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A peripherally inserted central catheter (PICC) was inserted through the right basilic vein and placed within the superior vena cava of a patient for fluid and medication administration during postoperative management of bladder cancer. Following the development of sepsis, contrast-enhanced CT was

Background: Despite studies on low immunoglobulin G (IgG) levels in critically ill patients, their association with clinical outcomes in sepsis patients remains disputed. Herein, we determined the association between low IgG levels and clinical outcomes and investigated the 28-day mortality in patients with low IgG levels. Methods: We retrospectively identified 238 patients whose serum IgG levels were measured upon intensive care unit admission using medical record data collected between January 2013 and August 2018. We extracted data on patient characteristics, severity scores (APACHE II, SOFA score), neutrophil-lymphocyte ratio (NLR), procalcitonin levels, and serum IgG levels and calculated the cut-off value for the IgG level according to the evaluated clinical outcomes. The primary outcome was 28-day mortality. Results: There were no significant differences in NLR and procalcitonin levels between survivors and non-survivors; serum IgG levels were significantly higher in survivors than in non-survivors (P = 0.004). A serum IgG cut-off value of 670 mg/dL was calculated from receiver operating characteristic curve analysis, and serum IgG levels significantly predicted survival with an area under the curve of 0.63 (95% CI, 0.54–0.72) (P = 0.004). Patients with low IgG levels (

Introduction In Acute Respiratory Distress Syndrome (ARDS), the heterogeneity of lung lesions results in a mis-match between ventilation and perfusion, leading to the development of hypoxia. The study aimed to examine the association between computed tomographic (CT scan) lung findings in patients with ARDS after abdominal surgery and improved hypoxia and mortality after prone ventilation. Material and Methods A single site, retrospective observational study was performed at the Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan, between 1st January 2004 and 31st October 2018. Patients were allocated to one of two groups after CT scanning according to the presence of ground-glass opacity (GGO) or alveolar shadow with predominantly dorsal lung atelectasis (DLA) on lung CT scan images. Also, Patients were divided into a prone ventilation group and a supine ventilation group when the treatment for ARDS was started. Results We analyzed data for fifty-one patients with ARDS following abdominal surgery. CT scans confirmed GGO in five patients in the Group A and in nine patients in the Group B, and DLA in 17 patients in the Group A and nine patients in the Group B. Both GGO and DLA were present in two patients in the Group A and nine patients in the Group B. Prone ventilation significantly improved patients’ impaired ratio of arterial partial pressure of oxygen to fraction of inspired oxygen from 12 h after prone positioning compared with that in the supine position. Weaning from mechanical ventilation occurred significantly earlier in the Group A with DLA vs the Group B with DLA (P < 0.001). Twenty-eight-day mortality was significantly lower for the Group A with DLA vs the Group B with DLA (P = 0.035). Conclusions These results suggest that prone ventilation could be effective for treating patients with ARDS as showing the DLA.

Background Myxedema coma, which occurs due to hypothyroidism, is a rare and life-threatening condition. Some patients have hemodynamic dysfunction, which consequently leads to cardiac arrest. The rarity of this condition makes it difficult to determine the cause of cardiac arrest. It is important to diagnose myxedema coma based on clinical findings, including physical examination and laboratory parameters. We present a case of undiagnosed and untreated hypothyroidism that initially caused myxedema coma and then led to cardiac arrest. Case presentation A 56-year-old woman who had no medical history was transferred to our hospital for the management of return of spontaneous circulation due to sudden cardiac arrest. Findings of laboratory tests revealed that she had hypothyroidism. On physical examination, she was found to have a puffy face, thin eyebrows, and severe systemic non-pitting edema. Therefore, the patient was clinically diagnosed with myxedema coma, which was the cause of cardiac arrest. She was treated with thyroid hormone and hydrocortisone, resulting in improvement in her general condition, except for the neurological dysfunction. Conclusions This case suggests that myxedema coma is caused by undiagnosed and untreated hypothyroidism, leading to sudden cardiac arrest. Our findings are useful in the differential diagnosis of hypothyroidism based on characteristic physical examination findings. Clinicians should be aware of the differential diagnosis of myxedema coma based on findings from physical examination and laboratory testing of thyroid function, and the treatment should be started immediately.

