Yuki Enomoto

Prolonged use of dexmedetomidine in an infant with respiratory failure following living donor liver transplantation

We used dexmedetomidine for more than 2 months in a mechanically ventilated infant without serious adverse effects. An infant with liver cirrhosis of unknown cause underwent living donor liver transplantation at the age of 9 months. Long‐term mechanical ventilation was required postoperatively, and midazolam with fentanyl had been used to sedate the patient. They required increase to 1.7 mg·kg−1·h−1 and 3.5 μg·kg−1·h−1, respectively, which were still inadequate. On postoperative day 29, dexmedetomidine was added. The rate of dexmedetomidine infusion was increased gradually to 1.4 μg·kg−1·h−1. It was discontinued temporarily to exclude drug‐induced liver dysfunction. However, without dexmedetomidine, adequate sedation level was unattainable. Liver dysfunction was likely to be attributed to cytomegalovirus infection and after restarting dexmedetomidine, the respiratory condition improved. He was extubated 10 weeks after the operation. Dexmedetomidine was successfully tapered off over the following 2 weeks with no signs of withdrawal. Dexmedetomidine was a useful sedative for an infant who required mechanical ventilation for a prolonged period of time.

Continuous Veno-Venous Hemodiafiltration and Plasma Exchange in Infantile Acute Liver Failure.

Objectives: The purpose of the current study was to assess our multidisciplinary approach consisting of early application of neurology-oriented intensive care, aggressive artificial liver support and liver transplantation at the appropriate time for infants with acute liver failure. Design: Retrospective cohort study. Setting: A tertiary pediatric medical center in Japan. Patients: Seventeen infants younger than 12 months with acute liver failure who subsequently underwent liver transplantation between February 2006 and June 2011. Interventions: None. Measurements and Main Results: The patients varied from 1 to 11 months, with a median of 6 months. The median body weight was 8.0 kg (range, 2.7–10 kg). With respect to the encephalopathy grading before liver transplantation, four cases were categorized as grade II, seven cases were categorized as grade III, and five cases were categorized as grade IV. Continuous veno-venous hemodiafiltration and plasma exchange were applied to all the infants until liver transplantation. Bilirubin, ammonia, prothrombin time/international normalized ratio and creatinine decreased significantly after continuous veno-venous hemodiafiltration + plasma exchange (p < 0.001). The median value of catecholamine index changed from 10 to 0 (range, 0–20.6). Notably, among the 16 infants who underwent electroencephalography assessment, five did not show slow waves throughout their stay, and one who did so before treatment ceased to show any after treatment. The all patients underwent living-donor liver transplantation and were subsequently discharged from the PICU. The overall survival rate was 88% (15/17) with a median follow-up period of 28 months (range, 2–64 mo). Regarding the neurological outcomes of the survivors, 73% (11/15) had no neurological morbidities and 20% (3/15) had mild disabilities. Conclusions: Our multidisciplinary approach for infants with acute liver failure achieved favorable outcomes. Further investigations are needed to examine the efficacy of the artificial liver support.

Development of the Japanese version of the Preschool Confusion Assessment Method for the ICU

Delirium is associated with various negative clinical outcomes, such as decline in cognitive ability, increased length of hospital stay, and higher mortality. For these reasons, early diagnosis of delirium is critical. Unfortunately, there are no reliable diagnostic criteria or tool of delirium for infants and preschool‐aged children in Japan.

Improving the neurological prognosis following OHCA using real-time evaluation of cerebral tissue oxygenation: a case report

Background The neurological prognosis is poor for patients suffering from out‐of‐hospital cardiac arrest (OHCA), in the absence of bystander cardio pulmonary resuscitation (CPR), and showing asystole as the initial waveform. However, such patients have the potential of resuming social activity if cerebral tissue oxygen saturation can be preserved. Case presentation We recently encountered a 60‐year‐old man who had suffered an OHCA in the absence of bystander CPR, and who successfully resumed complete social activity despite initial asystole and requiring at least 75 min of chest compressions before return of spontaneous circulation (ROSC). In this case, chest compression was appropriately performed concurrently with real‐time evaluation of cerebral tissue oxygenation using near‐infrared spectroscopy (NIRS). As a result, the cerebral tissue oxygenation was well maintained, leading to resumption of social activity. Conclusions Improved neurological prognoses can be expected if OHCA patients with the potential for social activity resumption are identified, using NIRS, and effective cardiopulmonary and cerebral resuscitation is performed while visually checking CPR quality.

Targeted age, device deployment, and problems associated with pediatric defibrillation in pediatric prehospital emergency medical care settings in Japan

The use of automated external defibrillators was expanded to include infants according to the 2010 cardiopulmonary resuscitation guidelines in Japan. However, deployment has been slower for pediatric patients in Japan, because there are fewer appropriate pediatric patients for automated external defibrillators than adults. This study aimed to investigate the targeted age range for pediatric defibrillation and device deployment of defibrillators for pediatric patients in prehospital emergency medical care settings in Japan, and present the issues associated with automated external defibrillators.

Medical equipment deployment in pediatric emergency prehospital medical units in Japan

The deployment status of pediatric emergency equipment in ambulances in Japan is unknown. To investigate the status of and issues associated with prehospital emergency medical care for pediatric patients, we conducted a descriptive epidemiological study. We carried out a Web‐based survey of 767 fire defense headquarters in Japan, of which 671 responded (valid response rate, 88%). Most of the fire defense headquarters equipped all of their ambulances with oxygen masks (82%), bag‐valve masks (for neonates, 83%; for children, 84%), straight laryngoscope blades (for neonates, 47%; for children 68%), blood pressure cuffs for children (91%), oximeter probes (78%), and stiff neck collars (91%); but despite the need for other equipment such as nasopharyngeal and oropharyngeal airways, and Magill forceps, they were insufficiently deployed. In Japan, prehospital emergency medical equipment deployment does not meet the needs of pediatric patients. Minimum equipment standards need to be established for pediatric prehospital care.

