Microaspiration around the cuff and biofilm formation on the surface of the endotracheal tube play important roles in the pathophysiology of ventilator-associated pneumonia (VAP). Several prophylactic interventions, such as adequate cuff pressure control and subglottic secretion drainage, are included in the current guidelines for the prevention of VAP. Additionally, new technologies aimed to suppress fluid leakage around the cuff and biofilm formation on the surface of the endotracheal tube have been investigated. Among them, the improvement of the cuff material and shape, and an antibiotic coating on the endotracheal tube have been successfully reduced the incidence of VAP in clinical trials.

View full abstract

Background: Antipyretic treatments are common practices in intensive care. However, there is no enough understanding of the risk and benefit of antipyretic treatments in non-neurological critically ill patients. Methods: We have conducted a systematic review of the literature to assess the effect of antipyretic treatments on non-neurological critically ill patients. Results: Our literature search retrieved sixteen articles. Reviews of these articles revealed that: (1) Antipyretic effect among studies are largely variable; (2) The threshold body temperature for administration of antipyretic treatments are varied, although half of studies define it as 38.5°C; (3) Heart rate, minute ventilation and oxygen demand may decrease according to the temperature reduction using antipyretic treatments; (4) Antipyretic treatments using acetaminophen and non-steroidal anti-inflammatory drugs decrease blood pressure; (5) There is no studies to assess whether such a antipyretic effects improve patient-centered outcomes including morbidity, length of ICU stay and mortality. Conclusion: The reduction of respiratory and/or oxygen demand by using antipyretic treatments might be beneficial to some non-neurological critically ill cohorts. However, data on this area are insufficient to conclude their risk and benefit. There is an urgent need for randomized controlled study to determine optimal antipyretic strategies in non-neurological critically ill patients.

View full abstract

Post-transfusion graft-versus-host disease (PT-GVHD) was previously thought to affect only immunocompromised patients. However, it has been found that immunocompetent individuals can also develop PT-GVHD if the donor(s) has one-way matched human leukocyte antigen (HLA) with the recipient. Japanese are known to be at higher risk of PT-GVHD, because there are few HLA haplotypes. The Japan Society of Transfusion Medicine and Cell Therapy (JSTMCT) issued the first guidelines on the irradiation of blood and blood components to prevent PT-GVHD in 1992, and issued the fifth version of the guidelines in 2010. Since 2000, there have been no cases definitively diagnosed as developing PT-GVHD after transfusions of blood products supplied by the Japanese Red Cross Blood Center. However, it became clear that there were more than a few institutions using non-irradiated blood based on a questionnaire survey of practices in 2007 and 2010 conducted by the JSTMCT. These guidelines seem to be effective in preventing the occurrence of PT-GVHD in Japan. However, there is a concern that recognition of both the severity of PT-GVHD and importance of its prevention has been declining. The occurrence of PT-GVHD after non-irradiated blood transfusion due to the lack of recognition of this disease should be prevented.

View full abstract

Objectives: To investigate the prognostic factors for the acute occlusion of the superior mesenteric artery (SMA). Methods: Twenty-seven patients with SMA occlusion were divided into a death group and survival group based on their survival status 28 days after admission. Results: Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (18.2±6.4) and lactate (8.1±4.3 mmol/l) and creatinine (2.3±1.1 mg/dl) levels of the death group were significantly higher than those of the survival group. The duration between the appearance of symptoms and initiation of treatment in the death group was 15 hours and equal to that of the survival group. Conclusions: To predict the prognosis, not the duration between the onset of symptoms and initiation of treatment but lactate and creatinine may be important.

View full abstract

Objectives: We performed a prospective study to investigate an optimal loading dose regimen of teicoplanin (TEIC) that aimed to generate therapeutic trough levels within 48 hours. Methods: ICU patients with proven or suspected methicillin-resistant Staphylococcus aureus (MRSA) infection were prospectively enrolled. Based on body weight and creatinine clearance (CrCl), a TEIC loading dose was chosen using nomogram to reach the therapeutic trough level (15μg/ml) within 48 hours. Patients received an adjusted dose of TEIC every 12 hours on day 1, 2, and once a day thereafter. Serum TEIC level at 48 hours after the first administration was recorded as the initial trough level. Results: 73 patients were enrolled. The mean of TEIC initial loading dose was 472.6±11.4 mg (8.2 mg/kg) and the mean of total loading dose was 1,890±251.8 mg. The mean trough level at 48 hours was 17.1±5.8μg/ml. No nephrotoxicity or other severe adverse effects were observed. Conclusions: Following the nomogram, we could easily decide the loading dose and the target TEIC trough level could be reached within 48 hours without evidence of severe adverse effects.

