Although subarachnoid hemorrhage (SAH) due to ruptured aneurysm occurs less frequently than other forms of stroke, it is more likely to occur in younger people and has a higher mortality. The neurological prognosis of patients with SAH is improving with increasingly better understanding of the pathophysiology and management. Cerebral vasospasm has been believed as being the major cause of delayed cerebral ischemia (DCI), but other mechanisms than vasospasm alone have also come to be recognized as being involved in DCI. If DCI or cerebral infarction occurs after SAH, the physical functions are likely to deteriorate. Over the past 60 years, strategies for the prevention and treatment of DCI have been developed, although few have become established in clinical practice. This review provides an overview of the pathophysiology, monitoring, prevention and therapeutic management of DCI.

Objective: The aim of this study was to identify the factors associated with reintubation for respiratory function test immediately before extubation. Methods: We enrolled postoperative patients admitted to the ICU on mechanical venti lator between June 2016 and July 2018. These patients could undertake respiratory function test immediately before extubation and were categorized into two groups based on the status of intubation within 72 hr of extubation. The patients were 1:2 matched by APACHE II score, gender, and operative procedure. The patient characteristics and their respiratory functions were compared between the two groups. Results: Of the 324 patients, 9 were reintubated (2.8%). The difference in patient characteristics was not significant between the reintubation and non-reintubation (18 patients) groups, albeit the maximal expiratory pressure (MEP) was significantly lower in the reintubation group. Over half of the reasons for reintubation were difficulties in sputum production. Conclusion: A low MEP immediately before extubation tends to increase the frequency of reintubation requirement.

In the middle of a pandemic wave of coronavirus disease 2019（COVID-19） with a resultant shortage of adult ICU beds in the region, we provided intensive care for an adult patient with COVID-19 at a freestanding children’s hospital. The patient was a 75-year-old man diagnosed with COVID-19 after febrile illness, who was admitted to another hospital for dyspnea. He was intubated for progressive respiratory failure and transferred to the PICU at our hospital for further intensive care. After 48-hour lung-protective ventilation with continuous neuromuscular blockade and prone positioning, oxygenation and compliance of the respiratory system had improved. However, because of concerns regarding a large tidal volume and ventilator-associated pneumonia, we carefully determined the timing of extubation in teleconsultation with adult ICU physicians. The patient was extubated five days after admission and transferred back to the referring institution seven days after admission. Accepting and providing care for this patient at the children’s hospital required meticulous planning, collaborations inside and outside of the hospital, and staff education to ensure the quality of adult care while maintaining smooth functioning of the children’s hospital.

Metformin-associated lactic acidosis (MALA) is well known; however, only few studies have performed the blood concentration measurement of MALA and autopsy. We report a fatal autopsy case of MALA and respiratory failure wherein the plasma metformin concentration (PMC) was notably high. A 64-year-old female presented to our department with vomiting and was prescribed metformin for diabetes. She was admitted to the ICU after a diagnosis of MALA, acute kidney injury, and pneumonia. She died despite antibiotic administration, mechanical ventilation, and renal replacement therapy. Her PMC was remarkably elevated to 51.9 mg/L. Autopsy confirmed the presence of focal fusion pneumonia, but any specific cause of lactic acidosis was not found. This is a very rare case wherein both PMC measurement and autopsy were performed. Accumulation of PMC and clinical features are important for diagnosing MALA. Further reports and investigation are required to confirm whether specific pathological findings of MALA exist.

A 22-year-old woman was referred to our hospital with intratumoral hemorrhage in a left adrenal tumor, severe shock, and loss of consciousness. In the differential diagnosis, we considered various diseases that cause shock, and simultaneously carried out systemic management, including massive intravenous fluid replacement, continuous administration of catecholamines via infusion pumps, artificial respiration, and steroid replacement. The patient’s condition stabilized within a few days. However, we suspected hypertensive crisis that was possibly attributable to a pheochromocytoma because of the rapid increases in blood pressure upon mild stimulation and initiated α- and β-blocker treatment. After a retroperitoneoscopic adrenalectomy, the patient was discharged uneventfully on the 62 nd of admission. Pheochromocytoma multisystem crisis is a very rare disease; however, intensivists need to understand its pathogenesis because of the high mortality rate of this endocrine disease. Furthermore, it is important to understand and appropriately manage the patient’s continually changing clinical condition while monitoring vital signs to make an accurate diagnosis.