Ever since the first report, 65 years ago, of a patient with acute renal failure (ARF) recovering following blood purification (BP) therapy, various methods for BP have been developed and applied in clinical settings. BP therapy has now become as important and indispensable as artificial respiratory support. However, there are numerous issues that still need to be resolved, such as the time of initiation, the mode and the dose of BP, and the materials for the hemofilter membrane. Recently, a new classification for ARF has been established and standardization of the treatment of ARF around the world has begun. The Japanese standard of therapy for ARF appears to be superior to that of the rest of the world. We must therefore construct a database by collaborative research and further detailed investigations. With such collaboration, the Japanese medical standard can come to be recognized around the world. Moreover, we can ride the wave of the standardization of treatment around the world.

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Objectives: A retrospective observational study was conducted to evaluate whether the plasma level of soluble E-selectin, one of the adhesion molecules, might be related to organ dysfunction in patients with systemic inflammatory response syndrome (SIRS). Methods: The data of 52 patients admitted to the ICU with SIRS and initiated on mechanical ventilation were retrospectively evaluated. Results: The plasma levels of soluble E-selectin determined within 24 hours of admission to the ICU were significantly correlated with the Sequential Organ Failure Assessment (SOFA) scores. Furthermore, the scores for respiratory dysfunction (evaluated by the P/F ratio) in the SOFA scoring system were also significantly correlated with the plasma levels of soluble E-selectin. In relation to respiratory dysfunction, the plasma levels of soluble E-selectin were higher in patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS) than in the non-ALI/ARDS patients, and a receiver operating characteristic (ROC) analysis revealed that this parameter might be a specific marker of ALI/ARDS. Conclusions: E-selectin, one of the adhesion molecules, might be closely related to the occurrence of respiratory dysfunction in patients with SIRS.

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Paraneoplastic limbic encephalitis (PLE) causes neurological psychiatric symptoms, seizures, and memory defects due to the immunological mechanism. It is often associated with small-cell lung cancer, germ-cell tumor of the testis and breast cancer. Recently, several cases of anti-N-methyl-D-aspartate receptor antibody positive PLE (anti-NMDAR encephalitis) with ovarian teratoma have been reported. The optimal management of anti-NMDAR encephalitis is regarded as tumor resection and immunotherapy. If the tumor resection is performed promptly, the neurological prognosis is good, but complete recovery takes a long time. We report a 23-year-old woman demonstrating anti-NMDAR encephalitis associated with ovarian teratoma. After the diagnosis, she underwent tumor resection promptly and several kinds of immunotherapy were administered. Although she required long-term intensive care to control seizures, she finally recovered without serious complications. If a young woman with no anamneses shows symptoms of encephalitis, anti-NMDAR encephalitis should be considered. If a tumor is detected, it should be resected promptly. Anti-NMDAR encephalitis has a relatively good prognosis, therefore persistent efforts to control seizures and rigorous medical management to prevent complications are important.

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A patient with liver cirrhosis due to primary sclerosing cholangitis developed spontaneous bacterial peritonitis (SBP) and developed toxic shock-like syndrome (TSLS) caused by Streptococcus pyogenes. In addition to conventional intensive care strategies, continuous hemodiafiltration (CHDF) involving two consoles using a polymethylmethacrylate (PMMA) membrane hemofilter (double PMMA-CHDF) was performed. The patient successfully recovered from refractory shock through improvement of hypercytokinemia. The pathophysiology of TSLS is thought to be hypercytokinemia induced by the reaction of streptococcal pyrogenic exotoxin (SPE), which possesses superantigenic activity with T cell receptor. Therefore, it is suggested that double PMMA-CHDF may have a role in controlling hypercytokinemia irresponsive to conventional treatment strategies.

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We experienced 2 cases of refractory thrombotic thrombocytopenic purpura (TTP) responding to neither plasma exchange (PE) nor rituximab but successfully treated with combination chemotherapy. Case 1: A 49-year-old woman was referred to our hospital with severe anemia (Hb 4.8 g/dl) and thrombocytopenia (platelet 1.1×10⁴ /μl). The diagnosis of TTP was established based on psychoneurotic symptoms and fever that developed after hospitalization. Treatments with PE, steroid plus rituximab, vincristine monotherapy, and cyclophosphamide monotherapy were successively performed, but without clinical benefit. After these treatments proved unsuccessful, CHOP (cyclophosphamide, adriamycin, vincristine, and prednisolone) therapy led to remission of disease. Case 2: A 64-year-old man was referred to our hospital with thrombocytopenia (platelet 0.9×10⁴ /μl). Progressive psychoneurotic symptoms, hemolytic anemia, thrombocytopenia, and fever led to the diagnosis of TTP. A disintegrin-like and metalloprotease with thrombospondin type I motif 13 (ADAMTS13) activity was below 0.5%, and an inhibitor of ADAMTS13 was detected. Treatment with PE and rituximab was successively performed without clinical benefit. After these treatments proved unsuccessful, COP (cyclophosphamide, vincristine, and prednisolone) therapy led to remission of disease. Intensive combination chemotherapy appears to be effective in treating TTP refractory to both PE and rituximab therapy.

