelerate vascular calcifica- um and shortness of breath. He ingested himself eight tion and increase mortality, especially in patients with tablets of Acetazolamide (250 mg each) to address these chronic renal failure. Our previous study revealed kefir symptoms. Upon presentation to emergency, he was di- peptide could reduce high fat diet (HFD)- induced ath- agnosed with severe Diabetic Ketoacidosis, High Altitude erosclerosis by attenuating oxidative stress in apolipo- Cerebral Edema and Pneumonia with Shock. Resusci- protein E knockout (ApoE-/- KO) mice. The present study tation was started with fluid, insulin, antibiotics, vaso- aims to investigate the effects of Kefir peptide on bone pressors and mechanical ventilation. Despite adequate mass and vascular calcification simultaneously. fluid resuscitation, bicarbonates and other supportive Methods: 7-week old male ApoE-/- KO and normal measures, his acidosis and shock persisted. He was then C57BL/6 mice were randomly divided into the following 6 managed with hemodialysis. After the first session of groups (n = 6): (1) B6 normal control: C57BL/6 mice on a hemodialysis, improvement in acidosis and shock was normal chow diet; (2) ApoE control: ApoE-/- KO mice on a noted. Over the course of his stay, Cerebral Edema and normal chow diet; (3) mock: ApoE-/- KO mice on an HFD Pneumonia improved and successfully extubated. He + PBS treatment; (4) KL: ApoE-/- KO mice on an HFD + was later discharged to home. low-dose kefir peptides (100 mg/kg, daily gavage); (5) KH: Conclusion: This case describes an episode of severe ApoE-/- KO mice on an HFD + high-dose kefir peptides

250 KSCCM·ACCC 2020 Oral Presentation

(400 mg/kg, daily gavage); and (6) Atorvastatin: ApoE-/- was seen, which resulted in near-total obstruction with KO mice on an HFD + Atorvastatin (10 mg/kg/day) treat- valve-manner movement. Since rigid bronchoscopy ment. After 13-week treatment, the mice were sacrificed couldn’t be performed right away, we decided to remove for the evaluation of bone and vascular changes. OFTP by flexible bronchoscopy. We used biopsy forcep Results: The atherosclerotic lesion development in and removed OFTP entirely without complication. The ApoE-/- KO mice was established after fed the high-fat patient’s symptoms improved immediately after remov- diet for 13 weeks compared to the normal chow diet-fed ing the pseudomembrane. The biopsy specimen showed B6 and ApoE control groups. Comparing with HFD-fed fibrinopurulent and necrotic material. The patient was ApoE mock group, the administration of kefir peptides discharged without further deterioration. significantly decrease the levels of ox-LDL, TNF-α in the blood, as well as the inflammation in aorta with Keyword: Kefir peptides, atherosclerosis , Osteoporosis

Oral ICU General (3) 22 Removal of Obstructive Fibrinous Tracheal Pseudomembrane showing near total obstruction with valve-manner movement by flexible bronchoscopy: A Case Report Jongyeol OH, Jick Hwan HA Division of pulmonology, allergy and critical care medicine, Incheon Saint Oral Presentation Mary’s Hospital, the Catholic University of Korea, Korea

Case: Introduction: Obstructive fibrinous tracheal pseu- domembrane (OFTP) is a rare condition associated with endotracheal intubation, usually presents as a thick tu- bular, rubber-like, whitish pseudomembrane molding Figure 1. OFTP_expiration the tracheal wall under bronchoscopy. OFTP requires early detection and urgent management, as it causes a life-threatening tracheal obstruction. Herein, we report a case of OFTP developed after 7 days intubation and re- moved by flexible bronchoscopy. Case presentation: A 69 year-old male patient diagnosed with esophageal cancer and lung cancer was hospitalized for surgery. The patient underwent laparoscopic trans- thoracic radical esophagectomy and VATS right upper lobe lobectomy sequentially. After surgery he was trans- ferred to ICU and maintained intubation with a 8.0-mm cuffed tracheal tube. Intra-cuff pressure was monitored and maintained about 28 cmH20. After 7 days, extuba- tion was performed and the patient soon complained of dyspnea and stridor sound was heard. He was referred to the pulmonology and bronchoscopy was done. On flexible bronchoscopy under conscious sedation, a Figure 2. OFTP_inspiration white, rubbery membrane encircling the upper trachea

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 251 Oral Presentation

to proper antibiotics in intensive care unit. We report a case of acute mitral regurgitation as an unexpected cause of diffuse alveolar hemorrhage with lobar consolidation mimicking atypical pneumonia. Case Report: A 37-year-old male transferred from a local medical center to our tertiary emergency medical center with high fever, myalgia, cough, sputum and fresh blood tinged sputum. Chest Computed Tomography showed al- veolar interstitial infiltrates limited to only right upper lobe and small amount of pleural effusion on the same side. Intravenous administration of ceftriaxone and azithromy- cin was started for presumed community acquired pneu- monia. Fiberoptic bronchoscopy showed diffuse alveolar hemorrhage. On suspicion of atypical lobar type pneumo- Figure 3. OFTP_specimen nia, transamic acid, steroid and Tamiflu were all applied. Conclusion: Rigid bronchoscopy is accepted as a stan- Fever and tachypnea were resolved, but tachycardia was dard therapy for removal of OFTP. Because it allows persistent. Echocardiography disclosed severe eccentric for rapid detachment of the pseudomembrane from mitral regurgitation due to posterior leaflet chordae rup- the thrachea while safely maintaining a patent airway. ture. Valvuloplasty of mitral valve was performed and in- However, if OFTP seems to be life-threatening but rigid traoperative TTE showed no residual mitral regurgitation. bronchoscopy can’t be performed right away, trying to Conclusion: The present case shows that acute mitral remove OFTP with flexible bronchoscopy may be a good regurgitation should be considered as an etiology of alternative. unilateral atypical pulmonary consolidation, especially Obstructive fibrinous tracheal pseudomem- Keyword: in patients with non-resolving pneumonia with proper brane, Flexible bronchoscopy, Airway obstruction medication. Accurate diagnosis with echocardiography and early surgical intervention can be a resolution of a life-threatening condition of mitral regurgitation. Oral ICU General (3) 23 Acute Mitral Regurgitation as an unexpected cause of atypical unilateral pulmonary consolidation Jung Hee KIM1,2, Jong Hyun BAEK1,2,3 1Thoracic & Cardiovascular Surgery, Yeungnam University medical center, Korea; 2Thoracic & Cardiovascular Surgery, The Korean Society of Critical Care Medicine, Korea; 3Thoracic & Cardiovascular Surgery, The Korean Society of Acute Care Surgery, Korea

Case: Introduction: Most cases of unilateral pulmonary consolidation are associated with various pulmonary causes including, pulmonary tuberculosis, bronchiecta- sis, necrotizing pneumonia, aspergilloma, and pulmo- nary malignancy. However, unilateral pulmonary infil- tration is also attributable to cardiac causes. Acute mitral regurgitation should be suspected as an etiology of atyp- ical unilateral pulmonary consolidation unresponsive

252 KSCCM·ACCC 2020 Oral Presentation

Figure 1. KSCCM-chest PA discharged without any complications.

Conclusions: TEE was very useful for diagnosing a foreign body in the posterior part of the heart. TEE performed during the perioperative period should be performed beyond the level of re-confirming the findings of TEE per- formed prior to surgery.

Figure 1. Indwelling cath

Figure 2. KSCCM-chest CT

Keyword: Acute mitral regurgitation, Unilateral pulmonary consolidation, Diffuse alveolar hemorrhage Oral Presentation

Oral ICU General (3) 24 Incidental detection of a retained left atrial catheter via intraoperative transesophageal echocardiography in a patient undergoing tricuspid valve replacement: A case report Figure 2. TEE. Wan JU1, Joungmin KIM2 1Department of Anesthesiology and Pain Medicine, Chonnam University Keyword: Transesophageal echocardiography, Left atrial Hospital, Korea; 2Department of Anesthesiology and Pain Medicine, Chonnam catheter, Cardiac foreign body National University Medical School, Korea

Case: Introduction: A cardiac foreign body can cause Oral ICU General (3) 25 thrombosisWITHDRAWAL or infection, but sometimes it may not cause any symptoms in a patient. High flow nasal cannula application during Case Presentation: A 75-year-old female patient with intubation with a laryngomalacia infant patient: severe tricuspid regurgitation underwent tricuspid valve Case report replacement(TVR) under general anesthesia. She had a Ji-Yoon KIM, Mi Ae JEONG history of mitral valve replacement (MVR) and tricuspid Anesthesiology and Pain Medicine, Hanyang University Medical Center, Korea annuloplasty surgery 20 years ago. A hyper-echoic float- ing intracardiac foreign body considered to be a left atrial Case: Introduction: High flow nasal cannula (HFNC) use catheter used previous MVR surgery was observed in the has become increasingly popular when intubation or to left atrium during TEE examination. It was not mentioned help after extubation to prevent hypoxemia in ICU and in the preoperative imaging studies. After removing the during anesthesia practice. Here we have successfully used foreign body, the planned TVR operation proceeded and HFNC during intubation in a laryngomalacia infant patient.

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Case report: Two-month-old, male infant was scheduled Conclusion: We concluded that HFNC is potentially useful for general anesthesia to operate inguinal hernia and un- and efficient for preventing desaturation during difficult descended testis. The infant patient had subcostal retrac- intubation in a laryngomalacia infant patient. tion and frequent desaturation events and was diagnosed Keyword: High flow nasal cannula laryngomalacia. The patient was preoxygenated by deliver- ing oxygen (2 L/kg/min) via HFNC for 3 minutes and after sedation, intubation was succeeded after 20 minutes and Oral ICU General (4) 26 during intubation trial oxygen saturation levels did not de- A Case of Pulmonary Tumor Thrombotic creased below 98%. Microangiopathy Treated with High Dose Steroid and Heparization Jae Young CHOI1, Dong Hyun LEE1, Jin-Heon JEONG1, Kyung hee LIM2, Jae Hwang CHA3 1Department of Intensive Care Medicine, Dong-A University College of Medi- cine, Korea; 2Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Korea; 3Division of Gastroenterology,Depart- ment of Internal Medicine, Dong-A University College of Medicine, Korea

Case: IntroductionPulmonary tumor thrombotic mi- croangiopathy (PTTM) causing fatal pulmonary hyper- tension is a rare presentation of malignancy. There is no definite treatment even though it is properly diagnosed. Here, we describe a patient with PTTM from gastric can- cer treated with high dose steroid and heparization Case Presentation: A 45-year-old previously healthy woman visited ER with dyspnea . Her initial vital signs were unstable and bedside echocardiogram showed a RV pressure overload (PASP was 62 mmHg) . Chest CT Figure 1. 1113 F5 showed no evidence of PTE. Abdomen CT showed dif- fuse gastric wall thickening with enhancing masses. we clinically diagnosed the patient as PTTM. Heparization with intravenous steroid was prescribed and hemody- namic support using ECMO was initiated. Hemodynamic parameters became stable and ECMO was finally weaned on the 4th day after initiation (Figure 1). On the next day of ECMO weaned, gastric lesion revealed AGC (Figure 2). Conclusion: Here, we present a case of PTTM as an ini- tial symptom of AGC, which required ECMO support and showed transient response to high dose steroid and hep- arin suggesting the efficacy in the acute phase of PTTM. Keyword: PTTM, Pulmonary hypertension, Gastric can- cer

Figure 2. Intubation

254 KSCCM·ACCC 2020 Oral Presentation

cer patients [1]. This study assessed the prognosis of ICU admitted cancer patients. Methods: Total 303 patients who had been stayed in ICU of Chonnam National University, Hwasun Hospital from January to April 2019 were detected. After excluding cases of scheduled surgery (95) and non-malignancy (49), we re- viewed 159 cases retrospectively. And We calculated SAPS III scores with respective estimated mortality rates and as- sessed predictability of ICU mortality. Results: 159 patients (67.3% males) were recruited with a

Figure 1. KJB flow mean age of 66.3 years and overall ICU mortality rate was 58.49% (93 out of 159 patients). The mean SAPS III scores of survivals and non-survivals were 70.9±12.6 and 78.7±13.8 points, respectively. The mean length of ICU stay was 7.86±10.2 days. Logistic regression showed that the essen- tial factors associated with increased ICU mortality were longer ICU stay, longer mechanical ventilation, use of va- soactive drugs, high ECOG performance score before ICU admission, low PaO2/FiO2 ratio and high SPAS III score. Oral Presentation Conclusions: Our study suggests that SAPS III score also can be used for assessment ICU mortality in cancer pa- tients.

Figure 2. KJB cancer Table 1. Univariate analysis of ICU mortality

Oral ICU General (4) 27 Prognosis of oncological patients in intensive care unit Min-Seok KIM, Bo-Gun KHO, Cheol-Kyu PARK, In-Jae OH, Young- Chul KIM Department of Internal Medicine, Chonnam National University Medical School, Korea

Introduction: Recently, ICU admission of cancer patients has been an extremely controversial issue, because of con- cerns about use of limited resources and lack of critical care beds. So, selecting patients likely to benefit from ICU admission have been emphasized. But, in cancer patients, assessment of the critical illness and risk stratification is more difficult, especially in predicting the outcome. There are three models (APACHE II, SAPS III and SOFA) which Keyword: ICU mortality, Cancer patients, SAPS III score had been used as predictors of mortality in critically ill can-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 255 Oral Presentation

Oral ICU General (4) 28 Table 1. Demographic data of nursing home residents who admitted to medical intensive care unit Clinical characteristics of nursing home/hospital residents who admit to medical intensive care unit Sua KIM1,2, Beong Ki KIM3, Yu Jin KIM3, Je Hyeong KIM1,3 1Critical care medicine, Korea University College of Medicine, Ansan Hospital, Korea; 2Cardiology, Korea University College of Medicine, Ansan hospital, Ko- rea; 3Pulmonology, Korea University College of Medicine, Ansan hospital, Korea

Introduction: Nursing home/hospital residents (NHR) are frequently suffering from multi-morbidity, function- al and cognitive impairments, often leading to hospital admissions with severe conditions. We investigated the epidemiology and the clinical outcome of NHRs who ad- mitted to medical intensive care unit (ICU). Methods: NHRs who consecutively admitted medical ICU of Korea University Ansan hospital via Emergency department from July 2018 to December 2019 were retro- spectively evaluated using their medical records. Results: There were 167 NHRs (12.1%) among 1450 Oral ICU General (4) 29 medical ICU patients during the study period. They were 74.9±11.4 years, 85 (50.9%) patients were women, Left ventricular decompression during veno- and 104 (61.9%) patients had stroke or dementia as the arterial extracorporeal membrane oxygenation comorbidity. Infection was the most common cause of Ho Jin YONG1, Kyung Joon KIM1, Doh Hyung KIM2, Tae Soo KANG3, admission (n = 114, 68.2%); pneumonia (n = 50, 30%) and Dong Min KIM3, Sung Wook CHANG4 urinary tract infection (n = 49, 29.8%) were the common 1Internal Medicine, Dankook University Hospital, Korea; 2Internal Medicine, Di- vision of Pulmonary Medicine and Allergy, Dankook University Hospital, Korea; causes, and 92 (55.1%) of them were diagnosed with 3Internal Medicine, Division of Cardiology, Dankook University Hospital, Korea; sepsis. The length of ICU stay was 6 (interquartile range 4Thoracic and Cardiovascular Surgery, Dankook University Hospital, Korea [IQR] 3-11) day and length of hospital stay was 15 (IQR, Case: IntroductionLeft ventricular (LV) distention during 8.5-24.5) day. In-hospital mortality was 40 (23.8%), and of veno-arterial extracorporeal membrane oxygenation was related with pneumonia as the cause of admission (VA-ECMO) is a critical problem causing serious complica- (Odds ratio [OR] 2.93, 95% confidence interval [CI] 1.23- tions such as myocardial ischemia, pulmonary edema, and 7.02, p=0.016) and malignancy as the comorbidity (OR intracardiac thrombosis. 6.85, 95% CI 2.29-20.46, p=0.001). At discharge, 50 (39.0%) Case 1: VA-ECMO was applied to a 55-year old male pa- patients showed Glasgow Coma Scale less <12, 28 (21.9%) tient with acute heart failure. Visible arterial pulsation and patients had tracheostomy tube and 17 (13.3%) patients aortic valve movement was not observed by transthoracic were under hemodialysis. echocardiogram 2 hours later. Left atrial venting by septos- Conclusions: In NHRs who admitted medical ICU, sepsis tomy was performed (Figure 1). due to pneumonia and urinary tract infection was the Case 2: VA-ECMO was applied to a 59-year old male pa- common cause of admission. Their mortality was high tient with cardiogenic shock by acute myocardial infarction and the condition at discharge was poor. The measures after percutaneous coronary intervention. Retrograde tran- for reducing preventable infection and the proper guide saortic LV venting was performed to prevent LV distension for preemptive end of life care in NHR maybe required. (Figure 2). Keyword: Nursing home/hospital, Epidemiology Conclusion: LV distension is a serious complication during VA-ECMO, which needs immediate intervention for LV venting. Physicians using VA-ECMO should recognize it

256 KSCCM·ACCC 2020 Oral Presentation earlier and choose an appropriate method for LV decom- Oral ICU General (4) 30 pression to improved outcome. Development of Sepsis sub-classification for risk prediction and personalized treatment Jung Hwa LEE1,7, Doyeop KIM2, Seung-Won LEE3, Chi oh SONG4, Ka- Kyung KIM5, Jeongwon HEO6, Seung Min PACK1, Young Joo LEE1 1Critical care medicine, Ewha Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea; 2Biomedical Informatics, Ajou University School of Medicine, Korea; 3Data Science, College of Software Convergence, Sejong University, Seoul, Korea; 4Computer Engineering, Linewalks Inc., Korea; 5Clinical Diagnostic, Macrogen Inc, Korea; 6Internal Medicine, Kangwon Na- tional University Hospital, Kangwon National University School of Medicine, Korea; 7Neurology, Ewha Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea

Introduction: Sepsis is a major life threatening condi- tion, affecting millions of people around the world each year, killing one in four (and often more), and increasing in incidence. Although sepsis can develop and evolve in heterogenous conditions and patterns, current definition of sepsis does not differentiate their sub-phenotypes for optimal treatment. Because of various host factors and Figure 1 diverse etiologies, considering all possible features to cat- egorize the sepsis patients is challenging for physician. Oral Presentation This study aim to develop new classification for sepsis by using large cohort data and machine learning algorithms. We also investigated their differences of outcomes in- cluding hospital mortality, long term outcomes and re- sponse to the treatments among the sub-phenotypes. Methods: We used 3rd edition of the Medical Informa- tion Mart for Intensive Care III (MIMIC-III) data set. To collect sepsis patients who met sepsis-3 criteria, defini- tion of suspected infection as the acquisition of a body fluid culture temporally contiguous to administration of antibiotics and was used. We used K-means classification analysis to identify distinct patient sub-phenotypes Results: We found the optimal fit with the 4 sub-phe- notypes of α, β, γ, and δ using consensus k means. Figure 2 There were 1878 in theα phenotype, 3302 in the β, 1451 in the γ and 1836 in the δ. The α phenotype was the Keyword: ECMO, Venting, LV decompression youngest and showed normal lactate level compared with other phenotype. Theβ phenotype was the oldest and had more cancer history. Theγ phenotype had high level of glucose, more metabolic acidosis, and kidney disease. Finally, the γ phenotype showed multiple organ failure and instability in hemodynamics. 28-day mortali- ty was lowest for the α phenotype and highest for the δ

