Acute and Critical Care

Volume 13 (2); November 1998

Reviews

Biological Role of Nitric Oxide: Hyeyoung Kim; Korean J Crit Care Med. 1998;13(2):139-146.

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Abstract PDF: No abstract available.

Hemorrhagic Shock and Nitric Oxide: Cheungsoo Shin; Korean J Crit Care Med. 1998;13(2):147-155.

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Abstract PDF: No abstract available.

Sepsis and Nitric Oxide: Seong Wan Baik; Korean J Crit Care Med. 1998;13(2):156-157.

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Abstract PDF: No abstract available.

Inhaled NO in ARDS: Chae Man Lim; Korean J Crit Care Med. 1998;13(2):158-162.

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Abstract PDF: No abstract available.

Nutritional Support in the Critically Ill Patients: Sung Su Chung; Korean J Crit Care Med. 1998;13(2):163-178.

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Abstract PDF: No abstract available.

Original Articles

The Effects of Nitric Oxide on Oxygen Balance in Cerebral Ischemia: Doo Ik Lee, Young Kyu Choi, Oak Za Chi; Korean J Crit Care Med. 1998;13(2):179-185.

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Abstract PDF: Bockground: Nitric oxide (NO) is an important regulator of blood flow and also works as a neuronal messenger via cyclic GMP. Recent studies regarding the therapeutic utility of nitric oxide synthase (NOS) inhibitors in reducing ischemia-induced neuronal damage are very controversial. The possible neuroprotective effect of NO or NOS inhibitors in ischemic neuronal damage could occur at the vascular and or neuronal level. This study investigated whether the NOS inhibitor, NG-nitro-L-arginine-methyl ester (L-NAME) would alter oxygen balance in ischemic cerebrocortex of isoflurane-anesthetized rats.
METHODS
Fifteen minutes after middle cerebral artery occlusion, L-NAME (1.5 mgxmin-1kg-1) was infused intravenously to the L-NAME group (n=14), and normal saline was given to the control group (n=14) for 45 minutes. Regional cerebral blood flow was determined with [14C]iodoantipyrine, and arterial and venous oxygen saturations were determined by microspectrophotometry.
RESULTS
Regional cerebral blood flow of the ischemic cortex was significantly lower than that of the contralateral cortex in both groups. In the control group, ischemic cortex; 55+/-13, contralateral cortex; 110+/-29 mlxmin-1100 g-1, and in the L-NAME group, ischemic cortex; 35+/-13, contralateral cortex; 90+/-24 mlxmin-1100 g-1. Compared with the blood flow in the ischemic cortex of the control group, L-NAME significantly reduced ischemic blood flow by 36%. Venous oxygen saturation was significantly increased in the ischemic cortex (41+/-1% in control, 44+/-3% in L-NAME) but decreased in the contralateral cortex (65+/-3% in control, 61+/-3% in L-NAME) by L-NAME. Ischemic cortical oxygen consumption in the L-NAME group was 39% lower than that in the corresponding control group, whereas the difference was only 11% in the contralateral sides between groups. The ratio of oxygen supply to consumption was lower in the ischemic than in the nonischemic regions in both groups. In the ischemic cortex, this ratio was significantly lower in the control group (1.7+/-0.1) than in the L-NAME group (1.9+/-0.1). In contrast, the ratio tended to be decreased by L-NAME in nonischemic regions.
CONCLUSIONS
These observations suggest that despite a decrease in cerebral blood flow, inhibition of nitric oxide synthesis mildly improves the oxygen supply and consumption balance in the ischemic cortex.

Changes of Sodium, Potassium, Chloride and Bicarbonateion Concentrations in Apneic Rabbits: Hyun Jung Kim, Kwang Won Yum, Yong Rak Kim; Korean J Crit Care Med. 1998;13(2):186-193.

