Since “the recommendation on ideal terminal care in intensive care” was presented in our society in 2006, attention has come to be focused on providing care to the families of terminally ill patients. In this study, we reviewed the literature published from overseas after 2000 on the care for the families of terminally ill patients in the field of intensive care. The results were as follows. When the family is unexpectedly told that the patient is close to death, they are likely to have a psychological crisis and to show grief reactions. The need for surrogate decision-making can make the mental health of the family worse, while it can increase the family's satisfaction level with terminal care. Therefore, the process of decision-making is important. Of importance for family care are provision of guidance for family-centered decision-making and maintenance of good communication with the family, which can lead to improved family satisfaction with terminal care. Furthermore, adequate control of pain of terminally ill patients serves as an indirect way of providing care for the family. It is also important to meet the needs of the family.
During renal replacement therapy for clinical patients, we sometimes encounter problems such as bolus infusion of the anticoagulant with a syringe pump (hereinafter simply called “pump”), and regurgitation of blood into the syringe and delayed start of the infusion due to regurgitation. These problems are primarily related to the structural space remaining after installation of the syringe onto the pump attached to a renal replacement therapy machine. In addition, some other factors (compliance of the syringe and pump, and sudden change of pressure within the blood circuit) can also produce problems. The volume of regurgitation or bolus infusion is about 1 ml or less. However, if the frequency of poor blood removal becomes higher, the exact amount of the anticoagulant remaining in the system becomes unclear, making proper management of dosing difficult. Regarding delayed start of infusion, the delay has been reported to be about 40 minutes for both the maintenance hemodialysis devices and the slow continuous renal replacement therapy machines. Thus, when drugs with short half-live are used, delayed start of infusion can cause coagulation of blood within the circuit. The routine countermeasures advisable clinically to prevent these problems are: (1) avoidance of the formation of a structural space, (2) use of low-compliance and low-volume syringes, and (3) increasing the drug infusion rate per unit time. Henceforth, we shall take actions to promote standardization of this kind of pump by the manufacturing enterprises concerned.
We investigated the relationship between alcohol and confusion in the ICU. We studied 83 patients, ranging in age from 65 to 81 years old, who were observed in the ICU after undergoing abdominal surgery. The patients were divided into two groups; patients who drank 25 g/day or more of alcohol (Group A), and non-drinkers (Group B). All patients were given a neuropsychological screening evaluation, including a mini-mental state test, the Japanese version of the state-trait anxiety inventory, a depression scale test and plasma cortisol concentration was measured before surgery, at 15 and 60 minutes after skin incision, the end of surgery, and 24 and 48 hr after surgery. Confusion in the ICU occurred in 7 of 18 patients (39%) in Group A and 4 of 65 patients (6%) in Group B. The occurrence of confusion in the ICU in patients of Group A was significantly higher than that in patients of Group B. Plasma cortisol concentrations 15 and 60 min after the skin incision, 60 min after the end of surgery, the next day and the 3rd day after surgery in patients of Group A (31.4±6.8, 29.2±7.6, 33.1±8.7, 29.4±6.9 and 28.3±5.8μg/dl) were significantly higher than those in patients of Group B (23.7±6.1, 21.4±7.4, 24.6±7.2, 19.5±6.4 and 18.7±6.0μg/dl). In conclusion, the incidence of confusion in the ICU was significantly higher in chronic alcohol drinkers than in no drinkers, and the plasma cortisol concentration was increased in chronic alcohol drinkers who developed confusion in ICU. Increased cortisol concentrations appear to be associated, or even to cause, confusion in the ICU in chronic alcohol drinkers.
Objectives: We analyzed the impact of the resuscitation guideline changes on the outcome of out-of-hospital cardiac arrest of cardiac origin witnessed by bystander. Methods: We reviewed 5,018 cases of bystander-witnessed cardiac arrest of cardiac origin that occurred in the Osaka prefecture between January 2005 and December 2008. We categorized these 5018 cases into 2 groups (group G2000: 2,185 cases and group G2005: 2,833 cases) on the basis of whether cardiac arrest occurred before or after changes were introduced in the guidelines and analyzed the outcomes. Results: The use of life-support measures, including intubation and drug administration by paramedics and public access defibrillation, was significantly higher in G2005 than in the G2000 group. The time interval between the emergency call and first defibrillation attempted by the paramedics was significantly longer in G2005 than in G2000. Also, the rate of restoration of spontaneous circulation, 1-month survival, and 1-month neurologically favorable survival was significantly higher in G2005 than in G2000. On the basis of the multivariate analysis, we found that G2005 demonstrated high 1-month neurologically favorable survival. Conclusions: The results suggest that the changes to the resuscitation guidelines have resulted in improved outcomes of out-of-hospital cardiac arrest of cardiac origin witnessed by bystander. Similar studies should be conducted in other areas to confirm the findings of our study.
