During mechanical ventilatory assistance, patient-ventilator asynchrony occurs frequently. To avoid patient-ventilator asynchrony, the ventilator gas delivery pattern must match the patient's breathing pattern. Asynchrony may cause one or more of the following: poor gas exchange; hyperinflation of the lung; increased work of breathing owing to ventilator-induced diaphragmatic dysfunction; increased duration of both mechanical ventilation and ICU length of stay; and greater mortality. However, patient-ventilator asynchrony is easily overlooked. There are three general types of asynchrony: trigger asynchrony, cycling asynchrony, and flow asynchrony. Trigger asynchrony - caused by auto-triggering, ineffective inspiratory efforts (missed triggering), double triggering, and reverse triggering - occurs when the ventilator does not start pressurization in synchrony with the patient’s inspiratory effort. Cycling asynchrony occurs when the inspiratory time of patient, ventilator do not match, and may occur as premature cycling or delayed cycling. Flow asynchrony occurs when ventilator flow delivery does not match the inspiratory demand of the patient. To deal with this common problem, bedside clinicians need better understanding of causes, graphical characteristics and appropriate management of each asynchrony.

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In recent years, the number of studies on albumin and its use in critically ill patients has been increasing, and these studies have provided important insights into the clinical use of albumin for the treatment of different pathological conditions. Although many clinical studies involving the administration of albumin during the acute phase, with a target serum albumin level of 2.5 to 3.0 g/dl, have been reported, the superiority of albumin treatment has not been demonstrated. In patients with a decreased intravascular volume or severe sepsis, the use of albumin is not associated with an improvement in the mortality rate, compared with the use of crystalloids. Furthermore, the efficacy of albumin for fluid resuscitation in patients with traumatic brain injury or for the initial treatment of acute stroke has not received evidence-based support. In the former situation, a poorer prognosis has actually been noted. On the other hand, albumin is superior to other plasma expanders for preventing circulatory failure and for reducing mortality after large-volume paracentesis. Therapeutic plasma exchange using albumin as a replacement fluid is an effective treatment for neurological disorders. At present, no clear thresholds for albumin administration exist, and the decision to use albumin products should be made after careful consideration of the disease and the patient's condition.

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Objective: To clarify the relationships between the preoperative physical function and the development of ICU-acquired delirium (ICU-AD) in cardiac surgery patients. Methods: The subjects included 107 patients who underwent elective cardiac surgery from October 2013 to May 2014 in our hospital. They were classified into the ICU-AD group and the no-ICU-AD group. The age, sex, body weight, BMI, medical history, preoperative physical function, cognitive and mental function, cardiac ultrasound test results, blood biochemistry test results, surgery information, and postoperative ICU information, were compared between the two groups. Results: The preoperative lower knee extension muscle strength (0.31±0.11 kgf/kg vs 0.40±0.14 kgf/kg, P<0.05), grip strength (21.4±10.7 kgf vs 28.2±10.4 kgf, P<0.05) and one leg standing time (5.3±3.6 seconds vs 25.7±22.4 seconds, P<0.01) in the ICU-AD group were significantly lower than those in the no-ICU-AD group. The results of a logistic regression analysis revealed that the preoperative one leg standing time, depression and total ventilation time were predictors of ICU-AD. Conclusion: The preoperative physical function of the patients who developed ICU-AD after cardiac surgery was lower than that of the patients who did not develop ICU-AD.

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Objectives: The indications for noninvasive positive pressure ventilation (NPPV) have been expanded in recent years, and previously reported predictors of NPPV failure may not be applied for current NPPV patients. In this study, we retrospectively examined clinical data to reevaluate the predictors of NPPV failure. Methods: Patients who were treated with NPPV in our ICU between August 2010 and July 2012 were divided into two groups; success and failure. The success group included patients who were weaned from NPPV, while the failure group included patients who eventually required tracheal intubation. Baseline patient characteristics, results of the first arterial blood gas (ABG) test after the initiation of NPPV, duration of NPPV, length of ICU stay, and ICU mortality were compared between the two groups. Results: The success group included 96 patients and the failure group included 40 patients. The results of the ABG test (pH, PaCO₂, P/F ratio) showed no difference between the two groups. Duration of NPPV was similar between the two groups but length of ICU stay was longer (P<0.01) and ICU mortality was higher (P<0.01) in the failure group when compared with the success group. Conclusions: Our results suggest that the results of the first ABG test following NPPV initiation may not be accurate predictors of NPPV failure.

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[in Japanese]

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