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 257 Oral Presentation phenotype. (α: 29.1%, β: 31.6%, γ: 44.0%, δ: 51.7%) cin was added. However, symptoms went worse, and she (p<.001) succumbed due to uncontrolled intraabdominal infection Conclusions: In this large-scaled clustering analysis of including BK virus associated fulminant colitis. patients with sepsis, new four sub-phenotypes of sepsis were identified. They showed different clinical character- istics , outcomes and responses to treatments. Keyword: Sepsis, Response to fluid , ub-PhenotypeS

Oral ICU General (4) 31 A case of BK virus associated fulminant colitis after allogenic hematopoietic stem cell Figure 1. transplantation in patient with mixed phenotype acute leukemia Byung-Hyun LEE, Ka-Won KANG, Yong PARK, Byung Soo KIM Internal medicine, Korea University College of Medicine, Korea

Case: Introduction: BK virus reactivation has been known to cause serious complications such as hemorrhagic cystitis and tubulointerstitial nephritis in patients undergoing allo- Figure 2. genic hematopoietic stem cell transplantation (allo-HSCT). However fulminant colitis is a rare complication associated Conclusion: Our report shows that BK virus reactivation with BK virus reactivation. We report a case of BK virus as- causes fulminant colitis in patients underwent allo-HSCT. sociated colitis after allo-HSCT. Keyword: BK virus, Colitis, Stem cell transplantation Case presentation: A 21-year old woman underwent al- lo-HSCT from a recipient of matched unrelated donor. Re- duced intensity conditioning regimen was used to the pa- Oral ICU General (4) 32 tient. Acute graft-versus-host disease was developed at 27th Unusual case report for invasive pulmonary day after transplantation. Methylprednisolone 1 mg/kg/ aspergillosis to arise in patient on short-term day was started, and the dose of steroid was increased to 1.5 steroid treatment mg/kg/day. On day 38, sigmoidoscopy showed erythema- Seung Hoon KIM, Gyu Yeon KIM, Hyun Soo JOO, Jin Woo KIM tous mucosal lesions and ulcerations. Biopsy revealed crypt Internal medicine, The Catholic University of Korea Uijeongbu St. Mary’s Hos- apoptotic bodies with focal crypt loss and CMV immunos- pital, Korea tain-positive cells. Ganciclovir was started. On day 55, an Case: Background: Invasive pulmonary aspergillosis abdomen computed tomography (CT) showed marked (IPA) in immunocompetent host who had no traditional wall thickening of entire colon. Meropenem was started. risk factors is rare. Here, we present a case of IPA after a However, abdominal pain did not improve despite antibi- short period of steroid treatment. Case presentation: A otic treatment. On day 85, bloody diarrhea was developed, 70-year-old woman visited to the emergency department and follow-up CT scan showed diffuse wall thickening of with complaints of dyspnea, purulent sputum, and fever. internal colon and small bowel loop. Sigmoidoscopy re- Her medical history included diabetes mellitus, Parkin- vealed acute ulcer with dystrophic calcification and biopsy son’s disease. Her home medications included levodopa, showed positive for SV40 immunostain. BK virus DNA aspirin, and metformin. Vital signs in the emergency de- was detected in urine by real-time PCR (7.01 Log copies/ partment were temperature 37.1℃, blood pressure 58/49 mL). Hemorrhagic cystitis was not developed. Cidofovir mm Hg, heart rate 116/min, respiratory rate 30/min, was administrated at 5 mg/kg once a week, and levofloxa-

258 KSCCM·ACCC 2020 Oral Presentation and oxygen saturation 75% with nasal cannula flow of 5 L/min. She was intubated for respiratory failure. Chest computed tomography(CT) showed multifocal patchy consolidations and numerous bronchiolitis in both lungs (Fig. 1). Under the diagnosis of sepsis caused by bacterial pneumonia, we started broad spectrum antibiotics. But her chest radiograph has not improved and sputum mi- crobiology showed persistent multidrug-resistant gram negative bacteria. So we started intravenous hydrocor- Figure 2. tisone 5mg/kg/day from day 13 of admission with the objective of clinical improvement for severe pneumonia. After 5 days from steroid treatment, we newly noted multiple cavitary lesions in chest radiograph. So we per- formed bronchoscopy for fungal microbiology evalua- tion. In bronchoscopy, we found mucosa hyperemia, and cream-colored plaques throughout the trachea and right main bronchi (Fig. 2). Galactomannan (GM) testing for Figure 3. serum and bronchial washing specimen were all positive. Follow up chest CT scan showed newly formed necrotic cavities with surrounding ground glass opacification halo Oral ICU General (4) 33 in both upper lobes (Fig. 3). As the result, we stopped

Rhabdomyolysis during free flap surgery in the Oral Presentation systemic steroid after 7 days of injection. Considering her patient with severe peripheral vascular disease acute kidney injury state, we started itraconazole 200mg/ Jun-Young JO, In-Cheol CHOI day orally. However, the clinical course continues to de- Anesthesia and pain medicine, Asan Medical Center, Korea teriorate and she died from septic shock. Keyword: Invasive pulmonary aspergillosis, Steroids, Case: Introduction: We here report a case of rhabdomyoly- Lung sis with acute kidney injury after free flap reconstruction surgery. Case Presentation: A 69-year-old male with severe peripheral artery disease underwent partial glossectomy, partial pharyngectomy with MRND and free flap recon- struction using anterolateral thigh. During the surgery we monitored dorsalis pedis arterial blood pressure invasive- ly. Creatine kinase (CK) level at the day after surgery was 10608 IU/L, and serum creatinine was increased from 0.98 mg/dL to 1.49 mg/dL. Vigorous fluid resuscitation was per- formed and CK level was decreased over several days. He was discharged 3 weeks later without complication. Con- clusion: Early recognition of rhabdomyolysis is important in reducing morbidity and mortality. Abundant fluid sup- ply is essential for the treatment, but delicate management including close monitoring of flap site is important for that Figure 1. kind of case to improve the prognosis of free flap transplan- tation.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 259 Oral Presentation

calling only (non-screening group). The primary outcome was time to activation defined as the time from the first documented physiological derangement until the time at which the MET was activated. Results: In active screening group, 1,022 (19.4%) cases were activated by EMR-based screening system. Median time to activation was shorter in active screening group than non-screening group (48.5 min vs. 63.0 min, p<0.001). Although the total duration of management by MET was not different between the two groups, active screening Figure 1. group had lower ICU admission (39.7% vs. 50.5%, p<0.001). In addition, shorter length of hospital stay (24.0 days vs. Keyword: Rhabdomyolysis, Peripheral artery disease, Free 25.0 days, p<0.001) and lower hospital mortality (29.3% vs. flap surgery 34.1%, P0.001) were observed in active screening group. Conclusions: Automated MET activation through EMR- Oral RRT 01 based screening in addition to traditional calling system was associated with shortening of time to MET activation Efficacy of a medical emergency team activated and better clinical outcome. by an electronic medical record-based screening Keyword: Medical emergency team, Electronic medical system record, Rapid response system Ryoung-Eun KO1, Soo Jin NA1, Myeong Gyun KO2, Ahra KO2, Kyeongman JEON1,3 1Department of Critical Care Medicine, Samsung Medical Center, Sungkyunk- Oral RRT 02 wan University School of Medicine, Seoul, Korea; 2Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 3Division of Pulmonary and Critical Care Medicine, The effect of daytime rapid response system on Department of Medicine, Samsung Medical Center, Sungkyunkwan University return of spontaneous circulation in patient with School of Medicine, Seoul, Korea cardiac arrest in a tertiary university hospital 1,2 2, 2, 3 Introduction: Afferent limb failure is the most important Ji Young JANG , Jungwon LEE , Seulgi OH , Dae Ja UM , Hongjin SHIM2,4, Sung Oh HWANG5, Seok Jeong LEE2,6, Won-Yeon LEE2,6 and challenging step in medical emergency team (MET). 1Department of Surgery, National Health Insurance Service Ilsan Hospital, To improve early recognition of unexpected deterioration, 2 Korea; Rapid response team , Wonju Severance Christian Hospital , Korea; objective scores have been proposed but still required cli- 3Department of Anesthesiology , Yonsei University Wonju College of Medicine, Korea; 4Department of Surgery, Yonsei University Wonju College of Medicine, nician activation of the MET and thereby limited the auto- 5 Korea; Department of Emergency Medicine, Yonsei University Wonju College mated. Recently, we modified our afferent limb using elec- of Medicine, Korea; 6Department of Internal Medicine, Yonse University Wonju 7 tronic medical recording (EMR) as a screening tool linked College of Medicine, Korea; Division of Nursing, Wonju Severance Christian Hospital, Korea to automated MET activation. The objective of this study was to investigate the efficacy of EMR-based screening and Introduction: Recently, the lack of manpower in the hos- automated activation of MET. pital due to limited working hours to improve the training Methods: All consecutive patients aged ≥18 years who had environment of residents, and the intensive care unit (ICU) received MET intervention were prospectively registered and ward due to the overcrowding of the university hospi- between March 2013 and December 2019. Since August tal is worsening. Therefore, in order to identify the deteri- 2016, automatic activation of MET through EMR-based oration of ward patients early and take appropriated care, screening has been implemented in addition to traditional a rapid response system (RRS) has recently been operated clinician activations of MET. A total of 5,257 activations each hospital with government support. The purpose of during this period (active screening group) were compared this study was to evaluate the effect of daytime RRS on with a historical control of 4,502 activations by clinician return of spontaneous circulation (ROSC) in patients with

260 KSCCM·ACCC 2020 Oral Presentation cardiac arrest. the prevention of cardiopulmonary resuscitation (CPR). Methods: Between August and December 2019, Medical Despite the increased implementation of MET, few studies records about 81 CPR cases were analyzed retrospectively. have made an effort to investigate the proper quality index Age, sex, department of admission, duration, place, result for clinical outcomes resulting from MET activation. The of CPRs, and RRT activation were collected. objective of this study was to investigate the proper quality Results: The mean age was 70.6 years and male was 58%. metric for clinical outcomes of MET activation with MET Forty-four (54.3%) CPRs were performed within 15 min- maturation. utes. Thirty-three CPRs (40.7%) were conducted in ward Methods: All consecutive patients aged ≥18 years who had and 33 cases of cardiac arrest occurred at daytime. RRS been the recipients of MET intervention were prospectively team screened patient’s condition before CPR in 20 cases. collected between January 1st, 2010 and December 31st, Forty-two cases (51.9%) of CPRs were terminated with 2019. The number of in-hospital cardiac arrest (IHCA) ROSC. When ROSC and non-ROSC groups were compared, patients and discharged patients was also collected. The in- ROSC group had trended to have fewer elderly patients cidence rate and mortality were calculated as the number (age<70 years: 52.4% vs 71.8, p=0.072) and more common of patients per annum divided by the total number of dis- RRT activation than non-ROSC group (33.3% vs 15.4%, charge patients, represented as cases per 1,000 discharged p=0.061). There were significantly shorter CPR periods (< patients. 15minutes) in the ROSC group than those in the non-ROSC Results: The number of discharge patients increased from group (71.4% vs 35.9%, p=0.001). Logistic regression anal- 6,039 in 2010 to 8,399 in 2019 (P trend=0.001). However, the ysis showed that RRT activation (OR 4.076 95%CI 1.117- incidence of MET activation did not change from 16.06 in 14.114, p=0.027) and short CPR period (OR 5.178 95%CI 2010 to 15.48 in 2019 (P trend=0.421). Moreover, the inci- 1.869-14.343, p=0.002) were independent predictive factors dence of total CPR was unchanged from 0.77 in 2010 to 1.06 Oral Presentation for ROSC. in 2019 (P trend=0.929). According to preventability, the Conclusions: Daytime-RRT activation may affect ROSC in incidence of preventable CPR decreased from 0.19 in 2010 CPR patients. Therefore, large scaled and prospective stud- to 0.12 in 2019 (P trend=0.025). By contrast, the incidence ies about this topic are needed. of non-preventable CPR was unchanged from 0.41 in 2010 Keyword: Rapid response system, Cardiopulmonary resus- to 0.58 in 2019 (P trend=0.927). Hospital mortality was citation, Return of sponetaneous circulation significantly decreased from 9.20 in 2010 to 7.23 in 2019 (P trend=0.009). Conclusions: The incidence of preventable CPR and hospi- Oral RRT 03 tal mortality were found to be associated with MET matu- Changing trends of cardiopulmonary resuscitation ration. The incidence of preventable CPR is a better quality with mature medical emergency team in general metric of clinical outcomes than the incidence of total CPR. ward patients Keyword: Cardiopulmonary resuscitation, Medical emer- Hohyung JUNG1, Ryoung-Eun KO1, Myeong Gyun KO2, Ahra KOH2, gency team, Quality index Kyeongman JEON1,3 1Department of Critical Care Medicine, Samsung Medical Center, Sungkyunk- wan University School of Medicine, Seoul, Korea; 2Intensive Care Unit Nursing Oral RRT 04 Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; 3Division of Pulmonary and Critical Care Medicine, Limited effect of the group III rapid response Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea team on monitoring and treatment in deteriorating ward patients Introduction: Clinically significant deterioration of pa- Tae Sun HA1, HYESEON YUN3, Seok Jae LEE1, AERIN BAEK2, JIHYE OH3 tients admitted to general wards is a complication of hospi- 1Surgery, Soonchunhyang University Bucheon Hospital, Bucheon, Gyeong- tal care which is recognized. In order to reduce the number gi-Do, Republic of Korea, Korea; 2Medicine, division of Pulmonary, Soonchun- hyang University Bucheon Hospital, Bucheon, Gyeonggi-Do, Republic of Korea, of avoidable adverse events occurring, a medical emergen- 3 Korea; Rapid Response Team Nursing, Soonchunhyang University Bucheon cy team (MET) have been proposed and substantiated for Hospital, Bucheon, Gyeonggi-Do, Republic of Korea, Korea

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 261 Oral Presentation

Introduction: The purpose of the study was to exam the Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea effect of a rapid response team (RRT) implementation of the group III on monitoring and treatment in deteriorating Introduction: The objective of this study is to investigate ward patients with limited medical resources. the risk factors for early medical emergency team (MET) Methods: We retrospectively reviewed the data of deteri- reactivation, which is defined as repeated MET calls within orating adult patients who were contacted to the RRT of 72 hours after the index MET call in the patients remaining Soonchunhyang University Bucheon Hospital. Our RRT on the ward after index MET activation. as goup III only works during daytime hours (8 AM to 5 Methods: This study is a retrospective analysis of prospec- PM) on weekdays. This study was performed during two tively collected data. All consecutive patients over 18 years 5-month periods before and after the implementation of of age who received MET intervention in a university-affili- RRT. ated, tertiary referral hospital were included. Results: There were 61.5 RRT activations per 1,000 ad- Results: Of the 3,989 cases eligible for analysis, 514 cases missions and activations per day during daytime hours (12.9%) were classified into the reactivation group, with the were identified as 29.2% of total RRT activations. Actually, remainder assigned to the nonreactivation group. When RRT activations were most frequently occurred between compared with index calls, respiratory problems increased 6 AM and 8 AM (13.5%), followed by between 2 PM and but circulatory problems decreased with repeated calls. 4 PM (11.4%) and between 9 PM and 11 PM (11.0%). The Among the reactivation group, 249 (48.5%) patients were implementation of RRT as group II (6 AM to 10 PM) will transferred to the intensive care unit (ICU) after repeated cover 76.4% activations of total RRT activations. The rates of calls. MET activation during nighttime (adjusted OR 1.24, cardiac arrests and potentially preventable cardiac arrests 95% CI 1.01–1.53), activation due to bedside concern about during day time hours after RRT implementation were de- overall deterioration without abnormal physiological vari- creased from 0.98 to 0.21 per 1,000 admissions, but the dif- ables (adjusted OR 1.31, 95% CI 1.01–1.70), and the pres- ferences did not reach statistically significance. For patients ence of tachypnea at the time of MET deactivation (adjusted who required admission to the ICU, there was a significant OR 1.28, 95% CI 1.00–1.64) were all associated with MET reduction in ICU mortality from 57.1% to 33.3% (p=0.049). reactivation. In addition, tachypnea at the time of MET Conclusions: The implementation of RRT showed a trend deactivation remained a risk factor for MET reactivation re- to decrease of cardiac arrest for ward patients, and was ef- quiring ICU admission (adjusted OR 1.65, 95% CI 1.11–2.45). fective in reducing ICU mortality for patients who needed Conclusions: An increased risk of early MET reactivation ICU admissions. However, RRT implementation as group was associated with MET activation during nighttime, by III had a limited effect on monitoring and treatment in de- bedside concern about overall deterioration, and with the teriorating ward patients that occurred per day. Therefore, presence of tachypnea at the time of MET deactivation. at least RRT implementation as group II should be per- Keyword: Hospital rapid response team, Hospital emer- formed to achieve maximum effectiveness, which requires gency service, Intensive care unit the active and financial support of the government. Keyword: Rapid response team, ICU mortality, Deterioration Oral RRT 06

Oral RRT 05 The Intensity of Rapid Response Team Operation and General Ward Cardiopulmonary Resuscitation Risk Factors for Early Medical Emergency Team Incidence Reactivation in Hospitalized Patients Dong Hyun LEE, So Hye KIM, Jin-Heon JEONG 1 2 2 3 Yeonseok CHOI , Soo Jin NA , Ryoung-Eun KO , Myeong Gyun KO , Intensive Care Medicine, Dong-A University Hospital, Dong-A University, Col- Ahra KOH3, Chi Ryang CHUNG2, Gee Young SUH1,2, Kyeongman JEON1,2 lege of Medicine, Busan, Korea 1Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Introduction: Although early rapid response team (RRT) Seoul, Korea; 2Department of Critical Care Medicine, Samsung Medical Center, was reported as full-time operating team, similar efficacy Sungkyunkwan University School of Medicine, Seoul, Korea; 3Intensive Care

