The issue of “the best PEEP (positive end-expiratory pressure)” in acute respiratory failure remains highly contoversial. Many intensivists are confused how to optimize PEEP. We reviewed the effects of PEEP on cardiorespiratory systems, pulmonary surfactant and cytokines, and pulmonary morphology. To find out the best PEEP, we discussed minimal PEEP, PEEP for maximizing oxygen delivery, PEEP for preventing ventilator-associated lung injury (VALI), and PEEP for reducing respiratory work load. There is no definite criterion to identify the best PEEP. To identify the best PEEP, further studies are required.

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Objective: To assess the clinical aspects of patients with acute renal failure (ARF) requiring renal replacement therapy (RRT) in our ICU. Design: Retrospective epidemiologic study. Subjects: 126 critically-ill patients with ARF requiring RRT admitted to the ICU from January 1999 to December 2001. Results: The in-hospital mortality was 61.1%. The most common causes of ARF were sepsis and ischemia/low blood pressure. The majority of patients had ARF in conjunction with multiple organ failure, especially the non-survivors. Renal function was recovered in 87.8% of the survivors during hospitalization. The mean length of RRT for non-survivors was 20.4 days. Seventy-four percent of the non-survivors died within 30 days. Discussion and Conclusion: With the advances in medical technology and improved medical techniques, patients in ARF who may not have survived before these advances can live long in ICU. However their condition remains critical and prognosis depends on the severity of the diseases which led to ARF and on concomitant organ failures. Although most survivors recovered renal function, there were some patients who received long-term RRT with no significant benefit and poor prognosis. Attension should be paid in each case to evaluate the severity of ARF and primary and/or coexisting diseases and to decide whether to start (or continue) RRT or not.

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According to the “guideline for prevention of surgical site infection (SSI)” published by the Centers for Disease Control and Prevention (CDC) in 1999, we selected two agents for anti-microbial prophylaxis. We adopted these agents for patients undergoing cardiac and thoracic aortic surgery. Anti-microbial agents were injected one hour prior to making the incision, and one final injection again after the operation. This protocol was applied consecutively to 120 patients treated by the same surgeon from September 1999 to January 2002. The first group (59 patients) received sulbactam/ampicillin (SBT/ABPC). The selection of this drug was based on the sensitivity rate for 58 colonies of coagulase negative staphylococci cultured at our institute. The second group (61 patients) received cefazolin (CEZ). This drug was selected because it was recommended by the CDC as being the most popular anti-microbial prophylaxis. The incidence of SSI was 3.4% (2/59) in the SBT/ABPC group, and 9.8% (6/61) in the CEZ group (NS). The incidence of deep incisional SSI was 1.7% (1/59) in the SBT/ABPC group, and 4.9% (3/61) in the CEZ group (NS). The incidence of SSI in patients with ischemic heart disease was 4.0% (1/25) in the SBT/ABPC group, and 14.6% (6/41) in the CEZ group (NS). The incidence of deep incisional SSI in patients with ischemic heart disease was 0% (0/25) in the SBT/ABPC group, and 7.3% (3/41) in the CEZ group (NS). We concluded that CDC's recommendations concerning anti-microbial prophylaxis for cardiac and vascular surgery is effective when using SBT/ABPC at our hospital. The rate of multi-drug resistant bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), is very high in Japan. Therefore shortening the period of prophylactic antibiotics decreased enfective complications that arise with multi-drug resistant bacteria excluding MRSA.

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We report an adult case of rhabdomyolysis with creatine kinase (CK) elevation and myoglobinuria while continuous propofol infusion for sedation. A 35 year-old, 100kg weight, 190cm height man with diabetes mellitus was admitted to our hospital for nausea and vomiting. He became apneic after MRI study, then was intubated and resuscitative effort took place on the way to ICU. He was diagnosed as cerebellar infarction and underwent suboccipital external decompression without delay. Genaral anesthesia was maintained with nitrous oxide, oxygen, sevoflurane, fentanyl and vecuronium. The patient returned to ICU after the four hours surgery. Propofol was infused continuously at 3mg·kg^-1·hr^-1 from the first postoperative day (1 POD) to control his delirium but was discontinued because of serum CK elevation up to 2, 381U·l^-1 on 3 POD, and 2, 334U·l^-1 on 4 POD respectively compared with 119U·l^-1 as preoperative value. Since malignant hyperthermia was not likely, dantrolene was not given and his body temperature fluctuated in the range between 36.2°C and 38.7°C. The patient was conclusively diagnosed as rhabdomyolysis by reason of CK elevation and myoglobinuria (404ng·ml^-1 at 4 POD). His serum CK and urinary myoglobin concentration returned to normal about one month after when he left the hospital. It remains unclear how propofol infusion affected development of rhabdomyolysis but we suggest that you should check serum CK level while you administer propofol continuously as a sedative to prevent a patient from propofol-induced rhabdomyolysis.

