A night shift as a part of regular work hours should not be conducted as sole night watch or extra light work. There is some confusion in the management of ICUs in Japan, as to whether the mission of duty intensivists should be considered as a night shift or as a sole day/night watch during hospital closing. We assessed the workload of duty intensivists in our institution by questionnaire survey. The questionnaire survey was facilitated over 69 days, from Jan. 30, 2003. Each duty intensivist evaluated his/her hours of work by a six grade scale, immediately after his/her duty. Workload grade 0, 1, 2, 3, 4, 5 corresponded to sleep, sole watch, light work: including change of respirator settings, IV injection, ordinary tasks: including change of respirator settings followed by arterial blood gas analysis, changes of continuous catecholamine/vasodilator infusion settings, extraordinary order of electrolyte balance adjustments, changes of continuous hemodialysis filtration device settings, discussion about a change of management policy to a consultant of responsible department of a patient, more than ordinary tasks: including ICU admission on emergency, the heaviest tasks: including CPR. Overall fatigue was expressed to a 100mm VAS. More than or equal ordinary tasks for the day-time during hospital closing (9:00-17:00), evening (17:00-1:00), midnight (1:00-9:00) was 58.8%, 41.7% and 28.5%, respectively. Likewise, sleep or sole watch for the same work period was 8.1%, 11.8% and 34.9%, respectively. Sleep duration was 2.5±1.3 hours (mean±SD). Overall fatigue VAS was 54.9±18.1mm. A correlation was found between workload grades per hour and overall fatigue VAS in the whole population (r=0.737). The Japanese Labor Standards Act defines a day/night watch as light work, including inspection tour and telephone correspondence to other departments and outsiders. Sleep time of at least six hours is simultaneously ensured. Therefore the day/night watch is authorized separately from regular work. Since intensivists frequently managed more than or equal ordinary tasks on their duty, and since their sleep duration was insufficient, the duty workload at our institution was not applicable to the sole day/night watch. The mission of duty intensivists in institutions similar to our own in Japan should be considered as a part of the regular 40 hour work week.

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Hemophagocytic syndrome (HPS) is a clinicopathologic entity characterized by systemic proliferation of benign hemophagocytic histiocytes in the bone marrow, associated with fever, cytopenias, liver dysfunction and coagulopathy. We report a case of HPS associated with cytomegalovirus (CMV) infection in a patient with rheumatoid arthritis (RA). A 75 year-old female, who had been diagnosed with RA 15 years previously, was admitted to our hospital for the operation of atlantoaxial subluxation. She suddenly had a high fever and a severe diarrhea, her peripheral blood parameters showed pancytopenia and bone marrow aspirate revealed a decreased nuclear cell count and macrophage phagocytizing blood cells indicating HPS. To take into consideration her clinical course, complicating with heart failure, acute renal failure, liver dysfunction and DIC, her HPS was classified considered to be a severe form of HPS. We administered 1, 000mg of methylprednisolone for 3 days followed by 60mg of prednisolone (PSL) daily, but her condition did not improved. Then we administered etoposide (50mg·day^-1) in addition to PSL. Three days after the initiation of etoposide injection, she died from acute pulmonary thromboembolism revealed by postmortem examination. We speculated the etiology for the HPS was bacterial and fungal infection due to immunosuppresion induced by long-term usage of the steroid, but the pathological examination suggested that cytomegalovirus infection strongly played an important role for triggering the HPS.

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A 74-year-old woman with pneumonia suddenly developed eruptions all over her body surface. The eruptions became blisters and then ruptured. She was diagnosed as toxic epidermal necrolysis (TEN). Septic shock had occurred on the hospital day 8. Once the shock was properly treated, but she suffered from severe sepsis again on the hospital day 13 and finally died on the hospital day 20. In this case bacterial translocation (BT) was suggested to cause sepsis by reason that both a blood culture and a stool culture revealed the same type of Escherichia coli and that their resistances to antibiotics were completely the same. TEN patients often suffer from BT because they need longtime parenteral hyperalimentation and broadspectrum antibiotics. Selective decontamination of digestive tract may be useful against BT to prevent sepsis.

