Takuya Takashima, Nobuto Nakanishi, Yuta Arai and Jun Oto : The effect of high-flow nasal cannula on diaphragm dysfunction including paradoxical diaphragmatic contraction in the intensive care unit., The Journal of Medical Investigation : JMI, 68, 1.2, 159-164, 2021.
(要約)
Background : Diaphragm dysfunction is a serious problem. However, a few management techniques exist for diaphragm dysfunction. Methods : Adult patients treated with high-flow nasal cannula (HFNC) in the intensive care unit were included in this study. The diaphragm function was evaluated using ultrasound measurement of thickening fraction before and after HFNC liberation. Normal diaphragm contraction was defined as thickening fraction ≥ 15% without HFNC, whereas decreased or paradoxical diaphragm contractions were 0%-15% or < 0%, respectively. Results : Forty patients were enrolled, and 16 (40%) had normal diaphragm contraction, whereas 19 (48%) or 5 (13%) had decreased or paradoxical diaphragm contractions, respectively. Thickening fraction increased after HFNC liberation (27.0% ± 25.7% vs. 38.8% ± 34.5%, p = 0.03 in HFNC vs. no HFNC) in patients without diaphragm dysfunction. In patients with decreased diaphragm contraction, thickening fraction did not change with or without HFNC (8.9% ± 11.7% vs. 6.7% ± 5.2%, p = 0.35), whereas paradoxical contraction decreased with HFNC (1.0% ± 10.2% vs. -10.3% ± 2.7%, p = 0.04) in patients with paradoxical diaphragm contraction. Conclusions : The work of breathing decreased with HFNC in patients without diaphragm dysfunction, but did not decrease in patients with decreased diaphragm contraction. Paradoxical diaphragm contraction decreased with HFNC. J. Med. Invest. 68 : 159-164, February, 2021.
(キーワード)
Adult / Cannula / Diaphragm / Humans / Intensive Care Units / Ultrasonography
Immobilization hypercalcemia is a rare complication in critically ill patients and causes weakness and gastrointestinal symptoms, symptoms that may lead to delayed rehabilitation and mobilization. A45-year-old woman developed ARDS and received prolonged mechanical ventilation. She received deep sedation to control excessive inspiratory effort and agitation until the 10th day. She developed hypercalcemia, which induced nausea and vomiting, on the fifth day. It was difficult to implement early physical rehabilitation and mobilization due to hypercalcemic symptoms. She was diagnosed with immobilization hypercalcemia and received alendronate sodium and elcatonin. The serum corrected calcium rapidly normalized and nausea disappeared after these drugs administration. After that, she underwent rehabilitation and was liberated from mechanical ventilation on the 63rd day. For the diagnosis of immobilization hypercalcemia, it is important to recognize risk factors such as long-term immobility, obesity, and an internal history of antiestrogens preparation. We should consider pharmacological intervention if it is difficult to implement early rehabilitation and mobilization due to symptoms of hypercalcemia.
Nobuto Nakanishi, Rie Tsutsumi, Kanako Hara, Takuya Takashima, Emiko Nakataki, Taiga Itagaki, Masafumi Matsuo, Jun Oto and Hiroshi Sakaue : Urinary Titin Is a Novel Biomarker for Muscle Atrophy in Nonsurgical Critically Ill Patients: A Two-Center, Prospective Observational Study., Critical Care Medicine, 2020, 48(9), 1327-1333, 2020.
(要約)
In nonsurgical critically ill patients, urinary titin level increased 10-30 times compared with the normal level. The increased urinary titin level was associated with lower limb muscle atrophy, occurrence of ICU-acquired weakness, and ICU mortality.
Background : Non-invasive positive pressure ventilation (NPPV) is highly recommended for immunocompromised patients with acute respiratory failure. In this population it remains uncertain, however, whether high flow nasal canula(HFNC)is as beneficial as NPPV. Methods : We retrospectively studied immunocompromised patients with acute respiratory failure admitted to our ICU from 2011 to 2018. The background and clinical outcomes of patients initially treated with HFNC and NPPV were compared. Results : Upon admission, 12 patients were treated with HFNC and 10 with NPPV. While the length of ICU stay was significantly shorter in HFNC group (HFNC4．6days vs. NPPV13．8days, p=0．02), no intergroup difference was seen in ICU mortality (16．7% vs.30．0%, p=0．46)or intubation rate(33．3% vs.50．0%, p=0．43). Conclusions : For immunocompromised patients with acute respiratory failure, HFNC may be an alternative to NPPV. Further prospective investigation is warranted.
