The recent 10 years are regarded as a turbulent decade at medical malpractice cases, since two cases happened. One of the two cases was the incident of giving patients antiseptic solutions via an intravenous drip at Tokyo Metropolitan Hiroo Hospital, and the other was the incident of mixing up patients at Yokohama City University Hospital both in 1999. Lots of movement occurred in the field of medical cases. In this paper, I would like to view such medical malpractice cases and suggest the understanding of the uncertainty of medical treatment should be the keyword to understand the relation between doctors and patients.

View full abstract

The quality of management for acute myocardial infarction (AMI) in Japan using coronary angioplasty or coronary artery bypass graft surgery is excellent. However, epidemiological data is lacking, which is a major problem for further development of management for AMI in Japan. The guideline for ST-elevation AMI by the Japanese Circulation Society will be published in 2008, but it does not include nationwide epidemiological data in Japan. Obtained data from nationwide network would make the next guideline more useful for physicians and also it would be better for further development of the AMI management in Japan. Therefore, in this article rationale of the nationwide data network system and how to collect the data regarding AMI would be discussed with the results of questionnaire survey by the Committee of Coronary Care Unit in the Japanese Society of Intensive Care Medicine.

View full abstract

Objectives: To assess the optimal dosage of teicoplanin in critical care settings. Methods: A retrospective analysis of data obtained from fifty patients without renal replacement support who received teicoplanin therapy in the ICU was performed. Results: Serum trough teicoplanin concentration at 48 hours after starting administration rarely exceeded 10 or 15μg·ml⁻¹ (40% and 15%, respectively) by conventional recommended dosage. Predicted serum trough teicoplanin concentration at 24 hours after the first dosage following 600 mg and 12 mg·kg⁻¹ of teicoplanin administration every 12 hours estimated by Bayesian method were 14.5±5.8 and 15.8±5.1μg·ml⁻¹, respectively. Additionally, serum concentration of five patients with impaired renal function was similar to that from patients with normal renal function at 96 hours after the first dosage. Conclusions: In critical care settings, larger initial dosage of teicoplanin was required to obtain optimal serum concentration regardless of patient's renal function.

View full abstract

Background: Approximate entropy (ApEn) measures complexity of time-series data. A larger value of ApEn indicates higher randomness, and vice versa for a smaller value. Recently, ApEn of the body temperature curve of ICU patients with septic multiple organ dysfunction syndrome (MODS) has been reported to be inversely correlated with sequential organ failure assessment (SOFA) score, and to possibly predict ICU survival. Objectives: We performed a retrospective study to validate the findings by using the stored data in our general ICU. Methods: Adult septic patients with MODS, admitted to our ICU during the past 18 months, and in whom bladder temperature was continuously monitored at 30-min interval for more than 4 days, were retrospectively enrolled. ApEn was calculated on 68 bladder temperature data points over the preceding 33 hours at every 9:00 am. SOFA score was also determined at 9:00 am. Results: Thirty patients were included. Twenty nine of 30 patients showed an inverse correlation between ApEn and SOFA, 10 of which were statistically significant. A significant difference was seen in ApEn, maximum-SOFA score, and maximum-max-lactate level between survived (n=25) and expired (n=5) cases. However, logistic analysis showed that only maximum-SOFA score was a significant factor associated with ICU outcome. Conclusion: ApEn cannot predict the outcome of ICU patients with septic MODS.

View full abstract

We report a case of severe sepsis with disseminated intravascular coagulation (DIC) induced by a ureteral stone. An 85-year-old woman was admitted to hospital with fever. Urinary tract infection was suspected and antibiotic therapy was started. She subsequently developed a state of shock the next day, and was transferred to our hospital. Her laboratory data upon admission were already showing DIC and multiple organ dysfunction syndrome (MODS). Furthermore, her serum endotoxin level was high (15.5 pg·ml⁻¹). Abdominal CT scanning showed a left ureteral stone and left hydronephrosis. The patient died on the 2nd day in hospital. Drainage of urine by a transurethral catheter, endotoxin removal therapy, and continuous hemodiafiltration were not able to improve her condition. Escherichia coli was isolated from both her blood and urine. We conclude that age, procrastination over systemic inflammatory response syndrome (SIRS), and acceleration of endotoxin release from gram-negative bacteria by antibiotics were the critical factors in this case.

View full abstract

We present two infant cases where noninvasive positive pressure ventilation (NPPV) worked effectively as a weaning strategy after prolonged mechanical ventilation. Case 1: An 11-month-old girl was admitted to our unit because of cardiac failure due to congenital mitral regurgitation. Her trachea was intubated and ventilated for 33 days. After the extubation, she suffered from tachypnea and increasing tracheal secretion. NPPV [continuous positive airway pressure (CPAP) mode; PEEP 4 cmH₂O; F_IO₂ 0.3] was applied and she was weaned from NPPV successfully 28 days later. Case 2: A 10 month-old girl developed an upper respiratory tract infection and obliterative bronchitis. She had undergone Blalock-Taussig shunt and uniforcalization for double outlet right ventricle, pulmonary atresia and major aortopulmonary collateral arteries at 1 month old. Her trachea was intubated and ventilated for 24 days. Applying NPPV (CPAP mode; PEEP 5 cmH₂O; F_IO₂ 0.4) soon after the extubation of her trachea, she needed re-intubation. On the 37th in ICU day, her trachea was extubated again and immediately applied NPPV [spontaneous and timed (S/T) mode; expiratory positive airway pressure (EPAP) 4 cmH₂O; inspiratory positive airway pressure (IPAP) 6 cmH₂O; F_IO₂ 0.4]. She was weaned from NPPV successfully 4 days later. In conclusion, NPPV was also useful tool for infants who were difficult to wean from prolonged mechanical support.

