It has long been appreciated that critically ill patients are complicated by persistent hyperglycemia despite high-dose administration of insulin. While this so-called insulin resistance could be a marker of severity in critically ill patients, many studies suggest that blood glucose control contributes to the reduction of modality in patients with central nervous or myocardial diseases. A large-scale clinical trial for post-surgical patients has demonstrated that intensive insulin therapy to strictly regulate blood glucose level improved the modality and mortality while recent study showed that this therapy could be applied to medical ICU patients staying over 3 days. This review has focused on the beneficial effects of strict blood glucose control on systemic inflammatory response and vital organ function, and thereby has discussed its implications and substantial mechanisms to improve the outcome of such critically ill patients.

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Phosphodiesterase (PDE) III inhibitors (milrinone, amrinone, olprinone) are widely used in cardiovascular surgery as therapeutic agents for perioperative acute ventricular failure. PDE III inhibitors possess unique characteristics as inodilators, with both positive inotropic and vasodilatory effects. Recent research on PDE III inhibitors has focused on issues of dose, efficacy, and safety. On the basis of recent clinical studies, the new concept of preemptive therapy of PDE III inhibitor has been introduced in cardiovascular surgery. Preemptive therapy of PDE III inhibitor involves the administration of milrinone, amrinone, or olprinone in the early period of extracorporeal circulation during which downregulation of beta-adrenergic receptors, inflammatory responses, and reperfusion injury occur. This therapy reduces the risk of low output syndrome and anaerobic metabolism after extracorporeal circulation and reperfusion, leading to (1) hemodynamic optimization and (2) reasonable balance of oxygen supply and demand. Determination of the safety of PDE III inhibitors should be continued to reduce the risk of side effects that were not recognized in the small clinical studies. The concept of preemptive therapy of PDE III inhibitor may also be useful in the areas of aortic surgery and organ transplantation.

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Electric countershock may cause injury to skeletal muscle with the elevations of cardiac troponin T (cTnT) and heart-type fatty acid-binding protein (h-FABP), and subsequently may affect the results of whole blood panel tests. A total of 27 patients with atrial flutter (n = 2) or atrial fibrillation (n = 25) were enrolled. Patients underwent electric countershock and blood sampling for cTnT and h-FABP at baseline and at various time points (immediately, 3, 6, and 24-hr after procedure). Whole blood panel tests for cTnT and h-FABP were also performed at the respective time points. Mean h-FABP was elevated 2.3 fold after electric countershock (P < 0.05), while there was no change in cTnT. The positive rates with the whole blood panel test was significantly higher for h-FABP than for cTnT at each time point (maximum diversity h-FABP: 55.6% v.s. cTnT: 0% at 3-hr after EC, P < 0.01). Electric countershock did not result in elevation of cTnT despite a rise in h-FABP. These data suggest that myocardial damage following electric countershock was minimal and that elevation of h-FABP may result from skeletal muscle damage. Thus, cTnT may be a more clinically useful for diagnostic indicator of myocardial damage. Furthermore, the whole blood panel test for cTnT has superiority to that for h-FABP following resuscitation, as levels are not affected by electric countershock.

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Objective: To describe the nature and problems associated with end-of-life care (EOLC) in an intensive care unit. Design: Retrospective chart review study. Setting: Intensive care unit of an urban hospital's emergency and critical care medicine department. Patients: All patients who admitted to and expired in the ICU between April 2004 and March 2005. Measurements and main results: Sixty-one patients (male 36 : female 25) expired in the ICU, however, only five patients had indicated their wishes beforehand. Despite having been explained about the poor chance of recovery, the family desired aggressive treatment in 34 cases at first. However, in 47 cases, the families indicated their wish for “do not attempt resuscitation (DNAR)” in the end. The course of treatment for all the patients was decided after consultation between the doctor-in-charge and the patient's family. There were no cases with consulting ethical conference. After the decision for DNAR was conveyed in the ICU, some treatment options were withheld or withdrawn. Conclusions: Obviously, EOLC should be based on the needs in individual cases, however, in all cases, the decisions on EOLC should be made by a medical team or at the level of the institution. The following issues in relation to EOLC are in need of urgent debate. (1) How can a patient's treatment course be mapped out without a knowledge of the patient's own wishes. (2) How can it be determined that a patient cannot recover. (3) Treatment options within the ethical framework, after deciding on DNAR.

