Upper limb muscle atrophy associated with in-hospital mortality and physical function impairments in mechanically ventilated critically ill adults: a two-center prospective observational study.

Upper limb muscle atrophy was associated with in-hospital mortality and physical function impairments; thus, it is prudent to monitor it. (321 words) TRIAL REGISTRATION: UMIN 000031316 . Retrospectively registered on 15 February 2018.

In this two-center prospective observational study, we included adult patients who were expected to require mechanical ventilation for > 48 h and remain in the intensive care unit (ICU) for > 5 days. We used ultrasound to evaluate the cross-sectional area of the biceps brachii on days 1, 3, 5, and 7 and upon ICU discharge along with assessment of physical functions. The primary outcome was the relationship between muscle atrophy ratio and in-hospital mortality on each measurement day, which was assessed using multivariate analysis. The secondary outcomes were the relationships between upper limb muscle atrophy and Medical Research Council (MRC) score, handgrip strength, ICU Mobility Scale (IMS) score, and Functional Status Score for the ICU (FSS-ICU).


Effect of Electrical Muscle Stimulation on Upper and Lower Limb Muscles in Critically Ill Patients: A Two-Center Randomized Controlled Trial.

In critically ill patients, electrical muscle stimulation prevented upper and lower limb muscle atrophy and attenuated proteolysis and decreased the length of hospitalization.


Change in diaphragm and intercostal muscle thickness in mechanically ventilated patients: A prospective observational ultrasougraphy study


Bacterial Contamination of Circuit Inner Surfaces After High-Flow Oxygen Therapy.

Bacterial contamination of inner surfaces of the circuit after high-flow oxygen therapy was relatively high.


Humidification Performance of Passive and Active Humidification Devices Within a Spontaneously Breathing Tracheostomized Cohort.

In spontaneously breathing subjects with tracheostomy, an heated-and-humidified high-flow system achieved higher absolute humidity than did an HME.


Effect of High-Flow Nasal Cannula on Thoraco-Abdominal Synchrony in Pediatric Subjects After Cardiac Surgery.

After cardiac surgery, HFNC oxygen therapy at 2 L/kg/min improved thoraco-abdominal synchrony and decreased breathing frequency in pediatric subjects. (Clinical trial registration: UMIN000023426.).


Upper and lower limb muscle atrophy in critically ill patients: an observational ultrasonography study.


electrical activity of the diaphragm during reverse triggering - a case report.


経鼻高流量療法/ネーザルハイフローセラピー:生理学的効果．

経鼻高流量療法/ネーザルハイフローセラピー:生理学的効果．


ARDS患者に投与すべき熱量はどのように決めるのか? --- ARDS-その常識は正しいか?-


Patient-ventilator asynchrony during assisted mechanical ventilation

During mechanical ventilatory assistance, patient-ventilator asynchrony occurs frequently. To avoid patient-ventilator asynchrony, the ventilator gas delivery pattern must match the patient's breathing pattern. Asynchrony may cause one or more of the following: poor gas exchange; hyperinflation of the lung; increased work of breathing owing to ventilator-induced diaphragmatic dysfunction; increased duration of both mechanical ventilation and ICU length of stay; and greater mortality. However, patient-ventilator asynchrony is easily overlooked. There are three general types of asynchrony: trigger asynchrony, cycling asynchrony, and flow asynchrony. Trigger asynchrony - caused by auto-triggering, ineffective inspiratory efforts (missed triggering), double triggering, and reverse triggering - occurs when the ventilator does not start pressurization in synchrony with the patient's inspiratory effort. Cycling asynchrony occurs when the inspiratory time of patient, ventilator do not match, and may occur as premature cycling or delayed cycling. Flow asynchrony occurs when ventilator flow delivery does not match the inspiratory demand of the patient. To deal with this common problem, bedside clinicians need better understanding of causes, graphical characteristics and appropriate management of each asynchrony.

患者-人工呼吸器非同調(以下，非同調)は，人工呼吸中に見られる頻度の高い事象である．人工呼吸器のガス供給パターンと，患者の呼吸パターンにずれがある場合，非同調が生じる．非同調は，ガス交換障害，肺過膨張，呼吸仕事量の増大，人工呼吸期間やICU滞在期間の延長をきたし，患者予後への影響も指摘されているが，その認識は高いとは言えない．非同調は，(1)患者の吸気努力に一致して人工呼吸器の送気が開始しない不適切なトリガー(オートトリガー，ミストリガー，二重トリガー，逆行性トリガー)，(2)吸気から呼気へ転じるタイミングのずれ(送気の早期終了，送気の終了遅延)，(3)人工呼吸器の送気流量と患者の吸気流量の過不足，の3つに大別される．ベッドサイドの医療者には，これら非同調の原因，グラフィックモニタ波形上の特徴，対処方法について深い理解が求められる．

Journal of the Japanese Society of Intensive Care Medicine


FIO2 in an Adult Model Simulating High-Flow Nasal Cannula Therapy.


High-Flow Nasal Cannula Oxygen Therapy in Adults: Physiological Benefits, Indication, Clinical Benefits, and Adverse Effects.

