Massive pulmonary embolism is a life-threatening disorder associated with high mortality and morbidity. The majority of deaths in patients with shock occur within the first few hours after presentation, and rapid diagnosis and treatment are therefore essential to save lives. A percutaneous cardiopulmonary support system can be helpful in critical situations involving cardiac arrest or refractory shock, by providing circulation and oxygenation and thus time for definitive diagnosis. Emergency CT angiography provides diagnostic information for the presence of pulmonary embolism and right ventricular dysfunction. Thrombolysis is generally accepted in unstable patients with massive pulmonary embolism, since it effectively resolves thromboembolic obstruction and promptly reduces pulmonary artery pressure and resistance with a concomitant increase in cardiac output. However, thrombolytic agents cannot be fully administered for cases with a high risk of bleeding. On the other hand, catheter or surgical embolectomy is an optimal treatment for massive pulmonary embolism patients with contraindications for thrombolysis. Catheter therapy can be performed with a minimum dose of thrombolytic agents or without such agents, and can be combined with various procedures including catheter fragmentation or embolectomy in accordance with the extent of the thrombus on a pulmonary angiogram. ICUs should establish diagnostic and therapeutic protocols beforehand and rehearse multidisciplinary management for patients with massive pulmonary embolism. Coordination among a skilled team composed of intensivists, cardiologists, radiologists, cardiac surgeons and clinical engineers is crucial to maximize success.

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Objectives: Patients with systemic inflammatory response syndrome (SIRS) sometimes demonstrate atrial fibrillation with a rapid ventricular response, which is not easy to control. We examined the effect of landiolol, a short-acting selective β1-adrenergic receptor blocker on paroxysmal atrial fibrillation with a rapid ventricular response caused by SIRS. Methods: Sixteen patients of paroxysmal atrial fibrillation with a rapid ventricular response caused by SIRS were injected with landiolol and the changes in heart rate and blood pressure were recorded. In 9 of 16 patients, hemodynamic parameters including cardiac index were measured. Next, we compared the effects of landiolol, digoxin, cibenzoline, and verapamil for 63 patients with paroxysmal atrial fibrillation and a rapid ventricular response caused by SIRS. All data were from reviewing 3 years of retrospective data. Results: Landiolol certainly decreased the heart rate without inducing a massive decline in blood pressure. Landiolol decreased cardiac index, but increased the stroke volume index. Landiolol decreased the heart rate more than the other drugs. The blood pressure lowering effect of landiolol was comparable to those of cibenzoline and verapamil. The success rate of pharmacological cardioversion using landiolol was higher than that using digoxin or verapamil, and was nearly equal to that using cibenzoline. Conclusions: Landiolol was effective for paroxysmal atrial fibrillation with a rapid ventricular response caused by SIRS.

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To assess the combination effect of a genetic recombinant human soluble thrombomodulin (rTM) with conventional therapy on the treatment of disseminated intravascular coagulation (DIC), we conducted a comparative retrospective study of coagulation fibrinolysis, vascular endothelial damage, organ damage and mortality rate after 90 days among 17 patients with septic DIC treated with combination of rTM with conventional therapy (rTM group) and 16 patients treated with conventional therapy alone (non-rTM group). In the rTM group, a comparison between findings obtained on day 1 and day 7 of administration showed statistically significant decreases in the levels of soluble fibrin (P = 0.039) and E-selectin (P = 0.044), the DIC score (P = 0.017) and the Sequential Organ Failure Assessment (SOFA) score (P = 0.03), which were used to evaluate therapeutic efficacy, but no significant decreases were observed in the non-rTM group. On day 7 of administration, the plasminogen activator inhibitor-1 (PAI-1) level in the patients treated with the rTM was significantly lower than in the untreated patients (P = 0.025). A survival analysis did not show a significant difference between the two groups, but the results suggested a tendency toward a higher survival rate in the rTM group (P = 0.064). The results of our study suggested that treatment of combination of rTM with conventional therapy may have yielded considerable benefits to the treatment of septic DIC.

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Objectives: The objective of the present study was to clarify the elements that would encourage nurses to adopt a constructive attitude after committing nursing errors. Methods: The study involved nurses working at a hospital with 200–300 beds. A survey was conducted using an anonymous self-administered questionnaire that was circulated and collected via mail. The reliability and validity of the newly developed questionnaire items for this survey were assessed, and the existing valid elements (coping profile and organizational climate) were accordingly added. The relationship between these elements and constructive behavioral change was analyzed. Results: The result suggested that constructive behavioral change is associated with “support from the head nurse”, “coping profile”, and “organizational climate”. Conclusions: These results suggest that “appraisal support” from head nurses is a useful factor in achieving constructive behavioral change. A “problem-focused coping style”, which aims to solve the problems by directly focusing on them, and an “active type” organizational climate are useful in achieving constructive behavioral change.

