Non-Oliguric Hyperkalemia in Extremely Low Birth Weight Infants

곽재령,권명훈,이장훈,박문성,김성환 연세대학교의과대학 2013 Yonsei medical journal Vol.54 No.3

Purpose: It is to examine clinical manifestations, early biochemical indicators, and risk factors for non-oliguric hyperkalemia (NOHK) in extremely low birth weight infants (ELBWI). Materials and Methods: We collected clinical and biochemical data from 75 ELBWI admitted to Ajou University Hospital between Jan. 2008 and Jun. 2011 by reviewing medical records retrospectively. NOHK was defined as serum potassium ≥7 mmol/L during the first 72 hours of life with urine output ≥1 mL/kg/h. Results: NOHK developed in 26.7% (20/75) of ELBWI. Among NOHK developed in ELBWI, 85% (17/20) developed within postnatal (PN) 48 hours, 5% (1/20) experienced cardiac arrhythmia and 20% (4/20) of NOHK infants expired within PN 72 hours. There were statistically significant differences in gestational age, use of antenatal steroid, and serum phosphorous level at PN 24 hours, and serum sodium, calcium, and urea levels at PN 72 hours between NOHK and non-NOHK groups (p-value <0.050). However, there were no statistical differences in the rate of intraventricular hemorrhage, arrhythmia, mortality occurred,methods of fluid therapy, supplementation of amino acid and calcium, frequencies of umbilical artery catheterization and urine output between the two groups. Conclusion: NOHK is not a rare complication in ELBWI. It occurs more frequently in ELBWI with younger gestational age and who didn’t use antenatal steroid. Furthermore, electrolyte imbalance such as hypernatremia, hypocalcemia and hyperphosphatemia occurred more often in NOHK group within PN 72 hours. Therefore, more use of antenatal steroid and careful control by monitoring electrolyte imbalance should be considered in order to prevent NOHK in ELBWI.

Is Unenhanced Abdominal CT Scan Necessary for the Diagnosis of Acute Appendicitis in Children?

곽재령,전우찬,박은정,이두환,최상천,민영기,이지숙 대한응급의학회 2014 大韓應急醫學會誌 Vol.25 No.6

Purpose: This study was designed to evaluate the questionof whether a computed tomography (CT) protocol withoutan unenhanced phase could be used for diagnosis ofappendicitis in pediatric patients who visited the emergencydepartment (ED) with acute non-traumatic right lowerabdominal pain. Methods: We retrospectively selected 100 samples frompediatric abdominal CT scans performed in the ED andread by pediatric radiologists. Thirty emergency physicianswere separately asked to evaluate the samples twice. Thefirst evaluation was performed without the unenhancedphase (protocol A). The second evaluation was performedwith both the unenhanced phase and the contrastenhancedphase (protocol B). The sensitivity and specificityof each protocol for diagnosis of suspected acute appendicitiswere determined. Intraobserver and interobserveragreements were measured using kappa statistics. Results: The mean sensitivity and specificity of the two protocolswere similar. The sensitivities of protocol A and protocolB were 97.13% (95% Confidence interval=96.13-98.14) and 97.60% (96.67-98.53), respectively. The specificitiesof protocol A and protocol B were 95.47% (94.34-96.59) and 94.67% (93.33-96.00), respectively. The meankappa value for intraobserver agreement between resultsfrom the two protocols was 0.91 (0.88-0.93). The kappavalue for interobserver agreement was 0.90 (0.89-0.91) forprotocol A and 0.87 (0.86-0.88) for protocol B. Conclusion: It is feasible to perform a CT scan without anunenhanced phase for evaluation of suspected appendicitisin children with abdominal pain visiting the ED.

소아 급성 신우신염에서 99mTc-DMSA 스캔의 진단적 한계

김병기,곽재령,박지민,배기수 대한소아청소년과학회 2010 Clinical and Experimental Pediatrics (CEP) Vol.53 No.3