High-flow nasal cannula (HFNC) oxygen therapy is carried out using an air/oxygen blender, active humidifier, single heated tube, and nasal cannula. Able to deliver adequately heated and humidified medical gas at flows up to 60 L/min, it is considered to have a number of physiological advantages compared with other standard oxygen therapies, including reduced anatomical dead space, PEEP, constant FIO2 , and good humidification. Although few large randomized clinical trials have been performed, HFNC has been gaining attention as an alternative respiratory support for critically ill patients. Published data are mostly available for neonates. For critically ill adults, however, evidence is uneven because the reports cover various subjects with diverse underlying conditions, such as hypoxemic respiratory failure, exacerbation of COPD, postextubation, preintubation oxygenation, sleep apnea, acute heart failure, and conditions entailing do-not-intubate orders. Even so, across the diversity, many published reports suggest that HFNC decreases breathing frequency and work of breathing and reduces the need for respiratory support escalation. Some important issues remain to be resolved, such as definitive indications for HFNC and criteria for timing the starting and stopping of HFNC and for escalating treatment. Despite these issues, HFNC has emerged as an innovative and effective modality for early treatment of adults with respiratory failure with diverse underlying diseases.


高流量経鼻カニューラ酸素療法:理論と実践．

高流量経鼻カニューラ酸素療法:理論と実践．

分子呼吸器病 2016年3月号

分子呼吸器病 2016年3月号


Delirium during noninvasive positive pressure ventilation: a prospective observational study.

Journal of Pulmonary & Respiratory Medicine


Timing of tracheostomy in ICU patients: a systematic review of randomized controlled trials.

The optimal timing of tracheotomy in critically ill patients remains a topic of debate. We performed a systematic review to clarify the potential benefits of early versus late tracheotomy. We searched PubMed and CENTRAL for randomized controlled trials that compared outcomes in patients managed with early and late tracheotomy. A random-effects meta-analysis, combining data from three a priori-defined categories of timing of tracheotomy (within 4 versus after 10 days, within 4 versus after 5 days, within 10 versus after 10 days), was performed to estimate the weighted mean difference (WMD) or odds ratio (OR). Of the 142 studies identified in the search, 12, including a total of 2,689 patients, met the inclusion criteria. The tracheotomy rate was significantly higher with early than with late tracheotomy (87 % versus 53 %, OR 16.1 (5.7-45.7); p <0.01). Early tracheotomy was associated with more ventilator-free days (WMD 2.12 (0.94, 3.30), p <0.01), a shorter ICU stay (WMD -5.14 (-9.99, -0.28), p = 0.04), a shorter duration of sedation (WMD -5.07 (-10.03, -0.10), p <0.05) and reduced long-term mortality (OR 0.83 (0.69-0.99), p = 0.04) than late tracheotomy. This updated meta-analysis reveals that early tracheotomy is associated with higher tracheotomy rates and better outcomes, including more ventilator-free days, shorter ICU stays, less sedation, and reduced long-term mortality, compared to late tracheotomy.


左室流出路狭窄を伴ったたこつぼ型心筋症においてβ遮断薬が著効した一例．

左室流出路狭窄を伴ったたこつぼ型心筋症においてβ遮断薬が著効した一例．


High-flow nasal cannula oxygen therapy in adults.

High-flow nasal cannula (HFNC) oxygen therapy comprises an air/oxygen blender, an active humidifier, a single heated circuit, and a nasal cannula. It delivers adequately heated and humidified medical gas at up to 60 L/min of flow and is considered to have a number of physiological effects: reduction of anatomical dead space, PEEP effect, constant fraction of inspired oxygen, and good humidification. While there have been no big randomized clinical trials, it has been gaining attention as an innovative respiratory support for critically ill patients. Most of the available data has been published in the neonatal field. Evidence with critically ill adults are poor; however, physicians apply it to a variety of patients with diverse underlying diseases: hypoxemic respiratory failure, acute exacerbation of chronic obstructive pulmonary disease, post-extubation, pre-intubation oxygenation, sleep apnea, acute heart failure, patients with do-not-intubate order, and so on. Many published reports suggest that HFNC decreases breathing frequency and work of breathing and reduces needs of escalation of respiratory support in patients with diverse underlying diseases. Some important issues remain to be resolved, such as its indication, timing of starting and stopping HFNC, and escalating treatment. Despite these issues, HFNC oxygen therapy is an innovative and effective modality for the early treatment of adults with respiratory failure with diverse underlying diseases.


印象記 第42回日本集中治療医学会学術集会．

印象記 第42回日本集中治療医学会学術集会．


Withholding and withdrawal of life-sustaining treatments in intensive care units in Asia.

Whereas physicians in ICUs in Asia reported that they often withheld but seldom withdrew life-sustaining treatments at the end of life, attitudes and practice varied widely across countries and regions. Multiple factors related to country or region, including economic, cultural, religious, and legal differences, as well as personal attitudes, were associated with these variations. Initiatives to improve end-of-life care in Asia must begin with a thorough understanding of these factors.