Background and Oblectives: We evaluated the success rate of endoscopically positioned nasojejunal feeding tubes and the intragastric countercurrent of contrast medium thereafter. Method: This retrospective observational study investigated patients who were admitted to a single intensive care unit and required endoscopic placement of a post-pyloric feeding tube between January 2010 and June 2016. The feeding tube was grasped with forceps via a transoral endoscope and inserted into the duodenum or jejunum. Thereafter, we assessed the position of the tube and the intragastric countercurrent using abdominal radiography with contrast medium. Results: The tube tip was inserted at the jejunum and the duodenal fourth portion in 55.8 and 33.6% of patients, respectively. The tip of the inserted tube had moved into the jejunum of 71.7% of patients by the following day. The countercurrent rate was significantly lower among patients with a tube inserted into the duodenal fourth portion or more distal than among those with tubes inserted more proximally (8.4 vs. 45.4%, p = 0.0022). Conclusions: The endoscopic insertion and positioning of a nasojejunal feeding tube seemed effective because the rate of tube insertion into the duodenal fourth portion or more distal was about 90%. The findings of intragastric countercurrents indicated that feeding tubes should be inserted into the duodenal fourth portion or beyond to prevent vomiting and the aspiration of enteral nutrients.

Background: Healthcare workers must be protected during extubation of patients with coronavirus disease 2019 (COVID-19) owing to the presence of aerosolized droplets. Herein, we report a technique for extubating a patient with COVID-19 while minimizing aerosol dispersion. Case Report: We retrospectively identified a total of 79 patients admitted to our hospital from February 2020 to January 2021. Six of these patients were intubated for mechanical ventilation, 2 of whom had to be extubated. We prepared a clear vinyl sheet in the shape of a tent to place over the patient, and 2 staff members, both well experienced in airway management, stood outside the tent on either side of the patient. Before extubation, we confirmed that the patient’s consciousness level was good and the patient had no distress by adjusting the dose of sedative drugs. After extubation, a surgical mask was placed on the patient’s face. Conclusion: Our experience indicates that this method of extubation in a patient with COVID-19 could be safely implemented to protect healthcare workers.

Appropriate nutritional therapy is closely associated with the complication rate and clinical course in critically ill patients...

Background Clinical evidence showing the effectiveness of recombinant human soluble thrombomodulin (rhTM) for treating sepsis-induced disseminated intravascular coagulation (DIC) and organ dysfunction (particularly renal injury) is limited because of differences in the inclusion criteria and disease severity among patients. This study aimed to assess the association between rhTM and outcomes in septic DIC patients with acute kidney injury (AKI). Methods This retrospective observational study analyzed the data of patients who were admitted to the intensive care unit (ICU) of a single center between January 2012 and December 2018, and diagnosed with sepsis-induced DIC and AKI. Data were extracted as follows: patients’ characteristics; DIC score, as calculated by the Japanese Association for Acute Medicine and the International Society of Thrombosis and Hemostasis criteria; serum creatinine levels; and ICU and 28-day mortality rates. The primary outcome was the dependence on renal replacement therapy (RRT) at ICU discharge. The propensity score (PS) was calculated using the following variables: age, sex, septic shock at admission, DIC score, and KDIGO classification. Subsequently, logistic regression analysis was performed using the PS to evaluate the outcome. Results In total, 97 patients were included in this study. Of these, 52 (53.6%) patients had received rhTM. The dependence on RRT at ICU discharge was significantly lower in the rhTM than in the non-rhTM group (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.19–0.97; P = 0.043). The serum creatinine levels at ICU discharge (OR, 0.31; 95% CI, 0.13–0.72; P = 0.007) and hospital discharge (OR, 0.25; 95% CI, 0.11–0.60; P = 0.002, respectively), and the 28-day mortality rate (OR, 0.40; 95% CI, 0.17–0.93; P = 0.033) were significantly lower in the rhTM than in the non-rhTM group. Moreover, the Kaplan–Meier survival curve revealed significantly lower mortality rates in the rhTM than in the non-rhTM group (P = 0.009). No significant differences in the DIC score and AKI severity were observed between the groups. Conclusions Among sepsis-induced DIC patients with AKI, rhTM administration was associated with lower dependence on RRT at ICU discharge, improvement in renal function, and lower 28-day mortality rate.

Multiple organ dysfunction induced by sepsis often involves kidney injury. Extracellular histones released in response to damage-associated molecular patterns are known to facilitate sepsis-induced organ dysfunction. Recombinant human soluble thrombomodulin (rhTM) and its lectin-like domain (D1) exert anti-inflammatory effects and neutralize damage-associated molecular patterns. However, the effects of rhTM and D1 on extracellular histone H3 levels and kidney injury remain poorly understood. Our purpose was to investigate the association between extracellular histone H3 levels and kidney injury, and to clarify the effects of rhTM and D1 on extracellular histone H3 levels, kidney injury, and survival in sepsis-induced rats. Rats in whom sepsis was induced via cecal ligation and puncture were used in this study. Histone H3 levels, histopathology of the kidneys, and the survival rate of rats at 24 h after cecal ligation and puncture were investigated. Histone H3 levels increased over time following cecal ligation and puncture. Histopathological analyses indicated that the distribution of degeneration foci among tubular epithelial cells of the kidney and levels of histone H3 increased simultaneously. Administration of rhTM and D1 significantly reduced histone H3 levels compared with that in the vehicle-treated group and improved kidney injury. The survival rates of rats in rhTM- and D1-treated groups were significantly higher than that in the vehicle-treated group. The results of this study indicated that rhTM and its D1 similarly reduce elevated histone H3 levels, thereby reducing acute kidney injury. Our findings also proposed that rhTM and D1 show potential as new treatment strategies for sepsis combined with acute kidney injury.

