Both Intensive Insulin Therapy (IIT) and the low-dose hydrocortisone administration for septic shock are the hot stocks in the Surviving Sepsis Campaign guidelines 2004. However, the questions have occurred along with the accumulation of the recent evidences, and the recommendation levels for these treatments had been withdrawn. In contrast, although not included in the international guidelines, the treatments such as the direct-hemoperfusion with polymyxin B-immobilized column (PMX-DHP), anticoagulant therapy for disseminated intravascular coagulation (DIC) and sivelestat sodium for acute respiratory distress syndrome (ARDS), which are widely applied in Japan, attracts attention. Indeed, there are some significant differences in the therapeutic strategies for severe sepsis between Japan and other advanced countries. With regard to the PMX-DHP, although it has been ignored in the other countries, the recent randomized controlled study (RCT) performed in Italy proved its efficacy. Antithrombin was recommended not to administrate in DIC patients in the European guideline, while its administration is recommended in Japanese one. The efficacy of sivelestat sodium was proven again in the post-marketing surveillance performed in Japan, after the contrastive results from USA. Under these confusing situations, we clinicians must realize that the evidences for severe sepsis are quite unstable. There should not be any doubt for the importance of the evidence based medicine, however, we should recognize the differences of the genetics, health care systems and the historic backgrounds as well, and when we apply the certain treatment to the patients, we must consider not only the clinical evidences but also follow the individual experiences and the scientific knowledge. Actually, we think that the tailor-made medicine is just required for treatment of severe sepsis, and the uniform guideline treatment is not suitable.

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A 31-year-old-male was admitted to our hospital with chest pain that had persisted for two days. We found ST segment elevation in leads V2-6 on electrocardiograms and blood tests indicated a severe inflammatory reaction and elevated cardiac enzymes. Acute anterior myocardial infarction was suspected and coronary angiography revealed complete obstruction of the left anterior descending coronary artery. Reperfusion therapy with catheter devices was unsuccessful. Blood cultures upon admission confirmed infection with Streptococcus intermedius on the following day. Cardiographic ultrasound revealed mitral valve regurgitation and a mass located on the valve, indicating infective endocarditis and coronary embolism. Because heart failure worsened due to mitral valve regurgitation, valve replacement was performed on day three. Coronary embolism is a known complication of rare infective endocarditis, and a treatment strategy has not been established. However, selecting the wrong treatment can result in severe complications. Physical examinations should be conducted in consideration of the possibility of infective endocarditis with coronary embolism when younger patients have no risk of arteriosclerosis or when myocardial infarction is accompanied by symptoms of infection. Coronary angioplasty should be selected according to each patient's condition.

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A 64-year-old woman with frequent episodes of food aspiration complained of sudden dyspnea while she was eating udon noodles, and she was transferred to our hospital by ambulance. Respiratory rales were audible in the right lower lung field on arrival to the emergency department. No abnormalities were observed on a chest X-ray film, however, a foreign body 10-cm long and 5-mm thick was observed in the airway from the trachea to the right middle bronchus on a chest computed tomographic scan. An attempt at bronchoscopic removal of the foreign object with basket forceps and aspiration failed because the noodle was torn into pieces. Therefore, we attached a 10-mm long plastic tube, cut from the middle of a suction tube, to the tip of the endoscope (like a hood) and tried to trap and aspirate the noodle into the lumen. This procedure was successful at removing the foreign body without tearing it. The patient was discharged from the hospital with no respiratory complications after an overnight admission. Bronchoscopy using a handmade hood is effective at removing soft and brittle foreign bodies that are difficult to grasp with endoscopic forceps.

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A 73-year-old woman, suffered from a sudden onset of consciousness disturbance, was transported to an emergency hospital. Right cerebellar hemorrhage and obstructive hydrocephalus were diagnosed, and single burr hole drainage was performed to remove the hematoma. The consciousness level improved gradually after the surgery, however, a few days later, the consciousness level worsened again. Computed tomography (CT) and magnetic resonance imaging did not reveal any clues as to the cause of the worsened consciousness level. She became in the shock state and transported to our hospital. On admission, laboratory data showed evidence of severe renal and liver dysfunction, hypernatremia and severe hypercalcemia. Fluid resuscitation was started, then furosemide and calcitonin were administered. The hypercalcemia improved gradually, with gradual improvement also of the consciousness disturbance. Hormonal examinations revealed hyperparathyroidism, and CT showed a parathyroid adenoma as the cause of the hypercalcemic crisis. Hypercalcemia induces polyuria and excessive thirst. If a patient's consciousness level is normal, he/she will drink water in response to the thirst; however, our patient could not drink water because of the consciousness disturbance associated with cerebellar hemorrhage, resulting in worsening of dehydration and severe hypercalcemia. In the case of unexplained consciousness disturbance in critically-ill patients, hypercalcemia should be considered as a cause of the consciousness disturbance.

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Cases of caffeine toxicosis from overdose have recently been increasingly seen because caffeine is available in a wide variety of over-the-counter formulations, including beverages, appetite suppressants, anti-common cold medications, and various combination analgesic preparations in Japan. We report two cases with caffeine overdose who survived as a result of our treatment. Case 1: A 34-year-old female was admitted to our emergency and critical care center in a state of cardiopulmonary arrest (CPA). We concluded the CPA was caused by an overdose of caffeine in a cold medicine. Case 2: A 33-year-old male took 240 tablets, each of which contained 100mg of caffeine in a suicide attempt. Potentially fatal arrhythmias occurred with resistance to vascular medications in both cases. We performed gastric lavage and administered activated charcoal. Specifically, hemoadsorption treatment was added in Case 2. This resulted in the rapid disappearance of the arrhythmia, hypertension and other symptoms of caffeine poisoning. Therefore, hemoadsorption was suggested as the most beneficial treatment for caffeine toxicosis.

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