Objectives: Epidemiology and care practices for pediatric sepsis in community hospitals were evaluated using a diagnosis procedure combination (DPC) database. Methods: We collected DPC data from 66 community hospitals nationwide in 2007 and identified 388 pediatric (age, 1 month to 19 years) and 5,215 adult patients using the sepsis-related international classification of disease (ICD)-10 coding. Results: Pediatric sepsis comprised 6.9% of the total number of cases and infants accounted for 46.1% of this population. The incidences of sepsis per 1,000 admissions were 8.4 and 14.5 in pediatric and adult patients, respectively. Rates of in-hospital mortality were significantly lower among pediatric than adult patients (0.5% vs. 33.5%, P < 0.01), as were the need for intensive care procedures and length of ICU stay (P < 0.01). The mean cost per day during admission was about 40,000 yen, which was comparable between pediatric and adult patients. Conclusions: The incidence of sepsis is relatively higher, and the severity and mortality outcomes are lower and better, respectively, among pediatric than adult patients in community hospitals registered by the DPC database. Problems with the structure or clinical application of the ICD-10 coding or specific case-mixes in community hospitals might affect these findings.
Case: A 34-year-old male fell into a hydrochloric acid tank at a chemical factory during work without any witnesses. His whole body had been immersed in hydrochloric acid (approximately 35% concentration in a tank measuring 2m in depth) for about 10 minutes (maximum estimated time interval) and then was transferred to the hospital in 18 minutes after he had fallen into the tank. On arrival he was lucid, spoke clearly and was moderately hyperventilated. Transnasal intubation was performed prophylactically to avoid any airway obstruction due to subsequent swelling. An initial examination of the arterial blood gas (ABG) showed pH 6.76, PaCO2 26.3 mmHg, PaO2 268 mmHg, BE −27.8 mmol/l, lactate 124 mg/dl, P50 98 mmHg, which indicated severe lactate acidosis and abnormally elevated P50. He was given 250 ml of sodium bicarbonate in order to correct this severe metabolic acidosis (pH < 7.0) and the following ABG showed pH 7.111, PaCO2 33.7 mmHg, PaO2 492 mmHg, BE −17.4 mmol/l, lactate 107 mg/dl, P50 34 mmHg, which indicated a remarkable improvement of P50 and PaO2. His condition worsened and he died 2 days after presentation due to total body deep chemical burns. Conclusion: This is the first report of such a severe metabolic acidosis with hyperlactatemia and an abnormal elevation of P50 due to total body emersion in concentrated hydrochloric acid case, which is considered to have resulted in the massive absorption of hydrochloric acid through the systemic skin, thus contributing to the aggravation of toxic symptoms.
The treatment strategy for acute respiratory distress syndrome (ARDS) requires the prompt removal of extravascular lung water index (ELWI) while controlling the progression of increased pulmonary vascular permeability (PVP). This report describes a patient who developed ARDS and survived due to successful early ventilator weaning, with the administration of the strict control of body fluid. PiCCO® (Pulsion Medical Systems, Germany) was used to monitor both ELWI and PVP. A 72-year-old female was admitted to another hospital because of acute respiratory failure and rapidly deteriorating oxygenation, after complaining of dyspnea a few days earlier. She was diagnosed to have acute respiratory failure caused by pneumonia. The patient was intubated and thereafter was transported to the ICU at Fukuoka University Hospital on the following day. ARDS was diagnosed based on the diffuse infiltrative shadow progressing rapidly in the bilateral lung fields, P/F ratio of 73, and a detailed hemodynamic assessment with PiCCO®. The patient was placed on mechanical ventilation and antibiotics, and sivelestat sodium was administered to control the increased PVP, which caused the increase of ELWI. The body fluid was also strictly controlled to maintain a euvolemic state. The PVP was normalized on the 3rd day and the increased ELWI thereafter gradually decreased. A chest radiograph disclosed a marked improvement of the diffuse infiltrative shadow in both lung fields on the 6th day and the P/F ratio improved to over 300. The patient was successfully weaned from the mechanical ventilation and could then be discharged from the ICU.
During therapeutic hypothermia (TH) in patients after cardiopulmonary resuscitation, it is often necessary to administer a neuromuscular blocking agent due to shivering, thus making it difficult to evaluate the depth of sedation. We herein report two patients who underwent TH while controlling the sedation dosage based on the bispectral index (BIS) level, and we also evaluated BIS using portable electroencephalograms (pEEG). First, a 37-year-old male was administered a sedative dosage due to the fact that the BIS level was under 60. pEEG showed α waves and similar changes to those associated with the BIS level were observed. The patient awoke early after TH. Second, a 63-year-old male was managed without sedation because the BIS level remained under 10. pEEG showed flat waves and the neurological prognosis indicated a poor outcome. BIS is useful and readily-controlled, however, BIS has not yet been established as an accepted evaluation method in patients with brain disorders. However, light sedation could be avoided in these cases due to the use of BIS. In addition, a BIS value of 0 was thus suggested to be a possible diagnostic factor for a poor neurological prognosis.
We report a complicated pediatric case that was difficult to wean from artificial ventilation. A 12-year-old girl with severe scoliosis and congenital muscular dystrophy showed a low vital capacity. A common cold triggered acute respiratory insufficiency with hypoxemia and hypercapnea, making artificial ventilation necessary. As she had a difficult airway, it took about 2 hours to achieve endotracheal intubation. Moreover, she performed self-extubation twice, resulting in pneumonia and pulmonary atelectasis. A vicious cycle was formed by the difficult airway, self-extubation and increased doses of sedatives. In order to break this cycle, a tracheostomy was performed. As a result, she could be weaned from artificial ventilation and attend school using a speaking cannula.