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Objective: To assess the validation of the simple technique to insert enteral feeding tube (EFT) transpylorically without using supporting devices or drugs. Patients: Critically ill patients who entered intensive care units of two hospitals of Yokohama City University since April 1st 2003 to May 31st 2005, and needed nutritional support via transpyloric tube. Method: We used ARGYLE™ “New Enteral Feeding Tube”. Every advance 3 cm was followed by confirmation if it loops back or not, abdominal auscultation was done at many sites. If changes in resistance of insertion was felt, or pitch or duration of the sound was heard differently, we considered tube proceeded beyond pylorus, and withdraw the stylet to end the procedure. Tube tip was confirmed by radiographically. Results: We inserted 71 times in 64 patients, and succeeded 56 times (78.9%). Although the duration of procedure was shorter in success cases (21.6 ± 4.8 min) than in failure cases (51.3 ± 33), the difference was not significant (P = 0.050). There were no critical complications. Conclusion: This simple technique is practical in success rate, duration of procedure.

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Objectives: A retrospective study of 284 cardiovascular surgical patients seen between January 1, 1999 and September 30, 2004 was conducted to determine whether appropriate antimicrobial prophylaxis reduces surgical site infection (SSI) rate. Methods: The study period was divided into four according to the period of antimicrobial prophylaxis administration and the SSI rate was evaluated. The first period from January 1 to August 31, 1999 served as an 8-month baseline period, during which the mean duration of antimicrobial prophylaxis was 8 days (Group A; 36 patients). The 10-month period from September 1, 1999 to November 30, 2000 was the next period (Group B; 64 patients). The Centers for Disease Control and Prevention (CDC) guidelines for preventing SSI were introduced during this period. The mean duration of antimicrobial prophylaxis was reduced to 4 days. The 16-month period from December 1, 2000, to March 31, 2002 was the third period (Group C; 59 patients). The mean duration of antimicrobial prophylaxis was reduced to 24 hours. The fourth period lasted 30 months from April 1, 2002, to September 30, 2004 (Group D; 125 patients). From the beginning of this period, the administration of antimicrobial prophylaxis was limited to only during surgery. Results: The rate of SSI was 8.3% (superficial SSI : 2.8%, deep SSI (mediastinitis) : 5.6%) in Group A, 1.6% (0%, 1.6%) in Group B, 0% (0%, 0%) in Group C, and 0.8% (0%, 0.8%) in Group D. The rate of SSI was significantly lower in Group D than in Group A (P = 0.035) despite the reduction in antibiotics. Conclusions: Careful management and appropriate antimicrobial prophylaxis according to the CDC recommendations have a beneficial effect on reducing SSI in cardiovascular surgery.

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We report a patient with severe obesity who suffered cardiopulmonary arrest (CPA) after drastic weight loss but successfully survived with cardiopulmonary resuscitation and critical care in the ICU. We describe the patient's care and discuss the relationship between drastic weight loss and secondary prolongation of corrected QT interval (long QT syndrome) with development of torsades de pointes (Tdp). The corrected QT interval (QTc) observed upon the first visit of the patient to the outpatient unit was 0.475 sec, with a body mass index (BMI) of 67.5. QTc was prolonged to 0.507 sec after drastic weight reduction to achieve a BMI of 60.8. That was further prolonged to 0.608 sec upon ICU admission following resuscitation. Postresuscitation treatment in the ICU was successful, and she was discharged from the ICU on the 7th day. Strict medical weight control after discharge from the ICU successfully shortened QTc within the normal range. The relationship between BMI and QTc observed in the present case suggests that severe obesity and excessive weight loss caused prolongation of QTc and CPA. These findings contribute to elucidation of the pathology of sudden death in the severe obese population.