262 KSCCM·ACCC 2020 Oral Presentation of part-time RRT has been reported. Authors sought to in- 6Critical Care Center, Seoul National University Hospital, Korea; 7Department of Neurology, Seoul National University Hospital, Korea vestigate the intensity of RRT and incidence of in-hospital cardiopulmonary resuscitation (CPR) Introduction: Rapid response system (RRS) is becoming Methods: The RRT of Dong-A University Hospital started an essential part of patient safety concerning the early rec- in April 2017 as a part-time RRS operating 8 hours on week- ognition and management of deteriorating patients in gen- days. In March 2018, RRT operation time was extended to eral wards. In August 2015, this hospital launched an RRS 15 hours on weekdays and finally, extended to 24 hours a for 21 surgical wards initially. Six medical wards have been day, 7 days a week on February 2019. We retrospectively gradually added since June 2017, and finally, we expand- reviewed the incidence of in-hospital cardiopulmonary ed RRS to cover 6 additional medical wards in July 2019. resuscitation (CPR) according to stepwise extension of RRT This study aims to determine the effects of expanding the operation. coverage of a rapid response system (RRS) on code rates in Results: For the study period (36 months before and 33 medical wards. months after RRT implementation), 113,394 patients ad- Methods: This retrospective study included adult patients mitted and 127 cases of CPR occurred. For the 36 months admitted to 12 medical wards in Seoul National University before RRT implementation, the next initial RRT period (11 Hospital from January 2015 to December 2019. We com- months), the second RRT period (11 months), and the third pared the code rates during 3 periods: from January 2015 RRT period (11 months), CPR per 1000 admission was 1.27, to May 2017 (29 months, pre-RRS period), from June 2017 1.08, 0.90 and 0.86 (p=0.381). In logistic regression analysis, to June 2019 (25 months, post-RRS1 period) and from July Age, Hospital length of stay, Charlson-comorbidity score, 2019 to December 2019 (6 months, post-RRS2 period). SPSS and incremental intensity was independently associated software Version 25.0 for Windows (SPSS Inc., Chicago, IL, with CPR development (Table 1) USA) was used for statistical analyses. Oral Presentation Results: The total number of patients who were admitted in 12 medical wards during pre-RRS, post-RRS1 and post RRS2 period were 55,517, 50,215, and 12,462 respectively. Our RRS works on weekdays, initially from 7 a.m. to 7 p.m. but shifting to 7 a.m. to 11 p.m. starting in May 2019. The code rates decreased from 3.57 to 2.33 per 1,000 admissions between pre-RRS and post-RRS1 period, and 2.33 to 1.36 Conclusions: The incremental intensity is associated with per 1,000 admissions between post-RRS1 and post-RRS2 decremental tendency of in-hospital CPR. period. This reduction of code rates was statistically signifi- Keyword: Rapid response team, Cardiopulmonary resusci- cant (p<0.01). tation Conclusions: Expanding an RRS coverage was associated with significant reductions of code rates in medical wards. Oral RRT 07 Keyword: Rapid response system, Cardiopulmonary resus- citation, Medical wards Effects of expanding the coverage of a rapid response system on code rates in medical wards Sulhee KIM1, Seongkyeong LEE1, Jina KIM1, Hwajung LEE1, Soyoung Oral RRT 08 PARK1, Sang-Min LEE2, Jinwoo LEE2, Jaeyoung CHO2, Hong Yeul LEE2, Hyun Joo LEE3, Hannah LEE4, Ho Geol RYU4, Seung-Young OH5,6, Eun The attitude and barriers to implementation of Jin HA6, Sang-Bae KO7 rapid response system 1Rapid Response Team, Seoul National University Hospital, Korea; 2Division Choon geun LEE, Jaeyoung CHO, Nakwon KWAK, Sun Mi CHOI, Jinwoo of Pulmonary and Critical Care Medicine, Department of Internal Medicine, LEE, Young Sik PARK, Chang-Hoon LEE, Chul-Gyu YOO, Young Whan Seoul National University Hospital, Korea; 3Department of Thoracic and Car- 4 KIM, Sang-Min LEE diovascular Surgery, Seoul National University Hospital, Korea; Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Korea; Division of Pulmonary and Critical Care Medicine, Seoul National University 5Department of General Surgery, Seoul National University Hospital, Korea; College of Medicine, Seoul national university hospital, Korea

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 263 Oral Presentation

Introduction: Rapid response system (RRS) have been been used as a treatment for childhood leukemia or high implemented in many hospitals for the patient safety with grade solid tumor. However, many pediatric patients who regard to the early recognition and management of deterio- received BMT tend to have high morbidity and mortality. rating patients in general wards, and their effectiveness has This study aimed to identify the risk factor for pediatric been proven in several previous studies. However, cultural intensive care unit (PICU) mortality in critical ill pediatric reasons or the burden of criticism can be often a barrier to patients with BMT. the implementation and activation of RRS. In August 2015, Methods: We retrospectively reviewed the medical records our hospital launched an RRS. So this study was conducted of patients who received BMT and admitted to PICU of to evaluate the perception of RRS and the barriers felt by tertiary care children’s hospital between Jan 2010 and Dec nurses and doctors. 2019. Multivariate logistic regression analysis was used to Methods: We conducted personal interview with question- identify the relationship between mortality and variables. naire surveys for medical staff working at the wards who Results: A total of 131 patients were included. There were can activate RRS at Seoul National University Hospital from 63(48.1%) boys and 68(51.9%) girls. Median age [interquar- august to december in 2015. This questionnaire is composed tile range] was 11 years [0-20 years]. The most common of total 17 items with Likert scale. The target population for BMT type was haploidentical (38.9%) and respiratory com- the survey consisted of ward nurses and medical doctors. plication (44.3%) was the most common reason for ICU Results: A total of 278 medical staff (nurse (n=239), doctor admission. Overall PICU mortality was 32.1% (42/131). In (n=39)) were surveyed. About a half of the nurses who re- comparison between survivors and non-survivors, pediat- sponded to this survey had more than five years of service ric risk of mortality-III(PRISM-III), B-type natriuretic pep- experience. 77.3% of the respondents thought that RRS tide (BNP), use of mechanical ventilator(MV) or inotropics was helpful for the management of patients, and 80.2% and patients with septic shock or CMV infection were sig- responded that RRT gave an opportunity to improve the nificantly differences in the whole cohort. In multivariate skill in managing unstable patients. However, 80.2% of the logistic regression, PRISM-III, use of MV, CMV infection respondents preferred calling the covering resident before and septic shock were independent risk factors of PICU activating RRS when the patients was sick. In addition, mortality. (p<0.05 for all variables) 43.0% of the respondents were reluctant to activate RRS be- Conclusions: In our study, critically ill pediatric patients cause they were afraid to be criticized. with BMT tend to have high mortality which was signifi- Conclusions: Many medical staff believed that RRS was cantly associated with PRISM-III score system, use of MV, helpful for patients’ medical care and improved their ability septic shock and CMV infection. for managing unstable patients. However, they still thought Keyword: Bone marrow transplantation, Pediatrics , Inten- that the covering resident had a priority in emergencies and sive care they were afraid of being criticized in case of RRS activation. Keyword: Rapid resoponse system, Medical emergency teams, Rapid response teams Oral PED 02 Outcomes of extracorporeal membrane Oral PED 01 oxygenation support in pediatric hemato- oncology patients Risk factors for mortality in critically ill pediatric Hong Yul AN, Yu Hyeon CHOI, You Sun KIM, June Dong PARK patients with bone marrow transplantation Department of Pediatrics, Seoul National University Hospital, Seoul National 1 3 2 2 Da Hyun KIM , Won Kyoung JHANG , Kyung-Nam KHO , Hyery KIM , University College of Medicine, Korea Ho Joon IM2, Seong Jong PARK3 1Pediatrics, Asan Medical Center, Korea; 2Division of Pediatric Hemato-On- Introduction: To review the outcomes of pediatric patients cology, Asan Medical Center, Korea; 3Division of Pediatric Critical Care, Asan with malignancies or who underwent hematopoietic stem Medical Center, Korea cell transplantation (HSCT) and received extracorporeal Introduction: Bone marrow transplantation (BMT) has membrane oxygenation (ECMO) support.

264 KSCCM·ACCC 2020 Oral Presentation

Methods: We retrospectively analyzed the records of he- collected their initial biochemical data including thiamine mato-oncology pediatric patients who received ECMO in and vitamin C levels at PICU admission between June 2019 the pediatric intensive care unit (PICU) at Seoul National and December 2019 in Severance Hospital. The scores of University Children’s Hospital between January 2012 and GCS and PIM3 were recorded at admission, and PRISM III December 2019. was calculated at 24 hours after admission to PICU. Results: Eighteen patients (12 boys and 6 girls) received Results: A total of 177 cases were admitted to PICU during ECMO during the 8-year period in the single pediatric in- the study period, 63 cases were enrolled in this study. Three stitute. Eight patients (44.4%) received veno-arterial (VA) cases of in-hospital mortality were observed (4.8%). The ECMO for septic shock (n=4), acute respiratory distress most common predisposing medical condition was neu- syndrome (ARDS) (n=2), stress-induced myopathy (n=1), rologic problem (63.5%) and the most common cause of and hepatopulmonary syndrome (n=1). Ten patients PICU admission was sepsis (38.1%). The median value of (55.6%) received veno-veno (VV) ECMO for ARDS due to thiamine as 3.6 ug/dL (IQR, 2.9-4.5 ug/dL), and vitamin C Pneumocystis pneumonia (n=1), air leak (n=3), influenza as 2.84 ug/mL (IQR, 1.61-4.55 ug/mL). Thiamine deficien- (n=1), hemorrhage (n=1), and unknown origin (n=4). All cy was noticed in 6 patients (9.5%), and 17 patients (27%) patients received chemotherapy; among them, 8 patients showed vitamin C deficiency. There were no differences received anthracycline drugs and 12 patients (66.7%) un- in vitamin levels according to reasons for PICU admission. derwent HSCT. Ten patients (55.6%) were diagnosed with Vitamin C levels were affected by nutritional status. And malignancies, and 8 patients (44.4%) were diagnosed with serum lactate and CRP levels were increased in a vitamin non-malignant disease. Five of 18 patients (27.8%) survived C-deficient group (p=0.033 and p=0.007). In patients with ECMO in the PICU, and 4 patients (22.2%) survived to hos- vitamin C deficiency, duration of mechanical ventilation pital discharge. Three of 4 patients (75%) who underwent and length of stays in PICU were longer than non-deficient Oral Presentation ECMO for septic shock survived, and 5 of 8 patients (62.5%) patients (p=0.032 and p=0.004, retrospectively). There were who underwent VA ECMO survived. However, all patients no significant differences in mortality and other predictive who underwent VA ECMO for ARDS and VV ECMO died. scores according to vitamin C levels. Conclusions: ECMO is a feasible treatment option for re- Conclusions: Vitamin C deficiency was associated with spiratory or heart failure among pediatric patients receiv- elevated levels of inflammatory markers and increased ing chemotherapy or undergoing HSCT. However, patients lengths of mechanical ventilation and PICU admission. with ARDS still have a long way to go in terms of receiving Our results can support the potential benefit of vitamin C ECMO. administration in critically ill children. Keyword: Pediatric, Hemato-Oncology, ECMO Keyword: Vitamin C, Pediatric , Critical care

Oral PED 03 Oral PED 04 Low concentration of Vitamin C and prognosis in P50 implies adverse clinical outcomes in critically ill children Pediatric Acute Respiratory Distress Syndrome by Min Jung KIM, Soo Yeon KIM, Ga Eun KIM, Jae Hwa JUNG , Yoon Hee reflecting extrapulmonary organ dysfunction KIM, Myung Hyun SOHN, Kyung Won KIM Jae Hwa JUNG, Yura KIM, Ga Eun KIM, Soo Yeon KIM, Min Jung KIM, Department of Pediatrics, Yonsei University College of Medicine, Korea Yoon Hee KIM, Kyung Won KIM, Myung Hyun SOHN Introduction: Intravenous administration of high-dose Department of Pediatrics, Severance Children’s Hospital, Yonsei University College of Medicine, Korea vitamins has been focused in critically ill patients, as an adjunctive therapy for life-threatening conditions. We eval- Introduction: Hypoxemia and related multisystem organ uated the association of serum concentration of vitamins failure are significant contributors to the mortality of pedi- with patients’ prognosis. atric acute respiratory distress syndrome (PARDS). Hypox- Methods: We reviewed retrospectively PICU patients and emia leads to a change in the oxygen-hemoglobin dissoci-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 265 Oral Presentation ation curve and also the oxygen partial pressure at which treatment modality for respiratory distress in children, and hemoglobin is 50% oxygen saturated (P50) to preserve tis- it is known to provide sufficient oxygenation and reduce sue oxygenation. The purpose of the study was to evaluate the work of breathing. Our objective was to assess whether the P50 levels in PARDS and determine the associations of the SpO2/FiO2 (SF) ratio could predict HFNC outcomes in P50 with clinical outcomes in PARDS. children with respiratory distress. Methods: This single-center, retrospective study included Methods: The subjects of study are children who were 280 patients diagnosed as PARDS by the Pediatric Acute treated with HFNC due to respiratory distress from April Lung Injury Consensus Conference definition, who re- 2013 to March 2019 in Severance Children’s Hospital. quired invasive mechanical ventilation and had document- HFNC failure was defined as when the patient needed to ed arterial blood gas results at the time of diagnosis. Thir- be treated with mechanical ventilation due to aggravation ty-six patients who admitted for post-operative vital status of respiratory distress. In contrast, HFNC success was de- monitoring or seizure control were designated as controls. fined as when the patient was improved with HFNC. We P50 levels were calculated from the arterial blood gas analyzed the SF ratio during HFNC treatment compare to results at the time of PARDS diagnosis, and the Pediatric the PaO2/Fi logistic organ dysfunction-2 score was used for assessing organ dysfunction. Results: P50 was significantly elevated in PARDS patients than in controls [26.6 (24.3 – 29.5) vs. 22.8 (18.6 – 27.1), p<0.001], and was significantly higher in patients with se- vere PARDS than in those with mild PARDS [28.6 (26.1 – 31.3) vs. 25.5 (23.2 – 28.0), p<0.001]. The risk of pulmonary and extrapulmonary organ dysfunction was significantly increased by P50 [adjusted OR (95% C.I.); 1.128 (1.055- 1.206), and 1.068 (1.013-1.127), respectively]. The same was true for the risk of mortality [adjusted HR (95% C.I.); 1.043 (1.012-1.075)]. In mediation analyses, 85.2% of the relation- ship between mortality and P50 was mediated by extrapul- monary organ dysfunction. Conclusions: P50, which may reflect the degree of hypox- emia in PARDS, can also serve as an indicator of extrapul- Results: We included a total of 142 patients with arteri- monary organ dysfunction. High P50 at the time of PARDS al blood gas analysis (ABGA) results in the exploratory diagnosis may imply unfavorable clinical outcomes by cohort. The following regression equation described reflecting extrapulmonary organ dysfunction. the relationship between the SF and PF ratio: SF Keyword: Pediatrics, ARDS, P50 =129.2562+0.3874xPF (p<0.001), r=0.690 (95% CI, 0.594- 0.7663, p<0.001). The initial SF ratio in the failure group (median [interquartile range], 202.5[148.3-263.6]) was Oral PED 05 significantly lower than that in the success group (243.75 [175.8-243.7], p<0.001). The area under the curve (AUC) Clinical usefulness of SpO2/FiO2 ratio in children of the initial SF ratio was 0.752 (95% CI; 0.672-0.832, with high-flow nasal cannula p<0.001), and the best cutoff point was 230. The initial Ga Eun KIM, Jae Hwa JUNG, Soo Yeon KIM, Min Jung KIM, Yoon Hee SF ratio under 230 was an independent predictor for KIM, Kyung won KIM, Myung Hyun SOHN the treatment with mechanical ventilation (OR 7.4, 95% Department of Pediatrics, Severance Children’s Hospital, Yonsei University CI, 3.5-16.00, p=0.001). In the validation group (N=130), College of Medicine, Seoul, Korea children whose SF ratio continuously exceeded 230 were Introduction: High-flow nasal cannula (HFNC) is a useful 86.7%. In contrast, all the children whose SF ration con-

266 KSCCM·ACCC 2020 Oral Presentation tinued below 230 failed with HFNC treatment, and 65.4% monitoring is required because complications, such as of children whose SF ratio was below 230 at least once decannulation, within 1 week after surgery can result in failed with HFNC treatment. mortality. Conclusions: The SF ratio can be used as a noninvasive Keyword: Tracheostomy, Postoperative complication, predictor for HFNC outcomes in children with respirato- Pediatric intensive care unit ry distress, instead of the PF ratio. Keyword: High flow nasal cannula, SpO2/FiO2 Oral PED 07 The Experience of Education on non-specialist Oral PED 06 for the reliable identification and management Tracheostomy in Pediatric Intensive Care Unit: of pediatric sepsis Indication and Complications Da Eun ROH, Jung Eun KWON, Yeo Hyang KIM Jung Eun KWON1, Da Eun ROH1, Hyun Ho CHO2, Yeo Hyang KIM1 Department of Pediatrics, School of Medicine, Kyungpook National University, Division of Pediatric Cardiology, Kyungpook National University Children’s 1 Department of Pediatrics, School of Medicine, Kyungpook National University, hospital, Daegu, Korea Division of Pediatric Cardiology, Kyungpook National University Children’s 2 hospital, Daegu, Korea; Department of Otolaryngology-Head and Neck Sur- Introduction: Pediatric Intensive Care Unit (PICU) in- gery, School of Medicine, Kyungpook National University, Daegu, Korea tensivists in Kyungpook National University Children’s Introduction: We aimed to evaluate the characteristics Hospital have been training and educating doctors about of patients needed tracheostomy in PICU, indication for pediatric sepsis recognition and early response since tracheostomy, and complications after tracheostomy. 2018 based on Sepsis-3. The present study was conducted

Methods: Patients who underwent tracheostomy in to evaluate the doctor’s recognition for pediatric sepsis Oral Presentation Kyungpook National University Children’s Hospital from and adequacy of initial treatment. February 2017 to December 2019 were selected. We ret- Methods: Sepsis was recognized in patients with Sequen- rospectively reviewed medical records of age, underlying tial Organ Failure Assessment (SOFA) score of 2 points disease, tracheostomy indications, duration of ventilator or more. Even if the SOFA score was less than 2 points, use and postoperative complications. patients with hypothermia or hyperthermia, inappropri- Results: Thirty-seven patients (M/F 18/19) needed tra- ate tachycardia, altered mental state, reduced peripheral cheostomy. Mean age was 6.0±6.4 years and mean body perfusion were recognized as sepsis. We retrospectively weight was 13.1±9.8kg. The duration from intubation to reviewed the medical records of patients (the time to tracheostomy was 14.4 ± 14.4 days. Among them, 25 pa- recognizing sepsis and antibiotics, volume of bolus fluid tients (25/37, 68%) had neurologic impairment and 5 pa- given in the first 2 hour, and use of respiratory support tients (25/37, 14%) had craniofacial anomaly. Twenty-six and vasoactive agents) admitted to PICU with sepsis from patients (26/37, 70%) had tracheostomy due to prolonged January 01, 2019 to December 31, 2019. intubation, and 8 patients (8/37, 22%) were performed Results: A total of 66 patients (35 male, mean age due to upper airway obstruction. Six patients underwent 2.48±4.16 year) were included in the analysis. Twenty additional guiding suture during surgery, and 3 of them nine patients (44%) had underlying co-morbidity. PICU underwent penetration suture. Postoperative complica- admission source was emergency department (56/66, tions occurred in 21 patients (21/37, 57%). Among them, 68%), inpatient floor (12/66, 18%), and transfer from oth- 8 cases (8/21, 38%) were related to delayed wound heal- er hospitals (9/66, 14%). The initial and the peak SOFA ing. There were 5 cases (5/21, 24%) that required cannula score during hospitalization were 3.27±3.04 and 5.33±4.94 reinsertion due to decannulation within 1 week after sur- points, respectively. Respiratory score was the highest gery. Among of 5 cases, three cases occurred before 2018 among SOFA score variables. Fifty-six patients (84%) and one case died due to cannula malposition. received intravenous fluid bolus of 21±13cc per body Conclusions: Most of complications related with tra- weight (kg) in the first 2 hour. The time to first dose of cheostomy occur within 1 week after surgery. Closed broad spectrum antibiotics was 3.81±6.87 hours. Before

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 267 Oral Presentation

PICU admission, inotropes treatment was started in 3 pa- sion is independently associated with unplanned ICU re- tients and respiratory support was applied in 18 patients. admission both within 48 hrs and 120 hrs among surgical Plasma lactic acid was checked for all patients and mean ICU patients. However, lactate level has relatively poor level was 2.87±1.81 mmol/L. Final survival rate was 91% predictive capability for unplanned ICU readmission, (60/66). and a new model is needed to predict unplanned ICU re- Conclusions: It is necessary to educate and training admission among surgical patients. doctors on the improvement and awareness of pediatric Keyword: Lactate, Hyperlactatemia, Intensive Care Units sepsis. Keyword: Pediatric sepsis

