Purpose: The aims of this study were to analyse the current state of paediatric patient intra-hospital transport receiving extracorporeal membrane oxygenation (ECMO). With this analysis and considering our transport system, the problem of transport can become clear. Subjects and Methods: We retrospectively reviewed the medical records of patients who were transported while receiving ECMO at our hospital between March 2010 and August 2013. Results: Subjects comprised 11 patients who underwent 17 transports [median age: 7 months and 28 days (range: 11 days - 7 years and 8 months); median body weight: 4.8 kg (range: 2.6 - 22 kg)]. All transports were completed. Regarding serious complication of transport, 1 ECMO flow drop was observed. About this transport, patient was treated with prepared equipment, and then ECMO flow was recovered. Except this case, serious complications such as thrombotic events or hemorrhagic one were not observed. Body temperature was significantly decreased before and after transport. Discussion: Complication of ECMO flow drop was happened because patient was bleeding and patient's vital signs weren't stable despite blood transfusion before transport. We removed warm water tank system from ECMO because of its heaviness. This was the cause of decreased body temperature. Conclusions: The results suggested that systemisation including equipment (such as introduction of portable warm tank system) is necessary for ECMO transport.

View full abstract

Purpose: This study was conducted to examine the relationship between ambulation independence and cross-sectional area of the lumbar major muscle in patients with colon perforation. Methods: We retrospectively examined the cases of 32 colon perforation patients who underwent emergency laparotomy. We divided the patients into two groups: ambulation independence (n=21) and ambulation dependence (n=11). Results: A logistic regression analysis revealed that the APACHE II score, outcome, and the rate of change of the area of the psoas major were factors relevant to ambulation independence. Conclusion: As decreases in the cross-sectional area of the psoas major during intensive care possibly affect patients' gait ability after being discharged from the ICU, it may be necessary to prevent any loss of the psoas major muscle strength by promoting early mobilization whenever possible or, if not possible, actively providing in-bed muscle training even for ICU patients.

View full abstract

Background: The number of people of an extremely advanced age has recently seen a rapid increase in Japan. Thus, an increasing number of such individuals are brought to emergency critical care centers. Many such individuals have poor ability to conduct activities of daily living (ADL) or have dementia, and thus the medical profession often suffers from having to implement intensive therapies. Therefore, the significance of intensive therapy for extremely elderly patients is a timely topic of discussion given their background factors and potential outcomes. Methods: The sample was composed of 66 ICU patients aged 90 or older who had been brought to our facility between January 2009 and December 2011. We retrospectively reviewed their medical records to investigate diseases, patient background factors, operations/treatments after admission, and outcomes. Results: The median age of study participants was 92 years, and 68% were women. Nineteen patients died in the center, 19 were discharged, and 28 were transferred to other centers. The half-year and 1-year survival rates of the 47 discharged/transferred patients were 74.3% and 54.7%, respectively. Significant poor prognostic factors were identified, namely, male, dementia, poor ADL, and residential care. Male gender and poor ADL were found to be independent prognostic factors by multivariate analysis. Discussion: Most extremely elderly patients had a poor long-term outcome, though a few followed a favorable course owing to their treatments. Thus, we question the general significance of intensive therapy for extremely elderly patients in emergency medical centers. Medical practitioners should provide patients and their families with reasonable health care.

View full abstract

We report a rare case of traumatic axillo-brachial artery (Ax-BA) pseudoaneurysm and huge thoracic hematoma associated with proximal humeral fracture. An 88-year-old woman underwent operation for proximal humeral fracture after an accidental fall. Thereafter, she was in a state of shock and had respiratory failure. Emergency computed tomography revealed a ruptured left Ax-BA pseudoaneurysm and huge thoracic hematoma. We selected a simple method for the minimum invasive surgery and performed endovascular treatment (selective coil embolization for the injured artery) and surgical removal of the hematoma. The postoperative course was uneventful.

