Lung ultrasound has become widespread in the management of critically ill patients. Up till very recently, sonographic evaluation of the lung was believed to be a very limited tool, because from the very low acoustic impedance of lung air it was very difficult to construct clear ultrasound images. It had been used only to confirm fluid accumulation in the chest cavity. Now, however, pulmonary parenchymal abnormalities can be diagnosed by understanding the imaged artifacts or in combination with sonographic findings. Ultrasound systems can be brought swiftly to the patient and examination can be started promptly. There is little doubt that it will continue to spread as a point-of-care diagnostic method. Currently, the auscultation technique forms part of the medical education curriculum in order to determine whether the chest anatomy is normal or abnormal. I think lung ultrasound should be considered as an additional part in the curriculum for the education of medical students or residents. In this review article I want to discuss the examination method, the basic findings, the meanings of various signs, the typical diagnosis and also the pit-falls in lung ultrasound imaging.

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Objective: The reliability, validity, and responsiveness of the Japanese version of the Critical-Care Pain Observation Tool (CPOT-J) were examined. Methods: A total of 27 postoperative cardiovascular patients in the ICU were assessed by the researcher and 16 clinical nurses with ≥1 year of ICU experience. Agreement between nurse and researcher scores was used to determine inter-rater reliability. Correlations between the CPOT-J and the Richmond Agitation-Sedation Scale (RASS), vital signs, and numeric rating scale (NRS) were examined to determine validity. CPOT-J scores before, just after, and 20 min after painful stimulation were used to assess responsiveness. Results: Inter-rater reliability was high (κ=0.803). Weak correlations were seen between the CPOT-J and each of RASS, sBP, dBP, HR (r=0.260, r=0.343, r=0.337, and r=0.302, respectively). Respiratory rate and NRS showed moderate correlations with the CPOT-J (r=0.601 and r=0.652, respectively). CPOT-J were found to be significantly increased just after stimulation. Conclusion: Although discriminant validity with agitation was unable to be determined, criterion-related and convergent validities were acceptable. The CPOT-J offers a highly reliable measurement tool for evaluating the degree of and changes in pain among ICU patients.

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Objectives: Acute kidney injury (AKI) after cardiac surgery is associated with short- and long-term outcomes. The aim of this study was to investigate incidence rate, risk factors, and features of AKI after cardiac surgery with cardiopulmonary bypass (CPB). Methods: A single center retrospective study of postoperative AKI following cardiac surgery with CPB from 2011 to 2013 was performed. AKI in this study was defined as that which occurred within 7 days after surgery and diagnosed by the Acute Kidney Injury Network criteria. Results: A total of 263 patients met inclusion criteria. Of these 64 patients developed AKI, and two required dialysis within one week after the surgery. Multivariate analysis revealed that male sex (OR 4.20), diabetes mellitus (OR 3.34), increased body mass index (OR 1.11), a lower pre-operative estimated glomerular filtration rate (OR 0.963), and a longer CPB time (OR 1.01) were independent risk factors for AKI. Ninety-one-percent of AKI patients were classified into AKIN stage 1 and 78% were withdrawn from the AKI definition within 2 days after diagnosis. Conclusion: Except for male sex, the risk factors for AKI in this study were the same as in previous studies from the US and European countries. Most patients with AKI only presented a mild creatinine increase and recovered in a short period.

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A 37-year-old woman was admitted to our emergency room for disturbed consciousness. She had been diagnosed with type 1 diabetes mellitus at age 8 and received continuous subcutaneous insulin infusion therapy for 3 years. After admission, she was diagnosed with and treated for diabetic ketoacidosis (DKA), and her symptoms improved temporarily. Forty-eight hours after admission, however, she developed dyspnea and hypoxemia and was diagnosed with acute respiratory distress syndrome. She was intubated and placed on mechanical ventilation. However, life-threatening hypoxemia with a P/F ratio of 65 and massive serous tracheal discharge of ˜5 l/day persisted. We therefore decided to initiate veno venous extracorporeal membrane oxygenation (ECMO). Nine days after ECMO initiation, the patient was successfully weaned off ECMO; however, her health was subsequently complicated by a catheter-related bloodstream infection. This was followed by infectious endocarditis, and she died from septic shock and multiple organ dysfunction syndrome on day 35. There have been scarce clinical reports on acute respiratory distress syndrome secondary to DKA, but a very high mortality rate from infectious complications has been suggested. Our report indicates that introducing early ECMO as a rescue treatment for life-threatening hypoxemia in acute respiratory distress syndrome resulting from DKA is possible if the patient's ketoacidosis has been successfully controlled.

