Microalbuminuria is an established risk factor for renal disease progression in patients with diabetes mellitus, and it is a documented risk factor for increased cardiovascular event among patients with diabetes or general population. Moreover, a lot of kinds of studies were conducted in ICU. Microalbuminuria as well as procalcitonin and CRP was a biomarker of infection, and as well as Acute Physiology and Chronic Health Evaluation II score, and Sequential Organ Failure Assessment score was a predictive factor for outcome in septic patients. Microalbuminuria increased after operation and improved soon. Microalbuminuria increased but the elevation due to the measurement timing and severity in burn patients. Microalbuminuria increased and might be associated with microvascular permeability after severe stroke patients. Microalbuminuria was a more accurate predictive ability for acute kidney injury than estimated glomerular filtration ratio. Because these findings were supported with the studies of a single center and relatively small population, future studies must be conducted to confirm and validate the findings.

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Objectives: To determine the rate at which rehabilitation was delayed after coronary artery bypass grafting (CABG) and to identify factors related to that delay. Methods: Subjects were 529 patients who underwent elective CABG followed by standard rehabilitation at 8 facilities nationwide. Patients were divided into 2 groups depending on whether their rehabilitation was successful or if it was delayed. If patients were able to walk unassisted within 8 days of surgery, their rehabilitation was deemed to be successful. If patients took 9 days or longer to walk unassisted, their rehabilitation was deemed to be delayed. Factors thought to be most closely related to delayed rehabilitation were chosen from 7 categories. Basic patient information, preoperative lab results, and surgical information were assembled, and factors related to delayed rehabilitation were examined. Results and Discussion: Postoperative rehabilitation was delayed at a rate of 10.4%, and that delay was most often “heart-related”. Logistic analysis identified several factors for delayed rehabilitation, including a history of musculoskeletal disorders, preoperative Cr and preoperative estimated glomerular filtration rate (eGFR). Conclusion: Having a history of musculoskeletal disorders and impaired renal function prior to surgery delayed postoperative rehabilitation.

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Objectives: We investigated the effect of oxygen flow rates and fitting conditions of the non-rebreathing oxygen mask with a reservoir bag (RM) on the F_IO₂ using a high-fidelity patient simulator (HPS). Methods: We utilized an adult standard male model of the HPS (minute ventilation=9.8 l/min). After 10 min of spontaneous breathing with room air, oxygen was administered at flow rates of 6, 8, 10, 12, and 15 l/min with a loosely fitted RM, a gently fitted RM, and a tightly fitted RM. Measurements of the partial pressure of oxygen detected in simulated alveoli (P_AO₂) were recorded every 5 min following the changes in the oxygen delivery flow rate. The F_IO₂ was calculated using the following formula: P_AO₂=760 (atmospheric pressure)× F_IO₂-partial pressure of alveolar carbon dioxide (P_ACO₂). The percentage of air in inspired gas was calculated at each measuring point. Results: The F_IO₂ with a loosely fitted RM, a gently fitted RM, and a tightly fitted RM reached 0.64, 0.85, and 0.90, respectively, at an oxygen flow rate of 15 l/min. For the tightly fitted mask, the percentages of air in inspired gas was 52, 39, 30, 22, and 13, and the F_IO₂ was 0.59, 0.69, 0.76, 0.83, and 0.90 at oxygen flow rates of 6, 8, 10, 12, and 15 l/min, respectively. Conclusion: With respect to the respiratory conditions of a simulated standard adult model, the F_IO₂ was obtained at the expected level with the tightly fitted RM. However, the F_IO₂ decreased and the inspiratory resistance increased at low oxygen flow rates with a tightly fitted RM. A decrease in the F_IO₂ was significant at any oxygen flow rate with a loosely fitted RM. Therefore, oxygen flow rates should not be lowered at any fitting conditions of a RM.

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Background: We investigated the relationship between protein C (PC) activity and the prognosis of septic disseminated intravascular coagulation (DIC). Methods: We conducted a retrospective, single center study of 50 cases of septic DIC, including 42 of recovery from DIC, between October 2008 and January 2011. We investigated the relationship of severity, organ damage, and coagulation and fibrinolysis factor with prognosis using receiver operating characteristic curve. Results: Both antithrombin (AT) and PC activities at the time of DIC diagnosis correlated to prognosis of septic DIC and recovery from DIC. The cut-off values for AT and PC activities associated with survival were ≥50.2% and ≥39.9%, respectively. AT activity had a higher negative predictive value and sensitivity, whereas PC activity had a higher positive predictive value and specificity. Conclusion: Similar to AT activity, PC activity is useful to predict the prognosis of septic DIC.

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Objectives: We assessed the combination effect of use of genetic recombinant human soluble thrombomodulin (rTM) with antithrombin (AT) in the treatment of sepsis-induced disseminated intravascular coagulation (DIC) after conducting surgical interventions. Methods: We performed a retrospective analysis of septic shock patients admitted to our intensive care unit between August 2008 and February 2012 who were diagnosed as having DIC. The patients underwent surgical interventions for infection. The patients with sepsis who met the diagnostic criteria for acute DIC (JAAM) and showed an AT level of less than 70% were treated with AT products (AT group). The septic DIC patients treated with rTM in addition to the above treatment were designated as the AT+rTM group. Differences between the AT and AT+rTM groups were investigated to determine the effect of rTM by evaluating the clinical course according to the hemostatic markers and organ dysfunction during the treatment and the outcomes of the patients at 60 days. Results: The AT group and the AT+rTM group comprised 10 patients each. There were no significant differences in clinical characteristics and laboratory data except for AT activity on admission between the two groups. SOFA score, P/F ratio and the change of platelet count, FDP, and AT activity on the 3rd, 5th, and 7th days were not significantly different between the two groups. All patients in both groups survived 60 days after admission, and length of ICU stay, mechanical ventilation time, and continuous hemodiafiltration time over the period of observation were not significantly different between the two groups. Conclusion: Generally, treatment for septic DIC is directed towards the underlying problem or inciting cause. Early rTM treatment combined with AT after surgical intervention did not appear to be an influential strategy for the management of septic DIC.

