Disseminated intravascular coagulation (DIC) is a frequent complication of sepsis. During the course of infections, platelets and coagulation factors can become activated inside blood vessels. Thrombus formation inside blood vessels is generally considered to be harmful because it compromises the blood supply to organs. However, recent studies have suggested that thrombosis during the early stage of infections plays a major physiological role in immune defense. This defensive role of thrombosis is now referred to as immunothrombosis. DIC might be an advanced stage of immunothrombosis wherein the immune system is no longer able to restrict pathogen spreading, and immunothrombosis becomes overwhelmed. In this stage, uncontrolled immunothrombosis causes multiple organ dysfunction syndrome and could be detrimental to the host. In this review, we focus on neutrophil extracellular traps (NETs), an important player in immunothrombosis, and extracellular histones, key components of NETs, and discuss how extracellular histones impact the conditions of septic DIC.

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Objectives: To review our experience with pediatric veno arterial extracorporeal membrane oxygenation (VA-ECMO) at our University Hospital ICU. Methods: We reviewed the clinical records of all pediatric patients maintained on VA-ECMO between April 2008 and March 2013. Results: We experienced forty VA-ECMO runs for patients ranging in age from 3 days to 6 years. Thirty-nine of these patients had congenital heart disease (CHD). The overall survival rate was similar to the world standard at 75% and 58% for weaned off ECMO and discharged, respectively. According to a paper previously reported by our institution, the survival rate for discharged patients has significantly improved from 21% to 58% within the past 15 years. Within the last five years, the survival rate has improved from 33% to 100% for patients successfully weaned ECMO. In addition, within the same five-year period, the survival rate has remained at the same level for patients that have been successfully discharged. Conclusions: The outcomes of VA-ECMO have improved at our institution. What remains to be addressed is to identify the optimal anticoagulant therapies, improve the treatment techniques and complete further long-term observations of these patients.

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Objectives: Monitoring the continuous cardiac output (CCO) with a retained pulmonary artery catheter is valuable for the postoperative management of cardiac surgery patients. Intermittent pneumatic compression (IPC) is also useful for preventing deep venous thrombosis in such patients. We experienced a novel case of a patient with rhythmic continuous cardiac index (CCI) fluctuations during IPC. We conducted the present study to determine whether the oscillations were caused by the IPC and whether the degree of oscillations differed between different IPC devices. Methods: We retrospectively reviewed the records of cardiac patients in the ICU. We measured the amplitudes and frequencies of CCI oscillations in each patient. First, we compared the CCI oscillations with IPC to those without it. Second, we compared the oscillations between patients using two different types of IPC devices. Results: CCI oscillations were observed in all patients, but they disappeared when IPC was not used. Furthermore, the amplitudes and frequencies of the CCI oscillations differed significantly between IPC devices. Conclusion: The CCI oscillations disappeared when IPC was stopped and differed between different IPC devices.

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Zonisamide is an anticonvulsant. Oligohidrosis is a known side effect of zonisamide treatment in children. However, few studies have reported zonisamide-induced oligohidrosis in adults. We report two cases, each of oligohidrosis and hyperthermia after administration of zonisamide in adult patients with brain trauma. <Case 1> A 21-year-old man was injured in a traffic accident. Treatment with 300 mg/day zonisamide was administered 22 days after the admission. Although, no symptoms of infection were observed, prolonged hyperthermia was noted. The patient became afebrile 3 days after the zonisamide dose was decreased. <Case 2> A 25-year-old man was injured in a traffic accident. Treatment with 300 mg/day zonisamide was administered 3 days after the admission. After drug administration, prolonged hyperthermia was observed. The patient became afebrile 3 days after termination of zonisamide treatment. In adults, zonisamide can induce oligohidrosis and hyperthermia. Thus, the side effects of zonisamide treatment should be considered in the differential diagnosis of hyperthermia.

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Patients with profound hyponatremia and severe symptoms following polydipsia often show polyuria and rapid sodium correction, which is associated with a risk osmotic demyelination syndrome. We report two cases of polydipsia leading to profound hyponatremia with severe symptoms. One patient was treated by infusion of a large volume of free water, while the other was treated with desmopressin acetate and 3% hypertonic saline. Overcorrection of serum sodium was avoided in both patients. Desmopressin acetate with hypertonic saline is a safe and useful treatment for severe hyponatremia following polydipsia.

