우리나라의 중환자의학 세부전문의 제도

김동찬 대한중환자의학회 2009 Acute and Critical Care Vol.24 No.3

The Korean Society of Critical Care Medicine (KSCCM) has introduced the Subspecialty System for Critical Care Medicine in Korea under the auspices of the Korean Academy of Medical Sciences (KAMS) in March 2008. Nine medical societies that included the Korean Association of Internal Medicine, the Korean Academy of Tuberculosis and Respiratory Diseases, the Korean Society of Anesthesiology, the Korean Neurological Association, the Korean Neurosurgical Society, the Korean Surgical Society, the Korean Society of Emergency Medicine, the Korean Society for Thoracic and Cardiovascular Surgery and the Korean Pediatric Society participated to the new critical care subspecialty. The Board of Critical Care should be certified again every 5 year after achieving the required qualification by the KSCCM. This paper summarizes the Subspecialty Certification System for Critical Care Medicine in Korea. 1980년 7월 26일 일본 동경에서 개최된 서태평양 중환자의학회(Western Pacific Association of Critical Care Medicine, WPACCM) 창립 총회에 참석을 계기로 대한중환자의학회의 창립과 함께 우리나라에서 중환자의학이 시작되었고 2010년이면 대한중환자의학회는 30세의 청년기를 맞이한다. 그 동안 우리나라 중환자의학의 발전과 국내중환자진료의 문제점들을 개선하고 극복하기 위한 여러 가지 노력들이 있었으나 그중 중환자의학 세부전문의 제도의 시작은 그 핵심이라고 하겠다. 이는 이 제도를 통하여 중환자 진료의 체계적인 수준 향상과 국내 중환자의학의 학문적, 임상적 발전이 이루어지는 기초를 마련한 것이기 때문이다. 이 제도의 성공적인 정착과 발전을 위해서는 이를 뒷받침할 내실 있는 교육 및 수련제도의 정착이 중요하며, 중환자의학에 관련된 모든 사람들의 아낌없는 지원과 노력이 필요하다. 그리고 무엇보다 성인중환자실에 전문의 전담의사가 중환자진료를 담당할 수 있는 국가의 제도적 뒷받침이 시급히 이루어져야 한다.

중환자실 구성이 2009년 인플루엔자 A/H1N1 중증환자의 사망률에 미친 영향

조재화,이훈재,홍상범,서지영,박무석,김석찬,곽상현,이명구,임재민,이현경,고윤석,대한중환자학회h1n1연구회 대한중환자의학회 2012 Acute and Critical Care Vol.27 No.2

Background: During 2009 pandemic period, many Koreans were infected and admitted with Influenza A/H1N1. The primary aim of this study was to evaluate whether the structures of an intensive care unit (ICU) were associated with the outcomes of critically ill patients. Methods: This retrospective observational study examined critically ill adult patients with influenza A/H1N1, who were admitted to 24 hospitals in Korea, from September 2009 to February 2010. We collected data of ICU structure, patients and 90 days mortality. Univariate and multivariate logistic regression analysis, with backward elimination, were performed to determine the most significant risk factors. Results: Of the 239 patients, mortality of 90 days was 43%. Acute physiology and chronic health evaluation (APACHE) II score (p < 0.001), sequential organ failure assessment (SOFA) score (p < 0.0001), nurse to beds ratio (p = 0.039) and presence of intensivist (p = 0.024) were significant risk factors of 90 days mortality. Age (p = 0.123), gender (p = 0.304), hospital size (p = 0.260), and ICU type (p = 0.409) were insignificantly associated with mortality. In a multivariate logistic regression analysis, patients with less than 6 SOFA score had significantly lower mortality, compared with those with more than 10 SOFA score (odds ratio 0.156, p < 0.0001). The presence of intensivist had significantly lower mortality, compared with the absence (odds ratio 0.496, p = 0.026). Conclusions: In critically ill patients with influenza A/H1N1, the severity of the illness and presence of intensivist might be associated with 90 days mortality.

응급실에서 실시된 전문심혈관소생술동안 에피네프린의 사용: 현재의 심폐소생술 지침에 부합하는가?

