Osamu Umegaki

Use of central venous saturation monitoring in a patient with pediatric cardiac beriberi

The patient was a 1-year-and-4-mo-old boy. He had drunk about 1 L of an isotonic drink for infants daily since about 10 mo after birth. He was examined by a local doctor due to anorexia and vomiting, found to have cardiomegaly, and transported to our hospital with suspected myocarditis. After admission, the patient showed polypnea, a decreased level of consciousness, and marked metabolic acidosis and lapsed into circulatory insufficiency, requiring catecholamine administration, endotracheal intubation, and extracorporeal membrane oxygenation. Initially, low-output heart failure due to acute myocarditis was suspected, but the central venous oxygen saturation was high, at 82%. Considering high-output heart failure to be more likely, we evaluated its cause and noted, by urinary organic acid analysis, increases in lactate, pyruvate, 3-OH-butyrate, acetoacetate, metabolic products of branched-chain amino acids, 2-ketoglutarate, 2-OH-glutarate, 2-keto-adipate, and 2-OH-adipate. Since the vitamin B1 level was reduced to 12 ng/mL (normally 20-50 ng/mL), a diagnosis of cardiac beriberi due to vitamin B1 deficiency was made. When unexplained heart failure is observed in children, cardiac beriberi must be excluded as a differential diagnosis of myocarditis and cardiomyopathy. The measurement of the central venous oxygen saturation may be useful for the diagnosis.

The Influence of Human Soluble Recombinant Thrombomodulin on In-Hospital Mortality in Patients with Acute Respiratory Distress Syndrome and Disseminated Intravascular Coagulation: A Retrospective Multicenter Study

Background: Patients with acute respiratory distress syndrome (ARDS) often develop disseminated intravascular coagulation (DIC), which can worsen clinical outcomes. Anticoagulant therapy such as human soluble recombinant thrombomodulin (rTM) treatment may help to resolve DIC and improve prognoses. This study analyzes the influence of rTM treatment on in-hospital mortality in patients with both ARDS and DIC. Methods: In a retrospective cohort study, we examined 75 patients with ARDS and DIC who had been admitted to the intensive care units of 3 university hospitals between March 1, 2008 and February 29, 2016. Data were extracted from clinical records. Subjects were divided into a control group comprising 38 patients who were not administered rTM and an rTM group comprising 37 patients who were administered rTM. Kaplan-Meier survival analysis was performed to produce survival curves and the log-rank test was used to compare survival between the 2 groups. We conducted a Cox proportional hazards regression analysis where the dependent variable was in-hospital mortality and the main independent variable of interest was the use of rTM; the hazard ratio of rTM use was calculated. Results: The variables of with P values below 0.2 were age (P=0.15), source of sepsis (P=0.17), rTM use (P=0.02) and AT concentrate use (P=0.17) between the survivors and non-survivors. There was no significant difference in the ARDS severity levels between the rTM group and the control group (P=0.71). In-hospital mortality was significantly lower (P=0.02) in the rTM group (37.8%) than in the control group (65.8%). The hazard ratio of rTM use for mortality was 0.49 (95% confidence interval: 0.26-0.95; P=0.03). In addition, the log-rank test showed that the rTM group had significantly better survival than the control group (P=0.04). Conclusion: Our study indicates that rTM treatment significantly improved prognoses in patients with both ARDS and DIC.

Sudden onset of artery dissection in a 32-year-old woman with vascular Ehlers-Danlos syndrome due to psychological stress of her mother’s death: a case series

BackgroundPatients with vascular Ehlers-Danlos syndrome (EDS) are susceptible to significant vascular complications, such as aortic and visceral arterial ruptures, aneurysms, and dissection. We describe a case of repeated bleeding in a 57-year-old woman and a case of sudden onset of artery dissection in her daughter, both of whom were previously diagnosed with vascular EDS and managed at our institution.Case presentationA 57-year-old woman was admitted to our emergency department due to sudden onset of left low back pain. Her past history included vascular EDS. An urgent abdominal computed tomography (CT) scan revealed a left-sided retroperitoneal hematoma and left external iliac artery dissection. Stent graft repair was performed. Five hours postoperatively, cardiac arrest occurred and resuscitation attempts failed. The 32-year-old daughter with genetically diagnosed vascular EDS was notified of the death of her mother during the customary end-of-life conference. Six hours after her mother’s death, she was admitted to our emergency department due to sudden onset of left low back pain. On examination, she was not in hypovolemic shock, and weak pulses were palpable in the bilateral dorsalis pedis. An urgent abdominal CT scan revealed a right-sided retroperitoneal hematoma around the right external iliac artery and left external iliac artery dissection. She was admitted to the intensive care unit and underwent conservative therapy consisting of bed rest and antihypertensive therapy with nicardipine. She developed no further vascular complications requiring surgical intervention and was discharged on the 21st hospital day.ConclusionsVascular rupture can be fatal in patients with vascular EDS. This report underscores the importance of strategic management of vascular complications to prevent rupture, and the importance of psychological care for the bereaved family given the hereditary nature of vascular EDS.