View full abstract

Background: Organ donation after brain death in children younger than 15 years old has been accepted since the revised organ transplant law was passed on July 13th 2010 in Japan. Objective: To determine the incidence of brain death in the pediatric intensive care unit (PICU) of Nagano Children's Hospital and whether organ donation is possible in children requiring end-of-life care in the PICU. Methods: This study is a retrospective, single center study. Study period was from January 1st, 2001 to January 31th, 2011. The medical records of patients who died in the PICU were reviewed to determine if the patients had findings of brain death. Patients who met the exclusion criteria according to the revised organ transplant guideline were also assessed. Thus, the number of patients who could probably be considered organ donors was determined. Results: Of the 3,031 patients admitted during the 10 year study period, 100 died. In all, 31 patients had findings of brain death. Of these patients, 18 met the exclusion criteria. Therefore, the number of probable organ donors was 13 (13% of dead patients, 0.4% of total admissions). Annual number of probable organ donors was 1.3 patients in the PICU. The causes of death in the probable organ donors were hypoxic encephalopathy (46%), cerebral infarction (31%), and intracranial hemorrhage (23%). Conclusions: The probable organ donors in this study were 13% of dead children and 0.4% of total admissions in our PICU.

View full abstract

In recent years, attention has been focused on the genus Acinetobacter as a pathogenic bacterium of healthcare associated infections. Many cases are the opportunistic infection toward the compromised hosts. In this study, we report a case which needed the intensive care owing to Acinetobacter baumannii blood stream infection through the peripheral vein catheter. The patient was a 69-year-old male and was admitted to the hospital owing to the upper gastrointestinal hemorrhage. When he entered the hospital, rubefaction was found on the keeping place of the peripheral vein catheter, which was subsequently taken off. However, the situation worsened and he had to be controlled in ICU. At the ICU, he had septic shock, disseminated intravascular coagulation and acute renal failure, and A. baumannii was detected from the blood culture. His condition improved by multidisciplinary treatment. He was allowed out of ICU on the 18^th day and left the hospital walking on his own on the 36^th day. It has been often reported that genus Acinetobacter happens to gain multiple drug resistance toward antimicrobial agents and that such antibiotic-resistant bacteria outbreaks in and out of ICU. Although the blood stream infection through the peripheral vein catheter has been seldom reported, it happens that the non-compromised hosts have the blood stream infection like this case. To say nothing of the usual preventive measure against the infection, it is also important that we use antimicrobial agents properly in order not to grow the multiple drug resistant bacteria.

View full abstract

Objectives: We retrospectively analyzed the clinical profiles of patients with septic shock who underwent direct hemoperfusion with polymyxin B immobilized fibers (PMX-DHP) to determine which factors contribute to outcomes. Methods: We compared the clinical results, infection sites and causative organisms (gram-negative or -positive) among 29 patients with septic shock. Circulation status was assessed by the dose of catecholamine use before and after PMX-DHP. Results: The overall survival rate was 66% (19/29). The mortality rates of the patients were: respiratory tract infection, 38% (3/8); abdominal cavity, 25% (1/4); undetermined site, 75% (6/8). All those with infections of the urinary tract (n=5) and lower extremities (n=4) survived. Mortality rates between patients with gram-positive and -negative infection did not significantly differ. The more marked decrease in the dose of catecholamine use was made among survivors than non-survivors. Conclusion: The clinical result might be influenced by the infection site. Positive or negative gram staining did not seem to be related to clinical outcomes. Restoration of collapsed circulation in response to PMX-DHP treatment might be an important factor linked to better outcomes.

View full abstract

Acute adrenal insufficiency is a rare but lethal event. Its symptoms are not specific, and therefore its diagnosis is frequently difficult. We report a 78-year-old man who presented with shock after a surgical procedure performed two months previously. In spite of adequate fluid resuscitation, catecholamine use, and glucose infusion, the patient's symptoms, which included hypotension, bradycardia, and hypoglycemia, persisted. Hence, we suspected acute adrenal insufficiency and administered hydrocortisone intravenously for the purpose of treatment and diagnosis. Subsequently, the patient exhibited a rapid improvement and recovery. We have described a case of acute adrenal insufficiency that manifested as hypotension, bradycardia, resistance to catecholamine use, and hypoglycemia after a surgical procedure performed two months previously. Since adrenal crisis is a life-threatening state, in cases of catecholamine-resistant cardiac insufficiency and refractory hypoglycemia, physicians should consider the possibility of an adrenal crisis and rapidly initiate steroid therapy.

View full abstract

We report on a patient with cervical abscess who underwent hyperbaric oxygen therapy early during the clinical course. A 65-year-old male was transported to our critical care center because of severe swelling and redness from face to neck, and pus discharge from the mouth. CT revealed a large abscess extending from the maxillary sinus to the peritracheal space, and we therefore performed an emergency operation consisting of drainage and debridement. We did not drain the abscess completely because these abscess expand many space. After operation, the patient was admitted to our ICU. Beginning on day 4, we performed hyperbaric oxygen therapy [2 ATA (atmospheres absolute), 60 min] 14 times to eliminate remaining abscess and to treat anaerobic bacterial infection. By day 5, the severe swelling and redness from face to neck had dissipated. A CT taken on day 13 showed no evidence of the remaining abscess. The patient's status improved and on day 11 he was transferred from the ICU to the ward, and soon after was transferred to another hospital for rehabilitation. The efficacy of hyperbaric oxygen therapy in treating soft tissue infection has recently been reported. We propose that using this therapy at early clinical stages may be effective in treating the patients with anaerobic bacterial infection who have not undergone complete drainage.