For patients with no real chance of recovering a meaningful life, 1029 respondents (70.2%) reported almost always or often withholding whereas 303 (20.7%) reported almost always or often withdrawing life-sustaining treatments; 1092 respondents (74.5%) deemed withholding and withdrawal ethically different. The majority of respondents reported that vasopressors, hemodialysis, and antibiotics could usually be withheld or withdrawn in end-of-life care, but not enteral feeding, intravenous fluids, and oral suctioning. For severe hypoxic-ischemic encephalopathy after cardiac arrest, 1201 respondents (82.0% [range between countries, 48.4%-100%]) would implement do-not-resuscitate orders, but 788 (53.8% [range, 6.1%-87.2%]) would maintain mechanical ventilation and start antibiotics and vasopressors if indicated. On multivariable analysis, refusal to implement do-not-resuscitate orders was more likely with physicians who did not value families' or surrogates' requests (adjusted odds ratio [AOR], 1.67 [95% CI, 1.16-2.40]; P = .006), who were uncomfortable discussing end-of-life care (AOR, 2.38 [95% CI, 1.62-3.51]; P < .001), who perceived greater legal risk (AOR, 1.92 [95% CI, 1.26-2.94]; P = .002), and in low- to middle-income economies (AOR, 2.73 [95% CI, 1.56-4.76]; P < .001). Nonimplementation was less likely with physicians of Protestant (AOR, 0.36 [95% CI, 0.16-0.80]; P = .01) and Catholic (AOR, 0.22 [95% CI, 0.09-0.58]; P = .002) faiths, and when out-of-pocket health care expenditure increased (AOR, 0.98 per percentage of total health care expenditure [95% CI, 0.97-0.99]; P = .02).


For critically ill patients, is high-flow nasal cannula oxygen delivery a suitable alternative to mechanical ventilation?


Neurally adjusted ventilatory assist improves patient-ventilator synchrony in a patient with tetanus and unstable diaphragmatic electrical activity.

A 79-y-old man with generalized tetanus was admitted to the ICU. A left-forearm wound was surgically debrided, and the wound was closed. On postoperative day 1, after the patient experienced opisthotonos and convulsions, endotracheal intubation was performed. Propofol and diazepam were infused but failed to stop the convulsions. Morphine, midazolam, dantrolene, and rocuronium were used to ameliorate the muscle spasms. Magnesium sulfate was also infused. On postoperative day 15, patient-ventilator asynchrony was apparent. The patient showed recurrent tachypnea and bradypnea, which seemed typical of Cheyne-Stokes respiration. A neurally adjusted ventilatory assist (NAVA) catheter was inserted transnasally, and electrical activity of the diaphragm (Edi) was monitored. Readings showed regular attempts to breathe at 40-50 breaths/min with periodic changes in Edi amplitude. NAVA mode improved patient-ventilator synchrony. Periodic breathing continued for 2 weeks. We stopped monitoring Edi on postoperative day 39. He began respiratory rehabilitation and was transferred to a hospital for rehabilitation on postoperative day 80. We encountered periodic respiration in a patient with tetanus. Edi monitoring revealed periodic amplitude change. The cause of the periodic breathing pattern in this patient could not be determined but may be attributable to side effects of the pharmacologic interventions or the natural history of the disease itself. NAVA mode improved patient-ventilator synchrony.


Performance of ventilators compatible with magnetic resonance imaging: a bench study.

None of the MRI-compatible ventilators maintained V(T), F(IO2), and PEEP at set levels. Vital signs of patients with unstable respiratory mechanics should be monitored during transport and MRI.


Hyperoxemia in mechanically ventilated, critically ill subjects: incidence and related factors.

During mechanical ventilation of critically ill subjects, P(aO2) increased, and F(IO2) decreased. One in 4 subjects were hyperoxemic at T2, and hyperoxemia persisted until T3.


開心術後の重篤な低酸素血症を発症した新生児を膜型人工肺で長期管理した一症例―ローラーポンプのトラブルと遠心ポンプでの流量安定化の試み―


Current status of studies about optimal composition of amino acid and protein for ICU patients: systematic review.


Delayed Discharge from the Intensive Care Unit

集中治療室からの退室遅延の実態


Complete bronchial obstruction by granuloma in a paediatric patient with translaryngeal endotracheal tube: a case report.

Although continuous or frequent stimuli in tracheostomized patients may cause tracheal granulomas, little is known about management of patients with translaryngeal intubation. A 1-month-old Japanese boy, weighing 3.5kg, was admitted to our hospital owing to cardiac failure caused by an atrial septal defect and intractable arrhythmia. To treat his unstable cardiovascular status, surgery was performed to close his atrial septal defect. After the operation, stenosis was detected by auscultation and flow limitation worsened. A bronchoscopy revealed granulomas completely obstructing his right bronchus and partially obstructing his left bronchus. Dexamethasone infusion partially reduced the mass, after which removal by yttrium aluminium garnet laser was tried. The airway obstruction was not resolved, however, because of granuloma reproliferation. Budesonide (aerosol liquid) inhalation was started, and tissue was reduced using an yttrium aluminium garnet laser and physically removed using forceps. After continued budesonide inhalation, he was successfully liberated from the ventilator. Life-threatening airway obstruction by granulomas developed in a translaryngeally intubated paediatric patient. The granuloma was detected after a couple of weeks of intubation. A bronchial granuloma is rare in paediatric patients. It should be suspected with evidence of bronchial obstruction. Treatment with corticosteroids and surgery using a laser maybe indicated.


救急・集中治療医学レビュー

救急・集中治療医学レビュー


この患者をどう管理する―躊躇わずに筋弛緩薬を用いて徹底して肺を守り，病態改善後は速やかに浅鎮静を目指す―．


Hygrometric properties of inspired gas and oral dryness in patients with acute respiratory failure during noninvasive ventilation.

