Background: Patients in the intensive care unit (ICU) often receive sedation and analgesia. Protocolized sedation and daily interruption of sedation are two major examples of sub-optimal sedation practice. To achieve better understanding of the clinical effects on outcomes, we performed a systematic review of randomized controlled trials (RCTs). Methods: We searched the MEDLINE database from January 1990 to October 2010 for English-language RCTs assessing the impact of protocolized sedation or daily interruption of sedation on outcomes among critically ill patients requiring mechanical ventilation for >24 h. Results: Eight RCTs showed that protocolized sedation or daily sedation interruption reduced the duration of mechanical ventilation by 8.2% and ICU stay by 15.3%, but did not reduce mortality compared with standard practice. Daily interruption of sedation, however, has less benefit compared to protocolized sedation in terms of duration of mechanical ventilation and increases the risk of self-extubation and acute coronary syndrome. Conclusions: Protocolized sedation and daily interruption of sedation decrease the duration of mechanical ventilation and ICU stay. Weak evidence suggested the superiority of protocolized sedation over daily interruption of sedation based on adverse events due to daily interruption of sedation.

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Prophylaxis for venous thromboembolism (VTE) is part of standard ICU therapy in Western countries. However, the application of this therapy is not sufficient in Japan. A relatively high risk of bleeding and the unreliable bioavailability of unfractionated heparin and warfarin may explain this situation. Enoxaparin, a low-molecular weight heparin, and fondaparinux, a selective factor Xa inhibitor, have better performances in terms of efficacy, stability and consistent activity. Furthermore, the long half-lives of these agents allow subcutaneous injections to be performed 1–2 times/day. However, careful observation is necessary when these agents are used. In addition to indirect factor Xa inhibitors, which work via antithrombin, direct factor Xa inhibitors have been aggressively developed. The results of clinical studies have reportedly been sufficient. Under these circumstances, we think that VTE prophylaxis may be entering a new era.

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In 2006, Pronovost et al recommended five bundle approaches to prevent catheter-related blood stream infection (CRBSI). These include 1) hand hygiene before catheter insertion, 2) maximal sterile barrier precautions (MSBP) when inserting the central venous catheter (CVC), 3) skin hygiene using 2% chlorhexidine before CVC insertion, 4) avoid the femoral vein for CVC insertion, and 5) remove catheters when unnecessary. These approaches have been strongly advocated in the United States of America. However, our randomized controlled trial conducted in Japan did not reveal the efficacy of MSBP. Evidence regarding prevention of CRBSI remains controversial. This review focuses on multifarious aspects of the evidence regarding the prevention of CRBSI.

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Although intrapulmonary percussive ventilation (IPV) is beneficial for improving gas exchange in acute respiratory failure (ARF), the mechanisms have not been clearly elucidated. The effects of IPV on gas exchange were compared with those of PEEP without percussion. A controlled, crossover study was conducted to compare the two types of ventilation [synchronized intermittent mandatory ventilation (SIMV) + PEEP with superimposed IPV, and SIMV + increased PEEP] in eight patients with ARF requiring mechanical ventilation. Changes in blood gases were evaluated after the ventilation at the same mean airway pressure. There was no difference in the improvement of the P/F ratio between the two types of ventilation; however, there was a greater improvement in the PaCO2 values and the tidal volume after the SIMV + PEEP with superimposed IPV than that of with increased PEEP. These results suggest that the beneficial effects of IPV on gas exchange are not caused simply by the elevated airway pressure, but they are mediated by the percussion effect.

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Objectives: The early extubation of pediatric patients after cardiac surgery has become a contemporary trend. We aimed to determine which factors are associated with earlier extubation at our institution. Methods: We retrospectively reviewed a database of 395 infants and children who entered the pediatric ICU after cardiac surgery between January 2006 and December 2008. Patients were assigned to groups that had been extubated ≤3 hr (n = 219, 55.4%) and >3 hr (n = 176, 44.6%) of admission. Background and therapeutic factors associated with extubation ≤3 hr of admission were assessed using univariate and multivariate analyses. Results: Multiple logistic regression analysis revealed that body weight (P = 0.005), Risk Adjustment for Congenital Heart Surgery (RACHS) -1 category (P = 0.0001), and intra-operative fentanyl dose (P < 0.0001) were significantly associated with earlier extubation. The incidence of reintubation and respiratory complications were 0.5% and 4.6%, respectively, when patients were extubated ≤3 hr of admission. Conclusions: Extubation at ≤3 hr after admission was associated with body weight, cardiac procedure, and intraoperative fentanyl dose. The incidence of reintubation and respiratory complications were low when patients were extubated ≤3 hr of admission.

