Mortality of patients with chronic obstructive pulmonary disease: a nationwide populationbased cohort study

BACKGROUND/AIMS: Chronic obstructive pulmonary disease (COPD) is a major cause of mortality in the world. There are no population-based studies on longterm mortality in COPD patients in Korea. METHODS: Using the large, population-based, National Health Insurance Service- National Sample Cohort (NHIS-NSC), we identified COPD patients using the International Classification of Disease-Tenth Revision (ICD-10) and prescription details in the NHIS-NSC during 2003 to 2013. We analyzed the survival curves of COPD patients by sex, age, and cause of death. RESULTS: A total of 14,127 individuals older than 40 years were diagnosed with COPD. There were a total of 3,695 deaths (26.2%) in COPD patients during the study period. The 5-year mortality of COPD patients was 25.4% (29.9% in males and 19.1% in females). The mortality rate increased rapidly with age. The most common cause of death in COPD was chronic lower respiratory disease. CONCLUSION: This study described long-term mortality in COPD patients in Korea. Higher mortality was observed in males, and it was closely related to age.ope

Use of bioelectrical impedance analysis for the assessment of nutritional status in critically ill patients

Malnutrition is common in the critically ill patients and known to cause a variety of negative clinical outcomes. However, various conventional methods for nutrition assessment have several limitations. We hypothesized that body composition data, as measured using bioelectrical impedance analysis (BIA), may have a significant role in evaluating nutritional status and predicting clinical outcomes in critically ill patients. We gathered clinical, biochemical, and BIA data from 66 critically ill patients admitted to an intensive care unit. Patients were divided into three nutritional status groups according to their serum albumin level and total lymphocyte counts. The BIA results, conventional indicators of nutrition status, and clinical outcomes were compared and analyzed retrospectively. Results showed that the BIA indices including phase angle (PhA), extracellular water (ECW), and ECW/total body water (TBW) were significantly associated with the severity of nutritional status. Particularly, PhA, an indicator of the health of the cell membrane, was higher in the well-nourished patient group, whereas the edema index (ECW/TBW) was higher in the severely malnourished patient group. PhA was positively associated with albumin and ECW/TBW was negatively associated with serum albumin, hemoglobin, and duration of mechanical ventilation. In non-survivors, PhA was significantly lower and both ECW/TBW and %TBW/fat free mass were higher than in survivors. In conclusion, several BIA indexes including PhA and ECW/TBW may be useful for nutritional assessment and represent significant prognostic factors in the care of critically ill patients.ope

Nutritional support process for a patient with short bowel syndrome in conjunction with panperitonitis: a case report

Short Bowel Syndrome (SBS) is a condition that causes malabsorption and nutrient deficiency because a large section of the small intestine is missing or has been surgically removed. SBS may develop congenitally or from gastroenterectomy, which often change the motility, digestive, and/or absorptive functions of the small bowel. The surgical procedure for SBS and the condition itself have high mortality rates and often lead to a range of complications associated with long-term parenteral nutrition (PN). Therefore, careful management and appropriate nutrition intervention are needed to prevent complications and to help maintain the physiologic integrity of the remaining intestinal functions. Initial postoperative care should provide adequate hydration, electrolyte support and total parenteral nutrition (TPN) to prevent fatal dehydration. Simultaneously, enteral nutrition should be gradually introduced, with the final goal of using only enteral nutrition support and/or oral intake and eliminating TPN from the diet. A patient should be considered for discharge when macro and micronutrients can be adequately supplied through enteral nutrition support or oral diet. Currently, there is more research on pediatric patients with SBS than on adult patient population. A 35-year-old man with no notable medical history was hospitalized and underwent a surgery for acute appendicitis at a local hospital. He was re-operated on the 8th day after the initial surgery due to complications and was under observation when he suddenly complained of severe abdominal pain and high fever. He was immediately transferred to a tertiary hospital where the medical team discovered free air in the abdomen. He was subsequently diagnosed with panperitonitis and underwent an emergency reoperation to explore the abdomen. Although the patient was expected to be at a high risk of malnutrition due to short bowel syndrome resulting from multiple surgeries, through intensive care under close cooperation between the medical and nutrition support team, his nutritional status improved significantly through continuous central and peripheral parenteral nutrition, enteral nutrition, and oral intake. The purpose of this paper is to report the process of the patient's recovery.ope

Nutrition Support in the Intensive Care Unit of 6 Korean Tertiary Teaching Hospitals: A National Multicenter Observational Study