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Abstract PDF: BACKGOUND: During apnea, as in any other acid-base disturbance, ion exchanges between intra- and extracellular compartments are expected, but few studies have reported such findings. The purpose of this study was to observe serum sodium, potassium, chloride and bicarbonate concentrations during apnea until death.
METHODS
Seventeen New Zealand White Rabbits (weight 2.0~3.0 kg) were subjected to apneic oxygenation. Then we measured heart rate, blood pressure, intracranial pressure, arterial blood gas analyses and serum electrolytes (sodium, potassium, chloride and bicarbonate) concentrations during apnea until death.
RESULTS
Heart rate decreased because of sinus bradyarrythmia at 10 minutes after apnea and thereafter continued to increase. Blood pressure increased up to 30 minutes after apnea and thereafter continued to decrease. Intracranial pressure consistently increased during apnea. Serum bicarbonate and chloride ion concentrations showed reciprocal changes, but there was no significant correlation. Serum sodium and potassium concentrations increased up to 40 minutes and 30 minutes respectively, and thereafter decreased until death. All serum ion concentrations were within normal limits.
CONCLUSION
The serum sodium, potassium, chloride and bicarbonate concentrations were maintained within normal limits during apneic oxygenation until death.

Volume Changes under Isotonic Condition Containing Thiopental in Brain Astrocytoma Cells: Young Seok Lee, Bong Ki Moon, Sang Gun Han, Young Joo Lee, Jeong Yeon Hong, Kyeong Jin Lee, Soo Han Yoon, Keum Hee Chung, Hyun Jue Gill; Korean J Crit Care Med. 1998;13(2):194-197.

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Abstract PDF: BACKGOUND: Cell volume regulation is especially important in the brain because the brain is confined within a non-compliant vault and cannot tolerate significant perturbations in cell size. Cerebral cell volume regulation mechanisms are activated by sustained disturbances in plasma osmolality. The constancy of cell volume under physiological conditions is generally thought to reflex a balance between influx and efflux of solute and is therefore critically dependent on the properties of the plasma membrane. Cell volume regulation have not been described under isoosmotic solution. The object of the study was to know the effects of thiopental on cell volume change in isoosmotic condition.
METHODS
We made isoosmotic solution without thiopental (Group 1) and isoosmotic solution with 22.9 mM (Group 2), 16.8 mM (Group 3), 13.3 mM (Group 4) thiopental, separately, in order to study changes in cell volume under isoosmotic solution. We put cultured human brain astrocytoma cells into isoosmotic solution for each group and calculated cell volume using Coulter Counter after 30 minutes.
RESULTS
Cell volume was shown to be 5084+/-8580 (micrometer3)in Group 1, 501+/-854 (micrometer3) in Group 2, 1183+/-3839 (micrometer3) in Group 3, and 624+/-1100 (micrometer3) in Group 4. We discovered that cells in Group 2,3,4 were shrunk relative to cells in Group 1 (p<0.01). And there were significant differences in cell volume among thiopental groups.
CONCLUSIONS
Thiopental may has an effect on cell membrane properties and decrease cell volume under isoosmotic solution in brain astrocytoma cell.

Endobronchial Insufflation of Air Supports Ventilation in Apneic Dogs: Ji Han Rhyu, Sun Gyoo Park; Korean J Crit Care Med. 1998;13(2):198-204.

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Abstract PDF: BACKGOUND: Mass casualties from organophosphorus inhalation die from respiratory depression. Gas supplies and equipment are limited for mechanical ventilation of multiple subjects in emergency situation. Endobronchial insufflation of air (EIA) can be simply performed with air compressor and catheter. The author tried to examine the usefulness of EIA in five apneic dogs induced by tetrodotoxin (TTX) infusion.
METHOD
Five anesthetized dogs were intubated with endotracheal tube and endobronchial insufflation catheter and instrumented with arterial catheter and ventilated with controlled mechanical ventilation (CMV) while 12 microgram/kg TTX was infused intravenous over 90 minutes to produce apnea. EIA of 1 microliter/kg/min was delivered through a 35 cm long, 0.8 cm ID catheter with a forked end placed astride the carina. During conventional ventilation, arterial blood gases and pH were measured (base line, BL). The data were measured after confirmation of apnea for 1 minute (time=0, control value), and then measured serially for 4 hours of EIA.
RESULT
All animals survived and were alert and neurologically normal within 24 hours. The changes of arterial oxygen tension (PaO2) were no significant difference between control value and 10, 20, 30 minute (p<0.05), and arterial carbon dioxide tension (PaCO2) were significant increase in control value compared to base line (p<0.05), and pH were no significant difference in all values (p<0.05). Spontaneous respiratory efforts slowly returned after 45 minute of EIA and resulted in the improvement of gas exchange.
CONCLUSION
EIA recognized as a sort of ventilatory technique is useful only when other equipments could not be available. The EIA catheter can be placed by cricothyroidotomy. EIA is very helpful in supporting ventilation, and it also helps the apneic dogs stay in normal condition.

