The prevalence of cardiovascular morbidity and mortality is higher in patients with chronic kidney disease (CKD), especially those with end-stage renal disease, than in the general population. Congestive heart failure (CHF) is a representative cardiovascular disease. Although atherosclerotic coronary artery disease (≥75% stenosis) is the main cause of CHF, left ventricular hypertrophy and increased aortic stiffness may hasten the progress of myocardial ischemia in CKD patients with mild to moderate (<50%) coronary stenosis. Myocardial ischemia or CHF markedly increases the risk of sudden cardiac death (SCD) in patients with CKD. Finally, we review herein the data to support the use of pharmacologic and device-based therapies for the prevention of cardiovascular events including myocardial ischemia, CHF and SCD.

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As knowledge of the pathophysiology of organ dysfunctions has been increasing, so the survival of critically ill patients has been improving. After ICU admission, patients with hematological malignancies, however, are still at high risk. We retrospectively evaluated outcome, and risk factors related to mortality of such patients admitted to our ICU. Reviewing medical records of patients admitted between 2005 and 2011, we collected data for age, gender, reasons for ICU admission, Acute Physiology and Chronic Health Evaluation (APACHE) II score, presence and progress of underlying disease, number of organ dysfunction, pancytopenia, treatment with or without bone marrow transplantation, ventilatory support, including noninvasive positive pressure ventilation (NPPV), cause of death, length of ICU stay, ICU mortality, and hospital mortality. Of the 35 patients we found with hematological malignancies, 20 (57.1%) died in the ICU. ICU mortality was lower in patients with only NPPV than those who were intubated. Number of organ dysfunction was also related to ICU mortality. Patients with hematological malignancies remained poor prognosis. NPPV was thought to be effective to care respiratory failure of those who did not cause severe organ dysfunction.

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We presented a two-month-old girl with severe autoimmune hemolytic anemia (AIHA) who was successfully treated by extracorporeal membrane oxygenation (ECMO). The patient visited her previous physician for poor complexion; with anemia subsequently noted. Due to a positive direct Coombs test which rendered cross-matching test unsuitable, the patient was transferred to our hospital without any blood transfusion. At admission, she was in a state of shock with respiratory distress, requiring emergency attention that included tracheal intubation, type O Rh+ erythrocyte transfusion and rapid fluid resuscitation. Initial blood test showed hemoglobin level of 1.6 g/dl, at pH 6.76, with -27.7 mmol/l of base excess and 22 mmol/l of lactic acid. Echocardiography revealed significant impairment of left ventricular contraction. Catecholamine treatment did not recover the cardiogenic shock, and ECMO was eventually started five hours after admission. The ECMO treatment was effective for the recovery from the cardiogenic shock. The patient was withdrawn from ECMO on day 5, and was discharged without any neurological deficit. This is the first report of ECMO being used for infant cardiogenic shock arising from AIHA. Going forward, we propose ECMO as an important consideration for the management of severe AIHA.

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Since the recent report, airway pressure release ventilation (APRV) may improve the hemodynamics than conventional positive pressure ventilation after bidirectional cavopulmonary shunt (BCPS) and Fontan operation. We present the case a four-month-old boy with asplenia syndrome and total anomalous pulmonary venous connection (TAPVC). He had undergone TAPVC repair three days after birth and BCPS three months after birth. Because his superior vena cava (SVC) pressure was 19 mmHg and venous collaterals increased, we could not wean the patient from mechanical ventilation for more than a month. Subsequently, APRV with spontaneous breathing was initiated (F_IO₂ 0.8, T high 2.5 sec, T low 0.5 sec, P high 15 cmH₂O, P low 0 cmH₂O) with the goal of enhancing pulmonary blood flow that is accompanied by a decrease in intrapleural pressure to < 0 cmH₂O; this led to a prompt decrease in SVC pressure (19 mmHg to 14 mmHg) and amelioration of cyanosis. He was extubated four days after APRV initiation (F_IO₂ 0.5, T high 2.2 sec, T low 0.3 sec, P high 6 cmH₂O, P low 0 cmH₂O). This case report indicates that APRV can be one of the options after BCPS in infants.

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We treated a patient with flecainide intoxication who presented with traumatic shock and ventricular rhythm on initial examination. The patient was an 89-year-old man who had fallen over while riding his motorized bicycle. He was lucid on arrival at the hospital; however, he exhibited ventricular rhythm with a systolic blood pressure of 60-70 mmHg and a heart rate of 75 /min. Ventricular rhythm was considered the cause of low blood pressure, electrical defibrillation was attempted but was failed. Sinus rhythm was restored by the administration of intravenous amiodarone. Coronary angiography was performed to ascertain the cause of the ventricular rhythm, but no evidence of acute coronary syndrome was found. Ventricular rhythm recurred at the end of this study; however, continuous intravenous amiodarone was initiated and sinus rhythm was again restored. The patient had a history of myocardial infarction and atrial fibrillation and had been taking oral flecainide, which resulted in a high concentration of flecainide in the blood and he was diagnosed with flecainide intoxication. Elevated blood concentrations of antiarrhythmics may induce the development of fatal arrhythmias. Detailed confirmation of patients' medical history, evaluation of blood concentrations of drugs, and familiarity with treatment methods are essential.

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A 63-year-old man visited a local clinic because of fever. He tested positive for influenza virus A H1N1 antigen, and was administered oseltamivir. On the fifth day of illness, he showed severe respiratory failure. Therefore, he was transported to our hospital, placed on noninvasive positive airway pressure ventilation, and started on peramivir, short-term high-dose steroid therapy. On the sixth day of illness, he developed disseminated intravascular coagulation (DIC), which was treated with anticoagulation therapy. Because the dyspnea worsened, he was intubated on the 13th day of illness, and placed on extracorporeal membrane oxygenation (ECMO) on the next day. However, because his condition did not improve, he had to be placed on ECMO for a long period of time. The patient's condition was complicated by upper gastrointestinal bleeding on the 34th day, and he died of multiple organ dysfunction on the 52nd day. This case suggests that such patients should be carefully managed with bleeding complications in mind, because treatment with ECMO is associated with the development of DIC-like conditions.

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A 76-year-old man undergoing follow-up examinations for emphysema was admitted to our hospital with severe hypoxemia. We diagnosed pneumonia and empyema and initiated mechanical ventilation to treat the hypoxemia. However, the patient developed acute respiratory distress syndrome (ARDS), and CO₂ retention was observed; therefore, we set the ventilator in the bilevel positive airway pressure (BIPAP) mode with a plateau pressure of 30 cmH₂O and respiratory rate of 35 /min; however, CO₂ retention and acidosis did not improve (PaCO₂ 58.6 mmHg; pH 7.201). We initiated extracorporeal CO₂ removal (ECCO₂R) and observed improvement in PaCO₂ (38.1 mmHg) and pH (7.396) for 3 hours. The ECCO₂R was stopped on the 6th ICU day and extubation was performed on the 11th ICU day. ECCO₂R seemed to be effective for ARDS cases involving difficulty in management of CO₂.

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[in Japanese]

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