Background: Fever is common in critically ill patients. Antipyretic therapy for fever is routinely performed in intensive care. However, there is not sufficient information on how body temperature should be controlled in non-neurological critically ill patients (ICU patients). Methods: We have conducted a systematic review of the literature to assess the impact of fever and antipyretic therapy on mortality in ICU patients. Results: Our literature search retrieved twenty-seven articles. Review of these articles revealed that 1) fever is associated with increased mortality, 2) among ICU patients with infection, fever may be associated with decreased mortality, 3) there have been no observational studies to assess the relationship between fever and mortality in ICU patients in which information on antipyretic therapy was included, 4) aggressive antipyretic therapy (starting when body temperature is >38.5 degrees Celsius) tends to increase mortality. Conclusions: Data on fever and antipyretic therapy in ICU patients are insufficient to guide a choice of therapy. A randomized controlled trial would be ethically difficult to conduct. Large multicenter observational trials are needed to understand the interaction among fever, antipyretic therapy and outcomes in ICU patients.

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The rapid and accurate detection of causative pathogens, infective foci, and the severity of illness are specifically important for diagnostic strategies for infection in critical care settings. Difficulties in obtaining appropriate samples and/or the time required for traditional microbiological culture methods have been undesirable. Procalcitonin (PCT) or soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) have a relatively higher diagnostic ability compared with traditional biomarkers for infection, such as CRP or neutrophil counts. A meta-analysis, however, revealed that no single biomarker can be used for the definite diagnosis of infection. A PCT-guided treatment algorithm could become an option for curtailing excess antimicrobial use without affecting mortality. No other new biomarkers that have been developed experimentally or clinically have been established for clinical utilization. Intensivists should recognize that a comprehensive pathogen-directed diagnostic approach remains central but should be supplemented with currently available microbiological diagnosis in combination with an appropriate assessment of current biomarkers and the severity of each patient's illness.

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The acceptance of a manuscript for publication in a scientific journal is an indication that the contents of the manuscript have been approved by the scientific journal on the basis of current scientific validity. The approval is made through the process of peer review in which a few scientists who are experts on the manuscript's contents review the manuscript. Reviewers spend a lot of time on evaluating each manuscript, and in such a sense, peer review entails much hard work. Reviewers offer valuable advice for free because they have an intense passion for the development of their area of research. In this regard, peer review is the fundamental basis of science. The main component of a scientific journal is original papers. In each original paper, the authors propose a clear hypothesis, test the validity of the hypothesis with the methods they adopt, and clearly state whether the hypothesis is valid or not. The evaluation of a scientific journal should be made on the basis of the quality, importance, and strength of the published papers and not the impact factor.

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An original article contains several sections: Abstract, Introduction, Materials and Methods, Results, Discussion, Conclusions, References, Tables, Figure legends, and Figures. The order of writing should be as follows: Materials and methods, Results with Figures/Tables, Discussion with Conclusions, and Introduction. No results should be included in Materials and methods section. Figures and Tables should be presented according to the target journal's style guidelines. Correct Figure legends and titles for all tables are very important for presenting the contents of the article. In Discussion, authors should discuss their own data and should not talk about general issues, keeping in mind that over-speculation should be avoided. It is easier to write Introduction after completing the other parts. Other papers should only be referenced if they have been understood completely. Structured abstract is an independent section and is composed of four sections: Objective, Materials and methods, Results, and Conclusions. Finally, “Instructions for Authors” of the target journal should be read and completely understood.

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Objectives: While it is known there is a poor prognosis for medical ICU patients who require reintubation after failed extubation, no data exist for emergency center ICU patient outcomes. Preliminary study to reduce failed extubation, we examined indications for mechanical ventilation, rates of extubation failure, time to reintubation, the etiology for extubation failure, and outcomes in emergency center ICU patients. Methods: During an 18-month period, this university hospital retrospective cohort study collected data from patients admitted to the emergency center ICU who were mechanically ventilated by an endotracheal tube for more than 6 hours. Extubation failure was defined as reinstitution of mechanical ventilation within 72 hours. Results: Causes leading to mechanical ventilation in 114 intubations included pulmonary 18 (15.8%), cardiac 11 (9.6%), neurologic 23 (20.2%) and other 62 (54.4%). A total of 12 out of 114 (10.5%) required reintubation due to failed extubation (time to reintubation: 1.5 (1.0–7.8) hours). Reintubation was airway-related in 11 patients, and nonairway-related in 1 patient. Out of these 12 patients, 1 (8.3%) died. Conclusions: As compared to medical ICU patients, the extubation failure rate was similar, the time to reintubation was shorter, and there was a lower mortality of failed extubation. While pulmonary and cardiac factors were minor causes of the mechanical ventilation, the major etiology for reintubation was airway-related. Current findings are in contrast to that normally seen for medical ICU patients, and thus, lower mortality rates might exist in emergency center ICU patients.

