Ventilator-associated pneumonia (VAP) is a type of nosocomial pneumonia that occurs in patients undergoing mechanical ventilation. Is a “zero” incidence of VAP possible? Several recent studies on VAP prophylaxis have shown the efficacy of the “VAP bundle”, which is a combination of several patient care processes. One of the most famous VAP bundles is “the Ventilator Bundle” of the Institute for Healthcare Improvement (IHI). This bundle consists of 5 components, elevation of the head of the bed, daily “sedation vacations” and assessments of the readiness for extubation, peptic ulcer disease prophylaxis, deep venous thrombosis prophylaxis, and daily oral care with chlorhexidine. The Japanese Society of Intensive Care Medicine also presented a new VAP bundle (JSICM-VAP bundle) in 2010. Surveillance is indispensable for the evaluation of such bundles, and the Japan Nosocomial Infections Surveillance (JANIS) data for VAP is available in Japan for the years 2000 and onwards. However, the criteria for the diagnosis of VAP differ between surveillance and clinical diagnosis. Therefore, the Centers for Disease Control and Prevention (CDC) have proposed new surveillance criteria for “ventilator-associated events (VAEs)” that do not limit such events to VAP. A VAP incidence of zero is difficult, however, because the spread of VAP bundles depends on a team approach centered on paramedical staff, making it possible for patient prognosis to be improved with improvements in VAP prophylaxis.

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Objective: Recently we have conducted preventive interventions against decubitus ulcers by a team of nurses. In this study, we tried to evaluate the effectiveness of these interventions by analyzing the factors in the development of decubitus ulcers in patients. Method: Three hundred seventy nine patients brought into the Advanced Critical Care and Emergency Center of Okayama Univ. Hospital were selected as the subjects. Among them, 203 patients, for whom the assessment of decubitus ulcer prevention had been made by the nursing team, were allotted to the intervention group. And remaining 176 patients were allotted to the control group. We compared the incident rates of decubitus ulcers between the intervention group and the control group and, at the same time, we investigated into its risk factors too. Result: The number of those who had developed decubitus ulcers was 20 (11%) in the control group and 9 (4%) in the intervention group, which shows the incidence rate of decubitus ulcers was reduced. It was found from logistic analysis that the albumin value and bony prominences are a risk factor of decubitus ulcer development and that the decubitus ulcer prevention by the nursing team reduced the risk of decubitus ulcer development. Conclusion: Decubitus ulcer prevention by a nursing team are beneficial for reducing decubitus ulcer development.

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Objective: We hypothesized that the transporting efficiency of aerosol nebulization could increase ventilation by reducing the impact of the trigger flow during mechanical ventilation. This study was aimed at evaluating the volume of the transporting aerosol by trigger flow and proposing a new position of the ultrasonic nebulizer in the circuit. Methods: In a conventional circuit configuration, the nebulizer was located at the edge of the Y-piece, and in the proposed circuit configuration, the nebulizer is located between the Y-piece and the endotracheal tube. In both configurations, the filters were set at the other edge of the Y-piece and the other side of the endotracheal tube. Ten percent saline (10 ml) in the nebulizer unit with filter cap was nebulized for 30 minutes. The weight of the filters before and 30 minutes after nebulizing were measured, and the delivered and lost percentages were calculated. Results: The delivered aerosol percentage in the proposed method was significantly higher compared to conventional method. Simultaneously, the lost aerosol percentage in the conventional method was significantly higher. Conclusion: The proposed method showed the superiority of our new position of the nebulizer to the conventional.