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Spontaneous coronary artery dissection (SCAD) was diagnosed when there was a radiolucent flap or an artery with double lumens detected by coronary angiography (CAG). We identified these findings by using optical coherence tomography (OCT) and intravascular ultrasound (IVUS) in two young females with acute coronary syndrome. Case 1 A 50-year-old female without cardiovascular risk factors (non-ST elevation acute coronary syndrome). CAG demonstrated diffuse, sub-occlusive and flow-limiting stenosis in the right coronary artery. No angiographic images suggesting arterial dissections were recognized. IVUS showed an intramural hematoma, but could not clearly delineate a dissected-intimal interface. The additional resolution obtained by OCT provided a more complete vessel visualization and showed the distribution of the intimomedial dissection flap in the culprit lesion. A bare-metal stent was implanted into the culprit lesion. Case 2 A 42-year-old female with a smoking habit (ST elevation acute coronary syndrome). A coronary angiogram showed diffuse and smooth stenosis (middle portion) and focal stenosis (apical portion) in the left anterior descending artery. OCT demonstrated an intramural hematoma and an intimal tear in the culprit lesion. A drug-eluting stent was deployed in the mid-portion of the left anterior descending artery. The distal lesion was managed conservatively. Conclusion When only coronary angiograms were evaluated, the intimal flap and intramural hematoma in our cases could not be confirmed, and SCAD might have been misinterpreted. Intracoronary imaging tools, such as OCT and IVUS, could provide high-resolution images of the vessel wall and improve the diagnosis of SCAD.

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We report 2 cases of acute respiratory distress syndrome (ARDS) associated with Legionella pneumonia successfully treated with permissive hypoxemia. The patients were diagnosed as Legionella pneumonia with detection of urinary antigen of Legionella, and treated with intravenous levofloxacin. They were mechanically ventilated with a mode of pressure support ventilation. The first case was a 59-year-old male. The P/F ratio decreased to 64 because of severe pneumonia. The second case was a 64-year-old male. The P/F ratio decreased to 58. The PEEP level was set at 13-15 cmH₂O and the end-inspiratory plateau pressure was 22-25 cmH₂O in both cases. We induced permissive hypoxemia of SpO₂ 88% and PaO₂ 50 mmHg to set F_IO₂ 0.6-0.7 and to maintain airway pressure 25 cmH₂O or under as lung protective strategy. No hypoxic damage of any vital organs or progressive metabolic acidosis was detected. They recovered from severe ARDS without any residual dysfunction of vital organs.

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We describe a rare case of carvedilol and propafenone toxicity. An 80 years-old woman receiving cardiopulmonary resuscitation for cardiac arrest was admitted to our emergency room. She had a history of hypertension, paroxysmal atrial fibrillation and dementia. Cardiopulmonary resuscitation was continued along with adrenaline injection. Although she was successfully resuscitated, her heart rate immediately decreased to 10-20 /min. She received a continuous infusion of adrenaline. Moreover, a temporary pacing electrode was inserted, but pacing frequently failed. Within 10 hours, the hemodynamics became stable with a heart rate of 70 /min. Thereafter, the adrenaline infusion was stopped, and the pacing electrode was removed. Based on the medical records, we noted that she had been prescribed carvedilol, olmesartan, azelnidipine and propafenone, and she had taken many prescriptions simultaneously. The plasma concentrations of propafenone and 5-OH propafenone were higher than their therapeutic doses. Hence the cardiac arrest followed by severe bradycardia and pacing failure may be due to the overdose of carvedilol and propafenone. For old age, propafenone might induce toxicity and cardiac arrest easily.

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A 60-year-old man, who had a trauma with a bamboo broom to the left forearm ten days before admission, developed myotonia in his left arm, neck stiffness, and trismus. A scab had already formed over the wound. Tetanus was clinically diagnosed and he was sedated, ventilated, and given circulatory support. He was also initially treated with antibiotics and 3,000 units of tetanus immune globulin. Debridement of the wound site was performed four days after admission because of continued mild swelling, and an intracorporeal foreign body was found. Clostridium tetani was isolated from the foreign body despite the patient receiving antibiotics. He was discharged on day 55. To the best of our knowledge, isolation of Clostridium tetani is rare, and this is the first case of Clostridium tetani isolation from an intracorporeal foreign body while using antibiotics. If the foreign body had not been found, the clinical symptoms might have been exacerbated or protracted. In Tetanus cases, wound debridement should be performed for therapeutic purposes even when wounds are in advanced stages of healing.

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Background: Amplitude-integrated electroencephalogram (aEEG) is now commonly used to monitor cerebral function in neonatal intensive care units (ICU); however, few reports on its use in pediatric and adult ICU's, particularly in patients with traumatic brain injuries, have been written. Case report: The brain function of two patients with severe traumatic brain injuries is monitored using aEEG. In case 1, a three-month-old girl presents with frequent posttraumatic seizures from an acute subdural hemorrhage caused by a motor vehicle accident. aEEG monitoring detects frequent nonconvulsive seizures upon which anti-epileptic drugs are thus administered. In case 2, a seven-year-old boy presents with altered mental status with involuntary movements from diffuse axonal injury also due to a motor vehicle accident. aEEG, however, does not show any evidence of seizure activity. Conclusion: aEEG can be a useful tool to detect posttraumatic seizures and can improve the management of severe traumatic brain injuries in children.

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[in Japanese]

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