Endotracheal intubation and Macintosh laryngoscopes have been long accepted as the gold standard for airway management. Recent advancements in video technology have led to the development of indirect video laryngoscopes, thus avoiding the need for direct visualization of the vocal cords. Tracheal intubation can be rapidly and safely accomplished during active chest compressions by indirect video laryngoscopes with endotracheal tube guides. Supraglottic airway devices have been widely accepted as the standard airway device in anesthetic practice, especially in Europe and the USA. These devices have proven useful not only in difficult airway management but to secure the airway during CPR (cardiopulmonary resuscitation) and hospital rapid response systems. Further developments in technology and devices are anticipated to improve patient safety and curative efficacy.

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The Organ Transplantation Act of Japan was amended in 2010. Consequently, the number of patients undergoing organ transplantations from brain-dead donors and left ventricular assist device (LVAD) implantation is increasing simultaneously. Randomized evaluation of mechanical assistance for the treatment of congestive heart failure (REMATCH) trial revealed the effectiveness of LVAD for end-stage heart failure, which also accelerates the implants of LVAD. In Japan, fewer patients undergo heart transplantation compared with those in the United States or European countries, and the waiting period for heart transplantation in Japan is far longer than that in the United States (960 days vs. 56 days). However, no definitive guidelines for managing such patients have been published yet. We attempted to provide an outline of LVAD (indication, devices, pre- and postoperative management including long-term outcomes) from our experiences and previously published articles.

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Objective: To assess the clinical factors affecting the reliability of a pharmacokinetic simulation model for vancomycin (VCM) in critically ill children. Materials and methods: We enrolled 84 patients admitted to our pediatric intensive care unit and treated with VCM between March 2010 and November 2011. The mean pediatric logistic organ dysfunction (PELOD) score was 10.7±10.6. The prediction error was calculated from the observed and predicted concentrations by using the pharmacokinetic simulation software. We analyzed which clinical factor affected the prediction error by using the univariate analysis. Results: The mean prediction error was −16±64%. We found that the PELOD score, percent fluid overload (%FO), and estimated creatinine clearance (estCCr) affected the prediction error. The prediction error was higher in patients whose PELOD score was ≥20 (12.4±68.0%, P < 0.05), %FO was ≥10 (13.1±42.7%, P < 0.05), and estCCr was < 50 (−44.8±80.6%, P < 0.05). Conclusion: The PELOD score, %FO, and estCCr affected the reliability of the pharmacokinetic simulation model for VCM in critically ill children.

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Objective The rapid response system (RRS) has been implicated in decreasing the incidence of unexpected cardiac arrest in wards and hospital mortality. It has recently been incorporated in medical safety campaigns in many countries. Our hospital implemented RRS aiming to reduce the incidence of cardiac arrest in wards. Methods: RRS, which was commenced in September 2009, could be activated by all doctors, nurses, and rehabilitation staff in the hospital. All cases were prospectively recorded. We conducted a before-and-after study to compare the incidences of unexpected cardiac arrest in wards and hospital mortality 24 months after RRS implementation. Results: There were 68 cases of RRS activation during the 24 months of the study (6.6 cases per 1,000 hospital admissions). The incidence of unexpected cardiac arrest in wards (from 0.70 to 0.68 per 1,000 admissions) and that of hospital mortality (from 8.56 to 7.62 per 1,000 admissions) remained approximately the same despite RRS implementation. However, ICU mortality rate in patients who were unexpectedly admitted to the ICU was significantly reduced [from 10.7% to 3.8%; relative risk 0.36, 95% confidence interval (CI) 0.13–0.98]. Conclusion: Although RRS implementation in our hospital did not contribute to a reduction in the incidence of unexpected cardiac arrest in wards and hospital mortality, the mortality rate in unplanned ICU admissions from ward was significantly reduced. The search for a better system and a regular audit is further required.

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Objective: S100B protein concentration increases in cerebrospinal fluid (CSF) after subarachnoid hemorrhage (SAH). Herein, we investigated the relationship between S100B protein concentration in CSF and the neurological outcome in patients with SAH. Methods: We studied 55 consecutive patients undergoing surgery within 48 hours after SAH between June 2006 and May 2008. A spinal drainage catheter was inserted through lower lumbar interspace before surgery. CSF was sampled, and S100B protein concentration was measured. General clinical data, Hunt-Hess (H-H) grade and Fisher group, aneurysm size and site, and blood glucose level were recorded at admission. Similarly, Glasgow coma scale (GCS) score and systemic inflammatory response syndrome (SIRS) score were recorded. At discharge, neurologic outcome was assessed with the Glasgow outcome scale. Results: Among 55 patients, 25 (45%) had unfavorable neurologic outcome. At admission, Fisher group, H-H grade, blood glucose, SIRS score, and S100B protein concentration in CSF were higher and GCS score was lower in patients with unfavorable neurologic outcome, compared with patients with favorable neurologic outcome. The area under the receiver operator characteristic curve of S100B protein concentration in CSF for unfavorable neurologic outcome was 0.65. Conclusions: Increase of preoperative S100B protein concentration in the CSF after SAH would be related to unfavorable neurologic outcome. However, S100B was not an accurate significant predictor of unfavorable neurologic outcome compared to other established prognostic factors.

