장기기증을 위한 뇌사자 관리

길은미,박재범 대한이식학회 2015 Korean Journal of Transplantation Vol.29 No.3

Since the Harvard criteria for brain death was proposed in 1968, deceased donor, mainly brain death donor (BD), organ transplantation has been performed worldwide and given the chance for a new life to patients suffering from end-stage organ disease. In Korea by the eager efforts promoting brain-dead organ donation, fortunately, the number of organ donations from the brain-dead has increased successfully in the last decade. However, the disparity between the number of patients awaiting organ transplantation on the list and the number of actual organ donations has become wider and the organ shortage remains a limitation for new lives by transplantation. Because of donor organ restriction, optimal management of brain-dead donors is increasingly important. In addition, the favorable clinical outcomes of recipients is directly associated with the well-preserved organ function of brain-dead donors, which can be accomplished by the maintenance of optimal perfusion. However the brain-dead condition leads to various and profound pathophysiological changes in the neuroendocrine and cardiovascular systems, and management of brain-dead organ donors usually includes active intensive care for maintaining organ function. Therefore, to enhance the potential organ graft function and increase the organ supply, physicians must have knowledge of the pathophysiology of brain death and must deal with rapid hemodynamic changes, endocrine and metabolic abnormalities, and respiratory complications. This article reviews the pathophysiologic changes resulting from brain death and the adequate management for maximizing use of organs recovered from brain death donors. 국내에서는 1969년 생체 기증자 신장이식을 시작으로, 1979년 최초로 뇌사자 장기이식을 성공하였고, 이후 이식관련 의료수준은 괄목할 만한 발전을 이루었으나, 여전히생체이식이 더 높은 비율을 차지하고 있다. 1999년 장기등 이식에 관한 법률이 제정되었고, 2000년에 장기이식 관리센터(Korean Network for Organ Sharing, KONOS)가 설립되었으며, 2010년 한국 장기기증원(Korea Organ Donation Agency, KODA)이 출범되었다. 2011년에는 뇌사 추정자신고제가 도입되어 뇌사자 장기이식 활성화를 위해 노력하고 있지만 아직 장기이식 대기자 수에 비해 장기 제공자의 수가 현저히 부족한 것이 사실이고 우리나라는 아직 뇌사자 장기이식이 활성화되지 못한 나라에 속한다. 2015년7월 말 기준 21,625명의 환자들이 장기이식을 대기하고 있으며(간장 4,565명, 신장 15,444명, 췌장 837명, 심장 541 명, 폐장 189명, 소장 20명, 췌도 29명) 이는 2000년 2,840 명과 비교하여 약 7.6배 정도 증가되어 매우 빠른 증가추세를 보인다. 2014년에 446명의 뇌사장기기증자(deceased organ donor)로부터 1,445건의 장기기증이 진행되었다. 이는 2000년 52명의 뇌사장기기증자에 비해 비약적인 증가이지만, 절대적인 기증자의 수는 여전히 이식 대기자 수에비교하여 부족한 현실이다. 공여장기가 부족한 현실에서 효율적인 장기의 분배 및이식을 위해서는 잠재기증자에 대한 활발한 신고와 중환자전문의(intensivist)를 통한 세심하고 적극적인 관리가중요하다. 최근 연구에서 잠재기증자 관리에서 중환자전문의가 포함된 팀을 적용 후 이식 가능한 장기구득의 수가유의하게 증가함을 보고하였다(1). 중환자전문의의 참여가 증가함에 따라 뇌사자 관리에 중환자 치료에 적용되는기준과 동일한 기준 적용이 확산되면서 뇌사자의 혈역학적 안정성 유지 및 장기구득의 향상을 보이고 있으나, 아직까지 뇌사자에 대해 특화된 표준관리지침은 매우 제한적이다(2,3). 이에 저자는 뇌사자의 병태생리적 변화에 대해 알아보고, 최근 보고된 연구들을 바탕으로 하여 적절한뇌사자 관리 및 치료에 대해 기술하고자 한다.