View full abstract

A case of reversible posterior leukoencephalopathy syndrome (RPLS) accompanying HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome is reported. A 39-year-old woman with no pregnancy-induced hypertension, attended our hospital because of acute epigastralgia at 22 weeks' gestation. One hour after arrival, she developed seizures complicated by HELLP syndrome. We performed an emergency cesarean section and admitted her to the ICU. On the first postoperative day, anisocoria was observed. A head CT showed cerebral edema. We initiated therapy with glycerol and magnesium, and maintained normothermia. A head MRI showed high signal intensity lesions in the white matter of the bilateral frontal and occipital lobes on T2-weighted and FLAIR images. We diagnosed RPLS. An magnetic resonance angiography (MRA) showed vasospasm at the cerebral arteries. She made good progress and moved to the obstetrics ward on postoperative day 15. Follow-up MRI and MRA revealed that the hyperintensity lesions on T2-weighted and FLAIR images had disappeared and the vasospasm was improved.

View full abstract

A 43-year-old man receiving combination therapies, including steroid therapy, for Crohn's disease, was admitted to our department with pain in the left lower extremity. Physical examination revealed periproctal abscess, and the swelling was accompanied by redness and snow grasping sense at the perineum, left buttock, thigh, and lower leg. Blood examinations revealed the signs of an inflammatory reaction and acute kidney injury, while CT scan revealed extensive subcutaneous gas along the fascial planes extending from the perineum to the left lower leg. Under the diagnosis of Fournier's gangrene which had progressed to widespread lower extremity gas gangrene, emergency incisional open drainage and debridement were performed. The diagnosis of non-clostridial gas gangrene (mixed infections) was made based on the results of microbial examination of the drained pus. After the operation, daily wound irrigation, total parenteral nutrition, transanal ileus tube insertion for fecal drainage, administrations of meropenem and immunoglobulin, and steroid cover were performed. Although re-incision of the abscess at the left thigh was required on the 8^th hospital day, the following clinical course was uneventful. After auto skin grafting for the incisional wounds, the patient was discharged on the 247^th hospital day.

View full abstract

The use of anticoagulation therapy for Lemierre's syndrome remains controversial. Nonetheless, this treatment is relatively common and has been reported as safe with no attributed bleeding complications. We present a rare case of a patient who developed massive pulmonary hemorrhage during treatment with anticoagulation therapy for Lemierre's syndrome. A previously healthy 18-year-old woman presented with fever, neck pain, and worsening dyspnea following symptoms of acute pharyngitis. CT scans of the neck and chest taken on admission to a hospital revealed thromboses of the left facial vein and left internal jugular vein and diffuse pulmonary emboli. A blood culture grew Fusobacterium necrophorum. In addition to antibiotic therapy, anticoagulation therapy with enoxaparin was initiated. On hospital day 7, enoxaparin was replaced with rivaroxaban. On day 11, the patient experienced massive pulmonary hemorrhage, for which she required massive transfusions and endotracheal intubation with subsequent mechanical ventilation. The risk of pulmonary hemorrhage must be weighed against the potential benefits when starting anticoagulation therapy in patients with Lemierre's syndrome having substantial pulmonary emboli.

View full abstract

Purpose: This study was carried out to elucidate what role nurses working in emergency care thought they should play in terminal care in the intensive care and what difficulties they felt in practice. Method: Nurses who were working in the ICU/emergency department of a particular hospital in Japan were asked to answer the questions on a questionnaire form. The hospital had local guidelines on terminal care in place, and in the analysis of replies, an emphasis was given to how these guidelines affected the subjects' perception of nursing role in terminal care. Results and Discussion: The subjects were aware of their role as a provider of family support to ensure that the family understood the situation; as an advocate to convey the family's wishes to the doctor, and as a listener to whom the family could confide their emotions. A comparison of the study results against the Guidelines on Mental Care of Families of Terminally Ill Patients set out by the Japanese Society of Intensive Care Medicine revealed that the subjects lacked awareness of the role of championing the right of family members to make decisions on behalf of the terminally-ill patient. The nurses' clinical experiences were related to their understanding of their roles and practices in terminal care.

View full abstract