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Purpose@#Acute care surgery (ACS) has been practiced in several tertiary hospitals in South Korea since the late 2000s. The medical emergency team (MET) has improved the management of patients with clinical deterioration during hospitalization. This study aimed to identify the clinical effectiveness of collaboration between ACS and MET in hospitalized patients. @*Methods@#This was an observational before-and-after study. Emergency surgical cases of hospitalized patients were included in this study. Patients hospitalized in the Department of Emergency Medicine or Department of Surgery, directly comanaged by ACS were excluded. The primary outcome was in-hospital mortality rate. The secondary outcome was the alarm-to-operation interval, as recorded by a Modified Early Warning Score (MEWS) of >4. @*Results@#In total, 240 patients were included in the analysis (131 in the pre-ACS group and 109 in the post-ACS group). The in-hospital mortality rates in the pre- and post-ACS groups were 17.6% and 22.9%, respectively (P = 0.300). MEWS of >4 within 72 hours was recorded in 62 cases (31 in each group), and the median alarm-to-operation intervals of each group were 11 hours 16 minutes and 6 hours 41 minutes, respectively (P = 0.040). @*Conclusion@#Implementation of the ACS system resulted in faster surgical intervention in hospitalized patients, the need for which was detected early by the MET. The in-hospital mortality rates before and after ACS implementation were not significantly different.
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Purpose@#Cytomegalovirus (CMV) infection is common in immunocompromised patients. Enterocolitis caused by CMV infection can lead to perforation and bleeding of the gastrointestinal (GI) tract, which requires emergency operation. We investigated the demographics and outcomes of patients who underwent emergency operation for CMV infection of the GI tract. @*Methods@#This retrospective study was conducted between January 2010 and December 2020. Patients who underwent emergency GI operation and were diagnosed with CMV infection through a pathologic examination of the surgical specimen were included. The diagnosis was confirmed using immunohistochemical staining and evaluated by experienced pathologists. @*Results@#A total of 27 patients who underwent operation for CMV infection were included, 18 of whom were male with a median age of 63 years. Twenty-two patients were in an immunocompromised state. Colon (37.0%) and small bowel (37.0%) were the most infected organs. CMV antigenemia testing was performed in 19 patients; 13 of whom showed positive results. The time to diagnose CMV infection from operation and time to start ganciclovir treatment were median of 9 days. The reoperation rate was 22.2% and perforation was the most common cause of reoperation. In-hospital mortality rate was 25.9%. @*Conclusion@#CMV infection in the GI tract causes severe effects, such as hemorrhage or perforation, in immunocompromised patients. When these outcomes are observed in immunocompromised patients, suspicion of CMV infection and further evaluation for CMV detection in tissue specimens is required for proper treatment.
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Background@#Current international guidelines recommend against deep sedation as it is associated with worse outcomes in the intensive care unit (ICU). However, in Korea the prevalence of deep sedation and its impact on patients in the ICU are not well known. @*Methods@#From April 2020 to July 2021, a multicenter, prospective, longitudinal, noninterventional cohort study was performed in 20 Korean ICUs. Sedation depth extent was divided into light and deep using a mean Richmond Agitation–Sedation Scale value within the first 48 hours. Propensity score matching was used to balance covariables; the outcomes were compared between the two groups. @*Results@#Overall, 631 patients (418 [66.2%] and 213 [33.8%] in the deep and light sedation groups, respectively) were included. Mortality rates were 14.1% and 8.4% in the deep and light sedation groups (P = 0.039), respectively. Kaplan-Meier estimates showed that time to extubation (P < 0.001), ICU length of stay (P = 0.005), and death P = 0.041) differed between the groups. After adjusting for confounders, early deep sedation was only associated with delayed time to extubation (hazard ratio [HR], 0.66; 95% confidence inter val [CI], 0.55– 0.80; P < 0.001). In the matched cohort, deep sedation remained significantly associated with delayed time to extubation (HR, 0.68; 95% 0.56–0.83; P < 0.001) but was not associated with ICU length of stay (HR, 0.94; 95% CI, 0.79–1.13; P = 0.500) and in-hospital mortality (HR, 1.19; 95% CI, 0.65–2.17; P = 0.582). @*Conclusion@#In many Korean ICUs, early deep sedation was highly prevalent in mechanically ventilated patients and was associated with delayed extubation, but not prolonged ICU stay or in-hospital death.
