Numbers of clinical trials have been performed to establish the standard therapy for severe sepsis in the recent years. However, many of them have reported the inconsistent results from which had ever reported: 1) Intensive insulin therapy –effectiveness for severe sepsis could not be proven in a randomized controlled study (RCT) named VISEP, so that it won't be recommended to control the glucose level in the normal range strictly. 2) Steroids–CORTICUS failed to show the effectiveness of physiologic dose of hydrocortisone on survival in septic shock patients. 3) Intravenous immunoglobulin–although SBITS, the only one large scale RCT did not show the benefit of intravenous immunoglobulin on survival, the following systemic reviews supported its efficacy. 4) Recombinant human activated protein C (rhAPC) –survival benefit was reported in a recent large scale database. However, the other systematic review reported the contradictive result. Its efficacy is still controversial, but since the bleeding tendency is significant, the use of rhAPC should be limited in the life-threatening severe sepsis. Further studies should be needed to address the above issues. In summary, we have to understand that some parts of the guideline are based on the inconsistent evidences, and further blush up is required.

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Recently, less-invasive cardiac output monitors have been paid much attention for better management for critically ill patients instead of conventional thermodilution method with pulmonary artery catheter. However, adequate assessment of accuracy of these less-invasive monitors is warranted. Statistical method described by Bland and Altman should be applied to adequately assess agreement between two different methods for cardiac output measurement. However, several cautions must be paid to undergo or interpret Bland-Altman analysis. First, criteria to accept interchangeability remains to be concretely defined. Since the conventional thermodilution method demonstrates significant variation around 20%, the similar degree of variations is widely accepted. However, more liberal criteria may be acceptable. Another approach that more than 75% of bias measurements were within ±20% of the mean may be used. Second, special statistical handling is required if the repeated measurements per individual were made. In this commentary article, these important aspects of Bland-Altman analysis are reviewed.

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Background: One study showed that the difference (DCO₂) between central venous (PvCO₂) and arterial carbon dioxide tension (PaCO₂) inversely and strongly correlated with cardiac index (CI). We carried out to determine whether DCO₂ was alternative for CI. Methods: Twenty patients with central venous catheter were included for the study. On the next day after admission to ICU, we sampled the arterial blood and central venous blood for measurement of DCO₂. Simultaneously, we measured cardiac output (CO) by dye dilution method and calculated CI. We evaluated the correlation between DCO₂ and CI. Result: The correlation (r² = 0.509, P = 0.03) was significant in the only low CI patients (CI < 2.5 l·min⁻¹·m⁻¹), but not in normal CI patients. Conclusion: The present results suggested that DCO₂ might not be the alternative method for CI.

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Although remarkable progress has been made in the treatment of fulminant hepatic failure (FHF) in recent years, selection or indication for blood purification therapy and liver transplantation remains difficult because of the difficulty in accumulating cases and lack of the volume of pediatric FHF. We report 10 cases of pediatric FHF encountered at the National Center for Child Health and Development during the last 2 years. Eight cases survived, and living-related transplantation was performed in 7 cases. This report highlights the importance of a multidisciplinary team approach for the management of pediatric FHF in the pediatric critical care setting with timely transplantation as a backup option.

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We experienced a 67-year-old woman with pheochromocytoma representing as takotsubo cardiomyopathy. The patient was admitted to our hospital with nausea and vertigo. Three days after admission she complained of discomfort in her chest and ST elevation was observed. We suspected acute coronary syndrome, and an emergent cardiac catheterization was performed. The coronary angiography revealed no obstructive coronary lesion, however, apical ballooning was observed on the left ventriculography. She was diagnosed as having takotsubo cardiomyopathy and admitted to ICU. We started to control her tachycardia with landiolol, an ultra-short acting β-1 adrenoceptor antagonist. Thereafter, she continued to vomit and we gave her intravenous droperidol. After that, her blood pressure decreased immediately and her heart rate increased. We tried to treat it with fluid resuscitation and phenylephrine, but it was insufficient. As a result, we increased the dosage of landiolol, and it was effective for stabilizing her hemodynamics. We started oral administration of propranolol and decreased intravenous landiolol. Her hemodynamic state became stabilized, and she was able to be discharged from ICU. However she died due to severe metabolic acidosis and disseminated intravascular coagulation following the development of intestinal ischemia. Pathological findings revealed pheochromocytoma on her left adrenal gland. Contraction band necrosis that was found at the endocardium of her left ventricle apex suggested brief vasospastic episodes of occlusion followed by vasodilatation and reperfusion. We speculated that coronary microvascular spasm caused by catecholamine overproduction might have contributed to the abnormality of the left ventricle wall motion, and landiolol might have improved it.

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We report a 62-year-old female case of septic shock after percutaneous nephrolithotripsy (PNL). Because she developed hypotension, blood clotting abnormality, and respiratory failure on the next day, she was transferred to the ICU and diagnosed septic shock. She subsequently developed acute respiratory distress syndrome. We began respiratory support, and administered catecholamines and antibiotics. Her general condition recovered gradually and she was weaned from respiratory support on the 10th day. Septic shock after PNL is very rare and is caused by bacteria in the calculus and pyelovenous bacterial contamination due to the elevation of renal pelvis pressure. Although PNL is not so invasive, septic shock may happen, needing intensive care.

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Serum CK levels that represent the severity of rhabdomyolysis are considered to be correlated with the development of acute renal failure. Here we report 2 cases of extreme rhabdomyolysis caused by hyponatremia and ethanol intoxication, in which peak serum CK levels were 541,300 and 621,912 IU·l⁻¹, respectively. They were resuscitated with crystalloid solution under strict monitoring of urine volume and renal function, and did not develop acute renal failure during the course. No other specific treatments were required. Acute physiology and chronic health evaluation (APACHE) II scores in these 2 cases were 11 and 2 points, respectively, and both patients met the criteria of systemic inflammatory response syndrome (SIRS) only on the first day of admission. It is suggested that the development of acute renal failure in rhabdomyolysis mainly depends on the initial severity of the disease as indicated by APACHE II score or persistent systemic inflammation as indicated by the duration of SIRS rather than the severity of muscle destruction.

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