Objective: The state of prolonged ICU stays (ICU-LOS) in Japanese intensive care units is unknown. Using the Japanese Intensive Care Patient Database (JIPAD), we investigated ICU-LOS in Japan. Method: Data on adult patients (≧ 16 years old) other than burn patients and patients admitted for minor treatments who were admitted to an ICU between April 1, 2015, and March 31, 2019, were retrieved from JIPAD. The patients were divided into short-term (≦14 days) and long-term (≧15 days) groups based on their ICU-LOS. The APACHEⅡandⅢ scores, ICU-LOS, hospital-LOS, and total number of ICU-bed days were then compared between the two groups. ICU-LOS was categorized into 0, 1, 2-7, 8-14, 15-21 and ≧22 days, and hospital mortality after ICU discharge was compared according to the ICU-LOS categories after adjustments for other factors, such as the APACHEⅢ scores. Results: Among 79,620 patients admitted to ICU during the study period, 2,364 patients (3.0%) remained in ICU for more than 14 days. Long-term patients had severer illnesses and required more intensive treatments such as a mechanical ventilator or hemodialysis. The long-term group occupied 25.0% of all ICU bed days, and Japanese medical insurance claims for ICU bed fees were not made for 47.6% of the occupied beds. The ICU- and hospital- mortality rates were higher in the long-term group. Hospital mortality after ICU discharge was significantly higher for the long-term ICU-LOS group. Conclusion: According to JIPAD data, 3.0% of severely ill adult patients admitted to Japanese ICUs remained in the ICU for more than two weeks, and a longer ICU-LOS was associated with a higher mortality rate.

Background: The present study evaluated the advantages of measuring the serum ionized magnesium (iMg) level when performing cardiac surgery. Methods: In this prospective cohort study of 35 consecutive patients who underwent elective cardiac surgery from December 2018 to May 2019, the patients were divided into two groups, namely Group P (n=25, with cardiopulmonary bypass [CPB]) and Group C (n=10, without CPB). The perioperative changes in the iMg values were compared between the groups and any correlations between the iMg and total magnesium (tMg) levels were analyzed. Results: A significant increase in the iMg level was seen in group P after cardioplegia administration (1.04 [0.54- 1.26] mmol/L), it remained elevated even in the ICU after surgery (0.86 [0.75〜1.00] mmol/L). In addition, the correlation coefficient between the iMg and tMg level was 0.404 in group P at the end of surgery. Conclusions: During cardiac surgery, we should be aware of hypermagnesamia as a potential consequence of cardioplegia administration. Therefore, monitoring the serum magnesium level using iMg is beneficial to avoid the overadministration of magnesium during perioperative management.

We herein report a case of superior mesenteric vein (SMV) thrombosis due to protein C (PC) deficiency successfully treated with anticoagulant therapy, that is, a combination of heparin and antithrombin (AT) formulation. A 46-year-old man was brought to our hospital with the chief complaint of abdominal pain for the past 6 days. Abdominal contrast computed tomography revealed a thrombus extending from the SMV to the portal vein, an edema in the small intestinal wall, and ascites. However, the intestinal blood flow was preserved. Based on the laboratory examination results that showed a reduction in PC activity, the patient was diagnosed with SMV thrombosis due to PC deficiency. Anticoagulant therapy, comprising of a combination of heparin and AT formulation, was administered under careful monitoring in the intensive care unit. The symptoms and laboratory findings improved with the regressing thrombus. The patient was discharged from the hospital on the 22nd day after admission. Therefore, anticoagulant therapy with a combination of heparin and AT formulation could be used as a treatment for SMV thrombosis due to PC deficiency.

Cardiac tamponade is a rare (0.36％) but serious complication of surgery for esophageal cancer and can be lethal, if not dealt with promptly. We experienced a case of cardiac tamponade after subtotal esophagectomy using gastric reconstruction, via the retrosternal route, in a patient with thoracic esophageal cancer. In collaboration with multiple clinical departments, hemostasis was performed three times under left and right intercostal thoracotomy. As a result, it was possible to save the patient’s life without damaging the gastric reconstruction. This case highlights the possibility of cardiac tamponade, developing due to bleeding from pericardial veins, as a complication of esophageal cancer surgery. If changes in hemodynamics are observed, careful examination by echocardiography or computed tomography is recommended.

A 60-year-old man who received oral metformin for the treatment of type 2 diabetes mellitus was transferred by ambulance to our hospital after developing acute kidney injury and lactic acidosis. During intensive treatment that included sodium bicarbonate administration and dialysis, he developed osmotic demyelination syndrome (ODS). ODS can arise when rapid changes in osmotic pressure occur, even in the absence of chronic hyponatremia. In the present case, we administered multiple doses of sodium bicarbonate for the treatment of severe metabolic acidosis. The patient’s serum sodium levels subsequently increased, which may have induced the onset of ODS. Evidence on the use of sodium bicarbonate for the treatment of metabolic acidosis remains insufficient with regard to treatment efficacy, appropriate methods of administration, and other factors. Therefore, patients administered sodium bicarbonate should be closely monitored for hypernatremia, a known adverse effect. In addition, indications for sodium bicarbonate administration should be carefully considered.

Cardiac rupture is rare, but lethal complication of acute myocardial infarction. Early diagnosis and emergent surgical treatment are crucial to repair cardiac rupture. In this case, a winking coronary sign on coronary angiogram was observed just after percutaneous coronary intervention to distal-left anterior descending artery. Winking coronary sign was reported in some cases of ventricular septal rupture. We therefore anticipated cardiac rupture by monitoring parameters obtained from a Swan-Ganz catheter in the coronary care unit. Right atrial pressure, mixed venous oxygen saturation, and v wave in pulmonary arterial pressure are rapid and clear parameters of free wall rupture, ventricular septal rupture, and papillary muscle rupture, respectively. After 2-hr stay in the CCU, increasing right atrial pressure was displayed with concomitant complaints by the patient of discomfort. Blood pressure was 79/68 mmHg and cardiac tamponade due to free wall rupture was suggested. Large pericardial effusion was detected by echocardiogram and emergent surgery was performed. Winking coronary sign has been reported in ventricular septal rupture, but no previous reports have described this sign in free wall rupture. We could anticipate cardiac rupture by carefully monitoring parameters obtained from the Swan-Ganz catheter. Early diagnosis and emergent surgical treatment averted lethal outcomes.

Delayed hypercalcemia sometimes occurs in the diuretic phase of rhabdomyolysis-induced acute kidney injury (AKI), and may be caused by the absorption of heterotopic calcifications in injured muscles. A 60s-year-old woman with perforated peritonitis was admitted to our ICU. She developed oliguric AKI due to septic shock and rhabdomyolysis, and was treated with renal replacement therapy (RRT) for 30 days after admission to the ICU. Although she developed hyperphosphatemia from day 16 of admission during weaning from RRT, it spontaneously improved on day 43 of admission. She subsequently developed mild drowsiness and nausea, and laboratory tests revealed severe hypercalcemia, with a maximum serum ionized calcium level of 1.63 mmol/L on day 59 of admission. Her hypercalcemia and symptoms improved after treatment with a diuretic agent and fluid infusion. Serial CT images showed worsening muscle calcifications that resolved prior to the onset of hypercalcemia. These findings strongly support the hypothesis that the absorption of heterotopic calcifications in injured muscles caused hypercalcemia in this case. This case also suggests that hyperphosphatemia in the subacute phase of rhabdomyolysis-induced AKI may exacerbate heterotopic calcification and subsequent hypercalcemia.