Antipsychotic drugs are widely used to treat mental disorders including schizophrenia. In Western countries, pulmonary thromboembolism (PTE) has been reported in patients treated with atypical antipsychotic drugs including clozapine as well as conventional antipsychotic drugs including chlorpromazine. By accumulation of many evidence, the US guideline of PTE treatment recently described that the use of antipsychotic drugs is one of the risk factors of PTE. On the contrary, it is not recognized well in Japan. However, recent studies in Japan suggest that the rate of PTE associated with antipsychotic drugs is remarkably higher. Although the mechanism has not been known, hypotheses such as platelet aggregation intervened by 5-HT_2A receptor and lupus-like syndromes have been proposed. It is expected that the more studies in this field may lead objective methods to prevent PTE associated with antipsychotic drugs, a life threatening disease, in the near future.

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Most countries have formal training programs in intensive care medicine, which programs are accessible to trainees from any of the major base specialties. In a few countries, intensive care medicine is a primary specialty, in which trainees can take a specialty course following completion of undergraduate training and registration. Intensive care units directed by certified intensivists are reported to have a lower mortality rate than those directed by other physicians. Postgraduate training course for intensive care medicine in Japanese Society of ICM has urgently to be prepared, in which well-designed training courses are anticipated for the trainees accessible from a variety of other specialty courses.

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Several kits for percutaneous tracheostomy and cricothyrotomy are widely used in the intensive care settings. Although the principles of these techniques are simple, the procedures should be carefully performed considering the draw-backs and limitations of each technique and kit. One of the most crucial problems is the placement of preexisting tracheal tube. Withdrawal of the tracheal tube for making the intratracheal space and for bronchoscopic confirmation causes the situation that securing the airway and the maintenance of ventilation are not guaranteed. Another important problem is a large resistance to insertion of the tracheostomy tube into the trachea. In the Griggs' method, the manipulation skill of the guidewire-dilating forceps determines the difficulty in the placement of the tracheostomy tube and the incidence of related complications. Although cricothyrotomy techniques with kits seem to be easier than percutaneous tracheostomy techniques, similar care should be taken to avoid complications during the procedures. In the cricothyrotomy kit using the Seldinger method, thrust for overcoming the resistance to insertion of the tracheal cannula through the cricothyroid membrane is often required due to the step between the introducer and the tracheal cannula.

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To identify factors predicting ICU mortality and post-ICU survival in critically ill cancer patients admitted to ICU, a retrospective study of 586 patients was performed. Primary site and clinical stage of cancer, anti-cancer treatments prior to ICU admission, cause of ICU admission, treatments in ICU, type and number of organ failures, development of sepsis, outcome in ICU, survival time after ICU discharge, cause of death, and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were recorded. The impact of each variable on ICU mortality and post-ICU survival was studied by univariate and multivariate analysis. The analyses of predictors of post-ICU survival were conducted in each of six observation periods (1 month, 3 months, 6 months, 1 year, 3 years, and 5 years after ICU discharge) to assess the predictors in relation to time progress. ICU mortality was 30%. Independent predictors of ICU mortality were brain tumor “odds ratio (OR) 2.93, 95% confidence interval (95%CI) 1.30∼6.60”, neurological failure (OR 4.08, 95%CI 2.07∼8.05), APACHE II scores (each 5 points; OR 1.31, 95%CI 1.07∼1.60), number of organ failures (OR 2.75, 95%CI 1.95∼3.88), and sepsis (OR 3.00, 95%CI 1.57∼5.73). Independent predictors of post-ICU survival were clinical stage, respiratory failure, hepatic failure, renal failure, APACHE II scores, and lung cancer. Clinical stage was consistently an independent predictor of post-ICU survival in every observation periods, although critical illness-related variables influenced post-ICU survival within one year after ICU discharge and the variables as predictors changed in each observation period. We conclude that to treat critically ill cancer patients in ICU are to treat anti-cancer treatment-associated complications of the patients with advanced or treatment-resistant cancers.

