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.

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.