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Purpose@#Critically ill patients often require multidisciplinary treatment for both acute illnesses and pre-existing medical conditions. Since different medical conditions are managed in the intensive care unit (ICU), consultation is often required. This study aimed to identify the frequency and type of consultation required and analyze changes in consultation patterns after the introduction of intensivist-directed care in the surgical ICU (SICU). @*Methods@#Between June 2006 and December 2013, a retrospective cohort study was conducted to identify the frequency and type of consultation at 3 different ICUs. Consultations for patients who were admitted to the ICUs for more than 48 consecutive hours were included. The pattern of consultations in each ICU was investigated. In addition, the pattern of consultations before and after the implementation of intensivist-directed care in the SICU was compared. @*Results@#During the study, 11,053 consultations were requested for 7,774 critically ill patients in a total of 3 ICUs. Consultations with the Departments of Cardiology, Infectious Diseases, and Pulmonology were requested most frequently in the SICU. However, after the implementation of the intensivist-directed care approach, there was an increase in the frequency of consultation requests to the Department of Neurology, followed by the Departments of Cardiology, and Infectious Diseases. @*Conclusion@#Analysis of consultation patterns is an important method of assessing the complexity and severity of illnesses, and of evaluating the needs of available health system resources. Based on our findings, we suggest the development of an appropriate protocol for frequently consulted services.
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Purpose@#This retrospective study investigated the feasibility, diagnostic, and therapeutic advantages of the gastrografin challenge on patients with adhesive small bowel obstruction (ASBO). @*Methods@#There were 125 patients reviewed who were admitted to the Department of General Surgery at a single institution (September 2018 to August 2019) with a diagnosis related to ASBO. The study population included 100 patients (114 cases) who had received initial conservative management. Patient characteristics and operation rates were compared between the gastrografin challenge success group and failure group, and operation rates and length of hospital stay were compared between the gastrografin challenge group and “non-challenge” group. @*Results@#During the study period, 21 patients with ASBO underwent the gastrografin challenge. The challenge was successful in 17 patients where the bowel obstruction was resolved without the need for surgery. Among patients who failed the challenge, 2 patients underwent adhesiolysis and 2 patients were able to progress their diet avoiding surgery. In patients who underwent surgery (n = 2), the length of hospital stay was significantly shorter in the gastrografin challenge group compared with the “non-challenge” group sub analysis (n = 13 cases; 10.5 vs. 20 days, p = 0.038), indicating that the gastrografin challenge assisted rapid decision-making for surgery. No adverse events were reported for the 21 gastrografin challenges. @*Conclusion@#In patients with ASBO, the gastrografin challenge is an accurate, safe method to determine the need for surgery. In addition, the gastrografin challenge may reduce the length of stay in patients who required surgery for ASBO resolution.
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Purpose@#The aim of this study was to assess the efficacy of intravenous hydrocortisone, ascorbic acid, and thiamine (HAT) combination therapy in complicated intraabdominal infection (cIAI) patients with septic shock. @*Methods@#This was a single-center, retrospective before-after clinical study comparing clinical outcomes of cIAI patients with septic shock treated with HAT in a surgical intensive care unit (ICU). Delta modified sequential organ failure assessment (mSOFA) scores were evaluated to assess recovery of organ dysfunction. Additional outcomes included procalcitonin level change, daily vasopressor dosage, mean number of days free of mechanical ventilation in 28 days, and renal replacement therapy days. @*Results@#The delta mSOFA score (ICU admission mSOFA score minus 7th-day mSOFA score) was significantly higher in the HAT group than in the control group on the 7th day (2.30 vs. –0.90, P = 0.003). The median 7-day change in procalcitonin score was higher in the control group than in the HAT group (5.94 vs. 10.72, P = 0.041). The difference in vasopressor score between the 1st day and the 4th day was significantly higher in the HAT group (17.63 vs. 9.91, P = 0.005). @*Conclusion@#In our study of cIAI in patients with septic shock, administration of HAT therapy may improve the recovery from organ dysfunction.