Primary Invasive Intestinal Aspergillosis in a Non-Severely Immunocompromised Patient

길은미,하태순,서지영,정치량,박치민 대한중환자의학회 2016 Acute and Critical Care Vol.31 No.2

Invasive aspergillosis (IA) is most commonly seen in patients with risk factors, such as cytotoxic chemotherapy, prolonged neutropenia, corticosteroids, transplantation and acquired immune deficiency syndrome. IA commonly occurs in the respiratory tract. Extrapulmonary aspergillosis is usually a part of a disseminated infection, and primary invasive intestinal aspergillosis is very rare. Herein, we report a case of an immunocompetent 53-year-old male who suffered recurrent septic shock in the intensive care unit (ICU) and was finally diagnosed as invasive intestinal aspergillosis without dissemination. IA is rarely considered for patients who do not have an immune disorder. Thus, when such cases do occur, the diagnosis is delayed and the clinical outcome is often poor. However, there is a growing literature reporting IA cases in patients without an immune disorder, mostly among ICU patients. Primary intestinal aspergillosis should be considered for critically ill patients, especially with severe disrupted gastrointestinal mucosal barrier.

Primary Invasive Intestinal Aspergillosis in a Non-Severely Immunocompromised Patient

길은미,하태선,서지영,정치량,박치민 대한중환자의학회 2016 Acute and Critical Care Vol.31 No.3

Invasive aspergillosis (IA) is most commonly seen in patients with risk factors, such as cytotoxic chemotherapy, prolonged neutropenia, corticosteroids, transplantation and acquired immune deficiency syndrome. IA commonly occurs in the respiratory tract. Extrapulmonary aspergillosis is usually a part of a disseminated infection, and primary invasive intestinal aspergillosis is very rare. Herein, we report a case of an immunocompetent 53-year-old male who suffered recurrent septic shock in the intensive care unit (ICU) and was finally diagnosed as invasive intestinal aspergillosis without dissemination. IA is rarely considered for patients who do not have an immune disorder. Thus, when such cases do occur, the diagnosis is delayed and the clinical outcome is often poor. However, there is a growing literature reporting IA cases in patients without an immune disorder, mostly among ICU patients. Primary intestinal aspergillosis should be considered for critically ill patients, especially with severe disrupted gastrointestinal mucosal barrier.

Perioperative Care of Severely Ill Patients: Acute Kidney Injury and Hepatic Encephalopathy

길은미 ( Eunmi Gil ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Efficiency of Computerized Insulin Infusion Glucose Control in Critically Ill Patients

임희정,박치민,길은미,유기상,최경진,진상만 대한외상중환자외과학회 2020 Journal of Acute Care Surgery Vol.10 No.2

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 < 0.001). The percentage of BSTs within normal range increased from 22.5% to 44.9% after implementing the protocol (p < 0.001). Severe hyperglycemia (> 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.

타 병원에서 전원 온 중환자에서의 다재내성균 보유 경향에 대한 분석

허창호,이대상,길은미,박치민 대한외상중환자외과학회 2017 Journal of Acute Care Surgery Vol.7 No.1

Purpose: To assess the prevalence of multidrug-resistant organisms (MDROs) in inter-hospital transferred critically ill patients.Methods: This is a retrospective study. The study population comprised patients who were transferred from other hospitals or health care units into the medical or surgical intensive care unit of Samsung Medical Center from January 2012 to December 2014. We evaluated the acquisition of clinically significant MDROs including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), extended-spectrum beta-lactamase (ESBL)- producing Gram-negative bacteria, and carbapenem- resistant Gram-negative bacteria (CRGNB).Results: Three hundred and twenty-one patients were included in this study. One hundred and fifty-one patients (47.0%) had at least one species of MDRO, 21.5% in MRSA, 27.1% in VRE, 15.6% in CRGNB, and 3.7% in ESBL. The prevalence of MDROs was significantly higher in male (52.7%), patients with diabetes (61.6%), patients with combined infectious diseases (51.6%), and medical patients (49.3%). Patients with MRSA had significantly longer length of stay than the patients without MRSA. The patients with CRGNB had higher mortality than the patients without CRGNB.Conclusion: The prevalence of MDROs in inter-hospital transferred critically ill patients was very high. Patients with MDROs in this study had longer hospital stay and higher mortality. These patients require more attention for isolation and hygiene protocols, and antibiotic choices. (J Acute Care Surg 2017;7:9-14)