Oral Quality (1) 01 Lactate level and unplanned intensive care unit readmission in surgical patients: A retrospective cohort study Chami IM1, Tak-Kyu OH2 1Surgery, Seoul National University Bundang Hospital , Korea; 2Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital , Korea Figure 1. Introduction: This study aimed to investigate the asso- ciation between lactate level during intensive care unit (ICU) stay and unplanned ICU readmission rates within 48 hrs or 120 hrs in surgical patients. Methods: This single-center retrospective cohort study evaluated adult patients who were discharged from the ICU between January 2012 and December 2018. The association between lactate level (initial lactate at ICU admission, peak level during ICU stay, and last level be- fore ICU discharge) and unplanned ICU readmission was investigated using uni- and multivariable logistic regres- sion analysis. Figure 2. Results: The cohort comprised 3,707 patients. Among them, unplanned ICU readmission within 48 and 120 hrs occurred in 78 (2.1%) and 335 (3.9%) patients. In the multivariable model, 1 mg dl-1 increase in peak lactate level during ICU stay was associated with 1.1-fold in- crease of unplanned ICU readmission within 48 hrs (odds ratio: 1.10; 95% confidence interval: 1.02 to 1.2; p=0.016), whereas both initial and last lactate level during ICU stay were not significantly associated. A similar trend was ob- served for unplanned ICU readmission within 120 hrs. In receiver operating characteristic analysis, the area under Figure 3. the curve (AUC) of initial, last, and peak lactate level were 0.61, 0.53, and 0.63, respectively. Conclusions: The peak lactate level during ICU admis-

268 KSCCM·ACCC 2020 Oral Presentation

Oral Quality (1) 02 shorten the Tracheostomy decision time delay. Keyword: Shared decision making, Tracheostomy, pro- Novel Interactive Patient Centered Care- The longed intubated patient Introduce of Shared Decision Making Impact on Early Tracheostomy in Prolonged Intubated Critical Patient Oral Quality (1) 03 Shu-Hung KUO1, Ming-Sun CHUANG1, Che-Shang YANG1, Chun- Chuang LIN1, Chun-Ping YANG1, Hsi-Chen CHEN1, Mong-Chen WU1, Prognostic Value of Neutrophil Gelatinase- Whei-Ni CHEN1, Se-Chun CHUANG1, Shu-Ya CHUANG1, Hsin-Li Associated Lipocalin (NGAL) Ratio Measurement LIANG1, Wei-Chun HUANG1,2,3,4 to Predict Acute Kidney Injury in the Intensive 1Critical care medicine and cardiovascular center, Kaohsiung Veterans General Care Unit (ICU) Patients 2 Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taiwan; Adika Zhulhi ARJANA1, Ninda DEVITA2, Isni MEILASARI1 3Physical Therapy, Fooyin University, Taiwan; 4Graduate Institute of Clinical 1 Medicine, Kaohsiung Medical University, Taiwan Clinical Pathology and Laboratory Medicine, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada, Indonesia; 2Medical Doctor Introduction: Tracheostomy creation was poorly accept- Programme, Faculty of Medicine, Universitas Islam Indonesia, Indonesia ed, though with superiorly odds to pros, owing to cultural Introduction: Intensive Care Unit (ICU) patients have a mis-understanding, in Taiwan. By retrospective cohort data high susceptibility to the occurrence of acute kidney inju- analysis, we try to unvealed the impact of introducing SDM ry. This incident will have a direct impact on the patient’s on early Tracheostomy (less than 14 days) in prolonged in- morbidity and mortality. Examination of the possibility of tubated critical patients. the occurrence of acute kidney injury will have great ben- Methods: Medical record of tertiary medical center adult efits for the patient so that it can be prevented earlier by ICU admitted respiratory failure patient from Jan. 1st , 2016

better handling of hydration. This prediction opportunity Oral Presentation to Dec. 31th , 2017 was retrospectively reviewed, and fur- is demonstrated by neutrophil gelatinase-associated lipo- ther subdivided into pre-SDM and post-SDM intervention calin (NGAL). NGAL is an iron-transporting protein rapidly period for analysis. accumulating in the kidney tubules and urine after neph- Results: Pre-SDM early and late Tracehostomy rate were rotoxic and ischemic insults, has been put forward as an 42% and 58% individually, with ventilator weaning rate early, sensitive, non-invasive biomarker for acute kidney (43(79.6%) v.s 46 (62.2%), p: 0.034), ventilator days (35.3+/- injury. This study aims to determine the prognostic per- 18.1 v.s 47.2+/-16.1, p<0.001), in-hospital mortality(1(1.9%) formance of the NGAL ratio examination in predicting the v.s 6 (8.1%), p: 0.237), and length of hospital stay (59.7+/-35.1 incidence of acute kidney injury in patients treated at the v.s 69.2+/-24.6, p: 0.091) of prolonged intubated patient. ICU Post-SDM early and late Tracehostomy rate were 39% and Methods: This study is a cohort study involving ICU pa- 73% individually, with ventilator weaning rate (27(69.2%) v.s tients treated at Dr. Sardjito General Hospital with all 56 (76.7%), p: 0.389), ventilator days (34.6+/-17.6 v.s 47.5+/- diagnoses. Samples were taken of patients <24 hours of 28.4, p: 0.004), in-hospital mortality (4 (10.3%) v.s 6 (8.2%), ICU admission first time and then checked again on day 2 p: 0.737), and length of hospital stay (57.2+/-21.8 v.s 68.4+/- hospitalization. The occurrence of acute kidney injury uses 26.8, p: 0.028) of prolonged intubated patient. After SDM AKIN criteria and is enforced on the 3rd day after treatment was introduced, ventilator days and length of hospital stay at the ICU. Statistical analysis uses the ROC curve with the of prolonged intubated patient was found reduced 13 days help of Medcalc’s statistical program and 11 days individually in compared in between groups. Results: A total of 80 patients (55 male, 25 female) were The Tracheostomy decision making time delay was found 5 studied. NGAL levels at admission were significantly high- days less after SDM introduced. er among patients who subsequently developed AKI [43.8 Conclusions: This study revealed introducing shared de- (8.5-15000) ng/mL vs. 87.4 (0.3-15000) ng/mL, p=0.006] cision making on early Tracehostomy in prolonged intu- and these higher levels persisted over the following 2 days. bated critical patient might improve total Tracheostomy On the basis of receiver-operating characteristic analysis, rate, reduce ventilator days and length of hospital stay, and NGAL ratio measurements could predict AKI [area under

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 269 Oral Presentation the curve (95% confidence interval) 0.764 (0.655-0.852)] Results: Regarding to this study incidence of pressure ulcer with p=0.0457. A cut-off point >1.0322 for NGAL ratio had a were 28 cases of 53 pressure injury. We assessed by wound sensitivity of 0.86 and specificity of 0.71 in predicting AKI. stage 56.6% of overall first stage, 35.84% of second stage, 5.66% of third stage. Although 64.15% of overall pressure ulcer were spontaneous injury and then 35.85% of overall case were ICU acquired pressure ulcer. Evaluated by Bra- den scale all participants of study for risk of pressure ulcer. There were no risk of pressure ulcer 52.9%, medium risk of pressure ulcer 30%, and high risk of pressure ulcer 2.9%. Preventive measure methodology are changing patients position, using foam and normal pillow to the those hos- pitals. Physiotherapist only in 4 ICU was available and no dietitian on the day of the Study. Notified only one ICU had Braden scale evaluation protocol for pressure injury. The report or documentation about of pressure injury is avail- able only in the 3 ICUs of all over studied hospitals. Conclusions: 41.2% of overall patients were pressure ulcer who admitted to the Central hospital and District hospital of Ulaanbaatar. Incidence of HAPU 35.85%. The pressure ulcer’s risk factors are mechanical ventilated, vasopressor Figure 1. ROC. treatment, to decrease Glasgow score, high and middle Conclusions: NGAL ratio have prognostic value to predict scored SAPS II, risk factor increased by Braden score, long the earlier event of acute kidney injury event term hospital stay, old patients. Keyword: ICU patients, NGAL ratio, Acute Kidney Injury

Oral Quality (1) 04 Study in prevalence of decubitus in intensive care unit of mongolian hospitals Battsetseg BAASANJAV, Naranpurev MENDSAIKHAN The First Central Hospital Of Mongolia, Mongolian Society of Intensive Care Medicine, Mongolia

Introduction: Pressure injuries remain among the most important complications of hospitalization. They are asso- ciated with and increased infection risk, pain and disabil- Keyword: Intensive care unit, Pressure ulcer, Braden scale ity, high levelWITHDRAWAL of dependence, longer hospitalization, and as such higher hospital costs. Patients admited to ICUs are at particular high risk for pressure injuries because of their Oral Quality (1) 05 debilited physical condition and exposure to numerous risk factors. The impact of ABCDE bundle on the outcome of Methods: This study is multicenter one day prevalence. patients with mechanical ventilator We use protocols European pressure ulcer advisory panel, Chin-Ming CHEN1,2 National pressure ulcer advisory panel, Pressure injury alli- 1Intensive Care Medicine, Chi-Mei Medical Center, Taiwan; 2Center for Quality Management, Chi-Mei Medical Center, Taiwan ance.

270 KSCCM·ACCC 2020 Oral Presentation

Introduction: Acute respiratory failure (ARF) followed 1Division of Nursing, Severance Hospital, Yonsei University Health System, Seoul, Korea, Korea; 2Anesthesiology and Pain Medicine, Anesthesia and Pain by the use of mechanical ventilation (MV) may increase Research Institute, Yonsei University College of Medicine,, Korea mobility and mortality in intensive care unit (ICU). This study was to find the impact of ABCDE (daily Awakening, Introduction: Prompt and accurate airway establishment Breathing trial, drug Coordination, Delirium survey and in critically ill patients has a huge impact on their prog- treatment, and Early mobilization) bundle on the outcome nosis. Emergency airway management in non-operating of MV patients with ARF in the ICU. room increase the risk of complication. We operated rapid Methods: The study was conducted in a 19-bed medical response system(RRS) including attending anesthesiologist ICU of a medical center in Southern Taiwan. An Interdisci- and support whole airway management in our hospital. plinary Team initiated the protocol within 72 hours of me- Our aim was to investigate the status of airway manage- chanical ventilation when patients become hemodynam- ment team. ically stable. We performed daily sedation interruption, Methods: We reviewed the cases that our team was acti- coordination and avoidance of benzodiazepine as possible. vated to secure the airway. Reason for activation, response We used the Confusion Assessment Method for the ICU time, the way of airway management, and the outcome of (CAM-ICU) for delirium survey. We also performed a four- the patients were retrospectively investigated. step mobilization program. The study periods were divided Results: Total 74 activations were reviewed. 34 cases to phase 1 (before ABCDE bundle, from Dec 1, 2015 to Mar (45.9%) were cardiac arrest situations. The majority oc- 31, 2016), education (from Jul 1 to Sep 30, 2016) and phase curred in the general ward (44.6%) and ICU(45.9%). 9 2 (after ABCDE bundle, from Oct 1 to Dec 31, 2016). The patients were pediatric patients. Most common reasons endpoint was the impact of ABCDE bundle on the outcome for activation were severe hypoxemia (31.1%) and failed of ARF patients with MV, and the factors to influence ICU intubation attempts (16.2%). The success rate of airway stays. establishment on the first attempt by rapid response team Oral Presentation Results: Compared between phase 1 and phase 2, there was 89.2%. No patient needed surgical airway. There was were some differences, including disease severity, blood no adverse outcome and malpractice complaint related urea nitrogen (BUN) and Creatinine level. The patients in airway management. phase 2 had a significantly lower mean ICU stay (8.0 vs.12.0 days), medical costs (22.1 vs. 31.7 X 10000 New Taiwan Dol- lars) and mortality (8.3 vs. 36.6 %). The associated factors of shorter ICU stays by using Hierarchical regression model included: higher body mass index and hemoglobin, lower BUN and ABCDE bundle. Conclusions: The performance of ABCDE bundle can im- prove the outcome of ARF patients with MV, especially on the ICU stays. We will apply the successful experiences as benchmarking to the other ICUs in our hospital and other hospitals in Taiwan. Keyword: Acute Respiratory Failure, Bundle Care, Me- chanical Ventilator

Oral Quality (1) 06 The impacts of airway management team on the prognosis of critically ill patients Sumi CHOI1, Seungho JUNG2, Jeongmin KIM2, Minju KIM1, Sungwon NA2

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 271 Oral Presentation

Conclusions: The intervention of airway management by would, accordingly, attenuate psychological distress. RRS could have a significant impact on improving the pa- tient’s prognosis by preventing life threatening complica- tions related inappropriate airway secure. Keyword: Airway management, Rapid response system, Critical care

Oral Quality (1) 07 Decreased psychological distress in ICU caregivers Keyword: Family care, Intensive care unit , Music therapy after singing-based music therapy intervention Sungwon NA1, Ji Woo SEO1, Ga Eul YOO2, Soo Ji KIM2,3, Jeonmgmin KIM1, Myung Sun YEO2 Oral Quality (2) 08 1Department of Anesthesiology and Pain Medicine, Yonsei University College 2 The application of quality improvement and of Medicine, Korea; Department of Music Therapy, Graduate School, Ewha Womans University, , Korea; 3Music Therapy Education, Graduate School of artificial intelligence to improve the outcome of Education, Ewha Womans University, Korea patients with ventilator in the intensive care units 1 2 Introduction: Family caregivers of patients in the intensive Jou-Chun CHEN , Chin-Ming CHEN 1 2 care unit (ICU) have been increasingly emphasized as an Department of Healthcare Administration , Asia University, Taiwan; Intensive Care medicine, Chi-Mei Medical Center, Taiwan important part of the patients’ recovery. Among supporting intervention, music is beneficial for enhancing the care- Introduction: Critically ill patients admitted to intensive givers’ psychological health. While music listening is easily care unit (ICU) due to acute respiratory failure (ARF) with adopted in this setting, there are increasing needs for de- mechanical ventilator (MV), as the occurrence of ventila- veloping diversified use of music for caregivers. Therefore, tor-associated event (VAE) or ventilator-associated pneu- this study investigated the effects of singing-based music monia (VAP), might have a poor prognosis. The application therapy for alleviating psychological distress in ICU care- of quality improvement (QI) program with the aids of givers. artificial intelligence could improve the outcome of those Methods: Twenty four caregivers of ICU patients received patients. a one-hour single session of individual music therapy. Par- Methods: The study was conducted in a 19-bed medical ticipants engaged in singing with a live accompaniment ICU of a medical center in Southern Taiwan. An interdisci- in which their emotional states were reflected with music. plinary team initiated the weaning protocol with a four-step Songs were selected to help them relate their psychological mobilization program within 72 hours of MV when patients issues to the lyrics. Before and after the session, partici- become hemodynamically stable. With the integration of pants completed the Center for Epidemiologic Studies De- AI, ventilator clouds and Clinical Informatics Systems (CIS) pression Scale (CES-D), State-Trait Anxiety Inventory (STAI) with computer transformation of vital signs surveillance, and visual analog scales of their emotional states. we could safely monitor patients with MV weaning. Before Results: Participants showed significantly decreased endotracheal removal, we applied weaning APP (Chi-Mei CES-D and STAI anxiety scores following the session. Also, extubation Scores 8) based on our previous 3602 patients’ they showed significant increases in happiness and com- data via the train and test from an artificial neural network fort and a significant decrease in sadness (See Table 1). (ANN). We inputted 8 items to predict the possibility of lib- Conclusions: This study supports that short-term sing- eration from MV within 72 hours. . ing-based music therapy has potential for relieving de- Results: Before QI (Jan 1 to March 31, 2018), the mean ICU pression and anxiety of ICU caregivers. It also implies that stays were 12.0 days, with a VAE rate of 14.6 ‰ and an av- singing involves more active engagement in managing erage hospital cost of 350,000 New Taiwan Dollars (NTD). a caregiver’s physical and emotional regulation, which After QI (Nov 1 to Dec 31), the ICU stays, VAE rate and hos-

272 KSCCM·ACCC 2020 Oral Presentation pital costs were down to 8.7days, 0 and 190,000 NTD. The bation within 24 hours) was 0. extra nursing hours also decreased from 312 to 56 hours Conclusions: We found that patient with early rehabilita- per month. tion program can reach weaning predictors after five days Conclusions: The integration of QI, AI, ventilator clouds of training. In this study, we recruited the patient’s family and CIS can improve the quality and outcome of ARF pa- for our rehabilitation team, and rehabilitation was done tients with MV. We will apply the successful experiences to during the family visiting period. During this process, we the other ICUs in our hospital, and may serve as a bench- found that family members could provide the medical marking for other hospitals in Taiwan. team with help in care. Keyword: Acute Respiratory Failure, Quality Improvement, Keyword: Early rehabilitation , Mechanical ventilation, Artificial Intelligence Acute respiratory failure

Oral Quality (2) 09 Oral Quality (2) 10 Head Nurse Baseline survey on hand hygiene compliance at Pei Jun CHEN intensive care units in Iraq 1 2 3 4 Intensive care unit, Chi Mei Medical Center, Chiali, Taiwan Jinki JUNG , Sukh Que PARK , Min Chang KANG , Bo Young LEE , Eun Hynag CHU5, Layla ALI HAKEEM6, Ali Saad JABER AL ALLAWEE7 Introduction: For the “patient-centered” cross-team inte- 1International Project Corp., Soonchunhyang University Hospital, Korea; 2Neu- grated medical care in the intensive care unit, the members rosurgery, Soonchunhyang University Hospital, Korea; 3Surgery, Soonchun- hyang University Hospital, Korea; 4Pulmonology and Allergy, Soonchunhyang include the intensive care unit attending physician and the University Hospital, Korea; 5Intensive Care Unit, Soonchunhyang University nursing leader, the nurse, the senior nurse, the pharmacist, Hospital, Korea; 6Intensive Care Unit, Ghazi Hariri Hospital for Specialized Sur- gery, Korea; 7Intensive Care Unit, Baghdad Teaching Hospital, Korea Oral Presentation the dietitian, the rehabilitation teacher, etc., and the family members. Through the intervention of team therapy, the Introduction: The incidence of Hospital Acquired Infec- patient is provided with comprehensive care. The patient tion(HAI) is high in intensive care units(ICUs) and HAI can weaning the mechanical ventilation as soon as possible adversely affects the prognosis of the patient. Hand hy- by early rehabilitation and can recover health and have a giene(HH) is the most effective and economic way to pre- quality of life in a secure environment. vent HAI. HH is more important in countries with limited Methods: The study was conducted in the 11-bed med- medical resources such as Iraq. This study was conducted ical ICU of a -bed medical center in southern Taiwan. A WITHDRAWAL to find improvements from the baseline survey of HH at multidisciplinary team, was set up to initiate the early re- ICUs in Iraq. habilitation program within 72 hours of MV after patients Methods: Soonchunhyang University Medical Center has had become hemodynamically and respiratory stable and performed baseline survey of the project supported by encouraged family members to join together. Through the Korea International Cooperation Agency on HH compli- cooperation of multidisciplinary team, the protocol was ance at ICUs(32beds) in Iraq Medical City from Nov 2019 divided into four stages. The first and second stages were to Jan 2020. Survey materials were developed based on passive joint movement in the bed and the active joint the World Health Organization Guideline. The survey on movement in the 60-90 degree sitting position. Patient was sitting on the bed without the back support during contin- knowledge and perception of HH and hand contamination uous respiratory training at the third stage and respiratory test was conducted. Based on hand plate criteria, hand muscle training on the bedside companion chair at the contamination was classified into low(1-9 Colony Forming fourth stage. Unit, CFU) and high(>10 CFU) groups. The HH compliance Results: From January 2018 to December 2018,The overall monitoring was performed by direct observation. Whether weaning rate of the intensive care unit was 67.97% com- to perform only hand rub or wash is expressed as “compli- pared with the average data 59.73% at 2017 (without the ance(yes/no)”, and in all 6 steps as “compliance(yes and 6 rehabilitation program); the extubation failure rate (reintu- steps)”.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 273 Oral Presentation

Results: The level of HH knowledge and perception of 30 health workers at ICUs were 55.8±10.5 and 58.0±29.0, respectively. In the low hand contamination group, knowledge and perception scores were high, but only perception scores were statistically significant(60.0±0.0 vs 55.3±11.0, p=0.42, 82.7±12.9 vs 55.3±29.1, p=0.03). Of 125 cases, compliance(yes/no) was 83%, but compliance(yes and 6 steps) was 18%. Technicians had the lowest rate of compliance(yes/no) (70%) and a compliance(yes and 6 steps) of physical therapist, technician and janitor was 0%. Among the 6 steps of HH procedure, the finger- tips(30%) was the lowest. Conclusions: This study is meaningful to understand the current status of HH activities at ICUs in Iraq. Overall hand hygiene knowledge and perceptions and the 6 step hand hygiene compliance were low. In the future, there will be a need for training and monitoring with a focus on these areas.