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We report our experience with two cases of erroneous puncture of the vertebral artery (VA) that occurred during our attempt at central venous catheterization via the internal jugular vein (IJV). Case 1 was a 2-year-old girl with hemolytic-uremic syndrome caused by enterohemorrhagic Escherichia coli O-111. A dialysis catheter placed in the left ventricle via the VA was confirmed by radiography and computed tomography. Thereafter, a concomitant arteriovenous fistula was also found, which necessitated percutaneous embolization. Case 2 was a 14-year-old boy with supravalvular aortic stenosis who underwent patch enlargement of the aortic annulus. The central venous catheter was inserted during anesthesia induction, and aberrant intrusion of the catheter into the left ventricle was confirmed by radiography. Surgery was carried out under cardiopulmonary bypass, and the catheter was removed postoperatively, without any associated arteriovenous fistula formation. Erroneous puncture of the VA may cause serious complications. To prevent erroneous puncture of the VA, it is necessary to identify the VA located dorsal to the IJV under ultrasonic guidance, and to avoid piercing the posterior wall of the IJV. In addition, to ensure medical safety, improvement of the skills of the operators for the procedure through improvement of the teaching methods is desirable.

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Distigmine bromide, an anticholinesterase, is available for the treatment of strangury. Because this drug was reported to cause cholinergic crisis as a severe side effect, the clinical dose has been limited. However, cases of cholinergic crisis are still reported. We experienced a case of shock caused by severe pneumonia and paralytic ileus. Initially, the condition was considered as septic shock. However, it was later, diagnosed as cholinergic crisis because the patient took distigmine bromide and the serum cholinesterase level decreased significantly. Because most of the drug is excreted in the feces, drug concentration in the blood increases when gastrointestinal peristalsis decreases, which is observed in conditions such as paralytic ileus, we must be aware that cholinergic crisis may occur in patients with paralytic ileus.

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A case in which somatostatin analogue was effective in treating massive pleural and pericardial effusion secondary to alcohol-induced chronic pancreatitis is reported. A patient with alcohol-induced chronic pancreatitis and cirrhosis consulted his family physician for epigastric pain and poor appetite and was diagnosed with acute exacerbation of chronic pancreatitis. Thereafter, he was admitted to our hospital for further treatment. On admission, the calculated severity assessment score of acute pancreatitis according to the Japanese criteria was 2 prognostic points, while contrast-enhanced CT revealed grade 1 disease. Hence, we started ordinary therapy for acute pancreatitis. However, since the patient experienced aggravation of dyspnea due to accumulation of a large amount of pleural and abdominal fluids, he was moved to the ICU on the fifth day after onset of symptoms. Chest X-ray revealed a huge pleural effusion and echocardiography showed a large amount of pericardial fluid. The exudative pleural and pericardial fluid contained very high levels of amylase (70,000 IU/l), suggesting the existence of a pancreatic fistula. On the 16th day after symptom onset, we commenced continuous subcutaneous administration of somatostatin analogue. One week after administration, with decreasing pleural and pericardial fluids, his general condition improved. Diagnosis of the cause of pleural and pericardial exudate in this patient was difficult. However, the high level of amylase in pericardial fluid, and its decrease with administration of somatostatin analogue, led us to conclude that pancreaticopericardial fistula was the cause of the pericardial effusion in this case. The administration of somatostatin analogue seems to be effective in patients with pancreatic fistulas.

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Objective: To investigate and report cases of hanging admitted to our emergency medical center over the past 8 years. Method: We retrospectively examined medical records of 203 cases of hanging admitted to our center from January 2003 to June 2011. Results: Of the 203 cases, 154 were in a state of cardiopulmonary arrest (CPA) when the ambulance team arrived; none of them survived. While the prevalence of bystander cardiopulmonary resuscitation (CPR) was significantly higher in the second half than in the first half, there was no significant improvement in the outcomes. The results indicated that a score of 3 on Glasgow coma scale and occurrence of CPA were factors for bad prognosis. Conclusions: As with previous reports, we conclude that the prognosis of cases of hanging with out-of-hospital CPA is extremely poor.

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Deep venous thromboses are more likely to develop during pregnancy. A 39-year-old woman developed acute massive pulmonary embolisms and cardiac arrest during cesarean section. She was resuscitated with percutaneous cardiopulmonary support (PCPS). Heparin was continuously administered for anticoagulation. Thromboses in the pulmonary arteries were fragmented using a balloon catheter. She developed severe hemorrhage from the respiratory tract and abdominal cavity, and the hemorrhage was controlled by keeping the activating clotting time low. In addition to these complications, heparin-induced thrombocytopenia (HIT) occurred after withdrawal of PCPS and was treated with argatroban. She subsequently recovered without any complications and achieved full rehabilitation.

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[in Japanese]

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