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Objectives: Delirium is frequently observed in elderly patients after upper abdominal surgery. The purpose of the present study was to examine whether perioperative physiotherapy prevented and improved postoperative delirium in elective upper abdominal surgery patients. Methods: A total of 338 patients who underwent elective upper abdominal surgery were examined between 2002 and 2009. The subjects included 202 patients who underwent perioperative physiotherapy (intervention group) and 136 patients who did not undergo perioperative physiotherapy (control group). One examined factor was whether or not the incidence of postoperative delirium, the onset of delirium from surgery, and the duration of delirium were all clearly reported in the clinical records. Results: The incidence of postoperative delirium in the intervention group (7.9%) was significantly lower than that in the control group (25.7%) (P < 0.001). The onset of delirium from surgery occurred at a significantly earlier time in the intervention group in comparison to the control group (P = 0.019). The duration of delirium in the intervention group (1.1±0.4 days) was significantly shorter than that in the control group (2.1±1.5 days) (P < 0.001). In the multiple logistic regression model, perioperative physiotherapy [odds ratio (OR) 0.20, 95% confidence interval (CI) 0.10 to 0.39, P < 0.001] , age (OR 1.09, 95%CI 1.05 to 1.14, P < 0.001) and cerebrovascular disease (OR 3.52, 95%CI 1.43 to 8.70, P = 0.006) were independent risk factors of postoperative delirium. Conclusions: Our findings suggest that perioperative physiotherapy reduces the incidence of delirium and prevents prolongation of such delirium.

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The cases of intake of organophosphate pesticides reported in Japan are mainly due to oral ingestion associated with attempted suicides. We report a case of organophosphate pesticide poisoning in which percutaneous absorption was suspected to be the cause. A 61-year-old woman was brought to our hospital because of consciousness disturbance. She was found lethargic, lying in the bathroom, by her husband. She had a significant medical history of hypertension. On admission, her Glasgow coma scale (GCS) score was 14/15. Her vital signs were as follows: body temperature, 35.3°C; blood pressure, 185/102 mmHg; heart rate, 106 /min; and respiratory rate, 23 /min. Her oxygen saturation was 100%. Her pupils were 2 mm in diameter, equal in size, round, and reactive. The rest of the examination was unremarkable. Chest X-ray, head CT, and head MRI were performed, but failed to identify the cause of the consciousness disturbance. Three hours after arrival, her oxygen saturation level had fallen and diaphoresis, miosis, and lacrimation had developed, while she was intubated under sedation. Prior to tracheal intubation, we asked her whether she had taken any organophosphate agent, which she denied. No organophosphate smell was detected from the endotracheal tube. Nine hours after arrival, her cholinesterase level was reported to be 11 IU/l, and we could finally confirm the diagnosis. Pralidoxime and atropine therapy was accordingly started. Seventeen hours after arrival, her family brought bottles of pesticide (smithion^®) to the hospital. It transpired that she had handled this organophosphate pesticide without wearing gloves, and that earlier she had received abrasions to her hands. Therefore, it was assumed that the organophosphate was easily absorbed through her skin. Critical care physicians should bear in mind that whenever they see patients with consciousness disturbance, percutaneously absorbed organophosphate poisoning could be one of the causes.

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We administered argatroban as an anticoagulant for percutaneous cardiopulmonary support (PCPS) in a patient suspected to have heparin-induced thrombocytopemia (HIT). Before the HIT antibody turned out to be negative, we stopped the administration of heparin, and instead begin to administer another anticoagulant for patients strongly suspected HIT. The efficacy of argatorban for HIT has been previously reported, however, the efficacy of the use of argatroban through an extracorporeal device remains to be elucidated. In this case, we performed PCPS for 15 days under the administration of argatorban while adjusting the dose to maintain activated clotting time (ACT) in the same range as that achieved when administering heparin and no complications such as thrombosis or bleeding occurred. This case demonstrated that argatroban was effective as an anticoagulant for PCPS. It is necessary to further discuss the optimal dosage of ACT, however, argatroban was found to be effective as an anticoagulant for PCPS in a patient with HIT.

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Primary hyperparathyroidism (PHPT) is known as a rare cause of acute pancreatitis. We report on the case of a 21-year-old male with PHPT. To our knowledge, this is the first report of PHPT which simultaneously caused severe acute pancreatitis (AP) and ureteral stones (US). The patient was admitted to our hospital with AP and US complicating hypercalcemia. He presented with severe circulatory shock and multiple organ failure requiring mechanical ventilation and continuous hemodiafiltration. He was diagnosed as having PHPT and suffered from refractory hypercalcemia, but it was successfully controlled by the administration of bisphosphonate. He was successfully weaned from mechanical ventilation and continuous hemodiafiltration, and discharged from the ICU on the 24th ICU day. Thereafter he underwent a parathyroidectomy and transurethral ureterolithotripsy.

