Randomized controlled trial (RCT) can provide high grade evidence, which might determine the benefit of a therapy for patients. Recently, the number of published RCT is increasing in critical care medicine. Occasionally, more than one RCT are conducted on the same therapy and show different results (e.g. positive and negative). A possible explanation for the conflicting results is that a positive trial is conducted and assessed in an environment with a higher chance of false positive results. To read RCT critically, one need to understand three important factors that make the probability of false positive results increased. The first is subgroup analysis, which increases the number of comparisons and leads to selection biases. The results from subgroup analysis should be confirmed with another RCT in this subgroup. The second is single center open label studies, which cause the Hawthorne effect and result in less generalizability. The results from such trials should be confirmed by multicenter RCT. The third is early termination for benefit, which makes the chance of α error increased. We should take a careful criticism of the results, when a RCT contains at least one of these three factors.

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Objectives: We discussed what depth of chest compression during pediatric cardiopulmonary resuscitation (CPR) is adequate and safe. Methods: Anterior-posterior (AP) chest diameter (external AP) and the distance between sternum and vertebral body (internal AP) were measured in 66 children without intra-thoracic disorders. Based on these measurements, residual internal AP chest diameter (residual AP) was calculated in the settings of each 1/3 or 1/2 external AP was compressed. Additionally, we retrospectively reviewed if there was any organ injury by CPR in 10 deceased children who underwent autopsy after CPR events. Results: The average of residual AP was 1.5±3.4 mm with compression of 1/2 external AP, and was 22.6±4.4 mm with compression of 1/3 external AP. Residual AP was less than 10 mm in 98% and was less than 0 mm in 30% with compression of 1/2 external AP. There was no organ injury in the autopsy. Conclusions: We concluded that the adequate and safe depth of chest compression during pediatric CPR is “1/3 of external AP chest diameter”. When we teach the pediatric CPR, this conclusion should be interpreted judicially to avoid weak and inadequate chest compression.

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The prognosis of critically ill patients is affected by the policy of ICU. In our hospital, the department of Emergency and Critical Care Medicine was established on January 1, 2004, and since then full-time intensivists have decided the whole treatment. The purpose of this study was to investigate if the change of ICU policy affected the prognosis of the critically ill patients. We enrolled 2,989 patients who admitted to ICU from 2001 to 2006. We compared their prognosis between 3 years before (F group) and after the change of ICU policy (L group). ICU mortality decreased from 13.2% in F group to 6.1% in L group. Length of ICU stay also decreased from 7.4±16.1 day (F group) to 5.6±9.7 day (L group). These findings were the case in the subgroup of the patients who needed mechanical ventilation for longer than 48 hours: the mortality decreased from 23.4% (F group) to 12.8% (L group), and the length of ICU stay decreased from 23.0±35.4 day (F group) to 16.3±18.5 day (L group), respectively. These results suggest that the management by intensivists improved the prognosis.

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Objectives: The introduction of a lump-sum payments based on a diagnosis-procedure combination (DPC) has had a great impact on intensive care in Japan. In this study we examined the correlation between DPC-based payments and the severity of illness of critically ill patients. Methods: The profit-loss indicator (ΔP%) was calculated from the amount of DPC-based payment and the amount that would have been paid by totaling the cost of each individual item by the piece rates. The correlation between acute physiology and chronic health evaluation II (APACHE II, A-II) scores and ΔP% values was analyzed, and the association between A-II scores and ΔP% values in cases in which the patient had died or in which blood purification had been performed was investigated. Results: No statistically significant correlation was found between the A-II scores and ΔP% values. There was a positive correlation between the A-II scores and ΔP% values in 18 cases in which the patient died, while the ΔP% value was greater than +20% and less than − 20% in 1 patient and 6 patients, respectively. There was a negative correlation between the A-II scores and ΔP% values in the 23 cases in which blood purification had been performed. 7 of the 23 patients whose A-II score was above 19 died. Conclusions: Novel DPC related to severity of illness of critically ill patients should be developed in intensive care.

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Objectives: This study was designed to assess the efficacy of early enteral nutrition after cardiac surgery. We studied the difference between 2 groups: one group consisted of patients who received early enteral nutrition (EN group) after surgery and the other group consisted of patients who received intravenous hyperalimentation and late ingestion (IVH group). Design: Retrospective epidemiological study. Subjects: Two hundred and forty cardiac surgery patients who were treated between March 1999 and December 2003 were divided into 2 groups based on the mode of nutrition. In the EN group, 120 patients received early enteral nutrition and in the IVH group, 120 patients received intravenous hyperalimentation and late ingestion. Results: The mean duration of use of the central venous catheter was 8.7 days in the IVH group and 4.2 days in the EN group (P < 0.001). The mean length of the hospital stay was 22 days in the IVH group and 17 days in the EN group (P < 0.05). The total number of postoperative infections in the EN group was lower than that in the IVH group (P < 0.01). The number of patients who had gastrointestinal complications and the rate of weight loss during the hospital stay did not differ between the 2 groups. Conclusions: The results revealed that early enteral nutrition was safe, and it reduced the use of the central venous catheter, postoperative infections, and the duration of hospital stay.

