During the stress response, the energy demand of the body is fulfilled by the interaction between the endogenous and exogenous energy supplies. The stress response physiologically leads to the catabolism and provision of endogenous energy substrates, despite an adequate exogenous energy supply. Therefore, there is a greater likelihood that the sum of the endogenous and exogenous energy substrates is substantially in excess of the total energy expenditure and eventually causes overfeeding with negative impacts on the metabolic response when increasing the exogenous energy supply without regard for the endogenous energy supply. Even during the acute phase of severe stress, conventional nutrition support therapy has adopted the basic concept of exogenously providing all of the so-called “energy requirement” which is equated to predicted or measured resting energy expenditure. As a result, nutrition support therapy might be expected to inevitably promote the risk of overfeeding. In fact, there are astoundingly few studies that have been able to demonstrate clinically relevant benefits with nutritional support, especially in relation to critical illness. Furthermore, recent investigations have demonstrated that even the appropriate quantity of energy and/or protein does not appear to consistently improve patient outcomes, especially in relation to body composition, but when given in excess can exert adverse effects such as hyperglycemia and various sorts of nutritional stress. In the light of these issues, the author recommends a new concept of caloric provision based on energy substrates kinetics under the stress response.

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The gut immune function has developed with the presence of intraluminal bacterial flora which leads to the outside world, accompanied by the growth of mucosal barrier to protect these bacteria from invasion. In contrast, the gut is the most vulnerable organ to any types of insult, hence its nickname the “canary of the body”, and excessive inflammatory responses evoked by a variety of insults could, in turn, have deleterious effects on this barrier structure and function. Together with the abnormal overgrowth of bacterial flora, these changes could make critically ill patients even worse. A recent study indicates that gut-associated lymphoid tissue (GALT) tightly presented around the gut plays a consequential role in the immune system of the living body. In this review, we discuss the implications of the gut immune function in the critically ill.

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The onset of delayed neurological sequelae (DNS) is one of the prognostic factors in the subacute and chronic phases of carbon monoxide (CO) poisoning. The pathophysiology of DNS is associated with neural cell death and demyelination due to ischemia caused by CO exposure. DNS is diagnosed by a lucid interval after acute CO poisoning and delayed onset of neuropsychiatric symptoms such as cognitive and personality changes, parkinsonism, incontinence, dementia, and psychosis. Otherwise, a battery of neuropsychological tests is useful in detecting DNS. The incidence of DNS has been reported to be 0-46% in CO poisoning patients. Consciousness disturbance on admission, age of 36 years or more, higher carboxyl hemoglobin levels, exposure intervals greater than or equal to 24 hr to start the therapy, and elevation in white blood cell count (> 10,000 /μl) were reported as predictive factors for DNS. Hyperbaric oxygen (HBO) therapy might be effective in preventing DNS, but this remains controversial. Further examination is needed to clarify the efficacy of HBO to prevent DNS.

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Quality indicators are essential to improve quality of care in the health care setting. Nursing-sensitive indicators (NSIs) consist of direct assessment of actual nursing practice or results strongly influenced by the care provided by nurses. In the critical care setting, it is challenging to develop generally acceptable NSIs because the majority of delivered care is provided by a variety of professionals, and the nursing staff's responsibilities may vary among different ICUs. The development of NSIs in the critical care setting is necessary, in addition to defining what the critical care-specific responsibilities of the nursing staff should be under such settings.

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Objectives: A key element in enhanced postoperative recovery is early mobilization. However, this may be hindered by orthostatic hypotension (OH). The purpose of the present study was to investigate the incidence of OH during early mobilization and to identify independent risk factors for OH in patients after gastrectomy for gastric cancer. Methods: A total of 211 patients who had undergone elective gastrectomy for gastric cancer with perioperative physiotherapy between 2004 and 2011 were examined. The causative factors and incidence of OH were all clearly reported in the clinical records. Results: The incidence of OH on day 1 after gastrectomy was 37% (78 cases). In the multiple logistic regression model, ischemic heart disease [odds ratio (OR) 2.317, 95% confidence interval (CI) 1.118-4.805, P = 0.024], the postoperative serum albumin level (OR 0.362, 95%CI 0.180-0.725, P = 0.004), the postoperative WBC count (OR 1.008, 95%CI 1.000-1.017, P = 0.043) and postoperative mean arterial pressure (OR 0.968, 95%CI 0.947-0.991, P = 0.006) were identified as independent risk factors for OH. Conclusion: The early posture cardiovascular response is impaired after gastrectomy, thus leading to a high incidence of OH. The presence of ischemic heart disease, the postoperative serum albumin level, the postoperative WBC count and postoperative mean arterial pressure were significant factors for the development of OH.

