Recently, percutaneous ventricular assist devices (VADs), and third-generation implantable VADs have become available in Japan. Each of the devices has its own characteristics and needs to be used in specialized facilities with a thorough assessment of the adaptation to patients. Patients with severe end-stage heart failure who crashed there circulation should be evaluated for treatment options such as heart transplant registration and implantable VADs, while being supported by mechanically assisted circulation. Implantable VADs are used as a bridge to cardiac transplantation in patients who are eligible for cardiac transplantation. In patients with relatively stable periods of severe heart failure, the appropriate timing of treatment should not be missed and heart transplant registration and implantable VADs should be considered to achieve good outcomes. Destination therapy, which will be introduced in Japan soon, may open the door to the use of implantable VADs for patients with severe end-stage severe heart failure who are not candidates for cardiac transplantation.

Although the Henderson-Hasselbalch approach to acid-base physiology and disorders has been the dominant approach, it may fail to identify the precise problems in hyperchloremia, hyperphosphatemia, hypophosphatemia, and hypoalbuminemia. The Stewart approach is more effective in detecting acid-base disturbances and quantifying individual components of acid-base abnormalities in such situations. However, it is difficult to apply the original Stewart approach in clinical settings. By introducing the modified Stewart approach, which was proposed by Figge and his colleagues, the amounts of nonvolatile acids in plasma can be detected in such complex acid-base disturbances. Moreover, by using the goal-seek function of Excel, pH in the near future can be estimated, it will help us to better understand clinical acid-base physiology as well.

Objective: The aim of this study was to identify the relationship between functional status at ICU discharge and discharge destination in elderly patients requiring prolonged ICU stay after cardiac surgery. Methods: A total of 278 patients aged 65 years or above (75±6 years, female 42%) who stayed in ICU for 3 days or longer after elective cardiac surgery were enrolled. Patients were divided into two groups according to the discharge destination; discharge to home (n=245) and transfer to other facility or hospital (n=33). We assessed the clinical characteristics as well as functional status using the functional status score for the ICU (FSS-ICU). The association between FSS-ICU and discharge destination was evaluated by logistic regression analysis. Receiver operating characteristics (ROC) curve analysis was used to calculate the optimal cutoff value of FSS-ICU for home discharge. Results: Multivariate logistic regression analysis identified age, operation time, and FSS-ICU score at ICU discharge as predictors of home discharge. The cut-off FSS-ICU score predicting home discharge was 21 points as determined by ROC curve. Conclusion: Functional status at ICU discharge assessed by FSS-ICU is an independent predictor of discharge destination in elderly patients who require prolonged ICU stay after cardiac surgery.

A 68-year-old man was transferred to our hospital presenting with a 3-day history of massive neck swelling and dyspnea; he had medical histories of hypertension, diabetes, and liver cirrhosis. He developed severe respiratory distress with impaired consciousness. He was intubated and admitted to the ICU. For massive neck swelling with purpura and multiple organ failure, he was treated using antibiotics, continuous hemodiafiltration, and drainage of the post-pharyngeal abscess. We found ulcers and blisters, suspicious of necrotizing fasciitis (NF), on his left cervicothoracic skin on hospital day 2. We planned to perform an incision and drainage, but he died within 24 hours of admission. Hypervirulent Klebsiella pneumoniae (hvKP) was detected from blood cultures (positive string test). Genetic testing and whole-genome analysis revealed that this strain belonged to capsule serotype K2 , ST65, and rmpA-positive. To our knowledge, no cases of NF caused by this strain have been reported in Japan. Here, we present a rare case of hvKP infection.

Objectives: Peripherally inserted central catheters (PICCs) have increasingly been used in clinics because they allow for safe insertion. However, there have been few reports on their safety in emergency medicine in Japan. Therefore, this study aimed to elucidate the situation surrounding the use of PICCs in the ICUs of hospitals' emergency centers and examine their safety. Methods: One hundred and twenty-three PICCs that were inserted into patients in the ICU of an emergency center were retrospectively examined. Results: The rate of successful indwelling was 91.1% (112 PICCs). The complications related to catheter insertion were aberrant placement (6.5%, 8 PICCs) and arterial puncture (1.6%, 2 PICCs). The mean number of indwelling days was 9.1±8.9, and 83.0% (93 PICCs) were removed without complications. The main post-indwelling complications were suspected catheter related blood stream infection (11.6%, 13 PICCs) and catheter closure (1.8%, 2 PICCs). Conclusions: It was confirmed that PICCs were left indwelling safely.