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Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication of controlled ovarian stimulation, and its main pathophysiology is increase of capillary permeability, especially in the lungs. There has been no reported case of OHSS documented by quantitative evaluation of vascular permeability. Here we report a case of OHSS in which we used PiCCO^® (Pulsion Medical Systems, Germany) to obtain numerical data for the clinical course of the pathophysiological status. A 30-year-old pregnant female developed OHSS after infertility treatment and was admitted to our hospital due to increased pleural effusion and ascites. On the 11th hospital day, she fell into cardiac arrest and was transferred to the ICU after successful resuscitation. She needed 20 cmH₂O of PEEP for maintenance of appropriate oxygenation on a mechanical ventilator. An initial examination using a PiCCO^® catheter showed that the extravascular lung water index (EVLWI) was 24.8 ml/kg and pulmonary vascular permeability index (PVPI) was 5.8. After vigorous body fluid and respiratory management, EVLWI and PVPI decreased to 6.2 ml/kg and 2.2, respectively, on the 4th ICU day. She was successfully weaned from the mechanical ventilation and delivered a baby by cesarean section. Both the mother and child are doing well. PiCCO^® monitoring provides useful quantitative information in evaluating the clinical condition of OHSS.

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Ventilator-associated pneumonia (VAP) is the most frequent hospital-acquired infection among ventilated patients. The purpose of this study was to evaluate factors affecting the development of VAP and to verify the hypothesis that postural change decreases the incidence of VAP. We performed a retrospective observational study on patients who had been admitted to the emergency room of a Showa university hospital between January 2008 and September 2010. A total of 111 patients who matched the inclusion criteria were involved in this study. VAP developed in 32 patients (28.8%); compared to the patients without VAP, the ones who developed VAP had greater amounts of transfusion and higher rates of blood transfusion, enteral nutrition, and continuous infusion of muscle relaxant. Multivariate logistic regression analysis revealed that a longer duration of mechanical ventilation was independently associated with the development of VAP. An increase in postural change within 24 hours of endotracheal intubation did not have influence on the incidence of VAP. Our results suggest that an increase in postural change within 24 hours of endotracheal intubation may not prevent the incidence of VAP.

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We report a 35-year-old man with early-onset diabetes who experienced cardiac arrest due to concurrent diabetic ketoacidosis (DKA). The patient had been managed on oral medication for type 2 diabetes. He had general malaise and asked a neighborhood physician to make a house call. As he lost consciousness during the examination, he was transported to the emergency department of our hospital. Despite cardiac arrest after arrival, spontaneous circulation was restored after 31 minutes of cardiopulmonary resuscitation and he was admitted to the ICU. At the time of ICU admission, he had marked hyperkalemia, hyponatremia, and hyperglycemia as well as hemoconcentration due to osmotic diuresis. Blood sugar and electrolyte corrections, as well as circulatory control, while conducting mild hypothermia therapy, achieved improvement and the patient was discharged from the ICU on day 13. Although type 2 diabetes is basically ketosis resistant, it was assumed that drinking large quantities of soft drinks had induced so-called soft drink ketosis, which is accompanied by acidosis and the induction of hyperkalemia, ultimately resulting in cardiac arrest.

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A 21-year-old man who was diagnosed with acute myocarditis was referred to our hospital in a state of cardiogenic shock. He was treated with carperitide, steroid therapy, and intra-aortic balloon pumping for hemodynamic support under mechanical ventilation. Despite the initial therapy, hemodynamic conditions rapidly deteriorated and the patient had a cardiac arrest on day 12. We initiated percutaneous cardiopulmonary support with mild therapeutic hypothermia, following which his hemodynamics improved with favorable neurological recovery. On day 16, the cannulation sites of the left superficial femoral artery (SFA) and the right femoral vein were closed; however, refractory bleeding from the surgical wounds suddenly occurred on days 24 and 29, and the patient underwent emergent angioplasty of the left SFA with a right great saphenous vein patch. The surgically-resected specimen from the left SFA revealed extensive vessel necrosis with bacterial organisms, but no neutrophil infiltration. These results suggested that the high-dose steroid use and therapeutic hypothermia led to poor wound healing caused by immunosuppression. The patient recovered during careful rehabilitation and was discharged from the hospital on day 73.

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[in Japanese]

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