Verifying the validity and reliability of the Japanese version of the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale

Background Pediatric patients, especially in the preverbal stage, cannot self-report intensity of pain therefore several validated observational tools, including the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale, have been used as a benchmark to evaluate pediatric pain. Unfortunately, this scale is currently unavailable in Japanese, precluding its widespread use in Japanese hospitals. Objectives To translate and verify the validity and reliability of the Japanese version of the FLACC Behavioral Scale. Method Back-translation was first conducted by eight medical researchers, then an available sample of patients at the University of Tsukuba Pediatric Intensive Care Unit (from May 2017 to August 2017) was enrolled in a clinical study. Two researchers evaluated the validity of the translated FLACC Behavioral Scale by weighted kappa coefficient and intraclass correlation coefficients (ICC). Observational pain was simultaneously measured by the visual analog scale (VAS obs) and reliability was evaluated by correlation analysis. Result The original author approved the translation. For the clinical study, a total of 121 observations were obtained from 24 pediatric patients. Agreement between observers was highly correlated for each of the FLACC categories (Face: κ = 0.85, Leg: κ = 0.74, Activity: κ = 0.89, Cry: κ = 0.93, Consolability: κ = 0.93) as well as the total score (Total: κ = 0.95,). Correlation analysis demonstrated a good criterion validation between the FLACC scale and the VAS obs. (r = 0.96) Conclusion Our Japanese version of the FLACC Behavioral Scale shows high validity and reliability.

Development of the Japanese version of the Cornell Assessment of Pediatric Delirium

Delirium is a form of acute cerebral dysfunction and is associated with increased length of hospital stay, mortality, and health‐care costs for adult patients in intensive care. However, in Japan, there are currently no reliable criteria or tools for diagnosing delirium in critically ill pediatric patients. The purpose of this study was to translate the Cornell Assessment of Pediatric Delirium (CAPD)—a screening tool for pediatric delirium—from English to Japanese for use in the diagnosis of delirium for pediatric patients in pediatric intensive care units.

Enteral nutrient gel causes formation of a huge gastric bezoar

Dear Editor, A 58-year-old Asian woman hung herself. When emergency medical service arrived, she was under cardiopulmonary arrest with asystolic rhythm. Sixty minutes later, her circulation was restored and she was then transferred from a rural hospital to our hospital. When the patient was brought to our hospital, she was unconscious, and her pupils were dilated and had no light reflex. Computed tomography images showed diffuse brain swelling and unclear corticomedullary junctions, and electroencephalography revealed no brain activity. After admission to the intensive care unit, noradrenaline and vasopressin were started, and were continued for 2 months due to persistent vasodilatory shock. On day 7, we started glutamine, fiber, and oligosaccharide (GFO; Otsuka Pharmaceutical Factory, Inc., Naruto City, Japan) through a nasogastric tube, and on day 10, watery diarrhea ensued after receiving low residual liquid diet. On day 12, we changed the enteral nutrient to HINE E-GEL (Otsuka Pharmaceutical Factory, Inc.), a low residual liquid diet changing from a liquid to a jelly in a low pH environment. The next day, diarrhea stopped. After HINE E-GEL was given consistently, soft stool was excreted regularly, without vomiting. Because serum phosphorus increased, we started other low residual liquid nutrients. As the patient developed watery diarrhea thereafter, we continued giving HINE E-GELwith lanthanum carbonate. On day 28, a plain abdominal x-ray revealed that her stomach was filled with calcified substances (Fig. 1). A few days later, she started vomiting. To dissolve the bezoar, 500 mL commercially available Coca-Cola (Coca-Cola East Japan Co, Ltd., Tokyo, Japan) was administered through a nasogastric tube once a day according to several previous reports. The bezoar was reduced gradually thereafter. Gastric bezoars in critically ill patients have been rarely reported. Some case reports showed intestinal bezoars were caused by reduced gastrointestinal motility, which most frequently occurred after gastrointestinal surgery. Although our patient had not undergone surgery, her intestinal motility might have been impaired because of her critical condition. Another risk factor for bezoar is feeding substances. Aluminum hydroxide, sucralfate, cholestyramine, and nifedipine are supposed to be the causes of pharmacobezoar. Our patient enterally received lanthanum carbonate, esomeprazole, hydrocortisone, and bifidobacterium. Among them, only lanthanum carbonate was reported as a cause of a pharmacobezoar in a patient who swallowed chewable tablets without chewing repeatedly, resulting in formation of a rectal bezoar; our patient was administered lanthanum carbonate dissolved in water through a nasogastric tube. To our knowledge, liquid diet in jelly form has not been reported as a cause of bezoar. Clinicians should be aware that low residual liquid diet changing from a liquid to a jelly in a low pH environment, which is widely used to prevent gastro-esophageal regurgitation and diarrhea, can cause gastric bezoar in critically ill patients with reduced intestinal motility.

Effects of the elective introduction of extracorporeal membrane oxygenation on outcomes in pediatric myocarditis cases

To investigate the necessary indicators to diagnose pediatric myocarditis and choose appropriate candidates for extracorporeal membrane oxygenation therapy.