Ryoichi Ochiai

The Japanese guidelines for the management of sepsis

SummaryThis is a guideline for the management of sepsis, developed by the Sepsis Registry Committee of The Japanese Society of Intensive Care Medicine (JSICM) launched in March 2007. This guideline was developed on the basis of evidence-based medicine and focuses on unique treatments in Japan that have not been included in the Surviving Sepsis Campaign guidelines (SSCG), as well as treatments that are viewed differently in Japan and in Western countries. Although the methods in this guideline conform to the 2008 SSCG, the Japanese literature and the results of the Sepsis Registry Survey, which was performed twice by the Sepsis Registry Committee in intensive care units (ICUs) registered with JSICM, are also referred. This is the first and original guideline for sepsis in Japan and is expected to be properly used in daily clinical practice.This article is translated from Japanese, originally published as “The Japanese Guidelines for the Management of Sepsis” in the Journal of the Japanese Society of Intensive Care Medicine (J Jpn Soc Intensive Care Med), 2013; 20:124–73. The original work is at http://dx.doi.org/10.3918/jsicm.20.124.

Combined effects of propofol and mild hypothermia on cerebral metabolism and blood flow in rhesus monkey: a positron emission tomography study.

PurposePropofol reduces the cerebral metabolic rate for oxygen (CMRO2), regional CMRO2 (rCMRO2), cerebral blood flow (CBF), and regional CBF (rCBF), but maintains the coupling of cerebral metabolism and blood flow. Under mild to moderate hypothermia, the coupling is maintained, while rCBF is reduced, but no direct measurement of rCMRO2 has yet been reported. This study aimed to evaluate the effects of propofol under normothermic and mild hypothermic temperatures upon rCMRO2, rCBF, and their regional coupling, through direct measurement by positron emission tomography.MethodsRhesus monkeys were anesthetized with 65% nitrous oxide and propofol. Then rCBF and rCMRO2 were measured under four sets of conditions: infusion of a low-propofol dose (12 mg·kg−1·h−1) at normothermic temperatures (38°C), a high dose (25 mg·kg−1·h−1) at normothermic temperatures, a low dose under mild hypothermia (35°C), and a high dose under mild hypothermia. The ratio of rCBF/rCMRO2 was calculated from these data.ResultsReductions in CMRO2 and rCMRO2 in most regions were associated with two factors: the higher propofol dose and the induction of hypothermia, but there was no interaction between these factors. Concerning blood flow, no significant reduction was observed, except for CBF by the induction of hypothermia. The ratio of rCBF/rCMRO2 was constant in this study setting.ConclusionDuring propofol anesthesia, it is possible to reduce cerebral metabolism throughout the entire brain as well as in any brain region by increasing the propofol dose or inducing hypothermia. The concurrent use of these two interventions has an additive effect on metabolism, and can be considered as safe, as their combination does not impair the coupling of cerebral metabolism and blood flow.

Reduction in the incidence of acute kidney injury after aortic arch surgery with low-dose atrial natriuretic peptide: a randomised controlled trial.

BACKGROUND Acute kidney injury (AKI) after surgery is associated with an increased risk of adverse events and death. Atrial natriuretic peptide (ANP) dilates the preglomerular renal arteries and inhibits the renin–angiotensin axis. A low-dose ANP infusion increases glomerular filtration rate after cardiovascular surgery, but it is not known whether it reduces the incidence of AKI or the mortality rate. OBJECTIVE To evaluate whether an intravenous ANP infusion prevents AKI in patients undergoing aortic arch surgery requiring hypothermic circulatory arrest. DESIGN A randomised controlled study. SETTING Operating room and intensive care unit at Kawasaki Saiwai Hospital, Kanagawa, Japan. PATIENTS Forty-two patients with normal preoperative renal function undergoing elective repair of an aortic arch aneurysm. INTERVENTION Patients were assigned randomly to receive a fixed dose of ANP (0.0125 &mgr;g kg−1 min−1) or placebo. The infusion was started after induction of anaesthesia and continued for 24 h postoperatively. MAIN OUTCOME MEASURES The primary end-point was the incidence of AKI within 48 h after surgery. RESULTS AKI developed in 30% of patients who received ANP compared with 73% of patients who received placebo (P = 0.014). Intraoperative urine output was almost 1 l greater in patients who received ANP (1865 ± 1299 versus 991 ± 480 ml in the control group, P = 0.005). However, there were no differences in mean arterial pressure or number of episodes of hypotension between the groups. Length of hospital and intensive care stays were not significantly different, nor was there a difference in 30-day mortality. No patients required haemodialysis or continuous renal replacement therapy. CONCLUSION We found that an intravenous infusion of ANP at 0.0125 &mgr;g kg−1 min−1 is an effective intervention for reducing the incidence of postoperative AKI, and appears to afford a degree of renal protection during and after cardiovascular surgery. TRIAL REGISTRATION Kawasaki ANP trial, UMIN Clinical Trials Registry ID: UMIN000011650

