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.

Nasogastric Tube Syndrome: Why Is It Important in the Intensive Care Unit?

Taehyun Kim,Seong Min Kim,Sung Birm Sohn,Yeon Ho Lee,Sang Youn Lim,Jae Kyeom Sim 대한중환자의학회 2015 Acute and Critical Care Vol.30 No.3

Although the nasogastric tube (NGT) is widely used in critically ill patients, most intensivists do not give much thought to it or its possible complications. NGT syndrome is a rare but fatal complication characterized by throat pain and vocal cord paralysis in the presence of NGT. Recently, we experienced a case of NGT syndrome developed in an 86-year-old female twelve days after NGT insertion. We immediately removed the NGT and secured the airway by tracheostomy. She was treated successfully with an intravenous antibiotic, steroid and proton pump inhibitor and the syndrome did not recur after reinsertion of the NGT.

Acute Colchicine Poisoning Treated with Granulocyte Colony Stimulating Factor and Transfusion

Sung-Hwa Lee,Sung Wook Park,Sang-Kyoon Han,Soon-Chang Park 대한중환자의학회 2015 Acute and Critical Care Vol.30 No.3

Colchicine poisoning is rare but can cause potentially life-threatening toxic complications such as hypovolemic shock, cardiovascular collapse and multiple organ failure. In this case report, we describe a case of a 20-year-old female who presented to the emergency department after suicidal ingestion of a toxic dose of colchicine. She developed thrombocytopenia, neutropenia and acute respiratory distress syndrome that required blood transfusion and administration of granulocyte colony stimulating factor for the prevention of infectious complications. With regard to the clinical manifestations of colchicine toxicity, we discussed suggested mechanisms.

신종인플루엔자 바이러스 폐렴과 병발한 자발종격동기종 2예-증례 보고-

태재웅,김은진,장우진,김민정,전해리,정은수,고영민 대한중환자의학회 2010 Acute and Critical Care Vol.25 No.3

Influenza A virus, (H1N1 Subtype), was identified as the cause of outbreaks of febrile respiratory infection in Mexico, the US, Canada and elsewhere during the spring of 2009. In Korea, a novel virus infection showing many variable complications was also pandemic. We report two cases of spontaneous pneumomediastinum, complicating viral pneumonia, caused by Influenza A virus, (H1N1 Subtype).

소량의 Fentanyl 투여 후 발생한 근육 강직과 폐 부종 -증례 보고-

임성규,김종일,손유빈,이지희 대한중환자의학회 2012 Acute and Critical Care Vol.27 No.3

Fentanyl-induced muscular rigidity has been reported exclusively in patients when large fentanyl dosages were employed in the operating room or in the pediatric intensive care unit. Rigidity and pulmonary edema after analgesic doses of fentanyl had not been reported previously. A 25-year-old man underwent removal of a foreign body and application of an Ilizarov frame of tibia under general anesthesia. The patient received 100 μg of fentanyl during emergence of anesthesia and the procedure of dressing. On arrival to the anesthetic recovery room, the patient presented with muscular rigidity and about 1 hour later, developed pulmonary edema. The notable predisposing factors were rapid injection of fentanyl and history of treatment with antidepressants and haloperidol, modifiers of serotonin and dopamine levels. From this case, we suggest the need for careful observation for the development of muscle rigidity complicating airway management in patients taking antidepressants and antipsychotics, especially after administration of an analgesic dose of fentanyl.

급성 허혈성 뇌졸중에서의 페닐에프린을 이용한 혈압 상승 요법-증례 보고-

전상범,손호연 대한중환자의학회 2010 Acute and Critical Care Vol.25 No.3

Decreased cerebral perfusion is associated with a poor prognosis for a patient suffering from acute ischemic stroke. Induced hypertension may improve the cerebral perfusion and stroke symptoms. However, there is not enough clinical evidence to support this therapy and it is rarely performed in daily practice. Here we report three patients with acute ischemic stroke and cerebral hypoperfusion who were successfully treated with induced hypertension using intravenous phenylephrine. Phenylephrine infusion may be a treatment option for patients suffering from acute ischemic stroke and cerebral hypoperfusion.

