Factors Affecting Invasive Management after Unplanned Extubation in an Intensive Care Unit / 대한구급학회지

BACKGROUND: Unplanned extubation (UE) of patients requiring mechanical ventilation in an intensive care unit (ICU) is associated with poor outcomes for patients and organizations. This study was conducted to assess the clinical features of patients who experienced UE and to determine the risk factors affecting reintubation after UE in an ICU. METHODS: Among all adult patients admitted to the ICU in our institution who required mechanical ventilation between January 2011 and December 2013, those in whom UE was noted were included in the study. Data were categorized according to noninvasive or invasive management after UE. RESULTS: The rate of UE was 0.78% (the number of UEs per 100 days of mechanical ventilation). The incidence of self-extubation was 97.2%, while extubation was accidental in the remaining patients. Two cases of cardiac arrest combined with respiratory arrest after UE were noted. Of the 214 incidents, 54.7% required invasive management after UE. Long duration of mechanical ventilation (odds ratio [OR] 1.52; 95% confidence interval [CI] 1.32-1.75; p = 0.000) and high ICU mortality (OR 4.39; 95% CI 1.33-14.50; p = 0.015) showed the most significant association with invasive management after UE. In multivariate analysis, younger age (OR 0.96; 95% CI 0.93-0.99; p = 0.005), medical patients (OR 4.36; 95% CI 1.95-9.75; p = 0.000), use of sedative medication (OR 4.95; 95% CI 1.97-12.41; p = 0.001), large amount of secretion (OR 2.66; 95% CI 1.01-7.02; p = 0.049), and low PaO2/FiO2 ratio (OR 0.99; 95% CI 0.98-0.99; p = 0.000) were independent risk factors of invasive management after UE. CONCLUSIONS: To prevent unfavorable clinical outcomes, close attention and proper ventilatory support are required for patients with risk factors who require invasive management after UE.

Factors Affecting Invasive Management after Unplanned Extubation in an Intensive Care Unit / 대한중환자의학회지

BACKGROUND: Unplanned extubation (UE) of patients requiring mechanical ventilation in an intensive care unit (ICU) is associated with poor outcomes for patients and organizations. This study was conducted to assess the clinical features of patients who experienced UE and to determine the risk factors affecting reintubation after UE in an ICU. METHODS: Among all adult patients admitted to the ICU in our institution who required mechanical ventilation between January 2011 and December 2013, those in whom UE was noted were included in the study. Data were categorized according to noninvasive or invasive management after UE. RESULTS: The rate of UE was 0.78% (the number of UEs per 100 days of mechanical ventilation). The incidence of self-extubation was 97.2%, while extubation was accidental in the remaining patients. Two cases of cardiac arrest combined with respiratory arrest after UE were noted. Of the 214 incidents, 54.7% required invasive management after UE. Long duration of mechanical ventilation (odds ratio [OR] 1.52; 95% confidence interval [CI] 1.32-1.75; p = 0.000) and high ICU mortality (OR 4.39; 95% CI 1.33-14.50; p = 0.015) showed the most significant association with invasive management after UE. In multivariate analysis, younger age (OR 0.96; 95% CI 0.93-0.99; p = 0.005), medical patients (OR 4.36; 95% CI 1.95-9.75; p = 0.000), use of sedative medication (OR 4.95; 95% CI 1.97-12.41; p = 0.001), large amount of secretion (OR 2.66; 95% CI 1.01-7.02; p = 0.049), and low PaO2/FiO2 ratio (OR 0.99; 95% CI 0.98-0.99; p = 0.000) were independent risk factors of invasive management after UE. CONCLUSIONS: To prevent unfavorable clinical outcomes, close attention and proper ventilatory support are required for patients with risk factors who require invasive management after UE.

Changes of Kidney Injury Molecule-1 Expression and Renal Allograft Function in Protocol and for Cause Renal Allograft Biopsy / 대한이식학회지