The Effect of Clonidine Pretreatment on Bupivacaine-induced Cardiac Toxicity in Rabbit: Eun Ju Lee, Jin Young Chon, Yong Woo Choi, Se Ho Moon; Korean J Crit Care Med. 1998;13(2):205-211.

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Abstract PDF: BACKGOUND: Bupivacaine, an amide type local anesthetic, is frequently used for regional anesthesia. Bupivacaine overdose induces cardiac toxicity and directly depresses both cardiac electrophysiology and hemodynamic status. Clonidine, an imidazolin alpha-2-adrenoreceptor agonist, given prophylactically may delay the toxic manifestation of bupivacaine overdose and does not accentuate the subsequent hypotension. We studied the effect of clonidine pretreatment on bupivacaine induced cardiac toxicity.
METHODS
Fourteen rabbits (seven in each group) were anesthetized with ketamine and rompun, and tracheostomy was performed. Spontaneous ventilation with room air was continued throughout the experiment. Electrocardiogram, heart rate, and invasive arterial blood pressure were continuously recorded. Clonidine 5 microgram/kg (clonidine group) or saline (control group) was injected intravenously in randomized fashion. After 15 minutes, an intravenous infusion of bupivacaine was started at 0.3 mg/kg/min. The time of occurrence of the bupivacaine-induced toxic events: first dysrhythmia, 25% and 50% reduction in basal heart rate and mean arterial pressure, and asystole were recorded. At 5, 10, 15, and 20 minutes after bupivacaine infusion, 2 ml of whole blood were withdrawn via femoral arterial catheter for determination of bupivacaine concentration.
RESULTS
The threshold time at the first dysrhythmia was significantly greater in the clonidine group (27.2+/-4.5 min) than control group (19.9+/-1.2 min). The threshold times at the 25 and 50% reduction in basal heart rate were significantly greater in the clonidine group (23.7+/-5.8 min, 33.2+/-5.1 min) than control group (16.6+/-2.9 min, 22.9+/-2.8 min) and in basal mean arterial pressure were significantly greater in the clonidine group (15.6+/-2.6 min, 25.3+/-3.7 min) than control group (9.7+/-2.7 min, 16.3+/-5.8 min). The threshold time at the asystole was significantly greater in the clonidine group (38.2+/-7.7 min) than control group (28.7+/-3.4 min). At 5, 10, 15, and 20 minutes after bupivacaine infusion, there was no significant difference in the plasma bupivacaine concentration between two groups.
CONCLUSION
This study demonstrates that clonidine pretreatment delays the cardiac toxic manifestations of bupivacaine overdose. And plasma bupivacaine concentration was not influenced by clonidine pretreatment.

Number of Beds and Types of Intensive Care Unit (ICU) in University and Non-University Hospitals in Korea: Shin Ok Koh, Pyung Hwan Park, Myoung Hoon Kong, Chang Young Jeung, Woong Mo Lim, Yong Lak Kim; Korean J Crit Care Med. 1998;13(2):212-217.