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Purpose@#This retrospective study investigated the feasibility, diagnostic, and therapeutic advantages of the gastrografin challenge on patients with adhesive small bowel obstruction (ASBO). @*Methods@#There were 125 patients reviewed who were admitted to the Department of General Surgery at a single institution (September 2018 to August 2019) with a diagnosis related to ASBO. The study population included 100 patients (114 cases) who had received initial conservative management. Patient characteristics and operation rates were compared between the gastrografin challenge success group and failure group, and operation rates and length of hospital stay were compared between the gastrografin challenge group and “non-challenge” group. @*Results@#During the study period, 21 patients with ASBO underwent the gastrografin challenge. The challenge was successful in 17 patients where the bowel obstruction was resolved without the need for surgery. Among patients who failed the challenge, 2 patients underwent adhesiolysis and 2 patients were able to progress their diet avoiding surgery. In patients who underwent surgery (n = 2), the length of hospital stay was significantly shorter in the gastrografin challenge group compared with the “non-challenge” group sub analysis (n = 13 cases; 10.5 vs. 20 days, p = 0.038), indicating that the gastrografin challenge assisted rapid decision-making for surgery. No adverse events were reported for the 21 gastrografin challenges. @*Conclusion@#In patients with ASBO, the gastrografin challenge is an accurate, safe method to determine the need for surgery. In addition, the gastrografin challenge may reduce the length of stay in patients who required surgery for ASBO resolution.
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Purpose@#The aim of this study was to assess the efficacy of intravenous hydrocortisone, ascorbic acid, and thiamine (HAT) combination therapy in complicated intraabdominal infection (cIAI) patients with septic shock. @*Methods@#This was a single-center, retrospective before-after clinical study comparing clinical outcomes of cIAI patients with septic shock treated with HAT in a surgical intensive care unit (ICU). Delta modified sequential organ failure assessment (mSOFA) scores were evaluated to assess recovery of organ dysfunction. Additional outcomes included procalcitonin level change, daily vasopressor dosage, mean number of days free of mechanical ventilation in 28 days, and renal replacement therapy days. @*Results@#The delta mSOFA score (ICU admission mSOFA score minus 7th-day mSOFA score) was significantly higher in the HAT group than in the control group on the 7th day (2.30 vs. –0.90, P = 0.003). The median 7-day change in procalcitonin score was higher in the control group than in the HAT group (5.94 vs. 10.72, P = 0.041). The difference in vasopressor score between the 1st day and the 4th day was significantly higher in the HAT group (17.63 vs. 9.91, P = 0.005). @*Conclusion@#In our study of cIAI in patients with septic shock, administration of HAT therapy may improve the recovery from organ dysfunction.
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Background@#Despite the increasing importance of rehabilitation for critically ill patients, there is little information regarding how rehabilitation therapy is utilized in clinical practice. Our objectives were to evaluate the implementation rate of rehabilitation therapy in the intensive care unit (ICU) survivors and to investigate the effects of rehabilitation therapy on outcomes. @*Methods@#A retrospective nationwide cohort study with including > 18 years of ages admitted to ICU between January 2008 and May 2015 (n = 1,465,776). The analyzed outcomes were readmission to ICU readmission and emergency room (ER) visit. @*Results@#During the study period, 249,918 (17.1%) patients received rehabilitation therapy. The percentage of patients receiving any rehabilitation therapy increased annually from 14% in 2008 to 20% in 2014, and the percentages for each type of therapy also increased over time. The most common type of rehabilitation was physical therapy (91.9%), followed by neuromuscular electrical stimulation (29.6%), occupational (28.6%), respiratory, (11.6%) and swallowing (10.3%) therapies. After adjusting for confounding variables, the risk of 30-day ICU readmission was lower in patients who received rehabilitation therapy than in those who did not (P < 0.001; hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.65–0.75). And, the risk of 30-day ER visit was also lower in patients who received rehabilitation therapy (P < 0.001; HR, 0.83; 95% CI, 0.77–0.88). @*Conclusion@#In this nationwide cohort study in Korea, only 17% of all ICU patients received rehabilitation therapy. However, rehabilitation is associated with a significant reduction in the risk of 30-day ICU readmission and ER visit.