Procalcitonin (PCT) is a useful marker for systemic bacterial infection, and is considered to be closely correlated with the severity of sepsis. We encountered a patient with suspected neuroleptic malignant syndrome (NMS) who exhibited hyperprocalcitonemia in the absence of bacterial infection. The patient was a 66-year-old man with oropharyngeal carcinoma who was admitted to the hospital, and while hospitalized, he underwent gastrostomy as he was not able to eat properly. On postoperative day 3, the patient developed high fever, and blood biochemistry tests revealed elevated serum levels of CRP, PCT, and CK. Sepsis and rhabdomyolysis were suspected and the patient was admitted to the intensive care unit. Because the vital signs were stable, no foci of infection could be detected on physical examination, and the dose of haloperidol had been increased after the gastrostomy, NMS induced by dose escalation of a psychotropic drug was suspected. The serum CRP and PCT levels decreased with parenteral fluid management alone. In this case, although the cause of PCT elevation was not clarified, we should pay attention to the possibility of PCT elevation without systemic bacterial infections.
Some reports have been published of fatal complications associated with insertion of a nasogastric tube. The study presented here deals with on our experience with a patient in whom insertion of a nasogastric tube led to esophageal perforation. An 87-year-old female was hospitalized, presenting with hematemesis. Emergency endoscopy showed an esophageal hiatal hernia and lower esophageal erosion, which were identified as the sources of the bleeding. On day 4 of hospitalization, it was found that the patient was having difficulty ingesting food orally. A nasogastric tube was therefore inserted, and its intragastric placement was confirmed by means of chest X-ray and gastric bubble auscultation. However, because of stomach pain 10 hours after the start of continuous tubal feeding, enteral feeding was halted immediately. We subsequently confirmed that the patient had developed a fever and an elevated inflammatory response. Since findings on a chest-abdominal CT led us to suspect the feeding tube had caused esophageal perforation, so we performed emergency surgery. The feeding tube was found to have strayed, penetrating from the posterior esophageal wall into the retroperitoneal space. The patient's postoperative course was good. Although insertion of a feeding tube is a comparatively simple procedure, there is no guarantee that the tube is placed in correct position even if its position is confirmed by standard means of chest X-ray and gastric bubble auscultation. Our experience indicates that reliable method for confirming the position of the tube is necessary.
A patient presented with severe adult H1N1 influenza associated-pneumonia. The patient had signs of an upper respiratory infection and antibiotics were administered. He developed severe hypoxia due to pneumonia after 5 days. Influenza rapid antigen test was negative. Although he required receiving intensive care because of the severe hypoxia, P/F ratio was 75 and Murray score was 3.4, and therefore he was treated with extracorporeal membrane oxygenation (ECMO) on the 2nd day. He began to recover from acute respiratory distress syndrome on the 5th day, and he was weaned from ECMO on the 7th day because P/F ratio was 289. It is important to know that negative rapid antigen tests do not exclude H1N1 influenza. ECMO is considered to be used for a short period of time when administered to patients presenting with severe hypoxia after having demonstrated a recovery of their respiratory function.
Objectives: This study examined the regularity of the month and time of death in ICU patients. Methods: In this retrospective study, we surveyed time-related phenomena regarding the month and time of death in patients with fatal outcome during the ICU stay. The survey items included the year, date, and time of death, as well as the direct cause of death. We analyzed diurnal changes regarding the time of death using the least squares method employing a triangular function, and evaluated the 24-hour rhythm. Results: It was demonstrated that patient deaths peaked in the summer and winter months. The peak hour was around 15:00. Conclusion: Consideration should be given to the rhythmic regularity shown in the month and time of death in patients to improve the ICU shift work and management system.
The Nursing Division of the Japanese Society of Intensive Care Medicine has conducted a national survey to obtain data on nursing in ICUs. A 31-item questionnaire was generated by the standing committee members and local chapter representatives and was sent to 1,188 hospitals. Four hundred and eighty-one ICUs from 471 hospitals replied. The mode of the number of ICU beds was 6. The proportion of ICU beds to all hospital beds was 1.8%. The median number of annual ICU admissions was 1,220 patients, and the median number of average length of stay was 4.4 days. Three-quarters of the ICUs were general ICUs, and most of the medical directors were affiliated with anesthesiology. Health care professionals other than critical care nurses or physicians were employed in one-quarter of the surveyed ICUs, but less than 10% of the ICUs employed these personnel in round-the-clock shifts. New graduate nurses were assigned to two-thirds of the ICUs. New employee nurses accounted for 25% of the nurses in the ICU annually. The annual turnover rate was 10%. The nurse-patient ratio was 1:2 or less in more than 80% of the ICUs on weekdays and nights. The results of the questionnaire implied a need of more accurate statistics of length of ICU stay, development of reliable ICU database, and determination of acceptable proportion of new employed nurses.