Nobuto Nakanishi, Takuya Takashima and Jun Oto : Muscle atrophy in critically ill patients: a review of its cause, evaluation, and prevention, The Journal of Medical Investigation : JMI, 67, 1, 1-10, 2020.
(要約)
Critically ill patients exhibit prominent muscle atrophy, which occurs rapidly after ICU admission and leads to poor clinical outcomes. The extent of atrophy differs among muscles as follows: upper limb: 0.7%-2.4% per day, lower limb: 1.2%-3.0% per day, and diaphragm 1.1%-10.9% per day. This atrophy is caused by numerous risk factors such as inflammation, immobilization, nutrition, hyperglycemia, medication, and mechanical ventilation. Muscle atrophy should be monitored noninvasively by ultrasound at the bedside. Ultrasound can assess muscle mass in most patients, although physical assessment is limited to almost half of all critically ill patients due to impaired consciousness. Important strategies to prevent muscle atrophy are physical therapy and electrical muscular stimulation. Electrical muscular stimulation is especially effective for patients with limited physical therapy. Regarding diaphragm atrophy, mechanical ventilation should be adjusted to maintain spontaneous breathing and titrate inspiratory pressure. However, the sufficient timing and amount of nutritional intervention remain unclear. Further investigation is necessary to prevent muscle atrophy and improve long-term outcomes. J. Med. Invest. 67 : 1-10, February, 2020.
Nobuto Nakanishi, Rie Tsutsumi, Yoshihiro Okayama, Takuya Takashima, Yoshitoyo Ueno, Taiga Itagaki, Yasuo Tsutsumi, Hiroshi Sakaue and Jun Oto : Monitoring of muscle mass in criticaly ill patients: comparison of ultrasound and two bioelectrical impedance analysis devices, Journal of Intensive Care, 7, 61, 2020.
(要約)
Skeletal muscle atrophy commonly occurs in critically ill patients, and decreased muscle mass is associated with worse clinical outcomes. Muscle mass can be assessed using various tools, including ultrasound and bioelectrical impedance analysis (BIA). However, the effectiveness of muscle mass monitoring is unclear in critically ill patients. This study was conducted to compare ultrasound and BIA for the monitoring of muscle mass in critically ill patients. We recruited adult patients who were expected to undergo mechanical ventilation for > 48 h and to remain in the intensive care unit (ICU) for > 5 days. On days 1, 3, 5, 7, and 10, muscle mass was evaluated using an ultrasound and two BIA devices (Bioscan: Malton International, England; Physion: Nippon Shooter, Japan). The influence of fluid balance was also evaluated between each measurement day. We analyzed 93 images in 21 patients. The age of the patients was 69 (interquartile range, IQR, 59-74) years, with 16 men and 5 women. The length of ICU stay was 11 days (IQR, 9-25 days). The muscle mass, monitored by ultrasound, decreased progressively by 9.2% (95% confidence interval (CI), 5.9-12.5%), 12.7% (95% CI, 9.3-16.1%), 18.2% (95% CI, 14.7-21.6%), and 21.8% (95% CI, 17.9-25.7%) on days 3, 5, 7, and 10 ( < 0.01), respectively, with no influence of fluid balance ( = 0.04, = 0.74). The muscle mass did not decrease significantly in both the BIA devices (Bioscan, = 0.14; Physion, = 0.60), and an influence of fluid balance was observed (Bioscan, = 0.37, < 0.01; Physion, = 0.51, < 0.01). The muscle mass assessment at one point between ultrasound and BIA was moderately correlated (Bioscan, = 0.51, < 0.01; Physion, = 0.37, < 0.01), but the change of muscle mass in the same patient did not correlate between these two devices (Bioscan, = - 0.05, = 0.69; Physion, = 0.23, = 0.07). Ultrasound is suitable for sequential monitoring of muscle atrophy in critically ill patients. Monitoring by BIA should be carefully interpreted owing to the influence of fluid change. UMIN000031316. Retrospectively registered on 15 February 2018.
