Hannah Lee

Validation of the APACHE IV model and its comparison with the APACHE II, SAPS 3, and Korean SAPS 3 models for the prediction of hospital mortality in a Korean surgical intensive care unit

Background The Acute Physiology and Chronic Health Evaluation (APACHE) IV model has not yet been validated in Korea. The aim of this study was to compare the ability of the APACHE IV with those of APACHE II, Simplified Acute Physiology Score (SAPS) 3, and Korean SAPS 3 in predicting hospital mortality in a surgical intensive care unit (SICU) population. Methods We retrospectively reviewed electronic medical records for patients admitted to the SICU from March 2011 to February 2012 in a university hospital. Measurements of discrimination and calibration were performed using the area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow test, respectively. We calculated the standardized mortality ratio (SMR, actual mortality predicted mortality) for the four models. Results The study included 1,314 patients. The hospital mortality rate was 3.3%. The discriminative powers of all models were similar and very reliable. The AUCs were 0.80 for APACHE IV, 0.85 for APACHE II, 0.86 for SAPS 3, and 0.86 for Korean SAPS 3. Hosmer and Lemeshow C and H statistics showed poor calibration for all of the models (P < 0.05). The SMRs of APACHE IV, APACHE II, SAPS 3, and Korean SAPS 3 were 0.21, 0.11 0.23, 0.34, and 0.25, respectively. Conclusions The APACHE IV revealed good discrimination but poor calibration. The overall discrimination and calibration of APACHE IV were similar to those of APACHE II, SAPS 3, and Korean SAPS 3 in this study. A high level of customization is required to improve calibration in this study setting.

Association Between Perioperative Hyperglycemia or Glucose Variability and Postoperative Acute Kidney Injury After Liver Transplantation: A Retrospective Observational Study.

BACKGROUND: Glucose control can be difficult in the intraoperative and immediate postoperative period of liver transplantation. Hyperglycemia and glucose variability have been associated with acute kidney injury (AKI) in critically ill patients. We performed a retrospective study to test the hypothesis that perioperative glucose levels represented by time-weighted average glucose levels and glucose variability are independently associated with the incidence of postoperative AKI in patients undergoing liver transplantation. METHODS: On the basis of blood glucose levels during liver transplantation and the initial 48 hours postoperatively, adult liver transplant recipients were classified into 4 groups according to their time-weighted average glucose: normoglycemia (80–200 mg/dL), mild hyperglycemia (200–250 mg/dL), moderate hyperglycemia (250–300 mg/dL), and severe hyperglycemia (>300 mg/dL) group. Patients were also classified into quartiles depending on their glucose variability, defined as the standard deviation of glucose measurements. The primary outcome was postoperative AKI. RESULTS: AKI after liver transplantation was more common in the patients with greater perioperative glucose variability (first versus third quartile; OR, 2.47 [95%CI, 1.22–5.00], P = .012; first versus fourth quartile; OR, 2.16 [95% CI, 1.05–4.42], P = .035). CONCLUSIONS: Our study suggests that increased perioperative glucose variability, but not hyperglycemia, is independently associated with increased risk of postoperative AKI in liver transplantation recipients.

Effect of sham feeding with gum chewing on postoperative ileus after liver transplantation—a randomized controlled trial

Postoperative ileus (POI) is a common complication after major abdominal surgery. Gum chewing has been shown to stimulate bowel motility and decrease duration of POI after abdominal surgery. We evaluated the effect of gum chewing in reducing the time to first flatus and on oral calorie intake in patients undergoing living or deceased donor liver transplantation. Patients were randomized into the sham feeding group or the control group. The sham feeding group chewed two pieces of xylitol flavored gum for 15 minutes, three times a day after extubation until oral nutrition was tolerated. The control group received the same routine care except for the gum chewing. Fifty‐nine patients were randomized into the sham feeding group (n=30) or the control group (n=29). There was no difference in the time to first flatus (72 [66.1‐82.9] hours vs 69.0 [57.6‐77.2] hours, P=.422). Cumulative energy intake (2.8 [5.8‐23.2] % vs 10.0 [8.5‐15.9] %, P=.695) and length of intensive care unit stay (4.2 [3.9‐5.3] days vs 4.0 [6.7‐4.5] days, P=.077) were also similar. In conclusion, sham feeding with gum chewing did not shorten the duration of POI nor facilitate oral intake after liver transplantation. (Clinicaltrials.gov number: NCT 01956643).