View full abstract

We describe a patient with invasive pulmonary aspergillosis (IPA) that was followed by infectious endocarditis. A 67 year-old man had been ventilated in the ICU because of Klebsiella pneumoniae that had spread hematogenically from a liver abscess. Transesophageal echocardiography (TEE) had revealed mild mitral valvular regurgitation, and no vegetation. Although the pneumonia improved, Aspergillus fumigatus was obtained from the sputum. Micafungin was started, but the respiratory status of the patient gradually became exacerbated. A chest CT revealed a new lesion, and the serum was positive for aspergillus antigen. The patient was diagnosed with IPA, and started on amphotericin B. However, amphotericin B had to be replaced with voriconazole due to renal damage. The respiratory status of the patient improved again, but weaning from the ventilator was difficult. Mitral regurgitation and a large mass on the mitral valve were revealed by TEE. Mitral regurgitation may have worsened the respiratory failure, and the fungal mass caused embolism in a remote organ. The mass was surgically removed and mitral valve plasty was performed. The patient was weaned from the ventilator and transfered to a ward.

View full abstract

We present a rare case of an infant with life-threatening congenital tracheal stenosis with esophageal atresia and coarctation of the aorta. Airway management was very difficult due to large-bore and long residual esophageal fistula and extensive, severe tracheal stenosis. Furthermore, recurrent episode of tracheal granulation and pulmonary atelectasis exacerbated pulmonary gas exchange. Aggressive use of bronchofiber scope was considered to be essential for the diagnosis of ventilatory failure. The patient received tracheoplasty at 6 months, and is still been managed under mechanical ventilation.

View full abstract

Delirium is an impairment of cognitive function manifesting a lack of concentration, disturbance of consciousness, and alteration of sleep wake cycle, which occurs an abrupt onset and develops within a relatively brief duration. This report describes the patient's perception about experience of delirium in the ICU. A patient in the early sixty underwent a surgery for left side atrioventricular valve replacement and maze procedure. On postoperative day 2, he exhibited pessimistic attitude, resistance and refusal to medical treatment, and disorientation of day and time. Only his family visitation was able to let him recognize real world and feel secure. After recovering from delirium, on postoperative day 8, he said “I am so sorry that I was disgraceful shape when I stayed in the ICU” with tears running. This case illustrates that the experience of delirium seriously distress the patients. It is recommended that nursing staff caring for patients with delirium need to understand such patient suffering.

View full abstract

A 70-year-old man with a past history of myocardial infarction was scheduled for transurethral resection of bladder tumor. He had undergone percutaneous coronary intervention 107 days before the surgery with a bare metal stent placed at #4 atrioventricular nodal branch (#4AV) of the right coronary artery. The cardiologist as well as the anesthesiologist preoperatively evaluated the cardiac function of the patient as normal, and the surgery was performed under general anesthesia. The patient was extubated after full recovery from the general anesthesia lasting for 45 minutes, but he immediately developed hypoxemia and was reintubated. Echocardiography and chest radiograph revealed acute heart failure associated with pulmonary edema. He was admitted to our CCU, where he was mechanically ventilated and was supported with catecholamines and coronary dilators. He responded well to the treatment and was discharged from the CCU on the 24th postoperative day. A close review of his preoperative serial tests including plasma brain natriuretic peptide measurements and electrocardiograms revealed that another ischemic event might have occurred within 3 weeks before the surgery, resulting in deterioration of his cardiac function, which had been undetectable during preoperative physical examination. A patient with deteriorating cardiac function may be at high risk of developing decompensated heart failure even after a short period of general anesthesia. Detailed preoperative cardiovascular evaluation as well as careful anesthetic management is crucial to safer managements of cardiac patients for non-cardiac surgery.

View full abstract

Posterior reversible encephalopathy syndrome (PRES) is a condition characterized by neurological symptoms including headache, seizures, disturbance of consciousness, and abnormalities of the white matter of the posterior lobe on imaging studies. We describe a first case of PRES associated with hemolytic uremic syndrome (HUS) in Japan. A 83-year- old woman was hospitalized with abdominal pain and melaena. Her mental status was depressed and she developed a seizure on the 3rd hospital day. Escherichia coli O-157 and verotoxin were detected and no abnormalities were found on brain CT or MRI. On the 6th hospital day, CT showed the low-density areas in right posterior lobe and bilateral external capsules. The consciousness level was improved gradually, and the low density areas were obscured on the 19th hospital day, and disappeared on the 27th hospital day. We therefore diagnosed encephalopathy as PRES clinically. PRES might be due to the damage to endothelial cells caused by HUS. Consciousness disturbances with HUS should be followed by CT or MRI with the possibility of PRES in mind.

View full abstract