Background: Malnutrition is a frequent nutritional problem among ICU patients, and their nutritional status is known to affect clinical prognosis. We conducted this study to examine nutritional status and actual nutrition delivery in the ICU patients and its relations to clinical outcomes. Methods: This study was a multicenter retrospective observational study based on the medical records of 163 patients admitted to ICU of tertiary teaching hospitals in Korea. We included the patients who were treated with mechanical ventilation for 3 or more days and received enteral or parenteral nutrition. Results: According to albumin and total lymphocyte count levels, 54.6% of the subjects were moderately or severely malnourished. Mean percentage of calorie and protein delivery to estimated needs for 10 days were 55.8 ± 29.3% and 46.1 ± 30.1%, respectively. While parenteral nutrition (PN) started at 1.6 ± 1.4 days after admission, enteral nutrition (EN) did at 3.6 ± 2.1 days. Days to PN and EN start, the calorie and protein amount via EN or PN were significantly different among 6 hospitals. No clinical outcomes differed by the levels of calorie or protein delivery. In-hospital mortality was significantly higher in the severely malnourished group at admission as compared to the other 2 groups (54.3% vs. 31.2% vs. 27.7%, p ＜ 0.05) Conclusions: Malnutrition prevalence is high among Korean intensive care unit patients, but current nutritional therapy practice is inconsistent across institutions and far below the international guidelines. Systematic efforts should be made to develop nutritional support guidelines for Korean ICU patients.ope

Effect of various anesthetic induction agents on blood magnesium and calcium concentration.

BACKGROUND: Decrease in blood magnesium and calcium concentration is associated with an increase in the incidence of arrhythmia, especially during the induction period. Therefore, it is important to evaluate the effects of propofol, pentothal sodium, and sevoflurane on calcium and magnesium concentration. METHODS: Thirty-six premedicated, ASA grade I patients were selected and randomly allocated into 3 groups. Six percent sevoflurane inhalation (sevo group), propofol 1.5 mg/kg (propofol group), and 5 mg/kg of pentothal sodium (pento group) were administered for anesthetic induction and anesthetic maintenance was done with end-tidal sevoflurane concentration at 3.5%. Blood sampling was performed during the pre-induction period (pre-induction), just before tracheal intubation (pre-intubation), and 2 min after intubation (post-intubation). pH corrected ionized magnesium and calcium were calculated and analyzed simultaneously. RESULTS: Both total calcium and magnesium concentrations decreased significantly in all groups during the pre-intubation and post-intubation periods compared with the pre-induction period. Ionized calcium only decreased significantly during pre-intubation and post-intubation in the pento group, and did not change throughout the study period in the sevo and propofol groups. Ionized magnesium did not change throughout the study period in any of the groups. pH corrected ionized calcium decreased significantly only at post-intubation in the pento group. CONCLUSIONS: All anesthetic induction agents administered in this study can be used safely in terms of magnesium-associated arrhythmia. However, ionized calcium concentration decreased in the pento group, but all values were within normal limits. This finding indicated that it is safe to use propofol, pentothal sodium, and sevoflurane for anesthetic inductionope

The Effects of Repetitive Alveolar Recruitment on Oxygenation and Compliance in ARDS patients

Background If the effects of alveolar recruitment are beneficial, but of short duration, repetitive recruitment maneuvers (RMs) will be necessary to maintain oxygenation. This study was performed to assess the effect of repetitive alveolar recruitment, with high-sustained inflation pressure on oxygenation and compliance of the respiratory system, in patients with acute respiratory distress syndrome. Methods Ten adult patients on ventilator support, with controlled mechanical ventilation, received three repetitive RMs with a high-sustained inflation pressure. The time intervals from the first to second RM and from the second to third RM were 8.42 ± 0.56 hours and 12.43 ± 1.45 hours, respectively. Recruitment was conducted by setting the ventilator mode to a continuous positive airway pressure of 40 cmH2O for 40 seconds. After each alveolar recruitment, the previous ventilator settings in the pressure control mode were re-established with a high positive end expiratory pressure. The FIO2, PaO2/FIO2 and lung compliance (tidal volume/[plateau pressure - PEEP]) were recorded with reference to the arterial blood gas analysis at both 30 minutes pre and post recruitment. Results The FIO2 was able to be decreased from 0.9 to 0.5 while maintaining the PaO2 at higher than 80 mmHg after three recruitments. The PaO2/FIO2 improved from 98 to 288 and the compliance of the respiratory system improved from 26 to 41 ml/cmH2O after three recruitments. Conclusions Our results suggest that repetitive recruitment can be used to maintain the beneficial effects of alveolar recruitment in patients with acute respiratory distress syndrome when supported using a lung protective mechanical ventilation strategy.ope

Thermodiluted relative tidal volume estimation using a thermal camera in operating room under spinal anesthesia