Persistent left superior vena cava: diagnosed by bedside echocardiography in a liver transplant patient: a case report

In most cases, persistent left superior vena cava (PLSVC) is asymptomatic and discovered accidentally. This case involves a 43-year-old male who underwent an emergency cadaveric liver transplantation. Postoperatively, the left internal jugular vein was cannulated using a sono-guided Seldinger technique in the intensive care unit. But the chest X-ray showed that the catheter followed the left paramediastinal course instead of crossing midline to the right to enter the superior vena cava. In consideration of the patients status, an intra-arterial or extra-vascular placement could be excluded. For a diagnosis, we performed a bed-side transthoracic echocardiography with an agitated saline micro-bubble test. When agitated saline was injected through the catheter, the coronary sinus was initially opacified, and then the right atrium followed. In conclusion, we were able to make a diagnosis of PLSVC by a bedside test without radiation exposure.

Sudden severe hyperammonemia and status epilepticus -a case report-

There are various causes to a low level of consciousness in patients in the intensive care unit. Neurological injury, infection, and metabolic disarray are considered as some of the causes. A 39 year-old female patient was transferred to our hospital with septic shock due to ascending colon perforation. The patient had previously received ovarian cancer surgery and a cycle of chemotherapy at another hospital. Emergent operation for colon perforation was successful. After the operation, she was treated in the intensive care unit for infectious and pulmonary complications. She suddenly showed deterioration in her level of consciousness and had a generalized seizure. At the time of her seizure, she had severe hyperammonemia. Brain CT showed severe cerebral edema that was absent in the CT scan taken 2 days before. Continuous renal replacement therapy was conducted but was ineffective in lowering the level of serum ammonia and the patient subsequently died.

Comparison of APACHE IV with APACHE II, SAPS 3, MELD, MELD-Na, and CTP scores in predicting mortality after liver transplantation

The Acute Physiology and Chronic Health Evaluation (APACHE) IV score and Simplified Acute Physiology Score (SAPS) 3 include liver transplantation as a diagnostic category. The performance of APACHE IV-liver transplantation (LT) specific predicted mortality, SAPS 3, APACHE II, Model for End-stage Liver Disease (MELD)-Na, MELD, and CTP scores in predicting in-hospital and 1 year mortality in liver transplant patients was compared using 590 liver transplantations in a single university hospital. In-hospital mortality and 1 year mortality were 2.9% and 4.2%, respectively. The APACHE IV-LT specific predicted mortality showed better performance in predicting in-hospital mortality (AUC 0.91, 95% CI [0.86–0.96]) compared to SAPS 3 (AUC 0.78, 95% CI [0.66–0.90], p = 0.01), MELD-Na (AUC 0.74, 95% CI [0.57–0.86], p = 0.01), and CTP (AUC 0.68, 95% CI [0.54–0.81], p = 0.01). The APACHE IV-LT specific predicted mortality showed better performance in predicting 1 year mortality (AUC 0.83, 95% CI [0.76–0.9]) compared to MELD-Na (AUC 0.67, 95% CI [0.55–0.79], p = 0.04) and CTP (AUC 0.64, 95% CI [0.53–0.75], p = 0.03), and also in all MELD groups and in both living and deceased donor transplantation. The APACHE IV-LT specific predicted mortality showed better performance in predicting in-hospital and 1 year mortality after liver transplantation.