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Objectives: A retrospective observational study was conducted to clarify the factors that could affect postoperative emergence or extubation time, analgesia or sedation in the patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Methods: After institutional approval, 425 consecutive patients were studied. Data were collected from patients' medical records, and the correlations were determined between emergence time, extubation time, time before giving analgesics or sedatives and age, gender or body mass index as patient factors, anesthetic dose of fentanyl, duration of anesthesia, fluid balance as anesthesia factors, and CPB time as a surgical factor. Multiple stepwise regression analysis was used, and a value P<0.05 was considered as significant. Results: Significant positive correlations were found between emergence time and age and CPB time, between extubation time and anesthesia time, CPB time and age. The time to giving analgesics correlated with age, CPB time and fluid balance. The time to sedatives correlated with anesthesia time. The standardized correlation coefficients were between 0.087 and 0.324. The anesthetic dose of fentanyl showed no correlation with each postoperative condition. Conclusions: Postoperative emergence time, extubation time, analgesia or sedation were demonstrated to be affected by anesthesia time, CPB time, age or fluid balance, however, because of the low correlation coefficients, it is suggested that each factor cannot independently affect postoperative patient care.

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We have experienced 3 cases of low dose hydrocortisone infusion for acute respiratory distress syndrome (ARDS) caused by community-acquired pneumonia. The patients were 68∼83 years old. Two of them were male and one was female. P/F ratio were 60∼107 mmHg after tracheal intubation. After intravenous bolus of glucocorticoid (prednisolone 50 mg to one patient, hydrocortisone 200 mg to two patients), continuous infusion of hydrocortisone was performed at a rate of 10 mg · hr^-1. In 2 cases, blood gases were improved and the patients were successfully weaned from ventilator on 8th and 9th day. In one case, the patient died on 11th day, caused by toxic shock syndrome. But blood gas was improved until 10th day when her P/F ratio was 236 mmHg. Low dose hydrocortisone infusion for ARDS may have clinical efficacy to improve oxygen exchange.

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A 68-year-old man, diagnosed as having triple lung cancer, underwent a right lower lobectomy 4 months after undergoing a left upper lobectomy. He developed acute lung injury, possibly because of massive bleeding, shock and blood transfusion during the surgery. Despite an improvement in lung oxygenation, he was unable to be weaned from mechanical support. We then changed our treatment goal to the start of home mechanical ventilation (HMV). As a result, his condition was improved remarkably, accompanied by adequate nutrition. On the 305th postoperative day, he returned home. HMV may be an option for improving the quality of life of patients who become ventilator-dependent.

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Highly active antiretroviral therapy (HAART) for human immunodeficiency virus (HIV) infection has produced significant declines in morbidity and mortality from acquired immunodeficiency syndrome (AIDS). Despite improved treatment with HAART, the mortality of HIV infected patients admitted to the ICU with multiple organ failure (MOF) remains high. We encountered a case of respiratory and renal failures in an HIV infected patient. A 29-year-old male was admitted to our ICU for treatment of renal failure with continuous hemodiafiltration (CHDF) and respiratory failure with mechanical ventilation. The patient had a P/F ratio of 117, serum creatinine of 7.7 mg · dl^-1 and CD4 lymphocytes of 2.5 μl^-1. With mechanical support and administration of antibiotics and endovenous corticosteroids, the patient's respiratory and renal functions were gradually improved. He was weaned from mechanical ventilation and CHDF and was discharged from the ICU. HAART was started at the hospital to which the patient was transferred. The number of newly reported HIV infections and AIDS diagnoses continues to increase steadily, making Japan an exception among high-income countries. Although intensive care for HIV infected patients is associated with various problems, such as the criteria for ICU admission and risk of infection to healthcare workers, the number of HIV infected patient who receive intensive care are likely to increase.

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A man in his twenties who had undergone splenectomy 5 years previously was admitted to our hospital in a shock state, with a history of high grade fever, vomiting, diarrhea and a washed out feeling since the previous day. His consciousness level deteriorated rapidly after admission, and based on the clinical findings and the results of investigations, he was diagnosed as having meningitis caused by penicillin-resistant Streptococcus pneumoniae. Despite aggressive treatment with antibiotics, intravenous immunoglobulin, steroids, etc., his condition deteriorated rapidly and he died on the 8th day of the illness. Splenectomy predisposes to infections by bacteria possessing a peroxidase (POD) membrane, which can cause meningitis and fulminant sepsis. Therefore, patients who have undergone splenectomy as well as their families must be made aware of this predisposition to severe infections and be urged to seek urgent medical attention even for mild symptoms of infection. In addition, preventive measures, such as vaccination with a pneumococcal vaccine should be strongly considered in these patients. Because some of these bacterial strains causing severe infections may be penicillin-resistant, careful choice of antibiotic therapy is required.

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