The outcome of critical care includes not only physical recovery, but also psychological recovery. Neuropsychological issues such as post-traumatic stress disorder (PTSD) and neurocognitive impairment following intensive care are major issues impeding quality of life in patients. Recent studies have indicated that approximately 10% of the post-ICU patients have PTSD and related symptoms including intrusion, avoidance, and hyperarousal. Several studies have suggested that sedation management and delusional memory affect the development of PTSD symptoms. Neurocognitive impairment often occurs in patients following intensive care, although it is often unrecognized. Some evidence has suggested that delirium in the ICU is one of the risk factors of PTSD and neurocognitive impairment. Improvements in sedation management might play an important role in preventing these issues.

View full abstract

Various ventilatory modes have been proposed and evaluated in clinical settings in parallel with advances in the engineering of ventilators and knowledge of the pathophysiology of respiratory failure. Synchrony between spontaneous and mechanical breathing, a reduction in the workload required for breathing, and comfort are the most important factors when mechanical ventilation is performed to assist spontaneous breathing. However, the ventilatory modes should also be evaluated with regard to lung protection to avoid ventilator-associated lung injury in patients with hypoxemic respiratory failure, such as those with acute respiratory distress syndrome. At present, no mode is regarded as superior to the others, partly because of insufficient clinical data. Clinicians should select a ventilatory mode after considering the advantages and disadvantages associated with each mode.

View full abstract

Objectives: To describe the clinical course and outcomes of patients with lower intestinal perforation (LIP), and determine the risk factors for increasing disease severity. Methods: We reviewed the clinical records of patients with LIP admitted to the ICU after emergency surgery, between April 2006 and March 2008. We analyzed the demographic data, clinical and laboratory data, severity of illness on ICU admission, and the incidence of organ dysfunction. The outcome measures were ventilator-free days, ICU-free days (IFD), and the 28-day mortality. The risk factors for the shortening of the IFD, as a surrogate marker of increase in the severity of LIP, were assessed by Spearman's correlation and multivariate logistic regression analysis. Results: Of the 50 patients with LIP enrolled, 20 (40%) developed shock, 12 (24%) had disseminated intravascular coagulation and renal dysfunction, and 10 (20%) had acute lung injury or acute respiratory distress syndrome, within 5 days after ICU admission. The overall 28-day mortality was 6.0 %. The multivariable logistic regression analysis identified the Sequential Organ Failure Assessment (SOFA) score (odds ratio, 1.85; P = 0.025) and leukopenia (odds ratio, 20.6; P = 0.016) as independent risk factors for the shortening of IFD. Conclusions: Shock and coagulopathy are common in the acute postoperative phase in patients with LIP. The SOFA score and leukopenia on ICU admission are associated with critical illness in patients with LIP.

View full abstract

Objectives: To find out whether the depth of chest compression during infant cardiopulmonary resuscitation reached the target value. Methods: Ten residents in our department who are American Heart Association–Basic Life Support/Pediatric Advanced Life Support (AHA-BLS/PALS) providers performed chest compressions to target depths of 1/3 (33 mm) of anterior-posterior (AP) chest diameter on a specially made infant chest compression measurement simulator. The actual depths of compression delivered was measured. The measurement was repeated after feedback and the results were compared. Results: The actual compression depths before feedback were considered to be insufficient as they were significantly too shallow, 30.0 ± 4.2 mm (91% of the target value). After feedback, compression depths statistically improved to 32.4 ± 1.5 mm (98%) (P = 0.016), and showed smaller compression variations. Conclusions: It was shown that the actual chest compression depths delivered tended to be shallower than the target value when target value of 1/3 was used on infant manikins. Performance improved after feedback. To obtain quality performance during infant cardiopulmonary resuscitation, it is important to give appropriate feedback on the actual depth of chest compression delivered.

View full abstract

Bronchoalveolar lavage (BAL) was performed in 5 patients with acute respiratory distress syndrome (ARDS; ARDS group hereafter) and 2 patients with respiratory failure (non-ARDS group hereafter) within 3 hours of intubation before ARDS treatment other than mechanical ventilation. ARDS was diagnosed based on the criteria defined by the American-European Consensus Conference. BAL fluid (BALF) and sera samples were obtained on the same occasion. The presence of 17 cytokines/chemokines in these specimens was simultaneously determined using a Bio-Plex^® Suspension Array System. The levels of these cytokines/chemokines in BALF and sera samples were compared between the ARDS group and the non-ARDS group. The levels of chemokine granulocyte colony-stimulating factor (G-CSF), monocyte chemoattractant protein-1 (MCP-1) (monocyte chemoattractant factor), and macrophage inflammatory protein-1β (MIP-1β) in the BALF samples were significantly higher in the ARDS group than in the non-ARDS group. The level of pro-inflammatory cytokine interleukin (IL)-6 in BALF was also higher in the ARDS group than in the non-ARDS group. In contrast, the levels of IL-1β and IL-8 in BALF were higher in the non-ARDS group than in the ARDS group. The levels of these cytokines in BALF were higher than the corresponding sera levels in both groups. These results indicate that severe initial alveolar injury significantly activates chemokines in patients with ARDS caused by direct lung injury (such as pneumonia), unlike the increased levels of the inflammatory cytokines IL-1β and IL-8 in BALF of patients with early ARDS.