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Tolvaptan, an arginine vasopressin V2 receptor antagonist, is considered to be an important drug for treating heart failure in children; however, there are few reports about its use in such cases. Herein, we describe our retrospective investigation into the efficacy and safety of tolvaptan in infants. This study examined 5 pediatric heart failure cases involving children with congenital heart disease (CHD) who were admitted to the ICU during the perioperative period or due to a history of CHD. The children were administered tolvaptan as a treatment for water retention after other diuretic drugs had proved to be ineffective. Improvements in their short-term clinical symptoms, such as weight reduction and increased urine volume, were observed after the administration of tolvaptan. The dosage ranged from 0.1-0.3 (median 0.1) mg/kg/day, which was lower than the doses used in previous studies, suggesting that tolvaptan is effective at low doses.

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We recently experienced a patient who developed stress cardiomyopathy during the course of chronic inflammatory demyelinating polyneuropathy (CIDP). The patient was a 56-year-old woman who developed CIDP at 45 years of age and experienced repeated exacerbation-remission cycles several times thereafter. The most recent CIDP occurrence caused left facial nerve paralysis and muscle weakness in both legs; therefore, she was admitted with a diagnosis of CIDP acute exacerbation. Respiratory muscle paralysis and limb paralysis occurred the day after she was admitted; she was put on a ventilator in the ICU, and intravenous immunoglobulin therapy was administered. After admission to the ICU, the patient's hemodynamics varied greatly. On day 3 after ICU admission, an echocardiogram showed wall motion abnormalities. The base of her heart showed normal contractions but akinesis at the apex, leading to the diagnosis of stress cardiomyopathy. She also had a fever higher than 40°C. Wall motion abnormality was improved by the seventh day after ICU admission, and her limb paralysis and fever also improved. Unlike in Guillain-Barré syndrome, which is related to CIDP, severe autonomic neuropathy in CIDP is rare. We speculate that severe autonomic neuropathy might have been a cause of takotsubo cardiomyopathy in this case.

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A 16-year-old male who showed the return of spontaneous circulation (ROSC) following cardiopulmonary arrest (CPA) by hanging was emergently taken to the hospital. The time to ROSC from cardiac arrest was at least 18 minutes and the GCS score was 3 points on admission. After admission, the patient received therapeutic hypothermic therapy, and was subsequently given amantadine, starting on the 49th hospital day, for a persistent drug-resistant fever and disturbance of consciousness, with which the fever resolved and the level of consciousness improved. Through physiotherapy, the patient could recover neurologically and was discharged on foot 4 months after admission. Although patients with ROSC following CPA by hanging are considered to show a poor prognosis, the present case actually showed a favorable outcome, with discharge on foot.

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Reported here is our experience with a severe burn patient complicated with diabetes mellitus whose blood glucose level was controlled by artificial pancreas. A 70-year-old woman had been under insulin therapy for diabetes mellitus. She became unconscious while taking a bath at home. The bath continued to fill with hot water, and she suffered burns covering 40% total body surface area (TBSA). Enteral feeding was started soon after injury, but the patient developed complication of sepsis and blood glucose was poorly controlled, so artificial pancreas was introduced on day 6. Blood glucose level was favorably controlled around 150 mg/dl thereafter, and intake of the targeted nutrition became possible. Artificial pancreas enabled tight glucose control without inducing hypoglycemic attack, and the required dose of insulin was evident, thereby facilitating blood glucose control after withdrawal. Initiation of enteral feeding at early stage is recommended for burn patients from the viewpoint of suppressing hypercatabolic protein. However, blood glucose control is often difficult in patients complicated with diabetes mellitus, due to aggravation of insulin resistance triggered by injury. Artificial pancreas was considered a very useful tool for such a patient.

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Purpose: The purpose of this study was to simultaneously measure time course changes in pressure of compression stocking and oxygenation state of the gastrocnemius muscle (MG) during passive dorsiflexion in patients who admitted to the ICU after surgery. Methods: Participants comprised five patients in post-surgical state of esophageal cancer (mean age, 59.4±6.1 years). Patients were performed exercise consisted of 10 cycles involving passive dorsiflexion and release until a few hours after surgery. Changes in oxygenated hemoglobin (oxy-Hb), deoxygenated hemoglobin (deoxy-Hb) and total hemoglobin (t-Hb) of medial belly of the MG were measured by near infrared spectroscopy. Changes in pressure of compression stocking was simultaneously measured at the lateral side of the MG. Results: The compression pressure was 20.4±1.6 mmHg at rest and increased up to 4.2±3.2 mmHg during dorsiflexion. oxy-, deoxy-, and t-Hb decreased during dorsiflexion, and recovered during release. t-Hb after 5-min passive exercise significantly decreased as compared with those before exercise. Conclusions: Increase in compression pressure during dorsiflexion may induced by changes in shape of calf. Passive exercise for 5 min might decrease muscle blood volume in patients while wearing compression stockings studies.

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