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Objective: The purpose of this study was to examine the relationship between the presence of Howell-Jolly bodies (HJb) and spleen volume and to assess the change in spleen volume during the course of treatment. Methods: The study included 39 patients (28 male, 11 female), with a spleen volume of ≤100 cm³. HJb were detected on a peripheral blood smear (performed at least twice) and spleen volume was determined by CT. Moreover, the change in the spleen volume of HJb-positive patients was assessed by several CTs. Results: The patients were divided into 3 groups according to the presence of HJb on peripheral blood smear tests: group I, HJb were detected during all peripheral blood smear tests; group II, HJb were detected during at least one of the tests; and group III, HJb were not detected during any test. The mean spleen volumes of the male patients in groups I, II, and III were 25.6 cm³, 45.3 cm³, and 71.1 cm³, respectively. The mean spleen volumes of the female patients in groups II and III were 59.8 cm³ and 62.2 cm³, respectively. Group I had no female patients. Changes in spleen volume were studied in 11 patients. The spleen volume remained almost constant in 8 patients and increased by 2-fold in 3 patients because of congestion. Conclusion: Our results suggest a correlation between the appearance of HJb and spleen volume in male patients. The spleen volume did not change in most cases, when the general condition of the patients was stable. The appearance of HJb and spleen volume may be indications of the immunological function of the spleen.

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This report presents 6 cases of acute lithium intoxication that were treated over the past 10 years. The range of the lithium overdose was 2,800 mg to 16,800 mg, and the overdose in all cases was greater than 40 mg/kg, which is the dose considered to induce lithium intoxication. The lithium serum concentration of two cases was greater than the lethal concentration (4 mmol/l). One of the two cases was treated with continuous hemodiafiltration (CHDF). The serum lithium concentration of the patient without CHDF gradually decreased and remained at a supranormal range of 36 hours after the treatment. On the other hand, the serum lithium level of the case with CHDF rapidly decreased and it finally reached the therapeutic level, and no post-dialysis rebound effect in the lithium concentration was detected. The serum lithium concentration cannot be easily measured in the clinical setting and the patient's conditions are not always in line with the serum lithium concentration. Therefore, in cases with toxic serum concentration or when an amount greater than 40 mg/kg of lithium is taken, CHDF may provide the most effective clearance of lithium from the circulation.

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Posterior reversible encephalopathy syndrome (PRES) is a clinical entity characterized by neurological symptoms and radiological findings of symmetrical vasogenic edema. There have been various reports of this syndrome in a variety of clinical settings. We describe here a case of PRES from acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise (ALPE). A 16-year-old male developed abdominal pain with nausea and vomiting following physical exercise at school (anaerobic exercise, in the form of 200-meter track racing), which lasted for 3 days from onset. He was admitted to our hospital with seizures and a disturbance of consciousness. Laboratory tests on admission revealed a serum creatinine level of 5.05 mg/dl and uric acid of 13.1 mg/dl, without any elevation of serum myoglobin and creatinine phosphokinase. The non-oliguric acute renal failure improved without any treatment other than proper volume load and diuretics. Renal computed tomography scan, performed several hours after contrast medium administration, revealed multiple wedge-shaped areas of contrast enhancement; therefore, the patient was diagnosed with ALPE. Brain CT showed no abnormal findings, although cranial MRI with T2-weighted and fluid attenuated inversion recovery (FLAIR) imaging revealed increased signal intensities in the subcortical white matter bilaterally. Since the apparent diffusion coefficient (ADC) map showed a vasogenic edema pattern, the patient was diagnosed as PRES. In diagnosing PRES, it may be essential to bear the possibility of PRES in mind. MRI provides a useful means of diagnosis.

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We report a case of external pacemaker malfunction analyzed by pacing system analyzer for complete atrio-ventricular block following mitral valve replacement and maze procedure. The malfunctions were inappropriate heart rate increase and marked bradycardia. The increase in heart rate resulted from safety pacing by crosstalk based on sensing of atrial pacing stimuli during ventricular refractory period. The bradycardia resulted from inhibition of ventricular pacing by crosstalk based on sensing of atrial pacing stimuli after ventricular refractory period. Hemodynamics was stable even during the malfunctions, because marked bradycardia was not sustained. The height of the crosstalk wave was higher than that of auto-atrial wave. Therefore, the atrial pacing output was decreased. The external pacemaker in postoperative cases with DDD pacing would be managed safely by using the pacing system analyzer for placement of epicardial leads.

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[in Japanese]

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