Because noninvasive ventilation (NIV) delivers medical gas at high flow, inadequate humidification may cause oral dryness and patient discomfort. Heated humidification can be used during NIV, but little has been reported about the effects on the hygrometric conditions inside an oronasal mask and oral dryness during 24 hours on NIV. We measured absolute humidity (AH) inside oronasal masks on subjects with acute respiratory failure during 24 hours on NIV. A single-limb turbine ventilator and oronasal mask with an exhalation port were used for NIV. Oral moistness was evaluated using an oral moisture-checking device, and 3 times during the 24 hours the subjects subjectively scored the feeling of dryness on a 0-10 scale in which 10 was the most severe dryness. Sixteen subjects were enrolled. The mean ± SD AH inside the mask was 30.0 ± 2.6 mg H2O/L (range 23.1-33.3 mg H2O/L). The median oral moistness was 19.2% (IQR 4.4-24.0%), and the median oral dryness score was 5.5 (IQR 4-7). AH and inspired gas leak correlated inversely, both within the subjects (r = -0.56, P < .001) and between the subjects (r = -0.58, P = .02). AH and oral moistness correlated within the subjects (r = 0.39, P = .04). Oral breathing was associated with reduced oral moistness (P = .001) and increased oral dryness score (P = .002). AH varied among the subjects, and some complained of oral dryness even with heated humidifier. Oral breathing decreased oral moistness and worsened the feeling of dryness.


Effect of high-flow nasal cannula on thoraco-abdominal synchrony in adult critically ill patients.

High-flow nasal cannula (HFNC) creates positive oropharyngeal airway pressure and improves oxygenation. It remains unclear, however, whether HFNC improves thoraco-abdominal synchrony in patients with mild to moderate respiratory failure. Using respiratory inductive plethysmography, we investigated the effects of HFNC on thoraco-abdominal synchrony. We studied 40 adult subjects requiring oxygen therapy in the ICU. Low-flow oxygen (up to 8 L/min) was administered via oronasal mask for 30 min, followed by HFNC at 30-50 L/min. Respiratory inductive plethysmography transducer bands were circumferentially placed: one around the rib cage, and one around the abdomen. We measured the movement of the rib-cage and abdomen, and used the sum signal to represent tidal volume (V(T)) during mask breathing, and at 30 min during HFNC. We calculated the ratio of maximum compartmental amplitude (MCA) to V(T), and the phase angle. We assessed arterial blood gas and vital signs at each period, and mouth status during HFNC. We used multiple regression analysis to identify factors associated with improvement in thoraco-abdominal synchrony. During HFNC, breathing frequency significantly decreased from 25 breaths/min (IQR 22-27 breaths/min) to 21 breaths/min (IQR 18-24 breaths/min) (P < .001), and MCA/VT (P < .001) and phase angle (P = .047) significantly improved. HFNC improved thoraco-abdominal synchrony in adult subjects with mild to moderate respiratory failure.


The investigation of prognosis of hematological malignancies in ICU patients

集中治療室に入室した血液悪性腫瘍患者の予後の検討

As knowledge of the pathophysiology of organ dysfunctions has been increasing, so the survival of critically ill patients has been improving. After ICU admission, patients with hematological malignancies, however, are still at high risk. We retrospectively evaluated outcome, and risk factors related to mortality of such patients admitted to our ICU. Reviewing medical records of patients admitted between 2005 and 2011, we collected data for age, gender, reasons for ICU admission, Acute Physiology and Chronic Health Evaluation (APACHE) II score, presence and progress of underlying disease, number of organ dysfunction, pancytopenia, treatment with or without bone marrow transplantation, ventilatory support, including noninvasive positive pressure ventilation (NPPV), cause of death, length of ICU stay, ICU mortality, and hospital mortality. Of the 35 patients we found with hematological malignancies, 20 (57.1%) died in the ICU. ICU mortality was lower in patients with only NPPV than those who were intubated. Number of organ dysfunction was also related to ICU mortality. Patients with hematological malignancies remained poor prognosis. NPPV was thought to be effective to care respiratory failure of those who did not cause severe organ dysfunction.

重症患者の生存率は臓器障害の病態生理学の進歩により改善してきている．しかし血液悪性腫瘍患者の予後はICU入室後も依然として悪い．今回，当院ICUに入室した血液悪性腫瘍患者の予後に及ぼす背景因子を後方視的に調査した．2005年から2011年に入室した患者の年齢・性別・ICU入室理由・Acute Physiology and Chronic Health Evaluation(APACHE)IIスコア・基礎疾患・臓器障害・汎血球減少・骨髄移植・入室期間・呼吸管理〔noninvasive positive pressure ventilation(NPPV)を含む〕・死亡理由・ICU死亡率・院内死亡率を調査項目とした．35人が入室し，ICU死亡率は57.1%だった．NPPVのみで管理できた症例では，気管挿管を施行した症例に比べてICU死亡率が低かった．また臓器障害数とICU死亡率は関連を認めた．ICUに入室する血液悪性腫瘍患者の予後は依然不良であった．呼吸不全以外の臓器障害が軽度であれば，NPPVによる呼吸管理は呼吸不全の治療として有効であると考えられた．

Journal of the Japanese Society of Intensive Care Medicine


赤血球輸血:適応と目標，投与方法―欧米のガイドラインをもとに―

赤血球輸血:適応と目標，投与方法―欧米のガイドラインをもとに―


過去11年間に当院集中治療部に入室した産科患者の臨床像の検討

過去11年間に当院集中治療部に入室した産科患者の臨床像の検討


Thiamylal sodium-induced leukopenia in a patient of tardive dystonia

チアミラールによる薬剤性白血球減少症が疑われた遅発性ジストニアの一症例．


The nutritional needs of critically ill patients do not change according to their stage

ICU患者のエネルギー消費量と病勢との関連の検討．


Temperature of gas delivered from ventilators.


