Performance of ICU practice has never been measured in our country. It can be considered that both government and professional societies were not interested in quality nor safety of medical services. However, after the introduction of DPC (diagnosis procedure combination), performance measurement becomes extremely important to improve quality and safety of ICU practice as well as optimal reimbursement, in which performance coefficient is incorporated. In this article, performance measurement in ICU and its reflection to performance-based reimbursement is suggested and hopefully this new system will be implemented within 2 years.

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Sedation plays an important role in managing patient care in the ICU. Adequate control of sedation depth is associated with outcomes, including duration of mechanical ventilation and ICU length of stay. Therefore, assessment tools for depth of sedation should have enough reliability, validity, and clinical usability. To date, subjective scales are most commonly used to assess the depth of sedation. The Ramsay Scale, Sedation-Agitation Scale (SAS), Motor Activity Assessment Scale (MAAS), and Richmond Agitation-Sedation Scale (RASS) are frequently used for adult patients. In the present review, we clarify the most useful scale from those discussed in the literature. The Ramsay Scale, the oldest scale (developed in 1974), is frequently used around the world, however, assessment for level of agitation is limited. Reliability and validity of SAS and MAAS have been evaluated, however, their evaluation did not cover all aspects of validity in different populations. In contrast, validity and reliability of RASS has been more evaluated than other scales, and suggests that RASS has enough validity and reliability for clinical use. Thus, to date, RASS is the most useful scale for assessment of depth of sedation in adult ICU patients among the sedation scales.

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Efficacy and safety of an intravascular cooling system were examined in survivors of cardiac arrest. Eighteen comatose patients who had been successfully resuscitated after cardiac arrest were included. Therapeutic hypothermia was performed with intravascular cooling system in the 6 cases (IC group) and with conventional surface cooling method in 12 cases (conventional group). The time to reach the target temperature and the average thermal burden (difference between actual and target temperature, ATB) were compared. Time to reach the target temperature in the IC group was tend to be shorter than in the conventional group (249±91 vs. 407±157 min). The ATB in the IC group were significantly smaller than that in the conventional group in both maintenance phase (0.03±0.02 vs. 0.32±0.16: P<0.01) and rewarming phase (0.12±0.04 vs. 0.34±0.16: P<0.05). No specific complications associated with the new cooling system were observed. The new intravascular cooling technique seems to be more effective than the conventional technique.

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Hemofiltration replacement fluid might deposit crystals in the circuit after being used for a continually long period. In this study, the crystal depositions in the circuit, and the electrolytes compositions and the gas analysis of the fluid in the circuit were investigated under various conditions with the fluid flow rate of 10 ml·min⁻¹ for 96 hrs. The crystals were observed in the outlet of a roller pump, but not in the inlet. The crystals were observed after 48 hrs at the circuit pressure of 100 mmHg, and were increased with the elapsed time. As the stimulation was added to the fluid, because the circuit was compressed with the rotation of the pump, it was considered that the bicarbonate ions might be decomposed to the carbonate ions. Therefore, the crystals of calcium carbonate might be observed in the outlet of the pump. Also, the crystals might grow up big, and be increased with the elapsed time. However, the crystals were decreased with the increase of the circuit pressures. It was considered that the decomposition of bicarbonate ions might be depressed with the circuit pressure of over 100 mmHg, because the PCO₂ was 70∼100 mmHg. The gas analysis changed at every 24 hrs interval, but it was within a constant range for 96 hrs. There was no change on the electrolytes compositions for 96 hrs. Accordingly, as the crystals may flow into the blood, it is recommended that the circuit using hemofiltration replacement fluid should be exchanged before the crystals are deposited.

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Objectives: Delirium is frequently observed in patients with acute aortic dissection. The purpose of this study was to examine whether delirium could be prevented when patients were given pamphlets which provided knowledge about the disease and therapy. Methods: Pamphlets were introduced in 2003. Forty-five medically treated patients with acute aortic dissection were examined between 2000 and 2005. The causative factors of delirium and the occurrence rates of delirium, ‘not following prescribed rest levels’ and ‘self-removal of catheters’ were determined through chart review. Results: Delirium occurred most frequently on the second day of admission (42.9%), and the occurrence rate decreased significantly after the use of pamphlets (from 64.0% to 25.0%, P = 0.009). The frequencies of ‘not following prescribed rest levels’ and ‘self-removal of catheters’ were also decreased. CRPmax and ‘beginning of oral fluid intake’ were significantly different between patients with pamphlet and those without pamphlet. Stepwise logistic regression analysis showed that only pamphlet use was independently associated with delirium onset. Conclusion: It was suggested that pamphlets were effective in preventing delirium in patients with acute aortic dissection.

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Tracheal agenesis is a rare lethal congenital anomaly. We describe a neonate with this anomaly who presented with respiratory distress and no audible cry. His lungs were ventilated with an endotracheal tube inserted into the esophagus. He was suspected to have tracheal agenesis. At 3 hours of age, operation was performed, consisting of pseudotracheostomy using esophagus, distal esophageal ligation, cervical esophagostomy for saliva drainage and gastrostomy. After the first operation, it was difficult to maintain adequate ventilation because the esophagus and fistula was used as a part of airway. Application of high PEEP and sedation did not improve his ventilation effectively. So at 52 days of age, he underwent anastomosis of esophagus and trachea with external stenting under cardiopulmonary bypass. After the second operation, his clinical condition became stable, and on postoperative day 34, he was successfully weaned from mechanical ventilation, and discharged from hospital at 10 months of age.

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Using the intra-aortic balloon occlusion (IABO) and monitoring the radial and femoral artery pressure, we were able to successfully treat a 32-year-old woman in hemorrhagic shock due to a penetrating abdominal wound, without major adverse effects. The patient was discovered on the floor, having stabbed herself in the abdomen. On arrival to our hospital, her level of consciousness was Japan coma scale III-200. Her systolic blood pressure was 50 mmHg. We inserted the IABO catheter, while giving a large bolus of rapid infusion. With the IABO catheter in place, circulation was temporarily stabilized, and an emergency surgery was performed. Because the inferior vena cava and the portal vein was injured, her blood pressure decreased when the IABO balloon was deflated during surgery. Therefore, we controlled the degree of occlusion by adjusting the volume of the balloon, according to the surgical process and the monitored radial and femoral artery pressure. Although the aortic occlusion lasted for nearly 2 hours, no major adverse effect was noted post-operatively. By monitoring the femoral artery pressure and adjusting the IABO balloon volume, longer aortic interception may be achieved in cases of massive abdominal bleeding.

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