Objectives: To evaluate the impact of the presence of pediatric intensivists on clinical outcomes, including mortality, in our PICU. Methods: The presence of pediatric intensivists in our PICU was implemented into our practice in February 2010. To evaluate the impact on clinical outcomes before and after the implementation, we reviewed all the patients who were admitted to our PICU from April 1, 2008 to March 31, 2012. We calculated the expected mortality based on the pediatric index of mortality 2 (PIM2) scoring system and investigated the impact of the implementation on PICU mortality, duration of mechanical ventilation, and PICU length of stay using multivariable analysis. Results: A total of 1,111 patients were admitted to our PICU over the 4-year period; 520 in pre-implementation period and 591 in post-implementation period. The PIM2 score was significantly higher in the post-implementation arm (P<0.001). The presence of pediatric intensivists was associated with lower PICU mortality [OR 0.36 (95%CI 0.15-0.89), P=0.026], shorter length of PICU stay [relative risk (RR) 0.94 (95%CI 0.89-0.98), P=0.004], and shorter duration of invasive mechanical ventilation [RR 0.94 (95%CI 0.89-0.99), P=0.045]. Conclusion: The presence of pediatric intensivists improved patient outcomes in our PICU.

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Background: Some patients who have received treatment in the ICU may be readmitted to the ICU after being discharged. This study aimed to investigate the frequency and cause of readmission to the ICU. Methods: We retrospectively collected data for 879 patients discharged from the ICU between 2012 and 2013 and applied the following exclusion criteria: dead on discharge, age < 18 years, or insufficient data. Results: There were 36 readmissions to the ICU. A multivariate analysis revealed independent predictors of readmission: APACHE II score [OR = 1.11 per point], a minitracheostomy [15.5], main clinical department (abdominal surgery [7.34], head and neck surgery [9.03], other surgery [4.74]). Of these, 25 patients were readmitted from the adjacent high care unit (HCU). Eighteen patients were readmitted with respiratory complications. Conclusion: Patients with high APACHE II scores and those who need minitracheostomy for sputum excretion should receive more attentive evaluation before discharge from the ICU and more effective care at step-down units such as the HCU.

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Indomethacin is a medication for nephrogenic diabetes insipidus. We herein report a case that was successfully treated with high-dose indomethacin (225 mg/day) for nephrogenic diabetes insipidus. A 35-year-old female had been receiving treatment for manic depression psychosis with lithium since 18 years of age. She was transferred to our emergency center due to an overdose of ingested phenobarbital and chlorpromazine. On the second hospital day, she developed hypernatremia and polyuria (over 450 ml/hr) which proved to be resistant to treatment with vasopressin. We diagnosed her to have nephrogenic diabetes insipidus. Because she had been taking lithium for manic depression psychosis for the previous 17 years, lithium was thus suspected to be the cause of diabetes insipidus. After diagnosing the patient to have nephrogenic diabetes insipidus, we discontinued lithium administration and switched the treatment to an indomethacin suppository (150 mg/day). However, her symptoms persisted. We considered that the blood concentrations of indomethacin were low, because the high creatinine clearance had been caused by the patient's polyuria. Therefore, we gradually increased the dose of indomethacin. Subsequently, high-dose indomethacin (225 mg/day) effectively brouight about an improvement in the symptoms of polyuria and hypernatremia. Our findings suggest that high-dose indomethacin therapy is an effective approach for treating patients with nephrogenic diabetes insipidus.

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A 29-year-old man was diagnosed with pulmonary arterial hypertension (PAH) 5 years ago. He had not been treated for PAH. He was transferred to our hospital after visiting a nearby hospital for chest pain and being diagnosed with pulmonary artery dissection. After admission, he emergently underwent a prosthetic graft replacement of the main pulmonary artery and bilateral pulmonary artery plication. Subsequently, he was transferred to the ICU and we immediately started aggressive treatment for the refractory PAH including multiple medications therapy, strict sedation and mechanical ventilation. Good control of PAH was achieved, and he was finally extubated on POD 21, discharged from the ICU on POD 29, and discharged from the hospital on POD 101. Because the mortality rate of PAD is very high, early surgery and strict postoperative management are required.

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The patient, a 64-year-old woman, had a history of bronchiectasis. She experienced a sudden onset of major hemoptysis and was transported by ambulance to our facility. Tracheal intubation and bronchoscopy were performed. Because the hemoptysis had resolved by the time she arrived at our hospital, a conservative approach with close observation was adopted. On hospital day 3, the patient experienced massive hemoptysis accompanied by poor oxygenation, and veno venous extracorporeal membrane oxygenation (VV-ECMO) was initiated. Angiography results indicated bleeding from the right bronchial artery. Vascular embolization with gelatin sponge particles (Serescue^®, Astellas) was performed to stop the bleeding. Oxygenation did not improve, and tracheobronchial oozing was observed. Therefore, severe limitations were placed on anticoagulant therapy during ECMO. The tracheobronchial area was filled with blood clots, and respiratory management was conducted while carefully removing blood clots via bronchoscopy. High frequency oscillatory ventilation was started on hospital day 15, when ventilation of the lungs gradually began to occur. On hospital day 32, the patient was taken off ECMO. On hospital day 95, the patient was transferred to a different hospital to undergo rehabilitation. This patient had a high risk of hemorrhage, and strong limitations were placed on the use of anticoagulants during ECMO. However, thrombotic complications occurred only once during the ventilator circuit change, and ECMO was safely discontinued despite restrictions on the use of anticoagulants.

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The patient is a female of 17 years of age. She presented with consciousness disturbance as the chief complaint and was admitted to our hospital with the diagnosis of status epilepticus (SE); she was moved to ICU to receive a respiratory treatment on the 2nd hospital day. A close examination at the hospital revealed that the cause of SE was due to systemic lupus erythematosus (SLE). While treating the primary disease, antiepileptic drug treatment started in order to control SE was unsuccessful; therefore, general anesthesia was induced with intravenous anesthetics. Despite the induction of general anesthesia with intravenous anesthetics, it was difficult to control SE, so inhalation anesthetic agent isoflurane was added from the 10th hospital day, which brought a success in controlling SE. The duration of the use of isoflurane continued for 38 days, but a long-term management was possible because there was no serious complication due to isoflurane was observed during the course of the treatment. Adding inhalation anesthetic agents can be considered as one of the options in the case where controlling SE is difficult through general anesthesia with intravenous anesthetic agents.

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We asked nurses and patients' family members to complete a questionnaire about their satisfaction with family nursing. Both populations think highly of the family support and the reporting on the patient's condition. But for most items, family members were more satisfied than nurses, especially visiting hours and limits on visiting duration. Family members rated these items highly, whereas nurses felt it was difficult to keep to the visiting hours and the limits on visiting duration. Although patients' family members were highly satisfied with our nursing, they felt they could not spend a calm time with the patient. So, we imagined being a patient's family member and from that perspective, we will try to examine several things we could do to improve family nursing.

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[in Japanese]

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