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A 58-year-old man underwent lower anterior rectal resection under general anesthesia for rectal cancer. He had no history of a specialized disease and his preoperative renal function was normal. The intraoperative and early postoperative course was uneventful, and 1 g of cefmetazole sodium (CMZ) for prevention of surgical site infection was administered every 12 hours since just before the operation. Approximately 36 hours after the operation, we noted a sudden onset of oliguria that persisted despite fluid volume loading and furosemide administration; 6 hours later, the oliguria progressed to anuria. Laboratory data at the onset of anuria showed elevated levels of blood urea nitrogen (25.8 mg/dl) and creatinine (3.37 mg/dl) and high fractional excretion of sodium (15.7%). Computed tomography revealed no ureter obstruction. A diagnosis of CMZ-induced acute renal failure (acute tubulointerstitial nephritis) was made. CMZ treatment was discontinued, and continuous hemodiafiltration (CHDF) was attempted. Forty-three hours later, urine production started and increased rapidly, after which, CHDF was discontinued. The patient's clinical course since then was uneventful, and he discharged 29 days after the operation.

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Although rib involvement may occur in patients with multiple myeloma, the development of pathological flail chest is rare. We experienced a patient with multiple myeloma who presented with flail chest and respiratory failure. A 63-year-old man with multiple myeloma experienced multiple rib fractures and complained of chest pain and dyspnea. The patient underwent chemotherapy, but treatment was discontinued because he developed drug-induced hypersensitivity syndrome. His dyspnea and chest pain progressed, and he was admitted to the ICU. Even after endotracheal intubation, flail chest of the lower thoracic segments were evident bilaterally on inspiration. A PEEP was applied and increased up to 15 cmH₂O to stabilize his flail chest. The patient underwent a tracheostomy, as the duration of ventilatory support was expected to be lengthy. The PEEP was gradually decreased to 6 cmH₂O on day 27 after endotracheal intubation, while avoiding the occurrence of flail chest. After treatment with a high dose of dexamethasone starting on day 73, his chest pain was gradually alleviated, and his flail chest disappeared, as evidenced by a CT scan. The patient was weaned from long-term ventilatory support on day 131.

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We describe the case of a 75-year-old woman who was admitted to our ICU because of status asthmaticus and required mechanical ventilation. She was treated with high-dose corticosteroids and deep sedation without neuromuscular blocking agents, and overcame the crisis. She remained comatose for several days even after discontinuation of sedatives, and thereafter her serum creatine kinase level increased to 9,150 U/l. As she regained consciousness, flaccid motor paralysis of all extremities became evident. Electrophysiological studies indicated acute myopathy. A muscle biopsy specimen demonstrated selective loss of myosin myofilaments, thus the diagnosis of acute quadriplegic myopathy was made. Not only high-dose corticosteroid therapy, but also immobilization due to sedatives and prolonged comatose state was considered to contribute to the development of this acute quadriplegia.

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It is known that patients with anorexia nervosa have a decreased resting energy expenditure (REE). A 26-year-old female diagnosed as anorexia nervosa presented to our hospital with severe emaciation. After admission, enteral feeding was started at a low dose (600 kcal/day). It was gradually increased to 866 kcal/day on day 2 after admission. Subsequently, unstable circulatory dynamics, hyperglycemia, hypophosphatemia and hypokalemia developed, and refeeding syndrome was suspected. Therefore, enteral feeding was reduced to 630 kcal/day 4 days after admission. Her REE was measured based on indirect calorimetry. Feeding was then performed based on the measured REE. Her condition soon thereafter stabilized. Overfeeding often induces refeeding syndrome, however, inadequate feeding leads to a further deterioration of the patient's condition. Anorexia nervosa requires optimal feeding. Therefore, feeding based on the measured REE can help to prevent complications, such as refeeding syndrome.

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A 34-year-old male with schizophrenia ingested gold (I) potassium cyanide at his office. He thereafter presented at the emergency department with nausea, vomiting, and abdominal pain. He was conscious, and his vital signs were stable upon admission, however, convulsions were observed in the right upper part of his body. We therefore diagnosed him to have cyanide poisoning based on information obtained from the patient who was still conscious. Sodium nitrite and sodium thiosulfate were administrated immediately. His condition deteriorated, and hyperlactatemia progressed, in spite of the administration of these two drugs. Hypoxia and hyperlactatemia also progressed. As a result, the patient was intubated and treated with hydroxocobalamin. Dimercaprol was also administered because the consumed poison contained gold. Following these treatments, the patient's condition improved. He was extubated on the 2^nd hospital day and showed a good recovery. Thereafter, he was moved to another hospital to receive treatment for his schizophrenia. We experienced a case of cyanide poisoing which is rare in Japan. We report this case while focusing on the appropriate antidotes that should be administered to such patients.

