Journal of Acute Care Surgery

Critical care, System

Analysis of Medical Consultation Patterns in Medical and Surgical Intensive Care Units: Changes in the Pattern of Consultation after the Implementation of Intensivist-Directed Care: Min-Jung Bang, So-Kyung Yoon, Kyoung Won Yoon, Eunmi Gil, Keesang Yoo, Kyoung Jin Choi, Chi-Min Park; J Acute Care Surg 2021;11(3):102-107. Published online November 23, 2021; DOI: https://doi.org/10.17479/jacs.2021.11.3.102

Abstract
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Purpose
Critically ill patients often require multidisciplinary treatment for both acute illnesses and pre-existing medical conditions. Since different medical conditions are managed in the intensive care unit (ICU), consultation is often required. This study aimed to identify the frequency and type of consultation required and analyze changes in consultation patterns after the introduction of intensivist-directed care in the surgical ICU (SICU).
Methods
Between June 2006 and December 2013, a retrospective cohort study was conducted to identify the frequency and type of consultation at 3 different ICUs. Consultations for patients who were admitted to the ICUs for more than 48 consecutive hours were included. The pattern of consultations in each ICU was investigated. In addition, the pattern of consultations before and after the implementation of intensivist-directed care in the SICU was compared.
Results
During the study, 11,053 consultations were requested for 7,774 critically ill patients in a total of 3 ICUs. Consultations with the Departments of Cardiology, Infectious Diseases, and Pulmonology were requested most frequently in the SICU. However, after the implementation of the intensivist-directed care approach, there was an increase in the frequency of consultation requests to the Department of Neurology, followed by the Departments of Cardiology, and Infectious Diseases.
Conclusion
Analysis of consultation patterns is an important method of assessing the complexity and severity of illnesses, and of evaluating the needs of available health system resources. Based on our findings, we suggest the development of an appropriate protocol for frequently consulted services.

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Procedure, Emergency surgery

Feasibility of the Gastrografin Challenge for Adhesive Small Bowel Obstruction: Ki-Sang Jung, Kyoung Jin Choi, Kyoung Won Yoon, Keesang Yoo, Eunmi Gil, Chi-Min Park; J Acute Care Surg 2021;11(2):58-63. Published online July 7, 2021; DOI: https://doi.org/10.17479/jacs.2021.11.2.58

Abstract
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Purpose
This retrospective study investigated the feasibility, diagnostic, and therapeutic advantages of the gastrografin challenge on patients with adhesive small bowel obstruction (ASBO).
Methods
There were 125 patients reviewed who were admitted to the Department of General Surgery at a single institution (September 2018 to August 2019) with a diagnosis related to ASBO. The study population included 100 patients (114 cases) who had received initial conservative management. Patient characteristics and operation rates were compared between the gastrografin challenge success group and failure group, and operation rates and length of hospital stay were compared between the gastrografin challenge group and “non-challenge” group.
Results
During the study period, 21 patients with ASBO underwent the gastrografin challenge. The challenge was successful in 17 patients where the bowel obstruction was resolved without the need for surgery. Among patients who failed the challenge, 2 patients underwent adhesiolysis and 2 patients were able to progress their diet avoiding surgery. In patients who underwent surgery (n = 2), the length of hospital stay was significantly shorter in the gastrografin challenge group compared with the “non-challenge” group sub analysis (n = 13 cases; 10.5 vs. 20 days, p = 0.038), indicating that the gastrografin challenge assisted rapid decision-making for surgery. No adverse events were reported for the 21 gastrografin challenges.
Conclusion
In patients with ASBO, the gastrografin challenge is an accurate, safe method to determine the need for surgery. In addition, the gastrografin challenge may reduce the length of stay in patients who required surgery for ASBO resolution.

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Critical care

Bedside Ultrasound-Guided Peripherally Inserted Central Catheter Placement by Critical Care Fellows in Critically Ill Patients: A Feasibility and Safety Study: Jeeyoun Lim, Chi Ryang Chung, Jeong-Am Ryu, Eunmi Gil; J Acute Care Surg 2021;11(1):30-35. Published online March 24, 2021; DOI: https://doi.org/10.17479/jacs.2021.1.30

Purpose
In the intensive care unit, a peripherally inserted central catheter (PICC) may be an alternative option to standard central venous catheters, particularly in patients with coagulopathies or at high risk of infection. The purpose of this research was to assess the feasibility of bedside ultrasound (US)-guided PICC placement by critical care fellows on intensive care units.

Methods
All bedside US-PICCs inserted by critical care fellows from July 2013 to September 2015 were retrospectively reviewed focusing on the rate of successful insertion, complications of insertion, or during maintenance.