Keyword: Intensive Care Unit, Hand Hygiene Compli- ance, Iraq

Oral Quality (2) 11 Quick Sepsis-related Organ Failure Assessment score and Modified Early Warning Score for detecting clinical deterioration of patients in general ward Ryoung-Eun KO1, Kyung-Jae CHO2, O-Yeon KWON2, Hyun-Ho PARK2, Yeon Joo LEE3, Joon-Myoung KWON4, Jinsik PARK5, Jung Soo KIM6, Man-Jong LEE6, Ah Jin KIM6, You Hwan JO7, Yeha LEE2, Kyeongman JEON1,8 1Department of Critical Care Medicine, Samsung Medical Center, Sungkyunk- wan University School of Medicine, Seoul, Korea; 2VUNO, Seoul, , Korea; 3Division of Pulmonary and Critical Care Medicine, Seoul National University Bundang Hospital, Gyeonggi-Do, Korea; 4Department of Critical care and Emergency Medicine, Mediplex Sejong Hospital, Incheon, Korea; 5Division of Cardiology, Cardiovascular Center, Mediplex Sejong Hospital, Incheon, Korea; 6Division of Critical Care Medicine, Department of Hospital Medicine, Inha College of Medicine, Incheon, Korea; 7Department of Emergency Medicine, Seoul National University Bundang Hospital, Gyeonggi-Do, Korea; 8Division of Pulmonology and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Introduction: The Modified Early Warning Score (MEWS) has been widely used to assess patients who are at risk of clinical deterioration and who may require a higher level of care, but required practitioner’s calculation. Recently, the quick Sequential Organ Failure Assessment (qSO-

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FA), based on its ability to predict in-hospital mortality Medicine, Seoul National University College of Medicine, Korea and prolonged intensive care unit (ICU) stay in patients Introduction: To comparison of clinical aspects such as with suspected infection, has been considered to re- disease severity, code rate and mortality of unplanned place MEWS because of its simplicity. However, there is admissions to intensive care unit (ICU) in two type of no study evaluating the usefullness of qSOFA score for medical ward: hospitalist ward and non-hospitalist ward. detecting clinical deterioration in general ward patients Methods: This retrospective study included adult pa- compared with MEWS. tients admitted to two medical wards, at Seoul National Methods: All consecutive adult patients who were admit- University Hospital between Jun. 12, 2016 and Dec. 31, ted to the general wards were included in the 12-months 2019; the sample comprised 51 patients admitted to hos- study period from five hospitals in Korea. The clinical de- pitalist ward and 425 patients admitted to non-hospitalist terioration was defined as in-hospital cardiac arrest and ward. We compared code rates and in-hospital mortality unexpected intensive care unit (ICU) transfer. rates between the hospitalist ward and non-hospitalist Results: Of the 173,057 patients, 117 experienced ward. in-hospital cardiac arrest (IHCA) and 141 experienced Results: The most common reason for unplanned admis- unexpected ICU transfer. The MEWS outperformed the sions to ICU was respiratory failure in both ward (64.7%, qSOFA score for predicting IHCA (AUROC: 0.792 vs. 0.640; n=33 vs. 55.1%, n=234, respectively), and second reasons p<0.001). Besides, the MEWS showed better performance for those were post CPR care in hospitalist ward (19.6%, than the qSOFA score for predicting unexpected ICU n=10) and septic shock in non-hospitalist ward (17.6%, transfer (AUROC: 0.767 vs. 0.716; p<0.001). The MEWS ≥5 n=75), respectively. MEWS (The Modified Early Warning had a sensitivity of 16.5% and specificity of 99.2% for the Score) was significantly increased in hospitalist ward prediction of IHCA compared with 14.1% and 98.2% for

(6.75 vs. 5.61, p=0.011). Also, code rates from two med- Oral Presentation qSOFA score ≥2. The MEWS ≥5 had a sensitivity of 18.2% ical wards significantly higher in hospitalist ward than and specificity of 99.4% for the prediction of unexpected in non-hospitalist ward (19.6%, n=10 vs. 10.1%, n=43, ICU transfer compared with 15.8% and 98.6% for qSOFA p=0.049). However, in-hospital mortality was no signifi- score ≥2. A cumulative 10% of patients met MEWS ≥5 9 cantly difference between two groups (50.98%, n=26 vs. hours before the IHCA compared with 5 hours for the 41.18%, n=175, p=0.180). qSOFA score ≥2. Moreover, a cumulative 10% of patients Conclusions: Critical score of MEWS and code rate were met MEWS ≥5 15hours before an unexpected ICU trans- significantly higher in hospitalist ward than non-hospi- fer compared with 14 hours for qSOFA score ≥2. talist ward. However, in aspect of mortality, there was no Conclusions: The MEWS is more accurate than the qSO- significant difference between two groups. FA score for predicting clinical deterioration in general Keyword: Hospitalist, Cardiopulmonary resuscitation, ward patients. Hospital mortality Keyword: Quick-SOFA, Modified early warning score, Deteriorating patients Oral EM/CPR 01 Oral Quality (2) 12 Characteristics and outcomes of in-hospital cardiac arrest in a tertiary referral center with Comparison of clinical aspects of unplanned rapid response system admissions to intensive care unit (ICU) in Hohyung JUNG1, Ryoung-Eun KO1, Myeong Gyun KO2, Ahra KOH2, two medical ward: hospitalist ward and non- 1 hospitalist ward Kyeongman JEON 1Department of Critical Care Medicine, Samsung Medical Center, Sungkyunk- Sang Won YOON, Jaeyoung CHO, Nakwon KWAK, Jinwoo LEE, Young wan University School of Medicine, Korea; 2Intensive Care Unit Nursing Sik PARK, Chang-Hoon LEE, Chul-Gyu YOO, Young Whan KIM, Sun Mi Department, Samsung Medical Center, Sungkyunkwan University School of CHOI, Sang-Min LEE Medicine, Korea Division of Pulmonary and Critical Care Medicine, Department of Internal Introduction: In-hospital cardiac arrest (IHCA) is de-

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 275 Oral Presentation fined as a cardiac arrest that occurs in a hospital and for Oral EM/CPR 02 which resuscitation is attempted. Despite the increased morbidity and mortality, few studies have documented Successfully resuscitated refractory ventricular details about characteristics and outcomes of IHCA, fibrillation with double sequence defibrillation: a case report especially in the environment of mature rapid response system (RRS). This study describes the baseline charac- Sung-Hyuk CHOI, Young-Hoon YOON, Jung-Youn KIM, Young-Duck CHO, Sung-Jun PARK, Eu-Sun LEE, Ji-Young LEE teristics and outcomes of adult patients with IHCAs at a Department of Emergency Medicine, College of Medicine, Korea University, tertiary hospital with RRS in Korea. Seoul, Korea Methods: This retrospective observational study includ- IntroductionIf the initial rhythm is ventricular fibril- ed all consecutive IHCAs occurred in adult (more than Case: lation (VF) or pulseless ventricular tachycardia (VT) in 18years) patients admitted to general wards at Samsung cardiac arrest, there are high survival rates and good neu- Medical Center between January 1, 2010 and December rologic outcomes. But the mortality rate goes higher when 31, 2019. refractory ventricular fibrillation (RVF) occurs. We report Results: There were 800 IHCAs during 10 years. The me- one case of successfully resuscitated RVF with double se- dian (IQR) age of patients suffering a cardiac arrest was quence defibrillation (DSD). 64.5 years (53.0 – 74.0) and 58.4% were male. Majority Case presentation: A 51-year-old man visited the emer- patients admitted at medical service (72.9%). Malignancy gency department (ED) with chest pain. The initial EKG (47.8%) and cardiovascular disease (26.8%) were the most showed markedly elevated ST-segment on V1-V5 leads and common pre-existing conditions. The median day from VF arrest occurred. Although 10 defibrillations were given admission to cardiac arrest was 9.7 (4.0 – 22.7) days. Two for 20 minutes, there was no response. 2 times of DSD were third of IHCAs occurred during the weekdays and around performed by placing additional pads on the patient’s ante- half of IHCAs at night time. Limitation of treatment were rior-posterior position and giving maximum energy setting not discussed previously in 87.1% and only 15.1% were sequentially. The patient returned to spontaneous circula- managed by RRS team in 24 hours before cardiac arrest. tion and he discharged with cerebral performance category Most common presumed cause of arrest was respiratory 1 after 14 days of hospital admission. (44%), followed by cardiovascular (29.5%) and unknown Conclusion: DSD could be one of the optional treatments cause (11.4 %). At the time of cardiac arrest, PEA (50.6 %) to terminate RVR. and asystole (27.0 %) was most commonly observed, and Keyword: Double sequence defibrillation, refractory ven- 85.4% of IHCAs were witnessed. Although 76.1% were tricular fibrillation successfully resuscitated but only 31.2% survived and either transferred to other hospital (14.0%) or discharged to home (17.2%). Oral EM/CPR 03 Conclusions: Consistent with previous reports, the ma- Effects of Mild Therapeutic Hypothermia in jority of initial rhythms in IHCAs were non-shockable Post-anoxic Comatose Patients with Hypotension but successfully resuscitated. However, 31.2% survived Events to hospital discharge and only 17.2% were discharged Jae Hoon LEE home. Emergency department, Dong-A university college of medicine, Korea Keyword: In-Hospital cardiac arrest, Cardiopulmonary ressuscitation, Outcome Introduction: Hypotension events are known as com- mon adverse events with poor prognosis in cardiac arrest patients. However, only few studies have been conducted on the possible effects of targeted temperature man- agement (TTM) according to the timing of hypotension. Therefore, this study aimed to determine how hypoten-

276 KSCCM·ACCC 2020 Oral Presentation sion events during 33°C TTM influence the prognosis Figure 1. Flow sheet. and complications in cardiac arrest patients and to assess the risks of hypotension events according to timing of the events. Methods: This prospectively conducted multi-centered observational study included 1373 comatose patients treated with 33°C TTM. Patients with hypotension events found before and during TTM were compared and differ- ences in prognosis according to the timing of hypoten- sion were investigated. The primary outcome was mor- tality of patients measured at discharge, 1 and 6 months after discharge. Secondary outcomes were the incidence of complications and length of ICU stay according to im- plementation of TTM. Results: Patients with poor neurologic outcome (cerebral performance category [CPC] score of 3-5) on the day 180 were 560 of 704 patients in the hypotension group before TTM and 556 of 701 patients in the hypotension group during TTM. Mere difference was found between the pa- tients with hypotension before and during TTM in surviv- al rates (hazard ratio [HR] 1.51 vs 1.51), incidence of com- plications and length of ICU stay. Hypotension events Oral Presentation within 12 hr after TTM indicated more risks than those occurred at different time points (HR 1.66) and hypoten- sion persisting both before and during TTM indicated even greater hazards (HR 2). Differences in lactate level were found, even with the initial fluid therapy (p<0.001). Conclusions: Compared to the those with hypotension found before TTM, the patients with hypotension found during TTM were shown to have no effects on survival rates, occurrence of complications, and length of ICU stay. It is essential for physicians to be aware of the risks of Keyword: Out-Of-Hospital Cardiac Arrest, Hypothermia, Induced, Hypotension

Figure 2. Hazard ratio.

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Table 1. Comparison of complications and length of ICU stay according to tim- creatine kinase (15,250 IU/L) value increased a lot. And ing of hypotension events his both lower leg tissue pressure increased to 180mmH- g/170mmHg (Rt/Lt). We performed fasciotomy on day 2nd hospitalization. Hyperbaric oxygen therapy (HBOT) of 2.0 ATA for 90 min was applied twice a day for 7days. Conclusion: His condition gradually improved over 6 months and he did not require amputation. He left only a mild neurological disorder in his foot and transferred to a rehabilitation center six months after being hospitalized. Hyperbaric oxygenation therapy was effective as adjuvant therapy in isocyanate-induced compartment syndrome. Keyword: Isocyanates, Compartment syndrome, Hyper- baric oxygenation

Oral EM/CPR 05 Coronary angiography is associated with post- cardiac arrest outcomes in patients with ever shockable rhythm Chih-Wei SUNG1, Chien-Hua HUANG2, Wen-Jone CHEN2,3, Wei-Tien CHANG2, Jia-How CHANG1, Min-Shan TSAI2 1Emergency medicine, National Taiwan University Hospital Hsin-Chu Branch, Taiwan; 2Emergency medicine, National Taiwan University Hospital, Taiwan; 3Internal Medicine, National Taiwan University Hospital, Taiwan

Oral EM/CPR 04 Introduction: Sudden cardiac arrest is associated with high morbidity and mortality worldwide. Emergent coro- Successful adjunctive treatment of compartment nary angiography (CAG) has been proved to improve out- syndrome by acute isocyanates inhalation using comes in patients with ST-segment elevation myocardial hyperbaric oxygen therapy infarction or cardiogenic arrest, who usually present with Dongki KIM, Junho HAN, Sungmin LEE, Tag HEO initial shockable rhythm. However, the influence of CAG on Emergency medicine, Chonnam National university hospital, Korea outcomes in cardiac arrest survivors with non-shockable remains unclear. Besides, whether the benefit of emergent Case: IntroductionIsocyanates are the raw materials that CAG differs between patients with either shockable or make up all polyurethane products. Isocyanate is a power- non-shockable awaits investigation. This study focuses on ful irritant to the mucosal membrane’s respiratory tracts, the effect of emergent CAG toward outcomes in cardiac ar- eyes, and skin. Pulmonary symptoms, especially occupa- rest survivors with either ever shockable or non-shockable tional asthma, are the predominant manifestations after rhythm. isocyanates toxicity. Methods: This multicenter cohort study retrospectively Case presentation: We report mental change and com- recruited 970 non-traumatic adult cardiac arrest survivors partment syndrome complicated by rhabdomyolysis as an from 2012 to 2017. The enrolled patients were classified extraordinary manifestation of acute isocyanates toxicity into ever shockable and non-shockable groups. In each during printing waterproofing water tank. A 58-year-old group, patients were further stratified by the application male recovered consciousness after 6 hours of emer- emergent CAG or not. The in-hospital mortality and poor gency department visit and began to complain of severe neurological recovery were compared between groups. Cox pain in the lower leg. As a result of the laboratory test, the proportional hazard model and multivariate logistic regres-

278 KSCCM·ACCC 2020 Oral Presentation sion were used to evaluate the association between CAG General Hospital, Taiwan; 7Physical Therapy, Fooyin University, Taiwan; 8Grad- uate Institute of Clinical Medicine, Kaohsiung Medical University, Taiwan and outcomes. Results: There were 312 (32.2%) patients in the shockable Introduction: Cardiac arrest patients who achieved spon- group and 658 (67.8%) patients in the non-shockable group. taneous circulation after resuscitation, targeted tempera- Among patients with initial shockable rhythm, 182 (58.3%) ture management (TTM) showed increase rate of a favor- patients of them received emergent CAG. The emergent able neurologic outcome and survival rate in comparison CAG was significantly associated less in-hospital mortal- with standard critical care treatment alone. The aim of this ity [adjusted hazard ratio (aHR) = 0.38, 95% CI 0.25–0.58, study is to evaluate the relationship between the reduction p<0.001] and less neurological disability [adjusted odds of time to reach target temperature after implementation of ratio (aOR) = 0.30, 95% CI 0.15–0.60 p<0.001] in the shock- a multidisciplinary team to start earlier with targeted tem- able group. Ninety patients (13.7%) in the non-shockable perature management in the emergent department and group received emergent CAG. Among patients with initial the association with neurological and survival outcomes in non-shockable rhythm, emergent CAG did not show signif- patients after cardiac arrest. icance in both less in-hospital mortality and less neurologi- Methods: Subjects were consecutive emergency depart- cal disability. ment patients after cardiac arrest with return of sponta- neous circulation and in comatous status. We analyzed 26 consecutive patients with early initiation of targeted tem- perature management in the emergency department (from Dec. 2018 to Aug. 2019). Thirty-three out of hospital cardiac arrest patients with late initiation of targeted temperature management in the ICU setting served as controls (from Oral Presentation Jan. 2017 to Nov. 2018). Neurologic outcome was measured. Results: In patients with late initiation of targeted tempera- ture management in the intensive care units, the median Figure 1. time to reach the target temperature was 409 minutes. In the patients with early initiation of targeted temperature Conclusions: In patients with ever shockable rhythm, management in the emergency department, the median emergent CAG is associated with better survival and neu- time to reach the target temperature was 265 minutes rological outcomes. (p=0.014). Eight patient with early initiation of targeted Keyword: Coronary angiography, Outcomes, Shockable temperature management in the emergency department rhythm had a favorable neurologic outcome (CPC 1) as compared to 6 patient with late initiation of targeted temperature Oral EM/CPR 06 management in the ICU had favorable neurologic outcome with CPC 1 (p=0.033). The survival rate improved from Association between the reduction of time to 36.36% in the control group, to 50% (p=0.292) in the inter- reach target temperature and clinical outcomes vention group. in patients treated with targeted temperature Conclusions: Early initiation of TTM after cardiac arrest management after cardiac arrest may improve survival and neurological outcome. There- 1 2 2 Kun-Chang LIN , Thung-Hsien HSU , Yun-Te CHANG , Wang-Chuan fore, expanded alertness among emergency department JUANG3, Jie-Ling HUANG4, Cheng-Chang YEN3, Hai-Yu CHEN4, Ya- physicians and nursing stuff Meei LUE4, Ru-Huei WANG4, Yong-Huei TANG4, Hsin-Li LIANG1, Wei- Chun HUANG1,6,7,8 Keyword: cardiac arrest, targeted temperature manage- 1 ment, Target temperature Critical care medicine and cardiovascular center, Kaohsiung Veterans General Hospital, Taiwan; 2Emergency, Kaohsiung Veterans General Hospital, Taiwan; 3Neurology, Kaohsiung Veterans General Hospital, Taiwan; 4Nursing, Kaoh- siung Veterans General Hospital, Taiwan; 5Quality management, Kaohsiung Veterans General Hospital, Taiwan; 6School of Medicine, Kaohsiung Veterans