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Purpose@#The aim of this study was to investigate how rates of surgical site infections (SSI) were changed over 2 years after applying colon SSI bundle in patients who underwent colon surgery. @*Methods@#The multidisciplinary working group developed a care bundle consisting of 8 components, including several recommendations of Surgical Care Improvement Project and monitoring of medical/surgical hand washing. We implemented the care bundle for each patient who underwent colon surgery from April 2013 to December 2014. @*Results@#Overall bundle compliance was 87.9% before implementation, 88.2% in 2013, and 90.5% in 2014. In particular, compliance of the following 3 components was substantial improved during the project period; discontinuation of prophylactic antimicrobial agent within 24 hours of surgery (from 88.3% to 100%), surgical hand washing (from 50.0% to 78.9%), and medical hand washing (from 74.7% to 82.8%). The rate of SSI was 8.0% (12/150) during 3 months before implementation, 3.3% (16/480) from April to December in 2013, and 2.3% (14/607) in 2014. @*Conclusion@#After implementation of multidisciplinary care bundle, the compliance of each component was increased and rates of SSIs were significantly decreased compared to those before the quality improvement project.
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Wound healing is a coordinated process of sequential events consisting of four phases: hemostasis, inflammation, proliferation, and remodeling. Many factors can affect each phase of this process and have a harmful or beneficial effect on wound healing.Nutrition is closely associated with the wound healing process and is one of the major influencing factors on the outcomes of wound healing. Malnutrition and nutrient deficiencies could adversely affect wound healing and delay it. Many kinds of nutrients can enhance the healing process. Physicians should always assess every patient’s nutritional status to determine nutritional deficiencies.This will enable supplementation, thereby enhancing wound healing. Herein, we review the relationship between nutrition and wound healing, and the effects and mechanisms of each nutrient that is closely related to the wound healing process.
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Purpose@#The aim of this study was to analyze the temporal change of resuscitation fluid use based on all fluids administered in a surgical intensive care unit (ICU). @*Methods@#The administration of resuscitation fluid to all patients admitted to a surgical ICU of a tertiary referral hospital was investigated from 2008 to 2015. The types and volumes of fluid, and laboratory data taken within 7 days after ICU admission were evaluated. Resuscitation fluids were defined as fluids infused according to stat orders, rather than routine orders. @*Results@#There were a total of 8,885 admissions to the ICU for 7,886 patients. The volumetric proportion of crystalloid to total resuscitation fluids increased significantly over the study period (p < 0.001; 79.6% in 2008; 93.7% in 2015). Although the proportion of 0.9% saline to crystalloids decreased, that of balanced solutions increased (p < 0.001; 29.5% in 2008; 55.6% in 2015). The use of colloids decreased from 20.4% in 2008, to 6.3% in 2015 (p < 0.001). Proportions calculated using the number of individual fluids administered revealed trends similar to those calculated using volumetric data. The amount of infused 0.9% saline was weakly correlated with the lowest blood pH and the highest serum chloride levels (ρ = -0.26 and 0.19, respectively). @*Conclusion@#Changes in the trends of fluid resuscitation practice were noted in a single surgical ICU over the 8-year study period. Crystalloid use increased owing to a rise in the utilization of balanced solutions with a downward trend in colloid use.
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Purpose@#Thromboelastography (TEG) was investigated for the diagnosis of coagulopathy compared with traditional coagulation tests, in association with disease severity in patients with severe sepsis or septic shock. @*Methods@#Retrospective data was collected from a single center between January 25th to March 24th, 2016. There were 18 patients with severe sepsis or septic shock admitted to intensive care units included in this study. Laboratory tests including TEG were performed at admission. Disease severity was measured using the Simplified Acute Physiology Score III, Sequential Organ Failure Assessment score, and the level of lactate. @*Results@#There were 18 patients (61% males; median age, 60.5 years) who were diagnosed with severe sepsis, or septic shock requiring a norepinephrine infusion (n = 10, 55.6%). Of these, 4 patients had traditional coagulation tests, and TEG profiles which confirmed hypercoagulability. Eight patients had follow-up tests 48 hours post-admission with a Sequential Organ Failure Assessment score of 6.5 (3-9.5) at admission, decreasing to 4 (2-11) after 48 hours (although not significantly lower), however, the lactate level decreased statistically significantly from 2.965 at admission, to 1.405 mmol/L after 48 hours (p < 0.05). The TEG profiles tended to normalize after 48 hours compared with admission, but there was no statistically significant difference. @*Conclusion@#Coagulopathy with severe sepsis or septic shock patients can be life-threatening, therefore it is important to diagnose coagulopathy early and precisely. TEG can be a feasible tool to confirm coagulopathy with traditional coagulation tests.
