Community-onset Necrotizing Fasciitis Caused by Extended-spectrum Beta-lactamase-producing Eshcerichia coli / 대한내과학회지

Necrotizing fasciitis (NF) is an uncommon but fatal infectious disorder that rapidly destroys connective tissue, causing extensive necrosis, severe sepsis, multiple organ failure, and death. NF is more common in patients with comorbid medical conditions. Most NF is caused by bacteria extending from localized skin infections, or remote bacteremia. Escherichia coli (E. coli) has been isolated from polymicrobial NF, but is rarely causative of monomicrobial NF. In addition, NF attributable to community-onset, extended- spectrum beta-lactamase (ESBL)-producing E. coli has not been described previously. As ESBL-producing E. coli are becoming significant pathogens of community-acquired infections worldwide, we report an exceptional case of community-onset NF attributable to monomicrobial ESBL-producing E. coli in a patient with liver cirrhosis.

Experience of Advance Directives in a Hospice Center

To protect patient autonomy when confronting death, the importance of advance directives (ADs) has recently became an issue and gradually accepted in Korea. However, in real practice, ADs were not completed by patients but their families in most cases. To analyze the current situation of performing ADs, we reviewed medical charts of 214 terminal cancer patients admitted to the hospice center from October 2012 to September 2013. Seventy-six (35.5%) patients completed ADs. All ADs were completed by patients themselves. The most common reason for not completing ADs was poor physical and/or mental condition. As a proxy, the majority of patients preferred their spouses (55.3%). Few patients wanted life sustaining treatment (1.3%), however palliative sedation was accepted in 89.5%. The median timing of ADs after admission was three (0-90) days, and duration of survival since ADs was 22 (1-340) days. In conclusion, approximately one third of terminal cancer patients completed ADs by themselves. Considering that patient's poor condition is the main reason for not completing ADs, earlier discussion regarding ADs is necessary to enhance patients' participation.

Experience of Advance Directives in a Hospice Center

To protect patient autonomy when confronting death, the importance of advance directives (ADs) has recently became an issue and gradually accepted in Korea. However, in real practice, ADs were not completed by patients but their families in most cases. To analyze the current situation of performing ADs, we reviewed medical charts of 214 terminal cancer patients admitted to the hospice center from October 2012 to September 2013. Seventy-six (35.5%) patients completed ADs. All ADs were completed by patients themselves. The most common reason for not completing ADs was poor physical and/or mental condition. As a proxy, the majority of patients preferred their spouses (55.3%). Few patients wanted life sustaining treatment (1.3%), however palliative sedation was accepted in 89.5%. The median timing of ADs after admission was three (0-90) days, and duration of survival since ADs was 22 (1-340) days. In conclusion, approximately one third of terminal cancer patients completed ADs by themselves. Considering that patient's poor condition is the main reason for not completing ADs, earlier discussion regarding ADs is necessary to enhance patients' participation.

A Case of Hemolytic Uremic Syndrome in a Lung Cancer Patient Treated with Gemcitabine / 결핵및호흡기질환

Hemolytic uremic syndrome (HUS) is a rare disorder characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. HUS arises from a wide spectrum of conditions, and chemotherapeutic agents have been reported to be associated with HUS, including Mitomycin, Cisplatin, Bleomycin, and Gemcitabine. A 76-year-old man treated with Gemcitabine due to non-small cell lung cancer developed clinical and laboratory findings compatible with HUS. Gemcitabine was ceased and hemodialysis and plasma exchange were utilized and he recovered. A high level of suspicion for HUS is necessary when cancer patients are treated with Gemcitabine, and prompt recognition and treatment are also essential.

Evaluation of the Relationship between Circadian Blood Pressure Variation and Left Atrial Function Using Strain Imaging

BACKGROUND: Non-dippers were reported as showing different left atrial function, compared to dippers, but no study to date investigated the changes in the left atrial function according to the diurnal blood pressure pattern, using tissue Doppler and strain imaging. METHODS: Forty never treated hypertensive patients between 30 and 80 years of age were enrolled in this study. Patients were classified as non-dippers when, during night time, they had a blood pressure decrease of less than 10%. Strain of the left atrium was measured during late systole, and peak strain rates of the left atrium were measured during systole, early and late diastolic periods. RESULTS: The left atrial expansion index, left atrial active emptying volume and left atrial active emptying fraction were all significantly increased in non-dippers. They also had increased values of mean peak left atrial strain (dippers = 21.26 +/- 4.23% vs. non-dippers = 24.91 +/- 5.20%, p = 0.02), strain rate during reservoir (dippers = 1.29 +/- 0.23 s-1 vs. non-dippers =1.52 +/- 0.27 s-1, p = 0.01) and contractile period (dippers = -1.38 +/- 0.24 s-1 vs. non-dippers = -1.68 +/- 0.32 s-1, p < 0.01). CONCLUSION: Strain and strain rate acquired from color Doppler tissue imaging demonstrate exaggerated reservoir and booster pump function in never-treated, non-dipper hypertensive patients. These methods are simple and sensitive for the early detection of subtle changes in the left atrial function.