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 279 Oral Presentation

Oral EM/CPR 07 Clinical Outcomes of Extracorporeal Cardiopulmonary Resuscitation for Cardiac Arrest of Surgical Patients Jong-Kwan BAEK, Jeong Woo LEE, Tae Yoon KIM, Hak-Jae LEE, Suk- Kyung HONG Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, Korea

Introduction: Extracorporeal cardiopulmonary resuscita- tion (ECPR) is an advanced rescue therapy, that uses the extracorporeal membrane oxygenation (ECMO), to support circulation for patients with cardiac arrest. ECPR maintains vital organ perfusion while potential reversible causes of the cardiac arrest can be identified and treated. The pur- pose of this study was to report the clinical outcomes of ECPR and assessed the role of ECPR in surgical patients with cardiac arrest. Methods: We retrospectively reviewed the medical records of surgical patients who experienced in-hospital cardiac arrest and received ECPR at the Asan Medical Center be- tween January 2015 and December 2018. Results: During the four-year study period, 11 surgical patients with cardiac arrest were received cardiopulmo- nary support with ECPR. Four of these patients lived after ECPR. Cardiac arrest occurred in 9 patients with non-car- diac cause and 2 patients with cardiac cause. (Table 1.) In 9 cases of non-cardiac causes group, 6 cases were septic shock, 1 case each of hypovolemic shock, anaphylactic shock and respiratory arrest. The mean duration of con- ventional cardiopulmonary resuscitation (CCPR) before the ECPR were 35.5 min. Table 2 shows the clinical in- formation for each patient. The mean duration of ECMO support for these four survivors was 3.6 days. Although there is no statistical significance, the mean duration of CCPR appears to be shorter in survivor group (27.8 ± 16.1 min) than in non-survivor group (39.8 ± 27.5 min). The clinical outcome of each survivor shows Table 3. All survi- vors were discharged without sequelae or medical devices. Conclusions: ECPR can be a option of rescue therapy and should be considered carefully and quickly in surgical pa- tients with cardiac arrest. Keyword: ECPR, ECMO, Cardiac arrest

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Oral EM/CPR 08 Oral Nursing 01 Prediction of In-hospital cardiopulmonary arrest Efficacy of Inhaled Budesonide on Prevention in cancer patients of Acute Mountain Sickness during Emergent Wonho HAN, Sungwoo KANG, Jeehee KIM Ascent: A Meta-analysis of Randomized Intensive care unit, National Cancer Center, Korea Controlled Trials GAURAV NEPAL Introduction: Clinical deterioration is known to occur in Medicine, Tribhuvan University Institute of Medicine, Nepal about 10% of hospitalized patients. In addition, 60 to 70% of patients with In-hospital Cardiopulmonary arrest (CPR) Introduction: Acute Mountain Sickness (AMS) is a patho- have vital signs abnormally 6 to 8 hours ago. However, physiologic process that occurs in non-acclimated geneti- there is still controversy over method of predict clinical de- cally susceptible individuals rapidly ascending to high-al- terioration or CPR. In addition, cancer patients have a poor titudes. Barometric pressure falls at high altitude and it prognosis. This study was conducted to investigate clinical translates to a decreased partial pressure of alveolar oxygen characteristic of CPR and to analyze the vital sign abnor- (PAO2) and arterial oxygen (PaO2). A gradual staged ascent mality or laboratory test for prediction of CPR in cancer with sufficient acclimatization can prevent acute mountain patients. sickness but emergent circumstances requiring exposure to Methods: We retrospectively reviewed 688 patients with rapid atmospheric pressure changes – such as for climbers, malignancy disease who had CPR at the National Cancer disaster or rescue team procedures, and military operations Center in Korea from January 2010 to December 2018. – establishes a need for effective prophylactic mediations. This systemic review and meta-analysis aim to analyze the Clinical characteristics and vital sign before cardiac arrest 6 incidence of AMS during rapid ascent of non-acclimatized hours were investigated. More than 140 beat/min, systolic Oral Presentation individuals receiving inhaled Budesonide compared to blood pressure below 80 mmHg, respiratory rate of more those receiving no intervention. than 30 times/min, oxygen saturation of less than 85% or Methods: This current meta-analysis was conducted ac- Modified Early Warning Score (MEWS) 5 points or more cording to the guidance of the Preferred Reporting Items were defined as abnormal vital signs. In the blood test be- for Systematic Reviews and Meta-Analyses Protocols state- fore arrest, pH less than 7.2, pO2 below 55mmHg, pCO2 ment. We searched PubMed, Google Scholar and Embase above 50mmHg and TCO2 below 12mEq/L were defined as for relevant studies. The efficacy of budesonide in reducing laboratory test abnormality incidence of AMS was evaluated by calculating the pooled Results: Vital sign abnormality was found in 43.0% (296/688 ORs and 95% CIs. The efficacy of budesonide in main- patients) of all patients, and lab abnormality was present 6 taining hemoglobin-oxygen saturation was evaluated by hours before cardiac arrest in 50.3% (346/688 patients). Pa- calculating standard mean difference (SMD) and 95% con- tients with vital sign or lab abnormality were 71.2% (490/688 fidence intervals. patients). The most common causes of cardiac arrest were Results: We found that at high altitude, inhaled BUD was respiratory failure (251/688 patients, 36.5%) and sepsis not effective in reducing the incidence of AMS [OR: 0.62; (190/688 patients, 27.6%). There was vital sign or lab abnor- 95% CI, 0.24 to 1.55, p=0.30] (figure 1) but was effective in mality in 69.7% (175/251 patients) in respiratory and 83.6% reducing the occurrence of severe symptomatology [OR: (159/190 patients) in sepsis. 0.32; 95% CI, 0.11 to 0.93, p=0.037] (figure 2). In addition, Conclusions: In-hospital Cardiopulmonary arrest in can- systematic-review found that BUD is not effective in main- cer patients can be predicted 6 hours before using vital taining or improving pulmonary function and hemoglo- signs and laboratory test abnormality. Especially in many bin-oxygen saturation. Systematic-review found no adverse sepsis patients, CPR could be predicted in advance, so ag- effects of BUD in the dose used for prophylaxis of AMS. gressive early treatment may be expected to reduce CPR Conclusions: Our systematic review showed that pro- and in hospital mortality. phylactic inhaled BUD is not effective in preventing AMS Keyword: Cardiopulmonary arrest, Cancer , Vital sign during emergency ascent.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 281 Oral Presentation

cy room (ER) and 4 years of medical intensive care unit (MICU), respectively, volunteered to join the team. An in- tensivist also joined to RRS team as a consultant. RRS team was equipped with a portable ventilator, a video laryngo- scope, and Point-Of-Care-Testing (POCT) machine. We ad- opted RRS screening program into our Electronic Medical Record (EMR) system. If a patient’s information exceeds the RRS activating criteria, an alarm is directly sent to RRS team by short message service (SMS). Additionally, nurses Figure 1. Forest plot AMS Inchidence. can also realize the alarm sign directly from screen with color change. The mean RRS visits were 61cases per month, and the mean ICU admission rate though RRS team were 8.7cases per month. Among ICU-admitted patients, mean 36.3 patients have discharged alive between June and December in 2019. Usually, RRS activation were done by screening program (80.8%), followed by direct calling from nurses in charge (12.65). Conclusion: During the 7- month of operation period, we have experienced many trials and errors. Delayed record- Figure 2. Severe AMS. ing of patients’ information and the lack of awareness were Keyword: Mountain Sickness, Altitude sickness, Acute main obstacles for successful implementation of RRS team. mountain sickness Keyword: RRS, Implementation, ICU

Oral Nursing 02 Oral Nursing 03 Implementation of rapid response team of SNU- Development of End-of-life Nursing Care SMG Boramae Medical Center Protocol for Intensive Care Unit: Delphi Survey Daeun JUNG1, Jung-Hee SONG1, Tae-Yeon PARK1,2, Seoyoung YOON1,2, Method Jung-Nam AHN1,2, Eunyoung HEO2 Jungeun KIM 1Critical Care Medicine, SNU-SMG Boramae medical center, Korea; 2Internal Intensive care unit, Yonsei cancer center, Korea Medicine, SNU-SMG Boramae medical center, Korea Introduction: There are many reported instances of nurses IntroductionRapid response system (RRS) have Case: who face psychological and medical difficulties when pro- been introduced to provide early intervention for patients viding care for patients in the ICU. Therefore, there should with unexpected clinical deterioration. Due to the rapid be an implementation of standardized protocols for end- response service pilot program started by the Korean Min- of-life nursing care for patients in the ICU to improve the istry of Health and Welfare since May 2019, the implemen- quality of care for these patients, the overall quality of med- tation of RRS is increasing rapidly, especially in tertiary ical practices, and working capacities of nurses in the ICU. hospitals. Boramae Medical Center is 800-bed general Ultimately, these improvements are expected to improve hospital, which has relatively weak resources compared to the level of satisfaction among ICU nurses. The purpose of tertiary hospitals. We are going to introduce the process of this study is to develop an end-of-life nursing care protocol implementing RRS in our hospital. for nurses in the ICU, verify the protocol, and then use the A project of RRS imple- Implementation and Progress: results to propose a standardized end-of-life nursing proto- mentation was started from May, 2019. Two experienced col. nurses, who have been working over 6 years in emergen- Methods: For this study, feedback from experts was col-

282 KSCCM·ACCC 2020 Oral Presentation lected on a draft end-of-life nursing care protocol and risk factors of heel pressure injury inpatients in the car- developed based on existing literature. Then, a Delphi sur- diovascular intensive care unit and to use it as a basis for vey study was designed to finalize the protocol. The target developing an intervention for cardiovascular disease pa- group for this study was 30 experts. The first round of the tients with high risk of heel pressure injury. Delphi study was conducted using a four-point scale sur- Methods: The subjects of this study were 31 patients with vey, with the content validity ratio (CVR) analyzed using heel pressure injury from January to December 2017 in the descriptive statistic methods. cardiovascular surgical intensive care unit and cardiovas- Results: The draft end-of-life nursing care protocol, was cular medical intensive care unit of University hospital. 61 developed and proposed based on the review of existing lit- patients inrolled controlled group that were randomized to erature, then was divided into following three separate ar- double the number of patients. In order to collect data for eas with 24 categories. The consensus from the first-round this study, a survey was prepared by querying an electronic Delphi survey on the end-of-life nursing care protocol medical record, and a survey paper including general char- showed a CVR of 0.33 or higher for all 24 categories, thus acteristics, disease-related characteristics, treatment char- proving the validity of the proposed draft as a standardized acteristics in intensive care unit, and degree of pressure protocol. Furthermore, reflecting on the feedback of the injury. participating experts, an extra category was added to the Results: The results of cardiac surgery(χ2 =16.858, p<.001), protocol, resulting in a total of 25 categories. operation time (t = 3.465, p=.001), use of mechanical ven- Conclusions: The results of this study are expected to help tilator (χ2 = 19.421, p<.001), vasoconstrictor use (χ2 = leading hospitals in South Korea to outline the roles and 13.614, p<.001), sedative drugs Use (χ2 = 20.525 p<.001) range of tasks of ICU nurses in end-of-life care, thus im- and ECMO treatment (χ2 = 3.352, p<.001) were significant proving pre-existing difficulties in end-of-life care for pa- risk factors. tients. Keyword: Heel pressure injury, Risk factor Oral Presentation Keyword: ICU nurse, End-Of-Life nursing protocol, Delphi Survey Method Oral Pulmo (1) 01

Oral Nursing 04 Impact of non-cystic fibrosis bronchiectasis on critically ill patients Risk Factors associated with Heel Pressure Injury Youngmok PARK, Ah Young LEEM, Kyung Soo CHUNG, Moo Suk PARK, in Adult Patients in Cardiovascular Intensive Care Young Sam KIM, Su Hwan LEE Unit Division of Pulmonology, Department of Internal Medicine, Severance Hospi- tal, Yonsei University College of Medicine, Seoul, Republic of Korea, Korea Hyeon Jeong LEE1, Min Young HAN2 1 2 Heart intensive Care Unit (HICU), Severance Hospital , Korea; Coronary Care Introduction: Bronchiectasis is becoming a significant Unit (CCU), Severance Hospital , Korea health issue, but there are little data from critically ill pa- Introduction: Heels have a high risk of pressure injury tients. We investigated the impact of non-cystic fibrosis due to anatomical physiological causes. The heel has little bronchiectasis in patients with critical illnesses. subcutaneous tissue, so the pressure exert directly on the Methods: We enrolled the patients who admitted to the bone. There is also a fat layer without distribution of blood 24 beds medical intensive care unit (ICU) of Severance vessels, it is very vulnerable to ischemia and only one mus- hospital between July 2016 and April 2019. Bronchiectasis cle has in the subcutaneous fat layer. Patients who admit patients were defined as those who had official reports of the intensive care unit with heart disease are more vulner- bronchiectasis in chest computed tomography (CT) taken able to heel pressure injury because they often undergo before the ICU admission. The severity of bronchiectasis cardiac surgery, special treatment such as extracorporeal was measured with the number of lobes involved in chest membrane oxygenator(ECMO) and intraaortic balloon CT, and those who had three or more involved lobes were pump(IABP). The purpose of this study is to analyze the classified as severe bronchiectasis.

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 283 Oral Presentation

Results: A total of 1207 patients were enrolled. The mean with ventilators due to acute or chronic respiratory fail- age was 64.8 ± 14.2 years, and 760 (63%) patients were ure who had crackle lung sound caused by the sputum or men. The APACHE-II score and SOFA score at the time of could not cough enough to emit the sputum. The volume ICU admission were 25.0 ± 9.1 and 8.5 ± 3.9, respectively. of the sputum was counted for 24 hours before and during Endotracheal intubation was conducted in 816 (68%) pa- applying the machine and bronchoscopy was done to eval- tients, and there were 837 (69%) patients with combined uate tracheal mucosal injury. The nurses in charge of each septic shock. The overall ICU mortality and in-hospital patient filled in questionnaires after the study. mortality of the patients were 26% and 42%, respectively. Results: From 8th to 23rd November 2019, 5 patients was Bronchiectasis was present in 148 (12%) patients with a finally enrolled. The average age was 67.8 and the majority median involvement of four lobes. In univariate analysis, of underlying disease was pneumonia (n=3). 2 had trache- the presence of bronchiectasis was related to the increase ostomy tubes and the others had endotracheal tubes. Com- of in-hospital mortality (OR 1.43, 95% CI 1.02–2.03). The pared to the amount of the sputum, the ability of suction of Cochran-Armitage trend test showed that the increase of this machine was not inferior to human hand. The tracheal involved lobes in bronchiectasis was related to the rise of mucosal injury was improved in 3 cases and similar in 2 ICU mortality (P for trend 0.009) and in-hospital mortality cases after applying this machine. The vital sign, electrocar- (P for trend <0.001). In logistic regression analysis, patients diogram and the ventilator setting did not worsen during with severe bronchiectasis had higher odds of death at ICU and after applying the machine. The nurses gave 5.73 marks discharge (OR 1.10, 95% CI 1.003–1.194) and hospital dis- out of 7. charge (OR 1.17, 95% CI 1.06–1.29). Conclusions: In this prospective study, the overall safety Conclusions: Severe bronchiectasis had a negative impact and efficacy of this suction machine was not inferior to -hu on ICU mortality and in-hospital mortality in critically ill man hand. We expect that human labour can be reduced patients in the medical ICU of Severance hospital. dramatically by using this suction machine. Keyword: Bronchiectasis, Severe bronchiectasis, Mortality Keyword: Suction machine, Intensive care unit, Ventilator

Oral Pulmo (1) 02 Oral Pulmo (1) 03 Clinical Safety and Efficacy of the Machine with Change in Management and Outcome of Automatic Closed-Suction System Mechanical Ventilation in Korea Yune Young SHIN, Young-Jae CHO Jae Kyeom SIM, Gee Young SUH Pulmonology, Seoul National University Bundang Hospital, Korea Department of Critical Care Medicine, Samsung Medical Center, Sungkyunk- wan University School of Medicine, Seoul, Korea Introduction: As the average age has got older worldwide- ly, the number of patients with acute or chronic respiratory Introduction: Despite update of strategies for mechanical disease who need airway suction has got increased rapidly. ventilation (MV), there are few studies describing contem- At present airway suction is done by human hand entirely porary status of MV in Korea. Moreover, it is difficult to and the mean number is 24 a day. For this reason a ma- compare them because of heterogeneity in study design. chine with automatic closed-suction system was invented We investigated change in management and outcome of based on domestic technology. However, the clinical case MV in Korea between 2010 and 2016. of applying this machine to the patients with ventilators in Methods: International, prospective observational cohort the intensive care unit is lack. Therefore we did this study to study has been conducted every six year since 1998. Adult evaluate clinical safety and efficacy of this machine in the patients who required invasive ventilation longer than 12 intensive care unit. hours or non-invasive ventilation (NIV) longer than 1 hour Methods: This pilot study was prospective in the medical were eligible. Korean ICUs participated in 2010 and 2016 intensive care unit of Seoul national university Bundang cohorts. We extracted and analyzed the Korean data. hospital. The machine applied for 24 hours to the patients Results: 226 patients from 18 ICUs and 275 patients from

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12 ICUs enrolled in 2016 and 2010. In 2016 compared (MV) for more than 2 days in medical ICUs from No- to 2010, use of NIV outside ICU increased (10.2 vs 2.5%, vember 2017 to October 2019. T-piece SBT for 30 min p=0.001), but its use in ICU little changed. Pressure-control was conducted until June 2019 and 8 cmH2O pressure ventilation was the most frequently applied mode, followed support ventilation (PSV) SBT for 30 min has been used by pressure-support ventilation and volume-control ven- since July 2019 according to the institutional weaning tilation, whose use decreased significantly. Initial PEEP (6 protocol. After excluding patients who initiated ventilator vs 6 cmH2O, p=0.141) and TV (7.1 vs 7.4 ml/kg, p=0.372) between April 1 and June 30, 2019, patients with ECMO, were similar, but peak pressure (22 vs 24 cmH2O, p=0.011) and whose outcome data were not available, the weaning was lower. More patients received sedatives (70.7 vs 57.0%, outcome based on the WIND (Weaning according to a p=0.002) and analgesics (86.5 vs 51.1%, p<0.001). Use of New Definition) classification were compared between benzodiazepine, particularly midazolam decreased (27.9% the T-piece group (n = 674) and PSV group (n = 97). vs 47.4%, p<0.001), and awakening trial was conducted Results: Successful weaning rate (61.0% vs. 62.9%, more often (48.4% vs. 31.0%, p=0.002). More patients at- P=0.718) and days from the initiation of MV to liberation tempted weaning trial (71.4% vs. 61.4%, p=0.029) and ac- from MV (5 [4–9] days vs. 5 [3–7] days, P = 0.424) were cidental extubation rate much decreased (1.1% vs. 10.2%, similar between the two groups. However, days from the p<0.001). ICU mortality were similar (31.4% vs. 35.6%, first separation attempt to liberation from MV was short- p=0.343), and ICU length of stay had a trend to decrease er in PSV group (0 [0–2] days vs. 0 [0–0] days, P = 0.002). (10 vs 9 days, p=0.054). The incidence of delirium (37.4% vs. In PSV group, the proportion of group 1 (61.9% vs. 43.5%) 8.0%, p<0.001) and ICU-acquired weakness (5.0% vs. 0.7%, classified by the WIND classification was higher and p=0.004) increased. Group 2 (4.1% vs. 17.4%) and Group 3 (8.3% vs. 13.7%) Conclusions: ICU mortality has not improved since 2010. were lower than T-piece group (P = 0.001). There was no But awareness and management of pain, agitation, deliri- statistical difference in hospital mortality and length of Oral Presentation um, and ventilator liberation have improved. stay. Keyword: Mechanical ventilation, Pain, Agitation Conclusions: PSV SBT was associated with a shorter du- ration of weaning from MV and better weaning outcomes in critically ill adult patients admitted to medical ICU. Oral Pulmo (1) 04 Keyword : Mechanical ventilation, Ventilator weaning, Association of pressure support vs. T-piece Spontaneous breathing trial spontaneous breathing trials with weaning outcomes in medical intensive care unit Oral Pulmo (1) 05 Kyeongman JEON1, Soo Jin NA1, Myeong Gyun KO2, Jimyoung NAM1 1Department of Critical Care Medicine, Samsung Medical Center, Sungkyunk- Innovative thoracic phantom for lung pathologies wan University School of Medicine, Korea; 2Intensive Care Unit Nursing simulation Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea Chun-Yi TSAI2, Wen-Min TSENG2, Hsiu-Yung PAN3, Wei-Chun HUANG1 1Critical Care Medicine, Kaohsiung Veterans General Hospital, Taiwan; 2Emer- Introduction: Recent guidelines suggest the inspiratory gency Medicine, Kaohsiung Veterans General Hospital, Taiwan; 3Emergency pressure augmentation rather than T piece or continuous Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan positive airway pressure as initial spontaneous breath- Introduction: Point-of-care Ultrasonography (PoCUS) for ing trial (SBT) when concerning ventilator liberation. lung pathologies evaluation is used increasingly by emer- The objective of this study was to investigate the clinical gency physicians to identify the cause of fever and dyspnea. outcomes according to the method of SBT in critically ill While pathological finding such as pneumonia and empy- adult patients admitted to medical intensive care units ema is difficult to practice on standardized Patient. Ultra- (ICUs). sound models for lung pathologies simulation had been Methods: This is a prospective observational study with described before. Convert to expensive commercial taring consecutive patients receiving mechanical ventilation phantom, this study is to investigate innovative formulation