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Purpose@#Intensive IV insulin infusion therapy has been applied widely to critically ill patients. However, IV insulin protocols are complex, and require repeated calculations. The purpose of this study was to evaluate the safety and efficiency of a computerized insulin infusion (CII) protocol to replace manual insulin infusion protocols, for glucose control in critically ill patients. @*Methods@#This was an observational study (September 2016 to January 2017) of 43 patients in ICU whose blood glucose level was between 140-180 mg/mL and could not be controlled by the conventional manual insulin protocol. The CII protocol was integrated in to the electronic medical record order system, and automatically calculated the insulin infusion dose and blood sugar test (BST) interval. BSTs were taken 48 hours pre- and post-initiation of the CII protocol. The proportion of BSTs in the normal (70-180 mg/mL), hypoglycemic (70 mg/mL), and severe hyperglycemic (> 250 mg/mL) range were recorded. @*Results@#The mean number of BSTs performed before using the CII protocol was 10.3/person and 0.4/hour, and after implementing the protocol, increased to 21.7/person and 0.7/hour. The mean glucose level (281.4 mg/mL) decreased after using the CII protocol (195.5 mg/mL; p 250 mg/mL) decreased from 47.3% to 17.9% after protocol implementation (p = 0.020). @*Conclusion@#The CII protocol safely and successfully maintained a normal glucose range, and decreased severe hyperglycemia in intensive care patients.
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Wound healing is a coordinated process of sequential events consisting of four phases: hemostasis, inflammation, proliferation, and remodeling. Many factors can affect each phase of this process and have a harmful or beneficial effect on wound healing.Nutrition is closely associated with the wound healing process and is one of the major influencing factors on the outcomes of wound healing. Malnutrition and nutrient deficiencies could adversely affect wound healing and delay it. Many kinds of nutrients can enhance the healing process. Physicians should always assess every patient’s nutritional status to determine nutritional deficiencies.This will enable supplementation, thereby enhancing wound healing. Herein, we review the relationship between nutrition and wound healing, and the effects and mechanisms of each nutrient that is closely related to the wound healing process.
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Purpose@#The aim of this study was to analyze the temporal change of resuscitation fluid use based on all fluids administered in a surgical intensive care unit (ICU). @*Methods@#The administration of resuscitation fluid to all patients admitted to a surgical ICU of a tertiary referral hospital was investigated from 2008 to 2015. The types and volumes of fluid, and laboratory data taken within 7 days after ICU admission were evaluated. Resuscitation fluids were defined as fluids infused according to stat orders, rather than routine orders. @*Results@#There were a total of 8,885 admissions to the ICU for 7,886 patients. The volumetric proportion of crystalloid to total resuscitation fluids increased significantly over the study period (p < 0.001; 79.6% in 2008; 93.7% in 2015). Although the proportion of 0.9% saline to crystalloids decreased, that of balanced solutions increased (p < 0.001; 29.5% in 2008; 55.6% in 2015). The use of colloids decreased from 20.4% in 2008, to 6.3% in 2015 (p < 0.001). Proportions calculated using the number of individual fluids administered revealed trends similar to those calculated using volumetric data. The amount of infused 0.9% saline was weakly correlated with the lowest blood pH and the highest serum chloride levels (ρ = -0.26 and 0.19, respectively). @*Conclusion@#Changes in the trends of fluid resuscitation practice were noted in a single surgical ICU over the 8-year study period. Crystalloid use increased owing to a rise in the utilization of balanced solutions with a downward trend in colloid use.