Results
A total of 177 US-guided PICCs were inserted in 163 patients and included in the analysis. The median age was 62 years (IQR 50-70 years) and 104 cases (58.8%) were male. There were 172 cases (90.4%) of PICCs inserted in the upper arm. Anticoagulant therapy was used in 26 patients (14.7%) and 8 patients (5.2%) had severe coagulopathies. The median procedural time was 30 minutes (IQR 19-45 minutes). Insertion success rate was 93.2%, and there were no major complications during insertions except for malposition (12.1%). Catheters remained in place for a total of 3,878 days (median 16 days: IQR 8-31 days). There was only 1 case (0.6%) of catheter-related bloodstream infection, and 2 cases (1.2%) of symptomatic venous thromboembolism.

Conclusion
Bedside US-guided placement of PICCs by critical care fellows is safe and feasible. The success rate of the procedure was “acceptable,” and was not associated with significant risks of infectious and non-infectious complications, even in patients with coagulopathies.

Citations

Citations to this article as recorded by

Analysis of tip malposition and correction of peripherally inserted central catheters under ultrasound-guidance: 5-year outcomes from a single center
Eunju Jang, Soo Mi Son, Ki-yoon Moon, Seunghoon Lee, Hong Seok Han, Sun Cheol Park, Jang Yong Kim, Sang Seob Yun
The Journal of Vascular Access.2025; 26(1): 72. CrossRef
Analysis of Risk Factors for Peripherally Inserted Central Venous Catheter-Associated Bloodstream Infection
Sungho Lee, Kwanhoon Park, Kang Yoon Lee, Dongbeen Choi, Ji Young Jang
Journal of Acute Care Surgery.2024; 14(1): 9. CrossRef
Development and validation of an updated PICC length prediction formula based on anteroposterior chest radiographs for the ultrasound-guided bedside placement
Hyoung Nam Lee, Sangjoon Lee, Sung-Joon Park, Youngjong Cho, Hwan Hoon Chung, Robert Jeenchen Chen
PLOS ONE.2023; 18(11): e0294598. CrossRef
Validation of the PICC length prediction formula based on anteroposterior chest radiographs for bedside ultrasound-guided placement
Youngjong Cho, Sangjoon Lee, Sung-Joon Park, Hyoung Nam Lee, Hwan Hoon Chung, Robert Jeenchen Chen
PLOS ONE.2022; 17(11): e0277526. CrossRef
Feasibility of Peripherally Inserted Central Catheter Placement in COVID-19 Patients Isolated in the Intensive Care Unit of a Small Volume Center (291-Bed Hospital)
Min Chang Kang, Kyungwon Lee
Journal of Acute Care Surgery.2022; 12(3): 125. CrossRef

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5 Crossref

Critical care

Efficiency of Computerized Insulin Infusion Glucose Control in Critically Ill Patients: Hee Jung Lim, Chi-Min Park, Eunmi Gil, Keesang Yoo, Kyoung-Jin Choi, Sang-Man Jin; J Acute Care Surg 2020;10(2):53-57. Published online July 24, 2020; DOI: https://doi.org/10.17479/jacs.2020.10.2.53

Abstract
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Purpose
Intensive IV insulin infusion therapy has been applied widely to critically ill patients. However, IV insulin protocols are complex, and require repeated calculations. The purpose of this study was to evaluate the safety and efficiency of a computerized insulin infusion (CII) protocol to replace manual insulin infusion protocols, for glucose control in critically ill patients.
Methods
This was an observational study (September 2016 to January 2017) of 43 patients in ICU whose blood glucose level was between 140-180 mg/mL and could not be controlled by the conventional manual insulin protocol. The CII protocol was integrated in to the electronic medical record order system, and automatically calculated the insulin infusion dose and blood sugar test (BST) interval. BSTs were taken 48 hours pre- and post-initiation of the CII protocol. The proportion of BSTs in the normal (70-180 mg/mL), hypoglycemic (70 mg/mL), and severe hyperglycemic (> 250 mg/mL) range were recorded.
Results
The mean number of BSTs performed before using the CII protocol was 10.3/person and 0.4/hour, and after implementing the protocol, increased to 21.7/person and 0.7/hour. The mean glucose level (281.4 mg/mL) decreased after using the CII protocol (195.5 mg/mL; p < 0.001). The percentage of BSTs within normal range increased from 22.5% to 44.9% after implementing the protocol (p < 0.001). Severe hyperglycemia (> 250 mg/mL) decreased from 47.3% to 17.9% after protocol implementation (p = 0.020).
Conclusion
The CII protocol safely and successfully maintained a normal glucose range, and decreased severe hyperglycemia in intensive care patients.