View full abstract

This is a report of the case of an 18 year-old woman who was admitted to a psychiatric hospital for anorexia nervosa. After admission, hypoglycemic coma developed as a complication, and although she recovered from the coma in response to intravenous glucose administration, an ultrasonic echocardiogram (UCG) demonstrated takotsubo cardiomyopathy. Because the patient's serum phosphate level had decreased to 0.9 mg·dl⁻¹, she was diagnosed with refeeding syndrome and admitted to the ICU. Artificial feeding (both enteral and parenteral), early supplementation with phosphorous, and other electrolytes were started at a reduced calorific rate. The patient recovered, and she was discharged to a general ward on ICU day 16. When nutrition is started after prolonged starvation, it is important to start at a reduced calorific rate and to monitor vital signs, electrolyte levels, and water balance closely in order to prevent refeeding syndrome.

View full abstract

Four cases of thyroid crisis are herein reported. The prompt diagnosis and immediate treatment resulted in all 4 patients achieving a complete recovery from the crisis. However, one patient unfortunately died from hypoxic encephalopathy which had been caused by cardiopulmonary arrest during transportation to our hospital. As pointed out in the previous studies, all 4 patients showed signs of cardiac decompensation during the treatment. Based on the findings of these present cases as well as those of previous reports, we would like to emphasize the need for strict hemodynamic monitoring of all patients associated with thyroid crisis. Moreover, we believe that it is extremely important to evaluate the thyroid function when trauma patients demonstrate persistent and unusual tachycardia and pyrexia after the onset of injury.

View full abstract

Anorexia nervosa (AN) is a potentially fatal condition that requires critical care management during the course of treatment. Recently, we treated 2 female patients with AN who developed hypophosphatemia during their stay in the ICU. The patients were aged 55 and 31 years. In course of time, they had developed consciousness disturbance while staying at home and were transferred to our hospital. On arrival, both the patients were in a state of shock. In spite of the measures taken to correct hypotension and hypoglycemia, their consciousness levels did not improve. As a result, they were admitted to the ICU. Both the patients showed low levels of interleukin-6 (IL-6) in blood tests, despite the septic shock. At first, their blood phosphorus levels were high. However, the phosphorus levels decreased sharply when nutritional support was started; this indicated a severe deficiency of phosphorus in their bodies. Both the patients responded well to the treatment, and they were transferred to general wards within 5 days. These results suggest that a mechanism involving modifications in the secretion pattern of IL-6 could explain some of the observations regarding the immunosuppressive function in underweight AN patients. We concluded that the restriction of energy intake, frequent monitoring of blood phosphorus levels, and phosphorus replenishment were important in the nutritional management of patients with AN.

View full abstract

We investigated 12 patients who entered ICU after cesarean section due to bleeding and needed allogenic transfusions during a period from January 2005 to April 2008. The average age of the 12 subjects was 33 years. The 12 included 4 patients with placental abruption, 2 patients with uterine atony, 2 patients with placenta previa, 2 patients with placenta accreta, 1 patient with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, and 1 patient with uterine rupture. Eight of the patients developed obstetric disseminated intravascular coagulation (DIC) as a complication. The average ICU stay period was 3 days, and the average hospitalization period was 20 days. All patients were successfully discharged from the hospital. The average transfusion volume of red cell concentrates, fresh frozen plasma, and platelet concentrates was 18, 15, and 18 U, respectively. Seven patients required hemostasis. Three patients received only transcatheter arterial embolization (TAE), 2 patients received only total hysterectomy, 1 patient received emergency total hysterectomy due to hemorrhagic shock during TAE, and 1 patient received TAE due to continuous bleeding after total hysterectomy. Establishment of a cooperative system among obstetricians, ICU physicians, anesthesiologists, and radiologists in addition to a system for emergent blood transfusion is recommended.

View full abstract

We report a case of anaphylactic shock in patients on β-blockers. It was difficult to treat anaphylactic shock, and the patient lapsed into cardiopulmonary arrest. A 65-year-old man was stung by a bee and anaphylaxis caused fatal shock to him. Seven months ago, he had experienced acute myocardial infarction. During that hospitalization, treatment of β-blocker therapy was initiated. Intramuscular and intravenous injection of epinephrine were not effective. The patient lapsed into cardiopulmonary arrest after being carried into emergency room. Cardiopulmonary resuscitation and a large amount of epinephrine administration resulted in return of spontaneous circulation. It was considered that β-blocker drug that was medicated since hospital treatment affected epinephrine therapy. If anaphylaxis occurs in a patient receiving a β-blocker drug, it should be treated with increased dose epinephrine such as 2 to 5 times more at each injection than the usual dose of anaphylactic shock.

View full abstract

The objective of this study was to investigate physician staffing and patient outcome in Japanese ICUs. ICU physician staffing, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and patient outcome were prospectively collected from 178 ICUs in October 2007. Physicians were not present at 10:00 AM in 21% of the ICUs, and this percentage increased to as much as 36% during the nighttime. The peak of the distribution of APACHE II scores was 11 to 12. The measured mortality was lower than the predicted mortality based on the APACHE II score. ICU physician staffing varied significantly among the ICUs. To improve the quality of critical care in Japan, ongoing data collection is needed to determine the factors related to patient outcome.

View full abstract