A comparison of plasma levobupivacaine concentrations following transversus abdominis plane block and rectus sheath block.

Levobupivacaine is commonly used as the local anaesthetic of choice in peripheral nerve blocks, but its pharmacokinetics have not been fully investigated. We compared the changes in plasma concentrations of levobupivacaine following transversus abdominis plane block and rectus sheath block. Fifty woman undergoing laparoscopy were randomly allocated to receive either a transversus abdominis plane block or an rectus sheath block. In both groups, 2.5 mg.kg−1 levobupivacaine was administered, and blood samples were obtained 15 min, 30 min, 60 min and 120 min after injection. The mean maximum plasma concentration (Cmax) and mean time to reach Cmax (Tmax) as determined by non‐linear regression analysis were 1.05 μg.ml−1 and 32.4 min in the transversus abdominis plane group and 0.95 μg.ml−1 and 60.9 min in the rectus sheath group, respectively. The plasma concentration of levobupivacaine peaked earlier in the transversus abdominis plane group than in the rectus sheath group and the maximum plasma concentration depended on the dose administered but not the procedure.

The Japanese Respiratory Society Noninvasive Positive Pressure Ventilation (NPPV) Guidelines (second revised edition)

Division of Sleep and Respiratory Medicine, Nihon University School of Medicine Department of Pediatrics, National Hospital Organization Yakumo National Hospital Department of Respiratory Medicine, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases Department of ER/Disaster Medical Care, Tokushima University Hospital Respiratory and Sleep Medicine Center, Osaka Kaisei Hospital Anesthesiology and Intensive Care Medicine of Toho University Omori Medical Center Cardio-Respiratory Sleep Medicine, Department of Cardiovascular Medicine, Juntendo University, Graduate School of

Low levels of urinary liver-type fatty acid-binding protein may indicate a lack of kidney protection during aortic arch surgery requiring hypothermic circulatory arrest

STUDY OBJECTIVE To examine the change in liver-type fatty acid-binding protein (L-FABP) levels in patients undergoing aortic arch surgery and the correlation between L-FABP and postoperative acute kidney injury. DESIGN Prospective observational study. SETTING Operating room of a general hospital. PATIENTS 36 adult patients. INTERVENTIONS AND MEASUREMENTS Urine samples were obtained to measure urinary L-FABP at initiation of cardiopulmonary bypass (CPB) and 5 minutes after termination of hypothermic circulatory arrest. MAIN RESULTS 22 (61.1%) patients developed acute kidney injury within a 48-hour period. L-FABP increases more than a thousand-fold were found. In patients who subsequently developed acute kidney injury, significant increases in L-FABP were noted from 2.9 (3.6) ng/mg of creatinine before CPB to 62.1 (995.6) ng/mg of creatinine 5 minutes after termination of circulatory arrest. Values in patients who did not develop acute kidney injury increased from 1.1 (5.7) ng/mg before CPB to 1133.0 (6358.8) ng/mg of creatinine showing a significant mean difference (P = 0.011). The area under the L-FABP receiver operating characteristic curve at 5 minutes after termination of circulatory arrest was 0.758. A cutoff value of 75.13 ng/mg of creatinine yielded both good sensitivity (1.000) and specificity (0.546) for detecting non-acute kidney injury. Patients who developed acute kidney injury after aortic arch surgery demonstrated lower levels of urinary L-FABP. CONCLUSIONS Low levels of urinary L-FABP may indicate kidney injury and lack of renal protection.

