This article at first explained pharmacological action, clinical use for hemophilia with inhibitor or acquired inhibitor of blood coagulation, and side effects of recombinant activated factor VII (rFVIIa) based on a cell-based model of hemostasis. And then we reviewed off-label use of rFVIIa in various types of uncontrolled bleeding. Massive uncontrolled bleeding is an important cause of morbidity and mortality, and every attempt should be made to control bleeding by conventional means before considering a trial of rFVIIa. rFVIIa is now used to control bleeding in blunt trauma patients, postoperative bleeding after cardiac surgery, surgical bleeding, life-threatening post-partum hemorrhage, and acute intracerebral hemorrhage. However, rFVIIa is not currently recommended for use in the management of uncontrolled bleeding associated with penetrating trauma, elective surgery, liver surgery, and bleeding in patients with liver cirrhosis. rFVIIa efficacy should be monitored visually and by assessing transfusion requirement. rFVIIa appears to be relatively safe with rare incidence of thromboembolic adverse events, however, the events after use of rFVIIa should be carefully monitored.

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Transfusion-related acute lung injury (TRALI) is a life threatening adverse reaction to transfusion. It is characterized by noncardiogenic pulmonary edema developed during or within 6 hours after transfusion. Due to underrecognition of this complication, acute lung injury (ALI) after transfusion may be attributed to other causes such as allergic reaction, circulatory overload, or other risk factors. Recent study in the ICU of tertiary care medical center reveals high incidence of suspected TRALI cases. TRALI has relatively better prognosis as compared to ALI with other causes. Early diagnosis and intervention may improve the outcome of the patients with TRALI. Further study will elucidate the incidence and mechanisms of TRALI and the potential preventive measures.

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Objectives: To evaluate the usefulness of a thoracic electric bioimpedance (TEB) method as a monitor in patients with acute myocardial infarction whose pulmonary capillary wedge pressure (PCWP) was normal. Methods: Thirty-six patients with a diagnosis of acute myocardial infarction were included. Thoracic fluid content (TFC) and PCWP were measured with a TEB method and a pulmonary artery catheter, respectively. Cardiac index (CI) was also measured with a TEB method and a conventional thermodilution (TD) method simultaneously. The correlation between TFC and PCWP, CI measured with both methods, TFC and CI, PCWP and CI, were examined. Results: TFC was correlated with PCWP (r = 0.45, P = 0.0036). CI measured with both methods had a positive correlation (r = 0.68, P = 0.000057) and Bland-Altman plot yielded a mean ±2SD of the difference of CIs, that was −0.10±1.26 l·min⁻¹·m⁻². TFC had no significant correlation with CI. PCWP was inversely correlated with CI (r =−0.49, P = 0.0067 with CI measured with a TEB method and r =−0.47, P = 0.0096 with CI measured with a TD method). Conclusions: It was suggested that the TEB method could reflect pulmonary fluid states and cardiac output in patients with acute myocardial infarction whose PCWP was normal. This method could be a choice as a monitor in this group of patients.

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Objectives: To investigate whether the mortality rate of critically ill patients after cardiac surgery is improving, we reviewed the outcome of patients in the ICU at the National Cardiovascular Center. Methods and Patients: We retrospectively reviewed the medical charts of patients who had died in the ICU between 1997 and 2006. The outcome and primary reasons for ICU death were then analyzed. Results: A total of 337 patients (3.3%) among the 10,086 ICU admissions died in the ICU. The annual mortality rate decreased from 5.2% in 1997 to 1.8% in 2004, when the manpower of intensivists seemed the most efficient. The primary reasons for ICU death were heart failure (35%), operation-related complication (28%), infection (15%), intestinal disorder (10%), central nervous system disorder (7%), and respiratory failure (4%). The ICU mortality rates attributed to heart failure, operation-related complication, central nervous system disorder, and respiratory failure all decreased through the observation period. However, the ICU mortality rate attributed to infection and intestinal disorder did not change. Conclusions: The outcome of cardiac surgery patients has improved, but infection and intestinal disorder complications require further attention.

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A 30-year-old man presenting with dyspnea and chest pain about 15 hours earlier, was referred to our hospital. On arrival, his systolic blood pressure was about 86 mmHg, and heart rate was 130 min⁻¹. He had developed hypopituitarism since 14 years old after the resection of a craniopharyngioma. Echocardiogram demonstrated pulmonary hypertension, and computed tomogram with contrast media showed massive pulmonary thromboembolism. Pulmonary arterial pressure was about 65 mmHg. He was treated with intravenous anticoagulant therapy and recombinant tissue plasminogen activator. Thereafter, the patient's pulmonary arterial pressure decreased to 45∼50 mmHg and the heart rate declined to 70∼80 min⁻¹, while dyspnea and chest pain disappeared. Oral anticoagulant was started, and on hospital day 4, he was moved to the general ward. The patient was discharged on hospital day 39. Patients with hypopituitarism continuously treated with hormone replacement therapy are thought to easily develop an unstable coagulative state leading to repetitive thromboembolism considered in panhypopituitarism.

