Hydroxyethyl starch (HES) is the most frequently used colloid worldwide. In addition, low molecular weight HES is usually not associated with kidney injury or bleeding. However, recent clinical trials have revealed that HES, particularly 6% HES (130/0.4), is associated with kidney injury in septic patients. The current evidence for perioperative 6% HES (130/0.4) administration is difficult to assess because of research misconduct by Dr. Boldt. Further, in 2012, 6% HES (70/0.5) is the only formulation available in Japan. Thus, although perioperative 6% HES (70/0.5) is not associated with either kidney injury or bleeding, very few clinical trials have evaluated its efficacy or side effects. Because the safety of 6% HES (70/0.5) with regard to sepsis has not been confirmed yet, it should therefore be used with caution in clinical settings.

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Purpose: Dr. Daren K. Heyland, Queens University, Canada, has been leading the International Nutrition Survey (INS), international cross-sectional survey regarding nutritional therapy in ICU since 2007. The present subgroup analysis of data from 9 Japanese ICUs participating INS 2011 database aimed to evaluate our current nutritional therapy. Methods: Adult patients receiving mechanical ventilation were included. Main outcome variables were nutritional dose, contents, and timing of initiation. Japanese data were then compared with those from Asia and the other sites. Results: In Japanese ICUs, mean values of administered energy/target energy ratio, administered protein/target protein ratio, and percentage of patients receiving nutritional therapy were well below those in Asian and other sites ICUs. In Japan, the initiation timing of enteral nutrition was delayed compared with other countries. Discussion: From this subgroup analysis of large international survey, nutritional therapy in Japanese ICUs has a room for the improvement. This analysis could be a good opportunity to improve nutritional therapy in each participating ICU. More ICUs will be invited for the INS 2013 to improve nutrition therapy in Japan.

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During the period from October to December 2009, we tried noninvasive positive pressure ventilation (NPPV) management in 14 patients with pneumonia infected by novel influenza A (A/H1N1pdm) virus, aged 4 to 12 years old, who had respiratory distress with hypoxemia (SpO₂ <95% under oxygen), but without unconsciousness. NPPV management made improvement of respiratory distress within 24 hours in 12 patients. However, NPPV intervention was not accepted in another 8-year-old patient, and did not improve respiratory distress in the other 9-year-old patient. Further investigation is necessary to determine effects of NPPV management in children with pneumonia infected by A/H1N1pdm.

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Human parechovirus (HPeV) infections exhibit various symptoms which are prone to becoming serious during the neonatal period and early infancy, causing septic shock or encephalopathy and possibly leading to death and/or serious neurologic aftereffects. We hereby report on our experience with two infant cases in which septic shock was caused from HPeV infection andintensive care management was required. The case 1 was a 1-month-old boy observed with septic shock, encephalopathy, and intestinal obstruction. Nine days of intensive care were required, including 7 days of respirator management. The case 2 was a 1-month-old boy observed with sepsis. Three days of intensive care were required. In these two cases, no apparent aftereffects were observed upon discharge from the hospital. HPeV infection in newborns and infants may become serious, causing aftereffects in the central nervous system; therefore, appropriate intensive care management and medium to long-term follow-up are necessary.

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A 60-year-old male was transferred to our institution with sudden onset of dyspnea. Severe disturbance of consciousness, whole body cyanosis, and hypoxia were evident; therefore, he was admitted to ICU, and mechanical ventilation was instituted immediately. Chest radiographs revealed 80.0% of cardiothoracic ratio and pulmonary edema in both the lung fields. Further, transthoracic echocardiography revealed massive pericardial effusion; thus, pericardial drainage was performed. On day 3 of admission, the pericardial drain was removed. Subsequently, the patient's respiratory and circulatory condition worsened; therefore, the pericardial drain was replaced, which resolved his respiratory and circulatory condition. The patient was eventually extubated on day 11 of admission. Cardiac computed tomography and cardiac magnetic resonance imaging revealed a 3.0 cm mass on the anterior aspect of the right ventricle. On day 32 of admission, surgery was performed. Operative findings revealed a 3.0 cm mass at the right atrioventricular groove. Following resection of the mass, persistent leakage of lymph fluid was evident; therefore, a pericardial window was created. A diagnosis of cardiac lipoma was confirmed on the basis of the pathological findings. The patient's postoperative course was uneventful, and he was discharged on day 40 of admission. This case demonstrates that although cardiac lipoma is a rare benign cardiac tumor, in rare instances, it might result in respiratory failure due to substantial pericardial effusion.

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A small proportion of patients who survive severe traumatic brain injury (TBI) have symptoms suggestive of excessive sympathetic discharge, here termed “paroxysmal sympathetic hyperactivity (PSH)”, otherwise known as dysautonomia. PSH prolongs the ICU stay and is detrimental to the recovery of patients. This report presents two cases of PSH after severe TBI. Both patients had an admission Glasgow come scale (GCS) score of 4, and the onset of clinical episodes of PSH occurred on the seventh post-traumatic day in case 1 and on the first day in case 2. Both patients had episodes every day until the administration of gabapentin controlled the paroxysmal autonomic changes. PSH is an under-recognized, yet important, source of complications following TBI. The timely recognition of the clinical presentation of PSH is therefore important for intensivists.

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The mortality of septic shock patients is still high because of developing multiple organ failure with unstable hemodynamics. We treated septic shock patients with our hemodynamic multimodality strategy to improve outcome. We therefore retrospectively analyzed the outcome of 72 septic shock patients secondary to intra-abdominal infection. Hemodynamic strategy consisted mainly of noradrenaline and a small amount of vasopressin to maintain a mean blood pressure greater than 80 mmHg, and volume loading assessed by the left ventricular preload using cardiac echocardiography. The mean age was 75.8 years (range: 46-97) and the mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 25.3 (14-41). The mean 28-day mortality rate and the hospital mortality rate were 8.3% and 16.7% respectively, which was lower than the predicted mortality rate of 61.4% based on APACHE II score. Renal replacement therapy was needed in only 9.7% and no one developed chronic renal failure. In conclusion, the significantly lower mortality rate of septic shock patients treated in our ICU suggests that our hemodynamic multimodality strategy is effective for improving the clinical outcome.

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Patients with various diseases are admitted to the intensive care unit (ICU), regardless of the department responsible for treating them. Since the conditions of ICU patients can change rapidly, intravenous medications are often stopped and discarded for various reasons. Therefore, we have conducted a prospective observational study to learn more about the reasons intravenous medications were discarded and how much they cost. During the two-week observation period, 382 intravenous medications were discarded, and the total cost was 262,525 yen. Cardiac surgery patients had the highest number of discarded intravenous medications, and these medications were the most expensive. Among all medications, carperitide, followed by dexmedetomidine, was the most costly medication discarded. “Change in the treatment course” was the most common reason for discarding medications. This study revealed the reasons for discarding intravenous medications and the related cost during daily clinical practice in our ICU. It seems the active participation of pharmacists in daily practice would help decrease unnecessary medical expenditure in the ICU.

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[in Japanese]

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