Effect of high-dose furosemide on the prognosis of critically ill patients.

PURPOSE: Diuretics are used frequently in critically ill patients. We investigated the effects of furosemide on the prognosis. MATERIALS AND METHODS: Following a retrospective review of patients admitted to the medical intensive care unit (ICU), we analyzed risk factors with variables including initial furosemide dose for ICU mortality. RESULTS: A total of 448 patients were included. Total furosemide dose during the first three days of the ICU stay (odds ratio (OR) 2.35, 95% confidence interval (CI) 1.01-5.02) and fluid balance during the same period (OR 3.04, 95% CI 1.46-6.31) were associated with ICU mortality, as were malignancy, chronic furosemide use, and APACHE II score. However, in oliguric patients, positive fluid balance was associated with ICU mortality (OR 22.33, 95% CI 1.82-273.72) but the high-dose furosemide was not. In contrast, in non-oliguric patients, high-dose furosemide was associated with ICU mortality (OR 2.47, 95% CI 1.01-5.68); however, the positive fluid balance showed only a trend for high ICU mortality. CONCLUSION: Early high-dose furosemide use is associated with ICU mortality, particularly in non-oliguric patients. We suggest that furosemide should be used with caution even in non-oliguric critically ill patients until the safety is confirmed in powered study.

Early replacement of pulmonary valve after repair of tetralogy: is it really beneficial?

OBJECTIVES: Debate on the proper timing of pulmonary valve replacement (PVR) after repair of tetralogy of Fallot (TOF) is still continuing. Significant pulmonary regurgitation (PR) could result in right ventricular (RV) dysfunction, exercise intolerance, arrhythmia, and sudden death. We analyzed clinical results of PVR after repair of TOF to investigate potential risk factor for late outcomes. METHODS: From January 1993 to July 2002, 58 patients (38 males and 20 females) received PVR after repair of TOF. More than moderate degree of PR was observed in these patients by echocardiography. Mean age at PVR was 13.5+/-9.6 years (1.2-44) and TOF repair was performed at 5.2+/-7.1 years of age (0.5-34). Therefore, PVR was performed at 8.3+/-5.2 years (4 months-28 years) after repair. Preoperative electrocardiogram showed complete right bundle branch block in 49 patients (84.5%). Mean duration of QRS complex was 142+/-30 ms. Major arrhythmia occurred in eight patients. Twenty-nine patients complained decreased physical activity and 10 patients showed clinical signs of right heart failure. RESULTS: Early death occurred in one patient (2.5%). Major complication occurred in three patients (complete heart block in two, aortic rupture in one). Follow-up was performed for 2.5+/-2.4 years (46 days-10.3 years). There was no late death. Postoperative cardiothoracic ratio was significantly decreased (0.61+/-0.07 to 0.55+/-0.06, P < 0.001). Marked symptomatic improvement was noted in all patients. Postoperative symptomatic group (n = 14) showed older age at repair of TOF (12.5+/-10.7 vs 2.6+/-2.3 years, P = 0.003), older age at PVR (23.2+/-12.8 vs 10.1+/-5.0 years, P = 0.001), longer interval between repair of TOF and PVR (10.6+/-7.0 vs 7.5+/-4.2 years, P < 0.05), higher degree of functional class (2.4+/-0.5 vs 1.4+/-0.8, P < 0.001), and longer duration of hospitalization (30.0+/-14.2 vs 18.9+/-11.4 days, P = 0.004) than postoperative asymptomatic group (n = 43). CONCLUSIONS: In patients with significant PR after repair of TOF, PVR had clinical benefits including symptomatic improvement with low mortality and morbidity. Proper timing must be carefully selected according to objective evaluation of RV function. In our study, earlier PVR prior to symptomatic manifestation showed beneficial effects.

Aortic arch reconstruction using regional perfusion without circulatory arrest.

OBJECTIVES: Deep hypothermic circulatory arrest during repair of aortic arch anomalies may induce neurological complications or myocardial injury. Regional cerebral and myocardial perfusion may eliminate those potential side effects. METHODS: From March 2000 to March 2002, 48 neonates or infants with complex arch anomaly were operated on using the regional perfusion technique. Thirty-three patients were male and the median age was 24 days (range 5-301 days). Preoperative diagnosis consisted of coarctation or interruption of the aorta associated with ventricular septal defect (group I, n = 26) and arch anomaly with complex intracardiac defects such as hypoplastic left heart syndrome or its variants (group II, n = 22). Arterial cannula was inserted through the innominate artery and the flow rate was regulated to about 50-100 ml/kg per min during regional perfusion. Simultaneous myocardial perfusion was maintained using a Y-connected infusion line. Cardioplegia was applied during intracardiac repair. RESULTS: Cardiopulmonary bypass and aortic cross-clamp times were 154 +/- 49 and 39 +/- 34 min, respectively. Temporary circulatory arrest for intracardiac procedures was performed in eight patients. However, the mean arrest time was minimized (range 1-18 min). The descending aorta clamping time was 33 +/- 16 min. Operative mortality rates in each group were 0 and 18.2% (0/26 and 4/22). Late mortality rates were 0 and 11.1% (0/26 and 2/18) during 9.1 months of follow-up. Complications consisted of low cardiac output in eight cases, transient neurological problems in two cases, and transient renal insufficiency in two cases, respectively. CONCLUSIONS: Regional perfusion is feasible and can be used with acceptable results. It may reduce potential complications following aortic arch reconstruction using circulatory arrest. However, repair of aortic arch in the patients with complex intracardiac defects still imposes a significant rate of mortality and morbidity.

