Cerebral nerve injury is a critical condition in the management of patients in intensive care. Pathological conditions such as cerebral ischemia, head trauma and low oxygen can result in marked impairment of cerebral function, even if the patient's life is saved. We sometimes encounter sudden changes in a patient's condition not only during intensive care, but also during cardiac arrest in emergency situations, and transient low-oxygen and ischemic conditions accompanying with serious shock. We have been studying the mechanisms to prevent pathological conditions leading to neuronal cell death that have been exposed to such emergency conditions, and to discover therapeutic methods to minimize the neuronal damage after insult. With advances in the understanding of the mechanism of neuronal cell death, technology in intensive care for salvaging neuronal cell that are at the brink of death and for recovery of brain function has progressed. However, no breakthrough has been achieved in the development of effective therapy. Protection of the brain from terminal impairment and preservation of function will be an issue in intensive care in the 21st century. To achieve this goal, it is critical to clarify the key mechanism causing neuronal cell death. This report discusses the importance of the calcineurin/immunophilin signal transduction mechanism as a new mechanism that is involved in the induction of ischemic brain damage.

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We present a summary of the intensive care provided to 20 patients who underwent heart transplantation at the National Cardiovascular Center. Nineteen patients suffered from dilated cardiomyopathy, of which 18 had been supported by a left ventricular assist system. In the ICU, cardiac pacing was applied in all patients, with 9 patients requiring isoproterenol infusion in addition, to maintain an appropriate heart rate. All patients received infusions of low-dose of dopamine and atrial natriuretic peptide. The immunosuppression regimen consisted of cyclosporine (or tacrolimus), mycophenolate mofetil, and methylprednisolone in the patients with normal hepatorenal function. Earliest removal of catheters and tubes was always attempted at the ICU. Most of the patients were discharged from the ICU and transferred to the ward on postoperative day 8, without any serious events. In addition to the conventional intensive care provided to patients undergoing open heart surgery, management of the denervated heart and preservation of renal function are important targets of acute care in patients undergoing heart transplantation.

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Psychometrics is a method to measure psychological phenomenon, and it is, “a scale of a mind” to grasp invisible psychological phenomenon. Psychometrics makes possible to compare individual difference of psychological phenomenon by converting answers for several questions into a score. In the process of psychometrics development, the target psychological phenomenon needs to be defined as a theoretical construct, and a standardized procedure is required to develop question items that reflect the construct. Particularly important feature of the psychometrics is to measure the target psychological phenomenon accurately and appropriately. “Reliability” and “validity” are the indicators to determine accuracy and appropriateness of the psychometrics. This report provides basic knowledge necessary to utilize a psychometrics to clinical practice and research study focusing on development procedure and reliability and validity.

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Objective: To compare nafamostat mesilate (NM) and heparin as anticoagulant drugs for continuous renal replacement therapy (CRRT). Method: Filter life, bleeding complications and cost were compared retrospectively for patients treated with NM (from April 2003 to March 2004, Period 1) and those treated with heparin (from April 2004 to March 2005, Period 2). Result: Fifty filters were used in Period 1 and 101 filters were used in Period 2. Filter life was significantly longer in Period 1 (34.6 hours) compared to Period 2 (18.6 hours). There was no bleeding complication during both periods. Requirement of blood transfusion was also similar between the two periods. The cost in Period 1 was greater than in Period 2, with a difference of more than fifty thousand yens per day. Conclusion: CRRT with NM had a longer filter life, the same bleeding complication rate and a higher cost compared to heparin.

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Background: Cerebral injury after total arch replacement remained one of devastating complications, which require strategies for its prevention and treatments. In the present study we retrospectively evaluated the factors related to symptomatic cerebral injury after total arch replacement. Methods: Twenty five patients who underwent total arch replacement under selective cerebral perfusion with hypothermia were included for analysis. The associations between the development of postoperative symptomatic cerebral injury and perioperative factors were analyzed. Results: Symptomatic cerebral injury developed in 6 patients (24%), of which 4 patients (16%) had transient symptoms. The patients with cerebral injury had higher incidence of preoperative ischemic heart disease compared with those without injury. In patients with injury, the lowest temperature during circulatory arrest was lower, and cardiopulmonary bypass time, aortic clamp time were longer than those without injury. Total doses of fentanyl were larger in patients with injury than those without injury. Conclusion: These results suggest that the incidence of cerebral injury after total arch replacement was high and the risk factors related to cerebral injury were preoperative ischemic heart disease, lowest tympanic temperature, cardiopulmonary bypass time, aortic clamp time, and fentanyl doses.

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Objective: We changed the preventive measures against infections in our ICU according to the revised Guidelines for the Prevention of the Intravascular Catheter-Related infections in 2002. The main changes about the use of central venous catheters (CVC) were the adoption of maximal barrier precautions at the time of insertion and discontinuation of scheduled catheter replacement (every 10 days). We investigated the change in the incidence of catheter-related infections and other complications following the introduction of these changes. Methods: We conducted a retrospective review of the data of patients who underwent CVC insertion before the introduction of the changes (Gruop A; n=80) and after the introduction of the changes (Group B; n=73) at our ICU between July 2002 and July 2003. Results: No significant differences were noted between Group A and Group B in the diagnoses on admission, the initial Acute Physiology and Chronic Health Evaluation II scores (APACHE II scores), age, sex, or distribution of the sites of insertion of CVC. There was also no significant difference in the duration of the catheter use between the two groups. There was one case of catheter-related infection and a mechanical complication in both the groups. Neither difficulty in achieving hemostasis nor thrombus formation was noted in either group at the time of withdrawal of the catheter in cases requiring prolonged catheterization. Conclusions: Adoption of the revised guidelines of the Centers for Disease Control and Prevention (CDC), including discontinuation of the regular replacement of CVCs, was not associated with any increase in the incidence of catheter-related infections, or any changes in the incidence of other complications.

