Objective: We aimed to evaluate the efficacy and safety of a clinical path for early enteral nutrition in critically ill patients requiring mechanical ventilation in an open-system ICU. Methods: We performed a retrospective study to compare 48 patients to whom the clinical path was applied (Path group) with 40 patients who received enteral nutrition before the start of the application of the path (Control group). Results: The median time from the start of mechanical ventilation to the initiation of enteral nutrition was significantly reduced in the Path group as compared with that in the Control group (median, 22 vs. 45 hours; P = 0.03). The incidence of diarrhea and vomiting did not increase in the Path group. There was no significant difference in the duration of mechanical ventilation and in-hospital mortality between the two groups. Conclusion: Early enteral nutrition in critically ill patients requiring mechanical ventilation was achieved with a clinical path for enteral nutrition in an open-system ICU, without increasing gastrointestinal complications.

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The patient was a 77 years old woman. She was admitted to the emergency room for severe dyspnea. Her vital signs at the hospital arrival were pulse rate of 111 /min, blood pressure of 70/52 mmHg, and percutaneous arterial oxygen saturation 91% on room air. ST depression of right chest leads on electrocardiogram, bilateral massive pulmonary embolism on contrast-enhanced chest CT, and dilated right ventricle compressing the septal wall of the left ventricle on echocardiography were shown, and consequently, she was diagnosed with acute massive pulmonary embolism. Immediately, we started anti-coagulation therapy with heparin administration. The emergency surgical embolectomy was indicated to perform simultaneously. Since there was a possibility of hemodynamic deterioration, we decided to initiate percutaneous cardiopulmonary support (PCPS) to avoid sudden circulatory collapse. The postoperative cardiopulmonary condition was stable and PCPS was not required throughout the peri-operative period in this case. She was successfully weaned off the respirator and catecholamine administration was discontinued on 1^st postoperative day. Under the program of early rehabilitation, she recovered with no neurological sequelae and was discharged from the ICU on 4^th postoperative day. Acute massive pulmonary embolism has a high mortality rate and is a life threatening disorder that must be treated as soon as possible, and intensive care is essential to rescue these patients. For acute massive pulmonary embolism, early diagnosis and appropriate treatment greatly improve the mortality. When undertaking cardiopulmonary management including PCPS in patients who do not respond to the medical treatment or require the surgical treatment, we should make the coordination between departments in the hospital. It is necessary to have a consensus in the management of the acute pulmonary embolism and the multimodal intensive therapy that is to be provided.

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Background: Self-extubation can occur in patients on mechanical ventilation in ICU. This study aimed to evaluate the frequency of self-extubation, the reintubation rate after self-extubation, the clinical characteristics of patients that undergo reintubation after self-extubation, and the prognosis of patients that experience self-extubation at our ICU. Methods: We retrospectively evaluated incident reports and ICU data that were prospectively collected between April 2013 and March 2015. Results: A total of 590 patients required mechanical ventilation. Of these, 41 patients (7%) experienced self-extubation. We selected 33 patients for our study after excluding 8 patients with missing data. Sixteen patients (48%) required reintubation, whereas 17 patients (52%) did not. The patients were reintubated more often after self-extubation (16 of 33) than after planned extubation. Chronic heart failure and a requirement for noradrenaline were found to be risk factors for reintubation after self-extubation (50% vs. 12% and 56% vs. 18%, respectively; both P<0.05). The patients who required reintubation experienced significantly longer ICU stays and a higher complications rate than those who not did require reintubation (20±14 vs. 10±5 days and 5 vs. 0, respectively; both P<0.05). All deaths involved patients that underwent reintubation. Conclusions: Patients with unstable hemodynamics, for example, those with chronic heart failure or that require noradrenaline, are at high risk of reintubation after self-extubation. Reintubation after self-extubation is associated with a significantly longer ICU stay and a tendency towards a higher complications rate. Physicians should manage patients with unstable hemodynamics carefully.

