New-onset refractory status epilepticus (NORSE) is an intractable form of status epilepticus where individuals with no prior history of epilepsy suddenly develop seizures. Consideration of a ketogenic diet (KD) is recommended by the American Epilepsy Society. Here we report a case of NORSE with a positive outcome following the introduction of KD under ventilator management. The case was a 27-year-old man with no significant medical history. The patient developed refractory status epilepticus following a COVID-19 infection and was diagnosed with NORSE. Multidrug anticonvulsants and general anesthesia were introduced; however, his seizure control was poor. Although steroids and intravenous immunoglobulins were administered, his seizure was not well-managed, leading to the introduction of KD. In Japan, there are no commercially available KD preparations for adults suitable for tubal feeding, so custom KD was prepared and administered. Although long-term intensive care was required, the patient's seizures were gradually controlled. While the efficacy of KD for refractory status epilepticus in adults has not been confirmed to the same degree as in children, reports emphasizing its efficacy and safety are increasing. KD may also be considered for adult NORSE cases that are difficult to control.

Horner’s syndrome (HS) has been reported to be caused by other medical problems; however, it is not well-recognized as a complication after median sternotomy (MS). Our patient experienced excessive preoperative sweating, which assisted in diagnosing HS, postoperatively. Accordingly, we carefully observed other cases and discovered five patients in three years who developed HS after MS. Brachial plexopathy is a neurological complication that can occur after MS. These complications can be prevented by taking necessary precautions while using a retractor because the extended force is of sufficient magnitude to fracture the upper rib and may lead to such complications. The medical staff should be aware of HS as a potential complication after MS.

We present the case of a 43-year-old man who developed severe pneumonia secondary to influenza virus infection. Following respiratory failure, the patient was placed on mechanical ventilation and initiated on venovenous extracorporeal membrane oxygenation（VV-ECMO） support. However, on the 10th day of hospitalization, he deteriorated into shock. Transthoracic echocardiography revealed significant right ventricular dilatation with compression of the left ventricular wall, leading to a diagnosis of right ventricular failure-induced shock. Despite attempts with inotropic drug therapy, the patient remained in shock, prompting a decision to convert the circuit to veno-arteriovenous ECMO (V-AV ECMO). Following the conversion, a notable improvement was observed in the right heart failure and shock, and the patient was successfully weaned from V-AV ECMO on the 15th day. In cases where right heart failure and shock complicate VV-ECMO management, converting circuits to V-AV ECMO may be useful, particularly in addressing concerns related to differential hypoxemia.

A woman in her 80s was admitted for abdominal surgery. She was taking an SGLT2 inhibitor for diabetes and had been taken off the medication for 3 days before surgery. Diabetic ketoacidosis (DKA) is a side effect of SGLT2 inhibitors; however, it did not occur in this case. This was probably due to the use of added sugar infusions and insulin during the perioperative period. However, severe dehydration due to polyuria was observed on the first postoperative day. Central diabetes insipidus was initially suspected, and arginine vasopressin (AVP) was initiated. However, because of significant urinalysis, we concluded that the prolonged drug effect of SGLT2 inhibitors had caused polyuria. The initiation of SGLT2 inhibitors causes osmotic diuresis which occurs due to urinary glucose excretion. However, a compensatory response usually occurs, and the fluid balance is maintained without any dehydration. The AVP is involved in this process to maintain fluid homeostasis. In this case, the prolonged effect of the SGLT2 inhibitor and the defective secretion of AVP were thought to have caused polyuria. The patient's urinary output was controlled within the appropriate range by administering AVP. In this case, despite carrying out preoperative drug withdrawal, the patient still became dehydrated owing to polyuria caused by prolonged drug effect of SGLT2 inhibitors. We report this case because AVP is considered to be an effective treatment for polyuria.

We experienced a case of acute respiratory distress syndrome and circulatory failure due to severe acute pancreatitis, which veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was successfully employed. The patient was a 45-year-old male who presented with epigastric pain and hypoxemia and was admitted to the ICU. On admission, he had severe hypoxemia and circulatory failure of unknown etiology, necessitating VA-ECMO initiation. He was weaned off VA-ECMO on the second day and from the ventilator on the sixth day of admission. Initial blood test results showed elevated pancreatic enzyme levels, and CT revealed mildly elevated lipid concentrations in the pancreatic head. To investigate the cause, contrast-enhanced CT of the chest and abdomen was performed on the seventh day of hospitalization, which revealed swelling of the entire pancreas and findings consistent with severe acute pancreatitis. Respiratory and circulatory failure, initially of unknown cause at admission was later determined to be due to severe acute pancreatitis. Subsequently, his condition improved. On the 11th hospital day, he was discharged from the ICU, and on the 24th hospital day, he was discharged as a home ambulator,　We successfully treated a case of severe acute pancreatitis complicated by respiratory and circulatory failure using VA-ECMO.