Impact of Left Heart Bypass on Arterial Oxygenation During One-Lung Ventilation for Thoracic Aortic Surgery

OBJECTIVE The aim of this study was to reveal the mechanism of improved arterial oxygenation by measuring the changes in oxygenation before and after initiation of left heart bypass (LHB) during one-lung ventilation (OLV) for thoracic aortic surgery. DESIGN Prospective, observational study. SETTING Single-institution, private hospital. PARTICIPANTS The study comprised 50 patients who underwent aortic surgery via a left thoracotomy approach with LHB circulatory support. INTERVENTIONS Patients were ventilated using pure oxygen during OLV, and the ventilator setting was left unchanged during the measurement period. MEASUREMENTS AND MAIN RESULTS The measurement of partial pressure of arterial oxygen (PaO2) was made at the following 4 time points: 2 minutes after heparin infusion (point 1 [P1]), 2 minutes after inflow cannula insertion through the left pulmonary vein (P2), immediately before LHB initiation (P3), and 10 minutes after LHB initiation (P4). The mean±standard deviation (mmHg) of PaO2 measurements at the P1, P2, P3, and P4 time points were 244±121, 250±123, 419±122, and 430±109, respectively, with significant increases between P1 and P3, P1 and P4, P2 and P3, and P2 and P4 (p<0.0001, respectively). No significant increase in PaO2 was seen between P1 and P2 or between P3 and P4. CONCLUSIONS The improved arterial oxygenation during OLV in patients who underwent thoracic aortic surgery using LHB can be attributed to the insertion of an inflow cannula via the left pulmonary vein into the left atrium before LHB.

MAC value of desflurane may vary for different machines.

To address potential differences between results from calculation of MAC equivalent, we show, graphically, the relationship between concentration equivalent to 1 MAC for different ages and manufacturers (Supplementary Figure). When these data are compared with the data from the manufacturer of desflurane, age-corrected MAC values are likely to be underestimated for young people by the Perseus or GE. Nihonkoden and Apollo tend to overestimate MAC equivalent for elderly people. For example, if desflurane concentration is 6.6 %, all machines display MAC as 0.9 for a 15-year-old patient. However, MAC may be displayed as 1.0–1.2 for a 49-year-old patient and 1.3–1.6 for a 89-year-old. To avoid intraoperative recall, we must achieve clinically appropriate anesthesia without the need for repeated calculation of MAC value.

Comparison of estimated continuous cardiac output and transesophageal echocardiography cardiac output for noninvasively measuring cardiac output in pediatric patients undergoing kidney transplant surgery: 3AP4-2

Background and Goal of Study: Estimated continuous cardiac output (esCCO) is a new method for noninvasively and continuously estimating cardiac output (CO), which has rarely been evaluated in children. In the present study, we aimed to assess the accuracy and reliability of the esCCO system in pediatric patients. Materials and methods: Cardiac index (CI) was determined simultaneously using esCCO (CIesCCO) and TEE (CITEE) as our reference method 1) in 11 pediatric kidney transplant patients who were recruited prospectively. Hemodynamics undergo large changes af ter large volume fluid infusion in renal transplantation, making it suitable for examining esCCO trending ability in such cases. We then measured the CITEE; the first measurement thus obtained was used for calibration, and the esCCO was subsequently measured. Af ter the initial calibration measurement, CITEE was measured three times (1 before volume loading, 2 af ter volume loading and 3 before completion of surgery). Results and discussion: 33 paired readings from 11 pediatric patients were collected. CITEE was increased significantly from 1 to 2(p < 0.05). CITEE was decreased significantly from 2 to 3(p < 0.05). The correlation coef ficient between CIesCCO and CITEE was 0.75 (p < 0.001) . The dif ference in the CI value between CIesCCO and CITEE was 0.21 ± 1.01 L/min/ m2 (95% confidence limits of -1.81 to 2.23 L/min). The percentage error was 44.5%. Changes in CITEE greater than 15% from 1 to 2 or 2 to 3 were 16 points, and those lead to a change of CIesCCO in the same direction in 100%. A sensitivity and specificity that the changes in CIesCCO greater than 15% can detect the changes in CITEE greater than 15% were calculated using ROC analysis. ROC analysis showed a sensitivity of 87.5% and specificity of 100%(AUC 0.958 % CI 0.881-1.036). Conclusion(s): esCCO is a new noninvasive and cost-ef fective method to estimate cardiac function continuously. We found a poor agreement between the two methods. However we found a good agreement of trend between the two methods. esCCO may be suf ficient for trend monitoring. References: 1. Justin JS, Michael BF (2008) Cardiac output measurement in pediatric anesthesia. Pediatr Anesth 18:1019-1028