In the field of intensive care, increasing attention is being paid to post-intensive care syndrome in recent years, and an intervention focused on approaches such as the ABCDE bundle is recommended. However, if a patient does not respond actively and positively, the effect of such interventions is not sufficient. By shortening the hospitalization period, our nurses' agenda is changing. It is a therapeutic action support for patients with prehospitalization, such as measures to stabilize cardiac function before surgery and early detection of heart failure before surgery. It is important to evaluate the patient's adherence and promote adherence behavior in order to work on issues such as rehabilitation while the condition is severe. I surveyed research trends for patients with open-heart surgery in the world, because these patients are commonly admitted to an ICU. In the future, it will be necessary to clarify the concept of adherence and patient support methods that promote adherence. It also suggested the need for research on adherence in the ICU.

Background: A Rapid Response System (RRS) triggered by a single parameter has been introduced in our hospital. Although the criteria were designed for non-obstetric patients, the RRS concept can be applied to obstetric care. Objective: This study aimed to assess the trigger criteria of RRS compared with the modified early obstetric warning system (MEOWS) criteria as a screening tool for obstetric morbidity. Method: We retrospectively reviewed the medical records of women admitted to the maternal and fetal ICU of Kitasato University Hospital in 2015. Based on recorded physiological parameters, all cases were investigated on whether they met the trigger criteria of the Kitasato RRS (KRRS) and MEOWS. Additionally, the obstetric morbidity defined in this study of each case was determined. The diagnostic sensitivity and specificity of KRRS and MEOWS for obstetric morbidity were evaluated. Results: During the study period, 67 of 373 patients met the criteria for obstetric morbidity. The KRRS criteria for diagnosing obstetric morbidity were 51% sensitive and 74% specific, and the MEOWS criteria were 83% sensitive and 79% specific. Of the 33 patients with morbidity but who did not meet the KRRS criteria, 32 were diagnosed with hypertensive disorders of pregnancy. Of 80 patients with no morbidity, but triggered the KRRS criteria, 32 had tachycardia due to ritodrine. Discussion: The sensitivity of the KRRS trigger criteria was lower than that of the MEOWS criteria; this could be attributed to the inability of the KRRS trigger criteria to detect obstetric-specific conditions. KRRS was triggered in cases with non-morbid conditions suggesting that KRRS will not adapt to the physiological changes in obstetric patients. Conclusion: The KRRS criteria have low sensitivity to obstetric morbidity. If KRRS is introduced to an obstetric ward, informing RRS members about the specific conditions of the obstetric patients will be imperative.

A 77-year-old woman was admitted to the ICU following unexplained shock. She was primarily admitted to our hospital for postoperative rehabilitation. She had developed paralytic ileus after the operation and received magnesium oxide (990 mg/day) approximately 25 days before the ICU admission. The electrocardiography on admission revealed bradycardia with atrioventricular and sinoatrial block. Simultaneously, the results of her blood gas analysis showed that her serum ionic magnesium (iMg²⁺) concentration level was high, up to 2.34 mmol/L, which is equal to a total serum magnesium (Mg) concentration level of 11.9 mg/dL. Since we assumed that hypermagnesemia was the primary cause of the shock, continuous hemodiafiltration to decrease the serum Mg concentration level was performed. With a decrease in serum Mg concentration level, the heart rate returned to normal sinus rhythm, and she recovered from the shock. She was discharged from the ICU on the 12th day. Retrospective data showed that serum Mg concentration level elevated rapidly the day before admission to the ICU. As we have known previously, most cases of hypermagnesemia in the elderly patients are iatrogenically induced by Mg products, as evidenced by patients’ renal dysfunction. In such cases, dysfunction of Mg excretion results in a gradual elevation of serum Mg levels. However, as in this case, acute elevation of serum Mg levels is accompanied with paralytic ileus because intestinal Mg absorption is promoted; i.e., bowel obstruction becomes a cause of acute hypermagnesemia even if there is no preexisting renal dysfunction.

Dabigatran, a well-known direct oral anticoagulant (DOAC), is commonly used, because dabigatran does not require laboratory monitoring, and has lower risk of bleeding than warfarin. However, major bleeding such as intracranial hemorrhage is still a critical cause of concern for patients on dabigatran therapy. We present the case of a 76-year-old female patient with subarachnoid hemorrhage (SAH) and intracerebral bleeding who was taking dabigatran daily for atrial fibrillation. She presented with loss of consciousness and was eventually diagnosed with SAH and intracerebral bleeding. We treated the patient with an antidote, idarucizumab, for dabigatran reversal after which she underwent emergency craniotomy. No bleeding events occurred during the operative and postoperative phase. Non-elective surgery in patients on DOACs requires adequate preoperative preparations because of the increased risk of hemorrhage. Development of the new antidotes will improve perioperative safety for patients taking DOACs.

Inferior vena cava (IVC) filter occlusion requiring emergency intervention has been rarely reported. Here, we report a patient who developed obstructive shock due to IVC filter occlusion and was successfully treated using catheter thrombectomy. A 54-year-old Caucasian male was admitted for radiation therapy for groin melanoma. Despite the initiation of unfractionated heparin therapy, an IVC filter was placed after exacerbation of deep venous thrombosis and pulmonary embolism. Two days after IVC filter placement, the patient developed shock and was admitted to the ICU. Considering the lack of response to septic shock management and imaging findings, obstructive shock due to IVC filter occlusion was suspected. After catheter thrombectomy, the IVC filter was partially recanalized followed by gradual hemodynamic stabilization. Heparin-induced thrombocytopenia (HIT) was suspected owing to thrombosis and thrombocytopenia. Heparin was replaced with argatroban. The patient was diagnosed with HIT and was administered anti-coagulant therapy until discharge from the ICU. Occlusion of the IVC filter should be considered a potential cause of obstructive shock.

Intratracheal bleeding during extracorporeal surgery can be fatal. Inhaled nitric oxide (NO) selectively dilates healthy alveolar vessels, improves pulmonary vascular resistance and ventilatory blood flow ratio, and consequently improvement of oxygenation is expected. A 66-year-old man underwent total arch replacement for a thoracic aortic aneurysm. A large volume of bleeding was observed from the endotracheal tube immediately after withdrawal from extracorporeal circulation. Bleeding from the right bronchus, pulmonary artery injury was suspected due to the pulmonary artery catheter. Since the oxygenation failure and circulatory collapse were sustained, we inserted extracorporeal membrane oxygenation (ECMO) and returned the patient to the ICU. Improvement in oxygenation performance was poor, and inhaled NO was initiated 3 days after surgery. Improvement of oxygenation and decrease of pulmonary artery pressure were observed, which allowed withdrawal from the ECMO and removal from the ventilator. Inhaled NO was effective in improving hypoxemia after endotracheal hemorrhage.