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Abstract PDF: BACKGOUND: The number of ICU beds related to the number of general acute care beds provides a broad measure of intensive care, but it has obvious limitations and underestimates extreme regional differences. As a first step, we evaluated the number of ICU beds or the ratio of ICU beds to hospital beds in university and non-university hospitals in Korea.
METHODS
The number of ICU beds and hospital beds, the ratio of the number of ICU beds to hospital beds, and the types of ICU in each range of ICU beds and hospital beds in the university and non-university hospital were analyzed as well.
RESULTS
Thirty university hospitals had 1,824 ICU beds out of 25,966 hospital beds, an average of 7.0%. The number of ICU beds ranged from 17 to 159 beds and hospital beds ranged from 400 to 2,000 beds in university hospitals. Fourteen non-university hospitals had 377 ICU beds out of 6,121 hospital beds, an average of 6.2%. In non-university hospitals, the number of ICU beds ranged from 6 to 67 beds with 50 to 700 hospital beds. If there was only one ICU, e.g. multidisciplinary, or more than one, the director of a multidisciplinary and surgical ICU was usually filled by an anesthesiologist, while the directors of other ICUs were usually specialists according to each specific ICU.
CONCLUSIONS
There was a large disparity in the number of ICU beds and in the ratio of ICU beds to hospital beds between university and non-university hosptials, and even between university hospitals.

Reliable Verification of Endotracheal Tube Location by Pilot Balloon Compression Technique of Tracheal Tube: Sang Kyi Lee; Korean J Crit Care Med. 1998;13(2):218-223.

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Abstract PDF: BACKGOUND: Correct placement of an endotacheal tube (ETT) is crucial, and an ideal test for confirmation of proper ETT placement should be simple and quick to perform, reliable, safe, inexpensive, and repeatable. Palpation of the ETT cuff at the suprasternal notch has been used by clinicians for many years, however the effectiveness of the technique has never been documented. So the author evaluated an efficacy of the pilot balloon compression technique to verify the correct location of an ETT.
METHODS
After anesthetic induction and confirmation of orotracheal intubation, the patient's head is placed in a neutral position. The ETT is withdrawn or advanced while gentle, repeated pressure is applied with the fingers at the pilot balloon. Simultaneously, the suprasternal notch is palpated in the other hand. When the cuff maximally distends from the pressure applied at the pilot balloon, the ETT is secured. After securing the ETT, the distances from its tip to the upper incisor and the carina were measured by means of fiberoptic laryngoscopy.
RESULTS
Endobroncheal intubation was noted in three patients (3%). Average distance from the tip of the ETT to upper incisor in men was 23.9 cm (range, 21.7~26.9) and in women 22.5 cm (range, 20.0~26.0). Average distance to the carina in men was 2.6 cm (range, -0.5~5.0) and in women 1.8 cm (range, -0.6~4.4).
CONCLUSIONS
In this study, location of the ETT was not reliably confirmed by the technique. So the technique should need some modification. When maximal sensation of the ETT cuff is palpated 2.4~3.3 cm in men and 3.2~3.7 cm in women above the suprastenal notch, the location of the ETT tip is theoretically reliable. However, the technique should not be used to verify endotracheal intubation itself.

Effects of Intravenous Lidocaine on Intra-abdominal Pressure during Endotracheal Suctioning: Wha Ja Kang, Seok Hee Ham, Young Kyu Choi, Moo Il Kwon; Korean J Crit Care Med. 1998;13(2):224-228.

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Abstract PDF: BACKGOUND: We evaluated the effect of intravenous lidocaine (1 mg/kg and 2 mg/kg) on intra-abdominal pressure (IAP) during endotracheal suctioning.
METHODS
We studied 40 patients undergoing endotracheal intubation during mechanical ventilation. Group I (1 mg/kg) and group II (2 mg/kg)were given lidocaine double fashion. The endotracheal suctioning (ETS) was done 1, 3, 5 and 7 min after the injection of lidocaine. IAP, systolic blood pressure (SBP), diastolic blood preassure (DBP), and heart rate (HR) during ETS were recorded, IAP was measured using a transurethral bladder catheters. The cough response to ETS was classified as " cough score".
RESULTS
Before administration of lidocaine, ETS produced significant increase in SBP, DBP, IAP and HR compared with baseline values in the two groups (p<0.05). Both groups showed no significant changes in SBP, DBP, and HR during the study. In group I, ETS produced a significant increase in IAP 5 and 7min after lidocaine treatment (p<0.05). There were significant differences between the two groups 5 and 7 min after lidocaine treatment (p<0.05). The score of cough decreased significantly in both groups 3 min after lidocaine treatment but there was a significant difference between the two groups at 7 min.
CONCLUSIONS
We concluded that lidocaine pretreatment significantly blunted the increase in IAP, SBP DBP and HR caused by ETS and this effect lasts for 3 min in group I and 7 min in group II.

