Certified nurse (CN) and certified nurse specialist (CNS) certifications have begun in late 1990s in Japan, and the number of educational institutions and certified nurses are rapidly increasing. Among them, intensive care CN and critical care CNS are relevant to critical care discipline, and 421 and 16 nurses are registered respectively as of August 2008. Five-year clinical experience is required prior to enter CN or CNS program. After finishing a half-year formal education for CN and a master's course for CNS, they need to pass examinations offered by Japanese Nursing Association. CNs identify problems to be resolved in order to improve standard of the care while working with staff nurses. CNSs obtain up-dated information and research findings, scrutinize them for their applicability, and tactically introduce them. Through publications and/or lectures of such practice, CNSs strive to increase level of care nationwide. Both CNs and CNSs are expected to contribute to advancement of quality of critical care nursing by collaborating as equal colleagues.

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Objective: We measured the levels of soluble adhesion molecules in acute lung injury (ALI) patients and patients at risk of ALI, and then analyzed the correlations between the levels of the adhesion molecules and those of inflammatory cytokines to determine whether these factors are involved in the specific pathophysiology of ALI with sepsis. Methods: We conducted a case-control study comparing ALI (n = 13) and ALI-free (n = 14) patients with sepsis. Soluble adhesion molecules (soluble intracelluler adhesion molecule -1(sICAM-1), sE-selectin and soluble vascular cell adhesion molecule-1(sVCAM-1)), tumor necrosis factor-α(TNF-α) and interleukin-8 (IL-8) in the plasma were measured by enzyme-linked immunosorbent assays. Results: In the comparisons of the soluble adhesion molecule levels between ALI and ALI-free patients with sepsis, the sE-selectin level showed the most significant increase (P < 0.001), and was most strongly correlated with the TNF-α (P < 0.01) and IL-8 (P = 0.001) levels. sE-selectin was more specific factors for ALI, based on their greater areas under the receiver operating characteristic (ROC) curve (P < 0.01). Conclusion: Among the measured factors, sE-selectin appears to be involved in the specific pathophysiology of ALI with sepsis.

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Objective: To investigate the safety and reliability of central venous catheterization (CVC) by means of axillary vein puncture with real-time ultrasound and fluoroscopic guidance. Method: This CVC procedure consists of axillary vein puncture with real-time ultrasound guidance and handling of guidewire, dilator and catheter under fluoroscopy. A series of procedures was performed by a single operator. The number of puncture, the success rate, and the number of mechanical complications were recorded. Results: 45 procedures were performed. The mean puncture time was 1.4. The puncture success rate was 97.8%. The axillaly vein was catheterized successfully in 95.6% of the cases. There were no mechanical complications. Conclusion: This method secured a high success rate with less puncture times and no mechanical complications. Therefore, this can be the more useful alternative technique for CVC than subclavian vein puncture, and has the potential of being established as the safer and more reliable technique of CVC. Further investigations involving more operators are needed.

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Objectives: To evaluate simplicity and reliability of Richmond Agitation Sedation Scale (RASS) at the introduction period of the scale to our emergency and critical care department. Methods: All patients who were mechanically ventilated in the ICU were evaluated with RASS. For 6 months after introduction, RASS scores were compared between those evaluated by nurses in-charge and by educators, with weighted κ statistic. At the end of the data collection period, nurses were asked to answer a questionnaire on usage of RASS. Results: Fifty-nine patients were evaluated with RASS. Trauma was the most common diagnosis, followed by cardiac and gastrointestinal diseases. There was high agreement in RASS scores evaluated by nurses in-charge and by educators, with quite high weighted κ statistic (0.930) in 118 RASS evaluations. Most of answers by nurses to the questionnaire were affirmative to usage of RASS. Conclusions: RASS can be used accurately with a short preparation period. Nurses were able to understand necessity of sedation scales and look after patients became more confidently.

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Objectives: Noise in hospital is recognized as a problem to affect the health of the patients and the staff, but strategies to reduce it and measures for its assessments are not fully established. We acoustically measured and analyzed the noise in pediatric ICU (PICU) which was shown to be the noisiest place in hospital by previous studies. Methods: We measured sound level in PICU of Osaka Medical Center for Maternal and Child Health. Equivalent continuous A-weighted sound pressure level (LAeq) for 5 minutes and peak sound pressure level (LAPK) was measured at 10:00 of consecutive 7 days and every three hours in a weekday. The frequency analysis was performed in 1/3-octave bands in the range of 20∼12,500Hz. Results: LAeq was more than 60 dBA and LAPK was more than 90 dBA at all the mesuring points. The sound pressure level of each 1/3 octave band was similar over the wide range of frequencies, demonstrating the sound pressure level of low frequency was high. Conclusions: Noise in Pediatric ICU exceeded the WHO standard for community noise in specific environments, which may cause the damage to the health of patients and medical staff. Frequency analysis showed noise level of the low frequency was especially high.