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We report the case of a patient with severe anaphylactic shock that was successfully treated with vasopressin. A 55-year-old male patient, who was scheduled for esophagectomy, developed anaphylactic shock by the administration of corticosteroid and antibiotics after the induction of general anesthesia. His blood pressure gradually decreased, and cardiopulmonary resuscitation (CPR) was promptly initiated. Intravenous adrenaline (1 mg, 9 times) had no effect on cardiac arrest. After injection of 20 IU of vasopressin, spontaneous circulation was restored. Intra-aortic balloon pumping and percutaneous cardiopulmonary support (PCPS) were needed to stabilize the patient's hemodynamics. The patient's hemodynamic state and oxygenation gradually improved, and PCPS was terminated on the 4th postoperative day (POD) and extubated on the 8th POD. He showed no neurological deficit because of immediate initiation of CPR and PCPS.

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We experienced a case of Vibrio vulnificus necrotizing fasciitis in a patient with a history of total gastrectomy and splenectomy. Successful treatment was achieved by a combination of bilateral lower extremity amputation and direct hemoperfusion using polymyxin B immobilized fiber (PMX-DHP). A 67-year-old woman was transferred to our intensive care unit with bilateral lower extremity cellulitis and sustained septic shock. She had eaten raw seafood the night before. Based on the patient's history and the characteristic skin lesions, we suspected necrotizing fasciitis caused by Vibrio vulnificus infection. Fluid resuscitation, antibiotic therapy, and intravenous catecholamine administration were initiated. Amputation of the bilateral lower extremities was performed 8 hours after admission because of sustained shock and progressive gangrenous changes at the level of the knees. PMX-DHP was performed twice after surgery. The patient's hemodynamic state improved after the second PMX-DHP; she was extubated on the 8th hospital day, and catecholamine was tapered off on the 9th hospital day. On the 12th hospital day, the patient's general condition had improved and she was transferred to an affiliated hospital for rehabilitation. We suspect that her history of gastrectomy and splenectomy might have been a risk factor for Vibrio vulnificus infection. In addition, we consider that surgical resection of the focus of infection might be the only possible life-saving therapy in cases of Vibrio vulnificus infection.

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A 66-year-old female presented with progressive left-sided chest pain. The electrocardiogram (ECG) showed changes typical of an anterior wall myocardial infarction. She immediately underwent coronary angiography which revealed normal coronary arteries. Cardiac MRI (CMR) was then performed, which showed diffuse high intensity on T2-weighted images and transmural late gadolinium enhancement (LGE) in the apical wall. While transmural LGE was not typical for myocarditis, the patient was diagnosed with acute myocarditis based on the clinical and angiographic findings in addition to the high intensity of T2-weighted image. During the course of the disease, the apical wall developed an aneurysm corresponding to the area of transmural LGE on CMR and an intraventricular thrombus formed in the aneurysm. She was given heparin and discharged after resolution of the thrombus. Further evaluation is warranted if this uncommon imaging finding is detected to prevent thromboembolic complications.

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A previously healthy 37-year-old woman was diagnosed with acute myocarditis and admitted to the local hospital. Despite maximal inotropic support she became hypotensive, requiring introduction of intra-aortic balloon pumping (IABP). Subsequently, she was transferred to our hospital for further treatment, where she was diagnosed with cardiogenic shock and multiple organ failure. She required intubation, following which percutaneous cardiopulmonary support (PCPS) and continuous hemodiafiltration were introduced. Four days of support with PCPS did not affect cardiac recovery, and we implanted a left ventricular assist device (LVAD) on day 5 after admission. A right ventricular assist device (RVAD) was added because her right ventricular function had deteriorated. Her cardiac function gradually recovered, and she was successfully weaned from both LVAD and RVAD on postoperative day (POD) 11. We could remove IABP on POD 14. She was weaned from the respirator on POD 24, discharged from ICU on POD 29, and was weaned from hemodialysis on POD 49. After rehabilitation, the patient was discharged from our hospital on POD 102. VAD may provide strong mechanical circulatory support for patients with fulminant myocarditis, which is resistant to conventional therapy including IABP or PCPS. Early induction of VAD is recommended before organ failure advances.

