Noninvasive positive pressure ventilation (NPPV) in adults is an effective treatment for the patients with chronic respiratory failure and would be beneficial for acute respiratory failure (ARF). In children, several studies have showed that NPPV might improve oxygenation and decrease respiratory muscle effort and dyspnea in patients with hypoxemic ARF. And also it is expected that NPPV would reduce the chances of endotracheal intubation and reintubation after extubation. However, there are few studies about nosocomial infection, ICU stay, hospital stay and mortality in those children with ARF. Among the several reasons that might cause NPPV difficult to be introduced into children with hypoxemic ARF, fewer lineup of appropriate size of pediatric interfaces, such as nasal masks, oronasal masks, is one of those. Although treatment by NPPV for pediatric acute respiratory failure is very attractive means, it might not be always promising because there are not enough evidence available yet. One should keep in mind not to miss the appropriate timing for intubation, because children have less respiratory reserve and are less co-operative. NPPV in hypoxemic ARF children should be managed carefully by a trained pediatric critical care team in pediatric ICU.

View full abstract

We analyzed data for 16 instances of more than one hour of NPPV administered to 13 patients who were admitted to our intensive care unit during a nine-month period. The success rate (avoidance of endotracheal intubation) was 62.5%. During NPPV, patients who did not require intubation (Group S, N=10) showed significant improvement in P/F ratio (P<0.01) and significant respiratory rate reduction (P<0.05). These variables did not change significantly for patients who required intubation (Group F, N=3). P/F ratio deteriorated during NPPV in Group F (P<0.01). Patients in Group S required NPPV for less than 30 hours. Two patients in Group F, who were later diagnosed as suffering diaphragmatic nerve paralysis, were intubated after less than 7 hours of NPPV. The other patient was intubated after more than 26 hours of NPPV. We suspect that the failure to avoid extubation in this patient may have been influenced by the criteria used for deciding to reintubate and that this may partly account for the variable results that are often reported for NPPV for patients with acute respiratory failure. In conclusion appropriate criteria for reintubation during NPPV should be investigated.

View full abstract

On-line continuous hemodiafiltration (on-line CHDF) can exchange large volume of fluid and remove blood solutes of wide range of molecular weight. We applied it in combination with continuous plasma exchange (CPE) to a case of multiple organ failure including fluminant hepatic failure. A 51-year-old woman with a complaint of general fatigue was admitted. She was tentatively diagnosed and treated as heart failure and transferred to ICU after sudden ventricular flutter and successful resuscitation. We immediately applied on-line CHDF in order to cope with oliguria, cardiac dysfunction, and elevation of hepatic enzymes and added CPE in series on the next day. The combination therapy was done twice and has improved patient's consciousness so as to react to our calls. Simple on-line CHDF then intermittent hemodialysis took over it and, in accordance with recovery of her general conditions, the patient was discharged from ICU on the 33rd day . From this experience we suggest that the combination therapy of CPE and on-line CHDF in series is effective to treat multiple organ failure.

View full abstract

A 22-year-old man with chronic renal failure caused by atypical hemolytic uremic syndrome (HUS) underwent an ABO incompatible renal transplant from his living father following preoperative double filtration plasmapheresis twice and one plasma exchange (PE). Function of the transplanted kidney was good immediately after the surgery, but urinary output on the 1st postoperative day decreased and the patient received PE and hemodialysis. Despite careful control of circulation and coagulation, renal function was lost on the 3rd postoperative day and the grafted kidney was removed. Histological features of the removed allograft indicated blood vessel type rejection and not recurrence of HUS.

View full abstract

A 68-year-old patient who had undergone esophagectomy suffered from ARDS and needed prolonged mechanical ventilation. On postoperative day 19, his arterial blood gases were pH7.30, PaO₂ 68mmHg, PaCO₂ 93mmHg at F_IO₂ 0.95 under PEEP 10cmH₂O, pressure control ventilation (PCV) 15cmH₂O. Since bacterial cultures of bronchoalveolar lavage fluid resulted as negative for two times, we considered the patient was free from bacterial pneumonia. Methylprednisolone (MP) was administered according to Meduri's report. Blood gases improved gradually followimg the administration of MP and the patients was successfully weaned from a ventilator. We presume that MP was effective for this patient. No matter how MP is effective, it suppresses immunity and therefore we should carefully evaluate if infection exists or not. As a conclusion, longterm low-dose MP may be available for the fibroproliferative phase of ARDS so far as infection is excluded.

View full abstract

We experienced a child case of fulminant myocarditis which needed extracorporeal life support (ECLS). A five-year-old boy who had diagnosed as dehydration was transferred to our ICU to treat dyspnea with bloody sputa. As was diagnosed as cardiogenic shock, he was intubated and mechanically ventilated under sedation. Transthoracic echocardiography demonstrated diffuse hypokinesis of left ventricle and 22% ejection fraction and myocarditis was suspected as a cause of cardiogenic shock. We decided to use ECLS instead of intravenous cathecolamine to avoid critical tachycardia and arrythmia. His heart rate fell to 140min^-1, blood pressure and urine output increased, and pulsation of radial artery returned to be palpable soon after the induction of ECLS. The patient was weaned from an ECLS within 48 hours and from a ventilator on the 16th day. He survived 40 days' hospitalization and was discharged on foot with mild degree of recurrent nerve palsy as a complication. We think that ECLS was a reasonable and effective treatment in this case.

View full abstract

Enterovirus (EV) genarally causes hand-foot-and-mouth disease which resolves spontaneously, but is sometimes followed by a fatal central nervous system infection. The authors have experienced a pediatric case of acute EV 71 brainstem encephalitis. A three-year-old male child was admitted to our ICU in a state of severe consciousness disturbance (JCS 300), after suffering from fever, abdominal pain, and vomiting for several days. T2-weighted magnetic resonance imaging showed hyperintensity in the brainstem. Treatment with pressure- regulated volume-controlled ventilation, and intermittent infusions of glycerol and γ globulin were immediately initiated. However, circulatory collapse and pulmonary edema occurred suddenly on the 2nd ICU day, and brain edema on brain CT and slowing of electroencephalographic activity were aggravated. After initiating steroid administration and mild hypothermia therapy (3 days, esophageal temperature 34-35°C), brain edema was gradually improved. Administration of TRH seemed to further improve consciousness (JCS 20), and he was transferred to the pediatric ward on the 46th ICU day. In the treatment of EV brainstem encephalitis, continuous vigilance and management of cardiopulmonary function and the suppression of secondary neuronal injury caused by an elevated inflammatory reaction are important. Mild hypothermia therapy may exert an inhibitory effect on the development of secondary neuronal injury related to excitotoxicity and the cytokine mechanism.

View full abstract