Objectives: To survey the management of pediatric septic shock in Japanese pediatric intensive care units (PICUs) and obtain the basic data for improving the practices in the management of pediatric sepsis. Methods: A questionnaire concerning the management of pediatric septic shock using a case scenario was sent to ICU and PICU medical directors of 29 units in Japan. Results: Responses were obtained from 27 units. Of these, only 33% of the facilities obtained 2 sets of blood cultures before starting antibiotic administration. A total of 52% of the facilities gave antibiotics within 1 hr of septic shock recognition, and 59% considered starting vasopressors if a patient was still hypotensive despite 40-60 ml/kg of fluid resuscitation. The vasopressors chosen were dopamine (33%), noradrenaline (30%), and adrenaline (26%). Arterial lactate, an arterial blood gas analysis, and central venous oxygen saturation (ScvO₂) values were used to determine the severity of septic shock. Conclusion: The performance of multiple sets of blood cultures and earlier administration of appropriate antibiotics need to be encouraged in order to improve the practices in pediatric septic shock.

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A 7-year-old girl was diagnosed with traumatic spleen injury (IIIa) caused by abdominal contusion. Shock persisted after transcatheter arterial embolization. The abdominal distension suggested the presence of abdominal compartment syndrome (ACS) due to hemorrhagic ascites. The shock rapidly improved after peritoneal drainage. Accurate diagnosis of ACS requires the measurement of intra-abdominal pressure, which can be difficult. Hence, intra-vesical pressure (IVP) was used as a substitute. In cases of pediatric ACS, accurate diagnosis and rapid treatment, by recognizing variations in normal IVP is important, along with understanding the definition of intra-abdominal hypertension and ACS and the method of measuring IVP between children and adults.

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Peripartum cardiomyopathy (PPCM) is an idiopathic cardiomyopathy that presents with severe heart failure secondary to left ventricular systolic dysfunction, toward the end of pregnancy or in the months after delivery, in the absence of any other cause of heart failure. A 40-year-old multigravida at 36 weeks and 6 days of gestation, who complained of dyspnea for 2 days, was referred to the Department of Obstetrics and Gynecology in our hospital. She had an ejection fraction of 18%. Chest radiograph showed pulmonary edema and pleural effusion; the patient had no history of heart disease. She was diagnosed with PPCM. After an emergency caesarean section, she was treated in the ICU with noninvasive positive pressure ventilation, a diuretic, and dobutamine. She was discharged from the ICU on POD 2. Although her general condition improved, and she was discharged from the hospital on POD 23 with persistent low cardiac output, she developed cerebellar infarction 6 months later.

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We encountered a patient who developed paroxysmal sympathetic hyperactivity (PSH) after cardiopulmonary resuscitation, which was difficult to treat. The patient was a 33-year-old man who visited us with the chief complaint of general malaise that had persisted for several days. Marked dehydration and nephropathy, rhabdomyolysis, and hyperkalemia were observed, and he experienced cardiopulmonary arrest after arrival at the hospital. While spontaneous circulation was resumed by cardiopulmonary resuscitation, and therapeutic hypothermia was applied, the condition progressed to hypoxic-ischemic encephalopathy. Paroxysmal tachycardia, hypertension, tachypnea, sweating, fever, and myotonia developed in response to stimulation from the 7th hospital day, and the patient was diagnosed as having PSH. The PSH was difficult to treat, and long-term general care was necessary. However, the frequency of paroxysm was decreased by treatment with labetalol, clonazepam, gabapentin, bromocriptine, and dantrolene. Few cases of PSH associated with hypoxic-ischemic encephalopathy have been reported in Japan. The development of PSH should be considered for both head injury and hypoxic encephalopathy.

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Background: Re-expansion pulmonary edema (RPE) often occurs following minimally invasive cardiac surgery (MICS) involving differential lung ventilation. We investigated factors related to respiratory failure following MICS in our hospital. Methods: We included a total of 97 patients who had undergone MICS. Patients were divided into two groups by P/F ratio following surgical procedures of 4-6 hr: (1) high oxygenation group (group H, n=72, P/F ratio>300) and (2) low oxygenation group (group L, n=25, P/F ratio≤300). We compared these groups and investigated the related factors retrospectively. Results: One patient in group H and five patients in group L were diagnosed with RPE. In group L, preoperative albumin levels were low, differential lung ventilation time was long, and the volume of fresh frozen plasma (FFP) administered during surgery was high compared with the corresponding values in group H. Conclusion: Awareness of the potential occurrence of RPE should be kept in mind in the case of prolonged cardiac surgery or case with FFP transfusion.

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