Survey on the Infection Control of Multidrug-Resistant Microorganisms in General Hospitals in Korea / 병원감염관리

BACKGROUND: The control of multidrug-resistant microorganisms (MDROs) is important in preventing healthcare-associated infections. We performed a survey to evaluate the current system for control of MDROs in general hospitals in Korea. METHODS: A questionnaire consisted of queries about infection control systems, personnel, antibiotic use monitoring systems, isolation and barrier precautions, and obstacles to and opinions about MDROs. The questionnaire was mailed to 145 hospitals with more than 300 beds in November 2005. RESULTS: One hundred and two of the 145 (70.3%) hospitals responded; 65.3% of the responded hospitals had antibiotics control programs and 96.0% of those had control programs for MDROs. Surveillance cultures for vancomycin-resistant enterococcus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) were taken in 21.6% and 16.7% of the hospitals, respectively. Over 90% of the hospitals had guidelines with respect to wearing gloves, collecting infectious wastes, and cleaning the environment for MRSA and VRE, but less than a half of the hospitals had the same standard for extended-spectrum beta-lactamase-producing gram-negative bacteria and carbapenem-resistant gram-negative bacteria. Most hospitals recommended gowning when contamination or invasive procedures were anticipated, but for VRE patients, gowns were used more strictly whenever there was contact with MDROs. Major obstacles related to isolation of patients infected or colonized with MDROs were the cost for isolation rooms (37.3%), and proposed solutions were reimbursement from the medical insurance company (86.3%), construction of a nationwide management system (61.8%), and effort by individual hospitals (58.8%) for MDROs infection control. CONCLUSION: Most of the hospitals have adopted control programs, but more needs to be done. Further efforts, including periodic reporting of antibiotic resistance, sufficient cost reimbursement, and providing education and increased awareness are urgently needed.

Anesthetic Management in a Patient with Latex Anaphylaxis after Tourniquet Release: A case report / 대한마취과학회지

Latex is the second most common cause of anaphylaxis during anesthesia. The increasing number of reports of latex-induced anaphylaxis are a major concern for anesthesiologists. We encountered a 56-year-old male patient who developed severe anaphylactic shock whilst under anesthesia when the tourniquet was deflated during elbow arthrolysis. A subsequent allergy workup revealed an IgE mediated hypersensitivity to latex. This case highlights the need for anesthesiologists to be able to diagnose the signs and symptoms of allergic reactions in patients under anesthesia.

Analgesia after Arthroscopic Shoulder Surgery: Study of Effective Concentration of Continuous Patient-Controlled Subacromial Ropivacaine Infusion / 대한마취과학회지

BACKGROUND: The aim of this study was to estimate the effective concentration of subacromial ropivacaine for the control of postoperative pain after arthroscopic shoulder surgery. METHODS: In a prospective, randomized double-blind trial, 60 patients were divided equally into 3 groups; Groups I, II, and III. At the end of surgery, a bolus dose (0.75% ropivacaine 150 mg, depomedrol 40 mg) was injected via the trocar and a continuous subacromial infusion catheter was inserted into all patients. The drugs were administered for 48 hours after surgery. Group I was given 0.11% ropivacaine in 96 ml of normal saline, which consisted of 0.75% ropivacaine (15 ml), and fentanyl (10 microgram/kg). Group II received 0.15% ropivacaine in 96 ml saline consisting of 0.75% ropivacaine (20 ml) and fentanyl, (10 microgram/kg). Group III received 0.23% ropivacaine in saline consisting of 0.75% ropivacaine (30 ml) and fentanyl (10 microgram/kg). The rate of continuous infusion was, 2 ml/hr. The VAS for pain at rest and the range of motion (ROM) exercise, the amounts of supplemental analgesics and side effects were assessed postoperative 3, 9, 24 and 48 hours. RESULTS: There was no significant difference in the VAS for pain at rest and ROM exercise as well as in the amounts of supplemental analgesics between the three groups. CONCLUSIONS: 0.11% ropivacaine with 10 microgram/kg fentanyl provides effective postoperative analgesia at rest and during ROM exercise after arthroscopic shoulder surgery.

Acute Pulmonary Edema following Failed Intubation: A Case Report / 대한구급학회지

Pulmonary edema that follows upper airway obstruction may occur in a variety of clinical situations. Post anesthetic laryngospasm has been implicated as the most frequent cause of this syndrome. Risk factors for development of post laryngospasm pulmonary edema include difficult intubation; nasal, oral, or pharyngeal surgical site; and obesity with obstructive apnea. We report a case that developed acute bilateral pulmonary edema after laryngospasm induced by failed intubation.

Anesthetic Management of a Patient with Brugada Syndrome: A case report / 대한마취과학회지

Brugada syndrome is characterized by a distinctive electrocardiographic pattern (right bundle branch block and a ST segment elevation in the right precordial leads), but without structural heart disease. It is a rare genetic disorder, with an autosomal dominant inheritance pattern. Many factors during general anesthesia (medication, bradycardia, temperature changes) can precipitate malignant dysrhythmia in this patient, so careful choice of anesthetics is required. We experienced the anesthetic management of a 50-year-old male patient with Brugada syndrome, who underwent an emergency operation, under general anesthesia for acute appendicitis. Surgery was performed uneventfully, and the patient was discharged without complication.

Anesthetic Management of a Patient with Brugada Syndrome: A case report / 대한마취과학회지

Brugada syndrome is characterized by a distinctive electrocardiographic pattern (right bundle branch block and a ST segment elevation in the right precordial leads), but without structural heart disease. It is a rare genetic disorder, with an autosomal dominant inheritance pattern. Many factors during general anesthesia (medication, bradycardia, temperature changes) can precipitate malignant dysrhythmia in this patient, so careful choice of anesthetics is required. We experienced the anesthetic management of a 50-year-old male patient with Brugada syndrome, who underwent an emergency operation, under general anesthesia for acute appendicitis. Surgery was performed uneventfully, and the patient was discharged without complication.