패혈증에서 근위축의 기전

이기동,김호철 대한중환자의학회 2010 Acute and Critical Care Vol.25 No.1

Muscle wasting is commonly seen in patients with sepsis as a consequence of the catabolic response in skeletal muscle. Muscle wasting can occur in cases that have an imbalance between degradation and synthesis of muscle proteins. Although decrements in the synthesis of muscle proteins may contribute to sepsis-induced muscle wasting, it has been recognized that increments in its degradation play a more essential role in muscle wasting. Muscle wasting in sepsis patients has some significant clinical consequences such as reduced ambulation and exercise tolerance, and an increased risk for pulmonary and thromboembolic complications. Several mechanisms have been proposed for sepsis-induced muscle wasting. Increased proteolysis via the ubiquitin-proteasome pathway and the calpains system is one of the principal mechanisms of muscle wasting induced by sepsis. Calpains are activated by calcium, which increases in patients with sepsis. The activation of the calpains system disrupts the sarcomere of the myofibrils, resulting in the release of myofilaments that are subsequently ubiquitinated and degraded by the 26S proteasome complex. Recent studies have suggested that transcriptional factors such as NF-κB and FoxO, and the apoptosis and autophagy-lysosome pathways may also be involved in sepsis-induced muscle wasting. This review briefly summarizes the contribution of these mechanisms of muscle wasting in patients with sepsis and the possible therapeutic agents to treat it.

한 내과계 중환자실에서 사망한 환자들의 심폐소생술 거절 현황

이광하,장항제,홍상범,임채만,고윤석 대한중환자의학회 2008 Acute and Critical Care Vol.23 No.2

Background: Do-not-resuscitate (DNR) in the event of a cardiac arrest is the most common and important discussion between a patient`s family and physicians among the end-of-life decision-making process. To observe the performance of a DNR order in critically ill patients, we analyzed the incidence of DNR orders, the changes in therapeutic levels after DNR orders, and the cases of violated DNR codes in patients who had died in a Korean medical intensive care unit (ICU) between 1 January 2006 and 30 June 2006. Methods: The charts of patients who had died in the medical ICU were retrospectively reviewed. Results: One hundred two patients were enrolled. The ICU and hospital lengths of stay of the patients were 12.4 ± 14.0 and 23.2 ± 21.1 days, respectively. Hematologic malignancy (24.5%) accounted for the most common premorbid diagnosis before ICU admission. Seventy-five patients (73.5%) had DNR orders. The DNR order was suggested by the physician in 96% of the patients. There was no significant difference in the clinical parameters and the performance of a DNR order. Eighty-four percent of the patients with a DNR order had received the order within 3 days death. The withholding of additional therapy or withdrawing of current therapy occurred in 57.3% of the patients. The DNR order was violated in 9 cases (12%). Conclusions: DNR orders are well-accepted by the patient`s family in the ICU. However, DNR orders are initiated when patient death is imminent.

경구기관삽관 시 기관삽관 기구에 따른 경추 움직임 비교: 마네킨 예비 연구

이상현,최혁중,강형구,강보승,임태호 대한중환자의학회 2010 Acute and Critical Care Vol.25 No.4

Background: In patients with limited cervical spine movement, equipment for orotracheal intubation should achieve sufficient laryngeal exposure with the least cervical spine movement. This study was designed to compare movement of the cervical spine during the orotracheal intubation with various intubating equipment. Methods: Twelve emergency physicians & residents with a total experience of >50 cases of endotracheal intubation in two emergency centers were assigned to perform orotracheal intubation with four different airway devices,including the Macintosh laryngoscope (ML), DCI video laryngoscope (DCI), Airway Scope (AWS) and Levitan Scope (LS), using the same manikin (AmbuⓇ airway management trainer) in random sequences. Movement of the C-spine was examined by measuring the angle formed by two lines which are parallel to the anterior surface of the C2 and C7 vertebrae bodies. The angle was measured when Cormack-Lehane grade II glottis exposure was achieved during intubation. Results: Mean cervical spine movements were 37.6 ± 9.2o, 32.2 ± 14.2o, 32.2 ± 6.45o and 17.4 ± 10.0o with the ML, DCI (p = 0.347), AWS (p = 0.094), and LS (p < 0.001), respectively, compared to that of ML. Cervical spine movement by LS was 54% less than that by ML. LS produced less cervical spine movement in comparison to DCI (p = 0.013) and AWS (p = 0.001). Conclusions: The Levitan Scope produced less movement of the cervical spine when compared to the Macintosh laryngoscope, DCI video-laryngoscope and Airway Scope during orotracheal intubation in a single airway training manikin model.