Blood lactate/ATP ratio, as an alarm index and real-time biomarker in critical illness

The acute physiology, age and chronic health evaluation (APACHE) II score and other related scores have been used for evaluation of illness severity in the intensive care unit (ICU), but there is still a need for real-time and sensitive prognostic biomarkers. Recently, alarmins from damaged tissues have been reported as alarm-signaling molecules. Although ATP is a member of the alarmins and its depletion in tissues closely correlates with multiple-organ failure, blood ATP level has not been evaluated in critical illness. To identify real-time prognostic biomarker of critical illness, we measured blood ATP levels and the lactate/ATP ratio (ATP-lactate energy risk score, A-LES) in critically ill patients. Blood samples were collected from 42 consecutive critically ill ICU patients and 155 healthy subjects. The prognostic values of blood ATP levels and A-LES were compared with APACHE II score. The mean ATP level (SD) in healthy subjects was 0.62 (0.19) mM with no significant age or gender differences. The median ATP level in severely ill patients at ICU admission was significantly low at 0.31 mM (interquartile range 0.25 to 0.44) than the level in moderately ill patient at 0.56 mM (0.38 to 0.70) (P<0.01). Assessment with ATP was further corrected by lactate and expressed as A-LES. The median A-LES was 2.7 (2.1 to 3.3) in patients with satisfactory outcome at discharge but was significantly higher in non-survivors at 38.9 (21.0 to 67.9) (P<0.01). Receiver operating characteristic analysis indicated that measurement of blood ATP and A-LES at ICU admission are as useful as APACHE II score for prediction of mortality. Blood ATP levels and A-LES are sensitive prognostic biomarkers of mortality at ICU admission. In addition, A-LES provided further real-time evaluation score of illness severity during ICU stay particularly for critically ill patients with APACHE II scores of ≥20.0.


Incidence of bacterial contamination in infusion set needles.

We examined the incidence and types of bacterial contamination in 265 infusion set needles in adult critically ill patients. Bacterial contamination was detected in 15 samples (5.7%), and a total of 17 organisms were isolated. Ten were coagulase-negative staphylococci (CNS) and Staphylococcus aureus, and the remainder were -Streptococcus, Corynebacterium, and gram-negative rods. Although the contamination was not directly related to catheter-related bloodstream infections exchanging infusion bottles can cause intraluminal contamination and is a possible route of these infections.

AJIC - American Journal of Infection Control


An in-hospital mortality equation for mechanically ventilated patients in intensive care units.

Model 2 may potentially serve as an alternative model for predicting mortality in mechanically ventilated patients, who have so far required physiological data for the accurate prediction of outcomes. Model 2 may facilitate the comparative evaluation of in-hospital mortality in multicenter analyses based on administrative data for mechanically ventilated patients.


Effect of certified training facilities for intensive care specialists on mortality in Japan.

Patients admitted to the intensive care unit in CFs had better outcomes. To improve patient outcomes, more board-certified intensivists are required in Japan.


Two cases of cytomegalovirus colitis with thrombocytopenia and gastrointestinal bleeding during the treatment of systemic lupus erythematosus

Systemic lupus erythematosus治療中にサイトメガロウイルス腸炎による血小板減少と消化管出血が疑われた2症例


A case of feeding tube-induced duodenal perforation in a critically ill infant after palliative cardiac surgery

栄養チューブによる十二指腸穿孔をきたした1乳児症例


A case of tongue necrosis due to an endotracheal tube

気管チューブにより舌壊死をきたした一例


Accuracy of recorded body temperature of critically ill patients related to measurement site: a prospective observational study.

Accurate measurement of body temperature is an important indicator of the status of critically ill patients and is therefore essential. While axillary temperature is not considered accurate, it is still the conventional method of measurement in Asian intensive care units. There is uncertainty about the accuracy of thermometers for the critically ill. We compared the accuracy and precision of bladder, axillary and tympanic temperature measurements in critically ill patients. A total of 73 critically ill patients admitted to the intensive care unit of a teaching hospital were prospectively enrolled. Every four hours, we measured body temperature at three sites (bladder, axillary and tympanic). If the patient had received an indwelling pulmonary artery catheter, blood temperature was also recorded and this was compared with bladder, axillary and tympanic temperature readings. For all patients, axillary and tympanic temperature readings were compared with bladder temperature readings. Accuracy and precision were analysed using Bland-Altman analysis. When blood temperature data was available, the mean difference between blood and bladder temperature readings was small (0.02±0.21°C). Compared with bladder temperature, mean difference for axillary temperature was -0.33±0.55°C and for tympanic temperature it was -0.51±1.02°C. For critically ill patients, recorded axillary temperature was closer to bladder temperature than tympanic temperature.


