In the ICU, electrocardiogram (ECG) and SpO₂ are required for patient monitoring. An ECG shows cardiac electrical activity, but pulse oximetry can measure the pulse rate and SpO₂ using plethysmogram. Arterial blood drawing is not needed, and the SpO₂ measurements are noninvasive, unlike SaO₂ measurements. SpO₂ is measured using a red light, an infrared light, and absorption spectroscopy. There are many factors affecting the measurement of SpO₂. A low peripheral circulation and body movement can make the detection of the pulse wave difficult, greatly decreasing the accuracy of the SpO₂ measurement. The solution for this disturbance to the measurement varies according to each maker. Understanding the principle of measurement is necessary for the interpretation of SpO₂ values. There are two methods for measuring SpO₂: transmittance and reflectance. The reflection type measures SpO₂ at the supra-orbital artery, wherein arterial heartbeat is maintained at the time of a shock and the hypothermia. Moreover, the reflection type has a shorter discrimination time to SpO₂ change than the finger of limb. This method is suitable for ICU patients with low peripheral perfusion and motion artifacts.

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Objective: Severe acute bronchiolitis in infants is characterized by narrowing of the small airways and increased airway resistance, necessitating respiratory support and prolonged admission to PICU. Although a mixture of helium and oxygen gas (heliox) is known to decrease airway resistance, it is unclear whether heliox inhalation therapy shortens the length of PICU stay. This study aimed to determine whether respiratory support using heliox shortens the length of PICU stay and/or the duration of tracheal intubation. Methods: This prospective, interventional, single-center study included infants aged <2 years who were consecutively admitted to the PICU from November 2012 to December 2014 for treatment of severe acute bronchiolitis. Inclusion criteria were Modified Wood’s Clinical Asthma Score of ≥5 despite supportive therapy and arterial oxygen saturation of ≥92% in ≤40% oxygen. Patients on nasal continuous positive airway pressure received heliox through nasal prongs, whereas those on ventilators received heliox through tracheal tubes. The primary outcome was length of PICU stay and secondary outcomes were duration of tracheal intubation and safety of heliox inhalation therapy. Results: During the study period, 10 infants with severe acute bronchiolitis fulfilled the inclusion criteria (heliox group). Another 11 patients treated between April 2010 and March 2012 who were not eligible for heliox treatment were included as controls (control group). The length of PICU stay (4.7±1.1 days vs. 8.6±2.8 days, P<0.005) and the duration of tracheal intubation (3.8±1.4 days vs. 7.6±2.8 days, P<0.005) were shorter in the heliox group than in the control group, respectively. Conclusions: Heliox inhalation therapy during treatment for severe acute bronchiolitis may shorten the length of PICU stay and the duration of tracheal intubation.

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Acute myocarditis includes the disease fulminant myocarditis, in which hemodynamic collapse during the course of the disease can lead to death. The incorporation of percutaneous cardiopulmonary support (PCPS) is important to help patients survive the acute phase of this disease. However, acute myocarditis is a relatively rare disease, and few reports have presented detailed treatment results from a single institution. In the present study, we investigated 18 patients with acute myocarditis who were treated at our center between April 2003 and November 2013. We assessed age, sex, vital signs at the time of hospitalization, examination findings at the time of hospitalization, and interventions and prognosis following hospitalization. Among 8 patients who presented with cardiogenic shock during the course of the disease, 6 had fulminant myocarditis and PCPS was considered necessary owing to hemodynamic collapse. Among these 6 patients, 2 experienced cardiac arrest immediately following admission, 3 experienced cardiogenic shock within 6 hours of admission, and 1 experienced hemodynamic collapse after presenting with cardiogenic shock 6 days following hospitalization. Among patients with acute myocarditis, those who experience cardiogenic shock immediately after hospitalization have a high likelihood of requiring PCPS.

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Propofol infusion syndrome (PRIS) is a fatal syndrome associated with continuous propofol infusion, which causes several serious clinical conditions such as rhabdomyolysis, acute kidney injury (AKI), lactic acidosis, and hyperlipidemia. We report the case of a 44-year-old adult male patient suspected of having PRIS who was successfully treated by promptly discontinuing propofol infusion. The patient underwent total arch replacement for Stanford type A aortic dissection. Propofol was used for postoperative sedation, but his serum CK level was elevated up to 15,247 IU/l. He also developed AKI and lactic acidosis. Therefore, we strongly suspected PRIS, so propofol was discontinued. His serum CK level subsequently decreased, and AKI and lactic acidosis improved rapidly. CT scan showed some high-density areas in the hip and femoral muscles, which can be considered post-rhabdomyolysis changes. Serum CK, pH, and lactate levels should be measured routinely during prolonged propofol infusion, and alternative sedatives should be administered promptly if PRIS is suspected.