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A 76-year-old man was transferred to the ICU because of a suddenly worsened respiratory function. He noticed a skin tumor on his back a few weeks ago. Chest radiograph showed diffuse bilateral infiltration. Computed tomography demonstrated interstitial pneumonia-like findings and systemic lymph node swelling. Inguinal lymph node biopsy revealed that he suffered from non-Hodgkin lymphoma, which expressed both CD4(+) and CD56(+). Bronchoalveolar lavage (BAL) revealed that almost all cells were lymphoma cells, which also expressed both CD4(+) and CD56(+). Respiratory failure was managed according to the strategy toward acute respiratory distress syndrome. After chemotherapy, his respiratory function significantly improved. This case indicates that acute respiratory failure, which shows diffuse bilateral infiltration on chest radiograph, can be caused by the lung involvement of malignant lymphoma. BAL is useful for diagnosis, and chemotherapy would improve respiratory failure.

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A 71-year-old female who showed markedly high serum (1→3)-β-D-glucan level during and after septic shock is reported. The patient presented septic shock 10 days after low anterior resection for rectal cancer. The level of her serum (1→3)-β-D-glucan was elevated to 5, 220pg·ml^-1 and Candida albicans was isolated from her blood culture. In spite of full circulatory support with inotropes, she lost renal function and continuous hemodiafiltration (CHDF) was induced. The patient recovered from septic shock and was weaned from mechanical ventilation by means of two weeks intensive care including circulatory support, CHDF and antifungal agents. She remained renal failure and therefore has undergone hemodialysis. Concentration of serum (1→3)-β-D-glucan was in very high (500-1, 000pg·ml^-1) level from ICU admission onward even when she recovered and left ICU. Other reasons of high β-D-glucan like cellulose membrane of a dialyser, parenteral nutrient or drugs are hardly possible. The best effort was made to detect focus of fungal infection but not successful and we speculate that deep mycosis lurked silently.

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A case of severe tetanus with acute renal failure (ARF) caused by rhabdomyolysis is presented. A 47-year-old man was admitted to our hospital because of mild muscle rigidity and trismus. When disturbance in consciousness, opisthotonos and marked sympathetic overactivity occurred on the 2nd hospital day, he was transferred to the ICU. He was diagnosed as severe tetanus following an 8 day incubation period and ARF, which was associated with high serum creatine phosphokinase level and hypermyoglobinemia. He was treated with anti-tetanus therapies (penicilline G, dantrolene, γ-globulin and toxoid), anti-autonomic crisis therapies (either dopamine or Ca²⁺ blocker) and continuous hemodiafiltration (CHDF) for ARF. The CHDF support was needed for 22 days, until renal function was recovered. However, myoglobin levels in blood and urine were persistently high for more than 38 days. In the case of severe tetanus, intensive support for ARF must be considered in addition to anti-tetanus therapies.

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Four patients who underwent antero-posterior cervical fusion suffered from severe upper airway obstruction caused by pharyngeal edema/or hematoma. Three of the patients who were extubated after operation needed emergency and prolonged reintubation and the another one remained intubated because pharyngoscopy on the first postoperative day had showed swelling of pharynx. Pharyngoscopy was repeated regularly to confirm the diminution of swelling and the patients were successfully extubated. It is necessary to pay attention to delayed upper airway obstruction due to edema/or hematoma agter antero-posterior cervical fusion. A pharyngoscopy is useful to evaluate the upper airway.

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A 28-year old woman was admitted to a maternity unit because of preterm labour at 22 week of gestation. She had no cardiac risk factors. The β₂-agonist ritodrine (15mg·day^-1) was orally administered since 15 week of gestation, and was switched to continuous and intravascular administration at 67-200μg·min^-1 after admission. At 38 week of gestation, Caesarean operation was carried out. After delivering a healthy baby with an Apgar score of 9, she suddenly complained of dyspnea and was transferred to an intensive care unit. She was diagnosed as pulmonary edema due to acute heart failure. Echocardiogram demonstrated evident hypokinesis. Both [²⁰¹T1]-thallium chloride and [¹²³I]-metaiodobenzylguanidine scintigram on the 9th day showed poor uptake. The serum creatine phosphokinase (CPK) level remained normal. She was given oxygen and a diuretic, which rapidly improved pulmonary edema. She spent 4 days in the intensive care unit and discharged on the 19th day thereafter. Chronic administration of the β₂ agonist for prevention of premature labour might be associated with acute pulmonary edema and so-called “takotsubo” myopathy (ampulla-like left ventricular dysfunction).

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