Purpose:We aimed to prove the relative limitation of 99mTc-DMSA scintigraphy (DMSA) compared to computed tomography (CT) in diagnosing acute pyelonephritis (APN) in children. Methods:Since September 2006, after a 64-channel CT was imported, 10 DMSA false-negative patients have been identified: these patients underwent a CT scan for acute abdomen or acute febrile symptoms and were diagnosed as having APN; however, their DMSA scans were clear. We focused on these 10 DMSA false-negative patients and analyzed their clinical findings and CT results. We used Philips Brilliance Power 64-channel CT scanner for the CT scan and Siemens Orbitor Nuclear Camera 60 Hz for the DMSA scan. Results:The 10 DMSA false-negative patients were mostly males (80%) and infants (80%). They had fever for a mean of 1.1-day duration before admission and showed increase in acute reactants: leukocyte, erythrocyte sedimentation rate, and C-reactive protein. The CT findings of renal lesions were focal in 6 (60%) cases and diffuse in 4 (40%) cases, and most of the lesions were unilateral in 80% of patients. CT proved that 22 renal lesions were neglected by DMSA. Differential renal function test by DMSA was also of no use in the evaluation of renal lesions. Conclusion:In this study, DMSA scan showed limitation in finding renal cortical lesions of CT-proven APN patients. DMSA false-negative results seem to occur at early-phase disease of infantile age, but more prospective studies are needed to determine the reasons and their prevalence. 목적:소아에서 급성 신우신염 진단시 computed tomography (CT)와 비교하여 99mTcDMSA scintigraphy (DMSA)의 상대적 제한점이 있음을 확인하고자 하였다. 방법:64채널 CT가 도입된 2006년 9월 이후 3년 동안 급성복증이나 발열성 급성병증으로 복부 CT검사를 받은 환아 중 급성 신우신염의 소견을 보였으나 후속으로 시행된 DMSA에서는 이상소견을 발견되지 않은 ‘DMSA 위음성 환자’ 10명을 연구대상으로 선정하여 이들의 임상상과 CT 소견을 분석하였다. CT촬영에는 필립스사의 브릴리언스-64 모델을, DMSA 스캔에는 Siemens사의 Orbiter 75 기종을 사용하였다. 결과:총 10명 중 남자가 8명, 영유아가 8명이었으며 내원당시 평균 1.1일간 발열이 있었고 말초혈액 백혈구 수, 적혈구침강속도, C-반응단백 등의 급성반응표지가 증가된 상태였다. DMSA 정상 소견을 보였던 10명에서 CT 신장환부 소견은 국소적인 경우가 6례, 미만성인 경우가 4례였다. 대개 일측성이었으며 양측 신장 모두 침범된 경우는 2례였다. DMSA에서 확인되지 않은 CT상 병변 개수는 총 22개 확인되었다. DMSA 비교신기능 측정법은 신손상 정도를 가늠하는데 도움이 되지 않았다. 결론:본 연구를 통하여 DMSA검사는 CT검사상 양성인 급성 신우신염의 신장환부를 밝혀내지 못하는 제한점이 있음이 확인되었다. DMSA 위음성 결과는 주로 질병초기에 영아 환자에서 흔히 발생하는 것으로 보이나, 그 정확한 이유와 발생 비율 등을 밝히기 위해서는 전향적인 추가조사가 필요하다.

선천성수신증 환아에서 방광요관역류 및 요로감염 발생에 대한 고찰

김종호,곽재령,박지민,배기수,Kim, Jong-Ho,Kwak, Jae-Reyung,Park, Jee-Min,Pai, Ki-Soo 대한소아신장학회 2009 Childhood kidney diseases Vol.13 No.2