Acute cardiac failure in a pregnant woman due to thyrotoxic crisis.

Introduction. Cardiac failure during pregnancy is usually related to preeclampsia/eclampsia, rarely to hyperthyroidism. While hyperthyroidism can easily lead to hypertensive cardiac failure and may harm the fetus, it is sometimes difficult to distinguish hyperthyroidism from normal pregnancy. Case Presentation. We encountered a case of 41-year-old pregnant woman with hypertensive cardiac failure. Because we initially diagnosed as pre-eclampsia/eclampsia, Caesarian section was performed. However, her symptoms still persisted after delivery. After thyroid function test results taken on the day of admission were obtained on the fourth day, we could diagnose that her cardiac failure was caused by thyrotoxic crisis. Conclusions. Hypertensive cardiac failure due to hyperthyroidism during pregnancy is rare and difficult to diagnose because of similar presentation of normal pregnancy. However, physicians should be aware of the risks posed by hyperthyroidism during pregnancy.


Effect of leak on patient-ventilator dyssynchrony during noninvasive positive pressure ventilation: comparison among ventilator brand

非侵襲的陽圧換気中のリークが患者-人工呼吸器間との不同調に及ぼす影響:機種間での比較

Journal of the Japanese Society of Intensive Care Medicine


Change in ratio of observed to expected deaths in pediatric patients after implementing a closed policy in an adult ICU that admits children.

Backgrounds. We examined the effect on the prognosis of critically ill pediatric patients after a closed ICU policy was implemented into an adult ICU that admitted children. Materials and Methods. We assessed the Pediatric Index of Mortality 2 (PIM2) score of pediatric patients (≤15 y.o.) admitted to the ICU from 2001 to 2009. In our teaching hospital, the department for intensive care was established in January 2004. Since then, for critical care patients, we have followed a closed ICU policy with full-time intensivists. We subsequently compared PIM2 scores and the ratio of observed-to-expected deaths (O/E ratio) for three three-year periods: 2001-2003 (before closed policy), 2004-2006, and 2007-2009. Results. Data was collected from 532 pediatric patients. While the PIM2 score statistically significantly increased from 0.066 ± 0.130 for 2001-2003 to 0.114 ± 0.239 for 2004-2006 and 0.086 ± 0.147 for 2007-2009, the O/E ratio decreased from 1.49 for 2001-2003 to 0.82 for 2004-2006 and remained at 0.82 for 2007-2009. Conclusion. The O/E ratio for critically ill pediatric patients improved after the establishment of a closed policy in an adult ICU that admitted children.


Evaluating stroke treatment in the south Tokushima ? medical areas without stroke specialists

脳卒中専門医不在地域における脳卒中治療と予後の検討

INTRODUCTION:For cranial nerve diseases, particularly stroke, early-stage treatment by stroke specialists cansignificantly alter patient prognosis. With respect to the treatment of acute cerebral infarction, t‐PAwas approved for health insurance coverage in Japan in November2005, and has greatly influencedmedical practice. However, the use of t‐PA necessitates an expertise in stroke treatment, and thedrug cannot be used in areas where stroke specialists are absent. Consequently, disparities maybe occurring in stroke treatment among different areas. We accordingly aimed to evaluate strokepatients in the south Tokushima Ⅱ medical areas(south Ⅱ medical areas)without stroke specialistsand those transferred to the stroke care unit in the Stroke Center of Tokushima UniversityHospital(Tokushima University Hospital SCU), and to clarify the presence or absence of disparitiesin area-based stroke treatment in Tokushima.METHODS:The subjects were103stroke patients in the south Tokushima Ⅱ medical areas without strokespecialists and 317 stroke patients in Tokushima University Hospital SCU, who were assessedbetween October1，2009and September30，2010.RESULTS:In the areas without stroke specialists, the prognosis of42% of the cerebral infarction patientswas related to the absence of stroke specialists, and to geographical disadvantages. In48% of thecerebral infarction patients in the areas without stroke specialists, the lapse time after the onset ofcerebral infarction exceeded3h at their initial examinations. However, this is considered likely tobe improved by the implementation of stroke awareness activities.DISCUSSION:Cerebral infarction, which is common in the elderly, is expected to increase in frequency andseverity in the future. Therefore, rigorous prevention, awareness activities to spread super-acutestroke treatment using t‐PA, and medical environmental improvement are necessary.


A bench study of the effects of leak on ventilator performance during noninvasive ventilation.

Some of the ventilators compensated for leak better than others. With the larger leak none of the ventilators maintained the set PEEP or pressure support.


ショックにおける輸液療法

ショックにおける輸液療法


非侵襲的陽圧人工呼吸管理中に縦隔気腫を発症した症例

非侵襲的陽圧人工呼吸管理中に縦隔気腫を発症した症例


A Chest computed tomography of a patient revealing severe hypoxia due to amniotic fluid embolism: a case report.