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Noninvasive positive pressure ventilation (NPPV) has been applied to various types of respiratory failure. However, perioperative application of NPPV is still controversial. In addition, there are very limited reports regarding NPPV after cardiovascular surgery. Therefore, we retrospectively surveyed the reason and outcome of NPPV in patients after cardiovascular surgery. We divided 53 patients, who developed post-extubation acute respiratory failure after cardiovascular surgery, into 2 groups: group S, in which re-intubation was prevented, and group F, in which re-intubation was needed. We compared patients' profile, operative data, preceding mechanical ventilation, initial settings of NPPV, and respiratory and hemodynamic parameters before and after starting NPPV. Twenty-three patients needed re-intubation, while 30 patients did not. Group F had larger operative bleeding, larger transfusion and longer mechanical ventilation than group S. In group S, after starting NPPV, respiratory rate and PaCO₂ decreased, while PaO₂ increased. In contrast, in group F, the decreases in respiratory rate and PaCO₂ were small and PaO₂ did not increase. During NPPV, group S showed lower PaCO₂ and higher P/F ratio than group F. In group S, after starting NPPV, heart rate decreased and mixed venous oxygen saturation increased, although the changes were not significant in group F. Length of ICU stay was longer in group F than group S, but hospital day was not different between the groups. In conclusion, NPPV seemed to be useful in post-extubation acute respiratory failure in patients after cardiovascular surgery. In the group S in which re-intubation was not needed, respiratory and hemodynamic parameters improved in a short time.

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A man of 58 years old was hospitalized with acute abdominal pain, but he developed cardiac arrest and was admitted to the ICU after resuscitation. From electrocardiogram and echocardiographic findings, acute myocardial infarction was suspected. Following coronary angiography, we found 90% stenosis and thrombus in the #7 area of the left anterior descending artery, and performed thrombus aspiration and a stent insertion. However, decreased systemic vascular resistance and severe metabolic acidosis persisted, and as a result shoshin beriberi was suspected. We subsequently administered vitamin B₁ to the patient. The metabolic acidosis improved 12 hours later. Blood pressure and systemic vascular resistance increased smoothly, and the patient could be weaned from mechanical ventilation on his 5th day in the ICU. Afterwards, it was realized that the vitamin B₁ concentration in his blood at the time of admission was only 19 ng · ml^-1. He tended to drink beer in large quantities every day, and this is regarded as the cause of vitamin B₁ deficiency and the origin of the beriberi.

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We have experienced a case of penetrated ulcer of the reconstructed gastric tube to the pericardium. A 72-year-old man was admitted to the hospital because of palpitation, dyspnea and severe dehydration in April 2006. He had received a subtotal esophagectomy and a retrosternal esophagogastrostomy for carcinoma of the lower intrathoracic esophagus 4 years before this admission. He was treated using antibiotics and infusion. He developed shock and respiratory arrest 8 hours after the admission. AST, ALT, LDH and CK rised and metabolic acidosis developed. Chest CT revealed the air in the pericardial space and pleural effusion. He was treated using vasopressor and compensated metabolic acidosis. But his general condition deteriorated, resulting in death 45 hours after the admission. The autopsy clarified ulcer penetration of the gastric tube to the pericardium, purulent pericarditis and intestinal necrosis. No recurrence of the esophageal cancer was observed. The long axis of ulcer size was 4 cm. The penetration of the reconstructed gastric tube ulcer is a fatal complication after surgery for esophageal cancer. Early diagnosis and treatment of a lesion of a gastric tube is essential in patients complaining of a pectoralgia or chest discomfort after the esophageal surgery.

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We report two patients with postoperative deep mycosis. An 81-year-old and a 71-year-old woman respectively developed fever associated with elevated serum CRP 3 and 19 days after esophageal surgery. Adminstration of antifungal agents was commenced upon finding a high serum concentrations of (1→3) -β-D-glucan and positive cultures for Candida. However, β-D-glucan concentrations continued to rise. Changes in β-D-glucan concentrations showed no relationship to those in CRP or the clinical course in either patient. Soon CRP and clinical findings improved with treatment adjustments concerning antifungal agents. Antifungal therapy was subsequently ceased while β-D-glucan concentrations remained higher level than normal. Both patients were stable after cessation of antifungal therapy and were discharged in good clinical condition. It was difficult to ascertain whether such elevation in β-D-glucan concentrations resulted from persistant fungal infection or false positive. The present cases and some previous reports suggest that antifungal therapy can be ceased when the clinical condition has clearly improved and the serum concentrations of β-D-glucan tends to decline, even though it remains higher level than normal.

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