Free flaps are used in reconstructive surgery for head and neck cancer, trauma, and burns. Because the flaps require monitoring, the patient needs to be transferred to the ICU postoperatively. The main postoperative complications of free flaps are thrombosis, hematoma, fistula, and flap failure. To recognize the occurrence of postoperative complications, it is necessary to evaluate the condition of the flap every few hours. Although one report recommends monitoring of flaps for the first 72 hours postoperatively, in Japan, it may be impractical to keep the patient in the ICU solely for monitoring of flaps. Because thrombosis may occur with mechanical pressure, free flaps must be maintained without stress. However, agitation and delirium can cause stress. Previous reports on postoperative free flaps were based on retrospective observational studies; thus, randomized controlled trials are required. In this article, we provide basic knowledge of free flap management in the ICU, and discuss management problems.

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Sleep is classified into rapid eye movement (REM) and non-REM (NREM) phases. The centers of sleep and wakefulness are located in the anterior and posterior hypothalamus, respectively. The sleep-wake cycle is controlled by a combination of circadian and homeostatic mechanisms, and regulated by neurotransmitters such as GABA (γ-aminobutyric acid), histamine, orexin, acetylcholine, noradrenaline, serotonin, as well as adenosine. As NREM sleep enhanced by pro-inflammatory and suppressed by anti-inflammatory cytokines, immuno-endocrine system is also involved in the regulation of the sleep. Sleep in critically ill patients characterized by prolonged sleep latency, decreased sleep efficiency, decreased slow-wave and REM sleep, and fragmentation of sleep. The underlying illness and severity of acute illness, as well as the medications, standard of care, and environmental factors in the ICU can cause sleep deprivation. Improvements of patient care and environmental factors can increase the apparent sleep quality and reduce the incidence of delirium in critically ill patients.

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In order to investigate stressful experiences of ICU patients who were on artificial respirators for 12 hours or longer and discover the factors relevant to such experiences, we developed the Japanese version of the ICU Stressful Experiences Questionnaire (ICU-SEQJ) consisting of 34 stressful experience items, and interviewed such patients before they left the ICU. Nearly 80 percent of the patients experienced thirsty, not being able to talk and nearly 70 percent experienced not being able to move freely, difficulty talking, discomfort caused by the endotracheal tube, pain and tense, with subjective levels ranging from moderately to very strongly stressful. Patients without previous histories, emergency patients admitted to the ICU and patients with jobs experienced significantly stronger stress. A multiple linear regression analysis indicated that the CRP value before extubation affected the stressful experiences more than the other factors. The intubation duration, analgesic and sedative doses, and pain complaints weakly collated with the stressful experiences. Among 96 patients, 10 patients remembered none of the 7 items relating to tracheal intubation. Their stressful experience levels were significantly low. The relevant factors were a high Propofol dose, deep sedation and old age. Since stressful experiences are problematic for many ICU patients, and are affected by patient ICU admission conditions and previous histories, nurses must predict patient needs, make assessments for each case and intervene to reduce stressful experiences.

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Inhaled nitric oxide (INO) and the high flow nasal cannula (HFNC) are useful for post-operative management after pediatric cardiac surgery. INO therapy is effective in patients with pulmonary hypertension and after the Fontan procedure. HFNC therapy is effective as pulmonary support after extubation. INO is generally used in patients on ventilators. Hence, it is sometimes difficult to decide whether or not ventilator management should be continued solely for INO therapy. Combining HFNC and INO therapy allows continuation of NO administration. We successfully treated 3 patients (2 total anomalous pulmonary venous return patients, and 1 post-Fontan procedure patient) with HFNC-NO therapy. HFNC-NO therapy can stabilize circulation, improve respiratory function, and is effective in patients with severe residual pulmonary hypertension and after the Fontan procedure.

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The usefulness of plasma exchange (PE) for hemolytic uremic syndrome (HUS) by enterohemorrhagic Escherichia coli (EHEC) is unclear. On the other hand, there were no reports of the relationship between central nervous system (CNS) disorder and renal dysfunction. We report three pediatric patients with HUS by EHEC, two patients with PE and one without PE, and their renal dysfunction. The subjects were 3 patients with HUS by EHEC admitted to the ICU. On admission, anuria was noted in all subjects. Continuous hemodiafiltration (CHDF) was started. In 2 patients with CNS disorder, PE was performed for 3 days starting from 9 and 10 days after the onset of digestive symptoms, respectively. In these patients, CNS disorder was not observed on discharge from the ICU. The CHDF period was 9 and 13 days, respectively. It was 36 days in a non-PE-treated patient without CNS disorder.

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The minimal inhibitory concentration (MIC) of vancomycin (VCM), as measured using the MicroScan WalkAway^® prompt method (MW prompt), for treating methicillin-resistant Staphylococcus aureus (MRSA) has been reported to be higher than that measured using other automated susceptibility testing methods or the turbidity method. Therefore, the efficacy of VCM therapy in treating MRSA infections with an MIC of 2μg/ml of VCM, measured using MW prompt, remains unclear. In this study, we investigated the clinical and bacteriological efficacy of VCM therapy in 11 cases of MRSA pneumonia with an MIC of 1μg/ml (MIC-1 group) or 2μg/ml (MIC-2 group) of VCM as measured using MW prompt. Bacteriological success rate was 50% in the MIC-1 group but 0% in MIC-2 group. Clinical success rate was obtained in 67% of the MIC-1 group and in 20% of the MIC-2 group. In conclusion, similar to previous studies, the present study revealed that the efficacy of VCM therapy in treating MRSA with an MIC of 2μg/ml of VCM, measured using MW prompt, is lower than that with an MIC of 1μg/ml of VCM.

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Objective: Little is known about distribution of the workload related to continuous renal replacement therapy (CRRT). The purpose of this multicenter survey is to examine the timing of CRRT initiation and the related work. Methods: A total of 6,024 circuits in 1,785 patients who underwent CRRT at 24 acute care facilities from January to December 2013 were enrolled in the survey. The timing of CRRT initiation, frequency of nighttime circuit exchange, and availability of clinical engineers (CEs) at night was examined. Results: There were 12/24 (50%) facilities with CEs in-house at night. Comparing the day (8:00-17:00) shifts with night (17:00-8:00), the timing of CRRT initiation and frequency of circuit exchanges were performed at ratios of 50.4:49.6, and 70.6:29.4, respectively. In a significant number of facilities without CEs in-house at night, doctors or nurses performed the CRRT circuit priming and return of blood left in the circuit at night (P < 0.05). A lower frequency of nighttime circuit exchanges was observed in facilities without night float CEs than in facilities with them (P < 0.01). Conclusion: CEs are in-house at night in only 50% of the hospitals surveyed. The distribution of CRRT-related workload may depend upon CE's duty hour policies.

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