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Status epilepticus is often nonconvulsive and its clinical findings include disturbance of consciousness. There is no standard diagnostic criteria for nonconvulsive status epilepticus (NCSE), and diagnosis is based on abnormal electroencephalographic findings consistent with clinical findings. Focal lesions of convulsive status epilepticus with increased perfusion were recently well depicted by arterial spin labeling (ASL). Herein, we reported a case of NCSE showing focal luxury perfusion on ASL. In the patient, ASL clearly revealed the focal hyperperfusion area. After appropriate anticonvulsant treatment, clinical symptoms completely resolved. Our data suggests that ASL can be used as a secondary diagnostic tool in an emergency, when electroencephalography is not possible.

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Although herpes simplex virus (HSV) infection manifests with a range of symptoms, progression to fulminant hepatitis is rare. We describe herein our experience treating a patient with HSV that developed into fulminant hepatitis and virus-associated hemophagocytic syndrome (VAHS). The patient was a 26-year-old woman who initially presented to another hospital with chief complaints of fever and general malaise, and was immediately admitted based on a diagnosis of acute hepatitis. Hepatic dysfunction failed to improve, so she was then referred to our hospital and admitted to our Department of Gastroenterological Medicine for further care and was then transferred to the intensive care unit the following day for systemic care. Fulminant hepatitis, hemophagocytic syndrome (HPS), and disseminated intravascular coagulation were diagnosed based on the findings of physical examination and hematology on admission, and she was started on plasma exchange, high-dose steroid therapy, and immunosuppressive therapy. HSV was subsequently identified as the underlying cause based on the results of virus antibody testing and liver biopsy immunostaining, and antiviral drugs were added to the treatment regimen. The patient responded to treatment and was released from the ICU 13 days after admission. While fulminant HSV hepatitis is rare, delays in treatment can adversely impact patient prognosis. Early biopsy should therefore be considered in the event of fulminant hepatitis of HSV.

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Pulmonary embolism and deep vein thrombosis are often accompanied by an elevated D-dimer, and can cause paradoxical embolism in patients with a patent foramen ovale. We report the case of a patient with a patent foramen ovale in whom discovery of the embolic source was delayed by with low D-dimer elevation. A 52-year-old man was admitted with cerebellar infarction of the posterior inferior cerebellar artery resulting in a right thalamus infarction after 6 days, as well as a left vertebral artery acute occlusion after 8 days. He underwent thrombectomy by intravascular surgery. We diagnosed him with embolism from the removed thrombus, and transesophageal echocardiography revealed a patent foramen ovale. Pulmonary embolism and deep vein thrombosis were found upon further investigation, and he was started on anticoagulation therapy. Paradoxical embolism associated with patent foramen ovale is included in recent years as one etiology of embolic stroke of undetermined source (ESUS). Embolic source scrutiny is essential because of the cases with pulmonary embolism and deep vein thrombosis are existed with low D-dimer elevation.

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Objective: A retrospective study was conducted to elucidate the clinical significance of leukemoid reaction (LR) in the general ICU. Methods: After analyzing the data of all ICU admissions during the latest 4-year period, we enrolled the patients for this study whose WBC count in peripheral blood exceeded 30,000 /μl during the ICU stay. The medical records were reviewed for their underlying disease, laboratory findings and 6-month mortality rate. Result: LR occurred in 46 patients, aged 41-93 yr, corresponding to 1.9% of all ICU admissions. They were divided into two groups: a group with infectious diseases (infection group) and another group with non-infectious diseases (non-infection group). There were 31 patients in the infection group including 24 cases by which caused bacteria were revealed, while the non-infection group comprised 15 patients, including six intraabdominal bleeding, four post-cardiopulmonary resuscitation and five other diseases. The maximal WBC (Max. WBC) count, duration of LR, concurrent malignancy and steroid requirement were significantly higher in the infection group than in the non-infection group, whereas neither group showed statistical differences in the gender distribution or catecholamine requirement. A higher percentage of subjects in both groups (87%) revealed a “shift to the left” of neutrophil in the differential WBC. Of the 46 patients with LR, 25 died (16 from the infection group and 9 from the non-infection group), indicating a 6-month mortality rate of more than 50% in each group. No correlation was found between the high mortality rate and the Max. WBC count or duration of LR. Conclusion: The overall incidence of LR in our ICU admissions was approximately 2%. LR was associated with an increased mortality rate (>50%), irrespective of the underlying disease with an infectious or non-infectious cause. Understanding the clinical significance of LR is useful for intensive care management.

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We conducted a survey of critically-ill pediatric patients less than sixteen years old, who admitted in all departments (15 hospitals, 24 departments) treating them in Kumamoto prefecture in 2010. The response rate was 96%, and the number of critically-ill pediatric patients was 386 (1.44/1,000 less than sixteen years old). This incidence is equivalent to that reported in foreign countries and Japan; therefore, it could be used as a basis for determining the number of beds required in PICU in Japan in the future.

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