Lemierre’s syndrome is a severe disease that is caused by laryngopharynx infection and develops into septic thrombophlebitis of the internal jugular vein and subsequent septic embolism of whole body organs. Severe pharyngeal pain is one of the initial symptoms of the disease, but it is difficult to distinguish Lemierre’s syndrome from COVID-19. Organ involvement is often confirmed in the lungs and bone joints, but complication to the central nervous system is rarely observed. We experienced a case of Lemierre’s syndrome during isolation for COVID-19. During the treatment course, the patient developed various central nervous system complications, including encephalitis, cerebral abscess, stenosis of the internal carotid artery, and cerebral infarction. This case shows that in treatment for severe pharyngeal pain, careful attention is required for differential diagnosis from severe pharyngeal infection and COVID-19. When severe Lemierre’s syndrome is confirmed, careful follow-up observation is needed based on the possibility of central nervous system complications, and head imaging tests should be conducted.

Poor facial color, one of the indicators for health care professionals to detect abnormalities, is a subjective evaluation. Therefore, this study was conducted to determine the changes in forehead skin color of patients in shock, over time, using a spectrophotometer to display skin color in terms of L* (lightness), a* (redness), and b* (yellowness) values, and to identify the associated factors. Nine patients underwent colorimetry three times. In six of the 16 measurement intervals, facial skin color changed as L* decreased and a* increased (improvement in facial color). In three measurement intervals, L* increased and a* decreased (worsening of facial color). Improvements in complexion were associated with a reduction in the lactate level rather than changes in the mean arterial pressure or the hemoglobin level. The changes in skin color are presumed to be related to pathological changes.

The criteria for extubation in patients with poorly controlled hyperthyroidism remain undefined because various stimuli can trigger thyroid storm, necessitating careful management. Herein, we present the case of a 49-year-old male with a history of Graves' disease who discontinued thiamazole treatment six months prior to admission. The patient was diagnosed with duodenal perforation and underwent emergency surgery after receiving intravenous thiamazole and hydrocortisone. Preoperatively, the patient did not meet the diagnostic criteria for a definitive thyroid storm. Postoperatively, extubation was delayed owing to the patient’s hyperthyroid state, and he was transferred to the ICU. Extubation was performed on the second postoperative day. However, the patient developed acute heart failure and agitation shortly thereafter. Additional inorganic iodine was administered after reintubation. Once adequate thyroid hormone control was confirmed, extubation was successfully performed, and the patient’s subsequent course was uneventful. Therefore, this case highlights the importance of ensuring proper management of hyperthyroidism and preventing sympathetic overactivity before extubation in patients with poorly controlled thyroid function.

Foodborne botulism has rarely been reported in the past decade. Here, we report two cases, each presenting with unique complications. Case 1 involved a 41-year-old woman who presented with symptoms of diplopia, dysarthria, and muscle weakness. After a thorough review of her medical history, botulism was suspected. Despite receiving antitoxin therapy, her muscle strength did not improve, necessitating a tracheostomy on the fourth day of hospitalization. On the sixth day, she developed non-occlusive mesenteric ischemia (NOMI), which required surgical intervention. Postoperatively, her recovery progressed well, and she was discharged from the ICU on the 17th day. Case 2 involved a 48-year-old man, who was the spouse of Case 1, and presented with symptoms of diplopia and dysarthria, raising clinical suspicion of botulism. Despite receiving antitoxin therapy, the patient required mechanical ventilation. On the fourth day of hospitalization, he developed ventilator-associated pneumonia (VAP). A tracheostomy was performed on the 12th day, and by the 20th day, mechanical ventilation was no longer necessary. Although NOMI is a rare complication of botulism treatment, its high mortality rate-rather than its rarity-poses a threat to survival. Nevertheless, the patient survived. The diagnosis of botulism is challenging due to its symptom overlap with other neuromuscular disorders. In Case 1, the patient’s medical history, as provided by her family, enabled prompt diagnosis and facilitated the initiation of appropriate treatment.

The detection of Candida species in respiratory tract specimens presents a diagnostic challenge, particularly in distinguishing between pneumonia and colonization. A definitive diagnosis often requires highly invasive procedures, such as lung biopsy. Here, we report a case of Candida pneumonia in a patient with febrile neutropenia, diagnosed clinically through radiological findings and tissue culture, which resulted in a fatal outcome despite medical intervention. The patient was a 72-year-old man undergoing chemotherapy for oropharyngeal cancer. On Day 13 of hospitalization, he developed febrile neutropenia, and by Day 16, he was transferred to the intensive care unit due to hypotension. Imaging studies revealed pneumonia characterized by ground-glass opacities and cavitary lesions. Although Candida albicans was the only organism isolated from sputum cultures and bronchoalveolar lavage fluid, distinguishing between colonization and active infection proved challenging. A definitive diagnosis of Candida pneumonia was established via tissue culture. However, the patient's condition worsened progressively, ultimately leading to his death on Day 39 of hospitalization. If characteristic imaging findings of Candida pneumonia are present and Candida is repeatedly detected in lower respiratory tract specimens of the immunocompromised patients, treatment for Candida pneumonia may be considered after excluding other possible clinical scenarios.