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We report a case of acquired hemophilia A associated with retroperitoneal hematoma. The patient was a 75-year-old man. He was transported to our hospital because of transient loss of consciousness and motor paralysis. He exhibited hypovolemic shock state, and CT scans revealed a retroperitoneal hematoma. The prothrombin time (PT) was 27%, PT-international normalized ratio (PT-INR) was 2.09 and the activated partial thromboplastin time (APTT) was 66.7 seconds. Because the prolonged APTT was not corrected when his plasma was mixed with an equal volume of normal plasma, we suspected that the coagulopathy was caused by acquired hemophilia A. Recombinant activated factor VII, corticosteroids, and cyclosporine were effective. Later, we obtained the data demonstrating that the factor VIII activity was less than 1% and the autoantibody to factor VIII was 222.7 Bethesda unit·ml⁻¹. Acquired hemophilia A is a rare disease which causes severe bleeding disorder. In case the APTT was extremely prolonged, we need to suspect acquired hemophilia A. In addition to hemostatic treatment and immunosuppressive therapy, the infection control is important in the management of acquired hemophilia A.

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Some critically ill patients occasionally have delayed gastric emptying by impaired gastric peristalsis. We report the effectiveness of rikkunshito for improvement of delayed gastric emptying in three critically ill patients. Case 1: A 63-year-old woman underwent mechanical ventilation because of severe pneumonia following treatment of Wegener's granulomatosis. Rikkunshito was administered because gastric contents discharged via nasogastric tube increased to 500 ml·day⁻¹ and persisted for a few days. About three days after administration of rikkunshito, regurged gastric volume was reduced. Case 2 and 3 underwent replacement of thoraco-abdominal aortic aneurysm. In the postoperative period under mechanical ventilation, the volume of nasogastric drainage increased to 250∼500 ml·day⁻¹ shortly after enteral feeding had been started via jejunal or gastric tube. About 2 days after administration of rikkunshito, the volume of nasogastric drainage was reduced in these patients. In all three cases, the amount of gastric contents discharged via a nasogastric tube was decreased after administration of rikkunshito, and subsequently enteral nutrition was successfully performed. Rikkunshito has been demonstrated to have beneficial pharmacological effects such as improvement of the gastric peristalsis and increases in blood flow and defensive factors of gastric mucosa. Therefore, it is thought that administration of rikkunshito is effective for improving delayed gastric emptying in critically ill patients.

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We have experienced a case of a large floating thrombus in intact descending aorta. A 47-year-old woman was admitted to our hospital because of lumbago and claudication. Thoracoabdominal CT showed large mobile thrombus. She has no previous history of illness except for the lumbar compression fracture. We started anticoagulation therapy. At the 4th day after the admission, additional anticoagulation therapy with ticlopidine hydrochloride and sarpogrelate hydrochloride were started because of platelet increase in counts. At the 8th day, The CT showed regression of the thrombus and then we added the urokinase. The CT at the 23rd day revealed completely resolved thrombus. Thrombus formation in a morphologically normal aorta is rare. So we discussed the management.

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We report a case of acute disseminated encephalomyelitis (ADEM) complicated by organophosphorus poisoning and lumbar spondylosis. A 62-year-old man with a history of bronchial asthma and prostatic hyperplasia was admitted to our hospital due to weakness of the lower extremities, intestinal obstruction, and disturbance of consciousness. He also experienced myosis and sialorrhea, following episodes of headache and fatigue. Lumbar X-ray CT findings and the history of exposure to organophosphorus compounds indicated lumbar spondylosis and poisoning, respectively. Because of unstable circulation and respiration, he was admitted to the ICU. Ten days later, the patient developed hypesthesia below the level of Th4, and 13 days later, meningeal irritation syndrome was observed. Additional diagnosis based on MRI findings, cerebrospinal fluid analysis, and monophasic process indicated ADEM. In the present case, expansion of the paralyzed area contributed to establishing the diagnosis, although the misleading case history made early diagnosis difficult.

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