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A 42-year-old male was hospitalized due to fever and generalized malaise. He was healthy, and past medical history included splenectomy 20 years previously due to a traffic accident. He presented with scattered petechiae on his face, obvious purpura on his extremities and ears, and no any signs or symptoms of shock. Laboratory findings revealed disseminated intravascular coagulation (DIC), liver dysfunction, and acute renal failure. After transfer from his local hospital and admission at our institution, he was diagnosed as acute infectious purpura fulminans (AIPF) from clinical manifestations and the etiology of infection. The etiologic agent was identified as Streptococcus pneumoniae both by a commercial kit for the antigen of S. pneumoniae present in the urine and by blood culture. Empirical antibiotics were administered for pneumococcal infection. Immediate anti-DIC treatment was initiated and included antithrombin, fresh frozen plasma (FFP), recombinant human soluble thrombomodulin (rTM), artificial ventilation and continuous hemodiafiltration. The purpuric lesions on his extremities and ears resolved the day following anti-DIC treatment. Thereafter, he recovered from DIC without any gangrene, no complications developed, and he was discharged about 1 month after admission. This experience indicates that FFP administered as a replacement for protein C and rTM could be a useful therapy for DIC resulting from AIPF.

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While iodoform gauze has a good antiseptic effect, cases of iodoform toxicity are not common. Iodoform can cause neurological symptoms such as disturbance of consciousness, and intoxication occurs with relative ease under certain suitable conditions. Medical practitioners may often misdiagnose disturbance of consciousness for various reasons, and the actual cause of disturbance of consciousness should be clarified. We now report a case of prolonged disturbance of consciousness caused by the use of iodoform gauze in the treatment of necrotizing fasciitis. A 70-year-old diabetic female, who used insulin injections, acquired necrotizing fasciitis in her left buttock and underwent surgery involving release of purulent discharge and debridement. The surgical area was packed with iodoform gauze following surgery, and the gauze was replaced daily. The patient's general condition gradually improved, but disturbance of consciousness, around Glasgow coma scale E2VTM4, was prolonged. We discontinued iodoform gauze treatment, following which consciousness improved slowly. The blood serum iodine level was too high. Although we often use iodoform gauze as an effective treatment for infected sites, we must take heed of its potential toxic neurological effects.

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A 50-year-old woman with facial swelling after dental treatment visited our emergency department. We initially suspected that the swelling was caused by a drug-induced allergy; therefore, the patient was administered anti-allergy therapy. However, the patient did not respond to the therapy. On the basis of examination and a medical interview, we suspected that the swelling was caused by hereditary angioedema (HAE). The condition was eventually diagnosed as type I HAE on the basis of low levels of complement component 4 (C4) and C1-esterase inhibitor (C1-inh) and their functional activities. The patient was treated with a regimen of antifibrinolytics and 17-α-alkylated androgens for both short-term and long-term prevention of recurrence. The patient's medical interview revealed sudden death of a family member. Herein, we report 2 cases of HAE. In addition, we provide several arguments about the necessity of an epidemiologic survey on HAE, free access to HAE information, and establishment of a C1-inh supply system in our country.

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The patient was a 59-year-old woman who underwent thoracoscopic left lower lobectomy for the treatment of a lung adenocarcinoma. Fall of blood pressure was noted 2 hours after the operation. As a contrast-enhanced CT of the abdomen showed extravasation of contrast material from the spleen, a diagnosis of hemorrhagic shock associated with splenic rupture was made, and emergency transcatheter arterial embolization was performed. After the embolization, angiography showed disappearance of the extravasation during the arterial phase, whereas some extravasation was still evident during the portal venous phase. Therefore, emergency splenectomy was carried out. Pathologic examination of the spleen revealed hemorrhage, but there were no aneurysms or tumor metastases. There have been two cases of splenic rupture occurring after thoracic surgery reported in the literature, and there were left-side thoracotomy in every case. The cause and underlying mechanisms still remain unclear. Thus, it is of importance to bear in mind the possibility of intra-abdominal bleeding even in thoracic surgery patients developing evidence of hemorrhagic shock.

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We described a case of post-resuscitation care for an 81-yr-old male patient. The patient had medical history of schizophrenia and the neuroleptics intoxication was initially suspected, however, bispectral index monitoring showed the value over 70 after 13 hr from the resuscitation and the possibility of an extreme intake of antipsychotics including lithium was excluded. Advanced cardiopulmonary life support was successfully performed and the patient was dehospitalized without any severe neurological complications.

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Objective: We retrospectively assessed the clinical incidence and risk factors for ICU-attributable muscle weakness by surveying the medical records of patients admitted to the emergency ICU. Materials and methods: We investigated the medical records of patients who required mechanical ventilation between 2006 and 2007. Muscle weakness was determined as Medical Research Council (MRC) score of <48, manual muscle test (MMT) level of <4 evaluated by nurses in at least one extremity, or medical recordings that indicated abnormal activities. Clinical factors and laboratory data that could influence the onset of muscle weakness were collected from the medical records. Results: Out of 916 patients admitted to the ICU who required mechanical ventilation over the 2-year study period, 495 were evaluable. Among these, 82 (16.6%) had muscle weakness. The incidence of muscle weakness was 47 (34.1%) among 138 patients who required ≥7 days of mechanical ventilation. Independent predictors of muscle weakness were duration of mechanical ventilation, use of muscle relaxants, neurological disease and blood urea nitrogen (BUN). Conclusions: ICU-attributable muscle weakness was some degree of feature in critically ill patients who required mechanical ventilation. The duration of mechanical ventilation, muscle relaxants, neurological disease and BUN was associated with ICU-attributable muscle weakness.

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