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 285 Oral Presentation for making the phantoms to simulate lung consolidation, presented to our emergency department with acute-on- abscess and collapsed lung with pleural effusion, and also set shortness of breath. He was diagnosed with chronic able for simulate procedure such as thoracentesis. obstructive pulmonary disease (COPD) 3 months earlier Methods: We used silicon material as nu bra with pork at another hospital, and was receiving bronchodilator rib to build phantom’s chest wall and agar power for the therapy. Physical examination at our emergency depart- pathological lung. We dissolved the agar power with boiled ment revealed diffuse expiratory wheezing. Supine chest water, after thoroughly mixed up, left it cooled down to X-ray showed mild emphysematous changes bilaterally. room temperature. We froze the formed jelly in home re- Electrocardiogram and cardiac enzymes were unremark- frigerator for 10 hours then took it our and left it returned to able. He was eventually intubated due to progressive room temperature. The process of freezing and defrosting dyspnea, and after days of treatment in the intensive care will make the texture of jelly soft and fragile, hence, the unit respiratory weaning was difficult due to persistent sonographic imaging would be similar to the pattern of low tidal volume. Computed tomography disclosed an lung empyema. By adjusting the amount of agar powder, endotracheal tumor near the carina with nearly total different pattern would be demonstrated: with the amount obstruction of the airway (Figure A). Percutaneous car- of powder increased, the particles seen wound increased, diopulmonary bypass using extracorporeal membrane which made it looks like collapsed lung under sonographic oxygenation (ECMO) was begun, and the tumor was ex- study. For creating the model of consolidation, we added cised. Histopathological examination revealed mucoepi- Gelatine into the agar powder to make the jelly harder. dermoid carcinoma. He was weaned from the ventilator Conclusions: The phantom for lung pathologies created after operation and was transferred to the general ward in our study could be made easily with inexpensive cost and discharged 4 days later. In a retrospective review of and the images of sonographic study are similar to the real an upright chest X-ray taken 3 months earlier carefully, a ones. This model could be used to teach common lung pa- round filling defect could be identified in the lower tra- thologies seen in clinical scenes and also able to help stun- chea (Figure B). dent practice thoracentesis procedure. Conclusion: Our case emphasizes the need for careful Keyword: Point-Of-Care Ultrasonography, Simulation, interpretation of chest X-ray in every patient with dys- Lung pnea which is the key for early diagnosis of a tracheal mucoepidermoid carcinoma. ECMO as a life-saving mo- dality, which should also be born in mind when caring Oral Pulmo (1) 06 for a patient with an obstructive endotracheal lesion. Looking into the center of a chest X-ray: a rare Keyword: Mucoepidermoid carcinoma, Airway total ob- case of mucoepidermoid carcinoma causing struction, Chest X-Ray nearly impossible airway Chi-Hsin CHEN1, Wei-Tien CHANG2, Chih-Wei SUNG1, Jia-How CHANG1, Edward Pei-Chuan HUANG1,2 1Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Taiwan; 2Department of Emergency Medicine, National Tai- wan University Hospital, Taiwan

Case: Introduction: Mucoepidermoid carcinoma is a neoplasm of the airway epithelium mostly occurring in the elderly. Airway obstruction with dyspnea is usually the first symptom. Once the tumor grows larger, it may Figure A. Figure B. cause total airway obstruction leading to an impossible airway and becomes potentially visible on chest X-ray as a filling defect in the tracheal air column. Case presentation: A 76-year-old nonsmoking male

286 KSCCM·ACCC 2020 Oral Presentation

Oral Pulmo (1) 07 Table 1. Risk factors that influence the incidence of ARDS Validity of lung injury prediction score as a predictor of acute respiratory distress syndrome in intensive care unit sanglah hospital denpasar Cynthia Dewi SINARDJA, Budi HARTONO Department of Anesthesia and Intensive Care, Faculty of Medicine, Udayana University, Indonesia

Introduction: Acute Respiratory Distress Syndrome (ARDS) is a serious clinical problem throughout the world with high economic burden, high morbidity and mortality. Effective therapies for ARDS have not been found resulting in an awareness of the importance of its prevention. A major obstacle to ARDS prevention is identification of patients at risk for ARDS. The validity of the lung injury prediction score (LIPS) as a predictor of Conclusions: LIPS is valid as a predictor of ARDS. Factors ARDS is still controversial. The purpose of this study is to other than LIPS that associated with ARDS are driving pres- assess the validity of LIPS as a predictor of ARDS in the sure 15 cmH2O or more, positive fluid balance, and admin- Intensive Care Unit (ICU) at Sanglah Hospital, Denpasar, istration of plasma transfusions. Bali. Keyword: LIPS, ARDS, ICU Methods: This study is an analytic observational study Oral Presentation with a cohort retrospective design. This study involved ICU patientsWITHDRAWAL at Sanglah General Hospital Denpasar in Oral Pulmo (1) 08 2018. Retrospectively, LIPS scores were assessed when admitted to ICU and followed up for 7 days. The diagno- A Randomized Control Trial Comparing Channeled sis of ARDS is made according to the Berlin criteria. Videolaryngoscope and Macintosh Laryngoscope Results: Among the 451 subjects involved, the lowest For Endotracheal Intubation in The Critically ill LIPS score was zero and the highest was 11.5. At the cut Dharanindra MOTURU off point of 5, this score has a sensitivity of 85.71% and Department of Critical Care Medicine, Bharati Vidyapeeth University- College specificity of 80.77%, positive predictive value of 27.3%, Of Medicine, India negative predictive value of 98.5%, positive likelihood Introduction: The National Audit Project (NAP-4) of the ratio (LR) of 4.46 and negative LR 0.177, with area under Royal College Of Anaesthetists revealed 60 percent of ROC curve (AUC) of 0.86 (95% CI 0.81-0.91) airway related events that occur in the ICU have led to death and brain damage compared to 14 percent in the operating room. This emphasizes the Physiologically Dif- ficult Airway in the ICU. One of the causes includes a lack of use of appropriate equipment. Recent Metanalysis of Video laryngoscopy in critically ill for endotracheal intu- bation were ambiguous. Methods: We conducted a parallel-group Randomized control trial of 143 patients comparing a channeled Video laryngoscope -King Vision(KVL) with Macintosh laryn- goscope for emergent endotracheal intubation in ICU by Figure 1. Frequency of ARDS base on LIPS score Critical care medicine residents experienced and trained with video laryngoscopy. Exclusion criteria were patients

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 287 Oral Presentation with upper airway deformities and subglottic stenosis. Oral Pulmo (2) 09 Primary Objectives were a)First attempt success rate at intubation b)Time taken for Intubation c) Glottic view The Exploration of Recurrent Intubation with Obtained in terms of Cormack & Lehane grading(CML). Ventilator of Older Patients at ICU in a Southern Patients were randomized using Sequentially Numbered Taiwan Hospital 1,2 3 4 Opaque Sealed Envelopes and an Airway assessment was Jia-Wei LIN , Shu-Chen HSING , Kuei-Ling TSENG 1 done using the MACOCHA score. DAS UK Guidelines for Departments of Neurology Medicine, Chi Mei Medical Center, Liouying, Tai- wan; 2Departments of Healthcare Management, Chia Nan University of Phar- Tracheal Intubation in Critically ill were followed. macy and Science, Tainan, Taiwan; 3Departments of Respiratory Therapy, Chi 4 Results: The First attempt success rate at endotracheal Mei Medical Center, Tainan, Taiwan; Departments of Respiratory Therapy, Chi Mei Medical Center, Tainan, Taiwan intubation with KVL was 95.8 % compared to 81.2% with Macintosh Laryngoscope(p<0.05). The time taken for in- Introduction: Critical patients with intubation at inten- tubation with KVL was 28.77±2.63 seconds compared to sive care unit (ICU) were high mortality and high costs. 34.84 ±2.72 with Macintosh(p=0.003). In KVL group 78.1% Especially, older patients were accompanying recurrent of the cases were having glottic view of CML grade 1, 21.9% intubation with ventilator that was one of risk factor. The were having CML grade 2a, compared to 8.6% of cases in aim of this study was focused on the exploration of recur- Macintosh group with CML grade 1, 68.6% with grade 2a, rent intubation with ventilator for these older patients. 20% with grade 2b and 2.8% with 3a, p=0.0001 Methods: This retrospective observational study was in Channeled Video laryngoscope has im- Conclusions: a medical center in southern Taiwan. All nonagenarian proved the first attempt success rate, lessened time re- patients admitted to the medical and surgical ICU, were quired for intubation and improved glottic visibility. A enrolled between 01 Jan 2017 and 31 Dec 2018. Those channeled video laryngoscope along with adequate train- who were received recurrent intubation with ventilator ing in video laryngoscopy may improve the first attempt over two times and older patient (Age≧65) included in success rate for endotracheal intubation in the critically ill. this study. Statistical analyses were conducted using the Keyword: Tracheal intubation in the Critically ill, Vid- eolaryngoscopy in critically ill, Physiologically difficult SPSS software package (version 18.0). The results are ex- airway pressed as mean standard deviation (SD) for continuous variables and frequency (%) for categorical variables. The data was analyzed using the chi-square test and Student’s t-test. For all tests, a p value of less than 0.05 was consid- ered statistically significant. Results: No eligible patients required exclusion from this study. A total of 2091 patients were enrolled during the study period with a mean age of 76.4±7.7 years (range, 65 to 102),table 1. All older patients were recurrent intu- bation with ventilator ( defined : intubation with venti- Figure 1. Primary objectives. lator≧2times at ICU). However, 678 patients were died, the overall mortality was 32.4%. The longer MV days and higher APACHE II score had a significantly in-hospital mortality, table 2. In addition, Intubation due to Age, Cat- egory of transferred ICU, on MV times, ICU Length, TISS, COMA scale were obviously high risk factors (p<0.001). Conclusions: The results of this study showed that Cate- gory of transferred ICU was a reliable indicator to identify patients at high risk of in-hospital mortality. Especially, Figure 2. Glottic visibility - Copy. medicine ICU of older patients undergo recurrent intu-

288 KSCCM·ACCC 2020 Oral Presentation bation with ventilator were high mortality, more than Oral Pulmo (2) 10 surgery ICU. Due to the medicine of older Keyword: Recurrent intubation, Mortality, intensive care Impact of timing of renal replacement therapy unit initiation on outcome of acute kidney injury in septic patients in a tertiary care centre in a low- middle country Muhammad Sohaib AZHAR, Nasir KHOSO, Madiha HASHMI, Zahoor AHMED Anaesthesiology Department, Aga Khan University, Pakistan

Introduction: To determine whether the timing of initia- tion of continuous renal replacement therapy (CRRT) af- fects outcome in patients with acute renal failure (ARF) in term of 28 days mortality. Methods: Methodology: This retrospective data reviewed all patients who developed acute kidney injury and CRRT was initiated between 2009 to 2018 (10 years) and enrolled all septic cases and age more than18 years who had admit- ted in surgical intensive care unit. Renal replacement thera- py started with a blood urea nitrogen (BUN) of <100 mg/dL was defined as ‘‘early’’ initiation, and initiation with a BUN

≥100 mg/dL was defined as ‘‘late.’’ Kaplan-Meier survival Oral Presentation analysis was performed and median survival was comput- ed. In all instances, the level of statistical significance was Results: Forty patients were included in our analysis. Thirty patients (75%) had ‘‘early’’ CRRT initiation, with a mean BUN of 66 ±20.2 mg/dL and 10(25%) patients had ‘‘late’’ CRRT initiation with a mean BUN of 137 ±28.4 mg/ dL. There was no significant difference in APACHE II score and GCS between the 2 groups. The overall survival rates in both groups were 49.6%, and 10.4% at 10 and 25 days, respectively. Median survival time was not statistically significant between early and late CRRT groups [9(2.74) vs. 11(0.41); p=0.997]. Survival rates in the ‘‘early’’ RRT group were 70% and 16.7% at 10, and 25 days, respectively. The survival rates for the patients in the ‘‘late’’ RRT group were 57.1%, 11.5% at 10 days and 25 days respectively. Conclusions: Septic patients who developed AKI and start- ed on early or late continuous renal replacement therapy did not showed in any mortality benefit at 28 day between two groups. Keyword: Acute Kidney Injury, Renal Replacement Thera- py, Sepsis

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 289 Oral Presentation

Oral Pulmo (2) 11 Factors associated with extubation failure in Intensive Care Unit Patients after Spontaneous Breathing Trial Niraj Kumar KEYAL1, Roshana AMATYA2, Gentle Sundar SHRESTHA3, Saurabh PRADHAN4, Krishna Kumar AGRAWAL5, Hem Raj PANERU6 1Critical Care Medicine, B & C Medical College Teaching Hospital & Research Center Pvt Ltd. Birtamode-5, Jhapa. Province no 1, Nepal, Nepal; 2Anaesthe- siology, Tribhuvan University Teaching Hospital.Maharajgunj Kathmandu., Nepal; 3Anaesthesiology, Tribhuvan University Teaching Hospital.Maharajgunj Kathmandu, Nepal; 4Anaesthesiology, Tribhuvan University Teaching Hospital. Maharajgunj Kathmandu, Nepal; 5Nephrology, Nepal Medical College, Nepal; 6Anaesthesiology, Tribhuvan University Teaching Hospital.Maharajgunj Kath- mandu, Nepal

Introduction: Extubation failure is defined as reintubation Figure 1. Kaplan-Meir estimate of survival within 48 hours[2] of extubation and occurs in about 24.5% of patients.[3-4] It is associated with prolong stay, tracheos- Table 1. Demographic characteristics of patients tomy and higher mortality. The purpose of this study was to know the risk factor for extubation failure in ICU patients after successful Spontaneous Breathing Trial. Methods: It was a prospective observational study done in 108 patients who were planned for extubation in Insti- tute of Medicine Kathmandu. Patients were assessed by intensivistWITHDRAWAL clinically and decided whether a patient can be extubated on clinical grounds. Spontaneous Breathing Trial was done for 2 hours by T-piece in patients who met clinical and objective criteria. ABG was done in all patients who successfully completed Spontaneous Breathing Trial. Patients with successful SBT, acceptable ABG were extubat- ed. Patients were observed for 48 hours for extubation fail- Table 2. Clinical and laboratory parameter before CRRT ure. Reason for extubation failure was noted. Patients with unacceptable ABG underwent other modes of weaning. Results: Out of 108 patients who passed the SBT, 96(88.88%) patients had acceptable ABG and were extubat- ed and 12(11.11%) patients did not have acceptable ABG and were chosen to have other mode of weaning. Out of 12 patients, 5(41.66%) underwent successful extubation to BiPAP and 7(58.33%) underwent tracheostomy. Out of 96 patients who were extubated, 85(88%) underwent success- ful extubation and 11(12%) underwent unsuccessful extu- bation.COPD and Duration of mechanical ventilation was identified as a risk factor for extubation failure in this study. (p<0.05) Conclusions: This study demonstrates that COPD and duration of mechanical ventilation was a risk factor for ex- tubation failure in this study. We need a composite scoring

290 KSCCM·ACCC 2020 Oral Presentation system to predict extubation failure as different studies hypercapnic groups (18.6% vs. 21.3%, p=0.586). After have identified different risk factor for extubation failure. propensity score matching, there was also no signifi- cant difference in the reintubation rate between the two Table 1. Risk factors for extubation failure groups (13.8% vs. 20.0%, p=0.481). In the propensity score-matched cohort, compared using a generalized estimating equation logistic regression model, there was no significant difference in the reintubation rate between the two groups (p=0.346). Conclusions: When attempting extubation in patients Keyword: Chronic obstructive airway disease, Extubation, with improved respiratory failure, HFNC therapy may be Spontaneous breathing trial helpful in most patients regardless of hypercapnia, except those with hypercapnic respiratory failure. According to this study results, HFNC can be applied more broadly in Oral Pulmo (2) 12 hypercapnic patients in clinical situations. Large-scale, prospective, randomized controlled study are required High-flow nasal cannula therapy can be effective for extubated patients with hypercapnia for definitive conclusions. Keyword: High-Flow nasal cannula , Hypercapnia, Hong Rae CHO1, Jong-Joon AHN2, Chuiyoung PAK3, Jin Hyoung KIM3, Post-Extubation Byung Ju KANG2 1Department of Surgery, Ulsan University Hospital, Korea; 2Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Korea; 3Department of Internal Medicine, Ulsan University Hospital,

Korea Oral Presentation

Introduction: A high-flow nasal cannula (HFNC) may be helpful in patients at risk of extubation failure. Al- though most previous studies have evaluated its efficacy in patients without hypercapnia, in clinical practice, physicians have been frequently using HFNC in patients with hypercapnia. We investigated the efficacy of HFNC therapy for patients with hypercapnia compared to those without hypercapnia in a post-extubation state.