An educational program for decreasing catheter-related bloodstream infections in intensive care units: a pre- and post-intervention observational study

BackgroundCentral venous catheters (CVCs) are commonly used in the management of critically ill patients. This study aimed to determine whether an educational program could reduce the rate of catheter-related bloodstream infections (CRBSIs) in intensive care units (ICUs).FindingsAll patients admitted to a medical ICU at a college affiliated with the Japan Society of Intensive Care Medicine between January 2008 and December 2014 were surveyed prospectively for the development of CRBSIs. A mandatory educational program (the intervention) targeting an infection control committee consisting of physicians was developed by a multidisciplinary task force to highlight correct practices for preventing CRBSIs. The program included a 30-min video-based introduction, 120-min lectures with a number of hands-on training sessions, a post-test, posters, safety check sheets, and feedback from the infection control committee. Lectures based on the education program were held every 3 months, and participants were free to choose when they attended the lectures. Each participant was required to view the 30-min introduction before attending the 120-min lectures and complete the post-test after each lecture. Safety check sheets were made to ascertain adherence to contents of the educational program. Posters describing the educational program were posted throughout the ICU. A pre- and post-intervention observational study design was employed, with the main outcome measure being yearly CRBSIs. We also calculated cost savings that resulted from improved CRBSI rates.During the 12-month pre-intervention period, four episodes of CRBSIs occurred in 1171 patient ICU-days (i.e., 3.4 per 1000 patient ICU-days). In the first year after the intervention, the rate of CRBSIs decreased to 0 in 1157 patient ICU-days (P ≤ 0.05). The estimated cost savings secondary to this decreased rate for the 1 year following introduction of the program was between 1850,000 and 27,000,000 yen (

Bacillus cereus pneumonia in an immunocompetent patient: a case report

14,800–

Oral sildenafil for persistent pulmonary hypertension early after congenital cardiac surgery in children

216,000).ConclusionsA program aimed at educating healthcare providers on the prevention of CRBSIs led to a dramatic decrease in the rate of primary bloodstream infections. This suggests that educational programs may substantially decrease medical care costs and patient morbidity attributed to central venous catheterization when implemented as part of mandatory training.

Post-Operative Dexmedetomidine-Based Sedation After Uneventful Intracranial Surgery for Unruptured Cerebral Aneurysm: Comparison with Propofol-Based Sedation

BackgroundBacillus cereus (B. cereus) rarely causes lower respiratory tract infections, although most reported cases of B. cereus pneumonia are fatal despite intensive antibiotic therapy. We present a case of B. cereus pneumonia in an immunocompetent patient.Case presentationAn 81-year-old woman was transferred from a district general hospital to our hospital for treatment of congestive heart failure. The patient presented with a nonproductive cough, dyspnea, edema in both lower extremities, orthopnea, fever, and occult blood in the stool. A chest radiograph indicated bilateral pleural effusion and pulmonary congestion. After diuretic therapy and chest drainage, bilateral pleural effusion and pulmonary congestion improved. On day 2, she experienced severe respiratory distress. B. cereus was isolated from two blood sample cultures. On day 4, her condition had progressed to severe respiratory distress (PaO2/FiO2 ratio = 108). A chest radiograph and computed tomography indicated extensive bilateral infiltrates. She was transferred to the intensive care unit and was intubated. B. cereus was also isolated from five blood sample cultures at that time. After isolating B. cereus, we switched antibiotics to a combination of imipenem and levofloxacin, which were effective. She had no history of immunodeficiency, surgery, ill close contacts, risk factors for HIV or tuberculosis, recent central venous catheter insertion, or anthrax vaccination. She improved and was discharged from the intensive care unit after several days.ConclusionThis is a rare case of B. cereus pneumonia in an immunocompetent patient, who subsequently recovered. Bacillus should be considered as a potential pathogen when immunocompetent patients develop severe pneumonia.