Taiga Itagaki, Nobuto Nakanishi, Takuya Takashima, Yoshitoyo Ueno, Natsuki Tane, Yumiko Tsunano, Toshiyuki Nunomura and Jun Oto : Effect of controlled ventilation during assist-control ventilation on diaphragm thickness : a post hoc analysis of an observational study., The Journal of Medical Investigation : JMI, 67, 3.4, 332-337, 2020.
(要約)
Background : Since diaphragm passivity induces oxidative stress that leads to rapid atrophy of diaphragm, we investigated the effect of controlled ventilation on diaphragm thickness during assist-control ventilation (ACV). Methods : Previously, we measured end-expiratory diaphragm thickness (Tdiee) of patients mechanically ventilated for more than 48 hours on days 1, 3, 5 and 7 after the start of ventilation. We retrospectively investigated the proportion of controlled ventilation during the initial 48-hour ACV (CV48%). Patients were classified according to CV48% : Low group, less than 25% ; High group, higher than 25%. Results : Of 56 patients under pressure-control ACV, Tdiee increased more than 10% in 6 patients (11%), unchanged in 8 patients (14%) and decreased more than 10% in 42 patients (75%). During the first week of ventilation, Tdiee decreased in both groups : Low (difference, -7.4% ; 95% confidence interval [CI], -10.1% to -4.6% ; p < 0.001) and High group (difference, -5.2% ; 95% CI, -8.5% to -2.0% ; p = 0.049). Maximum Tdiee variation from baseline did not differ between Low (-15.8% ; interquartile range [IQR], -22.3 to -1.5) and High group (-16.7% ; IQR, -22.6 to -11.1, p = 0.676). Conclusions : During ACV, maximum variation in Tdiee was not associated with proportion of controlled ventilation higher than 25%. J. Med. Invest. 67 : 332-337, August, 2020.
Takuya Takashima, Nobuto Nakanishi, Yoshitoyo Ueno, Natsuki Tane, Yumiko Tsunano, Taiga Itagaki and Jun Oto : Changes of diaphragm function before and after withdrawal of high flow nasal cannula in patients with acute respiratory failure., The 32nd Annual Congress of European Society of Intensive Care Medicine, Berlin, Germany, 2019.
Early mobilization is an effective way to improve the physical function of critically ill patients, but there are numerous barriers to mobilization. One such is an early ward transfer. Mobilization is often insufficient in a ward, and the patient cannot be liberated from mechanical ventilation. We experienced a case of a successfully liberated patient from prolonged mechanical ventilation in long-term mobilization as orchestrated by a multidisciplinary team in the ICU. A 45-year-old female was admitted to the ICU and placed on mechanical ventilation for acute respiratory distress syndrome(ARDS). We deployed a mobilization protocol, which was mostly restricted to passive exercise in the first 2 weeks after admission. On day 30, the patient recovered from unstable respiration, but could not be liberated from mechanical ventilation because of muscle weakness, diagnosed as ICU-acquired weakness. The patient was gradually mobilized and transferred to a chair on day 35, and she was able to stand on day 56. On day 65, she was completely liberated from mechanical ventilation and discharged from the ICU 70 days after her initial admission. Long-term mobilization is important for liberation of a patient from prolonged mechanical ventilation as well as early mobilization in the ICU.
Yoshitoyo Ueno, Takuya Takashima, Nobuto Nakanishi, Natsuki Tane, Yumiko Tsunano, Taiga Itagaki and Jun Oto : Timing of tracheostomy in acute stroke patients., 6th SG-ANZICS Intensive Care Forum, Singapore, 2019.
国際会議:
1.
Yoshitoyo Ueno, Takuya Takashima, Nobuto Nakanishi, Natsuki Tane, Yumiko Tsunano, Taiga Itagaki and Jun Oto : Timing of tracheostomy in acute stroke patients., 6th SG-ANZICS Intensive Care Forum, Singapore(April 20-22), Singapore, Apr. 2018.
2.
Takuya Takashima, Michihiro Nakamura, Koichiro Hayashi, K Miyamoto, M Nakano, S Akiyama and Kazunori Ishimura : Nano-biodistribution study using organosilica nanoparticles containing near-infrared fluorescent dye., 6th International Symposium on Nanomedicine (ISNM2012), Shimane, Nov. 2012.