이승준,이병국,정경운,이형연,허탁,민용일,윤종근,임재훈 대한중환자의학회 2011 Acute and Critical Care Vol.26 No.2

Background: Consensus guidelines clearly define how epinephrine is administered during cardiopulmonary resuscitation (CPR). In South Korea, it is not known whether epinephrine is administered in accordance with the current advanced cardiovascular life support (ACLS) guidelines during actual practice. We sought to investigate adherence to ACLS guidelines during actual CPR in terms of the dose of epinephrine and the interval between doses. Methods: A retrospective review of medical records was performed on 394 adult cardiac arrest patients who received CPR at an emergency room. Data including the duration of CPR, the dose of epinephrine, and the interval between doses was collected from CPR records. Results: Standard-dose epinephrine (1 mg) was used in 166 of 394 patients (42.1%). In 58.8% of patients, the average between-dose interval was within the 3−5 min recommended in the guidelines, whereas it was shorter than 3 min in 31.4% of patients. As a whole, epinephrine was administered in accordance with the current ACLS guidelines in only 96 of 394 patients (24.4%). Logistic regression analysis revealed the duration of CPR to be an independent factor affecting the use of standard-dose epinephrine and the adequate between-dose interval. Conclusions: Epinephrine was not administered according to the ACLS guideline in most patients. A national multi-center study is required to determine whether the poor adherence to the ACLS guideline is a widespread problem. In addition, efforts to improve adherence to the ACLS guideline are required.

기종성 신우신염의 임상양상 및 예후

양원석,김원영,손창환,서동우,이재호,김원,임경수 대한중환자의학회 2012 Acute and Critical Care Vol.27 No.2

Background: Emphysematous pyelonephritis (EPN) is a rare and potentially life-threatening condition that requires prompt evaluation and management. However, its clinical presentation and outcomes vary widely. This study was conducted to ascertain the clinical features and prognostic factors regarding EPN. Methods: All patients diagnosed with EPN radiologically and treated at the emergency department in the university- affiliated, tertiary-referral center, from January 1999 to December 2009 were evaluated. The patients’ demographic and clinical characteristics, computed tomographic findings, treatment, and outcomes were analyzed retrospectively. Results: Overall 14 patients diagnosed with EPN were admitted. There were 12 females and 2 males. A history of diabetes was found in 12 (85.7%) patients and was the most common comorbidity. The chief complaint among patients was flank pain (42.9%). Severe sepsis or septic shock was noted in 10 (71.4%) patients. Thirteen cases had unilateral involvement and one case had bilateral involvement. More than half of patients had Escherichia.coli in culture. Mean serum levels of HbA1c, creatinine, C-reactive protein (CRP) were 9.4 ± 2.7, 2.4 ± 1.4 mg/dl, and 22.4 ± 13.1 mg/dl. Eight (57.1%) patients received antibiotic treatment alone and four (28.6%) patients received the concurrent percutaneous drainage as well as antibiotics. Hospital mortality was 7.1%. A higher initial serum CRP level (20.3 vs. 49.8 mg/dl, p = 0.02) and HbA1c level (8.7 vs. 16.4, p = 0.01) was associated with hospital mortality. Conclusions: Antibiotics alone provide a high success rate for the treatment of EPN. Higher serum CRP and HbA1c level was associated with a higher mortality rate in patients with EPN.

Extraction of Endobronchial Tooth by Flexible Bronchoscopy Using Fishnet Basket in Patients of Intensive Care Unit with Artificial Airway

김경찬 대한중환자의학회 2014 Acute and Critical Care Vol.29 No.1

Foreign body aspiration into the tracheobronchial tree can cause serious problems. Tooth aspiration can occur during emergency endotracheal intubation. However, removal of a tooth from the airway is difficult because of the round shape and smooth surface of the tooth. Here, I report extraction of a tooth from the airway by flexible bronchoscopy using fishnet basket in intensive care patients. The procedure was performed in six patients. All patients were critically ill with an artificial airway (n = 4; endotracheal tube, n = 2; tracheostomy tube). The tooth location was right bronchial tree in three patients and left bronchial tree in three patients. Tooth extraction failed in two patients because the teeth were impacted in the distal bronchus during bronchoscopy. There was no complication such as life threatening arrhythmia or hypoxemia during the procedure. Using flexible bronchoscopy with a fishnet basket, we were able to extract aspirated teeth from patients with an artificial airway.

Total Unilateral Obstruction by Sputum Immediately after Tracheal Bougienage

김규남,전종헌,정미애,최성락,이영선 대한중환자의학회 2014 Acute and Critical Care Vol.29 No.1

A 25-year-old man developed tracheal stenosis due to prolonged intubation for five days. Immediately after bougienage, his left lung was not possible to ventilate and emergency tracheostomy was performed to produce ample space for airflow. Fiberoptic bronchoscopy showed that his left main bronchus was totally obstructed by sputum at the entrance of the superior and inferior lobar bronchi. Inadequate airway clearance increases the risk of infection and airway obstruction. We suggest chest physiotherapy be applied to all patients in the intensive care unit (ICU), especially patients with tracheal stenosis, due to its positive impact on pulmonary functional ability and ICU stay.