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Basic, Infection/Sepsis

Thromboelastographic Evaluation in Patients with Severe Sepsis or Septic Shock: A Preliminary Analysis: Sokyung Yoon, JooYen Lim, Chi-Min Park, Dae-Sang Lee, Jae Berm Park, Kyoungjin Choi, Keesang Yoo, Eunmi Gil, Kyoung Won Yoon; J Acute Care Surg 2020;10(2):47-52. Published online July 24, 2020; DOI: https://doi.org/10.17479/jacs.2020.10.2.47

Abstract
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Purpose
Thromboelastography (TEG) was investigated for the diagnosis of coagulopathy compared with traditional coagulation tests, in association with disease severity in patients with severe sepsis or septic shock.
Methods
Retrospective data was collected from a single center between January 25th to March 24th, 2016. There were 18 patients with severe sepsis or septic shock admitted to intensive care units included in this study. Laboratory tests including TEG were performed at admission. Disease severity was measured using the Simplified Acute Physiology Score III, Sequential Organ Failure Assessment score, and the level of lactate.
Results
There were 18 patients (61% males; median age, 60.5 years) who were diagnosed with severe sepsis, or septic shock requiring a norepinephrine infusion (n = 10, 55.6%). Of these, 4 patients had traditional coagulation tests, and TEG profiles which confirmed hypercoagulability. Eight patients had follow-up tests 48 hours post-admission with a Sequential Organ Failure Assessment score of 6.5 (3-9.5) at admission, decreasing to 4 (2-11) after 48 hours (although not significantly lower), however, the lactate level decreased statistically significantly from 2.965 at admission, to 1.405 mmol/L after 48 hours (p < 0.05). The TEG profiles tended to normalize after 48 hours compared with admission, but there was no statistically significant difference.
Conclusion
Coagulopathy with severe sepsis or septic shock patients can be life-threatening, therefore it is important to diagnose coagulopathy early and precisely. TEG can be a feasible tool to confirm coagulopathy with traditional coagulation tests.

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Critical care

Clinical Significance of Creatine Kinase Elevation in Critically Ill Patients: Chi-Woo Lee, Seung-Wook Choi, Dae-Sang Lee, Eunmi Gil, Chi-Min Park; J Acute Care Surg 2018;8(1):13-18. Published online April 30, 2018; DOI: https://doi.org/10.17479/jacs.2018.8.1.13

Abstract
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Purpose:

Creatine kinase (CK) elevation is caused by rhabdomyolysis, intense exercise, muscle damage, and several drugs. This study evaluated the clinical significance of elevated serum CK levels in patients with an intensive care unit (ICU) and their effects on muscle strength.

Methods:

The database of 179 patients, who were examined with CK at least once among patients in the Samsung Medical Center ICU database, was reviewed retrospectively. Forty- eight patients with a myocardial infarction were excluded and 131 patients were analyzed. The clinical features of patients with an elevated CK of more than 2,000 IU/L (more than 10 times the normal value) and those who did not were compared.

Results:

The ICU stay days were longer in the high elevation group than the other group (8.6 days vs. 21.7 days, p=0.002). The high elevation group was more likely to go to other treatment centers than home after discharge (14.6% vs. 60.0%, p=0.007). When the Medical Research Council scale was measured, the score of the high elevation group was lower than that of the other group (17.2 vs. 13.3, p=0.006).

Conclusion:

Patients with high CK levels were more likely to receive invasive treatment in the ICU, so their muscle strength may decrease with increasing ICU stay and were less likely to be discharged home because of difficulties in living alone. Therefore, in patients with high CK, anticipating long-term treatment in an ICU, minimizing muscle loss, and maintaining functional muscle strength through active rehabilitation will be helpful for the prognosis of the patient.

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Basic, Critical care

Prevalence of Multidrug Resistant Organisms in Inter-Hospital Transferred Critically Ill Patients: Changho Heo, Dae-Sang Lee, Eunmi Gil, Chi-Min Park; J Acute Care Surg 2017;7(1):9-14. Published online April 30, 2017; DOI: https://doi.org/10.17479/jacs.2017.7.1.9

Abstract
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Purpose:

To assess the prevalence of multidrug-resistant organisms (MDROs) in inter-hospital transferred critically ill patients.

Methods:

This is a retrospective study. The study population comprised patients who were transferred from other hospitals or health care units into the medical or surgical intensive care unit of Samsung Medical Center from January 2012 to December 2014. We evaluated the acquisition of clinically significant MDROs including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), extended-spectrum beta-lactamase (ESBL)-producing Gram-negative bacteria, and carbapenem-resistant Gram-negative bacteria (CRGNB).

Results:

Three hundred and twenty-one patients were included in this study. One hundred and fifty-one patients (47.0%) had at least one species of MDRO, 21.5% in MRSA, 27.1% in VRE, 15.6% in CRGNB, and 3.7% in ESBL. The prevalence of MDROs was significantly higher in male (52.7%), patients with diabetes (61.6%), patients with combined infectious diseases (51.6%), and medical patients (49.3%). Patients with MRSA had significantly longer length of stay than the patients without MRSA. The patients with CRGNB had higher mortality than the patients without CRGNB.

Conclusion:

The prevalence of MDROs in inter-hospital transferred critically ill patients was very high. Patients with MDROs in this study had longer hospital stay and higher mortality. These patients require more attention for isolation and hygiene protocols, and antibiotic choices.