ABSTRACT: INTRODUCTION: Amniotic fluid embolism is one of the most severe complications in the peripartum period. Because its onset is abrupt and fulminant, it is unlikely that there will be time to examine the condition using thoracic computed tomography (CT). We report a case of life-threatening amniotic fluid embolism, where chest CT in the acute phase was obtained. CASE PRESENTATION: A 22-year-old Asian Japanese primiparous woman was suspected of having an amniotic fluid embolism. After a Cesarean section for cephalopelvic disproportion, her respiratory condition deteriorated. Her chest CT images were examined. CT findings revealed diffuse homogeneous ground-glass shadow in her bilateral peripheral lung fields. She was therefore transferred to our hospital. On admission to our hospital's intensive care unit, she was found to have severe hypoxemia, with SpO2 of 50% with a reservoir mask of 15 L/min oxygen. She was intubated with the support of noninvasive positive pressure ventilation. She was successfully extubated on the sixth day, and discharged from the hospital on the twentieth day. CONCLUSION: This is the first case report describing amniotic fluid embolism in which CT revealed an acute respiratory distress syndrome-like shadow.


集中治療室closed化の心臓血管外科術後患者予後への影響

集中治療室closed化の心臓血管外科術後患者予後への影響


大量の減量を必要とし，非侵襲的陽圧換気で管理した重症心原生肺水腫の1症例

大量の減量を必要とし，非侵襲的陽圧換気で管理した重症心原生肺水腫の1症例


非侵襲的陽圧換気を用いて気管挿管を回避しえた重症急性膵炎による急性呼吸促迫症候群の1例


Permissive hypercapnia, instituted via reduction of pressure amplitude on pulmonary tissue protection during high frequency oscillatory ventilation, is not protective in a rat model of acid-induced lung injury.

Assuming that HFOV (high frequency oscillatory ventilation) with hypercapnia could be more protective than normocapnia, in a rat model of lung injury, we evaluated the effect of hypercapnic acidosis during HFOV. After inducing lung injury by intratracheal instillation of hydrochloric acid (HCl), we randomly assigned the animals to two groups: in the hypercapnia group (n=9), airway pressure amplitude (Pamp) was titrated to achieve PaCO2 greater than 80 mmHg; in the normocapnia group (n=9), Pamp was titrated to achieve PaCO2 less than 50 mmHg. Hemodynamics, histology, wet-to-dry ratio and inflammatory cytokines were evaluated after all the animals had received HFOV for 5 h. While the right-lung wet-to-dry ratio in the hypercapnia group was statistically significantly lower than in the normocapnia group (7.70+/-1.31 vs. 8.59+/-0.66, p<0.05), no statistically significant intergroup differences were found for blood pressure, heart rate, alveolar-arterial oxygen gradient, levels of cytokines (TNF-alpha, IL-6 and CINC-1) in bronchoalveolar lavage fluid and serum, and lung histological injury scores. Although edema formation was less pronounced in the hypercapnia group, we found no increased numbers of inflammatory cytokines or general histological evidence to suggest that permissive hypercapnia during HFOV was protective.


Low-density lipoprotein apheresis in a pediatric patient with refractory nephrotic syndrome due to focal segmental glomerulosclerosis

Focal segmental glomerulosclerosis (FSGS) often leads to refractory nephrotic syndrome (NS). A high level of low-density lipoprotein (LDL) is a risk factor for the progression of NS. An 8-year-old girl presented with severe proteinuria refractory to steroid therapy. She was diagnosed with non-IgA diffuse mesangial proliferative glomerulonephritis. Oral prednisolone, methylprednisolone (mPL) pulse therapy, and cyclosporine and cyclophosphamide therapy failed to achieve remission. Follow-up renal biopsy revealed FSGS. Her serum level of LDL was high, and LDL-apheresis (LDL-A) was performed five times, followed by mPL pulse therapy. Urinary protein decreased from 2-4 g x day(-) to 0.5-1.0 g x day(-). LDL-A may be beneficial in the treatment of multidrug-resistant FSGS.


Heart failure after extubation due to coronary steal phenomenon in tetralogy of Fallot

冠盗血現象のため抜管後に心不全に陥った Fallot 四徴症の一症例


Influence of endotracheal tube bore on tidal volume during high frequency oscillatory ventilation: A model lung study

In adults, the influence of endotracheal tube bore on tidal volume (VT) during high-frequency oscillatory ventilation (HFOV) has been little studied. Via full-length 6, 7, 8, and 9 mm internal diameter (ID) endotracheal tubes (ETTs), a model lung (TTL, Michigan Instruments, MI) was ventilated using a high-frequency oscillator designed for adult patients (R100; Metran, Japan). Oscillation settings were: frequency, 5, 7, and 9 Hz; mean airway pressure, 15 cmH2O; oxygen inspiratory fraction, 0.21. At each setting: oscillator pressure swing was set at maximum; and each test combination was conducted with the model-lung compliance set at 20 and 50 mL/cmH2O. During the trials, a position sensor attached to the model-lung upper surface provided analog electrical signals for lung movement that were converted to VT evaluation data. Pressure and volume signals were digitized using an analog-to-digital converter and recorded in a computer. At each setting, three waveforms were analyzed and the average value used. At each setting, measured VT was proportional to ETT internal cross-sectional area (CSA). Regression analysis of VT showed correlation with the CSA, as expressed by formula, y=2.173x where x is CSA and y is VT (R2=0.99, p<0.001) at 5 Hz and compliance of 50 cmH2O. In an adult-simulating model lung, VT during HFOV varies in proportion to ETT CSA.


