Motohiro Sekino

Quantitative analysis of the relationship between sedation and resting energy expenditure in postoperative patients.

ObjectiveTo analyze quantitatively the relationship between sedation and resting energy expenditure or oxygen consumption in postoperative patients. DesignA prospective, clinical study. SettingAn eight-bed intensive care unit at a university hospital. PatientsThirty-two postoperative patients undergoing either esophagectomy or surgery of malignant tumors of the head and neck who required mechanical ventilation and sedation for ≥2 days postoperatively. InterventionsNone. Measurements and Main ResultsA total of 133 metabolic measurements were performed. Ramsay sedation scale (RSS), body temperature, and the dose of midazolam were evaluated at the time of the metabolic cart study. All patients received analgesia with buprenorphine at a fixed dose of 0.625 &mgr;g·kg−1·hr−1 continuously. Midazolam was used for induction and maintenance of intravenous sedation after admission to the intensive care unit. The initial dose was 0.04 mg·kg−1·hr−1 and was adjusted to achieve a desired depth of sedation at 3, 4, or 5 on the RSS every 4 hrs. The degree of sedation was classified into three states: light sedation (RSS 2–3; n = 49), moderate sedation (RSS 4; n = 39), and heavy sedation (RSS 5–6; n = 45). ResultsWith increasing the depth of sedation, oxygen consumption index (mL·min−1·m−2), resting energy expenditure index (REEI; kcal·day−1·m−2), and REE/basal energy expenditure (BEE) decreased significantly. Oxygen consumption index (mean ± sd), REEI, and REE/BEE were 151 ± 18, 1032 ± 120, and 1.29 ± 0.17 in the light sedation, 139 ± 22, 947 ± 143, and 1.20 ± 0.16 in the moderate sedation, and 125 ± 16, 865 ± 105, and 1.13 ± 0.12 in the heavy sedation, respectively. ConclusionAn increase in the depth of sedation progressively decreases in oxygen consumption index and REEI in postoperative patients.

Antithrombin Supplementation and Mortality in Sepsis-induced Disseminated Intravascular Coagulation: A Multicenter Retrospective Observational Study

ABSTRACT Supplemental doses of antithrombin (AT) are widely used to treat sepsis-induced disseminated intravascular coagulation (DIC) in Japan. However, evidence on the benefits of AT supplementation for DIC is insufficient. This multicenter retrospective observational study aimed to clarify the effect of AT supplementation on sepsis-induced DIC using propensity score analyses. Data from 3,195 consecutive adult patients admitted to 42 intensive care units for severe sepsis treatment were retrospectively analyzed; 1,784 patients were diagnosed with DIC (n = 715, AT group; n = 1,069, control group). Inverse probability of treatment-weighted propensity score analysis indicated a statistically significant association between AT supplementation and lower in-hospital all-cause mortality (n = 1,784, odds ratio [95% confidence intervals]: 0.748 [0.572–0.978], P = 0.034). However, quintile-stratified propensity score analysis (n = 1,784, odds ratio: 0.823 [0.646–1.050], P = 0.117) and propensity score matching analysis (461 matching pairs, odds ratio: 0.855 [0.649–1.125], P = 0.263) did not show this association. In the early days after intensive care unit admission, the survival rate was statistically higher in the propensity score-matched AT group than in the propensity score-matched control group (P = 0.007). In DIC patients without concomitant heparin administration, similar results were observed. In conclusion, AT supplementation may be associated with reduced in-hospital all-cause mortality in patients with sepsis-induced DIC. However, the statistical robustness of this connection was not strong. In addition, although the number of transfusions needed in patients with AT supplementation increased, severe bleeding complications did not.

Synthetic atrial natriuretic peptide improves systemic and splanchnic circulation and has a lung-protective effect during endotoxemia in pigs.