View full abstract

Acute fatty liver of pregnancy (AFLP) is a serious maternal illness caused by microvesicular fatty infiltration of hepatic and renal cells that can arise during the third trimester of pregnancy and result in significant perinatal and maternal mortality. We describe AFLP with hepatic and renal failure, multiple organ failure and disseminated intravascular coagulation (DIC) in a 43-year-old woman at 36 weeks of pregnancy. She was treated with respiratory and circulatory management in the ICU after Cesarean delivery. On postoperative day 1, she had perihepatic hematoma after liver biopsy for a diagnosis of AFLP and severe hemorrhage. She was transfused with a large volume of blood products and administered with blood coagulation factor (recombinant activated factor VII). She also underwent continuous hemodiafiltration and three transcatheter arterial embolizations. Her general status improved and she was discharged from the ICU on postoperative day 9. This experience indicated that in a patient with AFLP and hepatic failure, liver biopsy entails a risk of severe hemorrhage, and that liver biopsies for a diagnosis AFLP should be performed after recovering from coagulopathy.

View full abstract

Traumatic asphyxia occurs when a strong external force is exerted on the thorax. It is characterized by petechiae of the face, neck, and precordium, bulbar conjunctival congestion, and facial swelling. Loss of consciousness may also result from cerebral ischemia or hypoxia. We experienced a 42-year-old man of traumatic asphyxia caused by being trapped under a truck. This case had neurological impairment including loss of consciousness and visual disturbance and additionally suffered tension pneumothorax and liver injury associated with hemorrhagic shock. Although loss of consciousness was observed immediately after the injury, the patient recovered without any cerebral disturbance, excluding visual involvement. Traumatic asphyxia is sometimes complicated by severe thoracoabdominal injury because of compression of the thorax and abdomen. Loss of consciousness and neurological impairment including visual disturbance may also occur in many cases. It is necessary to provide the appropriate treatment based on Japan Advanced Trauma Evaluation and Care even though patient might be in poor neurological condition.

View full abstract

Objectives: The subspecialty and the background of Japanese intensivists were analyzed. Methods: The number of board certified physicians from the Japanese Society of Intensive Care Medicine (JSICM), the Japanese Society of Anesthesiologists (JSA), the Japanese Association for Acute Medicine (JAAM), the Japanese Circulation Society (JCS), and the Japan Neurosurgical Society (JNS) was calculated. Results: Among the critical care board certified physicians, 69.0% had board certified by JSA, 41.6% by JAAM, 3.86% by JCS and 1.76% by JNS, respectively. Conclusions: The majority of intensivists in Japan have anesthesiology board.

View full abstract

Objective: To evaluate current practices and problems with analgesia and sedation in Japanese ICUs using a questionnaire survey. Methods: Doctors, nurses, and pharmacists working in ICUs at board-certified training facilities for intensive care specialists were asked to fill out the form detailing the generic names and administration methods of analgesics, sedatives, and neuromuscular blocking agents and the assessment methods of analgesia and sedation that were used for adult patients admitted to the ICU between June 1 and 30, 2009 who received mechanical ventilation with tracheal intubation or tracheostomy, noninvasive ventilation (NIV), or no ventilatory support. Results: We received replies to the questionnaire from 97 ICUs (response rate: 44%). In mechanical ventilated patients with tracheal intubation or tracheostomy, the continuous intravenous administrations of fentanyl and propofol were the most frequently used analgesic and sedative, respectively, and neuromuscular blocking agents were used in about 10% of the patients. In patients with NIV, the continuous intravenous administration of dexmedetomidine was used most frequently. Thirty-eight and 64% of the patients without any ventilatory support were not administered any analgesics or sedatives, respectively. Although it was subjective, pain was mainly assessed by ICU nurses. Sedation level was mainly assessed by the Richmond Agitation-Sedation Scale. The use of analgesics, the practice of daily interruption of sedatives, and the assessment of delirium using the confusion assessment method for the ICU were unsatisfactory. Conclusion: Although there were some problems, the practice of analgesia and sedation in Japanese ICUs was generally acceptable.

View full abstract

An analysis was made of 44 critically ill patients who were admitted to ICU with 2010 influenza. Children (under 16 years of age) accounted for 19, and adults 25. All children survived, but 13 adults (52%) died. Duration of mechanical ventilation, ICU stay, and hospital admission were all shorter in children compared to adults (6 vs 12 days, 7 vs 17 days, and 14 vs 26 days, respectively). Compared to adults, consciousness disorder was frequently observed, but multiple organ failure was rare in children. Only 1 child and 14 adults were treated with extracorporeal membrane oxygenation (ECMO), and the child survived but 9 adults died. Maximum PEEP and maximum peak inspiratory pressure (PIP) were lower in children compared to adults (8 vs 19 cmH₂O, and 25 vs 30 cmH₂O, respectively). High dose steroids were administered less frequently in children (32% vs 56%). Sivelestat sodium hydrate was not administered in children, but was administered in 52% of adult patients. Since the number of patients studied was small and the database had a selection bias (sampling bias), the results of this analysis are difficult to generalize.

View full abstract