② 意外に難しいスライディング・スケール法による血糖管理 --- 人工膵臓を用いた外科手術周術期血糖管理法


Plasma proinflammatory and anti-inflammatory cytokine and catecholamine concentrations as predictors of neurological outcome in acute stroke patients

Proinflammatory and anti-inflammatory cytokines may play a pivotal role in cerebral inflammation, which is implicated in the development of brain injury. Systemic cytokine release is mediated by the sympathetic nervous system and catecholamines. The aim of this study was to investigate which parameters, among plasma levels of interleukin-1beta (IL-1beta), interleukin-6 (IL-6), interleukin-10 (IL-10), and tumor necrosis factor alpha (TNF-alpha) and the levels of the catecholamines, epinephrine and norepinephrine, contribute to the clinical outcome in acute stroke patients. Thirty-seven acute stroke patients (ischemic, n = 19; hemorrhagic, n = 18) were enrolled. All of them were admitted to our hospital within 8 h after stroke onset. Neurological status was evaluated by a modified National Institute of Health Stroke Scale (mNIHSS) on admission and by a modified Rankin Scale (mRS) at 1 month. An mRS score of 3 or more at 1 month was considered to indicate poor outcome. Serum samples for the cytokine and catecholamine measurements were collected on admission. Plasma levels of IL-1beta, IL-6, IL-10, and TNF-alpha were determined by an enzyme-linked immunosorbent assay (ELISA) method and epinephrine and norepinephrine concentrations were determined by high-performance liquid chromatography with electrochemical detection (HPLC-EC). In the ischemic stroke patients, poor outcome was noted in 9 (47%). There were no significant differences in cytokine or catecholamine concentrations between patients with poor and good outcomes, and there was no association between clinical outcome and cytokine and catecholamine concentrations. In the hemorrhagic stroke patients, poor outcome was noted in 10 (56%). IL-6 and IL-10 levels were higher in patients with poor outcome. On logistic regression analysis, higher values of IL-6 were significantly associated with clinical outcome at 1 month (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.02-1.54). In ischemic stroke, plasma cytokines and catecholamines were not predictors of neurological outcome at 1 month. In hemorrhagic stroke, high levels of IL-6 in the early phase indicated a poor neurological outcome.


Influence of Lipid Emulsion for the Hematocrit Value Measured With Continuous Hematocrit Monitor.

Continuous monitoring of hematocrit with a CRIT-LINE monitor (CLM) is used to prevent excess ultrafiltration during hemodialysis and continuous renal replacement therapy. The presence of substances affecting the scattering and absorption rates of multiple wavelengths of near infrared rays of CLM in the blood may affect the measured values with CLM. We examined the influences of lipid emulsion (LE) on hematocrit and relative blood volume (RBV) which were measured with CLM using an in vitro experimental model with human blood. Additions of 10% or 20% of LE increased the hematocrit measured by LCM and decreased the percent change of RBV in proportion to the dose. One percentage of 20% LE in the plasma increased the expected hematocrit measured with CLM by 2.9%. The decrease of initial hematocrit from 48.1% to 43.4% decreased the expected percent change of RBV from -3.4% to -3.7% with the addition of 1 ml of 20% LE to 100 ml blood. These findings indicate that additions of LE increase hematocrit that is measured with CLM in proportion to the dose of LE. Low levels of initial hematocrit will increase the degree of expected percent change of RBV. Attention should be paid to the influence of LE during monitoring with CLM.


Influence of leukocytapheresis therapy for ulcerative colitis on anemia and hemodynamics.

In Japan, leukocytapheresis (LCAP) therapy has been carried out for ulcerative colitis as an effective therapy with a low incidence of side-effects. In the present study, we serially investigated the influence of LCAP therapy on anemia and hemodynamics in patients with ulcerative colitis using a non-invasive method with a Crit-Line monitor (CLM) (Hema Metrics Inc., Salt Lake City, UT and Boston, MA, USA). We carried out LCAP on 10 patients with ulcerative colitis using a CS-100 Cellsorba EX LCAP filter in 34 courses of LCAP. The mean hematocrit value, which was measured using the Crit-Line monitor, was 21.8 +/- 0.2% (21.0-22.4%), which showed no significant changes after each LCAP therapy. The actual erythrocyte count, hemoglobin and hematocrit values decreased by 244 000/mm3, 0.7 g/dL and 2.1%, respectively, however, the differences were insignificant. These values corresponded to 7.8, 8.0 and 7.6% of the values before LCAP, respectively. There were no significant changes in systolic blood pressure, diastolic blood pressure, or heart rate during LCAP. The results of this study suggest that one course of LCAP does not exacerbate anemia, and it does not influence hemodynamics. However, considering the exacerbation of anemia in patients with severe ulcerative colitis caused by massive melena, monitoring with a less invasive Crit-Line monitor and a vital information monitor might be useful.


低体温療法中に著明なヘモグロビン値の変化を認めた3症例

低体温療法中に著明なヘモグロビン値の変化を認めた3症例

Journal of the Japanese Society of Intensive Care Medicine


熱傷治療中にabdominal compartment syndrome (ACS)の危険性から回避した症例


心膜切開後症候群に対してアスピリンが有用であった小児症例

心膜切開後症候群に対してアスピリンが有用であった小児症例


重症患者における発熱と解熱処置に関する systematic reviewFever and antipyretic therapy in critically ill patients