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A 62-year-old woman with an unremarkable medical history was admitted to our hospital with severe diarrhea and frequent vomiting. She was diagnosed with infectious colitis and dehydration, and was subsequently treated with adequate fluid management; however, her clinical condition did not improve. Laboratory findings indicated the presence of thrombocytopenia, renal insufficiency, and rhabdomyolysis. Her serum ferritin level was extremely high, and bone marrow aspiration showed evidence of phagocytic histiocytes. Based on these findings, the patient was diagnosed with hemophagocytic syndrome (HPS) and treated by intravenous administration of prednisolone, following which her condition improved drastically the next day. HPS is a rare condition characterized by high fever, hepatosplenomegaly, multiple organ dysfunction, coagulopathy, and pancytopenia. It is caused by cytokine overproduction, resulting in uncontrolled hemophagocytosis, and can be classified as primary or secondary depending on various clinical conditions. HPS with viral infections or malignant lymphoma is well documented. This report describes a rare case of secondary HPS associated with bacterial colitis and demonstrates that unexplained fever, thrombocytopenia, and multiple organ dysfunction should be investigated to eliminate the possibility of HPS in critical care settings.

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Extracellular glutamate concentration was measured continuously to detect ischemia of compressed brain tissue after evacuation for acute subdural hematoma. In case 1, the extracellular glutamate concentration was still normal in the compressed brain tissue on the side of the injury when the measurement was commenced. The glutamate levels on the opposite side and intracranial pressure were also still normal at the same time point. The glutamate levels on the injury side began to rise later, from 2 hours after the measurement was commenced. The intracranial pressure increased to 20 mmHg by 2 hours from the elevation of the glutamate levels on the side of the injury, in parallel with the elevation on the opposite side. Brain CT showed no new traumatic lesions and showed brain edema in the compressed brain tissue on the injury side. Cerebrospinal drainage and diuretics were administrated. As observed in case 1, the extracellular glutamate concentration in case 2 was already elevated on the injury side when the measurement was commenced. Yet in this case, the glutamate levels returned to normal within 3 hours. The glutamate levels on the opposite side and intracranial pressure also remained normal. Microdialysis monitoring is useful to detect ischemia of compressed brain tissue after evacuation for acute subdural hematoma. We need to further study the usefulness of extracellular glutamate concentration measurement by microdialysis in patients in the same clinical setting.

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A 5-year-old child suffering from fever, vomiting and convulsions was transported to an emergency medical center. He was administered anticonvulsant and performed tracheal intubation. A diagnosis of acute encephalopathy caused by 2009 influenza A (H1N1) was made, and the child was admitted to our hospital. He was admitted to the ICU and initiated on mechanical ventilation under sedation and treatment of brain edema. After that he never had convulsions. On hospital day 7, he woke up under administration of only dexmedetomidine, and extubation was performed. However, thereafter, the child developed stridor suggestive of upper airway stenosis, labored breathing with intercostal retraction, and tachypnea. Therefore, noninvasive positive pressure ventilation (NPPV) was initiated using a helmet (CASTER “R” for children). There was little air leak, and the respiratory condition showed prompt improvement. There were no problems with the use of helmet NPPV, and we could communicate successfully with the child and hear his voice. The following day, he could be weaned off from the NPPV, and re-intubation could be avoided. These findings suggest that the helmet may be a useful device for NPPV in children, because it doesn't appear to give rise to a feeling of suffocation, and has high acceptability even among children.

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Adult-onset Still's disease (AOSD) is a systemic inflammatory disease characterized by a high spiking fever with an evanescent rash, arthritis, and multiple organ involvement. Cardiopulmonary manifestations of AOSD include pericarditis and pleuritis, but myocarditis is rare. We report a 39-year-old man with AOSD who was diagnosed while hospitalized for myocarditis. The patient presented with diarrhea and vomiting and was admitted to a neighborhood hospital. On the following day, an electrocardiogram showed a diffuse ST elevation, and an elevated troponin T level was observed. Because coronary angiography did not reveal any abnormalities, myocarditis was suspected. The patient developed hypoxia and pulmonary effusion, so mechanical ventilation (MV) and intra-aortic balloon pumping (IABP) were initiated. The patient was transferred to our hospital and admitted to the ICU with IABP and MV. Shortly thereafter, percutaneous cardiopulmonary support (PCPS) was initiated. A myocardial biopsy led to a diagnosis of myocarditis. The patient's cardiac function improved thereafter. The patient was weaned from PCPS and IABP on the 3rd and 4th ICU days, respectively, however, MV was continued because of tachypnea caused by a high fever. On the 5th ICU day, a rash appeared and spread to the proximal limbs and trunk. After ruling out infections and malignancies, the patient was diagnosed as having AOSD, and treatment with corticosteroids was initiated on the 14th ICU day. The patient's fever improved, and his respiratory rate decreased. The patient was weaned from MV on the 20th ICU day, and discharged to the general ward on the 23rd ICU day.