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We report a case of severe Guillain-Barré syndrome in which sequential evaluations of nerve conduction velocity were useful for determining the timing to start weaning from mechanical ventilation. A 54-year-old man was admitted to our ICU because of progressive symmetrical muscle weakness of the extremities. Since the patient complained of dyspnea and numbness of extremities, the patient's trachea was immediately intubated and the patient received mechanical ventilation with administration of sedatives. The results of cerebro-spinal fluid examination revealed elevated protein without cell (albumin-cytological dissociation). Electrodiagnostic study on the 1st ICU day demonstrated significant reduction in amplitude with prolonged distal latencies and temporal dispersion. These data showed that the Guillain-Barré syndrome was a severe form of demyelinated neuropathy. Electrodiagnostic study on the 4th ICU day showed complete nerve conduction block. The patient received plasmapheresis seven times and high-dose steroid therapy. Electrodiagnostic study on the 8th ICU day showed that impaired nerve conduction had recovered in response to these treatments. Weaning from mechanical ventilation was therefore started, and the patient's tracheal tube was extubated on the 11th ICU day without any sequelae. Electrodiagnostic study by measurements of peripheral nerve conduction velocity might be a valid adjunct method for evaluation of the status of Guillain-Barré syndrome that requires mechanical ventilation.

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Tracheoinnominate artery fistula is a relatively rare but often life- threatening complication of tracheostomy. We successfully treated a case of 15-year-old boy complicated with tracheoinnominate artery fistula following tracheostomy. He had suffered from cerebral palsy and severe scoliosis and was forced to be under mechanical ventilation with tracheostomy because of progressive respiratory deterioration. TracheoSoft^® was used with a cuff positioned at the lower trachea to overcome the tracheomalacia. Two months after tracheotomy, sudden massive hemorrhage occurred through the tracheostoma. Continuing cardiopulmonary resuscitation, we succeeded in controlling the hemorrhage by adjusting the position of an overinflated tracheal tube cuff. After bedside control of hemorrhage, prompt operation with a division of innominate artery was performed. His postoperative course was uneventful, and he was discharged from intensive care unit on the 6th postoperative day. We may have to plan a preventive operation with a division of innominate artery for a patient with many risk factors for the development of tracheoinnominate artery fistula.

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A 61-year-old female was transferred to our intensive care unit because of severe pain in the buttocks and back. Based on the results of blood examination and CT imaging, a diagnosis of infectious spondylitis/diskitis, with iliopsoas abscess was made. Blood culture grew Staphylococcus aureus. The appropriate antibiotics and gamma globulin were administered and abscess drainage was performed. However, the patient showed no improvement. Therefore, hyperbaric oxygen (HBO) therapy was added from the 22nd hospital day. Thereafter, the patient's general condition was steadily improved, and she was discharged from our ICU on the 42nd hospital day. The efficacy of HBO therapy has been reported previously for the treatment of diseases such as gas gangrene and osteomyelitis. More recently, various reports on the efficacy of HBO for aerobic bacterial infections have also been published. We propose that HBO therapy might be useful for the treatment of infections in patients who do not show satisfactory response to conventional therapy.

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A 48-year-old male was referred to the ICU for ARDS induced by infection of staphylococcus pneumonia. Chest X-ray and CT scans showed diffuse bilateral infiltrates and the P/F ratio after emergency intubation was 54. A poor arterial oxygenation prompted various postural drainage positions including prone position. On the second day, worsening conditions led us to perform manual breathing assist respiratory physiotherapy. A temporary P/F ratio improvement was observed. On the sixth day, rapidly worsening emphysema change appeared in chest X-ray, and was to suspect ventilator induced lung injury (VILI). Despite secession of the manual breathing assist method, deteriorating of the emphysema change led to patient worsening general condition and death on the ninth morning. We feel that performing the manual breathing assist respiratory physiotherapy on an acute phase of ventilator assisted ARDS patient is not in concordance with the pulmonary protection strategy of low volume ventilation. Therefore, a careful consideration of indication and method technique must be considered.

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A 65-year-old male underwent a right pneumonectomy for lung cancer. On the first operative day, cyanosis was appeared on the upper left half of the body. He felt dyspnea and became shock. Superior vena cava (SVC) syndrome was diagnosed by enhanced CT scans of the chest. There were extensive thrombi from the SVC to the left brachiocephalic vein. Emergency thrombectomy was performed, resulting in improvement of the patient's condition. However, the patient soon developed cyanosis again. We began the thrombolytic therapy, because relapsing thrombosis was strongly suspected. In response to this therapy, his symptom became better, and thrombi disappeared on the diagnostic images. The case was very rare, because the patient had no typical risk factor.

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