Early enteral nutrition after admission is recommended for critically ill patients. Hyperglycemia is considered to be associated with the mortality and morbidity of critically ill individuals. We employed a high-fat low-carbohydrate enteral formula, reported to be useful for controlling blood glucose in diabetes, for patients admitted to our trauma and critical care center from April 2010 instead of the standard enteral formula. The aim of this study was to clarify the effect on glycemic control of this high-fat low-carbohydrate enteral formula in comparison with the standard enteral formula. A total of 147 mechanically ventilated patients hospitalized between April 2009 and March 2011 were enrolled in this study. Among them, 74 patients hospitalized between April 2009 and March 2010 received the standard enteral formula (Group S), while 73 patients hospitalized between April 2010 and March 2011 received the high-fat low-carbohydrate enteral formula (Group G). Enteral feeding was started within 7 days after admission. Each formula was given continuously starting at a rate of 20 ml/hr, which was increased to provide an appropriate caloric intake within a few days of starting nutritional support. We measured the maximum blood glucose level and need for insulin therapy after starting enteral nutrition in both groups. There were no significant differences between the two groups with regard to age, sex, underlying diseases, and blood glucose at the start of feeding. The maximum blood glucose level of group S (163±32.0 mg/dl) was significantly higher than that of group G (151±28.4 mg/dl) (p=0.022). The rate of starting insulin therapy was significantly higher in group S (12.2%) than in group G (1.37%) (p=0.018). No differences were observed between the two groups with regard to mortality, intensive care unit stay, and gastrointestinal morbidity. In conclusion, a high-fat low-carbohydrate enteral formula is more effective for glycemic control in critically ill patients compared with a standard enteral formula.

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Background and Aim: Surgical site infection is the most frequent complication after limb amputation for severe blunt trauma. Numerous emergency operation methods for amputation have been developed to minimize infection. Since 2008, our institution has changed the strategy for surgical procedures from primary suture to second-look surgery because a few infection cases resulted after initial surgery. Here, we attempted to determine whether the new strategy has improved post-surgical infection rates.
Materials and Methods: Nineteen limb amputations were performed at our institution between 2006 and 2010. We divided these cases into two groups according to the strategy used: primary suture (11 limbs) and second-look surgery (8 limbs), respectively. We investigated the post-surgical infection rates between the two groups and between upper and lower limb amputations.
Results: No significant differences in the patients' backgrounds, such as age, gender, ISS, and MESS were detected between the two groups, except hemorrhagic shock. The infection rates of the primary suture and second-look surgery groups were 45% and 0% for total limbs (p=0.0395), 17% and 0% for upper limbs (p=0.6), and 80% and 0% for lower limbs (p=0.0397), respectively. The differences in the rates for total and lower limbs were statistically significant between the two groups. In addition, two cases of amputation over the proximal joint did not develop infection.
Discussion and Conclusion: Based on the markedly lower infection rates observed in amputation patients who received second-look surgery, we propose that this treatment strategy should be considered in cases of emergency amputation after severe blunt trauma to prevent post-surgical infection, which frequently develops due to the damaged or necrotic soft tissue remained after initial surgery. However, in cases of amputation at the upper limb or over the proximal joint, second-look surgery may not be necessary.

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This paper reports a case of severe tetanus complicated with nonclostridial gas gangrene, that originated from a contused wound to the right lower leg caused by the great tsunami of The Great East Japan Earthquake, in which landiolol was effective to treat severe circulatory changes. A 50-year-old female patient, who was diagnosed with diabetes by a local doctor, but remained untreated, was injured in her right lower leg during the tsunami of The Great East Japan Earthquake on March 11, 2011. Subsequently, gas gangrene was suspected due to the presence of snow ball crepitation and signs of gas pooling on X-ray, and the patient was referred to the author's hospital. From the next day, posterior cervical pain, trismus, and severe circulatory changes were observed, diagnosed as complications of severe tetanus. The wound was debrided, while PIPC/TAZ and tetanus immunoglobulin therapies were performed. Circulatory management continuously using midazolam and vecuronium initially did not show favorable outcomes, and the circulatory system was promptly stabilized by the additional administration of landiolol, a β₁ receptor antagonist. This may be regarded as a result of β₁ receptor stabilization with landiolol, resolving tetanus-associated autonomic disturbances leading to circulatory changes; however, there have been no studies reporting the use of landiolol for tetanus in Japan, and, therefore, it may be necessary to continuously examine its effects. Further, considering that, to the author's knowledge, tetanus complicated with nonclostridial gas gangrene has not been reported after 1984, this may be quite a rare case.

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A 74-year-old man was admitted to our hospital because of anorexia and general fatigue. Four years ago, a cyst was detected in his right hepatic lobe, and 5 months back, he had undergone pancreaticoduodenectomy for gastric cancer. On admission, he showed no signs of systemic inflammatory response syndrome, and an abdominal CT scan showed an enlarged liver cyst with a maximum diameter of 18 cm. During the waiting period for cystic drainage, he suddenly developed severe sepsis, disseminated intravascular coagulation (DIC), and acute respiratory failure due to the infected liver cyst. According to the Surviving Sepsis Campaign guidelines, early goal-directed therapy and antibiotic treatment with meropenem were started. Two hours after the onset of severe sepsis, emergency percutaneous transhepatic cystic drainage was performed, and 4,200 ml of purulent fluid was aspirated. Although endotoxin adsorption (PMX-DHP) was implemented for the treatment of septic shock, the patient died 15 hours after the onset of sever sepsis. Later, Klebsiella oxytoca was cultured from the blood sample and drained fluid. If we had correctly diagnosed enlargement of the liver cyst as a sign of infection and had predicted progression to severe sepsis, we could have rescued the patient with emergency cystic drainage at the time of admission.

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