A case of levofloxacin-induced anaphylaxis with elevated serum tryptase levels.

Levofloxacin, a fluoroquinolone and L-isomer of the racemate ofloxacin, has been approved for the treatment of acute and chronic bacterial infections. Gastrointestinal complaints are the most frequently reported adverse drug reactions to fluoroquinolones. Other adverse events include headache, dizziness, increased liver enzyme levels, photosensitivity, tachycardia, QT prolongation, and eruptions. Anaphylaxis has been documented as a rare adverse drug reaction to levofloxacin; however, diagnostic tests are needed to evaluate whether these reactions are the result of levofloxacin treatment. While the results of skin tests are considered unreliable due to false-positive responses, the oral provocation test is currently considered to be the most reliable test. Tryptase, a neutral protease, is the dominant protein component of secretory granules in human mast cells, and an increased serum concentration of tryptase is a highly sensitive indicator of anaphylaxis. Herein, we report a case of levofloxacin-induced anaphylaxis in which the patient exhibited elevated serum tryptase levels and a positive oral levofloxacin challenge test result. As anaphylaxis is potentially life-threatening, the administration of fluoroquinolones to patients who have experienced a prior reaction to this type of agent should be avoided.

A case of radiation bronchitis induced massive hemoptysis after high-dose-rate endobronchial brachytherapy.

High-dose-rate endobronchial brachytherapy (HDREB) have been used as the treatment of early endobronchial cancer, as well as for palliation of advanced cancer. However, fatal hemoptysis can occur after HDREB at the rate of 7~32%. We report a case of massive hemoptysis due to radiation bronchitis developed after HDREB. A 67-year-old man was treated with HDREB for early endobronchial cancer on the left upper lobe bronchus. He complained of persistent cough from 4 weeks after completion of HDREB. Radiation bronchitis was observed on the bronchoscopy at 34 weeks, and it was progressed from mucosal swelling and exudate formation to necrosis and ulceration without local relapse. In addition, he died of massive hemoptysis after 15 months. The patient had no sign or radiologic evidences to predict the hemoptysis. This case implies that HDREB directly contributes to an occurrence of a fatal hemoptysis, and follow-up bronchoscopy is important to predict a progression of radiation bronchitis and fatal hemoptysis.

Risk factors related with mortality in patient with pulmonary tuberculosis.

BACKGROUND: The prevalence rate of pulmonary tuberculosis (PTB) is steadily decreasing in South Korea. However, PTB is a disease with relatively high mortality and morbidity rates throughout Korea. Although there are many studies and statistics about the risk factors of PTB mortality in many countries, there are only a limited number of domestic papers on this topic. The aim of this study is to determine predictive factors for mortality among in-hospital patients associated with PTB. METHODS: From December 2006 to January 2011, we reviewed medical records of 2,122 adult patients diagnosed with tuberculosis at a single tertiary hospital in a suburban area. In this study period, 960 patients were diagnosed with PTB by positive Acid fast bacilli smear and/or mycobacterial culture of the respiratory specimen. We compared the groups of patients deceased and patients discharged alive with PTB. The number of dead patients was 82 (47 males, 35 females). RESULTS: Mortality was significantly associated with increased values of white blood cells (WBC), blood urine nitrogen (BUN), creatinine, C-reactive protein (CRP), numbers of involved lung field, and length of hospitalization. Also, it was associated with the decreased values of hemoglobin, lymphocyte, sodium, albumin, and cholesterol. Furthermore, admission through the emergency department, initial intensive care unit admission, and drug resistant PTB affected mortality in PTB patients. Independent predictors associated with PTB mortality are BUN, initial intensive care unit care, and admission during treatment of tuberculosis. CONCLUSION: In our study, mortality of pulmonary tuberculosis was related with parameters associated with nutritional status, disease severity at the time of admission, and drug resistance.

The efficacy of immediate diet for reducing local adverse events of inhaled corticosteroid: a pilot study.

BACKGROUND: Local adverse events associated with inhaled corticosteroid use, including dysphonia, pharyngitis and oral candidiasis, can affect adherence for treatment. 'Mouth rinsing method' has been used for reducing local adverse events, but it cannot ensure complete prevention. The goal of this pilot study was to identify whether the 'immediate diet method' can reduce local adverse events in a limited number of patients. METHODS: The study was conducted in a total of 98 patients, who had been prescribed a medium-dose fluticasone propionate for the first time, from January to October in 2010. One training nurse had performed the education on how to use the inhaler, including the mouth rinsing method. And with follow-ups at one month intervals, any patient who experienced such adverse events were educated on the immediate diet method, having a meal within 5 minutes after using an inhaler and they were checked on any incurrence of adverse events with one month intervals for 2 months. RESULTS: The mean age of patients was 65.9 years old. The local adverse events had incurred from 18.4% of the study subjects. When performed the follow-up observation in 18 patients with local adverse events after education on the immediate diet method, 14 patients (77.8%) had shown symptomatic improvements. Three of 4 patients did not show any improvement, in spite of implementing the immediate diet method. The other 1 patient did not practice the immediate diet method properly. CONCLUSION: The immediate diet method may be useful in reducing the local adverse events, caused by the use of inhaled corticosteroid.