Background: Trauma is one of the important causes of death for children in Japan. However, there is a lack of epidemiologic data regarding major pediatric trauma injuries. As a result, the number of patients, the necessity of medical resources and medical outcomes are unknown. Objective: To estimate the necessity for pediatric trauma ICU (PT-ICU) beds in Okayama prefecture, we conducted an epidemiologic survey. Method: We conducted a retrospective cohort study involving nine ICUs in Okayama prefecture, which accept major pediatric trauma patients. Patients included in the survey were 14 years of age or younger and admitted to ICUs due to blunt or penetrating trauma. Results: Between January 2008 and December 2010, a total of 149 patients were included in this survey. Of these patients, 119 (79.9%) were hospitalized at tertiary medical centers. For 97.1% of the observation period (1,064/1,096 days), the number of patients was two or less per day. The adequate number of PT-ICU beds was estimated to be one for every 100,000 people aged 14 or less. Conclusion: In Okayama prefecture, major pediatric trauma patients are centralized to tertiary medical centers and their treatment outcome is acceptable. By assigning the adequate number of PT-ICU beds in designated hospitals, an improvement in trauma care can be expected.

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Objectives: The aim was to evaluate low non-protein calorie/nitrogen (NPC/N) ratio enteral nutrition compared to our conventional enteral nutrition in critically ill patients. Methods: An unblinded randomized control study was performed in a single tertiary emergency critical care center. Patients with mechanical ventilation were randomized to receive our conventional enteral diet (Group S, n=15) or low NPC/N enteral diet (Group A, n=13) and monitored for 28 days. The main outcomes measured were ventilator-free days (VFD) and ICU length of stay. The secondary outcomes were SOFA score, plasma albumin and prealbumin, adverse events and mortality. Results: The total calories delivered was similar in both groups, but protein delivery was significantly higher in patients in group A (P=0.02) who received low NPC/N enteral nutrition. There were also favorable trends in group A for VFD (P=0.10) and improved nutritional markers (plasma albumin and prealbumin) (P=0.13, P=0.10). There was no difference between the study groups in SOFA score change or survival. Conclusion: In critically ill patients, a higher provision of protein in enteral nutrition could be associated with decreased length of mechanical ventilation and improvement of nutritional markers.

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Objectives: To evaluate the utility of ventilator-associated events (VAE) surveillance in a PICU. Methods: Prospective ventilator-associated pneumonia (VAP) surveillance and retrospective VAE surveillance was conducted over 24 months in a PICU in Japan. For surveillance, the definition of pediatric VAP established by Centers for Disease Control and Prevention (CDC) was applied, while pediatric VAE was provisionally defined according to its new adult VAE criteria by CDC. Result: Incidences of VAP and VAE were 7.1 and 9.4 per 1,000 device days, respectively. The duration of mechanical ventilation and ICU stay was significantly longer among VAP patients as compared with non-VAP patients, and it was longer among VAE patients as compared with non-VAE patients. Only 25% of the patients with VAP fulfilled VAE criteria. Conclusion: VAE can potentially replace VAP for surveillance in pediatric critical care surveillance.

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A 30-year-old man with acquired immunodeficiency syndrome was admitted to our ICU because of acute respiratory failure, and immediately intubated and mechanically ventilated. Four weeks later, pneumothorax developed. This pneumothorax was treated with continuous chest drainage, but persistent air leaks continued. This resulted in inadequate lung expansion and inappropriate oxygenation. The definitive treatment for continuous pneumothorax is surgical repair. In this case, however, the severe respiratory failure did not allow any surgical procedure. To decrease the air leakage, we decided to implement bronchial embolization with endobronchial spigots. As a result, the air leaks were successfully decreased, and he was weaned from the ventilator. One week later, he safely underwent elective lung-volume reduction surgery. Endobronchial occlusion seems to be a useful procedure for patients with severe respiratory failure caused by persistent pneumothorax.

