202 32nd World Congress of Internal Medicine (October 24-28, 2014) WCIM 2014
PS 0596 Critical Care Medicine The Incidence and Prognosis of VAE
Jae Kyeom SIM1, Jee Youn OH1, Kyung Hoon MIN1, Gyu Young HUR1, Sung Yong LEE1, Jae Jeong SIM1, Kyung Ho KANG1
Korea University Guro Hospital, Korea1
Background: The Centers for Disease Control and Prevention (CDC) announced new surveillance defi nition of ventilator-associated event (VAE) to overwhelm the inac- curacy and subjectivity of ventilator-associated pneumonia (VAP). We designed this study to examine the incidence and prognosis of VAE.
Methods: We conducetd retrospective survey with medical record reveiw. Patients admitted to intensive care unit in a single tertiary hospital were eligible. Patients less than 18 years or on mechanical ventilation (MV) less than 2 calendar days were ex- cluded.
Results: 97 patients and 120 episodes of MV were analyzed. 56 patients were male.
Mean age was 68 years. 33 of 97 patients died. VAE occurred in 12 patients and 12 episodes. Male and female were even. Mean age of patients with VAE was 71 years.
Mean time to VAE onset was 5.3±3.9 days. Two patients experienced two VAEs during one MV episodes. Both died during the second VAE. Only one patient survived in VAE group. VAE group showed higher mortality (OR, 31.5; 95% CI, 3.842-258.232).
Conclusions: The VAE was not uncommon and associated with poor prognosis. A large controlled study is required to identify risk factors and to develop preventive strategy.
PS 0597 Critical Care Medicine Mechanical Ventilation with Propofol and Remifent- anil of a Patient with Huntington’s Disease in Medical Intensive Care Unit
Dae Hyun KIM1, Hyung Woo KIM1, Ji Yeol YANG1, Ji Sun KIM2, Jin Young AHN1, Ki Man LEE1, Kang Hyeon CHOE1, Youjin CHANG1
Department of Pulmonary and Critical Care Medicine, Chungbuk National University Hospital, Korea1, Department of Neurology, Chungbuk National University Hospital, Korea2
Introduction: Huntington’s disease(HD) is a progressive, fatal neurodegenerative dis- order characterized by progressive motor dysfunction, cognitive decline and psychiat- ric disturbance. As dysphagia caused by pharyngeal muscle dysfunction increases the risk of aspiration, most of patients died of pulmonary complications. For this reason, patients with HD were at risk of being admitted to the intensive care unit(ICU) and undergoing mechanical ventilation(MV). However, there is no suffi cient data for seda- tion therapy during MV in the ICU. We introduce a sedation management of a patient with HD admitted to the ICU.
Case: A 42-year-old male was admitted to the medical ICU due to dyspnea and fever for two days. He was diagnosed as HD 2 years ago. He had frequent aspiration events and his chorea was uncontrolled. He had respiratory distress with large amount of yellowish sputum. His chest radiography showed consolidation at right lower lung fi eld. He was assessed as aspiration pneumonia and he underwent MV. As an initial sedatives, remifentanil and dexmedetomidine were started. However, his movement could not be controlled with maximal doses of the two drugs. His requirement of MV was not high, but he was likely to injure his airway with his endotracheal tube. We added atracurium inevitably, and tapered off dexmedetomidine. Then, his chorea was controlled. After 3 days we tried to stop atracurium, but, his chorea was aggravated again. After adding propofol, we could stop atracurium. With combination of propofol and remifentanil, he got a proper sedative state of -1~-2 of RASS. Three days later, he underwent tracheostomy and had successful weaning from MV on Hospital Day 10.
Conclusion: Propofol and remifentanil could be an effective sedative therapy during MV in the ICU in the patients with HD.
PS 0598 Critical Care Medicine Respiratory Failure in Severe Neuroparalytic Snake Bite - Experience of A North Indian Tertiary Care Hospital
Arjun KHANNA1
VMMC and Safdarjang Hospital, India1
Background: Poisonous snake bites are a common, life threatening emergency in trop- ical Asian countries like India. The aim was to treat patients with neuroparalytic snake bite using polyvalent Anti snake venom(ASV) along with ventilatory support and to assess outcome with respect to hospital survival, duration of mechanical ventilation, amount of ASV given and complications if any, associated with mechanical ventilation or ASV.
Methods: The study included 58 patients with severe neurotoxic snake bite who re- quired mechanical ventilation for respiratory failure. They were administered 200 ml of polyvalent ASV. Outcome measures studied included hospital survival, duration of mechanical ventilation, amount of ASV given and complications associated with me- chanical ventilation or ASV administration.
Result: All patients were administered an initial bolus dose of 200 ml ASV, followed by repeated doses of 100 ml ASV every six hours until the patient showed signs of neurological recovery. Mean total dose of ASV administered was 412 ml. All patients were initially ventilated using Assist control(A/C) mode of ventilation. Mean duration of ventilation on A/C mode was 30.89 hours. 56 patients were weaned off success- fully using pressure support mode. Mean duration of weaning was 7 hours. 4 patients developed Ventilator associated pneumonia 2 patients expired, one due to ventilator associated pneumonia and the other due to septicaemia. 56 patients who survived did not have any residual neurological defi cit clinically.
Conclusion: We conclude that in the management of neurotoxic snake bite, adminis- tration of a high initial bolus dose of 200 ml ASV and repeated doses of 100 ml ASV every six hours until signs of neurological recovery, supported by Assist control mode of ventilation resulted in an early recovery, a reduced total dose of ASV consumed, re- duced the duration of mechanical ventilation, reduced the incidence of complications and thus, was much more cost effective.
PS 0599 Critical Care Medicine Who and When is at Risk for Acute Coronary Syn- drome
Yulia VENEVTSEVA1, Aleksandr MELNIKOV1, Tatiana GOMOVA1, Elena FEDOTOVA1 Tula State University, Russia1
Background: Acute coronary syndrome (ACS) is the most common reason for hos- pitalization worldwide. We aimed to examine the prevalence of noncardiac comor- bidities and time of onset of ACS in a population of patients hospitalized in the Tula Clinical Emergency Hospital in 2013.
Methods: The study sample consisted of 345 patients: 123 women (W) aged 48-89 yrs and 222 men (M) 35-86 yrs. In hospital mortality rate was 2.6%. 55 W and 58 M were diagnosed with ST segment elevation, 39 and 54 - with non-ST elevation my- ocardial infarction and 29 W and 110 M - with unstable angina. All pts were treated noninvasively.
Results: The most prevalent comorbidities were excessive weight (66% of W and 55%
of M), diabetes mellitus (23.5 and 10.8%) and chronic kidney disease (CKD; 39.8 and 14.0%). The exact time of chest pain onset was available in 77 W and 102 M. Symp- tom onset rates were calculated according to the hour of the day (circadian rhythm).
Peak occurred in the morning hours (6-12 a.m.) with 29.9% in W and 28.4% in M, pain arises at night (0-6 a.m.) in 22.0 and 18.6%. Afternoon symptom onset (0-6 p.m.) was seen in 29.9 and 29.5% and the evening (6-12 p.m.) – in 18.2 and 23.5% of pts.
The ACS rhythm depending on age has been seen in the 60-70 yrs in both sexes, in 70-80 yrs W and was lacking in the older ones. Clear rhythm observed in pts having digestive disorders with prevalence of onset in night (W) and afternoon (M). W with CKD had nocturnal and afternoon peaks. The night-time was dangerous for W and M with cerebrovascular disease.
Conclusions: Age, gender and comorbidity tend to infl uence the onset of ACS that may be used in clinical practice.