BACKGROUND: Pharmacological blockade of the renin-angiotensin system is thought to maintain gut perfusion during circulatory stress and thereby avoid later failure of distant organs. In this controlled experimental study, we investigated the effects of carperitide, a synthetic atrial natriuretic peptide that inhibits the renin-angiotensin system, on the systemic and splanchnic circulation during fluid-resuscitated endotoxemia in pigs. METHODS: Sixteen domestic pigs of both sexes were randomly divided into 2 groups. The pigs were anesthetized and their lungs ventilated before receiving either saline (Group A: n = 8) or carperitide (Group B: n = 8). After a baseline measurement was taken, the pigs from both groups received a continuous infusion (1.7 μg · kg−1 · h−1) of endotoxin for 240 min. Group B received a continuous infusion of carperitide (0.05 μg · kg−1 · min−1) starting 30 min before the endotoxin infusion and lasting until the end of the study, whereas Group A received the same volume of saline. Fluid resuscitation was titrated to maintain pulmonary artery wedge pressure between 10 and 12 mm Hg. Systemic and regional hemodynamics, oxygenation variables, and the arterial-to-intestinal Pco2 gap were measured at baseline and after endotoxin infusion for 240 min. The primary end points were cardiac index, superior mesenteric artery flow index, and Pco2 gap at the end of this study (T240). RESULTS: Cardiac index and superior mesenteric artery flow index in Group B were significantly higher than those in Group A at T240 (83 ± 15 vs 135 ± 23 mL · kg−1 · min−1, P < 0.001; 2.6 ± 1.4 vs 7.9 ± 4.8, P = 0.01), respectively. Carperitide administration resulted in a significantly better maintenance of intestinal mucosal perfusion assessed by the Pco2 gap at T240 (33.0 ± 14.5 vs 11.6 ± 10.0 mm Hg, P = 0.004). The Pao2/Fio2 ratio in Group B was significantly greater than that in Group A from T60 to T240. CONCLUSIONS: In this porcine fluid-resuscitated endotoxemia model, a low dose of carperitide administered before endotoxemia maintained systemic and splanchnic circulation, and prevented the deterioration of oxygenation. Atrial natriuretic peptide infusion is a potentially beneficial therapy with respect to systemic and splanchnic circulation as well as the respiratory system during sepsis.

Plasmapheresis therapy has no triglyceride-lowering effect in patients with hypertriglyceridemic pancreatitis.

Kyohei Miyamoto, Masayasu Horibe, Masamitsu Sanui, Mitsuhito Sasaki, Daisuke Sugiyama, Seiya Kato, Takahiro Yamashita, Takashi Goto, Eisuke Iwasaki, Kunihiro Shirai, Kyoji Oe, Hirotaka Sawano, Takuya Oda, Hideto Yasuda, Yuki Ogura, Kaoru Hirose, Katsuya Kitamura, Nobutaka Chiba, Tetsu Ozaki, Taku Oshima, Tomonori Yamamoto, Keiji Nagata, Tetsuya Mine, Koji Saito, Motohiro Sekino, Tomoki Furuya, Naoyuki Matsuda, Mineji Hayakawa, Takanori Kanai and Toshihiko Mayumi

Intestinal fatty acid-binding protein level as a predictor of 28-day mortality and bowel ischemia in patients with septic shock: A preliminary study

Purpose: We sought to evaluate the levels of intestinal fatty acid‐binding protein (I‐FABP), a biomarker of enterocyte injury, as a predictor of 28‐day mortality and bowel ischemia in septic shock patients. Material and methods: In this preliminary prospective observational study, 57 adult septic shock patients under mechanical ventilation were enrolled. Serum I‐FABP levels and prognostic biomarkers were recorded upon intensive care unit (ICU) admission. Results: The overall 28‐day mortality rate of participants was 23% (13/57). Non‐survivors displayed significantly higher lactate (p = 0.009), I‐FABP (p = 0.012), and N‐terminal pro‐B‐type natriuretic peptide (p = 0.039) levels compared to survivors. Only I‐FABP was associated with 28‐day mortality (odds ratio, 1.036; 95% confidence interval, 1.003–1.069; p = 0.031) in a multiple logistic regression analysis adjusted for the Acute Physiology and Chronic Health Evaluation II score. When divided into low and high I‐FABP groups based on the optimum cut‐off value of 19.0 ng/mL for predicting 28‐day mortality, high‐I‐FABP patients had a significantly higher incidence of non‐occlusive mesenteric ischemia (NOMI) (2% [1/43] vs 29% [4/14]; p = 0.011). Conclusions: I‐FABP level at ICU admission can serve as a predictor of 28‐day mortality in septic shock patients and is associated with the incidence of NOMI. HighlightsWe studied intestinal fatty acid‐binding protein and mortality in septic shock.I‐FABP level was a predictor of 28‐day mortality in septic shock patients.Predictive ability of ICU baseline I‐FABP in septic shock patients was evaluated.

Severe Pneumonia Caused by Toxigenic Corynebacterium ulcerans Infection, Japan

Corynebacterium ulcerans infection was recently recognized as a zoonosis. We present 2 cases of severe pneumonia complicated by diffuse pseudomembrane formation on the bronchus caused by C. ulcerans-producing diphtheria toxin. Our purpose is to alert medical professionals to the virulence of Corynebacterium species other than C. diphtheriae.

Recovery of muscle weakness and physical function in a patient with severe ICU-acquired weakness following pulmonary embolism: A case report

Although ICU‐AW is a common condition in critically ill, it is unclear which intervention is best to treat. We applied combined exercise training and nutritional supplementation, and these were effective to recover the skeletal muscle function and exercise capacity. We should recognize necessity of nutritional support in ICU‐AW patients.