Background: Estimating relative tidal volume is an important factor when monitoring breathing status. The relationship between temperature and respiration volume has rarely been studied. In this paper, a formula was derived for calculating thermodiluted respiration volume from temperature changes in the nasal cavity. To evaluate the proposed formula, the study compared the relative tidal volume estimated by the proposed formula with that recorded by a respiration volume monitor (Exspiron1Xi, RVM). Thermal data were obtained for 8 cases at a rate of 10 measurements per second. Simultaneous recordings by the RVM are regarded as the reference. Results: The mean of ICC coefficient is 0.948 ± 0.030, RMSE is 0.1026 ± 0.0284, R-squared value is 0.8962 ± 0.065 and linear regression coefficient [Formula: see text] is 0.966 ± 0.104, [Formula: see text] is 0.042 ± 0.057. Bland-Altman plot showed 96.01% of samples that the difference between the measured and estimated values exists within 2 standard deviations. Conclusions: In this paper, a model that can thermodynamically calculate the relationship between thermal energy and respiration volume is proposed. The thermodiluted model is a feasible method for estimating relative respiration tidal volumes.ope

Triage Decision For ICU Admission And Patients’ Outcome

Background: We constructed a prospective study to evaluate the outcome of patients referred to an intensivist for ICU admission as well as the factors associated with ICU admission refusal. Methods: Patients referred for ICU admission to medico-surgical ICU in our hospital for 16 weeks were included in this study. We classified the reasons for refusal into three categories: inappropriate referral; triage; futility. Also we classified admitted patients into two categories: immediate admission; delayed admission. After initial evaluation of a patient by an intensivist, we checked the patient’s outcome for following 28 days. Results: 632 patients had been referred for ICU admission during study period. Among them, 445 (70%) patients were admitted and 187 (30%) patients were refused ICU admission. 116 patients were refused because of inappropriate referral, 52 for triage and 19 for futility. 394 patients were admitted immediately and 51 were refused initially but were later admitted. When 116 inappropriate referral patients were excluded, the mortality rates for immediate admission, delayed admission and triage/futility were 14.4%, 39.2% and 56.3%, respectively (P ＜ 0.05). Standardized mortality ratio was 0.70 for immediate admission, 1.20 for delayed admission, 1.28 for triage and 1.30 for futility (P ＜ 0.05). The factors associated with refusal for ICU admission were age, medical division, diagnostic group and high Mortality Probability Model II0 (MPM II0) grades. Conclusions: Because the triage decision for ICU admission influences the patients’ outcome, an intensivist must carefully come to a decision when admitting patients to ICU by considering the appropriate guidelines for ICU admission and triage.ope

Clinical Outcomes of Patients Readmitted to Intensive Care Unit

Background: The government has attempted to control the cost of health care. However, this policy can increase the number of premature discharges from the intensive care unit (ICU), which will then increase readmission rate to the ICU. Readmission to the ICU during the same hospital stay has been identified as a quality indicator. The aim of this study was to determine the clinical features and outcome of patients readmitted to the ICU during the same hospital stay. Methods: For this study, reviewed the data from all patients admitted to the ICU between July 1, 2000 and Jun 30, 2001 were retrospectively analyzed. The data in this study included the patient demographics, hospital and ICU admission date, the diagnosis on ICU admission, co-morbid disease of the patients, Acute Physiology and Chronic Health Evaluation (APACHE) II scores on the ICU admission, the lengths of the ICU stay, the hospital days, and the patients´ outcomes on hospital discharge. The reason for readmission was classified as either a recurrence of the initial disease or an occurrence of new complications, and the non-survivors and survivors after readmission to the ICU were compared. Results: The readmission rate was 7.5% and the mortality rate of the readmitted patients was 66%. The age, gender, the severity score at admission, and disease distributions were not significantly different between the readmitted patients and the non-readmitted patients. However, the lengths of the ICU stay and hospital days of the readmitted patients were significantly longer than those of the non-readmitted patients. Conclusion: Patients requiring ICU readmission during the same hospital stay had higher hospital mortality rates than the patients discharged from the ICU who did not require a subsequent readmission.ope

Hemoglobin and mortality in patients with COPD: a nationwide population-based cohort study

Purpose: Previous studies have reported that anemia increased mortality in patients with COPD. However, it is unclear whether anemia is associated with increased COPD mortality in the general population. The purpose of our study is to identify whether anemia is related to long-term mortality in COPD using a large population-based database. Patients and methods: Using the National Health Insurance Service-Health Screening Cohort, we identified COPD patients with available hemoglobin level. We analyzed mortality among patients with COPD from 2003 to 2013 according to hemoglobin level. Results: A total of 7,114 patients with COPD were identified. Mean age was 65.0+/-9.3 years, and 62.9% were male. Anemia was present in 469 patients (6.6%). The overall mortality rate was 46.5% in anemia and 32.1% in non-anemia groups (p<0.001). The hazard ratio of anemia for mortality was 1.31 (95% CI, 1.11-1.54). Among patients with anemia, the hemoglobin level correlated well with mortality. Conclusion: Anemia was associated with increased long-term mortality of COPD, and even mild anemia was related to a significantly increased risk.ope