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Purpose@#Thromboelastography (TEG) was investigated for the diagnosis of coagulopathy compared with traditional coagulation tests, in association with disease severity in patients with severe sepsis or septic shock. @*Methods@#Retrospective data was collected from a single center between January 25th to March 24th, 2016. There were 18 patients with severe sepsis or septic shock admitted to intensive care units included in this study. Laboratory tests including TEG were performed at admission. Disease severity was measured using the Simplified Acute Physiology Score III, Sequential Organ Failure Assessment score, and the level of lactate. @*Results@#There were 18 patients (61% males; median age, 60.5 years) who were diagnosed with severe sepsis, or septic shock requiring a norepinephrine infusion (n = 10, 55.6%). Of these, 4 patients had traditional coagulation tests, and TEG profiles which confirmed hypercoagulability. Eight patients had follow-up tests 48 hours post-admission with a Sequential Organ Failure Assessment score of 6.5 (3-9.5) at admission, decreasing to 4 (2-11) after 48 hours (although not significantly lower), however, the lactate level decreased statistically significantly from 2.965 at admission, to 1.405 mmol/L after 48 hours (p < 0.05). The TEG profiles tended to normalize after 48 hours compared with admission, but there was no statistically significant difference. @*Conclusion@#Coagulopathy with severe sepsis or septic shock patients can be life-threatening, therefore it is important to diagnose coagulopathy early and precisely. TEG can be a feasible tool to confirm coagulopathy with traditional coagulation tests.
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Purpose@#Intensive IV insulin infusion therapy has been applied widely to critically ill patients. However, IV insulin protocols are complex, and require repeated calculations. The purpose of this study was to evaluate the safety and efficiency of a computerized insulin infusion (CII) protocol to replace manual insulin infusion protocols, for glucose control in critically ill patients. @*Methods@#This was an observational study (September 2016 to January 2017) of 43 patients in ICU whose blood glucose level was between 140-180 mg/mL and could not be controlled by the conventional manual insulin protocol. The CII protocol was integrated in to the electronic medical record order system, and automatically calculated the insulin infusion dose and blood sugar test (BST) interval. BSTs were taken 48 hours pre- and post-initiation of the CII protocol. The proportion of BSTs in the normal (70-180 mg/mL), hypoglycemic (70 mg/mL), and severe hyperglycemic (> 250 mg/mL) range were recorded. @*Results@#The mean number of BSTs performed before using the CII protocol was 10.3/person and 0.4/hour, and after implementing the protocol, increased to 21.7/person and 0.7/hour. The mean glucose level (281.4 mg/mL) decreased after using the CII protocol (195.5 mg/mL; p 250 mg/mL) decreased from 47.3% to 17.9% after protocol implementation (p = 0.020). @*Conclusion@#The CII protocol safely and successfully maintained a normal glucose range, and decreased severe hyperglycemia in intensive care patients.
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PURPOSE: A review was performed to determine the frequency of activating medical emergency teams (MET) in surgical wards, so that resource allocation could be optimized.METHODS: A retrospective observational study was performed to determine the time and frequency when MET were deployed (N = 465) to patients (n = 387) who were admitted to the surgical ward, from March 2013 to July 2016 due to emergency situations.RESULTS: Of the 465 MET activations, 8 did not incur any further intervention. The review showed an average of 151 minutes from onset of symptoms to MET activation, and an average of 110 minutes until intervention (additional diagnosis / treatment). The number of MET activations increased year by year from 2013 to 2016. The transfer of patients to the intensive care units also increased from 34 in 2013, to 82 in 2016. The lowest number of MET activations occurred between 04:00 and 05:00, but there was no difference in the number of MET activations between day and night. However, MET activation in response to acute respiratory distress was significantly higher during the nighttime (p = 0.003).CONCLUSION: Patients admitted to a surgical ward have more serious complications. This study showed that the use of MET in surgical wards has increased year by year, and the frequency of calls between day and night was not different, except higher MET activations observed at night in patients with acute respiratory distress.
Subject(s)
Humans , Diagnosis , Emergencies , Hospital Mortality , Hospital Rapid Response Team , Intensive Care Units , Observational Study , Resource Allocation , Retrospective StudiesABSTRACT
No abstract available.