목적 : 선천성 수신증 환아에서 방광요관역류(VUR)가 어떠한 관련이 있는지 또한 요로감염 발생 여부와 어떠한 연관이 있는지 정보가 부족하다. 이에 연구자들은 VCUG를 시행 받은 선천성 수신증 환아를 대상으로, 수신증과 VUR 간의 연관성 및 요로감염 발생 여부에 대하여 분석을 하여 환자관리에 도움이 되는 정보를 마련하고자 하였다. 방법 : 연구는 2002년 1월 1일부터 2008년 12월 31일까지 아주대학교 병원에서 선천성 수신증으로 진단된 생후 1개월 이내의 환아 중, VCUG를 시행 받은 122명을 대상으로 후향적 연구를 하였다. 측정치의 통계분석은 SPSS version 16.0을 사용하여 logistic regression, T-test, chi-square test 등을 실시하였으며, P<0.05인 경우 통계학적으로 유의한 것으로 평가하였다. 결과 : 총 122명의 선천성 수신증 환자 중 남자가 많았고(73%), 주로 편측 수신증을 가진 환자가 많았으며(77%), 그 중 좌측(84.0%) 수신증 환자가 유의하게 많았다. VUR은 총 23명(18.9%)에서 발견되었다. 수신증의 심한 정도는 좌우측에 따른 차이를 보이지 않았으며, VUR의 정도도 좌우측에 따른 차이를 보이지 않았다. 수신증을 1-4단계로 나누었을 때, 각 단계별로 VUR의 발생빈도 차이는 관찰할 수 없었으나, 수신증을 경한 수신증(1-2단계)과 중한 수신증(3-4단계)으로 나누었을 때 중한 수신증에서 VUR의 발생 빈도가 유의하게 높음을 확인할 수 있었다. 또한 영아기 동안에 요로감염 발생을 살펴보면, 수신증이 심하거나 VUR이 있을 경우 그 발생빈도가 높았다. 결론 : 선천성 수신증 환아에서 수신증의 정도가 심할 경우 더욱 VUR의 빈도가 더 높았으며, VUR이 존재할 경우 영아기에 요로감염이 더 흔히 발생함을 알 수 있었다. Purpose : We checked voiding cystourethrography (VCUG) in patients with congenital hydronephrosis (CHN) and followed up the occurrence of urinary tract infection(UTI) in these patients. And we tried to figure out the relationship between CHN and VUR and UTI. Methods : We performed a retrospective study in 122 CHN patients who received VCUG from 2002 to 2008 at Ajou University Hospital. We executed logistic regression, chi-square test and T-test using version 16.0 SPSS package for the statistical analysis. P<0.05 was regarded as significant. Results : Most patients with CHN were male (73%) and there was a tendency of preferences for unilateral (77%) and left (84%) occurrence of hydronephrosis. The incidence of VUR was 18.9% among 122 CHN patients and no laterality difference was found to the severity of VUR or hydronephrosis. The incidences of VUR and UTI was higher in group of higher grade (III-IV) CHN patients, when compared to the lower group, respectively. When VUR was present in CHN patients, the incidence of UTI during infancy was also higher. Conclusion : The incidence of VUR was higher in patients with higher grades of CHN. The incidence of UTI during infancy was higher when VUR was present in the CHN patients.

Clinical characteristics of acute drug-induced dystonia in pediatric patients

박현웅,곽재령,이지숙 대한응급의학회 2017 Clinical and Experimental Emergency Medicine Vol.4 No.3

Objective Dystonia is a movement disorder in which muscles contract uncontrollably. Acute drug-induced dystonia (DID) can be diagnosed through detailed history taking and physical examination. This study aimed to identify the clinical characteristics of DID in children, which could help emergency physicians diagnose these conditions more efficiently. Methods We reviewed medical records of children aged below 18 years diagnosed with drug-related dystonia after discharge from the emergency department over 10 years. We collected the patients’ age, sex, suspected causative drugs, initial diagnosis of the prescribing physician, duration of drug-taking, diagnostic evaluations, treatment methods, and prognosis. Results Seventy-nine patients were enrolled. The mean age was 11.3±4.9 years (range, 4.0 months to 18.0 years), and 41 patients (51.9%) were boys. The most common cause of DID was gastrointestinal medications in 45 patients (57.0%), followed by antipsychotics in 23 patients (29.1%). Eleven (24.4%) out of 45 patients with DID due to gastrointestinal medications had the initial diagnosis of upper respiratory infection, and seven (30.4%) out of 23 patients with DID due to antipsychotics had the initial diagnosis of non-psychotic diseases. Younger children received more diagnostic procedures and were more frequently admitted. A benzodiazepine (67.1%) was the most common single drug for treatment. Conclusion Physicians should not only acknowledge DID in order to reduce unnecessary workup and admission, but also know that antiemetics and antipsychotics are common causes of DID. Therefore, physicians should try to avoid multidrug prescriptions in children.