Methods: We performed a retrospective cohort study of critically ill patients who received HFNC therapy after extubation at intensive care units of one university hospi- tal between January 2012 and June 2018. After excluding patients with hypercapnic respiratory failure (pH < 7.35 & PaCO2 ≥ 45 mmHg), we classified the patients into nonhypercapnic (PaCO2 < 45 mmHg) and hypercapnic (PaCO2 ≥ 45 mmHg) groups according to their PaCO2 levels immediately before HFNC therapy. We compared the outcomes of both groups and adjusted them through propensity score matching. Results: A total of 419 patients were enrolled, 75 of whom were included in the hypercapnic group. The reintuba- tion rate was similar between the nonhypercapnic and

The 40th KSCCM Annual Congress · Acute and Critical Care Conference 2020 291 Oral Presentation

Methods: We performed a single center, open-label trial in which patients under MV for longer than 12 hours who fulfilled criteria for planned extubation were randomly assigned to undergo SBT in one of two ways: with a T-piece therapy or with HFOT. The primary end-point was rate of weaning failure rate, which was defined as failed to SBT within 3 days or reintubation within 48 hours after extuba- tion. Analysis was by intention to treat. Results: Of 30 patients (mean age, 70 ± 9; 70% men), 16 received HFOT and 14 T-piece therapy. Median time from intubation to SBT did not differ between HFOT (5.2 [2.0- 7.7] days) and T-piece group (3.4 [1.6-6.2] days). There were also no differences in other baseline characteristics be- tween groups. The weaning failure rate was 21% (3/16 pa- tients) in the HFOT and 19% (3/14 patients) in the T-piece group (p>0.999). SBT success was 100% (16/16 patients) in the HFOT and 93% (13/14 patients) in the T-piece group (p=0.946). Reintubation within 48 hours after extubation did not significantly differ: 2/15 patients (13.3%) in the HFOT vs 2/13 patients (15.4%) in the T-piece group. A multivariable regression demonstrated that the variables borderline associated with weaning failure were days of MV before SBT (OR 1.75; 95% CI 0.99-3.10; p=0.056) and rapid shallow breathing index (OR 1.08; 95% CI 0.99-1.18; p=0.080), whereas age, type of SBT, and SOFA score were not. The ICU and hospital mortality, and ICU length of stay were not significant different between groups. Oral Pulmo (2) 13 Conclusions: HFOT was not superior to T-piece therapy in Effect of high flow oxygen therapy in SBT on weaning in MV patients. spontaneous breathing trial on weaning: An Keyword: Spontaneous breathing trial, High flow oxygen interim analysis of randomized trial therapy, T-Piece therapy Hong Yeul LEE, Jaeyoung CHO, Nakwon KWAK, Jinwoo LEE, Sun Mi CHOI, Young Sik PARK, Chang-Hoon LEE, Chul-Gyu YOO, Young Whan KIM, Sang-Min LEE Oral Pulmo (2) 14 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Korea Characteristics and outcome of lung cancer patients admitted to intensive care units Introduction: High flow oxygen therapy (HFOT) is a Hee-Sung KIM, Yoon Mi SHIN promising first-line therapy for acute respiratory failure Department of Internal Medicine, Chungbuk National University Hospital, and preventing post-extubation respiratory failure. To date, Chungbuk National University college of Medicine, Korea little consensus exists on optimal method of spontaneous Introduction: Lung cancer survival has improved over breathing trial (SBT) and role of HFOT have not been eval- time, but many lung cancer patients at the end of life have uated for SBT. The aim of this study is to determine the ef- been receiving intensive care therapy despite poor progno- fect of HFOT in SBT on weaning in mechanical ventilation sis. We analyze outcome of lung cancer patients admitted (MV) patients.

292 KSCCM·ACCC 2020 Oral Presentation to intensive care units and identify characteristics associat- Keyword: Lung cancer, Intensive care units, APACHE II ed with mortality. score Methods: A retrospective analysis of the medical record of Table 1. 97 lung cancer patients who were admitted to the ICU be- tween January 2014 and December 2018 was performed. Results: Among 97 patients, 72 (74.2%) patients had non- small cell lung cancer, 15 (15.5%) patients had small cell lung cancer, and in the remaining 10 patients, the type of lung cancer could not be determined. In patients with non- small cell lung cancer, 44 patients had stage IV. 12 patients with small cell lung cancer had extensive stage disease. The Table 2. main reasons for admission in ICU were acute respiratory failure due to pneumonia (58 patients) and cancer progres- sion (15 patients). Median ICU stay length was 24.0 [13- 42] days. During the ICU stay, mechanical ventilation was required in 67 patients. 84 patients received antibiotics and 40 patients received corticosteroid therapy. Of the 97 pa- tients, 63 died in ICU (64.9%) and 34 survived and returned home (35.1%). Predictive factors of mortality during ICU were APACHE II score and need for mechanical ventilation. Conclusions: Triage policies using APACHE II score and requirement of mechanical ventilation may be useful for Oral Presentation determining the withdrawal of intensive care.

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No. 회사명 Company Company Profile & Product

3M was founded in 1902 as a mining venture and a culture of innovation has driven our success for more than 117 years. 3M Korea is supplying about 17,000 products including medical related products and maintaining superiority in the market by each business division by presenting better quality standards and leading the growth of industry. 1 한국쓰리엠 3M Korea Especially, 3M Korea Medical Solutions Division is pioneering medical advancement in hospitals by infection prevention, patients monitoring, skin protection & wound healing. 3M is providing Tegaderm™ CHG dressing, Curos and other solutions for reducing catheter related bloodstream infections. It is contributing to the improvement of medical quality.

Pfizer, which was founded in Brooklyn, USA in 1849, began operating in Korea in the 1960s. Since then, Pfizer has contributed significantly to economic and workforce 한국화이자 2 Pfizer Korea Ltd. development in Korea, invested heavily in innovation and research to support the 제약㈜ development of new medicines, and given back to the community through new partnerships and philanthropic ventures.

Medtronic plc (www.medtronic.com), headquartered in Dublin, Ireland, is among the world’s largest medical technology, services and solutions companies – alleviating pain, restoring health and extending life for millions of people around the world. 메드트로닉 Medtronic employs more than 90,000 people worldwide, serving physicians, hospitals 3 Medtronic Korea 코리아 and patients in more than 150 countries. The company is focused on collaborating with stakeholders around the world to take healthcare Further, Together. Launched in 2000 as a subsidiary of Medtronic, Medtronic Korea has been offering advanced medical technologies, products and services for patients and other customers in Korea.

한국엠에스디 MSD is a global healthcare company that delivers innovative health solutions through 4 MSD Korea 유한회사 its prescription medicines, vaccines, biologic therapies, and animal health products.

HANLIM Pharm. was established in 1974 and have been selected as "Innovative Pharmaceutical Company" in 2012 With the mission of "Protecting the Precious Human Life from Various Forms of Diseases". ULTIAN® Inj. (No.1 product in remifentanil) Hanlim Pharm. 5 한림제약㈜ is indicated as strong analgesic agent for IV administration during induction and CO.,LTD. maintenance of general anaesthesia and providing of analgesia and sedation in mechanically ventilated ICU with rapid onset & offset of action, providing reduced-time to extubation after cessation of sedation and ICU-LOS.

에드워즈 Edwards Our company is driven by a passion to help patients. We partner with clinicians to 6 라이프사이언시스 LifeSciences develop innovative technologies in the areas of structural heart disease and critical 코리아㈜ Korea care monitoring to help patients live longer, healthier and more productive lives.

Royal Philips is a leading health technology company focused on improving people’s health and enabling better outcomes across the health continuum from healthy living and prevention, to diagnosis, treatment and home care. Philips leverages advanced technology and deep clinical and consumer insights to deliver integrated solutions. 7 필립스 PHILIPS Headquartered in the Netherlands, the company is a leader in diagnostic imaging, image-guided therapy, patient monitoring and health informatics, as well as in consumer health and home care. Philips generated 2019 sales of EUR 19.5 billion and employs approximately 81,000 employees with sales and services in more than 100 countries.

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Fresenius Medical Care is the world’s leading provider of products and services for individuals with renal diseases of which around 3.5 million patients worldwide Fresenius regularly undergo dialysis treatment. Through its network of 4,000 dialysis clinics, ㈜프레제니우스 8 Medical Care Fresenius Medical Care provides dialysis treatments for 345,000 patients around the 메디칼케어코리아 Korea globe. Fresenius Medical Care is also the leading provider of dialysis products such as dialysis machines or dialyzers. Along with the core business, the company focuses on expanding the range of related medical services in the field of Care Coordination.

Established in 1990, the Korean arm of Roche’s global diagnostics division, has offered innovative products and services for early detection, prevention, diagnosis, treatment and monitoring of disease by testing samples of blood, bodily fluid, or tissue. The organization consists of four business units – Centralised and Point of Care Solutions, Molecular Diagnostics, Tissue Diagnostics and Diabetes Care, and has a very broad product portfolio of high-throughput in-vitro diagnostic (IVD) systems for hospitals and commercial diagnostic laboratories, instruments and reagents for life science research, point-of-care testing devices for use in doctors’ offices and blood glucose meters for people with diabetes. In 2019, the company launched a cloud-based clinical decision Roche support data platform, NAVIFY Tumor Board, and entered the digital healthcare field in 9 한국로슈진단 Diagnostics earnest. In particular, Roche Diagnostics works together with Roche Pharma to diagnose Korea genetic and histological traits of individuals to ensure optimal treatment, making efforts to improve the quality of life in human beings in the era of personalized medicine. In addition, Roche Diagnostics Korea is committed to corporate social responsibility through its continuous CSR programs such as fund-raising walking campaign for children in Africa, CSR agreement to support for underprivileged children in Korea, and outreach program for childhood diabetes. It was awarded as the year’s Best Employer in Korea by Aon Hewitt for 3 consecutive years from 2015 to 2017. In 2019, it won the Grand Award for 100 Great Companies to Work for in Korea hosted by the Great Place To Work Institute. More information is available at www.roche-diagnostics.co.kr.

We are a global healthcare company that specializes in lifesaving medicines and technologies for infusion, transfusion and clinical nutrition. In the field of biosimilars, we 프레지니우스카비 Fresenius Kabi focus on autoimmune diseases and oncology. Our products and services are used to 10 코리아 Korea help care for critically and chronically ill patients. With our corporate philosophy of “caring for life”, we are committed to putting essential medicines and technologies in the hands of people who help patients and finding the best answers to the challenges they face.

Yuhan Corporation’s story began with Dr. Ilhan New’s commitment to his country: to provide his fellow Koreans with the best medications and treatments available. Now, over 80 years later, the spirit of our founder continues to drive Yuhan forward as we reach out to the world, to improve the health and well-being of people everywhere. Yuhan’s willow tree, the literal translation of Dr. New’s surname, has become our symbol of integrity. It represents not only the quality of our products, but the ethics, 11 유한양행 YUHAN transparency and social responsibility of our management philosophy as well. Today, Yuhan continues to grow as a global company, with the wellness of people as our first priority. Yuhan’s state-of-the-art research and development facilities are where it all begins. Our focused R&D efforts have yielded Revanex, a new acid-pump antagonist designed to treat gastric ulcers, as well as a number of new drug entities for antibiotics, cancer, hepatitis C, arthritis, osteoporosis, and other conditions. Completed in 2006, our Ochang General Formulations Plant is highly automated and in full compliance

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No. 회사명 Company Company Profile & Product

with current Good Manufacturing Practices (cGMP). It features scalable, flexible production lines and advanced logistics systems, giving Yuhan the capability to bring high-quality medicines to market and to patients quickly and efficiently. Our large-scale Shi Hwa Synthetic Plant, opened in 1998, remains at the leading edge of pharmaceutical technology. Both Ochang and Shi Hwa are approved by the United States Food and Drug Administration (FDA), the European Medicines Agency and the European. Directorate for the Quality of Medicines (EMEA/EDQM), Australia’s Therapeutic Goods Administration (TGA), Japan’s Pharmaceuticals and Medical Devices Agency (PMDA), and other regulatory organizations. Together, these plants allow us deliver active pharmaceutical ingredients (APIs), manufactured to the highest standards, to our partners around the globe. Yuhan is prepared, with new ideas and methods, to take the lead toward a future filled with new pharmaceutical discoveries and continuing growth. As we endeavor to earn the trust of our customers and uphold our social responsibilities, Yuhan will create greater value for our stakeholders through ongoing innovation and international expansion. Yuhan will always be with you, our customers and partners, to create a healthier and more prosperous society.

The Korea National Institute for Bioethics Policy was established in 2012 to carry out specialized surveys, research, and education on bioethics policy and contribute to Korea National having biomedical science and its technologies safely researched, developed, and used (재)국가생명윤리 Institete for in the course of development for prevention and treatment of human diseases. As the 12 정책원 Bioethics Policy life-sustaining treatment decisions system has been implemented since February 2018, (KoNIBP) our institution is performing the function by being designated as the National Agency for Management of Life-sustaining Treatment to properly manage life-sustaining treatment, decision to withdraw or withhold LST and the implementation thereof.

Kyongbo Pharmaceutical was founded in 1987 with the explicit purpose of improving the health and the lives of humankind. Committed to developing active ingredients of the highest quality through innovations in manufacturing technology, Kyongbo Pharmaceutical became the first company in South Korea to develop the antibiotic Cefaclor. Our ongoing work to advance our own manufacturing and quality- management standards has even earned us the cGMP certifications from various authorities such as FDA in US, EDQM in Europe, PMDA in Japan, and CFDA in the KyongBo China, giving us the license to manufacture active ingredients for sterile injectables 13 경보제약 Pharmaceuticals and first generic drugs. Thanks to our continuing investments in facilities and R&D, we are exporting $85,000,000’s worth of products such as cephalosporin antibiotics, antihyperlipidemic agents, and anti-cancer drugs to more than thirty countries around the world and fast becoming a truly global corporation. Since 2001 Kyongbo Pharmaceutical has manufactured various finished products including anesthetic, cardiovascular, digestive and antibiotic. Kyongbo Pharmaceutical is committed to evolving into a humanitarian corporation offering high-quality pharmaceuticals that improve the health and lives of humankind.

Koonja Publishing Inc is a medical publisher and covers Medical Science, Dentistry, Korean Medicine, Nursing, Guides to Examinations, Health Care, and even Child Care, leading the Koonja 14 군자출판사 market in South Korea. Koonja Publishing Inc cooperates with societies and professionals Publishing Inc to develop well-made medical contents and has supplies of around 3000 kinds contents. Since its open in 1980, it has developed and supplied around 100 books every year.

GC Pharma, Becoming a leader In the global health industry, Ushering in a healthier 15 GC녹십자 GC Pharma future For all humankind

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Mindray as one of the leading global providers of medical devices and solutions, firmly committed to the mission of “advance medical technologies to make healthcare more accessible”. Mindray possesses a sound global R&D, marketing and service network. Inspired by the needs of customers, adopting advanced technologies and transform them into accessible 16 마인드레이메디칼 Mindray Medical innovation, bringing healthcare within reach. Today, Mindray’s products and services can be found in healthcare facilities in over 190 countries and regions. Mindray has been at the forefront of the battle, supporting our health care partners with accessible resources and information to win the fight as the world unites to combat COVID19, rapid and open sharing of resources is more important than ever.

MEK-ICS has taken the lead of developing and commercializing ventilators based on Korea’s first and unique respiratory technologies. We are proactive in expanding the application of our respiratory care solutions developed by various research activities in order to help more patients. This effort will allow us to expand our top-notch technologies to both hospital and homecare sectors with the presentation of various evidences on how the demographic and environmental changes have effects on 17 ㈜멕아이씨에스 MEKICS Co., Ltd. respiration and health of the mankind. MEK-ICS has a strong belief that product safety and quality of raw materials must in no way be compromised. To this end, we have established internal systems and R&D bases satisfying the quality and safety standards for the functionality of respiratory care products. Those help us correctively understand overseas local market circumstances and build a technologically cooperative agent system, thereby contributing to MEC-ICS evolving into a global player in the respiration care market.

A global leader in in vitro diagnostics for over 55 years, bioMérieux has always been driven by a pioneering spirit and unrelenting commitment to improve public health worldwide. The Company is present in 44 countries and serves more than 160 countries with the support of a large network of distributors. It provides diagnostic bioMérieux 18 ㈜비오메리으코리아 solutions that improve patient health and ensure consumer safety. bioMérieux KOREA develops and produces in vitro diagnostic solutions (systems, reagents, software and services) for private and hospital laboratories, mainly for the diagnosis of infectious diseases. The results obtained from a patient sample (blood, urine, stool, cerebrospinal fluid, saliva, etc.) provide doctors with information to support their decisions.

ChinooMed ChinooMed Co., Ltd. is specialized in airway management products. We specialize 19 주식회사 친우메드 Co., Ltd. especially in video laryngoscope and bronchoscope.

GE Healthcare is the $19.8 billion healthcare business of GE (NYSE: GE). As a leading provider of medical imaging, monitoring, GE Healthcare enables precision health in diagnostics, therapeutics and monitoring through intelligent devices, data analytics, applications and services. With over 100 years of experience in the healthcare industry 20 지이헬스케어 GE Healthcare and more than 50,000 employees globally, the company helps improve outcomes more efficiently for patients, healthcare providers, researchers around the world. Follow us on Facebook, LinkedIn, Twitter and The Pulse for latest news, or visit our website https://corporate.gehealthcare.com/ for more information.

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No. 회사명 Company Company Profile & Product

Headquartered in Dublin, Ohio, Cardinal Health, Inc. (NYSE: CAH) is a global, integrated healthcare services and products company, providing customized solutions for hospitals, health systems, pharmacies, ambulatory surgery centers, clinical laboratories and physician offices worldwide. The company provides clinically-proven medical products and pharmaceuticals and cost-effective solutions that enhance supply chain efficiency from hospital to home. Cardinal Health connects patients, providers, payers, 카디널헬스 Cardinal Health pharmacists and manufacturers for integrated care coordination and better patient 21 코리아(유) Korea Ltd. management. Backed by nearly 100 years of experience, with approximately 50,000 employees in 46 countries, Cardinal Health ranks among the top 25 on the Fortune 500. Cardinal Health is more than a business, more than a partner, more than hard workers. It’s wings. Its unrivaled scale and focused approach leads to better solutions. The company’s strength flows from four areas of expertise: logistics, product, business and patient solutions. Cardinal Health welcomes new challenges, anticipates trends, and as Wings, brings support, speed, and mile-high vision to all customers.

Fisher&Paykel healthcare is a world leader in medical devices and systems for use in respiratory care and acute care and in the treatment of obstructive sleep apnea Our 피셔앤파이클 Fisher&Paykel global headquarters are located in Auckland, New Zealand and our products are 22 헬스케어아시아 Healthcare manufactured in New Zealand and in Mexico and in sold in over 120 countries. In the 리미티드 last year we estimate that our product were used in the treatment of more than nine million patients worldwide.

Dräger is a leading international company in the fields of medical and safety technology. Founded in Lübeck in 1889, Dräger has grown into a worldwide, DAX- listed enterprise in its fifth generation as a family-run business. “Technology for Life” is our guiding principle. In clinical settings, industry, mining or emergency services, 한국드레가 Draeger Korea 23 Draeger products protect, support and save lives. In the field of safety, Draeger 주식회사 Co., Ltd. offers complete hazard management solutions (gas detection systems, respiratory protection, firefighting equipment etc.). The medical product range covers e. g. anesthesia workstations, ventilation equipment for intensive care, neonatal care, patient monitoring and workplace systems.

Astellas Pharmaceutical Korea, Inc. is an affiliate of leading pharmaceutical company in Japan, which has excellent research and development capability and worldwide sales network. Mycamine® injection(micafungin sodium) is FDA-approved echinocandin 한국아스텔라스 Astellas Phama 24 class anti-fungal drugs that have lower rate of resistance to fungi compared to azole- 제약 Korea.Inc class drugs and excellent anti-fungal effects against Candida species. Mycamine® injection can be used for the prevention and treatment of Candidiasis and Candidemia in ICU patients.

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이 발표논문집은 2020년도 정부재원으로 한국과학기술단체 총연합회와 서울관광재단의 지원을 받아 발간되었음. This work was supported by the Korean Federation of Science and Technology Societies Grant funded by the Korean Government and Seoul Tourism Organization.