Objectives: To examine the association between high-intensity type ICUs and in-hospital mortality in adult ICUs in Japan. Methods: In this retrospective cohort study, data of adult patients admitted to ICUs between April 2022 and March 2023 was collected from the Japanese Intensive Care Patient Database. We analyzed the association between high-intensity type ICUs and in-hospital mortality using logistic regression adjusted for confounders. Results: The analysis included 65,395 cases admitted to 87 adult ICUs (of which 69 were high-intensity type), with 5,862 in-hospital deaths (9.0%). Regression analysis showed that the adjusted odds ratio for high-intensity type ICUs was 0.96 (95% CI 0.88～1.05, P=0.36). In the subgroup of postoperative patients, the adjusted odds ratio for high-intensity type ICUs was 0.81 (95% CI 0.70～0.95, P=0.008). Conclusion: In Japan, high-intensity type ICUs were not significantly associated with reduced in-hospital mortality. However, a significant association was observed in adult postoperative patients.

Background: Using the Japanese Intensive Care Patient Database (JIPAD), we investigated the characteristics of patients who were emergently readmitted to the ICU during the ongoing hospitalization and identified the risk factors for ICU readmission. Method: We extracted JIPAD records on patients aged 16 years or older who were registered between April 2018 and March 2020 and had undergone emergency ICU readmission during ongoing hospitalization. The key variables examined were the readmission rate, emergency readmission rate, in-hospital and ICU mortality rates, length of hospital stay (hospital LOS), occurrence of multiple readmissions, and prolonged total ICU LOS (≧ 15 days). Factors related to emergency ICU readmission were subjected to multiple logistic regression analysis. Results: Among the 69,594 records, 3,018 (4.3%) showed readmitted to the ICU and 2,001 (2.9%) indicated emergency ICU readmissions. Among the 2,001 records, 1,718 the first emergency ICU readmission records, which patients were admitted to the ICU only twice, were used to analyze as a representative of emergency ICU readmission. The mortality, median hospital LOS, and rate of prolonged total ICU LOS in patients with emergency readmission were 3.8-times (27.2% vs. 7.2%), 3.1-times (59 days vs. 19 days), and 9.7-times (31.9% vs. 3.3%) greater than those in the patients without readmission, respectively. Male sex, APACHE III score, tracheostomy at ICU admission, ICU LOS, continuous renal replacement therapy, hemodialysis, and non-invasive positive pressure ventilation were identified to be the factors associated with emergency readmission. Conclusion: Emergency ICU readmission during ongoing hospitalization was associated with higher in-hospital mortality, a higher rate of prolonged total ICU LOS, and a longer hospital LOS.

Objectives: To report the determination of brain arrest and death determined by neurological criteria and the frequency of adverse events during apnea testing in a pediatric intensive care unit (PICU). Methods: This is a retrospective, single-center descriptive study. The setting was the PICU in Aichi Children’s Health and Medical Center, a tertiary care center. All the children who underwent determination of brain arrest and death determined by neurological criteria between February 2016 and December 2023. We documented the number of these determinations, number of apnea tests, and frequency of adverse events during apnea tests. We also analyzed patient characteristics, such as age at admission to the PICU, Pediatric Cerebral Performance Category score, Pediatric Index of Mortality 3 score, diagnosis, and outcome. Results: The study included 29 patients. The total number of determination of brain arrest and death determined by neurological criteria was 63 cases. Apnea tests were performed in 51 cases (81%); among these cases, adverse events occurred in 11 cases (22%). Conclusion: The frequency of adverse events during the apnea test in our PICU was similar to those reported in previous studies.

Objective: The aim of this study was to examine the relationship between pain and sleep quality, as measured by the Japanese version of the Richards-Campbell Sleep Questionnaire (J-RCSQ), to explore methods for improving sleep quality. Methods: This was a retrospective observational study involving patients aged 20 years or older. Data were collected on the day of ICU discharge, including patient factors [e.g., J-RCSQ, pain-related numerical rating scale (NRS)], nursing care factors (e.g., frequency of observations and position changes), and environmental factors (e.g., ICU bed occupancy rate). Patients were divided into two groups based on the median J-RCSQ average score. The NRS was dichotomized (0 vs. ≥1) and analyzed using univariate analysis, followed by multivariate logistic regression as the main analysis. In addition, a supplementary analysis was performed using a three-category NRS model: 0 (no pain), 1‒3 (mild pain), and ≥4 (a pronounced pain), to assess the impact of pain severity. Results: Data from 252 patients were analyzed. In the main analysis, sleep quality was significantly associated with the presence of pain (OR 0.549, 95% CI 0.306-0.973, P＝0.042). In the supplementary analysis, the OR for mild pain (NRS 1-3) was 0.677 (95% CI: 0.342-1.338, P＝0.261), while that for a pronounced pain (NRS ≥4) was 0.426 (95% CI: 0.204-0.888, P＝0.023). Conclusion: Decreased sleep quality was associated particularly with a pronounced pain, and even mild pain showed a non-negligible association. These findings suggest the importance of assessing pain and prioritizing adequate pain management to improve sleep quality.