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Objectives: To examine the trends of continuous neuromuscular blocking agent (NMBA) use in our PICU. Methods: We retrospectively examined 84 critically ill children who were managed with continuous NMBA using vecuronium bromide (Vb) in the PICU between January 2010 and December 2012. The children were divided into 7 groups according to the indications for continuous NMBA. We retrospectively investigated the duration of Vb administration, total Vb dose, and period from Vb discontinuation to extubation. Results: Among all the children who were put on mechanical ventilation, Vb was continuously administered in 84 (10.5%; median age, 2 months). Continuous NMBA was introduced for the following indications: (1) prevention of pulmonary hypertension (33 cases; median duration of NMBA, 43 hr); (2) protective lung ventilation (16 cases; median duration, 72 hr); (3) protection of surgical anastomosis (12 cases; median duration, 112 hr); (4) prevention of intra-abdominal hypertension (9 cases; median duration, 63 hr), (5) prevention of shivering during therapeutic hypothermia (5 cases; median duration, 116 hr); (6) prevention of tracheal bleeding (5 cases; median duration, 93 hr); and (7) other reasons (4 cases; median duration, 133 hr). Conclusion: No criteria governed the start or discontinuance of NMBA in each group. Further studies are required to investigate the effects of continuous NMBA on the mortality and morbidity rates of critically ill children managed with this approach.

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Approximately 10% of patients with hemolytic uremic syndrome (HUS), characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure, are classified as having atypical HUS (aHUS) owing to the absence of an episode of diarrhea caused by verotoxin-producing Escherichia coli. Over 50% of cases are caused by complement dysregulation, but some cases occur after infection with pathogens such as Streptococcus pneumoniae, influenza virus, and others. We report the case of a 2-month-old infant with aHUS associated with pertussis. She was admitted to a local hospital with pneumonia caused by Bordetella pertussis infection and transferred to our intensive care unit owing to the development of secondary aHUS. In addition to continuous hemodialysis for severe renal dysfunction, she was treated with plasma therapies, including plasma exchange. Her condition improved and her renal function fully recovered. All of the reported cases of aHUS associated with pertussis have been in infants. When treating infants with pertussis-related aHUS, we must pay attention to the burden of the treatment itself, such as continuous hemodialysis and plasma exchange, on the infants.

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A 42-year-old woman was admitted to the hospital with a complaint of abdominal pain, nausea and vomiting. She was diagnosed with severe acute pancreatitis based on the laboratory results and the enhanced CT of the abdomen. She was transferred to the ICU due to the aggravation of prognostic factor from 1 to 5 during the first 3 days of admission. Due to the extremely high serum triglyceride (TG) level (12,815 mg/dl) at the time of admission, her acute pancreatitis seemed to be caused by her severe hypertriglyceridemia. Plasma exchange was not performed because TG level was already decreased to 1,990 mg/dl when she arrived in the ICU. Continuous i.v. of both insulin and heparin were administered to further decrease the TG level. In the ICU, the TG level was decreased rapidly, and the supportive therapy such as fluid therapy and enteral feeding helped her recover from the acute pancreatitis. She was discharged from ICU on the day 14. The patient in this study had extremely high level of TG caused by various factors including diabetes, obesity, and drugs.

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A 4-year-old boy with no history or family history of related disease came to our hospital with cardiopulmonary arrest. He had fainted after running to the entrance of his home. After 30 minutes of cardiovascular resuscitation, circulation returned spontaneously. Polymorphic ventricular tachycardia and fibrillation were often seen and were suppressed by β-blockers, suggesting catecholaminergic polymorphic ventricular tachycardia (CPVT). No finding was made from resting electrocardiogram, except sinus bradycardia. Exercise electrocardiography was difficult for him because of his age. Two single nucleotide polymorphisms (SNPs) in calsequestrin 2 (CASQ2) confirmed the diagnosis.

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