A 67-year-old man exhibited systemic convulsions and persistent disturbance of consciousness immediately after the operation of posterior inter-body fusion for the lumbar vertebrae L4-L5. Pseudohypoxic brain swelling (PHBS) was cited as a possible cause of these symptoms because the image change unique to hypoxic encephalopathy was found at the head CT and MRI, in spite of observing neither obvious hypoxemia nor lasting low blood pressure during the operation, and a large volume of extradural drainage existed after the operation. The level of consciousness was improved by removing the extradural drain and treating with some conservative treatment such as horizontal position. Eventually, he was discharged from the hospital without having neurological deficit. The pathophysiology of PHBS is considered to be a cerebral venous perfusion disorder due to a sudden loss of cerebrospinal fluid caused by a cerebrospinal fluid leak or negative pressure drainage management after spinal surgery. It is crucial to understand the risk and the pathophysiology of PHBS as a complication after spinal surgery.

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In recent years, endovascular aortic repair (EVAR) has been applied to cases of ruptured abdominal aortic aneurysm and has been reported to have mortality rates similar to open-abdominal synthetic graft replacement. Here, we report a case in which abdominal compartment syndrome (ACS) worsened after an emergency EVAR. A 62-year-old man had emergency EVAR performed on his abdominal aortic aneurysm, while an intra-aortic balloon occluder was placed in his descending aorta and the balloon was dilated. No endoleak was observed after the stent placement performed without the dilated balloon. However, his vital signs remained unstable, his abdominal bloating worsened, and his intra-abdominal pressure reached 50 mmHg, which led to ACS. We performed an emergency decompressive laparotomy, but the patient suffered cardiopulmonary arrest, and died during surgery. It may be important to perform early decompressive laparotomy if ACS is suspected, because, once ACS occurs, the probability of death increases even if the EVAR performed on ruptured aortic aneurysm is successful.

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Hemolytic uremic syndrome (HUS) rarely occurs following Clostridium difficile infection (CDI). We report a case of HUS following CDI that was successfully treated with plasma exchange (PE). A 71-year-old woman was transferred to our hospital because of thrombocytopenia and renal dysfunction following CDI. Because she was diagnosed with disseminated intravascular coagulation caused by CDI, we started treatment with recombinant human thrombomodulin, antithrombin, and vancomycin. Continuous hemodiafiltration was also initiated to treat anuria. However, these interventions did not improve her thrombocytopenia or anuria, and she subsequently progressed to hemolytic anemia. Nine days after admission, she was diagnosed with thrombotic microangiopathy owing to hemolytic anemia, thrombocytopenia, and renal dysfunction. Therefore, PE was performed for 3 days. Thrombotic microangiopathy is a general term for HUS and thrombotic thrombocytopenic purpura. However, thrombocytopenic purpura was considered unlikely because a disintegrin-like and metalloproteinase with thrombospondin type 1 motif, member 13 (ADAMTS13) activity decreased slightly and specific antibodies to ADAMTS13 were not detected. Stool culture on admission was negative for Escherichia coli O157. Her anemia, thrombocytopenia, and renal dysfunction improved dramatically after 3 days of PE. Forty-two days after admission, she was discharged from the intensive care unit and she was transferred to an affiliated hospital without any sequelae.

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We have been using an intravascular cooling system for targeted temperature management therapy. A 38-year-old man with heat stroke was transferred to the intensive care unit of our hospital. By using the intravascular cooling system, we could efficiently control his body temperature. Compared with heat stroke patients treated with conventional cooling methods in our hospital from 2008 to 2011, the time to achieve the target temperature and the rate of decline in body temperature were similar. However, patients treated with conventional cooling methods developed a rebound of high body temperature, while our patient’s body temperature remained stable. This intravascular cooling system may be useful to control body temperature in patients with heat stroke.

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We experienced four pediatric cases who lived long term after being diagnosed as brain-dead by clinical features. In all of the cases, we did not declare brain death and continued life-prolonging treatment. In November 2014, the guideline about terminal care for emergency and intensive care medicine was published. This guideline defined brain death as the end of life. Because of the social background in those days and a lack of consensus on cures for terminal illnesses, we continued treatment to sustain patients' lives in two of the four cases. Cases of child abuse, wherein no one has parental authority or the ability to decide upon the treatment method on behalf of the patient, or problems of family acceptance could make it difficult to withdraw life-sustaining treatment. However, in order to protect the affected children's dignity, brain death should be judged appropriately and the option of terminating cures should be presented to their families.

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Pediatric acute fulminant myocarditis (AFM) has progressive mobility with multiple organ failure. Some cases deteriorate, result in not living. In this time, we had a case of pediatric AFM with recovery from multiple organ failure according to fast induction of cardiac assistant devices. She had peripheral extracorporeal membrane oxygenation (ECMO), central ECMO and biventricular assist device, at last. After intensive care for 5 months, her heart needed only left ventricular assist device implantation. She could to be waiting for the chance of heart transplantation at home.

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