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Vancomycin administered through the oral route is not usually absorbed from the intestinal mucosa into blood. However, serum vancomycin levels were elevated after oral administration in 2 patients with ileocolitis and renal dysfunction. Case 1: A 61-year-old female developed severe sepsis after undergoing autologous peripheral blood stem cell transplantation for malignant lymphoma. She was orally administered 0.5 g of vancomycin for diarrhea associated with Clostridium difficile infection every 6 hrs before ICU admission. In addition, she was intravenously administered 0.5 g of vancomycin twice per day for the prevention of methicillin-resistant Staphylococcus aureus infection. The patient was admitted to the ICU, and continuous hemodiafiltration (CHDF) was started for renal dysfunction. Intravenous administration of vancomycin was stopped after serum vancomycin concentration reached 33.7μg/ml (trough); subsequently, the serum vancomycin concentrations after 2 and 7 days were 43.5 and 45.0μg/ml, respectively. After the discontinuation of oral administration, the serum concentration of vancomycin decreased gradually. Case 2: A 63-year-old female who had taken prednisolone for idiopathic thrombocytopenic purpura and autoimmune hemolytic anemia was diagnosed with paralytic ileus and sepsis. She had developed severe diarrhea due to Clostridium difficile infection. Further, she had renal dysfunction, for which CHDF was started. The patient was orally administered 0.5 g of vancomycin every 6 hrs; subsequently, the serum concentration of vancomycin after 10 days was 10.3μg/ml. It can be assumed that vancomycin is absorbed from the intestinal mucosa and accumulates in the blood of these patients with ileocolitis and renal dysfunction. Hence, it is important to therapeutically monitor the serum vancomycin concentrations when administering the drug orally to patients with ileocolitis and renal dysfunction.

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We report on the perioperative management of a 38-year-old-female with severe pulmonary hypertension (PH) associated with systemic lupus erythematosus (SLE). The patient had been diagnosed with SLE 12 years ago and developed PH 9 years ago. She had a history of several hospitalizations for acute exacerbations of PH and was receiving home oxygen therapy. In April 2008, she underwent left total hip arthroplasty under general anesthesia for femoral head necrosis. Postoperatively she developed an acute exacerbation of PH and cor pulmonale, and she died of sudden circulatory collapse on postoperative day 2. Treatment with sildenafil during the postoperative period had transiently improved her right ventricular failure as a result of its selectively dilating effect on the pulmonary arteries, but it was suspected of causing the circulatory collapse because of interactions with concomitant drugs.

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[in Japanese]

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[in Japanese]

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Objective: Disseminated intravascular coagulation (DIC) is a serious complication associated with various underlying disorders, including sepsis. The aim of the current study was to investigate the status of therapy for patients with sepsis-induced DIC and to examine the association between 28-day mortality and use of anticoagulants. Methods: A multicenter cross-sectional study was performed from January 1, 2007 to December 31, 2008 in 45 ICUs in Japan. Using administrative data, 579 cases of sepsis-induced DIC were identified among patients who were admitted to an ICU, and these cases were used to assess the status of DIC therapy. The 28-day mortality was adjusted for the Critical care Outcome Prediction Equation (COPE) score, the Charlson comorbidity index and patient age, and associations with anticoagulants were then examined. Results: Protease inhibitors were used in 413 cases (71.3%), and antithrombin, unfractionated heparin, and low molecular weight heparin/danaparoid were used in 313 (54.1%), 385 (66.5%) and 201 (34.7%) cases, respectively. The overall 28-day mortality was 37%. In a Cox proportional hazards regression model, the hazard ratio (HR) of unfractionated heparin was 1.41, with a significant adverse effect on mortality (P=0.02). In a similar analysis, the HRs for protease inhibitors, antithrombin and low molecular weight heparin/danaparoid were 0.86, 0.90 and 0.88, respectively. These agents showed a tendency to reduce 28-day mortality, but the effect was not significant. Conclusions: A review of administrative data revealed that protease inhibitors were most frequently used in DIC anticoagulation therapy in ICUs in Japan. Unfractionated heparin was the only therapy to have a significant adverse effect on mortality.

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Central venous catheterization (CVC), which is one of the important therapeutic procedures for critically ill patients, has some possibility of serious complications such as pneumothorax, hemothorax and catheter-related infection. Since May 2007, we started to establish a safe CVC system in Gunma University Hospital. It based on following 4 fundamental rules; (1) CVC should be performed by the experienced and certified doctors, (2) Seldinger's technique should be taken for CVC, (3) examination of the anatomical position of vessels using ultrasound device should be done prior to CVC, (4) CVC in day surgery unit is recommended. In this paper, we introduce the system for CVC in Gunma University Hospital.

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