Measurement of creatinine clearance (CCr) is widely used for the evaluation of kidney function. However, CCr measured with diuresis for 24 hours (24hrCCr) is time-consuming. While there have been reports on measurement of CCr with samples of urine collected in shorter intervals, there has been few reports on an one-hour urine sample for CCr measurement (1hrCCr). We compared 24hrCCr, as the standard measure, with 1hrCCr. Forty-two patients had 56 complete sets of 24hrCCr and 1hrCCr values. Agreement between methods was assessed using Spearman's correlation coefficients and Bland-Altman plots. Multivariate analysis was performed by multiple linear regression to identify independent etiologic factors associated with the percentage change between 24hrCCr and 1hrCCr. There was a significant correlation between 24hrCCr and 1hrCCr (r=0.72, P<0.0001) . Bias was 14.2 ml/min, and 95% limits of agreement were -59.8 to 88.2 ml/min. After multivariate analysis, the factors significantly associated with percentage change between 24hrCCr and 1hrCCr was urine creatinine concentration in the one-hour urine collection (P=0.015) , change in urine volume before the one-hour urine collection (P<0.0001) and change in estimated glomerular filtration rate (eGFR) (P=0.0002) . 1hrCCr is not an adequate substitute for 24hrCCr in an ICU setting. The discrepancy between 24hrCCr and 1hrCCr may be caused by measurement error and dynamic changes in kidney function.

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Introduction: Dexmedetomidine (DEX) is an alpha 2-adrenergic agonist that can be used for sedation of non-intubated patients in intensive care. Objectives: The goal of the study was to evaluate DEX as conservative therapy for pain relief, blood pressure control and comfort in patients with acute aortic dissection. Methods: The subjects were 14 patients with acute aortic dissection who underwent conservative therapy in the ICU of our hospital from January 2010 to February 2012. Use of supplemental drugs and intratracheal intubation for analgesia, sedation, blood pressure control and pulse control was evaluated retrospectively. Results: DEX was administered at doses of 0.07-0.79μg/kg/hr for a mean period of 132±56 hr in combination with nicardipine (0.008-0.14 mg/kg/hr) in 14 patients, landiolol in 5, fentanyl in 9, and nitroglycerin in 3 patients. Haloperidol and risperidone were used to maintain sleep at night in 6 and 2 patients, respectively. All patients were treated without intratracheal intubation. Conclusions: DEX was effective as conservative therapy for patients with acute aortic dissection.

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An 83-year-old female underwent low esophagectomy and total gastrectomy for esophageal cancer. After surgery, she was managed conservatively for anastomotic leakage. Forty seven days postoperatively, she vomited blood. Upper gastrointestinal endoscopy showed no focus of bleeding. At fifty two days after the operation, she vomited large amounts of blood and therefore went into hemorrhagic shock. Chest enhanced CT revealed that the descending aorta penetrated into the abscessed cavity where there was anastomotic leakage. We conducted an emergency endovascular repair with a stent graft. She went into cardiopulmonary arrest due to hyperkalemia as a result of massive transfusion during surgery. She was treated by emergency chest compressions by the surgeons. A postoperative CT study revealed a complex deep injury of the liver and hemorrhagic ascites caused by intraoperative cardiopulmonary resuscitation. However, she achieved hemodynamic stability, so she was followed without further surgery. We considered that the liver injury had been caused by either compression which had been performed at an incorrect location because the surgical drape had blocked the view of the patient’s body, by excessive pressure, or a combination of both.

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A 45-year-old male was scheduled to undergo septal myomectomy for hypertrophic obstructive cardiomyopathy. A double aortic arch was detected before the operation, but the patient was asymptomatic with no apparent compression of the airway caused by the vascular ring. Expiratory phase wheezing and dyspnea were noted immediately after postoperative extubation, and reintubation was performed. Bronchoscopy revealed obstruction of the trachea due to swelling of the membranous portion of the trachea in the direction of the tracheal lumen when coughing, and a diagnosis of tracheomalacia was made. Tracheostomy was performed and the patient was weaned from mechanical ventilation on postoperative day eleven and discharged from the ICU on postoperative day twelve. Tracheomalacia is thought to be caused by weakening of the supportive tissue of the airway, and the collapse of the airway in this case was thought to have been caused by surgical stress. It is concluded that either swelling around the vascular ring caused by surgical manipulation of the aorta compressed the trachea encircled by the vascular ring, or that the supportive power of the membranous portion of the trachea was reduced by the surgical procedure. This case reveals the possibility that tracheomalacia may occur postoperatively in adult patients with a double aortic arch even if they are asymptomatic preoperatively.

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Objectives: To evaluate current status and problems for the management of analgesia and sedation in Japanese PICU by nurses' viewpoint. Method: A questionnaire concerning analgesia and sedation strategies was sent to all 25 PICUs in Japan. Results: Responses were obtained from 17 units. Among them, 41.2% of the facilities use objective evaluation scoring for pain and 23.5% for sedation, while 23.5% of the facilities set the ideal level of pain relief and 41.2% do so for sedation. In addition, 11.8% follow a protocol for pain relief and 5.9% for sedation. In 29.4% of the facilities, nurses control pain and in 17.6%, they control sedation. The commonly used sedatives and analgesics were midazolam, fentanyl and dexmedetomidine. Most of the units recognized withdrawal syndrome, and tried non-pharmacological interventions. Only 29.4 % of nurses were satisfied with the existing pain management practices and 47.1% were satisfied with sedation practices. Conclusion: According to Japanese PICU nurses, the current management strategies for analgesia and sedation are not yet satisfactory.

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