Severe muscle weakness concomitant with preferential depletion of myosin has been observed in several pathological conditions. Here, we used the steroid-denervation (S-D) rat model, which shows dramatic decrease in myosin content and force production, to test whether electrical stimulation (ES) treatment can prevent these deleterious changes. S-D was induced by cutting the sciatic nerve and subsequent daily injection of dexamethasone for 7 days. For ES treatment, plantarflexor muscles were electrically stimulated to produce four sets of five isometric contractions each day. Plantarflexor in situ isometric torque, muscle weight, skinned muscle fiber force, and protein and mRNA expression were measured after the intervention period. ES treatment partly prevented the S-D-induced decreases in plantarflexor in situ isometric torque and muscle weight. ES treatment fully prevented S-D-induced decreases in skinned fiber force and ratio of myosin heavy chain (MyHC) to actin, as well as increases in the reactive oxygen/nitrogen species-generating enzymes NADPH oxidase (NOX) 2 and 4, phosphorylation of p38 MAPK, mRNA expression of the muscle-specific ubiquitin ligases muscle ring finger-1 (MuRF-1) and atrogin-1, and autolyzed active calpain-1. Thus, ES treatment is an effective way to prevent muscle impairments associated with loss of myosin.

Objective: The purpose of this study was to clarify whether initiation of a rapid response system (RRS) affected the incidence of unplanned intensive care unit (ICU) admissions (UIAs) for treatment of organ dysfunction in the early postoperative period. Methods: We retrospectively identified patients admitted unexpectedly to the ICU from general wards within the first 72 h after surgery between January 2006 and December 2017. Patients with UIAs were divided into two groups: a pre-RRS group (January 2006-May 2013); and a post-RRS group (June 2013-December 2017). We extracted data on the patients' characteristics, intraoperative status, and postoperative conditions. Student's t-test and Fisher’s exact test were used to compare the patients' characteristics and incidences of UIA in the pre- and post-RRS groups. Results: Thirty-nine patients (0.06%) underwent UIAs from general wards within the first 72 h after surgery. Preanesthetic condition as evaluated by ASA-physical status (ASA-PS) was ≥ 2, showing that most patients displayed some form of pre-anesthetic complication. The most frequent reasons for UIA were hypoxia in 19 patients (48.7%), shock in 12 patients (30.8%), and disturbance of consciousness in 4 patients (10.3%). The mortality rate in the pre- RRS group was 11.5%. SOFA score was significantly lower in the post-RRS group than in the pre-RRS group. The odds ratio for UIA between the pre- and post-RRS groups was 0.756 (95% confidence interval: 0.388-1.471). This result was not significant, but introduction of an RRS may be associated with an up to 25% reduction in UIA. Conclusion: Introduction of an RRS did not reduce the incidence of UIA significantly, but severity of organ failure in patients with UIA decreased, resulting in lower UIA-associated mortality. Introduction of an RRS and careful observation of respiration-associated vital signs are therefore crucial to prevent UIA and UIA-related mortality after elective surgery.

Background Rectus sheath block is a common peripheral nerve block for patients undergoing umbilical hernia repair surgery. However, rectus sheath block alone can affect only anterior branches of intercostal nerves and, therefore, is incomplete for postoperative analgesia for the anterior abdomen, which is innervated by both anterior and lateral branches. We describe a successful perioperative analgesia with ultrasound-guided para-umbilical block after pediatric umbilical hernia surgery. Case presentation A 4-year-old child underwent hernia repair surgery. Following induction of general anesthesia, the anatomy of the umbilical region was observed under ultrasound with a 5–10-MHz linear probe. An ultrasound-guided injection between the rectus abdominis muscle and the posterior lobe of the rectus sheath and an injection into the subcutaneous space around the umbilicus were performed. The peripheral nerve block was effective during surgery, and the patient required no additional rescue analgesia during the perioperative period. There were no complications. Conclusion We performed ultrasound-guided para-umbilical block with four injections. This peripheral nerve block could be an efficient technique for complete perioperative analgesia.