One Hundred Seven Days of ECMO as a Bridge to Lung Transplantation: The Longest Duration Among Elderly Patients

김은정,백효채,박무석,김명화,고신옥,이유진,나성원 대한중환자의학회 2014 Acute and Critical Care Vol.29 No.1

Extracorporeal membrane oxygenation (ECMO) is a means for supporting adequate gas exchange in patients with severe respiratory failure and is the only therapeutic option for ventilation-refractory patients awaiting lung transplantation. Moreover, defining the patients likely to benefit from ECMO as a bridge to transplantation has recently become a point of interest. Here, we report a case of prolonged ECMO support to a patient awaiting lung transplantation. A 66-year-old woman was diagnosed with acute interstitial pneumonia and was placed on veno-venous (VV) ECMO due to unsatisfactory gas exchange despite maximal ventilator care. She underwent bilateral lung transplantation after 99 days of ECMO and was successfully weaned from it on the 107th ECMO day. This is the longest period of ECMO support to be reported among elderly patients.

연명치료 중지에 대한 내과 전공의들의 인식과 심리적 스트레스

문재영,이희영,임채만,고윤석 대한중환자의학회 2012 Acute and Critical Care Vol.27 No.1

Background: In order to promote the dignity of terminal patients, and improve end-of-life care (EOL care) in Korea, consensus guidelines to the withdrawal of life-sustaining therapies (LST) were published in October, 2009. The aim of this study was to assess the current perception of the guideline among internal medicine residents and to identify barriers to the application of the guidelines. Methods: The study was designed prospectively on the basis of data from e-mail survey. We surveyed 98 medical residents working in 19 medical centers. Results: 75.5% of respondents agreed with withdrawing (WD) of LST and 33.3% (33/98) of respondents were unaware of the guideline. Although 58.1% of all respondents had taken an EOL care class in medical school, about 30% of residents did feel uncomfortable with communicating with patients and surrogates. The most important obstacle for decision of WD of LST was the resident’s psychological stress. 39.8% of medical residents felt guilty or failure after a patient’s death, and 41.8% became often or always depressed in a patient’s dying. Conclusions: In order to protect and enhance the dignity and autonomy of terminal patients, the improvement of the medical training program in the hospitals and the more concern of educational leaders are urgent.

삼첨판 수술 시 발생한 매듭지어진 폐동맥 카테터 -증례 보고-

이경천,정월선,김용범,이지연 대한중환자의학회 2012 Acute and Critical Care Vol.27 No.1

The use of pulmonary artery catheter can be helpful in managing patients after cardiac surgery. Nevertheless, there is a risk of serious complications, such as knotting. A 61 year old man underwent tricuspid valve replacement under cardiopulmonary bypass (CPB). After implantation of a stented tissue valve in the tricuspid valve, repositioning of the catheter was performed. After weaning from CPB, an abnormal pattern of pulmonary artery pressure was suddenly observed on the monitor. Resistance was met when removing the catheter with the balloon deflated, at a 20 cm distance from the tip of the catheter. Chest radiography showed a knot in the catheter within the right brachiocephalic vein. Superior vena cava opened and the distal part of the catheter with the knot was successfully removed.

자궁경을 이용한 자궁근종 제거술 시 발생한 희석성 저나트륨혈증

옥시영,유승화,김상호,백영희 대한중환자의학회 2009 Acute and Critical Care Vol.24 No.2

Hysteroscopy is utilized for making the diagnosis and treating a series of uterine disease. It`s advantages are more accurate removal of lesion, a short operating time, low morbidity and rapid postoperative recovery. However, serious complications can happen following hysteroscopic surgery. The complications can be divided into the procedure-related, media-related and postoperative events. The procedure-related complications include cervical laceration, uterine perforation, bowel and bladder injury, and hemorrhage. The media-related complications include hyponatremia, gas embolism and excessive fluid absorption. The postoperative events include endometritis and postoperative synechiae. We experienced hyponatermia with pulmonary edema due to excessive fuid absorption in a 52-year-old woman who underwent elective hysteroscopic myomectomy under general anesthesia. She was treated with oxygen therapy, normal saline and furosemide and she recovered without sequelae.