소아 환자에서 요추천자를 시행하기 위한 진정제의 선택: 케타민-미다졸람과 케타민-프로포폴의 진정 효과 비교

고유라,전우찬,곽재령,이지숙 대한응급의학회 2018 대한응급의학회지 Vol.29 No.1

Purpose: This study was conducted to compare the safety and effectiveness of intravenous ketamine-midazolam (KM) and ketamine-propofol (KP) combination for the lumbar puncture (LP) procedure in children. Methods: This was a retrospective analysis of patients aged ≤18 years old who received intravenous injection of KM or KP for undergoing LP in the pediatric emergency department. To investigate the effectiveness of KM and KP, we compared the sedation success rate, induction time, procedure time and total sedation time. In addition, adverse events and complications were recorded to assess the safety of the agents. Results: A total 61 patients were enrolled in study. Twenty-eight patients were given KM and 33 patients received KP. All sedations were successful in both groups. While the mean induction time in KM was shorter than in the KP group (3±4 vs. 6±5 minutes, p=0.02), the total sedation time in the KP group was significantly shorter than that in the KM group (33 ±26 vs. 61±43 minutes, p<0.01). There were no adverse effects such as hypotension, bradycardia or hypoxic event. Conclusion: This study showed that intravenous KM and KP are hemodynamically stable and have few side effects when applied for pediatric sedation during lumbar puncture. Although KM has a shorter induction time than KP, KP has a shorter duration of sedation. Both of these materials can be considered useful agents for sedation when conducting painful procedures in children.

급성위장염 소아환자에서 ondansetron 경구요법 시행 후정맥내 수액요법 빈도 및 응급실 체류시간의 변화

권순광,양희원,최민정,고유라,곽재령,이지숙 대한소아응급의학회 2018 대한소아응급의학회지 Vol.5 No.2

Purpose: Oral ondansetron is a safe and effective antiemetic drug to facilitate oral rehydration therapy in acute gastroenteritis (AGE) with mild dehydration. We investigated the effect of oral ondansetron therapy on intravenous (IV) hydration frequency and emergency department length of stay (EDLOS) in dehydrated children with AGE. Methods: We reviewed 15,813 children aged 12-60 months with primary diagnosis of AGE who visited a tertiary care university-affiliated hospital emergency department. The enrolled children were divided into the pre- (from January 2009 to June 2011) and post- (from January 2016 to June 2018) ondansetron groups according to the implementation of oral ondansetron therapy in the emergency department. As primary outcomes, IV hydration frequency, EDLOS, and hospitalization rate were compared between the 2 groups. As secondary outcomes, EDLOS and hospitalization rate were compared between the children in the post-ondansetron group who underwent the therapy, and those who did not. Results: Of 7,990 enrolled children, 3,300 (41.3%) were designated as the post-ondansetron group, and among them 1,093 (33.1%) underwent oral ondansetron therapy. This group showed a lower IV hydration frequency, a shorter median EDLOS compared to the other group (55.8% vs. 61.9%, P < 0.001; 175.0 vs. 223.0 minutes, P < 0.001, respectively), and a higher hospitalization rate (9.9% vs. 7.9%, P < 0.001). The children in the post-ondansetron group who underwent the therapy showed a shorter median EDLOS and a lower hospitalization rate compared to those who did not (142.0 vs. 205.0 minutes, P < 0.001; 2.9% vs. 13.4%, P < 0.001, respectively). Conclusion: Oral ondansetron therapy may reduce IV hydration frequency and EDLOS in dehydrated children with AGE, and can be considered in those having severe vomiting.

The Clinical Differences between Urgent Visits and Non-Urgent Visits in Emergency Department During the Neonatal Period

양형준,전우찬,양희정,곽재령,서효원,이지숙 대한의학회 2017 Journal of Korean medical science Vol.32 No.11

As neonates are brought to the emergency department (ED) for various complaints, it is challenging for emergency physicians to clinically determine the urgency of the visit. We sought to explore clinical characteristics associated with urgent visits to the ED. We conducted a retrospective study by reviewing medical records of neonatal visits to a tertiary pediatric regional emergency center for 5 years. Cases of patients who were discharged after checking only chest or abdominal X-ray or discharged without workup, were classified as non-urgent visits. Cases where more examinations were performed, or when the patient was hospitalized, were classified as urgent visits. Various clinical features and process in the ED were compared between the groups. Of the 1,008 cases enrolled in this study, 856 (84.9%) were urgent and 152 (15.1%) were non-urgent visits. After adjustment by multiple logistic regression analysis, non-urgent visits were associated with self-referrals rather than physician-referrals (odds ratio [OR], 5.96), visits in the evening rather than at night or daytime (OR, 2.51), patient visits from home rather than from medical facilities (OR, 2.19; 95). Fever and jaundice were the most common complaints (25.7% and 24.5%, respectively), and their OR of non-urgent visit was relatively low (adjusted OR 0.03 and 0.03, respectively). However, other common complaints, such as vomiting and cough (7.4% and 7.1%, respectively), were more likely to be non-urgent visits (adjusted OR 2.96 and 9.83, respectively). For suspected non-urgent visits, emergency physicians need to try to reduce unnecessary workup and shorten length of stay in ED.