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Bacillus cereus (B. cereus) is a gram-positive aerobic or facultative anaerobic spore-forming bacterium. It is known as a casual agent of food-borne disease, and causes a self-limiting gastroenteritis. A few cases of fatal encephalopathy due to emetic toxin of B. cereus have been reported in the literature. We report a patient who developed B. cereus-associated encephalopathy in Japan. A 5-year-old boy developed acute gastroenteritis after eating fried rice that had been prepared a day before. Within an hour, he vomited five times and developed generalized tonic convulsions. He had fever and was comatose upon admission. A fecal culture revealed B. cereus, and he was diagnosed with acute encephalopathy. Intracranial pressure (ICP) was monitored after admission, and was maintained lower than 20 mmHg with cerebral perfusion pressure (CPP) above 45 mmHg. The ICP was controlled by whole-body hypothermia, barbiturate infusion, and osmotic diuretics. Although his life was saved, he exhibited severe neurological defects. In the present case, it was difficult to control ICP. ICP monitoring may have significantly contributed to control ICP/CPP, and, by doing so possibly avoided complications of B. cereus encephalopathy. We conclude that ICP monitoring in patients with encephalopathy is useful for detecting aggravation of brain edema and may improve prognosis.

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We investigated the disaster preparedness of intensive care units at several institutions. Preparations for disasters such as power blackouts, abruption of water and gas supply had been made at many institutions. Reinforced settings for medical equipment in the event of earthquakes as well as preparations for resuscitation equipment were also in place. A manual outlining the command and control systems to be followed in times of disaster was available in most hospitals. However, whether such manuals are adequately thorough is not commonly known. A few hospitals had prepared a manual specifically for their ICU, but less than half of the institutions performed disaster training. Additional measures for outbreaks of critical infectious diseases, such as influenza pandemics, are needed.

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Background: The novel influenza A (2009-H1N1) pandemic caused acute respiratory distress syndrome (ARDS) in some patients, who were treated with mechanical ventilation or extracorporeal membrane oxygenation (ECMO). Objective: To clarify the outcome of critical care for patients infected with 2009-H1N1 in Japanese ICU. Design, Setting, and Patients: An observational study using database information. Sixty-seven participating 67 ICUs in Japan were enrolled. The number of patients was 219 people. Results: Children (under 16 years of age) accounted for 162 patients (median age of 6 years; IQR (interquartile range): 5 to 9 years), adults (16 years of age or older) accounted for 57 patients (median age of 43 years; IQR: 31 to 56 years). Among the adults, the median Acute Physiology and Chronic Health Evaluation (APACHE) II score was 19 (IQR: 15 to 23). Among the adults, 35.7% (20/56) had a body mass index (BMI) of more than 25. Two patients were pregnant. The percentage of adults with underlying disease was 16.4% (9/55). The percentage of children with an underlying disease was 3.7% (6/162). The overall mortality rate among children was 2.5%, with 95% confidence interval (CI) of 0.7 to 6.2. The adult mortality rate was 28.1%, with a 95%CI of 16.9 to 41.5. Eighty percent of the pediatric patients (129/162) and 94.7% of the adult patients (54/57) were received mechanical ventilation. Of these patients, 6 had acute lung injury (ALI), 61 had ARDS. One patient with ALI was died. Among the patients with ARDS, 39 patients were adults and 22 were children, the mortality rates were 33.3% (13/39); 95%CI: 19.1 to 50.2 and 4.6% (1/22); 95%CI: 0.1 to 22.8, respectively. Among the 183 ventilated patients, 7.1% (13/183) were treated with percutaneous cardio-pulmonary support (PCPS) or ECMO. Of these patients, the mortality rate among adults was 20% (2/10); 95%CI: 2.5 to 55.6, and no deaths occurred among children. PCPS or ECMO for ARDS in adults tended to decrease the risk of death compared with mechanical ventilation (odds ratio, 0.364; 95%CI: 0.04 to 3.52; chi-square: 0.181; P = 0.671). Neither seasonal influenza vaccine and pandemic vaccine recipients died. The antiviral drugs, oseltamivir was prescribed for 96.8% (212/219) of the patients. Zanamivir was prescribed for 11.9% (26/219). Both drug were prescribed in 10.0% (22/219). Conclusions: The mortality rate was lower among children than among adults. The adult mortality rate was higher than among rates reported in other developed countries. PCPS or ECMO for the treatment of adult patients with 2009-H1N1-associated ARDS may be effective, but a statistically significant difference was not observed. Our database had selection bias (sampling bias); therefore, the results of this analysis are difficult to generalize.

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