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A 4-year-old boy diagnosed with influenza virus-associated encephalopathy was admitted to our ICU. On admission, the level of consciousness was II-20 according to Japan coma scale. Body temperature was 40.4°C and brain CT showed cerebral edema. Combination therapy of mild hypothermia, anticytokine and antivirus agents was initiated immediately after admission based on the recent published findings that inflammatory cytokines play a major role in the pathogenesis of influenza virus-associated encephalopathy. During the course of treatment, a brain CT revealed an attenuation of brain edema. Hypothermia was discontinued on hospital day 5. The patient recovered consciousness and was extubated on hospital day 8. Single photon emission computed tomography (SPECT) revealed increased cerebral blood flow and positron emission tomography (PET) of the brain revealed improved glucose metabolism of bilateral basal ganglia and thalami on hospital day 10 in comparison with the findings on admission. The patient was discharged without any neurological sequelae on hospital day 17. This treatment strategy appears to be effective for managing severe influenza encephalopathy.

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A 62-year-old man, stung on 18 places by hornets, was admitted to our ICU because of consciousness disturbance. He was in severe shock and treated with epinephrine and resuscitative fluids. He was discharged on the 4th hospital day. The course of shock was considered not as anaphylaxis but as anaphylactoid reaction because his low plasma IgE levels. Seguential measurements of plasma histamine, serotonin and 5-hydroxyindole acetic acid (5-HIAA, a metabolite of serotonin) demonstrated increased concentrations of serotonin, on arrival, 6 hours after, 12 hours after, and of 5-HIAA 6 hours after admission. And therefore we concluded histamine and serotonin were likely to cause his shock.

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Posterior reversible encephalopathy syndrome (PRES) is a condition characterized by symptoms including headache, seizures, visual disturbances, altered mental function, and abnormal neuroimagings in the posterior regions of the cerebral hemispheres. PRES is named as reversible but not always reversible. A 6-year-old girl undergoing combined chemotherapy with cyclosporine A and prednisolone for the treatment of hemophagocytic syndrome (HPS) developed hypertention and coma. She was diagnosed with PRES by brain MRI. We stopped using immunosuppressive agents and gave nifedipine to lower her blood pressure but, on the 3rd ICU day, we resumed them to treat relasped HPS. We controlled her blood pressure by continuous intravenous nicardipine to prevent PRES and the patient has recovered completely in clinical signs in the 4th ICU day and in radiological findings at a later time. So far as we search this is the first case of PRES resulting from HPS.

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Many studies have recently shown the effectiveness of continuous vasopressin infusion in catecholamine-resistant septic shock, although controversial. We experienced a case of catecholamine-resistant septic shock effectively treated with continuous vasopressin infusion. A 79-year-old woman was admitted to our hospital because of dyspnea. The initial plain chest roentgenogram showed consolidation in the right lower lung. She was diagnosed as pneumonia and treated immediately. She suffered from septic shock and acute renal failure 3 hours after the admission. Her circulatory system was unstable and didn't effectively respond to catecholamines. At the hospital day 3, continuous infusions of norepinephrine 0.74μg·kg^-1·min^-1, dobutamine 2.2μg·kg^-1·min^-1 and dopamine 15.7μg·kg^-1·min^-1 has started but her circulatory system was still unstable. Continuous vasopressin infusion at a rate of 0.034IU·min^-1 after bolus injection of vasopressin 5IU made it possible to wean from norepinephrine shortly. To avoid side effects of vasopressin, we terminated vasopressin in 48 hours. Finally, she recovered from septic shock without any severe side effects of vasopressin. This case demonstrates the effectiveness of continuous vasopressin infusion to control circulatory instability in catecholamine-resistant septic shock.

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