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This report presents the case of a neonate with septic shock and acute respiratory distress syndrome (ARDS) caused by invasive group A streptococcal infection. Mechanical ventilation was performed with plateau pressure of 28 cmH₂O and PEEP of 8 cmH₂O. However, progressive hypoxemia continued and extracorporeal membrane oxygenation (ECMO) was considered. At this point, esophageal pressure was measured and transpulmonary pressure was calculated as 18 cmH₂O. Based on previous research indicating that transpulmonary pressures of ≤25 cmH₂O does not exacerbate pulmonary injury, the plateau pressure was increased to 38 cmH₂O and PEEP to 14 cmH₂O. Hypoxemia improved, septic shock was treated successfully, and the neonate was extubated on day 8 and discharged from the ICU on day 13. This case suggests that ECMO can be avoided in neonates with rapidly progressive severe ARDS by adjusting ventilation support based on transpulmonary pressure.

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The patient was a 70-year-old man who was transferred to our hospital by his local physician due to severe sepsis arising from a chronic skin lesion on the lower extremity. Sepsis resolved following aggressive wound treatment and administration of antibiotics. Kerstersia gyiorum (K. gyiorum) was later detected from wound cultures. Progress in the classification and identification of bacteria by 16S rRNA(16S ribosomal RNA) analysis led to the classification of K. gyiorum as a bacterium in 2003, but the number of reported cases remains limited. The difficulty of identifying K. gyiorum is cited as one reason for this lack of reports. In the present case, the bacterium was identified by MALDI-TOF MS (matrix assisted laser desorption/ionization time of flight mass spectrometry). Now that analysis is possible at medical facilities due to advances in testing equipment, bacteria that were previously difficult to identify can be relatively easily identified. An increase in the number of cases of identified bacteria that were previously reported only infrequently and that we were previously unaccustomed to hearing about, such as in the present case, is easily conceivable going forward. Further accumulation of cases and knowledge of treatment are anticipated.

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A 66-year-old man with no allergic history underwent primary percutaneous coronary intervention in the left anterior artery for anterior myocardial infarction with implantation of a drug-eluting stent 3 months ago. Here he underwent a contrast medium infusion for follow-up of vertebral artery dissection by cranial CT angiography. During the infusion, generalized rash, decreased blood pressure, and loss of consciousness occurred. His symptoms of anaphylaxis improved after an intramuscular injection of 0.3 mg of adrenalin, but he complained of typical chest pain. An electrocardiogram revealed ST elevation in the anterior leads for which we diagnosed Kounis syndrome. Coronary angiography revealed occlusion of the stent for which direct stenting of the left anterior artery was successfully performed. Contrast medium must be administered in the examination and treatment of Kounis syndrome, even in cases triggered by contrast medium. In this case, the stent was placed under steroid administration. The patient's postoperative course was good without recurrence of the anaphylaxis. In conclusion, during the treatment of patients with allergic reactions, the possibility of concurrent acute coronary syndrome should be considered. Coronary angiography and percutaneous coronary intervention must be performed for the assessment and treatment of Kounis syndrome, even in cases triggered by contrast medium.

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Objectives: The study was conducted to compare the combined effect of dexmedetomidine (DEX) and oral or suppository Yokukansan (YKS) on sedation after cardiac surgery in pediatric patients. Methods: Eighteen postoperative patients were divided into three groups according to YKS combined with continued administration of DEX: non-YKS (NY) group, gastric tube (oral) YKS (GY) group, and intrarectal suppository YKS (RY) group. YKS was administered at a dose of 0.1 g/kg every four hours. The sedation level was evaluated using Richmond Agitation-Sedation Scale and Behavioural Observational Pain Scale, and ketamine was administered for patients with scores ≥2 in either scales. The total dose of ketamine administered per body weight was used to define the sedative effect. Results: The ketamine dose (median) was 1.5, 1.0, and 0 mg/kg/day in NY, GY, and RY groups, respectively. Compared with the NY group, the GY group used less ketamine but the difference was not significant (P=0.49) and the RY group used a significantly lower dose (P=0.03). Conclusions: The combination of DEX and suppository YKS was effective for sedation in children after cardiac surgery, while DEX combined with gastric tube (oral) YKS was not sufficient in efficacy.

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[in Japanese]

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