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A 39-year-old man suffered from cardiac arrest due to drowning in a swimming pool after drinking and eating. Bystander-initiated cardiopulmonary resuscitation (CPR) including mouth-to-mouth ventilation was performed for approximately 2 min, which restored his spontaneous circulation and breathing at the scene. On arrival at our hospital, abdominal distension, hematemesis, and tracheal obstruction due to the aspiration of gastric contents were observed. Chest CT scan revealed reticulonodular infiltrates and ground-glass opacity with a gravitational density gradient in the bilateral lung fields, suggestive of acute respiratory distress syndrome (ARDS) associated with drowning. Abdominal CT image revealed gastric dilatation and massive pneumoperitoneum. A diagnosis of upper gastrointestinal perforation, most likely due to the bystander-initiated CPR was made, and an emergency laparotomy was performed. A longitudinal laceration approximately 7 cm in length was found from the right anterior wall of the abdominal esophagus to the lesser curvature of the stomach, and was repaired. Although the postoperative respiratory management of ARDS required considerable effort, the trachea was extubated on the 9th day after admission, and discharged from the hospital on the 30th day, without any neurological sequelae. We consider that the reduction in the lung compliance associated with diffuse lung injury and/or the increase in airway resistance associated with tracheal obstruction, combined with the preceding gastric distension by drinking and eating, could facilitate gastric insufflation during the mouth-to-mouth ventilation, and eventually resulted in gastric perforation despite the brief duration of CPR.

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We report a case of septic shock due to Pasteurella multocida following a minor cat scratch. It is rare for local infection due to Pasteurella multocida to progress to systemic inflammation. A 68-year-old man with shock after blunt trauma was transported to our emergency room by ambulance. His inflammatory reaction was high, and his general condition suggested septic shock. He showed mild swelling and redness of the left elbow, left forearm, and left chest. He had sustained a cat scratch on left forearm 11 days earlier and had a chest blow trace. We cut the erythematous portion open but found no evidence of gangrenous fasciitis. However, Pasteurella multocida was identified by culture of a decoction and blood. We started antibiotics, but disseminated intravascular coagulation (DIC) appeared on the second ICU day. The DIC initially improved with treatment, but respiratory status did not. Super-infection spread to the lung, and the patient died on the 24th ICU day.

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We report a successful case of coil embolization for accidental pulmonary artery perforation due to pulmonary artery catheterization (PAC) that was performed as preoperative examination in the patient with severe aortic stenosis (severe AS). The patient was recovered from life-threatening circulatory shock by the emergency coil embolization with one-lung ventilation. The patient was extubated on day 2 and transferred from ICU to the general ward on day 5. Twelve days after embolization, elective aortic valve replacement (AVR) was performed and discharged after a 42-days hospital stay without complications.

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Objective: Insulin-like growth factor I (IGF-1) has neuroprotective and neurogenerative functions, and is a prognostic factor for cerebral ischemia. We measured serial changes in serum IGF-1 levels in patients resuscitated after cardiopulmonary arrest (CPA) and evaluated the relationship between IGF-1 levels and patient outcomes. Method: Patients who survived for at least 12 hours after return of spontaneous circulation (ROSC) were included in this study. All subjects were at least 15 years old, and none of them had potentially fatal trauma. Serum IGF-1 level was measured immediately after ROSC, and 1, 3, 6, 9 and 12 hours later. We divided the patients into 2 groups: survival group, patients who survived for at least 1 week after ROSC and non-survival group, patients who died within 1 week. Results: There were 16 objective cases; of these, 9 were in the survival group. The IGF-1 levels immediately after ROSC was 98.1±16.9 ng/ml in the survival group and 64.8±9.6 ng/ml in the non-survival group (mean±standard error of mean). Serial changes in IGF-1 levels differed significantly between the 2 groups (P < 0.05). Furthermore, IGF-1 levels were significantly lower in the non-survival group at all measurement time points (P < 0.05). Conclusions: Our preliminary data suggest that IGF-1 levels in patients with ROSC might predict patient outcomes.

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The purpose of this study was to investigate differences in the abilities of nurses to recognize hyperactive and hypoactive delirium. A mail survey was send to 3,755 nurses; the survey contained questions regarding the signs and symptoms of hyperactive and hypoactive delirium. Responses were made using original Likert-type scales. The participants were asked to rate the items that they judged signs and symptoms of delirium. The number of responses that were eligible for analyses was 1,681. A significant difference in the ability of nurses to recognize hyperactive and hypoactive delirium was observed. The recognition of hypoactive delirium was not influenced by the workplace or the number of years of nursing experience. These results suggested that, regardless of nursing experience or work place, hypoactive delirium is not well-recognized by nurses in Japan.

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Background: External cooling is a traditional method of promoting patient comfort as well as being a routine practice for antipyretic therapy. There has been controversy, however, about the indications for application of antipyretic therapy including external cooling for febrile patients in ICU due to the potential side effects of external cooling. We therefore investigated the understanding of antipyretic therapy and application of external cooling by Japanese ICU nurses (ICNs). Methods: We conducted a written questionnaire survey among ICNs at 7 ICUs. Results: We received 197 responses. The definition of fever by ICNs was 37.5 [37.15–38.0] °C (median [interquartile range]) , and the body temperature threshold for application of external cooling was 38.0 [38.0–38.5] °C. Ninety-nine percent of ICNs selected ice pack/pillow for external cooling. External cooling was recognized as an effective method of reducing fever by 85.1% of respondents. Cooling was applied at the patient's request (78.6%) and in response to increased body temperature (84.2%). Cooling practice did not change due to the sedation level in 44.7% of responses, and did not change due to infectious state in 70.7% of responses. Conclusions: Insufficient knowledge and inappropriate decision making for application of cooling by ICNs is suggested.

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