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We encountered a case of consciousness disturbance and respiratory failure due to refeeding syndrome including hypophosphatemia. A 69-year-old female diagnosed as agranulocytosis caused by methotrexate in rheumatoid arthritis, transfered to our hospital for complication with pneumonia, heart failure and disseminated intravascular coagulation. Thereafter she developed acute respiratory failure and consciousness disturbance because of CO₂ retention, she had mechanical ventilatory support. Despite an improvement of CO₂ retention, a somnolence of unknown cause remained for several days. Nutrition support was changed from peripheral intravenous nutrition to total parenteral nutrition (TPN) after admission on our hospital, and serum phosphorus showed a low value. We considered the cause of somnolence as refeeding syndrome especially hypophosphatemia. The serum phosphorus increased with addition of phosphorus to TPN, somnolence and respiratory condition were improved. As a result tracheal tube was able to extubate. It is important to consider the serum phosphorus level carefully in case of start or change of TPN.

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A 57-year-old man with a past medical history of hypertension and hyperlipidemia was brought to the emergency department by ambulance with severe sepsis. He had no previous history of head trauma and surgery. We immediately started a set of treatments for severe sepsis, including fluid resucitaton, but his blood pressure was refractory, and he was transiently suffered from cardiac arrest. His initial and secondary laboratory tests revealed the rapid development of disseminated intravascular coagulation (DIC) during the 2 hrs after arrival. The patient was admitted to the ICU and intensively treated with multidisciplinary treatment, including meropenem, hydrocortisone and gamma globulin. However, he died 22 hrs after arrival. Subsequent autopsy revealed that the patient was suffered from severe septicemia, and bacterial meningitis caused by Staphylococcus aureus and Pseudomonas aeruginosa. Although emergency physicians or intensivists do not frequently have a chance to examine adult patients with bacterial meningitis, we have to aware that some of these patients are complicated with fluminant septic shock and DIC.

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We examined the characteristics at the patients with septic shock caused by urinary tract infection, i.e., age, sex, primary urological diseases, laboratory data, the bacteria cultured from blood and urine, acute physiology and chronic health evaluation II (APACHE II) score, sepsis-related organ failure assessment (SOFA) score, treatments (antibiotics, polymyxin immobilized fiber column-direct hemoperfusion, surgical intervention), duration of ICU stay and the outcome. The patients age (4 males and 11 females) was ranged from 24 to 86 (65±14). The primary diseases were urinary obstruction by ureteral stones (n=11), acute prostatitis (n=2), renal abscess (n=1) and bladder rupture (n=1). Gram-negative rods and gram-positive cocci was detected in the blood culture 10 (including 7 with Escherichia coli) and 2 cases respectively, and the same bacteria got together from urine and blood culturing in the 9 cases. The APACHE II score ranged from 11 to 35 (22±6), and the SOFA score was between 7 and 19 (11±3). Mechanical ventilation was applied in 6 cases. Antibiotic therapy with carbapenem in 11 cases and surgical intervention with urinary stents worked well for improvement of septic state. All patients returned to ward with recovery. The reason of good prognosis in this kind of urological sepsis might be the easy diagnosis by CT and/or ultrasonography, leading to the quick planning for treatment.

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Objectives: To examine the pharmacokinetics of danaparoid sodium in patients undergoing continuous hemodiafiltration (CHDF). Methods: Six patients requiring CHDF with acute-disseminated intravascular coagulation (DIC) score above 4 points were enrolled in this study at Gifu Prefectural Tajimi Hospital between 2002 and 2005. They received a single i.v. injection of danaparoid sodium 1,250 units (1 ml). Anti-activated factor X activity (anti-Xa activity) in plasma was measured at 8 time points (before i.v. injection and 0.5, 2, 4 , 8 , 12 , 24, and 48 hours after i.v. injection). Results: Derived time-concentration data were analyzed pharmacokinetically using a two-compartment model, and elimination half life was estimated. Mean half-life of anti-Xa activity in plasma in the 6 patients was 27.1 hours, and about twice that in normal individuals (14.3 hours). However, mean anti-Xa activity in plasma returned to pre-injection level by 48 hours after i.v. injection. Conclusions: Our findings suggest that danaparoid sodium may be safely given to patients undergoing CHDF with consideration given to dosing interval. Further detailed studies of a large number of patients are needed to more clearly determine the pharmacokinetic characteristics of danaparoid sodium.

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We use the defibrillator in emergency, so it causes confusion that the defibrillator breaks down at the time of use. We inspect defibrillators two times a year in department of clinical engineering. Some of them have transcutaneous pacing function. In the check of the defibrillator, we must not only measure actual measurement of the energy but also inspect the function of transcutaneous pacing. But we had not inspected the function of transcutaneous pacing, because defibrillator manufacturers have not made its method clear. Therefore we originally have devised a method of checking the function of transcutaneous pacing (it was based on JIS T 1356). It became generally possible to inspect defibrillators with transcutaneous pacing.

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