화장품에 의한 접촉피부염 환자에서 광첩포시험

엄성희 ( S. H. Um ),길은미 ( E. M. Gil ),김태흥 ( T. H. Kim ) 대한피부과학회 2003 大韓皮膚科學會誌 Vol.41 No.3

Backround:Cosmetic compounds are widely consumed and their use is increasing by socioe-conomic developments. Although they may also induce photoallergic contact dermatitis, information about incidence and frequent allergens are not available in Korea. O

다발성 외상으로 인한 심한 폐 좌상과 스트레스성 심근병 환자에서 체외막형 산화기의 치료 경험

이대상 ( Dae Sang Lee ),길은미 ( Eun Mi Gil ),이아란 ( A Lan Lee ),하태순 ( Tae Sun Ha ),정치량 ( Chi Ryang Chung ),박치민 ( Chi Min Park ),조양현 ( Yang Hyun Cho ) 대한외상학회 2014 大韓外傷學會誌 Vol.27 No.4

A 55 year-old man hit a vehicle while riding a bicycle. He was diagnosed as left hemopneumothorax, multiple rib fracture, cerebral hemorrhage, and skull fracture. Initially he suffered from hypoxia requiring 100% oxygen with a mechanical ventilator. Finally he became hypotensive. Venovenous extracorporeal membrane oxygenation (ECMO) was initiated to support patient’s gas exchange. Because hypotension and left ventricular dysfuction persisted, we converted the mode of support to veno-arterio-venous ECMO. Over four days of intensive care, we could wean off ECMO. The patient went to rehabilitation facility after 45 days of hospitalization. Although trauma and bleeding are considered as relative contraindication of ECMO, careful decision making and management may enable us to use ECMO for trauma-related refractory heart and/or lung failure. [ J Trauma Inj 2014; 27: 229-32 ]

Feasibility of the Gastrografin Challenge for Adhesive Small Bowel Obstruction

정기상,최경진,윤경원,유기상,길은미,박치민 대한외상중환자외과학회 2021 Journal of Acute Care Surgery Vol.11 No.2

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 (<i>n</i> = 2), the length of hospital stay was significantly shorter in the gastrografin challenge group compared with the “non-challenge” group sub analysis (<i>n</i> = 13 cases; 10.5 vs. 20 days, <i>p</i> = 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.

Safety and feasibility of ultrasound-guided insertion of peripherally inserted central catheter performed by an intensive care trainee

이용우,유정암,김영오,길은미,송영목 대한신경집중치료학회 2020 대한신경집중치료학회지 Vol.13 No.1

Background: We investigated the safety and feasibility of ultrasound-guided peripherally inserted central venous catheter (PICC) placements performed by intensive care medical trainees in comparison to PICC placements performed by intensivists. Methods: This was a retrospective and observational study of adult patients who underwent PICC placement and were admitted to the intensive care unit (ICU) between July 2013 and March 2018. Ultrasound-guided PICC was performed at the bedside by an intensivist or intensive care medical trainee if intrahospital transport was inappropriate. The primary endpoint was PICC-induced complications. The secondary endpoint was initial success of PICC. Results: A total of 209 patients underwent PICC placement during the study period. There were no significant differences in age, sex, body mass index, comorbidities, causes of ICU admission, or severity scores between the trainee-led PICC and intensivist-led PICC groups. Difficult venous access (42.6%) and requirement for central line infusion (39.2%) were the most common reasons for PICC placement. The basilic vein (62.2%) was the most common target vein among patients who underwent PICC. There were no significant differences in complications between the two groups (P=0.473). In addition, the initial success rate and procedural time were similar between the two groups (P=0.108 and P=0.076, respectively). There were no insertional injuries and moderate or severe bleeding in patients with PICC. Conclusion: Ultrasound-guided PICC placement by an intensive care medical trainee may be safe and feasible compared to PICC placement by an intensivist.