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Amniotic fluid embolism is one of the most severe complications in the perinatal period. We report a case of a 35-year-old woman who was suspected of having an amniotic fluid embolism. After a cesarean section for placental abruption, vaginal bleeding occurred, and the patient's circulatory and respiratory conditions deteriorated. She was transferred to our hospital and underwent an emergency laparotomy to achieve hemostasis. On admission to the ICU, she suffered from severe respiratory failure, cardiac dysfunction, and renal failure. Her P/F ratio was as low as 67 mmHg, so we performed mechanical ventilation. Because findings of transesophageal echo and pulmonary artery catheter suggested severe congestion, we adjusted the preload with phlebotomy and continuous hemofiltration. Extubation of the tracheal tube was performed on postoperative day 4, and the patient was discharged from the hospital on postoperative day 48. A definitive diagnosis was possible because serum zinc coproporphyrin levels were high on admission to the ICU. When abnormal bleeding, respiratory distress and circulatory dysfunction are seen to occur in patients in the perinatal period, it is important to bear the possibility of an amniotic fluid embolism in mind, and to proceed with appropriate intensive care intervention.

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Posterior reversible encephalopathy syndrome (PRES) is characterized by headache, abnormalities of mental status and visual perception, and seizures with radiological findings of symmetrical vasogenic edema that mainly involve the white matter of the parieto-occipital lobes. Although PRES is reversible when adequate managements are instituted, delayed diagnosis and therapy can result in irreversible neurological sequelae. Most cases of PRES occur in association with abnormal hypertension, and the favoured pathogenic theory for PRES suggests autoregulatory disturbance with hyperperfusion due to hypertension, causing a breakdown of the blood-brain-barrier and resulting in vasogenic edema. Since the first description of PRES in 1996 by Hinchey et al, as PRES has become better recognized, various situations have been identified, but few perioperative cases of pediatric patients have been reported yet. Here we report a case of 5-year-old boy with liver metastasis of Wilms' tumor presenting with PRES after partial hepatectomy possibly due to perioperative persistent hypertension, who was discharged without any subsequent neurological deficit with anti-hypertensive therapy and control of intracranial pressure. Strict managements of blood pressure and fluid balance should be considered in the perioperative settings of pediatric abdominal surgery as well due to the possible risk of PRES.

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We report an orthopedic patient who survived a fatal pulmonary embolism (PE) during pelvic surgery. Reconstruction of pelvic fracture was scheduled for a 59-year-old man following 10 days of pelvic traction after a traffic accident. The values for SpO₂, end-tidal carbon dioxide (EtCO₂), and systolic blood pressure suddenly decreased when massive bleeding occurred due to vascular injury during the surgery. Arterial blood gas analysis demonstrated a low value of PaO₂ and a discrepancy between EtCO₂ and PaCO₂ values. The occurrence of PE was suspected based on both the results of arterial blood gas analysis and distension of the right heart detected by transesophageal echocardiography. Percutaneous cardiopulmonary support (PCPS) was immediately introduced due to unstable hemodynamics and unresolved hypoxia. Surgical thrombectomy for PE was performed with cardiopulmonary bypass two days after the first procedure because of persistent hemodynamic and respiratory failure. PCPS was successfully removed three days after the pulmonary thrombectomy. A temporary inferior vena cava filter was placed for the prevention of PE due to residual deep vein thrombosis before rehabilitation proceeded. The patient was discharged without any complications following the completion of rehabilitation. Conclusion: The decision to introduce PCPS and surgical treatment should be made without delay for a critically ill patient with PE.

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Serum protein binding of micafungin (MCFG), which has anti-fungal effects also on non-candida fungi such as Aspergillus fumigatus, is 99.8%. In this study, we defined the mechanism by which MCFG exerts its action despite high protein binding properties. Lowest concentration of MCFG needed for suppression in the growth of Candida albicans was determined by two methods: the minimum inhibitory concentration (MIC) and disk methods. In each method, the agent was diluted either by RPMI1640/3-(N-morpholino) propanesulfonic acid (MOPS) (RPMI) or inactivated serum, which simulated clinical situation. Unexpected low MIC (1μg·ml⁻¹) was found in serum-diluted samples: if consider serum protein binding, 30 folds higher concentration than those obtained would be required. The disk method, determining concentration plus exploring diffusion factors of the agent, revealed the results supporting those in MIC method. These results indicate that despite high protein binding in vitro, MCFG exerts anti-fungal effects through possible mechanisms, such as its weak protein binding, which needs to be clarified in the future.

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