Intracranial hemorrhage induced uncontrolled seizure in a deceased donor liver transplant patient: a case report

Seizure is the second most common neurologic complication after liver transplantation and may be caused by metabolic abnormalities, electrolyte imbalance, infection, and immunosuppressant toxicity. A 61-year-old male patient underwent liver transplantation due to hepatitis B virus-related liver cirrhosis with portal systemic encephalopathy. The immediate postoperative course of the patient was uncomplicated. However, on postoperative day (POD) 6, weakness developed in both lower extremities. No abnormal findings were detected on a brain computed tomography (CT) scan on POD 8, but a generalized tonic clonic seizure developed which was difficult to control even with multiple antiepileptic drugs. A follow-up brain CT scan on POD 15 showed a 2.7 cm sized acute intracranial hemorrhage (ICH) in the left parietal lobe. The patients mental status improved after 2 months and he was able to communicate through eye blinking or head shaking. Our case reports an acute ICH that manifested into a refractory seizure in a patient who underwent a liver transplant.

Impact of timing and duration of postoperative delirium: a retrospective observational study

Background: Recent reports suggest that not all critically ill patients with delirium share the same consequences. The outcomes of surgical intensive care unit patients with postoperative delirium were evaluated depending on the onset and duration of delirium. Methods: A total of 527 patients who were admitted from the operating theater and cared for in the surgical intensive care unit for >24 hours were evaluated for delirium using the Confusion Assessment Method for intensive care unit, 3 times a day. Patients were analyzed according to the onset time and duration of delirium. Patients were classified into 4 groups according to the onset and duration of delirium: no delirium, early brief delirium (delirium for <1 day on postoperative day 0), late brief delirium (delirium for <1 day after postoperative day 0), and persistent delirium (delirium for ≥1 days). Duration of stay (intensive care unit and hospital) and mortality (intensive care unit, hospital, and 1‐year) were outcomes of interest. Results: Of the 527 patients, delirium developed in 119 (22.6%) patients. More than two‐thirds of the patients developed delirium on postoperative day 0 or 1, and 70% of patients developed delirium for >24 hours (persistent). Persistent delirium was associated with longer intensive care unit (4.6 [1.1–53.3] vs 1.6 [1.1–37.5] days) and hospital duration of stay (24 [3–112] vs 16 [2–225] days) and higher hospital mortality (14.5% vs 2.2%) compared to no delirium (P < .01). Conclusion: For postoperative intensive care unit patients, intensive care unit and hospital duration of stay did not seem to differ between patients with early brief delirium or no delirium, whereas patients with late brief or persistent delirium seemed to show longer intensive care unit and hospital duration of stay and higher mortality.

Emergency department visits and unanticipated readmissions after liver transplantation: A retrospective observational study

Improved survival after LT are likely to result in increased healthcare resource utilization. The pattern and risk factors of emergency department (ED) visits and unanticipated readmissions, associated cost, and predictors of healthcare resource utilization after liver transplantation (LT) patients who received LT between 2011 and 2014 were analyzed. A total of 430 LT recipients were enrolled and the 1 year all-cause mortality was 1.4%. ED visits occurred in 53% (229/430) and unanticipated readmissions occurred at least once in 58.6% (252/430) of the patients. Overall risk factors for ED visits after LT included emergency operation [OR 1.56 (95%CI 1.02–2.37), p = 0.038] and warm ischemic time of >15 minutes [OR 2.36 (95%CI 1.25–4.47), p = 0.015]. Risk factors for readmissions after LT included greater estimated blood loss during LT [OR 1.09 (95%CI 1.02–1.17), p = 0.012], warm ischemic time of >15 minutes [OR 1.98 (95%CI 1.04–3.78), p = 0.038], and hospital length of stay of >2 weeks.

Management of bronchopleural fistula using a modified single lumen tube

Bronchopleural fistula (BPF) is defined as a pathologic connection between the tracheobronchial tree and the pleural space with persistent air leak for more than 24 hours. It is associated with poor prognosis after pneumonectomy [1], which mainly contributes to the occurrence among elective lung resections despite the outstanding advances in surgical techniques. Mechanical ventilation is always problematic for balancing the actual ventilation and the leakage in patients who present a BPF after pulmonary resections. High airway pressure to achieve sufficient minute ventilation may aggravate air leakage and interfere the healing process [2]. We describe a case in which a modified single-lumen endobronchial tube was used in a patient who developed BPF after right lower lung lobectomy in order to improve ventilation and allow adequate suctioning.