BACKGROUND: Kidney injury molecule-1 (KIM-1) is known as a good ancillary marker of acute kidney injury (AKI) and its expression has also been observed in acute rejection and chronic graft dysfunction. We tested usefulness of KIM-1 as an indicator of acute and chronic renal graft injury by correlating KIM-1 expression with renal graft function and histology. METHODS: A total of 133 zero-time biopsies and 42 follow-up biopsies obtained within 1 year posttransplantation were selected. Renal tubular KIM-1 staining was graded semiquantitatively from 0 to 3 and the extent of staining was expressed as the ratio of KIM-1 positive/CD10 positive proximal tubules using Image J program. RESULTS: KIM-1 was positive in 39.8% of zero-time biopsies. KIM-1 positive cases were predominantly male and had received grafts from donors with older age, deceased donors, and poor renal function at the time of donation, compared with KIM-1 negative cases. KIM-1 expression showed correlation with delayed graft function and acute tubular necrosis. In comparison of KIM-1 expression between stable grafts (n=23) and grafts with dysfunction (n=19) at the time of repeated biopsy, the intensity/extent of KIM-1 staining and renal histology at zero-time did not differ significantly between the two groups. Histologically, KIM-1 expression was significantly increased with both acute and chronic changes of glomeruli, tubules and interstitium, peritubular capillaritis, and arteriolar hyalinosis. CONCLUSIONS: KIM-1 can be used as an ancillary marker of AKI and a nonspecific indicator of acute inflammation and tubulointerstitial fibrosis. However, KIM-1 expression at zero-time is not suitable for prediction of long-term graft dysfunction.

Successful Pediatric ABO-Incompatible Kidney Transplantation without Pretransplant Plasmapheresis: Report of a Case / 대한이식학회지

Immunologic responses of infants and younger children differ from those of adults. Therefore, application of different pretransplant strategies for antibody depletion in younger ABO-incompatible transplant recipients is appropriate. A 12-month-old male infant with end stage renal disease after acute tubular necrosis was scheduled to undergo kidney transplantation from an ABO-incompatible living donor. He did not undergo pretransplant plasmapheresis, as the titer of the anti-ABO antibody was less than 1:4. After kidney transplantation, posttransplant renal function and anti-ABO titers were stable until posttransplant 2 years.

Clinical Characteristics and Risk Factors for Renal Cell Carcinoma after Kidney Transplantation / 대한이식학회지

BACKGROUND: The occurrence of malignancy following kidney transplantation has been estimated three to five times the incidence compared to that of the general population. It is estimated that particularly in renal cell carcinoma (RCC), the relative risk increases. The aim of this study was to analyze the characteristics, risk factors, and prognosis of RCC following kidney transplantation. METHODS: Total number of 3,272 kidney recipients who underwent transplantation from April 1979 to December 2012 and patients who had RCC following kidney transplantation were retrospectively reviewed and analyzed. RESULTS: We found that among 232 cases of posttransplant malignancies, 25 recipients were diagnosed with RCC. We have observed in our study that it took an average of 175.2+/-71.0 months to develop RCC after their first kidney transplantation. However, with longer follow up period, interval incidence of RCC increased. Fourteen patients (56%) were diagnosed with RCC 15 years after transplantation. We also found that with reference to the risk factor analysis for posttransplant RCC, the long-term follow-up period was the only independent risk factor. In our study, 21 patients with RCC were treated with radical nephrectomy. Of them, 16 patients survived, and four RCC-related deaths occurred. Furthermore, the patient survival rate of RCC recipients was lower than that of the nonmalignancy group despite the graft survival rate were not different. CONCLUSIONS: We conclude that the incidence of RCC increased in a time-dependent manner following kidney transplantation. Therefore, we strongly recommend the procedure of regular-interval screening for the patients who are on compulsive long-term immunosuppression.

The effect of erythromycin on gastrointestinal motility in subtotal gastrectomized patients / 대한외과학회지

PURPOSE: Our objective was to determine the effect of erythromycin (EM) in improving gastrointestinal motility in subtotal gastrectomized patients. We used radio-opaque Kolomarks as an objective method. We conducted a prospective, controlled clinical trial study of 24 patients. METHODS: All patients underwent subtotal gastrectomy with 3 capsules containing Kolomarks (20 markers per 1 capsule) in the remnant stomach before anastomosis. From the day of the operation to the 2nd postoperative day, patients in the EM group began receiving 200 mg of EM intravenously for 30 minutes continuously. We counted the number of Kolomarks in the stomach, passed by stomach, in rectum, and in stool with serial simple abdominal X-ray films on the first postoperative day up to the 7th postoperative day. RESULTS: The study population included 14 patients in the control group and 10 patients in the EM group. The two study groups were compared in terms of their characteristics including age, gender, past medical history, cancer stage, and operation type. No significant differences were found for the demographics between the two groups. We only found a significant difference for the number of Kolomarks passed by the stomach on the 3rd postoperative day (P = 0.026). CONCLUSION: Our results demonstrated that 200 mg of EM intravenous infusion during the postoperative period induced rapid gastric emptying, although it did not improve gastrointestinal motility for the entire gastrointestinal tract in subtotal gastrectomized patients.