Effectiveness of Left Infrascapular Skin Temperature Monitoring in the ICU: Young Joo Lee, Hyun Jue Gill, Kuem Hee Chung, Jeong Yeon Hong, Bong Ki Moon, Myoung Eun Kim, Min Hyup Choi, Young Seok Lee; Korean J Crit Care Med. 1998;13(2):229-233.

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Abstract PDF: BACKGOUND: Many sites are used to measure the body temperature and each site has different physiologic and practical importance. Several types of skin temperature monitoring have been used as simple, inexpensive and viable alternatives in many settings. In the operating area, it is difficult to insert a temperature probe during operation. The object of this study was to compare the difference and the correlation between the temperature of the left infrascapular skin region and temperatures of axilla, nasopharynx and rectum, METHODS: Forty-two adult patients who were admitted at surgical ICU were studied. After covering the bed with insulator and sheets, patients were placed in supine position. Temperature monitoring was done at the same time using four temperature probes from two bedside patient monitors in the same patient. The temperatures were measured twice at 30 minutes after application of the temperature probe at 10 minute intervals and the average temperature was recorded.
RESULTS
The differences between skin temperature and rectal, nasopharyngeal, and axillary temperatures were -0.64+/-0.21degrees C (p<0.05), -0.40+/-0.21degrees C, and 0.24+/-0.21degrees C respectively. The lineal correlation between skin temperature and rectal, nasopharyngeal, and axillary temperatures were 0.839, 0.854, and 0.819, respectively (p<0.001).
CONCLUSION
This study suggests that the monitoring of the skin temperature at the left infrascapular skin region is well correlated with the nasopharyngeal, rectal and axillary temperatures. And it will be an easy, simple and safe method which can be used for the patients who are alert but need continuous temperature monitoring in the intensive care unit and as well as for the patients who are in the middle of operation.

Quality Assessment of Blood Transfusion in Operating Room: Myoung Gil Chae, Byeung Ho Byeun, Dong Hee Kang, Hae Kyu Kim, Seong Wan Baik, Kyoo Sub Chung; Korean J Crit Care Med. 1998;13(2):234-238.

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Abstract PDF: BACKGOUND: Transfusion of red blood cells is a life saving measure in the management of a variety of surgical conditions. A guideline for blood transfusion during elective surgical procedure is necessary to reduce the risks of transfusion-associated complications, excessive blood bank workload, excessive blood request and overtransfusion, and the cost. From this, a program of quality assessment was adopted to improve blood transfusion practice and to establish the guideline for blood transfusion in elective surgery at Pusan National University Hospital.
METHODS
Fifty-six patients undergoing elective surgery was divided 2 groups. Transfusion (T) group was 18 persons. Non-transfusion (NT) group was 38 persons. The preoperative, pre-transfusion, postoperative, and post-transfusion hemoglobin (Hb), hematocrit, mean arterial blood pressure (MAP), heart rate (HR), average amount of transfused red blood cell units, allowable blood loss, and the amount of infused crystalloids and colloids was estimated for 9 months in Pusan National University Hospital.
RESULTS
There were no significant differences in Hb between T & NT group. Hb decreased significantly until postoperative 3rd day in NT group. Platelet count decreased in NT group on postop. 3rd day. There were no significant differences in MAP & HR. One-ninth of T group was overestimated blood loss & 18.4% of NT group was underestimated blood loss. One-third of transfusion patient were overtransfused & 36.2% of transfused RBC was unnecessary. Nearly 90% of patient was transfused packed RBC with FFP concurrently.
CONCLUSIONS
To minimize overtransfusion, transfusion based on intraoperative hematocrit is necessary. If possible, single use of packed RBC is recommended when the blood loss is below allowable blood loss. In massive bleeding above allowable blood loss, combined administration of FFP and packed RBC or transfusion of whole blood will be better.

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