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We report a case of hypertrophic cardiomyopathy diagnosed by endomyocardial biopsy, after cardiopulmonary arrest (CPA) initially suspected to be due to ischemic heart disease. An otherwise healthy 69-year-old male with treated hypertension had sudden CPA while playing tennis. Bystanders started cardiopulmonary resuscitation and performed automated external defibrillator within one minute. The patient was rescucitated and subsequently transferred to the emergency room by ambulance. On arrival, his vital sign were as follows: heart rate, 112 /min; blood pressure, 117/78 mmHg; Japan coma scale II-10. Electrocardiogram showed atrial fibrillation and ST depression in V2-V6. Echocardiography revealed mild diffuse left ventricular hypokinesis. Ischemic heart disease was suspected as the most likely cause of CPA and coronary angiography was performed, on which a 90% stenotic lesion of the middle left anterior descending artery was identified; percutaneous coronary intervention was performed. After intervention, left ventricular wall motion gradually returned to normal on echocardiography, and cardiac enzymes remained within normal limits. This case had some atypical features of ischemic heart disease, and we pursued further examinations including cardiac magnetic resonance imaging and electrophysiology examination, in which extrastimulus examination provoked non-sustained ventricular tachycardia. Subsequent endomyocardial biopsy detected tangled arrangements, and nuclear enlargement and concentration, consistent with hypertrophic cardiomyopathy. A cardiac defibrillator was placed. This case illustrates the importance of thorough investigation for combined heart disease, even when ischemic heart disease is thought to be a primary cause of CPA.

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Objectives: The aim of our study was to determine whether high flow-volume large size polymethyl methacrylate-hemodiafiltration (high performance-HDF, HP-HDF) leads to elimination of procalcitonin (PCT) in patients with septic shock. Patients and methods: In a prospective study, eighteen critically ill patients with septic shock treated with HP-HDF were evaluated. Blood concentrations of PCT were measured in prefilter and postfilter at 1 hour and 3 hours after set-up of HP-HDF. We measured the blood PCT levels of the patients the following day. Results: The postfilter blood levels of PCT were significantly lower than the prefilter blood levels of PCT at 1 hour and also 3 hours after set-up of HP-HDF. The PCT clearance of this extracorporeal circuit was significantly different between 1 and 3 hours. There was no significant difference of blood PCT concentration between the first and second ICU day. Conclusion: We conclude that PCT is removed from the blood of patients with septic shock during HP-HDF.

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Patients with Stanford type B acute aortic dissections complicated with malperfusion are at a high risk for open surgical repair. Thoracic endovascular aortic repair (TEVAR) has been used for patients with complications such as malperfusion. Patients who have undergone TEVAR show lower mortality and morbidity rates than those who have undergone open surgical repair. We experienced the case of a 79-years-old woman who had a Stanford type B acute aortic dissection complicated with acute kidney injury caused by renal malperfusion. We performed hemodialysis for acute kidney injury. The expansion of the false lumen caused narrowing of the true lumen and renal malperfusion. An emergent TEVAR was done under general anesthesia. We used intraoperative transesophageal echocardiography (TEE) to assist stent graft positioning and to evaluate blood flow of both true and false lumens. The patient's renal function was recovered, and she did not require postoperative hemodialysis. We conclude that TEVAR is useful for critical ill patients with Stanford type B acute aortic dissections complicated with renal malperfusion, and early diagnosis of renal malperfusion is important for preventing irreversible kidney injury.

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Severe combined immunodeficiency (SCID) is the most severe form of primary immunodeficiency. The hematopoietic stem cell transplantation is essential for the most types of SCID to survive. Early diagnosis and prevention of infection is important. We report a case of SCID and Pneumocystis jirovecii pneumonia, which occurred in a 4-month-old girl. She presented with slowly progressive respiratory failure and failure to thrive without an episode of fever. On admission, her SpO₂ was 85% (room air). Her WBC count was normal with low lymphocyte count, and her CRP value was normal. A chest X-ray revealed bilateral infiltrates and absence of thymus. In spite of standard antibiotic treatment, her respiratory condition exacerbated. Considering her atypical clinical course, we checked her immunological status and detected absence of T cell and B cell function. She was diagnosed as having SCID, and Pneumocystis jirovecii was detected in her sputum by PCR (polymerase chain reaction). Trimethoprim-sulfamethoxazole was started and her respiratory status improved, after which HLA (human leukocyte antigen)-matched umbilical cord blood hematopoietic stem cell transplantation was successfully done. When we take care of an infant with severe infection with atypical clinical course such as not-responding to standard antibiotic therapy, the possibility of primary immunodeficiency should be considered.

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We conducted a survey to assess knowledge and perceptions about sepsis. The questionnaire was delivered to the following categories of respondents: resident doctors without certification in intensive care medicine (D), nurses (N), medical students (MS), nursing students (NS), students in a university of science (SS), and patients who came to an outpatient clinic for preoperative assessment for anesthesia (P) (total n = 503). The term “sepsis” itself is perfectly recognized by respondents inside the medical community, but is recognized only by 53% of SS and 49% of the P. Thirty % of NS, 83% of SS, and 41% of P did not know the meanings of the word sepsis, while 33% of D, 47% of N, 45% of MS, and 32% of NS incorrectly answered that sepsis means “bacteria in blood”. The mortality of sepsis (28-50%) was correctly answered by 60% of D, 29% of N, 13% of MS, 15% of NS, 8% of SS, and 2% of P. The knowledge of the term itself is insufficient for people outside medical community. The correct knowledge of the definition and pathophysiology of sepsis is insufficient even for people inside the medical community. There is room for improving knowledge about sepsis for lay people and for health care personnel who are not critical care professionals.

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[in Japanese]

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[in Japanese]

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